Caesarean section is the most frequently performed surgery in adults, with a total of 20 million procedures per year. More than 70% of cases are due to lack of labor progression, fetal distress, breech presentation or previous cesarean section. Obstetric anesthesia practice has substantially changed over the last 20 years. The main cause of this is the introduction of regional techniques to the detriment of general anesthesia, which has reduced maternal mortality due to complications such as gastric aspiration or difficulty in orotracheal intubation. In general, we can affirm that regional anesthesia is the most frequently used anesthetic technique for cesarean section, reserving general anesthesia for urgent or life-threatening situations.
Approximately 3% to 4% of term fetuses are in breech presentation, and this is a common indication for cesarean delivery. Twenty percent of elective cesarean sections are due to breech position. External cephalic version (ECV) is an obstetric maneuver that applies external pressure to the fetal posture through the maternal abdomen, to convert a breech presentation to a vertex presentation. Since the risk of adverse events after an ECV is small, the possibility of ECV should be offered in all pregnancies with breech presentation, provided that there is no contraindication. A standardized protocol, an experienced gynecologist and adequate analgesia can facilitate the maneuver and improve the success rate, turning the ECV into a maneuver with an excellent safety profile which is an interesting option to avoid a cesarean section.
Amniotic fluid embolism (AFE) is an uncommon pathology, whose incidence ranges from 2 to 8 per 100,000 births, depending on the country. This syndrome has four cardinal symptoms: circulatory collapse, respiratory distress, cyanosis and coma. If the patient survives cardiorespiratory failure, disseminated intravascular coagulopathy occurs, leading to incoercible bleeding and eventually death. Clinical diagnosis is based on Clark's four criteria: sudden cardiorespiratory arrest, established disseminated intravascular coagulation prior to bleeding, and all of these occurring peripartum in the absence of fever. The two main differential diagnosis syndromes are pulmonary thromboembolism and myocardial infarction. Treatment consists of cardiopulmonary support of the patient. Despite aggressive measures, such as the placement of ventricular assist devices and external oxygenation membranes, the prognosis continues to be poor. The main death cause is incoercible bleeding caused by disseminated intravascular coagulopathy.
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