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Abstract

Anaesthesia practice for caesarean section (CS) has evolved in the past 20 years. This article aims to update occasional obstetric anaesthesiologists, obstetricians and clinicians involved in the management of pregnant women on the latest guidelines and recommendations for anaesthesia management, including pre-operative evaluation, informed consent, intra-operative and postoperative management for CS. In addition, this article will also summarise the management of CS associated emergencies such as difficult intubation, obstetric major postpartum haemorrhage, local anaesthetic toxicity and (pre-) eclampsia. At the end of the article, a charted summary will be provided as an aide memoire.

Keywords

Caesarean section anaesthesia informed consent difficult intubation haemorrhage local anaesthetic toxicity pre-eclampsia eclampsia

Introduction

Anaesthetic management of caesarean section (CS) has an important influence on maternal and foetal outcomes. The anaesthesia practice for CS has changed with time, reflecting the latest research evidence, international guidelines and changes in demographics of the parturient. The purpose of this article is to give occasional obstetric anaesthesiologists, clinicians and health professionals involved in peri-partum care an overview of the anaesthetic management for CS and the latest recommendations on management of anaesthetic and obstetric emergencies arising from CS. We also aim to present a charted summary to serve as a useful aide-memoire at the end of this article. The readers can store the summary in their hand held devices for quick reference in the future. This article aims to explain the summary guide in more detail and outlines the source of the evidence. This article does not aim to replace formal teaching, training, textbooks or local departmental guidelines.

Pre-operative evaluation

The aims of pre-operative evaluation are as follows:

To identify medical and obstetric comorbidities that may increase anaesthetic and surgical risks.

To establish the urgency and reason of CS.

To obtain anaesthetic informed consent.

To enable patient preparation.

To identify medical and obstetric comorbidities

In addition to the general anaesthetic history and examination, anaesthesiologists should enquire about obstetric specific issues during the pre-operative evaluation. Comprehensive pre-operative assessment of complicated obstetric patients, which should be done early during the antenatal period,^1,2 is outside the scope of this article. It is important to note that many hospitals have established anaesthetic antenatal clinics and complicated patients may have already been reviewed in such clinics where plans such as early labour epidural might have been drafted. Anaesthetic involvement should start from early antenatal period for complicated patients (e.g. congenital heart diseases); and for uncomplicated patients, early patient education on various anaesthetic and analgesic options for vaginal and caesarean deliveries is important. Anaesthesiologists should aim to be familiar with all the patients in labour ward as some of them may benefit from early anaesthetic involvement such as early labour epidural analgesia (e.g. obese parturient or twin pregnancies etc.). The key relevant issues in clinical assessment of obstetric patients are summarised in the summary sheet.

Establish reason and urgency of CS

Anaesthesiologists need to establish the reason for CS for two reasons:

To identify anaesthesia and surgical risks as explained above.

For emergency CS, urgency depends on the indication for CS and this will influence the choice of anaesthetic technique. Table 1 shows a commonly used system for CS categorization.³

Table 1.

Categories of caesarean section.

Category 1	Immediate threat to life of woman or foetus (e.g. placental abruption, uterine rupture, active bleeding, severe foetal compromise)
Category 2	Maternal or foetal compromise, not immediately life threatening (e.g. breech, previous caesarean section in labour, non-reassuring foetal status (NRFS))
Category 3	Needing early delivery but no maternal or foetal compromise (e.g. low AFI, previous caesarean section but not in labour
Category 4	At a time to suit the woman and maternity team

Foetal distress and extreme foetal bradycardia frequently cause much anxiety for the patients, relatives and staff. While awaiting CS, anaesthesiologists and obstetricians should consider intrauterine foetal resuscitation.⁴ Communication between obstetricians and anaesthesiologists is vitally important and should start from the moment the parturient is admitted to labour ward through to the post-partum period. The key steps are shown in the summary sheet.

