OAH14-2021

Local anaesthetic toxicity

• Without circulatory arrest, treat hypotension, bradycardia, and
tachyarrhythmia, and consider lipid rescue.

• Do not use propofol instead of lipid rescue, and do not use lidocaine
as an antidysrhythmic agent.

Lipid rescue

The use of 20% lipid solution ‘lipid rescue’ has been reported in a small
body of animal work and in two published case reports in humans, with
apparently dramatic effect. The lipid solution used in the case reports
was Intralipid 20%; the effect is thought to be through a ‘lipid sink effect’
whereby the lipophilic local anaesthetic is removed from effector sites by
the lipid. Intralipid 20% is stocked in theatre 1. A full description of
evidence, cases and dose recommendations is at www.lipidrescue.org. It
is not appropriate to use propofol or etomidate formulated in lipid.

Lipid dose

Give an initial intravenous bolus of 1.5 mL kg-1 over one minute and
follow with an intravenous infusion at 15 mL kg-1 h-1. After five minutes
give a repeat bolus if cardiovascular stability has not been restored or an
adequate circulation deteriorates. After a further five minutes a final
third bolus can be given. Double the infusion rate to 30 mL kg-1 h-1 at any
time after five minutes if a stable and adequate circulation has not been
achieved. Do not exceed a maximum cumulative dose of 12 mL kg-1.

Magnesium sulfate

Magnesium sulfate can be used in refractory cases, especially if
hypomagnesaemia is present. It is readily available in labour ward, critical
care, and theatres. Indications and administration are as below.
Rapid administration of magnesium can cause asystole.

Torsade de pointes

Activate the emergency call and get someone to call a cardiologist. Apply
basic and advanced life support as necessary.

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Local anaesthetic toxicity
Use the standard magnesium mix as on page 440,. Give IV magnesium
sulfate 2 g (diluted to 10 mL with 0.9% sodium chloride solution) over 15
minutes followed with 1 g h-1.

Refractory ventricular fibrillation
This is in the context of ongoing cardiac arrest with LA toxicity. Apply
basic and advanced life support as necessary. Do not delay electrical
defibrillation and intravenous adrenaline.
Give magnesium as above. Intravenous amiodarone has been used
successfully. The adult dose of amiodarone is 300 mg made up to 20 mL
with 5% glucose. A further dose of 150 mg may be given for recurrent or
resistant VT/VF, followed by an infusion of 1 mg mL-1 for six hours.

68. McClure JH, Rose M. Bretylium is finally discontinued. Bulletin 28. London:
Royal College of Anaesthetists, 2004.

69. Association of Anaesthetists of Great Britain and Ireland AAGBI Safety
Guideline: Management of Severe Local Anaesthetic Toxicity. London: AAGBI,
2010.

144 Obstetric Anaesthetists Handbook OAH14-2021

Collapse and cardiopulmonary arrest

Collapse and cardiopulmonary arrest

For active management with checklist® M-QRH

Sudden unexplained loss of consciousness is a good indication of
inadequate cardiac output, especially coupled with cyanosis and a
profound fetal bradycardia, and should mandate immediate CPR.

Ensure that the mother has been placed into the left lateral position
(except when the use of external cardiac compression indicates manual
left lateral displacement) and that high-flow oxygen therapy and
intravenous access have been established.

Commence basic and advanced life support as appropriate. Intravenous
access should be above the inferior vena cava. Consider using an
intraosseous driver to the humerus if venous access cannot otherwise be
obtained.

Where the mother is unconscious and has no airway reflexes, protect the
airway with a cuffed endotracheal tube, starting at size 7.0 mm.

The presence of a pulse may be an unreliable indicator of adequate
cardiac output. In the absence of a recordable blood pressure or other
indicator of cardiac output, the early initiation of external cardiac
compressions may be lifesaving [70]. Delivering chest compressions to a
mother with a beating heart is unlikely to cause harm. However, delays in
diagnosis of cardiac arrest and starting CPR will adversely affect survival
and must be avoided.

Be careful to exclude hypoglycaemia.

Aortocaval compression will impair the effectiveness of external cardiac
compression in late pregnancy such that cardiac output will be reduced
to only 10%. Place the woman in a supine position for external cardiac
compression; you must ensure that manual left lateral displacement of

OAH14-2021 Obstetric Anaesthetists Handbook 145

Collapse and cardiopulmonary arrest

the uterus is performed [71,72]. Allow for potentially increased recoil time
to allow the heart to refill.

Use the usual doses of drugs and electrical energy. Chest compressions
will probably need more force than in the non-pregnant.

Request that the arrest team, the consultant anaesthetist, and the
consultant obstetrician are called immediately. The consultant on call for
critical care should be involved sooner rather than later for appropriate
cases.

Determine the cause. It may fall into one or more of three groups.

• Pre-existing maternal conditions e.g., epilepsy.

• Pathological syndromes of pregnancy e.g., eclampsia, embolus.

• Iatrogenic causes e.g., total spinal anaesthetic.

Focused, point of care ultrasound investigations can help guide decision
making in the management of maternal collapse. A limited cardiac echo
study as well as a FAST scan can provide vital clues to differentiate key
diagnoses and is the gold standard of care for a woman with severe
cardiovascular instability or compromise. [73]

Collapse during caesarean birth may be related to all the causes above,
but in particular local anaesthetic toxicity (page 141) and air embolism
should be considered. Subclinical air entry occurs in most caesarean
births, and rarely may progress to cardiovascular collapse. Activate the
emergency call and prevent further embolism by returning the uterus to
the abdomen, flooding the operative field with sodium chloride 0.9%
solution, and positioning the mother head-up. Give supportive treatment
as necessary.

If the woman is still pregnant, after 20 weeks, and unresponsive to
resuscitation at four minutes after collapse, with no circulation, consider
immediate delivery to aid resuscitation – see below for perimortem
caesarean section.

Document all events as soon as possible and as accurately as possible.
Delegate someone to write down when and what drugs are given.

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Collapse and cardiopulmonary arrest

Prepare a report as soon as possible, while events are still fresh in the
mind, and ensure that others involved do so too.

The decision to terminate Advanced Life Support should only be taken
after discussion with the consultant anaesthetist and consultant
obstetrician on call, and the senior midwife. The mother’s family must be
kept informed, and their wishes ascertained and respected in conjunction
with expert medical decisions.

PMCS (perimortem caesarean section)

The welfare of the mother takes precedence over that of the fetus. While
perimortem caesarean delivery may aid fetal survival, it is undertaken for
the benefit of the mother as a resuscitative measure including where the
fetus is known to be dead. It is probably best seen as resuscitative
hysterotomy. Case reports indicate that emptying the gravid uterus
significantly augments venous return and thus cardiac output during
resuscitation [74]. Do not waste time confirming fetal viability.

Pregnant women will swiftly become hypoxic and irreversible brain
damage ensues after 4-6 minutes. However, if the gestational age is over
20 weeks and there is no response to correctly performed CPR within 4
minutes of maternal collapse or if resuscitation is continued beyond this,
then PMCS should be undertaken to assist maternal resuscitation. Ideally,
delivery will be achieved within five minutes of the witnessed arrest
[75,76,77].

• Trigger the massive haemorrhage protocol at the time of decision to
undertake perimortem caesarean section.

• ALS techniques must be maintained during the delivery.

• Perimortem caesarean section should be undertaken where the
resuscitation is taking place. With no circulation, blood loss is
minimal, and no anaesthetic required. If necessary, the woman can
be moved to an operating theatre later for anaesthesia,
haemorrhage control and so on.

Below 20 weeks it is considered that PMCS would not be of benefit.

OAH14-2021 Obstetric Anaesthetists Handbook 147

Collapse and cardiopulmonary arrest

70. MBRRACE-UK. Saving Lives, Improving Mothers’ Care: Lessons learned to
inform maternity care from the UK and Ireland Confidential Enquiries into
Maternal Deaths and Morbidity 2013–15. Oxford: MBRRACE, December 2017,
pages 67-8.

71. Lipman S, Cohen S, Einav S et al. The society for obstetric anesthesia and
perinatology consensus statement on the management of cardiac arrest in
pregnancy. Anesth Analg 2014; 118:1003-16.

