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A 38-year-old Caucasian nulliparous patient was first seen at 12 weeks' gestation. She initially presented with a 2-day history of generalised lower abdominal cramps and no other associated symptom...

Following induction of general anaesthesia for emergency caesarean section the trachea could not be intubated, and ventilation was established only following two cricothyroidotomies. The baby was delivered unimpaired, and tracheostomy subsequently performed. On the intensive care unit, maternal cardiorespiratory variables were satisfactory, although surgical emphysema of the face and neck became apparent. Increasing abdominal distension was relieved by suction to a pelvic drain. Radiographs revealed bilateral pneumothoraces, pneumomediastinum and pneumoperitoneum, which were resolved by intrapleural drainage.

A primigravida with severe kyphoscoliosis and acute lower respiratory tract infection underwent emergency caesarean section (CS) under continuous spinal anaesthesia without complications in a major maternity hospital. This report highlights the anaesthetic challenges and the importance of early involvement of the anaesthesiologist. DOI: http://dx.doi.org/10.4038/slja.v21i2.5551

administered with hyperbaric bupivacaine 0.5%, 2.3 ml and fentanyl 15 mcg. Surgery proceeded uneventfully, patient remained haemodynamically stable and anaesthesia recovery was uncomplicated. Postoperative pain was managed with oral paracetamol, mefenamic acid and patient-controlled intravenous morphine. Satisfaction for anaesthesia was found to be high due to good maternal and foetal outcome. Discussion General anaesthesia for Caesarean section in patients with intracranial haemorrhage has been described. However, because of the rarity of the condition, there is no consensus with regards to optimal anaesthetic care. Despite the numerous advantages that spinal anaesthesia can offer, the authors did not find any precedent reports in the literature. In addition to the known risks of the spinal anaesthesia, post-duralpuncture headache (PDPH) may be difficult to diagnose in a patient with existing headaches. Practitioners are required to remain vigilant, because worsening headache, due to PDPH, may confound the evaluation of re-bleed in intracranial aneurysm. Conclusion In a patient, with recent SAH and minimal neurological deficit undergoing emergency Caesarean section, spinal anaesthesia should be considered, as it has multiple advantages.

Ebstein′s anamoly is a rare congenital heart defect comprising less than 1% of patients with congenital heart disease. Among the congenital heart lesions, Ebstein′s anamoly is one of the most diverse in presentation, severity and management. Even though pregnancy in women with Ebstein′s anamoly is usually well-tolerated, they are at increased risk of developing ventricular and supraventricular tachycardias, congestive cardiac failure, sudden collapse and even death. Here, we report a case of the pregnant woman with mild pre-eclampsia, known case of Ebstein′s anamoly posted for emergency caesarean section.

The most common arrhythmia seen during pregnancy is paroxysmal supraventricular tachycardia and Wolff-Parkinson-White syndrome accounts for majority of this in such population. The presence of pre-disposing factors may facilitate the onset of tachyarrhythmias in previously asymptomatic parturients with the WPW syndrome such as increased hemodynamic, hormonal, autonomic, and emotional changes. Therefore, meticulous monitoring is essential perioperatively. Epidural anesthesia providing added advantage of hemodynamic stability and post-operative analgesia is preferred in such pregnant patients undergoing emergency cesarean section.

A case of postpartum haemorrhage due to major placenta praevia with a mild degree of accreta and thrombocytopenia is presented. The baby was delivered via emergency caesarean section that was successfully managed by bilateral uterine artery ballooning followed by embolization, which saved the patient's life and preserved her fertility.

In a retrospective review of 79 women with 1 or more previous Caesarean section, 33 (41.8%) women agreed to a trial of vaginal birth. Twenty nine women had labour induced and 26 (89.7%) of them had a successful vaginal delivery. Four women laboured spontaneously and 1 of them needed an emergency Caesarean section for failure to progress. The overall vaginal delivery rate for women selected to undergo a trial of vaginal birth after Caesarean was 87.9%. The overall emergency Caesarean section rate was 4 of 33 (12.1%). During the study period the Caesarean section rate for the hospital fell from 32.2% to 11%. This study suggests that induction of labour in women with a previous Caesarean section is very successful in achieving vaginal delivery and has a role to play in remote and rural hospitals.

Cardiac arrest occurred on arrival in the recovery room after emergency Caesarean section under subarachnoid block. The patient was resuscitated successfully and recovered with no adverse effects. The current literature is reviewed and the pathophysiological mechanisms involved in the aetiology of cardiac arrest under subarachnoid block are discussed. Early use of adrenaline to treat severe bradycardia or hypotension is recommended.