Obtaining informed consent

There are unique considerations for consent taking in obstetrics, the main being capacity during active labour and the lack of time during emergency CS. Ideally the consenting process should be initiated when the patient is not in pain or under distress e.g. during antenatal consultation. Nonetheless, the review by Broaddus and Chandrasekhar showed that ‘despite pain and anxiety, women maintain the capacity to understand and recall inform imparted during labour’.⁵

There is a wide variation in information given to mothers with respect to the complications associated with neuraxial blocks (NABs) and their actual incidence.⁶ The amount and the nature of information that should be provided to the patient should be determined by the question: ‘What would this particular patient regard as relevant when coming to a decision about which of the available options to accept?’⁷ When counselling for the risks and benefits between general anaesthesia (GA) and regional anaesthesia (RA), the increased risk of maternal airway complication and neonatal depression that are associated with GA,⁸ and the occasional requirement of conversion from RA to GA, have to be mentioned. A summary of the risks counselled for obstetric anaesthetic procedures for CS is shown in the summary sheet.^9–13

Patient preparation for anaesthesia

Due to increased risk of gastric reflux and regurgitation, gastric acid prophylaxis is commonly used in obstetric anaesthesia. H₂ receptor blocker, oral or intravenous (IV), depending on urgency of the CS, and antacids such as sodium citrate are commonly used. If time allows, basic investigation such as full blood count and blood group and screen should be carried out before every CS, and other investigation as appropriate. However, urgent CS should not be delayed due to lack of investigation. In emergency CS, the anaesthesiologist could start anaesthesia while waiting for investigation result.

Intraoperative management

Preparation for CS

Irrespective of the mode of anaesthesia and patients’ risk factors, every CS should be prepared in such a way that a patient can be resuscitated efficiently if haemorrhage occurs or conversion to GA becomes necessary. Please see summary sheet for preparations required for CS.

Modes of anaesthesia

The mode of anaesthesia is dependent on patient, anaesthetic and obstetric considerations. In general, RA (spinal anaesthesia, combined spinal epidural or epidural top up) is preferred over GA due to concerns of increased incidence of difficult airway and risk of pulmonary aspiration in the obstetric population. The common indications of general anaesthetics are maternal request, very urgent CS, RA contra-indicated (e.g. coagulopathy, maternal hypovolaemia) and failed RA. RA has the added benefit of minimal maternal-foetal drug transfer and allowing skin-to-skin bonding after birth. In certain parturient where CS is anticipated to be prolonged and difficult, anaesthesiologist may prefer the use of a neuraxial catheter to allow local anaesthetic (LA) top up in prolonged operation. The commonly used techniques for CS are shown in the summary sheet.

Coagulation abnormalities and NAB

NAB in patients with coagulation abnormalities require special consideration as they have increased risk of vertebral canal haematoma post block. A guide of safety threshold is shown in the summary sheet. It excludes patients with trauma, sepsis, massive transfusion, disseminated intravascular coagulation (DIC) and liver failure.¹⁴

Management of NAB or GA associated hypotension

It is common post NAB or GA induction that maternal hypotension occurs. It is important to treat maternal hypotension as it may decrease uteroplacental blood flow. Treatment threshold for hypotension should depend on normal maternal blood pressure, presence of symptoms (e.g. hypotension induced dizziness, nausea and vomiting) and foetal condition (if undelivered). A rough guide is to avoid blood pressure less than two thirds of normal maternal blood pressure. Controversies regarding the appropriate treatment of maternal hypotension had revolved around the use of fluids pre-loading versus co-loading and type of vasopressor (phenylephrine versus ephedrine due to effects on foetal acid-base status).¹⁵ For fluid therapy, co-loading may be more effective than pre-loading but fluid resuscitation remains an unreliable treatment for maternal hypotension.¹⁶ Vasoconstrictors are usually needed, of which phenylephrine may be a better choice compared to ephedrine as it leads to better foetal acid-base status. Phenylephrine boluses of 20–100 mcg or infusion of 25–50 mcg/min after spinal anaesthesia seem effective.¹⁷ Maternal reflex bradycardia may occur after phenylephrine administration which can be treated with glycopyrrolate 200–300 mcg. Ephedrine in boluses of 3–6 mg is a useful second line vasopressor when phenylephrine alone cannot achieve the desired vasopressor effect.

