Extensor tendon injury during cesarean delivery

Fetal laceration is a recognized complication of cesarean delivery; however, major injuries are rare. The case of a healthy newborn who sustained an injury to the extensor pollicis longus tendon during cesarean delivery is reported. The tendon was repaired surgically on the sixth day of life with good recovery of function.     

Active warming during cesarean delivery.

We tested the hypothesis that 15 min of forced-air prewarming, combined with intraoperative warming, prevents hypothermia and shivering in patients undergoing elective cesarean delivery. We simultaneously tested the hypothesis that maintaining maternal normothermia increases newborn temperature, umbilical vein pH, and Apgar scores. Thirty patients undergoing elective cesarean delivery were randomly assigned to forced-air warming or to passive insulation. Warming started 15 min before the induction of epidural anesthesia. Core temperature was measured at the tympanic membrane, and shivering was graded by visual inspection. Patients evaluated their thermal sensation with visual analog scales. Rectal temperature and umbilical pH were measured in the infants after birth. Results were compared with unpaired, two-tailed Student's t-tests and chi(2) tests. Core temperatures after 2 h of anesthesia were greater in the actively warmed (37.1 degrees C +/- 0.4 degrees C) than in the unwarmed (36.0 degrees C +/- 0.5 degrees C; P < 0.01) patients. Shivering was observed in 2 of 15 warmed and 9 of 15 unwarmed mothers (P < 0.05). Babies of warmed mothers had significantly greater core temperatures (37.1 degrees C +/- 0.5 degrees C vs 36.2 degrees C +/- 0.6 degrees C) and umbilical vein pH (7.32 +/- 0.07 vs 7.24 +/- 0.07). IMPLICATIONS: Perioperative forced-air warming of women undergoing cesarean delivery with epidural anesthesia prevents maternal and fetal hypothermia, reduces maternal shivering, and improves umbilical vein pH.     

Electrogastrography during and after cesarean delivery

Purpose  Although it has been generally believed that parturients have delayed gastric emptying during anesthesia, the most recent reports suggest that gastric emptying is not delayed during pregnancy except during labor. Electrical slow waves in the stomach determine the frequency and the peristaltic nature of gastric contractions. In this study we performed electrogastrography during and after elective cesarean section (CS) in an attempt to evaluate gastric motility. Methods  Sixteen American Society of Anesthesiologists physical status I or II term parturients undergoing elective CS were enrolled. Combined spinal-epidural anesthesia was initiated with 10 mg of bupivacaine plus 10 μg of fentanyl. Fourchannel electrogastrography was obtained for 10 min prior to venous catheter insertion (baseline), 10 min following spinal injection of bupivacaine and fentanyl (Sp-1), 10 to 20 min following spinal injection (Sp-2), 10 min prior to the end of operation (end), and finally 10 min on the seventh postoperative day (POD 7). Results  The mean ± SD values for dominant frequency of electrogastrography (DF) were determined as: 1.57 ± 0.36 cpm (baseline), 1.81 ± 0.32 cpm (Sp-1), 2.08 ± 0.36 cpm (Sp-2), 1.96 ± 0.36 cpm (end), and 3.02 ± 0.28 cpm (POD 7). The DF of Sp-1, Sp-2, and end were significantly higher than that of baseline (P < 0.05). The DF of POD 7 was significantly higher than that of baseline, Sp-1, Sp-2, and end (P < 0.01). Conclusion  Electrogastrography analysis suggests that the frequency of gastric contractions during CS was less than that in the postpartum period. Presented, in part, at the American Society of Anesthesiologists 2005 Annual Meeting, October 22–26, 2005, Atlanta.     

Uterine inversion after nitroglycerin use during cesarean delivery

Intravenous nitroglycerin was used to provide uterine relaxation for cesarean delivery of a macrosomic infant. The procedure was complicated by uterine inversion, and subsequent uterine atony. While several other factors may have contributed to the uterine atony, nitroglycerin administration might have played a role. Further, while nitroglycerin was helpful in facilitating the delivery of the macrosomic infant, the risk of uterine inversion must be considered.     

