The document discusses anesthesia management for emergency cesarean sections during complicated pregnancies, including risks, common indications for cesarean delivery, and the importance of timely decision-making. It outlines different anesthetic modalities, preoperative considerations, and specific management strategies for various complications such as umbilical cord prolapse and abnormal fetal presentations. The document emphasizes the need for careful evaluation, patient preparation, and the potential risks associated with both maternal and fetal outcomes.

1. Anesthesia for Emergency LSCS,
Management in complicated pregnancy
(Preterm, Prematurity and Multiple
gestation)

2. Incidence
• Cesarean delivery rates  US increased by 50% between 1998 and
2016
• From 22% to 32% of all births
• Globally 14.1 – 23.6 %
• Nepal  cesarean rate 34.4% of the total deliveries (Shrestha et al –
2021)
• 2/3rd
 emergency LSCS

3. Indications for cesarean delivery
• Fetal mal-presentation
• Massive bleeding (placenta previa or
accreta, abruptio placentae, uterine rupture)
• Non-reassuring fetal status/ distress
• Labor dystocia/ arrest of dilation/ NPOL
• Prior cesarean delivery
• Umbilical cord prolapse
• Cephalo-pelvic disproportion
• Prematurity
• Prior uterine surgery involving corpus
• absolute or relative C/I to neuraxial
anesthesia (coagulopathy, moderate or
severe aortic stenosis)

4. Signs of fetal distress
• Non-reassuring fetal heart rate pattern
• Repetitive late decelerations
• Loss of fetal beat-to-beat variability associated with late or deep
decelerations
• Sustained fetal heart rate <80 beats/min
• Fetal scalp pH <7.20
• Meconium-stained amniotic fluid
• Intrauterine growth restriction

5. Emergency LSCS?
• Decision to delivery interval
• Not > 30 minutes in category 1
• Not > 75 minutes in category 2

6. Intra-uterine fetal resuscitation
• Application of active measures to a parturient in active labor to improve
oxygenation to fetus and reverse fetal hypoxia and acidosis
• Provided placenta is functioning normally
• Anesthetist involvement ?  labor epidural anesthesia started or emergency
LSCS planned
• Left lateral recumbent positioning  relieves aorto-caval compression 
improve uterine, placental and umbilical blood flow
• Stop oxytocin and start tocolytics (terbutaline 250 mcg S/c)
• High flow oxygen
• IV crystalloid infusion
• Vasopressor use

7. Anesthetic modalities
• Choice of anesthesia depends on  urgency of the procedure,
condition of mother and fetus, anesthetist’s personal expertise and
mother’s wish
Modalities include:
• Neuraxial anesthesia – spinal, epidural, CSE
• General anesthesia

8. Pre anesthetic consideration
• Preoperative evaluation - regardless of planned delivery mode or type
of anesthetic technique
• Full stomach and risk of aspiration
• Difficult airway
• Difficult neuraxial anesthesia
• Aorto-caval compression and supine hypotension
• Possibility of massive bleeding and transfusion requirement

9. Patient preparation
• Always consider full stomach
• Antacid prophylaxis against aspiration pneumonia  0.3M sodium citrate, 30
mL, 30 to 45 min prior to induction
• Patients with additional R/F for aspiration  morbid obesity, GERD, difficult
airway, emergency surgical delivery without an elective fasting period
• IV Ranitidine 50mg/ metoclopramide 10 mg or both 1-2 h prior to induction
of GA
• Always consider difficult airway
• Proper positioning of head and neck  facilitate ETT placement in obese 
elevation of shoulders, flexion of cervical spine, extension of atlanto-occipital
joint

11. OR preparation
• Medications  readily available to safely provide GA for an emergent or unanticipated
situation
• Equipment to manage the difficult airway should be readily available
• An oxygen source
• Equipment for bag and mask ventilation
• Laryngoscopes (direct and video)
• Several ETTs of different sizes with available stylets and bougies
• Other (not ETT) airway devices (eg, oral, nasal, supraglottic airways)
• Suction
• Pulse oximetry and CO2 detection (preferably waveform capnometry)
• Stethoscope
• Tape
• Blood pressure and electrocardiography (ECG) monitors
• Intravenous access
• A flexible fiberoptic bronchoscope

