Successful delivery in a morbidly obese patient after failed intubation and regional technique
Bristol, UK
* E-mail: mark.scrutton{at}ubht.nhs.uk
Editor—We read with interest the letter describing a Caesarean section under local anaesthetic infiltration in a patient with a BMI of 49 after failed intubation and subsequent failed neuraxial blockade.1 Although successful, we cannot agree with the authors that local infiltration is an appropriate de novo technique to carry out a Caesarean section in the UK in any patient, but particularly in a morbidly obese woman.
The most recent report into maternal mortality in the UK 2003–05, ‘Saving mothers’ lives', highlights the risks associated with obesity in the obstetric population.2 Ideally, such patients should be referred for anaesthetic review antenatally. On admission to the labour ward, they should be reviewed by the duty anaesthetist and an anaesthetic management plan should be made in case operative delivery is required. Regional anaesthesia is preferred in obesity but requires a skilled anaesthetist and appropriate equipment. A back-up plan to convert to general anaesthesia must always be considered and advanced airway skills, including awake fibreoptic, should be available.
If the need for a Category 1 Caesarean section arises in such a woman, the duty obstetrician, midwife, and anaesthetist must be aware that there may be a delay in establishing anaesthesia and senior help may be required. During this time, attention must be paid to optimizing fetal condition using intrauterine resuscitative measures.3 In most Category 1 Caesarean sections, there is no evidence that the most rapid anaesthetic technique (general anaesthesia with rapid sequence induction) improves neonatal outcomes, as indicators of fetal distress lack specificity.4
In general, it is held that the mother's life must not be deliberately endangered in deference to the baby. Embarking on a Caesarean section under local infiltration commits the mother to the dangers of abdominal surgery with a high risk of anaesthetic failure. In such circumstances, manipulation of viscera is likely to cause pain, nausea, vomiting, and loss of patient co-operation. Morbid obesity increases these risks. As the authors had already established that they were in a ‘can't intubate/can't ventilate’ scenario, we would ask what their ‘Plan B’ would have been had complications arisen.
We would suggest that local infiltration should be reserved as a possible mode of supplementing inadequate regional blocks in some circumstances and to provide postoperative analgesia after general anaesthesia. It is not, as the authors suggest, an appropriate ‘life-saving technique in emergency Caesarean section in morbidly obese patients’.
Swansea, UK
* E-mail: drsangy{at}hotmail.com
Editor—We would like to thank Dr Scrutton and colleagues for their interest in our case. The mother presented directly to the labour ward ‘in labour’ in the early hours of the morning as already mentioned. Even with meticulous planning, no one can predict the onset of pre-term labour accompanied by fetal distress. And what if a very carefully placed epidural catheter were to ‘fall-out’? These things do happen! Obese patients have high initial rate of unsuccessful regional anaesthesia, especially epidural catheter placement. In one study, the initial placement of epidural catheter failed in 42% of morbidly obese parturient, but only 6% in control patients.5
In answer to the points they raise. We first would like to make it clear that we have not recommended local anaesthetic for LSCS as an appropriate de novo technique in any part of the world including UK. We wished to highlight the usefulness of this technique in a situation like we found ourselves in. Local anaesthetic for Caesarean section was an established technique for LSCS just a few decades ago. The obstetric literature in 1960s and 1970s has an abundance of such references, including comparative studies,6 and was at that time described as safer than general anaesthesia by some authorities.
We are aware of the CEMACH recommendations mentioned by Dr Scrutton. This patient presented to the labour ward early in the morning with fetal distress. The anaesthetist was called to attend for an emergency section; therefore, before an anaesthetic review for epidural could be arranged. We saw the patient in the operating room.
We do not agree with Dr Scrutton and team that local infiltration anaesthesia in such a situation was ‘like putting mother's life in danger deliberately’, as the mother, her partner, and the rest of the family were appraised of the situation and were keen to go ahead with it, and to have delivery of a live baby. As we understand, there is no evidence that Caesarean section under local anaesthesia has an increased incidence of mortality than any other form of anaesthesia.
Finally, we agree with Dr Scrutton, in that normally, local anaesthesia should be supplementary to other forms of anaesthesia. This situation was extraordinary. We reiterate, we do not recommend local anaesthesia as a sole technique for Caesarean section, but would like to share our experience of a successful delivery under local anaesthetic infiltration. In our case with no complications to either baby or mother.
References
1 Patil S, Sinha P, Krishnan S. Successful delivery in a morbidly obese patient after failed intubation and regional technique. Br J Anaesth (2007) 99:919–20.
2 Cooper GM, McClure JH, Anaesthesia chapter from Saving Mothers’ Lives: reviewing maternal deaths to make pregnancy safer. Br J Anaesth (2008) 100:17–22.
3 Thurlow JA, Kinsella SM. Intrauterine resuscitation: active management of fetal distress. Int J Obstet Anesth (2002) 11:105–16.[CrossRef][Web of Science][Medline]
4 Yentis SM. Whose distress is it anyway? ‘Fetal distress’ and the 30-minute rule. Anaesthesia (2003) 58:732–3.[CrossRef][Web of Science][Medline]
5 Saravanakumar K, Rao SG, Cooper GM. Obesity and obstetric anaesthesia. Anaesthesia (2006) 61:36–48.[CrossRef][Web of Science][Medline]
6 Stangl J. Caesarean section under potentiated local anaesthesia. Zentralbl Gynakol (1965) 87:862.[Medline]
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