How UK obstetric anaesthetists assess neuraxial anaesthesia for caesarean delivery: National surveys of practice conducted in 2004 and 2010

Surgical sensation during caesarean section: a qualitative analysis

BACKGROUND

Caesarean section (CS) is a major abdominal surgery performed usually on a young and healthy population under neuraxial anesthesia with little to no sedation. This creates a distinct surgical experience whereby patients are aware of the surgical process, physical sensations, and their environment. This study aimed to provide an in-depth descriptive assessment of subjective surgical experience during CS under regional anaesthesia. We expected the information gained would enhance our current understanding and better alleviate patient anxiety through informed counselling.

METHODS

This qualitative descriptive study was conducted at a Canadian academic centre. Twenty patients participated in semi-structured interviews within a week of CS, using an interview guide developed for this study. Patient medical records were reviewed to collect demographic and surgical information. Thematic analysis was conducted using an inductive approach to determine common themes.

RESULTS

Nine themes were identified. Five themes were identified in the category of surgical sensation and four themes were identified in the category of peri-operative education.

CONCLUSIONS

Patients commonly experienced pressure and movement sensations at varying intensity, and most did not experience pain. Environmental factors, including sounds and distraction by the newborn, affected perception of surgical sensation. Patients wish to receive pre-operative counselling regarding potential surgical sensations, as well as ongoing communication from their anaesthesiologist. These results can be used to guide informed discussions with patients and direct further investigation in this area.

Inadequate neuraxial anaesthesia during caesarean delivery: a survey of practitioners

BACKGROUND

We aimed to determine the knowledge, training, practices and attitudes of obstetric anaesthetic practitioners with regard to failed neuraxial anaesthesia for caesarean delivery.

METHOD

We performed a contemporaneous and representative survey in an innovative fashion. We conducted an international cross-sectional study of obstetric anaesthetic practitioners at the Annual Scientific Meeting of the Obstetric Anaesthetists' Association (OAA 2021). Validated survey questions were collected in real time using an audience response system.

RESULTS

Of the 426 participants who logged into the survey system, 356 provided responses (4173 responses to 13 questions, across all grades/seniority of practitioner). The number of responses to questions ranged from 81% to 61%. Survey responses suggest that it is routine for respondents to inform patients about the difference between pain and expected intra-operative sensations, (320/327, 97.9%) but less routine to inform patients of the risk of intra-operative pain (204/260, 78.5%), or the possibility of conversion to general anaesthesia. (290/309 93.8%). Only 30% of respondents reported the use of written guidelines for follow-up of patients who experience intra-operative pain under neuraxial anaesthesia, and only 23% reported formal training in management of intra-operative pain under neuraxial anaesthesia. Respondents felt that inadequate block duration, prolonged surgery, and patient anxiety were contributory factors to failed anaesthesia, and the contributory factors differed between grade/seniority of practitioner. Modalities used to test a block were cold, motor block and light touch, with approximately 65% of respondents routinely using three modalities.

CONCLUSIONS

Our study survey found that the consent process may not always be adequately comprehensive, and that standardised documentation and testing of the block and focused training may be beneficial to prevent patient dissatisfaction and the chance of litigation.

Neuraxial and general anaesthesia for caesarean section

Caesarean section (CS) is one of the most performed operations worldwide. In many parts of the world, there has been a reduction in anaesthetic associated obstetric mortality, and this has been attributed to the increased use of neuraxial anaesthesia and improved safety of general anaesthesia, alongside improved training and organisational changes. In resource-limited countries, anaesthesia contributes disproportionately to maternal mortality, with one in seven deaths being due to anaesthesia. A major contributory factor to this is the severe shortage of trained anaesthetic providers. Goals for anaesthesia for CS include the woman's comfort and foetal well-being, focusing on strategies to minimise morbidity and mortality for both. Anaesthetic options for CS include neuraxial techniques (spinal or combined-spinal epidural or epidural extension of labour analgesia) and general anaesthesia. There is increasing evidence of the benefit of neuraxial techniques over general anaesthesia in terms of maternal and foetal outcomes. For elective CS, spinal and combined-spinal anaesthesia predominate. General anaesthesia is mainly reserved for Category 1 CS where there is an immediate threat to the life of the mother or the baby. This review discusses the practical aspects of neuraxial and general anaesthesia for CS.

Prevention and management of intra-operative pain during caesarean section under neuraxial anaesthesia: a technical and interpersonal approach

A woman who experiences pain during caesarean section under neuraxial anaesthesia is at risk of adverse psychological sequelae. Litigation arising from pain during caesarean section under neuraxial anaesthesia has replaced accidental awareness under general anaesthesia as the most common successful medicolegal claim against obstetric anaesthetists. Generic guidelines on caesarean section exist, but they do not provide specific recommendations for this area of anaesthetic practice. This guidance aims to offer pragmatic advice to support anaesthetists in caring for women during caesarean section. It emphasises the importance of non-technical skills, offers advice on best practice and aims to encourage standardisation. The guidance results from a collaborative effort by anaesthetists, psychologists and patients and has been developed to support clinicians and promote standardisation of practice in this area.

A study of factors influencing surgical cesarean delivery times in an academic tertiary center

BACKGROUND

Knowledge of hospital-specific average cesarean delivery operative times, and factors influencing length of surgery, can serve as a guide for anesthesiologists when choosing the optimal anesthetic technique. The aim of this study was to determine operative times and the factors influencing those times for cesarean delivery.

