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Finally, in a 2012 review of 91 published cases of
BOX 43.1 EQUIPMENT CHECKLIST FORINITIATING A
PERIMORTEM CESAREAN DELIVERY
14
maternal cardiac arrest, PMCD was performed in 76 of
91 of the cases, but only 7% of the patients were delivered by 5 minutes (though nearly 90% of the arrests were
General
Crashcart
witnessed). Over half of mothers survived to hospital
discharge.
17
Even though PMCD is now a recommended practice
Backboard
Surgical
BSI Equipment
(Gloves/ Gown/ Mask/ Eyeshield)
Scalpels(3)
in the setting of maternal cardiac arrest, it has rarely been
performed within the AHA time guidelines.
8,15,16,18
Eorts
to improve adherence to these guidelines include provider
education, implementation of “maternal code blue” protocols, and simulation teamwork training.
8,14,15,18
Barriers to
timely implementation of PMCD during simulated maternal cardiac arrests included eorts to move the patient from
the labor suite to the operating room for delivery, futile
Skin Preparation Solution
Laparotomy Sponges
eorts to monitor fetal viability, and equipment delays
(scalpel). Maternal CPR was also negatively aected during patient transport during simulated maternal in- hospital
Kelly Clamps(4)
Mayo Scissors
Retractor
CordClamps
cardiac arrest.19 is nding suggests that time should not
be wasted moving patients to the operating theater for a
PMCD.
4,8,14,19
In addition, attempts to assess fetal viability
should not delay or guide the potentially life- saving intervention of a PMCD.
4,8,15
Perimortem cesarean delivery is a component of the
Neonatal
AHA guidelines for maternal cardiac arrest with a periviable fetus. Unsuccessful manual displacement of the gravid
Blankets and Heated Incubator
BagMask
uterus during maternal cardiac arrest may hasten the need
for an emergent surgical delivery to optimize ongoing
resuscitative eorts. APMCD performed in a timely man-
Bulb Suction
Emergency Medications
ner may improve both maternal and fetal outcomes. Given
the rarity of maternal cardiac arrest, provider education is
essential to the eective adherence of AHA guidelines in
the setting of cardiopulmonary collapse.
gestational age). Eight of 12 women (67%) regained CO
following PMCD, with two maternal and ve neonatal survivors. ere were no survivors (maternal or fetal) aer out-
CASE- BASED LEARNING DISCUSSION
of- hospital maternal cardiac arrest. While no PMCD was
performed within 5 minutes, all surviving neonates were
delivered within 30 minutes8 (Table43.2).
1. What is the rst thing you would do as the anesthesia
provider in this case of a maternal cardiac arrest with
CPR ongoing? What modications would you make
to the adult Basic Life Support/ Advanced Cardiac
TABLE43.2 TIME TODELIVERY INWOMEN UNDERGOING
PERIMORTEM CESAREAN DELIVERY FROMSTART
OFRESUSCITATION
8
Life Support algorithm in the management of this
patient?
2. e patient is being ventilated at the head of the bed by
Time Number of Cases
<5 min 0
5–15 min 4
>15 min 8
an additional anesthesia provider, and the initial pulse
and rhythm check revealed pulseless electrical activity
(PEA), aer which CPR was resumed. At what point
would you initiate preparations for a PMCD? What if
the gestational age were 20weeks?
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307
3. What equipment and resources are needed to facilitate
a PMCD? Would you move the patient to the
operating theater?
4. In what circumstances would you consider performing a
PMCD before the 4 minutemark?
5. Immediately following the PMCD the patient has
a return of spontaneous circulation. What is your
immediate plan for managing this patient?
REFERENCES
1. Lipman SS, Daniels KI, Arafeh J, Halamek LP. e case for OBLS:a
simulation- based obstetric life support program. Seminars in
Perinatology. 2011;35:74– 79.
