FRCA Notes

Anaesthesia for Non-caesarean Obstetric Surgery

This exquisitely brief repository of information is more for completeness, rather than any true expectation of it appearing in an FRCA exam.

Anaesthesia for retained placenta is mentioned in the core curriculum, but the other surgeries are in absentia.

  • All cases should have:
    • Appropriate antibiotic prophylaxis (if necessary) as per local policy
    • VTE prophylaxis (if necessary) as per local policy
    • Appropriate post-operative analgesia as indicated
  • The risk here is the potential for (ongoing) PPH owing to 'tissue' and 'tone' issues
  • One therefore needs to make an assessment, in conjunction with our obstetric and midwifery colleagues, of:
    • Total blood loss so far
    • Rate of ongoing blood loss
    • Haemodynamic stability of the patient
  • This will inform choice of anaesthetic technique
  • In any case, wide-bore (16G) IV access and blood for group and save/cross-match is pertinent

Regional anaesthesia

  • Generally preferable, especially if blood loss volume is <1L, there is minimal ongoing loss and relative haemodynamic stability
  • Options include:
    • Incremental epidural top-up
    • Spinal anaesthetic ± short-acting opioid (e.g. 2ml 0.5% heavy marcaine + fentanyl 15μg)
  • One only needs a block to ~T7, though require higher dose post-partum to achieve the same level of block compared to the parturient
  • If uterine relaxation is required, sublingual GTN can be used
  • Give uterotonic post-delivery of the placenta

General anaesthesia

  • GA may be preferable if there is large volume (>1L), rapid or ongoing bleeding ± haemodynamic instability
  • Ensure antacid prophylaxis is given and use an RSI technique
  • If uterine relaxation is required, increase depth of (volatile) anaesthesia
  • Give uterotonic post-delivery of the placenta

  • Only need sacral block to repair the tear itself
  • Slightly higher block may allow exploration of deeper/higher structures and cover L1/2 in case anterior structures are affected

  • Regional anaesthesia is ideal
    • Spinal - smaller volumes of LA are needed (e.g. 1.5-1.8ml 0.5% heavy marcaine ± fentanyl 15-25μg) but keep sitting up if possible to ensure dense block
    • Epidural top-up - may only need ≤10ml

  • May have to do in lateral position as sitting on a tear may be rather painful!
  • Ensure post-operative laxatives are prescribed, as they can reduce the risk of wound dehiscence

  • Surgical duration up to fifteen minutes but often less
  • Day-case procedure
  • Spinal anaesthetic with:
    • Prilocaine (e.g. 2.5ml 2% heavy prilocaine)
    • Bupivacaine (e.g. 1.5ml 0.5% heavy bupivacaine)

  • Removal is often done without anaesthetic