2023.1 Day 1 VIVA 7

It is 2pm on a weekday. You are on-call, and the elective list is finished for the day. The oncall obstetrician rings you, informing you of her decision to take Beth into theatre for a LSCS. You were given the following details about Beth:

Background:

  • 40-year-old lady from interstate, G5P4 (2 x vaginal deliveries; 2 x LSCS). Currently 38 weeks gestation

  • Booked for an elective LSCS somewhere else interstate

  • Came to attend a funeral at Scenarioville

  • Presented in labour. 4cm dilated on VE. CTG reassuring.

  • Bedside ultrasound performed today showed a low-lying anterior placenta

  • No previous medical records locally. Patient’s pregnancy handbook unavailable.

  • Had lunch 2 hours ago.

What are your main concerns with this patient? How will you proceed with assessing this patient?

What are your main concerns for this patient?

  • Placenta previa with previous LSCS → high risk of placenta accreta spectrum (PAS).

  • Grand multiparity (G5P4) → increased risk of uterine atony & postpartum haemorrhage (PPH).

  • Unknown antenatal history → unclear surgical complexity, possible undiagnosed comorbidities.

  • Recent meal (2 hours ago) → aspiration risk with general anaesthesia (GA).

  • Uterine rupture risk (previous two LSCS, now in labour).

How would you assess this patient before proceeding? ( 📃Notes)

  • History:

    • Prior LSCS details (e.g., classical or lower segment incision).

    • Obstetric complications in previous pregnancies (PPH, difficult placenta delivery).

    • Personal/family history of anaesthetic complications.

  • Examination:

    • Airway assessment (aspiration risk, suitability for GA).

    • Haemodynamic status (BP, HR, signs of hypovolaemia).

    • Abdominal examination (tenderness, uterine tone).

  • Investigations:

    • Bloods: FBC, G&H, crossmatch (at least 2 units if placenta previa).

    • Ultrasound: Placental location, possible PAS features.

    • IV access: Two large-bore IV cannulas.

Can this case be managed safely in Scenarioville, or should she be transferred?

  • No. To safely manage this the hospital should have:

    • Experienced obstetrician & surgical backup (for PAS management).

    • Blood products available (massive transfusion protocol if needed).

    • High dependency care support (for PPH management).

Blood products, experienced obstetric care are available, but Scenarioville doesn't have dedicated HDU/ICU space. While there are beds with continuous monitoring, this is not the standard of care.

If these are unavailable, urgent transfer to a tertiary centre should be arranged. Measures should be taken to arrest the labour.

How would you consent the patient for anaesthesia?

  • Explain neuraxial vs GA options & risks.

  • Discuss risk of major haemorrhage & possible hysterectomy.

  • Inform about potential need for GA conversion & blood transfusion.

  • Document clearly & answer patient’s concerns.

What is your choice of anaesthetic technique and why?

  • Preferred: Spinal anaesthesia (if no contraindications) due to:

    • Reduced aspiration risk compared to GA.

    • Better postoperative pain control.

    • Avoids airway difficulties in an obstetric emergency.

  • Spinal technique modifications for repeat LSCS:

    • Higher dose of hyperbaric bupivacaine (e.g., 2.2-2.5 mL of 0.5% heavy bupivacaine).

    • Fentanyl (15 mcg) + preservative-free morphine (100-150 mcg) for postoperative analgesia.

    • Vasopressor infusion ready (phenylephrine, metaraminol) to manage hypotension.

  • General anaesthesia (GA) if:

    • Haemodynamic instability.

    • Patient refuses spinal.

    • Surgical complexity suggests prolonged duration.

PPH Management

During surgery, the patient develops a >1.5L blood loss with hypotension. What is your immediate management? (📃Notes)

  • Communicate: Declare a PPH emergency, call for help, activate massive transfusion protocol.

  • Resuscitate:

    • Early blood product transfusion (not just crystalloids):

      • PRBCs guided by clinical status (Hb may not yet reflect loss).

      • Fibrinogen replacement (Cryoprecipitate or Fibrinogen concentrate) early.

    • Tranexamic acid (1g IV) ASAP (reduces bleeding, improves survival).

    • Uterotonics:

      • Oxytocin 5-10 IU IV bolus + infusion.

      • If ongoing atony: Carboprost (Hemabate), Ergometrine (avoid in hypertensive patients).

  • Surgical management:

    • Explore uterus for retained products or atony.

    • Consider intrauterine balloon tamponade, B-Lynch suture, or hysterectomy if uncontrolled.

When would you consider converting to GA?

  • If haemodynamic instability persists (hypotension, tachycardia despite resuscitation).

  • If surgical complexity increases (e.g., need for hysterectomy, extensive haemostasis efforts).

  • If patient becomes unresponsive or unable to protect airway.

How would you safely induce GA in a haemodynamically unstable obstetric patient?

  • Prepare for a difficult airway (ramped position, 2-person BMV, extra assistnace if available, suction ready).

  • RSI with cricoid pressure (due to aspiration risk).

  • Ketamine 0.5-1 mg/kg for induction vs Alloquats of 20-40mg propofol (avoid high-dose propofol).

  • Suxamethonium (1-1.5 mg/kg) or Rocuronium (1.2 - 2 mg/kg) for paralysis.

  • Titrate fentanyl or alfentanyl cautiously (25-50 mcg fentanyl initially) to maintain haemodynamics.

  • Uterotonic Therapy

  • Aggressive haemodynamic support with vasopressors (noradrenaline, metaraminol).

Bonus Question

If the bleeding persists despite all interventions, what are your next steps?

  • Other pharmacological interventions in PPH (Notes📃)

    • Resuscitation

      • Position/Fluids/Blood

      • Optimise clot formation (Avoid acidosis, hypothermia, Hypocalcaeima)

      • Transfuse

    • Uterotonics

      • 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).

  • If refractory bleeding → hysterectomy as a last resort. Prior to this:

    • Surgical Mx (B-Lynch suture or other uterine compression sutures.)

    • Consider retrieval constraints (distances, availability, likelihood of irretrievable deterioration)

    • Patient will require high-level monitoring in and atleast HDU/ICU postoperatively which cannot be done in Scenarioville.

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