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You have attempted to top up an epidural for a category one caesar for fetal distress. The block seems adequate but once the surgeons enter the abdomen your patient complains of significant pain and you decide to convert to general anaesthesia. You perform an RSI with propofol and rocuronium. After intubation she has a heart rate of 130 and an NIBP of 155 / 90. Your registrar asks “why didn’t we give her any opioid?” and you patiently explain that we avoid opioids until after delivery because we don’t want them to cross the placenta and to cause respiratory depression in the neonate……………but is this always true??? Hi everyone, Join Jacob and I as we discuss the recent literature surrounding this topic. What is the evidence? What about the short acting opioids such as alfentanil & remifentanil? What are the advantages / disadvantages of using an opioid and what are the downsides of not using opioids? References Best practice in obstetric general anaesthesia: an umbrella review of pharmacological strategies for induction of general anaesthesia. Anaesthesia, 81: 1269-1280. 2026. https://doi.org/10.1111/anae.70214 Induction opioids for caesarean section under general anaesthesia: a systematic review and meta-analysis of randomised controlled trials International Journal of Obstetric Anesthesia, 2019; 40, 4-13

Join Sarah & Declan as we continue our series covering the ANZCA final exam curriculum for obstetrics across four episodes. This second episode covers complications in labour and delivery including management of postpartum haemorrhage. We hope this resource will be helpful for everyone, but especially those of our trainees preparing for the final exam. To get the most out of it, we suggest regularly pausing the podcast to answer each question yourself, before listening to our answers. Of course there is much more detail expected in the exam, but if you can answer all these questions confidently, we think you’ll have a great chance. If you find this podcast helpful, or have suggestions for future episodes in this series, please send us an email to let us know. Resources mentioned in this episode: Question 1: AFE, haemorrhage management BJA Education — Haemostatic agents in the management of obstetric haemorrhage (2024) https://www.bjaed.org/article/S2058-5349(24)00089-1/fulltext RANZCOG — Management of Postpartum Haemorrhage (2021) https://www.ranzcog.edu.au/wp-content/uploads/Management-Postpartum-Haemorrhage.pdf BJA Education — Amniotic fluid embolism (2018) https://www.bjaed.org/action/showPdf?pii=S2058-5349%2818%2930060-X BJA Education — Point-of-care viscoelastic testing (2022) https://www.bjaed.org/article/S2058-5349(22)00094-4/fulltext Deranged Physiology — Interpretation of abnormal ROTEM data https://derangedphysiology.com/main/required-reading/haematology-and-oncology/Chapter-108/intepretation-abnormal-rotem-data Question 2: GA unstable bleeding pt, uterine inversion management RANZCOG — Management of Postpartum Haemorrhage (2021) https://www.ranzcog.edu.au/wp-content/uploads/Management-Postpartum-Haemorrhage.pdf BJA Education — Uterine inversion (2024) https://www.bjaed.org/article/S2058-5349(24)00009-X/fulltext Question 3: Placenta accreta planning and management RANZCOG — Placenta Accreta Spectrum (PAS) (C-Obs 20) (2023) https://ranzcog.edu.au/wp-content/uploads/Placenta-Accreta-Spectrum.pdf BJA Education — Management of patients with suspected placenta accreta spectrum (2022) https://www.bjaed.org/article/S2058-5349(21)00131-1/fulltext Question 4: Foetal demise SOAP — Interdisciplinary Consensus Statement on Neuraxial Procedures in Obstetric Patients with Thrombocytopenia (2021) https://www.soap.org/assets/docs/Consensus/SOAP%20Consensus%20Statement%20Thrombocytopenia%202021.pdf

Hi everyone Dexmedetomidine, is both a difficult word to pronounce correctly in casual conversation but also a useful pharmacological tool in many different situations. This week I am joined by one of our fellows Dr Han Lu to discuss dexmedetomidine, it’s history, it’s basic pharmacology and then more specifically it’s use in different clinical situations where it may be useful in obstetrics and gynaecology. Thanks Han for a great Tuesday talk and a very informative podcast! References Han’s powerpoint talk Effectiveness of dexmedetomidine on patient-centred outcomes in surgical patients: a systematic review and Bayesian meta-analysis. BJA September 2024 Crowe. G, et al Perioperative Applications of Dexmedetomidine. ATOTW 469 — Perioperative Applications of Dexmedetomidine April 2022 Douglas MS, Soloniuk LJ, Jones J, Derderian R, Baker C, Stier G. Intravenous dexmedetomidine use in obstetric anesthesia: a focused review. Int J Obstet Anesth. 2025 May;62:104345. doi: 10.1016/j.ijoa.2025.104345. Epub 2025 Feb 13. PMID: 40090158 Atipamezole – alpha 2 agonist reversal agent used in veterinary practice

