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Obtaining Consent for Anesthesia

The key elements defi ning adequate consent (also see Chapter 13) are:

explanation of the procedure

explanation of risks, benefi ts and alternative options

answering any questions the patient may have

Cesarean delivery represents an occasion of great signifi cance to the parents, but sometimes generates considerable psychological stress.

Elements unique to cesarean delivery include having major surgery while fully alert and potentially consenting to major surgery while in severe pain or under great stress, with little time to refl ect on options. In urgent cases, consent is often given in a busy, noisy envi- ronment, when surrounded by a large number of unfamiliar staff, and while facing the possible loss of a child or serious personal risks.

General principles to note are:

Spending time obtaining informed consent establishes rapport and

may contribute to avoiding litigation should complications arise.

Most women want to maximize the information they receive about

anesthesia (and analgesia) and are not made more anxious by full disclosure of complications.

Obstetric Anesthesia81

The provision of information through pamphlets or other patient

education resources in the antenatal period, at anesthetic or preadmission clinics, improves opportunities for frank discussion at the time of surgery.

Providing an opportunity for the woman to ask questions is important.

The details of the discussion should be documented (consent forms

can be used as a checklist or aid).

Some of the difficulties facing the obstetric anesthesiologist in particular include:

The anesthesiologist is often expected to provide effective and safe

anesthesia within minutes of meeting the patient for the fi rst time.

However, in very few (only 20 % ) of unplanned cesarean deliveries was there no prior indication of the potential need for operative intervention.

The amount of time for informed discussion may be signifi cantly

constrained. Nevertheless, even in emergent situations, it is Table 4.1 Advantages and Disadvantages of Regional Anesthesia for Cesarean Delivery

Advantages Maternal safety

No airway management diffi culties with consequent risks of aspiration of

gastric content or hypoxic organ injury Less blood loss

Neonatal outcome

Immediate resuscitation at birth less likely to be required than after

general anesthesia

Desirable postoperative outcomes Less risk of nausea and vomiting

Delayed recovery of consciousness and drowsiness avoided

Early interaction with the newborn

Early resumption of oral intake

High quality analgesia achievable by several means

Consumer satisfaction

Presence of mother and father/support person at birth enhances birth

experience for parents

Early skin-to-skin contact improves maternal-infant bonding

Early attachment of infant to the breast

Disadvantages

Potential for hypotension, leading to maternal syncope, nausea or vomiting symptoms, and fetal compromise

Potential for post-dural puncture headache

Anesthesia cannot be established as quickly as general anesthesia

82Anesthesia for Cesarean Delivery

important to explain as much as possible about what is happening, while obtaining a brief history and performing a basic physical exam- ination of vital signs and the airway.

Always visit the woman postoperatively, to answer any questions

or concerns which may remain.

Consent for Regional Anesthesia

When obtaining consent for a regional anesthetic, the anesthesiologist has a valuable opportunity to establish rapport, assuage anxieties, and order drug therapy, if necessary.

The effects of regional anesthesia should be explained, and a treat-

ment plan agreed upon (Table 4.2 ).

The fear of pain during needle insertion or during surgery can be

minimized by empathetic reassurance. In rare instances, the applica- tion of topical local anesthetic cream, if time allows, may be helpful.

Although rarely necessary, the use of light sedation (intravenous

midazolam 1–2 mg, fentanyl 0.5–1 mcg/kg or remifentanil 0.1–0.25 mcg/kg) may be considered. These drugs are unlikely to affect neonatal outcomes, but should be timed to avoid maternal amnesic effects that detract from the birth experience.

Closed claims and similar studies indicate that litigation often results from maternal dissatisfaction with the management of pain during cesarean delivery, so it is critically important to explain common sensations. The patient should be aware that.

Pressure and stretching are normal parts of the experience.

Mild intraoperative pain is not uncommon (5

• % –20 % depending on

the situation).

More severe pain will not be ignored.

If pain leads to a complaint, the anesthesiologist should be able to demonstrate that they had taken reasonable steps to warn about it, and about conversion to general anesthesia. In addition,

The regional technique used must have been reasonable.

The block should have been tested and noted to be adequate prior

to surgery.

Pain should have been treated when it was reported.

The anesthesiologist should have provided follow-up and support.

