Anesthesia for Operative Caesarean Section Delivery

- Annexes

➡️Annex I: Evidence-to-Decision tables

1. Fasting for Solids Before Elective Cesarean:

Criterion	Judgment
Problem	Aspiration risk during anesthesia.
Benefit	Reduces gastric volume and acidity.
Risk/Harm	Minimal; may cause discomfort if prolonged fasting.
Certainty of Evidence	High (Supported by major anesthesia guidelines from ASA* and Royal College of Anaesthetists (UK), well-conducted observational studies, Clinical guidelines, Some randomized controlled trials; though fewer due to ethical considerations).
Values & Preference	High value on safety; patients may prefer shorter fasting.
Resource Use	No additional cost.
Equity	Standardized across populations.
Acceptability	High among clinicians; variable among patients.
Feasibility	High; easily integrated into pre-op protocols.
Recommendation	Strong recommendation for 6–8 hours of fasting for solids.

2. Uterine Displacement:

Criterion	Judgment
Problem	Aortocaval compression reduces maternal cardiac output.
Benefits	Improves maternal hemodynamics and fetal perfusion.
Risk/Harm	Minimal; may be uncomfortable or logistically challenging.
Certainty of Evidence	Moderate (ASA Guidelines, NICE (UK) guidelines and multiple observational studies)
Values & Preference	High value on fetal safety
Resource Use	No cost; simple intervention.
Equity	Universally applicable
Acceptability	High
Feasibility	High; easily implemented.
Recommendation	Strong recommendation to maintain uterine displacement until delivery.

3. Neuraxial versus GA:

Criterion	Judgment
Problem	GA increases maternal risk and neonatal depression; neuraxial preferred.
Benefit	Improved Apgar scores, reduced maternal mortality, and better pain control.
Risk/Harm	Neuraxial may fail or be contraindicated in emergencies.
Certainty of Evidence	High (ASA, NICE, Cochrane review, ACOG, well-designed cohort studies, systematic reviews, meta-analyses, and high-quality RCTs).
Values & Preferences	High value on maternal safety and neonatal outcomes.
Resource Use	Neuraxial is cost-effective and widely available.
Equity	Promotes safer care across diverse populations.
Acceptability	High among clinicians and patients.
Feasibility	High; standard practice in most settings.
Recommendation	Strong recommendation for neuraxial over GA when feasible.

4. Fluid Preloading or Coloading:

Criterion	Judgment
Problem	Strong recommendation to maintain uterine displacement until delivery.
Benefits	It may reduce the incidence of hypotension.
Risk/Harm	Equivocal benefit; risk of fluid overload in some patients.
Certainty of Evidence	Low (Systematic review and meta-analysis equivocal, RCTs and meta-analyses; inconsistent findings).
Values & Preferences	Moderate value on the prevention of hypotension.
Resource Use	Low cost; widely available.
Equity	Accessible in most settings
Acceptability	High among clinicians.
Feasibility	High; easily integrated into workflow.
Recommendations	Conditional recommendation for preloading or coloading.

5. Use of Phenylephrine for Hypotension in Caesarean Section:

Criterion	Judgment
Problem	Hypotension during neuraxial anesthesia is common and can affect fetal perfusion.
Benefit	More stable maternal BP; improved fetal acid-base status vs. ephedrine.
Risk/Harm	Risk of maternal bradycardia; requires monitoring.
Certainty of Evidence	High (ASA guidelines, International Consensus Statement, Meta-analysis of RCTs).
Values & Preferences	High value on fetal safety and maternal stability.
Resource Use	Readily available; cost-effective.
Equity	Widely accessible.
Acceptability	High among anesthesiologists.
Feasibility	High; easily implemented.
Recommendation	Strong recommendation for phenylephrine as a first-line vasopressor.

6. Vasopressor Use: Phenylephrine vs. Ephedrine:

Criterion	Judgment
Problem	Hypotension affects maternal and fetal outcomes.
Benefits	Phenylephrine improves fetal acid-base status; both drugs restore BP.
Risk/Harm	Phenylephrine may cause bradycardia; ephedrine may worsen fetal acidosis.
Certainty of Evidence	High (ASA guidelines, International Consensus Statement, Meta-analysis of RCTs).
Values & Preferences	High value on fetal safety and maternal stability.
Resource Use	Widely available and inexpensive.
Equity	Standard across institutions.
Acceptability	High among anesthesiologists.
Feasibility	High; routinely used.
Recommendation	Strong recommendation for phenylephrine as a first-line agent.

