Anaesthesia for emergency caesarean sections poses significant risks. General anaesthesia should only be used if regional techniques cannot be employed within 30 minutes or are contraindicated due to maternal instability. Spinal or epidural anaesthesia are preferred for their safety advantages when time allows. Proper preparation, vigilant monitoring, and treatment of hypotension are essential to mitigate risks during regional or general anaesthesia for emergency caesarean sections.

1. Anaesthesia for Emergency
Caesarean Section
GUIDE: Dr. Mukesh Somwanshi
PRESENTER: Dr. Khushboo

2. Cesarean Section-Introduction
 C/S rate 30% at US (18% in India)
 Emergency CS makes up about 2% of births
 Guideline of ACOG &ASA- CS be started within
30min of recognition for its need.
 More likely to be met if patient in theatre
within 10 minutes of decision
Davies and Collis 2007
 20 patients had GA for Grade 1CS
 4/20 actually needed GA
 10/20 could have regional
 6/20 did not need a
caesarean section

3. Anaesthesia
related mortality
• 3-12% maternal death
• Sixth leading cause of maternal
mortality
◦ Majority during G/A: failed intubation,
ventilation, oxygenation and
pulmonary aspiration of gastric content
◦ Risk factors: age>34yrs, nonwhite
group, obesity, multiple pregnancy,
hypertensive disorder of pregnancy,
previous PPH, emergently performed

4. Caesarean Section-Grading
 Grade 1:An immediate threat to the life
of the mother or fetus-Emergency
 Grade 2:Maternal or fetal compromise
that was not immediately life threatening-
Urgent
 Grade 3:The mother needed early
delivery but there was no maternal or
fetal compromise-Scheduled
 Grade 4:Delivery was timed to suit the
mother or staff-Elective

5. Davis guideline
• Davis related urgency of CS with
method of anaesthesia.
• If time of decision to operate to time of
delivery desirable is-
A. <30min:GA
B. 30-45min:SAB
C. 45-60min:extension of existing epidural
D. 60-90min:new epidural block

6. Caesarean section-
elective(grade-4)
Indication:
 A. Labour unsafe for mother and fetus:
 Risk of uterine rupture-previous CS
 Risk of maternal h’age
 B. Dystocia
 Abnormal presentation
 Fetopelvic disproportion
 Dysfunctional uterine activity
Anaesthesia:
• Epidural-If epidural catheter already
introduced
• Spinal-either single shot or CSE

7. caesarean section-Scheduled
(Grade-3)
Indication:
 Chronic uteroplacental insufficiency
 Abnormal fetal presentation with ruptured
membrane (not in labor)
Anaesthesia:
• Epidural-if already established top up
• Spinal-if epidural not established
• General-if regional contraindicated

8. Cesarean Section-
Urgent(grade-2)
Indication:
 Dystocia
 Failed trial of forceps
 Active genital herpes infection with ROM
 Previous classical C/S and active labor
 Cord prolapse without fetal distress
 Variable deceleration with prompt recovery and
normal FHR variability
Anaesthesia:
• Extension of preexisting epidural
• Spinal-if time permits but no repeated attempts
• general-if regional contraindicated

9. cesarean section-
emergency(grade-1)
Indications:
 Massive maternal hemorrhage
 Ruptured uterus
 Cord prolapse with fetal bradycardia
 Agonal fetal distress (e.q., prolonged
bradycardia or late deceleration with no FHR
variability)
Anaesthesia:
General anaesthesia unless
preexisting epidural anesthesia can be
extend satisfactorily

10. Proactive Anaesthetic
Management
 Identify those at risk of anaesthetic
complications
 Preconception
 During Pregnancy
 During labour (ward rounds)
 Particular Concerns
 Obesity
 Recent migrants
 Language, Social Issues,
Undiagnosed/Untreated Illness
 Sepsis
 Preeclampsia

11. In Utero Fetal Resuscitation
 Syntocin off
 Position full left lateral
 Oxygen
 I.v. infusion of 1 litre RL
 Low blood pressure: i.v. vasopressor
 Tocolysis: -Terbutaline 250 μg (s.c),
Glyceryl trinitrate 400 μg (metered
aerosol doses)
 Monitor Fetus-It may get better

12. Anesthetic technique
 Spinal anesthesia
 Epidural anesthesia
 Combined Spinal-Epidural anesthesia
 General anesthesia

13. What Anaesthetic Technique?
• Choice depends on
 Indication for the surgery
 The degree of urgency
 Maternal status
 Desire of the patient
 Overwhelming preference of RA for maternal
safety
 GA -associated with significantly shorter DDI
-associated with 16.7X greater risk of death
-should be used only when absolutely
necessary
 Risk for fetus?Is there time for Regional

14. Pre-Existing Epidural
 Is there an epidural in place?
-Is it working?
-Should I remove the epidural and put in a
spinal/CSE
• Do I have time for a spinal/CSE de novo
- Anaesthetic factors -Patient factors
 Has it had a test dose?
-Could it be intrathecal? -Could it be
intravenous?
 When was this last topped up?
 Has it ever worked?
 Topping up an epidural
-How Much?-20mls, Divided doses?

