急診剖宮產(chǎn)的

麻醉選擇和術中處理費敏2010-3-26急診剖宮產(chǎn)的

麻醉選擇和1DefinitionAbdominaldelivery

asurgicalprocedurethatpermitsdeliveryoftheinfantthroughincisionsintheabdominalanduterinewall.DefinitionAbdominaldelivery2CesareanSectionCaedere–SecoPompiliusII

730BCnotwidelyuseduntilthe1920sCesareanSectionCaedere–Seco3IndicationsforCesareanSectionRepeatScheduledFailedattemptatvaginaldeliveryDystociaAbnormalpresentationTransverselieBreechMultiplegestationFetalstress/distressDeterioratingmaternalmedicalillnessPreeclampsiaHeartdiseasePulmonarydiseaseHemorrhagePlacentapreviaPlacentalabruptionIndicationsforCesareanSecti4CesareanSection>60%unplannedMoreextensiveperipartummonitoringLowerthresholdforsurgicalinterventionCesareanSection>60%unplanned5Whatisan‘emergency’Caesareansection?-Category1&2GradeDefinition(attimeofdecisiontooperate)Category1ImmediatethreattolifeofwomanorfetusCategory2Maternalorfetalcompromise,notimmediatelylife-threateningCategory3NeedingearlydeliverybutnomaternalorfetalcompromiseCategory4AtatimetosuitthewomanandmaternityteamWhatisan‘emergency’Caesare6Category1

IndicationPlacentalabruptionuterinerupture

cordprolapse

ActivelybleedingplacentapraeviaIntrapartumhemorrhagePresumedfetalcompromisewithseverelyabnormalCTGand/orseverefetalacidosisCategory1IndicationPlacenta7The30-minuteruleamaximumdecision-to-deliverytimeof30minforCategory1situation

AssociationofAnaesthetistsofGreatBritainandIrelandandObstetricAnaesthesists’Association.Guidelinesforobstetricanaesthesiaservices;2005.

HillemannsP,StraussA,HasbargenU,etal.Crashemergencycesareansection:decision-to-deliveryintervalunder30minanditseffectonApgarandumbilicalarterypH.ArchGynecolObstet2005;273:161–165.anaesthetistinformed–deliveryThe30-minuteruleamaximumde8PerianestheticEvaluationAdirectedhistoryandphysicalexaminationplateletcountAnintrapartumbloodtypeandscreenforallparturientsreducesmaternalcomplicationsPerianestheticrecordingofthefetalheartratereducesfetalandneonatalcomplicationsPerianestheticEvaluationAdir9AdirectedhistoryandphysicalexaminationMaternalhealthandanesthetichistoryRelevantobstetrichistoryAirwayandheartandlungexaminationBaselinebloodpressureBackexaminationwhenneuraxialanesthesiaisplannedorplacedAdirectedhistoryandphysica10

PlateletcountAroutineintrapartumplateletcountdoesnotreducematernalanestheticcomplicationsSuspectedpreeclampsiaorcoagulopathyEclamptic-plt>80*109.l-1

MoodleyJ,JjuukoG,RoutC.EpiduralcomparedwithgeneralanaesthesiaforCaesareandeliveryinconsciouswomenwitheclampsia.BritishJournalofObstetricsandGynaecology2001;108:378–82.

PlateletcountAroutineintr11AspirationProphylaxisclearliquidsupto2hbeforeinductionofanesthesiaAfastingperiodforsolids6–8h(fatcontent?)Furtherrestrictionmorbidobesity,diabetes,difficultairwaynonreassuringfetalheartratepatternAntacids,H2ReceptorAntagonists,andMetoclopramidereducesmaternalcomplicationsAspirationProphylaxisclearli12Perianesthetic–MaternalPositionAortocavalcompression3mechanismsuteroplacentalperfusionvenousreturnC.O.andBPObstructionofuterinevenousdrainageuterinevenouspressureanduterinearteryperfusionpressureCompressionofaortaorcommoniliacarteriesuterinearteryperfusionpressurePerianesthetic–MaternalPosit13Perianesthetic–MaternalPositionAvoidaortocavalcompressionKinsellaSM.Editorial.Lateraltiltforpregnantwomen:why15degrees?Anaesthesia2003;58:835–7.Perianesthetic–MaternalPosit14ChoicesofAnesthesiaGeneralanesthesiaRegionalanesthesiaLocalanesthesiaChoicesofAnesthesiaGenerala15ChoicesofAnesthesiadependsontheindicationsforthesurgerythedegreeofurgencymaternalandfetusstatusdesiresofthepatientSafest

