the queen elizabeth hospital king’s lynn nhs foundation ... · theatres and central delivery...

The Queen Elizabeth Hospital King’s Lynn NHS Foundation Trust Clinical Guideline for Anaesthesia for Caesarean Section

Clinical Guideline Anaesthesia for caesarean section Author/s: R Jones, A Surendran Author/s title: Specialty Doctor, Consultant Anaesthetist Approved by: Anaesthetic Clinical Governance Committee Date approved: 18/06/2017 Review date: 18/06/202 of 24

A Clinical Guideline For use in:

Theatres and Central Delivery Suite

By: Anaesthetists, Obstetricians, Midwives and Theatre Staff

For: Women who need caesarean delivery

Division responsible for document: Core Services

Key words: Anaesthesia, Caesarean section

Name of document author: R. Jones, A.Surendran

Job title of document author: Specialty Doctor, Consultant Anaesthetist

Name of document author’s Line Manager:

Sue Abdy

Job title of author’s Line Manager: Clinical Director, Theatre Services Group

Supported by: Anaesthetic Department

Assessed and approved by the: Clinical Guidelines Group

Date of approval: 18/06/2017

Ratified by or reported as approved to:

Anaesthetic Clinical Governance Committee, Obstetrics and Gynaecology Guidelines Group

To be reviewed before: This document remains current after this date but will be under review

18/06/2020

To be reviewed by: Lead Obstetric Anaesthetist

Reference: L33

Version No: V2

Description of changes: Entire guideline has been re-written with inclusion of charts

Compliance links: NICE, OAA, AAGBI

If Yes - does the guidance deviate from the recommendations of NICE? If so why?

Not applicable

This guideline has been approved by the Trust's Clinical Guidelines Group as an aid to the diagnosis and management of relevant patients and clinical circumstances. Not every patient or situation fits neatly into a standard guideline scenario and the guideline must be interpreted and applied in practice in the light of prevailing clinical circumstances, the diagnostic and treatment options available and the professional judgement, knowledge and expertise of relevant clinicians. It is advised that the rationale for any departure from relevant guidance should be documented in the patient's case notes. The Trust's guidelines are made publicly available as part of the collective endeavour to continuously improve the quality of healthcare through sharing medical experience and knowledge. The Trust accepts no responsibility for any misunderstanding or misapplication of this document.



Contents page

1. Definitions of terms used

2. Anaesthesia for Caesarean Section

3. Pre- operative assessment

4. Consent

5. Pre Medication

6. Choice of technique

7. Preparation for all types of anaesthesia

8. Single shot spinal anaesthesia

9. Epidural top up anaesthesia

10. Spinal anaesthesia following inadequate epidural analgesia

11. General anaesthesia

12. Post-delivery measures

13. Post-operative analgesia

14. Post-operative care

15. Complications

16. Foetal Distress

17. Birthing partner in theatre

18. References

19. Appendix 1 Flow chart - OAA/ DAS failed tracheal intubation

20. Appendix 2 Flow chart – Anaesthesia options for caesarean section

21. Appendix 3 Flow chart – Anaesthetic considerations

22. Appendix 4 Regime for post-operative analgesia

23. Appendix 5 Monitoring compliance

24. Appendix 6 Equality impact



1. Definitions of Terms Used

Anaesthesia is the loss of bodily feeling

Caesarean Section is a surgical incision into the uterus to deliver a baby.

2. Anaesthesia for Caesarean Section

The vast majority of Caesarean sections in the UK, both elective and emergency, are

performed under regional anaesthesia. General anaesthesia however is often indicated for

category one sections (i.e. when there is immediate threat to life of mother or foetus) and

when a regional technique is absolutely contra-indicated or has failed. Spinal anaesthesia

is often appropriate for urgent Caesarean section, although a previous Confidential

Enquiry into Stillbirths and Deaths in Infancy (CESDI) had deemed repeated attempts

inadvisable in the absence of significant risk factors for general anaesthesia.

All anaesthetic procedures and their follow-ups must be entered on the BadgerNet

electronic maternity records.

Classification of the urgency of Caesarean Sections:

Category Definition (at time of decision) Time standard from decision to delivery

1 Immediate threat to life of woman or foetus e.g.

Haemorrhage, cord prolapse, severe foetal

bradycardia

<30mins

2 Maternal or foetal compromise, not immediately life-

threatening, e.g. Breech contracting, obstructive

labour

Up to 75mins

3 Needing early delivery but no maternal or foetal

compromise e.g. Failure to progress Up to 24hrs

4 At a time to suit the woman and maternity team Elective

3. Pre-operative assessment

Even if the anaesthetist is presented with an unknown patient whose foetus is in extremis,

a focused assessment must not be omitted. Important points are:

Previous anaesthetics and family history of significant anaesthetic problems

Present and past medical history

Present and past obstetric history e.g.

o Pre-eclampsia

o Placental position in this pregnancy

o Past history of post-partum haemorrhage

Drug history and allergies.

