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

- Heart rate
:
15%
CHANGES
- Stroke volume :
- Cardiac output:
- Blood volume :

35%
30-40%
35-40%

- Red cell :
30% , but
- plasma volume
:
50%
anaemia

- Pain

SV and CO 40%

physiological

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
Anatomy
CHANGES
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
Shorter induction time
Lower failure rate
Better CVS control
Rapid control of convulsion in

RA
Advantages
Avoid problems related to GA
Awake patient
Effective analgesia

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
Contraindication
Choices:
ANAESTHESIA
Spinal/ Epidural/ CSE
- Patient refusal
- Local/systemic
-

infection
Hypovolaemic state
Fixed cardiac output
state
Coagulopathy
Unskilled/
unsupervised operator

Local protocol

Post RA:
- Left lateral tilt
- Oxygen supplement
- Check blockade
level :T4
- Monitor BP, PR, RR,
SpO2

GENERAL ANAESTHESIA
When?
- RA contraindicated
- RA potentially
dangerous
- RA takes long time to
be established
- RA inadequate block

Preparation
- Drugs to be prepared:
- anaesthetics
- resuscitation

- Airway device:

airways, ETT &

various sizes of laryngoscope
blades

- 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

HEAD ELEVATED
LARYNGOSCOPY POSITION
stacking

MATERNAL DISEASES IN
PREGNANCY
1. Hypertensive disorders
11-17%
2. Gestational diabetes

5-11%

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
(without proteinuria)
Preeclampsia (proteinuria >0.3g/day)
Severe preeclampsia
Eclampsia

SEVERE
PREECLAMPSIA
Def: BP >160/110 mmHg
with proteinuria >5g/d
associated with signs of
organ hypoperfusion:
Oliguria < 500ml/day
Cerebral disturbances
Epigastric /RUQ pain
Pulmonary oedema
HELLP syndromes

Management:
Anti hypertensive
Labour analgesia
Early delivery

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

CARDIOVASCULAR DISEASES IN
PREGNANCY
ANY
QUESTION ?

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

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