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Department of Anaesthesia

Obstetric
Anaesthetists
Handbook

Third Edition
August 2003
(Next review by August 2004)

www.anaesthetics.uk.com
University Hospitals Coventry and Warwickshire NHS Trust
Department of Anaesthesia

Obstetric Anaesthetists Handbook

Dr Mark Porter, consultant obstetric anaesthetist


Email: mark.porter@uhcw.nhs.uk
Internal email: Porter Mark (RKB)

The consultant members of the Obstetric Anaesthesia Group


have agreed this handbook.
Further copies are available from the Anaesthetics Office at
Walsgrave Hospital on extension 8580.
Email: anaesthesia@uhcw.nhs.uk
Internal email: Anaesthesia (RKB)

The guidelines within are presented in good faith


and are believed to be accurate. The responsibility
for actions and drug administration remains with
the clinician concerned.

Edition history
First edition August 1999
Second edition June 2000
Reprinted September 2002
Third edition August 2003

My thanks are due to Dr John Elton for his encouragement and


assistance. These guidelines have been produced with close
reference to the Obstetric Guidelines written by Dr Louise
Farrall (consultant obstetrician) and Mrs Carmel McCalmont
(clinical midwife manager).

2 Obstetric Anaesthetists Handbook 3


Contents

Contents
Contents 3

Introduction and scope of guidelines 9


Points to remember 9
Principal changes to the third edition 11

Confidential Enquiry into Maternal and Child Health 13

Orientation to the Women’s Hospital 15


Unit workload 15
Staff 15
Unit description 17
Working in the delivery suite 18
Criteria for being the duty obstetric anaesthetist 18
Principal duties 18
Seeking advice and senior help 20
Referral to the consultant anaesthetist on call 21
Seeking advice on unusual techniques 22
Preparations for emergency anaesthesia 24
Theatre equipment 24
Prepared drugs 24
Difficult intubation 26
Failed intubation drill 26
Further considerations 27
Known previous, or anticipated, difficult intubation 27
Obstetric emergencies 29
Obstetric haemorrhage 29
Antepartum haemorrhage 33
Postpartum haemorrhage (PPH) 33
Obstetric Anaesthetists Handbook 3 3
Contents
Pharmacological treatment of uterine atony 34
Uterine inversion 35
Umbilical cord prolapse 35
Uterine rupture 35
Amniotic fluid embolism 36
Eclampsia 36
Unexplained collapse and cardiopulmonary arrest 36
Transfer to intensive care unit 39

Information recording 41
Clinical Adverse Events 41
Patient records 41
Clinical audit 43
Postnatal review 43
Audit projects 43
Training and assessment 45
Training opportunities 45
Assessment 46
Feeding and antacid prophylaxis 47
Pre-operative fasting times for elective surgery 47
Feeding 47
H2-receptor antagonists 47
Sodium citrate 48
Thromboprophylaxis 49
Graduated compression stockings (TED stockings) 49
Caesarean section 49
Central nerve block and vertebral canal haematoma 51
NSAIDs 51
Heparins 51
Fondaparinux 52

4 Obstetric Anaesthetists Handbook 3


Contents
Indications for haematological investigations 52
Complicating factors 53
Space-occupying lesions in the vertebral canal 53
Antenatal referral to the anaesthetist 56

Preoperative preparation and assessment 57


General considerations 57
Cross-match policy 57
Cardiac disease 58
Information and consent for obstetric anaesthesia
procedures 60
General considerations 60
Consent for epidurals 61
Information for mothers 64
Epidurals for labour – key facts 64
Pain relief in labour 66
Caesarean section: your choice of anaesthesia 72
Management of regional blocks 80
Infection control 80
Monitoring the extent of central nerve blocks 80
Neuraxial fentanyl and pruritus 83
Neuraxial fentanyl and pruritus 84
Pain relief for labour 85
Epidural analgesia – general considerations 85
Technique for epidural analgesia in labour 87
Inadequate epidural analgesia 90
Problematic epidurals 91
Unintentional dural puncture (‘dural tap’) 92
Diagnosis of low pressure headache 95
Follow up for patients with low pressure headache 95
Guidelines for blood patch 95

Obstetric Anaesthetists Handbook 3 5


Contents
Hypotension and epidural block 97
Total spinal block or high block 98
Subdural block 98
Tocolytic drugs 100
Nifedipine 100
β2-adrenergic agonists 100
Glyceryl trinitrate 100
Other drugs 101
Common obstetric problems 102
Malpresentations and malpositions 102
Multiple pregnancy 103
General considerations for caesarean section 104
Choice of technique 104
Time standards 104
Chaperones 106
Antibiotics 107
Uterine displacement 107
Uterine relaxation 107
Prevention of postpartum haemorrhage 107
Postoperative analgesia and antiemesis 108
Postoperative handover 111
Postoperative follow-up 112
Regional blocks for surgery 113
Information and consent 113
Monitoring and patient contact 113
Spinal anaesthesia – general considerations 114
Technique for spinal anaesthesia 115
Using labour epidurals for operative surgery 117
Failure of regional anaesthesia 121
Repeating a block 121

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Contents
Analgesic supplementation 123
Converting from regional to general anaesthesia 123
General anaesthesia for caesarean section 125
Practical points to remember 125
Postoperative period 126
Placenta praevia 127
Patient assessment and stabilisation 127
Senior assistance 128
Anaesthetic management 128
Intraoperative haemorrhage and extended surgery 130
Pre-eclampsia 132
Diagnosis and definitions 132
Management aims 133
Case responsibility 134
Antenatal high dependency care in pre-eclampsia 134
Antihypertensive treatment 134
Fluids in pre-eclampsia 136
Anticonvulsant treatment 139
HELLP syndrome 140
Magnesium administration 141
Epidural analgesia in pre-eclampsia 143
Anaesthesia for caesarean section in pre-eclampsia 145
The postnatal period in pre-eclampsia 147
High dependency care 149
Admission considerations 149
Principles of patient management 149
Discharge considerations 150
Other operative procedures 151
Retained placenta 151
Postpartum evacuation 151

Obstetric Anaesthetists Handbook 3 7


Contents
Surgery on pregnant women 151
Cervical cerclage 152
Diabetes in pregnancy 153
Management during labour and caesarean section 153
Gestational diabetes 154
Further reading 155

CCST syllabus 157


CCST 2 – senior house officer 157
CCST 3 – junior specialist registrar 158
CCST 4 – senior specialist registrar 161
The OAA Training Module 163
Basic training 164
Advanced training 167
Normal laboratory values in pregnancy 169
Haematology 169
Biochemistry 169
Arterial Blood Gases 170
Fetal Blood Gases 170
Index 171

8 Obstetric Anaesthetists Handbook 3


Introduction and scope of guidelines

Introduction and scope of guidelines


This handbook is intended to assist you in your duties as the
obstetric anaesthetist at Walsgrave Hospital. We expect you to
perform to a high standard in a demanding environment. We
have provided you with information to allow you to orient
yourself, and specific advice on a number of matters that will
arise. This handbook contains clinical guidelines that have been
developed from national recommendations and evidence
review, reinforced by local audit. They represent a consensus of
opinion on obstetric anaesthetic practice. They are not
exhaustive and do not include the minor variations seen in
consultants' daily work.
The guidelines do not necessarily represent the only good
practice, but they do represent good practice and the practice
you are expected to follow.
You should read this handbook through, as or before you start
work as the obstetric anaesthetist. This handbook is not a
textbook and nor is it completely comprehensive. There are
other sources of information that you must use:
• Your professional skills and training.
• Your knowledge derived from personal study (see ‘Further
reading’, page 155).
• The University Hospitals Coventry and Warwickshire
‘Anaesthetists Handbook’ (published every August and
February) [AH].
• The University Hospitals Coventry and Warwickshire
‘Obstetric Guidelines’ (April 2003), available on the
delivery suite.
In any case where you are unsure as to the safe and effective
way to proceed, you must seek advice from a more senior and
experienced member of staff. This may be another anaesthetist,
or indeed a midwife or obstetrician.

Points to remember
There are some cardinal points that should be remembered
when confronted by any situation in obstetric anaesthesia [1].

Obstetric Anaesthetists Handbook 3 9


Introduction and scope of guidelines

• The pregnant woman comprises two people: the mother


and the fetus. Changes seen in the mother such as
hypotension will have adverse effects on the fetus if not
treated promptly.
• The maintenance of adequate oxygenation and placental
perfusion are the goals of the treatment of the pregnant
woman.
• All pregnant women after the first trimester are at risk of
aspiration of gastric contents during general anaesthesia
and for this reason regional anaesthesia should be used
wherever possible.
• Aortocaval compression must be anticipated and treated in
all pregnant women by lateral displacement of the uterus
either manually or by positioning the mother in the wedged
or lateral position.
• Always summon senior anaesthetic assistance when
significant problems are anticipated, or if not anticipated
then very soon after difficulties arise.

1. Problems in Obstetric Anaesthesia. Rubin A, Wood M. Butterworth-


Heinemann, Oxford, 1993. Pages ix-x.

10 Obstetric Anaesthetists Handbook 3


Principal changes to the third edition

Principal changes to the third edition


This edition of the Obstetric Anaesthetists handbook contains
several significant changes from the previous edition. These
are:
• Brought up to date in synchrony with Obstetric Guidelines.
• New advice on haemorrhage following CEMD (30).
• ICU transfer guideline as mandated by CNST (39).
• Introduction of Obstetric Anaesthesia Procedure Record
(42).
• Epidural laminated card for delivery rooms (64).
• Patient information – OAA leaflet text included (66).
• Infection control advice (80).
• Advice on management of pruritus (83).
• Recommendation to learn and use saline for loss of
resistance (87).
• Introduction of premixed fentanyl and bupivacaine solution
(89).
• New referral mechanism for follow up of low pressure
headache (95).
• New section on tocolysis (100).
• New section on common obstetric problems (102).
• New urgency grading for caesarean section (104).
• Syntocinon dose adjusted to 5 units as in CEMD (107).
• New postoperative analgesia and antiemesis regime (108).
• Prohibition on giving spinal analgesia in delivery room
(113).
• No longer recommend supplemented oxygen in regional
block (115).

Obstetric Anaesthetists Handbook 3 11


Principal changes to the third edition

• New guideline for failed regional anaesthesia (121).


• Section on converting from regional to general
anaesthesia (123).
• Change of policy for placenta praevia (127).
• New advice on magnesium therapy after MAGPIE trial
(141).
• CCST syllabus in obstetric anaesthesia included (157).

12 Obstetric Anaesthetists Handbook 3


Confidential Enquiry into Maternal Deaths

Confidential Enquiry into Maternal and


Child Health
This replaces and assimilates the Confidential Enquiry into
Maternal Deaths. The latest report, available at
www.cemach.org.uk/, is that for the triennium 1997-99 [2]. This
handbook has been updated in line with the report’s
recommendations of good practice.
The recommendations for anaesthesia and intensive care are
as follows.

Anaesthesia and intensive care


Early communication of anticipated problems and review of the
patient by a critical care clinician would prevent delay in
admission to intensive care in many cases. This applies
particularly in cases identified to be at increased risk such as
those with HELLP syndrome (haemolysis, elevated liver
enzymes and low platelet count) which can deteriorate rapidly,
as shown in this Report.
Dedicated obstetric anaesthesia services should be available in
all consultant obstetric units. These services should be capable
of taking responsibility for regional analgesia, anaesthesia,
recovery from anaesthesia and the management and
monitoring of intravenous fluid replacement therapy.
Adequate advance notice of elective caesarean sections in
high-risk women must be given to the obstetric anaesthetic
service. The notice must be sufficient to allow the consultation,
investigation and assembly of resources needed for these
cases to take place.
When presented with problem cases requiring special skills or
investigations, obstetric anaesthetists should not hesitate to call
on the assistance of anaesthetic colleagues in other sub-
specialties as well as colleagues in other disciplines.
Invasive central venous and arterial pressure measurement can
provide vital information about the cardiovascular system which
can be life saving. Invasive monitoring via appropriate routes
should be used particularly when the cardiovascular system is
compromised by haemorrhage or disease.

Obstetric Anaesthetists Handbook 3 13


Confidential Enquiry into Maternal Deaths
Care of women at high risk of maternal haemorrhage must
involve consultant obstetric anaesthetists at the earliest
possible time.
Anaesthetists have a responsibility, as do all medical
practitioners, to ensure that drugs are given in the correct dose,
at the correct rate, by the correct route and by the most
accurate means.
It seems not to be widely appreciated that oxytocin
(Syntocinon®, Alliance) can cause profound, fatal hypotension,
especially in the presence of cardiovascular compromise.
Administration should follow the guidance in the British National
Formulary, Martindale and other standard formularies. When
given as an intravenous bolus the drug should be given slowly
in a dose of not more than 5 iu.

2. Why Mothers Die 1997-99. Confidential Enquiries into Maternal


Deaths. RCOG Press, London, 2001.

14 Obstetric Anaesthetists Handbook 3


Orientation to the Women’s Hospital

Orientation to the Women’s Hospital


Unit workload
There are some 4,000 to 4,500 deliveries per year, counting the
GP unit on M5 from which transfers are made when
interventions are required. We are responsible for performing
anaesthesia procedures on more than 2,000 women per year.
The bulk of these are 1,000 epidurals and almost 1,000
caesarean sections.

Staff

Consultant obstetric anaesthetists


Members of the Obstetric Anaesthesia Group are:
• Dr Edwin Borman
• Dr Falguni Choksey (lead assessor)
• Dr Robin Correa
• Dr John Elton (lead clinician and auditor)
• Dr Ravi Joshi
• Dr Mark Porter (handbook editor)
• Dr Julie Sherwin
Drs Borman, Choksey, Elton, Porter and Sherwin have fixed
commitments in the delivery suite. During absences on leave
the remaining members of the group endeavour to give informal
cover in order to enhance supervised training. The consultant
rota is at www.anaesthetics.uk.com/ and the weekly rota details
fixed commitments and trainee cover.

Non-consultant and trainee staff


The following text is taken from the Anaesthetists Handbook.
All non-consultant anaesthetists must spend at
least one supervised session in the delivery
suite with a consultant anaesthetist or a post-

Obstetric Anaesthetists Handbook 3 15


Orientation to the Women’s Hospital
fellowship trainee before working without direct
supervision as the on call obstetric anaesthetist.
Service lists may be cancelled to allow this
introduction to working facilities, practices and
duties.
Locum anaesthetists should not commence
work as the obstetric anaesthetist until
approved by the general consultant on call for
the day, and they have been issued with a copy
of the Obstetric Anaesthetists Handbook.
(There are copies available on the delivery
suite). This consultant should satisfy himself or
herself that the locum understands their
responsibilities and duties, and the path of
referral for help and advice.

Operating Department Practitioners (and ODAs)


The senior ODP for the delivery suite is Mrs Glenda
Widdowson.
There is an assigned ODP for the delivery suite from 09.00-
17.00 on weekdays. If it is quiet during this period the ODP may
be in the gynaecology/ENT theatre suite adjacent to delivery
suite. During the out-of-hours period, assistance must be
obtained through main site second-floor theatre control on
extension 8425. The ODP there will usually come over while the
ODP on call is mobilised, if the case is sufficiently urgent.
The Trust intends to implement a resident ODP for delivery
suite in 2003. Contact details are as above.
You are not permitted to anaesthetise a woman without
assistance. In dire and life-threatening emergencies a member
of the midwifery staff may be asked to assist you – to the
exclusion of all other duties – pending the arrival of an ODP or
other anaesthetist.

Theatre staff
The obstetric theatre sister is Sister Jane Green. She is present
during daytime theatre sessions and also has a management
role for the theatres. At other times, a duty midwife will act as
the scrub sister.

16 Obstetric Anaesthetists Handbook 3


Orientation to the Women’s Hospital

Unit description
The delivery suite is on the ground floor of the Women’s
Hospital, on the main Walsgrave site. Entrance is controlled by
a card swipe keyed to your ID badge, and there is a card
attached to the obstetric anaesthesia bleep. The delivery suite
contains an assessment and admissions area, four pre- and
postoperative rooms (A – D), eight delivery rooms (1 – 8) and
two operating theatres with a single recovery bay. Rooms 8 and
7 are equipped for high dependency care. There is a small
doctors’ office near the midwives’ station.
There is a communicating door linking to the Women’s Hospital
operating theatres. The anaesthetics room of WM3 is used as a
second obstetric theatre if the dedicated second theatre is non-
operational.
Wards M3 and M6 are the main antenatal and postnatal wards
on the third and sixth floors respectively.
M5 is the general practice obstetric ward on the fifth floor; you
may need to go there for follow-ups.
Entry to the wards is controlled by the card swipe mentioned
above.
The new unit will be opening in the new hospital presently being
constructed on the Walsgrave site, in December 2003.

Obstetric Anaesthetists Handbook 3 17


Working in the delivery suite

Working in the delivery suite


Criteria for being the duty obstetric
anaesthetist
You should fulfil the following criteria before and while working
as the duty obstetric anaesthetist.
• At least one year working in clinical anaesthesia.
• A satisfactory record of appraisal in obstetric
anaesthesia.
• Approval from the lead clinician, Dr Elton (or the
consultant anaesthetist on call in the case of locum
anaesthetists).
• At least one accompanied session (for orientation) in
the delivery suite at Walsgrave Hospital.
Specialist registrars appointed to the Walsgrave Hospitals are
assumed to satisfy the first three criteria although approval may
be withdrawn in the case of severe problems. All trainees
should have at least one orientation session.
For locum anaesthetists, see ‘Non-consultant and trainee staff’
on page 15.

Principal duties
The residents’ room is on the ground floor of the Womens’
Hospital. The bleep (2178) is handed from the outgoing to the
incoming second on, usually in the delivery suite doctors’ office,
at 09.00 hours and 17.00 hours. You are the principal
anaesthetist to the delivery suite, and are expected to base
yourself there. Your principal duties are:
• Provision and supervision of safe and effective epidural
analgesia for pain relief in labour.
• Preparation of ‘obstetric theatre fridge’ drugs for
emergency general anaesthesia.
• Provision of safe and effective anaesthesia for operative
delivery and obstetric surgery.

18 Obstetric Anaesthetists Handbook 3


Working in the delivery suite

• Review and treatment, where necessary, of patients who


have recently received an epidural, spinal or general
anaesthetic.
• Completion and maintenance of audit records.
• Management of high dependency obstetric patients in the
labour ward, in conjunction with obstetricians and
midwives.
• Performance of preoperative assessment (in the evening
before surgery) and discussion of the choice of
anaesthetic technique for elective caesarean section
(subarachnoid block should be recommended in the
absence of contraindications).
• Antenatal assessment of patients with medical problems
that may influence anaesthetic management at time of
delivery.
On occasion you may be asked for help by the first-on in the
gynaecology theatres or receive an urgent or arrest call to ward
M1 (gynaecology) or M2 (ENT), as both these are in the
Women’s Hospital. You should respond appropriately but
remember that your first duty is to obstetric anaesthesia – refer
calls to the third on call anaesthetist if necessary. Rarely you
may be asked by the third on call anaesthetist to assist in the
main block or undertake a transfer. Always inform the senior
midwifery sister if you take on a commitment elsewhere.

Presence on the delivery suite


You are permitted to leave the delivery suite whether to rest, or
to perform other duties. You should inform the senior midwife
when leaving the Women’s Hospital to go to the Main Block or
the Doctors’ Residences, and ensure that you are immediately
available using the allocated bleep at all times.
Common obstetric problems
You should be present on the delivery suite during the second
stage in vaginal breech delivery and in multiple pregnancy, and
during external cephalic versions. See page 102.

Obstetric Anaesthetists Handbook 3 19


Working in the delivery suite
Handover
The outgoing and incoming duty obstetric anaesthetists should
formally hand over responsibility at the change of shift in the
morning and in the evening. All clinical activities should be
discussed and in particular, patients in high dependency care
should be reviewed together. The bleep and keys should also
be handed over. You may not leave the bleep on the delivery
suite and go off duty without handing over.
The keys attached to the bleep include the key to the drugs
fridge in the obstetric operating theatre, keys to the desk draws
in the doctor’s office, and a swipe card for the delivery suite
door.

Seeking advice and senior help


There will be times when you need to ask advice or request
help [see AH for general advice].

Calling the third on call anaesthetist


Many sections in this handbook refer to the necessity to seek
senior advice. This means the third on call anaesthetist or the
consultant anaesthetist on call. You should call the third on call
anaesthetist first, particularly if a second pair of hands is
required urgently.
If you are an anaesthetist in SpR year 3 or above, then you
should use a greater degree of flexibility and discretion. You
should call the third on call anaesthetist for practical assistance.
You may make those decisions that are here reserved for third
on call anaesthetists and if you need advice, call the consultant
anaesthetist on call.

The consultant anaesthetist on call


There is always a consultant anaesthetist responsible for the
delivery suite.
Monday to Friday 09.00-17.00
There is a member of the Obstetric Anaesthesia Group
assigned to the delivery suite for regular sessions (when not on
leave; if away informal consultant cover may be supplied).

20 Obstetric Anaesthetists Handbook 3


Working in the delivery suite
Out of hours and during leave
The general consultant on call provides cover. You may contact
this consultant at any time via the hospital switchboard, usually
after calling the third on call anaesthetist.

Calling members of the Obstetric Anaesthesia Group


Members of the Obstetric Anaesthesia Group are available for
consultation during working hours. Check with the anaesthetics
manager (extension 8580) to see who is most conveniently
placed.
On occasion the general consultant on call will not be a member
of the Obstetric Anaesthesia Group. After first calling the
general consultant on call, group members may be called
through the switchboard particularly for problems relating
specifically to obstetric anaesthesia. This is an informal
arrangement and there is no commitment to be available.

Asking other professionals for help


Always remember that you work with other professionals in
obstetric anaesthesia. The views of midwives and obstetricians
should be sought and taken into account.

Referral to the consultant anaesthetist on call


There are certain cases, which you must notify to the
consultant anaesthetist on call:
• Potential difficult intubation (page 27).
• Amniotic fluid embolism (page 36).
• Eclampsia (page 36).
• Unexplained collapse and cardiopulmonary arrest (page
36).
• Exceptions to the fasting policy (page 47).
• Vertebral canal haematoma (page 53).
• Prescription of sedative premeds (page 57).
• Elective cases out of hours (page 57).
• Major problems with consent (page 60).
• Subarachnoid analgesia following dural tap (page 93).

Obstetric Anaesthetists Handbook 3 21


Working in the delivery suite

• Total spinal anaesthesia (page 98).


• Placenta praevia (page 127).
• Severe pre-eclampsia requiring caesarean section (page
146).
• Cases for which admission to high dependency care or the
intensive care unit is considered (page 149).
• Any other cases about which you feel unsure after seeking
the advice of the third on call anaesthetist, such as cases
of severe co-existing medical disease.

Seeking advice on unusual techniques

General
No handbook can be totally comprehensive. There may be
instances when it is appropriate to use techniques that are not
described here. You must seek senior advice before doing so,
from the third on call anaesthetist and in many cases from the
consultant anaesthetist.
In particular, you must not administer any substance to the
epidural or subarachnoid spaces, which is not recommended in
this handbook.
If you are asked by the obstetrician to administer a drug for an
obstetric indication, you may do so only if you are aware of the
principal contraindications and side effects of that drug.

Parenteral opioids
Fentanyl is the only opioid which you are permitted to
administer to the epidural or subarachnoid spaces.
Intramuscular opioids are a mainstay of treatment of mild to
moderate labour pains and are used in the delivery suite. The
effectiveness, and therefore the ethical basis, of using
intramuscular or intravenous opioids to treat labour pain is
repeatedly challenged; they may have no significant efficacy but
many side-effects [3,4]. You should therefore consider very
carefully, and with senior advice, how it would be appropriate to
respond to a request, which may be made from the midwives or
obstetricians, for an intravenous infusion of opioid to treat
labour pains. The same applies to PCA opioids.

22 Obstetric Anaesthetists Handbook 3


Working in the delivery suite
Intravenous opioids may be used in high-dependency care for
postoperative pain, either as main analgesia or to supplement
an epidural infusion.

3. Olofsson C, Ekblom A, Ekman-Ordeberg G, Granstrom L, Irestedt


L. Lack of analgesic effect of systemically administered morphine
or pethidine on labour pain. Br J Obstet Gynaecol 1996; 103: 968-
72.

4. Aly EE, Shilling RS. Are we willing to change? Anaesthesia 2000;


55: 419-20.

Obstetric Anaesthetists Handbook 3 23


Preparations for emergency anaesthesia

Preparations for emergency


anaesthesia
You must be aware at all times of the options for conducting
emergency anaesthesia, and be assured that cases can be
conducted with the minimum of delay. The response time for a
particular condition will vary (see page 104) and we do not
presume that general anaesthesia is always the appropriate
choice for emergencies – unless contraindicated or impossible,
spinal anaesthesia or epidural extension should be used for
caesarean section. You will find detailed advice in this
handbook.

Theatre equipment
You should check that both the main and second obstetric
theatres are available for operation in conjunction with the
senior midwifery sister. If the second theatre is non-operational,
then Women’s Theatre 3 (gynaecology/ENT) anaesthetics room
is the second theatre – check its status.

Prepared drugs
Your ability to match the required standards for response times
in the obstetric theatre will depend on the prior preparation of
drugs for anaesthesia.

General anaesthesia
The fridge in the anaesthetics room attached to the main
obstetric theatre must contain at all times the following drugs
prepared for immediate use. Label the syringes with time, date,
name of drug and name of anaesthetist preparing them, and
cap the syringe with a blind hub. You must prepare them so that
no syringe is more than 48 hours old.
• Thiopentone sodium 500 mg in 20 ml.
• Suxamethonium 100 mg in 2 ml.
• Ephedrine 30 mg in 10 ml.
• Atracurium 25 mg in 2.5 ml (5 ml syringe).
• Atropine 600 µg in 1 ml (2 ml syringe).

24 Obstetric Anaesthetists Handbook 3


Preparations for emergency anaesthesia
Regional anaesthesia
You should prepare a tray containing unopened drugs for use in
‘Quickmix’ epidural anaesthesia for caesarean section (see
‘Extending the epidural for a caesarean section’ on page 118).
This tray should be kept in the drugs cupboard.
• Lignocaine 2% 20 ml (16.9 ml to be used).
• Sodium bicarbonate 8.4% (1 ml to be used).
• Adrenaline 1 mg in 1 ml, with unopened 1 ml syringe
(0.1 ml to be used).
You will need to obtain the fentanyl ampoule from the controlled
drugs cupboard.

Intravenous fluids
You should prepare two one-litre bags of Hartmann’s solution
with blood giving sets and three-way taps to hang in the
obstetric theatre. These bags should have no additives.
Ephedrine 60 mg should be swiftly added when required and
the bag labelled. These bags must be renewed at no more than
24-hour intervals.
You should ensure that the theatre warming cabinet contains
three litres of unopened Hartmann’s solution.

Obstetric Anaesthetists Handbook 3 25


Difficult intubation

Difficult intubation
Failed or difficult intubation is a leading cause of anaesthesia-
related maternal mortality and death is more often a result of
hypoxia than inhaled gastric contents. Failed intubation occurs
in at least 1:300 obstetric anaesthetics and in as many as
1:150.
Be ready to accept that failed intubation might happen to you,
even after trying alternative tools. The difficult intubation
equipment on the ‘airway trolley’ includes introducers, smaller
tubes and polio blade, McCoy blade (levering) and short-
handled laryngoscopes.

Failed intubation drill


1. Do not persist with futile attempts where oxygenation is
endangered.
2. Maintain cricoid pressure and oxygenation throughout.
3. Call for help.
• Theatre personnel and obstetricians.
• A midwife should call the third on call anaesthetist as
an emergency (in normal hours, any nearby
anaesthetist should be summoned).
4. Maintain ventilation with oxygen from a facemask. Use an
oral or nasopharyngeal airway if necessary. Once
suxamethonium has worn off let the patient breathe
spontaneously.
5. Insert a suction catheter in the mouth and leave it there.
6. You should decide in conjunction with the obstetrician how
urgent surgery is, bearing in mind the risk to the woman. If
some delay is acceptable use a regional technique – a
spinal anaesthetic is preferred. Local anaesthetic
infiltration by the obstetrician may be needed as a last
resort.
7. If delay is unacceptable, keep the patient breathing
spontaneously using a volatile agent. Try inserting a
laryngeal mask – this may give you good control of the
airway leaving your hands free. Remember that it does not
give protection against aspiration. Keep cricoid pressure
on.

