Obstetric Anaesthesia Handbook

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The Simpsons Centre for Reproductive Health Obstetric Anaesthesia Handbook

A Guide for Anaesthetists

The Obstetric Anaesthesia Handbook

Published at the Royal Infirmary of Edinburgh, Edinburgh.

This edition published October 2020

Version 1.6.4

Wherever the art of medicine is loved, there is also a love of humanity. HIPPOCRATES

Excellence is an art won by training and habituation. We do not act rightly because we have virtue or excellence, but we rather have those because we have acted rightly. We are what we repeatedly do. Excellence, then, is not an act but a habit. ARISTOTLE

Contents

Contents 4 Contributors 16 Disclaimer 16 Terms of Use 17 Abbreviations & Acronyms 18 Obstetric Anaesthetic Staff & Service Provision 23 Consultant Obstetric Anaesthetic Staff 23 Secretary 24 Provision of Obstetric Anaesthetic Service 24 Training 24 Timetable 25 Weekday Routine 25 Weekly Routine 25 Monthly Routine 26 Cardiac Arrest and Collapse in Pregnancy 28 Introduction 28 Initiation of Cardiac Arrest Response 28 Responsibilities of Team Members 29 Modifications to Standard Algorithms 31 Maternal Collapse & Resuscitation of Pregnant Patient 34 Maternal Cardiac Arrest Protocol 35 Maternal Collapse: Non-cardiac Arrest Protocol 36 References 37 4

Management of Difficult and Failed Intubation 38 References 46 Antacid Prophylaxis during Established Labour in Preparation for Anaesthesia 47 Elective Caesarean Section 48 Anaesthesia for Emergency Caesarean Section 49 Emergency Caesarean Section Classification & Management: 49 Category 1 (formerly crash or stat) Caesarean Section 49 Category 2 (formerly urgent) Caesarean Section 50 Communication 52 Recovery from Epidural Top-up or Spinal Anaesthesia 52 Management of Severe Local Anaesthetic Toxicity 53 Recognition 53 Immediate Management 53 Treatment 54 Follow-up 55 Malignant Hyperthermia: Acute Management 58 Diagnosis 58 Initial Actions 59 Specific Management & Resuscitation 61 Task List 63 Dantrolene 65 Ongoing Management 66 5

Pharmacy Dispensary 66 Recovery & Further Management 67 Malignant Hyperthermia: Management of Susceptible Patients 70 Basic Principles 70 Preparation of the Anaesthetic Machine 70 Location of additional Vapor-Clean filters 71 Obstetric Haemorrhage 72 Introduction 72 Antepartum Haemorrhage 72 Postpartum Haemorrhage 73 Blood Products 73 Non-Blood Products 74 Uterotonics 75 Surgical techniques 76 Massive Placental Abruption 76 Antepartum Haemorrhage Protocol 79 Postpartum Haemorrhage Protocol 80 Major Obstetric Haemorrhage Protocol 81 Major Obstetric Haemorrhage Aide Memoire 82 References 84 Interventional Radiology in the Management of Major Obstetric Haemorrhage 85 Introduction 85 Planned LUSCS with Interventional Radiology 85 Emergency Management of MOH by Interventional Radiology 88 Stable patients with PPH 88

Internal Iliac Occlusion Balloon Catheters 89 References 92 Eclampsia and Severe Pre-eclampsia 93 Introduction 93 Definitions 93 Summary of End Organ Changes in Severe Pre- eclampsia 95 Management of Eclampsia 96 Management of Severe Pre-eclampsia 98 Managing Hypertension in Pre-eclampsia 101 Anaesthetic Considerations in the Treatment of Pre-eclampsia 104 Anaesthesia for Caesarean Section in Severe Pre-eclampsia 106 Magnesium Sulphate Protocol 108 Complications: Pulmonary Oedema 110 Complications: Oliguria 110 References 112 Standard Operating Procedure for Skin Asepsis Prior to Neuraxial Block Insertion 114 Standard Operating Procedure for Insertion of Neuraxial Blocks 114 Epidural Guidelines 116 Aims and Standards for Epidural Analgesia in Labour 116 Indications 116 Contraindications 117 Recommended Procedure 117

Indications to Call Anaesthetist 120 Removal of Epidural Catheter 121 Recovery from Epidural 122 References 122 Patient Controlled Epidural Analgesia (PCEA) 123 PCEA Advantages 123 PCEA Disadvantages 123 Regime for PCEA with McKinley Bodyguard Epidural Pump 123 Monitoring, Observations and Documentation 124 Contact Anaesthetist 125 References 125 Mobile Epidurals 126 Aim 126 Exclusions to Mobilising with Epidural 126 Extent of Mobilisation 127 Technique 127 Monitoring 129 Combined Spinal Epidural for Labour Analgesia 131 Introduction 131 Indications 131 Contraindications 132 Technique 133 Troubleshooting 134 References 134

Epidural Analgesia, Intravenous Fluid Administration and Blood Pressure Monitoring 136 Intravenous Cannulation 136 Blood Pressure Monitoring Following an Epidural 136 Management of Hypotension 137 Blood Pressure Maintenance with Phenylephrine Infusions 138 Introduction 138 References 140 Epidural Troubleshooting 141 Summary of Causes of Ineffective Epidurals 141 Signs and Symptoms of Incorrectly Placed Epidural 142 Causes of Ineffective Epidurals 142 Management of Insertion and Placement Difficulties 145 Management of Ineffective Epidurals 146 Additional Points 149 References 150 Accidental Dural Puncture 151 1. Re-insertion of Epidural Catheter at Another Interspace 151 2. Deliberate Insertion of the Catheter into the Subarachnoid Space 151 References 153 Treatment of Post Dural Puncture Headache 154 9

Management 154 References 157 High Regional or Total Spinal Block 159 Management 159 References 161 Postpartum Pain 163 Introduction 163 Caesarean Section, Rotational Forceps Delivery, Complex (3rd & 4th degree) Tears 163 Perineal Pain after Forceps or Spontaneous Delivery and Pain Associated with Haemorrhoids 167 After Pains 168 The Carefusion IVAC™ PCAM™ Pump for PCA after Caesarean Section under General Anaesthesia 168 Discharge Analgesia following Caesarean Section, Rotational Forceps Delivery, Complex (3rd & 4th degree) Tears 170 References 171 Post-operative Nausea and Vomiting 173 Risk factors for PONV include: 173 Prophylaxis 173 Treatment 174 Patient Controlled Analgesia in Labour with Remifentanil 175 Introduction 175 Criteria for use 175 10

Explanation and Verbal Consent 176 Observations 177 Safety Points 178 Remifentanil for Use During Caesarean Section Under General Anaesthesia 180 Introduction 180 Indications 181 Contraindications 181 Side Effects 181 Preparation 182 Regimen 182 References 183 Women Who Decline Blood Products 187 Introduction 187 Guidelines 187 Antenatal Care 188 Intrapartum Care 190 Haemorrhage 191 Postnatal Care 193 References 194 Diabetes and Pregnancy 195 Introduction 195 Gestational Diabetes 195 Flowchart for Gestational Diabetes: Antenatal Admission 196 Type I and Type II Diabetes Mellitus 198 Flowchart for Care of Women with Type I or Type II Diabetes in Pregnancy 199

IV Insulin Sliding Scale 201 Guideline for all Diabetic Pregnant Patients Receiving Steroids 201 IV Insulin Sliding Scale for Patients Receiving Steroids 202 Hypoglycaemia and Pregnancy 203 Diabetic Ketoacidosis and Pregnancy 203 References 207 Prophylaxis Against Venous Thromboembolism For Women Undergoing Caesarean Section 208 Introduction 208 Dosage and Timing of Dalteparin 208 Prescription 209 Duration of treatment 209 Cautions 210 Contraindications 211 Alternative management (when dalteparin contraindicated) 211 Table of Suggested Prophylactic Doses of Dalteparin Following Caesarean Section 211 Antibiotic Prophylaxis 213 Maternal Obesity 215 Introduction 215 Background 215 National Guidelines 216 Antenatal: Anaesthetic Assessment in Metabolic Clinic 216 Intrapartum 218

Equipment 218 Epidural analgesia 219 Spinal Anaesthesia 220 General Anaesthesia 222 Points to note 224 Postpartum 225 Associated documents 225 References 225 Needle phobia: Antenatal Guideline For Women Refusing Routine Blood Taking in the Community 227 Introduction 227 Aim 227 Guidelines 228 Referral Letter for All Patients with a West Lothian GP 231 Referral Letter for All Patients with a Non-West Lothian GP 234 Obstetric High Dependency Care 237 Admission Criteria 237 Conditions Requiring HDU Care 237 On Admission 237 On Discharge 238 Management of the Pregnant Patient in the Intensive Care Unit 239 Pregnant Patients Requiring Caesarean Section in the Intensive Care Unit 242

Points for the Intensivist and Obstetric Anaesthetist 242 Points for the Obstetrician, Obstetric Anaesthetist, Midwife and Scrub Team 243 Points for the ICU Nurse-in-Charge and Intensivist 244 Points for the Neonatal Team 245 Following Caesarean Section 246 Aide Memoire for Obstetric Anaesthetic Follow- ups 247 Minimal Interval from Delivery to Review 247 Ask About 248 Document 248 Further Follow-up 248 Headaches 249 Neurological problems 250 Feedback to Medical Staff 251 References 253 Management of Adverse Incidents in Obstetric Anaesthesia 254 Why Report? 254 How to Report 255 What Happens to Datix® Reports? 256 References 257 Guideline for the Care of Obstetric Anaesthetists after a Significant Adverse Event 258 Initial Response 258

Discussing the Adverse Event with Affected Staff 259 Arranging Support for Affected Staff 261 Support for Documentation of Adverse Event 263 Supporting Recovery and Return to Work 264 Providing/Receiving Feedback from Affected Staff 265 Sources of Additional Support 265 References 267 Appendix A: Checklist for Women Who Decline Blood Products 268 Appendix B: PCEA Prescription Chart 269 Appendix C: Obstetric Anaesthesia Handover 271 Appendix D: Society for Obesity and Bariatric Anaesthesia Summary 273 Appendix E: Women with Back Problems - Information for Pregnant Women 274 Appendix F: RIE Obstetric Anaesthesia Escalation Policy 277 Indications for Consultant Obstetric Anaesthetist Attendance & Consultation 277 Attendance of the Consultant Obstetric Anaesthetist for Epidural Analgesia 279

Contributors

This handbook has been written by the consultant obstetric anaesthetists at the Royal Infirmary of Edinburgh.

Designed and edited by Dr Alistair Simpson.

Disclaimer

The clinical guidelines have been authored and agreed by all the consultant obstetric anaesthetists working in the Simpsons Centre for Reproductive Health. They are consensus-based, using clinical evidence when it is available. They are not intended to anticipate every conceivable clinical situation and should be modified and adapted when required. The authors have no responsibility for the persistence or accuracy of URLs for external or third-party internet websites referred to in this publication and do not guarantee that any content on such websites is, or will remain, accurate or appropriate.

This handbook has been created for the exclusive use of staff (and anaesthetists in particular) working in the Royal Infirmary of Edinburgh. It may not been distributed, copied, shared or otherwise used outwith this institution without the explicit written consent of the editor. Failure to adhere to the terms of use is a violation of the copyright of the authors and editor and will be acted upon accordingly.

Abbreviations & Acronyms

The following abbreviations may be encountered during the course of exposure to obstetrics. Some abbreviations can have multiple meanings; the definitions given here are those pertaining to obstetrics.

AAGBI Association of Anaesthetists of Great Britain and Ireland AED Automated External Defibrillator AFE Amniotic Fluid Embolus AFI Amniotic Fluid Index APH Ante-Partum Haemorrhage ARM Assisted Rupture Membranes BTS Blood Transfusion Service CEMACH Confidential Enquiry into Maternal And Child Health CMACE Centre for Maternal And Child Enquiries CSE Combined Spinal Epidural CTG Cardiotocograph D&C Dilatation & Curettage DAS Difficult Airway Society DCDA Dichorionic Diamniotic twins EBL Estimated Blood Loss ECV External Cephalic Version (external manual rotation of in utero fetus (usually from breech to cephalic)) 18

EFW Estimated Fetal Weight FBC Full Blood Count FBS Fetal Blood Sample FH Fetal Heart (rate) FONA Front Of Neck Access (for emergency airway access) FSE Fetal Scalp Electrode GBS Group B Streptococcus GDM Gestational Diabetes Mellitus GTT Glucose Tolerance Test hCG human Chorionic Gonadotrophin HELLP Haemolysis, Elevated Liver enzymes, Low Platelets HFFD Haig-Ferguson Forceps Delivery HIE Hypoxic Ischaemic Encephalopathy HVS High Vaginal Swab IOL Induction of Labour IR Interventional Radiology IUFD Intrauterine Fetal Demise IUGR Intrauterine Growth Restriction IV Intravenous K(R)FD Keilland’s (Rotational) Forceps Delivery LMP Last Menstrual Period LOA Left Occiput Anterior LOP Left Occiput Posterior LOT Left Occiput Transverse L(U)SCS Lower (Uterine) Segment Caesarean Section 19

MEWS Maternal Early Warning Score MI Membranes Intact (or Myocardial Infarction) MOH Major Obstetric Haemorrhage MROP Manual Removal Of Placenta OA Occiput Anterior OAA Obstetric Anaesthetists’ Association ODP Operating Department Practioner OP Occiput Posterior OT Occiput Transverse PCEA Patient-Controlled Epidural Analgesia PCR Protein Creatinine Ratio PET Pre-Eclamptic Toxaemia (archaic terminology for pre-eclampsia) PID Pelvic Inflammatory Disease PIH Pregnancy Induced Hypertension PND Postnatal Depression PPH Post-Partum Haemorrhage

PROM Prolonged Rupture Of Membranes RFM Reduced Fetal Movement RIE Royal Infirmary of Edinburgh ROA Right Occiput Anterior ROM Rupture of Membranes ROP Right Occiput Posterior ROT Right Occiput Transverse SAD Supraglottic Airway Device SGA Small for Gestational Age 20

SPD Symphysis Pubis Dysfunction SRM Spontaneous Rupture Membranes SVD Spontaneous Vertex Delivery TENS Transcutaneous Electric Nerve Stimulator TOF Trial Of Forceps TOP Termination Of Pregnancy TXA Tranexamic Acid U&E Urea and Electrolytes UKOSS United Kingdom Obstetric Surveillance System VBAC Vaginal Birth After Caesarean section VTE Venous Thromboembolism

Administration & Contacts

Obstetric Anaesthetic Staff & Service Provision

Consultant Obstetric Anaesthetic Staff

Office Name Mobile/Pager Email Telephone

Dr Nicki 07713 23178 [email protected] Alexander 514233

Dr Amanda 07989 23226 [email protected] Bull 445540 Dr Ros Burns 23151 #6580 [email protected] Consultant Lead Dr Catherine 07879606584 [email protected] Collinson Dr Ollie 23153 07812141483 [email protected] Daly

Dr Karen 07711 23203 [email protected] Darragh 532754

Dr Craig 23141 07958379144 [email protected] Grice

Dr Shahul 07885 23218 [email protected] Hameed 566774

Dr Rachel 23154 07703359005 [email protected] Hignett Dr #6891 Bernhard 23159 [email protected] 07542328825 Heidemann Dr Naomi 23141 07845147228 [email protected] Hyndman

Dr Alistair 07659 22808 [email protected] Milne 525522

Dr Adam 07980 23219 [email protected] Paul 268047

Dr Linzi 07595 23210 [email protected] Peacock 920521

Dr #6301 Charlotte 22808 07973 [email protected] Scott 730116 Dr Alistair 07794 23153 [email protected] Simpson 406463

Dr Karen 07890 23154 [email protected] Stevenson 312992

Dr Kate 07796 23178 [email protected] Theodosiou 098287

Dr Sarah #6422 23154 [email protected] Thompson 07981242237

Dr Arlene 23178 07884432104 [email protected] Wise

Secretary Hazel Cherrie. Telephone: 23151. Email: [email protected].

Provision of Obstetric Anaesthetic Service A 24 hour clinical service is provided for labour analgesia and anaesthesia, anaesthesia for operative delivery, support for high dependency care, the assessment and management of high- risk pregnancy and for the management of obstetric emergencies.

Training Undergraduate, postgraduate and midwifery obstetric anaesthetic training are provided on an individual basis and as part of the weekly and monthly timetable.

Timetable

Weekday Routine 0800 – 0830 Anaesthetic trainee & consultant on-call handover 0800 Draw up emergency drugs and check anaesthetic machines 0830 Labour ward and HDU combined ward round with obstetric and midwifery staff (starts in labour ward resource room) 1200 HDU anaesthetic round to check laboratory results 1700 – 1800 HDU combined ward round and consultant handover 2000 – 2030 Anaesthetic trainee handover

Weekly Routine Monday: 1400 Perinatal mortality meeting Tuesday: 1300 Metabolic clinic Thursday: 0800 Case notes review meeting Friday: 0830 Perinatal morbidity meeting in Chancellor’s Building

0900 – 1300 High risk obstetric anaesthetic clinic

Monthly Routine Maternity Morbidity & Mortality Meetings These meetings occur on Friday afternoons approximately every 2 – 3 months. . Contact Dr Nicki Alexander for more information.

Obstetric Anaesthetic Trainee Tutorials These are held on an ad hoc basis depending on clinical activity.

Obstetric GA Simulation These sessions are held on an ad hoc basis depending on clinical activity.

PROMPT Course The PROMPT (PRactical Obstetric Multi- Professional Training) course takes place several times per year and includes participants from anaesthesia, obstetrics and midwifery. All anaesthetists working in the obstetric department are expected to attend a course every three years. To enquire or book a place, please contact Beth Turner ([email protected]).

Clinical Emergencies

Cardiac Arrest and Collapse in Pregnancy

Introduction Maternal collapse can be defined as reduction of maternal consciousness or cardiac arrest at any stage during pregnancy or in the early post partum period. This is a rare but potentially life threatening event thought to occur in up to 14:100,000 births and can arise from a number of problems with maternal cardiac, respiratory or neurological systems. The outcome for the mother, and often the fetus, relies on prompt recognition and effective management by a multidisciplinary team.

Initiation of Cardiac Arrest Response 1. In the event of a cardiac arrest, a call should be made to switchboard via the number 2222. A clear and concise message should be given stating: “maternal cardiac arrest” and request the “obstetric emergency team and the cardiac arrest team” (this is important; otherwise the respective teams will not be alerted to attend). Remember to give the location. The message should be repeated to avoid any misinterpretation.

2. A rapid call will be initiated by switchboard to all pagers on the group alert system:

Group One (general) CCU StR CCU senior nurse Anaesthetic StR On-call ODP

Group Two (obstetric) Resident Obstetric Anaesthetic StR (pager 2204) Resident Obstetric StR Obstetric Anaesthetic Consultant (pager 2003; 0800-1800 Monday – Friday)

Responsibilities of Team Members Before the team arrives It is the responsibility of the ward/departmental midwifery/nursing staff to institute basic life support. In the case of a pregnant patient ensure they are adequately tilted in the left lateral position using manual uterine displacement. The cardiac arrest trolley, including oxygen and suction, should be at the patient’s side before the arrest team arrives.

Where appropriately trained staff are available defibrillation should begin immediately, if indicated i.e. it should not be delayed until the

29 arrival of the arrest team. Cardiac rhythm monitoring (using Philips Multifunction Electrode Pads attached to the patient’s chest and connected to the Automated External Defibrillator (AED)) should be commenced as soon as practical.

When oxygen is available it should be attached to the bag valve mask reservoir system and administered without delay.

In cardiac arrest secondary to local anaesthetic toxicity, which is unresponsive to standard resuscitation treatment, intravenous treatment with Intralipid 2% is recommended. Bags of this are located on the cardiac arrest trolleys in obstetric theatres and labour ward respectively.

Team members: Roles on arrival Designated team leader The most senior StR for the unit concerned Responsible for the overall organisation and management of the arrest

Airway management The duty anaesthetist (if able to attend)

Airway assistant Duty ODP (if able to attend)

Medical and ODP staff may not be immediately available so the interim management of the arrest is the responsibility of the ward midwifery or nursing staff with the assistance of the senior midwife or nurse on his/her arrival. The senior midwife or nurse, on arrival, should assume responsibility for the management of the arrest pending the arrival of medical staff. Thereafter they will assist as required.

Cardiac arrest trolley locations Obstetric theatres (recovery bay) (Philips HeartStart XL+) Labour ward (in alcove next to room 5) (AED) Ward 119 (in corridor) (AED) Ward 211 (near entrance) (AED) Obstetric triage (in corridor) (AED)

Modifications to Standard Algorithms  Start resuscitation according to standard ALS guidelines.  The hand position for chest compressions may need to be slightly higher (2–3 cm) on the sternum for patients with advanced pregnancy (e.g. >28 weeks).  Manually displace the uterus to the left to minimise inferior vena cava compression.

 Defibrillation energy levels are as recommended for standard defibrillation. If left lateral tilt or large breasts make it difficult to place an apical defibrillator electrode, use an antero-posterior or bi-axillary electrode position.  Consider using a tracheal tube 0.5–1.0 mm smaller than usual as the trachea can be narrowed by oedema and swelling. Supraglottic airway devices are a suitable alternative if intubation is not possible and may provide a more rapid means of oxygenation than potentially prolonged intubation attempts.  Establish IV access as soon as possible, preferably at a level above the diaphragm (to avoid poor circulation of drugs and fluid from inferior vena cava compression).  Identify and correct the cause of the arrest using 4 Hs and 4 Ts as appropriate.  If resuscitation attempts fail to achieve return of spontaneous circulation, consider an immediate caesarean section to deliver the fetus. Aim to deliver the infant within 5 minutes of the mother’s cardiac arrest. This may benefit the mother from 20 weeks’ gestation onwards, when aortocaval compression can be significant, and benefit the newborn infant from 24 weeks’ gestation.

 The priority is always the treatment and survival of the mother.

Maternal Collapse & Resuscitation of Pregnant Patient

Maternal Cardiac Arrest Protocol

Maternal Collapse: Non-cardiac Arrest Protocol

References Deakin, C., Brown, S., Jewkes, F. et al. 2015. Resuscitation council (UK) guidelines 2015: Prehospital resuscitation. London: Resuscitation Council (UK). Johnston, T.A., Grady, K. 2011. Green-top guideline no. 56: Maternal collapse in pregnancy and the puerperium. London: Guidelines Committee of the Royal College of Obstetricians and Gynaecologists.

Management of Difficult and Failed Intubation

 Every woman seen by the anaesthetic team should have an airway assessment to predict possible difficulty with intubation, mask ventilation, supraglottic airway device (SAD) insertion and front-of-neck access.  Any patient with a predicted difficult airway should be discussed with the Consultant Anaesthetist.  Before starting a general anaesthetic, senior help and their whereabouts should be identified with the theatre team.  Optimal positioning including head up tilt or ramping is essential for all patients.  5 L/minute via nasal cannulae should be applied as soon as the patient arrives in theatre and should be left in place.  High flow nasal oxygen should be considered for the high risk patient after discussion with the consultant on duty.  Thorough preoxygenation should be performed, aiming for EtO2 of > 0.9.  Ensure appropriate doses of induction agent are given (thiopentone 5–7 mg/kg or propofol 2– 38

3mg/kg). An extra syringe of propofol should be within reach to help to prevent awareness or facilitate SAD insertion.  Ensure appropriate dose of muscle relaxant is given: approximately 1.5 mg/kg of actual body weight for suxamethonium and 1 mg/kg for rocuronium.  Gentle bag mask ventilation should be performed after the patient loses consciousness whilst waiting for the muscle relaxant to take effect.  During difficult laryngoscopy or bag-mask ventilation consider adjusting or removing cricoid pressure early.  Always remove cricoid during SAD insertion.  In the event of a failed intubation, the awake/proceed discussion should involve a Consultant Anaesthetist.

