Cap 26

Anesthesia for Cesarean Delivery

HISTORY

Cesarean delivery is defined as the birth of an infant through incisions in the abdomen
(laparotomy) and uterus (hysterotomy). Although the technique is commonly associated
with the birth of the Roman Emperor Julius Caesar, medical historians question this
possibility, given his birth in an era in which such operations were invariably fatal (100 bc)
and the acknowledged presence of Caesar’s mother in his later life.1 Although the term
cesarean section is commonly used, the Latin words caedere and sectio both imply “to cut,”
and modern linguists argue that use of both words is redundant. Consequently, cesarean
delivery is the preferred term.

Morbidity and mortality, most often associated with hemorrhage and infection, limited the
use of cesarean delivery until the 20th century, when advances in aseptic, surgical, and
anesthetic techniques improved the safety for both mother and baby. Today, cesarean
delivery is the most common major surgical procedure performed in the United States,
accounting for more than 30% of all births and 1 million procedures each year.2 Globally,
the incidence of cesarean delivery has progressively increased; however, the rate varies
dramatically by country, ranging from 0.4% to 45.9% (Figure 26-1).3 Maternal, obstetric,
fetal, medicolegal, and social factors are largely responsible for this variability, resulting in
significant differences in cesarean delivery rates even among individual obstetricians and
institutions (Box 26-1).4
INDICATIONS

The common indications for cesarean delivery include dystocia, malpresentation,

nonreassuring fetal status, and previous cesarean delivery (Box 26-2). An elective cesarean
delivery can be performed for obstetric or medical indications or at the request of a
pregnant patient, and it is typically planned and performed prior to the onset of labor.5 A
cesarean delivery performed during labor for a planned vaginal delivery can also occur for
a wide range

of maternal and fetal indications but may need to be conducted in an urgent or emergent
manner. A prior cesarean delivery does not necessitate cesarean delivery in a subsequent
pregnancy. A trial of labor after cesarean (TOLAC), which if successful is called a vaginal birth
after cesarean (VBAC), is an alternative option; the use of TOLAC, once growing in
popularity, has declined in recent years for a variety of reasons (Figure 26-2) (see Chapter
19).
OPERATIVE TECHNIQUE

The technical aspects of performing a cesarean delivery are comparable worldwide, with
minor variations. A midline vertical abdominal incision allows rapid access and greater
surgical exposure; however, the horizontal suprapubic (Pfannenstiel) incision offers better
cosmesis and wound strength. Similarly, a low transverse uterine incision, in comparison
with a vertical incision, allows for a lower incidence of uterine dehiscence or rupture in
subsequent pregnancies, as well as a reduction in the risks of infection, blood loss, and
bowel and omental adhesions. Vertical uterine incisions are most often used in the
following situations: (1) when the lower uterine segment is underdeveloped (before 34
weeks’ gestation), (2) in delivery of a preterm infant in a woman who has not labored, and
(3) in selected patients with multiple gestation and/ or malpresentation. In some cases, a
vertical uterine incision is performed high on the anterior uterine wall (i.e., classic incision),
especially in the patient with a low-lying anterior placenta previa or when a cesarean
hysterectomy is planned. Uterine exteriorization following delivery facilitates visualization
and repair of the uterine incision, particularly when the incision has been extended laterally.
Although the effect of exteriorization on blood loss and febrile morbidity remains
controversial,6 higher rates of intraoperative nausea, emesis, and venous air embolism as
well as postoperative pain have been observed.7,8

MORBIDITY AND MORTALITY

Complications of cesarean delivery include hemorrhage, infection, thromboembolism,

ureteral and bladder injury, abdominal pain, uterine rupture in subsequent pregnancies,
and death (Box 26-3).9 Nonelective cesarean delivery is associated with a greater risk for
maternal morbidity than elective cesarean delivery; a 2008 study of all deliveries in Finland
indicated that the rates of severe maternal morbidity were 5.2, 12.1, and 27.2 per 1000
vaginal, elective cesarean, and nonelective cesarean deliveries, respectively.10 Maternal
mortality has decreased during the past 75 years (see Chapter 40). Since 1937, when the
maternal mortality rate for nulliparous women undergoing cesarean delivery in the United
States was 6%, the risk for death associated with the procedure has decreased by a factor
of nearly 1000 owing to the availability of blood transfusions, antibiotics, safer anesthetic
techniques, and critical care units.11 Maternal morbidity and mortality vary widely from
country to country. In most developed nations, the rate of maternal death associated with
all cesarean deliveries remains higher than that associated with vaginal deliveries.3,12 The
risk for maternal death for a planned, elective primary cesarean delivery may not differ from
that associated with a planned vaginal delivery, but performance of cesarean delivery
places the mother at higher risk for morbidity (and perhaps mortality) in subsequent
pregnancies and cesarean deliveries.

Clark et al.12 identified the causes of maternal death in a retrospective study of 1.5 million
deliveries that occurred between 2000 and 2006 within a health care network composed of
primary, secondary, and tertiary care hospitals in 20 states (Table 26-1). Only 15% of
maternal deaths were related to preexisting medical conditions; most deaths occurred in
women classified as being at low risk at the beginning of pregnancy. The investigators
concluded that 17 deaths (18%) could have been prevented by provision of more
appropriate medical care. (Causality was determined by evaluating whether the maternal
death could have been avoided with the use of an alternative route of delivery, with the
assumption that all other details remained the same prior to delivery.) The preventable
deaths were associated with postpartum hemorrhage (8), preeclampsia (5), medication
error (3), and infection (1). Cesarean delivery was determined to be directly responsible for
maternal death in four cases, including hemorrhage from surgical vascular injury in three
cases and sepsis from surgical injury to the bowel in the fourth. Deaths associated with, but
not directly caused by, cesarean delivery were associated with perimortem procedures or
caused by thromboembolic phenomena; of the nine patients who died of thromboembolic
phenomena, none had received peripartum mechanical or pharmacologic
thromboprophylaxis. The investigators concluded that cesarean delivery per se was only
rarely the causative factor in maternal death; in the majority of cases, death was related to
the indication for the cesarean delivery rather than the operative procedure. Nonetheless,
these investigators also concluded that the risk for death caused by cesarean delivery is
approximately 10 times higher than that for vaginal birth and likely could be reduced with
the implementation of universal perioperative thromboprophylaxis (see later discussion).
Neonatal morbidity, in particular respiratory system morbidity (thus potentially resulting in
the anesthesia provider’s involvement in neonatal resuscitation), is greater with elective
cesarean delivery than with vaginal delivery.14 Patterns and rates of neonatal mortality are
similar to those of maternal mortality; the higher neonatal mortality rates observed after
cesarean delivery most likely reflect the conditions that prompt nonelective cesarean
delivery.15

