Background and Aims: Spinal anesthesia is the preferred technique over general anesthesia in caesarean section. General anesthesia is still used for category-1 emergency caesarean section because of time constraints. We usually follow rapid sequence general anesthesia in obstetrics to avoid aspiration. However, this technique poses several problems. An approach of spinal anesthesia termed as rapid sequence spinal anesthesia has been described. The present study was designed to compare the time intervals (time for anesthesia, time to surgical readiness, incision to delivery time, emergence time) and Apgar score between rapid sequence spinal anesthesia and rapid sequence general anesthesia during category-1 caesarean section and to evaluate whether rapid sequence spinal anesthesia is a better option in category-1 caesarean section. Materials and Methods: In this prospective randomized study, 60 patients of American Society of Anesthesiologists physical status (ASA-PS) I posted for category-1 emergency caesarean section were randomly allocated into two equal groups and received either of the two techniques. Demographic data, respective time intervals, and Apgar scores were noted and compared. Results: The time for anesthesia, surgical readiness, and emergence were significantly longer (P < 0.001) in rapid sequence general anesthesia group as compared to rapid sequence spinal anesthesia group (144.80 ± 3.42 vs 131.20 ± 3.40 s, 178.76 ± 4.09 vs 169.93 ± 3.08 s, 512.13 ± 34.33 vs 222.10 ± 12.80 s). No significant difference was found in incision to delivery time and Apgar scores between the two groups. Conclusion: Because anesthesia to delivery time is shorter in rapid sequence spinal anesthesia, this technique may be equivalent to rapid sequence general anesthesia in category-1 emergency caesarean section.

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Neuraxial blocks in parturients with scoliosis and/or previous back surgery have traditionally been avoided due to concerns such as difficulty, increased complications, and decreased efficacy. Recent studies suggest that with attention to proper anesthetic technique and improvements in surgical procedures the success rate of neuraxial blocks is improved. The use of ultrasound may also improve the success rate of neuraxial blocks and should be considered. We review the recent literature and suggest practical approaches to neuraxial blocks in these parturients.

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Headache is a common occurrence during pregnancy. A postural headache is invariably considered to be a postdural puncture headache in patients who receive neuraxial anesthesia with or without obvious or incidental dural puncture. Cerebral venous thrombosis (CVT) is rare in pregnancy and in the postpartum period, with an incidence of 1:10,000–1:25,000. Pregnancy-induced changes in coagulation result in a hypercoagulable state, which may naturally reduce the incidence of postpartum hemorrhage, but may also increase the risk of CVT. Postpartum headache being frequently encountered may complicate the diagnosis of CVT. We report a case of a woman who developed a postpartum CVT after an accidental wet tap and intrathecal catheter placement during labor.

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Presentation of Cerebral venous sinus thrombosis (CVST) is clinically confusing. We present a case of 31 years an old postpartum woman who was treated with intravenous hydrocortisone for post dural puncture headache (PDPH) and developed CVST. We aim to present the diagnostic difficulties of such cases and the potential role of dural puncture and corticosteroids in the occurrence of CVST.

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Postural orthostatic tachycardia syndrome (POTS) is an autonomic disorder which is characterized by postural tachycardia and orthostatic symptoms without associated hypotension. We report a case of a parturient, after her consent, with POTS, who underwent a cesarean section under spinal anesthesia. The anesthetic implications are also discussed.

