Anesthetic management for the peripartum care of women with Fontan physiology

BackgroundAs outcomes for surgical palliation have improved, women with single ventricle congenital heart disease are surviving into their reproductive years and may become pregnant. The cardiovascular changes of pregnancy may stress the Fontan circulation and pose significant risk to the mother and fetus.MethodsPregnant women with Fontan physiology were identified from the Ahmanson/UCLA Adult Congenital Heart Disease Center database. A total of 37 pregnancies were identified between 2000 and 2019. Twenty live births from 19 patients were reviewed and compared for cardiac history, obstetric history, anesthetic management and cardiovascular outcomes.ResultsMedian gestational age at delivery was 35 weeks. Ten of 20 births were by cesarean delivery. An epidural technique was used as the primary anesthetic for 19 deliveries and general anesthesia was used for one cesarean delivery. An arterial line was placed in the peripartum period for three deliveries. Central venous access was established in the peripartum period for one patient. The mean blood loss for cesarean deliveries was 626 mL (range 240–1200 mL). The mean net peri-operative intake/output was positive 93.5 mL. Three patients were briefly transferred to the intensive care unit postpartum for higher level monitoring and care.ConclusionEpidural anesthesia is safe and effective for both vaginal and cesarean deliveries. Judicious fluid management is critical in minimizing postpartum cardiovascular complications. Many patients do not require a higher level of care, invasive monitoring or central venous access during the peripartum period.     

Severe maternal morbidity in a general intensive care unit in Nigeria: clinical profiles and outcomes

BackgroundData on outcomes of obstetric admissions to intensive care units can serve as useful markers for assessing the quality of maternal care. We evaluated the intensive care unit utilization rate, diagnoses, case-fatality rate, mortality rate and associated factors among obstetric patients.MethodsA prospective observational study of obstetric patients admitted to the general intensive care unit was performed. Women at 24 or more weeks of gestation, or within six weeks postpartum, who were admitted to the intensive care unit constituted the study population.ResultsA total of 101 obstetric patients were admitted to the intensive care unit. Obstetric patients accounted for approximately 12% of all intensive care unit admissions. Over 90% of admissions were from direct obstetric morbidity such as hypertensive disorders (41.6%), major obstetric haemorrhage (37.6%) and sepsis (11.9%). Forty-three women (42.6%) died, giving an overall mortality rate of 1 in 2.4. Sepsis had the highest case-fatality rate (1 in 1.7) followed by obstetric haemorrhage (1 in 2.1) and hypertensive disorders (1 in 3.6). In univariable logistic regression analysis, abdominal delivery and/or peripartum hysterectomy, had 2.7-fold (95% CI 1.1 to 6.5) increased risk of maternal death as compared to vaginal delivery.ConclusionDirect obstetric morbidities constituted the leading reasons for obstetric admissions to the intensive care unit, with sepsis accounting for the highest case-fatality rate. Abdominal delivery and/or peripartum hysterectomy increased risk of death among obstetric admissions.     

Peripartum outcomes and anaesthetic management of parturients with moderate to complex congenital heart disease or pulmonary hypertension*

We performed a retrospective cohort analysis of pregnancies among women with moderate to complex congenital heart disease or pulmonary hypertension over a 12‐year period, resulting in a cohort of 107 cases in 65 women. Neuraxial analgesia or anaesthesia was provided in 84%, 89% and 95% of spontaneous vaginal, operative vaginal and caesarean deliveries, respectively. The caesarean delivery rate was 43% compared to our institution average of 27% over the same period (p = 0.02), and 38% had operative vaginal deliveries compared to a 10.5% institution rate (p < 0.01). Invasive monitoring was used in 28% of all deliveries. There were one maternal and two neonatal deaths. This study provides detailed anaesthetic and peripartum management of women with congenital heart disease, a patient population in whom evidence‐based practice and data are largely lacking. We observed a predominance of neuraxial anaesthetic techniques, increased caesarean and operative delivery rates, and favourable maternal and neonatal outcomes. Multicentre studies and registries to compare anaesthetic and obstetric management strategies further and delineate risk factors for adverse outcomes are required.     

