Presentation 1 | Caesarean Section | Childbirth

Anaesthesia For Cesarean Delivery

Presentation by : Dr Prabhakar Moderator : Dr Sunita Gupta.

Anaesthesia For Cesarean Delivery

HISTORY

Anaesthesia For Cesarean Delivery
Cesarean Delivery – Birth of an infant through Laparotomy and Hysterotomy. Cesarean technique was commonly associated with the manner Julius caeser (100 BC) was born with continued presence of Caeser’s mother in his life when such operations were invariably fatal . Latin word -- Caedere and sectio both imply to cut.

Anaesthesia For Cesarean Delivery

Indications for Cesarean Delivery

Anaesthesia For Cesarean Delivery Factors contributing to the increasing Cesarean Delivery Rate : Maternal Factors : • Increasing proportion of deliveries in nulliparous women • Delayed childbearing and increasing maternal age • Increasing prevalence of obesity Obstetrics Factors : • Increasing use of labour induction • Fewer vaginal breech deliveries • Fewer instrument vaginal deliveries • Fewer attempts at trail of labour after Caesarean delivery • Increasing availability of Cesarean delivery in developing nations .

.Anaesthesia For Cesarean Delivery Fetal Factors : • Increasing incidence of fetal macrosomia • Increasing incidence of Multiple Gestation • Ex Utero intrapartum treatment (EXIT) procedures Practice environment factors : • Concern for malpractice litigation • Increased use of electronic fetal heart rate monitoring • Concern for pelvic floor injury associated with vaginal birth • Desire for scheduled procedures.

Anaesthesia For Cesarean Delivery Indications for Cesarean Delivery Maternal : • Antepartum or intrapartum hemorrhage • Arrest of labor • Breech presentration • Chorioamnionitis • Deteriorating maternal condition (e.g severe preeclampsia) • Dystocia • Failure of induction of labour • Genital herpes • High order multiple gestation (or twin gestation in which twin A has breech presenatation) • Maternal request • Placenta previa • Placental abruption • Previous myomectomy • Prior classic utyerine incision • Uterine rupture .

Anaesthesia For Cesarean Delivery Fetal : • Breech presentation or other malpresentation • Fetal intolerance of labor • Macrosomia • Nonreassuring fetal status • Prolapsed umbilical cord Obstetricain : • Desire to avoid difficult forceps or vacuum delivery .

Anaesthesia For Cesarean Delivery Morbidity and Mortality .

Anaesthesia For Cesarean Delivery Anaesthetic Complications : Haemorrhage : • Uterine atony • Uterine lacerations • Broad ligament hematoma Infection : • Endometritis • Wound infection Complications of Cesarean Delivery : .

aspiration • Chronic pain Future Pregnancy Risks : • Placenta previa • Placenta accreta • Uterine rupture • Obstetric hysterectomy . injury • Genitourinary : bladder or urethral injury • Respiratoory : Atelecftasis. adhesions.Anaesthesia For Cesarean Delivery Postoperative Complications: • Cardiovascular: Venous thromboembolism • Gastrointestinal : ileus.

Anaesthesia For Cesarean Delivery .

Anaesthesia For Cesarean Delivery Prevention of Cesarian Delivery .

.Anaesthesia For Cesarean Delivery • Neuraxial labour analgesic techniques were thought to increase the cesarean delivery rate. • RCT have indicated that epidural analgesia is not associated with a higher cesarean delivery rate than systemic opioid analgesia .

• Analgesia for External Cephalic Version • Intrauterine resuscitation including pharmacologic uterine relaxation in cases of uterine tachysystole. . including analgesia for trial of labor after cesarean delivery and instrumental vaginal delivery .Anaesthesia For Cesarean Delivery Some Cesarean deliveries may be avoided through the provision of • Adequate labor analgesia.

Anaesthesia For Cesarean Delivery Obstetric management of Nonreassuring Fetal status :  Optimize maternal position:  Administer supplemental oxygen  Maintain maternal circulation : • To avoid or relieve Aortocaval compression • To relieve umbilical cord compression  Discontinue oxytocin  Consider administration of tocolytic agent for treatment of uterine tachysystole or hypertonus. balanced salt solution. • Perform rapid intravenous administration of a non dextrose containing. • Treat hypotension with either ephedrine or phenylephrine .

Anaesthesia For Cesarean Delivery Preparation of Anaesthesia .

heart. and lung examination consistent with ASA guidelines. relevant obstetric history. and baseline blood pressure and heart rate measurements. allergies.Anaesthesia For Cesarean Delivery Preanaesthetic evaluation : • A focused preanaesthetic history and physical examination includes • A review of maternal health and anaesthetic history. . • Performance of airway .

Anaesthesia For Cesarean Delivery Informed consent : .

9. 8. 6.Anaesthesia For Cesarean Delivery Blood Products : Peripartum hemorrhage remains a leading cause of maternal mortality worldwide • Risk factors for peripartum hemorhage are listed 1. 2. 7. 5. 10. 3. Abnormal placentation Advanced maternal age Anticoagulation Bleeding disorder Chorioamnionitis Fetal demise Fetal malpresentation General anaesthesia Increased parity/grand parity Instrumental vaginal delivery . 4.

17. 21. 12. 19. 13.Anaesthesia For Cesarean Delivery 11. 18. 14. 15. polyhyromnios) Uterine leiomyoma . myomectomy) Proilonged labour Retained placenta Toccolytic therapy Trauma (blunt or penetrating) Uterine distention (Macrosomia. Internal trauma (Internal version. Multiple gestation. 22. curettage) Oxytocin augmentation of labor Placental abruption Precip[itous delivery Preeclampsia (Thrombocytopenia. 16. 23. coagulopathy) PROM Previous uterine surgery(Cesarean delivery. 20.

