Obstetric Anaesthesia and Analgesia
OA_1.3 Describe the circulatory and respiratory changes that occur in the transition from foetus to neonate at birth
Circulatory and Respiratory Changes in the Transition from Foetus to Neonate
At birth, the neonate undergoes significant physiological changes to transition from placental to pulmonary gas exchange. These changes involve complex adaptations in the circulatory and respiratory systems.
Respiratory Changes
Initiation of Breathing:
Mechanical Stimuli: Compression of the thorax during vaginal delivery expels fluid from the lungs. Recoil upon delivery allows air entry.
Chemical Stimuli: Hypoxia, hypercapnia, and acidosis during labour stimulate the respiratory centre in the medulla.
Thermal and Sensory Stimuli: Cold exposure and tactile stimulation further promote initial breaths.
Clearance of Lung Fluid:
Fluid in the fetal lungs is absorbed by the pulmonary lymphatics and circulation.
Aeration reduces pulmonary vascular resistance (PVR), allowing alveoli to fill with air.
Surfactant Production:
Surfactant reduces alveolar surface tension, preventing atelectasis and facilitating effective gas exchange.
Circulatory Changes
Increased Pulmonary Blood Flow:
Aeration of the lungs decreases PVR.
Increased pulmonary blood flow enhances oxygen uptake and carbon dioxide clearance.
Closure of Fetal Shunts:
Foramen Ovale:
Increased left atrial pressure (due to pulmonary venous return) and decreased right atrial pressure (due to reduced umbilical venous return) cause functional closure.
Anatomical closure typically occurs within weeks to months.
Ductus Arteriosus:
Oxygen exposure and decreased prostaglandins (from placental removal) promote ductal constriction.
Functional closure occurs within hours; anatomical closure follows within days.
Ductus Venosus:
Ceases to function after cord clamping, directing portal blood flow to the liver.
Switch from Parallel to Series Circulation:
Fetal circulation operates as parallel circuits (oxygenated and deoxygenated blood mix).
Postnatally, the circulatory system transitions to a series circuit with complete separation of oxygenated and deoxygenated blood.
Key Hemodynamic Changes
Increased Systemic Vascular Resistance (SVR):
Clamping the umbilical cord eliminates low-resistance placental circulation, raising SVR.
Reduction in Right-Sided Pressures:
Decreased venous return from the placenta and reduced PVR lower right atrial and right ventricular pressures.
Summary
Respiratory Transition: Initiation of breathing, lung fluid clearance, and surfactant production enable pulmonary gas exchange.
Circulatory Transition: Closure of fetal shunts, increased pulmonary blood flow, and shift to series circulation establish effective systemic and pulmonary circulation.
These adaptations are critical for survival outside the womb, ensuring oxygenation and perfusion of neonatal tissues.
OA_1.6 Describe the special considerations for the pre anaesthetic consultation in pregnant patients
Special Considerations for the Pre-Anaesthetic Consultation in Pregnant Patients
Pregnancy introduces unique physiological, pharmacological, and anatomical changes that necessitate tailored anaesthetic planning. A thorough pre-anaesthetic consultation focuses on maternal and fetal safety while addressing the specific needs of the patient and procedure.
1. Patient History
Obstetric History:
Current gestation, obstetric complications (e.g., preeclampsia, gestational diabetes, placenta previa), and fetal status.
Previous pregnancies, mode of delivery, and anaesthetic history (including complications like failed epidurals or difficult intubation).
Medical History:
Chronic conditions (e.g., hypertension, asthma, cardiac disease) and their impact during pregnancy.
Venous thromboembolism (VTE) risk factors, including thrombophilia or history of DVT/PE.
Surgical History:
Previous abdominal/pelvic surgeries or scars impacting anaesthetic or surgical plans.
Medication and Allergies:
Current medications, including supplements and anticoagulants (e.g., low-molecular-weight heparin).
Review teratogenic risks and timing of anticoagulant cessation for neuraxial anaesthesia.
2. Physical Examination
Airway Assessment:
Pregnancy-associated oedema, weight gain, and hormonal changes can increase the risk of a difficult airway.
