CTG definitions

ean level of the FHR when this is stable, excluding accelerations and decelerations. It is determined over a time period of 5 or 10 minutes and expressed in bpm. Preterm fetuses tend to have values towards the upper end of this range. A trend to a progressive rise in the baseline is important as well as the absolute values

Normal Baseline FHR
110-160 bpm

Abnormal bradycardia
<100 bpm

Abnormal tachycardia
>180 bpm

Baseline variability
The minor fluctuations in baseline FHR occurring at three to five cycles per minute. It is measured by estimating the difference in beats per minute between the highest peak and lowest trough of fluctuation in a one-minute segment of the trace

Normal baseline variability
Greater or equal to 5 bpm between contractions

Non-reassuring baseline variability
Less than 5 bpm for 40 minutes or more but less than 90 minutes

Abnormal baseline variability
Less than 5 bpm for 90 minutes or more

Accelerations
Transient increases in FHR of 15 bpm or more and lasting 15 seconds or more. The significance of no accelerations on an otherwise normal CTG is unclear

Decelerations
Transient episodes of slowing of FHR below the baseline level of more than 15 bpm and lasting 15 seconds or more

Early decelerations
Uniform, repetitive, periodic slowing of FHR with onset early in the contraction and return to baseline at the end of the contraction

Late decelerations
Uniform, repetitive, periodic slowing of FHR with onset mid to end of the contraction and nadir more than 20 seconds after the peak of the contraction and ending after the contraction. In the presence of a non-accelerative trace with baseline variability < 5 bpm, the definition would include decelerations < 15 bpm

Variable decelerations
Variable, intermittent periodic slowing of FHR with rapid onset and recovery. Time relationships with contraction cycle are variable and they may occur in isolation. Sometimes they resemble other types of deceleration patterns in timing and shape

Atypical variable decelerations
Variable decelerations with any of the following additional components: i. loss of primary or secondary rise in baseline rate, ii. slow return to baseline FHR after the end of the contraction. iii. prolonged secondary rise in baseline rate, iv. biphasic deceleration, v. loss of variability during deceleration, vi. continuation of baseline rate at lower level.

Prolonged deceleration
An abrupt decrease in FHR to levels below the baseline that lasts at least 60-90 seconds. These decelerations become pathological if they cross two contractions, i.e. greater than 3 minutes

Sinusoidal pattern
a regular oscillation of the baseline long-term variability resembling a sine wave. This smooth, undulating pattern, lasting at least 10 minutes, has a relatively fixed

confidential enquiries 2006-2008

International definition : maternal mortality RATIO number of direct and indirect deaths per (denominator:100000 live births)

UK: maternal mortality rate: denominator-per 100000 maternities)

overall maternal mortality rate: 11.39 (previous triennium 13.95)

Direct- mortality rate: 4.67 (previously 6.24)

• overall reduction,
• decrease in PE, hemorrhage,
• increase in deaths from sepsis esp group A strep
• causes: haemorrhage, AFE, genital tract sepsis, preclampsia and ecclampsia
• anaesthesia: 7 died

Indirect - suicide, asthma, epilepsy, cardiac disease (conditions aggravated by pregnancy)

• unchanged

severe preeclampsia

(Oct-2008 Q8) A 25yo primigravida patient presents to the delivery suite at 38 weeks gestation complaining of a headache and difficulty with her vision. Her BP is 180/115 and she has clonus. CTG monitoring shows no indications of foetal distress. Outline your initial management of her pre-eclampsia

This term pregnant patient has severe pre-eclampsia (definition)and has signs of impending ecclampsia, which is a life-threatening condition. After a focused history and examination I would arrange for urgent lab investigations especially looking at the renal panel, PT/PTT , liver enzymes, Mg and FBC for platelet count.

My initial management wound be to stabilize the patient and discuss with her obstetrician …(multidisciplinary )and arrange for expedient delivery of the child.