REMEMBER TO ASK: HAS THE PATIENT HAD CLEXANE? TIME AND DOSE



Airway assessment

Starvation time and antacid prophylaxis. It is appropriate in category 1 and 2 sections to administer an anaesthetic even when the patient is not starved

Blood results as appropriate

o FBC o U & Es and Coagulation tests are indicated only if there is any suggestion of

pre-existing kidney disease, pre-existing clotting anomalies or PET.

o G & S / Fast issue / Cross match as appropriate

o Where clinically appropriate DO NOT DELAY CATEGORY 1 AND SOME

CATEGORY 2 SECTIONS waiting for the blood results, but do ensure that

samples have been sent

4. CONSENT

Women must receive an explanation of the proposed anaesthetic technique, its limitations

and the possible complications and side effects as deemed acceptable by any reasonable

person. It must include the possibility of regional anaesthesia proving inadequate and the

measures that will be taken to remedy the situation. Written consent is not essential,

although the risks/benefits that have been discussed and the fact that oral consent was

obtained should be documented. A patient with capacity has an absolute right to refuse to

consent to medical treatment for any reason (rational or irrational). This pertains even

though the consequence may be her own death or serious handicap of the child she bears

(please see Trust guidelines on Consent)

1. Consent for general anaesthesia should include:

Sore throat

Muscle pains

Awareness

Dental damage

2. Consent for regional technique should include:

Failure

Inadequate block requiring conversion to general anaesthetic

Sensations to be expected

Hypotension

Nausea and vomiting

Shivering

Itching

Post dural puncture headache

Nerve injury

3. For either technique discuss

Analgesic suppository if used

Post-operative analgesic plan



5. PRE-MEDICATION (see ‘L31 Antacid prophylaxis in Labour’ guideline)

Elective Caesarean Section Morning Cases

i. Ranitidine 150mg tablet orally at 2200 hrs the night before surgery

ii. Ranitidine 150mg tablet orally at 0700 hrs on the day of surgery

iii. 30mls of 0.3 Molar Sodium Citrate orally prior to start, confirmed as part of

the WHO checklist Afternoon Cases

iv. Treat as for morning cases with the addition of Ranitidine 150mg tablet

orally at 1200 hrs. (Total 3 doses)

Emergency Caesarean Section

Either

i. Ranitidine 50mg IM given at time of decision (takes 45mins to work)

unless Ranitidine 150mg orally has been given within the last 6 hours

Or

ii. Ranitidine 50mg IV diluted to 20mls with normal saline given over 5-

10mins (preferably with ECG monitoring)

And

iii. 30mls of 0.3 Molar Sodium Citrate orally just prior to entering

theatre/ start

iv. Metoclopramide 10mg IV is indicated if the patient had a meal

6. CHOICE OF ANAESTHETIC TECHNIQUE

The preferred technique, where not contraindicated, is spinal anaesthesia or epidural

extension where appropriate (see reference J: NICE Guideline 132). There are a number of

conditions where general anaesthesia may be preferred, these include:

Obstetric indications

Actual or anticipated major haemorrhage

o Severe fibroid uterus

o Placenta accreta, increta or percreta

o Grade 4 placenta praevia

Inverted uterus

Ruptured uterus

Cord prolapse

Pre-eclampsia with coagulopathy

Profound foetal distress

Non-Obstetric indications for general anaesthetic include:

Absolute:

Maternal refusal of regional anaesthesia

The need for rapid delivery of the baby e.g. severe foetal distress

Maternal coagulopathy (see guidelines for anti-coagulation and neuroaxial

blockade)

Severe uncorrected hypovolaemia



Local infection of the lower back

Raised intracranial pressure

Failed regional anaesthetic

Relative:

Maternal haemodynamic instability (e.g. severe valvular stenosis)

Sepsis; providing the mother is not cardiovascularly compromised a single shot

spinal may be acceptable)

Gross spinal deformity

HIV is NOT a contraindication for regional anaesthesia. BUT, use universal precautions;

consider eye protection and double gloving.

Always consult with the operating obstetrician regarding category and urgency, so a

mutually agreed plan can be formulated. IS THERE ENOUGH TIME TO PERFORM A REGIONAL BLOCK WITHOUT COMPROMISING MOTHER OR BABY? Seek senior help if you are in doubt You should remember that your prime duty is to the mother and it is not appropriate to take untoward and excessive risks with her life in an attempt to prevent harm to the foetus Always document the time anaesthetic services are requested but bear in mind this may differ from the decision to deliver time We should aim to deliver the baby within the specified time from decision, not request

7. PREPARATION for ALL types of Anaesthesia:

1) Ensure the anaesthetic machine and all equipment has been checked, including

suction and tilting function of operating table.

2) Secure adequate IV access;14G-16G cannula (2 x 16 or 14G cannulas in the event of

haemorrhage or anticipated haemorrhage)

3) Attach routine monitoring; BP, ECG and pulse oximetry

4) Complete the WHO checklist;

5) Ensure antacid prophylaxis has been given

6) Once IV access has been secured commence IV Hartmann’s infusion. IV antibiotics

should be given in line with Trust (and National guidelines); in our Trust, at the time of

writing, this is 1.5g Cefuroxime IV and 500mg Metronidazole IV. In the case of

confirmed penicillin allergy; both antibiotics should be replaced with Clindamycin

600mg IV. No additional antibiotics are needed for those women who require

antibiotic prophylaxis for cardiac problems.

A pregnant patient under any form of anaesthetic must be tilted to the left whilst supine

to avoid aorto-caval compression until the baby is delivered.