72. Jeejeebhoy FM et al. Cardiac Arrest in Pregnancy: A Scientific Statement From
the American Heart Association. Circulation. 2015; 132:00-00. DOI:
10.1161/CIR.0000000000000300.

73. MBRRACE-UK. Saving Lives, Improving Mothers’ Care: Lessons learned to
inform maternity care from the UK and Ireland Confidential Enquiries into
Maternal Deaths and Morbidity 2015-17. Oxford: MBRRACE, December 2019.
Recommendation 16, page v.

74. Eldridge AJ & Ford R. Perimortem caesarean deliveries. Int J Obstet Anesth
2016; 27:46-54.

75. Morris S, Stacey M. Resuscitation in pregnancy. BMJ 2003; 327:1277-9.
76. Katz V, Balderston K, DeFreest M. Perimortem cesarean delivery: Were our

assumptions correct? American Journal of Obstetrics and Gynecology 2005;
192:1916-20.
77. Royal College of Obstetricians and Gynaecologists. Maternal Collapse in
Pregnancy and the Puerperium (Green-top Guideline No. 56), December 2019.

148 Obstetric Anaesthetists Handbook OAH14-2021

Uterine inversion

Uterine inversion

For active management with checklist® M-QRH

You should consider this diagnosis if there is severe abdominal pain after
delivery or if there is shock out of proportion to the apparent blood loss.
Blood loss is often underestimated. Diagnose and treat shock with
prompt resuscitation for the haemorrhage.
Give oxygen and establish venous access.
Give atropine as necessary for the vagal bradycardia.
Prepare for a general anaesthetic in the event of rapid replacement not
being possible with tocolytic therapy. Volatile general anaesthesia relaxes
the uterus for replacement. Consider using ketamine 0.5-1 mg kg-1,
instead of propofol.
You may need to use tocolytic drugs e.g.
• GTN sublingual spray 400 mcg. This is one or two puffs from the

spray, under the tongue.
• Terbutaline 100 mcg intravenous (2 mL when 500 mcg in 1 mL has

been diluted to 10 mL with sodium chloride 0.9% solution).
After replacement of the uterus, use uterotonic drugs.
Neurogenic shock is rare but may occur and should not be treated with
large volumes of intravenous fluids.

OAH14-2021 Obstetric Anaesthetists Handbook 149

Uterine rupture

Uterine rupture

You should consider this diagnosis if there is sudden cessation of uterine
activity or abdominal pain between contractions, sometimes despite the
epidural. Fetal distress, vaginal blood loss and shock may all be present.
This is often but not always in the context of vaginal birth after
caesarean.

Give oxygen, establish venous access, and call a massive obstetric
haemorrhage alert. When the fetus is found it may be in a large
abdominal pool of blood.

Send for senior help. Diagnose and treat shock. The mother’s welfare is
paramount, and shock should be treated to render induction of
anaesthesia safe. However, in extremely rare circumstances operative
resuscitation may be required.

Prepare for immediate induction of general anaesthesia, using a reduced
dose of induction agent e.g., ketamine 0.5-1 mg kg-1, for caesarean
delivery and repair.

Expect massive obstetric haemorrhage and manage accordingly.

150 Obstetric Anaesthetists Handbook OAH14-2021

Umbilical cord prolapse

Umbilical cord prolapse

For active management with checklist® M-QRH

Assess the mother with a view to reassuring her that proper management
will protect her and the baby for safe delivery. Traditionally this has been
a mandatory indication for general anaesthesia. This has now changed
with better management of the presentation [78] and regional
anaesthesia is preferred, whether epidural or spinal.

Measures to maintain fetal wellbeing include the examiner keeping their
hand in the vagina pushing the fetal presenting part upward until a
urethral catheter has been employed. The catheter is used to fill the
bladder with up to 500 mL sodium chloride 0.9% solution and then
clamped. The examiner’s hand can then usually be removed without
adverse effect on fetal oxygenation. Assessment of the delivery can take
place, with forceps in the delivery room if the vertex is below the ischial
spines. Otherwise, rapid transfer to the operating theatre should allow
regional anaesthesia to be employed if the fetal heart rate has recovered.
Subcutaneous terbutaline 250 mcg can be used as a tocolytic.

The obstetricians will monitor the fetal heart rate during block
development and release the clamp on the catheter to allow safe
abdominal incision.

78. Sabri N. Cord prolapse. UHCW clinical guideline CG1158, November 2016.

OAH14-2021 Obstetric Anaesthetists Handbook 151

AFE (amniotic fluid embolism)

AFE (amniotic fluid embolism)

For active management with checklist® M-QRH

This is rare but devastating and may be a misnomer for an anaphylactic
reaction of delivery: a unique maternal immunological response to
foreign antigens in the fetal compartment [79]. Before making the
diagnosis, you should endeavour to exclude pulmonary embolism from
other causes, acute left ventricular failure, acid aspiration syndrome;
also, eclampsia and local anaesthetic toxicity if convulsions feature in the
presentation.

The incidence of AFE is around 5.5 per 100,000 maternities (range: 2-15)
with a mean case fatality rate of 25% (range: 13%-48%) [80].

Significant premonitory signs and symptoms, i.e., respiratory distress,
cyanosis, restlessness and altered behaviour, may give the first clue to
diagnosis before collapse and haemorrhage occur. Uterine
hyperstimulation with oxytocin or dinoprostone (Propess) is a risk factor
for AFE and use of a tocolytic such as terbutaline should be considered.

The classic triad is hypotension, hypoxia, and coagulopathy.

Diagnosis

UKOSS (UK Obstetric Surveillance System) has defined diagnostic criteria.
In the absence of any other clear cause the diagnosis of AFE is made by:

Either

Acute maternal collapse with one or more of the following features:

• Acute fetal compromise

• Cardiac arrest

• Cardiac rhythm problems

152 Obstetric Anaesthetists Handbook OAH14-2021

AFE (amniotic fluid embolism)

• Coagulopathy

• Hypotension

• Maternal haemorrhage

• Premonitory symptoms (e.g., restlessness, numbness, agitation,
tingling)

• Seizure

• Shortness of breath

Excluding mothers with maternal haemorrhage as the first
presenting feature in whom there was no evidence of early
coagulopathy or cardio-respiratory compromise.

Or

• Mothers in whom the diagnosis was made at post-mortem
examination with the finding of fetal squames or hair in the lungs

Management

The management is supportive at senior level, starting with Basic and
Advanced Life Support. Activate the massive obstetric haemorrhage call
whatever the blood loss at the point of diagnosis.

Haemostatic failure is almost certain to develop during the acute event
and in survivors – see page 124 for treatment. Hypofibrinogenemia is a
particular feature, indicating cryoprecipitate infusion. Give tranexamic
acid as an anti-fibrinolytic agent.

The mother should be transferred to the critical care unit. Contact the
consultant anaesthetist on call for advice when this condition is
suspected and involve the critical care consultant and team early.

There has been a case report of the successful use of lipid rescue for AFE,
with recovery on the first dose followed by later deterioration and
successful response to the second dose [81]. Do not interrupt life support
measures, but in extremis this is worth trying.

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AFE (amniotic fluid embolism)
In the case of collapse with cardiac arrest, resuscitation should include
perimortem caesarean section within five minutes as a maternal
resuscitative measure [82] – see page 147.

79. Metodiev, Y, Ramasamy P, Tuffnell D. Amniotic fluid embolism. BJA Education
2018; 18(8): 234-8.

80. Frati P, Foldes-Papp Z, Zaami S, Busardo FP. Amniotic fluid embolism: what
level of scientific evidence can be drawn? A systematic review. Curr Pharm
Biotechnol 2014; 14: 1157e62.

81. Lynch W, McAllister RK, Lay JF Jr, Culp WC Jr. Lipid Emulsion Rescue of
Amniotic Fluid Embolism-Induced Cardiac Arrest: A Case Report. A&A Practice
2017; 8(1 Feb):64-6.

82. MBRRACE-UK Saving Lives, Improving Mothers’ Care: Lessons learned to
inform future maternity care from the UK and Ireland Confidential Enquiries
into Maternal Deaths and Morbidity 2009-2012. Oxford: MBRRACE-UK, 2014.

