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Summary

  1. Top of page
  2. Summary
  3. The 30-minute business
  4. In utero fetal resuscitation
  5. Anaesthetic options
  6. Depth of anaesthesia
  7. Pre-eclampsia
  8. Postoperative concerns
  9. Fluid balance
  10. Placenta praevia and accreta
  11. Conclusions
  12. References

Good multidisciplinary communication is crucial to the safe management of women requiring non-elective Caesarean section. Anaesthetists should participate actively in resuscitation of the fetus in utero; relief of aortocaval compression is paramount. Epidural top-up with levobupivacaine 0.5% is the anaesthetic of choice for women who have been receiving labour epidural analgesia. If epidural top-up fails to provide bilateral light touch anaesthesia from S5 – T5, a combined spinal-epidural technique with small intrathecal dose of local anaesthetic is a useful approach. Pre-eclampsia is not a contra-indication to single-shot spinal anaesthesia, which is the technique of choice for most women presenting for Caesarean section without an epidural catheter in situ. Induction and maintenance doses of drugs for general anaesthesia should not be reduced in the belief that the baby will be harmed. Early postoperative observations are geared towards the detection of overt or covert haemorrhage.

What is an ‘emergency’ Caesarean section? A four-point classification (Table 1) of urgency of Caesarean section, similar to that used by the National Confidential Enquiry into Perioperative Deaths, has been validated by concordance between anaesthetists' and obstetricians' gradings of theoretical and actual scenarios [1]. In this review, Category 1 and 2 operations are regarded as ‘emergencies’. A Category 3 case (e.g. a woman who has booked for an elective Caesarean section but goes into labour ahead of her scheduled operation date) is no longer elective, but neither is this a true ‘emergency’ scenario.

Table 1.   Categorisation of urgency of Caesarean section [1].
GradeDefinition (at time of decision to operate)
Category 1Immediate threat to life of woman or fetus
Category 2Maternal or fetal compromise, not immediately life-threatening
Category 3Needing early delivery but no maternal or fetal compromise
Category 4At a time to suit the woman and maternity team

The recently published first textbook of evidence-based obstetric anaesthesia contains little to inform best practice for emergencies [2]. The revised Association of Anaesthetists of Great Britain and Ireland/Obstetric Anaesthetists' Association guidelines for obstetric anaesthesia services deal with configuration of the service and staffing issues [3]. The National Institute for Health and Clinical Excellence (NICE) has published a comprehensive guideline for Caesarean section [4], but much in this article represents a personal opinion of the safest and most effective approaches for management of mother and baby in the non-elective situation.

The 30-minute business

  1. Top of page
  2. Summary
  3. The 30-minute business
  4. In utero fetal resuscitation
  5. Anaesthetic options
  6. Depth of anaesthesia
  7. Pre-eclampsia
  8. Postoperative concerns
  9. Fluid balance
  10. Placenta praevia and accreta
  11. Conclusions
  12. References

The National Sentinel Audit of Caesarean sections [5] defined 30 min as a standard for decision-delivery interval in the Category 1 situation, although such a timeframe is not stipulated in the NHS Litigation Authority's Clinical Risk Management Standards [6]. Shortcomings of establishing 30 min as a ‘rule’ have been detailed by NICE [4] and discussed in editorials [7, 8]. A true Category 1 emergency, e.g. ongoing maternal antepartum haemorrhage and sustained fetal bradycardia secondary to placental abruption, realistically demands delivery in less than half this time for neonatal survival without ischaemic-hypoxic injury. General anaesthesia will almost always be indicated. On the other hand, cord prolapse is not necessarily a Category 1 emergency. Provided the cord is decompressed and the fetus not seriously compromised, regional anaesthesia is an option (with continuous fetal monitoring during establishment of the block).

Anaesthetists' involvement can begin only once they have been informed of a case, and audits of response times should measure ‘anaesthetist informed – delivery’ intervals. The importance of good multidisciplinary communication (midwife-obstetrician-anaesthetist-theatre practitioner) cannot be overstressed [9].

