Obstetric OT Preparation
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Direct answer
Two patients share one operating table in every caesarean section, and the theatre prepares for both: for the mother, a rapid-sequence induction setup with working suction, 15–30 degree left uterine tilt against aortocaval compression, cross-matched blood traceable in minutes, and a PPH tray with oxytocin, ergometrine, carboprost and misoprostol; for the newborn, a checked radiant warmer with a resuscitation trolley — small self-inflating bag, appropriately sized masks, low-pressure suction, and warming linen. Elective lists run spinal anaesthesia with the same readiness behind them — an elective caesarean can become the haemorrhage or the depressed neonate of now. The technician's craft is that neither trolley ever needs assembling after the emergency begins.
What you must remember
- Aortocaval compression: from about 20 weeks, supine position compresses the inferior vena cava — 15–30 degrees left tilt or manual uterine displacement is standard for every obstetric procedure.
- Aspiration risk: pregnancy delays gastric emptying and raises acidity — rapid sequence induction with cricoid pressure, and prophylaxis such as a non-particulate antacid or ranitidine per protocol for elective cases.
- Spinal anaesthesia for caesarean: pencil-point needle (25–27 G), hyperbaric bupivacaine 0.5% commonly 2–2.5 mL (about 10–12.5 mg) with opioid adjunct; block to about T4 for surgical anaesthesia; hypotension pre-empted with fluids and vasopressor ready.
- Neonatal trolley: functioning radiant warmer, self-inflating bag (paediatric size) with masks from neonatal down, T-piece device if used, suction regulated to low negative pressure (roughly 80–100 mmHg), stethoscope, timer, warm towels — checked before every case, not every day.
- PPH tray: oxytocin 5 IU slow IV at delivery with infusion prepared, ergometrine 0.25 mg IM (avoided in hypertension and pre-eclampsia), carboprost 250 μg IM every 15 minutes to a maximum of 8 doses (avoided in asthma), misoprostol 800 μg sublingual as a further line.
- Blood readiness: group and save minimum for low-risk cases, cross-matched units for expected difficulty — with the emergency release ("group O negative") pathway known.
- Third stage and counting: controlled cord traction, a staged placenta tray, and counts as rigorous as any laparotomy.
- Uterotonic cross-check: the tray's contraindications checked aloud — ergometrine with hypertension, carboprost with asthma — before the rush, not during it.
Elective list to emergency add-on in one shift
The morning list is three elective caesareans under spinal. Before the first patient: the neonatal trolley checked item by item — warmer heated, bag assembled and valve tested, two mask sizes, suction set low, towels warmed. The spinal trolley carries pencil-point needles, fluids running, vasopressor drawn; the mother tilted as soon as she lies down; the PPH tray sealed, its contraindications flagged on the card.
Mid-list the call comes: fetal distress, category-one section, general anaesthesia. The calm converts on rehearsed rails — table tilting left, suction at the head tested at the catheter, RSI drugs drawn, cricoid pressure assigned by name. The surgeon preps while the anaesthetist induces; the scalpel waits only for the anaesthetist's "go". The neonate arrives depressed: warmed towels, drying, airway positioning, bag ventilation at the warmer, the timer running while the paediatric team called. Mother-side, the oxytocin runs, the placenta is inspected, counts complete, and both trays are restocked before the next patient — readiness is the treatment.
Where students slip
The examination traps are the tilt's reason and the uterotonic contraindications. "Left tilt for comfort" scores nothing — it relieves aortocaval compression, preventing supine hypotension and placental underperfusion; the number (15–30 degrees) and manual uterine displacement belong in the answer. The drug pairs get swapped under pressure: ergometrine avoided in hypertension and pre-eclampsia, carboprost avoided in asthma — a viva favourite because both sit on the same tray card. Candidates also describe neonatal resuscitation equipment in adult terms: the self-inflating bag must be the paediatric size with a pressure-limiting valve, suction must be low-pressure, and the first intervention is drying and warmth. Finally, "counting can be skipped in a bleeding caesarean" is a failing answer — PPH is exactly the case where packs are lost and exactly why counts are never suspended.
Frequently asked questions
Why is left uterine tilt used in obstetric anaesthesia?
To relieve aortocaval compression by the gravid uterus beyond about 20 weeks — 15–30 degrees left lateral tilt or manual uterine displacement maintains venous return and placental perfusion.
What spinal dose is typical for elective caesarean section?
Hyperbaric bupivacaine 0.5%, commonly about 2–2.5 mL (10–12.5 mg) through a 25–27 G pencil-point needle, targeting a block to around T4, with hypotension pre-empted.
What must the neonatal resuscitation trolley carry?
A functioning radiant warmer, paediatric self-inflating bag with pressure-limiting valve, term and preterm masks, low-pressure suction, warm towels, stethoscope and timer — checked before every delivery.
Which uterotonics make up the PPH tray?
Oxytocin (5 IU slow IV with infusion), ergometrine 0.25 mg IM, carboprost 250 μg IM (repeat to 8 doses) and misoprostol 800 μg sublingual — staged with their contraindications flagged.
Why is ergometrine avoided in pre-eclamptic patients?
It causes intense vasoconstriction and can precipitate hypertensive crisis; carboprost is similarly avoided in asthma — hence the tray's cross-check card.