Speed of spinal vs general anaesthesia for category‐1 caesarean section: a simulation and clinical observation‐based study

Controversy exists as to whether effective spinal anaesthesia can be achieved as quickly as general anaesthesia for a category‐1 caesarean section. Sixteen consultants and three fellows in obstetric anaesthesia were timed performing spinal and general anaesthesia for category‐1 caesarean section on a simulator. The simulation time commenced upon entry of the anaesthetist into the operating theatre and finished for the spinal anaesthetic at the end of intrathecal injection and for the general anaesthetic when the anaesthetist was happy for surgery to start. In the second clinical part of the study, the time from intrathecal administration to ‘adequate surgical anaesthesia’ (defined as adequate for start of a category‐1 caesarean section) was estimated in 100 elective (category‐4) caesarean sections. The median (IQR [range]) times (min:s) for spinal procedure, onset of spinal block and general anaesthesia were 2:56 (2:32 ‐ 3:32 [1:22 ‐ 3:50]), 5:56 (4:23 ‐ 7:39 [2:9 ‐ 13:32]) and 1:56 (1:39 ‐ 2:9 [1:13 ‐ 3:12]), respectively. The limiting factor in urgent spinal anaesthesia is the unpredictable time needed for adequate surgical block to develop.     

Operating room‐to‐incision interval and neonatal outcome in emergency caesarean section: a retrospective 5‐year cohort study

We conducted a 5‐year retrospective cohort study on women undergoing caesarean section to investigate factors influencing the operating room‐to‐incision interval. Time‐to‐event analysis was performed for category‐1 caesarean section using a Cox proportional hazards regression model. Covariates included: anaesthetic technique; body mass index; age; parity; time of delivery; and gestational age. Binary logistic regression was performed for 5‐min Apgar score ≥ 7. There were 677 women who underwent category‐1 caesarean section and who met the entry criteria. Unadjusted median (IQR [range]) operating room‐to‐incision intervals were: epidural top‐up 11 (7–17 [0–87]) min; general anaesthesia 6 (4–11 [0–69]) min; spinal 13 (10–20 [0–83]) min; and combined spinal‐epidural 24 (13–35 [0–75]) min. Cox regression showed general anaesthesia to be the most rapid method with a hazard ratio (95%CI) of 1.97 (1.60–2.44; p < 0.0001), followed by epidural top‐up (reference group), spinal anaesthesia 0.79 (0.65–0.96; p = 0.02) and combined spinal‐epidural 0.48 (0.35–0.67; p < 0.0001). Underweight and overweight body mass indexes were associated with longer operating room‐to‐incision intervals. General anaesthesia was associated with fewer 5‐min Apgar scores ≥ 7 with an odds ratio (95%CI) of 0.28 (0.11–0.68; p < 0.01). There was no difference in neonatal outcomes between the first and fifth quintiles for operating room‐to‐incision intervals. General anaesthesia is associated with the most rapid operating room‐to‐incision interval for category‐1 caesarean section, but is also associated with worse short term neonatal outcomes. Longer operating room‐to‐incision intervals were not associated with worse neonatal outcomes.     

Rapid sequence spinal anaesthesia for category‐1 urgency caesarean section: a case series

General anaesthesia is the fastest method for anaesthetising a category‐1 caesarean section but is associated with increased maternal morbidity and mortality. We describe the ‘rapid sequence spinal’ to minimise anaesthetic time. This consists of a no‐touch spinal technique, consideration of omission of the spinal opioid, limiting spinal attempts, allowing the start of surgery before full establishment of the spinal block, and being prepared for conversion to general anaesthesia if there are delays or problems. We present a case series of 25 rapid sequence spinal anaesthetics for category‐1 caesarean section. The mean (SD [range]) decision‐delivery interval was 23 (6 [14–41]) min. After excluding cases where there was an identified delay, the median (IQR [range]) time to prepare and perform the spinal was 2 (2–3 [1–7]) min, and time to develop a ‘satisfactory’ block was 4 (3–5 [2–7]) min. The total time to induce spinal anaesthesia was 8 (7–8 [6–8]) min. There were three pre‐operative conversions to general anaesthesia and three women had pain during surgery that did not require treatment. Our data indicate that one might expect to establish anaesthesia in 6–8 min using a rapid sequence spinal. Careful case selection is crucial. While rapid anaesthesia is important, the reduction of the decision‐delivery interval also requires attention to other stages in the pre‐operative process.     

