Where there is no Anaesthetist- C- Section Under Local Anaesthesia

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Where there is no Anaesthetist-C- Section Under
Local Anaesthesia

• Dr N S Iyer MBBSDGO
• Retd Civil Surgeon ,Kerala Govt health services,
• Former PO Safe Motherhood UNICEF,Chennai,
• Presently- Consultant ,Averting Maternal Death
  and Disability programme(AMDD)
• Indian Institute of management, Ahmedabad

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• Local anesthesia is a safe alternative to
  General, Ketamine or Spinal Anesthesia when these
  anesthetics are persons trained in their use are
  not available.
• - Managing Complications in
• Pregnancy and Childbirth
• IMPAC, WHO Publication.

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MMR Global,India,Kerala
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Source.MOHW(GOI) SRS
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Demographic Profile -Kerala
Census 2001-SRS 2002
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• In spite of having high level of literacy women
  in Kerala do not hesitate to give consent for CS
  to be done under Local if required.
• Though CSLA involves a certain amount of risk for
  the doctor and a little discomfort to the patient
  it is definitely a pleasure for the doctor to
  have saved the life of a mother especially with
  the available limited facilities

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Why CSLA

• In emergency situations when the next available
  institution is far away to save the mother and
  baby this is found to be a very good alternate
  solution..
• In sub district hospitals when cases are referred
  from peripheral PHCs with Obstructed labour,
  undignosed Breech, APH etc ,it may be fatal to
  transfer the case again to another centre. The
  loss of either mother or the baby is certain

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• A study was done on 3487 cases of C sections in
  Gh thiroor in Kerala.
• Period of study April 1994-march 2002
• Total births -23850
• LSCS- 3487
• CSLA- 3392
• CSGA/SA -95

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Primi 32 Multi 68 Parity 1-3
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Indications.
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Wound Infection 8 Post Operative paralytic
ileus 3 Perinatal deaths 0.50 Normal
POP 88.50 Ceasrean Hysterectomy 0.20
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In 177 cases done under Local prior to joning
the Pvt service
Complications
Indications
It can be seen that there is not much
difference in indications and Complications
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Advantages

• Easy methodology
• No time lapse in starting the surgery
• Recovery is smooth-Post operative pain and
  vomiting is less when compared to other forms of
  anaesthesia.

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Disadvantages

• No Proper relaxation. Bowel and omentum may
  interfere.
• More than 2 Previous section with adhesion may
  cause difficulty
• Pfannensteil incision may be difficult.
• Delivering the baby in deep transverse arrest may
  be difficult

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Other Cases on LA

• Caesarean Hysterectomy -6 cases
• Abruptio Placentae-Acute abdomen Successful CS
  -2 cases
• Rupture Uterus -2 cases
• Severe PIH-PPH-2 cases

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Who Can doo

• Well experienced Confident surgeon
• To be done quickly
• Gentle and minimum handling of tissues
• Well trained assistant
• Proper counseling of patient and relatives and
  good rapport with them

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How to do-The procedure

• Premedication-
• Inj Rantac 1 amp,
• Inj Reglan /Phenergan 25 mg .
• Inj Atropine Sulphate .6 mg,IV line,
• 2 Xylocaine-diluted up to 40 ml 200mg maximum.
• Inject Fortwin amp IM/IV
• TPR Chart. BP monitoring

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• Infiltrate the skin with 1/0.5 Xylocaine. Sub
  umbilical vertical incision is preferred.
• Infiltrate on either side of the proposed
  incision. Incise the skin and the infiltrate
  rectal sheath. Infiltrate the parietal and
  visceral peritoneum over the site of incision.
• Once the baby is delivered and cord clamped 50 mg
  Pethidine given IV and 50 mg IM to the woman.
• Placenta expelled. Massage the uterus.The
  uterine and abdominal wound closed.

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Can we provide anaesthesia service to all?

• There is an unmet need of C section in India.
• Facility surveys indicates poor availability of
  anaesthetist even in metros.
• Most of the sub district hospitals do not even
  have one anaesthetist
• Short training on anaesthesia even for MBBS
  doctors is not favoured by the persons concerned
  .
• Cannot even imagine to have nurse anaesthetist.
• The deficiency is perpetual

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The issue

• We preach, but dont practice
• CSLA not mentioned in any of the training
  programme for Emergency Obstetric Care
• Poor dissemination of WHO endorsement.
• Lack of support from Professional bodies

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THANQ