Quick Hits in Obstetric Anesthesia

This book provides easy to follow guidance on how to manage emergency situations and common problems in obstetric anesthesia. The book provides different anesthetic recipes for obstetric procedures and describes challenges that will be encountered on a day-to-day basis. There are trouble-shooting chapters and ‘what to do lists’ for frequent dilemmas. The book covers obstetric-specific resuscitation and medical emergencies seen on the labor ward. Antenatal and postpartum complications relating to anesthesia are covered as well as issues that may arise during follow up of patients who have had neuraxial anesthesia during delivery. Quick Hits in Obstetric Anesthesia should be used as a cognitive aid for emergency cases and as a decision-making tool for urgent management plans. It is a guide to common problems and provides core knowledge to facilitate anesthesia care on labor wards for all grades of anesthetist. Foreword Contents 1 Epidurals for Labour Analgesia Indications Contra-Indications Consent Position Equipment Procedure Drugs Test Dose Regimens References 2 Combined Spinal-Epidural Analgesia for Labour CSE Technique Advantages of the CSE Technique Disadvantages Associated with a CSE Drugs Used for the Intrathecal Component References 3 Non-neuraxial Options for Labour Analgesia Nurse / Midwife Administered Analgesia Anaesthetist Administered Analgesia Entonox ® Transcutaneous Electrical Nerve Stimulation (TENS) Complementary Therapies Intramuscular Opioids Intravenous PCA Alternative PCA Regimens References 4 Management of the Woman with an Intrauterine Fetal Death (IUFD) Definitions Incidence Causes Complications Investigations Obstetric Management Analgesia for Labour with IUFD References 5 Category 4/Planned Caesarean Delivery Anaesthetic Management Anaesthesia Pre-assessment Intra-operative Management Post-operative Monitoring Common Problems Occurring Intra- or Postoperatively References 6 Spinal Anaesthesia for Caesarean Delivery Contra-indications Consent Potential Risks and Side Effects Needles Position Intrathecal Drugs and Doses Block Assessment Common Problems Encountered References 7 Combined Spinal-Epidural Anaesthesia for Caesarean Delivery The CSE Technique Indications CSE Spinal Doses A Practical Approach to Using A Low-dose CSE Technique References 8 Epidural Top-Up for Caesarean Delivery Indications Contra-indications Factors Affecting Decision to Top-up an Existing Epidural Catheter Epidural Top-up Regimens How to Top-up Where to Top-up Block Assessment Failed Epidural Top-up Abandoned Top-up End of Surgery References 9 General Anaesthesia for Caesarean Delivery Indications Contraindications Pre-Assessment Induction of Anaesthesia Drugs for Rapid Sequence Induction Obtunding the Hypertensive Response to Laryngoscopy Maintenance of Anaesthesia Postoperative Management Problems Specific to General Anaesthesia for Caesarean Delivery References 10 Hypotension During Spinal Anaesthesia for Caesarean Delivery Background Haemodynamic Changes Standards for Monitoring Vasopressors Mechanical Strategies Fluid Strategies References 11 Pain Relief After Caesarean Delivery Introduction Multimodal Analgesia Neuraxial Opioids Systemic Opioids Non-Steroidal Anti-Inflammatory Drugs (NSAIDS) Adjuvants Patient Controlled Epidural Analgesia (PCEA) Transverse Abdominis Plane Block (TAP) Quadratus Lumborum Block (QLB) Summary References 12 Manual Removal of Placenta Indication Incidence Definition of Retained Placenta Pathophysiology of Third Stage of Labour Risks Factors Associated with Retained Placenta Complications of Retained Placenta Anaesthetic Management of a Patient Undergoing Manual Removal of Placenta Surgical Procedure (Fig. 12.1) [2] General Anaesthesia Neuraxial Anaesthesia References 13 Cervical Cerclage (Insertion and Removal) Definition Indications Contraindications Anesthestic Management Spinal Anesthesia with Hyperbaric Local Anesthetic General Anesthesia Disadvantages of General Anesthesia Advantages of General Anesthesia Potential Risks Associated with Cervical Cerclage Removal of Transvaginal Cerclage Discharge Criteria References 14 External Cephalic Version Background