FRCA obstetrics

SCAN ME Final FRCA course | Coventry | 26 July 2021
Dr Mark Porter | consultant obstetric anaesthetist

Slides at anyflip.com/janls/apxh/

Answering questions in obstetric anaesthesia | Dr Mark Porter FRCA | anyflip.com/janls/apxh/ 1

Answering questions in obstetric anaesthesia | Dr Mark Porter FRCA | anyflip.com/janls/apxh/ 2

Topics (1) Topics (2) 2021 2020 2019 2017-18

The obstetric PDPH PROSPECT MBRRACE Consensus on Enhanced
airway study report uterotonics maternal care
AFE &
Coincidental maternal NICE NG192 Pandemic Hypertension Consensus on
surgery collapse caesarean learning definitions and spinal
Maternal Benchmarking
obesity Heart disease birth indicators treatment hypotension

PDPH SALVO trial cell
salvage

Severe pre- Remifentanil Neuraxial WOMAN trial
eclampsia pain relief block testing TXA

Obstetric Red cell
haemorrhage salvage

Blocks and
intraoperative

pain

A tour of the world of obstetric anaesthesia as seen by the examiners… possibly…

Answering questions in obstetric anaesthesia | Dr Mark Porter FRCA | anyflip.com/janls/apxh/ 3

The obstetric airway 4
Coincidental surgery
Maternal obesity
Severe pre-eclampsia
Obstetric haemorrhage
Surgical blocks and intraoperative pain
PDPH
AFE & maternal collapse
Heart disease
Remifentanil pain relief
Red cell salvage

Answering questions in obstetric anaesthesia | Dr Mark Porter FRCA | anyflip.com/janls/apxh/

Answering questions in obstetric anaesthesia | Dr Mark Porter FRCA | anyflip.com/janls/apxh/ 5

Reduced oxygen Increased Left tilt reducing
reserve & FRC oxygen effectiveness of
cricoid pressure
consumption

Anatomy Rapid sequence Greater
induction done prevalence of
• Shortened neck,
airway oedema, hastily obesity
(enlarged breasts)

Isolated location Psychological Active labour
pressure of
expectation

Answering questions in obstetric anaesthesia | Dr Mark Porter FRCA | anyflip.com/janls/apxh/ 6

Airway
sources

Answering questions in obstetric anaesthesia | Dr Mark Porter FRCA | anyflip.com/janls/apxh/ 7

Maintain your Use 2nd gen Fibrescopes Trained
skills SADs for rescue available recovery staff

•Obstetric •Obstetric •Anaesthetic •All staff
anaesthetists anaesthetists departments working in the
need to should be should provide recovery area
maintain their familiar and a service where of a delivery
airway skills skilled with the skills and suite including
including supraglottic equipment are midwifery staff
strategies to airway devices available to must be
manage for rescuing deliver awake competency
difficult the airway: fibreoptic trained, with
intubation, particularly intubation skills must be
failed those designed whenever it is regularly
intubation and to protect from indicated updated.
CICV aspiration and
to facilitate
ventilation and
or intubation

Answering questions in obstetric anaesthesia | Dr Mark Porter FRCA | anyflip.com/janls/apxh/ 8

Answering questions in obstetric anaesthesia | Dr Mark Porter FRCA | anyflip.com/janls/apxh/ 9

Preoperative assessment Antacid premedication Developing learning
and preparation
•Ranitidine, 150 mg x 2 •DAS recommendations
•Anticipate the PO, or 50 mg IV during RSI
difficulties – both
present and modifiable •Omeprazole PO 20-40 •Nasal cannulas to
mg, or IV 40 mg slow augment
•Right equipment – preoxygenation
laryngoscope, suction, •Sodium citrate 0.3M,
SADs, fibrescope, 30 mL PO •Facemask ventilation
ramping before intubation
•Consider IV
•Training and equipment metoclopramide 10 mg •Videolaryngoscope as
for front-of-neck rescue standard

•Good communication •Consider use of
with the operating Transnasal Humidified
theatre team Rapid-Insufflation
Ventilatory Exchange
•Avoid GA if possible (THRIVE)

Answering questions in obstetric anaesthesia | Dr Mark Porter FRCA | anyflip.com/janls/apxh/ 10

