Acid aspiration prophylaxis in labour: a survey of UK obstetric units

BACKGROUND: The risk of acid aspiration is still a major concern in pregnant patients. In view of the increasing numbers of drugs available to decrease gastric acid production, it seemed timely to reassess acid aspiration prophylaxis policies in the UK. METHOD: An OAA-approved postal survey of 250 UK lead consultant obstetric anaesthetists was conducted in 2004 in order to establish the current practice of acid aspiration prophylaxis in labour. If acid aspiration prophylaxis was used, further questions were asked relating to subgroups of patients, category, dose and route of administration of drugs used and whether there was an anticipated change in practice. RESULTS: A response rate of 83% was achieved. There had been a decrease in the routine use of acid aspiration prophylaxis to 32% of units, an increase in the use of acid aspiration prophylaxis in "at risk" groups to 61% and a decrease in the number of units never using prophylaxis to 7%. Oral ranitidine administered six-hourly is the most common practice. There is little use of proton pump inhibitors. CONCLUSION: Compared to previous surveys of UK practice there has been an overall increase in the use of acid aspiration prophylaxis.     

Acid aspiration prophylaxis in obstetrics in France: a comparative survey of 1998 vs. 1988 French practice

BACKGROUND AND OBJECTIVE: To survey French anaesthetic practice regarding acid aspiration prophylaxis and compare it with an earlier survey. METHODS: A confidential questionnaire was sent to all 800 maternity units in France to assess three major topics: (a) drugs used for pharmacological prophylaxis; (b) regional anaesthesia for labour and Caesarean section and (c) techniques used for general anaesthesia and endotracheal intubation. RESULTS: Two-hundred-and-two units responded. Pharmacological prophylaxis was regularly used for labouring women in 78% of the responding units in 1998 (compared with 63% in 1988, P < 0.05). Antacid drug use before Caesarean section had increased from 75% in 1988 to 97% in 1998 (P < 0.05). General anaesthesia was used for Caesarean section by less than 2% of responding units (vs. 21% in 1988, P < 0.05). In contrast, there was little change in the use of endotracheal intubation for instrumental delivery (53% vs. 50%) or manual removal of the placenta (15% vs. 16%) between 1988 and 1998. The use of cricoid pressure increased significantly during the 10 yr period (50% vs. 88%, P < 0.05) and the technique was correctly described by 80% of the responding units (vs. 50%, P < 0.05). Similarly, the use of succinylcholine increased significantly from 25% (1988) to 479 (1998) (P < 0.05). CONCLUSIONS: There was a significant overall improvement of French practice regarding acid aspiration prophylaxis in obstetrics. However, the complete prophylaxis strategy is still not used in every patient emphasizing the need for continuing medical education.     

Acid aspiration prophylaxis in Australian obstetric hospitals--a survey

During 1987 a confidential survey of all hospitals in Australia providing obstetric services was undertaken to determine the antacid medications used routinely as prophylaxis against acid aspiration pneumonitis. Of the 567 hospitals surveyed, 379 (67%) responded. Of these, 243 hospitals provide an obstetric service which includes caesarean section, and 67% of these perform less than 500 deliveries per annum. Aspiration prophylaxis during labour was used in 22.4% of responding hospitals. Prior to elective caesarean section, 11.5% used no prophylaxis, and 39.4% used particulate antacids such as magnesium trisilicate mixture (33.3%) or Mylanta (6.1%). Sodium citrate mixture was the most popular therapy (37%). Results were similar in the emergency caesarean section group. The use of cimetidine or ranitidine was uncommon in all groups. Results of this survey suggest marked differences in attitudes towards acid aspiration prophylaxis between Australian and British obstetric anaesthetic practices.     

Current Danish practice for aspiration prophylaxis in obstetric anaesthesia: a survey

A survey of 45 Danish anaesthetic departments providing obstetric services was conducted to discover which forms of prophylaxis against pulmonary aspiration of acid gastric contents are currently used in obstetric patients. Very few departments used regular aspiration prophylaxis during active labour. For caesarean section pharmacologic prophylaxis was administered by approximately one third of the departments. Sodium citrate was the preferred agent. The use of H(2)-receptor antagonists was uncommon. Metoclopramide was not used. For emergency caesarean section gastric emptying was used by 62% of the departments.     