8. SINGLE SHOT SPINAL ANAESTHESIA

Spinal anaesthesia is the preferred technique, where not contraindicated. (Consider the

value of CSE in cases where surgery may be prolonged or where epidural analgesia is

considered for the post-operative period.)

A. Drugs:

Phenylephrine infusion prepared at a concentration of 50mcg/ml in a 60ml

syringe loaded in a syringe driver

1% Lidocaine for skin infiltration

0.5% Heavy Bupivacaine

Spinal opioid - diamorphine 300 micrograms.

B. Equipment:

Monitoring and machine prepared

Spinal pack

Conduct of the anaesthetic: 1) Follow steps for preparation 7 (above)

2) After IV access start phenylephrine infusion immediately at a rate of 20mls /hour. This

could be titrated depending on the haemodynamic response.

3) Position the patient either sitting or in the lateral (ideally left) position

4) Scrub and use full aseptic technique including wearing a facemask

5) Prepare the patients back with 0.5% chlorhexidine in alcohol and allow this to dry

6) Draw up an appropriate dose of local anaesthetic and opioid using filter needles

a. The amount of local anaesthetic required to produce a reliably adequate spinal

block is dependent on multiple factors; including patient factors, anaesthetist’s

technique and drug choice. If 0.5% heavy bupivacaine is used the required dose

normally lies between 10-14mg (2 – 2.8mL)

b. The chosen type and total dose of local anaesthetic and opioid used should be

one that the individual anaesthetist and/or supervising anaesthetist is familiar

with

c. Choice of opioid

i. Intrathecal diamorphine 0.3mg provides excellent post-op analgesia and

facilitates enhanced recovery process 7) Choose a suitable lumbar interspace, preferably L3/L4

8) Use a pencil point needle such as a 24/25G Sprotte needle

9) Once the intrathecal injection has been performed:

a. Spray the injection site with a plastic dressing (Opsite)

b. Immediately position the patient supine with 15 degrees left lateral tilt

10) For all obstetric cases NIBP should be set at 3 minutes interval

a. Any undue hypotension should be treated with titrated infusion of

phenylephrine

Faintness, dizziness, nausea and vomiting, tachycardia, sweating is almost always due to

hypotension, and early vasopressors may be considered, even before a blood pressure

reading has been obtained



b. Profound bradycardia due to vasovagal reflex or cardiac sympathetic blockade

should be promptly treated with either glycopyrrolate 300–600mcgmcg or

atropine 600mcg.

c. It may be necessary to increase left lateral tilt or in rare circumstances reverse tilt

to right lateral in order to prevent aortocaval compression

11) Consider administering oxygen by mask if there is foetal distress (see later guidance),

12) Whilst waiting for the anaesthetic to establish, urine catheterisation can be carried out

by the midwife or a suitably trained person.

13) Check both the upper and lower end of the block with both cold and light touch. This

should be clearly documented on the anaesthetic chart. Do not start surgery unless

there is:

a. A bilateral sensory block to T4 when tested with cold (ice pack or ethyl chloride

spray)

b. A bilateral sensory block to T5 when tested with light touch (piece of cloth or

paper tissue)

c. A bilateral sacral block (test lateral aspect of both feet S1)

14) When confident, clearly communicate with the surgeon and declare to the whole

team that “patient is ready for surgery”

At delivery, proceed to follow guidelines for post-delivery (page 7)



9. EPIDURAL TOP-UP ANAESTHESIA

If an epidural has been used for analgesia in labour and has been effective, it should be

topped up for surgery (time allowing). This is only reliably effective when the epidural has

been problem free, if not consider siting a spinal anaesthetic

A. Topping-up the epidural:

1) Follow steps for preparation

2) Check the block has been trouble free during labour

3) Assess the height of the block and ensure it is bilateral

4) Ensure IV access is still patent and adequate

5) Assess and consent the patient, remembering to warn of the possibility of discomfort

or pain and the possibility of conversion to general anaesthesia

6) Once you have commenced topping the epidural up DO NOT leave the patient and

monitor the blood pressure every 3 minutes

7) The CTG should be monitored throughout until surgery is about to start

8) 15° left lateral tilt (or wedge) should be maintained throughout the top-up procedure

9) Suggested top-up solution:

a. Mix 50 -100 micrograms fentanyl in 10mls of 0.5% Levobupivacaine. Bolus in 5ml

increments. This may be carried out in the delivery room during or prior to

transfer, provided the anaesthetist remains with the patient. Up on arrival to

theatre reassess the sensory and motor block. A further 10ml of 0.5%

levobupivicaine without fentanyl may be required. A total volume of up to 25ml

may be required to reach T4 block.

10) If, at any stage, you suspect subarachnoid block, stop injecting and re-assess. Or, if

after administering 20ml there is inadequate block consider all options available and

seek advice if appropriate

11) Treat hypotension as for spinal anaesthesia

12) If a high block is produced but the patient is conscious and breathing adequately give

supplemental oxygen by facemask

13) If a total spinal is produced DON’T PANIC. See total spinal guidelines.

