MOT obstetric anaesthesia update 2022 02 03

MOT day | Coventry | 5 August 2021

Dr Mark Porter | consultant obstetric anaesthetist

MOT update Slides at anyflip.com/janls/jzpj/ Dr Mark Porter FRCA

Welcome For active management with checklist® M-QRH

Coventry on one slide 13:20-14:10

Getting started Slides at anyflip.com/janls/jzpj/ Dr Mark Porter FRCA

Recent changes

Incidents and learning
Anything else you’d

like to ask or talk about

MOT update

MOT update Slides at anyflip.com/janls/jzpj/ Dr Mark Porter FRCA

•Test: 3 mL lidocaine 2% •15 mg heavy •Propofol and •PCIA now available
•Levobupivacaine bupivacaine rocuronium •30 mcg bolus dose
+ 0.4 mg diamorphine •Set up by anaesthetist
1mg mL-1 •Size 7.0 tube •Moving to free choice
+ fentanyl 2mcg mL-1 •Metaraminol 10 mg in •Morphine 15 mg iv
50 mL at 50mL h-1 for soon
•Establishing dose 10- 15-20 minutes GA
20 mL in left lateral Remifentanil
Spinals
Epidural
PCEA

•Red cell salvage for all •Level 1 and specialised •Refer all patients to •Expect help and
caesareans level 2 care follow-up on CRRS support from
consultants
•Return rate just under •No metaraminol •Follow up yesterday’s
10% •Charts reflect patients on CRRS •And main theatre team
•Refer to labour ward
•Wash swabs multidisciplinary •Telephone follow-up
management for PDPH coordinator
Cell salvage
EMC Follow-ups Support

Check the laminated wall charts in the operating theatres

MOT update Slides at anyflip.com/janls/jzpj/ Dr Mark Porter FRCA

Obstetric anaesthesia update

MOT update Slides at anyflip.com/janls/jzpj/ Dr Mark Porter FRCA

Confirm Confirm
badge access CRRS access
to the clinical
to the
area follow-up

lists

Confirm K2 Start to
access for familiarise
yourself with
records
the
guidelines

MOT update Slides at anyflip.com/janls/jzpj/ Dr Mark Porter FRCA

MOT update Slides at anyflip.com/janls/jzpj/ Dr Mark Porter FRCA

You will need CRRS access With that access you can
as part of the job
make patient referrals to
the obstetric anaesthesia

follow-up service

One referral per patient You deliver the follow-up USE K2

service when working on
labour ward; add the open

list of referrals to your
CRRS summary lists

If, after you have been

shown how to do add the
list, you still can’t do it:
complete an ICT Services

application and email to me

MOT update Slides at anyflip.com/janls/jzpj/ Dr Mark Porter FRCA

MOT update Slides at anyflip.com/janls/jzpj/ Dr Mark Porter FRCA

Confirm Confirm
badge access CRRS access
to the clinical
to the
area follow-up

lists

Confirm K2 Start to
access for familiarise
yourself with
records
the
guidelines

MOT update Slides at anyflip.com/janls/jzpj/ Dr Mark Porter FRCA

Obstetric anaesthesia update

MOT update Slides at anyflip.com/janls/jzpj/ Dr Mark Porter FRCA

CG172 caesarean section Most cases
undertaken with fluid
Preoperative team brief – maternity cases resistant surgical mask
and appropriate eye
Time of call if urgent: __:__
protection.
Category: 1£ 2£ 3£ 4£ FOR SCANNING PURPOSES
AFFIX PATIENT LABEL General anaesthesia:
Date of team brief: _ _ / _ _ / _ _ _ _
2 metres and 5
Team brief start: _ _ : _ _ End: _ _ : _ _ minutes if not

Team brief is mandatory for all procedures. For urgent cases (category 1 and 2) this must be timely and rapid, usually held as protected.
soon as possible outside the labour room. After team brief the responsible obstetrician must stay with the patient to provide
ongoing care and avoid delay. Reconsider urgency on arrival in theatre.

