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Obstetrics for Anaesthetists
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Book description

Anaesthetists on labour wards form an important part of the multi-disciplinary team. In addition to providing analgesia and anaesthesia, they are also involved in the acute management of conditions related to pregnancy, and coordinate and plan the care of patients with coexisting medical diseases. This requires an understanding of specialized obstetric procedures and the terminology and conditions unique to obstetrics. Obstetrics for Anaesthetists is a practical manual designed to provide anaesthetists with a clear knowledge of obstetrics and the implications this will have on their anaesthetic practice. Each chapter includes algorithms for the management of obstetric emergencies and text boxes highlighting the anaesthetic implications of a condition. Edited by an obstetric anaesthetist and an obstetrician, and with contributions from many leading practitioners, Obstetrics for Anaesthetists is an invaluable practical guide to all aspects of obstetrics relevant to anaesthetic practice.

Reviews

'The aim of this book is to provide a core understanding of obstetrics relevant to anaesthetic practice … this is accomplished with clarity and great readability. A pocket-sized paperback, this is a concise manual of obstetric terminology and procedures with implications for anaesthesia. It will be of value not only to anaesthetists but to a wider audience including obstetric trainees and midwives … It is easy to read, provides essential basic obstetric information and is a useful quick reference handbook.'

Source: International Journal of Obstetric Anaesthesia

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Contents

  • 1 - Maternal physiology and obstetrics
    pp 1-10
    • By John Clift, Consultant Anaesthetist, City Hospital, Sandwell and West Birmingham Hospitals NHS Trust, Birmingham
  • View abstract

    Summary

    Obstetrics describes the care related to pregnancy. An understanding of the changes in maternal physiology and pathophysiology of pregnancy-related disorders is essential to provide safe, effective obstetric care. This chapter summarises the implications the physiological changes occurring in pregnancy will have on anaesthetic practice. The physiological changes include changes in cardiovascular and haematological system, respiratory system, gastrointestinal system and central nervous system. Patients with cardiovascular disease need close monitoring and multidisciplinary care throughout the pregnancy with the involvement of obstetricians, anaesthetists, intensivists and cardiologists. Pregnant patients should be considered to be at risk from aspiration from approximately 16/40 (before if symptoms of reflux). Patients should be premedicated with an H2-blocking drug the evening before and on the morning of Caesarean section. 30ml 0.3 Mol sodium citrate should be given immediately before a rapid sequence induction with cricoid pressure, which is used when administering general anaesthesia.
  • 2 - Antenatal care
    pp 11-21
    • By Clare Tower, Clinical Lecture, Maternal and Fetal Health Research Centre, St Mary's Hospital, University of Manchester, Manchester, UK
  • View abstract

    Summary

    The National Institute for Health and Clinical Excellence (NICE) produced guidelines for antenatal care provision. The first antenatal visit or 'booking visit' is essential to identifying potential risk factors. Most women in the UK attend for booking in the late first trimester or early second trimester. Those attending in the third trimester are likely to have risk factors placing them in a higher risk category. Blood pressure (BP) should be measured at booking. Pregnant women are offered screening for rubella, syphilis, hepatitis B and HIV. Screening policies for fetal abnormality vary from region to region. The National Screening Committee suggested that women with a risk of 1:250 or more should be offered additional testing in the form of amniocentesis or chorionic villus sampling. Serum alphafetoprotein (AFP) testing in the second trimester is offered as a screening test for neural tube defects.
  • 3 - Induction of labour
    pp 22-30
    • By Rebekah Samangaya, Specialist Registrar, Rochdale Hospital, Pennine Acute Hospitals, NHS Trust, Rochdale, UK
  • View abstract

