Anesthesia for Cesarean Delivery (CD)
🔹 1. Preoperative
Assessment
- Focused
Hx + PE: airway assessment สำคัญมาก (pregnant =
difficult airway risk ↑)
- Lab:
individualized
- Type
& screen (high bleeding risk)
- Hb,
platelet, coagulation (specific indication)
- High-risk
→ antenatal
anesthesia consult
🔹 2. Preparation
Aspiration prophylaxis
- Pregnancy
= aspiration risk ↑
- Elective:
fasting ตาม guideline ปกติ
- Urgent:
ไม่ delay →
ให้ prophylaxis
- nonparticulate
antacid
- H2
blocker
- metoclopramide
Premedication
- Avoid
sedative (placental transfer + amnesia)
- ถ้าจำเป็น → midazolam low dose (1–2 mg IV)
Fetal monitoring
- ตรวจ FHR ก่อน–หลัง neuraxial block
🔹 3. Choice of Anesthesia
✅ First-line: Neuraxial
anesthesia (>95%)
Types
- Spinal
- CSE
(combined spinal-epidural)
- Epidural
🔥 Indications for General
Anesthesia (GA)
- Emergency
(no time)
- Failed
neuraxial
- Contraindication
(coagulopathy, infection, hypovolemia)
- Massive
hemorrhage / complex surgery
- Maternal
refusal
🔹 4. Neuraxial Anesthesia
(Key Points)
🎯 Target level
- Sensory
level T4
📌 Spinal anesthesia (นิยมที่สุด)
- Drug:
- Bupivacaine
(hyperbaric)
- fentanyl
10–15 mcg → intraop
analgesia
- morphine
→ postop analgesia
- Advantages:
- rapid
onset, reliable, low dose
📌 Epidural anesthesia
- ใช้เมื่อมี labor epidural อยู่แล้ว
- Drug:
- Lidocaine
2% + epinephrine ± bicarbonate
- หรือ chloroprocaine (emergency)
- ต้อง titrate dose
📌 CSE (combined
spinal-epidural anesthesia)
- combine
rapid onset + flexibility
- ใช้ใน case prolonged surgery / high risk
🔹 5. Intraoperative
Management
Position
- Left
uterine displacement (LUD) →
ลด aortocaval compression
Hemodynamic
- Spinal
→ hypotension common
(sympathetic block)
🎯 Goal BP
- Maintain
within ±10–20% baseline
💊 Vasopressor
(first-line)
- Phenylephrine
infusion
- start
25–75 mcg/min
- bolus
50–100 mcg PRN
- Better
than ephedrine (↓
fetal acidosis)
Fluid
- Co-loading
crystalloid 500–1000 mL
PONV prophylaxis
- Ondansetron
4 mg IV
Oxytocin
- Start
infusion after delivery
- Avoid
rapid bolus →
hypotension risk
🔹 6. Complications
❗ Hypotension
- Most
common
- Manage:
vasopressor + fluid
❗ High spinal block
- Symptoms:
dyspnea, weak grip
- Severe
→ respiratory failure → intubation
❗ Inadequate block
- ห้ามผ่าตัดถ้า block ไม่พอ
- Options:
- เติม epidural
- convert
GA
❗ Pain during surgery (~15%)
- Treat
aggressively
- escalate
→ GA if needed
🔹 7. General Anesthesia
(Key Clinical Points)
⚠️ Risks
- Difficult
airway
- Awareness
(สูงกว่า surgery ทั่วไป)
Induction
- RSI
(rapid sequence induction)
- Drugs:
- Propofol
/ etomidate
- Ketamine
(shock)
Maintenance
- High
volatile agent until delivery
- หลัง delivery:
- fentanyl
+ midazolam
🔹 8. Postoperative
Analgesia
Multimodal (standard)
- Neuraxial
opioid (gold standard)
- acetaminophen
- NSAIDs
- opioid
systemic → PRN
🔹 9. Key Takeaways
(High-yield)
- Neuraxial
= first choice
- Phenylephrine
= vasopressor of choice
- Target
T4 block
- Avoid
hypotension →
fetal outcome
- Never
proceed surgery with inadequate block
- GA
reserved for emergency / contraindication
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