We have adopted the national OAA/DAS Guidelines for the management of difficult and failed intubation in obstetrics, as detailed in the following algorithms.

References Mushambi, M.C., Kinsella, S.M., Popat, M. et al. 2015. Obstetric Anaesthetists’ Association and Difficult Airway Society guidelines for the management of difficult and failed tracheal intubation in obstetrics. Anaesthesia (70)11: 1286- 1306.

Antacid Prophylaxis during Established Labour in Preparation for Anaesthesia

The following patients admitted in established labour and all potential emergency obstetric interventions should be given ranitidine 150 mg 6 hourly orally:

 All patients before receiving a first dose of opioid analgesia (morphine, diamorphine, remifentanil)  All patients before receiving epidural analgesia  All patients before receiving oxytocin to induce or augment labour  Before blood sent for group & screen if intervention is anticipated  ΒΜΙ > 35  Severe pre-eclampsia  Abnormal presentation  Multiple births  Antepartum haemorrhage  Previous caesarean section, other uterine surgery or post-partum haemorrhage > 1 litre  Trial of labour after previous caesarean section

 Abnormal CTG

A Patient Group Direction (PGD) is included in the Midwife Formulary for these indications.

If ranitidine has not been given within 6 hours of anaesthesia the anaesthetist may wish to give intravenous ranitidine when the decision to operate is made. When giving intravenous ranitidine, 50 mg should be diluted in a volume of 20 mL of sodium chloride 0.9% and given intravenously slowly over 3 minutes.

Sodium citrate (0.3M) 30 mL orally should also be given to all patients prior to inducing general anaesthesia.

Elective Caesarean Section Ranitidine 150 mg should be given orally 1 – 2 hours preoperatively. Where possible, it is recommended that the same dose is also given on the preceding evening. A PGD is included in the Midwife Formulary for this indication.

Anaesthesia for Emergency Caesarean Section

Identify women at high risk of operative delivery by consultation with co-ordinating midwife and obstetric staff. The duty anaesthetist should meet such women and discuss, where appropriate, advantages of early epidural analgesia. Regular antacid prophylaxis with ranitidine should be administered to such women (see guideline).

Emergency Caesarean Section Classification & Management: Category 1 (formerly crash or stat) Caesarean Section This indicates that conditions are immediately life threatening for the mother and/or fetus. This normally requires general anaesthesia unless contraindicated due to airway difficulties or other relevant maternal co-morbidity. 30 mL 0.5% sodium citrate should be administered before induction of anaesthesia. If adequate regional anaesthesia for immediate operative delivery has already been achieved by top-up of an existing well functioning epidural then this may be an alternative.

Category 2 (formerly urgent) Caesarean Section Indicates maternal and/or fetal compromise which is not immediately life threatening. Ask the responsible obstetrician for the time scale for delivery.

Existing effective epidural Top-up in labour ward with 10 – 15 mL 2% lignocaine + 1:200,000 adrenaline. Onset time of surgical anaesthesia can be reduced further by alkalinising 2% lignocaine + 1:200,000 adrenaline by adding preservative-free sodium bicarbonate 8.4% (2 mL), if available. Give a further 5 – 10 mL 2% lignocaine + 1:200,000 adrenaline and 3 – 4 mg epidural diamorphine in theatre. An additional 5 – 10 mL top-up may be required if the block is still not adequate for surgery (maximum dose 7 mg/kg). An alternative is 0.5% levobupivacaine, using volumes as above (maximum dose 2 mg/kg); however, block onset is slower and the risk of deleterious side-effects is greater (for instructions see “emergency epidural top-up” box kept in theatre 3).

Adequate epidural block for surgery requires absent light touch and pinprick sensation up to and including T5 or cold to T4. Skin over the operative site should be anaesthetic to a tight pinch with forceps. Motor block should be such that there is inability to perform a straight leg 50 raise with either leg. S1-S3 segments should be adequately blocked.

It is essential to remember that epidural anaesthesia will wear off with time. Additional top-ups will therefore be required depending on the duration of the operation. As a guide, begin additional top-up of the epidural 45 minutes after the first top-up when using 2% lignocaine.

No existing epidural or ineffective epidural in labour Spinal anaesthesia is advised with 2.5 – 2.7 mL 0.5% heavy bupivacaine with 0.3 – 0.4 mg diamorphine. Fentanyl 15 µg (0.3 mL) can be used in place of diamorphine to increase speed of preparation of spinal injection, but PCA morphine will be required post-operatively as its duration of action is only 3 – 4 hours.

Adequate spinal block for surgery requires a T4 – T5 sensory block as described above and complete motor block in both legs.

 If a spinal anaesthetic has to be given on top of a partially effective epidural, beware that the dosage of spinal injection needs to be reduced – failure to do so may result in a high or total spinal block. Trainees should discuss the dose with the consultant on duty and consider giving oral sodium citrate in case general anaesthesia is required. 51

Communication It is essential to communicate effectively with obstetric, midwifery and theatre staff on any change in the urgency of operative delivery as the emergency evolves. It is essential the fetal heart rate is monitored continuously. If there is any deterioration then a general anaesthetic may be indicated.

Recovery from Epidural Top-up or Spinal Anaesthesia During the recovery phase after a spinal anaesthetic or epidural top-up for a procedure, straight-leg raising should be used as a screening method to assess motor block. If the woman is unable to straight-leg 4 hours from the last dose of epidural/spinal local anaesthetic, the anaesthetist should be called to assess whether the woman’s care should be escalated to investigate the possibility of reversible causes of neurological injury.

Women should be informed of the likely timescale for resolution of their neuraxial block and encouraged to alert staff should this be delayed.

Management of Severe Local Anaesthetic Toxicity

Recognition Signs of severe toxicity:  Sudden alteration in mental status, severe agitation or loss of consciousness, with or without tonic-clonic convulsions  Cardiovascular collapse: sinus bradycardia, conduction blocks, asystole and ventricular tachyarrhythmias may all occur  Local anaesthetic toxicity may occur some time after an initial injection

Immediate Management  Stop injecting the local anaesthetic  Call for help  Maintain the airway and, if necessary, secure it with a tracheal tube  Give 100% oxygen and ensure adequate lung ventilation (hyperventilation may help by increasing plasma pH in the presence of metabolic acidosis)  Confirm or establish intravenous access

 Control seizures: give a benzodiazepine, thiopental or propofol in small incremental doses  Assess cardiovascular status throughout  Consider drawing blood for analysis, but do not delay definitive treatment to do this

Treatment In circulatory arrest  Start cardiopulmonary resuscitation (CPR) using standard protocols  Manage arrhythmias using the same protocols, recognising that arrhythmias may be very refractory to treatment  Consider the use of cardiopulmonary bypass if available

Give intravenous lipid emulsion (following the regimen overleaf)  Continue CPR throughout treatment with lipid emulsion  Recovery from local anaesthetic-induced cardiac arrest may take > 1 hour  Propofol is not a suitable substitute for lipid emulsion 54

 Lidocaine should not be used as an anti- arrhythmic therapy

Without circulatory arrest Use conventional therapies to treat:  Hypotension  Bradycardia  Tachyarrhythmia

Consider intravenous lipid emulsion (following the regimen overleaf)  Propofol is not a suitable substitute for lipid emulsion  Lidocaine should not be used as an anti- arrhythmic therapy

Follow-up  Arrange safe transfer to a clinical area with appropriate equipment and suitable staff until sustained recovery is achieved  Exclude pancreatitis by regular clinical review, including daily amylase or lipase assays for two days  Report cases as follows:

o in the United Kingdom to the National Patient Safety Agency (via www.npsa.nhs.uk) o in the Republic of Ireland to the Irish Medicines Board (via www.imb.ie) If lipid has been given, please also report its use to the international registry at www.lipidregistry.org. Details may also be posted at www.lipidrescue.org.

AND

–1 Do not exceed a maximum cumulative dose of 12 mL.kg

Malignant Hyperthermia: Acute Management

Diagnosis

Clinical Tachycardia Tachypnoea / raised EtCO2 Increased O2 uptake Masseter spasm after suxamethonium Rigidity / fasciculation Arrhythmias Cyanosis / low SpO2 Skin mottling

Temperature rise (approximately 1° / 5mins) Soda lime hot & rapidly consumed Sweating +++ Blood pressure unstable

Monitoring & Investigations Severe decrease in SpO2 Hypercarbia Metabolic acidosis Hyperkalaemia Myoglobinaemia Caogulation screen abnormality Creatine kinase increase

 Volatile agents can cause the onset of MH up to 2 hours after the start of anaesthesia.

Initial Actions  Discontinue anaesthetic immediately (when possible)  Remove anaesthetic vaporisers, turn oxygen flow to 10 L/min, put Vapor-Clean filters (charcoal filters which remove volatile anaesthetic) in the circuit. In emergency situations the filters only last for 1 hour due to the reservoir of volatile already in the patient. Filters must be changed at 1 hour, or the patient transferred to a volatile-free circuit. There is a stock of Vapor-Clean filters in the RIE and SJH.  Use TIVA for remainder of anaesthetic  Intubate patient & hyperventilate with 100% oxygen at 3x minute ventilation. Aim for EtCO2 of 3.5 – 4 kPa.  Ask surgeon to: o Abandon the operation as soon as is practical o Insert a urinary catheter  Send for, reconstitute and inject dantrolene  Commence body surface cooling with cool water sponging  Inform consultant anaesthetist in charge and get a second anaesthetist

 Inform critical care

MH Treatment Overview Hyperventilation Intubate and use 100% oxygen and no volatile agents. Use Vapor-Clean filters. When able, switch to new breathing system with new soda lime canister. Ventilate at approximately 3 x minute ventilation. IV cannula Large bore; cooled fluids.

Dantrolene 2.5 mg/kg IV rapidly. Cooling 1. Stop warming devices and switch to cooling mode if device permits. 2. Surface cooling with cool water sponging. 3. Monitor core temperature; aim to keep temperature < 41.5°C. Ice cooling is no longer recommended as it can cause intense vasoconstriction which retains body heat and can raise the core body temperature even more. 4. IV cooled fluids : 4 x 1000 mL 0.9% saline minimum stored in fridge. Alternatively put fluids in ice bucket to cool before administration. RIE: Cardiothoracic theatre 4; theatre 20-24 anaesthetic rooms. SJH: Fridge in Main Theatre Store Room.

Specific Management & Resuscitation Use two anaesthetists and ODP

 Hyperventilate o Intubate, 100% oxygen (use new breathing circuit, no volatile agent)

o 3 x minute ventilation; aim for EtCO2 of 3.5 – 4 kPa  Maintenance of anaesthesia o Propofol 1% (30-50 mL/hour or TCI 4 µg/mL)  Dantrolene o 2.5 mg/kg bolus then 1 mg/kg every 10 – 15 minutes IV (up to 10 mg/kg) until signs of hypermetabolism (acidosis, pyrexia, muscle rigidity) are resolving o Do not delay dantrolene to insert CVP line o Note that dantrolene can interact with calcium channel blockers (e.g. verapamil) and precipitate profound hypotension  Hyperkalaemia management o Hyperventilation

o Insulin 0.15 units/kg + 0.5 mL/kg 50% dextrose as rapid IV infusion (10 units insulin in 50 mL 50% dextrose in adults) o Calcium chloride 10% 0.1 mL/kg or calcium gluconate 10% 0.3 mL/kg  Arrhythmia management o Amiodarone: 3 mg /kg slowly IV o Lignocaine: 1 mg/kg IV o Metoprolol: 1-2 mg IV as required o Magnesium 2 g (8 mmol) over 15 minutes. Repeat once. o Hyperkalaemia management as above  Acidosis management o Dantrolene (treats primary cause) o Hyperventilation o Consider 0.5 – 1 mmol/kg sodium bicarbonate for pH < 7.2. 8.4% sodium bicarbonate is 1 mmol/mL: give 100 – 200 mL and review.  Renal management o Maintain urine output 2 mL/kg/hour by maintaining intravascular volume: 0.9% saline

o Mannitol 20% (at room temp) 2 mL/kg/hour up to 500 mL o Frusemide 40 mg IV o Forced alkaline diuresis (mannitol, frusemide , sodium bicarbonate) for myoglobinaemia. May require subsequent renal replacement therapy.  Inotropic support o Adrenaline / noradrenaline infusions as required  Disseminated intravascular coagulation o FFP, cryoprecipitate, platelets o Check plasma CK as soon as able

Task List  Ensure temperature probe inserted o Tissue destruction will occur from approx 41.5°C o Do not overcool: cease active cooling if temp drops to 38°C  Insert arterial line o Check arterial blood gases o Pay particular attention to: 63

. Acidosis . Hyperkalaemia

. PaCO2 . Glucose level . Urea and electrolytes . Creatine kinase and myoglobin (lithium heparin tube) . Coagulation screen  Urine o Once urinary catheter in situ send 20 mL urine sample for myoglobin o Maintain urine output at ≥ 2 mL/kg/hour

 Anaesthetic record o Ensure an accurate anaesthetic record is being kept o Document times, temperatures, drugs and monitor recordings o Document blood results  Insert central venous line when appropriate

Dantrolene Get malignant hyperthermia box Locations RIE: General/Orthopaedic theatre recovery - Clean Utility Area – lower shelf Critical Care (Ward 118) lean Utility Area – work surface corner SJH: Main theatre suite – Recovery Room on dedicated trolley

MH box contents  Dantrolene sodium: 12 vials x 20 mg  Water for injection: 8 bottles x 100 mL  1 bottle opener  Set of instructions Dantrolene reconstitution 1. Lay out contents on trolley 2. Mix dantrolene o Mixing dantrolene can be very time consuming. Use as many people as are available. o 12 vials will be required for a 100 kg patient up to every 10 minutes o Dantrolene must only be mixed with sterile water

. 60 mL water for each 20 mg vial o Arrange for 12 more dantrolene vials to be brought to theatre from pharmacy immediately . 800 mL (8 x 100 mL bottles) of sterile water for injection are required per box of 12 dantrolene vials

Ongoing Management Ensure adequate stocks of resuscitation & TIVA drugs are maintained Ensure the following are available in theatre:  Frusemide  Mannitol 20%  Insulin  Dextrose 20% or 50%  Contact Pharmacy for additional dantrolene if required

Pharmacy Dispensary RIE: Monday to Friday 0830 – 1830 Ext 22911 Saturday 0830 – 1500 Ext 22911 Sunday 1000 – 1400 Ext 22911

SJH Monday to Friday 0900 – 1700 Ext 52037 Saturday 0915 – 1400 Ext 52037

Out with these times, contact the on-call pharmacist via the hospital switchboard. If necessary more dantrolene can be mobilised from other hospitals: ask Pharmacist to co-ordinate.

Recovery & Further Management With rapid diagnosis and treatment most cases of MH will recover. After the initial crisis has been stabilised, the patient should be admitted to an intensive care unit noting the following: Retriggering May occur Oral dantrolene (if possible) should be given for 48 hours: 4 mg/kg/day in divided doses Unnecessary stress should be avoided as this can trigger MH

Hypothermia Can be induced by over vigorous cooling during recovery

Diuresis Should be maintained to reduce the possibility of myoglobin induced renal failure

Bleeding disorders A DIC type coagulopathy is common

Pulmonary oedema Common

Muscle oedema Compartment Syndrome may require fasciotomy. Spinal anaesthesia is often the method of choice for this.

Consider other diagnoses Myopathy Ecstasy ingestion Neurolept malignant syndrome

Further management Patients suspected of having MH and their blood relatives should be counselled regarding implications of MH and referred later for formal investigation. The patient is referred via the NHS Lothian Safe Haven pathway. This referral should be discussed / approved by your Clinical Director. See http://intranet.lothian.scot.nhs.uk/Directory/safe haven/Pages/default.aspx.

Additional support Malignant Hyperthermia Services University Dept. of Anaesthesia St. James's University Hospital Leeds LS9 7TF

Leeds malignant hyperthermia hotline Direct line: 0113 206 5270 Fax: 0113 206 4140 Emergency Hotline: 07947 609601 (usually available outside office hours)

Malignant Hyperthermia: Management of Susceptible Patients

Basic Principles  Do not use trigger agents i.e. volatile anaesthetic agents and suxamethonium. All other muscle relaxants as well as IV agents are considered to be safe.  Use a TIVA technique  Monitor temperature continuously intraoperatively  Postoperatively continue measuring temperature and heart rate every 15 minutes for 4 hours

 It is safe to recover MH susceptible patients alongside patients who have received volatile anaesthetics, as the concentration of volatile in the air will not reach a level that can trigger MH (5ppm).

 Same day discharge of day surgery patients is safe, following standard discharge criteria

Preparation of the Anaesthetic Machine Follow these steps in this order:

1. Ensure that anaesthetic vaporizers are disabled by removing them 2. Remove old breathing circuit & reservoir bag 3. Replace the soda lime with a fresh canister 4. Flush the machine with air at a rate of > 10L/min for 90 seconds 5. Place Vapor-Clean filters on both inspiratory and expiratory limbs. These filters are effective in keeping gas concentration below 5 ppm for up to 12 hours with fresh gas flows of at least 3 L/minute. 6. Attach a new breathing circuit & reservoir bag 7. Change the filters after 12 hours of use

Location of additional Vapor-Clean filters Within NHS Lothian filters can be sourced from: RIE main recovery (in the MH kit): telephone extension 23130 RIE obstetric theatres (in theatre 3 anaesthetic room): telephone extension 23113 SJH Main Theatre Stock Room: telephone extension 54268

Obstetric Haemorrhage

Introduction Obstetric haemorrhage is any significant blood loss in pregnancy or labour, or a blood loss of more than 500 mL after delivery. The recent UK triennial report and the Scottish Audit of Severe Maternal Morbidity identify haemorrhage as a persistent cause of maternal morbidity and death. Prompt assessment, management, communication with and early involvement of senior medical and midwifery staff are essential to minimize catastrophic outcomes.

Antepartum Haemorrhage Antepartum haemorrhage (APH) complicates 3% of pregnancies: One-third due to placental abruption One-third due to placenta praevia One-third due to other causes (e.g. uterine rupture) Placental abruption refers to the abnormal separation of the placenta from the uterine wall. Blood loss and a loss of the circulatory communication between the maternal and placental circulation can cause fetal compromise. Placenta praevia refers to the abnormal implantation near the uterine os and carries a high risk of severe haemorrhage.

Uterine rupture is more common after previous caesarean section, a short time interval since previous caesarean section and induction of labour.

Postpartum Haemorrhage Postpartum haemorrhage is classified according to the five Ts: Tone (uterine atony): accounts for 70% of PPH Tissue (retained products of conception) Thrombin (coagulopathy) Trauma Toxins Postpartum haemorrhage is more common after placenta praevia, multiple pregnancy, polyhydramnios, previous PPH, Asian ethnicity, obesity, prolonged labour and primiparae over 40 years of age.

Blood Products Four units of O-negative blood are kept in the blood fridge next to theatre 3; these should be used if there is any delay in providing type-specific or fully crossmatched blood. Electronic issue of crossmatched blood means that blood can be issued rapidly; two blood samples are needed by the BTS laboratory to provide this.

Consideration should always be made of blood products other than red cell concentrate in the context of ongoing haemorrhage. Clinical information and investigations such as ROTEM® will help to guide this. Fresh frozen plasma and platelets are now given earlier than previously, and usually with ratios of FFP and red cells near 1:1.

Fibrinogen levels fall in obstetric haemorrhage and low levels are associated with poorer outcomes. A fibrinogen level of >2 g/L should be targeted. Cryoprecipitate and FFP should be considered to replace low fibrinogen.

Other products such as fibrinogen concentrate and Factor VIIa should be used in consultation with the consultant anaesthetist and haematologist.

Non-Blood Products Cell salvage is available in obstetric theatres and should be considered in any obstetric patient at higher risk of haemorrhage. Cell salvage should not be used without tranexamic acid (1 g over 10 minutes) (NICE 2015).

Tranexamic acid is currently under consideration as a standard treatment for obstetric haemorrhage and should be given in major 74 obstetric haemorrhage. A dose of 1 g is given over 10 minutes.

Calcium levels fall in haemorrhage; these are replaced by administering 10 mL of 10% calcium gluconate.

Hypothermia impairs coagulation; all IV fluids should be warmed using a warming device and a forced air warmer should be considered to warm the patient if required.

Uterotonics Uterotonics are an important part of the management of uterine atony with or without ongoing haemorrhage: Syntocinon® (synthetic oxytocin): 5 + 5 units IV Side effects: hypotension and reflex tachycardia Syntocinon® infusion: 40 units in 500 mL 0.9% saline (or 100 mL in patients with pre-eclampsia) Ergometrine (an ergot alkaloid): 500 µg IM or IV (higher risk of severe adverse reactions if given IV), repeated to a maximum of 2 doses in total Side effects: diarrhoea, nausea and vomiting Contraindicated in pre-eclampsia as can cause severe, prolonged hypertension Carboprost (prostaglandin F2α): 250 µg IM every 15 minutes to a maximum of 8 doses in total 75

Side effects: bronchospasm, hypertension Contraindicated in asthmatics Misoprostol (prostaglandin E1): 400 µg – 1 mg PR, SL or orally.

Surgical techniques Techniques which may be undertaken by the obstetricians to control haemorrhage include: Intrauterine balloon tamponade (e.g. Bakri® balloon) Uterine compression sutures (e.g. B-Lynch suture) Interventional radiology (e.g. internal iliac balloon occlusion) Pelvic vessel ligation Hysterectomy

Massive Placental Abruption Abruption definition Partial or complete separation of placenta from uterine wall prior to delivery of the fetus.

Signs of massive abruption Sudden onset of severe abdominal pain and tenderness Maternal shock (sometime disproportionate to revealed blood loss) Uterine irritability:

Uterus may be woody hard on palpation (not seen if placenta posterior), or CTG may show frequent, small contractions (can look like tachysystole) Fetal compromise on CTG or intrauterine fetal death If fetal death is associated with clinical diagnosis of abruption always consider massive abruption and complications, e.g. DIC (30% cases) – even if not present at diagnosis these are likely to develop within a few hours.

Risk factors (list not exhaustive) Previous APH in this pregnancy Previous abruption IUGR Polyhydramnios Advanced maternal age Multiparity Smoking/cocaine/amphetamines

Management Involve experienced obstetric and anaesthetic staff immediately. The most senior staff in the hospital for both specialities must attend the patient immediately and if not resident the on-call consultants must be asked to come in.

Resuscitate and manage as per major obstetric haemorrhage guideline. Ensure volume replacement is adequate (risk of renal failure). Immediate point of care testing – take extra green blood tube for ROTEM® and extra 2 mL syringe blood sample for HemoCue® as soon as diagnosis made.

Delivery If there is significant haemorrhage and the CTG is not normal then expedite delivery by caesarean section. In other situations various factors will dictate decision: maternal condition, gestation, amount of haemorrhage and fetal monitoring and viability. Generally delivery will be vaginal; labour can be very rapid in this situation. However if massive abruption occurs and the patient is not in labour, especially with actual or potential DIC, a caesarean section should be considered. If bleeding into the myometrium has occurred (Couvelaire uterus) this can impede the ability of the uterus to contract thus delaying labour and also increasing the risk of postpartum haemorrhage. Delay makes DIC more likely. If the maternal condition is stable and an assisted rupture of membranes (ARM) is possible, then this should be done immediately. Oxytocin can be used for augmentation although it is rarely needed. ITU/HDU care will be needed after delivery.