Management of the obstetric airway

Difficult and/or failed intubation is more common in pregnant patients and is associated with increased risk of morbidity and mortality compared to the general population. Guideline published by the Obstetric Anaesthetists’ Association and Difficult Airway Society for the management of difficult and failed tracheal intubation in obstetrics provides useful frameworks and algorithms on how to optimize obstetric airway management and algorithm for failed intubation.¹⁸ The essential take home messages are:

Preparation of additional airway equipment as deemed necessary (difficult airway trolley).

Presence of specialist anaesthesiologist.

Ramp patient up for intubation such that the tragus of the ear is in the same horizontal plane as the sternal notch.

Ensure the operating table can be tilted.

Properly applied cricoid pressure (right angle to tilt), which should be released partially if impairing view of cords, mask ventilation or LMA insertion.

Pay meticulous attention to effective pre-oxygenation, with the aim of achieving an end tidal oxygen concentration (etO₂) of ≥90% before anaesthetic induction.

Consider concurrent oxygenation via nasal cannula (5 l/min) during pre-oxygenation and intubation.

One can also consider the use of high flow humidified nasal oxygenation systems (up to 60 l/min) to increase apnoea time,¹⁹ although studies in the obstetric population are lacking.

Consider gentle face mask ventilation with peak airway pressure <20 cmH₂O while waiting for muscle relaxant to take effect.

Use short handle laryngoscope or videolaryngoscope ± ETT introducer as default.

Use adequate dose of muscle relaxant: succinylcholine 1.5–2 mg/kg or rocuronium 1–1.2 mg/kg. If rocuronium is used, sugammadex in a dose of 16 mg/kg should be readily available for reversal of rocuronium in situations of ‘cannot intubate and cannot ventilate’.

Team decision whether to proceed with CS or to abandon and wake upon intubation failure should be made before induction. Factors that influence the decision include maternal condition, anaesthesiologist experience, aspiration risk, surgical factors, feasibilities of alternative airway devices and anaesthesia method and foetal condition.

Three attempts to intubation only, the third attempt should be done by experienced personnel, thereafter,

The focus should be on oxygenation either with a supraglottic airway device (SAD) or face mask. Early insertion of SAD should be considered if face mask ventilation is difficult or the decision to proceed with CS has been decided. Second generation SAD with a gastric channel is preferred.

Call for help and declare emergency early.

If ‘cannot intubate and cannot ventilate’ occurs, front of neck procedure (e.g. cricothyroidotomy) to gain airway access is necessary.

If attempts to oxygenate fail and cardiac arrest occurs, start maternal cardiopulmonary resuscitation (CPR) and peri-mortem CS. Preparation of difficult airway and management of obstetric fail intubation is shown in the summary sheet.

Antibiotics prophylaxis

In the past, fear of unnecessary foetal exposure to antibiotics masking foetal infection and leading to emergence of resistant strains has discouraged clinicians from giving antibiotics before delivery of the baby (before clamping of the umbilical cord). However, recent evidence strongly advocates administration of antibiotics before knife to skin, as this practice significantly reduces the rate of endometritis with no significant neonatal adverse effects.^20,21 The antibiotics that are commonly used are third generation cephalosporin such as cefazolin 2 g IV bolus or Augmentin 1.2 g IV bolus or IV clindamycin 600–1200 mg (for penicillin allergy).

Uterotonics

Oxytocin (Syntocinon) is used to reduce the risk of post-partum haemorrhage (PPH) from uterine atony. However, in high doses or rapid IV infusions, it can cause hypotension, cardiac dysrhythmias and ischaemia which can be fatal in patients with cardiac disease or haemodynamic instability.²² There has been much debate in recent years regarding its effective dose, which varies between 1 and 3 IU as a slow bolus. In general, elective CS requires a smaller dose for effective uterine contraction as compare with emergency CS especially when labour had been augmented.^23,24 Our institution has a pragmatic approach to oxytocin dose at CS, which is 5 IU slow IV after cord clamping and if obstetricians feel the uterus is still not well contracted after oxytocin, an infusion of 5–10 IU h⁻¹ for 4 h will be started. An alternative to oxytocin is carbetocin (Duratocin) 100 mcg IV slow bolus. Studies had shown that it is more effective in preventing PPH at CS,²⁵ but its safety in parturient with cardiac diseases and haemodynamic instability has not yet been proven. For patients who are at high risk of PPH and require other uterotonics, please see under major PPH. A list of commonly used uterotonics, their doses and side effects is shown in the summary sheet.

