Cesarean Section (elective, term)
Patient phenotype
Term pregnant woman (37+ weeks), repeat C/S or breech or maternal request. Aspiration risk by definition. Possible PIH, GDM, obesity. Most awake under spinal.
Procedure
Pfannenstiel or low-transverse incision, hysterotomy, deliver baby, deliver placenta, close uterus + abdomen. Typical surgical time 45–60 min.
Anesthetic plan
Spinal anesthesia preferred (bupivacaine 0.75% hyperbaric 12 mg + fentanyl 15 mcg + morphine 0.1–0.2 mg). GA reserved for true emergency or contraindication to neuraxial.
Setup
- ·Standard ASA monitors + non-invasive BP
- ·16-gauge PIV minimum
- ·Spinal kit (25-gauge pencil-point Whitacre)
- ·Pre-loaded phenylephrine infusion
- ·Bicitra 30 mL PO + ranitidine + metoclopramide
- ·Left uterine displacement always — pillow under right hip
Biggest concerns by phase
Aspiration risk — pregnant = full stomach
Even fasting, pregnancy = decreased LES tone + increased intra-abdominal pressure. Bicitra 30 mL PO within 30 min of induction (nonparticulate). H2 blocker + metoclopramide if time allows. RSI absolute if GA needed.
Spinal hypotension — phenylephrine first-line, NOT ephedrine
Sympathectomy + aortocaval compression → maternal hypotension → uteroplacental hypoperfusion. Phenylephrine infusion 0.5–1 mcg/kg/min started at spinal placement, titrated to baseline BP. Phenylephrine preserves umbilical artery pH better than ephedrine.
Failed intubation in OB GA — high-stakes airway
Pregnant airway = edematous, breasts in the way, full stomach, desats fast (FRC ↓, O₂ consumption ↑). Failed intubation rate ~1:300 vs. ~1:2000 general population. Plan: video laryngoscope first, supraglottic airway second, emergency front-of-neck access third. Awake fiberoptic if known difficult.
High spinal — recognize early, support airway + circulation
Cephalad spread of LA can cause apnea + cardiovascular collapse. Watch for: ascending sensory block, dyspnea, hand weakness, hypotension. Rapid intervention: O₂, vasopressor, fluid, intubate if respiratory failure. Continue LUD always.
Uterine atony post-delivery — oxytocin protocol + escalation
Oxytocin 3 IU IV slow over 30 sec, then 30 IU in 500 mL NS infusion. NEVER bolus 10 IU push (cardiovascular collapse, has caused arrest). Second-line: methylergonovine 0.2 mg IM (avoid in HTN), carboprost 250 mcg IM (avoid in asthma), misoprostol 800 mcg PR/SL. TXA 1 g IV.
Postpartum hemorrhage, AFE, eclampsia — early recognition
PPH = > 500 mL vaginal or > 1000 mL cesarean. Watch for atony, retained products, lacerations, coagulopathy. AFE = sudden hemodynamic collapse + DIC near delivery. Eclampsia = seizure in PIH patient — magnesium 4–6 g loading dose, BP control.
Mock-defense scenarios
Practice answering these out loud. The probes show what an examiner is listening for.
Your spinal is in for an elective C-section. Five minutes later BP is 70/40, HR 50, the patient says her hands feel weird and she can't catch her breath. What's happening and what do you do?
What an examiner probes for
- ▹Recognizes high spinal — cephalad block to cervical levels
- ▹First moves: O₂, LUD, phenylephrine + atropine, prepare to intubate
- ▹Awareness: trendelenburg only if airway secured (LA still mobile)
- ▹Communication: tell surgeon, tell patient, prepare for GA conversion
Baby is delivered, oxytocin running. The uterus is boggy, you see ongoing bleeding from the surgical field, BP starts dropping. EBL is now at 1500 mL. What's your escalation?
What an examiner probes for
- ▹Names second-line uterotonics in order: methylergonovine, carboprost, misoprostol — with contraindications
- ▹TXA 1 g over 10 min
- ▹Massive transfusion activation if continued
- ▹Communication: surgeon may need B-Lynch suture, hysterectomy, IR embolization
Sources
- AANA Practice Considerations: OB
- ACOG Practice Bulletin 209
- SMFM PPH guidelines
Anatomy reference
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