→ Discuss indications of general anesthesia for operative delivery → Explain aspiration risk for general anesthesia in pregnancy and prevention strategy Outline anaesthesia plan of care for induction, maintenance and emergency Describe effect of volatile anaesthetics on uterine blood flow and tone Discuss intraoperative strategies to prevent postoperative nausea and vomiting Discuss other complications of general anaesthesia and clinical management

1. GENERAL ANESTHESIA
&
C-SECTION
PART I
Dasht-e Barchi Project
Kabul - December 2018
Dr. Sandro Zorzi
References:
- Anesthesiology - Longnecker Ed. 2017
- Obstetric Anesthesia Handbook 2010 Fifth Edition S.Datta
- Practice Guidelines for Obstetric Anesthesia ASA 2015
- Essential Obstetric and newborn care MSF 2015

2. Learning Objectives:
MODULE 4 GENERAL ANAESTHESIA:
● → Discuss indications of general anesthesia for operative delivery
● → Explain aspiration risk for general anesthesia in pregnancy and prevention strategy
● Outline anaesthesia plan of care for induction, maintenance and emergency
● Describe effect of volatile anaesthetics on uterine blood flow and tone
● Discuss intraoperative strategies to prevent postoperative nausea and vomiting
● Discuss other complications of general anaesthesia and clinical management
● List recovery room disharge criteria following general anaesthesia for C-section

3. General OR Spinal?
- Consider selecting neuraxial techniques in preference to general anesthesia for most
cesarean deliveries.
- The decision to use a particular anesthetic technique for cesarean delivery should be
individualized, based on anesthetic, obstetric, or fetal risk factors (elective vs. emergency)
the preferences of the patient, and the judgment of the anesthesiologist. Regional
anaesthetic techniques are not absolutely contraindicated in patients taken to urgent C-
section.
→ Uterine displacement (usually left displacement) should be maintained until delivery
regardless of the anesthetic technique used.
- General anesthesia may be the most appropriate choice in some circumstances
(e.g.,profound fetal bradycardia, ruptured uterus, severe hemorrhage, severe placental
abruption, umbilical cord prolapse, and preterm footling breech).

4. SPINAL CONTROINDICATION?
Absolute Contraindications:
- Patient refusal or inability to cooperate
- Localized infection at insertion site
- Sepsis (distributive shock!)
- Severe coagulopathy
- Uncorrected hypovolemia (SHOCK!)
Relative Contraindications:
- Mild coagulopathy
- Severe maternal cardiac disease (including congenital and acquired disorders)
- Neurologic disease (including intracranial and spinal cord pathologies)
- Severe fetal depression

5. GENERAL ANESTHESIA +/-
The advantages of general anesthesia are as follows:
1. Speed of induction
2. Reliability
3. Reproducibility
4. Controllability
5. Avoidance of hypotension
The following are disadvantages of general anesthesia:
1. Possibility of maternal aspiration
2. Problems of airway management
3. Narcotization of the newborn
4. Maternal awareness during light general anesthesia

6. ...SO GENERAL WHEN...
● Patient refuses regional technique
● Regional technique is contraindicated
● Emergency C/S when there is inadequate/absent regional analgesia and to delay will
cause undue risk to the fetus / mother
WHY? MOST COMMON COMPLICATIONS OF GENERAL
ANESTHESIA ARE:
● Failed intubation
● Failed ventilation causing death or neurological injury
● Awareness
● Aspiration pneumonia

7. ASPIRATION RISK...WHY?
Pregnant women in labor should always be considered to have a full stomach irrespective of
the time of their last meal.
● Upward & anterior displacement of the stomach by the uterus leads to increase in
intragastric pressure and decrease in gastroesophageal angle.
● Gastric emptying time is significantly slower during labor and hence gastric volume is
increased. Opioids administered by any route will further increase the gastric emptying
time.
● Reduction of lower esophageal sphincter pressure and decrease gastrointestinal motility
and food absorption due to increased progesterone levels with risk of regurgitation and
aspiration of gastric contents.
● Gastric emptying remains abnormal on the first postpartum day and returns to normal on
the second day!!

