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.     

Facilitating learning in the operating theatre and intensive care unit

Almost every aspect of anaesthetic and intensive care practice can be taught within the operating theatre and intensive care unit. This includes knowledge in the areas of medicine, anatomy, pharmacology, physiology, measurement and statistics, invaluable psychomotor and global skills and abilities, as well as the many important non-clinical aspects of anaesthesia and intensive care including effective communication, leadership, management, ethics and teaching. The operating theatre and intensive care unit offer many advantages and pose numerous challenges to education. This paper briefly discusses what can be taught in the operating theatre and intensive care unit, the educational challenges and benefits of teaching in these unique environments, implications for teaching and what consultants and trainees can do to positively influence the educational activity. The paper concludes with suggestions for facilitating learning in the operating theatre and intensive care unit including the Soldier's Five, practice vivas, skills training, endoscopic dexterity, interesting article exchange, in-service sessions, electronic resources and use out of hours.     

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.     

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.     

多学科协作教学模式在麻醉科住院医师规范化培训中的应用

目的 评价多学科协作(MDT)+SimMan模拟人+基于问题学习(PBL)教学模式用于麻醉科住院医师规范化培训(住培)教学中的效果。方法 选择麻醉科住培医师60名,男27名,女33名。采用随机数字表法分为两组：传统教学模式组(C组)和MDT+SimMan模拟人+PBL教学模式组(M组),每组30名。教学结束后,评价住培医师理论考试成绩、实际操作技能水平、教学质量(急救意识增强、急救能力提高、队伍配合意识增强、主动学习积极性提高及理论结合实践能力提高)和教学满意度情况。结果 M组理解记忆题、临床应用题、综合分析题得分、理论考试总分明显高于C组(P<0.05)。M组心肺复苏成功比例及胸外按压、人工呼吸、气管插管、硬膜外穿刺的单项操作得分明显高于C组(P<0.05)。M组住培医师的教学质量、教学满意度明显高于C组(P<0.05)。结论与传统教学模式比较,MDT+SimMan模拟人+PBL教学模式可提高麻醉科住培医师规范化培训的教学质量,提高住培医师满意度,值得推广。     

A survey of interventional radiology for the management of obstetric haemorrhage in the United Kingdom

BackgroundMassive haemorrhage remains a leading cause of maternal death worldwide. Interventional radiology can be used to prevent or treat life-threatening haemorrhage, but evidence for its efficacy is limited to case series predominantly from large tertiary centres. The current availability of interventional radiology for management of obstetric haemorrhage in the UK is unknown.MethodsA postal questionnaire on the use of interventional radiology was sent to the lead clinician for obstetric anaesthesia in 226 UK maternity units.ResultsThe response rate was 72%; 74 respondents (46%) had considered and 51 (31%) used interventional radiology for control of obstetric haemorrhage. Its use was primarily confined to large tertiary obstetric units and limited by availability of equipment and staff.ConclusionsInterventional radiology to assist in the management of obstetric haemorrhage is not uniformly available in the UK and experience remains limited. Access to this resource is subject to striking local variability and influenced by the size and nature of the hospital supporting the delivery unit.     

Immediate birth – an analysis of women and their babies undergoing time critical birth in a tertiary referral obstetric hospital

BackgroundAt our institution, the emergency obstetric ‘code green’ activates the system for immediate birth, usually by caesarean section. This study aimed to determine the incidence of immediate birth, indications, modes of anaesthesia, and short-term neonatal and maternal outcomes.MethodA review was performed for all women at the Royal Women’s Hospital, Parkville, Australia who underwent immediate birth over a two-year period: January 1, 2013 to December 31, 2014.ResultsWithin the study period 14,115 women gave birth, of which 387 women underwent an immediate birth, the majority (83%) by caesarean section. The commonest indication for immediate birth was prolonged fetal bradycardia (53%), however cord prolapse (4%) produced the most rapid decision-to-delivery interval, with a median [IQR] time of 14 [13–16] min versus 18 [14–23] min for all immediate births (P < 0.01). Epidural top-up was the most common anaesthesia method. Conversion to general anaesthesia following inadequate neuraxial anaesthesia occurred in 6.2% of women. Among 103 general anaesthetics, there was one failed intubation (successful ventilation) and one dental injury. Nine women (2.3%) were admitted to the high dependency or intensive care units, and there were no maternal deaths. Babies born by caesarean section with a decision-to-delivery interval of less than 30 min were more likely to have longer times to establish respiration (22.6% vs 16.7%, P < 0.001).ConclusionRequest for immediate delivery is a common obstetric emergency. Epidural top-up has become the most common anaesthetic technique. Rapid delivery times can be achieved with an integrated emergency response system.     