PREVENTION OF CESAREAN DELIVERY

Neuraxial labor analgesia was earlier thought to increase the cesarean delivery rate
compared with nonmedicated labor or other analgesic techniques; however, randomized
controlled trials and sentinel event studies indicate that neuraxial analgesia is not
associated with a higher cesarean delivery rate than systemic opioid analgesia (see Chapter
23).16,17 Moreover, the combined spinal-epidural (CSE) technique for labor analgesia,
despite its association with fetal bradycardia, does not result in an increase in the total
cesarean delivery rate.18,19 Some cesarean deliveries may be avoided through the
provision of (1) adequate labor analgesia, including analgesia for trial of labor after cesarean
delivery and instrumental vaginal delivery; (2) analgesia for external cephalic version (see
Chapter 35); and (3) intrauterine resuscitation, including pharmacologic uterine relaxation
in cases of uterine tachysystole.

Maternal Labor Analgesia The National Institutes of Health consensus statement on

cesarean delivery on maternal request emphatically concluded that “maternal request for
cesarean delivery should not be motivated by unavailability of effective [labor] pain
management.”5 It is of concern that a survey of 1300 hospitals indicated that as recently as
2001, 6% to 12% of hospitals in the United States did not provide any form of labor
analgesia.20 Although the availability of labor analgesia, especially in the form of neuraxial
techniques, has increased during the past three decades,20 there are still institutions,
predominantly smaller ones, where cesarean deliveries are likely performed because of
nonexistent or inadequate labor analgesia. Adequate maternal analgesia and perineal
relaxation are also important for instrumental (forceps, vacuum) vaginal deliveries.
Neuraxial techniques can optimize anesthetic conditions for these obstetric procedures (see
Chapter 23).

External Cephalic Version Singleton breech presentations occur in 3% to 4% of term

pregnancies. The Royal College of Obstetricians and Gynaecologists21 and the American
College of Obstetricians and Gynecologists (ACOG)22 caution against a vaginal breech
delivery, given the increased risk for emergency cesarean delivery and neonatal injury.
External cephalic version (ECV), a procedure by which manual external pressure is applied
to the maternal abdomen to change the fetal presentation from breech to cephalic, remains
a viable option. ECV is usually performed between 36 and 39 weeks’ gestation.

Neuraxial analgesia or anesthesia has been observed to increase the success of an ECV of a
fetus with a breech presentation (see Chapter 35). Two recent, independent meta-analyses
both concluded that the use of neuraxial blockade resulted in a significant improvement in
the ECV success rate.23,24 Both randomized and nonrandomized studies have indicated
that the use of neuraxial blockade improves the overall success rate by 13% to 50%.
Moreover, in these studies, the use of neuraxial blockade did not appear to compromise
maternal and fetal safety, and specifically it did not increase the incidence of fetal
bradycardia, placental abruption, or fetal death.

Intrauterine Resuscitation Evidence of intrapartum fetal compromise (nonreassuring fetal

status) should prompt the obstetric team (including obstetric and anesthesia providers and
nurses) to attempt intrauterine fetal resuscitation (Box 26-4). In cases of uterine
tachysystole, the administration of nitroglycerin (50 to 100 µg intravenously) may provide
rapid onset (40 to 50 seconds) uterine relaxation.25 Higher doses of intravenous
nitroglycerin (200 to 500 µg) have been described for uterine relaxation in other settings
(e.g., internal podalic version, ECV, uterine prolapse)26; to date, a nitroglycerin dose-
response study evaluating uterine tone as well as side effects (e.g., hypotension) has not
been performed. Nitroglycerin may also be administered via other routes (e.g., sublingual,
topical), but the bioavailability associated with the use of these routes is different and highly
variable. For example, three sprays of sublingual nitroglycerin (400 µg/spray) have been
used for uterine tocolysis27; however, the bioavailability of nitroglycerin by this route is
approximately 38%. Nitroglycerin relaxes the uterus through the production of nitric oxide
in uterine smooth muscle.28 Although the use of nitroglycerin has not been uniformly
demonstrated to be superior to placebo for the promotion of uterine relaxation,29 a
number of reports have indicated its value in cases requiring acute tocolysis.30
Nitroglycerin does not provide total relaxation of the cervix because the majority (85%) of
cervical fibers are fibrous in origin.

PREPARATION FOR ANESTHESIA

The anesthetic management of cesarean delivery may depend in part on the obstetric
indications for operative delivery. The anesthesia provider should consider the patient’s
medical, surgical, and obstetric history, the presence or absence of labor, the urgency of
the delivery, and the resources available in preparing for a cesarean delivery.

Preanesthetic Evaluation All women admitted for labor and delivery are potential
candidates for the emergency administration of anesthesia, and an anesthesia provider
ideally should evaluate every woman shortly after admission. Optimally, for high-risk
patients, preanesthesia consultation should occur in the late second or early third trimester,
even if a vaginal delivery is planned. This practice offers the opportunity to provide patients
with information, solicit further consultations, optimize medical conditions, and discuss
plans and preparations for the upcoming delivery.32,33 Early communication among the
members of the multidisciplinary team is encouraged.34 In some cases, the urgent nature
of the situation allows limited time for evaluation before induction of anesthesia and
commencement of surgery; nonetheless, essential information must be obtained and risks
and benefits of alternative anesthetic management decisions should be considered. A
focused preanesthetic history and physical examination includes (1) a review of maternal
health and anesthetic history, relevant obstetric history, allergies, and baseline blood
pressure and heart rate measurements; and (2) performance of an airway, heart, and lung
examination consistent with the American Society of Anesthesiologists (ASA) guidelines
(see Appendix B).34,35

Informed Consent Recognized by the courts as early as the 18th century, the concept of
informed medical consent was defined in 1957 as a requirement that the physician explain
to the patient the “risks, benefits, and alternatives” of a procedure.36 The ethical issues in
obtaining consent from the obstetric patient can be challenging because of the clinical
situations encountered, such as (1) the pain and stress of labor; (2) birth plans (in which the
patient dictates in advance those interventions that are “acceptable” and “not
acceptable”); (3) rapidly changing maternal and fetal status, often requiring emergency
care; and (4) fetal considerations, which may involve consideration of extrauterine viability
and the definition of independent moral status (i.e., the existence of fetal rights equal to
those of the mother). Discussion of this last issue may invoke theological, moral, ethical,
and philosophical arguments (see Chapter 33). Informed consent has the following three
elements: threshold, information, and consent (Box 26-5).

