This document discusses the anesthetic management of obstetric emergencies such as major obstetric hemorrhage and fetal compromise. It covers the challenges in managing obstetric hemorrhage including difficulty in estimating blood loss and early diagnosis of shock due to masking of signs by normal pregnancy physiology. The management approach "ORDER" is outlined which includes organization, resuscitation, defective coagulation, evaluation of response, and remedying the cause of bleeding. General anesthesia techniques for cesarean sections in hemorrhage emphasize rapid sequence induction, cricoid pressure, and hemodynamic support through fluid resuscitation and blood product transfusion to maintain coagulation.

1. ANAESTHETIC
MANAGEMENT
OF OBSTETRIC
EMERGENCIES
D R V I D H I G A J J A R
A S S I S TA N T P R O F E S S O R
D E PA R T M E N T O F A N A E S T H E S I A
A M C M E T M E D I C A L C O L L E G E

2. LEARNING OBJECTIVES
At the conclusion of this lecture, participants should be
able to:
1. Identify conditions that lead to maternal
hemorrhage and fetal distress.
2. Co-ordinate obstetric management techniques.
3. Internalize anesthetic management of maternal and
fetal emergencies.

3. Obstetric
emergencie
s
Major Obstetric Haemorrhage
Foetal Compromise
Associated
emergencies
PIH & Eclampsia
Difficult airway
Maternal Cardiac arrest

4. Major Obstetric Haemorrhage

5. MAJOR OBSTETRIC HAEMORRHAGE
• Obstetric hemorrhage, a preventable
condition, is one of the leading causes
of death in developing countries.
• A Practice Bulletin from the American
College of Obstetricians and
Gynecologists places the estimate at
140,000 maternal deaths per year i.e
1woman every 4 minutes
• Early recognition and a
multidisciplinary team approach in
the management are the
cornerstones of improving the
outcome of such cases.

6. TYPES OF OBSTETRIC HEMORRHAGE
Conception
22-24
weeks
Foetal
viability
Delivery
ANTEPARTUM
HAEMORRHAGE
Placenta previa
Placental abruption
Coagulopathies
Uterine rupture
PRIMARY
24 hours 6 weeks
SECONDARY
POST PARTUM
HAEMORRHAFE
LOCAL CAUSES-Cervical lesions, clinical examination

7. CAUSES OF PPH-4T’s
THROMBIN • Pre-eclampsia
• Placental abruption
• Bleeding disorders: Haemophilia, Anticoagulation, von-Willebrand disease,
low fibrinogen
• Septicemia
TISSUE • Retained placenta
• Placenta accrete
• Retained products of conception
TONE • Placenta previa
• Over distension of uterus: multiple pregnancy, polyhydroamnios,macrosomia
• Previous PPH
TRAUMA • Caesarean section
• Episiotomy
• Macrosomia(>4 kg baby)
OTHERS • Asian ethnicity
• Anaemia
• Induction of labour
• Obesity
• Age

8. MAJOR OBSTETRIC HAEMORRHAGE-DEFINITION
Although no consensus exists on the definition of massive obstetric
hemorrhage, presence of either of the following has been described:*
• Sudden blood loss > 1500ml (25% of the blood volume)
• Blood loss of 50% of the circulating blood volume in < 3
hours
• Blood loss > 150ml/min within 20 min (≥50% blood
volume)
• Peripartal drop of hemoglobin concentration of ≥4g/dl
• Transfusion ≥4units of blood

9. HOW IS OBSTETRIC HEMORRHAGE DIFFERENT?
Obstetric hemorrhage is challenging to anesthesiologists
as it is usually sudden in onset, rapid and life
threatening.
a.Inability to recognize the risk factors
b.Difficulty in exact blood loss estimation
c. Difficulty in early diagnosis
d.High uteroplacental blood flow

10. A. INABILITY TO RECOGNIZE THE RISK FACTORS
• This occurs due to inappropriate clinical evaluation and
inadequate investigation of the expectant mother.
• A high degree of suspicion is hence needed to identify
the risk factors responsible for hemorrhage in the
antenatal period.
• USG not only helps in confirming the cause of hemorrhage but
may also diagnose the presence of concealed hemorrhage in an
otherwise asymptomatic patient.

