introduction to the labour ward at st mary's...

Labourwardinductionforanaesthetistsv1.028/10/2013 DrsCMullington,AJeeyaweeraandJBray

IntroductiontotheLabourWardatStMary'sHospital

TheMaternityUnitatStMary'shasadeliveryrateofapproximately4,000deliveriesperyear.Thereisa24-hourepiduralserviceavailableandaCaesareansectionrateofapproximately30%.WiththelargestrecurrentmiscarriageclinicintheUKtheunitcatersforhigh-riskpregnanciesanddeliveriesfrom27/40gestation.PleasereadthefollowingandfamiliariseyourselfwiththeLabourWardbeforeyourfirstoncallOrientation

ThematernityunitissituatedintheClarenceMemorialandCambridgeWingsandincludes:

Labourward(on1stfloor)


AlecBourne1(labourward)1stfloorClarenceMemorialWingLabourrooms–4to12(maincorridor)Poolroom5HDU/Recovery(4beds)2TheatresDayassessmentunit

AlecBourne2(antenatalandpostnatalward)2ndfloorClarenceMemorialWingEastandWestWingBirthingUnit(GroundfloorClarenceWing)GroundfloorCambridgeWingMidwiferyLead

Locationofequipmentonlabourward

Equipment LocationEpiduraltrolley InstorecupboardAirwayequipment TrolleyinLWTheatre1(includingGlideScope)Resustrolley Outsidebirthingroom7PETtrolley Outsidebirthingroom7OxfordHELPmattress InstoreroomoppositeLWTheatre1Level1infuser InstoreroomoppositeLWTheatre1Drugs Anaestheticdrugs CupboardsandfridgeinLWTheatre1

Birthingrooms(1-11) HDU/Recovery

Fireescape

Theatre2

Entrance DAU

Theatre1

1

Handoverroom

Sluiceroom

Storerooms

Toilet/changingroom

Office

Storeroom Kitchen

Offices

Pharmacy

Staffroom Airwayequipment

Anaestheticdrugs

OxfordHELPmattress

Resus&PETtrolley

ABGmachine

Epiduraltrolley

Coffee

Controlleddrugs

Bloodfridge

MHbox

Intralipid


Controlleddrugs Mainpharmacyonlabourward(midwifeinchargehaskey)Blood 2UnitsofO-vebloodarekeptinbloodfridgeonlabourwardMalignanthyperthermiabox Aboveivfluidsshelvesintheatre120%Intralipid Indrugfridgeintheatre1UsefulcontactnumbersAnaestheticteam

• AnaestheticSR 1201• AnaestheticSHO 1213• ITUSpR 1212• LWODP 1672

Obstetricians• ObstetricSR 2099• ObstetricSpR 1101• ObstetricSHO2100

Paperwork

• Epiduralproforma–tobecompletedforalllabourepidurals.Thisisnotaprescription(thisisonCerner)buttorecordmidwifetop-ups/observationsduringlabour.

• BLACKlabourwarddiary–ALLprocedures/interventionstoberecordedhere/handwritten.Placepatientstickerinnotes

• SAFERhandoverproforma-completeateachhandover(08:00,17:00and20.00)andfileinfolder

• Stickersforconsent,follow-upandpost-opanalgesia• Standardblueanaestheticchartsfortheatreprocedures• PDPHfolder(seelater)

Cerner

• Documentlabourepiduralsandtheatrespinals/CSEsonCerner• GotoMaternityWhiteboard-SMHlabourward-rightclickonpatient-openpregnancyview–

structurednotes-Type(anaesthetics)–Title(epiduralprocedurenote)• Templatecanbemodified/personalizedandsavedtofavourites• Prescribe0.1%levobupivacaine+2mcg/mlfentanyltop-up(lowdoseepiduralsolution)

10-15mlsevery30mins• AnalgesiafollowingCaesareansection

UseCaesareansectionprescriptioncaresetforallpatientswhichwilldefaulttothefollowing

Enoxaparin40mgs/catbedtime(22:00)Paracetamol6hrlyDiclofenacsuppositories100mg(2doses12hrlypost–op).Youwillneedtomodifythestarttimeofthenextdosetofollowonfrom1stdoseintheatreotherwiseCernerwilldefaultandprescribeforthenextavailabledosingslot(8,12,18,22)whichmaybetoosoon.Pleasedonotchartanalgesiaforanytimesoutsideofagreedstandarddosingtimes(8,12,18,22)ortheygetmissed


Ibuprufen600mgsqds(defaultstotdsafter3days).Remembertomodify1storaldosetocommence10hoursafter3rddoseofPRdiclofenacDihydrocodeine30mgqdsPrnDihydrocodeine30mg6hrlMorphinesulphate10-20mg2hrly