Évaluation du devenir professionnel d'infirmiers cambodgiens spécialisés en anesthésie-réanimation,formés dans le cadre de l'action humanitaire

ObjectivesTo assess the working conditions of Cambodian male nurses specialised in anaesthesia and intensive care (NSAIs), degree of satisfaction, whether training was suited to the Cambodian needs and practical application of training.Study designProspective survey.PersonsTwo training years including 30 NSAIs.MethodExternal assessors evaluated working conditions, practice of anaesthesia, analysed logbooks and theatre reports, organised semi-directive interviews and examinations using clinical cases.ResultsOut of the 30 NSAIs, 28 had an appointment, mainly in anaesthesia (80% of their activity) and three-quarters of them felt that their skills were appreciated by their superiors. Seventeen had some form of responsibility in the management of a department. For the administration of an anaesthetic, 13 NSAIs of the second year had achieved an acceptable level of performance and resolved effectively 85% of the submitted cases. Twenty-two NSAIs reported difficulty in applying techniques learned during their training to real working conditions. The causes were poor equipment, poor organisation and poor relations with the hierarchy. The latter cause decreased the capacity to take appropriate decisions, which was the most common error made by the second year NSAIs. Finally, as their wages remained unchanged, 19 out of the 28 NSAIs were obliged to look for an additional source of income.ConclusionThis survey shows the medium-term effectiveness of an NSAI training programme basing on teaching and public health principles and organised In the humanitarian aid sector.     

Distractions during critical phases of anaesthesia for caesarean section: an observational study

Aviation's ‘sterile cockpit’ rule holds that distractions on the flight deck should be kept at a minimum during critical phases of flight. To assess current practice at comparable points during obstetric regional anaesthesia, we measured ambient noise and distracting events during 30 caesarean sections in three phases: during establishment of regional anaesthesia; during testing of regional blockade; and after delivery of the fetal head. Mean (SD) noise levels were 62.5 (3.9) dB during establishment of blockade, 63.9 (4.1) dB during testing and 66.8 (5.0) dB after delivery (p < 0.001). The median rates of sudden, loud (> 70 dB) noises, non‐clinical conversations and numbers of staff present in the operating theatre increased during each of the three phases. Conversely, entrances into, and exits from, theatre per minute were highest during establishment of regional anaesthesia and decreased over the subsequent two time periods (p < 0.001).     

Struggles with autonomy: Exploring the dual identities of surgeons and learners in the operating room

BackgroundDeveloping autonomy is a critical component of becoming an attending surgeon. General surgery training has evolved in recent decades, however, leaving residents less time to work with attendings to establish entrustment. Limited entrustment can impact resident learning and engagement.MethodsA constructivist grounded theory approach was used to guide interviews of 12 general surgery residents and 10 attendings.ResultsEngagement in the OR is perceived by both residents and attendings as fundamental to achieving autonomy. Our study uncovered three key tensions: 1. Residents and attendings both occupy dual roles in the OR; 2. System demands put those roles in tension and opposition constantly; 3. Residents and attendings do deploy strategies to seek balance in those tensions.ConclusionsIn an academic OR setting, competing priorities can negatively impact resident engagement. Participants described some strategies for helping residents and attendings prioritize learning and teaching to better prepare residents for future practice.     

