1. DR G SIYAKA Obstetric anaesthesia 2013-06-03 1

2. OUTLINE Physiological changes of pregnancy Anaesthesia for caesarean delivery Analgesia for labour Complications and contraindications to neuraxial anaesthesia Medical conditions in pregnancy Obstetric emergencies 2013-06-03 2

3. Physiological changes of pregnancy Cardiovascular Changes in CO, SV,HR Changes in BP,SVR Aorta-caval compression Respiratory Lung mechanics Gas exchange Oxygen consumption 2013-06-03 3

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6. Physiological changes of pregnancy Airway Haematological Blood volume Anaemia, thrombocytopaenia Clotting factors Gastrointestinal Delayed stomach emptying LOS tone 2013-06-03 6

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9. Evaluating the pregnant patient History Examination Special investigations Informed consent and premed 2013-06-03 9

10. Anaesthesia for caesarean delivery Anaesthetic technique Pre-operative evaluation Theatre preparation Regional anaesthesia(spinal) Fluid co-load Baseline monitoring Aseptic technique 2013-06-03 10

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15. Anaesthesia for caesarean delivery Needle Drugs Testing your block Managing hypotension Uterotonic therapy 2013-06-03 15

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19. Anaesthesia for caesarean delivery General anaesthesia Only if contra-indication to spinal anaesthesia Pre-op evaluation,check aspiration prophylaxis been given Monitoring Pre-oxygenation, RSI with cricoid pressure Confirm intubation and allow surgeon to start 2013-06-03 19

20. Maintenance of anaesthesia with volatile MAC 0.75,oxygen 50% and nitrous oxide/air Oxytocin Analgesia – opioids, NSAID, paracetamol,+/_ block(TAP) Reverse NMBs Extubate awake 2013-06-03 20

21. Analgesia for labour Physiology of labour 1 st stage 2 nd stage 2013-06-03 21

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23. Analgesia for labour Pre-operative evaluation Check emergency equipment Epidural analgesia Preparation Needle Drugs including test dose Infusion regimens 2013-06-03 23

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25. Analgesia for labour Combined spinal epidural(CSE) Rationale for doing CSE Needles Drugs Infusion regimens 2013-06-03 25

26. Complications of neuraxial anaesthesia Hypotension High spinal blockade PDPH ( classic description) Infection ( meningitis, arachnoiditis, epidural abscess) Spinal haematoma Failed spinal 2013-06-03 26

27. Contraindications to neuraxial blockade Absolute Pt refusal, uncooperative Severe hypovolaemia Infection at injection site Coagulopathy ( platelets, INR, urea) Fixed output states (AS, constrictive pericarditis,HOCM) Raised intracranial pressure Patient refusal 2013-06-03 27

28. Contraindications to neuraxial blockade Relative Systemic sepsis Active neurological disease Previous back surgery Complex surgery 2013-06-03 28

29. Medical conditions in pregnancy Hypertension Classification-chronic hypertension -pre-eclampsia -eclampsia -gestational hypertension Problems related to pre eclampsia 2013-06-03 29

30. Medical conditions in pregnancy Pre eclampsia Treatment goals Seizure prophylaxis Blood pressure control : methyldopa, CCB, labetalol Fluid management ULTIMATELY DELIVERY OF PLACENTA 2013-06-03 30

31. Obstetric emergencies Major obstetric haemorrhage i.e. blood loss> 500ml post vaginal delivery, 1000ml post c/section delivery Causes APH (placenta praevia, placental abruption, uterine rupture) PPH( atony, retained tissue, trauma, coagulopathy) 2013-06-03 31

32. Management Assess History medical and obstetric Exam,may even need an EUA Monitor ECG,NIBP,oxygen saturation Consider invasive monitoring IABP, CVP 2013-06-03 32

33. Resuscitate Oxygen 10- 15 L/min If pre-delivery keep in L lateral Two large bore cannulae Take blood for FBC, clotting profile, X match Fluids : crystalloid, colloid,blood Transfuse if Hb 1.5, fibrinogen < 1.0 g/L 2013-06-03 33

34. Stop the bleeding Bimanual compression Oxytocin Carboprost Misoprostol 2013-06-03 34

35. Stop the bleeding Uterine balloon tamponade B Lynch compression sutures Devascularisation Hysterectomy as last resort 2013-06-03 35

36. Adjuncts Cell salvage Interventional radiology Methotrexate Tranexamic acid Recombinant factor VIIa 2013-06-03 36

37. Obstetric emergencies Amniotic fluid embolism 2013-06-03 37