Post-operative management

Analgesia

Post-operative analgesia is important for maternal well-being and should start intra-operatively. A common post-CS analgesic combination in our institution is shown in the summary. In patients who are at high risk of or suffer from post-operative nausea and vomiting (PONV), anti-emetics should be considered.

Precaution in breast feeding mothers

Nursing mothers are often reluctant to take post CS analgesia because of the fear of adverse effects of the drugs on the infants. One should advise nursing mothers that the harmful effects of excessive pain on maternal and infant wellbeing (decreased ability to breast feed and bond with the infant) should be balanced against the possibilities maternal transfer of drugs into breast milk and causing harm. A multimodal strategy is widely adopted, with the analgesic choice based on knowledge of transfer characteristics into breast milk and potential impact on the infant. The lowest possible effective dose should be used and the infant should not be breastfed when drug levels in breast milk peak.²⁶ In general, regular paracetamol and NSAID in short term use are safe and milk levels are low. Ibuprofen (600–800 mg oral every 8 h) has the best-documented safety, followed by mefenamic acid (most commonly prescribed in our local setting) and ketorolac. The use of COX2 specific inhibitors like celecoxib and parecoxib also showed no harm. The use of naproxen and indomethacin, however, is less recommended.²⁷ Short-term maternal use of opioids is also considered safe and rarely presents a hazard to the newborn.^26,28,29 The worry about opioid exposure in breast milk is respiratory depression in the infant, leading to apnoea and hypoxic sequelae. Morphine is the opioid of choice as only small amounts reach the infant.³⁰ Lipophilic opioids like fentanyl and alfentanil are also not likely to cause problems. There may be minimal risk with the use of oxycodone and tramadol in the first 3 days after CS as breast milk consumption by the neonate is not too high. Repeated doses thereafter should be used with caution as milk intake increases and infant should be monitored for central nervous system depression. The use of codeine and pethidine is not recommended.

Post-operative follow-up

It is good practice for anaesthesiologists to follow their patients post-operatively. This practice is even more important in obstetric anaesthesia. Post-operative follow-up allows anaesthesiologists to identify complications from anaesthesia and sub-optimal post-operative management early.

CS-related emergencies

Hypertensive disorders in pregnancy

Clinicians should be familiar with recognition and management of pre-eclampsia and eclampsia as they contribute significantly to maternal morbidity and mortality. Hypertensive disorders in pregnancy can generally be divided into four categories.³¹

Pre-existing or chronic hypertension – hypertension diagnosed before pregnancy or before 20 weeks gestation

Gestational hypertension – hypertension (>140/90 mmHg) after 20 weeks gestation but without features of pre-eclampsia (below)

Pre-eclampsia – hypertension (>140/90 mmHg) after 20 weeks gestation with new onset proteinuria.

Severe pre-eclampsia is pre-eclampsia with presence of severe end-organ complications:

Cardiorespiratory: pulmonary oedema

Renal: severe proteinuria >3+ on dipstick, oliguria <500 ml/24 h, rise in serum creatinine, raised uric acid

Hepatic: elevated bilirubin, transaminitis, right upper quadrant pain.

Neurological: visual disturbances, headache, hyperreflexia with clonus

Haematological: thrombocytopenia, DIVC, haemolysis.

Eclampsia – pre-eclampsia with presence of seizures.

For CS, both RA and GA are suitable modes of anaesthesia but RA is preferred as it obviates the need for instrumentation of an oedematous airway and avoids excessive sympathetic stimulation and hypertensive response to direct laryngoscopy. However if RA is contraindicated, the intubation response can be attenuated with boluses of esmolol (1.5 mg/kg), GTN (2 mcg/kg), labetalol (10 mg titrate up to 1 mg/kg), lignocaine (1–1.5 mg/kg given 2–3 min before laryngoscopy) or remifentanil (1 mcg/kg).³² If remifentanil is used for GA induction, it is important to warn the attending neonatologist regarding possible transient neonatal respiratory depression.³³

For severe pre-eclamptic and eclamptic patients, delivery of the foetus is the only effective treatment. The decision on timing and mode of delivery should be a shared management decision made between the obstetricians, maternal–foetal medicine specialists, neonatologist and anaesthesiologists this should take into consideration both maternal and foetal well-being. Generally, delivery should be performed within 8 h of an eclamptic fit. Before delivery, the patient needs to be stabilised first. Generally, the goals of therapy are:

Control of blood pressure but not compromising placental perfusion.

