Unpublished Posters: Obstetric Anaesthesia 2010 (Newcastle) P1 P R Madhivathanan , P Jatoth ,* A Rodin,* M K Balasubramanian Department of Anaesthesia, Barnet General Hospital, London, UK, *Department of Obstetrics & Gynaecology, Barnet General Hospital, London, UK Introduction : Uterine inversion is a rare and potentially life threatening complication of pregnancy that can be associated with massive haemorrhage. We describe a recent case where uterine inversion occurred following vaginal birth after previous caesarean section (VBAC). Case report : A 27-year-old healthy woman (G2P1) with previous history of one caesarean section presented with spontaneous onset of labour at 37 weeks of gestation. She was very keen on vaginal delivery. After a prolonged labour with entonox and intramuscular pethidine for analgesia, she gave birth to a baby girl. Active management of the third stage was instituted. Following the delivery of the placenta , brisk blood loss of 500ml was noted and the patient complained of severe back pain. She appeared pale and shocked, with a heart rate of 131 beats/ min and BP of 78/49 mmHg. Active fluid resuscitation improved BP and heart rate. The obstetrician suspected uterine scar dehiscence in the first place given the history of previous caesarean. Uterus was well contracted on examination of the abdomen. Vaginal examination was difficult as the patient was in severe pain. Decision was made to examine under anaesthesia. In the operating theatre a rapid sequence induction with thiopental and suxamethonium was performed and anaesthesia was maintained with sevoflurane in 50% oxygen and nitrous oxide. Vaginal examination under anaesthesia revealed incomplete uterine inversion (fundus not extending beyond external os) with large amounts of blood clots. The uterine scar from previous caesarean was intact. The uterus was reduced without any difficulty with the volatile anaesthetic providing excellent tocolysis. The estimated blood loss was 2500ml. Intraoperative fluid management included 2 litres of crystalloid, 1 litre of colloid and 2 units of blood. Postoperative haemoglobin was 6.1g/dl and further 2 units of blood were transfused. Subsequent recovery of the patient was uneventful. Discussion : Acute uterine inversion occurs between 1:2000 and 1:6400 deliveries. In our case, as vaginal examination proved difficult, and the uterine inversion was incomplete, it was difficult to make a diagnosis in the labour room. Examination under anaesthesia not only helped to diagnose but also promptly treat uterine inversion. Although the classical description of shock out of proportion to blood loss was initially noted in our case , this was probably due to underestimation of blood loss. References P81 Acute uterine inversion following vaginal birth after caesarean (VBAC): a case report 1 1 2 1. Sarna MC, Hess P, Takoudes T C, Chaudhury A K. Postpartum hemorrhage. In: Datta S, ed. Anesthetic and obstetric managment of high risk pregnancy. 3rd ed. New York: Springer; 2004: 123, 129. 2. Beringer R M, Patterill M. Puerperal uterine inversion and shock. Br J Anaesth 2004; 92: 439-441. SC Rowell , KM Howie ,* J Reid Anaesthesia, Queen Mother's Hospital, Glasgow, UK, *Anaesthesia, Southern General Hospital, Glasgow, UK Introduction: A generator test in May 2006 at a paediatric and maternity unit in Glasgow proved problematic. The generator failed and staff scrambled to deal with the consequences. The first patients were being transferred into theatre and a child was on bypass (which was hand pumped until resumption of mains power). Despite the potential for serious harm there were no casualties. Regular tests are now carried out. Method: We decided to audit testing preparation to see if lessons had been learned. We looked at charging of pumps and monitors prior to testing. These rely on battery power in the event of mains failure. All clinical staff had been notified in advance of the test as normal. Results: Less than 30% of pumps and 50% of other equipment including monitoring were charging prior to the generator test. Conclusion: Difficulties could be encountered in the event of power failure due to a lack of charged equipment. Reasons may include lack of knowledge of issues and solutions during testing and lack of communication between engineers and staff highlighting potential local problems. It is not enough to announce the date of testing. Communication between departments is vital to plan for and hopefully avoid deleterious consequences. Written test procedures could provide a framework to ensure quality preparation and safe testing procedures. Drills to familiarise staff with failure procedures may improve performance in this area Reference P82 Audit of pre-generator testing preparation .1 1. Stymiest DL. Managing hospital emergency power testing programs. American Society for Healthcare Engineering of American Hospital Association.
Unpublished Posters: Obstetric Anaesthesia 2010 (Newcastle)
P1
P R Madhivathanan, P Jatoth,* A
Rodin,* M K Balasubramanian Department of
Anaesthesia, Barnet General Hospital, London, UK, *Department of
Obstetrics & Gynaecology, Barnet General Hospital, London, UK
Introduction: Uterine inversion is a rare and potentially life
threatening complication of pregnancy that can be associated with
massive haemorrhage. We describe a
recent case where uterine inversion occurred following
vaginal birth after previous caesarean section (VBAC).
Case report : A 27
-year-old healthy woman (G2P1) with
previous history of one caesarean section presented with
spontaneous onset of labour at 37 weeks of gestation. She
was very keen on vaginal delivery. After a prolonged
labour with entonox and intramuscular pethidine for
analgesia, she gave birth to a baby girl. Active management
of the third stage was instituted. Following the delivery of
the placenta , brisk blood loss of 500ml was noted and the
patient complained of severe back pain. She appeared pale and
shocked, with a heart rate of 131 beats/ min and BP of
78/49 mmHg. Active fluid resuscitation improved BP and
heart rate. The obstetrician suspected uterine scar
dehiscence in the first place given the history of previous
caesarean. Uterus was well contracted on examination of
the abdomen. Vaginal examination was difficult as the
patient was in severe pain. Decision was made to
examine under anaesthesia. In the operating theatre a rapid
sequence induction with thiopental and suxamethonium
was performed and anaesthesia was maintained with
sevoflurane in 50% oxygen and nitrous oxide. Vaginal
examination under anaesthesia revealed incomplete uterine
inversion (fundus not extending beyond external os)
with large amounts of blood clots. The uterine scar from
previous caesarean was intact. The uterus was reduced without any
difficulty with the volatile anaesthetic providing
excellent tocolysis. The estimated blood loss was 2500ml.
Intraoperative fluid management included 2 litres of
crystalloid, 1 l i
tre of colloid and 2 units of blood.
Postoperative haemoglobin was 6.1g/dl and further 2 units
of blood were transfused. Subsequent recovery of the
patient was uneventful.
Discussion: Acute uterine inversion occurs between 1:2000 and
1:6400 deliveries.
In our case, as vaginal examination
proved difficult, and the uterine inversion was incomplete,
it was difficult to make a diagnosis in the labour room.
Examination under anaesthesia not only helped to diagnose
but also promptly treat uterine inversion. Although
the classical description of shock out of proportion to blood
loss was initially noted in our case , this was probably due
to underestimation of blood loss.
References
P81
Acute uterine inversion following vaginal birth
after caesarean (VBAC): a case report
1
1
2
1. Sarna MC, Hess P, Takoudes T C, Chaudhury A K. Postpartum
hemorrhage. In: Datta S, ed. Anesthetic and obstetric managment of
high risk pregnancy. 3rd ed. New York: Springer; 2004: 123,
129.
2. Beringer R M, Patterill M. Puerperal uterine inversion and
shock. Br J Anaesth 2004; 92: 439-441.
Conclusion: Difficulties could be encountered in the event
of power failure due to a lack of charged equipment.
Reasons may include lack of knowledge of issues and
solutions during testing and lack of communication between
engineers and staff highlighting potential local problems. It i s
no t e nough t o a nnounce t h e
d a t e o f t e s t i ng . Communication
between departments is vital to plan for and hopefully avoid
deleterious consequences. Written test procedures could provide a
framework to ensure quality preparation and safe testing
procedures. Drills to familiarise staff with failure procedures may
improve performance in this area
Reference
.1
1. Stymiest DL. Managing hospital emergency power testing programs.
American Society for Healthcare Engineering of American Hospital
Association.
P2 Unpublished Posters: Obstetric Anaesthesia 2010
(Newcastle)
Irfan Mansur, Ajay Swami Department of
Anaesthesia, Kettering General Hospital, Kettering, UK
Introduction: Carboprost is used in refractory cases
of atonic post partum haemorrhage. Pulmonary oedema is a
known complication after the administration of carboprost (1,2,3).
We describe a case of a healthy primigravida
needing mechanical ventilation for pulmonary oedema after
the administration of carboprost .
Case History : 17-year-old primigravida at 37 weeks gestation was
admitted after spontaneous rupture of
membranes. There was no significant past medical or
antenatal history. Labour was induced with dinoprostone and
oxytocin infusion. Patient requested epidural analgesia, which
provided good pain relief. Patient was transferred to theatre for
trial of instrumental delivery due to failure to progress . The t r
ia l o f ins t rumenta l de l ivery was unsuccessful and caesarean
section was indicated. Both the procedures were carried out under
epidural anaesthesia with 10mls 0.5% Bupivacaine , 8mls 2%
Lignocaine and 50mcg of fentanyl. After delivery and removal of
placenta uterine a t o n y was unsuccessful ly treated w i t h m a
n u a l compression, intravenous oxytocin and intrauterine
misoprostol. The estimated blood loss was approximately
2000mls which was replaced with 3 units of blood and 1
litre of crystalloids. Anaesthetist gave three doses of 250 mcg
intramuscular carboprost 15 minutes apart and bleeding stopped.
