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1. Indication and emergency
2. Airway problems expected?
3. GA really necessary?
Three important questions
Disadvantages with GA for CS
Higher mortalityAirway problems?Aspiration?Awareness - recall?Hemodynamics?Atonia of the uterus?Neonatal effects?
1964-66 2000-02
CS % 3.4 21
CNB% ~0 ~80
Anesthesia relatedmortality per million anesthetics
360 10
Why mothers die
www.cemach.org.uk
Anesthesia related maternal mortality per million anesthetics
2000-2002
GA 50
CNB 3
Why mothers die
www.cemach.org.uk
Anesthesia related maternal mortality per million anesthetics 2000-2002
General anesthesia 50
Regional anesthesia 3
Why mothers die
www.cemach.org.uk
Selection bias!
23 failed tracheal intubations occurred in 5802 obstetric general anesthetics between 1981 and 1994 corresponding to 1/252
BJA 1996:76:680-684
20 failed tracheal intubations occurred in 4768 obstetric general anesthetics between 1999 and 2003 corresponding to 1/238
Anaesthesia 2005:60:168-171
4 failed tracheal intubations occurred in 1095 obstetric general anesthetics between 2005 and 2006 corresponding to 1/273
Int J Obst Anesth 2008:17:292-297
Why is airway handling more difficult in the obstetric patient?
• Anatomical changes
• Physiological changes
• Increased risk for aspiration
• Often an emergency situation
PaO2 after 60 sec of apnea
Br J Anaesth 1974:46:358-360
PaO2 before apnea (kPa)
PaO2 after apnea (kPa)
(%)
Pregnant 63.1 44.5 30
Non pregnant
67.6 59.9 11
Optimal technique
• Subarachnoidal injection L3-L4• Check BP and HR every minute until delivery• Position, left lateral tilt• Vasopressor readily avalible• Rapid isotonic saline infusion• Careful preop testing of blockade height• Optimal height of blockade – above T5• Slow inj. of oxytocin 5 IU after cord clamping
Contraindication, SPA
• Uncompensated hypovolemia• Severe Coagulopathies• Local infection• Patient refuses• Septicemia
GA and CS
• Always RSI
• Preoxygenation
• Emergency contra elective
• Cricoid pressure?
• What is good for the mother is good for the baby