OAH14-2021

Information recording

Cannula care pathway

All vascular lines must be monitored regularly. This is done using cannula
care pathways, recorded in K2 Guardian. The K2 system is often in use by
midwives when you attend a mother in her labour room or theatre, so
ask the midwife to enter the cannula care details in K2 Guardian. If this is
not done, then you must enter it yourself on K2.

Blood transfusion forms

You should complete the standard hospital blue blood transfusion
pathway form where allogeneic blood is to be used. It is not to be used
for reinfusion of salvaged red cells.

Clinical Adverse Events

There is a Trust procedure in operation for clinical adverse events. The
obstetric CAE safety huddle takes place every week and aims to capture
and learn from all adverse events.
The following clinical and non-clinical events (that may or may not have
led to actual harm) should be reported through the Datix system.

Maternal incident

• Blood loss > 1500 mL – massive obstetric haemorrhage.
• Blood loss > 1000 mL and no salvaged red cells returned to mother.
• Damage to visceral/vascular structure.
• Eclampsia.
• Failed or double instrumental delivery.
• Hysterectomy or laparotomy.
• Critical care admission.
• Maternal death.
• Obstetric emergencies.
• Pulmonary embolism.

OAH14-2021 Obstetric Anaesthetists Handbook 43

Information recording

• Readmission of the mother.
• Screening incidents.
• Sepsis.
• Third- and fourth-degree tears.
• Undiagnosed breech in labour.
• Uterine rupture.
• Venous thromboembolism.

Organisational incidents

• Unavailability of health records.
• Delay in responding to call for assistance.
• Unplanned home birth.
• Faulty equipment.
• Conflict over case management.
• Potential service user complaint.
• Medication error.
• Retained swab or incident.
• Hospital-acquired infection.
• Violation of local protocol.
• Security / verbal abuse / violence / accidents.

Fetal or neonatal incidents

• Apgar score < 7 at five minutes.
• Birth trauma.
• Cord pH < 7.05 arterial or < 7.1 venous.
• Fetal laceration during any operative procedure.
• Neonatal death.

44 Obstetric Anaesthetists Handbook OAH14-2021

Information recording

• Neonatal seizures.
• Stillbirth > 500 g.
• Unexpected admissions to neonatal intensive care: where Apgar

scores remain < 4 at ten minutes or the baby has already required
intubation.
• Undiagnosed fetal anomaly.
• Unidentified IUGR.
• New patient registration errors.

Anaesthetic incidents

• Dural tap.
• Failed intubation.
• High blocks (epidural and spinal).
• Accidental intravenous injection of local anaesthetic.
• Anaphylaxis.
• Hypoxia (SpO2 < 90%), any cause.
• Pulmonary oedema.

Other reportable incidents

• Aspiration of gastric contents.
• Conversion from regional to general anaesthesia during caesarean

birth.
• Persistent neurological deficit.
• Vertebral canal haematoma.
• Other events you consider reportable.
Comprehensive records must be made in the medical notes if
appropriate. You should report the incident to the daytime consultant
anaesthetist as well as, if the incident is sufficiently urgent, report to the
consultant anaesthetist on call.

OAH14-2021 Obstetric Anaesthetists Handbook 45

Postnatal review

Postnatal review

The department undertakes continuous outcome audit of the provision
of obstetric anaesthesia. All anaesthetists conducting cases must refer
the mother for follow-up as below.

Our standard is to review all mothers at least once before discharge, on
the first day after the block or anaesthetic. Mothers who have had
epidurals for labour pain relief, or spinals for manual removal or perineal
tear repair, may have left hospital before the daily review.

As the duty obstetric anaesthetist, it is your duty to complete the follow-
up components of this audit. This is best done in the morning because
discharges tend to occur in the early afternoon (mothers who have had
elective caesarean birth are routinely discharged home on the afternoon
following their caesarean birth), and in any case you should finish the
follow-ups before 15:00 so that any diagnosed complications may be
treated during normal hours.

If a woman has no ongoing anaesthesia-related problems on the first day,
discharge her from follow-up. She does not need to stay on the follow-up
list simply owing to a urinary catheter that has not yet been removed.
This is a common postnatal occurrence and in the absence of other
neurological signs or symptoms, does not need follow-up by an
anaesthetist.

CRRS follow-up system

This is where we record follow-up of mothers who have received
anaesthesia care procedures. You may need to make additional entries in
the clinical notes, K2 or CRRS, where significant complications are found,
or treatment needed.

Preparations

1. You will need CRRS access as part of the job, and as part of
employment induction you will also be granted access to the

46 Obstetric Anaesthetists Handbook OAH14-2021

Postnatal review

Obstetric Anaesthesia Open Referrals List. If this has not happened
contact the consultant clinical specialty lead.

2. With basic CRRS access you can make maternal referrals to the
obstetric anaesthesia follow-up service.

3. You also deliver the obstetric anaesthesia follow-up service when
working on labour ward. Add the open list of referrals to your CRRS
summary lists.

Making a referral

Open the mother’s CRRS page and select “referrals and requests”. Make
a referral to the ‘Obstetric anaesthesia’ service as an inpatient and a
template form will open.
To facilitate follow-up, enter at least the type of anaesthesia procedure,
the time, the obstetric indication and the name of the anaesthetist.
Adapt as appropriate. If there is further information necessary for the
postnatal round, put it below this on the referral form.

Second procedures

When undertaking a second procedure, such as repeat epidural, or spinal
for Cat 2 CS, do not create a new patient referral. Instead open the
previous form and add a second procedure into the text. There will be
more than one procedure on the patient form when you come to do the
follow-up.

Records and information

The entry you make in CRRS forms part of the patient record and is there
for ever. If there is further information necessary, e.g., neuropathy or
other complications on follow-up, write in the mother’s main medical
record on K2 Athena as appropriate, or make a note in CRRS. If you are
considering doing this, it is probably wise to seek the advice of a
consultant. See ‘patient records’ on page 40.

OAH14-2021 Obstetric Anaesthetists Handbook 47

Postnatal review

Double entry

Several mothers have had accidental multiple referrals. You should make
a single referral for each mother, even if she has multiple procedures
recorded.
If you find a double referral, check to make sure that there is no follow-
up information on it, then delete all text from the form and replace with
‘accidental double referral’ or some such, and close the referral.

Printed lists – confidential waste

If you print the summary list, dispose of it in the confidential waste bin,
not in ordinary bins or theatre yellow bags.

While you are on the postnatal ward

Make sure that you check with the midwives on ward 24 whether there
are any mothers needing anaesthesia assessment for category 3
caesarean birth.

48 Obstetric Anaesthetists Handbook OAH14-2021

Clinical audit and quality improvement

Clinical audit and quality improvement

While attached to the labour ward you have an ideal opportunity to carry
out audit projects. You will be working as a member of a small group of
residents and consultants, on a more regular basis than is the case in
much of anaesthesia. There is a systematic program of audit, in which
you may be invited to participate, but the best way of becoming involved
is to originate your own project – and to do so in advance of your
rotation through the labour ward. Planning for a multidisciplinary audit
that runs during your two-month attachment is a reliable path to success.
Make sure that you inform the lead consultants about proposed projects
to avoid duplication.