15. General points
 Assess all patient for GA
 Consent form signed
 Explain the procedure to patient
 LUD maternal position
 Secure a large bore IV cannula
 Give IV fluid RL 15-20ml/kg in 30min
 In urgent situation don’t wait
 Give antacid therapy
 Effect of Block form T4 to S5
 Agree the start of op with surgeon
 Avoid medication before the delivery of baby
 Oxytocin 5IU slow IV after delivery of baby and
Infusion of oxytocin 20IU in 500ml RL for 4hrs
 Monitoring : ECG, NIBP, pulse oximeter, fetal monitoring
Additional monitors for GA: ETCO2, nerve stimulator, temp probe

16. Spinal Anaesthesia
• Position-sitting/lateral
• Insert spinal needle with aseptic precaution in
L3-4 or L4-5 interspace
• Inject 2-3ml bupivacaine 0.5% heavy alone or
with adjuvant
• Lie the mother in left lateral tilt
• Monitor BP in every 2min
• Avoid fall in BP
• vasopressor if reqired
Phenylephrine or epheridine
• Check the effect and Allow to start

17. DRUGS USED FOR SPINAL ANAESTHESIA
Choice of drug: 2-3ml of 0.5% heavy bupivacaine
+/-additive: 200-300mcg morphine
:5-10 mcg sufentanil
: 10-25mcg fentanyl
Drug DOSAGE(mg) Duration(min)
Lignocaine 50-60 45-75
Bupivacaine 10-15 60-120
Tetracaine 7-10 120-180
Procaine 100-150 30-60
Adjuvant drugs
Morphine 0.200-0.300 360-1080
Fentanyl 0.010-0.025 180-240
Sufentanil 0.005-0.010 180-240

18. Spinal anaesthesia
Adv:
 Simple
 Rapid onset
 Dense blockade
 Awake patient
 Negligible maternal risk of systemic
local toxicity
 Minimal transfer of drug to infant
 Negligible risk of local anesthetic
depression of infant
 No risk of failed intubation/aspiration

19. Disadv:
 Rapid onset of sympathetic
blockade – abrupt, severe
hypotension
 Recovery time may be
prolonged (if procedure shorter
than anticipated)
 Could not prolong the
anaesthesia
 Airway not secured for
emergency
 Not possible for emergency

20. Epidural Anaesthesia
• Not the first choice for CS;only used if
epidural in situ for labour
• Check the epidural position and patency
• Top up with local anaesthetic agent with or
without adjuvant as 20-30ml solution slow
bolus
• Monitor the BP(hypotension less likely but if
occur treat with ephedrine or phenylephrine)
• If time allow use gold standard method(5ml
increment in 5min)

21. DRUGS USED FOR EPIDURAL ANAESTHESIA
Choice of drugs:
1. 20 ml lignocaine 2% + 1:200,000 adrenaline (slightly faster
onset)
2. 20 ml (levo-)bupivacaine 0.5% (slightly better quality block?)
3. 10 ml lignocaine 2% + 1:200,000 adrenaline + 10 ml
bupivacaine 0.5% (the best of both worlds?)
Drug Dosage (mg) Duration (min)
2% lido with epineph 300-500 75-100
2-chloroprocaine 450-750 40-50
0.5% Bupivacaine 75-125 120-180
0.5% Ropivacaine 75-125 120-180
Adjuvant Drugs
Morphine 3-4 720-1440
Fentanyl 0.050-0.100 120-240
Meperidine 50-75 240-720
sufentanil 0.010-0.020 240-720

22. Epidural anesthesia
Adv:
 Titrated dosing and slower onset (volume
dependent, not gravity dependent)
risk of severe hypotension and reduced
uteroplacental perfusion
 Incremental dose (for longer operation)
Duration of surgery not an issue
 Less intense motor blockade good for
pts with multiple gestation or pulmonary
disease
 Lower extremity “muscle pump” may
remain intact may incidence of
thromboembolic disease