26 Obstetric Anaesthetists Handbook 3


Difficult intubation
8. If there is severe respiratory obstruction and hypoxia is
supervening, you must create a surgical airway. The
method used is chosen according to the experience of the
senior anaesthetist present.
• Large-bore (14G) intravenous cannula inserted
through the cricothyroid membrane, attached to the
15 mm connector from a 3.5 mm I.D. endotracheal
tube or a 20 ml syringe barrel that you have
‘intubated’ with a standard endotracheal tube.
• Cricothyrotomy pack.
• Minitracheostomy pack.
9. Maintain deep anaesthesia throughout the procedure.

Further considerations
Make sure that the clinical notes are marked with a prominent
hazard warning and inform the patient of the nature of the
problem.
Some authorities recommend using the left lateral position from
the time that it is recognised that the intubation is not possible.
This lessens the likelihood of aspiration but makes the airway
control and surgery more difficult. In the absence of vomiting or
actual regurgitation we feel it is better to complete the operation
as speedily as possible but recognise that there will be
occasions when the left lateral position should be used.

Known previous, or anticipated, difficult


intubation
You should perform an airway assessment, including
Mallampati score and an assessment of other relevant
anatomical and obstetric features, in all patients presenting for
operative procedures. This is of particular importance in pre-
eclampsia (see page 145).
You should determine whether a difficult intubation could be
anticipated. It is not possible to give exact criteria for this and
the predictive power of criteria may not be good. However, if
you are faced with a patient whose Mallampati class is 3 or 4
and who has associated features such as a short neck or a
receding mandible etc., it is reasonable to anticipate a difficult
intubation. In this case regional analgesia for labour and
regional anaesthesia for operative procedures should be used
unless contraindicated.
Obstetric Anaesthetists Handbook 3 27
Difficult intubation
You must notify the consultant anaesthetist on call before
undertaking general anaesthesia in a patient in whom you
anticipate a difficult intubation.
If the plan is for an awake intubation, the fibreoptic intubating
laryngoscope is normally kept in the second obstetric theatre.
Dr Robin Correa has particular experience in its use.

Mallampati’s airway assessment


Conducted with the patient sitting upright, opening the mouth as
far as is possible and maximally protruding the tongue.
• Class 1: soft palate, fauces, uvula and tonsillar pillars
visible.
• Class 2: soft palate, fauces and uvula only seen.
• Class 3: soft palate, base of uvula seen.
• Class 4: soft palate not visible at all.

28 Obstetric Anaesthetists Handbook 3


Obstetric emergencies

Obstetric emergencies
• All obstetric emergencies must be managed
immediately in conjunction with midwifery and
obstetric staff.
• Call for help immediately if you are not able, for any
reason, to give immediate, safe and effective
treatment.
• Consider sending for senior help early and in any case
where this is specifically indicated.
If you are the only anaesthetist nearby and you are engaged in
the care of another patient, you should bear in mind the advice
of the Association of Anaesthetists of Great Britain and Ireland:
“If it is essential for the anaesthetist to leave the
patient to deal with a life-threatening
emergency nearby (which is a matter of
individual judgement), he or she should instruct
another person to observe the patient’s vital
signs and should delegate overall responsibility
to another registered medical practitioner” [5].
Specific advice on some emergencies is given below.

Obstetric haemorrhage
Major haemorrhage is defined as a haemorrhage in excess of
15% of circulating volume (typically 1000 ml using an estimated
blood volume at term of 100 ml/kg).
There are appropriate immediate actions as below; and further
considerations for antepartum and postpartum haemorrhage
follow. The successful management of major haemorrhage
includes obstetric management specific to the cause of the
haemorrhage – usually delivery for antepartum haemorrhage
and uterine contraction or surgical repair for postpartum
haemorrhage.

Immediate action
1. Give high-flow oxygen.
2. Prevent aortocaval compression.

Obstetric Anaesthetists Handbook 3 29


Obstetric emergencies
3. Ask somebody to call the specialist registrar obstetrician
and staff to assist you.
4. Insert at least two 14G intravenous cannulae (the second
after samples and fluid administration).
5. Take blood samples for:
• FBC (4 ml).
• Coagulation screen (4 ml).
• Cross-match (12 ml). Request at least four units – six
or more if there are clinical signs of hypovolaemia or
shock. In major haemorrhage request ‘type-specific’
blood for resuscitation.
6. Start intravenous fluids, usually Hartmann’s solution or
gelatin until blood arrives. Four litres of warmed
Hartmann’s solution are kept in the warming cabinet in
theatre. Adjust the rate of administration to the response
and clinical signs, especially pulse rate and blood
pressure. You have the principal responsibility for fluid
resuscitation.
7. Send for any cross-matched blood which is available; O
Rh-negative blood if none.
8. Consider sending for senior help.
9. Request that a urinary catheter be inserted.
10. Prepare for general anaesthesia to evaluate or repair the
source of haemorrhage. Even though you should
resuscitate the patient prior to anaesthesia, reduced doses
of induction agents may be indicated.
11. You must send for senior help if considering operative
resuscitation in unresponsive life-threatening
haemorrhage.
12. Reassess the patient regularly and often, and record your
findings.

Consultant attendance
CEMD has made an unambiguous recommendation regarding
obstetric haemorrhage [6]:
If haemorrhage occurs, experienced consultant
obstetric and anaesthetic staff must attend.

30 Obstetric Anaesthetists Handbook 3


Obstetric emergencies
Further actions
1. The Confidential Enquiry has made recommendations on
obstetric haemorrhage [7]. These recommendations
emphasise the following points.
• Accurate estimation of blood loss.
• Prompt recognition and treatment of clotting
disorders.
• Early involvement of a consultant haematologist.
• Involvement of a consultant anaesthetist in
resuscitation.
• The use of adequately sized intravenous cannulae.
• The importance of monitoring central venous
pressure.
2. We also recommend additional monitoring.
• End organ monitoring through use of a urinary
catheter.
• Invasive arterial pressure monitoring.
3. Ensure the measurement and charting of observations in
conjunction with the midwife.
4. Consider using blood if signs of shock do not resolve with
crystalloid or colloid administration or if estimated blood
loss exceeds 20%.
5. Think ahead and order extra blood products early. Warm
the blood using a blood warmer.
6. Monitor and maintain the patient’s temperature.
7. A blood filter is unnecessary and delaying unless the
patient has known white cell antibodies.
8. Once six units blood have been given, re-check FBC and
coagulation screen. Give blood products for coagulation
according to the coagulation screen results and in
conjunction with haematology and obstetric staff.
9. Any patient who requires blood transfusion needs to be
catheterised. Aim for a urine output of at least 0.5 ml/kg/hr.
10. Consider insertion of CVP line if oliguric, or more than 4
units of blood have been transfused.
11. Arrange for high dependency care (Room 8) and liaise
closely with other team members so that responsibilities
are clear.

Obstetric Anaesthetists Handbook 3 31


Obstetric emergencies
Recommendations for the management of women at
known risk of haemorrhage – 2001
Obstetric haemorrhage remains a cause of concern to the
Confidential Enquiry. The latest report made further
recommendations [8] in the case that obstetric haemorrhage
can be anticipated.
Where a delivery is known to be one with a higher risk of major
bleeding, for example placenta praevia, especially with previous
caesarean section, myomectomy scars, uterine fibroids,
placental abruption or previous third-stage complications, the
following steps are essential.
• Possible prepartum anaemia should be checked and
corrected in the antenatal period if possible.
• A consultant should perform all elective or emergency
surgery.
• A consultant should give any anaesthetic.
• Adequate intravenous access (two large-bore cannulae)
should be in place before surgery starts.
• At least four units of blood should be cross-matched and
immediately available.
• A central venous pressure line should be in place, either
pre-operatively or whenever it is apparent that bleeding is
excessive.
• If bleeding is excessive, the obstetrician should consider
either embolisation of uterine arteries by an interventional
radiologist or further surgical procedures, such as internal
iliac ligation, hysterectomy, B-Lynch suture or Billings
suture. Any obstetrician who does not feel competent to
perform any of the above should immediately call a
colleague to assist or, if necessary, a vascular surgeon.
• The advice of a consultant haematologist should be sought
to assist in the management of coagulopathy, for example
due to disseminated intravascular coagulation or massive
transfusion. The most appropriate blood product
replacement is dependent on the result of coagulation

32 Obstetric Anaesthetists Handbook 3


Obstetric emergencies
tests and full blood count and may involve cryoprecipitate,
fresh frozen plasma and platelets.

Antepartum haemorrhage
See also ‘Placenta praevia’ on page 127.

Placental abruption
1. Clinical features of major placental abruption are:
• Abdominal pain and a tense, tender uterus.
• Shock.
• Vaginal bleeding in low proportion to the degree of
shock.
• Fetal distress or death.
2. Establish basic measures (see page 29).
3. Coagulation disorders are more common in this condition.
You should request fibrinogen and FDPs specifically on
the coagulation screen, and you should order two units of
fresh frozen plasma immediately on making the diagnosis.
Do not wait for haematological evidence of coagulopathy.
4. DIC or consumption coagulopathy occurs often in major
abruption and initial coagulation studies must be repeated
after 1-2 hours. Platelet transfusion may be required.
5. There is a high risk of postpartum haemorrhage following
placental abruption and you should prevent this with a
Syntocinon infusion (see page 107).

Postpartum haemorrhage (PPH)


1. Establish basic measures (see page 29).
2. The most common cause is uterine atony. Other causes
that you should consider in discussion with the obstetrician
are genital tract trauma, and coagulopathies.
3. Determine with the obstetrician whether Syntocinon (by
bolus or infusion) is indicated and administer it. See below
for drug treatment.
4. Examination under general anaesthesia is indicated by:
• Failure of uterine contraction with obstetrical methods.
• Persistent bleeding with uterine contraction.

Obstetric Anaesthetists Handbook 3 33


Obstetric emergencies
5. Consider intensive care for the postoperative management
of patients who have had hysterectomy performed to
control haemorrhage.

Pharmacological treatment of uterine atony


• Standard prophylaxis is intramuscular Syntometrine
(Syntocinon 5 units with ergometrine 500 µg), given at the
delivery of the infant.
• Syntocinon may be given by intravenous bolus (5 units;
dilute 10 units into 10 ml with dextrose 5%), repeated
once, or by infusion of 20 units Syntocinon in 50 ml
dextrose starting at 15 ml/h. Intravenous Syntocinon,
especially but not only in doses above 5 units, can cause
hypotension and circulatory collapse if given in the
presence of hypovolaemia.
• Ergometrine 500 µg given intramuscularly. Avoid the
intravenous route because of the high incidence of
provoked nausea. If you must give it intravenously, use a
dose of 125 to 250 µg. Ergometrine is a hypertensive
agent and is relatively contraindicated in pre-eclampsia
and other hypertensive conditions.
• Carboprost (Hemabate, or prostaglandin F2α) is indicated
for uterine atony unresponsive to ergometrine or
Syntocinon. It is given as an intramuscular dose of 250 µg
repeated every 90 minutes if needed, or up to every 15
minutes in severe cases (no more than 1000 µg). Side
effects include nausea, vomiting, flushing, bronchospasm
and hypertension. Excessive dosage may cause uterine
rupture.
• Carboprost is kept in the obstetric theatre refrigerator.
Carboprost must not be given intravenously.
Intravenous administration is associated with severe
bronchospasm, systemic and pulmonary hypertension.
The surgeons may give it into the myometrium in severe
cases. Observe the patient carefully: it is possible for an
intramyometrial dose rapidly to enter the systemic
circulation via uterine venous plexuses.

34 Obstetric Anaesthetists Handbook 3


Obstetric emergencies

• It may be used with caution in asthmatic patients, weighing


the severity of asthma against the urgency of the need to
increase uterine tone.

Uterine inversion
1. You should consider this diagnosis if there is severe
abdominal pain after delivery or if there is shock out of
proportion to the apparent blood loss.
2. Give oxygen and establish venous access.
3. Diagnose and treat shock.
4. Prepare for a general anaesthetic in the event of rapid
replacement not being possible. Volatile general
anaesthesia relaxes the uterus for replacement – you
should use a reduced dose of induction agent.
5. After replacement of the uterus, give Syntocinon as an
intravenous bolus and then an infusion (see ‘Prevention of
postpartum haemorrhage’ on page 107).
6. Neurogenic shock is rare but may occur and should not be
treated with large volumes of intravenous fluids.

Umbilical cord prolapse


Prepare for immediate induction of anaesthesia for caesarean
section. A general anaesthetic will usually be required because
of the mother’s distress and her position. Delivery should be as
rapid as possible while maintaining patient safety.

Uterine rupture
1. You should consider this diagnosis if there is sudden
cessation of uterine activity or abdominal pain between
contractions, sometimes despite the epidural. Fetal
distress, vaginal blood loss and shock may all be present.
2. Give oxygen, establish venous access and send serum for
issue of four units of type-specific blood.
3. Send for senior help.
4. Diagnose and treat shock. The mother’s welfare is
paramount and shock should be treated so as to render
induction of anaesthesia safe. However, in extremely rare
circumstances operative resuscitation may be required.

Obstetric Anaesthetists Handbook 3 35


Obstetric emergencies
5. Prepare for immediate induction of general anaesthesia,
using a reduced dose of induction agent, for caesarean
section and repair.
6. Expect major obstetric haemorrhage and manage
accordingly.

Amniotic fluid embolism


This is rare. Before making the diagnosis you should endeavour
to exclude pulmonary embolism from other causes, acute left
ventricular failure, acid aspiration syndrome; also eclampsia
and local anaesthetic toxicity if convulsions feature in the
presentation.
The treatment is supportive, starting with Basic and Advanced
Life Support, and should be given at least in high dependency
and probably in the intensive care unit. Contact the consultant
anaesthetist on call for advice when this condition is suspected,
and involve the intensive care consultant and team early.

Eclampsia
1. This is the occurrence of tonic-clonic seizures usually but
not always in the presence of pre-eclampsia. 40% of cases
occur after delivery, almost always within the first week.
2. Ensure that the patient has been placed into the left lateral
position and that oxygen therapy and intravenous access
have been established.
3. Check the patient’s history and medication for the prior
existence of epilepsy or other epileptogenic condition.
4. See page 139 for ‘Anticonvulsant treatment’. You should
make sure that magnesium therapy is commenced as
soon as possible (see page 141).

Unexplained collapse and cardiopulmonary


arrest
1. Ensure that the patient has been placed into the left lateral
position (except when external cardiac compression is
required) and that oxygen therapy and intravenous access
have been established.
2. Commence Basic and Advanced Life Support as
appropriate.

36 Obstetric Anaesthetists Handbook 3


Obstetric emergencies
3. If it is necessary to place the woman in a supine position
for external cardiac compression, you must ensure that
manual left lateral displacement of the uterus is performed,
or failing that use a left lateral tilt to 15 degrees or an
obstetric wedge placed under the pelvis.
4. Request that the arrest team, the consultant anaesthetist
and the consultant obstetrician are called immediately. The
consultant on call for the intensive care unit should be
involved sooner rather than later for appropriate cases.
5. Determine the cause. It may fall into one or more of three
groups.
• Pre-existing maternal conditions e.g. epilepsy.
• Pathological syndromes of pregnancy e.g. eclampsia,
embolus.
• Iatrogenic causes e.g. total spinal anaesthetic.
6. The welfare of the mother takes precedence over the
fetus. However, if the gestational age is over 24 weeks
and resuscitative attempts fail to revive the mother, then
immediate delivery by caesarean section should be
performed within 5 minutes of the arrest. ALS techniques
must be maintained during the delivery. A series of reports
have shown this to have a beneficial outcome for both
mother and fetus. Below 24 weeks it is considered that
immediate caesarean section would not be of benefit.
7. Document all events as soon as possible and as
accurately as possible. Delegate someone to write down
when and what drugs are given. Prepare a report as soon
as possible, while events are still fresh in the mind, and
ensure that others involved do so too.
8. The decision to terminate Advanced Life Support should
only be taken after discussion with the consultant
anaesthetist and consultant obstetrician on call, and the
senior midwife. The patient’s family must be kept informed,
and their wishes ascertained and respected in conjunction
with expert medical decisions.
9. In the event of death, you should ensure that an autopsy is
requested.

Obstetric Anaesthetists Handbook 3 37


Obstetric emergencies

5. Recommendations for Standards of Monitoring during Anaesthesia


and Recovery. Association of Anaesthetists of Great Britain and
Ireland; London 1994.
6. Why Mothers Die 1997-99. Confidential Enquiries into Maternal
Deaths. RCOG Press, London, 2001; page 94.
7. Why Mothers Die: Report on Confidential Enquiries into Maternal
Deaths in the United Kingdom 1994-1996. UK Health Departments;
London 1998; page 55.
8. Why Mothers Die 1997-99. Confidential Enquiries into Maternal
Deaths. RCOG Press, London, 2001; page 102, table 4.3.

38 Obstetric Anaesthetists Handbook 3


Transfer to intensive care unit

Transfer to intensive care unit


Each year a small number of women are transferred to the
intensive care unit for the management of critical illness.
The standards of care for the transfer of such patients are the
same as for non-pregnant patients as determined by the
Intensive Care Society.

Inform
You are responsible for informing:
• Consultant anaesthetist, obstetrician and intensivist.
• Any other consultants involved or to be involved.
• The delivery suite supervisor.
• The receiving intensive care unit.
Keep the relatives informed and reassured at all times.

Accompanying staff

• A midwife will accompany all transferred patients.


• An anaesthetist trained to manage transport cases or a
critical care physician will accompany critical cases.
• An ODP will be required to accompany an intubated
patient. For transfer between hospitals, a paramedic may
take this role.

Monitoring
You should use a high monitoring standard including:
• Pulse oximetry.
• Invasive arterial blood pressure.
• Central venous pressure.
• ECG.
• Expired carbon dioxide.
• Temperature.

Obstetric Anaesthetists Handbook 3 39


Transfer to intensive care unit
Equipment
When working remotely it is particularly important to check
equipment, including the following:
• Working batteries.
• Portable ventilator.
• Battery powered syringe drivers for drug infusions.
• Oxygen delivery system.
• Suction equipment.
• Drugs.
• Intravenous fluids.

Records
You should make sure that all notes are completed and taken
with the patient
You should make a comprehensive record of the transfer:
• Recorded observations as would be done on the
intensive care unit.
• Clinical notes detailing all significant events.

Transport
Transport to the main Walsgrave Hospital will be via the tunnel
system on a bed or trolley capable of being tilted head down.
Transfer to another hospital will be in a fully equipped
paramedic ambulance.
The patient should be kept warm at all times.

40 Obstetric Anaesthetists Handbook 3


Information recording

Information recording
Clinical Adverse Events
There is a Trust procedure in operation for clinical adverse
events (previously called clinical incidents).
We regard the following clinical and non-clinical events (that
may or may not have led to actual harm) as reportable:
• Unnotified serious medical complications.
• Failed intubation.
• Aspiration of gastric contents.
• Conversion from regional to general anaesthesia
during caesarean section.
• Any obstetric emergency (see page 29).
• Anaphylaxis.
• Persistent neurological deficit.
• Vertebral canal haematoma.
• Eclampsia.
• Dural tap.
• Total spinal.
• Admission to intensive care or coronary care.
• Major breach of these guidelines.
• Failure of team working.
• Other events you consider reportable.
Comprehensive records must be made in the medical notes if
appropriate. You should talk to a consultant member of the
Obstetric Anaesthesia Group as soon as possible during normal
working hours unless the incident is sufficiently urgent to report
to the consultant anaesthetist on call.

Patient records

Operative obstetrics
You must complete a standard Trust anaesthesia chart for all
cases in the operating theatre, including ‘trial of assisted
delivery’ for which you provide surgical anaesthesia but no
caesarean section is performed. A fluid chart and drug chart will
also be required.

Obstetric Anaesthetists Handbook 3 41


Information recording
Obstetric Anaesthesia Procedure Record
One of these records should be completed for every obstetric
anaesthesia case, including those for whom a Trust
anaesthesia chart is also completed. The OAPR contains basic
procedural information and follow-up data on the front, and the
standard epidural analgesia record chart for use by
anaesthetists and midwives, on the back.
All cases recorded on OAPRs should be assigned a number –
starting at 0001 at each New Year. This number must correlate
with the number on the index list.
Procedure records should be filed in the patient’s medical
record, in the Anaesthesia section. They should not be retained
as a separate piece of paper or kept in the doctors’ office.

Epidural analgesia
You must complete the record and prescription chart for
epidural analgesia on the back of the OAPR. File this chart in
the patient’s medical record in the Anaesthesia section.
In the case of extension to surgical anaesthesia, a standard
Trust anaesthesia chart must also be completed.

Index list
Procedure records are filed in the patient’s notes. You should
maintain an index list in the doctors’ office that correlates with
the numbers on the procedure records. This index list is used in
following up the patients (see page 43).

Entries in the main patient record


There will be occasions when you should make entries in the
main patient record. Always cross-refer these entries to any
anaesthetics documentation, and ensure that the notes are
continuous with those made by the midwife and the obstetrician.

42 Obstetric Anaesthetists Handbook 3


Clinical audit

Clinical audit
Postnatal review
The department undertakes continuous outcome audit of the
provision of obstetric anaesthesia. All anaesthetists conducting
cases must commence an Obstetric Anaesthesia Procedure
Record (see page 42), cross-referencing this with the index list
kept in the doctors’ office.
As the duty obstetric anaesthetist it is your duty to complete the
follow-up components of this audit. This is best done in the
morning because discharges tend to occur in the early
afternoon, and in any case you should finish the follow-ups
before 15.00 hrs so that any diagnosed complications may be
treated during normal hours.
The index list is the key to co-ordinating the follow-up process
successfully.
Each day you should update the index list for the patients who
have not yet been reviewed – their postnatal ward will be listed
in the midwives’ delivery record book. Take the folder with the
index list to the postnatal wards, find and review the patients.
Postnatal review information should be recorded on the
procedure records.
When patients are discharged from follow-up, tick the
appropriate box on OAPR, and tick the row on the index list.

Audit projects
While attached to the delivery suite you have an ideal
opportunity to carry out audit projects. You will be working as a
member of a small group of residents and consultants, on a
more regular basis than is the case in much of anaesthesia.
There is a systematic program of audit, in which you may be
invited to participate, but the best way of becoming involved is
to originate your own project – and to do so in advance of your
rotation through the delivery suite. Planning for a
multidisciplinary audit that runs during your two-month
attachment is a reliable path to success.
The Royal College of Anaesthetists has published a recipe
book for carrying out audit, which contains detailed advice for

Obstetric Anaesthetists Handbook 3 43


Clinical audit
conducting general audits and those specific to obstetric
anaesthesia [9]. Suggested audits include:
• Timely anaesthetic involvement in the care of high-
risk mothers.
• Adequacy of staffing.
• Consent given by women during labour.
• Response times for epidural requests.
• Response times for operative delivery.
• Monitoring of mother and fetus before and during
regional analgesia.
• Dural puncture rates.
• Technique of anaesthesia for caesarean section.
• Failed and difficult intubation in obstetrics.
• Monitoring for caesarean section.
• Awareness during obstetric anaesthesia.
• Monitoring of obstetric patients in recovery and HDU.
• Adequacy of post caesarean section pain relief.
• Record keeping for caesarean section.
Dr Elton is the auditor for obstetric anaesthesia. There is an
annual joint audit meeting with the obstetricians and midwives
at which you could make presentations.

9. Raising the Standard: a compendium of audit recipes for


continuous quality improvement in anaesthesia. Royal College of
Anaesthetists; London 2000. http://www.rcoa.ac.uk/audit.htm

44 Obstetric Anaesthetists Handbook 3


Training and assessment

Training and assessment


Training opportunities
There are ten consultant sessions per week, excepting leave,
and you should be able to develop your skills and knowledge
while attached to the delivery suite in a two-month block, in
addition to the experience that you will gain. You have a great
responsibility in ensuring that this happens satisfactorily. You
should raise any concerns at an early stage.
You should read the Obstetric Anaesthetists Association’s
recommendations on training (see page 157). In particular, for
more junior anaesthetists before starting the block, you should
ensure that you have read around the theoretical aspects of
obstetric anaesthesia listed on page 164.
The Royal College of Anaesthetist syllabus for CCST is on page
157.
During quiet times on the delivery suite read around the subject,
and request any more senior anaesthetists to teach you about
the subjects listed. Pick a subject and challenge your
supervisor.

Clinical audit
Before and during your block you will be well positioned to carry
a clinical audit project through to completion. See page 43.

Guideline review
This handbook contains many clinical guidelines, which should
be the subject of regular review as is the case with other such
guidelines within the Trust. During your block you may be asked
to conduct one of these reviews, or may identify a guideline that
you are interested to review. Help is always welcome.

Service developments
The service we offer to patients is comprehensive, satisfactory
and safe. However, obstetric anaesthetists, trainees and
consultants, aspire to continuous improvement although change
can be difficult to coordinate. If you have an idea for a service

Obstetric Anaesthetists Handbook 3 45


Training and assessment
development you are welcome to discuss this with any of the
consultants. If supported by the group, we will help you to take it
forwards.

Assessment
You should ensure that any relevant assessments are
completed. Senior house officers have a Walsgrave document,
and specialist registrars have a training record that is applicable
to all the hospitals in the school.
If you feel that this is not happening satisfactorily then you
should discuss the situation with the lead assessor. The lead
assessor is Dr Falguni Choksey, although any consultant
member of the Obstetric Anaesthesia Group may conduct
assessments in obstetric anaesthesia.

46 Obstetric Anaesthetists Handbook 3


Feeding and antacid prophylaxis

Feeding and antacid prophylaxis


Pre-operative fasting times for elective surgery
Fasting reduces the risk of aspiration of stomach contents.
Nevertheless, you must secure the airway using a rapid
sequence induction when inducing general anaesthesia in
obstetric cases, unless the patient is more than 48 hours
postpartum and has no other indication for rapid sequence
induction.
Exceptions to the following standards must be discussed with a
consultant.
• 4 hours for clear fluids and water.
• 6 hours for food.

Feeding
Low-risk women may consume light food and drinks. After
opioid or epidural analgesia is administered, clear non-
carbonated fluids only may be consumed. In cases of
complicated pregnancy or labour, water only may be consumed.

H2-receptor antagonists
All labouring women should be given ranitidine 150 mg p.o.
every six hours, and those given opioids should receive
ranitidine 50 mg i.m. (or slowly i.v.) every six hours. The
obstetricians or midwives should prescribe this.
Women having urgent surgery who have not had ranitidine
within six hours should be administered ranitidine p.o. (if at least
90 minutes before surgery) or i.m. or i.v. as appropriate. You
should check that this has been done.
You should prescribe a premedicant when assessing the
patients before their elective caesarean section. Use ranitidine
150 mg at 22.00 hrs and again at 08.00 hrs on the day of
surgery (see page 57).

Obstetric Anaesthetists Handbook 3 47


Feeding and antacid prophylaxis

Sodium citrate
Sodium citrate 0.3M 30 ml should be given immediately prior to
surgery or a ‘trial of assisted delivery’ in which you have been
asked to provide regional anaesthesia or stand by for
caesarean section. You should check that this has been done.

48 Obstetric Anaesthetists Handbook 3


Thromboprophylaxis

Thromboprophylaxis
Graduated compression stockings (TED
stockings)
These stockings should be used for all patients undergoing
caesarean section, long-term bed rest, prolonged admission,
and all high-dependency patients on delivery suite.

Caesarean section
Subcutaneous unfractionated heparin 7500 i.u. should be
prescribed twice daily by the obstetrician for women having
caesarean section, if they fall into at least one of the categories
for high risk. These categories are based on professional
recommendations [10, 11].
1. Previous personal or family history of deep venous
thrombosis, pulmonary embolism or thrombophilia (if not
already anticoagulated).
2. Paralysis of lower limbs (other than due to uncomplicated
regional anaesthesia).
3. Extended surgery such as caesarean hysterectomy.
4. Patients with two or more of the following risk factors.
• Age over 35 years.
• Obesity (more than 80 kg booking weight).
• Parity 4 or more.
• Gross varicose veins.
• Current infection.
• Pre-eclampsia.
• More than four days immobility prior to surgery.
• Heart or lung disease.
• Cancer.
• Inflammatory bowel disease or nephrotic syndrome.
• Emergency caesarean section in labour.
You should check that this prescription has been made, and be
prepared to administer the first dose during caesarean section.
Consult with the operating obstetrician in every case. See
‘Heparins’ on page 51 for timing of dose.

Obstetric Anaesthetists Handbook 3 49


Thromboprophylaxis
Fractionated or low-molecular weight heparins are being more
widely used in pregnancy, for conditions such as
antiphospholipid antibody. Fractionated heparins must not be
used unless discussed with a consultant, usually under
expert haematological advice.

