Abstracts of free papers presented to the Obstetric ......012 Effect of P6 acupressure on nausea and...

Abstracts of free papers presented to the Obstetric Anaesthetists' Associationannual meeting in Cardiff, UK on 5-6 June, 2003

ORAL PRESENTATIONS

001 Fetal effects of combined spinal~epidural (CSE) vs epidural labour analgesia: a prospective,randomised studyN Patel, R Fernando, SC Robson, MO Colurnb, GR Lyons

002 Suprasternal Dopplerestimation of cardiac output: standard versus sequential CSE for caesarean sectionJK Bray, R Fernando, N Patel, MO Colurnb

003 A comparison of transcutaneous electrical stimulation (TES) with touch sensation to assessspinal block for caesarean sectionSAH Zaidi, IF Russell

004 A comparison of lateral, sitting and Oxford positions for CSE anaesthesia for elective caesareansectionMWM Rucklidge, MJ Paech, J Lain, S Evans, SM Yentls

005 The effect of intrathecal diamorphine on block height in elective caesarean sectionS Saxena, A Robinson, RC Wilson, MO Columb, G Lyons

006 A comparison of fentanyl and diamorphine as adjuncts in spinal anaesthesia for caesarean sectionSLane, U Misra, Z Arleen, P Evans, Q Smith

007 Prophylactic oral ephedrine: effect on hypotension after subarachnoid block for caesareansection - a double~blind, controlled, randomised trialEBright, H Brownlow, R Gande, H Underhill, H Wise, P Swayne

008 A randomised double-blind trial of Kapanol (sustained release morphine) versus placebo foranalgesia following elective caesarean sectionT Skinner, T Parris-Piper, F Storr, J Hill

009 Depot Synacthen for the treatment of post-dural puncture headacheM Ruckl/dge, S Yenl/s, M Paech, J Lain, S Yeo, R Fernando, PN Robinson, ON Lucas, M Albin

010 Combined spinal~epidural(CSE) vs epidural labour analgesia: Does initial intrathecal analgesiareduce subsequent epidural bupivacaine requirements?N Patel, R Fernando, MO Columb, JK Bray, V Sodhi, GR Lyons

011 Sevoflurane as an inhalationaI analgesic in labour: a pilot stUdyS Yeo, SM Yen!is, C Brennan, A HoJdcroft, A Stewart

012 Effect of P6 acupressure on nausea and vomiting during labourSAH Zaidi, Z Ral/que, IF Russell

013 Labour outcome in obese parturients - a prospective auditR S/vasankar, A Seghal, S Harries, RE Collis

014 Thromboelastography (TEG) changes in the post-partum periodH Grogan, H Galton, M Vucevic

015 A national survey of external cephalic version (ECV) for breech presentation in the 3rd trimesterA Swami, MC Mushambl, M Hablba, C Archdeacon

016 Staffing for obstetric anaesthesia: current UK practiceJ Thompson, V Hariharan, F Umerah, C Grange

017 A comparison of pinprick, cold and touch levels during spinal anaesthesia for caesarean sectionIF Russell

018 Accidental subdural injection during obstetric epidural block, it's commoner than you think!Epidurogram evidenceCB Collier

019 A randomised trial comparing general with spinal anaesthesia for caesarean section inpreeclamptics with a non~reassuring fetal heart traceR Dyer, I Efs, J Farbas, L Schoeman, G Torr, M James

020 Six year audit of high regional blocks in obstetric anaesthesiaM Dresner, A Brennan, J Freeman

021 An integrated pathway of care (IPOC) in obstetric anaesthesiaPE Shannon, J Collins

022 Spontaneous vaginal delivery and ambulation after "mobile" epidural analgesia in labour: theComparative Obstetric Mobile Epidural Study Group UKMJA Wilson lor COMET

81-S11

POSTER PRESENTATIONS

Labour analgesia

P01 Comparison of continuous and intermittent administration of epidural roplvacalne with fentanylfor analgesia during labourCS Moore, POW Fettes, JB Whiteside, GA McLeod, JA Wiidsmith

P02 Patient controlled analgesia for labour: a pilot studyR Sivasankar, A Seghai, SE Harries, RE Coiiis

P03 Obstetric and neonatal outcomes following continuous epidural infusion versos patientcontrolled epidural analgesia in labourJ McCormack, I Boyne

P04 Epidural block: does choice of spinal interspace affect analgesia at delivery?L Parker, JE Duggan

P05 Birth plans for labour analgesia: Tell me what you want, what you really, really want!N Waliace, DA Hili

POB Who should provide antenatal information about epidural analgesia?PA Seai, H Weliesley, MJL Scrutton

PO? The availability and value of information resources about labour analgesia used by antenatalwomenR Sharma, T Bhagat, M Trivedi, J Bamber

POS Real~time vs postnatal maternal satisfaction scores in labouring parturient with regionalanalgesiaKN Litchfield, R Agaram, J Ruddy, GP Martinelii, S Young, C Greenhalgh

POg The introduction of pain scores for the early assessment of adequate epidural analgesia in labourB Bahlmann, A Sehgal, RE Coliis

Anaesthesia for caesarean section

P10 Prevention of hypotension after spinal anesthesia for cesarean section: 6% pentastarch versusRinger's solutionEM Shilman

P11 The ED95 of hyperbaric bupivacaine in spinal anaesthesia for caesarean sectionS Saravanan, A Robinson, S Saxena, R Wilson, G Lyons

P12 ED50 of intrathecal bupivacaine with fentanyl for caesarean section, and the effect of epiduralvolume extensionN Beale, BEvans, S Chitre, C Wright, G Lyons, GM Stocks, J Crowhurst

P13 Assessing the block for caesarean section: what do we mean by touch?J Mukherjee, R Srivastava, GM Stocks

Surveys and audit

P14 Male anaesthetists: a risk factor for caesarean section under general anaesthesia?K Robins, S CiJau, G Lyons

P15 Caesarean section under general anaesthesia: an audit of practiceM Way, I Rice, W Hodge, S Hughes

P16 A retrospective audit of the use of general anaesthesia for caesarean sectionsDA Baines, JH Bamber

P17 Anaesthesia for caesarean section: a ten year survey in a UK regionJG Jenkins, MM Khan

P18 Anaesthetic delivery times for caesarean section at Queen Elizabeth Central Hospital, Blantyre,Malawi: is a 3D-minute informed to start of operative delivery time achievable?M O'Regan

P19 Complications following obstetric anesthesia in an obstetric referral center: a prospectiveevaluation in 6976 patients over a 4-year periodC Vandewaeter, A Teunkens, E Vandermeersch, B Spitz, M Hanssens, M Van de Velde

P20 Survey of anaesthetic management of twin deliveriesVL Tucker, H Swales Southampton General Hospital, Southampton, UK

P21 A survey of the management of failed or inadequate regional anaesthesia for caesarean sectionP Suaris, V Skelton

P22 A survey of obstetric practice: elective caesarean section; the place for partnersA Brand, I Wrench

S12-S41

P23 Training in obstetric anaesthesia in the UK: a national surveyJ Robinson, J Crowhurst, F Piaat

P24 Prophylactic administration of ranitidine to women in labour: an audit cycleo Duncan, SA Thompson, AF McCrae

P25 Recovery from anaesthesia in obstetrics: an audit of midwifery skills in the recovery areaCR Evans, FJ MeGiii, S Morris

P26 Audit of anaesthetic record~keepingduring caesarean sectionS Halder, R Sanders, C Hopkins, J Ourbridge, SM Yentis

P27 Syntocinon management of the third stage at caesarean section: an audit of the introductionof 5-unit bolusS May, P Stone, I Keslin, J Reid

P28 An audit of blood transfusions in obstetricsP Whiting, JD Alderson

High risk

P29 Impact of obstetric anaesthetic high risk referrals on supporting specialtiesA Nasil), I(N LitcM/eld, 0 Smith, S Young

P30 Care of the obstetric patient with cardiac disease: a retrospective survey of 61 parturientsCR Evans, AM Nadra, J Rogers, RE Coiiis

P31 An audit of thromboembolism risk assessment of mothers in labourM Abdel·Haliz, T O'Hare, R Sashidharan

P32 Pregnancy induced hypertension - time to redefine?KOng, R Sashidharan

P33 PerRoperative oesophageal Doppler monitoring in a parturient with Eisenmenger's SyndromeNL Purdie, GA McLeod, JK Nanson

P34 Anaesthetic management of achondroplasia for caesarean sectionSR Oeslkan, AS Badhe

Postoperative (analgesia and miscellaneous)

P35 Dose response to spinal diamorphine in the presence of regular NSAID therapy: a study inpatients undergoing caesarean sectionIJ Wrench, S Sangl1era, A Pinder, L Power, JE Peacock, RJS Birks, VJ Webster, DB Shepherd, MG Adams

P36 The effects of intrathecal diamorphine on gastric emptying after elective caesarean sectionH King, P Barclay

P37 Oral intake following caesarean section: a survey of postoperative fasting times and a telephonesurvey of practice in other unitsI~ '(au,., L Power, I Wrench, S Glover

P3B A comparison of intravenous patientRcontrolled analgesia morphine and subcutaneous morphinefor analgesia after caesarean sectiono Mitra, Fi I(umar, S Smith, E McGrady, F Bryden

1:>:~9 Postoperative pain relief, pruritus and nausea after cesarean section: comparison ofintraoperative propofol and droperidollpentazocineY Namba

Simulation

P40 The 'Managing Obstetric Emergencies and Trauma' (MOET) course: views of course participantsNL Lewis, S Wieteska, C Cox, K Grady

P41 Simulator~based learning for obstetric anaesthesiaT Blackburn, C Sadler, P Howell

P42 Management of eclampsia: a pilot stUdy on the effects of simulation on performanceOS Earl, SGO Fiees

P43 Obstetric "fire drills" surveyT Blackburn, C Sadler

Techniques

P44 A simple technique to reduce the incidence of loss of local anaesthetic solution during injectionfor spinal anaesthesiaJM Morgan, I Wrench

P4S Mechanism of epidural paresthesia: is it the catheter or needle?MAllen, G Vasdev, C Burkle, R MacKenzie, P Southam

P46 Is 81 motor block a reliable indicator of accidental intrathecal injection of levobupivacaine?S Babu, B Bahlmann, WW Mapleson, RE Collis

P47 In vitro changes in heparin resistance during pregnancy using thrombolelastography (TEG®)J Cropp, H Gorton, G Lyons

Non trainee posters

P48 Luer lock versus bayonette lock for spinal anesthesia during a combined spinal epiduraltechniqueF Chaudhry, K Scott, B Harrison, G Vasdev

P49 Use of the pulse contour cardiac output (PiCCO) monitor in caesarean section in a parturient withmitral stenosisTML Chan, P Groves

PSG Caesarean section for severe pre~eclampsia: a survey of UK consultant obstetric anaestheticpracticeWJ Wighl, V By/hell

P51 Vasodilatation by magnesium in the dorsal hand veinR Landau, JA Scott, RM Smiley

P52 Ambulatory epidural analgesia and the duration of laborM Karraz

P53 Survey of audit practices in United Kingdom obstetric anaesthesiaM Dresner

P54 A critical analysis of the incidence of caesarean section in Latin America: A ColombianexperienceC Restrepo, M Arango, N Socha, M Campo, A Gomez, S Ram/rez

P55 Urgency of caesarean section: do obstetricians and anaesthetists agree?SM Kinsella, MJL Scrutton

P56 Survey of anaesthetic support staff in obstetric units in England and WalesA Qureshi, M Slevens, F Plaa/

P57 The role of the anaesthetist in mother's experiences of elective caesarean section: a pilot studyS Hughes, A Holdcrolt, E Keogh

P58 PreRoperative anxiety and post operative satisfaction in women undergoing elective caesareansectionJA Hobson, P Slade, I Wrench, L Power

PS9 Comparative obstetric mobile epidural trial (COMET): epidural fentanyl dose and neonataloutcomesM Lewis on behalf of The COMET Study Group

O01. Fetal effects of combined spinal-epidural (CSE)vs. epidural labour analgesia: a prospective,randomised studyN. Patel, R. Fernando, S. Robson,* M. Columb, G. LyonsDepartment of Anaesthesia, Royal Free Hospital,London and *Fetal Medicine, Royal Victoria Infirmary,Newcastle, UKIntroduction: Fetal heart rate (FHR) abnormalitieshave been associated with intrathecal analgesia morefrequently than epidural analgesia for labour.1 Our aimwas to determine if there was a difference in cardioto-cograph (CTG) patterns, Apgar scores and umbilicalcord acid-base status following initiation of labour an-algesia via the intrathecal or epidural route.

Method: After ethics approval, 115 healthy women at 2–6 cm cervical dilatation requesting regional analgesiawere recruited to this prospective, double-blind study andrandomised into 2 groups: epidural group received 0.1%bupivacaine 20 mL + fentanyl 2 lg/mL; CSE group re-ceived intrathecal bupivacaine 2.5 mg + fentanyl 5 lg.The CTG was recorded for 30 min before the injectionand for 60 min after. Baseline FHR, variability, number ofaccelerations per hour and number of decelerations wererecorded. Traces were categorised as pathological, sus-picious or normal according to NICE guidelines.2 Modeof delivery, Apgar score, umbilical artery (UA) pH andbase excess (BE) were recorded. Data were analysed byintention-to-treat and included repeated measures analy-sis of variance, v2 and McNemar tests.

Results: Patient data, obstetric characteristics, mode ofdelivery, Apgar scores and umbilical cord gases weresimilar between groups. A total of 113 CTGs were anal-ysed. There were no differences in CTG variables be-tween groups. However within groups, there was asignificant increase in the total number of pathologicaland suspicious CTGs (P < 0.05) and a reduction in ac-celeration rate (P < 0.01) after injection.

Outcome measure Epidural (n = 53) CSE (n = 62)

Before After Before After

Baseline FHR (bpm) 134 (8) 135 (10) 135 (9) 136 (9)Variability (bpm) 10 (3.5) 9.7 (3.7) 9.6 (2.6) 9.9 (3.1)*Accelerations (n/h) 11 {0.8} 8.4 {0.8} 12 {0.8} 9.9 {0.8}Decelerations (n) 4 16 9 14Pathological CTG (n) 0 4 1 3*Suspicious CTG (n) 0 7 1 5Apgar 1 and 5 min 9[9,9]; 10[10,10] 9[9,9]; 10[10,10]UA pH 7.25 {0.01} 7.23 {0.01}UA BE (mmol/L) �8.22 {0.76} �7.87 {0.73}

Data are number, mean (SD)/{SEM}, or median [IQR]. *P < 0.05.

Conclusion: No significant difference was found inCTG variables, Apgar scores or umbilical cord acid-basestatus between women who received initial intrathecalor epidural labour analgesia.

References1. Palmer C M, Maciulla J E, Cork R C et al. The incidence of

fetal heart rate changes after intrathecal fentanyl labor analgesia.Anesth Analg 1999; 88: 577–581.

2. National Institute for Clinical Excellence (NICE): ClinicalGuideline C. The use of electronic fetal monitoring, 2001.

O02. Suprasternal Doppler estimation of cardiacoutput: standard versus sequential combined spinalepidural anaesthesia for caesarean sectionJ. K. Bray, R. Fernando, N. Patel, M. O. ColumbDepartment of Anaesthesia, Royal Free Hospital,London, UKIntroduction: Sequential combined spinal epidural(Seq CSE) anaesthesia using a lower intrathecal dosemay provide better cardiovascular stability compared toa standard dose (Std CSE),1 especially for high-riskwomen requiring caesarean section. The aim of ourstudy was to compare cardiac output using suprasternalDoppler in women undergoing caesarean section undereither Std CSE or Seq CSE anaesthesia.

Method: Following ethics approval, 40 healthy womenat term scheduled for elective caesarean section underregional anaesthesia were recruited and randomised totwo groups. Baseline recordings of heart rate (HR),blood pressure (BP), linear and volumetric Doppler in-dices were made in the left lateral tilt position before andafter intravenous fluid preloading. All CSE procedureswere performed in the sitting position. All women re-ceived intrathecal fentanyl 15 lg with either hyperbaricbupivacaine 10 mg (Std CSE) or bupivacaine 5 mg (SeqCSE). An additional 10 mL of epidural bupivacaine0.5% w/v was given at 15 min to the Seq CSE group ifpredefined sensory targets were not met. The Std CSEgroup received epidural supplementation at 20 min forthe same criteria. BP, HR, cardiac output (CO), minutedistance (MD), stroke distance (SDist), stroke volume(SV), peak velocity (PV) and corrected flow time (FTc)were measured at 5-min intervals after intrathecal in-jection and before surgery. Ephedrine 6 mg was givenfor 20% reductions in BP. Statistical analyses includedrepeated measures analysis of variance (RMANOVA)and covariance (ANCOVA) of extreme measures.

Results: Patient data, ephedrine use, HR, BP and COwere similar in groups. Fluid preload increased allDoppler indices (RMANOVA P < 0.005). SDist and SVwere lower following Seq CSE (ANCOVA P < 0.05),with serial measures showing greater within-subjectvariability (variance ratio test P < 0.05).

Group MD(cm)

CO(L/min)

SDist*(cm)

SV*(ml)

PV(cm/s)

FTc(ms)

Std CSE(n = 20)

1404.18(217.44)

5.26(1.04)

17.51(2.73)

63.94(10.76)

96.33(7.61)

361.69(41.11)

Seq CSE(n = 20)

1408.30(217.41)

4.86(1.37)

16.41(4.54)

55.39(16.78)

92.89(16.20)

356.85(41.11)

Data are mean (SD) for lowest recorded measure; *P < 0.05.

Conclusion: SDist and SV changes following sequen-tial CSE for caesarean section suggest no overall im-provement in cardiovascular stability compared withstandard CSE.

Reference1. Thoren T, Holmstrom B, Rawal N, Schollin J, Lindeberg S,

Skeppner G. Sequential combined spinal epidural block versusspinal block for cesarean section: effects on maternal hypotensionand neurobehavioral function of the newborn. Anesth Analg 1994;78: 1087–1092.

International Journal of Obstetric Anesthesia (2003) 12, S1–S11doi:10.1016/S0959-289X(03)00043-8

O03. A comparison of transcutaneous electricalstimulation (TES) with touch sensation to assessspinal block for caesarean sectionS. A. H. Zaidi, I. F. RussellDepartment of Anaesthesia, Castle Hill Hospital,Cottingham, Hull, UKIntroduction: The current recommended level of blockfor caesarean section under spinal anaesthesia is touchsensation blocked to T5. Some do not accept touch is asuitable modality since it cannot predict appreciation ofTES stimulation.1 However, TES as a surrogate stimulusfor surgery under spinal anaesthesia has only been as-sumed – it has never been tested. We set out to test thisassumption.

Method: After ethics approval, the levels of block topinprick and touch (Neurotip) and TES of 12 womenhaving spinal anaesthesia (0.5% heavy bupivacaine 2.5–3 mL plus diamorphine 100 lg/mL) for elective cae-sarean section were recorded at 2, 5, 10, 15 and 20 minand then every 10 min until the end of surgery. TES wasassessed using a peripheral nerve stimulator connectedvia an electronic multiplexer to 5 pairs of ECG elec-trodes. These were placed in close pairs at the L3, T10,T6, T2 and C5 dermatomes. At 1-s intervals a 1-s burstof 10 mA at 50 Hz was applied to each electrode pair inturn. All testing was performed moving in a cranial di-rection from the groin.

Results: As in previous studies, no correlation wasfound between touch and TES appreciation. However,neither was any relationship between TES levels andpain-free surgery observed. The levels of block to TESpaired with their associated levels of block to touchduring closure are shown in the figure.

The TES levels at delivery also ranged from L2 to T6while the block to touch always included T6 and above.Conclusion: The level of block to TES during pain-freecaesarean section ranges from L2 to T2. Appreciation ofTES stimuli at 10 mA and 50 Hz cannot be used topredict a pain-free caesarean section.

Reference1. Sakura S, Sakaguchi, Y, Shinzawa M, Hara K, Saito Y. The

assessment of dermatomal level of surgical anaesthesia after spinaltetracaine. Anesth Anal 2000; 90: 1406–1410.

O04. A comparison of lateral, sitting and Oxfordpositions for CSE anaesthesia for elective caesareansectionM. W. M. Rucklidge,*,� M. J. Paech,* J. Lain,*S. Evans*, S. M. Yentis�

Departments of Anaesthesia, *King Edward MemorialHospital, Perth, Australia and �Chelsea & WestminsterHospital, London, UKIntroduction: Studies investigating the influence ofmaternal position on CSE anaesthesia for caesareansection have produced conflicting results.1,2 We con-ducted a randomised study comparing three positions forinduction of CSE anaesthesia.

