cesarian section general versus regional anesthesia presented by: tareq salwati tareq salwati...

Cesarian SectionCesarian SectionGeneral versus General versus Regional AnesthesiaRegional Anesthesia

Presented by:Presented by:Tareq Salwati Tareq Salwati SSC-AnaesDepartment of AnesthesiologyDepartment of AnesthesiologyMaternity and Childrens’s HospitalMaternity and Childrens’s HospitalJarwal, The Holy CapitalJarwal, The Holy Capital

Why do we need Why do we need cesarian sectionscesarian sections??

Why do we need Why do we need cesarian sectionscesarian sections::

To prevent maternal To prevent maternal and foetal morbidity and foetal morbidity and mortalityand mortality

Examples for Indications for Cesarian Examples for Indications for Cesarian

Sections:Sections:

Labor unsafe for mother and fetusLabor unsafe for mother and fetus::

Increased risk of uterine ruptureIncreased risk of uterine rupture

Previous classic cesarean sectionPrevious classic cesarean section

Previous extensive myomectomy or Previous extensive myomectomy or uterine reconstructionuterine reconstruction

Examples for Indications for Cesarian Examples for Indications for Cesarian

Sections:Sections: Labor unsafe for mother and fetusLabor unsafe for mother and fetus::

Increased risk of maternal Increased risk of maternal hemorrhagehemorrhage

Central or partial placenta Central or partial placenta previaprevia

Abruptio placentaeAbruptio placentae

Previous vaginal reconstructionPrevious vaginal reconstruction

Examples for Indications for Cesarian Examples for Indications for Cesarian Sections:Sections:

DystociaDystocia Abnormal fetopelvic relationsAbnormal fetopelvic relations

Fetopelvic disproportionFetopelvic disproportionAbnormal fetal presentationAbnormal fetal presentationTransverse or oblique lieTransverse or oblique lieBreech presentationBreech presentationDysfunctional uterine activityDysfunctional uterine activity

Examples for Indications for Cesarian Examples for Indications for Cesarian Sections:Sections:

Immediate or emergent Immediate or emergent delivery necessarydelivery necessary

Fetal distressFetal distress

Umbilical cord prolapseUmbilical cord prolapse

Maternal hemorrhageMaternal hemorrhage

AmnionitisAmnionitis

Genital herpes with ruptured Genital herpes with ruptured membranesmembranes

Impending maternal deathImpending maternal death

Why do we need Why do we need anesthesia for cesarian anesthesia for cesarian sectionsection??

Why do we need Why do we need anesthesia for cesarian anesthesia for cesarian sectionsection??

It would be It would be otherwise otherwise extremely painful extremely painful

for the motherfor the mother!!! !!!

Choices of Anesthesia Choices of Anesthesia availableavailable::


General General anesthesiaanesthesia



Regional Regional anesthesiaanesthesia


General anesthesiaGeneral anesthesia

Regional anesthesiaRegional anesthesia

Local anesthesiaLocal anesthesia


AdvantagesAdvantages::

General anesthesiaGeneral anesthesiaAdvantagesAdvantages::

Rapid onsetRapid onset


Controlled airway Controlled airway and ventilationand ventilation


Anesthetist's hands are Anesthetist's hands are free for fluid management free for fluid management and hemodynamics and hemodynamics control in cases of major control in cases of major bleeding.(that is, the bleeding.(that is, the airway is already secured)airway is already secured)


Almost never Almost never failsfails


Minimal cooperation needed Minimal cooperation needed from the patientfrom the patient

((possibly only topossibly only to insert canula andinsert canula and

tolerate a face masktolerate a face mask.).)

General General AnesthesiaAnesthesia

DisadvantageDisadvantagess::

General AnesthesiaGeneral AnesthesiaDisadvantagesDisadvantages::

1616 X higher X higher anesthesia related anesthesia related mortality compared mortality compared to regional to regional anesthesiaanesthesia..


Risk of difficult/failed Risk of difficult/failed intubationintubation


Risk of difficult/failed Risk of difficult/failed intubationintubation

Risk of failed intubation in Risk of failed intubation in parturients is 10 X higher parturients is 10 X higher than in non-obstetric than in non-obstetric populationpopulation..


Risk ofRisk of

pulmunary pulmunary aspirationaspiration


Contributes toContributes to

uterine uterine relaxation/atonyrelaxation/atony


Extra time needed at Extra time needed at end of procedure to end of procedure to wake up the the wake up the the patientpatient


Usually faster onset Usually faster onset of postoperative of postoperative painpain


Risk ofRisk of

Malignant Malignant hyperthermiahyperthermia


Mother and child Mother and child deprived from early deprived from early bondingbonding


Risk of intaoperative Risk of intaoperative awareness under awareness under anesthesia (higher risk anesthesia (higher risk than general population)than general population)


Exposure of fetus to Exposure of fetus to depressant effect of depressant effect of general anestheticsgeneral anesthetics


When you face an unexpected When you face an unexpected difficult intubation in a case of a difficult intubation in a case of a really urgent cesarian, then really urgent cesarian, then everybody in the theater is in big everybody in the theater is in big stressstress..


