1. Obstetric Anaesthesia & Management of the ill pregnant woman
Dr Beenu Madhavan
Consultant Anaesthetist
University Hospital Lewisham
Lewisham & Greenwich NHS Trust

2. What do Anaesthetist do?

3. Thank you
Any questions?

5. Role of the Anaesthetist
Integral part of care of the pregnant woman
Antenatal assessment, peri partum care, joint handover
Education - midwives, antenatal & enhanced recovery pathway, crisis resource management
High risk obstetric patient - assessment and stabilisation

6. Role of the Anaesthetist
Coordinate theatre, aid communication
Care of the critically ill pregnant or post partum woman
Sepsis in Pregnant Women
Cardiorespiratory Emergencies
Neurological Emergencies in Pregnancy

7. What do we want to know about?
Antenatal co-existing disease
Obstetric complications
Cardiovascular problems
Obesity
‘Back’ problems
Haematological issues
Diabetes / endocrine
Neurological

8. Why Obstetric Anaesthesia?
Exciting challenges – Obs Ana increasing in complexity
Complex medical problems now appear regularly on the labour ward
Increasing caesarean section rate,
Home birth in hospitals,
Obesity epidemic
Working with midwifery and obstetric colleagues

9. Personal specification
Able to work as part of a multidisciplinary team
seeing selected women antenatally
care of women during labour, delivery and post-partum.
A good understanding of what your obstetric colleagues are getting up to!
CTG, foetal blood gases, STAN

10. Skills
Skilled in regional analgesia/anaesthesia for labour and operative deliveries,
and perhaps on some occasions providing effective general anaesthesia for a caesarean section
Suitably skilled to recognise and treat the sick parturient on the labour ward and liaise with intensive care

11. Attitude Can work without a routine, sometimes at unsocial hours.
Recognises and enjoys the alternative lifestyle to that provided in a windowless operating theatre.
Willing to humbly accept praise, gratitude and even champagne for relieving pain and safely supporting a woman through a difficult delivery.

12. Training Women represent half of the population
caesarean section is the most frequently performed operation in the UK
Obstetric anaesthesia is a basic core topic in anaesthetic training
all trainees will spend a significant proportion of their early training/on-call years dealing with pregnant women.

13. Obstetric anaesthesia demands extra
at least six months as an obstetric fellow
out of programme training/research (OO PT)
fascinating opportunities for out of programme training in the developed or developing world.

14. Standards

15. Best Practice

17. Maternal Anaesthetic Emergencies

18. MBRRACE-UK: Lessons for anaesthesia
Anaesthetists (and maternity team) should practice drills for managing peri-operative airway crises including severe bronchospasm, mechanical obstruction and difficult intubation
Anaesthetists (and the maternity team) must be ready to deal with adverse effects of local anaesthetics including accidental intrathecal or intravenous injection
Prompt action and good communication within the maternity team are crucial when dealing with sudden unexpected catastrophes

19. Anaesthetic Emergencies
Failed Intubation
High/total spinal block
Local anaesthetic toxicity

20. Anaesthetic Emergencies
Not just emergencies involving the anaesthetist and the woman
Require multi-professional awareness and management

21. Failed Intubation

22. Indications for general anaesthesia
Severe maternal or fetal compromise requiring immediate emergency birth
Regional anaesthesia contraindicated (e.g. coagulopathy, haemodynamic instability)
Failed or inadequate regional anaesthesia
Maternal request

23. General anesthetic requires intubation in the pregnant woman
Placement of an endotracheal (ET) into the trachea to maintain an open and secured airway
Required because pregnant women are at increased risk of aspiration of gastric contents
Prevents aspiration during surgery
Failed intubation is an immediate life threatening emergency:
Failure to insert the ET tube into the correct place
The woman will be apnoeic, and without an ET tube oxygen may not reach the lungs
Explain what intubation is, why it is required and why failed intubation is an emergency.

24. Failed Intubation
More common in obstetric versus general surgical population (1:250 vs 1:2,200)
Complete dentition
Increased pharyngeal and laryngeal oedema
Large tongue, large breasts
Rapid desaturation and the stressful environment
Rising obesity rates are likely to make the situation worse

25. Intrauterine fetal resuscitation
Intrauterine fetal resuscitation for the compromised fetus:
S Stop syntocinon®: stop any oxytocin infusion
P Position – left lateral: to minimise aortocaval compression
I Intravenous fluid bolus: 250–500mL crystalloid to improve uteroplacental perfusion (if not contraindicated)
L Low blood pressure: treat (e.g. with fluids, vasopressors) if low
T Tocolysis: consider tocolytic to improve uteroplacental blood flow

26. Risk factors for difficult intubation
Known previous difficult intubation
Obesity
Pre-eclampsia
Congenital airway difficulties:
(e.g. Klippel-Fiel, Pierre Robin)
Acquired airway difficulties restricted neck movement, limited mouth opening:
(e.g. rheumatoid arthritis, ankylosing spondylitis, cervical spine fusions)
Discuss that high risk women should be referred for an anaesthetic review antenatally. Discuss your on unit’s policy and guidelines.