14) If you get signs of local anaesthetic toxicity STOP INJECTING see local anaesthetic

toxicity guidelines

15) Ensure an adequate block has been achieved prior to commencing surgery

16) Treat intra-operative pain as for spinal anaesthesia (see complications)

17) Once the baby has been born follow the post-delivery guidelines (page 7)



10. SPINAL ANAESTHESIA FOLLOWING INADEQUATE EPIDURAL ANALGESIA

A spinal anaesthetic following epidural analgesia can result in an unpredictably high or

low block, with the possibility of a total spinal. Any mother having this procedure should

be warned of the need for general anaesthetic either due to inadequate block or high

block. The resulting spinal block is likely to be higher with a higher starting epidural block

and if a large volume of local anaesthetic has been injected down the epidural catheter i.e.

after a failed epidural extension, just prior to performing the spinal. Removing or leaving

the catheter in situ for a spinal is a personal preference. It can be useful to extend spinal

block but this should be attempted only if comfortable to do so. Smaller doses of local

anaesthetic have been recommended to avoid producing a total spinal.

A. Performing the spinal:

1) Perform steps for preparation

2) Check the existing block height

3) Check the drip is patent and adequate

4) Position the patient either in the lateral or sitting position. If the patient has a

significant block then the sitting position is inappropriate

5) Carefully remove the epidural catheter dressing, leaving the catheter in place and

disinfect the back with 0.5% chlorhexidine in alcohol, allowing it to dry

6) Choose a suitable local anaesthetic agent and opioid (see spinal anaesthetic),

approximately two thirds of your normal dose is recommended. Do not exceed 2ml

and inject the fluid very slowly

7) Perform the spinal as per spinal anaesthetic protocol

8) Re-secure the epidural catheter and commence monitoring the blood pressure every 1-

2 minutes

9) Maintain continuous verbal contact with the patient and assess the extent of the block

10) Treat hypotension as per spinal anaesthetic protocol

11) If an excessively high block is produced but the patient is still conscious and breathing

adequately reassure the patient, give supplemental oxygen by face mask and

frequently monitor the block height

12) If a total spinal is produced DON’T PANIC. See total spinal guidelines

13) Allow surgery to commence when the block is adequate and proceed as for spinal

anaesthesia for LSCS.



11. GENERAL ANAESTHESIA

All women undergoing general anaesthesia must be considered for RSI until 14 days post-partum

Drugs:

Emergency drugs are immediately available, and checked on a daily basis by the ODA/P

covering obstetric theatres. These comprise of:

Propofol (minimum 200mg)

Suxamethonium 100mg x 2

Atropine 600mcg

Atracurium 50mg OR Rocuronium 50mg

Phenylephrine infusion (as above)

These are kept locked in the fridge in the obstetric theatre. It is ultimately the

anaesthetist’s responsibility to check these are available. If the anaesthetist has a

preference to use specific induction agents, this should be his or her responsibility to check

and ensure their immediate availability.

Equipment:

The Obstetric theatre is stocked with all the usual equipment needed for general and

regional anaesthesia with additional equipment for difficult intubation and major

haemorrhage. All anaesthetists should be familiar with the equipment that is normally

available and check it is present

Additional airway equipment on the Obstetric difficult intubation trolley includes:

Short handled laryngoscope

Polio blade laryngoscope

McCoy laryngoscope

Laryngeal mask airways including intubating laryngeal masks and proseal

laryngeal masks

ETT down to size 6

High flow ‘THRIVE’ oxygen and a free-standing glidescope are available in the CDS theatre

Oxford ‘HELP’ pillow which is kept in Room J (obstetric recovery room)

Conduct of the anaesthetic:

Follow steps for preparation

The patient should have been catheterised and prepped prior to induction and the

surgeon should be scrubbed and ready to commence

Pre-oxygenate the patient by attaching the ‘THRIVE’ high flow nasal oxygen as soon

as the patient has entered theatre

Have suction ready and switched on

All patients with a BMI over 40 should be positioned with a slight head up tilt or

ramp position with the use of Oxford pillow

Large breasts can interfere with laryngoscopy. Ensure a person is free to push the

breasts down in case of difficult with laryngoscopy.

Induce the patient with a rapid sequence induction. Consider use of cricoid pressure

performed by a trained ODP. Be aware that cricoid pressure can make laryngoscopy

more difficult. If difficult intubation is encountered, prepare to fully release the

cricoid.



o Propofol 1.5-2.5mg/kg (use an appropriately small dose if haemorrhage has

occurred). Other agents are available in main theatres in extreme

circumstances

o Suxamethonium 1-1.5mg/kg or RSI dose (1.0-1.2mg/kg) of Rocuronium

o 1mg of Alfentanil or 100mcg of Fentanyl is recommended to obtund the

vasopressor response to intubation and possibly skin incision for all GA

caesarean sections. Alert the neonatal team of the neonatal effect.

Confirm correct tube placement by ensuring capnograph trace is present and

listening to the chest prior to release of cricoid pressure

The risk of failed intubation in the obstetric patient has been reported as 1:200, eight times that of the general population. It is therefore important if general anaesthesia is to be undertaken that a proper airway assessment is done, even in

the emergency situation Remember patients do not die from failure to intubate. They do die from

prolonged attempts to intubate in the face of hypoxia and from unrecognised oesophageal intubation

“IF IN DOUBT, TAKE IT OUT”

In the event of a failed intubation resort to the failed intubation drill (see OAA/

DAS guidelines 2015 - appendix)

In preference use Sevoflurane in 50% Oxygen and 50% Nitrous oxide, unless higher

oxygen concentrations are required clinically. Alternatively, Desflurane may be used

as volatile anaesthetic vapour. The inhalation agent should be over pressured

initially and good communication maintained with surgeon to ensure surgery

commences once MAC >1 has been achieved

Be aware that obstetric general anaesthesia is a risk factor for accidental

awareness during anaesthesia due to the increased incidence of obesity and

protracted airway management and high rates of emergency surgery.

