1. University of Gondar
College of medicine and health science
department of anesthesia
Misganaw(MSc)
1
preoperative assessment of
obstetric patients and RSI

2. Objectives
At the end of these session students could able to:
 Do preoperative assessment of obstetric client
 Perform RSI
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3. Introduction
 Preoperative assessment is an important component of
managing obstetric patients and should not be
underestimated.
 It allows you to build a rapport with your patient, and can
alert you to problems at an early stage, giving you time to
formulate a plan for the patient’s management.

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4. CONT…
 preoperative assessment is very important for obstetric
patients because;
 It allows identification of mothers at higher risk of
complications during pregnancy and delivery (referred to
as high-risk patients)
 Minimize risk for patients by planning their care -
assistance may be needed
 To know and decide the urgency of the
procedure(immediate,emergency,urgent and elective) 4

5.  Potential difficulties identified by obstetric staff early
in pregnancy, should ideally be referred to a senior
anaesthetist in a timely manner to jointly consider
available options. E.g. significant cardiac disease,
obesity, difficult airway
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6. AUSCULTATION
 who needs preoperative assessment in obstetrics?
 All patients requiring anaesthetic intervention
 This includes both general and regional anaesthesia
 In exceptional circumstances, there may not be time to
complete a full preoperative assessment, but a brief
assessment should still be completed
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7.  When should patients be seen for a preoperative
assessment?
 As early as possible
 High risk patients should be seen around 30-34 weeks if
possible so that problems can be identified and management
plans made for delivery
 Patients for elective caesarean section can be seen in the days
preceding admission or as early as possible on the day of
surgery Identify patients on the labour ward with whom you may
be involved and see them as early as possible
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8.  Identify patients on the labour ward with whom you may b
e involved and see them as early as possible
 Pregnant women should be offered a haemoglobin asses
sment before CS to identify those who have anaemia.
 Although blood loss of more than 1000ml is infrequent aft
er CS (it occurs in 4 to 8% of CS)
 Pregnant women having CS for APH, are at increased ris
k of blood loss greater than 1000 ml and should have the
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9.  Antacid Prophylaxis • Antacid prophylaxis should be
prescribed to all women undergoing caesarean section. •
A combination of H2 antagonist (e.g. ranitidine) and
metaclopramide is frequently prescribed orally if time
permits and can be given IV in the emergency situation.
• These measures aim to increase gastric pH and reduce
gastric volume. Acid aspiration syndrome is more
common if volume aspirated >25mls and pH
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10.  Prescribe antibiotics (one dose of first-generation cephalospor
in or ampicillin)
 To reduce the risk of aspiration pneumonitis: Empty stomach,
Pre-medication with an antacid (sodium citrate 0.3% 30 mL or
magnesium trisilicate 300 mg) + Cimetidine IV 1 hr before C
S 10

11. PREPARETION
 Women having CS with regional anesthesia require an
indwelling urinary catheter to prevent over-distension of
the bladder, because the anaesthetic block interferes with
normal bladder function
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12.  Category 1 (immediate): Immediate threat to life of
woman or fetus - decision to delivery time up to 30 mins.
Category 2 (emergency): Maternal or fetal compromise
with no immediate threat to life of woman or fetus –
decision to delivery time up to 1 hour
Category 3 (urgent): Requires early delivery - decision to
delivery time up to 24 hours
Category 4 (elective): No maternal or fetal compromise,
at a time to suit the woman and maternity services
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13. RAPID SEQUENCE INDUCTION (RSI)
 Rapid sequence induction (RSI) is a method of achieving rapid
control of the airway whilst minimising the risk of regurgitation
and aspiration of gastric contents.
 Intravenous induction of anaesthesia, with the application of
cricoid pressure, is swiftly followed by the placement of an
endotracheal tube (ETT)
 RSI is only required in patients with preserved airway reflexes.
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14. HISTORY OF RSI
 RSI was originally described in 1961 by Sellick1 as:
 • Emptying of the stomach via a gastric tube which is then
removed
 Pre-oxygenation
 Positioning the patient supine with a head-down tilt
 Induction of anaesthesia with a barbiturate (e.g.
thiopentone) or volatile,and a rapid-acting muscle relaxant
(e.g. suxamethonium)
 • Application of cricoid pressure
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15. CLINICAL CONSIDERATIONS
 Laryngoscopy and intubation of the trachea with a cuffed
tube immediately following fasciculations .
Modified RSI’
Omitting the placement of an oesophageal tube
• Supine or ramped positioning
• Titrating the dose of induction agent to loss of
consciousness
• Use of propofol, ketamine, midazolam or etomidate to
induce anaesthesia
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16.  Use of high-dose rocuronium as a neuromuscular blocking agent
 Omitting cricoid pressure
RSI
Indication ?
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17. PREPARATION
 Preparation is vital, both of equipment and team members –
particularly if the team is unfamiliar with the environment or
 their colleagues.
 Anticipation of difficult airway and establishing oxygenation
plans prior to conducting RSI are essential.
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18. EMERGENCY INTUBATION
CHECKLIST
PREPARE PATIENT
PREPARE
EQUIPMENT
PREPARE FOR
DIFFICULTY
PREPARE
TEAM
•Monitoring
Pulseoximeter
BP (every 2 min)
Capnography
ECG
•Op>mal posi>oning
Ramping in obese patient
30° head up for head injury
Neck immobilization for
suspected C-spine injury
•Good IV access with fluid
running
•Adequatepreoxygenta>on
•Oxygen Supply
•Airway
equipment
Facemask
Airway adjuncts
Self-infla=ng bag
2laryngscopes
Appropriate ET tubes
Bougie or stylet
Suction
Tube tape or =e
•Drugs
RSI drugs
Vassopressor
Maintenance of
seda=on and
paralysis
•Prepare for difficult
airway if
an>cipated
VDO laryngoscope
LMA
Cricothyroidotomykit
•Difficult airway trolley
present
•Oxygena>on plan in
event of
failed intuba>on
•Other specific
problems
an>cipated?
•Confirm
roles
ØIntubator
ØDrugs
ØCricoid
pressure
ØIn-
linestabilisa=on
(C-spine injury)
•Senior help
accessible
PROCEED TO RSI WHEN
ALL CHECKS CONFIRMED
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19. CRICOID PRESSURE
 Cricoid pressure is the application of force to the
cricoid cartilage of the patient.
 The rationale is that the upper oesophagus is
occluded by being compressed between the
trachea and the cervical vertebrae, preventing
passive reflux
of gastric contents and subsequent development of
aspiration pneumonitis.
 Between thumb and index figure
 10 Newtons
 30 Newtons
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20.  Cricoid pressure
 INDICATIONS
 risk of reflux and
 aspiration of gastric contents
Contraindications
A laryngeal injury
Caution cervical spine injury 20

21.  CONTROVERSY AROUND CRICOID PRESSURE
 Concerns include:
• reduced quality of laryngoscopy,
• lack of evidence of effectiveness in preventing reflux
and aspiration,
• reduced lower oesophageal sphincter tone and
therefore increasing reflux risk,
• worsening of undetected laryngeal or cervical spine
injury,
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 degree of force being applied by the operator,
 patient discomfort, gagging or coughing, and
 increasing physical and cognitive workload for the
operators.

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