Obstetric Anesthesia Practice Significantly Evolved: A Field for Cesarean Delivery Parturient for the Provision of Safe Anesthesia in Urgent Circumstances

General anesthesia and Obstetric Anesthesia is the gold standard for a cesarean section but there are some cases where general anesthesia is unavoidable. The use of general anesthesia for cesarean delivery has decreased in recent years due to the widespread use of neuraxial techniques. The choice of anesthesia techniques for cesarean delivery depends on several factors, including the patient’s psychology and the attending physician’s experience. It is chosen because of its safety profile and its benefits to the mother and fetus. It may be indicated due to emergency, maternal refusal of regional techniques, or regional contraindications. Major complications include failed intubation, gastric content aspiration, and increased bleeding risk. This study aims to evaluate the impact of a newly launched team on obstetric anesthesia practice.

Effect of Body Mass Index on Anesthesia Characteristics and Vasopressor Requirements during Spinal Anesthesia for Elective Cesarean Section

Background: There is a debate about the dose of hyperbaric bupivacine for spinal anesthesia for cesarean delivery in obese parturients. While it is concessive that the dose of spinal bupivacine is reduced in pregnant compared with non-pregnant parturient due to many factors. But it is still controversial whether local anesthetic should further reduce in obese patients or not. In this perspective, observation study, we tested the influence of BMI on vasopressor requirements and block height. Methods: Three groups of 40 parturients, group A (Body mass index (BMI) 2), group B (BMI 30 - 45 Kg/m2) and group C (BMI > 45 kg/m2) requiring elective cesarean section were recruited all patients received 12.5 mg subarachnoid hyperbaric bupivacine combined with 20 ug fentanyl. Dermatomal levels were assessed after subarachnoid injection using touch sensation at 2 minutes interval for first 10 minutes then every 5 minutes. Vasopressor requirements in the first 45 minutes after subarachnoid injection, and maximum block heights using touch sensation were assessed as primary outcomes. Secondary outcomes were extent of motor block (peak flow rate), technique difficulty (number of attempts), maternal side effects and neonatal outcomes. Results: There was no significant difference in mean blood pressure (MBP) between group A and B but the difference was significant in group C in relation to other two groups, mean number of hypotensive episodes was significantly higher in group C than group A, B with no significant difference in incidence between group A and B (P Conclusion: Sensory testing using touch modality to detect extent of anesthesia, showed at 25 minutes after spinal anesthesia induction, significantly higher level in group C than the other two groups. Vasopressor requirements during the first 45 minutes of spinal anesthesia were not different between group A, B but significantly higher in group C. Time for regression of anesthesia was longer in group C, which may be helpful regarding longer surgical time. Single shots spinal anesthesia of 12.5 mg hyperbaric bupivacine produce clinically equivalent effect in parturients with BMI 2 with no need for dose reduction but caution and dose adjustment recommended in parturients with BMI > 45 Kg/m2.

Psychotic due to bath salts and methamphetamines:emergency cesarean section under general anesthesia

The use of ＂bath salts＂ or other new psychoactive substances,otherwise known as ＂legal highs＂,is increasing.Illicit drug use during pregnancy is not uncommon.Nevertheless,literature reporting bath salts and their effect on pregnancy is scant.Besides,there seems to be no literature about bath salts and conduct of general anesthesia.This case report describes a general anesthetic for the surgical delivery of an infant to a woman under the acute influence of bath salts and methamphetamines.

Comparison the effect of ephedrine and phenylephrine in treatment of hypotension after spinal anesthesia during cesarean section

Background and Objective: The effectiveness of ephedrine and/or phenylephrine, in treatment of hypotension secondary to spinal anesthesia for cesarean section and their effects on fetal/neonatal outcome were studied. Methods and Materials: Sixty healthy parturients were randomly assigned to two groups;group E (n = 33) received boluses 5 mg/ml increments ephedrine and group P (n = 27) received a boluses of phnylephrine 100 μg/ml increments for treatment of hypotension after spinal block during cesarean section. Changes in maternal blood pressure and heart rate, and incidence of nausea-vomiting, neonatal Apgar score at 1 and 5 minutes of delivery, and umbilical arterial blood gas values were recorded. Results: There were no differences in treatment of hypotension following sympathectomy after spinal block with two drugs. Neonatal outcome was similar in two groups. There were not significant differences in umbilical arterial values in two groups. Conclusion: Ephedrine and phenylephrine are both effective vasopressores for treatment of hypotension associated to spinal block during cesarean section without adverse effects on infants/neonates.