Routine orogastric aspiration of stomach contents during general anaesthesia for caesarean section was recommended in the latest triennial report on maternal deaths. We conducted a postal survey which revealed that the majority of obstetric units do not follow this guideline. Following the report, we aspirated the stomach contents of all our patients undergoing general anaesthesia for caesarean section and analysed the aspirate volume and pH. Despite routine antacid prophylaxis, a large proportion of our emergency patients remain at risk for aspiration pneumonia. We thus concur with the recommendation that the stomach should be aspirated during general anaesthesia for emergency caesarean section.

A rare example of the partial rupture of the umbilical vein resulting in a cord haematoma is reported. CTG alterations made possible to anticipate the deterioration of the foetal condition and a healthy infant was delivered by emergency caesarean section. Cross sections of the umbilical cord revealed the lack of one of the umbilical arteries and the haematoma having interfered with the foetal circulation.

Cyclosporin has been established in the management of steroid resistant severe ulcerative colitis. We read the letter by Dor and Blanshard ( Gut 2003; 52 :1070-a) regarding the severe side effects of cyclosporin used in a patient with steroid resistant severe ulcerative colitis after undergoing emergency Caesarean section. We would like to report our experience of a pregnant patient with steroid resistant severe distal ulcerative colitis in whom remission was induced with cyclosporin. She delivered …

Peripartum cardiomyopathy is defined as the onset of acute heart failure without demonstrable cause in the last trimester of pregnancy or within the first 6 months after delivery. It occurs in about 1 in 4000 deliveries and is often unrecognized as symptoms of normal pregnancy commonly mimic those of mild heart failure. We describe a previously asymptomatic patient who presented with a cardiac arrest at induction of general anaesthesia for emergency Caesarean section and subsequently developed acute heart failure. This case is unique both in its mode of presentation and the total absence of antecedent symptoms or signs of cardiac disease.

We hypothesise that in labours induced for gastroschisis, fewer caesarean sections are performed than in labours induced for other indications at the same gestation. If labour does not occur spontaneously before 38 weeks in uncomplicated cases of gastroschisis, labour is induced at our hospital. Cases of gastroschisis from January 1997 to October 2002 were identified using our anomaly database and cross-referenced with the Ciconia Maternity Information System (CMIS). Cases induced were matched for gestation and parity in a ratio of 1 : 3 with controls induced for all other reasons (CMIS did not indicate the reason for induction). Ninety-eight cases of gastroschisis were identified. Five women were delivered by elective caesarean section. Thirty-seven women laboured spontaneously, of whom two had an emergency caesarean section and one had an instrumental vaginal delivery. Forty-nine women were induced and these were matched with 147 controls. Thirty-four of the study group were nulliparous. The average ges...

This is a case report of spontaneous haemoperitoneum caused by ruptured utero-ovarian vessels during the third trimester of pregnancy. The patient presented with acute abdominal pain and hypotension twice to the emergency room. The initial diagnosis was placental abruptio and the patient had emergency caesarean section. There was utero-ovarian plexus laceration and suture-ligation was performed. The maternal outcome was good. The infant had birth asphyxia and was extubated on the third day. Both mother and infant were discharged in good condition.

Background Diabetes in pregnancy accounts for a disproportionately high caesarean section (CS) rate. Pursuant to our previous in vitro laboratory findings of impaired uterine contractility in diabetics (DM), we hypothesised that more emergency C/S in DM are secondary to delay in the first stage of labour reflecting poor uterine function. Methodology We conducted a case control retrospective study at Liverpool Womens9 Hospital over a 10 -year period from January 2001 to January 2011. Of 73 560 deliveries, 1183 were diabetic (DM) pregnancies. We compared delivery outcomes with 1099 non-DM controls matched for age, parity and previous C/S. Results The C/S rate was higher in DM compared to controls; the overall CS rate was 65% in type 1 DM (table 1). There was a higher number of C/S for failed induction and C/S due to delay in first stage in DM patients including DM with normal BMI (table 2). Conclusion These results suggest that even accounting for differences in BMI, diabetic women had an increased rate of emergency C/S due to delay in the first stage of labour compared to non-DM, supporting the laboratory findings of deficient myometrial contractility.

Aim To determine the change in management of the pathological cardiotocograph (CTG) in labour with regards to the use of fetal blood sampling (FBS) prior to delivery by emergency Caesarean section. Methods A retrospective study of a population delivered by emergency Caesarean section, the primary indication being an abnormal CTG was conducted in 2008. This study was repeated in 2010. Results Fifty cases were reviewed each time. There was 50% increase in the number of FBS attempted in this re-audit. There was 85% increase in the appropriate interpretation and management of all FBS taken. In 2008, 9/50 (18%) cases had a successful normal pH level taken but all proceeded straight to Caesarean section regardless. However in 2010, 11/13 cases (85%) had successful normal pH levels taken and all were reviewed in the appropriate time frame. 5/11 (45%) cases had repeat FBS taken. The remainder 7/11 (65%) cases were reviewed as appropriate and delivered by Caesarean section for other obstetric indications, primarily failure to progress. A general improvement in the documentation of the procedure of FBS was noted. Conclusions With a background of rising local and national Caesarean section rates, this re-audit demonstrates a significant increase and much improved use of FBS to establish fetal pH levels in cases where delivery by Caesarean section is contemplated because of a pathological CTG.