Agents that can be used include IV labetalol (10–20 mg IV boluses for acute control, maintained with infusion of 5–20 mg/h) or IV hydralazine (5–10 mg boluses, maintained with infusion of 10–20 mg/h). Oral medications include labetalol, nifedipine, prazosin or methyldopa if patient is well enough for oral intake and absorption.

Seizure prophylaxis.

All patients with neurological symptoms should have magnesium sulphate 4 g IV over 15 min given as a loading dose, followed by a maintenance of 1–2 g per hour infusion, aiming for plasma concentration within the therapeutic range of 2–4 mmol/l. While on therapy, the patient should be monitored for loss of patellar reflexes, oliguria (<0.5 ml/kg per hour) and respiratory or CNS depression which will require reduction in rate or cessation of infusion.³⁴

Seizure treatment.

Seizures should be promptly aborted with IV magnesium sulphate (IV 4g loading over 15 min, a further of 2–4 g given if initial bolus has already been given) or IV diazepam 5–10 mg, if magnesium is not available or contra-indicated. All supportive measures such as left lateral tilt, airway, breathing and circulation management is mandatory as per any obstetric emergency.

Strict control of fluid balance.

Due to increased capillary permeability in pre-eclampsia, fluid intake must be strictly maintained, as these patients are prone to pulmonary oedema. The standard IV fluid regime is 85 ml/h, inclusive of all intravenous drug volumes. Consider central venous measurement in patients with precarious cardiorespiratory function.

After delivery, patient should be kept in critical care area for hemodynamic monitoring, antihypertensive therapy, magnesium infusion if required and strict fluid control. Management of pre-eclampsia and eclampsia is shown in the summary.

Major post-partum haemorrhage (PPH)

The traditional definition of primary PPH is the loss of 500 ml or more of blood from the genital tract within 24 h of the birth of a baby. The causes of PPH can be conveniently recalled by the ‘4 Ts’:

Tone – uterine atony

Tissue – retained products of conception

Trauma – genital tract injury

Thrombin – acquired or inherited clotting deficiencies

PPH can be minor (500–1000 ml) or major (more than 1000 ml). Major could be divided into moderate (1000–2000 ml) or severe (more than 2000 ml). Allowing for the physiological increase in pregnancy, the total blood volume at term is approximately 100 ml/kg. A blood loss of more than 40% of total blood volume is generally regarded as ‘life-threatening’. The volume of blood loss that triggers PPH protocols is usually around 1500 ml; however, this figure is only a reference, as transfusion trigger also depends on maternal comorbidity (e.g. pre-op anaemia), speed of transfusion services and degree of ongoing blood loss. Each institute should have a major haemorrhage protocol. This article’s recommendation is based on the Royal College of Obstetricians and Gynaecologists’ latest green top guidelines.³⁵

