Anesthesia for Cesarean Section

Michelle Gros, FRCPC Feb 13, 2008

Cesarean Section
Cesarean section rate in Canada in 2005 was 23.7% (CIH) Cesarean section rate in US now exceeds 24% Incidence of anesthesia-related maternal mortality is declining Anesthesia remains responsible for ~ 3-12% of all maternal deaths Majority during general anesthesia (failed intubation, failed ventilation and oxygenation, and or aspiration) Associated factors include obesity, hypertensive disorders of pregnancy, and emergently performed procedures

Cesarean Section
Review of anesthetic technique used for all c-sections performed at Brigham and Womens hospital between 1990 and 1995 GA from 7.2% in 1990 to 3.6% in 1995 Are we getting enough experience in GAs for csections?

Preparation for Anesthesia - Meds

Minimize drugs prior to delivery of infant If necessary, midazolam 0.5 1 mg or fentanyl 25-50 ug IV Small doses minimal fetal and neonatal depression Disadvantage of benzos ? Anticholinergics decreases secretions

Atropine crosses placenta - FHR and variability Glycopyrrolate does not cross placenta

Aspiration prophylaxis

Preparation for Anesthesia - Meds

CJA 2006; 53(1): 79-85. RCT of 60 women Either 1 ug/kg fent and 0.02 mg/kg midaz IV, OR an equal volume IV NS at time of skin prep for spinal No between group differences of neonatal outcome variables (Apgar, neurobehavioural scores, continuous oxygen saturation) Mothers had no difference in recall of the birth

Preparation for Anesthesia IV Fluids

Prior to regional 15-20 mL/kg RL or NS 30 mins prior Rout et al. 1993 incidence of hypotension from 71% to 55% if prehydrated Message:

Additional means are necessary In urgent situation not necessary to wait for fluid bolus

hypotension means improved uteroplacental perfusion ?crystalloid vs. colloid

Preparation for Anesthesia IV Fluids

CJA 2000; 47: 607-610. Crystalloid preload no longer magic bullet Study found 1 L crystalloid preload was of no value in preventing hypotension Both speed and volume of preloading unimportant Still reasonable to give modest preload prior to spinal Patients are often relatively dehydrated BUT no need to delay emergency surgery in order to preload

Preparation for Anesthesia IV Fluids

Siddik showed 500 mL pentaspan more effective than 1 L NS in reducing hypotension (40% vs. 80%) N+V also reduced in colloid group

Neonatal outcome unaffected

Riley et al showed less hypotension in colloid group (45% vs. 85%) but no difference in nausea scores or neonatal outcome

Preparation for Anesthesia IV Fluids

French et al showed less hypotension in colloid group (12.5% vs. 47.5%), again no differences in neonatal outcome Karinen et al failed to find any differences in hypotension when colloid was used

Preparation for Anesthesia IV Fluids

Disadvantages to Colloid?

Expensive Anaphylactoid reactions Coagulation effects

Preparation for Anesthesia IV Fluids

Is type, amount, timing of fluids that important? Also consider:

Effective LUD - 15 often not enough Aggressive use of vasopressors Low dose spinal anesthesia

Preparation for Anesthesia Maternal Position

Avoid aortocaval compression Results in uteroplacental perfusion by 3 mechanisms:
1)

venous return C.O. and BP Obstruction of uterine venous drainage s uterine venous pressure and uterine artery perfusion pressure Compression of aorta or common iliac arteries uterine artery perfusion pressure

2)

3)

Preparation for Anesthesia Monitors

Standard monitors +/- art, CVP

FHR

Before, during, after administration of anesthesia Evaluates effects of maternal position, anesthesia, hypotension, and other drugs on the fetus

General Considerations

? Support person ? Oxygen

General Considerations - Oxygen

For elective c-section, current evidence suggests that supplementary oxygen is unnecessary For emergency section further data are required Improvement of fetal oxygenation should be primary objective this achieved in short-term by using very high FiO2 BUT, possibility of reperfusion injury with free radicals