Operation: Caesarean £ Trial of instrumental delivery £ Perineal repair £ MROP £
Sterilisation £ Cervical suture £ EUA £ Other:

Team leader: Team introductions £ Resuscitaires checked £ Instruments available £
Obstetrician: Anaesthesia machines checked £ Recovery checked £

Midwife: State indication, placental site and any other concerns including medical £
Gestation weeks: _____
Anaesthetist & Is a more senior obstetrician needed to start the operation? No £ Yes £
ODP:
Body weight: _____ kg BMI: _____ Blood group: _______ Recent Hb: _____

Group + Save in date: No £ Yes £ Red cell antibodies: No £ Yes £

Antacid given: No £ Yes £ Woman’s language needs considered £

State plans for anaesthesia, blood provision, cell salvage and any other concerns £

Allergies: No £ Yes £

Agreed anaesthesia plan: Epidural top-up £ Spinal £ GA £ Other £

Caesarean Obstetric history: G P Past caesareans _____
sections –
category 3 Other concerns: No £ Yes £ If premature: steroids No £ Yes £ magnesium No £ Yes £
and 4
Neonatal team needed: No £ Yes £

Delayed cord clamping: No £ Yes £ Skin-to-skin: No £ Yes £

Infection risk (e.g. CPE, MRSA)? No £ Yes £ Significant coronavirus risk? No £ Yes £

PPE decision: Standard PPE £ Full PPE, with respirator mask, for key staff £
Operating theatre for use: Theatre 1 £ Theatre 2 £ Other: theatre ___

Any other concerns, needs or issues? No £ Yes £ Offer help to transfer patient to theatre

Dr Mark Porter 31 July 2020

PPE decision: Standard PPE £ Full PPE, with respirator mask, for key staff £
Operating theatre for use: Theatre 1 £ Theatre 2 £ Other: theatre ___

MOT update Slides at anyflip.com/janls/jzpj/ Dr Mark Porter FRCA

Syringes contain 500
micrograms
diamorphine.

Ask ODP to discard Promoting a
down to appropriate reliable supply of
diamorphine
amount.
Reducing dilution
Draw the appropriate steps in spinal
amount into the anaesthesia
bupivacaine NRFit

syringe for intrathecal
administration.

MOT update Slides at anyflip.com/janls/jzpj/ Dr Mark Porter FRCA

•To reduce the morbidity •Women who are not •Anaemic if <110 g/L in first •Iron transport protein.
burden of iron deficiency and optimised for delivery are at trimester or <105 g/L later. •May be increased in
anaemia. risk. inflammation.
•Check at booking and 28 •Check if high-risk or anaemic.
•To actively treat both iron •Maternal: infection, APH, weeks; check ferritin if high- •Treat with iron if <30 mcg/L.
deficiency and anaemia and PPH, depression. risk or anaemic.
optimise for delivery.
•Fetal: SGA, preterm birth, •Prescribe PO or IV iron unless
•Optimise at Hb≥120 g/L. mortality. optimised ≥120 g/L.

Purpose Why worry? Antenatal Ferritin

•Check Hb ± ferritin on •Women who delivered with •More than one tablet per day •May be needed for women
booking CS. untreated anaemia or had risks side-effects with no who don’t take or were not
significant obstetric increase in absorption. prescribed oral iron, or non-
•Prescribe iron if not haemorrhage: •Ferrous sulfate 200 mg OD responders.
optimised. for three months after •Check dose.
•Consider IV iron 1000 mg in restoration to optimal, or •Check drug charts and
•IV iron indicated if anaemic or recovery. after delivery, if needed. patient.
iron-deficient or intolerant of •Monofer in September.
PO iron. •PO iron OD 3 months. Oral iron
IV iron
Preoperative Postnatal