The Royal College of Anaesthetists has published a recipe book for
carrying out quality improvement projects, which contains detailed
advice for conducting general audits and those specific to obstetric
anaesthesia [13]. The Ockenden Report contained the following
recommendation:

Quality improvement methodology should be used to audit and improve
clinical performance of obstetric anaesthesia services in line with the
recently published RCoA 2020 ‘Guidelines for Provision of Anaesthesia
Services for an obstetric population’. [14]

Obstetric practice is at B7, pages 241-66. We suggest that you should aim
to compete at least one of these projects during any intermediate or
higher attachment in obstetric anaesthesia. Liaise with Dr Nirojan Siva
about this – he is the QI lead consultant.

• Information for mothers about analgesia and anaesthesia during
delivery.

• Anaesthetic care for women who are obese during pregnancy.

• Response times for the provision of intrapartum analgesia and
anaesthesia.

• Regional analgesia during labour.

• Airway and intubation problems during obstetric general
anaesthesia.

OAH14-2021 Obstetric Anaesthetists Handbook 49

Clinical audit and quality improvement

• Caesarean birth anaesthesia: technique and failure rate.
• Pain relief after caesarean birth.
• Monitoring of mothers in recovery and receiving enhanced

maternity care.
• Timely anaesthetic involvement in the care of high-risk and critically

ill women.
• Postnatal obstetric anaesthetic adverse effects and complications.
Audit and quality improvement projects in obstetric anaesthesia are
often presented at both the anaesthesia and the obstetrics QIPS
meetings.

13. Royal College of Anaesthetists. Raising the Standard: RCoA quality
improvement compendium, 4th edition. London: RCoA, September 2020.

14. Independent Maternity Review. Ockenden Report: Emerging Findings and
Recommendations from the Independent Review of Maternity Services at the
Shrewsbury and Telford Hospital NHS Trust. London: HMSO, 10 December
2020.

50 Obstetric Anaesthetists Handbook OAH14-2021

Training and assessment Training and assessment

Chapter contents 51
Training opportunities 52
Workplace training objectives 52
Assessments of progress

Training opportunities

There are at least 24 consultant sessions per week across wards, theatres
and clinics in the maternity service, excepting rare occasions of leave for
which a replacement cannot be found, and you should be able to develop
your skills and knowledge while attached to the labour ward, in addition
to the experience that you will gain. You have a great responsibility in
ensuring that this happens satisfactorily. You should raise any concerns at
an early stage.
The knowledge and skills syllabuses are listed in the assessment
documentation. During quiet times on the labour ward read around the
subject, and request any more senior anaesthetists to teach you about
the subjects listed. Pick a subject and challenge your supervisor.

Clinical audit

Before and during your placement you will be well positioned to carry a
clinical audit project through to completion. See pages 49 and 55.

Guideline review

This handbook contains many clinical guidelines, which should be the
subject of regular review as is the case with other such guidelines within
the Trust. During your block you may be asked to conduct one of these

OAH14-2021 Obstetric Anaesthetists Handbook 51

Training and assessment

reviews or you may identify a guideline that you are interested to review.
Help is always welcome.

Service developments

The service we offer to mothers is comprehensive, satisfactory, and safe.
However, obstetric anaesthetists, registrars, and consultants, aspire to
continuous improvement although change can be difficult to coordinate.
If you have an idea for a service development, you are welcome to
discuss this with any of the consultants. If supported by the group, we
will help you to take it forwards.

Workplace training objectives

Within the obstetric team, the registrar should play a full part;
communicating effectively about anaesthetic and analgesic techniques
used in obstetrics and developing organisational skills. They should
consolidate clinical management of common obstetric practice but
recognise and treat common complications exercising proper judgement
in calling for help.

Assessments of progress

It is your responsibility as a registrar to make sure that your assessments
are completed. To do this, you need to:

• Obtain the documents.

• Have consultants sign for observed procedures.

• Complete the logbook.

• Attend the oral interview (arrange with Dr Amarasekara).
The assessment strategy for the RCoA 2021 anaesthetics curriculum has
been published [15,16] and contains some new provisions alongside the
continuation of much of the old. Workplace assessments can be
formative or summative, and support training at stages 1, 2, and 3. We
can offer appropriate assessments at each of these stages. Evidence from

52 Obstetric Anaesthetists Handbook OAH14-2021

Training and assessment

the assessments will brought together into the Holistic Assessment of
Learning Outcome (HALO).

Broadly, if you do not get the documentation completed, you can neither
make progress in your obstetric anaesthesia assessments nor burnish
your halo.

Initial assessment of obstetric competence

This is a summative RCoA assessment, to be completed by the end of
CT2. The IACOA must be obtained by all anaesthetists in training before
being considered safe to work in an obstetric unit without direct
supervision.

This comprises four areas of professional activity:

• Safe administration of epidural/CSE for pain relief in labour.

• Safe administration of epidural top-up for an emergency caesarean
section.

• Safe administration of spinal/CSE for elective or emergency
caesarean section.

• Safe administration of general anaesthesia for elective or
emergency caesarean section.

SLEs are used as formative assessment during this training period, and
they should show a consistent supervision and entrustment level of 3 by
the end of this period of training so that the trainee can take part in the
obstetric anaesthesia on call rota.

The IACOA will also take into account logbook data, consultant feedback
and achievement of specific learning objectives from simulation training.

Achieving the IACOA does not signal the completion of training in
obstetrics during Stage 1. Further training will be required in order to
attain the required key capabilities.

A consultant, recognised by the GMC as a trainer, will be required to sign
the IACOA certificate.

It is your responsibility to arrange a time for this assessment to occur,
and to highlight to the clinical specialty lead if you are having any

OAH14-2021 Obstetric Anaesthetists Handbook 53

Training and assessment

problems accruing the required experience or assessments in a timely
fashion before your first scheduled on-call duty. Ideally you will complete
the assessment at least 2 weeks prior to your first scheduled on-call.

Formative RCoA assessments

You will need to collect your evidence for the structured learning events
(SLEs), multi-source feedback (MSF), and multiple trainer reports (MTRs)
required by the RCoA during your time in Coventry. With ample
consultant supervision and across our suite of clinics, planned operating
lists and labour ward sessions, we offer plenty of opportunity for this.
Undertaking propositions such as audits and quality improvement
projects is a way of contributing to this and we encourage anaesthetists
in training to do this in stages 1 and 2.

Stage 3 training

We are happy to undertake advanced assessment for specialty registrars
who wish to develop an interest in obstetric anaesthesia, up to the level
of supporting application for a consultant post in the sub-specialty. We
have a number of opportunities for development of new clinical and
organisational areas, interfacing with trust clinical governance and
management functions and so on. Come and speak to us about what you
would like to achieve during your attachment, and speak with the
resource managers in the office about appropriate scheduling during
your attachments to support your development.

