Case Studies

Case 14 - Obstetrics

You are called to the delivery suite for a 39-year-old woman (gravida 5) who has a retained placenta and a post partum haemorrhage. She requires manual removal of the placenta. She has not clinically shocked but the estimated blood loss is 1000 mL. She is otherwise well.

• 1. What are the advantages and disadvantages of regional anaesthesia?

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  Correct answer: Advantages: avoids the risks of GA.
  Disadvantages: risk of hypotension in a hypovolaemic patient.

• 2. What are the advantages and disadvantages of general anaesthesia? Advantages: quick and reliable. Disadvantages: GAs have greater morbidity and mortality associated with them. Tracheal intubation is much more difficult in obstetrics patients.

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  Correct answer: Advantages: quick and reliable.
  Disadvantages: GAs have greater morbidity and mortality associated with them. Tracheal intubation is much more difficult in obstetrics patients.

• 3. The patient has been fasted for 12 hours: does she need tracheal intubation?

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  Correct answer: All obstetric patients require rapid sequence induction and tracheal intubation due to the risk of inhalation of gastric contents.

• 4. The patient loses another 500 mL of blood rapidly and requires immediate blood transfusion. If there is no cross-matched blood available, what would you do?

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  Correct answer: Give O negative or group-specific blood.

• 5. Attempted manual removal under a spinal anaesthetic fails as the placenta remains adherent and blood loss continues. The surgeons wish to perform a laparotomy and possible hysterectomy. How would you manage the patient?

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  Correct answer: This will require a general anaesthetic, with potential for massive blood loss and transfusion. Senior help will be required. The patient will need invasive monitoring, blood products and HDU/ICU postoperatively.