What is the most important consideration before starting anesthesia in a patient requiring an emergency cesarean section?

Pre-Anesthesia Planning for Emergency Cesarean Section

Before starting anesthesia for an emergency cesarean section, the most important consideration is to discuss with the obstetric team whether to wake the patient or proceed with surgery if tracheal intubation fails, and to ensure aspiration prophylaxis is administered. 1

Critical Pre-Induction Steps

Team Communication and Decision-Making

• Discuss the "wake or proceed" decision with the obstetric team before induction - this conversation must happen pre-operatively, not during a crisis. 1

• The decision is influenced by maternal factors (airway assessment, aspiration risk, hemodynamic stability), fetal factors (reversible vs. irreversible causes of distress), staff availability (second anesthetist, difficult airway equipment), and clinical urgency. 1

• Determine whether you would be prepared to continue surgery with a supraglottic airway device if intubation fails - this mental preparation is essential before induction. 1

Aspiration Prophylaxis

• Administer sodium citrate 0.3M 30ml immediately before induction to neutralize gastric acid. 1

• If not already given, administer intravenous H2-receptor antagonist to reduce gastric acid production and aspiration risk at extubation. 1

• Recognize that gastric emptying is unpredictably slowed during labor, and eating in labor increases residual gastric volume regardless of fasting duration. 1

Airway Assessment and Equipment

• Perform focused airway assessment including Mallampati score, neck movement, mouth opening, thyromental distance, and jaw protrusion. 1

• Ensure difficult airway equipment is immediately available and the team is familiar with its location - standardization of airway equipment within the hospital is highly recommended. 1

• Consider whether a second anesthetist should be present before induction, and if appropriate, delay induction while awaiting their attendance. 1

Fetal Status Evaluation

• Distinguish between reversible causes of fetal distress (uterine hyperstimulation, maternal hypotension, aortocaval compression) versus irreversible causes (major placental abruption, fetal hemorrhage, ruptured uterine scar, umbilical cord prolapse with sustained bradycardia). 1

• Employ intrauterine fetal resuscitation measures before transfer to the operating theater and re-evaluate the urgency of surgery after these interventions. 1

• Recognize that fetal condition is likely maintained during delay in the majority of cases, except when irreversible causes are present. 1

Patient Positioning

• Optimize patient position before the first intubation attempt - this is essential and cannot be corrected mid-crisis. 1

• Apply lateral uterine displacement to prevent aortocaval compression. 1

• Consider 20-30° head-up position, which increases functional residual capacity in pregnant women, increases safe apnea time, improves laryngoscopy view, and may reduce gastroesophageal reflux. 1

• In morbidly obese patients, use the "ramped" position aligning the external auditory meatus with the suprasternal notch, which is superior to the standard sniffing position. 1

• Check for elaborate hair braids that may require removal before anesthesia as they can affect neck extension. 1

Common Pitfalls to Avoid

• Never proceed to induction without having the "wake or proceed" conversation - this decision cannot be made rationally during a failed intubation crisis. 1

• Do not assume all fetal distress requires immediate delivery - many causes are reversible with intrauterine resuscitation, allowing time for safer anesthetic planning. 1

• Avoid delaying aspiration prophylaxis until the patient is in the operating room - sodium citrate should be given immediately before induction. 1

• Do not proceed without confirming difficult airway equipment availability - in obstetric emergencies, there is no time to search for equipment during a crisis. 1

• Minimize noise and distractions during preparation and induction to ensure all staff remain aware of the developing situation. 1

Special Considerations for Anticipated Difficult Airway

• If a difficult airway is anticipated, antenatal multidisciplinary planning should include assessment of equipment and personnel available out-of-hours, and elective cesarean section should be considered if these resources are lacking. 1

• When general anesthesia is required with anticipated difficult airway, perform a risk assessment regarding the probability of safe airway management after induction - awake tracheal intubation should be used if safe airway management cannot be assured. 1

• For category-1 cesarean section with predicted difficult airway, rapid sequence induction with videolaryngoscopy achieves induction in approximately 100 seconds versus 9 minutes for awake fiberoptic intubation, though this carries a calculated risk of ultimate failed airway control of 21 per 100,000 cases. 2