Department of Anaesthesia Obstetric Anaesthetists Handbook Eighth Edition February 2015 For review by February 2018 j.mp/OAH2015 University Hospitals Coventry and Warwickshire NHS Trust Department of Anaesthesia Obstetric Anaesthetists Handbook Dr Mark Porter, consultant obstetric anaesthetist Email: [email protected]; internal email: Porter Mark (RKB) The consultant members of the Obstetric Anaesthesia Group, and the clinical director for anaesthesia, have agreed this handbook as a clinical guideline. Further copies are available from the Anaesthesia Office at the University Hospital, Coventry. Email: [email protected]; internal email: Anaesthesia (RKB) The guidelines within are presented in good faith and are believed to be accurate. The responsibility for actions and drug administration remains with the clinician concerned. Edition history First edition August 1999 Second edition June 2000 Reprinted September 2002 Third edition August 2003 Fourth edition February 2005 Fifth edition August 2006 Sixth edition January 2009 Seventh edition February 2013 Eighth edition February 2015 My thanks are due to Dr John Elton who inspired this book and Dr Seema Quasim who helped with the revision of the eighth edition. These guidelines have been produced with close reference to the obstetric and maternity clinical guidelines available on the e-library. 2 Obstetric Anaesthetists Handbook 2015 Document control for approved clinical guidelines Important note All clinical guidelines change with time. We have carefully considered the relative merits of having collected guidelines published on paper against having a set of guidelines available on an intranet. On balance we feel that the usability of a handbook outweighs the potential for live changes if we required you to consult the intranet all the time. All users of clinical guidelines should be confident that they are working from the approved version – the latest authorised version. As users you should ensure that the version that you are working to matches the latest version on the e-library and that all updates since the hard copy was issued are incorporated. Important updates will be displayed in a prominent position in the maternity theatres office and in the maternity operating theatres. You should check these locations as part of your work. Furthermore, some of our work is done through shared management of patients, particularly those receiving obstetric high dependency care. Guidelines for their management may change from time to time and you should be alert to changing requirements. If you are in doubt at any time you should seek senior help. Guideline title Obstetric Anaesthetists Handbook; OAH8 Guideline type Revised guideline: eighth edition Division Diagnostics and Service Specialty Anaesthesia Author name Dr Mark Porter, consultant anaesthetist Reviewer name Dr Seema Quasim, consultant anaesthetist Expiry and revision February 2018 Obstetric Anaesthetists Handbook 2015 3 Contents Contents Introduction and scope of guidelines 12 Changing guidelines 12 A word on guidelines 13 Points to remember 13 Principal changes in this edition 15 Orientation to the University Hospital 16 Delivery unit description 16 What we offer 17 Staff 19 Working in the labour ward 22 Criteria for being the duty obstetric anaesthetist 22 Principal duties of the resident 22 Presence on the labour ward 25 Excessive workload 26 Seeking advice and senior help 26 Referral to the consultant anaesthetist 28 Seeking advice on unusual techniques 29 Disposal of medicinal products 31 Autonomy and responsibility 31 Preparations for emergency anaesthesia 33 Theatre equipment 33 Prepared drugs 33 Emergency treatment 35 Failed or difficult intubation 37 4 Obstetric Anaesthetists Handbook 2015 Contents Airway assessment 38 Preparing yourself 39 Failed intubation drill 40 Obstetric haemorrhage 43 APH (antepartum haemorrhage) 49 PPH (postpartum haemorrhage) 50 Pharmacological treatment of uterine atony 51 Blood component therapy 54 Haemostatic failure 59 Perioperative systemic haemostatic agents 59 Interventional radiology 63 Women who refuse blood transfusion 64 Local anaesthetic toxicity 66 Other emergencies 70 Eclampsia 70 Uterine inversion 70 Umbilical cord prolapse 71 Uterine rupture 71 AFE (amniotic fluid embolism) 72 Unexplained collapse and cardiopulmonary arrest 73 Perimortem caesarean section 74 Critical care 76 High dependency care on labour ward 76 Admission and referral criteria for critical care unit 80 Transfer to the critical care unit 83 Sepsis 86 Obstetric Anaesthetists Handbook 2015 5 Contents Diagnosis of sepsis 87 Sepsis Six bundle – actions in the first hour 89 Indications for transfer to critical care 91 Anaesthetic considerations 91 Antenatal referral 93 Needle phobia 97 Maternal