OAH14-2021

Diabetes in pregnancy

Planned caesarean birth

This applies to gestational diabetes, and type 1 and type 2 diabetes
where control is good. Mothers with type 1 and type 2 diabetes should
be delivered by 38+6 weeks by induction or caesarean birth, and with
complicated gestational diabetes, between 38 and 40+6 weeks. Mothers
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 mother 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.

408. Farrall L, Murthy N, Goodwin W. Diabetes in pregnancy. UHCW clinical
guideline CG1011, October 2018.

409. National Institute for Health and Care Excellence. Diabetes in pregnancy:
management from preconception to the postnatal period. London: NICE,
February 2015 (last updated December 2020); NG3.

OAH14-2021 Obstetric Anaesthetists Handbook 493

Thrombocytopenia 495
496
Thrombocytopenia

Chapter contents
Management of thrombocytopenia in pregnancy
Intrapartum care for moderate or severe thrombocytopenia

See the hospital guideline on this [410]. 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.

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

494 Obstetric Anaesthetists Handbook OAH14-2021

Thrombocytopenia

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. Mothers with gestational thrombocytopenia are generally
considered at low risk of bleeding complications during birth. The fetus
can be assumed to have a normal bleeding risk.

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). Mothers with ITP are at high risk of bleeding during birth. The
fetus should be assumed to be at risk of significant bleeding.

COVID-19 thrombocytopenia produces a mild to moderate reduction in
the platelet count, and although counts below 100 × 109 L-1 may be rare,
profound thrombocytopenia may be seen [411].

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 mother is symptomatic with bleeding.

OAH14-2021 Obstetric Anaesthetists Handbook 495

Thrombocytopenia

• The platelet count is < 20 × 109 L-1.

• 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 mother 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.
Mothers undergoing caesarean birth 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

496 Obstetric Anaesthetists Handbook OAH14-2021

Thrombocytopenia

individually. Check the platelet count within the last six hours before CNB
if thrombocytopenia is suspected.

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 mother 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 mother 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 mothers.
Entonox is, as in any labour, the mainstay of pharmacological analgesia. If
the mother 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 250.

NSAIDs will be contraindicated for postnatal analgesia.

OAH14-2021 Obstetric Anaesthetists Handbook 497

Thrombocytopenia

410. Farrall L, Arbuthnot C. Diagnosis and management of idiopathic and
gestational thrombocytopenia in pregnancy. UHCW clinical guideline CG1800,
July 2016.

411. Bampoe S, Odor PM, Lucas DN. Novel coronavirus SARS-CoV-2 and COVID-19.
Practice recommendations for obstetric anaesthesia: what we have learned
thus far. Int J Obstet Anesth 2020; 43:1-8.

498 Obstetric Anaesthetists Handbook OAH14-2021

HIV in pregnancy

HIV in pregnancy

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

If HIV+ mothers 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 [412] and
the British HIV Association [413].

Mode of delivery

The likeliest case is that cART will have suppressed the virus to very low
levels. For mothers 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 mothers with a plasma viral load of 50-399 HIV RNA copies mL-1 at 36
weeks, planned caesarean birth should be considered, considering the
viral load, the trajectory of the viral load, length of time on treatment,
adherence issues, obstetric factors, and the mother’s views.

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

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

OAH14-2021 Obstetric Anaesthetists Handbook 499

HIV in pregnancy

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

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

• Untreated mothers 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 mothers on cART with a plasma HIV viral load
<1000 HIV RNA copies mL-1.

Preoperative assessment

Make sure that you are not overheard as this may compromise
confidentiality (see page 19). Be wary of family members, friends, and
indeed the non-soundproofing bed space curtains.

Management in caesarean birth

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 [414], 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.

500 Obstetric Anaesthetists Handbook OAH14-2021

HIV in pregnancy

412. Anyanwu L, Walpole C. Management of HIV in pregnancy. UHCW clinical
guideline CG1139, October 2017.

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

414. 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.

OAH14-2021 Obstetric Anaesthetists Handbook 501

Medical conditions 502
506
Medical conditions 508
510
Chapter contents 511
COVID-19
HPA axis suppression
Peripartum hyponatraemia
Obstetric cholestasis
Ehlers-Danlos syndrome

Comprehensive textbooks have been written about maternal medicine,
as on page 57. This section contains information on some miscellaneous
conditions that come up now and then.

COVID-19

COVID-19 will continue to cause critical maternal illness for the
foreseeable future, even rarely in those who are fully vaccinated. The
following draws on RCOG/RCM guidance [415] and the 2021 MBRRACE
report [416]. The situation changes all the time and at the time of
publication infection is predominantly among the unvaccinated
population, with all women being hospitalised having not had two
vaccine doses, and with the delta variant. This variant is associated with a
higher proportion of hospitalised mothers experiencing pneumonia,
respiratory support, and critical care. Premature birth, and caesarean
birth, is more common for hospitalised mothers. Ensure care for
pregnant and postpartum women with COVID-19 follows the latest
RCOG/RCM guidance.

Severe maternal COVID-19 disease is more common with the known risk
factors of increased age, obesity, and Black and other ethnic minority

502 Obstetric Anaesthetists Handbook OAH14-2021

Medical conditions

origin. Many women with active COVID-19 are likely to have caesarean
births, and while any indication can occur, there is a high proportion of
maternal or fetal compromise indications.

General anaesthesia

We continue to use general anaesthesia despite it being an aerosol-
generating procedure, and nationally it is used to a greater extent for
mothers with COVID-19 than in mothers who do not have COVID-19.
There is a growing appreciation of the incidence of coagulopathy in
mothers with COVID-19, and the following guidelines clarify the
indications for investigations before CNB. Reductions in the GA rate
observed during the COVID-19 pandemic have not included those
mothers with severe COVID-19, of whom some had been or were
intubated for maternal respiratory compromise [417].

