Anesthesia for

cesarean section

Tom Archer, MD, MBA
UCSD Anesthesia
A unique psychosocial surgery
Outline

C-section a unique psychosocial surgery
How the OB anesthetist should behave.
Evolution of techniques
Neuraxial block physiology and
management
GA physiology and management.
Management of common problems


C-section a unique
psychosocial surgery
Psychological / interpersonal aspects
Unique surgery, happy event gone awry.
Strike a balance between happy event and
risky surgery.
Most patients are awake and want to be.
Team approach (patient, family, nursing, OB,
anesthesia)
Support person present in OR.
Family members in the labor room (face
them).
Discretion about medical info JW, drug use,
previous abortions, etc.
Anticipate and be available
Know every patient on the floor. Introduce
yourself early.

Be accessible to OBs and nurses.

Get informed early about potential
problems (airway, obesity, coagulopathy
JW, congenital heart disease)

Remember the basics (IV access, airway)

Anticipate and be available
We need a certain knowledge of OB to know
what is going to happen. Try to think one or two
steps ahead.

Placenta isnt out yet in room 7
The lady in 6 has a pretty bad tear.
Strip review in 3, please.
We cant get an IV on the lady in 4.
Can you give us a whiff of anesthesia in 8? We dont
need much.


Evolution of technique
Last 30 years: decreasing use of GA, now
about 5% of cases. Was 20-30% in 70s at
UCSD.

Epidural was all the rage in 70s and 80s.

SAB (or epidural) are now preferred
anesthetics.
Anesthesia for C/S
basic interventions

Happy event (sort of)
Gastric acid neutralization
Left uterine displacement
Fluid loading
Supplemental oxygen
Support person in room (regional only)


Anesthesia for C/S
Complications
Sympathectomy / hypotension
Nausea
Bradycardia
High spinal / respiratory paralysis
Aspiration
Difficult intubation
Local anesthetic toxicity
Failed regional anesthesia
Persistent neurological deficit
C/S red flags
I dont feel so goodI think Im going to
throw up (Hypotension until proven
otherwise).
Doc, I feel like Im not getting enough to
breathe
The floppy arm sign.
The shaking head sign.
Spinal-- advantages
Uniquely appropriate in C/S (happy event).

Really amazing when you think about it.
Awake and smiling.
Arms and hands are normal.
Major surgery inside the abdomen.

Quick, solid, simple, reliable, pretty safe.

LA + narcotic gives great block.

Can give long-acting analgesia (intrathecal MS)
Regional anesthesia for c/s
in Turkey (SOAP outreach)

Spinal-- disadvantages

Fixed duration (unless continuous spinal).

Rapid onset of sympathectomy or high
block.

Small chance of PDPH.
SAB
absolute contraindications
Patient refusal

Uncorrected hypovolemia

Clinical coagulopathy

Infection at site of injection


SAB
obsolete contraindication


Severe pre-eclampsia

Not associated with increased chance of
severe hypotension with neuraxial block.

Show me the literature if you disagree.
SAB
relative contraindications
Spinal cord, LE nerve disease.

Spinal deformity, instrumentation

Back problems / fear of block

Laboratory coagulopathy

Bacteremia
SAB
relative contraindications


Potential for hypovolemia

Stenotic cardiac valve lesions (?)

Pulmonary hypertension (?)


Basic C/S monitoring
Talk with the patient!
Does her face display anxiety?
Take a deep breath!
Have her squeeze your fingers
What is her hand temperature?
Are the hand veins dilated?
Do your hands feel normal or do they feel
a little numb?

SAB / epidural cause
sympathectomy
Dilation of capacitance vessels (70-80% of
blood volume)
May cause drop in CO

Dilation of resistance arterioles (0.1-0.4
mm diameter).
Drop in SVR


SAB / epidural cause
sympathectomy


www.cvphysiology.com/Blood%20Pressure/BP019.htm
SAB / epidural cause
sympathectomy


www.cvphysiology.com/Blood%20Pressure/BP019.htm
38 y.o. female, repeat c/s, 420 #, gestational hypertension, continuous
spinal: fall in SVR, rise in CO with onset of block. Increased SVR with
phenylephrine.
When is sympathectomy
(low SVR) bad?