+mostexpedient

midwifeanesthetistobstetricianChoicesofAnesthesiadepend16Regionalanesthesia>85%emergencyCaesareansection<3%RegionalanesthesiarequireconversiontoGARegionalanesthesia>85%emerge17RegionalanesthesiaEpiduralanesthesiaspinalanesthesiaCombinedSpinal/Epidural(CSE)RegionalanesthesiaEpiduralan18Epidural√AsfastasGATitrateddosingandsloweronsetriskofseverehypotensionandreduceduteroplacentalperfusionDurationofsurgerynotanissueLessintensemotorblockadeLowerextremity“musclepump”mayremainintactincidenceofthromboembolicdiseaseEpidural√19Epidural×RiskofsystemiclocaltoxicityGreaterplacentaltransferofdrugthanwithspinalBUT–doesnotaffectneonatalApgarscoreandoflittleclinicalsignificancewhenappropriatedosesusedRiskofhighspinalEpidural×20EpiduralThespeedofonsetThechoiceoflocalanestheticPossibleadjuvantsEpiduralThespeedofonset21Epidural0.5%bupivacaine0.75%ropivacaine0.5%levobupivacaine2-chloroprocainelidocaine1.8%lidocaine,0.76%bicarbonateand1:200000epinephrine

AllamJ.Anaesthesia2008;63:243–249.Epidural0.5%bupivacaine22Epiduralfailure24%failtoachieveapain-freeoperation

KinsellaSM.Aprospectiveauditofregionalanaesthesiafailurein5080caesareansections.Anaesthesia2008;63:822–832.ConversiontoSpinalanesthesia?unpredictablehigh-spinalblocksarelativecontraindicationtogivespinalanaesthesiafollowingepiduralanalgesiainlabourthedoseoflocalanesthesiaby20–30%anduseadditionofopioidsanormaldoseoflocalanesthesiaafter30minsincethelastdoseofepiduralwithnodocumentedblockEpiduralfailure24%failtoac23Spinal√SimpleRapidonsetDenseblockadeNegligiblematernalriskofsystemiclocaltoxicityMinimaltransferofdrugtoinfantNegligibleriskoflocalanestheticdepressionofinfantSpinal√Simple24Spinal×Rapidonsetofsympatheticblockade–abrupt,severehypotensionLimiteddurationSpinal×Rapidonsetofsympath25SpinalBupivacaine(isobaric/hyperbaric)levobupivacaine,ropivacaine

lessmotorblockade&toxicityadditionofopioid(Morphine,fentanylorsufentanil)ReducetheneededdoseoflocalanaesthesiashortenthetimetoreadinessforsurgeryenhancesblockadeofvisceralpainpostoperativeanalgesiaSpinalBupivacaine(isobaric26SpinalPeoloadcoloadApplicationofmonitorsSupplementaloxygenLeftuterinedisplacementAggressivetreatmentofhypotensionSpinalPeoloadcoload27AggressivetreatmentofhypotensionAggressivetreatmentofhypote28AggressivetreatmentofhypotensionExaggeratedLUDIVfluidsEphedrineand/orphenylephrine

Reflexbradycardia(HR<45-50bpm)

anticholinergicagentAggressivetreatmentofhypote29CombinedSpinal–Epidural(CSE)

Initiallydescribedin1981(epiduralcatheteratL1-2andspinalatL3-4)CombinedSpinal–Epidural(CS30CSE√RapidonsetanddensityofspinalanesthesiacombinedwithversatilityofepiduralanesthesiaLow-dosespinalreducetheincidencesofcardiovascularinstabilityespeciallyusefulinhighriskcardiacpatientsCSE√Rapidonsetanddensityo31CSE×Inabilitytotestepiduralcatheter18%rateoffailureextratimeconsumptionCSE×Inabilitytotestepidura32Generalanesthesia15%ofCSwasperformedundergeneralanesthesiainUSMajorityofCSweredoneunderurgentoremergentsituationsGeneralanesthesia15%ofCSwa33IndicationsforGAFetaldistressSignificantcoagulopathyAcutematernalhypovolemiaandHomodynamicinstabilitySepsisorlocalskininfectionfailedregionalanesthesiaMaternalrefusalofregionalanesthesiaIndicationsforGAFetaldistre34