Endotracheal intubation is challenging while wearing PPE, and moreover
difficult intubation rates have been higher in patients with COVID-19
[418]. If inducing general anaesthesia in COVID-19, make sure that you
have a second anaesthetist with you to assist.

Pain relief in labour, neuraxial blocks and coagulopathy

Entonox is safe to use with the standard single-patient microbiological
filter, not leading to ambient contamination.

Do not use remifentanil for women with COVID-19 disease.

We recommend epidural analgesia earlier in labour to pre-empt some GA
indications. Indications for neuraxial analgesia and anaesthesia are not
altered by the presence of coronaviruses unless as below.

COVID-19 thrombocytopenia is important and can be profound, but it is
not common. It may be more common in women with less serious or
asymptomatic disease, rather than those with severe COVID-19, who are
more likely to have normal or high platelet counts.

Pregnant women with COVID-19 have higher risks of haemostatic (1%)
and thromboembolic (0.3%) complications than in pregnant women
without COVID-19 [419], although the extent and distribution of these

OAH14-2021 Obstetric Anaesthetists Handbook 503

Medical conditions

risks are not well understood. COVID-19 coagulopathy is likely to
correlate with the severity of the disease. COVID-19 infection may cause
placental inflammation which itself leads to coagulopathy.

Consequently, investigating haemostasis before CNB is important, and
any impairment may improve after delivery.

Investigation guidelines will develop with time – look out for updates as
the evidence base develops. Until such time we suggest the following.

Check the latest platelet and coagulation tests for all labouring mothers
with COVID-19 infection and ask for repeat tests as indicated below if

possible. Pass this information on at handover.

Investigations before CNB in asymptomatic negative or pending mothers

No special investigations are warranted for these indications.

Investigations before CNB in mothers with mild COVID-19

This will include mothers with pyrexia and dry cough but not hypoxia or
dyspnoea at rest, and a clinical suspicion or laboratory confirmation of
COVID-19 infection.

Before undertaking CNB in a mother with diagnosed or clinically
suspected asymptomatic or mild COVID-19 infection, check the most
recent platelet count. Ideally this will have been taken in the last 6 hours;
if urgency does not permit this and CNB is indicated, inform the mother
that there have been reports of low platelet counts in mothers with mild
disease, and this may increase risk of bleeding in the spine by a very small
amount. Follow the usual advice on platelet levels (page 201) except that
in women with COVID-19, concurrent aspirin usage is likely to increase
bleeding risk. A low platelet count while on aspirin starts to increase risk
significantly and you should seek senior advice.

Investigations before CNB in mothers with lower respiratory inflammation

This will include mothers with moderate, severe, and critical COVID-19
disease. They may be dyspnoeic at rest or on mild exercise, hospitalised

504 Obstetric Anaesthetists Handbook OAH14-2021

Medical conditions

for management of COVID-19 disease, or dependent on supplementary
oxygen.

Before undertaking CNB in a mother with diagnosed or clinically
suspected moderate, severe, or critical COVID-19 disease, check a recent
platelet count, coagulation screen and fibrinogen level, taken in the last 6
hours. Follow the usual advice on platelet levels (as above and page 201).

The indications for general anaesthesia will remain on the usual obstetric,
haemodynamic or consent bases, and we should avoid using it in women
with active chest disease unless absolutely necessary. If there are
coagulopathic abnormalities, seek senior advice regarding the relative
risks of regional and general anaesthesia. You may need to speak to the
consultant anaesthetist and the haematologist. The mother may need
active treatment for diagnosed abnormalities to avoid general
anaesthesia. Before undertaking anaesthesia, inform the critical care unit
of the mother’s anticipated needs afterwards.

Mothers with severe respiratory symptoms

Pregnant women, particularly those with associated comorbidities, seem
to be at higher risk of severe complications of SARS-CoV-2 infection [420].
As well as age, obesity, and Black and other ethnic minority origin,
important associated risk factors for severe maternal disease are
pulmonary co-morbidities, hypertension, and diabetes. Obstetric and
neonatal outcomes appear to be influenced by the severity of maternal
disease; the more common complications include caesarean births,
neonatal prematurity, and admission to the neonatal intensive care unit.

When assessing pregnant women with respiratory symptoms include the
consideration of SARS-CoV-2 and the different pattern of symptoms in
pregnant compared to non-pregnant women. Be aware that the degree
of respiratory symptoms may mask the severity of underlying lung
pathology and that progression to respiratory failure in COVID-19 can
occur rapidly.

An urgent senior multidisciplinary team review should be arranged for
any unwell mother with suspected or confirmed COVID-19. This includes:

OAH14-2021 Obstetric Anaesthetists Handbook 505

Medical conditions

• Mothers who are requiring oxygen to maintain saturations between
94% and 98%.

• Mothers with a respiratory rate above 20 breaths min-1.

• Mothers with a heart rate greater than 110 beats min-1.

The review must include a consultant anaesthetist and a consultant
intensivist for consideration of transfer of the mother to the critical care
unit. Evidence in this area will develop rapidly. At present it is likely that
mothers may only benefit from critical care treatment if their oxygen
requirement is at or greater than 50%, possibly with a high respiratory
rate approaching 40 breaths min-1.

It is important to assess oxygenation carefully. Take care when mothers
have darker skin tones and make sure that saturation monitoring is used
to evaluate possible hypoxia.

Mothers with COVID-19 should be fully treated as for non-pregnant
women where indicated including with dexamethasone, tocilizumab and
other specific treatments that may be developed.

Venous thromboembolism

Even in the absence of pre-existing risk factors, women who are pregnant
or immediately postpartum who have a diagnosis of COVID-19 will have
three different factors associated with venous thromboembolism – the
hypercoagulable state of pregnancy and the puerperium, the hyper-
coagulable state associated with COVID-19, and potentially reduced
mobility due to self-isolation. Make sure that appropriate thrombo-
prophylaxis has been considered and prescribed. The evidence base on
this is likely to develop during 2021.