Risk Risk factors Induction Maintenance Emergence
include:
1:19,000 50% of AAGA 30% of AAGA 20% of AAGA
general Use of
thiopental Should we be Reduced Poor
1:8,000 with withholding volatiles and management
NMBs Emergencies,
and also RSI opioids? N2O of NMB
1:670
caesarean Use of NMBs Beware Perhaps some
section. antibiotic resistance to
Patient female syringes
± young ± drugs.
obese Have spare IV
hypnotic
OOH case

Obstetric anaesthesia Junior The 64 recommendations to
anaesthetist mitigate AAGA include always
is overrepresented by practising well and carefully,
a factor of 10x Prolonged and basing patient consent on
airway
incidence information
management

Swift start to
surgery

Answering questions in obstetric anaesthesia | Dr Mark Porter FRCA | anyflip.com/janls/apxh/ 11

4 patients had
PTSD

Incidence 1:256; Associates:

•for CS, 1:212 •BMI extremes
•OOH
Direct •ketamine or
questioning thiopental
•(NMB, RSI etc)
about awareness
Study:
“Action is needed to reduce this very high risk
•3000 patients and national consensus guidelines would help
•2017-18 to ensure consistency of anaesthesia practice.”
•UK

Answering questions in obstetric anaesthesia | Dr Mark Porter FRCA | anyflip.com/janls/apxh/ 12

Answering questions in obstetric anaesthesia | Dr Mark Porter FRCA | anyflip.com/janls/apxh/ 13

Maternal hypotension Maternal hypoxia Maternal hypercapnia

•Cardiac output increased by up •Increased oxygen consumption •Causes fetal respiratory
to 50% in pregnancy in pregnancy. acidosis, possibly myocardial
depression
•Reduced uteroplacental •Direct cause of uteroplacental
perfusion and fetal hypoxia vasoconstriction & fetal hypoxia

Maternal hypocapnia Premature onset of
labour
•Reduced oxygen delivery to
fetus with shift in dissociation •Provoked by the local or
curve systemic inflammation, surgery
or drugs (beta blockers,
vasoconstrictors)

Answering questions in obstetric anaesthesia | Dr Mark Porter FRCA | anyflip.com/janls/apxh/ 14

Protect the mother Avoid postoperative Most senior available Prophylactic tocolysis
and thus the fetus NSAIDs due to risk of surgeon
•Terbutaline SC
•Airway assessment •Premature closure •Minimal surgical 250 mcg
•Antacid prophylaxis of the ductus trauma
arteriosus
•Prevention of •Laparoscopic
aortocaval •Oligohydramnios technique preferred
compression

•Extra maternal
preoxygenation
(hyperoxia is safe)

•Rapid sequence
induction if GA

Most senior available anaesthetist 15

• Modified physiological homeostasis
• Maintain cardiac output and blood pressure
• Ensure mild hypocapnia
• Prevent aortocaval compression
• Regional anaesthesia if at all possible

Answering questions in obstetric anaesthesia | Dr Mark Porter FRCA | anyflip.com/janls/apxh/

Neonatal ICU Fetal Fetal lung
forewarned maturation with
neuroprotection steroid injections
with magnesium

sulfate

Continuous Obstetrician present Consider
for immediate postoperative care
intraoperative and delivery by CS
postoperative fetal on labour ward
monitoring with CTG

Answering questions in obstetric anaesthesia | Dr Mark Porter FRCA | anyflip.com/janls/apxh/ 16

Answering questions in obstetric anaesthesia | Dr Mark Porter FRCA | anyflip.com/janls/apxh/ 17

CAVE: Comorbidities | Airway | Veins | Epidural

Comorbidities Airway Veins Epidural

•Symptoms of • Anticipated • Intravenous •Ability to
diabetes, difficulty with access identify
hypertension, tracheal landmarks,
CAD, GI reflux intubation and •NIBP cuff size thickness of fat
airway adjuncts and consider and length of
•Rarely in needed arterial line needle
morbid obesity:
pulmonary •Assess for • Consider
hypertension ramped ultrasound
and RVF position from start or
availability as
•Large robust rescue
equipment

•VTE risk –
antenatal for
timing and
postoperative
for prescription

Answering questions in obstetric anaesthesia | Dr Mark Porter FRCA | anyflip.com/janls/apxh/ 18

Increased risk of: 19
1. Venous thromboembolism –

antenatal and postnatal
2. Gestational diabetes mellitus
3. Pregnancy-induced hypertension

and pre-eclampsia
4. Induction of labour
5. Caesarean birth
6. Postpartum haemorrhage
7. Postoperative wound infection

