You are working in the pre-admission clinic. Charlie, a 28 year old pregnant with MCDA twins, at 27 weeks gestation. She is highly anxious about the birth and delivery of her babies via lower segment caesarean section. She is demanding to have a general anaesthetic.
The relevant medical and obstetric history includes:
G2P0
MCDA Twin pregnancy
Previous miscarriage - managed with dilatation & currettage under GA
Past Medical History
Obssessive Compulsive Disorder
Anxiety
Insomnia
Migraines
GORD
Medications
Elevit
Omeprazole
Allergies
Tramadol - vomiting
Morphine - extreme pruritus
OPENING QUESTION
Candidate has 2 minutes reading time to plan their initial response to the first question below
Click each question to reveal a suggested answer
Outline how you would alleviate her concerns?
- Have an empathetic approach and listen actively
- Legitimise her concerns and genuine interest in anaesthesia and delivery plan.
- Inquire what her specific concerns and anxieties relate to e.g.
- needlephobia
- risks to spinal block
- OT environment
- Outline the different modes of anaesthesia for birth with an emphasis on the safety and benefits of a neuraxial approach for both maternal and foetal outcomes
- Provide more detailed information regarding risk related to spinal and epidural blocks
Charlie explains she has a severe needlephobia and is terrified of the spinal block. How do you respond to this?
- Take a focused history regarding previous hospital experiences with phlebotomy, IV cannulation and previous anaesthesia to understand what this anxiety stems from
- Explain different strategies that can be used to lessen the psychological impact e.g
- invite support person to chaperone
- music
- practice deep breathing exercises
- use of N2O at time of IV cannulation for sedation / anxiolysis
- use of LA
- US guidance for IV and/or spinal to maximise success and minimal attempts
- Small judicious dose of propofol (e.g. 20 – 30mg) for anxiolysis during spinal
- (if this answer given by candidate, probe for their dose).
PROGRESS QUESTIONS
What more do you want to know about her allergies?
- Context of morphine exposure
- Severity – itch only or with rash and angiodema?
- Similar reaction to other opioids?
She asks how you can be certain the neuraxial block is working before surgical incision. How do you explain this?
As per recommended guidelines published in Anaesthesia (2022):
3 modalities are tested to confirm adequate density and height up to T5 level, including
- light touch / cold
- sharp pinprick
- motor block (straight leg raise)
This is checked and rechecked before any surgical incision
Expected sensations that remain unchanged are stretching/pulling and deep pressure.
What are your unique perioperative considerations for delivering twins via caesarean section?
- Anaesthetic factors: greater engorgement of epidural veins -> higher risk of bloody tap/intravascular catheter, tighter epidural and subarachnoid spaces -> lower LA doses, prolonged OT time for LSCS.
- Maternal factors: pre-eclampsia, severe aorto-caval compression, worse anaemia, worse GORD, higher incidence of PPH, uterine atony
- Foetal factors: IUGR of one twin, malpresentation, premature labour, placenta praevia spectrum
10 weeks later Charlie is on your list for an elective LSCS. What is your anaesthetic plan?
Response should have a systematic approach outlining the key issues/goals, additional pre-op planning, intra-operative management and post-op care specific to this patient
Key Issues
Twin pregnancy - increased risk of neonatal resus, major PPH, prolonged operating time
Severe anxiety - challenging cooperation for IV access and neuraxial block
Morphine allergy - alternative to intrathecal morphine
Post-op pain - possibly difficult to control
Anaesthesia
If candidate gives alternative answer to CSE e.g. spinal block, epidural top-up or GA they must give sufficient justification. GA should not be 1st choice in this case.
Benefits of CSE: superior quality neuraxial block with subarachnoid LA. Epidural facilitates ongoing neuraxial block for prolonged surgical time in context of twin delivery. Provides option for post-op analgesia with lowest risk of drug transfer to breast milk and is opioid sparing. CSE provides quicker onset anaesthesia, preventing idle waiting time for establishing a de-novo epidural block which is undesirable in an anxious patient.
Mode: CSE specifically in anaesthetic bay for better privacy for her anxiety
Method: spinal block according to ANZCA Major Regional Anaesthesia guidelines. e.g. with 2.5mL hyperbaric bupivacaine, 20mcg fentanyl, intentionally omitting morphine, followed by epidural catheter.