Dealing with a Patient Refusing Regional Anesthesia Many contraindications to regional anesthesia (Table 4.3 ) are relative.

In most instances, regional anesthesia will remain the anesthetic of choice. Despite this, some women will initially refuse regional

Obstetric Anesthesia83

anesthesia due to fear of pain either during block placement or during the surgery, or because of cultural unfamiliarity. In this situation -

Attempt to allay the patient’s concerns with compassionate but

realistic discussion, pointing out the advantages.

Respect the patient’s fi nal decision. Some women may have had a

distressing experience previously (for example, multiple failed attempts at insertion or severe pain during surgery) and will refuse any reasoned argument.

Regional Anesthesia for Nonelective Cesarean Delivery Cesarean deliveries can be classifi ed by their degree of urgency, and this classifi cation can be useful in determining an appropriate anesthetic

Table 4.2 Discussion Points at Consent for Regional Anesthesia

Advantages compared with general anesthesia

Enjoyment of the birth experience (including the father)

Fewer life-threatening complications (high-block, local anesthetic toxicity) Possibly lower mortality rate (extremely rare)

More alert neonate at birth Procedural events

Positioning and needle insertion Onset and testing of block Intraoperative positioning

Postoperative analgesic options (pros and cons, side effects) Post-block effects

Shaking

Nausea and vomiting Syncope Itch

Insertion site tenderness Intraoperative events

Abdominal stretching and pressure

Pain (incidence/location/timing/severity/treatment plan including conversion to general anesthesia)

Infrequent complications Post-dural puncture headache Rare complications

Neuraxial infection High block requiring intubation Neurological injury Extremely rare complications Death

84Anesthesia for Cesarean Delivery

(Table 4.3 ). For emergency or urgent cesarean delivery (Categories 1, 2 and 3), if a functioning epidural catheter is in place, it can be used to rapidly achieve a surgical anesthetic block (within 10–20 minutes), or spinal anesthesia can be established (within 10–20 minutes). General anesthesia is occasionally preferable, and may be mandated by failure of regional anesthesia or as the quickest means of anesthetizing the parturient (5–15 minutes) when there is life-threatening fetal compromise (Table 4.4 ).

In addition to the advantages of regional anesthesia noted above, a number of other factors have led to decreased use of general anesthesia. These include:

liberalization of the limits traditionally applied to defi ne when

regional anesthesia is safe

greater use of epidural analgesia during labor

better interdisciplinary communication, leading to earlier maternal

anesthetic assessment and preparation for operative delivery greater expertise in rapidly establishing safe regional anesthesia.

The American College of Obstetricians and Gynecologists (ACOG) suggests that when risk factors are identifi ed, “the obstetrician obtain antepartum consultation from an anesthesiologist” and that strategies such as early intravenous access and placement of an epidural or spinal

Table 4.3 Potential Contraindications to Regional Anesthesia

Infection risk

bacteremia and sepsis

• Infection

septic shock

local skin infection at insertion site

Severe immunocompromise in the presence of other risk factors Exacerbation of preexisting disease states

raised intracranial pressure

severe aortic stenosis

severe pulmonary hypertension

Maternal hypovolemia with cardiovascular instability obstetric or non-obstetric major hemorrhage

Vertebral canal hematoma risk severe thrombocytopenia

coagulopathy

anticoagulation

vertebral canal vascular pathology

Obstetric Anesthesia85

catheter be developed “to minimize the need for emergency induc- tion of general anesthesia in women in whom this would be especially hazardous”.

Consent for General Anesthesia

When obtaining consent for general anesthesia for cesarean delivery, a number of topics need to be discussed (Table 4.6 ). Place emphasis on:

Benefi ts and risks

Common events and symptoms

Preparation, and postoperative sequele

If the patient’s request for general anesthesia appears inadvisable, document in detail how her decision was reached.

Table 4.4 Categorization of Cesarean Delivery

Category 1: Non-elective cesarean delivery because there is an immediate threat to the life of the mother or fetus

Category 2: Non-elective cesarean where delivery is indicated because of maternal or fetal compromise that is not immediately life-threatening Category 3: Non-elective cesarean where early delivery is needed but there is no maternal or fetal compromise

Category 4: Elective cesarean delivery scheduled at a time to suit the mother and the medical team

Adopted by many hospitals based on Lucas DN, et al. J Royal Soc Med.

