Cesarean Section

Anesthesia Implications

Position: Supine, arms at side on armboards
Time: 1-2 hours (average)
Blood Loss: Very High (500+ ml)
Post-op Pain: Moderate (3-6)
Maintenance Paralytic: No
Blocks: Quadratus Lumborum, TAP

Preloading – Have fluid hung on patient, ready to open when ready to roll to the OR

Oxytocin – Oxytocin is used to minimize bleeding after the baby is delivered. It is usually given immediately after the baby is delivered. Some surgeons prefer to have it given after the placenta is delivered. Have 20-30 units of oxytocin ready to be added to the bag and opened at the surgeons preferred time. This may also be mixed preoperatively as 20 units IV in a 1 Liter bag of LR. There have also been reports of formulations of 30 units in 500ml.

Bleeding prophylaxis – One gram of Tranexamic acid (TXA) is becoming a common pretreatment for bleeding prophylaxis. Ask the surgeon.

Additional blood-loss control – Know where to find methergine (0.2 mg IM) and/or Hemabate (150-250 mcg IM). These are drugs that are used to treat a “boggy” uterus – formerly known as uterine atony. This is a uterus that hasn’t responded to Pitocin.

Difficult Airway Risk – Have standard GETA setup equipment handy. Natural edema during pregnancy put these patients are at high risk of a difficult airway.

Pressure support – Phenylephrine and Ephedrine primarily to keep the patients blood pressure up and to keep the placenta/baby perfused. Support with these drugs after the spinal (and subsequent drop in blood pressure) helps tremendously in keeping the patient from getting nauseous.

Zofran – 4mg pre-spinal placement has been shown to mitigate hypotension and significantly decrease the incidence of shivering.

Antimuscarinics – Have atropine/robinul available to treat vagal/bradycardic events.

Aspiration prophylaxis:
Bicitra: 30 ml PO given 30 minutes prior to the C-section which immediately neutralizes (makes more alkaline) the contents of the stomach.
Metoclopramide: 5 mg – very common to give IV preoperatively or added to the initial bag of fluids
Famotadine (Pepsid): 20 mg IV
Robinul: 0.1 mg.

Thromboembolism Prophylaxis – Ted hose and ICD’s are very common for thromboembolism prophylaxis.

Foley – this is applied either before surgery, or after the spinal.

Spinal anesthesia: 150 mcg Duramorph + 15-20 mcg Fentanyl + 0.75% Bupivicaine (see dosing below):
Less that 5 feet tall (1.2 to 1.4 cc’s)
5 feet tall to 5’4” (1.4 to 1.6 cc’s)
Over 5’4” (1.6 cc’s)

Left Uterine Displacement (LUD) – Once the spinal is placed, the patient will be positioned on the table. Make sure to have some left tilt to the table to displace the uterus. This will keep fetal circulation optimal.

Prophylactic phenylephrine infusion – started just after spinal placement instead of bolus doses decreases the incidence, frequency and magnitude of hypotension with no difference in neonatal APGARs or cord gases.

The Allis Test – performed by the surgeon to determine if the spinal block is sufficient to make the incision. The surgeon will do this by simply clamping the skin at the abdomen with the Allis clamps to determine sensation. They will be watching you to confirm that the patient is not reacting to the stimulation.

Uterine massage – There may be a “uterine massage”, which consists of heavy pressure put on the abdomen by the nurse to stop uterine bleeding. You may consider warning the mother that there will be quite a bit of pressure/discomfort.

Pro Tip: Sympathectomy, which is common with spinal/epidural anesthesia, will allow greater dominance of the parasympathetic system. Expect reduced blood pressure and some nausea within 3-5 minutes after the spinal. Some practitioners will give phenylephrine and/or ephedrine to remedy the nausea (which is most often a result of rapidly reducing blood pressure), or less commonly 0.1-0.2 mg of Robinul (glycopyrrolate).

If GETA is absolutely necessary – Induction doesn’t happen until the surgical area is fully prepared and drapes are up. Propofol + Succinylcholine is most popular. Ketamine (2.5 mg/kg) is a great option if there is hemodynamic instability. However, if Ketamine is used, be aware that it passes into breast milk. Always consider the parturient a full stomach, so use RSI with the sellick’s maneuver. Because these cases are quick, usually Succinylcholine is the NMB of choice for intubation. Inform the surgeon after the patient has been intubated with confirmed ETCO2. Standard gases – usually sevoflurane turned up high. Baby will be delivered in a matter of minutes. OG tube to remove gastric contents. Once the patient is intubated, make sure to have pitocin ready to go in at the same interval (after delivery of baby/placenta). The procedure is then treated as a regular GETA. Emergence shouldn’t be done until after the uterine massage has been completed. Standard AWAKE extubation. Consider a TAP or QL block for abdominal pain prior to extubation.

Aspiration risk – Parturients remain aspiration risks postoperatively. Treat intraoperatively to prevent complications, and monitor closely.

High Blood Loss (general considerations): Type and cross, CBC, and CMP should be done prior to the procedure. Consider having an A-line, blood tubing, and extra push-lines. Depending on the fragility of the patient, you may want to have blood in the room and available.

Indications for a cesarean section include but are not limited to: Antepartum or intrapartum hemorrhage, arrest of labor, breech presentation, chorioamnionitis, deteriorating maternal condition, dystocia, failure of induction, genital herpes, maternal request, placenta previa, placental abruption, previous myomectomy, uterine rupture, fetal intolerance to labor, suspected macrosomia, prolapsed umbilical cord

During spinal anesthesia: The shorter the patient the higher the chance of a difficult spinal. Shorter patients have less space between the spinal processes. Obese patients compound the difficulty by creating more tissue between the spinal column and the skin. When attempting a mid-line approach on these patients, a small deviation of the angle of the needle at the skin can create a large deviation from the spinal column.

Watch closely for pruritus caused by the intrathecal opioids and treat. Treatment is variable and has mixed results. One of the most popular is ondansetron (Zofran). Nalbuphine (Nubain) is also very effective.