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Cardiac disease

demonstrated with an ejection fraction less than 45%. It is usually but not
always a form of dilated cardiomyopathy.

Diagnosis of peripartum cardiomyopathy

You should consider diagnosing peripartum cardiomyopathy in patients
with:
• Orthopnoea.
• Tachycardia.
• Excessive tiredness.
• Respiratory distress.
• Rapid respiratory rate.
• Desaturation.
• Pallor.
• Clear or pink frothy sputum.
• Chest crackles.
• Hyper- or hypotension.
• Peripheral shutdown.
• New cardiac murmurs.
• Hepatomegaly.
• Altered level of consciousness.
• Overwhelming sense of doom and distress.
It is a diagnosis made by exclusion; you should exclude other causes of
pulmonary oedema.

Management

The initial management is as for acute heart failure: oxygen (if hypoxic),
diuretics and vasodilators; opiates and inotropes should be used more
selectively. Consider the need for mechanical ventilation in respiratory

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failure. Activate treatment for acute heart failure by calling for
cardiological assistance.

Delivery should be performed according to obstetric indications with
vaginal delivery being preferable if there is no obstetric indication for
caesarean section. Epidural analgesia should be recommended. Use an
arterial line. The principles of anaesthesia and analgesia are as for any
patient with cardiac failure: maintain normal to low heart rate to
decrease oxygen demand and prevent large swings in blood pressure.
Use alfentanil 20 mcg kg-1 to prevent a hypertensive response to
intubation if using general anaesthesia.

Institute anticoagulation in patients with massively enlarged cardiac
chambers (ejection fraction less than 35%).

Postnatal course

• Enalapril is the current drug of choice.

• Peripartum cardiomyopathy is progressive throughout the mother’s
obstetric career.

• Half of all patients continue to have heart failure after six months.
They are advised against a further pregnancy, as the recurrence risk
is high and the mortality if it does occur is nearly 100%.

• If the heart failure has completely resolved the mortality risk in
future pregnancies is 15%.

Known disease

You should seek senior advice on all cases of known congenital or
acquired cardiac disease in pregnant patients that come to your
attention. The best current reference is the European Society of
Cardiology guidelines on the management of cardiovascular diseases
during pregnancy [332]. The risk tables are included below as a guide to
the severity of what you may have referred to you in an emergency.
Treatment will be specific to the patient and her condition.

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Women with cardiac disease have an increased risk of obstetric
complications, including premature labour, pre-eclampsia, and
postpartum haemorrhage.

Lumbar epidural analgesia will be recommended for vaginal delivery in
most of these conditions and may be appropriate for planned caesarean
section. It reduces the sympathetic activation consequent upon severe
pain, reduces the urge to push and provides anaesthesia for surgery. You
should consider carefully whether the other forms of anaesthesia are safe
even in category 1 caesarean section. Beware the systemic hypotension
that even an uncomplicated epidural can produce. Use with caution in
patients with obstructive valve lesions.

Modified WHO classification of maternal cardiovascular risk

The diagnosis examples in the table are appropriate for the mWHO
classification if the patient is otherwise well and uncomplicated.

mWHO 1

No detectable increased risk of maternal mortality and no/mild
increase in morbidity.

Maternal cardiac event rate is 2.5-5%.

• Small or mild:

• Pulmonary stenosis.

• Patent ductus arteriosus.

• Mitral valve prolapse.

• Successfully repaired simple lesions (atrial or ventricular septal
defect, patent ductus arteriosus, anomalous pulmonary venous
drainage).

• Atrial or ventricular ectopic beats, isolated.

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mWHO 2
Small increased risk of maternal mortality or moderate increase in
morbidity.
Maternal cardiac event rate is 5.7-10.5%.
• Unoperated atrial or ventricular septal defect.
• Repaired tetralogy of Fallot.
• Most arrhythmias (supraventricular arrhythmias).
• Turner syndrome without aortic dilatation.
mWHO 2-3 (depending on individual)
Intermediate increased risk of maternal mortality or moderate to
severe increase in morbidity.
Maternal cardiac event rate is 10-19%.
• Mild left ventricular impairment (EF>45%).
• Hypertrophic cardiomyopathy.
• Native or tissue valvular heart disease not considered mWHO I

or IV (mild mitral stenosis, moderate aortic stenosis).
• Marfan or other HTAD (heritable thoracic aortic disease)

syndrome without aortic dilatation.
• Aorta <45 mm in aortic disease in bicuspid aortic valve

pathology.
• Repaired coarctation.
• Atrioventricular septal defect.

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mWHO 3

Significantly increased risk of maternal mortality or severe morbidity.
Expert counselling required. If pregnancy is decided upon, intensive
specialist cardiac and obstetric monitoring needed throughout
pregnancy, childbirth, and the puerperium.

Maternal cardiac event rate is 19-27%.

• Moderate left ventricular impairment (EF 30-45%).

• Previous peripartum cardiomyopathy without any residual left
ventricular impairment.

• Mechanical valve.

• Systemic right ventricle with good or mildly decreased
ventricular function.

• Fontan circulation, if otherwise the patient is well and the
cardiac condition uncomplicated.

• Unrepaired cyanotic heart disease.

• Other complex heart disease.

• Moderate mitral stenosis.

• Severe asymptomatic aortic stenosis.

• Moderate aortic dilatation (40-45 mm in Marfan syndrome or
other HTAD; 45-50 mm in bicuspid aortic valve, Turner syndrome
with ASI 20-25 mm m-2, tetralogy of Fallot <50 mm).

• Ventricular tachycardia.

mWHO 4

Extremely high risk of maternal mortality or severe morbidity;
pregnancy contraindicated. If pregnancy occurs termination should be
discussed. If pregnancy continues, care as for class III.

Maternal cardiac event rate is 40-100%.

• Pulmonary arterial hypertension.

• Severe systemic ventricular dysfunction (EF <30% or NYHA III-IV).

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• Previous peripartum cardiomyopathy with any residual left
ventricular impairment.

• Severe mitral stenosis.

• Severe symptomatic aortic stenosis.
• Systemic right ventricle with moderate or severely decreased

ventricular function.
• Severe aortic dilatation (>45 mm in Marfan syndrome or other

HTAD, >50 mm in bicuspid aortic valve, Turner syndrome with
ASI >25 mm m-2, tetralogy of Fallot >50 mm).

• Vascular Ehlers-Danlos.

• Severe (re)coarctation.

• Fontan with any complication.

Cardiac murmurs

All patients with cardiac murmurs should be assessed carefully prior to
anaesthesia. Most will have a flow murmur associated with the increased
cardiac output of late pregnancy. Some may have longstanding,
documented, benign murmurs.

Referral to a cardiologist

You should refer patients for an opinion on diagnosis and management
rather than just for investigations. This will usually include ECG and
echocardiography examinations – see page 116. Dr Adamson has specific
expertise in this area as our lead consultant cardiologist for maternity.

Echocardiography is recommended in any pregnant patient with
unexplained or new cardiovascular signs or symptoms.

Seek senior anaesthetic advice if any abnormalities are discovered on
investigation or referral.