Threshold Elements Threshold elements include the ability of the patient to meet the basic
definition of competence, which refers to the patient’s legal authority to make a decision
about her health care. Although some cognitive functions may be compromised by the
effects of pain, exhaustion, and analgesic drugs,38 evidence suggests that most laboring
women retain the capacity to hear and comprehend information during the consent
process.36

Information Elements The premise that a patient should be informed about the risks of a
planned procedure in a language that she understands is the basis for the information
elements of the consent process. In part, the difficulty with obtaining informed consent for
anesthesia lies in determining the incidence of anesthesia-related morbidity and mortality.
Jenkins and Baker39 surveyed the risks associated with anesthesia and compared them with
risks inherent in daily living to provide contextual comparisons for patients. The
investigators concluded that the perceptions regarding anesthesia risks held by anesthesia
providers, surgeons, and the public are somewhat optimistic and that the consent process
should include a more realistic and comprehensive disclosure. A second difficulty is
determining what risks require disclosure. White and Baldwin40 stated:

Anesthesia is by nature a practical specialty; every procedure [is] performed carrying a

range of risks, which may be minor or major in consequence, common or rare in incidence,
causal or incidental to the harm sustained (if any), convenient or inconvenient in timing,
expected or unexpected, relative or absolute, operator-dependent or any combination of
the above. In addition, there are significant difficulties in communicating risk, caused by
patient perceptions, anaesthetist perceptions and the doctor-patient interaction, and
complicated by the range of communication methods (numerical, verbal, or descriptivE A
survey conducted among obstetric anesthesia providers in the United Kingdom and Ireland
found a consensus that the following neuraxial anesthetic risk factors should be disclosed:
(1) the possibility of intraoperative discomfort and a failed/partial blockade, (2) the
potential need to convert to general anesthesia, (3) the presence of weak legs, (4)
hypotension, and (5) the occurrence of an unintentional dural puncture (with the use of an
epidural technique).41 Backache and urinary retention were considered “optional” for
discussion, and the risk for paraplegia was considered unworthy of mention unless the
patient specifically asked about it.41 Among obstetric patients, the desire for risk disclosure
varies. In a study from Australia, Bethune et al.42 reported a significant range (between 1 :
1 and 1 : 1 billion) in the level of risk for complications of epidural analgesia at which
pregnant women wished to be informed. In a similar study from the United Kingdom in
which the risks associated with general anesthesia were discussed, Jackson et al.43 found
that 50% of pregnant women wished to know all risks that occurred at a frequency of
greater than 1 : 1000. Overall, pregnant women appear to want more rather than less
information regarding the risks of anesthetic interventions.44

Consent Elements In obtaining consent, care must be taken to preserve patient autonomy
by providing information in a noncoercive, nonmanipulative manner (i.e., avoiding a
paternalistic or maternalistic approach). Barkham et al.37 observed that there are occasions
when noncoercive forms of influence may be appropriate and that reasoned argument can
be used to persuade patients of the merits of a particular course of action. For example, a
woman with anatomy consistent with a difficult airway who is requesting general
anesthesia for an elective cesarean delivery may reconsider her choice after rational
persuasion. In many cases, the course of action most appropriate for maternal health is also
beneficial to the fetus. In some cases, however, the best interests of the mother may
conflict with those of the fetus. For example, emergency cesarean delivery with general
anesthesia is often performed primarily for the benefit of the fetus but may involve higher
risk to the mother than a nonemergency procedure performed with neuraxial anesthesia.
This conflict in relative risks and benefits will most likely intensify in the future as
intrauterine fetal surgery becomes more common.

Informed Refusal The National Institute of Clinical Excellence (NICE) is a part of the National
Health Service in the United Kingdom. The NICE guidelines for cesarean delivery state that
“after providing the pregnant woman with evidence-based information and in a manner
that respects the woman’s dignity, privacy, views, and culture whilst taking into
consideration the clinical situation … a competent pregnant woman is entitled to refuse
treatment, even when the treatment would clearly benefit her or her baby’s health. Refusal
of treatment needs to be one of the woman’s options.”45 Although compliance with
maternal requests is the usual course of action, a court-based decision is sometimes made
on behalf of the unborn infant (see Chapter 33). The anesthesia provider is not obliged to
honor a patient’s or obstetrician’s request (e.g., general anesthesia in a morbidly obese
patient with a difficult airway), particularly when it conflicts with the clinician’s experience
and knowledge of acceptable risks and benefits.46 Overall, anesthesia providers are
encouraged to (1) engage in, rather than withhold, a discussion of anesthetic risks; (2)
recognize that their own biases may influence the presentation of risks; (3) understand how
the perception of risks is modified by the situation; and (4) provide contextual explanation
of risks, to help place potential complications in perspective.39 When recognized as an
opportunity to foster a closer patient-physician relationship and greater involvement of the
patient in her care, rather than simply as a tool to avoid litigation, informed consent can
help guide the decision-making associated with anesthesia care.
Blood Products Peripartum hemorrhage remains a leading cause of maternal mortality
worldwide (see Chapters 38 and 40).47 There is little difference in blood loss between an
uncomplicated elective cesarean delivery and an uncomplicated planned vaginal birth48;
however, a cesarean delivery performed during labor is associated with greater blood
loss.49 Risk factors for peripartum hemorrhage are listed in Box 26-6.