HPA axis suppression

Prolonged use of glucocorticoids leads to negative feedback on the HPA
(hypothalamic pituitary-adrenal) axis leading to a reduction in
endogenous production of glucocorticoids. Some mothers at risk of HPA
axis suppression will need steroid replacement during surgery – those
who have adrenal insufficiency or who are taking long-term oral steroids,

506 Obstetric Anaesthetists Handbook OAH14-2021

Medical conditions

equivalent to 5 mg or more prednisolone daily for more than 3 weeks
[421]. This should also be considered for those mothers who have
received multiple short-course treatments in the last year, or who have
received a single short course against a background of long-term use
within the last year, or has regular need for repeated courses [422]. High
dose inhaled, topical or nasal steroids may also cause HPA suppression.

These recommendations are not affected by maternal steroids given for
fetal lung maturation. Do not offer supplemental hydrocortisone in the
intrapartum period to mothers taking only inhaled or topical steroids at
normal doses – check whether they have been warned about high doses
and seek advice if concerned.

Look for the steroid plan in the mother’s medical notes.

Mothers 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.

Mothers having planned or emergency caesarean birth

Continue their regular oral steroids and give intravenous hydrocortisone
when starting anaesthesia; the dose will depend on whether the mother
has received hydrocortisone in labour, e.g.:

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

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

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

UK national anaesthesia guidelines recommend the same doses in
pregnancy as for other adults, resulting in higher dose recommendations
for delivery and postnatal care of 100 mg IV hydrocortisone on induction,
followed by initiation of an IV infusion of 8.33 mg h-1 (200 mg 24h-1) until
the mother can take her oral steroid dose. This infusion is then continued
at the double rate for 48 hours before reinstating normal dosing [423].

OAH14-2021 Obstetric Anaesthetists Handbook 507

Medical conditions

Discuss all steroid-dependent mothers with the obstetricians, and if
necessary, an obstetric physician, and form an agreed plan.

Peripartum hyponatraemia

There is increasing awareness of hyponatraemia as a clinical problem on
labour wards. A clinical guideline is awaiting post-QIPS review; check this
for further details.

The normal serum sodium level in pregnancy is 130-140 mmol L-1, lower
than in non-pregnant women. Sometimes it can fall much lower,
particularly in labour. The diagnosis of peripartum hyponatraemia is
made on an acute finding of less than 130 mmol L-1 during labour or the
48 hours after delivery; excessive water intake and oxytocin use is
prevalent at these times, adding to the lower serum sodium that occurs
naturally. It can cause serious neurological sequelae in the mother and
the neonate.

This guideline is based on existing guidelines from the Guidelines and
Audit Implementation Network (GAIN) from Northern Ireland [424].

Signs and symptoms of acute hyponatraemia

Symptoms correlate with the severity of hyponatraemia and the speed of
change in sodium concentration, although it is possible to have a low
plasma sodium without symptoms (especially if chronic).

Early symptoms are non-specific and may be attributed to pregnancy,
labour, and common conditions such as pre-eclampsia but may also be
early signs of cerebral oedema. These include anorexia, nausea, lethargy,
apathy, and headache.

Severe signs and symptoms include disorientation, agitation, seizures,
depressed reflexes, focal neurological deficits, Cheyne-Stokes respiration,
and coma.

508 Obstetric Anaesthetists Handbook OAH14-2021

Medical conditions

Peripartum sodium monitoring pathway

When to monitor sodium levels:
• Signs of acute severe hyponatraemia: vomiting, seizures, confusion,

reduced level of consciousness/coma, cardiorespiratory arrest.
• Fluid balance greater than 1500 mL positive from start of labour.
• Noted to have a sodium less than 130 mmol L-1 for any reason.
• On an antenatal oxytocin infusion.
• Requiring intravenous insulin while in labour.
Patients requiring repeated samples will benefit from an arterial line and
ABG sodium analysis.

Intrapartum serum sodium when monitoring indicated

³130 mmol L-1 125-129 mmol L-1 and asymptomatic

Monitor Na+ 6-hourly or Repeat Na+ 4-hourly; inform obstetric,
sooner if there is an indication anaesthetic and neonatal teams;
monitor in EMC; consider fluid
to repeat e.g., positive fluid restriction to 80 mL h-1.
balance 1500 mL.

£124 mmol L-1 or symptomatic
Repeat Na+ 2-hourly; review need for oxytocin; inform obstetric, anaesthetic &
neonatal teams; discuss physicians & critical care; monitor in EMC (or critical

care if symptomatic); check plasma and urine osmolality; fluid restriction to
30 mL h-1; if severe symptoms, consider treatment with hypertonic saline 2.7%.

OAH14-2021 Obstetric Anaesthetists Handbook 509

Medical conditions

Postpartum serum sodium – most recent result

³130 mmol L-1 125-129 mmol L-1 and asymptomatic

No further testing required Repeat Na+ 4-hourly; inform obstetric
unless clinically indicated; and anaesthetic teams; monitor in EMC;
transfer to postnatal ward.
consider fluid restriction to 80 mL h-1.

£124 mmol L-1 or symptomatic
Repeat Na+ 2-hourly; review ongoing need for oxytocin; inform obstetric &
anaesthetic teams; discuss physicians & critical care; monitor in EMC (or critical
care if symptomatic); check plasma and urine osmolality; fluid restriction to
30 mL h-1; if severe symptoms, consider treatment with hypertonic saline 2.7%.