7. Neuraxial Opioids for Postoperative Analgesia:

Criterion	Judgment
Problem	Postoperative pain affects recovery, bonding, and mobility.
Benefits	Improved analgesia; reduced need for systemic opioids.
Risk/Harm	Risk of pruritus, nausea, and respiratory depression.
Certainty of Evidence	Moderate (high-quality RCTs and systematic reviews/meta-analyses).
Values & Preferences	High value on effective pain control and opioid-sparing strategies.
Resource Use	Cost-effective; widely available.
Equity	Promotes standardized pain management.
Acceptability	High among patients and clinicians.
Feasibility	High; standard practice.
Recommendation	Conditional recommendation for neuraxial opioids post-CS.

8. Use of Pencil-Point Spinal Needles:

Criterion	Judgment
Problem	Postdural puncture headache is a common complication.
Benefit	Significantly reduces headache incidence.
Risk/Harm	None; technique-dependent.
Certainty of Evidence	Moderate (Meta-analysis of RCT, systematic reviews and clinical studies).
Values & Preferences	High value on minimizing complications.
Resource Use	Slightly higher cost; widely available.
Equity	Promotes safer care across settings
Acceptability	High among anesthesiologists.
Feasibility	High; requires training and stocking.
Recommendation	Conditional recommendation for pencil-point needles.

9. Use of Neuraxial Adjuvants (e.g., lidocaine, epinephrine, and fentanyl) for management of Intraoperative Pain During CS:

Criterion	Judgment
Problem/ Intervention	. Inadequate analgesia under neuraxial anesthesia during CS. . Epidural administration of lidocaine ± bicarbonate/epinephrine; lipophilic opioids.
Benefits	Rapid onset of analgesia; avoids conversion to GA; improves maternal comfort.
Risk/Harm	Risk of systemic toxicity, sedation, pruritus, nausea; rare neonatal respiratory depression
Certainty of Evidence	Moderate (Committee on Obstetric Anesthesia, RCTs, systematic reviews, Cohort studies, and clinical trials)
Values & Preferences	High value is placed on avoiding GA and maintaining maternal awareness during delivery.
Resource Use	Low to moderate; agents are generally available and inexpensive.
Equity	High potential to reduce disparities in pain management if protocols are standardized.
Acceptability	High among clinicians and patients when explained clearly.
Feasibility	High in settings with epidural access and trained staff.
Recommendation	Strong recommendation to use neuraxial adjuvants as first-line for breakthrough pain

10. Conversion to GA for management of Intraoperative Pain during CS:

Criterion	Judgment
Problem/ Intervention	- Refractory pain during CS despite adjuvant use. - Conversion to GA.
Benefits	Definitive pain control; avoids psychological trauma.
Risk/Harm	Increased maternal morbidity: aspiration risk, neonatal depression.
Certainty of Evidence	High (Practice Guidelines for Obstetric Anesthesia, Committee on Obstetric Anesthesia, AAGBI Guidelines, randomized trials, high-quality observational studies, and expert consensus).
Values & Preferences	Patients value pain relief and safety; some may prefer to remain conscious.
Resource Use	High; requires GA resources.
Equity	Risk of disparities if patient complaints are dismissed.
Acceptability	Acceptable when indicated and discussed.
Feasibility	Feasible in equipped ORs with trained staff.
Recommendation	Strong recommendation to convert to GA when pain is refractory and the patient accepts.

11. Use of IV Adjuvants (e.g., fentanyl, ketamine, dexmedetomidine) for management of Intraoperative Pain during CS:

Criterion	Judgment
Problem/ Intervention	- Breakthrough pain or anxiety during cesarean delivery under neuraxial anesthesia. - IV administration of short-acting opioids, ketamine, dexmedetomidine.
Benefits	Rapid relief of pain and anxiety; may prevent GA conversion.
Risk/Harm	Sedation, respiratory depression, hallucinations, bradycardia; neonatal effects possible.
Certainty of Evidence	High (based on Committee on Obstetric Anesthesia, ASA Guidelines, randomized controlled trials, systematic reviews)
Values & Preferences	Patients value pain relief and maintaining consciousness; preferences vary.
Resource Use	Moderate; requires monitoring and availability of agents.
Equity	May improve access to pain relief if protocols are inclusive and patient-centered.
Acceptability	Variable: requires clear communication and consent.
Feasibility	Feasible with trained staff and monitoring equipment.
Recommendation	Strong recommendation to use IV adjuvants based on patient needs and context.

Obstetric Emergencies:

12. Airway Emergencies:

Criterion	Judgment
Problem	Failed intubation and airway compromise are major risks in obstetric anesthesia.
Benefits	Difficult airway cart and strategy reduce morbidity and mortality.
Risk/Harm	Minimal; risk if equipment is unavailable or staff untrained.
Certainty of Evidence	High (based on ASA guidelines, guidelines for obstetric anesthesia, Difficult Airway Society and the Obstetric Anaesthetists' Association, expert consensus, and observational studies).
Values & Preferences	High value on maternal safety and airway control.
Resource Use	Moderate; requires stocking and training.
Equity	Promotes safer care across institutions.
Acceptability	High among anesthesiologists.
Feasibility	High; requires protocol and simulation.
Recommendation	Strong recommendation for airway emergency preparedness.