15. Royal College of Anaesthetists. 2021 Curriculum for a CCT in Anaesthetics.
London: RCoA, August 2021.

16. Royal College of Anaesthetists. Assessment Strategy for 2021 Anaesthetics
Curriculum. London: RCoA, August 2021.

54 Obstetric Anaesthetists Handbook OAH14-2021

Obstetric anaesthesia structure

Obstetric anaesthesia structure

Lead obstetric anaesthetist Dr Mark Porter #1486 / 24462

Obstetric anaesthetists with regular or flexible sessions

Dr Anuji Amarasekara #1232 Dr Tom McCarthy #5453

Dr Carol Bradbury #4323 Dr Anju Patil #4663

Dr Falguni Choksey #1485 Dr Jaison Paul #1234

Dr John Elton #2855 Dr Seema Quasim #4327

Dr Alastair Fairfield #5168 Dr Megha Reddy #4385

Dr Charlotte Grove Dr Meghna Sharma #4670

Dr Clare Ingram #1358 Dr Nirojan Siva #5052

Dr Richard Jackson #4321 Dr Ewa Werpachowska #1878

Dr Elena Lynes #4923

Clinics

Caesarean planning double clinic Dr Porter, Dr Siva &
Weekly Friday afternoon Coventry Dr Fairfield

High-risk anaesthesia clinic Dr Elton & Dr Amarasekara

Thursday afternoon in weeks 3 and 4

High-risk anaesthesia clinic Dr Werpachowska
Wednesday afternoon in week 1

Multidisciplinary cardiac clinic Dr Quasim
4-weekly Wednesday morning (week
3)

Liaison meetings

Grand safety huddle for CAEs Clinical specialty lead &
Weekly Tuesday 14:00 – 15:00 interested

Labour Ward Specialty Council Clinical specialty lead
Tuesday 15:00 week 4

OAH14-2021 Obstetric Anaesthetists Handbook 55

Obstetric anaesthesia structure

Lead roles

Trainees: pastoral and summative Dr Amarasekara
assessments

UKOSS reporter Dr Choksey

Midwife refresher day training Dr Porter organiser;
delivered by all

Enhanced maternal care lead and Dr Siva
training days for midwives

Pain relief vivas for midwives Dr Elton & Dr Fairfield

Mandatory Obstetrics Training (MOT) Dr Sharma
Day for registrar rotations

Practical Obstetrics MultiProfessional Dr Lynes organiser;

Training (PROMPT) monthly days delivered by all

PDPH follow-up and records Dr Fairfield
completion

Obstetric Anaesthetists Handbook Dr Porter
and updates

Pain relief in labour induction for Dr Porter
medical students

Quality improvement lead (RCoA Dr Siva
Quality Improvement Compendium)

There are many opportunities to get involved with supporting and
specialist work in obstetric anaesthesia – ask for details

56 Obstetric Anaesthetists Handbook OAH14-2021

Further reading and recommended books

Further reading and recommended books

The following publications are recommended to you for further reading
or reference. For a relatively small specialty within anaesthesia there are
many authors who have produced good books even when restricted to
the English language. They are not all listed here.

Core standards texts – free downloads

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

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 2016-18. Oxford: MBRRACE, December
2020.

National Institute for Health and Care Excellence. Hypertension in
pregnancy: diagnosis and management: NG133. London: NICE, June
2019.

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

Royal College of Anaesthetists. Guidelines for the Provision of Anaesthesia
Services for an Obstetric Population 2020. London: RCoA, January 2020.

National Institute for Health and Care Excellence. Intrapartum care for
healthy women and babies: CG190. London: NICE, December 2014 (last
updated February 2017).

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

This is found on the OAA national guidelines page at

www.oaa-anaes.ac.uk/Clinical_Guidelines

OAH14-2021 Obstetric Anaesthetists Handbook 57

Further reading and recommended books

Recommended books

Rachel Collis, Sarah Harries & Abrie Theron. Obstetric Anaesthesia,
second edition. Oxford Specialist Handbooks in Anaesthesia, 2020.
Available on Kindle.

Róisín Monteiro, Marwa Salman, Surbhi Malhotra and Steve Yentis.
Analgesia, anaesthesia and pregnancy: a practical guide, fourth edition.
Cambridge University Press, 2019. Available on Kindle.

Kirsty MacLennan, Kate O’Brien and W. Ross Macnab (eds.) Core Topics in
Obstetric Anaesthesia. Cambridge University Press, 2015. Available on
Kindle.

Current textbooks

Catherine Nelson-Piercy (ed.) Handbook of Obstetric Medicine, sixth
edition. Boca Raton: CRC Press, 2020. Available on Kindle.

Charlotte J. Frise & Sally Collins. Obstetric Medicine. Oxford Specialist
Handbooks in Obstetrics and Gynaecology, 2020. Available on Kindle.

Thomas L. Archer (ed.) Obstetric Anesthesia: A Case-Based and Visual
Approach. Springer Nature Switzerland, 2020. Available on Kindle.

Tauqeer Husain, Roshan Fernando and Scott Segal (eds.) Obstetric
Anesthesiology: An Illustrated Case-Based Approach. Cambridge
University Press, 2019. Available on Kindle.

David H. Chestnut, Cynthia A. Wong, Lawrence C. Tsen, Warwick D. Ngan
Kee, Yaakov Beilin, Jill Mhyre and Brian T. Bateman (eds.) Chestnut’s
Obstetric Anesthesia: Principles and Practice, sixth edition. Philadelphia:
Elsevier, 2019. Available on Kindle.

Vicki Clark, Marc Van de Velde & Roshan Fernando (eds.) Oxford
Textbook of Obstetric Anaesthesia. Oxford University Press, 2016.

David R. Gambling, M. Joanne Douglas & Robert S.F. McKay (eds.)
Obstetric anesthesia and uncommon disorders, second edition.
Cambridge University Press, 2008. Available on Kindle.

58 Obstetric Anaesthetists Handbook OAH14-2021

Further reading and recommended books

Specialised books

Cathy Winter, Timothy Draycott, Neil Muchatuta & Jo Crofts (eds.)
PROMPT Course Manual, third edition. Cambridge University Press,
October 2017.

PROMPT-CIPP Course Participant’s Handbook: Care of the Critically Ill
Pregnant or Postpartum Woman (Critical Care Prompt Practical Obstetric
Multi-Professional Training). Cambridge University Press, January 2019.

Sarah Paterson-Brown and Charlotte Howell. Managing Obstetric
Emergencies and Trauma: The MOET Course Manual, revised third
edition. Cambridge University Press, 2016. Available on Kindle.

Edwin Chandraharan and Sabaratnam Arulkumaran (eds.) Obstetric and
Intrapartum Emergencies: A Practical Guide to Management, second
edition. Cambridge University Press, June 2021. Available on Kindle.

Ian McConachie. Controversies in Obstetric Anesthesia and Analgesia.
Cambridge University Press, 2011. Available on Kindle.

Dawn Adamson, Mandish Dhanjal and Catherine Nelson-Piercy (eds.)
Heart Disease in Pregnancy. OUP: Oxford Specialist Handbooks in
Cardiology, 2011.

Alexander Heazell & John Clift. Obstetrics for anaesthetists. Cambridge
University Press, 2008. Available on Kindle.

Donald Caton. What a blessing she had chloroform: the medical and
social response to the pain of childbirth from 1800 to the present. Yale
University Press, 1999.

Web sites

Obstetric Anaesthetists Association – www.oaa-anaes.ac.uk

OAA information for mothers – www.LabourPains.com

Royal College of Anaesthetists – www.rcoa.ac.uk

Association of Anaesthetists of Great Britain and Ireland – www.aagbi.org

Society for Obstetric Anesthesia and Perinatology – www.soap.org

Royal College of Obstetricians and Gynaecologists – www.rcog.org.uk

OAH14-2021 Obstetric Anaesthetists Handbook 59

Further reading and recommended books

MBRRACE-UK: Mothers and Babies: Reducing Risk through Audits and
Confidential Enquiries across the UK – www.npeu.ox.ac.uk/mbrrace-uk

Gone but not forgotten

Stephen H. Halpern & Joanne M. Douglas (eds.) Evidence-based obstetric
anesthesia. Oxford: BMJ Books, 2005.

