Obstetrics – emergency Caesarean

 

*Need to add into this somehow that the patient is tilted left lateral*

 

Emergency GA Caesarean:

Pre-op

·      Treatment: e.g. blood pressure

·      Investigations: blood tests, check ultrasound

·      Phone calls: theatre NIC, anaes NIC, O&G, paeds, ±blood bank
(Anaes nurse: prepare for GA LUSCS ±massive transfusion)

Intra-op

·      Anaes: relaxant GA with mRSI

o  Induction: propofol 3mg/kg, sux 1.5mg/kg
If shocked: propofol 2mg/kg, sux 1.5mg/kg, metaraminol + CSL
If PET: alf 20mcg/kg

o  Maintenance: sevo/nitrous

o  Emergence: remi TCI if PET

·      Airway: ETT + video laryngoscope + ramped/tilted + good pre-ox

·      Access: large PIVC ±A-line pre-op

·      Probes: standard ±A-line + temp + BIS

·      Pain: morphine 20mg after delivery, beware NSAID & tramadol if PET

·      People: O&G scrubbed and patient prepped, paeds present

·      Oxytoxics: oxytocin bolus + infusion, +/- ergot, +/- carbaprost

Post-op

·      HDU

 

Emergency Caesarean spinal:

Pre-op

·      Investigations: blood tests, check ultrasound

o   Plt >80: yes

o   Plt 50-80: depends on reason and trend

o   Plt <50: no

·      Phone calls: theatre NIC, anaes NIC, O&G boss, paeds
(Anaes nurse: prepare for GA LUSCS ±massive transfusion)

Intra-op

·      Anaes: spinal

o  0.5% heavy bupivacaine 2.2mL

o  Fentanyl 15mcg

o  Morphine 100mcg only if local familiarity and protocol

o  End-points: sensory (T4-6), motor (Bromage 0-1), pain (Bonnies)

·      Airway: native

·      Access: large PIVC, preload with 500mL CSL, phenylephrine infusion

·      Probes: standard + temp (incl warming)

·      Pain: not until PACU

·      People: O&G present, paeds present

·      Oxytocics: oxytocin bolus + infusion, +/- ergot, +/- carbaprost

Post-op

·      Analgesia: paracetamol, ibuprofen, oxycodone, tramadol

·      Monitoring: explain red flags to patient, pain service review

·      Disposition: ward vs HDU

 

Emergency Caesarean epidural top up:

Pre-op

·      Assess epidural: catheter and sensory/motor/pain

·      Investigations: blood tests, check ultrasound

·      Phone calls: theatre NIC, anaes NIC, O&G boss, paeds
(Anaes nurse: prepare for GA LUSCS ±massive transfusion)

Intra-op

·      Anaes: epidural top-up

o  Lignocaine 2% with adrenaline 1/200K 5mL q5min, max 20mL
(no adrenaline if PET)

o  Fentanyl 50mcg

o  End-points: sensory (T4-6), motor (Bromage 1), pain (Bonnies)

·      Airway: native

·      Access: large PIVC, preload with 500mL CSL, phenylephrine infusion

·      Probes: standard + temp (incl warming)

·      Pain: not until PACU

·      People: O&G present, paeds present

·      Oxytocics: oxytocin bolus + infusion, +/- ergot, +/- carbaprost

Post-op

·      Analgesia: paracetamol, ibuprofen, oxycodone, tramadol

·      Monitoring: explain red flags to patient, pain service review

·      Disposition: ward vs HDU