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Anaesthesia and analgesia for women with cardiac
disease

Always check for the management plan in cases of known disease. It will
usually be on CRRS and printed at the front of the medical record.
This section is limited to some general considerations for cardiac cases.

Mode of anaesthesia

Regional anaesthesia and analgesia is the usual choice unless specified
otherwise in the cardiology plan [333]. We would usually offer epidural
analgesia, and this should be low-dose as per our usual PCEA regime.
For operative cases, aim to preserve cardiovascular stability by using
sequential techniques such as lumbar epidural top-up or combined
spinal–epidural.

Haemodynamic monitoring

Unless otherwise specified in the delivery plan, women with mWHO risk 3
or 4 should have an arterial line inserted for haemodynamic monitoring
during delivery, and consider central venous access. Consider it for
women with mWHO 2 risk.

Oxytocic drugs

Oxytocin can produce adverse cardiovascular effects. It must be given at
the lowest effective dose and by slow infusion, avoiding bolus doses. The
mixed preparation Syntometrine can have unpredictable effects and
should usually be avoided.
Always look for the management plan in the antenatal record. If there is
no plan, then consider using the following oxytocic regime.

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Management of the third stage of labour for women with modified
WHO 3 or modified WHO 4 heart disease [334]

Condition Uterotonics Drugs to avoid
because of potential
Significant aortopathy First-line uterotonic harm
Oxytocin Ergometrine (because
Marfan syndrome and of risk of hypertension-
Loeys–Dietz with aortic Second-line uterotonics induced aortic
dilatation >40 mm. Misoprostol dissection or rupture)
Carboprost
Bicuspid aortopathy Long-acting oxytocin
and aortic dilatation First-line uterotonic analogues and
>45 mm. Slow infusion of ergometrine (because
oxytocin to avoid of risk of hypertension-
Previous aortic sudden haemodynamic induced heart failure)
dissection. change

Turner syndrome and Second-line uterotonics
aortic size index Misoprostol
>25 cm/m2. Carboprost

Limited or fixed low
cardiac output, or
preload-dependent
circulation

Severe systemic
ventricular dysfunction
(ejection fraction
<30%).

Severe valvular
stenosis.

Hypertrophic
cardiomyopathy with
diastolic dysfunction or
significant outflow tract
obstruction.

Fontan circulation.

Cyanotic heart disease.

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Condition Uterotonics Drugs to avoid
Pulmonary arterial because of potential
hypertension. First-line uterotonic harm
Oxytocin
Coronary artery Second-line uterotonics Ergometrine,
disease. Misoprostol carboprost and long-
First-line uterotonic acting oxytocin
Oxytocin analogues (because of
risk of worsening
pulmonary
hypertension)

Ergometrine (because
of risk of coronary
ischaemia)

Second-line uterotonics

Misoprostol

Give oxytocin slowly and carefully; at this dose it will reduce the risk of
postpartum haemorrhage and have a minimal impact on cardiovascular
parameters in the third stage of labour [335]. Run the standard dilution of
20 units in a 50-mL syringe, at 30 mL h-1 for 10 minutes (5 mL volume to
be infused). This will administer 2 units over the 10 minutes. Then
continue at 1.8 mL h-1. This will administer 0.72 units per hour. These
infusion doses can be increased if necessary and with attention to the
arterial line.

Avoid ergometrine if possible as it will cause an increase in systemic
vascular resistance. If needed to gain control of an atonic bleeding
uterus, use 500 mcg diluted to 10 mL with sodium chloride 0.9% solution
and give 25-50 mcg slowly with vigilance – watch the arterial line.

Avoid carboprost if possible as it will cause an increase in pulmonary
arterial resistance and decrease pulmonary artery blood flow.

Misoprostol is safe in cardiac disease.

Patients with cardiac anomalies are often best managed by avoiding
caesarean section. The use of early epidural analgesia allows the best
management of the stress of labour by reducing the surges in cardiac

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output seen in contractions. The epidural may also be needed for
instrumental delivery to avoid a prolonged second stage and for slow
establishment of a caesarean section block if operative delivery is
indicated.

ICD (implantable cardioverter-defibrillator) and pacemaker

ICDs should remain activated for vaginal delivery but may need
inactivation for surgical delivery due to the potential for use of
diathermy, peripheral nerve stimulation and less common equipment
such as MRI and defibrillators. Pronounced postoperative shivering can
confuse the sensing function and lead to inappropriate discharge. Magnet
inactivation will not disable the anti-bradycardia pacing functions of an
ICD. [336]

Bipolar diathermy is preferred to monopolar but is not reliably safe. The
management plan may include use of a magnet to prevent the ICD firing
during anaesthesia and surgery. The magnet is kept in the controlled
drugs cupboard of theatre 2, and there is a further magnet in main
theatre recovery, in the controlled drugs cupboard. Tape it over the ICD
insertion site in an emergency to disable the shock function. Remove it if
a shock is required from the device.

Ideally, and with time to plan, call the cardiac devices technician on
extension 26417 for help and advice about disabling and re-enabling the
device; this will prevent accidents due to misplacement of a magnet
device. They can also give guidance about intraoperative placement of
external defibrillator pads, usually anterior-posterior; consider their use
where an ICD is in place and disabled. In some circumstances, magnet
inactivation may be preferable as it is rapidly reversible in an emergency.

Antibiotic prophylaxis

Antibiotic prophylaxis against infective endocarditis is not recommended
routinely for obstetric procedures or childbirth [337].

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325. Ray P, Murphy GJ, Shutt LE. Recognition and management of maternal cardiac
disease in pregnancy. Br J Anaes 2004; 93:428-39.

326. Rout CC. Anaesthesia and analgesia for the critically ill parturient. Best Pract
Res Clin Obstet Gynaecol 2001; 15:507-22.

327. Royal College of Physicians. Managing acute medical problems in pregnancy;
Acute Care Toolkit 15. London: RCP, November 2019.

328. Quasim S, Morse K. Early warning scores – a lesson from a maternal death. Int
J Obstet Anesth 2018; 36: 130-1.

329. Adamson DL, Dhanjal MK, Nelson-Piercy C. Heart disease in pregnancy. 2011.
OUP: Oxford Specialist Handbooks in Cardiology. Page 29.

330. Nelson-Piercy C. Handbook of Obstetric Medicine, fifth edition. Boca Raton:
CRC Press. Arrhythmias section in Heart Disease chapter.

331. Sliwa K, Hilfiker-Kleiner D, Petrie MC et al. Current state of knowledge on
aetiology, diagnosis, management, and therapy of peripartum
cardiomyopathy: a position statement from the Heart Failure Association of
the European Society of Cardiology Working Group on peripartum
cardiomyopathy. Eur J Heart Fail 2010; 12:767-78.

332. Regitz-Zagrosek V, Roos-Hesselink JW, Bauersachs J, Blomström-Lundqvist C,
Cífková R, De Bonis M et al. 2018 ESC Guidelines for the management of
cardiovascular diseases during pregnancy: The Task Force for the
Management of Cardiovascular Diseases during Pregnancy of the European
Society of Cardiology (ESC). Eur Heart J 2018; 39(34):3165-241.

