ANESTHESIA FOR C/S

PREAPARED By: Lielt Dawit

ADVISOR: Bethelhem Girma
 CONTENTS
 Objective
 Introduction
 Definition
 surgical approaches to C/S
 Indication for C/S
 Physiological Changes in pregnancy
 Placental transfer of drugs
 Anesthesia for C/S
 Regional Vs GA
 Difficult airway management
 Prophylactic antibiotics and other drugs
 Post-op care
 Complications of C/S
 Summary
 Reference 2
OBJECTIVES

At the end of this presentation you should be able

to:
 Define and list the types of cesarean section
 List indications of cesarean section
 Describe the physiological changes during
pregnancy
 Explain about Placental transfer of drugs
 Briefly explain the different anesthetic
techniques
 Describe the management of difficult airway
 Explain about post operative pain management
 List the complications of cesarean section
3
INTRODUCTION

 In recent years, the frequency of cesarean

delivery has increased markedly.
 Successful anesthesia for cesarean delivery
can be accomplished in a number of ways.
 Understanding of maternal and fetal
physiology, pathophysiology, and
pharmacology is mandatory.
 The two major anesthetic approaches are
regional and general anesthesia.

4
DEFINITION
 A cesarean section is defined as the delivery
of an infant through incisions in the
abdominal and uterine walls.

 It is often performed when a vaginal delivery

would put the baby's or mother's life or
health at risk.

 Some are also performed upon maternal

request

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SURGICAL APPROACHES TO CESAREAN
SECTION

There are two approaches:

 Midlineor vertical
 Lower segment

Traditional Cesarean section

 The classic Cesarean section (C-section) involves a long,

vertical incision in the midline of the abdomen.

 Is associated with post-surgical complications and is not

commonly used today.
6
7
……CONT’D

The lower uterine segment Cesarean section

(LUCS)

 incision is made just above the pubic

hairline just above the bladder
 It is a horizontal incision
 Complications are minimal
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9
INDICATION FOR CESAREAN SECTION

 Nonreassuring fetal status

 Cephalopelvic disproportion

 Malpresentation

 Prematurity

 Prior cesarean delivery

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 Indications…cont’d

 Prior uterine surgery

 Dystocia

 Fetal distress

 Deteriorating maternal medical illness (Heart

disease, Pulmonary disease, Preeclampsia)

 Placental abruption

 Placenta previa
11
  
PHYSIOLOGICAL CHANGES

 Maternal changes in pregnancy occur as a

result of:

• hormonal alterations
• mechanical effects of the gravid uterus
• Increased metabolic and oxygen requirements

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CARDIOVASCULAR CHANGES
Parameter Change Amount (%)
Heart rate Increased 20–30
Stroke volume Increased 20–50
Cardiac output Increased 30–50
Contractility Variable ±10
Central venous pressure Unchanged -------
Systemic vascular Decreased 20
resistance

Systemic blood pressure Slight decrease Midtrimester 10–15 mm

Hg,
then rises

Pulmonary vascular Decreased 30

resistance

Pulmonary artery Slight decrease ------

pressure 13
CLINICAL IMPLICATIONS
 An increased cardiac output might not be
well tolerated by pregnant women with
valvular heart disease (e.g., aortic or mitral
stenosis) or coronary arterial disease.

 The diastolic blood pressure drops by I0 to 15

mm Hg.

 There is a decrease in mean arterial pressure

because of an associated decrease in
systemic vascular resistance.

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HEMATOLOGICAL
 A rise in total red blood cell mass

 Dilutional anemia is caused by the rise in plasma

volume.

 A modest leukocytosis is observed.

 A normal pregnancy creates a demand for about

1000 mg of additional iron.