23. Disadv:
• Dural puncture :1/200-1/500 in
experienced hands, higher in training
institution
• If unintentional dural puncture, PDPH
• Slower onset
• Cant use for emergency situation if
epidural catheter is not introduced
previously
• Risk of systemic local toxicity

24. Combined spinal epidural
 Not used commonly
 Either needle through needle or seperate space
technique
 Two different technique used:
-normal spinal dose and epidural for back up
or;
-small intrathecal dose with extension through
epidural
 Monitor the BP

25. combined spinal epidural
Adv:
 Rapid onset and density of spinal
anesthesia combined with versatility of
epidural anesthesia
Disadv:
 Potential for high spinal
 Inability to test epidural catheter
 Higher spinal failure rate
 Only 1 published report of presumed
unintentional insertion of epidural
catheter through dural puncture site
 Not useful for emergency condition

26. M/m of inadequate regional block
 If can not do spinal-> try epidural
 If can not do epidural-> try spinal
 If can not do regional->call for help or; give GA
 If pt c/o pain intraop
-if epidural in place give topup of LA+/-opioid
-small increment dose of iv opioid (if post
delivery)
-low dose ketamine 0.25mg/kg
-if pt does not respond GA
-iv midazolam if pt anxious post delivery but
having good analgesia

27. Complication
1.Hypotension:
 20-30% decrease in BP or <100mm Hg
 d/t sympathectomy+a-c compression
 t/t-IV fluid bolus
-LUD
-Supplemental oxygen
-iv bolus of ephedrine(5-15mg) or
phenylephrine(25-50mcg)

28. 2.Unintentional IV injection:
a)Lignocaine and chloroprocaine presents
as frank seizures
m/m-thiopental50-100mg /propofol small
dose
-maintenance of airway and
oxygenation
b)Bupivacaine cause rapid and profound
cardiovascular collapse
m/m-amiodarone
-cardiac resuscitation

29.  3.Unintentional intrathecal
injection:
(Total spinal)
 If recognised immediately try to
aspirate
 Pt placed supine with LUD
 Treat hypotension with iv fluid and
vasopressors
 If high spinal intubate and ventilate
with 100%oxygen

30.  4.PDPH
 Mostly after unintentional dura
puncture
 m/m-bed rest;hydration; oral analgesic
-epidural saline injection(50ml)
-caffiene sodium benzoate(500mg
iv)
-epidural blood patch(15-20ml)

31. General anaesthesia
• More than 90%of CS are in regional because
increased mortality and morbidity with GA
• Indications for GA:
1. technical failure of regional technique
2. contraindication to regional technique
- pt refusal
- sepsis
-hemodynamic instability
-raised ICP
-abnormal coagulation
3. surgical indication (eg. anterior placenta
previa with previous CS)
4. obstetric indication (eg. severe fetal distress)

32. Pre operative
 Fast pre-op assessment
 Essential equipment to be carefully checked and
laid out before induction of anaesthesia
-Macintosh laryngoscopes: 1 standard blade, 1 long blade
and 1 polio blade or short handle
-McCoy levering laryngoscope
-Endotracheal tubes (ETT) with a range of sizes 6 – 8
-Oral and nasopharyngeal airways
-Malleable introducer
-Gum elastic bougie
-Laryngeal mask airway (LMA) and ProSeal laryngeal
mask
-Cricothyroidotomy set
-Wedge for prevention of a-v

33. Premedication
 Antacid regimen:
Elective
-rantidine150mg orally 2hrs preop
-0.3 molar sodium citrate 30ml orally
-10mg metoclopromide orally
Emergency
-rantidine50mg diluted in 20ml saline slow iv
-0.3 molar sodium citrate 30ml orally
• Antisecretory: Glycopyrrolate 0.1mg iv
• No opioids or BZDs before delivery of
baby

34. Rapid sequence Induction
Preoxygenate(O2 6 l/min for3 mins/4 vital capacity breaths)
IV Thiopentone 250 - 350 mg (4-5mg/kg)
In hypotensive crises Ketamine(1-1.5mg/kg)
Start cricoid pressure as consciousness lost &maintain till
intubate
Succinylcholine 50-100 mg(1-1.5mg/kg)
Intubation with a smaller ETT size 6-7mm
Cuff inflated and found to be leak free.
 CHECK POSITION OF ENDOTRACHEAL TUBE (ETT)

