Obsgynaecritcare

This week Dr Esther Godfrey, an intensivist and anaesthetist from Wales, joins us on the podcast. Esther is visiting WA on a family holiday, and yet she kindly offered to come and speak with us this morning. In this episode Esther shares a very moving personal experience and then we discuss all the amazing work she and her colleagues have been doing in this space in Wales and now across the UK / Ireland – The SuPPORT Project (see the links below). Thank you Esther – and thank you to your family for letting us borrow you for the morning! Links The SuPPORT Project website

You have attempted to top up an epidural for a category one caesar for fetal distress. The block seems adequate but once the surgeons enter the abdomen your patient complains of significant pain and you decide to convert to general anaesthesia. You perform an RSI with propofol and rocuronium. After intubation she has a heart rate of 130 and an NIBP of 155 / 90. Your registrar asks “why didn’t we give her any opioid?” and you patiently explain that we avoid opioids until after delivery because we don’t want them to cross the placenta and to cause respiratory depression in the neonate……………but is this always true??? Hi everyone, Join Jacob and I as we discuss the recent literature surrounding this topic. What is the evidence? What about the short acting opioids such as alfentanil & remifentanil? What are the advantages / disadvantages of using an opioid and what are the downsides of not using opioids? References Best practice in obstetric general anaesthesia: an umbrella review of pharmacological strategies for induction of general anaesthesia. Anaesthesia, 81: 1269-1280. 2026. https://doi.org/10.1111/anae.70214 Induction opioids for caesarean section under general anaesthesia: a systematic review and meta-analysis of randomised controlled trials International Journal of Obstetric Anesthesia, 2019; 40, 4-13

Join Sarah & Declan as we continue our series covering the ANZCA final exam curriculum for obstetrics across four episodes. This second episode covers complications in labour and delivery including management of postpartum haemorrhage. We hope this resource will be helpful for everyone, but especially those of our trainees preparing for the final exam. To get the most out of it, we suggest regularly pausing the podcast to answer each question yourself, before listening to our answers. Of course there is much more detail expected in the exam, but if you can answer all these questions confidently, we think you’ll have a great chance. If you find this podcast helpful, or have suggestions for future episodes in this series, please send us an email to let us know. Resources mentioned in this episode: Question 1: AFE, haemorrhage management BJA Education — Haemostatic agents in the management of obstetric haemorrhage (2024) https://www.bjaed.org/article/S2058-5349(24)00089-1/fulltext RANZCOG — Management of Postpartum Haemorrhage (2021) https://www.ranzcog.edu.au/wp-content/uploads/Management-Postpartum-Haemorrhage.pdf BJA Education — Amniotic fluid embolism (2018) https://www.bjaed.org/action/showPdf?pii=S2058-5349%2818%2930060-X BJA Education — Point-of-care viscoelastic testing (2022) https://www.bjaed.org/article/S2058-5349(22)00094-4/fulltext Deranged Physiology — Interpretation of abnormal ROTEM data https://derangedphysiology.com/main/required-reading/haematology-and-oncology/Chapter-108/intepretation-abnormal-rotem-data Question 2: GA unstable bleeding pt, uterine inversion management RANZCOG — Management of Postpartum Haemorrhage (2021) https://www.ranzcog.edu.au/wp-content/uploads/Management-Postpartum-Haemorrhage.pdf BJA Education — Uterine inversion (2024) https://www.bjaed.org/article/S2058-5349(24)00009-X/fulltext Question 3: Placenta accreta planning and management RANZCOG — Placenta Accreta Spectrum (PAS) (C-Obs 20) (2023) https://ranzcog.edu.au/wp-content/uploads/Placenta-Accreta-Spectrum.pdf BJA Education — Management of patients with suspected placenta accreta spectrum (2022) https://www.bjaed.org/article/S2058-5349(21)00131-1/fulltext Question 4: Foetal demise SOAP — Interdisciplinary Consensus Statement on Neuraxial Procedures in Obstetric Patients with Thrombocytopenia (2021) https://www.soap.org/assets/docs/Consensus/SOAP%20Consensus%20Statement%20Thrombocytopenia%202021.pdf

Hi everyone Dexmedetomidine, is both a difficult word to pronounce correctly in casual conversation but also a useful pharmacological tool in many different situations. This week I am joined by one of our fellows Dr Han Lu to discuss dexmedetomidine, it’s history, it’s basic pharmacology and then more specifically it’s use in different clinical situations where it may be useful in obstetrics and gynaecology. Thanks Han for a great Tuesday talk and a very informative podcast! References Han’s powerpoint talk Effectiveness of dexmedetomidine on patient-centred outcomes in surgical patients: a systematic review and Bayesian meta-analysis. BJA September 2024 Crowe. G, et al Perioperative Applications of Dexmedetomidine. ATOTW 469 — Perioperative Applications of Dexmedetomidine April 2022 Douglas MS, Soloniuk LJ, Jones J, Derderian R, Baker C, Stier G. Intravenous dexmedetomidine use in obstetric anesthesia: a focused review. Int J Obstet Anesth. 2025 May;62:104345. doi: 10.1016/j.ijoa.2025.104345. Epub 2025 Feb 13. PMID: 40090158 Atipamezole – alpha 2 agonist reversal agent used in veterinary practice

