Review Note

Last Update: 03/27/2025 09:23 PM

Current Deck: ACG Part 2::Obstetrics

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Commit #309757

SS_OB 1.34 Discuss the anaesthetic management of problems that may arise with labour and delivery, including the following situations:
- Uterine rupture

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Commit #309757

Uncommon but potentially fatal to both mother and baby

In unscarred uterus: 0.5–2 per 10,000 deliveries

In VBAC: 22–74 per 10,000 deliveries

Disruption of the uterine muscle extending to and involving the uterine serosa or extension into bladder or broad ligament

No single pathognomonic clinical feature indicative of uterine rupture, but the presence of any of the following peri-partum signs should raise concern:

Abnormal CTG – fetal bradycardia (most sensitive sign)

Severe abdominal pain, especially persisting between contractions

Chest or shoulder tip pain

Sudden onset shortness of breath

Acute onset of scar tenderness

Abnormal vaginal bleeding or haematuria

Cessation of previously efficient uterine activity

Maternal tachycardia, hypotension, or shock

Loss of station of the presenting part

Anaesthetic management

Pre-op:
- Continuous intrapartum care to monitor progress and enable prompt identification and management of uterine scar rupture with continuous electronic fetal monitoring following the onset of uterine contractions for the duration of the planned VBAC.
- Large IV access.
- Group and save with access to prompt crossmatch if required.
- Oral intake should be restricted to clear fluids because of the higher probability of needing an immediate LSCS under GA. (consider omeprazole)
- Epidural anaesthesia is not contraindicated in a planned VBAC.
  - Concerns that epidural anaesthesia may mask symptoms of uterine rupture are not considered sufficient to contraindicate epidural use.
  - NICHD study – planned VBAC success rates were higher among women who received epidural anaesthesia compared to those who did not.
- Pre-anaesthesia evaluation and counseling should occur early in patient’s care.

Intra-op (for uterine rupture):
- Expeditious laparotomy and resuscitation is essential to reduce the associated morbidity and mortality for mother and infant.
- GA
- Circulation:
  - Left lateral.
  - 2 large bore IV access.
  - Bloods – crossmatch blood, FBE, coags, POC viscoelastic tests.
  - Warm all resuscitation fluids.
  - Use group-specific or O-negative blood while waiting.
  - Level 1 warmer and rapid infusion device.
  - Monitor HCT and Hb.
  - Restore normovolaemia.
  - Consider invasive monitoring.
- Communication is vital:
  - Mobilize porters.
  - Notify theatre staff.
  - Request cell saver with separate suction for amniotic fluid.
  - Alert blood bank, haematologist, and neonatologist.

Tocolytic drugs in uterine rupture:

May require HDU/ICU for post-op monitoring if large haemorrhage.

Gold coast notes