Felicity Reynolds (ed.) Regional analgesia in obstetrics: a millennium
update. London: Springer-Verlag, 2000.

Anita Holdcroft & Trevor A. Thomas. Principles and practice of obstetric
anaesthesia and analgesia. Oxford: Blackwell Science Ltd, 2000.

David Dewan & David Hood (eds.) Practical obstetric anesthesia.
Philadelphia: W.B. Saunders, 1997.

Robin Russell, Mark Scrutton & Jackie Porter (edited by Felicity Reynolds)
Pain relief in labour. London: BMJ Publishing, 1997.

Ian F. Russell & Gordon Lyons (eds.) Clinical problems in obstetric
anaesthesia. London: Chapman and Hall Medical, 1997.

60 Obstetric Anaesthetists Handbook OAH14-2021

MBRRACE anaesthesia recommendations

MBRRACE anaesthesia recommendations

The UK and Ireland national confidential enquiries into maternal deaths
and morbidity have run since the early part of the twentieth century and
are now undertaken by the MBRRACE-UK collaboration (Mothers and
Babies: Reducing Risk through Audits and Confidential Enquiries).
MBRRACE reports are now published on an annual basis rather than the
traditional triennial reports that ran from 1952 to 2012 (published 2014).
The authors try to focus on preventable factors and lessons to be
learned. The chapter headings within the annual reports now rotate
roughly every three years.

2014 Sepsis, haemorrhage, AFE, anaesthesia, neurology, other
medical complications [17].

2015 Mental health, VTE, cancer, domestic abuse, late deaths.

2016 Cardiovascular disease, hypertensive disorders, early pregnancy,
critical care.

2017 Epilepsy and stroke, psychosis, general medical and surgical
disorders, sepsis, anaesthesia, haemorrhage or AFE [18].

2018 Haemorrhage, VTE, mental health, vulnerable groups,
malignancy.

2019 Cardiovascular care, breast cancer, hypertensive disorders,
accidental deaths, critical care.

2020 Neurology, general surgery, anaesthesia, VTE, haemorrhage and
AFE, infection [19].

Key messages for anaesthetic care in the 2014 report

1. Subdural haematoma and cerebral venous sinus thrombosis are
well recognised complications of dural puncture and pregnancy,
respectively. Both should always be included in the differential
diagnosis of persistent headache after dural tap or post-dural
puncture headache.

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MBRRACE anaesthesia recommendations

2. Anaesthetists should practice drills for managing peri-operative
airway crises including severe bronchospasm, mechanical
obstruction, and difficult intubation/oesophageal intubation.

3. Pregnant or postpartum women recovering from anaesthesia
require the same standard of postoperative monitoring, including
documentation, as non-obstetric patients.

4. Anaesthetists must be always ready to deal with the adverse effects
of local anaesthetics including accidental intrathecal or intravenous
injection and minimise the use of strong concentrations as far as
possible.

5. Prompt action and good communication within and between teams
are crucial when dealing with sudden unexpected catastrophes,
especially when the diagnosis is not immediately clear.

6. All ambulance services should ensure their staff are trained in the
relief of aortocaval compression during transfer of all pregnant
women. How this was achieved must be routinely documented for
each woman.

7. Units should ensure appropriate observations on all women. If an
Early Warning Score system is in place, units should regularly audit
their completion and ensure that abnormal results trigger the
locally determined action.

8. All Serious Untoward Incident investigations of pregnant or
postpartum women should include an obstetric anaesthetist.

Key messages for anaesthetic care in the 2017 report

1. In sudden-onset severe maternal shock e.g., anaphylaxis, 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.

2. Anaesthetists must continue to be vigilant about the risk of
pulmonary aspiration in pregnant women who require general

62 Obstetric Anaesthetists Handbook OAH14-2021

MBRRACE anaesthesia recommendations

anaesthesia. An individualised risk assessment should be made, and
appropriate precautions taken.

3. In cases of massive obstetric haemorrhage women must be
adequately resuscitated and bleeding stopped prior to extubation
following general anaesthesia. Evidence of adequate resuscitation
should be sought prior to extubation.

4. Aortocaval compression should be suspected in any supine
pregnant woman who develops severe hypotension after induction
of anaesthesia, even if some lateral tilt has been applied. If there is
a delay in delivery, putting the woman into the left lateral position
may be the only option if other manoeuvres fail or if the woman has
refractory severe hypotension.

5. In the absence of contraindications such as hypertension,
prophylactic vasopressors should be administered to pregnant
women who have spinal anaesthesia.

6. The choice of endotracheal tube for pregnant women should start
at size 7.0 mm and proceed to smaller tube selections if needed
(size 6.0 mm and 5.0 mm). It is recommended that all resuscitation
carts used in maternity units should include endotracheal tubes no
larger than 7.0 mm and include smaller sizes such as 6.0 mm and
5.0 mm.

7. Pregnant women with complex needs or a complex medical history
should have timely antenatal multidisciplinary planning, and an
experienced obstetric anaesthetist should contribute to the
planning.

8. Hospital serious incident reviews should comment on the quality of
the documentation i.e., observations and the clinical management,
of adverse serious events. The reviews should also comment on
whether there was any process for debriefing and support available
to staff involved in these very stressful situations.

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MBRRACE anaesthesia recommendations

Key messages for anaesthetic care in the 2020 report

1. Ensure that women on prophylactic and treatment dose
anticoagulation have a structured management plan to guide
practitioners during the antenatal, intrapartum, and postpartum
period. Identify clear lines of responsibility to facilitate prescribing
of thromboprophylaxis when indicated in the plan.

2. Ensure maternity units have protocols to support decision-making
in the provision of neuraxial analgesia and anaesthesia to women
who may be at risk of having abnormal coagulation.

3. Where there is concern about a woman’s condition during recovery
after surgery the anaesthetist has a responsibility to make a full
assessment, diagnosis and a plan of care which may include
escalation measures and seeking senior advice. The anaesthetist has
a responsibility to ensure the plan of care has been implemented
and to reassess the woman’s condition.

17. 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 2009-12. Oxford: MBRRACE, December
2014.

18. 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.

19. 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 2016-18. Oxford: MBRRACE, December 2020.

64 Obstetric Anaesthetists Handbook OAH14-2021

Each Baby Counts anaesthesia recommendations

Each Baby Counts anaesthesia
recommendations

The Each Baby Counts reports are published by the Royal College of
Obstetricians and Gynaecologists. In 2017 the college produced a themed
report on anaesthesia care [20]. It is useful to know what the
obstetricians are told about recommendations on anaesthesia practice
and theatre cases.

Key findings include:

Many of the lessons on “human factors”, identified in the Each Baby
Counts 2015 full report, are echoed in this latest report
Although there were no babies for whom anaesthetic problems were
thought to be the sole contributory factor to their outcome, most of the
anaesthetic issues noted in these reviews contributed additionally to
delays in delivery
There is a clear need to optimise communication about the urgency of
delivery to allow for informed choice of method of anaesthesia.
Key themes for improvements also included the care of women with
partially effective regional anaesthesia and failed intubation.

Key recommendations

All reviews should involve an obstetric anaesthetist and should include
review of the detailed anaesthetic record.
Anaesthetists should always be informed of the degree of urgency of
delivery. As an aid to communication, the classification of urgency of
caesarean birth should be used for all operative deliveries, vaginal as well
as abdominal.
A decision about the purpose of transfer to theatre and urgency of any
delivery should be made together with the anaesthetist before transfer
to theatre. The degree of urgency should be reviewed on entering

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Each Baby Counts anaesthesia recommendations

theatre prior to the WHO check, and the obstetrician should confirm the
degree of urgency directly to the anaesthetist.

