FRCA obstetrics

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1. Focal neurological signs 1. Post-dural puncture headache
2. Stress, fatigue, dehydration
• dFaifcfeicudlrtoieosping / Arm weakness / Speech 3. Hypertensive disorders of pregnancy
4. Migraine
2. Persistent severe headache 5. Intracranial tumour or other space-occupying
3. Proteinuria
4. Seizures lesion
5. Uncontrollable vomiting 6. Intracranial haemorrhage or infarction – stroke
6. Evidence of infection with meningism 7. Meningitis - viral, bacterial, chemical
7. Altered consciousness 8. Subdural haematoma
8. eHpeiadduarcahl ebslopoedrspisatticnhgeasfter two 9. Cerebral venous thrombosis
10. Benign intracranial hypertension

Gutsche’s sign to aid diagnosis

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Appropriate referral, information Conservative therapy, invasive “When conservative therapy is
and follow-up must be done procedures other than EBP, ineffective and the woman

epidural fluids are all pretty much experiences difficulty performing
useless with insufficient supporting activities of daily life and caring for

evidence her baby, an EBP should be
considered”

If EBP done at < 48 hours (for “There is currently insufficient So, we must have a smart process
evidence to suggest that an EBP to find women with PDPH, and
symptom control), there is a higher
likelihood of needing a 2nd EBP reduces the risk of chronic offer EBPs for symptom control
headache or back pain, cranial
subdural haematoma, cerebral

venous sinus thrombosis or

improves outcome in cranial nerve
palsy in obstetric PDPH”

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About 1 in 5 don’t stop the headache so 54
that you might need another one

There may be pain when the blood is
injected into your back

Your back may be sore for a few days
afterwards

There is a small chance (less than 1%) of
another dural puncture

Infection, nerve damage or bleeding into
your back are other rare complications

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

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Clinical presentation Differential diagnosis

Maternal collapse Insidious onset Obstetric causes Non-obstetric
causes
• Dyspnoea • Fetal distress • Eclampsia
• Pulmonary • Cough • Placental • Anaphylaxis
• Headache • Pulmonary
oedema • Chest pain abruption
• Cardiopulmonary • Seizures • Peripartum embolus
• Uterine atony • Pulmonary
arrest • Bronchospasm cardiomyopathy
• Cyanosis aspiration
• Hypotension • Septic shock
• Dysrhythmias • Haemorrhagic
• Consumption
shock
coagulopathy • Myocardial
• Diagnosis by
infarction
exclusion • Drug toxicity
• Total spinal block
• Intracranial

haemorrhage

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Physical Immune

• Amniotic fluid enters maternal • Immune process
circulation through ruptured • Fetal antigens stimulate
membranes or vessels,
probably in lower uterus or cascade of endogenous
cervix mediators
• ‘Anaphylactoid syndrome of
• Fetal squames, lanugo or pregnancy’ – multisystem
mucin found reaction, similar to septic shock
• Biphasic response
• Physical blockage • Pulmonary vasospasm, right
• Pulmonary vasospasm
• Cardiac failure heart failure, 30 minutes
• Hypoxaemia • Left heart failure in survivors
• Death
+ DIC, uterine atony

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Very uncommon Displace uterus
•1:30 000 – few people have seen it in real life to improve venous
return to the heart
Feeling pulse can be unreliable
•Start CPR if in doubt or BP<50 mmHg •left manual uterine
displacement
Gravid uterus
•Practise aortocaval compression •Effective CPR not hindered
•Ventilation difficult – pressure on diaphragm
•Fetus takes cardiac output from mother – deliver Perimortem caesarean
section at location
Airway risks or assisted vaginal birth
•Avoid acid aspiration
•Mitigate difficult intubation •At >23 weeks
•Within 5 minutes of arrest
Anticipate bleeding •Facilitates maternal
•MOH call, uterotonics, TXA
resuscitation
Pulmonary hypertension in AFE
•Restrict fluids and use echocardiography Intralipid for AFE?
•Use vasopressors and inotropes, with pulmonary vasodilators
•Consider ECMO if prolonged CPR or refractory right heart failure