    Summary

    The indications for induction of labour (IOL) can be divided into fetal or maternal indications. The IOL is initiated for a specific indication, due to the associated risks. Prolonged pregnancy is the most common indication for IOL. Guidelines from the National Institute for Health and Clinical Excellence (NICE) recommend offering IOL to women between 41 and 42 weeks gestation. The main risk for women with prolonged ruptured membranes is intra-uterine infection. Maternity units throughout the UK have different policies on timing of IOL and the location where induction is commenced. Intrauterine fetal death (IUFD) may occur at any stage of pregnancy. The causes of IUFD include fetal anomalies, infection, fetal hypoxia secondary to placental insufficiency. IUFD should be confirmed by two obstetricians or ultrasonographers, and is confirmed by visualisation of the inactive fetal heart. Women with IUFD have to deal with grief and labour pain.
  • 4 - Normal labour
    pp 31-39
    • By Sarah Vause, Consultant in Feto-Maternal Medicine, St Mary's Hospital, Manchester, UK
  • View abstract

    Summary

    This chapter distinguishes between nulliparous and multiparous women. Multiparous women have more compliant cervix and faster progress in labour. In primiparous women, the cervix usually becomes completely effaced before dilating, whereas in multiparous women the cervix may begin to dilate before effacement is complete. The chapter explains the three stages of labour, the onset and mechanism of labour, the duration of a normal labour and characteristics of a dysfunctional labour. During normal labour the fetal head flexes and rotates to an occipito-anterior (OA) position as it descends through the pelvis. Obstruction can occur if a fetal head is deflexed, or fails to rotate in the usual way. When managing women in labour important interventions appear to be appropriate: one-to-one support during labour, accurate diagnosis, use of a partogram to identify slow progress, which in turn permits appropriate interventions including the use of amniotomy and oxytocin.
  • 5 - Abnormal labour
    pp 40-51
    • By Jenny Myers, Clinical Lecturer, Maternal and Fetal Health Research Centre, St Mary's Hospital, University of Manchester, Manchester, UK
  • View abstract

    Summary

    This chapter discusses pre-term labour, abnormalities at different stages of labour, placenta accreta, and certains emergencies such as cord prolapse and shoulder dystocia. The management of threatened preterm labour is aimed at maximising neonatal survival by prolonging the pregnancy. The administration of corticosteroids 24 to 48 hours prior to delivery significantly improves perinatal morbidity and mortality. Oxytocin is commonly used in abnormal labour and effectively increases uterine activity and causes cervical dilatation. Uterine hyperstimulation is a common side effect of oxytocin administration and this is the reason for the incremental regime used to accelerate or induce labour. Retained placenta is a cause of major obstetric haemorrhage. Abnormal progress in the first and second stages of labour is associated with fetal malpresentations and malpositions. Shoulder dystocia is a very serious obstetric emergency and in current obstetric practice is a significant cause of perinatal morbidity and mortality.
  • 6 - Fetal monitoring
    pp 52-69
    • By Justine Nugent, Clinical Research Fellow, Maternal and Fetal Health Research Centre, St Mary's Hospital and University of Manchester, Manchester, UK
  • View abstract

    Summary

    Electronic fetal monitoring (EFM) primary screening test is a highly sensitive test detecting a disease with a low prevalence. The fetal heart rate (FHR) trace or cardiotocograph (CTG) has five recognisable features: uterine activity, baseline FHR, baseline variability, accelerations and decelerations. The National Institute for Health and Clinical Excellence guidelines on EFM recommend that a CTG or FHR trace is classified into one of three groups: normal, suspicious or pathological based on the presence of reassuring and non-reassuring features. Fetal blood sampling (FBS) is used to identify compromised fetuses that need immediate delivery from those that are fine. There is a need for a monitoring system with a high specificity and sensitivity for detecting fetal acidosis and allowing timely and appropriate intervention without putting the fetus at risk. Currently, systems being researched include fetal ECG analysis and fetal oxygen saturation monitoring.
  • 7 - Pre-eclampsia and hypertensive disorders of pregnancy
    pp 70-87
    • By Egidio da Silva, Specialist Registrar in Anaesthesia and Intensive care University Hospitals, Birmingham, Queen Elizabeth Hospital, Birmingham, UK, Wilson Chimbira, Lecturer in Anaesthesiology, University of Michigan, Ann Arbor, Michigan, USA
  • View abstract