Assess Mallampati score, thyromental distance, and neck mobility.
Cardiorespiratory System:
Evaluate for signs of pregnancy-induced hypertension or pulmonary oedema.
Assess baseline oxygen saturation and cardiac function if high-risk.
Venous Access:
Identify potential challenges in establishing IV access due to oedema.
Abdominal and Neurological Examination:
Note fundal height for uterine size and assess for neurological deficits that may affect neuraxial techniques.
3. Physiological and Pharmacological Considerations
Increased Risk of Aspiration:
Gastric emptying is delayed; consider aspiration prophylaxis (ranitidine, sodium citrate, metoclopramide).
Altered Pharmacokinetics:
Reduced plasma protein binding and increased renal clearance can affect drug metabolism and dosing.
Hypercoagulable State:
Pregnancy increases VTE risk, influencing regional anaesthesia decisions.
4. Fetal Considerations
Fetal Well-Being:
Collaborate with obstetricians to ensure adequate fetal monitoring if indicated.
Teratogenic Risk:
Avoid or minimize exposure to teratogenic drugs, especially during the first trimester.
5. Planning Anaesthesia
Type of Anaesthesia:
Prioritise neuraxial techniques where feasible to avoid general anaesthesia risks.
Positioning:
Plan for left uterine displacement during procedures to avoid aortocaval compression.
Postoperative Care:
Discuss pain management strategies, balancing maternal comfort with fetal safety.
6. Communication and Consent
Risk Discussion:
Explain procedure-specific risks, including aspiration, difficult airway, and impact on fetal health.
Informed Consent:
Ensure the patient understands anaesthetic choices and associated risks.
7. Multidisciplinary Collaboration
Coordinate with obstetricians, midwives, and neonatologists for comprehensive care.
Summary
The pre-anaesthetic consultation for pregnant patients requires a detailed history, careful examination, and planning that accounts for maternal-fetal physiology. Special attention to airway management, aspiration risk, and fetal monitoring is essential to optimise outcomes for both mother and baby.
OA_1.10 Discuss the role of epidural, spinal, and combined spinal epidural block for caesarean birth
Role of Epidural, Spinal, and Combined Spinal-Epidural (CSE) Block for Caesarean Birth
Regional anaesthesia is the preferred approach for caesarean birth, offering effective analgesia and anaesthesia while minimising risks associated with general anaesthesia. The choice among epidural, spinal, and combined spinal-epidural (CSE) depends on clinical scenarios, patient factors, and anaesthetist expertise.
1. Epidural Block
Description: A catheter is placed in the epidural space, allowing the administration of local anaesthetics and/or opioids.
Indications:
Planned caesarean births where the patient already has an epidural in place for labour.
High-risk pregnancies requiring titratable and prolonged anaesthesia.
Advantages:
Flexibility: Dose adjustments provide controlled, gradual onset of anaesthesia.
Extended Use: Catheter facilitates prolonged anaesthesia or postoperative analgesia.
Stable Haemodynamics: Gradual onset minimises the risk of sudden hypotension.
Disadvantages:
Slower Onset: May take 10–20 minutes to achieve full block.
Inadequate Block: Risk of patchy or incomplete anaesthesia.
Technical Challenges: Higher failure rates compared to spinal anaesthesia.
2. Spinal Block
Description: A single injection of local anaesthetic, often combined with opioids, into the subarachnoid space.
Indications:
Elective caesarean births requiring rapid onset of anaesthesia.
Situations where prolonged duration is not anticipated.
Advantages:
Rapid Onset: Complete anaesthesia within 3–5 minutes.
High Reliability: Predictable and dense sensory and motor block.
Minimal Equipment: No catheter placement required.
Disadvantages:
Finite Duration: Limited by the single dose of local anaesthetic.
Risk of Hypotension: Sudden sympathetic blockade may cause significant hypotension.
Post-Dural Puncture Headache (PDPH): Associated with dural puncture.
3. Combined Spinal-Epidural (CSE) Block
Description: A combination of spinal and epidural techniques, where a spinal injection is administered, and an epidural catheter is placed for extended use.
