Obstetric

Anaesthesia
Manual
2020
 Westmead Obstetric
Anaesthesia Manual 2020
The purpose of these guidelines is to help anaesthetists, obstetricians and midwives. It is hoped
that the guidelines will clarify the principles of management of obstetric anaesthesia at Westmead
Hospital. This will lead to greater uniformity and consistency of practice, better teamwork and
safety, leading to improved patient care. The guidelines are not rules, and helpful comments from
all parties are welcomed.

Contents Page
General duties
Consultants
Registrars 5
Daily duties
General points
Consent
General Points
Regional analgesia in labour 6
Regional anaesthesia for caesarean section

Regional analgesia for labour

Considerations
Contraindications
Absolute
Relative
Technique
Afterwards 7-11
Special circumstances
Thrombocytopaenia
Anticoagulants
Pre-eclampsia
Maternal pyrexia
Haematological disorders

Epidurals for pain relief in labour

Introduction
What is an epidural?
How is the epidural performed?
12-13
What are the risks?
Will it affect my labour?
Afterwards

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 Contents Page
Complications of epidurals
During insertion
14
Immediate
Delayed
Subdural block
Aetiology
15
Characteristics
Management
High Block
Characteristics 16
Management
Total spinal 17

Accidental dural puncture

Immediate action (preferred option)
For labour analgesia
18-19
For caesarean section
Alternatively, (less preferred option)
At delivery

Post dural puncture headache (PDPH)

Definition
Significance
19-21
Recognition
Differential Diagnosis
Management
Local anaesthetic toxicity
22-23
Intralipid
Westmead Hospital Guidelines for Use of Remifentanil in
24
Labour
Obstetric glyceryl trinitrate use 25
Uterotonic drugs 25

Maternal illness
The sick obstetric patient
Recognition of the deteriorating obstetric patient.
Caring for the sick obstetric patient – the acute care unit. 26-30
CERS for peripartum patients
Level 1 – Clinical review
Levels 2&3 – Rapid Response and Code Blue/ALS

Venous thromboembolic disease

Labour
Postpartum prophylaxis
Calf compressors
Compression stockings
31-32

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 Contents Page
Hypertensive Diseases of Pregnancy and Pre-eclampsia
Definition
Gestational hypertension
Chronic hypertension
Chronic hypertension with superimposed pre-eclampsia

Pre-eclampsia
Clinical features
Risk factors
33-39
Pathophysiology
Management
Anti-hypertensive therapy
Fluid Management
Seizure Prophylaxis
Delivery
Long term effects
HELLP

Collapse of parturient
40
Amniotic fluid embolism
41
Major obstetric hemorrhage
Post-partum Haemorrhage (PPH)
Risk factors
Management
PPH ≤ 1L guideline
PPH > 1L guideline
Code crimson
42-47
Uterine inversion
Placental abruption
Cell salvage
Indication in obstetrics
Contraindications
Rules for use in obstetrics

Caesarean section
Classification
Class 1 (Code critical)
Class 2 (previously called Code urgent)
Class 3
Class 4
Notification of class 1 – code critical caesarean sections
Notification of class 2-4 caesarean sections
General Points for CS
Investigations
48-53
Diabetes Mellitus
Coordination of caesarean sections by severity rating
Intrauterine Fetal Resuscitation

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 Contents Page
Patient preparation for caesarean section
Antacid therapy for aspiration prophylaxis
Class 1 – code critical and class 2 caesarean sections
Class 3
Class 4
Fasting in labour
Parturients in labour
54-56
Semi-elective and urgent CS
Elective CS
Transfusion Preparation
Elective CS (low risk)
Elective CS (high risk)
Inpatients on the antenatal ward
Birth unit
Anaesthesia for caesarean section
Single shot spinal
Principles of safe management
Spinal Drug doses
Epidural and combined spinal/epidural anaesthesia
Indications for epidural
Epidural top up
Combined spinal epidural
Postop epidural infusions
57-63
Pain at caesarean section
General anaesthesia
Pre-operative
Induction of general anaesthesia for a code critical CS
Difficult intubation hints
Maintenance and reversal
Post GA
Intravenous PCA

Skin to Skin at Caesarean section

Benefits of skin to skin contact for the neonate 64
Benefits of skin to skin contact for the mother
Caesarean postoperative care
Immediate Post op care
Prescriptions after caesarean section 65
Intravenous fluid

Anaesthesia for other operative procedures

Retained placenta/ products of conception
Repair of perineal tears
Laparotomy/Laparoscopy 65-69
EXIT procedure
Neonatal Difficult Airway Kit

Articles
70
Post Dural Puncture GP Notification Letter 71

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General duties

Consultants (In hours carry 8486 page)

Consultants are on call from 06:00 to 17:30 and then from 17:30 to 06:00. Depending on the day
and the time of day they may or may not be in the hospital. They are responsible for oversight and
training of the registrars. They are the first line of call for the anaesthetic management of privately
insured obstetric patients. (N.B. After hours, many consultants feel the anaesthetic registrar on site
should be called first and liaison with the consultant based on patient preference and clinical need).
The obstetric anaesthesia consultants are also second line help after hours, if extra anaesthetic
help is needed and the general consultants have already been called in.

Registrars
An on-site registrar carries the 8596 (obstetric) pager 24 hours a day. After hours & on weekends,
this registrar also carries the 9288 page, covering pain management, trauma & ALS calls.
Note: between 0800 -1400 on Saturday and Sunday the SRMO carries and attends pain referrals.

Daily duties
● Receive handover from the previous shift registrar (night → day at 08:00)
● Put your name and contact details on the Birth Unit white board.
● The obstetric anaesthesia consultant and registrar should meet with the midwifery team
leader and obstetric registrar at 08:30 to discuss the patients present in or expected to
present to the birth unit.
● Epidural insertion requests should be attended to in a timely manner.
● Review any patients in the obstetric Acute Care area.
● Gather the obstetric epidural audit forms for follow-up and proceed to review these patients.
This ideally should be performed early in the shift, before the usual increase in epidural
workload of the unit occurs. Completed forms should be returned to the folder in Birth Unit.
● The registrar's primary priority is to cover the Birth Unit and associated tasks. During
normal working hours, the registrar is expected to stay in the Birth Unit unless doing
epidural audits. Other than epidural insertions, registrars may be required to:
○ Make anaesthetic assessments
○ Assist in venous access if requested (still the primary responsibility of the
obstetricians and midwives)
○ Provide anaesthesia in theatres for emergency cases from the Birth Unit
● At 17:00 a birth unit board handover should occur to the following shift’s registrar.

General points
● The obstetric anaesthetist is not an epidural technician. S/he is part of a team working
closely with the obstetricians, midwives and paediatricians and should take an active role in
clinical management decisions.
● Be prepared to discuss pain relief options with mothers in labour.
● Be prepared to supervise midwives in training for epidural top ups.
● Introduce yourself to the midwives/obstetricians if you haven't met.
● Help with the education of medical students, midwives and residents when able.
● Always knock and wait for an answer before entering a delivery room.

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Consent

General Points
Signed consent is not necessary for regional analgesia in labour or anaesthesia for caesarean
section. You should make a brief record of the risks/benefits that you have discussed with the
woman since it is not unheard of for the woman to deny later that they were warned about a
possible complication.
If the patient is very distressed, keep explanations short and simple, with more detail to be given
once settled. Record this in the notes, e.g. "only brief explanation before insertion as distressed".
Always offer the opportunity to ask questions, and give honest answers. Any problems regarding
consent must be referred to the consultant obstetric anaesthetist.
Epidural analgesia in labour is very safe, and while it is important to inform patients of the risks
involved, it is worthwhile emphasizing how safe the process is to avoid unnecessarily distressing
the patient. This could be couched as "labour epidurals are very safe and we do about 1000-2000
every year at Westmead with very few complications, but like everything, there are risks which
include ..."
A mentally competent mother has the right to refuse treatment regardless of the consequences.

Regional analgesia in labour

You must tell the woman about the following risks. (The figures are only an aide memoire for
discussion of relative risk, and do not need to be included in every discussion unless further
questioned by the patient.)
● hypotension (1:50)
● post dural puncture headache (1:200, if blood patch is required 70% success with 1st patch,
90% with second if needed)
● failure, complete (needing resite: 1:20) or partial
● nerve damage including paralysis
○ temporary (1:1,000)
○ >6 months (1:13,000)
○ severe injury including paralysis (1:250,000)
● infection
○ abscess (1:50,000)
○ meningitis (1:100,000)
● bleeding including haematoma (1:170,000)
You should consider telling the patient about the potential association of epidural with increased
risk of instrumental delivery, but no increased risk of caesarean section.

Regional anaesthesia for caesarean section

You must tell the woman about the risk of:
● hypotension and nausea
● likelihood of sensation (touch/pulling) during the operation
● possibility of pain
● the occasional need for general anaesthesia
● use of analgesic suppositories (if relevant)
● post dural puncture headache
● other risks of neuraxial block as above
You should consider telling the woman about itching and shaking.

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Regional analgesia for labour
Ideally the patient should have received and read the information about the epidural insertion
procedure and risks, which are provided on laminated cards on each epidural trolley in birth unit,
prior to consideration of an epidural.

Considerations
● The time from request to attending a mother for an epidural should ideally not exceed
30min. If there is a request for an urgent epidural and you are busy elsewhere then you
should consider asking for help. The obstetric anaesthesia consultant is available to assist
in hours, or help can be sought from the 8460 after hours if they are not otherwise busy.
● Establish the rationale for the request for a regional block. Enquire as to when the woman
was last examined. Sudden escalation of pain is often symptomatic of an imminent delivery
(especially in parous women).
● Is there is a strong likelihood that the woman will proceed to an operative delivery? It is
worth explaining to her that her analgesia for labour can be converted to anaesthesia for
forceps or CS.
● A platelet count is not routinely required prior to epidural insertion in patients with an
uncomplicated pregnancy.

Contraindications

Absolute
● Uncorrected anticoagulation or coagulopathy
● Local sepsis
● Patient refusal

Relative
● Imminent birth of baby
● Certain anatomical neurological anomalies e.g. Tethered cord
● Hypovolemia or ongoing antepartum hemorrhage
● Gross spinal deformity
● Severe fetal distress
● Systemic sepsis: T >38 °C not treated with antibiotics

Technique
1. Obtain consent.
2. IV access, ideally a 16G cannula (with local anaesthesia; minimum 18G cannula).
3. FBC not required unless there is evidence of pre-eclampsia, antepartum bleeding has
occurred, or anaemia or thrombocytopaenia is suspected.
4. IV fluids should be commenced but a IV fluid bolus is not a prerequisite prior to neuraxial
insertion. Current practice is however, that 500ml of IV fluid is usually given during epidural
insertion. IV fluids should then be continued as per the current Management of maternal
fluid balance in labour and postpartum V1.0.
5. It is reasonable for the midwife to continue to monitor the CTG during epidural insertion.
6. Full aseptic precautions (mask, scrub, gown, gloves ± cap).
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7. Ideally epidural or CSE should be done at L3/4 or below. Be aware that most anaesthetists
think they are going lower than they actually are by 1-2 levels.
8. Catheter is inserted after using a standard loss of resistance (LOR) technique. 3-5cm
should be left in the epidural space.
9. The epidural clip should be fitted to the end of the epidural and the catheter aspirated
looking for the presence of blood or CSF. The epidural filter should then be attached. A
green clip should also be placed over the standard epidural clip to prevent it from opening.
10. An epidural test dose of 5ml of the premix epidural solution (Bupivacaine 0.125% +
5mcg/ml fentanyl) should be given. If there are no signs of intrathecal injection the
remaining 15mls should be administered.
11. Currently at Westmead the technique for maintenance of analgesia is Programmed
Intermittent Epidural Bolus + Patient Controlled Epidural Analgesia (PIEB + PCEA).

PIEB + PCEA has been shown to provide better spread of the administered epidural
solution than infusions, which allows for reduced total local anaesthetic requirements. This
is generally the default option for maintaining epidurals in birth unit.

Epidural infusions are rarely employed, usually for mothers with cardiac comorbidities.

The usual epidural mixes used (after establishing with Bupivacaine 0.125% + 5mcg/ml
fentanyl) are:
o PIEB + PCEA
§ Ropivacaine 0.1% + 2mcg/ml fentanyl
§ Suggested prescription (below)
Delay
PIEB PIEB
PIEB PCEA PCEA Hourly time till
dose lockout
odose dose lockout limit first
range interval
o (ml) (ml) (mins)
(ml) (mins) (ml) bolus
o (mins)
8 0-15 60 5 10 25 30

o Epidural infusions
§ Bupivacaine 0.125% Plain or with 2.5mcg or 5mcg/ml fentanyl
§ Rate 8-14 ml/hr (rate determined based on clinical circumstances)

12. A combined spinal-epidural technique (CSE) can be used if the woman is extremely
distressed (esp. late in labour).
○ In this situation, a spinal dose of 2mls of the standard epidural solution (bupivacaine
0.125% + 5mcg/ml fentanyl) can be used.
○ If a CSE is done, the subsequent epidural dose should be given when the pain
begins to reoccur after the spinal dose has been given.
○ In the rare event that a PIEB regime is prescribed after a CSE, the
normal PIEB program can be used provided there is no concerns about the epidural
catheter location.

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 13. In case of suspected dural tap, the following can be used to differentiate saline and CSF.

CSF Saline
Temperature warm cold
Protein present absent
Glucose ≥ trace absent
pH ≥7.5 <7.5

14. If the patient has an oxytocin infusion running and is distressed to a degree that is affecting
communication, the infusion may be reduced, then may be increased again once pain relief
achieved. This should be done in consultation with the obstetric team.
15. Record your insertion in the eMR using the template which has been created.
16. Prescribe the epidural prescription on the “Obstetric Epidural Analgesia” paper form.
17. Enter epidural details into the epidural database and print a follow up form and place it in
the folder in birth unit.
18. Review the efficacy of the patient’s analgesia, answer any questions the patient may have
and give them an epidural card. The registrar should explain concerning signs and
symptoms and the phone number to call if they have any concerns.

Afterwards
1. The midwife must be continuously present for at least 20 mins post initial epidural top up.
2. BP, pulse should be recorded every 5 minutes for 20 mins after initial top up.
3. The mother should be nursed in a position that avoids aortocaval compression throughout
labour.
4. Continuous CTG monitoring will be commenced by midwives.
5. The midwife should programme the PIEB +PCEA machine and attached it to the epidural
as soon as possible.
6. A light diet can be given if there are no obstetric risk factors. Women with risk factors can
drink clear fluids.

The anaesthetic registrar carrying the 8596 page must be notified of any neurological deficit
persisting >6h after the last top up. This must be assessed and followed up by the
anaesthetic team immediately.