and Indications Contraindications Performing ECV Pain Management Complications [4] References 15 Artificial Rupture of the Membranes Indications Contraindications Procedure Setting and Preparation Procedure (for a Right-Handed Examiner) Anaesthetic Considerations Pain Management Managing the Risks Efficacy References 16 Consent Capacity Standards of Information Disclosure Types of Consent Birth Plans Emergency Delivery References 17 Documentation Standards The Anaesthetic Chart References 18 Umbilical Cord Prolapse Incidence Preventative Measures When to Suspect Umbilical Cord Prolapse Immediate Management of Umbilical Cord Prolapse Anaesthetic Considerations for Delivery Key Points in the Management of Umbilical Cord Prolapse Management if Gestational Age Is at the Threshold of Viability (Defined as 23+0 to 24+6 Weeks of Gestation) References 19 Expedited and Emergency Caesarean Delivery Definition Intended Benefits of Caesarean Delivery [1] Categorisation of Caesarean Delivery by Urgency Risks Associated with Caesarean Delivery Counseling and Consent Preparation for Category 1 Caesarean Delivery Anaesthesia Technique References 20 Operative Vaginal Delivery Indications Risk Factors for Operative Vaginal Delivery Location Anaesthetic Options Patient Positioning Complications Antibiotics References 21 Massive Obstetric Haemorrhage Definition Causes and Associated Risk Factors Immediate Management Therapeutic Targets During On-Going Haemorrhage [4, 6–9] Obstetric Management of Massive Obstetric Haemorrhage [1] Radiological Post-Haemorrhage Management References 22 Uterine Atony Definition Risk Factors Pharmacological Management [2–4] Surgical Management References 23 Uterine Inversion Definition Anatomical Classification of Uterine Inversion (Fig. 23.1) [4] Classification of Uterine Inversion (Fig. 23.1) [4] Time-Course Risk Factors Presentation Management Medical Management Surgical Management References 24 Amniotic Fluid Embolism Pathophysiology Presentation Diagnosis Management Prognosis References 25 Vaginal Birth After Caesarean Delivery Benefits of Successful VBAC vs. Planned Repeat Caesarean Delivery Indications for VBAC Contraindications to VBAC Risks of VBAC Anaesthetic Considerations Routine Care Emergency Care Anaesthetic Preparation for VBAC References 26 Shoulder Dystocia Definition Mechanism of Shoulder Dystocia Incidence Significance Useful Mnemonic Teamwork Exercises Reference 27 Normal Labour Definition Terminology Used to Describe Cervical Status Stages of Normal Labour [2] Mechanism of Normal Labour Duration of Labour Progress of Labour Fluids and Oral Intake During Labour References 28 Cardiotocography (CTG) References 29 Antenatal Care for Uncomplicated Pregnancies Schedule of Appointments Antenatal Screening Indications for Referral to Anaesthetist References 30 Partogram Definition History Components Interpretation of Labour Progress Evidence References 31 Induction of Labour Definition Incidence Important Considerations Associated with Induced Labour Indications for Induction of Labour [1, 4] Risks/Complications Associated with Induction of Labour [1, 5–11] Timing of Induction of Labour [1] Contraindications to Induction of Labour [11] Mechanical Methods References 32 Augmentation of Labour Definition Methods Used to Augment Labour Mode of Action of Oxytocin Oxytocin Infusion for Augmentation of Labour Timing of Augmentation of Labour Assessment of the Progress of Labour During Augmentation Advantages of Augmentation with Oxytocin Risks Associated with Augmentation with Oxytocin Special Considerations Cardiovascular Disorders QT Syndrome Water Intoxication Renal Impairment Evidence When Oxytocin Inductions Were Compared with Expectant Management in a Systematic Review [5] Trials Comparing Amniotomy and Intravenous Oxytocin Versus Placebo or Other Specified Treament [7] References 33 Pre-term Birth Definitions Incidence Neonatal Impact Causes of Spontaneous Pre-term Labour (Fig. 33.2) Clinical Presentation Investigations Risk Prediction Tools Prevention Management of PTL Management of PPROM References 34 Malpresentation Definitions General Management of Malpresentation Breech Presentation Vaginal