Cesarean section

Cesarean section

Anesthesia type	General vs. Regional
Airway	ETT if GA
Lines and access	2 large bore PIV
Monitors	Standard ASA
Primary anesthetic considerations
Preoperative	Full stomach precautions Aspiration prophylaxis Left lateral tilt
Intraoperative
Postoperative
Article quality
Editor rating	Comprehensive
User likes	2

A Cesarean section, also known as C-section, is a surgical procedure where the baby is delivered through an incision in the uterus. C-sections are typically performed when a vaginal delivery would put the mother or baby at risk. As of 2017, about 32% of deliveries in the United States were performed via C-section.

Preoperative management

Patient evaluation

System	Considerations
Neurologic
Cardiovascular	Pregnant patients typically have decreased systemic vascular resistance, decreased diastolic pressure, decreased MAP, increased HR, and increased CO. Left uterine tilt to minimize aortocaval compression Evaluate for pregnancy induced hypertension (PIH)
Respiratory	Pregnant patients typically have compensated respiratory alkalosis, increased minute ventilation, decreased FRC, and increased oxygen consumption. Decreased FRC results in rapid desaturation if ventilation is compromised. Atelectasis can occur secondary to an elevated diaphragm, thereby causing V/Q mismatch and decreased PaO2. Increased MV and decreased FRC increase uptake of inhalational agents. Mucosal capillary engorgement in upper airway may necessitate smaller endotracheal tube.
Gastrointestinal / Hepatic	Increased gastric pressure Decreased esophageal sphincter tone Decreased gastric motility Full stomach precautions Risk for aspiration Liver enzymes may be mildly elevated Check for HELLP
Hematologic	Increased RBC mass, plasma volume, and blood volume Leukocytosis Iron deficiency anemia + dilutional anemia of pregnancy Excessive blood loss possible with uterine atony, multiple gestation, previous C-section, placental pregnancy, placental abruption, pregnancy induced hypertension, or prolonged labor.
Renal	Increased renal blood flow, GFR, and creatinine clearance Decreased serum creatinine and BUN Dependent edema secondary to increased water and sodium retention
Other

Labs and studies

• T&S
• T&C only if significant blood loss anticipated
• Coagulation panel
• Chemistry panel
• Complete Blood Count (CBC)
• Other tests as indicated by H&P

Patient preparation and premedication

• Full stomach precautions
• Nonparticulate oral antacid (e.g. sodium citrate) immediately prior to general or regional anesthesia
• Intravenous promotility agent (eg. metoclopramide)
• Intravenous antacids (e.g. ranitidine, famotidine)
• Anxiolysis not typically used unless patient is extremely anxious

Regional and neuraxial techniques

• Epidural, spinal, and combined spinal-epidural (CSE) techniques are all commonly employed
  • Check coagulation and platelets panel prior to neuraxial anesthesia

Intraoperative management

Induction and airway management

• Avoid nasal airways due to potential for mucosal capillary engorgement in upper airway

Positioning

• Left lateral tilt (15^o) to avoid aortocaval compression and supine hypotension.

Maintenance and surgical considerations

• Anticipate EBL of 700-1000 mL
  • Be prepared for excessive blood loss if underlying risk factors
• Immediately post-partum, ~600-800 mL of blood will enter the central circulation (placental autotransfusion), which will increase cardiac output

Procedure variants

	Neuraxial	General
Unique considerations	Decreased BP common with spinal anesthesia Given fluid pre-load or co-load Be prepared to provide bolus as vasopressors as needed	Rapid sequence induction (RSI)
Position
Surgical time
EBL
Postoperative disposition
Pain management
Potential complications