RN's Role in Managing OB Complications

Vyacheslav Belous, DO

Journal of Perinatal and Neonatal Nursing

Vol. 23, No. 1, pp. 23–30

Complications in Obstetric Anesthesia

Nursing’s Role to Anticipate, Recognize, and Respond

Bernadette Balestrieri-Martinez, MSN, RNC, CCNS

This article discusses the important role of nursing staff in being able to recognize complications of obstetric anesthesia.  It stresses the importance of enhanced education in early recognition and treatment of obstetric anesthesia and proposes a curriculum for this purpose. Major complications are listed and detailed, which include local toxicity, high block, post-dural puncture headache, unilateral blocks or patchy blocks, bladder dysfunction, maternal pyrexia, neurologic complications, pulmonary aspiration, difficult/failed intubation, hypotension, hypovolemia, malignant hyperthermia, and cardiovascular instability.

Does Anesthesia Cause Birth Defects? Dr. Giles

Erin Giles, DO

The American College of Obstetricians and Gynecologists in February 2011 documented committee opinion on nonobstetric surgery during pregnancy.  Nonobstetric surgery during pregnancy is a concern for all the providers involved, including anesthesiologists, obstetricians, surgeons and pediatricians.  In practice, it is a multi-disciplinary team approach in caring for the woman and fetus.  The team can decide the optimal time to proceed with surgery following the guidelines documented by committee opinion that a pregnant woman should never be denied surgery regardless of trimester, nonurgent surgery should be performed in the second trimester when spontaneous abortion and preterm complications are least likely, and elective surgery should be performed after delivery.  

As an anesthesiologist I take comfort in the generalization stated in this committee opinion that no currently used anesthetic agents have been shown to have any teratogenic effects in humans when using standard concentrations at any gestational age.  It is important to note that there is difficulty in conducting clinical trials in this patient population; therefore data is limited to support this.  Possibly further studies would give us more insight into anesthesia and teratogenicity.  In summation, this committee opinion along with a team approach can help direct our care for nonobstetric surgery during pregnancy.

Hypotension in OB Spinal Anesthesia, Dr. H. Chang

Helen A. Chang, DO

Article:
Hypotension in obstetric spinal anesthesia: a lesson from pre-eclampsia. G. Sharwood-Smith and
G.B. Drummond. British Journal of Anesthesia. 2009, 102 (3): 291-294.

Summary:
Vasopressors are oftentimes used to prevent hypotension after spinal anesthetics for cesarean section. Why expectant mothers become hypotensive may be due to several theories:

1. Spinal anesthesia almost always causes hypotension in normal pregnancy

2. Cardiac output can be reduced by aortocaval compression in the supine position from decreased venous return

3. A marked bradycardia with concomitant reduction in cardiac output and severe hypotension can occur suddenly

Many studies and therapies have been proposed to elude why drastic changes in hemodynamics may occur. There is no escape from the fact that therapies based on the concept of caval compression do not reliably prevent hypotension after a spinal technique. Compliance is more important than resistance in the venous system. Venous capacitance and its regulation in pregnancy are important in understanding the hemodynamic response to spinal anesthesia.

Sensors that normally autoregulate arterial pressure (carotid sinus and aorta) are part of the baroreflex pathway. Why does this reflex fail to maintain arterial pressure after spinal anesthesia in pregnancy? Answer is possibly seen in the pathophysiology of pre-eclampsia. In pre-eclampsia, vascular epithelium is damaged by placental-derived proteins, leading to an imbalance between pro-/anti-angiogenic growth factors. This results in persistent vasoconstriction. Sympathomimetic vasopressors to sustain arteriolar tone have become the most important strategy for safe spinal anesthesia in contemporary practice. This still holds despite the theory of caval occlusion as the culprit  for hypotension following a spinal in normal pregnancy

Case Study: Amniotic Fluid Embolism, Dr. Cartier

Cameron Cartier, DO

Case Scenario: Amniotic Fluid Embolism

Bruno Riou, MD, Ph D

Anesthesiology, January 2012 issue

          Amniotic fluid embolism is a rare condition found in the time period immediately prior, during and shortly after deliver which can have catastrophic consequences. This condition is very difficult to diagnose in the early stages and we do not currently have a precise pathophysiology cause to this condition, although it is thought to be partly immune mediated or anaphylactic in nature.  The diagnosis remains a diagnosis of exclusion, but should be considered in any peripartum patient that presents with any combination of acute hemodynamic collapse, respiratory distress/hypoxia, DIC and/or mental status change without any other medical explanation.

          Some early signs and symptoms include: acute dyspnea and/or cyanosis, sudden tachycardia, hypotension, acute agitation/ALOC, seizure, coagulopathy, sudden desaturation, loss of EtCO2, ST changes and fetal distress.

          The managemnt of this condition relies on early suspicion and early aggressive hemodynamic support. The main therapies include oxygenation, circulatory support and correction of coagulopathy. Immediate Cesarian section improves neonatal neurological recovery and overall maternal outcome.

Amniotic Fluid Embolism, Dr. Halonen

Jeff Halonen, DO

Case Scenario: Amniotic Fluid Embolism

Bruno Riou, MD, Ph D

Anesthesiology, January 2012 issue

          Amniotic fluid embolism is a rare condition found in the time period immediately prior, during and shortly after deliver which can have catastrophic consequences. This condition is very difficult to diagnose in the early stages and we do not currently have a precise pathophysiology cause to this condition, although it is thought to be partly immune mediated or anaphylactic in nature.  The diagnosis remains a diagnosis of exclusion, but should be considered in any peripartum patient that presents with any combination of acute hemodynamic collapse, respiratory distress/hypoxia, DIC and/or mental status change without any other medical explanation.

          Some early signs and symptoms include: acute dyspnea and/or cyanosis, sudden tachycardia, hypotension, acute agitation/ALOC, seizure, coagulopathy, sudden desaturation, loss of EtCO2, ST changes and fetal distress.

          The managemnt of this condition relies on early suspicion and early aggressive hemodynamic support. The main therapies include oxygenation, circulatory support and correction of coagulopathy. Immediate Cesarian section improves neonatal neurological recovery and overall maternal outcome.