Distraction techniques:
- partner present
- play music from phone as patient requests
- continously talk to patient, distract with conversation, maintain rapport
- have N2O available (this assumes wall N2O is in the anaesthetic bay. Otherwise, location should be OR)
If candidate does not volunteer distraction techniques or how anxiety is managed, this needs prompting.
Monitoring & Access
Standard monitoring during neuraxial block
Large bore IV access - at least 18G
Drugs
Bolus 1L of Hartmann's during the insertion of block
Metaraminol / phenylephrine infusion primed, connected and ready to start immediately post-block
Pre-drawn cephazolin, carbetocin with other uterotonics & TXA readily available and 2%lig w/ 1:200,000 adrenaline for epidural top-up PRN.
Extra
Valid G+S
Paediatric teams present with dual resuscitaires
Pre-block team huddle
Check adequacy of block for surgical anaesthesia with 3 tiered modalities: light touch/ice, forcep pinch, motor block (SLR).
Post-Op
TAP blocks / catheters at end of case
PCA
Oral analgesia regimen
APS review
Candidate should emphasise the importance of tactful communication with the patient throughout different phases of anaesthesia and surgery.
COMPLICATION QUESTIONS
(Regardless of candidate's answer, a CSE is performed). You are in the anaesthetic bay. During the CSE procedure, after spinal dosing and prior to threading the epidural catheter, Charlie becomes agitated and begins to hyperventilate and cry uncontrollably. She states she is feeling faint, says her heart is racing, and reports a sensation of numbness in her arms.
What is your differential diagnosis for her current symptoms, and how would you assess and manage them?
Candidate to consider at least:
High spinal block
LAST
Anxiety-induced hyperventilation / Panic attack
Vasovagal episode
Should be able to articulate how they would differentiate these based on clinical signs – e.g., dermatomal block height, respiratory effort, hemodynamics, pupil size, motor tone – and how they would act immediately while maintaining safety for both mother and babies
There are clear signs of clinical deterioration that could be due to a profound rapid onset subarachnoid block resulting in severe hypotension, accounting for her symptoms.
- Abandon epidural catheter - spinal block is primary mode of anaesthesia anyway
- Reposition patient supine, semi-reclined
- Instruct nurse to repeat all vital signs
- Assess ABCD and temporise with IV fluid bolus 500mL and metaraminol bolus 0.5mg
- Specifically assess for high block: dense LL motor weakness, onset of bilateral arm weakness, paraesthesia, bradycardia, short shallow breathing pattern, impending doom, reduced consciousness
Her blood pressure is now 70/40 mmHg, heart rate is 40 bpm, and she is drowsy and reporting difficulty breathing. How do you manage this scenario now?
Expect a crisis management response that is systematic and reflects recognition of a high spinal block.
- Call for emergency help
- Reassess vital signs and consiousness
- Airway support
- Oxygenation, assess for signs of spontaneous ventilation
- Vasopressors (e.g., ephedrine 12 – 15mg, adrenaline 25 – 50mcg) or atropine 0.6 – 1.2mg – if candidate gives metaraminol or phenylephrine – probe for rationale. If drug doses not volunteered – seek to clarify
- intravenous fluid bolus
- Communicate to surgeon – expedite for an emergency LSCS & preparation for RSI, GA
- Consider other DDx: LAST, PE, AFE, placental abruption
- Bonus point if candidate demonstrates excellent situational awareness & addresses how to manage the patient’s support person who would be still be present in the room (assuming above life-saving measures are also applied).
Hypotension persists and patient has now lost consciousness. What are your next steps?
Assess understanding of a life threatening situation that demands an emergency call for help, time-critical emergent delivery of babies, RSI, risk of difficult airway in pregnancy, aspiration risk, and considerations for twin pregnancy, including uterine displacement and worsened aortocaval compression.
- Alert the theatre team and check the patient for a response and a pulse, with gravest concerns that she is now in cardiac arrest
- In this specific situation I would rapidly intubate the patient without hesitation, using a VL and then instruct the team to immediately start CPR as per resuscitation / ALS guidelines.