Ventilate with an appropriate minute volume to maintain an end tidal CO2

between 4.0 to 5.0 kPa

Prolonged neuro muscular blockade is less desirable to facilitate rapid recovery

after surgery. But if necessary paralysis can be maintained with aliquots of non-

depolarising muscle relaxant e.g. 10mg boluses of Atracurium or Rocuronium

If the blood pressure falls consider:

Speeding up the maintenance fluid infusion

Titrating increments of a vasoconstrictor

Increasing lateral tilt, or in some circumstances reverse it

Using fluid or blood as appropriate

New guidelines suggest opioids should be given at induction. Communication of

opioid use should be made with the neonatal team

Follow post-delivery guidance

Oxytocin infusion is recommended in ALL patients undergoing general anaesthetic

A nerve stimulator should be used to assess neuromuscular blockade. Reverse as

appropriate using; intravenous Neostigmine 2.5mg with Glycopyrrolate 0.5mg.

Sugammadex should only be considered for exceptional circumstances eg. Morbid

obesity, difficult intubation. Reversing dose of intravenous Sugammadex after an

intubating dose of Rocuronium is 2-4mg/kg



12. POST DELIVERY MEASURES

1) Once the baby has been born (in line with new delayed cord clamping protocol):

a. Administer Oxytocin 5 IU (Syntocinon) usually given as a slow intravenous bolus.

Side effects, as for other utero-tonic drugs, may include nausea and

hypotension, which should be treated as described

b. Commence an oxytocin infusion (20 IU of oxytocin made up to 20mls with

normal saline) at a rate of 10mls/hour over two hours if indicated (usually

agreed with the surgeon)

c. The lateral tilt should be removed

2) Intravenous Ondansetron 4 should be given in theatre to all mothers receiving

parenteral opioids

3) Diclofenac 100mg PR if consent from the mother has been obtained. Intravenous

Diclofenac 7mg is a suitable alternative. Contra-indications include:

Intolerance to NSAID e.g. some asthmatics and patients with PMHx of a GI

bleed

Allergy to NSAID

Significant PET

Coagulopathies

Significant haemorrhage

Renal impairment 13. POST-OPERATIVE ANALGESIA

1) Prescribe an appropriate analgesic regimen e.g.

a. Oral morphine 20mg given 2 – 4 hourly PRN (buprenorphine 200-400mcg every 6 hours

if morphine intolerant)

b. Paracetamol 1g QDS PO regularly

c. Ibuprofen 400mg 6 hourly regularly (if no contra indications)

2) With epidural in situ administer 3mg diamorphine via epidural, flushed with 2mls of

Normal Saline

3) TAP block can be performed under ultrasound guidance with 40ml of 0.25% L-

bupivacaine immediately after the surgery, prior to extubation. An equally effective

alternative would be direct rectus sheath infiltration of the same amount of local

anaesthetic under direct vision by the surgeon at the time of wound closure. They can

reduce opiate requirements postoperatively.

4) During general anaesthetic, administer 10mg morphine IV intra-operatively and

commence IV PCA in recovery (1mg/ml) with 1mg bolus and a lockout time of 3

minutes. It is the responsibility of the anaesthetist to ensure that the PCA is set up

correctly. The PCA connector should go directly to the cannula and there should be no

three-way tap downstream of the bifurcation point. Fluids must run constantly to

maintain PCA line patency. Where syntocinon is running, a three way tap may be added

at the insertion point of the fluid line to PCA connector and run from there. However,

an additional cannula is equally advised where possible.



5) Prescribe an anti-emetic e.g. Cyclizine 50mg 8hrly PRN for PONV

6) Central opioid induced itching: Chlorpheniramine 4 mg orally 4-6 hourly for itch

Limit intravenous fluids to 1 litre if suitable for enhanced recovery pathway.

Ensure that appropriate thromboprophylaxis risk assessment is entered on the

BadgerNet and appropriate dose is prescribed

14. POST-OPERATIVE GUIDELINES (see Trust guidelines FOR OBSTETRIC RECOVERY AND ENHANCED RECOVERY IN OBSTETRICS)

Ensure safe transfer of patient to recovery and ensure accurate handover to recovery staff.

Please ensure documentation is complete with the minimum information required being:

Urgency (category of the section)

Timings of the procedure; knife to skin, delivery of the baby

Blood loss

Routine observations and drugs administered

All epidural and spinal interventions should be documented on a

epidural/spinal chart including doses of opiates used Indications for post-delivery Syntocinon infusion:

This should be started routinely in the following circumstances:

a. Over-distended uterus

Multiple pregnancy

Large baby

Polyhydramnios

b. Bleeding tendency

Past history of PPH

Antepartum haemorrhage in this pregnancy

Anticoagulant/antithrombotic therapy or Coagulopathy

Placenta praevia

Fibroid uterus

High BMI

c. Abnormal contractility

Prolonged and/or obstructed labour

Use of Syntocinon infusion during labour

Failure of the uterus to contract adequately

Pre-eclampsia

Pyrexia

15. COMPLICATIONS

Insufficient block following epidural top-up:

If 20mls of solution do not achieve a block approaching T4 then it is unlikely that further

increments will help. Under these circumstances carefully consider other options with the

obstetrician and patient. Take into account the CTG. If you are unsure seek senior advice.