10. RCOG guideline No.28: Thromboembolic disease in pregnancy


and the puerperium. Royal College of Obstetricians and
Gynaecologists, April 2001.
11. Obstetric Guidelines 2003. University Hospitals Coventry and
Warwickshire NHS Trust, April 2003.

50 Obstetric Anaesthetists Handbook 3


Central nerve block and vertebral canal haematoma

Central nerve block and vertebral canal


haematoma
Vertebral canal haematoma is very rare, especially in obstetric
anaesthesia. The incidence is 1:150,000 for epidurals, and
about 1:220,000 for spinals. It is also rare in patients receiving
concurrent central nerve block (CNB) and antithrombotic drugs
so long as sensible guidelines are followed [12]. This section
details our guidelines in Coventry. This section also deals with
thrombophilic disorders including those of pregnancy.
Ignoring these guidelines is associated with a vertebral canal
haematoma risk of about 1:10,000.
You must discover the patient’s antithrombotic and
anticoagulant history prior to undertaking CNB.
The advice here is supported by the ASRA consensus
statements [13] and the SIGN guideline [14].

NSAIDs
NSAIDs, including aspirin, administered for thromboprophylaxis,
postoperative pain or prevention of pre-eclampsia are not a sole
contraindication to CNB.
Concurrent use of other medications affecting clotting
mechanisms may increase the risk of bleeding complications.
See page 53 for ‘Complicating factors’.

Heparins
1. Patients prescribed fractionated or low-molecular
weight heparins subcutaneously as antithrombotics.
• Fractionated heparins include dalteparin (Fragmin),
enoxaparin (Clexane), tinzaparin (Innohep) and
certoparin (Alphaparin).
• LMWH are used in pregnancy for patients with lupus
anticoagulant, antiphospholipid syndrome and a
variety of thrombophilias.
• Perform the CNB or remove the epidural catheter
before the first dose, or twelve hours after the
previous dose.

Obstetric Anaesthetists Handbook 3 51


Central nerve block and vertebral canal haematoma
• Fractionated heparins should not be administered for
two hours after catheter removal, or 24 hours after a
bloody tap.
2. Patients prescribed unfractionated heparins
subcutaneously as antithrombotics.
• Unfractionated heparins include generic heparin,
Calciparine, Minihep and Monoparin.
• Perform the CNB or remove the epidural catheter
before the first dose, or four hours after the previous
dose.
• Unfractionated heparins should not be administered
for one hour after catheter removal.

Fondaparinux
Fondaparinux is a novel factor Xa inhibitor. The risk of spinal
haematoma is unknown. Your technique should be based on
single needle pass, atraumatic needle placement, and
avoidance of indwelling neuraxial catheters. Seek senior advice
and help.

Indications for haematological investigations


1. A platelet count should be performed within the preceding
six hours for any patient in the following groups.
• Those who have received more than one dose of
subcutaneous heparin prior to CNB (including those
who have been on long-term heparin during
pregnancy);
• Those who have pre-eclampsia [15].
2. The platelet count must be 100,000/µl or above for CNB to
be performed except as below.
3. A coagulation screen (and platelet count) should be
performed within the preceding six hours for all patients in
the following groups.
• Platelet count below 100,000/µl.
• Severe pre-eclampsia [16] – (not for uncomplicated
pre-eclampsia with platelet count at least 100,000/µl).
• Intrauterine death unless within six hours.
• Placental abruption.
• Infection.
• Major haemorrhage.

52 Obstetric Anaesthetists Handbook 3


Central nerve block and vertebral canal haematoma
• Amniotic fluid embolism.
• Intravenous heparin has been given within the last 24
hours.
4. In order for CNB to be performed in these patients the
following conditions should be met.
• The platelet count must be above 80,000/µl.
• The coagulation screen must be normal (see page
168).
• Minimise vessel trauma – consider asking an
experienced anaesthetist to perform the CNB.
5. Consider using a platelet transfusion if the following factors
are all true:
• The platelet count is below 80,000/µl.
• The coagulation screen is normal.
• CNB is strongly indicated.
Seek senior advice in this case.

Complicating factors
Expert advice should be sought, and haematological tests for
coagulation status should be performed, in these cases.
• There is a known thrombocytopenia, coagulopathy or
evidence of abnormal bleeding.
• There has been recent therapeutic anticoagulation,
including with heparin (whether subcutaneous or
intravenous).
• NSAIDs and heparins have been used together within the
last week. This will be particularly important in the case of
a postoperative epidural infusion for many high-risk cases.
• There are other complicating factors.

Space-occupying lesions in the vertebral canal

Diagnosis
You should elicit neurological symptoms at the postnatal review
visit. A woman with any symptoms should be carefully
examined and the results documented. Seek senior advice
immediately if you suspect neurological damage.

Obstetric Anaesthetists Handbook 3 53


Central nerve block and vertebral canal haematoma
Space-occupying lesions can be caused either by haematoma
or abscess. Compression of the spinal cord, cauda equina or
isolated nerves or their blood supply may lead to paraplegia,
cauda equina syndrome or nerve root damage.
Features of a vertebral canal haematoma are:
• Bilateral leg weakness.
• Wide sensory deficit in the legs.
• Apparent persistence of the central nerve block
beyond its expected duration.
• Back pain and tenderness.
Features of an abscess are:
• Fever.
• Malaise.
• Back pain – marked local tenderness of the spine at
the level of the abscess.
• Headache.
• Later, bladder and bowel dysfunction, lower extremity
pain and neurological signs.

Management
1. The definitive management is activated by making a
prompt referral to the neurosurgeon on call via the hospital
switchboard.
2. An urgent MRI scan is required for definitive diagnosis. Do
not attempt to book MRI scans yourself unless requested
to do so after referral to the neurosurgeon.
3. The definitive treatment for a compressing vertebral canal
haematoma is a decompression laminectomy. The time
between haematoma formation and surgical
decompression determines final neurological outcome and
should be within eight hours at most. Laminectomy is also
performed for epidural abscess.
4. You should inform the following colleagues.
• The consultant anaesthetist on call.
• One of the consultant obstetric anaesthetists, if
possible.
• The obstetrician on call.
5. You should report vertebral canal haematoma as a clinical
adverse event.

54 Obstetric Anaesthetists Handbook 3


Central nerve block and vertebral canal haematoma

12. Checketts MR, Wildsmith JAW. Central nerve block and


thromboprophylaxis – is there a problem? Br J Anaesth 1999; 82:
164-7.
13. American Society of Regional Anesthesia. Second Consensus
Conference on Neuraxial Anesthesia and Anticoagulation (2002)
http://www.asra.com/

14. Scottish Intercollegiate Guidelines Network. Prophylaxis of Venous


Thromboembolism (Publication number 62; October 2002)
http://www.sign.ac.uk/
15. Barker P, Callender CC. Coagulation screening before epidural
analgesia in pre-eclampsia. Anaesthesia 1991; 46: 64-7.

16. Barker P, Callender CC. Coagulation screening before epidural


analgesia in pre-eclampsia. Anaesthesia 1991; 46: 64-7.

Obstetric Anaesthetists Handbook 3 55


Antenatal referral to the anaesthetist

Antenatal referral to the anaesthetist


You may be asked to talk to a mother who is expecting a
normal labour or a mildly complicated delivery, perhaps a
caesarean section. Give time to do this properly, remembering
to discuss enough information for informed consent, and
document this fully in the notes. Make a note of the case in the
obstetric anaesthesia diary in the doctors’ office on delivery
suite.
If asked to see a complicated case or any case where you are
unsure, refer the case to a consultant member of the Obstetric
Anaesthesia Group at the next available opportunity. Document
this in the notes.
Referring the case to a consultant does not preclude talking to
the woman yourself but you should make the situation clear to
the mother.

56 Obstetric Anaesthetists Handbook 3


Preoperative preparation and assessment

Preoperative preparation and


assessment
General considerations
As the duty obstetric anaesthetist you should see all patients
scheduled for elective caesarean section. There are usually two
of these booked, and they will usually be on the ward from
about 20.00 hrs. You should assess the patient and start a
Trust anaesthetic record sheet. Our standard technique for
caesarean section is spinal anaesthesia and this should be
recommended to the woman if not contraindicated. You should
record the chosen technique on the record sheet.
Prescribe ranitidine 150 mg at 22.00 hrs and 08.00 hrs, and
sodium citrate 0.3M 30 ml immediately prior to surgery. Do not
prescribe metoclopramide unless specifically indicated as this is
given intravenously following administration of subarachnoid
block. Use other drugs (salbutamol for example) where
indicated, but remember that any premedicants will be
administered while the patient is pregnant and the appropriate
guidelines on prescribing in pregnancy must be followed. Only
in exceptional circumstances, and after consultation with the
consultant anaesthetist on call, should a sedative or opioid be
prescribed.
Patients who wish to come in on the day of surgery, should be
assessed by an anaesthetist beforehand and given two
ranitidine tablets to be taken at home as above.
Elective caesarean sections may be delayed because of more
urgent work the next day. You, or somebody that you ask,
should speak to any mother having a delay of more than four
hours and offer her either an intravenous infusion to maintain
hydration or the opportunity to have the operation rescheduled
for the next available opportunity [17]. You should inform the
consultant anaesthetist on call of elective cases proposed
during on-call periods.

Cross-match policy
All operative cases must have serum grouped and saved.
Cross-match should be performed as described here.

Obstetric Anaesthetists Handbook 3 57


Preoperative preparation and assessment
Elective caesarean section
Group and save serum only unless any of the following factors
are present, in which case two units of blood should be
requested:
• Two or more previous caesareans or previous
abdominal surgery.
• Multiple pregnancy.
• Gross polyhydramnios.
• Fibroid uterus.
• Placenta praevia (request at least six units of blood).
• Abnormal maternal antibodies.
• Previous postpartum haemorrhage.

Emergency caesarean section


Cross-match all cases, usually for two units of blood. In the
case of uterine rupture (see page 35) or antepartum
haemorrhage (see page 33; and ‘Placenta praevia’ on page
127) request four or more units depending on circumstance.
You may occasionally be requested to proceed without cross-
match because of dire emergency. If this happens you should
perform the following actions.
• Document the precise nature of the emergency and the
name of the operating obstetrician.
• Ensure at least that a serum sample has gone across to
the laboratory, by ‘Dire Need’ portering arrangements,
marked for emergency cross-match and that somebody
has telephoned the haematology technician and
impressed the nature of the dire emergency on them.
• Be prepared to request either type-specific blood or use
the O-Rh negative blood stored in the Women’s Hospital
(two units) depending upon transfusion needs.

Cardiac disease

Known disease
You should seek senior advice on all cases of known congenital
or acquired cardiac disease in pregnant patients that come to
your attention.

58 Obstetric Anaesthetists Handbook 3


Preoperative preparation and assessment
Cardiac murmurs
All patients with cardiac murmurs should be assessed carefully
prior to anaesthesia. Most will have a flow murmur associated
with the increased cardiac output of late pregnancy. Some may
have longstanding, documented, benign murmurs.
Patients who do not fall into these two categories, or have any
symptoms associated with their murmur, should have further
investigation.

Referral to a cardiologist
You should refer patients for an opinion on diagnosis and
management rather than just for investigations. This will usually
include ECG and cardiac echosonography (ultrasound)
examinations.
Seek senior anaesthetic advice if any abnormalities are
discovered on investigation or referral.

Antibiotic prophylaxis
Women with prosthetic heart valves, valvular heart disease or a
prior history of bacterial endocarditis should be given antibiotic
prophylaxis.
The current recommendations [18] are intravenous amoxicillin
1 g with intravenous gentamicin 120 mg at induction with oral
amoxicillin 500 mg six hours later. Patients who are allergic to
penicillin or who have received more than one dose of penicillin
in the previous month should receive intravenous clindamycin
300 mg slowly over at least ten minutes at induction (150 mg if
clindamycin commenced prior to theatre), and then oral or
intravenous clindamycin 150 mg six hours later.

17. Guidelines for Obstetric Anaesthesia Services. Association of


Anaesthetists of Great Britain and Ireland and Obstetric
Anaesthetists Association; London 1998; page 11.
18. British National Formulary 45, March 2003.

Obstetric Anaesthetists Handbook 3 59


Information and consent for obstetric anaesthesia procedures

Information and consent for obstetric


anaesthesia procedures
General considerations
Recent professional advice has been issued on consent for
anaesthesia [19,20]. You should practise according to the
following recommendations [21].
“There is no difference between the principle of
obtaining consent for obstetric anaesthesia and
any other medical treatment. A patient has the
right to give or withhold consent or withdraw
consent even after it has been given. Consent
may be implied or expressed; it may be oral or
written.
“The patient is entitled to receive an explanation
of the proposed procedure in simple language
and should be capable of understanding the
information given. The explanation should
include the nature and purpose of the proposed
procedure, as well as any material risks
attached to it. The patient should be given an
opportunity to ask any questions she may have
relating to the procedure. The CEMD state;
“Every effort must be made to improve the
quality of information provided and to make
sure that it is presented in an appropriate
form” [22].
“Although the mechanism for obtaining consent
will vary from unit to unit, it is important that
every unit should develop a policy whereby,
during the antenatal period, patients are given a
detailed, unbiased explanation about pain relief
and operations under regional and general
anaesthesia. If possible, an anaesthetist should
give these explanations. It is still necessary to
give the patient an explanation at the time of
the proposed procedure, even though she may

60 Obstetric Anaesthetists Handbook 3


Information and consent for obstetric anaesthesia procedures
not fully understand exactly what is being said
because of pain or being confused by analgesic
or sedative drugs. All explanations should be
documented and witnessed.”
Expectant mothers attending the antenatal clinics are given
leaflet information regarding the available choices in the
delivery suite. They are encouraged to form their own choices in
advance of labour. Women always retain the right to change
their mind, and you should respect this. On occasion this may
mean that a woman in labour appears to change her mind in a
contrary fashion, but she has this right.
Unusual restrictions on treatment should be noted in the
antenatal record. Where restrictions on a woman’s treatment
inevitably result in danger for the fetus, it is conceivable that an
approach to the courts may be made. Such approaches may be
successful where the court is of the opinion that the woman is
no longer a competent person to give or withhold consent.

Concerns about patient safety


Any instance, in which you feel that restrictions on consent may
lead to harm for the woman, or approaches to the courts are
mooted, must be reported immediately to the consultant
anaesthetist on call.

Birth plans
A birth plan is a form of advance statement and must be
respected unless the situation falls outside the expected
circumstances or there is evidence that the mother may have
changed her mind since signing it.

Consent for epidurals


You may be asked to establish epidural analgesia in women
whose competency is called into question because of pain, or
analgesic or sedative drugs. The process of consent started
antenatally as described above, and in the delivery room may
be oral and implied. However, all women for whom you propose
to establish epidural analgesia must have an explanation at
least and be offered the opportunity to refuse or to ask
questions. This explanation is documented on the epidural form
that you must complete for each woman.

Obstetric Anaesthetists Handbook 3 61


Information and consent for obstetric anaesthesia procedures
Although you should use your professional skills in making this
explanation, we suggest that the following is explained as a
minimum:
• An epidural involves the insertion of a catheter near to the
spine and is performed by an anaesthetist.
• It is the best method of labour analgesia known, with a
success rate of about five in six – the remaining one in six
will often respond to further attention.
• The fetus generally benefits and there is no consistent
evidence to show that you are more likely to have an
operation as a result of the epidural.
• A drip will be required in order to prevent a potential fall in
blood pressure.
• Pregnancy and labour cause backache – epidurals do not,
beyond minimal discomfort sometimes experienced on the
first postpartum day [23,24].
• Your legs may become weak, though we minimise this and
you should be able to move comfortably around the bed.
• Severe postpartum headache due to technical difficulties
occurs in about 1:150 epidurals. Treatment will be
provided if this becomes a problem.

19. Information and Consent for Anaesthesia. Association of


Anaesthetists of Great Britain and Ireland; London 1999.

20. Guidelines for Obstetric Anaesthesia Services. Association of


Anaesthetists of Great Britain and Ireland and Obstetric
Anaesthetists Association; London 1998.
21. Guidelines for Obstetric Anaesthesia Services. Association of
Anaesthetists of Great Britain and Ireland and Obstetric
Anaesthetists Association; London 1998; pages 13-14.

22. UK Health Departments. Report on the Confidential Enquiries into


Maternal Deaths in the United Kingdom 1991-1993. London:
HMSO, 1996.

62 Obstetric Anaesthetists Handbook 3


Information and consent for obstetric anaesthesia procedures

23. Russell R, Dundas R, Reynolds F. Long term backache after


childbirth: prospective search for causative factors. BMJ 1996; 312:
1384-8.
24. Buggy D, MacEvilly M. Do epidurals cause back pain? Br J Hosp
Med 1996; 56: 99-101.

Obstetric Anaesthetists Handbook 3 63


Information for mothers

Information for mothers


This section contains three information resources for mothers.
You should read them carefully as a guide to how you should
conduct conversations with patients.

Epidurals for labour – key facts


This card, devised by Dr M. Wee in Poole, is provided in each
delivery room for mothers to read. Mothers may ask you
detailed questions about these statements.
This card is intended as a summary only.
If you wish to know more please ask your midwife or
anaesthetist.

Epidurals

• Usually provide excellent pain relief.


• Can be adjusted to allow you to be comfortable but not
numb.
• Should allow you to move around the bed and push your
baby out.
• Take at least 20 minutes to set up and 20 minutes to work.
• Can be extended for Caesarean section if required.

Also note …

• You need a drip before you can have an epidural.


• Some epidurals do not work fully and need to be adjusted
or replaced.
• In general epidurals do not affect the baby.

Side effects

• Your blood pressure may fall after the epidural is inserted.


This is treated with the drip and/or drugs.

64 Obstetric Anaesthetists Handbook 3


Information for mothers

• Your labour may slow down for a while.


• You may feel itchy.
• Some women shiver after epidural top ups.

Possible problems

• Severe headache may occur after an epidural (less than 1


in 100 chance). It is worse sitting up and improves if you
lie down. It may start up to several days after your baby is
born. You must see an anaesthetist as special treatment
may be needed.
• Backache is NOT more common after an epidural. It is
very common after any pregnancy. There may be
tenderness where the epidural went in which lasts a few
days.
• Nerve damage is a very rare possibility – about 1 in
12,000.

Obstetric Anaesthetists Handbook 3 65


Information for mothers

Pain relief in labour


OAA, second edition, January 2001
This is the text of the OAA booklet that is designed for antenatal
use.
This booklet will give you some idea about the pain of labour
and what can be done to relieve it. You will need further
information from those who are looking after you about the
types of pain relief available at your own hospital. We hope that
if you know what to expect and, with good pain relief if need be,
you will find the birth of your baby can be a satisfying
experience.

What will labour feel like?


Towards the end of pregnancy you may notice your uterus
tightening from time to time. When labour starts these
tightenings become regular and much stronger. This may cause
pain that at first feels like strong period pain but usually gets
more severe as labour progresses. The amount of pain varies.
Your first labour is usually the longest and hardest. Sometimes
it is necessary to start labour artificially or to stimulate it if
progress is slow, and this may make it more painful. Over 90%
of women find they need some sort of pain relief.

Preparing for labour


It is helpful to attend antenatal classes run by midwives who
know about the hospital where you are booked. They can teach
you about pregnancy and labour and caring for your baby. They
will tell you what to expect when you go into hospital, what
procedures may be needed and the reasons for them.
Understanding what may happen during labour will make you
feel less anxious. It is also helpful to visit the hospital where you
plan to have your baby. All this will help you to relax and cope
better.
During pregnancy physiotherapists or midwives will teach you
control of breathing and ways of helping you to cope with
contractions. They will also teach you correct ways of moving
and good positions for working and how to relax in order to
minimise problems with your joints and back, during and after
your pregnancy.

66 Obstetric Anaesthetists Handbook 3


Information for mothers
At these classes you can also learn about the types of pain
relief that are in use. Ask to see an anaesthetist if you want
further advice about certain types of pain relief and whether
they may be suitable for you. Anaesthetists are the doctors who
provide epidurals, and who can also advise you about other
types of pain relief. In some hospitals they give regular talks on
pain relief to expectant mothers and their partners.

What methods of pain relief are available?


There are several ways of helping you cope with pain. A
supportive companion is invaluable. Relaxation is important and
moving around sometimes helps. Bathing in warm water and
massage, particularly having your back rubbed, can help you
relax and ease some pains away. Music can be helpful.
It is difficult for you to know beforehand what sort of pain relief
will be best for you. The midwife who is with you in labour is the
best person to advise you. Here are some of the facts about the
main methods of pain relief that you may be offered.

Alternative methods
There are several ways of helping you to cope with pain,
especially in early labour. Your companion can help with some
of them. Although the amount of actual pain relief they produce
is uncertain some people find them very helpful. You can ask
whether any of these methods are used in your hospital.
• Aromatherapy • Herbalism
• Hypnosis • Reflexology
• Homeopathy • Acupuncture

Transcutaneous electrical nerve stimulation (TENS)

• A gentle electrical current is passed through four flat pads


stuck to your back. This creates a tingling feeling. You can
control the strength of the current yourself.
• It is sometimes helpful at the beginning of labour,
particularly for backache. If you hire one you can start it at
home. Some hospitals will also lend them out.
• It has no known harmful effects on your baby.

Obstetric Anaesthetists Handbook 3 67


Information for mothers
While you may manage your labour with only the help of TENS,
it is more likely that you will require some other sort of pain
relief in the later stages.

Entonox
(50% nitrous oxide and oxygen, sometimes known as gas)
• You breathe this through a mask or mouthpiece.
• It is simple and quick to act, and wears off in minutes.
• It sometimes makes you feel light-headed or a little sick for
a short time.
• It does not harm your baby and it gives you extra oxygen,
which may be beneficial for you and your baby.
• It will not take the pain away completely but it may help.
• It can be used at any time during labour.
You, yourself, control the amount of gas you use, but to get the
best effect timing is important. You should start breathing the
gas as soon as you feel a contraction coming on so that you will
get the full effect when the pain is at its worst. You should not
use it between contractions or for long periods as this can make
you feel dizzy and tingly. In some hospitals other substances
may be added to the gas to make it more effective, but these
may make you more sleepy.

Pethidine

• Usually given by injection, into a muscle, by midwives.


• It may make you drowsy, but it may also make you less
worried by the pain.
• It may make you feel sick, but you should be given
something else to reduce this effect.
• It may make your baby drowsy, but an antidote can be
given by injection after birth. If pethidine is given only
shortly before delivery, the effect on your baby is very
slight.

68 Obstetric Anaesthetists Handbook 3


Information for mothers

• It delays stomach emptying which might be a hazard if a


general anaesthetic is needed. You should not eat or use
the birthing pool if you have had pethidine.
• It may delay the establishment of breast-feeding.
• It has less effect on pain than Entonox.
Though pethidine has less effect on pain than gas, many
mothers find it makes them more relaxed and able to cope with
pain, though some find it disappointing. It can also be given
directly into a vein for a faster effect, and some hospitals use a
machine (called Patient controlled analgesia, PCA) which
allows you to press a button to give yourself measured small
doses when you feel you need them.

Other injected drugs


Pethidine is the drug licensed for use by midwives, although a
number of other similar drugs have been used to relieve labour
pain. Those worth mentioning are diamorphine, fentanyl and
meptazinol, which some units feel give better pain relief. They
act in a similar way to pethidine.

Epidurals

• Given into a very small tube in your back.


• Most complicated method, performed by an anaesthetist.
• Little effect on your baby.
• A small risk of headache.
• May cause a drop in blood pressure.
• Most effective method of pain relief.

Who should have an epidural?


Most people can have an epidural, but certain complications of
pregnancy and bleeding disorders may make it unsuitable. If
you have a complicated or long labour your midwife or
obstetrician may recommend that you have one. In such
circumstances it will benefit you and your baby.

Obstetric Anaesthetists Handbook 3 69


Information for mothers
What does it involve?
You will first need a drip, that is fluid running in to a vein in your
arm. This is often necessary in labour for other reasons. You
will be asked to curl up on your side or sit bending forwards.
Your back will be cleaned and a little injection of local
anaesthetic given into the skin, so putting in the epidural should
hardly hurt. A small tube is put into your back near the nerves
carrying pain from the uterus. Care is needed to avoid
puncturing the bag of fluid that surrounds the spinal cord, as
this may give you a headache afterwards. It is therefore
important to keep still while the anaesthetist is putting in the
epidural, but after the tube is in place you will be free to move.
Once the tube is in place, pain-relieving drugs can be given as
often as is necessary, or continuously by a pump. While the
epidural is taking effect, the midwife will take your blood
pressure regularly. The anaesthetist and your midwife will also
check that the epidural is working properly. It usually takes
about 20 minutes to work, but occasionally it doesn’t work well
at first, and some adjustment is needed.

What are the effects?

• Nowadays it is usually possible to provide pain relief


without numbness or heavy legs, in other words a ‘mobile
epidural’.
• An epidural should not make you feel drowsy or sick, nor
does it normally delay stomach emptying.
• Occasionally it drops your blood pressure, which is why
you have the drip.
• It sometimes makes you shivery at first, but this usually
stops quite soon.
• It may prolong the second stage of labour and reduce the
urge to bear down but with time the uterus should push the
baby out. Even with an epidural you are more likely to
have a normal delivery than any other type of delivery.
• It removes much of the stress of labour, which is good for
the baby.
• Breast-feeding is not impaired, in fact it is often helped.

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Information for mothers

• In this country as a whole, there is about a one in 100


chance of your getting a headache after an epidural, but
hospitals vary in their headache rate so you might enquire
about this. If you develop a headache afterwards, it can be
treated.
• Backache is common during pregnancy and often
continues afterwards when you are looking after your
baby. There is now good evidence that epidurals do not
cause long-term backache, though you may feel local
tenderness for a day or two afterwards.
• About one in 2000 mothers gets a feeling of tingling or pins
and needles down one leg after having a baby. Such
problems are more likely to result from childbirth itself than
from an epidural. Other more serious problems happen
even more rarely.

What if you need an operation?


If you should need any operation such as caesarean section or
forceps delivery, you may not need a general anaesthetic, as
the epidural can often be used instead. A stronger local
anaesthetic and other pain-relieving drugs can be injected into
your epidural tube to provide an adequate anaesthetic for your
operation. This is safer for you and the baby.

What about spinals?


Epidurals are rather slow to act, particularly in late labour. If the
pain-killing drugs are put directly into the bag of fluid
surrounding the nerves in your back, they work much faster.
This is called a spinal. A much smaller needle is used for a
spinal than for an epidural, so the risk of headache is small. In
some hospitals spinals, or a combination of spinals and
epidurals, are used for pain relief in labour and spinal
anaesthesia is commonly used for caesarean section.

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Information for mothers

Caesarean section: your choice of anaesthesia


OAA, first edition, March 2003
This is the text of the OAA booklet that is designed for antenatal
use.
About one in five babies is born by caesarean section and two
thirds of these are unexpected; so you may like to glance at this
booklet, even if you do not expect to have a caesarean yourself.

Having a baby is an unforgettable experience


A caesarean section can be just as satisfying as a vaginal
delivery, and if it turns out you need a caesarean section, you
should not feel this is in any sense a failure. The most important
thing is that you and your baby are safe. A caesarean section
may be the best way to ensure this.
There are several types of anaesthesia for caesarean section.
This booklet explains the various choices. You can discuss the
choice of anaesthetic with your anaesthetist. Obstetric
anaesthetists are doctors who specialise in the anaesthetic care
and welfare of pregnant women and their babies.
Your caesarean section may be planned in advance; this is
called an elective caesarean section. This may be advisable if
there is an increased chance of complications developing
during a vaginal delivery. One example might be if your baby is
in an unusual position in the later stages of pregnancy.
In some cases, caesarean section may be recommended in a
hurry, usually when you are already in labour. This is an
emergency caesarean section. This may be recommended
because of poor progress in labour; because the baby’s
condition is deteriorating or a combination of the two.
Your obstetrician will discuss with you the reasons for your
caesarean section and obtain consent for the operation.

Types of anaesthesia
There are two main types; you can be either awake or asleep.
Most caesareans are done under regional anaesthesia, when
you are awake but sensation from the lower body is numbed. It
is usually safer for mother and baby and allows both you and
your partner to experience the birth together.