Intrapartum care for women on full anticoagulation

Women requiring full anticoagulation in pregnancy and labour present their care providers with complex management problems, particularly during the peripartum period. Available guidelines often fail to address the practical issues of balancing the risks of recurrent thrombotic events and haemorrhage during labour. This is especially the case in women at high risk of recurrent thromboembolism, in whom the usually recommended temporary peripartum reduction in the level of anticoagulation may be considered unsafe. In order to achieve a satisfactory outcome without undue intervention, multidisciplinary management involving obstetricians, haematologists and anaesthetists is essential. Intrapartum care plans should be made during pregnancy to address the conduct of labour and delivery, anticoagulation, analgesia in labour and the management of any arising obstetric, anaesthetic or haematological complications. In the following we address the practical issues requiring particular attention, as well as management options, in fully anticoagulated patients using a clinical case for illustration.     

National obstetric anaesthetic practice in the UK 1997/1998

In the United Kingdom, the Royal College of Obstetricians and Gynaecologists requires maternity units recognised for training to complete annual statistical returns. Analysis of these data revealed that anaesthetists were directly involved in more than 251 000 procedures in the peripartum period in 1997/1998. There had been an increase in the number of women delivered by Caesarean section (18. 5% of all deliveries) compared with previous reports. The proportion of Caesarean sections performed under regional anaesthesia had increased for both elective and emergency Caesarean section deliveries (85.5% and 70.2%, respectively). For pain relief in labour, there had been neither an increase nor a decrease in the uptake of regional analgesia (23.6%). There were limited training opportunities for anaesthetists in general anaesthesia for Caesarean section and for obstetricians in vaginal breech delivery. The known admissions to intensive care units equated to over 100 women per month in the United Kingdom requiring intensive care as a result of childbirth.     

Obstetric anaesthetic management in a patient with the Fontan circulation

We describe the pregnancy and obstetric anaesthetic managementof a patient with congenital tricuspid atresia who had undergonethe Fontan procedure in childhood. The unique arrangement ofthe Fontan circulation combined with the haemodynamic alterationsduring pregnancy presents special anaesthetic considerationsfor both analgesia during labour and anaesthesia for Caesareansection. ^* Present address: Department of Anaesthesia, St George's Hospital,London SW17 0QT.     

Regional blockade for delivery in women with scoliosis or previous spinal surgery

We conducted a prospective observational study between 1992 and 2001 identifying obstetric patients with untreated or surgically corrected scoliosis or lumbar-sacral fusion surgery. The regional techniques for labour and delivery that were offered were epidural analgesia, combined spinal epidural anaesthesia (CSE), single shot spinal or continuous spinal anaesthesia (CSA) depending on the degree of scoliosis, previous surgery, cardio-respiratory compromise and planned mode of delivery. Forty women were included in the study, one woman with two separate deliveries, giving 41 cases for analysis. Twenty-four women presented in labour: 11 required no regional technique, seven received effective epidural analgesia and six received CSA. Seventeen women presented for elective caesarean delivery: two received a CSE technique, two received single shot spinal and 13 had CSA. From a total of 19 CSA techniques attempted sixteen catheters were successfully inserted and produced good analgesia or anaesthesia for vaginal or operative delivery in 12 women (63%). There was one case of post dural puncture headache following a CSA for labour and delivery. We discuss the choices available for regional anaesthetic techniques in scoliotic women and the relative merits of each.     

Determinants of women's dissatisfaction with anaesthesia care in labour and delivery

Patient-centred care and factors associated with patient satisfaction with anaesthesia have been widely studied. However, the most important considerations in the setting of obstetric anaesthesia are uncertain. Identification of, and addressing, factors that contribute to patient dissatisfaction may improve quality of care. We sought to identify factors associated with < 100% satisfaction with obstetric anaesthesia care. At total of 4297 women treated by anaesthetists provided satisfaction data 24 h after vaginal and 48 h after caesarean delivery. As 78% of women were 100% satisfied, we studied factors associated with the dichotomous variable, 100% satisfied vs. < 100% satisfied. We evaluated patient characteristics and peripartum factors using multivariable sequential logistic regression. The following factors were strongly associated with maternal dissatisfaction after vaginal delivery: pain intensity during the first stage of labour; pain intensity during the second stage of labour; postpartum pain intensity; delay > 15 min in providing epidural analgesia and postpartum headache (all p < 0.0001). Pruritus (p = 0.005) also contributed to dissatisfaction after vaginal delivery, whereas non-Hispanic ethnicity was negatively associated with dissatisfaction (p = 0.01). After caesarean delivery, the intensity of postpartum pain (p < 0.0001), headache (p = 0.001) and pruritus (p = 0.001) were linked to dissatisfaction. Hispanic ethnicity also had a negative relationship with dissatisfaction after caesarean delivery (p = 0.005). Thus, inadequate or delayed analgesia and treatment-related side-effects are associated with maternal dissatisfaction with obstetric anaesthesia care. Development of protocols to facilitate identification of ineffective analgesia and provide an appropriate balance between efficacy and side-effects, are important goals to optimise maternal satisfaction.     