Method: Following ethical approval, 100 healthywomen presenting for elective caesarean section werestudied. After a 10-mL/kg crystalloid preload, parturi-ents were randomised to the left lateral (group L),Oxford (group O) or sitting (group S) position beforespinal anaesthesia with 0.5% heavy bupivacaine2.5 mL + fentanyl 10 lg using a CSE technique. Par-turients in group L were then turned to right lateral,group O turned to right Oxford and group S to supineleft wedged positions until ready for surgery. Maternalblood pressure was recorded regularly and ephedrineadministered according to strict protocol. Time toachieve surgical anaesthesia (loss of light touch to T5bilaterally) and highest sensory level were recorded.Statistical analysis included Kruskal Wallis and FishersExact tests with a 0.05 and b 0.9.

Results: Data were available from 96 women

Lateral(n = 29)

Oxford(n = 32)

Sitting(n = 35)

P

Pre-incisionephedrine (mg)

21(12–30)[6–48]

18(7.5–24)[6–48]

12(6–21)[6–42]

0.044

Total ephedrine(mg)

30(18–30)[6–66]

21(18–30)[6–54]

18(11–23)[6–38]

0.055

Time to T5(min)

9(6–3)[4–30]

15.5(9–22)[4–34]

14(9–18)[6–36]

0.004

Needed top-upto reach T5 (n)

1 (3) 7 (22) 1 (3) 0.012

Values are median (interquartile range [range]) or number (%).

There were no significant differences in blood pres-sure or neonatal outcome.

Conclusion: Surgical anaesthesia for elective caesareansection is most quickly achieved after CSE anaesthesiain the lateral position; although ephedrine requirementsbefore re-positioning for surgery may be less in thesitting position. The Oxford position does not appear toconfer any additional advantages.

References1. Patel M, Samsoon G, Swami A, Morgan B. Posture and the spread of

hyperbaric bupivacaine in parturients using the combined spinalepidural technique. Can J Anaesth 1993; 40: 943–946.

2. Russell R, Popat M, Richards E, Burry J. Combined spinal epiduralanaesthesia for caesarean sections: a randomised comparison ofOxford, lateral and sitting positions. International Journal ofObstetric Anesthesia 2002; 11: 190–195.

International Journal of Obstetric AnesthesiaS2

O05. The effect of intrathecal diamorphine on blockheight in elective caesarean sectionS. Saxena, A. Robinson, R. C. Wilson,M. O. Columb, G. LyonsDepartment of Obstetric Anaesthesia, St. James’sUniversity Hospital, Leeds, UKAims: Opiate analgesics are commonly added to intra-thecal bupivacaine to improve patient comfort duringcaesarean delivery (CS). The addition of diamorphine tobupivacaine in spinal anaesthesia may reduce the doseof the latter needed for an effective dermatomal blockheight.1 The aim of this study was evaluate the impact ofintrathecal diamorphine on block height, by comparingthe doses of bupivacaine required to achieve a T5 block,with and without intrathecal diamorphine, using se-quential allocation.

Methods: Women scheduled for elective CS, ASAgrades I–II, with a single healthy fetus, height range150–180 cm and weight 50–120 kg, were randomisedinto two groups. Group A were assigned to spinal an-aesthesia with bupivacaine alone. Group B received in-trathecal bupivacaine with diamorphine 400 lg using asyringe-blinding technique. The doses of intrathecalbupivacaine were calculated according to the up anddown dosing technique. The starting dose of bupivacaineused in both groups was 13 mg. When block heightreached T5, the dose of bupivacaine was considered ef-fective, and a decrement of 0.5 mg of bupivacaine wasgiven to the next woman. Failure to reach T5 meant anincrease in dose for the next woman, and an epiduralbolus to achieve a comfortable block. Doses given wereanalysed using the Dixon and Massey up and down for-mula.2 Using data from a previous study, group size wasset at 40.Results: The two groups were comparable in terms ofsubject characteristics. The mean (95% CI) doses for thetwo groups were 10 (9.68–10.52) mg for group A and9.5 (9.02–9.97) mg for group B (NS).

Conclusions: The addition of diamorphine to intrathe-cal bupivacaine does not affect the height of the blockachieved by this local anaesthetic agent in elective CSwith spinal anaesthesia.

References1. Choi D H, Ahn H J, Kim M H. Bupivacaine-sparing effect of

fentanyl in spinal anesthesia for cesarean delivery. Reg Anesth PainMed. 2000; 25: 240–245.

2. Dixon W J, Massey F J. Intoduction to Statistical Analysis, 4th Ed.New York: McGraw-Hill, 1983: 428–439.

O06. A comparison of fentanyl and diamorphine asadjuncts in spinal anaesthesia for caesarean sectionS. Lane, U. Misra, Z. Arfeen, P. Evans, Q. SmithDepartment of Anaesthesia, Sunderland RoyalHospital, UKIntroduction: Intrathecal diamorphine is commonlyused to provide analgesia after caesarean section. Stud-ies have shown that it is equally1 if not more effective2

than morphine in equivalent doses. However, morphinedoes not provide any intra-operative coverage, and isoften used in conjunction with fentanyl. Diamorphinecould possibly be used to provide both intra-operativeand postoperative analgesia whilst avoiding excesspruritus and hypotension.

Method: In a randomised, double-blinded trial, 99 pa-tients presenting for elective caesarean section werestudied. Each patient was given either fentanyl 15 lg(F), diamorphine 0.25 mg (D), or both (FD) in additionto heavy 0.5% bupivacaine. Discomfort, nausea, pruri-tus, ephedrine use and time taken to establish block wererecorded intra-operatively, and discomfort, morphinePCA use, nausea and pruritus postoperatively.

Results: Analysis of variance revealed the following.There were no differences in intra-operative discomfort,time to achieve block or intra-operative ephedrine usebetween the groups. There was no difference in post-operative PCA use between te groups D and FD, butPCA use was significantly greater in group F. Postop-erative pruritus was significantly more prevalent ingroup FD than in the other groups.

Conclusion: The results show that diamorphine pro-vides the same intra-operative benefit as fentanyl, withno increase in time to achieve adequate block. We havealso demonstrated that diamorphine provides the samepostoperative analgesia as fentanyl and diamorphinecombined, but with less pruritus.

References1. Barkshire, Russell R. A comparison of bupivacaine-fentanyl-

diamorphine with bupivacaine-fentanyl-morphine for caesareansection under spinal anaesthesia. International Journal of ObstetricAnesthesia 2001; 10, 4–10.

2. Husani S W, Russell I F. Intrathecal diamorphine compared withmorphine for postoperative analgesia after caesarean section underspinal anaesthesia. Br J Anaesth 1998; 81: 135–139.

S3Oral presentations

O07. Prophylactic oral ephedrine: effect onhypotension after subarachnoid block for caesareansection – a double-blind, controlled, randomised trialE. Bright, H. Brownlow, R. Gande, H. Underhill,H. Wise, P. SwayneSalisbury District Hospital, Wiltshire, UKIntroduction: Maternal hypotension remains the mostfrequent complication of spinal anaesthesia for caesar-ean section. This can have adverse consequences forboth mother and baby. Ephedrine is the vasoconstrictormost commonly used in obstetric practice in the UK.The oral route of administration offers potential advan-tages; peak plasma levels are lower so reducing thepossibility of maternal tachycardia and hypertension.Orally administered ephedrine (30 mg) has been suc-cessfully used to reduce the incidence of hypotensionfollowing spinal anaesthesia in a trial involving 200women undergoing lower abdominal surgery.1

Methods: After ethics committee approval, 40 womenwere randomised to two groups by sealed sequentialenvelopes. Each participant received an identical capsulethat was either placebo or contained ephedrine 30 mg.This was taken by mouth one hour before institution ofthe spinal anaesthetic. All participants then receivedHartmann’s solution 15 mL/kg before subarachnoid in-jection of 0.5% heavy bupivicaine 2.5 mL and diamor-phine 0.25 mg, using a 25-gauge pencilpoint needle withthe patient in the sitting position on the operation table.On completion of the injection, the patient was posi-tioned supine and left-tilted by 15�. Patients were givenbolus injections of rescue ephedrine 6 mg on each oc-casion their systolic blood pressure was less than 80% ofthat recorded before the spinal injection. The patient wasasked to report feelings of nausea using a visual analoguescale. Apgar scores were recorded 1 and 5 min after birthas were umbilical venous pH values. Statistical analysiswas performed using the Mann-Whitney test.Results: There was no significant difference betweengroups in amount of intravenous rescue ephedrine re-ceived, total amount of fluid administered intraopera-tively or visual analogue scores for nausea. Apgarscores at 1 and 5 min did not differ between the groupsbut there was a difference in the umbilical vein pHvalues. Neonates of mothers in the ephedrine group hada median umbilical vein pH of 7.33, which was lowerthan that of the neonates of mothers in the placebogroup, their median pH being 7.37 (P = 0.0209).

Conclusion: Prophylactic oral ephedrine administeredto mothers before subarachnoid block for caesareansection is not recommended.

Reference1. Prophylactic oral ephedrine reduces the incidence of hypotension

after subarachnoid block. Can J Anaesth 1994; 41: 1091–1093.

O08. A randomised double-blind trial of Kapanol(sustained release morphine) versus placebo foranalgesia following elective caesarean sectionT. Skinner, T. Parris-Piper, F. Storr, J. HillDepartment of Anaesthesia, National Women’s Hospital,Auckland, NZIntroduction: There is currently considerable diversityin the management of pain following caesarean section.Opiate drugs such as morphine are often given via in-travenous, intramuscular, spinal or epidural routes andcan be combined with regular paracetamol and non-steroidal anti-inflammatory drugs. Kapanol capsules area modified release formulation providing more consis-tent plasma levels of morphine than oral morphinetablets, allowing them to be given once or twice daily.1

They have been used extensively in Australasia forcontrol of postoperative and chronic pain. We aimed toevaluate the efficacy of Kapanol when used in the first24 h following elective caesarean section.

Method: Ethics committee approval was obtained forthe study, which recruited 60 patients divided into twogroups. ASA I and II patients undergoing elective cae-sarean section were given standard non-opioid combinedspinal-epidural (CSE) anaesthesia. Immediately after theoperation, group K received Kapanol 40 mg and group Pan identical placebo, as selected by a block randomisa-tion in this double-blind technique. Twelve hours latergroup K received a further 20-mg dose of Kapanol andgroup P another placebo. Both groups received pethidinevia a patient controlled epidural analgesia (PCEA) pumpalong with regular paracetamol and diclofenac. Pain wasrecorded at 4, 8 and 24 h, using visual analogue scores.Pethidine consumption was recorded hourly with totalsat 24 h.

Results: The groups were demographically similar with4 withdrawals in each group following randomisation.Contrary to expectation, there was not a statisticallysignificant reduction in PCEA pethidine consumption inthe first 24 h after operation associated with the use ofKapanol. There were no significant differences in painscores between the two groups. There was, however, astatistically significant increase in sedation in theKapanol group across 24 h (sedation score >1/4: groupP; n = 13, group K; n = 2, P = 0.002) although nopatient felt excessively sedated.

Conclusion: Kapanol confers no analgesic benefitwhen given to patients using PCEA pethidine in the first24 h after caesarean section. Further study is required toevaluate the benefit of Kapanol in the transition fromepidural to oral analgesia, more than 24 h after surgery.

Reference1. Gourlay G K. Sustained relief of chronic pain. Pharmacokinetics

of sustained relief morphine. Clin Pharmacokinet 1998; 35:173–190.


O09. Depot Synacthen for the treatment ofpost-dural puncture headacheM. Rucklidge,*,� S. Yentis,* M. Paech,� J. Lain,�

S. Yeo,* R. Fernando,� P. N. Robinson,§

D. N. Lucas,* M. Albin–

Departments of Anaesthesia, *Chelsea & WestminsterHospital, London, UK, �King Edward MemorialHospital, Perth, Australia, �Royal Free Hospital,London, UK, §Northwick Park Hospital, Harrow, UKand –Lewisham Hospital, London, UKIntroduction: Adrenocorticotrophic hormone (ACTH)and its synthetic analogue Synacthen have been reportedto be effective treatments for post dural puncture head-ache (PDPH), although evidence of efficacy remainsanecdotal.1,2 We conducted a double-blind randomisedstudy investigating the effectiveness of Synacthen forthe treatment of PDPH.

Methods: After ethical approval and written informedconsent, 18 women with PDPH within 72 h of docu-mented dural puncture were randomised to receive depotSynacthen 1 mg or saline 1 mL i.m. Severity of PDPHwas measured using a 10-cm visual analogue scale(VAS) after sitting upright for 1 min, before and at in-tervals for 48 h after injection. Data were analysed usingthe Mann-Whitney rank-sum or Fisher’s exact tests, withP < 0.05 taken as statistically significant.Results: The groups were similar for age, weight,height, parity, gestation and onset of PDPH. There wasno difference in the severity of PDPH (Figure) or re-quirement for epidural blood patch (6/9 (67%) followingSynacthen and 7/9 (78%) after saline).

Conclusion: This study does not support the use ofSynacthen 1 mg i.m. for parturients with PDPH. Thenumber of subjects involved is small, however, and weare unable to comment whether a different dose ormethod of administration may be beneficial.

References1. Collier B B. Treatment for post dural puncture headache. Br J

Anaesth 1994; 72: 366–367.2. Kshatri A M, Foster P A. Adrenocorticotropic hormone infusion

as a novel treatment for postdural puncture headache. Reg Anesth1997; 22: 432–434.

O10. Combined spinal-epidural (CSE) vs. epidurallabour analgesia: does initial intrathecal analgesiareduce subsequent epidural bupivacaine requirements?N. Patel, R. Fernando, M. O. Columb, J. K. Bray,V. Sodhi, G. R. LyonsDepartment of Anaesthesia, Royal Free Hospital,London, UKIntroduction: It has been suggested that intrathecalanalgesia via the CSE technique during the first stage oflabour may reduce subsequent epidural bupivacaine re-quirements. Our aim was to estimate the minimum localanalgesic concentration (MLAC) or median effectiveconcentration (EC50) of epidural bupivacaine1 follow-ing an initial intrathecal or epidural injection.Method: After ethics approval, 115 women requestingepidural analgesia at 2–6 cm cervical dilatation were re-cruited into this prospective, double-blind study andrandomised to 2 groups: the epidural group received 0.1%bupivacaine 20 mL + fentanyl 2 lg/mL as first injection(1st inj); CSE group – received intrathecal bupivacaine2.5 mg + fentanyl 5 lg. Analgesia was assessed using a100-mm visual analogue pain score (VAPS). Only womenwith effective analgesia (VAPSO10 mm at 30 min) wereincluded. When further analgesia was requested, bupiva-caine 20 mL was given (2nd inj). The concentration wasdetermined by the response of the previous subject in thatgroup. An effective dose (VAPS O10 mm 30 min after2nd inj) directed a 0.01%decrementwhereas an ineffectivedose directed a 0.01% increment for the next subject. Du-ration of analgesia, VAPS and sensory block height at 0, 15and 30 min were assessed for both injections. The MLACof epidural bupivacaine for the 2nd inj was estimated usingthe Dixon and Massey formula. Repeated measures anal-ysis of variance was used, with P < 0.05 significant.

Results: Eighty women completed the study. Patientdata, obstetric characteristics andVAPSat each time pointwere similar in the two groups. MLAC estimates showedthat bupivacaine requirements were increased by a factorof 1.38 in the CSE group (95% CI 0.95–2.06, P = 0.078).Compared to the epidural group, block height was sig-nificantly lower after the 1st inj (P = 0.02) and before the2nd inj (P < 0.001) in the CSE group.

Group *MLAC %(95% CI)

�Duration1st

inj, minmean (SD)

Max blockheight to pinprick:

median (IQR)

�Post 1st inj �Pre 2nd inj

Epidural 0.034 111 (38) T6 T9(n = 40) (0.02, 0.05) (T8, T4) (T11, T7)CSE 0.047 86 (21) T8 L1(n = 40) (0.04, 0.05) (T10, T6) (L4, T10)

*Unpaired t test P = 0.078; �P < 0.001; �P = 0.02.

Conclusion: Initial intrathecal analgesia did not reducesubsequent epidural bupivacaine requirements. The 38%increase in MLAC with CSE may be due to the greaterdegree of analgesic block height regression.

Reference1. Columb M O, Lyons G R. Determination of the minimum local

analgesic concentrations of epidural bupivacaine and lidocaine inlabor. Anesth Analg 1995; 81: 833–837.

Figure: Severity of PDPH after saline (shaded) and Synacthen (clear).P > 0.05. Data are median, interquartile range and range.


O11. Sevoflurane as an inhalational analgesic inlabour: a pilot studyS. Yeo, S. M. Yentis, C. Brennan, A. Holdcroft,A. StewartMagill Department of Anaesthesia, Chelsea &Westminster Hospital, London, UKIntroduction: Inhalational anaesthetic agents such asisoflurane1 and enflurane2 have been used for pain reliefin labour but maternal intolerance and side effects havelimited their effectiveness for routine use. Sevoflurane israpidly acting and pleasant to breathe, but has not beenstudied for use in labour. The aim of this study was todetermine the optimum sevoflurane concentration foruse as an inhalational analgesic in labour.

Methods: After local research ethics committee ap-proval and informed written consent, 22 parturients wererecruited antenatally. Once in established labour andrequesting inhalational analgesia, they self-administeredsevoflurane via a mouthpiece using a Penlon OMVdraw-over vaporiser with continuous monitoring of in-spired and expired gases throughout 10 consecutivecontractions. The inspired concentration of sevoflurane(FISevo), initially at 0%, was increased by 0.2% for eachcontraction to a maximum of 1.4%, and decreased ifexcessive sedation occurred (inability to complete themeasurement scores). Maternal pulse, BP and SpO2 andfetal CTG were monitored continuously. Between con-tractions, mothers were asked to score their previouscontraction using a visual analogue scale (VAS) of0-100 mm for pain relief and sedation.

Results: All but one woman completed the study. Bothpain relief and sedation scores increased between FISevo0.4% and 1.2% (Table). There was no increase in painrelief score beyond FISevo 0.8%. No adverse eventswere observed apart from excessive sedation in fourwomen (19%) at 1.2%. None experienced excessivesedation at 1.0% or 0.8%.

Table: Median (IQR) [range] VAS scores (mm)

FISevo 0.4% 1.2%

Pain relief 44 (43–56) [4-93] 74 (72–78) [50–80]Sedation 55 (43–56) [0–98] 71 (71–73) [33–97]

Conclusions: We conclude that the optimum FISevofor pain relief in labour is 0.8%. This will provide thebest balance between pain relief and sedation, thus al-lowing a safety margin from excessive sedation and anycumulative effects which may occur during prolongeduse.

Acknowledgements: Midwives M. Good, M. Hunter and F.Walkinshaw for their enthusiasm in recruiting women. S. Yeo wassupported by an OAA Research Fellowship.

References1. Wee M Y K, Hassan M A, Thomas T A. Isoflurane in labour.

Anaesthesia 1993; 48: 369–372.2. McGuiness C, Rosen M. Enflurane as an analgesic in labour.

Anaesthesia 1984; 39: 24–26.

O12. Effect of P6 acupressure on nausea andvomiting during labourS. A. H. Zaidi, Z. Rafique, I. F. RussellDepartment of Anaesthesia, Castle Hill Hospital,Cottingham, Hull, UKIntroduction: Nausea and vomiting represent a signif-icant problem for the majority of women during labourand routine anti-emetics are commonly prescribed.Acupressure at P6 (Neiguan point) is a non-invasive,non-pharmacological method to prevent this commoncomplaint. It has been shown to reduce nausea andvomiting after opioid administration, regional and gen-eral anaesthesia and during pregnancy.1 This techniqueis appealing due to its apparent simplicity, ease of ap-plication, safety and cost-effectiveness. We designedthis study to find out if it is effective during labour.Method: After ethics approval for this randomiseddouble blind study, 80 patients were recruited intotreatment and control groups. All patients above 18years presenting for normal delivery were included andwomen with prior knowledge or experience of usingacupressure or acupuncture were excluded. Patientswere not given routine anti-emetics. The wrist bandswere positioned correctly in the treatment group andincorrectly in the control group. Nausea and vomitingwere assessed two hourly using 100-mm visual analogue(VAS) and verbal rating scales (VRS). The number ofepisodes of active vomiting and rescue drugs used totreat it were also recorded. The wrist bands were re-moved two hours after the delivery.

Results: Although there was a difference at VAS scoreat 2, 4 and 8 h after the application of acupressure bandsbetween the groups, this difference was not found to bestatistically significant. Fourteen patients had a historyof motion sickness out of which 10 were in the treatmentgroup. 20% of patients required rescue anti-emetic in thecontrol group and 5% in the treatment group (P = 0.05).