In utero fetal resuscitation

  1. Top of page
  2. Summary
  3. The 30-minute business
  4. In utero fetal resuscitation
  5. Anaesthetic options
  6. Depth of anaesthesia
  7. Pre-eclampsia
  8. Postoperative concerns
  9. Fluid balance
  10. Placenta praevia and accreta
  11. Conclusions
  12. References

The role of the anaesthetist in maternal resuscitation and management of life-threatening obstetric emergencies has been reviewed recently [10]. The anaesthetist should also be an active participant in measures (Table 2) that might ameliorate isolated fetal compromise [11] and even avert the need for Caesarean section. Some clinical scenarios (e.g. iatrogenic uterine hyperstimulation with synthetic oxytocin) are obviously more amenable to resolution than others (e.g. placental abruption). Whatever the aetiology of maternal or fetal compromise, measures to relieve aortocaval compression [12] are vital. Having moved the mother from labour bed to theatre table, left-lateral tilt until delivery is all too easily forgotten.

Table 2. In utero fetal resuscitation [11].
1Syntocinon off
2Position full left lateral
3Oxygen
4I.v. infusion of 1 litre crystalloid
5Low blood pressure: i.v. vasopressor
6Tocolysis: terbutaline 250 μg (s.c), glyceryl trinitrate 400 μg (metered aerosol doses)

Anaesthetic options

  1. Top of page
  2. Summary
  3. The 30-minute business
  4. In utero fetal resuscitation
  5. Anaesthetic options
  6. Depth of anaesthesia
  7. Pre-eclampsia
  8. Postoperative concerns
  9. Fluid balance
  10. Placenta praevia and accreta
  11. Conclusions
  12. References

The Royal College of Anaesthetists' compendium of audit recipes [13], published before the 4-point categorisation, proposed that > 85% of ‘emergency’ Caesarean sections should be under regional anaesthesia, and that fewer than 3% of regional blocks should require conversion to general anaesthesia.

The anaesthetic technique of first choice for the woman labouring with epidural analgesia will be top-up of that epidural. Unless contra-indicated, single-shot spinal anaesthesia is appropriate for the majority of women without labour epidural analgesia who require Category 2 Caesarean section.

Epidural top-up

Women receiving epidural analgesia in labour should be reviewed regularly to identify suboptimal blocks (e.g. missed segments) that predict potentially inadequate surgical anaesthesia if topped up for Caesarean section. Women at risk of operative delivery, e.g. ‘trial of scar’ or non-reassuring cardiotocogram, should be given regular oral ranitidine to reduce the acidity of gastric contents. Midwives can initiate this therapy according to a Patient Group Direction. A high proportion of women presenting for emergency Caesarean section should have received ranitidine in labour [14]. Good multidisciplinary communication is pivotal – e.g. if an imminent fetal scalp pH result will seal an increasingly likely fate (Caesarean section for the woman with non-reassuring cardiotocogram), the anaesthetist and theatre team should be informed. Only very rarely does the need for emergency Caesarean section arise ‘out of the blue’[15]. Advance warning can provide the extra time that can prove crucial in allowing successful conversion of labour analgesia to surgical anaesthesia.

Extending a low-dose labour epidural block to provide a dense block for Caesarean section anaesthesia is not the same as establishing de novo single-shot epidural anaesthesia (widely practised before single-shot spinals became popular). Inferences cannot be made from older studies of drug mixtures for single-shot epidurals. The issue of whether demonstrable benefits outweigh the risks of adding bicarbonate and/or adrenaline to a sole local anaesthetic or mixture of local anaesthetics has been explored recently [16]. My preferred choice of local anaesthetic is levobupivacaine, the S-enantiomer of bupivacaine, which is less cardiotoxic than racemic bupivacaine in the event of accidental intravascular injection. Whether the top-up should be administered in delivery room or theatre is controversial [17]. Topping-up in the delivery room might gain time, but maternal monitoring is suboptimal when the risk of high block or systemic local anaesthetic toxicity is greatest. Waiting until arrival in theatre before starting to top-up can invoke obstetrician impatience and a call for general anaesthesia. A compromise is to administer a small initial dose in the delivery room (e.g. 5 ml levobupivacaine 0.5%) and further 5-ml increments as required in theatre.

The efficacy of epidural anaesthesia is consistently reported as inferior to that of spinal anaesthesia in both elective and emergency situations [18, 19]. Blockade of light touch sensation from S5 to T5 should avoid the need for supplementation or conversion to general anaesthesia. Drops of ethyl chloride allow evaluation of both cold and light touch sensation. The addition of epidural fentanyl 50 μg minimises pain from visceral traction. On account of the imprecision in determination of dermatomal levels, it has been proposed that block height be recorded on a diagram [20].

