LSCS

1. Anaesthesia For
LSCS
Dr. Himanshu Jangid

2. Indications for a LSCS
 The most common indications for cesarean delivery include
 “failure to progress,”
 non-reassuring fetal status,
 cephalopelvic disproportion,
 malpresentation,
 prematurity,
 and previous uterine surgery.

3. Problems Due To Physiological
Changes
 The pregnant uterus compresses the vena cava and the aorta and
obstructs blood flow.
 The conscious patient can respond by improving her position, but
under general anaesthesia this is impossible.
 Spinal or epidural anaesthesia considerably worsens the problem
due to the sympathetic blockade produced.
 By tilting the patient to the left by about 15 degrees the pressure
from the uterus on the vena cava is reduced.
 This can be achieved by tilting the operating table or by placing a
wedge under the patient's right buttock.

4. Problems Due To Physiological
Changes
 Diminished tone in the lower oesophageal sphincter
 in later pregnancy the raised intra-abdominal pressure
 altered gastro-oesophageal angle make gastric reflux more likely.
 In labour the administration of opioids markedly slows gastric
emptying.
 During induction of anaesthesia passive regurgitation of stomach
contents into the pharynx may occur, and lead to aspiration
pneumonia.

5. Problems Due To Physiological
Changes
 This is likely if the pH of the stomach contents is less than 3 (very
acidic) and more that 30 mls of fluid is aspirated.
 Minimized by
 using local anaesthesia instead of general anaesthesia when
possible,
 by reducing food intake in labour to minimise stomach contents and
 by a careful rapid sequence induction of anaesthesia using cricoid
pressure
 The stomach acid should also be neutralised if a Caesarean section
is planned.
 An intravenous H2 blocker such as ranitidine or cimetidine is
effective but takes an hour to work.
 An antacid such as 30mls of 0.3 Molar sodium citrate is reliable if
given immediately before induction of anaesthesia and will last about
1 hour

6. Problems Due To Physiological
Changes
 There is a greater increase in plasma volume than red cell mass
causing dilutional anaemia.
 Cardiac output is increased.
 Patients with cardiac disease (either congenital or valvular) are at
particular danger during pregnancy.

7. Problems Due To Physiological
Changes
 There is a decrease in the resting lung volume caused by pressure
from the enlarged uterus,
 There is an increase in the basal metabolic rate.
 Oxygen reserves are therefore diminished
 Hypoxia develops rapidly if airway problems occur.

8. Problems Due To Physiological
Changes
 Many drugs used in anaesthesia cross the placental barrier
 Thus may affect the fetus, particularly opioids such as morphine and
sedatives such as diazepam.
 During anaesthesia these drugs should be avoided until the
umbilical cord has been clamped.

9. Goals
 General goals in choosing anesthesia are
 (1) the safety of the mother;
 (2) the safety of the baby;
 (3) the comfort of the mother
 (4) the ability to perform the surgery under that anesthetic technique.

10. Choice of Anaesthesia
 The choice of anesthesia for cesarean section is determined by
multiple factors
 indication for operating,
 its urgency,
 patient and obstetrician preferences,
 and the skills of the anesthetist.

11. Choices for Anaesthesia
 Neuraxial Anesthesia
 Spinal Anesthesia
 Epidural Anesthesia
 CSE
 Continous spinal
 General Anaesthesia

12. Regional vs General
Anaesthesia
 Regional anesthesia has become the preferred technique
 General anesthesia has been associated with higher maternal
mortality.
 Deaths associated with general anesthesia
 related to airway problems,
 such as inability to intubate,
 inability to ventilate,
 or aspiration pneumonitis,
 whereas deaths associated with regional anesthesia are related to
 excessively high neural blockade
 local anesthetic toxicity.

13. Regional vs General
Anaesthesia
 Advantages of regional anesthesia include
 (1) Less neonatal exposure to potentially depressant drugs,
 (2) A decreased risk of maternal pulmonary aspiration,
 (3) An awake mother at the birth of her child, with the father also
present if desired, and
 (4) The option of using spinal opioids for postoperative pain relief.
 The choice between spinal and epidural anesthesia is often based
on physician preferences.

