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Chapter: Clinical Anesthesiology: Anesthetic Management: Obstetric Anesthesia

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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.

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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