What is the recommended anesthetic approach for a 13-year-old undergoing an emergency Cesarean section (C-section) at 37 weeks Gestational Age (GA)?

Case-Based Multiple Choice Question: Emergency Cesarean Section in a 13-Year-Old

Clinical Vignette

A 13-year-old primigravida at 37 weeks gestational age presents to labor and delivery with fetal bradycardia requiring emergency cesarean section. She has no epidural catheter in place. She is NPO for 4 hours, has normal airway anatomy on examination, and vital signs are stable. She is anxious but cooperative.

Question: What is the most appropriate anesthetic approach for this patient?

A. General anesthesia with rapid sequence induction to expedite delivery

B. Spinal anesthesia with intrathecal morphine 75 μg, followed by multimodal analgesia

C. Epidural anesthesia with 2% lidocaine to avoid dural puncture risks

D. Combined spinal-epidural with low-dose intrathecal bupivacaine only

E. General anesthesia because neuraxial techniques are contraindicated in adolescents

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Answer and Explanation

Correct Answer: B

Neuraxial anesthesia, specifically spinal anesthesia with intrathecal morphine, is the optimal choice for this emergency cesarean section, even in a 13-year-old patient. 1, 2, 3

Rationale for Spinal Anesthesia

The American Society of Anesthesiologists recommends neuraxial anesthesia over general anesthesia for emergency cesarean sections due to superior maternal and fetal safety profiles. 2, 3 This recommendation applies regardless of patient age, as adolescents age 13 have adult-like airway anatomy, though pregnancy-related physiologic changes still warrant careful assessment. 2

Why Each Answer is Correct or Incorrect

Option A (General Anesthesia) - INCORRECT

• General anesthesia carries significantly higher risks in pregnant patients, including failed intubation (1 in 250-300 compared to 1 in 2000 in non-pregnant patients) and aspiration. 2, 4
• Mortality following cesarean delivery under general anesthesia is attributable chiefly to failed intubation or other induction-related issues. 4
• Never proceed with general anesthesia without considering neuraxial options first, as the risks of failed intubation and aspiration are significantly higher in pregnant patients. 2
• General anesthesia should be reserved for situations where neuraxial techniques are contraindicated or when there is immediate threat to maternal life requiring the fastest possible delivery. 3, 4

Option B (Spinal with Intrathecal Morphine) - CORRECT

• Spinal anesthesia provides the most reliable neuraxial block with the fastest onset, making it ideal for emergency situations. 5
• Intrathecal morphine 50-100 μg is recommended for postoperative analgesia with level I evidence. 1, 2
• The dose of 75 μg falls within the optimal range, providing adequate analgesia with reduced side effects compared to higher doses. 6, 1
• Age-appropriate explanation and emotional support should be provided, with involvement in decision-making when possible. 2

Option C (Epidural Anesthesia) - INCORRECT

• Epidural anesthesia has slower onset (18.3 minutes to T4 block) compared to spinal anesthesia (9.7 minutes), making it less suitable for emergency situations. 7
• Epidural techniques have higher failure rates, with 22% of patients experiencing intraoperative pain compared to 0% with combined spinal-epidural approaches. 7
• Epidural extension would only be appropriate if an epidural catheter were already in place from labor analgesia. 1, 2

Option D (Combined Spinal-Epidural with Bupivacaine Only) - INCORRECT

• While combined spinal-epidural (CSE) is an acceptable technique with several advantages including better motor block and lower pain scores, 8, 7 omitting intrathecal morphine sacrifices superior postoperative analgesia. 6, 1
• Intrathecal morphine 50-100 μg should be added to spinal anesthesia for postoperative pain management, with basic analgesics (paracetamol and NSAIDs) and IV dexamethasone. 6, 1, 2
• The question of CSE versus single-shot spinal is less critical than ensuring intrathecal opioid is included.

Option E (General Anesthesia Due to Age) - INCORRECT

• There is no age-based contraindication to neuraxial techniques in adolescents. 2
• By age 13, airway anatomy is adult-like, though careful assessment remains essential given pregnancy-related changes. 2
• Appropriate legal guardian consent must be obtained while respecting the patient's assent. 2

Complete Anesthetic Protocol

The optimal approach includes: 1, 2

Pre-anesthetic preparation:

• Aspiration prophylaxis immediately given emergency nature and full-term pregnancy 2
• Large-bore IV access (16-18 gauge minimum) with fluid coloading or preloading 2
• Age-appropriate explanation and emotional support 2

Spinal anesthetic technique:

• Intrathecal morphine 50-100 μg (75 μg is optimal in this range) 1, 2
• Hyperbaric bupivacaine 0.5% (typically 2.0-2.5 mL for cesarean section) 7
• IV dexamethasone 4-8 mg after delivery for additional analgesia and antiemetic effect 1, 9

Postoperative multimodal analgesia:

• Scheduled oral/IV paracetamol 6, 1, 2
• Scheduled oral/IV NSAIDs 6, 1, 2
• Opioids for rescue only when other strategies fail 2

Monitoring and management:

• Continuous non-invasive blood pressure, pulse oximetry, and ECG 2
• Prompt treatment of hypotension (SBP <90 mmHg or >20% decrease from baseline) with phenylephrine boluses 50-100 μg 2
• Fetal heart rate monitoring until delivery 2

Key Clinical Pearls

• Spinal anesthesia is first-line for cesarean section regardless of urgency, unless absolute contraindications exist (patient refusal, severe hypovolemia, coagulopathy). 1, 2, 3
• The 2021 PROSPECT guidelines specifically note their recommendations for elective cesarean section under neuraxial anesthesia should not be applied to emergency situations or general anesthesia cases. 6 However, the 2025 guidelines specifically address emergency cesarean sections and confirm neuraxial techniques remain preferred. 2
• Approximately 15% of patients experience intraoperative pain during cesarean delivery, necessitating adequate testing of the neuraxial block before skin incision. 5
• Never delay treatment of hypotension—maintain SBP within 20% of baseline to ensure uteroplacental perfusion. 2