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Obstetrics - Coggle Diagram

- - - - Raised PVR, R heart failure, hypoxia
      - Direct myocardial depression (humeral factors + hypoxia)
      - Left heart failure, pul oedema, hypotension, ARDS
  - - - Fetal tissue/AF forced into maternal circulation causing transient pulmonary vasospasm
    - - Biochem mediators in amniotic fluid trigger anaphylactoid reaction
- - - - Contraindications (Haem)
        
        Raised WCC/maternal sepsis
        
        Deranged coagulation
        
        Low platelets
        
        ?Severe preeclampsia/HELLP
- - - - 24h urinary protein > 300mg or Urine protein:creatinine ratio (PCR) >30mg/mmol
  - - - NBM and give antacid
    - - Access
      - IV antiHTN to target BP <150/100
        
        1st line IV or PO labetalol
        
        2nd line IV hydralazine
        
        3rd line PO nifedipine
      - Regular BP check/ Aline
    - - ?Pul oedema, assess sats & RR. O2 if low sats
      - ?Fluid restrict to 1ml/kg/h (Max 80ml/h)
    - - FBC, platelet count & coag screen
    - - Assess hyper reflexia, headache, vision
        
        Consider Mg (4g loading + 1g/h infusion) if present or significant proteinuria
        
        Monitor deep tendon relfexes (loss ~= 10mmol/L concentration)
    - - Urine PCR and dip, monitor u/o & U&Es
    - - Assessment of airway and suitable plan made early
      - Assess for voice change, hoarseness, swelling - larygeal oedema will make intubation harder
    - - Monitor transaminases and bilirubin
    - - Continuous CTG
      - Uric acid - marker of severity
      - Plan for delivery - cure is removal of placenta
  - - - Limit fluid to 80ml/h - unless matching loss
      - Higher PEEP to maintain O2 may be required
    - - Atony due to GA - ergometrine contraindicated due to HTN it can cause
    - - Adequate pain relief before waking - TAP blocks + morphine
      - Mg use will prolong NMB - check with nerve stimulator
    - - Consider A line
      - Short acting opioid to minimise symp response (alfentanil 10mcg/kg)
      - ?Labetalol to reduce pressor repsonse to extubation 10-20mg IV
    - - More likely difficult and higher risk of awareness
      - Airway oedema can worsen over course of surgery so deflate cuff and check for leak prior to extubation
    - - Avoid NSAIDs
- - - - Known dural puncture/difficult epidural/junior anaesthetist
      - Fronto-occipital headache, worse standing, better lying flat
      - Assoc Sx - Neck stiff, tinnitus, hypacusia, photophobia, nausea
    - - R/o other causes
      - Temp normal
      - CVS normal
      - Neuro - CN abnormality - CNs II, III, IV, VI, VII
      - Leak @ puncture site
  - - - Meningitis
      - Sinusitis
      - Encephalitis
    - - Dehydration
      - Caffiene withdrawal
    - - Migraine
      - Cerebral vein thrombosis
      - Cerebral infarction
      - SAH
      - Posterior reversible leukoencephalopathy syndrome
    - - Primary or Secondary
    - - Tension headache
      - Benign intracranial HTN
      - Pneumocephalus
    - - Features of infection
      - Features of pre-eclampsia
  - - - Adequate oral/IV hydration
      - Stool softeners
      - Antiemetics
      - Encourage mobilisation
      - Simple analgesia - PCM & NSAIDs
      - Regular r/v and assessment of Sx and function
    - - Pt afebrile, >24h since epidural, other causes ruled out
      - Consent - back bruise, backache, PDPH, nerve damage, infection, seizure, failure to Rx headache 30-40%
      - 2 anaesthetists, ideally 1 consultant
      - Theatre, full asepsis
      - Target @ or space below prev epidural
      - 30ml blood withdrawn
      - Give up to 30ml blood into epidural space via Tuohy
      - Flush Tuohy with saline
      - Pt flat for 2h, no heavy lifting/straining for 2/52. Written discharge summary
- - - - Infective endocarditis
      - Degenerative calcification
      - Rheumatic fever
  - - - Fixed LA output cannot cope
        
        Pulmonary oedema
        
        Stretch predisposes to AF
    - - Shorter diastole time and flow time across stenosed valve
    - - Cannot be done with a stenosed valve
        
        Reduced ET, dyspnoea and cyanosis
    - - Reduces coronary artery perfusion and risk of ischaemia
  - - - A&B
        
        O2
        
        Avoid N2O and hypoxia (can increase PVR)
        
        Sats monitoring
      - C
        
        Aline
        
        ECG
        
        Blood loss monitoring
        
        Cautious IVF
        
        L tilt for venous return
      - Pharm
        
        Syntocin infusion rather than bolus to avoid tachycardia and vasodilation
      - D
        
        Early epidural to avoid symp driven HR increase (cautious top ups)
      - Obstetric
        