12. Neuraxial vs general anesthesia
• 2001 survey of obstetric anesthesia practices in United States
• Revealed most patients undergoing CS  spinal or epidural anesthesia
• Neuraxial techniques advantages:
• Prevent airway manipulation
• Lessen risk of gastric aspiration
• Avoid use of depressant anesthetic drugs
• Allow mother to remain awake during delivery
• May be associated with less operative blood loss
• Less immediate neonatal depression
• Awake mother who can experience birth of her child

13. Neuraxial Anesthesia
• Simplicity, speed of onset, reliability
• Blockade up to T4 dermatome
• Most common complication hypotension  risk of decreased utero-
placental perfusion
• Measures to decrease incidence and severity of hypotension 
 left uterine displacement
 intravenous fluid administration
 liberal use of vasopressors to prevent and treat hypotension.

14. Single shot spinal
• Hyperbaric 0.5% - 0.75% bupivacaine (10 - 11mg [2.0 – 2.2 mL])
• Reliably provides 90-120 minutes of surgical anesthesia
• Despite adequate dermatomal level for surgery  varying degrees of
visceral discomfort, nausea, vomiting  during exteriorization of uterus
and traction on abdominal viscera
• Improved perioperative anesthesia/analgesia  addn of fentanyl (10 to 20
μg), sufentanil (2.5 to 5 μg), or morphine (0.1to 0.15 mg) to LA
• Fentanyl  rapid onset, short acting  provides little additional
postoperative analgesia
• Vs morphine longer latency  provide anesthesia for 12-18 hours after
delivery

15. Lumbar Epidural Anesthesia
• Vs spinal anesthesia  epidural anesthesia is slower onset and larger drug
requirement to establish adequate sensory block
• Major advantages  ability to titrate extent and duration of anesthesia
• Caution to avoid unintentional intrathecal or intravascular injection
• Commonly used agents for obstetric epidural anesthesia  2% lidocaine with
epinephrine- 5 μg/mL (1:200,000) and 3% 2-chloroprocaine
• Adequate anesthesia  15 to 25 mL of LA in divided doses over 5-10 minutes
• 2-Chloroprocaine  rapid onset of reliable block with minimal risk of
systemic toxicity  extremely high rate of metabolism in maternal and fetal
plasma
• 2% lidocaine with epinephrine + sodium bicarbonate (1 mEq/10 mL lidocaine)
+ fentanyl conversion to surgical anesthesia urgent cesarean delivery.

16. Combined Spinal/Epidural Anesthesia
• Advantages  rapid onset of dense block with low anesthetic dose, ability to
extend duration of anesthesia, provide continuous postoperative analgesia
• Lower incidence of breakthrough pain and intraoperative shivering
• Standard technique  spinal dose of LA as for standard spinal anesthesia
• Incidence of hypotension is lower
• Induction to incision time  prolonged

17. Rapid sequence spinal
• First mentioned by Kinsella in 2003
• Recently developed technique for most urgent category-1 cesarean section in
NICE guidelines
• Designed to satisfy the time constraint in spinal anesthesia
• Characterized by specific anesthetic procedure 
 methods of sterilization,
 dose of anesthetics,
 required level of spinal anesthesia before starting surgery for shortening the decision-
delivery interval
• Requires effective deployment of medical staffs and teamwork
• Role of each staff defined

18. Components of the rapid sequence spinal
• Deploy other staff for IV cannulation and monitoring  don’t inject spinal till cannula
secured
• Pre-oxygenate during attempt via face mask
• ‘No touch’ technique – gloves only with glove packet as sterile surface for equipment
• Skin prepared with single wipe of 0.5% chlorhexidine solution
• If no opioid  increase dose hyperbaric bupivacaine 0.5% (up to 3 ml)
• Local infiltration not mandatory
• One attempt at spinal unless obvious correction allows a second
• If necessary start surgery when block height at T10 and ascending
• Be prepared to convert to general anesthesia  keep mother informed

19. General anesthesia  RSI
• Necessary when absolute
or relative C/I to neuraxial
anesthesia
• Emergent delivery
plecludes central neuraxial
block

