Unpublished Posters: Obstetric Anaesthesia 2012 (Liverpool) P1 P2

Unpublished Posters: Obstetric Anaesthesia 2012 (Liverpool) P1

J Kerr,N Osborn Anaesthetics, Heart of England NHS Foundation Trust, Birmingham, UK

Introduction: Cell salvage is common in obstetric practice, inwhich a leucocyte depleting filter is advised to remove fetalsquames and amniotic fluid. Severe acute hypotensionoccurred on four occasions of attempted infusion of cellsalvaged blood during a caesarean section in a lady withplacenta percreta, which resolved on removal of the filter. Wereview the literature on hypotension associated with leucocytedepleting filters, and explore the option of removing the filter.

Case Report: A 35 year old lady, G8P7, underwent caesareansection at 35/40 for placenta percreta. In our trust the ElectraConcept machine with a Leukoguard RS filter is used.After safe delivery of the baby, heavy blood loss ensued andallogeneic blood given. 1.5 litres of cell salvaged blood wasprocessed and transfused. Acute hypotension occurred (BP58/40) which resolved on cessation of the cell salvaged bloodand treatment with vasopressors and crystalloid. A further 2attempts at transfusion of cell salvaged blood resulted insevere hypotension. A central venous catheter was inserted toassess fluid balance and the cell salvage transfusion wasrecommenced. This caused a dramatic fall in BP and CVP. Thefilter was removed, as this has been implicated in hypotension.

Cell salvaged blood was transfused freely with no furtheradverse blood pressure events noted.

Discussion : There are many causes of hypotension in thisscenario, but clinically it was felt the filter was responsible.The vasodilator bradykinin is produced as a result of plateletsand FXII adhering to the negatively charged filter. The mainconcern of removing the filter is of amniotic fluid embolism,but it is not clear which elements of the fluid are responsible.Tissue factor and alpha-fetoprotein are effectively cleared bywashing alone. The filter removes leucocytes, phosopholipidsand particulates of amniotic fluid. The AAGBI recommendsthat the decision to transfuse blood potentially contaminatedwith amniotic fluid is the clinician's. As yet, no adverseevents have been reported as a result of removal of the filter.Adverse events should be repor ted to Medicine andHealthcare Regulatory Agency (www.mhra.gov.uk) a n dSerious Hazards Of Transfusion (www.shotuk.org).

References

P81 Repeated hypotension associated with leucocyte depleting filter during infusion of cell salvaged blood

TM TM

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2

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1. Kessack LK, Hawkins N. Hypotension and autologous blood transfusion. Anaesthesia 2010; 65: 745-748

2. Iwama H. Bradykinin-associated reactions in white cell -reduction filter. J Crit Care; 16: 74-81

3. Allam J, Cox M, Yentis SM. Cell salvage in obstetrics. Int J Obs Anaest 2008; 17; 37-45

4. AAGBI safety guideline Blood transfusion and the anaesthetist 2009 http://www.aagbi.org/sites/default/files/cell%20_salvage_2009_amended.pdf

PM Slater Anaesthesia and Critical care, Northampton General Hospital, Northampton, UK

Introduction: The use of certain words and phrases withnegative emotional content can exacerbate unwantedsymptoms for patients. Anaesthet is ts f requent ly uselanguage containing negative suggestion whilst siting labourepidurals. We are currently unaware whether anaesthetistsare able to identify negative language and if they consider itsuse to be appropriate or inappropriate.

Method: All anaesthetists in the department at Northamptongeneral hospital were sent a typed questionnaire form returnedanonymously. Two explanations of an epidural were providedto anaesthetists (figure 1); one a traditional explanationcontaining negative language (explanation 1) and the otheravoiding negative language (explanation 2). Anaesthetistswere asked whether there was any difference between the 2explanations and if so what the difference was. They were alsoasked which of the 2 explanations was more appropriate to usefor a labouring woman and why.

Results: The questionnaire was sent to 59 anaesthetists and36 replied - a response rate of 61%. 27 of 36 anaesthetists(75%) indicated that the 2 explanations were different becausewords with negative emotional content are used in explanation1 but not in explanation 2. With regards to which explanationwas more appropriate to use for labouring women, 6 (17%)chose explanation 1, 18 (50%) chose explanation 2, 9 (25%)indicated both were appropriate, 1 indicated neither wasappropriate and 2 made no decision.

Discussion: Three quarters of anaesthetists noticed that the 2explanations differed due to the use of negative language inone but not the other. However, only half of anaesthetists feltthat the explanation avoiding negative suggestive languagewas more appropriate to use. This indicates that anaesthetistsare divided as to whether language with negative emotionalcontent is appropriate to use in patient communication in thisclinical setting. The reasons for this need to be exploredfurther to aid training in anaesthetists' communication skills.

References

P82 A survey of anaesthetists' preference on the language used to explain an epidural to labouring women

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Figure 1 - Explanations of epidural

1. The epidural is a small plastic tube which we put in the back using a

needle. We put pain killer through it until you've delivered the baby.

To put the epidural in, we'll sit you forward and you'll feel a sharp

scratch and sting as we inject some local anaesthetic in the skin. Some

women feel pain as the epidural goes in but let us know if it's sore and

we'll inject some more local anaesthetic.

2. The epidural is a small plastic tube which we place in the back. We

put medicine through it to keep you comfortable until you've delivered

the baby. To put the epidural in, we sit you forward and numb the back

with some local anaesthetic first so that it's more comfortable to put

the epidural in. Some women feel some pushing as it goes in but let us

know if anything bothers you and we'll make it as comfortable as

possible.

1. Varelmann D, Pancarro C, Capiello EC, Camann WR. Nocebo induced hyperalgesia during local anesthetic injection. Anesth Analg 2010; 110(3): 868-70

2. Slater P, Sellors J, Cyna AM. Communications during epidural catheter placement for epidural analgesia. Anaesthesia 2011; 66(11): 1006-11

P2 Unpublished Posters: Obstetric Anaesthesia 2012 (Liverpool)

A Senathirajah ,M Khan ,A Troy Anaesthesia, Countess of Chester Hospital, Chester, UK

Introduction: Obtaining consent for labour epidurals is anongoing issue . Despite our current practice of providingearly antenatal information which includes printed informationof analgesic options, as well as the anaesthetist's verbalexplanation pre-procedure, the consent process can beproblematic. A significant measure of the informed consent isrecall of information provided .We performed this prospectiveaudit where 43 women were interviewed within 48 hours ofdelivery to assess their ability to recall the vital informationshared.The results showed poor recall despite early antenatalinformation and availability of antenatal classes.

Method: We performed this prospective audit looking atmothers who had a labour epidural. Mothers were interviewedby the 2 auditors using a questionnaire (approved by PALS)within 48 hours of delivery. 43 mothers were interviewed withtheir consent.

The interview consisted of discussing reasons for epiduralrequest and recollection of risks that had been explained inboth the written and verbal explanation. They were also askedin they felt the had given 'informed consent' - a term that wasexplained to the mother.

Results: 95.3% (41/43) had printed information available.

32.5% (14/43) mothers considered having an epidural as part oftheir birth plan.

60.4% (26/43) mothers did not consider an epidural, of which57.6% (15) read the printed information.

90.7% (39/43) had pain scores of >6.

Maximal number of risks recalled without prompt(maximumscore 12)- 9 (mode - 2). Minimum recalled - 0

Maximal number of risks recalled with prompt - 12 (mode - 8).Minimum - 0

88.4% (38/43) mothers felt they gave 'informed consent'.

Discussion: The AAGBI states that mothers may not beincapacitated while in labour, and if so, they are capable ofgiving informed consent . At times it is difficult to decide ifthey do possess capacity. This audit highlights this problem.Their pain scores are severe, many have used diamorphine orentonox and they have all demonstrated a lack of recall.Despite this, the vast majority feel they gave informedconsent. Would this opinion still remain if they faced acomplication? We proposed a shortened list of 'Pros and Consof Epidurals' to read in the labour room or ward. This allowsmothers to re-consider their options while they are not in fullyestablished labour, and without the interference of strongmedication on their judgement. We also propose to encouragemidwifery and antenatal class staff to discuss labouranalgesia. As it can be seen from this audit, verbal informationappears to be better retained than written.

References

P83 Audit Labour epidural and maternal risk recollection are our women giving informed consent?

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1. Jackson A, Henry R, Avery N et al. Informed consent for labour epidurals: what labouring women want to know. Can J Anaesth 2000:47:1068-73

2. http://www.soap.org/media/newsletters/spring1998/procon.htmAccessed Jan 12, 2012

3. DCA, Mental Capacity Act 2005: Code of Practice, p.41

4. Association of Anaesthetists of Great Britain and Ireland (AAGBI) - Consent for Anaesthesia (Revised Edition January 2006)

R Jadhav ,J Glen,*R O'Connor,* Anaesthesia, Wishaw General, Glasgow, UK, *Anaesthesia, Southern General Hospital, Glasgow, UK

Introduction: Informed consent for CNB in labour is a legalrequirement and it is accepted that despite the stresses oflabour, women retain capacity . A national survey in 2009showed that wide variations exist across the country regardingthe information given to women regarding CNB . However,survey data and clinical practice often differ. Our aim was toaudit current practice by analysing anaesthetic charts andnoting documentation of risk during consent. We also auditedthe use of written information cards and maternal satisfaction.

Method: A three day snapshot of all elective obstetric casesrequiring CNB for labour analgesia or caesarean section wereanalysed in five maternity units in the West of Scotland. Thetype of blockade, grade of anaesthetist, use of an informationcard, along with documentation of risk was recorded.Quotation of incidence of specific risks was not audited.Women were then followed up prospectively within 48 hoursto ask if they were satisfied with the consent process.