Indications:
Elective or emergency caesarean births where rapid onset and prolonged anaesthesia are required.
Patients at risk of prolonged surgery or with uncertain surgical duration.
Advantages:
Rapid Onset: Spinal component provides immediate anaesthesia.
Flexibility: Epidural catheter allows extension of anaesthesia or postoperative analgesia.
Versatility: Useful for managing prolonged or complex surgeries.
Disadvantages:
Technical Complexity: Requires expertise in placement and carries risks of both techniques.
Potential for Catheter Failure: Epidural catheter may not always function as intended.
Dual Risks: Combines risks of spinal (e.g., hypotension) and epidural (e.g., inadequate block).
Comparative Considerations
Summary
Spinal anaesthesia is ideal for most elective caesarean births due to its rapid, reliable onset.
Epidural anaesthesia is preferred when flexibility and prolonged duration are required, such as for patients already in labour or those at higher risk of hypotension.
CSE block combines the advantages of both techniques, making it suitable for situations requiring rapid onset and prolonged anaesthesia or analgesia.
Selection should consider maternal, fetal, and surgical factors to optimise safety and efficacy.
OA_1.11 Discuss the management of complications of neuraxial analgesia and anaesthesia in childbirth
Management of Complications of Neuraxial Analgesia and Anaesthesia in Childbirth
Neuraxial techniques, including epidural and spinal anaesthesia, are widely used in childbirth for labour analgesia and caesarean anaesthesia. While generally safe, complications can occur, requiring prompt recognition and management to ensure maternal and fetal safety.
1. Hypotension
Cause: Sympathetic blockade leads to vasodilation and reduced venous return.
Recognition:
Maternal hypotension (systolic BP < 100 mmHg or >20% drop from baseline).
Symptoms include nausea, dizziness, or fetal bradycardia on CTG.
Management:
Immediate: Left lateral tilt to relieve aortocaval compression.
Fluid resuscitation with crystalloid or colloid boluses.
Vasopressors: Administer phenylephrine or ephedrine.
Monitor maternal BP and fetal heart rate closely.
2. High or Total Spinal Block
Cause: Excessive spread of local anaesthetic into the thoracic or cervical spinal cord.
Recognition:
Sudden difficulty breathing, hypotension, or loss of consciousness.
Bradycardia or paralysis.
Management:
Immediate airway support: Administer oxygen; intubate if necessary.
Cardiovascular support: Treat hypotension with fluids and vasopressors.
Rapid escalation to advanced life support if cardiac arrest occurs.
3. Post-Dural Puncture Headache (PDPH)
Cause: Dural puncture with CSF leakage reduces intracranial pressure.
Recognition:
Severe headache worsened by sitting or standing, relieved by lying flat.
May include nausea, tinnitus, or neck stiffness.
Management:
Conservative: Hydration, caffeine, and simple analgesics.
Definitive: Epidural blood patch (15–20 mL autologous blood injected into the epidural space).
4. Neurological Injury
Cause: Direct trauma, haematoma, infection, or ischaemia.
Recognition:
Persistent paraesthesia, motor weakness, or loss of bladder/bowel control.
Management:
Urgent neurology/neurosurgery consultation.
MRI or CT to assess for haematoma or other structural issues.
If haematoma is confirmed, urgent decompression may be required.
5. Local Anaesthetic Systemic Toxicity (LAST)
Cause: Accidental intravascular injection of local anaesthetic.
Recognition:
Early signs: Tinnitus, metallic taste, circumoral numbness, agitation.
Progression to seizures, arrhythmias, or cardiac arrest.
Management:
Immediate cessation of local anaesthetic administration.
Airway management and oxygenation.
Treat seizures with benzodiazepines (e.g., midazolam).
Administer intravenous lipid emulsion (20%) as per LAST protocols.
Advanced cardiac life support if required.
6. Epidural Haematoma
Cause: Bleeding into the epidural space, often related to coagulopathy or traumatic placement.
Recognition:
Severe back pain, motor/sensory deficits, or urinary retention.
Onset may be delayed hours to days.
Management:
Urgent MRI or CT for diagnosis.
