Obstetric Anaesthesia Nursing Guide

Labour Analgesia Options

A stepwise approach from non-pharmacological to regional techniques, tailored to maternal preference, clinical status, and stage of labour.

Non-Pharmacological Methods

TENS & Hydrotherapy

TENS: Transcutaneous electrical nerve stimulation — electrodes on lower back; modulates pain via gate control theory
Water immersion: Warm bath/pool (37°C); reduces cortisol; improves maternal satisfaction; avoid after membrane rupture in some units

Psychological Techniques

Breathing techniques: Lamaze/patterned breathing; reduces tension and anxiety; requires antenatal training
Hypnobirthing: Self-hypnosis and guided imagery; evidence for reduced pharmacological analgesia use; requires trained practitioner

Entonox (Nitrous Oxide)

Composition

50% Nitrous Oxide : 50% Oxygen (N₂O:O₂)

Self-Administered

Onset

~30 seconds — patient begins inhaling at contraction start

Technique

Hold mouthpiece (not mask) firmly — inhale deeply at contraction onset, release at peak/end

Nursing Duty

Flush system between patients (cross-infection prevention); check tubing integrity; educate on timing

Side effects

Nausea, dizziness, light-headedness — stops rapidly on removing mouthpiece

Nurse Tip: The 30-second onset means the patient must start inhaling as soon as a contraction begins — coach her to anticipate the contraction rather than react to peak pain.

Systemic Opioids

Drug	Route	Key Points	Neonatal Risk
Pethidine	IM / IV	100mg IM; widely used; active metabolite norpethidine	Respiratory depression — worst if birth 1–3h post-dose
Diamorphine	IM	5–7.5mg IM; better analgesia than pethidine; more commonly used in UK	Respiratory depression; shorter neonatal risk window
Morphine	IM / IV	Less common in active labour; used in latent phase	Neonatal respiratory depression; crosses placenta

Neonatal Reversal: Naloxone 0.1 mg/kg IM to neonate if respiratory depression present. Have resuscitation equipment immediately available. Notify paediatrics in advance if opioid given within 4 hours of delivery.

Remifentanil PCA

Route: Patient-controlled IV — ultra-short-acting opioid (half-life ~3 min)

Typical setting: 0.2–0.4 mcg/kg bolus, lockout 2 minutes (unit protocol dependent)

Mandatory monitoring requirements:

Continuous SpO₂ — pulse oximetry throughout
Continuous one-to-one nursing — nurse must not leave bedside
Oxygen therapy available at bedside
Respiratory rate monitoring every 15 minutes minimum
Dedicated IV line — not to be used for anything else

Oversedation risk: Rapid dose titration can cause apnoea — nurse must remain present, naloxone available. If SpO₂ <94% or sedation score >2 — stop PCA immediately, stimulate, call anaesthetist.

Regional Analgesia Overview

Epidural

Gold standard; continuous infusion; converts to CS anaesthesia; see Tab 2

Combined Spinal-Epidural (CSE)

Spinal for rapid onset; epidural for maintenance; popular in active labour

Spinal

Single shot; used for CS; see Tab 3

Pudendal / Paracervical Block

Limited use; second stage perineal analgesia only; operator-dependent

Epidural Analgesia

The most effective form of labour analgesia. Requires careful patient selection, positioning assistance, and ongoing monitoring by the anaesthesia nurse.

Epidural Space Anatomy

Located between the ligamentum flavum and the dura mater
Contains fat, blood vessels, lymphatics, and spinal nerve roots
Identified by loss of resistance (LOR) technique using air or saline
Typical depth from skin: 4–6 cm (varies with BMI — obstetric patients often deeper)
Catheter inserted 3–5 cm into space for continuous infusion

Contraindications

Absolute Contraindications

Patient refusal
Infection at insertion site
Uncorrected severe hypovolaemia
Coagulopathy (INR >1.5; APTT ratio >1.5)
Thrombocytopenia <80 × 10⁹/L