Birthweight is known to be an important independent prognostic factor for morbidity and mortality of pre-term infants. However, little is known regarding the effect of birthweight on an infants9 ability to tolerate labour. We set out to compare birthweights in term infants born by spontaneous vaginal delivery and those born by emergency caesarean section for suspected fetal compromise (fetal distress). One hundred term infants born by emergency caesarean section due to fetal distress in labour and 100 infants born by spontaneous vaginal delivery were identified from hospital birth records. Birthweight and gestation at delivery were documented for all infants and birthweight centiles calculated. Infants born by emergency caesarean section due to an identifiable cause such as umbilical cord prolapse or placental abruption were excluded. Infants delivered by emergency caesarean section for fetal distress had a mean birthweight of 3415g, a median of 3376, and a range of 2144g – 4810g. Infants delivered by spontaneous vaginal delivery had a mean birthweight of 3535g, a median of 3550g, and a range of 2600g – 4480g. When matched for gestation, infants born by emergency caesarean section had a significantly lower mean birthweight centile (46), compared to infants born by spontaneous vaginal delivery (56) (p=0.02). This data suggests that infants born by emergency caesarean section due to fetal distress are less well grown (when matched for gestation) than infants born by spontaneous vaginal delivery, and that feto-placental reserves are related to birthweight even in the apparently appropriately grown fetus.

Aim To assess decision to delivery interval (DDI) among women requiring caesarean section (CS) for category I&II. To examine factors associated with delay of time. To compare spinal and epidural top-up anaesthetic, in these cases. Methods Data were collected prospectively for all women having CS for grade I&II. Special data collection form was designed looking for time interval from diagnosis to arrival in theatre, start of the operation, and time of delivery. Secondary outcome measures included cord PH, rate of postpartum haemorrhage and intra-operative complications. We have excluded cases of trial of instrumental delivery from the study. Results One hundred and seventy one patients were examined including 27 cases of Grade I CS and 144 cases of Grade II CS. Out of 27 women with grade I CS 12 had CS under spinal anaesthetic with median DDI 33 min (range 16-51) and epidural top-up in 15 cases with median DDI 23 min (16-44). Out of 144 grade II CS, 38 women had CS under spinal anaesthesia with a median DDI 50 (20-133) and epidural top-up in 106 with a median DDI 45 min (19-185). Low cord PH was observed in 11.1% of grade I CS and in 6.9% of grade II CS. Conclusion The duration of DDI is quite variable among women having emergency CS. Each unit need to assess its own rate and analyse cause for delay and impact on neonatal outcome.

We reviewed the deliveries in a teaching hospital in a multiracial community over the period of one year (1988), and investigated the relationship between maternal height, ethnic origin, and the extremes of birth weight with the likelihood of emergency lower segment caesarean section (LSCS). After excluding patients with obvious indications for LSCS, 5,050 patients were entered in the study. Chi-square analysis showed that the risk of emergency LSCS is significantly higher in the Indians compared to Chinese and Malays, but does not differ significantly between the latter two groups. Logistic regression analysis showed that birth weight of less than 2,500 g or greater than 3,500 g is the most significant association with emergency LSCS rate. Conditional logistic regression showed that, provided the individuals conformed to the characteristics of the cohort in this study, risk of emergency LSCS for a 150 cm (25th centile) tall Indian pregnant lady is almost twice that of a 158 cm (75th centile) tall non-Indian).

Eighteen percent of 212 consecutive emergency caesarean sections at term were classified as truly 'urgent' (requiring delivery within 20 min). The interpretation of the intrapartum cardiotocographs was generally accurate, although after an independent review of the tracings six cases classified originally as 'urgent' had Krebs scores > 4. Among the 'urgent' cases the median total time interval from decision to operate to delivery of the baby was 25 min (IQR between 20 and 33). One-third of the 'urgent' cases had total time intervals exceeding 30 min and the longest delay was 56 min. Acidotic FBS results and antepartum haemorrhage produced most rapid responses. Nine percent of the babies required SCBU admission. Seven percent of the patients in the study had general anaesthetics for their operations. Although the achievement of a total time interval delay of between 20 and 30 min was possible with regional anaesthetic techniques, a general anaesthetic was needed to obtain a time interval of less than 20 min. In conclusion, regional anaesthetic techniques can provide response times which are acceptable for the majority of 'urgent' caesarean sections with the administration of a general anaesthetic occasionally justified in the fetal interest.

