Obstetrics Archives - obsgynaecritcare: Recent Episodes
Roger Browning - Anaesthetist
Join Sarah & Declan as we introduce a new series, covering the ANZCA final exam curriculum for obstetrics across four episodes. This first episode covers analgesia, neuraxials, and GA in pregnancy.
We hope this resource will be helpful for everyone, but especially those of our trainees preparing for the final exam. To get the most out of it, we suggest regularly pausing the podcast to answer each question yourself, before listing to our answers. Of course there is much more detail expected in the exam, but if you can answer all these questions confidently, we think you’ll have a great chance.
If you find this podcast helpful, or have suggestions for future episodes in this series, please send us an email (obsgynaecritcare@gmail.com) to let us know.
Here are links to some of the resources mentioned in this episode:
Question 1 (scoliosis, labour analgesia, inadequate block for labour, nerve injury)
· BJA Education, Oct 2024, Neuraxial anaesthesia in the parturient with pre-existing structural spinal pathology o https://www.bjaed.org/article/S2058-5349(24)00077-5/fulltext
· BJA Education Nov 2019, Non-regional analgesia for labour: remifentanil in obstetrics o https://www.bjaed.org/article/S2058-5349(19)30114-3/fulltext
· RANZCOG Guideline – Pain Relief in Labour and Childbirth o https://ranzcog.edu.au/wp-content/uploads/Pain-Relief-Labour-Childbirth.pdf
· BJA Education, Feb 2005, Analgesia in labour: non-regional techniques o https://www.bjaed.org/article/S1743-1816(17)30574-7/fulltext
· BJA Education, Apr 2013, Post-natal neurological problems o https://www.bjaed.org/article/S1743-1816(17)30057-4/fulltext
Question 2 (hypotension post-epidural, conversion of labour epidural to surgical epidural, PDPH)
· BJA Education, Jan 2020, Conversion of labour epidural analgesia to surgical anaesthesia for emergency intrapartum Caesarean section o https://www.bjaed.org/article/S2058-5349(19)30149-0/fulltext
· Consensus Practice Guidelines on Postdural Puncture Headache From a Multisociety, International Working Group: A Summary Report o https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2808365
Question 3 (failed top-up conversion to GA, post-op analgesia)
· ObsgynaeCritCare Podcast Episode 147 Pain during caesarean a discussion with Matt o https://www.obsgynaecritcare.org/pain-during-caesarean/
Question 4 (obs patient for GA, prescribing in pregnancy)
· BJA Education, Feb 2021Anaesthesia and non-obstetric surgery in pregnancy o https://www.bjaed.org/article/S2058-5349(20)30143-8/fulltext
· Australian categorisation system for prescribing medicines in pregnancy o https://www.tga.gov.au/resources/health-professional-information-and-resources/australian-categorisation-system-prescribing-medicines-pregnancy
The post 151 Obstetrics in the ANZCA final exam part 1 appeared first on obsgynaecritcare.
Join us as Declan and Roger discuss the evidence for routine table tilt during elective caesarean section.
Has this changed your practice? What is your opinion on this topic? We’d love to read your emails.
As mentioned in the episode we would love to do a future episode on Q&A so if you have any questions on any topic you would like us to tackle please send them in!
Send your comments / questions to: obsgynaecritcare@gmail.com
References Hughes EJ, Price AN, McCabe L, Hiscocks S, Waite L, Green E, Hutter J, Pegoretti K, Cordero‐Grande L, Edwards AD, Hajnal JV. The effect of maternal position on venous return for pregnant women during MRI. NMR in Biomedicine. 2021 Apr;34(4):e4475. * Couper S, Clark A, Thompson JM, Flouri D, Aughwane R, David AL, Melbourne A, Mirjalili A, Stone PR. The effects of maternal position, in late gestation pregnancy, on placental blood flow and oxygenation: an MRI study. The Journal of physiology. 2021 Mar;599(6):1901-15. * Higuchi H, Takagi S, Zhang K, Furui I, Ozaki M. Effect of lateral tilt angle on the volume of the abdominal aorta and inferior vena cava in pregnant and nonpregnant women determined by magnetic resonance imaging. Anesthesiology. 2015;122(2):286-293. * Fujita N, Higuchi H, Sakuma S, Takagi S, Latif MA, Ozaki M. Effect of right-lateral versus left-lateral tilt position on compression of the inferior vena cava in pregnant women determined by magnetic resonance imaging. Anesthesia & Analgesia. 2019 Jun 1;128(6):1217-22. * Aust H, Koehler S, Kuehnert M, Werdehausen R, Schleppers A, Reese PC, Reyher C. Guideline-recommended 15° left lateral table tilt during cesarean section in regional anesthesia—practical aspects: an observational study. Int J Obstet Anesth. 2016 Aug;27:47-53. * Crawford JS, Burton M, Davies P. Time and lateral tilt at Caesarean section. Br J Anaesth. 1972 May;44(5):477-84. * Lee AJ, Landau R, Mattingly JL, Meenan MM, Corradini B, Wang S, Goodman SR, Smiley RM. Left lateral table tilt for elective cesarean delivery under spinal anesthesia has no effect on neonatal acid–base status: a randomized controlled trial. Anesthesiology. 2017;127(2):241‑249. * Jackson KL, Smiley RM, Lee AJ. Neonatal acid-base status before and after discontinuing routine left uterine displacement for elective cesarean delivery: a retrospective cohort study (2014–2017). Int J Obstet Anesth*. 2025;62:104350.
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Hypothetical Case:
You are called to MFAU to see a woman who has just arrived via RFDS (royal flying doctor service)
She is a 23 y.o indigenous woman from the Kimberley in the far north of WA. She is 33/40 G1P0 complex social history and possible substance use disorders
She has PPROM (pre term premature rupture of membranes) and suspected early chorioamniotis and has been given antibiotics / nifedipine and a few litres of crystalloid fluid during the flight.