BP = CO x SVR

Whenever you cant increase CO!
Uncorrected hypovolemia
IVC compression
Stenotic valve lesions
Pulmonary hypertension


Tricuspid
Pulmonic
Pulmonary
capillaries
Mitral
Aortic
stenosis
Resistance arterioles
Aortic stenosis at rest
Cardiac output not sufficient to cause
critically high LV intracavitary pressure /
LV failure.
LV dilation / hypertrophy
Tricuspid
Pulmonic
Pulmonary
capillaries
(edema)
Mitral
Aortic
Stenosis
Resistance arterioles decreased SVR
Aortic stenosis with SAB:
increased cardiac output /
arteriolar vasodilation:
Decreased SVR Fall in systemic BP and
/ or increase in LV intracavitary pressure
ischemia or LV failure.
LV failure /
ischemia
38 y.o. female, repeat c/s, 420#, continuous SAB. Delivery with
increased CO at 17, oxytocin 3 U bolus at 18, phenylephrine at 19
When is sympathectomy
(low SVR) bad?



With bolus of other vasodilator (oxytocin)

Oxytocin 10 u bolus
When is sympathectomy
(low SVR) bad?


When drop in SVR could exacerbate R > L
shunt.
ASD
VSD
PDA

LA
RA
LV
RV
Decreased
SVR
desaturation
Increased
pulmonary
vascular
resistance
desaturation
Ao
PA
Decompensated patient with ASD, VSD or PDA-- Decreased SVR or
increased pulmonary vascular resistance increased RL shunt and
increased arterial desaturation.
Decompensated patient with REAL RL shunt.
LA
RA
LV
RV
High SVR,
Minimal
RL shunt
Ao
PA
Low
pulmonary
vascular
resistance
Normal, compensated patient with ASD, VSD or PDA-- high SVR and low
pulmonary vascular resistance minimal RL shunt.
Compensated patient with POTENTIAL RL shunt.
JW with previa / accreta for c-hyst. GA. Induction at 7, 8, intubation
before 9, incision after 9. Note rise in SVR and fall in CO with GA.
How to prevent a sympathectomy
from being a problem



Keep the SVR up with a vasopressor like
phenylephrine.
Preventing or treating hypotension
from sympathectomy: augment venous return (CO).
Trendelenburg (empty capacitance vessels into central
thoracic veins)

LUD (get pressure off vena cava)

Fluid loading (fill capacitance vessels)
Crystalloid
Hetastarch

Arteriolar constrictors (inc SVR)
Ephedrine, phenylephrine

Venous constrictors (inc venous return)
Ephedrine, phenylephrine



Hypotension with SAB or epidural
Pre-load does not prevent reliably.

500 mL hetastarch better than 1500 mL
crystalloid.

First symptom is nausea or I dont feel so
good.


Hypotension
Use phenylephrine (neosynephrine) if tachycardia.

Use ephedrine if bradycardia.

Use atropine if severe bradycardia.

Glycopyrolate works slowly.
Sympathectomy

www.sympathecto
my.co.uk/ETS.php
Sympathectomy

Endoscopic transthoracic
sympathectomy

Virtually all patients immediately develop warm, dry hands and leave
the hospital the same day as surgery.
www.sd-neurosurgeon.com/.../hyperhidrosis.html
Hyperhydrosis Rxd with
T3 sympathectomy
Horners syndrome
Horners syndrome

Bradycardia

With hypotension: High block of
cardioaccelerator fibers (T1-T5).

Also can be reflex bradycardia with
hypertension from phenylephrine
Inc SVR and BP with bradycardia from neo 50
mcgm at 4. Brady occurs after SVR and BP changes.
Left Uterine Displacement
(LUD)
Colman-Brochu S 2004
http://www.manbit.com/OA/f28-1.htm

Manbit images
http://www.manbit.com/OA/f28-1.htm
Chestnut chap. 2
www.siumed.edu/~dking2/erg/images/placenta.jpg
from Google images