Controlgroupn = 40

Treatmentgroupn = 40

P

Mean age (years) 28.5 29.1 0.6Mean weight (kg) 78.48 76.23 0.4Mean VAS (mm) 0 h 3.7 6.03 0.46(nausea and vomiting) 2 h 13.48 5.66 0.09

4 h 10.57 6.91 0.48 h 27.00 10.00 0.112 h 12.85 8.00 0.5

H/O motion sickness 4 (10%) 10 (25%)Required rescue drug 8 (20%) 2 (5%) 0.05

Conclusion: The incidence of nausea and vomiting wasless in the treatment group than the control group asshown in the previous studies but the difference was notstatistically significant.

Reference1. O’Brien B, Relyea M J. Efficacy of P6 acupressure in the treatment

of nausea and vomiting during pregnancy. Am J Obstet Gynecol1996; 174: 708–715.


O13. Labour and anaesthetic outcome in obeseparturients: a prospective auditR. Sivasankar, A. Seghal, S. Harries, R. E. CollisDepartment of Anaesthetics, University Hospital ofWales, Cardiff, UKIntroduction: Obesity (BMI >30 kg�m–2) is a signifi-cant in western societies and it is increasingly recogni-sed that pregnancy in the obese is associated with highobstetric intervention rates and a poorer outcome1

compared to the non-obese.

Methods: The BMIs of all women coming to the an-tenatal clinic were recorded, and 120 whose bookingBMI values were over 30 kg�m)2 were followed untildelivery with recordings of labour outcome and anaes-thetic interventions.Results: From April to September 2002, 1130 mothersbooked at the University of Wales, Cardiff, for theirantenatal care. Of these, 211 had a booking BMI > 30kg�m)2 (18.7%).

BMI (kg�m)2) Induction rate Caesarean section rate

Overall population 23.6% 26.6%30–40 36.7% 36.3%>40 33.3% 44.4%

The caesarean section rate in primipara with a BMIof 30–40 kg�m)2 was 46.9% which increased to 50%in women with a BMI > 40 and in multipara witha BMI 30–40 the caesarean section rate was36.6% increasing to 42.4% in women with BMI >40. Eighty-four obese women received anaesthesia(70%), compared with 34% in the whole population.The anaesthetics received by the women were: epi-dural 46, CSE 18, spinal 19 and general 1. There wereseveral difficulties siting regional blocks but therewere no major complications and the majorityworked well for labour and delivery. There were threestillbirths and three admissions to the special babycare unit for preterm delivery in the obese group.

Conclusion: Obesity is a major problem in our popu-lation. Our audit confirms the work of others thatpregnancy and delivery in the obese parturient require ahigher than normal rate of obstetric intervention. Despitesome technical problems, our audit additionally dem-onstrates that with early, timely anaesthetic involvementit was possible to perform almost all operative deliveriesusing a regional technique, thus reducing the risks ofgeneral anaesthesia in this high-risk population.

Reference1. Bongain A, Isnard V, Gillet J-V. Obesity in obstetrics and

gynaecology. Eur J Obstet Gynecol Reprod Biol 1998; 77: 217–228.

O14. Thromboelastography (TEGsR ) changes in thepost-partum periodH. Grogan, H. Gorton, M. VucevicLeeds General Infirmary, Leeds, UKIntroduction: Pregnancy is associated with a hyper-coaguable state and the TEG� reflects this.1 Thesechanges begin in the first trimester and return tonormal in the post-partum period over a variable pe-riod of time.2 Very little data has been collected onthe trends and timing of these changes either usingconventional laboratory tests or TEG� analysis. Wereport the post-partum TEG� changes that occurred in20 women undergoing elective caesarean section fromthe day of their operation until 72 h post-partum.

Methods: ASA 1 women presenting at term for elec-tive caesarean section were recruited. Serial TEG�

analyses were performed. Samples were taken pre-op-eratively (baseline) and on a daily basis until the pa-tient went home. 0.36 mL of blood was taken via a22G cannula in the ante-cubital fossa and fresh wholeblood was analysed by TEG� within 4 min of vene-puncture.r and k (mm), a angle (degree), maximum amplitude(MA in mm) and patient characteristics were re-corded.

Results: The box plot below shows the trend of the 2.5,25, 50, 75, and 97.5 centiles in r value over 72 h aftercaesarean section. There was significant differencewhen comparing the baseline value to days three andfour (Kruskall–Wallis P <0.007).

Conclusion: This series illustrates that although thewomen remain hypercoaguable during this time periodthere is some suggestion of a change towards non-pregnancy values on days three and four.

References1. Hawthorne L. Haematological disorders in pregnancy. In: Russell I

F, Lyons G (eds). Clinical Problems in Obstetric Anaesthesia.London: Chapman and Hall Medical, 1997: 67–85.

2. Sharma S K, Philip J, Wiley J. Thromboelastographic changes inhealthy parturients and post-partum women. Anesth Analg 1997; 85:94–98.


O15. A national survey of external cephalic version(ECV) for breech presentation in the 3rd trimesterA. Swami, M. C. Mushambi, M. Habiba, C. ArchdeaconDepartments of Anaesthesia, Obstetrics andGynaecology, Leicester Royal Infirmary, UKIntroduction: The incidence of breech presentation atterm is 3–4%. A recent study has shown that vaginalbreech delivery is associated with increased perinatalmortality (1.3%) and neonatal morbidity (3.8%) com-pared to 0.3% and 1.4% respectively in planned caesar-ean section1 (CS). Following these results, it is nowconsidered safer to deliver all term breech babies by CS.Where appropriate, ECV should be offered to womenwith breech presentation in order to reduce the CS rate.Immediate success rate for ECV on average is 58%2 withfinal cephalic presentation at birth of 48%.3 We carriedout a survey of the use of ECV for breech presentation inobstetric units throughout the UK.

Methods: An Obstetric Anaesthetists’ Association(OAA) approved questionnaire was sent to all lead ob-stetric anaesthetic clinicians in the UK in April–July 2001.Questions asked included which units were doing ECVs,how the service was organised, success and complicationsrates and what analgesia patients received.

Results: Of the 261 forms sent out, 183 (70%) werereturned. One hundred and fifty seven units (88%) car-ried out ECVs. Of these, 99 units (63%) had an organ-ised ECV service. Ninety-nine units (63%) hadobstetrics guidelines for ECV compared to only 12 units(8%) that had anaesthetic guidelines. In 102 units (65%),ECVs were carried out on the delivery suite or in theatre.Only 65 units (41%) kept patients fasted and 40 (25%)secured i.v. access before ECV. Antacid prophylaxiswas administered in 30 units (19%). Forty units (25%)always informed the anaesthetist about ECVs. Six units(4%) used regional analgesia and 21 (13%) inhalationagents. Forty units (25%) always used tocolysis. Overallsuccess rate for ECV was low with only 17 units (11%)having more than 50% success but 80 (51%) did notknow the success rate. In 72 units (46%) less than 5% ofwomen needed emergency CS within 24 h.

Conclusion: The audit showed that a large number ofunits offer ECV but the standards of the service vary.Anaesthetic input into ECVs is minimal.

References1. Hannah M E, Hannah W J, Hewson S A et al. Planned caesarean

section versus planned vaginal birth for breech presentation at term:a randomised multicentre trial. Term Breech Trial CollaborativeGroup. Lancet 2000; 356: 1375–1383.

2. American College of Obstetricians & Gynaecologists. Clinicalmanagement guidelines for obstetrician – gynaecologists. ExternalCephalic Version. ACOG Practice Bulletin. Feb 2000; 13: 1–7.

3. Mushambi M C. External cephalic version: new interest and oldconcerns (Editorial). International Journal of Obstetric Anesthesia2001; 10: 263–266.

O16. Staffing for obstetric anaesthesia: current UKpracticeJ. Thompson, V. Hariharan, F. Umerah, C. GrangeNuffield Department of Anaesthesia, Oxford, UKIntroduction: Increased obstetric workload has neces-sitated reevaluation of obstetric services in the UK.Guidelines1 produced by the Association of Anaesthe-tists and the Obstetric Anaesthetists Association (OAA)recommend a duty anaesthetist be available 24 h per dayand that at least one consultant session be allocated forevery 500 deliveries. The aim of our study was to in-vestigate current obstetric anaesthetic cover in UKhospitals.

Method and Results: Following OAA approval 246questionnaires were sent to the lead obstetric anaesthe-tist at each hospital in the UK. Initial response rate was70% (22% tertiary referral, 78% secondary referralhospital). All units had an anaesthetist available 24 h perday. Units ranged from 150 deliveries/year withoutdedicated consultant sessions (i.e., without other anaes-thetic commitments) to those units with 6300 deliveriesper year with several tiers of trainees and 20 consultantdaytime sessions per week. In 79% of units dedicatedobstetric anaesthetic trainees covered during the day, inaddition to support from various numbers of allocatedconsultant sessions per week (Table).

Consultant sessions/week % Units Deliveries/year (range)

0 5 150–13000.5–3.5 12 250–25004–6.5 23 900–40007–9.5 19 1750–500010–13 34 2000–580015–20 7 3500–6300

A dedicated trainee provided cover at night in 62% ofunits. Although none of the units had resident obstetricanaesthetic consultants on call at night, a specific ob-stetric anaesthetic group provided consultant cover in10.4% of units (on call rotas ranged from 1 in 5 to 1 in10). 10.9% of units had future plans in progress fordeveloping a specific consultant obstetric on call rota.

Discussion: With increasing numbers of high-riskpregnancies and obstetric intervention, consultant an-aesthetic presence remains an essential component inmaintaining good standards of care. Although all unitshad an available anaesthetist 24 h per day only 76% ofunits complied with the minimum standards of oneconsultant session per 500 deliveries.

Reference1. Guidelines for obstetric anaesthetic services AAGBI and OAA

working party 1998.

International Journal of Obstetric AnesthesiaS8 International Journal of Obstetric AnesthesiaS8

O17. A comparison of pinprick, cold and touch levelsduring spinal anaesthesia for caesarean sectionI. F. RussellHull Royal Infirmary, Hull, HU3 2JZ, UKIntroduction: Although touch is believed to be a betterpredictor of efficacy of neuraxial block many use cold orpinprick as these levels are believed to be closely relatedto touch (2 and 4 segments difference).1 The literatureabounds, however, with studies in which many womenrequire intra-operative supplements despite “adequate”levels of block to pinprick or cold. Data collected by theauthor have been analysed to compare the levels of blockassessed by cold, pinprick and touch.

Methods: Data were collected from 102 women un-dergoing caesarean section with spinal anaesthesia (2–3 mL of 0.5% bupivacaine plus diamorphine100 lg �mL)1). Levels of block were assessed routinelywith cold and touch (ethyl chloride), sharp pinprick(Neurotip) and touch (Neurotip) at 2, 5, 10, 15, 20, 30min and again at the end of surgery. Ethical approvalwas obtained for analysis and publication of these data.Two-minute data were not used in the analysis.

Results: The differences between the level of block totouch (anaesthesia) and that to pinprick (analgesia), coldand ethyl chloride spray-touch are shown in the figure[median, quartiles, range, outliers (o) and extremes (*)].The latter two are defined as lying 1.5–3 and >3 box-lengths from the edge of the box. One point marked �appears to be an original data transcription error.

Four women required analgesic intervention. All fourhad levels of block to cold and pinprick above T4with complete motor block of the legs and touchlevels assessed as below T6.

Conclusion: The data demonstrate that the level ofblock to cold or pinprick cannot be used to predicted thelevel of block to touch. A pinprick or cold level aboveT4 with complete motor block of the legs could notpredict the need for further analgesia. No woman with ablock to touch (either modality) which included T6 re-quired intervention.

Reference1. Brull S J, Greene N M. Time-courses of zones of differential

sensory blockade during spinal anesthesia with hyperbarictetracaine or bupivacaine. Anesth Analg 1989; 69: 342–347.

O18. Accidental subdural injection during obstetricepidural block, it’s commoner than you think!Epidurogram evidenceC. B. CollierDepartment of Anaesthesia, Royal Hospital for Women,Sydney, Australia

Introduction: The unintentional subdural injection oflocal anaesthetics intended for the subarachnoid space isa well-known cause of failed spinal blocks. Accidentalsubdural injection of such solutions during attemptedepidural block, although considered rare, is known toproduce extensive and occasionally life-threateningblocks.1 Recent epidurogram evidence suggests thataccidental subdural injection may also be a cause offailed or inadequate epidural block.Method: This study formed part of an on-going inves-tigation, using epidurograms,2 into the cause of unsat-isfactory epidural blocks at caesarean section. Followingethics committee approval, all mothers whose blockshad been inadequate or atypical, and whose catheterswere still in place, were invited to undergo epiduralcontrast injection and radiographic screening, between24 and 48 h postpartum. The contrast used was Iopamiro300 in a dose of up to 10 mL, with AP and lateral X-raysbeing taken.

Results: Forty mothers have been investigated, over a10-year period, the epidurograms of three, unexpectedly,revealing posterior subdural spread of contrast. Theseblocks had been inserted by experienced obstetric an-aesthetists, reporting a single pass, uncomplicated in-sertion in each case. The clinical picture was similar inall three, featuring the slow onset of surgical anaesthe-sia, and requiring additional doses of local anaesthetic(2% lignocaine with adrenaline). Total doses of35–40 mL were administered over a 40–50 min period,and the surgery was pain-free. Satisfactory postoperativepain relief was provided by midwife-administered in-termittent boluses of pethidine 50 mg in 10 mL, al-though the analgesia was reported to be slow in onset(30–40 min). Back or nerve root pain was reportedduring top-ups in all three patients and all developedtransient numbness in one or more dermatomal areaswith most of the top-up doses.

Conclusion: It appears as if local anaesthetic injectioninto the posterior subdural space results in slow andrestricted spread of blocks, whereas anterior subduralinjection is well known as being associated with exag-gerated spread of blocks. The true incidence of acci-dental subdural block may be higher than the usuallyaccepted figure of 0.8%.1

References1. Collier C B. Accidental subdural block: Four more cases and a

radiographic review. Anaesth Intensive Care 1992; 20: 215–232.2. Collier C B. An Atlas of Epidurograms, Sydney: Harwood

Academic, 1998.


O19. A randomised trial comparing general withspinal anaesthesia for caesarean section inpreeclamptics with a non-reassuring fetal heart traceR. Dyer, I. Els, J. Farbas, L. Schoeman, G. Torr,M. JamesDepartment of Anaesthesia, University of Cape Town,Cape Town, South AfricaIntroduction: There are no randomised studies onneonatal outcome following spinal versus generalanaesthesia for caesarean section in preeclampticswith a non-reassuring fetal heart trace. This studyexamined both markers of neonatal hypoxia andmaternal haemodynamics.

Methods: Seventy patients were randomised to general(group G, n = 35) or spinal anaesthesia (group S,n = 35). After a crystalloid preload, group G receivedthiopentone, magnesium sulphate and suxamethoniumi.v. before intubation, followed by nitrous oxide 50% inoxygen, isoflurane 0.75–1.5% and morphine after de-livery. The target end-tidal PCO2 was 4–4.5 kPa. GroupS received 0.5% hyperbaric bupivacaine 1.8 mL plusfentanyl 10 lg at the L3/4 interspace. Heart rate andblood pressure were measured at specific time-points.Hypotension was treated with ephedrine. A maternalarterial and a neonatal umbilical arterial (UA) blood gassample were taken at delivery. Resuscitation require-ments were recorded.

Results: Both groups were haemodynamically stable.Group S patients required more ephedrine (13.7 vs.2.7 mg). Maternal PaCO2 was lower in group S (3.85 vs.4.32 kPa). One-minute Apgar scores were lower ingroup G. Median neonatal UA pH was lower (7.20 vs.7.23), and mean base deficit greater (7.13 vs.4.68 mmol/L) in group S. Within- and between-groupanalysis showed that if maternal diastolic blood pressureon admission was >110 mmHg, neonatal UA base def-icit was greater in group S. There was no difference inthe number of patients with Apgar scores <7 at 1 or5 min or UA pH < 7.2, or in the requirements for re-suscitation.

Conclusions: In patients with severe preeclampsia,spinal anaesthesia for caesarean section was associatedwith a greater mean neonatal umbilical arterial basedeficit. The clinical significance remains to be estab-lished. Maternal haemodynamic stability was similarand acceptable with either anaesthetic technique. Thechoice of anaesthetic technique should not be based onconcerns relating to neonatal acidosis.

O20. Six year audit of high regional blocks inobstetric anaesthesiaM. Dresner, A. Brennan, J. FreemanLeeds General Infirmary, Leeds, UKIntroduction: The OAA’s National Obstetric Anaes-thesia Database (NOAD) project surveyed high regionalblocks during 2002. Our unit had none to contribute inthis time frame, but we wanted to investigate our prac-tice since data collection began, six years ago. Thissingle unit audit may provide a useful benchmark to becompared with NOAD’s findings.

Methods: For the purpose of this study a high blockwas defined as one which necessitated respiratorysupport with bag and mask, or intubation and venti-lation. Data collected between April 1997 and January2003 were retrieved from audit databases.

Results: The results table shows the number of highblocks against the total number of procedures per-formed. Spinal after epidural refers to a single shotspinal anaesthetic given to a woman with an epidural insitu.

Technique High blocks Incidence

Epidural analgesia 1/6796 0.01%CSE analgesia 0/2296 0%Spinal anaesthesia 0/3784 0%CSE anaesthesia 0/222 0%Topped up epi/CSE 1/995 0.1%Spinal after epidural 5/342 1.46%

Discussion: Each case of high block warrants detaileddiscussion beyond the scope of an abstract. The twocases caused by epidural analgesia and a topped up CSEinvolved unrecognised intrathecal catheterisation man-aged in violation of unit protocols. Spinal anaesthesiaafter epidural analgesia poses the greatest risk of highblock. No predictors for this complication, such asprevious epidural doses or spinal drug dose, could beidentified. This appears to be a sporadic complicationthat requires explanation at consent and appropriatesafety precautions. It is of interest to note that the use ofthis technique in our unit increased in the light of fivecases of litigation for pain during topped up epiduralanaesthesia. The superior performance of spinal anaes-thesia in this role has been documented in an earlierabstract.1 Despite the resultant complications, no lastingmorbidity has been caused to mothers or babies and nocomplaint or litigation has ensued.

Reference1. Cole P, Dresner M, Stockwell J, Freeman J. Anaesthesia for

emergency caesarean section in women already receiving epiduralanalgesia. International Journal of Obstetric Anesthesia 2001; 10:215.


O21. An integrated pathway of care (IPOC) inobstetric anaesthesiaP. E. Shannon, J. CollinsDepartment of Anaesthesia and Critical Care,Doncaster Royal Infirmary, Doncaster, UKIntroduction: The integrated pathway of care (IPOC)in obstetric anaesthesia aims to provide a coherent ap-proach to improving the care given to the pregnantwoman. It describes a targeted, step-by-step manage-ment plan for the referral of women from the communityto specialist anaesthetic services and back again, placingthe emphasis on information, choice and safety. Theimpetus for this approach has come from two areas.Firstly, anaesthetists have appreciated the need toprovide good, high-quality information on anaesthetic-related issues to all pregnant women, and to identifyhigh-risk women earlier and more consistently.1 Sec-ondly, there has been the development of midwifery-ledcare such that the majority of pregnant women maynever be assessed by a doctor.2

Method: Over a 12-month period, 147 women screenedby their community midwife using a simple question-naire were referred to the Obstetric Anaesthesia Service(OAS). This represented about 5% of all deliveries(approximately 3500 per annum). A consultant from theOAS reviewed the referrals and instigated further in-vestigation as necessary.

Results: We found that 58 of the referrals (40%) re-quired no further action. These were considered rela-tively trivial, such as mild well-controlled asthma orknown allergy. Eighty-nine women (60%) were tele-phoned, allowing further information to be collectedplus discussion, explanation and reassurance as appro-priate. Of these, 9 (10%) required a further face-to-faceconsultation with or without subsequent on-goingmanagement. No one needed to be seen urgently(within 24 h). Overall therefore, only 9 women (6%)needed to be physically seen by an anaesthetist.

Conclusion: We consider that we have:• improved the effectiveness of the OAS byproviding direct access for women to a high-qualityservice;

• eliminated the reliance on medical obstetricreferral;

• created a new awareness of the value of theOAS to community midwives;

• improved the chances of identifying anaesthetichigh-risk women.We hope to establish the IPOC in electronic form

soon.

