30.

CAESAREAN DELIVERY

The choice of anaesthesia for caesarean delivery depends on the experience of the
anaesthesia provider, the wishes of the mother, the urgency of the procedure and the
health of the mother and foetus. Options include spinal, epidural, combined spinal-epidural
(CSE) and general anaesthesia. Single-shot spinal is the most economic and safe anaesthesia
choice for the vast majority of patients.

Providing  safe and effective anaesthesia for caesarean delivery requires a detailed
understanding of the physiologic changes associated with pregnancy, labour and delivery.
The anaesthesia provider must avoid hypotension, avoid neonatal depression and be aware
that difficult tracheal intubation and aspiration of gastric contents with general anaesthesia
are major causes of maternal morbidity and mortality. 
Preoperatively they must perform a focused preoperative assessment with particular
attention to determine any comorbidities that would impact the anaesthesia plan, assess
the airway for possible difficult intubation and identify any contraindications to regional
anaesthesia. Preoperative laboratory testing should be individualized. Though the possibility
of a low-risk mother requiring a blood transfusion is less than one percent, a blood type and
screen is frequently performed. Baseline haemoglobin, platelet count, and coagulation
testing may be indicated for specific conditions. Restriction of fluids and food in labour for
women at low risk of complications is not justified, however women scheduled for elective
caesarean delivery should be appropriately fasted for solids and fluids. Verification of fasting
compliance should be confirmed at the time of procedure.  For elective caesarean delivery,
an oral H-2 receptor (ranitidine or cimetidine) should be given the night before and two
hours before surgery. For emergency caesarean delivery, a H-2 receptor antagonist may be
given as soon as the decision to operate is made. All patients should receive a non-
particulate oral antacid such as sodium citrate, within 1 hour of the start of anaesthesia.
Large-bore intravenous access is essential  as obstetric haemorrhage is rapid and massive if
it occurs. The average blood loss from a caesarean delivery is 800 to 1000 ml, but the
contraction of the uterus autotranfuses approximately 500ml.
Antibiotic prophylaxis should be given for all caesarean deliveries. Ideally it should be
administered at least 30 minutes prior, to ensure a bactericidal concentration is reached by
the time of skin incision. Narrow-spectrum antibiotics that are effective against gram-
positive and gram-negative bacteria with some anti-anaerobic activity are the most
appropriate choice e.g. a first-generation cephalosporin. 
Because the prime determinant of foetal perfusion is maternal mean arterial pressure, it is
critical to avoid maternal hypotension. In the term pregnant woman, heart rate and stroke
volume, and hence cardiac output are already increased to meet the metabolic demands,
impairing the ability of the cardiovascular system to compensate. Challenging previous
teaching for the management of supine hypotensive syndrome of pregnancy, routine lateral
tilt during caesarean delivery may not be necessary if maternal blood pressure is
aggressively supported with a vasopressor. In the majority of mothers, the collateral azygos
system  compensates for the caval obstruction by redirecting blood flow. Inferior vena cava
obstruction is only significantly relieved by ≥30° of left tilt and the aorta is not compressed
in the supine position. Usually the lateral tilt applied is either ineffective or not used with a
sufficient degree of tilt and a lateral tilt of 15 degrees causes a significant impediment to
surgical conditions and maternal discomfort due to sensations of sliding off the operating
table. During maternal cardiac arrest in late pregnancy, current guidelines recommend
manually displacing the uterus and keeping the patient in the supine position to allow
effective resuscitative efforts. 
Nausea and vomiting are corrected by correction of hypotension. ECG, blood pressure and
SaO2 monitoring should continue until discharge from recovery. For emergency Caesarean
section, foetal heart rate monitoring should be undertaken during induction of anaesthesia
for as long as feasibly possible.
During pregnancy there are increases in numerous clotting factors. Embolic phenomenon
remains a significant cause of postoperative morbidity. The risk for VTE increases with
gestational age, reaching a maximum just after delivery. Caesarean delivery is a significant
additional risk factor. All women who have had a caesarean delivery should be considered
for thromboprophylaxis with low molecular weight heparin (LMWH). LMWH should be
withheld for 4 hours after spinal/epidural anaesthesia.
Uterine contraction prevents uterine bleeding after delivery. The uterus should be
massaged, and oxytocin is administered with an initial bolus dose of 1 to 5 IU intravenously,
followed by a titrated infusion 10 IU/h. Oxytocin (10 IU intramuscularly ) or a fixed dose
combination of oxytocin and ergometrine (5 IU/500 µg IM) may be given after delivery in
settings where infusion pumps are not available. One side-effect of oxytocin is relaxation of
vascular smooth muscle that will cause a fall in diastolic and systolic blood pressure, and a
reflex tachycardia. Hypovolaemic patients may have a serious fall in blood pressure.
Post-operative analgesia should be multimodal including regular acetaminophen
(paracetamol), if appropriate, regular non steroidal anti inflammatory drugs, and PRN oral
opioid. Early oral intake, removal of the urinary catheter and mobilisation should be
promoted.