Hypothetical Case: You finish injecting the spinal anaesthetic for your patient who has come for an urgent caesarean section. She has pre-eclampsia and her blood pressure just before you started was 180/100. Just after lying down she starts vomiting and unfortunately the non invasive blood pressure cuff is going up and down but not giving you a number – she is shaking and can’t stop moving around. Is she vomiting because of hypotension, should you give her a bolus of phenylephrine? What if she is actually still hypertensive – you don’t want to push her BP over 200. Wouldn’t it be great if you had a beat to beat continuous display of her BP – maybe you should have placed an arterial line before starting. Are there any other options that might have been helpful??? Hi everyone, This week I am joined by John to discuss continuous non-invasive blood pressure monitoring. Many of these technologies have actually been around for a number of years now, but despite this don’t seem to be in commonplace usage. There does seem to be a recent renewed interest in re-evaluating these technologies. How do these technologies work? How accurate are they? Have there been any improvements? What are the economics and costs? Thanks John for all your hard work researching this topic! Methods Arterial Applanation Tonometry Volume Clamp Method Photoplethysmography (PPG): Origins to Modern Applications in Wearable Technology References Enhancing Patient Safety with Continuous Blood Pressure Monitoring – APSF (Anesthesia Patient Safety Foundation Newsletter 2026)

Declan and Sarah discuss strategies for obstetric questions in the ANZCA final exam.

Join us as Declan and Roger discuss the evidence for routine table tilt during elective caesarean section.   Has this changed your practice? What is your opinion on this topic? We’d love to read your emails.  As mentioned in the episode we would love to do a future episode on Q&A so if you have any questions on any topic you would like us to tackle please send them in! Send your comments / questions to: [email protected] References Hughes EJ, Price AN, McCabe L, Hiscocks S, Waite L, Green E, Hutter J, Pegoretti K, Cordero‐Grande L, Edwards AD, Hajnal JV. The effect of maternal position on venous return for pregnant women during MRI. NMR in Biomedicine. 2021 Apr;34(4):e4475.  Couper S, Clark A, Thompson JM, Flouri D, Aughwane R, David AL, Melbourne A, Mirjalili A, Stone PR. The effects of maternal position, in late gestation pregnancy, on placental blood flow and oxygenation: an MRI study. The Journal of physiology. 2021 Mar;599(6):1901-15.  Higuchi H, Takagi S, Zhang K, Furui I, Ozaki M. Effect of lateral tilt angle on the volume of the abdominal aorta and inferior vena cava in pregnant and nonpregnant women determined by magnetic resonance imaging. Anesthesiology. 2015;122(2):286-293.  Fujita N, Higuchi H, Sakuma S, Takagi S, Latif MA, Ozaki M. Effect of right-lateral versus left-lateral tilt position on compression of the inferior vena cava in pregnant women determined by magnetic resonance imaging. Anesthesia & Analgesia. 2019 Jun 1;128(6):1217-22.  Aust H, Koehler S, Kuehnert M, Werdehausen R, Schleppers A, Reese PC, Reyher C. Guideline-recommended 15° left lateral table tilt during cesarean section in regional anesthesia—practical aspects: an observational study. Int J Obstet Anesth. 2016 Aug;27:47-53.  Crawford JS, Burton M, Davies P. Time and lateral tilt at Caesarean section. Br J Anaesth. 1972 May;44(5):477-84.  Lee AJ, Landau R, Mattingly JL, Meenan MM, Corradini B, Wang S, Goodman SR, Smiley RM. Left lateral table tilt for elective cesarean delivery under spinal anesthesia has no effect on neonatal acid–base status: a randomized controlled trial. Anesthesiology. 2017;127(2):241‑249.  Jackson KL, Smiley RM, Lee AJ. Neonatal acid-base status before and after discontinuing routine left uterine displacement for elective cesarean delivery: a retrospective cohort study (2014–2017). Int J Obstet Anesth. 2025;62:104350.  You need to add a widget, row, or prebuilt layout before you’ll see anything here. 🙂

