Anaesthesia for cesarean delivery

and other procedures during

pregnancy

Moderator
Dr Nidhi
Speakers
Dr Rajeev
Dr Ravi Bhat
Dr Bhuvaneshwari
Obstetric anaesthesia-history
 1847
 James Simpson-ether
 1853
 Queen Victoria-chloroform
 1900
 Labour analgesia-cocaine
 1902
 Caeserean delivery-spinal
Indications
 Obstetric

 Emergency
 Fetal distress
 APH
 Dystocia
 Failure of induction
 Elective
 Failure to progress
 Previous caeserean delivery
 CPD
 Placenta previa
 Severe PIH
 Malpresentations
 Multiple pregnancy
Preanesthetic evaluation
History Examination
 Urgency  Height/weight

 Fasting time  Vitals/systems

 Gestational age  Airway

 Fetal well being  Spine

 Pregnancy related Investigations

pathology  Hb

 C/I regional  Electrolytes /RFT

 Sciatica/backache  RBS
 Choice of Anaesthesia
 Safest and most comfortable to mother

 Least depressant to newborn

 Optimal working conditions

 Regional vs GA
 Regional anaesthesia-
advantages

 Awake mother
 Avoids problems with airway
 Failed intubation
 Aspiration
 Avoids drug induced neonatal depression
 Preparations for regional
 Check resuscitation equipment and drugs
 Oral non particulate antacid 1 hr
prior/H2blocker/PPI/metoclopramide
 Transport with left uterine displacement
 Baseline vital signs
 10ml/kg dextrose free balanced salt
solution
 Supplemental oxygen
Suggested technique
 Spinal
 Thin ,non cutting needle
 Bupivacaine 12-15 mg or lignocaine 60-75mg
 Opioids
 Fentanyl 10-25 µg or morphine 0.1-0.25 mg
 Position with left uterine displacement
 10 degree trendelenberg tilt
 Monitoring
 BP every min till 20 min then every 5 min
 ECG
 Pulse oximetry
 Epidural anesthesia

 Test dose
 pH adjustment options
 1ml sodabicarb to 10ml lidocaine
 0.1 ml to 20ml bupivacaine
 Epidural opioid
 Fentanyl 50-100 µg
 Morphine 50µg/kg
Changes in spinal column in
pregnancy
 Exaggerated lumbar lardosis
 Cephalad spread of LA
 Yoshimo et al –MRI analysis
 apex of lumbar lardosis
 thoracic kyphosis reduced

(BJA 1995;75:6-8)
Dose of local anaesthetics
 50-70% of dose required in non pregnant women
 Increased cephalad spread
 Influencing factors
 Mechanical

 Caval compression
 Onset of labor
 Exaggerated lardosis
 Hormonal
 Increased progesterone and endorphins
 Biochemical
 Lower CSF proteins
 CSF buffering capacity
 Complications and
management

Hypotension Anxiety/spotty
 SBP falls by 30% or anaesthesia
<100mmHg  Midazolam 1-2 mg
 Increase i.v infusion  Fentanyl 2µg.Kg-1
 LUD
 40%nitrous by mask
 10-15 mg ephedrine
 0.25mg/kg ketamine
 10 to 20 ml lidocaine
iv intraperitoneally
 Complications
Inadequate anaesthesia High or total spinal
 proceed to GA  Hypotension

Nausea and vomiting  motor sensor block

 Metoclopramide 10mg  Bradycardia

 ondansetron 4 mg i.v  Apnoea

 droperidol 0.5mg  Loss of airway reflexes

 unconsciousness

 Rx
 airway

 Ventilate

 vasopressors
Local anaesthetic toxicity Failed regional block
 Convulsions
 GA
 Unconsciousness
 Arrythmia
 cardiovascular collapse
 rx
 Airway
 ventilate with oxygen
 barbiturate propofol or BZD
 CPR
Post dural puncture
headache
 prophylactic
blood/saline
 Bedrest
 Hydration
 caffeine therapy
 epidural blood patch
General anaesthesia

