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ANAESTHESIA FOR CAESAREAN

SECTION
ROLE OF INTRAUTERINE
RESUSCITATION
Presenter: Dr Neha Gupta
Moderator: Dr Geetanjali

University College of Medical Sciences & GTB


Hospital, Delhi
www.anaesthesia.co.in

email: anaesthesia.co.in@gmail.com

James Young Simpson (1811-1870)

HISTORY
1847 : Introduction of inhalational agents
James Young Simpson on Jan 19, 1847 first used chloroform
to anaesthetize a woman with a deformed pelvis for
delivery.
Early 20th century: Expanded use of opioids
Twilight sleep was a technique developed by Von
steinbuchel. It combined opioids with scopolamine to
make women amnesic during labor .
Mid 20th century (1900-1930): Refinement of regional
anaesthesia

INTRODUCTION
Until 19th Century: Performed only for the most desperate
situations, with very high mortality rates.
Early 20th Century: Mortality rates 10%, but still performed
only for the most severe cases of contracted pelvis
In India the caesarean rates have increased from 21.8%
in 1988-89 to 25.4% in 1993-94 *

(* Bhasin SK, Rajoura OP, Sharma AK,et al. A high prevalence of caesarean
section rate in East Delhi. Indian J Community Med 2007;32:222-4)

CAESAREAN SECTION

It is defined as the birth of an infant through


incision in the abdomen(laparotomy) and
uterus(hysterotomy).
(derived from the latin word caedere which imply to cut)

INDICATIONS FOR CAESAREAN


SECTION
Absolute
Maternal
Cephalo-pelvic Disproportion
Non progression of labour
Fetal:
Fetal Distress
Non-cephalic presentations
Multiple gestations

Pregnancy Related
Abruptio Placenta
Grade 3 or 4 Placenta Previa
Cervical obstructive lesions
Large vulvar condylomata

Relative
Maternal
Relative CPD
Maternal preference

Fetal:
Twins with first in non

cephalic presentation

Pregnancy Related
Lesser degrees APH
Previous Caesarean

COMPLICATIONS OF CS
Hemorrhage
Uterine atony
Uterine laceration
Broad ligament hematoma
Infection
Endometritis
Wound infection
Post op complications
Cardiovascular: venous thromboembolism
Gastrointestinal: ileus, adhesions, injury
Genitourinary: bladder or ureter injury
Respiratory: atelectasis , aspiration
Chronic pain
Future risk
Placenta previa,placenta accreta, uterine rupture

PAIN PATHWAYS
During Caesarean Section:
Pain due to Incision Pfannensteil / Midline
Pain due to stretching to the skin and

subcutaneous tissues
Intraperitoneal dissection and manipulation
Additional somatic pain due to diaphragmatic
stimulation
Involves dermatomes up to T8 and visceral pain
pathways up to T4 levels
Implications: Aim is to achieve T4 dermatomal

level

ANAESTHESIA FOR CASEAREAN SECTION

Techniques of Anaesthesia:
1. Regional Anaesthesia
Subarachnoid Block
Epidural Anaesthesia
Combined Spinal-Epidural Anaesthesia
2. General anaesthesia
3. Local anaesthesia

Anaesthesia for Caesarean Section


Depends on:

Indication for CS

Urgency of the procedure

Maternal and fetal health

Maternal desires
If time not a factor
RA preferred
Epidural for Labour Analgesia in-situ
Extension of Block
RA contraindicated, or Emergency procedure
GA

Classification of caesarean section


according to urgency
Category 1- requiring IMMEDIATE delivery
-a threat to maternal or fetal life
Category 2- requiring URGENT delivery
-maternal or fetal compromise that is not
immediately life threatening
Category 3- requiring EARLY delivery
-no maternal or fetal compromise
Category 4-ELECTIVE delivery
-at time suited to the woman and maternity
staf

Category 1 sections should be delivered within


15 minutes
Examples of category 1 include1.Major haemorrhage
2.Profound and persistent fetal
bradycardia
3.Prolapsed cord
4.Shoulder dystocia
5.Uterine rupture

REGIONAL ANAESTHESIA
Definitive benefits over GA, including
No risk of aspiration
No risk of failed intubation or ventilation
Less blood loss
Less fetal exposure to drugs
Better neurobehavioral score of fetus at birth
Analgesia can be extended to postoperative

period

SPINAL ANAESTHESIA
SAB most common and preferred technique for CS.