Preparation for obstetric hemorrhage includes (1) reviewing the patient’s history for
anemia or risk factors for hemorrhage (e.g., placenta previa, prior uterine surgery, possible
placenta accreta); (2) consulting with the obstetric team regarding the presence of risk
factors;

(3) reviewing reports of ultrasonographic or magnetic

resonance images of placentation; (4) obtaining a blood sample for a type and screen or
crossmatch; (5) contacting the blood bank to ensure the availability of blood products; (6)
obtaining and checking the necessary equipment (blood filters and warmers, infusion
pumps and tubing, compatible fluids and medications, and standard clinical laboratory
collection tubes [to check hemoglobin, platelets, electrolytes, and coagulation factors]); and
(7) consulting with a blood bank pathologist, hematologist, and/or interventional
radiologist in selected cases (Box 26-7). Currently, there is a lack of consensus as to which
patients require a blood type and screen and which patients require a crossmatch.34 The
maternal history (previous transfusion, existence of known red blood cell antibodies) and
anticipated hemorrhagic complications, as well as local institutional policies, should guide
decision-making. In certain high-risk cases (e.g., suspected placenta accreta), blood
products (i.e., 2 to 4 units of packed red blood cells) should be physically present near or in
the operating room before making the surgical incision, if possible. If an interventional
radiologist plans to place prophylactic intravascular balloon occlusion catheters before
surgery, and if neuraxial anesthesia is planned, the

anesthesia provider should place an epidural catheter prior to placement of the balloon
catheters (see later discussion).50
Monitoring Attention should be given to the availability and proper functioning of
equipment and monitors for the provision of anesthesia and the management of potential
complications (e.g., failed intubation, cardiopulmonary arrest).34 Equipment should be
checked on a daily basis and serviced at recommended intervals. The equipment and
facilities available in the labor and delivery operating room suite should be comparable to
those available in the main operating room.34 The ASA standards for basic monitoring apply
to the provision of anesthesia for all patients.51 Within obstetrics, basic monitoring consists
of maternal pulse oximetry, electrocardiogram (ECG), and noninvasive blood pressure
monitoring,* as well as fetal heart rate (FHR) monitoring.

Automated blood pressure monitors that use oscillometric methods indicate lower systolic
and diastolic blood pressures than auscultatory methods between 11% to 22% of the time
in normotensive pregnant women.53 Forearm, wrist, and finger blood pressure monitors
have been developed but have not yet undergone adequate validation. In general, blood
pressure measurements at locations distal to the heart tend to reflect higher systolic and
lower diastolic blood pressures, respectively, relative to central aortic pressure.52 Invasive
hemodynamic monitoring should be considered in women with severe cardiac disease,
refractory hypertension or hypotension, pulmonary edema, or unexplained oliguria. ECG
abnormalities are often observed in late pregnancy and are believed to be due to
hyperdynamic circulation, circulating catecholamines, and/or altered estrogen and
progesterone concentration ratios (see Chapter 2). During cesarean delivery with neuraxial
anesthesia, ECG changes have a reported incidence of 25% to 60%54,55; in this setting,
administration of droperidol, ondansetron, and oxytocin may be associated with
prolongation of the QTc interval,56,57 and oxytocin administration may be associated with
ST-segment depression.58 The significance of these ECG findings as an indicator of cardiac
pathology remains controversial, because only a small minority of parturients experience
myocardial ischemia as measured by elevated serum cardiac troponin levels.59 The
placement of five ECG leads improves the sensitivity of detecting ischemic events;
combining leads II, V4, and V5 resulted in a sensitivity of 96% in detecting ST-segment
changes in a nonobstetric population.60 In a prospective study of 254 healthy women
undergoing cesarean delivery with spinal anesthesia, Shen et al.61 determined the
incidence of first- and second-degree atrioventricular block (3.5% for each), severe
bradycardia (< 50 beats/ min; 6.7%), and multiple premature ventricular contractions
(1.2%). The investigators speculated that a relative increase in parasympathetic activity
occurred as a result of spinal blockade of cardiac sympathetic activity.

Most of the dysrhythmias were transient and resolved spontaneously. Monitors that
process the electroencephalogram to indicate the depth of anesthesia have received only
limited evaluation in women undergoing cesarean delivery.62 Whether routine use of these
monitors can reduce the incidence of intraoperative awareness during general anesthesia
for cesarean delivery is unclear (see later discussion). An indwelling urinary catheter is used
in almost all women undergoing cesarean delivery.63 A urinary catheter helps avoid
overdistention of the bladder during and after surgery. In cases associated with
hypovolemia and/ or oliguria, or anticipated significant blood loss, a collection system that
allows precise measurement of urine volume is helpful. An evaluation of the FHR tracing by
a qualified individual may be useful before and after administration of anesthesia.34
Whether FHR evaluation should be performed before every cesarean delivery is
controversial. The ACOG64 has stated that the decision to monitor the fetus either by
electronic FHR monitoring or by ultrasonography before a scheduled (elective) cesarean
delivery should be individualized, because data are insufficient to determine the value of
FHR monitoring before elective cesarean delivery in patients without risk factors. In
contrast, the National Collaboration Centre for Women’s and Children’s Health in the
United Kingdom has stated that the FHR should be monitored during the initiation of the
neuraxial technique and until the abdominal skin preparation for cesarean delivery has
begun.45 In most cases of emergency cesarean delivery, a previously placed fetal scalp (or
buttock) ECG electrode can be used to monitor the FHR before, during, and after the
initiation of anesthesia. Typically, the fetal scalp electrode is removed when the surgical
drapes are applied to the abdomen, but in some cases the scalp electrode may be left in
place until just before delivery, when the circulating nurse reaches under the drapes to
disconnect the electrode. In cases of emergency cesarean delivery, continuous FHR
monitoring is useful for at least three reasons. First, the FHR abnormality often resolves; in
some cases, the obstetrician will then elect to forgo the performance of a cesarean delivery.
In other cases, the obstetrician may continue with plans to perform a cesarean delivery but
continuous FHR monitoring may facilitate the administration of neuraxial anesthesia. For
example, an improved FHR tracing allows time for extension of adequate epidural
anesthesia or administration of spinal anesthesia. Second, continuous FHR monitoring may
guide management in cases of failed tracheal intubation. If intubation fails and there is no
evidence of fetal compromise, both the anesthesia provider and the obstetrician will have
greater confidence in a decision to awaken the patient and proceed with an alternative
anesthetic technique. By contrast, if there is evidence of ongoing fetal compromise, the
anesthesia provider may decide to provide general anesthesia by means of a face mask or
supraglottic airway (e.g., laryngeal mask airway [LMA]), and the obstetrician may proceed
with cesarean delivery (see Chapter 30). Third, intraoperative FHR monitoring allows the
obstetrician to modify the surgical technique according to the urgency of delivery.