Management of massive obstetric haemorrhage should be a multi-disciplinary effort. It includes early recognition and communication with the rest of the multi-disciplinary team. The multi-disciplinary team includes obstetricians, anaesthesiologists, haematologists, interventional radiologists, midwives, theatre, anaesthetic nurses and neonatologists. Major obstetric haemorrhage can become fatal very quickly and experienced clinicians should be involved as early as possible. The management of primary major PPH is shown in the summary. It involves supportive therapy with airway control and supplemental oxygen ± ventilation to decrease oxygen consumption from work of breathing; aggressive maintenance of intravascular volume with fluids and blood products; while simultaneously identifying the underlying cause and giving directed treatment. These may include non-pharmacological / surgical means (such as mechanical manoeuvres to increase uterine tone, bimanual compression, controlled cord traction, uterine compression suturing, tamponade balloon, artery ligation, peri-partum hysterectomy or interventional radiology) and pharmacological means (predominantly uterotonic drugs and correction of coagulation deficits). Good supportive care such as avoiding hypothermia by using rapid infusers with warming ability and warming device for patients and correction of electrolytes (e.g. calcium and potassium) during massive transfusion are also very important. Uterotonic drugs should be used in a stepwise approach. If no coagulation test is available, 12–15 ml/kg of fresh frozen plasma should be given after 4 units of pack red cells transfusion. FFP should be considered earlier for conditions with a suspected coagulopathy, such as placental abruption or amniotic fluid embolism, or where detection of PPH has been delayed. If prothrombin time/ activated partial thromboplastin time is more than 1.5 times normal and haemorrhage is ongoing, more than 15 ml/kg of FFP are likely to be needed to correct coagulopathy. Cryoprecipitate should be used for fibrinogen replacement to keep plasma fibrinogen level of greater than 2 g/l during ongoing PPH. Platelets should be transfused when the platelet count is less than 75 × 10⁹/l. In addition to blood products, anti-fibrinolytic agents such as tranexamic acid seems to be a useful complement for treatment of PPH.³⁶ If available, thromboelastography can provide timely coagulation parameters to direct replacement of blood product,³⁷ and cell salvage can minimise use of allogenic blood transfusion.³⁸ The main concern surrounding the use of cell salvage during obstetric haemorrhage is the risk of reinfusing foetal contaminants with the theoretical risk of causing amniotic fluid embolus (AFE). However, to date there are no proven cases in the literature of AFE caused by reinfusion of salvaged blood. The use of leucodepletion filters in this situation has also shown a significant reduction in contamination from amniotic fluid.³⁹ Appropriate levels of monitoring, including intra-arterial and central venous pressure monitoring should be considered and established early. When bleeding is severe and cannot be stopped, temporary pressure on the aorta by the surgeon can halt the bleeding and allow anaesthesiologist time to catch up with volume and blood product replacement. If resources are available early involvement of interventional radiologist for uterine artery embolization or internal iliac artery balloon catheterization can decrease the need for caesarean hysterectomy, morbidity and mortality.⁴⁰

Systemic LA toxicity

Systemic LA toxicity in the obstetric context may occur when a dose of LA meant for epidural administration is inadvertently given intravascularly due to a migrated or misplaced epidural catheter. Signs of toxicity occur when plasma levels of LA exceed toxic concentrations and involved both cardiovascular and neurological manifestations. CNS effects range from initial excitation (tingling, peri-oral numbness, metallic taste in the mouth), progressing to generalized tonic-clonic seizures and eventually coma. Cardiovascular effects include direct myocardial depression, bradycardia, arrhythmias and ultimately cardiovascular collapse. Immediate treatment involves supportive care and administering lipid emulsion.^41,42 The management of LA toxicity is shown in the summary.

Conclusion

This article and its attached summary do not aim to replace formal teaching, textbooks, local hospital guidelines or protocols. Instead, it serves to provide a quick and easy to follow guide for obstetricians, occasional obstetric anaesthesiologists, clinicians and health professionals when needed.

Footnotes

Declaration of Conflicting Interests

The authors declare that there is no conflict of interest.

Funding

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

Charted summary

References

Rai

Lua

Popat

et al . Antenatal anaesthetic assessment of high-risk pregnancy: a survey of UK practice. Int J Obstet Anesth 2005; 14: 219–222.

Cooper

McClure

JH.

Maternal deaths from anaesthesia. An extract from Why Mothers Die 2000–2002, the Confidential Enquiries into Maternal Deaths in the United Kingdom Chapter 9: Anaesthesia. Br J Anaesth 2005; 94: 417–423.

Torloni

Betran

Souza

et al . Classifications for cesarean section: a systematic review. PLoS One 2011; 6: e14566.

Thurlow

Kinsella

SM.

Intrauterine resuscitation: active management of fetal distress. Int J Obstet Anesth 2002; 11: 105–116.

Broaddus

Chandrasekhar

Informed consent in obstetric anesthesia. Anesth Analg 2011; 112: 912–915.

Middle

Wee

MYK

. Informed consent for epidural analgesia in labour. Anaesthesia 2009; 64: 161–164.

Gild

WM.

