24 – General Anaesthesia and Failed Intubation in a Category 1 Caesarean Section




24 General Anaesthesia and Failed Intubation in a Category 1 Caesarean Section


Richard McGuire and Sharon Smith



This chapter contains two scenarios relating to general anaesthesia for a category 1 caesarean section.


The first scenario takes the anaesthetist through a straightforward category 1 caesarean section requiring general anaesthesia. This may be used to assess conduct of general anaesthesia for caesarean section as per requirement for the Royal College of Anaesthetists (RCOA) initial assessment of competence in obstetric anaesthesia.


The second scenario is a failed intubation. This is appropriate for all grades of anaesthetists and should be practised with the whole theatre team including obstetricians and midwives.



Scenario 1



Scenario in a Nutshell



General anaesthesia for a category1 caesarean section.


Stage 1: Preparation for a GA category 1 caesarean section.


Stage 2: Induction and maintenance of anaesthesia.


Stage 3: Waking and extubation.



Target Learner Groups


Anaesthetists, midwives, operating department practitioners/anaesthetic nurses, theatre scrub team, obstetricians.















Specific learning opportunities
Demonstrate competencies around general anaesthesia for caesarean section as described in RCOA 2010 Curriculum – Annex B
Effective preparation for and management of induction of general anaesthesia for category 1 caesarean section

Demonstrate clear communication in the team, particularly the verbalising of Plan A, B and C of the airway strategy, how to contact emergency anaesthetic assistance in case of difficult airway and whether planning to continue surgery using a supraglottic airway or wake the patient up in the event of a failed intubation













































Suggested learners (to represent their normal roles) In theatre from the start Available when requested
Anaesthetic CT2
Obstetric ST3+
Midwife
Operating Department Practitioner (ODP)/anaesthetic nurse
Theatre team – scrub nurse
Theatre team – runner
Suggested facilitators
Faculty to play role of midwife finishing shift (can be played by facilitator running scenario)


Details for Facilitators



Patient Demographics









Name: Freya


Age: 29


Gestation: 38+4


Booking weight: 78 kg


Parity: P0



Scenario Summary



29-year-old primiparous woman at 38+4 weeks gestation.


Labouring on Delivery Suite following induction of labour for reduced fetal movements.


Has progressed slowly to 6 cm dilated using entonox for analgesia.


Developed sustained fetal bradycardia resulting in decision for category 1 caesarean section for fetal distress.



Set-up Overview for Facilitators






















Clinical setting Obstetric theatre
Patient position Just arrived in theatre, being positioned on operating table
Initial monitoring in place None
Other equipment 16G cannula dorsum left hand
Useful manikin functions Intubation


Medical Equipment


For core equipment checklist, see Chapter 9, including advanced airway equipment.



















Additional equipment specific to scenario



  • Premedication:



  • Ranitidine (IV if not had PO) Sodium citrate




  • Induction drugs:



  • Induction agents – thiopentone, propofol



  • Opioids – alfentanil, fentanyl, morphine



  • Muscle relaxants – suxamethonium, rocuronium, atracurium




  • Other drugs:



  • Oxytocin



  • Anti-emetics



  • Reversal agents: neostigmine, sugammadex



  • Paracetamol



  • Diclofenac




  • Quantitative peripheral nerve stimulator




  • Contact details for emergency anaesthetic assistance




  • WHO checklist/time out



Information Given to the Learners

























Information given to anaesthetic trainee and obstetric trainee before they enter theatre
You have both just arrived to start your night shift on delivery unit. As you arrive, you are told that a woman has just been rushed through to theatre for a category 1 caesarean section for a fetal bradycardia.
Information given in theatre to anaesthetic trainee, obstetric trainee, theatre team, midwife and obstetrician from midwife who has just transferred the patient to theatre
Time: 20:30
The SBAR handover from the transferring midwife is as follows:
Situation: This is Freya, who is having a fetal bradycardia.
Background: 29-year-old, fit and well primip, BMI 27, who is 38 weeks pregnant with no allergies. She was induced for reduced fetal movements and laboured uneventfully to 6 cm dilatation, then had a fetal bradycardia. She was using entonox for analgesia.
Assessment: Observations were all normal.
Recommendation: She needs a category 1 caesarean section.