A national cohort study to investigate the association between ethnicity and the provision of care in obstetric anaesthesia in England between 2011 and 2021

There is evidence that ethnic inequalities exist in maternity care in the UK, but those specifically in relation to UK obstetric anaesthetic care have not been investigated before. Using routine national maternity data for England (Hospital Episode Statistics Admitted Patient Care) collected between March 2011 and February 2021, we investigated ethnic differences in obstetric anaesthetic care. Anaesthetic care was identified using OPCS classification of interventions and procedures codes. Ethnic groups were coded according to the hospital episode statistics classifications. Multivariable negative binominal regression was used to model the relationship between ethnicity and obstetric anaesthesia (general and neuraxial anaesthesia) by calculating adjusted incidence ratios for the following: differences in maternal age; geographical residence; deprivation; admission year; number of previous deliveries; and comorbidities. Women giving birth vaginally and by caesarean section were considered separately. For women undergoing elective caesarean births, after adjustment for available confounders, general anaesthesia was 58% more common in Caribbean (black or black British) women (adjusted incidence ratio [95%CI] 1.58 [1.26–1.97]) and 35% more common in African (black or black British) women (1.35 [1.19–1.52]). For women who had emergency caesarean births, general anaesthesia was 10% more common in Caribbean (black or black British) women (1.10 [1.00–1.21]) than British (white) women. For women giving birth vaginally (excluding assisted vaginal births), Bangladeshi (Asian or Asian British), Pakistani (Asian or Asian British) and Caribbean (black or black British) women were, respectively, 24% (0.76 [0.74–0.78]), 15% (0.85 [0.84–0.87]) and 8% (0.92 [0.89–0.94]) less likely than British (white) women to receive neuraxial anaesthesia. This observational study cannot determine the causes for these disparities, which may include unaccounted confounders. Our findings merit further research to investigate potentially remediable factors such as inequality of access to appropriate obstetric anaesthetic care.     

Obstetric analgesia in 28 women with idiopathic thrombocytopenic purpura

OBJECTIVE: To assess complications arising from regional analgesia for obstetric labor and delivery in women with idiopathic thrombocytopenic purpura (ITP). MATERIAL AND METHODS: Retrospective study of case records of women with ITP who gave birth at our hospital over the 10-year period from 1993 through 2002. Quality control checklists were applied to case records before including them for study. The chart had to contain information on the type of analgesia/anesthesia used during labor or cesarean section, the results of complete peripartum coagulation tests, and a record of the presence or absence of anesthetic complications. Twenty-eight births involving 24 patients with ITP were studied. RESULTS: Regional analgesia/anesthesia, usually by epidural infusion, was the technique most often used. All patients had prothrombin and cephalin times within the normal ranges. Regional analgesia/anesthesia was never used in cases where the platelet count was less than 70,000/mm3. In such cases, general anesthesia was used for cesareans, with endovenous administration of opioids. No analgesia was used when the patient declined it for normal deliveries. Eleven cesarean deliveries and 17 vaginal deliveries were recorded. No complications were observed either with regional or endovenous techniques. CONCLUSIONS: The regional neuroaxial techniques used in this series of women with ITP, in whom platelet counts exceeded 70,000/mm3, were not associated with hemorrhagic complications.     

The parturient with coronary heart disease

Cardiac disease is one of the leading indirect causes of maternal mortality in the UK, exceeding numbers of direct deaths from thromboembolism and hypertension combined. Over one year in our unit we managed six women with coronary heart disease. In this series five women had stable coronary heart disease. Three delivered electively by caesarean section under combined spinal-epidural anaesthesia, a further two women had spontaneous vaginal deliveries, one planned under epidural analgesia, the second unplanned after a rapid labour. The sixth woman had unstable angina requiring percutaneous coronary intervention in the 28th week of pregnancy and went on to deliver by caesarean section under general anaesthesia. Regional anaesthesia was avoided in this case because of antiplatelet and anticoagulant medication. There is a lack of level-one evidence to direct the management of these women. Clinical decisions were directed by guidelines for the perioperative management of patients with cardiac disease in non-cardiac surgery and the management of all cardiac disease in the obstetric population. A multi-disciplinary approach was taken, with a collaborative plan made for each pregnancy and delivery. A thorough clinical history and examination together with transthoracic echocardiography allows risk stratification of women with coronary heart disease at risk of peripartum cardiac events. Further investigation specific to each woman's management can then be undertaken.     