    Summary

    Success in the management of pre-eclampsia is partly dependent on a multidisciplinary approach by the midwifery, obstetric, anaesthetic, intensive care and neonatal teams. Fetal complications of pre-eclampsia also result from placental dysfunction, and may be acute or chronic. The presentation of chronic pathology depends on the duration and severity of the changes to the placenta, but may include intra-uterine growth restriction (IUGR), which may ultimately lead to intra-uterine fetal death (IUFD). An accurate clinical assessment of patients with hypertension and/or pre-eclampsia is essential as the clinical course, and subsequent management is different for women with pregnancy-induced hypertension, pre-eclampsia and severe preeclampsia. Maintenance of fluid balance is essential in the management of severe pre-eclampsia, to prevent iatrogenic pulmonary oedema due to fluid overload. Hypotension occurring during Caesarean section or following regional anaesthesia is treated by careful fluid resuscitation. Women with severe pre-eclampsia and eclampsia require close monitoring after delivery.
  • 8 - Operative obstetrics
    pp 88-106
    • By Jo Gillham, Consultant in Feto-Maternal Medicine, St Mary's Hospital, Manchester, UK
  • View abstract

    Summary

    This chapter explains the indications for the Caesarean section organised into four categories. In principle, the considerations are that the decision to delivery time for category 1, where immediate threat to life of women or fetus, should be less than 30 minutes and mother's safety is paramount. The majority of deliveries are achieved through a low transverse abdominal skin incision and a transverse incision through the lower segment of the uterus. The chapter discusses the maternal or fetal compromise, the necessity of early delivery, and elective Caesarean section, explaining their ractical surgical steps, complications, and Caesarean hysterectomy. Instrumental delivery can be achieved through the use of vacuum extractor and forceps. Obstetricians should remain familiar with the technique of assisted vaginal breech delivery, as some patients will present with breech presentation in preterm labour or in advanced labour. Twin pregnancies have a higher incidence of pre-term labour, IUGR and preeclampsia.
  • 9 - Obstetric haemorrhage
    pp 107-119
    • By Alexander Heazell, Clinical Research Fellow, Maternal and Fetal Health Research Centre, St Mary's Hospital, University of Manchester, Manchester, UK
  • View abstract

    Summary

    Obstetric haemorrhage results in massive blood loss endangering the life of the mother, and the infant in the case of antepartum haemorrhage (APH). This chapter discusses placenta praevia, vasa praevia, postpartum haemorrhage (PPH), uterine atony, genital tract trauma, clotting disorders, and uterine inversion. The Confidential Enquiry into Maternal and Child Health (CEMACH) recommends that all obstetric units have a protocol for the management of obstetric haemorrhage; all individuals working in delivery units should be familiar with local guidelines. APH is a major cause of perinatal morbidity and mortality, including an increased risk of premature delivery. Placental abruption may be partial or complete separation and can occur at any stage of pregnancy. The intervention following placental abruption is dependent upon the severity of the abruption and the presence of fetal compromise. General anaesthesia with relaxation by volatile agents is the most proven anaesthetic technique to correct the inversion.
  • 10 - Thromboembolic disorders of pregnancy
    pp 120-129
    • By Mark Tindall, Consultant in Anaesthesia, Dudley Group of Hospitals, Dudley, West Midlands, UK
  • View abstract

    Summary

    Successive reports from the Confidential Enquiry into Maternal and Child Health (CEMACH) have highlighted failures in recognition of risk factors for venous thromboembolism (VTE) and provision of adequate prophylaxis. VTE is a significant cause of mortality and morbidity in pregnancy. There are two different manifestations of VTE - deep vein thrombosis (DVT) and pulmonary embolism (PE). DVT organizes clots that occur in the venous system, usually in the large veins of the leg or pelvis. PE is a clot that causes occlusion of artery in the pulmonary circulation. The blockage of the artery can be caused by air, fat, amniotic fluid or blood clot. The accurate diagnosis of VTE requires both clinical assessment and objective testing. Spiral CT scan is used to identify PE. Both the prophylaxis and treatment of VTE can potentially have implications on the provision of regional anaesthesia or analgesia during labour and delivery.
  • 11 - Infection
    pp 130-135
    • By Paul Dias, Specialist Registrar in Anaesthetics and Intensive Care, Royal Wolverhampton Hospitals, NHS Trust, Wolverhampton, UK
  • View abstract

