D.N. Lucas

Sepsis in obstetrics and the role of the anaesthetist

Sepsis in pregnancy and the puerperium remains a significant cause of maternal mortality and morbidity worldwide. Major morbidity arising as a result of obstetric sepsis includes fetal demise, organ failure, chronic pelvic inflammatory disease, chronic pelvic pain, bilateral tubal occlusion and infertility. Early recognition and timely response are key to ensuring good outcome. This review examines the clinical problem of sepsis in obstetrics and the role of the anaesthetist in the management of this condition.

MBRRACE-UK: Saving Lives, Improving Mothers' Care – implications for anaesthetists

In December 2014, the latest UK Confidential Enquiry into Maternal Deaths report was published, covering the surveillance period from 2009 to 2012. This is the first report since a significant change in the organisational structure of the body responsible for surveillance and dissemination of reports. The Confidential Enquiry Reports are regarded as a gold standard worldwide and have contributed to quality improvement of maternity care both in the UK and elsewhere. This article aims to give obstetric anaesthetists an overview of the current report and highlight the pertinent implications for anaesthetic practice.

Enhanced recovery in obstetrics--a new frontier?

Enhanced recovery or ‘fast track surgery’ was first described by Wilmore and Kehlet more than 10 years ago. Although initially associated with minimally-invasive laparoscopic surgery, other types of open surgery have been integrated into enhanced recovery pathways. Following its introduction in colorectal surgery, it is now advocated for many other specialities including urological, orthopaedic, gynaecological and breast surgery. Enhanced recovery has transformed the delivery of perioperative practice and more recently it has been suggested that the key principles could be applied to acute medicine. The core ethos of enhanced recovery is to speed up a patient’s recovery after surgery and improve patient outcomes, with associated benefits for staff and healthcare systems. Enhanced recovery pathways are underpinned by four principles:

Lithium toxicity and the parturient: case report and literature review

A 39-year-old gravida 8, para 6 woman at 34 weeks of a twin gestation was admitted to the antenatal ward with severe agitation and restlessness. She had a history of unstable bipolar disorder for which she was treated with lithium. Before admission she had been under close supervision by psychiatric and obstetric teams and lithium levels had been stable. However, an acute deterioration in renal function secondary to ureteric obstruction resulted in toxic plasma lithium levels and associated clinical features. An emergency caesarean section was carried out under general anaesthesia. We provide a review of the current literature including: the pharmacology of lithium, the effects of lithium on fetus and mother, and the current guidelines for management of lithium treatment during pregnancy. Lithium is prescribed relatively rarely during pregnancy. We aim to increase awareness about the issues involved in the management of women receiving lithium during pregnancy.

Surgical safety checklists in obstetrics.

Surgical deaths and complications are a major problem worldwide. The World Health Organisation (WHO) has recently launched the Safe Surgery Saves Lives campaign. The aim of the campaign is to improve surgical safety for the patient by improving anaesthetic and surgical practice and communication. This campaign includes the use of surgical safety checklists, which provide a core set of checks to improve safety in any theatre environment (the ‘sign in/time out/sign out’ form). The National Patient Safety Agency (NPSA) has issued an alert mandating that an adapted version of the WHO checklist be completed for every patient undergoing a surgical procedure in England and Wales. This will be compulsory by February 2010. The form was designed for surgery of all types, but we were concerned that it was not appropriate for obstetrics and would not be used effectively. We have therefore modified the peri-operative safety checklist used in

The 30 minute decision to delivery time is unrealistic in morbidly obese women.

The worldwide incidence of obesity has increased dramatically over the last few years. Obesity is associated with increased morbidity and mortality, particularly related to cardiovascular disease and diabetes and this is reflected in the obese obstetric patient where maternal and neonatal morbidity are greater than in the non-obese parturient. Maternal obesity is recognised as one of the most commonly occurring risk factors seen in obstetrics; in the last CEMACH report more than half the women who died were obese. The World Health Organisation has stratified obesity into three levels (Table 1). Aside from the increased medical risks associated with obesity, the obese parturient is more likely to require medical intervention during labour and delivery. Observational studies have consistently demonstrated that obese women have a higher incidence of intrapartum complications. Compared to a non-obese parturient, an obese woman is more likely to have her labour induced and require instrumental delivery. Several studies have demonstrated a significant relationship between increasing maternal body mass index (BMI) and caesarean section (CS), with meta-analysis suggesting an odds ratio of 2.05 for obese women compared to those with a normal BMI. National recommendations are that urgency of caesarean section should be classified using a four point system. This classification of urgency does not suggest times for the decision to delivery interval (DDI). However it is a widely quoted audit standard that in a nonelective caesarean section (category 1 and 2) the baby should be delivered within 30 min of the decision to deliver. When considering whether this is a reasonable expectation in a morbidly obese parturient it is necessary to examine three key areas:

An audit of the efficacy of a structured handover tool in obstetric anaesthesia.

INTRODUCTION The SAFE handover tool was developed to reduce critical omissions during handovers in obstetric anaesthesia. It comprises a simple proforma onto which the outgoing team documents patients who fall into one of four anaesthetically relevant categories: Sick patients; At-risk patients (of emergency caesarean section, major haemorrhage or anaesthetic problems); Follow-ups; and Epidurals. We hypothesised that its use would reduce the number of critical omissions at handover. METHODS The efficacy of the SAFE handover tool was assessed through several audit cycles in a single maternity unit. The four SAFE categories were considered the gold standard, since they encompassed the consensus opinion of senior obstetric anaesthetists with respect to parturients they most wanted to know about at handover. Against these criteria it was possible to compare the number of cases that should have been handed-over against the number that were actually handed-over. RESULTS After implementation of the handover tool, patients were four times more likely to be handed-over than without the use of the tool: an increase from 49% to 79% of relevant cases (P<0.0001, OR 4.1, 95% CI 2.19-7.6). The handover tool was particularly effective at increasing the handover rates of Sick and At-risk parturients, which increased from 21% to 67% (P<0.0001, OR 7.7, 95% CI 2.7-21.7) and 25% to 78% (P<0.01, OR 9.9, 95% CI 1.6-61.6), respectively. CONCLUSION The SAFE handover tool significantly increased handover rates of anaesthetically relevant parturients. It is easy to remember and consistent with UK National Health Service Litigation Authoritys guidance on risk management in maternity units.

A novel airway checklist for obstetric general anaesthesia

was not indicated in this case; this was confirmed after discussion with our neurosurgical colleagues. Although pulsatile bleeding is usually associated with arterial puncture, in the clinical situation of pregnancy and labour in particular, raised intra-abdominal pressure can cause increased venous pressure within the valveless venous plexus of Bateson potentially producing significant haemorrhage. Anaesthetists should be reminded of the potential for damage to these vascular structures, especially in the obstetric patient. Thankfully, it would seem that cases such as ours are rare.

The role of carbetocin in the prevention and management of postpartum haemorrhage

Carbetocin is a new synthetic analogue of oxytocin. It has a longer half life than oxytocin. This review examines the current evidence for the use of carbetocin as an alternative to oxytocin, as a first-line agent in the pharmacological management of the third stage of labour.