METHODS

We conducted a retrospective review of all 1348 cesarean deliveries performed at an academic hospital in 2011. The primary outcome was mean operative time for first, second, third and fourth or more cesarean deliveries. The secondary goal was to identify factors influencing operative time. Variables included age, body mass index, previous surgery, gestational age, urgency of cesarean delivery, anesthesia type, surgeon's seniority, layers closed, and performance of tubal ligation.

RESULTS

Mean (standard deviation) operative times for first (n=857), second (n=353), third (n=108) and fourth or more (n=30) cesarean deliveries were 56 (19), 60 (19), 69 (28) and 82 (31) minutes, respectively (P <0.0001, all groups different). Emergency status of the case and later gestational age were associated with shorter operative times. Higher body mass index, a less senior surgeon, the number of layers closed, and tubal ligation, increased operative times. These factors accounted for 18% of the variability.

CONCLUSIONS

Third and fourth cesarean delivery or the presence of other factors that could increase operative time may warrant catheter-based anesthetic techniques or the addition of adjunctive medications to prolong spinal anesthetic block. Institutional and individual surgeon factors may play an even more important role in determining surgical time.

Learning from the Law. A review of 21 years of litigation for pain during caesarean section

The large majority of caesarean sections in the UK are now carried out under neuraxial anaesthesia. Although this technique is widely accepted as being the safest option in most circumstances, the use of regional anaesthesia increases the risk of patients experiencing intra-operative discomfort or pain. Pain during operative obstetric delivery is the commonest successful negligence claim relating to regional anaesthesia against obstetric anaesthetists in the UK. In the following article, using a database of over 360 cases spanning 21 years, we break down and examine the recurrent components of medicolegal claims concerning pain during caesarean section and consider how anaesthetists might avoid litigation.

Pencil-point needle bevel direction influences ED50 of isobaric ropivacaine with fentanyl in spinal anesthesia for cesarean delivery: a prospective, double-blind sequential allocation study

BACKGROUND

There is little evidence on the influence of bevel direction of a pencil-point needle on the median effective dose (ED50) of isobaric ropivacaine and fentanyl in spinal anesthesia for cesarean delivery.

METHODS

In this prospective, double-blind, sequential allocation study, 82 parturients scheduled for elective cesarean delivery under combined spinal-epidural anesthesia were included. We sought to determine the median effective dose of intrathecal 0.75% isobaric ropivacaine plus fentanyl 15μg with two different bevel directions of a 26-gauge Whitacre needle using up-down sequential allocation. Parturients were randomly allocated to either Group Ce (needle aperture oriented in a cephalad direction) or Group Ca (aperture directed caudally). The initial dose was 0.75% ropivacaine 11.25mg plus fentanyl 15μg in both groups. Each dose was classified as effective if, after 15min and during the next 60min, there was inability to appreciate pin-prick as sharp at T4, a visual analogue pain score <2 and no requirement for an epidural rescue bolus.

RESULTS

Eighty patients were included in the analysis. The ED50 in group Ca was significantly higher (13.09mg, 95% CI 12.19-14.00) than in group Ce (10.10mg, 95% CI 9.54-10.65, P <0.001).

CONCLUSION

The orientation of the distal aperture of a 26-gauge Whitacre needle during induction of spinal anesthesia for cesarean delivery influences the ED50 of 0.75% ropivacaine.

Effect of sitting position on equal-dose spinal anaesthetic for caesarean section and post-partum tubal ligation

BACKGROUND

We studied the hypothesis that an equal spinal anaesthetic dose administered in the sitting position to patients undergoing post-partum tubal ligation (PPTL) and caesarean section (CS) would yield similar sensory block characteristics and analgesic efficacy.

METHODS

This prospective, non-randomised trial recruited 20 women undergoing PPTL within 48 h of vaginal delivery and 20 undergoing CS. Spinal anaesthesia comprising intrathecal hyperbaric bupivacaine 12 mg and morphine 100 μg was administered at L3/4 with patients sitting. Our primary end point was the maximal dermatomal sensory block (to cold).

RESULTS

Baseline demographics were comparable, but PPTL patients had greater parity, with mean ± standard deviation 17.54 ± 11.2 h from delivery to spinal anaesthesia, and shorter duration of surgery, 17.54 ± 11.2 vs. 40.3 ± 15.5 min. Similar maximal sensory blocks (to cold) were achieved in group PPTL vs. CS, T4 (T1-T5) vs. T3 (T1-T5), P = 0.104, in comparable times, 8.6 ± 2.6 vs. 7.6 ± 3.0 min, P = 0.267. PPTL patients had significantly faster two-segment block regression (70.7 ± 23.5 vs. 97.6 ± 23.9 min, P = 0.001) and to T10 (120.8 ± 35.6 vs. 145.1 ± 24.3 min, P = 0.016), with less hypotension (25% vs. 65%, P = 0.025) and phenylephrine (20.0 ± 60.6 μg vs. 120.0 ± 119.6 μg, P = 0.005).

CONCLUSION

The same dose of hyperbaric bupivacaine 12 mg and morphine 100 μg administered in the sitting position to both PPTL and CS parturients yielded similar maximal sensory blocks, but PPTL exhibited faster block regression and less hypotension/vasopressor requirement.