Anaesthesia For Cesarean Delivery Monitoring : • • • • Pulse oximetry ECG Non invasive BP monitoring FHR monitoring (Fetal scalp or buttock ECG) .

Anaesthesia For Cesarean Delivery Equipment and Suggested resources for obstetrics Anaesthesia .

Aspiration Prophylaxis . nonobese. • Thus uncomplicated patient undergoing elective cesarean – may drink modest amount of clear liquids upto 2 hrs before induction . • It has been known that gastric emptyinh half time of 300 ml of water is shorter than that of 50 ml of water in healthy. • A fasting of 6 to 8 hrs is required for solids . • For prophylaxis – H2 receptor antagonist reduces secretion of gastric juice • Metoclopramide is a prokinetic and hasten gastric emptying.Anaesthesia For Cesarean Delivery • Gastric emptying of clear liquids in pregnancy occurs relatively quickly. • Omeprazole achieves higher gastric Ph than ranitidine. non laboring pregnant women .

Anaesthesia For Cesarean Delivery Prophylactic Antibiotics : • Incidence and severity of post cesarean infection especially endometritis is reduced. • Benefits are equal when given before abdominal incision or immediately after umbilical cord clamping . .

5 L crystalloid is administrered to prevent or reduce the incidence and severity of hypotension • Prehydration with crystalloid does not reliably prevent neuraxial anaesthesia induced hypotension • Supplemental medication for anxiety .Anaesthesia For Cesarean Delivery Other preparations before cesarean surgery are : • Aseptic technique should be used • Intravenous Access and Fluid management • Traditionally 1 to 1.

• This Ramp position is useful especially in sever obese females . • Trendelenburg (Head down position) may augment venous return and reduce hypotension in spinal anaesthesia is questioned. nausea. tachycardia. vomiting and dizziness. • Left lateral tilt of minimum 15 degrees is beneficial . sweating.Anaesthesia For Cesarean Delivery • After 20 wks gestation . • Supine Hupotensive syndrome : manifests as pallor. Positioning : . • The use of slight 10 degrees head up position is beneficial to reduce incidence of hypotension after initiation of hyperbaric spinal anaesthesia. all pregnanat women swhould be positioned with left uterine displacemtn to minimize aortocaval compression .

• An FiO2 of 0. Supplemental oxygenation : .35 to 0.4 does not improve fetal oxygenation.Anaesthesia For Cesarean Delivery • Evidence suggests that use of FiO2 of 0.6 in non laboring women undergoing cesarean section with spinal anaesthesia may improve umbilical venous oxygen content by only 12% .

Anaesthesia For Cesarean Delivery Anaesthetic technique: .

Anaesthesia For Cesarean Delivery Overview of Neuraxial Anaesthetic Techniques .

Anaesthesia For Cesarean Delivery Local Anaesthetic used for Spinal Anaesthesia .

vomiting.Anaesthesia For Cesarean Delivery • Fentanyl : 2.1 to 0. • Diamorphine. sufentanil (2. 6. hypotension and sedation side effects.25mcg improves the quality and duration. Pruritis. improves intraoperative analgesia and decreases shivering. provides 12 to 24 hrs post cesarean delivery analgesia. nausea. • Preservative free morphine : 0. • Spinal clonidine : 60 to 150 mcg .5 to 60 mcg .25 mg .5 to 20 mcg) has been used with bupivacaine in cesarean . Adjuvant Agents .

Anaesthesia For Cesarean Delivery Epidural anaesthesia : .

Anaesthesia For Cesarean Delivery Extension of Epidural labor analgesia .

Anaesthesia For Cesarean Delivery General anaesthesia: .

The most common cause for for this complaint in neuraxial blockade is hypotension (causing hypoperfusion of the brain stem) and not high spinal Other causes are due to blunting of thoracic proprioception .Anaesthesia For Cesarean Delivery Anaesthetic complications:  Awareness and Recall The following factors contribute to the risk of maternal awareness during GA  Dysnoea: Avoidance of sedative premedication Deliberate use of low concentration volatile halogenated dose during hypotension and hemorrhage Presence of partial neuraxial blockade requiring GA conversion.

 Supine stress test was considered positive if  Increase in maternal heart rate more than 10bpm  A decrease in SBP of more than 15mmHg  Signs and symptoms related to supine position in pregnanacy  A decrease in SBP of more than 20 to 30%  A decrease in SBP lower than 100 mmHg . apnoea. acidosis.  Preoperative supine stress test would predict the occurrence of maternal symptoms .  The definition of maternal hypotension is controversial. on mother – unconsciousness pulmonary aspiration.Anaesthesia For Cesarean Delivery  Hypotension :  Common sequela of neuraxial anaesthetic techniques. and cardiac arrest. and neonatal depression .  Consequences of hypotension on fetus – hypoxia.

If impaired phonation . including bradycardia and hypotension.Anaesthesia For Cesarean Delivery High Neuraxial blockade : Not uncommon T2 level involved. respiratory depression . unconsciousness. High blockade can also result in CVS seqelae. Consider GA . ..

.Anaesthesia For Cesarean Delivery  Nausea and vomiting.

Anaesthesia For Cesarean Delivery .

Anaesthesia For Cesarean Delivery Pruritis: .

.Anaesthesia For Cesarean Delivery Thank You .

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