Q1: Perioperative Plan for Eclamptic Patient Posted for Caesarean Section (10 Marks)

A. PRE-OPERATIVE ASSESSMENT

History & Clinical Assessment

• Establish time of last seizure, frequency, and duration
• Note antihypertensive and anticonvulsant therapy already received (MgSO4 dose, labetalol, hydralazine)
• Assess level of consciousness, GCS, any lateralizing neurological signs
• History of headache, visual disturbances, epigastric pain (HELLP markers)
• Review gestational age, fetal status, urgency of delivery
• Record fluid intake/output - urine output must be >25 mL/hr

Airway Assessment (CRITICAL)

• Eclamptic patients frequently have laryngeal/pharyngeal oedema due to fluid shifts and pre-existing preeclamptic oedema
• Assess Mallampati grade, neck mobility, mouth opening
• Anticipate a difficult airway - have video laryngoscope, smaller ETT sizes (6.0-6.5), surgical airway backup ready

Investigations

Monitoring Setup (Pre-op)

• Continuous SpO2, ECG, NIBP q5 min (or intra-arterial line if BP uncontrolled)
• Foley catheter for urine output monitoring
• Large-bore IV access x2
• Pulse oximetry monitoring for MgSO4 toxicity

B. PRE-OPERATIVE MANAGEMENT (Before OR)

Seizure Control - MgSO4 (Drug of Choice)

• Loading dose: 4-6 g IV over 15-20 minutes
• Maintenance: 2 g/hr IV infusion
• Monitor for hypermagnesaemia: loss of deep tendon reflexes (Mg ~10 mg/dL) and respiratory depression (Mg ~12 mg/dL)
• Antidote: Calcium gluconate 1 g IV slowly
• If seizures persist: lorazepam 2-4 mg IV, or diazepam 5-10 mg IV

Antihypertensive Therapy

• Target: systolic <160 mmHg, diastolic <105-110 mmHg (aggressive reduction risks uteroplacental insufficiency)
• Labetalol: 20 mg IV bolus, repeat q10 min up to 300 mg total dose
• Hydralazine: 5-10 mg IV q20-30 min (watch for reflex tachycardia)
• Nifedipine: 10 mg oral (rapidly effective)

Fluid Management

• Restrict to 80-100 mL/hr total fluid intake (including MgSO4 and oxytocin infusions)
• Do NOT preload aggressively - colloid osmotic pressure is low and fluids readily extravasate → risk of pulmonary oedema
• Avoid diuretics unless pulmonary oedema is present

C. ANAESTHESIA CHOICE

Preferred: Neuraxial Anaesthesia (Regional)

• Avoids the haemodynamic surge of laryngoscopy (dangerous in poorly controlled hypertension)
• Avoids difficult airway risks from laryngeal oedema
• Reduces circulating catecholamines
• Attenuates hypertensive response to pain
• Reduces risk of failed intubation

Spinal Anaesthesia

• Preferred for elective/semi-elective C-section
• Contrary to older belief, hypotension is actually LESS severe in preeclamptic women compared to normotensive parturients (due to existing vasospasm)
• Vasopressors must be immediately available: phenylephrine (first-line) or ephedrine
• Use hyperbaric bupivacaine 0.5% (10-12.5 mg) + fentanyl 25 mcg + preservative-free morphine 100-200 mcg (for post-op analgesia)

Epidural Anaesthesia

• Preferred if labour epidural already sited, or for gradual titration
• Prevents sudden sympatholysis
• Allows top-up for conversion to C-section

Combined Spinal-Epidural (CSE)

• Offers advantages of both: fast onset of spinal + ability to extend with epidural

When General Anaesthesia is Needed

• Severely thrombocytopenic (<70,000/mm³) or coagulopathic
• Uncontrolled seizures
• Fetal emergency requiring immediate delivery
• Patient refusal of regional
• Failed regional block