Ischaemia/reperfusion injury in survivors
•Reduce fever, avoid hyperoxia (wean FiO2), control blood glucose

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Answering questions in obstetric anaesthesia | Dr Mark Porter FRCA | anyflip.com/janls/apxh/ 59

Cardiovascular
collapse

It can be too easy to Chest Red flag symptoms Hypoxia not
underestimate the severity of pain swiftly
red flag signs and signs might
Dyspnoea indicate acute responsive
•As representing the changes of normal or cardiovascular to simple
pregnancy measures
•Or by assuming that the woman is orthopnoea decompensation
basically well and will recover shortly and underlying Oxygen required
to maintain
With any of these signs disease
saturations, for
•Consider whether there is new or more than two
previously unsuspected cardiovascular
or thromboembolic disease hours (four
•Take prompt action to seek a diagnosis hours after GA)
or revise the current working diagnosis

Any other Tachycardia
dysrhythmias.
out of
(AF might proportion
indicate severe to blood loss

infection or
sepsis)

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Sinus tachycardia

15 degrees left
axis deviation due
to diaphragmatic

elevation

T-wave changes,
commonly T-wave
inversion in III and

aVF

Non-specific ST
changes e.g. ST
depression, small

Q waves

Supraventricular

and ventricular
ectopic beats

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Answering questions in obstetric anaesthesia | Dr Mark Porter FRCA | anyflip.com/janls/apxh/ 62

Cardiac output Heart failure Risk variation in
pregnancy
• CO up by by 35-50% • Blood volume up
by 45-50% at term Left-side
• HR up by 15%, lesions
reducing diastolic • Heart failure may
filling time start in the 2nd and Right-sided
3rd trimesters and lesions
• SV up by 25-30% be progressive
• Increase in Stenotic
• Pulmonary lesions
transvalvular oedema
gradients and Regurgitant
upstream • AF and lesions
pressures lead to thromboembolic
pulmonary events
hypertension

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Find the obstetric cardiology plan and records of joint 64
planning with consultant anaesthetists; admit to obstetric
HDU and call the consultant anaesthetist and cardiologist.

Presenting in labour, one hopes that the woman has been
assessed as being able to withstand labour – no
pulmonary hypertension, no severe disease

Thromboprophylaxis, or therapeutic anticoagulation – AF

Low-concentration epidural to reduce sympathetic
outflow and to facilitate assisted delivery – both reduce
cardiovascular stress

Epidural for caesarean section – titratable

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

Monitoring Normalise Maintain Prevent Preload
heart rate adequate increase in control
and rhythm pulmonary
SVR Avoid
vascular aortocaval
Arterial line Control HR – Prevent resistance compression
use beta and maintain
spinal Do not use
blockers or hypotension carboprost venous
return
opioids with a
vasopressor

infusion

Consider Maintain SR; Oxytocin – by Prevent pain, Constrain
central line – infusion only hypoxia, fluids before
discuss with treat AF
cardiologists promptly hypercarbia, and after
acidosis delivery
with rate
control and

cardioversion

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Give oxytocin slowly Avoid ergometrine
and carefully; usually if possible as it will
as an infusion; watch cause an increase in
the arterial line for systemic vascular
acute vasodilatation resistance; watch

the arterial line

— Always check Avoid carboprost if Misoprostol is safe
the cardiology possible as it will in cardiac disease
plan for
specifics for cause an increase in
this patient pulmonary arterial

resistance and
decrease pulmonary

artery blood flow

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“This question scored poorly with
many candidates seemingly have little
knowledge or experience of PCA
Remifentanil. Many did not know the
dose or optimal timing, and few knew
anything about the necessary
protocols to ensure safe delivery of
the drug in an Obstetric unit.”