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Background: Postoperative shivering is an important common complication after general anesthesia. This may lead to dissatisfaction and a sense of discomfort, especially in parturients undergoing cesarean section. In addition to warming, many drugs have been investigated for prevention of shivering. The aim of this study was to evaluate the efficacy of intravenous paracetamol for prevention of shivering after general anesthesia in cesarean section. Materials and Methods: In this prospective randomized double-blind controlled clinical trial, 110 pregnant women, physical Status I or II, based on the classification of American Society of Anesthesiologists (ASA), aged 18–40 years, who were scheduled for elective cesarean section under general anesthesia were included in the study. They were randomly divided into two groups of 55 each. One group received 100 ml normal saline, and another group received 1 g of paracetamol in 100 ml normal saline intravenously, 15 min after the delivery of the baby. The anesthesia technique was similar in both the groups. Tympanic membrane temperature was measured before and after the induction of anesthesia and every 15 min till the end of recovery from anesthesia. Postanesthetic shivering was graded on a scale of 0 to 4; if the score was more than 2, it was treated with 25 mg pethedine. Vital signs and side effects were recorded during the surgery and recovery period. Results: There were no significant differences between the two groups regarding age, weight, height, and duration of surgery (P > 0.05). Shivering was seen in 5 parturients (9.1%) in paracetamol group (group A) and 28 parturients (50.9%) in the saline group (group N). On a scale of 0 to 4, shivering was of lower intensity in paracetamol group compared to the saline group (P < 0.05). There was a fall in core temperature in both the groups after induction of anesthesia, which was statistically similar (P > 0.05). There was no difference in the incidence of hypotension, nausea, and vomiting among the two groups (P > 0.05). Conclusion: The prophylactic use of intravenous paracetamol during surgery is effective for the prevention of postoperative shivering.

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Labor and delivery are associated with high mortality in parturients with primary pulmonary hypertension with Eisenmenger's syndrome. Epidural anesthesia during labor has been shown to be effective in reducing the morbidity and mortality. We administered epidural labor analgesia successfully to a parturient with primary pulmonary hypertension with Eisenmenger's syndrome. A team approach for such patients leads to successful outcome.

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This case report details an interesting case of suspected spinal bifida in an obstetric patient who presented for an elective cesarean section. A large scarred/dimpled area, surrounded by significant hair growth in the region of the lumbar spine had been missed in multiple antenatal and preoperative assessments and was recognized on the day of the surgery as the patient was being prepared for spinal anesthesia. The patient was uncertain regarding the pathology of the lesion, and all investigations relating to this had been undertaken in Pakistan where she lived as a child. General anesthesia was undertaken because magnetic resonance imaging had not been performed and tethering of the spinal cord could not be ruled out clinically. The patient suffered from significant blood loss intra and postoperatively, requiring a two unit blood transfusion. She was discharged after 5 days in the hospital. This case highlights the need for thorough examination in all obstetric patients presenting to the preoperative clinic, focusing on the airway, vascular access, and lumbar spine. Patients may not always disclose certain information due to a lack of understanding, embarrassment, forgetfulness, or language barriers. Significant aspects of their care may have been undertaken abroad and access to these notes is often limited. Preoperative detection of the lesion would have allowed further investigation and imaging of the lesion and enabled more comprehensive discussions with the patient regarding anesthetic options and risk.

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Background: A renewed interest has emerged in the use of bolus or intravenous (IV) infusion of phenylephrine for management of hypotension during spinal anesthesia (SA) for caesarean section to achieve optimal maternal and neonatal outcome. The aim of our study was to investigate the efficacy of using three different phenylephrine infusion regimens to maintain maternal baseline blood pressure during SA for caesarean delivery. Materials and Methods: Ninety parturients undergoing SA for elective caesarean delivery received an IV infusion of phenylephrine in one of three different concentration ratios. The groups contained a potency equivalent of 100 μg/min, 80μg/min, and 60 μg/min infusion doses. The infusions were adjusted to maintain systolic blood pressure (SBP) near the baseline until uterine incision. Hemodynamic changes in mother and umbilical cord blood gases were compared. Results: As concentration of phenylephrine increased, following significant trends were noticed: in group A, 10/29 (34.5%) patients had hypotension as compared to 2/28 (7.4%) patients in group B and 4/28 (14.3%) patients in group C. On the other hand, we found that the incidence of hypertension and bradycardia was higher in groups B (22/28; 4/28) and C (26/28; 10/28) as compared to those in group A (3/29; 2/29), respectively. Neonatal acid-base status in all three groups was favorable. Conclusions: As the concentration of phenylephrine increased, the tendency for SBP to be above the baseline increased, along with an incidence of bradycardia. Therefore, we conclude that low dose infusion regimens of phenylephrine, i.e. between 60 μg/min and 80 μg/min, will be more effective in prevention of hypotension during SA for caesarean delivery.

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