- if candidate gives NMB, this is acceptable. If an induction agent is given probe for rationale
- I would prioritise application of the debrillator and assess for a shockable or non-shockable rhythm
- Unique to the parturient, LUD will need to be maintained and timekeeper to alert us at 4min – when perimortem C/S will be required if no ROSC.
- I would delegate assistants to manually ventilate with 100% FiO2 at 12 breaths per minute, obtain larger bore IV access, bolus 1L of CSL and prepare syringes of 1mg adrenaline and an adrenaline infusion (3mg in 50mL)
At 4min, ROSC has not been acheived. The obstetrician immediately performs a classical inicision and delivers the two neonates. He promptly asks you to give some uterotonics. How do you respond to his request?
The priorities at this point are:
- continuing CPR
- balancing the need for haemostasis and uterine tone with haemodynamic stability
- oxytocin should be given slowly and carefully e.g. 1 unit bolus followed by 5 units /h - candidate must recognise the benefits & risks of oxytocin in this situation
- Uterine blood loss is minimal prior to ROSC, but can be profound with high quality CPR and after ROSC.
The neonates require CPAP but are otherwise stable. Mother acheives ROSC soon after emptying the gravid uterus. Vital signs: BP 87/50, HR 50, SpO2 95%. What are you next steps in management?
- Support end-organ perfusion – adrenaline / norad infusion (0.05 – 0.5 mcg/kg/min), arterial line
- Maintain sedation for tube tolerance (propofol / fentanyl + midaz / other any other reasonable combo)
- Prepare for post-resuscitative care (refer to ICU for admission, prevent hypothermia, cardiac monitoring)
AFTERMATH QUESTIONS
You follow-up Charlie the next day in ICU after she has been extubated. She is extremely distressed, tearful and refuses to speak with the medical team. She says she “felt everything.” How do you approach this situation?
- Priorities:
- Assess for accidental awareness – modified Brice Questionnaire
- Open disclosure
- Refer patient for psychological counselling if agreeable – high risk of PTSD / birth trauma
- Document discussions thoroughly
- Alert medical indemnity provider
- Plan for further follow-up
Approach: Listen empathetically and validate her concerns, open disclosure with offer for early debriefing and apology. Invite patient's support person to be present
(if not volunteered) How do you assess the risk of awareness?
Modified Brice Questionnaire:
1. What is your last memory before going to sleep
2. What is the first memory when you woke up?
3. Do you remember anything in between?
4. Did you have any dreams or nightmares during surgery?
5. What is the worst thing you remember?
Ideally ask on 3 separate occasions: PACU, POD1, POD7
Investigate / Analyse:
- Corroborate history from patient and anaesthetic / medical file and colleagues present during the case
- Attempt to identify a cause -> in this case cardiovascular collapse and intubation without anaesthesia and reduced anaesthesia given haemodynamic instability. A common cause in cases of AAGA
END OF VIVA
Sources
Racheal Collis et al, Obstetric Anaesthesia, 2 edn, Oxford Specialist Handbooks in Anaesthesia (Oxford, 2020)
Plaat, F., Stanford, S.E.R., Lucas, D.N., Andrade, J., Careless, J., Russell, R., Bishop, D., Lo, Q. and Bogod, D. (2022), Prevention and management of intra-operative pain during caesarean section under neuraxial anaesthesia: a technical and interpersonal approach. Anaesthesia, 77: 588-597. https://doi.org/10.1111/anae.15717
Eldridge AJ, Ford R. Perimortem caesarean deliveries. International Journal of Obstetric Anesthesia. 2016;27:46-54. doi:10.1016/j.ijoa.2016.02.008
J. J. Pandit, T. M. Cook, W. R. Jonker, E. O'Sullivan, on behalf of the 5th National Audit Project (NAP5) of the Royal College of Anaesthetists and the Association of Anaesthetists of Great Britain, Ireland, A national survey of anaesthetists (NAP5 Baseline) to estimate an annual incidence of accidental awareness during general anaesthesia in the UK, BJA: British Journal of Anaesthesia, Volume 110, Issue 4, April 2013, Pages 501–509, https://doi.org/10.1093/bja/aet016
RHW Anaesthesia 