2. Vanden Hoek TL, Morrison LJ, Shuster M, etal. Part12:cardiac
arrest in special situations:2010 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation. 2010;122:S829– 61.
3. Reidy J, Russell R. CMACE 2006– 2008. Int J Obstet Anesth.
2011;20:208– 12.
4. Katz VL. Perimortem cesarean delivery:its role in maternal mortal-
ity. Seminars in Perinatology. 2012;36:68– 72.
5. Hayden FJ. Maternal mortality in history and today. Med J Aust.
1970;1:100.
6. Katz VL, Dotters DJ, Droegemueller W. Perimortem cesarean deliv-
ery. Obstetrics and Gynecology. 1986;68:571– 6.
7. Mhyre JM, Tsen LC, Einav S, Kuklina EV, Leert LR, Bateman
BT. Cardiac arrest during hospitalization for delivery in the United
States, 1998– 2011. Anesthesiology. 2014;120:810– 8.
8. Dijkman A, Huisman CM, Smit M, Schutte JM, Zwart JJ, van
Roosmalen JJ, Oepkes D. Cardiac arrest in pregnancy:increasing use
of perimortem caesarean section due to emergency skills training?
BJOG. 2010;117:282– 7.
9. Montgomery WH, Herrin TJ, Lewis AJ. Basic life support for physicians. American Heart Association. 1983;8.
10. Ueland K, Novy MJ, Peterson EN, etal. Maternal cardiovascular
dynamics. IV:e inuence of gestational age on the maternal cardiovascular response to posture and exercise. Am J Obstet Gynecol.
1969;104:856.
11. Higuchi H, Takagi S, Zhang K, Furui I, Ozaki M. Eect of lateral
tilt angle on the volume of the abdominal aorta and inferior vena
cava in pregnant and nonpregnant women as determined based on
magnetic resonance imaging. Anesthesiology. 2015;122:286– 93.
12. Chestnut D, Polley L, Tsen L, Wong C. Chestnut’s Obstetric
Anesthesia:Principles and Practice. Philadelphia, PA:Mosby; 2009;
943;191– 2.
13. McLennan CE. Antecubital and femoral venous pressure in normal
and toxemic pregnancy. Am J Obstet Gynecol. 1943;45:568.
14. Lipman S, Cohen S, Einav S, et al. e Society for Obstetric
Anesthesia and Perinatology consensus statement on the management of cardiac arrest in pregnancy. Anesthesia- Analgesia.
2014;118:1003– 16.
15. Lipman S, Daniels K, Cohen S, Carvalho B. Labor room setting
compared with the operating room for simulated perimortem
cesarean delivery: a randomized controlled trial. Obstet Gynecol.
2011;118:1090– 94.
16. Katz V, Balderston K, DeFreest M. Perimortem cesarean delivery: Were our assumptions correct? Am Journal of OB/ GYN.
2005;192:1920– 21.
17. Einav S, Kaufman N, Sela HY. Maternal cardiac arrest and perimortem caesarean delivery: evidence or expert- based? Resuscitation.
2012;83:1191– 200.
18. Berkenstadt H, Ben- Menachem E, Dach R, etal. Decits in the provision of cardiopulmonary resuscitation during simulated obstetric
crises:results from the Israeli Board of Anesthesiologists. Anesthesia
and Analgesia. 2012;115:1122– 6.
19. Lipman SS, Wong JY, Arafeh J, Cohen SE, Carvalho B. Transport
decreases the quality of cardiopulmonary resuscitation during simulated maternal cardiac arrest. Anesth Analg. 2013;116:162– 7.
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44.