Medication Availability and Storage The drugs used for the provision of general and
neuraxial anesthesia, including vasopressors and emergency medications, should be readily
available. The Joint Commission65 mandates that all medications should be secured.
Currently, only Schedule II controlled substances as classified by the Drug Enforcement
Agency66 need to be secured in a “substantially constructed locked cabinet.”67 Other drugs
and products, including anesthetic medications, should be “reasonably secure” but not
necessarily locked. These drugs include the Schedule III drug thiopental, as well as
succinylcholine and vasopressor agents. The Joint Commission has defined “reasonably
secure” as storage in areas not readily accessible or easily removed by the public. Federal
law requires

that all hospitals receiving Medicare funding adhere to conditions of participation, which
state that “drugs and biologicals must be kept in a secure area, and locked when
appropriate.”67 This rule applies to noncontrolled substances.
Equipment Labor and delivery units may be adjacent to or remote from the operating
rooms. In some facilities, the unit is located on a separate floor but shares a common
operating room facility (used for other surgical procedures), whereas in others it is a
geographically separate, selfcontained unit with its own operating room facilities.
Regardless of location, the equipment, facilities, and support personnel available in the
labor and delivery operating room should be comparable to those available in the main
operating room.34 In addition, personnel and equipment should be available to care for
obstetric patients recovering from major neuraxial or general anesthesia. Resources for the
conduct and support of neuraxial anesthesia and general anesthesia should include those
necessary for the basic delivery of anesthesia and airway management as well as those
required to manage complications (e.g., failed tracheal intubation). The immediate
availability of these resources is particularly important, given the frequency and urgency of
anesthesia care.

Consideration should be given to having some of the equipment and supplies immediately
available in one location or in a cart (e.g., difficult airway cart, massive hemorrhage cart,
malignant hyperthermia box) specifically located on the labor and delivery unit. Equipment
and supplies should be checked on a frequent and regular basis. Securing special-situation
equipment and supplies in a cart with a single-use breakthrough plastic tie helps ensure
that the cart is kept in a fully stocked state.

Aspiration Prophylaxis The patient should be asked about oral intake, although insufficient
evidence exists regarding the relationship between recent ingestion and subsequent
aspiration pneumonitis (see Chapter 29). Gastric emptying of clear liquids during pregnancy
occurs relatively quickly; the residual content of the stomach (as measured by the cross-
sectional area of the gastric antrum 60 minutes after the ingestion of 300 mL of water) does
not appear to be different from baseline fasting levels in either lean or obese nonlaboring
pregnant women.68,69 Moreover, when measured by serial gastric ultrasonographic
examinations and acetaminophen absorption, the gastric emptying half-time of 300 mL of
water is shorter than that of 50 mL of water in healthy, nonlaboring, nonobese pregnant
women (24 ± 6 versus 33 ± 8 minutes, respectively).68 The healthy patient undergoing
elective cesarean delivery may drink modest amounts of clear liquids up to 2 hours before
induction of anesthesia.34 Examples of clear liquids are water, fruit juices without pulp,
carbonated beverages, clear tea, black coffee, and sports drinks. The volume of liquid
ingested is less important than the absence of particulate matter. Patients with additional
risk factors for aspiration (e.g., morbid obesity, diabetes, difficult airway) or laboring
patients at increased risk for cesarean delivery (e.g., nonreassuring FHR pattern) may have
further restrictions of oral intake, determined on a case-by-case basis.34 Ingestion of solid
foods should be avoided in laboring patients and patients undergoing elective surgery (e.g.,
scheduled cesarean delivery or postpartum tubal ligation). A fasting period for solids of 6
to 8 hours, depending on the fat content of the food, has been recommended.34 A
reduction in gastric content acidity and volume is believed to decrease the risk for damage
to the respiratory epithelium if aspiration should occur. Oral administration of a
nonparticulate antacid (0.3 M sodium citrate, pH 8.4) causes the mean gastric pH to
increase to greater than 6 for 1 hour; it does not affect gastric volume.70,71 H2-receptor
antagonists (ranitidine, famotidine), proton pump inhibitors (omeprazole), and
metoclopramide reduce gastric acid secretion and volume but require at least 30 to 40
minutes to exert their effects.72 In a systematic review of interventions used to reduce the
risk for aspiration pneumonitis in women undergoing cesarean delivery, Paranjothy et al.73
found a significant reduction in the risk for gastric pH less than 2.5 with antacids (relative
risk [RR], 0.17; 95% confidence interval [CI], 0.09 to 0.32), H2-receptor antagonists (RR,
0.09; 95% CI, 0.05 to 0.18), and protonpump antagonists (RR, 0.26; 95% CI, 0.14 to 0.46),
compared with no treatment or placebo. The combined use of an antacid and an H2-
receptor antagonist was found to be more effective in reducing pH less than 2.5 than
administration of placebo or an antacid alone.73 Sodium citrate was associated with a
higher incidence and severity of nausea than an H2-receptor antagonist (famotidine).74
Metoclopramide is a promotility agent that hastens gastric emptying, increases lower
esophageal sphincter tone, and decreases nausea and vomiting.75,76 Prior to surgical
procedures, the timely administration of a nonparticulate antacid, an H2-receptor
antagonist, and metoclopramide should be considered, especially for nonelective
procedures.34