Breech Delivery Anaesthetic Management of Breech Presentation References 35 Placenta Praevia Definition Classification Incidence Risk Factors Presentation Diagnosis Management Anaesthetic Considerations References 36 Placenta Accreta Spectrum Definition Incidence of Placenta Accreta Spectrum Risk Factors Complications of Placenta Accreta Diagnosis Management Preoperative Management Intraoperative Management Surgical Considerations Postoperative Management Choice of Anaesthetic Technique References 37 Intrauterine Growth Restriction Background Definition Incidence Antenatal Testing Timing of Delivery (Table 37.3) Route of Delivery References 38 Multiple Gestation Incidence Types of Placentation Anatomical Changes Physiological Changes Circulatory System Respiratory System Central Nervous System Gastrointestinal System Hematological System Antenatal Care Anesthesia Considerations Mode of Delivery Planned Trial of Labour / Normal Vaginal Delivery Planned Caesarean Delivery Unplanned Caesarean Delivery Acknowledgements References 39 Pre-eclampsia and HELLP Syndrome Definition Pathophysiology Airway Respiratory Cardiovascular Neurological Haematological Renal Hepatic Fetal Management of Pre-eclampsia Prevention Blood Pressure Management Seizures Fluid Management Analgesia and Anaesthesia for the Pre-eclamptic Patient Labour Analgesia Anaesthesia for Caesarean Delivery Neuraxial Anaesthesia General Anaesthesia (GA) References 40 Cholestasis of Pregnancy Pathophysiology Management References 41 Gestational Diabetes Introduction Epidemiology Management of Diabetes in Pregnancy Recent Developments for Treating Diabetes References 42 Obstetric Venous Thromboembolism Background Prevention Important Points Pharmacological Agents Low Molecular Weight Heparin (LMWH) Unfractionated heparin (UFH) Warfarin (Vitamin K Antagonist) Other Agents Investigation and Diagnosis of Obstetric VTE (Table 42.6) Treatment of Obstetric VTE References 43 Obesity Obstetric Implications Anaesthetic Implications Anaesthetic Management References 44 Peri-Partum Cardiomyopathy Definition and Incidence Pathophysiology Symptoms and signs Management Complications Anaesthetic Considerations Anaesthetic Aims for a Patient with Peripartum Cardiomyopathy Uterotonics Conclusion References 45 Complex Congenital Heart Disease and Pregnancy Antenatal Care and Delivery Strategies Anaesthetic Strategies Important Complex Congenital Heart Disease Circulations and Repairs Conclusion References 46 Thrombophilias Common Inherited and Acquired Thrombophilias Factor V Leiden Mutation Protein S Deficiency Prothrombin Mutation Protein C Deficiency Antiphospholipid Syndrome (APS) Incidence Clinical Implications Timing of Neuraxial Analgesia or Anesthesia (see Chap. 49) References 47 Haemophilias Mode of Inheritance Acquired Haemophilias Incidence Laboratory Findings Clinical Implications Pathophysiology Treatment Obstetric Management Anaesthetic Management References 48 Von Willebrand Disease Pathophysiology Pregnancy and VWD Management Neuraxial Anaesthesia Major Obstetric Haemorrhage References 49 Low Molecular Weight Heparin, Unfractionated Heparin and Neuraxial Anaesthesia Heparin Dosing Indications for Heparin During Pregnancy Dosing and Timing of Heparin Administration in Relation to Neuraxial Anaesthesia References 50 Accidental Dural Puncture Definition Incidence Risk Factors Patient Operator Recognition Management Documentation References 51 Post Dural Puncture Headache Incidence Mechanism Risk Factors for Developing PDPH Needle Considerations Operator Considerations Patient Considerations Diagnosis Assessment Management References 52 Epidural Blood Patch Mechanism Patient Selection Efficacy Procedure References 53 Intrapartum Fever Definition Causes Maternal Consequences Fetal Consequences Management Anesthetic Implications Neuraxial Anesthesia General Anesthesia References 54 Failed Epidural Analgesia During Labour Risk Factors for Failed Labour Epidural Analgesia Causes of Failed Labour Epidural Analgesia Assessment of Inadequate Labour Epidural Analgesia Troubleshooting Considerations Follow up References 55 Failed Spinal Anaesthesia for Caesarean Delivery Introduction