A national survey of safe practice with epidural analgesia in obstetric units

The National Patient Safety Agency (NPSA) identified practice improvements with regard to epidural injections and infusions and released a patient safety alert on 28th March 2007. Prior to this, the Obstetric Anaesthetists' Association had considered the draft document and wished to assess current compliance in UK obstetric units. A postal survey of consultant-led obstetric anaesthetic units in the UK was performed in September 2006 to look at practice prior to the release of the safety alert. The response rate was 89%. Many units are already following the guidance from the NPSA but nearly one in four units have experience of wrong route drug errors related to confusion between systems for intravenous and regional drug administration.     

Anaesthesia for caesarean section — a German survey

Background: Anaesthetic practice for caesarean section has changed during the last decades. There is a world-wide shift in obstetric anaesthetic practice in favour of regional anaesthesia. Current data concerning anaesthetic practice in patients under-going caesarean section from Germany are not available. A comparison with figures from the UK, USA, Norway and other European countries might be of general interest.
Methods: Questionnaires on the practice of anaesthesia for caesarean section and anaesthetic coverage of the obstetric units were sent to 1178 university, tertiary care, district, community and private hospitals in Germany.
Results: The 532 completed replies of this survey represent 46.9% of the German obstetric units. Most hospitals (42.3%) have delivery rates between 500 and 1000 per year. General anaesthesia is the most common anaesthetic technique for elective (61%), urgent (83%) and emergency caesarean section (98%). Epidural anaesthesia is performed in 23% of scheduled and 5% of non-scheduled caesarean sections, and spinal anaesthesia in 14% and 10%, respectively. Acid aspiration prophylaxis before elective caesarean section is used in 68.7% of the departments. The majority of the departments provide a 24-hour anaesthetic coverage; however, in only 6.2% of the units, this service is assigned to obstetric anaesthesia, exclusively.
Conclusion: Compared to data from 1978, anaesthetic practice for caesarean section has changed with an increase in regional anaesthesia. However, German anaesthetists prefer general anaesthesia for caesarean section. In contrast, anaesthetists in other countries predominantly use regional techniques, and the difference to German practice is striking. International consensus discussion and recommendations as well as comparable European instruments of quality control in obstetric anaesthesia are desirable.     

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.     

Antenatal anaesthetic assessment of high-risk pregnancy: a survey of UK practice

BACKGROUND: Anaesthetists are frequently involved in the management of high-risk pregnancy. Antenatal referral permits time to prepare an appropriate management plan for labour and delivery. This survey looked at current methods of referral in the UK and the role of a formal clinic. METHOD: A postal questionnaire was sent to lead consultant anaesthetists of 256 UK obstetric units enquiring into methods of referral for high-risk pregnancy. RESULTS: Replies were received from 196 units (response rate 77%). Only 30% of units that responded ran a formal anaesthetic pre-assessment clinic, the remaining 70% relying on ad hoc referrals of high-risk cases. Larger units were more likely to run formal clinics. Some units wishing to introduce a formal clinic had not been able to do so because of financial constraints. CONCLUSION: Most hospitals were satisfied with current arrangements for referral of high-risk pregnancy. A mechanism for anaesthetic referral of high-risk pregnancy is vital, but in many units is not via a formal clinic.     

A survey of facilities for high risk women in consultant obstetric units

Reports on Confidential Enquiries into Maternal Deaths and the Obstetric Anaesthetists' Association have made recommendations about the provision of staff and facilities in consultant obstetric units. We have carried out a postal survey of all units in the UK concerning provision of recovery facilities, high dependency and intensive care, and anaesthetic staffing. Replies were received from 232 units (89%). The results show that although many units had achieved recommended standards, this was not universal. In particular, only 62% had a designated and staffed recovery area, only 41% had specific obstetric high dependency beds and there were a number of units with no consultant anaesthetic sessions or trained anaesthetic assistants available around the clock. Despite the practical and financial difficulties in achieving recommended standards, it should be noted that purchasers of health care have been encouraged to ensure that the recommendations are implemented.     