Results: All units obtained only verbal consent for CNB. Atotal of 113 anaesthetic records were audited over five centres,of which 42% were spinals, and 58% epidurals. Consent wasdocumented in 94% and risks quoted in 88% of cases.Consultants performed 25% of cases, trainees 55% and trustgrade doctors 20%. The five most commonly documented riskswere inadequacy (73%), headache (60%), hypotension (59%),infection (50%), and non-specific neurological consequences(54%). The highest percentage of risk documentation was bytrainees. A wide variation of other risks and complicationswere documented in different units by different grades ofanaesthetists. Three units had ready access to a localinformation card, but only 19% of women overall received it.Despite this, all women were happy with the consent processat follow-up.

Conclusions: The vast majority of practitioners documentconsent for neuraxial blockade in labour. There is, however,marked disparity between units and individuals. In particular, itis of interest that almost half of practitioners do not documentthe risk of headache or neurological damage. Despite 100%maternal satisfaction, there is evidence to suggest that writteninformation can help patient recall and aid consent , yet this isnot widely used in our region. The consistent use of astandardised written consent tool, quoting risks and theirincidence could aid both patients and anaesthetists inobtaining consent for CNB, and standardise the processacross the region.

References

P84 Documentation of risk associated with central neuraxial blockade (CNB) in labour in obstetric anaesthesia: an audit of maternity units in the West of Scotland

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1. Saunders.TA, Stein.DJ, Dilger.JP. Informed consent for labour epidurals: a survey of Society for Obstetric Anaesthesia and Perinatology Anaesthesiologists from the USA. International Journal of Obstetric Anaesthesia 2006; Vol 15, Issue 2: 98-103

2. Middle.JV, Wee.K. Informed consent for epidural analgesia in labour: a survey of UK practice. Anaesthesia 2009; 64:161-164

3. Gerancher.JC, Grice.SC, Dewan.DM, Eisenach.J. An evaluation of informed consent prior to epidural analgesia for labour and delivery. International Journal of Obstetric Anaesthesia 2000; volume 9, Issue 3:168-173


A V M Riccoboni,E Evans Department of Anaesthetics, St Georges Hospital, London, UK

Introduction: Women have the right to be involved in theircare during delivery and need to make decisions. Informedconsent is required to site an epidural. The ability to recallknowledge is a major component of informed consent and isincreased by the provision of antenatal written information.Multi-modal sources of information are used regulary, yetdespite this, recall remains poor. The benefits of shortmessaging services (SMS) on healthcare outcomes are evidentand are being increasingly used by clinicians in novel ways.We look at the current sources used to deliver facts onepidural complications, information recall and the need for anovel approach to improve epidural complications' awareness.

Method: A questionnaire was designed to test recall of a totalof 6 epidural complications, the range of antenatal educationreceived, and views on the benefits of receiving an SMS inthis period. This occurred over 3 months, from September toNovember 2011. Mothers involved had used various methodsof analgesia in labour and were on their first post partum day.Standardised questions were asked by the same anaesthetist.Complications chosen were taken from the OAA leaflet.

Results: 90 mothers were questioned. 69% had epiduralsdespite only 40% planning one. 80% received some form ofepidural information antenatally. 44% received an OAA leaflet,10% could not remember and 46% did not receive one. 89%wanted another service providing information with 78%thinking that this should be with an SMS and that it would bebenefcial. Only 2% managed to recall all 6 complications withonly 13% doing this post prompting (Table 1).

Conclusion: Provision of an SMS is a simple and effective wayof meeting mothers' demands and may aid recall of epiduralcomplications. This simple use of technology, combined withincreased availability of the OAA leaflet, could enhance theinformed consent process . Further research is beingundertaken.

References

P85 Mothers' knowledge of epidural complications: can we do more?

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Table 1 . Number of complications recalled pre and post prompting of

answer

Number answered correctly Pre-prompting % Post -prompting %

0 10 2

1 28 10

2 29 7

3 10 22

4 11 26

5 10 20

6 2 13

1. Scott W. Ethics in obstetric anaesthesia. Anaesthesia 1996; 51: 717-718

2. Braddock C. The emerging importance and relevance of shared decision making to clinical practice. Med Decis Making 2010; 30: 5s-7s

3. Stewart A, Sodhi V, Harper N, Yentis S. Assessment of the effect upon maternal knowledge of an information leaflet about pain relief in labour. Anaesthesia 2003; 58:1003-1022

4. Bethune L, Harper N, Lucas D et al. Complications of obstetric regional anaesthesia: how much information is enough? Int J Obstet Anesth Jan 2004; 13: 30-34

5. Yaeger V, Menachemi N. Text messaging in healthcare: A systematic review of impact studies. Advances in healthcare management 2011; 11: 235-265

V J Hunt,A Banks Anaesthesia, NUH NHS Trust, Nottingham, UK

Introduction: Bladder care is an important part of intrapartummanagement. Adequate bladder care can reduce the incidenceof bladder overdistension and enable prompt recognition ofwomen who have voiding dysfunction. The use of epiduralanalgesia is associated with postpartum bladder dysfunction.NICE guidelines, in line with WHO recommendations, advisethat emptying of the bladder should be routine once inestablished labour. This has been adapted in our institution asone of the observations to be recorded four -hourly once thef i rs t s tage of labour i s es tabl ished. We aud i t ed thedocumentation of bladder care given to women in establishedfirst stage of labour who received epidural analgesia.

Method: 50 consecutive patients receiving epidural analgesiawere retrospectively identified from the labour ward admissionbook, working backwards from 31st July 2011. The intrapartumrecord was examined and the times, methods and volumes ofbladder emptying for the duration of labour were recorded.Some leeway was granted due to the often pressuredsituations and the very small space available on the partogramfor the urine void check. Where documented, the time from thelast pre-delivery bladder care episode to the first postpartumvoid was recorded, excluding those women who werecatheterised with an in-dwelling catheter. We also noted themode of delivery, the length of labour and whether a referralwas made to a specialist for postpartum voiding difficulties.

Results: 50 sets of records were identified. 37/50 (74%)patients had at least four hourly bladder emptying recordedduring the first stage of labour; 13/50 (26%) did not. Thisincluded up to an hour extra for maternal interventions, crisesand discrepancies in record keeping. There was incompletedocumentation of first postpartum void in 21 cases (42%), butdocumented times of 8 hours in 2 cases, 10 hours in 2 cases,and 1 instance each of 12,13,14 and 15 hours between the lastpre-delivery void and the first postpartum void. None of thewomen were referred to a specialist for bladder dysfunctionbut 2 were discharged home with in-dwelling catheters whichwere successfully removed after 7 days.

Discussion: Despite local and national guidelines, bladdercare in labouring women receiving epidural analgesia wasbelow our audit standard, with only 74% of the casesfollowing the local guideline. Perhaps more worryingly, therewere some instances of prolonged periods, with the effects ofepidural blockade on the bladder, when bladder care seemed tobe lost in the transition from labour suite to ward. As a resultof this audit we plan to heighten awareness of the issue ofbladder care in labour, particularly in the context of epiduralanalgesia, and work closely with the obstetricians, midwivesand urogynaecologists in reviewing the current clinicalguidelines.

References

P86 Audit of intrapartum bladder care in women receiving epidural analgesia

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1. R Kearney, A Cutner Review Postpartum voiding dysfunction. The Obstetrician and Gynaecologist 2008;10:71-74.

2. National Collaborating Centre for Women's and Children's Health. Intrapartum care. Clinical Guideline September 2007. Available at http://www.nice.org.uk/nicemedia/live/11837/36280/36280.pdf. Accessed October 28 2011.

3. D Mathew, A Simm, S Tao Management of the first stage of labour. Cross Health Care Boundaries Maternity Clinical Guideline, Nottingham University Hospitals NHS Trust. Implementation date November 2010.


A Thangamuthu ,M Purva Anaesthetics, Hull Royal Infirmary, Hull, UK

Introduction : Evidence suggests that lateral position forplacing epidurals is safer than sitting as it results in fewerdural punctures, inadvertent vessel cannulation and a betterfunctional block for the mother. .We wanted to investigate therelationship between position, epidural failure rate andcomplications among the trainees in our hospital

Method: 1407 epidurals were analysed from our computeriseddatabase from September 2010 to November 2011. Epiduralfailure was defined by the presence of any of the followingfactors: inadequate pain relief by 45 minutes of placement,dural puncture, resiting or mother dissatisfied at follow upvisit.

Results: Overall lateral position was used to place only 18.3%of all epidurals .CT2 trainees placed signifantly more epiduralsin the lateral position than any other grade of trainee.(p 8hrs on delivery

suite -1.4%

Retained products of

conception -2.3%Sepsis -1.4%

< 8hrs on delivery

suite - 92.7%

Clotting abnormality -

0.6%Pyrexia -12.9%

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1. Al-Foudri H, Kevelighan , Catling S. CEMACH 2003-5 Saving Mother s lives: lessons for anaesthetists. Continuing Education in Anaesthesia, Critical Care & Pain 2010;Volume 10 Number 3: 81-87.

2. Callaghan WM, Kuklina EV, Berg CJ. Trends in postpartum hemorrhage: United States, 19942006. American Journal of Obstetrics and Gynaecology 2010; 202:353.e1-6.

3. Specific therapies for PPH.UKOSS Newsletter 26;July 2011


D Castillo,P Barclay,* *Anaesthesia, Liverpool Womens Hospital, Liverpool, UK, Anaesthesia, University Hospital Aintree, Liverpool, UK Introduction:The Anaesthetic Information Mangement System(AIMS) has been sugges ted as an a l te rna t ive to thetraditional, handwritten approach. Anecdotally, uptake in UKObstetric Anaesthesia has been slow. Our department, in atertiary centre for Obstetrics and Gynaecology, installed anAIMS (Centricity Anaesthesia, GE) in late 2009. Since that timeit has been configured specifically for local requirements, andhas been found to be particularly beneficial in Major ObstetricHaemorrhage (MOH). We detail its installation and uptake.Method: Basic software was locally configured. In particular adedicated task list for MOH (accessible during any case) wasc r e a t e d . I t a l l o w s : h a n d s f r e e c a p t u r e o f g a s a n dc a r d i o r e s p i r a t o r y d a t a ; o n e t o u c h d o c u m e n t a t i o nintraoperative timings; quick documentation of lines, withboxes to detail site, ANTTetc; a template for prescription ofuterotonics and common fluids - including barcode scanningof blood product numbers; reminders for use of equipment(forced air warmer, temperature probe, cell salvage) and fort a k i n g b l o o d t e s t s ( F B C , c o a g u l a t i o n a n dthromboelastometry); captures data from syringe drivers (suchas Phenylephrine inusions during neuraxial anaesthesia).