Anaesthetists should use a structured and validated anaesthetic
handover tool between shifts and, if possible, participate in the routine
labour ward handover/review of the delivery suite board. This will help
maintain situational awareness and enable early anticipation of
anaesthetic difficulties.

All women who receive epidural analgesia should be reviewed to ensure
the effectiveness of the epidural and to minimise delays should the need
for operative delivery arise. The functioning of an in-labour epidural
should be taken into consideration when deciding on the most
appropriate and timely means of anaesthesia for operative delivery.

The safety of the mother must be always the primary concern. Women
should not be put at risk of airway problems through inadequate
preparation/positioning due to haste to achieve rapid delivery. The
required equipment for the management of difficult and failed tracheal
intubation in obstetrics detailed in the OAA/DAS guidelines should always
be available and all anaesthetists should undergo specific difficult airway
training.

There is a need for the development of a structured communication tool
to include the three-fold elements of the delivery plan: mode of delivery,
location of birth and category of urgency. This will form a key Each Baby
Counts implementation output from this report, and the RCOG is
committed to collaborating with the relevant organisations to produce
this at the earliest opportunity.

20. Royal College of Obstetricians and Gynaecologists. Each Baby Counts: Themed
report on anaesthetic care, including lessons identified from Each Baby Counts
babies born 2015 to 2017. London: RCOG; 2018

66 Obstetric Anaesthetists Handbook OAH14-2021

Normal laboratory values in pregnancy

Normal laboratory values in pregnancy

Haematology > 120 g L-1 (see page 161 for definitions)
5-15 × 109 L-1 (up to 25 during labour)
Haemoglobin 150-450 × 109 L-1
White cell count
Platelets

APTT 0.8-1.2
INR 1.0-1.3
PT 10-13 seconds

Fibrinogen 4-5 g L-1 (aim >2 in MOH)
FDP < 0.6 mg L-1

Biochemistry Pregnancy UHCW adult range

Sodium 130-140 mmol L-1 133-146
Potassium
Urea 3.5-5.1 mmol L-1 3.5-5.3
Creatinine
Albumin 1.5-4.5 mmol L-1 2.5-7.8
Urinary PCR
Bilirubin 40-70 µmol L-1 50-90
Alkaline Phosphatase
AST 25-42 g L-1 35-50
ALT
Lactate (venous) < 30 mg mmol-1 (≥ 30 confirms pre-eclampsia)
Ferritin
4-20

90-600 u L-1 35-105

10-30 u L-1 8-40

6-32 u L-1 5-38

0.4-2.2 mmol L-1

> 30 10-150

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Normal laboratory values in pregnancy
Arterial blood gases

pH 7.44 Lactate 0.5-1 mmol L-1
pCO2 4.1 kPa BE 0-3.5 mmol L-1
pO2 13.6 kPa pO2/FiO2 >50

Fetal blood gases

Blood is taken for cord gases at emergency caesarean births, as a
measure of the fetal state at the time of delivery. The umbilical artery
specimen reflects the state of the fetus and the umbilical vein specimen
that of the placental perfusion. It is not easy to quote normal values, as
the fetus whose mother has been in labour will be more acidotic than the
one delivered by caesarean birth. The values quoted below are a guide
only. The pH and base deficit are used more in clinical practice than the
pO2 and pCO2.

The concept of respiratory and metabolic acidoses may be helpful.
Diagnosed in the same way as with ordinary arterial blood gases, a
fetoplacental perfusion problem initially manifests as a respiratory
acidosis. When significant hypoxia becomes established, then a metabolic
acidosis picture emerges.

Umbilical artery Umbilical vein

pH 7.25 or higher 7.3 or higher

BE -6 or more positive -4 or more positive

pO2 2.3 kPa 3.7 kPa

pCO2 7.3 kPa 5.3 kPa

Fetal scalp sampling

A pH > 7.25 is reassuring. Between 7.21 and 7.25 close observation and
further testing in thirty minutes is indicated. A pH reading ≤ 7.20 indicates
urgent delivery to prevent the risk of a pH ≤ 7.00 in cord gases at delivery.

68 Obstetric Anaesthetists Handbook OAH14-2021

Drug shortages and supply changes

Drug shortages and supply changes

Chapter contents 69
70
Ampoule sizes and drug presentations 71
Action if diamorphine PFS are not available 72
CHG (chlorhexidine gluconate)
Heavy bupivacaine

From time to time, individual drugs will go into a shortage state and will
not be available on a basis that may cover a range from an impending
shortage that does not materialise, to one that lasts weeks or months.
Look out for notices about consequential changes that we may need to
make from time to time. This section covers some of the more common
shortages that we can face.

Ampoule sizes and drug presentations

Some drugs (such as diamorphine and oxytocin) are subject to variable
supply. Check each ampoule before use.

Diamorphine is usually supplied made up in clean (not sterile) wrapped
PFS (pre-filled syringes). The PFS will have 0.5 mg diamorphine in 0.5mL
sodium chloride 0.9% solution.

Check all drugs and amounts with your ODP carefully and explicitly while
drawing them up for neuraxial anaesthesia – the trust standard is an
audible two-practitioner check of the medicinal form, dosage, expiry date
and indication with your ODP.

Oxytocin is usually supplied in ampoules of 10 units but can arrive in a
different size with 5 units in each ampoule.

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Drug shortages and supply changes

Action if diamorphine PFS are not available

Diamorphine supplies are under threat on a regular basis owing to
regulatory requirements and the use of the production lines for vaccines
against COVID-19. It has become the mainstay of analgesia after a
caesarean birth and cannot be easily replaced. This section gives
alternatives for use in spinal anaesthesia (see page 345) if the
diamorphine PFS supply fails.

PFS not available; diamorphine supplied as powder

Do the following if our PFS supply fails, and we stock diamorphine 5 mg
powder ampoules.

Use a 10-mL syringe (to avoid confusion with the bupivacaine) and draw
up 5 mL sodium chloride 0.9% solution from an ampoule held by the ODP,
using the yellow filter needle. Use this to dilute the diamorphine from a
5-mg diamorphine ampoule. You now have a 1 mg mL-1 solution of
diamorphine.

To administer 0.4 mg in a spinal anaesthetic you will need 0.4 mL. Use a
1-mL syringe to draw up > 0.4 mL diluted diamorphine from the 10-mL
syringe containing 1 mg mL-1 solution. Discard the excess until exactly
0.4 mL (0.4 mg) is contained in the syringe.

Use the 5-mL syringe to draw up the 3 mL 0.5% heavy bupivacaine and
then draw up the 0.4 mL diamorphine. Discard the rest of the
diamorphine from the 10-mL syringe in the manner recommended for all
controlled drugs.

Diamorphine unavailable

The Obstetric Anaesthetists Association has given advice [21]. The
appropriate alternative treatment is morphine and fentanyl.

Spinal anaesthesia using morphine and fentanyl

Draw up the following as an intrathecal dose of 3.5 mL.
• 100 micrograms intrathecal morphine (0.1 mL in a 1-mL NRFit

syringe; check amount as morphine preparations can vary).

