Preterm twins for caesarean under spinal28-year-old woman, 74 kg, with a dichorionic twin pregnancy at 34 weeks; first twin breech

The patient

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1. Consider

   What are your considerations?

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   • A 28-year-old with preterm twins at 34 weeks, first breech, for category 2 caesarean under spinal. Patient
   • Twins exaggerate pregnancy: her cardiac output rises about 20% more than with one baby.
   • Her large uterus compresses the cava when supine, so spinal hypotension is likely. Disease
   • Twins and anaemia make atony and haemorrhage more likely for her.
   • Two preterm babies: steroids are done, and each twin needs its own neonatal team. After surgery

2. Prepare

   How do you prepare her?

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   • Two large-bore cannulas and a crossmatch, given her anaemia and bleeding risk. Patient
   • Sodium citrate 15–30 mL within the hour, and a wedge for left uterine displacement.
   • Phenylephrine infusion from the start at 25–50 mcg/min, with a crystalloid co-load. Disease
   • Oxytocin, carboprost, methylergonovine and tranexamic acid ready before incision.

3. Plan

   What is your anaesthetic plan?

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   • Spinal: hyperbaric bupivacaine 10–12 mg, fentanyl 10–25 mcg and preservative-free morphine 0.1–0.2 mg. Disease
   • Block checked to T4 before the surgeon starts.
   • Her BP cycled every 1–3 minutes through the first 20 minutes.
   • After delivery, oxytocin 1–3 IU IV slowly, then 2.5–15 IU/h by infusion. After surgery
   • Both neonatal teams ready; the second twin may need help at birth.

4. Crisis

   Five minutes after the spinal she feels sick, her hands tingle, and the block is at T2. BP 78/40, HR 52. What do you do?

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   • High block with hypotension and bradycardia: call for help, increase her tilt, raise her legs. (Crisis)
   • With HR 52, ephedrine boluses, not phenylephrine, and fluid running fast.
   • Glycopyrrolate 0.1–0.2 mg IV; adrenaline 2–10 mcg/min if she stays slow and low.
   • Phenylephrine only once her heart rate has recovered.
   • Her nausea is from low pressure; restoring it treats the nausea.
   • Check breathing, voice and grip; a weak voice means the block is climbing.
   • Intubate if she can't speak, ventilate, or loses consciousness.

5. Crisis

   After both babies, the uterus is boggy; blood loss 1500 mL. BP 86/50, HR 124. What do you do?

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   • Atonic PPH: major haemorrhage call, obstetrician compressing the uterus. Crisis
   • Oxytocin infusion increased to 18–36 IU/h.
   • Carboprost 0.25 mg IM, repeat every 15–60 minutes; caution if she's asthmatic.
   • Methylergonovine 0.2 mg IM, as she isn't hypertensive.
   • Tranexamic acid 1 g, run over 10 minutes; we're inside the 3-hour window after birth.
   • Blood and fibrinogen early; balloon, compression sutures or hysterectomy if drugs fail.
   • HDU afterwards with close watch on bleeding and urine output. After surgery