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Trial of progression to epidural after IM
pethidine (control) or PCA remifentanil 40
mcg, with a 2-minute lockout (intervention)

Remifentanil reduced the median VAS pain
score and increased maternal satisfaction

Remifentanil halved epidural conversion
rates compared to pethidine and reduced

instrumental delivery rate

The increased low maternal oxygen
saturation rates with remifentanil did not

result in adverse sequelae

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Pre-requisites PCIA methods Collapse or fetal Labour after
bradycardia intrauterine death
• No parenteral • IV ondansetron
opioids in last 4 • Sats may not • PCIA relatively
hours • Anaesthetist change contraindicated
present to initiate
• Continuous 1:1 and observe for • Turn the woman • Use 20 mcg
midwife presence ≥5 boluses on her side starting dose
assured
• Initial dose 30 mcg • Give facemask • Do not increase
• Dedicated labelled (20 mcg if booking oxygen the dose
small cannula in weight <50 kg or
arm not hand; no IUD) • Encourage her to • Continuous
lines, no flushing breathe midwife presence
• Two-minute remains
• Patient lockout • Do not allow any mandatory
information sheet more demands on
• ↓20 mcg if too the machine
• Relative avoidance much
in multiple • Consider need for:
pregnancy, • ↑40 mcg with • Naloxone
obesity, pre-term, further 200 mcg
IUD observation if not • Atropine
enough 600 mcg

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Less neonatal Lower incidence Reduced need for Shorter duration
resuscitation of pyrexia oxytocin infusion of labour
(vs pethidine)
(vs epidural) (vs epidural) (vs epidural)

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Answering questions in obstetric anaesthesia | Dr Mark Porter FRCA | anyflip.com/janls/apxh/ 71

Advantages Disadvantages

• Patient preference • Needs equipment, training
and multidisciplinary effort
• Warm fresh autologous
product – better oxygen • Potential for amniotic fluid
transport embolism – AAGBI
recommends leucocyte filter
• Reduces need for allogeneic
blood and so reduces • Potential for rhesus
transfusion complications isoimmunisation – Kleihauer
• Mismatched identity test for fetal haemoglobin
• Mismatch due to serological
limitations • Can be slower than donor
blood – use two machines
• Reinfusion threshold lower
than for transfusion – better • May not avoid need for other
recovery? blood components than
autologous red cells
• Blood resource conservation

Answering questions in obstetric anaesthesia | Dr Mark Porter FRCA | anyflip.com/janls/apxh/ 72

Intraoperative cell Blood lost at The aspirate is
salvage in section is aspirated washed and

obstetrics through a filter into centrifuged
a reservoir

One sucker; no Which is connected Concentrated red
leukocyte filter to a patient vein cells are

resuspended in a
reinfusion bag

Two salvage But... SALVO trial…
processors?

Answering questions in obstetric anaesthesia | Dr Mark Porter FRCA | anyflip.com/janls/apxh/ 73

Modest evidence in support (not significant though) where primary
outcome is decreasing use of donor blood.

Safe; two cases refractory hypotension in 750 reinfusions – filter.

Unlikely to be considered as cost-effective (but depends on cost of Khan KS et al. Cell salvage and
unit of RBC and kit for cell salvage). donor blood transfusion during
cesarean section: A pragmatic,
Consider value of avoiding donor blood. multicentre randomised
controlled trial (SALVO). PLoS
Significantly increased risk of feto-maternal haemorrhage. Med 2017; 14(12): e1002471.

•More anti-D needed?
•Sensitisation to other rare antigens?

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Key messages
from the report 2020

In 2016-18, 217 women died during or up to six weeks after pregnancy,
from causes associated with their pregnancy, among 2,235,159 women
giving birth in the UK.
9.7 women per 100,000 died during pregnancy or up to six weeks after
childbirth or the end of pregnancy.

We need to talk about SUDEP Epilepsy and stroke 13%
Act on:

Night-time Uncontrolled Ineffective to prevent 29 women
seizures seizures treatment Sudden
Unexpected 50 women
Death in
EPilepsy 33 women

A constellation of biases Cardiac 28 women

566 women died during 510 women (90%) disease 23% 23 women
or up to a year after had multiple 20 women
pregnancy in the UK problems Blood clots 15% 15 women
and Ireland
Overweight Mental 6 women
or obese Known health 4 women
281 heart 9 women
disease conditions 13%