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There are three types of regional anaesthesia:
1. Spinal - the most commonly used method. It may be used in
planned or emergency caesarean section. The nerves and
spinal cord that carry feelings from your lower body (and
messages to make your muscles move) are contained in a bag
of fluid inside your backbone.
Local anaesthetic is put inside this bag of fluid, using a very fine
needle. A spinal works fast with a small dose of anaesthetic.
2. Epidural - A thin plastic tube or catheter is put outside the
bag of fluid, near the nerves carrying pain from the uterus. An
epidural is often used to treat the pain of labour using weak
local anaesthetic solutions. It can be topped up if you need a
caesarean section by giving a stronger local anaesthetic
solution. In an epidural, a larger dose of local anaesthetic is
necessary than with a spinal, and it takes longer to work. Your
epidural can be topped up if needed.
3. Combined spinal-epidural or CSE - a combination of the two.
The spinal can be used for the caesarean section. The epidural
can be used to give more anaesthetic if required, and to give
pain-relieving drugs after the operation.
General anaesthesia - If you have a general anaesthetic you
will be asleep for the caesarean section. General anaesthesia is
used less often nowadays. It may be needed for some
emergencies; if there is a reason why regional anaesthesia is
unsuitable or if you prefer to be asleep.
The pros and cons of each are described later in this booklet.
First it is useful to know what happens when a caesarean
section is planned, and a date given for your operation.

Pre-operative assessment
Normally you will visit the hospital before you come in for your
operation. The midwife will see you and take some blood from
you for tests before the operation. She will also explain what to
expect. Most women go home after the assessment and come
back to hospital on the day of the operation, but you may need
to stay in the night before. You may be given tablets to reduce
the acid in your stomach and prevent sickness; you need to
take one the night before the operation and one on the morning
itself. This will be explained to you.

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Information for mothers
The anaesthetist’s visit
You should be seen by an anaesthetist before your caesarean
section. The anaesthetist will review your medical history and
any previous anaesthetics. You may need an examination or
further tests. The anaesthetist will also discuss the anaesthetic
choices with you and answer your questions.

On the day
The midwife will confirm the time of your operation and check
that you have taken your tablets. Your bikini line may need to
be shaved.
You will have a name band on your wrist or ankle.
The midwife may help you to put on special tight stockings
(called TED stockings) to prevent clots forming in your legs.
You will be given a theatre gown to put on. Your birthing partner
can accompany you and the midwife to the operating theatre.
Special theatre clothes will be provided.
In theatre, equipment will be attached to measure your blood
pressure, heart rate, and the amount of oxygen in your blood,
quite painlessly. Using a local anaesthetic to numb your skin,
the anaesthetist will set up a drip to give you fluid through your
veins. Then the anaesthetic will be started.

What will happen if you have regional anaesthesia?


You’ll be asked either to sit or to lie on your side, curling your
back. The anaesthetist will paint your back with sterilising
solution, which feels cold. He or she will then find a suitable
point in the middle of the lower back and will give you a little
local anaesthetic injection to numb the skin.
This sometimes stings for a moment.
Then for a spinal, a fine spinal needle is put into your back; this
is not usually painful. Sometimes, you might feel a tingling going
down one leg as the needle goes in, like a small electric shock.
You should mention this, but it is important that you keep still
while the spinal is being put in. When the needle is in the right
position, local anaesthetic and a pain-relieving drug will be
injected and the needle removed. It usually takes just a few
minutes, but if it is difficult to place the needle, it may take
longer.

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For an epidural, a larger needle is needed to allow the epidural
catheter to be threaded down it into the epidural space. As with
a spinal, this sometimes causes a tingling feeling or small
electric shock down your leg. It is important to keep still while
the anaesthetist is putting in the epidural, but once the catheter
is in place, the needle is removed and you don’t have to keep
still.
If you already have an epidural catheter for pain relief in labour,
then all the anaesthetist has to do is put a stronger dose of local
anaesthetic down the catheter, which should work well for a
caesarean section. If the caesarean section is very urgent, it
may be decided that there is not enough time for the epidural to
be extended, so a different anaesthetic may be recommended.
You will know when the spinal or epidural is working because
your legs begin to feel heavy and warm. They may also start to
tingle.
Numbness will spread gradually up your body.
The anaesthetist will check how far the block has spread to
make sure that you are ready for the operation. It is sometimes
necessary to change your position to make sure the anaesthetic
is working well. Your blood pressure will be taken frequently.
While the anaesthetic is taking effect, a midwife will insert a
tube (a urinary catheter) into your bladder to keep it empty
during the operation. This should not be uncomfortable. The
tube may be left in place until the next morning, so you won’t
need to worry about being able to pass water.
For the operation, you will be placed on your back with a tilt
towards the left side. If you feel sick at any time, you should
mention this to the anaesthetist. It is often caused by a drop in
blood pressure. The anaesthetist will give you appropriate
treatment to help you.
Until the baby is born, you may be given oxygen through a
transparent plastic mask to make sure the baby has plenty of
oxygen before the birth.

The operation
A screen separates you and your birthing partner from the
operation site. The anaesthetist will stay with you all the time.
You may hear a lot of preparation in the background. This is

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because the obstetricians work with a team of midwives and
theatre staff.
Your skin is usually cut slightly below the bikini line. Once the
operation is under way, you may feel pulling and pressure, but
you should not feel pain. Some women have described it as
feeling like ‘someone doing the washing-up inside my tummy’.
The anaesthetist will assess you throughout the procedure and
can give you more pain relief if required. Whilst it is unusual,
occasionally it may be necessary to give you a general
anaesthetic.
From the start it takes about ten minutes before the delivery.
Immediately after the birth, the midwife quickly dries and
examines your baby. A paediatrician may do this with the
midwife. After this, you and your partner will be able to cuddle
your baby.
After the birth, a drug called Syntocinon is put into your drip to
help tighten your uterus and deliver your placenta. An antibiotic
will also be put into the drip to reduce the risk of wound
infection. The obstetrician will take about another half-hour to
complete the operation. Afterwards, you may be given a
suppository in your back passage to relieve pain when the
anaesthetic wears off.

When the operation is over


You should be helped to sit up slightly, and then taken to the
recovery room where you will be under observation for a while.
Your partner and baby can usually be with you. Your baby will
be weighed and then you can begin breast feeding if you like. In
the recovery room, your anaesthetic will gradually wear off and
you may feel a tingling sensation in your legs. Within a couple
of hours you’ll be able to move them again. The pain relieving
drugs given with your spinal or epidural should continue to give
you pain relief for a few hours. When you need more pain relief,
ask the midwife.

What will happen with general anaesthesia?


You will be given an antacid to drink and a urinary catheter will
be inserted before your general anaesthetic. The anaesthetist
will give you oxygen to breathe through a facemask for a few
minutes. Once the obstetrician and all the team are assembled,

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the anaesthetist will give the anaesthetic in your drip to send
you to sleep.
Just before you go off to sleep, the anaesthetist’s assistant will
press lightly on your neck. This is to prevent stomach fluid
getting into your lungs.
The anaesthetic works very quickly.
When you are asleep, a tube is put into your windpipe to
prevent stomach contents from entering your lungs and to allow
a machine to breathe for you. The anaesthetist will continue the
anaesthetic to keep you asleep and allow the obstetrician to
deliver your baby safely. But you won’t know anything about all
this.
When you wake up, your throat may feel uncomfortable from
the tube, and you may feel sore from the operation. You may
also feel sleepy and perhaps nauseated, for a while. But you
should soon be back to normal. You will be wheeled to the
recovery area where you will meet up with your baby and
partner. You may be given a patient controlled analgesia (PCA)
machine, which provides you with pain relief at a press of a
button whenever you need it. If not, ask the midwife when you
need more painkillers.

Some reasons why you may need general anaesthesia:

• In certain conditions when the blood cannot clot properly,


regional anaesthesia is best avoided.
• There may not be enough time for regional anaesthesia to
work.
• A very abnormal back may make regional anaesthesia
difficult or impossible.
• Occasionally, spinal or epidural anaesthesia does not work
well.

Pain relief after the operation


There are several ways to give you pain relief after caesarean
section:
• Regional: you can be given a long acting pain killer with
the spinal or epidural.

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Information for mothers

• Epidural: in some hospitals the epidural catheter is left in


for later use.
• Suppositories are often given at the end of the operation.
• Injection into a muscle of morphine or similar painkiller, by
a midwife.
• Into a drip: (morphine or similar drug) you can control the
amount yourself. This is called patient-controlled analgesia
or PCA.
• By mouth: a midwife can give you tablets such as Voltarol
or paracetamol.

Advantages of regional compared with general anaesthesia

• Spinals and epidurals are usually safer for you and your
baby.
• They enable you and your partner to share in the birth.
• You won’t be sleepy afterwards.
• They allow earlier feeding and contact with your baby.
• You will have good pain relief afterwards.
• Your baby will be born more alert.

Disadvantages of regional compared with general


anaesthesia

• Spinals and epidurals can lower the blood pressure,


though this is easily treated.
• In general, they may take longer to set up than a general
anaesthetic.
• Occasionally, they may make you feel shaky.
• Rarely, they don’t work perfectly; so a general anaesthetic
may be necessary.
Also they may cause:

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Information for mothers

• Tingling down one leg, more with spinals. (In about one in
ten thousand spinals, this may last several weeks or
months).
• Itching during the operation and afterwards, but this can be
treated.
• Severe headache, in fewer than one in a hundred women.
This can be treated.
• Local tenderness in your back for a few days.
This is not unusual.

Spinals and epidurals do not cause chronic backache


Unfortunately backache is very common after childbirth,
particularly among women who have suffered with it before or
during pregnancy, but spinals and epidurals do not make it
more so.
Having a baby by caesarean section is safe and can be a very
rewarding experience. Many women choose to be awake for the
procedure. Others may need to be asleep for the reasons
discussed above.
We hope that this booklet will enable you to make an informed
choice for your caesarean section.

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Management of regional blocks

Management of regional blocks


The majority of your anaesthesia interventions on the delivery
suite will be central nerve blocks for analgesia or surgery. This
section deals with practical management issues for central
nerve blocks.

Infection control
Breaching the protections of the central nervous system carries
the risk of introducing infection. While the area remains
controversial and rigorous evidence is lacking, the Association
of Anaesthetists of Great Britain and Ireland has made
recommendations [25]. In particular, you should wear a
facemask when establishing central neuraxial block.
Maximal barrier precautions involve full hand
washing, the wearing of sterile gloves and
gown, a cap, mask and the use of a large sterile
drape. The skin entry site should be cleaned
with an alcoholic Chlorhexidine gluconate
solution or alcoholic Povidone-iodine solution.
The antiseptic should be allowed to dry before
proceeding.
Certain invasive anaesthetic procedures require
this optimum aseptic technique: -
• Insertion of central venous catheters
• Spinal, epidural and caudal procedures
The Working Party is aware that many
anaesthetists do not employ this level of
asepsis for ‘one-shot’ spinals or epidurals but
believes when central neural spaces are
penetrated full aseptic precautions are required.

Monitoring the extent of central nerve blocks


You should monitor immediate effects of administered neuraxial
drugs, and their sensory, motor and autonomic effects as the
block establishes.

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Management of regional blocks
Contact with the mother
Maintain eye and verbal contact during and after any injection,
checking for the signs of intrathecal and intravascular
placement. You should then assess segmental height of block
using a cocktail stick or wrapped ice.

Intrathecal placement
This may be diagnosed three to five minutes after
administration down an epidural catheter if there is:
• Rapid disappearance of labour pains.
• Hypotension.
• Motor block in the legs.
• Loss of pain sensation on the lateral border of the
heel (S1).
• A warm upper foot.

Intravascular placement
This is suggested by:
• A metallic taste in the mouth.
• Tingling of the lips.
• Buzzing in the ears.
• A feeling of light-headedness.
Cardiovascular collapse may follow.

Autonomic block
Bilateral warm dry feet are an early sign of a successful epidural
block.
You should ensure that there is regular monitoring and
recording of the blood pressure. This will allow detection and
treatment of hypotension.
Extension of the autonomic block into the segments innervating
the sympathetic cardioaccelerator fibres (T1 to T4) may rarely
lead to bradycardia requiring glycopyrrolate treatment.

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Management of regional blocks
Sensory examination
The uterine nerve supply is T10 to L1 and perineum S2/3/4
C5 area over the deltoid
C6 thumb
C7 middle finger
C8 little finger
T4 Angle of Louis, nipple – caesarean section, trial of
assisted delivery
T8 epigastrium – other operative procedures
T10 umbilicus – epidural analgesia for labour
T12 symphysis
L4 medial aspect of the leg
L5 space between first and second toes
S1 lateral border of the heel
S2 posterior aspect of thigh
S3 area over the ischial tuberosity
S4, S5 perianal region

Motor examination
C5 deltoid – raises elbow to level of shoulder
C6 biceps – flexes forearm
C7 triceps – extends forearm
C8 flexes wrist and fingers
T1 spreads fingers
Block levels above here are too high. Block levels
below here are acceptable, although for epidural
analgesia motor blockade should be minimised.
L2 iliopsoas – flexes hip
L3 quadriceps – extends knee
L4 tibialis anterior – dorsiflexes ankle
L5 extensor hallucis longus – extends toes
S1 gastrocnemius – plantarflexes ankle

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Management of regional blocks

Neuraxial fentanyl and pruritus


Pruritus can occur following the neuraxial administration of
fentanyl. It is quite common in obstetric patients.
Reassure the mother about the cause and that it is likely to
resolve spontaneously in a short time. This is usually the only
treatment needed.
If the pruritus is distressing and further treatment is needed,
administer:
• Propofol 10 mg. In sub-hypnotic doses this can give
relief.
• Or repeat bolus doses of naloxone 50 µg to a
maximum dose of 400 µg. Warn the mother that the
analgesic effects of fentanyl may be reversed.
Consider avoiding neuraxial opioids in patients at high risk –
those with eczema, psoriasis or a previous history of neuraxial
opioids inducing pruritus.

25. Infection control in anaesthesia. Association of Anaesthetists of


Great Britain and Ireland; London, November 2002.

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Pain relief for labour

Pain relief for labour


We offer epidural analgesia for relief of pain associated with
labour and assisted delivery. Epidurals are described in detail
below.
As a matter of routine, we do not offer the combined
spinal/epidural technique in labour. We do however aim for
sensory and not motor loss, allowing mobility in the bed.
We do not recommend the use of spinal analgesia for pain
relief. Conduct of spinal analgesia is contraindicated in places
where full monitoring and resuscitation facilities are not
available. The risks associated with spinal blockade outside
theatre are too high.

Epidural analgesia – general considerations

Response time
We offer a 24-hour ‘on-demand’ service for pain relief in labour.
The relevant professional standard is: [26]
“The time from informing the anaesthetist of the
mother’s request until attending the woman
should ideally not exceed 30 minutes and, in
any case, not exceed 60 minutes, other than in
exceptional circumstances”.
You must attend promptly. If you anticipate that the response
time will exceed 30 minutes you should inform the midwife and
consider calling the third on call anaesthetist for assistance.
Calls to the third on call anaesthetist must be made by you or
on your express instruction.

Indications
The most common indication for epidural analgesia is maternal
request but there may be instances when epidural analgesia is
preferred for medical reasons. These include:
• Pre-eclampsia (see ‘Epidural analgesia in pre-
eclampsia’, on page 143).
• Multiple pregnancy.
• Breech presentation for vaginal delivery.

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Pain relief for labour
• Diabetes mellitus.
• Respiratory disease e.g. asthma.
• Cardiovascular disease.
• Sickle cell disease.
• Premature labour.
• Prolonged labour.
• Intrauterine growth retardation.
• Intrauterine death (see ‘Indications for haematological
investigations’ on page 52).
• Anticipated instrumental delivery.

Contraindications
See ‘Central nerve block and vertebral canal haematoma’, on
page 51.
• Unwilling patient.
• Coagulopathy or anticoagulation (see page 51).
• Local sepsis at the epidural site.
• Septicaemia as evidenced by pyrexia (above 37.5˚C
or if symptomatic) unless the cause is known (e.g.
Cervagem pessaries).
• Raised intracranial pressure (not benign intracranial
hypertension).
• Uncorrected hypovolaemia.
• Fetal distress until fetal blood sample performed or
obstetric confirmation given.
• Inadequate staff to look after the mother.

Relative contraindications (discuss with a more senior


anaesthetist)
• Technical difficulties e.g. previous back surgery,
kyphoscoliosis, and gross obesity.
• Neurological disorders.
• Potential severe haemorrhage e.g. placenta praevia.
A consultant anaesthetist should have seen women with
complex medical disorders antenatally, following which a plan is
made and recorded in the medical case notes. Find the plan
and follow it.

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Desirable block
You should aim to relieve the pain of labour:
• For humane reasons of itself.
• To reduce maternal anxiety, especially fear of the
next pain.
• To reduce the severe physiological stress for mother
and fetus that follows pain.
You should aim to avoid:
• Gross motor blockade, unless specifically indicated.
• Complete sensory loss, which interferes with the
mother’s ability to be a full partner in the delivery of
her child.
The therapeutic target is bilateral sensory block to T10.
The ideal block relieves that component of pain for which she
sought relief in the first place, and no more.

Aortocaval compression
Avoid aortocaval compression. Patients with epidurals are
nursed in full lateral position, supine with an obstetric wedge, or
sitting up more than 30 degrees.

Technique for epidural analgesia in labour

Performing the block


1. When an epidural is requested you should ascertain that
there are no contraindications to epidural analgesia,
explain the procedure briefly to the mother and obtain
verbal consent consistent with the mother’s condition (see
‘Information and consent for obstetric anaesthesia
procedures’ on page 60).
2. Note the blood pressure prior to performing the epidural.
An intravenous infusion of Hartmann’s solution (1000 ml)
should then be attached to a large bore cannula (16G or
14G; use lignocaine analgesia for insertion) and set
running at a rate to go in over about six hours. A preload is
not mandatory but should be considered if there is
significant passage of time since normal fluid intake.

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Pain relief for labour
3. There are few indications for intravenous fluids other than
Hartmann’s solution to be used in labour but examples
are:
• Dextrose and insulin, in the insulin dependent diabetic
patient.
• 0.9% saline in those with homozygous sickle cell
disease.
• Albumin in severe pre-eclampsia.
Maternal ketosis is an indication for fluid, not an indication
for the administration of glucose in labour.
4. The patient should then be positioned either in the left
lateral or sitting positions according to the anaesthetist and
mother’s preferences. The epidural should be sited using
the technique with which you practice safely and
effectively
5. Loss of resistance to saline is the recommended
technique, which you should learn and use. The use of air
is associated with an increased rate of accidental dural
puncture, ascending back pain, intense and immediate
headache, convulsions, patchy block and air embolus [27].
6. You should secure the catheter in place leaving 3-5 cm in
the epidural space; 4 cm is preferred. Use a small amount
of Opsite spray and allow to dry before fixing the covering
large Opsite dressing, without using swabs. This is secure
and allows full inspection of the site.
7. Maintain fetal monitoring using cardiotocography during
the insertion of the epidural.
8. If you have difficulty siting the epidural, call for help. Do not
persist in fruitless attempts.
9. Maintain maternal and fetal monitoring during the test
dose.
10. A test dose of 3 ml lignocaine 2% (without adrenaline)
should be given and a period of 5 minutes allowed for it to
gain its full effect and to ascertain whether the catheter
has inadvertently been placed in the subarachnoid space
or a blood vessel. (See ‘Monitoring the extent of central
nerve blocks’ on page 80).
11. Although the catheter should always be aspirated prior to
administering a dose, the non-appearance of blood does
not exclude intravenous catheter placement.

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Documentation and records
The epidural chart is on the back of the Obstetric Anaesthesia
Procedure Record. You should record details of the technique
used and the prescription made. File the chart in the patient’s
medical record, under Anaesthesia.

Intermittent bolus top-ups


This is the standard method used in the delivery suite.
If there are no adverse reactions to the test dose, top-ups can
proceed with bupivacaine in doses not exceeding 15 mg
bupivacaine per 5 minutes.
We now have premixed bupivacaine and fentanyl ampoules for
use by anaesthetists and midwives. They contain 10 mg
bupivacaine and 20 µg fentanyl made up to 10 ml. Obtain two
ampoules before starting the epidural. The suggested first dose
is 15 ml.
You should sign the boxes on the epidural chart to prescribe
subsequent doses to be administered by the midwife. The
standard prescription is
10 ml – bupivacaine 10mg + fentanyl 20 µg – in 40
sitting or lateral position for analgesia in labour minutes
If the ampoules are not available then you should make up your
bupivacaine and fentanyl mixture. It should contain more opioid
because the midwife will not be able to give further fentanyl with
the bolus doses. The first dose should be 15 mg bupivacaine
(6 ml 0.25% bupivacaine) and 100 µg fentanyl (2 ml) made up
to 15 ml with saline 0.9%. The final concentration is 0.1% with
fentanyl 6.7 µg/ml. The prescription should be for:
10 ml 0.25% bupivacaine (25 mg total) – in sitting or one
lateral position for analgesia in labour hour
We suggest that you prescribe this bolus anyway should there
be supply problems after the epidural is sited. You should also
allow for instrumental delivery in the delivery room:
10 ml 0.5% bupivacaine (50 mg total) – in sitting or once
lateral position for analgesia in assisted delivery only
During topping-up the blood pressure should be checked at 0, 5
and 10 minutes. Blood pressure readings and the efficacy of the
first top-up should be recorded on the epidural chart. If there
Obstetric Anaesthetists Handbook 3 89
Pain relief for labour
have been no problems, subsequent top-ups may be
administered by the midwife to your prescription. The midwives
will top up when analgesia is below T10 on assessment.
Bupivacaine should not be given in concentrations exceeding
0.25% during the first stage of labour unless specifically
indicated. Do not allow the bupivacaine dose to exceed 2 mg/kg
in a four-hour period.

Epidural infusions
If the labour is likely to last longer than 3 hours after siting the
epidural you should consider administering an epidural infusion.
This may lead to:
• Better continuous analgesia.
• Better cardiovascular stability.
• Enhanced safety with the use of a dilute solution.
• Good sensory result without gross motor blockade.
• Better mobility around the bed.
• Decrease in midwifery workload.
Use a yellow infusion line – these are kept in the epidural
storage bay with the epidural trolleys. Do not use a clear line as
it could be confused with a Syntocinon or other intravenous
infusion.
The infusion mix should be 0.1% bupivacaine with fentanyl
2 µg/ml, running at 10 ml/hr initially.
Prefilled 50 ml syringes are available on the delivery suite.
Should you need to prepare an infusion, use five ampoules of
the premixed fentanyl and bupivacaine, or 10 ml 0.5%
bupivacaine + 2 ml fentanyl (100 µg) made up to 50 ml with
0.9% saline. Prescribe additional boluses in case the infusion
gives inadequate relief.
Be vigilant for inadequate relief of pain. The same problems
may occur with infusions as with intermittent top-ups, e.g.
missed segments.

Inadequate epidural analgesia


Many problems can be anticipated and resolved through regular
review of the patient and regular block assessment. You will
need to keep in close liaison with the midwife caring for the
mother.

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Missed segments
1. You should consider the diagnosis when there is persistent
pain in one place following epidural administration.
2. Inspect the insertion site.
3. Lay the patient on the unblocked side and give a further
top-up of 8 ml 1% lignocaine, with up to 100 µg fentanyl
(do not exceed 100 µg fentanyl in the first two hours and
then 100 µg fentanyl in each four hours). If this is not
effective pull out the catheter by 1 cm or until only 3 cm is
in the space and top up again.
4. Do not persist in trying to rescue an inadequate epidural.
Discuss the situation with the mother and propose resiting
the catheter as an early option. Record catheter resitings
on the audit chart.

Perineal and suprapubic pain


This can be difficult to treat particularly if the fetus is in the
occipito-posterior position. Bolus using 0.25% bupivacaine with
up to 50 µg fentanyl . This may be repeated (do not exceed
100 µg fentanyl in the first two hours and then 100 µg fentanyl
in each four hours). The mother should be 30º upright.
Other possibilities are:
• Performing a caudal or a low epidural at the L5/S1
interspace.
• Resiting the epidural.

Problematic epidurals

Unusually deep epidural space


Extra long epidural needles, required in about 1:1000 epidurals,
are kept in the store cupboard near to Room 4, and in the
anaesthetics room of the obstetric theatre.

Bloody taps
1. Flush the cannula and withdraw until no further blood
appears on aspiration.
2. If there is a sufficient amount of catheter in the epidural
space (2.5 to 3 cm) proceed carefully with the test dose.

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Pain relief for labour
3. Failing this, resite the epidural either in the same space or
another.
4. Two bloody taps in the same space warrant choosing
another space.
5. Always aspirate before giving any top-up.

Unintentional dural puncture (‘dural tap’)


These guidelines relate to the management of women in whom
inadvertent puncture of the dura has occurred during insertion
of an epidural for analgesia or surgery. There are two
alternative strategies from which you must choose. You should
make the choice in consultation with more senior anaesthetists
as described, and after as much discussion with the mother as
is appropriate (see page 60).

First alternative: resite the epidural


1. Once dural tap has occurred, you should usually site an
epidural in an alternative lumbar interspace.
2. In the event of successive dural taps, abandon epidural
analgesia and anaesthesia and consider alternative
methods including repeated subarachnoid block as below.
3. On resiting the epidural, you should administer a test dose
and first top-up dose of local anaesthetic. When you are
happy that satisfactory analgesia has resulted and that the
distribution of the block, determined by cutaneous testing,
is appropriate for the volume of anaesthetic given,
midwives may administer any subsequent top-ups in the
normal fashion except as provided for below. This is
unusual – the midwife may not be content to do this – and
you may need to attend regularly. An acceptable
alternative is to use a dilute infusion (no more than 0.1%
bupivacaine) with careful monitoring.
4. The prescription for local anaesthetic should limit each
increment of a top-up to no more than 12.5 mg
bupivacaine (12.5 ml 0.1% or 5 ml 0.25%), each increment
being separated by at least 5 minutes. Explicit instructions
must be recorded indicating when the anaesthetist should
be called:
• If hypotension occurs.

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• If pain disappears too quickly and after a small
volume.
• If the mother complains of any difficulty with breathing
or swallowing.

Second alternative: use repeated bolus subarachnoid block


Do not drain more than a few drops of cerebrospinal fluid.
1. If the Tuohy needle has caused the tap, consider giving a
single bolus of 1.0 ml bupivacaine 0.25% (2.5 mg) with or
without 0.5 ml fentanyl (25µg). You must use a filter
needle. You may give this single dose without calling
senior help so long as you are a specialist registrar of year
three or above.
5. Alternatively, deliberately place the catheter in the
subarachnoid space, inserted 2 cm into the subarachnoid
space, secure it and label it as a subarachnoid catheter.
Then proceed as below for a catheter tap.
6. If the catheter causes the dural tap, secure it and label it
without giving any drugs. You must consult the consultant
anaesthetist on call and inform the third on call
anaesthetist before administering a subarachnoid dose.
7. Remember to fit the particle filter. Check that the
intravenous infusion is running and that ephedrine is ready
to administer, and that the patient is in the left lateral or
supine wedged position.
8. Administer 1 ml bupivacaine 0.25% (2.5 mg) (with fentanyl
25 µg if this is the first dose) and flush with 1.5 ml 0.9%
saline. Achieve satisfactory analgesia (usually S5 to T10)
with further flushed increments of 0.5 ml bupivacaine
0.25% at 5-minute intervals with careful monitoring.
9. The maximum subarachnoid dose of fentanyl over any
time period is 25 µg.
10. You must administer all doses and under no
circumstances whatsoever are you allowed to leave the
delivery suite while a subarachnoid catheter technique is in
progress.
11. The patient must not be allowed to sit up. This may result
in a high block.

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12. For caesarean section or other operative procedures
except as below, with the patient in a lateral or wedged
supine position, administer 0.5 ml to 1.0 ml increments of
hyperbaric bupivacaine 0.5% until surgical anaesthesia is
achieved. The dose should be adjusted to the existing
block. The maximum dose is 4.0 ml bupivacaine and
fentanyl may not be given.
13. For outlet forceps delivery 1.0 ml to 2.0 ml hyperbaric
bupivacaine 0.5% should be used in the sitting position.
Fentanyl may not be given.

Delivery and the postnatal period


Once the mother is comfortable, an explanation of the events
that have occurred and the implications for her should be given
and recorded in the notes. Make a clear plan of action and
record it. Communicate with the midwives and the obstetricians.
Leave the epidural catheter in after delivery (not a
subarachnoid catheter).
It is not necessary for the mother to lie on her side throughout
labour; she may sit up if she wishes to. Elective instrumental
delivery is not specifically indicated following dural tap, although
long and strenuous pushing should be avoided.
After delivery, you should attach a 1 litre bag of saline 0.9% via
a drip set to the epidural catheter via the filter, using
hydrostatic feed and not a pump. Under no circumstances
whatsoever may a subarachnoid catheter be continued after
delivery, or any infusion fluids be connected. The infusion
should be administered over the next 24 hours at 60 ml/hr (total
1.5 litres). The mother may be discharged to the ward with clear
instructions to the postnatal midwives. Once completed, the drip
and the epidural catheter should be removed. There is no need
for the mother to lie flat post-delivery; she may mobilise as she
wishes, although it is recognised that the presence of an
epidural infusion may limit activity. She must be encouraged to
take copious oral fluids. You should prescribe regular
paracetamol treatment.
The duty anaesthetist should review the mother twice daily and
advise on further action, including epidural blood patch or
NSAIDs, that may be necessary should the mother develop a
persistent low pressure headache typical of dural puncture.