Relative Contraindications

Thrombocytopenia 80–100 × 10⁹/L (anaesthetist judgement)
Prior spinal surgery / scoliosis
Raised intracranial pressure
Anticoagulation (time intervals must be observed)

Procedure Assistance — Nurse Role

Confirm IV access established (minimum 18G); fluid preload/co-load as per anaesthetist instructions

Position patient: seated (preferred — opens interspinous spaces) or lateral decubitus. Encourage maximal lumbar flexion — "chin to chest, curve back like an angry cat"

Continue fetal monitoring (CTG) during procedure — note baseline FHR

Maintain sterile field; assist anaesthetist with equipment; label syringe

Secure catheter to skin; document insertion level (e.g., L3–L4) and depth

Post-insertion: BP every 5 min × 20 min; CTG continuous; check sensory level at 15 min

Drug Combinations

Standard Labour Epidural

Bupivacaine 0.1% + Fentanyl 2 mcg/mL — continuous infusion 8–12 mL/hr

First Line

Top-Up for CS

Bupivacaine 0.5% 15–20 mL (in 5 mL increments) via epidural catheter — allows conversion to surgical anaesthesia

Conversion

PCEA (Patient-Controlled Epidural)

Background infusion + bolus on demand (e.g., 5 mL bolus, 20-min lockout) — greater patient satisfaction, less motor block

PCEA

Sensory Block Monitoring

Ice / Cold Test (Sensory Level)

Apply ice or ethyl chloride spray to skin
Compare sensation bilaterally — start midline chest, move downward
Document level by dermatome (T4 = nipple, T6 = xiphisternum, T10 = umbilicus, T12 = inguinal)
Adequate labour analgesia: T10–L1 bilaterally
Adequate for CS: T4 bilaterally

Bromage Motor Score

Score	Ability
0	Full movement — no block
1	Unable to raise extended leg
2	Unable to flex knee
3	Unable to flex ankle/foot — complete motor block

Target for labour: Bromage 0–1 (mobile epidural). Target for CS: Bromage 3.

Inadequate Epidural

Key Principle: Replace a poorly functioning epidural early — before an emergency CS arises. A failed labour epidural that cannot be topped up for emergency CS forces general anaesthesia, which carries higher maternal risk.

Check catheter position and depth
Reposition patient; check for unilateral block
Withdraw catheter 1–2 cm if intravascular signs
If no improvement in 2 top-up attempts — inform anaesthetist to consider reciting

High Block — Emergencies

High Block Warning Signs:

Numbness spreading to neck, arms, or hands
Increasing respiratory difficulty or inability to speak in full sentences
Hypotension unresponsive to vasopressors
Bradycardia
Anxiety, altered consciousness

Action: Stop epidural infusion immediately → call anaesthetist → left lateral tilt → O₂ → IV fluids → vasopressor → prepare for airway management

High Spinal Emergency Management Protocol▼

HIGH SPINAL / TOTAL SPINAL — EMERGENCY

CALL FOR HELP — crash team / senior anaesthetist immediately

Stop epidural/spinal drug delivery — clamp infusion

Left uterine displacement — wedge under right hip (15–30°)

100% O₂ by tight-fitting mask; if apnoeic — bag-mask ventilation (IPPV)

IV fluid bolus — 500 mL crystalloid rapid infusion

Vasopressor: Phenylephrine 50–100 mcg IV bolus (or ephedrine 6 mg if bradycardia)

If unconscious/apnoeic — RSI and intubation by anaesthetist

Prepare for emergency CS if fetal compromise present

Document time, drugs given, block level, maternal and fetal status

Spinal Anaesthesia for Caesarean Section

The preferred technique for elective and most emergency CS. Rapid onset, reliable block, avoids airway manipulation.