After 5 minutes of 3rd dose of carboprost patient developed sinus
tachycardia of 130/min, dyspnoea and oxygen saturation fell to 80%
with bilateral wheeze and crepitations on chest auscultation . T h
e p a t i e n t w a s intubated needing high airway pressures and
the chest radiograph showed acute pulmonary oedema. Treatment for
pulmonary oedema was started and patient transferred to
intensive care unit where she was extubated 6 hours later.
Patient was discharged home on the third postoperative day
Discussion: Carboprost is useful for treating uterine atony which
does not respond to other drugs, but side effects are not uncommon
(1,2). Hypoxia related to carboprost could b e d u e t o p u l m o
n a r y o e d e m a ( a s i n t h i s c a s e ) ,
bronchoconstriction(1)e v e n i n n o n a s t h m a t i c s ( 2 ) o
r pulmonary shunting leading to ventilation/perfusion mismatch.
CEMACH case report "Why Mothers Die 1997- 1999" indicated that the
lack of understanding of side effects of carboprost including
bronchospasm and pulmonary oedema was one of the contributing
factors to a patient’s death.(3).We emphasize caution in
prescribing carboprost with special attention to minimum dosage
interval of 15 minutes with minimising the maximum
dosage of 2mg. Patient reactions to drug administration
should be carefully monitored during and after anaesthesia and
unnecessary over hydration should be avoided to prevent the
occurrence of pulmonary oedema
References
P83 Carboprost induced pulmonary oedema during caesarean
section
1. Harber C,Levy D,Chidambaram S,Macpherson M. Life-threatening
bronchospasm after intramuscular carboprost for postpartum
haemorrhage. BJOG 2007; 114(3):366-8.
2. Cooley DM, Glosten B, Roberts JR, Eppes PD, Barnes RB.
Bronchospasm after intramuscular 15-methyl prostaglandin F2 alpha
in a nonasthmatic patient. Anesth Analg 1991; 73:87–9
3. Thomas TA, Cooper G. Why Mothers Die 1997–1999 (Chapter 9:
Anaesthesia).TheConfidentialEnquiries into Maternal Deaths in the
United Kingdom. London: Royal College of Obstetricians &
Gynecologists, 2001; 134-49
Conclusion: A combination of numerical and colour coded MEOWS is an
unique and invaluable tool to aid admission and discharge of the
sick parturient to OHDU. We believe
that it is a simple, convenient and robust early warning
system to al low t imely inst i tut
ion of appropriate
management. In addition, we recommend that the presence
of a clearly documented discharge summary would allow
better follow up and after care of the patients on the ward.
We are in the process of introducing the discharge
summary form in our unit. Reference
P84 Introduction of modified early obstetric warning score
chart
1
1. Lewis G (ed). Saving mothers' lives: reviewing maternal deaths
to make motherhood safer -2003-2005. London: CEMACH; 2007
Unpublished Posters: Obstetric Anaesthesia 2010 (Newcastle)
P3
K O'Connor, J Robertson, J Reid
Anaesthetic Department, Queen Mothers Hospital, Glasgow, UK
Introduction:
MEOWS scoring systems are a newly
introduced method of recognising and monitoring the sick
obstetric patient and have been recommended by CEMACH . Our unit
(3000 deliveries) recently introduced this
observation system and we aimed to assess the mode of delivery and
anaesthetic type associated with red and yellow triggers.
Methods: All patients who delivered in our 70 bed unit over a 4
week period were identified and case notes analysed retrospectively
for details of abnormal observations recorded, type of anaesthetic
and mode of delivery.
Results: 264 patients delivered in the 4 weeks with 247 (94%) of
case notes available for review. Of these, 54 (21.9%) had no MEOWS
chart and 4 (1.6%) had only one set of observations documented. 189
(77%) had a MEOWS chart with >1 recording with and average
duration of 48.6 hours (range 0-216 hours). 31 patients triggered a
red score
while 90 triggered a yellow. Details of red and yellow
scores are summarised in table below:
FVD= Forceps or vacuum delivery
Discussion:
Patients who underwent general anaesthesia
trigger a higher mean red and yellow score than other
modes of delivery emphasising their high risk status. Interestingly
patients who received an epidural triggered almost double the mean
red score compared with patients who underwent spinal anaesthesia.
Of epidural patients who triggered a red score, 33% had a caesarean
section and 66% delivered vaginally. Caesarean section patients
trigger
more than double the number of red scores than mothers
who had a spontaneous vaginal delivery. However, once a
score is triggered, all modes of delivery have similar mean red
scores. This suggests that patients not undergoing caesarean
section are less likely to become unwell but once they do become
sick they are as unstable as post-operative patients. Vaginal
instrumental deliveries trigger scores similar to caesarean section
patients.
Reference
P85 Mode of delivery and type of anaesthetic
associated with triggering modified early obstetric
warning scoring (MEOWS) system
1
SVD, n=125 6 (4.8) 24 (4) 35(28) 125 (3.6)
FVD , n=84 * 11 (13.1) 53 (4.8) 18 (21.4) 117
(6.5)
LSCS, n=38 14 (36.8) 60 (4.3) 37 (97.4) 261 (7.1)
Anaesthetic
*
1. Confidential Enquiry into Maternal and Child Health. Saving
Mothers' Lives- 2003-2005 - the 7th report of the confidential
enquiries into maternal deaths in the UK. London: CEMACH;
2007
S Friar, S Kanakarajan Department of
Anaesthesia, Aberdeen Maternity Hospital, Aberdeen, UK
Introduction: National reports have recommended the use of
Obstetric Early Warning Scores (OEWS) for the detection and
management of critically ill patients . Our hospital uses an
adapted chart for the obstetric population, with abnormal
physiological observations generating an OEWS score which
potentially triggers a predetermined action or response. This
scoring system however lacks validation as the physiological ranges
used are a best
guess. Furthermore an OEWS chart will only be useful if
applied effectively. We planned to describe the pragmatic
use of an OEWS chart in our clinical practice.
Method: One hundred case notes were randomly selected from the
daily discharge list over a period of three months
from February 2009 to April 2009. Abnormal parameters
which were scored, triggering a response were noted and
any action taken was recorded. Abnormal parameters
which were not scored and did not trigger a response were also
noted.
Results: Ninety of the one hundred case notes contained a
completed chart. Overall 1008 observations were recorded
of which 779 (77.2%) observations were scored. From 195
actual triggering events 110 (56.4%) triggering events were
recorded by midwifery staff. Of these triggering events
105 (53.8%) had a response recorded. The majority of actual trigger
events were yellow events i.e. less abnormal
changes. The parameter most likely to trigger an event was
systolic blood pressure. No events were triggered by
SpO2 or respiratory rate.
Discussion: The efficacy of an OEWS chart to 'track and trigger' a
response depends on accurate scoring and improving the sensitivity
and specificity of the chart
itself. We noted a high incidence of triggering due to
systolic blood pressure which may represent over
sensitivity of this parameter. No triggering for SpO2
and respiratory rate may represent a lack of specificity however it
is more likely that this is confounded by the relatively well
population audited as opposed to a true lack of predictive power of
these parameters . We have shown that in
practice the use of an OEWS chart is prone to inadequate recording
of observations, incomplete scoring and failure to
document or act on the trigger itself. The human factors
af fec t ing the use of these char t s warran t fur ther
investigation.
References
P86 Not so trigger happy? A retrospective audit of the use of an
obstetric early warning score chart
1
Heart Rate
36
12
Temperature
4
2
Lochia
3
0
Proteinuria
2
4
2
1. Lewis G. (ed) 2007. The confidential enquiry into maternal and
child health (CEMACH). Saving mothers ’ lives; reviewing
maternal deaths to make motherhood safer -2003-2005.
P4 Unpublished Posters: Obstetric Anaesthesia 2010
(Newcastle)
HM King, PJ Youngs Department of
Anaesthesia, Derriford Hospital, Plymouth, UK
Introduction: The National Institute for Clinical Excellence
(NICE) have produced guidel ines on
inadver tent perioperative hypothermia (temperature <36ºC) as
there is
evidence that this may increase the risk of perioperative
morbidity. However, this guidance excludes parturients.
W e a s s e s s e d t h e c h a n g e i
n p a t i e n t
temperature during elective caesarean section in order to
ascertain whether there was a need for active warming. Method: Data
from 43 patients was collected prospectively over a two month
period. Core temperature was measured u s i n g t h e s a m e i n f
r a r e d t y m p a n i c t h e r m o m e t e r (Thermoscan, Braun)
which has an accuracy of ±0.2ºC
(manufacturers data). Temperature was measured in the
right ear prior to anaesthetic and on arrival in the recovery
suite. Ambient operating theatre temperature and humidity
were recorded.
Results: The mean postoperative temperature in recovery was 36.3ºC
(35.2-36.9ºC). The mean temperature decrease was 0 .6 ºC ( 0
-1.6ºC). 6 women had a postoperative
temperature below 36 ºC (35.2 -35.8ºC). Th is was no t related to
theatre temperature, humidity or duration of surgery. Three
patients started with temperatures below 36.5ºC, two of which then
had post operative temperatures below
36ºC. One patient had warmed intravenous fluids and
none had forced air warmers. There was no significant
difference in postoperative temperature between the 8
patients who had standard hospital blankets and the 34 who
did not. There was no significant difference in temperature
decrease in patients that had spinal anaesthesia (n=17) or combined
spinal-epidural anaesthesia (n=26).
