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OBSTETRIC ANAESTHESIA CASE STUDIES

Case No 15.1. Pre eclampsia

|Tungaa is having her first baby. She has a history of mild hypertension but is not on any medication for it. At her 34 week |

|check the midwife has noticed that her blood pressure is 145/105 mmHg and Tungaa has been complaining of headache and |

|peripheral oedema. |

What are the diagnostic features of pre-eclampsia?

Pre-eclampsia refers to a syndrome characterised by the new onset of hypertension and proteinuria after 20 weeks of gestation in a previously normotensive woman.

Diagnostic features of pre-eclampsia are:

1. Systolic blood pressure ( 140 mmHg or Diastolic blood pressure ( 90 mmHg. The elevation in blood pressure should be at least 6 hours but no more than 7 hours apart.

2. Proteinuria of 0.3 grams or greater in a 24 hour urine specimen for diagnosis. 5g or more is a criterion of severe disease.

3. Creatinine > 80 (M/L is a criterion of severe disease.

4. Thrombocytopenia is a criterion of severe disease.

5. Evidence of haemoconcentration.

6. Microangiopathic haemolysis is suggested by an elevated lactate dehydrogenase and red cell fragmentation (schistocytes or helmet cells) on peripheral blood smear and is an indication of severe disease. Note however that haemolysis can decrease the haematocrit.

7. Serum alanine and aspartate aminotransferases > 40 IU/L, albumin < 20g/L and a prolonged INR suggest hepatic dysfunction and is a criterion of severe disease.

1. Clarke, SD; Nelson-Piercy, C. Pre-eclampsia and HELLP syndrome. Anaesthesia and Intensive Care Medicine 9:3: 2008: 110-4.

2. Norwitz, ER; Repke, JT. “Management of preeclampsia.” (Chapter). Uptodate Online 17.3.

3. August, P; Sibai, B. “Clinical features, diagnosis, and long-term prognosis of preeclampsia.” (Chapter). Uptodate Online 17.3.

What are the options for blood pressure management and what blood pressure would be optimal?

Options for blood pressure management are:

1. Methyldopa up to 3g daily in 2-4 divided doses.

2. Calcium channel blocker (e.g. nifedipine) or beta-blockers (e.g. labetalol).

3. Alpha-blockers (e.g. doxazosin).

4. Hydralazine.

Atenolol, angiotensin converting enzyme inhibitors, angiotensin receptor-blocking drugs and diuretics should be avoided.

Antihypertensive treatment should be started in women with a systolic blood pressure over 160 mmHg or a diastolic pressure over 110 mmHg to allow prolongation of pregnancy, reducing the risk of abruption, maternal complications of cerebrovascular accident and hypertensive encephalopathy. There is currently a lack of clinical data however to support an “optimal” target blood pressure other than a systolic pressure < 160 mmHg and a diastolic pressure < 110 mmHg.

1. Clarke, SD; Nelson-Piercy, C. Pre-eclampsia and HELLP syndrome. Anaesthesia and Intensive Care Medicine 9:3: 2008: 110-4.

2. Tuffnell, DJ; Shennan, AH; Waugh, JJS; Walker, JJ. The Management of Severe Pre-Eclampsia/Eclampsia. Royal College of Obstetricians and Gynaecologists. March 2006.

Tungaa’s vision is becoming blurred. The obstetrician wants to commence magnesium sulphate. Describe how you would do this. What are the risks of magnesium administration? How should she be monitored?

Magnesium sulphate is usually given as a 4g slow intravenous bolus dose over 15 minutes and continued with an infusion of 1g/hour over 24-48 hours postpartum or after the last seizure, whichever is the later. The infusion dosing should be adjusted accordingly in patients with renal insufficiency aiming for a level of 2-4 mmol/L.

Risk of magnesium sulphate include:

- Rapid infusion causing peripheral vasodilation and hypotension.

- Diaphoresis, flushing, nausea, vomiting, headache, muscle weakness, visual disturbances and palpitations.

- Pulmonary oedema is a rare side effect.