Definition of Failed Spinal Anaesthesia for Cesarean Delivery Presentation and Causes of Failed Spinal Anaesthesia Management of Failed Spinal Anaesthesia Intraoperative Failure, After Delivery References 56 Pain and Distress During Caesarean Delivery Causes Management Repeat (2nd) Spinal? Intraoperative Analgesia Follow Up References 57 Backache After Neuraxial Anesthesia Incidence Etiology Mechanism Risk Factors for Postpartum Backache Prevention Management References 58 Peripheral Nerve Lesions After Neuraxial Anesthesia Introduction Incidence Risk Factors Etiology Prevention Diagnosis and Management References 59 Spinal Cord Lesions After Central Neuraxial Blockade Incidence Spinal Cord Pathologies Following Central Neuraxial Blockade References 60 Obstetric Nerve Palsies: Common Lesions and Causes Incidence Lumbosacral Trunk Obturator Nerve Palsy Femoral Nerve Palsy Lateral Cutaneous Nerve of Thigh Sciatic Nerve Palsy Common Peroneal Nerve Palsy Other Nerve Palsies Bladder Dysfunction Safeguards to Minimise Peripheral Nerve Damage References 61 Reported Awareness Under General Anaesthesia Risk factors for AAGA Patient Anaesthetic Technique Surgery Environment Recognition: During Anaesthesia Clinical Signs Anaesthesia Recognition: Postoperative Steps to Minimise AAGA and Its Impact Consent Documentation Drugs Management Suspected Intraoperative Awareness Postoperatively References 62 The Patient Requesting Neuraxial Anaesthesia with Previous Spinal Surgery Contraindications Procedure Specific Problems Neuraxial Procedures References 63 Breastfeeding and Anaesthesia Considerations for Anaesthesia Safety of Anaesthetic and Analgesic Drugs in Breastfeeding Women [2–5] Drugs Used in Anaesthesia Perioperative Strategies to Maximise Safety and Minimise the Impact of Anaesthetic Drugs on Breastfeeding [4, 5, 6] Impact of Intrapartum Techniques on Breastfeeding References 64 Difficult and Failed Intubation in Obstetric Anaesthesia What is the incidence of failed intubation in obstetric anaesthesia? Reasons for Airway Difficulty Should Surgery Proceed After Failed Intubation? Change in Practice Key Messages from the DAS/OAA Failed Tracheal Intubation Guidelines References 65 Recognition and Management of High Spinal Anaesthesia Introduction Causes Recognition Management Other Important Considerations References 66 Aspiration of Gastric Contents Associated Morbidity and Mortality Immediate Management Late Management Prophylaxis Pharmacological Prophylaxis Gastric Ultrasound References 67 Local Anaesthetic Toxicity Local Anaesthetic Toxicity and Obstetric Anaesthesia Risk Factors in Obstetric Anaesthesia Presentation of Local Anaesthetic Systemic Toxicity Management of Local Anaesthetic Systemic Toxicity Lipid Emulsion Doses Cardiac Arrest and LAST References 68 Anaphylaxis Management of Anaphylaxis Investigation of Anaphylaxis References 69 Malignant Hyperthermia MH Susceptibility in Pregnancy MH Safe Anaesthesia Presentation of MH Management of MH Diagnosis Or References 70 Maternal Resuscitation References 71 Intrauterine Resuscitation Identification of Fetal Distress Mechanisms of Fetal Hypoxia Aortocaval Compression Techniques for Intrauterine Resuscitation Transfer to the Operating Theatre and Emergency Caesarean Delivery References 72 Neonatal Resuscitation Dry and Cover the Baby Call for Help if Required Open the Airway Inflate the Lungs Chest Compressions Monitoring Post Resuscitation Care Apgar Score References 73 Anesthetic Management of Pregnant Patients with Novel Coronavirus Background Clinical Presentation Testing Personal Protective Equipment (PPE) General Considerations for Peripartum Patients Positive for SARS-CoV-2 (symptomatic and asymptomatic) or PUIs (patients under investigation) Antepartum Considerations for Patients Positive with SARS-CoV-2 or PUIs Intrapartum Considerations for Patients Positive with SARS-CoV-2 or PUIs Vaginal Delivery in Patients Positive for SARS-CoV-2 or PUIs Cesarean Delivery in Patients Positive with SARS-CoV-2 or PUIs Postpartum Considerations for Patients Positive with SARS-CoV-2 or PUI with a Postpartum hemorrhage Vertical Transmission Breastfeeding Conclusion Disclaimer References Index