Category 1 section under spinal

This can be a highly stressful situation. There may be little time to prepare. Communication here is absolutely vital. Is there time for a single attempt at a spinal? Many different things will need to occur in parallel here.

In the operating theatre

• Patient will likely be in a left lateral position for intra-uterine resuscitation
• IV access- delegate to obstetrician/midwife
• Antacid prophylaxis
  • 0.3M sodium citrate
  • Omeprazole 40mv IV
  • Metoclopramide 10mg IV
• Ask ODP to put oxygen mask on patient to pre-oxygenate, and attach monitoring

If there is time to attempt a spinal

• Chlorhexidine on back + sterile gloves
• 3ml of 0.5% heavy bupivicaine (faster to draw up)
  • (Alternatively 2.5ml heavy + 25mcg (0.5ml) fentanyl)
• Ask for timer to be started
• One attempt/ no more than 3 mins
• Allow surgery to start if bilateral block at T10 (umbilicus) and ascending

Intra-op

• Start phenylephrine at ~20ml/hr (15-30ml/hr acceptable)
  • Aim for systolic ≥ 90% baseline
  • Adjust in 5-10ml increments
• Left tilt on table
• 5 units of oxytocin given slowly after cord clamped
• Dexamethasone 6.6mg
• TAP blocks at end (if no intrathecal opiate given)
• Diclofenac 100mg PR by surgeon

Documentation

Always document (if true):

• Sensory block
  • Before start: Cold to T4, light touch to T6
  • By delivery: Light touch S5 to T4
• Motor block: unable to straight leg raise
• Sympathetic block: warm feet
• Mother comfortable throughout
• If there was pain, that you offered analgesia and GA
• Documenting timings is critical here

Post-op

• Paracetamol 1g QDS
• Ibuprofen 400mg QDS (to start after diclofenac worn off)
• Dihydrocodeine 30mg QDS
• Oramorph 20mg 2 hourly PRN
• Lactulose 10-20ml BD
• Ondansetron 4mg PRN