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Diagnosis of low pressure headache


Headache is a common symptom in the post partum period –
perhaps one in six of all parturients. Low pressure headache. is
classically occipitofrontal, aggravated by sitting or standing,
alleviated by lying supine and may be associated with neck
stiffness, neck and shoulder ache, diplopia and tinnitus.
Abdominal compression with the palm of the hand, while the
mother is sitting, may relieve the headache during the
subsequent couple of minutes – Gutsche’s sign.
It is essential to determine whether recumbence brings relief.
Low pressure headache is rarely immediate unless
subarachnoid injection of air has occurred (pneumocephalic
headache). It typically develops after the first 24 hours.
Be vigilant for other causes of post partum headache,
particularly pre-eclampsia.

Follow up for patients with low pressure


headache
Patients with significant low pressure headache, whether
caused by spinal or epidural needles, and whether a blood
patch has been performed or not, should be referred for
postnatal review by the Pain Management Department at six
weeks.
This is important in detecting long-term complications.
Untreated dural leak may lead to chronic headache or cranial
subdural haematoma. Tinnitus may become chronic. Blood
patching can be performed as a late treatment.
Refer to the pain management secretaries on extension 8628 or
5089 to see Sister Sue Millerchip in her pain clinic.

Guidelines for blood patch


Epidural blood patch is used to manage a persistent,
incapacitating dural puncture headache; this may occur either
as a result of inadvertent dural puncture during insertion of an
epidural or after a spinal anaesthetic. The mother must not be
pyrexial or have clinical evidence of current infection, since
to introduce infected blood into the epidural space could
be disastrous.

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Blood patch should normally be performed only after the first 24
hours. Patching in the first 24 hours is associated with lower
success rates and bacteraemia is often present. We do not
support routine prophylactic blood patching although this may
be considered if the patient has an epidural catheter still in
place, thus reducing the risks of the procedure. Always discuss
the case with the responsible consultant.
The procedure must be carried out on the delivery suite. Two
anaesthetists are usually required, or you may enlist the help of
another doctor who understands the procedure. A consultant
anaesthetist should carry out the epidural component.
1. Explain the procedure carefully to the woman and obtain
consent. The mother should be counselled as to the
chances of success and the method of the technique: if a
20 ml volume is injected, the success rate is over 90%.
Many patients feel significant immediate relief; most
patients feel better within a couple of hours. Occasionally,
a patient who is initially helped by a patch will develop a
recurrent headache on the second or third day, which may
require a second patch to be performed. Although serious
complications are unusual, some patients will experience
transient backache.
2. The first anaesthetist inserts an epidural needle in the
normal manner, using standard equipment that would be
needed for any epidural. The first anaesthetist then injects
20 ml blood (provided by the second anaesthetist) into the
epidural space, over 30 to 60 seconds. Occasionally,
patients complain of pain in the back or between the
shoulder blades while the injection of blood is being
performed. Often, by pausing for 30 seconds or slowing
the rate of injection, you can inject the full 20 ml.
3. The second anaesthetist is responsible for drawing 20 ml
blood from the patient. Full aseptic precautions should be
taken. The following items are needed:
• A large intravenous cannula (14G)
• A regional anaesthesia dressing pack, sterile gloves
etc.
• Skin preparation solution
• 2 ml and 20 ml syringes
• 25G needle
• Lignocaine 1% 5 ml

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Pain relief for labour
4. The second anaesthetist inserts the cannula into a large
vein in the arm and when the epidural needle is sited,
hands over 20 ml of blood to the first anaesthetist. We do
not recommend the sending of blood culture specimens.
5. Small dressings are placed over the puncture sites and the
patient is placed supine. She must stay on the delivery
suite for at least half an hour, during which time no special
observations are needed. She may then return to her
ward; it is important that she remain in bed for a further
two hours; at that stage she may resume normal activity as
she wishes. Lactulose should be prescribed for any
constipation. Body temperature should be recorded every
four hours for 24 hours.
6. It is important that the patient is seen on the daily ward
round during the next day.
7. Arrange follow up as on page 95.

Hypotension and epidural block


Hypotension is defined as a decrease in systolic blood pressure
by 20% from the initial reading and is often accompanied by
symptoms of dizziness and nausea in the mother. It is
accentuated by aortocaval compression or hypovolaemia from
whatever cause (e.g. dehydration, blood loss). This guideline is
appropriate in the case where an ephedrine infusion is not
already in progress during the establishment of regional
anaesthesia.
On making the diagnosis you should:
1. Administer supplemental oxygen.
2. Place the mother in the left lateral position.
3. Run in fluids appropriate to the pulse rate and blood
pressure.
4. If she is still hypotensive, administer ephedrine boluses
intravenously, starting with 6 mg.
5. Notify the midwife.
6. Check the block level (motor and sensory) and seek other
causes of hypotension.

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Pain relief for labour

Total spinal block or high block


An unrecognised ‘dural tap’ or a catheter that migrates
subsequent to insertion may result in a high block leading to
difficulty with breathing particularly if the block reaches cervical
level and causes diaphragmatic impairment. Total spinal can of
course occur as a complication of spinal anaesthetics, either de
novo or when performed after an epidural block.
1. You should notify the consultant anaesthetist on call, of all
such cases.
2. Your first concern should be to protect and secure the
airway and prevent respiratory failure. High block can
provoke great anxiety in the patient, which must not be
confused with respiratory failure. Establish whether
diaphragmatic weakness exists. If the diaphragm is not
weak, then the patient will probably not need intubation.
Advise her to take a deep breath in and out, and if she can
do this counsel her that she is able to breathe.
3. In the event that intubation is needed, you should intubate
and ventilate the patient until the block has worn off,
usually about two hours. Although muscle relaxation is not
essential it is humane to provide amnesia and a routine
rapid sequence induction of anaesthesia in theatre is the
safest method of attaining ideal intubating conditions.
Amnesia can be maintained by the use of midazolam.
4. However, the situation may require immediate intubation
or assisted ventilation.
5. Prevent aortocaval compression.
6. Any hypotension must be treated.
7. Fetal distress may indicate caesarean section, but
otherwise a total spinal does not rule out a normal delivery.
Prompt recognition and treatment of the condition should
ensure that neither child nor mother come to any harm.

Subdural block
1. This is indicated by the following signs:
• The block spreading high over 20-30 minutes,
sometimes to cervical dermatomes.
• Nasal stuffiness and Horner’s Syndrome.
• Patchy sensory block and sacral sparing.

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• Minimal motor block.
• Relative maintenance of blood pressure.
2. Respiratory embarrassment may indicate airway support
and mechanical ventilation, as for total spinal anaesthesia.
3. Subdural block is due to the separation of the arachnoid
mater from the dura mater and is dangerous because a
bolus injection down the catheter may rupture the
arachnoid and produce a subarachnoid block.
4. You should inform the third on call anaesthetist and
remove the ‘epidural’ catheter. Resite it at a different
place.
5. You should administer all further epidural doses,
cautiously and with vigilance.
6. In the event that spinal anaesthesia is needed, reduce the
dose of bupivacaine by one third unless the effects of the
subdural block have completely disappeared. Inform the
third on call anaesthetist prior to doing the spinal
anaesthetic.

26. Guidelines for Obstetric Anaesthesia Services. Association of


Anaesthetists of Great Britain and Ireland/Obstetric Anaesthetists
Association; London 1998; page 10.
27. Reynolds F. Dural puncture and headache. In Regional analgesia
in obstetrics: a millennium review. Springer-Verlag, London 2000;
pages 312-3.

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Tocolytic drugs

Tocolytic drugs
You may be asked to use tocolytic drugs or to anaesthetise a
patient who has had them administered. Indications include:
• Preterm labour.
• Intrauterine fetal resuscitation.
• External cephalic version.
• Uterine hypertonicity.
• Retained placenta.
• Uterine inversion.

Nifedipine
Nifedipine is used by the obstetricians to treat premature
contractions. The dose is 20 mg orally before conversion to a
slow-release preparation.
It may cause profound hypotension. If you are asked to see a
patient for this, make sure that intravenous access is patent and
commence fluid resuscitation.

β2-adrenergic agonists
The most common agents are terbutaline and salbutamol.
Terbutaline 250 µg may be given subcutaneously. At this dose
significant side effects are very rare.
Terbutaline or salbutamol boluses may be given intravenously
with caution (100 µg to 250 µg).
Potential side effects are tremor, hypotension, tachycardia and
pulmonary oedema. Hypokalaemia and hyperglycaemia may be
seen with prolonged administration.
Anaesthetic management following the use of β2-adrenergic
agonists involves the careful avoidance of excessive fluid
administration. Monitor the patient and observe closely. You
should be careful when using ephedrine because of the risk of
excessive tachycardia.

Glyceryl trinitrate
Glyceryl trinitrate will reliably give brief uterine relaxation,
especially for procedures such as external cephalic version or
retained placenta. With careful monitoring give intravenous

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Tocolytic drugs
boluses of 50 µg or one dose of sublingual spray (most
preparations are 400 µg per dose).
Glyceryl trinitrate may cause severe hypotension and a
throbbing headache. Rapid intravenous injection may also
cause nausea and retching, and palpitations.

Other drugs
Magnesium has tocolytic effects although it is rarely used for
this purpose. See page 141.
The oxytocin-receptor antagonist atosiban has been used for
preterm labour in cases where β2-adrenergic agonists are
unsuitable such as cardiac disease. It has similar side effects to
β2-adrenergic agonists.

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Common obstetric problems

Common obstetric problems


Malpresentations and malpositions
These problems recur time and time again. You should be
aware when they happen on the delivery suite. Many problems
can be anticipated satisfactorily with:
• Vigilance.
• The timely establishment of a good regional block.
• Your presence on the delivery suite during the second
stage of labour for some problems.

Occipito-posterior presentation
This happens in about 10% of term pregnancies. There is slow
progress with severe pain in the mother’s back – often resistant
to epidural blockade. Manual or forceps rotation may be
attempted in order to bring the fetal head into the occipito-
anterior position.
You should ensure that a good epidural block is established
and that the mother has received fentanyl either by recent bolus
or by infusion. You may need to use a more concentrated local
anaesthetic solution.

Breech presentation
This happens in about 4% of term pregnancies. Caesarean
section is a common delivery option but some are delivered
vaginally, and unexpected breech presentation can occur. You
should, in cooperation with the mother and the midwife, ensure
that a good epidural block is established.
The midwives will inform you when a mother is in the second
stage of labour in vaginal breech delivery. You should be
present on the delivery suite.

External cephalic version


This is offered to mothers with uncomplicated breech
presentation between 37 and 42 weeks. They will be prepared
as for caesarean section and booked in the delivery suite diary.

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Common obstetric problems
You should be present on the delivery suite during the version
because an emergency caesarean section may be needed.
Some obstetricians may ask you to administer intravenous
tocolytic drugs (see page 100). Monitor the patient carefully,
especially pulse rate and blood pressure.

Multiple pregnancy
Vaginal delivery may be offered if the first twin is in a cephalic
presentation.
You should become aware of all labouring mothers with multiple
pregnancy (and be prepared to recommend epidural analgesia).
You should be present on the delivery suite during the second
stage of labour in cases of multiple pregnancy. Although the
need for caesarean section for the second twin is rare, there are
a number of complications that could arise for which you may
be needed immediately, including postpartum haemorrhage.
You should also ensure that the epidural block is adequate for
the manipulations that may be needed to extract the second
fetus.
You should take special care to avoid supine hypotension as
this is more common with multiple pregnancy.

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General considerations for caesarean section

General considerations for caesarean


section
Choice of technique
The preferred technique where not contraindicated is spinal
anaesthesia (or epidural extension where appropriate). See
‘Central nerve block and vertebral canal haematoma’ on page
51.
There are a number of obstetric conditions which indicate
general anaesthesia, most of which are discussed further in
relevant sections of this handbook, including for example:
• Actual or anticipated major haemorrhage.
• Fibroid uterus.
• Placenta praevia in some cases (see page 128).
• Other conditions of abnormal placentation e.g.
placenta accreta, increta or percreta.
• Inverted uterus (see page 35).
• Ruptured uterus (see page 35).
• Some cases of severe pre-eclampsia – (see page 145).
• Transverse lie with oligohydramnios.
• Profound fetal bradycardia or acidosis is a relative
indication – see below.
Always consult with the operating obstetrician to formulate a
plan and seek senior help early if you are in any doubt.

Time standards
The obstetrician is responsible for diagnosing the indications for
caesarean section and for ensuring that all staff concerned
know the indication and any implications for the urgency of
surgery. This communication is vital for the achievement of the
time standards.
Controversy remains over the contribution of time standards to
neonatal outcome and there is little evidence of a thirty-minute
critical threshold in intrapartum hypoxia [28, 29].

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General considerations for caesarean section
The Royal College of Anaesthetists, the Royal College of
Obstetricians and Gynaecologists, the Obstetric Anaesthetists
Association and the CEMD have all adopted a physiologically
based classification for research and reporting purposes [30]:
1. Emergency: immediate threat to life of woman or fetus.
2. Urgent: maternal or fetal compromise which is not
immediately life-threatening.
3. Scheduled: needing early delivery but no maternal or fetal
compromise.
4. Elective: at a time to suit the patient and maternity team.
In practice we need a set of standards to which we can aspire,
and which will guide our response to an indication for
caesarean section. The following is in use on the delivery suite.

Class Time standard Example indications


(Decision to
delivery)
Immediate 20 minutes Sustained fetal bradycardia
Cord prolapse
Uterine rupture
Uterine abruption
Emergency 30 minutes Fetal distress
Urgent 30 minutes if Failure to progress in labour
possible Planned caesarean section
now in labour
Semi- 12 hours Deterioration in situation
elective
Elective Elective Breech
Previous section

Emergency caesarean sections warrant the opening of the


second theatre if staff can be mobilised to achieve delivery
within the time standards. Urgent caesarean sections scheduled
while an operative case is proceeding may be able to wait until
the theatre and staff become available.

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General considerations for caesarean section
You must endeavour to maintain these time standards and in
order to do so:
• The obstetrician who requests anaesthesia for caesarean
section must determine the urgency at the time of
decision, and ensure that this is promptly communicated to
the obstetric anaesthetist.
• The patient must be promptly presented to the operating
theatre, within five minutes for delivery inside twenty
minutes, and within ten minutes for delivery inside thirty
minutes.
• Preparatory actions for caesarean section should be
undertaken in theatre prior to induction of general
anaesthesia or awaiting onset of spinal anaesthesia.
You should remember that your prime duty is to the mother and
it is not appropriate to take untoward and excessive risks with
her life in an attempt to prevent harm to the fetus.
Spinal anaesthesia or epidural extension, where not
contraindicated, is the anaesthesia method of choice for
emergency and urgent caesarean sections. This is compatible
with a twenty-minute response time if there are no undue delays
at other points in the procedure. We understand however that
there can be considerable pressure on you to perform general
anaesthesia, particularly if there have been delays before
theatre. General anaesthesia is often slightly quicker than
regional anaesthesia and may need to be used in certain cases
where not otherwise indicated.
• Severe maternal anxiety.
• Difficulty with the regional technique leading to serious
delay and imperilling achievement of the time standard.
Have someone watch the clock for you.
• Serious delay in presenting the patient to you for
anaesthesia.
Close liaison with the obstetrician is imperative.

Chaperones
A midwife will be assigned to accompany the patient to theatre.
This is a very important function, enhancing patient safety and

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General considerations for caesarean section
reducing maternal anxiety. You should ensure that the
chaperoning midwife is not distracted from this function, for
example by being asked to be a theatre runner.

Antibiotics
All patients undergoing caesarean section should have a single
dose of antibiotic prophylaxis against wound infection,
administered by you after the umbilical cord has been cut.
You should administer cefuroxime 750 mg. If the patient is
allergic to cephalosporins you should give erythromycin 1 g
intravenously after delivery. Separate anaerobic cover is not
needed unless specifically indicated in an individual case.

Uterine displacement
Women undergoing caesarean section should be managed with
aortocaval decompression through tilting the operating table 15
degrees to the left. You should remove the tilt after delivery and
after consulting the surgeon.

Uterine relaxation
The surgeons may anticipate difficulty with operative delivery,
which can be reduced by uterine relaxation.
• Prematurity.
• Breech in labour.
• Transverse lie with ruptured membranes.
You can help by giving additional volatile anaesthetic (if the
patient is under general anaesthetic) or subcutaneous
terbutaline 250 µg. Terbutaline may be given intravenously with
caution (100 µg to 250 µg). These should be given well before
uterine incision. See page 100 for ‘Tocolytic drugs’.
Administer a postpartum Syntocinon infusion after use of
uterine relaxants.

Prevention of postpartum haemorrhage


In all cases of operative delivery in which you are involved you
should, after checking with the obstetrician, administer 5 units of
Syntocinon intravenously following severance of the umbilical
cord. Do not use ergometrine or Syntometrine. You should draw
up Syntocinon 1 ml diluted to 10 ml with dextrose 5%.

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General considerations for caesarean section
Following this, you should set up and administer a Syntocinon
infusion (of 20 units made up to 50 ml with dextrose 5%) by
infusion pump, starting at 15 ml/h (consult with the operating
obstetrician), in cases fitting one or more of the following
criteria:

Distended uterus
• Multiple pregnancy
• Big baby (>4 kg)
• Polyhydramnios

Uterine scar
• Previous caesarean section

Bleeding tendency
• Previous postpartum haemorrhage
• Antepartum haemorrhage in this pregnancy
• Anticoagulant or antithrombotic therapy
• Placenta praevia
• Fibroid uterus
• Coagulopathy

Abnormal contractility
• General anaesthesia
• Pre-eclampsia
• Pyrexia
• Long labour
• Delay in first stage of labour
The infusion usually runs for two hours. If in doubt, administer
the Syntocinon infusion.
See page 34 for ‘Pharmacological treatment of uterine atony’.

Postoperative analgesia and antiemesis


We use combination therapy, by different routes and using
different types of drug, to control postoperative pain, nausea
and vomiting.

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General considerations for caesarean section
Intraoperative antiemesis
You should administer a single dose of granisetron 1 mg
intravenously to all patients after the umbilical cord has been
cut. Granisetron should be given over 30 seconds diluted to
5 ml with saline. This dose may be repeated once if nausea and
vomiting develop.

Analgesia
Give intravenous morphine for operations with general
anaesthesia.
There is strong evidence that NSAIDs reduce opioid
requirement after caesarean section [31]. We use diclofenac in
suppository form because it provides a strong analgesic boost
on the first and subsequent postoperative mornings in order to
assist with mobilisation. This is important in the prevention of
thromboembolic disease.
Patients who have asthma should be asked if they have taken
NSAIDs in the past. Diclofenac is not contraindicated if the
patient gives a specific history that they do not have a
bronchoconstriction reaction to NSAIDs. Paracetamol is not a
NSAID.
We avoid parenteral analgesia. Regular oral treatment with
codeine and paracetamol is the main treatment. Patients may
administer their own oral morphine to a safe limit. If rescue
analgesia is needed, then intermittent intramuscular morphine
can be used.

Patients who can take diclofenac


1. Patients who are not sensitive to diclofenac should
receive it as part of their postoperative analgesia. Unless
contraindicated, you should prescribe:
• Rectal diclofenac 100 mg every 16 hours as required.
• Intramuscular morphine 15 mg every three hours as
required, not to be administered at the same time as
oral morphine.
• Oral co-codamol 8/500 two tablets, four times a day
regularly.
• Oral morphine 10 mg to a maximum of 50 mg in 12
hours as needed, not to be administered at the same
time as intramuscular morphine

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General considerations for caesarean section
• Buccal prochlorperazine 6 mg two times a day as
required (Buccastem®).
2. Diclofenac should not be administered in rectal or oral
form to patients who are recovering from severe pre-
eclampsia until at least 24 hours after delivery. These
patients will often be receiving an epidural infusion or
intravenous opioids. Diclofenac should also not be used in
patients who are hypovolaemic or have raised plasma
creatinine.
3. Paracetamol must not be co-prescribed with co-codamol.
4. It is appropriate to discharge patients home on:
• Oral co-codamol 8/500 two tablets, four times a day
as required.
• Oral diclofenac 50 mg three times a day as required.

Patients who are sensitive to diclofenac


1. Patients who are sensitive to diclofenac should be
prescribed postoperative analgesia with an increased
opioid component. Unless contraindicated, you should
prescribe:
• Intramuscular morphine 15 mg every three hours as
required, not to be administered at the same time as
oral morphine.
• Oral paracetamol 1 g regularly four times a day.
• Oral codeine 60 mg four times a day as required.
• Oral morphine 10 mg to a maximum of 50 mg in 12
hours as needed, not to be administered at the same
time as intramuscular morphine
• Buccal prochlorperazine 6 mg two times a day as
required (Buccastem®).
2. It is appropriate to discharge patients home on:
• Oral paracetamol 1 g four times a day as required.
• Oral codeine 60 mg four times a day as required.
Co-codamol 30/500 tablets are available as an alternative to
separate paracetamol and codeine treatment. Be aware that the
compound preparation given regularly can be quite sedating. It
should only be used with caution. You should check availability
on the postnatal ward prior to use.

110 Obstetric Anaesthetists Handbook 3


General considerations for caesarean section
Summary of analgesia and antiemesis
In theatre
• Intravenous granisetron 1 mg.
• Intravenous morphine 15 mg as part of a general
anaesthetic.
On the drug chart for later administration
• Rectal diclofenac 100 mg every 16 hours as required.
Giving diclofenac in theatre has been associated with
clinical adverse events; the first dose should be given
in the recovery area and not in theatre.
• Intramuscular morphine 15 mg every three hours as
required. Intramuscular morphine is given as a first
postoperative dose to establish adequate blood
levels. Subsequent doses are for rescue analgesia if
the oral morphine is not sufficient.
• Oral co-codamol 8/500 two tablets, four times a day
regularly. (Codeine 60 mg and paracetamol 1 g in
patients for whom diclofenac is contraindicated.)
• Oral morphine to a maximum dose of 50 mg in each
12 hours, self-administered.
• Buccal prochlorperazine 6 mg twice a day as needed
for nausea and vomiting.

Postoperative handover
Your handover to the recovery midwife for postoperative care
should include at least the following points.
• Clinical summary of patient.
• Details of anaesthesia procedure including drugs
administered.
• Transfer to Room 8 if indicated.
• Postoperative prescriptions for indicated drugs:
• Analgesia and anti-emetics.
• Fluids and blood.
• Syntocinon infusion.
• Heparin thromboprophylaxis.
• Supplemental oxygen after general anaesthesia.

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General considerations for caesarean section

Postoperative follow-up
The patient will be followed up by the duty obstetric anaesthetist
the next day (in the case of epidural and general anaesthesia)
and for three days (in the case of spinal anaesthesia). If
problems develop the patient may need to be seen for longer or
more frequently, or a referral made to a consultant anaesthetist.

28. Tuffnell DJ, Wilkinson K, Beresford N. Interval between decision


and delivery by caesarean section – are current standards
achievable? BMJ 2001; 322: 1330-1333.
29. James D. Caesarean section for fetal distress. BMJ 2001; 322:
1316-1317.
30. Lucas DN, Yentis SM, Kinsella SM, Holdcroft A, May AE, Wee M,
et al. Urgency of caesarean section: a new classification. J R Soc
Med 2000; 93: 346-350.

31. Guidelines for the use of non-steroidal anti-inflammatory drugs in


the perioperative period. Royal College of Anaesthetists; London
1998.

112 Obstetric Anaesthetists Handbook 3


Regional blocks for surgery

Regional blocks for surgery


The techniques are described below. The majority of caesarean
sections are performed with a spinal technique. Epidural block
placed for labour can usually be extended if required.
Occasionally, epidural anaesthesia is indicated for surgery –
you should discuss such cases with a senior anaesthetist.
Regional blocks for surgery must be performed in the operating
theatre with skilled assistance. We do not support the
establishment of regional anaesthesia in delivery rooms.
The combined spinal/epidural technique should not be used for
surgery other than in exceptional cases, which should be
discussed with a senior anaesthetist. Examples would include:
• Planned caesarean hysterectomy.
• Postoperative epidural infusion after caesarean section for
pre-eclampsia.

Information and consent


We prefer regional blocks. See page 78.
A potential trap when talking to a patient is to refer to general
anaesthesia as unsafe, or to imply that general anaesthesia is
an inferior and dangerous method compared to the more
modern regional anaesthesia. Firstly, this is not true; and
secondly, you may have cause to recommend conversion to
general anaesthesia, or the mother may choose general
anaesthesia in the first place. The results of falling into the trap
are to make the mother much more anxious and also to cause
serious embarrassment to the anaesthetist who later
recommends a general anaesthetic.
So beware the trap. Recommend regional anaesthesia if
indicated, but do not create concerns over a method you may
need to use.

Monitoring and patient contact


You must maintain the required standard of monitoring during
regional anaesthesia for surgery. The AAGBI has issued clear
advice [32]:

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Regional blocks for surgery
"An anaesthetist of appropriate experience
must be present throughout general
anaesthesia... The anaesthetist must undertake
frequent clinical observations as well as
reviewing the information provided by
monitoring devices. The same standards must
apply when an anaesthetist is responsible for a
local anaesthetic or sedative technique for an
operative procedure."
Patients undergoing regional techniques have limited
experience of the operating theatre routines and have limited
vision. You must maintain contact with the patient in order to
reassure her and to detect any problems immediately - such as
inadequate anaesthesia. In particular, you must not allow the
patient to feel that you have left her alone (or with her partner).

Spinal anaesthesia – general considerations

Indications
• Elective caesarean section.
• Emergency caesarean section not in labour.
• Emergency caesarean section with no regional
analgesia in place.
• Emergency caesarean section with non-working
epidural in place.
• Trial of assisted delivery (particularly Kiellands’
forceps).
• Manual removal of placenta.
• Evacuation of retained products of conception.
• Cervical cerclage (insertion of Shirodkar suture).

Contraindications
See ‘Central nerve block and vertebral canal haematoma’, on
page 51.
• Unwilling patient.
• Coagulopathy or anticoagulation (see page 51).
• Sepsis.
• Hypovolaemia or active bleeding.
• Cardiac disorders with restricted cardiac output or
shunt.

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Regional blocks for surgery
Relative contraindications
• Need for immediate caesarean section, e.g. scar
dehiscence or profound fetal bradycardia (see ‘Time
standards’ on page 104).
• Neurological disorders.
• Spinal deformity or surgery.
• Obstetric requirement for general anaesthesia.
• Risk of haemorrhage e.g. Placenta praevia, fibroid
uterus.

Block required
• Caesarean section or trial of assisted delivery – S5 to
T4 bilaterally.
• Other surgery (e.g. manual removal of placenta or
postpartum evacuation) – S5 to T8 bilaterally.

Technique for spinal anaesthesia


1. Explain the procedure and possibility of low-pressure
headache (1 in 230 for atraumatic needles).
2. Ensure that intubating equipment is always present
whenever spinal anaesthesia is performed.
3. Check that sodium citrate and ranitidine have been given
as appropriate. Note the preoperative blood pressure.
4. Establish intravenous access (14G or 16G cannula to a
large vein) and connect a three-way tap. Check the
patient’s fluid status and if she has had no fluids for more
than twelve hours consider giving a preload (bearing in
mind the likely amount of fluid to be infused with the
ephedrine). You should use an ephedrine-containing
infusion instead of a volume preload technique [33].
5. Administer metoclopramide 10 mg intravenously unless
given recently as a premedicant. This will counteract
nausea and vomiting following the regional block [34].
6. Connect an infusion bag of Hartmann’s solution
(compound sodium lactate) 1000 ml with 60 mg ephedrine
added and labelled. Draw up 30 mg of ephedrine in 10 ml.
7. Position the patient, usually in the sitting position. Prepare
the area and allow it to dry. Infiltrate the interspace with
lignocaine.