14. Spinal Anaesthesia

15. Spinal Anaesthesia
 Advantages
 It has a very rapid onset and provides a dense neural block.
 Little risk of local anesthetic toxicity and minimal transfer of drug to
the fetus.
 Failures (including incomplete or patchy blocks) are very infrequent
with spinal anesthesia.
 Disadvantages
 The finite duration of anesthesia
 A higher incidence of hypotension.

16. Spinal Anaesthesia
 Hyperbaric solutions : adjust block height by adjusting table position.
 Despite achieving an adequate (T4) block, some degree of visceral
discomfort during cesarean section, particularly in situations in which
the obstetrician exteriorizes the uterus.

 The quality of the spinal anesthesia can be improved by the addition
of epinephrine, morphine,fentanyl, or sufentanil.

17. Spinal Anaesthesia
 Hyperbaric bupivacaine is the most commonly used agent
 Its duration of action of 1.5 to 2 hours is well matched to the duration
of surgery in most cases.
 Most practitioners now use a set dose of hyperbaric bupivacaine.
 Neither patient height, weight, nor body mass index appears to
correlate with block height.
 Doses above 15 mg significantly increase the risk of complications,
including high block, and are not recommended.

18. Spinal Anaesthesia
 Epinephrine 0.1 mg can enhance the quality of the block
 Adding 12.5–25 mcg of fentanyl or 5–10 mcg of sufentanil to the
local anesthetic solution enhances the intensity of the block and
prolongs its duration without adversely affecting neonatal outcome.
 Addition of preservative-free morphine, 0.2–0.3 mg, can prolong
postoperative analgesia up to 24 h but requires special monitoring
for delayed postoperative respiratory depression.

19. Spinal Anaesthesia
 Cesarean section requires a T4 sensory level.
 Because of the associated high sympathetic blockade, all patients
should receive a 1000- to 1500-mL bolus of lactated Ringer's
injection prior to neural blockade.
 Crystalloid boluses do not consistently prevent hypotension but can
be helpful in some patients.
 Smaller volumes (250–500 mL) of colloid solutions, such as albumin
or hetastarch, are more effective.

20. Spinal Anaesthesia
 After injection of the anesthetic, the patient is placed supine with left
uterine displacement; supplemental oxygen (40–50%) is given;
blood pressure is measured every 1–2 min until it stabilizes.
 Intravenous ephedrine, 10 mg, should be used to maintain systolic
blood pressure > 100 mm Hg.
 Small intravenous doses of phenylephrine, 25–100 mcg, or an
infusion up to 100 mcg/min may also be used safely.

21. Spinal Anaesthesia
 Some studies suggest less neonatal acidosis with phenylephrine
compared to ephedrine.
 Prophylactic administration of ephedrine (5 mg intravenous or 25 mg
intramuscular) has been advocated by some clinicians for spinal
anesthesia, as precipitous hypotension may be seen but is not
recommended for most patients because of a risk of inducing
excessive hypertension.

22. Spinal Anaesthesia
 Hypotension following epidural anesthesia typically has a slower
onset.
 Slight Trendelenburg positioning facilitates achieving a T4 sensory
level and may also help prevent severe hypotension.
 Extreme degrees of Trendelenburg may interfere with pulmonary
gas exchange.

23. Epidural Anaesthesia
 Epidural anesthesia is preferred over spinal anesthesia by some
clinicians because of the more gradual decrease in blood pressure
associated with epidural anesthesia.
 Continuous epidural anesthesia also allows better control over the
sensory level.
 Epidural anesthesia for cesarean section is generally most
satisfactory when an epidural catheter is used.

24. Epidural Anaesthesia
 The catheter facilitates achieving an initial T4 sensory level, allows
supplementation if necessary, and provides an excellent route for
postoperative opioid administration.
 After a negative test dose, a total of 15–25 mL of local anesthetic is
injected slowly in 5-mL increments.