- Magnesium toxicity is related to serum concentration:

- Loss of deep tendon reflexes (4-5 mmol/L)

- Respiratory paralysis (5-7.5 mmol/L)

- Cardiac arrest (10-12.5 mmol/L)

Evidence of toxicity is monitored by:

- Loss of deep tendon reflexes.

- Decrease in respiratory rate to < 12/min.

- Urine output, as oliguria increases the risk of developing toxicity.

Calcium gluconate 1g (10mls) over 10 minutes can be given if there are concerns of cardiopulmonary compromise.

1. Clarke, SD; Nelson-Piercy, C. Pre-eclampsia and HELLP syndrome. Anaesthesia and Intensive Care Medicine 9:3: 2008: 110-4.

2. Tuffnell, DJ; Shennan, AH; Waugh, JJS; Walker, JJ. The Management of Severe Pre-Eclampsia/Eclampsia. Royal College of Obstetricians and Gynaecologists. March 2006.

3. Norwitz, ER; Repke, JT. “Management of preeclampsia.” (Chapter). Uptodate Online 17.3.

What other management does Tungaa require?

Severe pre-eclampsia is an indication for delivery of the baby and placenta. If however the foetus is less than 34 weeks gestation, delivery can be deferred and corticosteroids given, with the benefits of conservative management reassessed every 24 hours.

Given that Tungaa’s baby is 34 weeks gestation, a decision to deliver at an institution with appropriate personnel and facilities for care of the preterm neonate can be made.

1. Tuffnell, DJ; Shennan, AH; Waugh, JJS; Walker, JJ. The Management of Severe Pre-Eclampsia/Eclampsia. Royal College of Obstetricians and Gynaecologists. March 2006.

2. Norwitz, ER; Repke, JT. “Management of preeclampsia.” (Chapter). Uptodate Online 17.3.

The obstetrician decides that Tungaa will require caesarean delivery, as she is not suitable for induction of labour. Discuss how you should manage her pre eclampsia before delivery.

Tungaa’s condition must be stabilised prior to anaesthesia.

This involves:

- Controlling the blood pressure with the options discussed above.

- Appropriate fluid management.

- Volume expansion is a controversial area of management. Pre-eclampsia causes a reduction in intravascular volume, leaking capillaries and low albumin, making women prone to pulmonary oedema with excessive intravenous fluids. Most protocols suggest limiting fluid intake to 1 ml/kg/hr and repetitive fluid challenges should be avoided in the absence of invasive monitoring. Fluid boluses however may reduce sudden hypotension if a neuroaxial blockade is planned.

- Invasive haemodynamic monitoring (arterial and central venous pressures) can be used in complicated patients such as those with severe cardiac or renal disease, oliguria, refractory hypertension or pulmonary oedema.

- Checking that the coagulation is normal.

- Consider giving platelets in the presence of thrombocytopenia.

- Consider giving fresh frozen plasma with a raised INR or APTT.

- Prevent eclampsia.

- Magnesium sulphate is the prophylaxis of choice.

- Diazepam can also be used.

1. Pescod, David. Developing Anaesthesia Textbook 1.6 p122-3.

2. Sheenan, AH. Pre-eclampsia and the anaesthetist. Anaesthesia and Intensive Care Medicine 8:7: 2007: 279-81.

3. Tuffnell, DJ; Shennan, AH; Waugh, JJS; Walker, JJ. The Management of Severe Pre-Eclampsia/Eclampsia. Royal College of Obstetricians and Gynaecologists. March 2006.

4. Norwitz, ER; Repke, JT. “Management of preeclampsia.” (Chapter). Uptodate Online 17.3.

What anaesthetic would you choose for Tungaa? Justify your choice. Are there any special considerations with your choice of anaesthesia?

The choice of anaesthetic is either a general anaesthetic or a neuroaxial technique (spinal, epidural or combined spinal-epidural) and will depend on the:

- Health of the mother and the foetus.

- Technical ability of the anaesthetist (it is safer to use a familiar technique).