STAT CAESAREAN DELIVERY
PREPARATION, PLANNING, AND TEAM PERFORMANCE
Michael G. Richardson
CLINICALCASE
In this chapter, “STAT CD” refers to the highest level of
urgency, Category 1, which demands prompt delivery to
At 2 AM, the anesthesiologist was alerted about a healthy 29year- old woman G3P1 at term, who developed contractions at
home, had spontaneous rupture of membranes with prolapse
of cord, and is being transported by ambulance. She was to be
transferred directly to the Labor and Delivery (L&D) operating room (OR) to undergo STAT cesarean delivery (CD) if
there was fetal heart activity. e neonate was delivered nine
minutes aer the parturient emerged from the elevator.
address an immediate threat to mother, fetus, or both. Such
cases include fetal indications (prolonged fetal bradycar-
dia; umbilical cord prolapse) and maternal +/ - fetal indi-
cations (severe hemorrhage, placental abruption, uterine
rupture, acute catastrophic critical illness— e.g., amniotic
uid embolus (AFE), disseminated intravascular coagula-
tion (DIC), maternal cardiopulmonary arrest).4 e CD
urgency classication should not to be confused with the
American three- tier electronic fetal monitoring (EFM)
PRECISE DEFINITIONS:COMMUNICATING
CLINICAL URGENCY AND ENHANCING
RESEARCH
One- third of the nearly four million annual births in the
United States occur via CD.1 e proportion of CDs conducted under true “STAT” emergent conditions is uncertain,
perhaps because of variation in the denition of “emergency
CD” (EmCD).2 Aclassication scheme developed by Lucas
et al.,3 and subsequently adopted nationally in the United
Kingdom, tightly links the urgency of CD to the level of maternal or fetal physiologic compromise.4 e scheme addresses
the clinical importance of unambiguously communicating the
perceived urgency of CD in order to reduce misunderstanding
among healthcare team members. It also facilitates quality outcomes research regarding the eect of timely delivery for life-
classication scheme.5 “Category” refers to urgency classi-
cation throughout this chapter.
Further categorization of fetal bradycardia classies
underlying pathologies into irreversible (cord prolapse, placental abruption, uterine rupture, preeclampsia, and failed
instrumental delivery), potentially reversible (iatrogenic
uterine tachysystole, postneuraxial anesthesia, aortocaval
compression), or unknown.
2,6
In one study, only 39 of 236
(16.6%) Category 1 CDs for fetal bradycardia in singleton pregnancies were deemed to have irreversible causes
and there was an inverse relationship between cord arterial
blood gas parameters and bradycardia- to- delivery interval in this group.6 is correlation was not observed in the
other two groups (reversible and unknown), nor did those
cord blood gas parameters correlate with cesarean decisionto- delivery intervals.
threatening conditions.2 ere are four categories of urgency:
• Category 1:Immediate threat to the life of the woman
orfetus
LOW BUT REAL INCIDENCE OFSTAT CD:SAFE
CONDUCT OFGENERAL ANESTHESIA IS
ANESSENTIALSKILL
• Category 2:Maternal or fetal compromise that is not
immediately life threatening
• Category 3:No maternal or fetal compromise, but
requiring early delivery
• Category 4:Delivery timed to suit woman orsta
Several investigators have used rigorous classication
of CD urgency in reporting the incidence of Category
1 CDs and the use of general anesthesia for those cases.
Over a 4- year period (2000– 2004) with 4,158 CDs at a
tertiary academic center, 324 (8%) were urgency category
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1.Atotal of 144 (44%) of these STAT CD surgeries were
with general anesthesia (GA), either as the primary technique (115 cases, or 80%) or as a secondary rescue technique for failed neuraxial anesthesia (29 cases, or 20%).7
Another report from a tertiary obstetrics center identied
114 “crash” CDs in a 1- year period, which represented
3.4% of 3,371 cesareans, and 0.7% of the total 16,267
deliveries over a 1- year period.8 Six years later, the same
hospital reported similar results, nding 98“crash” CDs
(2.7% of all CDs).9 ree indications— fetal bradycardia,
cord prolapse, and abruption— accounted for 87%8 and
95%9 of cases, respectively. General anesthesia was used in
roughly 90% of cases across both studies. Another large
academic center reported on 236 Category 1 CDs, representing 5.7% of all CDs, and 0.9% of 26,028 deliveries
in a 3- year period.6 In a related study, nearly half of 1,095
CDs performed with GA reported from 13 Australian
hospitals during an 18- month period (2005– 2007) were
classied as Category 1.10 In a series of 6,393 CDs over
an 8- year period at an academic center, 851 (13.3%) were
conducted under GA, 676 of which were performed with
GA for reasons other than failed attempt to perform neuraxial anesthesia.