Discussion: Inadvertent hypothermia occurred in 14% of patients.
The risk of hypothermia could be reduced with the use of warmed
intravenous fluids as this has been shown to mitigate the decrease
in maternal temperature during elective caesarean section under
combined spinal-epidural anaesthesia. Care should also be taken on
the admission ward to ensure that patients are kept warm prior to
surgery. Consideration should be given for inclusion of pregnant
women in the NICE guideline.
References
1
2
1. Perioperative hypothermia (inadvertent): full guideline.
National Institute for Health and Clinical Excellence clinical
guideline CG65. April 2008.
http://www.nice.org.uk/nicemedia/pdf/CG65Guidance.pdf
2. Woolnough M, Allam J, Hemingway C, Cox M, Yentis SM. Intra-
operative fluid warming in elective caesarean section: a blinded
randomised controlled trial. Int J Obstet Anesth 2009; 18,
346-351.
E De Silva, B Pigera, LC
Karunaratna Anesthetics, Basildon & Thurrock
University Hospital, Basildon, UK Background: Post -operative
observation after caesarean section is of utmost importance to
reduce post operative complications and improve patient
satisfaction.There are specific NICE guidelines for post -operative
observation following caesarean sections.Some obstetric units in
the UK
have introduced MEOWS charts as an early warning
system.
Aim::The current practise of post -operative recovery following
caesarean section on our obstetric unit was compared with the NICE
guidelines.We also looked at the effectiveness of the MEOWS chart
as an early warning tool.
Methodology:Data was collected retrospectively using a
questionnaire which was fi l led in by the obstetric anaesthetic
registrar and recovery nurses.We analysed data from 52 patients who
had undergone both elective and emergency sections.We also looked
at the MEOWS chart which should have been filled in by the
midwifery and nursing staff on the ward.
Results:All post section patients were observed on a 1 to
1 basis on the post anaesthetic care unit.100% compliance with NICE
guidelines
-Al l pos t s e c t i on pa t i en t s we
re l ooked a f t e r on
PACU by properly qualified nurses (band 5 or 6)
-All post
-section patients had regular monitoring of
RR,HR,BP,pa in and seda t ion sco res
and a i rway
control .100% compliance with guidelines.
-49/52 patients had 1/2 hourly monitoring for two hours
on PACU/post-operative wards.94% compliance with
guidelines
-2/48 patients were monitored for 12 hours after receiving
intrathecal or epidural diamorphine.2% compliance with NICE
guidelines
- Though all patients had MEOWS charts attached to their
post-opera t ive ca re p lan ,no char t was comple ted
appropriately by the nursing staff.
Conclusion:Immediate
post-operative care at PACU is compliant
with current NICE guidelines.Monitoring of patients after
intrathecal and epidural opioids is not satisfactory and needs
improving.
P88 Post caesarean section observations.Are we compliant with NICE
guidelines?
1. NICE guideline-care of the woman after CS (ref CG 13)1.6
Unpublished Posters: Obstetric Anaesthesia 2010 (Newcastle)
P5
Results:
Conclusions: Currently 25.3% consultant anaesthetists either do not
use alcoholic chlorhexidine or do not know
which disinfectant they use. There is evidence that
alcoholic chlorhexidine is the most
effective skin
disinfective and should be the agent of choice. Many
anaesthetists keep the disinfectant on the same surface as the
spinal equipment and a large proportion do not always
allow the solution to dry prior to commencing the spinal
anaesthetic. Although the risk of contamination remains
small, it could be eliminated by changing these practices.
Reference
P89 Skin disinfection prior to spinal anaesthesia: a survey of
current UK practice
1
isopropyl alcohol 285 49.8%
2% chlorhexidine gluconate in 70% isopropyl alcohol
149 26%
Iodine plus alcoholic chlorhexidine 8 1.4% Other disinfectant 7
1.2%
Unknown 5 0.9%
1. Pratt RJ, Pellowe CM, Wilson JA et al. epic2: national evidence-
based guidelines for preventing healthcare-associated infections in
NHS hospitals in England. J Hosp Infect 2007; 65 suppl
1:s1-64
RJ Kearns, V Uppal, J Bonner,* EM
McGrady Princess Royal Maternity Unit, Glasgow Royal
Infirmary, Glasgow, UK, *Department of Anaesthesia, Ninewells
Hospital, Dundee, UK Introduction: The provision of safe and
procedurally robust peri-operative care should be a fundamental
goal of any surgical team. Surgical safety checklists have been
shown to improve teamwork, safety and minimise list disruption . In
keeping with National Patient Safety Agency guidance , we
introduced a surgical safety checklist
for patients undergoing elective caesarean section. Such
patients are usually awake and pre
-operative anxiety is common
. We wished to evaluate the effects of such
checks on our patients.
Methods: Local ethics committee approval was sought and
deemed not to be necessary. Patients undergoing elective
caesarean section during August to November 2009 were
asked 3 questions relating to the performance of the surgical
safety checklist. Responses were recorded as yes or no for
the first question, and with a Likert scale (strongly disagree,
disagree, neither, agree, strongly agree) for the subsequent 2
questions.
Results: 58 randomly selected patients undergoing elective
caesarean section were asked the following: "The theatre team
performed a series of checks at the start and end of the operation.
Did you notice this?" 45 patients (75%)
remembered the checks being performed. 11 patients (19%) remembered
when prompted and 2 (3%) did not remember even when prompted. The
56 patients who recalled the checks being performed were asked a
further 2 questions;
"If I said the checks made you worried, how would you
reply?" All patients either disagreed or strongly disagreed
with this statement.
"If I said the checks were reassuring, how would you reply?" 52
patients (93%) either agreed or strongly agreed with this
statement. 4 patients (7%) neither agreed nor disagreed.
Conclusion: One of the arguments against the use of
surgical safety checklists is the concern that patients may find it
worrying or "unprofessional" that staff expected to be familiar
with their case, ask fundamental questions such as their name and
procedure to be performed. In obstetric thea t re , the pa t ien t
i s o f ten awake making th i s a
particularly pertinent issue. Our results suggest that although
the majority of patients are aware of the checks being
performed, they do not find this worrying and may find it
reassuring. Perceived effects on patient anxiety should not
constitute a reason to abandon surgical safety checklists.
References
1,2
3
4
1. Lingard L, Regehr G, Orser B et al. Evaluation of a
pre-operative checklist and team briefing among surgeons, nurses,
and anaesthesiologists to reduce failures in communication. Arch
Surg 2008;143:12-7
2. Nundy S, Mukherjee A, Sexton JB et al. Impact of preoperative
briefings on operating room delays: a preliminary report. Arch Surg
2008; 143:1068-72
3. National Patient Safety Agency. Patient safety alert. WHO
surgical safety checklist 2009. www.npsa.nhs.uk/nrls/alerts-and-
directives/alerts/safer-surgery-alert/
4. Holdcroft A, Parshall Am, Knowles MG, Waite KE, Morgan BM.
Factors associated with mothers selecting general anaesthesia for
lower segment caesarian section. J Psychosom Obstet Gynaecol
1995;16:167-70
P6 Unpublished Posters: Obstetric Anaesthesia 2010
(Newcastle)
RJ Kearns, J Bonner,* V Uppal, M
Mackenzie, M Young, EM McGrady
Princess Royal Maternity Unit, Glasgow Royal Infirmary, Glasgow,
UK, *Department of Anaesthesia, Ninewells Hospital, Dundee, UK
Introduction: Provision of care in the operating theatre involves
complex interactions between organisational, procedural and inter
-personal components. Surgical safety checklists have been shown to
improve efficiency and team
work as well as reducing morbidity and mortality.
National guidelines recommend that such checklists be performed for
all theatre cases by 2010.
We introduced pre and post -
operative surgical safety checklists for elective caesarean
sections in obstetric theatre. After a 3 month introductory
period, an evaluation of compliance was performed.
Methods: An independent, impartial anaesthetist (JB) attended
elective
caesarean sections during November 2009.
Completion of the
pre-operative checklist (patient identity,
indication for caesarean section, allergies, neonatology
presence), and post -operative check (analgesia,
oxytocics, antibiotics, thromboprophylaxis, skin to skin) was
examined. Staff participation, roles assumed and adverse events
were reviewed.
Results: Audit forms were completed for 34 of the 44
elective caesarean sections in the 1 month evaluation period,
giving an audit compliance rate of 77%. Results are tabulated
below:
Unforeseen adverse events occurred in 2 patients (high spinal
block and failed regional block) These were not felt to have
been preventable from the pre-operative check. Conclusion: Our
compliance rates with pre and post - operative checks were 61% and
68% respectively. Benchmark
data on this topic is scarce, though in a procedure so integral
to patient safety, one could argue that the target should be
100%. Although safety checklists should take minutes and
not cause delay, it is not always possible for all staff to attend
due to clinical demands. Working patterns may need to be
reviewed in order to improve this. Achieving a sustained
change in practice is challenging, particularly in the complex
and dynamic environment of the operating theatre. If we are
to continue to develop in our practice, we must recognise the
importance of the function of the team as a unit and accept
our limitations as individuals. We plan to re-audit
compliance
after a period of further education and consultation with staff.
