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These guidelines have been prepared by the consultant anaesthetists in CUH. Please familiarise yourself with them before you commence practice in CUMH, start your module or go on-call.
Founded : 2014
Thrombo-embolismis forty times more common in pregnant patients than in comparable age-matched controls.
LMWH and Patients in labour;
The principal concern for anaesthetists is the very rare incidence of vertebral canal haematoma.
A history of venous thrombosis or anti-phospholipid syndrome (may be suspected from a history of recurrent miscarriages) are indications for ante-natal prophylaxis with low-molecular weight heparin (LMWH) (Innohep in CUMH). Patients on LMWH should be advised that when labour starts they should not take another dose until regional anaesthesia has been established.
If patients require LMWH during labour, leave a gap of at least two hours after the insertion of the epidural catheter before the Innohep can be administered. If the epidural was difficult or a venous cannulation occurred these should be discussed with your consultant +/- haematologist on-call.
The catheter should be removed at least 10 hours after the most recent dose.
Some patients (e.g. prosthetic heart valve, multiple PEs etc.) require a much higher dose of Innohep. This is known as the therapeutic dose. These patients (as opposed to a prophylactic dose patients) require a 24 hours interval between the most recent Innohepdose and the institution of neur-axial anaesthesia. Beware that LMWH action is prolonged in pregnancy and renal failure. Discuss all such patients with your consultant +/- haematologist on-call. Anti Xa levels should be discussed in advance of sending samples to the lab.
Persistent weakness of the legs of any such patient receiving LMWH and a regional block should be treated with the utmost importance. Always ask your consultant for help if doubt exists regarding the resolution of any RA in LMWH patients.
Table 1: Major risk factors for VTE/PE in pregnancy (data obtained from various pregnancy related studies)
Age >35 1.4-1.7
Obesity (BMI >30) 1.7-5.3
Active medical illness 2.1-8.7
Family history VTE 2.9-4.1
Varicose Veins 2.4
Multiparity (>2) 1.6-2.9
Multiple pregnancy 1.6-4.2
Assisted reproduction technology 2.6-4.3
Additional Ante/Post Partum risk factors
Planned caesarean delivery 1.3-2.7
Emergency caesarean delivery 2.7-4.0
Placental abruption 2.5-16.6
Postpartum infection 4.1-20.2
Postpartum haemorrhage 1.3-12.0
Currently signed consent is not required for regional anaesthesia in labour in CUMH or specifically for C section. We are in the process of developing information hand-outs. In the meantime, you should explain the intended procedure clearly and briefly, outlining the following points to patients requesting an epidural
Consent for Epidural:
You must explain;
-Post-dural puncture headaches, incidence approx 1%
-80% chance of requiring a blood-patch ('another epidural') if headache occurs
-Potential for failure of epidural to achieve adequate analgesia (5%)
-5% of epidurals may need to be re-sited
You should consider explaining:
-Confinement to bed
-Urinary catheter is required
-Blood pressure needs to be monitored
You do not need to explain (unless asked):
-Long term backache
-Transient parasthesia (temporary neuropathy occurs in 1:2000 cases irrespective of epidural status).
-Vertebral canal haematoma, abscesses or cauda equine syndrome (exceedingly rare approx. (> 1:200,000 for each complication)
Anesthesiology 2004; 101:950–9
Consent for C-section:
You must explain
-Hypotension & nausea
-Likelihood of some sensation during the procedure (approx 30%)
-Possibility of pain during the procedure (approx 10%)
-Occasional need for general anaesthesia (approx 1% of elective patients)
-Rectal administration of simple analgesics
-Possible post-dural puncture headache (approx 1%)
You should consider explaining;
-Pruritus caused by neur-axial opioids
You do not need to explain:
-Long term backache
-Transient parasthesias (temporary neuropathy occurs in 1:2000 cases irrespective of epidural status)
-Vetebral canal haematoma, abscesses or scauda equine syndrome (exceedingly rare (each > 1:200,000)
Trainee scheduled for the CUMH theatre;
Start time; 08:15, finish time ; circa 17:00
Aim to have the first patient on the table for 08:30 hrs.
Check the anaesthetic machines, airways and suction devices
Draw up fresh resus drugs as appropriate.
Ensure appropriate infusions and oxytocics are available.
Write your name and number on the whiteboard in theatre to assist with daily communication. Identify your anaesthetic nurse and introduce yourself.
Each obstetric theatre should be prepared in the same fashion.
3 syringes ephedrine 3mgs/ml
3 syringes phenylephrine 100 ug / ml
3 1 litre bags of Hartmann's including oxytocin 40 i.u. / litre
2 syringes of oxytocin 1 unit / ml
Anti - emetics available
Thiopentone 20 cc syringe 25 mgs / ml
2 syringes of Suxamethonium 100 mg / 2 cc syringe
Selection of ETTs 6.0/7.0 cuffs checked
LMA # 3 and #4 available
Laryngoscopes Mac 3 & 4,
Mc Coy and stubby all checked and available.
Difficult airway cart (including sterile fibre-optic scope) available in CUMH theatre 2.
Trainee scheduled for CUMH labour ward.
Take the on-call phone (61517 on internal phone lines, 086-7871517 from outside line) from the on-call trainee. You also need to receive the emergency pager (both are required as crash calls cannot be sent via the mobile phone).
Write your name and number on the whiteboard in the labour ward to assist daily communication.
Take a proper hand-over from the on-call trainee and discuss patients highlighted in the communication diary (e.g. headache patients who may need review or high-risk patients due to arrive to labour ward)
Join the obstetricians on their labour ward round. At this stage they are usually approaching the HDU. Make it your priority to join their discussions on the HDU patients.
If you leave the labour ward make sure you have both the phone and pager with you at all times.
Introduce yourself to obstetricians, patients and midwives if you or they are new. Familiarise yourself with the locations of the emergency room and clinics.
Always remember to knock before entering a labour room.
Because of the very busy workload in CUMH at night we try to roster the CUMH resident trainee for only 16 hours / shift maximum (i.e. 16:00 to 08:00 the following morning). When the duty anaesthesia trainee comes on dity please stay until it is the right time to leave and check with your consultant. Late afternoon is a particularly busy time in the labour ward and we frequently require extra hands on the deck at this time of day.
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