ANESTHESIA FOR EMERGENCY CESAREAN SECTION
Indications for emergency cesarean section
include massive bleeding (placenta previa or accreta, abrup-tio placentae, or
uterine rupture), umbilical cord prolapse, and severe fetal distress. A
distinction must be made between a true emergency requir-ing immediate delivery
(previously referred to as “crash”) and one in which some delay is possible.
Close communication with the obstetrician is neces-sary to determine whether
fetus, mother, or both are in immediate jeopardy.
The choice of anesthetic technique is deter-mined by consideration for
maternal safety (airway evaluation), technical issues, and the
anesthesi-ologist’s personal expertise. Criteria leading to the diagnosis of
nonreassuring fetal status should be reviewed as the fetal evaluation may be
based on criteria with poor predictive accuracy and the fetal status may
change. This information is required to choose the anesthetic technique that
will produce the best outcome for both mother and fetus. Rapid institution of
regional anesthesia is an option in selected cases but is problematic in
severely hypo-volemic or hypotensive patients. If general anes-thesia is
chosen, adequate denitrogenation may be achieved rapidly with four maximal
breaths of 100% oxygen while monitors are being applied. Ketamine, 1 mg/kg, may
be substituted for propofol in hypo-tensive or hypovolemic patients.
Table 41–5 lists commonly accepted signsof fetal
distress, an imprecise and poorly defined term. In most instances the diagnosis
is primarily
based on monitoring of fetal heart rate. Because worrisome fetal heart
rate patterns have a rela-tively high incidence of false-positive results,
care-ful interpretation of other parameters, such as fetal scalp pH or fetal
pulse oximetry, may also be nec-essary. Moreover, continuation of fetal
monitoring in the operating room may help avoid unnecessary induction of
general anesthesia for fetal distress when additional time for use of regional
anesthesia is possible. In selected instances where immedi-ate delivery is not
absolutely mandatory, epidural anesthesia (with 3% chloroprocaine or
alkalin-ized 2% lidocaine) or spinal anesthesia may be appropriate.
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