Answering questions in obstetric anaesthesia | Dr Mark Porter FRCA | anyflip.com/janls/apxh/

Before delivery 20

•Having a high body mass index makes complications more likely
•You have the same choices as other women but some options

may be more difficult or take longer
•It is usually better to have an epidural for labour and an epidural

or spinal for caesarean section

During delivery

•We need to check timing of blood thinning injections
•We advise being ready for possible interventions by having an

epidural in place from early in labour
•Placing a labour epidural earlier in labour allows extra time for a

possibly difficult technique
•It is your choice whether to have one, but we advise that you do
•We try to avoid GA – it increases risk for you and baby
•If you do need a general anaesthetic, we will check how to

reduce the risk of difficult intubation and ventilation
•You will need to avoid food during labour and also take antacids

such as ranitidine

After delivery

•To prevent blood clots in your legs, you will need good pain relief
to move around, and blood thinning injections

Answering questions in obstetric anaesthesia | Dr Mark Porter FRCA | anyflip.com/janls/apxh/

ἐκλαμψία 21
a light flash
a sudden occurrence

Answering questions in obstetric anaesthesia | Dr Mark Porter FRCA | anyflip.com/janls/apxh/

Selection of sources

Answering questions in obstetric anaesthesia | Dr Mark Porter FRCA | anyflip.com/janls/apxh/ 22

Removal of
proteinuria as
necessary criterion

Lower blood
pressure target on
treatment ≤ 135/85

Use of PlGF testing
(DG23, 2016)

Answering questions in obstetric anaesthesia | Dr Mark Porter FRCA | anyflip.com/janls/apxh/ 23

Hypertension Chronic Gestational Severe
hypertension hypertension hypertension
•Blood pressure
of 140mmHg • Hypertension • New •Blood pressure
systolic or that is present hypertension over 160 mmHg
higher, or at the booking presenting after systolic or over
90mmHg visit, or before 20 weeks of 110 mmHg
diastolic or 20 weeks, or if pregnancy diastolic
higher [2019] the woman is without
already taking significant
antihypertensive proteinuria
medication
when referred
to maternity
services

•It can be primary
or secondary in
aetiology

Answering questions in obstetric anaesthesia | Dr Mark Porter FRCA | anyflip.com/janls/apxh/ 24

New onset of hypertension (over 140 mmHg aminotransferase over 40 IU/litre] with
systolic or over 90 mmHg diastolic) after 20 or without right upper quadrant or
weeks of pregnancy and the coexistence of one epigastric abdominal pain)
or more of the following new-onset conditions:
  neurological complications such as
1. proteinuria (urine protein:creatinine ratio of eclampsia, altered mental status,
30 mg/mmol or more or albumin:creatinine ratio blindness, stroke, clonus, severe
of 8 mg/mmol or more, or at least 1 g/litre [2+] headaches or persistent visual
on dipstick testing) or scotomata

2. other maternal organ dysfunction:   haematological complications such as
thrombocytopenia (platelet count
  renal insufficiency (creatinine below 150,000/microlitre), disseminated
90 micromol/litre or more, intravascular coagulation or haemolysis
1.02 mg/100 ml or more)
3. uteroplacental dysfunction such as fetal growth
  liver involvement (elevated restriction, abnormal umbilical artery doppler
transaminases [alanine waveform analysis, or stillbirth
aminotransferase or aspartate

New gestational hypertension +
[proteinuria ± maternal organ dysfunction ± uteroplacental dysfunction]

Answering questions in obstetric anaesthesia | Dr Mark Porter FRCA | anyflip.com/janls/apxh/ 25

Eclampsia Severe pre-eclampsia * HELLP Syndrome

• A convulsive condition • Pre-eclampsia with severe • Haemolysis, elevated liver
associated with pre- hypertension that does enzymes and low platelet
eclampsia not respond to treatment count
or is associated with
ongoing or recurring
severe headaches, visual
scotomata, nausea or
vomiting, epigastric pain,
oliguria and severe
hypertension, as well as
progressive deterioration
in laboratory blood tests
such as rising creatinine or
liver transaminases or
falling platelet count, or
failure of fetal growth or
abnormal doppler findings

Answering questions in obstetric anaesthesia | Dr Mark Porter FRCA | anyflip.com/janls/apxh/ 26