GA

√RapidonsetControlledairwayandventilationhandsarefreeforfluidmanagementandhemodynamicscontrolincasesofmajorbleedingAlmostneverfailsMinimalcooperationneededfromthepatientGA√Rapidonset35GA×17XhigheranesthesiarelatedmortalitycomparedtoregionalanesthesiaRiskofdifficult/failedintubation

10Xhigherthaninnon-obstetricpopulationRiskofpulmunaryaspirationContributetouterinerelaxation/atonyExtratimeneededatendofproceduretowakeupthethepatientUsuallyfasteronsetofpostoperativepainRiskofmalignanthyperthermiaRiskofintaoperativeawarenessExposureoffetustodepressanteffectofGAMorecostlyGA×17Xhigheranesthesia36MostimportantcausesofmortalityduetoGAInabilitytointubateInabilitytoventilateAspirationpneumonitisMostimportantcausesofmorta37SuggestedTechniqueforCesareanSectionThepatientisplacedsupinewithawedgeundertherighthipforleftuterinedisplacement.Preoxygenation100%O23–5minThepatientispreparedanddrapedforsurgeryarapid-sequenceinductionwithcricoidpressure

propofol,2mg/kg(orthiopental4mg/kg)succinylcholine,1.5mg/kg

Ketamine,1mg/kg,isusedinsteadofthiopentalinhypovolemicorasthmaticpatients.SuggestedTechniqueforCesare38SuggestedTechniqueforCesareanSectionSurgeryisbegunonlyafterproperplacementoftheendotrachealtubeisconfirmedbycapnography.Excessivehyperventilation(PaCO2<25mmHg)shouldbeavoidedbecauseitcanreduceuterinebloodflowandhasbeenassociatedwithfetalacidosis.SuggestedTechniqueforCesare39SuggestedTechniqueforCesareanSection50%

N2Oinoxygenwithupto0.75MACofalowconcentrationofavolatileagentisusedformaintenanceAmusclerelaxantofintermediateduration(mivacurium,atracurium,cisatracurium,orrocuronium)isusedforrelaxationSuggestedTechniqueforCesare40SuggestedTechniqueforCesareanSectionAfterdelivered,20–30Uofoxytocinisaddedtoeachliterofintravenousfluid.N2Oconcentrationmaythenbeincreasedto70%and/oradditionalintravenousagents,suchasadditionalpropofol,anopioidorbenzodiazepine,canbegiventoensureamnesiaSuggestedTechniqueforCesare41SuggestedTechniqueforCesareanSectionIftheuterusdoesnotcontractreadily,anopioidshouldbegiven,andthehalogenatedagentshouldbediscontinuedMethylergonovine(Methergine),0.2mgintramuscularly,mayalsobegivenbutcanincreasearterialbloodpressure

15-MethylprostaglandinF2(Hemabate),0.25mgintramuscularly,mayalsobeusedSuggestedTechniqueforCesare42SuggestedTechniqueforCesareanSectionAnattempttoaspirategastriccontentsmaybemadeviaanoralgastrictubetodecreasethelikelihoodofpulmonaryaspirationonemergenceAttheendofsurgery,musclerelaxantsarecompletelyreversed,thegastrictube(ifplaced)isremoved,andthepatientisextubatedwhileawaketoreducetheriskofaspiration.SuggestedTechniqueforCesare43ObstetricHemorrhagicEmergenciesObstetricHemorrhagicEmergenc44ObstetricHemorrhagicEmergenciesLarge-boreintravenouscathetersFluidwarmerForced-airbodywarmerAvailabilityofbloodbankresourcesEquipmentforinfusingintravenousfluidsandbloodproductsrapidlyObstetricHemorrhagicEmergenc45SuggestedResourcesforAirwayManagementduringInitialProvisionofNeuraxialAnesthesiaLaryngoscopeandassortedbladesEndotrachealtubes,withstyletsOxygensourceSuctionsourcewithtubingandcathetersSelf-inflatingbagandmaskforpositive-pressureventilationMedicationsforbloodpressuresupport,musclerelaxation,andhypnosisQualitativecarbondioxidedetectorPulseoximeterSuggestedResourcesforAirway46SuggestedContentsofaPortableStorageUnitfor

