These can be stressful situations. Ideally intubation is immediately followed by knife to skin, with the abdomen prepped before induction. There is a very high incidence of difficult intubation, and of awareness under anaesthesia in these situations.
Pre-op
- AMPLE history
- Antacids as per local protocol
Peri-op
- Left tilt on table
- Ensure 16G cannula in situ, running well
- Category 1 sign in/ time out
- Abdomen fully prepped, draped etc
- Thorough pre-oxygenation
- Consider nasal specs for apnoeic oxygenation
- RSI
- Alfentanil 1-2 mg
- Propofol ~180mg (have second syringe available)
- Rocuronium 1.2mg/kg
- Videolaryngoscope
- ETT
- O2/ sevoflurane (+/- nitrous oxide)
- Oxytocin when requested by surgeons, given slowly over 5 minutes
- Morphine 10mg after delivery
- Dexamethasone 6.6mg and ondansetron 4mg
- TAP blocks
- Reversal likely to require sugammadex
Post-op
- Morphine 1-10mg IV in recovery
- Paracetamol 1g QDS
- Ibuprofen 400mg QDS
- Dihydrocodeine 30mg QDS
- Oramorph 20mg 2 hourly PRN
- Lactulose 10-20ml PRN
- Ondansetron 4mg PRN
- Naloxone 100mcg PRN
Alternatives
- Induction
- Thiopentone
- Used in 52.9% of obstetric GA (DREAMY trial)
- Suitable alternative to propofol, but in these situations familiar drugs are likely safer- for many this is propofol
- Can be mistaken for antibiotics due to straw colour
- Suxamethonium
- Used in 86% of obstetric GA (DREAMY trial)
- Potentially quicker acting
- Will likely need another muscle relaxant for the operation
- Opiate free induction
- No opiate transferred to fetus
- There is a high incidence of AAGA in these operations and a short acting opiate is probably useful here
- Thiopentone
Anaesthetic Recipes 
Do you give alfentanil at induction as routine for GA Cat 1?
Any situations (other than fetal bradycardia) where you would NOT give it at induction?
Interesting to see others’ practice. Nice website by the way!
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Good question and thanks! I do routinely give Alfentanil for my GA Cat 1s. The literature is a little…. sparse, but there’s a suggestion that not modifying the maternal stress response to laryngoscopy and intubation compromises placental perfusion. Using alfentanil apparently improves oxygen in cord gases, at the cost of slightly lower APGARs. If the bradycardia is caused by some form of hypoperfusion, I’m left wondering how much alfentanil is transferred? Alfentanil has the shortest duration of any of the “neat” opioids I have access to- I imagine remifentanil would be an excellent choice, but would require drawing up and there simply isn’t the time. What do you do?
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My centre has a pretty fixed practice prop/sux RSI for emergency obstetric GA, so no opioid unless specifically indicated, which for practical purposes is only really PET (cardiac issues rare). So my experience of induction opioids in obs is fairly limited
Interesting point about alfentanil and placental perfusion, do you have a reference for the article?
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Here’s the reference to the article: Gin, Tony & Ngan-Kee, Warwick & Siu, Yuk & Stuart, Joyce & Tan, Perpetua & Lam, Tim. (2000). Alfentanil Given Immediately Before the Induction of Anesthesia for Elective Cesarean Delivery. Anesthesia and analgesia. 90. 1167-72. 10.1097/00000539-200005000-00031. There doesn’t seem to be much literature surrounding this topic.
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Useful meta-analysis on this topic:
https://www.obstetanesthesia.com/article/S0959-289X(18)30619-8/fulltext
In a nutshell, alfentanil/remifentanil at co-induction doses for obs GA is fine.
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What’s your thinking/rationale for going roc over sux?
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If I have given sux, I often need to give another relaxant at a busy time in the case. With rocuronium I give a single drug instead of two, and can have immediate reversal at the end. Sux still works well though.
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