11. B. DIFFICULTY IN EXACT BLOOD LOSS ESTIMATION
• Underestimation both in volume and rapidity as estimation is usually
subjective
• Hidden blood loss
• Various methods have been developed such as…
• The ‘message’ from the majority of studies comparing various methods of
blood loss estimation was; that the higher the measured blood loss, the
greater the underestimation by visual assessment.
• Thus, meticulous clinical observation and a high index of suspicion are
required to detect and eventually treat MOH early; else inadequate
volume replacement is inevitable.

13. C. DIFFICULTY IN EARLY DIAGNOSIS
• Maternal physiology is well prepared for hemorrhage,…
• Early signs of shock like tachycardia and increased
vascular resistance are masked by the normal
changes of pregnancy.
• Hemodynamic collapse occurs only when almost 35-45% of
circulating volume is lost.

14. HOW TO DIAGNOSE EARLY?
• The “rule of 30”-to diagnose 30% of her blood volume
–  SBP by 30 %,
– HR by 30%,
–  RR > 30/min,
–  Hb or Hct drops by 30%
–  urine output to <30 ml/h, the patient is likely to have lost 30% of
her blood volume.
• The “shock index” defined as the heart rate divided by systolic BP
(normal up to 0.9 in obstetrics) could aid in the earlier recognition of
haemodynamic compromise, prior to changes in HR or BP alone.
• MEOWS includes looking for signs such as tachycardia, hypotension,
hypotension, decreased urine output, pallor, pain, temperature & spO2.

16. D. HIGH UTEROPLACENTAL BLOOD FLOW
• The uteroplacental unit receives 12% of the cardiac output at
term pregnancy i.e. 700 ml/min.
• Hence, it forms a potential source of rapid bleeding, which if
unabated may become life threatening.
• Hemodynamic status should always be correlated to the
blood loss and any discrepancy has to be communicated to
the obstetrician without delay.

17. MANAGEMENT OF MASSIVE OBSTETRIC
HEMORRHAGE- “ORDER”
The following is a plan for managing massive obstetric hemorrhage,
adapted from Bonner. The word order is a useful mnemonic for
remembering the basic outline.
ORDER-Organization
• Call experienced staff (including obstetrician & anesthetist).
• Alert the blood bank and hematologist.
• Designate a nurse to record vital signs, urine output,
and fluids and drugs administered.
• Place operating theater on standby.

18. Mx Of MOH-ORDER-RESUSCITATION

19. Mx Of MOH-ORDER-DEFECTIVE BLOOD COAGULATION
• “Massive transfusion ‘pack’ consisting of
– 4 units of O-negative PCV,
– 4 units of FFP and
– 1 apheresis pack of platelets.” should be ready with blood bank.
Defective
Coagulation
Dilutional
Altered from onset
from haemorrhage

20. Mx Of MOH-ORDER-DEFECTIVE BLOOD COAGULATION
The main therapeutic goal of management of massive blood loss
is to maintain:
• Hemoglobin > 8 g%
• Platelet count > 75 x 103 /liter
• Prothrombin time (PT) < 1.5 x mean control
• Activated prothrombin time (APTT) < 1.5 x mean
control
• Fibrinogen > 1.0 g/l
• 2006 guideline from the British Committee for Standards in Hematology

