GA for Caesarean Section

Selected Guideline Examples Date
Aberdeen Maternity Hospital March 2017
Wider Scope
  • Guidelines may include information, or refer to separate guidelines concerning: pre-eclampsia; Category 1 CS; intrauterine resuscitation; failed intubation
General Points
  • Pre-op assessment of airway
  • Use of antacid prophylaxis
  • Rapid sequence induction with importance of adequate preoxygenation emphasised
  • Measures to avoid awareness
  • Advice re extubation
  • Analgesia
  • Suggestion to reduce hypertensive response to intubation
We Liked
  • Clear structured guideline with the steps arranged chronologically (St George's, Leicester)
  • Discussion of pros and cons of GA section (Leicester)
  • Reminder of intra-uterine resuscitation to prevent a potential GA (Aberdeen)
  • Details on how to preoyxgenate, including specifying high oxygen flow rate and mention of "flat-topped" capnography to guarantee an adequate seal during preoxygenation (Aberdeen)
  • Details on how much cricoid pressure to apply
  • Warning to avoid excessive cricoid pressure (Aberdeen, Leicester)
  • Difficult intubation hints (Nottingham)
  • Mention of positioning in obese women (ramping)
  • Never to reach for an unfamiliar device in an emergency (Nottingham)
  • Specifying desired end tidal CO2 before delivery (4.0 kPa)
  • Catheterisation before starting GA (Coventry)
  • Importance of ensuring patient is sufficiently anaesthetised before skin incision (Aberdeen)
  • Comparison of nitrous oxide to inhaled remifentanil! (Aberdeen)
  • Importance of calling for help early
  • Analgesia options being discussed including blocks (Leicester)
  • Blood loss estimation if required with hemocue (Leicester, Nottingham)
  • Importance of proper recovery and immediate availability of anaesthetist (Leicester)
  • Importance of monitoring suxamethonium block and using nerve stimulator especially following use of magnesium (Coventry, Nottingham)
We Didn't Like
  • Didactic doses of induction agents
  • No mention of rocuronium and suggamadex as alternative strategies for muscle relaxation
  • To give 1L of iv fluid (could be detrimental in severe pre-eclampsia)
  • Withdraw inhalational agent if post-partum haemorrhage / failure of uterine contraction, replace with alternative anaesthesia (Nottingham)
  • 3 mg dose of alfentanil to obtund hypertensive responses of intubation is not supported by literature
  • 0.5mcg/kg is too small a dose to blunt the cardiovasvascular response to intubation (1mcg/kg more appropriate (AMH)
  • Avoiding fentanyl use due to effect on neonate. (Aberdeen)
  • Lack of references – all guidelines mandate adequate references
  • The suggestion to use "the same post-operative analgesic prescription as for regional anaesthesia' which underestimates the contribution of intrathecal/epidural opioid in those mothers who have had a regional technique
Not Sure
  • FiO2 1.0 before delivery if there is fetal distress, with increased inhalational agent to make up for withdrawal of N2O
  • Advice to see normal capnograph trace during pre-oxygenation. This is very desirable to test the function of the (sidestream) sampling. However, with high fresh gas flow rates the exhaled CO2 concentration will be low or unregistered
  • Of using at least 6L/ min of fresh gas flow at all times during a GA for LSCS to prevent awareness (Aberdeen)
  • Use of etomidate as an induction agent ( Nottingham)
  • Some recommend the 50:50 mix of oxygen and nitrous oxide while others do not (St George's)
  • Issues around consent for TAP blocks at the end of the procedure (Aberdeen)
  • Could mention QL2 blocks as an alternative to TAP blocks
Other
  • One unit specifies practice related to presence of partner; this is no doubt ‘common practice’ in some units but not specified in these GA guidelines (presence of partners surveyed in OAA survey #28)
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