The obstetric team have evaluated her – she has small for gestational age baby, and is complaining of dyspnoea.
Her observations are: HR 110, NIBP 124/60, SpO2 91% on room air, T38.1
Her bloods are relatively normal except for an unexpected high BNP.
You do a focussed bedside transthoracic ECHO and unexpectedly see on the PLAX (parasternal long axis view) a classical hockey stick / domed appearance of severe mitral stenosis. She also has Pulmonary B-lines (indicating pulmonary oedema) and a flattened interventricular septum, very large atrium & doppler through the tricuspid valve confirms severe pulmonary hypertension.
The team decides she would be better cared for in a hospital with cardiothoracic services – however she suddenly becomes more breathless – SpO2 86% on oxygen, NIBP 80/40 HR 125, and there is a prolonged foetal bradycardia…………………
Hi Everyone,
This week I am joined by Dr Clinton Ellis, a cardiothoracic anaesthetist based in Sir Charles Gairdner Hospital, and Graeme. We discuss the management of rheumatic heart disease in pregnancy – a challenging condition which unfortunately is still relatively prevalent amongst indigenous women here in Australia.
This was a wide ranging discussion so I have decided to split this into two 40min episodes. Even though we talk for over 80min I feel like we just scratched the surface on this! If you have any questions or comments send them through – I will try and get Clinton to answer them.
Finally a huge shout out and thank you to the Darwin based authors of the ANZCA 2023 Blue Book article on this condition: Namrata Jhummon-Mahadnac, Matthew Mathieson, and Akshay Hungenahally! See the link to their well written narrative review on this topic below:
ReferencesAustralasian Anaesthesia 2023 (aka the Blue Book) – see page 39 “Obstetric anaesthesia in rheumatic heart disease – a unique perspective from the Top End”
Oral vaccine could prevent rheumatic heart disease in NZ
VIDEO: Researchers close to a vaccine for strep-A and rheumatic heart disease
The post 149 Rheumatic heart disease in pregnancy part 2 appeared first on obsgynaecritcare.
Hypothetical Case:
You are called to MFAU to see a woman who has just arrived via RFDS (royal flying doctor service)
She is a 23 y.o indigenous woman from the Kimberley in the far north of WA. She is 33/40 G1P0 complex social history and possible substance use disorders
She has PPROM (pre term premature rupture of membranes) and suspected early chorioamniotis and has been given antibiotics / nifedipine and a few litres of crystalloid fluid during the flight.
The obstetric team have evaluated her – she has small for gestational age baby, and is complaining of dyspnoea.
Her observations are: HR 110, NIBP 124/60, SpO2 91% on room air, T38.1
Her bloods are relatively normal except for an unexpected high BNP.
You do a focussed bedside transthoracic ECHO and unexpectedly see on the PLAX (parasternal long axis view) a classical hockey stick / domed appearance of severe mitral stenosis. She also has Pulmonary B-lines (indicating pulmonary oedema) and a flattened interventricular septum, very large atrium & doppler through the tricuspid valve confirms severe pulmonary hypertension.
The team decides she would be better cared for in a hospital with cardiothoracic services – however she suddenly becomes more breathless – SpO2 86% on oxygen, NIBP 80/40 HR 125, and there is a prolonged foetal bradycardia…………………
Hi Everyone,
This week I am joined by Dr Clinton Ellis, a cardiothoracic anaesthetist based in Sir Charles Gairdner Hospital, and Graeme. We discuss the management of rheumatic heart disease in pregnancy – a challenging condition which unfortunately is still relatively prevalent amongst indigenous women here in Australia.
This was a wide ranging discussion so I have decided to split this into two 40min episodes. Even though we talk for over 80min I feel like we just scratched the surface on this! If you have any questions or comments send them through – I will try and get Clinton to answer them.
Finally a huge shout out and thank you to the Darwin based authors of the ANZCA 2023 Blue Book article on this condition: Namrata Jhummon-Mahadnac, Matthew Mathieson, and Akshay Hungenahally! See the link to their well written narrative review on this topic below:
ReferencesAustralasian Anaesthesia 2023 (aka the Blue Book) – see page 39 “Obstetric anaesthesia in rheumatic heart disease – a unique perspective from the Top End”
Oral vaccine could prevent rheumatic heart disease in NZ
VIDEO: Researchers close to a vaccine for strep-A and rheumatic heart disease
The post 148 Rheumatic heart disease in pregnancy part 1 appeared first on obsgynaecritcare.
Hi everyone,
Pain during caesarean is a very challenging and distressing event – for the patient, their partner, the anaesthetist and all the staff present in theatre.
This week we catch up with Matt Rucklidge, who recently gave a presentation on this topic at the obstetric anaesthesia meeting in London. We discuss why this has become a “hot topic” in the anaesthesia world in recent times, what is the true incidence, and many other aspects of this difficult topic.
ReferencesThe following is a first person narrative story from a patient with commentary from an uninvolved obstetric anaesthetist. Disappointingly from elselvier this article is unfortunately not open access but is well worth a read:
Stanford SE, Bogod DG. Failure of communication: a patient’s story. Int J Obstet Anesth. 2016 Dec;28:70-75. doi: 10.1016/j.ijoa.2016.08.001. Epub 2016 Aug 23. PMID: 27717633.
Podcast: The Retrievals Season 2 from NY Times
Prevention and management of intraoperative pain during Caesarean sectionOrbach-Zinger, S. et al.BJA Education, Volume 25, Issue 2, 50 – 56
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Hi Everyone,
This week I sat down with Declan to discuss a fascinating therapy which is used in many areas of medicine.