Refer to CG 1159 on eLibrary for details and further information

MOT update Slides at anyflip.com/janls/jzpj/ Dr Mark Porter FRCA

Asymptomatic and Mild disease Moderate, severe Vigilance
pending and critical disease
• Recent platelet • Check
• No special count • Investigations investigation
actions within 6 hours status in labour
• Small chance of ward patients
being low • Platelets, with COVID-19
coagulation and
• If urgent and no fibrinogen • Keep them up to
recent FBC, date
inform mother of • If normal,
increased risk proceed as • Pass on at
and suggest RA indicated handover

• Remember to
inform critical
care

• If low, seek
advice on
treatment and
relative risks of
GA/RA before
proceeding

These guidelines will develop with time – look out for updates

MOT update Slides at anyflip.com/janls/jzpj/ Dr Mark Porter FRCA

Beware long
operations:

warn the
surgeons at 45

minutes

Use the audit Do not use it 2 mL (40 mg)
form as we for trials or for cervical
establish the caesareans –
use of 2% heavy block time cerclage
prilocaine too short

3 mL (60 mg)
for MROP and
perineal repair

•Still need
metaraminol for this
but probably less

Use an audible two-practitioner check of the operation, drugs and doses

MOT update Slides at anyflip.com/janls/jzpj/ Dr Mark Porter FRCA

Obstetric anaesthesia update

MOT update Slides at anyflip.com/janls/jzpj/ Dr Mark Porter FRCA

CG172 caesarean section Incidents of
patients being
Preoperative team brief – maternity cases barrelled into
theatres without
Time of call if urgent: __:__
team brief
Category: 1£ 2£ 3£ 4£ FOR SCANNING PURPOSES
AFFIX PATIENT LABEL Team briefs for
Date of team brief: _ _ / _ _ / _ _ _ _ urgent cases must
be timely and rapid
Team brief start: _ _ : _ _ End: _ _ : _ _
Four roles to bring
Team brief is mandatory for all procedures. For urgent cases (category 1 and 2) this must be timely and rapid, usually held as information:
soon as possible outside the labour room. After team brief the responsible obstetrician must stay with the patient to provide
ongoing care and avoid delay. Reconsider urgency on arrival in theatre.

Operation: Caesarean £ Trial of instrumental delivery £ Perineal repair £ MROP £
Sterilisation £ Cervical suture £ EUA £ Other:

Team leader: Team introductions £ Resuscitaires checked £ Instruments available £
Obstetrician: Anaesthesia machines checked £ Recovery checked £

Midwife: State indication, placental site and any other concerns including medical £
Gestation weeks: _____
Anaesthetist & Is a more senior obstetrician needed to start the operation? No £ Yes £
ODP:
Body weight: _____ kg BMI: _____ Blood group: _______ Recent Hb: _____

Group + Save in date: No £ Yes £ Red cell antibodies: No £ Yes £

Antacid given: No £ Yes £ Woman’s language needs considered £

State plans for anaesthesia, blood provision, cell salvage and any other concerns £

Allergies: No £ Yes £

Agreed anaesthesia plan: Epidural top-up £ Spinal £ GA £ Other £

Caesarean Obstetric history: G P Past caesareans _____
sections –
category 3 Other concerns: No £ Yes £ If premature: steroids No £ Yes £ magnesium No £ Yes £ •Team leader
and 4 •Obstetrician
Neonatal team needed: No £ Yes £ •Midwife
•Anaesthetist and ODP
Delayed cord clamping: No £ Yes £ Skin-to-skin: No £ Yes £
Dr Mark Porter FRCA
Infection risk (e.g. CPE, MRSA)? No £ Yes £ Significant coronavirus risk? No £ Yes £

PPE decision: Standard PPE £ Full PPE, with respirator mask, for key staff £
Operating theatre for use: Theatre 1 £ Theatre 2 £ Other: theatre ___

Any other concerns, needs or issues? No £ Yes £ Offer help to transfer patient to theatre