General Anesthesia for Cesarean Section in a Pregnant Woman with Immune Thrombocytopenic Purpura (ITP): A Case Report and Review of the Literature

Background: Management of immune thrombocytopenia (ITP) during pre- gnancy can be challenging, particularly by identifying a threshold for safe administration of neuraxial/general anesthesia and minimizing postpartum hemorrhage. There is controversy over the safety of cesarean section (CS) in ITP patients. In this case report, we discuss general anesthesia management in a patient with ITP with severe thrombocytopenia. Case Presentation: A 28-year-old female with relapsed/refractory ITP and severe thrombocytopenia underwent general anesthesia and emergent cesarean section with successful outcomes and minimal bleeding. Platelet counts before CS were 5000 × 109 L, the patient received 1 unit of platelets before the procedure and 1 unit of platelet and tranexamic acid 500 mg was injected slowly during the procedure. No evidence of bleeding and no complications were observed in the patient or newborn. Conclusions: In an emergent circumstance, general anesthesia and cesarean section procedure were performed safely in a patient with severe thrombocytopenia, no hemorrhagic complications were seen for this patient or neonate. Objective of This Manuscript: To share our experience of a safe emergent CS procedure and general anesthesia in a patient with severe thrombocytopenia. Our experience may guide the management of ITP patients in emergent delivery circumstances.

Pregnant women’s awareness and acceptance of epidural anesthesia and its influence on cesarean section rate control in China: A qualitative study

Background: Epidural anesthesia, as an effective pain relief method, could be viewed as an attempt to encourage vaginal delivery and control cesarean section. Increased demand caused by psychosocial factors such as fear of childbirth and labor pain is supposed to be one predictable drive of high cesarean section rate in present China. Little qualitative information on women’s awareness and perceptions of epidural anesthesia was found, but conscious efforts should be focused on this part to help generate policy-making priority. Methods: This study was carried out under an exploratory descriptive design in Bao’an Maternity and Child Health Hospital. Those interested in participating would be invited to focus group discussion or individual interview according to a semi-structured open-ended guide after collecting the participants’ demographic characteristics. The thematic content analysis approach was used for data analysis. Results: Five major themes were identified: 1. the sources to gain information on epidural anesthesia;2. clinical impact;3. social impact on awareness;4. association between epidural anesthesia and cesarean section;5. attitudes and questions about the current service implementation. Discussions: The interplay between pregnancy knowledge, socio-economic conditions, social support, insurance policy environment, women’s judgment of health care quality influences the ways women acknowledge and utilize epidural anesthesia service. Conclusions: As maternal requested CS due to low pain tolerance emerges gradually, natural labor with epidural anesthesia is a more suitable childbirth option, which is also expected to function in reducing CS rate by service-providers and administrators in the health departments of China besides building up a pain-free labor environment.

Anesthesia management for cesarean section in a pregnant woman with odontogenic infection:A case report

BACKGROUND In recent years,people have paid more attention to oral health with the development of stomatology.Due to the various physiological changes during pregnancy,such as changing hormone levels and immune functions,oral diseases have a high incidence during pregnancy,and the prevention and treatment of oral diseases have also received the attention of both dentists and obstetricians.However,the anesthetic management of pregnant patients with oral disease,especially severe maxillofacial infections,and patients who need surgical treatment or have obstetric emergencies and need to terminate their pregnancy is not clear.CASE SUMMARY This article describes a parturient patient with a severe masseteric space infection who had an emergency cesarean section.CONCLUSION This case report aims to discuss the important anesthetic considerations for these patients.