Hypertonic saline 2.7% is given in 2 mL kg-1 aliquots to raise the sodium
level in the first hour by 5 mmol L-1 from the nadir. This will reduce the
immediate danger from cerebral oedema while minimising the risk of
overly rapid correction and osmotic demyelination. Hypertonic saline can
be commenced while awaiting transfer to critical care. Sodium levels at
or below 120 mmol L-1 will need this urgent treatment to avoid seizures,
and it may be necessary in the range 121-124 mmol L-1.

Blood osmolality goes in a yellow topped blood tube and is sent to
biochemistry. Urine sodium and osmolality go in a universal urinary
container, sent to biochemistry for analysis. This should be taken at the
same time as blood osmolality.

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.

510 Obstetric Anaesthetists Handbook OAH14-2021

Medical conditions

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 mothers. Check the
most recent coagulation screen before undertaking the epidural – it
should have been done in the last week [425].

Ehlers-Danlos syndrome

This diagnosis is not uncommon in young women. It is a form of inherited
connective tissue disease and is often classified into four types, though
diagnoses may be qualified as showing features of different types. Types
1-3 are generally not associated with increased obstetric anaesthesia risk
in themselves. Check the mother’s medical records and after assessing
for necessary individual adjustments for joint hypermobility, skin
hyperelasticity and bruising tendency, pneumothorax etc, proceed as
necessary.

Type 4 Ehlers-Danlos syndrome is associated with collagen abnormalities
with the possibility of bowel, uterine or vascular rupture, including aortic
dissection. Check the physician’s plans, and beware atypical or sudden
onset of pain in mothers with type 4 EDS.

Local anaesthetic resistance

Some women with EDS will relate that they have local anaesthetic
resistance, and that local anaesthesia does not work in them, often but
not exclusively in relation to dental treatment. This remains an area of
controversy with some reports of successful local anaesthesia in such
patients [426], but some women bring letters from doctors or dentists
stating they have LA resistance. Several such mothers have had successful
CNBs for caesarean birth in Coventry. Other things permitting, it is best to
proceed as one would normally, undertaking CNB with consent as
appropriate in the assumption that it will work, and being careful to

OAH14-2021 Obstetric Anaesthetists Handbook 511

Medical conditions

undertake a full block check with good records before commencing
surgery.

415. RCOG/RCM. Coronavirus (COVID-19) infection and pregnancy. Version 13:
updated 19 February 2021. Guidance for healthcare professionals on
coronavirus (COVID-19) infection in pregnancy, published by the RCOG, Royal
College of Midwives, Royal College of Paediatrics and Child Health, Public
Health England and Public Health Scotland. This version and updates are
available at https://www.rcog.org.uk/en/guidelines-research-
services/guidelines/coronavirus-pregnancy/

416. MBRRACE-UK. Saving Lives, Improving Mothers’ Care. Rapid report 2021:
Learning from SARS-CoV-2-related and associated maternal deaths in the UK,
June 2020-March 2021. Oxford: MBRRACE, July 2021.

417. Knight M, Bunch K, Vousden N, et al. Characteristics and outcomes of
pregnant women admitted to hospital with confirmed SARS-CoV-2 infection
in UK: national population based cohort study. BMJ 2020;369:m2107.

418. Wong DJN, El-Boghdadly K, Owen R, et al. Emergency Airway Management in
Patients with COVID-19: A Prospective International Multicenter Cohort
Study. Anesthesiology 2021(August); 135:292-303.

419. Servante J, Swallow G, Thornton JG, et al. Haemostatic and thrombo-embolic
complications in pregnant women with COVID-19: a systematic review and
critical analysis. BMC Pregnancy Childbirth 2021; 21:108.

420. Vouga M, Favre G, Martinez-Perez O, et al. Maternal outcomes and risk
factors for COVID-19 severity among pregnant women. Nature Scientific
Reports 2021; 11:13898.

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

422. Erskine D, Simpson H. Exogenous steroids treatment in adults. Adrenal
insufficiency and adrenal crisis-who is at risk and how should they be
managed safely. NHS Specialist Pharmacy Service,

512 Obstetric Anaesthetists Handbook OAH14-2021

Medical conditions

https://www.sps.nhs.uk/articles/advice-on-issuing-the-steroid-emergency-
card-update-23rd-december-2020/ accessed 24 May 2021.

423. Woodcock T, Barker P, Daniel S, Fletcher S, Wass JAH, Tomlinson JW, Misra U,
Dattani M, Arlt W, Vercueil A. (2020), Guidelines for the management of
glucocorticoids during the peri-operative period for patients with adrenal
insufficiency. Anaesthesia 2020; 75:654-63.

424. Guidelines and Audit Implementation Network. Guideline for the Prevention,
Diagnosis and Management of Hyponatraemia in Labour and the Immediate
Postpartum Period. Belfast: Regulatory and Quality Improvement Authority,
March 2017.

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

426. Brighouse D. Guard B. Anaesthesia for caesarean section in a patient with
Ehlers-Danlos syndrome type IV. Br J Anaesth 1992; 69:517-9.

OAH14-2021 Obstetric Anaesthetists Handbook 513

Index

A amniotic fluid embolism
CNB, 200
abruption. See placental emergency, 152
abruption MOH, 123, 124

Accuro USS, 209 anaemia
causing atony, 112
acute fatty liver of pregnancy, maternal adaptation, 285
446
anaesthesia emergency, 24
adrenaline
epidural extension, 357 anaesthetic agents
use in pregnancy, 403
advance statement, 188
analgesia
airway in recovery, 386
assessment, 81
front of neck, 86 antibiotics
maternal adaptation, 284 endocarditis, 489
sepsis, 461
alarm system, 24 sepsis and regional block,
463
alfentanil surgical prophylaxis, 294
cardiac dose, 480
intraoperative pain, 377 anticoagulation
morphine allergy, 249 CNB, 201
pre-eclampsia, 449
antiembolism stockings, 308,
ambulance transfers, 421 310

amiodarone antiemetic
local anaesthetic toxicity, general anaesthesia, 383
144
antithrombotics

