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Cesarian Section General versus Regional Anesthesia. Presented by: Tareq Salwati SSC-Anaes Department of Anesthesiology Maternity and Childrens ’ s Hospital Jarwal, The Holy Capital. Why do we need cesarian sections?. Why do we need cesarian sections:.

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cesarian section general versus regional anesthesia

Cesarian SectionGeneral versus Regional Anesthesia

Presented by:

Tareq Salwati SSC-Anaes

Department of Anesthesiology

Maternity and Childrens’s Hospital

Jarwal, The Holy Capital

why do we need cesarian sections1
Why do we need cesarian sections:

To prevent maternal and foetal morbidity and mortality

examples for indications for cesarian sections labor unsafe for mother and fetus
Examples for Indications for Cesarian Sections:Labor unsafe for mother and fetus:

Increased risk of uterine rupture

Previous classic cesarean section

Previous extensive myomectomy or uterine reconstruction

examples for indications for cesarian sections labor unsafe for mother and fetus1
Examples for Indications for Cesarian Sections:Labor unsafe for mother and fetus:

Increased risk of maternal hemorrhage

Central or partial placenta previa

Abruptio placentae

Previous vaginal reconstruction

examples for indications for cesarian sections dystocia
Examples for Indications for Cesarian Sections:Dystocia

Abnormal fetopelvic relations

Fetopelvic disproportion

Abnormal fetal presentation

Transverse or oblique lie

Breech presentation

Dysfunctional uterine activity

examples for indications for cesarian sections immediate or emergent delivery necessary
Examples for Indications for Cesarian Sections:Immediate or emergent delivery necessary

Fetal distress

Umbilical cord prolapse

Maternal hemorrhage

Amnionitis

Genital herpes with ruptured membranes

Impending maternal death

why do we need anesthesia for cesarian section1
Why do we need anesthesia for cesarian section?

It would be otherwise extremely painful for the mother !!!

choices of anesthesia available2
Choices of Anesthesia available:

General anesthesia

Regional anesthesia

choices of anesthesia available3
Choices of Anesthesia available:

General anesthesia

Regional anesthesia

Local anesthesia

general anesthesia advantages1
General anesthesiaAdvantages:

Controlled airway and ventilation

general anesthesia advantages2
General anesthesiaAdvantages:

Anesthetist's hands are free for fluid management and hemodynamics control in cases of major bleeding.(that is, the airway is already secured)

general anesthesia advantages4
General anesthesiaAdvantages:

Minimal cooperation needed from the patient

(possibly only to

insert canula and

tolerate a face mask).

general anesthesia2
General Anesthesia

Disadvantages:

general anesthesia disadvantages
General AnesthesiaDisadvantages:

16 X higher anesthesia related mortality compared to regional anesthesia.

general anesthesia disadvantages1
General AnesthesiaDisadvantages:

Risk of difficult/failed intubation

general anesthesia disadvantages2
General AnesthesiaDisadvantages:

Risk of difficult/failed intubation

Risk of failed intubation in parturients is 10 X higher than in non-obstetric population.

general anesthesia disadvantages3
General AnesthesiaDisadvantages:

Risk of

pulmunary aspiration

general anesthesia disadvantages4
General AnesthesiaDisadvantages:

Contributes to

uterine relaxation/atony

general anesthesia disadvantages5
General AnesthesiaDisadvantages:

Extra time needed at end of procedure to wake up the the patient

general anesthesia disadvantages6
General AnesthesiaDisadvantages:

Usually faster onset of postoperative pain

general anesthesia disadvantages7
General AnesthesiaDisadvantages:

Risk of

Malignant hyperthermia

general anesthesia disadvantages8
General AnesthesiaDisadvantages:

Mother and child deprived from early bonding

general anesthesia disadvantages9
General AnesthesiaDisadvantages:

Risk of intaoperative awareness under anesthesia (higher risk than general population)

general anesthesia disadvantages10
General AnesthesiaDisadvantages:

Exposure of fetus to depressant effect of general anesthetics

general anesthesia disadvantages11
General AnesthesiaDisadvantages:

When you face an unexpected difficult intubation in a case of a really urgent cesarian, then everybody in the theater is in big stress.