The preparation and storage of anaesthetic drugs for obstetric emergencies: a survey of UK practice

BackgroundTraditionally anaesthetic drugs for obstetrics are prepared as a contingency and stored until they are required for emergency use or have expired. Expiry is based on presumed reduction in sterility and efficacy although evidence for this is inconsistent. Preparation in advance introduces the risk of error and potential for tampering by a third party. Discarding and re-preparing drugs daily represents significant wastage with associated cost implications. We predicted that practice of drug preparation would differ widely across the UK, so conducted a national survey.MethodA postal questionnaire was sent to lead consultant obstetric anaesthetists at each of the 223 consultant-led UK obstetric units enquiring about the preparation of anaesthetic drugs for obstetric emergencies.ResultsThe response rate was 75%; 87% of units routinely draw up emergency drugs, most commonly thiopental and succinylcholine. Only 10% routinely use commercially-prepared succinylcholine syringes, although a further 8% would use them if available. Thiopental is prepared by anaesthetists in 78% of units, operating department practitioners in 8% and pharmacy in <7% of cases. Drugs are changed every 24 h in 80% of units and weekly in 6%. With one exception, all units changing drugs weekly use pharmacy-prepared thiopental.ConclusionThe majority of UK obstetric units routinely draw up emergency drugs every 24 h. With conflicting evidence regarding sterility and efficacy this represents tremendous wastage and potential for drug error and tampering. We propose that nationwide introduction of commercially- and pharmacy-prepared drugs with long shelf lives would improve safety and cost effectiveness.     

Aspiration and regurgitation prophylaxis in paediatric anaesthesia

BACKGROUND: Surveys of aspiration prophylaxis in paediatric anaesthesia do not exist. METHODS: A postal survey was sent out to all UK members of the Association of Paediatric Anaesthetists (APA) to assess current practice. We asked about minimum fasting times for liquids and solids/milk, their routine acid aspiration prophylaxis and perceived risk factors for emergency and elective surgery in children those less than 1 year old and those aged 1-14 years. We also asked if the APA member had more than 10 years experience in paediatric anaesthesia. RESULTS: One hundred and two (55.1%) APA members replied out of a total of 185 questionnaires sent. Eighty-eight (88/102) were considered valid. Fasting in emergencies is approximately 4 h for solids/milk and 2 h for clear liquids. Fasting for elective surgery is between 5 and 6 h for solids/milk and 2 h for clear liquids. Pharmacological methods to reduce the risk of aspiration are not used. Mechanical methods vary from 40-50% for cricoid pressure and 20-30% for nasogastric aspiration if a tube is present. The presence of a hiatus hernia is perceived by over 80% as a risk factor, previous aspiration by over 60%, difficult intubation, cerebral palsy and sepsis by 20-30%. CONCLUSION: Perceived risk factors vary with "experience": hiatus hernia, difficult intubation and cerebral palsy are less important whereas previous aspiration and renal failure appear to be more important for paediatric anaesthetists with less than 10 years in paediatric anaesthetic practice.     

National survey of obstetric anaesthesia clinical practices in the republic of Austria

BackgroundThe aim of this study was to describe the current obstetric anaesthetic practices in Austria by performing a comprehensive questionnaire survey.MethodsA questionnaire was sent via email to key anaesthesiologists from obstetric anaesthesia departments of 81 hospitals registered at the Austrian Ministry of Health.ResultsOf 81 departments contacted, 65 (80%), covering 84% of annual births in Austria, responded to the 82-question survey. Epidural analgesia was offered universally, at a rate under 30% in 56 (86%) of respondent hospitals. The caesarean section rate was under 30% in 44 (68%) respondent obstetric units. All respondents provided spinal anaesthesia as the primary anaesthetic technique for elective caesarean section. Three (5%) respondents administered long-acting intrathecal morphine and 18 (28%) respondents did not routinely administer any intrathecal opioid. Wound infiltration for acute postoperative pain control was practiced in two (3%) respondent units. A transversus abdominis plane block was offered as rescue analgesia in 14 (22%) departments. Spinal hypotension was treated using a prophylactic phenylephrine infusion in two (3%) respondent hospitals. Prophylactic antibiotics were administered prior to skin incision by 31 (48%) respondents.ConclusionThis survey reveals that obstetric anaesthetic practices in Austria differ in part from current European and American guidelines. Findings will direct the national workforce on obstetric anaesthesia that aims to introduce into Austria practice guidelines, based on international collaborations and guideline recommendations.     