Special considerations for each choice can be divided into their advantages and disadvantages.

|Technique |Advantages |Disadvantages |

|General anaesthetic |If there is an immediate threat to the life |Pre-eclamptic patients may be difficult to |

| |of the mother or the foetus, general |intubate with severe oedema of the airway. |

| |anaesthesia is often used. |Hypertension can be exacerbated during |

| | |laryngoscopy and extubation. |

|Neuroaxial blockade |Minimal risk of aspiration and lower risk of |Contraindicated if there are bleeding |

| |anaphylaxis. |disorders: platelet count should ideally be |

| |Neonate is more alert promoting early bonding|above 100 x 109 and INR < 1.5. |

| |and breastfeeding. |Can cause sudden hypotension in pre-eclamptic|

| |Faster recovery for the mother. |women who are intravascularly depleted. |

| |Better postoperative analgesia and earlier | |

| |mobilisation. | |

1. Pescod, David. Developing Anaesthesia Textbook 1.6 p124.

2. Sheenan, AH. Pre-eclampsia and the anaesthetist. Anaesthesia and Intensive Care Medicine 8:7: 2007: 279-81.

3. Eldridge, J. “Anaesthesia for Caesarean Section.” (Chapter) p712-3. Allman K, Wilson I. Oxford Handbook of Anaesthesia. Oxford University Press 2006.

The next day, you are in the ward and are asked to attend Tungaa urgently as she appears to be having a seizure. What is your management?

Place Tungaa in the left lateral position and administer oxygen. Assess the airway, breathing and circulation and once this is stabilised, administer an additional bolus of 2g magnesium sulphate followed by an increase in the rate of infusion to 1.5-2g/hr.

If there are repeated seizures, consider alternative agents such as diazepam, phenytoin or thiopentone. If she develops status epilepticus, intubation is likely to be necessary to protect the airway and maintain oxygenation.

1. Tuffnell, DJ; Shennan, AH; Waugh, JJS; Walker, JJ. The Management of Severe Pre-Eclampsia/Eclampsia. Royal College of Obstetricians and Gynaecologists. March 2006.

Case No 15.2. Maternal haemorrhage

|Enkhee has just delivered her 3rd baby and you are called to the obstetric ward to help manage a retained placenta. The |

|midwife says there has been 700 ml of blood loss and that it is continuing. She needs an urgent manual removal of placenta. |

Discuss how you will estimate blood loss and your immediate management of the situation.

Blood loss can be external and internal. Estimation of true blood loss is very difficult as internal blood loss is concealed within the uterine cavity or the retroplacental space.

Pregnancy induced physiological changes can also mask the clinical picture with tachycardia, increased stroke volume and compensatory vasoconstriction maintaining the blood pressure. Other clues of ≥15% circulating blood volume loss include slow capillary refill or cold peripheries, changes in mental state and a decrease in urine output. Hypotension is a late and ominous sign as it may only arise when 30-50% of the mother’s blood volume has been lost.

Immediate management would be:

1. Call for help and mobilize appropriate staff (senior midwife, obstetric and anaesthetic staff, porters and Blood Transfusion Service staff).

2. Give supplemental oxygen. If she is not maintaining her airway or breathing adequately, intubate and ventilate.

3. Insert two 14G cannulae and take blood for crossmatching if not done already.

4. Fluid resuscitate with crystalloid and/or colloid.

5. Give crossmatched, type specific or O negative blood if there is >40% of total blood volume loss and/or the presence of ECG abnormalities.

6. Urine output and invasive monitoring of arterial pressure should be started but should not delay surgery. Early central venous pressure monitoring is not essential as hypotension is almost always due to hypovolaemia.

7. Prepare the patient for theatre for urgent removal of placenta in order to treat the cause of haemorrhage.

8. With continuing haemorrhage, ensure warming and rapid transfusion devices are available.

9. Correct coagulopathy with platelets, fresh frozen plasma and cryoprecipitate as indicated.

1. Pescod, David. Developing Anaesthesia Textbook 1.6 p120.

2. Wise, A; Clark, V. Obstetric haemorrhage. Anaesthesia and Intensive Care Medicine 8:8: 2007: 326-30.

3. Eldridge, J. “Massive obstetric haemorrhage.” (Chapter) p732-3. Allman K, Wilson I. Oxford Handbook of Anaesthesia. Oxford University Press 2006.

