Caesarean Section – Neuraxial Block

 

Pre-op assessment: mother

Is spinal safe?

·     CVS: hypovolaemia or heart disease

·     Haem: coagulopathy

·     Neuro: Arnold-Chiari malformation, SOL with raised ICP

·     MSK: spine surgery or deformity

Is CSE better?

·     Heart disease

·     Many previous abdo surgery

·     Multiple gestation

Is GA better?

·     Expect haemorrhage

·     Expect conversion + expect difficult airway

Is haemorrhage likely?

·     Anterior + low-lying placenta

·     Inherited coagulopathy

·     Acquried coagulopathy

 

Issues: mother

Neuraxial side effects

·     Nausea

·     Shivering

·     Dyspnoea

·     Hypotension

Neuraxial wrong dose

·     Failed block

·     Total spinal

Neuraxial complications

·     Dural puncture headache

·     Neuro damage

Caesarean complications

·     Haemorrhage

·     Organ injury

 

Issues: baby

Risk of asphyxia

·     Supine aortocaval compression

·     Maternal hypotension

·     Uterine incision

Risk of drug toxicity

·      

Risk of resp distress

·      

 

Goals: mother

No paralysis

·     Identify contraindications: anticoagulants, DIC, HELLP

·     Education: look out for paralysis, paraesthesia, bladder/bowel dysfx

·     Follow-up: acute pain service review next day

No failed block

·     Consider higher dose or CSE if at risk (early gestation, large)

·     Check with ice early + adjust table

·     Bonnies tests before incision

·     Communication with surgeon

No total spinal

·     Consider lower dose or CSE if at risk (multiple pregnancy, small)

·     Check with ice early + adjust table

No hypotension

·     500mL CSL pre-op

·     Check with ice early + adjust table

·     Ephedrine 3mg q2min

No haemorrhage

From AABGI consensus:

·     Elective: oxytocin 1 unit + 5 units/h

·     Intrapartum: oxytocin 3 units + 10 units/h

 

Goals: foetus

No asphyxia

·     Avoid maternal hypotension

·     Left lateral tilt or right hip wedge

·     Do not draw up oxytocin before delivery

No drug toxicity

·     Minimise drug exposure before delivery

 

Management of complications:

Failed spinal

·     Stop operation

·     Confirm diagnosis

·     Discuss with patient + surgeon

·     Options: local infiltration, N2O, opioid, GA

Haemorrhage

·     Tissue

·     Trauma

·     Tone

·     Thrombin

 

Why is neuraxial preferable to GA?

 

Mother

·     ↓Acute pain

·     ↓Chronic pain

·     ↓Bleeding

·     ↓Infection

·     ↓Major disasters

·     Avoid risks of GA

Foetus

·     ↓Respiratory depression

·     ↓Neurotoxin exposure

Bonding

·     Mother is awake

·     Baby is awake

·     Partner is present