21. Blood
Product
Recommendation IN MOH Compatibility Interaction Notes
PCV To keep Hb>8g/dl • Type specific, cross matched
• O negative can be used in
emergency
• Start infusion without waiting
for lab results in case of
massive blood loss
Platelets To keep Platelet count > 75 x
103 /liter
• ABO compatibility preferred.
• ABO incompatible have 
• lifespan &  risk of infection
• Rh(+/-) compatibility necessary
• If surgical intervention is
necessary, maintain the
platelet count at more than
80-100 x 103 /liter
FFP To keep
• Prothrombin time (PT) < 1.5
x mean control
• Activated prothrombin time
(APTT) < 1.5 x mean
• control
• ABO compatibility preferred.
• Blood product most often
associated with TRALI (Tranfusion
Related Acute Lung Injury)
• Must be thawed (20-30 min)
before administration
• In MOH; often given in 1:1:1
ratio FFP: PCV: platelets
Cryo
precipitate
To maintain the fibrinogen
level above 1-1.5 g/L if FFP has
not been successful
ABO compatibility not necessary. • One pool (5 bags make one
pool or 1625 mg of
fibrinogen) of cryo is
expected to raise the
fibrinogen level by about 0.5
g/L

22. Mx Of MOH-ORDER-DEFECTIVE BLOOD COAGULATION
Other measures: 1.Recombinant factor VIIA
• Not the first line treatment and is very expensive
• Recombinant factor VIIa promotes homeostasis at the site of the injury, once major bleeding is
controlled
• Before administration patient should ideally have
– platelet count 20,000/mm3,
– fibrinogen >1 g/dl,
– temperature >32°C,
– pH >7.2, and
– ionized calcium levels normal
• Optimal dose in obstetric hemorrhage is unknown though dose of 90 mg/kg is used.
• Despite having a very short half-life, (2-6 h), it may cause thromboembolism later on
• It is recommended to give deep vein thrombosis (DVT) prophylaxis once the bleeding risk is
considered to be low.
• Latest guidelines, however, do not recommend the routine use of rFVIIa in the management of
major PPH.
adequate functioning of
clotting cascade

23. Mx Of MOH-ORDER-DEFECTIVE BLOOD COAGULATION
• Other measures: 2. Intraoperative Cell Salvage (IOCS)
• Established technique in MOH
• Requires specialized machine
• To be administerd within 8 hours of preparing machine
• Initial concerns regarding the potential for harvest and retransfusion
of amniotic fluid causing so-called “amniotic fluid embolus”
prevented its use in obstetrics.
• Amniotic fluid effectively filtered by the machine
• Further LDFs are also known to remove bacteria from blood & results
in clinically insignificant bacteremia.
• Mainly indicated for : Jehovah’s witness and in patients with
anticipated massive blood loss(placenta accreta, percreta)

24. Mx Of MOH-ORDER-DEFECTIVE BLOOD COAGULATION
• Other measures : 3 Autologous blood
transfusion:
The use of preautologous blood deposit is not
recommended in pregnancy (exception being a mother
who is Jehovah’s witness).
• Other measures: 4 Tranexamic ACID
• Its role in obstetric bleeding is not established except
in cases of genital tract trauma.

25. Mx Of MOH-ORDER-EVALUATION OF RESPONSE
• Monitor
– Vitals: P, ECG, BP, sPO2
– Urine output
– ABGA
– Consider CVP
– Frequent auscultation of the lung fields helps detect
pulmonary edema or the development of adult respiratory
distress syndrome
– Periodic CBC, Coagulation profile
• Arterial line placement also may aid in monitoring blood pressure
and allowing easy access for blood work

26. Mx Of MOH-ORDER-REMEDY THE CAUSE OF
BLEEDING- ANTEPARTUM HAEMORRHAGE
– If fetus is live, viable & full term, deliver the fetus and
placenta immediately with LSCS
– If fetus is dead, consider induction of labour or LSCS
(Obstetric decisicion)
– Beware of subsequent PPH