• Difficult/failed intubation due to upper airway oedema
• Hypertensive surge on laryngoscopy - must be attenuated
• MgSO4 potentiates non-depolarising muscle relaxants (rocuronium) - use reduced doses and monitor with nerve stimulator
• If patient has limb weakness from high Mg levels, consider discontinuing infusion during surgery, though ACOG recommends continuing

• Pre-oxygenation for 3-5 min
• Rapid Sequence Induction (RSI): propofol + succinylcholine (or rocuronium 1.2 mg/kg with sugammadex reversal plan)
• Attenuate intubation hypertension with: esmolol, labetalol, remifentanil, or nicardipine - one of these MUST be given
• Small ETT (6.0-6.5 mm) for oedematous airway
• Have video laryngoscope and LMA as rescue device

D. INTRA-OPERATIVE MANAGEMENT

• Continue MgSO4 infusion
• Control BP aggressively intra-op (target <160/110 mmHg)
• Limit IV fluids
• After delivery: oxytocin infusion (not bolus - can cause hypotension) + carboprost/misoprostol ready (because MgSO4 causes uterine relaxation → risk of uterine atony)
• Phenylephrine infusion preferred over ephedrine for spinal hypotension (less fetal acidosis)

E. POST-OPERATIVE ANALGESIA

F. POST-OPERATIVE MONITORING (ICU/HDU Level)

• Continuous SpO2, BP q15-30 min for 24-48 hours (one-third of eclamptic seizures occur postpartum)
• Monitor urine output (>30 mL/hr)
• Watch for pulmonary oedema - peaks in first 24h postpartum as fluid shifts back intravascularly
• Monitor platelet trend - remove epidural catheter only when platelets are stable and adequate
• Continue antihypertensives (nifedipine, methyldopa) for at least 48h postpartum
• Continue MgSO4 for 24h post-delivery

Q2: Labour Analgesia and Pain Pathways in Labour

A. PAIN PATHWAYS IN LABOUR

First Stage Pain (Latent + Active Labour)

• Source: Uterine contractions causing cervical dilatation, uterine ischaemia, and lower uterine segment distension
• Character: Visceral, poorly localised, cramping/pressure pain referred to the lower abdomen, lower back, and thighs
• Pathway:
  • Afferent fibres travel with sympathetic nerves (A-delta and C fibres)
  • Pass through the uterovaginal plexus (Frankenhauser plexus)
  • Enter the spinal cord via T10, T11, T12, and L1 dorsal nerve roots
  • Pain is referred to the dermatomes of T10-L1 (lower abdomen, groin, lower back)

Second Stage Pain (Descent + Expulsion)

• Source: Distension of the vagina, vulva, perineum, and pelvic floor by the descending presenting part
• Character: Somatic, sharp, well-localised pain in the perineum
• Pathway:
  • Afferent fibres travel in the pudendal nerve (S2, S3, S4)
  • Enter the spinal cord at S2-S4 posterior horn
  • This is somatic pain - sharp and localised

Summary of Pain Levels

B. METHODS OF LABOUR ANALGESIA

1. Neuraxial Analgesia (Gold Standard)

a) Epidural Analgesia

• Most effective and flexible method
• Catheter inserted at L2-L3 or L3-L4 space
• Drugs: Dilute local anaesthetic + opioid (e.g., bupivacaine 0.1% + fentanyl 2 mcg/mL)
• Advantages:
  • Best pain relief (attenuates catecholamine response)
  • Can be extended for operative delivery
  • Reduces BP response in preeclampsia
  • Allows patient-controlled epidural analgesia (PCEA)
• Timing: When patient requests, regardless of cervical dilation (not contraindicated early)
• CSE (Combined Spinal-Epidural): Faster onset of spinal + flexibility of epidural catheter

b) Spinal Analgesia (Single Shot)

• Useful for imminent delivery
• Fentanyl 25 mcg + bupivacaine 2.5 mg intrathecally

2. Systemic Opioid Analgesia

3. Inhalational Analgesia

• Entonox (50% N2O + 50% O2): Patient-controlled inhalation; mild-moderate relief; safe for fetus; simple to use

