كتاب
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