Antepartum Haemorrhage Protocol

Postpartum Haemorrhage Protocol

Major Obstetric Haemorrhage Protocol

Major Obstetric Haemorrhage Aide Memoire

Time #1: Time #2: Time #3:

MOH 2222 call Time By whom Step down call Senior anaesthetist called Time Senior anaesthetist

IV access #1

IV access #2

Arterial line

CVP line

Bair Hugger®

Temperature

Belmont® rapid infuser

Cell salvage

Hemocue®

ROTEM®

BTS products Products ordered Time ordered Time arrived 82

ABG

FBC

Coagulation

U&E

Tranexamic acid

Second dose antibiotic Transfer Departure time Destination

Notes: Use this table as an aide memoire during a major obstetric haemorrhage. Boxes can be ticked to indicate completion and results/details entered as appropriate. Enter times in the column headers.

References Knight, M., Kenyon, S., Brocklehurst, P. et al. [eds] 2014. Saving Lives, Improving Mothers’ Care Lessons learned to inform future maternity care from the UK and Ireland Confidential Enquiries into Maternal Deaths and Morbidity 2009-2012. Oxford: MBRRACE-UK. Brace, V., Penney, G., Hall, M. 2004. Quantifying severe maternal morbidity: a Scottish population study. British Journal of Obstetrics and Gynaecology, 111(5): 481-4. Lennox, C., Marr, L. 2014. Scottish Confidential Audit of Severe Maternal Morbidity: reducing avoidable harm - 10th Annual report. Edinburgh: Healthcare Improvement Scotland. Paterson-Brown, S., Howell, C. [eds]. 2014. Massive Obstetric Haemorrhage. In: Paterson- Brown, S., Howell, C. [eds] Managing Obstetric Emergencies and Trauma, 3rd ed. Cambridge: Cambridge University Press, 297-312. Plaat, F., Shonfeld, A. 2015. Major obstetric haemorrhage. BJA Education, 15(4): 190-3. National Institute for Health and Care Excellence. 2015. Blood transfusion NICE guideline NG24. London: NICE.

Interventional Radiology in the Management of Major Obstetric Haemorrhage

Introduction Interventional Radiology (IR) has a place in the prevention of haemorrhage with placenta accreta by placement of internal iliac artery balloon catheters prior to caesarean section. Embolisation down these catheters can also be carried out postpartum or as a de novo procedure. This guideline identifies the staff and equipment necessary for the management of these patients as well as the location for their treatment.

Planned LUSCS with Interventional Radiology Indications  Patients at high risk of probable placenta accreta  All Lothian women with a known anterior placenta praevia and a history of previous caesarean section should deliver at RIE

Informing Relevant Senior Staff The patient should have been previously scanned by Dr Walker to identify potential placenta accreta/percreta (as per placenta praevia protocol). The date for LUSCS should be agreed between patient’s Obstetric Consultant, Senior 85

Obstetrics/Gynaecology Consultant and Anaesthetic Consultant (Hazel Cherrie (telephone extension 23151) will let you know which Anaesthetic Consultant is on on the proposed day). If possible provide at least 2 weeks’ notice to Interventional Radiologist and Superintendent Radiographer (Joan Ritchie or deputy) on extension 23788.

Location of LUSCS All procedures will take place in theatre 3 (configuration of theatre 2 is not suitable for IR equipment).

Patient Preparation  Patient should be consented for LUSCS, interventional radiology and hysterectomy  Fast and oral ranitidine  Baseline U&E, FBC, coagulation and crossmatch major obstetric haemorrhage (MOH) pack (inform BTS of possible placenta accreta)  Insert urinary catheter and apply diathermy pad on ward, i.e. prior to the insertion of femoral artery catheters)  Partner to remain on postnatal ward Anaesthesia  Minimum of 2 experienced anaesthetists & 2 ODPs 86

 The ODPs should book the carbon fibre table top from vascular theatre as soon as notified of the date of LUSCS and bring it to theatre 3 on day  Arterial line insertion prior to GA  Liaise with radiologist regarding correct positioning of vascular catheters prior to GA  ‘High flow’ central line inserted after induction of anaesthesia  Rapid infuser blood warmer and cell saver must all be available and primed  Forced air warmer, HemoCue®, ROTEM® and temperature probe should be available  Drugs to be readily available: usual GA drugs plus vasopressors and oxytocin infusion 40 units/500 mL 0.9% saline  Double check MOH pack available  Inform ITU/HDU of possible admission  If significant accreta, femoral sheaths to stay in situ for at least 12 hours, attached to a flush bag, and to be removed by anaesthetist  Inform paediatricians if using remifentanil

Emergency Management of MOH by Interventional Radiology Indications  Unstable patient who cannot be moved to IR. There must be consultant to consultant communication prior to decision regarding site of ongoing management.  Uncontrolled haemorrhage after using conventional obstetric measures, either prior to or after hysterectomy at time of LUSCS or with PPH  Undiagnosed placenta percreta noted prior to uterine incision on opening the abdomen at time of LUSCS

The radiologist will come to theatre to insert femoral artery balloons. Switchboard will have on- call radiologist’s and radiographer’s contact numbers. Get C-arm and table from outside theatre 19. Expected time for IR staff to set up is approximately 1 hour. Attempts to correct coagulopathy should be ongoing.

Stable patients with PPH These are patients who continue to bleed vaginally or internally on return to the labour ward due to genital tract trauma after spontaneous or instrumental vaginal delivery, 88

LUSCS, or hysterectomy. Uterine atony would normally be treated by conventional obstetric measures. The patient should go to the IR suite. A CT angiogram is performed and interpreted by an interventional radiologist who will decide whether or not to proceed to embolisation in the vascular lab, whilst the patient remains in the radiology department.

Internal Iliac Occlusion Balloon Catheters These catheters are placed immediately prior to surgery in women who have a significant risk of life threatening haemorrhage. If inflated, these balloons can significantly reduce intraoperative haemorrhage. They are inserted under radiological guidance via access sheaths placed in the common femoral arteries, passed over the iliac bifurcation and into the contralateral internal iliac arteries. As such, they carry significant risks themselves and require careful management.

Management CTG monitoring There is potential to compromise uterine blood supply with the catheters even without the balloons inflated, therefore there must be continuous CTG monitoring during radiological placement of the balloon catheters and at all

89 times thereafter (other than transfer up to theatre).

Patient must remain supine with legs straight This will minimise the risk of catheters dislodging which can render them ineffective or cause arterial damage. Urinary catheter must be inserted prior to radiological placement of the balloon catheters. In the rare event of epidural analgesia being used post operatively, the epidural must also be inserted prior to balloon catheter placement.

Both femoral access sheaths (for the internal iliac catheters) have side arms that must be attached to pressurised saline bags via pressure transducer sets at all times Unpressurised bags can lead to backflow of arterial blood or thrombus formation on or in access sheath.

Pressurised saline bags must remain hanging at all times Bags lying in the bed risk air emboli due to air entering the line from the giving set. Radiology use pressurised saline bags with heparin. These can be changed in theatre to standard invasive monitoring saline flush bags without heparin.

Sheaths must not remain in situ longer than necessary This is due to increased risk of intra-arterial thrombus, acute limb ischaemia and vascular damage.

Responsibility These lines are the responsibility of the inserting radiologist pre- and intra-operatively. Post- operatively, they are the responsibility of the anaesthetic team.

Removal Plan should be documented as follows:

Internal iliac sheaths to be removed at: Right ______am/pm Left ______am/pm

To be removed by ______

 20 – 30 minutes of direct continuous firm pressure over arterial puncture site (arterial puncture site may be 2 – 3 cm or more proximal to skin puncture site depending on body habitus)  Bed rest for 6 hours after removal  Beware of the potential for haematoma and limb ischaemia after sheath removal: there

should be hourly assessment of puncture site and lower limb perfusion for 6 hours (white, painful leg reflects ischaemia)

References Mok, M., Heidemann, B., Dundas, K. et al. 2008. Interventional radiology in women with suspected placenta accreta undergoing caesarean section. International Journal of Obstetric Anesthesia, 17(3): 255-61. Arulkumaran, S., Walker, J.J., Watkinson, A.F. et al. 2007. RCOG Good Practice Guideline No. 6: The role of emergency and elective interventional radiology in postpartum haemorrhage. London: RCOG. Johnston, T.A., Paterson-Brown, S. 2011. Green- top guideline no. 27: Placenta praevia, placenta praevia accreta and vasa praevia : diagnosis and management. London: Guidelines Committee of the Royal College of Obstetricians and Gynaecologists. Paterson-Brown, S., Singh, C. 2010. Developing a care bundle for the management of suspected placenta accreta. The Obstetrician & Gynaecologist, 12(1): 21-7.

Eclampsia and Severe Pre-eclampsia

Introduction Pre-eclampsia affects 2 – 8% of pregnancies with 0.5% of maternities in the UK suffering severe pre- eclampsia. Eclampsia affects 2.7/10,000 maternities. The fatality rate from pre- eclampsia/eclampsia is at its lowest rate of 0.25/100,000 maternities due to good standards of care. Eclampsia is part of the clinical spectrum of pre-eclampsia. Seizures may complicate pre- existing pre-eclampsia or be the first presentation of the condition. The Confidential Enquiries into Maternal Deaths persistently show substandard care when looking after affected patients. In particular, the control of hypertension and management of fluid balance have been highlighted.

Definitions  Pre-eclampsia gestational hypertension of >140/90 mmHg on two separate occasions ≥4 hours apart accompanied by significant proteinuria of >300 mg in a 24-hour collection of urine, arising after the 20th week of gestation in a previously normotensive woman and resolving completely by the 6th postpartum week

 Severe pre-eclampsia is pre-eclampsia with severe hypertension and/or with symptoms, and/or biochemical and/or haematological impairment  Eclampsia is defined as one or more convulsions in association with pre- eclampsia  Mild hypertension is a diastolic blood pressure 90 – 99 mmHg, systolic blood pressure 140 – 149 mmHg  Moderate hypertension is a diastolic blood pressure 100 – 109 mmHg, systolic blood pressure 150 – 159 mmHg  Severe hypertension is a diastolic blood pressure 110 mmHg or greater, systolic blood pressure 160 mmHg or greater

Summary of End Organ Changes in Severe Pre- eclampsia

CVS Hypertension and ↑SVR ↓plasma volume ↑response to vasopressors ↓capillary oncotic pressure (COP) Normal or ↓cardiac indexDisparity between CVP and pulmonary arterial wedge pressure (PAWP) ↑capillary permeability

RS Risk of pulmonary oedema (low COP + ↑capillary permeability)

Hepatic Periportal necrosis Subcapsular haemorrhage Spontaneous liver rupture

CNS Vasospasm Ischaemia Cerebral oedema Haemorrhage Hypertensive Encephalopathy

Renal Glomerular swelling Fibrin deposition Oliguria Proteinurea ↓GFR

Haematology Low grade DIC Haemolysis (HELLP)

Management of Eclampsia Immediate resuscitation Call for Help Dial 2222: State “Obstetric Emergency” and location

Airway Flatten and place in left lateral position Assess airway – Clear and maintain

Breathing High flow oxygen

Circulation Intravenous access x 2 (16 gauge) Bloods Brown tube U&Es, LFTs, urate Red tube FBC Green tube Coagulation Blue tube Group and save Yellow tube Serum glucose Fluid restriction to 80 mL/hour

Immediate management of seizure Obtain Eclampsia box from labour ward, antenatal ward or obstetric triage Magnesium sulphate See Magnesium sulphate protocol Recurrent seizure

2 g bolus of magnesium sulphate over 5 minutes or 4 g bolus over 5 minutes if >70 kg at booking Third or more seizure Consultant anaesthetist and obstetrician must attend and consider intubation, ICU management and CT brain. Maternal stabilisation and blood pressure control is vital prior to intubation in order to minimise maternal risk. Neuroimaging should be performed urgently if any focal neurology present or persistent seizures. Consider use of diazepam or thiopentone/propofol.

Maternal monitoring Once initially stabilised, transfer to labour ward MEWS chart Pulse, respiratory rate, oxygen saturations measured every 10 minutes for two hours then half hourly. Blood pressure Appropriate size/ level of heart. Korotkoff 5 (silence). Correlate manual with automated BP cuff. Every 15 minutes until stable, then half hourly. Keep BP<150/100.

Fetal assessment Continuous CTG in acute setting

Plan for delivery after mother stabilized, discuss with consultant regarding induction of labour versus caesarean section Ultrasound scan: growth, liquor volumes, umbilical artery Doppler if conservative management

Treat hypertension See Managing Hypertension in Pre-eclampsia Only oxytocin should be used for third stage (risk of precipitating rapid rise in blood pressure with ergometrine or Syntometrine®)

Management of Severe Pre-eclampsia The following signs and symptoms in isolation or any combination may indicate fulminating pre- eclampsia. Transfer to labour ward and consider delivery. Management plan should be discussed at obstetric and anaesthetic consultant level.

Definition Severe hypertension (diastolic >110 mmHg or systolic >160 mmHg) and proteinuria (PCR >30 mg/mmol or >300 mg protein in 24 hour urine collection). or Mild or moderate hypertension (140/90 – 159/109 mmHg) and proteinuria with at least one of the following: 98

Severe headache Visual disturbances Severe RUQ pain or vomiting Papilloedema Signs of clonus (> 3 beats) Liver tenderness HELLP syndrome Platelets falling <100 x 109/L Abnormal liver enzymes (ALT > 70)

Symptoms & signs Cerebral: Headache, blurred vision, altered consciousness, hyperreflexia, clonus Respiratory: Shortness of breath, pulmonary oedema or cyanosis Liver: Epigastric or right upper quadrant abdominal pain, vomiting Renal: Oliguria Bloods: Raised urate, creatinine or urea Impaired liver function tests Thrombocytopenia (platelet count <100 x 109/L or falling rapidly) HELLP

Management IV access & bloods FBC, U&Es, coagulation, LFTs, urate, group & save Monitor

Start MEWS chart Blood pressure every 15 minutes for 2 hours then half-hourly Pulse, oxygen saturation and respiratory rate every 10 minutes for 2 hours then every 30 minutes Monitor fluid balance and urine output carefully Commence CTG Ranitidine 150 mg orally Fast patient Steroids If <34 weeks’ gestation Treat hypertension See Managing Hypertension in Pre- eclampsia Magnesium sulphate Discuss magnesium sulphate with consultant. Should only be used in very severe cases and great caution if used antenatally due to possible effect on fetus, interaction with anaesthetic drugs and risk of uterine atony. See Magnesium Sulphate Protocol Fluid balance Catheterise Commence fluid balance chart Restrict to 80 mL/hour total intake

100

If urine output < 120 mL in 6 hours then manage according to Management of Oliguria in Treatment of Pre-eclampsia Delivery Discuss mode of delivery with on call obstetric consultant

Managing Hypertension in Pre-eclampsia Target blood pressure should be clearly documented in patient’s notes, usually 140-150 mmHg systolic and 90-100 mmHg diastolic. Beware synergistic effects of different drug classes including magnesium sulphate; cases of severe hypotension have been reported. An interaction between nifedipine and magnesium sulphate leading to profound muscle weakness has been reported. Anaesthetic staff should be informed of patients, as invasive monitoring may be required.

First line: Labetalol 200 mg orally stat. Repeat dose once after 30 minutes if no response. Cautions Contraindicated in patients with AV block or bradycardia (<60 bpm) Caution in patients with asthma

101

Second line: Nifedipine (if labetolol contraindicated) 10 mg orally (not sublingual) Wait 30 minutes; repeat dose once if necessary

Third line: Labetalol intravenously If oral therapy inadequate Target blood pressure should be clearly documented in patient’s notes Bolus 50 mg over 5 minutes Repeat to a maximum of 200 mg in 10 minute intervals Rate Infusion rate is started at 4 mL/hour (20 mg/hour) Rate doubled every 30 min to a maximum of 32 mL/hour or until target blood pressure is achieved (usually less than 150/95 mmHg) Cautions Labetalol should be used with caution in patients with asthma/liver damage Contraindicated in patients with AV block or bradycardia (<60 bpm) Monitor blood pressure closely during administration, check manually before major treatment decisions made Beware of pulmonary oedema Side Effects

102

Headache, dizziness Sweating Tremor Urinary retention Ankle oedema Masks symptoms of hypoglycaemia GI upset Sleep disorder Hallucinations and rarely psychoses

Fourth line: Hydralazine intravenously To be considered where labetalol either unsuitable or unsuccessful Bolus 10 – 20 mg every 10 – 20 minutes Measure BP every 5 minutes 5 mg (5 mL) IV bolus may be given slowly Run at 2.5 mg/hour (2.5 mL/hour) Rate doubled every 30 minutes until target blood pressure achieved then maintain Rate should not exceed 10 mL/hour Consider alternatives if tachycardia, flushing or nausea are problems Do not infuse with glucose Side Effects Profound hypotension (rapid dose increase) Flushing Nasal congestion

103

Palpitations Tachycardia GI upset

Epidural An epidural is useful in controlling blood pressure

Anaesthetic Considerations in the Treatment of Pre-eclampsia Regional analgesia and anaesthesia Epidural analgesia is recommended. This will help to prevent surges in blood pressure and may improve perfusion through the feto-placental unit. An epidural can be topped up for surgical intervention as usual. Note: An epidural is not a substitute for intravenous antihypertensive therapy and these drugs should be continued throughout anaesthesia.

Spinal anaesthesia is not contraindicated in severe pre-eclampsia. Blood pressure is better maintained than in non pre-eclamptic patients therefore vasopressor use is reduced.

Contraindications to regional blockade The usual contraindications apply. In addition note that: Platelet counts may fall rapidly 104

A platelet count should be taken within 6 hours of regional blockade If platelets >100 x109/L proceed with block If platelets <100 x109/L take coagulation sample and perform ROTEM®  Platelets 75 – 100 x109/L, coagulation screen & ROTEM® normal: proceed with block  Platelets <75 x109/L or coagulation screen or ROTEM® abnormal: block contraindicated

Other considerations An increased dose of intrathecal drug may be required if patient is preterm with a small uterus Vasopressors should be used with caution. Patients with severe pre-eclampsia are very sensitive to vasopressors and large surges in blood pressure may result. May require long spinal or Tuohy needles due to oedema Avoid adding epinephrine to solutions Caution with IV fluid administration (easy to precipitate pulmonary oedema because of increased vascular permeability) Epidural catheter removal should not be undertaken until thrombocytopenia and coagulation have been corrected

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Withhold dalteparin until coagulation status verified post-operatively

Anaesthesia for Caesarean Section in Severe Pre- eclampsia Patients should not be delivered until medically stable i.e. blood pressure and fitting controlled Continue intravenous antihypertensives throughout duration of anaesthesia

Regional anaesthesia See above Preferable to general anaesthesia if possible

General anaesthesia Call for senior anaesthetic help Assess airway. Beware facial oedema and hoarseness of voice or voice change (may predict difficult intubation). Prepare drugs and equipment for difficult and failed intubation, especially videolaryngoscope and small endotracheal tubes Consider arterial line if blood pressure unstable, receiving ≥ 2 intravenous antihypertensives, or receiving magnesium Modify RSI to attenuate haemodynamic response to laryngoscopy; consider using: Magnesium 4 g IV over 15 minutes, if not already given 106

Alfentanil 1 – 2 mg Remifentanil infusion during preoxygenation at 0.2 – 0.5 µg/kg/minute. At clinician’s discretion give a bolus of 0.5- 1 µg/kg at induction Labetalol, if not already receiving intravenous infusion Tracheal intubation If trauma occurs, perform laryngoscopy prior to considering extubation and assess for leak around ETT whilst maintaining cricoid pressure Non-depolarising neuromuscular blockade will be prolonged by magnesium therefore blockade should be guided by neuromuscular monitoring Cautious infusion of IV fluids. Replace deficits including blood loss.

Prevention and treatment of postpartum haemorrhage Use syntocinon instead of syntometrine® for management of postpartum haemorrhage. Ergometrine is contraindicated in hypertensive patients as it causes a further rise in BP which may precipitate a stroke.

Analgesia NSAIDs should be avoided until severe pre- eclampsia resolving

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Magnesium Sulphate Protocol Discuss with consultant prior to commencement An interaction between nifedipine and magnesium sulphate leading to profound muscle weakness has been reported

Loading dose Magnesium Sulphate 4 g over 15 minutes Draw 8 mL of 50% magnesium from 10 mL vial Add to 100 mL bag of 0.9% saline IV infusion at 400 mL/hour

Maintenance Magnesium 1 g per hour Maintenance for 24 hours after last seizure or until 24 hours after delivery, whichever is later 10 mL of 50% magnesium (5 g) Add to 40 mL 0.9% saline (total volume 50 mL) IV infusion at 10 mL/hour

Second seizure 2 g (4 mL) of 50% magnesium over 5 minutes or 4 g over 5 minutes if booking weight >70 kg Make up to 10 mL with 0.9% saline

Monitoring of patient receiving magnesium infusion Respiratory rate, reflexes and oxygen saturations should be measured every 10 minutes for two

108 hours then half hourly. Urine output should be checked hourly. Oxygen saturation If <95% (on air), stop infusion and inform senior duty doctor Patellar/arm reflexes If absent, stop infusion and inform senior duty doctor Respiratory rate If < 12, stop infusion and inform doctor Urine volumes If < 20 mL/hour, half infusion If <10 mL/hour, stop infusion If any of the above adverse signs occur then check magnesium levels (magnesium toxicity level >5 mmol/L). Therapeutic range is 2 – 4 mmol/L.

Side effects Nausea, vomiting, diarrhoea Dizziness, confusion Itching/tingling Thirst Muscle weakness, reduced or absent tendon reflexes Hypotension, palpitations, tachycardia Respiratory depression and arrest Cardiac arrest

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Calcium gluconate Calcium gluconate 10% 10 mL should be administered over 10 minutes in the event of respiratory depression or cardiac arrest. Remember to stop magnesium infusion.

Complications: Pulmonary Oedema Consider if oxygen saturation <95 %, tachypnoea, dyspnoea or cough.

Management Sit patient up High flow oxygen via face mask with reservoir bag Exclude sedation from opiates Chest x-ray Arterial blood gases Inform senior anaesthetist and obstetrician Very careful fluid balance with fluid restriction Furosemide 10 – 20 mg slowly IV Consider ICU referral

Complications: Oliguria Defined as urine output <120 mL in 6 hours Consult senior obstetric and anaesthetic staff Assess patient including auscultation of chest, measurement of respiratory rate and oxygen saturation Check urinary catheter not blocked 110

Check pre-eclampsia bloods if not performed in last 4 hours Consider overall fluid balance: calculate and replace fluid deficits Administer fluid challenge 250 mL Plasmalyte over 15 minutes and assess at one hour At one hour: If urine output ≥ 20 mL then return to 80 mL/hour fluid regime If urine output < 20 mL then discuss central venous pressure (CVP) line

CVP Action <0 mmHg Repeat 250 mL Plasmalyte over 15 minutes Check CVP after fluid bolus

0 – 5 mmHg Continue with 80 mL/hour (1 mg/kg/hour) Check CVP hourly

>5 mmHg Furosemide 10 – 20 mg IV Check CVP after 30 minutes If oliguria persists check U&Es If urine output <20 mL/hour consult with renal physician

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References Knight, M. on behalf of UKOSS. 2007. Eclampsia in the United Kingdom 2005. British Journal of Obstetrics and Gynaecology, 114(9): 1072-1078. National Institute for Health and Clinical Excellence. 2010. NICE guidelines CG107: Hypertension in pregnancy: diagnosis and management. London: National Institute for Health and Clinical Excellence. MBRRACE-UK. 2015. Saving Lives, Improving Mothers’ Care: Surveillance of maternal deaths in the UK 2011-13 and lessons learned to inform maternity care from the UK and Ireland Confidential Enquiries into Maternal Deaths and Morbidity 2009-13. Oxford: MBRRACE-UK. Winter, C., Crofts, J., Laxton C. et al [eds.]. 2013. PROMPT course manual. Second edition. Cambridge: Cambridge University Press. Tranquilli, A.L., Dekker, G., Magee, L. el al. 2014. International Society for the Study of Hypertension in Pregnancy. The classification, diagnosis and management of the hypertensive disorders of pregnancy: A revised statement from the ISSHP. Pregnancy hypertension, 4(2): 97-104.

