1. Cesarian Section General versus Regional Anesthesia Presented by: Tareq Salwati Tareq Salwati SSC-Anaes Department of Anesthesiology Maternity and Childrens ’ s Hospital Jarwal, The Holy Capital

2. Why do we need cesarian sections?

3. Why do we need cesarian sections: To prevent maternal and foetal morbidity and mortality

4. 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

5. Examples for Indications for Cesarian Sections: Labor unsafe for mother and fetus: Increased risk of maternal hemorrhage Central or partial placenta previa Central or partial placenta previa Abruptio placentae Abruptio placentae Previous vaginal reconstruction

6. Examples for Indications for Cesarian Sections: Dystocia Examples for Indications for Cesarian Sections: Dystocia Abnormal fetopelvic relations Abnormal fetopelvic relations Fetopelvic disproportion Abnormal fetal presentation Transverse or oblique lie Breech presentation Dysfunctional uterine activity

7. Examples for Indications for Cesarian Sections: Immediate or emergent delivery necessary Examples for Indications for Cesarian Sections: Immediate or emergent delivery necessary Fetal distress Fetal distress Umbilical cord prolapse Maternal hemorrhage Amnionitis Genital herpes with ruptured membranes Impending maternal death

8. Why do we need anesthesia for cesarian section?

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

10. Choices of Anesthesia available:

11. General anesthesia

12. Choices of Anesthesia available: General anesthesia Regional anesthesia

13. Choices of Anesthesia available: General anesthesia Regional anesthesia Local anesthesia

14. General anesthesia

15. Advantages:

16. General anesthesia Advantages: Rapid onset

17. General anesthesia Advantages: Controlled airway and ventilation

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

19. General anesthesia Advantages: Almost never fails

20. General anesthesia Advantages: Minimal cooperation needed from the patient (possibly only to insert canula and insert canula and tolerate a face mask). tolerate a face mask).

21. General Anesthesia Disadvantages:

22. General Anesthesia Disadvantages: 16 X higher anesthesia related mortality compared to regional anesthesia.

23. General Anesthesia Disadvantages: Risk of difficult/failed intubation

24. General Anesthesia Disadvantages: Risk of difficult/failed intubation Risk of failed intubation in parturients is 10 X higher than in non-obstetric population.

25. General Anesthesia Disadvantages: Risk of pulmunary aspiration

26. General Anesthesia Disadvantages: Contributes to uterine relaxation/atony

27. General Anesthesia Disadvantages: Extra time needed at end of procedure to wake up the the patient

28. General Anesthesia Disadvantages: Usually faster onset of postoperative pain

29. General Anesthesia Disadvantages: Risk of Malignant hyperthermia

30. General Anesthesia Disadvantages: Mother and child deprived from early bonding

31. General Anesthesia Disadvantages: Risk of intaoperative awareness under anesthesia (higher risk than general population)

32. General Anesthesia Disadvantages: Exposure of fetus to depressant effect of general anesthetics

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

34. General Anesthesia Disadvantages: Risk of broken teeth.

35. General Anesthesia Disadvantages: Sore throat postoperatively due to the endotrachial tube.

36. General Anesthesia Disadvantages: More costly (costs more money $$$).

37. Most important causes of mortality due to General anesthesia: Inability to intubate Inability to ventilate Aspiration pneumonitis

38. Regional anesthesia

39. Advantages:

40. Regional anesthesia Advantages: Anesthesia related mortality much lower than general anesthesia.

41. Regional anesthesia Advantages: No need for intubation

42. Regional anesthesia Advantages: No difficult/failed intubation

43. Regional anesthesia Advantages: Less risk of pulmunary aspiration

44. Regional anesthesia Advantages: Awake mother when the baby is born.

45. Regional anesthesia Advantages: Early bonding of mother and child.

46. Regional anesthesia Advantages: Mothers are often very happy when shown their baby while they did not notice that the surgery has even yet started!!

47. Regional anesthesia Advantages: Almost no exposure of fetus to anesthetic drugs.

48. Regional anesthesia Advantages: No contribution to uterine relaxation/atony.

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

50. Regional Anesthesia Disadvantages

51. Regional Anesthesia Disadvantages: slower in onset “ arguably? ” (related to skill of anesthesiologist)

52. Regional Anesthesia Disadvantages: Occasionally you will find “ Bone ” in your way. Or “ No ” CSF.

53. Regional Anesthesia Disadvantages: Occasionally will have a failed/incoplete block. failed/incoplete block. or delayed onset.

54. Regional Anesthesia Disadvantages: Risk of high/complete spinal block. (intubation may be needed)

55. Regional Anesthesia Disadvantages: Risk of post dural puncture headache.

56. Regional Anesthesia Disadvantages: Risk of spinal/epidural hematoma.

57. Regional Anesthesia Disadvantages: Risk of spinal cord injury Closed claims Analysis of the ASA from 1990 – 2003 reported: 11 cases for vaginal delivery 11 cases for vaginal delivery 5 cases for cesarian section 5 cases for cesarian section

58. Regional Anesthesia Disadvantages: Risk of inadvertant intravascular injection of local anesthetic. “ cardiac arrest ”.

59. Regional Anesthesia Disadvantages: Needs some cooperation from the patient to sit/lie still.

60. Most important Causes of death due to Regional anesthesia:

61. Excessively high neural blockade

62. Most important Causes of death due to Regional anesthesia: Excessively high neural blockade Local anesthetic toxicity.

63. ? Why is regional anesthesia preferred when ever possible?

64. :Because of Anesthetic Mortality

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

66. 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)

67. That is, General Anesthesia cases death 16 X more frequent than regional Anesthesia !!!!!

68. THANK YOU! Reference: Clinical Anesthesiology, G.Edward Morgan,Jr. et al, 4 th edition, 2006 PocketMedicine Obstetric Anesthesia Version 1.1.0/2005.11.7 LWW mobile Clinical Anesthesia, 5 th edition Version 8.0.26/2007.4.5 Liability assiciated with obstetric anesthesia, Anesthesiology 2009: 110:131-9 www.salwati.com