Informed consent: a review. Anesth Analg 1989; 68: 649–653.

Ong

Cohen

Palahniuk

RJ.

Anesthesia for cesarean section – effects on neonates. Anesth Analg 1989; 68: 270–275.

Obstetric Anaesthetists’ Association. General anaesthetic for unplanned caesarean section (CS) information card, www.labourpains.com/assets/_managed/cms/files/InfoforMothers/GA%20FOR%20UNPLANNED%20CS/GA%20For%20Caesarean%20CS%20-%20Information%20Card-FEB15.pdf (2012, accessed 06 February 2016).

10.

Obstetric Anaesthetists’ Association. Regional anaesthetic for caesarean section (CS) – information card, www.labourpains.com/assets/_managed/cms/files/InfoforMothers/REGIONAL-ANAESTHESIA/Feb%2015%20Regional%20Anaesthesia%20for%20CS%20English-1.pdf (2012, accessed XXXXXX).

11.

Cook

Woodall

Frerk

Fourth National Audit Project of the Royal College of Anaesthetists and the Difficult Airway Society. Major complications of airway management in the UK. Report and findings. The Royal College of Anaesthetists and the Difficult Airway Society, London, 2011.

12.

Cook

Counsell

Wildsmith

JAW

et al . Major complications of central neuraxial block: report on the Third National Audit Project of the Royal College of Anaesthetists. Br J Anaesth 2009; 102: 179–190.

13.

Gordon

Mckechnie

Jeffery

Pediatric presence at cesarean section: justified or not?

Am J Obstet Gynecol 2005; 193: 599–605.

14.

Harrop-Griffiths

Cook

Gill

et al . Regional anaesthesia and patients with abnormalities of coagulation. Anaesthesia 2013; 68: 966–972.

15.

McDonell

An update in obstetric anaesthesia. Ann Queenstown Update Anaesth 2012; 1: 11–17.

16.

Mercier

FJ.

Fluid loading for cesarean delivery under spinal anesthesia: have we studied all the options?

Anesth Analg 2011; 113: 677–680.

17.

Ngan Kee

. Prevention of maternal hypotension after regional anaesthesia for caesarean section. Curr Opin Anaesthesiol 2010; 23: 304–309.

18.

Mushambi

Kinsella

Popat

et al . Obstetric Anaesthetists’ Association and Difficult Airway Society guidelines for the management of difficult and failed tracheal intubation in obstetrics. Anaesthesia 2015; 70: 1286–1306.

19.

Patel

Nouraei

SA.

Transnasal humidified rapid-insufflation ventilatory exchange (THRIVE): a physiological method of increasing apnoea time in patients with difficult airways. Anaeshesia 2015; 70: 323–329.

20.

Baaqeel

Timing of administration of prophylactic antibiotics for caesarean section: a systematic review and meta-analysis. BJOG 2013; 120: 661–669.

21.

Costantine

Rahman

Ghulmiyah

et al . Timing of perioperative antibiotics for cesarean delivery: a metaanalysis. Am J Obstet Gynecol 2008; 199: 301-e1.

22.

Thomas

Cooper

and Editorial Board of the Confidential Enquiries into Maternal Deaths in the United Kingdom. Maternal deaths from anaesthesia. An extract from why mothers die 1997–1999, the confidential enquiries into maternal deaths in the United Kingdom. Br J Anaesth 2002; 89: 499–508.

23.

Butwick

Coleman

Cohen

et al . Minimum effective bolus dose of oxytocin during elective caesarean delivery. Br J Anaesth 2010; 104: 338–343.

24.

Stephens

Bruessel

Systematic review of oxytocin dosing at caesarean section. Anaesth Intensive Care 2012; 40: 247–252.

25.

Rosales-Ortiz

Aguado

Hernandez

et al . Carbetocin versus oxytocin for prevention of postpartum haemorrhage: a randomised controlled trial. Lancet 2014; 383: S51.

26.

Schug

Palmer

Scott

et al . Acute pain management: scientific evidence. 4th ed. Melbourne: Australian and New Zealand College of Anaesthetists and Faculty of Pain Management, 2015, p.647.

27.

Bloor

Paech

, Nonsteroidal anti-inflammatory drugs during pregnancy and the initiation of lactation. Anesth Analg 2013; 116: 1063–1075.