Background There is a widespread assumption, but limited evidence, that consultant presence on the delivery suite improves obstetric outcomes. Objectives The main objective was to evaluate whether consultant presence on the delivery suite is associated with a lower emergency caesarean section (CS) rate. The secondary aim was to assess the effect of type of subspecialty training on the rate of emergency CS. Methods A retrospective review of all emergency CS at a tertiary referral obstetric unit between July 2009 and December 2010. Elective CS deliveries were excluded. The emergency CS rate was compared between periods with and without consultant presence. Delivery Suite is covered by a senior registrar (usually a subspecialty trainee) when a consultant is not present. We also compared the emergency CS rate between sessions covered by obstetrics and gynaecology subspecialty senior registrars. Results During this 18-month period, there were 8051 deliveries (1502 emergency CS). The emergency CS rate during consultant time was 17.9%, compared with 21.5% in senior registrar time (p Conclusions Our study supports the belief that Consultant presence on the Delivery Suite reduces intervention, specifically the emergency CS rate. It reinforces the recommendation that consultant presence should be increased, particularly in higher risk units.

A male infant was born by emergency caesarean section at 34(+4) weeks for failed induction of labour. Shortly after birth a depression about the same size as the baby's fist was noted over the right parietal region. After careful consideration of the perinatal history and examination findings, the baby was diagnosed with faulty fetal packing. At 3-month follow-up, the defect had completely corrected without intervention.

A 25 year old, 68 kg, primigravida, was taken up for emergency caesarean section for meconium stained liquor and fetal distress. She was a known case of pre eclampsia and her blood pressure was controlled on tab methyl dopa. she was administered general anaesthesia. after delivery of baby she went into postpartum hemorrhage which was controlled with intramyometrial prostodin. but immediately after its administration she went into acute pulmonary edema.

A postal questionnaire on blood ordering practices and blood availability was sent to 89 randomly selected maternity units within the United Kingdom. The replies demonstrated a wide variation in crossmatching practices. Of those units that replied, 56% crossmatch for elective and 64% for emergency Caesarean section, 54% for manual removal of placenta, and 29% for fetal distress in labour. The remainder 'group and screen' for these indications. Lack of 24 h cover by a resident haematology technician, and location of blood banks distant to the obstetric unit were associated with significant delays in blood availability. More extensive use of the 'group and screen' technique may reduce unnecessary crossmatching without jeopardizing patient safety, and is advocated for maternity units.

A survey of 45 Danish anaesthetic departments providing obstetric services was conducted to discover which forms of prophylaxis against pulmonary aspiration of acid gastric contents are currently used in obstetric patients. Very few departments used regular aspiration prophylaxis during active labour. For caesarean section pharmacologic prophylaxis was administered by approximately one third of the departments. Sodium citrate was the preferred agent. The use of H 2 -receptor antagonists was uncommon. Metoclopramide was not used. For emergency caesarean section gastric emptying was used by 62% of the departments.

A number of small-scale studies investigating various aspects of midwifery care for women in labour are the subject of this chapter. Although not extensive enough to warrant a separate chapter each, they are nonetheless of sufficient importance to merit inclusion in the series. Papers describing the studies were first presented at Research and the Midwife conferences but the conference proceedings are not necessarily readily available. The studies are of artificial rupture of the membranes in labour (Henderson, 1985), the use of a chair in the second stage of labour (Hillan, 1984; Romney, 1984; 1987), postpartum haemorrhage (Moore and Levy, 1982; 1983) and women’s reaction to delivery by caesarean section (Kirchmeier, 1985). Each study is described, the findings presented and discussed in the light of some studies which have been reported since the original studies were concluded. However, no attempt has been made to review all the literature in each area. Lessons which can be learnt and implications for practice and further research are discussed in a final section.

Objectives To examine the associations between fear of childbirth and emergency caesarean section and between fear of childbirth and dystocia or protracted labour and fetal distress.

Caecal bascule is an unusual type of volvulus that presents a challenging diagnosis for clinicians. We present a case of a forty-two year old female who developed a perforated caecal bascule five days post emergency caesarean section. The diagnosis of caecal bascule was made intraoperatively during a hemicolectomy. Greater awareness of this phenomenon and its clinical and radiological findings is important to avert the development of bowel perforation or gangrene.

Female conjoined twins (thoraco-omphalopagus) were delivered by emergency caesarean section in a private nursing home. On examination, one of the twins was dead and was threatening the survival of the surviving twin (twin A). An emergency separation was performed to salvage the surviving twin.