References1. Association of Anaesthetists of Great Britain and Ireland and

Obstetric Anaesthetists’ Association. Guidelines for ObstetricAnaesthesia Services. London, 1998

2. Cumberledge Report. Changing Childbirth: Report of the ExpertMaternity Group. London: HMSO, 1993

O22. Spontaneous vaginal delivery and ambulationafter “mobile” epidural analgesia in labourThe Comparative Obstetric Mobile Epidural Trial(C.O.M.E.T.) Study Group, Birmingham UniversityDepartments of Public Health & Epidemiology &Anaesthesia, Leicester Royal Infirmary Departmentsof Anaesthesia & Obstetrics, St Thomas’ Hospital,Kings’ College London, UK

Introduction: We recently demonstrated that com-bined spinal epidural (CSE) and low dose infusion(LDI) epidural techniques, for analgesia in labour, areassociated with a reduced instrumental vaginal deliveryrate, relative to traditional epidurals.1 It is unclearwhether this increase in spontaneous vaginal deliveryrate results from factors associated with maternal am-bulation in labour per se or the enhanced perinealsensation afforded by “mobile” epidural analgesia, as-sisting active and passive expulsion of the fetus. Wehave undertaken a secondary analysis of the associationbetween walking in labour with a mobile epidural insitu and subsequent delivery mode.

Method: From a total of 1054 nulliparous women re-cruited to the C.O.M.E.T. study, 701 women wererandomised in labour to receive CSE or LDI, each usinga low-dose mixture of 0.1% bupivacaine with fentanyl2 lg/mL. A modified Bromage score of lower limbpower was recorded at 30 min after epidural insertionand hourly thereafter, until delivery. A record was madeeach hour of whether women had remained in bed, stoodout of bed or walked. Those women who stood out ofbed or walked, at any time in labour, were labelled“ambulatory,” those who remained in bed throughoutlabour were labelled “sedentary.” Subgroup analysis ofambulatory and sedentary women was performed fordelivery mode.

Results: A similar proportion of women in each“mobile” epidural group were ambulatory during labour:CSE (37.9%) and LDI (36.6%). There was no differencein the incidence of spontaneous vaginal delivery, in-strumental vaginal delivery or caesarean section be-tween ambulatory and sedentary groups.

Ambulatory n = 261 Sedentary n = 440

Delivery mode CSEn = 133

LDIn = 128

CSEn = 218

LDIn = 222

Spontaneous vaginal 61 (46%) 54 (42%) 89 (41%) 96 (43%)Instrumental� 36 (27%) 37 (29%) 66 (30%) 61 (28%)Caesarean section 36 (27%) 37 (29%) 63 (29%) 65 (29%)�Includes forceps and ventouse delivery.

Conclusion: Within the limitations of subgroup analy-sis, there was no association between ambulation after“mobile” epidural analgesia and delivery mode.

Reference1. Comparative Obstetric Mobile Epidural Trial (COMET) Study

Group UK: Effect of low-dose mobile versus traditional epiduraltechniques on mode of delivery. Lancet 2001; 358: 19–23.


P01. Comparison of continuous and intermittentadministration of extradural ropivacaine withfentanyl for analgesia during labourC. S. Moore, P. D. W. Fettes, J. B. Whiteside,G. A. McLeod, J. A. W. WildsmithUniversity Department of Anaesthesia, NinewellsHospital, Dundee, UKMethod: Forty primigravid women requesting epiduralanalgesia in early labour gave consent to a study of twomodes of administration. In all patients an epidural cath-eter was inserted at L2/3 or 3/4. After a 5-mL test dose, afurther 10–15 mL of 0.2% plain ropivacaine was titratedto produce analgesia and bilateral sensory block to T10.Patients were randomly assigned to receive an infusion ofropivacaine 2 mgÆL)1 plus fentanyl 2 lgÆL)1 at 10 mL h)1

starting immediately, or hourly 10-mL boluses of thesame solution injected at 2 mLÆmin)1, starting 30 minlater. Delivery pumps were identical. Analgesia was re-corded by a blinded assessor using a Visual AnalogueScale (VAS; 0–100mm) and aVerbal Rating Score (VRS;0 = no pain, unaware of contraction; 1 = aware but notpainful; 2 = painful) at 5-min intervals until time zero,and then at 30-min intervals. If analgesia was deemedinadequate at any time, up to two additional 10-mL bo-luses of the study mixture were given. Sensory block wasmeasured bilaterally using a short bevelled 27 swg dentalneedle. Motor block was assessed bilaterally using both amodified Bromage score (0–3) and a straight-leg raisingscale (0–5). Maternal pulse rate and blood pressure wererecorded regularly and fetal heart rate was monitored bycardiotocograph. Hypotension (P30% decrease in sys-tolic blood pressure) was treated in one patient in thecontinuous infusion group (after an additional bolus) us-ing ephedrine 6 mg. Fisher’s exact test and Kaplan Meiersurvival analysis were used to analyse non-parametricdata, and Student’s t-test for parametric data.

Results: There were no differences between the twogroups in demographics, duration of labour, mode ofdelivery or neonatal outcome; nor were there differencesin sensory or motor block, or in the occurrence of uni-lateral block. 12 (60%) patients in the infusion grouprequired one or more additional boluses compared to 4(20%) patients in the bolus group (95% CI: 9.6 to61.7%, P < 0.05). Therefore the bolus group had a lowertotal drug dose than the infusion group (P = 0.02).

Conclusion: In agreement with previous work,1 theintermittent bolus group required less rescue medication,and a lower total drug dose to maintain similar painscores, sensory and motor block compared to the con-tinuous infusion group. This represents a reduction ininterventions and anaesthetic workload, and the ap-proach may have wider application.

Reference1. Duncan L A, Fried M J, Lee A, Wildsmith J A W. Comparison

of continuous and intermittent administration of extraduralbupivacaine for analgesia after lower abdominal surgery. Br JAnaesth 1998; 80: 7–10.

P02. Patient controlled analgesia for labour: a pilotstudyR. Sivasankar, A. Seghal, S. E. Harries, R. E. CollisDepartment of Anaesthetics, University Hospital ofWales, Cardiff, UK

Introduction: Opioids are widely used for pain relief inlabour, as there is a need for an acceptable alternative toepidural analgesia. Although the general move has beento consider short-acting opioids via the i.v. patient-controlled analgesia (PCA) route,1 the role of longer-acting opioids has not been evaluated. The aim of thispilot study was to evaluate differing opioids in labour,delivered using an i.v. PCA device.

Method: Following ethical approval, a partial doubleblind randomised control trial was set up with five patientgroups; four PCA groups using diamorphine, fentanyl,morphine and pethidine and a control group receiving i.m.pethidine 100 mg 4 hourly. All PCA groups received anequivalent volume of loading and on demand bolus dose,with a lock-out time of 10min. Equivalent bolus doses foreach PCA group were diamorphine 1 mg, fentanyl 20 lg,morphine 2 mg, pethidine 20 mg, with a loading dose 2.5times the bolus dose. All mothers were permitted to useadjuvant analgesia or to withdraw from the study and optfor epidural analgesia if preferred. Pain during contractionwas assessed on a verbal numerical scale of 0–10 andsedation scored between contractions on a scale of 1–4(1 = awake, 4 = unrousable).

Results: 24 mothers were recruited to the pilot study.The mean hourly doses of i.v. PCA opioid deliveredwere: diamorphine 3.97 mg, fentany l 89 lg, morphine12.9 mg, pethidine 74.1 mg. the median scores at time 0,time 1–2 h and time 1 h-delivery were:

All the mothers used adjuvant Entonox for analgesia. Tenof the 24 mothers requested conversion to epidural anal-gesia. The incidence of maternal side effects was low. AnApgar score of less than 7 was recorded in 7 babies in thePCA groups. At 24-h follow-up, the median dissatisfac-tion scores were diamorphine 4, fentanyl 2, morphine4, pethidine 3 and i.m. pethidine 7, (1 = very good,10 = very poor).

Discussion: Pain scores in the diamorphine groupshowed a clinically significant improvement, particularlyin the two hours following i.v. loading. Despite little re-ported change in overall pain scores during labour, at 24-hfollow-up mothers had high satisfaction scores in all PCAgroups.

Reference1. Morley-Forster P K, Reid D W, Vandeberghe H A. Comparison

of patient-controlled analgesia fentanyl and alfentanil for labouranalgesia. Can J Anaesth 2000; 47: 113–119.

International Journal of Obstetric Anesthesia (2003) 12, S12–S41doi:10.1016/S0959-289X(03)00044-X

Pain scores (0–10) Sedation (1–4)

T0 T1-2 T1-dell. T0 T1-del.

Diamorphine 7.5 4.5 5.5 1 1.5Fentanyl 5 5.5 8 1 2Morphine 7.5 8 8 1 1.5Pethidine 7 6.5 7 2 1.5Pethidine i.m. 7.5 6 7 1 1.5

P03. Obstetric and neonatal outcomes followingcontinuous epidural infusion versus patientcontrolled epidural analgesia in labourJ. McCormack, I. BoyneDepartment of Anaesthesia, Forth Park MaternityHospital, Kirkcaldy, Fife, UK

Introduction: Patient controlled epidural analgesia(PCEA) provides analgesia for labour comparable withthat of continuous epidural infusion (CEI), with thebenefit of reducing total dose of local anaesthetic ad-ministered.1,2 This study aimed to confirm analgesia andmaternal satisfaction during transition of unit policyfrom CEI to PCEA. In addition, we wished to study theeffects of each regime on progression of labour, methodof delivery and neonatal outcome.

Methods: With the approval of the clinical governancesupport team, 80 patients were recruited to receive eitherCEI (n = 40) of 0.1% bupivacaine 10 mL/h plus fenta-nyl 2 lg/ml with additional manual top-ups as required,or PCEA (n = 40) of 10-mL boluses of identical solutionwith a 30-min lock-out. Volume of local anaesthetic(LA) given, epidural block height, bolus doses (bothPCEA and manual top-ups), side effects, progression oflabour, delivery method and neonatal Apgar scores wererecorded. The data were analysed using unpaired t-testsand v2 tests as appropriate.

Results: The results are summarised in the table(mean € SD [95% CI]). There were no significant dif-ferences in maximal block height, side effects, painscores, motor block or overall maternal satisfaction be-tween PCEA and CEI groups.

Conclusion: This study confirms that PCEA is an ef-fective alternative to CEI in labour, with the benefit ofsignificantly reducing both local anaesthetic administra-tion and the need for extra anaesthetist intervention,without compromising method of delivery or neonatalApgar scores. This unit has adopted the PCEA regime asstandard protocol as a result of the outcomes demon-strated by this study.

References1. Gambling D R, Yu P, Cole C, McMorland G H, Palmer L. A

comparative study of patient controlled epidural analgesia (PCEA)and continuous infusion epidural analgesia (CIEA) during labour.Can J Anaesth 1988; 35: 249–254.

2. Purdie J, Reid J, Thorburn J, Asbury AJ. Continuous extraduralanalgesia: comparison of midwife top-ups, continuous infusions andpatient controlled administration. Br J Anaesth 1992; 68: 580–584.

P04. Epidural block: does choice of spinal interspaceaffect analgesia at delivery?L. Parker, J. E. DugganWansbeck General Hospital, Northumberland, UK

Introduction: We have shown previously1 that spon-taneous vaginal delivery (SVD) is painful for about 25%of mothers with epidural analgesia, and that the mostpowerful predictor of this outcome is pain in labour.2 Ina departmental audit restricted to mothers with goodanalgesia in labour, SVD was painful in 20%, and in-terspace was found to be an independent factor for thisoutcome (n = 2613; P > 0.05). We decided to investi-gate this further.Methods: Data from five units* using the WansbeckEpidural Audit System3 was pooled and analysed. Thedatabase contains 15875 records. We extracted 6577cases that had SVD with a complete set of follow-updata. Of these mothers, 5816 rated analgesia for firststage as excellent or satisfactory, and these cases weresub-divided by interspace into groups. These groupswere compared with respect to pain on delivery (POD):pain-free (PF), comfortable (Com), uncomfortable(Unc), painful (Pful).

Results: Overall mothers rated POD as (%): PF 43;Com 34; Unc 16; Pful 8. No epidurals were sited aboveT12 or below L5. The groups were comparable in termsof onset, stage of labour when the epidural was inserted,indication for epidural and parity. Breakdown of PODby interspace is given in Table 1.

Table 1: POD by spinal interspace (%)

Discussion: In this larger study, we found that inter-space had no effect on analgesia for unassisted vaginaldelivery in mothers with good analgesia in labour.However, the finding that delivery was rated uncom-fortable or painful by about 24% of mothers despite awell functioning epidural suggests there is room forimprovement. We should pay more attention to anal-gesia for the second stage of labour.

References1. Anthoniz M, Duggan J E. How was it for you? An analysis of 18000

obstetric epidurals. International Journal of Obstetric Anesthesia2001; 10: 245.

2. Booth D, Duggan J E. Epidural analgesia: can a painful vaginaldelivery be predicted? International Journal of Obstetric Anesthesia2002; 11 (Suppl): 34

3. Duggan J E, Orwin A, Halford M. Development of a fullycomputerised system to audit an epidural service. InternationalJournal of Obstetric Anesthesia 1997; 6: 214.

*Wansbeck General Hospital, Sunderland Royal Hospital, RoyalVictoria Hospital, Blackpool, Dewsbury Hospital, Leeds General In-firmary.

CEI PCEA P

LA (mg/h) 18.0 € 8 (15.6–20.9) 12.2 € 4.7 (10.8–13.7) 0.000007Total LA (mg) 92.8 € 32.7 (81-105) 70.2 € 34.1 (60–80) 0.003Extra top-ups 1.0 € 1.1(0.6–1.3) 0.4 € 0.8 (0.1–0.7) 0.005Failure to progress 65% 65% 0.99Caesarean sections 30% 52% NSInstrumental delivery 35% 13% NSApgar score 1 min 8.3 € 1[8.0–8.6] 8.6 € 0.8 [8.3–8.8] 0.29

5 min 9.2 € 0.5[9.0–9.4] 9.0 € 0.3 [8.9–9.1] 0.06

Interspace PF Com Unc Pful

T12L1 (n = 31) 35 32 17 8L1L2 (n = 529) 37 32 21 8L2L3 (n = 3225) 42 34 15 7L3L4 (n = 1913) 44 34 14 7L4L5 (n = 118) 42 31 17 8

S13Poster presentations

P05. Birth plans for labour analgesia: tell me whatyou want, what you really, really want!N. Wallace, D. A. HillThe Ulster Hospital, Belfast, UK

Introduction: The government report “ChangingChildbirth”1 emphasised the need for maternal choiceand patient-centred care. A parturient will often docu-ment her wishes for labour and delivery in a birth plan.Failure of staff compliance with a documented birth planmay lead to litigation. It is known that women will re-quest epidural analgesia despite no advance planning.2

Informed consent is necessary before epidural insertionbut is difficult to obtain from a parturient in severe pain,who may already have received Entonox or opioids. Wetherefore aimed to assess the predictive value of a birthplan for labour analgesia.

Methods: This was a retrospective survey of 100women selected at random. Parturients were interviewed21–72 h post partum about their antenatal wishes forlabour analgesia, reasons for this choice, the actual an-algesia received, what analgesia they would wish forfuture labours, and their general satisfaction. Medicalnotes were examined for a previously documented birthplan and the labour partogram.

Results: In the antenatal period, 80% of all women haddocumented a birth plan for labour analgesia. For nul-liparous patients, the most common reason for antenatalchoice of labour analgesia was friends’ rather thanprofessional advice. Whilst 28% had planned epiduralanalgesia, 72% actually received it. This change is sig-nificant (P = 0.039). Most parous women planned to usewhat they had had in a previous labour for analgesia;44% planned whilst 48% received epidural analgesia.No patient was unhappy that she had received epiduralanalgesia when she had not actively planned this. Ofthose who had received epidural analgesia 98% said thatthey would request this in subsequent labours comparedwith 76% of those who had used Entonox only and 68%of those who had received pethidine.

Conclusions: If a parturient has planned to use epiduralanalgesia for labour, she will most likely receive it.Nulliparous women frequently request epidural analge-sia despite no advance planning. Whilst it may be goodprofessional practice for anaesthetists to read the birthplan before epidural insertion, we must be prepared toaccept a change from the written instructions as mostnulliparas’ expectations of labour pain are falsely low.As maternal satisfaction with epidural analgesia is high,many women will plan this for subsequent labours andadvise friends likewise. The anaesthetic workload inlabour ward will therefore increase.

References1. Department of Health. Changing Childbirth. London: HMSO; 1993.2. Proctor’s Problems. Today’s Anaesthetist 2002; 17 (Winter): 108.

P06. Who should provide antenatal informationabout epidural analgesia?P. A. Seal, H. Wellesley, M. J. L. ScruttonSt. Michael’s Hospital, Bristol, UK

Introduction: There is significant variability betweenmaternity units as to who provides information about therisks and benefits of epidural analgesia in labour. Fol-lowing ‘Changing Childbirth,’1 anaesthetist-led antena-tal sessions were discontinued in our unit (4500deliveries/annum, 25% epidural rate). Currently, infor-mation is provided by midwives with no formal anaes-thetic input. This prospective audit examines mothers’views on the quality of that information and whetherthey would support reintroduction of anaesthetist-ledantenatal classes.

Methods: 126 consecutive mothers who had receivedepidural analgesia for labour were asked questions onthe source of antenatal information, how it compared totheir experience of epidural analgesia and whether theywould have attended an anaesthetist-led antenatal ses-sion if afforded the opportunity.

Results: 81% had received information from theirmidwife, 41% from friends or relations, 29% from booksor the internet and 21% from non-anaesthetic doctors.Only medically complicated women had the opportunityto meet an anaesthetist antenatally (<2%). In all othercases, information was provided by the anaesthetist onlyimmediately before siting the epidural. Insertion of theepidural, quality of pain relief and side effects werebetter than expected in 72%, 71% and 62% and worse in9%, 8% and 6% respectively. The overwhelming ma-jority of mothers would either definitely (42%) orprobably (39%) have attended an anaesthetist-led ante-natal session if given the opportunity.

Discussion: While these results might suggest that theantenatal information provided by non-anaesthetists wasoverly pessimistic, it is well recognised that questioningmothers on the first post-partum day is biased by theiroverall birth experience.2 The need to provide accurateinformation on epidural analgesia and concerns aboutthe ability to gain adequate consent in labour wouldseem to mandate that women have the opportunity tospeak to anaesthetists in the antenatal setting. Lack ofresources and political pressure to ‘normalise’ labourmake this ideal difficult to realise. The positive responsefrom the mothers in our survey would appear to providesignificant support for the reintroduction of anaesthetist-led antenatal sessions.

References1. Department of Health. Changing Childbirth. London: HMSO; 1993.2. Morgan B M, Bulpitt C J, Clifton P et al. The consumers’

attitude to obstetric care. Br J Obstet Gynaecol 1984; 91:624–628.


P07. The availability and value of informationresources about labour analgesia used by antenatalwomenR. Sharma, T. Bhagat, M. Trivedi, J. BamberDepartment of Anaesthesia, Addenbrooke’s NHS Trust,Cambridge, UK

Introduction: There is a wide variety of informationresources about labour analgesia available to pregnantwomen including leaflets and Internet information pro-vided by hospital maternity services, including ourown.1 Awareness of how these information resources areused and rated by antenatal women may be of benefit inimproving the information resources provided by ma-ternity services. We undertook a survey of antenatalwomen to ascertain what resources were used and howuseful women found these resources.

Method: In a large maternity hospital setting, womenattending antenatal clinics were invited to complete ananonymous questionnaire. The questionnaire askedwhich methods of labour analgesia the woman had re-ceived information about, what was the source of theirinformation, how useful did the woman rate this source(using a 5-point scale) and whether she had easy accessto the Internet. The woman was also asked whether thiswas her first pregnancy and how many weeks pregnant.The first 100 completed questionnaires were analysed.

Results: 55% of women in their first pregnancy butonly 30% of women with a subsequent pregnancy werenot aware of any information about modes of labouranalgesia. The highest rated sources of information usedby women in their first pregnancy were the media (TV/radio/books/magazines) and relatives or friends. Forwomen in a subsequent pregnancy previous experience,midwife/GP and relative/friend were the most commonand highest rated sources of information. Our hospitalinformation leaflet was also rated highly but only citedby 25% of women. The hospital website and Internetresources were used by only 12 and 25% of womenrespectively and were not considered useful, despiteover 70% of women having easy access to the Internet.

Conclusion: Women most commonly use interpersonalresources, which are also highly rated. Hospital leafletsmay be highly rated but are not commonly used. Despitecommon access to the Internet, World Wide Web andhospital web resources are rarely used and are not rateduseful.