16 Sepsis 11%

Smoking Delayed Aged Bleeding 9%
177 antenatal over 35
Other
care 210 physical
107
conditions 7%
Known to Physical health Cancer 3%
social problems
342 Pre-eclampsia 2%
services Other 4%
131 Minority Pregnant Previous Mental
ethnic or in the year pregnancy health
Live in group post-pregnancy problems problems
deprived
119 566 209 198
areas
168 Non UK Unemploy-
citizen ment
94
52

Non Born Domestic
English outside abuse
speaking 61
UK
22 216

Systemic Biases due to pregnancy, health and other
issues prevent women with complex and multiple
problems receiving the care they need

Answering questions in obstetric anaesthesia | Dr Mark Porter FRCA | anyflip.com/janls/apxh/ 75

PROSPECT study NICE guideline Mortality national Pandemic learning
caesarean birth audit
•Anaesthesia •IJOA
May 2021 •NG192 •MBRRACE Aug 2020
Mar 2021 Dec 2020

Benchmarking Neuraxial block Uterotonic Hypertension
indicators monitoring consensus statement
(in topics)
•OAA/NPEU •OAA •Anaesthesia
May 2020 Mar 2020 Oct 2019 •NICE
Jun 2019
PDPH (in topics) Enhanced maternal
care Management of SALVO trial
•OAA spinal hypotension (in topics)
May 2019 •RCoA / ICS
Aug 2018 •AAGBI •Dec 2017
Jan 2018

WOMAN trial TXA 76

•Lancet
Apr 2017

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

One dose IV If no IT opioid: Surgical
dexamethasone LA by any
after delivery technique •Joel-Cohen incision
•Non-closure of
peritoneum
•Binders

IT opioids: Regular
paracetamol and
•Morphine 50- NSAIDs
100 mcg, or
•Diamorphine •with rescue opioids
300 mcg
RCTs 2014-20
included

•Planned RA only

“Implement strategies to minimise systemic opioid utilisation 77
and develop individualised or stratified post-discharge opioid
prescribing practices to reduce unnecessary opioid analgesic
consumption after elective caesarean section”

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

Decision-birth intervals reinstated Blood tests revised again
(they were audit criteria):
• 1.4.6 Before caesarean birth, carry out a full
• 1.4.3 Perform category 1 caesarean birth as blood count to identify anaemia, antibody
soon as possible, and in most situations screening, and blood grouping with saving
within 30 minutes of making the decision. of serum.

• 1.4.4 Perform category 2 caesarean birth as
soon as possible, and in most situations
within 75 minutes of making the decision.

Answering questions in obstetric anaesthesia | Dr Mark Porter FRCA | anyflip.com/janls/apxh/ 78

Indirect 5.59 Direct 4.12 9.71 per
100,000
•Cardiac •VTE
•Neurological •Suicide
•Haemorrhage
esp. SUDEP

Answering questions in obstetric anaesthesia | Dr Mark Porter FRCA | anyflip.com/janls/apxh/ 79

Key messages SUDEP • Night-time seizures
from the report 2020 • Uncontrolled seizures
Act on: • Ineffective treatment
In 2016-18, 217 women died during or up to six weeks after pregnancy,
from causes associated with their pregnancy, among 2,235,159 women
giving birth in the UK.
9.7 women per 100,000 died during pregnancy or up to six weeks after
childbirth or the end of pregnancy.

We need to talk about SUDEP Epilepsy and stroke 13%
Act on:

Night-time Uncontrolled Ineffective to prevent 29 women Systemic • due to pregnancy, health and
seizures seizures treatment Sudden biases
Unexpected 50 women other issues prevent women
Death in with complex and multiple
EPilepsy 33 women
problems receiving the care
A constellation of biases Cardiac 28 women they need

566 women died during 510 women (90%) disease 23% 23 women
or up to a year after had multiple 20 women
pregnancy in the UK problems Blood clots 15% 15 women
and Ireland
Overweight Mental 6 women
or obese Known health 4 women
281 heart 9 women
disease conditions 13%

16 Sepsis 11%

Smoking Delayed Aged Bleeding 9%
177 antenatal over 35
Other
care 210 physical
107
conditions 7%
Known to Physical health Cancer 3%
social problems
342 Pre-eclampsia 2%
services Other 4%
131 Minority Pregnant Previous Mental
ethnic or in the year pregnancy health
Live in group post-pregnancy problems problems
deprived
119 566 209 198
areas
168 Non UK Unemploy- • Venous air embolism
citizen ment
94 • Use reverse Trendelenburg
52 position routinely?