Special circumstances

Thrombocytopaenia
● Isolated platelet count >75,000 are acceptable for a regional block; a count between 50,000
and 75,000 should be discussed with the haematologist and consultant anaesthetist.
<50,000 is an absolute contraindication to a regional.
● In the presence of pre-eclampsia, the platelet function may not be normal and therefore a
neuraxial block should not be done when the count is <75,000. In the presence of fulminant
pre-eclampsia with a rapidly falling count, it may even be prudent to avoid regional when
the platelet count is platelet count <100,000. Discuss with consultant if in doubt.
● Aspirin and NSAIDs do not appear to change the risk of bleeding in neuraxial blocks.

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Anticoagulants
There are many guidelines in the literature in regards to the recommended time intervals between
last anticoagulant and antiplatelet administration and epidural insertion. It is recommended that you
follow the current published WSLHD Anticoagulation Guidelines (adult) V11.1 available on the
intranet. This document links to the current departmental recommendations regarding
anticoagulant and antiplatelet medications and obstetric epidurals which are outlined in the policy
and procedure document WSYD-PROC201996 V4.0 Intrapartum: Management of Epidural
Analgesia in Labour – Auburn, Blacktown and Westmead. (2018).

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Pre-eclampsia
Patients with mild to moderate pre-eclampsia should have had a platelet count less than 24h prior
to neuraxial procedures. Patients with severe pre-eclampsia should have FBC and coags less than
6h prior.

Maternal pyrexia
Current opinion is that it is safe to administer a regional block in these patients. If the patient is not
on antibiotics, discuss with the admitting team and give antibiotic prior to siting the epidural. If there
are any concerns the anaesthetic registrar should discuss the case with the obstetric anaesthesia
consultant.

Haematological disorders
In most patients, there will be an increase in the coagulation factor levels during pregnancy. There
should be a management plan in the notes, otherwise liaise with the haematologist and
obstetrician.

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EPIDURALS FOR PAIN RELIEF IN LABOUR

Information for mothers and partners

Introduction
An epidural is the most effective form of pain relief for childbirth. It also allows you to remain awake
and participate in the birth of your baby. Epidurals are usually straightforward to put in and very
safe, but as with any medical procedure there is the possibility of complications. You and your
partner should read this information sheet carefully so you can make an informed decision about
having an epidural for your labour and delivery. You can discuss this further with your anaesthetist,
obstetrician or midwife.

What is an epidural?
An epidural is an injection of pain killing medicines into the lower part of your back. This stops the
pain when you have a contraction. It is usually possible to stop the pain, but still allow you to move
your legs and to push when the time comes for your baby to be delivered. Epidurals are put in by
doctors who work in the Department of Anaesthesia at Westmead Hospital.

How is the epidural performed?

First you will have a "drip" inserted into a vein in your arm. This is to give you extra fluid to stop
your blood pressure dropping. Your anaesthetist will then position you, either lying on your side or
sitting up. Next your skin will be cleaned with an antiseptic solution and made numb with a small
amount of local anaesthetic. This may sting, but only for a few seconds. The epidural needle will
then be inserted. This is the most critical part of the procedure and it is important you stay as still
as is possible. Once the needle is in the right place a very small plastic tube (catheter) will be
threaded through the needle into the epidural space. During this you might feel some tingling or
faint "electric shocks" in your back or legs which is quite normal. You should tell your doctor if you
feel this. After this the needle is taken out and you are left with the flexible plastic tube in your
back. This tube is used to give the pain killing medicine. The epidural can be "topped up" as often
as needed through this plastic tube. You may lie comfortably on the plastic tube.

What are the risks?

There are some side effects from epidurals which are common, but are only temporary. These
include the following:
● Shivering and shaking
● Your legs may get heavy and feel numb
● Difficulty passing urine which may require a catheter to be inserted. This is common during
labour even when epidurals are not used.
● Your blood pressure may drop. This may make you feel sick. It can be easily treated.
● Localized backache at the site of the epidural injection for 7 to 10 days. Epidurals are not
linked with long term back pain.
There is the possibility of more serious, but very rare complications which you should know about.
These include:
● Headache, which happens about once every 200 epidurals.
● Breathing difficulties, and a severe drop in blood pressure.

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 ● Infection or a burst blood vessel where the epidural goes into the back. This is very serious,
but is very rare.
● Nerve damage — this is very rare.

Will it affect my labour?

Modern epidurals have very little effect on your labour. They are thought to increase the total
length of your labour by a very small amount but do not increase the chance of Caesarean section.
In some cases, an epidural may even speed up your labour. Should a Caesarean section be
required to deliver you baby, then the epidural can be used to provide the anaesthesia for the
surgery.

Afterwards
At the time your epidural is inserted the anaesthetist will give you a card for you to keep. This
provides the contact phone number to call should you experience any issues related to your
epidural.

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Complications of epidurals

During insertion
● Blood in catheter
Common problem, best avoided by not inserting during contractions. Alternatively
inject 5–10mL of normal saline via Tuohy needle, hold, then feed catheter. The
aspiration test is reliable with a low false negative rate (0.2–0.4%, Norris 1998). If
aspiration is positive for blood withdraw about 1cm, flush with saline and try to re-
aspirate. Repeat as necessary. If unable to leave sufficient catheter length in space
without aspirating blood, resite catheter.
● Dural puncture (see later)
● Paraesthesia or pain
Transient paraesthesia while threading catheter may be expected but if it persists
you must stop threading and withdraw the needle and the catheter together. If there
is pain on injection of local anaesthetic you should not proceed.

Immediate
● Inadequate block
● Hypotension
○ Usually defined as a drop in systolic BP of ≥20% from baseline. If uncorrected it
may compromise utero-placental blood flow.
○ If BP ≤90 mmHg, turn the woman on her side, give 500 mL of Hartmann's stat and
administer oxygen at 6 L/min. Maternal nausea and fetal heart rate <100/min should
be an indication for vasopressors even before the blood pressure is taken.
Metaraminol is generally now the vasopressor of choice in this circumstance and
can be administered by the anaesthetist in attendance.
● High block/subdural/total spinal
● Intravenous local anaesthetic → toxicity (see later)

Delayed
● Dural puncture and post dural puncture headache
● Neurologic complications
● Drug related complications

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Subdural block

Aetiology
Reynolds 1990 Separation of arachnoid from dura mater by epidural catheter. The subdural space
has more potential capacity posteriorly and laterally. Since the arachnoid and dura maters are
attached together on the ventral nerve root, the anterior nerve roots (which transmit motor and
sympathetic fibres) are relatively spared. In contrast to the extradural space, which terminates at
the foramen magnum, the subdural space extends cranially.

Characteristics
● Block spreading unexpectedly high over 20-30 min, sometimes as high as the cervical
dermatomes.
● Nasal stuffiness and Horner’s syndrome can develop
● Patchy sensory block, often with missed segments and persisting pain.
● Relative sacral sparing.
● Minimal motor block.
● Blood pressure can be well maintained (severe hypotension is rare)
● Probably more frequent than originally thought (up to 2%).
● Have a high index of suspicion if an epidural block has a 'bizarre' distribution. Seek advice
of senior anaesthetist.

Management
● Since the arachnoid is easily torn, a subdural catheter may rupture through following a
bolus dose, changing the block from a subdural to a subarachnoid or even total spinal. In
addition, post dural puncture headache may follow. Therefore, the catheter should not be
left in situ.
● Resite epidural at different site.
● If surgical anaesthesia required shortly after the diagnosis of a subdural block, consider a
combined spinal epidural technique at another space if time permits. A small subarachnoid
local anaesthetic dose can be supplemented by incremental epidural doses as necessary.
If delivery is urgent, general anaesthesia is indicated.

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High Block
A high block can occur with the unintentional placement of an epidural catheter in the
subarachnoid space or subdural spaces. It can also occur after migration of a previously correctly
positioned epidural catheter into the subarachnoid or subdural space or after the administration of
an inappropriate dose of epidural solution. Depending on the situation and the extent of spread of
the administered local anaesthetic, this can progress to a total spinal.

Characteristics
• Restlessness
• Dyspnoea
• Profound hypotension
• Weakness in arms or tingling
• Inability to speak

Management
This is generally supportive, and follows the usual ABCs.
• Call for help
• Supplemental oxygen
• Airway support
o May be required, including intubation and/or ventilation depending on the height of
the block
• Circulatory support
o IV fluid
o Vasopressors
o Prevention of aortocaval compression (wedge / left lateral tilt)
o Vagolytics
• FHR monitoring
o To ensure response to circulatory support is adequate for uteroplacental perfusion
• Maintain communication with the mother explaining what is occurring
o This should also occur in mothers with a total spinal and are ‘unconscious’ until a
small amount of hypnotic is administered

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Total spinal
Total spinal anaesthesia is the rapid onset of hypotension with widespread paralysis and apnoea,
due to the effect of local anaesthetic in the subarachnoid space. It can occur with the first dose of
local anaesthetic when the epidural catheter is wholly or partially intrathecal even if no CSF was
apparent on aspiration. It has also been reported following several top ups and some hours after
initiation of an epidural block. Inadvertent subarachnoid block can also occur where the dura has
been punctured and the epidural catheter has been inserted into another space.

Precautions to avoid total spinal anaesthesia:

● Epidural catheters must be carefully aspirated prior to injection of local anaesthetic.
● Top up doses should always be given incrementally.
● All top ups after dural puncture should be administered by an anaesthetist.

Detection:
● Rapid profound analgesia, hypotension, or evidence of increasing motor block are
suggestive of intrathecal injection.
● Apnoea will be preceded by respiratory distress due to intercostal and phrenic nerve
involvement.

Management:
● Place patient on her side. Call for help, call for arrest trolley, give oxygen and prepare for
possible intubation. As the patient may still be conscious, if intubating give a small dose of
thiopentone, propofol or midazolam.
● Treat hypotension with generous fluid infusion and ephedrine, metaraminol or
phenylephrine. Atropine may be required for bradycardia. Avoid aortocaval compression.
Consider CPR in extreme cases.
● Unconsciousness with dilated pupils should resolve if the respiratory and cardiovascular
systems are adequately supported.
● Following further resuscitation measures senior obstetric and anaesthetic staff should
decide on further management. LSCS may be indicated.

Death of mother or fetus due to total spinal anaesthesia should be totally

preventable.

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Accidental Dural puncture
Either needle or catheter has breached the meninges. A post dural puncture headache that
develops in the postnatal period may be the first manifestation.

Immediate action (preferred option)

If needle tap, thread the catheter into subarachnoid space. If catheter tap, leave catheter in CSF.
Aim for 4cm of catheter in the intrathecal space. Make sure that the catheter/filter is clearly labeled
as subarachnoid/intrathecal.

For labour analgesia

1. All subsequent administration of local anaesthetic/opioid MUST be given by an anaesthetist
personally.
2. No standing order prescription for top ups should be written.
3. Clearly document in notes and on epidural record that the catheter is subarachnoid and the
anesthetist is the only person to administer drugs through it.
4. Intermittent (1-3hrly) top ups of standard mix (bupivacaine 0.125% + fentanyl 5 mcg/ml) of
2ml (=2.5mg of bupivacaine and fentanyl 10mcg)
5. Following delivery, the intrathecal catheter is to be removed post delivery when stable. This
can be done by the midwife with the same technique as normal epidural catheter removal.
6. Follow up for 2 days on Acute Pain Round to check for evidence of post dural puncture
headache (PDPH).

For caesarean section

1. Anaesthetist to top up with bupivacaine 0.5% using 0.5ml bolus doses ± 15- 25mcg fentanyl
and 100mcg of intrathecal morphine.
2. Following Caesarean section the intrathecal catheter should be removed prior to transfer of
the woman to recovery.

Documentation of the removal of the intact intrathecal catheter should be done on the Obstetric
Epidural Analgesia chart.

Occasionally a confirmed intrathecal catheter may still provide suboptimal analgesia for the woman
or be unable to be attended to promptly enough with frequent top ups due to the workload of the
anaesthetic registrar covering birth unit. In such circumstances the Obstetric Anaesthesia
consultant should be contacted to provide advice.

Alternatively, (less preferred option)

Attempt to resite an epidural catheter at another interspace. If technically difficult, or at all unsure,
request more experienced help. If a further tap occurs, consultant input MUST be sought.

Remember
● Anaesthetists only to give any drugs. Remember that in the presence of a meningeal tear
the amount of local anaesthetic required for a resited epidural may be significantly less than
analgesia with intact meninges. This is especially important with top up of large doses for
LSCS.

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 ● An infusion regimen can only be considered after a catheter has been resited at another
interspace and only if several boluses have not exhibited excessively fast onset or an
unusually extensive block. Discuss with senior registrar or consultant first.
● Make sure everyone is aware of the block finally achieved.
● Inform and counsel woman and document management plan in notes.

At delivery
● Elective instrumental delivery at full dilation is advisable only if headache arises during
labour.

We do not recommend prophylactic blood patch before the headache develops.

- 19 -
Post Dural Puncture Headache (PDPH)

Definition

The International Headache Society (HIS) now defines a PDPH as a “Headache occurring within 5
days of a lumbar puncture, caused by cerebrospinal fluid (CSF) leakage through the dural
puncture. It is usually accompanied by neck stiffness and/or subjective hearing symptoms. It remits
spontaneously within 2 weeks, or after sealing of the leak with autologous epidural lumbar patch”.
(Russell, IJOA, 2018)

Although the definition doesn’t include a postural component, the headache is often positional in
nature. The severe postural headache is thought to be due to an acute reduction in CSF volume
and downward pull of pain sensitive structures caused by CSF loss. This may also be contributed
to by a reflex cerebral vasodilatation to restore intracranial volume.

Significance
Headache may be very debilitating. The obstetric population is especially at risk of developing
PDPH. Rarely cranial nerve injuries, intra-, extra- or subdural haematoma can occur. Coning has
been reported. Hence severe PDPH must be treated as more than just an inconvenience to the
patient.

Recognition
Suspect whenever subarachnoid or epidural block has been performed. Expect in up to 80%
following inadvertent dural puncture with an 18G Tuohy needle. Of those patients with headache
● 50% will be mild and need no treatment
● 35% will be moderate and may require treatment
● 15% will be severe, incapacitating and always require treatment

Severe, typical occipital and bifrontal headache occurring when patient sits or stands. Relieved by
lying flat. Onset is usually 24 to 48 hours following the dural puncture. Associated symptoms
include visual and auditory disturbance, nausea and vomiting.

Differential Diagnosis
● Meningitis ● Pre-eclampsia
● Cerebral infarction ● Metabolic (hypoglycemia, electrolyte
● Migraine imbalance)
● Cerebral haemorrhage ● Cerebral vein thrombosis

Management
1. Explanation and reassurance to the patient.
2. Daily (at least) anaesthetic review, by consultant.
3. Trial of conservative management for first 24-48 hours.
1. Bed rest for symptomatic relief.
§ Note there may be a need to prescribe thromboprophylaxis. (Refer to
guidelines)
2. Adequate (not over) hydration, oral or intravenous.