Emergency surgical decompression if confirmed.
7. Epidural Abscess
Cause: Infection introduced during catheter placement.
Recognition:
Fever, back pain, neurological deficits.
Symptoms may develop over days.
Management:
Blood cultures and MRI for diagnosis.
Broad-spectrum antibiotics.
Surgical drainage if neurological compromise occurs.
8. Inadequate or Failed Block
Cause: Incorrect catheter placement or anatomical variations.
Recognition:
Insufficient pain relief or patchy block.
Management:
Adjust catheter position or administer additional boluses.
Consider converting to general anaesthesia if failure persists during caesarean delivery.
Summary
Management of neuraxial complications requires timely recognition, maternal support, and targeted interventions. Regular monitoring during and after neuraxial anaesthesia is essential to detect complications early. A multidisciplinary approach involving anaesthetists, obstetricians, and other specialists ensures optimal maternal and fetal outcomes.
OA_1.12 Discuss the management of suboptimal neuraxial block including conversion to general anaesthesia for caesarean birth
Management of Suboptimal Neuraxial Block for Caesarean Birth
Suboptimal neuraxial blocks during caesarean birth require timely recognition and effective management to ensure patient safety and comfort while minimizing risks. The approach depends on the type of neuraxial block (epidural, spinal, or combined spinal-epidural), the timing of the issue, and the clinical scenario (elective vs. emergency caesarean birth).
1. Recognition of a Suboptimal Block
Signs and Symptoms:
Inadequate Analgesia: Pain during surgical incision or manipulation.
Patchy Block: Areas of inadequate sensory block.
Inadequate Level: Block does not extend to the required dermatome (usually T4 for caesarean).
Inadequate Motor Block: Partial paralysis leading to surgical difficulties.
2. Initial Management
A. Assess the Block
Verify the dermatomal level using ice or pinprick tests.
Evaluate the density of the block (sensory and motor).
Identify the underlying issue (e.g., technical placement, insufficient dose, anatomical factors).
B. Optimisation of the Block
Epidural Block:
Administer an additional bolus of local anaesthetic through the epidural catheter (e.g., 10–15 mL of 0.5% bupivacaine).
Adjust the catheter if malposition is suspected (e.g., pull back slightly).
Consider adding opioids or adjuncts (e.g., fentanyl, adrenaline).
Spinal Block:
For inadequate block height, administer a small top-up dose of local anaesthetic via a CSE catheter if placed.
In case of unilateral or patchy block, reposition the patient to redistribute the local anaesthetic.
CSE Block:
Use the epidural catheter for additional dosing to supplement the spinal block.
C. Pain Management During Optimisation
Administer intravenous opioids (e.g., fentanyl or morphine).
Consider nitrous oxide or ketamine as temporary adjuncts if the patient remains uncomfortable.
3. Conversion to General Anaesthesia
If the block remains inadequate or time-critical intervention is required (e.g., emergency caesarean for fetal distress):
A. Indications for Conversion
Persistent pain despite optimisation efforts.
High-risk or time-critical cases where neuraxial block augmentation is not feasible.
B. Preparation for General Anaesthesia
Maternal Communication:
Explain the need for conversion and obtain verbal consent.
Provide reassurance about the safety of general anaesthesia.
Equipment and Monitoring:
Ensure all equipment for rapid sequence induction (RSI) is ready.
Confirm availability of airway adjuncts and emergency medications.
Continue fetal monitoring until induction.
C. Induction Technique
Perform rapid sequence induction (RSI):
Preoxygenation for 3–5 minutes.
Induction with thiopentone or propofol and succinylcholine.
Apply cricoid pressure during intubation to reduce the risk of aspiration.
Confirm endotracheal tube placement with capnography.
Maintain anaesthesia with volatile agents and/or intravenous drugs.
D. Intraoperative Management
Monitor for uterine relaxation caused by volatile agents; mitigate with oxytocics as needed.
Provide adequate analgesia with opioids (e.g., fentanyl, morphine).
Monitor maternal hemodynamics closely.
4. Postoperative Care
Address any residual pain with multimodal analgesia (e.g., opioids, NSAIDs, and paracetamol).
