Anaesthesia for Obstetric Patient

CHALLENGES
Altered physiology Presence of fetus and gravid uterus Aortocaval compression Reflux and possible aspiration of

gastric contents Intubation difficulties Increased oxygen consumption

BLOOD AND CIRCULATORY CHANGES

- Heart rate - Stroke volume - Cardiac output - Blood volume
- Red cell
- plasma volume

: : : :

15% 35% 30-40% 35-40%

: : :

30% , but 50%

physiological anaemia

- Pain

SV and CO 40%

Anaesthetic implications
1. High cardiac output Presence of systemic or pulmonary hypertension, severe cardiac disease may induce cardiac failure and APO. May be obtunded by RA. 2. Venous distension Due to back pressure to the azygos and epidural veins by the gravid uterus. Decrease spinal LA requirement and increase risk of bloody tap.

Anaesthetic implications
3. Aortocaval compression Due to compression of aorta and IVC by the fetus causing VR and CO. Clinical features (may be masked GA/RA)

Symptomatic : maternal SOB and dizziness, Occult : reduced placental flow, fetal hypoxia

Relieved by lateral tilt or pelvic wedge

RESPIRATORY CHANGES
Anatomy Engorged airway apparatus:
nose, vocal cords, arytenoids

Lung volumes VT, MV, RR - due to O2 consumption and CO2

production

FRC, ERV ,RV

- due to upwards diaphragmatic

displacement

IC , VC no changes

RESPIRATORY CHANGES

Anaesthetic implications
1. Functional Residual Capacity :
Smaller O2 reservoir, high O2 consumption causing rapid

desaturation. Mandatory to preoxygenate.

2. Engorged airway:
Difficulty with laryngoscopy and tracheal intubation.

Compounded with large breast, weight and short neck. Use short handle. Airway obstruction is more likely to occur during sedation and anaesthesia. Oral mucosa easily traumatised.

GASTROINTESTINAL CHANGES
IAP, gastric volume and acidity.
pH<2.5 with volume 20-25mls ~ Mendelsons syndrome

LOS tone, gastric and intestinal mobility

Delayed gastric emptying in active phase of labour.

Increase risk of aspiration

Anaesthetic implications:
Neutralisation of gastric acid and RSI with cricoid pressure

(for GA) are mandatory

(Sodium citrate, H2 antagonist)

PREOPERATIVE ASSESSMENT
History - Age, parity, gestation period - Pregnancy complication - Fasting period - Medical, surgical and anaesthetic history - Allergies and medication history - Indication - Discussion and counselling on anaesthetic technique - Consent

PREOPERATIVE ASSESSMENT
Physical examination Airway assessment Cardiorespiratory system Lumbar spine Investigation FBC Renal profile Coagulation profile GSH 2 unit PC

General preparation
Elective case Fast from 12 midnight Oral Ranitidine 150mg ON and OM 0.3M 30ml Na citrate on OT call Emergency case IV Ranitidine 50mg stat 0.3M 30ml Na citrate 30 min before op IV Metoclopramide 10mg at induction

GA
Advantages

RA
Advantages
Avoid problems related to GA Awake patient Effective analgesia

Shorter induction time Lower failure rate Better CVS control Rapid control of convulsion in eclamptic pt Pt cooperation not required

Disadvantages

Difficult airway management Risk of regurgitation and aspiration Awareness Stress response on induction/reversal PONV Inadequate analgesia post op Hangover effect

Disadvantages

Sympathetic blockade Inadequate/failed block PDPH LA toxicity: inadvertent IV or intrathecal injection Complications of RA epidural abscess, haematoma

REGIONAL ANAESTHESIA
Contraindication - Patient refusal - Local/systemic infection - Hypovolaemic state - Fixed cardiac output state - Coagulopathy - Unskilled/ unsupervised operator
Choices: Spinal/ Epidural/ CSE Local protocol Post RA: - Left lateral tilt - Oxygen supplement - Check blockade level :T4 - Monitor BP, PR, RR, SpO2

GENERAL ANAESTHESIA
When? Preparation - RA contraindicated - Drugs to be prepared: - RA potentially dangerous - anaesthetics - resuscitation - RA takes long time to be - Airway device: airways, ETT & established various sizes of laryngoscope blades - RA inadequate block - Airway adjuncts: to be kept nearby - Standard monitoring - Reliable IV access - Surgeon in OT

GENERAL ANAESTHESIA
INDUCTION OF GA Ensure 2 skilled assistants present Wedge below the right hip to allow uterine displacement Preoxygenate with 10 l/minute for 3 minutes Administer Thiopentone 4-5mg/kg, Suxamethonium 100 mg Cricoid pressure is applied Ensure correct ETT position Medium acting muscle relaxant after Suxamethonium has worn off NO OPIOID till baby is delivered.

GENERAL ANAESTHESIA
MAINTENANCE OF GA O2:N2O ratio 1:1 with volatile MAC<1 Aggressive treatment of hypotension After baby delivered, change O2 : N2O to 1:2 ratio IV Oxytocin 5U slowly followed by infusion 40-80U over 4 hours IV opioid: Morphine 5mg Assess blood loss Rectal Diclofenac 100mg and SC LA infiltration Reversal and awake extubation Move the patient to the recovery area

PROBLEMS WITH GA IN MATERNITY PATIENTS

1.

Awareness Incidence 0.7 1.5% Due to : i) no sedative premedications, ii) high FiO2 iii) low volatile concentration used intraoperatively iv) avoidance of opioids

PROBLEMS WITH GA IN MATERNITY PATIENTS

2. Pulmonary aspiration pH<2.5 with volume >25mls ~critical factor Signs: - intraop bronchospasm - desaturation - postop tachypnoea and cyanosis

Mx:

- Immediate head down with oral/ETT suction, may need bronchial lavage. - Treat bronchospasm with bronchodilator. - Increase FiO2 and PEEP.

PROBLEMS WITH GA IN MATERNITY PATIENTS

3. Difficult intubation FaiIed intubation incidence 1:280 compared with 1:2200 in non-pregnant. Aim: - maintain oxygenation, - avoid aspiration

FAILED INTUBATION PROTOCOL

HEAD ELEVATED LARYNGOSCOPY POSITION

stacking

MATERNAL DISEASES IN PREGNANCY

1.

Hypertensive disorders
Gestational diabetes

11-17%
5-11%

2. 3.

Valvular heart disease (less common)

HYPERTENSIVE DISORDERS OF PREGNANCY

Definition: BP > 140/90mmHg after 20 weeks of gestation and settles within 6 weeks of delivery Types: Gestational Preeclampsia
Eclampsia

(without proteinuria) (proteinuria >0.3g/day)

Severe preeclampsia

SEVERE PREECLAMPSIA
Def: BP >160/110 mmHg with proteinuria >5g/d associated with signs of organ hypoperfusion:

ECLAMPSIA
Def: Generalized convulsion during hypertensive pregnancy up to day 7 of post delivery.
Management: ABC Abort seizure IV MgSO4 Anti hypertensive Early delivery

Oliguria < 500ml/day Cerebral disturbances Epigastric /RUQ pain Pulmonary oedema HELLP syndromes

Management: Anti hypertensive Labour analgesia Early delivery

CARDIOVASCULAR DISEASES IN PREGNANCY ANY

Clinical features: SOB at rest, ET, orthopnoea Pedal oedema Tachycardia, systolic murmurs, S3, basal rales Recognition is important
QUESTION ?

Management: Multidisciplinary consultation Referral to tertiary centre Early planning of mode of delivery