Anaesthetic protocol for manual removal of placenta


Manual removal of placenta (MROP) is a commonly performed procedure on the delivery suite. There is limited evidence suggesting the ideal regional anaesthetic regimen for this procedure. A block height of T10, recommended in early studies, is associated with a high incidence of discomfort during and after the procedure [1, 2]. More recent studies suggest that a block height at or above T6 to cold is necessary for maternal comfort during MROP [3].

We carried out an audit of anaesthesia for MROP in our institution, looking at anaesthetic technique, patient satisfaction, side-effects and details of the postoperative period including time to mobilisation and time to discharge. Twenty-six women underwent the procedure, with 22 (85%) receiving spinal anaesthesia and the remainder, top-up of an in-situ epidural. It was apparent that there was no standardised anaesthetic protocol. A high incidence of intra-operative discomfort contributed to poor patient satisfaction (Table 2). This contrasts sharply with very high satisfaction rates we have achieved with epidural analgesia and anaesthesia for caesarean section, for which formal guidelines and ongoing audit exist. We developed a regional anaesthetic regimen for MROP, consisting of intrathecal hyperbaric bupivacaine 0.5% adequate to achieve a block height of T6 with an opioid (diamorphine 300 μg) for all patients. For those with a working epidural in situ, our protocol advised a top-up using ropivacaine 0.75%, ensuring a block height of T6 and the addition of 3 mg diamorphine.

Table 2. Results before and after the introduction of a protocol for anaesthesia for patients undergoing manual removal of placenta
 Before (n = 26)After (n = 25)
Use of 2.6–3.0 ml intrathecal hyperbaric bupivacaine 0.5%15 (59%)20 (82%)
Use of 300 μg intrathecal diamorphine4 (15%)25 (100%)
Block level of T6 or above12 (45%)21 (84%)
Intra-operative discomfort3 (12%)0
Excellent intra-operative satisfaction22 (85%)25 (100%)
First mobilisation within 12 h21 (81%)23 (92%)
Removal of urinary catheter within 24 h22 (85%)23 (92%)
Excellent postoperative satisfaction10 (38%)24 (96%)

Practice was re-audited for six months after implementation of the new protocol. Data were collected for 25 women, of whom 22 (88%) received spinal anaesthesia, the remainder receiving epidural augmentation. Despite higher levels of block and consistent use of opioids, there was no increase in the prevalence of postoperative nausea and vomiting. Itch was reported by 4 (16%) women, likely to be secondary to the increased use of diamorphine.

Our audit has certain limitations. Some patients were assessed postoperatively as inpatients, and might be expected to have better recall of events than those followed up by telephone conversation after hospital discharge. We did not quantify the force applied by the surgeon during the procedure, which has been suggested to have a bearing on intra-operative discomfort [3], nor did we compare the use of different opioids such as fentanyl.

Our results suggest that using a higher dose of local anaesthetic to achieve a block height of T6 and addition of diamorphine provides good intra-operative analgesia and patient satisfaction without increasing the incidence of complications such as delayed mobilisation, urinary retention or nausea and vomiting.

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    No external funding and no competing interests declared.