Effects of ephedrine, phenylephrine and norepinephrine prevent hypotension after spinal anesthesia in cesarean section and comparison of effects on newborns

Objective: To compare the preventive effect of ephedrine, phenylephrine and norepinephrine on hypotension after lumbar anesthesia in cesarean section and their effects on newborns. Methods: 25 cesarean section women in our hospital from December 2016 to January 2018 were selected and divided into three groups according to different surgical medication, namely, ephedrine group (n=40), phenylephrine group (n=45) and norepinephrine group (n=40). Then the vital signs, neonatal blood gas analysis, neonatal Apgar score, adverse reactions of the three groups were compared. Results: The HR at T0~T3, and SBP and DBP at T0 and T1 had no difference among three groups (P>0.05). The HR, SBP and DBP at T3 ranking in a descending order was norepinephrine group, ephedrine group and phenylephrine group (P<0.05). The PCO2 and PO2 had no difference among three groups (P>0.05). The pH ranking in a descending order was norepinephrine group, ephedrine group and phenylephrine group (P<0.05). The SpO2 ranking in a descending order was phenylephrine group, ephedrine group and norepinephrine group (P<0.05). The Apgar score at birth in ephedrine group and norepinephrine group was significantly lower than that in phenylephrine group (P<0.05), while the Apgar score at post-birth 5 min and 10 min had no difference among three groups (P>0.05). The incidence of hypertension, gastrointestinal reaction, hyperhidrosis and palpitation in the phenylephrine group was significantly lower than that in the norepinephrine group (P<0.05). Conclusion: The phenylephrine and norepinephrine have no difference on the preventive effect of hypotension after spinal anesthesia in cesarean section, while safety of norepinephrine for puerpera and neonates is higher.

Effect of combined spinal and epidural anesthesia on the level of pain media, stress indicators and inflammatory factors in patients undergoing high altitude cesarean section

Objective: To discuss the effect of combined spinal and epidural anesthesia on the levels of pain media, stress indicators and inflammatory factors in patients undergoing high altitude cesarean section. Methods: Eighty patients who underwent cesarean section in our hospital from January 2017 to April 2019 were enrolled in the hospital. They were divided into two groups according to the patient's anesthesia. Fourty patients receiving epidural anesthesia were included in the control group, and another 40 patients received lumbar stiffness. The combined anesthesia patient was included in the observation group. Changes in pain mediators [Serum neuropeptide Y (NPY), endorphin (β-EP), substance P (SP)], stress indicators [Serum cortisol (Cor), C-peptide (C-P), advanced oxidative protein product (AOPP)], inflammatory factor levels [Hypersensitive C-reactive protein (hs-CRP), tumor necrosis factor-alpha (TNF-α)], and immunoglobulin levels [Serum IgA, IgG, IgM] were compared between the two groups. Results: Before anesthesia, there were no significant difference in pain media, stress index, inflammatory factor level and immunoglobulin level between the two groups (P>0.05). At 12 h after operation, the two groups of patients were NPY, β-EP, SP, Cor. The levels of C-P, AOPP, hs-CRP and TNF-α were higher than those before operation (P<0.05). The levels of IgA, IgG and IgM were lower than those before operation (P<0.05). Among them, observation group NPY, β-EP, SP, Cor, C-P, AOPP, hs-CRP and TNF-α were significantly lower than those of the control group (P<0.05). The serum levels of IgA, IgG and IgM were significantly higher than those of the control group (P<0.05). Conclusion: Combined spinal and epidural anesthesia can more effectively alleviate maternal pain in high altitude cesarean section, more effectively reduce the inflammatory stress response of patients, promote the humoral immune function of patients, and is beneficial to the early recovery of maternal postoperative, and has high clinical value.

