Analgesia/anaesthesia on labour ward for other procedures :

Pregnant patients presenting for other surgery Shirodkar suture External cephalic version (ECV) Instrumental delivery Trial of forceps anual removal of retained placenta Evacuation of retained products of conception (E!P"C) Suction termination of pregnancy (ST"P) #elivery follo$ing intra%uterine death

Analgesia/anaesthesia on labour ward for other procedures

Pregnant patients presenting for other surgery

Pregnant $omen may present for surgery either related or coincidental to their pregnancy& ost are young and fit 'ut the follo$ing must 'e 'orne in mind( #iagnosis of a'dominal conditions may 'e difficult) as may any a'dominal surgical procedure) 'ecause of the gravid uterus "'stetric conditions such as placental a'ruption and *E++P should 'e considered in the differential diagnoses $here appropriate& The risks of aortocaval compression) difficult air$ay management and aspiration of gastric contents must 'e remem'ered& The degree of risk $ill depend on the gestation) presenting pro'lem and any coexisting medical condition& The fetus is at risk from( effects of the primary illness effects of any drugs used effects on uteroplacental 'lood flo$ effects on fetal oxygen delivery premature la'our provoked 'y any of the a'ove In general) surgery is avoided during pregnancy) particularly during the first trimester& ,here it is unavoida'le consider the follo$ing( Careful pre%operative assessment and treatment $ith antacid therapy (after -. $eeks gestation) /void the supine position) and use left lateral tilt particularly after 01 $eeks gestation) to avoid aortocaval compression !egional versus general anaesthesia should 'e $eighed up for each individual case (23 volatile agents relax the uterus)& ost drugs are not licensed for use in pregnancy) use those 4kno$n to 'e safe5 and avoid ne$er drugs $hose effects are unkno$n& /void 20" (theoretical) not proven risk) /void drugs that might increase uterine tone (eg 'lockers) Vasoconstrictors can 'e used as appropriate) as maintenance of maternal 'lood pressure in 4normal5 range is more important than any theoretical effect of these drugs on placental perfusion *igh maternal p"0 does not cause uteroplacental vasoconstriction6 pC" 0 should 'e kept in the normal pregnant range& The fetus should 'e monitored pre% and postoperatively and if appropriate7possi'le) intraoperatively&

Shirodkar suture
This is carried out to prevent miscarriage due to cervical incompetence) usually at -0 8 -. $eeks gestation& / stitch or tape is used to encircle the cervix (transvaginally)& "ccasionally) $here the cervix is grossly disrupted) the procedure is carried out transa'dominally (these deliveries are usually 'y Caesarean section)& The stitch7tape is removed at 9: 8 9; $eeks gestation (no anaesthesia usually needed)& /naesthesia should 'e carried out as for <pregnant patients presenting for other surgery=) a spinal or epidural 'lock (T; 8 S>) usually 'eing chosen& The dose of local anaesthetic re?uired for a su'arachnoid 'lock is roughly :>@ of that used for caesarean section& In addition) tocolytic therapy may 'e considered necessary& Aeneral anaesthesia and 'locks have also 'een used 'ut are less favoured 'ecause of the risks they involve&

External cephalic version (EC !

Carried out for 'reech or shoulder presentation) this is $here the o'stetrician applies external pressure to rotate the fetus to a vertex position& It has a success rate of 01 8 ;1@& ECV should not 'e carried out $here there is placenta praevia) ruptured mem'ranes or there has 'een an antepartum haemorrhage& ECV is not carried out $here there are indications for Caesarean section& others are no longer kept nil 'y mouth& The procedure is usually carried out in maternity #ay Care& They are put in the tilted supine position and tocolytic drugs are sometimes used& The fetus is monitored carefully as fetal ($ith or $ithout maternal) 'radycardia may occur& ECV may cause considera'le discomfort and may not 'e tolerated& It is not usual practice on our unit to administer sedative7other anaesthetic drugs for ECV& If ECV fails) a Caesarean section is usually performed $ithin t$o $eeks of the attempt& /part from fetal distress) ECV may cause onset of la'our and haemorrhage&

"nstru#ental delivery
This may involve use of forceps (lo$) mid%cavity or high7rotational) or suction7Ventouse device& Indications for this type of delivery include( B Prolonged second stage (C0 hrs for prim) C-hr for multip) add - hr if epidural in situ) B aternal exhaustion B Dailure of presenting part to descend B Contraindication to Valsalva manoeuvre B Detal distress B Detal immaturity It is important to ensure a dense pelvic7perineal 'lock& If there is a $orking epidural( Ese > ml7> mins of either 'upivacaine 1&>@ or lignocaine 0@ F -(011)111 adrenaline) depending on the urgency of the situation& / volume of -1 ml is usually sufficient to provide good pelvic anaesthesia) especially if the mother is kept in the sitting position& If there is no $orking epidural( Ese a spinal anaesthetic techni?ue $ith -&> ml of hyper'aric 1&>@ 'upivacaine in the sitting position& This should provide good ?uality anaesthesia $hilst still allo$ing the mother to push& "nly rarely should general anaesthesia 'e needed&

