ANAESTHESIA AND INTENSIVE CARE MEDICINE --:- 1 2016 Published by Elsevier Ltd.
Please cite this article in press as: Davison R, Cockerham R, General anaesthesia for operative obstetrics, Anaesthesia and intensive care medicine
(2016), http://dx.doi.org/10.1016/j.mpaic.2016.05.003
OBSTETRIC ANAESTHESIA
Table 1
Preoxygenation, to an end tidal oxygen fraction 0.9 is pressure can increase intubation difficulty and in this event
essential prior to induction. This should be achieved by tidal should be gently released.
breathing through a circle system with tight-fitting facemask and Thiopentone (5e7 mg/kg) remains the most popular induc-
a fresh gas flow rate of 10 litres/minute. Recent computer tion agent in obstetrics despite a survey showing that 55% of UK
modelling indicates that 2 minutes of pre-oxygenation is suffi- anaesthetists rarely use thiopentone outside of obstetrics. NAP5
cient in a term pregnant patient.3 In pregnancy, reduced FRC and noted that thiopentone, used in 3% of anaesthetic inductions,
increased oxygen requirement result in quicker onset of desatu- was implicated in 23% of awareness reports. Concerns regarding
ration during apnoea with time to SaO2 less than 90% being propofol included its slower onset, short distribution half-life,
reduced by approximately 35%; labour, obesity and sepsis reduced titratability and cardiovascular depression.7 However,
shorten this time further.4 Nasal Oxygenation During Efforts evidence of increased awareness with thiopentone and
Securing A Tube (NODESAT) uses high flow (15 litres/minute) increasing familiarity with propofol support its use as a standard
oxygen via nasal cannula to fill the pharynx with oxygen during induction agent for GA in caesarean section in non-compromised
apnoea and has been shown to decrease time to desaturation.5 patients.6 A dose of 2.5 mg/kg is sufficient to prevent maternal
The efficacy of cricoid pressure is controversial, with correct awareness but is associated with hypotension. In a hypovolaemic
application often being more difficult than expected.6 An initial patient, alternatives include co-induction with a reduced dose of
force of 10 N should be applied prior to induction of anaesthesia, propofol and an opioid or ketamine (1e2 mg/kg). The sympa-
increased to 30 N after loss of consciousness and maintained thomimetic effects of ketamine make it unsuitable for women
until correct placement of the endotracheal tube is confirmed. with pre-eclampsia or cardiovascular disease.
Table tilt must be appreciated when applying cricoid pressure in Opioid analgesia has tended to be avoided until clamping of
order to provide reliable midline oesophageal compression and the umbilical cord due to concerns regarding reduced placental
not distort the laryngoscopic view. The National Institute for flow secondary to maternal hypotension, and respiratory
Health and Care Excellence (NICE) recommend the use of cricoid depression in the neonate due to transfer of drug. However, in
pressure and recent videolaryngoscopic studies have shown it is patients with pre-eclampsia or cardiac disease, opioids provide
effective for oesophageal occlusion.6 Poorly applied cricoid haemodynamic stability and protection from increases in MAP
ANAESTHESIA AND INTENSIVE CARE MEDICINE --:- 2 2016 Published by Elsevier Ltd.
Please cite this article in press as: Davison R, Cockerham R, General anaesthesia for operative obstetrics, Anaesthesia and intensive care medicine
(2016), http://dx.doi.org/10.1016/j.mpaic.2016.05.003
OBSTETRIC ANAESTHESIA
and ICP at intubation. Additionally, omission of opioids is a risk difference in terms of major maternal or neonatal outcomes.9
factor for awareness.8 Short-acting opioids (e.g. alfentanil and Overall, the effects of general anaesthetic agents should be
remifentanil) are recommended in patients in whom marked reversible and the uterine incision to delivery time is the most
haemodynamic fluctuations are dangerous. Opiates in healthy important determinant of neonatal outcome.7
women are more controversial but supported due to their benefit
in reducing awareness;6 however, neonatal resuscitation must be Risks associated with general anaesthesia
immediately available.
Aspiration of gastric contents
Suxamethonium (1e1.5 mg/kg), has traditionally been used
Gastric emptying remains unchanged during pregnancy and the
due its rapid onset, quick offset (thought to be helpful in the
American Society of Anaesthesiologists recommends that elec-
event of failed intubation) and low trans-placental transfer.
tive obstetric patients can consume clear fluids until 2 hours
However, a number of significant side effects have led to alter-
before surgery although they should also receive timely aspira-
natives being sought. Rocuronium use for rapid sequence in-
tion prophylaxis.3 During active labour there may be delayed
duction has increased and at 1e1.5 mg/kg provides excellent
gastric emptying, which may be compounded by parenteral
intubating conditions rapidly. Time to arterial desaturation is
opiate administration. NICE recommends labouring women are
prolonged and and intubating conditions are maintained for
restricted to light diet and clear fluids during labour. For elective
several attempts or emergency airway rescue procedures. In the
procedures The Enhanced Recovery Partnership by NHS Institute
event of requiring rapid reversal of profound neuromuscular
for Innovation & Improvement advocates clear carbohydrate-rich
block, sugammadex (16 mg/kg) given 3 minutes after a 1.2 mg/kg
energy drinks 2 hours prior to operation.
bolus dose of rocuronium can reverse the neuromuscular
A high risk of pulmonary aspiration is reported in the pres-
blockade to a train-of-four ratio of 0.9 within 2 minutes. The
ence of a high gastric volume and low pH (<2.5). Antacids (as
speed of recovery following sugammadex is dependent on both
single agent prophylaxis) are superior to H2-receptor-antagonists
dose and timing interval. Rocuronium does cross the placenta
which, in turn, are superior to proton-pump inhibitors for raising
in a dose-dependent fashion but subsequent consequences for
gastric pH. However, the effect on gastric volume is less
the fetus are unknown. The safety profile of sugammadex is
consistent. Appropriate timing of administration is important and
not yet completely established in parturients and there are
many labouring women at risk of requiring operative interven-
concerns regarding allergic reactions.6
tion are commenced on regular ranitidine (150 mg 6 hourly).