A Comparison of Spinal Anesthesia with Levobupivacaine and Hyperbaric Bupivacaine for Cesarean Sections:A Randomized Trial

Purpose: Levobupivacaine showed a lower risk of cardiovascular and central nervous system (CNS) toxicity than bupivacaine which is the most popular local anesthetic agent in obstetric practice. The aim of this study was to investigate the clinical efficacy of levobupivacaine compared with hyperbaric bupivacaine for spinal anesthesia for cesarean section. Methods: 60 pregnant women in ASA I - II group scheduled to have elective cesarean operation were allocated into the study. Patients were randomly divided into two groups. The combinations 10 mg levobupivacaine (0.5%) + fentanyl (15 μcg) for Group LF (n = 30) patients, 10 mg hyperbaric bupivacaine (0.5%) + fentanyl (15 μcg) for BF (n = 30) patients were intrathecally administrated a total of 2.3 cc. Sensory and motor block characteristics of the groups were assessed with pinprick and Bromage scale;observed hemodynamic changes and side effects were recorded. Results: The time to reach maximum dermatome for the sensory block, time to regression by two dermatomes and time to regress to T12 dermatome was found to be significantly long in Group BF. It was observed that in Group BF, the evolution of the motor block was faster and lasted longer. Whereas hypotension, bradycardia and nausea were less in Group LF, the need for ephedrine was higher in Group BF (p < 0.05). Conclusion: Since motor block time is shorter, and side effects like hypotension, bradycardia and nausea are less, the combination of levobupivacaine + fentanyl can be a good alternative in cesarean sections.

Vasopressors in obstetric anesthesia: A current perspective

Vasopressors are routinely used to counteract hypotension after neuraxial anesthesia in Obstetrics. The understanding of the mechanism of hypotension and the choice of vasopressor has evolved over the years to a point where phenylephrine has become the preferred vasopressor. Due to the absence of definitive evidence showing absolute clinical benefit of one over the other, especially in emergency and high-risk Cesarean sections, our choice of phenylephrine over the other vasopressors like mephentermine, metaraminol, and ephedrine is guided by indirect evidence on fetalacid-base status. This review article evaluates the present day evidence on the various vasopressors used in obstetric anesthesia today.

Effect of Height Adjusted Dose of Intrathecal Hyperbaric Bupivacine for Elective Cesarean Section: A Study of 2 Different Concentrations

Introduction: Study compare spinal anesthesia using hyperbaric bupivacine (0.5% - 0.75%) between fixed dose and height adjusted dose during elective cesarean section. Methods: Hundred parturients who had given their consent and were scheduled for elective cesarean section under spinal anesthesia, were divided into four groups—first group received 0.5% hyperbaric bupivacine fixed dose, the second group received 0.5% hyperbaric bupivacine in a dose adjusted to the height, the third received 0.75% hyperbaric bupivacine fixed dose, the fourth group received 0.75% hyperbaric bupivacine in a dose adjusted to height. The anesthesia onset time, haemodynamic changes, side effects and fetal outcome observed. Results: Spinal block provide excellent surgical anesthesia in all patients. Anesthesia onset time is longer in adjusted than fixed groups, in 0.5% (5 ± 0.816 vs. 3.84 ± 0.746) (P Conclusion: Adjusting dose of hyperbaric bupivacine (0.5% - 0.75%) to patient’s height, decreases the dose of bupivacine in use, it also provide adequate anesthesia for elective cesarean section with decrease the use of vasopressors, the incidence and severity of maternal hypotention also markedly reduced.

Comparison of a Standard Dose with a Low Dose of Levobupivacaine in Spinal Anesthesia for Caesarean Section

Obstetric anesthesia carries great responsibilities because there are two patients, the mother and the fetus. The purpose of the present study is to compare two doses of Levobupivacaine for spinal anesthesia at elective cesarean section, to determine the best dose that can give mother and fetal hemodynamic stability and a fast anesthesia recovery after the surgery. Method: We conducted a prospective randomized comparative study in 56 patients undergoing cesarean section with spinal dose of Levobupivacaine 6 mg (22 patients) and 10 mg (34 patients), both groups combined with 25 μg of fentanyl. The two doses of local anesthetic were compared with regard to sensory and motor blockade, the need for supplementation epidural, the severity of hypotension and other complications. Result: The 6 mg of levobupivacaine group presents no difference in the incidence of hypotension, bradycardia, nauseas or vomiting compared with the 10 mg of levobupivacaine group, but presents higher incidence of supplementary analgesia and lower mother satisfaction. Conclusions: The combination of 6 mg of levobupivacaine with 25 μg of fentanyl on spinal anesthesia can be an option for short time cesarean section, buy doesn’t present a superior profile in side effects over the 10 mg of levobupivacaine with 25 μg of fentanyl combination with worst maternal satisfaction.