Advantages of SAB
Disadvantages
Simplicity of technique
Limited Duration
Reliability
Rapid onset
Hypotension
Dense neural block
Less shivering Prolonged Motor block
Minimal fetal exposure to drugs Nausea &
Vomiting

EPIDURAL ANAESTHESIA
Advantages
Level Titrable
Slower onset of
sympathetic block
Block height and
Duration Extendable
Less intense motor
block
Post operative
analgesia
Less Chances of DVT

Disadvantages
Slow onset of
anaesthesia
Increased failure rates
Accidental IV injection
Catheter migration
Increased chances of
total / high spinal
Technically difficult

COMBINED SPINAL EPIDURAL


ANAESTHESIA
Rapid and predictable onset of SAB
Ability to augment anaesthesia

CSE TECHNIQUES
1.Use of conventional doses of hyperbaric drugs
2.Sequential CSE technique
3.Extradural volume extension (EVE) technique

COMBINED SPINAL EPIDURAL


ANAESTHESIA
Benefits:
Lower intrathecal dose of LA
Increased success rates for correct epidural

placement
More intense block, less intra operative pain
compared to epidural

Disadvantages:
Untested epidural catheter
Hypotension

GENERAL ANAESTHESIA
Indications:
Maternal refusal
Local site infection
Raised intracranial

tension
Severe Fetal Distress
Acute maternal
hypovolemia
Significant
coagulopathy
Inadequate RA/failed RA

Relative
Contraindications:
Anticipated difficult

airway
Malignant
hyperthermia
Severe asthma

CONSIDERATIONS IN REGIONAL
ANAESTHESIA
Preloading/ co-loading
Anti aspiration prophylaxis
Positioning in RA
Choice of LA
Choice of vasopressors
Epidural test dose
Complications of RA i.e. Nausea and vomiting,

Hypotension, Accidental intravascular injection


or dural tap under Epidural anaesthesia, PDPH,
LA toxicity

PRELOADING /CO-LOADING
Preloading- rapid adminisration of crystalloids (1-

1.5l) prior to initiation of intrathecal injection.


Co-loading- rapid administration of crystalloids(20
ml/kg) initiated at the time of intrathecal injection.
Crystalloids/ colloids
Implication Initiation of anaesthesia should not be
delayed in order to administer a fixed volume of
fluid.

Anti aspiration prophylaxis


Increased risk of
Gastric Aspiration
in pregnancy
- gastric motility
- LES tone
- gastric emptying

time.
- Intragastric
pressure

Antiaspiration Prophylaxis:
Planned CS:
Ranitidine 150 mg and Metoclopramide 10 mg
PO night before and 60-90 minutes before
surgery
Emergency CS :
0.3M Sodium Citrate, 30mL PO 30 Min before
Surgery.
Ranitidine 50 mg IV + Metoclopramide, 10
mg IV prior to surgery.

POSITIONING IN RA
Minimum left lateral tilt of 25
left lateral displacement to be maintained

with a wedge under the right buttock .

1o
cm

2.5
cm

34
cm

POSITIONS FOR RA
Lateral position
better
uteroplacental blood
flow
more comfortable
minimises patient
movement during
needle insertion

Sitting position
Distance from skin
to epidural space is
shorter
Interspinous spaces
difficult to appreciate
Restricted use : i.e.
umbilical cord
prolapse, footling
presentation.

CHOICE OF LOCAL ANAESTHETIC


FOR SAB
Drug

Dosage (mg)

Range (ml)

Duration
(min)

Bupivacaine(H)
(0.5%)

7.5-15

1.5-3

60-120

Ropivacaine

15-25

Lidocaine(H)
(5% )

60-80

60-120
1.2-1.5

45-75

chestnuts obstetric
anaesthesia (4th edition)

Local anaesthetics for epidural


anaesthesia
Drug

Dose range

Duration(min)

Bupivacaine 0.5%

75-125 mg

120-180

Ropivacaine 0.5%

75-125 mg

120-180

Lignocaine 2% with 300-500 mg


epinephrine 5g/ml

75-100

chestnuts obstetric anaesthesia


(4th edition)