Available options are:

a. Insert a spinal anaesthetic (see guidelines for spinal anaesthetic following

epidural analgesia or failed epidural anaesthesia)

b. Providing the patient is showing no signs of toxicity and the block is progressing

satisfactorily, the use of a further 5-10mls of 0.5% levobupivacaine is permitted.

Do not exceed the safe maximum dose of bupivacaine of 2mg/kg

c. Conversion to general anaesthetic

Pain during regional anaesthetic

Pain during LSCS under regional block has replaced awareness during general anaesthesia

as the main reason for litigation associated with this procedure. The patient who feels pain

during the operation is not necessarily the victim of negligence, however, to have a good

defence your documentation must demonstrate you took reasonable steps to minimise the

chance of pain and treated it promptly and effectively when it arose

a. Mothers should always be warned of the possibility of intra-operative pain or

discomfort and, in the event that this cannot be relieved, the need for

conversion to general anaesthesia

b. The complaint of pain or discomfort should be taken seriously, dealt with

promptly and documented

c. Reassure the mother and her partner

d. Assess the degree of pain / discomfort, bearing in mind the stage of the

procedure

e. If the discomfort is deemed severe or the mother indicates she is not happy to

remain awake then offer a general anaesthetic in the first instance

f. Consider temporarily stopping the surgery until treatment has been given. This

will not be possible if the uterus has been incised but the baby not yet delivered

and in cases of severe foetal distress and maternal haemorrhage

g. If the Mother is happy to stay awake the following treatment options can be

tried as appropriate:

i. A 50:50 mixture of nitrous oxide and oxygen given through the

anaesthetic machine

ii. Fentanyl 25 microgram increments IV

iii. Alfentanil 250 microgram increments IV

iv. Ketamine 10-20mg IV

v. Midazolam 2mg IV

vi. Local anaesthetic infiltration of the wound. This is usually only

appropriate if the procedure is nearing completion

h. If intravenous opioids or benzodiazepenes are given before the baby is

delivered then you must inform the paediatrician

i. Document accurately:

The time the patient complained of pain

How severe the discomfort was

Whether a GA was offered

What treatment options where used to remedy the situation

Whether this was satisfactory

j. Provide follow-up and support (referral to clinical psychologist, or obstetric

anaesthetic clinic) to the patient who felt pain during the operation



16. FETAL DISTRESS

If a decision has been made to deliver the baby via Caesarean section with evidence on the

CTG that there is foetal distress there are a few steps that should be taken to help

physiological stresses on both mother and baby. These include:

1) Alteration of maternal position – left lateral position

2) Maternal oxygenation – 10-15L/min of oxygen via face mask or nasal high-flow

oxygen

3) Correction of hypotension

4) Fluid resuscitation – 1L of Hartmann’s

5) Tocolysis – turn off syntocinon, consider terbutaline 250mcg SC or a GTN spray.

Acute tocolysis during Caesarean section may also be required when surgeon

experiences extreme difficulty to extract the baby or if the uterus goes in to

hypertonic contraction during caesarean section. GTN is available in the

obstetric theatre as a Sublingual spray. Usual recommended dose for

sublingual route is 200-400mcg, which can be repeated after 5 minutes.

17. BIRTHING PARTNER IN THEATRE

The mother is entitled to be accompanied by a birthing partner in theatre throughout the

procedure when regional anaesthesia is used. They should be briefed on what to expect

inside an operating theatre. The birthing partner must be clearly instructed that they may

only be allowed to watch the birth of the baby on discretion of the surgeon and the

anaesthetist. They may be asked to leave if any member of theatre team feels they pose a

risk to clinical performance or patient safety.



18. REFERENCES

1. Analgesia, Anaesthesia and Pregnancy A Practical Guide, chapter 36; S. M. Yentis, D.

Brighouse, A. May, D. Bogod, C. Elton.

2. Information and consent for anaesthesia. AAGBI; London 1999

3. MBRRACE 2016

4. Comparison of intrathecal fentanyl and diamorphine in addition to bupivacaine for

Caesarean section under spinal anaesthesia. Cown C.M, Kendall J.B, Wilkes R.G. BJA 2002;

89: 452-8.

5. Comparison of plain and alkalinised local anaesthetic mixtures of lignocaine and

bupivacaine for elective extradural Caesarean section. Fernando R, Jones H.M.BJA 1991; 67:

699-703.

6. Side effects of intrathecal and epidural opioids. Can J Anaesth 1995; 42: 891-903.

7. Levels of anaesthesia and intraoperative pain at Caesarean section under regional block.

Russell I.F. IJOA 1995; 4: 71-7.