obesity 99 Cardiac disease 101 Pulmonary oedema 101 Peripartum cardiomyopathy 104 Known disease 105 Management considerations 108 Feeding and antacid prophylaxis 111 Oral intake in labour 111 H2-receptor antagonists (ranitidine) 111 Sodium citrate 111 Oral intake and caesarean section 111 Thromboprophylaxis 114 Enoxaparin after caesarean section 114 Preoperative preparation and assessment 118 General considerations 118 The caesarean section preoperative clinic 118 Indications for blood reservation and blood tests 121 Information and consent for obstetric anaesthesia procedures 125 General considerations 125 6 Obstetric Anaesthetists Handbook 2015 Contents Consent for epidurals 127 Incidence of complications 128 Providing information in written form 128 Management of regional blocks 130 Infection control 130 Monitoring the extent of central nerve blocks 131 Assessing the block for surgery 134 Neuraxial opioids and pruritus 136 Severe postnatal complications of central nerve block 138 Prevention of severe complications 138 Guideline on central neuraxial block and haematoma prevention 138 Space-occupying lesions in the vertebral canal 143 Spinal cord damage 146 Meningitis 146 Serious and permanent harm 147 Neuropathy on the postnatal ward round 148 Pain relief for labour 153 Epidural analgesia – general considerations 153 Technique for epidural analgesia in labour 157 PCEA (patient controlled epidural analgesia) 159 Inadequate epidural analgesia 161 Problematic epidurals 162 Unintentional dural puncture (‘dural tap’) 162 Hypotension and epidural block 165 Total spinal block or high block 166 Subdural block 166 Obstetric Anaesthetists Handbook 2015 7 Contents Post-dural puncture headache 169 Diagnosis of headache 169 Treatment of post-dural puncture headache 170 Guidelines for blood patch 170 Follow up for patients with post-dural puncture headache 173 Tocolytic drugs 175 Common obstetric problems 178 Malpresentations and malpositions 178 Multiple pregnancy 179 General considerations for caesarean section 180 Choice of technique 180 Techniques for urgent caesarean sections 180 Time standards 182 Labour ward guideline on urgent caesarean section 183 Managing intrapartum fetal hypoxia 185 Intrauterine fetal resuscitation 186 ERAS (enhanced recovery after surgery) 187 Handover of care 188 Human immunodeficiency virus (HIV) 189 Chaperones 189 Presence of birth partner in theatre 189 Antibiotics 189 Uterine displacement 190 Uterine relaxation 190 Bleeding at caesarean section 191 Perioperative and postoperative fluids 193 Postoperative analgesia and antiemesis 194 8 Obstetric Anaesthetists Handbook 2015 Contents Postoperative care 199 Intraoperative cell salvage in obstetrics 202 Controversies 203 Other operative procedures 208 Retained placenta 208 Pain relief for instrumental delivery, perineal repair and manual removal of placenta 208 Postpartum evacuation 209 Surgery on pregnant women 210 Cervical cerclage 210 Regional blocks for surgery 211 Information and consent 211 Monitoring and patient contact 212 Oxygen administration to conscious patients 213 Spinal anaesthesia – general considerations 213 Technique for spinal anaesthesia 214 Tips for success in spinal anaesthesia 219 Prevention of spinal hypotension 220 Using labour epidurals for operative surgery 222 Total spinal block or high block 226 Failure of regional anaesthesia 230 Repeating a block 231 Perioperative pain and analgesic supplementation 232 Converting from regional to general anaesthesia 233 General anaesthesia for caesarean section 235 Postoperative period 237 Obstetric Anaesthetists Handbook 2015 9 Contents AAGA (accidental awareness under general anaesthesia) 238 Placenta praevia 240 Care bundle for placenta praevia and previous caesarean section 241 Patient assessment and stabilisation 241 Senior assistance 242 Blood provision 242 Anaesthetic management 243 Intraoperative haemorrhage and extended surgery 245 Hypertension in pregnancy including pre-eclampsia 248 Diagnosis and definitions 248 Management aims 251 Case responsibility 251 High dependency care in pre-eclampsia 251 Antihypertensive treatment 254 Fluids in pre-eclampsia 257 Anticonvulsant treatment 260 Magnesium emergency administration 261 HELLP syndrome 264 Epidural analgesia in pre-eclampsia 266 Anaesthesia for caesarean section in pre-eclampsia 267 The postpartum period in pre-eclampsia 270 Diabetes in pregnancy 273 Gestational diabetes 274 Human immunodeficiency virus (HIV) 276 Information recording 278 Clinical Adverse Events 278 10 Obstetric Anaesthetists Handbook 2015 Contents Patient records 280 Clinical audit 282 Postnatal review 282 Audit projects 282 Training and assessment 284 Training opportunities 284 Workplace training objectives 285 Assessment 285 Further reading