13. Cardiopulmonary Resuscitation (CPR)/Maternal Arrest:

Criterion	Judgment
Problem	Cardiac arrest in pregnancy requires a rapid, specialized response.
Benefits	Uterine displacement and timely cesarean delivery improve maternal and fetal outcomes.
Risk/Harm	Minimal if protocols are followed; delay increases mortality.
Certainty of Evidence	High (ERC guidelines, AHA Guidelines, Consultants and ASA Guideline-based consensus; limited direct obstetric CPR studies).
Values & Preferences	High value on maternal and fetal survival.
Resource Use	Moderate; requires trained teams and equipment.
Equity	Standardizes emergency response across settings.
Acceptability	High among obstetric and anesthesia teams.
Feasibility	High with drills and protocols.
Recommendation	Strong recommendation for pregnancy-specific CPR and timely delivery.

14. Hemorrhagic Emergencies:

Criterion	Judgment
Problem	Obstetric hemorrhage is a leading cause of maternal morbidity and mortality.
Benefits	Rapid access to blood products, cell salvage, and infusion tools improves survival.
Risk/Harm	Minimal if protocols are followed; risk of transfusion reactions or delays if systems are inadequate.
Certainty of Evidence	High (ASA members consensus, WHO Consolidated guidelines + implementation studies)
Values & Preferences	High value on maternal survival and timely intervention.
Resource Use	Moderate; requires blood bank coordination and equipment.
Equity	Improves care in high-risk populations.
Acceptability	High among clinicians.
Feasibility	High with institutional support.
Recommendation	Strong recommendation to maintain hemorrhage response resources.

➡️Annex II: ASA-PS: Obstetric Setting

ASA-PS Classification

Obstetric -Setting

ASA I

ASA II

Normal pregnancy, well controlled gestational hypertension (HTN), controlled preeclampsia without severe features, diet-controlled gestational Diabetes Mellitus (DM).

ASA III

Uncontrolled preeclampsia, gestational DM with complications or high insulin requirements, thrombophilia requiring anticoagulation.

ASA IV

Preeclampsia-complicated by HELP or Organ dysfunction, peripartum cardiomyopathy with EF < 40%, uncorrected/decompensated heart.

ASA V

Uterine rupture

➡️Appendix: Statement on Optimal Goals for Anesthesia Care in Obstetrics

Developed By: Committee on Obstetrics and Anesthesia
Last Amended: October13, 2021 (original approval: October 17, 2007)

Optimal Goals for Anesthesia Care in Obstetrics

Committee of Origin: Obstetrical Anesthesia

This joint statement from the American Society of Anesthesiologists (ASA) and the American College of Obstetricians and Gynecologists (ACOG) has been designed to address issues of concern to both specialties. Good obstetric care requires the availability of qualified personnel and equipment to administer general or neuraxial anesthesia both electively and emergently. The extent and degree to which anesthesia services are available varies widely among hospitals. However, for any hospital providing obstetric care, certain optimal anesthesia goals should be sought. These include:

1. Availability of a licensed practitioner who is credentialed to administer an appropriate anesthetic whenever necessary. For many women, neuraxial anesthesia (epidural, spinal, or combined spinal epidural) will be the most appropriate anesthetic.

2. Availability of a licensed practitioner who is credentialed to maintain support of vital functions in any obstetric emergency.

3. Availability of anesthesia and surgical personnel to permit the start of a cesarean delivery within 30 minutes of deciding to perform the procedure.

4. Because the risks associated with trial of labor after cesarean delivery (TOLAC) and uterine rupture may be unpredictable, the immediate availability of appropriate facilities and personnel (including obstetric anesthesia, nursing personnel, and a physician capable of monitoring labor and performing cesarean delivery, including an emergency cesarean delivery) is optimal. When resources for immediate cesarean delivery are not available, patients considering TOLAC should discuss the hospital's resources and availability of obstetric, anesthetic, pediatric and nursing staff with their obstetric provider¹; patients should be clearly informed of the potential increase in risk and the management alternatives. The definition of immediately available personnel and facilities remains a local decision based on each institution's available resources and geographic location.

5. Appointment of qualified anesthesiologist to be responsible for all anesthetics administered. There are many obstetric units where obstetricians or obstetrician-supervised nurse anesthetists administer labor anesthetics. The administration of general or neuraxial anesthesia requires both medical judgment and technical skills. Thus, a physician with privileges in anesthesiology should be readily available.