- 20 -
 3. Analgesia. Use regular paracetamol and diclofenac, providing the latter is not
contraindicated. Supplemental opioids are frequently required - usually prn
oxycodone.
4. Oral caffeine. Limited evidence. If used, treatment should not exceed 24hrs and
doses should not exceed 300mg with a maximum of 900mg in 24hrs. For
breastfeeding women, a lower maximum dose of 200mg in 24hrs should be
considered, especially those with low birth weight or premature infants.
4. Offer epidural blood patch (EBP) from Day 2 for unrelenting or disabling headache.
Epidural blood patch is the definitive treatment of PDPH, but if performed within 24 hours of
dural puncture it has a much higher failure rate than after 24 hours.
1. Consent the woman including risks.
Risks include:
§ Repeat dural puncture
§ Back pain (~ 50% during procedure, up to 80% at 24hrs. Usually
resolved over next few days. Dose NOT result in chronic back pain)
§ Neurological complications
- Arachnoiditis
- Spinal Haematoma
- Infection
o Localized to lower back
o Meningitis
2. This is a two person procedure.
3. Ensure the patient does not have local or systemic sepsis (examination, ­ temp).
4. Explain procedure and obtain consent.
5. Epidural blood patches are usually performed in Day Only recovery. Liaise with the
Recovery NUM regarding the area in Day Only recovery for the procedure and
timing.
6. Position the patient and identify the intervertebral space/level at or one below that of
the dural puncture.
7. Identify epidural space in usual manner (1st person).
8. Withdraw 20ml of venous blood from non-drip arm under aseptic conditions (2nd
person).
9. Slowly inject blood via Tuohy needle. Stop once 20 mls has been given or sooner if
back pain or sensation of tightness occurs.
10. Bed rest for 1 hour (preferably 2 hrs) + routine observations.

The reported success rate of epidural blood patches in studies varies considerably. Recent
evidence suggests complete and permanent relief of symptoms following a single EBP occurs
in only approximately one third of cases of epidural needle related dural puncture. If partial
relief is also included, the figure increases to 50-80% of cases. (Russell, IJOA 2018)

5. Some anaesthetists now offer bilateral sphenopalatine ganglion blocks as treatment before
offering an epidural blood patch. (There is only very limited scientific evidence for this –
unrandomized trial and case series).
6. Letter for patient and their GP. (See appendix for sample letter).

- 21 -
Local Anaesthetic Toxicity
Systemic toxicity may occur with overdose, rapid absorption or intravascular injection of local
anaesthetic drugs. ASRA 2010 Central nervous system manifestations may or may not occur
before cardiovascular collapse, and toxicity may develop immediately on injection, or up to 15-30
minutes later.
1. Be aware of the possibility of seizure or cardiac arrest whenever performing regional
analgesia and anaesthesia.
2. Always aspirate prior to injection down epidural catheter.
3. Administer bolus doses incrementally.
4. If cardiac arrest occurs manage as usual in pregnant patient, and see below.

Intralipid
Intralipid® 20% is used for treatment of severe local anaesthetic toxicity. A 500ml bottle is stocked
in the Birthing Unit drug room under “F” (for fat). Dosage is according to AAGBI guidelines, and
should not interrupt standard ACLS resuscitation

AAGBI Safety Guideline

Management of Severe Local Anaesthetic Toxicity

1
Signs of severe toxicity:

Recognition

2
Immediate
management

3
IN CIRCULATORY ARREST WITHOUT CIRCULATORY ARREST

Treatment

GIVE INTRAVENOUS CONSIDER INTRAVENOUS

LIPID EMULSION LIPID EMULSION

4
Follow-up
www.npsa.nhs.uk
www.imb.ie

www.lipidregistry.org www.lipidrescue.org

Your nearest bag of Lipid Emulsion is kept

- 22 -
- 23 -
Westmead Hospital Guidelines for Use of Remifentanil
in Labour
For women who are unable to have epidural analgesia during labour (coagulation
abnormalities, spinal abnormalities etc), those who effective epidural analgesia cannot be
achieved despite senior input or women not wanting an epidural but seeking more effective
analgesia than traditional non-epidural methods, remifentanil had been seen as an option for
providing intense short duration analgesia with minimal effect on the fetus at deliver.

Concerns have been raised about the safety of remifentanil PCA in labour however, due to a
number of episodes of maternal morbidity. Due to these safety concerns the anaesthetic
department at Westmead as decided that remifentanil will not be offered to women in
labour.

These women should still be offered alternative forms of analgesia including massage, heat
therapy, water therapy, TENS and nitrous oxide.

For situations as described above discuss the woman’s case with the Obstetric Anaesthesia
consultant and consider a Fentanyl PCA instead.

If a Fentanyl PCA is commenced, the following measures need to be taken.

• Monitoring of oxygen saturations with continuous pulse oximetry.

• Oxygen at 2L/min via nasal prongs
• 1:1 midwife care – midwife must stay in room
• Paediatric registrar is to attend delivery.
• Baby is to be monitored in Special Care Nursery (SCN) or Neonatal Intensive Care
(NICU) for 8 hours after delivery

The mother must be consented for the above

conditions prior to commencement of PCA

• PCA dosing is as per standard Fentanyl PCA starting regime, i.e.

o Fentanyl bolus dose 20mcg
o Lockout interval 5mins
• Background infusions are NOT to be used.

- 24 -
 Obstetric Glyceryl Trinitrate (GTN) use
Indications
● Urgent
○
Management of entrapped second twin
○
Hypertonic uterine contractions causing fetal distress
○
Uterine inversion
○
Head entrapment during breech delivery
○
Transverse lie with ruptured membranes
● Less urgent
○ Manual removal of retained placenta
○ External cephalic version
○ Tocolysis

Presentation and Administration

1. Anginine tablets 600mcg: using a gloved hand, rub along buccal mucosa or administer
sublingually until desired effect is reached

2. Glyceryl trinitrate for IV injection. (50mg/10mL ampoule)

Two possible methods of dilution:

○ Add whole ampoule (50 000 mcg) to 1000ml N saline/Hartmann’s and mix well. 1ml
now has 50mcg. Draw out 4ml (200mcg) and give as 1-4 ml bolus prn.
○ Use a 10ml syringe to draw up 1ml (5 000mcg) and dilute up to 10ml with N saline
(500mcg/ml). Discard 9ml and dilute up to 10ml again (50mcg/ml). 1-4 ml bolus prn.

Note: the woman may experience headache or hypotension (esp. with larger doses) and
this should be anticipated and managed appropriately.

Uterotonic drugs
Drug Brand name Example dose Side effects Contraindications

3 Units IV then 10Units/h tachycardia,

Oxytocin Oxytocin 10 u/mL
infusion for 4 h vasodilation

Ergometrine 500
mcg/mL, or as 0.5 mL IM and 0.5 mL hypertension,
vomiting,
Syntometrine® slow IV pre-eclampsia,
Ergometrine hypertension,
(5 units oxytocin (ie. 250mcg IM & vascular disease,
coronary spasm
+ 500 mcg 250mcg slow IV) cardiac disease
ergometrine)
250-500mcg Bronchoconstriction
Carboprost asthma,
Prostin 15M® intramyometrially or pulmonary
(15-methyl- pulmonary
(250 mcg/ml) 250mcg IM every 15 vasoconstriction;
PGF2α) hypertension
mins up to 2mg max cardiac arrest 0.1%
Misoprostol Cytotec®
800 mcg PR Chills, pyrexia
(PGE1) (200mcg tablets)

- 25 -
Maternal illness

The sick obstetric patient

Childbirth is a major event for women and their families. Whilst the majority of women remain well
during this time, it can be associated with serious morbidity and mortality. The latest figures for
Australia for the period 2008-2017 show that there were 248 maternal deaths within the period up
to 42 days delivery (AIHW report 2019 - Maternal deaths in Australia 2008-17). This represented a
Maternal Mortality Ratio of 6.7 deaths per 100,000 who gave birth. Causes of death are classified
as indirect and direct.
Indirect causes of death are considered to be those resulting from diseases or conditions
that are not directly obstetric but aggravated by the physiological changes of pregnancy. Indirect
causes of death are more common than direct.

The most common overall causes of death reported in Australia from 2008 to 2017:
o Complications of pre-existing cardiovascular disease and
o Non-obstetric haemorrhage (mostly intracranial haemorrhage and ruptured splenic
artery aneurysms).

The most common direct causes of death reported in Australia from 2008 to 2017:
1. Thromboembolism
2. Obstetric haemorrhage
3. Amniotic fluid embolism

There is increasing recognition that it is vital that sick obstetric patients are recognized and
provided with an appropriate level of care. It is estimated that 1.5 per 100 will require high
dependency care and 1 in 200 will require intensive care.

- 26 -
Maternal death occurs at varying times during and after pregnancy. The day of birth is the most
frequent time for mothers to die, but very early in pregnancy and in the first 2 weeks after delivery
also represent periods of greater risk.

Recognition of the deteriorating obstetric patient.

The UK triennial enquiries into maternal deaths (CEMACE) have repeatedly highlighted problems
in identifying acutely unwell women in the pregnancy and the peri-partum period. Particular issues
include:
1. Many staff in the maternity units rarely see seriously ill patients
2. Difficulty in distinguishing between symptoms and physiological changes of pregnancy and
illness, for example dyspnoea.
3. The physiological reserves of pregnant women may mask signs until late in an illness, for
example maintaining systolic blood pressure in the face of significant haemorrhage.

The CEMACE reports have recommended the use of modified early obstetric warning systems
(MEOWS). At Westmead this is done through the Standard Maternity Observation Chart. It is like
the Between the Flags chart used in general patients, but the parameters have been altered to
better reflect the physiological changes of pregnancy. Variations in observations outside the white
zone will trigger a clinical review or rapid response call which the home team will attend. If the
patient is in the birth unit, the anaesthetic registrar on the pager 8596 will also receive the call and
is expected to attend.

Previous CEMACE reports have emphasized the importance of a high respiratory rate and the
need to consider the cause for any oxygen saturation below 95% on air in a previously well peri-
partum woman. Preliminary studies suggest that MEOWS’ are sensitive in detecting maternal
morbidity (Singh 2010) and reduce late detection of maternal illness (Treadgold 2010). However,
they have high false positive rates particularly in relation to blood pressure and heart rate
parameters (Singh 2010) and further refinement may be required in the future. (Reidy 2011)

- 27 -
Caring for the sick obstetric patient – the acute care unit.
The acute care unit is a 2-bedded room located in birth unit (Rooms 16 & 17), which is designed
for pregnant and postpartum women who require a higher acuity level of care than is available on
the general wards but not requiring ICU. The two most common reasons for admission are
haemorrhage and preeclampsia but women with other acute conditions or underlying illness can be
accommodated if appropriate midwifery/nursing cover can be arranged.
The essentials for anaesthetic staff are:
1. Patients requiring ECG, arterial and central line monitoring can usually be admitted but not
those needing inotropes or any form of ventilation (except patient own CPAP).
2. The unit is largely staffed by birth unit midwives with extra training however specialized
nursing staff may be required for cardiac rhythm monitoring or lines depending on the staff
available.
3. If you need a bed, contact the birth unit team leader. If they cannot care for the patient
contact patient flow in hours or the ADON after hours. Explain exactly what care you need
and the most appropriate bed will be negotiated, either with extra staff in the acute care unit
or a bed in HDU (generally not ideal whilst the patient is still pregnant).
4. While in the acute care unit the obstetric team (+/- maternal fetal medicine) remains the
primary team in charge of the patient. It is however, expected that patients in these two
beds will have an anaesthetic review twice daily.
5. Anaesthetic staff will need to be involved in the insertion and care of lines in the acute care
unit.
6. Handover of patients between shifts of anaesthetic registrars is essential as is an at least
daily discussion with the anaesthetic consultant covering birth unit.
7. Regular discussion of these patients with the obstetric registrar (8867) is encouraged as is
early referral to the intensive care team via the senior registrar on page 8620 even if it is for
consultation only.

CERS for Peripartum patients

All patients in Western Sydney LHD should be managed as per the Clinical Emergency Response
System (CERS) policy. This policy outlines a number of levels of escalation. These levels are:

o Level 1 – Clinical Review

o Level 2 – Rapid Response
o Level 3 – Code Blue/ALS

The internal phone number to activate a rapid response or Code Blue/ALS is 2222.

The rules governing escalation are outlined in the CERS response matrix (see below):

- 28 -
 Clinical Emergency Response System (CERS) Framework for the Recognition and Management of Patients who are Clinically
Deteriorating – Adult Inpatient - WSLHD

Obstetric patients are governed by slightly altered criteria compared with other patients in the
hospital to take into account the physiological changes of pregnancy. Vital signs are recorded on
the Standard Maternity Observation Chart (SMOC). Below are the criteria that are applicable for
each level of escalation.

Level 1 - Clinical review

• Any observation in the Yellow Zone

• Increasing oxygen requirement
• Poor peripheral circulation
• Altered mental state: agitation, confusion or unexpectedly uncooperative
• Decreasing or absent deep tendon reflexes
• Greater than expected fluid and/or blood loss
• Anuria or urine output < 80mLs total over 4 consecutive hours
• Blood Glucose Level 2-4mmol/L
• New, increasing or uncontrolled pain (including headache and chest pain)
• Any risk factors, signs or symptoms of SEPSIS
• New proteinuria (≥ +)
• Concern by the woman or family member
• Concern by you or any staff

NOTE: SMOCs have a Blue Zone Response for Cumulative Blood loss. Initiate clinical care
as per SMOC guidance for cumulative blood loss that falls into the Blue Zone. If cumulative
blood loss enters the Yellow Zone, follow Yellow Zone response process.

- 29 -
Levels 2 & 3 Rapid Response and Code Blue/ALS

A Rapid Response is an urgent review for patients who have not immediately life threatening Red
Zone observations or Additional Criteria on a Standard Observation Chart.

A Code Blue/ALS is an immediate review for patients who have immediately life threatening Red
Zone observations or Additional Criteria on a Standard Observation Chart.

• Cardiac or respiratory arrest

• Airway obstruction or stridor Always call a CODE Blue/ALS
• Woman unresponsive
• Seizures
• Any observation in the Red Zone
• Increasing oxygen requirements to maintain oxygen saturation > 90%
• Sudden decrease in Level of Consciousness (LOC) (a drop of 2 or more points on the
GCS)
• Arterial Blood Gas: PaO2<60orPaCO2>60orpH<7.2orBE<-5
• Venous Blood Gas: PvCO2 > 65 or pH < 7.2
• Blood Glucose Level < 2mmol/L
• Deterioration not reversed within 1 hour of Clinical Review
• Persistent low urine output < 160mLs over 8 hours
• Serious concern by any patient or family member
• Serious concern by you or any staff member

- 30 -
Venous thromboembolic disease
Thromboembolism is again the leading cause of direct maternal death in Australia (AIHW report
2008-2017). In the UK (MBBRACE 2019), it also continues to be the leading direct cause of
maternal death. This is likely due to extensive recent efforts to reduce deaths due to sepsis and
hypertensive disease.