Results:The percentage of total cases documented with AIMShas grown steadily (approx. 700 -800 cases per month):

Discussion:AAGBI guidelines state that every anaestheticmachine should be equipped with a computerised anaestheticrecord keeping system connected to the patient monitorsandgiving a number of arguments for AIMS including:greater datacollection and accuracy, reduction in the Anaesthetists'workload, integration and easy access to other electronicpatient records, e.g. PACS, laboratory results. Others havepurported improved safety (for example, a prompt to giveprophylactic antibiotics) and improved clinical governance,through audit trails. Our experience has been consistent withthis - particularly during a rapidly changing clinical situationsuch as during MOH. It has integrated with departmentalguidelines on management of MOH, promoting clinicalconsistency, providing good quallty, legible and reproducibleprintouts. References

P111 Benefits of an Anaesthetic Information Management System in Massive Obstetric Haemorrhage

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1. J Balust and A Macario Can anesthesia information management systems improve quality in the surgical suite? Curr Opin Anaesthesiol 2009 22:215222

2. http://www.aagbi.org/publications/guidelines/docs/info_management08.pdf

3. W Sandberg, E Sandberg et al Real-Time Checking of Electronic Anesthesia Records Anesth Analg 2008;106:192201

M Naik,S Wray,* Anaesthesia , Queen Charlotte's and Chelsea Hospital, London, UK, *Anaesthesia , Barts and the London Hospital, London, UK

Introduction Haemorrhage frequently accounts for maternalmorbidity in the obstetric population. As a tertiary referralcentre with over 4000 deliveries per year, our caseloadincludes women with placenta praevia, accreta and percreta.We would like to describe our experience of major obstetrichaemorrhage requiring intensive care (ITU) admission, overthe past 4 years.

Methods Fol lowing R&D approval , we conducted adescriptive, retrospective notes review of all obstetric ITUadmissions between January 2008 and December 2011. Caseswere identified from ITU admission and discharge records.Information was obtained from individual case note review,ICNARC and the obstetric anaesthetic databases.

Results There were 25 intensive care admissions followingmajor obstetric haemorrhage between January 2008 andDecember 2011 . We were able to review 23 patient notes.Eleven patients were over 35 years old, with three over 40years old. Fifteen patients were multips. Gestation at deliverywas 20 -40 weeks. Fifteen patients delivered by urgent oremergency caesarean, the others delivered by ventouse,forceps, spontaneous vaginal delivery and one patient had alate termination. Blood loss ranged from 2.5 to 20 litres.Interventional radiology was required in 12 cases and 3patients developed complications from interventionalradiology, including lower limb ischaemia and iliac arteryrupture. All complications were treated promptly. Six womenhad placenta accreta or percreta, only two of whom had hadmore than one previous caesarean section. Three women hadplacenta praevia. Five mothers required hysterectomies. Thecommonest cause of haemorrhage was uterine atony.Therewere no maternal mortalities from haemorrhage.

Discussion Peri and post par tum haemorrhage is thecommonest cause of obstetric admission to our intensive careunit. These women reflect the most severe cases, yet oftenreturn to the obstetric high dependency unit within 24 -48hours. We are looking after an older obstetric population withcomplex medical issues. Our unit works closely withinterventional radiology and there is early multidisciplinaryinput for known complex cases. Three cases had complicationsfrom interventional radiology. Major obstetric haemorrhage(MOH) can follow normal vaginal deliveries from atony ortears, and therefore one should place emphasis on theimportance of early recognition and robust MOH protocols. Reference

P112 Blood, sweat, atony and tears.........a review of major obstetric haemorrhage intensive care admissions over four years

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1. CMACE. Saving Mothers' Lives: Reviewing maternal deaths to make motherhood safer: 2006-2008. The 8th Report on Confidential Enquiries into Maternal Deaths in the United Kingdom. BJOG 2011; 118 (Suppl. 1):1-203


C Parcha,S Gnanaseakaran ,P Karkhanis,M Wyldes Obstetric Anaesthetic Department, Heartlands Hospital, Birmingham, UK

Introduction: Peripartum hysterectomy is usually undertakenin cases of life threatening obstetric haemorrhage and istherefore considered a 'near miss' event. We describe amultidisciplinary experience in the management of patients thatrequired a peripartum hysterectomy in our institution.

Method: A total of 11 cases of peripartum hysterectomies wereidentified between december 2010 and december 2011.Permiss ion was obtained f rom the obste t r ic c l inicalgovernance department to review the cases. Case notes wereexamined and data was collected using an anaesthetic and anobstetric proforma. We looked at the causes, the anaestheticand obstetric management of these cases.

Results: O f t h e 1 1 c a s e s , s e v e n w e r e c a e s a r e a nhysterectomies, three had spontaneous vaginal delivery andone had a ventouse delivery. One was a planned caesareanhysterectomy and rest were emergencies.The mean age of thepatients was 32 years (range 25-42 years). Seven patients weregravida 5 or more, two were gravida 4 and two were gravida 3.Eight patients (72%) had a general anaesthetic from the outsetand in 3 patients (27%) spinal anaesthetic was converted to ageneral. Intraoperatively all patients had invasive bloodpressure monitoring and seven also had central venouspressure monitoring. The average estimated blood loss was4250ml per patient and all have received RBC and FFPtransfusions. Four also received cell salvaged blood. While 9out of 11 patients (81%) had undergone at least one previouscaesarean section, 4 had more than one. The most commonlyidentified cause of haemorrhage was uterine atony (73%). Twocases had ruptured uterus and a morbidly adherent placentawas found in one.

Discussion: A total of 7,689 deliveries were recorded betweendecember 2010 and 2011 in our institution. The incidence ofperipartum hysterectomy in UK is 40.6 per 100000 maternities.(95% CI, 36.4-45.4 per 100000 maternities). All cases wereperformed by obstetric consultants and nine differentconsultants performed the eleven peripartum hysterectomies.All the patients were managed with sequentially administereduterotonic agents. Four were managed with an intra -uterineRusch balloon with a vaginal pack, while none had a B Lynchbrace suture. Bilateral internal iliac balloon angioplasty wasperformed in the planned caesarean hysterectomy. Sevenpatients required level three care on the general critical careunit Four were successfully extubated at the end of theoperation and were admitted to the high dependency unit onthe labour ward. There were no case fatalities and all thepatients were safely discharged home with an average hospitalstay of 7 days.

Conclusion: The decision and management of peripartumhysterectomies was found to be timely and appropriate. Ourunit can provide cell salvage in planned high risk patients butit is not guaranteed in emergency due to lack of trained staff.We propose that criteria to recognise at risk patients shouldbe set and all such patients should be seen by a senioranaesthetist in the clinic.

Reference

P113 The common "uncommon" life threatening emergency - peripartum hysterectomy

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1. Knight M and UKOSS, Peripartum hysterectomy in the UK: BJOG; 114:1380-1387

VM Cowie,K Cummins,E Evans Department of Anaesthesia, St Georges Hospital, London, UK

Introduction: The most common cause of post partumhaemorrhage (PPH) is uterine atony, and major risk factors forPPH due to atony include oxytocin use in labour andprolonged labour . RCOG green top guideline 52 recommendsthe use of 5IU of oxytocin at time of birth for all caesareansections (LSCS), and there is evidence that the use of anoxytocin infusion in the immediate post partum period reducesthe need for second line uterotonic agents . Uterotonic drugshave a narrow therapeutic range and there few definitives tud ie s look ing a t oxy toc in dos ing and second -lineuterotonics. We aimed to audit the use of first and second lineuterotonic agents at our hospital in relation to indication forLSCS, prior use of oxytocin and estimated blood loss (EBL).

Method: The notes of 199 patients who underwent LSCSwhere audited chronologically from 1 January 2011. In additionto demographic data, the use of f irst and second l ineuterotonics were recorded and also EBL.

Results: Elective LSCS accounted for 49.7% of patients.Indications for emergency LSCS included failure to progress(38%), foetal distress (31%), antepartum haemorrhage (6%). Inthe emergency group, 84% were in labour, and of these 73%were on an oxytocin infusion to augment labour.. All patientsreceived a bolus dose of oxytocin at time of birth and 89% ofpatients received an oxytocin infusion following delivery.

Estimated blood loss (EBL) of more than 1000mls accountedfor 16.6% of patients. 70% of these patients did not receive asecond line agent.

Discussion: At our hospital we are routinely giving a bolus ofoxytocin at time of birth in line with the RCOG guideline. Nopatient received a second dose of oxytocin. In line with recentl i tera ture our data shows pat ients in obst ructed andaugmented labour are more likely to require a seconduterotonic agent, and we recommend that clinicians arevigilant to oxytocin receptor desensitisation in these patients.A high number of patients with EBL greater than 1000mls didnot receive a second line uterotonic, and we feel thisunderl ines the need for further investigation and thedevelopment of guidelines for dosing and drug choice of firstand second line uterotonics.

References

P114 The use of uterotonics to reduce post partum haemorrhage after caesarean section

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1. Drife J. Management of primary post partum haemorrhage. BJOG 1997; 104: 275-7.

2. Sheehan SR, Montgomery A, Carey M, McAuliffe F, Eogan M, Gleeson R, Geary M, Murphy D. Oxytocin bolus vs oxytocin bolus and infusion for control of blood loss at elective caesarean section: double blind, placebo controlled, randomised trial. BMJ 2011; 343: d4661.