Hypothetical Case: You finish injecting the spinal anaesthetic for your patient who has come for an urgent caesarean section. She has pre-eclampsia and her blood pressure just before you started was 180/100. Just after lying down she starts vomiting and unfortunately the non invasive blood pressure cuff is going up and down but not giving you a number – she is shaking and can’t stop moving around. Is she vomiting because of hypotension, should you give her a bolus of phenylephrine? What if she is actually still hypertensive – you don’t want to push her BP over 200. Wouldn’t it be great if you had a beat to beat continuous display of her BP – maybe you should have placed an arterial line before starting. Are there any other options that might have been helpful??? Hi everyone, This week I am joined by John to discuss continuous non-invasive blood pressure monitoring. Many of these technologies have actually been around for a number of years now, but despite this don’t seem to be in commonplace usage. There does seem to be a recent renewed interest in re-evaluating these technologies. How do these technologies work? How accurate are they? Have there been any improvements? What are the economics and costs? Thanks John for all your hard work researching this topic! Methods Arterial Applanation Tonometry Volume Clamp Method Photoplethysmography (PPG): Origins to Modern Applications in Wearable Technology References Enhancing Patient Safety with Continuous Blood Pressure Monitoring – APSF (Anesthesia Patient Safety Foundation Newsletter 2026)

Declan and Sarah discuss strategies for obstetric questions in the ANZCA final exam.

Join us as Declan and Roger discuss the evidence for routine table tilt during elective caesarean section.   Has this changed your practice? What is your opinion on this topic? We’d love to read your emails.  As mentioned in the episode we would love to do a future episode on Q&A so if you have any questions on any topic you would like us to tackle please send them in! Send your comments / questions to: [email protected] References Hughes EJ, Price AN, McCabe L, Hiscocks S, Waite L, Green E, Hutter J, Pegoretti K, Cordero‐Grande L, Edwards AD, Hajnal JV. The effect of maternal position on venous return for pregnant women during MRI. NMR in Biomedicine. 2021 Apr;34(4):e4475.  Couper S, Clark A, Thompson JM, Flouri D, Aughwane R, David AL, Melbourne A, Mirjalili A, Stone PR. The effects of maternal position, in late gestation pregnancy, on placental blood flow and oxygenation: an MRI study. The Journal of physiology. 2021 Mar;599(6):1901-15.  Higuchi H, Takagi S, Zhang K, Furui I, Ozaki M. Effect of lateral tilt angle on the volume of the abdominal aorta and inferior vena cava in pregnant and nonpregnant women determined by magnetic resonance imaging. Anesthesiology. 2015;122(2):286-293.  Fujita N, Higuchi H, Sakuma S, Takagi S, Latif MA, Ozaki M. Effect of right-lateral versus left-lateral tilt position on compression of the inferior vena cava in pregnant women determined by magnetic resonance imaging. Anesthesia & Analgesia. 2019 Jun 1;128(6):1217-22.  Aust H, Koehler S, Kuehnert M, Werdehausen R, Schleppers A, Reese PC, Reyher C. Guideline-recommended 15° left lateral table tilt during cesarean section in regional anesthesia—practical aspects: an observational study. Int J Obstet Anesth. 2016 Aug;27:47-53.  Crawford JS, Burton M, Davies P. Time and lateral tilt at Caesarean section. Br J Anaesth. 1972 May;44(5):477-84.  Lee AJ, Landau R, Mattingly JL, Meenan MM, Corradini B, Wang S, Goodman SR, Smiley RM. Left lateral table tilt for elective cesarean delivery under spinal anesthesia has no effect on neonatal acid–base status: a randomized controlled trial. Anesthesiology. 2017;127(2):241‑249.  Jackson KL, Smiley RM, Lee AJ. Neonatal acid-base status before and after discontinuing routine left uterine displacement for elective cesarean delivery: a retrospective cohort study (2014–2017). Int J Obstet Anesth. 2025;62:104350.  You need to add a widget, row, or prebuilt layout before you’ll see anything here. 🙂

