A comparison of informed consent for obstetric anaesthesia in the USA and the UK

The practice of 75 UK and 75 US obstetric anaesthetists in obtaining informed consent for obstetric anaesthesia (for caesarean section) and obstetric analgesia (for labour) was compared using a postal questionnaire. The response rate was approximately 60% for each group. Of the US anaesthetists 47% obtained separate written consent for obstetric anaesthesia compared to 22% of the UK group (P=0.012). Corresponding percentages for epidural analgesia were 52% for the US, and 15% for the UK (P < 0.001). Significantly more of the listed risks and benefits relating to general anaesthesia were discussed by the US anaesthetists compared to the UK group, median (interquartile range), 6 (4-7) and 3 (1-4), P < 0.001. There was no significant difference in discussion before regional anaesthesia but the US group discussed more information before epidural analgesia for labouring mothers obtunded by pain or drugs. These results suggest that discussion and documentation of informed consent for obstetric anaesthesia and analgesia could be improved in both countries, especially the UK.     

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.     

Issues of consent for regional analgesia in labour: a survey of obstetric anaesthetists

Anaesthetists are legally obliged to obtain consent and inform patients of material risks prior to administering regional analgesia in labour. We surveyed consultant members of the Australian and New Zealand College of Anaesthetists with a special interest in obstetric anaesthesia, in order to identify and compare which risks of regional analgesia they report discussing with women prior to and during labour. We also asked about obstetric anaesthetists' beliefs about informed consent, the type of consent obtained and its documentation. Of 542 questionnaires distributed, 291 responses (54%) were suitable for analysis. The five most commonly discussed risks were post dural puncture headache, block failure, permanent neurological injury, temporary leg weakness and hypotension. Obstetric anaesthetists reported discussing a mean of 8.0 (SD 3.8) and 10 (SD 3.8) risks in the labour and antenatal settings respectively. Nearly 20% of respondents did not rank post dural puncture headache among their top five most important risks for discussion. Seventy percent of respondents indicated that they believe active labour inhibits a woman's ability to give 'fully informed consent'. Over 80% of respondents obtain verbal consent and 57 (20%) have no record of the consent or its discussion. Obstetric anaesthetists reported making a considerable effort to inform patients of risks prior to the provision of regional analgesia in labour. Verbal consent may be appropriate for labouring women, using standardized forms that serve as a reminder of the risks, and a record of the discussion. Consensus is required as to what are the levels of risk from regional analgesia in labour.     

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.     

A survey of antenatal and peripartum provision of information on analgesia and anaesthesia

Pregnant women should receive information about what they might expect to experience during their delivery. Despite this, research shows many women are inadequately prepared for anaesthetic interventions during labour. We surveyed 903 postnatal women across 28 Greater London hospitals about: the analgesic and anaesthetic information that they recalled receiving during pregnancy and delivery; their confidence to make decisions on analgesia; and their satisfaction with the analgesia used. Wide variation was observed between hospitals. Overall, 67 of 749 (9.0%) women recalled receiving antenatal information covering all aspects of labour analgesia, and 108 of 889 (12.1%) covering anaesthesia for caesarean section. Regarding intrapartum information, 256 of 415 (61.7%) respondents recalled receiving thorough information before epidural insertion for labour analgesia, and 102 of 370 (27.6%) before anaesthesia for caesarean section. We found that 620 of 903 (68.7%) women felt well enough informed to be confident in their analgesic choices, and 675 of 903 (74.8%) stated that their analgesia was as expected or better. Receiving information verbally, regardless of provider, was the factor most strongly associated with respondents recalling receiving full information: odds ratio (95%CI) for labour analgesia 20.66 (8.98–47.53; p < 0.0001); epidural top-up for caesarean section 5.93 (1.57–22.35; p = 0.01); and general anaesthesia for caesarean section 12.39 (2.18–70.42; p = 0.01). A large proportion of respondents did not recall being fully informed before an anaesthetic intervention. Collaboration with current antenatal service providers, both in promoting information delivery and providing resources to assist with delivery, could improve the quality of information offered and women's retention of that information.     

Delegation in paediatric anaesthesia: a postal survey

BACKGROUND: We wished to determine a consensus view from UK paediatric anaesthetic consultants of what practical skills are safe and appropriate for an anaesthetic trainee to perform during an initial 3-month module in paediatric anaesthesia. METHODS: A postal survey was sent to all UK and Ireland members of the Association of Paediatric Anaesthetists (APA). This questionnaire was designed to determine which tasks were delegated to trainee anaesthetists. Two hundred and four questionnaires were despatched, replies were received from 165 consultant anaesthetists (80% response rate). RESULTS: More than 50% of the APA respondents would always or regularly allow an anaesthetic trainee in their first 3-month module in paediatric anaesthesia to perform; an ilioinguinal block, a penile block and a caudal (but not in a neonate). CONCLUSIONS: Anaesthetic registrars undertaking an initial module in paediatric anaesthesia should learn basic airway management, ilioinguinal blocks, penile blocks and caudals (but not neonatal caudals).     

