Manual Removal of Placenta

Summary

  • Dose: 2.4 ml 0.5% hyperbaric bupivacaine + 15 mcg fentanyl

  • Position: Patient lateral or sitting, immediately supine.

  • Expectation: Surgical anaesthesia for at least 60 mins.

General Anaesthesia v Regional Anaesthesia

  • These patients have the potential for large degree of blood loss (despite apparent haemodynamic stability). They are also commonly exhausted from labour and/or have a preference to be asleep for the procedure.

Evidence

  • Postpartum patients, in comparison to term pregnant patients, require larger doses to achieve a similar block.

    • Eight to twenty-four hours postpartum, post-partum tubal ligation (PPTL) patients require 30% more drug per segment than a patient having a LUSCS [1].

    • PPTL patients (~ 14 hours post-delivery) had a block to T3 with 12 mg (2.4 ml) 0.5% hyperbaric bupivacaine with 100 mcg morphine (patient lateral, immediately supine). This was opposed to LUSCS patients who achieved a T2 (statistically significant) level [2].

    • PPTL patients (~ 7.5 hours post-delivery) had a block to T4 with 12 mg (2.4 ml) 0.5% hyperbaric bupivacaine with 100 mcg morphine (patient sitting, supine within 2 minutes). This was opposed to LUSCS patients who achieved a T3 (not statistically significant) level [3].

  • 5% of patients will experience discomfort with a block (to cold) to T6. 22% of those with a block (to cold) to T9 or T10 will experience discomfort [4].

  • The use of 2.6-3.0 ml 0.5% hyperbaric bupivacaine with 300 mcg diamorphine was shown to achieve a T6 level in 84% of patients. No (0%) patient reported intraoperative discomfort [5].

References

  1. Abouleish. Postpartum tubal ligation requires more bupivacaine for spinal anaesthesia than does caesarean section. Anesth Analg 1986;65:897-900

  2. Teoh et al. Comparison of an equal dose spinal anesthetic for caesarean section and for post-partum tubal ligation. Int J Obstet Anes 2008;17(3):228-232.

  3. Kwok et al. Effect of sitting position on equal-dose spinal anaesthetic for caesarean section and post-partum tubal ligation. Acta Anaesthesiol Scand 2014;58(6):743-750.

  4. Broadbent & Russell. What height of block is needed for manual removal of placenta under spinal anaesthesia?  Int J Obstetric Anesth 1999;8(3):161-164.

  5. Adams & Menon. Anaesthetic protocol for manual removal of placenta (MORP). Anaesthesia 2013;68(1):104-105.