514 Obstetric Anaesthetists Handbook OAH14-2021

CNB, 196 Index

aortic dissection B
cause of pain, 475
hypertension, 433 balloon occlusion, femoral
catheter, 128
aortocaval compression, 4, 145
avoidance, 258, 295 base deficit
haemorrhage, 114
arterial line
care, 412 Belmont rapid infuser, 135
MOH, 106, 114 IO access, 138
obesity, 469
pre-eclampsia, 433 birth plan, 188
sepsis, 461
bleeding disorders
aspirin in CNB, 197 CNB, 201

assistance for anaesthetists, 14 bleep
1465 ODP, 14
asthma 1684 critical care, 418
carboprost, 116 2119 cardiology, 470
critical care, 419 2169 blood bank, 118
labetalol, 434 2178 junior, 14, 18, 20
NSAIDs, 303 2813 senior, 14, 26
2909 critical care outreach,
atrial fibrillation 461
cardioversion, 407 5054 consultant, 14, 25
causes, 472
blood patch. See epidural
atropine blood patch
preparation, 77
total spinal, 360 blood transfusion
uterine inversion, 149 checks, 118
electronic issue, 119
audible two-practitioner check, operative, 300
30, 69, 261, 347
blood transfusion pathway
audit form, 43
outcome, 46 cell salvage, 328
projects, 49
breakthrough pain
awareness, 383 operative, 374

azidothymidine, 500 breastfeeding

OAH14-2021 Obstetric Anaesthetists Handbook 515

Index

analgesia, 304 magnesium toxicity, 443
codeine contraindicated,
cannula care pathway, 43
304
in theatre, 292 carboprost
cardiac disease, 488
breech presentation, 281 uterine atony, 116

Bromage scores cardiac axis, 474
recording, 359
use, 230 cardiac decompensation
red flags, 471
bupivacaine
dose in spinal anaesthesia, cardiac murmurs, 484
346
dose limit, 266, 268 cardiology bleep, 470
ED95 intrathecal, 346
repeating, 376 cardiopulmonary arrest, 145
shortage, 72
troubleshooting inadequate cardiotoxicity of LA, 141
block, 268
cardiovascular physiology
C maternal adaptation, 285

CADD-Solis pump, 265 cardiovascular risk classes, 481

caesarean birth cardioversion, 407
assessment for elective, 175
category, 367 cefuroxime
clinic, 176 prophylactic, 294
cord gases, 68
diabetes, 491 cell salvage, 112
required block, 344 HIV, 500
time standards, 366 intrauterine sepsis, 464
with epidural extension, 356 Jehovah’s Witness, 330
obstetric haemorrhage, 119
calcium chloride sepsis, 325
MOH, 107 sickle cell disease, 324
transfusion, 127 sickle cell trait, 324
systemic sepsis, 464
calcium gluconate
cervical cerclage, 337, 343

chlorhexidine, 208, 345
2% sticks only available, 71

chlorphenamine
postoperative, 307

516 Obstetric Anaesthetists Handbook OAH14-2021

Index

pruritus in recovery, 219 in MOH, 109, 398
method, 377
cholestasis, 510
convulsions
clindamycin AFE, 152
prophylactic, 294 eclampsia, 439
hypoglycaemia, 439
clinic LA toxicity, 141
caesarean, 176 persistent, 442
complex, 156 PRES, 427
haematology, 158 prevention, 438
obstetric cardiology, 158
cord prolapse, 151
clinical autonomy, 37
COVID-19
clonidine aspirin, 504
postoperative pain, 387 coagulation screen, 505
critical care, 506
coagulopathy fibrinogen level, 505
CNB, 200 GA, 503
COVID-19, 503 guidance, 502
in HELLP syndrome, 445 platelet count, 199, 504, 505
PPE, 36
co-amoxiclav thrombocytopenia, 495
cervical cerclage, 337
cricoid pressure, 86, 194
codeine
contraindicated, 304 cricothyroidotomy, 87

colloid osmotic pressure, 436 critical care
cardiac disease, 478
combined spinal/epidural criteria, 416
anaesthesia, 341 eclampsia, 450
analgesia, 255 general indications for, 415
MOH, 128
complex referral clinic, 156 PPH, 103
pre-eclampsia, 431
consent, 185 referral, 417
caesarean birth, 189 sepsis, 461, 462
epidural blood patch, 189, transfers, 419
228
for epidural, 189
general, 185

conversion to GA
after failed neuraxial, 366

OAH14-2021 Obstetric Anaesthetists Handbook 517

Index epidural anaesthesia, 359,
365
crossmatch
antibodies, 182 general anaesthesia, 366,
placenta accreta, 396 381
placenta praevia, 395
intramuscular, 248
cryoprecipitate morphine allergy, 249
AFE, 124 perineal repair, 335
APH, 101 caesarean birth, 334
Belmont, 137 pruritus, 219, 337
DCR, 107 shortage, 69, 70
fibrinogen, 124 spinal anaesthesia, 365

CTPA, 476 DIC
CVP abruption, 101
tranexamic acid caution, 127
critical care, 411
placenta praevia, 398 diclofenac
pre-eclampsia, 437 dose reduction, 301
CXR haemorrhage, 303
cardiac disease, 473, 478 in pre-eclampsia, 303, 451
Cyklokapron, 124 suppository in theatre, 302

D difficult intubation, 80
anticipated, 380
damage control resuscitation
actions, 106 dihydrocodeine
principles, 104 in pre-eclampsia, 451
instead of diclofenac, 303
dantrolene TTO, 318
location, 8
disposal of drugs etc, 34
delayed cord clamping, 295
diabetes mellitus, 491 drug charts
diamorphine postoperative, 301