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Anaesthesia & Analgesia Epidurals

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Standard Operating Procedure for Skin Asepsis Prior to Neuraxial Block Insertion

We have had many pressure sores in labouring women in SCRH between 2010-2012. Unfortunately there was another case in May 2015. They occurred mainly in patients with epidurals for labour and coincided with a change in skin asepsis from betadine to chlorhexidine. The pattern of injury suggests that when chlorhexidine is not allowed to dry and pools (e.g. wet sheets, wet inco pads, wet clothes, wet CTG straps) and pressure is sustained to this area, then burns and ulcers may result.

Standard Operating Procedure for Insertion of Neuraxial Blocks  Once the patient is positioned, tuck an inco pad over underwear or CTG straps below the prep area  Before scrubbing, anaesthetist to apply 0.5% chlorhexidine spray to the back (only one application is required) and allow to dry  Spray application of chlorhexidine will prevent contamination with chlorhexidine of other equipment on the epidural trolley

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 Once block inserted, remove the inco pad and also ensure any wet sheets, clothing or CTG straps are removed  Instruct the midwife to fill out the relevant columns on the PCEA chart, i.e. skin check hourly and position change hourly  Warn patients about the risk of pressure sores and advise them to change position regularly

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Epidural Guidelines

Aims and Standards for Epidural Analgesia in Labour Establish effective analgesia before a mother has severe uncontrolled pain Attend within 30 minutes of request for analgesia, subject to staff availability Maintain analgesia during the second stage of labour Convert analgesia to anaesthesia for instrumental or operative delivery when required (anaesthetist to top-up)

Indications  Maternal request  Prolonged and painful labour (e.g. request for a second dose of diamorphine)  Malpresentation  Anticipated or actual instrumental delivery  Trial of labour  Pre-eclampsia  Diabetes  Obesity (BMI > 35)

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 Uncoordinated uterine activity managed by oxytocin infusion  Multiple pregnancy  Cardiac and respiratory disease

Contraindications Absolute  Full anticoagulant therapy  Coagulopathy  Hypovolaemia  Refusal by mother  Local anaesthetic allergy  Lack of appropriately trained staff

Relative  Local or systemic sepsis (mild pyrexia is not a contraindication)  Raised intracranial pressure  Fixed cardiac output

Recommended Procedure Establish the indication and review obstetric, medical and anaesthetic history.

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Fetal monitoring CTG for a period of 15 minutes before an epidural is sited CTG should be interpreted before starting the procedure Fetal heart monitored by CTG or by auscultation every 15 minutes The need for a fetal scalp electrode should always be considered.

Consent Provide mother with the laminated Epidural Information Card if she is considering an epidural and before she is distressed with pain. Obtain an informed, verbal consent, which should include a description of the technique, the benefits and an explanation of possible complications including:  Headache (1 in 100)  Backache (short term slight risk, long term no risk)  A very small risk of neurological damage (temporary 1 in 1,000, permanent 1 in 13,000)  Hypotension with consequent nausea or dizziness  Failure or patchy or unilateral block (1-2 in 10)  An increased risk of instrumental delivery (no increased risk of caesarean section) 118

 Itch  Anything the patient specifically wants to discuss

Techniques Ensure resuscitation equipment available Intravenous access (16G cannula) obtained, using local anaesthetic and flushed with 0.9% saline Full asepsis Make sure epidural filter is connected firmly to epidural catheter by ‘tug-test’ and wrap in sterile, transparent PVC bag from pack (see laminated illustration) Test dose (either 4 mL 2% lidocaine, or 10 mL of bag mixture) Aspirate before all top-ups Usual method of epidural analgesia is PCEA with bag mixture (0.1% levobupivacaine + 2 µg/mL fentanyl) via McKinley BodyGuard pump; 15 mL initial bolus loading dose Alternative is to prescribe intermittent top-ups to be given by midwife (5 + 5 + 5 mL) Top-up bags to be locked in drug cupboard not taken to birthing room

PCEA, mobile epidurals and CSE all have separate guidelines

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Monitoring Pulse and blood pressure PCEA: every 5 minutes for 20 minutes after loading dose, then half-hourly Intermittent top-ups: every 5 minutes for 20 minutes after all top-ups Pain assessment Motor block assessment Ensure 2-hourly position change for care of pressure areas

Indications to Call Anaesthetist  Systolic blood pressure decreases 20% below baseline  Patient feels nauseated or light-headed  Sensory level of block extends above the xiphisternum  Patient is unable to bend her knees or leg weakness is getting worse  Respiratory rate below 9 per minute  Analgesia inadequate  Instrumental delivery required  Fetal blood sampling (indication for anaesthetist to check epidural functioning well as may require rapid top-up for delivery)  Disconnected filter: 120

o Immediate discovery of disconnection: cut 10 cm off catheter with sterile scissors, wipe with alcohol/chlorhexidine skin wipe, allow to dry and reattach o Unknown duration of disconnection: resite epidural

Removal of Epidural Catheter Weight >60 kg and blood loss <1500 mL Epidural catheter can be removed without needing to assess FBC or coagulation. Dalteparin should be prescribed for 4 hours after the time of catheter removal, if obstetric bleeding has stopped.

Weight <60 kg and PPH*, or Blood loss >1500 mL, or Risk of ongoing bleeding (e.g. sepsis, thrombocytopenia, abruption or other consumptive process) Discuss the management of the epidural catheter with an anaesthetist prior to removal and dalteparin prescription. FBC, coagulation and/or ROTEM® may aid decision making.

*the volume of PPH of significance will depend on the individual patient if her weight is <60 kg. Remember that circulating volume in parturient at 121 term is approximately 100 mL/kg; therefore if weight is 50 kg then 1250 mL = 25% of total blood volume.

Recovery from Epidural During the recovery phase after an epidural, straight-leg raising should be used as a screening method to assess motor block. If the woman is unable to straight-leg raise 4 hours after epidural removal the anaesthetist should be called to assess whether the woman’s care should be escalated to investigate the possibility of reversible causes of neurological injury.

Women should be informed of the likely timescale for resolution of their neuraxial block and encouraged to alert staff should this be delayed.

References Faculty of Pain Medicine of the Royal College of Anaesthetists. 2010. Best practice in the management of epidural analgesia in the hospital setting. Available at http://www.aagbi.org/sites/default/files/epidural _analgesia_2011.pdf (accessed 31 May 2016). Jain , A., Chandra, R. 2016. [letter]. Anaesthesia News, 343: 29.

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Patient Controlled Epidural Analgesia (PCEA)

PCEA Advantages Parturient determines own degree of analgesia No delay between demand and delivery of top-up improves satisfaction Minimises midwifery time checking drugs and monitoring blood pressure Sealed system reduces infection and prevents accidental intravenous administration of local anaesthetic Less local anaesthetic is used compared to continuous infusions which improves mobility

PCEA Disadvantages Increased costs and time setting up and explaining the system Possibility of inadequate analgesia left untreated Possibility of undetected catheter migration Pump programming error

Regime for PCEA with McKinley Bodyguard Epidural Pump Use 0.1% levobupivacaine + fentanyl 2 µg/mL (250 mL pre-mixed bags) Test dose 4 mL 2% lidocaine (omit if mobile epidural)

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Loading dose 15 mL of mixture given from pump Pump pre-programmed as PCEA obstetrics, check settings with midwife

Background infusion Bolus dose Lockout Max per hour 5 mL/hour 10 mL 20 minutes 55 mL

Lockout Max per hour 20 minutes 55 mL

Monitoring, Observations and Documentation Blood pressure Following loading dose check every blood pressure every 5 minutes for 20 minutes. Record these readings on the epidural chart. Enter the baseline blood pressure (pre-epidural) and 15 minute blood pressure onto the white PCEA chart (see Appendix B). Thereafter check blood pressure every 30 minutes, regardless of timing of self-administered top-ups Check if parturient feels faint, unwell or CTG is non-reassuring.

Sedation score, pain scores and straight leg raising Record hourly Score these from 0 – 3 as described on the chart

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Bolus delivered and bolus demanded Record hourly These are obtained using the info button on the pump (press repeatedly to show total volume infused, bolus summary etc.)

Total volume infused Record hourly This is displayed constantly on the screen on the pump Ensure 2-hourly position change for care of pressure areas

Contact Anaesthetist If analgesia is inadequate For instrumental delivery as a stronger top-up will be required

References van der Vyver, M., Halpern, S. Joseph, G. 2002. Patient-controlled epidural analgesia versus continuous infusion for labour analgesia: a meta- analysis. British Journal of Anaesthesia, 89(3): 459-465. Halpern, S., Carvalho, B. 2009. Patient-controlled epidural analgesia for labor. Anesthesia and Analgesia, 108(3): 921-928.

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Mobile Epidurals

Aim To produce epidural analgesia which minimises motor block (leg weakness) while still providing analgesia. Note that mobility is not guaranteed and that motor block assessment must be carried out prior to any mobilisation. This service may not be available 24/7 and will depend on the level of activity in the labour ward and staff availability.

 Prior to requesting epidural analgesia CTG must be monitored and assessed for non- reassuring features for 15 minutes

Exclusions to Mobilising with Epidural  Obesity: upper weight limit of 100 kg (in case leg weakness occurs and assistance to return to bed is required which would be a manual handling issue)  Absence of person to assist with mobilisation  Diamorphine within previous 4 hours  Any hint of drug or alcohol usage by the parturient  Risk of cord prolapse

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 Failure of motor power assessment (see below)  Postural hypotension (see below) or feeling faint on standing  Advanced labour needing a rescue epidural for analgesia

Extent of Mobilisation  Transfer from bed to chair or bouncy ball, walking around birthing room or using toilet within birthing room  Constant presence of one person to assist with balance at all times (partner or midwife)  Motor power assessment must take place after each top up.  Mobilisation will only take place once a full motor power assessment has been carried out  If the parturient has been sitting or lying for 1 hour or more motor assessment must be repeated before further mobilisation  Appropriate footwear must be worn

Technique Venous access with a 16G cannula flushed with 0.9% saline should be established

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Epidural should be sited in the standard manner

1. Choose the Bodyguard pump marked ‘mobile epidural’ 2. Prime giving set and select ‘Labour ward, protocol (infusion at 0.1 mL/h, 0 mL PCEA bolus) 3. Give an initial dose: 10-20 mL (in 10 mL increments) 0.1% bupivacaine plus 2 μg/mL fentanyl (no lignocaine test dose) delivered by clinician bolus via the pump 4. Prescribe top-up doses for midwife administration on anaesthetic chart 5. Top up of ‘Mobile Protocol’ to be administered by the midwife a. 10 mL 0.1% levobupivacaine plus 2 μg/mL fentanyl can be administered every 30 minutes b. top-ups should only be given with the patient in bed c. to give a bolus: i. Press stop ii. Press bolus iii. Enter level 2 code: 855 and ‘ok’

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iv. Enter 10 mL and ‘ok’, bolus will be delivered

Monitoring  Pulse and blood pressure: every 5 minutes for 20 minutes following top up  Check for postural hypotension: blood pressure is checked immediately after standing and compared to the blood pressure when lying down. Postural hypotension is defined as a decrease in systolic blood pressure of 20 mmHg or more when standing  CTG will be monitored continuously by telemetry. If telemetry is unavailable standard CTG monitoring will be used, but mobilisation will be restricted to standing beside the bed or sitting in a chair next to the CTG machine.

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 Motor power assessment will be carried out by the midwife. Motor power assessment will be a 4 stage test. Parturient must be able to do all 4 stages below prior to walking:

Stage 1 Able to fully straight leg raise

Stage 2 Aware of normal sensation in soles of feet Stage 3 Able to stand beside bed with two assistants for balance – not for support Stage 4 Able to do three knee bends with help to balance only

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Combined Spinal Epidural for Labour Analgesia

Introduction Combined spinal epidural (CSE) is a useful analgesic technique in labour in selected patients. The onset of analgesia is slightly faster with CSE compared with epidural analgesia. Combined spinal epidural in labour was thought to enable women to mobilise for longer compared with epidural analgesia, but this is not supported by a recent Cochrane review. Combined spinal epidural in labour is associated with more pruritis if fentanyl (25 µg) is used compared with low-dose epidural analgesia, but no difference has been found in the incidence of post dural puncture headache, epidural blood patch, maternal hypotension, maternal satisfaction and mode of delivery. The Third National Audit Project (NAP3) reports the incidence of permanent harm from obstetric CSEs to be very rare: with pessimistic interpretation of the data they estimate this rate to be approximately 1:25,000. Use of CSE in labour is a skilled anaesthetic technique which requires training to perform competently.

Indications Combined spinal-epidural is recommended for women who require rapid analgesia in labour, i.e.: 131

 Patients requiring regional analgesia in advanced labour  Patients requiring analgesia in labour who are very distressed  Resiting of failed or poorly functioning epidural  Patients who have the urge to push against a non-fully dilated cervix

Contraindications  Usual contraindications to regional blockade  Morbidly obese patients  Potentially difficult airways  Poor fetal CTGs

Reliability of the epidural component needs to be assured. Where labour CSEs are used, spinal block precludes testing efficacy of the epidural component until the spinal block regresses.

 CSE is not contraindicated in the morbidly obese patient undergoing anaesthesia for caesarean section: CSE may be very useful in this situation

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Technique  CSE in labour should only be undertaken by senior anaesthetic trainees who are trained in this technique or by consultant anaesthetists  An ODP should be asked to assist and to check intrathecal drugs  Spinal block is established with 1.25 – 1.5 mL 0.25% plain bupivacaine and 25 µg fentanyl  Flush the Tuohy needle with a few millilitres of 0.9% saline to aid threading of the epidural catheter after spinal  Thread the epidural catheter as normal, secure, aspirate, and finally flush with another couple of millilitres of 0.9% saline  The first epidural top-up including test dose should be given by anaesthetist when spinal block begins to regress and patient requests further analgesia  Recommended test dose: 10 mL low dose bag mix (0.1% bupivacaine with 2 µg/mL fentanyl). A further 5 mL of low dose bag mix (total 15 mL) completes the top up dose. Low dose test dose may prolong duration of mobility  Subsequent epidural top ups are the same as for standard labour epidurals  A PCEA can be commenced 133

Troubleshooting Unable to obtain CSF with spinal needle Remove epidural needle and realign to try to obtain CSF. (The epidural catheter is more likely to work if CSF is obtained as this suggests that needle is midline). If loss of resistance has been very difficult to achieve, thread and secure epidural catheter. If dura has not been breached then attempt single shot spinal preferably at another appropriate level, or at the same level. If dura has been breached, then do not puncture dura a second time. Use the epidural catheter for analgesia.

Unable to thread epidural catheter Flush the Tuohy needle with more 0.9% saline and try again. If unsuccessful, then repeat epidural.

Failed or partially failed epidural analgesia Manage as for a standard epidural.

References Simmons, S.W., Taghizadeh, N., Dennis, A.T. et al. 2012. Combined spinal-epidural versus epidural analgesia in labour. Cochrane Database of Systematic Reviews, 10, CD003401.

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Cook, T.M., Counsell, D., Wildsmith, J.A. 2009. Major complications of central neuraxial block: report on the Third National Audit Project of the Royal College of Anaesthetists. British Journal of Anaesthesia, 102(2): 179-90. National Institute for Health and Clinical Excellence. 2014. NICE guidelines CG190. Intrapartum care for healthy women and babies. London: National Institute for Health and Clinical Excellence.

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Epidural Analgesia, Intravenous Fluid Administration and Blood Pressure Monitoring

Intravenous Cannulation A 16G intravenous cannula should be inserted in the hand or arm using local anaesthesia before inserting an epidural. The cannula should be flushed with 0.9% saline to ensure patency.

Intravenous fluids (normally Hartmann’s solution) are administered during labour for a number of specific purposes, for example:

 The infusion of drugs: e.g. oxytocin, antibiotics  For dehydration following prolonged fasting, vomiting or diarrhoea  To treat hypotension induced by an epidural or spinal anaesthetic

Blood Pressure Monitoring Following an Epidural The midwife should check the blood pressure and fetal heart rate every 5 minutes for the first 15 minutes after the first epidural dose or after a top up After 5 minutes in the prescribed position the mother may lie in whichever position she prefers

136 subject to the fetal heart rate and blood pressure remaining stable

Management of Hypotension If at any time the systolic blood pressure falls below 100 mmHg or by 20% of baseline the midwife should inform the anaesthetist and proceed as follows:

 Ensure the mother is in the lateral position (left or right depending on fetal heart)  Elevate the feet  Connect a 500 mL intravenous bag of Hartmann’s/Plasmalyte 148 solution and infuse it rapidly  Give oxygen 4 L/min by Hudson mask  If required, the anaesthetist will give intravenous phenylephrine or ephedrine  Check the blood pressure and fetal heart rate every 5 minutes for the next 15 minutes or every minute if the blood pressure is falling. Ephedrine must be available on the epidural trolley at all times.

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Blood Pressure Maintenance with Phenylephrine Infusions

Introduction Phenylephrine, a directly acting α-agonist used for the treatment of hypotension, has been shown to be a useful vasopressor in obstetric anaesthesia and does not cause a decrease in fetal cord pH. As it has a relatively short half-life it lends itself to administration by continuous IV infusion when treating hypotension induced by regional or general anaesthesia for operative / assisted delivery.

Indications Contraindications

Hypotension following Known sensitivity to regional anaesthesia for phenylephrine assisted or operative Hypertension delivery Severe pre-eclampsia or Hypotension following eclampsia (relative) general anaesthesia for assisted or operative delivery

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Preparation Regime

Inject 10 mg of Operative or assisted delivery phenylephrine into a 500 mL under spinal anaesthesia bag of 0.9% saline solution Start infusion at a rate of 60 to 90 (final concentration 20 mL/hour immediately after µg/mL) injecting spinal drugs. Adjust infusion rate according to Draw up 50 – 60 mL into a clinical response. syringe fitting into a Graseby syringe driver (e.g. 3100, Operative or assisted delivery 3400) under top-up epidural anaesthesia or general Connect the syringe to a anaesthesia Westcott Sae-flo anti-syphon Start infusion at a rate of 30 to 90 extension set (200 cm) and mL/hour if clinically required. flush through If phenylephrine is required consider giving a bolus of 40 µg Load the syringe into the (2 mL) before infusing. syringe driver and connect Adjust infusion rate according to the extension tubing to the clinical response. patient's IV access via a Coventry connector Use pump to administer 20 or 40 (MediPlus 6510) µg boluses as indicated

Use the purge or bolus Terminate or reduce infusions function on the driver to rapidly immediately after ensure the extension is delivery of the fetus if mother flushed prior to connecting remains symptom-free

Always administer together with a running IV infusion

This guideline does not cover the use of phenylephrine infusions in any cases other than uncomplicated deliveries.

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In the event of phenylephrine being unavailable, metaraminol infusion may be used instead, as follows: dilute 10 mg (1 mL ampoule) metaraminol with 59 mL 0.9% saline (0.17 mg/mL). Run at 40 mL/hour and increase/decrease by 10 mL/hour as required.

References Ngan Kee, W.D., Khaw, K.S., Ng, F.F. 2004. Comparison of phenylephrine infusion regimens for maintaining maternal blood pressure during spinal anaesthesia for caesarean section. British Journal of Anaesthesia, 92(4): 469-74.

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Epidural Troubleshooting

Epidural failure is a fact of life in obstetric anaesthesia. Its incidence is approximately 10 %. This chapter addresses causes for failure of epidural analgesia and the management of an ineffective epidural.

Summary of Causes of Ineffective Epidurals

Incorrect Placement Correct Placement

Subcutaneous insertion Insufficient activation Subdural Catheter migration Intrathecal Abnormal anatomy Intravenous Sacral sparing Precipitous labour Unrealistic expectations

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Signs and Symptoms of Incorrectly Placed Epidural

Epidural Symptoms & Block Location Complications Subcutaneous No block No analgesia Local tissue swelling

Subdural Patchy sensory block + High sensory block minimal motor block (including cervical) can occur

Intrathecal Dose dependent; may Haemodynamic and have total spinal block respiratory compromise Fetal bradycardia Post dural puncture headache

Intravascular No block Local anaesthetic toxicity Haemodynamic compromise / collapse

Causes of Ineffective Epidurals Subcutaneous This is the most common reason for failure to establish a block due to incorrect needle placement and is often the result of a false loss of resistance (loss of resistance occurring before entering the epidural space). It is more common in obese parturients and may be the result of the needle being off midline or too shallow.

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Subdural The subdural space is a potential space between the dura mater and the pia/arachnoid mater. Since the arachnoid is not punctured there will be no CSF. Symptoms are variable but may be seen as a relatively rapid (5 – 15 minutes) onset of patchy sensory block with limited motor block.

Subarachnoid Since the arachnoid is punctured, CSF will be present. This may occur following removal of the loss of resistance syringe, where CSF will be seen as a continuous flow of clear fluid from the Touhy needle, or after catheter insertion or migration, where clear fluid will be continuously aspirated. Symptoms will be that of a spinal anaesthetic and will therefore depend upon the volume and concentration of anaesthetic injected. A rapid onset of motor block (e.g. after a test dose) should alert the anaesthetist to a subarachnoid block. See the following chapter for management of an accidental dural puncture.

Intravascular This will usually be identified at the time of catheter insertion as the presence of blood in the catheter which can continuously be aspirated. If anaesthetic is injected symptoms will be related to the dose given and will be in accordance with local anaesthetic toxicity.

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Unilateral Block This can occur as a result of epidural placement in the lateral aspect of the epidural space or passage or migration through the intervertebral foramina.

Insufficient Activation An appropriate dose of local anaesthetic is required to achieve analgesia via an epidural catheter. The dose required will be dependent on several factors including height, weight and stage of labour. Typically 10 – 15 mL of bag mix is used as a bolus following catheter insertion, after a test dose is given. Failure to give sufficient anaesthetic to establish the block will result in inadequate analgesia.

Catheter Migration Epidural catheters can change their location after insertion as a result of patient movement and may become located in any anatomical structure in proximity to them (see tables above). The anaesthetist should be alert to this possibility, especially when giving bolus or top-up doses.

Abnormal Anatomy A patient who has abnormal anatomy of their back may experience an insufficient block depending on the abnormality present. This should be a differential diagnosis particularly

144 when the response to local anaesthetic is difficult to explain by other more common reasons.

Sacral Sparing The S2-S4 nerve roots innervate the vagina and perineum and are therefore responsible for pain sensation in the second stage in labour. They are large, covered with thick dura mater and lie further from the tip of an epidural catheter than the T10 – L1 nerve roots. This can be a reason for failure of an epidural in the second stage of labour.

Precipitant Labour If labour is precipitant there may be insufficient time to establish a functioning epidural.

Patient Expectations Patients should be made fully aware of the degree to which analgesia will be provided by an epidural, and that some symptoms can be more difficult to ameliorate.

Management of Insertion and Placement Difficulties Inability to Thread the Catheter This should alert the anaesthetist to the catheter not being in the epidural space. Retraction of the catheter through the Tuohy needle whilst the 145 needle is still in the back is not recommended due to the possibility of shearing off the catheter.

Blood in the Catheter If blood is not able to be aspirated try flushing the catheter carefully; if no blood is then present the catheter can be treated as normal. If blood is able to be aspirated, try withdrawing the catheter by 1 cm. If blood can still be aspirated then remove the catheter completely. If in doubt, take it out.

 Remember the apt adage: If in doubt, take it out. .

Paraesthesia Some transient paraesthesia following inseretion of the catheter is common. Persistent paraesthesia mandates removal of the catheter. Always document paraesthesia regardless of transience or permanence, including its location.