Is this pre- • Blood tests will Normal results reassure on
eclampsia? causation, but hypertension and
discriminate pre-eclampsia fetal growth restriction still need
from other causes of treatment and possibly delivery

hypertension or small Abnormal tests indicate prognosis
fetus and inform delivery plans

PlGF • Levels should rise during
involved in pregnancy, peak at 26-30
placental weeks

angiogenesis • Low levels indicate
pre-eclampsia

Soluble FMS- • High sFlt-1/PlGF ratio Tests can neither discriminate
indicates pre-eclampsia pre-eclampsia severity nor rule out
like tyrosine need for delivery
kinase-1

(sFlt-1) can

block

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The primary aims in Anaesthetists may Severe pre-eclampsia Symptoms of
the management of become involved for: must be managed in a severe pre-
pre-eclampsia are: eclampsia
Epidural high-dependency requiring
To deliver the analgesia in environment immediate
fetus in optimum admission and
labour Multiprofessional treatment:
condition team
Urgent control • Severe headache
To control and reduction of Appropriate • Visual problems such
maternal senior
hypertension arterial blood as blurring or flashing
pressure involvement • Severe pain just below
To prevent
eclampsia and Invasive Specialised level the ribs
monitoring of 2 care
the other arterial blood • Vomiting
complications CTG monitoring • Sudden swelling of
pressure
Aortocaval face, hands or feet
Anaesthesia for decompression
caesarean • Difficulty in breathing
section and VTE • Suspected fetal
prophylaxis
High dependency compromise
care initiation

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Arterial line, pulse and Control hypertension Administer supplemental
oxygen saturation; ≤ 135/85 (new 2019)
oxygen if SpO2 < 96%, usually
aortocaval decompression through nasal cannulas

Check that the laboratory Start the EMC observations Auscultate for pulmonary
samples have been sent: chart and documents oedema and repeat regularly

FBC, coag, biochemistry Check CTG is on every four hours; record
including LFT, G+S respiratory rate; insert

urinary catheter

Patient on monitored sips of Neurological assessment Thromboprophylaxis with
water only with ranitidine using AVPU and reflexes – antiembolism stockings,

150 mg given at six-hourly magnesium for cerebral encouragement of leg
intervals ± fluid restriction to ischaemia movement and (if delivery is
80 ml h-1 plus surgical losses
not indicated) enoxaparin

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Oral nifedipine or intravenous labetalol or hydralazine 30
(methyldopa)

Oral labetalol if these are unavailable – ISSHP

BP > 140/90 should be treated; keep BP below 150
mmHg; NICE has new target 135/85 for all forms of
hypertension

Women with proteinuria and severe hypertension, or
with hypertension and neurological symptoms, should
receive magnesium sulfate for convulsion prophylaxis

Arterial line monitoring for severe hypertension or
intravenous vasodilators

Answering questions in obstetric anaesthesia | Dr Mark Porter FRCA | anyflip.com/janls/apxh/

Monitor, control and limit Listen to the chest regularly Limit to 80 mL h-1 in severe
hypertension, plus losses

Do not use volume expansion Do not give aggressive or Do not pre-load for low-dose
challenge treatment for oliguria epidural analgesia, or co-load
prior to antihypertensives
(except for IV hydralazine) •These are not elderly patients with for CSE
shock
Co-load or vasoconstrictor
•The oliguria arises from glomerular infusion for spinal?
pathology

•Do not use diuretics

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CET (1995) showed that this Eclamptic seizures are self- MAGPIE trial (2002) showed
is the best available primary
limiting but may be lethal if some benefit in severe pre-
treatment and secondary left untreated eclampsia but NNT 60-120
prevention of eclampsia

Primary mode of action is to Although there are varying CET / Oxford protocol:
indications,
relieve cerebral vasospasm; Bolus 4 g (+ 2 g if necessary)
also reduces oxidative stress NICE recommends offering
magnesium to all women + 1 g h-1 ongoing
with severe pre-eclampsia continue 24 hours after
initiation or last seizure

Complications – heat and Same dose used for fetal

flushing, obstetric neuroprotection before 30
haemorrhage, muscle weeks, preventing cerebral

relaxant potentiation, palsy (max 24 hours or till
oliguria, weakness and delivery), consider up to 34

cardiac dysrhythmia to arrest weeks

Answering questions in obstetric anaesthesia | Dr Mark Porter FRCA | anyflip.com/janls/apxh/ 32