DECREASE IN LOCAL ANAESTHETIC


REQUIREMENT DURING PREGNANCY
1. Neural susceptibility to LA
2. Epidural plexus engorgement
3. CSF changes a)CSF protein (unbound drug)
b) CSF pH ( unionised drug)
4. Apex of thoracic kyphosis higher
5.Pelvic widening & resultant head down tilt in lateral
position

Pelvic widening & resultant head down tilt

Adjuvant agents
ADVANTAGES
Improves the quality of intraoperative

anaesthesia
Prolongs the postoperative analgesia
Reduce the dose of LA and thus the side
efects

ADJUVANTS
DRUG

DOSAGE

Range(ml)

Duration(min)

Fentanyl
(5o g/ml)

10-25 g

0.2-0.5

180-240

morphine

0.1-0.25 mg

720-1440

Sufentanyl

2.5-5g

180-240

Midazolam

1-2 mg

Side efects OF OPIOID ADJUVANTS


Pruritis
Delayed respiratory depression
Nausea and vomiting
Urinary retention
Reactivation of varicella zoster

Spinal Needles
Quincke type Spinal Needles

Whitacre type Spinal Needles

CHOICE OF VASOPRESSORS
Ephedrine:
mixed alpha and beta adrenergic receptor agonist
Increase blood pressure without a decrease in uterine

blood flow

DOSE 10 mg prophylaxis
5- 10 mg therapeutic
S/E
Tachyphylaxis
Can lower umbilical cord pH by
1.Readily cross placenta cause fetal tachycardia
2. Stimulate fetal metabolism by direct b-adrenergic efect
maternal tachycardia

Phenylephrine: (first line agent)

alpha-receptor agonist

Equally efective as ephedrine

better umbilical cord pH

better preserves uterine blood flow


Dose : 50- 100 g
S/E - maternal bradycardia

Why phenylephrine?
Does not have beta adrenergic agonist action
thus
No beta adrenergic action in fetus and thus
better maintain fetal metabolism
Least chances of fetal acidosis or hypoxia, as
reflected by better maintained umbilical cord
pH.

EPIDURAL TEST DOSE


Role To check the intrathecal and intravascular

placement of epidural catheter


3 ml LA + 15g Epinephrin (1:200,000)
Response - HR- 30 bpm, SBP 20 mmHg in 45
sec.
Test dose is less specific in labouring patients
Points against routine use
Aspiration of multiorifice catheter is 98% sensitive
Low concentration of LA
Recommended 2 stage safety check is ASPIRATE
and OBSERVE FOR 5 MIN.

RECOMMENDED SAFETY
PROCEDURE BEFORE INJECTION OF
TEST DOSE
Perform aspiration test
In labour- 2 ml of 1.5- 2% LA with out ADR
For C.S 3 ml of 1.5- 2% LA with 15g (1: 200,000)

ADR
In PIH, IUGR, DM or Fetal distress Bupivacaine in 5
ml increments
Test dose failure or Total spinal block Treat promptly
Prince G et al: Obstetric epidural test dose. A reappraisal.
Anaesthesia 1986.

Regional Anaesthesia
Complications
HYPOTENSION :
Def: in SBP of more than 20%-30% from baseline
OR a SBP lower than 100 mm hg.
Prevention :
Left uterine displacement
Prehydration
Prophylaxis with vasopressor
Leg elevation or wrapping
Treatment : i.v fluids
vasopressors

Regional Anaesthesia
Complications
NAUSEA AND VOMITING
CAUSES
1.Hypotension
hypotension
Gut ischemia
hypoperfusion

brain stem

Release of emetogenic
Stimulation of vomiting
Substance
Centre
Vomiting

2.
3.
4.
5.

Increased vagal activity


Surgical stimuli- exteriorisation of uterus
Bleeding
Drugs : ureterotonic agents

Treatment

Prevention of hypotension
Metoclopramide

Ondansetron

Regional Anaesthesia
Complications
Post Dural Puncture Headache
Risk factors:
Age<40
Women
Pregnancy
Use of wider guage and dura cutting spinl needle.
Symptoms:
Frontal / Occipital headache
Positional
Varying severity
Neck Stifness
Ocular or Auditory symptoms
Onset within 48 hours

Regional Anaesthesia
Complications
Pathophysiology
Leakage of CSF

Traction on pain sensitive structures

Treatment:
Early: Psychological support
prevent dehydration
Drugs: NSAIDs, Cafeine, Sumatriptan
Epidural Saline Patch
Epidural Blood Patch-15-20 mL autologous blood
used.