This podcast has a bit of everything, a quiz, a part one viva, dubious animal experimentation, discussions about laxatives, and even some references to cosmology and the Big Bang.
Thanks Declan for another entertaining episode.
The post 143 Magnesium in medicine with Declan appeared first on obsgynaecritcare.
You are called to assess a pregnant woman who presents to your hospital complaining of shortness of breath. She is 36 weeks pregnant with twins and tells you she had been getting progressively short of breath over the last month but put it down to the physical effects of the twin pregnancy in her abdomen. However last night she couldn’t get her breath lying flat, had to sleep sitting up on 3-4 pillows and feels that “it is much worse”. On examination she has a respiratory rate of 24/min, SpO2 = 92%, HR 105/min, BP 95/45 and you can hear crepitations in both lung fields. Her initial blood tests come back showing a raised plasma BNP and a bedside ECHO is done by a helpful colleague – who says “subjectively her LV isn’t contracting very well”.
Hi everyone,
This week I sit down with Dr Faith Njue the most qualified person here in WA to discuss the rare but important disease – peripartum cardiomyopathy. (See Faith’s Bio below).
Join us in our wide ranging discussion which touches on the diagnostic challenges, demographics, proposed mechanisms and general principles involved in managing these complex patients.
Thanks Faith for a great discussion!
Dr Faith Njue – Bio
Faith Njue graduated from the University of Western Australia and completed cardiology training in Perth. She undertook further subspeciality training in advanced heart failure/ heart transplantation at Fiona Stanley Hospital and the University of Ottawa Heart Institute in Canada. Thereafter, she undertook further fellowship in cardio-obstetrics at the John Radcliffe hospital in Oxford (UK).
She has special interest in women’s cardiovascular health, heart disease in pregnancy and heart failure. Faith runs the dedicated Western Cardiology cardio-obstetrics clinic, designed to support women at risk of or with pre-existing heart conditions, through preconception counselling, pregnancy and into the post-partum period. Cardio-obstetrics is an expanding subspecialty that focuses on prevention, early detection, and appropriate management of cardiovascular disease in pregnancy.
She holds public consultant positions at Sir Charles Gairdner and Fiona Stanley hospitals. She is part of the Advanced heart Failure and Cardiac Transplant team at FSH. She is the cardiology clinical lead for High Risk pregnancy at FSH.
ReferencesAnaesthesia and peripartum cardiomyopathy Chapman, K. Njue F, Rucklidge M. BJA Education, Volume 23, Issue 12, 464 – 472
Melanie Ricke-Hoch, Tobias J. Pfeffer, and Denise Hilfiker-Kleiner. Peripartumcardiomyopathy: basic mechanisms and hope for new therapies. Cardiovascular Research (2020) 116, 520–531. doi:10.1093/cvr/cvz252
Bauersachs J, König T, van der Meer P, et al. Pathophysiology, diagnosis and management of peripartum cardiomyopathy: a position statement from the Heart Failure Association of the European Society of Cardiology Study Group on peripartum cardiomyopathy. Eur J Heart Fail. 2019 Jul;21(7):827-843. doi: 10.1002/ejhf.1493. Epub 2019 Jun 27. PMID: 31243866
2018 ESC Guidelines for the Management of Cardiovascular Disease During Pregnancy. European Heart Journal 2018. Vol 39;3165-3241
Bromocriptine:
Koenig T, Bauersachs J, Hilfiker-Kleiner D. Bromocriptine for the Treatment of Peripartum Cardiomyopathy. Card Fail Rev. 2018 May;4(1):46-49. doi: 10.15420/cfr.2018:2:2. PMID: 29892477; PMCID: PMC5971672
Hilfiker-Kleiner D, Haghikia A, Berliner D, Vogel-Claussen J, Schwab J, Franke A, Schwarzkopf M, Ehlermann P, Pfister R, Michels G, Westenfeld R, Stangl V, Kindermann I, Kühl U, Angermann CE, Schlitt A, Fischer D, Podewski E, Böhm M, Sliwa K, Bauersachs J. Bromocriptine for the treatment of peripartum cardiomyopathy: a multicentre randomized study. Eur Heart J. 2017 Sep 14;38(35):2671-2679. doi: 10.1093/eurheartj/ehx355. PMID: 28934837; PMCID: PMC5837241.
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Hi everyone,
This week I am joined again by Dr David Owen an obstetrician here at KEMH. We sit down to discuss uterine inversion – an acute obstetric emergency. Luckily this condition is relatively rare – however because of this there can be challenges in recognising and treating this condition even amongst experienced individuals.
Should you be unlucky enough to encounter this rare condition, now having listened to our discussion you will be better prepared and confident you know what is required!
Thanks again David for your research and preparation for this episode!
ReferencesUterine inversionPararajasingam, S.S. et al.BJA Education, Volume 24, Issue 4, 109 – 112
Unfortunately (as of Feb 2025) this article is not yet open access – but it is very good if you can get it through your hospital or college library..
Uterine Inversion for the layperson – Cleveland Clinic
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Hi Everyone,
Welcome to Part Two of our discussion with two of the founding members of the Placenta Accreta Spectrum Team here at KEMH Dr Matt Epee-Bekima and Dr David Owen. This team was conceived in 2017 and began operating in 2018 – and has now cared for over 75 women with PAS – including 24 alone this year (2024). In this episode we continue our initial discussion with a more detailed dive into:
- Surgical management – team members, techniques and approach
- Techniques for catastophic bleeding – manual aortic compression, vascular clamping, interventional radiology
- Postpartum issues
- Controversies (ICU vs HDU, leaving placenta in -situ)
- Thoughts for the future
Thanks Matt & David for sharing the experiences and knowledge learnt by the PAS team over the last 7 years.