In the mean time I will give her supplemental O2 and place her in a left lateral tilt to reduce aortocaval compression in this situation where there is already compromised blood supply to the fetus. Standard monitoring in addition: BP on both arms, urine output

I would start IV magnesium as a slow bolus (loading dose___) followed by an infusion of ____ to achieve serum Mg level of 2-4mmol/L

I would also lower the blood pressure by starting IV labetalol as an infusion 10-50mg/hour, avoiding precipitous falls in BP and targeting a BP of 140-150/100-110

Fluid resus; regional if no contraindications, post op HD +/- CVP

Severe hypertension: BP 160/110

drugs for pregnant

http://www.scribd.com/doc/33591624/Prescribing-Medicine-in-Pregnancy-By-Australian-Drug-Evaluation-Committee

by 'australian drug evaluation committee' now advisory committee on prescription meds'

myasthenia gravis

tutorial today by Dr Hari - question was apparently asked in oct 2009

you are an anaesthetist in a rural hospital and the obstetrician calls you regarding an emergency CS for NRFS. She also has a past history of myasthenia gravis

1) how do you go about determining the degree of NRFS

-use of CTG - presence of late or variable decelerations, defined as decrease in HR of more than 15 beats lasting at least 30 s

-use of scalp pH (normal pH of neonate 7.25-7.35), so fetal distress is when scalp pH <7.25

2) how do you go about assessing this patient for op

don't just focus on the obstetric history- placenta praevia, antenatal history, GDM, lie etc, gestation

-history

-clinical exam

-go through relevant investigations

-old notes

history: extent of disease, control, recent exacerbations esp due to pregnancy

medications: pyridostigmine dose, steroids, immunosuppressants, plasmapheresis

autonomic instability

pre op PFT

issues of post op ventilation:

management: pre op aspiration prophylaxis, neonatologist, wedge , warm OT for baby

standard monitoring, airway trolley and difficult airway adjuncts, experienced surgeon, colleague to help with anaesthesia, AU

working IV plug

maintain with 02:n2o:inhalational, use bis to reduce amount of inhalational (potentiate nm weakness), nerve stimulator

pharmaco: duration of action of sux : unpredictable, may require higher dose eg 2mgkg

high dose may cause type 2 blockade, onset delayed

if on regular plasmapheresis, enzyme to metabolise sux may be reduced

increased sensitivity to relaxant

if not given usual meds preop: controversial- give IV neostigmne 1:30mg pyrido or NG pyrido?

non depolarising: give 1/10 of usual dose, titrate to nerve stimulator

• Ensure that the patient is reminded prior to induction of the possibility of a prolonged intubation*

Extubation: performed on awake patients and hopefully close to his/her baseline status. Reinstitute anticholinesterase medication, either by IV infusion or by reimplementation of the patient's oral regimen.

Leventhal criteria: Predictive scoring system for the need for postoperative ventilation

1) duration of disease for 6 years or longer

2) chronic comorbid pulmonary disease

3) pyridostigmine dose >750 mg/d

4) VC <2.9L

5) Other indicators include preoperative use of steroids, and previous episode of respiratory failure.

These predictors have not been widely validated. (1)

Drugs to avoid: Calcium Channel blockers, Magnesium, Aminoglycoside antibiotics as all of these may contribute to muscle weakness

Post-Op Bed: Patients should be monitored in either a ICU or step-down unit but NOT to a conventional surgical ward.

3) MG vs eaton lambert,

tensilon to differentiate

4) baby not breathing , mother not stable

priority is to stabilise mother

baby: SpO2 88% Hr 50, chin lift and BVM (? pressure gauge), towel under shoulders. intubate , start CPR

CVS collapse most likely due to hypoxia

call code blue, adrenaline 10mcg/kg

stop CPR when HR >60

ETT adrenaline 100mcg/kg (other routes IM, umbilical)

resus guidelines :ARC

5) PPH: anaes plan

-defined as? >500ml/24h

-fluid resus

-post partum : assum gastric physiology and aspiration risk still present up to 48h

-issues of recent GA, physiology changes, MG