Peri-operative management of caesarean section for the occasional obstetric anaesthetist – an aide memoire

Anaesthesia practice for caesarean section (CS) has evolved in the past 20 years. This article aims to update occasional obstetric anaesthesiologists, obstetricians and clinicians involved in the management of pregnant women on the latest guidelines and recommendations for anaesthesia management, including pre-operative evaluation, informed consent, intra-operative and postoperative management for CS. In addition, this article will also summarise the management of CS associated emergencies such as difficult intubation, obstetric major postpartum haemorrhage, local anaesthetic toxicity and (pre-) eclampsia. At the end of the article, a charted summary will be provided as an aide memoire

Neurovascular lesions in parturients: Anesthetic management for cesarean section

Cerebral arteriovenous malformation (AVM) or aneurysm in pregnancy is a complex situation and there is no definite recommendation regarding mode of anesthesia for patient with this type of intracranial pathology. We present a case series on the anesthetic management in two pregnant patients with either cerebral AVM or aneurysm presenting for elective cesarean section. Our case series highlights the following: (1) team working and collaboration with neurosurgeon and obstetrician to improve patient outcome; (2) crucial role of anesthetic management in reducing perioperative complications; (3) anesthetic management goals so as to minimize the risk of hemorrhage from an AVM or aneurysm

Severe aortic stenosis in a parturient with twins: The challenges

Aortic stenosis (AS) in young women is often the result of a congenital bicuspid aortic valve, occurring in 1–2% of the population. Although the anaesthetic management of parturients with AS remains controversial, the high rate of caesarean delivery is consistent among studies. A 30-year-old primi gravida with severe AS presented for elective caesarean section at 36 weeks gestation (twins). She had a failed balloon valvuloplasty 15 years ago and declined further intervention. Prior to induction, invasive lines and prophylactic extracorporeal membrane oxygenation cannulas were placed. A modified rapid sequence intubation technique with propofol/remifentanil target-controlled infusion and suxamethonium was performed. Anaesthesia was maintained using total intravenous anaesthesia. Both twins were delivered uneventfully and oxytocin infusion was commenced. Gradual desaturation to 95% occurred intraoperatively and a focused lung ultrasound and transthoracic echocardiogram were performed. Intravenous frusemide 20 mg was administered empirically. Post-operatively, the patient was extubated and transferred to the Intensive Care Unit for monitoring.Severe AS is associated with high risk of maternal morbidity and mortality. In our case, due to the twin gestation, cardiac output and metabolic demands rise exponentially leading to increased risks. A multidisciplinary approach with appropriate monitoring and point-of-care testing are key to such complex cases to achieve favourable maternal and foetal outcomes