Referenceshttps://www.kemh.health.wa.gov.au/~/media/HSPs/NMHS/Hospitals/WNHS/Documents/Clinical-guidelines/Obs-Gyn-Guidelines/Placenta-Accreta.pdf?thn=0
The post 140 The Placenta Accreta Spectrum Team at KEMH Part two. appeared first on obsgynaecritcare.
Hi Everyone,
This week I had the privilege of sitting down and recording two fascinating episodes with two of the founding members of the Placenta Accreta Spectrum Team from here at KEMH, Dr Matt Epee-Bekima and Dr David Owen. In this first episode we discuss the following:
- Definitions and pathology of placenta accreta spectrum
- What is the story behind the formation of the PAS team?
- Screening / Identification / Diagnosis and referral
- The optimisation and planning of the patient’s journey.
ReferencesKing Edward Memorial Hospital website – The Placenta Accreta Spectrum guideline
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Hi Everyone,
Join Graeme and I as we discuss two articles chosen from last months edition of IJOA (International Journal of Obstetric Anesthesia). In the first we discuss an article exploring whether the use of intermittent calf compression can reduce hypotension and vasopressor use in women undergoing caesarean section under spinal anaesthesia. The second article looks at the utility of preoperative electrical stimulation of acupressure points prior to caesarean section reduces postoperative pain and improves the quality of maternal recovery. There’s a sprinkling of our usual dad jokes at the end.
For regular listeners to the show join us again later this month when we hopefully will have a couple of episodes dedicated to the management of placenta accreta spectrum and an interview with the founders of the placenta accreta service setup 7 years ago here at KEMH – see you then!
ReferencesInternational Journal of Obstetric Anesthesia
Effect of pneumatic leg compression on phenylephrine dose for hypotension prophylaxis via variable rate infusion at cesarean delivery: an unblinded randomized controlled trial
Transcutaneous electrical acupuncture point stimulation and quality of recovery following cesarean delivery: A randomized controlled trial
The post 138 Journal club with Graeme IJOA Nov 2024 appeared first on obsgynaecritcare.
Your patient arrives in the anaesthetic room next to theatre, she’s booked for a non elective caesarean for failure to progress. She has an epidural in situ and you decide try to top it up – however after 25ml of lignocaine 2% with adrenaline and around 20min of waiting the block is stuck at the umbilicus and she can still move her legs relatively freely. This is obviously not going to be adequate – she is adamant she wants to be awake to see her baby born. You sit her up, pull out the epidural and do a single shot spinal with 2.1ml of heavy bupivacaine 0.5% + fentanyl 15mcg – after all you don’t want this block to fail as well!
You clean her back, lie her down and turn to talk to the midwife. When you turn back to the patient 30s later she looks a little purple and isn’t breathing…….
Hi everyone join Graeme and I this week as we discuss total spinal anaesthesia – a fascinating but somewhat scary rare emergency which can occur when we use regional anaesthesia in obstetric practice.
A big shout out to the team from Rotunda Hospital in Dublin who wrote the recent narrative review published in IJOA on this topic!
References1. Total spinal anaesthesia following obstetric neuraxial blockade: a narrative review Radwan, M.A. et al.International Journal of Obstetric Anesthesia, Volume 59, 104208 2. Sobhy S, Zamora J, Dharmarajah K, Arroyo-Manzano D, Wilson M, Navaratnarajah R, Coomarasamy A, Khan KS, Thangaratinam S. Anaesthesia-related maternal mortality in low-income and middle-income countries: a systematic review and meta-analysis. Lancet Glob Health. 2016 May;4(5):e320-7. doi: 10.1016/S2214-109X(16)30003-1. PMID: 27102195.
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What is the EXIT procedure? Who is it used for and how do we do it?
In our institution this procedure only occurs on average every 3-4 years. It is an event where a large diverse group of individuals, who often have never met each other, come together for a brief period of time to work as a highly complex team to achieve a great result for both the mother and baby.
Join Lloyd and I as we do a deep discussion on this uncommon but challenging multi-disciplinary procedure.
ReferencesMaternal anesthesia for EXIT procedure: A systematic review of literature.
The management of congenital upper airway anomalies and the ex-utero intrapartum treatment (EXIT) procedure
The post 135 The EXIT procedure with Lloyd Green appeared first on obsgynaecritcare.
Hi Everyone,
This week Matt and I agreed to get together to do another journal club episode (or more accurately I printed out an article, put it in Matt’s pigeon hole and told him to make himself available or else!).
We went to one of our favourite journals IJOA (International Journal of Obstetric Anesthesia), where we chose an article from the latest edition published in May.
The article is entitled “A narrative review of the literature relevant to obstetric anesthesiologists: the 2023 Gerard Ostheimer lecture.”
The background to this article is that every year the north american Society of Obstetric Anesthesia and Perinatology (SOAP) hold an annual conference. One of the highlights of these annual conferences is this lecture which is researched and then presented by a well respected obstetric anesthesiologist from the north american community. The lecture is a narrative review of the previous years published literature highlighting important papers and discussing their importance and relevance particularly in relation to current north american practice.
This year’s lecture was presented by Pervez Sultan from Stanford University, and it is drawn from a review of articles published in 2022 from 66 different journals. Over 12 different themes are discussed including (but not limited to) TIVA for GA Caesareans, dexamethasone for post CS analgesia, predicting epidural blood patch success, dural puncture epidurals and a number of other interesting topics.
Join Matt and I as we discuss these and muse over what relevance they may have to our current practice here in Western Australia as well as a couple terrible olympic themed dad jokes to close!