27. Mx Of MOH-ORDER-REMEDY THE CAUSE OF
BLEEDING- POSTPARTUM HAEMORRHAGE
Tone-Atony
– uterine massage
& non surgical
uterine
compression
– uterotonics
– compression
sutures
– arterial
embolisation/coili
ng
– arterial ligation
Trauma
– Repair genital
tract trauma
– Tranexamic acid
– Laprotomy for
primary repair of
uterus in cases of
uterine rupture
Tissue-Placental
complications
Manual removal of
uterus for retained
placenta followed
by uterotonics
Thrombin
• Correction of
coagulopthy
If all of above fail, consider laparotomy & hysterectomy

28. ROLE OF ANAESTHESIOLOGIST IN MOH-
• Resuscitation in ongoing haemorrahage
• Interventional radiology for arterial coiling
• In the OT, for exploration
• Maternal Collapse
GOALS
• Safety of the mother-MAIN FOCUS IN MOH
• Safety of the baby;
• Rapid resuscitation along with conduct of anaesthesia
• Predict, prevent, diagnose and treat coagulopathy

29. PREOPERATIVE ASSESSMENT
• Quick but thorough history and examination especially airway
examination
• Obstetric conditions, such as placental abruption or pre-eclampsia,
are noted.
• A recent CBC, RBS, Coagualtion profile-if done
• If not done; insert 2 large bore iv cannulas(>/= 16G)- Collect
sample for atleast 6 cross match & send Blood group, cross match.
• Depending on clinical assessment of loss, PCV should be ordered
at this stage if not already done.

30. CONSENT
Suggested topics for specific mention are:
• Current clinical condition of patient
• The practice of RSI (particularly pre-oxygenation and cricoid pressure),
•  blood loss,
• Failed intubation
• Awake extubation
• Awareness especially in MOH
• More neonatal depression
• Increased recovery period especially in High dependency unit
• Poorer pain relief,
• More postoperative nausea, sore throat
• Amniotic fluid embolism

31. PRE OPERATIVE PREPARATION
• Caesarean sections/Laparotomy in MOH are frequently performed as
emergencies in unprepared patients.
• Prepare and check equipment for obstetric anesthesia in advance,
• Particular attention should be paid to the function of the laryngoscopes,
the endotracheal tube and cuff, the suction apparatus & tilting table.
• All anaesthetic drugs needed for RSI should be drawn and clearly
labelled.
• Antacid prophylaxis should be given with either 0.3M 30 ml Sodium
citrate or IV Ranitidine 50 mg 20-30 min before induction.

32. SUGGESTED TECHNIQUE OF GENERAL ANESTHESIA
1. Apply routine monitors, including electrocardiography, pulse
oximetry, and capnography. Measure NIBP every 3 minutes.
2. Position the patient to achieve optimal position for airway access
& void aortocaval compression-Manual LUD
3. Preoxygenate with a high flow of oxygen for 3-5 minutes or 4
vital capacity breaths over 30 seconds.
4. Consider CVP and arterial line but do not delay resuscitation and
definitive management for the same.

33. SUGGESTED TECHNIQUE OF GENERAL ANESTHESIA
5. After the drapes are applied and the surgeon is ready, initiate a
rapid-sequence induction with thiopental, 4.0-5.0 mg/kg, and
succinylcholine, 1.0-1.5 mg/kg. In hypotensive crises, ketamine,
1.0-1.5 mg/kg and Etomidate 0.2-0.3 mg/kg should be
substituted for thiopental. A defasciculating dose of muscle
relaxant is not necessary.
6. Apply cricoid pressure of 10 N after preparing the patient
increase up to 30 N after patient loses consciousness and
continue until correct position of the endotracheal tube is
verified by etCO2 and chest rise and the cuff is inflated. At least
6 waveforms on etCO2 confirm endotracheal intubation.
7. Allow surgery once intubation is confirmed.