Perioperative arterial Rigorous fluid control Withhold NSAIDs e.g.
– pulmonary oedema diclofenac, ibuprofen
line and control of
hypertension

Regional GA

coagulopathy, ongoing
seizures, fetal compromise

Check Control exaggerated Check for dysphonia Caution with non-
platelets > 75 × 109 L-1 depolarising muscle
hypertensive or facial oedema – relaxants after Mg2+
response to proxy for laryngeal
laryngoscopy
oedema

Use vasopressors for Alfentanil or other Use ≤ 7.0 mm

spinal hypotension – appropriate endotracheal tube
beware variable technique [MBRRACE 2017]
effect

Ergometrine is safe 33
and effective in

monitored small IV
doses

Answering questions in obstetric anaesthesia | Dr Mark Porter FRCA | anyflip.com/janls/apxh/

Patient considered high-risk Antihypertensive treatment Continue fluid balance
withdrawn slowly or control
three days with four-hourly converted to long-term
checks and VTE prophylaxis treatment

•enalapril
•or nifedipine or amlodipine if black

Avoid NSAIDs unless other Be aware of significant
analgesia does not work long-term cardiovascular
risk for such women, and
•Whether NSAIDs cause any harm
remains controversial the need for long-term
follow-up
•Effective analgesia required
•Dihydrocodeine 30 mg QDS

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Answering questions in obstetric anaesthesia | Dr Mark Porter FRCA | anyflip.com/janls/apxh/ 35

15% Class 1 (<15%)
15% Class 2 (15-30%)
Class 3 (30-40%)
60% 10% Class 4 (>40%)

Class Blood EBL at 50kg EBL at 90kg Effects
Class 1 loss booking booking No change in vital signs; use salvaged red cells

<15% <750 mL <1350 mL

Class 2 15-30% 750-1500 mL 1350-2700 mL Peripheral vasoconstriction; use salvaged red cells,
allogeneic blood if not available

Class 3 30-40% 1500-2000 mL 2700-3600 mL Peripheral vasoconstriction no longer compensates, so
systolic blood pressure falls; use salvaged red cells,
check ABG and consider transfusion or DCR

Class 4 >40% >2000 mL >3600 mL Immediate threat to life with cardiovascular collapse,
unconsciousness at 50% loss; immediate ABG, DCR and
Allow for body size and surgical intervention if not already in progress
hence blood volume May be manageable with salvaged red cells alone if done
very well

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Make sure that the Belmont
red cell salvage rapid
infuser
works – you may not
need allogeneic
blood

Load up the rapid
infuser in advance if

torrential
haemorrhage

expected

Haemorrhage class 2:
consider arterial line

Haemorrhage class 3: 37
call for help and
monitor ABGs
Consider damage

control resuscitation

Answering questions in obstetric anaesthesia | Dr Mark Porter FRCA | anyflip.com/janls/apxh/

Restoring blood Restoration of Securing
haemostasis by
volume to maintain oxygen-carrying surgical treatment
tissue perfusion and capacity with and correcting
adequate
oxygenation coagulopathy
haemoglobin (fibrinogen>2 g L-1)
concentration

Delay in restoration of circulating volume may result in the 38
lethal triad of tissue hypoperfusion, organ failure and
disseminated intravascular coagulopathy

Answering questions in obstetric anaesthesia | Dr Mark Porter FRCA | anyflip.com/janls/apxh/

Haemorrhage – 39
the lethal triad

Damage control
resuscitation

developed for the
management of
trauma patients

The overriding aim is
to mitigate the lethal

triad and rapidly
restore physiological

stability

Early blood product
administration,

haemorrhage arrest
and restoration of

blood volume

Answering questions in obstetric anaesthesia | Dr Mark Porter FRCA | anyflip.com/janls/apxh/

Correct Give Avoid
acidosis tranexamic crystalloids &
acid doses vasopressors
with
transfusion Damage Maintain
control normothermia
Use resuscitation
balanced
transfusions Serial lactates
Keep communicating
(4:2:1)

Maintain Ensure early
normocalcaemia
haemorrhage
& avoid control
hyperkalaemia

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Platelets

FFP Cryoprecipitate
(fibrinogen)

Donor red cells Component Salvaged red
blood cells
therapy

Haemostatic blood component therapy 41

Answering questions in obstetric anaesthesia | Dr Mark Porter FRCA | anyflip.com/janls/apxh/

Risk Assessment for PPH is now becoming a routine part of the admission process in obstetric
led birth settings, leading to increased awareness of and early planning for PPH detection,
prevention and management.