Non-particulate antacids such as 0.3 M sodium citrate should be
Maintenance of anaesthesia
given just prior to induction.
The goals of anaesthetic maintenance are adequate feto-maternal The same risk of aspiration is present at extubation; residual
oxygenation with normocapnia for pregnancy (4e4.2 kPa), neuromuscular blockade must be reversed and emergence from
adequate depth of anaesthesia and minimal effects on both uterine anaesthesia should occur in the left lateral head-down position or
tone and the neonate. Hypotension should be minimized because semi-recumbent. Consideration may also be given to aspiration
the uteroplacental unit has no autoregulation and fetal hypoxia of stomach contents via a wide-bore orogastric tube before
may result. Volatile anaesthetic agents are most commonly used extubation in patients thought to have a full stomach.
but no one agent is superior to another. Minimum alveolar con-
centration (MAC) is reduced in pregnancy by 25e40%, particu-
Awareness
larly if there has been prior labour, but end tidal vapour
Obstetric general anaesthesia accounts for 0.8% of general an-
concentration should be maintained at more than 0.8 MAC to
aesthetics but approximately 10% of the reported cases of acci-
prevent awareness.7 However, a MAC >1 may result in neonatal
dental awareness were in an obstetric population e i.e. over a
depression from transplacental drug transfer and a dose-depen-
ten-fold increase in awareness under GA in obstetrics
dent reduction in uterine tone and contractility.6 Nitrous oxide
compared to other surgical specialities. NAP5 reports the esti-
may be added to reduce the amount of volatile agent required to
mated incidence of awareness under GA for caesarean section at
prevent awareness whilst limiting the effect on uterine tone.
1 in 670, significantly greater than the estimated 1 in 19,000 for
TCI propofol with remifentanil infusion has also been
general anaesthesia as a whole.8
described for induction and maintenance and may be used where
Risk factors for awareness include:
volatile based anaesthesia is contraindicated. The infusions will
rapid sequence induction
need to be titrated to effect and Bispectral Index (BIS) monitoring
use of thiopentone
can be used to observe depth of anaesthesia.
use of muscle relaxants
Postoperative analgesia should be multimodal using intrave-
omission of opioids
nous patient controlled analgesia in conjunction with regular oral
difficult airway management
paracetamol and non-steroidal anti-inflammatory drugs
obesity
(assuming no contraindication). The use of local anaesthetics,
emergency surgery
including transversus abdominis plane (TAP) block, can be
out of hours surgery
helpful.
short interval between induction and skin incision.
GA in obstetrics involves most of the above risk factors with
Caesarean section
an increased cardiac output promoting redistribution of induc-
GA for caesarean section is associated with higher blood loss tion agents and slower establishment of an adequate concentra-
than regional anaesthesia (RA) but there is no significant tion of volatile agent. The over pressure technique of volatile
ANAESTHESIA AND INTENSIVE CARE MEDICINE --:- 3 2016 Published by Elsevier Ltd.
Please cite this article in press as: Davison R, Cockerham R, General anaesthesia for operative obstetrics, Anaesthesia and intensive care medicine
(2016), http://dx.doi.org/10.1016/j.mpaic.2016.05.003
OBSTETRIC ANAESTHESIA
administration (using high initial vaporizer setting to rapidly magnesium sulphate (2 g), lidocaine, labetalol and esmolol are
raise alveolar concentration) after induction should be employed. all suitable agents according to the anaesthetists preference. A
Co-administration with nitrous oxide increases the alveolar par- hypertensive response to extubation must also be anticipated and
tial pressure of volatile agent through the second gas effect. can best be modified with b-blockers. Magnesium administration
Concerns regarding placental transfer and the tocolytic effects of prolongs the effects of non-depolarizing muscle relaxants and
volatile agents may limit the dose administered, but the com- monitoring of neuromuscular block is therefore essential.
plications of fetal exposure to anaesthetics are reversible and the
uterus maintains responsiveness to oxytocin up to 1e1.5 MAC.7 The future
Adequate induction and maintenance doses should be used and,
It is recognized that exposure to GA in obstetrics is diminishing.
if needed, vasopressors (phenylephrine, ephedrine) to treat hy-
Simulation-based training has been shown to improve anaes-
potension either as bolus doses or infusion. NICE recommends
thetists real-life performance and should be encouraged, espe-
use of depth of anaesthesia monitoring.
cially the rehearsal of failed intubation drills. Anaesthetic
Failed intubation technique must be appropriate to the individual patients clinical
The incidence of failed intubation in obstetrics is around 1 in 250 situation and the experience of the anaesthetist. There is
general anaesthetics or 1 in 25,000 deliveries. Weight gain and increasing evidence to support safety and efficacy of alternative
airway oedema in pregnancy make airway management more techniques in obstetric anaesthetic practice other than a tradi-
challenging which may be exacerbated by pre-eclampsia. The tional RSI. A
incidence of Mallampati class 4 airways increases by 34% be-
tween 12 and 38 weeks gestation and continues to increase
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ANAESTHESIA AND INTENSIVE CARE MEDICINE --:- 4 2016 Published by Elsevier Ltd.
Please cite this article in press as: Davison R, Cockerham R, General anaesthesia for operative obstetrics, Anaesthesia and intensive care medicine
(2016), http://dx.doi.org/10.1016/j.mpaic.2016.05.003