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Assessment and preparation

OAH14-2021 Obstetric Anaesthetists Handbook 155

Antenatal referral

Antenatal referral

You may be asked to talk to a mother who is expecting a normal labour or
a varyingly complicated delivery, perhaps a caesarean birth. Give time to
do this properly, remembering to discuss enough information for
informed consent, and document this fully in the notes. Occasionally
these mothers will come to labour ward specifically for this purpose. The
best place to make sure that your assessment will be recorded is as a
note on CRRS. Cross-refer to the main hospital medical record if more
space is needed. For obese mothers find and use the proforma designed
for these mothers.

Write your anaesthesia assessment in a note on CRRS.

If asked to see a complicated case or any case where you are unsure,
discuss the case with a consultant. Document this in the notes.

Referring the case to a consultant does not preclude talking to the
woman yourself but you should make the situation clear to the mother.

The following guideline is shared with the obstetricians – last issued July
2020.

The consultant obstetric anaesthetists discuss analgesia and anaesthesia
with pregnant women, especially those with complex medical, surgical, or
anaesthetic problems. We welcome referrals from our obstetric and
midwifery colleagues. We see mothers in a weekly clinic; if it is urgent,
bleep 5054 and speak to the consultant obstetric anaesthetist.

Using the clinic

Referrals are pooled. The consultant obstetric anaesthetists who do the
clinic are Dr John Elton, Dr Anuji Amarasekara and Dr Ewa
Werpachowska. Obstetricians or midwives book the mother with the
antenatal clinic receptionists using the clinic outcome slip or call 27350.
They are asked to leave a referral note on the mother’s CRRS page to
indicate the reason for referral.

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Antenatal referral

Indications for antenatal referral to anaesthetists

Any anxiety regarding labour analgesia or caesarean birth anaesthesia, or
desire to consult an anaesthetist.

Past or potential problems with anaesthesia

• Difficult or failed intubation.
• Airway problems; head and neck tumours or surgery.
• Anaphylaxis to anaesthetic drugs, local or general.
• Scoline apnoea (suxamethonium sensitivity). Take a blood sample

for cholinesterase and pseudocholinesterase in a purple EDTA
bottle (additional to any FBC); this test goes externally and takes up
to four weeks.
• Malignant hyperthermia susceptibility.
• Porphyria.
• Complications following previous central neuraxial block e.g., nerve
injury, epidural haematoma.
• Anxiety about back pain.
• Fear of repeat painful labour or operation.
• Problems or complaints after anaesthesia.
• Needle phobia.

Lumbosacral spine problems

• Uncomplicated back pain or disc prolapse does not need referral,
unless the mother is very anxious.

• Symphysis pubis dysfunction does not need referral.
• Previous back surgery e.g., Harrington rods, discectomy,

decompressive laminectomy.
• Congenital abnormalities e.g., kyphosis, scoliosis, myelo-

meningocoele.

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Antenatal referral

• Spinal cord injury.

Neurological disorders

• Multiple sclerosis.
• Myasthenia gravis.
• Intracranial hypertension, Arnold-Chiari etc.
• Muscular dystrophies.

Cardiorespiratory disease

Dr Adamson (consultant cardiologist), Professor Quenby (consultant
obstetrician) and Dr Quasim run a joint obstetric cardiology clinic once a
month. The following should all be referred to the joint clinic.
• Dyspnoea.
• Valvular diseases e.g., mitral stenosis, aortic stenosis, valvular

regurgitation.
• Cardiomyopathies e.g., HOCM, PPCM.
• Pulmonary hypertension.
• Dysrhythmias e.g., atrial fibrillation, supraventricular tachycardia.
• POTS (postural orthostatic tachycardia syndrome).
• Congenital heart disease, whether corrected or not.
• Previous heart surgery (except surgery for isolated secundum ASD).
• Audible cardiac murmurs are common. If more than grade 1,

symptomatic or associated with abnormal ECG then refer to the
joint obstetric cardiology clinic.

Haematological disorders

There is a joint obstetric haematology clinic. There will be a plan in the
clinical records, which may include DDAVP, tranexamic acid, coagulation
factor transfusion and advice about central neuraxial blocks. We will need
to assess the mother as well.

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Antenatal referral
• Bleeding abnormalities.
• Von Willebrand’s disease, haemophilia, or other inherited

coagulation disorders.
• Platelet deficiencies (thrombocytopenia < 100 × 109 L-1) or platelet

dysfunction.
• All heparin anticoagulation – prophylactic or therapeutic.
• Sickle cell anaemia.
Other
• Multisystem disease e.g., systemic lupus erythematosus,

rheumatoid arthritis.
• Obesity (BMI > 40 kg m-2 (or 35 kg m-2 with serious comorbidities).

[83]
• Refusal of blood products e.g., Jehovah’s Witnesses.

83. Denison FC, Aedla NR, Keag O, Hor K, Reynolds RM, Milne A, Diamond A, on
behalf of the Royal College of Obstetricians and Gynaecologists. Care of
Women with Obesity in Pregnancy. London: RCOG, green top guideline
number 72, November 2018.

OAH14-2021 Obstetric Anaesthetists Handbook 159

Avoiding iron deficiency and anaemia 161
162
Avoiding iron deficiency and anaemia 162
163
Chapter contents 165
Definitions 165
Antenatal care 167
Oral iron supplementation
Planned caesarean birth
Intrapartum management
Postpartum management
Parenteral iron infusions

Iron deficiency and its associated anaemia are common in pregnancy, and
associated with several serious adverse outcomes for the mother and the
fetus:

• Maternal – increased maternal risks of susceptibility to infection,
uterine atony, antepartum and postpartum haemorrhage.

• Fetal – low birth weight, fetal anaemia, preterm birth and perinatal
mortality, delivery by caesarean birth and unplanned admission to
neonatal intensive care.

Anaemia in the postpartum period is associated with increased risks of
postpartum depression and reduced breastfeeding duration.

In view of these morbid associations, it is essential that pregnant women
are adequately managed to improve both maternal and fetal outcome.
This management involves rigorous detection of those who are at risk of
iron deficiency or anaemia, or who are actually iron deficient or anaemic,
treatment with oral iron if at all feasible and treatment with intravenous
iron in later pregnancy if oral iron does not reverse anaemia, or if
anaemia is detected too close to delivery for oral treatment to have a

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Avoiding iron deficiency and anaemia

significant effect. The anaesthetist’s particular need is to optimise
mothers for delivery to reduce the chance of blood transfusion or
postoperative complications, and to enhance and support recovery.
Identification of untreated anaemia at the time of delivery indicates
inadequate management.
This section draws on the UHCW and the BSH guidelines [84,85].

Definitions

Haemoglobin levels indicating anaemia

First trimester Hb<110 g L-1

Second and third trimester Hb<105 g L-1

Postpartum Hb<100 g L-1

It is possible to be deficient in iron while not yet having a low
haemoglobin level.

Ferritin

Ferritin<30 mcg L-1 represents significant depletion of iron stores
regardless of the Hb result and should trigger management of iron
deficiency.

MCH

MCH<27 pg indicates iron deficiency.

Optimal haemoglobin level

A woman with Hb≥120 g L-1 at delivery is considered to have an optimal
Hb in our care.

Significant obstetric haemorrhage

This is a loss of more than 20% of the mother’s estimated blood volume.

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Avoiding iron deficiency and anaemia

Antenatal care

This is normally handled by the community midwives and the
obstetricians – see the UHCW guideline for details. Mothers on the
standard antenatal pathway will have a full blood count only, whereas
those with risk factors for iron deficiency or diagnosed anaemia will have
ferritin levels measured.

If the mother is diagnosed with a haemoglobinopathy or a macrocytic
anaemia (MCV>100 fL), the haemoglobinopathy team will be involved.

Intravenous iron is indicated for those who do not respond to or cannot
tolerate oral iron, or if surgery is planned within 6 weeks after the
diagnosis of iron deficiency.

Symptoms of iron deficiency and anaemia

These are usually non-specific unless anaemia is severe and include
(but are not limited to):

• Fatigue (most common) * • Shortness of breath

• Pallor • Irritability *

• Weakness • Poor concentration *

• Headache • Hair loss *

• Palpitations • Impaired temperature
• Dizziness regulation (feeling cold)

* These symptoms can occur in iron deficiency without anaemia.