A case of acute urinary retention after cesarean section caused by herpes zoster infection

We experienced a case of acute urinary retention after an elective cesarean section. In this case, an epidural catheter was inserted for the postoperative pain relief, and we had to rule out anesthetic complications including epidural hematoma. After careful investigation, sacral herpes zoster was found to be responsible for urinary retention. Early administration of antiviral agent was started and the outcome was good. As various factors may lead to postpartum urinary disorders, we should be careful not to miss serious complications.

Effects on newborns of applying bupivacaine combined with different doses of fentanyl for cesarean section

BACKGROUND The choice of anesthesia for cesarean section is very important.AIM To compare the effects of applying bupivacaine combined with different doses of fentanyl on newborns after cesarean section.METHODS We randomly divided one hundred and twenty patients undergoing cesarean section into the following 4 groups:group B(bupivacaine group),group BF10(bupivacaine combined with 10μg fentanyl),group BF30(bupivacaine combined with 30μg fentanyl)and group BF50(bupivacaine combined with 50μg fentanyl).The heart rate,mean arterial pressure,block plane fixation time and sensory block time were recorded.Umbilical artery blood was then collected immediately after fetal delivery for blood gas analysis and qualitative detection of fentanyl.Additionally,data on the neonatal 1-min and 5-min Apgar scores,results of umbilical artery blood gas analysis and qualitative detection of fentanyl in umbilical artery blood were recorded.RESULTS Although the mean arterial pressure decreased in all four groups at 3 min after anesthesia,the percentage of the decrease was less than 20%of the baseline.In addition,there were no significant differences in the 1-min or 5-min Apgar scores or the umbilical artery blood gas analysis among the four groups(P>0.05).Moreover,the concentration of fentanyl in umbilical artery blood was qualitatively detected using an ELISA kit,and the results in the four groups were negative.CONCLUSION Bupivacaine combined with fentanyl spinal anesthesia is effective in cesarean section.

Early vs. Delayed Cord Clamping at Full-Term Planned Cesarean Section: A Randomized Study

Objective: In cesarean section (CS), which, early vs. delayed cord clamping is better for neonatal and maternal hematocrit/hemoglobin level is not yet completely determined. This randomized controlled study attempted to determine this issue. Methods: Study population consisted of 64 full-term pregnant women/neonates undergoing planned CS: 32 received early cord clamping (ECC: 15 seconds after birth) and 32 delayed cord clamping (DCC: 90 seconds). We measured and analyzed 1) neonatal hematocrit at the first 24 - 48 hours, and 2) maternal-hemoglobin-change before and after CS. Results: Infants with ECC and DCC showed hematocrit (24 - 48 hours) of 57.47 ± 8.65 vs. 59.54 ± 7.67, showing no significant difference. Also, no significant differences were observed in the change in maternal hemoglobin in two groups. Conclusions: Cord clamping at 15 vs. 90 seconds did not yield neonatal hematocrit change or maternal hemoglobin change. As far as the present data (neonatal and maternal anemia) was concerned, cord may be clamped at 15 seconds in planned term CS.

The Effect of Ginger Capsule on Nausea and Vomiting during and after Caesarean Section under Spinal Anesthesia