11
In the late 1980s, risk of maternal anesthetic death was
reported to be 17 times greater with GA than with regional
anesthesia.12 is risk ratio has steadily declined to 6.7 in
the early 1990s, and 1.7 during 1997– 2002.13 ese analyses, based on death certicate data, lacked access to confounding factors, such as serious maternal comorbidity or
urgency of surgery. National maternal mortality data from
the United Kingdom are accepted as providing unequivocal evidence of superior safety with regional anesthesia
compared with GA, and form the basis for quality indicators.14 Arecent analysis of 257,000 deliveries, including
5,332 GA cases from 30 American institutions, from 2004
to 2009, used rigorous methods to examine outcomes, and
demonstrated a high degree of safety of GA for CD.15 e
vast majority of severe anesthesia complications in this
report occurred among parturients undergoing neuraxial
While the incidence of dicult and failed intubation is
known to be signicantly higher in parturients than in nonpregnant patients,
10,25,26
the outcomes following dicult
and failed intubation appear to have improved in recent
decades, possibly due to implementation of failed tracheal
intubation algorithms27 and introduction and use of supraglottic airways as primary rescue devices.
10,26– 28
With this
evolving knowledge regarding safety outcomes dierences
between GA and neuraxial anesthesia, providers must look
beyond the single issue of airway management when considering the optimal technique for STAT CD— GA may be
the best choice in some situations.
29
Despite the improved safety of GA in parturients, most
providers prefer to use neuraxial anesthesia during CD for
a variety of reasons.29 General anesthesia is a more complex
technique, involving more steps and drugs than neuraxial
anesthesia. It drastically alters the mother’s experience of
childbirth— she oen is whisked to the OR and submitted
to bladder catheter insertion, abdominal prep and drape,
preoxygenation via facemask, and the din of a large team
of providers in crisis mode, all while wide awake, fearing for
her baby’s life and/ or her own. ese are her last recalled
moments before GA is induced. Her partner and family are
usually not invited to the delivery, le behind to await news
of the outcome of the emergency surgery. Also, GA delays
mother– newborn bonding and can impact postoperative
analgesia.
In summary, GA is oen the anesthetic technique of
choice in STAT EmCD, with benets of reliability, speed,
and, in most cases, safety. ough overall quite rare, when
severe anesthetic complications or mortality do occur,
hypoxemia and/ or pulmonary aspiration of gastric contents are the typical causes, and substandard care is nearly
always involved,17 mandating expert airway management
and clear team communication during emergent conditions. Maintaining excellent airway management skills
(through practice and/ or simulation) and ready availability
of advanced airway equipment on the labor and delivery
unit are essential.
techniques. Overall, maternal death is rarely attributed to
complications of anesthesia, and most oen to maternal
coexisting illness.
16,17
Recent analyses of litigation claims
associated with obstetric anesthesia in the United States
REDUCE THENEED FORGA BYREDUCING
THENEED FORSTATCD
and United Kingdom conrm a high representation of
complications associated with neuraxial techniques.
Additionally, similar closed claims analyses highlight the
role that delays in anesthesia administration plays in neonatal death and brain damage.18 e variation in practice
around the world provides yet another perspective on safety
of GA for CD.