34. SUGGESTED TECHNIQUE OF GENERAL ANESTHESIA
8. Ventilate with 50% oxygen and 50% nitrous oxide and low
volatile concentration – ET volatile conc < 1 MAC. Consider 100%
oxygen in cases of fetal distress.
9. Adjust minute ventilation to maintain normocarbia(etCO2 and
use muscle relaxation as necessary with either a nondepolarizing
muscle relaxant or succinylcholine.
10. After delivery of baby, add oxytocin to intravenous fluids within 1
min of baby delivery.( 10 U in 500 ml)
11. After delivery of baby, increase nitrous oxide to 70%, augment
anaesthesia with administer an opioid and a benzodiazepine;
discontinue or reduce the volatile anesthetic.

35. SUGGESTED TECHNIQUE OF GENERAL ANESTHESIA
12. Reverse neuromuscular blockade as necessary at completion of
surgery. It is recommended to use Neuro muscular monitoring.
13. Extubate when the patient is awake, the anesthesia is adequately
reversed, and the patient is following commands. Every
extubation should be done with all preparations for re-
intubation.
14. Consider Paracetamol, Opioids, TAP block, Rectus sheath block,
Ilio-inguinal blocks and local infiltration of scar for analgesia.
15. Continue resuscitation with the fluid & blood products
throughout the surgery and maintain normothermia.

36. UTERINE INVERSION
• Rare emergency situation
• Turning inside out of all or part
of the uterus.
• Severe PPH with hemodynamic
instability may complicated by
vagal reflex mediated
bradycardia.
• R/F- Atony, short umbilical cord,
uterine anomalies patients
• Obstetric Management consists
of immediate repositioning &
uterotonics after that.
• MRP is required when placenta
not delivered within 30 min of
delivery
• Leading cause of both primary &
secondary PPH
• R/f- H/o of retained placenta, pre
term delivery, use of oxytocin, pre
eclampsia & multi parity
• Obstetric management includes
manual removal, may be
curettage and augmenting uterine
tone after MRP.
MANUAL REMOVAL OF
PLACENTA

37. GOALS & CONFLICTS OF MX OF INVERSION
& MRP(APART FROM MOH)
• Close communication with obstetrician during titration of tocolytic therapy
• Facilitation of uterine reduction: tocolytics (nitroglycerin, volatile anesthetics)
• 200-400 mcg IV bolus of NTG can facilitate tocolysis but we have to support
hemodynamics with fluids & vasopressors.
• If not successful GA with volatile agent is required.( RSI keeping in mind
difficult airway)
• 1.5 MAC of VA reduce uterine contractility by 50%.
• GA with volatile anaesthetics results in rapid onset of uterine relaxation and
rapid offset on turning off the agent.
• Treatment of uterine atony after reduction (medical & surgical)
• Regional anaesthesia may be considered in hemodynamically stable patients of
retained placenta.

38. POSTOPERATIVE DETAILS
• Continue resuscitation, and repeat laboratory tests.
• Monitor vital signs, urine output, and any ongoing losses.
• Care in an intensive care setting is advantageous, as is close
follow-up by the obstetric service.
• The patient must be monitored for complications
• Once bleeding is controlled and coagulopathy is corrected;
consider thromboembolism prophylaxis with mechanical
devices.
• Proper Documentation should be done from time to time.

39. Foetal
Compromise/
Non reassuring
foetal status

40. DEFINITION OF FOETAL COMPROMISE
• Up to 23% of cases of cerebral palsy are related to intrapartum
asphyxia.
• A well-coordinated team approach is vital
• The term ‘‘fetal distress’’ be replaced with the term ‘‘nonreassuring
fetal status,’’(ACOG)
• It compromises of impaired fetal gas exchange (asphyxia) and, at
the extreme, there can be a complete cessation of fetal gas
exchange (i.e, fetal anoxia) which can be lethal in less than 10
minutes
• Causes:
– Complete cord occlusion,
– sustained bradycardia,
– uterine rupture,
– ongoing tetanic uterine contractions

41. GUIDELINES FOR THE MANAGEMENT OF
URGENT CS FOR A FETAL INDICATION
• As soon as decision for CS is taken, Intrauterine fetal resuscitation should be
initiated immediately;
– Optimise Maternal Position-to relieve aorto caval compression & cord
compression
– Oxygen
– Intravenous crystalloids
– Intravenous vasopressor if blood pressure is low
– Oxytocin off
– Tocolysis in case of uterine tachysysytole: Terbutaline 250 μg (s.c), NTG 400
μg (metered aerosol doses)-
• The decision as to the method of anaesthesia is a balance between the degree
of urgency and the level of concern about maternal risks of general
anaesthesia.

