Anesthesia for Operative Caesarean Section Delivery

These Guidelines deal with the cornerstone steps of anesthetic management of patients undergoing operative Caesarean Section delivery.

1.     Peri-anesthetic Evaluation and Preparation for operative Caesarean delivery

1.1     History, Physical Examination and Lab tests

1.1.1        Conduct a focused Preanesthetic and Obstetric history, physical examination and review of Lab tests before providing anesthesia care for operative Caesarean delivery. (Strong)

1.1.2        Identify the indication for Caesarean Section (CS) and note the urgency of CS (Emergency, Urgent, Scheduled, or Elective). (Strong)

1.1.3        Record blood pressure at admission and assess clinical characteristics and wellbeing of the mother. (Strong).

1.1.4        Assess the Airway preoperatively. (Strong)

1.1.5        When a neuraxial anesthetic is planned, examine the patient’s back. (Strong)

1.1.6    Discuss the Anaesthetic Management including complications of Regional Anaesthesia and Risks of General Anaesthesia (Strong).

 

1.2     Ensure a Group and Save blood sample has gone and ensure an electronic issue of blood is available on the morning of the CS. If there is no electronic issue available blood must be cross matched. (GPS)

1.3     Order individualized platelet count based on a patient’s history (e.g., preeclampsia with severe features), physical examination, and clinical signs. (Strong)

1.4     Fetal heart rate patterns should be monitored by a qualified individual before and after administration of neuraxial analgesia for CS. (Strong)

1.5     Aspiration Prevention (Prophylaxis)

1.5.1        Permit clear liquids up to 2 hours before elective CS. (Strong)

1.5.2        Solid foods should be avoided.  If time permits, a fasting period for solids of 6 - 8 h before elective CS should be planned. (Strong)

1.5.3        All women for CS are to be given antacid for aspiration prophylaxis (nonparticulate Antacids, H2-receptor Antagonists, and/or Metoclopramide). (Strong)

 

2.     Anesthetic care and Requirements for Caesarean Delivery

2.1     Equipment, Facilities, and Support Personnel

2.1.1        Check all the Anesthetic equipment (2 machines and 2 intubation equipment) in main theatre and back up theatre. (Conditional)

2.1.2        Check Resources for the treatment of potential complications . (Strong)

2.1.3    Ensure that you know who your senior cover is and how to contact them. Call for help sooner rather than later and always notify the consultant of a serious labor ward emergency. (GPS)

2.1.4    At the start of each 24-hour emergency shift, ensure the availability of the Anaesthetic drugs, labelled and placed in the Anesthetic fridge. (Strong)

 

2.2     Type of Anesthesia: General, Epidural, Spinal, or Combined Spinal–Epidural Anesthesia

2.2.1        Uterine displacement (usually left displacement) should be maintained until delivery regardless of the anesthetic technique used. (Strong)

2.2.2        The decision to use a particular anesthetic technique for Caesarean delivery should be individualized. (Conditional)

2.2.3        Consider selecting neuraxial techniques in preference to general anesthesia for most Caesarean deliveries. (Strong)

2.2.4        General anesthesia may be the most appropriate choice in some circumstances when a rapid intervention is necessary. (Conditional)

2.3     Intravenous (IV) Fluid Preloading or Coloading with spinal anesthesia

2.3.1        Use IV fluid preloading or coloading to reduce the frequency of maternal hypotension after spinal anesthesia for Caesarean delivery. (Conditional)

2.3.2        Do not delay the initiation of spinal anesthesia in order to administer a fixed volume of IV fluid. (Conditional)

 

2.4     Vasopressors Use (Ephedrine or Phenylephrine) with neuraxial anesthesia

             Use either IV ephedrine or phenylephrine for treating hypotension during neuraxial

             anesthesia. In the absence of maternal bradycardia, consider selecting phenylephrine  

             because of improved fetal acid–base status in uncomplicated pregnancies. (Strong)

2.5     Consider selecting neuraxial opioids rather than intermittent injections of parenteral opioids for postoperative analgesia After neuraxial anesthesia for Caesarean delivery. (Conditional) 

3.     Neuraxial Block for Caesarean Section (Neuraxial Analgesia or Anesthesia in CS)

3.1 Management of thrombocytopenia for neuraxial block in patients with Caesarean Section

3.1.1        A neuraxial block could be performed in an obstetric patient with isolated thrombocytopenia with a platelet count down to 70,000/uL (70 × 10⁹/L) , with no other associated signs of a qualitative defect or an active coagulopathy. (Conditional)

