The collapsed parturient

This chapter covers a wide spectrum of causes for collapse on the labour ward or in the emergency department, for the first steps in management. The latest guidance on the management of cardiac arrest which the obstetric anaesthetist will be required to immediately attend and initiate in a pregnant woman is described in detail, with the steps needed to progress to perimortem caesarean delivery if resuscitation is not immediately effective. The serious complications of regional anaesthesia; high blocks, total spinals, and local anaesthesia toxicity are emphasized. Anaphylaxis, magnesium toxicity, and management of trauma in the obstetric patient are also outlined.

Thinking about obstetric anaesthesia

The labour ward can be a stressful and demanding experience for all anaesthetists, junior and senior alike. Therefore, starting to working on a labour ward presents a number of new challenges to the novice obstetric anaesthetist, in an environment which many may not have spent any time visiting or working within since medical school. A helpful A–Z of survival is set out, where although no point is more important than the other, it is a useful tool to guide you through your first weeks or months. The chapter also offers resources to help with non-English speaking mothers and suggested advice of how to deal with difficult situations or behaviour. The principles of conducting audit, research and quality improvement work, which are an integral part of improving service delivery and facilitating efficient management of a high quality service, are also described.

Anaesthesia for Caesarean section: General anaesthesia

There will always be the need to give GA to pregnant womrn, and it is paramount that the obstetric anaesthetist is well prepared to perform a GA quickly and safely. This chapter reviews the current evidence, drugs, and conduct of GA for CS, with emphasis on exemplary communication within the delivery suite team and meticulous airway assessment to identify features suggestive of additional anticipated difficulty. A helpful ‘pre-induction’ checklist illustrates the need for team-based communication in preparation and planning to mitigate against complications following induction. The latest guidelines from the Obstetric Anaesthetists' Association and Difficult Airway Society on the management of failed intubation and ventilation have been included. The chapter also includes up-to-date information on accidental awareness in obstetric surgery from NAP4, and the steps to avoid and manage aspiration if it occurs.

A–Z of conditions in obstetric anaesthesia

The final chapter is a comprehensive A–Z index of less familiar medical conditions, which may present to the obstetric anaesthetist during any busy day or night shift. The conditions described are a compilation of referenced case reports or case series from peer-reviewed publications in recent years. The information provided should instantly guide the reader to the known characteristics of the condition, and the key points to consider in the antenatal, peripartum and anaesthetic management planning.

The fetus

An understanding of the assessment of fetal well-being in labour and basic interpretation of the cardio-tocograph is important for any obstetric anaesthetist, in order to anticipate transfer to theatre for operative delivery as early as possible. Illustrated normal and abnormal CTG patterns, fetal ST analysis, fetal scalp capillary sampling, and interpretation of umbilical cord blood gases are discussed in detail. Methods of assessment of fetal well-being during pregnancy are discussed: ultrasound biometry, amniotic fluid volume, and umbilical artery Doppler, followed by the management of intra-uterine growth restriction. Finally, the effects of analgesia in labour, regional and general anaesthesia, and other drugs e.g. magnesium sulphate and terbutaline on the fetus are reviewed.

The sick and septic mother

Sepsis is a leading overall cause of direct and indirect maternal death in the UK. Successive recent confidential enquires have highlighted the importance of early recognition of sepsis markers, prompt initiation of treatment, and continuing monitoring to recognize further deterioration. The obstetric anaesthetist is key in leading the team in the management of any sick pregnant woman who presents to labour ward or the emergency department. This chapter includes sections on the assessment and identification of the septic mother, with a list of sepsis ‘red flag’ symptoms and signs, where immediate escalation in treatment is required. The sources and causes of sepsis are described. Management of sepsis on labour ward and transfer, if necessary, of the critically ill mother and management within critical care facilities are explained.

Anaesthesia and analgesia for specific obstetric indications

Specific obstetric conditions and complications require careful consideration by the obstetric anaesthetist before embarking on the required analgesia and anaesthesia management plan. This chapter covers the breadth of obstetric problems which may present on any labour ward, with their definition, the key issues to consider, and a proposed management plan. The following indications are covered in each sub-section; feticide, intrauterine death, abnormal presentation, multiple pregnancies, vaginal delivery after CS, preterm fetus, placenta previa and accreta, controlled rupture of membranes, fetal distress, cord prolapse, placental abruption, instrumental delivery, uterine inversion, EXIT (ex utero intrapartum treatment) procedure, retained placenta, and perineal suturing.

Peri-operative management of caesarean section for the occasional obstetric anaesthetist – an aide memoire

Anaesthesia practice for caesarean section (CS) has evolved in the past 20 years. This article aims to update occasional obstetric anaesthesiologists, obstetricians and clinicians involved in the management of pregnant women on the latest guidelines and recommendations for anaesthesia management, including pre-operative evaluation, informed consent, intra-operative and postoperative management for CS. In addition, this article will also summarise the management of CS associated emergencies such as difficult intubation, obstetric major postpartum haemorrhage, local anaesthetic toxicity and (pre-) eclampsia. At the end of the article, a charted summary will be provided as an aide memoire.