Choice of Anaesthesia

A single shot spinal is the most economical and safest anaesthesia for caesarean delivery for
most patients in the absence of contraindications. The advantages of regional anaesthesia
(spinal or epidural) include an awake mother, minimal newborn depression, reduced blood
loss and avoiding the risks of general anaesthesia. Additionally, neuraxial anaesthesia allows
for the administration of neuraxial opioids to decrease postoperative pain. General
anaesthesia may be necessary when regional anaesthesia is contraindicated
(hypovolaemia/haemorrhage, severe foetal distress, maternal preference, fixed cardiac
output, coagulopathy, sepsis at the site). Potential problems with general anaesthesia
include aspiration of gastric contents, failed intubation/oxygenation, uterine atony,
neonatal depression and maternal awareness.

Regional Anaesthesia

The level of the neuraxial block must always be tested bilaterally prior to surgery. Loss of
sensation to light touch/cold should extend from S5 to T4. A block to T10 dermatome is
required  to  abolish somatic pain and a block to T4 is required to abolish visceral pain and
discomfort. Most healthy parturients do not require supplemental oxygen during neuraxial
anaesthesia for uncomplicated caesarean delivery. Preloading with intravenous fluid is not
necessary unless the patient is known to be hypovolaemic. Maternal blood pressure should
be measured every 1- 2 minutes after the administration of neuraxial anaesthesia until
delivery to identify hypotension. After delivery, if stable, the interval may be extended to
every 5 minutes. Blood pressure should be maintained above 90% of baseline. Alpha-agonist
drugs are the most appropriate drugs for prevention and treatment of hypotension.
Intravenous  phenylephrine (50 – 100 μg), adrenaline (10 μg) or metaraminol (0.5 mg) have
been shown to cause less foetal acidosis than ephedrine (5 mg). A  phenylephrine infusion
(25-50 µg/min) may be commenced prophylactically and titrated to effect. Bradycardia
should be treated with glycopyrrolate or atropine.
Neuraxial anaesthesia is more commonly performed in the sitting position (versus the
lateral) as it is easier to identify the midline. Chlorhexidine in alcohol is recommended over
iodine for skin disinfection because it has a greater bactericidal effect that lasts several
hours. It must be  allowed to dry to ensure its efficacy.
The common risks of regional anaesthesia are hypotension, nausea, itch and shivering.
Breakthrough pain requiring supplemental analgesia or conversion to general anaesthesia
occurs infrequently and postural puncture headache is uncommon. Rare complications
include high block, total spinal, temporary/permanent neuropraxia, infection,
spinal/epidural haematoma and paralysis.
Spinal anaesthesia is a simple, rapid and reliable technique if there is no contraindication,
however the duration of anaesthesia is limited without the ability to extend anaesthesia.
The duration of a single shot spinal is variable (and depends on the agents used), but
normally provides adequate surgical anaesthesia for > 90 minutes. Hyperbaric bupivacaine is
frequently used for Caesarean delivery spinal anaesthesia with typical doses between 10
and 15 mg using 2.0 to 3.0 mL of 0.5% bupivacaine, or 1.3 to 2.0 mL of 0.75% bupivacaine.
Intrathecal preservative free opioid adjuncts such as fentanyl (10 - 25 µg) improve the
quality of anaesthesia, particularly by blocking the discomfort of visceral manipulation. The
addition of 100 µg of preservative free morphine may provide 14 - 36 hours postoperative
analgesia. The duration of anaesthesia with 2.0 to 3.0 ml of 2% lignocaine is limited to 60 -
90 minutes. Small-gauged, ideally 25 gauge or smaller, pencil-point spinal needles reduce
the incidence of postural puncture headaches compared to cutting needles.
Spinal anaesthesia for caesarean section is not 100% successful with a reported failure rate
between 2% and 4%. Sufficient time should be given for the block to establish, however the
maximum time for the onset is 15 – 20 minutes. If there is no urgency and after 20 minutes
there is no evidence of neuraxial anaesthesia the spinal anaesthesia may be repeated at a
different level with the full dose. If after 20 minutes there is a partial block, then it may be
best to place an epidural and titrate to an effect. With a partial block, proceeding with a
repeat full spinal anaesthesia dose could potentially lead to a high block. Where delivery is
urgent, the anaesthesia provider may need to proceed with general anaesthesia. If the block
fails after surgery has commenced, surgery must be immediately ceased, the mother
reassured and the spinal anaesthesia reassessed. Supplementary analgesia with i.v. or
inhaled adjuvants (opioids, ketamine, and nitrous oxide) may be needed. Conversion to GA
must be considered if analgesic dosing is insufficient.