CNB, 302 drugs in pregnancy for non-
dose in spinal anaesthesia, obstetric surgery, 287

346 dural tap, 271

duties of the obstetric
anaesthetist, 18

518 Obstetric Anaesthetists Handbook OAH14-2021

dysrhythmia, 472 Index

E enoxaparin
antenatal, 198
ECG before regional block, 198
cardiac disease, 473 postnatal, 308

echocardiography indication, Entonox
484 intraoperative pain, 377

eclampsia ephedrine
anaesthetic technique, 448 epidural hypotension, 275
anticonvulsant treatment, for epidural, 261
439 in non-obstetric surgery, 406
emergency measures, 439 in pre-eclampsia, 447, 449
postoperative care, 450 preparation, 77
postpartum, 450 spinal hypotension, 352

Ehlers-Danlos syndrome, 511 epidural analgesia and
anaesthesia
electronic issue of blood, 119 bleeding disorders, 201
bloody tap, 264
EMCERT, 416 caesarean birth, use for, 356
consent, 189
emergency help contraindications, 257
anaesthesia emergency, 24 drug administration, 36
obstetric emergency, 24 dural tap, 271
effect on labour, 259
endotracheal tube efficacy, 190
MBRRACE, 63 extension, 355, 356
recommended size, 81, 382 fetal effects, 190
use from 18-20 weeks, 405 for operative surgery, 333
hyperthermia with epidural,
enhanced maternal care, 409 260
admissions, 414 in pre-eclampsia, 446
handover, 20 inadequate pain relief, 267
severe pre-eclampsia, 430, indications, 256
450 infusion, postnatal, 451
intrathecal placement, 212
enhanced maternal care
discharge, 415

enhanced recovery, 291

OAH14-2021 Obstetric Anaesthetists Handbook 519

Index extubation
haemorrhage, 128
intravascular placement,
212 F

lipid rescue, 143 facemask ventilation, 86
long needles, 264
missed segment, 269 factor VIIa, 127
nursing position, 258
perineal pain, 270 failed intubation, 80
postoperative, 266 algorithms, 89
records, 40
response time, 256 fasting
technique, 261 caesarean, 172
ultrasound, 468 elective caesarean, 173
vertebral canal haematoma, in labour, 171
postpartum, 174
196
fentanyl
epidural blood patch, 227 dose limit, 268
epidural anaesthesia, 365
epidural bradycardia, 263 epidural extension, 357
intraoperative pain, 377
epidural hyperthermia, 260 intrathecal, 71, 273
PCA, 249
epidural trolley locks, 34 PCEA, 265
pruritus, 219
epidural volume extension, troubleshooting inadequate
376 block, 268

epilepsy fetal scalp
labour pain relief, 249 blood gases, 68

eptacog-alpha, 127 FFP
APH, 101
ERAS, 291, 300 cell salvage, 323
DCR, 107
ergometrine transfusion, 122
cardiac disease, 488
in pre-eclampsia, 116, 449 fibrinogen
MOH, 116

examination under
anaesthesia, 335

external cardiac compression,
145

external cephalic version, 281

520 Obstetric Anaesthetists Handbook OAH14-2021

mode of action, 123 Index
treatment aim, 101, 123
fibroid uterus, 290 H
fixation error, 84
fluid therapy H2-receptor antagonists. See
pre-eclampsia, 435 omeprazole
forceps
analgesia, 333 haematological disorder
FRC, 284 central neuraxial blocks, 158
front-of-neck procedure, 86 CNB, 197
furosemide, 438
haemorrhage
G antepartum, 101
crossmatch, 180
gallipots, 207 CNB, 200
gastric emptying time consultant attendance, 98
DCR, 104
postpartum, 174 emergency action, 97
general anaesthesia hysterectomy, 114
intraoperative, 398
conversion, 377 major, 299
method, 380 massive, 97
gentamicin MOH call, 98
prophylactic, 294 postpartum, 102
glycopyrronium bromide prevention of, 298
bradycardia, 354
in pregnancy, 404 handover
total spinal, 360 between anaesthetists, 20,
GTN 293
pulmonary oedema, 478 location, 21
tocolysis, 296 to recovery, 313
uterine inversion, 149
Gutsche’s test, 223 headache, 222, 227
risk in epidural anaesthesia,
190
risk in spinal anaesthesia,
344
severe, 427

HELLP syndrome. See pre-
eclampsia, severe

OAH14-2021 Obstetric Anaesthetists Handbook 521

Index anaesthesia for emergency,
109
Hemabate
uterine atony, 116 placenta praevia, 399
planned during caesarean,
heparin
CNB, 198 341
thromboprophylaxis, 308 PPH postoperative care, 103

high block, 359 I

high dependency care, 409 ibuprofen
contraindicated, 304
HIV, 499 dose reduction, 301
postoperative, 303
hydralazine, 434 standard dose, 306

hyperkalaemia ICD, 488
emergency treatment, 110 iliac artery catheters, 128
induction, inhalational, 194
hyperthermia infection in CNB, 200
epidural, 260 insulin infusion
malignant, 384
at delivery, 492
hypoglycaemia, 492 delayed operation, 493
diabetes, 491 interpreter, 187
HELLP syndrome, 446 interventional radiology, 128
intervertebral disc
hyponatraemia epidural analgesia, 257
investigations, 510 prolapse, 232, 240
peripartum, 508 intraosseous access, 138
treatment, 509 driver, 145
intrathecal catheter, 271, 272
hypotension intrauterine death
and CNB, 274 analgesia, 249
pre-eclampsia, 448 coagulation screen, 200
sepsis, 456
spinal, prevention, 352
total spinal, 360

hypoxia
fetal, 367
postoperative red flag, 313,
386, 472

hysterectomy, 114, 128

522 Obstetric Anaesthetists Handbook OAH14-2021

intubation, failed, 80 Index
isoflurane
lactate
preventing awareness, 388 haemorrhage, 114, 128
required concentration, 382 sepsis, 459, 461, 462

