m







 

Michelle Gros, FRCPC
Feb 13, 2008
 


 


Cesarean section rate in Canada in 2005 was 23.7% (CIH)

Cesarean section rate in US now exceeds 24%

Incidence of anesthesia-
anesthesia-related maternal mortality is declining

Anesthesia remains responsible for ~ 3-

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
 


 


Review of anesthetic technique used for all c-

c-sections
performed at Brigham and Women¶s hospital between
1990 and 1995

GA ï from 7.2% in 1990 to 3.6% in 1995

Are we getting enough experience in GA¶s for c-

c-
sections?
 m


 
m




 


Minimize drugs prior to delivery of infant

If necessary, midazolam 0.5 ± 1 mg or fentanyl 25
25--50 ug
IV
Small doses ± minimal fetal and neonatal depression
Disadvantage of benzos ± ?
Anticholinergics ± decreases secretions
u Atropine ± crosses placenta - [ FHR and ï variability
u Glycopyrrolate ± does not cross placenta
Aspiration prophylaxis
 m


 
m




 


CJA 2006; 53(1): 79-

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

m


 
m




 

Prior to regional ± 15
15--20 mL/kg RL or NS
30 mins prior
Rout et al. 1993 ± incidence of hypotension ï from 71%
to 55% if prehydrated
Message:
u Additional means are necessary
u In urgent situation ± not necessary to wait for fluid bolus
ï hypotension ± means improved uteroplacental
perfusion
?crystalloid vs. colloid
m


 
m




 

CJA 2000; 47: 607-

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
m


 
m




 

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
m


 
m




 

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
m


 
m




 

Disadvantages to Colloid?

u Expensive

u Anaphylactoid reactions

u Coagulation effects
m


 
m




 

Is type, amount, timing of fluids that important?

Also consider:

u Effective LUD - 15r often not enough

u Aggressive use of vasopressors

u Low dose spinal anesthesia

m


 
m




 


m 
Avoid aortocaval compression

Results in ï uteroplacental perfusion by 3

mechanisms:

1) ï venous return ï C.O. and BP

2) Obstruction of uterine venous drainage [¶s uterine venous

pressure and ï uterine artery perfusion pressure

3) Compression of aorta or common iliac arteries ï uterine

artery perfusion pressure
m


 
m




  


Standard monitors

+/
+/-- art, CVP

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


 

 

  ? Support person

  ? Oxygen
 Y


 

 
 

  For elective c-
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
short--term by using very
high FiO2

  BUT, possibility of reperfusion injury with free

radicals
m


  

   

m

m patients should receive aspiration prophylaxis,
regardless of planned anesthetic for c-
c-section

Large survey from Sweden

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


 m
 
 m
   

1) Non
Non--particulate antacid eg. 0.3 M sodium citrate

2) H2
H2--receptor antagonist
1) [ gastric pH, BUT does NOT alter pH of existing gastric
contents
2) Rout et al 1993±
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)
m


 m
 
 m
   

3) Proton pump inhibitor eg. losec

1) ï gastric acidity
2) One study found it less effective than ranitidine

4) Metoclopramide
1) Accelerates gastric emptying
2) ? Reliability of emptying stomach before c-
c-sxn
3) [ lower esophageal sphincter tone
4) Antiemetic effect
m


  

   

 

In obstetric patients - ï in SBP > 25% OR, any SBP <
100 mmHg

Measures of prevention:
1) Fluids
2) LUD
3) Prophylactic vasopressors (ephedrine, phenylephrine)
m


  

   

 

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

u No difference for prevention and treatment of maternal

hypotension

u Maternal bradycardia more likely to occur with phenylephrine

than with ephedrine

u No difference in the incidence of fetal acidosis (umbilical artery

pH < 7.2)
m


  

   

 

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


  

   

 

Varying reports of efficacy of prophylactic ephedrine

Some advocate 25 ± 50 mg IM before spinal, or 5

5--10
mg IV immediately after intrathecal injection

Chestnut ± don¶t give prophylactic ephedrine unless pt

has a low baseline BP (ie. SBP <105 mmHg before
spinal)
 m


  

   




1) Failed spinal
  ~ 1% of cases
 m


  

   




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


  

   




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

2) Failed epidural
  ~ 2-
2-6% of cases
 m


  

   




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

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


  

   




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

2) Failed epidural
  ~ 2-
2-6% of cases
  Repeat epidural
Watch for local toxicity
Pt impatient
  Spinal
Collection of local ± falsely think this is CSF
High spinal
m


  

   




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



 


Repeat Fetal stress/distress

u Scheduled Deteriorating maternal
u Failed attempt at vaginal medical illness
delivery
u Preeclampsia
Dystocia
u Heart disease
Abnormal presentation
u Pulmonary disease
u Transverse lie
u Breech Hemorrhage
u Multiple gestation u Placenta previa

u Placental abruption
 
 
  

  
 
  

1) Indication for c-
c-sxn
2) Urgency of procedure
3) Health of mother and fetus
4) Desires of mother
  

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
  

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


  Popularity increasing

  LA nerve roots (dural cuffs) by absorption

through arachnoid villi that penetrate dura

 
spread of anesthesia is volume dependent

 Ñ

Pros:
Titrated dosing and slower onset ï 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 ³muscle pump´ may remain
intact may ï incidence of thromboembolic
disease
 Ñ


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
 !
 
 Ñ
"Ñ

  Initially described in 1981 (epidural catheter at L1-

L1-2
and spinal at L3-
L3-4)
 !
 
 Ñ
"Ñ

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
 m






 



  

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