DifficultAirwayManagementforCesareanDeliveryRoomsRigidlaryngoscopebladesofalternatedesignandsizefromthoseroutinelyusedLaryngealmaskairwayEndotrachealtubesofassortedsizeEndotrachealtubeguidesRetrogradeintubationequipmentAtleastonedevicesuitableforemergencynonsurgicalairwayventilationFiberopticintubationequipmentEquipmentsuitableforemergencysurgicalairwayaccess(e.g.,cricothyrotomy)AnexhaledcarbondioxidedetectorTopicalanestheticsandvasoconstrictorsSuggestedContentsofaPortab47急診剖宮產(chǎn)的麻醉選擇和術中處理課件48SummaryAdistinctionmustbemadebetweenatrueemergencyrequiringimmediatedeliveryandoneinwhichsomedelayispossible

SpinalorepiduralanesthesiaispreferredtogeneralanesthesiaforcesareansectionbecauseregionalanesthesiaisassociatedwithlowermaternalmortalityHypotensionisthemostcommonsideeffectofregionalanesthetictechniquesandmustbetreatedaggressivelywithvasopressorsandintravenousfluidbolusestopreventfetalcompromiseSummary49SummaryRegardlessofthetimeoflastoralintake,allobstetricpatientsareconsideredtohaveafullstomachandtobeatriskforpulmonaryaspiration

Uterinedisplacement(usuallyleftdisplacement)shouldbemaintainedDeliveryunitsshouldhavepersonnelandequipmentreadilyavailabletomanageairwayemergencies,consistentwiththeASAPracticeGuidelinesforManagementoftheDifficultAirwaySummaryRegardlessofthetime50Thanks!Thanks!51急診剖宮產(chǎn)的

麻醉選擇和術中處理費敏2010-3-26急診剖宮產(chǎn)的

麻醉選擇和52DefinitionAbdominaldelivery

asurgicalprocedurethatpermitsdeliveryoftheinfantthroughincisionsintheabdominalanduterinewall.DefinitionAbdominaldelivery53CesareanSectionCaedere–SecoPompiliusII

730BCnotwidelyuseduntilthe1920sCesareanSectionCaedere–Seco54IndicationsforCesareanSectionRepeatScheduledFailedattemptatvaginaldeliveryDystociaAbnormalpresentationTransverselieBreechMultiplegestationFetalstress/distressDeterioratingmaternalmedicalillnessPreeclampsiaHeartdiseasePulmonarydiseaseHemorrhagePlacentapreviaPlacentalabruptionIndicationsforCesareanSecti55CesareanSection>60%unplannedMoreextensiveperipartummonitoringLowerthresholdforsurgicalinterventionCesareanSection>60%unplanned56Whatisan‘emergency’Caesareansection?-Category1&2GradeDefinition(attimeofdecisiontooperate)Category1ImmediatethreattolifeofwomanorfetusCategory2Maternalorfetalcompromise,notimmediatelylife-threateningCategory3NeedingearlydeliverybutnomaternalorfetalcompromiseCategory4AtatimetosuitthewomanandmaternityteamWhatisan‘emergency’Caesare57Category1

IndicationPlacentalabruptionuterinerupture

cordprolapse

ActivelybleedingplacentapraeviaIntrapartumhemorrhagePresumedfetalcompromisewithseverelyabnormalCTGand/orseverefetalacidosisCategory1IndicationPlacenta58The30-minuteruleamaximumdecision-to-deliverytimeof30minforCategory1situation

AssociationofAnaesthetistsofGreatBritainandIrelandandObstetricAnaesthesists’Association.Guidelinesforobstetricanaesthesiaservices;2005.

HillemannsP,StraussA,HasbargenU,etal.Crashemergencycesareansection:decision-to-deliveryintervalunder30minanditseffectonApgarandumbilicalarterypH.ArchGynecolObstet2005;273:161–165.anaesthetistinformed–deliveryThe30-minuteruleamaximumde59PerianestheticEvaluationAdirectedhistoryandphysicalexaminationplateletcountAnintrapartumbloodtypeandscreenforallparturientsreducesmaternalcomplicationsPerianestheticrecordingofthefetalheartratereducesfetalandneonatalcomplicationsPerianestheticEvaluationAdir60AdirectedhistoryandphysicalexaminationMaternalhealthandanesthetichistoryRelevantobstetrichistoryAirwayandheartandlungexaminationBaselinebloodpressureBackexaminationwhenneuraxialanesthesiaisplannedorplacedAdirectedhistoryandphysica61

PlateletcountAroutineintrapartumplateletcountdoesnotreducematernalanestheticcomplicationsSuspectedpreeclampsiaorcoagulopathyEclamptic-plt>80*109.l-1

MoodleyJ,JjuukoG,RoutC.EpiduralcomparedwithgeneralanaesthesiaforCaesareandeliveryinconsciouswomenwitheclampsia.BritishJournalofObstetricsandGynaecology2001;108:378–82.