42. Category Definition Indications Type of Anaesthesia
1 Immediate threat
to life of mother or
fetus
• Placental abruption,
• Bleeding placenta
previa major with
maternal hypovolaemia
• Uterine rupture &
• scar dehiscence,
severe foetal
bradycardia, cord
prolapse,
Failed instrumental
delivery with fetal
distress
General anaesthesia
unless preexisting
epidural anesthesia can
be extend satisfactorily
2 Maternal or foetal
compromise that is
not immediately
life threatening
Previous CS in labour,
Anterpartum haemorrhage
without hypovolaemia,
Failed IOL
Breech/brow/face/c
hin presentation,
• Epidural-if already
established top up
• Spinal-if epidural not
established but no
repeated attempts
• GA-if R/A is C/I
3 No maternal or
foetal compromise
but needs early
delivery
Previous CS not in labour Low AFI • Same as 2 but SA
can be attempted
>once
4 At a time to suit
the mother &
maternity unit
Risk of maternal h’age;
Abnormal presentation;
Fetopelvic disproportion;
Dysfunctional uterine
Same as 3

43. ANESTHESIA FOR FETAL COMPROMISE
• Rapid history with examination(especially airway examination) & Consent
• Clear antacid (sodium citrate)
• 100% O2 for 3– 5 min or 4 vital capacity breaths over 30 sec
• Optimal maternal positioning (left uterine displacement and airway)
• Continue to monitor fetal heart rate
• Check the intravenous line
REGIONAL ANAESTHEISA
Epidural extension
• 15–20 mL 2% lidocaine + epi 1/200 000
• 20–30 mL 3% 2-chloroprocaine
• 1-2 g/kg fentanyl(optional)
Spinal
• 12– 15 mg hyperbaric bupivacaine
• 15 mg fentanyl (optional)
• 0.1–0.2 mg morphine (optional)
• Rapid sequence spinal
GENERAL ANAESTHEISA
• Induction when surgeon ready to start
• Ketamine 1 mg/kg or
• Thiopentone 4 –6 mg/kg
• Succinylcholine 1.5 mg/kg
• Cricoid pressure
• 02 –100% until delivery
• Volatile agent: <1 MAC
• Opioid & BZD after delivery

44. RAPID SEQUENCE SPINAL ANAESTHESIA
Currently, the emphasis is on ‘Rapid Sequence Spinal Anaesthesia’, in which the
idea of performing spinal with bare essentials and limiting the number of
attempts at insertion.
The sequence in a ‘ Rapid Sequence Spinal’ are as follows:
1. Deploy other staff to secure the intravenous line
2. Preoxygenate during the attempt
3. ‘No Touch Technique’ use only gloves, chlorhexidine on swab to paint and use
glove packet as sterile surface
4. Local injection not mandatory
5. Add 25 mcg fentanyl, if there is time. If not consider increasing the dose of
bupivacaine
6. Only one attempt at spinal unless obvious correction allows a successful
second attempt
7. Start surgery once sensory level >T10 and ascending. Be ready for general

45. Special
Considerations
Difficult Airway

46. WHY DIFFICULT AIRWAY?
• The incidence of failed intubation is 10 times more in the obstetric
population & it has remained unchanged over years.
• The reasons of difficult airway in obstetric patients:
– Vascular & edematous mucosa of the upper respiratory tract
– Oedema may be exacerbated in pre eclampsia, oxytocin infusion &
Valsalva maneuvers in labour
– Large breasts
– Decreased FRC with Increased oxygen consumption reducing our
safety margin of apneic period
• Best management of this situation is anticiapting a difficult
airway and being fully prepared and equipped for it in each &
every case

