Cesarian Section General Versus Regional Anesthesia

8/2/2019 Cesarian Section General Versus Regional Anesthesia

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Cesarian SectionGeneral versus Regional

AnesthesiaPresented by:Tareq Salwati SSC-AnaesDepartment of AnesthesiologyMaternity and Childrenss HospitalJarwal, The Holy Capital


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Why do we need cesarian

sections?


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Why do we need cesarian

sections:To prevent maternal and

foetal morbidity andmortality


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Examples for Indications for Cesarian

Sections:

Labor unsafe for mother and fetus:

Increased risk of uterine rupture

Previous classic cesarean section

Previous extensive myomectomy oruterine reconstruction


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Examples for Indications for Cesarian Sections:

Labor unsafe for mother and fetus:Increased risk of maternal hemorrhage

Central or partial placenta previaAbruptio placentae

Previous vaginal reconstruction


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DystociaAbnormal fetopelvic relations

Fetopelvic disproportionAbnormal fetal presentation

Transverse or oblique lie

Breech presentation

Dysfunctional uterine activity


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Immediate or emergent

delivery necessaryFetal distress

Umbilical cord prolapse

Maternal hemorrhage

Amnionitis

Genital herpes with rupturedmembranes

Impending maternal death


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Why do we need anesthesia

for cesarian section?


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Why do we need anesthesia

for cesarian section?

It would be otherwise

extremely painful forthe mother !!!


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Choices of Anesthesia

available:


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available:

General anesthesia


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available:

General anesthesia

Regional anesthesia


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available:

General anesthesia

Regional anesthesia

Local anesthesia


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General anesthesia


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General anesthesia

Advantages:


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General anesthesia

Advantages:

Rapid onset


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General anesthesia

Advantages:Anesthetist's hands are free

for fluid management andhemodynamics control incases of majorbleeding.(that is, the airwayis already secured)


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General anesthesia

Advantages:

Almost never fails


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General anesthesia

Advantages:Minimal cooperation neededfrom the patient

(possibly only to

insert canula andtolerate a face mask).


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General Anesthesia

Disadvantages:


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General Anesthesia

Disadvantages:16 X higher anesthesia

related mortalitycompared to regional

anesthesia.


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General Anesthesia

Disadvantages:

Risk of difficult/failedintubation


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General Anesthesia

Disadvantages:

Risk of difficult/failed intubationRisk of failed intubation in

parturients is 10 X higher thanin non-obstetric population.


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General Anesthesia

Disadvantages:

Risk of

pulmunary aspiration


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General Anesthesia

Disadvantages:

Contributes to

uterine

relaxation/atony


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General Anesthesia

Disadvantages:Extra time needed at end

of procedure to wake upthe the patient


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General Anesthesia

Disadvantages:

Usually faster onset ofpostoperative pain


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General Anesthesia

Disadvantages:

Risk of

Malignant hyperthermia


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General Anesthesia

Disadvantages:

Mother and child deprivedfrom early bonding


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General Anesthesia

Disadvantages:

Risk of intaoperative awarenessunder anesthesia (higher riskthan general population)


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General Anesthesia

Disadvantages:

Exposure of fetus to depressant

effect of general anesthetics


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General Anesthesia

Disadvantages:

When you face an unexpected difficult

intubation in a case of a really urgentcesarian, then everybody in thetheater is in big stress.


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General Anesthesia

Disadvantages:

Risk of broken teeth.


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General Anesthesia

Disadvantages:

Sore throat postoperativelydue to the endotrachialtube.


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General Anesthesia

Disadvantages:

More costly (costs more money$$$).

Most important causes of


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Most important causes of

mortalitydue to General

anesthesia:

Inability to intubateInability to ventilate

Aspiration pneumonitis


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Regional anesthesia


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Regional anesthesiaAdvantages:


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Regional anesthesia

Advantages:

Anesthesia related mortalitymuch lower than generalanesthesia.


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Regional anesthesia

Advantages:

No need for intubation


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Regional anesthesia

Advantages:No difficult/failed intubation


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Regional anesthesia

Advantages:Less risk of pulmunaryaspiration


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Regional anesthesia

Advantages:

Awake mother when thebaby is born.


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Regional anesthesia

Advantages:

Early bonding of mother andchild.


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Mothers are often very happy when

shown their baby while they did notnotice that the surgery has even yetstarted!!


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Almost no exposure of fetus toanesthetic drugs.


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No

contribution to

uterinerelaxation/atony.


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No time needed at end of the

procedure to wake up the patient,thus immediately ready to leave torecovery room.


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Regional Anesthesia

Disadvantages


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Regional AnesthesiaDisadvantages:

slower in onset arguably?

(related to skill of anesthesiologist)


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Occasionally you will find Bone inyour way. Or No CSF.


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Occasionally will have a

failed/incoplete block.or delayed onset.


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Risk of high/complete spinal block.(intubation may be needed)


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Risk ofpost dural puncture headache.


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Risk of spinal/epidural hematoma.


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Risk of spinal cord injuryClosed claims Analysis of the ASAfrom 1990 2003 reported:

11 cases for vaginal delivery5 cases for cesarian section


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Risk of inadvertant intravascular

injection of local anesthetic.cardiac arrest.

i l h i


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Needs some cooperation from thepatient to sit/lie still.


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Most important Causes ofdeath due to Regional

anesthesia:


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Most important Causes ofdeath due to Regionalanesthesia:

Excessively high neural blockade


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Most important Causes ofdeath due to Regionalanesthesia:

Excessively high neural blockade

Local anesthetic toxicity.


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?Why is regional anesthesiapreferred when ever

possible?


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:Because of

Anesthetic Mortality


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Anesthetic Mortality

Anesthesia accounts forapproximately 23% of

maternal deaths.

A th ti M t lit (i


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Anesthetic Mortality (incesarian section)

32 deaths per 1,000,000 live birthsdue to general anesthesia

and 1.9 deaths per 1,000,000 live

births due to regional anesthesia.(Data collected between 1985 1990)


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That is, General Anesthesiacases death 16 X morefrequent than regional

Anesthesia !!!!!


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THANK YOU!Reference:Clinical Anesthesiology, G.Edward Morgan,Jr. et al , 4th edition, 2006PocketMedicine Obstetric Anesthesia Version 1.1.0/2005.11.7

LWW mobile Clinical Anesthesia, 5th edition Version 8.0.26/2007.4.5Liability assiciated with obstetric anesthesia, Anesthesiology 2009: 110:131-9

www salwati com

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Cesarian Section General Versus Regional Anesthesia

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