Persons administering or supervising obstetric anesthesia should be qualified to manage the infrequent but occasionally life-threatening complications of neuraxial anesthesia such as respiratory and cardiovascular failure, toxic local anesthetic convulsions, or vomiting and aspiration. Mastering and retaining the skills and knowledge necessary to manage these complications require adequate training and frequent application.

To ensure the safest and most effective anesthesia for obstetric patients, the Director of Anesthesia Services, with the approval of the medical staff, should develop and enforce written policies regarding provision of obstetric anesthesia. These include:

1. A qualified physician with obstetric privileges to perform operative vaginal or cesarean delivery should be readily available during administration of anesthesia. Readily available should be defined by each institution within the context of its resources and geographic location. Neuraxial and/or general anesthesia should not be administered until the patient has been examined and the fetal status and progress of labor evaluated by a qualified individual. A physician with obstetric privileges who concurs with the patient's management and has knowledge of the maternal and fetal status and the progress of labor should be responsible for midwifery back up in hospital settings that utilize certified nurse midwives/ certified midwives as obstetric providers.

2. Availability of equipment, facilities, and support personnel equal to that provided in the surgical suite. This should include the availability of a properly equipped and staffed recovery room capable of receiving and caring for all patients recovering from neuraxial or general anesthesia. Birthing facilities, when used for labor services or surgical anesthesia, must be appropriately equipped to provide safe anesthetic care during labor and delivery or postanesthesia recovery care.

3. Personnel, other than the surgical team, should be immediately available to assume responsibility for the depressed newborn. The surgeon and anesthesiologist are responsible for the mother and may not be able to leave her to care for the newborn, even when a neuraxial anesthetic functioning adequately. Individuals qualified to perform neonatal resuscitation should demonstrate:

3.1 Proficiency in rapid and accurate evaluation of the newborn condition, including Apgar scoring.

3.2 Knowledge of the pathogenesis of a depressed newborn (acidosis, drugs, hypovolemia, trauma, anomalies, and infection), as well as specific indications for resuscitation.

3.3 Proficiency in newborn airway management, laryngoscopy, endotracheal intubations, suctioning of airways, artificial vertilation, cardiac massage, and maintenance of thermal stability.

In larger maternity units and those functioning as high-risk centers, 24-hour in-house anesthesia, obstetric and neonatal specialists are usually necessary. Preferably, the obstetric anesthesia services should be directed by an anesthesiologist with special training or experience in obstetric anesthesia. These units will also frequently require the availability of more sophisticated monitoring equipment and specially trained nursing personnel.

A survey jointly sponsored by ASA and ACOG found that many hospitals in the United States have not yet achieved the goals mentioned previously. Deficiencies were most evident in smaller delivery units. Some small delivery units are necessary because of geographic considerations. Currently, approximately 34% of hospitals providing obstetric care have fewer than 500 deliveries per year.² Providing comprehensive care for obstetric patients in these small units is extremely inefficient, not cost-effective and frequently impossible. Thus, the following recommendations are made:

1. Whenever possible, smaller units should consolidate.

2. When geographic factors require the existence of smaller units, these units should be part of a well-established regional perinatal system.

The availability of the appropriate personnel to assist in the management of a variety of obstetric problems is a necessary feature of good obstetric care. The presence of a pediatrician or other trained physician at a high-risk cesarean delivery to care for the newborn or the availability of an anesthesiologist during active labor and delivery when TOLAC is attempted and at a breech or multifetal delivery are examples. Frequently, these physicians spend a considerable amount of time standing by for the possibility that their services may be needed emergently, but may ultimately not be required to perform the tasks for which they are present. Reasonable compensation for these standby services is justifiable and necessary.

A variety of other mechanisms have been suggested to increase the availability and quality of anesthesia services in obstetrics. Improved hospital design, to place labor and delivery suites closer to the operating rooms, would allow for safer and more efficient anesthesia care, including supervision of nurse anesthetists. Anesthesia equipment in the labor and delivery area must be comparable to that in the operating room.

Finally, good interpersonal relations between obstetricians and anesthesiologists are important. Joint meetings between the two departments should be encouraged. Anesthesiologists should recognize the special needs and concerns of the obstetrician and obstetricians should recognize the anesthesiologist as a consultant in the management of pain and life-support measures. Both should recognize the need to provide high quality care for all patients.

➡️References

1. Vaginal birth after previous cesarean delivery. ACOG Practice Bulletin No. 115. American College of Obstetricians and Gynecologists. Obstet Gynecol. 2010;116:450–463.

2. Bucklin BA, Hawkins JL, Anderson JR, et al. Obstetric anesthesia workforce survey: twenty year update. Anesthesiology. 2005;103:645–65