A national survey of obstetric early warning systems in the United Kingdom

BackgroundDespite recommendations in the two most recent Confidential Enquiries into Maternal and Child Health (CEMACH) reports, and improvements in patient care using early warning scoring systems (EWS) in the general adult population, no validated system currently exists for the obstetric population.MethodsWe performed an Obstetric Anaesthetists’ Association (OAA) approved postal survey of all UK consultant-led obstetric anaesthetic units in November 2007 to assess opinions on the value and of such a system and how it could be implemented, and invited comments and samples of systems already in use.ResultsThe response rate was 71%. Of those who replied a median usefulness score of 80% for a standardised national obstetric EWS was demonstrated. Eighty-nine percent of units thought it would be possible to implement a system, and although 96% of UK hospitals already use a non-obstetric EWS, only 23% of respondents thought this to be relevant to obstetric physiology and disease. Nine units returned copies of their obstetric EWS. Using extracts from some of the submitted versions we have designed and implemented a system locally and submitted it to the OAA for consideration.ConclusionsThe survey results support CEMACH recommendations for a nationally agreed obstetric EWS.     

A national survey of prevention of infection in obstetric central neuraxial blockade in the UK

We conducted a postal survey of all consultant-led UK obstetric anaesthetic units in August 2009, to assess the standard of aseptic technique used for neuraxial blocks. One hundred and sixty-four units responded giving a response rate of 76%; 93% of units (149/160) follow recommended precautions and attach a bacterial micropore filter to the epidural catheter. Epidural top-ups are provided by 72% (116/162) of units, with about two thirds using premixed solutions (of local anaesthetic with opioid) in a variety of ways: 51% (57/111) via a continuous infusion pump; 47% (52/111) by a prefilled syringe; and 23% (25/111) by multiple use of a premixed bag of solution. For spinals, 91% of units (149/164) add diamorphine: of these 85% (126/149) draw the diamorphine from non-sterile-wrapped ampoules. If required to draw opioid from a non-sterile-wrapped ampoule, 86% (119/138) of units use a micropore filter and 21% (29/138) wipe the ampoule neck with an alcohol swab. Although sepsis secondary to neuraxial block in obstetric practice is uncommon (declared by 8.5% of units over an unspecified period of time), there is scope for further improvement.     

Definitions in obstetric anaesthesia: how should we measure anaesthetic workload and what is 'epidural rate'?

Crude delivery rate is used to calculate requirements for consultant anaesthetic sessions in the UK, but this calculation is arbitrary and ignores differences in case-mix between units. The term 'epidural rate' is commonly used to indicate regional anaesthetic activity but has never been defined. We challenge both these concepts and illustrate our argument by applying different definitions of obstetric anaesthetic activity to prospectively collected maternity data from 31 211 deliveries over 5 years in two hospitals. Number of anaesthetic interventions is a more accurate reflection of obstetric anaesthetic activity than number of deliveries, with Northwick Park Hospital having about 200-600 more deliveries per year than Chelsea & Westminster Hospital but about 300-400 fewer anaesthetic interventions per year. 'Epidural rate' varied by up to 30% according to the definition used. We conclude that number of anaesthetic interventions should replace crude number of deliveries as a measure of obstetric anaesthetic activity, and that the term 'regional anaesthesia rate' should replace 'epidural rate'.     