What are the options for anaesthesia? Are there any advantages and disadvantages of each technique?

The choice of anaesthetic is either a general anaesthetic or a neuroaxial technique (spinal) and will depend on:

- How stable the mother is.

- Technical ability of the anaesthetist.

|Technique |Advantages |Disadvantages |

|General anaesthetic |If there is an immediate threat to the life |Risk of difficult airway and aspiration. |

| |of the mother or foetus, general anaesthesia | |

| |is often faster and safer. | |

| |Useful in anticipated prolonged or difficult | |

| |surgery. | |

| |Not contraindicated by coagulopathy. | |

|Neuroaxial blockade |Avoids a potentially difficult airway. |Contraindicated if there are bleeding |

| |Minimal risk of aspiration and lower risk of |disorders: platelet count should ideally be |

| |anaphylaxis. |above 100 x 109 and INR < 1.5. |

| |Associated with reduced blood loss and lower |Can cause sudden or worsen hypotension in |

| |transfusion requirements. |women who are intravascularly depleted and |

| | |haemodynamically unstable. |

1. Pescod, David. Developing Anaesthesia Textbook 1.6 p120.

2. Gleeson, C; Scrutton, M. Obstetric emergencies. Anaesthesia and Intensive Care Medicine 8:8: 2007: 326-30.

3. Pinder, A; Dresner, M. Massive obstetric haemorrhage. Current Anaesthesia & Critical Care 2005 16, 181-8.

Enkhee continues to bleed after removal of the placenta. You have administered a spinal anaesthetic and she is now becoming restless. What is your immediate management?

Her restlessness is most likely due to decreased cerebral perfusion from hypovolaemia. Other differentials include:

- Inadequate spinal.

- Eclamptic fit.

- High spinal.

Your immediate management should be:

1. Stabilise her airway, breathing and circulation.

2. Determine cause and treat as indicated e.g. rapid fluid or blood replacement for hypovolaemia, magnesium bolus for eclamptic fit.

3. Consider converting to a general anaesthetic if her restlessness does not resolve.

After 15 minutes, Enkhee has lost a further 900 ml of blood. How will you manage the situation?

If not already identified, this is massive obstetric haemorrhage which is blood loss greater than 1500mls.

Your management should be:

1. If not already done, call for help and inform the Blood Transfusion Service.

2. Review and stabilise her airway, breathing and circulation.

3. If not already done, reconsider intubating if Enkhee’s level of consciousness is reduced.

4. Fluid resuscitate with warmed crystalloid and/or colloid and/or blood.

5. Cause of haemorrhage should be identified and treated.

a. Uterine atony – Treatment options:

- Bimanual compression.

- Oxytocin 5-10 IU bolus IV followed by 10 IU/hr infusion.

- Ergometrine 100(g increments IV.

- Misoprostol 400(g per rectum or carboprost 250(g intrauterine.

- Surgical techniques – B lynch suture, uterine packing, intrauterine (Rusch) balloon, ligation of uterine or internal iliac arteries and hysterectomy.

b. Retained products – Surgical removal of products.

c. Genital tract trauma – Surgical repair.

d. Coagulopathy – Fresh frozen plasma, cryoprecipitate and platelets.

6. Recheck haemoglobin (aim for Hb > 7g/dL), platelets and coagulation profile.

7. Avoid hypothermia and maintain normothermia.

1. Wise, A; Clark, V. Obstetric haemorrhage. Anaesthesia and Intensive Care Medicine 8:8: 2007: 326-30.

2. Gleeson, C; Scrutton, M. Obstetric emergencies. Anaesthesia and Intensive Care Medicine 8:8: 2007: 326-30.

3. Pinder, A; Dresner, M. Massive obstetric haemorrhage. Current Anaesthesia & Critical Care 2005 16, 181-8.

The surgeon has performed a hysterectomy, but says that there appears to be general ooze from the operative surfaces. How will you assess her and manage her apparent coagulopathy?