20– 24
18,19
One approach to avoiding GA for STAT CD is to reduce
the number of STAT CDs. Obstetric conditions prompting STAT CD oen do not occur suddenly, without forewarning.30 Concern for fetal asphyxia oen occurs in the
setting of known risk factors (preeclampsia, diabetes,
postdates, multiple gestation, abnormal placentation, fetal
STAT CAESAREAN DELIVERY 309
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growth restriction) or clinical evidence (nonreassuring
EFM during contractions; low biophysical prole score;
abnormal vascular sonographic indices) of uteroplacental
insuciency with associated diminished margin of safety
for fetal oxygen delivery. In such situations, the anesthesiologist must monitor for, prevent, and/ or correct the neuraxial anesthesia- induced cascade of maternal hypotension,
impaired fetal oxygen delivery, and fetal decompensation
that may prompt STAT CD. Early recognition of fetal
compromise and institution of in utero resuscitation measures (increase maternal FiO2; ensure ventilation; lateral
position to alleviate aortocaval compression;
31,32
correction
of hypotension with phenylephrine; uterine relaxation—
discontinuing oxytocin, administering tocolytics)33 may
interrupt this cascade. e anesthesiologist should actively
participate in in utero fetal resuscitation, especially when it
is associated with hypotension during neuraxial anesthesia.
REDUCE NEED FORGENERAL ANESTHESIA
DURING A STATCD
preexisting continuous epidural for surgical anesthesia in
time for immediate operative delivery.7 Several attributes of
labor epidural analgesic performance help to predict success
or failure in converting it to a CD anesthetic block.
7,11,34– 36
e need for epidural redose for inadequate labor analgesia,
the number of top- up doses needed, and higher labor pain
scores during the 2 hours before top- up for CD are leading risk factors for failure of successful conversion. Another
risk factor is a cesarean classied as Category 1. Other
potential contributing factors that have been investigated
are duration of labor epidural analgesia, use of combined
spinal- epidural, and obesity; however, the impact of these
to overall risk is unclear.34 In women without preexisting epidural, “rapid sequence spinal anesthesia” may be an
option in well- practiced hands and with experienced team
familiar with this technique.
7,37,38
Despite skill and experience with neuraxial anesthesia for STAT CD, the urgency
of Category 1 CDs oen compels the use ofGA.
7
Importantly, maternal physiologic parameters falling
outside acceptable ranges may signify decompensation well
before progression to a life- threatening status.17 Obstetric
early warning systems require front- line providers to notify
A number of obstetric and maternal factors may place the
parturient at increased risk for STAT CD, including fetal
growth restriction, abnormal fetal surveillance parameters,
postdates, diabetes, multiple gestation, and trial of labor aer
cesarean. In order to reduce the risk of needing GA for STAT
CD, the astute obstetric anesthesiologist seeks out patients
with these risk factors and considers the followingitems:
qualied providers of such physiologic parameter deviations,
triggering a focused assessment and action plan and hopefully avoiding development of a life- threatening crisis.
17,39,40
Similarly, an obstetric emergency team rapid communication
alert system has been implemented to recruit the anesthesiology team in a timely fashion to permit rapid preparation
of the parturient for GA or successful conversion of epidural
labor to CD anesthesia.41 When summoned for STAT CD,
• Early assessment of parturient
• Development of plans for potential emergentCD
• In cases of high risk for STAT CD, encourage early
several factors combine to determine anesthetic options and
optimal technique for the mother. It may be useful for L&D
units to develop and implement an emergency protocol or
algorithm to guide management of EmCD (Figure44.1).
neuraxial analgesia, especially when hazards of
emergency GA are signicant (e.g., suspected dicult
intubation, severe hypertensive disease)
11,30
• Detailed discussion with patient, including informed
consent
• Collaborative multidisciplinary planning with OB
providers (obstetrician, midwife, nurse), including
special request to have low threshold to call should
maternal or neonatal condition change.