    Summary

    Infection occurring in pregnancy can result in significant morbidity and mortality for both mother and child. This chapter talks about prophylaxis, screening, chorioamnionitis, Group B streptococcal infection, human immunodeficiency virus (HIV), and genital herpes. It explains the implications of these infections on pregnancy and their postpartum management. Depending on the type of infection, there is an increased incidence of preterm delivery, intrauterine growth restriction, intrauterine and infant death and mother-to-child transmission of infection. Women undergoing repair of a third or fourth degree tear require intra-operative and post-operative antibiotic therapy to prevent infection which increases wound breakdown and the incidence of fistula formation. Group B streptococcal infection is the most frequent cause of severe sepsis in the first week of life. Treatment of women with high viral load of HIV usually consists of highly active antiretroviral therapy (HAART) to stabilize symptoms and reduce viraemia.
  • 12 - Life support in obstetrics
    pp 136-139
    • By Julian Chilvers, Consultant, Anaesthetist, City Hospital, Sandwell and West Birmingham Hospitals, NHS Trust, Birmingham, UK
  • View abstract

    Summary

    Cardiac arrest in pregnancy is an extremely rare occurrence. Effective resuscitation of the mother is the most effective way to optimise fetal outcome. Resuscitation attempts should follow the Resuscitation Council UK guidelines on advance life support; however, these need to be modified when dealing with a pregnant mother. The greatest chance for both mother and baby to survive during cardiac arrest is if the baby is delivered in order to relieve aortocaval compression. The incidence of perimortem CS in the UK is quoted as 1 in every 170,000 deliveries. The decision to proceed to perimortem caesarean section (CS) is dependent on gestation. Preparation for the perimortem CS should be made immediately on commencing resuscitation. It is recommended that a classical midline approach should be used to speed up the procedure as there is natural diastasis of the recti muscles in late pregnancy.
  • 13 - Drugs in obstetrics
    pp 140-148
    • By Lisa Penny, Specialist Registrar in Anaesthetics and Intensive Care, University Hospitals, Birmingham, Queen Elizabeth Hospital, Birmingham, UK
  • View abstract

    Summary

    Drugs used in obstetrics merit special mention because they have their effects on two patients rather than one. This chapter provides an understanding of the drugs commonly used by obstetricians, including drugs to increase uterine contractions, ergometrine, prostaglandins, tocolytics, atosiban, nifedipine, and beta2-adrenergic agonists. Oxytocin is a nonapeptide used to induce and augment labour and also to minimise post-delivery blood loss. The main use of tocolytics is to stop premature labour. They have also been used to facilitate delivery during Caesarean section by uterine relaxation and to treat uterine hyperstimulation, preventing fetal distress. Antihypertensive agents are widely used during pregnancy but they all cross the placenta and the available evidence does not always suggest that they are of benefit. Increasing the number of antenatal exposure of steroids is associated with reduced cognitive function, an increase in behavioural disorders and reduced birth weight.
  • 14 - Confidential enquiries into fetal, neonatal and maternal death
    pp 149-152
    • By Katie Clift, Specialist Registrar in Anaesthetics and Intensive Care, City Hospital, Sandwell and West Birmingham Hospitals, NHS Trust, Birmingham, UK
  • View abstract

    Summary

    The Confidential Enquiries into Maternal Deaths (CEMD) produced triennial reports entitled "Why Mothers Die" from 1952 up to and including the report for 1997/9. Confidential Enquiry into Maternal and Child Health (CEMACH) has not only continued the Why Mothers Die report and the Stillbirth Neonatal and Postnatal Mortality report but also undertakes focused enquiries e.g. The Diabetes Study. This chapter dicusses the main causes for maternal death, fetal and neonatal death, and the recommendations for anaesthesia services from the most recent "Why Mothers Die" (2000-2002) report. The major causes of indirect maternal deaths reported in the last triennium were cardiac, psychiatric and malignancies. Both stillbirth and neonatal mortality rates are higher in women in socially deprived areas and in women of Black or Asian ethnicity. Anaesthetists should be involved in the care of high-risk patients from early in pregnancy and a management plan made for the care of these women.

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