Risk of broken teethRisk of broken teeth..


Sore throat Sore throat postoperatively due to postoperatively due to the endotrachial tubethe endotrachial tube..


More costly (costs more More costly (costs more money $$$)money $$$)..

Most important causes of Most important causes of

mortalitymortality due to due to General anesthesiaGeneral anesthesia::

Inability to intubateInability to intubate

Inability to ventilateInability to ventilate

Aspiration Aspiration pneumonitispneumonitis

Regional Regional anesthesiaanesthesia

Regional anesthesiaRegional anesthesia

AdvantagesAdvantages::

Regional anesthesiaRegional anesthesiaAdvantagesAdvantages::

Anesthesia related Anesthesia related mortality much lower mortality much lower than general anesthesiathan general anesthesia..


No need for intubationNo need for intubation


No difficult/failed No difficult/failed intubationintubation


Less risk of pulmunary Less risk of pulmunary aspirationaspiration


Awake mother when the Awake mother when the baby is bornbaby is born..


Early bonding of mother Early bonding of mother and childand child..


Mothers are often very happy when Mothers are often very happy when shown their baby while they did shown their baby while they did not notice that the surgery has not notice that the surgery has even yet startedeven yet started!!!!


Almost no exposure of fetus Almost no exposure of fetus to anesthetic drugsto anesthetic drugs..


NoNo

contribution to contribution to uterine uterine

relaxation/atonyrelaxation/atony..


No time needed at end of the No time needed at end of the procedure to wake up the procedure to wake up the patient, thus immediately patient, thus immediately ready to leave to recovery ready to leave to recovery roomroom..

Regional Regional AnesthesiaAnesthesia

DisadvantagesDisadvantages

Regional AnesthesiaRegional AnesthesiaDisadvantagesDisadvantages::

slower in onset “arguablyslower in onset “arguably ”? ”?

((related to skill of related to skill of anesthesiologistanesthesiologist))


Occasionally you will find Occasionally you will find “Bone” in your way. Or “No” “Bone” in your way. Or “No” CSFCSF..


Occasionally will have aOccasionally will have a

failed/incoplete blockfailed/incoplete block..

or delayed onsetor delayed onset..


Risk of high/complete spinal Risk of high/complete spinal blockblock..

((intubation may be neededintubation may be needed))


Risk ofRisk of

post dural puncture post dural puncture headacheheadache..


Risk of spinal/epidural Risk of spinal/epidural hematomahematoma..


Risk of spinal cord injuryRisk of spinal cord injury

Closed claims Analysis of the Closed claims Analysis of the ASA from 1990 – 2003 ASA from 1990 – 2003 reportedreported::

1111 cases for vaginal deliverycases for vaginal delivery

55 cases for cesarian sectioncases for cesarian section


Risk of inadvertant Risk of inadvertant intravascular injection of local intravascular injection of local anestheticanesthetic..

““cardiac arrestcardiac arrest.”.”


Needs some cooperation from Needs some cooperation from the patient to sit/lie stillthe patient to sit/lie still..

Most important Causes Most important Causes of death due to Regional of death due to Regional anesthesiaanesthesia::


Excessively high neural Excessively high neural blockadeblockade


Excessively high neural Excessively high neural blockadeblockade

Local anesthetic toxicityLocal anesthetic toxicity..

??Why is regional Why is regional

anesthesia preferred anesthesia preferred when ever possiblewhen ever possible??

::Because ofBecause of

Anesthetic Anesthetic MortalityMortality

Anesthetic MortalityAnesthetic Mortality

Anesthesia accounts for Anesthesia accounts for approximately 2–3% of approximately 2–3% of

maternal deathsmaternal deaths..

Anesthetic Mortality Anesthetic Mortality (in cesarian section)(in cesarian section)

3232 deaths per 1,000,000 live deaths per 1,000,000 live births due to general anesthesiabirths due to general anesthesia

and 1.9 deaths per 1,000,000 live and 1.9 deaths per 1,000,000 live births due to regional births due to regional

anesthesiaanesthesia..((Data collected between 1985 – 1990Data collected between 1985 – 1990))

That is, General Anesthesia That is, General Anesthesia cases death 16 X more cases death 16 X more frequent than regional frequent than regional

Anesthesia !!!!!Anesthesia !!!!!

THANK YOUTHANK YOU!!ReferenceReference::Clinical Anesthesiology, G.Edward Morgan,Jr. et al , 4Clinical Anesthesiology, G.Edward Morgan,Jr. et al , 4thth edition, 2006 edition, 2006PocketMedicine Obstetric Anesthesia Version 1.1.0/2005.11.7PocketMedicine Obstetric Anesthesia Version 1.1.0/2005.11.7LWW mobile Clinical Anesthesia, 5LWW mobile Clinical Anesthesia, 5thth edition Version 8.0.26/2007.4.5 edition Version 8.0.26/2007.4.5Liability assiciated with obstetric anesthesia, Anesthesiology 2009: Liability assiciated with obstetric anesthesia, Anesthesiology 2009: 110:131-9110:131-9

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cesarian section general versus regional anesthesia presented by: tareq salwati tareq salwati...

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