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?

• 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?

• 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 (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.