CESAREAN SECTION
A cesarean section, often referred to as a C-section, is a surgical procedure used to deliver a baby through an incision in the mother's abdomen and uterus. This procedure is usually performed when a vaginal delivery would put the baby or mother at risk.
Some reasons for a C-section can include:
-
Multiple births: If a mother is having twins, triplets, or more, a C-section might be the safest delivery option.
-
Baby's health: If the baby has a known health concern or abnormality that could make a vaginal birth risky, a C-section may be recommended.
-
Position of the baby: If the baby is breech (bottom or feet first) or transverse (sideways), a C-section is often necessary.
-
Previous C-section: If a mother has had a previous C-section, especially if the incision was vertical, her doctor might recommend repeat C-sections for future births to reduce the risk of uterine rupture.
-
Failure to progress: If labor is not progressing as it should, a C-section might be the best option.
-
Placental issues: If there are problems with the placenta, such as placenta previa (when the placenta is so low in the uterus that it covers the cervix), a C-section might be required.
-
Mother's health: Certain health conditions, such as HIV or active genital herpes, might make a C-section the safer way to deliver the baby. In addition, if the mother has a health problem like heart disease or high blood pressure, a C-section might be the safest option.
-
Emergency C-section is commonly done for fetal distress/bradycardia, non-reassuring fetal heart tones (FHT), hemorrhage, uterine rupture, or a prolapsed umbilical cord.
After a C-section, women usually stay in the hospital for around three to four days before going home. Recovery from a C-section generally takes longer than from a vaginal birth. It's important for women to take it easy and get as much rest as possible to allow their bodies to heal.
Anesthetic Implications for Cesarean Section
Anesthesia type: Neuraxial block (Spinal or epidural). General anesthesia is appropriate if the neuraxial block is
refused, contraindicated, ineffective, or in an emergency
Airway: ETT if general anesthesia
Preoperative:
-
Always be prepared to implement general anesthesia
-
Aortocaval compression can occur in the supine position (decreased venous return, decreased cardiac output, and uteroplacental insufficiency can occur)
-
All pregnant patients are considered “full stomach”
-
GI prophylaxis against aspiration for the possibility of general anesthesia
-
Fetal heart tones (FHT) are commonly assessed before and after neuraxial anesthesia is implemented
-
Prior to the implementation of the neuraxial block, 500-1000 mL of fluid is usually infused due to hypotension from sympathectomy
-
A sensory block up to T4-T6 segmental level is required
-
The surgeon should check that mother is insensate via pinch test before making the initial incision
-
The patient should be instructed she should not feel sharp pain, but will likely feel movement and pressure
-
Pressure is commonly felt when applying manual pressure to deliver the fetal head and when the uterus is external to the abdominal cavity for suturing
-
The pregnant patient has compensated respiratory alkalosis (increased minute ventilation, decreased functional residual capacity, increased oxygen consumption
-
Smaller ETT is used for GETA due to mucosal capillary engorgement
-
Avoid nasal airways
-
Parturients have reduced time to desaturation during apnea
-
The pregnant patient has decreased systemic vascular resistance (SVR), decreased diastolic pressure and MAP, and increased heart rate and cardiac output
-
Iron deficiency anemia is normally superimposed on the dilutional anemia of pregnancy
-
Parturients have increased intragastric pressure, decreased esophageal sphincter tone, and decreased gastric motility predisposing them to aspiration pneumonitis
-
MAC of inhaled agents is decreased
-
Sensitivity to local anesthetics is increased
-
Contraindications to regional anesthesia include patient refusal, coagulopathy, active neurological disease, elevated intracranial pressure, and active infection at the site
-
Rapid sequence induction with cricoid pressure for GETA
Intraoperative:
-
Position: Supine with the arms extended on armboards
-
A wedge can be placed under the right hip for left uterine displacement
-
If the patient complains of nausea, treat for hypotension and give antiemetic
-
Ephedrine and phenylephrine (Neosynephrine) are the vasopressors commonly given
-
After delivery, the uterus is brought out of the wound to be sutured. This step can cause a lot of pressure and pain for the mother
-
After the baby is delivered: If the patient becomes anxious or complains of pain, it is ok to give benzodiazepines or narcotics
-
Pitocin (oxytocin) 20–40 units added to a 1 L bag of IV fluid and administered after delivery and separation from placenta
-
Oxytocin is the first-line uterotonic drug to prevent and treat uterine atony and postpartum hemorrhage
-
EBL +500 ml
-
Duration: 1-2 hours
-
Uterine massage is performed by nurse applying heavy pressure on the abdomen to stop uterine bleeding
Postoperative:
-
Tubal ligation may be performed at the time of cesarean section
-
For boggy and bleeding uterus, Methergine IM or Hemabate IM can be administered per surgeon request
-
if GETA, the patient should be extubated fully awake and fully reversed
-
Multimodal analgesia should be utilized
-
Patient-controlled analgesia (PCA)
Complications:
-
Amniotic fluid embolism
-
Venous thromboembolism (VTE)
-
Postpartum hemorrhage (PPH)
Sources:
Macksey, L. F. (2011). Surgical procedures and anesthetic implications: A handbook for nurse anesthesia practice.
Jaffe, R. A. (2020). Anesthesiologist's Manual of Surgical Procedures (6th ed.).
Singh-Radcliff, N. (2013). 5-Minute Anesthesia Consult.