Monitor for potential complications of general anaesthesia, such as aspiration or delayed emergence.
Provide clear documentation of the events and reasons for conversion to general anaesthesia.
Summary
Management of a suboptimal neuraxial block involves prompt assessment, efforts to optimise the block, and effective pain management. Conversion to general anaesthesia should be reserved for cases where the block cannot be rectified or urgent delivery is required. A structured and team-based approach ensures maternal and fetal safety while maintaining patient comfort and dignity.
OA_1.13 Discuss the considerations in providing general anaesthesia for elective and emergency caesarean birth
Considerations in Providing General Anaesthesia for Elective and Emergency Caesarean Birth
General anaesthesia (GA) for caesarean birth requires meticulous planning and adaptation to specific maternal and fetal needs. The considerations differ based on whether the procedure is elective or emergency, with maternal safety and optimal fetal outcomes being the primary goals.
1. Preoperative Considerations
Maternal History and Assessment
Airway Evaluation: Pregnant patients are at increased risk of difficult airway due to anatomical changes (e.g., weight gain, edema, and breast enlargement).
Co-Morbidities: Assess for conditions like preeclampsia, obesity, or cardiopulmonary disease.
Aspiration Risk: Pregnant patients have delayed gastric emptying and increased intra-abdominal pressure, raising the risk of aspiration.
Preparation
Fasting Status: Elective patients are typically fasted; emergency cases may require modified rapid sequence induction.
Antacid Prophylaxis: Administer ranitidine, sodium citrate, or proton pump inhibitors to reduce aspiration risk.
Plan for Airway Management: Ensure availability of experienced personnel and advanced airway equipment.
2. Intraoperative Considerations
Induction
Elective Cases: Adequate time for preoxygenation (3–5 minutes).
Emergency Cases: Rapid sequence induction (RSI) with cricoid pressure to minimize aspiration risk. Use agents like thiopentone or propofol for induction and succinylcholine for muscle relaxation.
Airway Management
Prioritize quick and secure intubation.
Be prepared for a difficult airway, with adjuncts (e.g., video laryngoscopes, supraglottic airways) readily available.
Anaesthetic Maintenance
Volatile Agents: Use agents like sevoflurane or desflurane for maintenance while avoiding excessive uterine relaxation.
Analgesia: Provide multimodal analgesia (e.g., IV opioids, ketamine, and adjuncts).
Neuromuscular Blockade: Use short-acting agents to allow rapid recovery.
Maternal Monitoring
Maintain maternal hemodynamics with fluid management and vasopressors (e.g., phenylephrine, ephedrine).
Monitor oxygenation and ventilation closely.
Fetal Considerations
Minimize the interval between induction and delivery to reduce fetal exposure to anaesthetic agents.
Apgar scores and immediate neonatal resuscitation may be required if GA impacts fetal wellbeing.
3. Emergency vs. Elective Differences
Emergency Caesarean Birth
Time-Critical Nature: Faster induction and potentially less time for preoxygenation.
Increased Risk of Aspiration: Due to lack of fasting and urgency of the situation.
Hemodynamic Instability: Preeclampsia, bleeding, or placental abruption may complicate management.
Elective Caesarean Birth
Predictable Environment: More time for preparation, including thorough airway assessment and patient optimization.
Lower Stress Environment: Easier to follow protocols and ensure maternal comfort.
4. Postoperative Considerations
Maternal Care
Monitor for residual neuromuscular blockade, hypoventilation, or aspiration pneumonia.
Pain management with a multimodal approach, including regional techniques if feasible (e.g., TAP block).
Provide psychological support, as some patients may feel distressed by the need for GA.
Neonatal Care
Ensure the neonate is assessed by the pediatric team immediately post-delivery.
Be prepared for resuscitation, especially in cases with prolonged induction-to-delivery intervals.
5. Summary of Challenges and Mitigation Strategies
Aspiration Risk: Mitigate with fasting, antacids, and RSI.
Difficult Airway: Prepare for challenges with appropriate equipment and expertise.
Uterine Atony: Avoid high volatile concentrations and use uterotonic agents.