Hypothetical Case: You are called to MFAU to see a woman who has just arrived via RFDS (royal flying doctor service) She is a 23 y.o indigenous woman from the Kimberley in the far north of WA. She is 33/40 G1P0 complex social history and possible substance use disorders She has PPROM (pre term premature rupture of membranes) and suspected early chorioamniotis and has been given antibiotics / nifedipine and a few litres of crystalloid fluid during the flight. The obstetric team have evaluated her – she has small for gestational age baby, and is complaining of dyspnoea. Her observations are: HR 110, NIBP 124/60, SpO2 91% on room air, T38.1 Her bloods are relatively normal except for an unexpected high BNP. You do a focussed bedside transthoracic ECHO and unexpectedly see on the PLAX (parasternal long axis view) a classical hockey stick / domed appearance of severe mitral stenosis. She also has Pulmonary B-lines (indicating pulmonary oedema) and a flattened interventricular septum, very large atrium & doppler through the tricuspid valve confirms severe pulmonary hypertension.  The team decides she would be better cared for in a hospital with cardiothoracic services – however she suddenly becomes more breathless – SpO2 86% on oxygen, NIBP 80/40 HR 125, and there is a prolonged foetal bradycardia………………… Hi Everyone, This week I am joined by Dr Clinton Ellis, a cardiothoracic anaesthetist based in Sir Charles Gairdner Hospital, and Graeme. We discuss the management of rheumatic heart disease in pregnancy – a challenging condition which unfortunately is still relatively prevalent amongst indigenous women here in Australia. This was a wide ranging discussion so I have decided to split this into two 40min episodes. Even though we talk for over 80min I feel like we just scratched the surface on this! If you have any questions or comments send them through – I will try and get Clinton to answer them. Finally a huge shout out and thank you to the Darwin based authors of the ANZCA 2023 Blue Book article on this condition: Namrata Jhummon-Mahadnac, Matthew Mathieson, and Akshay Hungenahally! See the link to their well written narrative review on this topic below: References Australasian Anaesthesia 2023 (aka the Blue Book) – see page 39 “Obstetric anaesthesia in rheumatic heart disease – a unique perspective from the Top End” Oral vaccine could prevent rheumatic heart disease in NZ VIDEO: Researchers close to a vaccine for strep-A and rheumatic heart disease

Hypothetical Case: You are called to MFAU to see a woman who has just arrived via RFDS (royal flying doctor service) She is a 23 y.o indigenous woman from the Kimberley in the far north of WA. She is 33/40 G1P0 complex social history and possible substance use disorders She has PPROM (pre term premature rupture of membranes) and suspected early chorioamniotis and has been given antibiotics / nifedipine and a few litres of crystalloid fluid during the flight. The obstetric team have evaluated her – she has small for gestational age baby, and is complaining of dyspnoea. Her observations are: HR 110, NIBP 124/60, SpO2 91% on room air, T38.1 Her bloods are relatively normal except for an unexpected high BNP. You do a focussed bedside transthoracic ECHO and unexpectedly see on the PLAX (parasternal long axis view) a classical hockey stick / domed appearance of severe mitral stenosis. She also has Pulmonary B-lines (indicating pulmonary oedema) and a flattened interventricular septum, very large atrium & doppler through the tricuspid valve confirms severe pulmonary hypertension.  The team decides she would be better cared for in a hospital with cardiothoracic services – however she suddenly becomes more breathless – SpO2 86% on oxygen, NIBP 80/40 HR 125, and there is a prolonged foetal bradycardia………………… Hi Everyone, This week I am joined by Dr Clinton Ellis, a cardiothoracic anaesthetist based in Sir Charles Gairdner Hospital, and Graeme. We discuss the management of rheumatic heart disease in pregnancy – a challenging condition which unfortunately is still relatively prevalent amongst indigenous women here in Australia. This was a wide ranging discussion so I have decided to split this into two 40min episodes. Even though we talk for over 80min I feel like we just scratched the surface on this! If you have any questions or comments send them through – I will try and get Clinton to answer them. Finally a huge shout out and thank you to the Darwin based authors of the ANZCA 2023 Blue Book article on this condition: Namrata Jhummon-Mahadnac, Matthew Mathieson, and Akshay Hungenahally! See the link to their well written narrative review on this topic below: References Australasian Anaesthesia 2023 (aka the Blue Book) – see page 39 “Obstetric anaesthesia in rheumatic heart disease – a unique perspective from the Top End” Oral vaccine could prevent rheumatic heart disease in NZ VIDEO: Researchers close to a vaccine for strep-A and rheumatic heart disease

