RESUSCITATION OF THE NEONATE AFTER C - SECTION ERIN SPENCER, M.ED., CVT, VTS ( ECC )
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DRUG CONSIDERATIONS 1 Anesthetics and analgesics cause depression of the fetus. In cases where there are viable (or possibly viable) fetuses, decisions surrounding the anesthetic and surgical plan of the dam/queen should focus around minimizing drug e ff ects on the fetuses. The first question is whether or not to pre-medicate the dam/queen. There are di ff erences in opinion about whether or not to give medications prior to induction but the key is to first evaluate each case on an individual basis. If premedication is indicated, it is important to use the safest drugs at the lowest doses possible. • Reversible drugs are ideal in case of severe depression in the neonate, but alpha-2 agonists should be avoided in C-sections. Any drug that may significantly decrease heart rate should be avoided since the neonate will depend on heart rate to maintain cardiac output (CO). • Opioids are a good choice but respiratory depression and bradycardia can occur in both the dam/queen and fetus and should be monitored for closely. Opioids are also a good choice as they can be reversed using naloxone. • Ideally, a short acting pre-med is ideal. Butorphanol and fentanyl may be considered in this situation. Butorphanol may be just enough to relax the dam/queen to minimize catecholamine release without severely depressing the fetus.
2 When using propofol as your induction agent, there is some argument to be made for preparing the dam the same as any other abdominal surgery. Propofol is initially rapidly absorbed by the fetus but then crosses back to the dam/queen quickly which would mean the optimal time to remove the neonates would be about 15-20 minutes after induction. Depending on the team’s skill level, preparation and approach can likely fall into this time frame. There are two di ff erent ways to approach surgical prep of the dam. Ideally, shaving and a “dirty” scrub of the surgical site should be performed prior to any drug administration. This will cut down on the time the fetuses are exposed to drugs. The integrity of the skin should be taken into consideration when shaving is performed in an active awake animal. There is an increased risk of micro-trauma to the skin and may put the dam at increased risk for skin irritation and infection post- operatively. If the dam is active, then any shaving should be done at minimum after premedications have taken e ff ect but may not be possible until after intubation. 3 Maintenance anesthesia during surgery with inhalants can be minimized through multi-modal e ff orts such as continuous rate infusions (CRI) and epidurals. Epidurals are a good option as they will have minimal to no e ff ect on the fetus. CRIs should be used judiciously until after removal of the fetuses and then can be increased as needed to allow for lowering the
inhalant anesthetic. Initial or additional pain medications can also be given at this point. 4 Buprenorphine can be used post- operatively for pain management in the dam/queen. ABC’S OF NEONATAL RESUSCITATION 1 It is important to be prepared for a dystocia or C-section situation at all times. Having a container with resuscitation supplies will help decrease the time from presentation to delivery of the fetuses and thus increase the chances for survival. Choose a container of appropriate size so that it can double as an enclosure for the neonates until they are returned to the dam/queen. The “A” of resuscitation refers to airway . • Fetal membrane material should be gently wiped away from the face. If the membrane is intact, it can be torn by hand. Care should be taken to make the tear away from the umbilical cord to avoid prematurely severing the cord. • Gentle suction using a bulb syringe or a large bore syringe (with stylet removed) attached to a syringe can be used to remove material from nasal passages and the oral cavity. There is some evidence that the use of a nasal aspirator that is used for human newborns may also be e ff ective at removing
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