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Regional blocks for surgery
8. Draw up hyperbaric bupivacaine through the filter needle.
The following doses should be used unless there are
clinical reasons to vary them. In the case of existing
regional block, e.g. epidural that is not being used for
surgical anaesthesia, you may need to reduce the dose
slightly. Seek senior help in this case.
• For T8 block: 2.0 ml.
• For T4 block: 3.0 ml.
9. Add 25 µg fentanyl (0.5 ml) through the filter needle.
10. Insert the spinal needle (atraumatic; 24G with introducer)
at the L3/4 interspace or lower. Insertion at L2/3 is
associated with direct injection into the spinal cord and
syrinx formation [35].
11. Ensure the syringe is firmly placed into the hub of the
spinal needle to avoid spillage. During injection, aspirate
after half the volume is injected to ensure the needle is still
in the subarachnoid space.
12. In the case of difficulty inserting the spinal needle,
remember that there is a ‘difficult regional’ box and use it.
There are extra long spinal needles and combined
spinal/epidural sets in the box. Call for assistance as an
early move.
13. Lie the patient down if sitting, with a pillow under the
shoulders, and tilt the table to the left if supine. Commence
the Hartmann’s with ephedrine infusion. Warn the patient
of potential nausea and titrate the infusion against the
blood pressure so as to maintain haemodynamic stability
and normality.
14. We do not recommend administering supplemental oxygen
to an awake patient unless:
• The patient has been sedated.
• The patient is hypoxic as shown by pulse oximetry.
Your clinical judgment is important here but if the
SpO2 is lower than 96% then you should consider
oxygen.
15. Monitor the patient carefully.
• Check the blood pressure at one-minute intervals (the
‘turbo’ setting on the Dräger) for the first 10 minutes
and every two minutes thereafter until stable (usually
20 minutes) - then revert to 5-minute intervals.

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Regional blocks for surgery
• Determine the extent of the block frequently at minute
intervals after four minutes, and make postural
adjustments as necessary.
16. If hypotension occurs, increase the rate of Hartmann’s with
ephedrine infusion. Be prepared to give a 6 mg bolus of
ephedrine.
17. Assess the block carefully and ensure that it is satisfactory
for surgery to commence. If not, see page 121 for advice.
18. Intravenous fluid treatment is divided into two phases. The
first phase takes about twenty minutes, usually until
delivery of the fetus. During this phase you are using fluids
and ephedrine to maintain blood pressure and cardiac
output against the sympatholytic effects of spinal
anaesthesia. The second phase runs approximately from
delivery until the end of the operation. During this phase
the sympatholytic effects are less important and you will be
maintaining blood pressure and cardiac output against the
fluid losses of surgery. At delivery you should check the
blood and amniotic fluid losses with the scrub midwife and
switch the intravenous fluid to an appropriate replacement
for the blood loss.
19. Follow up for 3 days minimum. If the patient wishes to go
home prior to this make sure that she knows how to
contact us if she develops a bad headache and take her
telephone number.

Using labour epidurals for operative surgery

Instrumental delivery or manual removal of placenta


Muscle relaxation is mandatory particularly in the case of a
rotational (high or Kiellands’) forceps. A sensory level from S5
to T8 with motor blockade is ideal (uterine nerve supply is T10
to L1 and perineum S2/3/4).
For vacuum extraction (‘ventouse’) or for low forceps a normal
epidural top-up may be administered in the delivery room,
usually with incremental doses of 0.5% bupivacaine and
fentanyl. Document the anaesthetic levels attained, and the
effect, on the epidural chart.
For rotational (high) forceps and for ‘trial of assisted delivery’
the top-up should be given as for caesarean section. Document

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Regional blocks for surgery
doses, levels and effect on the pink anaesthetics chart. Use of
‘Quickmix’ (see below) is advised and you should place yourself
in a position to provide caesarean section anaesthesia
immediately. This may mean accepting (with the consent of the
patient) a target block height higher than T8 so that the last
increment provides a satisfactory block for caesarean section.

Extending the epidural for a caesarean section


1. This is only reliably effective when the epidural is problem-
free. Consider removing it and siting a spinal anaesthetic if
this is not the case. If a spinal anaesthetic is performed
with an inadequately functioning epidural, the risk of high
block is about one in fifty.
2. You should aim for anaesthesia from S5 to T4 along with
motor blockade. You should determine the upper and
lower extent of the block. Use the ‘Quickmix’ outlined here
unless you have a specific reason for not doing so.
3. Exercise caution when opioids have been administered
recently to the patient.
4. You should use the following ‘Quickmix’ for caesarean
section anaesthesia, in divided and carefully monitored
doses as below, and in the operating theatre:
• 1 ml 8.4% bicarbonate (total dose 84 mg, or
4.2 mg/ml in the 20 ml).
• 0.1 ml ‘1 in 1000’ adrenaline using a 1 ml syringe
(total dose is 100 µg, or 5 µg/ml in the 20 ml).
• Make up to 20 ml with 2% lignocaine.
You should give fentanyl separately to the lignocaine,
bicarbonate and adrenaline mix, usually after 10 ml
Quickmix. The usual dose is 100 µg. Remember to flush it
in. Separate administration is particularly important if you
do not anticipate using the whole dose of either local
anaesthetic or fentanyl:
• If fentanyl has been given to the patient recently.
• If the existing block is quite high.
5. Have intravenous ephedrine available (30 mg in 10 ml). A
standard Hartmann’s solution 1000 ml with 60 mg
ephedrine added should be connected to the patient but
beware fluid overload in a patient who may have been on

118 Obstetric Anaesthetists Handbook 3


Regional blocks for surgery
an intravenous infusion for some time. Check the fluid
balance during labour.
6. You must not commence anaesthesia for caesarean
section in the delivery room. This practice entails too much
risk. You should instead ensure that the patient is taken to
theatre promptly once the decision to operate has been
made (see page 104).
7. The patient should be placed in the left lateral position, in
the operating theatre, and metoclopramide 10 mg
administered if it has not been given recently.
8. The dose should be administered over a ten-minute period
with careful observation of the patient. As a guide, you
might expect good anaesthesia with 20 ml in a patient
whose pre-theatre block was below the umbilicus, and 15
ml if above the umbilicus. Doses should be adjusted to
patient response.
9. During dosing, measure the blood pressure and sensory
levels at 1-minute intervals; record these at 5-minute
intervals on the pink anaesthetic sheet.
10. If satisfactory operating conditions are not obtained after
20 ml ‘Quickmix’ has been administered you must carefully
consider other options with the obstetrician and the
patient. See the advice for ‘Failure of regional anaesthesia’
on page 121.
11. Partners are usually allowed into theatre once the mother
has been draped. They should be spoken to before
coming into theatre, and understand that it may be
necessary for them to leave swiftly.
12. You should ensure that the block extends bilaterally from
S5 to T4 prior to the commencement of surgery. If it does
not, or if you or the patient are not confident that a
satisfactory block exists, see the advice on page 121.

32. Recommendations for standards of monitoring during anaesthesia


and recovery 3. Association of Anaesthetists of Great Britain and
Ireland; London 2000.
33. Jackson R, Reid A, Thorburn J. Volume preloading is not essential
to prevent spinal-induced hypotension at caesarean section. Br J
Anaesth 1995; 75: 262-5.

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Regional blocks for surgery

34. Chestnut DH, Vandewalker GE, Owen CL, Bates JN, Choi WW.
Administration of metoclopramide for prevention of nausea and
vomiting during epidural anesthesia for elective cesarean section.
Anesthesiology. 1987; 66:563-6.

35. Reynolds F. Damage to the conus medullaris following spinal


anaesthesia. Anaesthesia. 2001; 56: 238-47.

120 Obstetric Anaesthetists Handbook 3


Failure of regional anaesthesia

Failure of regional anaesthesia


Blocks sometimes fail. This happens in the hands of all
anaesthetists. There are a variety of actions that can be taken.
You have two priorities and you must keep them at the front of
your mind at all times.
1. Ensure the safety of your patient.
2. Deliver an appropriate and satisfactory anaesthetic for the
surgical procedure.
Problems with inadequate anaesthesia will be rare if:
• The block appeared technically satisfactory.
• A neuraxial opiate (fentanyl) has been used.
• Block testing was satisfactory.
Satisfactory block testing is mandatory before allowing surgery
to commence (see page 80). It is not possible to repeat a block
once surgery has commenced. The only options will be
analgesic supplementation and conversion to general
anaesthesia.
Breakthrough intraoperative pain is not uncommon during
obstetric regional anaesthesia. You should ensure that all
patients are forewarned, and that you respond to complaints of
pain. Unrelieved pain causes anxiety. Poor communication, and
especially failure to act promptly on complaints, may lead to
formal complaints and litigation.
Manage the patient sympathetically and expectantly. However,
you should give analgesic supplementation if the patient is in
any way distressed.

Repeating a block
Repeating a block may be an appropriate course of action.
Mothers are sometimes quite motivated to be awake at the
delivery of their child and with honest, careful explanation will
understand the reasons for failure and the possibilities for
remaining awake.
Seek senior advice and help if you are thinking of repeating a
block. You may need to discuss the dose or ask for technical
help.

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Failure of regional anaesthesia
In all cases of repeating a block, you should observe for the
side effects of central neuraxial block. In particular, observe for
respiratory depression and hypotension. Monitor the progress of
the block closely and maintain close verbal contact with the
mother.
The most difficult decision follows the finding of an upper limit to
the block of T5 to T7. This block will be inadequate for
caesarean section but is not far off. We do not recommend
repeating a block in these circumstances due to the risk of
complications. General anaesthesia is probably the best course.
Seek senior advice.

After an epidural anaesthetic


If the epidural dose has been given more than one hour before,
and there is no sensory effect, then proceed with spinal
anaesthesia in the usual way.
After giving an epidural anaesthetic dose for caesarean section,
and determining that the block is insufficient for surgery, a
reduced-dose spinal anaesthetic can be used.
Remove the epidural catheter and insert a spinal anaesthetic.
Clinical judgment and skill will be required. Suggested doses
are:
• Block below T10: give 2.5 ml bupivacaine 0.5%
without fentanyl.
• Block T10 to T8: give 2 ml bupivacaine 0.5% without
fentanyl.
Observe carefully for respiratory depression.

After a spinal anaesthetic


There are two options.
1. Wait twenty minutes after the first dose. Repeat the spinal
anaesthetic. Do not add more fentanyl. Suggested doses
are:
• No sensory effect or lumbosacral only: give
bupivacaine 15 mg.
• Block below T10: give bupivacaine 12.5 mg.
• Block T10 to T8: give bupivacaine 10mg.
2. Insert an epidural anaesthetic. The principal early effect
will be to reduce the volume in the spinal part of the

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Failure of regional anaesthesia
subarachnoid space by expanding the epidural space. This
will ‘squeeze’ the block upwards [36] and can convert an
apparently satisfactory spinal in which the drug had no
effect, to a block suitable for surgery. Use a reduced
volume of epidural injection – usually no more than 10 ml.

Analgesic supplementation
A variety of methods are available.
• Entonox or nitrous oxide in equal volume with oxygen by
face mask. Do not use a volatile agent.
• Intravenous alfentanil 5-10 µg/kg or fentanyl 1-2 µg/kg;
warn the paediatrician.
• Midazolam 1-3 mg.
• Surgical infiltration of local anaesthetic directly into the
wound or the peritoneal cavity.
Do not allow too long a time period attempting to resolve a
failed regional anaesthetic. The most reliable method is
conversion to general anaesthesia.

Converting from regional to general


anaesthesia
Conversion rates from epidural to general anaesthesia are
reported to fall in the range 4-13%; for spinal anaesthesia this is
0.5-4%.
Converting to general anaesthesia is more difficult if the
operation has already started. It is important to make a proper
assessment of the block and if in doubt do not commence
surgery.
The key to safety in converting is communication. Make sure
that the mother, the operating surgeons, the midwives, the ODP
and you know exactly what is going to happen. Act promptly,
but when your decision has been made, do not hurry or make
undue haste. You must maintain an air of professional authority
and calm demeanour.
Check the patient’s anaesthetic and medical history again. It is
possible to forget details relevant to general anaesthesia when
embarking on a regional technique.

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Failure of regional anaesthesia
Follow the technique described on page 125.
We suggest giving less than the full dose of intravenous
morphine recommended for caesarean section under general
anaesthesia. The failed regional block is likely to have some
effect in reducing morphine requirements and 5 or 10 mg
morphine is likely to be a safer dose. Make sure that you have
diluted morphine at hand for postoperative pain relief.

36. Blumgart CH. Ryall D. Dennison B. Thompson-Hill LM. Mechanism


of extension of spinal anaesthesia by extradural injection of local
anaesthetic. British Journal of Anaesthesia. 1992; 69: 457-60.

124 Obstetric Anaesthetists Handbook 3


General anaesthesia for caesarean section

General anaesthesia for caesarean


section
Practical points to remember
• Emergency cases would probably benefit from having the
urinary catheter and shave performed before induction of
anaesthesia. Consult with the obstetrician.
• You must preoxygenate the patient before inducing
anaesthesia.
• You must induce anaesthesia in all patients in theatre with
ECG, blood pressure cuff, gas analysis and pulse oximeter
attached.
• After rapid sequence induction, change the inspired gas
mixture to 33% oxygen in 66% nitrous oxide and
isoflurane. We do not recommend a 50:50 mix.
• Isoflurane should usually be 0.8% at end expiration unless
the obstetrician requests uterine relaxation, in which case
more should be given. This may be required in premature
delivery where there is little or no lower segment, breech in
labour, transverse lie etc.
• Record the class of emergency, the ‘decision to delivery’
interval, and the time of delivery.
After delivery:
• Give 5 units Syntocinon intravenously – slowly.
• Commence a Syntocinon infusion (see page 107).
• Give antibiotics (see page 107).
• Give intravenous morphine or fentanyl in appropriate
doses (morphine 15 mg minimum is recommended)
as indicated.
• Give an antiemetic agent (granisetron 1 mg is
recommended – see page 108).
• Consider thromboprophylaxis (see page 49).
Complete the following documentation:
• Pink anaesthetic record.
• OAPR (and enter in the index list).

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General anaesthesia for caesarean section
• Fluid chart.
• Drug chart.

Postoperative period
All patients having a general anaesthetic for caesarean section
should have a postpartum Syntocinon infusion (see ‘Prevention
of postpartum haemorrhage’ on page 107.
You should prescribe supplemental oxygen for at least two
hours.
Pain after a general anaesthetic caesarean section can be
severe despite the use of intravenous morphine after delivery.
You should assess the patient in recovery and be prepared to
give further intravenous morphine or other strong analgesics.
Midazolam 1-3 mg is useful in a patient who has intractable
pain despite large doses of morphine.

126 Obstetric Anaesthetists Handbook 3


Placenta praevia

Placenta praevia
Placental implantation in the lower uterine segment – placenta
praevia – presents a particular challenge due to the risk of
uncontrollable haemorrhage at delivery. Uterine blood flow at
-1
term is about 700 ml.min and you should be prepared for
heavy bleeding.
The incidence of placenta praevia is 0.1% to 1% in the third
trimester, increasing with maternal age, parity and the number
of previous caesarean sections. Most cases are managed by
caesarean section. The maternal mortality rate in third-trimester
placenta praevia can be up to 1%.
The two most ominous risk factors are:
• Active bleeding – risk of haemodynamic instability.
• Previous caesarean section – risk of placenta accreta.
The basic principles of management are:
1. Collaborative management with the midwives and
obstetricians.
2. Assessment of the obstetric and physiological status of the
patient.
3. Consultation with senior colleagues.
4. Assess the risk of major haemorrhage when considering
the anaesthetic management.

Patient assessment and stabilisation


When presented with a diagnosed case of placenta praevia,
determine basic information:
• Amount of blood lost (see ‘Obstetric haemorrhage’ on
page 29 if 1000 ml or more).
• Amount and type of fluid replaced.
• Physiological status of the patient.
• Decide if hypovolaemia is present, and commence
resuscitation if it is.
• Degree of urgency of surgery.

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Placenta praevia

• Position of placenta – find out whether it lies between


obstetrician and fetus.
• Whether there has been previous surgery to the uterus –
caesarean section or hysterotomy.
The placental position is
Classification of placenta
diagnosed definitively by
praevia
ultrasound examination.
Placenta praevia can be Grade 1: Low-lying placenta.
classified into grades 1 to 4 Grade 2: Marginal approach
and the position of the to internal os.
placenta can be assessed
(see box). The position may Grade 3: Partial coverage of
determine whether it will be internal os.
possible to deliver a non- Grade 4: Complete coverage
accreted placenta. of internal os.
Always talk to the Position: Anterior or
obstetrician about this. posterior.

Senior assistance
You must seek the assistance of the consultant anaesthetist
responsible for the delivery suite, when anaesthetising for
placenta praevia. Assess the patient, formulate a provisional
plan and then discuss the case.
A consultant anaesthetist should be present for all operative
cases of placenta praevia.

Anaesthetic management
The following guideline is relevant to placenta praevia. Other
factors may be important such as a history of relevant allergies
or coagulation disorders. Remember that the patient’s consent
should be informed by a discussion of all relevant factors. You
should assess the risk of major haemorrhage when considering
the anaesthetic management.
See page 32 for national recommendations for the care of
women at known risk of obstetric haemorrhage.
Request six units of cross-matched blood present in theatre.
Anticipate a minimum blood loss of 1500 ml in cases of anterior
placenta praevia, for example. All patients should have at least
two large-bore (14G) cannulae in place prior to induction of

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Placenta praevia
anaesthesia, with infusion warmers connected and an over
body warmer (Bair Hugger) in place. Monitor the patient’s
temperature and urine output carefully. Drugs for myometrial
stimulation must be readily available – see page 33.
Regional anaesthesia is as safe as general anaesthesia when
administered properly, and is associated with a significantly
reduced blood loss and need for transfusion [37,38]. All its other
advantages also apply here. Against this must be balanced the
impairment of sympathetic reflexes, and the difficulty of
managing prolonged surgery and heavy blood loss in a
conscious patient.

Regional anaesthesia
The indications are those associated with a low risk of major
haemorrhage or other complications:
• There is no active bleeding.
• The patient is normovolaemic, and haemodynamically
stable.
• Posterior placenta praevia.
• No previous caesarean sections – low risk of placenta
accreta.
• Singleton pregnancy and no history of post partum
haemorrhage.
• Previous haemorrhage and transfusion have not impaired
the patient’s coagulation ability. This would be unusual but
you should check.
In the absence of randomised controlled trials, there is debate
about the place of regional anaesthesia in high-risk cases. We
believe that regional anaesthesia is contraindicated if any of the
indications for general anaesthesia are present.
The technique of choice where a regional anaesthetic is
chosen, is either epidural or combined spinal-epidural
anaesthesia – whichever will be more reliable in your hands.
Although spinal anaesthesia can be used successfully, there is
a significant risk that the operation will outlast the anaesthetic.
Placement of an epidural catheter prevents this problem.

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Placenta praevia
Counsel the patient about the potential difficulties involved in
proceeding under regional anaesthesia, and ensure that she is
able to give informed consent
• Regional anaesthesia is our normal method of choice,
including in low-risk cases of placenta praevia.
• Although low, the risks of haemorrhage or extended
surgery are present.
• In that case the safest option would be to continue with
regional anaesthesia unless there is a strong reason to
convert to general anaesthesia.
• There is a potential need for rapid fluid and blood
administration.

General anaesthesia
Indications:
• Active bleeding.
You should resuscitate the patient and manage as for
major haemorrhage on page 29. Use a reduced dose of
etomidate as an induction agent. Establish central venous
pressure monitoring at the earliest opportunity. Use the
blood pressure, pulse rate, central venous pressure and
urine output to guide fluid replacement.
• Anterior placenta.
• Grade 4 placenta praevia.
• Previous caesarean section.
• Planned caesarean hysterectomy (gravid hysterectomy).

Intraoperative haemorrhage and extended


surgery
Do not attempt to manage intraoperative haemorrhage as a
single anaesthetist, particularly under regional anaesthesia –
always send for help from another anaesthetist. Establish
arterial line monitoring.
Haemorrhage or extension of surgery occurring after embarking
on regional anaesthesia poses a dilemma of management.
130 Obstetric Anaesthetists Handbook 3
Placenta praevia
Continuing under regional anaesthesia has been safely used
[39] and avoids the definite risks of emergency conversion. It is
important to understand that the sympatholytic effects of
regional anaesthesia are not abolished by induction of general
anaesthesia, but rather can contribute to haemodynamic
instability.
Consider converting from regional to general anaesthesia if the
patent is seriously distressed, uncomfortable or nauseous. If
this action is chosen, important considerations are:
• Restoration of circulating fluid volume.
• Continuous patient monitoring.
• Preparation for difficult intubation.
See page 123 for advice on converting to general anaesthesia.

37. Parekh N, Husaini SW, Russell IF. Caesarean section for placenta
praevia: a retrospective study of anaesthetic management. Br J
Anaesth 2000; 84: 725-30.
38. Frederiksen MC, Glassenberg R, Stika CS. Placenta previa: a 22-
year analysis. Am J Obstet Gynecol 1999; 180: 1432-7.

39. Chestnut DH, Dewan DM, Redick LF, Caton D, Spielman FJ.
Anesthetic management for obstetric hysterectomy: a multi-
institutional study. Anesthesiology 1989; 70: 607-10.

Obstetric Anaesthetists Handbook 3 131


Pre-eclampsia

Pre-eclampsia
Diagnosis and definitions
Pre-eclampsia, pre-eclamptic toxaemia and PET are all
synonyms for a clinical condition characterised by:
• The development of gestational hypertension in
association with:
• Proteinuria equivalent to a “+” Uristix result.
• (Oedema may be seen as an associated feature).
Pre-eclampsia is diagnosed in pregnant women on these
criteria [40]:
Hypertension
• Diastolic blood pressure ≥90 mmHg [or]
• Systolic blood pressure ≥140 mmHg [or]
• Rise of ≥15 mmHg diastolic or 30 mmHg systolic on
two occasions at least six hours apart.
and
Proteinuria
• ≥300 mg protein/24 hours [or]
• ≥1 g/l in two random specimens at least six hours
apart.
and/or
Oedema
• Generalised oedema after 12 hours of bed rest [or]
• Weight gain ≥ 2.5 kg in one week.
You should determine whether a patient with pre-eclampsia has
mild or severe disease. This is essential in order to determine
appropriate management.
Severe pre-eclampsia is diagnosed when pre-eclampsia exists
along with any one or more of the following complications:
Severe hypertension
• Immediate diagnosis if diastolic blood pressure >110
mmHg.
• Blood pressure ≥160 mmHg systolic on two occasions
at least six hours apart.

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Pre-eclampsia
Proteinuria
• 3 or 4 + on semiquantitative urine analysis [or]
• ≥5 g in 24 hours.
Pulmonary oedema
• Diagnosis of pulmonary oedema or cyanosis.
Abdominal pain
• Epigastric or right upper quadrant pain (hepatic
capsule stretching or hepatic necrosis).
Hepatic rupture
Impaired liver function
Cerebral or visual disturbances
• Headache.
• Blurred vision.
• Loss of consciousness (including convulsion which
defines eclampsia).
Thrombocytopenia
• Platelet count <100,000/µl.
HELLP syndrome
• Haemolysis, Elevated Liver enzymes, Low Platelets.
• See page 140.
Urate levels (uric acid levels) are raised in pre-eclampsia. This
is because of both renal dysfunction and the oxidative stress
associated with pre-eclampsia. Higher urate levels are
associated with a worse prognosis.

Management aims
The primary aims in the management of pre-eclampsia are:
• To deliver the fetus in optimum condition.
• To control maternal hypertension.
• To prevent eclampsia and the other complications.
Anaesthetists may become involved when:
• There is a need for epidural analgesia in labour.
• Anaesthesia for caesarean section is needed.
• High dependency care is required.
• General advice and support is needed.

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Pre-eclampsia

Case responsibility
Management of severe pre-eclampsia is a team effort involving
senior obstetricians, anaesthetists and midwives.
All cases of severe pre-eclampsia are under the care of a
consultant obstetrician and all significant events, decisions and
actions should be notified to or made by the consultant –
usually by the duty obstetrician.
You must also ensure that you have appropriate senior
anaesthetic input as required.

Antenatal high dependency care in pre-


eclampsia

Indications
Severe pre-eclampsia – the treatment recommendations in this
section are not appropriate for mild pre-eclampsia, which is
usually managed more conservatively.

Immediate actions

• Apply monitoring of blood pressure (NIBP in first instance),


pulse and oxygen saturation.
• Administer supplemental oxygen.
• Check that the laboratory samples have been sent (FBC,
coagulation screen, cross-match, biochemistry including
liver function tests).
• Institute a 15-minute observations chart and fluid balance
chart with hourly urine volumes.

Further actions
Formulate a plan for delivery of the fetus and placenta with the
obstetrician. This plan should include consideration of all the
sections in this chapter on pre-eclampsia.

Antihypertensive treatment
Intracerebral haemorrhage is one of the main causes of death
in the hypertensive diseases of pregnancy.

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Pre-eclampsia
Oral methyldopa has been used for many years and is known to
be safe. Labetalol and nifedipine are also used for chronic
control. Other drugs may be added for acute control.
Epidural analgesia is indicated in pre-eclampsia. It is useful to
reduce fetomaternal stress but is not effective as an
antihypertensive agent in itself.
You should use an arterial line for invasive blood pressure
monitoring in any woman whose diastolic blood pressure does
not settle below 100 mmHg easily, or who is receiving
intravenous vasoactive medications.
The treatment aim is to keep the diastolic blood pressure at 90
to 100 mmHg in order to prevent complications of pre-
eclampsia. Do not cause the systemic blood pressure to fall
precipitately and keep both mother and fetus under continuous
monitoring, including blood samples every six hours at least.

Monitoring blood pressure


Automated oscillotonometers may significantly underestimate
the diastolic blood pressure. Regular manual blood pressure
readings should be taken.

Choice of drug for acute hypertension


Hydralazine is the traditional intravenous treatment. Although
randomised controlled trials demonstrate that it can potentially
cause more maternal and perinatal adverse effects than
intravenous labetalol or oral nifedipine [41], its principal
advantages are its few contraindications and relative ease of
use. On the delivery suite it is the agent of choice for
intravenous treatment. Labetalol is available for refractory
cases.
Hydralazine is given as a first treatment of intravenous
hydralazine 5 mg (10 mg may be given), administered slowly.
Observe the effect over 20 minutes. Do not give further doses in
this time, as hydralazine does not act immediately. Then set up
an infusion of 40 mg made up to 40 ml with saline 0.9%, given
via syringe pump. Infusion rates are typically around 12 ml/hour.
Hydralazine may cause tachycardia; nifedipine may be used to
reduce the hydralazine dose and any complicating tachycardia.
Labetalol is started orally in the dose of 100 mg twice daily;
doses of 200 mg four times daily may be required. Acute control

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Pre-eclampsia
of severe hypertension is achieved with 10-20 mg intravenously
every ten minutes to a total dose of 200 mg. Maintenance
therapy is with intravenous labetalol (neat solution – 100 mg in
20 ml, or 5 mg/ml – via syringe driver only) at a dose of
20 mg/hour doubled every thirty minutes to a usual maximum of
160 mg/hour. 10% of patients may be resistant to its effects and
in these cases or when the dose is high, intravenous
hydralazine should be used in addition, as it is synergistic.
The most important contraindication to labetalol in the delivery
suite is maternal asthma, but you should remember that it is a
potent β-blocker. Hyperglycaemia can occur and it should be
used with care in diabetes.

Fluids in pre-eclampsia

General principles

• Careful control of fluid balance is of paramount


importance.
• Transient oliguria occurs in pre-eclampsia and is only
rarely complicated by acute renal failure. Management of
oliguria need not be so aggressive as in general surgical
patients.
• The reduced colloid osmotic pressure found in association
with severe pre-eclampsia increases the risk of pulmonary
oedema at ‘normal’ filling pressures.
• The pulmonary capillary wedge pressure is significantly
greater than the CVP in severe pre-eclampsia.
• CVP monitoring is indicated for the management of some
cases of severe pre-eclampsia.

Fluid balance

• You should maintain strict fluid balance control with hourly


urine measurement.
• The usual fluid regime for maintenance is 60 to 80 ml/hr
Hartmann’s solution.

136 Obstetric Anaesthetists Handbook 3


Pre-eclampsia

• Maintain the patient’s urine output at or above 0.4 ml/kg/hr.


You should usually wait to see if the urine output is low
over a four-hour period – as a guide, expect 100 ml urine
in 4 hours. If you are in any doubt, seek advice from the
obstetricians and from senior anaesthetists.
• Observe for the onset of pulmonary oedema. Auscultate
the chest regularly for signs. Mild hypoxia is a useful early
marker, although other causes such as infection must be
excluded. Continuous pulse oximetry must be used.