3.1.2        Avoid a neuraxial technique if platelet count is less than 50,000/µL (50 × 10⁹/L). (Conditional)

3.2     Ensure optimal positioning of the mother, either the ideal lateral or ideal sitting position. (Conditional)

3.3     Consider the use of pencil-point spinal needles instead of cutting-bevel spinal needles to reduce the incidence of postdural puncture headache. (Conditional)

3.4     We recommend using the lowest palpable lumbar interspace for lumbar neuraxial procedure. (Strong)

3.5     Ensure that the neuraxial block is adequate to proceed with surgery. A dense motor block, absent cold sensation up to T4, no sharp sensation by applying a gentle pinch in the surgical area are appropriate. (Strong)

4.     Epidural top up for Caesarean Section Delivery

4.1   For urgent Caesarean delivery, an indwelling epidural catheter may be used as an alternative to initiation of spinal or general anesthesia. (Conditional)

4.2   Assess if epidural is well-functioning to be topped up. If yes, proceed to top up. If no, remove and perform spinal anesthesia or general anesthesia. (Conditional)

5.     Thromboprophylaxis

5.1   Thromboprophylaxis should be prescribed at least 4 hours after spinal anesthesia or after  epidural catheter removal if the risk scoring for prophylaxis is triggered. (Conditional)

5.2   The dose for thromboprophylaxis after neuraxial block will be prescribed depending on the mothers booking weight unless there has been significant weight gain (>12 kgs). (Conditional)

6.     Management of Postdural Puncture Headache (PDPH)

6.1  Use conservative treatments for patients with mild PDPH without associated cranial symptoms. (Conditional)

6.2  Epidural blood patch should be offered for patients with moderate and severe PDPH with associated cranial symptoms who are unresponsive to conservative management. (Strong) 

7.     The Use of Adjuvant Medications and Management of Intraoperative Pain During Cesarean Delivery Under Neuraxial Blocks.

7.1   Recommend the use of neuraxial “Adjuvant Medications" (epidural lidocaine, epinephrine,  and lipophilic opioid) as adjuncts to manage the intraoperative pain during CS under neuraxial blocks. (Strong)

7.2   Recommend conversion of neuraxial block to General Anesthesia when pain is refractory to appropriate adjuvants (Strong)

7.3   Use of IV opioids, Ketamine, Dexmedetomidine, Midazolam or Anxiolytics in cases of inadequate analgesia during Caesarean section under neuraxial anesthesia.

7.3.1        Recommend short-acting opioids (e.g., fentanyl, remifentanil) as first-line IV agents (Strong)

7.3.2        Suggest ketamine or dexmedetomidine as a second line for analgesia and anxiolysis when opioids are insufficient (Conditional)

7.3.3        Suggest midazolam or dexmedetomidine for anxiolysis. (Conditional)

7.4   Recommend against the use of volatile agents like sevoflurane without airway protection during Caesarean delivery under neuraxial anesthesia. (Strong)

8.     Post-operative care for Caesarean Section

8.1   WHO sign-out must be done before leaving theatre (Strong)

8.2   Prescribe post-operative analgesia and thromboprophylaxis (if required). (Strong)

8.3   Provide post operative analgesia during Spinal Anaesthetic by opioids (fentanyl and morphine). (Conditional)

8.4   Provide epidural top-up by administration of morphine (1.0 mg) via epidural catheter for post operative analgesia. (Conditional)

8.5   Analgesia following General anaesthesia will require a Patient-controlled Analgesia (PCA) post operatively and local anesthetic infiltration of the wound or Transversus Abdominis Plane (TAP) /iliac crest blocks depending on your experience. (Strong)

9.     Management of Airway Emergencies in Obstetrics

9.1   Maintain a difficult airway cart and strategy.  (Strong)

9.2   Implement the basic elements of the guidelines for the management of difficult and failed tracheal intubation. Follow ASA airway guidelines. (Strong)

9.3   In case of “Cannot Ventilate, Cannot Oxygenate”, prepare for urgent Front-of-Neck Access (FONA) while simultaneously remove the possible reversible causes. (Strong)

10.  Cardiopulmonary Resuscitation (CPR)

10.1   Initiate Cardiopulmonary resuscitation (CPR) with pregnancy-specific modifications

  of the Advanced Life Support (ALS) algorithm of the non-pregnant population. (Strong)

10.2   Deliver the fetus within 4–5 minutes if circulation is not restored. (Strong)

10.3   Start immediate, high-quality CPR in the event of cardiovascular collapse due to local

  anaesthetic systemic toxicity (LAST) with early lipid administration. (Strong)

11.  Hemorrhagic Emergencies at Caesarean Section

11.1   Ensure early recognition, immediate availability of resources  to manage hemorrhagic emergencies and activation  of a multidisciplinary team. (Strong)

11.2  Ensure early activation of Massive Transfusion Protocol (MTP) and use balanced component therapy (Strong)