WHEN EMERGENCY GENERAL ANESTHESIA IS
NECESSARY, BE FULLY PREPARED
Ultimately, the eventual need for emergent GA is inevitable,
so the anesthesiologist’s ability to rapidly and safely conduct
GA for STAT CD is essential. Preparation and readiness are
key, and include eective systems of early notication, ready
availability of equipment and personnel, standard proto-
cols, and collaborative teamwork. Operating rooms that
Absent immediate threat to maternal and/ or neonatal
life, non- STAT EmCDs (category 2, 3, 4) aord time for
neuraxial anesthesia as an option. e urgency of Category
1 CD does not rule out regional anesthesia, however. If
notication is timely enough, a rapid bolus can convert a
are dedicated to operative obstetric care should be readied
to immediately receive a STAT CD case at all times. us,
a policy of cleaning and preparing the room immediately
aer a case nishes is recommended. e anesthesiologist
should consider a checklist (Box 44.1) to ensure full room
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311
Urgency Category 1 CD
Epidural catheter in situ?
Yes No
Performing well?*
Yes
Sufficient time to
augment block?
Yes
Expeditious epidural block
augmentation
Assess block in OR: ≥ T10 bilateral,
surgical sensory level, plus higher
sensory analgesic level?
No
Prepare
for GA
§
Yes
Proceed with CD,
but prepare for
backup GA,
if needed
Patient insensate to pre-
incision skin-clamp test?
No
No
No
Yes
Yes
Transfer to OR,
prepare for GA or RSS;
Sufficient time for RSS?†
Yes
Perform RSS
while preparing for
backup GA‡
Successful RSS ≤
60 seconds?
No
Proceed with GA
Proceed with
incision & delivery
No
*Judgment is based on familiarity with patient, labor analgesic course (including episodes of inadequate
analgesia, block asymmetry, number of top-up doses or corrective interventions), and presence of bilateral,
symmetric sensory block
§Incremental, fractionated administration, assessing carefully for high block or systemic toxicity. Rapid-onset
epidural drugs are chosen, such as 2% lidocaine/epinephrine (+/–NaHCO
†Anesthesiologist may advocate this, but should defer to obstetrician’s judgment and reevaluation of urgency
indication.
‡Most skilled proceduralist performs RSS, while other team member(s) prepare(s) for backup GA.
CD: Cesarean Delivery; GA: General anesthesia; RSS: Rapid sequence spinal anesthesia
Figur e4 4.1 An anesthesia management decision algorithm to help facilitate effective, timely, and safe administration of anesthesia for STAT cesarean
delivery. When threat to fetal or maternal life demands immediate delivery, key decision branch points include presence or not of effective preexisting
labor epidural analgesia, likelihood of timely enough extension of that epidural block, and time sufcient to perform rapid- sequence spinal anesthesia.
preparedness. Given the increased risks of dicult/ failed
intubation and potential complications, immediate access
to advanced airway devices, ideally on a designated emergency airway device cart, are essential.42 (Of note, a dicult
airway algorithm can be found in Figure 54.2 in the chapter
“Diculty Airway:Special Considerations in Pregnancy.”)
Timely notication of and response by the anesthesiologist is vital for Category 1 cases. Even an extra minute gives added time to conduct assessment, examination,
discussion, preparation, and reassurance. is should
be welcomed, encouraged, or better yet, expected and
audited.30 Aminute or two can also make the dierence
between failure and success in augmenting (“topping- up”) a
labor epidural to eect surgical anesthesia in time. Conduct
of anesthesia for STAT CD (Box 44.2) is predicated on
several fundamental physiologic principles. orough
denitrogenation/ preoxygenation helps to prevent maternal hypoxemia owing to physiologic changes (high oxygen
consumption, diminished FRC) upon inducing GA. Most
recommend prophylaxis against regurgitation of stomach
), or 2–3% 2-chloroprocaine.
3
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advised. Convincing improvements in decision- to- delivery
BOX 44.1 OB OR READINESS CHECKLIST
This checklist is an example of steps that can be per-
formed to ensure operating room readiness for safe anes-
thesia initiation during STAT cesarean delivery.