20. Suggested Technique for Cesarean Section
• Patient placed supine with wedge under right hip for left uterine displacement
• Denitrogenation with 100% oxygen for 3 to 5 min while monitors are applied
• Patient  prepared and draped for surgery
• When surgeons are ready  rapid-sequence induction with cricoid pressure performed
using propofol - 2 mg/kg, or ketamine -1 to 2 mg/kg, and succinylcholine -1.5 mg/kg
• Trained assistant applies cricoid pressure until airway is properly secured with a cuffed ETT
• Ketamine vs propofol in hypovolemic patients
• Excessive hyperventilation (PaCO 2 <25 mm Hg)  avoided  reduce uterine blood flow
 fetal acidosis
• 50% air in oxygen with up to 1 MAC expiratory volatile agent  maintenance of
anesthesia until delivery
• Nitrous oxide up to 70% can be added with concomitant reduction of the volatile agent to
0.75% MAC

21. Suggested Technique for Cesarean Section
• Low dose volatile agent  ensures amnesia but not adequate for causing excessive
uterine relaxation or prevent uterine contraction following oxytocin
• MR of intermediate duration (cisatracurium, vecuronium, or rocuronium)
• Caution with MGSO4  Prolonged neuromuscular blockade
• For elective CS  a slow 0.3 to 1 IU intravenous bolus of oxytocin over 1 min  f/b an I/V
infusion of 5 to 10 IU/h for 4 h
• IV agents as propofol, opioid, or benzodiazepine  ensure amnesia
• Uterus does not contract readily replace halogenated agent with opioid
• Methylergonovine (Methergine)  0.2 mg in 100 mL NS as IV infusion over 10 min
• Methylprostaglandin F2α (Hemabate)  0.25 mg IM
• Attempt to aspirate gastric contents via oral gastric tube  prior to emergence from GA
• Muscle relaxant completely reversed  gastric tube (if placed) is removed  extubated
awake to reduce risk of aspiration

22. Contra-indication of Rapid sequence intubation
• Absolute-
• Suspected difficult airway: No backup plan available.
• Medication allergy: Known reaction to RSI agents
• Severe hemodynamic instability: Risk of worsened hypotension.
• Relative-
• Upper airway obstruction: Risk of complete airway loss.
• Increased aspiration risk: Active regurgitation/vomiting.
• Intracranial or intraocular pressure: Caution with specific agents (e.g., ketamine,
succinylcholine).
• Severe hyperkalemia: Avoid succinylcholine.
• Neuromuscular disorders: Altered response to blocking agents.
• Inadequate preparation/equipment: Insufficient resources or expertise.

26. Risks of Emergency LSCS
Surgical/ anesthetic risks Maternal risks Fetal risks
Hypotension Aspiration Low APGAR scores
Allergic reactions Pulmonary and amniotic fluid embolism Transient tachypnea of Newborn
Atony Infection Injury during delivery
Injury to adjacent organs Post-partum hemorrhage
Massive blood transfusion Longer recovery
Infection- endometritis Hypertensive disorder
Post dural puncture headache, epidural
hematoma/abscess, meningitis
Local anesthesia systemic toxicity
Cardiac arrest
Adhesions
Future pregnancy complications:
Placenta accreta, previa, ectopic
pregnancy, uterine rupture ,etc
Chronic pain

27. Anesthesia for Complicated Pregnancy

28. UMBILICAL CORD PROLAPSE
• Prolapse of cord complicates  0.2% to 0.6% of deliveries
• Umbilical cord compression following prolapse  rapid fetal asphyxia
Predisposing factors:
• Increased cord length
• Mal-presentation
• Low birth weight
• Grand parity (> 5 pregnancies)
• Multiple gestations
• Artificial rupture of membranes
• Diagnosis suspected  sudden fetal bradycardia or profound decelerations
• Confirmed  physical examination
• Management  immediate steep Trendelenburg or knee–chest position  manual pushing of presenting
fetal part back upto pelvis until immediate CS under GA
• Fetus - not viable  vaginal delivery allowed to continue

