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Obstetrics

Obstetric Haemorrhage​

  • Major haemorrhage > 1000 ml
  • Massive Haemorrhage > 2000 ml or > 150 ml/min
  • Infuse all packs entirely
  • Use FBC, Coagulation, ROTEM to guide ongoing resuscitation

MOH Flowchart​

ROTEM-Guided Haemorrhage Management​

Uterotonic Drugs​

  • Syntocinon - 5 units loading, then infusion 125 ml/h (40 units in 500 ml saline)
  • Ergometrine 500 microg IM (ci HTN) - max 2x (included in syntometrine)
  • Syntometrine - 500 microg Ergometrine + 5 units Syntocinon IM (ci HTN)
  • Carboprost 250 microg IM q15m max 8x (ci Asthma)
  • Misoprostol 800 microg PR (ci Asthma)
  • TXA 1g IV

PET and Eclampsia​

Aim for Blood Pressure < 150/100

IV Antihypertensive Agents​

Hydralazine​

  • Loading
    • 20 mg Hydralazine in 20 ml saline (1 mg/ml)
    • Discard half, administer 5 ml over 15 min, repeat at 20 mins if required
  • Infusion
    • 40 mg Hydralazine in 40 ml saline (1 mg/ml)
    • Infuse 5 ml/h up to 18 ml/h

Labetalol​

  • Infuse 5 mg/ml solution at 4 ml/h (20 mg/h)
  • Double every 30 minutes or 160 mg/h

Magnesium​

  • 20 ml of Magnesium Sulphate 20% (4 grams) over 5 minutes
  • Infusion 5 ml/h

Obstetric General Anaesthetic​

Sodium Citrate and H2 receptor antagonist

  • Thiopentone > 5 mg/kg
  • Suxamethonium up to 150 mg
  • 1 mg IV Alfentanil if hypertensive
  • MAC 1-1.2 with sevo + 50% nitrous

Opioids immediately post delivery

Epidurals​

Procedure​

  1. L2/3 or L3/4 interspace
  2. Test dose 8ml bag mix (0.1% levobupivacaine + 2mcg/mL fentanyl)
  3. Load to 15-20 ml total of bag mix

For CSE:

  • A dose of 1ml 0.25% Levobupivicaine or 2 mls of the epidural mix (0.1% levobupivicaine + 2mcg/ml fentanyl)
  • epidural in next space up
  • don't load the epidural and set up the pump; advise the patient to use the PCA function when they feel the pain developing

Contraindications​

  • Declined by woman
  • Inadequate midwifery staffing or training
  • No CTG or inadequate monitoring of fetus
  • Local infection at proposed site of insertion
  • Raised intra-cranial pressure
  • Uncorrected hypovolaemia
  • Coagulopathy (platelets must be > 80, INR < 1.4)
  • Anticoagulant therapy (wait 12h from prophylactic dalteparin, 24h if > 5,000 units)
  • Spina bifida occulta (unless magnetic resonance imaging (MRI) scan shows normal anatomy)

Timing of Anticoagulants​

  • Dalteparin < 5,000 units
    • wait 12 hours before insertion / removal of catheter
    • wait 4 hours after insertion / removal before administering Dalteparin
  • Dalteparin 100 units/kg
    • Wait 24 hours before insertion / removal of catheter

Troubleshooting​

  • Missed segment – lie the woman affected side down and give a bolus of 10 ml low-dose mix (e.g. 10 ml 0.1% bupivacaine + 2mcg/ml fentanyl) or 5 +5 ml 0.25% bupivacaine. If no improvement manage as for unilateral block.
  • Unilateral block – withdraw the catheter by 1 – 2 cm and give a further dose of low-dose mix (e.g. 10 ml 0.1% bupivacaine + 2mcg/ml fentanyl) with the woman lying with the affected side down. If this fails to improve pain relief consider re-siting the epidural.
  • Patchy block – consider a top-up with fentanyl 50-100 mcg in 10 ml 0.9% sodium chloride to improve spread. A stronger dose of local anaesthetic (see above) may also be required. Consider the possibility of a subdural block (see below).
  • Persistent perineal pain – consider giving a bolus of fentanyl 50-100 mcg or clonidine 50-75 mcg and/or a sitting bolus top up of 5-10mls 0.25% Levobupivicaine.

Accidental Dural Puncture​

Immediate

  1. Attempt to thread the catheter 3 cm into the subarachnoid space, unless limited by pain or paraesthesia
  2. Clearly label the intrathecal catheter
  3. Administer 0.25% Levobupivicaine 1ml + 25 microg Fentanyl + 2 ml 0.9% saline flush
  4. Repeat doses of 0.5 - 1.5 ml 0.25% Levobupivacaine q1-2h with 2ml 0.9% saline flush
  5. Inform mother, midwifery, and obstetrics teams

Epidural Top Up​

  • Epidural top up of 20 ml: 10 ml 2% Lidocaine + 10 ml 0.5% Levobupivacaine
  • Administer in divided doses of 5 ml
  • At the end of surgery or before removal of the epidural catheter give: 3mg diamorphine or 3mg preservative-free morphine
  • If unable to effectively top-up epidural, give spinal with ~30% reduction in levobupivacaine dose

C-Section​

Elective​

  • Spinal: 2.4-2.6 ml 0.5% Heavy Bupivacaine + 300mcg diamorphine or 15-20 mcg fentanyl + 100 mcg preservative free morphine
  • Insufficient spinal?: expedite, alfentanil, local in incision, offer GA
  • Phenylephrine 100 microg/ml i.v. at 20-30 ml/h
  • For CSE: At 45 minutes post spinal, give 5 ml 0.5% levobupiv aiming for 20 to cover spinal wearing off

Emergency​

  • Consider Terbutaline 250 microg s.c. to relax uterus
  • Carbetocin 100 microg i.v. post-delivery
  • If syntocinon infusion ongoing - 5 units syntocinon and infusion (125 ml/h of 40 units in 500 ml saline)