Regional Anaesthesia
Complications
High Spinal Anaesthesia:
Rostral spread of intrathecal dose, or Inadvertent

intrathecal administration of epidural dose


Clinical Features:
Complete motor and sensory palsy,
Hypotension, Bradycardia,
Unconsciousness,
Loss of protective airway reflexes,
respiratory arrest

Treatment: Prompt tracheal intubation and ventilation

with 100% oxygen, maintenance of maternal


circulation

Regional anaesthesia
Complications
ACCIDENTAL DURAL PUNCTURE
Incidence-3% (in obstetric patients)

Steps to be followed in case of accidental dural puncture*


1.Injection of CSF from the epidural syringe back into the
SAS through epidural needle
2.Insertion of epidural catheter into the SAS
3.Injection of NS through intrathecal catheter before
removal
4.Administration of continous intrathecal labour analgesia
5.Leaving the intrathecal catheter in situ for a total of 1220 hours
*Kuczkowski K M et.al. Acta Anaesthesiol scand :2003

Regional Anaesthesia
Complications
LA toxicity:
IV injection of LA.

Bupivacaine most cardiotoxic,


Toxicity enhanced in pregnancy.
Clinical Features: Convulsions, Arrhythmias
Cardiovascular collapse
Treatment for CNS Symptoms-symptomatic
oxygen supplementation ,tracheal
intubation
Prevention Epidural test dose with adrenalin 15g.

ROLE OF INTRALIPID
Role - local anesthetic-induced cardiac arrest that is unresponsive
to standard therapy, in addition to standard cardio-pulmonary
resuscitation
Mechanism: . may serve as a lipid sink, providing a large lipid
phase in the plasma, enabling capture of the local anaesthetic
molecules and making them unavailable to tissues .Dose regime:
Intralipid 20% ,1.5 mL/kg i.v over 1 minute ,followed by 0.25
mL/kg/min,
Repeat bolus every 3-5 minutes up to 3 mL/kg total dose until
circulation is restored
Maximum dose - 8 mL/kg

Case 1
24 yr old, primigravidae, ASA grade I, with
complaints of
Amenorrhea for 9 months
Leaking per vaginum for 2 hours
Pain abdomen for 2 hours
Obstetric history- WNL
GPE WNL
Plan - Emergency LSCS in view of cephalopelvic
dispropotion in labour.

Single shot spinal anaesthesia

PATIENT PREPARATION
Preanaesthetic evaluation history

-clinical examination
Fasting was 8 hours.
Informed consent taken
Inj Ranitidine (50 mg i.v.), Inj metoclopramide(10

mg i.v.) 30 min prior to surgery


Monitoring i.e.ECG, NIBP ,Pulse oximetry.
Coloading : 1.5 l ringer lactate
Positioning : Left lateral Displacement maintained

with a Wedge under right buttock.

Sitting position
25 G quincke needle; in L3-L-4 space ;
10 mg(2 ml) of 0.5%bupivcaine H

T4 level achieved .
Oxygen by face mask to provide an Fio2 0.5 -0.6
No hypotension reported.
Pfannensteil Incision made, baby delivered within 15
min.
Injection oxytocin (5U i.v. f/b 15 U slow i.v. in 500 ml RL)
I/O - No complications.
Post op : level T6

ANAESTHESIA FOR CAESAREAN


SECTION
ROLE OF INTRAUTERINE
RESUSCITATION

MODERATOR: DR GEETANJALI

GENERAL ANAESTHESIA

GA associated mortality
Pulmonary aspiration- 1: 400-500 versus 1:

2000
Failed tracheal intubation 1: 300 versus 1:
2000

CONSIDERATIONS IN GA
Airway assesment
Positioning
Anti-aspiration prophylaxis
Preoxygenation
RSI
Skin incision uterine incision time, Uterine incision

baby delivery time


Uterotonic agents
Exterioratization of uterus
Complications i.e. Awareness,Aspiration,Difficult airway,
altered neonatal outcome, hypotension and others

WHY DIFFICULT AIRWAY?

WHY DIFFICULT AIRWAY?


Risk factor for airway complication in pregnancy
1.Airway edema
2.Weight gain
3.Enlarged breast
4. Full dentition
5. Decreased LES tone
6.Reduced gastric emptying during labour
Rapid desaturation due to Increased oxygen
consumption and reduced FRC.

