General Anesthesia for Cesarean Section

Indications:

Preoperative Evaluation:

All OB patients are considered to have full stomachs and therefore require awake intubation or rapid sequence induction if airway appears adequate.

Typical sequence of events: Notes:
  • Call attending. Call OR on-call resident for help if necessary.
 You will need all the hands you can get. the nurses and OB docs usually have their own hands full.
  • Administer sodium citrate 30 ml PO. (Prehydrate with 0.5-1 l lactated ringers prior to induction if time allows.)
 This is a non-particulate antacid and should be given to all C/Section patients, GA or regional.
  • Position patient in left uterine displacement (right hip bump) and table slightly flexed.
    •      		This will avoid supine hypotension syndrome and improve comfort.
  • Apply monitors (BP cuff, EKG, SpO2, twitch monitor, BIS).
    •
  • Ensure IV access (16-18 Ga IV minumum).
    •      		Check for good IV flow and sort out tubing/pumps.
  • Preoxygenate (100% FiO2 with good mask seal).
    •      		Remember, parturients desaturate rapidly (150 Torr/min vs 50 Torr/min non-pregnant) due to increased metabolic demand and decreased FRC.
  • Prep, drape, and obstetricians scrubbed and ready for incision prior to induction.
    •      		Minimize prepartum anesthesia time and fetal anesthetic exposure.
  • Rapid sequence induction: cricoid pressure, pentothal 4 mg/kg, succinylcholine 1.5 mg/kg
    •      		Do not use defasciculant, as this may cause problems with patients on Mg therapy.
  • Larygnoscopy, OETT placement with stylet, confirm placement with EtCO2 and bilateral breath sounds.
    •      		Consider use of small tube (6.0 - 7.0) in case of airway edema.
  • To OB team: "You may begin"
    •      		Secure tube as incision underway.
  • Anesthetic prior to delivery:
    • 50/50 N2O/O2 with ~ 0.6% Isoflurane
    • Controlled ventilation
    • Muscle relaxation with 1-2 mg vecuronium PRN
    •      		• Avoid hypoventilation or hyperventilation (maintain EtCO2 approx 30mmHg)

    • Muscle relaxants prolonged with Mg; monitor twitch closely. Do not give more than 1 mg of vecuronim (or equivalent) at a time if patient on Mg therapy.
  • Anesthetic following delivery:
    • 70/30 N2O/O2 + opiate
    • d/c volatile, esp. if uterine atony
    • midazolam 1-2 mg IV PRN
    • fentanyl 25-50 mcg / MS 2-5 mg PRN
    •      		• Remember that potent inhalation agents are very effective uterine relaxants and will prevent uterine contraction, leading to increased blood loss.
  • Pitocin 20U per 1000ml to IV bag
    • antibiotics ordered by OB team?
    •      		Rapid infusion until uterus contracts, then slow drip.
    Start antibiotics after delivery.
  • Extubate patient awake
    		• Check head lift or NIF (>40).