Appendix 5 Anaesthesia Protocol .

LOCAL ANAESTHESIA	AUGMENTED LOCAL	GENERAL ANAESTHESIA
atropine .5 mg	atropine.5 mg	atropine.5 mg
droperidol 1 mg (optional)	fentanyl .05 mg (1 ml) diazepam or midazolam 5 mg droperidol 1 mg (optional)	fentanyl .05 mg (1 ml) diazepam or midazolam 5 mg droperidol 1 mg (recommended)
ergometrine + oxytocin .5 mg + 5 IU (over 12 weeks only)	ergometrine + oxytocin .5 mg + 5 IU (over 12 weeks only)	ergometrine + oxytocin .5 mg + 5 IU (over 12 weeks only)
lignocaine 2 x 5 ml 1% or lignocaine + noradrenaline 4 x 5 ml 1% (over 14 weeks)	lignocaine 2 x 5 ml 1% lignocaine + noradrenaline 4 x 5 ml 1% (over 14 weeks)	etomidate 10 mg (5 ml) (to be repeated if necessary) and lignocaine + noradrenaline 4 x 5 ml 1% (over 14 weeks)

All medicines (except lignocaine) to be injected intravenously, preferably using a venous canula with a valved injection port to allow injection without contaminating the syringe.

Lignocaine to be injected 1.5 cm deep in the vaginal fold left and right of the cervix, somewhat above and under the midline (at 2, 4, 8 and 10 o'clock) to avoid the great uterine vessels. Before injecting the plunger must be drawn to make sure that the needle did not enter a vessel.

To deal with respiratory distress caused by the analgesic an injection of naloxone must be kept ready. To inhibit the effects of the sedative an injection of flumazenil may be given after the procedure. See Chapter 5 for details.

Occasionally the injection of the local anaesthetic may cause epileptiform fits and rarely muscular rigidity which may impair breathing. In that case an immediate IV injection of diazepam is indicated This situation with two case histories is discussed in Chapter 5 .

Many thousands of patients have been treated in the Netherlands under general anaesthesia according to the protocol which is described here. There have been no dangerous complications. It is therefore a very safe procedure which does not require a hospital setting.

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