Prophylactic Antibiotics With both elective (nonlaboring) and nonelective (laboring)

cesarean deliveries, a 60% decrease in the incidence of endometritis, a 25% to 65% decrease
in the incidence of wound infection, and fewer episodes of fever and urinary tract infections
have been demonstrated after prophylactic antibiotic administration.77 The ACOG78 has
recommended the prophylactic administration of a narrow-spectrum antibiotic, such as a
first-generation cephalosporin, within 1 hour of the start of cesarean delivery. Antibiotics
with efficacy against gram-positive, gramnegative, and some anaerobic bacteria are
commonly used for prophylaxis for cesarean delivery. Appropriate coverage includes
intravenous ampicillin 2 g, cefazolin 1 g, or ceftriaxone 1 g. Appropriate antibiotic coverage
should last for 3 to 4 hours; therefore, ampicillin may be less appropriate owing to a shorter
half-life.78,79 In parturients with a significant allergy to beta-lactam antibiotics (e.g., history
of anaphylaxis, angioedema, respiratory distress, or urticaria), intravenous clindamycin with
gentamicin is a reasonable alternative. Because of the greater volume of distribution, higher
doses of antibiotics should be considered in women with a body mass index (BMI) greater
than 30 kg/m2 or an absolute weight greater than 100 kg.78,80 After administration of
cephazolin 2 g, Pevzner et al.80 observed that the minimum inhibitory tissue concentration
for gramnegative rods was not achieved at the time of skin incision or closure in 20% of
obese women and 33% of morbidly obese women. The optimal timing of antibiotic
administration (before skin incision versus after clamping of the umbilical cord) and the
potential value of more broad-spectrum antibiotics remain controversial. In the past,
prophylactic antibiotics typically have been administered after umbilical cord clamping,
because of concern that fetal antibiotic exposure might mask a nascent infection and/or
increase the likelihood of a neonatal sepsis evaluation. However, in a meta-analysis,
Costantine et al.81 concluded that preincision antibiotic prophylaxis reduces the incidence
of postcesarean endometritis and total maternal infectious morbidity, without evidence of
adverse neonatal effects. Although earlier studies suggested that ampicillin and first-
generation cephalosporins are similar in efficacy to more broad-spectrum agents,77 more
recent trials have suggested that there is benefit associated with extendedspectrum
antibiotic prophylaxis that includes the addition of an agent that covers other organisms
such as Ureaplasma.79,82 Further investigation is necessary to determine whether more
broad-spectrum prophylactic antibiotic coverage improves maternal and fetal outcomes in
mothers with active or presumed infection (e.g., chorioamnionitis).

Aseptic Technique In the early 19th century, Ignác Semmelweis observed that puerperal
fever, known as “childbed fever,” was most likely transmitted when the first stage of labor
was prolonged and multiple individuals performed vaginal examinations with contaminated
hands. Since that time, the practice of hand hygiene has caused a significant reduction in
maternal and neonatal infectious morbidity. Epidural abscess and meningitis have been
reported as complications of neuraxial procedures in obstetric patients (see Chapter 32).
These cases have prompted questions regarding the best antiseptic solution for disinfecting
the skin,83 provider attire, and the appropriate dressing for the neuraxial catheter insertion
site (see Chapters 12 and 32). There is wide variation in aseptic practices. Regrettably, some
anesthesia providers do not wear a face mask, whereas others wear a gown, face mask, and
hat.84 “Rapidsequence spinal” has been described for cases of emergency cesarean
delivery in which the use of draping is omitted and a single-wipe skin preparation is used85;
however, many obstetric anesthesia providers would argue that this practice is unwise.
Subtle changes in circulating immunoglobulin levels induced by pregnancy may affect the
risk associated with exposure to infectious pathogens.86 As a consequence, obstetric
anesthesia providers should always give careful attention to aseptic technique, especially
during performance of a neuraxial technique. Proper sterile technique consists of wearing
a face mask, giving careful attention to hand hygiene, and donning sterile gloves before
initiating neuraxial blockade.87 Attention should also be given to the careful preparation of
anesthetic drugs during administration of either general or neuraxial anesthesia. Although
many local anesthetics have bactericidal properties that appear concentration
dependent,88 propofol and other anesthetic agents can support bacterial growth.89 An
increasing number of institutions are using premixed solutions of local anesthetic and
opioid (prepared under aseptic conditions in a hospital or compounding pharmacy) to limit
breaches in aseptic technique during the administration of neuraxial anesthesia.
Intravenous Access and Fluid Management The establishment of functional intravenous
access is of critical importance to the successful outcome of many clinical situations in
obstetric anesthesia practice. According to the Hagen-Poiseuille equation, the infusion rate
of fluid through a catheter is directly related to the pressure gradient of the fluid and the
fourth power of the catheter’s radius, and inversely related to the viscosity of the fluid and
the catheter’s length. Because the size of the catheter, more than the size of the vein,
dictates the flow rate, the use of a short, large-diameter catheter (e.g., 16- or 18-gauge) is
associated with the best flow.90 In general, a smaller but functional catheter is more
important than a larger catheter that is unreliable or requires frequent manipulation.
Smaller catheters may be acceptable in an emergency; volume and blood resuscitation can
be satisfactorily achieved using 20- and 22-gauge catheters (without evidence of greater
red blood cell destruction) with the use of dilution, pressurization, or both.91 However,
when large-bore peripheral venous access is problematic, especially when large blood loss
is anticipated, or administration of multiple blood products is required, the anesthesia
provider may choose to insert a central venous catheter. Although the administration of
intravenous fluids may decrease the incidence of neuraxial anesthesia–associated
hypotension, initiation of anesthesia should not be delayed to administer a fixed volume of
fluid,34 particularly in the case of an emergency cesarean delivery, in which the life and
health of the mother and the infant are best preserved with timely delivery. Vasopressors
can be used for both prophylaxis and treatment of hypotension. The type of fluid
(crystalloid, colloid) and the volume, rate, and timing of administration are relevant factors
in the prevention and treatment of hypotension.92,93 In most situations, a balanced salt
solution such as lactated Ringer’s solution is acceptable. Blood products are most often
administered with normal saline. Crystalloid or colloid solutions that contain calcium or
glucose should not be administered with blood products, owing to the risks for clotting (due
to reversal of the citrate anticoagulant) and clumping of red blood cells, respectively.
Traditionally, approximately 1 L of crystalloid
solution has been administered intravenously (as “prehydration” or “preload”) to prevent
or reduce the incidence and severity of hypotension during neuraxial anesthesia for
cesarean delivery. However, prehydration, even with large volumes (30 mL/kg), is minimally
effective in preventing neuraxial anesthesia–induced hypotension. Although an initial study
found that administering crystalloid solution at the time of the intrathecal injection (“co-
load”) was more efficacious than prehydration in preventing hypotension,94 later studies
did not support this finding,95 likely because the infusion rate was too slow.93 Colloid,
administered before or at the time of the intrathecal injection, is more effective than
crystalloid for preventing hypotension.96 Colloid administered before the intrathecal
injection (preload) is equally efficacious to administration at the time of injection (co-
load).95 In healthy patients, we rapidly administer approximately 1 L of crystalloid at the
time of initiation of neuraxial anesthesia. For patients at high risk for hypotension or the
consequences of hypotension, colloid may be administered before or at the time of
initiation of neuroblockade.93 Hypotension despite fluid administration is treated with
vasopressors (see later discussion).