Reference1. Available at the following URL on the web:

http://www.addenbrookes.org.uk/serv/clin/women/preg/labour1.html

P08. Real-time vs. postnatal maternal satisfactionscores in labouring parturients with regionalanalgesiaK. N. Litchfield, R. Agaram, J. Ruddy, G. P. Martinelli,S. Young, C. GreenhalghDepartment of Anaesthesia, Glasgow Royal Infirmaryand Glasgow Royal Maternity Hospital, Glasgow, UK

Background and Goals: Maternal satisfaction is notsolely dependent on the quality of labour analgesia andmight be unreliable when assessed postnatally.1 Weassessed maternal satisfaction while the parturient was inlabour (real-time) to see if it was comparable with scoresobtained 21–48 h postnatally.

Methods: A prospective cohort study of 73 womenrequesting regional analgesia for labour. Midwifery staffwere trained to assess maternal satisfaction with verbalrating score (VRS) and pain with visual analogue score(VAS) at one-hourly intervals. Data on type of analge-sia, complications and outcome of labour were alsonoted. Data were analysed with paired t-test, Friedmanone-way ANOVA and Wilcoxon signed-ranks test.

Results: 93% of women had epidurals and 7% CSEs;69% received epidural infusions (0.1% bupivacaine +fentanyl 2 lg/mL) and 30% midwife top-ups (0.25%bupivacaine 10 mL) according to protocol. Mode of de-livery: 22% emergency caesarean section, 38% instru-mental and 40% SVD. Most common reason foranaesthetic intervention was sacral discomfort (23%) andmissed segment/unilateral block (34%). Twenty minutesafter initiation of regional analgesia there was a signifi-cant decrease in pain (VAS 0 = 78mm,VAS 20min = 28mm, P < 0.0001). During labour mean VASwas <30 mmin all time periods. 85% and 86% of women respectivelywere satisfied with analgesia when questioned during la-bour (real-time) and postnatally.

Table: Maternal satisfaction scores

Conclusions: Satisfaction rates were similar to thoseusually quoted.2 Differences in maternal satisfactionwere not statistically significant when measured duringlabour or postnatally. We conclude that the assessmentof maternal satisfaction is valid even when used post-natally.

References1. McLure H, Yentis S. Clinical trials: what should we assess. In:

Bogod D, Brighouse D, Elton C et al. (eds.). Analgesia, Anaesthesia,and Pregnancy. London: Saunders, 2000: 148.

2. Robinson N, Salmon P, Yentis S. Maternal satisfaction. InternationalJournal of Obstetric Anesthesia 1998; 7: 32–37.

Maternalsatisfaction

Real-timen = 50

Postnataln = 50

P

VRS < 2(dissatisfied)

7 7 0.36

VRS > 2(satisfied)

43 43 0.15

Median score 2.5 3 0.192


P09. The introduction of pain scores for the earlyassessment of adequate epidural analgesia in labourB. Bahlmann, A. Sehgal, R. E. CollisDepartment of Anaesthetics, University Hospital ofWales, Cardiff, UK

Introduction: We introduced pain scores to assess theearly adequacy of analgesia and to help the anaesthetistmake an early decision about re-siting an ineffectiveepidural for labour analgesia.

Method: All pain scores were based on a verbal nu-merical score: 0 = no pain and 10 = the most severepain. Our normal labour ward protocol for establishingepidural analgesia is 10-mL epidural boluses containing0.1% bupivacaine with fentanyl 2 lg/mL given at 10-min intervals with assessment of blood pressure, sensoryand motor block before the next dose. The anaesthetistgives the top-ups until the mother is comfortable andfurther top-ups are then administered by the midwife.During this audit, the mother was asked to give abaseline pain score and further pain scores at 10-minintervals until she was happy with her pain relief. If thepain scores were not improving after three doses, theepidural was re-sited without further delay.

Results: 112 audit forms were collected, 11 were ex-cluded due to incomplete data. Of the remaining 101mothers, 91 had adequate analgesia within 30 min and afurther four within 40 min. Six epidurals were re-sited.Of the 91 mothers who were seen the following day, 90were satisfied with their epidural (98%). One motherwas unhappy with her epidural despite early pain-reliefbecause of a quick delivery.

Table: Median pain scores before epidural insertion anduntil the mother was comfortable

Nine epidurals, which worked well initially, neededadditional top-ups of bupivacaine and fentanyl given bythe anaesthetist. All mothers in this group either had atwin pregnancy or a fetus in a persistent OP presenta-tion. In this audit, there were two epidural failures whentopped up for a caesarean section.

Conclusion: During this audit period there was a veryhigh level of patient satisfaction with epidural analgesia.The simple use of a VAS allowed early detection of afailing epidural. Epidurals that worked well from theoutset mostly continued to work well throughout labourand were reliable for operative delivery. We have in-troduced the assessment and documentation of a VAS asroutine practice during the establishment of epiduralanalgesia.

P10. Prevention of hypotension after spinalanesthesia for cesarean section: 6% pentastarchversus Ringer’s solutionE. M. ShifmanDepartment of Anesthesiology, Republican PerinatalCenter, Petrozavodsk, Russia

Introduction: Spinal anesthesia for cesarean delivery isassociated with a strong risk of hypotension. Estimatingthe risk and treatment of this complication may signif-icantly reduce maternal and neonatal morbidity andmortality.1 The goal of the present study was to comparethe efficacy of pentastarch and Ringer’s solution for pre-infusion in patients undergoing elective cesarean sectionunder spinal anesthesia.

Method: After local ethics committee approval and in-formed consent, we performed spinal anesthesia in 270women presenting for elective cesarean section. Patientwere divided into two groups in a prospective, rando-mised, double-blind manner; the first group receivedpre-infusion with 8 mL/kg 6% pentastarch (Refortan,Berlin-Chemie/Menarini Group), and second – withRinger’s solution in the same dose. We compared theincidence of spinal-induced hypotension in each group.Hypotension was defined as a decrease in systolic arterialpressure to less than 70% of baseline values or 90 mmHg.Spinal anesthesia was induced at L3-4 interspace using a22-gauge Whitacre needle. After subarachnoid injectionof 0.5% bupivacaine solution (11–15 mg) with fentanyl(10 lg), blood pressure was measured with one-minuteinterval for the first 20 min and thereafter at 2-min inter-val. The state of the newbornwas assessed byApgar scoreat 1 and 5 min and by umbilical artery pH. Relativeephedrine requirement was estimated using the Man-Whitney U-test and other variables using Student’s t-testand v2. A P-value of <0.05 was considered statisticallysignificant.

Results: Fetal outcome was similar in the two groups.There was no difference in umbilical artery pH betweenthose whose mothers had been hypotensive (pH 7.33)and those that were normotensive (pH 7.33). Signifi-cantly more patients in the Ringer’s solution group(n = 78, 57.8%) became hypotensive than in the penta-starch group (n = 12, 8.9%) (P < 0.0001). Because nosignificant shifts of the heart rate were found before orafter pre-infusion, the significant decrease in frequencyof hypotension after pre-infusion with 6% pentastarchsolution can be attributed to the increase in stroke vol-ume. Linear regression analysis showed that the onlysignificant variable was type of fluid used for pre-infu-sion.

Conclusion: Pentastarch solution is effective for pre-infusion in cesarean section under spinal anesthesia andprovides an alternative to vasoconstrictors.

Reference1. Stamer U M, Messerschmidt A, Wulf H. Anaesthesia for

caesarean section: a German survey. Acta Anaesthesiol Scand1998; 42: 678–684.

Baseline 10 min 20 min 30 min 40 min

1 bolus n = 14 8.5 2.52 boluses n = 49 8 6 23 boluses n = 28 9 7 5 14 boluses n = 4 9.5 9 8 5 2Resited n = 6 8 7 7 7


P11. The ED95 of hyperbaric bupivacaine in spinalanaesthesia for caesarean sectionS. Saravanan, A. Robinson, S. Saxena, R. Wilson,G. LyonsDepartment of Obstetric Anaesthesia, St. JamesUniversity Hospital, Leeds

Introduction: Application of sequential allocation todose finding allows determination of the ED50. Thecombination of low variability and large sample size al-lows estimation of ED95 with reasonable precision. Theaim of this studywas to determine the ED95 of hyperbaricbupivacaine to achieve a block height of T5 as measuredby light touch, using the sequential allocation technique.

Method: In this prospective study, we recruited 40women of ASA grade I or II, height 150–180 cm, weight50–120 kg and scheduled to have elective caesareansection with a single healthy fetus. An epidural needlewas sited by midline approach at L2-3 in the sittingposition with an 18-gauge Tuohy needle by loss of re-sistance to saline. No test dose was given. Intrathecalinjection was given via a 27-gauge Whitacre needle atL3-4 using the midline approach. The dose of hyperbaricbupivacaine for the first patient was 13 mg and forsubsequent patients depended on whether the height ofthe block in the previous patient reached a level of T5when assessed by light touch. If the block did not reachT5 in 20 min, an epidural bolus was given before sur-gery. Analysis used the Dixon-Massey formula1 for theup-down dosing technique. Power calculation based onour epidural studies2 gave a sample size of 40.

Results: The ED50 of hyperbaric bupivacaine requiredfor a block height of T5 was 9.95 mg (95% CI 9.0–10.9). The ED 95 was 13.55 mg (95% CI 10.1–17 mg).

Conclusions: The ED95 of hyperbaric bupivacaine,required to achieve a block height of T5 when assessedby light touch, in spinal anaesthesia with a 27-gaugeWhitacre needle in the sitting position for caesareansection was 13.55 mg.

References1. Dixon W J, Massey F J. Introduction to Statistical Analysis 4th

Ed. New York: McGraw-Hill, 1983: 428–439.2. Lyons G, Columb M O, Hawthorne L, Dresner M. Extradural

pain relief in labour: bupivacaine sparing by extradural fentanylis dose dependant. Br J Anesth 1997; 78: 493–97.

P12. ED50 of intrathecal bupivacaine with fentanylfor caesarean section, and the effect of epiduralvolume extensionN. Beale, B. Evans, S. Chitre, C. Wright, G. Lyons,G. M. Stocks, J. CrowhurstQueen Charlotte’s & Chelsea Hospital, London,St. James’ University Hospital, Leeds

Introduction: Intrathecal bupivacaine with fentanyl iswidely used for the provision of anaesthesia for cae-sarean section (CS). There is however, little publishedinformation about the dose response relationship ofthese drugs for spinal anaesthesia. With epidural volumeextension (EVE), normal saline is injected into theepidural space immediately after intrathecal injection,and has been shown to extend spinal anaesthesia1 pos-sibly resulting in reduced intrathecal dosage require-ments for CS. The aim of this study therefore was todetermine the ED50 of heavy bupivacaine with fentanyl25 lg and to examine the effect of epidural volumeextension (EVE) on the ED50.

Methods: Following ethics committee approval, 52women receiving CSE for CS were randomised into twogroups to receive CSE either with EVE or without EVE(NEVE) in the left lateral position. Those allocated tothe EVE group received 0.9%w/v saline 7 mL via theepidural needle before threading the epidural catheter.Using a double blinded, up-down sequential allocationtechnique they received varying doses of heavy bupi-vacaine with fentanyl 25 lg. Anaesthesia was assessedusing touch to ethyl chloride spray. An effective dose,defined as achieving a sensory block to touch to thexiphisternum after 20 min with no requirement for anepidural top-up before 45 min, directed a 1-mg decre-ment of heavy bupivacaine for the next patient withinthat group. An ineffective dose directed a 1-mg incre-ment of bupivacaine. ED50 was calculated using themethod of Dixon and Massey.

Results: Patient characteristics were similar in the twogroups. The ED50 of bupivacaine with fentanyl for CSwas 6.0 mg (Table). There were no significant differ-ences in ED50, percentage drop in blood pressure orephedrine usage between the two groups.

Conclusion: Under the conditions of this study, lowdoses of bupivacaine with fentanyl intrathecally are ef-fective for CS. EVE has little effect on dosage reductionor side effects.

Reference1. Blumgart C H, Ryall D, Dennison B, Thompson-Hill

L M. Mechanism of extension of spinal anaesthesia byextradural injection of local anaesthetic. Br J Anesth 1992; 69:457–60.

Group(N = 26)

ED50 (mg)(95% CI)

Drop in systBP%

Ephedrineusage (mg)

NEVE 6.0 (4.9–7.1) 22.5 23.3EVE 5.2 (3.8–6.6) 16.8 20.8


P13. Assessing the block for caesarean section: whatdo we mean by touch?J. Mukherjee, R. Srivastava, G. M. StocksQueen Charlotte’s & Chelsea Hospital, Du Cane Road,London, UK

Introduction: There is a wide variation amongst an-aesthetists on how best to test the level of block forcaesarean section (CS). Cold sensation with ethylchloride (EC) is commonly used, but in order toachieve successful regional anaesthesia in all patientsfor CS it has been suggested that loss of touch to thedermatomal height of T5 should be achieved.1 How-ever, there are differing methods of assessing level ofblock to touch. We decided to compare the dermato-mal heights achieved in patients with successfulblockade using common methods of testing: EC coldand touch, blunt pin prick and cotton wool.

Method: After obtaining verbal consent, we assessed46 women who had received regional anaesthesia for CSusing bupivacaine with fentanyl. Once the attendinganaesthetist was confident that the patient was ready forsurgery, we asked patients when they first felt anysensation, using EC spray, blunt pin prick (using aNeurotip�), and stroke with cotton wool as well as whenthey felt cold with EC spray. We defined the height ofblock as the dermatomal level above which sensationwas first felt.

Results: All patients had successful regional anaesthe-sia for CS. There was a significant difference in der-matomal height between all methods of assessment(Friedman test, P < 0.0001). Comparison betweengroups in pairs were all significantly different except forEC touch vs pin prick (Dunn’s multiple comparison test,P < 0.05).

Conclusion: In patients with successful anaesthesiacommonly used methods of assessment give signifi-cantly different dermatomal levels. A wider range ofdermatomal levels was observed with touch than withcold. We found no significant difference between ECtouch and pin prick suggesting that these two tests maybe equivalent, but numbers studied were small. Whenthe dermatomal level to touch is determined, the type oftest for touch must be documented.

Reference1. Russell I F. Assessing the block for caesarean section.

International Journal of Obstetric Anesthesia 2001; 10: 83–85.

P14. Male anaesthetists: a risk factor for caesareansection under general anaesthesia?K. Robins, S. Chau, G. LyonsDepartment of Obstetric Anaesthesia, St James’University Hospital, Leeds, UK

Introduction: General anaesthesia for caesarean sec-tion is associated with an increase in maternal morbidityand mortality.1,2 A yearly audit of obstetric anaesthesiasuggested a sex bias in the number of general anaes-thetics performed for caesarean section. The aim of thisstudy was to explore this impression.

Methods: A retrospective observational study wasconducted using prospective data obtained from yearlyaudits of anaesthetic practice on the delivery suite forthe period 1991 to 2001. Anaesthetics for all proceduresduring this period, excluding those performed by con-sultants, were examined. The total number of generaland regional anaesthetics for male and female traineeswas compared using v2 test with Yates correction.

Results: A total of 5820 anaesthetics by 117 male and51 female trainees were analysed. The difference inincidence of general anaesthetics performed betweenmale and female trainees is strongly significant,P < 0.00001. The results are outlined in the table below.

Discussion: Males use general anaesthesia to a greaterextent than female trainees for procedures on the de-livery suite. The reason for this difference is purelyspeculative. All trainees are exposed to the same balanceof elective and emergency work. Consultants wereeliminated, as the majority of their work is elective. Ourdata did not distinguish between anaesthesia performedfor caesarean section from that performed for otherprocedures on the delivery suite. The vast majority ofprocedures were for caesarean section (67% of generalanaesthesia and 86% of spinal anaesthesia).

References1. Hawkins J L, Koonin L M, Palmer S K, Gibbs C P. Anesthesia

related deaths during obstetric delivery in the United States,1979–1990. Anesthesiology 1997; 86: 277–84.

2. Report on Confidential Enquiries into Maternal Deaths in theUnited Kingdom 1991–1993. London: HMSO, 1996.

Trainees GA RA Total Anaesthesia

Male (70%) 1201* (31%) 2709 (69%) 3910Female (30%) 465* (24%) 1445 (76%) 1910All 1666 (29%) 4154 (71%) 5820

*P <0.00001


P15. Caesarean section under general anaesthesia: anaudit of practiceM. Way,1 I. Rice,1 W. Hodge,2 S. Hughes11Department of Anaesthesia and 2Department ofObstetrics, Princess Anne Hospital, Southampton, UK

Introduction: There is potential for increased morbid-ity and mortality following caesarean section undergeneral anesthesia.1

Method: We conducted a retrospective audit of allcaesarean sections performed under general anaesthesiain 2001. Standards were those suggested by the RCAand our delivery suite protocol.

Results: Of the 4273 maternities at the Princess AnneHospital in 2001, 924 deliveries (21%) were by cae-sarean section, 81 (9.2%) under general anaesthesia. Ofthese 75 patient notes were obtained for review. Forty ofthe general anaesthetics (53.3%) were given for obstetricreasons, 30 (40%) anaesthetic, 3 (4%) other medicalreasons, and two (2.7%) not stated. Obstetric indicationswere: fetal bradycardia 16 (40%), APH/abruption 7(17.5%), anterior placenta praevia 7 (17.5%), cord pro-lapse 5 (12.5%), fetal acidosis 4, (10%), and eclampsia 1(2.5%). Anaesthetic indications were: failure of regionalbefore surgery 13 (43.3%), patient refusal 7 (23.3%),failure of regional during surgery 6 (20%), coagulopathy2 (6.7%) and sepsis 2(6.7%). The conversion rate fromregional to general anaesthesia was 2.83% for electiveand 1.09% for emergency caesarean section; 81.1% ofthe elective general anaesthetics were used for teaching.Thirty-one general anaesthetics (41.3%) were for class 1emergencies; of these 35.5% were delivered within15 min as per protocol. Nineteen (25.3%) were Class 2;of these 36.8% were delivered within the required30 min. Reasons for delay included: transfer from de-livery suite to theatres in 17, anesthetic reasons in 15 andobstetric reasons in 12 patients. Some patients had morethan one factor causing delay.

Conclusions: We met the <3% standard for conversionof regional to general anaesthesia for emergency cae-sarean section, but just fell short of the <1% for elective.There was a significant delay in getting patients totheatre. Recommendations: (1) emphasis on testing levelof block; (2) time sheets for patient transfer to aididentification of causes for delays; (3) reclassification ofemergency caesarean section in line with the RCOGNational Sentinel Caesarean Section Audit report.2

References1. Department of Health. Report on Confidential Enquiries into

Maternal Deaths in the United Kingdom. 1991–3. London: HMSO,1996.

2. Thomas J, Paranjothy S. Royal College of Obstetricians andGynaecologists Clinical Effectiveness Support Unit. NationalSentinel Caesarean Section audit Report. London: RCOG Press,2001

P16. An retrospective audit of the use of generalanaesthesia for caesarean sectionD. Baines, J. BamberRosie Maternity Hospital, Cambridge, UK

Introduction: The use of general anaesthesia for cae-sarean sections has declined in the past twenty years asregional anaesthesia is preferred. We wished to studywhy general anaesthesia was used for caesarean sectionin our unit.

Methods: All patients who received general anaesthe-sia for caesarean section in a calendar year were iden-tified. A random sample of half this population wasselected to have their casenotes retrieved. Using astructured form, the indications for general anaesthesiawere extracted from the casenotes.

Results: General anaesthesia was used in 134 caesareansections (4% of all elective caesarean sections and 8% ofall emergency caesarean sections). Maternal request wasthe indication for general anaesthesia in 45% of electivecaesarean sections and 22% of emergency caesareansections. General anaesthesia was required for failedregional anaesthesia in 17%, all of which were emer-gency cases. Four per cent of epidural and 0.3% spinalanaesthetics had to be converted to general anaesthesia.

Conclusions: The number of general anaesthetics ad-ministered for caesarean sections in our unit is lowerthan national rates.1,2 Our audit suggests that if thenumber of general anaesthetics is to be lowered furtherthen we should investigate why epidural anaesthesiafails and whether our use of spinal anaesthesia foremergency cases can be increased. There may also be arole for improving patient education to reduce thenumber of maternal requests for general anaesthesia.

References1. Shibli K U, Russell I F. A survey of anaesthetic techniques used for

caesarean section in the UK in1997. International Journal ofObstetric Anaesthesia 2000; 9: 160–167.

2. Thomas J, Paranjothy S. Royal College of Obstetricians andGynaecologists Clinical Effectiveness Support Unit. NationalSentinel Caesarean Section Audit Report. London: RCOG Press,2001.


P17. Anaesthesia for caesarean section: a ten yearsurvey in a UK regionJ. G. Jenkins, M. M. KhanDepartment of Anaesthesia, Royal Surrey CountyHospital, Guildford, UK

Introduction: Over the past generation there has been arise in the rate of caesarean section (CS). This rise hasbeen accompanied by an increased use of regional an-aesthesia (RA). We present data on anaesthesia for CS inthe South Thames-West (STW) region of the UK.