References
1,2
3
Professional group most often leading
check
midwives
(48%)
midwives
(57%) Midwife present during check 21 (100%)
23 (100%)
Anaesthetic nurse present during check 21 (100%)
23 (100%)
Anaesthetist present during check 21 (100%) 23 (100%)
Obstetrician present during check 20 (95%) 20
(87%)
1. Lingard L, Regehr G, Orser B, Reznick R, Baker GR, Doran D, et
al. Evaluation of a preoperative checklist and team briefing among
surgeons, nurses, and anesthesiologists to reduce failures in
communication. Arch Surg 2008;143:12-7
2. Haynes AB, Weiser TG, Berry WR, Lipsitz SR, Breizat AH,Dellinger
EP. A surgical safety checklist to reduce morbidity and mortality
in a global population. N Engl J Med 2009;360:491 -9
3. National Patient Safety Agency. Patient safety alert. WHO
surgical safety checklist. 2009. www.npsa.nhs.uk/nrls/alerts -and-
directives/alerts/safer-surgery- alert/
TR Christmas, SM Kinsella, FC Forrest
,* Anaesthesia, St Michael's Hospital, Bristol, UK,
*Anaesthesia, University Hospitals Bristol NHS Foundation Trust,
Bristol, UK
1
2
Baby and mother labels complete?
US scan to confirm fetal
lie/placental position?
* Category 1 LSCS
1. Haynes AB, Weiser TG, Berry WR et al. A surgical safety
checklist to reduce morbidity and mortality in a global population.
N Engl J Med 2009; 360: 491-499.
2. National Patient Safety Agency. Patient Safety Alert Update: WHO
surgical safety checklist (January 2009).
Unpublished Posters: Obstetric Anaesthesia 2010 (Newcastle)
P7
P Smith, C Phillips, G Allan
Anaesthetics, Worthing Hospital, Worthing, UK Introduction: Ob ta
in ing in fo rmed consen t f rom a labouring woman can be
challenging. This is an audit to compare adequacy of consent for
obstetric epidural analgesia to the standards set by the Royal
College of Anaesthetists.
Worryingly, 10 women (16%) did not remember being
given any antenatal education about epidural analgesia.
However, overall 56 (89%) felt that they had given fully
informed consent. In 9 (14%) sets of notes there was poor
documentation of the consent obtained, although in some of these
cases the epidural sheet had been lost.
Discussion: 63% of mothers questioned recalled antenatal education
regarding epidural analgesia, this is less than the 80% currently
recommended by the Royal College of Anaesthetists. Documentation of
consent was 86% (recommendation 100%), and 89% of mothers were s a
t i s f i e d t h a t t h e y h a d g i v e n i n f o r m e d c o n
s e n t (recommendation 100%). The fact that 65% reported seeking
extra information on epidurals suggests that there is currently
insufficient antenatal education. The importance of this is
illustrated by the fact that 38% of women did not feel able to
think clearly at the time of giving consent. Potential areas for
improving antenatal education are
provision of the OAA leaflet at the 36 week clinic rather
instead of at the booking visit, and more coverage of epidural
analgesia in antenatal classes. Our hospital has recently expanded
provision for the high risk obstetric clinic
such that 10% of all women will now be seen
- this is an opportunity to better educate them. In addition, the
introduction of a new electronic audit system should improve the
rates of documentation of consent.
P93 Audit of consent for epidural analgesia in labour in Worthing
hospital P R Greig, S Muddle, P
Patel
Nuffield Department of Anaesthetics, John Radcliffe Hospital,
Oxford, UK Background: Consent for procedures in labour is a
challenging aspect of anaesthetic practice. Consent is best
regarded a multistage process and some question if labouring women
are capable of fully informed consent.
Here we review the obstetric anaesthetic literature for
current opinions with respect to consent in labour and report the
results of a post-natal survey of women's recall of the consent
process for anaesthetic intervention in labour.
Methods: Women were surveyed 24 -48 hours post delivery with data
recorded for: anaesthetic procedure and indication, timing of
consent and recall of various points discussed as part of the
routine consent process. Statistical analysis was conducted using
chi-squared tests.
Results: The survey was completed by 94 women: 60 had received
labour analgesia; 18 underwent non -elective surgery and 16
underwent elective surgery. The majority of surgery was performed
under regional anaesthesia. Recall o f a p r e -proedure
conversation, specifically with an anaesthetist, was found in 94%,
and this did not vary between groups (p=0.474); 83% of women were
satisfied with the level of detail provided. Stage of labour
(p=0.162) and urgency of intervention (p=0.294) did not affect
their degree of satisfaction with the consent process. Birth plans
were drafted by 59 women, fewer than half of whom had expressly
planned for epidural analgesia. Recall of the consent process was
best in the elective surgery group (p=0.027).
Discussion: In the group of women surveyed, all had at least some
degree of recall of the consent process but a clinically
significant number remembered less than 50% of the details
provided. Whilst there is no evidence that women in labour lack
capacity to offer informed consent, this finding has medico-legal
implications. There is evidence that antenatal education can impact
on recall and improve consent.
A review of recent national guidelines
on the issue of consent suggest it is less appropriate to "just put
it in". We conclude women even in advanced labour retain capacity,
but advise that consent is most effectively taken at the earliest
practicable stage.
References
1
2
3 4 5
1. Saunders TA, Stein DJ, Dilger JP. Informed consent for labor
epidurals: a survey of society for obstetric anesthesia and
perinatology anesthesiologists from the United States.
International Journal of Obstetric Anesthesia 2006; 15:
98-103.
2. Bush DJ. A comparison of informed consent for obstetric
anaesthesia in the USA and UK. International Journal of Obstetric
Anesthesia 1995; 4:1-6.
3. Swan HD, Borshhoff DC. Informed consent - recall of risk
information following epidural analgesia in labour. Anaesthesia and
Intensive Care 1994; 22: 139-141.
4. White LA, Gorton P, Wee MYK, Mandal N. Written information about
epidural analgesia for women in labour: did it improve knowledge?
International Journal of Obstetric Anesthesia 2003; 12:
93-97.
5. Anonymous. Making decisions about investigations and treatment.
In: Consent: Patients and Doctors making decisions together. 1st
ed. London: General Medical Council; 2008: 9-25.
P8 Unpublished Posters: Obstetric Anaesthesia 2010
(Newcastle)
J M Dolan, S J Young, J
Kinsella,* Department of Anaesthesia, Princess Royal
Maternity, Glasgow, UK, *University Department of Anaesthesia,
University of Glasgow, Glasgow, UK Introduction: In our obstetric
anaesthetic practice we have recognised that many of our patients
are anxious when they appear on the labour suite. This suggests
that perhaps we are not targeting antenatal education at the
correct groups. We speculated that one group at risk of anxiety
would be those for whom there were concerns about fetal well-being.
The aim of this study was to compare anxiety levels in primiparous
patients undergoing induction of labour for fetal concerns, with
anxiety levels in primiparous patients undergoing induction of
labour for uncomplicated post dates pregnancies or for concerns
over maternal health.
Methods: The Beck Anxiety Inventory (BAI)- a 21 item validated
questionnaire - w a s g i v e n t o 2 5 0
consenting primiparous induction patients after obtaining
local Research Ethics Committee approval. the indication for
induction was also recorded and categorised as: postdates, maternal
concerns ( e.g. hypertension, diabetes, previous thromboembolism),
or fetal (e.g .reduced growth, reduced movement, oligohydramnios).
Data was analysed using the Kruskal-Wallis test.
There was no significant difference in the BAI scores between the 3
groups (p=0.135).
Conclusions: Contrary to our expectations we did not see any
difference in anxiety levels in either the fetal concern or the
maternal concern groups compared with our control population. This
work suggests that there would not be any
gain in terms of anxiety by refocusing antenatal education
towards mothers with maternal health or fetal wellbeing
concerns.
Reference
1
Post dates 13 0-44
Maternal Concerns 15 3-45
Fetal Concerns 12 3-34
1. Beck AT, Epstein N, Brown G, Steer RA. An inventory for
measuring clinical anxiety. Psychometric properties. J Consult Clin
Psychol 1988;56:893-897
A Kumar, S Rhodes Department of Anaesthesia,
James Paget University Hospital NHS Trust, Great Yarmouth, UK
Background: Informed consent about pain relief in labour and
regional anaesthesia for caesarian section can be challenging. It
is uncertain on the amount of information retained by women due to
the effects of pain and drugs. Currently information about the
complications of central neuraxial blockade is provided by
Obstetric Anaesthetists Association (OAA) leaflets, discussion with
midwives and anaesthetists.
Method: 50 women were interviewed 24 to 72 hours post natal during
May-June 2009. The women had either epidural (n=26), combined
spinal epidural (n=4) for labour pain or spinal anaesthesia for
caesarian section. Information collected included age, parity,
previous CNAB, source of information, satisfaction with the
information provided (scale of 1-10) and recollection of
complication by open and closed questions. The closed questions are
as shown in Chart 1.
Results: 27 (54%) & 16 (32%) of the 50 women were unable to
recall any of the complications by open and closed questions
respectively. Of the 16 women who were unable to recall
complications by closed questions, 14 were primiparas and 13 were
having the procedure for the first time. Only 2 women obtained the
information through OAA leaflets. The mean satisfaction with the
information provided was 8.5 (range 7-10).
