Is preparation for emergency obstetric anaesthesia adequate? A maternal questionnaire survey

BACKGROUND

Women are often unprepared for emergency obstetric procedures and need to receive information about anaesthesia quickly and succinctly. In the absence of previous studies, we sought feedback from women to find out how information was given, and particular areas of concern in order to define practice and improve women's experiences.

METHODS

After Ethics Committee approval this prospective structured questionnaire study was conducted in a teaching and a district general hospital. Women were recruited up to 48 h after anaesthesia.

RESULTS

Of 102 women studied, 55 had no prior knowledge of obstetric anaesthetic interventions and risks until told, usually by the obstetrician (n=47), just before the procedure. The most frightening aspect was anticipating the efficacy of regional anaesthesia (n=18), but 28 women were reassured by the explanation provided by the anaesthetist. All but two women expressed satisfaction with the content of information and the described attendant risks. Nevertheless, in contrast to our observed practice, 51 (50%) would have preferred having verbal information before labour preferably from an anaesthetist or midwife.

CONCLUSIONS

Most women were unprepared for emergency obstetric anaesthesia. Many received information just before the event. After delivery they expressed a clear preference for earlier information.

Extending low-dose epidural analgesia in labour for emergency Caesarean section ? a comparison of levobupivacaine with or without fentanyl

Women in labour receiving epidural analgesia with 15 ml bupivacaine 0.1% and 2 microg.ml(-1) fentanyl followed by 10-15-ml top-ups as required, who needed Caesarean section, were randomly allocated to receive 20 ml levobupivacaine 0.5% over 3 min with either 75 microg fentanyl (1.5 ml) or 1.5 ml saline. Further top-ups or inhaled or intravenous supplementation were given for breakthrough pain. Time to onset (loss of cold sensation to T4 and touch sensation to T5 bilaterally), quality of analgesia and side-effects were recorded. The study was stopped after 112 patients had been randomly assigned, due to a unit protocol change, from midwife-administered top-ups to patient-controlled epidural analgesia. Data from 51 patients given fentanyl and 54 given saline were available for analysis. There were no significant differences in onset times or supplementation between the groups, but there was more intra-operative nausea/vomiting with fentanyl (53%) than with saline (18%; p = 0.004). We found no advantage of adding fentanyl to epidural levobupivacaine when extending epidural analgesia in women already receiving epidural fentanyl during labour and there was an increased incidence of intra-operative nausea and vomiting. Power analysis suggested the same conclusion even had the study proceeded to completion.

The effect of alcohol swabs and filter straws on reducing contamination of glass ampoules used for neuroaxial injections

We have investigated the incidence of contamination of the contents of glass ampoules used for neuraxial injections, and whether this was reduced by wiping the outsides of the ampoules with isopropyl alcohol or using a filter straw. One hundred fentanyl and diamorphine ampoules used for routine regional anaesthesia were either wiped or not wiped with alcohol before their contents were aspirated, and the residual contents were swabbed and incubated. None of the swabs from the wiped ampoules grew organisms compared with nine (18%) from non-wiped ampoules (p = 0.004). In a second, laboratory study, 100 glass ampoules of saline were coated with Staphylococcus aureus and divided into four groups: wiped/not wiped with alcohol and with/without a filter straw. The contents of the ampoules were aspirated; the remnants and the aspirate were swabbed and incubated as before. Most contamination occurred in the unwiped groups and although numbers were small, filtering appeared to reduce contamination further. As filter straws also reduce the risk of injecting glass particles (even if not contaminated), our results suggest that wiping glass ampoules with isopropyl alcohol and using a filter straw should be part of routine practice when performing regional anaesthesia.

Analgesia with sevoflurane during labour: I. Determination of the optimum concentration † ‡

BACKGROUND

Sevoflurane has favourable physical qualities for inhaled analgesia during labour pain. The aim of this preliminary study was to identify its optimum concentration.

METHODS

In this open-labelled escalating-dose study, 22 parturients in labour self-administered sevoflurane at 10 contractions using an Oxford Miniature Vaporiser. The inspired concentration was increased by 0.2% after each contraction from 0% to 1.4% or decreased if sedation occurred. Visual analogue scores (0-100 mm) for pain intensity, pain relief, sedation, mood and coping were measured after each contraction.