Hi everyone, Pain during caesarean is a very challenging and distressing event – for the patient, their partner, the anaesthetist and all the staff present in theatre. This week we catch up with Matt Rucklidge, who recently gave a presentation on this topic at the obstetric anaesthesia meeting in London. We discuss why this has become a “hot topic” in the anaesthesia world in recent times, what is the true incidence, and many other aspects of this difficult topic. References The following is a first person narrative story from a patient with commentary from an uninvolved obstetric anaesthetist. Disappointingly from elselvier this article is unfortunately not open access but is well worth a read: Stanford SE, Bogod DG. Failure of communication: a patient’s story. Int J Obstet Anesth. 2016 Dec;28:70-75. doi: 10.1016/j.ijoa.2016.08.001. Epub 2016 Aug 23. PMID: 27717633. Podcast: The Retrievals Season 2 from NY Times Prevention and management of intraoperative pain during Caesarean sectionOrbach-Zinger, S. et al.BJA Education, Volume 25, Issue 2, 50 – 56

Hi everyone, Sepsis is an important cause of mortality and morbidity in our patients. It is common but can be difficult to diagnose, challenging to manage and sometimes downright scary. After being inspired by listening to an episode from “The Critical Care Commute Podcast” (with Dr Mervyn Singer a UK intensivist involved in sepsis 3.0), Graeme and I sit down to discuss some of these thought provoking areas of sepsis which are controversial and are still actively being researched. Thanks again Graeme! References The Critical Care Commute Podcast

Hi Everyone, This week I am joined by Dr Jen Kielty to discuss ERAS - Enhanced Recovery After Surgery. Jen has been helping us with the introduction of ERAS here at our hospital and also shares her experience with the introduction of ERAS into obstetrics at two hospitals back in Ireland. What is ERAS? Why is ERAS good for patients and good for the hospital? What are the components of an ERAS program? A big shout out to Dr Chloe Ayres here at KEMH as the champion for this initiative. Chloe has done a huge amount of work to make this a success here in our gynae-oncology patients and without her enthusiasm it probably would never have happened. Another big acknowledgement to my wife Andrea, who as the inaugural ERAS nurse has also had to do an amazing amount of work with staff and patients to make it a success! References ERAS Society guidelines for Obstetrics and Gynaecology

Hi everyone, This week Declan and I sit down to discuss a novel non opioid analgesic drug recently approved for use by the FDA, suzetrigine. What is it? How does it work? Why should we be interested in this new class of drugs and most importantly will it live up to it's hype? References Suzetrigine: First in a New Class of Nonopioid Analgesics for Acute Pain. Anesthesiology 142(6):p 989-991, June 2025. | DOI: 10.1097/ALN.0000000000005465 - Unfortunately this is not a free article but well worth a read if you can get to it through your hospital or college library. The accompanying podcast of this editorial is open access - follow the following link. podcast Suzetrigine Drug-Drug Interactions: Perioperative Anesthesia Considerations to Enhance Patient Safety

Hi Everyone, This week I sat down with Declan to discuss a fascinating therapy which is used in many areas of medicine. This podcast has a bit of everything, a quiz, a part one viva, dubious animal experimentation, discussions about laxatives, and even some references to cosmology and the Big Bang. Thanks Declan for another entertaining episode.