An audit of the effect of case selection on compliance with a 30-minute audit standard for decision-to-delivery interval at category 1 caesarean section

BackgroundOur hospital has an audit standard that ≥90% of women having category 1 (emergency) caesarean section should have a decision-to-delivery interval (DDI) ≤30 min. This audit aimed to identify potential influences of case selection on compliance.MethodsA prospective audit of category 1 caesarean section recorded urgency at time of decision for surgery and any urgency changes, as well as whether caesarean section followed failed operative vaginal delivery in the operating theatre.ResultsAmong 405 women, 158 women had failed operative vaginal delivery in the operating theatre followed by caesarean section, 247 had the delivery decision made in the labour room, 43 had a change in urgency. Depending on case inclusion, the proportion of women with DDI room, and 43 >30 min ranged between 8.3% (30/362; no urgency change, failed operative vaginal delivery included) and 21.9% (54/247; change in urgency, failed operative vaginal delivery excluded). The proportion of women with a DDI >30 min was 18.5% (42/227) if the decision for category 1 caesarean section was made in the labour delivery room (excluding cases of failed operative vaginal delivery).ConclusionsCompliance with an audit standard for (DDI) at category 1 caesarean section is markedly influenced by the inclusion criteria. For comparability with other publications, it is suggested urgency should be reported as that applied at the point of decision for caesarean section, however, category 1 caesarean section cases following failed operative vaginal delivery in the operating theatre should be identified and reported separately.     

Comparison of ultra-low,low and high concentration local anaesthetic for labour epidural analgesia: a systematic review and network meta-analysis

Lumbar epidural is the gold standard for labour analgesia. Low concentrations of local anaesthetic are recommended. This network meta-analysis investigated whether further reducing the concentration of local anaesthetic can improve maternal and neonatal outcomes without compromising analgesia. We conducted a systematic search of relevant databases for randomised controlled trials comparing high (>0.1%), low (>0.08% to ≤0.1%) or ultra-low (≤0.08%) concentration local anaesthetic (bupivacaine or equivalent) for labour epidural. Outcomes included mode of delivery, duration of labour and maternal/neonatal outcomes. Bayesian network meta-analysis with random-effects modelling was used to calculate odds ratios or weighted mean differences and 95% credible intervals. A total of 32 studies met inclusion criteria (3665 women). The total dose of local anaesthetic received increased as the concentration increased; ultra-low compared with low (weighted mean difference −14.96 mg, 95% credible interval [−28.38 to −1.00]) and low compared with high groups (weighted mean difference −14.99 [−28.79 to −2.04]), though there was no difference in the number of rescue top-ups administered between the groups. Compared with high concentration, ultra-low concentration local anaesthetic was associated with increased likelihood of spontaneous vaginal delivery (OR 1.46 [1.18 to 1.86]), reduced motor block (Bromage score >0; OR 0.32 [0.18 to 0.54]) and reduced duration of second stage of labour (weighted mean difference −13.02 min [−21.54 to −4.77]). Compared with low, ultra-low concentration local anaesthetic had similar estimates for duration of second stage of labour (weighted mean difference −1.92 min [−14.35 to 10.20]); spontaneous vaginal delivery (OR 1.07 [0.75 to 1.56]; assisted vaginal delivery (OR 1.35 [0.75 to 2.26]); caesarean section (OR 0.76 [0.49 to 1.22]); pain (scale 1–100, weighted mean difference −5.44 [−16.75 to 5.93]); and maternal satisfaction. Although a lower risk of an Apgar score < 7 at 1 min (OR 0.43 [0.15 to 0.79]) was reported for ultra-low compared with low concentration, this was not sustained at 5 min (OR 0.12 [0.00 to 2.10]). Ultra-low concentration local anaesthetic for labour epidural achieves similar or better maternal and neonatal outcomes as low and high concentration, but with reduced local anaesthetic consumption.     

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.     