The impact of anaesthetic trainees on elective caesarean section procedural times: a prospective observational study

Operating room efficiency is an important concern in hospitals today both in the public and private sectors. Currently, a paucity of literature exists to evaluate the impact of anaesthetic training on operating room efficiency in the Australian health system. At Monash Medical Centre, Clayton, private consultant operating sessions and public teaching operating sessions use the same operating theatres, nursing and technical staff. Consultant anaesthetists and obstetricians perform all tasks during private sessions, whereas anaesthetic and obstetric trainees perform many tasks during public sessions. In this prospective observational study, total case time, anaesthesia controlled time and the surgical time were measured for elective caesarean section under spinal anaesthesia in 59 patients (private consultant n = 29, public teaching n = 30). Increases in total case time (24 minutes, P < 0.001), anaesthesia controlled time (5.2 minutes, P < 0.015) and surgical time (19.25 minutes, P < 0.001) were observed in the public teaching group compared with the private consultant group. The participation of anesthetic trainees in caesarean sections results in a modest increase in anaesthetic controlled time of approximately five minutes per case or 16 minutes in an operative session with three cases scheduled. Elimination of anaesthetic 'training' time does not allow scheduling of an extra elective caesarean section. Reduced operating theatre throughput is unlikely to be a consequence of training specialist anaesthetists in this clinical setting.     

Obstetric epidural test doses: a survey of UK practice

BACKGROUND: With the advent of low-dose epidural analgesia in labour, the content of the test dose has once again become the subject of debate. METHOD: A postal survey of 500 members of the Obstetric Anaesthetists' Association was conducted in 1999-2000, assessing the use of test doses during epidurals in labour and for caesarean section. RESULTS: There was a 67% response rate. Test doses are used in labour, at elective caesarean section and before epidural top-up for emergency caesarean section, by 90%, 93% and 37%, respectively. There was large variation in both drugs and doses. During labour, doses of bupivacaine range from 3 to 20 mg and of lidocaine 15 to 90 mg. There has been a three-fold increase in the use of low-dose local anaesthetic test doses since a previous national survey in 1997. The size of local anaesthetic test doses used at caesarean section is also variable. Epinephrine is used in 5% of labour, 14% of elective and 34% of emergency caesarean sections. Signs and symptoms that are commonly sought after test doses include somatic motor block, blood pressure change, sensory effect and symptoms from systemic local anaesthetic. The effect of the test dose is usually assessed after 5 min. CONCLUSION: There is no consensus about the nature of the ideal test dose in obstetric anaesthesia. There is a trend to use less concentrated test doses during labour. Doses that risk a high block if given spinally are still used. Epinephrine, aspiration testing and cardiovascular monitoring are uncommon.     

A prospective observational study of the subjective experience of caesarean section under regional anaesthesia

The aim of our study was to determine the subjective sensation of caesarean section under regional anaesthesia. We performed a prospective, observational study of 205 patients undergoing caesarean section under regional anaesthesia in a UK district general hospital. Patients were asked open and closed questions relating to their physical and emotional experience during the operation. Seventy-three percent of patients chose the phrase "pulling and pushing" to describe the physical sensation of the operation, 75% described the experience as pleasant, and only 4% described it as unpleasant, the rest saying it was neither pleasant nor unpleasant. Ninety-six percent said they would by choice have any future caesarean section under regional anaesthesia, 3% were undecided and 1% said they would prefer a general anaesthetic next time. This study provides important precise information that may be given to patients before caesarean section under regional anaesthesia. We believe it will help minimise preoperative fears and increase patients' ability to make informed decisions about their care.     

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

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

Failure of regional blockade for caesarean section

This four-year retrospective study examined the quality of regional blockade for caesarean section. For patients having spinal anaesthesia, data were available on requirement for analgesic supplementation or conversion to general anaesthesia. In those having epidural anaesthesia, data were available only for conversion to general anaesthesia. A total of 1644 patients due to have caesarean section under spinal anaesthesia were studied and of these, 48 (2.9%) required general anaesthesia at some stage. Of the 1610 patients in whom a caesarean section was started under spinal, 12 (0.75%) received general anaesthesia while 175 (10.9%) required some analgesic supplementation. Of the 827 patients in whom epidural analgesia was in progress for labour and a decision was made to proceed to caesarean section, a total of 87 patients (10.5%) needed general anaesthesia. Of those (763) in whom caesarean section was started under epidural, only 17 (2.2%) were given general anaesthesia because of intra-operative pain. Although these results may fall short of best practice, they may enable the anaesthetist to give more accurate information to patients so that better informed consent can be obtained.     