Discussion: A considerable proportion of women were unable to
recall the complications, but they were well satisfied with the
amount of information provided. None of the women developed any
complication and the perception may have been different if they had
developed one. Also it was the younger women and first t ime
mothers who appeared less informed. Following Chester vs Afsar
case, the Dept of Health recommended that health care professionals
give information about all possible adverse outcomes. Alternate
sources of information like the internet can be utilized to provide
information to the target women (younger mothers and primiparas).
There is a need for a retrospective audit on women who have
developed complication after CNAB. References
P96 Information recalled by women about the complications of
central neuraxial blockade
(CNAB) in labour and childbirth
1,2
3
1. Kelly GD, Blunt C, Moore PAS, Lewis M. Consent for regional
anaesthesia in the United Kingdom: what is material risk? Int J of
Obstet Anesth 2004; 13: 71-4.
2. Bethune L, Harper N, Lucas ND, Robinson NP, Cox M, Lilley A,
Yentis SM. Complications of obstetric regional analgesia: how much
information is enough? Int J of Obstet Anesth 2004; 13: 30-4.
3. http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/
PublicationsPolicyAndGuidance/DH_103643
Unpublished Posters: Obstetric Anaesthesia 2010 (Newcastle)
P9
J Humphreys, S J Moss ,* Anaesthetics, Royal
Oldham Hospital, Oldham, UK, *Anaesthetics, Royal Bolton Hospital,
Bolton, UK Introduction: Patients must receive accurate, up to date
information so they can make an informed decision about medical
interventions and provide consent. We undertook an audit on
information about obstetric analgesia as per the college compendium
of audit recipes . Out of 50 women audited at greater than 36 weeks
gestation, only 24% had
received the hospital booklet on pain relief in labour. We
found most women obtained information from parenting books,
midwives, friends and the internet.
Methods: The purpose of this survey was to assess accuracy of
information in current UK parenting books, and on UK websites. The
information provided in the OAA Pain Relief in Labour leaflet was
summarised. From this a
survey form was devised to collect the following data from
books and the internet: types of non-pharmacological pain relief
options; types of pharmacological pain relief; epidural side
effects and complications. 4 different internet search engines were
used inputting the words: Pain relief; epidural; and labour.
Results: We looked at 20 books published in the UK between 1997 and
2009, and 20 websites. A total of 14 p o s s i b l e m e t h o d s
o f n o n -pharmacological and pharmacological pain relief were
searched for. 25% of books and 50% of the websites mention 10 or
more methods. The most commonly quoted forms of analgesia are TENS,
entonox, pethidine and epidurals. Table 1
For epidural analgesia we looked for reference to the 21 possible
side effects/complications listed in the OAA leaflet. Just 1 book
and only 4 websites discuss greater than 10 associated problems.
This includes the OAA website. The
most frequently documented side effects are: A fall in blood
pressure; post dural puncture headache (PDPH); failure; and
increased risk of instrumental delivery. Table 2
3 books and 2 websites have inaccurate information. They state that
epidurals increase the risk of caesarean section and cause long
term backache.
Discussion: Although women may be given the OAA
leaflet during their pregnancy, a lot of their information is
gained from reading parenting books and searching the
internet. These sources contain varied details that can be
misleading and false. We found that the internet offers more
accurate information, with some sites written by consultant
anaesthetists or referencing the OAA or the Royal College
of Anaesthetists. The OAA website accessing the pain relief
in labour leaflet is found on the fourth page of Google. As it
provides the most concise and accurate text, we believe it should
be made more visible to the public.
Reference
P97 Survey of the accuracy of information available in non medical
books and on the internet, compared with the Obstetric
Anaesthetists' Association pain
relief in labour leaflet
1
Books 80% 70% 90%
90%
Internet 100% 100% 100% 100%
Table
Nerve Damage
Books 65% 55% 60% 15% 45% 20%
Internet90% 80% 45% 70% 70% 25%
1. Royal College of Anaesthetists. Raising the Standard: A
compendium of audit recipes. Information about obstetric
anaesthesia and analgesia. RCoA, London 2000.
N Patel, R Padmagirison, W
Justin, D Chitre Anaesthetic, Southend
Hospital, Southend, UK Introduction: Peri-partum cardiomyopathy
(PPC) is a rare and life -threatening condition. We describe a case
of unrecognised PPC with superimposed pre-eclampsia and the dangers
of fluid therapy in these patients. Case Report: A 38-year-old G5P3
with a previous history of gestational hypertension, asthma and
thoracic scoliosis, had a history of reducing exercise tolerance in
the latter stages of her pregnancy; this had not been elicited
antenatally. At 37 weeks she had an uneventful caesarean section
for breech presentation and pre -eclampsia (high blood pressure,
proteinuria and severe peripheral oedema) under spinal anaesthetic.
Post-operatively she was treated for pre-eclamptic hypertension
with oral labetolol and was fluid restricted. The SpO2 was noted to
be 90% in the supine position, which corrected with 2L/min oxygen.
She was oliguric for 6hrs and was given a fluid challenge of 500ml
of normal saline over 1 hour. Once this had been administered, the
SpO2 was recorded as low. The patient then became unresponsive and
no pulse was detected. CPR was initiated immediately. After 2
cycles of CPR with adrenaline and atropine, there was a return of
spontaneous circulation (ROSC). The patient was intubated, sedated
and transferred to the ICU. A transthoracic echo (TTE) showed mild
concentric left ventricular hypertrophy and an undilated left
ventricle. There was severe systolic dysfunction with an ejection
fraction (EF) of 25-30%. The chest X -ray showed signs of pulmonary
oedema. She
stabilised very quickly with Fi02
requirements reducing from 1.0 to 0.4 within a couple of hours post
-arrest. No further inotropes were needed on ROSC. She was cooled
for 24 hours and received magnesium sulphate. She had a failed
extubation after 2 days due to recurrent pulmonary oedema and
severe hypertension. Frusemide was given and a GTN and esmolol
infusion were started, which lead to a successful extubation after
4 days in ICU. She was dischargd home from CCU 6 days after
delivery on 3 anti- hypertenive agents. A repeat TTE at this time
showed moderately impaired global LV systolic dysfunction with an
EF of 35-45%. The right ventricle was mildly dilated.
Discussion: PPC is a relatively rare condition occuring in 1 in
1,300 to 1 in 15,000 pregnancies , presenting with signs and
symptoms of left ventricular dysfunction. These patients can be
difficult to manage despite early diagnosis
and treatment. In this case the condition was undiagnosed,
and was superimposed with pre-eclampsia
which enhanced the hazardous nature of the situation. A relatively
small bolus of fluid in a vasoconstricted circulation with a poorly
contracting myocardium, lead to pulmonary oedema, hypoxia and
cardiac arrest. Modified Early Warning Scores
(MOEWS) had been used to summon medical help prior to
the cardiac arrest. This enabled prompt and effective advanced life
support to lead to a successful outcome for our patient. This case
highlights the fact that fluid therapy in a small group of patients
can be catastophic. Other risk factors that reduce
cardio-respiratory reserve must be taken into account before
initiating a fluid challenge. We discuss the haemodynamics,
monitoring and fluid therapy in such patients.
Reference
1
1. Abboud J, Murad Y, Chen- Scarabelli C, Saravolatz L, Scarabelli
TM. Peripartum Cardiomyopathy: a comprehensive review. Int J
Cardiology 2007; 118: 295-303.
P10 Unpublished Posters: Obstetric Anaesthesia 2010
(Newcastle)
Reference
P99 More frequent measurement of non-invasive blood pressure at
onset of spinal anaesthesia is not associated with a lower
incidence of hypotension
1
1. Cyna AM, Andrew M, Emmett RS, Middleton P, Simmons SW.
Techniques for preventing hypotension during spinal anaesthesia for
caesarean section. Cochrane Database of Systematic Reviews 2006,
Issue 4. Art. No.: CD002251. DOI:
10.1002/14651858.CD002251.pub2.
V Sharma, A Swinson, C Spencer, S
Mokashi,* R Russell Department of
Anaesthesia, John Radcliffe Hospital, Oxford, UK, *Department of
Anaesthesia, Singapore General Hospital, Singapore, Singapore
Introduction: During the last decade two thirds of the
increasing birth rate has been attributed to women born
outside the UK. Hence there is an increasing ethnic
diversity among women giving birth and requesting
neuraxial analgesia in UK maternity units. During this time the
prevalence of obes i ty in par tur ients has a lso increased.
Previous s tudies
have demonstrated a relationship between body mass
index (BMI) and distance from skin to the lumbar epidural space.
Reports of ethnic
influence on the distance from skin to epidural space have
been conflicting. The effect of ethnici ty and BMI
upon epidural space depth has not been studied in UK
parturients. The aim of this study was to establish if ethnicity or
BMI or both influence epidural space depth.
Methods: Following ethical approval, data on ethnicity,
height, weight and epidural space depth were prospectively
obtained from 1210 labouring women requesting epidural analgesia.
ANOVA was used to analyse effect of BMI on epidural space depth.
The influence of ethnicity and BMI
on epidural space depth were tested in a multiple linear
regression model. Ineffective epidurals and those performed in
lateral position and mixed race parturients were excluded from
analysis.
Results
: The mean epidural space depth was 5.4 cm (range
3-10 cm). Epidural depth increased with an increasing BMI.