Change in anaesthetic practice for Caesarean section in Germany

BACKGROUND: Initial data from 1996 revealed that in contrast to several other countries general anaesthesia was the preferred anaesthetic technique for Caesarean section in Germany. However, anaesthetic practice for Caesarean section has changed during the last decades world-wide. This investigation was performed to obtain more actual data on anaesthetic procedures in obstetric patients in German hospitals. METHODS: Questionnaires on the practice of anaesthesia for Caesarean section were mailed to 918 German departments of anaesthesiology. Furthermore, the survey evaluated severe perioperative complications in obstetric patients. RESULTS: The 397 completed replies in this survey represent 41.3% of all German deliveries in 2002. Spinal anaesthesia is now the most common technique (50.5%) for elective Caesarean section. In case of urgent and emergency Caesarean, delivery figures decrease to 34.6% and 4.8%, respectively. Epidural anaesthesia is performed in 21.6% of scheduled and 13.2% and 1.0% of non-scheduled urgent or emergency Caesarean sections, respectively. Four maternal deaths and several non-fatal episodes of gastric content aspiration were reported by the respondents. CONCLUSIONS: Compared to data obtained 6 years ago a significant increase in regional anaesthesia for Caesarean section has developed, with spinal anaesthesia being the preferred technique. Surveys can help to initiate discussion and improve current practice of anaesthetic care.     

Anaesthesia for magnetic resonance imaging: a survey of current practice in the UK and Ireland

The lack of information about standards for anaesthetic practice in magnetic resonance imaging is of concern, since increasing requests are being made for this service, often in units not designed for the purpose. An overview of current practice was sought by conducting a postal survey of magnetic resonance units in the UK and Ireland. Replies were received from 100 units (79%), 46 of which had an anaesthetic service provided. A wide diversity of practice and opinion on the conduct of anaesthesia in this field was evident from the replies received. The survey highlighted particular areas of concern about the personal safety of anaesthetists within such units, including exposure to magnetic fields, noise and unscavenged anaesthetic gases. The evidence for such concerns is reviewed.     

Entonox equipment as a potential source of cross-infection

A survey of the hospitals with obstetric units within the Anglia and Oxford Region was performed to assess current practices regarding the cleaning of, and use of filters with, Entonox apparatus. The survey revealed that there was no consensus regarding the cleaning of the equipment and, in contrast to anaesthetic machines in which microbiological filters are recommended and in widespread use, only 10% of the hospitals surveyed were using such filters with the Entonox apparatus in their units. Cleaning procedures were changed in 75% of hospitals when dealing with known 'high-risk' patients, the remaining hospitals treating all patients as 'high-risk' or denied caring for such patients. All patients should be protected from potential cross-infection, and the recommendation that a microbiological filter should be placed between patients and the breathing system should be extended to Entonox equipment.     

Use of anaesthetic rooms in obstetric anaesthesia; a postal survey of obstetric anaesthetists and departments in the United Kingdom

BACKGROUND: Use of anaesthetic rooms has been much discussed in the UK in recent years, but attitudes and practices of obstetric anaesthetists regarding their use for caesarean section have never been sought. METHOD: A postal survey was conducted to discover the extent of use of anaesthetic rooms versus operating theatre for induction of anaesthesia and reasons for using or not using them. Questionnaires regarding individual practices were sent to 400 randomly selected members of the Obstetric Anaesthetists' Association ( approximately 25% of UK membership). Questionnaires regarding departmental policies were sent to 100 "clinicians responsible for surveys" (approximately 38% of departments providing obstetric anaesthesia in the UK). RESULTS: For elective caesarean section, 70% of individual clinicians never used an anaesthetic room, 9% rarely, 5% usually, 9% for all regional anaesthetics and 6% always. For emergency caesarean section the corresponding figures were 83%, 5%, 5%, 3% and 2% respectively. Use of the anaesthetic room was independent of the seniority of anaesthetists. In 68% of departments it was standard practice or policy to induce all anaesthetics for caesarean section in the operating room. Conversely, only 1% of departments had a policy to induce all anaesthetics in the anaesthetic room. Patient safety was the usual reason given for anaesthetising in the operating room. CONCLUSION: The majority of obstetric anaesthetists have abandoned the use of anaesthetic induction rooms, the main reason being patient safety. For the same reason, two-thirds of departments providing obstetric anaesthesia consider induction of anaesthesia in the operating room their standard practice.