Cesarean section
Anesthesia type Neuraxial or general
Airway ETT if general
Lines and access 2 large bore PIV
Monitors Standard ASA
Fetal heart rate monitor
Primary anesthetic considerations
Preoperative Full stomach precautions

Aspiration prophylaxis

Left lateral tilt
Intraoperative
Postoperative

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. In the USA, about 32% of deliveries are via Cesarean section[1], and worldwide the figure is approximately 21%[2].

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[3]
  • 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

Operating room setup

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
  • Elevate the right hip to provide left uterine displacement
  • Adjunctive azithromycin 500mg IV to standard beta-lactam antibiotics shown to reduce the incidence in endometriosis and wound infection occurring in the first 6 weeks after Cesarean Section[4].

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
  • Post-operative transversus abdominal block (TAP block) or quadratus lumborum block.

Intraoperative management

Monitoring and access

Standard ASA monitors

Induction and airway management

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

Positioning

  • Left lateral tilt (15o) 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
  • Tranexamic acid 1g administered over 30-60 seconds during the first 3 minutes after birth, and after the uterotonic agent has been administered (e.g. oxytocin) is shown to reduce the incidence of post-operative blood loss > 1000 mL by POD #2 or RBC transfusion[5].
  • Start oxytocin 30U in 500mL fluid over 3 hours after clamping of umbilical cord
  • Monitor for hemodynamic variance after starting oxytocin
  • Additional uterotonics may be requested by surgeon if uterine tone is not adequate

Emergence

Postoperative management

Disposition

  • L&D PACU
  • Operating room PACU

Pain management

  • Epidural Morphine 1-3mg for long acting post-partum pain relief[6][7]
  • IT Morphine 50-150mcg for long acting post-partum pain relief if spinal performed[8]
  • IV acetaminophen
  • Ibuprofen PO post-op
  • ± ketoralac (dependent upon surgeon preference and total blood loss)
  • ± Wound infiltration
  • ± Transversus abdominal block (TAP block) or quadratus lumborum block (for patients undergoing general anesthesia or neuroaxial without intrathecal opioid administration)
  • ± Continuous local anesthetic pain pump

Potential complications

  • Ureteral injury
  • Post-partum hemorrhage

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
  • GA normally used with regional technique contraindicated or when there is not enough time to perform a block due to obstetric emergency
  • Rapid sequence induction (RSI)
Position Left lateral tilt Left lateral tilt
Surgical time 45-90min 30-45min (given emergency delivery indications)
EBL 500-1000mL 500-1000mL
Postoperative disposition L&D PACU L&D or OR PACU
Pain management 4 6
Potential complications Post-dural-puncture headache
  • Aspiration
  • Difficult Airway

References

  1. "FastStats". www.cdc.gov. 2021-03-24. Retrieved 2021-05-27.
  2. Boerma, Ties; Ronsmans, Carine; Melesse, Dessalegn Y.; Barros, Aluisio J. D.; Barros, Fernando C.; Juan, Liang; Moller, Ann-Beth; Say, Lale; Hosseinpoor, Ahmad Reza; Yi, Mu; Neto, Dácio de Lyra Rabello (2018-10-13). "Global epidemiology of use of and disparities in caesarean sections". The Lancet. 392 (10155): 1341–1348. doi:10.1016/S0140-6736(18)31928-7. ISSN 0140-6736. PMID 30322584.
  3. Buley, R. J.; Downing, 4 W.; Brock-Utne, J. G.; Cuerden, C. (1977-10). "Right versus left lateral tilt for Caesarean section". British Journal of Anaesthesia. 49 (10): 1009–1015. doi:10.1093/bja/49.10.1009. ISSN 0007-0912. PMID 921864. Check date values in: |date= (help)
  4. Tita, Alan T.N.; Szychowski, Jeff M.; Boggess, Kim; Saade, George; Longo, Sherri; Clark, Erin; Esplin, Sean; Cleary, Kirsten; Wapner, Ron; Letson, Kellett; Owens, Michelle (2016-09-29). "Adjunctive Azithromycin Prophylaxis for Cesarean Delivery". New England Journal of Medicine. 375 (13): 1231–1241. doi:10.1056/NEJMoa1602044. ISSN 0028-4793. PMC 5131636. PMID 27682034.CS1 maint: PMC format (link)
  5. Sentilhes, Loïc; Sénat, Marie V.; Le Lous, Maëla; Winer, Norbert; Rozenberg, Patrick; Kayem, Gilles; Verspyck, Eric; Fuchs, Florent; Azria, Elie; Gallot, Denis; Korb, Diane (2021-04-29). "Tranexamic Acid for the Prevention of Blood Loss after Cesarean Delivery". New England Journal of Medicine. 384 (17): 1623–1634. doi:10.1056/NEJMoa2028788. ISSN 0028-4793.
  6. Fuller, John G.; McMorland, Graham H.; Douglas, M. Joanne; Palmer, Lynne (1990-09). "Epidural morphine for analgesia after Caesarean section: a report of 4880 patients". Canadian Journal of Anaesthesia. 37 (6): 636–640. doi:10.1007/BF03006481. ISSN 0832-610X. Check date values in: |date= (help)
  7. Bollag, Laurent; Lim, Grace; Sultan, Pervez; Habib, Ashraf S.; Landau, Ruth; Zakowski, Mark; Tiouririne, Mohamed; Bhambhani, Sumita; Carvalho, Brendan (2021-05). "Society for Obstetric Anesthesia and Perinatology: Consensus Statement and Recommendations for Enhanced Recovery After Cesarean". Anesthesia & Analgesia. 132 (5): 1362–1377. doi:10.1213/ANE.0000000000005257. ISSN 0003-2999. Check date values in: |date= (help)
  8. Bollag, Laurent; Lim, Grace; Sultan, Pervez; Habib, Ashraf S.; Landau, Ruth; Zakowski, Mark; Tiouririne, Mohamed; Bhambhani, Sumita; Carvalho, Brendan (2021-05). "Society for Obstetric Anesthesia and Perinatology: Consensus Statement and Recommendations for Enhanced Recovery After Cesarean". Anesthesia & Analgesia. 132 (5): 1362–1377. doi:10.1213/ANE.0000000000005257. ISSN 0003-2999. Check date values in: |date= (help)