References / LinksA narrative review of the literature relevant to obstetric anesthesiologists: the 2023 Gerard W. Ostheimer lecture Int J Obstet Anesth 2024 May:58:103973. doi: 10.1016/j.ijoa.2023.103973. Epub 2024 Jan 3.
The post 134 Journal Club – a discussion of the 2023 Gerard Ostheimer lecture with Matt Rucklidge appeared first on obsgynaecritcare.
As the DA you are paged to come to PACU to review a patient with pre-eclampsia who has just had a PPH and a repair of a perineal tear after delivering in labour ward. The O&G team ordered a VBG because she was febrile and they want to assess her lactate and start her on some antibiotics. The O&G registrar is concerned however because her potassium / K has come back as 7.8 mmol/L….
Join Natalie and I as we discuss the issue of hyperkalaemia specifically in the context of women suffering from pre-eclampsia. Why are they at risk of this important electrolyte abnormality and what are the principles of management?
We also review a recent paper addressing some of the myths surrounding the treatment of acute hyperkalaemia (thanks to Casey at Broomedocs.com for bringing this paper to our attention).
Useful ReferencesGupta AA, Self M, Mueller M, Wardi G, Tainter C. Dispelling myths and misconceptions about the treatment of acute hyperkalemia. Am J Emerg Med. 2022 Feb;52:85-91. doi: 10.1016/j.ajem.2021.11.030. PMID: 34890894
LITFL, ECG library, Hyperkalaemia
Hyperkalaemia
A case of probable labetalol induced hyperkalaemia in pre-eclampsia. https://pubmed.ncbi.nlm.nih.gov/25370900
Hypocalcaemia and hyperkalaemia during magnesium infusion therapy in a pre-eclamptic patient https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4614650
Oh’s Intensive Care Manual. 7th Edition. Chapter 93 – Fluid and Electrolyte Therapy. Bersten A, Soni N et al. 2014.
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You receive a page from labour ward.
A woman at 35/40 weeks gestation has just arrived in the hospital very distressed in a lot of pain. A quick bedside ultrasound by the obstetric team has unfortunately demonstrated a large abruption and fetal death in utero. She is contracting strongly and beside herself in pain, the team would like you to come down and place an epidural for analgesia. The team are hoping she will deliver vaginally in the next few hours.
What is your approach in this situation?
Join Graeme and I as we discuss this complex and challenging clinical condition and the coagulopathy that can occasionally occur.
Here is a link to cases we have had in the past here at KEMH in the ROTEM Real Cases Discussed section:
Case 6 – Abruption and fetal death in utero
Case 11 – Abruption and severe coagulopathy
ReferencesCoagulopathy and placental abruption: changing management with ROTEM-guided fibrinogen concentrate therapy 2015 Liverpool Womens Hospital – this is not open access but available through the ANZCA library or your hospital library. It contains 4 very interesting case reports
Fibrinolytic and thrombotic DIC an explanation 2023 – This paper explains how there are two types of DIC one predominantly causing microvascular thrombosis and eventually factor depletion. The second which is possibly the mechanism seen in some abruptions is massive activation of fibrinolysis and fibrinogenolysis. WARNING this paper is highly technical!
The post 130 Coagulopathy in abruption a discussion with Graeme appeared first on obsgynaecritcare.
You are called to review a woman in labour ward. When you arrive you are told her epidural is no longer working. The epidural was placed by a colleague 5 hours ago and was working well. However in the last 20-30 minutes she has developed breakthrough pain despite a top up and pressing the PCEA a few times. You look at her back and the epidural dressing looks fine – no obvious explanation there.
Upon further questioning you are told that she had a caesarean in her previous pregnancy and she is attempting a VBAC. She tells you that since you arrived in the room the pain has changed. Now it is constant and she has developed pain in her shoulder. Suddenly the CTG deteriorates and within a few minutes the team are calling a code blue caesarean to theatre…..This is recollection of a real case from an evening shift a few years ago.
As you can probably guess this week we are discussing the important and somewhat scary topic of uterine rupture.
This week we are joined to discuss this topic by Dr David Owen. David is a senior obstetrician, who previous to WA worked at Liverpool Women’s Hospital and was a psychiatrist in a previous life.
Thanks David!
ReferencesUterine Rupture: A Seven Year Review at a Tertiary Care Hospital in New Delhi, India
Tocogram characteristics of uterine rupture: a systematic review
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A maternal death is always a tragic event for the mother, the child, the family and society at large. Unfortunately in some parts of the globe this is still a much too common event. Luckily for those of us living in higher resource countries it has now become relatively rare.
This week Matt and I sat down together to discuss the history of maternal mortality reporting, and all the useful knowledge we have been able to learn over the years from these important resources.
What are direct, indirect and coincidental maternal deaths? We touch on some aspects of the recent Australian reports and then go into depth on the long history of the UK reports which have many strengths such as their national funding, compulsory reporting, anonymous nature and very long history.
Thanks Matt
ReferencesMaternal Mortality Report Australia
Maternal Mortality World Health Organisation WHO
MBRRACE-UK Maternal mortality reports UK
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As the duty anaesthetist you are called down to the antenatal clinic by the obstetric team to see a pregnant woman with achondroplasia who is booked to deliver in your hospital.
What are the anaesthetic issues which can arise in this condition? What evidence is there in the literature for the optimal anaesthetic techniques? What will you discuss with this woman and how will you counsel her?
Join Declan and I as we discuss the anaesthetic issues of this relatively rare but sometimes challenging condition…
ReferencesDumitrascu CI, Eneh PN, Keim AA, Kraus MB, Sharpe EE. Anesthetic management of parturients with achondroplasia: a case series. Proc (Bayl Univ Med Cent). 2023 Dec 20;37(1):63-68. doi: 10.1080/08998280.2023.2261084. PMID: 38173994; PMCID: PMC10761160.