Prevention of Maternal Complications Aspiration

ALL patients should receive aspiration prophylaxis, regardless of planned anesthetic for c-section Large survey from Sweden

Incidence of aspiration ~ 15 per 10,000 cases of GA for c-sxn 3X greater than in nonobstetric surgery

Preventing Aspiration Pharmacologic Tx

1) 2)
1)

Non-particulate antacid eg. 0.3 M sodium citrate H2-receptor antagonist

gastric pH, BUT does NOT alter pH of existing gastric contents Rout et al 1993 IV ranitidine 50 mg + po Na citrate resulted in greater in gastric pH than Na citrate alone (provided >30 mins from time of administration to intubation)

2)

Preventing Aspiration Pharmacologic Tx

3)
1) 2)

Proton pump inhibitor eg. losec

gastric acidity One study found it less effective than ranitidine

4)
1)
2) 3) 4)

Metoclopramide
Accelerates gastric emptying ? Reliability of emptying stomach before c-sxn lower esophageal sphincter tone Antiemetic effect

Prevention of Maternal Complications Hypotension

In obstetric patients - in SBP > 25% OR, any SBP < 100 mmHg Measures of prevention:
1) 2) 3)

Fluids LUD Prophylactic vasopressors (ephedrine, phenylephrine)

Prevention of Maternal Complications Hypotension

Lee et al., CJA 2002 systematic review of RCTs of ephedrine vs. phenylephrine for tx of hypotension during spinal for c-sxn

No difference for prevention and treatment of maternal hypotension Maternal bradycardia more likely to occur with phenylephrine than with ephedrine No difference in the incidence of fetal acidosis (umbilical artery pH < 7.2)

Prevention of Maternal Complications Hypotension

Chestnut says: They still mostly use ephedrine Phenylephrine preferred in patients who may not tolerate tachycardia eg. MS

Prevention of Maternal Complications Hypotension

Varying reports of efficacy of prophylactic ephedrine Some advocate 25 50 mg IM before spinal, or 5-10 mg IV immediately after intrathecal injection Chestnut dont give prophylactic ephedrine unless pt has a low baseline BP (ie. SBP <105 mmHg before spinal)

Prevention of Maternal Complications Failures

1) Failed spinal

~ 1% of cases

Prevention of Maternal Complications Failures

1) Failed spinal

~ 1% of cases If delivery not urgent 2nd spinal

Prevention of Maternal Complications Failures

1) Failed spinal

~ 1% of cases If delivery not urgent 2nd spinal

2) Failed epidural

~ 2-6% of cases

Prevention of Maternal Complications Failures

1) Failed spinal

~ 1% of cases If delivery not urgent 2nd spinal

2) Failed epidural

~ 2-6% of cases Repeat epidural

Watch for local toxicity Pt impatient

Prevention of Maternal Complications Failures

1)

Failed spinal
~ 1% of cases If delivery not urgent 2nd spinal

2)

Failed epidural
~ 2-6% of cases Repeat epidural
Watch for local toxicity Pt impatient

Spinal
Collection of local falsely think this is CSF High spinal

Prevention of Maternal Complications Failures

Chestnut: ~ 5% planned epidurals converted to spinals High spinals in 3 of 27 (11%)

Indications for Cesarean Section

Repeat

Scheduled Failed attempt at vaginal delivery

Dystocia Abnormal presentation

Transverse lie Breech Multiple gestation

Fetal stress/distress Deteriorating maternal medical illness Preeclampsia Heart disease Pulmonary disease Hemorrhage Placenta previa Placental abruption

Choice of Technique

Choice of Technique
1) 2) 3) 4)

Indication for c-sxn Urgency of procedure Health of mother and fetus Desires of mother

Spinal
Pros:
Simple Rapid onset Dense blockade Negligible maternal risk of systemic local toxicity Minimal transfer of drug to infant Negligible risk of local anesthetic depression of infant