Central venous pressure monitoring in severe pre-


eclampsia
This is of value both during delivery and for the postpartum
management of fluid delivery. It removes much of the
guesswork that was involved in managing severely pre-
eclamptic patients. It should not be used routinely, but for the
clinical indications below, taking the patient’s medical history
into account.
CVP monitoring is indicated before induction of anaesthesia
(regional or general) in severe pre-eclampsia in the following
circumstances:
• Patients receiving continuous intravenous
antihypertensive therapy irrespective of the blood
pressure.
• Signs of cerebral irritability, including visual changes.
• Epigastric pain.
• Oliguria.
• Diastolic blood pressure greater than 105 mmHg after
initiation of magnesium therapy.
Detection of a negative CVP indicates a careful raising of the
CVP to 2-3 cm water prior to the establishment of a central
nerve block. Seek senior advice if you are in any doubt about
this.
You should choose the central venous access route based on
your own experience and the points below.
Use an ultrasound machine to guide placement [42]. There are
Sonosite machines in most of the theatre suites – you will need
to arrange for one of them to be borrowed until a dedicated
machine for the Womens’ Hospital.

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Pre-eclampsia
All central venous access must be conducted under continuous
ECG monitoring, and followed by chest X-ray examination when
convenient.
• Placement of a multilumen catheter in the internal
jugular vein is the approach most often used but may
be uncomfortable for the patient and hazardous if a
coagulopathy is present. It does have the advantage
of allowing multiple accesses for drug delivery and
sampling.
• The antecubital fossa approach via the brachial vein
is gaining popularity. Drum catheters for peripheral
access are available in the delivery suite. You should
take full aseptic precautions. Continuous distal
pressure wave monitoring should be used during final
adjustment of the position.
• The femoral vein approach may be used, after
seeking senior advice, if the above approaches are
not possible.
• The subclavian vein approach should not be used.
CVP monitoring is indicated following caesarean section if
agreed with the obstetricians:
• To assist with fluid management, especially where
oliguria is anticipated.
• If for any reason it was not established prior to
induction of anaesthesia for the indications listed
above.
CVP monitoring should be maintained until the patient begins a
diuresis, usually 24-36 hours after delivery.

Management of oliguria
If the patient is oliguric (urine output<0.4 ml/kg/hr), determine
the fluid balance over the last 24 hours and correct any fluid
deficits due to long labour or operative delivery etc. Do not
however give repeated fluid challenges – this may precipitate
pulmonary oedema. The albumin level should be measured
urgently.
You should consider measuring CVP if the patient is still
oliguric, and consider the use of albumin (if hypoalbuminaemic)
to raise CVP to a maximum of 6 cm water (5 mmHg).
Cautious fluid challenges of 250 ml isotonic colloid with CVP
monitoring may be given. A CVP greater than 6 cm water (5

138 Obstetric Anaesthetists Handbook 3


Pre-eclampsia
mmHg), measured at the fourth intercostal space in the
midaxillary line, is potentially dangerous and you should not
allow such relative fluid overload.
You should only consider diuretics if oliguria persists after
achievement of normovolaemia. The diuretic of choice is
intravenous dopamine at a dose of 2.5 µg/kg/min. Make up
200 mg dopamine to 50 ml with dextrose 5% and infuse via a
caval catheter. The rate will be typically about 3.0 ml/hr.
However, the management of oliguria in pre-eclampsia with an
adequate fluid status (CVP of 4 to 6 cm water, or 3 to 5 mmHg)
involves consultant-level discussion and cannot be safely
determined in a fixed protocol. You should ensure that
appropriate advice is available to the team.

Pulmonary artery pressure monitoring in severe pre-


eclampsia
Pulmonary artery catheters can only be used in the intensive
care unit, usually for postoperative monitoring.
Pulmonary capillary wedge pressure monitoring is only rarely
required, because left ventricular dysfunction is rare, and is
indicated for the management of:
• Pulmonary oedema unresponsive to diuretics,
morphine, and oxygen.
• ARDS.
• Severe or malignant hypertension unresponsive to
treatment.
• Persistent arterial desaturation when the origin is not
clear.
• Shock of unknown cause.
• Persistent oliguria unresponsive to fluid challenge.

Anticonvulsant treatment
The best and usually only anticonvulsant therapy required in
pre-eclampsia is to control systemic blood pressures. Signs of
cerebral irritability should be repeatedly sought: presence of
headaches or flashing lights, ankle clonus of more than three
beats or an aura of convulsion.
Magnesium sulphate may be considered for primary prevention
of convulsions in severe pre-eclampsia, but only after
consultation with the consultant obstetrician. The MAGPIE trial

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Pre-eclampsia
showed some benefit [43] but the results are believed to be
equivocal due to the very high number needed to treat (63 for
severe pre-eclampsia at best) in order to prevent one seizure
[44]. The primary action of magnesium is to relieve cerebral
vasospasm.
The occurrence of convulsions makes the diagnosis of
eclampsia for which intravenous magnesium sulphate should
be administered (see page 141). Evidence from the
Collaborative Eclampsia Trial clearly shows that magnesium
sulphate is the treatment of choice for the primary treatment
and secondary prevention of eclamptic convulsions [45]. The
consultant anaesthetist on call must be informed.
For acute control of convulsions intravenous diazepam 10 mg
may be given with appropriate control of the airway. Ensure that
there is no delay in the administration of magnesium sulphate.
In refractory cases you may have to anaesthetise the patient
using thiopentone – as part of an obstetric rapid sequence
induction – to terminate the convulsion. In such cases senior
help must be sought and the consultant anaesthetist on call
must be informed.

HELLP syndrome
This is an ominous form of severe pre-eclampsia – the extreme
end of the continuum of liver complications. The commonest
associated complications (more than 5%) of HELLP syndrome
are disseminated intravascular coagulation (consumption
coagulopathy), placental abruption, acute renal failure,
pulmonary oedema and pleural effusion. Mortality is more than
1%.
Diagnosis can be made when:
• Serum bilirubin and AST are elevated.
• Haemolysis is seen on abnormal peripheral blood
smear.
• The platelet count is below 100,000/µl.
The transaminase rise indicates hepatic ischaemia. The
haematology department may be able to run a haemolysis
screen.
All cases must be managed at consultant level.

140 Obstetric Anaesthetists Handbook 3


Pre-eclampsia
Specific points

• Platelet transfusion should be arranged if the count is


below 20,000/µl for vaginal delivery and 50,000/µl for
caesarean section. Extra blood should be ordered.
(HELLP is not an indication for immediate operative
delivery.)
• Regional techniques are contraindicated due to the risk of
bleeding.
• All drugs administered should have minimal hepatic and
renal metabolism.
• Severe hypoglycaemia may occur and should be sought
vigilantly.
• HELLP syndrome may occur in the postpartum period and
this is associated with pulmonary oedema and acute renal
failure.

Magnesium administration
Remember that magnesium sulphate is synergistic with non-
depolarising neuromuscular blocking drugs and their action will
be potentiated. Use them only in reduced doses with careful
neuromuscular monitoring. Fasciculations with administration of
suxamethonium may not occur after magnesium treatment.
Magnesium therapy is associated with an increased incidence
and severity of obstetric haemorrhage.
Nausea, vomiting and flushing are early signs of magnesium
toxicity. ECG signs can occur: PR and QRS prolongation. Deep
tendon reflexes disappear and apnoea and cardiac arrest may
follow.
1. Magnesium sulphate (MgSO4) is presented as ampoules
of 50% concentration (0.5 g/ml) that contain approximately
2+
2 mmol Mg /ml, available in 2 ml and 10 ml sizes.
2. Make up 50 ml 20% MgSO4 (contains 10 g MgSO4):
• 10 x 2 ml (1 g/ampoule),
• or 2 x 10 ml (5 g/ampoule),
made up to 50 ml with saline. 5 ml solution now contains
1 g MgSO4. The syringe should be mounted into an
infusion pump.

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Pre-eclampsia
3. Give 4 g (20 ml) MgSO4, over 5 minutes (240 ml/hr for 5
minutes carefully timed). If convulsions persist, follow this
with a further load of 2 g (10 ml) over 10 minutes (60 ml/hr
for 10 minutes carefully timed).
4. Maintain an intravenous infusion at 1 g (5 ml) MgSO4 per
hour. If clonus persists MgSO4 should be increased to 3 g
(15 ml) per hour.
5. Observe for cardiac or respiratory arrest while loading –
this can occur with rapid bolus infusion.
6. Clinical monitoring is sufficient when this dose regimen is
used.
• The respiratory rate should be checked before
treatment and every 15 minutes during treatment, and
should be 10 per minute or more.
• Patellar reflexes should be checked before treatment,
30 minutes after the loading dose and hourly
thereafter (use biceps tendon if epidural block
established), and should be present.
7. If signs of toxicity (respiratory rate below 10 or absent
deep reflexes) are found the infusion should be halted,
supplemental oxygen administered if not already given and
a blood sample for magnesium level taken. If there is no
rapid clinical improvement consider administering
intravenous calcium gluconate 1 g slowly, especially if
tendon reflexes are absent.
8. Check the blood magnesium concentration if you are
concerned that it lies outside the therapeutic range,
(symptoms or signs of toxicity or recurrent seizures); if
using a different regimen than the one above; or if renal
function is impaired (urine output less than 100 ml in four
hours or urea level above 10 mmol/l). Check levels at one
hour, four hours, then six hourly.
9. The therapeutic range is 2.0-3.5 mmol/l.
2+
10. Serum Mg levels:
> 5.0 mmol/l. Stop MgSO4 infusion.
Ask for consultant advice.
Calcium gluconate (1 g)
should be given over
10 minutes.

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Pre-eclampsia
3.5-5.0 mmol/l Stop the MgSO4 infusion for
15 minutes.
Restart at half previous rate if
urine output > 20 ml/hr.
If urine output < 20 ml/hr ask
for consultant advice.
2-3.5 mmol/l Therapeutic range.
< 2 mmol/l Increase the infusion rate to 3
g (15 ml/hr) for 2 hours.
Re-check serum concen-
tration and clinical state.
11. The kidney excretes magnesium and toxicity is more likely
if the renal output is poor. If the urine output is less than
20 ml/hr the MgSO4 should be guided by plasma
creatinine.
Creatinine < 100 µmol/l Continue as above.
2+
Check Mg every 2 hours.
Creatinine 100 - 150 µmol/l Reduce MgSO4 infusion to 1
g/hr (5 ml/hr).
2+
Check Mg every 2 hours.
Creatinine > 150 µmol/l Stop the MgSO4 infusion.
2+
Check Mg immediately and
every two hours.
2+
If Mg concentration is under
3.5 mmol/l, infuse MgSO4 at
0.5 g/hr (2.5 ml/hr). Seek
advice from the consultant
obstetrician.
12. If the urine output is less than 10 ml/hr do not use MgSO4.
Call the consultant obstetrician.
2+
13. If there are recurrent convulsions, check the Mg
concentration. Use intravenous diazepam and call senior
help for consideration of an alternative anticonvulsant.

Epidural analgesia in pre-eclampsia


Epidural analgesia is indicated for patients with pre-eclampsia:

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Pre-eclampsia
• Good analgesia reduces the swings in blood pressure
that are otherwise seen during contractions due to
catecholamine release.
• Uteroplacental perfusion is improved so long as
hypotension does not occur.
Epidurals used in this situation are managed much as any
other. However, there are some caveats.
• There is a higher risk of coagulation problems, including
vertebral canal haematoma, due to pre-eclampsia and its
treatment. See ‘Indications for haematological
investigations’ on page 52. For pre-eclampsia itself:
• Mild pre-eclampsia – check that there is a platelet
count within six hours which shows a level of
100,000/µl or above for central nerve block, and if not
request a platelet count (if less than 100,000/µl
request a coagulation screen as below).
• Severe pre-eclampsia – perform a platelet count and
a coagulation screen. The platelet count must be
above 80,000/µl and the coagulation screen normal
for central nerve block.
• Relative hypovolaemia means that vasodilation induced by
an epidural block may give rise to hypotension more
frequently. Vigilant monitoring and swift reaction are
required. As general rule, it is reasonable to preload a
labouring mother with mild pre-eclampsia with 500 ml of
crystalloid. Beware fluid overload in these patients: their
albumin concentration and thus colloid osmotic pressure is
reduced and they are more at risk of developing
pulmonary oedema.
• These patients are more sensitive to the effect of
vasopressor drugs such as ephedrine. However,
ephedrine should be used as indicated to prevent and treat
hypotension.
• The use of hypotensive drugs in labour may exacerbate
the vasodilator effects of an epidural and the dose may
need to be reduced. Epidural analgesia by infusion may be
preferable, especially in severe pre-eclampsia.

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Pre-eclampsia

Anaesthesia for caesarean section in pre-


eclampsia

Assessment and choice of technique


You should assess as for any operative procedure, paying
particular attention to:
• Laboratory results, including platelets and coagulation
studies as indicated (see page 52).
• Facial oedema, dysphonia, stridor or respiratory
distress – these signs are associated with glottic
oedema and difficult intubation.
• Cerebral irritability (visual disturbances, hyperreflexia
and clonus).
• Urine output.
• The extent to which the patient has been resuscitated
and hypertension controlled.
The patient should give informed consent but since choice of
technique is more likely to be modified by medical advice, you
must be prepared to make a firm recommendation to the
patient.
The quick onset of vasodilation in a patient who is relatively
hypovolaemic may give rise to marked hypotension – a disaster
for a compromised fetus. Traditionally this has contraindicated
the use of spinal anaesthesia. We believe however that
carefully managed, the benefits of spinal anaesthesia outweigh
the risks where it is otherwise indicated, for both mild and
severe pre-eclampsia except as below.
In the presence of cerebral irritability or eclampsia general
anaesthesia is the preferred technique, although regional
anaesthesia is not absolutely contraindicated. You must call for
senior help in these circumstances and notify the consultant
anaesthetist on call. There is usually at least two hours
stabilisation between eclampsia and caesarean section except
in the direst emergencies.
You should make every effort to control hypertension prior to
anaesthetising the patient. This may mean placing the fetus’
needs after those of the mother. If it is imperative to proceed
prior to stabilisation on an antihypertensive regimen, then
general anaesthesia is the preferred technique.

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Pre-eclampsia
Choice of technique: mild pre-eclampsia
You should proceed with anaesthesia for caesarean section as
otherwise indicated. The preferred technique is spinal
anaesthesia.

Choice of technique: severe pre-eclampsia


You should inform the consultant anaesthetist on call about any
patient with severe pre-eclampsia who needs a caesarean
section.
The preferred technique is spinal anaesthesia but there a
number of specific caveats that are mentioned here but detailed
elsewhere:
• Risk of vertebral canal haematoma (see page 52).
• Stabilisation on antihypertensive regimens (see page
134).
• Cerebral irritability or eclampsia (see page 145).

General anaesthesia and pre-eclampsia


It is important that the blood pressure is controlled prior to
induction. An acceptable level is 150/95; certainly a diastolic
below 100 mmHg should be the target. This may require the
use of labetalol and/or hydralazine and necessitates close
monitoring of blood pressure.
In patients with severe pre-eclampsia, once the blood pressure
is controlled, you should supplement the general anaesthetic by
giving 15-20 µg/kg of alfentanil one minute prior to induction.
You must inform the paediatrician if alfentanil is used.
A ‘standard’ technique is then used. Ensure that small
endotracheal tubes are available prior to induction. In patients
who are oliguric before caesarean section, or who have severe
pre-eclampsia, it is sensible to insert a CVP line once the
operation is finished; avoid the subclavian route as
coagulopathy may occur post-delivery (see page 137).
You should treat as for eclampsia for the acute control of
convulsions.

Postoperative high dependency care


You should consider certain patients for postpartum high
dependency care.

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Pre-eclampsia

• Eclamptic patients – these patients may require a period of


ventilation on the intensive care unit after caesarean
section.
• Patients with severe pre-eclampsia.
• Patients who are oliguric before delivery, even if they have
only mild pre-eclampsia.
• Patients with mild pre-eclampsia who, after a period of two
hours observation in recovery post delivery are seen to be
oliguric or require parenteral hypotensive or anticonvulsant
treatment.
• Patients with coagulopathy.
• Other patients about whom you are concerned.
Consult with the obstetrician to determine a plan for the patient.

The postnatal period in pre-eclampsia


Although delivery of the placenta results in resolution of pre-
eclampsia, mothers may still deteriorate. The peak incidence of
pulmonary oedema is in the postpartum period. Usually mothers
are better within 48 hours of delivery, though it may take longer.

General principles of management

• Fluid balance and the management of oliguria are as


important in the postnatal period as in the antenatal period
(see page 134).
• Monitor the blood pressure and use continuous pulse
oximetry. Treat hypertension (see page 134). Use
intravenous labetalol to treat hypertension in the first
instance, especially if tachycardia is a problem or if the
mother has been on oral labetalol predelivery. The
alternative is intravenous hydralazine. When oral intake is
feasible, consider using beta-blockers or nifedipine.
• Observe for the onset of cerebral irritability and treat
accordingly. Magnesium sulphate (see page 141) is the
treatment of choice.

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Pre-eclampsia

• Give analgesia as indicated (see page 108); continue with


an epidural infusion if the caesarean section was under
epidural; use a morphine infusion if not (intravenous or
PCA). Diclofenac should not be given for 24 hours after
delivery in severe pre-eclampsia.
• The patient should be ‘nil by mouth’ for 24 hours after a
caesarean section in pre-eclampsia. Continue ranitidine
intravenously or orally until the mother is eating and
drinking normally. This may be delayed further owing to
the development of paralytic ileus.
• Thromboprophylaxis: ask the midwives to put TED
stockings on the patient, and ensure that subcutaneous
heparin 7500 units twice daily has been prescribed.
• Continue observations and investigations from the
antenatal period until it is agreed by the responsible
consultant that the high-risk period has passed.
Work as a team with the obstetricians and midwives.

40. Management of preeclampsia. American College of Obstetricians


and Gynecologists. ACOG Technical Bulletin no. 91, 1986.
41. Magee LA, Ornstein MP, von Dadelszen P. Management of
hypertension in pregnancy. BMJ 1999; 318: 1332-6.

42. Ultrasound locating devices for placing central venous catheters


(Technology Appraisal Guidance No 49). National Institute for
Clinical Excellence, September 2002.

43. The Magpie Trial Collaboration Group. Do women with pre-


eclampsia, and their babies, benefit from magnesium sulphate?
The Magpie Trial: a randomised placebo-controlled trial. Lancet.
2002; 359: 1877-90.
44. Yentis SM. The Magpie has landed: preeclampsia, magnesium
sulphate and rational decisions. International Journal of Obstetric
Anesthesia 2002; 11: 238-41.

45. Duley L, Carroli G, Belizan J et al. Which anticonvulsant for women


with eclampsia – evidence from the collaborative eclampsia trial.
Lancet 1995; 345: 1455-63.

148 Obstetric Anaesthetists Handbook 3


High dependency care

High dependency care


Admission considerations
Room 8 is equipped as a high dependency care area. You
should familiarise yourself with the integrated monitor because
the midwives often ask the anaesthetist for advice regarding its
operation. Room 7 is also available although equipped to a
lower standard – you may need to find equipment for Room 7.
You should contact the consultant anaesthetist on call when
considering high dependency care. Occasionally an
obstetrician-initiated admission may be made without involving
you. You should determine whether this is a case that involves
obstetric anaesthesia and contact the consultant anaesthetist
on call as appropriate. If in doubt, call.
The patient’s care should be planned with the midwives and
obstetricians.
Patients should be considered for admission when their care
needs exceed those available in a standard delivery room.
Indications include:
• Severe pre-eclampsia and its complications, e.g.
oliguria, eclampsia and coagulopathy.
• Obstetric haemorrhage.
• Pre-existing maternal disease.
• And all the practical elements of care listed in
‘Discharge considerations’ below.

Principles of patient management


• You may ask the delivery suite ODP for help with
equipment and techniques, particularly those with which
the assigned midwife may be unfamiliar.
• High dependency charts are used. In particular, ensure
that the fluid balance sections are scrupulously completed.
• In many cases, receipt of high dependency care may allow
the use of an epidural infusion for postoperative analgesia
(see ‘Epidural infusions’ on page 90).

Obstetric Anaesthetists Handbook 3 149


High dependency care

• Although the patient is formally under the care of the


obstetricians, you should take part in a team approach.
You should see patients regularly and in particular jointly
with the obstetricians and midwives wherever possible.
• You should make entries in the case notes as required and
regularly. Comprehensive handover of care to the
incoming duty obstetric anaesthetist is particularly
important and should take place in the patient’s room.
• Be alert for developments which indicate intensive care
such as impending or actual failure of two or more organ
systems, or one organ system where this is the respiratory
system. You should discuss such developments
immediately with all appropriate staff including the
consultant anaesthetist on call, and if necessary the
consultant on call for Intensive Care.

Discharge considerations
Patients may be discharged only in conjunction with the
midwives and obstetricians.
In practice, a midwife will probably ask you if it is appropriate for
the patient to go to a postnatal ward. This will be appropriate if
the patient no longer requires:
• Invasive haemodynamic monitoring including arterial
blood gases.
• Regular and frequent blood tests (six hours).
• Close monitoring of renal function with central venous
catheter or hourly urine volumes.
• Intravenous vasoactive medications.
You should give formal handover to the ward obstetrician for
any woman discharged from high dependency care.
Humane considerations may suggest that a woman who has
lost a baby or is receiving an epidural infusion, for example, be
allowed to remain in Room 8 a little longer if there is no
immediate pressure for another admission.

150 Obstetric Anaesthetists Handbook 3


Other operative procedures

Other operative procedures


Retained placenta
You should respond to a request for anaesthesia within 30
minutes.
Regional methods are preferred if not contraindicated (epidural
or spinal with range from S5 to T8) , although some patients will
choose general anaesthesia after assessment. You should
consult with the obstetrician however and use general
anaesthesia if there is a significant risk of abnormal placentation
e.g. placenta accreta, increta or percreta, or excessive blood
loss.
You should assess the volume status of the patient with care,
resuscitating the patient by replacing any known blood losses
prior to induction of anaesthesia.
If uterine relaxation is required you should administer relaxant
drugs in regional anaesthesia or isoflurane in general
anaesthesia, remembering to do so well in advance of the
need. See page 100.

Postpartum evacuation
Women may come back to the delivery suite up to six weeks
after delivery for uterine evacuation. Although this is an urgent
procedure, it is not an emergency and the care of labouring
women takes priority e.g. establishing epidural analgesia.
We consider that the gastric emptying time returns to normal in
uncomplicated cases from 48 hours after delivery. The patient
should be fasted (see page 47). A rapid sequence induction is
not necessary unless otherwise indicated.

Surgery on pregnant women


Surgical procedures may be proposed in pregnant women
where they remain pregnant following surgery. You must seek
senior help in all such cases including that of cervical cerclage.
Other procedures may be proposed to you and they should
usually be undertaken in the main Walsgrave Hospital. Refer all
non-obstetric cases to the third on call anaesthetist.

Obstetric Anaesthetists Handbook 3 151


Other operative procedures

Cervical cerclage
This is also known as a McDonald’s or Shirodkar suture. The
procedure is performed on a pregnant patient in the second
trimester in order to reduce the rate of spontaneous
miscarriage.
We prefer a spinal anaesthetic as this keeps placental transfer
of drugs to a minimum and greatly reduces the risk of
pulmonary aspiration. Aim for anaesthesia from S5 to T8.
The obstetrician may require uterine relaxation during this
procedure. You should discuss appropriate methods with them.
If general anaesthesia is preferred by the patient, or considered
essential to the successful performance of the operation, then a
rapid sequence induction is mandatory.

152 Obstetric Anaesthetists Handbook 3


Diabetes in pregnancy

Diabetes in pregnancy
Pregnancy has profound effects on carbohydrate metabolism
and hence control of blood sugar is more difficult than in the
non-pregnant state. Usually there is a progressive and
unpredictable increase in insulin requirement after the first
trimester. The patient is managed jointly between the
diabetologists and obstetricians (Dr P. Biggs and Dr L. Farrall
respectively).

Management during labour and caesarean


section
The mother should have her normal insulin on the evening
before planned delivery.
Maternal normoglycaemia is the target during labour or
caesarean section, minimising the risk of neonatal
hypoglycaemia associated with maternal hyperglycaemia.

Glycaemic control

• Intravenous fluid: 5% dextrose, 1 litre 8 hourly.


• Insulin infusion (50 units Actrapid to 50 ml with 0.9%
saline) from infusion pump into the dextrose infusion line.
• Monitor blood glucose hourly during labour, and adjust the
insulin infusion rate with the patient’s individual pre-
planned regime (in the notes on a white card) as a guide to
initial therapy. This must be adjusted as necessary for the
individual case, aiming to keep blood glucose between 4
and 7 mmol/l.
• If labour lasts more than 12 hours check urea and
+
electrolytes; consider a K infusion.
• At delivery the insulin rate should be halved immediately.
• Once the blood sugar concentration is stable after delivery,
2 to 4 hourly glucose estimations are sufficient.
• Insulin infusion should be continued until the mother is
eating normally.

Obstetric Anaesthetists Handbook 3 153


Diabetes in pregnancy
Analgesia and anaesthesia
Epidural analgesia for labour is the technique of choice. It
reduces the acidosis of labour, reduces the stress response and
consequent hyperglycaemia, and detection of hypoglycaemia is
easier in the alert patient. Fluids administered for the epidural
should be through a separate intravenous line from the
dextrose. Hartmann’s solution is suitable.
Regional techniques should also be chosen for caesarean
section in the absence of contraindications.

Gestational diabetes
Patients with gestational diabetes (often a diagnosis made in
retrospect) should be managed as for a normal mother except
where glycaemic control indicates the use of insulin. They
should then be managed according to the guideline above. The
obstetricians will normally take this decision prior to admission
onto the delivery suite.

154 Obstetric Anaesthetists Handbook 3


Further reading

Further reading
The following publications are recommended to you for further
reading or reference. You will find some of them locked on the
delivery suite – the key is on the bleep.
• Guidelines for Obstetric Anaesthesia Services. Association
of Anaesthetists of Great Britain and Ireland/Obstetric
Anaesthetists Association; London 1998.
This is the key standards text in obstetric anaesthesia.

Reference texts

• Handbook of Obstetric Anesthesia. Edited by Craig M.


Palmer, Robert D’Angelo and Michael J. Paech. Bios,
Oxford, 2002.
ISBN 1 85996 232 7.
• Regional Analgesia in Obstetrics: a millennium update.
Edited by Felicity Reynolds. Springer-Verlag, London,
2000.
ISBN 1 85233 280 8.
• Principles and Practice of Obstetric Anaesthesia and
Analgesia. Anita Holdcroft and Trevor A. Thomas.
Blackwell Science Ltd; Oxford, 2000.
ISBN 0 86542 828 X.
• The Obstetric Anesthesia Handbook. Edited by Sanjay
Datta. Hanley and Belfus (3rd edition); Philadelphia, 2000.
ISBN 1 56053 405 2.
• Clinical Problems in Obstetric Anaesthesia. Edited by Ian
F. Russell and Gordon Lyons. Chapman and Hall Medical;
London, 1997.
ISBN 0 412 71600 3.
• Pain Relief in Labour. Robin Russell, Mark Scrutton and
Jackie Porter (edited by Felicity Reynolds). BMJ
Publishing; London, 1997.
ISBN 0 7279 1009 4.

Obstetric Anaesthetists Handbook 3 155


Further reading

• Practical Obstetric Anesthesia. Edited by David Dewan


and David Hood. W.B. Saunders Company; Philadelphia,
1997.
ISBN 0 7216 3658 6.

Specialised references

• Obstetric Anesthesia and Uncommon Disorders. Edited by


David Gambling and Joanne Douglas. W.B. Saunders
Company; Philadelphia, 1998.
ISBN 0 7216 6157 2.
• Anesthetic and Obstetric Management of High-Risk
Pregnancy. Edited by Sanjay Datta. Mosby (2nd edition);
St Louis, Missouri, 1996.
ISBN 0 8151 2280 2.

Web sites

• Obstetric Anaesthetists Association


http://www.oaa-anaes.ac.uk/
• Royal College of Anaesthetists
http://www.rcoa.ac.uk/
• Association of Anaesthetists of Great Britain and Ireland
http://www.aagbi.org/
• Society for Obstetric Anesthesia and Perinatology
http://www.soap.org/

Reports on the Confidential Enquiries

• Why Mothers Die: Report on Confidential Enquiries into


Maternal Deaths in the United Kingdom 1997-99.
http://www.cemach.org.uk/

156 Obstetric Anaesthetists Handbook 3


CCST syllabus

CCST syllabus
The Royal College of Anaesthetists has published a manual in
four parts for trainers and trainees, covering the CCST syllabus
in anaesthesia [46]. This governs the entire training period.
Relevant parts for obstetric anaesthesia and analgesia are
reprinted below. You should make sure that in quiet moments
on the delivery suite you ask the consultant anaesthetist for an
impromptu tutorial in relevant subjects.