333. National Institute for Health and Clinical Excellence. Intrapartum care for
women with existing medical conditions or obstetric complications and their
babies. London: NICE, 2019; NG121, section 1.3.34-8.

334. National Institute for Health and Clinical Excellence. Intrapartum care for
women with existing medical conditions or obstetric complications and their
babies. London: NICE, 2019; NG121, section 1.3.44.

335. Cauldwell M, Steer PJ, Swan L, Uebing A, Gatzoulis MA, Johnson MR. The
management of the third stage of labour in women with heart disease. Heart
2017; 103:945-51.

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336. Salman MM, Kemp HI, Cauldwell MR, Dob DP, Sutton R. Anaesthetic
management of pregnant patients with cardiac implantable electronic
devices: case reports and review. Int J Obstet Anesth 2018; 33:57-66.

337. National Institute for Health and Clinical Excellence. Prophylaxis against
infective endocarditis: Antimicrobial prophylaxis against infective endocarditis
in adults and children undergoing interventional procedures. London: NICE,
March 2008, last updated July 2016; CG64, section 1.1.3.

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Diabetes in pregnancy

Diabetes in pregnancy

Pregnancy has profound effects on carbohydrate metabolism and hence
control of blood sugar is more difficult for mothers who have diabetes
mellitus than in the non-pregnant state. Usually there is a progressive
and unpredictable increase in insulin requirement after the first
trimester. The patient is managed jointly between the diabetologists and
obstetricians. The medical notes will contain a suggested insulin
prescription for the delivery period including a continuous infusion of
insulin.

Maternal normoglycaemia is the target during labour or caesarean
section, minimising the risk of neonatal hypoglycaemia associated with
maternal hyperglycaemia.

Definitions drawn from the UHCW guideline [338]:

Type 1 diabetes: absolute insulin deficiency, prone to keto-acidosis and
dependent on exogenous insulin to sustain life.

Type 2 diabetes: defects in insulin secretion as well as insulin resistance.
More common in women of Asian and Afro-Caribbean ethnicity.

Gestational diabetes: carbohydrate intolerance of variable severity with
onset or first recognition during pregnancy.

Analgesia for labour

Epidural analgesia for labour is the technique of choice. It reduces the
acidosis of labour, reduces the stress response and consequent
hyperglycaemia, and detection of hypoglycaemia is easier in the alert
patient. It also facilitates anaesthesia for caesarean section, which is
indicated more commonly in women with diabetes. Fluids administered
for the epidural should be through a separate intravenous line from the
glucose. Hartmann’s solution is suitable.

Anaesthesia care

These points are taken from the UHCW guideline and the NICE guideline
[339].

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Diabetes in pregnancy

Women with diabetes and comorbidities such as obesity or autonomic
neuropathy will be offered an anaesthetic assessment in the third
trimester of pregnancy. Check for the assessment details in the antenatal
hand-held notes.

Monitoring of blood glucose is more difficult under general anaesthesia.
If general anaesthesia is used for the birth in women with diabetes,
monitor blood glucose every 30 minutes from induction of general
anaesthesia until after the baby is born and the woman is fully conscious.

Blood glucose control during and after delivery

Women with diabetes may become suddenly hypoglycaemic (blood
glucose < 4 mmol L-1). If concerned, check the blood sugar straight away.
Treat hypoglycaemia immediately with 15-20 g of whichever fast-acting
oral carbohydrate is to hand.

The capillary plasma glucose will be monitored every hour during labour
and birth in women with diabetes. The treatment target is to maintain
between 4 and 7 mmol L-1, using an intravenous dextrose and insulin
infusion for those women not achieving this. Women with type 1
diabetes and those with type 2 diabetes managed on insulin should have
this infusion from the onset of established labour.

If the woman has type 1 or 2 diabetes and is on a dextrose and insulin
infusion at delivery, halve the insulin rate immediately. If she has
gestational diabetes stop the dextrose and insulin infusion on delivery.
Check blood glucose one hour later.

Gestational diabetes during delivery

Manage women with gestational diabetes as for a normal mother except
where glycaemic control indicates the use of insulin. The obstetricians
will normally take this decision prior to admission onto the labour ward.

Discontinue insulin infusions immediately after birth for women who
have been diagnosed with gestational diabetes.

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Planned caesarean section

This applies to gestational diabetes, and type 1 and type 2 diabetes
where control is good. Women with type 1 and type 2 diabetes should be
delivered by 38+6 weeks by induction or caesarean section; with
complicated gestational diabetes, between 38 and 40+6 weeks. Women
with diabetes who are given steroids for fetal lung maturity will be
admitted for glucose monitoring and necessary treatment.
The mother should have her normal hypoglycaemics and food on the
evening before planned delivery. Omit hypoglycaemics, food and ERAS
glucose drinks on the day of surgery. The patient should be first on the
operating list. Make sure that her blood glucose level has been checked
before going to theatre. She should not normally need an intravenous
dextrose and insulin infusion as it will complicate care; it is indicated
where glycaemic control has been poor. Take her to theatre promptly,
and make sure that her blood glucose is checked immediately after
delivery in recovery, that food and drink is offered promptly (with glucose
check before and after) and that she is content to manage her own
insulin if needed after delivery.
If there is delay to surgery or her blood glucose is elevated, then start the
insulin infusion according to the procedure in the medical records.

338. Farrall L, Murthy N, Goodwin W. Diabetes in pregnancy. UHCW clinical
guideline CG 1011, October 2018.

339. National Institute for Health and Clinical Excellence. Diabetes in pregnancy:
management from preconception to the postnatal period. London: NICE,
February 2015; NG3.

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Thrombocytopenia 459
460
Thrombocytopenia 464
465
Chapter contents
Management of thrombocytopenia in pregnancy
Intrapartum care for moderate or severe thrombocytopenia
Long-term systemic steroids
Obstetric cholestasis

See the hospital guideline on this [340]. Only 1% of pregnant women will
have thrombocytopenia, or a platelet count less than 100 × 109 L-1. The
most common pregnancy-related cause is gestational thrombocytopenia
(75% of cases) with hypertensive disorders, HELLP syndrome and acute
fatty liver of pregnancy being very rare causes. Causes not related to
pregnancy are rare; idiopathic thrombocytopenia will be a coincidental
finding in up to 1:1000 pregnancies.

Definitions by platelet count

Platelet count 100-150 × 109 L-1 Physiological (due to haemodilution,
increased platelet consumption, and
increased platelet aggregation).

Platelet count 50-100 × 109 L-1 Moderate thrombocytopenia.

Platelet count < 50 × 109 L-1 Severe thrombocytopenia.

A low platelet count may be due to a clotted specimen or anticoagulant-
mediated platelet clumping. For a new diagnosis, repeated FBC and
confirmatory blood films are necessary.

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Thrombocytopenia

Common diagnoses

Gestational thrombocytopenia accounts for 70-80% of cases in
pregnancy and is typically characterized by a platelet count > 70 × 109 L-1,
occurring in the mid-second to third trimester, not associated with
hypertension or proteinuria. It is a diagnosis of exclusion with unknown
mechanism. No special management is required, but platelet count
< 70 × 109 L-1 indicates investigation for an alternative aetiology. It
typically resolves in the puerperium but may recur with subsequent
pregnancies.