You are called to assess a pregnant woman who presents to your hospital complaining of shortness of breath. She is 36 weeks pregnant with twins and tells you she had been getting progressively short of breath over the last month but put it down to the physical effects of the twin pregnancy in her abdomen. However last night she couldn't get her breath lying flat, had to sleep sitting up on 3-4 pillows and feels that "it is much worse". On examination she has a respiratory rate of 24/min, SpO2 = 92%, HR 105/min, BP 95/45 and you can hear crepitations in both lung fields. Her initial blood tests come back showing a raised plasma BNP and a bedside ECHO is done by a helpful colleague - who says "subjectively her LV isn't contracting very well". Hi everyone, This week I sit down with Dr Faith Njue the most qualified person here in WA to discuss the rare but important disease - peripartum cardiomyopathy. (See Faith's Bio below). Join us in our wide ranging discussion which touches on the diagnostic challenges, demographics, proposed mechanisms and general principles involved in managing these complex patients. Thanks Faith for a great discussion! Dr Faith Njue - Bio Faith Njue graduated from the University of Western Australia and completed cardiology training in Perth. She undertook further subspeciality training in advanced heart failure/ heart transplantation at Fiona Stanley Hospital and the University of Ottawa Heart Institute in Canada. Thereafter, she undertook further fellowship in cardio-obstetrics at the John Radcliffe hospital in Oxford (UK). She has special interest in women’s cardiovascular health, heart disease in pregnancy and heart failure. Faith runs the dedicated Western Cardiology cardio-obstetrics clinic, designed to support women at risk of or with pre-existing heart conditions, through preconception counselling, pregnancy and into the post-partum period. Cardio-obstetrics is an expanding subspecialty that focuses on prevention, early detection, and appropriate management of cardiovascular disease in pregnancy. She holds public consultant positions at Sir Charles Gairdner and Fiona Stanley hospitals. She is part of the Advanced heart Failure and Cardiac Transplant team at FSH. She is the cardiology clinical lead for High Risk pregnancy at FSH. References Anaesthesia and peripartum cardiomyopathy Chapman, K. Njue F, Rucklidge M. BJA Education, Volume 23, Issue 12, 464 - 472 Melanie Ricke-Hoch, Tobias J. Pfeffer, and Denise Hilfiker-Kleiner. Peripartumcardiomyopathy: basic mechanisms and hope for new therapies. Cardiovascular Research (2020) 116, 520–531. doi:10.1093/cvr/cvz252​ Bauersachs J, König T, van der Meer P, et al. Pathophysiology, diagnosis and management of peripartum cardiomyopathy: a position statement from the Heart Failure Association of the European Society of Cardiology Study Group on peripartum cardiomyopathy. Eur J Heart Fail. 2019 Jul;21(7):827-843. doi: 10.1002/ejhf.1493. Epub 2019 Jun 27. PMID: 31243866​ 2018 ESC Guidelines for the Management of Cardiovascular Disease During Pregnancy. European Heart Journal 2018. Vol 39;3165-3241​ Bromocriptine: Koenig T, Bauersachs J, Hilfiker-Kleiner D. Bromocriptine for the Treatment of Peripartum Cardiomyopathy. Card Fail Rev. 2018 May;4(1):46-49. doi: 10.15420/cfr.2018:2:2. PMID: 29892477; PMCID: PMC5971672 Hilfiker-Kleiner D, Haghikia A, Berliner D, Vogel-Claussen J, Schwab J, Franke A, Schwarzkopf M, Ehlermann P, Pfister R, Michels G, Westenfeld R, Stangl V, Kindermann I, Kühl U, Angermann CE, Schlitt A, Fischer D, Podewski E, Böhm M, Sliwa K, Bauersachs J. Bromocriptine for the treatment of peripartum cardiomyopathy: a multicentre randomized study. Eur Heart J. 2017 Sep 14;38(35):2671-2679. doi: 10.1093/eurheartj/ehx355. PMID: 28934837; PMCID: PMC5837241.

Hi everyone, This week I am joined again by Dr David Owen an obstetrician here at KEMH. We sit down to discuss uterine inversion - an acute obstetric emergency. Luckily this condition is relatively rare - however because of this there can be challenges in recognising and treating this condition even amongst experienced individuals. Should you be unlucky enough to encounter this rare condition, now having listened to our discussion you will be better prepared and confident you know what is required! Thanks again David for your research and preparation for this episode! References Uterine inversionPararajasingam, S.S. et al.BJA Education, Volume 24, Issue 4, 109 - 112 Unfortunately (as of Feb 2025) this article is not yet open access - but it is very good if you can get it through your hospital or college library.. Uterine Inversion for the layperson - Cleveland Clinic https://youtu.be/bYIPkNfPDUI