W N Weidenhammer,R O'Connor,E Harrison,*P Stone Department of Anaesthetics, Southern General Hospital, Glasgow, UK, *Blood Transfusion Services, Southern General Hospital, Glasgow, UK

Introduction: Haemorrhage is a major cause of maternalmortality. Availability of group-compatible blood within 10-15minutes at blood bank and prompt transport of bloodproducts to the required site is paramount in the successfulmanagement of a major haemorrhage. We assessed our localtimelines from activation of the major haemorrhage emergencycall (MHEC) to the transfusion of blood obtained from bloodbank as well as the average product requirement.

Method: 20 major haemorrhages with activation of a MHECwere identified over a one-year period. Times of MHEC, bloodproduct availability and transfusion times of on-site screenedO negative (O Neg) blood and blood bank issued blood werereviewed in 18 cases to assess any delays in the time ofprocessing and transporting of blood products. We alsoreviewed the use of labour suite screened O Neg blood, overallpacked red cells (PRC), fresh frozen plasma (FFP) and platelets(PLTS) in our unit during major obstetric haemorrhage.

The results were compared with a survey we undertook in ourdepartment's obstetric anaesthetists about the local provisionof blood products after a MHEC activation.

Results: In some cases transfusion had already begun beforethe MHEC, and in one case although a call was made, only oneunit of O Neg and one of group compatible blood was given.Excluding these the mean time from MHEC to transfusingblood bank blood was 26 min [range 15-35] in 11 cases.

61% [11/18] of cases used O Neg blood prior receiving bloodfrom blood bank. The mean time from the last O Neg unit to thefirst unit PRC from blood bank was 16 min [range 5-23]. Twocases of perceived compromised care in the last 2 years due toinadequate supply of on -site O Neg were reported in thesurvey. 77% [7/9] of consultants wanted to increase the O Negunits available from 2 to 4 units.

All 20 cases required PRC from blood bank, mean 5 units[range 1-12]. 70% [14/20] were given FFP, mean 4 units [range1-8]. 25% [5/20] required PLTS, mean 2 pool of PLTS [range 1-3]. 66% [6/9] of our consultant body supports a shock packwith a mean of 5 units PRC, 4 units FFP and 1 pool of PLTS.

Our consultant body agreed on 19 min [range 17.5-20] as aclinically acceptable time, but subjectively felt it takes 31 min[range 30-35] from a MHEC to transfusion of the first unit PRC.

Conclusions: A case can be made for increasing the number ofO Neg units available in our labour suite. Awareness of theblood product requirement during a major haemorrhage canguide the introduction of a shock pack and a facility torequest this will now be explored in our unit. Knowledge ofactual PRC delivery time may lead to improved care byadjusting the trigger for a MHEC, guiding timely requests andexploring strategies to minimise delay.

References

P115 Time to transfusion of blood products in major obstetric haemorrhage -strivingforimprovement

1

2

1. Centre for Maternal and Child Enquiries (CMACE). Saving Mothers' Lives: Reviewing maternal deaths to make motherhood Safer: 2006-2008. The Eighth Report on Confidential Enquiries into Maternal Deaths in the United Kingdom. BJOH 2011;118(Suppl. 1):1-203.

2. Obstetric haemorrhage. In: McClelland DBL, ed. Handbook of Transfusion Medicine. 4th ed. London: TSO; 2007:51.

AV Pyregov,SV Petrov Anesthesiology, Research Center for O&G and Perinatology ,Moscow, Russia

P116 WITHDRAWN FROM PRESENTATION: Comparative assessment of invasive and noninvasive methods of detection total hemoglobin in pregnant womens blood during abdominal delivery


EA Christie,P Yoxall Anaesthetics, St Helens Knowsley NHS Hospitals Trust, Liverpool, UK

Introduction: Post dural puncture headaches (PDPH) are acommon complication of central neuroaxial blocks. They aredebilitating for the new mother and have implications forlength of stay, investigations and interventions. NationalAudit Project (NAP) 3 estimated 25% of labouring womenreceive epidural analgesia, with 1% sustaining an accidentaldural puncture. Previous studies agreed with a rate of 1% forPDPH; 50-80% of these patients subsequently develop aPDPH. Our audit aim was to assess our rate of PDPH againstrecognised standards and highlight modifiable risk factors.

Method: A prospective audit over a 12 month period assessedall patients who sustained a PDPH from June 2010 to May2011. All epidural patients were routinely followed up after24hrs . A suspected PDPH was ini t ia l ly t reated wi thconservative management after a consultant review and ifPDPH persisted, a blood patch (BP) was carried out. Datacollected included number and timing of blood patches, repeatBP, grade of anaesthetist for the initial epidural and whetherfurther imaging was needed.

Results: 16 patients were diagnosed with PDPH in a 1 yearperiod, after insertion of an epidural or combined spinal -epidural (CSE). During the year approximately 800epidurals/CSE's were performed. Consequently our rate ofPDPH is 16/800 which is 2%, twice that expected. 15 out of the16 patients with a PDPH received a BP, 5 required a repeat BP.The initial epidural was carried out by consultants in 4 casesand trainees in 12 cases. 15 patients presented within the first72hrs after the epidural/CSE. The majority of patients had theirblood patches 2-3 days after the initial epidural (10 out of 16patients). The longest was 8 days. A cluster of PDPH wasnoted in March, with 4 cases reported in this month alone.

Discussion: Our rate of PDPH after epidural/CSE in the lastyear was twice that expected in the UK. Our epidural packscontain a long 21G hypodermic needle(45mm cutting needles)and no loss of resistance syringe. Infiltration of localanaesthetic may have lead to unnoticed dural punctures.Trainees rotate between multiple hospitals using a variety ofepidural packs and their experience may impact on the rate ofdural punctures. Peaks in PDPH may coincide with rotation oftrainees unfamiliar with the epidural packs presented to them.The incidence of PDPH is inversely related to the experience ofthe anaesthetist. Rising obesity in obstetric patients makesepidurals technically more difficult, multiple attempts mayincrease the risk of PDPH. Recommendations include removalof green hypodermic needle from the packs, and use of loss ofresistance syringe. Trainees new to obstetric anaesthesia haver igourous t ra in ing idea l ly in a cont inuous teachingblock/module and increased use of ultrasound.

References

P117 An audit assessing the post dural puncture headache rate in obstetric patients receiving epidural analgesia in a district general hospital.

1

2

3

3

1. Cook TM, Counsell D, Wildsmith JAW. Major complications of central neuroaxial block: report on the Third National Audit of The Royal College of Anaesthetists. British Journal of Anaesthesia 2009;102:179-90.

2. Thew M, Paech MJ. Management of postdural puncture headache in the obstetric patient. Current Opinion in Anaesthesiology 2008;21(3):288-92.

3. Turnbull DK, Shepherd DB. Post dural puncture headache: pathogenesis, prevention and treatment. British Journal of

AE Kavanagh ,L McWhirter,R Laird Anaesthetics, Altnagelvin Hospital, Londonderry, UK

Introduction: We describe a case of cerebral venous sinusthrombosis presenting as persistent headache followingaccidental dural puncture during epidural insertion.

Case report: An 18 year old primigravida in spontaneouslabour at term had a suspected catheter dural puncture duringinsertion of an epidural. She had a vacuum-assisted delivery ofa live male infant a few hours later. The patient developed asevere, postural headache the day after delivery, withassociated photophobia, nausea and vomiting. An epiduralblood patch was performed with immediate easing of theheadache, although the patient was not completely pain-free.The patient's headache worsened again 24 hours after theblood patch was performed. Neurological examination wasnormal. There were no features of meningism, rashes or seizureactivity. A CT brain scan showed suspicion of pathology inthe region of the point of origin of the straight sinus. MRIconfirmed straight sinus thrombosis, as well as generalisedthickening and enhancement of the dura felt to representintracranial hypotension. The patient's headache graduallyresolved over several weeks, and she did not develop anyneurological sequelae. No evidence of thrombophilia wasfound on screening. The patient was warfarinised for twelvemonths, and advised to avoid oestrogen -containing oralcontraceptives. A follow-up MRI/MR venogram at 4 monthsshowed no evidence of residual thrombus. Regarding futurepregnancies, it was recommended by a haematologist that thepatient commence prophylactic low molecular weight heparint h r o u g h o u t p r e g n a n c y , a n d t h a t t h e r e w e r e n ocontraindications to epidural or spinal anaesthesia.

Discussion: Cerebral venous sinus thrombosis (CVST) is anuncommon type of stroke with an incidence of 3 to 4 permillion people per annum. CVST in pregnancy occurs in 11.6per 100,000 deliveries, most commonly occurring in the 3rdtrimester and puerperium. Clinical features include headache,focal neurological deficits, visual disturbance, seizures andaltered level of consciousness. 4.5% of all CVST is associatedwith a mechanical precipitant such as dural injury. Our patienthad risk factors corresponding to all components of Virchow'striad: pregnancy-associated hypercoagulability, endothelialdamage as a result of intracranial hypotension and stretchingof blood vessels, and stasis of intracerebral blood flow as aresult of compensatory venous vasodilatation. The headacheassociated with CVST can mimic a post -dural punctureheadache, and there may be a dual diagnosis. Investigation forCVST should be considered in any patient with post -duralpuncture headache which persists or intensifies after an initialplateau.