35. Maintenance
• Before delivery of baby
 50% nitrous oxide + 50% oxygen pre-delivery
+volatile agent 0.5%halothane/iso/sevo
 NDMR atra/vec/roc(given once the
suxamethonium has worn off check by peripheral
nerve stimulator)
• After delivery of baby
 70% nitrous oxide + 30% oxygen +/-volatile agent
0.5%halothane/iso/sevo
 Once umbilical cord clamped–oxytocin
5IUstat;10-20 IU oxytocin in 500 mL crystalloid
at40-80 mIU/min
 IV Opioid

36. Recovery
 Residual NM blockade reversal (2.5mg
neostigmine + 0.5mg glycopyrrolate)
 If mother full stomach-empty by nasogastric
tube prior to extubation and remove
nasogastric tube before extubation
 Extubate only once mother awake
 Morphine via a patient controlled analgesia for
postop analgesia

37. Atonic uterus
 If atony does not respond to oxytocin:
◦ Methylergonovine 0.2 mg IM
◦ 15-methylprostaglandin F2-alpha 250
ug IM or IMM
◦ Discontinue volatile agent
Ergots:
◦ Severe hypertension
◦ Avoid in hypertensive
PGF2α:
◦ N+V, diarrhea, fever, tachypnea,
tachycardia, hypertension,
bronchoconstriction

38. DIFFICULT INTUBATION
•If2 or more adverse findings->consider regional
•IF GA essential FOI/retrograde intubation
•Limit succinylcholine to one dose unless the larynx can be
seen and an adequate airway maintained with a facemask
•There should normally be a maximum of 3 attempts before
proceeding to a failed intubation drill
TEST ADVERSE FINDINGS
Mouth opening < 4 cm (< two fingers)
Extension at the atlanto-occipital joint
- in the standard intubating position Little detectable movement at the
gentle manipulation may reveal up to atlanto-occipital joint
30 degrees of movement
Mallampati view of the pharynx with
mouth open and tongue maximally grade III or more (uvula not seen)
protruded
Thyromental distance measured with
< 6 cm (<three fingers)
the head fully extended and mouth
closed

39. Failed intubation drill

40. Pulmonary aspiration syndrome/
mendelson’s syndrome
 Presentation: Bronchospasm, tachypnea,
cyanosis, tachycardia, resp.distress
 Dx: CXR-patchy pulm infiltrate to pulm edema
oxymetry-decreased oxygen saturation
 Prev:-avoid GA
-avoid excessive sedation
-antacid regimen
-preoxygenation
-correct cricoid pressure
-skilled and rapid intubation
-gastric emptying before extubation
-awake extubation;lateral tilt after

41. >25 ml of gastric contents with a
pH of <2.5 are considered to be
critical factors
 M/m:-vigorous and immediate
-suction of airway
-increase inspired oxygen conc.
-treat bronchospasm with salbutamol 250mcg
iv
or aminophylline 250mg iv
-support circulation with ionotropes
e.g;dopamine
-manage in ICU with oxygen administration;
chest physiotherapy;and if necessary IPPV

42. General anaesthesia
Adv:
 Fast; Reliable (if you get the tube in)
 Almost never fails
 Duration is flexible
 Controlled airway and ventilation
 Doesn’t cause sympathectomy
 Patient is not awake (to experience
problems)
 Minimal cooperation needed from the

43. General anesthesia
Disadv:
 Risk of failed intubation and“can’t
intubate, can’t ventilate” scenario.
 Risk of maternal aspiration and neonatal
depression
 Patient not awake for birth.
 Nausea, post-op pain, sore throat
 Avoid GA in difficult intubation, hx of
malignant hyperthermia, severe asthma
 Contribute to uterine relaxation or atony

44. General Anesthesia –
Unconscious mother and awake
neonate? uptake by fetal liver (1st
1) Preferential
organ perfused by blood from umbilical
vein)
2) Higher relative water content of fetal
brain
3) Rapid redistribution of drug into
maternal tissues rapid reduction in
maternal – fetal conc gradient
4) Non-homogeneity of blood flow to
intervillous space
5) Progressive dilution in fetal circulation

45. Effects of Anesthesia on Fetus and
Neonate
 No significant difference in umbilical
cord blood gas between general or
regional anesthesia for elective or
emergency cs
 Crawford – found uterine incision to
delivery (U-D) interval is more
important than I-D interval
 A U-D interval >3 mins associated with
incidence of low umbilical cord blood
pH and Apgar scores, regardless of
anaesthetic technique

