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Obstetric Anaesthesia - Coggle Diagram
Obstetric Anaesthesia
Maternal Obstetric Haemorrhage
Severe Maternal Morbidity (SMM)
53% Major obstetric haemorrhage
Major obs haemorrhage (MOH) : Estimated blood loss ≥ 2500ml and / or transfused 5 units of blood
3.38 per 100 maternities
Physiological Changes in Pregnancy in Adapting to Blood Loss
Rise in plasma volume 40-50%
Cardiac output ↑ 25%
Minimising the impact of blood at delivery
Delays classical signs of hypovolaemia
Maternal Haemorrhage Considerations
Loss of RBC and clotting factors
No always apparent - abruption
Tachycardia can be confused with anxiety / normal for pregnancy
Hypotension is a late sign
High index of suspicion and early diagnosis is key
Classes of Hypovolaemic shock
Pillars of Emergency Care
Resus
A / B: Aiway, O2, ventilation
C: circulating volume restoration / blood products
Simultaneous Monitoring & Treatment
Physiological monitoring
Blood investigations
Reassessment
Definitive
Arrest bleeding
Definitive treatment: pharm / surgical
Guidlines
Women at higher risk of PPH should be identified and actively managed at each care oppertunit
Include screening / managment of antenatal anaemia / PPH risk factors
Prevention and Management of Primary Postpartum Haemorrhae Clinical Practive Guidelines
Call for help - code adult emergency
Identify communication lead
Role designation
Clear objectives
Situational awareness - rapidly changing
Effective communication
Stop bleeding
Resus
Contact transfusion lab
Review
Debrief - staff, pt, partner
Pain
The International Association for the
study of Pain (IASP)
an unpleasant sensory and emotional experience associated with, or resembling that associated with, actual or potential tissue damage
Causes of Uterine Pain
Smooth muscle contraction
Ischaemia
Inflammation - remodeling of cervix - dilating
Senstises nerve fibres
Bradykinin
5HT
Substance P
Prostaglandins
Histamine
The Ideal Pain relieving Agent
Provide effective analgesia
Safe for mother and baby
Predictable and constant in effects
Easy to administer
Under the control of the mother
Should not
Interfere with labour and delivery
Interfere with maternal conciousness
Types of Pain Relief
Pharmacological
Inhalational
Entonox
50% nitrous oxide 50% O2
Easily administered
Fast onset and offset
No effect on fetus
Controlled by pt
Disadvantages
Greenhouse gas effect
Lag in demand to peak onset of contraction
Regional Analgesia
Epidural
Benefits
Best mode of pain relief in labour
Pt controlled epidural analalgesia )PCEA)
Minimal effect on fetus
Can be extended to provide anaesthesia if require
Complications / Adverse effects
Hypotension 1:50
Accidental dural puncture 1:100
Nerve damage resolving in 6 months 1:1,000
Nerve damage persisting longer than 6 months 1:13,000
Epidural abcess 1:50,000
Meningitis 1:100,000
Complete spinal blosk leading to unconciousness
Spinal injury / paralysis 1:250,000
Disadvantages
Complications and adverse effects
Informed consent
Requires anaethesiological support - only done in hospital setting
Limits mobility
May prolong labour
May result in increased risk of assisted delivery
Contraindications
Coagulpathy - aquired or congenital
Sepsis
Neurological deficit
Anatomical deformities
Cardiac lesions - stenotic
Spinal
Combined spinal epidural
Opiods
IM pethidine
2.7% of women in labour
Poor analgesic effect
Sedation
N/V
Rapid transfer to fetus
No role in labour ward
IV Remifentanil
Patient controlled
Synthetic opioid agonist rapidly metabolised by esterases
Fast onset 1.2 min and off-set
No accumulation
No active metabolites
Crosses placenta but rapidly metabolised by fetus
Disadvantages
Maternal sedation, desaturation, apnoea, cardiac arrest
Requires 1:1 midwifery care