 Serum iron falls during pregnancy at the same

time as transferrin and total iron binding capacity
rise.
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CLINICAL IMPLICATIONS

The increased blood volume serves several

important functions:

 ittakes care of the increased circulatory need of

the enlarging uterus as well as the needs of the
fetoplacental unit,

 it fills the ever-increasing venous reservoir,

 itprotects the parturient from the bleeding at

the time of delivery, and

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COAGULATION FACTORS

Factor Change

II Unchanged

VII Increased + + +

VII, IX, X, XII Increased

XI Reduced

Fibrinogen Increased + + +

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 RESPIRATORY SYSTEM
Pulmonary System Change
Minute ventilation Increased 50%
Tidal volume Increased 40%
Breathing frequency Increased 15%
Lung volumes
Expiratory reserve volume Decreased 20%
Residual volume Decreased 20%
Functional residual capacity Decreased 20%
Vital capacity No change
Total lung capacity Decreased 0-5%
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CLINICAL IMPLICATION
 During induction of general anesthesia, PaO2
decreases more rapidly than in a non pregnant
patient (decreased FRC) and increased oxygen
uptake (increased metabolic rate).

 Preoxygenation prior to general anesthesia is

critical for patient safety.

 The increased airway edema makes both ventilation

and endotracheal intubation more difficult and
further increases the potential for complications.

 Nasal intubation should also be avoided

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GASTROINTESTINAL CHANGES
 Gastric pressure is increased by the gravid
uterus.

 Reduce esophageal sphincter tone.

 In addition, gastric emptying is delayed with

the onset of labor or administration of
opioids.

 Increased risk of aspiration

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CLINICAL IMPLICATION

 Pregnant women must be treated as having a

full stomach and an increased risk for
aspiration.

 Routine use of nonparticulate antacids, rapid

sequence induction, cricoids pressure as part
of general anesthesia.

 Pain, anxiety, and opioids administration can

further slow gastric emptying.

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RENAL CHANGES

 Renal blood flow and the glomerular

filtration rate are increased about 50% to 60%

 BUN and serum creatinine concentrations are

decreased about 50%

 There is decreased tubular resorption of both

protein and glucose, and excretion of these
in the urine is common.

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HEPATIC CHANGES
 Liver blood flow does not change significantly with
pregnancy.

 Plasma protein concentrations are reduced during

pregnancy because of dilution,

 Slightly increased liver function tests are common in the

third trimester.

 Plasma cholinesterase (pseudocholinesterase) activity is

decreased about 25%

 Incomplete gallbladder emptying and changes in bile

composition increase the risk of gallbladder disease during
pregnancy.
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CLINICAL IMPLICATION

 The decreased serum albumin levels can

result in increased free blood levels of highly
protein-bound drugs

 Even with lower activity of

pseudocholinesterase , normal dosing of
succinylcholine for intubation (1 to 1.5
mg/kg ) is not associated with prolonged
neuromuscular blockade

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NERVOUS SYSTEM

 Increased sensitivity to both general and

regional anesthetics.

 The MAC is decreased by 25% to 40% for

halothane and isofluran respectively

 A wider dermatomal spread of sensory

anesthesia during epidural anesthesia is due
to an engorged epidural venous plexus and
aortocaval compression.

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CLINICAL IMPLICATION

 Doses of both regional and general

anesthesia should be minimized

26
OTHER CHANGES
Metabolic
 The basal metabolic rate increases slowly over the
course of pregnancy, by 15-20%.

Musculoskeletal
 The hormone relaxin is responsible for both the
generalized ligamentous relaxation and the softening of
collagenous tissues.
 which is the main cause of lordosis during pregnancy.

Mammary Tissue
 Enlargement of the breasts. This can be one of the
reasons that makes intubation difficult in pregnant
women.
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PLACENTAL TRANSFER OF DRUGS

 Drugs cross the placenta mainly by three

Processes
 simple diffusion
 active transport
 Pinocytosis

 The extent of drug transfer is dependent on

numerous factors, including molecular
weight, protein binding, degree of lipid
solubility, maternal drug concentration, and
maternal and fetal pH.

