Emergency caesarean section

Emergency cesarean section is performed in the following situations:

1. Immediate threat to the life of the mother or child.
2. The pathology of a woman in labor or fetus, which does not represent an immediate threat to life.
3. The need for early delivery without the pathology of the mother or fetus.
4. In time, arranging both the patient and the obstetrician.

[1], [2],

Preoperative preparation for emergency cesarean section

• There is a rapid preoperative examination for allergies, medications, anesthesia in the past, and health in general. It is also necessary to clarify when the last meal of food or liquid was.
• Ensure intravenous access, if not already installed. Start rehydration - a fast infusion of the crystalloid, or colloid / blood in hypovolemia.
• Premedication: sodium citrate 0.3 M 30 ml per os, if OA is planned or probable. Metoclopramide 10 mg or ranitidine 50 mg can be administered intravenously if there is time.
• Position on the back with an inclination on the left side - put something under the right or tilt the plane of the table. If an anesthesia and delay are not expected, this can be applied immediately. If some kind of delay happened - the position completely on the left side is preferable, since in this position the aortocaval compression is minimal.
• Pre-oxygenation begins as soon as the patient is on the operating table.

Emergency cesarean section: choice of method of anesthesia

• General anesthesia can be started faster than any other, but it is associated with a large number of possible life-threatening complications for the woman in childbirth and rapid development of fetal depression. Factors that need to be quickly clarified for a reasonable choice of anesthesia: the urgency of the situation (to find out from the surgeon), the preference of the parturient woman (to ask the patient), and specific contraindications and difficulties (a short history, as mentioned above, preoperative airway examination, body mass index, spin , the state of the blood coagulation system). If an attempt is made to apply regional anesthesia, it is necessary to determine the time limit, if exceeded, general anesthesia will be started.
• Approaches to the use of an already established epidural catheter are different.

An epidural catheter providing adequate analgesia of labor may, in some cases, be insufficient for a painless operation. In some maternity hospitals routinely injected with a dose of local anesthetic into the epidural catheter, as soon as a decision is made about cesarean section, in others, as far as possible, try to perform a spinal catheter. An alternative selective approach is described below.

[3], [4], [5], [6], [7]

General anesthesia

• Formally, pre-oxygenation before general anesthesia involves breathing 100% oxygen through a tightly fitting facial mask for 3 minutes. Additional PAPs or several deep breaths can reduce airway contraction and improve the ventilation-perfusion ratio, as well as denitrogenation and PaO2. Three minutes of ventilation with a tidal volume provide more effective denitrogenation than pre-oxygenation with 4 breaths equal to ZHEP.
• In the case of hypovolemia or hypotension in the parturient, induction of anesthesia is advisable to perform ketamine or etomidate, rather than thiopental.
• If the fetus is deficient, maintain 100% of the FiO2 delivery, increase the concentration of the inhaled inhalation anesthetic to compensate for the absence of N20.

Spinal anesthesia

• In the most urgent situations, a "rapid sequential spinal anesthesia" may be required. An anesthesiologist knows the position for spinal puncture, but because of the prolapse or compression of the umbilical cord, the position of sitting or lying on the side sometimes has to be excluded. After a spinal puncture and the introduction of a local anesthetic, the patient is placed on her back with a slant on her left side.
• The addition of an additional lipophilic opioid (25 μg fentanyl or 0.3 mg diamorphine) can reduce discomfort for a certain level of the sensory block, but the expectation of delivery of this drug should not be an excuse for delaying the onset of spinal anesthesia. It should be remembered that the packaging of the ampoule can be non-sterile.
• A certain dose provides a higher level of the spinal block if it is injected after the epidural block. This effect is more pronounced, the larger the volume (volume effect) of the recently introduced dose of concentrated local anesthetic (the effect of an additional block). Similarly, the menacing level of the spinal block, which may require intubation, is more typical after epidural administration (1 out of 60 versus 1 several thousand after only the spinal one), and this risk is considered higher after recent epidural administration. Doses for spinal administration in a similar situation are the subject of numerous disputes: too much is fraught with a high block, too low is insufficient.

In cases of degree of urgency 2 or 3, sometimes a combined spinal-epidural anesthesia with low doses is recommended.

In more urgent situations, the general opinion tends to favor a single spinal administration with a decrease in local anesthetic dose by 20-40%.

Rapid consecutive spinal anesthesia

• Organize additional personnel for monitoring and catheterization of the vein - do not initiate a spinal injection until an intravenous catheter is installed and fixed.
• In the process of attempting spinal anesthesia, the patient must be pre-oxidized.
• Technique "without touch" - only gloves; chlorhexidine on a sterile napkin; Packing for gloves should be used as a sterile surface.
• Add 25 μg of fentanyl to 2.5 ml of 0.5% heavy bupivacaine if there is time; if delay in the delivery of fentanyl is possible - increase bupivacaine up to 3 ml.
• Local infiltration is not necessary.
• Only one attempt at spinal puncture - the second one is possible only if the correction guarantees success.
• If there is a need to start the operation, when the level of the block> T10 and the descending one - be ready to proceed to general anesthesia. Inform the woman in childbirth.

Epidural single-stage anesthesia

• Local anesthetics used: lidocaine 2%, bupivacaine 0.5%, a mixture of 50:50, L-bupivacaine 0.5%, ropivacaine 0.75%.
• Possible additives:
  • adrenaline 1: 200,000 (100 μg per 20 ml of local anesthetic solution)
  • sodium bicarbonate 8.4% (2 ml per 20 ml of lidocaine or a mixture of lidocaine with bupivacaine, 0.2 ml per 20 ml of bupivacaine);
  • fentanyl 100 μg.
• It is shown that some mixtures accelerate the effect, but the time required for their preparation should be taken into account.
• With the urgency of the 1st degree to think about the beginning of anesthesia in the ancestral hall

Emergency cesarean section requires that it is ready:

• a dropper for rapid infusion;
• vasopressor;
• oxygen supply and the ability to ventilate the lungs.

During an emergency caesarean section, the doctor should conduct a safety assessment every 15 seconds:

• Is the needle in the epidural space (ie, is there a leak)?
• Whether the puncture was spinal - whether the motor block is not redundant ± recurrent hypotension?
• Is the drug administered intravenously?
• Is the block effective? Do frequent repeated injections of the symptoms of the toxic effect of a local anesthetic are necessary?

If necessary, additional administration of medication may be necessary every 2 minutes.

Standard total volume for additional administration of 20 ml. Reduce to 15 ml, if the block is tall and dense, a woman of small stature.

Bupivacaine 0.5%

• Enter 3 ml (± 1 ml per dead space of the filter catheter); wait 30 seconds; evaluate the changes in the block (for example, the level of sensation of cold in S1, the rear fold of the foot), which may indicate spinal administration.
• Introduce another 2 ml; wait 1 min, assess symptomatology (strange taste, ringing in the ears), which may indicate an intravenous introduction.
• Introduce the rest.

Lidocaine 2%

As for bupivacaine, but:

• First, inject 2 ml (± 1 ml per dead space) of the filter catheter.
• Enter another 3 ml.
• Introduce the rest.

The doctor during the procedure such as emergency cesarean section should stay with the woman and maintain communication. Monitor blood pressure and pulse. Be ready to develop a high block. NB: if there is a suspicion or a puncture of the TMO, additional injections in the ancestral hall can not be done.

[8], [9], [10]