)
Umbilical artery (UA)
Umbilical vein (UV)
Uterine arteries Uterine veins
Mom
Fetus
Normal placental function: fetal and maternal circulations separated by thin
membrane (syncytiotrophoblast).
Lakes of
maternal blood
Archer TL 2006 unpublished
Fetal capillaries
in chorionic villi
Precariously oxygenated environment
P1 = uterine
artery pressure
P2 = uterine vein pressure
R = placental resistance
(fixed in short term)
Ohms Law of the placenta: O2 delivery = Placental blood flow = (P1 P2) / R
Aorto-caval compression decreases P1 (aorto) and increases P2 (caval)
Therefore, aorto-caval compression decreases O2 delivery to fetus.
Placenta blood flow
(O2 delivery) =
(P1 P2) / R
Archer TL 2006
General anesthesia-- advantages
Fast
Reliable (if you get the tube in).
Doesnt cause sympathectomy
Duration is flexible
Patient is not awake (to experience
problems).
Can be given despite coagulopathy
General anesthesia--
disadvantages

Patient not awake for birth.

Unprotected airway.

Possible cant intubate, cant ventilate
scenario.

Nausea, post-op pain, sore throat.
Functional residual capacity (FRC) is our air tank for apnea.
www.picture-newsletter.com/scuba-diving/scuba... from Google images
Pregnant Mom has a smaller air tank.
Non-pregnant
woman
www.pyramydair.com
/blog/images/scuba-
web.jpg

GA for C/S

Thorough pre-oxygenation
Cricoid pressure
Small tube (6.0-7.0)
RSI
50% N2O until delivery + 0.5 MAC
volatile.
60-70% N2O after delivery + midazolam +
narcotic.
Small dose non-depolarizing NMB, if
needed.

General anesthesia-- advantages

SVR is maintained high (no need to
increase CO)

Hypovolemia
Stenotic cardiac valve lesion
Pulmonary hypertension
Potential R>L shunt
JW with previa / accreta for c-hyst. GA. Induction at 7, 8, intubation
before 9, incision after 9. Note rise in SVR and fall in CO with GA.
Managing common problems
High block patient cant breathe
Move to anesthesia mask and circle system early. Dont
fuss around assessing the patient!

Reassure patient, tell them this happens, and tell them
you will help them breathe.

You usually dont have to intubate.

Sometimes patients will panic and shake head back and
forth to get the mask off of their face.

Assume accompanying hypotension. Give ephedrine or
neo as you reach for the mask.

High block patient cant breathe
If patient becomes unresponsive, you probably
should intubate BUT VENTILATE FIRST AND
DONT PANIC.

Assistant can give cricoid pressure but
VENTILATE, above all!

May not need relaxant to intubate.

Respiratory paralysis usually does not last long
(5-15 minutes).


Failed regional anesthesia

Be honest with yourself recognize failure.

Move on to plan B.


Aspiration
16 y.o. WF, Crystal, +Hx substance abuse, C/S
for failure to progress.

Epidural, patchy block, supplemented with
ketamine, fentanyl, diazepam.

I was vigilant with breath sounds (precordial
stethoscope era).

Baby OK. Mother OK in PACU at 4PM.


Aspiration
Called at home next AM: Pt SOB, transferred to ICU and
intubated.

I go to hospital, review nurses notes.

Nauseated during the night, got MS several doses. Lying
flat during the night.

SOB at 4AM. Aspiration? When? My fault?

Died 10 days later of progressive ARDS, hypoxia.


Aspiration

Not only during GA!

Use triple Rx freely (on everybody?)

Beware with
High spinal
Heavy supplementation for bad block
Never turn your back on a spinal.
STAT C/S
Often a flail.
Weve got to go. NOW!
Egos and emotions run high.
Does the patient know what is happening?
Talk to patient. Informed consent.
Dont endanger the mother to save the baby.
Know when and how to say no to the OB.
Stay calm.
Cover the basics (H&P, IV access, airway,
informed consent, patient asleep before incision.)
A stat C/S, once upon a time
Fetal decels
Rush to the OR
Anesthesiologist is sure he can get the tube in fast
He skips the pre-O2.
He cant intubate or ventilate
Patient arrests.
Code blue called, staff intubates.
Post op seizures, hypoxic encepalopathy.
Patient recovers after several days.
Summary
Regional anesthesia is elegant and uniquely
suited to C-section.

GA still has its place, and its dangers.

Early warning, good communications and
equanimity under pressure promote good
outcomes.
The End