28
 ...cont’d
 Almost all anesthetic drugs crosses the
placenta but the few drugs that do not cross
are the following:-

Anticholinergics
 Glycopylorate

Anticoagulants
 Heparin

Insignificant or very small amount transfer:-

Muscle relaxants
 succinylcholine
 NDMR
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ANESTHESIA FOR CESAREAN SECTION

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CHOICE OF ANESTHESIA
TECHNIQUE
Choice of anesthesia technique depends upon:

• The indication for cesarean section

• Urgency of the procedure

• The health of the mother and the fetus

• The desires of the mother

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PREOPERATIVE ASSESSMENT
 History
 Any medical history
 Previous anesthesia history
 History of medical illness

 physical examination

 Routine laboratory investigations

 Hemoglobin, hematocrit,
 crossed matched blood, platelet count

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REGIONAL ANESTHESIA

Indication

 Maternal desire to witness birth &/or avoid GA

 Risk factors for difficult air way or aspiration

 Presence of comorbid conditions

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 ...cont’d

Advantage
 Minimal risk of aspiration
 Decreased neonatal depression
 Better post operative analgesia and earlier
mobilization
 Awake parturient

Contraindication
 Infection at the site
 Severe hypovolemia
 Patient refusal
 Coagulation abnormalities

34
SPINAL ANESTHESIA

Advantages of spinal anesthesia for cesarean delivery

are:
1. Simplicity of technique
2. Speed of induction (in contrast to an epidural
block)
3. Decreased blood loss
4. Minimal fetal exposure to the drug(s)
5. An awake parturient
6. Minimization of risk of aspiration

 
35
 ...cont’d

Disadvantages of spinal anesthesia for cesarean

delivery :

1. High incidence of hypotension

2. Intrapartum nausea and vomiting
3. Possibility of headaches after dural puncture
4. Total or high spinal
5. Back pain
6. Infection (Meningitis)
7. Limited duration of action (unless a continuous
technique is used)
36
GENERAL PRECAUTIONS BEFORE
GIVING SPINAL ANESTHESIA
 Ensure equipment for general anesthesia or
resuscitation, monitoring and all emergency
drugs are available

 Explain the procedure and reassure the

woman

 Record base line vital signs

 Establish reliable intravenous infusion

37
SPINAL ANESTHESIA TECHNIQUE
 Metoclopramide 10 mg intravenously

 Clear antacid orally

 Large IV access. Give 15-20 ml/kg crystalloid

preload

 Application of monitors

 Lumbar puncture at L3 – L4

 left lateral or sitting position

38
 ...cont’d

 25 to 24 G sprotte needle or 27 to 25 G Whitacre needle

 Bupivacaine 12 mg

 Left uterine displacement

 Supplemental oxygen by face mask or nasal

 Add oxytocin to intravenous fluids

 Aggressive treatment of hypotension

 intravenous fluids , ephedrine and phenylephrine

39
DRUGS USED FOR SPINAL
ANESTHESIA FOR C/S
Drugs Dosage range(mg) Duration(minute)
Lidocaine 60 - 75 45 - 75
Bupivacaine 7.5 - 15 60 - 120
Tetracaine 7.0 – 10.0 120 - 180
Procaine 100 - 150 30 - 60
Adjuvant drugs

Epinephrine 0.1 – 0.2

Morphine 0.1 – 0.25 360 - 1080
Fentanyl 0.010 – 0.025 180 - 240
40
EPIDURAL ANESTHESIA

Advantages:-
 can be used for longer operations and also for
postoperative pain relief
 Avoidance of dural puncture
 Lesser incidence and severity of maternal
hypotension
Disadvantages:-
 Need for larger amounts of local anesthetic
agent
 Slower onset of anesthesia
 complexity of the technique

41
EPIDURAL ANESTHESIA TECHNIQUE

 Metoclopramide 10 mg intravenously
 Large IV access. Give 15-20 ml/kg crystalloid
preload
 Application of monitors
 2% lidocaine with epinephrine, 0.5%
bupivacaine , Continuous-infusion epidural
analgesia with a low concentration of local
anesthetic
 Routine left uterine displacement

42
 ...CONT’D
 Treatment of decreases in maternal blood pressure
with
 ephedrine (5 to 10 mg at a time)
 Phenylephrine (50 to 100 µg)

 Oxygen by face mask

 Add oxytocin to intravenous fluids

 Close monitoring for delayed respiratory depression

if epidural morphine is used.