Single-shot spinal

Active bleeding, cardiac disease, uncorrected coagulopathy and a high suspicion of bacteraemia are contra-indications to single-shot spinal anaesthesia. An adequate block for starting surgery should be conferred by a majority of de novo single shot spinals within 10–20 min [21]. Hyperbaric bupivacaine 0.5%, 2.5 ml is a mid-range dose, appropriate for most women; the addition of diamorphine 0.25 mg probably enhances blockade of visceral pain, and certainly provides postoperative analgesia. The attraction of this rather conservative dose of diamorphine (NICE recommends 0.3 mg) is the ease of dilution. I dissolve diamorphine 5 mg in normal saline 10 ml and aspirate 0.5 ml into a 5-ml syringe. The bupivacaine is added subsequently. When there is pressure of time, fentanyl 25 μg is an alternative opioid that requires no dilution [22]. However, this short-acting opioid does not confer postoperative analgesia. Preservative-free morphine is also available at an appropriate dilution (2 mg in 10 ml); 0.1 mg (0.5 ml of this solution) provides comparable postoperative analgesia to diamorphine 0.25 mg [23]. Obsessive maintenance of left-lateral tilt to offset aortocaval compression and prompt use of phenylephrine (now widely regarded as the vasopressor of choice) should mitigate the slight fetal acidosis that has been observed after spinal compared with epidural or general anaesthesia [24, 25].

Preload (administration of fluid before spinal anaesthesia) has been superseded by ‘coload’– a fluid bolus coinciding with the sympathetic blockade. Although phenylephrine can be given by infusion [26], 50–100 μg boluses are as efficacious. Phenylephrine 100 μg is equivalent to ephedrine 8 mg [27]. Timing is everything; the first dose of phenylephrine should be give pre-emptively rather than waiting for arterial pressure to decrease. Subsequent doses are best given in response to symptoms (nausea or light-headedness), which tend to precede hypotension. Reflex bradycardia (heart rate 45–50 beat.min−1) is to be expected after an alpha-adrenergic agonist, and an anticholinergic agent should be immediately available, although administration is rarely necessary. Women with preterm babies require more rather than less intrathecal local anaesthetic, presumably because of less engorgement of the inferior vena cava and therefore epidural veins, and consequently less compression of the thecal sac [28].

The incidence of hypotension (a 30% decrease in mean arterial pressure) after single-shot spinal anaesthesia in women with treated pre-eclampsia has been shown to be less than that in healthy parturients [29]. Eclamptic women who have regained consciousness and received intravenous magnesium can safely undergo regional anaesthesia, provided coagulation indices are acceptable (platelet count > 80 × 109 .l−1) [30].

Combined spinal-epidural

In the event of failure of a topped-up labour epidural to produce bilateral loss of light touch sensation from S4 to T5, single-shot spinal anaesthesia using a dose appropriate for a de novo spinal is not an inherently safe option because of the risk of excessively high block. Combined spinal-epidural anaesthesia is a useful recourse. A conservative spinal dose (hyperbaric bupivacaine 0.5% 1 ml) might well suffice and can be safely augmented by subsequent increments of epidural local anaesthetic.

General anaesthesia

Arguably, historical and contemporary evidence does not suggest that ‘traditional’ rapid sequence induction (thiopental, succinylcholine, cricoid pressure, intubation) is necessarily the safest approach to general anaesthesia for Caesarean section [31]. The most recent Report on Confidential Enquiries into Maternal Deaths in the United Kingdom [32] cited six deaths attributable to general anaesthesia, and featured the unwelcome reappearance of oesophageal intubation as a cause of mortality. The rarity of general anaesthesia for elective Caesarean section has meant that training opportunities have diminished. There is an increasing likelihood that a trainee's first experience of Caesarean section under general anaesthesia will be an emergency case [33]. There is a strong argument for rehearsal in a high-fidelity simulator [34]. Best practice demands competency-based training and assessment of all anaesthetists covering obstetric units.