Dr Mark Porter 31 July 2020

MOT update Slides at anyflip.com/janls/jzpj/

Do not act hastily Check equipment, Have a second pair KEEP
in RSI position and plan of hands unless CALM
before starting
Call for senior help very urgent and no
immediately when Use LMA Protector expected difficulty
trouble happens for rescue
Check ETT position AND

CALL

ANOTHER

ANAESTHETIST

MOT update Slides at anyflip.com/janls/jzpj/ Dr Mark Porter FRCA

MOT update Slides at anyflip.com/janls/jzpj/ Dr Mark Porter FRCA

From general Individuals to write
department policy on board coming in

and going out

The names of responsible 08:00 – write up names of

consultants should be staff in labour ward,
written on anaesthesia registrar and consultant,
charts and HDU charts.
and 2813 holder

20:00 (and 08:00

weekends) – write up
names of staff in labour
ward, and also the 2813

bleep holder and general
consultant on call

MOT update Slides at anyflip.com/janls/jzpj/ Dr Mark Porter FRCA

Bespoke prescriptions

Double charts and double or missed
prescriptions

Past drugs not checked

Time to start doses not specified

Page-by-page, line-by-line handover
and check not done in recovery

Previous drug charts not struck
through: multiple charts in use

MOT update Slides at anyflip.com/janls/jzpj/ Dr Mark Porter FRCA

Date the cannula and do the USE K2
cannula care pathway
Equipment checklist and check record
Sign the controlled drugs Labour Ward epidural trolleys
register
Checks of both trolleys must be completed daily at or soon after 08:00 and
Check the epidural trolleys the record book signed by the 2178 bleep holder

Dispose of unneeded drugs

1 February 2020 | version 1
Dr Scott Minns | Dr Paul Wyatt | Dr Mark Porter

MOT update Slides at anyflip.com/janls/jzpj/ Dr Mark Porter FRCA

Check CRRS for anaesthesia Epidural analgesia and anaesthesia
recommendation standards in maternity care

Ask the labour ward coordinator This standards document details the use of drugs and equipment for epidurals in labour ward and maternity
to send for someone else if you theatres. It is for use by anaesthetists and by midwives.
can’t attend or can’t do the block
For full descriptions of procedures see the Obstetric Anaesthetists Handbook 13th edition, 2020. Owing to the
Use NRFit equipment introduction of epidural NRFit connectors in July 2020, standards here are authoritative where different.

Audible double check for all drug Dr Mark Porter | 27 July 2020
administrations
Universal standards period should only exceed one hour in
Report all dural taps on Datix and exceptional circumstances.
email Dr Fairfield Drug checks 9. Before inserting an epidural, the anaesthetist
1. Any drugs administered to the epidural space will check hand-held antenatal notes and CRRS
notes for anaesthesia assessments and plans.
will be checked between two practitioners. 10. Patients will have IV access established before
2. The controlled drugs register will be signed by epidural insertion.
11. IV fluids should only be administered for a
two practitioners as per controlled drugs policies clinical indication. Epidural analgesia is not an
in labour ward and theatres. indication to start IV fluids.
3. Infusion bags of levobupivacaine and fentanyl
used for epidurals will have a patient label Top-up in theatre
affixed.
12. Where a patient is to be transferred to theatre
Connectors for an epidural top-up for surgical anaesthesia,
4. Equipment with NRFit connectors will be used the epidural pump will be discontinued and
disconnected, with the clamping adapter and
for all epidural catheter insertions. filter retained on the patient epidural catheter,
5. Equipment with NRFit connectors will be used and a hub cap placed on the filter to close and
protect it. The epidural bag and pump will be
for preparation and delivery of all epidural retained in the labour room for disposal.
administrations including epidural blood
patches. 13. Anaesthetists may administer epidural doses in
6. Equipment with Luer connectors will be used for theatre as required to achieve surgical
all intravenous, subcutaneous and intradermal anaesthesia and postoperative analgesia. All
administrations associated with epidurals, drugs drawn into NRFit syringes for neuraxial
including local anaesthesia to the skin. administration will be checked between two
Training and education practitioners.
7. Midwives caring for patients with epidural
analgesia will have had appropriate competency Disposal
training.
14. The total volume used will be entered on the
Process standards obstetric anaesthesia neuraxial chart.