AIRWAY ASSESSMENT
1.Mallampatti classification
2.Atlanto occipital joint extension
3.Thyromental distance
4. Mandibular protrusion test
Benumofs 11 point sytem for evaluation of
airway

AIRWAY ASSESSMENT
1.Mallampatti classification
2.Atlanto occipital joint extension
3.Thyromental distance
4. Mandibular protrusion test
Benumofs 11 point sytem for evaluation of
airway

CONSIDERATIONS IN GA
Airway assesment
Positioning
Anti-aspiration prophylaxis
Preoxygenation
RSI
Skin incision uterine incision time, Uterine incision

baby delivery time


Uterotonic agents
Exterioratization of uterus
Complications i.e. Awareness, hypotension, Uterine
atony, Blood loss, PONV, Difficult airway.

POSITIONING

RAMP POSITION in
morbidly obese
patients
-ideal position leads to
horizontal alignment
between the external
auditary meatus and
sternal notch
-achieved by use of
blankets or
commercially
available devices

Commercially available RAMP

CONSIDERATIONS IN GA
Airway assessment
Positioning
Anti-aspiration prophylaxis
Preoxygenation
RSI
Skin incision uterine incision time, Uterine incision

baby delivery time


Uterotonic agents
Exterioratization of uterus
Complications i.e. Awareness, Pulmonary aspiration,
Neonatal depression PONV, Difficult airway,
hypotension, Uterine atony, Blood loss,

Conduct of general anaesthesia


Preparation in OT:
Machine check
Difficult Airway cart with short handle laryngoscopes
Oropharyngeal airway
One extra styletted endotracheal tube
Magill forcep
Laryngeal mask airway
Intubating Laryngeal mask airway
Trained assistant to be available
Fiberoptic bronchoscope

Verify that surgeons are ready to begin the surgery

Conduct of General anaesthesia


Preoxygenation
Aim : increase in oxygen content and maximise the time to
desaturation.
1. conventional method : normal tidal volume for 3 minutes
2. 4 vital capacity breaths over 30 seconds(In emergency)
3. 8 vital capacity breaths over one minute.
Rapid Sequence Induction
Thiopental 4-5 mg/kg
Continued application of Cricoid Pressure (10 N when
awake,increase to 30N after loss of consciousness.)
Succinylcholine 1-1.5 mg/kg; wait for 30-40 seconds.

Why Rapid Sequence Induction?

Recommended technique for General

Anaesthesia
ProblemDifficult laryngoscopy and failed
intubation in group of patients who are
already at risk of rapidly developing
hypoxemia

Conduct of Anaesthesia - General


Anaesthesia
Sellicks Manoeuvre:
Dedicated Assistant
20-30 N (2-3 Kg) Force
Directed backwards
Continued till airway
secured and cuf is
inflated

INTRAVENOUS AGENTS
AGENT

F:M

THIOPENTONE

0.4 to 1.1

PROPOFOL

KETAMINE

CLINICAL
IMPLICATIONS

REMARKS

Freely difusible.
Prompt and reliable
induction.
Fetal brain levels <
levels enough to
cause depression
Popular agent of
choice

No analgesic and
amnesic efects.

0.65 to
0.85(bolus
2 to 2.5
mg/kg)
0.50 to
0.54 (inf @
6-9
mg/kg/hr)

FDA category B drug


may attenuate the
response to
laryngoscopy and
intubation
UBF no change

Sedative efect on
neonate
Lower 1 and 5 min
apgar scores (2.8
mg/kg)

1.26( in 1.5
0.5
min)

Used in
in hemodynamic
hypotension
Used
and asthma
instability

Rapidly crosses
placenta

Conduct of Anaesthesia - General


Anaesthesia
Maintenance of Anaesthesia:
GOALS:
1. Adequate maternal and fetal oxygenation
2. Maintain maternal normocapnia (avoid hyperventilation

as it may lead to uteroplacental vasoconstriction)


3. Appropriate depth to avoid awareness , promote
maternal comfort
4. Minimal efect on uterine tone.
5. Minimal adverse efect on neonate.

MONITORING - ASA recommended minimal mandatory


monitors

Pre-delivery: O2:N20 50:50 + 1 MAC Inhalational

agent

Post-delivery:
O2:N2O :: 30:70
Reduction of Inhalation agent(0.5-0.75 MAC)
Morphine 0.1 mg/kg or Fentanyl 1-2 g/kg.
Extubation done when neuromuscular blockade
fully reversed and patient is awake and responds
to command.

