What is the most important thing to do before starting anesthesia for a pregnant patient requiring an emergency cesarean section (C-section)?

Pre-Anesthesia Priority for Emergency Cesarean Section

Before starting anesthesia for an emergency cesarean section, the most critical step is to discuss with the obstetric team whether to "wake or proceed" if intubation fails, while simultaneously ensuring blood availability is confirmed given the high-risk nature of emergency cesarean delivery. 1, 2

Critical Pre-Induction Communication and Planning

The anesthesiologist must discuss with the obstetric team before induction whether to wake the patient or continue with surgery in the event of failed tracheal intubation, considering maternal factors, fetal factors, staff availability, and clinical urgency. 1 This decision-making framework is essential because:

• Emergency cesarean sections carry significantly higher risk of hemorrhage and need for transfusion compared to elective cases 2, 3
• General anesthesia itself is an independent risk factor for transfusion 2
• The decision to proceed versus wake depends on whether fetal distress is from reversible causes (uterine hyperstimulation, maternal hypotension, aortocaval compression) versus irreversible causes (major placental abruption, fetal hemorrhage, ruptured uterine scar, umbilical cord prolapse with sustained bradycardia) 1

Blood Availability Verification

Confirming blood availability before induction is critical in emergency cesarean sections because:

• Emergency cases have substantially higher rates of obstetric hemorrhage 2
• Coagulation disorders, bleeding in the third trimester, and severe pre-eclampsia are common indications for emergency cesarean under general anesthesia 2
• General anesthesia is associated with greater maternal blood loss compared to neuraxial techniques 3
• The mean blood loss during cesarean section is often underestimated by both anesthesiologists (498 ml) and obstetricians (592 ml), with actual calculated blood loss averaging 787 ml 4

Additional Essential Pre-Induction Steps

Aspiration Prophylaxis

• Administer sodium citrate 0.3M 30ml immediately before induction to neutralize gastric acid 1
• Gastric emptying is unpredictably slowed during labor, and eating in labor increases residual gastric volume regardless of fasting duration 1

Airway Assessment

• 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 knows its location 1

Patient Positioning

• Apply lateral uterine displacement to prevent aortocaval compression 1
• Consider 20-30° head-up position, which increases functional residual capacity, increases safe apnea time, improves laryngoscopy view, and may reduce gastroesophageal reflux 1

Fetal Status Evaluation

• Employ intrauterine fetal resuscitation measures before transfer to the operating theater when appropriate 1
• Re-evaluate the urgency of surgery after transfer to the operating theater 5

Common Pitfalls to Avoid

• Never proceed without confirming blood availability in emergency cases - the risk of hemorrhage requiring transfusion is substantially elevated 2
• Never skip the "wake or proceed" discussion - this critical decision must be made before induction, not during a failed intubation crisis 1
• Avoid delaying sodium citrate administration - it should be given immediately before induction 1
• Do not underestimate blood loss - both anesthesiologists and obstetricians consistently underestimate actual blood loss by approximately 300 ml 4