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Drug shortages and supply changes

• 20 micrograms fentanyl (0.4 mL in a 1-mL NRFit syringe).
• Take the 5-mL NRFit syringe and draw up 3 mL 0.5% heavy

bupivacaine, then the morphine and the fentanyl from their
syringes.
Exercise extreme care doing this with audible two-practitioner checks.
Do not prescribe parenteral opioids. Oral morphine solution is
acceptable.

Epidural analgesia

At the end of surgery or before removal of the epidural catheter give
3 mg preservative-free morphine and flush the epidural catheter with
2 mL 0.9% sodium chloride solution.

Intramuscular analgesia

Use 15 mg morphine IM where 10 mg diamorphine IM is indicated, e.g.,
mothers with epilepsy.

CHG (chlorhexidine gluconate)

There are occasional supply chain problems with 0.5% CHG / 70% alcohol
spray (Hydrex) . If this is unavailable, you should use BD Chloraprep sticks
2%.
As with the Hydrex spray, you must make certain that the BD Chloraprep
applicator solution is fully air-dried before undertaking the block.
BD Chloraprep applicators contain 2% chlorhexidine, which may raise
doubts. The Association of Anaesthetists recommends that 0.5% CHG is
preferred out of caution, but it does not ban the use of 2% CHG for
neuraxial anaesthesia prep. BD Chloraprep sticks are in use by obstetric
anaesthetists in several hospitals and recommended by BD for that
purpose.

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Drug shortages and supply changes

Heavy bupivacaine

Shortages in 2019 led to various alternative drugs being used. Informal
national advice to replace heavy bupivacaine with the same amount of
isobaric levobupivacaine produced inconsistent conclusions about the
necessity of using a hyperbaric mix to obtain reliable spinal anaesthesia
to T4. The Obstetric Anaesthetists Association warned of the potentially
variable block characteristics of isobaric bupivacaine with regards to
onset time and height of block compared to those of heavy bupivacaine
but has also circulated a summary observing no difference [22].

We currently use 2% heavy prilocaine for cervical suture and with this
handbook we are extending its use to manual removal of placenta and
perineal tear repair.

We used 2% heavy prilocaine (Prilotekal) successfully but note the
duration of surgical anaesthesia as below.

We undertook some cases successfully with a mixture of drugs: 1.4 mL
heavy prilocaine 2% (28 mg) and 1.6 mL levobupivacaine 0.5% (8 mg),
with 0.4 mg diamorphine. This gave equivalent onset times, and offset
times that went from 90-120 minutes.

In the case of complete absence of heavy bupivacaine, discuss available
options with the consultant anaesthetist on call.

Prilocaine for caesarean birth

Caesarean expected to take less than one hour from spinal injection to
vaginal swab: 65 mg or 3.25 mL of 2% heavy prilocaine. This dose is the
ED95 for a T4 block [23]. The total volume with 0.4 mL diamorphine is
3.65 mL.

Contraindications

• Prolonged duration of caesarean surgery expected: greater than
one hour.

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Drug shortages and supply changes

• Trial of instrumental delivery (prolonged procedure followed by
perineal suturing).

Consent – information for the mother

Due to a national shortage of our normal drug, we are using prilocaine.
This has a shorter duration of action which, although still suitable for
caesarean birth and other operations, may mean that if the operation is
prolonged unexpectedly, there is a slightly higher chance that we may
need to offer general anaesthesia for late discomfort.

You are likely to recover more quickly in terms of regaining mobility a
little earlier after the caesarean birth or other operation.

Precautions

2% heavy prilocaine is likely to produce less hypotension – use the
standard metaraminol infusion, watching carefully; be prepared to
reduce and terminate earlier.

2% heavy prilocaine has a rapid onset and does not last as long as
0.5% heavy bupivacaine.

• Surgeons to be present in theatre during spinal anaesthesia and not
leave.

• Most senior surgeon available to conduct surgery, preferably
consultant.

21. Obstetric Anaesthetists Association. OAA commentary on alternatives to
intrathecal and epidural diamorphine for caesarean section analgesia.
London, OAA, April 2021. Accessed 23 April 2021 at https://www.oaa-
anaes.ac.uk/ui/content/content.aspx?ID=4717

22. Arrow K 2019. https://www.oaa-anaes.ac.uk/Heavy-vs-Isobaric-Bupivacaine

23. Leloup R, Sandio A, Barlow P, Mbedi S, Goffard P, Kapessidou Y. Estimation of
the ED95 of intrathecal hyperbaric prilocaine for scheduled cesarean delivery:

OAH14-2021 Obstetric Anaesthetists Handbook 73

Drug shortages and supply changes

a dose-finding study based on the continual reassessment method. DOI:
10.13140/RG.2.2.31389.10722.

74 Obstetric Anaesthetists Handbook OAH14-2021

Emergencies in maternity care

All obstetric emergencies must be managed
immediately in conjunction with midwifery and
obstetric staff.
Call for help immediately if you are not able, for any
reason, to give immediate, safe, and effective
treatment.
Consider sending for senior help early and in any case
where this is specifically indicated.

Bleeding – massive haemorrhage
Breathing – difficulties
Convulsing

Senior resident (#2813) to attend to assess the
situation and provide leadership and support for the
obstetric anaesthetist. As with paediatric medical
emergencies or cardiac catheter cases, attendance may
not be immediate if tied up elsewhere and a consultant
may need to be called.

Any anaesthetic emergency can occur during obstetric anaesthesia.
Remember the Quick Reference Handbooks on the theatre wall – both
the AAGBI standard and the local Maternity QRH. Ask someone to read

from the appropriate checklist.

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Maintaining readiness 76
76
Maintaining readiness 78
78
Chapter contents
Operating theatres
Prepared drugs
Leaving anaesthetised mothers
Emergency bleep system

You must be aware at all times of the options for conducting emergency
anaesthesia and be assured that cases can be conducted with the
minimum of delay. The response time for a particular condition will vary
(see page 366) and we do not presume that general anaesthesia is always
the appropriate choice for emergencies – unless contraindicated or
impossible, spinal anaesthesia or epidural extension should be used for
caesarean birth. You will find detailed advice in this handbook.

Operating theatres

You should check that both the main and second obstetric theatres are
available for operation in conjunction with the senior midwifery sister. If
either theatre is non-operational, then you should identify a backup
theatre with the main theatres floor control on 28171 or 25959.

Prepared drugs

There have been several serious drug-related incidents. One common
factor is the advance preparation of too many drugs. When associated
with poor labelling this has the potential for lethality. It also raises issues
of sterility, and adequate handover between different anaesthetists.

76 Obstetric Anaesthetists Handbook OAH14-2021

Maintaining readiness

Any operative case should have one anaesthetist, whether registrar or
consultant, who is primarily responsible for the conduct of the
anaesthetic and the administration of drugs.
Do not draw up or prepare drugs for more than one case.
Storage of other prepared drugs may seem convenient but exposes
mothers to a higher risk of drug error. In particular, syringes that you
have prepared and not used must not be stored. Do not put your syringes
in the fridge for future use. It is good practice to prepare all drugs fresh
at the time of use.

General anaesthesia

You should make sure that the following drugs are immediately available
for use in the anaesthetics area attached to the main obstetric theatre.

• Propofol 200 mg in 20 mL ampoules.

• Rocuronium 50 mg in 5 mL ampoules in the fridge.

• Metaraminol 10 mg in 1mL ampoules ready for dilution.

• Ephedrine 30 mg in 1 mL ampoules ready for dilution.

• Atropine 600 mcg in 1 mL ampoules.