Early identification by means of Measuring Blood Loss is quickly becoming embedded in
practice, with over 90% of women having their postnatal blood loss measured.

Multidisciplinary Team Working is improving as a result of the training provided by OBS Cymru
teams. Clinicians including Midwives, HCAs, anaesthetists, obstetricians, ODPs, and students
working in maternity settings have received OBS Cymru training, and have embraced the 4
stage approach to PPH management.

ROTEM point of care testing machines have been installed in every labour ward in Wales to
allow access to rapid coagulation results and guide blood product management. Early data
suggests this is leading to a decrease in the administration of blood products for the reason of
PPH.

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Fibrinogen Near-patient

• Levels below 2 g L-1 are • OBSCymru emphasis
strongly predictive of • GPAS: “In tertiary units,
massive PPH, transfusion
needs, surgical intervention with a high risk population,
and the need for critical it is recommended that
care there should be equipment
to enable near patient
• Unclear as to causation or estimation of coagulation”
indeed whether fibrinogen • Thromboelastography
is a proven therapeutic (TEG) or
intervention • Thromboelastometry
(ROTEM)
• Cryoprecipitate or RiaSTAP
fibrinogen concentrate?

“Pragmatic randomised controlled trials are needed to establish
the role of viscoelastic haemostatic assays in major obstetric
haemorrhage, combined with robust cost effectiveness
analyses. The use of fibrinogen concentrate rather than
cryoprecipitate would be an important part of this analysis.”

Shah & Collis, Anaesthesia 2019;74:961-4

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Monitor serial lactates to Correct before extubation: Abnormal lactate may
• Haematological deficits
assess the adequacy of • Metabolic derangements indicate inadequate
resuscitation resuscitation, or ongoing
• Hypothermia
bleeding

Women must be adequately Recovery: the anaesthetist
resuscitated, and bleeding has a responsibility for a full
stopped prior to extubation assessment, diagnosis, a plan

following GA. of care and execution.

[MBRRACE 2017] [MBRRACE 2020]

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Answering questions in obstetric anaesthesia | Dr Mark Porter FRCA | anyflip.com/janls/apxh/ 45

Cold Pain

ice cube or ethyl pinprick or pinching
chloride
Or light touch - needs
Checks 1-2 skill and checks 1-2
dermatomes higher dermatomes lower
than pain
than pain

Motor block Use four Final surgeon’s check

loss of SLR modalities to toothed forceps
SLR present → pain assure the block,
Adequacy includes
during surgery while aware of communication
variability in

modalities

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Check and act •Allow positional change to improve the block
promptly before intrathecal fixing

•Watch the clock – 8 to 10 minutes

Physical Repeat spinal Insert epidural General
improvement of anaesthesia

block

Table head down Full dose if no For drug Don't say GA is
or flex the hips to block above T12 supplementation too risky

raise block

Valsalva Reduced dose if For volume Obtain consent
manoeuvre done no block above effects – EVE for changed plans

twice T8 (epidural volume
extension)

Tilt or turn onto 47
unblocked side if

not bilateral

Answering questions in obstetric anaesthesia | Dr Mark Porter FRCA | anyflip.com/janls/apxh/

Symptoms Signs

• Patient complains of • Hypotension and
difficulty in breathing, but bradycardia (high thoracic
can speak block)

• Patient appears agitated • Difficulty in squeezing
• Nausea and vomiting due to fingers – hand flexion

hypotension or cerebral • Quiet voice – not always
hypoxia • Shallow breathing
• Falling oxygen saturation
Be vigilant: high block is much • Fetal distress due to poor
more common when doing a
oxygenation
second neuraxial block • Loss of consciousness,

ventilation and vasomotor
integrity

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Reassure the mother Communicate with Check nature of
and her partner that the surgeons sensation – pain, or
effective action will
unexpected
be taken rummaging?

Document your Review your patient
diagnosis and your in recovery and
explain
actions

Pain before operation or before Pain after delivery: Pain towards end of surgery:
delivery:
•Halt surgery •Offer Entonox and local
•Halt surgery •Offer Entonox and alfentanil anaesthetic infiltration.
•Recommend conversion to •Consider general anaesthesia

general anaesthesia

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Answering questions in obstetric anaesthesia | Dr Mark Porter FRCA | anyflip.com/janls/apxh/ 50