Three hours into labor, the obstetrician notes a signif-icant increase in the vaginal bleeding and a fall in maternal blood pressure to 80/40 mm Hg with a pulse of 120 beats per minute. Late decelerations are noted on the FHR monitor. Assuming the patient has not yet received an epidural for regional analgesia, how would you anesthetize this patient for an emergency cesarean section?
To decide upon an anesthetic plan, both maternal and fetal condition must be evaluated. The maternal and fetal conditions have deteriorated since admission and are con-sistent with a worsening abruption complicated by signifi-cant blood loss and fetal distress. It should be remembered that the amount of vaginal bleeding may underestimate the true blood loss as a significant volume of blood may be concealed behind the placenta. The hemoglobin con-centration should be determined to guide blood trans-fusion therapy. Maternal coagulopathy, such as DIC, secondary to the placental abruption must also be ruled out. If maternal and/or fetal instability exist, cesarean delivery may be performed before the laboratory assess-ment is obtained.
Although spinal anesthesia can be rapidly established to provide surgical anesthesia for an emergency cesarean section, the presence of maternal coagulopathy and hypo-volemia due to hemorrhage are contraindications to the placement of a regional anesthetic. For these reasons, regional anesthesia should be avoided and the cesarean section should be performed under general anesthesia.
Prior to the induction of general anesthesia adequate intravenous access must be established. Blood should be drawn and sent for typing and crossmatching, hemat-ocrit level, platelet count, PT/PTT, fibrinogen level, and for the presence of fibrin degradation products. Fluid resuscitation should also begin immediately. Because the pregnant patient is considered to have a full stomach, a rapid sequence induction with cricoid pressure must be performed. In the hypovolemic patient, etomidate 0.1–0.2 mg/kg or ketamine 1 mg/kg intravenously should be considered as induction agents. Propofol and thiopental should probably be avoided as they are associated with more hypotension than ketamine or etomidate after induc-tion. Succinylcholine should be utilized to facilitate tracheal intubation.