Surgical Care at the District Hospital
Part 1 2 3 4 5 6 Primary Trauma Care Manual
Resusciation and Anaesthesia
Resuscitation and Preparation for Anaesthesia and Surgery
Management of emergencies and cardiopulmonary resuscitation
Other conditions requiring urgent attention
Intravenous access
Fluids and drugs
Drugs and resuscitation
Preoperative assessment and investigations
Anaesthetic issues in the emergency situation
Important medical conditions for the anaesthetist
Practical Anaesthesia
General anaesthesia
Anaesthesia during pregnancy and for operative  delivery
Pediatric anaesthesia
Conduction anaesthesia
Specimen anaesthetic techniques
Monitoring the anaesthetized patient
Postoperative management
Anaesthetic infrastructure and supplies
Equipment and supplies for different level hospitals
Anaesthesia and oxygen
Fires, explosions and other risks
Care and maintenance of equipment
Anaesthesia during Pregnancy and for Operative Delivery

Caesarean section is the commonest major operation in many areas of the developing world. Most cases present as emergencies in labour. Management of emergency caesarean section is the everyday activity of all anaesthetists.

Mothers may present in extremis in obstructed labour or with ruptured uterus, haemorrhage, sepsis or anaemia of several days’ duration. The primary reason for performing caesarean section in these circumstances is to save a mother’s life. Both general and spinal anaesthesia can be used. Epidural is less common owing to the time, expense and expertise required for use of the technique.

Several changes occurring in pregnancy are relevant for anaesthesia:

:: Blood volume begins to rise
:: Cardiac output begins to rise
:: There is less increase in the number of red cells, so the haemoglobin concentration falls
:: As the uterus enlarges, respiration comes to depend more on thoracic than diaphragmatic movement
:: Gastric emptying becomes less efficient.

In late pregnancy:

:: The uterus presses back on the inferior vena cava when the patient lies on her back, causing a fall in cardiac output
:: There may also be a severe fall in blood pressure – the “supine hypotensive syndrome” – but most non-anaesthetized patients are able to maintain their blood pressure by widespread vasoconstriction
:: During general or spinal anaesthesia, the capacity for vasoconstriction is lost; this is likely to result in a severe fall in blood pressure to levels that are dangerous for both mother and baby.
:: As the uterus enlarges, respiration comes to depend more on thoracic than diaphragmatic movement
:: Gastric emptying becomes less efficient.

Supine hypotension can be prevented merely by ensuring that the mother is never fully supine.

A pillow or sandbag must always be placed under one hip to tilt the uterus slightly to one side; this is perfectly simple to do even with the patient in the
lithotomy position. This simple precaution must always be carried out in obstetric patients receiving either general or spinal/epidural anaesthesia.

When you anaesthetize a pregnant woman for delivery, there are two patients to deal with: mother and child. Most drugs cross the placenta quickly. This is a problem, since the aim is to anaesthetize the mother, but to allow the baby
to be born without any drug-induced depression of body functions, especially of respiration. For this reason, drugs that can cause depression of the fetus, such as sedative premedication, should not be given.

Don’t be so concerned about the baby that you fail to give the mother a sufficient dose of anaesthetic.

A suitable general anaesthetic technique is outlined below. Spinal anaesthesia is often as good or better, and is described on pages 14–23 to 14–25.

1 Before inducing anaesthesia, give a 30 ml dose of a liquid antacid, such as sodium citrate 0.3 mol/litre (77.4 g/litre), to neutralize excess gastric acid.
2 Insert a wedge or cushion under one hip to tilt the uterus off the inferior vena cava:
Never induce anaesthesia with the patient in the lithotomy position
If she is already in that position, her legs must be lowered for induction
to avoid regurgitation of gastric contents.
3 Set up a fast-flowing infusion of an appropriate fluid into a large vein and
preoxygenate the patient.
4 Induce anaesthesia as for an emergency:
Apply cricoid pressure
Administer a previously calculated dose of thiopental or ketamine
Intubate the patient after giving suxamethonium
Give IPPV.

For a full account of managing the full stomach, see page 13 –32.

Laryngoscopy in the pregnant woman is sometimes more difficult than usual. Always prepare a spare tube of a small size (5–6 mm) in case the patient has laryngeal oedema secondary to pre-eclampsia.

Avoid high concentrations of ether or halothane, as these will reduce the uterine tone and increase bleeding. However, in a spontaneously breathing
patient, you will not be able to maintain adequate anaesthesia (the mother will push) at ether concentrations below about 8–10% or halothane below 1.5%. You may give opiates intravenously once the umbilical cord is clamped and then reduce the concentration of the volatile agent.

Be prepared to give an oxytocic drug intravenously when requested by the surgeon, but never give ergometrine to a woman with pre-eclampsia as it may cause a hypertensive crisis. Syntocinon causes hypotension and should be given in two divided doses of 5 mg IV.

The average blood loss from caesarean section is 600–700 ml, so make sure that you give enough fluid replacement. You may need to transfuse blood.
In additi

on to looking after the mother, you may have to resuscitate the baby, so be prepared with infant resuscitation equipment and a separate oxygen supply.

If mother and child are both critically ill, it is your clear duty to attend to the mother first.

Always try to have a trained assistant with you for these cases. At the end of anaesthesia, remember that the mother still has a full stomach; remove the tracheal tube with her in the lateral position.

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  Kep Points  
If using general anaesthesia in an eclamptic patient, there may be a huge rise in blood pressure at intubation

Prevent this with a bolus of
2–3 G magnesium sulfate
before intubation.