2000;93:346–350.

Table 4.5 When to Consider General, Rather than Regional, Anesthesia

Category 1 cesarean delivery (immediate threat to the life of the fetus or mother)

After two attempts to establish regional anesthesia have failed Following eclampsia or other seizure or maternal collapse, when the mother is not fully alert, medically stable, or has focal neurological signs When intraoperative pain under regional anesthesia is severe or uncontrolled by other means

Cardiac disease when reduction in systemic or pulmonary vascular resistance may lead to a critical event

Cardiac or respiratory disease when the patient cannot tolerate the supine or semi-supine position

Respiratory disease when postoperative ventilation will be required An uncooperative patient

86Anesthesia for Cesarean Delivery

Explaining the Effects of Anesthesia on the Baby Factors Affecting Neonatal Outcome

Much of the evidence about neonatal outcome and its relation to the method of anesthesia is of poor quality and pertains only to elective delivery of healthy women and fetuses. At emergency cesarean delivery, neonatal acid base balance can be improved irrespective of the method of anesthesia.

Meta-analysis comparing regional and general anesthesia suggests that neonatal umbilical cord blood pH and base defi cit is:

worse with spinal anesthesia compared with general anesthesia

(although the magnitude of difference is small)

affected by the severity and duration of maternal hypotension and

the duration of the uterine incision to delivery interval Table 4.6 Discussion Points at Consent for General Anesthesia

Disadvantages compared with regional anesthesia

Missing the birth experience (including the father)

Greater risk of life-threatening complications (hypoxemia, aspiration,

anaphylaxis)

Possibly higher mortality rate (extremely rare)

Assisted ventilation of the neonate more likely

Procedural events

Monitoring

Aspiration prophylaxis

Preoxygenation

Cricoid pressure

Postoperative analgesia

Common postoperative sequelae

Coughing

Nausea and vomiting

Sore throat

Drowsiness

Infrequent complications

Dental injury

Awareness

Hypoxemia

Failed intubation

Rare complications

Aspiration

Extremely rare complications

Neurological injury

• Death

Obstetric Anesthesia87 possibly made worse by the arterial occlusion associated with inad-

equate pelvic tilt (indicating the lateral position may be preferable when establishing regional anesthesia).

Effects of Regional Anesthesia

Fetal and neonatal effects of local anesthetic or opioid are usually

undetectable.

Only a Venturi type face mask delivering at least 60

• % inspired

oxygen will improve fetal oxygenation, but this should be consid- ered if the fetus is thought to be hypoxemic.

The biochemical and metabolic condition of the healthy fetus is

unaffected by regional anesthesia, provided ephedrine and sustained or profound hypotension are avoided (Table 4.7 ).

Control of hypotension with ephedrine results in lower umbilical

artery pH and higher base defi cit than control with phenylephrine or metaraminol.

Table 4.7 Anesthesia and Neonatal Acid-Base Status at Elective Cesarean Delivery 1kPa = 7.5mmHg

General (n = 30)

Epidural (n = 30)

Spinal (n = 30) Maternal

pH 7.36 (0.04) a 7.44 (0.06) 7.42 (0.03) pO 2 (kPa) 30.80 (1.37) 31.73 (1.56) 32.10 (1.50) Base defi cit (mmol/l) 5.10 (1.82) 2.43 (2.13) 3.21 (1.79) Umbilical vein

pH 7.33 (0.05) 7.34 (0.04) 7.34 (0.05)

PO 2 5.80 (0.33) 5.67 (0.36) 5.92 (0.51) Base defi cit 4.00 (2.10) 4.80 (1.81) 4.78 (2.23) Umbilical artery

pH 7.28 (0.04) 7.29 (0.07) 7.28 (0.02)

PO 2 2.90 (0.19) 2.91 (0.23) 2.87 (0.23) Base defi cit 4.31 (1.79) 4.58 (1.99) 4.53 (2.01) Values are mean (SD). a P < 0.01 compared with other groups. Reprinted from the International Journal of Obstetric Anesthesia , Vol. 2. Mahajan J, et al.

Anaesthetic technique for elective caesarean section and neurobehavioural status of newborns, 89–93, Copyright (1996), with permission from Elsevier.