Scenario Schedule












Suggested Topics for Debrief Discussion




  • To anaesthetist: did you feel that you prioritised tasks appropriately and got everything prepared in a timely way prior to induction of anaesthesia?



  • Would you change any aspects of how you did this for your next GA category 1 caesarean section?



  • How was communication within the theatre team: in particular, prior to induction, did the anaesthetist clearly verbalise:




    • Plan A, B and C of their airway strategy?



    • Who their emergency anaesthetic assistance is and how they could be contacted in case of difficult airway?



    • Plan made to either continue surgery using a supraglottic airway or wake the patient up in the event of a failed intubation?




Scenario 2



Scenario in a Nutshell



Caesarean section under general anaesthesia with failed intubation.


Stage 1: Preparation for a GA category 1 caesarean section.


Stage 2: Induction of anaesthesia and failed intubation.


Stage 3: Difficult mask ventilation, airway rescue with supraglottic airway device, decision to proceed/wake patient.



Target Learner Groups


Anaesthetists, midwives, operating department practitioners/anaesthetic nurses, theatre scrub team, obstetricians.

















Specific learning opportunities
Demonstrate competencies around general anaesthesia for caesarean section as described in RCOA 2010 Curriculum – Annex B
Effective preparation for and management of induction of general anaesthesia for category 1 caesarean section
Demonstrate clear communication in the team, particularly the verbalising of Plan A, B and C of the airway strategy, how to contact emergency anaesthetic assistance in case of difficult airway and whether planning to continue surgery using a supraglottic airway or wake the patient up in the event of a failed intubation
Knowledge of and timely progression through the DAS/OAA failed intubation in obstetrics algorithm
















































Suggested learners (to represent their normal roles) In theatre from the start Available when requested
Anaesthetic CT2
Anaesthetic ST3+
Obstetric ST3+
Midwife
Operating Department Practitioner (ODP)/anaesthetic nurse
Theatre team – scrub nurse
Theatre team – runner
Suggested facilitators
Faculty to play role of midwife transferring patient to theatre (can be played by facilitator running scenario)


Details for Facilitators



Patient Demographics









Name: Felicity


Age: 32


Gestation: 39+5


Booking weight: 90 kg


Parity: P0



Scenario Summary for Facilitators



32-year-old, 39+5 weeks gestation primiparous woman.


Labouring spontaneously on Delivery Suite.


Has progressed slowly to 5cm dilated using entonox for analgesia.


Developed sustained fetal bradycardia resulting in decision for category 1 caesarean section for fetal distress.


Requires a general anaesthetic.


Failed intubation occurs.


Able to ventilate with a supraglottic airway.


Decision to wake patient or proceed with caesarean section.



Set-up Overview for Facilitators






















Clinical setting Obstetric theatre
Patient position Just arrived in theatre, being positioned on operating table
Initial monitoring in place None
Other equipment 16G cannula dorsum left hand
Useful manikin functions Intubation


Medical Equipment


For core equipment checklist, see Chapter 9, including advanced airway equipment.



















Additional equipment specific to scenario



  • Premedication:



  • Ranitidine (IV if not had PO)Sodium citrate




  • Induction drugs:



  • Thiopentone, propofol



  • Opioids – alfentanil, fentanyl, morphine



  • Muscle relaxants – suxamethonium, rocuronium, atracurium




  • Other drugs:



  • Reversal agents: neostigmine, sugammadex




  • Quantitative peripheral nerve stimulator




  • Contact details for emergency anaesthetic assistance




  • WHO checklist/timeout

Only gold members can continue reading. Log In or Register to continue

Oct 24, 2020 | Posted by in OBSTETRICS | Comments Off on 24 – General Anaesthesia and Failed Intubation in a Category 1 Caesarean Section
Premium Wordpress Themes by UFO Themes