Obstetric epidural analgesia: relationship between obstetric variables and the course of labor

OBJECTIVES: To analyze the relationship between epidural analgesia and diverse obstetric and fetal variables as well as the impact of epidural analgesia on the rates of instrumental and cesarean delivery. PATIENTS AND METHODS: Observational study of women who gave birth at Fundación Hospital Alcorcón over a period of 3 years. All the women were offered obstetric epidural analgesia based on 0.0625% bupivacaine plus 2 microg/mL of fentanyl. The following data were recorded: age, nulliparity (yes/no) administration of epidural analgesia (yes/no), induction of labor (yes/no), stimulation of uterine activity with oxytocin (yes/no), type of delivery, fetal weight, duration of dilation, duration of expulsion, cause of cesarean. RESULTS: The records of 4364 women were gathered. The percentages of inductions, nulliparas, oxytocin stimulation, and fetal weight greater than 4 kg and less than 2.5 kg were higher among women taking epidural analgesia. The age of women who received epidurals was significantly lower. The durations of dilation and expulsion were longer among women receiving epidural analgesia, and epidural analgesia was associated with greater risk of instrumental and cesarean deliveries. The significant increase in administration of epidural blocks over the 3-year period of the study was not accompanied by an increased rate of instrumentally assisted deliveries or cesareans. CONCLUSIONS: It is difficult to evaluate the real influence of epidural analgesia on certain aspects of labor and its evolution. The strength of the association between epidural analgesia and greater risk of increased rates of instrumental and cesarean deliveries may be influenced by factors not considered in the present study.     

Challenges that opioid-dependent women present to the obstetric anaesthetist

A retrospective casenote review was performed to identify anaesthetic challenges relevant to the opioid-dependent obstetric population. Medical records showed that of the 7,449 deliveries during a 24 month period, 85 women (1.1%) were taking regular opioids such as methadone and/or heroin. Of these 67 (79%) received anaesthetic services, ten of whom (11.7%) were referred antenatally. Forty opioid-dependent women (47%) received epidural analgesia in labour compared with the overall hospital rate of 38%. Twenty-three women (27%) delivered by caesarean section: five received general anaesthesia, five combined spinal anaesthesia, five spinal anaesthesia and eight epidural anaesthesia. Twenty opioid-dependent women (23.5%) had documented problems related to labour analgesia and 17 (74%) had problems with analgesia after caesarean section. A variety of postoperative analgesia methods were administered in addition to maintenance methadone. Fourteen patients (16.5%) had difficult intravenous access and seven "arrest" calls were documented. One anaesthetist was exposed to hepatitis C. This review demonstrates the demands placed on obstetric anaesthetic services by opioid-dependent women. Early antenatal referral for anaesthetic review is recommended.     

The use of fibrinogen concentrate to correct hypofibrinogenaemia rapidly during obstetric haemorrhage

Haemorrhage is a common complication of childbirth with 0.65% of deliveries associated with significant (>1500 mL) peripartum blood loss. Hypofibrinogenaemia secondary to dilutional and consumptive coagulopathies can be challenging to correct quickly with conventional blood and plasma therapy. Fibrinogen concentrate offers rapid restoration of fibrinogen levels with a small volume infusion and minimal preparation time. It is effective in treating patients with congenital hypofibrinogenaemia, but there are few reports of its use in association with continuing obstetric haemorrhage. Six cases of obstetric haemorrhage, associated with hypofibrinogenaemia, treated with fibrinogen concentrate in conjunction with platelets, fresh frozen plasma, packed red blood cells, uterotonics and obstetric intervention are described. In all cases, laboratory assessed coagulation was rapidly normalised and severe haemorrhage improved. These cases suggest that fibrinogen concentrate may be an effective addition to conventional treatments for obstetric haemorrhage associated with hypofibrinogenaemia.     