4. Regional Nerve Blocks

5. Non-Pharmacological Methods

• Continuous supportive care (doula/midwife presence reduces analgesic requirement)
• Hydrotherapy (warm water immersion)
• TENS (Transcutaneous electrical nerve stimulation)
• Intradermal sterile water injections (low back pain)
• Breathing and relaxation techniques, hypnobirthing

C. ADVANTAGES OF EPIDURAL LABOUR ANALGESIA

1. Best quality pain relief across all stages
2. Reduces catecholamine surge → less fetal uteroplacental compromise
3. Attenuates hypertensive response (especially in preeclampsia)
4. Can be extended to surgical anaesthesia for C-section
5. Allows awake participation in childbirth
6. ACOG/SOAP: maternal request alone is sufficient indication

Q3: RECENT PPH MANAGEMENT - FLOWCHART FORM

Based on WHO Consolidated PPH Guidelines (2025) and the MOTIVE Bundle (WHO/FIGO 2025)

┌─────────────────────────────────────────────────────────────────┐
│              PREVENTION (Active Management of 3rd Stage)         │
│  • Oxytocin 10 IU IM at birth of anterior shoulder (1st line)   │
│  • Carbetocin (heat-stable) where available                      │
│  • Controlled cord traction + uterine massage                    │
└─────────────────────┬───────────────────────────────────────────┘
                      │
                      ▼
┌─────────────────────────────────────────────────────────────────┐
│           RECOGNITION / DIAGNOSIS OF PPH                        │
│                                                                  │
│  NEW 2025 WHO criteria:                                         │
│  • Blood loss ≥500 mL after vaginal delivery, OR                 │
│  • Blood loss ≥1000 mL after C-section, OR                      │
│  • ≥300 mL + any abnormal vital signs (NEW threshold)           │
│  • Use calibrated drapes/blood loss estimation tools             │
└─────────────────────┬───────────────────────────────────────────┘
                      │
                      ▼
┌─────────────────────────────────────────────────────────────────┐
│          IMMEDIATE RESPONSE: CALL FOR HELP + MOTIVE BUNDLE       │
│  (WHO/FIGO 2025 Consolidated PPH Guidelines)                     │
│                                                                  │
│  M - Massage of uterus (bimanual compression)                   │
│  O - Oxytocic drugs (uterotonics - see Step 1 below)           │
│  T - Tranexamic Acid (TXA) - WITHIN 3 HOURS of birth           │
│  I  - IV Fluids (isotonic crystalloids preferred)               │
│  V - Vaginal and genital tract examination                       │
│  E - Escalation if bleeding persists                            │
└─────────────────────┬───────────────────────────────────────────┘
                      │
                      ▼
┌─────────────────────────────────────────────────────────────────┐
│  STEP 1: UTEROTONICS + TXA (SIMULTANEOUSLY)                     │
│                                                                  │
│  Uterotonic Drugs (give in sequence / combination):             │
│  1. Oxytocin 10 IU IM/slow IV (first-line)                     │
│  2. Ergometrine/Syntometrine 0.5 mg IM                          │
│     (contraindicated in hypertension)                           │
│  3. Carboprost (PGF2α) 0.25 mg IM q15 min (max 8 doses)       │
│     (contraindicated in asthma)                                  │
│  4. Misoprostol (PGE1) 800-1000 mcg rectal/sublingual          │
│     (when injectables unavailable)                              │
│  5. Tranexamic Acid 1 g IV (within 3h; repeat if needed)       │
│     Antifibrinolytic - reduces mortality (WOMAN Trial 2017)     │
│                                                                  │
│  + Resuscitation: IV access x2, O2, blood products if needed    │
└─────────────────────┬───────────────────────────────────────────┘
                      │
              ┌───────┴───────┐
              ▼               ▼
         BLEEDING          BLEEDING
         STOPPED           CONTINUES
              │               │
              ▼               ▼
         CONTINUE        IDENTIFY CAUSE: THE 4 Ts
         MONITOR      ┌────────────────────────────┐
                      │ TONE (uterine atony - 70%)  │
                      │ TISSUE (retained placenta)  │
                      │ TRAUMA (lacerations,        │
                      │         uterine rupture)    │
                      │ THROMBIN (coagulopathy,     │
