Perioperative anaesthetic management of high-order repeat caesarean section: audit of practice in a university-affiliated medical centre.
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+/-20 kg 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+/-19 min (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.


CONCLUSIONS
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.
Ioscovich
A
A
Departments of Anesthesiology, Perioperative Medicine and Pain Treatment, Obstetrics and Gynecology and the Intensive Care Unit of the Shaare Zedek Medical Centre, Hebrew University, POB 3235, Jerusalem 91031, Israel. aioscovich@gmail.com
Mirochnitchenko
E
E
Halpern
S
S
Samueloff
A
A
Grisaru-Granovsky
S
S
Gozal
Y
Y
Einav
S
S
D000328:Adult; D015360:Analgesia, Epidural; D016362:Analgesia, Obstetrical; D000768:Anesthesia, General; D000773:Anesthesia, Obstetrical; D000775:Anesthesia, Spinal; D001034:Apgar Score; D017604:Cesarean Section, Repeat / Q000009:adverse effects; D017558:Elective Surgical Procedures; D017707:Erythrocyte Transfusion; D005260:Female; D006785:Hospitals, University; D006801:Humans; D007231:Infant, Newborn; D007431:Intraoperative Complications / Q000453:epidemiology; D008485:Medical Audit; D016343:Monitoring, Intraoperative; D010120:Oxytocics; D010121:Oxytocin; D011247:Pregnancy; D013529:Surgical Wound Dehiscence; D014599:Uterus / Q000293:injuries; D055815:Young Adult
D010120:Oxytocics; D010121:Oxytocin