Obstetric analgesia and anaesthesia — structured SAQ (15 marks)

(a) Epidural evidence counselling (4 marks)

One mark per named finding, maximum four. ^[1]

• Efficacy: epidural provides better pain relief and higher maternal satisfaction than non-epidural methods (Cochrane review, Anim-Somuah 2018).^[1]
• Caesarean: it does not increase the rate of caesarean section — this directly corrects her concern.^[1]
• Instrumental birth: there is an overall increase in assisted vaginal birth, though modern low-dose techniques reduce it: COMET showed normal vaginal birth rose from 35.1% to about 43% with low-dose mobile techniques.^[2]
• Long-term: no long-term backache; common short-term effects are hypotension, itch and accidental dural puncture.^[1]

(b) Spinal anaesthesia technique (5 marks)

• Drug and dose (1 mark): hyperbaric bupivacaine 0.5%, typically 12.5 to 15 mg intrathecally, with an intrathecal opioid (fentanyl or diamorphine) for postoperative analgesia.^[11][13]
• Block target (1 mark): test to a bilateral sensory level of T4 (cold or pinprick) and document the motor block before the incision.^[6]
• Hypotension prevention (2 marks): prophylactic phenylephrine infusion started at intrathecal injection, left uterine displacement, and co-loading with crystalloid — the international consensus preference because phenylephrine produces less fetal acidosis than ephedrine (bolus ephedrine 6 to 12 mg is second-line).^[6]
• Aseptic technique and positioning (1 mark): full sterility, midline approach, sitting or lateral, with monitoring and IV access established beforehand.^[1]

(c) Post-dural puncture headache (3 marks)

• Assess for postural character and red flags (1 mark): confirm the headache is worse sitting and better lying flat; exclude fever, focal neurology, seizure, altered consciousness or loss of the postural component — any of which demand imaging for alternative diagnoses.^[10]
• Supportive measures (1 mark): reassurance, postural advice (lie flat for comfort), hydration, regular analgesia (paracetamol, NSAID), caffeine; avoid straining.^[10]
• Epidural blood patch (1 mark): if severe or persisting beyond 24 to 48 hours, inject 20 to 30 mL of the woman's own venous blood into the epidural space at or one space below the puncture; a first patch relieves the majority of cases, a second may be needed for recurrence.^[10]

(d) Failed intubation response (3 marks)

• Plan A (1 mark): optimised laryngoscopy with a maximum of two attempts, calling for senior help early.^[5]
• Plans B and C (1 mark): Plan B — supraglottic airway (up to two attempts); Plan C — face-mask ventilation with or without cricoid pressure.^[5]
• The wake-or-proceed decision and Plan D (1 mark): if oxygenation is maintained and the fetus is not in extremis, wake the woman and return with a regional technique; if the fetus is dying and the airway is lost, proceed with a supraglottic airway; Plan D — front-of-neck access (scalpel-bougie cricothyroidotomy) if oxygenation cannot be maintained. State the factors: maternal condition, fetal condition, anaesthetist skill, obesity, surgical urgency, airway soiling.^[5]