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Questions and Answers
What position is the patient placed in on the operating table?
Supine with pelvic wedge (usually with lateral tilt)
Why do some centers prepare and drape the abdomen before induction?
To minimize induction-delivery interval and drug accumulation in the fetus, especially for emergencies.
What type of induction is used in cesarean sections?
Rapid sequence induction
What is the purpose of preoxygenation before induction?
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What medication is used to facilitate uterine contractions after delivery of the fetus?
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What is the purpose of IPPV (intermittent positive pressure ventilation) during maintenance?
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What is one of the potential intraoperative problems that can occur 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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What is the purpose of the preoperative assessment in pregnant patients?
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What is the recommended premedication to avoid in pregnant patients?
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What is the purpose of acid aspiration prophylaxis in pregnant patients?
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What is essential for theatre preparation in pregnant patients?
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What is the importance of monitoring during perioperative management in pregnant patients?
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Why is it essential to avoid the full supine position during perioperative management in pregnant patients?
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What is Cesarean delivery defined as?
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What is the most common type of incision made during 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 risk of hypoxia due to in late pregnancy?
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What is the risk of difficult intubation in late pregnancy?
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What is the risk of gastric acid aspiration in late pregnancy?
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What is the effect of aortocaval compression on venous return?
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What is the potential effect of aortocaval compression on fetal well-being?
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Study Notes
Cesarean Section Definition
- Cesarean delivery is defined as the surgical delivery of a fetus through surgical incisions made through the abdominal wall (laparotomy) and the uterine wall (hysterotomy)
Procedure
- Cesarean section is usually performed by lower uterine segment incision (horizontal cut through the abdomen and a horizontal cut through the lower part of the uterus)
- Another incision is called a vertical incision or cut on the uterus (also known as Bikini line incision)
Patient Characteristics
- The majority are fit females with an obstetric problem (presence of pregnancy)
- A minority have significant systemic diseases (hypertension or DM)
Physiology of Late Pregnancy
- Reduced respiratory reserve volume (RV) and FRC (high risk of hypoxia with apnea)
- RV = FRC−ERV (RV=2400-1200=1200 ml of air)
- Venous engorgement and edema of airway mucosa (difficult intubation)
- Susceptibility to gastric acid aspiration (high risk), due to decreased lower esophageal sphincter tone (vomiting)
- Presence of aortocaval compression (compression of the maternal abdominal aorta and inferior vena cava)
Aortocaval Compression
- Aortocaval compression occurs when the gravid uterus compresses the maternal abdominal aorta and inferior vena cava
- Compression of the IVC disturbs venous return, which decreases cardiac output, and compression of the aorta may reduce uteroplacental perfusion, resulting in fetal acidosis
- Aortocaval compression can be avoided by lying of the pregnant patient on the lateral position
Indications for General Instead of Regional Anesthesia
- Extreme urgency (no time for spinal or epidural block)
- Patient preference
- Existing or expected hypovolemia (hypotension)
- Sepsis, infection
- Clotting abnormality
- Neurological disease (e.g. epilepsy, hemiparesis, dysarthria, hearing defect)
- Failed regional technique
Preoperative Assessment
- The majority of women have been screened in the antenatal clinic (monitoring + follow up)
- Elective patients have a routine preoperative visit
- Emergencies may only have a rapid assessment
- Standard history and examination is important, with particular asking and search for presence of pre-eclampsia, diabetes, anemia, or other significant disease
Investigations
- Blood group
- Recent Hb
Premedication
- Avoid sedatives as they will affect the neonate
- Acid aspiration prophylaxis:
- H2 antagonist: Elective patients receive oral Ranitidine tab. (150 mg) previous night and 2-4 hours preoperatively, while Emergency patients receive 50 mg I.V. Ranitidine as soon as operative delivery is decided
- Anti-acid: Sodium citrate 30 ml orally 30- 45 min before induction, and Metoclopramide ampoule 10 mg I.V.
Theatre Preparation
- Experienced anesthetist
- Trained anesthetic assistant
- A full range of equipment and drugs for general anesthesia and difficult intubation aids should be available
- Facilities and personnel for resuscitation of the neonate (pediatrician)
- Donor blood should be available
Perioperative Management
Monitoring
- ECG
- Noninvasive blood pressure
- End tidal CO2
- Pulse oxymeter
- Temp. probe
Positioning
- Avoid full supine position at all times, including during transfer
- On operating table, place the patient supine with pelvic wedge (usually with lateral tilt)
Induction
- Rapid sequence induction
- Large size free flowing intravenous infusion set 18 (green) or 16 (grey) gauge x 2 cannula
- Preoxygenation (to increase FRC) (3-5 min)
- Cricoid pressure
- Sleep dose of Thiopentone (3-4 mg/kg) giving rapid loss of consciousness
- Suxamethonium (1-1.5 mg/kg) to allow rapid and easy tracheal intubation
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 start with (5 units I.V. bolus), plus infusion (15 units in 500 ml fluid over 3 hours) to facilitate uterine contractions
- If hypotonia (of uterine muscle) persists and bleeding continues, then give Methergine (0.2 mg I.M.)
- Give I.V. opioids in adequate dose
- Midazolam can be given
- Nitrous oxide continues
- 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 (by antidote)
- Tracheal tube no longer tolerated
- Fully recovered
- Extubation
- Transfer the patient to postnatal (after delivery) ward
Postoperative Period
- Adequate opioid or NSAID analgesia
- Early mobilization to reduce the risk of thrombo-embolism
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Description
Learn about the definition and procedure of cesarean section, a surgical delivery method involving incisions in the abdominal and uterine walls. Explore the different types of incisions used.