Assessment will include review of:

- Volaemic status from pulse, blood pressure, urine output and central venous pressure.

- Haemoglobin, platelets and coagulation profile.

- Ensure platelets, INR, APTT and fibrinogen are all normalised.

Management of her apparent coagulopathy will be:

- Ensure platelets, INR, APTT and fibrinogen are all normalised with appropriate blood products.

- If the bleeding is still significant and does not respond to conventional measures, consider antifibrinolytic agents (e.g. tranexamic acid 1g IV or aprotonin up to 2,000,000 IU bolus IV followed by infusion of 50,000-100,000 units/h. Note that there are only limited case reports reporting their successful use and it is associated with an increased thromboembolism risk.

- If bleeding still continues and as a last resort, consider the use recombinant factor VIIa (Novoseven). Note again that there are only limited case reports reporting their effectiveness in these scenarios and is not currently licensed for obstetric use. It is also very expensive and potential risks include inducing disseminated intravascular coagulation or thromboembolism. Discussion with a consultant haematologist is advised .

1. Wise, A; Clark, V. Obstetric haemorrhage. Anaesthesia and Intensive Care Medicine 8:8: 2007: 326-30.

2. Gleeson, C; Scrutton, M. Obstetric emergencies. Anaesthesia and Intensive Care Medicine 8:8: 2007: 326-30.

3. Pinder, A; Dresner, M. Massive obstetric haemorrhage. Current Anaesthesia & Critical Care 2005 16, 181-8.

Case No 15.3. Labour analgesia

|Ariuna is a 30-year-old primigravida who is seeking information about her options for pain relief in labour. She is currently |

|36 weeks pregnant and has no medical problems. |

What are the options for labour analgesia for a healthy primigravida? Discuss the advantages and disadvantages of these techniques.

|Options |Advantages |Disadvantages |

|Non-pharmacological – psychological, positioning and|Harmless techniques in reducing pain. |Have to be learnt beforehand. |

|movement, relaxation and breathing techniques, | |Success rate variable and often insufficient as sole |

|massage, heat and cold, imagery, hypnosis, | |modality requiring other pharmacological adjuvants. |

|acupuncture and transcutaneous electrical nerve | | |

|stimulation. | | |

|Inhalational – Entonox |Simple to use. |Can cause drowsiness, dizziness and nausea. |

| |Cheap. |Peak action is 45 secs before a contraction which is |

| |Short duration of action. |difficult to time. |

| |Safe for labouring women and their |Analgesic efficacy is limited compared with regional |

| |babies. |anaesthesia. |

|Parenteral – Opioids (e.g. pethidine, fentanyl and |Simple to use as both a stat dose and |Can cause confusion, sedation and respiratory depression|

|remifentanil). |as patient controlled analgesia. |to the mother. |

| |Cheap. |Can cause respiratory depression in the neonate |

| |Provides good pain relief. |especially pethidine in the compromised acidotic foetus.|

| |A viable substitute when regional |Close maternal, foetal and neonatal monitoring required.|

| |analgesia is contraindicated or | |

| |refused. | |

|Regional – Epidural, spinal or combined spinal |The most effective and reliable way of |Requires a greater level of skill to insert and monitor.|

|epidural. |initiating and maintaining analgesia. |Can fail or cause hypotension, backache, delayed |

| | |progress of labour and headache. |

| | |Rare complications include total spinal, local |

| | |anaesthetic toxicity, epidural haematoma or abscess and |

| | |permanent neurology. |

| | |Absolute contraindications include coagulopathy, |

| | |infection and relative contraindications include |

| | |aortic/mitral stenosis and neurological disease. |

1. Pescod, David. Developing Anaesthesia Textbook 1.6 p106-110.

2. Wee, M. Analgesia in labour: inhalational and parenteral. Anaesthesia and Intensive Care Medicine 2007, 8:7: 276-8.

Ariuna is keen on regional analgesia. Are there any side effects and risks that you wish to discuss with Ariuna about regional analgesia for labour?