Non Born Domestic Anaesthesia •More on next slide
English outside abuse
speaking 61
UK
22 216

Systemic Biases due to pregnancy, health and other
issues prevent women with complex and multiple
problems receiving the care they need

Answering questions in obstetric anaesthesia | Dr Mark Porter FRCA | anyflip.com/janls/apxh/ 80

New Existing
recommendations recommendations

Structured done better
management plan for
anticoagulation, with Timely antenatal MDT
for complex cases
prescribing
responsibilities Good communication
within and between
Decision-making
protocols for team crucial in
sudden catastrophe
neuraxial block in
coagulopathy risk Sudden-onset severe
shock, pulse not
Anaesthetist has care reliable: do ECC
responsibility in (NAP6)
recovery

Recovery to have 81
same standards as for

non-pregnant

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/ 82

↑ risk of severe Known socioeconomic Risk of antenatal
vertical transmission of
COVID-19, ICU risk gradient in
admission and death. maternal mortality is COVID-19 is low.
(Outside UK? With co- similar in COVID-19.

morbidities?)

↑ risk of VTE in Entonox can be used Epidural analgesia
COVID-19: prophylactic with a single-patient
microbiological filter. should be considered,
LMWH during provided platelet
admission and after counts are not low.

delivery.

Benefit from ICU if PPE: Overall HCW intubateCOVID –

FiO2 ≥50%, RR hazard ratio 7x for difficult intubation
approaching 40 aerosol but proper fit 1:120, eFONA 1:430.
breaths min-1. Worse in obstetrics?
testing mitigates.

Answering questions in obstetric anaesthesia | Dr Mark Porter FRCA | anyflip.com/janls/apxh/ 83

Core set Pragmatic set The percentage of women who had an
of priority epidural (or a combined spinal epidural)
derived from for labour analgesia who had an accidental
national measures to dural puncture;
published be used for
standards Whether there are guidelines for the
quality referral of patients to an anaesthetist for
improvement an antenatal review;

Whether there are elective caesarean
section lists with dedicated (i.e. not
expected to cover emergency work)
obstetric, anaesthetic and theatre staff;

Whether point-of-care testing is available
for estimation of haemoglobin;

The percentage of epidurals for labour

analgesia that provided adequate pain
relief within 45 min of placement (from
the start of epidural insertion).

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Serious neurological damage is rare, particularly so for anaesthetic causes.

Importance of regular (hourly) motor block tests.

During labour, call anaesthetist if SLR absent.

During the recovery phase use SLR as a screening method.

Four-hour threshold to assess if delayed recovery.

Women should be informed of the likely timescale for resolution and encouraged to alert staff if delayed.

All units should have guidelines for escalation, and women presenting later with new concerns. 85

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

— Despite the ubiquitous use of uterotonic — Administering supra-physiological doses of

agents during caesarean delivery, oxytocin to prevent postpartum
evidence-based recommendations are haemorrhage may have unintended
largely lacking consequences for the mother–infant dyad

— In addition, dosing of uterotonic agents, — For example, there is a modest inverse
especially oxytocin, is highly variable and association between oxytocin exposure
often subject to idiosyncratic requests from and breastfeeding success, possibly due to

obstetric colleagues downregulation of oxytocinergic signalling

— Little guidance exists to help clinicians mechanisms

balance the risk of failing to prevent — Another area where oxytocin might be

postpartum haemorrhage with possible increasingly relevant is postpartum

adverse effects from unnecessary overdose depression; intrapartum exposure to

oxytocin increased the risk of depressive or

anxiety disorder by over 30% at 1 year

Intrapartum oxytocin: time to focus on longer term postpartum, regardless of pre-pregnancy
consequences? psychiatric diagnoses
D. T. Monks A. Palanisamy
First published: 25 July 2019 https://doi.org/10.1111/anae.14746