Management of Ineffective Epidurals Assessment Assess the patient’s symptoms carefully, e.g. no block, partial or unilateral block, location and nature of pain (abdominal versus perineal, pressure versus discomfort etc). Enquire as to whether the epidural has worked at any point. Assess for any improvement following bolus 146 doses. Check the catheter location at the back and compare with documentation of the catheter insertion. Assess motor and sensory block height, using ethyl chloride spray for the latter. Enquire as to progress of labour and fetal position.

Bolus Dose Volume, concentration and dose should be considered. The primary determinant is thought to be dose, with volume playing a smaller role. A higher volume (and hence lower concentration) may provide a greater spread of analgesia when given as a bolus dose, compared to the same dose with a lower volume, but the evidence is equivocal. Typically, a bolus dose of bag mix should be considered for a block of insufficient height, and a smaller volume of higher concentration anaesthetic (e.g. 10 mL 0.25% levobupivacaine) should be considered for a block of insufficient quality/density.

Patient Positioning A laterally uneven block may be managed by lateral positioning of the patient prior to providing a bolus dose (less well blocked side down).

Catheter Manipulation The catheter can be withdrawn. It should be noted that less than 3 cm in the epidural space is associated with subcutaneous placement and

147 greater than 5 cm is associated with unilateral block.

Adjuvant Drugs Fentanyl Epidurally administered fentanyl provides rapid onset of excellent analgesia and can be useful in the case of sacral sparing. A dose of 50 – 100 µg is typically given.

Clonidine Clonidine is particularly helpful for patchy blocks. 75 µg is typically given, but a higher dose should be considered for obese patients. Since clonidine is an alpha-2 receptor agonist, hypotension may result.

Re-siting All anaesthetists should be humble with regards to epidurals and persistent attempts to manage an ineffective epidural should be avoided. If appropriate management techniques as noted above have failed to provide suitable analgesia, the epidural should be removed and re-sited.

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Additional Points Have a low threshold for seeking senior assistance if significant or repeated difficulty is encountered. Remember that seeking the assistance of an ODP from theatre is appropriate for challenging epidural insertions, particularly for those parturients who struggle to maintain an appropriate position for insertion.

 A poorly functioning labour epidural should not be topped-up for epidural anaesthesia. Rather, it should be removed and a spinal or CSE should be performed instead, if appropriate.

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References Hermanides, J., Hollmann, M.W., Stevens M.F., Lirk, P. 2012. Failed epidural: causes and management. British Journal of Anaesthesia, 109(2): 144-154. Kingsely, C., McGlennan, A., Brown, J.P., Abir, G. 2017. The labour epidural: troubleshooting. Anaesthesia Tutorial of the Week, World Federation of Societies of Anaesthesiologists. Available at ResearchGate. Southampton University Hospitals. 2010. Regional analgesia for labour. Obstetric Anaesthetists Association guidelines. Available at http://www.oaa- anaes.ac.uk/ui/content/content.aspx?id=190.

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Accidental Dural Puncture

There is an approximately 80% risk of a headache developing following an accidental dural puncture. There are two alternative management strategies:

1. Re-insertion of Epidural Catheter at Another Interspace The epidural should be resited in an adjacent interspace. Caution must be exercised when the first dose of local anaesthetic is given through the catheter as there is a significant risk of intrathecal diffusion via the dural puncture site. If a normal response is obtained following this dose the epidural should then be conducted as per normal.

2. Deliberate Insertion of the Catheter into the Subarachnoid Space Evidence for a reduced incidence of headache following this technique is equivocal. Furthermore use of intrathecal catheters is associated with a higher rate of failed analgesia. The needle tip is left in the subarachnoid space and the catheter inserted 2 cm only. The catheter must be clearly marked as being in the subarachnoid space. Care should be taken to avoid excessive loss of CSF volume. If this procedure is used the following guide should be applied:

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 The consultant on call must be contacted so that the procedure can be discussed in advance  Inform the attending midwife, midwife in charge of delivery suite, and obstetrician  The intravenous infusion should be running well and ephedrine (or phenylephrine) and atropine should be immediately available  An appropriate allowance for the dead space of a Portex 16G catheter & filter is 1.0 mL  With the patient in the lateral or supine wedged position, give 1 mL of 0.125% plain bupivacaine, followed by 0.5 mL increments of 0.125% or 0.25% bupivacaine (or 0.1% bupivacaine with fentanyl 2 µg/mL) until satisfactory analgesia is achieved.  Boluses should not be flushed through the catheter and filter with saline. Each time a top- up is administered careful consideration should be given to the 1 mL of local anaesthetic that is already in the catheter and filter system.  The anaesthetist must give all top-ups  It is important to appreciate that plain bupivacaine is slightly hypobaric and that sudden movement of the patient may cause displacement of the local anaesthetic in the CSF. Sitting up may result in high blocks.

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 For caesarean section, manual removal of placenta and rotational forceps delivery, with the patient in lateral or wedged supine position, 0.5 to 1 mL increments of 0.5% heavy bupivacaine are given, as judged by the level of the existing block, until adequate anaesthesia is achieved. (Usual total dose 3 mL; maximum dose 4 mL as pooling can occur in the sacral curve if the catheter is pointing caudally).  For outlet forceps delivery, with the patient in the sitting position, use 0.5% heavy bupivacaine 1 to 2 mL to achieve perineal anaesthesia  Obstetric management: there is no convincing evidence to suggest that a forceps delivery will reduce the incidence of post dural puncture headache

References Jagannathan, D.K., Arriaga, A.F., Elterman, K.G. et al. 2016. Effect of neuraxial technique after inadvertent dural puncture on obstetric outcomes and anesthetic complications. International Journal of Obstetric Anesthesia, 25: 23-29.

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Treatment of Post Dural Puncture Headache

The development of spinal headache is characterised by severe, disabling fronto-occipital pain with radiation to neck and shoulders. There may be neck stiffness. The pain may be completely relieved by lying supine. Although onset is commonly on the first or second day after dural puncture, it may occur on the same day.

Management Inform the consultant on call. Exclude other causes of severe headache. Document the PDPH by marking the appropriate boxes on the audit form (Headache Mild or Severe; Headache Spinal; Dural Tap). Complete the PDPH form on Trak: use the /PDPH shortcode. Unless there is a contraindication, prophylactic dalteparin should be prescribed for 22:00 for the inpatient stay. Discuss the problem and its management with the patient. Give her the PDPH information leaflet to read. There are basically two options depending on how disabling the headache is:

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Conservative management Encourage oral fluids and simple analgesia: paracetamol, ibuprofen or diclofenac, dihydrocodeine and/or tramadol (prescribe regular analgesics and an as required analgesic) unless contraindicated. Recording of 4-hourly observations must be initiated.

Pharmacological management Caffeine There is limited evidence to support the use of caffeine. If used, the dose should be less than 300 mg, with a total dose not exceeding 900 mg in 24 hours. For breastfeeding women, especially those with low birth weight or premature babies, a total 24 hour dose of 200 mg should be considered. It is difficult to provide accurate values for the caffeine content of drinks. As an approximate guide, a mug of coffee will contain 65 – 160 mg of caffeine; an espresso will contain 45 – 100 mg. Coca cola® and Coke Zero® contain 32 mg (in one can); Diet Coke® contains 42 mg per can. Tea contains 25 – 50 mg.

Other medication There is insufficient evidence to support the use of other agents including theophyllines, steroids, triptans and gabapentinoids.

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Epidural blood patch An epidural blood patch (EBP) should be considered when conservative management is ineffective and the woman experiences symptoms which impair functions of daily living, including care of her baby. They must be discussed with the consultant on call. Informed consent must be obtained. Current evidence suggests that one third of patients receiving an EBP will experience complete and permanent relief of symptoms. Complete or partial relief will occur in 50 – 80% of patients. In cases of partial or no relief, a second EBP can be performed provided that other causes of symptoms have been excluded.

The patient should be apyrexial – check the white blood count if indicated. Coagulation should be normal – if on low molecular weight heparin, appropriate timing is essential (i.e. at least 12 hours following a prophylactic dose or 24 hours following a treatment dose).

Although it has been suggested that efficacy may be improved by delaying epidural blood patch until 48 hours after dural puncture, this delay is not recommended as delay may increase the risk of serious sequelae including subdural haematoma. The timing for performing the blood

156 patch is at the consultant anaesthetist’s discretion.

Epidural blood patch technique A Tuohy needle is sited in the epidural space overlying the puncture site or one interspace below using a standard epidural technique. At least 20 mL of autologous blood are taken from the patient under sterile conditions. 20 mL of this blood are injected via the Tuohy needle into the epidural space. If the patient complains of discomfort in her back or down her legs the injection should be stopped. The patient lies flat for at least 2 hours and then mobilises gradually. She should be advised to avoid vigorous activity and straining for several days. The standard letter to the patient’s GP should be completed and uploaded to Trak. The patient should be given a Post Dural Puncture Information Leaflet (available in Hazel’s office) and contact information for medical advice. Follow-up is important and should as a minimum be done telephonically after one week and one month.

References Paech, M.J. 2005. Epidural blood patch – myths and legends. Canadian Journal of Anaesthesia, 52(s1): R1-5. 157

Sprigge, J.S., Harper, S.J. 2008. Accidental dural puncture and post dural puncture headache in obstetric anaesthesia: presentation and management: A 23-year survey in a district general hospital. Anaesthesia, 63: 36-43. Van de Velde, M., Schepers, R., Berends, N. et al. 2008. Ten years experience with ADP and PDPH in a tertiary obstetric anaesthesia department. International Journal of Obstetric Anesthesia, 17(4): 329-35. Paech, M.J. 2012. Iatrogenic headaches: giving everyone a sore head. International Journal of Obstetric Anesthesia, 21(1): 1-3. Scavone, B.M. 2015. Timing of epidural blood patch: clearing up the confusion. Anaesthesia, 70: 119-21. Obstetric Anaesthetists’ Association. 2018. Treatment of obstetric post-dural puncture headache. London: Obstetric Anaesthetists’ Association.

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High Regional or Total Spinal Block

The incidence is 1 in 27,000 obstetric epidurals. Strictly, total spinal is the subarachnoid injection of a large (epidural) dose of local anaesthetic, resulting in severe hypotension, profound bradycardia, respiratory arrest and loss of consciousness. However, a similar result can follow epidural or subdural injection of local anaesthetic: high regional block is defined as an excessively high block requiring tracheal intubation.

Although the features (weakness of upper arms, difficult breathing, slurred speech, sedation and high level of numbness) are typically rapidly ascending, these may develop late and insidiously.

Management Call immediately for an ODP and a second anaesthetist.

Equipment immediately required Cardiac arrest trolley (kept in resuscitation equipment bay by baby resuscitation room) with laryngoscope, endotracheal tubes and suction pump.

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Management technique  Position patient on her left side (or other method of uterine displacement). The patient must be positioned to eliminate aortocaval compression at all times.  Oxygen should be administered with a mask and bag as necessary.  500 - 1000 mL of Plasmalyte 148/Ringer’s lactate rapidly intravenously.  Ephedrine 15 mg intravenously. Repeat as necessary. Consider phenylephrine, adrenaline and atropine administration. Maintain the blood pressure with ephedrine or a phenylephrine infusion plus glycopyrrolate or atropine and an intravenous infusion as required.  If breathing is inadequate, perform rapid sequence induction with cricoid pressure. The patient should be intubated and kept ventilated and anaesthetised.  If intubation is difficult or fails, do not wait for the return of spontaneous ventilation – it may not occur. Proceed with emergency airway management and IPPV (see failed intubation drill).  Move the patient to the operating theatre for full monitoring including blood pressure, SpO2, EtCO2 and ECG.

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 In the event of fetal distress, caesarean section is advised.  The patient and her relative(s) should be reassured; allocate a team member to escort the partner/relative out of the room as soon as possible.

Consider alternative diagnoses, e.g. subarachnoid haemorrhage.

Post-event A post delivery visit is vital to explain what has happened and why. Further follow up may be needed to deal with psychological issues.

An adverse incident report must be filed.

References Yentis, S.M. 2001. High regional block – the failed intubation of the new millennium. International Journal of Obstetric Anesthesia, 10: 159-61.

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Pain & Analgesia

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Postpartum Pain

Introduction Analgesics tend to be most effective in acute pain when given regularly at adequate and timely dosages. Pain scoring must be part of routine assessment of analgesia requirement, using the tool on the MEWS chart. This guideline was formulated to assist with management of pain after caesarean section, rotational forceps delivery (KRFD), complex (3rd and 4th degree) tears, perineal pain, after-pains and postnatal haemorrhoids.  This guideline should work well for the majority of patients: there will be outliers – some who require less and others who require more analgesia. For the latter group consider contacting the Pain Team for help, using the referral form available on the Intranet. .

Caesarean Section, Rotational Forceps Delivery, Complex (3rd & 4th degree) Tears The anaesthetist will prescribe analgesia for the first 3 days after LUCS. The analgesia requirements will be reviewed on the first postoperative day and may be modified accordingly by an anaesthetist or other member of the medical staff or a non-medical prescriber. To ensure 163 effective pain management, opioids, non-steroidal anti-inflammatory drugs and paracetamol will all be prescribed by an anaesthetist at the time of LUCS unless there is a specific contraindication. After general anaesthesia transversus abdominus plane (TAP) blocks should be considered and PCA morphine should be provided.

Morphine sulphate patient controlled analgesia (PCA) after GA caesarean section Morphine sulphate 100 mg in 50 mL 0.9% saline (i.e. 2 mg/mL) Dose/Route: 1 to 2 mg bolus (2 mg usual); 5 minute lockout; intravenously Use standard PCA Chart An antiemetic may be added e.g. cyclizine 100 mg added to the 50 mL in PCA syringe

Regular analgesia Paracetamol 1 g every 6 hours orally; prescribe regular dosing (maximum dose 4 g/24 hours). If body weight is less than 50 kg reduce to 1 g 8 hourly or 500 mg 6 hourly (60 mg/kg body weight/24 hours). Compound paracetamol preparations should not normally be prescribed as first line unless the patient normally takes them. In the uncommon event of severe vomiting or ileus, the IV or PR route may be prescribed.

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Non-steroidal anti-inflammatory drugs (NSAIDs) Non-steroidal anti-inflammatory drugs (NSAIDs) are contraindicated in pregnancy-induced hypertension (PIH), major haemorrhage, low platelets, active or suspected peptic ulcer disease or if attacks of asthma, urticaria or acute rhinitis have been precipitated by aspirin or other NSAIDs. NSAIDs may cause a deterioration of renal function in patients with severe renal, cardiac or hepatic impairment.

Diclofenac suppository 100 mg should be given at time of LUCS. It must be prescribed on the prescription chart and patient consent must be obtained. Thereafter on the day of LUCS, ibuprofen tablets 400 mg orally four times a day should be given, preferably with food. Note that ibuprofen must be withheld until at least 8 hours since the diclofenac suppository.

Opioids Following caesarean section only, modified- release oral morphine (MST) should be prescribed: 20 mg 8 hours following spinal/epidural top-up and a second dose of 20 mg 12 hours later (i.e. 20 hours following spinal/epidural top-up). If booking weight is < 50 kg then reduce to 15 mg.

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Breakthrough analgesia Morphine (Oramorph) 10 mg hourly as required. Maximum 6 doses per 24 hours before review. Should not be given to patients with a PCA.

Antiemetics Ondansetron 4 mg 8 hourly IM/IV PRN. Cyclizine 50 mg 8 hourly IM/IV PRN. If contraindication to ondansetron or cyclizine, consider dexamethansone 6.6 mg IV instead.

Laxatives Lactulose 15 mL twice/day.

Summary of prescription for analgesia after LUCS Day Regular Analgesia As Required Analgesia

0 Paracetamol 1 g QDS Oramorph 10 mg hourly Ibuprofen 400 mg QDS MST 20 mg at 8 hours and 20 hours following spinal/epidural

1 – 2 Continue paracetamol & Oramorph 10 mg hourly ibuprofen

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Perineal Pain after Forceps or Spontaneous Delivery and Pain Associated with Haemorrhoids If perineal pain is anticipated after delivery, prescribe regular analgesics before leaving labour suite. In other situations the pain should be assessed (using pain score) on the postnatal ward and analgesics prescribed as appropriate.

Paracetamol 1 g every 6 hours orally (reduce dosage if body weight less than 50 kg – as above).

Diclofenac 100 mg suppository, after forceps or perineal repair. It must be prescribed on the prescription chart and patient consent must be obtained.

Ibuprofen 400 mg four times a day orally, with food. Note that ibuprofen must be withheld until at least 8 hours since the diclofenac suppository. See above for cautions and contraindications.

Morphine (Oramorph) 10 mg hourly as required. Maximum 6 doses per 24 hours before review.

Lactulose Consider prescribing lactulose 15 mL twice a day.

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After Pains Assess the severity of the pain using pain score. Start with regular paracetamol and add in as required ibuprofen if necessary. Administer about 1-2 hours before breastfeeding if possible to ensure peak analgesic effect.

The Carefusion IVAC™ PCAM™ Pump for PCA after Caesarean Section under General Anaesthesia  The drug used will be morphine: 100 mg added to 50 mL of 0.9% saline giving a concentration of 2 mg/mL. Cyclizine 100 mg may be added.  The bolus will be 1 mg or 2 mg, and the lockout time will be set at 5 minutes.  The morphine will be drawn up by the recovery nurse in the recovery room and the prepared syringe will accompany the pump with the patient back to the ward. The syringe should be appropriately labelled without obscuring the volume markings.  A 60 mL Luer-Lok™ syringe (BD Plastipak) should be used and the system must contain a Wescott Sae-Flo anti-syphon set with Y-connector and anti-reflux valve to prevent reflux into the IV fluid line.

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 The prescription for PCA will be written on the PCA chart.  The key will be removed from the pump once it has been set up in the patient's room. The syringe should be mounted to allow the midwifery staff to read the markings. There will be a key on each ward drug key ring. Removal of the key is to ensure no unauthorised resetting of the pump.  The obstetric anaesthetist on-call should be informed if the patient is not getting adequate analgesia and is making too many attempts to request drug from the pump. The anaesthetist should also be called and the pump switched off if the respiratory rate falls below 8 breaths per minute or the patient becomes unexpectedly drowsy.  Strong opioid by other route should not be prescribed concomitantly with PCA.  The PCA chart should be beside the patient's bed and filled in by the midwifery staff.  At the end of the infusion the total drug given should be noted and the remaining drug discarded. This should be entered in the chart and witnessed by a second member of the midwifery staff.

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 It is important that the pump is observed to be working accurately. The chart should therefore record the total dose given since reset (machine display) and the volume remaining in the syringe. These recordings should be made at least each hour.  If the syringe needs changing a new syringe should be used and attached to the existing extension set.  If there is a lack of trained midwifery staff, the duty anaesthetist should be advised. This should trigger a Datix® report.  When the PCA is no longer required, the pump and Wescott Sae-Flo anti-syphon set should be disconnected by the midwifery staff and the pump should be sent back to Labour Ward.

Discharge Analgesia following Caesarean Section, Rotational Forceps Delivery, Complex (3rd & 4th degree) Tears

 All patients should have a pain assessment prior to discharge .

Paracetamol 1 g four times a day for 5 days (supply 32). If body weight is less than 50 kg reduce to 1 g 8 hourly or 500 mg 6 hourly. 170

Ibuprofen 400 mg three times a day for 5 days (supply up to 24). Morphine sulphate liquid 5-10 mg 4-6 hourly as required (supply up to maximum 200 mg (100 mL). Lactulose 15 mL twice a day as required for 5 days (supply up to 300 mL) . Always review pain at discharge and deliver patient-centred analgesia .

References Lucas, N., Pickering, E., Plaat, F. 2012. Pain relief after caesarean section. In: Colvin, J.R., Peden C.J. [eds] Raising the standard: a compendium of audit recipes for continuous quality improvement in anaesthesia, 3rd ed. London: The Royal College of Anaesthetists. 226-7. Lavand’homme, P. 2010. Chronic pain after vaginal and cesarean delivery: a reality questioning our daily practice of obstetric anesthesia. International Journal of Obstetric Anesthesia, 19(1): 1-2. Bloor, M., Paech, M.J., Kaye, R. 2012. Tramadol in pregnancy and lactation. International Journal of Obstetric Anesthesia, 21(2): 163-7. UK Medicines Information. 2013. Codeine and breastfeeding: Is it safe and what are the alternatives? Available at

171 https://www.sps.nhs.uk/articles/codeine-and- breastfeeding-is-it-safe-and-what-are-the- alternatives/ Christmas, T., Bamber, J., Patient, C. 2015. Maternal satisfaction with analgesia following hospital discharge after caesarean section. International Journal of Obstetric Anesthesia, 24(1): 85-6. Audits of post partum analgesia at SCRH 2007-10 (available from Obstetric Anaesthesia Secretary).

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Post-operative Nausea and Vomiting

Post-operative nausea and vomiting (PONV) is a significant and unpleasant side-effect of surgery and anaesthesia. In some patients it can be recalled as the worst part of the whole hospital experience. It can also lead to medical complications such as wound dehiscence.

Like pain, PONV is multifactorial and therefore should be managed with a multimodal approach.

Risk factors for PONV include: Female Non-smoker History of travel sickness or PONV Operation site Use of opioids or nitrous oxide Use of ergometrine and (especially) carboprost Longer duration of surgery

Prophylaxis All elective caesarean section patients on the enhanced recovery pathway should receive ondansetron 4 mg IV at the time of the operation. Similarly any patient who receives ergometrine or carboprost should receive an antiemetic at the same time (usually ondansetron).

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Other patients undergoing operative procedures in theatre with risk factors for PONV will probably also benefit from prophylactic ondansetron.

Treatment All patients who have operative procedures in theatre should have at least one antiemetic prescribed in the ‘as required’ section of the kardex. The first line choice is usually ondansetron 4 mg 8 hourly. Cyclizine is more effective as a rescue therapy as compared with prophylaxis; remember that the IV administration of cyclizine is painful so it should be diluted first and injected slowly.

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Patient Controlled Analgesia in Labour with Remifentanil

Introduction Remifentanil is a relatively new synthetic opioid which is unique in that it incorporates an ester bond and is thus rapidly broken down by plasma esterases. It possesses a rapid onset of action combined with a very short half-life. Remifentanil pharmacokinetics and pharmacodynamics are similar in adults and neonates. This makes it a suitable agent for Patient Controlled Analgesia (PCA) in labour. Continuous one-to-one midwifery care and monitoring of oxygen saturation is required because of the drug’s potential to depress respiratory function and level of consciousness.

Criteria for use The mother must be more than 36 weeks’ gestation and in established labour. Mothers may have remifentanil PCA, even if they have received an oral, IM or IV opioid, as long as 4 hours has elapsed since administration and provided they are responsive to command on the AVPU scale. Remifentanil is not licensed for use via PCA and therefore must be prescribed by an anaesthetist.

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The mother must be monitored continuously with one-to-one midwifery care by an experienced midwife while the remifentanil PCA is being used. She should not be left unattended. Oxygen saturation monitoring must be established before the use of PCA has started. Entonox may be used in addition to the remifentanil PCA. Remifentanil PCA can be used during delivery and for the repair of tears or episiotomies.

Indications Contraindications

Patient request Oral, IM or IV opioid within 4 Contraindications to hours (including regional analgesia dihydrocodeine/codeine) Insufficient analgesia with Maternal refusal or inability to co- other methods operate Known sensitivity to remifentanil Impaired respiratory function Impaired level of consciousness Severe intrauterine growth restriction or pathological CTG

Explanation and Verbal Consent The mother must be informed regarding the remifentanil PCA and (verbal) consent must be obtained. She must be shown how to use the PCA. In particular she should be told to press the button when she first feels the contraction.

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The mother should also be informed that she may feel dizzy, mildly drowsy, sleepy, nauseated or itchy when using the PCA, that she might need to be given oxygen via nasal specs or face mask and that a dedicated IV line is required. Only the mother in labour can use the PCA button (not the midwife or relatives).