Epidural anaesthesia is an alternative technique. It has a slower onset than spinal

anaesthesia (20 minutes) and the anaesthesia may not be as effective but the dose of
epidural anaesthetic can be titrated and repeated if required. The epidural can also be used
for postoperative analgesia. A dose of 15 to 20 ml of 3% chloroprocaine, 0.5% bupivacaine
or 2% lignocaine with adrenaline 1:200,000 is usually effective. The addition of 50 - 100 µg
of fentanyl will improve the quality of anaesthesia. The anaesthesia provider should inject 5
ml of local anaesthetic every 5 minutes and assess the level of the block. Giving increments
of local anaesthetic will avoid hypotension and a high block. If the epidural is already in
place it simply needs to be topped up for Caesarean delivery. Dosing with 5 ml of 2%
lidocaine with 1:200 000 adrenaline (15 - 20 ml total) has a mean time to be ready for skin
incision of approximately 10 minutes. However, the anaesthesia provider cannot expect a
poor labour epidural (multiple unscheduled top ups, patchy block) to provide adequate
surgical anaesthesia. 

A CSE technique offers the advantage of a spinal anaesthetic with rapid onset of a dense
block, as well as the ability to administer additional anaesthetics through the epidural
catheter. It is commonly performed with a needle through the needle through-the-needle
technique where An epidural needle is used to identify the epidural space and a spinal
needle is then passed through the epidural needle into the subarachnoid space. Once the 
subarachnoid block is performed, an epidural catheter is placed that can be used
subsequently. CSE is preferred when prolonged surgery is expected. 

General Anaesthesia

General anaesthesia for caesarean delivery may be required for maternal refusal,
insufficient time for neuraxial, (although a single-shot spinal anaesthetic by an experienced
provider does not take much longer than general anaesthesia induction), failed neuraxial
anaesthesia, relative/absolute contraindications to neuraxial anaesthesia, anticipated major
haemorrhage and complex obstetric surgery.