How learning preferences and teaching styles influence effectiveness of surgical educators

BackgroundEffective surgical educators have specific attributes and learner-relationships. Our aim was to determine how intrinsic learning preferences and teaching styles affect surgical educator effectiveness.MethodsWe determined i) learning preferences ii) teaching styles and iii) self-assessment of teaching skills for all general surgery attendings. All general surgical residents in our program completed teaching evaluations of attendings.ResultsMultimodal was the most common learning preference (20/28). Although the multimodal learning preference appears to be associated with more effective educators than kinesthetic learning preferences, the difference was not statistically significant (80.0% versus 66.7%, p = 0.43). Attendings with Teaching Style 5 were more likely to have a lower “professional attitude towards residents” score on SETQ assessment by residents (OR 0.33 (0.11, 0.96), p = 0.04). Attendings rated their own “communication of goals” (p < 0.001), “evaluation of residents” (p = 0.04) and “overall teaching performance” (p = 0.01) per STEQ domains as significantly lower than the resident’s assessment of these cofactors.ConclusionIdentification of factors intrinsic to surgical educators with high effectiveness is important for faculty development. Completion of a teaching style self-assessment by attendings could improve effectiveness.     

Anaesthesia for caesarean section in women with complex cardiac disease: 34 cases using the Braun Spinocath® spinal catheter

BackgroundCardiac disease in pregnancy is now the leading medical cause of maternal mortality in the UK. Whilst anaesthesia has not been the precipitant of this morbidity, its safety cannot be taken for granted. Spinal catheter anaesthesia, a relatively uncommon choice in obstetric practice, offers the potential of maintaining haemodynamic stability through accurate and gradual titration of neuraxial blockade.MethodsThirty-four women with cardiac disease requiring caesarean section were selected for spinal catheter anaesthesia. All received invasive arterial pressure measurement but in only two were central venous catheters sited. After inserting a 24-gauge Braun Spinocath^®, spinal anaesthesia was induced using diamorphine 300 μg and 0.5% hyperbaric bupivacaine in 0.25-mL increments. Technical problems, block quality and haemodynamic stability were recorded.ResultsSuccessful anaesthesia was achieved in 33 women. Spinal catheterisation proved impossible in one case, but the catheter was successfully used to provide epidural anaesthesia. There were no conversions to general anaesthesia. Eight women (24%) received supplementation with intravenous alfentanil, but all reported high satisfaction. Mild, transient hypotension occurred in six women (18%), and there was one case of vasovagal syncope induced by rapid exteriorisation of the uterus. Three patients (8.8%) experienced post dural puncture headache requiring a blood patch; two had received repeat dural puncture during catheter insertion.ConclusionsIncremental spinal catheter anaesthesia offers effective anaesthesia with excellent haemodynamic control. Post dural puncture headache is of concern, and whilst it may be addressed by product modification, it currently limits widespread use of the Braun Spinocath in obstetric practice.     

Repeated simulation-based training for performing general anesthesia for emergency cesarean delivery: long-term retention and recurring mistakes

BackgroundThe percentage of women undergoing cesarean delivery under general anesthesia has significantly decreased, which limits training opportunities for its safe administration. The purpose of this study was to evaluate how effective simulation-based training was in the learning and long-term retention of skills to perform general anesthesia for an emergent cesarean delivery.MethodsDuring an eight-week obstetric anesthesia rotation, 24 residents attended lectures and simulation-based training to perform general anesthesia for emergent cesarean delivery. Performance assessments using a validated weighted scaling system were made during the first (pre-test) and fifth weeks (post-test) of training, and eight months later (post-retention test). Resident’s competency level (weighted score) and errors were assessed at each testing session. Six obstetric anesthesia attending physicians, unfamiliar with the simulation scenario, generated a mean attendings’ performance score. The results were compared.ResultsAt one week of training, residents’ performance was significantly below mean attendings’ performance score (pre-test: 135 ± 22 vs. 159 ± 11, P = 0.013). At five weeks, residents’ performance was similar to mean attendings’ performance score (post-test: 159 ± 21) and remained at that level at eight months (post-retention test: 164 ± 16). Of the important obstetric-specific tasks, left uterine displacement was missed by 46% of residents at eight months.ConclusionFollowing lectures and simulation-enhanced training, anesthesia residents reached and retained for up to eight months a competency level in a simulator comparable to that of obstetric anesthesia attending physicians. Errors in performance and missed tasks may be used to improve residency training and continuing medical education.     