PlateletcountAroutineintr62AspirationProphylaxisclearliquidsupto2hbeforeinductionofanesthesiaAfastingperiodforsolids6–8h(fatcontent?)Furtherrestrictionmorbidobesity,diabetes,difficultairwaynonreassuringfetalheartratepatternAntacids,H2ReceptorAntagonists,andMetoclopramidereducesmaternalcomplicationsAspirationProphylaxisclearli63Perianesthetic–MaternalPositionAortocavalcompression3mechanismsuteroplacentalperfusionvenousreturnC.O.andBPObstructionofuterinevenousdrainageuterinevenouspressureanduterinearteryperfusionpressureCompressionofaortaorcommoniliacarteriesuterinearteryperfusionpressurePerianesthetic–MaternalPosit64Perianesthetic–MaternalPositionAvoidaortocavalcompressionKinsellaSM.Editorial.Lateraltiltforpregnantwomen:why15degrees?Anaesthesia2003;58:835–7.Perianesthetic–MaternalPosit65ChoicesofAnesthesiaGeneralanesthesiaRegionalanesthesiaLocalanesthesiaChoicesofAnesthesiaGenerala66ChoicesofAnesthesiadependsontheindicationsforthesurgerythedegreeofurgencymaternalandfetusstatusdesiresofthepatientSafest

+mostexpedient

midwifeanesthetistobstetricianChoicesofAnesthesiadepend67Regionalanesthesia>85%emergencyCaesareansection<3%RegionalanesthesiarequireconversiontoGARegionalanesthesia>85%emerge68RegionalanesthesiaEpiduralanesthesiaspinalanesthesiaCombinedSpinal/Epidural(CSE)RegionalanesthesiaEpiduralan69Epidural√AsfastasGATitrateddosingandsloweronsetriskofseverehypotensionandreduceduteroplacentalperfusionDurationofsurgerynotanissueLessintensemotorblockadeLowerextremity“musclepump”mayremainintactincidenceofthromboembolicdiseaseEpidural√70Epidural×RiskofsystemiclocaltoxicityGreaterplacentaltransferofdrugthanwithspinalBUT–doesnotaffectneonatalApgarscoreandoflittleclinicalsignificancewhenappropriatedosesusedRiskofhighspinalEpidural×71EpiduralThespeedofonsetThechoiceoflocalanestheticPossibleadjuvantsEpiduralThespeedofonset72Epidural0.5%bupivacaine0.75%ropivacaine0.5%levobupivacaine2-chloroprocainelidocaine1.8%lidocaine,0.76%bicarbonateand1:200000epinephrine

AllamJ.Anaesthesia2008;63:243–249.Epidural0.5%bupivacaine73Epiduralfailure24%failtoachieveapain-freeoperation

KinsellaSM.Aprospectiveauditofregionalanaesthesiafailurein5080caesareansections.Anaesthesia2008;63:822–832.ConversiontoSpinalanesthesia?unpredictablehigh-spinalblocksarelativecontraindicationtogivespinalanaesthesiafollowingepiduralanalgesiainlabourthedoseoflocalanesthesiaby20–30%anduseadditionofopioidsanormaldoseoflocalanesthesiaafter30minsincethelastdoseofepiduralwithnodocumentedblockEpiduralfailure24%failtoac74Spinal√SimpleRapidonsetDenseblockadeNegligiblematernalriskofsystemiclocaltoxicityMinimaltransferofdrugtoinfantNegligibleriskoflocalanestheticdepressionofinfantSpinal√Simple75Spinal×Rapidonsetofsympatheticblockade–abrupt,severehypotensionLimiteddurationSpinal×Rapidonsetofsympath76SpinalBupivacaine(isobaric/hyperbaric)levobupivacaine,ropivacaine

lessmotorblockade&toxicityadditionofopioid(Morphine,fentanylorsufentanil)ReducetheneededdoseoflocalanaesthesiashortenthetimetoreadinessforsurgeryenhancesblockadeofvisceralpainpostoperativeanalgesiaSpinalBupivacaine(isobaric77SpinalPeoloadcoloadApplicationofmonitorsSupplementaloxygenLeftuterinedisplacementAggressivetreatmentofhypotensionSpinalPeoloadcoload78AggressivetreatmentofhypotensionAggressivetreatmentofhypote79AggressivetreatmentofhypotensionExaggeratedLUDIVfluidsEphedrineand/orphenylephrine

