Perioperative anaesthetic management of high-order repeat caesarean section: audit of practice in a university-affiliated medical centre

Ioscovich, A.; Mirochnitchenko, E.; Halpern, S.; Samueloff, A.; Grisaru-Granovsky, S.; Gozal, Y.; Einav, S.

doi:10.1016/j.ijoa.2009.01.014

« Previous Next »International Journal of Obstetric Anesthesia
Volume 18, Issue 4 , Pages 314-319, October 2009

Perioperative anaesthetic management of high-order repeat caesarean section: audit of practice in a university-affiliated medical centre

Departments of Anesthesiology, Perioperative Medicine and Pain Treatment, Obstetrics and Gynecology and the Intensive Care Unit of the Shaare Zedek Medical Centre, Hebrew University, Jerusalem, Israel and Department of Aaesthesia, Sunnybrook Health Sciences Center at Women’s College Hospital, University of Toronto, Canada

Accepted 23 January 2009. published online 10 August 2009.

A. Ioscovich, Lecturer and Chief of Gynecological and High Risk Obstetric Anesthesia Unit, Department of Anesthesiology, Perioperative Medicine and Pain Treatment, E. Mirochnitchenko, Resident, Department of Anesthesiology, Perioperative Medicine and Pain Treatment, A. Samueloff, Professor and Chair of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, S. Grisaru-Granovsky, Senior Lecturer and Staff Obstetric Surgeon, Department of Obstetrics and Gynecology, Y. Gozal, Associate Professor and Chair of the Department of Anesthesiology, Perioperative Medicine, and Pain Treatment, S. Einav, Lecturer and Director of Surgical Intensive Care, Shaare Zedek Medical Centre, Hebrew University Faculty of Medicine, Jerusalem, Israel; S. Halpern, Professor of Anaesthesia & Director of Obstetrical Anaesthesia , Department of Anaesthesia, Sunnybrook Health Sciences Center at Women’s College Hospital and the University of Toronto, Canada.

Abstract

Background

High-order (five or more) repeat caesarean sections (HORCS) are associated with increased rates of placenta praevia, placenta accreta and peripartum hysterectomy and prolonged surgical time secondary to intra-abdominal adhesions. This study summarizes our experience in the anaesthetic management of HORCS.

Methods

The files of all parturients undergoing HORCS between January 1995 and August 2007 were reviewed to determine surgical times, rates and causes of conversion from neuraxial to general anaesthesia and the need to supplement neuraxial anaesthesia with intravenous sedation.

Results

Parturients (n=108) were 35±4.5 years old with a gestational age of 37.5±1.5 weeks, weighed 88±20kg and had undergone 6±1 caesarean sections. Eighty-six (80%) were elective. Initial anaesthetic techniques included spinal (n=80, 74%), epidural (n=9, 8%), combined spinal-epidural (n=6, 6%) and general anaesthesia (n=13, 12%). Surgery lasted 38±19min (median 34, range 9-120). Fourteen parturients (13%) underwent intraoperative manipulations other than caesarean section, including three hysterectomies for haemorrhage (two placenta accreta, one praevia). There were no ruptures or dehiscences of the uterine scar, intraoperative bladder/ bowel injuries or re-explorations. Apgar scores <9 at 1 (n=9, 13%) and 5 (n=6, 5%) min were related to non-anaesthetic causes. Anaesthesia was converted from neuraxial to general in five cases (5/95, 5%) but only two were due to haemorrhage. No epidural top-up doses or intravenous sedatives/analgesics were required for spinal anaesthesia.

Conclusion

HORCS is not necessarily an indication for general anaesthesia provided uterine and placental abnormalities are sought preoperatively. In our practice single-shot spinal anaesthesia sufficed for uncomplicated HORCS.

Keywords: Anaesthesia, obstetrical, Caesarean section, Anaesthesia spinal, Anaesthesia, epidural, Complication