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Elective caesarean section Intrapartum caesarean section

Standard recommended Bolus 1 IU oxytocin; start oxytocin 3 IU oxytocin over ≥ 30 s; start
infusion at 2.5–7.5 IU.h−1 (0.04– oxytocin infusion at 7.5–
doses are higher than
required, with the 0.125 IU.min−1) 15 IU.h−1 (0.125–0.25 IU.min−1)

potential for acute
cardiovascular adverse

effects

If required after 2 min, give a further dose of 3 IU over ≥ 30 s

Oxytocin and carbetocin Consider second-line agent early in the event of failure of this regimen to
produce sustained uterine tone
dose requirements for
intrapartum caesarean Review the patient's clinical condition before discontinuing the infusion;
this will usually be between 2 h and 4 h after commencement
section are several times
greater than that for International consensus statement on the use of uterotonic agents during caesarean section
M. Heesen B. Carvalho J. C. A. Carvalho J. J. Duvekot R. A. Dyer D. N. Lucas et al
low-risk elective First published: 25 July 2019 https://doi.org/10.1111/anae.14757
caesarean section, and

therefore a universal
dose for all cases is not

appropriate

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— Enhanced maternity care is driven by a set of
competencies required to care for women with medical,
surgical or obstetric problems during pregnancy, peri- and
post-partum but without the severity of illness that
requires admission to a critical care unit.

— This care can be provided by any practitioner with the
necessary skills; EMC competencies overlap with those
required for level 2 care. These women require close
support and monitoring on the labour ward in the
expectation that their condition will resolve with
appropriate treatment.

— Level 2 Maternity Critical Care with more complex A NICE guideline on
obstetric or uncommon conditions can be delivered on ‘Intrapartum care for high risk
the labour ward or the critical care unit. women’ was published in April

— Level 3 Maternity Critical Care only on the critical care 2019: NG121
unit.

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— Vasopressors should be routine and preferably prophylactic; a-agonist
drugs are most appropriate.

— Although noradrenaline or metaraminol may be better due to a small
amount of b-agonist activity, phenylephrine is recommended due to the
amount of supporting data.

— Consider single-dilution techniques, and/or prefilled syringes.

— The use of smart pumps and two-drug vasopressor infusions can give
more cardiovascular stability than physician-controlled infusions.

— Maintain SAP ≥90% of baseline, and avoid <80% baseline.

— Maternal heart rate can be proxy for cardiac output – avoid high or low.

— Use less drug in women with pre-eclampsia.

Kinsella et al. International consensus statement on the management of hypotension with vasopressors during
caesarean section under spinal anaesthesia. Anaesthesia 2018 Jan;73(1):71-92. doi: 10.1111/anae.14080. Epub 2017 Nov 1.

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“The results suggest that Interest in (dilute)
norepinephrine, metaraminol, noradrenaline
and mephentermine have the

smallest risk of adversely
affecting fetal acid-base status,
and ephedrine had the greatest

risk”

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— Building on observations in trauma – early use of TXA

— Double-blinded RCT on ITT basis

— PPH: 1 g TXA plus 1 g if still bleeding at 30 minutes

— 20,060 women randomised

— Secondary outcome: death reduced (CI 0.65-1.0) with early

treatment (3 hours) NNT 267.

— Hysterectomy not reduced; adverse events similar

Bottom Line: TXA may be beneficial in reducing the risk of death due to PPH. The study has
some significant methodological limitations, including a change in power calculation and
hypothesis after it was commenced, as well as a low fragility index. As it is cheap with a good
safety profile in this study, consider giving TXA early in PPH. Early resuscitation, management of
coagulopathy and surgical assistance with source control, are the most important interventions.

WOMAN Trial Collaborators. Effect of early tranexamic acid administration on mortality, hysterectomy, and 91
other morbidities in women with post-partum haemorrhage (WOMAN): an international, randomised,
double-blind, placebo-controlled trial. The Lancet 2017; 389:2105-16.

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

SCAN ME

Slides at anyflip.com/janls/apxh/

Answering questions in obstetric anaesthesia | Dr Mark Porter FRCA | anyflip.com/janls/apxh/ 92