        Fetal monitoring
        
        ?Instrumental second stage to avoid maternal effort
    - - C
        
        Aline
        
        Replace blood with blood
        
        L tilt, IVF, monitor for effects of auto-transfusion
      - D
        
        Optimum anaesthesia is slow epidural top up, CSE or spinal catheter
      - A&B
        
        O2, sats, avoid N2O
      - Pharm
        
        If GA - ensure opiate at induction
        
        Phenylepherine infusion
        
        Avoid tachycardia drugs
        
        Short acting B-blockers as needed
      - Obstetric
        
        Early consideration of haemorrhage management
- - - - Leads to uterine vasoconstriction, poor perfusion and left shift of maternal ODC
    - - 10% in first trimester
      - 3-8w teratogens can affect organogenesis
      - 5% overall
    - - Failure in airway/ventilation leads to uterinoplacental constriction and fetal myocardial depression
  - - - RSI after antacid, extubate sitting up
      - Ventialtion targeted to ETCO2 and O2 sats
    - - L lateral tilt, good filling, maintain BP
      - Adequate analgesia to minimise catecholamine release
    - - Shortest anaesthesia duration possible
      - Avoid GA if possible
    - - D/w neonatologist if fetus viable (>24w)
      - D/w obs team - tocolysis and steroids for fetal lung maturation
- - - - Increased tongue size
      - Pharyngeal/laryngeal oedema
      - Increased breast size
      - Obesity
      - Increased fatty tissue
      - Active labour can cause difficulty with pre-oxygenation co-operation
    - - Anaesthetist - commonly junior & OOH
      - Team - minimal planning, poor communication, failure to warn & assist
    - - Intra-op challenge of converting RA to GA
      - Urgency causing failure of
        
        Premedicate with antacid
        
        Position correctly
        
        Starve patient
        
        Assess alternative anaesthetic modes
        
        Assess airway
      - Site of theatre is often isolated
  - - - Ensure adequate airway trolley & other equipment available
      - Staff training & simulations
      - Establish personnel bleep list for urgent CSs
      - MDT protocols for antenatal assessment and planning with pathways
      - Labour ward near to theatre complex
      - Guidance for effective staff handovers for at risk patients in the hospital
    - - Inpatient assessment of antepartum high risk patients
      - Junior -> Senior discussion about high risk patients
      - OP antenatal anaesthetic assessment of high risk patients
      - Regular ranitidine
      - Difficult patients d/w associated staff members
      - Assessment of epidural efficacy if in situ
    - - Equipment ready (inc difficult airway kit)
      - Optimium patient positioning (inc L tilt)
      - Team breif of airway plan
      - Pre-oxygenation, cricoid (only removed once cuff up and tube confirmed)
      - Planned day time delivery if possible
    - - Trained recovery staff
      - Awareness of opioid impact post op
      - Same care with extubation as intubation (?empty stomach with OG tube)
- - - - Hx of difficult airway
      - Airway assessment
      - Hx of anaesthetic issues
    - - OSA
      - Dyspnoea/asthma
      - Check sats while supine @ auscultate
    - - Hx of DM/GDM & r/v medication & glucose control
    - - Assess ET
      - Hx of IHD
      - BP & access
    - - Medication Hx
      - ?LMWH
    - - GORD
    - - Any issues?
    - - Weight, positioning
- - - - Room temp blood - reduces hypothermia
      - Often accepted by Jehovah's witnesses
      - Good value - costs about same as 1 unit of blood
      - Useful if atypical antibodies with difficult Xmatch
      - Avoid risk of allogenic transfusion (ABO, viral/bacterial/prion transmission, blood errors)
      - Normal 2,3 DPG so good O carrying capacity
    - - Risk of electrolyte imbalance
      - No platelets or coag factors so wont help haemorrhage
      - Risk of bacterial contamination
      - Red cell lysis due to suction
      - Staff training required
      - High cost per use if not used frequently in centres
      - Air embolism
      - If Rh+ve baby and Rh-ve mum, risk of alloimmunisation
        
        Ensure anti-D given
      - Leucodepletion filter can cause release of vasoactive substances & -> hypotension
      - Slow flow through leucodepletion filter
      - Volume overload
- - - - T4 to cold
      - T5 to light touch
      - S5 bilaterally - loss of sensation for catheter insertion, S2 sole of foot
      - Motor Bromage 3 (cant flex knees) or 4 (unable to move legs)
    - - Positioning
        
        Flex hips
        
        Cautious head down
        
        Unilateral roll if unilateral
      - Epidural
      - Repeat spinal - consider overall dose when doing this
      - ?convert to GA
    - - Ask obs team to stop surgery
      - Describe sensations - reassurance
      - Post op
        
        Ensure adequate post op analgesia
        
        Document experience
      - Pain relief
        
        If just started - consider repeat spinal (lateral)
        
        Entonox
        
        Alfentanil 250mcg aliquots
        
        Ketamine 5-10mg boli
        
        LA by surgeons
        
        GA
      - Ask for careful tissue handling, avoid exteriorisation of uterus if possible
    - - Symptoms
        
        DiB/difficulty speaking
        
        Anxiety, feeling faint
        
        Nausea & vomiting
        
        Tingling/weakness of arms or hands
      - Signs
        
        CVS instability - bradycardia and hypotension
        
        Objective weakness of hands, then arms, then shoulders
        
        Decreased resp effort, reduced saturations, weak cough
        
        Sedation