Idiopathic thrombocytopenic purpura (ITP) is an autoimmune disorder
characterised by immune destruction of otherwise normal platelets
occurring in response to an unknown stimulus. It is defined by an
abnormally low platelet count usually below 100 × 109 L-1. ITP occurs in
1:1000 or fewer pregnancies, accounting for around 3% of cases in
pregnancy. Although an uncommon cause of thrombocytopenia in
pregnancy, it is the commonest cause of a low platelet count in the first
and second trimesters. There is no specific diagnostic test and it remains
predominantly a diagnosis of exclusion. Some women start their
pregnancy with chronic ITP (longer than 12 months with or without
treatment).

Management of thrombocytopenia in pregnancy

Moderate or severe thrombocytopenia should be managed in the
monthly combined obstetric haematology clinic. Platelet counts should
be monitored monthly up to 34/36 weeks and weekly thereafter.

Treatment aims

Antenatal count > 20 × 109 L-1; for delivery > 50 × 109 L-1, and for regional
anaesthetic > 75 × 109 L-1.

Indications for treatment

• If the woman is symptomatic with bleeding.
• The platelet count is < 20 × 109 L-1.

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Thrombocytopenia

• Counts < 50 × 109 L-1 even in the absence of bleeding probably
warrant prophylactic treatment in the last few weeks of pregnancy,
prior to delivery.

• Counts in the range 50 to 80 × 109 L-1 may warrant treatment prior
to delivery to facilitate safe administration of CNB.

Treatment options

Steroids are the usual first-line treatment, started with a low dose of
prednisolone 20 mg once daily and in the absence of response after one
week, increased to 60 mg daily.

Intravenous immunoglobulin treatment is rarely needed and is
prescribed only by consultant haematologists.

Platelet transfusions are the last resort for ongoing bleeding or to cover
surgery. They will increase antibody titres and will not produce a
sustained increase in platelets levels.

Intrapartum care for moderate or severe
thrombocytopenia

The mode of delivery should be based on obstetric indications and not
the platelet count.

The woman should have had her platelet count checked on admission
and intravenous hydrocortisone 100 mg administered during labour if she
has received steroids during last six weeks of pregnancy.

Women undergoing caesarean section may need an intra-abdominal
drain and interrupted skin sutures due to the higher risk of postoperative
bleeding.

Anaesthetic management

Decisions about regional anaesthesia should be made before delivery
with an obstetric anaesthetist and each case must be risk assessed
individually.

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Thrombocytopenia

There is a very low risk of bleeding and no contraindication to CNB with a
platelet count > 75 × 109 L-1.

In idiopathic thrombocytopenic purpura and gestational
thrombocytopenia, the reduced numbers of platelets have normal
function, and after individual risk-benefit assessment and in the absence
of other coagulation abnormalities, CNB may if strongly indicated be
safely undertaken by experienced practitioners at platelet levels above
40 × 109 L-1.

Consider using a platelet transfusion if the patient is to have surgery, or if
the following factors are all true:

• The platelet count is below 50 × 109 L-1.

• The coagulation screen is normal.

• CNB is strongly indicated.

Seek senior anaesthetic and haematological advice about platelet
transfusions. The woman may need immunoglobulin treatment in the
postnatal period.

Where the platelet count < 75 × 109 L-1, avoid enoxaparin thrombo-
prophylaxis regardless of VTE risk scoring.

Analgesia where CNB is contraindicated

TENS is unlikely to be of benefit but may be valued by some parturients.
Entonox is, as in any labour, the mainstay of pharmacological analgesia. If
the woman requests intramuscular pethidine, keep the injection site
under review and if there is evidence of excessive bruising, avoid further
intramuscular injections. PCIA remifentanil is indicated for labour pain
where CNB is contraindicated on haematological grounds. See page 202.

NSAIDs will be contraindicated for postnatal analgesia.

340. Farrall L, Arbuthnot C. Diagnosis and management of idiopathic and
gestational thrombocytopenia in pregnancy. UHCW clinical guideline CG 1800,
July 2016.

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HIV in pregnancy

HIV in pregnancy

Women with HIV (human immunodeficiency virus) are treated with cART
(combination antiretroviral therapy) to achieve low viral loads for vaginal
delivery. The mode of delivery for HIV-positive women who cannot
achieve a low viral load on antiretroviral therapy is elective caesarean
section, or immediate caesarean section if they present in labour. This
will most effectively reduce the risk of vertical transmission to the child.

If HIV+ women have acute infection they should receive case organ-
specific supportive management by a multidisciplinary team of relevant
consultants is mandatory.

The guidelines here are taken from the UHCW clinical guideline [341] and
the British HIV Association [342].

Mode of delivery

For women with a plasma viral load of <50 HIV RNA copies mL-1 at 36
weeks, and in the absence of obstetric contraindications, a planned
vaginal delivery is recommended.

For women with a plasma viral load of 50-399 HIV RNA copies mL-1 at 36
weeks, planned caesarean section should be considered, taking into
account the viral load, the trajectory of the viral load, length of time on
treatment, adherence issues, obstetric factors and the woman’s views.

Where the viral load is ≥ 400 HIV RNA copies mL-1 at 36 weeks, planned
caesarean section is recommended. Where the indication for caesarean
section is the prevention of vertical transmission, caesarean section
should be undertaken at between 38 and 39 weeks’ gestation.

Vaginal birth after caesarean section should be offered to women with a
viral load <50 HIV RNA copies mL-1.

Intrapartum intravenous zidovudine (azidothymidine, AZT) infusion is
recommended for the following women.

• Women with high viral load (>1000 HIV RNA copies mL-1) in labour,
or with ruptured membranes, or admitted for planned caesarean
section.

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HIV in pregnancy

• Untreated women presenting in labour or with ruptured
membranes in whom the current viral load is not known.

There are no data to support the use of intrapartum intravenous
zidovudine infusion in women on cART with a plasma HIV viral load
<1000 HIV RNA copies mL-1.

Preoperative assessment

Make sure that you are not overheard so as to compromise
confidentiality (see page 18). Be wary of family members, friends, and
indeed the non-soundproofing bed space curtains.

Management in caesarean section

The preoperative zidovudine infusion, if indicated, should run for four
hours until operative delivery, and not too much longer. You must make
sure that the infusion times are coordinated with the operation time.
There is no specific contraindication to central neuraxial analgesia or
anaesthesia [343], or the use of intraoperative cell salvage.

Protection of staff

The normal universal infection control precautions protect against HIV
and other infection. In the case of needlestick injury you should report to
the theatre coordinator and immediately activate the standard trust
policy including consideration of post-exposure prophylaxis.

341. Anyanwu L, Walpole C. Management of HIV in pregnancy. UHCW clinical
guideline CG 1139, October 2017.

342. British HIV Association. Guidelines for the management of HIV infection in
pregnant women 2018.

343. Hughes SC, Dailey PA, Landers D, Dattel BJ, Crombleholme WR, Johnson JL.
Parturients infected with human immunodeficiency virus and regional
anaesthesia: clinical and immunological response. Anesthesiology 1995;
82:32-7.

