Emergency cesarean section

An emergency caesarean section is performed in the following situations:

1. Immediate threat to the life of the mother or child.
2. Pathology of the mother or fetus that does not pose an immediate threat to life.
3. The need for early delivery without pathology of the mother or fetus.
4. At a time that suits both the patient and the obstetrician.

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Preoperative preparation for emergency cesarean section

• A quick preoperative examination is performed to check for allergies, medications taken, previous anesthesia, and overall health. It is also necessary to clarify when the last meal or drink was consumed.
• Establish intravenous access if not already established. Initiate rehydration - rapid crystalloid infusion, or colloid/blood if hypovolemic.
• 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 a tilt to the left side - put something under the right or tilt the plane of the table. If no delays are expected with the onset of anesthesia and surgery - this position can be used immediately. If some delay occurs - the position completely on the left side is preferable, since in this position aortocaval compression is minimal.
• Preoxygenation should be started as soon as the patient is on the operating table.

Emergency Caesarean Section: Choice of Anesthesia Method

• General anesthesia can be initiated more quickly than any other anesthesia, but it is associated with a greater number of possible life-threatening complications for the mother and the rapid development of fetal depression. Factors that need to be clarified quickly to inform the choice of anesthesia include: the urgency of the situation (check with the surgeon), the mother's preference (ask the patient), and specific contraindications and difficulties (short history, as mentioned above, preoperative airway examination, body mass index, back, coagulation status). If regional anesthesia is attempted, a time limit must be determined before general anesthesia is initiated.
• Approaches to using an already placed epidural catheter vary.

An epidural catheter that provides adequate analgesia for labour may, in some cases, be insufficient to ensure a painless operation. Some hospitals routinely inject a dose of local anaesthetic into the epidural catheter as soon as the decision is made to perform a caesarean section, while others attempt a spinal section whenever possible. An alternative selective approach is described below.

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General anesthesia

• Formally, preoxygenation before general anesthesia involves breathing 100% oxygen through a tightly fitting face mask for 3 min. Additional CPAPs or several deep breaths can reduce airway collapse and improve ventilation/perfusion ratios, as well as denitrogenation and PaO2. Three minutes of tidal volume ventilation provides more effective denitrogenation than preoxygenation with four VEP breaths.
• In case of hypovolemia or hypotension in the mother, it is advisable to induce anesthesia with ketamine or etomidate rather than thiopental.
• In case of fetal insufficiency, maintain 100% FiO2 during delivery, increase the concentration of inhaled inhalation anesthetic to compensate for the lack of N20.

Spinal anesthesia

• In the most urgent situations, a "rapid sequence spinal anesthesia" may be required. The anesthesiologist knows the position for the spinal puncture, but due to prolapse or compression of the umbilical cord, sometimes sitting or lying on the side must be excluded. After the spinal puncture and the administration of local anesthetic, the patient is placed on her back, tilted to the left side.
• Administration of an additional lipophilic opioid (25 mcg fentanyl or 0.3 mg diamorphine) may reduce discomfort for a certain level of sensory block, but waiting for this drug to arrive should not be a reason to delay the onset of spinal anaesthesia. It should be remembered that the ampoule packaging may not be sterile.
• A given dose will produce a higher level of spinal block if given after an epidural. This effect is greater the larger the volume (volume effect) of the recently given dose of concentrated local anaesthetic (additional block effect). Similarly, a dangerously high level of spinal block that may require intubation is more common after an epidural (1 in 60 versus 1 in several thousand after spinal alone), and the risk is thought to be higher after a recent epidural. The doses to give for spinal block in this situation are the subject of much debate: too high a dose will produce a high block, too low a dose will produce an insufficient block.

In cases of urgency level 2 or 3, low-dose combined spinal-epidural anesthesia is sometimes recommended.

In more urgent situations, the general opinion is in favor of a single spinal injection with a reduction in the local anesthetic dose by 20-40%.

Rapid sequence spinal anesthesia

• Arrange for additional personnel to monitor and catheterize the vein - do not initiate spinal insertion until an IV catheter is in place and secured.
• During an attempt at spinal anesthesia, the patient must be preoxygenated.
• No-touch technique - gloves only; chlorhexidine on a sterile napkin; use the glove packaging as a sterile surface.
• Add 25 mcg fentanyl to 2.5 ml 0.5% heavy bupivacaine if time permits; if delay in fentanyl delivery is possible, increase bupivacaine to 3 ml.
• Local infiltration is not necessary.
• Only one attempt at spinal puncture - a second is only permissible if the correction guarantees success.
• If it becomes necessary to start the operation when the block level is >T10 and descending - be prepared to switch to general anesthesia. Inform the woman in labor.

Epidural single-stage anesthesia

• Local anesthetics used: lidocaine 2%, bupivacaine 0.5%, their mixture 50:50, L-bupivacaine 0.5%, ropivacaine 0.75%.
• Possible additives:
  • adrenaline 1:200,000 (100 mcg 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 mcg.
• Some mixtures have been shown to speed up the effect, but the time it takes to prepare them should be taken into account.
• In case of 1st degree urgency, consider initiating anesthesia in the delivery room.

An emergency cesarean section requires that you have the following items ready:

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

During an emergency cesarean section, the physician should perform a safety assessment every 15 seconds:

• Is the needle in the epidural space (i.e. is there a leak)?
• Did the spinal puncture fail - is there excessive motor block ± recurrent hypotension?
• Is the drug administered intravenously?
• Is the block effective - are frequent repeat injections necessary ± symptoms of local anesthetic toxicity?

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

The standard total volume for additional administration is 20 ml. Reduce to 15 ml if the block is high and dense, the woman is short.

Bupivacaine 0.5%

• Inject 3 ml (±1 ml for filter catheter dead space); wait 30 sec; assess block changes (eg, S1 cold sensation, foot dorsiflexion) that may indicate spinal administration.
• Administer another 2 ml; wait 1 min, assess symptoms (strange taste, ringing in the ears), which may indicate intravenous administration.
• Enter the rest.

Lidocaine 2%

As for bupivacaine, but:

• First, inject 2 ml (±1 ml for the “dead space” of the filter catheter).
• Add another 3 ml.
• Enter the rest.

During a procedure such as an emergency cesarean section, the doctor must remain with the woman and maintain communication. Monitor blood pressure and pulse. Be prepared for the development of a high block. NB: if a puncture of the dura mater has occurred or is suspected, additional injections cannot be made in the delivery room.

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