References

P118 Cerebral venous sinus thrombosis as a complication ofdural puncture

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2

3

4

1. Stam J. Thrombosis of the cerebral veins and sinuses. NEJM 2005;352:1791-8

2. Lanska DJ, Kryscio RJ. Risk factors for peripartum and postpartum stroke and intracranial venous thrombosis. Stroke 2000;31:1274-82

3. Saposnik G, Barinagarrementeria F, Brown RD et al. Diagnosis and management of cerebral venous thrombosis. A statement for healthcare professionals from the American Heart Association/ American Stroke Association. Stroke 2011;42:1158-92

4. Ferro JM, Canhao P, Stam J, Bousser MG, Barinagarrementeria F. Prognosis of cerebral vein and dural sinus thrombosis: results of the International Study on Cerebral Vein and Dural Sinus Thrombosis (ISCVT). Stroke 2004;35:664-70


YM Nawaz,S Arava,S Mulvany ,K O'Connor,M Rea Anaesthesia, Craigavon Area Hospital, Portadown, UK

Introduction: Obstetric patients are at particular risk of postdural puncture headache (PDPH) due to their gender, age andthe widespread use of neuraxial anaesthesia in this population. We reviewed the management of PDPH in our maternity unit

with emphasis on treatment and patient follow up.

Methods: We retrieved clinical information about all PDPHsand epidural blood patches (EBP) between 1999 and 2011 fromour obstetric anaesthesia database and patient notes.

Results: Seventeen patient notes were accessed from 35recorded cases of PDPH. Twelve cases followed an epiduraland five followed a spinal.

Figure: Treatment prescribed for patients with PDPH

Twelve patients were successfully treated with an EBPalthough two had a recurrent dural puncture and one wasreadmitted with a recurrent headache. Three out the fivepatients managed conservatively had symptom resolution atthe time of discharge. No means of follow up were documentedfor 14 patients (82%).

Discussion: Many treatments in current use have a limitedevidence base. Thirteen patients (76%) received caffeine,which is more effective than placebo in treating PDPH. 35% ofpatients were advised to have bed rest and 18% wereprescribed additional IV fluids however a recent cochranereview found no evidence of benefit from either strategy. All12 patients who underwent therapeutic EBP experiencedimprovement and this treatment is known to be more effectivethan conservative management. This review demonstratedinadequate follow up of patients who have a PDPH in our unitdespite the risk of serious morbidity and even death.Therefore we have devised a new local guideline for PDPHmanagement including a patient information leaflet, daily in-patient review by a senior anaesthetic trainee and a telephonefollow-up by a consultant anaesthet is t 4 -6 weeks postdischarge.

References

P119 Management of post dural puncture headache in a maternity unit: Retrospective review and new guideline

1

2

3

4

1

1. Turnbull DK. Shepherd DB. Post-dural puncture headache: pathogensis, prevention and treatment. Br J Anaesth 2003; 91: 718-729.

2. BasurtoOnaX,MartnezGarcaL,SolIetal.Drugtherapyfortreating post -dural puncture headache. Cochrane Database of Systematic Reviews 2011; 8: CD007887.

3. Sudlow CLM, Warlow CP. Posture and fluids for preventing post-dural puncture headache. Cochrane Database of Systematic Reviews 2002; 2: CD001790.

4. Boonmak P, Boonmak S. Epidural blood patching for preventing and treating post -dural puncture headache. Cochrane Database of Systematic Reviews 2010; 1: CD001791.

KA Parsons ,O Mateszko ,IJ Wrench Anaesthetics, Royal Hallamshire Hospital, Sheffield, UK

Introduction: Despite previous studies looking at changes inepidural pressures during local anaesthetic injection neverbefore has this been reported during the placement of a bloodpatch. This pilot study was designed to generate data andincrease understanding of a previously unstudied area.

Methods: This data is taken from the first patient involved inan ethically approved observational pilot study looking atobstetric patients undergoing blood patch for treatment ofpost dural puncture headache (PDPH). The patient hadclassical PDPH symptoms, a his tory consis tent withinadvertent dural puncture and gave written consent. Epiduralpressures were measured using a standard invasive pressuretransducer and recorded electronically.

Results: During continous manual injection of 20mls ofautologous blood over 50 seconds epidural pressure rosesteadily to 39mmHg. This pressure returned quickly tobaseline after 20 seconds (Fig. 1). At no point did the patientexperience any discomfort. This blood patch was successful inrelieving the patients' symptoms and did not need to berepeated.

Conclusion: This is the first patient in our pilot study. Fromthis and subsequent patients we hope to establish whetherthere are differences between successful and unsuccessfulprocedures and whether high epidural pressures areassociated with pain.

References

P120 Novel demonstration of epidural pressures during blood patch

1,2

1. Hirabayashi Y, Shimizu R, Matsuda I, Inoue S. Effect of extradural compliance and resistance on spread of extradural analagesia. British Journal of Anaesthetsia 1990; 65: 508-613

2. Paul DL, Wildsmith JAW. Extradural pressure following the injection of two volumes of bupivocaine. British Journal of Anaesthesia 1989; 62: 369-372


K O'Connor,F Bryden,K Litchfield Department of Anaesthesia, Princess Royal Maternity Hospital, Glasgow, UK

Introduction: Delayed presentation of post dural punctureheadache (PDPH) following discharge before symptomsmanifest can be successfully managed by late epidural bloodpatch. After treating two such patients we developed a followup service to review parturients with suspected accidentaldural puncture (ADP).

Methods: Suspected ADP parturients over one year wereinvited to anaesthetic clinic for consultation. A questionnairedocumented headache, associated symptoms, future labouranalgesia preferences and maternal satisfaction issues(assessed by visual analogue scales). ADP audit forms wereretrospectively reviewed for additional data.

Results: Fourteen of 39 parturients invited attended - twelvesuffered PDPH. Mean time to review was 5 months (range 2-9).Seven mothers were primiparous and five multiparous.Deliveries were by LUSCS (9), SVD (2) and instrumental (1).Three patients consulted primary healthcare professionalsregarding headache prior to clinic. One attempted but wasunable to contact anaesthetic services. At clinic six reportedcurrent headache. Four described classic symptoms of PDPH.Associated symptoms included photophobia (4), earache (2),back pain (2), nausea (1) and low mood (2). Mean duration ofsymptoms was 5.5 days (range 1-42). Seven patients receivedepidural blood patch (four after discharge). Neuroimaging wasperformed on three patients - one after anaesthetic follow up.One patient was referred to obstetrics and five have continuedanaesthetic follow up. Seven would avoid epidural in future.Table 1 summarises satisfaction scores (low score correlateshigh satisfaction).

Discussion:

Dural punctures may go undetected at epidural insertion.Most PDPHs resolve in seven days but headache can persistfor several years. Undiagnosed problems after ADP aredetrimental to quality of life with potentially disastrousconsequences. This service provides essential anaestheticfollow-up to this small but important group of patients. Ourexperience reflected evidence that information and emotionalsupport during consultation improves maternal satisfaction.

References

P121 Postpartumreviewafteraccidentalduralpuncture

1

Maternal scale Visual analogue score

0-2 2-4 4-6 6-8 8-10

n (%) n (%) n (%) n (%) n (%)

Max headache pain 0 (0) 0 (0) 0 (0) 2 (17) 10 (83)

Daily tasks 0 (0) 0 (0) 1 (8) 3 (25) 8 (67)

Care for baby 0 (0) 2 (17) 1 (8) 2 (17) 7 (58)

Bonding 5 (0) 0 (0) 0 (0) 5 (42) 2 (17)

Conservative management 1 (8) 1 (8) 0 (0) 4 (33) 5 (42)

Epidural blood patch (n=7) 7 (100) 0 (0) 0 (0) 0 (0) 0 (0)

Overall ADP management 5 (42) 1 (8) 1 (8) 2 (17) 4 (33)

Childbirth experience 1 (8) 3 (25) 3 (25) 3 (25) 2 (17)

1

1

1

2

1. Turnbull DK. Post dural puncture headache: pathogenesis, prevention and treatment. Br J Anaesth 2003; 91:718-29

2. Janssen PA. Development of psychometric testing of Care of Obstetrics Maternal Satisfaction. Res Nurs Health 2006; 29: 51-60

K Bruce-Hickman,D Gordon,L Wee Department of Anaesthesia, University College Hospital, London, UK

Introduction: Neuroaxial blockade is common practice inobstetric anaesthesia. Our aim was to evaluate the rate ofpostdural puncture headache (PDPH) and neurologicalsequelae following neuroaxial blockade in a busy Londonobstetric unit. We also looked at our conversion rate togeneral anaesthesia for surgery.

Methods: Anaesthetists performing neuroaxial blockade inobstetrics documented each procedure and any adverseeffects. Routine follow up of patients the next day allowed usto collect information about further complications. Theseresults were collected over a 5 year period between 2004-2008.

Results: A total of 11456 cases of neuroaxial blockade wereperformed. The results are shown in Table 1. Overall incidenceof PDPH was 0.777% and neurological sequelae was 0.471%.The conversion rate of neuroaxial blockade to generalanaesthesia for surgery was 1.292%.

Table 1. Incidence of PDPH and neurological sequelae

Discussion: Our incidence of PDPH for epidurals comparesfavourably to published data of 1% . Our incidence ofneurological complications is very high compared to publishedrates of 1 in 15000 . However, our follow up was in theimmediate post procedural period which included patients withtemporary residual neurological symptoms. The lack of longterm follow up prevented us from differentiating betweenthose with permanent neurological damage. Of note is the factthat spinals had the highest incidence of PDPH but the lowestincidence of neurological complications; although the numberof spinals performed were fewest. This could be due to the factpatients receiving top ups with an epidural or CSE wouldexperience prolonged block which is then picked up by ourfollow up the next day. Conversion to general anaesthesiacompares favourably with published results of 1.2% for spinaland 4.3% for epidural anaesthesia . This audit providescomparison data on some adverse effects following differenttypes of regional anaesthesia in obstetrics; but is limited bythe lack of long term follow up in patients with neurologicalcomplications. We are planning to improve our long termfollow up for this group of patients.

References

P122 The incidence of postdural puncture headache and neurological sequelae following neuroaxial blockade in obstetric anaesthesia: a five year study

Epidural Spinal CSE Total

5 Year Total 7369 1158 2929 11456

PDPH 50 14 25 89

PDPH % 0.679 1.209 0.854 0.777

Neurological sequelae 43 1 10 54

Neurological sequelae % 0.584 0.086 0.341 0.471

1

2

3

1. Bogod D. Complications after obstetric CNB. In: NAP3. The third national audit project of The Royal College of Anaesthetists. RCOA Press; 2009: 117-124.