Venous thromboembolism can occur at any stage during pregnancy, with the greatest risk in the
postpartum weeks.

Labour
Insertion and removal of a spinal or epidural catheter (neuraxial blockade) is associated with an
increased risk of spinal haematoma in the presence of anticoagulation.
● No LMWH for 12h before insertion or removal (24h if therapeutic dose)
○ enoxaparin (Clexane®) prophylactic dose 40mg sc daily
○ dalteparin (Fragmin®) prophylactic dose 5000units sc daily

Assess doses in the context of patient weight and renal function.

● No LMWH for 12h after insertion or 4hrs after removal

The most senior anaesthetist available should perform a block to minimize the risk of trauma,
where there is a risk of significant anti-Xa activity. It is important to monitor the patient continuously
after delivery for signs of spinal haematoma. You should seek advice, (and document this), if any
symptoms of weakness, numbness, back pain or bowel/bladder dysfunction occur. Onset may be
delayed >24h.

Any suspicion of spinal haematoma warrants rapid neurology/neurosurgical input. MRI is the
investigation of choice. Likelihood of full neurologic recovery decreases significantly after 8h.

Postpartum prophylaxis
1. Hydration and early mobilization
2. Enoxaparin 40mg sc daily until discharge for High Risk Postnatal women:
○ all caesarean deliveries/extended pelvic surgery
○ all morbidly obese patients (BMI >40kg/m2 in early pregnancy)
○ all vaginal deliveries with 4 or more risk factors
- Age >35 - Preeclampsia
- Booking BMI > 30 - Immobility >/= 4 days
- Parity > or = to 4 - Labour for >/= 12 hrs
- Major intercurrent illness - Instrumental delivery
- Major blood loss - Gross varicose veins
st
- VTE in 1 degree relative
- Heterozygous for Factor V Leiden or Prothrombin gene mutation
3. ± TEDS/sequential compression device in certain circumstances
4. Enoxaparin 40mg sc daily for 8wk for Very High Risk Postnatal women:
○ previous spontaneous VTE (i.e. no probable cause)
○ previous provoked VTE with any thrombophilia

- 31 -
 ○ lupus anticoagulant, or anticardiolipin antibody in high titre
○ deficiency of antithrombin III, protein C or protein S
○ Factor V Leiden or prothrombin gene mutation homozygote or double heterozygote
○ paraplegia
○ homozygous sickle cell disease
(WSLHD Anticoagulation Guidelines v11.1 June 2019)

Calf compressors
Currently obstetric department policy is that pneumatic calf compressors have no proven benefit
when used for less than a few days, and therefore generally are not needed during caesarean
section unless:
• They will be continued post operatively for > 24 hrs
• Thromboprophylaxis is contraindicated postoperatively

Compression stockings
Current obstetric department policy is that TEDS are generally not required at caesarean section
unless:

• LMWH is contraindicated postoperatively

• Patient at high risk of VTE (previous VTE or ³ 3 risk factors)

- 32 -
Hypertensive Disease in Pregnancy and Pre-eclampsia
New guidelines have been released which have replaced much of this part of
the Obstetric Anaesthesia Manual:

● WSLHD Procedure for Management of Hypertensive Disorders During

Birth and Early Postnatal Period
● WSLHD Procedure for the Antihypertensive Drug Management of Acute
Severe Hypertension in Pregnancy and Postnatal Period.

Both are available via the WSLHD Intranet.

A brief overview and highlights are provided below.

Hypertension is the most common medical disorder encountered during pregnancy

(occurring in 6-10% of pregnancies). It is a leading cause of both maternal and fetal
morbidity and mortality. In the longer term, women who develop hypertension during
pregnancy are at increased risk of chronic hypertension and cardiovascular disease.

Definition

Systolic BP > 140 mmHg and/or Diastolic BP > 90mmHg

Hypertension during pregnancy can be classified as a number of disease states.

• Gestational hypertension
• Pre-eclampsia
• Chronic hypertension
o Essential hypertension
o Secondary hypertension
o “White coat” hypertension
• Chronic hypertension with superimposed pre-eclampsia
Gestational Hypertension

Is the commonest form of hypertension seen in pregnancy. Occurs after 20 weeks

gestation, but usually after 37 weeks. Resolves by 12 weeks post-partum. No other signs
of pre-eclampsia. Outcomes are similar to normotensive pregnancies.

Chronic Hypertension

Mainly caused by essential hypertension (90%), especially with the increasing rates of
older and obese parturients. Hypertension is present before 20 weeks or patients have a
diagnosis prior to pregnancy. Secondary hypertension can be related to a number of
diseases, such as chronic kidney disease, endocrine disorders (e.g. phaechromocytoma),
aortic coarctation or systemic diseases with renal involvement (e.g. SLE, DM).

- 33 -
Chronic Hypertension with superimposed pre-eclampsia

The occurrence of new onset proteinuria, a sudden increase in proteinuria and/or HT or

the development of features of severe pre-eclampsia, in a patient with known
hypertension. Morbidity both fetal and maternal is greater than for pre-eclampsia alone.

Pre-eclampsia

Is a multisystem disorder specific to humans and unique to pregnancy consisting of

hypertension and the involvement of one or more organ systems, occurring after 20 weeks
gestation. Hypertension is commonly, but not always the first sign. Proteinuria is the next
most common sign but is not required for the diagnosis. Management is supportive and
the only definitive treatment is the delivery of the fetus.

Pre-eclampsia management is important, as is it the fourth most common cause of direct

maternal death in Australia (AIHW report 2008-17). In the latest maternal mortality report
from the UK (MBBRACE 19), deaths due to pre-eclampsia have remained low, likely due
to a heightened focus on this area as it had been repeatedly highlighted as one of the “Top
Ten” areas for improvement and had been sub-optimally treated previously.

Clinical features (other than HT)

• Renal
o Proteinuria (spot urine protein/creatinine ratio > 30mg/mmol)
o Serum or plasma creatinine > 90 µmol/l
o Oliguria <80ml/ 4hrs
o Increased urate not a diagnostic feature, but it is an indication of fetal
outcome.
• Haematological
o Thrombocytopaenia < 100,000
o Haemolysis (elevated LDH (>600), increased bilirubin, red cell
fragments, decreased haptoglobin)
o DIC
• Hepatic
o Raised LFTs esp. transaminases
o Severe right upper quadrant and /or epigastric pain
• Neurological
o Headache
o Visual disturbances
o Eclampsia
o Hyper-reflexia with sustained clonus
o Stroke
• Pulmonary edema
• Fetal unit
o Fetal growth restriction
o Abnormal umbilical artery Doppler flows
o Oligohydramnios
Pre-eclampsia, can be divided into several types.

- 34 -
 One classification is early vs late onset. Early type is that which occurs before 34
weeks, has a strong genetic component and comprises approximately 20% of cases.
Intrauterine growth restriction is more common with this form. Cardiovascular morbidity is
8 times a normal pregnancy. Risk of recurrence with subsequent pregnancies is high. Late
onset is more common and usually has other risk factors such diabetes, pre-existing
hypertension, multiple gestation or obesity. It occurs after 34 weeks, is less likely to recur
with subsequent pregnancies and cardiovascular morbidity is only mildly increased.
The other common division is into:

• Pre-eclampsia without severe features (“mild”)

o SBP 140 – 159mmHg and/or DBP 90 – 109mmHg

o Proteinuria >300mg/24hrs (Spot urine protein/creatinine ratio>

30mg/mmol)

• Severe pre-eclampsia
o SBP > 160mmHg and/or DBP >110mmHg

o Thrombocytopaenia, impaired liver function, creatinine > 2 x baseline,

pulmonary edema, persistent neurological symptoms
o Eclampsia
Risk factors
• Partner – related
o Fathered previous pre-eclamptic pregnancy
o Limited preconception exposure to paternal sperm

• Maternal
o Chronic disease (renal, diabetes, obesity)
o Family history of pre-eclampsia
o Previous pre-eclamptic pregnancy
o Age > 35 yrs
o Nulliparity

• Pregnancy related
o Multiple gestation
o Hydatiform mole
o IVF pregnancy

Pathophysiology
Increasingly understood. Results from a generalised endothelial dysfunction thought
to be related to abnormal placentation. Two stage model. The first asymptomatic stage
occurs early in pregnancy with incomplete cytotrophoblastic invasion and thus remodelling
of the spiral arteries, which occurs only in the decidua and not the myometrial segments.
Results in the lack of formation of the low resistance pathway and superficial placentation.
The second stage occurs later in pregnancy and results from the production of anti-
angiogenic factors (e.g. sFlt-1 and sEng) into the circulation resulting in endothelial
dysfunction.
The reason for the abnormal placentation is not fully known, but thought to be
immune related.
- 35 -
Management
Management of the disease is aimed at supporting the fetus and reducing the risks to the
mother until the decision for delivery. Treatment is tailored to the severity of the disease.
Delivery of the placenta is curative, although the pathophysiologic process may continue
well into the postpartum period.

Management is centred on:

• Fetal and maternal monitoring
• Control of hypertension
• Seizure prophylaxis
• Fluid balance optimization
• Obstetric decision regarding mode and timing of delivery.
Decisions regarding the appropriate location for delivery, especially regional hospitals
should be considered based on the capabilities of the hospital, severity of the disease and
gestation of the fetus. Early transfer should be considered.

In cases of pre-eclampsia prior to 34 weeks, if possible, delivery should be delayed for 24-
48 hrs to allow for steroids and possibly MgSO4 for neuroprotection (<30 weeks).
Unfortunately, in up to 40% of cases this is not possible.

Anti-Hypertensive therapy
For mild pre-eclampsia, there is controversy over the need to treat as it does not prevent
pre-eclampsia or adverse perinatal outcomes but does reduce the risk of severe
hypertension. Therefore, the decision to treat is based on local protocols.

For severe pre-eclampsia therapy is mandatory. Treatment with IV formulations should be

combined with the use of oral agents for more sustained effects. Continuous CTG
monitoring should be used for all situations where IV agents are used. The agent of choice
currently is Labetalol. IV and oral formulations are now available in Australia. Other agents
for use in hypertensive emergencies include hydralazine, nifedipine (oral) and diazoxide.
Labetalol (IV)
(Selective a-1 and non-selective b antagonist – 5 times b vs a effects)
• 20mg over 2 mins
• Onset 5 mins
• Repeat 20-50mg dose after 10-20mins up to 4 times
• Max cumulative dose 220mg
• Postural hypotension associated with its use IV up to 3 hrs after dose (60%)
• Contraindicated in asthma, heart block and bradycardia
Hydralazine (IV)
(smooth muscle relaxation – peripheral vasodilator)
• 5mg over 2mins
• Onset 5-20mins
• Repeat 5mg dose after 30 mins up to 3 doses
• Can cause reflex tachycardia, contraindicated in conditions where this is
considered adverse.

- 36 -
Monitor BP regularly after any IV antihypertensive dose. Administration of a IV fluid bolus
should be considered with hydralazine use but is generally not required for labetalol. Any
precipitous falls in BP should be treated with small (250ml) crystalloid boluses.

Blood pressure target should be

Systolic BP 140-150mmHg and Diastolic BP 90-100mmHg.

Fluid management
Careful fluid management is essential in pre-eclampsia to prevent the development of
pulmonary edema. Fluid should be administered at the rate of normal physiological
requirements. Generally, this is ~ 1ml/kg/hr or roughly 80ml/hr for most women. Additional
fluid should be based on blood losses or before regional anaesthesia or vasodilator
therapy.

A urine output of >80ml/4hrs is acceptable. In the face of urine output <80ml over a 4 hour
period, then the patient’s fluid status should be assessed, renal function checked (EUC)
and if there are no features of pulmonary edema, a 250ml bolus of crystalloid can be given
and the response reassessed over the next 4 hours.

Seizure Prophylaxis
Eclamptic seizures are generally self-limiting. Standard BLS with airway management and
oxygen supplementation is key. Magnesium sulphate is the drug of choice for prevention
of eclampsia. Its use is usually limited to patients with severe pre-eclampsia.

The prescription of magnesium sulphate can be initiated by the anaesthetist but should be
done in consultation with the obstetrician caring for the woman. The normal dose of
Magnesium sulphate is a:

4g bolus over 20mins then 1g/hr as an infusion.

At Westmead, there are premade Magnesium sulphate bags in birth unit containing 40g in
500ml. Therefore, using these bag the 4g bolus = 50mls and the infusion of 1g/hr is
equivalent to 13mls/ hour of the premade solution.

Blood levels don’t need to be monitored (except in patients with renal compromise) but
deep tendon reflexes should be regularly assessed to detect increased magnesium levels
prior to the level reaching toxicity. General observations such as BP, HR, Sats and RR
should all be routinely monitored.

Should eclamptic seizures occur in a patient on magnesium sulphate, a further 2-4g bolus
can be given over 10 mins. Magnesium should continue for at least 24 hrs after
commencement or after the last seizure. Despite appropriate magnesium therapy
recurrent seizures occur in 10-15% of cases. Neurology guidance should be sought to
guide further anti-seizure medication. Alternative diagnoses other than eclampsia should
be thought of in all cases, as eclampsia is not the most common cause of seizures during
pregnancy.
- 37 -
Delivery
The decision regarding the mode of delivery is an obstetric one, developed in consultation
with other team members. If vaginal delivery is chosen, good analgesia and blood
pressure control is needed. Should caesarean section be chosen, then regional
techniques are preferred. Spinal, epidural and CSE are all valid techniques for caesarean
section.

Additional monitoring is based on the clinical situation.

Both the absolute platelet count and the trend are important prior to performance of
regional techniques. Regionals are generally safe with platelet counts > 75,000.

Should a general anaesthetic be required, obtunding the hypertensive response to

intubation and extubation is essential. Choice of agent should be based on clinical
experience, though remifentanil provides a reliable response. Analgesia is important on
emergence. Preparation for a potential difficult airway should be undertaken prior to
induction. Paediatric support for the fetus once delivered should be available given often
SGA and anaesthetic exposure.

Avoid ergometrine in the event of bleeding, if possible, especially in severe hypertension.

Suggested technique
• Adequate fasting and antacid prophylaxis (sodium citrate)
• Preoperative blood pressure optimization
• Good IV access
• Pre-induction arterial line
• Pre-oxygenation
• Paediatrician in room
• Remifentanil infusion or 1µ/kg bolus
• Thiopentone or propofol + suxamethonium or rocuronium (provided immediate
access to Sugammadex is available)
• ETT
• Maintenance Volatile or propofol TCI
• Analgesia
o Paracetamol
o Morphine or fentanyl (once fetus delivered)
o Avoid NSAIDS/COX2 inhibitors
o TAP blocks
• Fluids
o Minimise, but replace losses
o Continue MgSO4
§ (note increased sensitivity to NMBD)
§ Continue for 24 hrs
• Avoid coughing on emergence.
• Monitor in appropriate setting.
• Strict fluid balance.