43
 DRUGS USED FOR EPIDURAL ANESTHESIA
Drug Dosage range(mg) Duration(minute)

Lidocaine2% with 300 – 500 75 – 100

epinephrine
Bupivacaine 0.5% 75 – 125 120 – 180

Ropuvacaine 0.5% 75 – 125

2-chloroprocaine 2% 450 – 750 40 – 50

Adjuvant drugs

Morphine 3–4 720 – 1440

Pethidine 50 – 75 240 – 720

Fentanyl 0.05 – 0.10 120 – 240

44
COMBINED SPINAL EPIDURAL
(CSE) TECHNIQUE
Advantages:-
 Speed of onset
 Lesser need for supplementary analgesics,
sedatives, and antiemetics
 Lower incidences of hypotension
 Lower dose of local anesthetics is used

 CSE block appears to combine the reliability

of spinal block and the flexibility of epidural
block. If properly done, the technique may
be associated with all of the advantages as
mentioned above.
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GENERAL ANESTHESIA
 General anesthesia is used for cesarean
delivery, typically when neuraxial anesthesia is
contraindicated or for emergencies because of
its rapid and predictable action.

Indication
 Maternal refusal to regional anesthesia
 Acute hypovolemia
 Significant coagulopathy
 Inadequate regional anesthesia
 Emergency situations (fetal distress) when there is
no time to perform regional anesthesia

46
 ...CONT’D

Advantages:-
 secured airway
 Better hemodynamic control
 A very rapid and reliable onset

Disadvantages:-
 Difficultintubation
 Risk of aspiration
 Awareness under anesthesia
 Neonatal Depression

47
CHOICE OF INDUCTION AGENTS

Goals:

 To preserve maternal blood pressure, cardiac

output and uterine blood flow

 To minimize fetal and neonatal depression

 To insure maternal hypnosis and amnesia

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 SUGGESTED TECHNIQUE
 Administer a nonparticulate antacid.
 metoclopramide or an H2 blocker -> if at high risk for
aspiration or failed intubation
 Apply routine monitors
 including
electrocardiography, pulse oximetry, and
capnography.
 Ensure that suction is functioning and equipment to
correct failed intubation is readily available.

49
...CONT’D
 Position the patient in a manner to achieve left
uterine displacement and optimal airway
position.
 De-nitrogenate with a high flow of oxygen for
3-5 minutes or 4 vital capacity breaths
 Initiate a rapid-sequence induction with
thiopental, 4.0 mg/kg, and succinylcholine,
1.0-1.5 mg/kg.
 Let your assistant apply cricoid pressure and
continue until correct position of the
endotracheal tube is verified and the cuff is
inflated.
50
 ...CONT’D

 In hypotensive crises, ketamine, 1.0-1.5 mg/kg,

should be substituted for thiopental.

 After delivery discontinue or reduce the volatile

anesthetic, and administer an opioid and a
benzodiazepine.

 Add oxytocin to intravenous fluids.

51
...CONT’D
 Insert an orogastric tube before completion
of surgery.
(optional)

 Reverse neuromuscular blockade as

necessary at completion of surgery.

 Extubate when the patient is awake, the

anesthesia is adequately reversed, and the
patient is following commands.
52
DIFFICULT AIRWAY

For anticipated difficult airway

 Regional Anesthesia
 Awake intubation: needs patient cooperation
 Fiber optic laryngoscopy
 Retrograde intubation
 Stylet, bougie

53
STEPS IN DIFFICULT AIRWAY MANAGEMENT
DURING CESAREAN SECTION

54
 ASSESSING THE NEWBORN

Apgar score
score

Sign 0 1 2

Appearance Blue , pale Pink body, Pink all over

Blue extremity

Pulse Absent < 100 / min > 100 / min

Grimace No response Some response Cry, cough

Activity limp Some flexion Active motion

Respiration Absent Slow Strong cry

55
INTERPRETATION OF APGAR
SCORE

56
 MEDICATIONS
 Naloxone:- if maternal opioid medication
 dose 0.1 mg/kg IV, IM

 Sodium bicarbonate:- is used in the case of

persistent acidemia and administration should be
guided by arterial blood gas measurements.
 dose 2 mEq /kg IV

 Epinephrine:- Epinephrine should be used to treat

asystol or persistent bradycardia
(<60beats/minute) despite 30seconds of effective
ventilation and external cardiac massage.
 dose 0.1 to 0.3 ml/kg 1:10,000 solution should be injected
intravenously or by endotracheal tube
57
 PROPHYLACTIC ANTIBIOTICS FOR C/S
Antibiotics in caesarean section have been given
after cord clamping, due to several potential
concerns;