Oral iron supplementation

Oral iron treatment carries a high burden of gastrointestinal side-effects
and poor compliance, especially when used in too high a dose. Once daily
or alternate day dosing of oral iron improves iron status adequately with

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Avoiding iron deficiency and anaemia

a reduced burden of side-effects and thus is likely to be better tolerated
and taken by our mothers. Once-daily dosing is the recommended
regimen; however, if mothers are finding it difficult to take their
supplement, then they should be encouraged to try an alternate-day
dosing regimen. Iron supplementation should ideally be taken with
orange juice and with an acidic stomach (i.e., on an empty stomach and
not after reflux or heartburn medication) to aid absorption. Taking
supplementation with tea, coffee or other medication should be avoided
as this can reduce absorption, as can many herbal teas to a lesser extent.
Gastric side-effects can be reduced if iron is taken after food, but it may
be preferable to use IV iron in such women. Iron can reduce
levothyroxine absorption; leave two hours between the drugs.

Iron supplementation requires 40-80mg of elemental iron per day. One
tablet per day of the following is appropriate:

• Ferrous sulfate (200 mg dose containing 65 mg elemental iron).

• Ferrous fumarate (210 mg dose containing 68 mg elemental iron).

Planned caesarean birth

Mothers are often booked in the middle of the third trimester. By this
time their iron status and Hb level should be optimised. However, at
present a significant proportion of mothers are presenting at caesarean
birth with iron deficiency anaemia, and this pathway will detect those
who need treatment and optimise them for delivery.

The appropriate treatment at this late stage is intravenous iron
supplementation. If you are assessing a mother for surgery and this
action has not been taken, then speak to the midwives about prescribing
and administering intravenous iron treatment – see page 167.

Remember that the treatment is often in two doses which must be given
a week apart.

If treatment is indicated but has not been given, and the caesarean birth
is booked for the next few days, it may well be more convenient to
administer an iron infusion in theatre recovery after the operation.

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Avoiding iron deficiency and anaemia

Pathway for planned caesarean birth

Patient booking form for CS completed

Assess patient needs
Risk factors for anaemia
• Known anaemia or iron deficiency.
• Non-absorbers (inflammatory bowel disease, gastric surgery, coeliac disease).
• Increased requirement (multiple pregnancy, parity ≥3, age <20 years, last pregnancy

<12 months ago).
• Likely to have reduced dietary intake including vegans and vegetarians.
• Has had prescribed iron supplementation in this pregnancy.
Increased importance of Hb optimisation
• Bleeding risk (previous PPH, fibroids, previous uterine surgery).
• Other (women who decline blood products, recent major bleed from any cause).

If known haemoglobinopathy
refer to patient’s individual specialist
plan regarding anaemia
management.

Write blood form to be done 4 weeks before planned CS (if ≤4 weeks left
then for bloods ASAP). All patients need Hb check. Women with risk

factors or increased importance as in box above require ferritin as well.

FBC FBC & ferritin

Results checked after referral

Hb ≥ 120 g/L. Hb 105-119 g/L Hb<105 g/L or ferritin
No further action required Prescribe PO iron if <30 mcg/L or Hb<120 g/L
patient is tolerant and and intolerant of PO iron.
unless any bleeding give dietary advice. Arrange IV iron ASAP.
episodes.

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Intrapartum management

This is usually determined by the last measured Hb level. Events in labour
may indicate a tailored approach.

Admitted intrapartum Known anaemia
• If known haemoglobinopathy refer to in pregnancy:

patient’s individual specialist plan. Hb<105 g/L after
• If symptomatic of anaemia regardless 34 weeks.

of Hb result, discuss with senior
obstetrician and senior anaesthetist for
consideration of appropriate
management and potential differential
diagnosis.

Review latest Repeat FBC,
FBC G+S

Not anaemic Anaemic Hb<105 g/L
Hb ≥105 g/L • Consider IV access (required if Hb<90 g/L).
No further action • Offer active management of third stage.
required during • If Hb level is more than two weeks old: repeat sample, and
intrapartum
phase. ensure valid G+S.
• Alert obstetric and anaesthetic teams.

Postpartum management

Mothers who were not optimised, or who had obstetric haemorrhage,
will need iron supplementation to recover at home. IV iron is indicated
for significant haemorrhage.

The following pathway should be applied along with other guidelines
about obstetric haemorrhage, allowing for patient factors such as
extremes of body weight and the clinical response to bleeding.

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Avoiding iron deficiency and anaemia

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

Last Hb≥120 g/L Last Hb105-119 g/L Last Hb<105 g/L or EBL≥1500 mL or
and EBL≤500 mL or EBL 501-999 mL EBL 1000-1499 mL MOH or

No further action PO iron once Review blood EBL>20% of
required unless daily for 3 tests; do ferritin estimated blood
if anaemic and
has further months if tolerant. no recent level; volume or
bleeding or Request GP to consider FBC for ongoing bleeding
symptoms. review response anaemia; FBC at
at 3 months. or persistent
(Consider this if 6-12 hours if tachycardia
Hb<105 g/L and haemorrhage
no symptoms.) Urgent blood gas
Hb & lactate;

review and repeat

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

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Treatment with oral iron in the postoperative period has a limited role as
it may be poorly absorbed and can have significant side-effects, limiting
the dose and efficacy. Intravenous iron is a more successful treatment for
iron deficiency anaemia after major surgery and in the postpartum
period. A pragmatic strategy is to deliver an intravenous dose after
significant haemorrhage followed by oral replenishment. Red cell salvage
and intravenous iron are employed to mitigate hospital-acquired
anaemia.

IV iron supplementation should be used for significant obstetric
haemorrhage, defined as a loss of more than 20% of the mother’s
estimated blood volume.

Notwithstanding the above, some mothers may not have obstetric
haemorrhage and yet present in delivery or at operation with iron
deficiency anaemia. Mothers for whom IV iron is indicated in late
pregnancy but who have not had it administered should receive an
appropriate dose of IV iron at a convenient point immediately after
delivery, in a labour room or in theatre recovery. IV iron is stocked on
labour ward and after agreement on the management plan, prescribe it
on the inpatient drug chart.

Circulating blood volume at term is 45% higher than in the non-pregnant
state, typically between 90-100 mL kg-1 of the booking weight, with the
lower figure being appropriate for morbid obesity. Significant blood loss
indicating consideration of postoperative parenteral iron infusion is 20%
of circulating blood volume. (Class 2 surgical haemorrhage is 15-30% of
circulating blood volume.)

Mothers who have received allogeneic or salvaged red cells should have
senior medical review before receiving IV iron.

Parenteral iron infusions

The current parenteral iron in use at the trust is Ferinject (ferric
carboxymaltose). This is a high-dose and rapidly infusing preparation. It
does not require a test dose. It has a similar safety profile in pregnancy
compared to iron sucrose with the benefit of reduced time of

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Avoiding iron deficiency and anaemia

administration. It has demonstrated proven efficacy in the management
of antenatal and post-partum anaemia. It is not contraindicated in
breastfeeding. Ferric carboxymaltose is rapidly cleared from the
circulation and is distributed to the reticuloendothelial system, primarily
to the bone marrow, with subsequent prolonged delivery to iron binding
proteins involved in haemopoiesis. It can be expected to increase Hb
levels by 20-40 g L-1 in 2-4 weeks in iron deficiency anaemia.

Ferinject dose calculation for antenatal iron deficiency

Booking body weight

Haemoglobin <35 kg 35-69 kg ≥70 kg

<100 g L-1 500 mg 1500 mg 2000 mg

100-140 g L-1 500 mg 1000 mg 1500 mg

≥140 g L-1 500 mg 500 mg 500 mg

Ferinject is often required in a greater amount than can be administered
in one infusion. The maximum single dose is 1000 mg or 20 mg kg-1.
Mothers requiring more than 1000 mg should have their dose split over
two infusions more than one week apart.

Before prescribing Ferinject, always check whether and when the mother
has received Ferinject previously. Ask the mother and check the
antenatal notes.

