M.Y.K. Wee

A national survey of obstetric early warning systems in the United Kingdom: five years on

The Confidential Enquiries into Maternal Deaths in the UK have recommended obstetric early warning systems for early identification of clinical deterioration to reduce maternal morbidity and mortality. This survey explored early warning systems currently used by maternity units in the UK. An electronic questionnaire was sent to all 205 lead obstetric anaesthetists under the auspices of the Obstetric Anaesthetists’ Association, generating 130 (63%) responses. All respondents reported use of an obstetric early warning system, compared with 19% in a similar survey in 2007. Respondents agreed that the six most important physiological parameters to record were respiratory rate, heart rate, temperature, systolic and diastolic blood pressure and oxygen saturation. One hundred and eighteen (91%) lead anaesthetists agreed that early warning systems helped to prevent obstetric morbidity. Staffing pressures were perceived as the greatest barrier to their use, and improved audit, education and training for healthcare professionals were identified as priority areas.

Informed consent for epidural analgesia in labour: a survey of UK practice.

Anaesthetists are legally obliged to obtain informed consent before performing regional analgesia in labour. A postal survey of consultant‐led UK anaesthetic units was performed in September 2007 to assess practice regarding obtaining informed consent before inserting an epidural, and documentation of the risks discussed. The response rate was 72% (161/223). There was great variation between units regarding which risks women were informed about and the likely incidence of that risk. One hundred and twenty‐three respondents out of 157 providing an epidural service (78%) supported a national standardised information card endorsed by the Obstetric Anaesthetists’ Association, with all the benefits and risks stated, to be shown to all women before consenting to an epidural in labour.

Written information about epidural analgesia for women in labour: Did it improve knowledge?

There is evidence that despite a distressed appearance, women in labour should be informed about the side effects and risks associated with epidural analgesia. An audit of 100 women who had used epidural analgesia for labour in our hospital and who had received a verbal explanation of the benefits, risks and side effects of epidural analgesia showed that the level of knowledge was low. An A5 laminated epidural information card was prepared summarising this information. The midwife and the anaesthetist used the card during labour as a focus for verbal discussion and as written reinforcement for the woman and her partner. A repeat audit of a further 100 women showed a statistically significant improvement in the level of knowledge about epidural analgesia. This audit suggests that the use of a written information card is beneficial. It improves and reinforces the process of giving information thus assisting the consent process.

A comparison of intramuscular diamorphine and intramuscular pethidine for labour analgesia: a two-centre randomised blinded controlled trial

Intramuscular (i.m.) pethidine is used worldwide for labour analgesia and i.m. diamorphine usage has increased in the UK in the last 15 years. This trial aims to ascertain the relative efficacy and adverse effects of diamorphine and pethidine for labour pain.

Thromboembolic deterrent stockings fail to prevent hypotension associated with spinal anaesthesia for elective caesarean section

This study was carried out to determine whether the use of thrombo-embolic deterrent (TED) stockings, in combination with an intravenous crystalloid preload, would prevent hypotension following spinal anaesthesia for caesarean section. Fifty parturients undergoing elective caesarean section under spinal anaesthesia were randomly allocated into two groups. TED stockings were applied to the study group 1 h before spinal anaesthesia but none were applied to the control group. Both groups received a crystalloid preload of 15 ml kg(-1) over 15 min before spinal injection. Significant hypotension, defined as an absolute value of systolic arterial pressure (SAP) of less than 90 mmHg and a decrease of more than 20% from baseline SAP was treated with 3 mg bolus of ephedrine as required. The difference in SAO between the two groups was not statistically significant. In the control group, 80% of parturients required ephedrine as opposed to 56% in the TED group; a difference that was also not statistically significant.

Obstetric anaesthetists' workload.

Summary The current recommendation of one consultant session per 500 deliveries with full sessional cover␣for units over 3000 deliveries is arbitrary and is not based on workload. The Audit Commission has questioned the wide variability of anaesthetic staffing on labour wards. The aim of this study was to investigate whether there is a relationship between current workload and obstetric anaesthetic staffing in five maternity units. In 1998, a 2‐week diary of workload in the participating obstetric units was assessed in terms of staffing and clinical and nonclinical activities. The busiest time was 08:00 to 12:30. The working patterns between consultants and trainees varied considerably. Time spent on nonclinical activity by consultants averaged 51%. Any calculation of consultant sessions will need to take into account nonclinical activities. Other factors requiring consideration are the number of high‐risk cases, as well as the number and experience of trainees.

Obstetric anaesthesia training in the Wessex region before and after introduction of Calman training

We canvassed the opinions of anaesthetic trainees by questionnaire in 1995 and 1998, before and after the introduction of Calman training in which the registrar and senior registrar grades were replaced by the specialist registrar grade. We received replies from 106 trainees in 1995 (90%) and 115 (92%) in 1998. The survey results demonstrate that the total experience in obstetric anaesthesia gained by trainees has not decreased. Experience of regional techniques (epidural, spinal and combined spinal-epidural) increased, but the proportion of senior trainees who had performed fewer than 20 general anaesthetics for caesarean section rose from 0/23 in 1995 to 4/33 (12%). In 1998, the majority of senior trainees had experience of general anaesthesia for fetal distress, severe preeclampsia, eclampsia and massive obstetric haemorrhage. Only a minority had experienced failed intubation or a total spinal. In 1995, 5/21 (24%) of senior house officers agreed or strongly agreed that they were on call before they felt confident about dealing with common problems. The proportion was still 4/23 (17%) in 1998.

Visual disturbances and seizures associated with pregnancy: a diagnostic dilemma and the role of radiological techniques as an aid to diagnosis

We present two cases of visual disturbances associated with tonic-clonic seizures during pregnancy and the associated radiological findings. We review the use of neuroimaging techniques as an aid to diagnosis and their role in elucidating the pathophysiology of cortical blindness.

Bacterial contamination of saline used for epidural procedures in an obstetric setting: a randomised comparison of two drawing-up techniques

BACKGROUND There is little evidence to inform practice regarding the optimum aseptic technique of drawing up saline for epidural insertion. Our regional practice is to draw up saline from a non-sterile packaged plastic ampoule, therefore introducing the risk of bacterial contamination. Usually, the anaesthetist draws up saline directly from the vial held by an assistant using a needle (needle technique). Alternatively, the saline vial is emptied onto a sterile tray by an assistant and then drawn up by the anaesthetist (tray technique). We hypothesised that the latter will lead to an increase in the number of contaminated saline samples as they are exposed to the environment. METHODS In labour rooms and before epidural catheter insertion, 110 samples of saline 20mL were randomly drawn up using our hospitals recommended epidural aseptic precautions, using either the needle or the tray technique. Equal amounts of saline were inoculated into aerobic and anaerobic blood culture bottles. RESULTS Eleven percent of samples in the needle arm and 24% of samples in the tray arm grew commensal micro-organisms including coagulase-negative Staphylococcus, Micrococcus luteus and Streptococcus viridans. A two-sided Fishers exact test for categorical unpaired data showed no statistical difference between the two arms of the trial (P=0.13). CONCLUSION The difference in the saline contamination rate between the two techniques did not reach statistical significance. As bacterial contamination occurred with both techniques, we recommend using sterile saline pre-packaged in the epidural tray or individually wrapped sterile glass saline ampoules.

Emergency Caesarean section – best practice

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