*PleasemakesureyouarehappywithCernerandprescribingbeforeyouareoncallDailyactivitiesonlabourwardShifts:Dayshift: 08:00-17:00Longday: 17:00-20:00Night: 20:00-08:00Handover:Anaesthetictakesplacedailyat08:00amand17:00and20:00.AtmorninghandoverpleaseDONOThandoverthebleep(1211)toaCT2(whoisoftencoveringtheday)unlessyouhaveconfirmedthattheconsultantforthedayisONSITEandcontactable.HandovershouldtakeplaceonLabourWardusingtheSAFERproforma.Obstetrichandovertakesplaceat08:30,13:00,17:00and20:00.Thesemaybeeitherwardand/orboardrounds.Pleasemakeeveryefforttoattendunlessyouareintheatre.Wardrounds

• Visitroomswithepiduralsrunningtoidentifyanyproblemsearly.• ReviewALLpatientsinrecovery/HDUwithobstetricteam• At24:00jointlyreviewALLHDUpatientsrequiringlevel2carewiththeobstetricregistrarandto

agreeplanovernighteg:ivfluidmanagementElectivesectionsTherearecurrently2dedicatedelectivesectionlistsperweek(Tues&Wedmornings)Thesearestaffedbyaseparateconsultantanaesthetistandobstetrician.Thesearelowrisk,rapidturnovercasesbutjuniortraineesmaybeabletoperformtheblocks,labourwardpermitting.Otherelectiveworkisspacedoutovertheweekandfittedaroundemergencywork(average2-3perday)AllwomenforelectiveCaesareanshould:

• Arrivestarvedat07:30am• Receivepremedicationwithranitidineandmetoclopramide• HavearecentFBCandactiveG&S(pleasecheck)


• HaveroutineCTGbeforegoingtotheatreNB:Twins-IftwogoodCTGtracereadingsarenotpossible,despitefollowing“twinguidelines”andcannotbeconfirmedbyultrasoundthendeliveryneedstobeexpedited.

Pleasedonotundertakeanyelectiveworkoutofhourswithoutcheckingwiththeconsultantoncall.FollowupsDuringquietperiodspleasemakeanefforttoreviewpatientswhohavehadanaestheticinputintheprevious24hours.Everypatientwhohasananaestheticinterventionshouldreceivefollowupinthe1st24hours.Useroutinefollow-upstickersandplaceindiarynexttopatient’soriginalprocedurePDPHDocumentfollow-upsonproformainPDPHfolder.Womenshouldbereviewed12hourlyasinpatientandfollowedupbytelephonefor3daysoncedischarged.DocumentonCerner.RemembertohandoveronSAFER.Informationsheetandcontactnumberstobegiventopatientondischargeandpost/faxletter(proforma)toGPArrangefollowupinDrWard’shighriskclinic(bookwithantenatalclinic)for6weeksSupervisiononlabourwardInhours(8am-5pm):Weeklyanaestheticconsultantlabourwardrota:

Monday DrGlennArnold/DrRachelBartlettTuesday DrShelleyWard(DrRachelBartlett–electivelist)Wednesday DrJoBray(DrBenGraham–electivelist)Thursday DrSooLim/DrNatalieCourtois(am)andDrMarkSacks(pm)(alternateweeksFriday DrAndzrejConn

HighriskanaestheticclinicrunbyShelleyWardonWednesdayamingynaeoutpatientsOutofhours(5pm-8am):Oncallanaestheticconsultant(distantsupervision)

• 5pm-9pm2ndonconsultant• 9pm-8am1stonconsultant

IndicationsforcallingconsultantGeneral:

• IfyouaremakinganITUreferralandthereisanybedrelatedissue• Ifyoufeelyouneedsenioradviceaboutanything• IFyouneedanextrapairofhands


Specific:• Severesepsis• Suspectedepiduralhaematoma• DifficultiesinperformingregionalanesthesiainCategory1or2emergencysections

Repeatedattempts (>3)arediscouragedandshouldbeescalatedtoconsultantoncallormostsenioranaesthetistinthehospitalifoutofhours

Policies/GuidelinesSummarisedbelowaresomeoftheSMHmaternitypolicies/guidelines.Thisisnotaninclusivelist!FullguidelinesmaybefoundonthehospitalintranetintheImperialMaternityPoliciesandProceduressection.Pleasereadthesebeforeyourfirstoncall.AccidentalduralpunctureSignsandsymptomsHeadachesarecommonafterlabourandnotallheadachesareduralpuncturerelated.However,anywomansufferingheadachepost-labourandanaestheticinterventionshouldhaveitexcluded.Aspinalheadacheischaracterisedclassicallybyathrobbingfrontalorretro-bulbarpainwhichisrelievedbylyingflatandIVCcompressionandworsenedbysittingorstanding,itmaybeaccompaniedbyoccipitalpain,neck-acheandtinnitus.However,allsortsofneurologicalsymptomshavebeenascribedtoDuraltapandcuredbybloodpatching,thereforeanatypicalpresentationmaywelloccur.ManagementattimeofpunctureTreatmentofaduralpuncturebeginsatthetimeofthepuncture:

• Informpatientandmidwifethataduralpuncturehasoccurred.• AfterduralpunctureDONOTpullouttheTuohyneedle-Trynottodrainmorethanafew

mlsofCSF(cerebralspinalfluid).Considerthreadingepiduralcatheterintothesub-arachnoidspace(ifsafe).

• Approximately2cmshouldbethreadedintothesub-arachnoidspace.• Labelasspinalcatheter.• Eachtop-upshouldbedonebytheanaesthetist• Top-updosesare2-3mlofthestandardlow-dosemixtureinincrementaldoses.Rememberthe

deadspaceinthecatheterandfilteris1ml.• Afterdeliveryremovecatheterasusual• IftheTuohyneedleiswithdrawn,resitetheepiduralaspacehigherorlower(thismaybethe

preferredoption)• Treatasanormalepidural,buteachtop-upshouldbegivenbytheanaesthetist.REMEMBER

EACHDOSEISATESTDOSE• Thereisnoindicationforassistedinstrumentaldelivery• TheConsultantObstetricAnaesthetistmustbeinformedASAP(inworkinghours)• Enterthewomen’sdetailsintothe‘highrisk/followup’folderonlabourward(StMary’s)


• IfthereisanydoubtwhetherthefluidseenflowingbackthroughtheepiduralneedleisCSForsaline,thetemperaturecanbeassessedonthebackoftheanaesthetist'shand(withglovesremoved),andothertestscanbeperformedusingaurinedipstick(seefullguidelinefordetails).

Anti-infectiveuseinpregnancyandbreastfeeding

• AntibioticsforCaesareansection1.5gcefuroximeand500mgmetronidazoleivover10mins.Giveafterregionalbutbeforedeliveryofbaby.Inpenicillinallergygive900mgclindamycinand5mg/kggentamicin(runtogetherin100mlsbagofsaline)

• Afullguidelineforantimicrobialuseisavailableontheintranet.Regionalanalgesiainobstetrics

• Requestsforanalgesiashouldbemetassoonaspossibleandtimefromrequestforanalgesiatotheanaesthetistattendingshouldnotexceed30minutes(OAAguideline).

• Ifyouanticipatethatyourresponsetimewillbelongerthan30-60minutespleaseattempttofindanalternativeanaesthetisttoattendthepatientoraskthemidwifetodoso.

• CTGmonitoringthroughout.• LabourwardODPisavailabletoassistwithdifficultepiduralsoutofhoursifyouask

CSEversusEpidural

• Therearetwomethodsforproducinganalgesia:1. ACombinedSpinalEpidural(CSE)needle-through-needletechniquemaybeused.Initial

rapidanalgesia(includingexcellentsacralanalgesia)isprovidedbythespinalinjectionof2.5milligramsoflevobupivacaineand25microgramsfentanyl-thespinalinjectionprovidesapproximately90minutesofanalgesia.Epiduraltop-upsof‘’lowdose’’0.1%levobupivacaine+fentanyl2microgramspermlcanthenbeused.

2. Astandardepiduralcanbesitedintheusualway(i.e.withoutthespinal).Top-upscanthenbeprovided,byusingthe’’lowdosemixture’’:0.1%levobupivacainewith2microgramspermloffentanyl.Thefirsttestdoseshouldbeaninitial10mlsfollowedbyafurther5-10mlsat5minsofthelowdosemixture.Further10-15mlslowdosetop-upsshouldbechartedevery30minsPRN.

Patchy,Missedsegment,unilateralblock

1. Alterpositionofwomanandorwithdrawcatheteroneortwocentimetres,maintainingsterility.Thisisindicatedwithaunilateralblock(whichmost“patchy”blocksare).

2. Giveupto20mlsbolustop-upofthelowdosemixture.3. Tryadditionalvolume:10mlsof0.9%sodiumchlorideandadditionalopiate:50micrograms

fentanyl.4. Ifthesedon’twork,don’tpersist,re-siteit.DONOTuse0.25%levobupivacaineasthiswillnot

helptheunblockedsegmentsbutwillconvertthealreadyblockedareafromanalgesiatoanaesthesiawithassociatedmotorweakness.