27. Use a ramped position for an obese woman –
Anatomical realignment using the Oxford HELP to improve intubating conditions
(© Alma Medical Products 2010, reproduced with permission)
Airway positioning
Using a ramped position for obese woman - to create a horizontal line between the sternal notch and the external auditory meatus

28. Failed intubation
When the anaesthetist has been unable to insert the endotracheal tube after two attempts
It is at this point that the failed intubation drill will begin and when help will be required from the team
Prepare to help after the first failed attempt at intubation.
Stress that at this point the woman’s life is in IMMEDIATE danger and that securing an airway is a priority. The team should support the anaesthetist.
The woman’s life is the priority and pressure to continue with the delivery should not be made by the obstetric team.

29. Failed Intubation
The anaesthetist and assistant will be unable to leave the woman so other team members will be needed to call for help
Collect specific items of equipment
Help with positioning and moving the patient
It will inevitably be a very stressful situation in which clear communication will be essential
The rest of the team should remain quiet, follow instructions and help the anesthetist and ODP.
No pressure to continue with the delivery should be made by the team until the anaesthetist has secured the airway.

30. Failed intubation The life of the woman is the anaesthetist’s priority
Sometimes the woman will be woken up
It might be appropriate to continue with surgery if oxygenation and ventilation are possible
If caesarean section is carried out under general anaesthesia without a secure airway it will be more risky
The most senior obstetrician should perform the surgery as quickly as possible
High concentrations of anaesthetic gases can cause uterine relaxation and increase the risk of haemorrhage
Fundal pressure may increase the risk of aspiration

31. Failed intubation – wake up or proceed
Explain that after a failed intubation the woman will normally be woken up and surgery will not be performed as the mother’s life takes priority.
In some circumstances if oxygenation and ventilation are possible (eg through a LMA) and suregry would improve the maternal condition (eg caesarean section for abruption) then surgery can proceed, however the most senior obstetrician avialble should perform the surgery as there is a greater risk of haemorrhage and the surgical time needs to be as short as possible.
OAA-DAS table to aid in the decision whether to wake the woman up, or to proceed with surgery in the event of failed intubation at caesarean section.
(Reproduced with permission from Obstetric Anaesthetists’ Association / Difficult Airway Society’)

32. Extubation & recovery from GA
Removal of the endotracheal tube is another time when airway emergencies can occur
Theatre staff should remain in theatre until the tube is safely removed and normal breathing is resumed
There may also be risks of respiratory complications during recovery from GA
Maternal mortality reports include women who have died from respiratory failure after GA at caesarean section
Staff should only recovery patients following GA if they have been regularly trained in theatre recovery

33. Failed intubation: best practice points
Identify women at risk of potential airway problems and refer for antenatal anaesthetic assessment
Early epidural in labour
Antacids (+ no solid food) in labour
Anaesthetists/anaesthetic assistants
check all intubation and difficult airway equipment daily
be familiar with its use and location
Take time to prepare before induction
Position & pre-oxygenate carefully
Call for help early and remember oxygenation is more important than intubation
Best practice is to prevent failed intubation.
Early epidurals in high risk patients should prevent the need for intubation as surgery can be performed under a regional block.
Antacids (e.g. H2 antagonists – Ranitidine 150mg 6hrly in labour) should be given to high risk women in labour )e.g. for woman with previous LSCS, twins, obesity, augmentation of labour (syntocinon infusion), suspicious CTG)
Correct positioning – see next slides

34. High / Total Spinal Block

35. High / Total spinal block
Height of block shows variability between individuals
High or total spinal block may result from:
Exaggerated response to correctly placed local anaesthetic
Consequence of local anaesthetic inadvertently placed in incorrect space, e.g. epidural local anaesthetic placed into intrathecal (spinal) space

36. Warning signs of rising block
Nausea
‘Not feeling right’
Breathlessness
Tingling, numbness or weakness in fingers or arms
Difficulty speaking
Difficulty swallowing
Sedation

37. ‘Total spinal’ It is a rare complication of epidural anaesthesia:
One end of a spectrum
Caused by direct action of local anaesthetic on high cervical nerve roots (includes nerves supplying diaphragm) and the brainstem.
Leads to:
Cardio-respiratory collapse
Unconsciousness
It is a rare complication of epidural anaesthesia:
incidence of approximately 1 in 16,000