RESULTS

The median (IQR [range]) pain relief and sedation scores increased from 44 (43-56 [4-93]) mm and 55 (43-56 [0-98]) mm at 0.2% sevoflurane, to 74 (72-78 [50-80]) mm and 71 (71-73 [33-97]) mm at 1.2% sevoflurane, respectively. Pain relief scores did not show any significant increase above 0.8% whilst sedation continued to increase, with excessive sedation occurring at 1.2% sevoflurane. No significant changes in other scores were measured.

CONCLUSIONS

We concluded that the optimal sevoflurane concentration in labour was 0.8%. This concentration allows a safety margin and balances the risk of sedation with the benefit of pain relief in labour.

Analgesia with sevoflurane during labour: II. Sevoflurane compared with Entonox for labour analgesia † ‡

BACKGROUND

We determined the optimal inspired sevoflurane concentration for use during labour as 0.8% in our previous study. This study compared sevoflurane at a concentration of 0.8% and Entonox((R)) (nitrous oxide 50%: oxygen 50%) for analgesia during labour in 32 healthy parturients.

METHODS

Each mother underwent two open-label, three-part sequences in random order, Entonox-sevoflurane-Entonox or sevoflurane-Entonox-sevoflurane. In each part the agent was self-administered during 10 contractions. A 100 mm visual analogue scores for pain relief and sedation was completed immediately after each contraction.

RESULTS

Two patients withdrew during administration of sevoflurane (because of its odour) and five during Entonox (requesting epidural analgesia). Of the remaining women, data were available for analysis from 29 participants: median (IQR [range]) pain relief scores were significantly higher for sevoflurane 67 (55-74 [33-100]) mm than for Entonox 51 (40-69.5 [13-100]) mm (P<0.037). Nausea and vomiting were more common in the Entonox group [relative risk 2.7 (95% CI 1.3-5.7); P=0.004]. No other adverse effects were observed in the mothers or babies. There was significantly more sedation with sevoflurane than with Entonox {74 (66.5-81 [32.5-100]) and 51 (41-69.5 [13-100]) mm, respectively; P<0.001}. Twenty-nine patients preferred sevoflurane to Entonox and found its sedative effects helpful.

CONCLUSIONS

We conclude that self-administered sevoflurane at subanaesthetic concentration (0.8%) can provide useful pain relief during the first stage of labour, and to a greater extent than Entonox. Although greater sedative effects were experienced with sevoflurane, it was preferred to Entonox.

A comparison of an anterior jaw lift manoeuvre with the Berman airway for assisting fibreoptic orotracheal intubation

This study compared the efficacy of an anterior jaw lift manoeuvre with that of the Berman airway in clearing the upper airway during oral fibreoptic tracheal intubation in anaesthetised, paralysed patients. Fifty patients were randomly assigned to undergo fibreoptic-assisted intubation with one method, followed by crossover to the alternative method. The time taken to view the vocal cords was the primary endpoint, and we also noted the rate of failure to view the cords, i.e. cords not seen after 120 s of endoscopy. Anterior jaw lift yielded significantly shorter times to view the vocal cords (median [interquartile range; range]: 22 [17-46; 7-120] s vs 40 [29-67; 21-120] s, p = 0.001) and a higher success rate (49/50 vs 42/50, p = 0.014). We conclude that the anterior jaw lift is more effective than the Berman device for achieving airway clearance in this setting.

Anaesthetic management of labour and caesarean delivery of a patient with hyperkalaemic periodic paralysis

We describe a parturient with hyperkalaemic periodic paralysis who presented for induction of labour and subsequently, caesarean section. Epidural analgesia and anaesthesia were used successfully in a multidisciplinary plan aimed at avoiding a peripartum attack and providing safe delivery. Management of this rare condition is discussed along with a review of the available literature.