Spinal Drug Regimen

Hyperbaric Bupivacaine 0.5%

Typical dose: 2.0–2.5 mL (10–12.5 mg) — hyperbaric formulation allows positioning to influence block spread

Primary

Fentanyl (intrathecal)

15–25 mcg — improves block quality; reduces dose of bupivacaine needed; minimal neonatal effect

Adjuvant

Morphine (intrathecal)

0.1–0.2 mg — provides post-operative analgesia up to 24 hours; respiratory depression monitoring required

Post-op Analgesia

Procedure — Nurse Assistance

IV access confirmed; IV fluids running (co-loading: 1–1.5 L crystalloid with or just after spinal)

Position: seated or lateral — assist patient to maintain position during insertion; coach breathing

Confirm CSF flow from spinal needle before injection — clear, free-flowing CSF

After injection — lower patient to supine slowly; apply left uterine displacement (wedge or manual tilt)

Check block height at 5 min and 10 min — ice test; target T4 (nipple level) for CS

BP every 2 min for first 15 min; SpO₂ continuous; FHR monitoring

Block Height Targets

Dermatome	Landmark	Significance
T4	Nipple line	Required for CS — visceral peritoneal pain otherwise felt
T6	Xiphisternum	Adequate for uterine exteriorisation; watch for high block above this
T10	Umbilicus	Adequate for labour only — insufficient for CS
T12	Inguinal fold	Lower limb anaesthesia only

Hypotension Management

Spinal hypotension occurs in up to 70–80% of obstetric patients — anticipate and treat proactively.

Phenylephrine

First-line vasopressor — 50–100 mcg IV bolus; or infusion 25–50 mcg/min; maintains uteroplacental perfusion

First Line

Ephedrine

6–12 mg IV — use if bradycardia accompanies hypotension (phenylephrine can cause reflex bradycardia)

If Bradycardia

Crystalloid Co-loading

1–1.5 L Hartmann's/0.9% NaCl — infuse rapidly at time of spinal injection (not before — preload less effective)

Fluid Strategy

Left Uterine Displacement

15–30° left tilt or manual displacement — relieves aortocaval compression — ALWAYS apply

Positioning

Post-Dural Puncture Headache (PDPH) — Diagnosis and Epidural Blood Patch▼

Diagnosis

Onset: 24–48 hours post procedure (rarely immediate)
Character: Severe, bilateral, frontal/occipital — often described as "worst headache of life"
Posture: Markedly worse when upright — relieved by lying flat (pathognomonic feature)
Associated: photophobia, neck stiffness, tinnitus, diplopia
Caused by: inadvertent dural puncture (epidural needle) or standard spinal needle; CSF leak → traction on meninges

Conservative Management (24–48h trial)

Bed rest (lying flat provides relief)
Adequate hydration — oral or IV
Caffeine 300–500 mg oral (2–3 cups coffee; or IV caffeine benzoate)
Regular NSAIDs (diclofenac) + paracetamol

Epidural Blood Patch (EBP)

Indication: PDPH not responding to conservative measures within 24–48h, or severe/debilitating headache
Procedure: 20 mL autologous blood drawn aseptically → injected into epidural space at same level as original puncture
Success rate: ~85–95% on first attempt
Nurse preparation: IV access, BP monitoring, sterile field, blood collection equipment, post-procedure 2h bed rest
Post-EBP: avoid straining, heavy lifting for 48h; observe for backache (common, transient)

Exclude: Meningitis, subdural haematoma, pre-eclampsia before assuming PDPH. Fever, neck rigidity, or neurological signs = urgent neurology/anaesthesia review.

Emergency Caesarean Section

Rapid classification, anaesthetic choice, and team-based emergency management are critical nursing competencies.

CS Category Classification

Category	Description	Target Delivery
Cat 1	Immediate threat to maternal or fetal life (cord prolapse, uterine rupture, severe fetal bradycardia)	30 minutes (NICE standard)
Cat 2	Maternal or fetal compromise — not immediately life-threatening	75 minutes (institutional target)
Cat 3	No maternal or fetal compromise but early delivery needed	Planned; hours
Cat 4	Elective — at time to suit patient and team	Scheduled

GCC Note: Category 1 CS requires the team to be assembled and surgical incision within 30 minutes of decision. The anaesthesia nurse role includes alerting theatre, preparing the anaesthesia machine, and assisting with rapid spinal or RSI setup simultaneously.

