Cesarean section : Colligative - Practical Wisdom in Anesthesia, Surgery, and Medicine.

Dec 14, 2012

Indications, Relevant Conditions

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Complications, Contraindications

If the patient is at high risk of intraoperative bleeding (eg low lying anterior placenta previa that the obstetrician will have to divide, or placenta accreta/ percreta/ increta) discuss the risk of bleeding with patient and obstetrician and consider general anesthetic technique with arterial line and cross-matched blood available. See placenta previa and placenta accreta for additional considerations.

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Endorsed by , Sud Agarwal , more...

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Dec 14, 2012

In the GA LUSCS with prolonged extraction of the neonate, notify the paediatrician that prolonged ventilation may be required to eliminate the infant's load of volatile anesthetic agent

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May 14, 2012

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Assessment, Workup

If the mother is tachycardic, check to see if tocolytics (eg terbutaline) have been given by the obstetrics team.

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Endorsed by , Brad O'Connor , more...

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Nov 09, 2011

Consider cardiomyopathy of pregnancy if the patient presents with history of worsening exertional dyspnoea during their pregnancy.

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Sep 13, 2011

Take a usual preanesthetic history, focusing on previous cesarean sections and other risk factors for placenta accreta or placenta previa, and peripartum hemorrhage. #improve

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Oct 17, 2015

what other risk factors?

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Consent, Discussion

Discuss spinal anesthesia plus risk of conversion to general anesthesia if spinal fails or unexpected hemorrhage is encountered

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Endorsed by , Damian Castanelli , more...

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Nov 14, 2011

Preoperative Optimisation

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Coordinating

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Medication management, Premed

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Equipment, Preparation

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Duration

Duration 60-90mins

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Aug 24, 2011

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Anatomy

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IV access

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Monitoring

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Special drugs

Administering a phenylephrine infusion 50-100mcg/min may help prevent hypotension and reduce the incidence of nausea and vomiting.

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Endorsed by , Pieter Peach , more...

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2 comments

Sep 20, 2012

How do you like to dilute it?

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10mg phenylephrine in 100mL Normal Saline (100mcg/mL).
60 mL/hr = 100 mcg/min; 30 mL/hr = 50 mcg/min; 15 mL/hr = 25 mcg/min

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Draw up vasopressor of choice prior to commencing case to minimise the time taken to effectively treat hypotension.

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Endorsed by , Natalie Smith , more...

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Mar 05, 2014

Administer antibiotics before skin incision. Expected benefit of reduced wound infection and endometritis should weighed against risk of anaphylaxis prior to delivery of neonate.

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Aug 12, 2011

Cefazolin 15-60min prior to skin incision decreased endometritis (RR 0.2) & wound infection risk (RR 0.52) compared with at the time of cord clamping. refl.in/1u & refl.in/1v

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Airway, Ventilation

The pregnant patient is considered to be at elevated risk of gastric reflux and pulmonary aspiration from the beginning of the second trimester. If general anaesthesia is required, consider rapid sequence intubation or awake intubation for expected difficult laryngoscopy refl.in/eu

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Oct 07, 2012

Positioning, Surgical access

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Ensure lateral tilt of >15 degrees with wedge to minimise risk of aortocaval compression.

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Aug 19, 2012

Anesthesiologists often overestimate their degree of tilt. Br. J. Anaesth. (2003) 90(1): 86-87 dx.doi.org/10.1093/bja/ae...

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If persistent hypotension despite a 15 degree lateral tilt and vasopressors, tilt to 90 degrees before administering more vasopressor. A delay in adequate tilt may result in inadvertant overdose of vasopressor which may result in hypertension when an adequate tilt is finally obtained and circulation returns

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Aug 21, 2011

If surgery is to be performed under general anaesthesia GA, surgeon should be scrubbed and patient prepped prior to induction. Ensure close communication with surgeon to prevent them inadvertantly commencing the operation prior to induction.

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Apr 26, 2012

Anesthesia, Analgesia, Antiemesis

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Procedure technique

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Spinal anaesthesia is appropriate for the majority of elective cases unless otherwise contraindicated.

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Endorsed by , Daniel Jolley , more...

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Jan 14, 2012

Analgesic regimen for LUSCS under spinal anesthesia.

Intraoperative:
parecoxib.

Postoperative:
Oxycodone SR 10-20mg and paracetamol in recovery.

Regular oxycodone SR 10-20mg bd, paracetamol, and diclofenac 50mg tds (crossed off for 24hrs).

PRN oxycodone 10-15mg 3/24 and PRN tramadol 100mg qid.

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Sep 30, 2013

Spinal doses for preterm parturients may need to be adjusted up. refl.in/fs

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Aug 26, 2011

21 of 25 preterm (<38/40) parturients given 2.25ml 0.5% heavy bupivicaine required additional analgesia c/w 0 of 25 term (>38/40) parturients in this 1997 study. refl.in/fs

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Cardiovascular, Renal, Fluids

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Good summary of evidence for volume preloading or "coloading" in spinal anesthesia. refl.in/1j p43

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Oct 01, 2011

Maintain maternal heart rate >60bpm for adequate cardiac output.

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May 18, 2011

Anticholinergic may be required. Atropine 300mcg titrated (or glycopyrrolate may be better as it doesn't cross placenta) or ephedrine as chronotropic vasopressor.

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