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Medical conditions 464
465
Medical conditions

Chapter contents
Long-term systemic steroids
Obstetric cholestasis

Long-term systemic steroids

Some women will need steroid replacement during surgery – those who
have adrenal insufficiency or who are taking long-term oral steroids,
equivalent to 5 mg or more prednisolone daily for more than 3 weeks
[344].
These recommendations are not affected by maternal steroids given for
fetal lung maturation. Do not offer supplemental hydrocortisone in the
intrapartum period to women taking only inhaled or topical steroids.

Women planning vaginal birth

Continue regular oral steroids. When they are in established first stage of
labour, add intravenous or intramuscular hydrocortisone and consider a
minimum dose of 50 mg every 6 hours until 6 hours after the baby is
born.

Women having planned or emergency caesarean section

Continue their regular oral steroids and give intravenous hydrocortisone
when starting anaesthesia; the dose will depend on whether the woman
has received hydrocortisone in labour, for example:

• Consider giving 50 mg if she has had hydrocortisone in labour.

• Consider giving 100 mg if she has not had hydrocortisone in labour.

464 Obstetric Anaesthetists Handbook OAH13-2020

Medical conditions

Give a further dose of hydrocortisone 6 hours after the baby is born (for
example, 50 mg intravenously or intramuscularly).

Obstetric cholestasis

Also known as intrahepatic cholestasis of pregnancy, this is a disorder
caused by an idiosyncratic cholestatic effect of oestrogen. It is
characterised by pruritus, often on the palms or soles, caused by elevated
serum bile acid levels in later pregnancy. Maternal outcome is usually
good though there is an increased risk of obstetric haemorrhage and fetal
adverse events.
Ursodeoxycholic acid is the treatment of choice until fetal lung maturity
allows early delivery; the condition is slowly progressive, and the only
definitive treatment is delivery.
Coagulopathy can occur due to vitamin K malabsorption but is rare.
Unless the condition is thought to have caused coagulation
abnormalities, epidural analgesia is positively indicated due to the
increased incidence of operative delivery in such women. Check the most
recent coagulation screen before undertaking the epidural – it should
have been done in the last week [345].

344. National Institute for Health and Clinical Excellence. Intrapartum care for
women with existing medical conditions or obstetric complications and their
babies. London: NICE, 2019; NG121, section 1.5.1-4.

345. Kenyon AP and Girling JC on behalf of the Royal College of Obstetricians and
Gynaecologists. Obstetric cholestasis (Green-top Guideline no. 43), April 2011.

OAH13-2020 Obstetric Anaesthetists Handbook 465

Index

A local anaesthetic toxicity,
101
abruption. See placental
abruption amniotic fluid embolism
CNB, 157
Accuro USS, 162 emergency, 110
MOH, 348, 349
acute fatty liver of pregnancy,
413 anaemia
causing atony, 338
adrenaline definitions, 119
epidural extension, 295 group and save, 139
Quickmix preparation, 72 maternal adaptation, 370
test dose, 214 parenteral iron, 125
postoperative, 123, 255
advance statement, 145 postpartum, 118

airway anaesthetic agents
assessment, 76 use in pregnancy, 371
front of neck, 80
maternal adaptation, 369 analgesia
caesarean, 246
alarm system, 23 guideline for caesarean, 248
in recovery, 322
alfentanil postoperative for other
cardiac dose, 444 cases, 276
intraoperative pain, 315
morphine allergy, 202 antibiotics
pre-eclampsia, 416 endocarditis, 452
other procedures, 274
ambulance transfers, 390 sepsis, 427

amiodarone

466 Obstetric Anaesthetists Handbook OAH13-2020

Index

sepsis and regional block, cardioversion, 375
429 causes, 436
atropine
surgical prophylaxis, 238 preparation, 72
total spinal, 299
antibodies uterine inversion, 107
red cell, 140 audit
outcome, 43
anticoagulation projects, 46
CNB, 157 awareness, 319

antiemetic azidothymidine, 462
general anaesthesia, 320
spinal anaesthesia, 285 B

antithrombotics back pain, 147, 185, 196
CNB, 153 balloon occlusion, femoral

aortic dissection catheter, 353
cause of pain, 439 base deficit
hypertension, 401
haemorrhage, 340
aortocaval compression, 4, 102 Belmont rapid infuser, 92
avoidance, 209, 239
IO access, 95
arterial line birth plan, 145
care, 381 bladder dysfunction, 184
MOH, 332, 340 bleeding disorders
obesity, 433
pre-eclampsia, 401 CNB, 158
sepsis, 427 bleep

aspirin in CNB, 154 1465 ODP, 13
1684 critical care, 387
assessments, 49 2119 cardiology, 435
2169 blood bank, 344
assistance for anaesthetists, 13 2178 junior, 13, 17, 19
2813 senior, 13, 24
asthma
carboprost, 342
critical care, 387
labetalol, 403
NSAIDs, 247

atracurium, 320

atrial fibrillation

OAH13-2020 Obstetric Anaesthetists Handbook 467

Index Bromage scores
recording, 297
2909 critical care outreach, use, 183
427
bupivacaine
5054 consultant, 12, 24 bolus in labour, 216
emergency calls, 73 dose after subdural block,
226
blood grouping policy, 139 dose in spinal anaesthesia,
285
blood patch. See epidural dose limit, 217, 219
blood patch ED95 intrathecal, 286
repeating, 314
blood transfusion shortage, 67
checks, 344 troubleshooting inadequate
electronic issue, 345 block, 219
exchange in sickle cell
disease, 266 C
minimisation, 337
operative, 244 CADD-Solis pump, 216
placenta praevia validity,
141 caesarean section
postoperative, 346 assessment for elective, 133
rates, 137 category, 305
refusal, 351 choice of technique, 280
reservation and crossmatch, clinic, 134
137 cord gases, 64
transfusion ratio, 333 diabetic patient, 455
treatment of acidosis, 331 required block, 284
time standards, 304
blood transfusion pathway with epidural extension, 295
form, 39 with spinal anaesthesia, 284
cell salvage, 269 with subarachnoid catheter,
223
breakthrough pain
operative, 312 calcium chloride
MOH, 333
breastfeeding
analgesia, 247
codeine contraindicated,
248
in theatre, 237

breech presentation, 231

468 Obstetric Anaesthetists Handbook OAH13-2020

Index

transfusion, 351 chlorhexidine, 162, 285

calcium gluconate chlorphenamine
magnesium toxicity, 410 postoperative, 250
pruritus in recovery, 172
carboprost
cardiac disease, 451 cholestasis, 465
uterine atony, 342
Clexane
cardiac axis, 439 antenatal, 155
postnatal, 251
cardiac decompensation
red flags, 436 clindamycin
prophylactic, 238
cardiac murmurs, 448
clinic
cardiac output monitoring, 365 caesarean, 114, 134
cardiology, 116
cardiology bleep, 435 complex, 114
haematology, 117
cardiopulmonary arrest, 102,
166 Clinical Adverse Event, 39

cardiotoxicity of LA, 98 clinical autonomy, 34

cardiovascular physiology clonidine
maternal adaptation, 369 inadequate epidural, 221
postoperative pain, 323
cardiovascular risk classes, 445
coagulopathy
cardioversion, 375 CNB, 157
in HELLP syndrome, 412
cauda equina syndrome, 187, placental abruption, 90
196
co-amoxiclav
cell salvage, 264, 338 confusion, 324
HIV, 463 prophylactic, 238
intrauterine sepsis, 429
Jehovah’s Witness, 271 codeine
obstetric haemorrhage, 345 contraindicated, 248
sepsis, 266
sickle cell disease, 265 colloid osmotic pressure, 404
sickle cell trait, 265
systemic sepsis, 430 combined spinal/epidural
usage figures, 137 anaesthesia, 281
analgesia, 206
cervical cerclage, 277, 283