8. CLINICAL IMPLICATIONS?
General anesthesia should be avoided when possible, and routine precautions (rapid
sequence induction and endotracheal intubation) should be employed when general
anesthesia is unavoidable. The routine use of nonparticulate antacid is important before
cesarean section and before induction of regional anesthesia.
Although there are few, if any, absolute
contraindications to general anesthesia, neuraxial
anesthesia remains a preferred method to avoid the
risks of airway management.
Anyway emergency airway equipment should be readily
available in all obstetric operating rooms.
Attempts should be made to minimize the risk of
maternal aspiration,even when the need for intubation
is not anticipated.

9. ASPIRATION PREVENTION:
- Routine prophylaxis against gastric acid aspiration: cimetidine PO (effervescent tablet
200 mg in 30 ml of water, 20 minutes prior to surgery).
- The patient undergoing elective surgery (e.g., scheduled cesarean delivery or postpartum
tubal ligation) should undergo a fasting period for solids of 6–8 h depending on the type
of food ingested (e.g., fat content)
- The uncomplicated patient undergoing elective surgery (e.g., scheduled cesarean delivery
NOT IN LABOR or postpartum tubal ligation) may have moderate amounts of clear liquids
up to 2 h before induction of anesthesia
- Solid foods should be avoided in laboring patients. Laboring patients with additional risk
factors for aspiration (e.g.:morbid-obesity, diabetes mellitus, and difficult airway) or
patients at increased risk for operative delivery (e.g., nonreassuring fetal heart rate
pattern) may have further restrictions of oral intake, determined on a case-by-case basis.

10. PERIANESTHETIC EVALUATION/PREPARATION
1) Conduct a focused history and physical
examination before providing anesthetic care
2) A communication system should be in place
to encourage early and ongoing contact
between obstetric providers, anesthesiologists,
and other members of the multidisciplinary
team
→ When a difficult intubation is suspected,
close communication with the obstetrician and
the woman is absolutely vital to make the final
decision.
A difficult or failed intubation drill is extremely
important,and every institution should have a
plan before the situation rises.

11. PREGNANCY-RELATED FEATURES THAT MAY CONTRIBUTE
TO AIRWAY DIFFICULTIES

12. FETAL DISTRESS?
If a GA is going to be hazardous, call for help early. The only exception is the need for
an immediate GA to save the mother’s life and the expectation that you will be able to
manage the airway. It may be possible to avoid a GA by using intra-uterine resuscitation to
relieve foetal distress as follows. As soon as decision made for emergency CS for foetal
compromise:
● Turn off Oxytocin infusion.
● Follow Obstetric guideline on Acute Uterine Relaxation if indication.
● Put patient in full left lateral position (try right lateral or knee-elbow if FBS remains abnormal).
● Give Oxygen 15 L/min by mask with reservoir.
● Give 1 litre of Hartmann’s by rapid IV infusion.
● Treat any hypotension with vasopressors.
● Transfer to theatre (do not delay for catheterisation/shave etc.)
● In theatre: re-assess foetal heart rate (FBS if necessary).
● Reassess degree or urgency – is there time for regional anaesthesia?
● Aim for delivery within 30 minutes from decision.

13. GOOD PLAN GOOD ANESTHESIA

14. EVALUATION….

15. TEST...
- What is the ASA classification of a pregnant woman (39 weeks gestional age) with severe pre-eclampsia?
a) ASA 2
b) ASA 2 E
c) ASA 3
d) ASA 3 E
e) ASA 4
- What is the ASA classification of a pregnant woman (39 weeks gestional age) with eclampsia and pulmonary edema?
a) ASA 2
b) ASA 2 E
c) ASA 3
d) ASA 3 E
e) ASA 4
- What is the ASA classification of a pregnant woman (39 weeks gestional age), 2 previous c-section and fetal distress for indication of the c-section
red code?
a) ASA 2
b) ASA3
c) ASA 2 E
d) ASA 3 E
e) ASA 4

16. KEY POINTS :
● The decline in general anaesthesia for Caesarean section has reduced many anaesthetists
experience and confidence in obstetric airway management → is important to evaluate
and to prepare the patient.
● Team working is essential to have better outcome and less complications!
● Correct patient positioning and pre-oxygenation is essential to provide optimal
conditions for intubation.
● For the fetus remember to limit the time between induction and uterine incision at
least to less than 3 minutes and avoid hypotension, hypoxia, acidosis, hyperventilation,
hypotermia. Better outcome of the newborn are given if the timing between induction
and delivery is less than 10 minutes.
● Knowing when to abandon each step of the failed intubation drill and move on to the
next is vital.
● Oxygenation and ventilation are the main priorities after failed intubation.