Choice of anaesthesia for category‐1 caesarean section in women with anticipated difficult tracheal intubation: the use of decision analysis

A predicted difficult airway is sometimes considered a contra‐indication to rapid sequence induction of general anaesthesia, even in an urgent case such as a category‐1 caesarean section for fetal distress. However, formally assessing the risk is difficult because of the rarity and urgency of such cases. We have used decision analysis to quantify the time taken to establish anaesthesia, and probability of failure, of three possible anaesthetic methods, based on a systematic review of the literature. We considered rapid sequence induction of general anaesthesia with videolaryngoscopy, awake fibreoptic intubation and rapid spinal anaesthesia. Our results show a shorter mean (95% CI) time to induction of 100 (87–114) s using rapid sequence induction compared with 9 (7–11) min for awake fibreoptic intubation (p < 0.0001) and 6.3 (5.4–7.2) min for spinal anaesthesia (p < 0.0001). We calculate the risk of ultimate failed airway control after rapid sequence induction to be 21 (0–53) per 100,000 cases, and postulate that some mothers may accept such a risk in order to reduce potential fetal harm from an extended time interval until delivery. Although rapid sequence induction may not be the anaesthetic technique of choice for all cases in the circumstance of a category‐1 caesarean section for fetal distress with a predicted difficult airway, we suggest that it is an acceptable option.     

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.     

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.     

Patient‐controlled oral analgesia versus nurse‐controlled parenteral analgesia after caesarean section: a randomised controlled trial

We assessed the effectiveness of early patient‐controlled oral analgesia compared with parenteral analgesia in a randomised controlled non‐inferiority trial of women undergoing elective caesarean section under regional anaesthesia. Seventy‐seven women received multimodal paracetamol, ketoprofen and morphine analgesia. The woman having patient‐controlled oral analgesia were administered four pillboxes on the postnatal ward containing tablets and instructions for self‐medication, the first at 7 h after the spinal injection and then three more at 12‐hourly intervals. Pain at rest and on movement was evaluated using an 11‐point verbal rating scale at 2 h and then at 6‐hourly intervals for 48 h. The pre‐defined non‐inferiority limit for the difference in mean pain scores (patient‐controlled oral analgesia minus parenteral) was one. The one‐sided 95% CI of the difference in mean pain scores was significantly lower than one at all time‐points at rest and on movement, demonstrating non‐inferiority of patient‐controlled oral analgesia. More women used morphine in the patient‐controlled oral analgesia group (22 (58%)) than in the parenteral group (9 (23%); p = 0.002). The median (IQR [range]) number of morphine doses in the patient‐controlled oral analgesia group was 2 (1–3 [1–7]) compared with 1 (1–1 [1–2]); p = 0.006) in the parenteral group. Minor drug errors or omissions were identified in five (13%) women receiving patient‐controlled oral analgesia. Pruritus was more frequent in the patient‐controlled oral analgesia group (14 (37%) vs 6 (15%) respectively; p = 0.03), but no differences were noted for other adverse events and maternal satisfaction. After elective caesarean section, early patient‐controlled oral analgesia is non‐inferior to standard parenteral analgesia for pain management, and can be one of the steps of an enhanced recovery process.     

Warming of patients during Caesarean section: a telephone survey*

We contacted the duty obstetric anaesthetist in 219 of the 220 consultant‐led maternity units in the UK (99.5%) and asked about departmental and individual practice regarding temperature management during Caesarean section. Warming during elective Caesarean section was routine in 35 units (16%). Intravenous fluid warmers were available in 213 units (97%), forced air warmers were available in 211 (96%) and warming mattresses were available in 42 (19%). Only 18 (8%) departments had specific guidelines for temperature management during Caesarean section. Personal intra‐operative practice was variable, although all of those contacted would initiate some form of active temperature management after a mean (SD) volume of blood loss of 1282 (404) ml, length of surgery of 78 (24) min, or core body temperature (if measured) of median (IQR [range]), 36 (35.5–36 [34–37.2]) °C.     

Intrathecal sufentanil decreases the median effective dose (ED50) of intrathecal hyperbaric ropivacaine for caesarean delivery

