Obstetric anaesthesia involves risks from both general anaesthesia and spinal anaesthesia due to physiological changes in pregnancy and the need to consider both mother and baby. The document outlines protocols for administering spinal anaesthesia including patient assessment, monitoring for complications like hypotension, and management of issues in recovery. It emphasizes vigilant monitoring and proactive treatment of any complications throughout the procedure and recovery.

1. Obstetric Anaesthesia

2.  GA or spinal ( both have risks)
In obs pt NB
-Physiological changes in pregnancy
-Difficult airway
-2 patients (mom and baby)

3. Spinal Anaesthesia

4. Spinal Contraindications
 Absolute:
 Uncontrolled haemorrhage
 Hypovolaemia
 Eclampsia with depressed level of consciousness
 Coagulopathy. (INR or PTT > 1.5 times normal
or platelets < 100 000)
 Local infection at site of puncture.
 Severe sepsis
 Obstructive cardiac lesions

5.  Patient refusal.
 Known hypersensitivity to local anaesthetics.
 Lack of resuscitative equipment or drugs
 Increased intracranial pressure
 Doctor unable to provide general anaesthesia

6. Relative Contra-Indications
 Relative contradictions:
 Active CNS disease (including multiple sclerosis)
 Primary herpes.
 Myasthenia gravis.
 Uncooperative teenage pregnancies
 Morbidly obese
 Extremely short (less than 150cm)
 Difficult airway
 Previous Lumbar surgery

7. PROTOCOL FOR NEURAXIAL
ANAESTHESIA IN OBSTETRICS
PREOPERATIVE PREPARATION
 Take a history and examine the patient, check consent for
surgery, check relevant investigations
 Discuss procedure with patient and obtain written consent
for neuraxial anaesthesia.
 Ensure that the patient has good intravenous access (18 G
minimum), aim to preload with 500-1000 ml crystalloid.
Check that the patient is catheterized.
 Administer prophylactic antibiotics: Kefzol 2g.

9. Administering the spinal
IN THEATRE
 Position the patient in the sitting position on the theatre bed
 Place monitors on patient (3-lead ECG, NIBP, SPO2) and obtain
initial readings.
 Prepare for insertion of spinal:
a. Identify appropriate intervertebral space (L3/L4)
b. Inject sufficient local anaesthetic into the
subcutaneous tissue
(suggest 2.5 ml 2% lignocaine into subcutaneous tissue)
c. Create an aseptic field (wear a mask, scrub hands,
put on sterile gown and sterile gloves),
 clean the field with chlorhexidine solution and drape the patient

10. 4. Insertion of the Spinal Needle:
 a. Use a 25 or 27 G pencil point spinal needle.
 b. Inject your spinal mixture (prepared in a 5 ml syringe) into
the subarachnoid space.
[1.8 ml 0.5 % heavy bupivacaine and 0.4 ml (20 ug) fentanyl]
 C. Apply dressing
 5. Position patient in the supine position, ensuring a degree of left
lateral tilt tilt to prevent aortocaval compression. Use of a vaculitre
as a wedge is acceptable.

11.  Continue ECG and SPO2 monitoring, as well as NIBP measured
every minute until the patient is confirmed to be
haemodynamically stable (you can then reduce intervals
to every 3 minutes).
 Talk to the patient in order to monitor patient’s cerebral perfusion
and general well-being.
 Use a forced air warmer and warm fluids to maintain
normothermia.

12. Spinal Anaesthesia
 Anatomy

13. Monitoring
 BP can drop after spinal
 Active Rx of Hypotension
 Ongoing rapid fluid administration
 Phenylephrine/Ephedrine/adrenaline
 Ensure adequate tilt
 Turn mother on her side!
 LOC
 Intubate
 Adrenaline (don’t be shy!)
 DELIVER THE BABY

14. High Spinal
 High index of suspicion
 ABC’s
 Loss Of Consciousness
 Intubate
 Adrenaline (don’t be shy!)
 DELIVER THE BABY

15. General Anaesthesia
 Potential problems:
 Failed/ difficult intubation
 Pulmonary aspiration of gastric contents
 Neonatal depression
 Maternal awareness

16.  Establish adequate IVI access and place the
patient in a left lateral tilt
 Establish monitoring as used for all general
anaesthetic cases
 Surgeons should be scrubbed and the
abdomen cleaned prior to induction.

17.  Perform a rapid sequence induction
 Adequate pre-oxygenation – at least 3 minutes of
breathing 100% oxygen or else at least 5 vital
capacity breaths.
 Adequate dose of propofol
 Apply cricoid pressure
 Give sux 1 mg/kg

18.  Supine:
 Aortocaval compression  decreased preload
 decreased cardiac output  decreased
uterine perfusion
 “Supine hypotensive syndrome”
 Wedge/left lateral tilt

19. Recovery room
 Continue monitoring and management
 Monitoring (HR, NIBP, SpO2)
 A+B
 – Oxygen, awake enough to maintain airway ?
 Do you need to keep ventilating and arrange ICU admission ?
 PONV ? Suction available
 C - Fluids/blood products
 Monitor and manage bleeding (wound, PV, urine) and
hypotension
 State of uterus
 D – Drugs
 Analgesia and antiemetics prescribed
 Oxytocin 20U into full vacolitre, running slowly (125mls/hour)

20. Post Dural Puncture Headache
 Due to leak from dura mater defect
 Causes decreased ICP, traction on structures
 Positional; better lying down, worse sitting up
 Exclude other causes of headache
 Meningitis
 Migraine

21.  Initial treatment is conservative
 Strict bed rest
 Simple analgesics
 [Caffeine]
 Epidural blood patch if not resolving within
24hours
 Sterile in theatre
 Patients’ own blood into EPIDURAL SPACE

22. Summary
 Before you start:
 Preoperative assessment – as if for GA
 Make the correct choice of type of anaesthetic
 Preparation – expect complications
 When you start:
 Use the safest technique
 Look out for complications at all times
 Proactive management of complications
 Once you have finished:
 Postoperative recovery and discharge
 Good documentation
 Before you leave:
 Clear, detailed instructions to the ward