Depth of anaesthesia

  1. Top of page
  2. Summary
  3. The 30-minute business
  4. In utero fetal resuscitation
  5. Anaesthetic options
  6. Depth of anaesthesia
  7. Pre-eclampsia
  8. Postoperative concerns
  9. Fluid balance
  10. Placenta praevia and accreta
  11. Conclusions
  12. References

The effects on the fetus of anaesthetics and opioid analgesics are ‘innocuous and reversible’[35]. The choice of drug regimen or doses used for women with cardiac or cerebrovascular disease should not be restricted on account of concerns for the fetus [36]. Dose-dependent respiratory depression is predictable and readily treatable by a neonatal paediatrician, who should be present to receive all neonates born by Caesarean section under general anaesthesia.

There is no justification for administration of low inspired vapour concentrations that risk awareness. To maintain bispectral index (BIS) values < 60 for ‘adequate’ depth of anaesthesia during Caesarean section, end-tidal vapour concentration > 0.75 MAC (+ 50% nitrous oxide) has been recommended [37]. There is no evidence that neonatal ‘outcome’ is adversely influenced by greater depth of maternal anaesthesia; the relaxant effect of modern, insoluble vapours on uterine tone is readily reversible. In the event of severe hypovolaemia, anaesthesia can be induced and maintained with intravenous ketamine, which has a useful sympathomimetic effect.

Pre-eclampsia

  1. Top of page
  2. Summary
  3. The 30-minute business
  4. In utero fetal resuscitation
  5. Anaesthetic options
  6. Depth of anaesthesia
  7. Pre-eclampsia
  8. Postoperative concerns
  9. Fluid balance
  10. Placenta praevia and accreta
  11. Conclusions
  12. References

In pre-eclampsia, general anaesthesia is indicated for uncorrected coagulopathy or symptoms (piercing headache, in particular) or signs consistent with impending eclampsia. An exaggerated pressor response to intubation, which would threaten the integrity of the cerebral circulation, will be averted reliably by a neuro-anaesthetic induction regimen (thiopental supplemented by alfentanil 10 μg.kg−1 or remifentanil 2 μg.kg−1). The threat of dangerous hypertension remains at extubation; antihypertensive pretreatment (e.g. labetalol in 10–20-mg increments) is effective. Non-depolarising neuromuscular blockade is significantly enhanced by therapeutic serum magnesium concentrations, and monitoring by peripheral nerve stimulation is essential.

Postoperative concerns

  1. Top of page
  2. Summary
  3. The 30-minute business
  4. In utero fetal resuscitation
  5. Anaesthetic options
  6. Depth of anaesthesia
  7. Pre-eclampsia
  8. Postoperative concerns
  9. Fluid balance
  10. Placenta praevia and accreta
  11. Conclusions
  12. References

Intrathecal diamorphine is the mainstay of postoperative analgesia after single-shot spinal anaesthesia. For epidurals or combined spinal-epidurals, 2.5 mg (10 times the intrathecal dose) is appropriate [38]. If there has been accidental or deliberate dural puncture (i.e. combined spinal-epidural) it should be borne in mind that there might be a route for a dangerous excess of opioid to reach the intrathecal compartment [39]. Unless there is hepatic dysfunction, paracetamol is given regularly to all women. Diclofenac is prescribed provided there are no contra-indications (notably renal dysfunction, e.g. in pre-eclampsia). Low molecular weight heparin is administered 2 h after removal of the epidural catheter. Synthetic oxytocin is given slowly as a 5-unit bolus immediately after delivery, followed by an infusion (10 units.h−1 for at least 4 h) to prevent uterine atony. The risk of postpartum haemorrhage is greater in women who have undergone emergency as opposed to elective Caesarean section. Clinical observation (e.g. uterine palpation) and physiological monitoring are configured to detect haemorrhage, which can be covert (concealed within the uterus or intraperitoneal) as well as overt.

Fluid balance

  1. Top of page
  2. Summary
  3. The 30-minute business
  4. In utero fetal resuscitation
  5. Anaesthetic options
  6. Depth of anaesthesia
  7. Pre-eclampsia
  8. Postoperative concerns
  9. Fluid balance
  10. Placenta praevia and accreta
  11. Conclusions
  12. References

Around 1% of women will require high dependency care after Caesarean section [4].