Anaesthetic Options for Emergency CS

Spinal Anaesthesia

Preferred even for Cat 1 if time permits (~8–10 min to block). Avoids airway risks. Convert existing labour epidural to surgical block if catheter functional.

General Anaesthesia (RSI)

Reserved for: failed regional, maternal haemorrhage/shock, true Cat 1 with no time for regional, patient refusal of regional.

Mendelson's Syndrome Prevention

Mendelson's syndrome = aspiration of acidic gastric contents → chemical pneumonitis → ARDS. Potentially fatal. Obstetric patients have delayed gastric emptying + high aspiration risk under GA.

Aspiration Prophylaxis Protocol

Ranitidine 150 mg PO 6–8 h before (or 50 mg IV if urgent) — reduces gastric acid secretion
Sodium citrate antacid 30 mL orally immediately before induction — neutralises existing gastric acid (must be given within 30 minutes of induction)
Metoclopramide 10 mg IV — optional; promotes gastric emptying
Rapid Sequence Induction (RSI) + cricoid pressure (Sellick's manoeuvre) during intubation
Nil by mouth policy enforcement — education to patients and ward staff

Failed RSI in Obstetrics — Emergency Drill▼

Failed intubation occurs more frequently in obstetrics (1:300 vs 1:2000 general surgical). Always have a failed intubation plan.

Anticipated Difficult Airway

If difficult airway expected: awake fibreoptic intubation (FOI) with topical airway anaesthesia. Patient cooperative; airway secured before induction. Nurse assists with topical spray, positioning, FOI equipment setup.

Can't Intubate / Can Ventilate (CICV) Algorithm

Failed intubation declared — do NOT make more than 2 attempts (mucosal trauma worsens view)

Maintain oxygenation via bag-mask ventilation (two-person technique if needed)

Insert supraglottic airway (LMA/ILMA) — if fetal/maternal compromise continues, proceed with surgery using LMA with cricoid pressure

If can't ventilate — surgical airway (front of neck access — scalpel cricothyrotomy)

Nurse role: maintain cricoid pressure until anaesthetist instructs release; prepare alternative airway devices; call for senior help

Post-Failed Intubation

Complete incident documentation
Debrief team; refer patient to anaesthesia clinic for future pregnancies
Provide patient with "difficult airway alert" documentation

Uterine Atony & PPH

Leading cause of maternal mortality. Uterine atony = failure of uterus to contract after delivery.

Oxytocin (Syntocinon)

5 IU slow IV bolus at delivery of anterior shoulder; then 10–40 IU infusion — first-line uterotonic

1st Line

Ergometrine

500 mcg IM — avoid in hypertension; causes vasoconstriction; combined with oxytocin in Syntometrine

2nd Line

Carboprost (PGF2α)

250 mcg IM every 15 min (max 8 doses) — avoid in asthma; bronchospasm risk

3rd Line

Tranexamic Acid

1 g IV over 10 min — give within 3 hours of PPH onset; repeat if bleeding continues at 30 min

Adjunct

Maternal Cardiac Arrest

Perimortem Caesarean Section (PMCS): If no ROSC after 4–5 minutes of CPR in a pregnant patient ≥20 weeks gestation — immediate CS at bedside. Relieves aortocaval compression and improves CPR efficacy.

Continue CPR throughout — do not pause for CS
Left uterine displacement during CPR — manual displacement by dedicated person
Call obstetric, anaesthesia, neonatal teams simultaneously
Standard ALS protocols apply — no drug modifications in pregnancy except avoid femoral IV access

Post-Anaesthesia Monitoring

Safe recovery from obstetric anaesthesia requires systematic assessment of block regression, respiratory monitoring, and multimodal analgesia.