2. Loo CC, Dahlgren G, Irestedt L. Neurological complications in obstetric regional anaesthesia. Int J Obstet Anesth 2009; 9: 99-124.

3. Pan PH, Bogard TD, Owen MD. Incidence and characteristics of failures in obstetric neuraxial analgesia and anaesthesia: a retrospective analysis of 19,259 deliveries. Int J Obstet Anesth 2004; 13: 227-233.


M Naik,K Bexon,G Stocks,H Bohjar,*C Sadler,* Anaesthesia , Queen Charlotte's and Chelsea Hospital, London, UK, *Anaesthesia, Barts and the London Hospital, London, UK

Introduction Following the most recent CMACE report , someof the problems highlighted included poor team work andfailures to recognise the critically unwell patient. Skills anddrills can be an excellent way of addressing this . In 2002 , anOAA survey was conducted reviewing the use of skills anddrills in maternity units. The aim of this telephone survey is toevaluate and compare the use of skills in obstetric units inLondon in 2012 with those previous survey results .

Methods We conducted a snapshot telephone survey ofmaternity units in the London deanery. We spoke to one ofthe consultant obstetric anaesthetists in each department . Weasked a series of 12 questions about the use, content andfrequency of multidisciplinary skills and drills as well as theuse of simulation and other methods to promote team working.

Results We spoke to 20 consultant obstetric anaesthetists .19/20 maternity units performed skills and drills on their labourwards and 4 units ran drills on antenatal wards.

One institution ran skills once every month. 16 centres had runa scenario within the last 3 months. 12 units directed their drillstowards the multidisciplinary team and 4 units specificallydirected the teaching to midwives. Similar factors in 2002 stillprohibit skills and drills in 2012.These include the lack of time,staff, protected teaching and resources.Ninety percent ofresponders felt that access to pre- prepared scenarios wouldbe useful.

Conclusion Our survey suggesrs that there is an enthusiasmfor skills and drills with an increase in units performing themon their units in London 2012. Although access to simulationcentres is easier, there is great value in performing scenarios inones working environment in terms of teamwork,knowledge ofworkplace and identifying areas of improvement. In a time offinancial constraints , limited time, staff and resource, thechallegne is to make this easier. We have developed MaternityUnit Multidisciplinary Skills (MUMS) ,14 prerepared scenarioscovering obstetric and medical emergencies based on casesdescribed in the latest CMACE report with assessmentchecklists. We have been using them for training in twoteaching hospitals and aim to pilot them locally and potentiallynationally as an online resource.

Reference

P123 A telephone survey of the use of skills and drills in twenty London obstetric units... could Maternity Unit Multidisciplinary Skills (MUMS) help?

2002

Units

n= 203

2012

Units

n=20

Performing skills and drills 45% 95%

Frequency of skills (>3 times year) 39% 75%

Scenarios used Haemorrhage 84% 70%

Eclampsia 32% 60%

Maternal cardiac arrest 33% 45%

Use of simulation 5% 45%

1. CMACE. Saving Mothers' Lives: Reviewing maternal deaths to make motherhood safer: 2006-2008. The 8th Report on Confidential Enquiries into Maternal Deaths in the United Kingdom. BJOG 2011 (Suppl. 1):1-203

J Boss ,J Teare,E Evans,P Hughes Anaesthetics, St Georges Hospital NHS Trust, London, UK

Introduction: A busy labour ward provides a rich environmentfor first-hand learning. Challenges to delivering safe, timelytraining in Obstetric Anaesthesia include fast turnover ofpatients, shift work and service pressure. Sound educationalprinicples support computer -mediated communication toreinforce adult learning As today's trainee has regularInternet access and checks e -mail daily we aimed to explorehow to offer a non -judgmental 'space' for interactive grouplearning and development of reflective practice, supporting e-Portfolios.

Methods: E-debates ran using group e-mail monthly from Mayto December 2011. A supervised trainee provided ananonymised scenario then asked key practical questionsregarding a clinical dilemma which they faced. Scenarios weremapped to the curriculum for Obstetric Anaesthesia for ST3-4in order to provide relevant discussions. Forum membersresponded using the 'reply -all ' function on their e -mailaccounts. Each debate rounded up with a scenario summaryand discussion including learning points highlighted byAnaesthetic and Obstetric Consultants. In addition traineeswere directed to useful resources such as relevant evidencebased guidelines and research publications. A questionnairewas distributed to participants via Survey Monkey to explorethe level of participation, functionality, relevance of topics,and to encourage forum development.

Results: 95 individuals part icipated in 7 e -Debates; 4anaes the t ic consul tants , 4 obs te t r ic consul tants , 58anaesthetic trainees and 25 obstetric trainees. The surveydemonstrated the educational usefulness of this mode oflearning. Comments included: 'found process very useful','thought provoking', 'diverse and relevant', 'things I had notconsidered', 'excellent idea', and 'even for those like me...justfollowing...there were good learning tips'.

Discussion: Within the NHS, time and finance are at apremium. We identified an opportunity to optimise the learningpotential of a rich clinical environment despite theseconstraints.Avirtuallearning'caf'offerstraineestheopportunity to invest in their own learning, share ideas andask ques t i ons i n a non -judgmental setting. Modelledparticipation is an effective way of enhancing learning in thiscontext. Relevance of discussion topics and ensuring thatparticipants have a social presence and can comment withoutintimidation, has been key to this project 's success.Developing complexity of ongoing scenarios can widen thenetwork of e -learning to include senior trainees and non -obstetric anaesthetists with on -call commitment to labourward.

References

P124 Anaesthesia and obstetric e-debate: an interactive educational virtual cafe

.1

2

3

1. Bryant BK. Electronic discussion sections: a useful tool in teaching large university classes. Teaching Psychol 2005; 32: 271275

2. Romiszowski A, Mason R. Computer-mediated communication. In: Jonassen DH, ed. Handbook of Research for Educational Communications and Technology. 2nd ed. Lawrence Erlbaum Associates: 2004: 397432.

3. Johnson DW, Johnson RT. Cooperation and the use of technology. In: Handbook of research for educational communications and technology. Simon & Schuster Macmillan; 1996:1017-1044.


A Tufchi,G Vickers Anaesthetics, Royal Oldham Hospital, Oldham, UK

Introduction: Traditionally job rotation among trainee doctorsand nurses have been shown to improve the organisationaland clinical skills of the trainee .However there have beenspeculations about the quality of care delivered to the patientsby continual rotation of doctors . In most of the hospitalacross NHS, doctors change hospitals in the month ofFebruary and August each year.

Methods: We collected the data from year 2004 to 2010 on ourmaternity unit where on the average we conduct about 3200deliveries each year. We analysed the follow up data of allemergency caesarean sections in that period (2672 cases) bythe month they were performed in, and looked at the trends inthe anaesthetic management.

Results: We found that the incidence of emergency caesareansections decrease in the month of February from the monthlyaverage of 227 to 199 cases. The incidence of foetal distressleading to emergency caesarean section increased in themonth of August from the monthly average of 19.5 to 30. Theincidences of emergency GA sections were found to be 21.1%and 22.13% in February and August respectively while themonthly average was 16.42%. On the contrary, the incidenceof emergency caesarean section performed under spinal blockseem to trough in February and August to 61.80% and 56.14%respectively as compared to the average of 64.48%.

Conclusion: We have noticed that there seems to be higherincidence of general anaesthesia and lower incidence of spinalanaesthesia performed in August and February for emergencycaesarean sections. Although these results may be influencedby many other factors, we think that these findings areinteresting considering that spinal anaesthesia is usually saferthan general anaesthesia in emergency caesarean section andthe data analysed is from seven years. The rotation of traineedoctors may influence the quality of care given to the patients.

References

P125 Is there any effect of job rotation among trainees on the outcome of patient care? An analysis of 7 years data.

1

2

1. Effect of job rotation and role stress among nurses on job satisfaction and organizational commitment.BMC Health Services Research 2009, 9:8.

2. The effect of house officer rotation on inpatient satisfaction and ward atmosphere: preliminary findings.http//www.biomedsearch.com/nih/effect-house-officer-rotation -inpatient/8164867.html

BM Daly,EM McGrady Anaesthesia, Princess Royal Maternity Hospital, Glasgow, UK

Introduction: Going on an on-call obstetric rota for the firsttime can be a daunting experience. A previous RCoA 2009survey regarding this, identified areas of particular concernsfor trainees. In order to facilitate a smoother transition toworking on a busy delivery suite, we decided to implement ahybrid theoretical teaching/simulation course aimed at CT2trainees about to commence their basic obstetric block. Thepr imary a im of the course was not only to increaseparticipants' knowledge, but also to increase confidence indealing with the practical aspects of regional anaesthesia andanalgesia on labour ward. This involved specific teaching ontrouble-shooting common clinical problems.

Methods: All CT2(ST2) trainees, prior to commencement oftheir basic obstetric block in the West of Scotland were invitedto attend a one day course. A programme was devised basedon the Royal College of Anaesthetists' curriculum. Facultyincluded Consultant obstetric anaesthetists and seniorregistrars with simulation experience. Multiple teachingtechniques were employed. Formal lectures covering a rangeof topics provided theoretical knowledge. A practicalworkshop involved the previously validated dural punctureSimulator MK2(M43B) for spinal/epidural analgesia andanaesthesia. Clinical scenarios were demonstrated with highfidelity simulator sessions using SimMan 3G. These scenariosincorporated anaesthetics non-technical skills teaching.

Table 1. Usefulness of session: 0=not useful, 4=Very useful

Results: The overall feedback after the course was verypositive. Five months later, 5 of the 7 trainees who had sincecompleted their obstetric block were asked to completeanother survey. This survey asked how confident they feltwith certain procedures/scenarios after the course, and sincethey had now completed their block, how useful the sessionshad actual ly been in pract ice. The part icipants werereasonably confident with key scenarios/procedures they hadbeen taught. We asked trainees to score usefulness with aLikert scale ranging from 0-4(See table).