Lange, E.M.S., Toledo, P., Stariha, J. et al. Anesthetic management for Cesarean delivery in parturients with a diagnosis of dwarfism. Can J Anesth/J Can Anesth 63, 945–951 (2016). https://doi.org/10.1007/s12630-016-0671-5
15 Ways Pregnancy Is Different For Little People – Good Lay Person Website
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You are called to a code blue on the postnatal ward. A 28 yr old female who is 1 day post a non elective caesarean section has just had a witnessed convulsion lasting 1-2 min. She has now regained consciousness but seems a little confused and is complaining that she “has lost vision in both of her eyes”. Her BP is 180/100, and all other vital signs are normal.
What is this most likely to be? What is your differential diagnosis (what things do you not want to miss)? What investigations would you like done?
This turns out to be an episode of eclampsia and PRES (posterior reversible encephalopathy syndrome).
What is PRES? What are it’s radiological features and what is the mechanism which leads to this disorder?
Join Graeme and I as we discuss this uncommon but fascinating condition.
ReferencesGewirtz AN, Gao V, Parauda SC, Robbins MS. Posterior Reversible Encephalopathy Syndrome. Curr Pain Headache Rep. 2021 Feb 25;25(3):19. doi: 10.1007/s11916-020-00932-1. PMID: 33630183; PMCID: PMC7905767.
Marcoccia E, Piccioni MG, Schiavi MC, Colagiovanni V, Zannini I, Musella A, Visentin VS, Vena F, Masselli G, Monti M, Perrone G, Panici PB, Brunelli R. Postpartum Posterior Reversible Encephalopathy Syndrome (PRES): Three Case Reports and Literature Review. Case Rep Obstet Gynecol. 2019 Jan 27;2019:9527632. doi: 10.1155/2019/9527632. PMID: 30809401; PMCID: PMC6369475.
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Hi everyone,
Join us this episode – Declan and I have scoured the literature for a few interesting articles of varying degrees of quality! We had fun discussing these articles and hopefully you will also enjoy our discussion.
Hopefully we will make this a regular feature every 3-4 months!
Articles Discussed###### 1 – Effect of Dural-Puncture Epidural vs Standard Epidural for Epidural Extension on Onset Time of Surgical Anesthesia in Elective Cesarean DeliveryA Randomized Clinical Trial
In this RCT published in JAMA – the time to surgical anaesthesia was 4 min faster when topping up a dural puncture epidural in comparison to a standard epidural catheter.
2 – Neuraxial buprenorphine for post-cesarean delivery analgesia: a case series
This correspondence from the International Journal of Obstetric Anesthesia (IJOA) this year discussed the experience of a small hospital which decided to use neuraxial buprenorphine when there was a morphine shortage.
3 – There’s No Such Thing as “Nonjudgmental” Debriefing: A Theory and Method for Debriefing with Good Judgment
This classic paper from 2006 is a must read for anyone who is involved in debriefing and simulation in healthcare.
4 – Improving blood product management in placenta accreta patients with severe bleeding: institutional experience
This short report from IJOA 2023 describes the experience of blood product management in patients with placenta accreta spectrum disorder in a large tertiary referral hospital in Israel.
5 – Incidence of Interstitial Alveolar Syndrome on Point-of-Care Lung Ultrasonography in Pre-eclamptic Women With Severe Features: A Prospective Observational Study
This observational study from Analgesia & Anesthesia 2022 examined 70 women with severe PET with lung ultrasound and ECHO to assess diastolic dysfunction.
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You are called to labour ward to place an epidural in a nulliparous woman who is obviously extremely distressed in pain. After you sit her up to clean her back you notice she has a long scar running down the middle of her back. Between contractions she tells you she had surgery as a teenager to straighten her back…..what does this mean?
Hi Everyone,
Graeme regularly teaches this topic to our anaesthesia trainees and I was surprised to realise that we haven’t done a podcast on this already. Join us as we discuss scoliosis, spina bifida, spinal surgery and other assorted spinal issues.
TRAGIC CASE OF AIRWAY DEATH DUE TO SEVERE KYPHOSCOLIOSIS – FROM WEST AUSTRALIANThe post 123 Obstetric anaesthesia and the abnormal spine with Graeme appeared first on obsgynaecritcare.
Hi everyone,
Welcome to part 3 of a 3 part series we have put together – 3 hypothetical cases involving anaemia / patient blood management scenarios. Thanks to the two great colleagues who made these discussions with me, Dr Anastazia Keegan Head of Haematology here at KEMH and Assoc Prof Nolan McDonnell a colleague from our Department of Anaesthesia.
These cases might sound familiar to any registrars who have attended the Thursday teaching run here over the last 8-9 years!
We had a lot of fun discussing these three cases and I hope there is a lot of great learning for those of you listening – thanks Anastazia and Nolan for giving up a few hours to put these together!
The post 121 PBM Case discussion with Anastazia and Nolan part 3 blood is not an option. appeared first on obsgynaecritcare.
Hi everyone,
Welcome to part 2 of a 3 part series we have put together – 3 hypothetical cases involving anaemia / patient blood management scenarios. Thanks to the two great colleagues who made these discussions with me, Dr Anastazia Keegan Head of Haematology here at KEMH and Assoc Prof Nolan McDonnell a colleague from our Department of Anaesthesia.
These cases might sound familiar to any registrars who have attended the Thursday teaching run here over the last 8-9 years!
We had a lot of fun discussing these three cases and I hope there is a lot of great learning for those of you listening – thanks Anastazia and Nolan for giving up a few hours to put these together!