$rial of forceps
This term is used $hen it is anticipated that forceps delivery may 'e difficult and all must prepared for rapid conversion to Caesarean section& Thus it is usually carried out in theatre $ith regional anaesthesia suita'le for instrumental delivery or Caesarean section& If there is a $orking epidural( Top up as a'ove& +ignocaine 0@ F -(011)111 adrenaline can 'e used to rapidly provide a 'lock suita'le for Caesarean section) should that 'e re?uired& 0> 8 >1 mcg of fentanyl can 'e added to optimise the ?uality of anaesthesia& If there is no $orking epidural( Ese a spinal anaesthetic techni?ue $here possi'le) using a dose suita'le to provide anaesthesia for Caesarean section) should it 'e needed& Aeneral anaesthesia should rarely 'e needed&

%anual re#oval of retained placenta

This is re?uired $hen the placenta has failed to deliver despite conservative measures (I 7IV oxytocics) turning into left lateral position) putting 'a'y to the 'reast) emptying 'ladder)& If surgical removal is re?uired) regional anaesthesia is prefera'le either 'y top%up of an existing epidural or use of a spinal anaesthetic techni?ue& /naesthesia should 'e ade?uate to allo$ manipulation of the uterus) thus a 'lock in the region of T; 8 T-1 to S> must 'e esta'lished& There is a significant risk of maGor haemorrhage $here the placenta7other products are retained& /de?uate intra%venous access and resuscitation are an essential part of management& In the presence of ongoing haemodynamic insta'ility) general anaesthesia (rapid se?uence induction) is appropriate& !arely) uterine inversion can complicate retained placenta and unless rapidly replaced the mother is likely to 'ecome hypotensive and 'radycardic& In this circumstance) general anaesthesia may $ell 'e re?uired& If the placenta7other products get trapped in the cervix a similar clinical picture may result from excessive vagal tone&

Evacuation of retained products of conception (E&P'C!

This procedure most commonly follo$s incomplete or missed a'ortion 'ut may 'e re?uired during the puerperium for retained placental tissue& /lthough a relatively minor operative procedure) the patient may 'e upset or distressed and is at risk of haemorrhage and sepsis& /fter full pre%operative assessment) intra%venous access is usually esta'lished in the anaesthetic room and a small dose of intra%venous midaHolam (- 8 0 mg) given& / 01 or 00 A cannula is ade?uate unless there is evidence of significant 'lood loss) $hen one or t$o -I or -. A cannulae should 'e used& "nce the patient is settled they can then 'e transferred to the operating theatre for induction of anaesthesia& / rapid se?uence induction or regional techni?ue should 'e used after -. $eeks gestation or if there is any suggestion of reflux in the history& / facemask or laryngeal mask $ith spontaneous ventilation is suita'le for most other cases& / high inspired concentration of volatile should 'e avoided as it may cause uterine relaxation and $orsen 'leeding& Intravenous fentanyl (>1 8 -11 mcg) and rectal diclofenac are suita'le analgesics& If a spinal techni?ue is used) a 'lock to T; 8 T-1 to S> $ill 'e sufficient to allo$ surgical manipulation of the $hole uterus& "xytocic drugs are no$ not routinely used (the uterus possesses fe$7no receptors in the first -0 8 -> $eeks of pregnancy)& If re?uested) ho$ever) > IE of syntocinon can 'e given IV slo$ly&

Suction ter#ination of pregnancy (S$'P!

/s $ith E!P"C a'ove) these cases are usually carried out as elective day cases on the daily operating list& ost are less than -> $eeks pregnant thus treated as non%pregnant from an acid aspiration and aortocaval compression point of vie$& /fter full pre%operative assessment) intra%venous access (01 8 00A) is usually esta'lished in the anaesthetic room and a small dose of intra%venous midaHolam (- 8 0 mg) given& "nce the patient is settled they can then 'e transferred to the operating theatre for induction of anaesthesia& Dollo$ing induction $ith propofol) a facemask or laryngeal mask $ith spontaneous ventilation is suita'le for most cases& Total intravenous anaesthesia $ith propofol or standard doses of volatile can 'e used for maintenance of anaesthesia& Intravenous fentanyl (>1 8 -11 mcg) and rectal diclofenac are suita'le analgesics& /s a'ove) oxytocic drugs are no$ not routinely used (the uterus possesses fe$7no receptors in the first -0 8 -> $eeks of pregnancy)& If re?uested) ho$ever) > IE of syntocinon can 'e given as a slo$ IV inGection&

(elivery following intra)uterine death

Jou may 'e asked to help $ith analgesia for these patients& Each case $ill need careful individual assessment and management& The follo$ing options can 'e considered( 3ath7relaxation7'reathing exercises7entonox7diamorphine Dentanyl PC/ (as per protocol F7% 'ackground infusion) if needed) orphine PC/ (as per protocol F7% 'ackground infusion) if needed) Epidural

!emem'er( idaHolam (1&> 8 -mg increments) may 'e offered to help alleviate stress K anxiety) 'ut patients should 'e $arned of possi'le amnesia (some $ill $ish to keep a clear memory of events) some $ill not and some may not have a strong opinion) Coagulopathy and sepsis can (precede and7or) follo$ fetal demise& Should an epidural 'e re?uested a full 'lood count F7% clotting studies may 'e needed /ny anaesthetic intervention $ill need the relevant monitoring 'y mid$ifery staff& This may need discussion $ith mid$ife in charge&