Relationship between labour analgesia modalities and types of anaesthetic techniques in categories 2 and 3 intrapartum caesarean deliveries

General anaesthesia is typically recommended for category 1 emergency caesarean delivery (CD). For categories 2-4 emergencies, either regional and general anaesthesia could be used. However, the factors influencing the choice of anaesthetic technique in these categories remain poorly understood. We analysed the association between the type of labour analgesia and subsequent anaesthetic techniques employed for intrapartum categories 2 and 3 CD. A prospective longitudinal cohort study was conducted at the University Medical Centre Ljubljana. A total of 300 women who underwent emergency CD between March and October 2021 were consecutively enrolled and categorised according to Lucas's classification of CD urgency. Parturients with category 1 and category 4 emergency CD were excluded from the analysis. Demographic, obstetric, and anaesthetic data were recorded. The techniques of anaesthesia (general, spinal, and epidural anaesthesia) employed for CD were analysed with respect to labour analgesia methods (remifentanil patient-controlled analgesia [remifentanil-PCA], epidural analgesia, and nitrous oxide). Of the participants, 124 (41.3%) had category 2, and 96 (32%) had category 3 emergency CD. Epidural analgesia was the most frequent analgesic option (43.8%), followed by remifentanil-PCA (20.7%) anditrous oxide (5.1%), while 30.4% of parturient women received no analgesia. All anaesthetic methods showed a significant relationship with analgesic modalities (P < 0.001). Remifentanil-PCA was associated with a higher incidence of general anaesthesia. Contraindication to epidural analgesia was the primary factor related to the transition from remifentanil-PCA to general anaesthesia. Most parturients who received epidural analgesia were successfully converted to epidural anaesthesia. Spinal anaesthesia was the most common technique in women using N2O and those without labour analgesia. General anaesthesia was associated with lower 5 min Apgar scores. The method of labour analgesia is associated with the anaesthesia technique employed for categories 2 and 3 CD. This finding may guide patient counselling and intrapartum anaesthetic planning. However, the analysis should be cautiously interpreted as the selection of anaesthesia is a complex decision influenced by several clinical considerations.

European guidelines on perinatal care- Peripartum care Episiotomy

1. Episiotomy should be performed by indication only, and not routinely (Moderate quality evidence +++-; Strong recommendation). Accepted indications for episiotomy are to shorten the second stage of labor when there is suspected fetal hypoxia (Low quality evidence ++–; Weak recommendation); to prevent obstetric anal sphincter injury in vaginal operative deliveries, or when obstetric sphincter injury occurred in previous deliveries (Moderate quality evidence +++-; Strong recommendation) 2. Mediolateral or lateral episiotomy technique should be used (Moderate quality evidence +++-; Strong recommendation). Labor ward staff should be offered regular training in correct episiotomy techniques (Moderate quality evidence +++-; Strong recommendation). 3. Pain relief needs to be considered before episiotomy is performed, and epidural analgesia may be insufficient. The perineal skin needs to be tested for pain before an episiotomy is performed, even when an epidural is in place. Local anesthetics or pudendal block need to be considered as isolated or additional pain relief methods (Low quality evidence ++–; Strong recommendation). 4. After childbirth the perineum should be carefully inspected, and the anal sphincter palpated to identify possible injury (Moderate quality evidence +++-; Strong recommendation). Primary suturing immediately after childbirth should be offered and a continuous suturing technique should be used when repairing an uncomplicated episiotomy (High quality evidence ++++; Strong recommendation