The delivery of obstetric anaesthetic care in UK maternity units: a survey of practice in 2021

BackgroundAnaesthetists are crucial members of the maternity unit team, providing peri-operative analgesia and anaesthesia, and supporting the delivery of medical care to high-risk women. The effective contribution from obstetric anaesthetists to safety in maternity units depends on how anaesthesia services are organised and resourced. There is a lack of information on how obstetric anaesthetic care is resourced in the UK.MethodsThe Obstetric Anaesthetists’ Association surveyed UK clinical leads for their hospital’s obstetric anaesthetic service and examined compliance with national recommendations.ResultsThere were 153 responses by lead obstetric anaesthetists from 184 maternity units in the UK (83%). The number of consultants per 1000 deliveries was 2.2 [1.6–2.7] (median [IQR]). In 20% of units, there was a dedicated on-call rota (on-call only for obstetric anaesthesia), whilst the remainder had a ‘combined’ on-call rota (on-call for other clinical areas in addition to obstetrics). Multidisciplinary ward rounds were held in 83% of units. Twenty-five (16%) units reported having no regular multidisciplinary ward rounds, of which nine (6%) did not have any multidisciplinary ward rounds. Planned operating lists for elective caesarean sections were provided in 77% of units.ConclusionsIn the largest survey of obstetric anaesthesia workload to be reported for any health system, we found significant disparities between obstetric anaesthesia service provision and current national recommendations for areas including consultant staffing, support for elective caesarean section lists, antenatal anaesthetic clinics, and consultant support for service development. Wide national variation in service provision was identified.     

A survey of obstetric an aesthesia practice in Flanders

The use of locoregional anaesthesia in obstetrics in Flanders was assessed by a postal questionnaire sent to the directors of the anaesthesia departments of the 72 hospitals with an obstetric unit. 59 (82%) answers were returned. In the group of parturients who had a vaginal delivery a neuraxial technique was requested by 65% of the patients and consisted of epidural analgesia in 84%, and combined spinal epidural analgesia in 16%. Test doses are used in labour in 67%. To perform the block--spinal as well as epidural--the sitting position is somewhat preferred over the left lateral (55 versus 45%). For caesarean section general anaesthesia was used in only 5% of the deliveries, whereas spinal, single or as a part of a CSE technique, was preferred in 80%; the epidural technique was applied in 15%. There is no clear preference in technique for postoperative analgesia after caesarean delivery as both parenteral and epidural analgesia are used in 50% of the cases.     

Cesarean delivery: a randomized trial of epidural analgesia versus intravenous meperidine analgesia during labor in nulliparous women

BACKGROUND: Controversy concerning increased cesarean births as a result of epidural analgesia for relief of labor pain has been attributed, in large part, to difficulties interpreting published studies because of design flaws. In this study, the authors compared epidural analgesia to intravenous meperidine analgesia using patient-controlled devices during labor to evaluate the effects of labor epidural analgesia, primarily on the rate of cesarean deliveries while minimizing limitations attributable to study design. METHODS: Four hundred fifty-nine nulliparous women in spontaneous labor at term were randomly assigned to receive either epidural analgesia or intravenous meperidine analgesia. Epidural analgesia was initiated with 0.25% bupivacaine and was maintained with 0.0625% bupivacaine and fentanyl 2 microg/ml at 6 ml/h with 5-ml bolus doses every 15 min as needed using a patient-controlled pump. Women in the intravenous analgesia group received 50 mg meperidine with 25 mg promethazine hydrochloride as an initial bolus, followed by 15 mg meperidine every 10 min as needed, using a patient-controlled pump. A written procedural manual that prescribed the intrapartum obstetric management was followed for each woman randomized in the study. RESULTS: A total of 226 women were randomized to receive epidural analgesia, and 233 women were randomized to receive intravenous meperidine analgesia. Protocol violations occurred in 8% (38 of 459) of women. There was no difference in the rate of cesarean deliveries between the two analgesia groups (epidural analgesia, 7% [16 of 226; 95% confidence interval, 4-11%] vs. intravenous meperidine analgesia, 9% [20 of 233; 95% confidence interval, 5-13%]; P = 0.61). Significantly more women randomized to epidural analgesia had forceps deliveries compared with those randomized to meperidine analgesia (12% [26 of 226] vs. 3% [7 of 233]; P < 0.001). Women who received epidural analgesia reported lower pain scores during labor and delivery compared with women who received intravenous meperidine analgesia. CONCLUSIONS: Epidural analgesia compared with intravenous meperidine analgesia during labor does not increase cesarean deliveries in nulliparous women.     