There are several normal changes of physiology in the obstetric patient that have major
implications for general anaesthesia. The upward displacement of the diaphragm by the
uterus and an increase in the transverse diameter of the thorax reduces functional residual
capacity (FRC) by 20% at term. Increased maternal resting metabolic rate and the increased
metabolic demands of the fetoplacental unit causes an increase in oxygen consumption.
This combination of reduced oxygen reserve and increased oxygen consumption leads to
rapid oxygen desaturation. Mucosal engorgement and laryngeal or pharyngeal oedema
contribute to the increased difficulty of tracheal intubation. The incidence of failed obstetric
intubation is reported to be around 1:300 compared to 1:3000 in general surgical patients.
Inability to secure an airway is the leading cause of anaesthetic-related maternal death. 
The following measures are recommended to prevent desaturation and improve intubation
conditions: the routine use of the head-up position during induction, preoxygenation with a
tight-fitting face mask for a minimum of 3 minutes aiming for end tidal oxygen
concentration greater than 90%, gentle mask ventilation before intubation (Pmax < 20
cmH2O) and apnoeic oxygenation via nasal cannula. This should start at low flow (< 5 l/min)
as it is uncomfortable for the patient but once asleep can be increased to 10 - 15 l/min.
As pregnancy progresses the risk of aspiration of gastric contents increases. The lower
oesophageal sphincter becomes less efficient at preventing oesophageal reflux, secretion of
gastric acid increases and the enlarging  uterus displaces the stomach, causing increased
intragastric pressure and loss of the protective effect of the diaphragm on the lower
oesophageal sphincter. In addition, gastric emptying is decreased during labour. All patients
should have antacid prophylaxis within 6 hours of surgery. The anaesthesia team should
confirm their rehearsed and articulated ‘airway plan B’ in case of failed intubation. Induction
of anaesthesia must be  “rapid sequence” ie: pre-oxygenation, short induction to intubation
interval and cricoid pressure. Patients should be preoxygenated for at least 3 minutes,
intravenous thiopentone 5 mg/kg or propofol 2.5 mg/kg administered, cricoid pressure
applied and suxamethonium 1 - 1.5 mg/kg given. Ketamine (1 - 2 mg/kg) is an alternative
induction agent for cardiovascular compromised mothers. Laryngoscopy and intubation is
performed after fasciculations cease. Cricoid pressure is recommended. An initial force of 10
N should be applied prior to induction of anaesthesia, increasing to 30 N after loss of
consciousness. It should be maintained until correct placement of the endotracheal tube,
but in the event of a difficult intubation may be gently released. Anaesthesia is maintained
with 50% oxygen in nitrous oxide and 0.5 MAC of volatile inhalation agent  (sevoflurane 1%,
enflurane 1%, isoflurane 0.75% or halothane 0.5%).  The historical practice of administering
a “light” anaesthetic with thiopentone and maintenance with nitrous oxide and oxygen
alone, in order to avoid neonatal sedation and reduce blood loss secondary to reduced
uterine tone results in 20 percent awareness. Though administration of intravenous opioids
is usually delayed until after the foetus is delivered, I.V fentanyl on induction is unlikely to
have a clinically significant effect on the newborn and may be beneficial for patients with
preeclampsia. The hemodynamic response to laryngoscopy may be exaggerated in
preeclamptic patients, and may result in intracranial haemorrhage and/or pulmonary
oedema. Alfentanil (10 μg/kg), remifentanil (1 μg/kg), magnesium sulphate (2 g), lidocaine
(1 - 1.5 mg/kg), labetalol (titrated with 10 mg IV boluses up to 1 mg/kg) and esmolol  (2
mg/kg )are all suitable agents. Following administration of syntocinon at delivery, opioid
analgesia should be given.
At the completion of surgery muscle relaxants should be reversed. The mother is extubated
either in the left lateral head down position or head up position. She is not extubated until
the airway reflexes are present. Attention to detail at the time of extubation is equally as
important as during intubation. 

Post operative analgesia may be completed with a NSAID, paracetamol and morphine. Local
anaesthetic wound infiltration and abdominal nerve blocks (transversus abdominis plane,
iliohypogastric and ilioinguinal nerves) result in a moderate reduction in opioid consumption
postoperatively.