Moderately common side effects include:

- Hypotension requiring treatment.

- Urinary retention.

- Delayed progress of labour.

- Failure of block – 1:10.

- Post dural puncture headache occurring in 24-48hrs which may require a blood patch - 1:100.

Rare side effects include:

- Subdural block – 1:1000.

- Temporary neurological injury – 1:2000.

- Epidural abscess – 1:5000.

- Systemic local anaesthetic (LA) toxicity – 1:10,000.

- Total spinal – 1:5000-50,000.

- Permanent neurological injury – 1:100,000.

- Epidural haematoma – 1:150,000.

1. Eldridge, J. “Complications of epidural analgesia.” (Chapter) p704-5. Allman K, Wilson I. Oxford Handbook of Anaesthesia. Oxford University Press 2006.

2. Bamber, J. Anaesthetist provided labour analgesia. Current Anaesthesia & Critical Care 2006 17, 131-41.

Outline how you would insert an epidural for analgesia for Ariuna?

Preparation

- Perform a preoperative assessment and obtain informed consent.

- Ensure environment is clean, well lit and quiet.

- Ensure a skilled assistant, intravenous access and appropriate monitoring is in place.

- Resuscitation drugs and equipment should be readily available and checked.

- Ensure a sterile technique with gowns, gloves and face mask.

Position the patient

- Position the patient in the lateral or sitting position and identify Tuffier’s line which joins the two iliac crests and passes through the L3/L4 interspace.

[pic]

Approach to the epidural space

- Infiltrate the skin and subcutaneous tissues over the chosen vertebral interspace (usually L3/L4 or L4/L5) with 1% lignocaine.

- An 18 or 16 gauge Touhy needle is introduced in the mid-line with the bevel directed cephalad. The needle passes through skin, supraspinous ligament and then into the interspinous ligament.

- At this point, remove the Touhy stylet and attach the Loss of Resistance (LOR) syringe using either air or saline.

- LOR should be detected as the needle passes through the ligamentum flavum and into the epidural space.

-

Inserting the catheter

- Insert the 20 gauge catheter to a sufficient depth and carefully withdraw the needle ensuring the catheter is not withdrawn with the needle.

- Calculate the depth to the epidural space and gently withdraw the catheter until it is 4-5cm in the epidural space.

- Attach the catheter hub and filter and apply a sterile dressing to the site.

-

Injection of test dose

- Aspirate for any CSF or blood and then inject 2-3mls of 2% lignocaine with adrenaline to detect an accidental subarachnoid or intravascular placement.

-

Establishing and maintaining analgesia

- The total dose of local anaesthetic (e.g. 10-15mls of 0.1% bupivacaine with or without fentanyl or 8-12mls of 0.25% bupivacaine) is given in increments until the correct block height (T10 for 1st stage of labour).

- An infusion of 0.125% bupivacaine or 0.2% ropivacaine with 2mcg/ml of fentanyl at 6-12mlshr can be started to provide ongoing analgesia with further top ups as required for breakthrough pain.

1. Pescod, David. Developing Anaesthesia Textbook 1.6 p108-109.

2. Fischer, B. Techniques of epidural block. Anaesthesia and Intensive Care Medicine 2009, 10:11: 552-6.

Ariuna comes in to labour at 40 weeks at your hospital and you agree to insert an epidural for labour. Shortly after insertion of her epidural, she becomes unconscious. What are the potential causes? Outline your immediate management.

Potential causes include:

1. Severe hypotension on establishment of block.

2. Total spinal.

3. Systemic LA toxicity.

4. Anaphylaxis.

Immediate management would be:

1. Call for help.

2. Maintain her airway and if necessary intubate.

3. Give 100% oxygen and support her breathing.

4. Support her circulation while avoiding aortocaval compression. Start cardiopulmonary resuscitation and advanced life support as indicated.