Coronary arterial air embolus occurring during cesarean delivery

We present a case of a severe systemic (paradoxical) air embolism occurring during spinal anesthesia for cesarean delivery in an otherwise healthy 35-year-old parturient. Uncomplicated spinal anesthesia and satisfactory surgical anesthesia were obtained; no sedatives were used and the patient was awake and alert and tolerating the procedure well. Immediately following infant and placental delivery (approximately 25 min after the spinal anesthetic was induced) the patient had acute onset of markedly decreased mental status, profound ventricular ectopy and labile blood pressure. The event lasted for approximately 10 min with spontaneous resolution. Neurologic status returned to normal by the end of the surgery, but electrocardiogram findings in the immediate postoperative period were consistent with myocardial ischemia and serial cardiac troponin levels confirmed myocardial injury. On postoperative day 1, an echocardiogram demonstrated the presence of a patent foramen ovale. The events in this case are likely to be due to paradoxical coronary and cerebral air embolism.     

Prophylactic phenylephrine infusion for preventing hypotension during spinal anesthesia for cesarean delivery

In a randomized, double-blinded, controlled trial, we investigated the prophylactic infusion of IV phenylephrine for the prevention of hypotension during spinal anesthesia for cesarean delivery. Immediately after intrathecal injection, phenylephrine was infused at 100 microg/min (n = 26) for 3 min. From that point until delivery, phenylephrine was infused at 100 microg/min whenever systolic arterial blood pressure (SAP), measured each minute, was less than baseline. A control group (n = 24) received IV bolus phenylephrine 100 microg after each measurement of SAP <80% of baseline. Phenylephrine infusion decreased the incidence (6 [23%] of 26 versus 21 [88%] of 24; P < 0.0001), frequency, and magnitude (median minimum SAP, 106 mm Hg; interquartile range, 95-111 mm Hg; versus median, 80 mm Hg; range, 73-93 mm Hg; P < 0.0001) of hypotension compared with control. Heart rate was significantly slower over time in the infusion group compared with the control group (P < 0.0001). Despite a large total dose of phenylephrine administered to the infusion group compared with the control group (median, 1260 microg; interquartile range, 1010-1640 microg; versus median, 450 microg; interquartile range, 300-750 microg; P < 0.0001), umbilical cord blood gases and Apgar scores were similar. One patient in each group had umbilical arterial pH <7.2. Prophylactic phenylephrine infusion is a simple, safe, and effective method of maintaining arterial blood pressure during spinal anesthesia for cesarean delivery. IMPLICATIONS: In patients receiving spinal anesthesia for elective cesarean delivery, a prophylactic infusion of phenylephrine 100 microg/min decreased the incidence, frequency, and magnitude of hypotension with equivalent neonatal outcome compared with a control group receiving IV bolus phenylephrine.     

Intrathecal fentanyl added to hyperbaric ropivacaine for cesarean delivery

BACKGROUND AND OBJECTIVES: Hyperbaric ropivacaine produces adequate spinal anesthesia for cesarean delivery. Addition of opioid to local anesthetics improves spinal anesthesia. We assessed the effect of fentanyl added to hyperbaric ropivacaine for spinal anesthesia for cesarean delivery. METHODS: Fifty-nine healthy, full-term parturients scheduled for elective cesarean delivery under spinal anesthesia were randomly assigned in a double-blind fashion to receive either fentanyl 10 micro g or normal saline 0.2 mL added to 0.5% hyperbaric ropivacaine 18 mg. Characteristics of spinal block, intraoperative quality of spinal anesthesia, side effects, complete analgesia (time to first feeling of pain), and effective analgesia (time to first request of analgesics) were assessed. RESULTS: Duration of sensory block was prolonged in the fentanyl group (P <.05). Duration of motor block was similar in both groups. The quality of intraoperative analgesia was better in the fentanyl group (P <.05). Incidence of side effects did not differ between groups. Duration of complete analgesia (143.2 +/- 34.2 minutes v 101.4 +/- 21.4 minutes; P <.001) and effective analgesia (207.2 +/- 32.2 minutes v 136.3 +/- 14.1 minutes; P <.001) were prolonged in the fentanyl group. CONCLUSIONS: Adding fentanyl 10 micro g to hyperbaric ropivacaine 18 mg for spinal anesthesia for cesarean delivery improves intraoperative anesthesia and increases the analgesia in the early postoperative period.     