28.

Hendrickson

McKeown

NJ.

Is maternal opioid use hazardous to breast-fed infants?

Clin Toxicol 2012; 50: 1–4.

29.

Montgomery

Hale

and Academy of Breastfeeding Medicine. ABM clinical protocol # 15: analgesia and anesthesia for the breastfeeding mother, revised 2012. Breastfeed Med 2012; 7: 547–553.

30.

Feilberg

Rosenborg

Broen Christensen

et al . Excretion of morphine in human breast milk. Acta Anaesthesiol Scand 1989; 33: 426–428.

31.

Laura

Anouk

Michael

et al . Diagnosis, evaluation and management of the hypertensive disorders of pregnancy: executive summary. J Obstet Gynaecol Can 2014; 36: 416–438.

32.

Pant

Fong

Scavone

Prevention of peri-induction hypertension in preeclamptic patients: a focused review. Anesth Analg 2014; 119: 1350–1356.

33.

Yoo

Jeong

Park

et al . Effects of remifentanil on cardiovascular and bispectral index responses to endotracheal intubation in severe pre-eclamptic patients undergoing Caesarean delivery under general anaesthesia. Br J Anaesth 2009; 102: 812–819.

34.

Duley

Gülmezoglu

Henderson-Smart

et al . Magnesium sulphate and other anticonvulsants for women with pre-eclampsia. Cochrane Database Syst Rev 2010; 11: CD000025.

35.

Mavrides

Allard

Chandraharan

et al . Prevention and management of postpartum haemorrhage. BJOG. Epub ahead of print 16 December 2016. DOI: 10.1111/1471–0528.14178.

36.

Sentilhes

Lasocki

Ducloy-Bouthors

et al . Tranexamic acid for the prevention and treatment of postpartum haemorrhage. Br J Anaesth 2015; 114: 576–587.

37.

Karlsson

Jeppsson

Hellgren

Major obstetric haemorrhage: monitoring with thromboelastography, laboratory analyses or both?

Int J Obstet Anesth 2014; 23: 10–17.

38.

Ashworth

Klein

AA.

Cell salvage as part of a blood conservation strategy in anaesthesia. Br J Anaesth 2010; 105: 401–416.

39.

Wee

MYK

Thomas

Verma

et al . AAGBI safety guideline: blood transfusion and the anaesthetist: intra-operative cell salvage, http://aagbi.org/publications/guidelines/docs/cell%20_salvage_2009_amended.pdf (2009, accessed 25 September 2016).

40.

Royal College of Obstetricians and Gynaecologists. The role of emergency and elective interventional radiology in postpartum haemorrhage. Royal College of Obstetricians and Gynaecologists good practice guideline no. 6. College guideline produced in conjunction with Royal College of Radiologists and the British Society of Interventional Radiology. London: Royal College of Obstetricians and Gynaecologists, 2007.

41.

Neal

Bernards

Butterworth

et al . ASRA practice advisory on local anesthetic systemic toxicity. Reg Anesth Pain Med 2010; 35: 152–161.

42.

Cave

Harrop-Griffiths

Harvey

et al . AAGBI safety guideline: management of severe local anaesthetic toxicity, https://www.aagbi.org/sites/default/files/la_toxicity_2010_0.pdf (2010, accessed XXXXXX).

Peri-operative management of caesarean section for the occasional obstetric anaesthetist – an aide memoire

Abstract

Keywords

Introduction

Pre-operative evaluation

To identify medical and obstetric comorbidities

Establish reason and urgency of CS

Obtaining informed consent

Patient preparation for anaesthesia

Intraoperative management

Preparation for CS

Modes of anaesthesia

Coagulation abnormalities and NAB

Management of NAB or GA associated hypotension

Management of the obstetric airway

Antibiotics prophylaxis

Uterotonics

Post-operative management

Analgesia

Precaution in breast feeding mothers

Post-operative follow-up

CS-related emergencies

Hypertensive disorders in pregnancy

Major post-partum haemorrhage (PPH)

Systemic LA toxicity

Conclusion

Footnotes

Declaration of Conflicting Interests

Funding

Charted summary

References