Emergency C-sections are performed for various reasons. This is a case report of emergency C-section performed due to fetal distress. This is a classic case report which emphasizes the importance of managing emergency C-sections according to international standards and acknowledges co-operation of obstetrician and anesthesiologist. We reviewed literature about emergency C-sections and discussed sensitive time intervals, types of anesthesia and neonatal resuscitation.
Emergency C-sections are very challenging for both anesthesiologists and obstetricians. They are associated with significant morbidity and mortality for both mother and newborn. This is a case of severe preeclampsia with a category 2 fetal heart rate tracing, which required emergency C-section. In this case report and literature review, we described choice of anesthesia, decision to delivery interval (DDI) and neonatal resuscitation.
A 25 y/o F G3P1101, estimated gestational age (EGA): 36w5d, with previous history of severe preeclampsia and preterm labor, s/p cervical cerclage presented to clinic with nausea, increased leg swelling, elevated blood pressure (BP) 160/88 in clinic, which did not resolve with labetalol 10mg IV and then resolved with IV hydralazine 5mg IV to 145/78. Cerclage was removed anticipating delivery without complications. Cervix 1/50/-3 after cerclage removal. Fetal heart Tracing category 2 with baseline 140 bpm, minimal variability, accelerations, recurrent deceleration that are a combination of late and variable decelerations as shown in
The patient was admitted for induction of labor with vaginal insertion of Cytotec, and several hours later was noticed to have decelerations to 80 bpm on fetal heart monitoring. These resolved after administration of O2 and left sided-positioning. However, subsequent episodes of decelerations were noted to 90 bpm and 70 bpm as shown in
C-section was performed under General anesthesia. IV Induction with Propofol 160 mg and Succinylcholine 100 mg and easy intubation with MAC 3 blade and ETT 7.0. Sevoflurane was used as maintenance agent for GA. Neonatology team was consulted and was present during C-section prior to delivery of Newborn. Newborn delivered with no spontaneous cry, cyanotic and no HR or respirations.
APGAR scores were 0 (1 min), 0 (2 min), 0 (3 min), 2 (10 min), and 3 (20 min). The neonatologist began non-invasive ventilation and CPR. Ultimately, intubation was performed, and two doses of epinephrine (0.3 ml and 0.6 ml) were administered. At 11 minutes of life HR noted to be 95 bpm. The baby was transferred to NICU with HR of 120 bpm, SPO2 90’s on 100% O2. Decision to delivery interval was 12 min and in room to delivery interval was 7 min.
Post-delivery baby was admitted to NICU and was started on hypothermia protocol due to clinical encephalopathy and severe acidosis on cord gas with pH of 6.5. She received IV Ampicillin and Cefepime for three days. Neurology was consulted. VEEG done, which did not reveal any epileptiform activity. Baby was eventually weaned to RA. She stayed a total of 2 weeks in the NICU and intermediate care nursery. Head US revealed an echogenic periventricular area in the left parietal lobe which may represent hypoxic ischemic encephalopathy (HIE). MRI brain with spectroscopy showed T2 hyperintensity in the left parietal periventricular white mater (likely secondary to ischemic insult) and a focus of hypointensity along the left caudothalamic groove (likely sequela of prior hemorrhage).
Baby is having regular follow up clinic visits. Despite her difficult birth baby is developing normally. No deficits noted in the neurological exam. She is feeding, voiding and stooling normally.
Emergency C-section is defined as C-section required because of immediate threat to life of woman or fetus. Urgent is defined as C-section required because of maternal or fetal compromise which is not immediately life-threatening. Scheduled is defined as needing early delivery but no maternal or fetal compromise. Elective is defined as C-section performed at a time to suit the woman and maternity team [
As it can be administered rapidly, GA is almost always recommended in emergency situations with the hope of improving neonatal survival without hypoxic-ischemic brain injury [
In the UK, a case series of 25 patients has described the use of spinal anesthesia in grade 1 C-sections. It is reported that anesthesia can be administered safely in suitable parturient in 6 - 8 min with “rapid sequence spinal anesthesia”, which consists of a “no touch technique” of donning gloves, the omission of spinal opioids with an increase of the dose of hyperbaric Bupivacaine 0.5% (up to 3 ml), and a limitation in the number of attempts [
Further literature review revealed, we should consider the need for an emergency hysterotomy (cesarean delivery) protocol as soon as 4 - 5 minutes after cardiac arrest in a pregnant woman to improve the survival rate of neonate [
According to the National Institute of Child Health and Human Development (NICHD) workshop report, a category I FHR pattern will have moderate variability. A category II pattern will have minimal variability, or absent variability accompanied by recurrent decelerations or marked variability. A category III pattern will have absent variability with recurrent late decelerations, recurrent variable decelerations or bradycardia [
Neonatal resuscitation is summarized in Algorithm 1 and Algorithm 2 and
Algorithm 1. Initial newborn evaluation.
Algorithm 2. Secondary evaluation.
Drug Therapy | Epinephrine 0.01 0.03 mg/kg IV/IO; repeat every 3 5 minutes if heart rate is less than 60 bpm. Epinephrine 0.05 0.1 mg/kg ETT (not preferred route). Crystalloid 10 mL/kg IV/IO Sodium bicarbonate (4.2%) 1 2 mEq/kg IV/IO only for prolonged resuscitation and only if effective ventilation Dextrose (10%) 0.2 g/kg then 5 mL/kg/hr IV/IO if blood glucose level is less than 40 mg/dL Naloxone is not recommended |
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Compressions | Check pulse at brachial or femoral artery. Compression landmarks: Lower third of sternum between the nipples Method: Thumbencircling Depth: Approximately onethird anteroposterior chest diameter Allow complete chest recoil after each compression Compression rate: 100 120 per minute Compressiontoventilation ratio of 3:1 Coordinate compressions with ventilation Minimize interruptions in compressions to less than 10 seconds |
Airway | Preterm newborns (<35 weeks) should receive low oxygen (FiO2 21% 30%). Suction after birth is only for babies with obvious obstruction or who require positive pressure ventilation. Suctioning during delivery has been shown to have no value. |
Meconium | If meconium is present and the newborn is vigorous with good respiratory effort and muscle tone, he or she may stay with the mother, and bulb suctioning can be considered. If the infant is born through meconiumstained amniotic fluid and presents with poor muscle tone and inadequate breathing efforts, move him or her to a radiant warmer and follow typical initial evaluation steps. If meconium is present, routine intubation for tracheal suction is not recommended. If meconium is present and the infant is nonvigorous, current literature does not support routine intubation. |
Ventilations | Rate of 40 60 breaths per minute Watch for visible chest rise. Administer positive endexpiratory pressure (PEEP), if available. |
Consider Intubation | Ineffective or prolonged bagmask ventilation Cardiopulmonary resuscitation (CPR) is being performed Special circumstances such as congenital diaphragmatic hernia |
Target Preductal SpO2 At Birth | 1 minute: 60% 65% 2 minutes: 65% 70% 3 minutes: 70% 75% 4 minutes: 75% 80% 5 minutes: 80% 85% 10 minutes: 85%95% |
The author states that the report describes the care of one or more patients. The patient consented to publication of the report. This is described in the report. No external funding and no competing interests declared.
The authors declare no conflicts of interest regarding the publication of this paper.
Nadavaluru, P., Hannaford, S., Amin, M., Park, H.J. and Xiong, M. (2018) Anesthesia Considerations in Emergency C-Section and Perioperative Neonatal Resuscitation: A Case Report and Review of Literature. Open Journal of Obstetrics and Gynecology, 8, 803-811. https://doi.org/10.4236/ojog.2018.89083