Supplemental Medications for Anxiety The administration of benzodiazepines, even low

doses (e.g., midazolam 0.02 mg/kg), may result in amnesia97,98; as a consequence,
benzodiazepines are typically avoided during awake cesarean delivery. However, on
occasion, particularly in women with severe anxiety or undergoing an emergency cesarean
delivery, the use of low doses of intravenous midazolam or an opioid may facilitate
performance of a neuraxial technique, awake tracheal intubation, or the induction of
general anesthesia. Anxiolytics may also assist in mitigating the feelings of distress during
the birthing experience, which may lessen the risk for developing post-traumatic stress
disorder.99 The use of low doses of sedative or anxiolytic agents has minimal to no neonatal
effects. Frölich et al.100 observed no differences in neonatal Apgar scores, neurobehavioral
scores, or oxygen saturation among women who were randomized to receive either
intravenous midazolam (0.02 mg/ kg) and fentanyl (1 µg/kg) or saline before administration
of spinal anesthesia for cesarean delivery.
Positioning After 20 weeks’ gestation, all pregnant women should be positioned with left
uterine displacement to minimize aortocaval compression. The supine hypotension
syndrome, which is caused by compression of the aorta and inferior vena cava by the gravid
uterus, can manifest as pallor, tachycardia, sweating, nausea, hypotension, and
dizziness.101,102 Uteroplacental blood flow is compromised by decreased venous return
and cardiac output, increased uterine venous pressure, and compression of the aorta or
common iliac arteries.103 The full lateral position minimizes aortocaval compression but
does not allow performance of cesarean delivery. In an editorial, Kinsella104 concluded that
15 degrees of left lateral tilt (left uterine displacement) significantly reduces the adverse
hemodynamic consequences of the supine position, although both the aorta and inferior
vena cava may remain partially compressed. However, most anesthesia providers
underestimate the degree of lateral tilt. In a systematic review, Cluver et. al.105 observed
no differences in maternal and early neonatal outcomes among various maternal positions
for cesarean delivery, but acknowledged that the small sample size in their study was a
serious shortcoming that limited the applicability of their observations. They also
acknowledged that the effect of maternal position may vary with different clinical situations
and that aortocaval compression may be more problematic in women with multiple
gestation, fetal macrosomia, or polyhydramnios.105 Anesthesia providers should recognize
that (1) individual susceptibility to aortocaval compression varies,106 (2) visual estimates
of lateral tilt may be in error,107 and (3) in symptomatic women, increasing the extent of
left uterine displacement may be beneficial. Lateral tilt should be used in all women in mid
to late pregnancy after the administration of neuraxial or general anesthesia, with greater
tilt used when feasible if aortocaval compression is suspected as the cause for maternal or
fetal compromise.108 The use of a slight (10 degrees) head-up position may help reduce
the incidence of hypotension after initiation of hyperbaric spinal anesthesia.109 The use of
a more significant head-up position (30 degrees) has been observed to significantly increase
functional residual capacity in parturients compared with the supine position, with the
effect diminishing with increasing BMI.110 In morbidly obese patients receiving general
anesthesia, the 30-degree head-up position may be particularly useful to improve
preoxygenation, denitrogenation, and the view of the glottis during direct laryngoscopy111;
this can be accomplished with blankets or commercially available devices (see Chapters 30
and 50). If blankets are used to create the ramp position, they should be stacked rather than
interlaced, to allow for rapid readjustment of the head and neck position if necessary. Ideal
positioning leads to the horizontal alignment between the external auditory meatus and
the sternal notch; this position (1) aligns the oral, pharyngeal, and tracheal axes (“sniffing
position”) and (2) facilitates insertion of the laryngoscope blade (see Chapter 30).112
Theoretically, the Trendelenburg (head-down) position may augment venous return and
increase cardiac output. The value of this approach in preventing hypotension during
neuraxial anesthesia has been questioned.105 After the initiation of hyperbaric spinal
anesthesia, the Trendelenburg position has been reported to result in more cephalad
spread of anesthesia in one study113 but not in others.114,115 However, this position had
no effect on the incidence of hypotension after administration of hyperbaric spinal
anesthesia.113,115 The optimal patient position for insertion of a neuraxial needle (or
catheter) may depend on clinical circumstances and the preferences and skills of the
anesthesia provider. Whether the use of the lateral or the sitting position is best for routine
initiation of neuraxial anesthesia is controversial.116,117 Advocates of the lateral position
cite a reduction of vagal reflexes, which can result in dizziness, diaphoresis, pallor,
bradycardia, and hypotension.118 Moreover, the lateral position may allow better
uteroplacental blood flow than the sitting position. Using technetium Tc 99m–radiolabeled
isotopes in pregnant women in the third trimester, Suonio et al.119 observed a 23%
reduction in uteroplacental blood flow when pregnant patients moved from the left lateral
recumbent to the sitting position. In contrast, Andrews et al.120 observed a greater
decrease in cardiac output in parturients placed in the left lateral position than in those in
the sitting position during initiation of epidural analgesia. Using substernal Doppler
ultrasonography, Armstrong et al.121 observed that maternal cardiac index, stroke volume
index, heart rate, and systolic blood pressure were higher by approximately 8% in the right
or left lateral positions than in the sitting or supine positions; however, there were no
significant differences among positions in fetal heart rate, pulsatility index, or resistivity
index. Some parturients find the lateral position more comfortable during administration of
neuraxial anesthesia122; this position may also limit side-to-side and front-to-back patient
motion during needle insertion. Moreover, because uterine compression of the vena cava
diverts blood into the epidural venous plexus,123 the use of the lateral position can reduce
hydrostatic pressure and return the engorged epidural venous plexus to its size in the
nonpregnant state.124 Bahar et al.125,126 observed that fewer needle/catheter
replacements occurred for needle- or catheter-induced venous trauma when epidural
procedures were performed in the lateral recumbent head-down position than in either the
sitting or the lateral recumbent horizontal position in both obese and nonobese parturients.
The lateral position may also be of value during epidural needle placement because it
minimizes the prominence of the dural sac. On the other hand, a bulging dural sac might be
preferable during administration of spinal or CSE anesthesia. Magnetic resonance imaging
and computed tomography studies have indicated that the cross-sectional area and the
anteroposterior diameter of the dural sac at the level of the L3-L4, L4-L5, and L5-S1
interspaces are significantly influenced by posture.127 Lumbar cerebrospinal fluid (CSF)
pressure is lower and dural sac cross-sectional area smaller in the recumbent position than
in the upright position.127 Bulging of the lumbar dural sac—particularly in the sitting
position— may decrease the force required to create a dural puncture with a Tuohy epidural
needle, but this possibility is unproven. In a randomized controlled trial, Yun et al.128
observed that the severity and duration of hypotension were greater in women randomly
assigned to receive CSE anesthesia (hyperbaric spinal bupivacaine with fentanyl) in the
sitting position than in those in the lateral position, despite no differences in the level of
sensory blockade. The sitting position may offer some advantages (e.g., physical landmark
recognition in obese parturients, practitioner preference).117 However, anesthesia
providers should be facile with the placement of needles for neuraxial techniques in both
the sitting and lateral positions, because the sitting position should not be used in some
situations (e.g., fetal head entrapment, umbilical cord prolapse, footling breech
presentation).116
Supplemental Oxygen The routine administration of supplemental oxygen during elective
cesarean delivery with neuraxial anesthesia has been a common practice since publication
of the seminal report by Fox and Houle129; their report demonstrated improved
oxygenation, better umbilical cord blood acid-base measurements, and less time to
sustained respiration in the neonate, when mothers undergoing cesarean delivery with
neuraxial anesthesia breathed 100% oxygen instead of air for at least 10 minutes. However,
later evidence suggested that routine oxygen administration may be unnecessary and
ineffective130 and may even be detrimental.131 The use of a fractional inspired
concentration of oxygen (Fio2) of 0.35 to 0.4 (which cannot be obtained by a nasal cannula
or a simple face mask with a flow rate less than 6 L/min132) does not improve fetal
oxygenation during labor or elective cesarean delivery. Although respiratory function can
deteriorate in parturients receiving neuraxial anesthesia,133,134 maternal or fetal
hypoxemia does not normally occur when parturients breathe room air.134 An Fio2 of 0.6
in nonlaboring women undergoing elective cesarean delivery with spinal anesthesia
increases the umbilical venous oxygen content by only 12%; an increase in oxygen content
is not observed when the uterine incision-todelivery (U-D) interval exceeds 180 seconds.135
Supplemental oxygen has both beneficial and detrimental effects. Through normal biologic
processes, oxygen is converted to reactive oxygen species, including free radicals. The
reactive oxygen species cause lipid peroxidation, alteration of cellular enzymatic functions,
and destruction of genetic material136; these adverse effects occur with the restoration of
perfusion after a period of ischemia (i.e., ischemia-reperfusion injury), including
intermittent umbilical cord occlusion and perhaps during uterine contractions.137 Reactive
oxygen species are present during hyperoxia (causing such disorders as neonatal
retinopathy and bronchopulmonary dysplasia) and in the setting of prolonged labor,
oligohydramnios, intermittent umbilical cord compression, and/or fetal
compromise.137,138 Hyperoxia in these settings (i.e., during the period of reperfusion
following ischemia) results in a higher level of lipid peroxidation.131,138 Term (but not
preterm) fetuses may be able to withstand the adverse effects of these reactive oxygen
species through a compensatory increase in antioxidants during labor.139,140
Antioxidants, the defense against reactive oxygen species, consist of enzymatic inactivators
(superoxide dismutase, catalase, peroxidase) and scavengers (ascorbate, glutathione,
transferrin, lactoferrin, ceruloplasmin). The activity of these compensatory mechanisms
and their relationships to gestational age and labor suggest that the highest risk for
ischemia-reperfusion injury occurs in preterm fetuses before the onset of labor.131,140 The
use of a very high Fio2 improves oxygen delivery to hypoxic fetuses for a limited period
(approximately

