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 ANAESTHESIA FOR CAESAREAN SECTION

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عدد الرسائل : 199
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تاريخ التسجيل : 27/07/2008

مُساهمةموضوع: ANAESTHESIA FOR CAESAREAN SECTION   الثلاثاء مايو 05, 2009 3:28 am

The rate of caesarean section has increased over the past few decades. The overall caesarean section rate is approximately 25% in developed countries. At the Royal Women’s Hospital (RWH) in Melbourne in 2003, there were 4882 deliveries. 28% were via caesarean section. At the private hospital, which is co-located with the RWH 46% of 2666 deliveries were via caesarean section.



The indications for caesarean section include: uterine dystocia, cephalopelvic disproportion, maternal haemorrhage, acute foetal distress, previous caesarean section, placenta praevia, prolapsed cord, hypertonic uterus, abnormal presentation and deteriorating maternal medical illness (eg pre-eclampsia, heart disease, respiratory disease).



Delivery via caesarean section will avoid severe trauma to the baby by avoiding a difficult mid forceps or a vaginal breech delivery. The increased use of monitoring of foetal wellbeing in labour has made it easier to identify a foetus in distress, which accounts for the largest proportion of emergency caesarean sections.



Caesarean section is most commonly performed under regional anaesthesia in the United Kingdom, USA and Australia. At the RWH in Melbourne in the year 2000, 12% of caesarean sections were performed under general anaesthesia (GA) whilst 88% were done under regional anaesthesia. In the UK in 1997, a survey of obstetric units found that of 60 455 caesarean sections, 78% were performed under regional anaesthesia. 72% of the emergency caesarean sections were performed under regional anaesthesia.



Regional anaesthesia



Maternal mortality is higher with caesarean than with vaginal birth. Maternal mortality rates are between 0 and 105 cases per 100,000 operations.

Anaesthetic mishaps account for about 2.4% of maternal deaths. This has been halved over the 1980-1990 decade due to the increased use of regional anaesthesia. The anaesthetic related maternal mortality rate is approximately 0.17 per 100,000 live births.



In the 1970s, obstetric anaesthesia was the 3rd most common cause of direct maternal death. Most of the deaths followed general anaesthesia, particularly for emergency caesarean section.



The risk of a serious life-threatening complication with GA occurs in approximately 1:350 cases and of attempted regional anaesthesia in 1:11 900 cases (mainly due to inadequate anaesthesia requiring conversion to GA).



The other advantages of regional over general anaesthesia include: avoidance of awareness under general anaesthesia, post operative analgesia, a reduction in the incidence of deep venous thrombosis, less neonatal depression, a reduction in blood loss, quicker return of gastro-intestinal function, improved maternal bonding and the ability of both parents to participate in the birth.



There are relatively few contraindications to regional anaesthesia, the absolute contraindications are: maternal refusal, coagulopathy, infection at the injection site, uncorrected hypovolaemia and raised intracranial pressure due to a space occupying lesion.



Maternal haemorrhage (abruption, uterine rupture) produces cardiovascular instability which usually necessitates general anaesthesia. Severe foetal compromise (cord prolapse, severe foetal distress) favours the use of general anaesthesia due to the shorter time to surgical readiness in a time-critical situation.



The patient for caesarean section requires a routine pre-operative visit. Special attention should be paid to; the airway, fasting status, pregnancy-related complications, obstetric history, obstetric ultrasound, and blood group and screen (a cross match should be performed if there is a high risk for bleeding).



The patient should have the risks and side effects of the procedure explained to her and she should be told what sensations she might experience during the operation.

Consent for regional anaesthesia should be obtained during the pre-operative visit.

Aspiration prophylaxis

A pregnant patient is at a higher risk of aspiration pneumonitis than the non-pregnant patient. All patients for caesarean section, regardless of the planned anaesthetic technique should receive prophylaxis against aspiration. The patient should fast for 6 hours after a light meal and be given ranitidine 150mg the night before surgery (or 6 hours before surgery if it is an afternoon case). The dose of ranitidine should be repeated 90 mins prior to surgery and a non-particulate antacid should be given on leaving the ward for theatre. At our hospital we use 0.3M sodium citrate 30ml.



In an emergency, give 50mg ranitidine intravenously when the decision to perform a caesarean is made and administer a non-particulate antacid on leaving the ward.