25. Epidural Anaesthesia
 Lidocaine 2% (with or without 1:200,000 epinephrine) or
chloroprocaine 3% is most commonly used.
 Addition of fentanyl, 50–100 mcg, or sufentanil, 10–20 mcg, greatly
enhances the intensity of the block and prolongs its duration without
adversely affecting neonatal outcome.
 sodium bicarbonate (7.5% or 8.4% solution) to local anesthetic
solutions to increase the concentration of the nonionized free base
and produce a faster onset and more rapid spread of epidural
anesthesia.
 (1 mEq/10 mL of lidocaine and 0.05 mEq/10 mL of bupivacaine or
ropivacaine)

26. Epidural Anaesthesia
 If pain develops as the sensory level recedes, additional local
anesthetic is given in 5-mL increments to maintain a T4 sensory
level.
 "Patchy" anesthesia prior to delivery of the baby can be treated with
10–20 mg of intravenous ketamine or 30% nitrous oxide.
 After delivery, intravenous opioid supplementation may also be
used, provided excessive sedation and loss of consciousness are
avoided.

27. Epidural Anaesthesia
 Pain that remains intolerable and unresponsive to these measures
necessitates general anesthesia with endotracheal intubation.
 Nausea can be treated intravenously with ondansetron 4 mg or
metoclopramide 10 mg.

28. Epidural Anaesthesia
 Epidural morphine, 5 mg, at the end of surgery provides good to
excellent pain relief postoperatively for 6–24 h.
 An increased incidence (3.5–30%) of recurrent herpes simplex
labialis infection has been reported 2–5 days following epidural
morphine in some studies.
 Postoperative analgesia can also be provided by continuous
epidural infusions of fentanyl, 25–75 mcg/h, or sufentanil, 5–10
mcg/h, at a volume rate of approximately 10 mL/h.
 Epidural butorphanol, 2 mg, can also provide effective postoperative
pain relief, but marked somnolence is often a troublesome side
effect.

29. CSE Technique
 Provides rapid onset of dense surgical anesthesia while allowing the
ability to prolong the block with an epidural catheter.
 Because the block can be supplemented at any time, the CSE
technique allows the use of smaller doses of local spinal anesthetics
thus reduce the incidence of high spinal block and hypotension.
 Potential problems of the CSE technique for cesarean delivery
include
 an inability to test the catheter,
 the possibility of a failed epidural catheter after spinal injection,
 the risk of enhanced spread of previously injected spinal drug after
use of the epidural catheter.

30. CSE Technique
 The classic technique required the use of large-bore epidural
needles; newer techniques use a 32-gauge microcatheter inserted
through a 26-gauge spinal needle.
 Abandoned after withdrawal of these catheters by the FDA.
 The advantages of continuous spinal anesthesia, however, remain,
and macrocatheters (e.g., placing an epidural catheter intrathecally)
can be used in high-risk parturients.

31. Continuous spinal anesthesia
 To perform continuous spinal anesthesia, the anesthesiologist
pierces the dura with an epidural needle and then threads the
epidural catheter 3 to 4 cm within the intrathecal space.
 Catheter placement can be tested by aspiration of CSF.
 Because a catheter is being used, smaller doses can be given in an
incremental fashion.
 Such administration is particularly advantageous in high-risk
parturients such as those with cardiac disease, respiratory disease,
morbid obesity, and neuromuscular disease.

32. Continuous spinal anesthesia
 To reduce the risk of headache after this technique,
 The epidural needle should be turned so that it is parallel to
the dural fibers at the time of insertion.
 Leaving the epidural catheter in situ for more than 12 hours
 Injecting a bolus of preservative-free normal saline before
removal of the catheter.

33. General Anaesthesia

34. General Anaesthesia
 Advantages:
 It can be given very quickly,
 blood pressure is more easily controlled,
 breathing is more easily controlled once the ability to breathe for the
patient is obtained.
 On patients with bleeding and clotting abnormalities, patients with
neurological problems, patients with infections that might be spread
to the spinal area if regional anesthesia is done, etc.

35. General Anaesthesia
 Disadvantages:
 the mother is unconscious and therefore unable to participate in the
process of birth or interact with the baby once it is delivered.
 After the operation, general anesthesia wears off relatively quickly
and can result in greater postoperative pain.