A. exposure of the fetus to antibiotics could lead to

false negative bacterial culture results

B. fetal antibiotic exposure could lead to an increase

infection with antibiotic-resistant organisms, and

C. to avoid the risk of severe fetal compromise in

the rare event of maternal anaphylaxis.
58
 ERGOMETRINE
 It is used to facilitate delivery of the placenta and to
prevent bleeding after delivery
Side effects
 nausea, vomiting, abdominal pain, diarrhea, headache,
dizziness, tinnitus, chest pain, palpitation, bradycardia,
transient hypertension and other cardiac arrhythmias,
dyspnea, rashes, and shock.
Dose:
 IM or IV injection(slowly diluted in 10ml 0.02 at a time)
at a dose of 0.2 – 0.5 mg.
Contraindications:
 eclampsia, preeclampsia or a history of hypertension and
in patients with peripheral vascular disease or heart
disease and retained placenta.
59
OXYTOCIN

Its effects are numerous, the most important

of which is uterine contraction. 
Dose : 20-30IUS infusion in 1000ml N/S or R/L

Side effects
 Hypotension and reflex tachycardia.
 It may prolong the Q-T interval and cause T-
wave flattening.
 Antidiuretic effects in high doses

60
 POST OPERATIVE CARE
 Good postoperative analgesia should be provided for
maternal comfort and mobility and to reduce
undesirable hemodynamic disturbances.

 Analgesia is best obtained using a multimodal

approach combining local anesthetic infiltration,
opioids, and paracetamol.

 Patient controlled analgesia (PCA) has become

common for post operative pain relief following
general anesthesia. Morphine remains the drug of
choice for this purpose.

61
COMPLICATIONS OF CESAREAN SECTION
 Infection.
 Blood loss.
 Nausea, vomiting, and severe headache after the
delivery (related to anesthesia and the abdominal
procedure).
 Bowel problems, such as constipation (ileus).
 Injury to another organ (such as the bladder)
 Maternal death (very rare)
 Adhesions

62
COMPLICATIONS...CONT’D

 Complications of regional anesthesia

 Complications of general anesthesia

 Anaphylaxis

63
 SUMMARY
 Pregnancy causes major physiological changes in the
mother, which affects our anesthetic management.
 Providing safe perioperative care for cesarean
delivery requires a detailed understanding of the
physiologic changes associated with pregnancy with
particular attention to changes in airway,
cardiovascular, respiratory and gastrointestinal
systems.
 when ever we give anesthesia we have to think of
both the mother and the fetus.

64
...CONT’D
 If the anesthetist follows the criteria for the
various anesthetic techniques, an excellent
maternal and fetal outcome should be
expected with either general or regional
anesthesia in the normal parturient.
 Neuraxial anesthesia is preferred to general
anesthesia because it minimizes the risk of
failed intubation, ventilation and aspiration.
 Multimodal approaches are preferable for
post operative analgesia
65
REFERENCES
1. Sanjay Datta(2006),Obstetric Anesthesia Handbook, fourth
edition, Springer science+business media Inc., USA
2. Ronald D. Miller, Manuel C. Padro(2005).Basics of
anesthesia sixth edition, Elsevier Inc., San Francisco,
California
3. Lars I. Eriksson, Lee A. Fleisher, Jeanine P. Wiener-
Kronish, William L. Young, Ronald D.Miller(2009). Miller’s
Anesthesia seventh edition, Churchill Livingstone Elsevier
4. Bruce F. Cullen, Robert K. Stoelting, Michael K. Cahalan,
M. Christine StockPaul G, Barash(2009).Clinical Anesthesia
sixth edition, Lippincott Williams and Wilkins,
Philadelphia
5. G. Edward Morgan, Jr., Maged S. Mikhail, Michael J.
Murray(2007). Clinical Anesthesiology 4th Edition,
McGraw-Hill Companies, Inc., USA
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 Motto

“Safe Anesthesia Safe

Life”

67
Thank You!!

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