88Anesthesia for Cesarean Delivery

Uncorrected hypotension may cause subtle neurobehavioral

changes in infant responsiveness and sucking.

Effects of General Anesthesia

Fetal drug exposure is limited by factors regulating placental

• transfer.

Fetal oxygenation is improved by giving the woman 100

• % inspired

oxygen, but no improvement in neonatal clinical outcome has been shown.

The sedative effects of the inhalational anesthetics and the respira-

tory depressant effects of opioid may be evident at birth, especially after a prolonged induction to delivery interval ( > 15 minutes).

A person experienced in neonatal resuscitation should be availa-

ble, because active resuscitation is more likely to be necessary (although usually confined to assistance in establishing first breaths).

In cesarean delivery for fetal compromise, lower Apgar scores

and neonatal intubation may be more likely than after regional anesthesia (Figure 4.1 ).

Percentage

100

80

60

40

20

0

Epidural General Spinal

1 min score

Epidural General Spinal

5 min score Apgar 1–4

Apgar 5–7 Apgar 8–10

Figure 4.1 Infl uence of anesthetic technique on neonatal condition after urgent cesarean section for fetal distress. Data derived from Marx, G.F., et al.

(1984) Fetal-neonatal status following cesarean section for fetal distress.

Br J Anaesth. 56:1011. Reprinted with permission from Reisner LS and Lin D, Anesthesia for cesarean section. In: Chestnut DH, Obstetric Anesthesia 2 nd ed.

1999, Elsevier.

Obstetric Anesthesia89

Patient Preparation

Preoperative Assessment

Ideally, a thorough pre-anesthesia assessment should be completed, including:

Patient characteristics (age, weight, fasting status).

Past medical and surgical history.

Systems review, medications and allergies.

Physical examination focusing on the cardiovascular and respiratory

systems, and the relevant airway investigations and imaging.

Additional elements related to pregnancy and cesarean delivery.

(Table 4.8 ) Fasting

The American Society of Anesthesiologist’s (ASA) practice guidelines recommend a fasting interval of at least 6 hours for solids prior to elective cesarean delivery.

In laboring women, oral intake should be limited to clear fl uids

alone, due to diffi culty predicting which women are at risk of surgical delivery.

In many cases, the urgency of delivery will take precedence over

fasting status. In parturients who have not been “nil per oris” (NPO),

Table 4.8 Pre-Anesthesia Assessment Related to Pregnancy and Cesarean Delivery

Past obstetric history Current obstetric history Indication for cesarean delivery Gestational age

Pregnancy-related diseases and disorders and their management Presence of ruptured membranes or labor

Fetal status during pregnancy and current fetal status Relevant surface landmarks, especially vertebral column Relevant investigations and laboratory tests

Hemoglobin concentration / hematocrit Platelet count

Blood group and hold or blood crossmatch Relevant imaging

Placental location Spinal anatomy

90Anesthesia for Cesarean Delivery

regional anesthesia is preferable in terms of avoiding the risk of aspi- ration.

Preoperative Optimization

Preoperative optimization is an important goal, irrespective of the urgency of delivery. Recent data from the CEMACH database noted the failure of staff to recognize the severity of maternal illness.

Undiagnosed or inadequately treated sepsis and cardiac failure are examples of conditions in which induction of anesthesia may precipi- tate a fatal event.

The timing of delivery in critically ill pregnant women requires careful consideration, preferably decided by a multidisciplinary team including obstetricians, obstetric physicians, neonatologists and anesthesiologists. Even if delivery appears mandated by an imme- diate threat to the life of the fetus, intrauterine resuscitation (see Chapter 15) may improve the fetal condition signifi cantly and gain preparation time. The life of the mother must always take priority over that of the fetus.

Airway Assessment

Diffi cult intubation (incidence 1 in 30–60) or failed intubation (inci- dence 1 in 250–1500) leading to hypoxemia, aspiration, and cardiac arrest, represents the most common fatal complication of obstetric anesthesia in developed countries (fatal complications of regional block are very rare except in developing countries).

Although difficulties may arise unexpectedly, in many cases good airway assessment will be predictive and critical to manage- ment planning. A high false positive rate (low specifi city) is not an issue, and a diffi cult airway cart should be available in all units, prefer- ably housed beside the operating table when general anesthesia is induced.