J lead clinician, 17

Jehovah’s Witness, 127 left lateral position for epidural
bolus, 270, 274, 281, 357
K
left lateral position for
K2 Athena, 40 subarachnoid block, 273
postnatal review, 47
lethal triad, 100
K2 Guardian, 40
cannula care, 33, 43 levobupivacaine
epidurals, 267, 271 dose limit, 266, 268
general anaesthesia, 305,
ketamine 366, 383
haemorrhage, 106, 382 intrathecal, 271, 273
in non-obstetric surgery, 406 PCEA, 265
increasing uterine tone, 403 rescue doses, 268
massive haemorrhage, 110 spinal for caesarean, 72
placenta praevia, 398 troubleshooting inadequate
postoperative pain, 387 block, 268
sepsis, 464
uterine inversion, 149 lidocaine
uterine rupture, 150 dose limit, 268
epidural extension, 357
ketosis, maternal, 261 epidural test dose, 264
rescue doses, 268
L troubleshooting inadequate
block, 268
labetalol
contraindications, 434 lipid rescue
pre-eclampsia, 434 location, 8

liver disorders, 444

local anaesthetic resistance,
511

local anaesthetic toxicity, 141

Lucina, 12

OAH14-2021 Obstetric Anaesthetists Handbook 523

Index

M infusions on labour ward,
275, 410
magnesium sulfate
eclampsia, 439 pre-eclampsia, 353
emergency, 440 preparation, 77
fetal protection, 440 spinal anaesthesia, 345
indications in severe pre- spinal hypotension, 352
eclampsia, 439
postoperative pain, 387 methyldopa
renal impairment, 442 pre-eclampsia, 432
severe pre-eclampsia, 438
shivering, 317 metoclopramide
toxicity, 443 epidural extension, 357
use in pregnancy, 403 general anaesthesia, 381
spinal anaesthesia, 344
major haemorrhage (not
massive) metronidazole
treatment, 299 manual removal of placenta,
333
malignant hyperthermia, 384 prophylactic, 294

Mallampati score, 82 midazolam
intraoperative pain, 377
manual removal of placenta postoperative pain, 387
required block, 333, 344
misoprostol
massive haemorrhage cardiac disease, 488
balloon catheters, 129 uterine atony, 114, 118
definition, 97
effects, 113 Modified Obstetric Early
surgical management, 114 Warning Scores, 413

meningitis MOEWS charts, 413
CNB sepsis, 463
monitoring during anaesthesia,
metaraminol 341
bradycardia, 213, 354
epidural extension, 357 morphine
in cardiac disease, 476 after failed CNB, 378
in pre-eclampsia, 447, 449 allergy, 249
in recovery, 316
infusion, 451
intraoperative, 383
intrathecal, 70

524 Obstetric Anaesthetists Handbook OAH14-2021

Index

PCA, 304 contraindicated in
postoperative, 386 pregnancy, 403
pulmonary oedema, 478
multiple pregnancy, 282 O
murmurs, 484
mWHO risk classes, 481 obesity, 467
blood loss, 113
N
OBS Cymru, 121
naloxone
PCEA, 266 obstetric cholestasis, 510
pruritus in recovery, 219
obstetric emergency, 24
NAP4 airway, 83
NAP5 awareness, 387 obstetric wedge, 258
needle phobia, 193
neostigmine Obstetrics Perioperative
Pathway, 41
dose, 382
nerve stimulator, 382 obstructive valve lesions, 481
nifedipine
occipito-posterior malposition,
pre-eclampsia, 435 239, 270, 280
nitrous oxide
oliguria
contraindicated in first criteria, 436
trimester, 403 pre-eclampsia, 437

GA cases, 382, 388 omeprazole
noradrenaline enhanced maternal care,
415
sepsis, 462 in labour, 171
NovoSeven, 127 planned surgery, 171, 175
NRFit pre-eclampsia, 430
pre-med pack, 177
epidural blood patch, 229
NSAIDs ondansetron, 301
use in pregnancy, 404
asthma, 303
CNB, 197 open systems, 207

Operating Department
Practitioners, 14

opioids

OAH14-2021 Obstetric Anaesthetists Handbook 525

Index PCEA, 265

intramuscular, 248 PCIA
use in pregnancy, 403 remifentanil, 497
Optiflow HFNOT, 85, 381
oxygen PCR, 428
cardiac decompensation,
penicillin allergy, 294
472
conscious mothers, 342 perineal repair, 335
postoperative, 386
sepsis, 461 peripartum cardiomyopathy,
oxytocic drugs, 115 478

oxytocin peripartum hyponatraemia,
bolus for operative delivery, 508
298, 383
cardiac disease, 487 pethidine
discussion, 297 intramuscular, 248
in pre-eclampsia, 449 morphine allergy, 249
in shock, 115 shivering, 316
postoperative infusion, 298
prophylaxis, 115 phenotype, 182
uterine atony, 115
phenylephrine
P spinal hypotension, 353

pacemaker, 488 physiological changes in
paracetamol pregnancy, 284

dose reduction, 301 placenta accreta, 333, 391
general anaesthesia, 383 balloon catheters, 129
partner in theatre, 293
patient information leaflets, placenta accreta spectrum
191 blood reservation, 181
PCA
needle phobia, 193 placenta praevia
opioids, 249 anaesthetic management,
396
blood reservation, 181
contraindicated technique,
343

placental abruption, 101
CNB, 200
in HELLP syndrome, 445

526 Obstetric Anaesthetists Handbook OAH14-2021

platelet count in CNB Index
COVID-19, 199
indications for, 199 enhanced maternal care,
pre-eclampsia, 199, 447 430, 450

platelet transfusion, 123, 202, HELLP syndrome, 444
445 magnesium sulfate, 439,

platelets 440
DCR, 107 monitoring, 430
vertebral canal haematoma,
polio blade laryngoscope, 83 447