Patients should be fasting in labour (allowing sips of clear fluid), particularly if they are at high-risk for an operative delivery because gastric emptying is delayed in labour.











Spinal anaesthesia

In order to reduce the risk of post dural puncture headache the smallest pencil point needle available (27 to 25G) should be used. If using a cutting needle, align the bevel parallel to the fibres of the dura. This reduces the risk of headache.



Inject Bupivacaine (plain or hyperbaric) 0.5% 2.2-2.5ml with fentanyl 10-20mcg. The use of an opioid allows for the reduction of the dose of local anaesthetic and provides early post-operative analgesia. Sufentanil (5-10mcg) can be used in place of fentanyl.



To reduce hypotension after the induction of spinal anaesthesia, co-load with 500ml of balanced salt solution or a colloid. Monitor the blood pressure and heart rate. Treat hypotension with metaraminol or phenylephrine. Ephedrine is a less effective, but widely used alternative. The mother should be positioned with a wedge under her right hip to achieve 15 degrees of left lateral tilt in order to minimise aorto-caval compression.





Epidural

A working labour epidural can be readily topped up to provide surgical anaesthesia for caesarean section using lignocaine 2%. Adding adrenaline 1:200,000 and bicarbonate (2ml of 8.4%) will speed up the onset of the block. Fentanyl may be added to allow for a reduction in the dose of local anaesthetic and improve post-operative analgesia. Inject 3ml to 5ml of local anaesthetic at a time. One may need up to 25 ml to establish surgical anaesthesia.



One of the advantages of an epidural over a spinal for caesarean section is the ability to titrate the level of the block. This reduces the risk of profound and sudden hypotension. The other obvious advantage is the unlimited duration of action if the catheter is used post operatively for analgesia. This is particularly useful for the pre-eclamptic patient.



Some of the problems with the use of an epidural for caesarean section are: the risk of inadvertent intravenous or subarachnoid injection, an increased time to surgical anaesthesia (particularly if the epidural is being inserted de novo before the caesarean section), an increased risk of post dural puncture headache if the dura is breached and a failed block in 2-6% of cases.



An inadequate block for surgery is more likely with an epidural than with a spinal. The anaesthetist needs to warn the patient of what sensations to expect during surgery. That is, some discomfort, particularly during the delivery of the baby when fundal pressure may be used. Not all sensation will necessarily be blocked. The patient can expect some sensation of touch and movement but not pain. Test for light touch as well as for cold sensation when establishing the block. The sympathetic block will be 2 segments higher than the sensory block. In order to block the pain of the incision, the dermatomal level should extend to T10-12. In order to achieve surgical anaesthesia for caesarean section one needs to block the peritoneum, which requires the block to be extended to T4.









CSE

The advantages of a combined spinal and epidural are the same as for an epidural with the added benefit of a rapid onset due to the spinal component. The dose of local anaesthetic in the spinal can be low and then extended with the epidural if necessary.

Side effects of regional anaesthesia

Hypotension is a common side effect of regional anaesthesia. A baseline maternal tachycardia may indicate relative hypovolaemia and an increased likelihood of hypotension. I personally load with fluid whilst the spinal is being inserted and use vasopressors (alpha agonists) to treat hypotension. A prophylactic infusion of phenylephrine 100mcg per min can be used. Ephedrine has been shown to increase foetal acidosis but is a reasonable option where alpha agonists are not available. Bradycardia should be treated early with atropine.



Nausea and vomiting is usually associated with hypotension or the use of opioids.



A reduced VC and ineffective cough can occur with a block extending to the thoracic segments. The patient may complain of dyspnoea due to intercostal muscle paralysis. The anaesthetist should maintain oxygenation by providing supplemental oxygen via a facemask and reassuring the patient. Diaphragmatic function is preserved so long as the block does not extend to C4. It is important to check upper limb power to exclude the possibility of an impending total spinal.



Itch occurs due to the use of neuraxial opioids. Although shivering is common, particularly with an epidural, the mechanism is not known. It can be treated with small doses of pethidine 20-25 mg or clonidine 25-50 mcg intravenously..
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عدد الرسائل : 171
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العمل/الترفيه : Anesthesiologist
تاريخ التسجيل : 09/07/2010

مُساهمةموضوع: رد: ANAESTHESIA FOR CAESAREAN SECTION   السبت مارس 19, 2011 11:15 pm

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ANAESTHESIA FOR CAESAREAN SECTION
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