OAH13-2020 Obstetric Anaesthetists Handbook 469

Index

complex referral clinic, 114 APH, 90
Belmont, 94
consent, 143 DCR, 333
caesarean section, 146 fibrinogen, 349
epidural blood patch, 146,
181 CTPA, 440
for epidural, 146
general, 143 CVP
critical care, 380
conversion to GA placenta praevia, 365
after failed neuraxial, 304 pre-eclampsia, 405
in MOH, 335, 365
method, 315 CXR
cardiac disease, 437, 442
cord prolapse, 108
Cyklokapron, 350
Coventry valve, 284
D
cricoid pressure, 80, 151
damage control resuscitation
cricothyroidotomy, 81 actions, 332
principles, 330
critical care
cardiac disease, 442 dantrolene
criteria, 385 location, 7
eclampsia, 417
general indications for, 384 delayed cord clamping, 239
MOH, 352
PPH, 91 diabetes mellitus, 136, 455
pre-eclampsia, 400
referral, 386 diamorphine
sepsis, 427, 428 CNB, 246
transfers, 388 dose in spinal anaesthesia,
285
crossmatch epidural anaesthesia, 297,
antibodies, 139, 140 303
general policy, 137 general anaesthesia, 304,
placenta accreta, 363 318
placenta praevia, 362 intramuscular, 201
reserving blood, 138 morphine allergy, 202
perineal repair, 275, 276
cryoprecipitate
AFE, 349

470 Obstetric Anaesthetists Handbook OAH13-2020

Index

pre-filled syringes, 65 eclampsia
pruritus, 172, 277 anaesthetic technique, 415
shortage, 65, 66 anticonvulsant treatment,
spinal anaesthesia, 303 407
as cause of collapse, 103
diclofenac, 249 emergency measures, 106,
asthma, 247 407
dose reduction, 245 postoperative care, 417
haemorrhage, 247 postpartum, 417
in enhanced maternal care,
256 electronic issue of blood, 345
in pre-eclampsia, 247, 418
suppository in theatre, 246 emergency help, 23

dihydrocodeine endotracheal tube
in pre-eclampsia, 418 MBRRACE, 61
instead of diclofenac, 247 recommended size, 75, 319
morphine allergy, 202 use from 18-20 weeks, 374

disc prolapse, 196 enhanced maternal care, 378
admissions, 383
disposal of drugs etc, 31 handover, 19
severe pre-eclampsia, 398,
drug charts 417
postoperative, 245
enhanced maternal care care
drugs in pregnancy for non- discharge, 385
obstetric surgery, 370
enhanced recovery, 235
dural tap, 221
enoxaparin
duties of the obstetric antenatal, 155
anaesthetist, 17 before regional block, 155
postnatal, 251
dysrhythmia, 436
Entonox
E intraoperative pain, 315

ECG ephedrine
cardiac disease, 438 epidural hypotension, 225
for epidural, 212
echocardiography indication, in pre-eclampsia, 414, 416
448 in pregnant patients, 375

OAH13-2020 Obstetric Anaesthetists Handbook 471

Index

preparation, 72 vertebral canal haematoma,
spinal hypotension, 291 153

epidural analgesia and epidural blood patch, 180
anaesthesia epidural chart
bleeding disorders, 158
bloody tap, 215 general, 37
caesarean section, use for, in epidurals, 217
294 epidural pyrexia, 211
consent, 146 epidural trolley locks, 31
contraindications, 208 epidural volume extension,
drug administration, 33 314
dural tap, 221 epilepsy
effect on labour, 209 labour pain relief, 202
efficacy, 147 eptacog-alpha, 351
extension, 293, 294 ERAS, 235, 244
fetal effects, 147 ergometrine
for operative surgery, 274 cardiac disease, 451
in pre-eclampsia, 413 in pre-eclampsia, 342, 416
inadequate pain relief, 218 MOH, 342
indications, 207 examination under
infusion, 414 anaesthesia, 276
infusion, postnatal, 418 external cardiac compression,
intrathecal placement, 166 102
intravascular placement, external cephalic version, 231
166 extubation
lipid rescue, 100 haemorrhage, 352
long needles, 214
missed segment, 220 F
nursing position, 209
perineal pain, 220 facemask ventilation, 80
postoperative, 217 factor VIIa, 351
pyrexia with epidural, 211 failed intubation, 75
response time, 207
technique, 212 algorithms, 83
ultrasound, 433

472 Obstetric Anaesthetists Handbook OAH13-2020

fasting Index
caesarean, 130
elective caesarean, 131 cell salvage, 264
in labour, 129 DCR, 333
postpartum, 132 transfusion, 348
fibrinogen
FBC indications, 140 mode of action, 349
treatment aim, 90, 349
fentanyl fibroid uterus, 235
dose limit, 219 fixation error, 78
dose limit, subarachnoid, fluid therapy
223 pre-eclampsia, 404
epidural anaesthesia, 303 foot drop, 192, 193
epidural extension, 295 forceps
intraoperative pain, 315 analgesia, 274
intrathecal, 223 FRC, 369
PCA, 202 front-of-neck procedure, 80
PCEA, 216 furosemide, 406
pruritus, 172
troubleshooting inadequate G
block, 219
gallipots, 161
Ferinject, 125 gastric emptying time
anaemia, 126
obstetric haemorrhage, 126 postpartum, 132
general anaesthesia
ferritin
repeating after Ferinject, conversion, 315
128 method, 317
threshold, 119 gentamicin
prophylactic, 238
ferrous fumarate, 121 group and save
prescription, 255 indications, 139
timing for elective, 141
ferrous sulfate, 121 GTN
prescription, 255 pulmonary oedema, 442

fetal scalp
blood gases, 64

FFP
APH, 90

OAH13-2020 Obstetric Anaesthetists Handbook 473

Index risk in epidural anaesthesia,
147
tocolysis, 240
uterine inversion, 107 risk in spinal anaesthesia,
284
Gutsche’s test, 176
severe, 395
H
HELLP syndrome. See pre-
H2-receptor antagonists. See eclampsia, severe
ranitidine
Hemabate
haematocrit uterine atony, 342
coagulopathy, 347
heparin
haematological disorder CNB, 155
central neuraxial blocks, 117 thromboprophylaxis, 251
CNB, 154
high block, 297
haemoglobin
optimal, 119 high dependency care, 378

haemorrhage HIV, 462
antepartum, 90
crossmatch, 138 hydralazine, 403
CNB, 157
consultant attendance, 329 hyperkalaemia
DCR, 330 emergency treatment, 336
emergency action, 327
hysterectomy, 340 hypoglycaemia, 456
intraoperative, 365 diabetes, 455
major, 243 HELLP syndrome, 413
massive, 327
MOH call, 329 hypotension
postpartum, 91 and CNB, 166, 224
prevention of, 242 pre-eclampsia, 415
aortocaval, 61
handover, 19, 237 intracranial \b, 177
location, 20 leucocyte depletion filter,
267
headache, 175, 180 maternal and fetus, 372
oxytocin, 341
permissive, 331
position after epidural, 213
sepsis, 422