Use the obstetric IV iron form when a mother is identified as needing IV
iron in the antenatal period. Book the woman into the induction diary
(max 3 infusions per day) with the midwife holding the diary. Try to
coordinate with other appointments the woman may have. Complete the
referral and prescription form (both pages) and place in the diary or with
triage. File the form in the mother’s medical record when treatment is
completed. Make an entry in the K2 antenatal notes that Ferinject has
been given.

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Avoiding iron deficiency and anaemia

Ferinject dose for intrapartum obstetric haemorrhage

For significant haemorrhage (>20% EBV), use a replenishment dose of
1000 mg Ferinject (to a maximum of 20 mg kg-1). Where a significant
haemorrhage has supervened on newly diagnosed iron deficiency
anaemia, seek senior advice, and formulate a bespoke plan.

Contraindications to parenteral iron supplementation

• First trimester of pregnancy.
• Known hypersensitivity to parenteral iron.
• Anaemia not attributed to iron deficiency.
• Iron overload.

Cautions

• Bacteraemia/sepsis.
• Increased risk of hypersensitivity.
• Atopy e.g., eczema or asthma.
• Immune or inflammatory conditions e.g., systemic lupus

erythematosus.
• Haemoglobinopathy (requires discussion with haematologist).
• Hepatic or renal dysfunction.
• Hypophosphataemia (can be caused by parental iron

administration).
• Extravasation of parenteral iron.

Follow-up after parenteral iron

• Prescribe once-daily enteral iron supplementation (one tablet each
day) to start five days after completion of parenteral iron and
continue for three months.

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Avoiding iron deficiency and anaemia
• Request the mother’s GP to assess iron status at completion of

treatment. This should be done by the obstetrician completing the
discharge papers.
• Do not repeat ferritin levels less than four weeks after the infusion
as this will not have allowed adequate time for iron utilisation and
erythropoiesis.

84. Whittingham E, Madden V, Porter M, Black N, Woodman J, Lynes E, Elton J.
Avoiding iron deficiency and anaemia in pregnancy and the postpartum
period. UHCW clinical guideline CG1159, November 2019.

85. Pavord S, Daru J, Prasannan N, Robinson S, Stanworth S, Girling J, et al. UK
guidelines on the management of iron deficiency in pregnancy. Br J Haematol.
2020 Mar; 188(6):819-30.

170 Obstetric Anaesthetists Handbook OAH14-2021

Feeding and antacid prophylaxis

Feeding and antacid prophylaxis

Chapter contents 171
171
Oral intake in labour 172
Suppression of acid reflux 172
Sodium citrate 174
Oral intake and caesarean birth
Postpartum fasting status

Oral intake in labour

Low-risk mothers may consume light food and drinks. After opioid or
epidural analgesia is administered, clear non-carbonated fluids only may
be consumed. In cases of complicated pregnancy or labour, water only
may be consumed.

Suppression of acid reflux

Offer mothers antacids and drugs to reduce gastric volumes and acidity
before caesarean birth as below [86]. We use omeprazole.
All labouring women receiving opioids by any route should be given oral
omeprazole 20 mg BD. Midwives can prescribe this.
Mothers having urgent surgery who have not had acid reflux
suppressants should be administered omeprazole 40 mg PO or very slow
IV as an alternative. You should check that this has been done.
We use acid reflux suppression as a premedicant before elective
caesarean birth. You will occasionally be asked to see such mothers. Use
omeprazole 40 mg at 22.00 hrs and again at 07.00 hrs on the day of

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Feeding and antacid prophylaxis

surgery. For those mothers going home to await their caesarean you
should use the pre-labelled outpatient boxes from antenatal clinic
containing two tablets.

Sodium citrate

You should make sure that sodium citrate 0.3M 30 mL has been given
immediately prior to general anaesthesia; usually within 20 minutes.
We do not routinely use it for regional anaesthesia. It may be offered in
case of maternal heartburn.

Oral intake and caesarean birth

Caesarean births are booked for the morning or all-day operating lists.
This list can be subject to delay because of the pressure of urgent and
emergency work. These delays can, with traditional fasting policies, lead
to lengthy fasting periods that are distressing to the mother and can
cause dehydration. The administration of sodium citrate can also be
unpleasant and is not needed except immediately prior to the induction
of general anaesthesia or in the case of actual heartburn.
The anaesthetist must secure the airway using a rapid sequence
induction when inducing general anaesthesia in obstetric cases, unless
the mother is more than 18 hours postpartum and has no other
indication for rapid sequence induction.
Many mothers presenting for non-elective caesarean birth may have had
a complicated pregnancy or labour. While such mothers are in labour,
they may consume only water. Other mothers may have had light food
during labour.
This guideline applies to both general anaesthesia and regional
anaesthesia.

Category 1 emergency: immediate threat to life of woman or fetus

Proceed with appropriate anaesthesia as soon as possible.

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Feeding and antacid prophylaxis

Category 2 urgent: maternal or fetal compromise that is not
immediately life threatening

Proceed with appropriate anaesthesia as soon as possible.

Category 3 scheduled: needing early delivery but no maternal or fetal
compromise

Ideally the mother will not have eaten any solid food in the preceding six
hours. Waiting for six hours can cause problems, because the operation
may then be delayed into the evening when fewer staff are around or
into the night. A wait may lead to further delay due to other mothers
needing care. Waiting does not obviate the need for rapid sequence
induction in the case of general anaesthesia. The pragmatic solution may
be to proceed with appropriate anaesthesia within six hours. Discuss such
cases with the consultant anaesthetist if you are in doubt.

Category 4 elective: at a time to suit the mother and maternity team

(See the ERAS section on page 291 for details about our enhanced
recovery programme.)

• Mothers may eat as they wish until 02:00 in the night before
caesarean birth.

• Mothers are encouraged to consume a drink (coffee or tea with a
small amount of semi-skimmed milk, or a fruit squash) on the
morning of caesarean birth. This drink should be finished by 07:00.

• Mothers who do not have diabetes are encouraged to consume a
non-carbonated carbohydrate drink on the morning of caesarean
birth. This drink should be finished by 07:00. Withhold this in
mothers with impaired glucose tolerance or diabetes.

• Mothers may consume unrestricted sips of tap water after this until
entering the operating theatre. This measure will increase comfort,
aid gastric emptying, and prevent an untoward increase in blood
viscosity [87,88].

• For all-day lists, identify and agree the order of mothers when
planning the list in the morning. Those who will be fourth and fifth

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Feeding and antacid prophylaxis
on the list should be offered a light breakfast such as coffee and
toast, to be consumed promptly.

Maternal hypoglycaemia
Some mothers with diabetes may have hypoglycaemia while awaiting
surgery. They should be advised to take whatever they need to stop their
hypo and that it will not interfere with the timing of surgery. If
administered, do not defer the caesarean birth to recommence fasting.

Postpartum fasting status

The gastric emptying time returns to normal in uncomplicated cases from
18 hours after delivery [89]. Within the first 18 hours after delivery, treat
the mother as you would one in labour – these procedures are going to
be urgent. After the first 18 hours, rapid sequence induction or
intubation is not necessary unless otherwise indicated.

86. National Institute for Health and Care Excellence. Caesarean birth: NG192.
London: NICE, 31 March 2021; section 1.4.18.

87. Levy DM, Webster VL. Unrestricted sips of water before caesarean section. Br
J Anaes 2004; 92:910.

88. Wong CA, Loffredi M, Ganchiff JN, Zhao J, Wang Z, Avram MJ. Gastric
emptying of water in term pregnancy. Anesthesiology 2002; 96:1395-1400.

89. Whitehead EM, Smith M, Dean Y, O’Sullivan G. An evaluation of gastric
emptying times in pregnancy and the puerperium. Anaesthesia 1993; 48:53-7.

174 Obstetric Anaesthetists Handbook OAH14-2021

Preparing mothers for anaesthesia

Preparing mothers for anaesthesia

Mothers for planned caesarean birth will normally be seen in the clinic
the week before (see below). The midwives will refer some inpatients to
you (e.g. transverse lie or placenta praevia on ward 24, or those
attending labour ward), in which case you should assess the mother and
start an anaesthetic record, or complete the existing perioperative
booklet. Check for women who have not been assessed on ward 24 when
you walk past.

Check notes on CRRS for any previous anaesthesia assessment.