Hemodynamic Instability: Monitor and treat promptly with fluids, vasopressors, and transfusions as needed.
Conclusion
Providing GA for caesarean birth requires balancing maternal and fetal safety, with meticulous planning in elective cases and rapid decision-making in emergencies. Understanding the physiological changes of pregnancy and the potential complications ensures effective and safe anaesthesia management.
OA_1.14 Discuss the assessment and management of patients with pre-eclampsia requiring analgesia and anaesthesia input for labour and delivery
Assessment and Management of Patients with Pre-Eclampsia Requiring Analgesia and Anaesthesia for Labour and Delivery
Pre-eclampsia is a multisystem disorder that presents unique challenges in the provision of analgesia and anaesthesia. Careful assessment and tailored management strategies are essential to optimize maternal and fetal outcomes.
1. Clinical Features of Pre-Eclampsia
Hypertension: BP ≥ 140/90 mmHg (severe ≥ 160/110 mmHg).
Proteinuria: ≥ 0.3 g/24 hours or protein/creatinine ratio > 30 mg/mmol.
End-Organ Dysfunction:
Neurological: Headache, visual disturbances, hyperreflexia, eclampsia.
Hepatic: Elevated transaminases, RUQ/epigastric pain.
Renal: Oliguria, rising creatinine.
Hematological: Thrombocytopenia, coagulopathy, hemolysis (HELLP syndrome).
2. Assessment
A. Maternal Evaluation
Hemodynamic Stability: Monitor blood pressure trends and signs of end-organ damage.
Coagulation Status: Perform a platelet count and coagulation studies to exclude contraindications to neuraxial techniques.
Neurological Status: Rule out eclampsia or impending seizure.
Fluid Balance: Assess for oliguria or fluid overload.
Airway Assessment: Swelling in pre-eclampsia increases the risk of difficult airway.
B. Fetal Evaluation
Monitor fetal heart rate (FHR) and well-being (e.g., Doppler studies for placental insufficiency).
3. Analgesia for Labour
A. Neuraxial Analgesia (Preferred Option)
Advantages:
Superior pain relief and reduction in catecholamine levels, improving uteroplacental perfusion.
Facilitates conversion to anaesthesia if an emergency caesarean is needed.
Precautions:
Platelet count should typically be > 75,000/μL (consult local guidelines).
Administer incremental doses to minimize hemodynamic instability.
Technique: Epidural or combined spinal-epidural (CSE).
B. Alternatives if Neuraxial is Contraindicated
Systemic analgesia with opioids (e.g., fentanyl, remifentanil PCA).
Nitrous oxide may be used but is less effective for severe pain.
4. Anaesthesia for Caesarean Delivery
A. Neuraxial Anaesthesia
Spinal or CSE (Preferred):
Ensure platelet count and coagulation status are adequate.
Use low-dose local anaesthetic to reduce hypotension risk.
Epidural Top-Up: Effective if epidural is already in place.
B. General Anaesthesia (GA)
Reserved for contraindications to neuraxial block (e.g., coagulopathy, severe thrombocytopenia).
Considerations for GA:
Difficult airway due to edema; ensure availability of advanced airway equipment.
Rapid sequence induction to minimize aspiration risk.
Avoid exaggerated hypertension during laryngoscopy; use agents like labetalol or esmolol.
5. Management of Hypertension
Target BP: Maintain systolic BP < 160 mmHg and diastolic BP < 110 mmHg.
First-line agents: Labetalol, hydralazine, or nifedipine.
Avoid excessive lowering of BP to prevent fetal compromise.
6. Seizure Prophylaxis
Magnesium Sulfate: Indicated for severe pre-eclampsia or eclampsia prophylaxis. Monitor for toxicity (loss of deep tendon reflexes, respiratory depression).
Have calcium gluconate available as an antidote.
7. Fluid Management
Avoid fluid overload to prevent pulmonary edema.
Use invasive monitoring (e.g., CVP, arterial line) in severe cases or oliguria.
Maintain a balance between avoiding hypovolemia and ensuring adequate perfusion.
8. Postpartum Considerations
Close monitoring in a high-dependency or ICU setting.
