dr g siyaka obstetric anaesthesia 2013-06-03 1. outline physiological changes of pregnancy...
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DR G SIYAKA
Obstetric anaesthesia
2013-06-03
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OUTLINE
Physiological changes of pregnancyAnaesthesia for caesarean deliveryAnalgesia for labourComplications and contraindications to
neuraxial anaesthesiaMedical conditions in pregnancyObstetric emergencies
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Physiological changes of pregnancy
CardiovascularChanges in CO, SV,HRChanges in BP,SVRAorta-caval compression
RespiratoryLung mechanicsGas exchangeOxygen consumption
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Physiological changes of pregnancy
Airway
HaematologicalBlood volumeAnaemia, thrombocytopaeniaClotting factors
GastrointestinalDelayed stomach emptyingLOS tone
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Evaluating the pregnant patient
History
Examination
Special investigations
Informed consent and premed
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Anaesthesia for caesarean delivery
Anaesthetic techniquePre-operative evaluationTheatre preparation
Regional anaesthesia(spinal)
Fluid co-loadBaseline monitoringAseptic technique
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Anaesthesia for caesarean delivery
NeedleDrugsTesting your blockManaging hypotensionUterotonic therapy
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Anaesthesia for caesarean delivery
General anaesthesia
Only if contra-indication to spinal anaesthesia
Pre-op evaluation ,check aspiration prophylaxis been given
MonitoringPre-oxygenation, RSI with cricoid pressureConfirm intubation and allow surgeon to start
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Maintenance of anaesthesia with volatile MAC 0.75,oxygen 50% and nitrous oxide/air
OxytocinAnalgesia – opioids, NSAID, paracetamol,+/_
block(TAP)Reverse NMBsExtubate awake
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Analgesia for labour
Physiology of labour
1st stage
2nd stage
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Analgesia for labour
Pre-operative evaluationCheck emergency equipment
Epidural analgesiaPreparationNeedleDrugs including test doseInfusion regimens
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Analgesia for labour
Combined spinal epidural(CSE)
Rationale for doing CSENeedlesDrugsInfusion regimens
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Complications of neuraxial anaesthesia
HypotensionHigh spinal blockadePDPH ( classic description)Infection ( meningitis, arachnoiditis, epidural
abscess)Spinal haematomaFailed spinal
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Contraindications to neuraxial blockade
AbsolutePt refusal, uncooperativeSevere hypovolaemiaInfection at injection siteCoagulopathy ( platelets, INR, urea)Fixed output states (AS, constrictive
pericarditis ,HOCM)Raised intracranial pressurePatient refusal
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Contraindications to neuraxial blockade
Relative
Systemic sepsisActive neurological diseasePrevious back surgeryComplex surgery
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Medical conditions in pregnancy
HypertensionClassification-chronic hypertension -pre-eclampsia -eclampsia -gestational hypertensionProblems related to pre eclampsia
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Medical conditions in pregnancy
Pre eclampsiaTreatment goals
Seizure prophylaxisBlood pressure control : methyldopa, CCB,
labetalolFluid managementULTIMATELY DELIVERY OF PLACENTA
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Obstetric emergencies
Major obstetric haemorrhagei.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)
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Management
AssessHistory medical and obstetricExam ,may even need an EUAMonitor ECG ,NIBP ,oxygen saturationConsider invasive monitoring IABP , CVP
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Resuscitate
Oxygen 10- 15 L/minIf pre-delivery keep in L lateralTwo large bore cannulaeTake blood for FBC , clotting profile, X matchFluids : crystalloid , colloid ,bloodTransfuse if Hb < 8 g/dl, platelets < 75 and
still bleeding, PTT > 1.5 , fibrinogen < 1.0 g/L
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Stop the bleeding
Bimanual compressionOxytocin CarboprostMisoprostol
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Stop the bleeding
Uterine balloon tamponadeB Lynch compression suturesDevascularisation Hysterectomy as last resort
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Adjuncts
Cell salvageInterventional radiologyMethotrexateTranexamic acidRecombinant factor VIIa
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Obstetric emergencies
Amniotic fluid embolism
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