Prescribe omeprazole 40 mg at 22.00 hrs and 07.00 hrs. Do not prescribe
metoclopramide unless specifically indicated as this is given intravenously
before anaesthesia. Use other drugs (e.g., salbutamol) where indicated
but remember that any premedicants will be administered while she is
pregnant and the appropriate guidelines on prescribing in pregnancy
must be followed. We do not use sedative premedicants.

You may also be asked to see mothers on the labour ward for later
surgery, e.g., after failed external cephalic version in the clinic. Ensure
that the actions as detailed for the planning clinic have been completed.

Planned caesarean births may be delayed because of more urgent work.
Make sure that the mothers are being offered oral water and in the case
of significant delay, proper refreshments coordinated with the time
planned for surgery.

Category 3 caesarean births can be undertaken during on-call periods.
Usually these will be cases where there is a robustly pressing indication,
such as failed induction or planned caesarean birth presenting with
rupture of membranes. A small number may be cases that we have not
been able to accommodate on planned caesarean birth lists, perhaps due
to high workload, neonatal cot availability and so on. You should inform
the senior resident anaesthetist in main theatres of all category 3 cases
proposed during on-call periods. Always consider such cases
sympathetically, remembering to make the care of the patient your first
concern, and liaising with a consultant anaesthetist as appropriate. You

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Preparing mothers for anaesthesia

should make sure that the obstetricians and midwives have a robust plan
for undertaking a simultaneous category 2 or category 1 case.

The caesarean preoperative clinic

This clinic runs every Friday afternoon in University Hospital, Coventry
under the supervision of Dr Porter, Dr Fairfield, and Dr Siva. Mothers
booked for caesarean birth in the following week attend.

Purpose of the clinic

• To assess mothers scheduled for planned caesarean births in the
following calendar week.

• To provide information on anaesthesia choices.
• To complete and file an anaesthesia record sheet.
• To issue acid reflux suppression as needed for self-administration.
• To support a model of care whereby admission for planned

caesarean birth takes place on the day of surgery.
• To optimise the mother including iron status, steroid treatment and

infection screening, and other components of perioperative
medicine.

Running the clinic

Booking the clinic is done by the midwives and the antenatal clinic staff. If
you are providing or helping with the clinic you will find it useful to get
the clinic list on your CRRS. Subscribe to the code:
• UPORM5PN – Friday at the University Hospital.
Mothers are booked at 10-minute intervals and seen in two clinic rooms.
The review should be the same as that performed for any preoperative
assessment and should incorporate the following elements:
• Completion of anaesthesia assessment record sheet in the

perioperative booklet.
• Check the nature and date of the booked operation.

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Preparing mothers for anaesthesia

• History from mother and examination as required.

• Documentation of all regular and as-required medications that the
mother takes, and a plan for continuing, withholding, stopping, or
changing during the hospital admission.

• Review of clinical notes as required.

• Check whether diagnostic blood samples or samples for ‘group and
save’ are needed and draw blood as necessary.

• Provision of the trust’s ‘Information from your anaesthetist about
planned caesarean birth’ (a written information sheet reinforces
oral information). Recommend LabourPains.com.

• Prescription and issue of prepared pre-med pack (omeprazole
40 mg × 2) unless there are very good and documented reasons for
difference, such as the mother already being on antacid treatment.

• Consider whether samples such G+S or FBC are indicated as below
and make the necessary arrangements.

• Consider the mother’s iron status and whether she needs oral or
parenteral iron – see page 160. At this stage, if she needs, we should
prescribe and arrange it.

• If the woman is to have a caesarean birth at less than 39 completed
weeks of gestation, and has not had two steroid injections, ask one
of the clinic midwives to arrange steroid injections for fetal lung
maturity. This will usually be in the clinic and the following day.

• Take an infection control history and ask the midwives to undertake
appropriate infection screening. At present this is a CPE rectal swab
for all women who have been an inpatient at any hospital other
than the University Hospital or the St Cross Hospital in the last 12
months, and any woman who has previously had a positive result
for CPE or has had contact with a person with a known positive
result.

• SARS-CoV-2 screening is done in the three days prior to planned
surgery. The woman will be contacted about this separately.

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Preparing mothers for anaesthesia

Steroid administration and CPE screening should have been done at the
time of booking the caesarean birth, but inadvertent failure to check
these actions may cause serious disruption to operating lists.

Our standard technique for caesarean birth is spinal anaesthesia and this
should be recommended to the woman if not contraindicated.

Contraindications to attendance on the day of surgery

Mothers whose planned care involves admission before surgery may be
assessed in the clinic if they present, but they must still attend for
admission the evening before surgery. This is rare.

• Mothers with diabetes mellitus usually come in on the day. (Prior
admission is required if they are to have betamethasone injections
for fetal lung maturation.) In general, advise them to miss both
breakfast and their morning metformin and insulin. Check that
there is a plan from the diabetology team in the notes. See page
455.

• HIV-positive mothers often come in on the day. They may very
rarely need an infusion of antiretroviral drugs before surgery (see
page 494). The timing of this will need to be closely coordinated
with the theatre team and the operation time.

The major group who are not admitted on the day of surgery are those
with indications for hospital observation such as unstable lie, steroid
injections with gestational diabetes mellitus, antepartum haemorrhage,
or placenta praevia.

Mothers who do not attend

It may be possible for them to come in on another occasion for an
informal appointment on labour ward, and while no guarantee can be
made to the mothers, endeavour to see them if asked.

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Indications for blood grouping and crossmatch

Chapter contents 180
180
Dire emergencies 182
All other obstetric surgery
Practical management of red cell alloantibodies

‘Reservation’ is the process in which the blood is checked out and placed
in the blood fridge in labour ward theatres. The time from this fridge to
the bedside is a few minutes faster than electronic issue for theatres, and
about the same for the antenatal and postnatal wards.

The hospital has implemented the BCSH three-day validity rule for blood
samples in pregnancy [90]. This means that electronic issue will not be
viable unless a fresh sample has been sent to the blood bank within the
validity period and there is no history of red cell antibodies. We do G&S
samples for all urgent surgery but not most elective surgery. NICE
guidance on caesarean birth called for a reduction in routine testing prior
to surgery [91]; although NICE has now reversed its advice on G&S [92],
we feel that our practice has been working well. Our revised guideline
takes these developments into account.

A formal deviation from the three-day validity rule is made for pregnant
women with no clinically significant alloantibodies who require blood
standing by for potential sudden massive obstetric haemorrhage, e.g.,
placenta praevia.

Fetomaternal transfer constitutes a smaller stimulus than transfusion,
because the number of foreign antigens is limited, and in many
pregnancies, the volume of red cells transferred from fetus to mother is
too small to stimulate a primary response. Be specific on the sample
request, and call blood bank on 25322 for advice in special cases.

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Indications for blood grouping and crossmatch

Blood transfusion is now very rare in maternity theatres. Reinfusion of
salvaged red blood cells happens in 10% of caesarean births and
allogeneic transfusion from donor (including the following day) in about
1%.

Dire emergencies

In the case of uterine rupture (see page 150) or antepartum
haemorrhage (see page 97) discuss MOH needs with the blood bank.

You may occasionally be requested to proceed without crossmatch or
known eligibility for electronic issue because of dire emergency. If this
happens you should perform the following actions.

• Document the precise nature of the emergency and the name of
the operating obstetrician.

• Ensure that a massive obstetric haemorrhage call has gone out.

• Ensure at least that a serum sample has gone across to the
laboratory, by ‘dire need’ portering arrangements, marked for
emergency crossmatch and that somebody has telephoned the
blood bank technician and impressed the nature of the dire need on
them.

• Be prepared to request either group-specific blood or use the
O Rh D negative blood stored in the blood fridge depending upon
transfusion needs.

All other obstetric surgery

Indications for samples in advance of surgery are as follows. In each case,
the responsible anaesthetist or obstetrician may reassess the
circumstances and request escalation as appropriate.

Serological crossmatch for a minimum of two units of red blood cells

A few mothers need serological crossmatch of 2 RBC or more. They may
have red cell antibodies or a significant expectation of heavy postpartum
haemorrhage:

180 Obstetric Anaesthetists Handbook OAH14-2021

• Massive obstetric haemorrhage call.

• Antepartum obstetric haemorrhage or uterine rupture.