CCST 2 – senior house officer

Knowledge
Physiological changes associated with a normal pregnancy
Functions of the placenta: placental transfer: feto-maternal
circulation
The fetus: fetal circulation: changes at birth
Pain pathways relevant to labour
Methods of analgesia during labour: indications and
contraindications
Effect of pregnancy on the technique of general and regional
anaesthesia
Principles of anaesthesia for incidental surgery during
pregnancy

Skills (to observe or perform)


Preoperative assessment of pregnant patient
Anaesthesia for retained products of conception
Analgesia for labour
Management of APH and PPH
Management of dilutional coagulopathy
Intubation problems in the full-term mother
Anaesthesia/analgesia for instrumental delivery
Anaesthesia for retained placenta
Anaesthesia for caesarean section

Obstetric Anaesthetists Handbook 3 157


CCST syllabus
Attitudes and behaviour
Attempt by conscientious care to recognise problems early
Seek senior help early
Good communication with mother, partner and other family
members
Calmness under pressure
Timely assistance and prompt response to requests for
analgesia and help
Reassurance to the mother
Compassion and kindness when the outcome of labour has
been poor

Workplace training objectives


All SHOs should have an attachment to an obstetric service to
observe and preferably perform the listed skills. It is recognised
that not all SHOs will be able to become highly skilled in
obstetric analgesia and it is accepted that in the time available
some SHOs will not be able to progress beyond direct
supervision.

CCST 3 – junior specialist registrar


This is a ‘Key Unit of Training’ in which SpR 1/2 trainees should
spend the equivalent of at least 1 month of training and,
normally, not more than 3 months.
Obstetric anaesthesia and analgesia is the only area of
anaesthetic practice where two patients are cared for
simultaneously. Pregnancy is a physiological rather than a
pathological state. Patient expectations are high and the mother
expects full involvement in her choices of care. The majority of
the workload is the provision of analgesia in labour and
anaesthesia for delivery. Multidisciplinary care for the sick
mother is increasingly important and highlighted.

Knowledge
Anatomy and physiology of pregnancy
Physiology of labour
Placental structure and mechanisms affecting drug transfer
across the placenta

158 Obstetric Anaesthetists Handbook 3


CCST syllabus
Basic knowledge of obstetrics
Gastrointestinal physiology and acid aspiration prophylaxis
Pharmacology of drugs relevant to obstetric anaesthesia
Pain and pain relief in labour
Emergencies in obstetric anaesthesia:
• pre-eclampsia, eclampsia, failed intubation, major
haemorrhage,
• maternal resuscitation, amniotic fluid embolus, total
spinal
Use of magnesium sulphate
Incidental surgery during pregnancy
Assessment of fetal well being in utero
Thromboprophylaxis
Feeding / starvation policies
Influence of common concurrent medical diseases
Management of twin pregnancy
Management of premature delivery
Maternal morbidity and mortality
Management of difficult or failed intubation
Maternal and neonatal resuscitation
Legal aspects related to fetus

Skills
Assessment of pregnant woman presenting for anaesthesia /
analgesia
Epidural / subarachnoid analgesia for labour
Management of complications of regional block and of failure to
achieve adequate block
Epidural and subarachnoid anaesthesia for Caesarean Section,
and other operative deliveries
Conversion of analgesia for labour to that for operative delivery
General anaesthesia for Caesarean Section
Airway management
Management of the awake patient during surgery

Obstetric Anaesthetists Handbook 3 159


CCST syllabus
Ability to ventilate the newborn with bag and mask
Anaesthesia for interventions other than delivery
Post-delivery pain relief
Management of accidental dural puncture and post-dural
puncture headache
Recognition of sick mother
High dependency care of obstetric patients
Optimisation for the ‘at risk’ baby

Attitudes and behaviour


To be aware of local guidelines in the obstetric unit
To communicate a balanced view of the advantages,
disadvantages, risks and benefits of various forms of analgesia
and anaesthesia appropriate to individual patients
To communicate effectively with partner and relatives
To help deal with disappointment
To be involved in the initial management of complaints
To communicate effectively with midwives
To obtain consent appropriately
To keep good records
To identify priorities
To attempt by conscientious care to recognise problems early
To allocate resources and call for assistance appropriately
To be aware of local audits and self audit

Workplace training objectives


Within the obstetric team, the trainee should play a full part;
communicating effectively about anaesthetic and analgesic
techniques used in obstetrics and developing organisational
skills. They should consolidate clinical management of common
obstetric practice but recognise and treat common
complications exercising proper judgement in calling for help.

160 Obstetric Anaesthetists Handbook 3


CCST syllabus
Recommended local requirements to support training

• Training should normally be provided in units carrying out


at least 2,000 deliveries annually.
• There should be at least 1 consultant anaesthetic session
allocated for every 500 deliveries. (In units with a frequent
turnover of inexperienced trainees, with a higher than
average epidural or Caesarean Section rate and/or a
substantial number of high risk cases, sessions above this
minimum will be required).
• Local protocols should be available to guide trainees in the
management of common obstetric emergencies based on
the individual units staffing and local support.
• Appropriately trained assistance for the anaesthetist (to
NVQ level 3 in Operating Department Practice or in
possession of the appropriate ENB qualification) must be
locally available whenever a trainee anaesthetist is
required to manage a patient during an operative delivery.
The person providing this assistance to the anaesthetist
should have no other duties at that time.
• Access for patients to critical care facilities must be
immediately available at all times.
• Appropriate anaesthetic ‘bench books’ should be available
within the delivery suite.

CCST 4 – senior specialist registrar


Training will build on the SpR 1/2 module in obstetric
anaesthesia. It is recognised that the ability to see and manage
some of the important major obstetric emergencies is to some
extent dependent on chance, but increased time in the specialty
increases the likelihood of active involvement.
To become skilled in:
• assessing women with factors complicating pregnancy;
• providing information about analgesia and anaesthesia to
pregnant women, with or without complicating factors, to
midwives and other professional groups;

Obstetric Anaesthetists Handbook 3 161


CCST syllabus

• advising on alternative methods to regional block for


analgesia ;
• allaying anxiety and dealing with disappointment;
• managing complications of regional block;
• managing emergencies including as pre-eclampsia,
eclampsia, major haemorrhage;
• being part of a multidisciplinary team;
• recognising and treating the sick mother;
• recognising when further advice or skills are needed; and
• neonatal resuscitation.
To enhance skills in:
• epidural and CSE insertion and management for labour;
• epidural and subarachnoid anaesthesia for Caesarean
Section, and other operative deliveries;
• conversion of analgesia for labour to that for operative
delivery; and
• general anaesthesia for Caesarean Section.
Objective: To achieve a greater emphasis on the trainee
undertaking more complex obstetric cases and becoming more
involved in team working.

46. The CCST in Anaesthesia. Royal College of Anaesthetists,


London, 2003. http://www.rcoa.ac.uk/publications/index.asp

162 Obstetric Anaesthetists Handbook 3


The OAA Training Module

The OAA Training Module


This material has been taken from the Obstetric Anaesthetists
Association web site.

Introduction
The Training Module that follows has been produced by an
OAA sub-committee to meet the demands of Calman training in
1999 and hopefully beyond. This version has been warmly
welcomed by both the Training Sub-Committee of the Royal
College of Anaesthetists (RCA) and the Joint Standing
Committee of the Royal College of Anaesthetists and the Royal
College of Obstetricians and Gynaecologists. We are therefore
making it available to the Members of the OAA now.
We are however mindful of the continuing discussions between
the RCA and specialist societies on training matters. The OAA
will therefore keep the module under review and continue our
dialogue with the RCA and other specialist societies so as to
facilitate any future developments in overall Anaesthesia
training.
We realise that National Modules cannot meet all local
circumstances and that locally important detail will be added by
Members. We hope that Members will find this Module helpful
as a template on which to build and develop their own local
training modules in Obstetric Anaesthesia.
The OAA recommendations for:
MODULAR TRAINING IN OBSTETRIC ANAESTHESIA
(14th April 1998)
These recommendations are intended to provide a common
national curriculum in obstetric anaesthesia for all trainees. In
collating them the OAA have been mindful of the RCA
guidelines on Calman Training and also Examination Curricula
and we hope that both the RCA and Association will endorse
the recommendations.

Logistics of training
Training requires the presence and active participation together
of at least one trainer and one trainee in the same unit for

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The OAA Training Module
sufficient time to allow the exchange and discussion of training
information or experience. It is recognised that this may be
difficult unless there is a predictable availability of sufficient
teaching opportunities. Topics to be addressed are shown
below (see core knowledge).
Training for obstetric anaesthesia seems to fall into Basic and
Advanced categories. Basic training consists of the acquisition
of core knowledge and skills followed initially by the supervised
application of these skills. All trainees will be expected to attain
at least this basic level of knowledge and competence. More
advanced training will be required for those aspiring to be
specialist obstetric anaesthetists. We have produced below a
comprehensive list of learning objectives for both basic and
advanced training. The lists comprise headings of topics to be
covered but not the detail within each topic. The detail is best
addressed by trainers locally.

Basic training

Acquisition of Core Knowledge and Basic skills


The first objective of any trainee should be to obtain and read a
copy of the guidelines of the local unit in which he or she is to
undertake training. Every obstetric unit should provide such
guidance which must include not only local geographical
information but also the unit protocols and guidelines for the
treatment of critical or emergency events (e.g. failed intubation,
major haemorrhage, eclampsia).
Supplementary reading of one or more Obstetric Anaesthesia
texts will improve the trainee’s understanding of the local
guidelines. Teaching units should maintain an availability of
recommended reading material, which would include such
textbooks, relevant journals, Reports on the Confidential
Enquiries into Maternal Deaths in the UK, and Changing
Childbirth.
Local training modules should address the following topics all of
which should be taught if full basic training in Obstetric
Anaesthesia is to be completed.

Core knowledge
1. Anatomy and physiology of pregnancy
2. Basic obstetric knowledge
164 Obstetric Anaesthetists Handbook 3
The OAA Training Module
3. Gastro intestinal physiology and antacid therapy
4. Pain and pain relief in labour (mechanisms)
5. Epidural/subarachnoid analgesia
6. General anaesthesia (GA) for parturients
7. Regional anaesthesia (RA) for parturients
8. Assessment of the pregnant woman presenting for
anaesthesia/analgesia
9. Emergencies in obstetric anaesthesia:
• Failed intubation
• Major haemorrhage
• Eclampsia and PIH
• Maternal & neonatal resuscitation
• Total spinal.
10. Anaesthesia for interventions other than delivery.
11. Audit
12. Pharmacology of drugs relevant to obstetric anaesthesia
In addition to the Core Knowledge covered in the list above
technical skills must be developed such that the Core
Knowledge can be applied to provide safe patient care. Twelve
months anaesthesia training / experience is commonly regarded
as a prerequisite before performing obstetric analgesia /
anaesthesia procedures in the absence of direct supervision.
Ideally, experience with basic techniques for GA, epidural and
subarachnoid anaesthesia should first be acquired with non-
obstetric patients. Following this period, further supervised
experience with obstetric patients will be required before the
trainee is competent to work in an obstetric unit without direct
supervision.

Basic skills
1. Communication skills
2. Organisational skills
3. Technical skills
Communication skills
Training in communication skills is fundamental to successful
obstetric anaesthesia practice. The majority of obstetric patients
presenting for analgesia or anaesthesia will be, and wish to
continue to be, awake. They wish to receive information about
their treatment and its consequences if possible before
treatment is given. Imparting this information requires clarity of

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The OAA Training Module
thought and expression together with sympathy and
understanding. These qualities are not easily taught and may
need much time devoted to them. The obstetric anaesthetist
trainer should assess the trainee to confirm competence in
communication skills before the trainee is allowed independent
action in the obstetric unit.
Organisational skills
• Applied to one's own activity
• Applied to other people's activities
• Applied to equipment
The trainee must be taught to identify priorities and allocate
resources. The obstetric unit can be very stressful with multiple,
simultaneous urgent demands for an anaesthetist's skill and
time. Appreciation of which of the multiple demands will require
additional or more senior assistance is vital. Such assistance
should be readily available if patient care and a trainee's
confidence are both to be nurtured.
Familiarity with the equipment used for GA and RA will help
build confidence. Learning to lay out equipment in a neat and
logical way so that it is immediately available for use will reduce
both stress levels and risks in difficult situations.
Basic Technical skills
1. Sterile techniques
Sterile technique is fundamental to the performance of regional
anaesthesia and analgesia. This skill is often taught poorly or
not at all.
2. Epidural, subarachnoid and general anaesthetic
techniques as appropriate for:
• Pain relief in labour
• Caesarean section
• Conversion from labour regional analgesia to
anaesthesia for operative delivery
• Postpartum pain relief
• Other operative deliveries
3. Medical record keeping
Recording complete information in a rational and clear way to
facilitate future medical and / or legal enquiry.

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The OAA Training Module
4. Personal record keeping
For both audit and training purposes.

Advanced training
Trainees who wish to prepare for a consultant post with a
special interest in obstetric anaesthesia need to acquire a more
advanced knowledge base, a higher level of skills and a
maturity of judgement of the parturient and her treatment.
These can only be achieved by further training and experience.
It is recognised that in order to gain in - depth experience it is
likely to be necessary and desirable to arrange attachments to
obstetric units other than the trainee’s centre or school.

Further core knowledge


An understanding of the pathophysiology of disease as it affects
obstetric anaesthesia management.
An understanding of the pathophysiology and differential
diagnoses of complications associated with obstetric
anaesthesia.

Advanced skills
1. Communication
2. Organisational skills
3. Technical skills
4. Research
The skills mentioned below should be taught while further
experience in basic skills is being obtained.
Communication
• Understanding and responding to the wide range of
demands made of obstetric anaesthetists by the parturient
and her partner, midwives, medical and paramedical staff,
and managers.
• Teaching the relevant aspects of obstetric anaesthesia
and analgesia to the public and all levels of NHS staff
Organisational skills

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The OAA Training Module

• A high level of personal organisation will be expected


(including the maintenance of records) as well as an ability
to organise others effectively and efficiently.
Technical skills
• Competence in a wide range of obstetric regional
anaesthesia and analgesia techniques.
• An ability to recognise and manage complications of
obstetric anaesthesia and analgesia.
• Ability to function as an effective member of a
multidisciplinary team caring for the parturient.
Research
Personal involvement in research relevant to obstetric
anaesthesia and analgesia is desirable though it is recognised
that this may not always be possible. Advanced trainees are
expected to be widely read and aware of current literature so
that they may evaluate critically obstetric anaesthetic research
literature. A trainee wishing to become a specialist obstetric
anaesthetist would be expected to have attended a number of
national or international meetings relevant to obstetric
anaesthesia.

168 Obstetric Anaesthetists Handbook 3


Normal laboratory values in pregnancy

Normal laboratory values in pregnancy


Haematology
Haemoglobin > 10 g/dl
White cell count 5-15 (up to 40 during labour)
Platelets 150,000-450,000/µl

APTT 0.8-1.2
INR 1.0-1.3
PT 10-13 seconds

Fibrinogen 1.5-4 g/l


FDP <0.3

Biochemistry
Pregnancy Walsgrave adult
range
Sodium 133-147 mmol/l 136-144
Potassium 3.5-5.1 mmol/l 3.7-5.0
Urea 1 .5-4.5 mmol/l 3.3-7.5
Creatinine 40-90 µmol/l 70-120
Albumin 25-42 g/l 34-48
Urate 110-350 µmol/l 170-520
Bilirubin 4-25
Alkaline Phosphatase 90-600 u/l 70-250
AST 8-40
ALT 10-50

Obstetric Anaesthetists Handbook 3 169


Normal laboratory values in pregnancy

Arterial Blood Gases


pH 7.44
pCO2 4.1 kPa
pO2 13.6 kPa
BE 0-3.5 mmol/l

Fetal Blood Gases


Blood is taken for cord gases at emergency caesarean
sections, as a measure of the fetal state at the time of delivery.
The umbilical artery specimen reflects the state of the fetus and
the umbilical vein specimen that of the placental perfusion. It is
not easy to quote normal values, as the fetus whose mother has
been in labour will be more acidotic than the one delivered by
caesarean section. The values quoted below are a guide only.
The pH and base deficit are used more in clinical practice than
the pO2 and pCO2.
The concept of respiratory and metabolic acidoses may be
helpful. Diagnosed in the same way as with ordinary arterial
blood gases, a fetoplacental perfusion problem initially
manifests as a respiratory acidosis. When significant hypoxia
becomes established, then a metabolic acidosis picture
emerges.
Umbilical artery Umbilical vein
pH 7.25 or higher 7.3 or higher
BE -6 or less -4 or less
pO2 2.3 kPa 3.7 kPa
pCO2 7.3 kPa 5.3 kPa

Fetal sampling
A pH of 7.2 is generally agreed as the lowest acceptable and
will indicate urgent delivery when obtained from a fetal scalp.

170 Obstetric Anaesthetists Handbook 3


Index

Index
abruption. See placental asthma
abruption labetalol, 136
advance statement, 61 NSAIDs, 109
airway assessment, 27 atosiban, 101
airway, surgical, 27 audit
albumin administration, outcome, 43
projects, 43
138
alfentanil, 146 backache, 62
intraoperative, 123 birth plan, 61
amniotic fluid embolism, blood patch. See epidural
36 blood patch
central nerve block, 53 breakthrough pain, 121
analgesia, postoperative, breech presentation, 102
109 analgesia, 85
antibiotic prophylaxis bupivacaine
endocarditis, 59 dose after subdural
wound infection at block, 99
operation, 107 dose in spinal
anticoagulation anaesthesia, 116
central nerve block, 53 dose limit, 90
antiemetic epidural infusion, 90
first dose for epidurals,
general anaesthesia,
125 89
rate limit for
spinal anaesthesia, 115
administration, 89
antithrombotics subarachnoid, 93
central nerve block, 51
caesarean hysterectomy,
aortocaval compression, 113
10
caesarean section
avoidance, 87, 107
after forceps, 118
ARDS, 139 assessment for
arterial line elective, 57
placenta praevia, 130 choice of technique,
pre-eclampsia, 135 113
aspirin cord gases, 170
central nerve block, 51 diabetic patient, 153
assessments, 46 required block, 115
time standards, 104
Obstetric Anaesthetists Handbook 3 171
Index
with epidural extension, cross-match policy, 58
118 placenta praevia, 128
with spinal CVP measurement
anaesthesia, 115 haemorrhage, 31
with subarachnoid indication in pre-
catheter, 94 eclampsia, 138
calcium gluconate, 142 insertion of line, 146
carboprost oliguria in pre-
uterine atony, 34 eclampsia, 139
cardiac disease, 58 placenta praevia, 130
pre-eclampsia, 137
cardiac murmurs, 59 technique, 137
cardiopulmonary arrest, diabetes mellitus, 153
36, 81 analgesia, 86
caudal analgesia, 91 diazepam, for convulsions,
cervical cerclage, 114, 152 140, 143
chaperone in theatre, 106 diclofenac, 109
Clinical Adverse Event, 41 asthma, 109
coagulopathy in pre-eclampsia, 110,
central nerve block, 53 148
in HELLP syndrome, diuretics
140 in pre-eclampsia, 139
placental abruption, 33 dopamine, 139
co-codamol 30/500, 110 dural tap, 92
co-codamol 8/500, 109 duties of the obstetric
colloid osmotic pressure, anaesthetist, 18
136 eclampsia
combined spinal/epidural anaesthetic technique,
anaesthesia, 113 145
analgesia, 85 anticonvulsant
consent, 60 treatment, 140
for epidural, 61 as cause of collapse,
general, 60 37
emergency measures,
conversion
36
to general anaesthesia,
postoperative care, 147
123
Entonox
convulsions
intraoperative, 123
control of, 140
ephedrine
cord prolapse. See
in pre-eclampsia, 144
umbilical cord prolapse

172 Obstetric Anaesthetists Handbook 3


Index
indication for infusion, external cardiac
115 compression, 37
infusion, 25, 115 external cephalic version,
epidural analgesia and 100, 102
anaesthesia fasting times, 47
bloody tap, 91
feeding, 47
caesarean section, use
for, 118 fentanyl
consent, 61 central nerve block, 22
contraindications, 86 dose in spinal
drug administration, 22 anaesthesia, 116
dural tap, 92 dose limit, epidural, 91
efficacy, 62 dose limit,
extension, 118 subarachnoid, 93
fetal effects, 62 epidural extension, 118
for operative surgery, epidural infusion, 90
117 first dose for epidurals,
in pre-eclampsia, 144 89
indications, 85 intraoperative, 123
information, 64 pruritus, 84
infusion, 90, 144 subarachnoid, 93
infusion, postnatal, 148 fetal scalp
intrathecal placement, blood gases, 170
81 fibreoptic intubating
intravascular laryngoscope, 28
placement, 81 fibroid uterus, 104
long needles, 91 cross-match, 58
missed segment, 91 Syntocinon infusion,
nursing position, 87 108
opioids, 22
fluid therapy
perineal pain, 91
pre-eclampsia, 136
response time, 85
technique, 87 fondaparinux, 52
vertebral canal forceps delivery
haematoma, 51 analgesia, 117
epidural blood patch, 95 fridge
epidural chart, 42, 89 prepared drugs, 24
epidural squeeze, 123 gastric emptying time
postpartum, 151
ergometrine, 107
uterine atony, 34 glyceryl trinitrate, 100
etomidate, 130 granisetron, 109, 125
Gutsche’s sign, 95

Obstetric Anaesthetists Handbook 3 173


Index
H2-receptor antagonists, hypotension, 10
47, See ranitidine and central nerve
haemorrhage block, 81, 97, 117
antepartum, 33 pre-eclampsia, 144,
cross-match, 58 145
Syntocinon infusion, total spinal, 98
108 hysterectomy, 34, 130
central nerve block, 52 index list, 42, 43
emergency action, 29
infection
intraoperative, 130 central nerve block, 52
postpartum, 33
prevention of, 107 infection control, 80
handover, 20 intensive care
eclampsia, 147
headache, 95
general indications for,
risk in epidural
150
anaesthesia, 62
pulmonary artery
risk in spinal catheters, 139
anaesthesia, 115
intrauterine death
HELLP syndrome. See
analgesia, 86
pre-eclampsia, severe
coagulation screen, 52
Hemabate
intrauterine growth
uterine atony, 34
retardation
heparins analgesia, 86
central nerve block, 51 intubation
thromboprophylaxis, 49
awake, 28
high block, 98 difficult, 27
high dependency care failed intubation drill, 26
admissions, 149 ketosis, maternal, 88
discharge, 150
keys, 20
handover, 20
severe pre-eclampsia, labetalol, 135, 146, 147
134, 147 contraindications, 136
hydralazine, 135, 146 lead assessor, 15, 46
synergism with lead clinician, 15, 18
labetalol, 136 lignocaine
hypertension, malignant, epidural extension, 118
139 missed segment, 91
hypoglycaemia test dose for epidurals,
diabetes, 154 88
HELLP syndrome, 141 locum anaesthetists, 16
magnesium sulphate
174 Obstetric Anaesthetists Handbook 3
Index
administration, 141 naloxone, 84
indication, 140 nifedipine, 135, 147
severe pre-eclampsia, tocolysis, 100
139
NSAIDs
tocolysis, 101 asthma, 109
toxicity, 142
central nerve block, 51
Mallampati assessment, postoperative
28 analgesia, 109
manual removal of OAA booklet for mothers,
placenta 66
required block, 115,
Obstetric Anaesthesia
151 Procedure Record, 42
mask, 80
occipito-posterior
McDonald’s suture. See presentation, 102
cervical cerclage
oliguria
methyldopa, 135 criteria, 136
metoclopramide haemorrhage, 31
epidural extension, 119 pre-eclampsia, 138
spinal anaesthesia, 115 Operating Department
use as premedication, Practitioners, 16
57 opioids
midazolam antacid policy, 47
intraoperative, 123 efficacy in labour, 22
postoperative, 126 parenteral, 22
monitoring during postoperative
anaesthesia, 113 analgesia, 110
morphine oxygen
infusion, 148 postoperative, 126
intraoperative, 125 oxytocic drugs, 34
postoperative, 109, pain clinic review, 95
110, 126
pulmonary oedema, paracetamol, 109
139 PCA, 22, 148
MRI scans, 54 placenta accreta, 127
multiple pregnancy, 103 placenta praevia, 127
analgesia, 85 anaesthetic
cross-match, 58 management, 128
Syntocinon infusion, classification, 128
108 contraindicated
murmurs, 59 technique, 86, 115
cross-match, 58

Obstetric Anaesthetists Handbook 3 175


Index
general anaesthesia, severe
130 anticonvulsant
regional anaesthesia, treatment, 139
129 antihypertensive
Syntocinon infusion, treatment, 135
108 arterial line, 135
placental abruption, 33 diagnosis, 132
central nerve block, 52 HELLP syndrome,
in HELLP syndrome, 140
140 high dependency
placentation, abnormal care, 134, 147
choice of technique, magnesium
sulphate, 140,
104, 151
141
platelet count in CNB monitoring, 134
indications for, 52 Syntocinon infusion,
pre-eclampsia, 52, 144 108
platelet transfusion, 141 vertebral canal
post dural puncture haematoma, 144
headache, 95 pre-eclamptic toxaemia.
postnatal review, 43 See pre-eclampsia
postpartum evacuation, premedication, 57
151 preterm labour, 100
required block, 115 prochlorperazine, 110
pre-eclampsia prolapsed umbilical cord.
anaesthetic technique, See umbilical cord
145 prolapse
central nerve block, 52
propofol
diagnosis, 132
diclofenac, 110 use in pruritus, 84
diuretic use, 139 pruritus, 84
epidural analgesia, pulmonary artery
135, 143 catheters. See
fluid therapy, 136 intensive care
fluids pulmonary capillary wedge
fluid balance, 136 pressure
preload, 144 pre-eclampsia, 136
general anaesthesia in, pulmonary oedema
146
as diagnostic sign, 133
management aims, 133 fluid overload in pre-
oliguria, 136
eclampsia, 137,
postnatal period, 147
138, 144

176 Obstetric Anaesthetists Handbook 3


Index
in HELLP syndrome, after subdural block, 99
140 and difficult airway, 26
indication for intensive caesarean section, use
care, 139 for, 57, 104
postpartum, 147 caesarean section, use
pre-eclampsia, 136 in, 113
Quickmix contraindications, 114
composition, 118 in continuing
ranitidine. See H2-receptor pregnancy, 152
in emergency, 106
antagonists
postnatal in pre- in labour, 85
indications, 114
eclampsia, 148
pre-eclampsia, use in,
premedication
prescription, 57 145, 146
repeating, 122
records, 41 replacing epidural, 122
renal failure technique, 115
indication for intensive vertebral canal
care, 139 haematoma, 51
transient oliguria, 136 stockings, graduated
response times compression, 49
epidural analgesia, 85 subarachnoid catheter, 93
immediate caesarean
subdural block, 99
section, 115
retained placenta, 151 supine hypotension, 103
retained placenta, 100, surgical airway. See
151 airway, surgical
salbutamol, 100 Syntocinon
bolus for operative
scar dehiscence, 115
delivery, 107, 125
Shirodkar suture. See postoperative infusion,
cervical cerclage 108
sickle cell disease uterine atony, 34
analgesia, 86 Syntometrine, 107
fluids, 88 prophylaxis, 34
sodium citrate terbutaline, 100, 107
administration, 48
theatres, operating, 24
premedication
prescription, 57 thiopentone
spinal use in convulsions, 140
analgesia, 85 thrombocytopenia, 53
spinal anaesthesia

Obstetric Anaesthetists Handbook 3 177


Index
thrombophilic disorders, urate levels, 133
51 urine output
thromboprophylaxis pre-eclampsia, 137
and central nerve uterine atony, 34
block, 51 uterine displacement, 10
postnatal in pre-
in caesarean section,
eclampsia, 148 107
tocolytic drugs, 100 in external cardiac
total spinal block, 98 compression, 37
as cause of collapse, uterine inversion, 35
37 uterine relaxation, 100
transfer methods, 151
leaving delivery suite, uterine rupture, 35
19
cross-match, 58
trial of assisted delivery
vaginal breech delivery,
clinical record, 41
102
epidural method, 117
required block, 115 ventouse delivery
sodium citrate, 48 analgesia, 117
twins. See multiple vertebral canal
pregnancy haematoma, 51
umbilical cord prolapse, 35

178 Obstetric Anaesthetists Handbook 3


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