Methods & Results: For some years obstetric anaes-thetists in the STW region have collected data on obstetricanaesthetic interventions. We have accurate data on ratesof CS and anaesthetic technique for CS in hospitals in theregion for the last decade. The CS rate rose from 13.9%(range 10.5–19.7%) in 1992 to 23.6% (18.5–27.3%) in2001. During the same period the rate of RA for electiveCS rose from 69.4% (48.9–83.9%) to 94.6% (89.6–98.5%) and for emergency CS rose from 49.3% (18.4–66.3%) to 86.8% (81.6–95%). In 2001 spinal anaesthesiawas used in more than 90% of elective CS. During theperiod of our study 1.3% of RAs for elective CS and 4.9%of RAs for emergency CS were converted to general an-aesthesia.

Discussion: The CS rate has nearly doubled in the lastdecade and there is no indication that the rate of increaseis slowing; the CS rate in each of the last four years isabove the line of trend. The RA rate for both electiveand emergency CS has risen and there has been a con-vergence of anaesthetic practice. In 2001 the CS rate andthe RA rate for both elective and emergency CS werehigher than both the England and Wales average and theaverage in SE England. The widespread use of spinalanaesthesia for elective CS may limit the opportunitiesto teach other techniques. The failure of RA for bothelective and emergency CS is unacceptable.

Reference1. Thomas J, Paranjothy S. Royal College of Obstetricians and

Gynaecologists Clinical Effectiveness Support Unit. NationalSentinel Caesarean Section Audit Report. London: RCOG Press,2001.

P18. Anaesthetic delivery times for caesarean sectionat Queen Elizabeth Central Hospital, Blantyre,Malawi: is a 30-minute informed to start of operativedelivery time achievable?M. O’ReganLecturer in Anaesthesia, Malawi College of Medicine,Queen Elizabeth Central Hospital, Blantyre, Malawi

Introduction: Perinatal mortality rates at Queen Eliza-beth Central Hospital are thought to be higher than thepublished Malawian urban figure of 35 per 1000 totalbirths. The timely provision of anaesthesia is clearly im-portant for those neonates born by caesarean section. In1998, TheAssociation of Anaesthetists of Great Britain&Ireland and the Obstetric Anaesthetists’ Association to-gether decreed that in fetal emergencies the time frominforming the anaesthetist to the start of operative deliveryshould not exceed 30 min.1 The aim of this study was toassess how close our institution is to achieving the 30-mintarget.

Method: The study was carried out with the approval ofthe professor of the anaesthetic department. For eachcaesarean sectionperformedduring a three-weekperiod inApril 2002 a timesheet questionnaire was completed by aqualified anaesthetist. The time from informing the an-aesthetist to the start of operative delivery was subdividedinto its component times. Key time points and explana-tions for delays were recorded. The urgency of the pro-cedurewas recorded and analysis focused on the clinicallyrelevant emergency and urgent cases. Time interval dataare expressed where appropriate as a median, range andpercentage exceeding an accepted or ‘reasonable’ dura-tion.

Results: For 78 consecutive patients the median [range]times from informing the anaesthetist about a case to thestart of operative delivery (I-KTS time) were 20 [6–75]and 41 [17–136] min for emergency and urgent cases re-spectively. In 69.2% of emergency cases, the 30-mintarget was achieved. Delays occurred in all the componenttime intervals examined. The anaesthetist was in theatrebefore the patient in 38 out of 52 cases (73%). Manysignificant delays were apparently not perceived by theanaesthetist

Conclusion: We were pleasantly surprised by the pro-portion of our emergency cases that fell within the 30-min gold-standard I-KTS time. An I-KTS time of lessthan 30 min should be routinely achievable in moreoptimal conditions. The delayed arrival of patients intheatre needs to be addressed. Education and repeatedaudit cycles using a timesheet may improve the anaes-thetists’ awareness of delays and decrease our I-KTStimes.

Reference1.Guidelines for obstetric anaesthesia services.London:TheAssociation

of Anaesthetists of Great Britain and Ireland and the ObstetricAnaesthetists’ Association, 1998.


P19. Complications following obstetric anesthesia inan obstetric referral center: a prospective evaluationin 6976 patients over a 4-year periodC. Vandewaeter, A. Teunkens, E. Vandermeersch,B. Spitz*, M. Hanssens*, M. Van de VeldeDepartments of Anesthesiology and *Obstetrics andGynecology, UZ Gasthuisberg, Leuven, Belgium

Introduction: Both obstetric general (GA) and regional(RA) anesthesia have been associated with morbidityand mortality. Respiratory complications following GAand post dural puncture headache (PDPH) and centralnervous system complications following RA, are themost important reasons for serious morbidity.1–3 As partof routine quality control, we prospectively evaluated allobstetric anesthesia procedures for four years.

Methodology: We report on all patients who underwentobstetric anesthesia between Jan 1998 and Dec 2001.Prospectively gathered evaluation forms and patientcharts were systematically reviewed. Demographic datawere recorded and the relevant medical and obstetrichistory was noted. The type of anesthesia performed aswell as the complications that occurred were noted. Ifcomplications occurred, their follow up was reviewed.

Results: In the four-year period of analysis, 6976 pa-tients underwent obstetric anesthesia. Data for 601 par-turients were incomplete and therefore excluded. Thusthe data from 6375 patients were used in the finalanalysis. Serious complications occurred in 1/87 patientsundergoing GA and in 1/172 undergoing RA. In allwomen with complications, recovery was complete.Serious complications are presented in the table.

Discussion: The overall serious complication rate ofour obstetric anesthesia service was 0.6%. This iscomparable to literature data reported. The incidence ofserious problems was higher in the GA group. Bothproblems in the GA patients were potentially life-threatening. Fortunately all patients, both in the GA andRA groups, recovered fully. The incidence of neurologicproblems and PDPH is similar to that reported in theliterature.

References1. Deaths associated with anaesthesia. In: Confidential Enquiries into

Maternal Deaths in the United Kingdom 1991–1993. London:HMSO, 87–103.

2. Van de Velde M, Teunkens A, Hanssens M, Van Assche FA,Vandermeersch E. Postdural puncture headache following combinedspinal epidural or epidural anaesthesia in obstetric patients. AnaesthIntensive Care 2001; 29: 595–99.

3. Rorarius M, Suominen P, Haanpaa M et al. Neurologic sequelaeafter caesarean section. Acta Anaesthesiol Scand 2001; 45: 34–41.

P20. Survey of anaesthetic management of twindeliveriesV. Tucker, H. SwalesSouthampton General Hospital, Southampton, UK

Introduction: There is often conflict between anaes-thetists, obstetricians and midwives regarding the man-agement of twin deliveries. It is commonly believed thatthe caesarean section rate for the second twin is in theorder of 10%. The controversy is whether the mothersshould receive an epidural top-up at full dilatation readyfor an immediate caesarean section if required, orwhether she should be managed expectantly, acceptingthat alternate forms of anaesthesia may have to be em-ployed should an immediate caesarean section be re-quired.

Method: With OAA approval, we surveyed each UKmaternity unit, by means of a questionnaire, to deter-mine their current practice. We attained a 75.9% re-sponse rate.

Results: Despite few actual protocols, most units(71.2%) advise patients to have epidural analgesia, al-though few (8.1%) see women with twin pregnancies inthe antenatal period. Most patients with two cephalictwins and a working epidural are managed on the labourward on a standard delivery bed without the presence ofan anaesthetist. Only 8.3% are topped up in readiness forimmediate caesarean section. If an instrumental deliverywas anticipated for cephalic twins, an increasing per-centage were delivered in theatre on an operating tablewith an anaesthetist present, although only 23.4% wereprepared for immediate caesarean section. If one twinwas breech but a vaginal delivery was still planned, overhalf (58.4%) were delivered in theatre but still only 35%were sufficiently topped up for immediate caesareansection.

Conclusion: General anaesthesia for twin pregnancycarries a significant morbidity and mortality. There ap-pears to be a discrepancy between the number of unitsactively recommending epidural analgesia for womenexpecting twins, and the fact that there is no consensus asto the best way to manage the epidural for safe delivery ofboth babies, with minimal risk to the mother. A low per-centage of epidurals are sufficiently topped up for im-mediate section, so presumably these ladies are subjectedto other forms of anaesthesia if caesarean section is nec-essary. Given the huge variation in current practice formanaging twin deliveries, would some national guide-lines not be appropriate?

General anaesthesia Difficult intubation 1 (1/174)Mendelson’s syndrome 1 (1/174)

Regional anaesthesia PDPH 28 (1/222)Neurologic complications* 6 (1/1034)Total spinal anesthesia 2 (1/3101)Infections 0

*Neurologic complications: two cerebrovascular incidents; four iso-lated nerve injuries of the lower extremities.


P21. A survey of the management of failed orinadequate regional anaesthesia for caesarean sectionP. Suaris, V. SkeltonKings College Hospital, London, UK

Introduction: Regional techniques are the preferredmethods of anaesthesia for caesarean section. A recentsurvey showed a conversion rate to general anaesthesia(GA) of 10.6% due to pain,1 but there is no consensus asto how to manage this.

Methods: An extensive questionnaire was circulated todelegates of the Obstetric Anaesthetists’ AssociationAnnual Meeting in May 2002. Clinicians were askedhow they would manage an inadequate block, using aspinal (S) or epidural (E), in categories 1, 2 and 3 cae-sarean sections, before skin incision, during opening ofthe peritoneum and after delivery of the baby.

Results: There was a return rate of 40% (206/515).Spinals (75%) and combined spinal epidural (CSE,20.4%) were the preferred method of anesthesia forcaesarean section. Failure of regional techniques wasdiscussed by 92.3% of clinicians at the pre-operativevisit but only 25.2% quoted a rate.

Table: First line management of inadequate block be-fore skin incision.

Conversion to GA was the first line management forpain felt during opening of the peritoneum in category 1(S-65.1%, E-60.2%), category 2 (S-53.4%, E-43.7%)and category 3 caesarean section (S-45%, E-32%). In-travenous opiates (i.v) were the second, and nitrousoxide the third most commonly used first line agentsusing both spinal and epidural. After delivery, only 15%(S) and 11% (E) opted for GA as first line. Top-ups werethe most common option in the epidural group (31.4).Opiates followed by nitrous oxide were then the mostpopular agents in both groups.Discussion: Inadequate regional anaesthesia does occurdespite our best efforts and is a large source of litigationagainst the obstetric anaesthetist. Our survey shows thatclinicians do discuss this problem with patients. GA inthese situations is a key tool particularly in Category 1and 2 patients despite our increasing use of regionaltechniques. A variety of methods were used to supple-ment blocks and this reflects the lack of a perfect re-gime.

Reference1. Shibli K U, Russell I F. A survey of anaesthetic techniques used for

caesarean section. International Journal of Obstetric Anesthesia2000; 11: 9–12.

P22. A survey of obstetric practice: electivecaesarean section, the place for partnersA. Brand, I. WrenchDepartment of Anaesthesia, Royal HallamshireHospital, Sheffield, UK

Introduction: Caesarean section is exceptionalamongst surgical procedures because it has emotionalimplications for the mother and the father. It doeshowever carry anaesthetic and surgical risks, and reportsin the literature detail sudden, unexpected and severecomplications following spinal anaesthesia.1,2 Our cur-rent practice in Sheffield is not to allow the partner inuntil the block is established to avoid the partner beingpresent when any complications at the onset of regionalanaesthesia occur. We are currently reviewing thispractice and felt it would be useful to carry out a na-tional survey of practice before revising our policy. Wethought that it would also be interesting to survey unitprotocols for general anaesthesia.Method: Having gained approval from the OAA, 254surveys were distributed to lead obstetric anaesthetistsnationally. The survey consisted of a sheet for regionalanaesthesia and another one for general anaesthesia.

Results: Of those surveyed 78% of forms concerningregional anaesthesia were returned. Of these 81% saidthat spinal was their preferred mode of regional anaes-thesia. The majority (48%) of replies stated that theyroutinely allowed partners in from the start of anaes-thesia to completion of surgery, 38% allowed them inonce the block was in, and 10% after surgery hadstarted. The principal reason for allowing them in all thetime was to calm and support the mother (39%). Theprincipal reasons given for admitting partners after theregional block was given was that the system works(23%), lack of space (22%) or in order to check theblock (19%). Reasons given for admitting partners afterknife to skin were to check the block was working(63%). Only 5% of units mentioned patient safety as areason for excluding the partner. Of those surveyed 62%of forms concerning general anaesthesia were returned.Of these 7% allowed partners in to witness the birth ofthe baby. The principal reason for excluding partnerswas that their presence was of no benefit to the mother(36%).

Conclusion: The majority of units surveyed allowpartners to be present the whole time for elective cae-sarean sections under regional anaesthesia. This suggeststhat severe complications of spinals are rare and maylead us in Sheffield to revise our policy.

References1. Chan Y K, Gopinathan R, Rajendram R. Loss of consciousness

following spinal anaesthesia for caesarean section. Br J Anaesth2000; 85: 474–476.

2. Watkins E J, Dresner M, Calow CE. Severe vasovagal attack duringregional anaesthesia for caesarean section. Br J Anaesth 2000; 84:118–120.

Method (%) Category [Spinal (S) or Epidural (E)]

1 S 1 E 2 S 2 E 3 S 3 E

GA 98 87.4 56.4 38.5 11.8 9S 2.0 10 31.9 46 52.9 54.7New E 0 0.5 8.8 3.5 28.4 16.9CSE 0 1.5 2.9 10.5 4.9 15.4


P23. Training in obstetric anaesthesia in the UK:a national surveyJ. Robinson, J. Crowhurst, F. PlaatQueen Charlotte’s Hospital, London, UK

Introduction: Training and assessment in obstetricanaesthesia are about to become competency based. Theaim of this survey was to provide an insight into currenttraining in obstetric anaesthesia.

Methods: A postal questionnaire was sent out to thelead obstetric anaesthetists in 258 centres. Each con-sultant was asked to distribute a separate questionnaireto three trainees on the obstetric rota.

Results: The final response rate was 81% for consul-tants and 43% for trainees.

• 22% of centres were non-compliant with theAssociation of Anaesthetists’ guideline of oneconsultant session per 500 deliveries.

• The majority of teaching is carried out on electivecaesarean section lists (97%) and during 1:1supervision on labour ward (83%).

• 59% of centres have academic teaching sessions.• 93% of consultants thought training could be improvedby increasing consultants’ sessions.

• 74% of trainees had undergone a training module inobstetric anaesthesia (average length three months).

• 58% of respondents had been involved in other areasof anaesthesia during the daytime.

• 87% of trainees had not undergone modular trainingbut covered obstetrics out of hours.

• In 30% of cases, back-up was provided by a seniortrainee.

• 40% of cover was still provided by consultants withoutfixed obstetric sessions.

• The most widely disliked aspect of obstetricanaesthesia was related to difficulties with otherprofessionals.

• The amount and intensity of out of hours work,working in isolation and being made to feel like ‘atechnician’, were other factors mentioned by trainees.

Discussion: Training in obstetric anaesthesia variesgreatly between centres. Where modular training ispractised it is often in name only. The aspects of ob-stetric anaesthesia disliked by trainees may reflect de-ficiencies in training. Many consultants commented onthe decreased availability of trainees on labour ward.The introduction of shift and partial shift systems inresponse to the reduction in junior doctors’ hours, meansthe actual time available to teach trainees is increasinglyreduced. This will need to be addressed.

P24. Prophylactic administration of ranitidine towomen in labour : an audit cycleD. Duncan,* S. A. Thompson,** A. F. McCraeDepartments of Anaesthesia, Royal Infirmary ofEdinburgh, *Western General Hospital, Edinburghand **The St. George Hospital, Sydney, Australia

Introduction: Women in labour may require emer-gency general anaesthesia. A serious complication maybe aspiration of gastric contents into the respiratorytract. It is therefore important to identify women whomay progress to operative delivery and to decrease thevolume and increase the pH of their gastric contents.This can be achieved effectively using a combination ofregular intra-muscular ranitidine plus sodium citrateimmediately before induction of anaesthesia.1 Our unithas a protocol that identifies “high risk” labour and thesewomen are given i.m. ranitidine by midwives. Wepresent an audit of this administration of prophylacticranitidine.

Methods: Data for the initial audit loop was collected bycasenote review for all women undergoing emergencyoperative procedures during a one week period. Obstetrichistory, events during labour, details of ranitidine ad-ministration and the mode of delivery were recorded.Following analysis of these data our protocol for midwifeadministration of ranitidine was widely publicised and aprogramme of staff education introduced. A repeat one-week audit was performed 6 months later. A further oneweek audit of all women in labourwas carried out to assessthe frequency of unnecessary ranitidine administration.

Results: Ranitidine was given to 15/18 women (83%)in the first audit and 21/24 (87.5%) in the repeat audit,although prescribing patterns differed between the au-dits. The protocol for ranitidine administration wascorrectly applied in 17% of cases in the first audit, and46% in the follow-up audit. Only 28% of patients in thefirst audit received optimal antacid prophylaxis (i.e. >1 hbefore delivery) versus 52% in the repeat audit. Reviewof all women in labour (n = 128) identified 65 who hadindications for ranitidine. Of these 43 (66%) went on toinstrumental or operative delivery.

Conclusion: Ideal antacid prophylaxis can be difficultto achieve in practice, despite education and encour-agement of staff to be proactive in the administration ofranitidine. Our protocol does predict most patients likelyto have operative deliveries, and the importance ofantacid therapy in these patients should be stressed.

Reference1. Colman R D, Frank M, Loughnan B A, Cohen D G, Cattermole

R. Use of i.m. ranitidine for the prophylaxis of aspirationpneumonitis in obstetrics. Br J Anaesth 1988; 61: 720–729.


P25. Recovery from anaesthesia in obstetrics: anaudit of midwifery skills in the recovery areaC. R. Evans, F. J. Mcgill, S. MorrisDepartment of Anaesthesia, University Hospital ofWales, Cardiff, UKIntroduction: Guidelines concerning the recovery fromanaesthesia have been clearly documented.1,2 AAGBI1

have published up-to-date recommendations for imme-diate post-anaesthetic recovery. The standards recom-mended should be applied to all areas where ananaesthetic is administered, which include the obstetricunit. In 2002 the Cardiff and Vale NHS Trust has a 27%caesarean section rate, 11% under general anaesthesia. Asafe recovery area is therefore essential. The OAA iscurrently undertaking a national survey into recoverypractice. In our units midwives care for patients duringrecovery, although post-anaesthetic recovery is a smallpart of their training. We therefore decided to examinewhether the recovery skills and knowledge of midwivesin our unit met expected standards.

Method: Thirty midwives were assessed over a two-day period. They were asked to complete a questionnaireabout their confidence in post-anaesthetic recovery andto act out a basic life support scenario in which theywere required to manage an apnoeic patient. They weremarked on their performance by two anaesthetists.

Results: 100% of midwives should be able to managethe airway appropriately. A sample of the results wereas follows:

• 50% of midwives felt that their airway managementskills were inadequate.

• 43% of midwives did not feel confident using a bagand mask, and interestingly of those who feltconfident, 71% were unable to use it properly.

• The basic manoeuvre of opening the airway wasomitted by 53% of midwives.

• Despite 100% of midwives feeling confident inmanaging a patient after spinal anaesthesia, only 67%felt happy managing one after GA.

Conclusion: Immediate post-anaesthetic recovery isimportant and should be managed by staff with appro-priate recovery skills. In view of the fact that a signifi-cant number of midwives were not confident in orcapable of managing post-anaesthetic airway complica-tions, changes need to be made. For example:

• Regular targeted training and assessment of themidwives.

• Having dedicated recovery staff for all postoperativeobstetric patients.

We await with eager anticipation the results of the na-tional survey to see how other units manage the recoveryof their patients.

References1. Immediate postanaesthetic recovery. Association of Anaesthetists

of Great Britain and Ireland, 2002.2. The Audit Recipe Book: Raising the Standard, section

06-obstetric services RCOA.

P26. Audit of anaesthetic record-keeping duringcaesarean sectionS. Halder,a R. Sanders,a C. Hopkins,b J. Durbridge,b

S. M. YentisbaMedical Students, Imperial College London; bMagillDepartment of Anaesthesia, Chelsea & WestminsterHospital, London, UKIntroduction: The Obstetric Anaesthetists’ Associationand the Royal College of Anaesthetists have recentlypublished guidelines for anaesthetic record-keepingduring a caesarean section.1,2 Our aim was to audit thestandard of record-keeping in our maternity unit.