29. ABNORMAL FETAL PRESENTATIONS & POSITIONS
• Breech Presentation
• Complicate 3% to 4% of deliveries
• Significantly increase both maternal and fetal morbidity and mortality rates
• Increases incidence of cord prolapse > 10 X
• External cephalic version may be attempted after 34 WOG and prior to onset of labor
• Spontaneous return to breech presentation before onset of labor may occur
• Administration of tocolytic agent controversial
• ECV can be facilitated and success rate improved by epidural analgesia with 2%
lidocaine and fentanyl
• ECV  successful in 75% of patients
• Can cause placental abruption and umbilical cord compression  Emergency LSCS

30. ABNORMAL FETAL PRESENTATIONS & POSITIONS
• Shoulders/head can be trapped after vaginal delivery of body  some
obstetricians prefer elective LSCS for all breech presentations
• Vaginal delivery  manual or forceps-assisted partial breech extraction
usually necessary
• Breech extraction not increased when epidural is used for labor—if labor is well
established prior to epidural activation
• Epidural anesthesia may decrease likelihood of trapped head  relaxes
perineum
• Fetal head can become trapped in uterus during C-section under regional
anesthesia
• Rapid induction of GA with volatile agent  relax the uterus
• Alternatively NTG 50 to 100 mcg IV can be given

31. ABNORMAL FETAL PRESENTATIONS & POSITIONS
• Abnormal Vertex Presentations
• Fetal occiput fails to spontaneously rotate anteriorly  persistent occiput
posterior presentation  more prolonged and painful labor
• Manual, vacuum, or forceps rotation becomes necessary  increases
likelihood of maternal and fetal injuries
• Regional anesthesia  perineal analgesia and pelvic relaxation  facilitates
manual or forceps rotation f/b forceps delivery
• Face presentation  fetal head hyperextended  generally requires LSCS
• Compound presentation  an extremity enters the pelvis along with either
head or buttocks
• Vaginal delivery still possible as the extremity often withdraws as labor
progresses

32. ABNORMAL FETAL PRESENTATIONS & POSITIONS
• Shoulder dystocia
• Impaction of shoulder against pubic symphysis  complicates 0.2% to
2% of deliveries
• One of the major causes of birth injuries
• Difficult to predict and most important risk factor is fetal macrosomia
• Obstetric Maneuvers  used to relieve shoulder dystocia
• Prolonged delay in delivery  fetal asphyxia GA/ Neuraxial

33. MULTIPLE GESTATIONS
• Approximately 1 in 150 births
• Complicated by breech presentation, prematurity, or both
• Anesthesia  necessary for version, extraction, or cesarean section
• Second infant (and any subsequent ones)  more depressed and asphyxiated
• Regional anesthesia  provides effective pain relief during labor, minimizes
need for sedative and analgesic medication & may shorten interval between
birth of 1st
and 2nd
twin
• Studies suggest  acid–base status of second twin - improved with epidural
• Prone to develop hypotension from aorto-caval compression  after regional
anesthesia  Uterine displacement

34. ANTEPARTUM HEMORRHAGE
• Placenta Previa
• Placenta implants in advance of the fetal presenting par
• Incidence 0.5% of pregnancies
• Risk factor  previous cesarean section or uterine myomectomy, multi-parity, advanced
maternal age, large placenta, previous placenta previa
• Anterior-lying placenta  increases risk of excessive bleeding for LSCS
• Presents as painless vaginal bleeding  stops spontaneously  severe hemorrhage can occur
any time
• Treated with bed rest and observation if gestation < 37 weeks and bleeding is mild to moderate
• > 37 WOG  delivery via LSCS
• Active bleeding or hemodynamic instability emergency LSCS under GA
• 2 large-bore IV lines; intravascular volume deficits replaced, blood must be available
• Bleeding can continued after delivery  PPH

35. ANTEPARTUM HEMORRHAGE
• Abruptio Placentae
• Premature separation of normal placenta
• Complicates 1% to 2% of pregnancies
• Mild (grade I) to 25% severe (grade III)  Emergency LSCS
• Risk factors  hypertension, trauma,short umbilical cord, multiparity, prolonged premature rupture of
membranes, alcohol abuse, cocaine use, and anatomically abnormal uterus
• Presentation  painful vaginal bleeding and tenderness to palpation
• Abdominal ultrasonography aid diagnosis
• Regional vs GA  urgency for delivery, maternal hemodynamic stability, and presence of coagulopathy
• Hemorrhage  revealed vs concealed (underestimation of blood loss)
• Severe abruptio placentae  cause coagulopathy and DIC  following fetal demise
• Fibrinogen levels  mildly reduced (150–250 mg/dL) in moderate abruptions vs < 150 mg/dL with fetal
demise
• Platelet count and factors V and VIII  low and fibrin split products elevated
• Need for massive blood transfusion  should be anticipated.