Recovery Criteria Before Transfer to Ward

Criterion	Standard
Motor block (Bromage)	Score 0 — full movement restored before transfer
Sensory block	Below T10 (umbilicus) before oral fluids permitted
Blood pressure	Systolic >90 mmHg or >80% of baseline, stable for 30 min
Analgesia	Adequate pain control (NRS ≤3 at rest, ≤5 on movement)
Consciousness	Alert, orientated, obeying commands (GA patients)
Oxygen saturation	SpO₂ ≥95% on room air
Urine output	Catheter draining; >0.5 mL/kg/h confirmed

Intrathecal Morphine Observations

Intrathecal morphine (0.1–0.2 mg) provides excellent post-CS analgesia but carries delayed respiratory depression risk for up to 24 hours post-injection.

Mandatory Monitoring Protocol:

Respiratory rate: Hourly for 24 hours
Sedation score: Hourly (RASS or Ramsey) — sedation precedes respiratory depression
SpO₂: Continuous overnight or per unit protocol
Naloxone: Must be immediately available at bedside (0.4 mg IV — repeat every 2–3 min as needed)
Nurse education: do not administer additional systemic opioids without anaesthesia review

Action if RR <10 breaths/min or sedation score >2: Stimulate patient → call anaesthesia nurse/doctor → administer naloxone → O₂ → consider ICU review

Urinary Catheter Management

Removal criteria (all must be met):

Motor block fully resolved (Bromage 0)
Patient mobile and able to stand
Adequate analgesia for mobilisation
Voiding trial within 4–6 hours of removal — document first void
If unable to void within 6 hours — reinsert catheter; reassess at 24h

Wound Analgesia Techniques

Wound Infiltration

Surgeon infiltrates wound edges with levobupivacaine or ropivacaine at closure — reduces opioid requirement in first 12–24h

TAP Block (Transversus Abdominis Plane)

Ultrasound-guided — local anaesthetic deposited in TAP plane; covers T10–L1 somatic afferents; typically performed by anaesthetist before or after CS

Multimodal Analgesia — Post-CS Protocol

Standard Multimodal Regimen:

Paracetamol 1 g PO/IV — every 6 hours, regular (not PRN)
Diclofenac 50 mg PO or 75 mg PR — every 12 hours (if no contraindications: renal function, bleeding risk, asthma)
PRN opioid — oral morphine 10 mg or codeine 30–60 mg — as rescue; caution with intrathecal morphine on board
Intrathecal morphine covers first 12–24h; reduce PRN opioid accordingly
Consider: oral gabapentin, wound infiltration, TAP block as additions

Breastfeeding consideration: All above drugs compatible with breastfeeding in standard doses. Codeine should be used with caution (CYP2D6 ultra-metabolisers at risk).

GCC Context — Obstetric Anaesthesia

Regional context, regulatory frameworks, and culturally-sensitive practice for obstetric anaesthesia nurses working in Gulf Cooperation Council countries.

CS Rates in GCC

Saudi Arabia and UAE have CS rates among the highest globally (>40%)
WHO recommended threshold: 10–15% (population level)
Drivers: cultural preference for CS, maternal request, physician preference, private hospital incentives
High CS rates increase demand for obstetric anaesthesia services and post-CS recovery nursing

Epidural Acceptance

Increasing uptake with patient education campaigns
Some cultural reluctance: fear of permanent paralysis (myth to address proactively)
Religious misconception: "natural labour is obligatory" — not supported by Islamic scholars
Nurse role: provide evidence-based education in Arabic if needed; involve family in counselling

Workforce

Obstetric anaesthesia in GCC predominantly delivered by expatriate anaesthesiologists and anaesthesia nurses
Ongoing push for nationalisation (Saudisation/Emiratisation)
DHA (Dubai Health Authority) and DOH (Abu Dhabi Department of Health) — licensing and competency standards
SCFHS (Saudi Commission for Health Specialties) — midwifery/nursing anaesthesia competency framework includes obstetric anaesthesia modules

Ramadan Implications

Fasting parturient: higher aspiration risk — delayed gastric emptying may be unpredictable despite religious fast
Regional anaesthesia (spinal/epidural) strongly preferred over GA to minimise airway manipulation
Sodium citrate and ranitidine should still be given pre-operatively
Pregnant women are exempt from Ramadan fasting under Islamic law — counsel sensitively
Fluids in active labour: permitted even during fast if medically indicated