The post 120 PBM case discussion with Anastazia and Nolan part 2 postpartum anaemia appeared first on obsgynaecritcare.
You are phoned and asked to review the venous blood gas from a woman who has just given birth in labour ward. She had a long and difficult labour and eventually required an instrumental delivery. The RMO tells you also that she was very difficult to take blood from and the tourniquet was on her arm for quite a long time. Her results show that she has a lactate of 2.5.
Does this result mean she has maternal bacterial sepsis? Does this mean she is in shock, not perfusing her organs properly and they are using anaerobic metabolism? Unfortunately it’s not that simple but these are common misconceptions that we might encounter when interpreting raised lactate levels.
What is lactate? How does the body handle it? What are the different conditions which can raise your lactate levels? If you want to know this and more listen in to our fascinating discussion this week.
Hi everyone,
This week I am joined by two new guests, Tim Marmion one of our talented junior registrars and Declan Sharp the new education fellow here at KEMH. This week Tim kindly agreed to give us a talk he recently wrote whilst working in ICU, on the challenges of lactate interpretation. I cornered him after the talk and he kindly agreed to share it with us on the podcast. Thanks Tim and Declan for a fascinating and educational topic!
ReferencesHow should we interpret lactate in labour? A reference study S.Dockree et al BJOG. 2022 Dec; 129(13): 2150–2156.
Blood Lactate Measurements and Analysis during Exercise: A Guide for Clinicians Matthew Goodwin et al J Diabetes Sci Technol. 2007 Jul; 1(4): 558–569.
Understanding Elevated Lactate
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Hi Everyone, “Three minutes after the administration on the spinal anaesthetic they became restless and complained of severe pain in both lower limbs and back. Their heart rate and blood […]
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Hi Everyone, Join Siv and I as we sit down to discuss a couple of interesting obstetric related topics. The first is the pharmacology around the choice and strength of […]
The post 116 Epidural local anaesthetics and another TXA article with Siv appeared first on obsgynaecritcare.
Hi Everyone, This week we are joined by Dr Anastazia Keegan an obstetric haematologist and the head of Haematology at our Women’s hospital here in Western Australia. Join us as […]
The post 115 Congenital bleeding disorders in pregnancy with Dr Anastazia Keegan appeared first on obsgynaecritcare.
Hi Everyone,
This is part 2 of a discussion (see the previous episode for part 1).
We have just returned from the Obstetric Anaesthesia Special Interest Group Satellite meeting held on May 3-4. I sat down two days after the meeting with Dr Matt Rucklidge (the convenor of this meeting and a colleague here at KEMH) and Prof Nuala Lucas one of the keynote invited speakers from the UK who is the president of the OAA UK (Obstetric Anaesthesia Association).
We discuss the highlights of this two day meeting and some of the takeaway learning points.
Thanks to Matt Rucklidge and Jane Brown who organised the speakers – an absolutely amazing line up of compelling speakers and topics!
Apologies for the audio quality – we didn’t have the usual microphones and had to record in a side room at the Sydney Convention centre at were unable to get away from the background elevator music……
Nuala flew straight from Sydney back to the OAA annual meeting this year being held in Edinburgh. If anyone is interested in attending any excellent Obstetric Anaesthesia meetings the OAA hold two very well regarded meetings held every year – see the links below:
ReferencesChallenges and Choices in Obstetric Anaesthesia – Sydney Convention centre May 3-4 2023
Obstetric Anaesthetist’s Association OAA-UK – see links to their annual meetings
Handbook of Communication in Anaesthesia & Critical Care: A Practical Guide to Exploring the Art Illustrated Edition. Dr Allan Cyna
The post 114 Highlights from the OA SIG Meeting Sydney part 2 appeared first on obsgynaecritcare.
Hi Everyone,
We have just returned from the Obstetric Anaesthesia Special Interest Group Satellite meeting held on May 3-4. I sat down two days after the meeting with Dr Matt Rucklidge (the convenor of this meeting and a colleague here at KEMH) and Prof Nuala Lucas one of the keynote invited speakers from the UK who is the president of the OAA UK (Obstetric Anaesthesia Association).
We discuss the highlights of this two day meeting and some of the takeaway learning points.
Thanks to Matt Rucklidge and Jane Brown who organised the speakers – an absolutely amazing line up of compelling speakers and topics!
Apologies for the audio quality – we didn’t have the usual microphones and had to record in a side room at the Sydney Convention centre at were unable to get away from the background elevator music……
Nuala flew straight from Sydney back to the OAA annual meeting this year being held in Edinburgh. If anyone is interested in attending any excellent Obstetric Anaesthesia meetings the OAA hold two very well regarded meetings held every year – see the links below:
ReferencesChallenges and Choices in Obstetric Anaesthesia – Sydney Convention centre May 3-4 2023
Obstetric Anaesthetist’s Association OAA-UK – see links to their annual meetings
Moran, NF, Bishop, DG, Fawcus, S, Morris, E, Shakur-Still, H, Devall, AJ, et al. Tranexamic acid at cesarean delivery: drug-error deaths. BJOG. 2023; 130(1): 114– 117. https://doi.org/10.1111/1471-0528.17292
The post 113 Highlights from the OA SIG Meeting Sydney part 1 appeared first on obsgynaecritcare.
You are called to a code blue medical on labour ward – a previously well nulliparous woman has just had a seizure, and now seems confused. Her observations are normal, she is not hypertensive and the CTG appears fine. She is presumed to have had an eclamptic seizure and is given oxygen, magnesium and has some urgent pre-eclampsia bloods and urine sent. The midwife states she has been trying to stay well hydrated with lots of coconut water and has been on oxytocin to augment her labour for a number of hours. Her results are all normal except for a sodium of 111. She suddenly starts to begin seizing again…….