I-D TIME AND U-D TIME

Induction delivery(I-D) time - less than 15


minutes
Uterine-delivery (U-D) interval- less than
90 seconds

Implication Abdomen preparation and draping


should be done before induction of
anaesthesia

UTEROTONIC AGENTS
1.Oxytocin infusion
Route : i.v.
Side efects :hypotension ,tachycardia, water
intoxication
Bolus injection Maternal tachycardia &
Hypotension
Dose : 200 Mu/min
2.Methylergometrin
Route :i.m /i.v.
Side efect: Severe Hypertension, bradycardia
Dose : 0.2 mg

3.PGF2 alpha (carboprost)


Route : i.m. /intramyometrial
Side Efects: Nausea, Vomiting, diarrhoea,
Fever, Tachycardia, Hypertension,
Bronchoconstriction
Contraindication: Bronchial Asthma
Dose - 250 g
Max Dose 2gm

EXTERIORISATION OF UTERUS
Increase the incidence of nausea and

vomiting
Cause a tugging sensation
Require a higher level of dermatomal block

Complication of general anaesthesia


AWARENESS AND RECALL
Causes:
1.Avoidance of sedative premedication
2.Deliberate use of low concentration of volatile
anaesthetic agent
3.Use of muscle relaxant
4.Reduction in dose of anesthetic agent during
hypotension
5.The mistaken assumption that high baseline
sympathetic tone is responsible for intraoperative
tachycardia.

Role of Depth of Anaesthesia monitoring i.e. BIS


BIS is an empirically derived EEG parameters
VALIDATED to greater extent
Desired value less than 60
Reduces but can not prevent awareness

episodes

How to avoid:
Lyons and Macdonald* recommend Larger induction dose of barbiturate(thiopental 5-7
mg/kg)
Isoflurane 1% prior to delivery
After delivery: administration of opioid and decrease conc
.of isoflurane

For RA:
Midazolam 0.075 mg/kg provide 30-60 min of anterograde
amnesia in RA

(* Lyons G ,Macdonald R. Awareness during caesarean section.


Anaesthesia 1991)

Complications of general
anaesthesia
ASPIRATION PNEUMONITIS
First Described by Mendelson in 1946.
Chemical injury to tracheobronchial tree and alveoli
caused by inhalation of sterile acidic gastric
contents.
RISK FACTORS:
Gastric Volume > 25mL
Gastric pH < 2.5
Predisposing Factors:
Impaired LES tone
Impaired laryngeal reflexes
Altered gastric motility
Absence of pre-operative fasting

Aspiration Pneumonitis
Pathophysiology:
Aspiration of Acidic Contents

Epithelial Degeneration
Interstitial & Alveolar Oedema
Haemorrhage into alveoli

Destruction of
Pneumocytes

ARDS & Pulmonary oedema

Decreased
Surfactant

Hyaline membrane
Formation
V/Q mismatch

Destruction of
Microvasculature

Increased Pulmonary
Vascular Resistance
Increased Vd/Vt

Aspiration Pneumonitis
Diagnosis
Time of presentation variable First 24 Hours
History of predisposing factors
Wheeze & laboured breathing
Progresses to ARDS and Pulmonary Oedema
CXR Changes with Hypoxemia: Suspect Silent

Aspiration
CXR: B/L flufy interstitial shadows

Aspiration Pneumonitis
Treatment:
Mild Nebulisation, Oxygen Inhalation
Severe Prompt intubation &Tracheal Suctioning
before Positive pressure ventilation
PEEP, CPAP To maintain oxygenation
Mech. Ventilation Low tidal volume (6mL/kg)
and Plateau Pressure <30 cm H20
Fluids : CVP guided
Antibiotics- not efficaceous, can lead to infection
by resistant organisms.
Steroids- not recommended

Prevention - Antiaspiration Prophylaxis:


Planned CS:
Ranitidine 150 mg and Metoclopramide 10 mg
PO night before and 60-90 minutes before
surgery
Emergency CS :
0.3M Sodium Citrate, 30mL PO 30 Min before
Surgery.
Ranitidine 50 mg IV + Metoclopramide, 10
mg IV prior to surgery.