Continue antihypertensives and magnesium sulfate as indicated.
Watch for postpartum complications such as pulmonary edema, worsening hypertension, or eclampsia.
Key Points
Neuraxial techniques are preferred for both labour analgesia and anaesthesia unless contraindicated.
Thorough assessment of coagulation and platelet status is crucial before any neuraxial procedure.
Hypertension management, fluid balance, and seizure prophylaxis are integral components of care.
Tailor the anaesthetic approach to the clinical severity and maternal-fetal needs, with contingency plans for rapid escalation.
OA_1.16 Discuss a general approach to the anaesthetic management of unexpected problems that may arise with labour and delivery, including when they require further investigation, optimisation and further specialist care.
General Approach to Anaesthetic Management of Unexpected Problems in Labour and Delivery
Unexpected issues during labour and delivery require prompt recognition, systematic management, and multidisciplinary collaboration to optimize outcomes for both mother and fetus. Below is a general approach:
1. Initial Assessment and Stabilization
A. Rapid Evaluation
Maternal Assessment:
Vital signs (heart rate, blood pressure, oxygen saturation).
Physical examination (e.g., bleeding, uterine tone, neurological status).
Fetal Assessment:
Continuous fetal heart rate monitoring for signs of distress.
B. Immediate Stabilization
Airway: Ensure airway patency and oxygen supplementation.
Breathing: Assess respiratory function, correct hypoxia.
Circulation: Establish IV access, monitor hemodynamics, and resuscitate as needed.
Disability: Address neurological status (e.g., seizure management).
2. Common Unexpected Problems and Management
A. Maternal Hypotension
Causes: Neuraxial block, hemorrhage, or sepsis.
Management:
Left lateral position to avoid aortocaval compression.
Fluid bolus and vasopressors (e.g., phenylephrine, ephedrine).
Investigate underlying causes (e.g., bleeding source).
B. Post-Dural Puncture Headache (PDPH)
Diagnosis: Severe positional headache post-neuraxial block.
Management:
Supportive care: hydration, caffeine.
Epidural blood patch if conservative measures fail.
C. Failed or Inadequate Neuraxial Block
Management:
Reassess and augment the block (e.g., repeat dosing or replacement).
Convert to general anesthesia if required.
D. Unanticipated Hemorrhage
Management:
Identify and treat the source (e.g., uterine atony, trauma, placental abruption).
Administer uterotonics, blood products, and consider surgical intervention.
E. Seizures
Causes: Eclampsia or other neurological conditions.
Management:
Magnesium sulfate for seizure control.
Antihypertensives for blood pressure management.
F. Fetal Compromise
Management:
Optimize maternal oxygenation, position, and circulation.
Expedite delivery if fetal distress persists (e.g., operative vaginal delivery or cesarean).
3. Further Investigation and Optimization
A. Maternal Investigations
Blood tests: FBC, coagulation profile, blood gases.
Imaging: Ultrasound for placental abnormalities or other pathology.
Additional monitoring: ECG or invasive arterial pressure monitoring if needed.
B. Fetal Monitoring
Continuous cardiotocography (CTG) or fetal scalp pH sampling.
C. Optimization
Treat reversible conditions (e.g., hypovolemia, anemia, electrolyte disturbances).
Ensure readiness for immediate delivery, if necessary.
4. Indications for Specialist Care
Refer to a multidisciplinary team or specialized center for:
Complex cardiac, respiratory, or neurological conditions.
Severe preeclampsia/eclampsia requiring ICU care.
Suspected or confirmed placenta accreta spectrum disorders.
Massive hemorrhage requiring interventional radiology or surgical expertise.
5. General Principles for Decision-Making
Teamwork: Engage obstetricians, neonatologists, and intensivists.
Communication: Provide clear, concise updates to the team and patient.
Documentation: Record events, interventions, and outcomes thoroughly.
Maternal and Fetal Safety: Prioritize interventions balancing maternal and fetal risks.
6. Key Considerations for General Anesthesia
Elective vs. Emergency: Consider urgency of the situation.
Aspiration Risk: Rapid sequence induction to minimize aspiration risk.