The distance to epidural space differed among ethnic groups even
after controlling for BMI (ANOVA p<0.001). The skin to epidural
space depth was significantly greater in Black/British Black (BB)
and Caucasians as compared with
Asians and Chinese (p<0.001). At BMI of 25, difference in
mean depth between BB and Chinese patients was greater than 1 cm.
At BMI of 30 or above, difference in mean depth increased up to 1
cm or more in BB and Caucasian patients as compared with Asian and
Chinese.
References
P100 Effect of ethnicity and body mass index on the depth of the
epidural space in parturients
1
3
1. D'Alonzo RC, White WD, Schultz JR, Jaklitsch PM, Habib AS.
Ethnicity and the distance to the epidural space in parturients.
Reg Anesth Pain Med 2008; 33: 24-9.
2. Segal S, Beach M, Eappen S. A multivariate model to predict
the
Unpublished Posters: Obstetric Anaesthesia 2010 (Newcastle)
P11
V Uppal, MA Leonard, SJ Young
Department of Anaesthesia, Princess Royal Maternity Hospital,
Glasgow, UK Introduction: Recent reports from the UK Confidential
Enquiry into Maternal and Child Health have highlighted
inequalities in the rate of maternal death among different ethnic
groups. A national cohort study using UK Obstetric Surveillance
System (UKOSS) has reported similar trend for severe maternal
morbidity. We aimed to find out what are the underlying factors
that might be responsible for differences in these outcomes.
Methods: We conducted a retrospective cohort study using
hospital maternity database from July 2007 to October 2009.
Statistical analysis was performed using MINITAB 15.1 statistical
software. Continuous variables were analysed using two-sample t
-test. Categorical data was analysed using chi-squared
test. One -way analysis of v a r i a n c e ( A N O V A ) w a s u s
e d t o a n a l y s e
continuous variables during subgroup analysis. P-value
of <0.05 was considered significant.
Results
: There were 13714 deliveries in our unit during this
27 months period. Ethnicity was recorded for 11306
parturients. 9653 parturients belonged to the non-ethnic
group. There were 1653 deliveries recorded for ethnic
population. This included African/Caribbean-Black (402), Chinese
(254), Indian (140), Pakistani (240), Ethnic White (351) and
unclassified Ethnics (266). Results are tabulated below. Values are
expressed as mean or percentage
Discussion: In this study, we were able to demonstrate var ious d i
f fe rences be tween the e thnic and non -
ethnic groups. Gestation at first review was four weeks
later for ethnic population, a factor that could be associated
with poorer outcome. Other factors (like smoking, higher BMI and
higher caesarean section rate) that could be associated with poorer
outcome were actually found more often in non -ethnic mothers.
Ethnic women were less likely than non-ethnic women to
receive both epidural and
opioid analgesia during labour. Subgroup analysis (data not
shown) revealed that the Chinese women were least likely to use
epidural analgesia during labour. Intention to breast
feed was lowest for non
-ethnic women and highest for
African-black and Indian women. We conclude that poorer
outcomes in ethnic population cannot be completely explained by the
factors reviewed in this study.
References
P101
Factors responsible for inequalities in maternal
outcomes among different ethnic groups
1
2
Weight (kg) 70.0 67.7 0.000
Body Mass Index (BMI) (kg.m )-2
25.4 24.8 0.000
Parity 0.78 0.93 0.011
Currently smoker (%) 22.6 1.7
0.000
Opioid use for labour analgesia (%)
53.4 44.7 0.000
Epidural analgesia (%) 37.6 29.5
0.000
Epidural failure rate (%) 5.9 4.7
0.412
Caesarean section rate (%) 30.4
27.5 0.017
Total blood loss (ml) 484 496
0.318
Breast feeding intention (%) 36.5
76.0 0.000
1. Lewis G, ed. The Confidential Enquiry into Maternal and Child
Health (CEMACH). Saving mothers ’ lives: reviewing maternal
deaths to make childhood safer—2003-2005. London: CEMACH,
2007.
2. Knight M, Kurinczuk JJ, Spark P, Brocklehurst P. Inequalities in
maternal health: national cohort study of ethnic variation in
severe maternal morbidities UKOSS. BMJ 2009 Mar 3; 338: b542
DJG Milne, A Quinn, A Pinder, H
Gorton Anaesthesia, Leeds General Infirmary, Leeds, UK
Introduction: Reports from the Confidential Enquiry into Maternal
and Child Health have shown a decrease in the number of anaesthetic
related deaths over recent years. However, a consistent cause of
death is hypoxia relating to a failure to intubate and ventilate.
The incidence of failed intubation among the pregnant population
has been estimated to be up to 8 times that of the non -pregnant
population in previous studies . However, a more recent study had
no cases of failed intubation in a set of 3430 general anaesthetic
cases
. As yet, no national data exist.
This study aims to calculate a national incidence for failed
intubation in obstetric general anaesthesia.
Results:
We would like to thank the OAA and UKOSS for their support.
References
P102 Failed intubation in obstetric general anaesthesia - interim
results of a national survey.
1
2,3
4
Previous difficult intubation 2 0 Predicted difficult airway
(Mallampati 3-4) 9/26
(34%) 4/27 (15%)
Urgency - grade 1 24 (54%) 43 (54%) Urgency - grade 2 10 (23%) 16
(20%)
Urgency - grade 3 3 (7%) 5 (6%) Urgency - grade 4 5 (11%) 10 (13%)
ICU admissions (majority not related to airway problems)
11 (25%) 7 (9%)
Cases managed with supraglottic airways
30 Cases managed with bag and facemask 3
Cases manages with surgical airway 1 Cases woken for alternative
anaesthesia 10
2,3
4
1. Lewis G. (Ed) The Confidential Enquiry into Maternal and CHild
Health (CEMACH). Saving Mothers Lives: reviewing maternal deaths to
make childhood safer - 2003-2005. London: CEMACH, 2007.
2. Rahman K, Jenkins JG. Failed tracheal intubation in obstetrics:
no more frequent but still managed badly. Anaesthesia 2005; 60:
168-71.
3. Hawthorne I, Wilson R, Lyons G, Dresner M.Failed intubation
revisited: 17-yr experience in a teaching maternity unit. British
Journal of Anaesthesia 1996; 76: 680-4.
4. Djabatey EA, Barclay PM. Difficult and failed intubation in 3430
obstetric general anaesthetics. Anaesthesia 2009, 64:
1168-1171
P12 Unpublished Posters: Obstetric Anaesthesia 2010
(Newcastle)
L de Lloyd, R Baraz, H
Ankireddy, R Collis, M Stacey
Anaesthetic department, University Hospital of Wales, Cardiff, UK
Introduction: Failed intubation during obstetric general
anaesthesia is an extremely challenging situation with
potentially devastating consequences. Algorithms have
been developed as a t raining tool
and to guide the
management of such a situation.
We discuss our experience of a failed intubation
during general anaesthesia for category one caesarean section (CS),
and reflect on the role and limitations of failed intubation
algorithms in obstetrics.
Case history: A labour epidural was sited during normal working
hours in a 40 year old primigravida, with moderate difficulty due
to mild lumbar scoliosis. While establishing labour analgesia,
prolonged fetal bradycardia occurred
requiring immediate caesarean delivery. Following airway
assessment and appropriate head and neck positioning, anaes thes i
a was induced us ing th iopen tone and suxamethonium. Direct
laryngoscopy revealed grade 3 view with only the tip of the
epiglottis visible. Attempts to intubate the trachea using bougie,
standard and McCoy blades with release of cricoid by two senior
anaesthetists failed. Ventilation using a guedel airway and 4 hands
was extremely difficult but improved slightly with a Proseal
LMA. Oxygen saturations were maintained above 90% at all
times. The fetal heart remained at 80bpm. At this stage, whether to
proceed with CS or wake the patient up was
considered. CS using a spontaneously breathing technique
was carried out uneventfully and a healthy
baby was delivered.
Discussion:
When presented with a category one CS the
anaesthetist is required to enable rapid delivery of a critically
distressed fetus, whilst providing safe anaesthesia for the mother,
in a highly time and emotionally pressurised situation. When faced
with a failed intubation, the reality of ‘waking the patient up’
is not as easy as it may sound. Difficulties inherent in
managing the airway of a supine pregnant patient, combined with
laryngospasm often
complicate the situation. The reality of managing the
critical clinical situation is far removed from the fluent
transitions of the algorithm. Waking the woman up in the
face of profound fetal distress and a partially obstructed
airway is an emotionally very difficult decision. Everyone
wants to ‘save the baby’ (but not to kill the mother).
Conclusion: How each case proceeds is influenced by unique patient
factors, anaesthetist experience and level of support available at
the time. Priority in the management of any failed intubation must
always be oxygenation and preserving the safety of the mother.
Anticipating the
difficult middle ground, and the powerful emotional stresses
of failed intubation in a category one CS, pose a significant
challenge for the training of anaesthetists. Algorithms, while
undoubtedly useful, fail to bridge the divide between theory and
clinical practice.
References
P103 Failed intubation in obstetrics; translation of theory into
practice
1,2
1. Nair A, Alderson JD. Failed intubation drill in Obstetrics. Int
J Obstet Anesth 2006;15: 172-4.
2. Harmer M. Difficult and failed intubation in obstetrics. Int J
Obstet Anesth 1997; 6: 25-31.