PONV prophylaxis, 301 pre-eclamptic toxaemia. See
pre-eclampsia
postoperative recovery, 313
pre-filled syringes
postpartum evacuation diamorphine, 347
required block, 344
premedication, 175
PPE, 36
preoxygenation
pre-eclampsia DAS recommendations, 85
anaesthetic technique, 448 RSI, 381
CNB, 199, 200
diagnosis, 424 PRES, 427
diclofenac, 303
epidural analgesia, 433, 446 prilocaine
fluid therapy, 435 spinal for caesarean, 72
fluids spinal for cerclage, 337
fluid balance, 436 spinal for T8 block, 346
general anaesthesia in, 449
management aims, 428 prochlorperazine
oliguria, 436 use in pregnancy, 404
postnatal period, 450
severe prolapsed umbilical cord. See
anticonvulsant treatment, cord prolapse
438
antihypertensive propofol
treatment, 432 avoiding AAGA, 388
arterial line, 433 dose, 381
preparation, 77
TIVA, 384

pruritus, 219

pulmonary embolism, 475

pulmonary oedema, 476

OAH14-2021 Obstetric Anaesthetists Handbook 527

Index

fluid overload in pre- immediate caesarean birth,
eclampsia, 436, 437, 447 343

in HELLP syndrome, 445 retained placenta, 332
oxytocin, 115 retained placenta, 333
postpartum, 450 rocuronium
pre-eclampsia, 436
in MH, 385
Q preparation, 77

Quickmix S
preparation, 77
use, 356 SAFER handover, 20
salbutamol
R
hyperkalaemia, 110
ramped position, 82 tocolysis, 296
rapid sequence induction, 194, scalpel cricothyroidotomy, 87
scar dehiscence, 343
381 scoline apnoea, 157
records second stage of labour, 259
sepsis, 455
failed intubation, 95 cell salvage, 464
recovery, 313 CNB, 463
red triangle alarm, 24 Shirodkar suture. See cervical
regional anaesthesia cerclage
shivering, 316
in emergency, 369 sickle cell disease
thromboprophylaxis, 196, cell salvage, 324
sodium bicarbonate
309 Quickmix preparation, 77
remifentanil, 497 sodium citrate
administration, 172
COVID-19, 251, 503 spinal anaesthesia
PCIA, 250 cervical cerclage, 337
TIVA, 384
renal failure
transient oliguria, 436
response times

528 Obstetric Anaesthetists Handbook OAH14-2021

contraindications, 343 Index
in labour, 255
indications, 343 Syntocinon. See oxytocin
pre-eclampsia, use in, 448 Syntometrine, 115
repeating, 376
replacing epidural, 375 cardiac disease, 485
vertebral canal haematoma, prophylaxis, 298

196 T

spinal analgesia, 255 team brief, 29, 368
teicoplanin
spinal catheter, 271, 272
prophylactic, 294
steroid replacement, 506 terbutaline

stockings, antiembolism, 308, cord prolapse, 151
310 fetal resuscitation, 370
prevention of premature
stop before you block, 30
epidural top-up, 356 labour, 406
tocolysis, 296
subarachnoid catheter, 271, uterine hyperstimulation,
272
152
subdural block, 275 uterine inversion, 149
theatres, operating, 76
sugammadex thiopental
escape dose, 382 seizure control, 142
in MH, 385 thrombocytopenia, 200
location, 8 COVID-19, 503
standard dose, 382 thromboprophylaxis, 308
and CNB, 197
supervision postnatal in pre-eclampsia,
consultant name on board,
19 451
responsible consultant, 25 postoperative duration, 310
thrombocytopenia, 497
supraventricular tachycardia TIVA, 384
cardioversion, 407 tocolysis, 296
torsade de pointes, 143
surgical safety checklist, 28,
370

suxamethonium
scoline apnoea, 157

OAH14-2021 Obstetric Anaesthetists Handbook 529

Index in caesarean birth, 295
uterine inversion, 149
total spinal block, 359 uterine relaxation, 295, 333,
tranexamic acid
383
cautions, 126 uterine rupture, 150
coagulation disorders, 197
DIC, 127 crossmatch, 180
doses, 126
general anaesthesia, 383 V
haematological plan, 158
haemorrhage, 124 vaginal breech delivery, 281
major haemorrhage, 299 vasopressors
perineal repair, 335
PPH prevention, 299 in pre-eclampsia, 447, 449
WOMAN trial, 125 in spinal anaesthesia, 345,
transfer
leaving labour ward, 19 352
transfusion ratio, 107 ventouse
trial of assisted delivery
required block, 344 analgesia, 333
ventricular fibrillation, 144
U vertebral canal haematoma,

umbilical cord prolapse. See 196
cord prolapse diagnosis, 232
in pre-eclampsia, 447
urate levels, 428 treatment, 235
urinary catheter vertebral canal infection
diagnosis, 233
diamorphine, 317 prevention, 207
urine output videolaryngoscope, 468
as standard, 83
pre-eclampsia, 437 VTE status. See
uterine atony thromboprophylaxis

causes, 102
sepsis, 457, 464
treatment, 115
uterine displacement, 4

530 Obstetric Anaesthetists Handbook OAH14-2021

Index

W white cell count, 459
WHO checklist, 28
water
in pre-eclampsia, 430 Z
oral, 172, 173, 175, 292
zidovudine, 500
wedge, 258
weekend consultant sessions,

25

OAH14-2021 Obstetric Anaesthetists Handbook 531

Please feed suggestions or corrections back to the author
Obstetric Anaesthetists Handbook