The value of surveys in obstetric anaesthesia

BackgroundThe Obstetric Anaesthetists’ Association (OAA) has facilitated national surveys in obstetric anaesthesia since 1998. We wanted to examine trends in OAA-approved surveys since this time.MethodsOAA-approved surveys performed between January 1998 and December 2012 were examined for the year they were carried out, the format (postal or electronic), the target group and the response rate. We determined whether each survey was presented or published. For each survey published as a substantive paper, we identified the number of times the publication had been cited. We also surveyed lead obstetric anaesthetists and expert witnesses practising in obstetric anaesthesia on the perceived usefulness of OAA-approved surveys.ResultsOne hundred and thirty-five surveys approved by the OAA were carried out between 1998 and 2012. Response rates have fallen over the years, reaching a current plateau of 65%. Response rates varied with the target group. Seventy-eight percent of surveys were presented and 83% were published in some form. For surveys published as substantive papers (n=34, 25%), the median [IQR (range)] number of citations was 6 [3–11 (0–36)] per publication. Our survey of lead obstetric anaesthetists had a response rate of 62%. Those who replied rated OAA surveys a median [IQR (range)] of 6 [5–7 (1–9)] on a 0–10 scale of usefulness to their clinical practice.ConclusionsResponse rates to OAA-approved surveys have declined but remain acceptable despite an increase in the number of surveys performed. Most surveys were presented or published in some form.     

Regional anaesthesia for caesarean section and what to do when it fails

Almost 90% of caesarean sections in the UK are carried out under regional anaesthesia. Preoperatively, women should be assessed and given adequate information regarding the regional technique. Antacid premedication and, in elective cases, an appropriate starvation period are mandatory. Regional anaesthesia should be established in the operating theatre, with both maternal and fetal monitoring in progress. Single-shot spinal is currently the most popular technique. Before surgery starts, assessment and documentation of the block are essential. Sensory block to light touch, and/or cold, should be measured. Surgery should be halted, if possible, if there is pain. Analgesic options include Entonox, intravenous opioids or ketamine, epidural ‘top-up’ and local infiltration; however, general anaesthesia should always be offered. All women should be followed up within 24 hours by the anaesthetic team.     

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.     

From the simulation center to the bedside: Validating the efficacy of a dynamic haptic robotic trainer in internal jugular central venous catheter placement

BackgroundThe objective of this study was to validate the transfer of ultrasound-guided Internal Jugular Central Venous Catheterization (US-IJCVC) placement skills from training on a Dynamic Haptic Robotic Trainer (DHRT), to placing US-IJCVCs in clinical environments. DHRT training greatly reduces preceptor time by providing automated feedback, standardizes learning experiences, and quantifies skill improvements.MethodsExpert observers evaluated DHRT-trained (N = 21) and manikin-trained (N = 36) surgical residents on US-IJCVC placement in the operating suite using a US-IJCVC evaluation form. Performance and errors by DHRT-trained residents were compared to traditional manikin-trained residents.ResultsThere were no significant training group differences between unsuccessful insertions (p = 0.404), assistance on procedure (p = 0.102), arterial puncture (p = 0.998), and average number of insertion attempts (p = 0.878). Regardless of training group, previous central line experience significantly predicted whether residents needed assistance on the procedure (p = 0.033).ConclusionThe results failed to show a statistical difference between DHRT- and manikin-trained residents. This study validates the transfer of skills from training on the DHRT system to performing US-IJCVC in clinical environments.