Spinal
Cons:
Rapid onset of sympathetic blockade abrupt, severe hypotension Limited duration Recovery time may be prolonged (if procedure shorter than anticipated)

Epidural

Popularity increasing LA nerve roots (dural cuffs) by absorption through arachnoid villi that penetrate dura spread of anesthesia is volume dependent

Epidural
Pros:
Titrated dosing and slower onset risk of severe hypotension and reduced uteroplacental perfusion Duration of surgery not an issue Less intense motor blockade good for pts with multiple gestation or pulmonary disease Lower extremity muscle pump may remain intact may incidence of thromboembolic disease

Epidural
Cons:
Slower onset Risk of systemic local toxicity Greater placental transfer of drug than with spinal BUT does not affect neonatal neurobehaviour and of little clinical significance when appropriate doses used Risk of high spinal

Combined Spinal Epidural (CSE)

Initially described in 1981 (epidural catheter at L1-2 and spinal at L3-4)

Combined Spinal Epidural (CSE)

Pros:
Rapid onset and density of spinal anesthesia combined with versatility of epidural anesthesia

Cons:
Potential for high spinal Inability to test epidural catheter Only 1 published report of presumed unintentional insertion of epidural catheter through dural puncture site

Spinal Anesthesia for C - Section

Metoclopramide 10 mg IV Clear antacid orally Intravascular volume expansion with RL or NS (15-20 mL/kg) Application of monitors Supplemental oxygen by face mask or nasal prongs Prophylactic intramuscular ephedrine (25-50 mg) in patients with a baseline SBP < 105 mmHg

Spinal Anesthesia for C - Section

Lumbar puncture at L3-4

Right lateral or sitting position

25-gauge Sprotte or Whitacre needle Bupivacaine 12 mg (heavy) Morphine 0.1-0.25 mg for postoperative analgesia Left uterine displacement Aggressive treatment of hypotension

Exaggerated LUD IV fluids Ephedrine and/or low dose phenylephrine

Drugs Used for Spinal Anesthesia for Cesarean Section

Drug
Lidocaine Bupivacaine Tetracaine Procaine Adjuvant drugs Epinephrine Morphine Fentanyl 0.1-0.2 0.1-0.25 0.010-0.025 ----360-1080 180-240

Dosage (mg)
60-75 7.5-15.0 7.0-10.0 100-150

Duration (min)
45-75 60-120 120-180 30-60

Epidural Anesthesia for C-Section

Maxeran 10 mg IV Clear antacid po IV expansion with RL or NS (15-20 mL/kg) Application of monitors Supplemental oxygen Epidural catheter at L23 or L3-4 LUD Test dose Therapeutic dose

5 ml boluses of 2% lido with epi 5ml boluses of 0.5% bupivacaine, 0.5% ropivacaine, or 3% 2chloroprocaine (lidocaine or 2-chloroprocaine q 1-2 mins, bupiv or ropiv q 2-5 mins)

Aggressive tx of hypotension

Drugs Used for Epidural Anesthesia for Cesarean Section

Drug
2% lido with epi 2-chloroprocaine 0.5% Bupivacaine

Dosage (mg)
300-500 450-750 75-125

Duration (min)
75-100 40-50 120-180

0.5% Ropivacaine
Adjuvant Drugs Morphine

75-125
3-4

120-180
720-1440

Fentanyl
Meperidine

0.05-0.10
50-75

120-240
240-720

Aids with Regional

40-50% N2O Low-dose ketamine (0.25 mg/kg) Fentanyl 50-100 ug IV Remifentanil Metoclopramide, ondansetron, or droperidol may be given to treat nausea Small dose of a benzodiazepine to treat anxiety and/or restlessness

Local Anesthetic?
Int. J Ob Anesth. 2006; 15: 106-114. Prospective, single blind study

Compared plain 0.5% bupivacaine (20 mL) with 2% lidocaine (20 mL) + 100 ug epi + 100 ug fentanyl for extending previous low-dose epidural analgesia for emergency c-sxn in 68 pts

Local Anesthetic?
Sig. longer prep time for mixture (3.0 vs. 1.25 min) Median onset time for block to T7 was 13.8 min for mixture and 17.5 min for plain bupivacaine

Difference not statistically different, and was offset by the longer prep time
Need for other intra-op supplementation was not significantly different between the groups Lidocaine is cheaper and less toxic than alternatives

Local Dose How Low Can We Go?