38. Risk factors for high regional block
Accidental dural puncture (recognised & unrecognised) during epidural insertion
Accidental subdural placement of epidural catheter
Large or rapid epidural top-ups (e.g. for category one caesarean section)
Spinal injection with epidural in situ
Epidural top-ups after recent spinal injection

39. Local Anaesthetic Toxicity

40. Local anaesthetic toxicity
‘A woman of slight build had a low dose infusion epidural during labour and was delivered by forceps. She had some bleeding and intravenous fluid and Syntocinon infusions were started. Shortly after she had a grand mal convulsion followed by ventricular fibrillation from which she could not be resuscitated. She had received 150ml of a 500ml bag of 0.1% bupivacaine in saline intravenously in error.’ CEMACH 2003–05
Local anaesthetic toxicity normally caused by inadvertent administration of local anaesthetic intravenously.

41. Local anaesthetic toxicity
LA are used widely in obstetric practice
More than 30% of women have an epidural, spinal or caudal anaesthesia for labour or birth
MBRRACE-UK 2014 highlights that every epidural top-up is potentially dangerous if concentrations of greater than 0.1% bupivacaine are given
All maternity units should have lipid emulsion and a protocol for its administration available
Local anaesthetic toxicity normally caused by inadvertent administration of local anaesthetic intravenously.

42. Symptoms & signs of local anaesthetic toxicity
Warning signs
Tingling (mouth/tongue/lips) Metallic taste in mouth Ringing in ears Lightheadedness Agitation/‘just not right’ Tremor
Severe toxicity
Cardiovascular: Neurological:
– Bradycardia – Severe agitation
– Heart block – Convulsions
– Ventricular arrhythmias – Loss of consciousness
– Asystole / cardiac arrest
All doctors and midwives should be aware of the symptoms and signs of local anaesthetic toxicity especially of they administer local anaesthetic themselves

43. Management of local anaesthetic toxicity
Immediate management
Stop injecting LA
Call for help
Maintain airway, intubate if necessary
Give 100% oxygen and ensure adequate ventilation
Confirm/establish IV access
Control seizures
Assess cardiovascular status throughout
Prompt recognition, call for help and ABC approach

44. Management of local anaesthetic toxicity
In cardiac arrest
Without cardiac arrest
Use conventional therapies to treat
Hypotension
Bradycardia
Tachyarrythmias
Consider intravenous lipid emulsion
Commence ALS using standard algorithm
Treat arrhythmias using standard protocols
Give intravenous lipid emulsion
Continue CPR throughout treatment with lipid emulsion
Recovery may take longer than 1hr

45. Lipid emulsion for local anaesthetic toxicity
AAGBI guidelines 2010:
Lipid emulsion for local anaesthetic toxicity
AAGBI: Association of Anaesthetists of Great Britain and Ireland
Lipid emulsion does not obviate need for good quality CPR, which may be required for at least an hour.

46. Management of LA toxicity
Special points
Propofol is not a suitable substitute for lipid emulsion
Arrhythmias are very refractory to treatment
Lidocaine should not be used as an anti-arrhythmic in this setting

47. Communication

48. Communication

50. Communication

51. Communication

52. Sepsis

54. Enhanced maternal care 2018

60. Challenges in Pregnancy
Vital signs
Overlap between physiological changes and inflammatory process.
Immune modulation
Differential response to infection
Young patients can look well until they are nearly dead

61. Enhanced maternal care 2018

67. Role of anaesthetists and management of septic obstetric patients
Critical care skills
Management of resuscitation
Provision of anaesthesia for surgery
Transfer
ITU/HDU, imaging
Post operative care

68. Anaesthesia in the ill pregnant woman
Neuraxial anaesthesia is relatively contraindicated
Sympathetic blockade, coagulopathy, seeding
Individualised plans / case by case
No hard evidence or guidelines
Remifentanil PCA
limitations

69. Anaesthesia in the ill pregnant woman
Delivery considerations
Uterine / non-uterine source
Timing in relation to resuscitation
Antenatal maternal resuscitation is key to foetal wellbeing
General Anaesthesia
Unable to provide safe neuraxial
Control respiratory / cardiovascular changes
Difficult intubation / oedema

70. What do we want to know about?
Antenatal co-existing disease
Obstetric complications
Cardiovascular problems
Obesity
‘Back’ problems
Haematological issues
Diabetes / endocrine
Neurological

71. Role of the Anaesthetist
Integral part of care of the pregnant woman
Antenatal assessment, peri partum care, joint handover
Education - midwives, antenatal & enhanced recovery pathway, crisis resource management
High risk obstetric patient - assessment and stabilisation

72. Role of the Anaesthetist
Coordinate theatre, aid communication
Care of the critically ill pregnant or post partum woman
Sepsis in Pregnant Women
Cardiorespiratory Emergencies
Neurological Emergencies in Pregnancy

73. Thank you