Background: The addition of opioid to local anaesthetics has become a well‐accepted practice of spinal anaesthesia for caesarean delivery. Successful caesarean delivery anaesthesia has been reported with the use of a low dose of intrathecal hyperbaric ropivacaine coadministered with sufentanil. This prospective, double‐blinded study determined the median effective dose (ED50) of intrathecal hyperbaric ropivacaine with and without sufentanil for caesarean delivery, to quantify the sparing effect of sufentanil on the ED50 of intrathecal hyperbaric ropivacaine. Methods: Sixty‐four parturients undergoing elective caesarean delivery with combined spinal–epidural anaesthesia were randomized into two groups: Group R (ropivacaine) and Group RS (ropivacaine plus sufentanil 5 μg). The initial dose of ropivacaine was 13 mg in Group R and 10 mg in Group RS. The effective dose was defined as a T₆ level attained within 10 min and no supplemental epidural anaesthetic required during surgery. Effective or ineffective responses determined, respectively, a 0.3 mg decrease or increase of the dose of ropivacaine for the next patient using an up–down sequential allocation. Results: The ED50 of intrathecal ropivacaine was 11.2 mg [confidence interval (CI) 95%: 11.0–11.6] in Group R vs. 8.1 mg (CI 95%: 7.8–8.3) in Group RS. Motor block was markedly more intense in Group R than in Group RS, and the incidence of shivering was lower in Group RS than in Group R. There were no differences in the onset time of sensory block or motor block, in the incidence of hypotension, nausea and vomiting. Conclusion: Intrathecal sufentanil 5 μg produced a 28% reduction of ED50 of intrathecal hyperbaric ropivacaine for caesarean delivery.     

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.     

The extension of epidural blockade for emergency Caesarean section: a survey of current UK practice

The conversion of epidural analgesia during labour to surgical anaesthesia for Caesarean section can have important medical and medicolegal implications. This survey sought to establish the current management for extending epidural blockade for emergency Caesarean section. A postal questionnaire was sent to the lead obstetric anaesthetist in all maternity units in the UK (n = 254). The response rate was 82% (n = 209). Of those surveyed, 68% (136) give the full dose of the local anaesthetic mixture in the delivery room, whilst 12.5% (25) initiate the top-up in the delivery room and give the remainder of the dose in theatre. Fifteen per cent (30) transfer the woman to theatre before commencing anaesthesia and 34% (68) give a test dose before the full anaesthetic dose. Guidelines for converting labour analgesia to anaesthesia for emergency Caesarean section were available in 64% (128) units. Bupivacaine 0.5% was the most commonly used agent, being used as the sole agent by 41.5% (81) units and in combination by a further 18% (36). Adrenaline was added to the chosen local anaesthetic by 30% (60) whilst 12% (24) added bicarbonate. In all, 13 combinations of local anaesthetics and adjuncts were used. The mode time to transfer the patient to theatre was 1 min. Of the 161 respondents who commenced anaesthesia in the delivery room, 71% (114) did not monitor the patient during transfer, whilst 87% (140) had ephedrine immediately available. Thirty-three respondents reported a total of 43 adverse incidents associated with the extension of epidural blockade. These included high blocks, inadequate blocks and possible intravascular injections, the latter resulting in two seizures and one cardiac arrest.     

Total intravenous anaesthesia for caesarean section in a patient with Marfan's syndrome

The case is described of a pregnant patient with Marfan's syndrome scheduled at 39 weeks' gestation for elective caesarean section carried out for the first time by total intravenous anaesthesia (TIVA) with continuous intravenous (i.v.) infusion of propofol. The diagnosis was based on a positive family history, classic phenotype, scoliosis, arachnodactyly, high narrow palate, hyperextensible joints, ectopia lentis and mitral valve prolapse, with a secondary low mitral insufficiency. Maternal and fetal surveillance did not detect complications during the course of pregnancy. Elective caesarean section was performed at 39 weeks due to high-risk pregnancy and to avoid the risk of haemodynamic alterations that take place during labour and delivery. The patient was given general anaesthesia with continuous i.v. infusion of propofol and boluses of atracurium and fentanyl after delivery. The haemodynamics and oxygen saturation remained stable during surgery. Apgar scores were 9 at 1 and 5 min. The post-delivery course was unremarkable and post partum echocardiography showed no changes from before caesarean section. The cardiovascular problems of Marfan's syndrome, the risk of haemodynamic changes associated with pregnancy and delivery, its anaesthetic implications and the possible advantages of TIVA with continuous i.v. infusion of propofol in the anaesthetic management of caesarean section in patients with this disease are discussed.     