474 Obstetric Anaesthetists Handbook OAH13-2020

Index

spinal, prevention, 291 intervertebral disc
total spinal, 299 epidural analgesia, 208
hypoxia prolapse, 185, 193
fetal, 305
postoperative red flag, 257, intraosseous access, 95
driver, 102
322, 436
hysterectomy, 340, 353 intrathecal catheter, 222, 223
intrauterine death
anaesthesia for emergency,
335 analgesia, 202
coagulation screen, 156
placenta praevia, 365 intrauterine fetal resuscitation,
planned during caesarean, 309
intubation, failed, 75
281 iron
PPH postoperative care, 91 postoperative prescription,

I 123, 255
isoflurane
ibuprofen
contraindicated, 247 preventing awareness, 324
dose reduction, 245 required concentration, 319
postoperative, 247 IV cannulas, 29
standard dose, 250
J
ICD, 452
ICS, 264 Jehovah’s Witness, 351
iliac artery catheters, 353
induction, inhalational, 151 K
infection control, 161
infection in CNB, 157 ketamine
insulin infusion haemorrhage, 318, 332
in pregnant patients, 375
at delivery, 456 increasing uterine tone, 371
delayed operation, 457 massive haemorrhage, 336
interpreter, 145 placenta praevia, 365
interventional radiology, 353 postoperative pain, 323

OAH13-2020 Obstetric Anaesthetists Handbook 475

Index Quickmix preparation, 72
rescue doses, 219
sepsis, 429 troubleshooting inadequate
uterine rupture, 109
block, 219
ketosis, maternal, 212
lipid rescue, 100
L location, 7

labetalol liver disorders, 411
contraindications, 403
pre-eclampsia, 402 LMA, 78

lactate local anaesthetic toxicity, 98
haemorrhage, 340, 352
sepsis, 425, 427 locum anaesthetists, 13

lead clinician, 16 Lucina, 11

left lateral position for epidural Lucozade, 131
bolus, 220, 225, 231, 296
lumbosacral plexopathy, 192
left lateral position for
subarachnoid block, 223 M

lethal triad, 329 magnesium sulfate
eclampsia, 407
levobupivacaine emergency, 408
dose limit, 217, 219 fetal protection, 408
general anaesthesia, 248, indications in severe pre-
304, 320 eclampsia, 407
intrathecal, 222, 223 LA toxicity, 100
PCEA, 216 muscle relaxants, 408
rescue doses, 219 postoperative pain, 323
spinal for caesarean, 67 PPH, 338
troubleshooting inadequate renal impairment, 409
block, 219 severe pre-eclampsia, 406
shivering, 260
lidocaine toxicity, 410
dose limit, 219 use in pregnancy, 371
epidural extension, 295
epidural test dose, 214 major haemorrhage (not
intraosseous, 97 massive)

476 Obstetric Anaesthetists Handbook OAH13-2020

Index

treatment, 243 use in pregnancy, 372

malignant hyperthermia, 321 metoclopramide
epidural extension, 296
Mallampati score, 77 general anaesthesia, 317
spinal anaesthesia, 285
manual removal of placenta use as premedication, 133
required block, 274, 284
metronidazole
massive haemorrhage caesarean, 239
balloon catheters, 353 manual removal of placenta,
damage control 274
resuscitation, 328, 331
definition, 327 midazolam
effects, 339 intraoperative pain, 315
lethal triad, 329 postoperative pain, 323
surgical management, 340
misoprostol
maternal obstetric palsy, 191 cardiac disease, 451
uterine atony, 340, 344
McDonald’s suture. See
cervical cerclage Modified Obstetric Early
Warning Scores, 383
MCH
threshold, 119 MOEWS charts, 383

meningitis monitoring during anaesthesia,
CNB sepsis, 429 281
postnatal, 189
morphine
meralgia paraesthetica, 192 after failed CNB, 316
allergy, 202
metaraminol GA dose, 248
bradycardia, 167, 292 in recovery, 259
epidural extension, 295 infusion, 257, 418
in cardiac disease, 440 intraoperative, 320
in pre-eclampsia, 414, 416 intrathecal, 66
infusions on labour ward, oral, 250, 277
225, 379 postoperative, 322
pre-eclampsia, 292 pulmonary oedema, 442
preparation, 72
spinal anaesthesia, 285 MRI scans
spinal hypotension, 291 booking, 188

OAH13-2020 Obstetric Anaesthetists Handbook 477

Index CNB, 154
contraindicated in
multiple pregnancy, 231
murmurs, 448 pregnancy, 371
mWHO risk classes, 445 in enhanced maternal care,

N 256

naloxone O
PCEA, 216
pruritus in recovery, 172 obesity, 432
blood loss, 339
NAP3 neuraxial, 190
NAP4 airway, 78 obstetric cholestasis, 465
NAP5 awareness, 323 obstetric emergency, 23
needle phobia, 150 Obstetric Neuraxial Procedure
nerve stimulator, 320
neurological symptoms, 184, and Monitoring Chart, 37
Obstetrics Perioperative
191
neuromuscular blockade, 318 Pathway, 38
neuropathy, 191 obstructive valve lesions, 445
nifedipine occipito-posterior

pre-eclampsia, 403 presentation, 220, 230
nitrous oxide oliguria

contraindicated in first criteria, 404
trimester, 371 pre-eclampsia, 405
omeprazole
GA cases, 319, 324 in labour, 129
noradrenaline surgery, 130, 135
omeprazole
sepsis, 428 doses, 67
NovoSeven, 351 omeprazole
NRFit, 28 surgery, 133
omeprazole
epidural blood patch, 182 enhanced maternal care,
NSAIDs
384
asthma, 247

478 Obstetric Anaesthetists Handbook OAH13-2020

Index

omeprazole uterine atony, 341
in pre-eclampsia, 399
P
ondansetron, 245, 248
use in pregnancy, 372 pacemaker, 452
paracetamol, 247, 249
open systems, 161
dose reduction, 245
Operating Department general anaesthesia, 320
Practitioners, 13 loading dose, 249
partner in theatre, 237
operation PCA
category, 73 needle phobia, 151
opioids, 202
opioids PCEA, 216
acid suppression policy, 129 PCIA
efficacy in labour, 201 remifentanil, 461
intramuscular, 201 penicillin allergy, 238
postoperative analgesia, 247 perimortem caesarean section,
use in pregnancy, 371 81, 104
perineal repair, 275, 276
Optiflow HFNOT, 80, 318 peripartum cardiomyopathy,
442
oxygen pethidine
cardiac decompensation, intramuscular, 201
436 morphine allergy, 202
conscious patients, 282 shivering, 260
postoperative, 322 phenylephrine
sepsis, 427 spinal hypotension, 291
physiological changes in
oxytocic drugs, 341 pregnancy, 368
placenta accreta, 274, 358
oxytocin balloon catheters, 353
bolus for operative delivery,
242, 320
cardiac disease, 341, 451
cause of PPH, 337
discussion, 241
in pre-eclampsia, 416
in shock, 341
postoperative infusion, 242
prophylaxis, 341
timing, 239