- 38 -
Long term effects
Pre-eclampsia increases the woman’s risk of cardiovascular disease significantly later in
life.

Relative risk of developing

condition later in life

Chronic hypertension RR 3.70

Ischaemic Heart Disease RR 2.16

End Stage Renal Disease RR 4.3

HELLP Syndrome
Syndrome of Haemolysis, Elevated Liver enzymes and Low Platelets.
• Haemolysis can be seen with raised bilirubin and LDH levels, red cell
fragments on blood film and reduced haptoglobin levels.
• Elevated liver enzymes (AST or ALT > 70 IU/L - usually in hundreds)
• Platelets less than 100,000 (can fall to very low levels but not usually < 10)
Occurs in 10-20% of cases of severe pre-eclampsia. Spectrum of disease as the above
represents “full-blown” HELLP. Partial HELLP with milder changes can occur.

Management consists of making the diagnosis, controlling hypertension (if present),

planning for delivery and blood product support to correct haematological abnormalities.
30% will not appear until postpartum.

- 39 -
Collapse of parturient
Collapse with or without seizure has a broad differential diagnosis, including:

● Circulatory shock
○ Haemorrhage: overt or concealed
○ Obstructive: amniotic fluid embolism, pulmonary embolism
○ Cardiogenic: myocardial infarction, LA toxicity, Mg toxicity
○ Distributive: total spinal anaesthesia, sepsis, anaphylaxis

● Neurologic disease
○ Epilepsy
○ Eclampsia
○ Intracranial haemorrhage (eg from aneurysm, AVM)
○ Stroke (e.g. paradoxical embolism)

(Classification is simplistic; many of these conditions fit more than one category.)

Management:
● ABC’s
● Make sure you know where the resuscitation trolley is in Birth Unit and you are familiar with
latest resuscitation guidelines.
● Intubate as soon as feasible.
● Manual displacement of the uterus to the left and raise legs.
● In the event of cardiac arrest, CPR will be ineffective unless aortocaval compression is
minimized.

Delivery by immediate “perimortem” caesarean section is indicated if there is no

response to advanced life support within 4 minutes.

Aim to start perimortem caesarean by 4 mins and have the fetus delivered by 5mins.

Perimortem caesarean may improve the effectiveness of maternal resuscitation, whether or not the
fetus is viable. AHA 2015.

- 40 -
Amniotic fluid embolism (AFE)
AFE is a rare event but a significant cause of maternal death given its incidence. AFE causes
death in between 1.9 – 6.1/100,000 deliveries (UpToDate - Dec 2019). Its incidence is higher than
this, as increased recognition and aggressive supportive management means its fatality has
reduced.

AFE is a clinical diagnosis. It can occur during or shortly after labour, caesarean section, and
occasionally second trimester termination. It is hypothesized that the entry of amniotic fluid into the
maternal circulation, leads to abnormal activation of humoral and immunological processes and the
release of vasoactive and procoagulant substances, similar to the systemic inflammatory response
syndrome. As a result, pulmonary pressures usually become acutely elevated, the RV pressure
increases, and the RV begins to fail. RV failure may subsequently lead to LV failure and systemic
hypotension. LV failure may also be the result of hypoxic injury to the LV, maternal inflammatory
mediator release or a direct depressant effect on the myocardium.

Acute pulmonary hypertension results in severe ventilation/perfusion matching, cardiogenic

pulmonary edema and hypoxic respiratory failure. Activation of factor VII, platelets and the release
of inflammatory mediators, likely activates the coagulation cascade leading to disseminated
intravascular coagulopathy (DIC), distal organ dysfunction and finally multi-organ failure.
(UpToDate - Dec 2019).

Clinical features:
● Sudden onset
● Dyspnoea, respiratory distress, hypoxia
● Chest pain, hypotension, circulatory collapse
● Coagulopathy, haemorrhage
● No other obvious explanation

Risk factors (suggested but not well established):

● Advanced maternal age
● Placental abnormalities
● Operative delivery
● Eclampsia
● Polyhydramnios
● Cervical laceration
● Uterine rupture

Treatment:
● Supportive: ABC, 100% oxygen, restoration of cardiac output
● Correction of coagulopathy
● early liaison with haematology as large amount of blood products may be required
● Possible role for selective pulmonary vasodilators and rFVIIa.
● Early delivery of fetus

- 41 -
Major obstetric hemorrhage
Obstetric hemorrhage can be primary or secondary (associated with coagulation failure) or both.

Primary 4 T’s
● Uterine atony (70%) Tone
● Genital tract trauma (20%) Trauma
● Retained placenta/ products of conception (10%) Tissue
● Placenta praevia
● Uterine rupture
● Uterine inversion

Secondary
● Pre-eclampsia/HELLP syndrome
● Intrauterine sepsis/septicemia
● Amniotic fluid embolism
● Preexisting coagulopathy Thrombin
● Incompatible blood transfusion
● Retained dead fetus

While blood is gushing out, it is useless and wasteful to give clotting factors or platelet
replacements. Once surgical haemostasis has been more or less achieved, continuous oozing is
quite possibly due to blood factor deficiencies.

Post-Partum Haemorrhage (PPH)

PPH is a common potentially life threatening complication of both vaginal and caesarean birth and
is a major cause of morbidity and mortality worldwide. UK data suggests there are 60 “near
misses” for every PPH maternal death CEMACH 2003-2005 UKOSS 2007. Primary PPH is blood
loss within the 1st 24hrs after delivery which involves
● Blood loss 500ml - 1000ml (minor PPH)
● Blood loss ≥ 1000ml (severe or major PPH) - Anaesthetist must be notified
● Any blood loss considered excessive by staff and which causes haemodynamic change to
the woman.

Risk factors
The major causes are related to the 4T’s- Tone, Trauma, Tissue, Thrombin NSW Health 2010
● Atonic uterus (70%)
● Genital tract trauma (20%)
● Retained placental tissue (10%)
● Primary coagulopathy <1%

Major PPH with massive transfusion will result in secondary coagulopathy in most cases. For 2/3 of
women there are no predisposing factors. Some women may require even closer attention
● pre-eclampsia- already depleted intravascular volume
● anaemia- reduced oxygen carrying capacity
● small women with smaller circulating volume

- 42 -
Management
In managing major obstetric haemorrhage, many steps should occur simultaneously. The
incidence and volume of PPH may be underestimated by up to 50% due to clinical difficulty in
estimating blood loss.

Delay is a major cause of maternal morbidity and mortality usually due to a combination of factors
including:
● failure to recognize excessive bleeding
● failure to institute prompt resuscitation
● failure to identify and control cause of bleeding

Therefore, consider:
1. Active management of 3rd stage (prophylactic oxytocin administration at delivery of anterior
shoulder, uterine massage and controlled cord traction) by obstetric team is the most
effective means of preventing PPH
2. Call for help: colleagues and senior staff (Anaesthetics / obstetrics / midwifery)
3. Ensure adequate oxygenation/ventilation (patent airway, supplemental oxygen +/-
intubation)
4. Blood for FBC, coagulation screen and fibrinogen, cross match.
5. Restore circulating blood volume and cardiac output
○ 2 large cannula (16G), vasoconstrictors
○ Initial volume should be 2 litres of warm Hartmann’s or Plasmalyte-148 followed
until blood is available.
○ Cell saver – if in OT
○ High pressure infusion devices can be considered
6. Monitoring
7. Rapid assessment
○ severity
○ aetiology
○ brief anaesthetic assessment including examination
8. Activate the Massive transfusion protocol if massive blood loss is suspected or has
occurred.
o Give blood and blood products based on severity, speed of bleeding guided by
ABG and coagulation studies (coags, fibrinogen, TEG) and haemodynamic and
clinical response to treatment.
o Blood products should ideally be given through a blood warming device
o Liaise with the transfusion haematology registrar (page 27150)
If urgent, give uncrossmatched Group O Rh negative blood if required.
o X-matched, type specific, O Rh neg depending on level of urgency
9. Treat cause
○ medical care - oxytocin, ergometrine, syntometrine, 15-methyl-PGF2α, misoprostol
○ surgical
10. Call for extra help as needed
11. Reassess
○ Continuing loss/effectiveness of resuscitation
○ Consider arterial line/temp probe
○ Consider further blood or blood products
12. Keep patient warm (Forced air warmer - “Cocoon” or “BAIR hugger”)
- 43 -
 13. Early administration of Tranexamic Acid (1g)
14. Consider the use of TEG to monitor any coagulopathy and guide replacement therapy
15. Monitor calcium levels and supplement particularly with large blood product replacements
16. Continuing care
○ birth suite/HDU/ICU
○ Monitoring
○ Management of any complications e.g. ARDS

PPH ≤ 1L guideline
Managed by obstetric team
Call for help
● Team leader
● Obstetric registrar
● Assign midwife/RMO for communication and documentation
Resuscitation
1. Insert large cannulas
2. Take blood for FBC, EUC, coags, fibrinogen, cross match if bleeding is rapid or
approaching 1L
3. Monitor and record blood pressure and pulse every five minutes (preferably with automatic
machine)
4. Give oxygen if physiologically compromised
Volume replacement
1. 1L crystalloid (Hartmann's)
2. Maintain fluid according to blood loss and symptoms; aim to replace 3× blood loss with
crystalloid; consider blood transfusion after 2-3L crystalloid
Managing atony
1. Keep patient warm
2. Massage fundus
3. Uterotonics
1. Oxytocin infusion 40 units / 1L Hartmann's at 250 mL/h via IV pump
2. Ergometrine 500 mcg im or 125 mcg slow iv (in the absence of hypertension or
peripheral vascular disease)
3. Misoprostol 800 mcg pr or gemeprost 1mg
4. Manual evacuation of uterine clots if bleeding despite adequate tone
5. Consider possibility of uterine inversion if difficult to palpate
6. Bimanual compression if still bleeding

Managing retained tissue

1. Re-examine placenta for completeness
2. Review ultrasound report for succenturiate (accessory) placental lobe
3. Proceed to theatre if retained products (e.g. cotyledons)

Managing lacerations
1. Thoroughly examine perineum, vagina and cervix
2. Consider uterine rupture
3. Consider need for theatre

- 44 -
Managing coagulopathy
1. reassess coagulation screen every 30 min if still bleeding (see below)

PPH > 1L guideline

Additional to first-line management:
Call for help
● Obstetric consultant
● Anaesthetic consultant
● Haematology consultant
● Blood bank
● Theatre
● Code blue/ALS (dial 222), especially if on postnatal ward
Resuscitation
1. Blood pressure, pulse, respiratory rate every five minutes
2. Temperature every thirty minutes
3. Insert arterial line
4. ECG, pulse oximetry
5. Continue bimanual compression as a bridge to definitive treatment
Volume replacement
1. give blood through pump set and warmer
2. anticipate coagulation problems and manage as per massive transfusion guidelines
In theatre
1. Intra-myometrial Carboprost (15-methyl-PGF2α) (250-500mcg, can also be given by deep
IM injection – 250mcg every 15 mins up to a maximum of 2mg); rarely by senior registrar in
delivery suite if theatre unavailable, ECG monitoring advised, 0.1% risk of cardiac arrest
2. Remove retained products
3. Repair lacerations
4. Tamponade
○ packing
○ Rusch/Bakri/Sengstaken devices
5. Laparotomy
○ arterial ligation (uterine, ovarian, internal iliac)
○ haemostatic suture (B-Lynch)
○ hysterectomy
6. Angio-embolisation if available
7. Prophylactic antibiotics
8. Thromboprophylaxis including calf compressors for five days
Some general notes on PPH
- Hypotension is a late and ominous sign
- Do not rely on a single Hb result, as it may give false reassurance by reflecting an
acceptable Hb value but in the context of a reduced circulating volume
- As the number of women with a history of previous caesarean sections increases,
so does the prevalence of abnormal placentation.
- Point of care testing coagulation testing (TEG) is available, but it requires a skilled
staff member to perform the assay. It will identify coagulation system deficiencies
faster than traditional laboratory tests. However, laboratory tests should still be
performed at regular intervals during PPH resuscitation to aid blood bank and
haematology in providing the required blood components.

- 45 -
Code crimson
Denotes PPH >1500ml OR Woman that continues to bleed and is symptomatic regardless of
volume lost.

This code may also be used for situations such as rupture ectopic pregnancy. In the above
situation, all the same staff are notified as with a code critical LSCS but allows theatre to set up for
management of major blood loss including laparotomy rather than setting up for LSCS.
Preparations should be made in theatre for managing this.

Uterine inversion
Uterine fundus becomes displaced, usually in 3rd stage of labour. It is classified as “complete” if
the fundus passes through the cervix.

Haemorrhage can be severe and the clinical signs of shock can be out of proportion to the blood
loss. A reflex bradycardia can be mediated by traction on the ligaments supporting the uterus.

Placental abruption
Premature separation of a normally situated placenta.

Intrauterine death implies that a large abruption has occurred, as sizable covert haemorrhage can
occur into the uterine myometrium. Coagulopathy can be expected in around half of women in
whom intrauterine death has occurred, but this is less unlikely if the fetus has been delivered alive.

Cell salvage

Indication in obstetrics
● Actual or anticipated major haemorrhage during CS e.g. Placenta praevia with risk factors
for placenta accreta
● CS in the patient with objections to donor blood transfusion
● Difficulty in the provision of cross-matched blood e.g. rare blood type

You should transfuse any salvaged blood using the same guidelines as with homologous blood.

Contraindications
● Presence of infection or malignant tumours in the operative field.
● Sickle cell disease (but not trait)
● Recovery of blood from vagina (potential for bacterial contamination from normal resident
bacteria).

The use of cell salvage is a clinical decision and each case should be considered individually. In
some situations, the benefit to the patient may outweigh the risk of the usual contra-indications,
particularly in situations of life threatening haemorrhage.

- 46 -
Rules for use in obstetrics
● Wherever possible the use of cell salvage should be discussed with the patient in advance
and this should be documented.
● The cell salvage machine operator must have undergone training, be competent and
understand cell salvage in the obstetric situation.
● Aspiration of amniotic fluid into the cell salvage collection reservoir must be minimized. This
can be done using a separate sucker for initial removal of amniotic fluid.
● Salvaged blood for reinfusion must be clearly labeled with the patient’s name, hospital
number and use by time and must be prescribed by medical staff, according to standard
operating procedures.
● Salvaged cells should be infused within 6 hours of the start of the collection through a
leucocyte depletion filter to minimize the risk of infusing fetal cell debris.
● Transfuse as per normal guidelines i.e. only as indicated and not just because salvaged
blood is there.

- 47 -
Caesarean section

Classification
All caesarean sections should be classified according to the severity of the primary indication. This
will indicate to all personnel the degree of urgency of the operation, which should facilitate
organization.