Reports on Confidential Enquiries into Maternal Deaths: management strategies based on trends in maternal cardiac deaths over 30 years

In the latest Report of the Confidential Enquiries into Maternal and Child Health (CEMACH; formerly Confidential Enquiries into Maternal Deaths (CEMD)), cardiac disease was the second commonest cause of maternal mortality. Currently there is much emphasis on appropriate referral and multidisciplinary planning for women with known cardiac disease. However, examining all maternal cardiac deaths in the CEMACH/CEMD reports over the last 30 years, to see whether the condition was known before pregnancy or developed during pregnancy, suggests that while reported maternal mortality due to cardiac disease overall has approximately doubled, the number due to known disease has changed little. Thus significant and increasing numbers of deaths occur in women without known disease, either in those with risk factors or in those who develop conditions in the absence of risk factors. Therefore, while there is a continuing need to counsel, refer and appropriately manage women with known pre-existing cardiac disease, attention must also be paid to screening women before pregnancy for evidence of cardiac disease or risk factors, and also to cardiac disease that develops de novo during pregnancy, since early screening and referral strategies alone will not prevent units from encountering such cases. All units therefore require processes for monitoring and managing women for the development of cardiac disease throughout their pregnancies.

Decision analysis in anaesthesia: a tool for developing and analysing clinical management plans

Traditional medical decision making is unstructured and incorporates evidence haphazardly. I present a more structured approach based on decision analysis, a model that considers all relevant options and outcomes informed by evidence where appropriate. This method is useful both for planning clinical management and for analysing decisions already taken.

A national survey of obstetric anaesthetic handovers

The handover of patient information between shifts enables continuity of care and increases patient safety. We surveyed UK practice during handovers in obstetric anaesthesia. A questionnaire was sent to 239 lead consultant obstetric anaesthetists to record routine practice in their unit and individual opinion about handover procedures. Responses were received from 168 anaesthetists, a 70% response rate. Handover policies were available in 10% of units. Most (76%) responding units had an allocated time for handover. In most units (76%), the duration of handover was reported as being < 15 min but the actual duration and depth of any discussion involved were not specified. Handovers were rarely documented in writing (7%). Consultant anaesthetists were most likely to be present at the morning handover and few handovers were multidisciplinary. Four percent of units reported critical incidents following inadequate handovers in the past 12 months. We identify features in handover procedures that could be improved.

Practical management of the parturient with congenital heart disease

Cardiac disease is becoming more common in women presenting for maternity care and is a major cause of maternal mortality in the UK. We present a review of the management of parturients with congenital heart disease, focusing on practical aspects and the problems that may be expected.

A comparison of the lateral, Oxford and sitting positions for performing combined spinal-epidural anaesthesia for elective Caesarean section

One hundred women were randomly allocated to the left lateral, Oxford or sitting position for induction of combined spinal-epidural anaesthesia for Caesarean section using 2.5 ml hyperbaric bupivacaine 0.5% and 10 mug fentanyl. Women in the left lateral were then turned to the right lateral position; women in the Oxford position were turned to the same position on their opposite side; and women in the sitting group were turned to the supine left tilt position. Women remained in these positions until ready for surgery, which was conducted in the supine position with a wedge placed under the right hip. Ephedrine requirements before re-positioning for surgery were less in the sitting position than in the other two positions: median (IQR [range]) doses for the lateral, Oxford and sitting groups were 21 (12-30 [6-48]), 18 (7.5-24 [6-48]) and 12 (6-21 [6-42]) mg, respectively; p = 0.04. Sensory block to touch sensation at the T5 dermatomal level was most quickly achieved in the lateral position with median (IQR [range]) block onset times for the lateral, Oxford and sitting groups of 9 (6-13 [4-30]), 15.5 (9-22 [4-34]) and 14 (9-18[6-36]) min, respectively; p = 0.004. In the Oxford position, more epidural catheters required dosing to achieve a sensory block of T5 before surgery: the number of patients (proportion) bolused in the lateral, Oxford and sitting groups was 1 (3%), 7 (22%) and 1 (3%), respectively; p = 0.01. We did not demonstrate any advantage in using the Oxford position for combined spinal-epidural anaesthesia for elective Caesarean section.