10 minutes); beyond this time, continued hyperoxia, especially in the setting of restored
perfusion, increases reactive oxygen species, placental vasoconstriction, and fetal acidosis.

A lower Fio2 may be of benefit in some situations. When asphyxiated infants are
immediately resuscitated at birth with air instead of 100% oxygen, better short-term
outcomes have been observed143,144; this finding may be a result of the shift in the
balance between beneficial oxygenation and detrimental free radicals.

In summary no significant improvent in maternalfetal oxygen transfer occurs until very high
levels of maternal Fio2 are used. At these levels, the resulting hyperoxia creates reactive
oxygen species. Preterm fetuses in nonlaboring mothers are the population at highest risk
for hyperoxia-induced injury. Nonetheless, the emergency cesarean delivery of the
compromised fetus should include maternal administration of a high Fio2. The greater
maternal oxygen consumption and reduced fetal oxygen delivery associated with uterine
contractions may exacerbate the fetal compromise; in these situations, supplemental
oxygen may augment fetal oxygenation and, perhaps, reduce the severity of fetal hypoxia.
However, diminishing fetal benefit appears to occur after 10 minutes. All women who are
at risk for requiring general anesthesia for emergency cesarean delivery should receive an
Fio2 of 1.0 after transfer to the operating table. Denitrogenation should always be
performed; if it is not performed, the mother is at risk for hypoxemia during apnea before
intubation, in turn putting the fetus at risk. When general anesthesia is administered in a
patient with fetal compromise, the mother should receive an Fio2 of 1.0 before and
immediately after induction of anesthesia, even though the subsequent increases in
umbilical venous and arterial oxygen content are not dramatic. The value of supplemental
maternal oxygen during elective cesarean delivery of a noncompromised fetus is
questionable. The only reason some obstetric anesthesia providers place nasal cannulae in
patients undergoing elective cesarean delivery with neuraxial anesthesia is to facilitate the
monitoring of expired carbon dioxide (to monitor the parturient’s ventilation).