MANAGEMENT OF ANESTHETIC COMPLICATIONS AND EMERGENCIES IN THE OBSTETRIC PATIENT

No other area in medicine requires closer communication and mutual respect than the obstetric emergency. Not only are there two patients involved, but also from both physiologic and medicolegal aspects, time is a critical factor. Selection of the appropriate anesthesia for emergent or urgent versus elective abdominal delivery can produce confusion and conflict. Should the choice always be general, or could we consider a regional anesthetic technique?(1,20) If a rational choice is to be made, the indication(s) for the emergent or urgent cesarean delivery must be clearly stated to the anesthesiologist. These could be maternal, fetal, or both, recognizing that these considerations often are interdependent. Maternal indications for immediate abdominal delivery (surgery within 10 minutes) include but are not limited to (1) acute maternal hemorrhage with hemodynamic instability, (2) emergency delivery to facilitate maternal cardiopulmonary resuscitation, and (3) surgery to provide immediate access for the repair of abdominal or pelvic structures after blunt or penetrating abdominal trauma.(3,21) Maternal situations that permit a more deliberate approach include dysfunctional active labor with failure of descent or dilatation, or both, and a worsening maternal condition such as severe preeclampsia with or without fetal decompensation. The diagnosis of ''fetal distress'' is often the basis of the call for a ''stat'' or emergent cesarean section. In 1992, the American College of Obstetricians and Gynecologists delivered an opinion that ''the term fetal distress is imprecise, nonspecific and has little positive predictive value.''(1) They urged that the severity of the alterations in the fetal heart rate and fetal status should be considered when choosing rapid sequence general endotracheal versus regional anesthesia. In actual practice, the proper use of the term fetal distress for immediate cesarean delivery denotes the situation where fetal demise is imminent if delivery is postponed. Fetal conditions that require immediate (less than 5-10 minutes) intervention include a prolapsed umbilical cord, prolonged bradycardia, and persistent severe or late decelerations with slow return to baseline accompanied by minimal or abscent beat-to-beat variability. A second group of less life-threatening fetal indications could allow time for a choice of general or regional anesthesia depending on maternal desires, body habitus, and the preference or skill of the anesthesiologist or provider (Table 1). In the emergency situation, the obstetrician must clearly communicate the maternal and fetal condition and the obstetrician's concerns for immediate or urgent delivery in order that the anesthesia team can formulate a rational choice of anesthesia.