Top-upsforinstrumentaldeliveries


• TheanaesthetistshouldbepresentduringANYdeliverythatcannotbemanagedsafelybythemidwifeand/ordifficultiesareanticipated.

• Forinstrumentalsintheroom:Iftheexistingblockhasbeenworkingwellandthereisnotagreatdegreeofurgency,15-20mlsofthetop-upsolution:0.1%levobupivacaine+fentanyl2microgramsperml+/-extrafentanyl(50-100micrograms)willbeeffective.

• Forinstrumentalsintheatre:Fastmixsolutionshouldbeused(seebelow).Thisshouldonlybegivenbytheanaesthetistwithfullmonitoring.

FastMix:

• 20mlpreservative-freelidocaine2%+2mlpreservative-freesodiumbicarbonate8.4%gentlyagitateanddiscard2mlsthenadd+0.1mladrenaline1:1000.


Hypertensioninpregnancy


Majorobstetrichaemorrhage


Severesepsis

• Sepsisisoftensinisterandpregnantwomenwithsepsiscandeteriorateanddierapidlyaftertheonsetofsymptoms.Itisvitalthatpromptrecognition,stabilisationandtreatmentoftheunderlyingcauseareinitiatedtoavoidtherapidescalationofdeteriorationthatleadstocelldeathand,ultimatelypatientdeath.

• Withinobstetricsmaternaldeathfromsepsishasrisenratherthandeclined.Itistheleadingdirectcauseofmaternaldeaththistriennium2006-2008(CEMD2011).Thediagnosisofsepsisisnotalwaysstraightforwardandduetothealteredphysiologythattakesplaceinpregnancyearlysignsmaybeobscured.

Clinicalsignsindicativeofsepsisconsistofoneormoreofthefollowing

• Pyrexia,hypothermiaorswingingpyrexia


• Tachycardia• Tachypnoea• Hypotension• Lowsaturationandhypoxia• Oliguria• Impairedconsciouslevel• Failuretorespondtoimplementedtreatment

Clinicalsymptomsassociatedwithsepsis(canbenon-specific)

• Diarrhoeaorvomiting• Cough• Rash• Abdominalpain• Rigor• Offensivedischarge• Urinarysymptoms

ManagementofsepsisAllwomensuspectedoridentifiedwithsepsisshouldbemanagedinitiallywithintheobstetrichighdependencyunit

• Bloodculturesshouldbeobtainedbeforeadministrationofantibioticshoweveritshouldnotpreventtimelyadministrationofantimicrobialtherapy

• Broadspectrumantibioticsshouldbeadministeredwithinonehourofsuspicionoridentificationofsepsis

• MeasureserumlactatealsosendbloodforCRP,FBC,LFT’sU&E’sandconsiderABG’s• Administerprescribedintravenousfluids• Inthepresenceofhypotensionand/oraserumlactate>4mmol/lcrystalloidsorequivalent

shouldbeadministeredat20ml/kg• Ifhypotensionhasnotrespondedtofluidresuscitationconsidervasopressorstomaintaina

meanarterialpressureof(MAP)>65mmHg• Ifhypotensionispersistentdespitefluidresuscitationand/orserumlactateis>4mmol/l

considercentralvenouspressuremonitoringtoachieveCVPof≥8mmHg• Aimtoachieveacentralvenousoxygensaturation(ScvO2)≥70%ormixedvenousoxygen

saturation(ScvO2)≥65%Furthermanagement

• AdministerO2therapyifsaturation<93%give15ltsviareservoirmask• Cultureareasthatmaybefocusofinfectioni.e.urine,LVS,HVS,wound,throat,

sputum,MRSAscreen• Discussallcaseswithmicrobiologist–thismustbedoneswiftlyincasesofpenicillin

allergy• Inserturinarycatheterandmonitorhourlyaimfor≥0.5ml/kg/hr• Consider12leadECG• Consideranyrelevantimagingtoconfirmsourceofinfection


• IfagroupAstreptococcalinfectionissuspectedorconfirmed,thewomanmustbeplacedinasideroomandcontactprecautionsshouldbeappliedforupto48hrsfollowingeffectiveantibiotictherapy.Theinfectioncontrolteammustbeinformed.

• Considerinsertionofarteriallineforaccuratehaemodynamicmonitoringandbloodsampling• Redpackedcellsmaybeconsideredwhenhaemoglobinfallsto<7.0g/dlaimforHbof7.0-

9.0g/dl

**THANKYOUFORTAKINGTIMETOREADTHISINDUCTIONINFORMATION.WEHOPEYOUWILLENJOYYOURTIMEWORKINGONLABOURWARDATSTMARY’S**

introduction to the labour ward at st mary's...

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