Fluid input and output must be charted meticulously. In pre-eclampsia, oliguria (urine output < 30 ml.h−1) after delivery is extremely common and does not necessarily imply volume depletion. Acute tubular necrosis is exceptionally rare in the absence of a compounding factor such as major haemorrhage or injudicious administration of a non-steroidal anti-inflammatory drug. No study has shown that crystalloid or colloid is superior. Crystalloid infusion may reduce plasma colloid oncotic pressure, but the longer half-life of colloid infusions may contribute to circulatory overload during the period of postpartum mobilisation of the increased extracellular fluid volume of pregnancy. If synthetic oxytocin is to be continued beyond the immediate postpartum period, administration should be in small diluent volumes by syringe pump (e.g. 60 units in 60 ml normal saline at 10 ml.h−1). Measurement of CVP can help substantiate a diagnosis of hypovolaemia, and assist its correction. Cautious volume expansion can reasonably be undertaken if CVP is ≤5 mmHg, but the circulating volume should be considered as full if CVP is > 5 mmHg and minimal intravenous fluids (e.g. normal saline 20 ml.h−1) should suffice. Disparity between CVP and pulmonary artery wedge pressure (PAWP) is a distinct possibility (PAWP may be considerably higher as a result of left ventricular dysfunction) [40]. Administration of blood and blood products seems to be a risk factor for the development of pulmonary oedema [41].

‘Why Mothers Die’[32] has drawn attention to the need for multidisciplinary training in the recognition of the insidious development of sepsis in women on postnatal wards. Tachypnoea always merits thorough investigation.

Placenta praevia and accreta

  1. Top of page
  2. Summary
  3. The 30-minute business
  4. In utero fetal resuscitation
  5. Anaesthetic options
  6. Depth of anaesthesia
  7. Pre-eclampsia
  8. Postoperative concerns
  9. Fluid balance
  10. Placenta praevia and accreta
  11. Conclusions
  12. References

The commonly held obstetric view that placenta praevia dictates general anaesthesia is not supported by available evidence. Guidelines from the Royal College of Obstetricians and Gynaecologists state that the choice of anaesthetic lies with the anaesthetist [42]. The difference between the mother who is actively bleeding (in whom sympathetic blockade might be disastrous) and the stable, volume-replete mother is sometimes not appreciated. Reducing the depth of general anaesthesia to treat intra-operative hypotension is not a substitute for addressing the problem of hypovolaemia, which requires aggressive management regardless of the type of anaesthetic. Placenta praevia overlying a previous Caesarean section scar raises the possibility of placenta accreta (abnormally firm attachment of the placenta to the uterine wall) and a particularly high risk of massive haemorrhage [43]. General anaesthesia with invasive monitoring, rapid fluid warming/infusion device, cell salvage facility, and provision for postoperative ICU admission might be considered prudent.

Conclusions

  1. Top of page
  2. Summary
  3. The 30-minute business
  4. In utero fetal resuscitation
  5. Anaesthetic options
  6. Depth of anaesthesia
  7. Pre-eclampsia
  8. Postoperative concerns
  9. Fluid balance
  10. Placenta praevia and accreta
  11. Conclusions
  12. References

• Good multidisciplinary communication is crucial; the categorisation of urgency should be discussed.

• Anaesthetists should participate actively in resuscitation of the fetus in utero; relief of aortocaval compression is paramount.

• Epidural top-up with levobupivacaine 0.5% and fentanyl is the anaesthetic of choice for the women receiving labour epidural analgesia who require Caesarean section.

• Combined spinal-epidural is useful if epidural top-up has failed to provide bilateral light touch anaesthesia from S5 – T5.

• Single-shot spinal anaesthesia is appropriate for most Category 2 emergencies (in women without labour epidural analgesia). Pre-eclampsia is not a contra-indication.

• Phenylephrine is the vasopressor of choice. Phenylephrine 100 μg = ephedrine 8 mg.

• Induction and maintenance doses of general anaesthesia drugs should not be reduced in the belief that the baby will be harmed.

• General anaesthesia is not indicated by default for placenta praevia.

• Early postoperative observations and monitoring are geared towards the detection of overt or covert haemorrhage; sepsis is a later, insidious complication.

References

  1. Top of page
  2. Summary
  3. The 30-minute business
  4. In utero fetal resuscitation
  5. Anaesthetic options
  6. Depth of anaesthesia
  7. Pre-eclampsia
  8. Postoperative concerns
  9. Fluid balance
  10. Placenta praevia and accreta
  11. Conclusions
  12. References
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