Airway assessment should be routine and performed at patient admission or as early as possible in labor. Ideally there are hospital- based systems of referral to the anesthesiology department of women of known or suspected high risk of airway diffi culty.

Risk Factors for a Diffi cult Airway

Risk factors must be sought and a comprehensive evaluation performed (Table 4.9 and Figure 4.2 ). Review of documentation of previous airway management is valuable, but unless reasonably contemporane- ous it may not refl ect the patient’s current condition.

Obstetric Anesthesia91 Table 4.9 Indicators of Potential Diffi culty with the Airway History

Previous anesthesia and airway management details (known diffi culty)

Breath sounds (stridor associated with airway infection or severe

preeclampsia) Examination and Tests

Morbid obesity (associated with diffi cult ventilation and

intubation)

Limited cervical spine or atlanto-occipital joint extension (including

due to large hair knots or buns) Short neck (thyromental distance < 6 cm)

Reduced laryngoscope access (e.g., anterior neck mass or large breasts)

Small oral cavity or large tongue (Grade 3 or 4 Mallampati view)

Temporomandibular joint dysfunction or reduced mouth opening

(inter-incisor distance < 3 cm)

Prominent upper incisors (inability to protrude lower teeth past upper

teeth or to bite upper lip) Receding mandible

Height to thyromental distance ratio

• > 21

Poor dentition (missing, loose, or prosthetic teeth)

Oral pathology

Most individual tests show poor specifi city and positive predictive value.

Combinations (e.g., Mallampati test and upper-lip bite test) are more accurate, and multiple factors multiply the relative risk of diffi cult airway management.

Class I

Class I Class II Class III Class IV

Class II Class III Class IV

Figure 4.2 Airway assessment. Upper panel: classifi cation of view of the pharyngeal structures during airway assessment. Lower panel: Classifi cation of direct laryngoscopic view. Upper panel modifi ed from Mallampati SR, et al. A clinical sign to predict diffi cult intubation: a prospective study. Can Anaesth Soc J. 1985; 32: 429-434. Lower panel modifi ed from Comarck RS and Lehane J.

Diffi cult intubation in obstetrics. Anaesthesia 1994; 39: 1105-1111. Reprinted with permission from Samsoon GLT and Yount JRB. Diffi cult tracheal intubation: a retrospective study. Anaesthesia 1987; 42: 488.

92Anesthesia for Cesarean Delivery

Airway management plans are best based on established algorithms, such as those endorsed by the ASA, with appropriate modifi cations for the obstetric population. Such plans include:

Avoiding nasal instrumentation if possible because of the risk of

epistaxis (due to increased vascularity and edema of the nasal mucosa).

Early placement of an epidural catheter during labor in women at

increased risk of diffi cult airway management (e.g., morbidly obese, known or suspected diffi cult intubation). This allows for rapid induction of surgical anesthesia if necessary.

Repeat airway assessment in laboring women to exclude changes

within the airway (e.g., mucosal or tongue swelling or laryngeal edema due to deteriorating preeclampsia).

Use of awake fiberoptic intubation when general anesthesia

appears necessary in a woman at high risk of difficult airway management.

If difficulty is anticipated the anesthesiologist should be familiar with and have prepared a range of equipment for intubation, aids to intubation, and both supraglottic and transtracheal airway devices.

The patient should be warned about possible dental and soft tissue injury. Experienced assistants are essential.

Minimization of Aortocaval Compression Physiology

Once the gravid uterus rises from within the pelvis (at approximately 20 weeks gestation) it may obstruct the inferior vena cava and/or the aorta (usually just below the bifurcation of the iliac arteries) when the woman lies supine.

At term, imaging shows that 90

• % of women lying supine have

partial or complete inferior vena caval obstruction (with diversion of venous fl ow via the azygous system) and 10 % –15 % become symptomatic (syncope, nausea) due to reduced cerebral perfusion.

Aortic obstruction and impaired placental fl ow may be silent but

cause fetal hypoxemia and acidosis.

These effects are exaggerated by anesthesia, due to venous pooling,

reduction in blood pressure, impaired compensatory vasoconstric- tion, and reduced cardiac output.

In combination with other events, the hemodynamic disturbance of aortocaval compression has contributed to case fatalities.