Fasting guidelines (ASA recommendations)


Clear liquids : uncomplicated patients for c.s.
can have clear liquid upto 2 hours before
induction of anaesthesia
Solids :- solid food to be avoided in labouring

patients
- In elective surgery fasting should be
6-8 hours
depending on the fat content

Complications of general
anaesthesia
HYPOTENSION most important cause Induction agents-intravenous

-inhalational
Use of oxytocin
Major Blood loss /PPH

Treatment
using the induction agent in appropriate doses
use of vasopressors as previously discussed
active management of PPH

Complications of general
anaesthesia
UTERINE ATONY
Causes:
High parity
Overdistended uterus
Prolonged labour
Abnormal placentation hypotension

Treatment :
Oxytocin(200mU/ min)
Methylergometrine(0.2 mg i.m.)
Prostaglandin F2 (250 g i.m.)

Complications of general
anaesthesia
POST OP NAUSEA AND VOMITING
Risk factors
Female gender
History of motion sickness
Use of perioperative steroids
Non smoking status

Drugs used for prevention


Drug

Dose

Time

Metoclopramide

10 mg i.v.

Prior to surgery or
after cord
clamping

Ondansetron

4 mg i.v.

After cord
clamping

Granisetron

40mcg/kg i.v.

After cord
clamping

CASE 2

22 yr primigravidae, ASA grade I, planned for


emergency LSCS in view of cord prolapse with
fetal distress
Obstetric history -WNL
GPE : WNL
Airway assessment- Mouth opening adequate

-MPG 2
-Neck movements-normal
-TMD - WNL

Informed consent taken


Inj ranitidine(50 mg i.v.), inj .metoclopramide (10 mg i.v.)
Necessary equipment prepared, monitors attached

preoxygenation with 100% oxygen


Abdomen cleaned and draped side by side
RSI with cricoid pressure,
4mg/kg thiopentone,
confirm ventilation
Succinylcholine 1.5 mg/kg,
Laryngocopic view of glottis (Cormack & Lehane GRADE III)
Failed tracheal intubation(2 attempts with change of
blade, use of styletted ET tube and change of hand)

Management of Failed
Intubation in Pregnant
Patients

Failed
Intubation

Call for help


Ventilate with 100% Oxygen
(1)Facemask with cricoid pressure OR
(2)LMA and cricoid pressure

Assess Ventilation and Oxygenation

Adequate

Assess Fetus

Fetal Distress

Mask with
cricoid
pressure

No Fetal Distress

Surgical Airway

Awaken Patient

Regional

Intubate

Fail

Succeed

Extubate over
Jet Stylet

Fail

Succeed

Rosens Modification of Tunstall Drill


(Failed Intubation Drill)
1.Maintain Cricoid Pressure
Place the patient Left lateral, Head Down.
2.Maintain oxygenation by IPPV with 100% oxygen
If difficult- Try change in position, oropharyngeal airway
or 2 person mask ventilation
3.If airway obstruction persists, Release cricoid pressure.
4. If ventilation & oxygenation easy, ventilate with oxygen, nitrous oxide
And halogenated agent.
Proceed with surgery with face mask ventilation
Allow resumption of spontaneous ventilation
5.Aspirate gastric contents & instil nonparticulate antacid with Orogastric
tube. Withdraw tube while suctioning oropharynx.
6.Level table. Place patient supine. Allow surgery to continue with
Inhalational anaesthesia. Expert paediatrician must be present.

Management of Failed
Intubation in Pregnant
Patients

Failed Intubation
Call for help
Ventilate with 100% Oxygen
(1) Facemask with cricoid pressure OR
(2) LMA and cricoid pressure
Assess Ventilation and Oxygenation
Inadequate

CVCI
Consider Non surgical Airway
(1) LMA with Cricoid Pressure OR
(2) Combitube OR
(3) TTJV

Surgical Airway:
(1) Cricothyrotomy OR
(2) Tracheostomy

Deliver Baby

Parturients die of desaturation


rather than not being able to
intubate

Use of PLMA in obstetrics


1. As a rescue device in cases where

conventional mask ventilation is difficult/


impossible.
2. As a conduit for intubation in case of difficult
intubation.
3. To facilitate fibreoptic intubation with
bronchoscope.
4. Role in Elective casesarean delivery - yet to
be established