Methods: The absence or presence of predefined dataitems in the anaesthetic charts of 50 women who hadundergone caesarean section was noted. As a conse-quence of this audit, a reminder sticker was developedand introduced, which prompted for the exact timeswhen the anaesthetist was ready, the anaesthetic/top-upwas started, the skin and uterus were incised and de-livery occurred. This sticker was made available to an-aesthetists attending all caesarean sections.Approximately one year after the sticker’s introductionthe audit was repeated, using the charts of another 53women.

Results: Number (proportion) of predefined data itemsrecorded before (Audit 1; n = 50) and after (Audit 2; n =53) introduction of a reminder sticker.

Discussion: The sticker is a cheap, useful and conve-nient prompt for the recording of critical events duringcaesarean section. In addition, the sticker appeared toprompt recording of other data items e.g. ASA grade,although we only specifically looked at five of these, ofwhich three were already commonly recorded. Thesticker (in electrical format) is available from the au-thors on request.

References1. Association of Anaesthetists of Great Britain and Ireland and

Obstetric Anaesthetists’ Association. Guidelines for obstetricanaesthesia services. London: AAGBI, 1998.

2. Smith A. New College guidelines for anaesthetic records: how docurrent forms measure up. Royal College of AnaesthetistsNewsletter 1997; 36: 3–6.

Audit 1 Audit 2 P value

Anaesthetist’s name 50 (100%) 52 (98%) NSDate of surgery 49 (98%) 50 (94%) NSOperation 49 (98%) 46 (86%) NSSurgeon’s name 12 (24%) 19 (35%) NSASA grade 10 (20%) 40 (75%) <0.0001Urgency of surgery* 15 (30%) 40 (75%) <0.0001Anaesthetic/top-up* 23 (46%) 45 (84%) <0.0001Anaesthetist ready* 5 (10%) 37 (69%) <0.0001Skin incision* 5 (10%) 39 (73%) <0.0001Uterine incision* 0 (0%) 26 (49%) <0.0001Delivery* 4 (8%) 42 (79%) <0.0001

*times prompted by sticker.


P27. Syntocinon management of the third stage atcaesarean section: an audit of the introduction ofa 5-unit bolusS. May, P. Stone, I. Kestin, J. ReidDepartment of Anaesthesia, Queen Mother’s Hospitaland Western Infirmary, Glasgow, UKIntroduction: The most recent Confidential Enquiryinto Maternal Deaths (1997–1999)1 recommends the useof no more than 5 units of Syntocinon as a slow i.v.bolus. In February 2002 the use of 5 units of Syntocinonwas introduced at the Queen Mother’s Hospital (QMH)to replace the previous routine 10-unit bolus. Retro-spective audit of routine hospital information showedonly 50% compliance with this new regimen. This wasfelt to result from obstetric requests for 10 units. Wetherefore aimed to assess the use of 5 units of Syntoci-non and its efficacy and safety compared with the rou-tine use of 10 units.

Methods: A prospective questionnaire completed bythe anaesthetist at time of caesarean section recordedvariables including dose of Syntocinon bolus, need forSyntocinon infusion, fall in BP (in first 82 cases), esti-mated blood loss and grade of staff involved. This auditdata was collected over three months between Septem-ber 2002 and January 2003. Retrospective audit of 120caesarean sections from late 2001 (10 units of Syntoci-non) was compared with the current data for blood lossand use of Syntocinon infusion. Looking at hypotension,the current data were compared with data from an auditof elective caesarean section under spinal anaesthesia atQMH in 1995 (10 units of Syntocinon).

Results: 148 questionnaires were returned. Two wereexcluded (placenta praevia and abruption). 129 patients(88.3%) had a 5-unit bolus of Syntocinon, nine (6.2%)received a 10-unit bolus, eight (5.5%) had 5+ further 5-unit boluses a few minutes later on surgical request.

Also there was no statistically significant difference inthe number of patients requiring a Syntocinon infusionto augment uterine tone whether 5 or 10 units were used(P= 0.25). Any hypotension was transient with an av-erage fall of 11.8% in mean BP and 5/79 falling below90 mmHg systolic, one requiring ephedrine. This toowas comparable to the data from 1995.

Conclusion: In our routine use at caesarean section, 5units of Syntocinon is an effective and safe alternative toour previous standard dose of 10 units.

Reference1. Department of Health Why mothers die 1997–1999. Report on

Confidential Enquiries into Maternal Deaths in the United Kingdom:2001.

P28. An audit of blood transfusions in obstetricsP. Whiting, J. D. AldersonDepartment of Anaesthetics, The Jessop Wing, RoyalHallamshire Hospital, Sheffield, UKIntroduction: Blood transfusions are an integral part ofmedical care, yet there is a wide variation in their use.1

They carry a significant risk of reaction and infection.2

Transfusion reactions are common, occurring in up to12% of blood recipients.3 There is also increasing evi-dence that patients tolerate, and physicians acceptanaemia more than previously. We audited our practicein Sheffield to see whether it was consistent with currentrecommendations.

Method: All women who gave birth in the Jessop Wingbetween 01/04/01 and 01/04/02 and received bloodproducts were identified from obstetric and coding da-tabases. Of this cohort of 157 patients, 144 sets of noteswere obtained. Each of the patient’s notes were re-viewed noting the type of delivery, number of transfu-sions administered, pre- and post-transfusionhaemoglobins, the apparent reason for transfusion andthe estimated blood loss. For the purposes of this audit a‘low postnatal haemoglobin’ was <8 g/dL with no ap-parent symptomatology.

Results: The overall transfusion rate was found to be2.7%. Patients were twice as likely to receive blood afteran emergency caesarean section as they were after anelective one. Of those patients transfused 16% had ahaemoglobin >8.1 g/dL, only 43% of whom were ac-tually symptomatic; 49% had a post-transfusion hae-moglobin >10.0 g/dL and 4% a haemoglobin >12.0 g/dL. In 18 (11.5%) of the cases it appeared from studyingthe notes that the reason for transfusion was purelybased on a low haemoglobin, (<8.0 g/dL).

Conclusion: In keeping with a previous audit at theNorth Staffordshire Hospital,3 our results indicate thattoo many of our patients are receiving blood transfu-sions. We should remember that donated blood is alimited resource, and should be treated as such: effi-ciently, conservatively, and appropriately.3

References1. CMO’s Update 34, Department of Health.2. Blood Transfusion and the Anaesthetist; The Association of

Anaesthetists; September 2001.3. Stones R, Enderby B, Ghosh S, Rigby C, Johanson R B. The

incidence of blood transfusion in obstetrics. Br J Midwifery 2001;9: 626–628.

2002/3 2001 P

Regional anaesthesia 95% 89% 0.61Proportion elective 49% 40% 0.26Blood loss <1000 mL 91.1% 94.2% 0.81Blood loss <1500 mL 100% 99.2% 0.95

Mode of delivery Number ofpatients

Numbertransfused

Normal 3549 51 (1.4%)Elective caesarean section 503 19 (3.8%)Emergency caesarean section 773 49 (6.3%)Forceps 336 18 (5.4%)Ventouse 545 20 (3.7%)


P29. Impact of obstetric anaesthetic high riskreferrals on supporting specialtiesA. Nasib, K. N. Litchfield, D. Smith, S. YoungDepartment of Anaesthesia, Princess Royal MaternityUnit at Glasgow Royal Infirmary, Glasgow, UKIntroduction: Management of high-risk pregnancyshould always be based on a multidisciplinary teamapproach.1 This unit has a protocol-driven referral ser-vice for clinic assessment of obstetric patients deemedhigh risk for anaesthesia. The aim of this study was todefine the number of high-risk patients who weremanaged by obstetric anaesthetists alone, compared withthose requiring additional input from supporting spe-cialties.

Methods: This was a retrospective analysis of theobstetric anaesthesia high-risk database, coveringcompleted pregnancies for the year from 1st January2002. This details referrals from both the medicalobstetric clinic and the antenatal clinic for senior an-aesthetic review. The attending anaesthetist had accessto resources such as local protocols, internet andtextbooks. An Excel spreadsheet was used for datacollection and analysis.

Results: There were a total of 89 cases of which 60required no further supporting specialty referral. Thecommonest reasons for anaesthetic review overall wereobesity (23), back problems (15) and allergy (9).The 29 supporting specialty referrals were as tabulated:

Conclusions: In this unit 67% of high risk referrals foranaesthetic assessment had a management plan formu-lated by the attending anaesthetist without consultingother specialties. The remaining 29 were spread overeight specialties. The commonest referral of cardiologysaw all 11 patients having echocardiography. (Thiscompares with a total of 5203 elective echocardiographyprocedures in this hospital over the same period.) Weconclude that a high-risk assessment service is unlikelyto a have a significant impact on supporting specialtyworkload and can be accommodated within the existingresources of a major teaching hospital.

Reference1. Schneider M C. Anaesthetic management of high-risk obstetric

patients. Acta Anaesthesiol Scand 1997; 41: 163–165.

P30. Care of the obstetric patient with cardiacdisease: a retrospective survey of 61 parturientsC. R. Evans, A. M. Nadra, J. Rogers, R. E. CollisDepartment of Anaesthetics, University Hospital ofWales, Cardiff, UKIntroduction: There is an increasing number of womenwho become pregnant with significant cardiac morbid-ity.1 This audit reviews 61 parturients who were seen inan obstetric anaesthetic clinic from July 1998 with ahistory of cardiac disease.

Method: Identified from clinic records, 61 case recordswere reviewed with agreement from the hospital auditdepartment. A detailed birth plan had been written in allthe patient’s notes with information on whether an epi-dural for labour was advised, type of anaesthetic forplanned caesarean section and the seniority of the an-aesthetist who should be involved in the care.

Results: Women’s ages ranged from 17–43 years. Theywere seen first in the clinic from 18 to 38 weeks’ ges-tation and problems ranged from arrhythmic to complexmultiple congenital lesions. At first consultation: 51were New York Heart Classification (NYHC) I, 8NYHC II and 3 NYHC III. Six presented for the firsttime during pregnancy; 17 required regular cardiacmedication before conception. All had an ECG and 54had an echocardiogram as part of their ante-natal workup. Those with significant disease had monthly serialechos. There was no anaesthetic input in 11 because ofuncomplicated or rapid delivery; 21 women had beenadvised to have epidural analgesia for labour and 17received it; 26 mothers in total had an epidural althoughtwo in addition had a GA for emergency caesareansections. Of the 18 planned and 9 urgent sections, therewere 14 low dose CSEs, 6 spinals and further planned“cardiac” GA. One mother was sent for urgent valvot-omy elsewhere. A consultant anaesthetist was present inall 19 cases where one was advised and 8 mothers wereadvised and received invasive monitoring. Postpartumcomplications included 13 with PPH >500 mL, onemyocardial infarction, three awaiting AVR and twomothers were placed on the heart-lung transplant list.There was one post partum death in a mother with Eh-lers Danlos syndrome. There were two mid-trimesterterminations, one for a deterioration in maternal condi-tion and the other for a warfarin embryopathy. Therewas one neonatal death and five neonates had congenitalheart disease.

Conclusion: The management of the mother with car-diac disease can be challenging, requiring a consultantanaesthetist for elective and emergency delivery. Earlyconsultation and carefully written plans in an obstetricanaesthetic clinic improve communication and themanagement of all pregnant women with cardiac dis-ease.

Reference1. Prospective multicentre study of pregnancy outcomes in women

with heart disease. Circulation 2001; 104: 515–521.

Specialty Number of Referrals

Cardiology 11Heamatology 7Immunology 3Neurology 1Orthopaedics 4Pharmacology 1Renal Medicine 1Rheumatology 1


P31. An audit of thromboembolism risk assessmentof mothers in labourM. Abdel-Hafiz,a T. O’Hare,b R. SashidharanaaDepartments of Anaesthesia and bWomen ServicesThe Royal London Hospital, UK

Introduction: Thromboembolism remains the leadingdirect cause of maternal death in the UK.1 Following theintroduction of the RCOG guidelines on thrombopro-phylaxis,2 deaths after caesarean section have fallendramatically.1 An audit in our department also reflectedthis.3 The most recent report on confidential enquiriesinto maternal deaths found that deaths from thrombo-embolism after vaginal deliveries have unfortunately notimproved.1

Methods: For a period of 6 weeks, we prospectivelyaudited the presence or absence of risk factors and theuse of thromboprophylaxis in women admitted in labourto our unit. The mothers were classified as moderate orhigh risk according to RCOG risk assessment profile.Staff caring for the mothers was not aware of the audit.

Results: A total of 290 women were reviewed duringthis period, of whom 79 were considered to be at somerisk of thromboembolism (table). Only eight mothersreceived any form of thromboprophylaxis. On the otherhand none of the women in the audit developed deepvein thrombosis or pulmonary embolus.

Discussion and conclusion: Interestingly, the eightwho received prophylaxis did so because they weredelivered by emergency caesarean section. Followingthis audit, we have established protocols for risk as-sessment and thromboprophylaxis in women deliveringvaginally on our unit. The last two reports on confi-dential enquiries into maternal deaths recommended thatall women with risk factors should be carefully screenedand consideration should be given to a wider use ofthromboprophylaxis during vaginal deliveries. Despitethis there is still a lack of awareness of risk factors andthe need for thromboprophylaxis. We reiterate the con-fidential enquiries’ recommendations that each unit de-velop guidelines, which can be applied within therequirements of their own units.

References1. Department. of Health. Why mothers die. Report on Confidential

Enquiries into Maternal Deaths in the United Kingdom 1997–99.London: TSO, 2001.

2. RCOG Working Party on Prophylaxis against Thromboembolism1995.

3. Leschinskiy D, Sashidharan R. Thromboprophylaxis in emergencycaesarean section: an audit cycle completed. (Abstract) InternationalJournal of Obstetric Anesthesia 2002; 11 (Suppl.): 22.

P32. Pregnancy induced hypertension: time toredefine?K. Ong, R. SashidharanDepartment of Anaesthetics, The Royal LondonHospital, UKIntroduction: Current WHO guidelines define preg-nancy-induced hypertension (PIH) as a diastolic pres-sures of 90 mmHg or more on two consecutive readings4 h or more apart.1 In the most recent ConfidentialEnquiries into Maternal deaths (CEMD), PIH is simi-larly defined as a diastolic pressure P90 mmHg.2

Definitions of PIH continue to rely on absolute levels ofpressure with little consideration of patients’ initialbooking pressure measurements. We would like to re-port a series of women who developed eclampsia in ourunit in whom a diagnosis of PIH was not made becausetheir blood pressures remained ‘normal’ according to theabove definitions. These women had significant in-creases in diastolic pressure in comparison to their lowbooking pressures.

Method: We retrospectively surveyed our units criticalincident database over a three-year period to identifywomen who developed eclamptic seizures. The medicalrecords of these women were reviewed.

Results: Over the period surveyed, seven women hadwitnessed seizures during pregnancy. Of these womenwith eclampsia, we identified four who did not havediastolic blood pressures above 90 mmHg at any stage.On the other hand they did have significant rises in di-astolic pressure around the time of seizure, compared totheir readings at booking.

Discussion: Our review shows that definitions of PIHwhich are based on absolute blood pressure thresholdsalone as recommended by WHO and the CEMD canresult in patients with preeclampsia not being identifieduntil they develop eclampsia. Various groups have pro-posed revisions to the definition of PIH so that significantincreases in baseline blood pressure are taken into ac-count.3 In our review, all four women who were missedhad such rises. We believe that women who have in-creases in diastolic pressure of 15 mmHg or more (or a20% rise from their booking pressures) warrant closeobservation. We suggest this should be reflected inguidelines on PIH.

References1. http://www.who.int/reproductive-health/impac/Acknowledgements.

html.2. Department of Health & others. Why mothers die. Report on

Confidential Enquiries into Maternal Deaths in the United Kingdom1997–99. London: TSO, 2001.

3. Redman C W G, Jefferies M. Revised definition of pre-eclmapsia.Lancet 1988; I: 809–812.

n Number given thromboprophylaxis

Mod risk 58 0High risk 21 8 (38%)


P33. Per-operative oesophageal Doppler monitoringin a parturient with Eisenmenger’s syndromeN. L. Purdie, G. A. McLeod, J. K. NansonDepartment of Anaesthesia, Ninewells Hospital andMedical School, Dundee, UKIntroduction: Maternal mortality in Eisenmenger’ssyndrome most frequently occurs in association withcaesarean section1 where both regional and general an-aesthesia may have deleterious effects on cardiovascularfunction. Haemodynamic instability may be successfullymeasured using a pulmonary artery flotation catheter,although its benefits may be limited by technical inser-tion difficulties, cardiac dysrhythmia and catheter-re-lated thromboembolic complications. In this report, theper-operative use of the oesophageal Doppler monitor(ODM) is described in a parturient with Eisenmenger’ssyndrome undergoing caesarean section.

Case report: A 26-year-old primigravida with Ei-senmenger’s syndrome (secondary to uncorrected sec-undum ASD) was admitted for oxygen therapy andthromboprophylaxis at 20 weeks’ gestation. On exam-ination she was dyspnoeic and cyanosed. During ad-mission she developed type II heparin inducedthrombocytopenia (platelet count 61 · 109/L) and anultrasound scan confirmed the presence of a grade IVplacenta praevia. Unexpectedly at 29 weeks she de-veloped clinical signs of pulmonary thrombo-embolismwith worsening hypoxaemia and required an emer-gency caesarean section. General anaesthesia consistedof i.v. ketamine 120 mg and fentanyl 500 lg withisoflurane 0.5% in 100% O2. Following induction anODM (Deltex Medical Ltd, Chichester, UK) was in-serted in addition to antecubital central venous andradial artery catheters. Intra-operative ODM findingsare shown in the table. At delivery oxytocin was giveni.v. at 30 units/h. Blood loss was 550 mL. The patientwas successfully extubated at 48 h and discharged fromthe intensive care unit after 11 days. Mother and babywere discharged from hospital six weeks after delivery.

Table: Intra-operative haemodynamic variables

Discussion: The ODM is a simple and useful tool forassessing haemodynamic stability in the critically illobstetric patient. Current modifications to the probe,which allow naso-oesophageal placement in awake pa-tients, may widen its future scope in obstetrics.

Reference1. Vongpatanasin W, Brikner M E, Hillis L D, Lange R A. The

Eisenmenger syndrome in adults. Ann Intern Med 1998; 128:745–755.

P34. Anaesthetic management of achondroplasia forcaesarean sectionS. R. Desikan,a A. S. BadhebaDepartment of Anaesthesia, St.Georges Hospital,London, UK and bDepartment of Anaesthesiology andCritical Care, JIPMER, Pondicherry, IndiaIntroduction: Achondroplasia is an autosomal domi-nant disorder and is the most common form of dwarfism.Decreased rate of endochondral ossification leads toshorter tubular bones, hence short extremities and rela-tively normal trunk. These patients usually requirecaesarean section for delivery. Patients with achondro-plasia may have foramen magnum stenosis andkyphoscoliosis therefore causing problems with endo-tracheal intubation as well as regional anaesthetic tech-niques. We report three cases, two for emergency andone for elective caesarean section, all managed underspinal anaesthesia.Case reports: Patient A, a 22-year-old primip,122 cm inheight, required emergency caesarean section. She wasgiven 500 mL of crystalloid preloading and spinal an-aesthesia with 1.3 mL of 0.5% heavy bupivacaine. Asensory level of T4 was obtained. A healthy male babywas delivered with no perioperative problems.

Patient B, a 19 year-old-primip, 120 cm in height, re-quired emergency caesarean section. Spinal anaesthesiawas established after some technical difficulty becauseof mild kyphoscoliosis. She was given 0.8 mL of 5%heavy lidocaine. A sensory level of T6 was achieved.Intraoperatively she needed ketamine 10 + 10 mg sup-plementation because of discomfort. She delivered ahealthy male baby.

Patient C, 24 years old, 123 cm in height, required anelective repeat caesarean section. She was preloadedwith 500 mL of crystalloid solution and a spinal with 1.3mL of 0.5% heavy bupivacaine. A sensory level of T2was obtained, resulting in bradycardia and hypotension,which were corrected with atropine and vasopressors.She delivered a healthy female baby and there were noother problems.

Discussion: General anaesthesia and epidural techniqueshave been used successfully in these patients for caesar-ean section. There were only two reported cases of use ofspinal anaesthesia for caesarean section in the literatureand there is paucity of data regarding the optimal dose oflocal anaesthetics for central neuraxial blockade. Weconclude that spinal anaesthesia is safe and effective inachondroplasia.

Reference1. Kalla G N, Fening E, Obiaya M O. Anaesthetic management of

achondroplasia. Br J Anaesth 1986; 58: 117–119.