Hypothetical Case: You are called to MFAU to see a woman who has just arrived via RFDS (royal flying doctor service) She is a 23 y.o indigenous woman from the Kimberley in the far north of WA. She is 33/40 G1P0 complex social history and possible substance use disorders She has PPROM (pre term premature rupture of membranes) and suspected early chorioamniotis and has been given antibiotics / nifedipine and a few litres of crystalloid fluid during the flight. The obstetric team have evaluated her – she has small for gestational age baby, and is complaining of dyspnoea. Her observations are: HR 110, NIBP 124/60, SpO2 91% on room air, T38.1 Her bloods are relatively normal except for an unexpected high BNP. You do a focussed bedside transthoracic ECHO and unexpectedly see on the PLAX (parasternal long axis view) a classical hockey stick / domed appearance of severe mitral stenosis. She also has Pulmonary B-lines (indicating pulmonary oedema) and a flattened interventricular septum, very large atrium & doppler through the tricuspid valve confirms severe pulmonary hypertension.  The team decides she would be better cared for in a hospital with cardiothoracic services – however she suddenly becomes more breathless – SpO2 86% on oxygen, NIBP 80/40 HR 125, and there is a prolonged foetal bradycardia………………… Hi Everyone, This week I am joined by Dr Clinton Ellis, a cardiothoracic anaesthetist based in Sir Charles Gairdner Hospital, and Graeme. We discuss the management of rheumatic heart disease in pregnancy – a challenging condition which unfortunately is still relatively prevalent amongst indigenous women here in Australia. This was a wide ranging discussion so I have decided to split this into two 40min episodes. Even though we talk for over 80min I feel like we just scratched the surface on this! If you have any questions or comments send them through – I will try and get Clinton to answer them. Finally a huge shout out and thank you to the Darwin based authors of the ANZCA 2023 Blue Book article on this condition: Namrata Jhummon-Mahadnac, Matthew Mathieson, and Akshay Hungenahally! See the link to their well written narrative review on this topic below: References Australasian Anaesthesia 2023 (aka the Blue Book) – see page 39 “Obstetric anaesthesia in rheumatic heart disease – a unique perspective from the Top End” Oral vaccine could prevent rheumatic heart disease in NZ VIDEO: Researchers close to a vaccine for strep-A and rheumatic heart disease

Hypothetical Case: You are called to MFAU to see a woman who has just arrived via RFDS (royal flying doctor service) She is a 23 y.o indigenous woman from the Kimberley in the far north of WA. She is 33/40 G1P0 complex social history and possible substance use disorders She has PPROM (pre term premature rupture of membranes) and suspected early chorioamniotis and has been given antibiotics / nifedipine and a few litres of crystalloid fluid during the flight. The obstetric team have evaluated her – she has small for gestational age baby, and is complaining of dyspnoea. Her observations are: HR 110, NIBP 124/60, SpO2 91% on room air, T38.1 Her bloods are relatively normal except for an unexpected high BNP. You do a focussed bedside transthoracic ECHO and unexpectedly see on the PLAX (parasternal long axis view) a classical hockey stick / domed appearance of severe mitral stenosis. She also has Pulmonary B-lines (indicating pulmonary oedema) and a flattened interventricular septum, very large atrium & doppler through the tricuspid valve confirms severe pulmonary hypertension.  The team decides she would be better cared for in a hospital with cardiothoracic services – however she suddenly becomes more breathless – SpO2 86% on oxygen, NIBP 80/40 HR 125, and there is a prolonged foetal bradycardia………………… Hi Everyone, This week I am joined by Dr Clinton Ellis, a cardiothoracic anaesthetist based in Sir Charles Gairdner Hospital, and Graeme. We discuss the management of rheumatic heart disease in pregnancy – a challenging condition which unfortunately is still relatively prevalent amongst indigenous women here in Australia. This was a wide ranging discussion so I have decided to split this into two 40min episodes. Even though we talk for over 80min I feel like we just scratched the surface on this! If you have any questions or comments send them through – I will try and get Clinton to answer them. Finally a huge shout out and thank you to the Darwin based authors of the ANZCA 2023 Blue Book article on this condition: Namrata Jhummon-Mahadnac, Matthew Mathieson, and Akshay Hungenahally! See the link to their well written narrative review on this topic below: References Australasian Anaesthesia 2023 (aka the Blue Book) – see page 39 “Obstetric anaesthesia in rheumatic heart disease – a unique perspective from the Top End” Oral vaccine could prevent rheumatic heart disease in NZ VIDEO: Researchers close to a vaccine for strep-A and rheumatic heart disease

Hi everyone, Pain during caesarean is a very challenging and distressing event – for the patient, their partner, the anaesthetist and all the staff present in theatre. This week we catch up with Matt Rucklidge, who recently gave a presentation on this topic at the obstetric anaesthesia meeting in London. We discuss why this has become a “hot topic” in the anaesthesia world in recent times, what is the true incidence, and many other aspects of this difficult topic. References The following is a first person narrative story from a patient with commentary from an uninvolved obstetric anaesthetist. Disappointingly from elselvier this article is unfortunately not open access but is well worth a read: Stanford SE, Bogod DG. Failure of communication: a patient’s story. Int J Obstet Anesth. 2016 Dec;28:70-75. doi: 10.1016/j.ijoa.2016.08.001. Epub 2016 Aug 23. PMID: 27717633. Podcast: The Retrievals Season 2 from NY Times Prevention and management of intraoperative pain during Caesarean sectionOrbach-Zinger, S. et al.BJA Education, Volume 25, Issue 2, 50 – 56