Observations Continuous one-to-one midwifery care. Continuous monitoring of the mother’s oxygen saturation by pulse oximetry is required during remifentanil PCA usage (baseline value obtained before start of PCA). 30 minute recording of respiratory rate, oxygen saturation, oxygen supplementation, sedation score. Hourly recording of pain, nausea and pruritus scores, volume in syringe and delivered volume and dose. CTG monitoring is not required unless otherwise indicated. A new syringe must be prepared no later than when volume in syringe falls to 10 mL. Use SCRH remifentanil PCA chart (kept at Labour Ward desk) for recordings rather than usual PCA chart.

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Equipment and infusion Regime

Dilute the contents of one Bolus: 30 µg (0.6 mL) ampoule of 2 mg remifentanil in 2 mL of 0.9% saline Remifentanil PCA, unlike morphine PCA for Inject these 2 mL into a 50 mL postoperative pain, requires syringe frequent adjustment

Dilute solution to 40 mL with Bolus dose may be increased 0.9% saline (giving to 40 µg (0.8 mL) or 50 µg (1 concentration of 50 µg/mL) mL) to achieve adequate Use standard PCA pump and a analgesia dedicated extension set with an anti-siphon valve Lockout: 3 minutes (lockout time should not be altered) A dedicated cannula (20 G or 22 G) should be inserted for the remifentanil PCA – this will overcome problems with dead space of a Y-piece used with a poorly running drip. Always use a dedicated intravenous cannula and make sure that a separate IV infusion is running concurrently.

Safety Points  Always use a dedicated intravenous cannula (no other drugs via the PCA cannula). At discontinuation of the PCA, the tubing must be disconnected from the cannula and the cannula flushed with 5 mL 0.9% saline to prevent drug in the tubing getting flushed in as a bolus leading to loss of consciousness and apnoea. 178

 Only the mother in labour can use the PCA button (not the midwife or relatives).  Equipment required to administer high flow oxygen must be in the room.  Ensure the midwife is aware that respiratory depression may occur and knows what to do in the event of respiratory depression or arrest.  Ensure that oxygen and an Ambu-type resuscitation bag are available in the room. A spare resuscitation bag is kept on the cardiac arrest trolley.  Remifentanil can cause short lived maternal or fetal bradycardia if the bolus is too large.

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Remifentanil for Use During Caesarean Section Under General Anaesthesia

Introduction General anaesthesia caesarean section has special requirements; haemodynamic stability, blunting of response to airway manipulation and to surgical stimulus, along with minimal neonatal effects. This can be difficult to achieve. The National Audit Project 5 report highlighted the risk of awareness in obstetric patients undergoing general anaesthesia for caesarean delivery (1/570). Opioid free anaesthesia prior to delivery is one of the factors contributing to this risk.

Remifentanil is a synthetic opioid which is unique in that it incorporates an ester bond and is thus rapidly broken down by plasma esterases. It possesses a rapid onset of action combined with a very short half-life. Remifentanil pharmacokinetics and pharmacodynamics are similar in adults and neonates making it a useful opioid for the use during caesarean section under general anaesthesia.

There are now many published papers on the use of remifentanil in anaesthesia for caesarean section, particularly in high-risk patients with significant neurological, cardiac or coagulopathic

180 disease, and it can help to reduce the risk of awareness and haemodynamic instability (see references).

Indications Intraoperative analgesia Avoidance of hypertensive response to intubation Avoidance of NMBAs including Suxamethonium Intraoperative control of blood pressure (e.g. in pre-eclampsia) Opioid based anaesthesia reducing volatile requirements, e.g. for patients with cardiac disease Reduce risk of awareness (To facilitate regional anaesthesia in cases of needle phobia)

Contraindications Known sensitivity to Remifentanil or other synthetic opioids Existing respiratory insufficiency

Side Effects Mother: hypotension and respiratory depression in the mother Neonate: (as it crosses the placenta) anticipate transient respiratory depression in the newborn (50% likely to require tactile stimulation and short-lived mask ventilation lasting less than 6 181 minutes); there is one case report of neonatal chest wall rigidity.

Preparation Dissolve 2 mg of Remifentanil in 2 mL of 0.9% sodium chloride solution and dilute up to 40 mL with 0.9% sodium chloride solution in a 50 mL syringe (final concentration = 50 µg/mL). Load the syringe into the syringe driver and connect to the patient's IV access via a Y- connector. Always administer together with a running IV infusion. If using a syringe driver capable of running infusions in µg/kg/minute, enter the patient’s weight and a rate of 0.5 µg/kg/minute. Otherwise ensure other means of converting µg/kg/minute into mL/hour (e.g. see http://www.manuelsweb.com/mcgkgmin.htm). Always inform neonatal staff of remifentanil use.

Regimen Run infusion at 0.2 – 0 .5 µg/kg/minute for last minute of pre-oxygenation. Give bolus of 0.5 – 1 µg/kg prior to induction agent. Aim to run at 0.1 – 0 .5 µg/kg/minute throughout case.

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Ventilate patient on oxygen / air (or N2O) / sevoflurane (or isoflurane). Aim for a MAC sevoflurane/isoflurane of approximately 0.75. Consider use of vasopressor if indicated. Consider use of glycopyrrolate for bradycardia. At uterine closure administer IV Morphine 10 – 20 mg and half remifentanil infusion rate. Discontinue infusion on start of skin closure.

References Park, B.Y., Jeong, C.W., Jang, E.A. et al. 2011. Dose-related attenuation of CVS responses to tracheal intubation by IV remifentanil bolus in severe pre-eclamptic patients undergoing caesarean delivery. British Journal of Anaesthesia, 106(1): 82-7. Yoo, K.Y., Jeong, C.W., Park, B.Y. et al. 2009. Effects of remifentanil on CVS and bispectral index responses to ET intubation in severe pre-eclamptic patients undergoing caesarean delivery under GA. British Journal of Anaesthesia, 102(6): 812-19. Draisci, G., Valente, A., Suppa, E. et al. 2008. Remifentanil for c-section under GA; effects on maternal stress hormone and neonatal well-being: a randomized trial. International Journal of Obstetric Anesthesia, 17(2): 130-6.

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Macfarlane, A.J., Moise, S., Smith, D. 2007. Caesarean section using total intravenous anaesthesia in a patient with Ebstein's anomaly complicated by supraventricular tachycardia. International Journal of Obstetric Anesthesia, 16(2); 155-9. Ngan Kee, W.D., Khaw, K.S., Ma, K.C. et al. 2006. Maternal and neonatal effects of remifentanil at induction of general anaesthesia for caesarean delivery: a randomised, double-blind, controlled trial. Anesthesiology, 104(1): 14-20. Mastan, M., Mukherjee, S., Sirag, A. 2006. Role of remifentanil for elective caesarean section in a morbidly obese, needle-phobic parturient. International Journal of Obstetric Anesthesia, 15(2): 176. Alexander, R., Fardell, S. 2005. Use of remifentanil for tracheal intubation for caesarean section in a patient with suxamethonium apnoea. Anaesthesia, 60(10), 1036-8. Orme, E., Grange, C.S., Ainsworth, Q.P. et al. 2004. General anaesthesia using remifentanil for caesarean section in parturients with critical aortic stenosis: a series of four cases. International Journal of Obstetric Anesthesia, 13(3): 183-7. Van de Velde, M., Teunkens, A., Kuypers, M. et al. 2004. General anaesthesia with target controlled infusion of propofol for planned caesarean 184 section: maternal and neonatal effects of a remifentanil-based technique. International Journal of Obstetric Anesthesia, 13(3): 153-8. Carvalho, B., Mirikitani, E.J., Lyell, D. et al. 2004. Neonatal chest wall rigidity following the use of remifentanil for caesarean delivery in a patient with autoimmune hepatitis and thrombocytopenia. International Journal of Obstetric Anesthesia, 13(1): 53-6. Hill, D. 2008. Remifentanil in Obstetrics. Current Opinion in Anaesthesiology, 21(3):270-4. Van de Velde, M. 2016. The use of remifentanil during general anesthesia for caesarean section. Current Opinion in Anaesthesiology, 29(3): 257-60. Pandit, J.J., Andrade, J., Bogod, D.G. et al. 2014. 5th National Audit Project (NAP5) on accidental awareness during general anaesthesia: summary of main findings and risk factors. British Journal of Anaesthesia, 113(4): 549-59. Breslin, D.S., Reid, J.E., Mirakhur, R.K. et al. 2001. Sevoflurane-nitrous oxide anaesthesia supplemented with remifentanil: effect on recovery and cognitive function. Anaesthesia, 56(2):114-9.

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Management of Obstetric Complications

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Women Who Decline Blood Products

Introduction Pregnant women are at risk of haemorrhage and women should therefore be counselled during the antenatal period regarding the implications of declining blood products. The Confidential Enquiry into Maternal Deaths in the United Kingdom has repeatedly found that women who decline blood products are at an increased risk of morbidity and mortality as a result of their refusal of blood components.

Guidelines Jehovah’s Witnesses refuse transfusion of packed red cells, plasma, platelets and white cells. The use of albumin, immunoglobulins and clotting factors and is left to the conscience of the individual member, as is the re-infusion of the patient’s own blood salvaged at the time of an operation with an intraoperative cell saver machine.

When a doctor undertakes the care of any patient a contractual agreement is entered into with that patient to treat them according to their wishes, if they are able to express themselves. A competent adult has the absolute right to refuse any aspect of medical treatment. It matters not whether the

187 reasons for the refusal are rational or irrational, unknown or even non-existent. If a patient is treated against their will, the delict (civil wrong) of assault is committed. Therefore, if blood has been refused by a patient, it may not be given. The management of these patients must, if possible, be planned and should involve senior clinicians. It is most important that the patients are seen alone preoperatively and that the anaesthetist and obstetrician determine exactly what forms of treatment the patient accepts or refuses. The possible consequences of refusing blood products, including death, should be made clear to the patient. This refusal must then be documented on a special consent form and witnessed by another doctor.

Antenatal Care  A woman’s refusal to accept blood products must be clearly documented in the special features section of their Maternity Trak record at the booking visit and a referral made to the consultant obstetrician and consultant anaesthetist o Locality consultant obstetrician o AnaestheticObstetricReferralsRIE@nhslo thian.scot.nhs.uk

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 When the anaesthetic referral is received, the obstetric anaesthetic secretary will send on a referral to a consultant haematologist. Oral iron ferrous sulphate should be prescribed 200 mg twice a day or ferrous fumerate 210 mg twice a day and given throughout pregnancy to maximize iron stores. Advice should be given to maximize oral iron absorption (such as avoiding tea, coffee, wholegrain and calcium containing products with the iron, but consider consuming with a source of vitamin C)  Women should meet with a consultant obstetrician and consultant anaesthetist at approximately 28 weeks having already been seen by the consultant haematologist. A clear management plan should be documented in both the obstetric and anaesthetic management plan sections of Maternity Trak. In addition, the checklist (Appendix 1) of what products and drugs are acceptable to the patient should be completed and placed in the patient’s notes and a photocopied checklist sent to the Labour Ward where a folder with all the current Witnesses’ checklist are kept.  Women should be advised that they should deliver at the Royal Infirmary of Edinburgh  Blood group and antibody status should be checked in the usual way.

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 A full blood count, serum ferritin and coagulation screen should be checked at booking, followed by a full blood count and serum ferritn at 28 weeks and 36 weeks to ensure that haemoglobin and iron stores are maximized during pregnancy.  At 28 weeks gestation the patient’s haemoglobin should be >110 g/L and ferritn >30. If the haemoglobin is <110 g/L or the ferritin <30 then refer to a consultant obstetrican for consideration of IV iron. A ferritin <30 should be treated irrespective of the haemoglobin level.  Ultrasound placentography should be done by 34 weeks’ gestation.

Intrapartum Care  Ensure there is an up to date full blood count and group and save sample in BTS on admission.  The on-call Consultant Obstetrician and anaesthetist should be informed when a woman declining blood products is admitted in labour and this communication should be documented in notes. The blood product checklist for the woman should be reviewed and communicated to all staff.

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 The estimated blood volume for the woman should be calculated as 100 mL/kg and documented in the notes.  Prophylactic oxytocics should be given in the third stage of labour.  Labour and delivery should be supervised by senior obstetric, anaesthetic and midwifery staff  The on-call consultant obstetrician and anaesthetist should be informed when a woman declining blood products is admitted in labour and this communication should be documented in the notes.  Senior medical staff should be aware when second stage commences and again if it is prolonged. They should also be informed if any adverse features occur.  Any operative delivery should be performed or directly supervised by senior medical staff.

Haemorrhage  If haemorrhage occurs, resuscitation should be prompt and if more than one uterotonic drug is required, the consultant obstetrician and anaesthetist should be involved.  Tranexamic acid 1 g IV should be given if the woman has lost more than 500 mL of blood.

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 A fluid warmer should be used from the start of fluid resuscitation and the cell saver set up.  In the context of major haemorrhage and general anaesthesia, consideration should be given to the use of total intravenous anaesthesia (TIVA) instead of an inhalational technique so as to reduce the vasodilatory effects of sevoflurane and isoflurane.  The patient should be kept informed and her status reviewed regularly. She should be given an opportunity to change her mind about her previously agreed treatment plan.  Near patient testing of haemoglobin and coagulation should be deployed with regular HemoCue® and ROTEM® samples while bleeding is ongoing  For severe haemorrhage (>25% of the calculated circulating volume) mobilize the products that the woman will accept, and discuss with the on call haematology consultant: o Prothrombin complex concentrate is held in Blood Bank, dose = 50 units/kg (round up to nearest full vial). o Recombinant factor VIIa held in ward 206, dose = 90 µg/kg (round up to nearest full vial).

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o Fibrinogen concentrate held in ward 206, dose = 70 mg/kg (round up to nearest full vial).  Cell salvage (if the patient accepts it) should be used at caesarean section and exploratory laparotomy.  Timely resort to hysterectomy is even more important than for other women.

Postnatal Care  Subsequent management may include hyperbaric oxygen, erythropoetin, parenteral iron.  MEWS should be recorded at least hourly for 4 hours postnatally.

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References Watch Tower Bible Tract Society of Pennsylvannia. 1990. How blood can save your life? Watch Tower Bible Tract Society of New York, Inc. Cantwell, R., Clutton-Brock, T., Cooper, G. et al. 2011. Saving Mothers' Lives: Reviewing maternal deaths to make motherhood safer: 2006-2008. The Eighth Report of the Confidential Enquiries into Maternal Deaths in the United Kingdom. British Journal of Obstetrics and Gynaecology, 118(Supplement 1): 1-203. Benson, K.T. 1989. The Jehovah’s Witness patient: considerations for the anaesthesiologist. Anaesthesia and Analgesia, 69(5): 647-56. British Medical Association. 1992. Rights and responsibilities of doctors. London: British Medical Association. Pavord, S., Myers, B., Robinson, S. et al. 2012. UK guidelines on the management of iron deficiency in pregnancy. British Journal of Haematology, 156(5): 588–600. Association of Anaesthetists of Great Britain and Ireland. 2016. AAGBI guidelines: the use of blood components and their alternatives 2016. Anaesthesia, 71(7):829-842.

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Diabetes and Pregnancy

Introduction 2 – 5% of pregnancies involve women with diabetes. The prevalence of diabetes is increasing, especially that of type 2 diabetes in women of reproductive age. Diabetes in pregnancy is associated with risks to the woman and the developing fetus. Pregnancy outcomes for women with diabetes and their babies are poor compared to those who do not have diabetes. Outcomes can be improved if excellent glycaemic control is achieved before and during pregnancy.

Gestational Diabetes Definition Glucose intolerance of variable onset with onset or first recognition during pregnancy.

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Flowchart for Gestational Diabetes: Antenatal Admission

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Intrapartum care Check capillary blood glucose on admission and check urine for ketones. Check capillary blood glucose hourly in labour. If capillary blood glucose > 7 mmol/L then the patient requires an IV insulin infusion.

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Type I and Type II Diabetes Mellitus Women with type I diabetes have an absolute requirement for insulin and quickly become ketotic without insulin. An increasing number of women are being seen with type II diabetes, and although these women are often not insulin treated prior to pregnancy, many will require insulin during pregnancy. In most respects, type I and II diabetes in pregnancy can be considered as of similar risk to mother and baby.

Intrapartum care Monitor capillary blood glucose hourly. IV insulin sliding scale in labour is likely to be necessary if the woman is vomiting or is unable to maintain glucose levels < 7 mmol/L. Aim to keep glucose levels between 4 – 7 mmol/L. If an elective caesarean section is undertaken then an IV insulin infusion should start at least 1 hour prior to theatre. Co-administration of IV fluids should take place if on an insulin infusion (5% glucose and 0.9% saline in addition where indicated).

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Flowchart for Care of Women with Type I or Type II Diabetes in Pregnancy

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Postnatal care After delivery of the placenta, insulin requirements will fall. For those who have been maintained on IV insulin sliding scale during labour or caesarean section:  Reduce insulin infusion rate after third stage by 50% initially.  Admit to labour ward HDU for ongoing management of IV insulin sliding scale.  Continue IV fluids as necessary.  Monitor capillary blood glucose 2 hourly.  Restart subcutaneous insulin using pre- pregnancy doses when eating normally and overlap with IV insulin infusion for at least 1 hour.

Breastfeeding Patients can take metformin when breastfeeding. Glibenclamide is also considered safe in breastfeeding. It is not known if gliclazide or glipizide pass into breast milk and the current recommendation is that they are not safe in breastfeeding. It is appropriate to relax immediate postnatal targets for capillary blood glucose - preprandial levels of between 6 and 8 mmol/L would typically be appropriate. Women should be aware of the risk of hypoglycaemia when

200 breastfeeding and should have appropriate rapid- acting carbohydrate available at all times.

IV Insulin Sliding Scale See below for prescribing a sliding scale in patients receiving steroids.

Preparation 50 units of Actrapid insulin in 50 mL of 0.9% saline in a syringe driver = 1 unit per mL. Start 5% glucose 500 mL + 20 mmol KCl, 4 hourly.

Blood Glucose (mmol/L) Insulin Infusion (mL/hour)

> 16.0 6 (call doctor – scale may need to be revised) 13.0 – 15.9 5 10.0 – 12.9 4 9.0 – 9.9 3 7.0 – 8.9 2 5.0 – 6.9 1 3.5 – 4.9 0.5(call doctor – scale may need to be revised)

Guideline for all Diabetic Pregnant Patients Receiving Steroids Betamethasone/dexamethasone is given to accelerate fetal lung maturation, but its administration is likely to cause significant hyperglycaemia and can potentially precipitate

201 ketoacidosis in women with diabetes during pregnancy. The risk of ketoacidosis is obviously greatest in women with type I diabetes, but is not absent in women with type II diabetes and GDM.

IV Insulin Sliding Scale for Patients Receiving Steroids 50 Units of Actrapid insulin in 50 mL of 0.9% saline in a syringe driver = 1 unit per mL. Start 5% glucose 500 mL + 20 mmol KCl, 4 hourly

Blood Glucose (mmol/L) Insulin Infusion (mL/hour)

> 16.0 6 (call doctor – scale may need to be revised) 13.0 – 15.9 4 10.0 – 12.9 3 7.0 – 9.9 2 5.0 – 6.9 1 4.0 – 4.9 0.5 < 4.0 Off (call doctor – scale may need to be revised)

 Check for urinary ketones at each void.  Check venous plasma glucose and U&E every 6 hours.  Check capillary blood glucose 2 hourly.  Liase with the Diabetes team for advice regarding when the infusion can be stopped (this is usually 24 – 48 hours after the final 202

steroid dose). RIE contact Diabetes Registrar, SJH contact Diabetes Consultant.

Hypoglycaemia and Pregnancy Hypoglycaemia is a significant problem in pregnancy and may be particularly frequent in the first trimester. Patients and partners must be made aware of this and the fact they may lose some, or occasionally all, typical hypoglycaemic warning symptoms. Hypoglycaemia is generally defined as a blood glucose level of <4 mmol/L and must be treated. Patients and their partner must know exactly how to treat a hypoglycaemic event. They should have available rapid acting carbohydrate (e.g. Dextrosol or Lucozade), glucogel and glucagon for injection.

Third trimester hypoglycaemia Reducing insulin requirements or hypoglycaemic episodes may be a marker of placental insufficiency and the patient should be seen by the obstetric/diabetic team as soon as possible.

Diabetic Ketoacidosis and Pregnancy Diabetic ketoacidosis (DKA) is a medical emergency. It occurs in around 1 – 3% of pregnancies in women with Type I diabetes. Although less common, it can occur in women with type II diabetes and GDM. 203

Causes Omission of insulin Intercurrent illness, especially infection Previously undiagnosed diabetes Hyperemesis Insulin pump failure Steroid administration Tocolytic agents

Maternal complications of DKA Severe dehydration and hypotension Acidosis Multi-organ dysfunction Cardiac arrhythmias due to electrolyte imbalance

Fetal complications of DKA Fetal loss (approx 9 – 30%) Lactic acidosis and fetal hypoxia Fetal heart rate abnormalities (transient – always stabilise mother first)

Diagnosis of DKA Elevated plasma and/or urinary ketones + Metabolic acidosis: H > 45 / pH < 7.3, HCO3 < 18 Hyperglycaemia is usually marked, but remember it is not a reliable guide to the severity of acidosis and in pregnant women the blood glucose may not be markedly raised.

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Signs of volume depletion: reduced skin turgor, tachycardia and hypotension Rapid and deep sighing respirations Vomiting/abdominal pain Drowsiness/reduced conscious level

Investigation of DKA Bloods: ABG, FBC, U&E, LFTs, serum bicarbonate, venous plasma glucose Infection screen, blood cultures, ECG, GCS where appropriate.

Management of DKA Medical emergency – call for medical help, obstetric and diabetes review ABC and SEWS chart HDU care Commence IV insulin at an initial rate of 6 units/hour, with 1 hourly capillary blood glucose monitoring. Commence IV fluids: 1 L 0.9% saline over 1 hour initially, then 1 L over 1 hour, followed by 1 L over 2 hours. Urinary catheter if oliguric. Repeat ABG, U&E and venous plasma glucose at 2 and 4 hours: remember DKA is associated with loss of total body K+ and replacement will always be needed, even if the initial serum level is normal or elevated.

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Add potassium (unless anuric) K+ > 5.0 mmol/L No supplements K+ 3.5 – 5.0mmol/L 20 mmol/L K+ < 3.5 mmol/L 40 mmol/L

 Note that 500 mL bags 0.9% saline containing 10 mmol or 20 mmol potassium are available

Commence 10% glucose 4 hourly when the blood glucose falls to 14 mmol/L or less. The insulin infusion rate should also be reduced at this stage, usually to 3 units/hour, although individual adjustment is appropriate. It may also be appropriate to continue with 0.9% saline in addition if the patient requires further fluid replacement. If 0.9% saline is not being continued you may be required to give glucose with added potassium (use ready-made bags).

 This guideline is an abridged version for anaesthetists of the full guideline Diabetes and Pregnancy, available on the intranet.

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References Scottish Intercollegiate Guidelines Network. 2013. 116 Management of diabetes: A national clinical guideline. Edinburgh: Scottish Intercollegiate Guidelines Network. National Institute for Health and Clinical Excellence. 2008. NICE clinical guideline CG63: Diabetes in pregnancy: Management of diabetes and its complications from pre-conception to the postnatal period. London: National Institute for Health and Clinical Excellence. Royal College of Obstetricians and Gynaecologists. 2011. Scientific Impact Paper No.23: Diagnosis and Treatment of Gestational Diabetes. London: Royal College of Obstetricians and Gynaecologists. HAPO Study Cooperative Research Group, Metzger, B.E., Lowe, L.P., Dyer, A.R. et al. 2008. Hyperglycemia and adverse pregnancy outcomes. New England Journal of Medicine, 358(19): 1991– 2002.