36. PREMATURE RUPTURE OF MEMBRANES
• PROM  leakage of amniotic fluid occurs before onset of labor
• Predisposes to chorioamnionitis, placental abruption and postpartum endometritis
• Diagnosis  nitrazine test: mildly alkaline pH of amniotic fluid (>7.1)  changes
nitrazine paper from orange to blue vs normal vaginal secretions - acidic pH <6
• Complicates 10% of all pregnancies & up to 35% of premature deliveries
• Predisposing factors  short cervix, prior history of PROM or preterm delivery,
infection, multiple gestations, polyhydramnios, and smoking
• Spontaneous labor occurs within 24 h of ruptured membranes in 90% of patients
• Management  balances risk of infection with risk of prematurity
• Delivery indicated after 34 WOG
• < 34 weeks  expectant management with prophylactic antibiotics, tocolytics, and
two doses of glucocorticoid (to accelerate lung maturation)

37. PRETERM LABOR
• Labor occuring between 20-37 WOG
• Incidence in Nepal 14%
• Incidence 8% of live-born in US
• Most common complication of 3rd
trimester
• 80% of all neonatal deaths
• Contributory maternal factors  extremes of age, inadequate prenatal care, unusual body
habitus, increased physical activity, infections, prior preterm labor, multiple gestations
• < 30 WOG age or weight < 1500 g  increases complications
• Combination of PROM + premature labor  umbilical cord compression, resulting in fetal
hypoxemia and asphyxia
• Breech presentation  prone to prolapse of cord during labor
• Inadequate production of pulmonary surfactant frequently  respiratory distress
syndrome (hyaline membrane disease) in < 35 WOG

38. PRETERM LABOR
• Traditionally FLM testing  determined to allow for safe preterm/early-term delivery
• Soft, poorly calcified cranium  predisposes to ICH during vaginal delivery.
• Preterm labor < 35 WOG  bed rest and tocolytic therapy initiated (goal of delaying
birth till lung maturity)
• Tocolytic therapy  delays birth by 48 hours in 75% of patients
• Commonly used tocolytics  β2-adrenergic agonist terbutaline (2.5-5 mg PO 4-6 hrly)
and magnesium (6 g IV over 30 min f/b 2–4 g/h IV)
• Maternal S/E  tachycardia, arrhythmias, myocardial ischemia, mild hypotension,
hyperglycemia, hypokalemia, and, rarely, pulmonary edema
• Other tocolytic agents  CCB (nifedipine) and prostaglandin synthetase inhibitors
• Fetal ductal constriction  >32 WOG with NSAIDS – indomethacin  transient and
resolves after discontinuation
• NSAID-associated AKI in fetus  cause oligohydramnios

39. PRETERM LABOR
• Anesthesia becomes necessary when tocolytic therapy fails to arrest labor.
• Goal for vaginal delivery of preterm slow, controlled delivery with minimal pushing by
mother
• Episiotomy and low forceps assistance  aid
• Spinal or epidural anesthesia  promotes complete pelvic relaxation
• C-section  for fetal distress, breech presentation, intrauterine growth retardation, or
failure of labor to progress
• Residual effects of β-adrenergic agonists  complicate GA
• Ketamine, ephedrine, and isoflurane  use with caution interaction with tocolytics
• Hypokalemia  intracellular uptake of K+ increase sensitivity to MR
• Magnesium therapy potentiates MR  predisposes hypotension secondary to
vasodilation
• Preterm newborns  depressed at delivery  need resuscitation

40. REFERENCES
Millers textbook of anesthesia 9th
edition
Barash clinical anesthesia,8th
edition
Morgan and Mikhail’s anesthesia 7th
edition