Role of prophylactic uterine artery balloon catheters in the management of women with suspected placenta accreta

Background

Placenta praevia and accreta are leading causes of major obstetric haemorrhage and peripartum hysterectomy. Detection is largely based on a high index of clinical suspicion, though the diagnostic accuracy of radiological imaging is improving. Interventional radiological techniques can reduce blood loss and the incidence of hysterectomy.

Methods

We have reviewed our experience with bilateral prophylactic uterine artery balloon occlusion in the management of women with suspected placenta accreta. Thirteen women at high risk of major haemorrhage due to placenta praevia or suspected placenta accreta were retrospectively studied. Uterine artery balloons were placed prophylactically under neuraxial anaesthesia in the angiography suite followed by caesarean delivery in the obstetric operating theatre.

Results

Intraoperative blood loss and transfusion requirements were low in our case series. There were no hysterectomies or admissions to the intensive care unit. Fetal bradycardia necessitating immediate caesarean delivery occurred in two women (15.4%).

Conclusion

In our case series in women with suspected placenta accreta, prophylactic use of uterine artery balloons was associated with a low requirement for blood transfusion but with possible increased risk of fetal compromise. Performing the interventional procedure at a different site from the operative room complicated management.     

Parturients with hypertrophic cardiomyopathy: case series and review of pregnancy outcomes and anesthetic management of labor and delivery

BackgroundAdvances in understanding the pathogenesis, diagnosis and management of hypertrophic cardiomyopathy have resulted in increased longevity and a better quality of life of affected patients considering pregnancy. Several case series which focused predominantly on obstetric details have reported generally good outcomes. However, there remains a paucity of data on the specifics of obstetric anesthesia in women with hypertrophic cardiomyopathy.MethodsAfter Institutional Review Board approval, we reviewed antepartum transthoracic echocardiograms, cardiology, obstetric, anesthetic, and nursing labor records with a focus on anesthesia for labor and delivery and early postpartum complications in patients with hypertrophic cardiomyopathy who delivered between January 1993 and December 2013.ResultsThere were 23 completed pregnancies in 14 patients: 12 parturients (52%) delivered vaginally, of whom seven (30%) required assistance (forceps, vacuum), and 11 (48%) had a cesarean delivery. In 17 cases (74%) delivery was uneventful, but six patients (26%) had complications including congestive heart failure (n=3) and postpartum hemorrhage (n=3). All patients had neuraxial labor anesthesia/analgesia, and none received general anesthesia. No hemodynamic instability or fetal distress directly related to anesthesia was documented.ConclusionThe database search of approximately 160 000 deliveries over 20 years revealed only a small number of hypertrophic cardiomyopathy patients with completed pregnancies. No maternal or neonatal deaths were documented. Overall morbidity rate was 26% with a 13% incidence of peripartum congestive heart failure. In patients with mild to moderate disease, neuraxial anesthesia was safe, effective and well tolerated with no hemodynamic instability related to administration of local anesthetics.     

UK registry of high-risk obstetric anaesthesia: report on cardiorespiratory disease

Forms were sent to members of the Obstetric Anaesthetists' Association requesting information on cardiorespiratory disease in pregnancy. Reports of 274 pregnancies in 259 women were received over four years (1997-2000). There were 83 valve lesions, 52 complex congenital heart disease, 112 miscellaneous heart disease and 27 respiratory disease. Half the mothers were classified as New York Heart Association grade I, 29% grade II, 14% grade III, 5% grade IV and six unknown. Thirty-nine mothers were seen by an anaesthetist only just before delivery. Regional analgesia for labour was more likely to be planned for severe (82%) than for mild symptoms (55%; P=0.039), but severity of symptoms did not affect choice of anaesthesia for caesarean section. Eighty-one women were delivered by elective caesarean section, 59 by emergency caesarean section, 82 had spontaneous and 49 assisted vaginal delivery. Three women suffered miscarriages. Regional analgesia was used in 73% of vaginal deliveries, Entonox or pethidine in 15% and no analgesia in 12%. Spinal anaesthesia was used in 21% of caesarean sections, an incremental regional technique (incremental epidural or combined spinal-epidural) in 40% and general anaesthesia in 39%. Forty-three women were admitted to intensive care units electively and 10 unplanned. Ninety-five per cent survived pregnancy in the same state as antepartum, 2% deteriorated and seven died. Ninety-four per cent of babies (258 babies) were delivered in good condition, nine in poor condition and seven died. Despite lack of denominator data and potential biases among the reported cases, the Registry provides a valuable snapshot of current practice in the UK.