Initiation 15. Disposal of the epidural bag will be undertaken
8. The time from the anaesthetist being informed by two practitioners and the controlled drugs
register signed.
that a woman is requesting an epidural and
ready to receive one until attending the mother 16. Disposal of controlled drugs in theatre will be
should not normally exceed 30 minutes. This undertaken by two practitioners and the
controlled drugs register signed.

Page 1 of 1

Use ultrasound if expected to be Slides at anyflip.com/janls/jzpj/ Dr Mark Porter FRCA
or found to be difficult

MOT update

EpiLong NRFit Tuohy The Pajunk epidural kit. Please note that the epidural catheter is marked to in 5s and 1s similar to
16G x 80mm the Portex, but is marked to 30 cm not just 20 cm.
This pack contains Luer syringes and needles. Use Luer connectors for skin injections.
Blue anaesthesia pack

NRFit Syringe 5ml Lock Use this to draw the epidural test dose, prime the catheter and administer the test dose.

NRFit Blunt Drawing Up Needle Use this to draw neuraxial solutions from an ampoule.
18G x 50mm with 5 micron filter
Catheter fixation device You will need to fix the catheter to the patient. Use the FixoCath – practise with a spare one first.
Boxes of 16G Lockit clamps are on order and will arrive soon – they are the same as the ones we
had before.

Skin dressings Rectangular Tegaderm over the catheter fixation device.
CADD-Solis administration set for Mefix as appropriate.
pump
The new administration sets have a blue plastic guard that must be removed before it is fitted to
the PCEA pump. The priming volume is just over 2 mL.

FixoLong NRFit (fixes filter to This is a yellow plastic holder and sticker for the epidural filter, holding the filter in position. It can
patient) be fixed to the patient’s shoulder.

NRFit Accessories Needle hub cap Before you leave, give one of these to the midwife for capping off the epidural filter at the end of
(male fitting) labour of for transfer to theatre.

MOT update Slides at anyflip.com/janls/jzpj/ Dr Mark Porter FRCA

Cold Pain

ice cube or ethyl pinprick or pinching
chloride
Or light touch - needs
Checks 1-2 dermatomes skill and checks 1-2
higher than pain
dermatomes lower 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
MOT update Dr Mark Porter FRCA
modalities

Slides at anyflip.com/janls/jzpj/

Check the Hb and book Beware PPH after long Beware bleeding from
the blood early
second stage – tears and unrecognised
instrumental or abnormal placentation
operative delivery
– check cumulative loss
and bucket contents

Call MOH Use MOH form

Risk of MOH MROP Trauma EUA
repair
Intrapartum Dr Mark Porter FRCA
caesarean

MOT update Slides at anyflip.com/janls/jzpj/

Set up collection for all caesarean section
cases

Process if blood loss more than about 600 mL
– discuss with the ODP

Reinfuse if red cells recovered

•Tell the woman she has not had a blood transfusion.
•Higher threshold for reinfusing women with sickle cell trait

No leukodepletion filter

MOT update Commence reinfusion in the operating theatre Dr Mark Porter FRCA
or theatre recovery, after an identity check

Slides at anyflip.com/janls/jzpj/

MOH: review patient

Successful management Patient not improving;
with cell salvage; management needs exceed

processing quickly and cell salvage alone
keeping up with losses

Patient not Call blood bank if not already done so,
improving check patient status and give further
information; make appropriate orders

Review Order MOH pack or Use O Rh Neg
patient (4 RBC + flyers; not if red
cell antibodies
appropriate other than PD
other products)