Objective: To study the efficacy of ginger on the Nausea and Vomiting during and after Cesarean Section under Spinal Anesthesia. Study Design: Double blind randomized controlled trial. Setting: Department of Obstetrics and Gynecology, Ahvaz University, Razi Hospital. Material and Method: From January 2008 to April 2008, 70 pregnant women underwent for elective cesarean section under spinal anesthesia were randomized received coded drug one hour prior section with 30 ml water. The patients were at term, single pregnancy, uterine and abdominal incision transversal, and spinal anesthesia with lidocain 5%. Patients were matched in two groups by these factors: age, height, weight, BMI, cause of cesarean section, gestational age, hypotention during and after cesarean section, duration of operation and nausea and vomiting in pregnancy. All patients were assessed for severity of nausea by visual analog nausea score (VANS). Frequency of vomiting and need antiemetic drug were evaluated during and 0/5, 1, 2, 4, 6 hours after cesarean section. Results: The results demonstrated the statistically significant differences in severity of nausea and vomiting during cesarean section (p = 0/000). Severity of nausea (p = 0/000) and vomiting (0/046) after cesarean section also was lower in ginger group than placebo group. There were statistically significant differences between two groups for need antiemetic drug during (0/000) and after (0/003) cesarean section. This need was lower in ginger group than placebo group. Side effects caused by ginger were not detected. Conclusion: Ginger has efficacy in decrease severity of nausea and vomiting during and after cesarean section under spinal anesthesia.

Emergency Cesarean Section in a COVID-19 Patient with Antepartum Hemorrhage: A Case Report

Introduction: Perioperative management of patients with corona virus disease 2019 (COVID-19) could be extremely challenging in order to keep the balance between providing optimal medical care and protecting health-care providers from the risk of infection. Also the respiratory effect of COVID 19 could also alter the course and outcome of surgery. Aim: We aim to report a 30-year-old COVID-19 patient who had emergency cesarean section on account of placenta praevia. Methodology: The cesarean section was done under subarachnoid block while there was no significant event perioperatively while preventive measures were taken to avoid cross infection with the managing team. Results: The patient had a safe anesthesia and surgery. Polymerase Chain Reaction (PCR) test was done fourth day after surgery was negative for the mother and child.

Comparison of two vasopressor protocols for preventing hypotension post-spinal anesthesia during cesarean section: a randomized controlled trial

Background:Norepinephrine infusion decreases hypotension after spinal anesthesia during cesarean section.This study aimed to compare the efficacy of norepinephrine infusion and ephedrine bolus against post-spinal hypotension in parturients.Methods:In this double-blinded,randomized controlled clinical trial,parturients scheduled for elective cesarean section were randomly allocated to receive norepinephrine infusion(0.05μg·kg^(-1)·min^(-1))just before spinal anesthesia continuing for 30 min or ephedrine bolus(0.15 mg/kg)just before spinal anesthesia.A rescue bolus(5μg norepinephrine for the norepinephrine group,and 5 mg ephedrine for the ephedrine group)was administered whenever hypotension occurred.Our primary outcome was the incidence of hypotension within 30 min of spinal anesthesia administration.Secondary outcomes included maternal and neonatal outcomes 30 min after spinal block,and neonatal cerebral oxygenation 10 min after birth.Results:In total,190 patients were enrolled;of these patients,177 were included in the final analysis.Fewer patients suffered hypotension in the norepinephrine group than in the ephedrine group(29.5%vs.44.9%,odds ratio[OR]:0.51,95%confidence interval[CI]:0.28-0.95,P=0.034).Moreover,the tachycardia frequency was lower in the norepinephrine group than in the ephedrine group(OR:0.22,95%CI:0.11-0.44,P<0.001),and patients suffered less nausea and vomiting(OR:0.28,95%CI:0.11-0.70,P=0.004).There was no difference in Apgar scores and umbilical arterial blood gas analysis between the two groups.However,neonatal cerebral regional saturations were significantly higher after birth in the norepinephrine group than in the ephedrine group(mean difference:2.0%,95%CI:0.55%-3.45%,P=0.008).Conclusion:In patients undergoing elective cesarean section with spinal anesthesia,norepinephrine infusion compared to ephedrine bolus resulted in less hypotension and tachycardia,and exhibited potential neonatal benefits.

Total intravenous anesthesia for cesarean section in a pregnant woman with spinal muscular atrophy

Spinal muscular atrophy （SMA） is a genetic neuromuscular disorder characterized by progressive degeneration of the anterior horn cell leading to a lower motor neuron lesion. It is characterized by degeneration of alpha neurons in the anterior horn cells of the spinal cord leading to progressive muscle atrophy and premature death, usually from respiratory failure.1 There are four types according to the symptoms （Table 1）.