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Questions and Answers
What position is the patient placed in on the operating table for cesarean section?
Supine with pelvic wedge (usually with lateral tilt)
Why is the abdomen prepared and draped before induction in some centers?
To minimize induction-delivery interval and drug accumulation in the fetus, especially for emergencies.
What is the purpose of preoxygenation before induction?
To increase FRC (functional residual capacity)
What medication is used to facilitate uterine contractions after delivery of the fetus?
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What is the purpose of cricoid pressure during rapid sequence induction?
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What type of ventilation is used during maintenance of anesthesia before delivery of the fetus?
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What is a potential intraoperative problem during cesarean section?
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What is the final step in the emergence and recovery phase after cesarean section?
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What is the recommended position to avoid aortocaval compression in a pregnant patient?
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What is an indication for general anesthesia instead of regional anesthesia in a pregnant patient?
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Why should sedatives be avoided in premedication for pregnant patients?
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What is the purpose of giving an H2 antagonist in premedication for pregnant patients?
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What should be available in the theatre preparation for pregnant patients?
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What is an important aspect of the preoperative assessment for pregnant patients?
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What is the purpose of giving metoclopramide in premedication for pregnant patients?
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What should be avoided during positioning of pregnant patients?
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How is cesarean delivery defined?
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What type of incision is commonly used in cesarean section?
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What is the characteristic of the majority of patients undergoing cesarean section?
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What is the reduced volume in late pregnancy that increases the risk of hypoxia with apnea?
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What is the formula to calculate residual volume (RV) in late pregnancy?
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What is the risk associated with decreased lower esophageal sphincter tone in late pregnancy?
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What is the effect of aortocaval compression on cardiac output and uteroplacental perfusion?
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What is the term for the compression of the maternal abdominal aorta and inferior vena cava by the gravid uterus?
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Study Notes
Cesarean Section
- Defined as the surgical delivery of a fetus through surgical incisions made through the abdominal wall and the uterine wall
- Usually performed by lower uterine segment incision (horizontal cut through the abdomen and uterus)
- Another incision type is vertical incision or cut on the uterus
Patient Characteristics
- Majority are fit females with an obstetric problem (pregnancy)
- Minority have significant systemic diseases (hypertension or DM)
Physiology of Late Pregnancy
- Reduced respiratory reserve volume (RV) and functional residual capacity (FRC) due to high risk of hypoxia with apnea
- Venous engorgement and edema of airway mucosa (difficult intubation)
- Susceptibility to gastric acid aspiration (high risk) due to decreased lower esophageal sphincter tone
- Presence of aortocaval compression (compression of maternal abdominal aorta and inferior vena cava)
Indications for General Anesthesia
- Extreme urgency (no time for spinal or epidural block)
- Patient preference
- Existing or expected hypovolemia (hypotension)
- Sepsis, infection
- Clotting abnormality
- Neurological disease
- Failed regional technique
Preoperative Assessment
- Majority of women have been screened in the antenatal clinic
- Elective patients have a routine preoperative visit
- Emergencies may only have a rapid assessment
- Standard history and examination is important, with particular attention to pre-eclampsia, diabetes, anemia, or other significant disease
Premedication
- Avoid sedatives as they will affect the neonate
- Acid aspiration prophylaxis:
- H2 antagonist (oral Ranitidine tab. 150 mg previous night and 2-4 hours preoperatively, and I.V. Ranitidine 50 mg as soon as operative delivery is decided)
- Antiacid (Sodium citrate 30 ml orally 30-45 min before induction, and Metoclopramide ampoule 10 mg I.V.)
Theatre Preparation
- Experienced anesthetist and trained anesthetic assistant
- Full range of equipment and drugs for general anesthesia and difficult intubation aids
- Facilities and personnel for resuscitation of the neonate
- Donor blood should be available
Perioperative Management
- Monitoring: ECG, noninvasive blood pressure, end-tidal CO2, pulse oximeter, and temp. probe
- Positioning: avoid full supine position, use pelvic wedge (lateral tilt) on operating table
- Induction: rapid sequence induction with Thiopentone (3-4 mg/kg) and Suxamethonium (1-1.5 mg/kg)
- Maintenance before delivery of the fetus:
- Nitrous oxide in oxygen
- Supplement with volatile agent
- Maintain neuromuscular block with Vecuronium or Atracurium
- IPPV (intermittent positive pressure ventilation)
- Maintenance after delivery of the fetus:
- Syntocinon (5 units I.V. bolus, plus infusion of 15 units in 500 ml fluid over 3 hours)
- Methergine (0.2 mg I.M.) if hypotonia persists and bleeding continues
- I.V. opioids in adequate dose
- Midazolam can be given
- Nitrous oxide can continue
- Adequate concentration of volatile agent
- Antibiotic can be given
Intraoperative Problems in Cesarean Section
- Aortocaval compression (hypotension)
- Failed intubation (difficulty)
- Massive bleeding
- Drug reaction (allergy)
- Amniotic fluid embolus
Emergence and Recovery
- Neuromuscular block is reversed
- Tracheal tube no longer tolerated
- Fully recovered
- Extubation
- Transfer the patient to postnatal ward
Postoperative Period
- Adequate opioid or NSAID analgesia
- Early mobilization to reduce the risk of thromboembolism
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Description
This quiz covers the anesthesia theory for cesarean sections, including definition, indications, and procedure. It's designed for 2nd-semester anesthesia students.