Han TH, Briamacombe J et al. The Classic

laryngeal mask airway is effective and


probably safe in selected healthy
parturients for elective caesarean delivery:
A prospective study of 1067 cases. Can J
Anesth 2001.
Conclusion LMA is efective and probably safe for
Casearean section in healthy selected parturients
when managed by experienced LMA user

Halaseh RK, et al. The use of PLMA in

casearean section experience in 3000


cases. Anesth Intensive Care 2010
Conclusion
PLMA
Selected patients
METHOD OF INSERTION
No aspiration
Good alternative to TT

Disadvantages :
1.Placement can induce vomiting, laryngospasm
2.Aspiration of gastric contents is not prevented.
3.Improper positioning can lead to gastric
insufflation
4.Use of PPV may be limited.
5.Multiple insertion attempts may lead to airway
trauma.
However, use of PLMA avoid these disadvantages
to an extent

Intrauterine fetal resuscitation


1. Optimise maternal position
Relieve aortocaval compression
Relieve umbilical cord compression
2. Administer supplemental oxygen
3. Maintain maternal circulation
Rapid administratiom of i.v. fluids
Use of vasopressors to treat hypotension
. In case of uterine tachysystole or hypertonus
Administration of tocolytic
Use of nitroglycerin (50-100 g i.v.) provide uterine
relaxation in 40-45 seconds .

KEY POINTS
During pregnancy LES tone is , gastric motility

- Increased risk of aspiration


The gastrointestinal changes persist 36 hours
post delivery
Role of supplemental oxygen during RA -in non
compromised fetus questionable
Left uterine displacement essential , irrespective
of technique used
Umbilical cord prolapse without fetal distressnot an absolute indication of GA

The combination of aspiration, test dose and

fractionation of dose increases the safety


Cricoid pressure can increase the C/ L grading by 1
End tidal MAC requirement of IAA to be maintained to 1

to prevent maternal awareness and uterine relaxation


While choosing IAA, must consider reduced MAC in

obstetric patients as well as the potential for maternal


awareness and uterine relaxation

REFERENCES
Obstetric Anaesthesia, Principles and Practice,

David H Chestnut, 4th Ed

Millers Anesthesia, 7th Ed


Wylie and Churchill Davidsons A Practice of

Anaesthesia, 7th Ed

Barash & Stolting Anaesthesia


Morgans Anaesthesia.

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anticipated difficult
airway
Accept airway
manipulation

avoid airway
manipulation

labour
v
v

CSE
LEA
CSA

Caesarean delivery

elective

emergenc
y

airway preparation

Awake laryngoscopy
Awake fob intubation

SPINAL
LEA
CSE
CSA

SPINAL
CSE
CSA

Awake tracheostomy

Conduct of Anaesthesia - General


Anaesthesia
Inducing Agents: Thiopentone Sodium, Ketamine,
Propofol.
Thiopentone Sodium:
Most popular. Safe
Prompt and reliable induction
No airway irritability.
Dose: 4-5mg/kg
Crosses placenta.
Peak UV conc. In 1 minute
UA:UV ratio 0.87 at I-D interval 8-22 min
Fetal brain levels < levels enough to cause depression
Disadvantage:
No analgesic and amnesic efects.

Propofol:
Controversial
Rapid smooth induction, rapid awakening.
Dose: 2-2.5mg/kg
F:M ratio at Delivery: 0.7
Neonatal Apgar scores and neurobehavioral scores

lower in propofol group compared to


Thiopentone(Celleno et al)
Greater incidence of maternal hypotension may
attenuate the response to laryngoscopy and
intubation
More expensive, provide vehicle for bacterial growth

Ketamine:
Rapid onset. Has sympathomimetic action.
Better in Asthma and hypovolemia
Provides analgesia, amnesia and hypnosis
Dose 1mg/kg.
100% oxygen can be administered

Disadvantages

Increases laryngoscopy and intubation response,


myocardial depression

Muscle Relaxants:
Succinyl Choline:
Dose-1-1.5mg/Kg
Optimal intubation time of 45 Sec
Minimal placental transfer

Rocuronium:
Dose: 0.6mg/kg (Intubation time 98 sec)

0.9-1.2 mg/kg (48 sec)


Duration of action prolonged: Anticipated
difficult airway

Vecuronium:
Dose:0.1 mg/kg(onset time -144 sec)
Used when scholine is contraindicated