The Generalist: Anesthesia for Crash C-Sections

The Generalist: Anesthesia for Crash C-Sections

Casey Parker, MD; Heidi James, MD; and Vanessa Cardy, MD

Consider the hair-raising scenario where a fetus needs to be delivered ASAP via C-section and you have an obstetrician who can do a C-section but Anesthesia is 30 minutes away. How would you safely anesthetize a late-term pregnant woman in your ED?

• The usual ED anesthetic options include
• Local or regional anesthetic block
• Procedural sedation
• A formal anesthetic including intubation 
• A spinal (subarachnoid) block is the standard option for an elective section, but is not the best in the ED:
• Too slow 
• The drugs are not familiar to many ED doctors
• Can cause profound hypotension 
• Procedural sedation: 
• Sedation is fast and familiar to ED doc
• It is complicated in heavily pregnant women.
• This is not a quick procedure and is very stimulating.
• Pregnant women do not do well with sedation:
• hypoventilation 
• risk of aspiration
• All the risks but few of the benefits of a formal intubation and anesthesia in ED. 
• Ketamine may affect the neonate.
• Dr. Casey Parker recommends a formal rapid sequence intubation (RSI) for urgent C-section in the ED: 
• Use all the usual tricks that you would use in a crash airway; for example, apneic oxygenation (ApOx), suction, videolaryngoscope, bougie, etc
• Proper positioning of the woman is key: 
• head up
• ramped
• lateral tilt (displace the fundus)
• Make your first attempt your best attempt.
• Follow with light sedation until the baby is born.
• Avoid opiates until after birth.
• Get HELP. Ask for specialist advice from the anesthetist and get a midwife in to help you.
• MIdwives are usually familiar with the medications and normal procedures around a C-section.
• Be prepared for bleeding—it can be big and brisk.
• Contract the uterus to stop the bleeding: 
• Use oxytocics aggressively.
• Start with 2-4 units of oxytocin IV slow push after birth.
• Use a massive transfusion protocol as you would in trauma.
• Generally pregnant women need fibrinogen earlier, so use it if you have it.
• While we hope you will never need to do this, now you know how.