Risks of regional anaesthesia for caesarean section: women's recall and information sources

Recall and information sources regarding the risks of regional anaesthesia in women having lower segment caesarean section have not been adequately assessed previously. We aimed to survey women's recall of their pre-anaesthesia risk discussion and determine where women, presenting for lower segment caesarean section under regional anaesthesia, obtain risk information. Following a small pilot survey, women's responses were recorded for "spontaneous" or "prompted" recalled risks, the information source and its reliability. One-hundred and fifty women were surveyed following caesarean section. Seventy women (46.7%) had an elective procedure and 80 (53.3%) had an emergency procedure. Overall, 142 women (94.6%) recalled at least four risks (44.6% spontaneously; 66% prompted). Of those women giving at least four spontaneous responses, 41 (58.6%) had elective and 26 (32.5%) had emergency lower segment caesarean section (P = 0.001). The majority of women stated that anaesthetists were the main, and most reliable, source of their information regarding risks of regional anaesthesia for caesarean section. This report identifies the risks associated with regional anaesthesia for caesarean section that women most frequently recall, namely headache, paralysis, nerve damage and inadequate block.     

Ethical and medico-legal aspects of obstetric anaesthesia

In obstetric practice, ethical and medico-legal problems centre on the ability of a labouring woman to give truly informed consent. Conflicts can also arise between the best health interests of the fetus and those of the mother. Consent to a procedure can be given by a competent patient who has been properly informed and has shown understanding of the risks, benefits and alternatives. Authority must be given voluntarily. The authors explore these elements with relevance to the pregnant and labouring woman. Is the patient competent in labour? Can she truly be informed and decide on a treatment plan in advance of labour without knowledge of the level of pain to be experienced? The Obstetric Anaesthesia Association recommends that information about procedures such as epidural analgesia should be given antenatally, with an explanation also being given and consent obtained in labour. There is a large disparity between individual patients about the level of risk at which they wish to be informed of a particular complication. The authors discuss areas of ethical difficulty in which the mother's health is put at higher risk for the benefit of the fetus (e.g. emergency caesarean section under general anaesthesia). Common medico-legal problems include pain during caesarean section under regional blockade and the neurological sequelae of regional block. Good documentation, honest communication with patients and fellow staff, early advice from senior colleagues and apologies where necessary may avert potential problems.     

Spinal anaesthesia for caesarean section following epidural analgesia in labour: a relative contraindication

Three cases are described in which epidural analgesia was performed during labour using an infusion of bupivacaine 0.125-0.25%. When, in all 3 cases, caesarean section was required for failure to progress, hyperbaric bupivacaine was given in doses of 10 mg, 12.5 mg and 15 mg respectively. Within 2-4 min all 3 patients had a high block, complained of difficulty in breathing and subsequently developed apnoea. The trachea was intubated after administration of thiopentone and succinylcholine and the operation continued. Cardiovascular support was provided by the administration of ephedrine injected intermittently intravenously. The spinal block receded and the patients were able to return to the ward without any further complications. All three mothers remain in good health and do not regret having had spinal anaesthesia for caesarean section. In contrast to previously reported cases of high spinal anaesthesia following unsuccessful epidural anaesthesia for caesarean section, this report describes 3 cases of high spinal following the administration of spinal anaesthesia upon an ongoing epidural infusion of local anaesthetic during labour. As no guidelines are available as to the recommended dose of spinal anaesthetic under such circumstances and, in view of the several case reports describing a similar complication under different circumstances, we suggest that spinal anaesthesia is contraindicated upon ongoing epidural analgesia or following a failed epidural.     

Awake fibreoptic intubation skills in obstetric patients: a survey of anaesthetists in the Oxford region

A survey of anaesthetists in the Oxford region was conducted to determine their skills and practice in performing awake fibreoptic intubation. Forty-two consultant obstetric anaesthetists (group O), 21 consultant anaesthetists with an interest in difficult airway management (group D) and 20 anaesthetic specialist registrars in their final training year (group S) were sent a questionnaire on management of a patient with a known difficult airway for elective caesarean section. All but one responded. If regional anaesthesia was unsuccessful or contraindicated, 75/82 respondents (91.5%) would choose to secure the airway by awake intubation. Of the remaining seven, six would use general anaesthesia and spontaneous respiration, five (6.1%) with the laryngeal mask airway and one (1.2%) with mask and airway and one (1.2%) local infiltration by the surgeon. Although awake fibreoptic intubation was the technique chosen by 98.7%, only six (8.1%) had experience of its performance in an obstetric patient. Of the 68 anaesthetists without such experience, only 12/31 (38.7%) group O compared to 13/18 (72.2%) group D and 12/19 (63.2%) group S would be confident to perform awake fibreoptic intubation in an obstetric patient. Only one anaesthetist in the survey practised awake fibreoptic intubation in non-obstetric patients regularly (>3/month). However, 69/82 respondents replied that all consultant obstetric anaesthetists should be experienced in performing awake fibreoptic intubation. We conclude that despite the value of awake fibreoptic intubation, consultant obstetric anaesthetists are less confident in performing it than those with an interest in difficult airway management and final year specialist registrars.     