5. Treat as indicated:

- Bolus of IV fluids ( vasopressors for hypotension.

- Ventilation in ICU for a total spinal.

- Hyperventilation ( anticonvulsants ( intralipid for LA toxicity.

- Adrenaline for anaphylaxis.

6. Monitor the foetus and if in distress consider delivery once mother is stable.

1. Eldridge, J. “Complications of epidural analgesia.” (Chapter) p704-5. Allman K, Wilson I. Oxford Handbook of Anaesthesia. Oxford University Press 2006.

Case No 15.4. Neonatal resuscitation

|You are in the labour ward when the midwife urgently requests your presence at the imminent delivery of a woman who is 42 |

|weeks gestation. The midwife says she thinks the baby will require resuscitation and there is no neonatologist present. |

What factors in the history and examination of a woman would indicate that the neonate may require resuscitation?

Factors in history include:

- Previous pregnancy loss – LOW RISK.

- Ruptured membranes > 18 hrs – LOW RISK.

- Multiple pregnancy ( 35 weeks – MODERATE RISK.

- Maternal diabetes, hypertension, polyhydramnios, oligohydramnios, intrauterine growth restriction, isoimmunisation, maternal infection, minor foetal complications – MODERATE RISK.

- Opiates given close to time of delivery – MODERATE RISK.

- Meconium-stained fluid (thick or thin) – MODERATE RISK.

- Vacuum or forceps for maternal indications – MODERATE RISK.

- Vacuum or forceps for foetal indication – HIGH RISK.

- Major foetal malformations, hydrops – HIGH RISK.

Factors on examination include:

- Breech presentation – MODERATE RISK.

- Non-reassuring foetal heart rate patterns – MODERATE RISK.

- Scalp pH 7.1-7.2 – MODERATE RISK.

- Scalp pH < 7.1 – HIGH RISK.

- Foetal compromise, prolapsed cord, placenta praevia or abruption. – HIGH RISK.

MODERATE RISK ( 16%.

HIGH RISK ( 47%

1. Pescod, David. Developing Anaesthesia Textbook 1.6 p116.

2. Aziz, K; Chadwick, M; Baker, M; Andrews, W. Ante- and intra- partum factors that predict increased need for neonatal resuscitation. Resuscitation 2008, 79, 444-52.

[pic]

What equipment do you consider you will need for newborn resuscitation?

Appropriate equipment will include:

- A means of recording the time of birth, assessment or response.

- A well-lit, flat area for assessment and treatment.

- A source of heat and warmth e.g. overhead heater and warm, dry towels and plastic bags.

- A stethoscope.

- Appropriately sized face masks and oropharyngeal airways – size 00, 0.

- Device to deliver positive pressure breaths e.g. T-piece device fed through a pressure limited gas supply or self inflating pressure limited bag-valve system with a 240ml volume bag.

- Supply of oxygen and air.

- Appropriately sized and type of laryngoscope e.g. size 00, 0, 1 Miller straight blade.

- Endotracheal tubes in different sizes ranging from 2.5 up to 4mm.

- Suction with catheters in the sizes of 6, 8, 10, and 12 French.

- Equipment to secure venous access through umbilical vein.

- Resuscitation drugs e.g. adrenaline, sodium bicarbonate, naloxone, glucose, and fluids.

1. Madar, J. Resuscitation of the newborn. Anaesthesia and Intensive Care Medicine 9:4, 2008, 142-6.

2. Australian Resuscitation Council. Airway management and mask ventilation of the newborn infant. February 2006.

The baby is delivered and is covered in meconium. He is floppy and not making any respiratory effort. What is your immediate response?

This is an emergency and your response should be:

1. Call for help.

2. Examine the pharynx under direct vision and aspirate any potential particulate meconium blocking the pharynx with a large bore suction catheter.

3. If still not breathing, give 5 inflation breaths and look for response.

4. If still no response, recheck head position, apply jaw thrust and repeat inflation breaths.

5. If still no response, try alternative airway opening manoeuvres and repeat inflation breaths.

6. If heart is not detectable or slow ( ................
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