Int J Ob Anesth, 2006; 15: 273-278. Randomized to receive either intrathecal hyperbaric bupivacaine 3.75 mg or 9 mg, plus 25 ug fentanyl, 100 ug morphine, and 1.5% lidocaine epidurally 3 mL Max sensory block achieved in low-dose group was significantly lower than that in conventional group (T4 vs. T2) Longer time to reach maximum sensory level in low dose group (8.6 min vs. 6.8 min)

Local Dose How Low Can We Go?

Low-dose group had less motor block, faster sensory regression to T10 and faster motor recovery No significant difference in need for epidural supplementation before or after delivery of baby Low-dose group less hypotension (14% vs. 73%) with less ephedrine usage

Spinal Bupivacaine Dosed According to Patient Height

Barash p 1149 Spinal bupivacaine 0.75% dosed according to patient height:

150-160 cm 8 mg 160-182 cm 10 mg >182 cm 12 mg

Onset of action: 2-4 mins Duration of action: 120-180 mins

Addition of Fentanyl to Spinal

Acta Anesth Scand, 2006; 50: 364-367. Tested effect of intrathecal fentanyl added to hyperbaric bupivacaine on maternal spirometry in 40 pts 2 groups:
1) 2) 2 mL hyperbaric bupivacaine 0.5% + 0.4 mL saline 2 mL hyperbaric bupivacaine 0.5% + 0.4 mL fentanyl (20 ug)

Performed spirometry on arrival to OR and 15 mins after subarachnoid blockade

Addition of Fentanyl to Spinal

Subarachnoid block with bupivacaine significantly peak expiratory flow rates No changes in VC or FVC Addition of intrathecal fentanyl:

Improved quality of blockade (T1.5 vs. T4) Did not lead to a deterioration in resp function compared with intrathecal bupivacaine alone

Addition of Fentanyl to Spinal

Int. J Ob. Anesth. 1997; 6: 43-48. Double-blind placebo-controlled study Compared periop pain relief with fentanyl, morphine, or combination In addition to bupivacaine group A received 1 mL NS, group B 25 ug fent, group C 100 ug morph, group D 25 ug fent + 100 ug morph Quality of intraop analgesia similar in all groups receiving opioid Opioid use increased side effects Postop analgesia with fentanyl inferior to morphine

Dose of Intrathecal Morphine?

No good conclusive study Many varied practices Anesth 1999; 90: 437-44. Dose-finding study for intrathecal morphine No difference in PCA morphine use between 0.1 and 0.5 mg groups Pruritis in direct proportion to dose No difference in N+V between groups Conclusion: no need to use more than 0.1 mg

Epidural Morphine for Post-op Pain Control

Anesth Analg. 2007; 105(1): 176-83. Compared 4 mg epidural morphine with 10 mg extended release epidural morphine Found superior and prolonged post-c-section analgesia (especially 24-48 hours post-op)

Risk Factors for Failure of Epidural Analgesia for C-Section

Acta Anesth Scand, 2006; 50: 1014-1018. Prospectively studied women undergoing c-sxn with a functioning epidural in place All pts received same epidural protocol 16 mL 2% lido, 1 mL bicarb, and 100 ug fentanyl given for c-sxn Failed epidural analgesia was defined as need to convert to GA

Risk Factors for Failure of Epidural Analgesia for C-Section

Of 101 pts, 20 (19.8%) required conversion to GA Failed epidural inversely correlated with pts age Directly correlated with:

