Emergent Cesarean Section ('crash C/S')
Patient phenotype
Acute fetal distress (Cat III tracing, prolonged decel, cord prolapse, placental abruption) requiring delivery within minutes. May or may not have epidural in place. Full stomach by definition. Clock starts ticking.
Procedure
Immediate transport to OR, surgeon scrubs while anesthesia induces, deliver baby ASAP. Decision-to-incision target ≤ 30 min (some standards ≤ 15 min for cord prolapse).
Anesthetic plan
Existing epidural? — top up with 3% chloroprocaine 20 mL (fastest neuraxial). No epidural? — GA RSI. Spinal too slow if true crash. The faster you get baby out, the better the outcome.
Setup
- ·Standard ASA monitors
- ·16-gauge PIV (if not present)
- ·Bicitra 30 mL PO immediately on entry
- ·RSI setup ready always (sux, propofol, succinylcholine 1.5 mg/kg)
- ·Difficult-airway cart at door
- ·Phenylephrine drawn for spinal
- ·Pre-load LUD + 100% O₂ via mask
Biggest concerns by phase
Decision pathway — neuraxial top-up vs. GA RSI
Working epidural in place + 5 min available → 3% chloroprocaine 20 mL (works in 3-5 min, fastest neuraxial). No epidural / failed top-up / immediate need → GA RSI. Don't waste 10 min trying spinal in a true crash.
GA RSI for OB — anticipate failed intubation
Pregnant airway = edematous + hypoxia-prone. Failed intubation rate ~1:300. Pre-O₂ to ETO₂ > 90%. Cricoid + RSI: propofol 2 mg/kg + sux 1.5 mg/kg (or roc 1.2 mg/kg + sugammadex). Plan B: video laryngoscope first, then SGA, then surgical airway. Awake fiberoptic if known difficult.
Awareness risk in OB GA
Light anesthetic until baby out (avoid neonatal depression) → high awareness risk. Once cord clamped, deepen with opioid + benzo + volatile. BIS or end-tidal MAC monitoring helps. Counsel patient pre-op if time.
Maternal hypotension — phenylephrine, LUD always
Avoid hypotension at all costs (uteroplacental hypoperfusion → fetal acidosis). Phenylephrine boluses or infusion. Continuous LUD. Avoid prolonged supine.
Post-delivery: deepen anesthesia + uterotonics
After cord clamped: stop volatile dose-dependent uterine relaxation, give opioid + benzo + N₂O. Oxytocin slow IV (NEVER bolus 10 IU). Be ready for atony.
Postop: PPH risk, neonatal evaluation, debrief
PPH risk elevated in emergent C/S (atony from prior labor). Continue oxytocin infusion. Neonatal team evaluates baby (especially if fetal distress was acute). Debrief with team — quality review for emergent cases.
Mock-defense scenarios
Practice answering these out loud. The probes show what an examiner is listening for.
Cord prolapse called — patient in active labor, 38 weeks, no epidural, fetal HR 60, decision to deliver in 5 minutes. You're walking into the OR. Walk me through the next 5 minutes.
What an examiner probes for
- ▹Bicitra immediately, 100% O₂ via mask, LUD
- ▹Pre-O₂ during prep (target ETO₂ > 90%)
- ▹Verify IV, drugs drawn (propofol, sux, phenylephrine)
- ▹Surgeon prepared to incise as anesthetic given
- ▹RSI: propofol 2 mg/kg + sux 1.5 mg/kg, cricoid, intubate, surgeon cuts
- ▹Post-delivery: deepen anesthetic, give opioid
Sources
- AANA Practice Considerations OB
- ACOG
- SOAP Difficult Airway in OB
Anatomy reference
Sourced reference images. 4 matches for "uterus pregnant pelvic obstetric".
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