36. Pre operative preparation
 Prophylaxis against severe nonparticulate aspiration pneumonia with
30 mL of 0.3 M sodium citrate 30–45 min prior to induction.
 Intravenous ranitidine, 50 mg, and/or metoclopramide, 10 mg, 1–2 h
prior to induction; such factors include morbid obesity, symptoms of
gastroesophageal reflux, a potentially difficult airway, or emergent
surgical delivery without an elective fasting period.
 Premedication with oral omeprazole, 40 mg, at night and in the
morning also appears to be highly effective in high-risk patients

37. Pre operative preparation
 Although anticholinergics theoretically may reduce lower
esophageal sphincter tone, premedication with a small dose
of glycopyrrolate (0.1 mg) helps reduce airway secretions and
should be considered in patients with a potentially difficult
airway.

38. Pre operative preparation
 Caesarean sections are frequently performed as emergencies in
unprepared patients.
 The procedure may be complicated by an unfasted patient, fetal
distress, severe haemorrhage, pre-eclampsia etc.
 Prepare and check equipment for obstetric anesthesia in
advance, so that your apparatus and drugs are immediately to
hand.
 This saves valuable time in an urgent case.
 Particular attention should be paid to the function of the
laryngoscopes, the endotracheal tube and cuff, and the suction
apparatus.

39. Suggested Technique of General
Anesthesia for Cesarean Section
 1. Administer a nonparticulate antacid. Additional agents such as
metoclopramide or an H2 blocker should be considered in patients at
high risk for aspiration or failed intubation.
 2. Apply routine monitors, including electrocardiography, pulse
oximetry, and capnography. Ensure that suction is functioning and
that equipment to correct failed intubation is readily available.
 3. Position the patient in a manner to achieve left uterine
displacement and optimal airway position.
 4. De-nitrogenate with a high flow of oxygen for 3-5 minutes or 4
vital capacity breaths.

40. Technique of General
Anesthesia
 After the drapes are applied and the surgeon is ready, initiate a
rapid-sequence induction with thiopental, 4.0-5.0 mg/kg, and
succinylcholine, 1.0-1.5 mg/kg.
 Apply cricoid pressure and continue until correct position of the
endotracheal tube is verified and the cuff is inflated.

41. Technique of General
Anesthesia
 In hypotensive crises, ketamine, 1.0-1.5 mg/kg, should be
substituted for thiopental.
 A defasciculating dose of muscle relaxant is not necessary.
 6. Ventilate with 50% oxygen and 50% nitrous oxide and a volatile
anesthetic as necessary.
 Maintain normocarbia and use muscle relaxation as necessary with
either a nondepolarizing muscle relaxant or succinylcholine infusion.

42. Technique of General
Anesthesia
 7. After delivery, increase nitrous oxide to 70%, discontinue or
reduce the volatile anesthetic, and administer an opioid and a
benzodiazepine.
 Add oxytocin to intravenous fluids.
 8. Insert an orogastric tube before completion of surgery.
 9. Reverse neuromuscular blockade as necessary at completion of
surgery.
 10. Extubate when the patient is awake, the anesthesia is
adequately reversed, and the patient is following commands.

43. Failed Intubation
 Physical changes associated with pregnancy, including
 weight gain,
 enlarged breasts,
 oropharyngeal edema
 Mallampati class 4 airway,
 a short neck,
 protruding maxillary incisors,
 and mandibular recession, can complicate endotracheal
intubation.

44. Failed Intubation drill
 Failed intubation drill.
 An appropriate course of action is as follows:
 Maintain cricoid pressure.
 Oxygenate using the facemask.
 Turn the patient on to the left side into a head down position and
allow her to wake up.
 Proceed with local anaesthetic block when the patient has regained
consciousness.
 If the operation is needed very urgently (eg for fetal distress or an
antepartum haemorrhage), re-establish spontaneous respiration
after the suxamethonlum has worn off, and continue the anaesthetic
under a facemask using nitrous oxide, oxygen and halothane or an
ether based technique.
 If problems are encountered with the airway, it may be necessary to
wake the patient up and use a regional technique.
 At all times ensure that the patient is well oxygenated.