                      │         DIC, von Willebrand)│
                      └────────────┬───────────────┘
                                   │
                                   ▼
┌─────────────────────────────────────────────────────────────────┐
│  STEP 2: MECHANICAL / SURGICAL FIRST-LINE INTERVENTIONS         │
│                                                                  │
│  For ATONY:                                                      │
│  • Bimanual uterine compression                                  │
│  • Aortic compression (if massive bleeding)                     │
│  • Intrauterine balloon tamponade (Bakri balloon / SOS Bakri)  │
│    - Success rate up to 91%                                      │
│                                                                  │
│  For TRAUMA:                                                     │
│  • Repair lacerations, episiotomy, haematoma                    │
│  • Explore for uterine rupture                                   │
│                                                                  │
│  For RETAINED TISSUE:                                            │
│  • Manual removal of placenta / ERPC                            │
└─────────────────────┬───────────────────────────────────────────┘
                      │  Bleeding continues
                      ▼
┌─────────────────────────────────────────────────────────────────┐
│  STEP 3: SURGICAL INTERVENTION                                   │
│                                                                  │
│  If abdomen open (C-section):                                    │
│  • Uterine compression sutures (B-Lynch suture, Hayman suture)  │
│  • Internal iliac artery ligation                                │
│  • Ovarian artery ligation                                       │
│                                                                  │
│  If abdomen not open:                                            │
│  • Proceed to laparotomy                                         │
│  • B-Lynch brace suture                                          │
│  • Stepwise devascularisation                                    │
│                                                                  │
│  Interventional Radiology (if available):                        │
│  • Uterine artery embolisation (UAE) - bilateral via femoral    │
│    access; preserve uterus; NOT first-line, NOT last resort      │
│    Use before hysterectomy as uterus-sparing option             │
└─────────────────────┬───────────────────────────────────────────┘
                      │  Bleeding still uncontrolled
                      ▼
┌─────────────────────────────────────────────────────────────────┐
│  STEP 4: OBSTETRIC HYSTERECTOMY (LAST RESORT)                   │
│                                                                  │
│  • Peripartum hysterectomy if all else fails                     │
│  • Total preferred over subtotal in most cases                  │
│  • Audit peripartum hysterectomy rate as quality measure        │
│                                                                  │
│  SIMULTANEOUSLY - RESUSCITATION / HAEMATOLOGY:                  │
│  • Transfuse pRBC, FFP, platelets (1:1:1 ratio in massive PPH)  │
│  • Cryoprecipitate / fibrinogen concentrate if fibrinogen <2 g/L│
│  • Correct hypothermia, acidosis, hypocalcaemia (lethal triad)  │
│  • Cell salvage intraoperatively where available                 │
│  • Activate massive haemorrhage protocol                        │
└─────────────────────────────────────────────────────────────────┘

Key Recent Updates (WHO 2025 / FIGO 2025):

1. New PPH trigger threshold: Act at ≥300 mL + abnormal vital signs (not just ≥500 mL)
2. MOTIVE Bundle replaces older stepwise approaches - simultaneous deployment
3. Tranexamic acid (TXA 1 g IV) is now firmly recommended within 3 hours of birth for all PPH (WOMAN Trial evidence - reduces death from bleeding by 19%)
4. TXA is NOT recommended prophylactically for prevention of PPH at vaginal or caesarean birth (2025 guideline change)
5. Carbetocin (heat-stable) replaces oxytocin in hot/humid resource-limited settings
6. Calibrated blood collection drapes recommended for accurate quantification
7. Blood transfusion with 1:1:1 ratio (RBC:FFP:platelets) for massive PPH
8. Uterine artery embolisation: use as uterus-sparing bridge before hysterectomy, not as a last resort

Quick Summary for Revision