Discussion: These results demonstrate that candidates hadfound the course quite useful in actual practice. As a result ofthe success of this pilot course, we aim to offer this course tomore participants beyond the region. We also hope that wecan develop it further to facilitate assessment of basicobstetric competencies prior to being on-call for obstetrics.

References

P126 Organising a novice obstetric anaesthetists'course: conception to completion and beyond

1

2

3

Session Median(Range)

Practical aspects of regional anaesthesia/general

anaesthesia for LSCS 4(4)

Trouble shooting on labour ward 3(3-4)

Medico-legal aspects 3(3-4)

Neuraxial blockade on dural puncture Simulator MK2 3(3-4)

Clinical scenarios with SimMan3G 4(4)

1. Jigajinni S. Trainee preparation and worries prior to commencing obstetric on-call. RCOA Bulletin 2010;63:18-20

2. Royal College of Anaesthetists.CCT in Anaesthesia Basic Level Annex B Aug 2010 B56-B58

3. Uppal V, Kearns RJ, McGrady EM. Evaluation of M43B Lumbar puncture simulator-II as a training tool for identification of the epidural space and lumbar puncture.Anaesthesia. 2011 Jun;66


C E Armstrong,A J Putland Anaesthesia, Royal Bolton Hospital, Bolton, UK

Introduction: Many anaesthetists working within the obstetricenvironment hold the perception that a disproportionatenumber of labour epidurals are requested out of hours,causing significantly increased workload at times of minimumstaffing and potentially unacceptable delays in epiduralresponse times (now subject to national standards ). Ourdelivery suite located within a busy district general hospitalhas undergone a programme of expansion in response to thereconfiguration of maternity and child health services inGreater Manchester. The annual delivery rate is expected torise from 4000 to over 6000 by 2013. This audit was conductedto evaluate the pre-expansion distribution of epidural workloadand response times thereby allowing some insight into thepotential impact of the anticipated increase in deliveries.

Methods: Data concerning all labour epidurals over a 12 monthperiod was extracted from a local obstetric anaestheticdatabase. The distribution of epidural requests over the 24hour period was analysed. Epidurals associated with a delayedresponse time of over 30 minutes were identified and thedistribution of request times for this subset also reviewed.

Results: 862 epidurals were documented over a 12 monthperiod (01/09/2010 - 31/08/11). There was an almost evendistribution of requests over the 24 hour period with 50% ofrequests occurring during the 12 hour night shift (20:30-08:29).29% of epidurals were requested within "normal workinghours" (weekdays 08:30 - 17:00). 39 (4.5%) epidurals wererecorded as incurring a delayed response time of over 30minutes (range 35-225 minutes) and of these, 19 were delayedby over 60 minutes. Of the 39 delayed epidurals 19 (49%) weredelayed during the 12 -hour night period. and 13 (33%) ofdelays occurred during "normal working hours" Interestingly,when considering the subgroup of epidurals delayed by over60 minutes, 13 (69%) requests occurred at night.

Discussion: Within our unit, the relatively even distribution ofepidural requests over the 24 hour period did not support thepopular perception of disproportionate epidural requests outof hours. However, only 29% were requested within "normalworking hours" and while this remains in proportion (normalworking hours account for 25% of hours in the week) is doeshighlight the truly 24-hour nature of the epidural service. Only39 (4.5%) of epidurals were recorded in our database as havinga delayed response time of over 30 minutes, althoughunexpectedly, 33% of these delays occurred during normalworking hours when staffing levels are supposedly at theirbest. Of those experiencing the longest delays (over 60minutes) 69% occurred at night, suggesting that there isalready some pressure on the service out of hours. Since theaudit period there have been several changes in preparationfor the re -configuration including, 3 sessions days forconsultant anaesthetists during the week, an extra tier of on-call consultant anaesthetist at night and 5 elective sectionsessions per week. We plan to re -audit 6 months afterreconfiguration.

Reference

P127 Truly a 24 hour service - distribution of labour epidural requests over the 24 hour period and impact on response times

1

1. Association of Anaesthetists of Great Britain and Ireland and Obstetric Anaesthetists' Association.Guidelines for obstetric anaesthesia services. AAGBI, London 2005

D Rangarajan,TA Tanqueray ,H Mulchandani Anaesthetics, Homerton University Hospital, London, UK

Introduction: With the prevalence of obesity rising, obstetricanaesthetists continue to encounter a range of difficultieswhen positioning obese women for regional anaesthesia. Wedescribe a novel position which we have found helpful.

Case Report: A 29 -year-old primiparous woman requiredcaesarean sect ion for t ransverse l ie and prote inur ichypertension at 36 weeks gestation. Weighing 190kg, she hada BMI of 62 and a history of asthma. We decided to use aCombined Spinal Epidural technique. Prior to anaesthesia, welaid the patient supine on the operating table in order toensure that the width extenders on the table were sufficienta n d t o a s s e s s t h e n e e d f o r p a n n i c u l u s r e t r a c t i o n .Manoeuvring the woman between the supine and sittingpositions was difficult and time-consuming. This made usreconsider our approach. We had concerns about the safety ofmoving her after central neuraxial blockade. It also seemedlikely that such a delay in repositioning would result in sacralpooling of the intrathecal hyperbaric bupivacaine solution,limiting the cephalad spread of sensory blockade. Rather thanusing the traditional sitting position (sitting perpendicular tothe length of the table, with feet on a stool), we sat the patientwith legs resting along the length of the table and kneesextended. Hence, as soon as the epidural was sited, she couldlie straight back into the supine, tilted position.

In the absence of bony landmarks, the L4/5 interspace wasvisualised using ultrasound. The epidural space was located ata depth of 8cm on the first pass and a needle-through-needletechnique used to deliver 12.5 mg heavy bupivacaine and300mcg diamorphine intrathecally. An epidural catheter wasthreaded promptly before the patient was lain flat. Despitehaving seen good flow of CSF, the spinal block whichdeveloped was patchy. The caesarean section was thensuccessfully performed under epidural blockade.

Discussion: This modified sitting position does not appear tohave been detailed in the medical literature, but had beenwitnessed in use, by one of the authors, at a busy maternityunit in Uganda, as a way of increasing speed and theatrethroughput. We found that it was well-tolerated by a morbidlyobese patient and led to a helpful flattening of her lumbarlordosis. However we did not demonstrate the successfulspread of spinal blockade we had hoped for.

P128 A modified sitting position for regional anaesthesia in the morbidly obese parturient


CS Hawe,U Carabine Department of Anaesthesia, Royal Jubilee Maternity Hospital, Belfast, UK

Introduction: A recently published guideline states that ananaesthetist at specialty training year (ST) 6 and above,or...equivalent...should be informed and available for the careofwomenwithBMI40duringlabouranddelivery . If suchcover was intended to be immediately available (interpreted as'in house': as stated for the obstetric consultant) this couldrequire significant changes to current out of hours rotaprovision within our regional maternity centre.

Methods: Over a 12 month period from 1st January - 31stDecember 2011, a retrospective review was conducted on theseniority of available anaesthetic personnel and the timing ofany required intrapartum intervention on two sub -sets ofpatients:1)thosewithBMI40atbooking2)thosewithbooking BMI 35-39.99(expectedtohaveBMI40attimeofdelivery ). This data was obtained from department rostersand the regional audit system (in which recording ofanaesthetic procedures had occasional inconsistencies).

Results: There were 5524 paturients who delivered during thisperiod. From data on the 4812 (87.1%) who had their BMIrecorded,335(7.0%)hadaknownorexpectedBMI40.Ofthese,overhalfdeliveredoutofhours(BMI40:77/121(63.6%); BMI 35-39.99: 111/214 (51.9%)).

Table: Anaesthetic provision for obese paturients

*08:00-18:00 Monday - Friday: consultant immediatelyavailable18:00-08:00 weekdays / weekends / public holidays:trainee(CT2)immediatelyavailable

Discussion: Within normal weekday hours of 08:00-18:00 theunit was able to meet the proposed standard. However out ofhours only 25% of the rostered resident anaesthetic cover wasprovidedbytraineesST6,despiteoverhalfofdeliveriestopaturientswithknownorexpectedBMI40occurringduringthese hours. This staffing provision would not provideimmediate cover of the seniority required by the guideline forapproximately two thirds of women who had interventions outof hours. To improve compliance a significant reorganisationof the rota to ensure senior trainee onsite presence out ofhours or compulsory attendance of the on -call consultantanaesthetist when these women are labouring would berequired. This would have workforce planning and costimplications. It is likely other units would also struggle to befully complaint without significant change to working patterns:especially for consultants. The intended interpretation of thisguideline requires discussion within the anaesthetic fraternity.

