Anaesthetic Approach

Anaesthetic team

Senior specialist obstetric anaesthetic support is essential.

The RCOG greentop guideline recommends an individualised approach to anaesthesia for caesarean section with suspected PAS, led by discussion between a senior obstetric anaesthetist and the patient pre-operatively. Both regional and general anaesthetic (GA) are deemed safe and effective, with insufficient evidence to support one approach over the other. It is vital however, that women opting for regional anaesthesia are warned of the potential for intra-operative conversion to GA, and advanced consent to do so is sought in advance.

Anaesthesia

Prior to surgery, the anaesthetic team will routinely secure a minimum of two wide-bore peripheral intravenous (IV) cannulas and an arterial line. In severe cases, a central line may also be considered for additional monitoring and vascular access.

Delivery is usually performed under regional blockade (high thoracic epidural anaesthesia). This then also provides post-operative pain relief. The decision for conversion to GA is made intraoperatively following a team-based discussion based on findings and proposed surgical plan (See Step 12).

Blood Products

At least 4 units of packed red cells are cross matched before each case. The team have a rapid infusion pump and a point of care thromboelastography in case of severe haemorrhage.

A massive haemorrhage pack containing packed red cells, platelets and cryoprecipitate can be delivered to the obstetric theatre in <10 minutes from request. Other blood products such as recombinant factor VII is available rapidly if required. The haematology service is informed whenever we deliver a PAS woman so that they are aware that there surgery occurring on site that has a significant haemorrhage risk.

Tranexamic acid is administered when blood loss reaches a significant level (usually 1000mls but can be less if the body weight of the woman is low).