Class 1 (Code critical)

For this group of women delivery needs to be immediate. As a general rule, this group is defined
by the presence of an immediate threat to the life of mother or fetus. The usual indications are not
exclusive and clinical judgement may include others.
o Cord prolapse (and not fully dilated and deliverable vaginally)
o Scalp lactate ³ 4.9 mmol/L using LactatePro
o Severe and unresolved fetal bradycardia > 9 mins
o Code critical can be cancelled in OT if bradycardia resolves
o CTG showing abnormal baseline with reduced variability and late or atypical variable
decelerations where a scalp lactate is unable to be performed and the obstetrician feels
the CTG qualifies as a ‘code critical’
o Placental abruption with pathological fetal heart rate pattern
o Failed assisted delivery with pathological fetal heart rate pattern
o Retained second twin.

A general anaesthetic may be required. However, topping up a working existing epidural block
is often as fast as a GA and is safer for the woman. In some situations, a spinal anaesthetic
can be inserted after consultation with the obstetric team. Close consultation between obstetric,
midwifery and anaesthetic teams is paramount.

The woman should be transported in a position which maximizes placental circulation e.g. left
lateral; IV fluids should be increased if in progress, and any oxytocin infusion stopped.
Due to the urgency of the procedure partners should not be present in theatre; they should remain
in birth unit unless the situation changes where they can be brought around to the operating room.

The CTG machine should be transferred to theatres with the patient. It should be reconnected as
soon as possible in the operating suite to reassess the fetal heart rate and to re-assess the
urgency of delivery with respect to fetal distress.

At this stage, for various reasons, there are no specific recommendations for time frames in which
the different category caesareans should be delivered. It is generally felt that code critical
caesareans should aim for a decision-to-delivery time of less than 30 minutes.

Class 2 (Previously called code urgent)

This represents a situation in which there is maternal and/or fetal compromise but it is not
immediately life threatening. The aim is to have the woman in the OT within 30mins and to have
the baby delivered within 60mins.

- 48 -
Indications include but not exclusive:
• Pathological CTG with scalp lactate <4.9mmol/L
• Pathological CTG where only one or two of abnormal baseline, variability and
deceleration pattern are present and the obstetric consultant/registrar feels the situation
doesn’t qualify as a class 1 caesarean.
• Failed instrumental delivery without pathological CTG
• Failure to progress in the second stage of labour and unsuitable for an instrumental
delivery.

Establishment of neuraxial anaesthesia should not delay delivery of the fetus beyond 60mins.
The woman should be transported in left lateral position. Fetal heart rate monitoring via doppler or
continuous CTG should be available in theatre and the rate should be recorded prior
commencement of anaesthesia.

Class 3
This represents a situation where there is no maternal of fetal compromise but the woman requires
early delivery. The aim is to have the woman in the OT within 90mins and to have the baby
delivered within 120mins. The time frames can be extended based on theatre case urgencies and
the availability of the obstetric consultant/registrar due to birth unit priorities. It can only be
extended after discussion between the obstetric consultant/registrar and the duty anaesthetist
(8460).

Indications include but not exclusive:

• Failure to progress in the first stage of labour with a normal CTG
• Booked elective caesarean section in early labour or following rupture of membranes
• Breech or twin presentation in early labour but planning caesarean delivery
• Premature delivery for preeclampsia after stabilization of blood pressure.

While awaiting delivery, the woman and fetus should be closely monitored especially where delay
in delivery occurs.

Fetal heart rate should be determined and documented prior to commencement of the caesarean.

Class 4

Essentially elective caesarean section. Delivery is timed to suit the woman and theatre availability.
These patients should be booked onto the elective caesarean section lists. Obstetric doctors
should contact the O&G departmental secretary to organize the date and time and submit the
required RFA to bookings.

Occasionally a late booking for an elective caesarean section (late diagnosed breech), will need to
be made and there are no available spots on the upcoming elective lists. In this circumstance the
O&G registrar/consultant will need to discuss the case with the duty anaesthetist (8460) to arrange
a suitable time for the case.

Skin-to-skin with the baby will generally be offered to the woman during elective caesarean
sections. This is encouraged and is beneficial to mother and baby. If clinically an issue arises with
the mother that makes this unsafe, communicate your concerns with the midwife and ask for the
baby to be removed from the mother’s chest so that the mother can be appropriately managed.

- 49 -
Notification of Class 1 (Code critical) caesareans

The midwife / obstetric registrar / CMO should call switchboard on 2222 and identify a “CODE
CRITICAL Caesarean Section Birth Unit. A group page will then be generated to all staff required.

Notification for Class 2 - 4 caesareans

● The obstetric registrar should inform the duty anaesthetist (8460) of the urgency of the
caesarean and the time of the call should be documented on the partogram
● The obstetric anaesthesia consultant (8486) or registrar (8596) should be informed by the
midwife / obstetric registrar
● Neonatal registrar should be informed by the midwife if the indication for CS requires their
presence.
● The woman’s partner / support people should be informed if they are not present and if the
woman chooses

Preparation:
● The woman should have intravenous access (18G/16G)
● Syntocinon should be ceased if in progress
● If an epidural is in place, an IDC should be in place with an hourly urine bag. If this is not
the case, an IDC should be inserted or the bag changed but it should not delay transfer to
the operating suite.
● It is recommended that the anaesthetist documents the indication and the declared urgency
of every non-elective CS on the anaesthetic chart.

General Points for CS

If there is excessive blood loss (>500mL), difficulty with haemostasis or the operation is > 60
minutes in duration the consultant should be called if not already present. The uterus should not be
exteriorized with a regional block without discussion with the anaesthetist.

Investigations
Each patient should have recent FBC and blood group and hold (where indicated). Pre-operative
transfusion is not usually considered at Hb>9g/dl.

In cases at high risk of hemorrhage, red cells should be cross-matched and delivered to theatre
prior to starting anaesthesia.

Note: ‘Turnaround’ times quoted by the transfusion laboratory are 40 minutes for a new specimen
and 10 minutes for a Group and Hold already in the lab. Group And Hold samples are only valid for
3 days.

Urea and electrolytes only if specifically indicated.

- 50 -
Diabetes Mellitus
Diabetes in pregnancy is very common. Below are the approved guidelines for the management of
diabetic patients in the perioperative
This document issetting with
valid on the regards
day toonly:
of printing caesarean sections.
14 Dec 2016

Western Sydney Local Health District

5. Planned morning LSCS

Diagnosis GDM or Type 2 GDM or Type 2 on insulin Type 1

Prior to Diet only 30 nits ins lin / da > 30 units insulin / day QID insulin regimen Pump therapy
Procedure metformin metformin Notify patient s endocrinologist or on-call
consultant
Cease metformin Cease insulin and Cease insulin Omit normal am insulin dose Discontinue pump
metformin (as applicable)
Commence insulin/glucose Commence insulin/glucose Commence insulin/glucose infusion at 0600hrs
infusion at 0600hrs infusion at 0600hrs
Titrate Insulin/glucose to Titrate Insulin/glucose to keep Titrate Insulin/glucose to keep BGLs 4 – 7 mmol/l
keep BGLs 4 – 7 mmol/l BGLs 4 – 7 mmol/l
Omit breakfast Omit breakfast omit breakfast omit breakfast omit breakfast
BGLs 2/24 BGLs 2/24 BGLs 1/24 BGLs 1/24 BGLs 1/24

Procedure

Post Commence fluids Commence fluids Commence fluids Commence fluids* Commence fluids*
Procedure
Endocrine team review insulin Endocrine team review insulin
Recommence diet Recommence diet once Recommence diet once Recommence diet once fluids are Recommence pump at basal rate and cease
once fluids are fluids are tolerated fluids are tolerated tolerated infusion as per Insulin Algorithm
tolerated
Give SC insulin prior to meal Recommence diet once fluids are tolerated
Cease insulin/glucose Cease insulin/glucose infusion as Give bolus insulin dose via pump prior to meal
infusion per Insulin Algorithm
BGLs Fasting and BGLs Fasting and 2 hrs pc BGLs Fasting and 2 hrs BGLs ½ ac and 2 hrs pc meals BGLs ½ ac and 2 hrs pc meals
2 hrs pc meals meals pc meals
Remove cannula only when BGLs Remove cannula only when BGLs stable and
Recommence Recommence medication Recommence medication stable and tolerating food tolerating food
medication only if (insulin or metformin) only if (insulin or metformin)
indicated by high indicated by high BGLs, as only if indicated by high
BGLs, as per per endocrine team BGLs, as per endocrine
endocrine team team

This document is valid on the day of printing only: 14 Dec 2016

Western Sydney Local Health District

Copyright WSLHD Page 10 of 17
Diabetes in Pregnancy: Intrapartum and Postnatal care Version 0.5
PlannedDate Created:
afternoon July 2009
LSCS (Arrival by 1100hrs on day of surgery) Last Updated: 2/8/2012
th th
Drug Committee
Diagnosis GDM orapproved:
Type 26 August
GDM 2012
or Type 2 GDM or Valid2 until:
Type on 6 August 2014 Type 1
on insulin insulin
Treatment diet only 30 ni in lin per da >30 units insulin per day QID insulin Pump therapy
metformin metformin metformin No if pa ien endocrinologi
or on-call consultant
Prior to Give metformin pre give normal am insulin & give normal am insulin and give normal am insulin pre Continue normal basal rate of
Procedure breakfast metformin pre breakfast
metformin pre breakfast breakfast) insulin

ligh b fa a light breakfast at 0600hrs light breakfast at 0600hrs light breakfast at 0600hrs light breakfast at 0600hrs
0600hrs
Replace MT with Replace MT CHO intake with Replace MT CHO intake with Replace MT CHO intake with Replace MT CHO intake with
CHO fluid (up appropriate CHO fluid (up to
to 1100hrs) 1100hrs) appropriate CHO fluid (up to appropriate CHO fluid (up to appropriate CHO fluid (up to

1100hrs) 1100hrs) 1100hrs)

BGLs 2/24 BGLs 2/24 BGLs Hourly BGLs Hourly BGLs Hourly
Commence Insulin /glucose Commence insulin/glucose infusion Cease pump and commence
infusion by 1100hrs by 1100hrs insulin/glucose infusion
omit pre-lunch insulin & Titrate Insulin/glucose to keep Titrate Insulin/glucose to keep BGLs Titrate Insulin/glucose to keep
metformin (if applicable) BGLs 4 7 mmol/l 4 7 mmol/l BGLs 4 7 mmol/l
omit lunch omit lunch omit lunch omit lunch omit lunch

Post- As for planned As for planned morning LSCS As for planned morning LSCS As for planned morning LSCS As for planned morning LSCS
procedure morning LSCS

Diabetes in pregnancy: Intrapartum and Postnatal care V1.0

Women with gestational diabetes do not usually need insulin after delivery.
Copyright WSLHD Page 11 of 17
Diabetes in Pregnancy: Intrapartum and Postnatal care Version 0.5
Date Created: July 2009 Last Updated: 2/8/2012
th th
Drug Committee approved: 6 August 2012 Valid until: 6 August 2014

- 51 -
Coordination of caesarean sections by severity rating

Urgency Examples Whom to Who Response Subsequent

call calls action
automatic: duty
anaesthetist
cord prolapse, scalp (8460), obstetric Patient
lactate >4.9, anaesthetic transferred to
terminal fetal consultant the operating
bradycardia, other (8486), obstetric suite ASAP by
Code severely doctor anaesthetic birth unit
critical pathological CTG or registrar (8596), midwives.
dial 2222
(Class 1) (e.g. in placental senior obstetric
(<15mins) abruption), failed midwife registrar (8867), On arrival, the
instrumental delivery theatre NUM/TL patient will be
with pathological (8780), delivery transferred to
CTG, maternal NUM/TL the assigned
cardiac arrest (27243), operating room.
neonatal
registrar (8785)

pathological CTG
with scalp lactate
≤4.9, pathological
CTG not requiring
Duty
"Code critical", failed anaesthetist will
instrumental delivery advise delivery
suite of
with normal CTG, page duty duty
Class 2 obstetric availability and
anaesthetist anaesthetist
(< 1hr) obstructed labour in doctor time for transfer,
(8460) (8460)
obstetric doctor
first stage with non- to submit
reassuring CTG, electronic
"green sheet".
failure to progress in
second stage and
unsuitable for
instrumental delivery

obstructed labour in
duty
first stage with
anaesthetist will
reassuring CTG,
advise delivery
booked caesarean
suite of
in early labour or page duty duty
obstetric availability and
Class 3 SROM, premature anaesthetist anaesthetist
doctor time for transfer,
delivery for maternal (8460) (8460)
obstetric doctor
condition (e.g. pre-
to submit
eclampsia), breech
electronic
in labour unsuitable
"green sheet"
for vaginal delivery

- 52 -
Intrauterine Fetal Resuscitation
Thurlow 2002 In an emergency caesarean section, especially a code critical situation the following
measures should be considered:
● Syntocinon off
● Position full left lateral
● Oxygen
● IV infusion of 1 litre of warm crystalloid
● Low BP: IV vasopressor
● Tocolysis: salbutamol 2 x 100mcg puffs, terbutaline 250 mcg sc, GTN 2 x 400mcg puffs
sublingual - repeat after 1 min until contractions stop: max of 3 doses (not if abruption/
antepartum haemorrhage), Anginine™ tablet 300 mcg sublingually (kept in theatre main
drug store)

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Patient preparation for caesarean section
The purpose of this document is to optimize women prior to Caesarean Section (CS). Where
possible the guidelines are based on the best available evidence.

For the purposes of these guidelines all parturients should be classified as either “high risk” or “low
risk”, on the basis of probability for the requirement for operative delivery or operative control of
post-partum haemorrhage.

Parturients should be classified as high risk in the following situations:

● Multiple pregnancy
● Anticipated difficult CS (3 or more previous CS, known fibroids, previous difficult operation)
● Placenta praevia (or increta, accreta, percreta)
● Morbid obesity (BMI > 35kg/m2)
● PIH or pre eclampsia
● Antepartum haemorrhage
● Anaemia (Hb < 100 g/L)
● Previous history of postpartum haemorrhage
● Pre-existing coagulopathy
● If there are known antibodies present
● VBAC (vaginal birth after caesarean section)
● Abnormal presentation (breech, abnormal lie)
● IUGR (intrauterine growth restriction)
● Slowly progressing labour

Antacid therapy for aspiration prophylaxis

Guidelines currently still recommend all patients who undergo CS should receive antacid therapy.
Studies have demonstrated monotherapy with ranitidine provides better gastric pH modification
than proton pump inhibitors. However, ranitidine was withdrawn in 2019. Below is how antacid
prophylaxis is currently managed at Westmead, due to the drug’s withdrawal.

Class 1 – Code Critical and class 2 caesarean sections

Oral sodium citrate should be provided on transfer to theatre.

Class 3
Oral sodium citrate 30ml should be provided on transfer to theatre.

Elective CS
Currently no antacid therapy is routinely provided for elective caesarean sections. Most elective
caesarean cases are performed under spinal anaesthesia, with a very low rate of conversion to
general anaesthesia. Oral sodium citrate can however be given in the anaesthetic bay, at the
attending anaesthetist’s discretion. It should be given to all caesareans which are planned to be
performed under general anaesthesia.