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Prophylaxis Against Venous Thromboembolism For Women Undergoing Caesarean Section

Introduction The anaesthetist normally prescribes prophylactic dalteparin after caesarean section. The majority of caesarean sections are performed under regional anaesthesia and the timing of dalteparin administration needs to balance the risks of deep venous thrombosis (DVT)/pulmonary embolus (PE) versus haematoma. All women having caesarean section should also have inflatable calf compression boots intraoperatively and in the recovery room. Note that dalteparin is not routinely to be prescribed for women who have forceps deliveries; a risk assessment form is available to calculate risk.

Dosage and Timing of Dalteparin The dose (units) appropriate for body weight (see table) of dalteparin is given subcutaneously. The first dose should be given 4 hours after delivery of the baby or removal of epidural catheter (whichever is later). The subsequent dose should be given at the closest to 24 hours later – at one of four possible times, chosen from the following: 1000, 1400, 1800 or 2200.

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Prescription When prescribing, the word “units” should be written in full. Usually the first dose will be prescribed on the Once Only part of the prescription chart. To prevent the risk of double dosing in the early postoperative period, the start date for dalteparin in the Regular Therapy section of the chart should be the following day. Also in this section, the prescriber should initial and enter the appropriate code number in the box corresponding to the day of surgery to indicate that a once only dose will be given instead. In cases of caesarean section under epidural anaesthesia, the anaesthetist should ordinarily ensure removal of the epidural catheter before the patient leaves theatre/recovery (see also Cautions, below and Removal of Epidural Catheter). If bleeding occurs on institution of the block or removal of epidural catheter, delay dalteparin to 12 hours later.

Duration of treatment Continue for 10 days. Women with previous thromboembolic disease should have dalteparin prescribed for 6 weeks (after discussion with haematologist).

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Cautions  Epidural catheters must not be removed within 12 hours of dalteparin administration. Cases for which it may be decided to leave the epidural catheter in situ include major obstetric haemorrhage and (rarely) the need for epidural analgesia postoperatively. In these cases the anaesthetist must write clear instructions on the front of the prescription chart.  Dalteparin should not be administered until coagulopathy has been corrected.  In all cases of concern the patient must be monitored for symptoms and signs of spinal/epidural haematoma, especially numbness and weakness in lower limbs, severe backache and bladder/bowel incontinence. If suspected, an anaesthetist should be contacted immediately.  Anti-factor Xa levels should be measured in women with renal impairment.

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Contraindications Absolute  Hypersensitivity to dalteparin including heparin- induced thrombocytopenia (HIT)  Intracerebral haemorrhage  Acute bacterial endocarditis

Relative  Acute haemorrhage  Congenital or acquired coagulopathies  Active gastric or duodenal ulceration

Alternative management (when dalteparin contraindicated) In these cases mechanical prophylaxis should be instituted: TED stockings and intermittent pneumatic compression (IPC), e.g. Flotron boots.

Table of Suggested Prophylactic Doses of Dalteparin Following Caesarean Section If severe renal impairment and/or creatinine clearance < 30 mL/min, contact Consultant Haematologist.

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Weight (kg) Dalteparin Dose

<50 2500 units daily 50 – 90 5000 units daily 91 – 130 7500 units daily* 131 – 170 10,000 units daily* >170 75 units/kg daily*

* may be given in two divided doses

 This guideline is for ready reference by the anaesthetists and does not replace the full guideline VTE Prophylaxis During Pregnancy Guidelines, available on the intranet.

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Antibiotic Prophylaxis

MRSA Procedure Antibiotic Alternative Positive Caesarean Cefuroxime Clindamycin Add section 1.5 g 600 mg teicoplanin immediately 400 mg prior to incision unless gestation < 32 weeks, in which case give following clamping of cord Assisted Not recommended delivery Perineal tear Co-amoxiclav Cefuroxime Add 1.2 g in theatre 1.5 g and teicoplanin (prophylaxis followed by oral metronidazole 400 mg recommended for 7 days 500 mg (minor rd th for 3 and 4 allergy) degree tears only) or

Clindamycin 900 mg (major penicillin allergy) Manual Co-amoxiclav Clindamycin Add removal of 1.2 g 600 mg teicoplanin placenta 400 mg

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Induced Metronidazole Substitute abortion 1 g PR metronidazole with or clindamycin

Metronidazole 600 mg 800 mg oral and azithromycin 1 g Substitute oral (if azithromycin chlamydia test is with doxycycline negative or not 100 mg twice required) daily for 7 days Evacuation of retained Not recommended products of conception *Note all doses are IV unless otherwise stated

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Maternal Obesity

Introduction This guideline aims to provide help and advice for the anaesthetic management of pregnant women who have a BMI ≥ 40 kg/m2, although many of the same principles apply to any women with a BMI ≥ 30 kg/m2.

Background Obesity (BMI ≥ 30 kg/m2) is prevalent in the United Kingdom (UK) population: according to the most recent data, 24 – 29% of adults in the respective UK countries are obese. Women who are classified as obese and babies of women who are obese are at much greater risk of antenatal complications (e.g. pregnancy-induced hypertension and pre-eclampsia, gestational diabetes, venous thromboembolism, cardiac disease, intrauterine growth restriction, fetal macrosomia, miscarriage, preterm delivery, congenital abnormalities and stillbirth), intrapartum complications (e.g. fetal distress and caesarean section (rate increases linearly with BMI)) and postnatal complications (e.g. postpartum haemorrhage, venous thromboembolism, sepsis, post-caesarean wound infection, low breastfeeding rates, admission to neonatal unit, admission to intensive care unit and 215 neonatal death) compared to women of healthy weight. Overweight and obese pregnant women also have a higher mortality, particularly due to thromboembolism and cardiac disease.

National Guidelines CMACE/RCOG joint guideline: Management of women with obesity in pregnancy AAGBI/SOBA (Society for Obesity and Bariatric Anaesthesia): Peri-operative management of the obese surgical patient 2015 The Society for Obesity and Bariatric Anaesthesia (SOBA) Single Sheet Guide (see Appendix D) – this single sheet is a useful aide-memoire for the anaesthesia management of obese patients

Antenatal: Anaesthetic Assessment in Metabolic Clinic All patients with a BMI ≥ 40 kg/m2 should be reviewed in the multidisciplinary metabolic clinic. This clinic occurs every Tuesday afternoon in the obstetric outpatient department in RIE and starts at 13:00. Patients should be reviewed no later than 34 weeks’ gestation.

History Co-morbidities noted, especially cardiorespiratory, diabetes, snoring and sleep apnoea

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Examination Airway assessment and discuss awake fibreoptic intubation if airway looks difficult Assess patient supine with manual uterine displacement or wedge – assesses cardio respiratory tolerance of this position if needed e.g. for caesarean section, and assesses optimal positioning for airway management Back assessed +/- lumbar spine ultrasound to assess depth to epidural space Venous access assessed Note current weight Vital signs including SaO2

Investigations All women have an ECG Further investigations if indicated e.g. chest x-ray, lung function tests, echocardiogram

Recommend early epidural Gives time to site if difficult Gives time to get epidural working well – higher rate of failure Reduce chance of GA Reduce cardiorespiratory work of labour Give information leaflets for raised BMI and epidural Write Anaesthetic Plan on Trak in special features section

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Intrapartum Duty anaesthetist should meet patient and review anaesthetic plan on Trak Inform consultant anaesthetist Regular ranitidine orally 6 hourly Avoid aortocaval compression Site two large bore cannulae early Recommend early epidural Large blood pressure cuff – must exceed diameter of arm by 20%. Arterial line preferred if difficulty with cuff Manual handling department for advice – telephone RIE extension 21750, SJH extension 53463

Equipment Weight limits of beds and tables

Weight Limit of Beds & Tables RIE SJH

RIE theatre table 454kg 400 kg (Maquet Betastar) Labour ward (Huntleigh) 170 kg 180 kg Ward bed (Huntleigh Contura) 267 kg 267 kg

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Regional anaesthesia equipment available in longer lengths

RIE SJH Epidural 135 mm 16G Tuohy needle 135 mm Tuohy needle (110 mm needle shaft) (110 mm needle shaft) (Portex) (Portex)

Spinal 120 mm 25G Pencan needle 120 mm 24G Sprotte 150 mm 25G Pencan needle needle 120 mm 25G Whitacre needle 150 mm 24G Sprotte needle

CSE 150 mm Sprotte needle can Braun Espocan CSE kit: 90 be passed through 135 mm mm Tuohy needle shaft Tuohy needle (careful as with 138.5 mm 27G spinal spinal needle protrudes 15 needle mm beyond end of Tuohy)

Epidural analgesia Warn parturient extra time may be required and failure rate could be up to 20%. Second assistant e.g. ODP may be needed to retract fat pads over lumbar area.

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Positioning Use sitting position (may help to sit in centre of bed with soles of feet together or sit on edge of bed with two footstools with pannus between thighs). Optimal positioning for very obese women can be achieved in the operating theatre where the table can be tipped downwards posteriorly to assist lumbar flexion.

Finding midline Consider ultrasound scan. Ask parturient if injection site feels midline. Use standard 10 cm Tuohy initially for most women – with compression of soft tissue, most epidurals are achievable with standard Tuohy. Leave 6 – 8 cm catheter in space: catheter will move with fatty tissue and catheter easier to pull back than to resite Sit woman upright from flexed position before securing catheter to skin: catheter tends to be pulled inwards into fatty tissue as woman sits up and if adherent to dressing will be pulled out of epidural space. Assess block height regularly especially with initial top-ups: may need lower volume top-ups.

Spinal Anaesthesia Consider CSE:

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 Gives dense spinal dose but flexibility of prolonging anaesthesia if surgery prolonged.  Can be easier to site spinal through Tuohy as better feel of soft tissues compared with spinal needle.  Block may be higher – spinal dose bupivacaine may be slightly reduced by up to 10%. Epidural catheter gives backup for lower spinal dose.

Positioning for insertion  As above for epidural  Avoid aortocaval compression with 15° left lateral tilt. At risk of aortocaval compression after delivery also.  Pannus usually positioned lateral to patient. Beware pannus retracted onto patient’s chest – can cause cardio respiratory compromise and fetal distress.  Pillows under shoulders and head to raise upper thorax. This will help avoid high block and improve respiration.  Use arm boards: facilitates IV access and insertion of arterial line if required  Pad arm boards to keep arms level with body and pad pressure areas

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 Oxygen 4 L/minute by Hudson mask may be required

General Anaesthesia  Have senior anaesthetist present  Expect difficult intubation in 10%  Ramped position optimal position for airway management (see figures 1 and 2). Use Oxford HELP pillows or pillows and blankets to ramp up patient from shoulders upwards. External auditory meatus should be level with sternum (head completely free from chest).  Take difficult airway trolley into theatre and explicitly discuss plan for difficult and failed intubation with team  Tilt 15° left lateral to avoid aortocaval compression as soon as possible (may need lateral support on table if pannus swings to left)  Administer ranitidine and sodium citrate

 Pre-oxygenate to EtO2 as high as possible – ideally > 85 – 90%  Use arm boards and pad pressure areas

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Figure 1. Sniffing morning air – suboptimal airway positioning. Note sternum above tragus (blue line).

Figure 2. Ramped positioning – airway positioning optimised. Note sternum level with tragus (blue line). Pillows/blankets used to elevate upper body and head by ramping up middle of the back, shoulders and head.

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 Thiopentone dose based on lean body weight, i.e. approximately 70 kg in an obese woman  Suxamethonium dose based on actual body weight at 1 – 1.5mg/kg  Short handled laryngoscope or McGrath video laryngoscope (if anaesthetist familiar with this)  Size 7 mm endotracheal tube  Tidal volume 5 – 7 mL/kg ideal body weight + PEEP, but may need pressure controlled ventilation. Aim for normocarbia.  A degree of head up tilt helps lung expansion  Use nerve stimulator and always reverse muscle relaxant  Plan extubation: consider orogastric tube to aspirate stomach pre-extubation. Extubate fully awake and sitting upright.  HDU post-op

Points to note At caesarean section incision may be supraumbilical – discuss with surgeon what incision plan is.

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Postpartum Nurse sitting up, care of pressure areas. Avoid shivering (increases oxygen requirement). If post GA: oxygen for 24 hours with oxygen saturation monitor and refer to physiotherapy for chest physiotherapy. Monitor respiratory rate for 24 hours if received spinal or epidural diamorphine (remember sleep apnoea). DVT prophylaxis with dalteparin: see separate guideline (dose is weight related). All women with BMI > 40kg/m2 need low molecular weight heparin venous thromboembolism prophylaxis for 6 weeks whatever the mode of delivery.

Associated documents Lothian - Obesity management during pregnancy and postnatally, 2011 Lothian - Prophylaxis against venous thromboembolism (VTE) during pregnancy, 2011 Lothian - Manual handling midwifery guidelines, 2009

References Knight, M., Kurinczuk, J.J., Spark, P. et al. 2010. Extreme obesity in pregnancy in the United Kingdom. Obstetrics & Gynaecology, 115(5): 989- 97. 225

Cantwell, R., Clutton-Brock, T., Cooper, G. et al. 2011. Saving Mothers' Lives: Reviewing maternal deaths to make motherhood safer: 2006-2008. The Eighth Report of the Confidential Enquiries into Maternal Deaths in the United Kingdom. British Journal of Obstetrics and Gynaecology, 118(Supplement 1): 1-203. Modder, J.F., Fitzsimons, K.J. 2010. CMACE/RCOG joint guideline: Management of women with obesity in pregnancy. Centre for Maternal and Child Enquiries and the Royal College of Obstetricians and Gynaecologists. Nightingale, C.E., Margarson, M.P., Shearer, E. et al. 2015. Peri‐operative management of the obese surgical patient 2015. Anaesthesia, 70(7): 859-76. Collins, J.S., Lemmens, H.J., Brodsky, J.B. et al. 2004. Laryngoscopy and morbid obesity: a comparison of the "sniff" and "ramped" positions. Obesity Surgery, 14(9): 1171-5.

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Needle phobia: Antenatal Guideline For Women Refusing Routine Blood Taking in the Community

Introduction The Confidential Enquiry into Maternal and Child Health 2000-2002 identified needle phobic women as being at greater risk of death. NHS Quality Improvement Scotland Maternal History Taking Best Practice Statement recommended “Women with a significant needle phobia (which prevents booking bloods being taken) should be referred for early support (e.g. hypnosis, psychological, psychiatric support) and to an obstetric anaesthetist or other appropriate specialist”.

Aim To manage women who refuse routine blood taking in the community during pregnancy.

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Guidelines All these women should be treated as high risk patients and therefore should have consultant obstetrician led antenatal care. The NHS Lothian Criteria for Antenatal Referrals to Anaesthesia include needle phobia. At present community midwives refer women who refuse to have booking bloods done to the anaesthetic antenatal clinic. When these women attend the clinic, in our experience 50% can be persuaded to have blood taken with the help of local anaesthetic cream and an experienced operator. The remaining 50% are the high risk group where a true phobia prevents cooperation with blood taking even though the safety reasons for having blood taken are well understood by the woman. This high risk group also includes the women who do not attend the clinic even though the importance of doing so is understood – avoidance behaviour.

The following pathway is the suggested best practice for women in Lothian who do not cooperate with blood taking in the community:

Stage 1 Input Priority referral should be made to the anaesthetic antenatal clinic with a documented list of blood tests required at around 12 weeks for trial of:  Explanation

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 Topical Local anaesthetic cream  Experienced venepuncturist Satisfactory outcome: patient returns to consultant obstetrician led antenatal care. Unsatisfactory engagement/outcome: proceed to Stage 2

Stage 2 Input Referral by consultant anaesthetist to sector Adult Mental Health Clinical Psychologist using appropriate standardised referral letter according to geographical location of patient’s GP (see list in Needle Phobia document on NHS Lothian Intranet). Referral recognised and treated as a priority.

Psychological assessment and treatment plan with aim for further attempt at blood taking by 28 weeks’ gestation, either in the anaesthetic antenatal clinic (RIE), or included as part of consultant obstetrician outpatient appointment with anaesthetic input (SJH).

Satisfactory outcome: patient returns to consultant obstetrician led antenatal care. Unsatisfactory engagement/outcome: proceed to Stage 3

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Stage 3 Input Assessment at home or in hospital by the Liaison Psychiatric team: bleep 4019 (RIE) or 3017 (SJH).  Graded exposure to be implemented  Discussion of an advanced directive

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Referral Letter for All Patients with a West Lothian GP University Hospitals Division Department of Anaesthesia, Critical Care & Pain Medicine Obstetric Anaesthesia

Patient: UHPI: CHI:

Dear

This ______year old lady who is currently ______pregnant (EDD ______) with her ______baby, was referred to the obstetric anaesthetic antenatal clinic by her community midwife who had been unable to obtain a blood sample on account of the patient’s needle phobia. She was SEEN AT / DID NOT ATTEND the clinic on ______and unfortunately her needle phobia was so severe that despite concerted efforts at reassurance, local anaesthetic cream and an experienced anaesthetist, she was unable to overcome her fear and we were therefore unable to obtain the required blood sample. We therefore feel that she requires specialist psychological treatment for her needle phobia.

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Untreated needle phobia carries considerable clinical risks including death when the sufferer is pregnant. It is necessary to obtain blood in early pregnancy for the safe management of the pregnancy. Therefore the first goal of psychological treatment is for the woman to accept venepuncture for blood samples. Haemorrhage and other obstetric complications can only be safely managed with adequate intravenous access which is the second goal of psychological treatment. The third goal is that the woman would accept a spinal or epidural anaesthetic (needle in the back) should operative delivery be required. It is therefore clinically urgent that this lady receives treatment for her phobia before she delivers.

It is NHS Lothian policy that pregnant women should be given priority access to psychological treatments.

We are aware that avoidance is a core feature of phobia and this may manifest itself in the patient’s failure to engage in psychological treatment. If this patient fails to engage with psychological treatment of her needle phobia please let her Consultant Obstetrician know within four weeks of receipt of this letter to allow contingency arrangements to be made.

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As psychological treatment progresses to the point where you feel this patient would tolerate a blood sample by an experienced venepuncturist please contact her Consultant Obstetrician. When she attends her Consultant Obstetric Outpatient appointment, the senior Labour Ward Anaesthetist will attempt further venepuncture.

Please do not hesitate to contact me to discuss this referral further if required.

Yours sincerely,

Consultant Obstetric Anaesthetist St. John’s Hospital, Livingston.

Cc: GP: Consultant Obstetrician: CMW:

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Referral Letter for All Patients with a Non-West Lothian GP University Hospitals Division Department of Anaesthesia, Critical Care & Pain Medicine Obstetric Anaesthesia

Simpson Centre for Reproductive Health Royal Infirmary of Edinburgh 51 Little France Crescent Edinburgh EH16 4SA Telephone: 0131 536 1000

Date:

Our Ref: Your Ref:

Dear

This ____year old lady who is currently ______pregnant (EDD ______) with her ______baby was referred to the obstetric anaesthetic antenatal clinic by her community midwife who had been unable to obtain a blood sample on account of the patient’s needle phobia. She was seen at the clinic on ______and unfortunately her needle phobia was so severe that despite concerted efforts at reassurance, 234 local anaesthetic cream and an experienced anaesthetist, she was unable to overcome her fear and we were therefore unable to obtain the required blood sample. We therefore feel that she requires specialist psychological treatment for her needle phobia.

It is NHS Lothian policy that pregnant women should be given priority access to psychological treatments. We are aware that avoidance is a core feature of phobia and this may manifest itself in the patient’s failure to engage in psychological treatment. If

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______fails to engage with psychological treatment of her needle phobia please let me know within four weeks of receipt of this letter to allow me to make contingency arrangements to minimise the risks.

As psychological treatment progresses to the point where you feel______would tolerate a blood sample by an experienced venepuncturist please contact me and she will be sent another appointment for the anaesthetic antenatal clinic.

Please do not hesitate to contact me to discuss this referral further if required.

Yours sincerely,

Consultant Obstetric Anaesthetist

Cc: CMW: Consultant Obstetrician: GP:

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Obstetric High Dependency Care

Admission Criteria The requirement for nursing and midwifery care and/or clinical monitoring that is beyond the remit of normal ward care. Obstetric or anaesthetic specialties may request HDU care of a patient: the other speciality must always be informed.

Conditions Requiring HDU Care The following are examples of clinical conditions which may require HDU care.

 Severe pre-eclampsia or eclampsia  Significant haemorrhage (APH or PPH)  Bakri® balloon tamponade or vaginal packs  Predicted prolonged recovery time following anaesthesia  Co-existing medical disorders that require close monitoring  Invasive monitoring

On Admission  A brief history and examination should be documented

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 Appropriate documentation should be completed  Monitoring, management plan, and medication reviews performed as appropriate  Baseline blood tests should be sent  Patient should be admitted on Wardwatcher

Intensive care should be considered if patient’s condition does not improve or deteriorates. ICU registrars at RIE can be contacted on bleep number 2306.

Upon admission to HDU, the consultant obstetrician on duty for labour ward will assume responsibility for the patient’s care. The responsible anaesthetist will be the consultant on- call for labour ward.

The midwife or nurse looking after the patient should have undergone competency-based training in HDU care.

On Discharge Upon discharge, the patient should be discharged on Wardwatcher and the discharge sheet printed for inclusion in the medical notes.

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Management of the Pregnant Patient in the Intensive Care Unit

 Perform a pregnancy test (urinary beta-hCG) on all female patients of child-bearing age admitted to the Intensive Care Unit (ICU), unless this has been performed and clearly documented earlier in the hospital admission.  Discuss with on-call obstetric and neonatal teams any critically-ill pregnant patient and arrange an urgent ultrasound. This is to assess whether early delivery is indicated as part of maternal resuscitation, to assess viability of the pregnancy and to guarantee obstetric follow-up.  Nurse pregnant patients with significant intra- abdominal mass (typically > 20 weeks’ gestation) in a left-tilted position using pillows or a wedge. This is to avoid aortocaval compression and compromise of the utero-placental circulation.  Pregnant critically-ill patients requiring intubation are at high risk of aspiration. Administer ranitidine (50 mg intravenously or 150 mg orally) pre-intubation when time allows. Administer sodium citrate 0.3 M (30 mL orally) immediately prior to intubation.  In all female, critically-ill patients of child- bearing age, consider obstetric complications

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until pregnancy has been ruled out by a negative pregnancy test. These include: o Eclampsia/pre-eclampsia (hypertension, acute liver failure, seizure, pulmonary oedema) o Amniotic fluid embolus (cardiovascular collapse, coagulopathy) o Antepartum haemorrhage o Pulmonary embolism o Cerebral venous sinus thrombosis (headache and reduced consciousness) – this requires a CT venogram to exclude; a non-contrast CT head is insufficient o Peripartum cardiomyopathy, aortic dissection and myocardial infarction o Obstetric sepsis/chorioamnionitis o Thrombotic thrombocytopenic purpura (thrombocytopenia, microangiopathic haemolytic anaemia, CNS signs, acute kidney injury, fever)  The obstetric team should liaise with the Midwife Coordinator to provide a midwife, and should arrange for CTG/continuous fetal monitoring if indicated.  A perimortem caesarean section kit should be immediately available at the bed space of any 240

pregnant ICU patient. If the pregnancy is viable, a neonatal resuscitaire should be immediately available in the event of perimortem caesarean section.  In a cardiac arrest involving a pregnant patient, perimortem caesarean section should be started within four minutes. The baby should be delivered within five minutes from onset of cardiac arrest.  Pregnant women are at high risk of venous thromboembolic disease before and after delivery. Follow standard NHS Lothian Critical Care VTE Prophylaxis Guidelines unless an absolute contraindication exists. Consider additional mechanical thromboprophylaxis.  Use the ‘Handover Sheet for Obstetric Patients Requiring Admission to General Critical Care’ (available on the NHS Lothian Critical Care Guidelines intranet site). This provides contact numbers for on-call obstetric and obstetric anaesthesia teams, as well as for the labour ward coordinator.