Uterine Relaxation: Avoid excessive uterine relaxation post-delivery.
7. Psychological Support
Provide reassurance to the patient and involve family members as appropriate.
Offer debriefing post-event to address concerns and improve understanding.
Summary
Early recognition of unexpected problems during labour and delivery is crucial.
A structured approach incorporating stabilization, cause-specific management, and timely referral ensures optimal outcomes.
Multidisciplinary care, communication, and documentation are key pillars of effective management
OA_1.17 Discuss the assessment and management of peri-partum haemorrhage
Assessment and Management of Peripartum Hemorrhage (PPH)
Peripartum hemorrhage, defined as blood loss exceeding 500 mL after vaginal delivery or 1,000 mL after cesarean delivery, is a major cause of maternal morbidity and mortality. Rapid assessment and structured management are critical.
1. Risk Factors
Identify patients at risk:
Antenatal Risk Factors: Placenta previa, placental abruption, multiple gestation, polyhydramnios, coagulopathies, previous PPH.
Intrapartum Risk Factors: Prolonged labor, instrumental delivery, uterine atony, trauma to the birth canal.
2. Initial Assessment
A. Primary Survey (ABCDE Approach)
Airway: Ensure patency and provide supplemental oxygen if necessary.
Breathing: Assess respiratory effort and oxygenation.
Circulation:
Check pulse, blood pressure, and capillary refill.
Establish large-bore IV access for fluid and blood product resuscitation.
Disability: Assess for signs of hypovolemic shock and altered consciousness.
Exposure: Examine for active bleeding sources, uterine tone, and retained placental tissue.
B. Quantification of Blood Loss
Use visual estimation or gravimetric methods for accuracy.
3. Causes of PPH (4 Ts)
Tone: Uterine atony (most common cause).
Trauma: Genital tract tears, uterine rupture, or inversion.
Tissue: Retained placental tissue or invasive placentation.
Thrombin: Coagulopathies (e.g., DIC, HELLP syndrome).
4. Immediate Management
A. Resuscitation
Position the patient flat with legs elevated or in Trendelenburg position.
Administer warmed IV fluids (crystalloid and colloid) to restore circulating volume.
Transfuse blood products as needed (packed red cells, FFP, platelets, cryoprecipitate).
B. Uterotonic Therapy
First-Line: Oxytocin infusion (10-40 units in 1,000 mL crystalloid).
Second-Line:
Ergometrine (contraindicated in hypertensive patients).
Carboprost (caution in asthmatics).
Misoprostol (rectal or sublingual).
5. Cause-Specific Management
Uterine Atony:
Perform uterine massage.
Administer additional uterotonics if required.
Balloon tamponade (e.g., Bakri balloon) if bleeding persists.
Trauma:
Identify and repair genital tract tears or uterine rupture.
Surgical intervention if necessary (e.g., laparotomy).
Tissue:
Manual removal of retained products of conception.
Consider surgical evacuation (D&C) if manual methods fail.
Thrombin:
Correct coagulopathy with targeted blood product therapy.
Use tranexamic acid (1 g IV) early to reduce bleeding.
6. Advanced Interventions
Interventional Radiology: Uterine artery embolization for refractory bleeding.
Surgical Management:
B-Lynch suture or other uterine compression sutures.
Hysterectomy as a life-saving measure in severe cases.
7. Monitoring and Supportive Care
Continuous monitoring of vitals, urine output, and blood loss.
ICU admission for ongoing management if hemodynamically unstable.
Psychological support for the patient and family.
8. Multidisciplinary Approach
Collaboration with obstetricians, anesthetists, hematologists, and interventional radiologists.
9. Prevention Strategies
Active management of the third stage of labor (AMTSL):
Prophylactic uterotonic administration.
Controlled cord traction.
Immediate uterine massage after placental delivery.
Key Points
Early recognition and resuscitation are critical in managing PPH.
A structured approach to identifying and treating the cause (4 Ts) is essential.
Advanced interventions, including surgical and radiological measures, may be necessary for refractory cases.
Multidisciplinary care and preventive measures improve maternal outcomes.
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