46. Pre eclampsia
 Preeclampsia has been defined as hypertension occurring after
20 weeks’ gestation or in the early postpartum period and
returning to normal within 3 months after delivery or onset after
20 weeks’ gestation and at least one of the following:
 • Proteinuria higher than 300 mg/24 hr
 • Oliguria or a serum-plasma creatinine ratio greater than
0.09 mmol/L
 • Headaches with hyperreflexia, eclampsia, clonus, or visual
disturbances
 • Increased liver enzymes, plasma glutathione S-transferase-alpha
1-1, or serum alanine aminotransferase or right abdominal quadrant
pain
 • Thrombocytopenia, increased lactate dehydrogenase (LDH),
hemolysis, disseminated intravascular coagulation (DIC)
 • Intrauterine growth retardation

47. Pre eclampsia
 Clinical Features
 The upper airway may become edematous in a preeclamptic woman
and result in the potential for airway compromise or difficulty in
intubation,
 Pulmonary edema occurs in up to 3% of these patients.
 The cardiovascular effects of preeclampsia
1. Hyperdynamic circulation, high cardiac output, normal to increased
systemic vascular resistance (SVR), and normal or slightly
decreased blood volume and filling pressures
2. Normal cardiac output and lower filling pressures, but increased
SVR
3. Highly elevated SVR, but reduced blood volume and decreased left
ventricular function

48. Pre eclampsia
 Treatment
 The mainstay of therapy in preeclampsia is
 control of hypertension,
 prevention of seizures,
 and delivery of the fetus.
 Hydralazine and labetalol are commonly used as antihypertensives
 Other agents include nitroglycerin, nifedipine, and esmolol. Sodium
nitroprusside may also be used, but only in the short term because
of a risk of cyanide toxicity in the fetus.

49. Pre eclampsia
 Magnesium sulfate is the drug of choice for seizure control and
prevention of recurrent eclamptic seizures.
 Initial dosing is 4 g MgSO4 given intravenously over a 10-minute
period, followed by a maintenance infusion at 1 g/hr.
 In the presence of renal failure, the rate of infusion should be
modified by evaluating serum magnesium levels.
 Magnesium has a narrow therapeutic index, with serum levels
between 2 and 3.5 mmol/L being safe and effective.

50. Anesthetic management
 Anesthetic management of a preeclamptic patient includes
 a detailed preanesthetic assessment that focuses on the severity of
the condition, associated features and systemic involvement,
evaluation of the airway, fluid status, and blood pressure control.
 Investigations should include a complete blood cell count, renal
profile, and liver function tests.

51. Anesthetic management
 Coagulation studies should be performed.
 However, before considering neuraxial analgesia or anesthesia, a
recent platelet count should be evaluated.
 DIC may require the administration of whole blood, platelets, fresh
frozen plasma, and cryoprecipitate. Initiation of neuraxial analgesia
during DIC is contraindicated.

52. Anesthetic management
 Neuraxial (epidural, spinal and combined spinal-epidural) techniques
offer many advantages for labor analgesia and can be safely
administered to the parturient with preeclampsia.
 Dilute epidural infusions of local anesthetic plus opioid produce
adequate sensory block without motor block or clinically significant
sympathectomy.
 the risk of a failed endotracheal intubation must be weighed against
the risk of transient hypotension when deciding between general and
regional anesthesia for cesarean delivery for the patients with
severe preeclampsia-eclampsia.

53. CONCLUSION
 To summarize, general anesthesia should be utilized only for a true
emergency when the situation will not allow any other options.
 Regional anesthesia (either spinal or epidural) offers an effective
means of anesthesia for cesarean section while allowing the mother
to remain awake
 The regional techniques also offer some advantages for the control
of pain after the operation.
 As with any anesthetic, make sure you discuss the options, risks
and benefits with a anesthesiologist who know your individual
condition and situation.

54. .
THANK
YOU