The other morning a woman at 34 weeks with twins came into the theatre for caesarean. She had been scheduled for the CS the previous evening and the usual morning chaos had prevented any of us getting to see her before she was ushered to the anaesthetic room. She was an emotional mess; her anxious behaviour was extreme, almost infantile, and was arguably in panic. It was the prospect of regional anaesthesia that seemed to be the main cause of her fear, although she declined (just!) the offer of general anaesthesia. We got on with it with a firm hand, and a bit of a stern word too, while she sobbed and demanded continuous reassurance throughout the procedure. I used a single shot spinal (10 mg bupivacaine and 20µg fentanyl) rather than a CSE because I felt she would not tolerate the greater fiddle of passing an epidural needle and catheter without distress and the chance of an accidental dural puncture. We got through it all, with sobbing and great tremulousness. I gave the remainder of the fentanyl amp and clonidine 40µg and she was happier once her little ones were delivered. But should I have offered more sedation or anxiolysis?
There are a few papers which indicate that chronic anxiety can lead to higher intervention rates, lower birth weights and the like. And I am sure I have seen a paper indicating higher anxiety in labour is associated with abnormal CTGs. And is it just good and compassionate medicine to treat severe anxiety?
It seems there might be little harm in using common sedation regimens. Midazolam/fentanyl (Frolich et al CJA 2006) , propofol infusion at about 200 mg/h (Cheng Acta Anaesthesiol Sin. 1997), and the readily accesssible N2O (Valjello, J Clin Anesth 2005) through a Hudson mask all reduced anxiety with no adverse effects on mother or neonate. Care should be taken with the propofol though; I am aware of one case of aspiration when propofol was given during an emergency cesarean for obstructed labour.
If I was better prepared (which I should have been) I might have done more for anxiolysis. Midazolam is locked up and I doubt the patient would have tolerated a Hudson mask. Propofol may have been an option but I would have betted that a reaction to propofol injection would have been extreme. Perhaps she justed needed a firm hand and stern word. She was a 31 year old adult.
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I do think that you should have offered her something to relieve her anxiety - c-sections are terrifying for many mothers and in some cases cause long term psychological trauma. If you have the resources to make it an easier psychological experience, why not use them? It's a whole person who is being tied down and cut open, not just a body.
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