OAH13-2020 Obstetric Anaesthetists Handbook 479

Index

placenta accreta spectrum pre-eclampsia
blood reservation, 139 anaesthetic technique, 415
CNB, 156, 157
placenta praevia diagnosis, 393
anaesthetic management, diclofenac, 247
363 epidural analgesia, 401, 413
blood reservation, 139 fluid therapy, 404
contraindicated technique, fluids
284 fluid balance, 405
reservation and crossmatch, general anaesthesia in, 416
137 management aims, 397
oliguria, 404
placental abruption, 90 postnatal period, 417
CNB, 156 severe
in HELLP syndrome, 412 anticonvulsant treatment,
406
platelet count in CNB antihypertensive
indications for, 156 treatment, 401
pre-eclampsia, 156, 413 arterial line, 401
enhanced maternal care,
platelet transfusion, 159, 347, 398, 417
412 HELLP syndrome, 411
magnesium sulfate, 407,
platelets 408
DCR, 333 monitoring, 398
vertebral canal haematoma,
polio blade, 77 413

PONV prophylaxis, 245 pre-eclamptic toxaemia. See
pre-eclampsia
post-dural puncture headache
diagnosis, 175 premedication, 133
follow-up, 178
treatment, 179 preoxygenation
DAS recommendations, 80
postnatal review RSI, 318
caesarean section, 260
standard, 43 prilocaine
symptomatic, 184 spinal for caesarean, 67

postoperative recovery, 258

postpartum evacuation
required block, 284

480 Obstetric Anaesthetists Handbook OAH13-2020

Index

spinal for cerclage, 278 rapid sequence induction, 151,
prochlorperazine 318

postoperative, 250 records, 37
prolapsed umbilical cord. See failed intubation, 89

cord prolapse recovery, 258
propofol
red cell antibodies, 140
TIVA, 321
pruritus, 172 regional anaesthesia
pulmonary embolism, 439 in emergency, 307
pulmonary oedema, 440 thromboprophylaxis, 153,
252
fluid overload in pre-
eclampsia, 405, 406, 414 remifentanil, 461
PCIA, 202
in HELLP syndrome, 412 TIVA, 321
oxytocin, 341
postpartum, 417 renal failure
pre-eclampsia, 404 transient oliguria, 404

Q response times
epidural analgesia, 207
Quickmix immediate caesarean
preparation, 72 section, 283
use, 295 retained placenta, 273

R resuscitative hysterotomy, 81,
104
ramped position, 77
ranitidine retained placenta, 274

enhanced maternal care, rocuronium
384 dose, 69, 318
in MH, 321
in labour, 129
in pre-eclampsia, 399 S
shortage, 66
surgery, 130, 133, 135 SAFER handover, 19

salbutamol
hyperkalaemia, 336
tocolysis, 240

OAH13-2020 Obstetric Anaesthetists Handbook 481

Index spinal analgesia, 206

scalpel cricothyroidotomy, 81 spinal catheter, 222, 223

scar dehiscence, 283 spinal cord damage, 189

scoline apnoea, 115 steroid replacement, 464

second stage of labour, 210 stop before you block, 27
epidural analgesia, 212
sepsis, 421 epidural top-up, 295
cell salvage, 429 spinal, 285
CNB, 429
subarachnoid catheter, 222,
Shirodkar suture. See cervical 223
cerclage
subdural block, 226
shivering, 259
sugammadex
sickle cell disease dose, 69, 319
cell salvage, 265 location, 7

sodium bicarbonate supervision
Quickmix preparation, 73 consultant name on board,
18
sodium citrate responsible consultant, 24
administration, 130
supraventricular tachycardia
spinal anaesthesia cardioversion, 375
after subdural block, 226
caesarean section, use for, surgical safety checklist, 26,
136, 234 308
caesarean section, use in,
280 suxamethonium
contraindications, 283 dose, 318
in continuing pregnancy, preparation, 72
278 scoline apnoea, 115
in labour, 206 shortage, 69
indications, 283 with magnesium, 408
pre-eclampsia, use in, 415
repeating, 314 Syntocinon. See oxytocin
replacing epidural, 313
technique, 284 Syntometrine, 341
vertebral canal haematoma, cardiac disease, 449
153 prophylaxis, 242

482 Obstetric Anaesthetists Handbook OAH13-2020

T Index

TAP blocks, 34 objectives, 49
opportunities, 48
team brief, 26 tranexamic acid
APH treatment, 90
terbutaline coagulation disorders, 154
cord prolapse, 108 doses, 351
dose, 309 general anaesthesia, 320
fetal resuscitation, 308, 309 haematological plan, 117
prevention of premature haemorrhage, 350
labour, 375 major haemorrhage, 243
tocolysis, 240 perineal repair, 276
uterine hyperstimulation, PPH prevention, 243
110 WOMAN trial, 350
uterine inversion, 107 transfer
leaving labour ward, 18
theatres, operating, 71 transfusion ratio, 333
trial of assisted delivery
thiopental required block, 284
avoiding AAGA, 324
dose, 318 U
preparation, 72
seizure control, 99 umbilical cord prolapse. See
cord prolapse
thrombocytopenia, 157
urate levels, 396
thromboprophylaxis, 251 urinary catheter
and CNB, 154
postnatal in pre-eclampsia, diamorphine, 260
418 urine output
postoperative duration, 253
thrombocytopenia, 461 pre-eclampsia, 405
uterine atony
TIVA, 321
causes, 91
tocolysis, 240 sepsis, 423, 429
treatment, 341
torsade de pointes, 100 uterine displacement, 4

total spinal block, 297
as cause of collapse, 103

training

OAH13-2020 Obstetric Anaesthetists Handbook 483

Index vertebral canal infection
diagnosis, 186
in caesarean section, 239 prevention, 161
in external cardiac
VTE status. See
compression, 102 thromboprophylaxis
uterine inversion, 107
uterine relaxation, 239, 274, W

319 water
uterine rupture, 109 in pre-eclampsia, 399
oral, 130, 132, 133, 236
crossmatch, 138
weekend consultant sessions,
V 24

vaginal breech delivery, 231 white cell count, 424
vasopressors WHO checklist, 26

in pre-eclampsia, 414, 416 Y
in spinal anaesthesia, 285,
yellow trays, 29
291
ventouse Z

analgesia, 274 zidovudine, 462
ventricular fibrillation, 101
vertebral canal haematoma,

153
diagnosis, 185
in pre-eclampsia, 413
treatment, 188

484 Obstetric Anaesthetists Handbook OAH13-2020

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Obstetric Anaesthetists Handbook