• Placenta praevia etc:
a. Moderate risk (uncomplicated low-lying placenta, not anterior
and no previous caesarean or other uterine pathology or
surgery): two units.
b. High risk (other risk factors, see page 395): four units.
c. Placenta accreta spectrum or other complicating pathology:
multidisciplinary planning essential; see page 395.

• Significant fibroids complicating delivery.

• Clinically significant red cell antibodies – see below on page 182.

• Sickle cell disease – call consultant haematologist.

• More than one G+S risk factor.

Group and save sample

• All category 1, 2 and 3 caesarean births, including category 4
caesarean birth now in labour.

• All urgent operations e.g., manual removal of placenta, perineal
tear repair.

A few mothers having category 4 caesareans should have G+S:

• Multiple pregnancy.

• Previous open abdominal surgery.

• Grand multiparity:
a. ≥ 3 previous caesareans.
b. ≥ 5 previous deliveries.

• Severe maternal anaemia (less than 90 g L-1) uncomplicated by
haemorrhage risk factors. For cell salvage in such cases, use the
small centrifuge bowl to maximise potential reinfusion.

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Indications for blood grouping and crossmatch

Antenatal screen only – no repeat sample

Most category 4 cases will not have indications for crossmatch or G+S
and so will not need a repeat sample.
PD alloantibodies are not clinically significant; repeating the maternal
sample is not required.
Intraoperative blood can be provided through red cell salvage, or issued
urgently as O-negative or, if there is time, serological or electronic
crossmatch against a fresh serum sample.

Full blood count and ferritin samples

FBC and ferritin should be done in the four weeks before delivery.
Consider repeating at admission if the last known Hb was less than
120 g L-1, or she has indications of iron deficiency or anaemia, or to assess
response to IV or PO iron treatment.

Practical management of red cell alloantibodies

Is a sample needed?

Presence of any history of atypical red cell antibodies (other than PD) will
delay blood provision. Check CRRS: all panels under Blood Bank. In the
GA panel, Previous Antibody History is listed at the end of the report. In
the ANC panel, Antibody File is listed at the start of the report. Check the
notes for advice from the red cell antibody MDT clinic as some such
mothers may not need crossmatch. If there is no advice, crossmatch 2
RBC after speaking to blood bank to check sample needs.

PD antibodies are not a concern, as a positive result indicates that
prophylactic anti-D antibodies have been administered to the woman.
Emergency O Rh D negative blood can be used for these mothers if they
have no other red cell antibodies.

Some mothers will have a red cell phenotype panel on their blood bank
CRRS results – this is listed as RCP. This has caused some confusion and
unnecessary crossmatching in the past. Phenotype reports are not
antibody reports.

182 Obstetric Anaesthetists Handbook OAH14-2021

Discuss red cell antibody status with the blood bank staff as the difficulty
in management can vary markedly. The scientist or haematologist will
advise on the following.

• Whether one or three serum bottles need to be sent for analysis.

• Whether the crossmatching can be handled locally in Coventry, or
whether the antibody is sufficiently challenging or rare to require a
sample to be sent to and blood obtained from the regional blood
bank in Birmingham with the concomitant delay. Very rarely, red
blood cells may only be available from the UK National Frozen Blood
Bank in Liverpool, where the notice period is a minimum of five
working days.

Timing of sample

Urgent cases: as soon as appropriate, when in labour or with the decision
to operate.

Planned cases: samples used for provision of blood in pregnancy must be
less than 72 hours old (except that in a woman at high risk of emergency
transfusion, e.g., placenta praevia, and with no clinically significant
alloantibodies, G+S samples are sent once a week to exclude or identify
any new antibody formation and to keep blood available if necessary).

Crossmatch samples should be received in the blood bank by the
morning before a planned caesarean birth, whatever the day of surgery.
If there is no convenient pre-existing appointment, arrange for the
sample to be done in the Fetal Well Being Unit on the late afternoon or
evening two days before surgery (about 36 hours in advance). Telephone
27427 to inform FWBU staff of the woman’s identity and the sample
needs, for the diary. FWBU is open until 20:00.

G+S samples (where there is no crossmatch) are best taken at the time of
a pre-existing appointment e.g., FWBU. If no other option is available,
they can be taken on the morning of the operation and sent urgently.

If open, mothers could attend the University Hospital phlebotomy service
or St Cross Hospital in Rugby. Many community facilities are closed
during the pandemic, but the Coventry NHS Walk-in Centre, or their GP

OAH14-2021 Obstetric Anaesthetists Handbook 183

Indications for blood grouping and crossmatch
or pharmacist may be available at other times. There are 40 local blood
test service locations: Google ‘UHCW blood tests’ for an interactive map
and contact list. Give the woman her blood bank request form and, if
indicated, a request form for FBC and ferritin.
If absolutely no other option is available, use labour ward triage – let
triage know on 27333. We do not have access to the coronavirus pod
bookings for synchronisation, but mothers could call FWBU to see if they
can be done at the same time.

90. Milkins C et al for the British Committee for Standards in Haematology.
Guidelines for pre-transfusion compatibility procedures in blood transfusion
laboratories. Transfusion Medicine 2013; 23:3-35.

91. National Institute for Health and Clinical Care Excellence. Caesarean section:
CG132. London: NICE, 2012, section 1.4.4.3.

92. National Institute for Health and Care Excellence. Caesarean birth: NG192.
London: NICE, 31 March 2021; section 1.4.6.

184 Obstetric Anaesthetists Handbook OAH14-2021

Information and consent Information and consent

Chapter contents 187
Concerns about patient safety 187
Interpreting and translation 188
Birth plans 189
Consent forms 189
Information about epidurals 191
Providing information in written form

Professional advice has been issued on consent for anaesthesia [93,94,95].
You should practise according to the following recommendations from
the OAA/AAGBI guidance:

“There is no difference between the principle of obtaining
consent for obstetric anaesthesia and any other medical
treatment.

“The patient is entitled to receive an explanation of the
proposed procedure in appropriate language. Interpreters
should be made available to women who do not speak English;
if at all possible, these should not be family members. The
explanation should include the nature and purpose of the
proposed procedure, as well as any material risks attached to
it. The patient should have the opportunity to ask any
questions.

“All explanations should be documented. The use of pre-
printed labels to insert in the record as confirmation of the
explanation is recommended.”

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Information and consent

Expectant mothers attending the antenatal clinics are given leaflet
information regarding the available choices in the labour ward. They are
encouraged to form their own choices in advance of labour. Mothers
always retain the right to change their mind, and you should respect this.
On occasion this may mean that a woman in labour appears to change
her mind in a contrary fashion; she has this right.

Unusual restrictions on treatment should be noted in the antenatal
record. Where restrictions on a woman’s treatment inevitably result in
danger for the fetus, it is conceivable that an approach to the courts may
be made. Such approaches will only be successful where the court
believes the woman is no longer a competent person to give or withhold
consent; recent decisions have shown that the woman’s autonomy and
right to make her own decisions is regarded as having great weight.

We must start from the presumption that all women have capacity to
make decisions about their treatment and care [96]. If you believe that
the mother lacks the capacity to give valid consent, and it is unclear that
urgent treatment is in her best interests, considering the circumstances
at the time, discuss this with the labour ward coordinator and the
consultant anaesthetist.

Consent discussions must include risks, benefits, and alternatives to
treatment, including where appropriate, no treatment. Through the
Montgomery case, the law has recently come into line with previous
professional advice to require doctors to provide the patient with
information about all material risks. The test of a material risk is whether
a reasonable person in the patient’s position would be likely to attach
significance to the risk, or the doctor should reasonably be aware that the
particular patient would be likely to attach significance to it [94]. Make
sure that when talking to women in advance of any anaesthesia
technique, you use open and facilitative discussion to encourage the
woman to raise any questions, points, or concerns that she may have,
whether covered in standard literature or not.

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Concerns about patient safety

You must report immediately to the consultant anaesthetist on call any
instance in which you feel that restrictions on consent may lead to harm
for the woman.

The legal position is clear: a pregnant woman with capacity can refuse
any treatment for any reason, even if this puts the unborn child at risk of
harm or death [94]. An emergency court order to authorise treatment
may be requested in such circumstances but will only be granted if the
court concludes that the woman lacks the relevant decision-making
capacity and that the treatment is in her best interests. As with most
other legal issues, this turns on capacity, its presumed presence, and
whether the mother can be shown not to have it. Our presumption must
be that she does have capacity.