47. HOW TO BE PREPARED FOR DIFFICULT AIRWAY?
• Quick but thorough preoperative assessment with special focus on
airway.
• Identify risk factors like
– Obesity, Neck circumference >60 cm,
– TM distance < 6cm,
– Mallampatti grade3-4,
– Airway edema &/or Tongue bite in Eclampsia,
– Irregular dentition.
• Discussing the entire plan of difficult intubation with the relatives and
patients (especially in emergency mother would be the first priority) and
obtaining well informed consent.
• Discussion with obstetrician whether to wake the patient in case of
difficult intubation
• Adequate antacid prophylaxis should be given.

48. PREPARATION OF OT
• Check proper functioning:
–anaesthesia machine and
–suction equipment,
–a tilting table
• Anaesthetic and emergency drugs drawn up in appropriate
dilutions in clearly labelled syringes.
• All difficult airway devices & cart should be checked & kept
ready.
• A competent assistant who is familiar with the equipment
available in the airway cart & with the proper technique of
applying cricoid pressure is vital to the entire scenario.

49. PREPARE PNEMONIC FOR DIFFICULT AIRWAY MANAGEMENT
P- Prepare team,
Prepare Patient,
Prepare Equipment
Give proper Position
Pre-oygenate,
Continue oxygenation through the
attempts, Align the axis
P- Plan A, Plan B, Plan C
Share with the team and be
ready to
implement accordingly
R- Reset-Increase frequency of
vitals
Resuscitate in between
A- Adjust anaesthetic agents &
doses
Attention to vitals
E- Examine the airway
Give Explicit instructions
R- Once intubated, Remain &
Review the patient and Document
E- Organise the Exit to High
dependency unit

51. Pre theatre preparation & Plan with team
Rapid sequence Intubation
1st intubation attempt
If poor view of larynx, optimise attempt by
Reducing/ removing cricoid pressure Repositioning head/neck
Use of bougie/stylet External laryngeal
manipulation
Fail Ventilate with facemask
Communicate with an assistant
2nd intubation attempt
Consider
• Alternate laryngoscope
• Removing cricoid pressure
2nd intubation attempt only by experienced colleague
Follow Algorithm 2-Obstetric failed tracheal intubation
S
A
F
E
O
B
S
T
E
T
R
I
C
G
A
Verify succesful
endotracheal
intubation
Proceed with
anaesthesia &
surgery
Plan extubation
ALGORITHM 1

52. Declare failed intubation
Theatre team to call for help
Priority to maintain oxygenation
Supraglottic airway device
(2nd generation preferable)
Remove cricoid pressure
(maximum 2 attempts)
Facemask+/- Oropharyngeal airway
Consider
• 2 person facemask technique
• Reducing/removing cricoid pressure
Is adequate
oxygenation
possible?
F
A
I
L
E
D
I
N
T
U
B
A
T
I
O
N
Follow Algorithm 3
Can’t intubate
Can’t oxygenate
Is it essential to
proceed with
surgery
immediately?
Wake up
Proceed
with
surgery
NO YES
NO YES
ALGORITHM
2

53. DECLARE EMERGENCY TO THE THEATRE TEAM
Call ADDITIONAL SPECIALIST HELP( ENT Surgeon/Intensivist)
Give 100% oxygen
Exclude laryngospasm-ensure neuromuscular blockade
Perform front of neck procedure
Is adequate
oxygenation
possible?
Initiate Maternal ACLS
Perimortem CS
NO
Is it essential/safe
to proceed with
surgery
immediately
YES
Wake up
Proceed
with surgery
NO YES
C
I
C
O
ALGORITHM 3