Regional anaesthesia

You should prepare a tray containing unopened drugs for use in Quickmix
epidural anaesthesia for caesarean birth (see ‘Extending the epidural for
a ’ on page 356). This tray should be kept on the work surface in theatre.

• Lidocaine 2% 20 mL.

• Adrenaline 1 mg in 1 mL, with unopened 1-mL syringe (0.1 mL to be
used).

• Sodium bicarbonate when available. The dose is 84 mg (1 mL of
8.4% solution) per 20 mL mixture. The Martindale sodium
bicarbonate with EDTA preservative is available and suitable for use.

You will need to obtain the opioid ampoule from the controlled drugs
cupboard.

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Maintaining readiness

Leaving anaesthetised mothers

If you are the only anaesthetist nearby and you are engaged in the care of
another patient, you should bear in mind the advice of the Association of
Anaesthetists of Great Britain and Ireland:

“Very occasionally, an anaesthetist working single-handedly
may be called on briefly to assist with or perform a life-saving
procedure nearby. Leaving an anaesthetised patient in these
circumstances is a matter for individual judgement, but
another anaesthetist or trained PA(A) should be sought to
continue close observation of the patient. If this is not possible
in an emergency situation, a trained anaesthetic assistant must
continue observation of the patient and monitoring devices.
Any problems should be reported to other available medical
staff in the area.” [24].

Emergency bleep system

Urgent and emergency theatre cases will go out over the bleep system,
using the categories on page 366. This will alert relevant theatre and
medical staff for the case. (Paediatricians will still need to be called
separately according to need.)
Operative cases other than caesarean birth will also be categorised.
Category 1 theatre case: an immediate threat or risk to the mother or
fetus, e.g., suspected uterine rupture, major placental abruption, cord
prolapse, fetal hypoxia or persistent fetal bradycardia.
Category 2 theatre case: all other urgent cases.

Managing labour ward emergencies

• Pull the emergency knob – the red triangle on the wall.

• Make 2222 call ‘obstetric emergency’ and state precise location.
• Call for senior help as appropriate.
• Nominate a lead professional to direct and allocate tasks.

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Maintaining readiness
• Give clear instructions and ensure they are acted upon.
• Designate one person to document events in the mother’s notes.
• Communicate with all team members and mother.
Specific advice on some emergencies is given in the next few chapters.

24. Association of Anaesthetists of Great Britain and Ireland. Recommendations
for standards of monitoring during anaesthesia and recovery 2015.
Anaesthesia 2016; 71:85-93.

OAH14-2021 Obstetric Anaesthetists Handbook 79

Failed or difficult intubation 81
82
Failed or difficult intubation 84
101
Chapter contents 102
103
Airway assessment 109
Preparing yourself 115
Guidelines for failed or difficult intubation 118
APH (antepartum haemorrhage) 121
PPH (postpartum haemorrhage) 124
DCR (damage control resuscitation) 127
Managing haemorrhage cases 128
Pharmacological treatment of uterine atony
Use of red blood cells
Use of haemostatic blood components
Use of systemic haemostatic agents
Mothers who refuse blood transfusion
Balloon occlusion catheters and fluoroscopy procedures

Failed or difficult intubation is a leading cause of anaesthesia-related
maternal mortality and death is more often a result of hypoxia than
inhaled gastric contents. Difficult intubation occurs in about 1:20
obstetric general anaesthetics, and failed intubation in about 1:300 or
400; the incidence of FONA (front of neck access techniques) is 1:60
failed intubations, and of death is 1:90 failed intubations [25,26]. Failure
of adequate preparation and action by the anaesthetist plays an
important role in this.

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Failed or difficult intubation

In 2018 the standard recommendation changed to 7.0 mm endotracheal
tubes, to mitigate the effect of difficulty especially with unexpected
airway oedema [27].
You should perform an airway assessment, including modified
Mallampati score and an assessment of other relevant anatomical and
obstetric features, for all mothers presenting for anaesthetic procedures.
You should determine whether difficult intubation could be anticipated.
It is not possible to give exact criteria for this and the predictive power of
criteria may not be good. However, if you are faced with a mother whose
Mallampati class is 3 or 4 and who has associated features such as a short
neck or a receding mandible etc, it is reasonable to anticipate a difficult
intubation.
You must notify the consultant anaesthetist on call before undertaking
general anaesthesia in a mother in whom you anticipate a difficult
intubation.
In all cases of unanticipated difficult intubation or failed intubation, call

for help.

Airway assessment

A detailed preoperative airway assessment can assist you in predicting
difficult intubation, difficult mask or SGAD ventilation and difficult front-
of-neck access. Effective airway management requires careful planning.
You should have a backup plan for when your primary plan fails.

History

During the preoperative visit, you should elicit previous difficult airway
alerts, surgeries or injuries in head and neck, radiotherapy, snoring,
obstructive sleep apnoea, neurological disorders.

Clinical examination:

Any gross craniofacial anomaly and gross abnormality of neck should be
apparent on clinical examination.

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Failed or difficult intubation

• Mouth opening: when fully opened should allow mother’s middle
three fingers held in vertical plane.

• Jaw movement: good forward movement (lower teeth can protrude
further than the upper teeth) is associated with easy laryngoscopy.

• Buck teeth are associated with high score on Mallampati
classification and limit the protrusion of lower teeth further than
upper teeth.

• Movement of cervical spine and extension at atlanto-occipital joint.

• Thyromental distance should be > 6.5 cm (measured while neck is
extended).

• Sternomental distance should be > 12.5 cm (measured while neck is
extended).

Modified Mallampati’s classification

Conducted with the mother sitting upright, opening the mouth as far as is
possible and maximally protruding the tongue. Allocate a class based on
what you see at the back of the mouth.

Class 1: Faucial pillars, soft palate and uvula seen.

Class 2: Faucial pillars and soft palate seen. Base of tongue
masks uvula.

Class 3: Only soft palate visible

Class 4: Even soft palate not visible.

Preparing yourself

Remember all the usual measures for ensuring that you succeed at
intubation: position the mother appropriately at the right height and with
one pillow under the occiput, with the neck flexed on the body and the
head extended on the neck. Consider using a head-up position, or in
morbidly obese mothers, using a ramped position. In this position, the
head and trunk are supported to align the external auditory meatus with
the sternal notch in the horizontal plane.

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Failed or difficult intubation

Use a suitable laryngoscope remembering that insertion into the
mother’s mouth can bring significant difficulty in rapid sequence
induction and pregnancy. Our department now uses videolaryngoscopy
as standard including in obstetric practice. The McGrath
videolaryngoscope is available in each obstetric theatre. It is worth
remembering that videolaryngoscopes can be difficult to insert into the
mouth during rapid sequence induction. We recommend taking
opportunities to gain experience with the polio blade laryngoscope. This
can sometimes be much more easily inserted and used.

Be ready to accept that failed intubation might happen in your practice,
even after trying alternative tools. The difficult intubation equipment on
the airway trolley includes introducers, smaller tubes and polio blade,
McCoy blade (levering) and short-handled laryngoscopes. The most
important factor in recovery is to follow a pre-planned drill calmly and
unhurriedly, as below, and not to start experimenting with unfamiliar
equipment.

Start with a size 7.0 mm endotracheal tube and proceed to smaller tube
selections if needed (size 6.0 mm and 5.0 mm).

You must use capnography to confirm the position of the endotracheal
tube, when intubating the trachea during induction of anaesthesia or
managing an intubated mother during anaesthesia.