Advantages
 More rapid induction
 Less cardiovascular instability
 Better control of airway and ventilation
 MAC for halothane, isoflurane 25 to 40
%
 ↓FRC →faster equilibration
 Suggested technique
 Non particulate antacid 1 hr prior
ranitidine/metoclopramide
 Uterine displacement
 Infusion with large bore catheter
 Rapid sequence intubation
 Preoxygenate
 Cricoid pressure
 Thio 4-5mg/kg and succinylcholine 1-1.5 mg/kg
 Intubate
 Nitrous and oxygen with 0.5 mac halogenated agent
 Avoid maternal hyperventilation
 Awake extubation
Prevention of acid aspiration

 Rapid intubation
 avoiding positive
pressure ventilation
 cricoid pressure
 awake extubation
 prophylaxis
 0.3 molar sodium citrate
 Ranitidine
 omeprazole
 metoclopramide
 Failed intubation
 Incidence
 1 in 280 to 1 in 300
 Changes in airway
 Capillary engorgement of mucosa
 Disposition of fat
 Tongue enlargement
 Airway edema
 Onset of labor
 Pre eclampsia
Failed intubation
unable to intubate

Call for help, maintain cricoid, 100% oxygen
LMA, combitube, TTJV, cricothyrotomy
 
Serious fetal distress minimal/no distress
  
Ventilation easy difficult Awake patient
halothane /o2 LMA, combitube
Cricoid, continue TTJV, cricothyrotomy
Difficult airway equipments
 Prevention of supine
hypotension
 Avoiding aortocaval compression
 Adequate preload
 Ephedrine/phenylephrine
 Leg elevetion/trendelenbergs
 Epinephrine
 Preoxygenation and maternal
ventilation
 Oxygen consumption by 20% ,FRC ↓ by 20%
 8 maximal capacity breaths in 1 min

 maternal hyperventilation

↓ paCO2  pH

Lt shift of O2curve uterine blood flow
 
Affinity of Hb placentaltransfer

Fetal pO2,anaerobic metabolism,metabolic acidosis
Effect of anaesthetic agents
Thiopentone Propofol
 4-5mg :no fetal  Lower Apgar scores

depression  Hypotonia

 Redistribution  Transient

 Non-homogeneity somnolence
 Progressive dilution  Not FDA approved
Ketamine Muscle relaxants
 Indicated  no effect on fetus
 Hypovolemia Nitrous oxide
 Acute asthma
 50%nitrous
 not prefered
 shorter I-D interval
 High BP
 >1mg/kg
 Low Apgar score
 Hypertonicity
Halogenated agents
 MAC

 improved uterine blood flow

 chance of increased bleeding

 Prevention of neonatal depression

Fetal outcome- regional vs GA
 Criteria
 Apgar score
 Acid base status
 Neurobehavioral status
 Prolonged I-D interval>10 to 15 min
U-D interval>3 min
 Emergency cesarean section
Fetal distress
 severe persistent bradycardia
 persistent late and variable decelerations
 loss of beat to beat variability
Fetal outcome
 similar in regional and GA (Marx et al)
(BJA 1984;56:1009-1013)
Advantages of GA
 less maternal HD changes
 rapidity
Uterotonics and tocolytics
Uterotonics Tocolytics
 Oxytocin  Terbutaline
 20u/500ml  Magnesium sulphate
 Methergin  NTG Patch
 0.25 mg  Nifedipine
 Prostodin  Atosiban
 0.25mg i.m
Postoperative analgesia
 Morphine
 0.2mg intrathecally
 3mg epidurally
 Pethidine /morphine
Anaesthesia for surgical
procedures during pregnancy
Effect of anaesthesia on
mother and fetus
Recommendations for
anaesthetic management
elective surgery
 deferred
Urgent surgery
 deferrred until midgestation
 minimise exposure
Emergency surgery
 regional block preferable
 Spinal anaesthesia – least fetal exposure
PAC
 efforts to allay maternal anxiety
GA
 adequate oxygenation
 avoid hyperventilation
Prevention
 Aspiration /supine hypotension
Monitoring
 fetal monitoring
 uterine activity monitoring/early tocolytics
Anaesthesia for laparoscopic
surgery during pregnacy
 Common procedures
 Cholecystectomy
 Appendicectomy
 ovarian /adnexal masses
 Open hasson technique
 IAP ≤15mmHg
 Maternal EtCO2
 Prolonged respiratory acidosis
 spontaneous abortion
 preterm labour
 Increased risk of DVT
 Intra op TV-USG