• Machine is turned on, machine checkout procedure
completed.
intervals (43% reduction) and composite adverse neonatal
outcome scores (due primarily to respiratory morbidity,
cord pH, sepsis, and 5- minute Apgar scores) were reported
aer implementation of a coordinated program designed
to decrease delays in emergent CDs for non- reassuring
EFM at a Tel Aviv academic center.47 Key program elements mirrored the Plan- Do- Study- Act cycle of quality
• Monitors:ECG leads on bed, cuff, pulse oximeter,
functioning capnograph, temperature probe/
esophageal stethoscope
• Functioning suction with rigid Yankhauerdevice
improvement: (1) documenting precise time intervals,
(2) preference for GA in parturients without preexisting
neuraxial anesthesia, (3) interprofessional team debriefs
aer each case to identify delaying obstacles, and (4)generation of case- specic strategies targeted to overcome
• Circuit “tube tree” inplace
• Preparedness for “rapid sequence spinal”— spinal
anesthesia kit, sterilegloves
each obstacle in subsequent cases. Also emphasized were
unambiguous communication of urgency, transfer to OR as
soon as possible aer decision, and abdominal disinfection
simultaneous with bladder catheterization. e rate of GA
• All routine drugs stocked and available
• Routine airway equipment— oral airways, laryngoscope
handles (including one short handle), blades,
endotracheal blades, intubating bougie, supraglottic
airway devices (e.g., laryngeal mask airway; iGel;
ProSeal)
increased from 24% to46.2%.
Recent reports have described benets of simulation
training for EmCD,
48– 52
although actual data regarding
improved maternal or neonatal outcomes are lacking.
Anesthesiology residents’ technical and nontechnical skills
were improved as assessed by simulation 2 and 8months
following didactic and simulation sessions managing GA
• Emergency airway cart with indirect laryngoscope
device(s) (e.g., McGrath laryngoscope; berscope);
cricothyroidotomykit
• Orogastrictubes
for CD.
obstetric critical events report improved performance
during in situ team drills aer simulation training,51 and
identication of common, recurring errors in team man-
48,49
Related studies of simulation of non- CD
agement of various obstetric emergencies.52 Apromising
• Intravenous set- up:crystalloid, Y- set IV tubing,
uidwarmer
• Bump for left uterinetilt
• Emergency protocol reminder cards— (e.g., procedure
time out; EmergencyGA)
alternative to resource intensive traditional high- delity
simulation being implemented and studies include unannounced in situ simulation and team training on the L&D
53– 56
unit.
contents (metoclopramide; adequate anesthetic depth;
rapid sequence induction, including succinylcholine)
and pH neutralization of stomach contents (premedication with sodium citrate, H2 blocker). Lack of evidence
of benet from application of cricoid pressure has been
noted in recent years,
excess or inadequate application of pressure.44 Although it
is still recommended by many, it is no longer universally
practiced.
45,46
e urgency of a life- threatening situation requiring
coordinated, time- pressured intervention risks human
errors (omitting steps, inaccurate assessments, miscommunication), so protocols and collaborative practice are
312 SECTION A. MATERNAL COLLAPSE
43,44
as have potential drawbacks of
FINALLY, A REMINDER TOREMEMBER
THEMOTHER AND HERBABY
Researchers in Sweden have explored the psychologically
traumatic eects experienced by parturients who have
experienced EmCD.
57– 61
Using validated psychological
assessments for posttraumatic stress disorder (PTSD) and
posttraumatic stress symptoms (PTSS), as well as structured interview methods, they found a signicant incidence
of PTSS 2– 6months aer EmCD, especially intrusive recollections and re- experiencing of the trauma in distressing
ways. At particular risk were immigrants, socially underprivileged, women with prior EmCD or vacuum delivery, and those who experienced intense fear of childbirth.