8. Chemical stability of bupivacaine, lidocaine and epinephrine in pH adjusted solutions.

Robinson J, Fernando R, Sun Wai Y.W, Reynolds F. Anaesthesia 2000; 55: 835-8

9. Urgency of Caesarean section: anew classification. Lucas D.N, Yentis S.M, Kinsella S.M. et al.

J R Soc Med 2000; 93: 346-50

10. NICE clinical guideline 132: Caesarean Section, /issued November 2011. Last modified August

2012

11. NAP4 Major complications of airway management in the United Kingdom March 2011

12. NAP5 Accidental Awareness during General Anaesthesia in the United Kingdom and Ireland

September 2014

13. Sugammadex reversal of rocuronium-induced neuromuscular block in Caesarean section

patients: a series of seven cases F. K. Pühringer, P. Kristen, C. Rex; BJA: British Journal of

Anaesthesia, Volume 105, Issue 5, 1 November 2010; 657–660,

14. AAGBI guideline: The Anaesthetic Team; Section 6; Recovery Post-Anaesthetic Care Unit.

15. ‘Reproduced from Mushambi MC , Kinsella SM, Popat M, Swales H, Ramaswamy KK, Winton

AL, Quinn AC. Obstetric Anaesthetists' Association and Difficult Airway Society guidelines

for the management of difficult and failed tracheal intubation in obstetrics. Anaesthesia

2015; 70: 1286 – 1306, with permission from Obstetric Anaesthetists’ Association / Difficult

Airway Society’



16. Appendix 1

Fail

Fail

*See Table 1, §See Table 2

© Obstetric Anaesthetists’ Association / Diffic

u

l t Airway Society (2015)

Master algorithm – obstetric general anaesthesia and failed tracheal intubation

Verify successful tracheal intubation

and proceed

Plan extubation

Pre-induction planning and preparation

Team discussion

Algorithm 1

Safe obstetric

general anaesthesia

Algorithm 2

Obstetric failed

tracheal intubation

Algorithm 3

Can’t intubate,

can’t oxygenate

Rapid sequence induction

Consider facemask ventilation (Pmax

20 cmH2O)

Laryngoscopy

(maximum 2 intubation attempts; 3rd intubation

attempt only by experienced colleague)

Declare failed intubation

Call for help

Maintain oxygenation

Supraglottic airway device (maximum 2 attempts) or facemask

Declare CICO

Give 100% oxygen

Exclude laryngospasm – ensure

neuromuscular blockade

Front-of-neck access

Success

Success

Wake§ Proceed with surgery§

Is it essential / safe

to proceed with surgery

immediately?*

YesNo

Full guidelines can be found at: http://www.oaa-anaes.ac.uk/ui/content/content.aspx?id=3447

http://www.oaa-anaes.ac.uk/ui/content/content.aspx?id=3447



17. Appendix 2

Gen

eralAna

esthe&

c(GA)

Obstetric

•

• • •

• • • • • Non

-obstetric

• • • • • • • • • •

Combine

dSpinalEpidural(C

SE)

New

procedu

re

Exis4ng

epidu

ralcathe

ter

Spinal not

not

NEV

ER

Epiduraltop

-up

MUST

twothirds



18. Appendix 3

ObstetricAnaesthesiaforCaesareanSec

on

Prepara

onforan

aesthesia:

• Fullpre-assessm

ent,checkantacidstaken,consent

form

,bloodstatus

• Machineandequipmen

tcheck

• Monitoring

• IVaccess,runHartm

ann’s,

preparephen

ylep

hrine

• IVan

bio

cs

Post-delivery:

• Slowbolus5IUsyntocinon

• Syntocinoninfusionifindicated

(ALLGA’s)

• Correct

lt

• Diclofenac100

mgPR

ifconsentedandnocontra-

indica

on

• Prescribethromboprophylaxis

• Documen

tbloodloss

• Oramoprh15-25

mg2-4hrly

• Paracetamol1gPO

QDS

• Diclofenac50m

gTD

SPO

•

+/-Ep

iduralbolusdiamorphine3m

g,2mlflu

sh

• PC

AforGA’s1mgbolus,3minlockout

• An

-eme

cse.g.cyclizine50

mgTD

S•

Fluids80

ml/hrun

lE&D

RegionalAnaesthesia(recommen

ded

):

• Spinal–si

ngorle

lateral

• Asep

ctechnique(0.5%chrlohexidinetoskin)

• 1%

lignocaineforskin

• 2-2.8m

l0.5%heavybupivicainewith0.3mgdiamorphineat

L3/4

• Commen

cephen

ylep

hrine

• Supinewithle

lateral

lt

• Ep

iduraltop-up–supinewithle

lateral

lt

• ONLYifperfectlyhap

pywithepidural

• 10

ml0.5%levobupivicainewith50microgram

fen

tanylin5m

l

boluses,m

onitorBPandpa

ent

• Further10m

lof0.5%

levobupivicaineonly

• Assessblock*further5-10m

l0.5%levoifdesperatelyneeded

•

STOPifhighblockortotalspinal–converttoGA

• Adeq

uateblock=T4;ensuresacralblockpresent

• Catheterwillberequired

•

Documen

tonspinal/ep

iduralchart

• Ifunsa

sfactoryblockatanypointofferGAorconvert;consider

rescuedosesofopioid(inform

neo

natesifgiven

priortodelivery)

• 2/3doses(<2m

l)inspinala

erepidural–leavingep

iduralcatheter

ispersonalpreference–injectslowlyashighriskforhighspinal!