Hi everyone,
This week I am joined by two guests – Siv our current education fellow and Jess who is a senior ICU trainee working in our department to discuss a very important but perhaps somewhat often overlooked condition – peripartum hyponatraemia. As we acknowledge in the podcast hyponatraemia is a huge topic and in order to make this podcast more manageable and practical we have chosen to focus specifically on peripartum hyponatraemia, it’s common causes, recognition & diagnosis, practical management and how to avoid the harms associated with excessively rapid correction.
Thanks Jess!
ReferencesGuideline for the Prevention, Diagnosis and Management of Hyponatraemia in Labour and the Immediate Postpartum Period – GAIN Northern Ireland March 2017
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Hi Everyone,
In our tertiary women’s hospital here in Perth we use remifentanil PCA in labour approximately 15 times a year – and we are told that in Australian terms this is considered a “heavy user” of this labour analgesic technqiue.
This week I sit down with Mike Jamison an anaesthetic fellow from Belfast spending a year with us here in Perth. When he arrived in WA we quickly learned from him that remifentanil PCA is commonly used for labour analgesia in Northern Ireland with one unit he worked in having prescribed this technique for more than 11,000 women. We sit down to have a deep dive into the use of remifentanil PCA in labour in Northern Ireland. What aspects of their approach have led it to become such a commonly utilised technique? What is their recipe? How do they prescribe it, how do they monitor the women and how is this technique now viewed amongst the obstetric, midwifery and wider Northern Irish community!
If you are attending the upcoming Obstetric Anaesthesia satellite meeting in Sydney in a few weeks – come along to hear Mike talk on this in person!
ReferencesIntravenous remifentanil patient-controlled analgesia versus intramuscular pethidine for pain relief in labour (RESPITE): an open-label, multicentre, randomised controlled trial. The Lancet volume 392, p662-672, AUGUST 25, 2018
Remifentanil patient-controlled intravenous analgesia during labour: a retrospective observational study of 10 years’ experience. H Murray, P Hodgkinson, D Hughes. Int J Obstet Anesth 2019 Aug;39:29-39
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Hi everyone,
This week three of us sit down to discuss a great review article (and topic) – the use of TIVA (total intravenous anaesthesia) for GA caesarean surgery.
For many the classic technique for a GA caesarean has been thio / sux tube then volatile & nitrous oxide. In recent years many aspects of this have started to change with propofol probably more commonly used as the i.v. induction agent and now in many cases rocuronium is used in preference to suxamethonium. Now with the much increased use of TIVA across anaesthesia practice there is a renewed interest in it’s role for women having caesarean surgery and GA for management of postpartum haemorrhage.
Join us as we discuss this article. What do we mean by TIVA? What are the potential benefits? (uterine tone, recovery, PONV) and are there risks? (awareness, fetal depression, over sedation).
It is fair to say there has not been a lot of high quality research done on this topic and there are more questions than definitive answers, but this article does well to summarise the issues and what we do know.
Informal Twitter Poll result from Parita!:
ReferencesThe role of total intravenous anaesthesia for caesarean delivery. Y. Metodiev, D.N. Lucas IJOA April 08, 2022
Comments on above article – M.Paech IJOA June 28, 2022
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Hi everyone, This week Graeme and I sit down for the first time in nearly a year and do a bit of a deep dive on the use of nitrous […]
The post 105 Nitrous oxide for labour analgesia with Graeme appeared first on obsgynaecritcare.
Hi everyone, This week Sneha leads a discussion with both Matt and myself where we take a deep dive into how to actually perform an epidural blood patch. Even though […]
The post 103 How to perform an epidural blood patch. appeared first on obsgynaecritcare.
Welcome to this podcast, the tenth in our series of obstetric anaesthesia basics. Join us for this the second part of a conversation where we discuss all things relating to […]
The post 102 Neuraxial anaesthesia for caesarean delivery part two appeared first on obsgynaecritcare.
Welcome to this podcast, the ninth in our series of obstetric anaesthesia basics. Join us for this the first part of a conversation where we discuss all things relating to […]
The post 101 Neuraxial anaesthesia for Caesarean section Part one appeared first on obsgynaecritcare.
Hi everyone, Join us this week as we briefly celebrate the 100th episode – almost exactly 5 years after the first episodes aired. Then we sit down to discuss some […]
The post 100 Learning from real haemorrhage case discussions appeared first on obsgynaecritcare.
Hi everyone, This is the second episode of two, where I sit down with my anaesthetic colleague Sneha and senior ICU trainee Jess to discuss the important and sometimes scary […]
The post 099 Maternal sepsis with Jess and Sneha Part 2 appeared first on obsgynaecritcare.
Hi everyone, This is the first episode of two, where I sit down with my anaesthetic colleague Sneha and senior ICU trainee Jess to discuss the important and sometimes scary […]
The post 098 Maternal sepsis with Jess and Sneha Part 1 appeared first on obsgynaecritcare.
Welcome to this podcast, the eighth in our series of obstetric anaesthesia basics. Join us for this conversation where we discuss all things relating to obstetric haemorrhage, a much feared […]
The post 097 Obstetric haemorrhage appeared first on obsgynaecritcare.
Welcome to this podcast, the seventh in our series of obstetric anaesthesia basics. Join us for this the second part of a conversation where we discuss all things relating to […]
The post 096 General anaesthesia for Caesarean section part 2 appeared first on obsgynaecritcare.
Welcome to this podcast, the sixth in our series of obstetric anaesthesia basics. Join us for this the first part of a conversation where we discuss all things relating to […]
The post 095 General anaesthesia for C Section part 1 appeared first on obsgynaecritcare.