general anesthesia disadvantages13
General AnesthesiaDisadvantages:

Sore throat postoperatively due to the endotrachial tube.

general anesthesia disadvantages14
General AnesthesiaDisadvantages:

More costly (costs more money $$$).

most important causes of mortality due to general anesthesia
Most important causes of mortality due to General anesthesia:

Inability to intubate

Inability to ventilate

Aspiration pneumonitis

regional anesthesia advantages
Regional anesthesiaAdvantages:

Anesthesia related mortality much lower than general anesthesia.

regional anesthesia advantages1
Regional anesthesiaAdvantages:

No need for intubation

regional anesthesia advantages2
Regional anesthesiaAdvantages:

No difficult/failed intubation

regional anesthesia advantages3
Regional anesthesiaAdvantages:

Less risk of pulmunary aspiration

regional anesthesia advantages4
Regional anesthesiaAdvantages:

Awake mother when the baby is born.

regional anesthesia advantages5
Regional anesthesiaAdvantages:

Early bonding of mother and child.

regional anesthesia advantages6
Regional anesthesiaAdvantages:

Mothers are often very happy when shown their baby while they did not notice that the surgery has even yet started!!

regional anesthesia advantages7
Regional anesthesiaAdvantages:

Almost no exposure of fetus to anesthetic drugs.

regional anesthesia advantages8
Regional anesthesiaAdvantages:

No

contribution to uterine relaxation/atony.

regional anesthesia advantages9
Regional anesthesiaAdvantages:

No time needed at end of the procedure to wake up the patient, thus immediately ready to leave to recovery room.

slide50
Regional Anesthesia

Disadvantages

regional anesthesia disadvantages
Regional AnesthesiaDisadvantages:

slower in onset “arguably?”

(related to skill of anesthesiologist)

regional anesthesia disadvantages1
Regional AnesthesiaDisadvantages:

Occasionally you will find “Bone” in your way. Or “No” CSF.

regional anesthesia disadvantages2
Regional AnesthesiaDisadvantages:

Occasionally will have a

failed/incoplete block.

or delayed onset.

regional anesthesia disadvantages3
Regional AnesthesiaDisadvantages:

Risk of high/complete spinal block.

(intubation may be needed)

regional anesthesia disadvantages4
Regional AnesthesiaDisadvantages:

Risk of

post dural puncture headache.

regional anesthesia disadvantages5
Regional AnesthesiaDisadvantages:

Risk of spinal/epidural hematoma.

regional anesthesia disadvantages6
Regional AnesthesiaDisadvantages:

Risk of spinal cord injury

Closed claims Analysis of the ASA from 1990 – 2003 reported:

11 cases for vaginal delivery

5 cases for cesarian section

regional anesthesia disadvantages7
Regional AnesthesiaDisadvantages:

Risk of inadvertant intravascular injection of local anesthetic.

“cardiac arrest”.

regional anesthesia disadvantages8
Regional AnesthesiaDisadvantages:

Needs some cooperation from the patient to sit/lie still.

most important causes of death due to regional anesthesia2
Most important Causes of death due to Regional anesthesia:

Excessively high neural blockade

Local anesthetic toxicity.

slide63
?

Why is regional anesthesia preferred when ever possible?

because of
:Because of

Anesthetic Mortality

anesthetic mortality
Anesthetic Mortality

Anesthesia accounts for approximately 2–3% of maternal deaths.

anesthetic mortality in cesarian section
Anesthetic Mortality (in cesarian section)

32 deaths per 1,000,000 live births due to general anesthesia

and 1.9 deaths per 1,000,000 live births due to regional anesthesia.

(Data collected between 1985 – 1990)

slide68
THANK YOU!

Reference:

Clinical Anesthesiology, G.Edward Morgan,Jr. et al , 4th edition, 2006

PocketMedicine Obstetric Anesthesia Version 1.1.0/2005.11.7

LWW mobile Clinical Anesthesia, 5th edition Version 8.0.26/2007.4.5

Liability assiciated with obstetric anesthesia, Anesthesiology 2009: 110:131-9

www.salwati.com