Pre-pregnancy weight Weight at end of pregnancy BMI Gestational week Number of top-ups VAS 2 hour before c-sxn

Risk Factors for Failure of Epidural Analgesia for C-Section

Therefore, younger, more obese pts at a higher gestational week, requiring more top-ups during labour, having a higher VAS in the 2 hours before csxn are at risk of inability to extend labour epidural analgesia to epidural analgesia for c-sxn

Indications for General Anesthesia for Cesarean Section

Indications for General Anesthesia for Cesarean Section

Dire fetal distress in absence of pre-existing epidural Acute maternal hypovolemia Significant coagulopathy Inadequate regional anesthesia Maternal refusal of regional anesthesia

General Anesthesia for Cesarean Section

Ranitidine and/or metoclopramide IV Clear antacid po LUD Application of monitors Denitrogenation (100% O2) Cricoid pressure IV induction

Pentothal, propofol, ketamine, or etomidate Succinylcholine (roc if sux contraindicated)

General Anesthesia for Cesarean Section

Intubation with 6.0-7.0 mm cuffed ETT 30-50% N2O in O2, and low conc of volatile (0.5 MAC) After delivery: Increased conc of N2O with low conc. Volatile Opioid IV hypnotic agent (eg. benzo, barbiturate, propofol) if needed Muscle relaxant (sux boluses or infusion, roc, cisatracurium) Extubation awake with intact airway reflexes

General Anesthesia Traditional RSI Necessary?

Int. J Ob Anesth. 2006; 15: 227-232

The effects on the fetus of anesthetics and opioid analgesics are innocuous and reversible
Dose-dependent neonatal respiratory depression is predictable and readily treatable by a neonatal pediatrician Choice of drug regimen for pt with cardiac or cerebrovascular disease should not be restricted on account of concern for the fetus Opioids should not be withheld in hypertensive disorders, when prevention of a dangerous hypertensive response to laryngoscopy and tracheal intubation is paramount

General Anesthesia
Adequate denitrogenation:

FRC O2 consumption

Baraka compared head-up and supine positions for denitrogenation in pregnant and non-pregnant pts Head-up position prolonged interval between onset of apnea and desaturation (SpO2<95%) in nonpregnant pts, BUT NOT in pregnant pts

General Anesthesia Induction Agents

Goals:
1) 2) 3)

Preserve maternal BP, CO, and uterine blood flow Minimize fetal and neonatal depression Ensure maternal hypnosis and amnesia

General Anesthesia Induction Agents

Thiopental Extensive published data Safe in obstetric pts 4 mg/kg Rapidly crosses placenta Detected in umbilical venous blood within 30 secs Equilibration in fetus rapid and occurs by time of delivery With doses 4 mg/kg peak concs in fetal brain rarely exceed threshold for depression

General Anesthesia Unconscious mother and awake neonate?

1) Preferential uptake by fetal liver (1st organ perfused by blood from umbilical vein) Higher relative water content of fetal brain Rapid redistribution of drug into maternal tissues rapid reduction in maternal fetal conc gradient

2) 3)

4)
5)

Non-homogeneity of blood flow to intervillous space

Progressive dilution in fetal circulation

General Anesthesia Propofol

Rapid, smooth induction of anesthesia Attenuates cardiovascular response to laryngoscopy and intubation more effectively than pentothal Does not adversely affect umbilical cord blood gas measurements at delivery Rapidly crosses placenta Rapidly cleared from neonatal circulation Detected low concs in breast milk Propofol and pentothol similar Apgar and neurobehavioural scores

General Anesthesia Ketamine

1 mg/kg Rapid onset Analgesia, hypnosis, and reliably provides amnesia Good in asthma or modest hypovolemia 1 mg/kg does NOT uterine tone (larger doses do) Rapidly crosses placenta Similar umbilical cord blood gas and Apgar scores with ketamine or pentothal