R Hartley, S Labor Department of
Anaesthetics, Salford Royal NHS Foundation Trust, Salford, UK
Introduction: Maternal obesity is an increasing problem and presen
ts s ign i f ican t anaes the t ic cha l lenges . Recommendations
from the most recent CEMACH report suggest that a consultant
anaesthetist should be directly involved in the management of all
morbidly obese parturients . Elsewhere, a
pragmatic approach to consultant involvement has been suggested
. In view of increasing prevalence of
obese parturients it may be appropriate to recommend
direct consultant involvement in cases with risk factors
identified by CAVE assessment (Co-morbidities, Airway, Venous
access, Epidural and related
techniques).
Methods: We audited the anaesthetic management of parturients
requiring intervention in theatre, between September and November
2009. Standards were taken from the latest CEMACH report . This
recommends that all morbidly obese women should undergo antenatal
assessment, and should be anaesthetised with the direct involvement
of a consultant anaesthetist.
Retrospectively we applied the CAVE acronym to identify risk
factors based on anaesthetic notes and recorded complications for
all patients with BMI>35kg/m .
Results: 1) 192 patients
required intervention in theatre during the audit.
2) Of these 18 had a BMI >
35kg/m at booking, all were seen in
antenatal clinic by a consultant anaesthetist.
3) 5 of these 18 patients with
BMI>35kg/m had no direct
or indirect consultant involvement during the theatre
intervention.
4) CAVE analysis identified 7
co-morbid conditions, no anticipated airway or venous access
difficulties, and 8 possible cases of difficulty with regional
techniques.
5) There were no cases of
difficult intubation or failed
regional anaesthesia.
Discussion: CAVE is a valuable tool for use by the multi-
disciplinary team to aid in care of the obese parturient. Although
our recommended standards are not being met, the findings and lack
of documented complications suggest that it would be appropriate to
recommend mandatory
direct consultant involvement for identified patients only.
It is anticipated that instituting CAVE assessment in our antenatal
clinic and delivery unit would aid education, and
the identification of high risk obese parturients. Following
this, anaesthetic management will be re-audited.
References
P104 Anaesthetic management of the obese parturient in Salford - an
audit of practice.
1
2
1
2
2
2
1. Lewis G, editor. The Confidential Enquiry into Maternal and
Child Health (CEMACH). Saving Mothers ’ Lives: reviewing
maternal deaths to make motherhood safer – 2003 – 2005. The Seventh
Report on Confidential Enquiries into Maternal Deaths in the United
Kingdom, London: CEMACH, 2007.
2. Morbidly obese patients should not be anaesthetised by trainees
without supervision. Proposer A.F. McCrae; Opposer M. Dresner. Int
J Obstet Anaesth 2009; 18; 373-378
Unpublished Posters: Obstetric Anaesthesia 2010 (Newcastle)
P13
A Bhat, J Barley, SG Rao, A
Surendran Department of Anaesthetics, The Queen
Elizabeth Hospital, King's Lynn, UK Introduction: Obese parturients
are at an increased risk of o b s t e t r i c a n d a n a e s t h e
t i c c o m p l i c a t i o n s .
CEMACH reported obesity as a contributory factor in 35%
of all maternal deaths in the latest triennial report. Early
insertion of epidural is recommended in these patients to
minimise the risks of general anaesthesia
. Previous studies have shown that obese parturients require less
epidural local
anaesthetic (LA) when compared to the non-obese.
Large doses of LA can cause undesirable motor block and a higher
incidence of operative deliveries.
Our audit aimed to compare the average hourly
local anaesthetic consumption and the mode of delivery in the four
body mass index (BMI) groups.
Methods: We established that an ethical committee
approval was not required for this audit. Our unit uses
continuous infusion with intermittent top-ups for labour epidural
analgesia. Data was collected prospectively from 179 parturients
with labour epidurals over a four month period.
Results: The results are tabulated below:
Discussion: Our audit has shown that epidural analgesia and high
BMI can increase the incidence of operative
deliveries. Obese parturients from our study group have
received comparitively more LA dosage than the non obese. This is
contradictory to existing evidence and could
have contributed for the higher incidence of operative
deliveries. The audit suggests the need for an alternative
mode of labour epidural administration like intermittent
boluses or patient controlled epidural analgesia (PCEA)
which have been shown to decrease the epidural LA requirement.
This may possibly decrease the operative
delivery rate with epidurals in not just the obese but also the
non-obese population. The results have given us an
incentive to change to PCEA mode for labour epidural
analgesia and we plan to repeat the study in future to
complete the audit cycle.
References
P105 Labour epidural analgesia and delivery outcomes in obesity- a
prospective audit
1
1
2
2
Group C (BMI 30-
Group D (BMI>35)
2
3
1. Saravankumar K, Rao SG, Cooper GM. Obesity and obstetric
anaesthesia. Anaesthesia 2002; 61: 36-48.
2. Panni MK, Columb MO. Obese parturients have lower epidural local
anaesthetic requirements for analgesia in labour. Br J Anaesth
2006; 96: 106-10.
3. http://www.nice.org.uk/nicemedia/pdf/IPCNICEGuidance.pdf
JA Cronje, S Gowrie-Mohan, A
Suxena, J Misra Dept of Anaesthesia, Lister
Hospital, Stevenage, UK Introduction: Accidental dural puncture is
a recognised complication of epidural insertion. Post dural
puncture headache (PDPH) subsequently develops in approximately 81%
of parturients . A low incidence (25%) of PDPH has been reported in
morbidly obese paturients after (18G) epidural anaesthesia . In
this s tudy we compared the incidence of PDPH in morbidly obese
parturients with non- morbidly obese parturients.
Method: Approval was obtained for this study from the
local research ethics committee. A prospective audit was carried
out on all patients known to have had an accidental dural puncture
with a 16G Touhy needle or complaining of PDPH after epidural
anaesthesia over an eleven year period at our institution. Data was
collected prospectively using a standardised form. Demographic data
included Body Mass Index (BMI), age and ASA status. Epidural
details included reason for request, level of epidural placement,
depth of epidural space, severity and associated symptoms of PDPH
and subsequent treatment.
Results:
One hundred and sixteen patients were identified
during the study period. Both groups were comparable in terms of
age & ASA status. The incidence of inadvertent dural puncture
was significantly higher in morbidly obese paturients than
non-morbidly obese parturients - 7.8% (44/564) versus 1.1%
(72/6540), respectively. There was a statistically significant
lower incidence of severe PDPH (necessitating epidural blood patch)
between morbidly obese (52.3%) and non-morbidly obese (86.1%)
paturients.
Discussion: The combined risks of obesity and pregnancy are
significant. Regional anaesthesia is the safest approach for
morbidly obese obstetr ic pat ients , but may be technically
challenging for the anaesthetist. Morbidly obese patients have
poorly defined anatomical landmarks that can make identification of
the epidural space difficult and increase the possibility of dural
puncture. The decreased incidence of PDPH in morbidly obese
paturients may relate to the large abdominal panniculus that
functions as the equivalent of an abdominal binder, elevating
intraabdominal pressures and retarding the degree of spinal fluid
leakage through the dural puncture site.
References
1
2
Age mean &
BMI mean & range
-
-
1. Paech M, Banks S. An audit of accidental dural puncture during
epidural insertion of a Touhy needle in obstetric patients. Int J
Obstet Anesth 2001; 10: 162-7
2. Faure E, Moreno R. Incidence of postdural puncture headache in
morbidly obese parturients. Regional Anesthesia 1994; 19:
361-3
P14 Unpublished Posters: Obstetric Anaesthesia 2010
(Newcastle)
PN Nair, GC Dignam, I Suri
Department of Anaesthesia, Warwick hospital, Warwick, UK
Introduction: Regional anaesthesia is often the preferred technique
in obstetric practice. However, in patients with raised BMI ,
relying on blind landmark techniques can make successful regional
anaesthesia difficult. Multiple attempts in establishing a
successful spinal anaesthetic increases pat ient d iscomfor t ,
infec t ion r i sk and damage to surrounding structures.
Methods: A prospective study of 23 patients undergoing
elective caesarian section for a 3 month period was done.
Current BMI and number of attempts at spinal insertion were
recorded. The depth of the spinal space was measured using
Sonosite® M-Turbo ultrasound machine before measuring the
actual depth with a spinal needle. We analysed the relation between
the ultrasound and actual depth, BMI and actual depth and BMI and
needle reinsertions. Patients were followed up to identify adverse
outcomes and patient satisfaction was determined on a six point
verbal numerical score.
Results:
The mean difference in ultrasound and actual
depth was 0.23 cm (SD 0.56, range
-0.02 to 1.99, P >0.05) with a positive
correlation coefficient of 0.85
(see figure). The correlation coefficient between BMI and
actual depth was 0.37. 21 patients received successful initial
placement, including two patients with a BMI >40. Two patients
(BMI 31 and 39) required two attempts. There were no reported
adverse effects. Patient satisfaction scores ranged between 4-6: 13
patients (57 %) scored 6 [very satisfied]; 9 (39 %) scored 5
[satisfied] and 1 (4%)
scored 4 [slightly less satisfied].