Evaluation of a novel waste anaesthetic gas scavenger device for use during recovery from anaesthesia

Volatile anaesthetic agents are a potential occupational health hazard to theatre and recovery staff. Operating theatres and anaesthetic rooms are required to be equipped with scavenging systems, but recovery units often are not. We compared exhaled, spectrophotometric sevoflurane and desflurane concentrations 15 cm from the mouth (‘patient breathing zone’) and 91 cm laterally to the patient (‘nurse work zone’) in 120 patients after tracheal extubation who were consecutively allocated to either ISO‐Gard mask oxygen/scavenging or standard oxygen mask, 0 min, 10 min and 20 min after arrival in the theatre recovery unit. Median (IQR [range]) duration of anaesthesia was similar between groups (control 76 (44–119 [15–484]) min vs. study group 90 (64–130 [15–390]) min, p = 0.136). Using the ISO‐Gard mask, the 20‐min mean patient breathing zone and nurse work zone exhaled anaesthetic levels were ~ 90% and 78% lower than those recorded in the control group, respectively, and were within the recommended 2 ppm maximum environmental exposure limit in the patient breathing zone of 53 out of 60 (88%) and the nurse work zone of all 60 (100%) patients on first measurement in the recovery room (vs. 10 out of 60 (17%) and 40 out of 60 (67%) in the control group). Our study indicates that the ISO‐Gard oxygen/scavenging mask reduces the level of exhaled sevoflurane and desflurane below recommended maximum exposure limits near > 85% of extubated patients within ~ 20 s of application in the recovery unit after surgery. We encourage the use of this mask to minimise the occupational exposure of recovery staff to exhaled volatile agents.     

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.     

Impact of dose‐finding studies on administration of oxytocin during caesarean section in the UK

Debate continues over the dose and methods of administration of oxytocin for the prevention of haemorrhage during caesarean section. We surveyed 206 lead obstetric anaesthetists in the UK to determine standard practice in their unit as well as any differences in practice for high‐risk cases. There were 150 responses (72.9% response rate). A total of 149 units use oxytocin. The majority use an initial 5‐IU dose, whilst a small proportion (8; 5.3%) administer a dose < 5 IU for elective caesarean section. The administration of a 10‐IU dose has ceased altogether. There is a broad range of administration methods, particularly with infusions. Forty (26.8%) respondents give a different oxytocin regimen following caesarean section in patients with severe pre‐eclampsia, 72 (48.3%) in those with cardiac disease of New York Heart Association class 1‐2, and 100 (66.7%) with class 3‐4. In conclusion, there is a trend towards the use of lower doses of oxytocin in caesarean section, but there are still wide variations in detail. We suggest that there is a need for a national protocol to standardise oxytocin administration.     

Hyperbaric prilocaine vs. hyperbaric bupivacaine for spinal anaesthesia in women undergoing elective caesarean section: a comparative randomised double-blind study

Hyperbaric bupivacaine spinal anaesthesia remains the gold standard for elective caesarean section, but the resultant clinical effects can be unpredictable. Hyperbaric prilocaine induces shorter motor block but has not previously been studied in the obstetric spinal anaesthesia setting. We aimed to compare duration of motor block after spinal anaesthesia with prilocaine or bupivacaine during elective caesarean section. In this prospective randomised, double-blind study, women with uncomplicated pregnancy undergoing elective caesarean section were eligible for inclusion. Exclusion criteria included: patients aged < 18 years; height < 155 cm or > 175 cm; a desire to breastfeed; or a contra-indication to spinal anaesthesia. Patients were randomly allocated to two groups: the prilocaine group underwent spinal anaesthesia with 60 mg intrathecal prilocaine; and the bupivacaine group received 12.5 mg intrathecal heavy bupivacaine. Both 2.5 µg sufentanil and 100 µg morphine were added to the local anaesthetic agent in both groups. The primary outcome was duration of motor block, which was assessed every 15 min after arriving in the post-anaesthetic care unit. Maternal haemodynamics, APGAR scores, pain scores, patient satisfaction and side-effects were recorded. Fifty patients were included, with 25 randomly allocated to each group. Median (IQR [range]) motor block duration was significantly shorter in the prilocaine group, 158 (125–188 [95–249]) vs. 220 (189–250 [89–302]) min, p < 0.001. Median length of stay in the post-anaesthetic care unit was significantly shorter in the prilocaine group, 135 (120–180 [120–230]) vs. 180 (150–195 [120–240]) min, p = 0.009. There was no difference between groups for: maternal intra-operative hypotension; APGAR score; umbilical cord blood pH; maternal postoperative pain; and patients’ or obstetricians’ satisfaction. We conclude that hyperbaric prilocaine induces a shorter and more reliable motor block than hyperbaric bupivacaine for women with uncomplicated pregnancy undergoing elective caesarean section.