Gen

eralAnaesthesia(GA):

• Warnm

otherofriskofaw

aren

ess1:60

0•

HiFlownasaloxygenim

med

iatelya

erarrivingintheatre

• Pe

rform

RSI

• Propofol(minim

um200mg,cau

oninhaemorrhage)

• Opiate;alfen

tanil1m

gorfentanyl100

mcg(inform

neo

nates)

• SuxamethoniumorRSIdoserocuronium

• Onlyallowsurgeo

ntostartwhen

MAC>1andcap

nography

confirm

ed(DASguidelinesifdifficultairway)

• En

sureEtCO2agen

torMACalarm

isON

• Sevofluranewith50%

nitrousoxide,oxygen50%

•

Aim

EtCO24kPa

• Maintainparalysis

• Titratevasopressorsasrequired

•

Iniateoxytocininfusiona

erbolusinALLcases

• IVm

orphine10

mgintra-opera

velya

erdelivery

• Nerves

mulatortodetermineneu

romuscularblockade–

reverseaccordingly

Foetaldistress:

1. Le

latpo

sion

2.

Oxygen

3. 1Lfluid

4. To

colysis(terbu

taline/

GTN

,syntooff)

5.

Correcthypoten

sion



19. Appendix 4

Post-operative analgesia regime for all caesarean sections

DRUG Dosage Maximum dose

in 24 hours

Caution

REGULAR

1. PARACETAMOL 1gm 6 hourly orally /

IV 4g

Liver impairment , caution in

severe pre-eclampsia – check

liver function tests

2. IBUPROFEN

400mg 6 hourly

2400mg

Check if patient received rectal suppository intra-operatively

prior to first dose.

AVOID

in severe pre-eclampsia, renal

impairment

(creatinine >70mmol/L), haemorrhage > 2000ml,

platelet count <75,

history of gastric intolerance,

severe asthma

CAUTION – previous history of

heart disease, morbid obesity

LACTATING MOTHERS MUST AVOID TRAMADOL or CODEINE PREPARATIONS

AS REQUIRED

3. ORAMORPH

(first choice for all cases performed

under regional anaesthesia)

OR

MORPHINE PCA

(preferably for all GA sections)

20mg 4 hourly

1mg bolus at

3minute lockout

120mg

60mg

Hourly MEOWS must be

carried out on all patients

receiving parenteral opioids

INTOLERANCE TO MORPHINE

4. BUPRENORPHINE 200mcg 6 hourly

as sublingual tablet

- as required

1200mcg Consult with on-call

anaesthetist.

Can be allowed to take home

if intolerant to NSAIDs

Limit use to maximum of 5

days

FOR ONGOING PAIN ISSUES CONTACT ON-CALL ANAESTHETIST ON BLEEP 1079

Management of common side effects:

NAUSEA and VOMITING

Intra-operatively all patients must receive a single intravenous dose of ONDANSETRON 4mg

As required PROCHLORPERAZINE 12.5mg IM and CYCLIZINE 50mg IM

PRURITUS

CHLORPHENIRAMINE 4mg orally or 10mg IM injection



20. Appendix 5

MONITORING COMPLIANCE

Key elements Process for Monitoring

By Whom (Individual / group /committee)

Responsible Governance Committee /dept

Frequency of monitoring

Safe outcome for mum

and baby

Review of clinical

incidents

Anaesthetic

department

and O&G

clinical

governance

group

Anaesthetic

governance

group. O+G

group

All cases

Patient satisfaction Anaesthetists follow up

all women after

procedure

Anaesthetic

department

Anaesthetic

governance

All cases

GA caesarean section

rates

Annual review of audit

data from BadgerNet

Lead Obstetric

Anaesthetist

Anaesthetic

governance

Annually



Appendix 6 EQUALITY IMPACT ASSESSMENT

STAGE 1 - SCREENING Name & Job Title of Assessor:

Date of Initial Screening: Date of Review:

Policy or Function to be assessed:

Yes/No Comments

1. Does the policy, function, service or project affect one group more or less favourably than another on the basis of:

Race & Ethnic background No

Gender including transgender Yes Female patients only

Disability:- This will include consideration in terms of impact to persons with learning disabilities, autism or on individuals who may have a cognitive impairment or lack capacity to make decisions about their care

No

Religion or belief No

Sexual orientation No

Age Yes Child bearing age

2. Does the public have a perception/concern regarding the potential for discrimination?

No

If the answer to any of the questions above is yes, please complete a full Stage 2 Equality Impact Assessment. Signature of Assessor: Date: Signature of Line Manager: Date:



STAGE 2 – EQUALITY IMPACT ASSESSMENT If you have indicated that there is a negative impact on any group in part one please complete the following, is that impact:

Yes/No Comments

1. Legal/Lawful under current equality legislation?

Yes

2. Can the negative impact be avoided? N/A

3. Are there alternatives to achieving the policy/guidance without the impact?

N/A

4. Have you consulted with relevant stakeholders of potentially affected groups?

N/A

5. Is action required to address the issues?

No

It is essential that this Assessment is discussed by your management team and remains

readily available for inspection. A copy including completed action plan, if appropriate,

should also be forwarded to the Equality & Diversity Lead, c/o Human Resources

Department.

the queen elizabeth hospital king’s lynn nhs foundation ... · theatres and central delivery...

Documents