Interpreting and translation

Care for mothers who do not speak or understand English is difficult and
challenging. Speak to the midwives about engaging the services of an
appropriate interpreter. This may be face to face if time allows but may
be telephone interpreting through Language Line Solutions.

The best way to use an interpreter is to talk directly to the mother as you
would normally. The interpreter will interpret for you. Do not treat the
mother as a third party, by having a conversation with the interpreter.

Information sheets regarding epidural and spinal for pain relief and
caesarean births in different languages are available online at
LabourPains.com. You should supplement oral interpretation by giving
appropriate translated materials.

Use of carers, relatives, friends, or members of staff

There is a trust policy on this. A mother may wish to communicate
confidential information and has a right for their confidentiality to be
respected. In addition, carers, relatives, friends, or members of staff may
not be able to communicate information on an impartial basis.

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Carers, relatives, or friends should not be used to provide face to face
interpreting and, if necessary, telephone interpreting should be used to
explain to the mother why this is not appropriate. If a mother refuses to
use a professional interpreter, record this decision in her medical notes.

It may be appropriate in an urgent situation for a carer, relative, or friend
to communicate basic information. All service users must be provided
with a professional interpreter at the earliest opportunity.

Children (under 16 years) must not be used to interpret at all. A face to
face, telephone or BSL interpreter should be arranged urgently.

Birth plans

A birth plan is a form of advance statement and must be respected as
written if the woman loses capacity. However, loss of capacity is very
rare. Further, there may be evidence that the situation falls outside the
expected circumstances or that the mother may have changed her mind
since signing it. “Just as one can give consent, one can also change one’s
mind when confronted with the pain of labor” [97]. If confronted with this
situation, involve the senior midwife in your discussion with the mother
and document the results thoroughly. It may also help to have a
postpartum discussion to make sure that any anxieties or questions that
the woman might have can be answered.

Scott’s views are widely quoted and respected [98]:

“It is unethical, I would maintain, to withhold pain relief from a
greatly distressed woman, actually begging for an epidural,
solely because of a statement written in her Birth Plan at a
time of ‘not knowing’, which states ‘I do not wish to have an
epidural in labour’.”

Women who have capacity and who request epidural analgesia during
labour, despite recording a refusal in their birth plan, must have their
request respected [94].

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Consent forms

As above, the process of consent must take place for all procedures. A
consent form is not the process of consent, it is a record of that process.

In Coventry, in common with most obstetric units, a separate consent
form signed by the mother is not required for labour analgesia.

However, ask the mother to sign a record of consent for epidurals done
for epidural blood patch and therefore as a procedure treating a rare
complication of central neuraxial block.

A record of consent for anaesthesia for operative surgery is covered by
the signed consent form for the surgery. In some circumstances including
some category 1 caesarean births, consent may be completed verbally,
and it is not feasible to use a consent form.

Whether a signed record of consent is used or not, you remain
responsible for making sure that the mother is properly informed about
the procedure. Ask yourself the question ‘What would this particular
patient regard as relevant when coming to a decision about which of the
available options to accept?’ [94]

Information about epidurals

You may be asked to establish epidural analgesia in mothers whose
capacity is compromised by pain, fatigue, or analgesic or sedative drugs.
These factors do not of themselves remove capacity. The process of
consent started antenatally as described above, and in the delivery room
may be oral and implied. However, all mothers for whom you propose to
establish epidural analgesia must have an explanation at least and be
offered the opportunity to refuse or to ask questions. This explanation is
documented on the epidural form that you must complete for each
woman.

Although you should use your professional skills in making this
explanation, we suggest that the following is explained as a minimum:

• An epidural involves the insertion of a catheter near to the spine
and is performed by an anaesthetist.

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• It is the best method of labour analgesia known, with a success rate
of about five in six – the remaining one in six will often respond to
further attention.

• The fetus generally benefits and there is no evidence to show that
you are more likely to have a caesarean birth because of the
epidural [99].

• There is little or no evidence that a PCEA will increase the chance of
forceps or ventouse delivery.

• If you have had a caesarean birth before, epidural analgesia is
associated with a reduced chance of another caesarean birth [100].

• A drip may be required to prevent a potential fall in blood pressure.

• Pregnancy and labour cause back pain – epidurals do not, beyond
minimal discomfort sometimes experienced on the first postpartum
day [101,102].

• Your legs may become weak, though we minimise this and you
should be able to move comfortably around the bed.

• Severe postpartum headache due to technical difficulties occurs in
about 1:100 epidurals. Treatment will be provided if this becomes a
problem.

Incidence of complications

The OAA epidural information card [103] gives the following complication
incidences:

• Significant drop in blood pressure – 1:50 – occasional.

• Not working well enough for labour – 1:8 – common.

• Not working well enough for caesarean – 1:20 – sometimes.

• Severe headache (epidural) – 1:100 – uncommon.

• Severe headache (spinal) – 1:500 – uncommon.

• Temporary nerve damage – 1:1,000 – rare.

• Nerve damage more than six months – 1:13,000 – rare.

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• Epidural abscess – 1:50,000 – very rare.

• Meningitis – 1:100,000 – very rare.

• Epidural haematoma – 1:170,000 – very rare.

• Accidental unconsciousness – 1:100,000 – very rare.

• Severe injury, including paralysis – 1:250,000 – extremely rare.
Many mothers who are nervous about risk will understand if you explain
that just under two thousand people die on British roads every year and
that in any one year, one’s chance of being killed in a road accident is
1:30,000. Most people accept this risk and implement strategies to
reduce it, e.g., having their car regularly serviced.

Providing information in written form

The Obstetric Anaesthetists Association publishes information for
mothers in a wide variety of languages. The information covers both
labour analgesia and theatre anaesthesia techniques. It is available at
LabourPains.com and it is worth reviewing it in a quiet moment to see
what mothers may know in advance.
We have a suite of patient information leaflets available on the eLibrary
and on the public-facing trust website. At present these include:

• Pain relief in labour.

• Epidural information sheet.

• Headache after an epidural or spinal injection.

• Anaesthesia for planned caesarean birth.

• Anaesthesia for urgent obstetric operations.

• Iron deficiency anaemia in pregnancy.

• Remifentanil – information for mothers.
These contain information on complications that is drawn from the
LabourPains.com leaflets. When assessing mothers for anaesthesia, you
may be able to find hard copy or print these leaflets, but it will often be

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easier simply to show the woman how to download them from the trust
website.

93. General Medical Council. Decision making and consent. London: GMC, 2020.

94. Association of Anaesthetists of Great Britain and Ireland. AAGBI: Consent for
anaesthesia 2017. Anaesthesia 2017; 72:93-105.

95. Association of Anaesthetists of Great Britain and Ireland and Obstetric
Anaesthetists Association. OAA/AAGBI Guidelines for Obstetric Anaesthesia
Services 3. London: AAGBI & OAA, June 2013.

96. General Medical Council. Decision making and consent. London: GMC, 2020;
principle 5.

97. Douglas MJ. Consent for obstetric analgesia and anesthesia. In: Stephen H.
Halpern & Joanne M. Douglas (eds.) Evidence-based obstetric anesthesia.
Oxford: BMJ Books, 2005; pages 3-9.

98. Scott WE. Ethics in obstetric anaesthesia. Anaesthesia 1996; 51:717-8.

99. National Institute for Health and Care Excellence. Caesarean birth: NG192.
London: NICE, 31 March 2021; section 1.3.4.

100. National Institute for Health and Care Excellence. Intrapartum care for
women with existing medical conditions or obstetric complications and their
babies. London: NICE, March 2019 (last updated April 2019); NG121, section
1.19.8.

101. Russell R, Dundas R, Reynolds F. Long term backache after childbirth:
prospective search for causative factors. BMJ 1996; 312:1384-8.

102. Breen TW. Epidural analgesia and back pain. In: Stephen H. Halpern & Joanne
M. Douglas (eds.) Evidence-based obstetric anesthesia. Oxford: BMJ Books,
2005; pages 208-16.

103. LabourPains.com, accessed January 2020.

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