Arabic Patient Consent for Anaesthesia

Principles:

Consent must be informed — provide information in Arabic (or patient's language) using certified medical interpreter if nurse/anaesthetist not fluent
Husband/family may be present for discussion but cannot consent on behalf of a competent adult
For emergency situations: implied consent applies when patient is unable to consent and life is at risk
DHA/DOH require documented consent forms (Arabic and English) for regional and general anaesthesia
Explain: benefits, risks (PDPH, hypotension, failure, nerve injury, high block), alternatives

Interactive Tool: Epidural Block Level Assessment Guide

Patient Symptoms (select all that apply)

Arms feel numb or tingling Cannot move arms Difficulty breathing / short sentences Nausea / vomiting Loss of / altered consciousness Chest tightness

Dermatome Level Tested (ice/cold test)

Bromage Motor Score

Block Height Interpretation

—

Adequacy for CS

—

Safety Alert

—

Hypotension Management

—

Call Anaesthetist?

—

GCC Exam Practice — 5 MCQs

1. A parturient has received intrathecal morphine 0.1 mg as part of her spinal anaesthetic for elective CS. She is transferred to the postnatal ward. Which monitoring is MOST critical?

A. Blood glucose every 2 hours B. Temperature every 4 hours C. Blood pressure every 30 minutes D. Hourly respiratory rate and sedation score for 24 hours

2. During insertion of an epidural catheter, the patient suddenly reports numbness spreading to her hands and begins to struggle to breathe. Her BP drops to 80/50. What is the MOST appropriate FIRST action?

A. Increase epidural infusion rate to improve the block B. Stop epidural drug delivery, call for help, administer O₂, and give IV vasopressor C. Administer IM pethidine for pain D. Ask the patient to sit upright to reduce the block level

3. A patient in Ramadan presents for Category 2 CS. She reports fasting since dawn (14 hours). Which anaesthetic approach is most appropriate and why?

A. General anaesthesia — the patient has been fasting safely B. No anaesthesia prophylaxis needed as she has been fasting C. Regional anaesthesia preferred; give sodium citrate + ranitidine regardless of fasting status D. Delay surgery until after Ramadan ends

4. A term parturient on remifentanil PCA for labour analgesia becomes drowsy with SpO₂ reading 89% and RR 7 breaths/min. What is the PRIORITY nursing action?

A. Increase PCA bolus dose to improve comfort B. Administer IM pethidine as an alternative C. Stop PCA, stimulate patient, apply O₂, call anaesthetist, prepare naloxone D. Reassure the patient and recheck in 15 minutes

5. According to DHA/DOH guidelines, what is the minimum platelet count threshold below which epidural insertion is considered an ABSOLUTE contraindication?

A. 100 × 10⁹/L B. 80 × 10⁹/L C. 50 × 10⁹/L D. 150 × 10⁹/L

MCQ Explanations:

Q1-D: Intrathecal morphine causes delayed respiratory depression up to 24h. Hourly RR + sedation score is mandatory. Naloxone must be at bedside.
Q2-B: Symptoms indicate a high/total spinal or inadvertent intravascular injection — stop the drug, call for help, secure airway, give vasopressor. Increasing the epidural would be catastrophic.
Q3-C: Fasting during Ramadan does not guarantee an empty stomach in obstetric patients (delayed gastric emptying). Regional anaesthesia avoids airway risk; aspiration prophylaxis must still be given.
Q4-C: Remifentanil PCA requires mandatory 1:1 nursing precisely for this scenario. Stop immediately, stimulate, oxygenate, give naloxone, call anaesthetist.
Q5-B: Platelet count below 80 × 10⁹/L is the threshold for absolute contraindication to epidural. Between 80–100 requires senior anaesthetist judgement.

GCC Obstetric Anaesthesia Nursing Guide — For educational use only — Always follow local unit protocols