Epidural hematoma following low molecular weight heparin prophylaxis and spinal anesthesia for cesarean delivery

Epidural hematoma is a very uncommon complication of spinal anesthesia. Its incidence has been reported to be between 1:200 000–250 000 in the obstetric population following neuraxial anesthesia. Cesarean delivery increases the risk of maternal venous thromboembolism significantly and recommendations to decrease its incidence and morbidity have been developed. Strategies to decrease venous thromboembolism include pharmacologic prophylaxis with unfractionated or low molecular weight heparin. We report a case of spinal-epidural hematoma occurring in a parturient who received spinal anesthesia for a planned, repeat cesarean delivery after low molecular weight heparin thromboprophylaxis.     

Epidural catheter function during labor predicts anesthetic efficacy for subsequent cesarean delivery

One of the benefits of labor epidural analgesia is that the catheter can be used to initiate a surgical block should the need for cesarean delivery arise. However, sometimes it is not possible to obtain adequate surgical anesthesia via a previously placed labor epidural catheter and it is unknown what factors are associated with this failure. We retrospectively investigated the incidence of failure to convert a labor epidural to a successful surgical block in our institution over a period of one year and determined the factors associated with this failure. There were 246 cases in which a patient had an epidural catheter placed for labor and then had a cesarean delivery. Of these 246 cases, 220 developed surgical anesthesia using the catheter. In six cases the anesthesiologist did not attempt to use the epidural catheter for the cesarean delivery. In 20 cases (classified as failed blocks), the catheter was injected, but another method of anesthesia was then used. Factors associated with failure of the epidural block were an increased requirement for supplemental local anesthetic boluses during labor in order to provide adequate analgesia and that the attending anesthesiologist for the cesarean delivery was not a specialist in obstetric anesthesia. Most epidural catheters placed for labor can be used to induce a surgical block. When significantly more local anesthetic than usual is required to maintain analgesia during labor, however, the epidural catheter may not be functioning properly and consideration should be given to replacing it.     

Intrathecal versus intravenous fentanyl for supplementation of subarachnoid block during cesarean delivery

Forty-eight healthy parturients scheduled for elective cesarean delivery were randomly allocated to receive intrathecally either 12 mg of hyperbaric bupivacaine plus 12.5 microg of fentanyl (n = 23) or bupivacaine alone (n = 25). In the latter group, IV 12.5 microg of fentanyl was administered immediately after spinal anesthesia. We compared the amount of IV fentanyl required for supplementation of the spinal anesthesia during surgery, the intraoperative visual analog scale, the time to the first request for postoperative analgesia, and the incidence of adverse effects. Additional IV fentanyl supplementation amounting to a mean of 32 +/- 35 microg was required in the IV Fentanyl group, whereas no supple- mentation was required in the Intrathecal Fentanyl group (P = 0.009). The time to the first request for postoperative analgesia was significantly longer in the Intrathecal Fentanyl group than in the IV Fentanyl group (159 +/- 39 min versus 119 +/- 44 min; P = 0.003). The incidence of systolic blood pressure <90 mm Hg and the ephedrine requirements were significantly higher in the IV Fentanyl group as compared with the Intrathecal Fentanyl group (P = 0.01). Also, intraoperative nausea and vomiting occurred less frequently in the Intrathecal Fentanyl group compared with the IV Fentanyl group (8 of 23 vs 17 of 25; P = 0.02). IMPLICATIONS: Supplementation of spinal bupivacaine anesthesia for cesarean delivery with intrathecal fentanyl provides a better quality of anesthesia and is associated with a decreased incidence of side effects as compared with supplementation with the same dose of IV fentanyl.