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BOX 44.2 CONDUCTING GA FORSTATCD
This is an example of an observable checklist of the many steps that are essential in rapidly transferring the urgency category 1 CD
parturient to the OR, anesthetizing her, and performing emergent cesarean delivery.
Mobilize:Move rapidly to the patient, recalling/ reviewing patient information from prior anesthesiology consultation, if done. If not
covering OB alone, mobilize/ deploy yourteam.
History:Obtain essential information from obstetrician, midwife, and/ or nurse. From patient:
• Last oralintake
• Allergies and medications other than vitamins? Blood thinners?
• Signicant medical problems? [e.g., heart, lung, abnormal bleeding]
• Prior general anesthesia? If so, any problems? Family historyofMH?
PhysicalExam
• Vital Signs— asknurse
• Observe:Presence of intravenous cannula? Obesity?
• Airway assessment and auscultatelungs
• If considering “rapid sequence spinal” (RSS), palpate lumbarspine
Anesthetic Plan Discussion: Use lumbar epidural already in place, place RSS,orGA
Transfer toOR Table and Position
• Full lateral position if RSS is planned
• Otherwise, left uterine tilt, >30° (wedge bump under Rt buttock, not ank!)
• Optimize for tracheal intubation
• Recheck FHR, if indicated
Immediate PreparationsforGA
• Administer 30 mL sodium citrate, PO (consider H
• Oxygen (ask patient to hold it tightly to face and breathe deeply)
• Place monitors, in order:NIBP (cycle immediately), SpO
• Nurse: applies SCDs, insert Foley bladder catheter, performed abdominalprep
• Obstetrician:places surgicaldrape
• Time- out procedure is conducted rapidly
- blocker and metoclopramide,IV)
2
, ECGleads
2
Conduct ofGA and Surgical Delivery
• GA is induced in RSI (State:“I am inducing anesthesia. Iwill tell you when you can start.”)
• FiO
1.0 + 1 MAC end- tidal volatile agent anesthetic
2
• After delivery, d/ c volatile agent, and administer:Opioid +/ - nitrousoxide
• + / - low dose volatile agent versus propofol infusion +/ - midazolam
• + / - nondepolarizing neuromuscular blocker
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BOX 44.2 CONTINUED
• Administer oxytocin and antibiotics, if the latter had not been administered
• Insert orogastric tube (OGT) and evacuate stomach contents as soon as possible
• Consider repeating a full, less time- pressured, and deliberate time- out procedure
Emergence
• If NDNMB used, reverse and assess residualNMB
• When surgery is completed, apply suction to OGT, andremove
• Extubate trachea when patient is fully emerged
• Transfer to recovery room, ensuring physiologic stability and adequate analgesia
• Arrange for adequate post- op analgesia orders, in absence of long- acting neuraxial opioid.
Women with PTSS more oen viewed their providers as
CASE- BASED LEARNING DISCUSSION
unprofessional or nervous, more oen reported their birth
experience as generally negative, had feelings of disappointment or shame in themselves, experienced protracted
fatigue, and feared intensely for their baby’s life. Measures
have been recommended to help detect women at risk,62
including
• Careful history to detect prior traumatic events or
“failures”
• Good communication during the delivery, to provide
1. If, based on airway assessment, you strongly suspect
diculty with intubation, how does this aect
yourplan?
2. What are the advantages and disadvantages of
“rapid sequence spinal” if you anticipate airway
management diculty? How would you go about
quickly determining whether “rapid sequence spinal” is
appropriate? What conversation would you have with
the obstetrician?
the mother with needed sense of control, foster trust,
and oer choices, as much as is possible
• Ensuring excellent pain control,and
• Engaging in discussion with her regarding the birth
experience.
CONCLUSION
Conduct of GA for STAT CD carries risk for the parturient.
Airway management approaches and skills using advanced
airway rescue devices mitigate those risks, but maintaining
individual and team skills is important. Key to safety is a
state of readiness for emergencies, well- developed routines/
protocols, and excellent teamwork and communication
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