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Fasting in labour
Fasting in labour is a contentious issue given the considerations of prolonged labour, high rates of
nausea and vomiting in parturients, decreased rates of gastric emptying and risk of aspiration
during CS. Parturients at Westmead Hospital should be managed by the following guidelines:

Parturients in labour
Parturients are permitted to eat a light diet during labour (usually during early labour), if tolerated.
Nausea and vomiting is common with labour and most woman will then only tolerate clear fluids.
After epidural insertion, oral intake should be that which is appropriate for their stage of labour.
High risk patients should be restricted to clear fluids only following establishment of labour.

Semi-elective and urgent CS

Parturients should begin fasting at the time that CS is first considered.

Elective CS
Patients should be fasted for theatre as per normal fasting guidelines, i.e. fasting from solids for
6hrs, clear fluids for 2hrs. Patients can be advised to have their last clear fluids just prior to leaving
home. Prolonged fasting should be avoided where possible.

Transfusion Preparation
Predicting and planning for blood transfusion is an issue receiving much attention at this time. It is
widely accepted that low risk patients undergoing elective CS have a negligible transfusion rate
and that these patients should not have compatibility testing performed as a matter of routine.
Which patients should be tested remains contentious. These local guidelines are presented based
on incomplete evidence and expert opinion.

Elective CS (low risk)

These patients do not require compatibility testing prior to CS

Elective CS (high risk)

These patients should have had a group and screen performed prior to their presentation to the
Day Surgery Unit or on the day of their surgery. Note that group and screen is only valid for 72h in
pregnancy. Patients who should have a group and screen include:
• Multiple pregnancy
• Repeat caesarean section (2 or more previous sections)
• Placenta praevia or suspected or confirmed accreta/increta/percreta
• Morbid obesity
• Preexisting coagulopathy
• Pre-eclampsia or Pregnancy induced hypertension (PIH)
Clinical discretion will guide whether a crossmatch is performed instead of a group and screen,
however a crossmatch should be considered for
● Anterior or grade 4 placenta praevia or placenta accreta/percreta/increta
● Preexisting coagulopathy

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Inpatients on the antenatal ward
These patients should have a current group and screen throughout their inpatient stay if any of the
high risk indicators are present as well as if they have had antepartum haemorrhage or
PIH/preeclampsia.

Birth unit
High risk patients should have a group and screen performed on admission. Low risk patients do
not require a group and screen if vaginal delivery is planned. If CS is being considered for any
patient (even if “low risk”) an effort should be made to obtain a group and screen whilst
preparations are being made for transfer to the operating theatre.

Transfer of patients for a Code Critical CS should not be delayed just for compatibility testing but
this should be communicated to the Anaesthetic team immediately on arrival to theatre. In the
context of large volume or ongoing blood loss a crossmatch is indicated i.e.:
● Anterior or grade 4 placenta praevia or placenta accreta/ percreta/ increta
● Uterine rupture
● Large antepartum haemorrhage
● Severe eclampsia with evidence of coagulopathy
● Preexisting coagulopathy

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Anaesthesia for caesarean section

Single shot spinal

More rapid anaesthesia with less anaesthetic and a denser block is obtained with a spinal
anaesthetic. Compared with an epidural there is less need for intraoperative analgesic
supplementation/ conversion to GA.

Should use small (24-27G) pencil point needle (Whitacre or Sprotte) as the incidence of headache
is much less than with comparative Quincke type needles.

If there is pain or paraesthesia in association with needle placement or injection, STOP and
withdraw needle.

Because it is recognized that the conus medullaris can extend lower than was previously
recognized (and anaesthetists often think they are going lower than they are) spinal needles
should never be inserted above L2/3 Reynolds 2001.

Advantages of regional anaesthesia include:

● minimal/absent:
○ aspiration risk
○ failed intubation
○ unintended awareness
○ neonatal depression
● reduced blood loss
● reduced DVT risk
● better postoperative analgesia
● participation of both parents in the birth experience
● ability to have skin to skin contact immediately after delivery

Principles of safe management

● Antacid prophylaxis
● Avoid aortocaval compression at all times (uterine displacement /operating table tilt/ hip
wedge)
● Phenylephrine or metaraminol infusions should be drawn up
● Drugs for general anaesthesia should be readily available
● Establish an i.v. infusion (Hartmanns, 16G cannula)
● All drugs which are to be injected into the subarachnoid space must be drawn up through a
particulate filter.
● If fentanyl is used, then the ampoule neck should be swabbed with an alcowipe before
drawing up
● Check BP prior to starting. As a general rule, maintain systolic arterial pressure above
100mmHg. Vasopressor infusions of phenylephrine or metaraminol, should be given after
spinal placement to maintain BP. There is at present no known advantage of either
vasopressor over the other and should be determined by the anaesthetist’s preference.

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Spinal Drug doses
1. Bupivacaine 0.5% heavy or plain 2.0 to 2.5ml
2. Fentanyl 15-25mcg
3. Morphine 100mcg

Pre-term women (28-35 weeks) have a requirement for more local anaesthetic than those at term
(>38 weeks), probably because of reduced caval compression and displacement of the dura by
engorged epidural veins James 1997.

Barbotage is not recommended but it is important to confirm that CSF can be aspirated during and
on completion of injection of the solution.

Alpha agonists tend to increase blood pressure with a concomitant decrease in heart rate. A
phenylephrine infusion may be used for prophylaxis against hypotension.
● Phenylephrine (1amp = 10mg) diluted into 100ml normal saline bag (100 mcg/mL). Draw up
20 or 50mL into a syringe.
● Start at 15 ml/hr (25mcg/min) when the spinal is inserted and titrate rate to BP. Aim to
titrate down rate after delivery of the baby with the aim to have stopped it by the end of
procedure.
● Ensure connected to side port of good flowing IV fluid line.

If woman becomes pale and nauseated or starts yawning, assume that the BP has dropped and
react accordingly. Don't wait for a BP reading.

IMPORTANT: Bradycardia may result from the block spreading to the sympathetic innervation and,
more ominously, a reflex response to decreased atrial filling. Bradycardia is an early warning that
venous return is diminished and hypotension will follow. Prompt treatment with fluid, a vasopressor
and possibly an anticholinergic agent should be given.

Unlike epidural analgesia that may be patchy, spinal anaesthesia virtually guarantees complete
sensory loss below the most cephalad level. Therefore, all the dermatomes do not need to be
tested.

Anaesthesia should extend from T4 to S4 at time of delivery. A block to T4 should be confirmed

and documented prior to starting surgery. The surgeon should also test the block with forceps at
the line of incision prior to incision.
- Blockade of light touch at T5 is emerging as a more specific measure of adequate
anaesthesia than blockade of cold at T4.

In the event of inadequate block, don't attempt a second intrathecal injection without discussion
with someone senior. Estimation of appropriate doses is difficult. If time permits insert an epidural
catheter and titrate dose. In the event of fetal compromise, general anaesthesia is indicated.

Post-operative
● Regular paracetamol 1g qid iv/po (0600/1200/1800/2200hrs) for 3 days
● Regular diclofenac 50mg tds po with food (0600/1400/2200hrs) OR ibuprofen 400mg tds for
3 days
● Mobilize normally.

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Parecoxib does not have TGA approval for breast feeding women. However, it is widely used and
is most likely safe. The dose is 40mg post delivery, instead of a diclofenac suppository. Parecoxib
also costs $17.72 vs $0.39 for PR diclofenac, with no obvious clinical superiority. Routine use of
parecoxib at caesarean section can add up to $30,000 extra in drug expenses alone for the
hospital without clinical benefit and should be used in situations where consent for suppositories
hasn’t been obtained (code criticals).

Oral oxycodone (5-10mg q2h) is not restricted in women who have received neuraxial opioids. If
there is inadequate pain control, then the acute pain service should be contacted.

Naloxone 40mcg IV q5min to maximum of 5 doses should be charted for pruritus.

The Neuraxial Opioid Observation chart should be completed (indicating if hourly observations
should be for 6 or 12 hrs). Second hourly observations will then continue for a total of 24 hours on
the ward.

Epidural and combined spinal/epidural anaesthesia

Indications for epidural

● Epidural is in situ and used for labour analgesia.
● When a regional technique is preferable to general anaesthesia but spinal anaesthesia is
relatively contraindicated e.g. cardiovascular disease.

Epidural top up
Explain the procedure and indications to patient. Emphasize that they will feel the sensation of
pressure but not pain. The most reliable indicator of an epidural top-up being successful for
anaesthesia is that it was providing good labour analgesia. If the woman has a patchy block,
consider resiting the epidural.

Use lignocaine 2% with adrenaline (18ml) and add fentanyl 100mcg (2ml). Use up to a total of
20ml of this mix. If the patient has received epidural fentanyl as part of their labour analgesia, there
may be no additional benefit to adding fentanyl to the top-up solution. In fact, this may be
associated with increased nausea and pruritus. Volume may be influenced by time since most
recent top up in the Birth Unit. If the woman is currently not feeling her contractions, consider
giving 10-15mL of the top-up solution initially.

The majority of the top up should be done in theatre, as administration of an anaesthetic dose in
the Birth Unit may risk the development of complications during the poorly monitored transit.
Carefully commencing the top-up in Birth Unit can however allow for rapid establishment of
anaesthesia and should be considered in urgent situations. No more than 10mL should be given in
birth unit. Once the top up is started, do not leave the patient.

Epidural blocks may be patchy, therefore all dermatomes should be tested on both sides and the
limits of the block and any missing segments should be documented. The obstetrician should test
the block prior to incision.

IV opioids such as fentanyl 20-50mcg increments can be used to control any breakthrough pain
and should not be withheld for fear of fetal depression. Oxygen and nitrous oxide mixes may also

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be administered via the anaesthetic breathing circuit. Unrelieved persistent pain MUST be treated
with a GA.

If uterine relaxation is required (e.g. for delivery of 2nd twin) 50-200mcg increments of IV GTN may
be given.

A dose of epidural preservative free morphine usually 3mg (though doses of between 1.5-3mg
may reduce itch without increased pain) (prefilled syringe 5mg/10ml) should be given after delivery
and will give good postoperative analgesia. Document this administration on the anaesthetic chart
and on the Neuraxial Opioid Observation Chart. The epidural catheter should then be removed at
the end of the case and prior to transfer to Recovery and an opsite dressing placed over the site.
Epidural catheter removal should be documented on an Obstetric Epidural Analgesia Observation
chart.

Postoperative analgesia same as single shot spinal

● Regular paracetamol 1g qid iv/po (0600/1200/1800/2200hrs) for 3 days
● Regular diclofenac 50mg tds po with food (0600/1400/2200hrs) OR ibuprofen 400mg tds for
3 days

Oral oxycodone (5-10mg q2h) is acceptable after epidural morphine. If inadequate pain control,
then the acute pain service should be contacted with consideration of a fentanyl PCA.

Neuraxial Opioid Observation chart should be completed (indicating if hourly observations should
be for 6 or 12 hrs). Second hourly observations will be needed for 24 hours on the ward. Removal
of the intact epidural catheter should be documented after removal on the Obstetric Epidural
Analgesia Observation chart.

Combined spinal epidural

Because it is now recognized that the conus medullaris can extend lower than previously thought
(and anaesthetists often misjudge the interspace), spinal needles should not be inserted above
L2/3.

Potential advantages
● The initial subarachnoid injection can be deliberately conservative to minimize the risk of a
dangerously high block (e.g. in the morbidly obese, or women with difficult airways).
● In addition, the haemodynamic consequences will be minimized.
● Catheter may be topped up in the case of prolonged surgery.
Potential disadvantages
● Epidural catheter is untested because of block by spinal anaesthetic.

Post op epidural infusion

If specifically indicated (e.g. severe PIH) a continuous epidural infusion can be continued
postoperatively.

Note that obstetric patients with epidural infusions can only be cared for in the following units.
● Birth Unit
● Intensive Care Unit
● Surgical Close Observation Unit (D3D)

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Pain at caesarean section
Inadequate management of pain at caesarean section remains the most common cause for
litigation in regional anaesthesia, and can result in long term psychological consequences for the
mother.

Never dismiss a mother's report of pain, and always treat pain to the satisfaction of the mother.
If pain occurs:
● ask the surgeon to stop if possible
● administer 50-70% nitrous oxide in oxygen
● give fentanyl 25mcg iv up to 100mcg
● give ketamine 20mg up to 60mg
● remifentanil infusion (up to 0.02 mcg/kg/min)
● local anaesthetic infiltration by surgeon

If there is clearly inadequate analgesia despite these interventions, offer the woman general
anaesthesia. It is important to minimize the time taken to reach this point; to attempt all the above
interventions before offering general anaesthesia may result in undue delay.

Document the events and what treatments were offered to the patient.

General anaesthesia
If a woman elects to have a general anaesthetic in preference to a regional block she should be
warned about the increased risks of neonatal sedation, blood loss and postoperative pain.
However, this shouldn't be laboured, as it may be necessary to give a general anaesthetic in the
face of a failed regional block. A suitable form of words may be "both methods are very safe, but
an epidural/spinal is safer".

Pre-operative
Usual anaesthetic assessment should be done with a focus on airway management. Rapid
sequence induction should be explained. If difficulty is anticipated, then summon help before
starting.
Ensure familiarity with difficult airway devices and algorithms, including videolaryngoscopes.
Always consider the use of a supraglottic airway as a rescue device when intubation is difficult.
Minimize aspiration risk with the use sodium citrate.
BIS or entropy monitoring.

Induction of general anaesthesia for a code critical CS

1. Woman should be transferred in left lateral position.
2. Skilled assistant.
3. Sodium citrate given.
4. Free running drip with Hartmann’s solution or Plasmalyte. Ideally via a 16G IV cannula.
5. Position woman on table with left lateral tilt of 15° and full monitoring.
6. Optimize head and neck position for intubation.
7. Oxygen 100% by close fitting facemask at sufficient flow to prevent rebreathing.
8. Pre-oxygenate for 3mins or until end tidal oxygen concentration is 90%.

- 61 -
 9. Lightly apply cricoid pressure, then administer induction agent Thiopentone 5mg/kg or
Propofol 1-2mg/kg. Wait until eyelids drop then apply full cricoid pressure and give
succinylcholine 1-1.5mg/kg or Rocuronium 1.2mg/kg.
10. For a mother with cardiovascular or cerebrovascular disease, do not withhold opioid at
induction for fear of neonatal respiratory depression.

Difficult intubation hints

A smaller tracheal tube than predicted is often needed in obstetrics (usually a 7.0 ETT), especially
if there is a history of URTI or pre-eclampsia, both of which dispose to laryngeal edema.
A videolaryngoscope should usually be available at all after hours obstetric cases, in hours it can
be readily obtained if required. At Westmead this will usually be a CMAC.

Do not maintain cricoid pressure at the expense of oxygenation.