Conclusion: Greater numbers are required for significant
results, however within this limitation depth of space does not
appear to correlate with BMI, except for perhaps at extremes of BMI
(patients with BMI <25 had depths below 4.8 cm and those with
BMI > 40 had depths above 6 cm). There does appear to be
positive correlation between ultrasound and actual depth. With
ultrasound assistance 21 out of 23 patients received successful
initial placement with a single further attempt for the remaining
two. Ultrasound provides an accurate assessment of depth and also
appears to aid efficient, safe placement with minimal attempts.
High recorded satisfaction perhaps represents less discomfort from
fewer attempts and/or reduced anxiety from patients' confidence in
a guided rather than blind technique. Reference
P107 Accuracy and patient satisfaction with ultrasound facilitated
spinal needle insertion for elective caesarean sections
1
1. Carvalho JCA. Ultrasound-facilitated epidurals and spinals in
obstetrics. Anesthesiology Clin 2008; 26: 145-158.
A Morris, R Leighton, P Sharpe
Department of Anaesthesia, University Hospitals of Leicester NHS
Trust, Leicester, UK Introduction: Ultrasound is now widely used
throughout all areas of anaesthesia. Within obstetric anaesthesia
it is becoming increasingly popular to guide placement of
epidurals, in particular to measure the depth of the epidural space
prior to needle puncture. It has been shown to reduce the number of
needle punctures and improve the quality of analgesia produced.
However, this requires the use of a different ultrasound technique
and probe from that with which most anaesthetists were familiar
with. We looked at the ability of anaesthetists to measure depth
using ultrasound.
Method: A model was developed to allow measurement of the dep th of
severa l s tandard ob jec t s by mul t ip le anaesthetists. The
model comprised of a container of a gelatine solution with 10
standardised objects suspended within it. 10 anaesthetists, of
different grades, performed an u l t r a s o u n d s c a n o f t h
e g e l a t i n e s o l u t i o n . E a c h
anaesthetist measured the depth of all the suspended objects
5 using a linear probe and 5 using a curved probe. The depth
of the objects was measured directly using a ruler.
Results : The r u l e r measu r ed dep th
o f t h e ob j e c t s
ranged between 0.3-6.7 cm. The mean ultrasound measured
depths ranged between 0.36-5.86 cm, the standard
deviations of the ultrasound measurements ranged between 0.06-0.4
cm. There is a good correlation between the ruler measured
and ultrasound measured depths.
Figure 1: Ruler measured vs ultrasound measured depth Discussion:
In this simple and innovative model depth
measurements made by anaesthetists using ultrasound
correlated well with the direct ruler measurements made.
This model provides a useful mecahnism for training and for further
research. References
P108 Measurement of depth by ultrasound in anaesthetic
practice
1,2
1. Grau T, Leipold RW, Conradi R, Martin E, Motsch J. Efficacy of
ultrasound imaging in obstetric epidural anaesthesia. J Clin
Anaesth 2002; 14: 169-75.
2. Grau T, Leipold RW, Conradi R, Martin E. Ultrasound control for
presumed difficult epidural puncture. Acta Anaesthesiol Scand 2001;
45: 766-71.
Unpublished Posters: Obstetric Anaesthesia 2010 (Newcastle)
P15
S Kuthanur Natarajan, K Nandakumar
Anaesthetics/Obstetrics, West Middlesex University Hospital,
Isleworth, UK Aim:To determine the adequacy and maternal
satisfaction of the pain relief following caesarean section.
Standards:Following are the standards set by Royal college of
anaesthetists
More than 90% of women should have a worst pain score
of 3 or less than 3 on Visual analogue scale (VAS)
More than 90% should be satisfied or very satisfied with
the pain relief
All should receive Non steroidal anti inflammatory agents (NSAID)
unless contraindicated
Methods:It is a prospective audit conducted in 30 obstetric
patients undergoing caesarean section. All these patients had
epidural or spinal diamorphine or fentanyl, diclofenac 100mg PR at
the end of the procedure, regular diclofenac and co-codamol. They
can also have oromorph as required with maximum dose of 30 mg in 4
hours. Pain scores were
recorded at 6 hours, 12 hours, 24 hours and 48 hours after
the caesarean section. Maternal satisfaction about the pain
relief was noted at the end of 48 hours.
Observations:Only 18 patients (60%) of women had a
worst pain score of 3 or less than 3 on VAS. Six patients
had a pain score of 5, two of them had pain score of 7 and four of
them had a worst pain score of 8.
Only 21 patients(70%) are satisfied or very satisfied with
the pain relief. Out of remaining nine patients, six said they
are not happy about the pain relief for initial 12 hours and
the remaining three said they are not happy at all for
whole 48 hours.
All patients have received NSAIDs .
P109 Adequacy of post caesarean section pain relief - an
audit
1
1. RCOA: Raising the Standard: A compendium of audit recipes
(Second edition 2006) - 8.9 Pain relief after caesarean
section
N Joshi, N Boniface, D Hurford, C
Hommers, N Wharton, M Scrutton
Obstetric Anaesthesia, St Michael's Hospital, Bristol, UK
Introduction: A RCOA audit standard suggests that >90% women
should have a visual analogue score (VAS) of ≤3cm for pain after
caesarean section (CS). >90% women should be satisfied with
their pain relief.
In 2008 an audit revealed a day 1 VAS
score ≤3cm for only 29% of women despite regular oral paracetamol
and NSAID. Patient satisfaction with analgesia was 69% on day 1.
There were also significant levels of nausea and pruritus following
CS. We p r e s e n t e d t h e r e s u l t s t o c o l l e a g u e
s a l o n g w i t h recommendations to convert from supplemental
PRN intramuscular morphine (10mg) to PRN oral morphine (10- 20mg
oramorph) following success in other units. PRN codeine phosphate
was omitted. One year later we re - audited.
Methods: Prospective data was collected from patients undergoing CS
during a four -week period in March 2009. .
Results: 100% of women received intra-thecal or epidural opioids
when CS was performed under regional blockade. CS under general
anaesthesia received PCA morphine init ial ly. 100% of women were
prescribed regular paracetamol and NSAIDS (unless contra-indicated)
along with PRN oral morphine.
Discussion: This audit confirms that a regimen substituting oral
morphine for intramuscular morphine can improve pain control .
Codeine phosphate (60mg NNT of 16.7)
maintains a high side effect profile and was successfully
eliminated from our analgesia prescription. Increased patient
satisfaction was observed.
References
1
2
3
1. Raising the Standard: a compendium of audit recipes. The Royal
College of Anaesthetists, 2006.
2. Antrobus H. Do-it-yourself pain control. ImpAct 4, 10th November
1999,
http://www.jr2.ox.ac.uk/bandolier/impact/imp04/i4±05.html
3. Oxford Pain Internet Site. Easy targets aren't always the right
ones,
http://www.jr2.ox.ac.uk/bandolier/painres/combos/comboed/html
P16 Unpublished Posters: Obstetric Anaesthesia 2010
(Newcastle)
R Dumpala, J Francis , M Jones, JA
Pickett Anaesthesia, Addenbrooke's Hospital, Cambridge,
UK Introduction: The Association of Anaesthetists of Great
Britain and Ireland recommends that UK obstetric units
have systems for referral and antenatal anaesthetic assessment of
high -risk parturients. A survey of UK
practice of antenatal anaesthetic assessment (2005) showed
that only 30% of responding units had formal anaesthetic assessment
clinics. No regional information could be
i n f e r r e d f r o m t h i s s u r v e y .
W e w i s h e d t o
investigate antenatal anaesthetic assessment in our region.
Methods: Questionnaires were sent to the lead anaesthetist for each
obstetric unit in our region. This was followed by
email or telephone reminder if no initial response. We asked
about anaesthetic clinic availability, year of establishment,
frequency, guidelines for referral, consultant cover on
labour ward and joint clinics with other specialties. We also
asked what value of BMI would trigger review at a clinic
since the Confidential Enquiries into Maternal and Child Health has
identified pregnant women with BMI > 35 at
greater risk from anaesthesia.
Results: Replies were received from 15 out of 17 units
(88%). Thirteen (87%) of the responding units had a
dedicated antenatal anaesthetic clinic. Nine (60%) of these
were certainly established before the 2005 survey. Frequency of the
clinics ranged from monthly to greater than once a week. The number
of consultant sessions on
labour ward ranged from 5 to 17 per week with larger units
generally having more. Fourteen units (93%) had clear guidel
ines on which women to refer for
antenatal
anaesthetic review. Fourteen units (93%) had a formal
referral mechanism, usually by letter. Only 1 unit had a joint
clinic (with cardiology and obstetrics).
The threshold BMIs for referral to a clinic are shown in
the Table.
Two units reviewed women below their normal trigger value if there
was other significant comorbidity.
Discussion: In East Anglia most obstetric units have formal
antenatal anaesthetic assessment clinics. All responding
units had some sort of system in place for referral of high
risk parturients. One unit which did not have a dedicated
clinic felt that it would be beneficial. BMI thresholds
for clinic review vary. This may reflect limited availability
of clinic appointments or differing opinion on level of BMI
that requires clinic assessment. Joint clinics with other
medical specialties are rare.
Reference
P111 Antenatal anaesthetic assessment: a survey of practice in East
Anglia
1
1
>35 4
>39 1
>40 6
>45 2
>50 1
No value given 1
1. Rai MR et al. Antenatal anaesthetic assessment of high-risk
pregnancy: a survey of UK practice. International Journal of
Obstetric Anesthesia 2005; 14: 21