References

P129 Audit of the seniority of anaesthetists available during thelabouranddeliveryofpaturientswithabodymassindex(BMI)40inatertiarymaternitycentre

1

2

No.requiringanaestheticintervention(%withST6immediately available)

Analgesia in

hours*

Analgesia out

ofhoursAnaesthesia in

hours*

Anaesthesia out

ofhoursBMI40 6 (100%) 22 (31.8%) 38 (100%) 14 (35.7%) BMI 35-

39.998 (100%) 8 (24.2%) 73 (100%) 10 (29.4%)

1. Modder J, Fitzsimmons KJ. CMACE/RCOG joint guideline: Management of women with obesity in pregnancy. March 2010.

2. Weight gain during pregnancy: Reexamining the guidelines. Washington, DC: National Academies Press; 2009.

LM Charco,PC Cuesta,B Garcia,VE Ortiz,F Carpintero,MRCalero,U Vicente,D Martinez-Pealver Anaesthesiology and Intensive Care, General University Hospital, Albacete, Spain

Introduction and objectives of the study; Epidural anaesthesiais being increasingly used to provide anaesthesia for laborpain. We often presuppose that obesity will increase neuraxialtechnique difficulty. With the current prevalence of obesity inparturients in spain materni ty units , we performed aprospective, observational study to establish the effect of thebody habitus as a predictive factor for difficult epidural block.Method; This is a prospective and observational study in termpregnant women. We collected the following patient data: age,body mass index (BMI; weight/height squared, kg/m2) andspinal anatomy (normal or deformed, subjectively frominspection and palpation) . Patients were clasiffied en normalbodyhabitusifBMI29.9orobeseifBMI30.Thetechniquewas done by anaesthesiology residents with prior experienceof at least 120 epidural blocks. Difficult epidural block wasconsedered if placement of the catheter requires more than apuncture in the skin or one puncture on the skin, but morethan a change of direction of the needle in the interspinousspace. The technique is considered adequate if after 20minutes of the initial dose the patient reported visual analogicscaleofpain3thanbefore.We also recorded numbers ofcomplications. R e s u l t s ; W e collected da ta f rom 120parturients, ASA I -II. Ages ranged from 15 to 41 years old,BMI was medium 32 3.44 . Were obese 60% of patients (72cases). Most epidural catheters were successfully placed atthe first attemp being difficult to puncture under the criteria ofthestudyin36.67%,inthiscasesonly40%hadBMI30.Wefound an incidence of 50% difficult puncture in patients withBMI30 . The incidence of epidural re-punction was 6 cases(5%), 4 of these were obese patients. Spinal anatomy hadeffect on the number of attempts, in deformed spinal anatomythe incidence of difficult punction was 33.3%.

Table 1: Effect of body habitus on the difficulty of puncture.

Conclusions; Our data collection procedures in 120 obstetricpatients in labor concluded that body habitus had nosignificant effect as a predictive factor for difficult epiduralblock in the obstetric patient. Some obese patients havesurprisingly easy neuraxial block placements. The most reliablemethod to determine in advance the possibility of a technicaldifficulty for epidural block in the obstetric patient is anexamination of the patient's back to identify the quality ofanatomical landmarks and obvious deformity of the spine.

Reference

P130 Body habitus as a predictive factor of difficult epidural block in parturients?

BODY HABITUS Non difficult Difficult total

Normal (IMC < 30) 46/95.83% 2/4.16% 48

Obese (IMC 30)

36 /50% 36/50% 72

1. 1. Sprung J, Bourke DL, Grass J, Hammel J, Mascha E, Thomas P et al. Predicting the difficult neuraxial block: a prospective study. Anesth Analg 1999;89(2):384-389.


E Ingram,D MacKin,V Cording,P Yoxall,* Department of Obstetrics, Whiston Hospital, Prescot, UK, *Department of Anaesthetics, Whiston Hospital, Prescot, UK Introduction: Maternal obesity is a common risk factor inobstetric practice with a prevalence of 16-19%. Obesity, a BMIof 30 or more, is associated with adverse obstetric outcomes.A prospective pilot audit was undertaken to investigatewhether booking BMI was a good stratification tool foridentifying risks associated with raised BMI in pregnancy.

Method: Women attending our fetal medicine assessment unitbeyond 37 weeks gestation, between November 2010 andJanuary 2011, were weighed and data obtained was inputtedonto a proforma. This included booking BMI, BMI at term,past obstetr ic his tory, pregnancy outcome, obstetr iccomplications and infant weight at delivery.

Results: Data on 45 patients was obtained. At booking, 28 hada normal BMI, 10 had a BMI between 30-35, and 7 had a BMIgreater than 35. Mean weight gain was 12.28kg ( -0.6kg 28.5kg). Fourteen patients with a normal booking BMI had aBMI greater than 30 by term and 2 had a BMI greater than 35at term. Four patients in the BMI 35-40 group achieved a BMIgreater than 40 by term. Women who crossed into the higherBMI group by term were found to have increased risk of -induction of labour; pre -eclampsia; polyhydramnios; andCaesarean section. Increased incidence of gestational diabeteswas identified despite not qualifying for GTT at 28/40, basedon BMI. Only 25% (4/16) women who crossed from the normalBMI group into the BMI greater than 30 category by termreceived appropriate thromboprophylaxis postnatally.

Conclusion: NICE guidelines on the management of obesity inpregnancy have been established. Our data suggest thatexcessive weight gain in pregnancy can result in a subset ofwomen crossing into a high risk BMI category. Do thesewomen need to be identified in order to reduce their risk ofcomplications during pregnancy and postnatally?

P131 Is booking BMI an adequate risk stratification for identifying the risks associated with raised BMI in pregnancy? N Airey,E Docker

Department of Anaesthesia, Arrowe Park, Wirral, UK

Introduction: Epidural analgesia is a common and popularmethod of pain relief in labour . However, the incidence ofobesity is rising and may make this choice of analgesia moredifficult to achieve . We decided to carry out a retrospectiveanalysis of all the epidurals performed in our hospital over a 2month period, looking at the relationship between the patientsBMI and the depth of the epidural space. We also investigatedif there was a relationship between the patients BMI and thesuccess of the epidural. Other outcomes investigated includedthe rate of instrumental or caesarean delivery, the incidence ofcomplications and patient satisfaction with the epidural.

Methods: Patients who received an epidural between 1stNovember and 31st December 2011 were included. Data wascollected from the hospital computer system and then crosschecked against the birth and theatre registers on labour ward.The patients BMI were calculated from the measurements atthe booking clinic. The results were analysed using SPSSsoftware.

Results: A total of 148 patients received epidurals (total of 573deliveries, 25.8%). The mean BMI was 26.74 (95% CI 25.95-27.53). The mean depth to the epidural space (DOS) was5.22cm (95% CI 5.07-5.37). A strong correlation was foundb e t w e e n t h e p a t i e n t s B M I a n d t h e D O S , r = 0 . 7 3 1

In total 44 of the epidurals failed to work effectively (29.1%).

65 patients required an instrumental or caesarean delivery ofwhom 36(55.4%) successfully received an epidural top-up.Complications included 8(5.4%) patients requiring a re-site and2(1.4%) dural punctures. On a follow up questionnaire 114(77%) reported feeling satisfied with the epidural.

Conclusion: There appears to be a strong posit ive andstatistically significant correlation between the patients BMI atbooking and the depth to their epidural space. There alsoappears to be a positive association between the patients BMIand the rate of epidural failure.

References

P132 Relationship between patients BMI, depth to epidural space and its effect on epidural success

1

2

BMI No. of failures Total no. of epidurals Failure rate

35 3 8 37.5%

1. Cambic CR, Wong CA. Labour analgesia and obstetric outcomes. Br J Anaesth 2010;105 Suppl 1:i50-60.

2. Kanagalingam MG, Forouhi NG, Greer IA, Sattar N. Changes in booking body mass index over a decade: retrospective analysis from a Glasgow Maternity Hospital. BJOG 2005;112:14313.


MJP Drake,MA Minehan Department of Anaesthesia, National Women's Health, Auckland City Hospital, Auckland, New Zealand

Introduction: A parturient presenting for caesarean deliverywith spinal muscular atrophy (SMA) can present manychallenges for the obstetric anaesthetist. SMA is associatedw i t h r e s p i r a t o r y i m p a i r m e n t , b u l b a r d y s f u n c t i o n ,musculoskeletal deformities including scoliosis, and anabnormal response to drugs acting at the neuromuscularjunction. We present a patient requiring caesarean sectionwho, in addition to SMA with severe scoliosis, had verylimited mouth opening, and was successfully managed byawake fibreoptic oral intubation (AFOI) facilitated byremifentanil sedation.

Case Report: Antenatal anaesthetic review revealed aprevious very difficult AFOI with mouth opening mechanicallylimited to under 2cm. A marked scoliosis was present despiteHarrington rod fixation. Her already limited respiratoryfunction deteriorated further during pregnancy so deliverywas planned for 32 weeks' gestation. Surgical access wasexpected to be difficult due to flexion deformities of the hips.With concerns of prolonged surgery, expected difficulties withneuraxial anaesthesia and anticipated difficult directlaryngoscopy, we opted for general anaesthesia followingAFOI.

The airway was initially topicalised with nebulised 4%lidocaine solution and 10% lidocaine spray. Sedation wasprovided with midazolam 0.5mg and a titrated infusion ofremifentanil between 0.05 and 0.1mcg/kg/min. A size 9 Bermanairway was passed between her incisors. A fibreoptic 'scopewas passed through the Berman airway. The larynx and vocalcords were visualised and topicalised with 4% lidocaineinjected through an epidural catheter in the suction channel ofthe 'scope. An endotracheal tube was passed easily into thetrachea with minimal cough. Anaesthesia was induced withoutneuromuscular blocking agents and maintained withdesflurane in air/oxygen and remifentanil. The surgery wasuneventful. With spontaneous tidal volumes of over 300mls atthe end of the case, we elected to extubate the patient awake inthe sitting position. An initially weak cough improvedthroughout the day and she was discharged home ten dayslater. The patient had recall up to the point of induction ofanaesthesia but did not find the experience unpleasant.

Discussion: Remifentanil's use is established for labouranalgesia however we are not aware of any published reportsof its use for AFOI in obstetrics. Its anti-tussive effects, shorthalf life, availability of pharmacological antagonists, andestablished fetal safety make remifentanil an ideal adjunct forAFOI in obstetrics, particularly in patients where it ispreferable to avoid neuromuscular blocking agents.

References

P133 Remifentanil sedation to facilitate awake fibreoptic intubation for caesarean delivery in a parturient with spinal muscular atrophy

1

2

1. Buettner AU. Anaesthesia for caesarean section in a patient with spinal muscular atrophy. Anaesth Intensive Care 2003;31:92-94.

2. Hinova A, Fernando R. Systemi

Documents

Unpublished Posters: Obstetric Anaesthesia 2012 (Liverpool) P1 P2