Two of the four recommendations from NAP4 are relevant here [28].

Recommendation: despite the relative infrequency of general
anaesthesia for caesarean birth, obstetric anaesthetists need to maintain
their airway skills including strategies to manage difficult intubation,
failed intubation and CICV [now defined as CICO].

Recommendation: obstetric anaesthetists should be familiar and skilled
with supraglottic airway devices for rescuing the airway: particularly
those designed to protect from aspiration and to facilitate ventilation
and/or intubation.

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Failed or difficult intubation

Guidelines for failed or difficult intubation

For active management with checklist® M-QRH

As with any clinical guideline, but perhaps most acutely here, bear in
mind that no clinical guideline can be a complete substitute for good
clinical judgement. You may need to vary the practice described here in
individual circumstances. Your success in doing so will be built on your
working knowledge of the guidelines themselves. Alternative actions,
such as decisions about whether to wake or proceed after difficult
intubation, will necessarily involve integrating more information than can
be presented in an algorithm that gives guidance.

Avoid fixation error. The overall aim of your actions is to provide safe
anaesthesia for the mother and deliver her of a baby, and not to succeed
in using any particular technique to achieve this aim. It is failure to
oxygenate that causes death, not failure to intubate.

We have adopted the joint guidelines published in 2015 by the Obstetric
Anaesthetists Association and the Difficult Airway Society. (Our previous
guideline from 2006 focused on the swift insertion of a ProSeal LMA or
LMA Supreme to oxygenate the mother before the offset of
neuromuscular blockade). The joint guidelines are necessarily based on a
limited clinical evidence base but nevertheless provide a consistent
framework for providing safe obstetric general anaesthesia [29].

The guidelines below are reproduced with permission from the Obstetric
Anaesthetists’ Association and the Difficult Airway Society [30]. There are
four algorithms and two tables, and you should study them carefully.
Think about how you will deal with this situation and practise the
algorithms with colleagues.

A master algorithm provides an overview.

Algorithm 1 gives a framework on how to optimise a safe general
anaesthetic technique in the obstetric patient and emphasises: planning

84 Obstetric Anaesthetists Handbook OAH14-2021

Failed or difficult intubation

and multidisciplinary communication; how to prevent the rapid oxygen
desaturation seen in pregnant women by advocating nasal oxygenation
and mask ventilation immediately after induction; limiting intubation
attempts to two; and consideration of early release of cricoid pressure if
difficulties are encountered.

Algorithm 2 summarises the management after declaring failed tracheal
intubation with clear decision points and encourages early insertion of a
(preferably second generation) supraglottic airway device if appropriate.

Algorithm 3 covers the management of the ‘can’t intubate, can’t
oxygenate’ situation and emergency front-of-neck airway access,
including the necessity for timely resuscitative hysterotomy (perimortem
caesarean section) if maternal oxygenation cannot be achieved.

Table 1 gives a structure for assessing the individual factors relevant in
the decision to awaken or proceed should intubation fail, which include:
urgency related to maternal or fetal factors; seniority of the anaesthetist;
obesity of the mother; surgical complexity; aspiration risk; potential
difficulty with provision of alternative anaesthesia; and post-induction
airway device and airway patency. This decision should be considered by
the team in advance of performing a general anaesthetic to make a
provisional plan should failed intubation occur.

Table 2 gives practical considerations of how to awaken or proceed with
surgery.

Some points introduced in these guidelines are discussed below.

Preoxygenation

If the mother is apnoeic and the airway is not being instrumented,
continued administration of 100% oxygen with a tightly fitting facemask
and maintenance of a patent airway allows continued oxygenation by
bulk flow to the alveoli (apnoeic oxygenation). Consider attaching nasal
cannulas with 5 L min-1 oxygen flow before starting preoxygenation, to
maintain bulk flow of oxygen during intubation attempts. There is an
Optiflow device outside theatre 5; consider its use to deliver high-flow
nasal oxygen therapy in cases of expected difficulty [31]. There remains

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Failed or difficult intubation

controversy over whether HFNOT offers any advantage over ordinary
face mask preoxygenation [32].

Cricoid pressure

This is universally used in the UK [33] though not so in many other
countries. Many mothers presenting for general anaesthesia will have
had omeprazole PO or IV and all should have sodium citrate administered
orally. Have a low threshold to reduce or remove cricoid pressure to
facilitate endotracheal intubation and particularly SGAD insertion.

Facemask ventilation

Bag-facemask ventilation can reduce oxygen desaturation safely when
used in conjunction with correctly applied cricoid pressure and a
restricted peak ventilation pressure (Pmax < 20 cm H2O), and it may allow
an estimation of the likelihood of successful bag-mask ventilation should
it be required during prolonged or failed intubation attempts. Consider its
use during rapid sequence induction after administration of induction
drugs.

Avoiding accidental awareness

Drugs given at induction can wear off during unexpectedly prolonged
airway manoeuvres. Make sure to give your patient sedative drugs during
prolonged difficult intubation procedures.
Similarly, be aware that intubation can be difficult in the absence of
neuromuscular blocking drugs.

Front-of-neck procedure

This will only rarely be required after failed intubation but may be
lifesaving where life is threatened by failure of oxygenation. Small-bore
cannula techniques have a high failure rate, especially in obese mothers.
Surgical airways may be more successful and provide a definitive airway.

Plan D: Emergency front of neck access

• Continue to give oxygen via upper airway.

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Failed or difficult intubation

• Ensure neuromuscular blockade.
• Position mother to extend neck.

Scalpel cricothyroidotomy
Equipment: Scalpel (number 10 blade) | Bougie | Tube (cuffed 6.0mm
ID).
Laryngeal handshake to identify cricothyroid membrane.

Palpable cricothyroid membrane

• Transverse stab incision through cricothyroid membrane.
• Turn blade through 90° (sharp edge caudally).
• Slide coude tip of bougie along blade into trachea.
• Railroad lubricated 6.0 mm cuffed tracheal tube into trachea.
• Ventilate, inflate cuff, and confirm position with capnography.
• Secure tube.

Impalpable cricothyroid membrane

• Make an 8-10 cm vertical skin incision, towards the head.
• Use blunt dissection with fingers of both hands to separate tissues.
• Identify and stabilise the larynx.
• Proceed with technique for palpable cricothyroid membrane as

above.

Complete oxygenation failure

If the front-of-neck procedure fails, then institute the cardiac arrest
procedure including immediate caesarean delivery if the fetus is greater
than 20 weeks’ gestation.

Continuing with anaesthesia or waking

See table 1. It is no longer appropriate to wake a mother routinely after
rescuing difficult or failed intubation, and in most cases general

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Failed or difficult intubation

anaesthesia will proceed when a satisfactory airway is established. The
overriding indications to proceed with general anaesthesia are maternal
compromise not susceptible to resuscitation and irreversible acute fetal
compromise due to such causes as major placental abruption, ruptured
umbilical scar, fetal haemorrhage, umbilical cord prolapse and failed
instrumental delivery. You should take into account the risks of repeated
anaesthesia to the mother, the original indication for general
anaesthesia, and whether regional anaesthesia is contraindicated (e.g.,
haemorrhage or maternal refusal).

If postponement is acceptable, then wake the mother. Subsequent
anaesthesia must be conducted with a consultant present. Use either a
regional technique or an awake intubation.

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Failed or difficult intubation

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Failed or difficult intubation

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Failed or difficult intubation

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Failed or difficult intubation

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