Scenario in a Nutshell
Total spinal develops after epidural top-up for caesarean section administered in the delivery unit room.
Stage 1: Developing symptoms and signs of high spinal. Recognition and initial management.
Stage 2: Total spinal develops. Cardiovascular support, intubation and ventilation, and delivery.
Target Learner Groups
Anaesthetists, midwives, obstetricians and operating department practitioners (ODPs)/anaesthetic nurses and theatre team.
| Specific learning opportunities |
|---|
| Demonstrate safe planning of transfer to theatre after an epidural top-up |
| Recognition of symptoms and signs of high/total spinal |
| Demonstrate safe management of a high/total spinal |
| Suggested learners (to represent their normal roles) | In the room from the start | Available when requested |
|---|---|---|
| Anaesthetic CT2 | √ | |
| Operating department practitioner/anaesthetic nurse | √ | |
| Midwife Coordinator | √ | |
| Midwife in room | √ | |
| Obstetric ST3+ | √ | |
| Suggested facilitators | ||
| Faculty to play role of night midwife finishing shift (can be played by facilitator running scenario) | √ | |
| Faculty to play role of patient’s partner | √ |
Details for Facilitators
Patient Demographics
Name: Amelia Age: 31 Gestation: 38+2 Booking weight: 85 kg Parity: P0 |
Scenario Summary for Facilitators
A 31-year-old, 38-week pregnant primigravida who is being induced for obstetric cholestasis.
She received an epidural for labour analgesia 7 hours ago.
On siting the epidural, three attempts were required at two different levels as the patient was very needle-phobic and unable to sit still. When the catheter was threaded, the patient reported some right leg paraesthesia and jumped in response. The catheter threaded easily and had a meniscal drop and negative aspiration.
Loading dose resulted in good analgesia and also a degree of weakness in the legs, particularly at the ankle joint. BP remained stable. Patient was monitored and given the PCEA once her pain returned. The epidural has worked well since.
CTG becomes pathological and the departing night anaesthetist administers epidural top-up in the room for category 1 caesarean section.
Patient develops symptoms and signs of a high spinal that develops into a total spinal.
Fetal bradycardia develops.
Patient requires emergency treatment of hypotension and bradycardia, intubation and ventilation followed by urgent caesarean delivery.
Set-up Overview for Facilitators
| Clinical setting |
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| Patient position |
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| Initial monitoring in place |
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| Other equipment |
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| Useful manikin functions |
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Medical Equipment
For core equipment checklist, see Chapter 9 including advanced airway equipment.
| Additional equipment required for this scenario | ||
|---|---|---|
| Epidural catheter (taped over shoulder) with epidural pump attached |
| High/total spinal block emergency checklist (if locally available |
| Vomit bowl |
| |
| Arterial line |
| Induction agents (thiopentone or propofol), neuromuscular blockers (suxamethonium or rocuronium) |
Information Given to the Learners
| Information given to CT2 anaesthetic trainee, midwife and obstetric ST3+ by the anaesthetic ST3 finishing their shift. |
|---|
| Time: 20:00 |
| SBAR handover: |
| Situation: We are just going for a category 1 caesarean section for a pathological CTG. |
| Background: Amelia is a 31-year-old primigravida. She is 38 weeks pregnant and being induced for obstetric cholestasis. |
| She has raised bile acids (22 μmol/l). ALT 42 IU/l, FBC and coagulation screen are normal. |
| She is on a syntocinon infusion and I sited an epidural 7 hours ago. Epidural insertion was difficult as Amelia is very needle-phobic and she found it very difficult to sit still. When I threaded the catheter, she reported some right leg paraesthesia and jumped in response. The catheter threaded easily and had a meniscal drop and negative aspiration. I spoke to the consultant after the first dose because she got some weakness in her legs, particularly dorsi-flexing her feet. Her blood pressure never dropped. We have kept a close eye on it and it has been absolutely fine ever since. I have just completed the top-up with 15 ml of 0.5% bupivacaine. |
| Assessment: All her observations have been fine. |
| Recommendation: Theatre team are ready whenever you are. All her paperwork is done. |