Remember women do not die from failure to intubate. They do die from

prolonged attempts to intubate in the face of hypoxia and from unrecognized

esophageal intubation → if in doubt, take it out and ventilate with bag and mask
and proceed down difficult intubation algorithm

Maintenance and reversal

When satisfied with ETT placement, switch to automatic ventilation.
Adjust fresh gas flow mix to 33-50% oxygen with N2O plus approximately 0.75 MAC of volatile
agent.
Remember the possibility of awareness at all times. Do not hesitate to increase the volatile as
needed. Monitor with BIS or entropy.

In the event of life threatening haemorrhage discontinuation of the volatile agent may be
considered as a measure to improve uterine tone, in such a situation, ketamine in 25mg
increments could be used to maintain anaesthesia or conversion to propofol TCI.

Estimation of blood loss may be difficult because of

● Mixing of blood with liquor
● Mothers preoperative increased circulation blood volume and rapid contraction of
uteroplacental circulation at delivery.

Therefore, significant loss can occur before development of tachycardia and hypotension. Extra
vigilance is therefore needed. Observe for pallor, which may signal need for transfusion.

Increments of non-depolarizing relaxant should be given.

After the umbilical cord has been clamped, give morphine IV 10-20mg or Fentanyl.

At the end of surgery, if a non-depolarizing muscle relaxant has been given then reverse and use a
nerve stimulator to confirm full recovery. This is particularly important if magnesium sulphate has
been given. Consideration of the use of Sugammadex should be made if incomplete reversal with
normal reversal agents or if there has been a short duration of surgery and large dose rocuronium
has been used at induction.

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Post GA
TAP blocks can be considered prior to emergence (20mL of 0.5% ropivacaine to each side is
usually adequate) plus:
1. Regular paracetamol (0600/1200/1800/2200) and diclofenac (with food 0800/1200/1800hrs)
for 3 days
2. Oxycodone 5mg QID regularly for 2 day.
3. PRN oxycodone 5-10mg q2h prn or PCA can be used for breakthrough pain
(PCA may not be as satisfying in the post-partum population as it is in general surgery,
owing to the restriction on mobilization and newborn care. It should not however be
withheld because of this, as good post-operative pain control is important to aid
mobilization and reduce complications).
4. Anti-emetics

Intravenous PCA
IV morphine or fentanyl (preferred) can be used when a CS has been performed under general
anaesthesia and / or there is a contraindication to regular NSAIDs.

This is prescribed in the same manner as for any general surgical patient having a PCA
commenced.

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Skin to skin at Caesarean section

At Westmead the practice of early newborn skin to skin contact is provided for mothers undergoing
caesarean section under neuraxial anaesthesia. It is an established routine for elective cases and
depending on midwifery staffing and activity in Birth Unit, it is also provided at appropriate
emergency caesarean cases. If the mother is accepting, not medically compromised and the
newborn is well after initial assessment, the newborn will be placed on the mother’s chest under a
baby blanket whilst the completion of surgery is occurring. The newborn and the mother’s support
person will remain in the operating room until surgery is completed and transfer to recovery with
the patient.

Benefits of skin to skin contact for the neonate

• Stabilizes respiratory, temperature and glucose.
• Regulates heart rate and blood pressure.
• Reduces stress hormones.
• Decreases crying.
• Increases the quiet alert state.
• Facilitates self-attachment for breastfeeding.
• Colonizes the newborn with good bacteria from the mother’s body, which along with
breastfeeding decreases allergic diseases.
o Just as important when the mother has made an informed decision not to
breastfeed – as the baby’s skin becomes colonized with the mother’s skin bacteria.
• Peristalsis is stimulated leading to early passage of meconium.

Benefits of skin to skin contact for the mother

• Diminishes perception of pain.

• Decreases anxiety levels.
• Increases stability of heart rate and blood pressure.
• Reduces risk of postpartum haemorrhage by up to 50% when the mother also breastfeeds
within the first 30 minutes of birth.
• Increases maternal behaviours.
• Mother shows more confidence in caring for her newborn.
• Increases success and duration of breastfeeding.

At the end of surgery skin to skin contact is maintained during the transfer process from operating
table to ward bed. This is undertaken by employing the usual careful patient transfer procedures.
The only difference is that the midwife will help in the transfer, to ensure the safety of the newborn.
The newborn is generally NOT removed for the transfer.

If at any time either the mother or newborn are compromised, skin to skin can be ceased through a
polite request to the midwife in attendance.

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Caesarean postoperative care.

Immediate postoperative care

All women who have undergone CS must remain in the recovery area for at least 30 minutes or
until discharge criteria have been met.

After general anaesthesia, supplementary oxygen should be administered until SpO2 is >95%
breathing air.

Before discharge from recovery ensure the following

1. Cardiovascular and respiratory variables are acceptable and stable.
2. Women have their pain controlled
3. Postoperative fluid, analgesia, antiemetics and LMWH have been charted

Prescriptions after Caesarean Section

Intravenous fluids
Bear in mind that up to 2-3 litres will generally have been given during surgery and that an
uncomplicated caesarean section patient should be drinking within a short time. The oxytocin
infusion (40units in 1000ml of Hartmann’s should be given over 4 hours). This is to be run via an
IVF infusion pump at 250ml/hr and a further 1 L of fluid prescription should ordinarily suffice for the
postop period. (these are prescribed via eFluids)

More fluid should only be prescribed due to clinical need (haemorrhage, protracted vomiting).

Particularly in pre-eclampsia be aware of potential fluid overload.

Women commonly become oliguric in the recovery ward. This is usually multifactorial, owing to the
antidiuretic effect of oxytocin, hypovolaemia from fasting and blood loss, and hypotension causing
renal hypoperfusion. Consider giving a 500mL of fluid (e.g. Hartmann’s or Plasmalyte). Always
assess the fluid status of the patient if you are asked to review oliguria.

Anaesthesia for other operative procedures

Apart from Caesarean section, you may be asked to provide anaesthesia for
● Insertion of cervical suture
● Trial of instrumental delivery
● Suturing of third degree tears
● Delivery of retained placenta
● Evacuation of products of conception
● Laparotomy/Laparoscopy

Regard every woman from 16 weeks of pregnancy until 2 days post-partum, or any woman with
symptoms of gastro-esophageal reflux as having a stomach full of acid contents. All women should
have antacid therapy determined by their urgency and anaesthetic technique. If a GA is chosen,
induction by rapid sequence induction is usually employed.

- 65 -
Some anaesthetists may use 2nd generation LMAs for cervical suture insertions up to 20 weeks if
they are well fasted and don’t have symptoms of gastroesophageal reflux.

Intrauterine procedures, particularly manual removal of placenta, require a block up to T6.

Spinal or epidural anaesthesia is preferable, especially if an epidural is already in place. Beware of
contraindications e.g. coagulopathy or hypovolemia, and ensure euvolaemia before establishing a
block.

The above procedures should be performed in the operating theatres.

Beware of any forceps/ vacuum delivery that turns into a Code Critical emergency CS. Discuss the
likelihood of vaginal delivery with the obstetrician. If there is any chance of a CS becoming
necessary, transfer to theatre and ensure adequate block to T4 prior to procedure starting.

The baby should be monitored in recovery (with CTG) and in the ward in the post-operative period
in the case of cervical suture.

Retained placenta/ products of conception

Any woman who is pale, tachycardic and hypotensive after delivery must be considered to have
lost a substantial amount of blood until proven otherwise. Care consideration of anaesthetic
technique should take into account the volume status of the woman.

If appropriate, 2.0-2.2ml plain or heavy bupivacaine 0.5% should ensure cold sensation blockade
to T6 and maternal intra-operative comfort. Hypotension in the course of regional anaesthesia for
retained placenta may be related to the extent of maternal blood loss rather than block height.

Repair of perineal tears

Repair of perineal tears can be performed under neuraxial or general anaesthesia. If an epidural is
insitu and working this can be topped up with Lignocaine 2% with Adrenaline. Usually only up to 10
mls is required to achieve sufficient block for the surgery depending on the degree of block prior to
top up. Epidural morphine can be given to help with post op pain, prior to epidural removal.

If a spinal is chosen a reduced dose of ~1.5ml of 0.5% heavy bupivacaine + 100mcg intrathecal
morphine is required. Fentanyl generally is not needed.

If a general anaesthetic is chosen, then the usual technique for a pregnant woman is applied, with
RSI and ETT.

Always be aware of blood loss prior to arrival in theatres when deciding your anaesthetic technique
as it may have been significant.

Avoid opioids in postoperative orders. Regular paracetamol and NSAIDs are usually all that is
required especially if neuraxial opioids have been given.

Laparotomy/Laparoscopy
Pregnant women not uncommonly present with abdominal pain and require such procedures as
appendicectomy or ovarian cystectomy. These are best performed under GA.
Avoid postoperative NSAIDs where the fetus remains undelivered.

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EXIT Procedure
The Ex Utero Intrapartum Procedure (EXIT) is a surgical technique employed in selected cases
where there is potential for severe difficulty in securing the newborn airway due to a number of
causes. These can range from masses of the head and neck (eg. Cystic hygroma, teratoma),
craniofacial abnormalities with mandibular hypoplasia (esp. if also associated with polyhydramnios
or tracheal compression), laryngeal/tracheal atresia or lung or mediastinal masses (EXIT to
ECMO).

Multidisciplinary meetings involving paediatric ENT, anaesthetists, obstetricians, neonatologists etc

should be conducted well before the delivery date and a clear plan for whether the EXIT is
indicated and the plan for paediatric airway management formulated and agreed upon. The EXIT
procedure should be planned for a specific date agreed upon by all involved specialties. EXIT
procedures can be done under either neuraxial or more commonly general anesthesia.

Anaesthetic technique (GA)

On the day of the EXIT procedure the woman should be prepared as is usual prior to any
caesarean section. Antacid prophylaxis should be given and IV access, usually with two (2) large
bore IV cannulas and an arterial line, should be established. Ensure a valid Group & Hold. Conduct
a team briefing with all members present including introductions to ensure all are present and any
issues identified and corrected prior to bringing the patient into the operating room. The patient is
positioned in the lithotomy position for the procedure. Ensure adequate active patient warming with
forced air methods and fluid warmers.

The goals of the anaesthetic (prior to full deliver of the newborn) are to:
1. Anaesthetize the mother safely
2. Ensure full uterine relaxation until full delivery of the newborn
3. Inhibit any attempt by the newborn to breathe at the time of delivery
4. Maintain uteroplacental blood flow

This is usually achieved through:

- High dose volatile anesthetic (2 MAC) 20 mins prior to skin incision
- 50mcg bolus of GTN ~ 5 mins prior to skin incision and an IV GTN infusion
(50mcg/min = ~6 ml/hr of standard GTN infusion (50mg in 100ml 5% glucose)
- Remifentanil infusion (at least 0.15 mcg/kg/min based on maternal weight 15 mins
prior to skin incision). Higher levels can be given to ensure inhibition of newborn respiratory
efforts.

Vasopressor support is usually required (phenylephrine or metaraminol infusion) because of the

high doses of medications employed. After uterine incision is made the newborn head and one arm
are delivered to allow the paediatric anaesthetist / ENT surgeon access to the airway. The NICU
registrar will attempt to establish IV access in the available arm and attach a pulse oximeter.

During this time the uterine volume is maintained by the infusion of warmed Hartmann’s to replace
the lost amniotic fluid and help prevent the detachment of the placenta. Ensure the mother is fully
muscle relaxed, usually not an issue if high dose rocuronium is used at induction.

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Once the newborn airway has been secured and the newborn fully delivered the aims of the
anaesthetic are the reverse of previously. That is:
1. Maximize uterine contraction (to stop bleeding)
- reduce volatile anaesthetic concentrations to normal levels to reverse the effects
on the uterus
- higher fresh gas flow rates and addition of nitrous oxide allows significant
reductions quickly whilst maintaining anaesthesia
- cease GTN infusion
2. Uterotonics (oxytocin bolus + infusion +/- others (eg. ergometrine)
3. Change to a longer acting analgesic
- cease remifentanil and add opioid of choice for post op analgesia

Remember to reduce the amount of vasopressor you are delivering as you reduce the other
medications which have a hypotensive effect to prevent rebound hypertension.

After delivery the reversal of the anaesthetic medication effects on the uterine tone are not
immediate and as such bleeding can be more than expected. A cell saver is routinely set up in
these cases in preparation for the potential increased blood loss.

A suggested room layout is provided in the diagram below.

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Neonatal Difficult Airway Kit

At various times you may be notified of a potentially difficult neonatal airway. This will hopefully
have been recognized well before delivery and arrangements made. If an EXIT procedure is
expected this generally will have been planned previously with contact details recorded. The
obstetric anaesthetic consultant should be notified of an EXIT occurring out of hours.

There will be other circumstances where the neonatal team will request the presence of a
paediatric anaesthetist at delivery. If notified of this, the procedure is as below:

1. Locate and bring the neonatal difficult airway emergency box (located in the
anaesthetic storeroom) to the patient’s bedside in birth unit including a CMAC.

2. Notify a neonatal difficult airway anaesthetist

- The list of neonatal difficult airway anaesthetists and their contact numbers
are on the lid of the emergency airway box.
- Contact the paediatric anaesthetist who has previously been notified of the
case. If this hasn’t previously occurred, then you should contact the first
person on the list and work your way down the list until you locate an
available paediatric anaesthetist, as there is no formal on-call roster for this
service.

The neonatal difficult airway kit contains various airway aids for use with a neonatal airway. This
includes small CMAC blades, small LMAs, various masks and bougies and a T piece.

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Articles
These articles have been nominated as required reading for the Obstetric Specialized Study Unit.
1. Recognition and management of maternal cardiac disease in pregnancy
2. Intrauterine resuscitation: active management of fetal distress
3. Newborn life support algorithm
4. Management of pre-eclampsia: issues for anaesthetists
5. Use of uterotonic drugs during caesarean section
6. Epidural blood patch: myths and legends
7. Maternal haemorrhage
8. Obesity and obstetric anaesthesia
9. Oxytocin: a guide for anaesthetists
10. Vasopressors in obstetrics: what should we be using?
And a bonus: General anaesthesia for emergency caesarean delivery: is the time worth the
potential risks?

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Post Dural Puncture
GP Notification Letter

Dear Doctor, Date: __ / __ / ____

Re:

Attach patient sticker

This letter is to inform you that the above patient experienced a dural tap during the insertion of her
labour epidural on the __/ __ / _____. Post delivery, she reported:

o No headache
o Mild – moderate headache
o Severe headache requiring blood patch.

This was treated with:

o Hydration
o Simple analgesics (paracetamol, NSAIDs)
o Opioids (_____________________)
o Blood patch.
o Other

On discharge her post dural puncture headache was:

• Resolved
• Mild
• Mod – severe but requesting analgesia but no further interventions currently.

Regards,

Dr ___________________

Anaesthetic Registrar / Consultant

Westmead Hospital
98455555 page 8596.

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