Requires supplemental O2
Coninous pulse oximetry monitoring
Timin of dose admin with contraction
Non-pharmacological
Natural
Education
Breathing techniques
Birth partner
Doula
Complementary
Aromaatherapy
Massage
Acupunture
Reflexology
Water immersion
Hypnosis
Transcutaneous electrical Nerve Stimulation (TENS)
Based on gate controlled theory of pain
Effective for early 1st stage of labour
Conlcusion
Lack of pain does not necessarily mean a positive birth experienc
Being empowered
Range of pain relief options
Epidural most affective
Aware of limitations of epidural
Casarean Section
Indications for Emergency CS
Emergency
Abruption placentae
Uterine rupture
Scar dehiscence
Cord prolapse
Active bleeding
Foetal distress
Urgent
Meconium stained liquour
2.Unfavourable foetal heart rate
Obstructed labour
Planned emergencies
Pre-eclampsia
Planned CS in labour
CS Decision
Preoperative assessment & examination
Assemble team and theatre set-up
Transfer to theatre
Induction of anaethesia
Skin prep, drape, incision
Classification of Urgency
Category 1: Emergency
Definition
Immediate threat to life of woman or fpetus
Example
Cord prolapse
Uterine rupture
Timing
Decision to delivery (DDI) time 30 min
Category 2: Urgent
Definition
Maternal or fetal compromise which is not immediately life threatening
Examples
Obstructed labour
Abnormal foetal heart rate
Timing
Up to 60 min
Category 3: Scheduled
Definition
Needing early delivery but no maternal or foetal compromise
Example
Planned elective CS in labour
Category 4: Elective
Definition
At a time to suit the woman and maternity team
Anaesthesia Technique for CS
GA
Disadvantages
Risk of difficult intubation 1:400 (higher in pregnancy
Risk of regurgitation and aspiration of stomach contents
Unable to participate in the birth process
Exposure of foetus to anaesthetic agents
Timing
5-10min
Top uo: >20min
Spinal
Time consuming
Timing
10-15min
Top up : >20min
Epidural
Top up of existing takes 13 min to be effective
Timing
10-15min
Top up: >20min
Regional
Technique of choice
Maternal Collapse
Emergency management
Call for help
Start basic life support
Displace uterus
Airway management
IV / Intraosseos access above diaphragm
Left lateral reover position if ROSC (pulse present)
Perimortem CS if no resumption of ciculation in 5 moin
Cariac Arrest In Pregnancy Algorithm
BLS / ACLS
Assemble maternal cardiac arrest team
Consider aetiology
Maternal / Obstetric intervention
Relieves compression of IVC - allowing blood to return to the heart
Causes / Contribution Factors
(BEAU-CHOPS)
B - Bleeding / DIC
E - Embolism: Pilmonary / coronary / amniotic fluid embolism
A - Anaethetic complications
U - Uterine atony
C - Cardiac disease: MI, Infarction, Aortic dissection, Cardiomyopathy
H - Hypertension / Pre-eclampsia / Eclampsia
O - Others: Ddx for cardiac arrest
H's and T's
: Hypoxia, hyper/hypokaelamia, hypo/hyperthermia, hydrogen ions (acidosis) , hypoglycaemia, tension pneumothorax, tamponade, toxins, trauma
P - Placental abruption / praevia
S - Sepsis
Anaesthesia in Obstetric Emergencies
Emergencies
Emergency caesarean delivery
Obstetric haemorrhage
MAternal cardiac arrest
Severe pre-eclampsia
Eclampsia
Maternal sepsis
Strategies to "Buy time"
Dedicated staff and infrastructure →
Dedicated obs anaesthetist, operating theatres within labour ward
Focused protocol
Communication system
Categorisation
Stat voice over paging
Colour coding system
Public annoucement system
Teamworking
Roles
Shared objectives
Communication
Situational awareness
PROMPT training
Anaesthetic technique
Intrauterine Resuscitation
Resus
Stop oxytocin
Position - left lateral / knees elbow for cord compression
Oxygen
Fluid
Tocolysis
Transfer
Reasses
Recheck fetal heart rate on arrival to theatre