46. Conclusion
 High risk patients should be seen
antenatally
 Anaesthetists should not feel bullied
to
achieve unsafe decision to delivery
times
 Stay calm.
 Don’t endanger the mother to “save”
the baby.
 DDI in grade 1 CS should be less
than 75minutes and NOT less than

47. Thanks for your
attention!

48. Special cases- Fetal distress
 Signs: nonreassuring FHR pattern
:fetal scalp Ph<7.20
:MSL
:Oligohydroamnios
:IUGR
 Anaesth m/m:100% oxygen by face mask
:LUD
:Epidural in situ-top up
:GA

49. Cord prolapse
 Sign: sudden fetal bradycardia or
profound deceleration
 m/m:Elevate presenting part
:100% oxygen
:LUD
:GA with rapid sequence
induction

50. Hypovolemic shock
 m/m of shock
 Induction with etomidate(100mcg/kg)
or ketamine(1.5mg/kg)
 100% oxygen

51. Antepartum Haemorrhage
 Prevent active uterine contraction
 GA If - Active bleeding/coagulopathy
-previous cs
-risk of placenta accreta
-haemodynamically unstable
• RA if-placenta not encroaching ant wall
-haemodynamically stable
• Secure two large bore iv cannula
• Iv fluid deficit vigorously corrected
• Blood must be available
• CVP Monitoring

52. Pregnancy induced
Hypertension
I. Pre-eclampsia
II. Eclampsia
III. HELLP (Hemolysis, Elevated Liver
Enzyme, and Low Platelets)
Anaesthesia:
• Mild-standard anaesthetic practice
• Severe-GA but Continuous epidural
anaesthesia first choice
• Seizures m/m-MgSO4

53. Important points in PIH
RA-avoid if platelet<1lac/dl
-Colloid fluid bolus before epidural
activation
-Avoid Epinephrine containing test dose
-Hypotension treated with small dose of
vasopressors (ephedrine5mg)
GA-Difficult intubation
-IV nitroprusside, trimethaphan or
nitroglycerin to control BP during GA
-IV Labetalol 5-10mg at the time of
intubation

54. Maternal heart disease
 Aim:minimise wide fluctuation in HR and
CO
:Intensive monitoring
• Anaesthesia:
 epidural anaesthesia is method of choice
 Judicious IV administration of crystslloid
 Small bolus dose of phenylephrine
 If GA-beta blocker and iv opioid before
induction
-rapid sequence induction with etomidate
-maintenance with

55. Others
 Instumental delivery:
-if epidural established : top up
-spinal
-GA: If regional not possible
• Manual removal of placenta:
-if haemodynamically stable : Regional
-if not stable : GA(avoid excess conc of
volatile agent)
• Evacuation of retained product
-spinal
-If GA no need of intubation(mask

56. General Anesthesia –Induction
Agents
Thiopental
• Extensive published data
• Safe in obstetric pts
• 4 mg/kg
• Rapidly crosses placenta
• Detected in umbilical venous blood within
30 secs
• Equilibration in fetus rapid and occurs by
time of delivery
• With doses 4 mg/kg – peak conc in fetal
brain rarely exceed threshold for

57. Induction agent
Propofol
 Rapid, smooth induction of anesthesia
 Attenuates cardiovascular response to
laryngoscopy and intubation more
effectively than pentothal
 Does not adversely affect umbilical cord
blood gas measurements at delivery
 Rapidly crosses placenta
 Rapidly cleared from neonatal circulation
 Detected low concs in breast milk
 Propofol and pentothol similar Apgar
and neurobehavioural scores

58. Induction agent
Ketamine
 1 mg/kg
 Rapid onset
 Analgesia, hypnosis, and reliably
provides amnesia
 Good in asthma or modest hypovolemia
 1 mg/kg does NOT uterine tone
(larger doses do)
 Rapidly crosses placenta
 Similar umbilical cord blood gas and
Apgar scores with ketamine or pentothal

59. General Anesthesia- muscle
relaxant
Succinylcholine
 1-1.5 mg/kg
 Muscle relaxant of choice for most
patients
 Highly ionized and water soluble, only
small amounts cross placenta so rarely
affects neonatal NM function
 Pseudocholinesterase activity 30% in
pregnancy, BUT recovery is not
prolonged
 Vd offsets the effect of activity
 intragastric pressure by fasciculation

60. General Anesthesia
Rocuronium
 1 mg/kg
 Only very small amounts cross placenta
 Apgar and neurobehavioural scores not
affected