54. RECOMMENDATIONS OF AIDAA GUIDELINES
• SpO2 of equal to or more than 95% as a cut-off for escalating airway
interventions
• Apnoeic oxygenation with nasal insufflation of 15 L/min oxygen during
apnoea should be performed in all patients.
• Modified rapid sequence induction using gentle intermittent positive
pressure ventilation with pressure limited to ≤20 cm H 2 O is acceptable.
• Limiting the number of intubation attempts to 2 before proceeding to
the next step
• We also aim to enforce a minimum standard of care through these
guidelines (such as, for instance, confirmation of tracheal intubation by
ETCO 2 monitoring).
• Every extubation should be considered as a potential reintubation.

55. Special Considerations
Maternal cardiac arrest

56. A-Anaesthetic causes High neuraxial
block
Hypotension
Loss of airway
Aspiration
Respiratory
depression
Local anesthetic
systemic toxicity
A-Accidents Trauma
B-Bleeding Coagulopathy
Uterine atony
Placenta accreta
Placental
abruption
Placenta previa
Retained
of conception
Uterine rupture
Surgical
Transfusion
reaction
C-cardiovascular causes Myocardial
infarction
Aortic dissection
Cardiomyopathy
Arrhythmias
Valve disease
Congenital heart
disease
D-Drugs Oxytocin, Magnesium, Drug error, Illicit
drugs, Opioids, Insulin, Anaphylaxis
CAUSES OF CARDIAC ARREST IN PREGNANCY

57. CHEST COMPRESSIONS IN PREGNANCY
• Use a firm back board
• Place patient supine
• Place hands in centre of chest
• Compress @100/min & depth of atleart 5cm
• Perishock pauses <10 seconds
• Allow complete chest recoil after each
compression
• Minimise interruptions chest recoil
APPROPRIATE AIRWAY MANAGEMENT IN PREGNANCY
• Give 100% Oxygen @>/= 15l/min
• Consider max 2 attempts of intubation & SGD insertion by
experienced provider
• If not successful consider front of neck access
• Avoid airway trauma
• Monitor capnography
• Avoid hyperventilation
• Minimise interruptions in chest compressions d/t airway
Note time of collapse & start CPR
Maternal interventions
Appropriate
airway
management
Secure IV
line above
diaphragm
Give typical ACLS
drugs & dosages
Assess mother for
hypovolemia & give
fluid &/or blood
products
If patient
receiving IV
MgSO4-
consider
reversal with
Calcium
Obstetric interventions
Continuous
manual LUD
Remove fetal monitors &
prepare for Perimortem
CS
If no ROSC by 4 minutes, start
perimortem CS & deliver baby by 5
minutes
Keep neonatal team ready

58. MANUAL LUD FOR AORTOCAVAL COMPRESSION
• In the pregnant patient, supine positioning will
result in aortocaval compression.
• Relief of aortocaval compression must be
maintained continuously during resuscitative
efforts and continued throughout postarrest
care.
• Chest compressions performed with the
patient in a tilt could be significantly less
effective than those performed with the
patient in the usual supine position.
• Manual LUD should be used to relieve
aortocaval compression during resuscitation.
• Additional benefits of manual LUD over tilt
include easier access for both airway
management and defibrillation, and high-
quality chest compressions without hindrance

59. PERIMORTEM CAESAREAN SECTION
• Irreversible brain damge can occur in 4-6 minutes as gravid uterus
impairs venous return & aortocaval compression.
• If no response to CPR within 4 minutes of CPR; perimortem CS
should be started simultaneously with resuscitation measures.
• Continue CPR during CS and afterwards to improve maternal
outcome.
• CS should be done at the site of resuscitation with minimum
aseptic precautions and equipment.

60. TAKE HOME MESSAGES
• Working as a team is
vital.
• Quick assessment and
decisions.
• Empathetic behavior
with patients family.
• Proper consent &
documentation are
need of the hour!!
>16G

61. THANK YOU FOR PATIENT LISTENING!!