General Anesthesia Succinylcholine

1-1.5 mg/kg Muscle relaxant of choice for most patients Highly ionized and water soluble, only small amounts cross placenta Maternal administration rarely affects neonatal neuromuscular function One study only doses > 300 mg result in significant placental transfer Pseudocholinesterase activity 30% in pregnancy, BUT recovery is not prolonged volume of distribution offsets the effect of activity

General Anesthesia Rocuronium

1 mg/kg Only very small amounts cross placenta Apgar and neurobehavioural scores not affected

General Anesthesia Maternal Awareness

Desire to minimize neonatal depression must be balanced against risk of awareness If another agent not given incidence of awareness in direct proportion to I-D interval 50% N2O/O2 alone 12-26% awareness

Awareness catecholamines uterine artery vasoconstriction and oxygen delivery to fetus

General Anesthesia Maternal Awareness

Common Approaches: 50/50 N2O/O2 with 0.5 MAC inhalational agent awareness to <1% Pregnancy anesthetic requirements by 30-40% No adverse affect on neonatal condition No maternal blood loss Discontinue volatile only if there is uterine atony that is unresponsive to oxytocin

General Anesthesia Oxygen

Piggott et al, BJA 1990 100% O2 higher umbilical venous blood pO2 and higher 1 minute Apgar scores, compared to 50% O2 100% O2 higher conc of iso, without maternal awareness or excessive bleeding Supports 100% O2 and higher volatile in cases of fetal distress Lawes et al, BJA 1988 elective c-sxn no difference in neonatal oxygenation or outcome between 33% and 50% O2

Cesarean Section Under Local

Potential indications: patient with severe coagulopathy, known difficult airway and requires emergency c-sxn No anesthesia provider immediately available and severe fetal distress

Can begin surgery and deliver infant Temporary hemostasis achieved until anesthetist arrives, then induce GA to complete the surgery

Cesarean Section Under Local

Need: 1) 2) 3) Midline abdominal incision Minimal use of retractors Do not exteriorize the uterus

Local Infiltration Anesthesia for Cesarean Section

1) 2) 3) Professional support person with patient Infiltration with lidocaine 0.5% (total dose < 500mg) Intracutaneous injection in midline from umbilicus to symphysis pubis 4) Subcutaneous injection 5) Incision down to rectus fascia 6) Rectus fascia blockade 7) Parietal peritoneum infiltration and incision 8) Visceral peritoneum infiltration and incision 9) Paracervical injection 10) Uterine incision and delivery 11) GA with ETT for uterine repair and closure, if needed

Cesarean Section Under Local

Disadvantages: 1) Patient discomfort 2) Potential for systemic toxicity and anesthesia may not be available to assist with resuscitation 3) Requires time 4) Does not provide satisfactory operating conditions for complications, eg. uterine atony, uterine laceration

Once Infant Delivered

Once umbilical cord clamped oxytocin given 10-20 U oxytocin in 1000 mL crystalloid and run at 40-80 mU/min Bolus IV oxytocin may cause maternal hypotension and tachycardia and should be avoided

Once Infant Delivered

If atony does not repond to oxytocin:

Methylergonovine 0.2 mg IM 15-methylprostaglandin F2-alpha 250 ug IM or IMM

Ergots:

Severe hypertension

PGF2:

N+V, diarrhea, fever, tachypnea, tachycardia, hypertension, bronchoconstriction Avoid in asthmatics

Once Infant Delivered

Exteriorize Uterus What to watch for:

Pain Nausea Hemodynamic changes Risk of VAE

Effects of Anesthesia on Fetus and Neonate

No significant difference in umbilical cord blood gas between general or regional anesthesia for elective or emergency c-sxn Goals: Effective LUD Ensure adequate maternal oxygenation Avoid maternal hyperventilation Avoid excessive doses of anesthetic agents Treat hypotension promptly

Effects of Anesthesia on Fetus and Neonate

Crawford found uterine incision to delivery (U-D) interval is more important than I-D interval A U-D interval >3 mins associated with incidence of low umbilical cord blood pH and Apgar scores, regardless of anesthetic technique