Reflexbradycardia(HR<45-50bpm)

anticholinergicagentAggressivetreatmentofhypote80CombinedSpinal–Epidural(CSE)

Initiallydescribedin1981(epiduralcatheteratL1-2andspinalatL3-4)CombinedSpinal–Epidural(CS81CSE√RapidonsetanddensityofspinalanesthesiacombinedwithversatilityofepiduralanesthesiaLow-dosespinalreducetheincidencesofcardiovascularinstabilityespeciallyusefulinhighriskcardiacpatientsCSE√Rapidonsetanddensityo82CSE×Inabilitytotestepiduralcatheter18%rateoffailureextratimeconsumptionCSE×Inabilitytotestepidura83Generalanesthesia15%ofCSwasperformedundergeneralanesthesiainUSMajorityofCSweredoneunderurgentoremergentsituationsGeneralanesthesia15%ofCSwa84IndicationsforGAFetaldistressSignificantcoagulopathyAcutematernalhypovolemiaandHomodynamicinstabilitySepsisorlocalskininfectionfailedregionalanesthesiaMaternalrefusalofregionalanesthesiaIndicationsforGAFetaldistre85

GA

√RapidonsetControlledairwayandventilationhandsarefreeforfluidmanagementandhemodynamicscontrolincasesofmajorbleedingAlmostneverfailsMinimalcooperationneededfromthepatientGA√Rapidonset86GA×17XhigheranesthesiarelatedmortalitycomparedtoregionalanesthesiaRiskofdifficult/failedintubation

10Xhigherthaninnon-obstetricpopulationRiskofpulmunaryaspirationContributetouterinerelaxation/atonyExtratimeneededatendofproceduretowakeupthethepatientUsuallyfasteronsetofpostoperativepainRiskofmalignanthyperthermiaRiskofintaoperativeawarenessExposureoffetustodepressanteffectofGAMorecostlyGA×17Xhigheranesthesia87MostimportantcausesofmortalityduetoGAInabilitytointubateInabilitytoventilateAspirationpneumonitisMostimportantcausesofmorta88SuggestedTechniqueforCesareanSectionThepatientisplacedsupinewithawedgeundertherighthipforleftuterinedisplacement.Preoxygenation100%O23–5minThepatientispreparedanddrapedforsurgeryarapid-sequenceinductionwithcricoidpressure

propofol,2mg/kg(orthiopental4mg/kg)succinylcholine,1.5mg/kg

Ketamine,1mg/kg,isusedinsteadofthiopentalinhypovolemicorasthmaticpatients.SuggestedTechniqueforCesare89SuggestedTechniqueforCesareanSectionSurgeryisbegunonlyafterproperplacementoftheendotrachealtubeisconfirmedbycapnography.Excessivehyperventilation(PaCO2<25mmHg)shouldbeavoidedbecauseitcanreduceuterinebloodflowandhasbeenassociatedwithfetalacidosis.SuggestedTechniqueforCesare90SuggestedTechniqueforCesareanSection50%

N2Oinoxygenwithupto0.75MACofalowconcentrationofavolatileagentisusedformaintenanceAmusclerelaxantofintermediateduration(mivacurium,atracurium,cisatracurium,orrocuronium)isusedforrelaxationSuggestedTechniqueforCesare91SuggestedTechniqueforCesareanSectionAfterdelivered,20–30Uofoxytocinisaddedtoeachliterofintravenousfluid.N2Oconcentrationmaythenbeincreasedto70%and/oradditionalintravenousagents,suchasadditionalpropofol,anopioidorbenzodiazepine,canbegiventoensureamnesiaSuggestedTechniqueforCesare92SuggestedTechniqueforCesareanSectionIftheuterusdoesnotcontractreadily,anopioidshouldbegiven,andthehalogenatedagentshouldbediscontinuedMethylergonovine(Methergine),0.2mgintramuscularly,mayalsobegivenbutcanincreasearterialbloodpressure

15-MethylprostaglandinF2(Hemabate),0.25mgintramuscularly,mayalsobeusedSuggestedTechniqueforCesare93SuggestedTechnique