Treat Call Review Apply treatment; establish resuscitation
acidosis again priorities and commence damage
blood
bank control resuscitation; arterial line and
regular samples; use Belmont rapid
infuser with blood and FFP; monitor
therapy by improvement in base excess
and lactate; regular fibrinogen tests

Order Patient improving; continue with regular review Dr Mark Porter FRCA
blood
Slides at anyflip.com/janls/jzpj/
MOT update

MOT update Damage Dr Mark Porter FRCA
control
resuscitation

Prevent:
● hypothermia
● coagulopathy
● acidosis

Give tranexamic
acid doses
Avoid crystalloids
& vasoconstrictors
Use balanced
transfusions
Maintain
normothermia
Correct acidosis
with transfusion
Ensure early
haemorrhage
control
Maintain
normocalcaemia

Slides at anyflip.com/janls/jzpj/

Standard MOH Cryoprecipitate Prospect of POC
pack 1 is 4 RBC, may be indicated coagulation
pack 2 is 4 RBC & 4 instead of FFP in testing and
FFP, pack 3 on is abruption, AFE, fibrinogen
4:2 (you must later massive concentrate in
order) haemorrhage autumn

Stage 2 PPH call Measurement of
from Monday 20 blood loss – new
September – 1000 weighing scales
mL etc

Promote early use
of TXA
(except DIC)

MOT update Slides at anyflip.com/janls/jzpj/ Dr Mark Porter FRCA

Delivery (vaginal If known haemoglobinopathy refer to patient’s individual
or caesarean): specialist plan regarding anaemia management and
decide based on
discuss with haematology if uncertain. Do not give iron
last Hb before
delivery and EBL unless advised by specialist team.

Last Hb≥120 g/L Last Hb105-119 Last Hb<105 g/L EBL≥1500 mL or Used for all deliveries
and EBL≤500 mL g/L or EBL 501- or MOH or
No further action if optimised and
No further action 999 mL EBL 1000-1499 mL EBL>20% of low EBL
required unless estimated blood
PO iron once Review blood Prescribe iron if not optimised or
has further daily for 3 tests; do ferritin volume or EBL > 500
bleeding or months if if anaemic and ongoing bleeding
symptoms. tolerant. no recent level; Blood tests and consider IV iron if
or persistent previously anaemic or EBL ≥ 1000
Request GP to consider FBC tachycardia
review response for anaemia;
FBC at 6-12 Urgent blood gas
at 3 months. Hb & lactate;
(Consider this if hours if
Hb<105 g/L and haemorrhage review and repeat
no symptoms.)

Hb>100 g/L and Hb 70-100 g/L or Hb<70 g/L or • Consider same
no symptoms and intolerant of PO symptomatic day IV iron or
tolerates PO iron transfuse as
iron or anaemia
PO iron once ferritin<30 mcg/L UHCW guideline.
daily for 3 Consider blood • If Hb≥100 g/L
months if Consider IV iron transfusion to recheck FBC at 6
tolerant. to rapidly optimise Hb 70 g/L ± IV
patient for home hours unless
Start PO iron 5 iron symptomatic
days after any IV (transfer to urgent

iron infusion. review).
Request GP to • If she received
review response allogeneic blood

at 3 months. or salvage red
cells, seek senior
advice before

arranging IV iron.

Beware misleading Hb levels during or immediately after active
bleeding. The Hb level may not reflect the severity of bleeding. Acidosis

markers (e.g. lactate) may be a better guide.

Appropriate management for women in these two groups may require clinical judgment as multiple factors

interact. Women with uncomplicated mild anaemia, recent blood tests and low blood loss may be more suitable
for oral iron; some women with modest loss may need blood tests if they have co-morbidities.

MOT update Slides at anyflip.com/janls/jzpj/ Dr Mark Porter FRCA

MOT update SCAN ME KEEP
CALM
anyflip.com/janls/tyit/
AND
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CALL
ANOTHER

ANAESTHETIST

Dr Mark Porter FRCA