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Pregnant Patients Requiring Caesarean Section in the Intensive Care Unit

The clinical priority is the care of the mother. The indication for caesarean section will probably be to improve maternal physiology rather than fetal outcome. Even early pregnancy is associated with respiratory and cardiovascular changes which worsen maternal physiology in critical illness. Improvements in maternal physiology can occur within minutes of delivery and may be life-saving.

Points for the Intensivist and Obstetric Anaesthetist  Discuss with the neonatal team all critically-ill women at ≥ 22 weeks’ gestation if delivery is expected.  Ensure blood is available via electronic-release (2 x samples to BTS). If perioperative major obstetric haemorrhage is very likely, ensure two units of cross-matched blood are immediately available.  Patients require large-bore intra-venous access (typically 2 x peripheral cannulae ≥ 16 G). Flow- rate through a standard central venous catheter is insufficient for rapid infusion of fluids.  Bring uterotonics from SCRH if these are not available in ICU. Discuss their use with the ICU 242

team: some may be contraindicated (e.g. carboprost in asthma or severe pulmonary oedema) or need modification to their usual mode of administration (e.g. slow infusion rather than bolus of Syntocinon®).  It may be surgically impossible to deliver the baby unless the patient is supine, although patients with severe respiratory failure sometimes tolerate this very poorly. Discuss optimal positioning early and certainly before knife-to-skin.  The risk of major obstetric haemorrhage is high. Consider use of intraoperative cell salvage and the Belmont Rapid Infusor.  Communicate with the neonatal team regarding drugs which will affect the fetus e.g. propofol and alfentanil infusions. Points for the Obstetrician, Obstetric Anaesthetist, Midwife and Scrub Team  Hold an early team brief (including neonatology) in SCRH as soon as operative delivery in ICU becomes likely. This should cover roles and responsibilities, equipment that will be needed (including to deal with complications e.g. hysterectomy), and management of contingencies such as major haemorrhage. Update the ICU consultant on any important decisions. 243

 There is no operating light available in ICU. This should be brought to ICU by the scrub team. Operating stools are also not routinely available.  This is a high-risk clinical scenario from a human factors perspective. Complete the WHO Surgical Safety Checklist before knife-to-skin to ensure aspects of routine intra-operative care are not omitted. The consultant intensivist and bedside nurse should be present at this point.  Surgical access when the patient is on an ICU bed is very challenging. These patients are unlikely to be stable enough to transfer to a portable operating table in ICU, although this should be considered as an option. A classical incision may be required to access the uterus. Points for the ICU Nurse-in-Charge and Intensivist  Space will be at a premium. When bed occupancy allows, consider moving neighbouring ICU patients to other bed spaces to maximise workspace.  Multiple trolleys are required to provide a flat surface for the anaesthetic and neonatal teams’ drugs and equipment. Source additional trolleys from HDU.  If the caesarean section corresponds with visiting time, plan to relocate visitors for the

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duration of the operation and subsequent neonatal resuscitation.  Close the bed space curtains of nearby, unsedated ICU patients in order to ensure privacy.  Ensure the Nurse-in-Charge has a portable phone. Rapid liaison with other specialties may be required in the event of emergency (e.g. paediatric ENT).  The nurse in charge, bedside nurse and a runner should all be present throughout the duration of the caesarean section and neonatal resuscitation. Points for the Neonatal Team  ICU staff may be unfamiliar with needs and priorities of the neonatal team. Communicate early with ICU medical or nursing staff if there is anything they can assist with.  The mother will probably be receiving multiple drugs which affect the fetus. These include alfentanil and propofol infusions.  Flat surfaces are at a premium; consider bringing trolleys from the neonatal unit to provide additional flat workspace.

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 The presence of the neonatal transport team can provide additional clinical support in the event of a complex neonatal resuscitation.  A cold light (to exclude neonatal pneumothorax) and neonatal difficult intubation equipment should be brought to ICU. Following Caesarean Section  Discuss any positive maternal microbiology results or other concern about maternal infection (e.g. presence of herpetic lesions) with the neonatal team. Updates between teams should be considered weekly or following major events.  Follow standard Critical Care Thromboprophylaxis guidelines unless an absolute contraindication exists. Consider additional mechanical thromboprophylaxis.  All staff should consider writing contemporaneous statements of their involvement in the event of future investigation by the Procurator Fiscal or other bodies.  Complete a Datix® incident report.  A multi-specialty, multi-professional, after- action review of events can capture valuable learning points from this rare clinical scenario.

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Aide Memoire for Obstetric Anaesthetic Follow-ups

 Follow-up visits to be lead by consultants or advanced trainees only, more junior trainees can join the consultant to do follow-ups but should not be tasked with doing this independently.  Remember to collect all forms, including those in theatres. Minimal Interval from Delivery to Review SVD: review from 4 hours postnatal Operative delivery/tear repair/retained placenta: review patients who have delivered before midnight

Please attempt to visit all patients (including those in HDU) before 5 pm, second visits may be required if patient not available first time.

 It is acceptable to wake apparently sleeping patients gently – if only to ensure that they are not unconscious due to diamorphine.

The short-term follow-ups box should be checked and attended to daily. If you have been unable to see patients or check the short-term follow-up box please hand over to

247 the consultant for the following morning by telephone call or text (no patient details!).

Ask About  Delivery of anaesthetic  Experience in labour and at delivery  Headache , motor power, sensory deficits, back pain for regional  Awareness if GA

Document  Any complications  Post-operative symptoms should be recorded on Trak and a letter sent to the GP.

Further Follow-up  Patients who have not yet mobilised from the bed or still have a urinary catheter in situ can be discharged from review if they report normal sensation and power when lying down.  If early (next day) review is required leave the audit form in the labour ward tray.  Only place forms in the short-term follow-up box when the immediate problem has been managed and the patient needs follow-up at a 248

later date. Please confirm with the patient the best telephone number to contact them on and write it on the audit form. Highlight date when follow-up call should be made (usually at 1 week and 1 month for PDPH).  Where there is a need to debrief a woman regarding difficult events, or failed or problematic anaesthesia/analgesia (as opposed to just checking headache status), audit forms can be passed to Dr Burns for further follow-up.

Headaches  Use the PDPH audit form and the GP letter (found beside the short term follow-up box, or ask Hazel), attaching both to the general audit form. The GP letter should be completed at the time of the patient receiving a blood patch or being discharged from hospital if no blood patch. Give the patient a PDPH leaflet. Complete the details on Trak using the /PDPH shortcode. Make sure the relevant boxes are ticked on the audit form.  Follow guidance on PDPH protocol, remember to change the dalteparin prescription to 22:00.  Give consideration to blood patch as soon as diagnosis of PDPH is made to minimise symptoms in initial 24 hours.

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 Once headache has been treated patient should have telephone review at 1 week and 1 month postnatally.  If a headache continues after second blood patch consider imaging to rule out intra-cranial pathology.  Please record all proven or suspected PDPH in the small notebook beside the short-term follow-up box.

Neurological problems  Examine the patient and determine likelihood of obstetric palsy versus anaesthetic complication.  If suspecting obstetric palsy (see table below) reassure patient, give them a neurological injury leaflet and complete GP letter. Make an entry on Trak. Advise midwives/obstetricians to refer to physiotherapy if there is a motor block. Patient does not require further anaesthetic telephone follow-up.  Suspect an anaesthetic complication if  there was pain during needle insertion  there is neuropathic pain postnatally (obstetric palsies are not typically painful)

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 there are worsening or late onset of symptoms  there is sphincter dysfunction  Consider need for MRI, physiotherapy, analgesia / pain clinic referral. Letter to GP and follow up by telephone at an interval appropriate to the injury.

Feedback to Medical Staff The consultant who identifies an anaesthetic complication should make it a priority to inform the anaesthetist who performed the procedure. Where a trainee is involved please inform Dr Wise (as the clinical supervisor) and/or Dr Daly (as the college tutor).

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Nerve / Site of Symptoms Signs Additional Roots compression information LCNT (L2-L3) Under the Neuropathic Abnormal Associated inguinal pain/paraesthesia sensation with ligament or over lateral aspect over the prolonged hip against the of thigh (meralgia lateral aspect flexion ASIS paresthetica). Can of the thigh (lithotomy be worse on position) standing or walking

Femoral (L2- Under the Abnormal Sensory loss Associated L4) inguinal sensation in the in femoral with ligament or femoral distribution. prolonged hip against the distribution. Weakness of flexion. ASIS Difficulty in knee Bilateral in climbing stairs extension. around 25% of Decreased cases patellar reflex

Obturator Thought to Groin pain and Sensory loss Bilateral in (L2-L4) be at the difficulty in inner thigh. around 25% of lateral wall walking Weakness of cases. of the lesser hip adduction Commonly pelvis and internal associated rotation with femoral nerve damage

Lumbosacral Posterior Abnormal Sensory loss Almost always plexus (L4-5, pelvic brim, sensation in the of lateral unilateral S1-S5) against the lumbosacral aspect of leg sacral ala distribution. and dorsum Tripping due to of foot. foot drop Weakness of dorsiflexion and eversion

Common Head of the Tripping due to Sensory loss Associated peroneal fibula foot drop in common with (L4-5, S1-S2) peroneal inappropriate distribution. positioning in Weakness of lithotomy dorsiflexion stirrups and eversion

Cutaneous Greater Numbness over Loss of Higher risk if sacral sciatic the buttocks sensation lying supine (cluneal) foramen over the with regional nerves buttocks anaesthesia (S2-S3) for prolonged periods (e.g. during CS)

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References Scavone, B.M. 2017. One patch or more? Defining success in treatment of post-dural puncture headache. International Journal of Obstetric Anesthesia, 29: 5-7 Duncan, A., Patel, S. 2016. Neurological complications in obstetric regional anesthetic practice. Journal of Obstetric Anaesthesia and Critical Care, 6(1): 3-10. Richards, A., McLaren, T., Paech, M.J. et al. 2017. Immediate postpartum neurological deficits in the lower extremity. International Journal of Obstetric Anesthesia, 31: 5-12

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Management of Adverse Incidents in Obstetric Anaesthesia

Why Report? Adverse incident (AI) reporting is a powerful tool which aims to generate learning thereby improving our healthcare systems. It also enables immediate patient safety, staff safety and organisational safety issues to be addressed urgently.

AI reporting is strongly encouraged in NHS Lothian.

In Anaesthesia at the RIE, we review incidents using the London Protocol [1]. This looks at the whole system in which the AI occurred, rather than attributing blame to individuals. For any AI of any severity there will be many factors which have contributed to the AI – “The Swiss Cheese Model of Accident Causation” [2].

We encourage voluntary reporting of all AIs of any severity. This includes incidents where no harm has occurred i.e. “Near Misses”.

However, the following significant adverse events (SAE) should trigger an incident report:  Maternal cardiac/respiratory arrest

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 Maternal death  Unanticipated ICU admission due to AI  Failed intubation  High/total spinal block  CNS trauma or infection  Awareness under GA  Anaphylaxis  Significant pain during surgery under regional anaesthesia

How to Report Please report via Datix® which is accessed via intranet homepage > Applications (drop down menu on upper right hand side). If you are reporting equipment-related issues, please provide the following information on Datix® report:

 Asset number of equipment (e.g. anaesthetic machines, infusion pumps)  Reference and LOT number for disposables (e.g. ETT, bougies etc.)

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What Happens to Datix® Reports? All reports are reviewed by specialty based clinical managers or designated medical staff: in anaesthesia, the lead for AIs is Dr Rachel Hignett. The reports are notified to the allocated reviewer by email, and are reviewed on Datix® quickly. Most incidents are dealt with by the reviewer. Some incidents are deemed to be “significant adverse events” (SAE). Examples of SAEs are provided above. Other events may be classed as significant either due to possible harm to patient, staff member or organisation, or an unexpected outcome: learning may be generated by looking at these incidents in more detail. An SAE reported to Datix® in anaesthesia will trigger a request for a RICaRD review (Rapid initial case review discussion) with staff members involved in the incident, and with the case notes and anaesthetic record. These RICaRD reviews are carried out by trained departmental consultant staff confidentially. We aim to discuss cases quickly with staff involved to find out key issues. These cases will go on to be presented at departmental monthly Morbidity and Mortality meetings. The Obstetric department have their own review processes for reviewing SAEs where the focus of care is thought to be more obstetric or midwifery e.g. mandatory reporting of major obstetric haemorrhage. These cases are discussed by a panel at a weekly multi-disciplinary meeting. 256

A very few SAEs will need a formal multidisciplinary review process e.g. to look in detail at the factors contributing to a maternal death. All reports are fed back via Anaesthesia and/or Maternity departmental Morbidity and Mortality monthly meetings, via email to the reporter once a review is completed on Datix®, and sometimes individually by the adverse incident lead.

References Taylor-Adams, S., Vincent, C., Street, P. 2004. Systems analysis of clinical incidents: the London protocol. Clinical Risk, 10(6): 211-20. Reason, J. 2000. Human error: models and management. British Medical Journal, 320(7237): 768-70.

For more information, please contact Dr Rachel Hignett.

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Guideline for the Care of Obstetric Anaesthetists after a Significant Adverse Event

In the event of a significant adverse event involving an obstetric anaesthetist in the Simpson’s Centre for Reproductive Health (SCRH) this guideline of current best practice should be consulted; this could be adapted for other anaesthetic specialties. An important principle is that there is separation of the care of the individuals involved from those providing the mandated organisational response.

Initial Response The on-call consultant obstetric anaesthetist must be informed if not already involved. The Lead Obstetric Anaesthetist (LOA) should be informed and should attend the hospital or nominate a deputy to attend to take charge of the care of the anaesthetists involved and make arrangements for ongoing obstetric anaesthetic cover. On arrival, the LOA or deputy should assess the situation and if required make arrangements to relieve the involved anaesthetic staff of their duties. Out of hours (OOH) this can be achieved by liaising with the Emergency Anaesthesia Team

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(EAT) and secondly by utilising available on-call consultant anaesthetists. If clinical activity is such that these options are infeasible, then the LOA should contact consultant obstetric anaesthetists. Following an adverse event and when safe to do so, staff affected should stop clinical duties; they should not participate in subsequent clinical duties that are non-urgent, for example labour epidurals. An informal and non-compulsory multidisciplinary debrief with all staff involved in the adverse event should be considered within a few hours (and ideally before staff leave their shifts). The purpose of this group debrief is not to “fact find” but to allay anxieties or misconceptions experienced by affected staff and to share individual feelings. This debrief should be facilitated by the most appropriate member of staff available at the time. Following a group debriefing, an opportunity for one-to-one debriefing should be offered.

Discussing the Adverse Event with Affected Staff Participation in discussing the adverse event should be encouraged, but it is recognised that early counselling can make things worse and prolong recovery for some people. The timing,

259 nature and content of debriefing will vary depending on the individuals affected. Once protected time away from duties has been achieved for those involved, the LOA should shift focus onto allowing those involved the opportunity to re-visit and describe events. The LOA should identify a safe and private environment away from any interruptions. Depending on the preference of those involved, the process may be done on a one-to-one basis or in a small group. The offer of an individual discussion is important as some may find it difficult to discuss how they are feeling in the presence of others. After discussing events, the LOA should impress the importance of documenting a record of events in the patient’s Trak record. This is not only good medical practice but will allow the LOA to review the facts of the case and identify any patient safety issues which require to be addressed immediately. It may also be useful for those involved to keep a copy of documentation in a secure location. The individual affected should also document their reflections and feelings for their own appraisal which they should keep in addition to Trak notes.

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During this initial discussion, the LOA will discuss arrangement of future meetings, the level of support for the individual affected and provisional plans for future clinical work. In the wake of an adverse event, staff can have different feelings about being within the workplace. Some wish to distance themselves whilst others find comfort in the workplace. This is an individual decision that should not be mandated, however prevention of “second victim” scenarios must be considered. Staff should be made aware of the sources of support available to them before leaving the hospital. The LOA should ensure that members of affected staff will have arrangements in place to get home safely after an adverse event.

Arranging Support for Affected Staff After a Significant Adverse Event it is important that the correct support is provided to staff. Getting the balance of support correct is a challenge; not enough support may leave the affected staff feeling isolated whilst too much support may leave the affected staff feel overwhelmed. Ultimately, repeated discussion with the individual staff member to establish optimal level of support will be required. 261

One of the early things to do is make staff aware of common thoughts and feelings experienced after an SAE as this will help them to understand their own feelings. The AAGBI’s guideline on Catastrophes in Anaesthetic Practice – dealing with the aftermath may be useful for affected staff to read. Anaesthetic staff affected by the event should be assigned a consultant peer supporter as soon as possible after the event. For trainees, this would normally be their Educational Supervisor or another consultant with whom the trainee feels comfortable; the trainee’s Clinical Supervisor should also be informed. In the case of trainees, the LOA should also inform the College Tutor, Training Programme Director and Regional Adviser as soon as possible so that the Deanery is involved in ongoing support. The Deanery will have a significant role in supporting affected trainees. The LOA has responsibility for supporting staff until a peer supporter is identified. Regular meetings should be arranged with the peer supporter and methods of establishing contact with the peer supporter should be clear e.g. mobile phone number.

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If requested, a change of peer supporter or alternative source of support should be accommodated without the need of justification.

Support for Documentation of Adverse Event The process of investigating the incident may be stressful to those who have not been in this position previously and those affected may benefit from support and guidance. Adequate time should be allocated for staff to complete all the necessary documentation and the departmental clinical governance procedure should be fully explained. This includes Morbidity and Mortality meetings in which they may take part. A report will be required to assist the review of any Significant Adverse Event. This should reflect the clinical scenario and responses. It should be completed in a timely manner. The peer supporter/Educational Supervisor will provide support with this. Consideration should be given to review of the statement by a medical defence organisation. They will provide guidance on report writing and identify grammatical errors.

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Supporting Recovery and Return to Work Close cooperation between the Anaesthetic Department and Deanery are required for planning return to work. The Professional Support Unit at the Deanery or Clinical Director can make an Occupational Health referral; this would often be done in consultation with the individual/Educational Supervisor/College Tutor/Regional Adviser. The individual’s general practitioner may also be involved. The LOA should be updated on the wellbeing of the individual from all those involved so that a plan can be made for the anaesthetists to return to work when appropriate. It is likely that affected staff will have anxieties about returning to the same clinical area or dealing with similar future cases. It may be helpful for affected staff to work alongside another colleague (perhaps the same colleague) for a period of time. Different individuals respond very differently in the extent and timing as to supportive requirements when returning to work. A supported return to clinical activities should be offered; this is especially important for out-of- hours work. This may involve returning staff to be entirely supernumerary.

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Trainee anaesthetists not on their obstetric attachment may benefit from supported sessions back in labour ward/obstetric theatres. They could also talk with those not directly involved or others close to them to provide an external perspective but must maintain patient confidentiality. These discussions are recognised to be helpful for the healing of affected staff. College Tutors should communicate with each other when trainees move to work in other hospitals to ensure continued support as they rotate through different anaesthetic departments.

Providing/Receiving Feedback from Affected Staff Staff affected should receive appropriate and regular updates as to the progress of the review and outcomes. Where good practice has occurred, staff should receive this feedback as soon as possible. Ongoing follow-up should take place to ensure sustained recovery and return to appropriate function.

Sources of Additional Support Sources of support should be highlighted to affected staff throughout this process: 265

 Peer Supporter  For trainees:  Educational Supervisor  Clinical Supervisors  College Tutor  Training Programme Director  Regional Adviser  Regional Adviser as an independent contact for consultant staff  AAGBI Wellbeing and Support: www.aagbi.org/professionals/welfare  AAGBI Mentoring Scheme: www.aagbi.org/professionals/welfare/mentor ing/aagbi-mentoring-scheme  RCOA ‘Career and Personal Difficulties’ website: www.rcoa.ac.uk/careers-and- training/career-and-personal-difficulties  Medical defence organisations (some also offer counselling services)  NHS Lothian Staff Support and Confidential Counselling Service: to arrange counselling sessions the Counselling Administrator can be called on 0131 5379373 (Monday – Friday, 08:30 – 16:30)  BMA ‘Your Wellbeing’ website: www.bma.org.uk/advice/work-life- support/your-wellbeing  BMA counselling phone line: 0330 1231245 (24 hours, 7 days a week)

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 General practitioner  The Samaritans: 116 123 (from any phone) (24 hours, 7 days a week)  Doctors Support Network website: www.dsn.org.uk

If an SAE has occurred which may have had a significant psychological impact, the LOA will liaise with the Staff Counselling Service to prioritise availability of counselling to affected staff, and for all staff affected to be made aware of this resource for accessing psychological support

References Association of Anaesthetists of Great Britain and Ireland. 2005. Catastrophes in anaesthetic practice – dealing with the aftermath. London: AAGBI. Available at www.aagbi.org/sites/default/files/catastrophes05 .pdf. NHS Lothian. Support for staff following a significant adverse event leaflet. Available on intranet or from LOA.

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Appendix A: Checklist for Women Who Decline Blood Products

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Appendix B: PCEA Prescription Chart

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Appendix C: Obstetric Anaesthesia Handover

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Appendix D: Society for Obesity and Bariatric Anaesthesia Summary

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Appendix E: Women with Back Problems - Information for Pregnant Women

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Appendix F: RIE Obstetric Anaesthesia Escalation Policy

A resident senior anaesthetist or consultant obstetric anaesthetist is accessible 24 hours a day by following this escalation pathway. If the coordinating midwife or senior members of the obstetric team have any specific concerns regarding an obstetric patient, they can contact the consultant obstetric anaesthetist directly via page system or switchboard.

Indications for Consultant Obstetric Anaesthetist Attendance & Consultation The Anaesthetic Department would expect the provision of specialist consultant input for all high- risk obstetric patients. The consultant obstetric anaesthetist is the person to deliver this input however, in the event of a life-threatening event between 20:00 and 08:00, immediate assistance can also be requested from the resident senior anaesthetist (bleep 2200). If the “Anaesthetic Management Plan” states to inform the Consultant Obstetric Anaesthetist about a patient’s arrival to the hospital please do so.

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The Consultant Obstetric Anaesthetist on-call must be informed about AND attend in the following situations:  Maternal cardiac arrest or maternal collapse  A pregnant patient being admitted to the Resuscitation Area of the Emergency Department  A pregnant patient being admitted to Critical Care  A patient with an intrauterine death that is complicated by an abruption or requiring delivery by caesarean section  A patient with severe pre-eclampsia, HELLP or eclampsia

The following situations require the input of a senior anaesthetist. The resident senior anaesthetist (bleep 2200) or the consultant obstetric anaesthetist on-call should be contacted to provide any additional support required for the following situations:  A patient with a postpartum haemorrhage where there is rapid ongoing blood loss and/or a total estimated blood loss of >1500 ml  A patient requiring to return to theatre for further surgical intervention

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 A patient with a low, anterior placenta who has had a previous caesarean section  A patient with a known or predicted difficult airway  A patient with significant pre-existing cardiac or respiratory disease – usually an Anaesthetic Management Plan exists on Trak for these patients.  A patient with severe sepsis requiring an anaesthetic for delivery  A pregnant patient with a non-obstetric pathology that requires an anaesthetic  The refusal of blood products by a patient in labour or who requires a caesarean delivery  A failure of epidural analgesia that has not been resolved by re-siting of the epidural  If an anaesthetic StR has any concerns about the management of a pregnant patient

Attendance of the Consultant Obstetric Anaesthetist for Epidural Analgesia The Anaesthetic Department’s expectation is that once an epidural request is made, or an existing epidural fails to provide adequate analgesia, an anaesthetist will attend the patient within 30 minutes of being notified. Only in exceptional 279 circumstances will an anaesthetist be unable to attend within 60 minutes. When either of these time scales are unlikely to be achieved by the labour ward anaesthetic StR, the coordinating midwife should follow the escalation pathway.

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