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.     

Complications of obstetric regional analgesia: how much information is enough?

Two hundred parturients who had received epidural analgesia during labour (100 in Melbourne, Australia and 100 in London, UK) were asked on the first postnatal day about their sources of antenatal information on pain relief in labour, their awareness of potential complications of epidural analgesia and the level of risk at which they would wish to be informed before consenting to a procedure. Sources of antenatal information were similar in the two countries although more women in Australia received information from an anaesthetist or obstetrician than in the UK, whilst more women in the UK received information from the media than in Australia. Knowledge of risks was also similar although the Australian subjects were more aware of infective complications while those in the UK were more aware of intravascular injection of local anaesthetic; these differences may reflect recent high-profile cases in the two countries. The preferred level of risk at which women wanted to be informed about a complication varied from 1:1 to 1:1,000,000,000 in all three centres. The majority of women considered that the benefits of epidural analgesia outweighed each of the potential complications. Women differ in their requirements for antenatal information about regional analgesia and its complications, with some wanting to know every complication, however rare. Anaesthetists should be flexible in their disclosure of information when obtaining consent for regional analgesia and consider the particular wishes of each patient rather than follow rigid centralised guidelines.     

Dorsal column function after epidural and spinal blockade: implications for the safety of walking following low-dose regional analgesia for labour

Walking after regional blockade for labour using low-dose combinations of bupivacaine and fentanyl is possible due to the maintenance of lower limb motor power. In order to investigate concerns that dorsal column function, important in maintaining balance, is impaired after such techniques, clinical assessment of lower limb proprioception and vibration sense was evaluated in parturients after either low-dose epidural ( n  = 30) or spinal blockade ( n  = 30) for labour analgesia and compared with spinal anaesthesia ( n  = 30) for elective Caesarean section using a larger total dose of local anaesthetic. Of the patients receiving low-dose regional labour analgesia 7% ( n  = 4) had abnormal dorsal column function compared with 97% ( n  = 29) receiving spinal anaesthesia for Caesarean section (p < 0.001). All patients in the Caesarean section group developed lower limb motor weakness, compared with only 10% ( n  = 6) in the low-dose groups (p < 0.001). There were no significant differences between the low-dose groups with respect to sensory block, motor block or dorsal column function. Overall, 90% of patients receiving low-dose bupivacaine/fentanyl regional labour analgesia had both normal lower limb motor power and dorsal column function. Assessment of these parameters is recommended before allowing patients to walk after low-dose regional techniques for labour.     

A survey in the West Midlands of the United Kingdom of current practice in managing hypotension in lower segment caesarean section under spinal anaesthesia

BackgroundSpinal anaesthesia, the most common form of anaesthesia for caesarean section, leads to sympathetic blockade and profound maternal hypotension resulting in adverse maternal and neonatal outcomes. Hypotension, nausea and vomiting remain common but until the publication of the National Institute of Health and Care Excellence (NICE) 2021 guidance, no national guideline existed on how best to manage maternal hypotension following spinal anaesthesia for caesarean section. A 2017 international consensus statement recommended prophylactic vasopressor administration to maintain a systolic blood pressure of >90% of an accurate pre-spinal value, and to avoid a drop to <80% of this value.This survey aimed to assess regional adherence to these recommendations, the presence of local guidelines for management of hypotension during caesarean section under spinal anaesthesia, and the individual clinician’s treatment thresholds for maternal hypotension and tachycardia.MethodsThe West Midlands Trainee-led Research in Anaesthesia and Intensive Care Network co-ordinated surveys of obstetric anaesthetic departments and consultant obstetric anaesthetists across 11 National Health Service Trusts in the Midlands, England.ResultsOne-hundred-and-two consultant obstetric anaesthetists returned the survey and 73% of sites had a policy for vasopressor use; 91% used phenylephrine as the first-line drug but a wide range of recommended delivery methods was noted and target blood pressure was only listed in 50% of policies. Significant variation existed in both vasopressor delivery methods and target blood pressures.ConclusionsAlthough NICE has since recommended prophylactic phenylephrine infusion and a target blood pressure, the previous international consensus statement was not adhered to routinely.