ODM Induction 20 min 40 min

CO (L/min) 6.1 7.9 6.1FTc (ms) 361 348 325PV (cm/s) 130 163 135SVR (dyn.s.cm)5) 751 544 881


P35. Dose response to spinal diamorphine in thepresence of regular NSAID therapy: a study inpatients undergoing caesarean sectionI. J. Wrench, S. Sanghera, A. Pinder, L. Power,J. E. Peacock, R. J. S. Birks, V. J. Webster,D. B. Shepherd, M. G. AdamsDepartment of Anaesthesia, C Floor, Royal HallamshireHospital, Sheffield, UKIntroduction: Previous workers have studied the opti-mal dose of spinal diamorphine for analgesia after electivecaesarean section in the absence of regular NSAIDs.1,2

NSAIDs reduce parenteral opiate requirement3 and itch-ing.4 We wished to establish whether regular adminis-tration of paracetamol and diclofenac would reduce thedose of spinal diamorphine that was required for goodpostoperative analgesia whilst reducing opiate-inducedside effects.

Methods: Following ethical approval 120 women un-dergoing elective caesarean section were randomised toone of four groups, double blinded. Spinal anaesthesiawas performed with 0.5% heavy bupivacaine and eitherplacebo or one of three different doses of diamorphine(100, 200 or 300 lg). Regular paracetamol and diclofenacwere administered postoperatively. Breakthrough painwas treated with subcutaneous diamorphine boluses.

Results: There was a dose dependent increase in anal-gesia and itching (number of times reported) with spinaldiamorphine. The incidence of nausea was similar be-tween groups.

Conclusions: The use of regular NSAIDs did not re-duce the trend towards itching with higher doses ofspinal diamorphine, although requirement for postoper-ative opioids was approximately 50% of that previouslyreported.1,2

References1. Skilton E W H, Kinsella S M, Smith A, Thomas T A. Dose response

study of subarachnoid diamorphine for analgesia after electivecaesarean section. International Journal of Obstetric Anesthesia.1999; 8: 231–235.

2. Kelly M C, Carabine A, Mirakhur R K. Intrathecal diamorphine foranalgesia after Caesarean section. Anaesthesia 1998; 53: 231–237.

3. Dennis A R, Leeson-Payne C G, Hobbs G J. Analgesia aftercaesarean section. The use of rectal dilofenac as an adjunct tospinal morphine. Anaesthesia 1995; 50: 297–299.

4. Colbert S, O’Hanlon D M, Chambers F, Moriarty D. The effect ofintravenous tenoxicam on pruritus in patients receiving epiduralfentanyl. Anaesthesia 1999; 54: 76–80.

P36. The effects of intrathecal diamorphine ongastric emptying after elective caesarean sectionH. King, P. BarclayDepartment of Anaesthesia, Liverpool Women’sHospital, Crown Street, Liverpool, UKIntroduction: At present there is no consensus re-garding the ideal period of postoperative starvation afterelective spinal caesarean section. Previous work hasshown that gastric emptying was significantly slower inthe first few hours after caesarean section under spinalanaesthesia than it was on the third postoperative day.1

We wished to identify the contribution that intrathecaldiamorphine made to this delayed gastric emptying.

Method: Forty women undergoing elective caesareansection under a standard spinal anaesthesia were ran-domly allocated to receive in addition 1 mL containingeither diamorphine 300 lg or 0.9% saline. Thirty min-utes after completion of surgery, a baseline venoussample was obtained before administering a 1.5-g doseof soluble paracetamol in 100 mL of water. Furthervenous samples were collected 15, 30, 45, 60, 90 and120 min after ingestion of paracetamol. Paracetamolconcentrations were measured by enzymatic assaymethod using Beckman CX-7 automated analyser. Sta-tistical analysis included the unpaired t-test with Welchcorrection.

Results: The time to maximum concentration (Tmax)was significantly longer in the diamorphine group(control 41.8 (20.8) min: diamorphine 72.6 (41.9) min(P < 0.01)). During the 2-h study period, mean (SD)morphine consumption via a patient controlled analgesia(PCA) device was significantly higher in the controlgroup (control 9.3 (3.6) mg; diamorphine 2.1 (2.1) mg;(P < 0.01)). Results are expressed as mean {SD}.

Conclusion: Intrathecal diamorphine may contribute tothe delay in gastric emptying that occurs immediatelyafter elective spinal caesarean section. Morphine con-sumption via the PCA in the control group may havemasked the true magnitude of the effect of intrathecaldiamorphine on gastric emptying.

Reference1. Patel S, Roberts G, Barclay P. Gastric emptying following elective

caesarean section (abstract). International Journal of ObstetricAnesthesia 2001; 10: 219.

Dose of spinaldiamorphine lg

0(n = 26)

100(n = 29)

200(n = 27)

300(n = 28)

24-h dose of s.c.diamorphine mg(mean (SD))

16.9 (10.1) 12.9 (9.8) 10.64 (8.67)* 6.88 (6.48)**

Post op itchingmoderate or severe/nil or mild

2/74 11/76* 17/64** 21/59**

*P < 0.01 cf control **P < 0.001 cf controlControl Diamorphine P-value

T max (min) 41.8 {20.8} 72.6 {41.9} 0.008C max (lmol L)1) 110.7 {47.7} 87.6 {38.7} 0.11AUC (lmol min L)1) 9503.8 {3528.1} 7707.5 {2780.0} 0.09


P37. Oral intake following caesarean section:a survey of postoperative fasting times and atelephone survey of practice in other unitsR. Kaur, L. Power, I. Wrench, S. GloverDepartment of Anaesthesia, Royal HallamshireHospital, Sheffield, UKIntroduction: Early feeding after caesarean section hasnot been shown to increase gastrointestinal symptoms orileus1 and it has been shown to reduce postoperativeopioid requirements.2 At the time of the survey, our unithad no guidelines for establishing oral intake after cae-sarean section. Our impression was that women wereoften not offered food or drinks for unnecessarily pro-longed periods postoperatively.

Method: One hundred and nine patients were reviewed24 h after caesarean section. Data were collected includ-ing urgency, type of anaesthesia and use of opioids. Thepatients were asked when they first drank and ate post-operatively.

Results: The table shows time (h) to first drinking andeating after different types of anaesthesia: mean (range).

There was no correlation between opioid consumptionand time to feeding in any of the three groups. Themanagers of eight local units were contacted in a tele-phone survey. In five of these, no written guidelines forfeeding after caesarean section were in use. Only threeunits used a patient-led approach.

Conclusion: Women were fasted for prolonged periodsafter caesarean section. Guidelines need to be in place,and a patient-led approach could improve satisfaction.

References1. Kramer R, Van Someren J K, Qualls C R, Curet L B.

Postoperative management of cesarean patients: the effect ofimmediate feeding on the incidence of ileus. Obstet Gynecol1996; 88: 29–32.

2. Burrows W R, Gingo A J Jr, Rose S M, et al. Safety and efficacyof early postoperative solid food consumption after caesareansection. J Reprod Med 1995; 40: 463–467.

P38. A comparison of intravenous patient-controlledanalgesia (PCA) morphine and subcutaneous (s.c.)morphine for analgesia after caesarean sectionD. Mitra, R. Kumar, S. Smith, E. McGrady, F. BrydenDepartment of Anaesthesia, Glasgow Royal Infirmary,Glasgow, UKIntroduction: PCA morphine is an effective method ofproviding analgesia after caesarean section. Subcutane-ous (s.c.) morphine is also used after various operations.A single study1 comparing the two methods after cardiacsurgery showed that s.c. morphine was as effective asPCA morphine. PCA pumps are very bulky and cancompromise the mobility of mothers and their ability tohold and nurse their babies. In this study, we comparedthe analgesic efficacy and the side-effects of PCA ands.c. morphine after elective caesarean section.

Method: In a prospective randomised controlled trial,after ethics approval, 50 patients with singletonpregnancy, ASA I-II, were randomised to receive ei-ther PCA morphine (1 mg/mL, 3-min lock-out) or s.c.morphine for postoperative analgesia. The operationwas performed under spinal anaesthesia. At the end ofsurgery, PCA was connected to the patient or a s.c.cannula was inserted on the upper chest, 10 mg ofmorphine was given and a local protocol followed fors.c. morphine. Morphine consumption, pain scores (ona 100-mm scale) and nausea scores were noted 6, 12and 24 h postoperatively. The Mann-Whitney U-testwas used to analyse the data.

Results: There were no significant differences betweenPCA and s.c. groups in morphine consumption, pain andnausea scores at 6, 12 and 24 h after surgery.

Table: Median values at 24 h

Conclusion: The study showed that s.c. morphine iscomparable to PCA morphine for postoperative anal-gesia and side-effects, and it can be a satisfactory al-ternative to PCA morphine for providing pain relief aftercaesarean section.

Reference1. Munro A J, Long G T, Sleigh J W. Nurse-administered

subcutaneous morphine is a satisfactory alternative to intravenouspatient-controlled analgesia morphine after cardiac surgery.Anesth Analg 1998; 87: 11–15.

n 1st drink 1st food Dissat

Elective regional 50 11.7 (7.5–18) 19.0 (8–28) 17/41Urgent regional 50 11.6 (7.5–23) 18.1 (9–30) 9/36General 9 12.9 (7.5–16) 23.5 (17.5–34) 0/3

Dissat = number of those commenting who were dissatisfied aboutpostoperative feeding

PCA s.c. 95% CI

Morphine dose 38 40 )5.0, +8.0Pain score rest 13 10 )4.0, +6.0

dynamic 20 22 )6.99, +5.0Nausea 0 0 )0.001, )0.002


P39. Postoperative pain relief, pruritus and nauseaafter cesarean section: comparison of intra-operativepropofol and droperidol/pentazocineY. NambaDepartment of Anesthesiology, Hokkaidoritsu EsashiHospital, Esashi, JapanIntroduction: Some cesarean section patients com-plain of the visceral pain following delivery of thefetus.1 Epidural morphine is reputed to provide ex-cellent relief of postoperative pain but is associatedwith complications such as pruritus, nausea, respira-tory depression and urinary retention.2 This study wasdesigned to evaluate the effect of systemic medica-tions given to relieve visceral discomfort during ce-sarean section on postoperative analgesia, pruritus andnausea following epidural administration of morphine/droperidol/bupivacaine.

Methods: Two groups of patients undergoing cesareansection under epidural anesthesia were studied. Theywere comparable in age, weight and height. After seeingtheir baby, 24 patients received propofol and 22 patientsreceived droperidol/pentazocine. A 2-mg bolus of mor-phine/2.5 mg of droperidol was given at the end of theoperation through the epidural catheter. Postoperativelymorphine 5 mg + droperidol 5 mg in 0.125% bupiva-caine 60 mL were infused continuously at a rate of 2mL/h. The patients evaluated pain and pruritus(1 = none or little; 2 = tolerable; 3 = intolerable, nau-sea: 1 = none; 2 = present). The Mann-Whitney testwas used for statistical analysis.

Results: Results (n and %) are shown on the table. Thedose of propofol given was 15 € 4 mL, droperidol3.2 € 1.3 mg and pentazocine 11.9 € 3.8 mg. Therewere no significant differences between the two groups.No ECG abnormalities were noted.

Conclusion: Satisfactory prophylaxis of nausea wasobtained in both groups. Further studies are necessary todetermine if postoperative pain and pruritus are affectedby these drugs.

References1. Gutsche E K, Cheek T G. Obstetric anesthesia and perinatology.

In: Longnecker De, Murphy F L (eds). Introduction to Anesthesia.Philadelphia: W.B. Saunders, 1997: 350–363.

2. VadeBoncour T R. Management of postoperative pain. In:Longnecker De, Murphy FL (eds). Introduction to Anesthesia.Philadelphia: W.B. Saunders, 1997: 456–465.

P40. The ‘Managing Obstetric Emergencies andTrauma’ (MOET) course: views of courseparticipantsN. L. Lewis, S. Wieteska, C. Cox, K. GradyAdvanced Life Support Group, Salford Quays, UKIntroduction: The MOET course was set up in 1998.Since then, 29 courses have been run in the UK in 11centres. Three hundred and seventy-one obstetricians,104 midwives, 85 anaesthetists and three accident andemergency doctors have attended these courses. Wewished to find out the views of participants on theMOET course.

Methods: Questionnaires were sent to 200 recentcourse participants and they were asked to rank theiropinion on the statements listed below: 1 = stronglyagree and 5 = strongly disagree.

Results: We received 125 replies and the median scoreswere as follows:

Conclusion: Overall, course participants strongly agreethat it is desirable for all senior obstetricians and obstetricanaesthetists to attend a MOET course. It was felt that theMOET course should be compulsory for senior obste-tricians but not for senior obstetric anaesthetists or mid-wives. Participants felt that the MOET course improvedboth their competence and their confidence in dealingwith obstetric emergencies, trauma in the obstetric pa-tient and neonatal resuscitation. There was also strongagreement that it is beneficial to learn about obstetricemergencies and trauma in a multidisciplinary setting.

Pain Pruritus Nausea

Score 1 2 3 1 2 3 1 2

Propofol 12 5 7 9 14 1 24 0% 50 21 29 38 58 4 100 0Droperidol/pentazocine

15 3 4 13 8 1 21 1

% 68 14 18 59 36 5 95 5

• The MOET course should be compulsory for all seniorobstetricians. 2

• It is desirable for senior obstetricians to attend a MOETcourse. 1

• The MOET course should be compulsory for all seniorobstetric anaesthetists. 3

• It is desirable for senior obstetric anaesthetists to attend aMOET course. 1

• All practising midwives should attend a MOET course. 3

• The MOET course has improved your competence indealing with obstetric emergencies. 2

• The MOET course has increased your confidence indealing with obstetric emergencies. 2

• The MOET course has improved your competence indealing with trauma in obstetric patients. 2

• The MOET course has increased your confidence indealing with trauma in obstetric patients. 2

• The MOET course has improved your competence indealing with neonatal resuscitation. 2

• The MOET course has increased your confidence indealing with neonatal resuscitation. 2

• It is beneficial to learn about obstetric emergencies andtrauma in a multidisciplinary setting. 1


P41. Simulator-based learning for obstetricanaesthesiaT. Blackburn, C. Sadler, P. HowellBarts and the London Medical Simulation Centre, St.Bartholomew’s Hospital, London, UK

Introduction: Simulation-based training has beenshown to be an effective tool.1 The Obstetric Anaes-thetic Training in the Simulator (OATS) course has beendeveloped as a training course for year 1 SpRs and se-nior SHOs. This one-day course challenges candidateswith a variety of obstetric-based high fidelity clinicalscenarios, exploring knowledge and clinical abilities.Each scenario is followed by a debriefing involvinggroup discussion and constructive feedback led by thecourse facilitators. The impact of the first five courseshas been evaluated.

Method: Questionnaires were completed at the begin-ning and end of the OATS course. Candidates wereasked to assess on a scale of 1 (not at all confident) to 10(very confident) “How confident are you in your abilityto manage the following range of obstetric anaesthesiaproblems?” In addition, they were asked “Will today’scourse assist you in your daily practice?” scoring 1 (notat all) to 10 (very much so). Data were evaluated usingWilcoxon signed ranks test (significance P <0.01).

Results: Data were collected from 29 candidates at-tending 5 OATS courses. Mean anaesthetic experiencewas 35 months (SD 11 months). Data are median (IQR).

Will today’s course help you in your daily practice?”Median (IQR) = 9 (8–10).

Conclusion: Attendance at the OATS course signifi-cantly improves trainees’ confidence in their ability tomanage a number of serious obstetric anaesthetic crises.In addition, trainees believe the course is helpful in theirdaily clinical practice. However, it is acknowledged thatcompetence and performance does not necessarily followconfidence.

Reference1. Forrest F, Taylor MA, Postlethwaite K, Aspinall R. Use of a

high-fidelity simulator to develop testing of the technicalperformance of novice anaesthetists, Br J Anaesth 2002; 88:338–344.

P42. Management of eclampsia: a pilot study on theeffects of simulation on performanceD. S. Earl, S. G. O. ReesCheltenham General Hospital, Cheltenham, UKIntroduction: Eclampsia is an uncommon clinicalemergency, with an incidence in the UK of 4.9/10 000maternities.1 Consequently many medical staff will beinexperienced in its acute management. Simulated crit-ical incidents are now increasingly used in medicalpractice to prepare for such rare events. We conducted apilot study investigating the effects of a programme ofeclampsia scenarios on team performance.

Method: Over a four-month period, monthly identicalscenarios of an antipartum eclamptic fit were performedin a delivery room. Anaesthetic, obstetric and midwiferystaff assumed appropriate roles, with an actress as thepatient. Timings from onset of seizure to clinical inter-ventions were recorded, and post-scenario commentswere sought as to how future performance could beimproved.

Results: Time from seizure onset to administration ofmagnesium sulphate ranged from 13 to 9 min. A numberof difficulties relating to magnesium administrationwere noted, resulting in a relatively constant time ofabout 6 min from recommendation of magnesium to itsactual commencement. Timings of calling for appro-priate help, adoption of left lateral position and oxygenadministration were more variable.

Conclusion: Simulated “eclampsia drills” can poten-tially improve team performance through education andfamiliarity. They may also highlight important systemdeficiencies and suggest remedies for these.

Reference1. Douglas KA, Redman CWG. Eclampsia in the United Kingdom.

Br Med J 1994; 309:1395–1400.

Pre-course Post-course P

Site CSE 9 (7–10) 9 (8–10) <0.01Maternal arrest 7 (5–7) 7 (7–8) <0.01Failed intubation 7 (6–8) 8 (7–9) <0.01Dural puncture 8 (6–9) 9 (8–10) <0.01Haemorrhage 7 (6–8) 8 (7–9) <0.01Post-natal PDPH 8 (7–9) 9 (7–9) <0.005Eclamptic fit 7 (5–8) 8 (7–9) <0.0005Total spinal 7 (5–8) 9 (8–9) <0.0005Thromboembolism 5 (4–7) 7 (7–8) <0.0005Amniotic fluidembolism

5 (4–7) 7 (6–8) <0.0005


P43. Obstetric “fire drills” surveyT. Blackburn, C. SadlerBarts and The London Medical Simulation Centre, St.Bartholomew’s Hospital, London, UKIntroduction: The confidential enquiries into maternaldeaths in the UK have recommended that all obstetricunits should organise regular “fire drills” for cases ofmassive haemorrhage.1 The Department of Health rec-ognises that medical simulation centres may have a role insuch training to “expose staff to risk situations with noactual patients involved.”2 This survey was compiled toascertain the level of implementation, experiences withlocation and staffing, the attitudes of anaesthetists to-wards them and the potential role for medical simulationcentres.

Method: OAA-approved questionnaire were sent to thelead consultant obstetric anaesthetist of all UK units.

Results: Questionnaires were posted to 260 units and203 completed forms were returned (78% response).Only 92 units (45%) had run “fire drills”: of these, 61%had run less than 3 in the last year. Haemorrhage was thecommonest scenario used (at 84% of units). Additionaldrills included maternal cardiac arrest (39%), collapse(33%) and convulsions (32%). All units except one,which involved midwives alone, ran multi-disciplinaryscenarios. At most units drills were run on labour ward(82%) or in obstetric theatre (33%). Although only 5%of units used simulation centres, 59% of respondents feltthey would be suitable. At 29% of units protocols hadchanged as a result of running the drills. The majority,111 units (55%) had not run “fire drills”. The mostfrequently cited reasons were “no time” (37%), “nofunding” (30%), “no staff” (19%), “don’t know” (15%)and “not worth the effort” (5%). Nevertheless, 49% ofthese units stated that they were intending to introducethem soon. Most respondents, 93% of the “fire drill” and74% of the “non fire drill” groups, agreed that othermultidisciplinary training exercises would be of value totheir units.

Conclusions: This survey suggests that just under halfof UK obstetric units have implemented “fire drills” forcritical situations. Only 18% of all units have run morethan two drills in the past year. The commonest reasonfor not implementing drills was lack of resources. Themajority of anaesthetists appear to appreciate the valueof multi-disciplinary team training. Whilst the clinicalenvironment may be the most appropriate location for“fire drills”, fitting this in with daily duties on a busylabour ward is proving difficult for many units. Whereavailable, simulation centres may offer an alternativelocation for multi-disciplinary training.

References1. Confidential Enquiry into Maternal Deaths in the United Kingdom

1994–1996 and 1997–1999.2. Building a Safer NHS for Patients. Department of Health 2001.

P44. A simple technique to reduce the incidence ofloss of local anaesthetic solution during injection forspinal anaesthesiaJ. M. Morgan, I. WrenchJessop Wing, Royal Hallamshire Hospital, Sheffield, UKIntroduction: Previous workers have shown that sig-nificant quantities of local anaesthetic may be lost inthe form of drops spilled from the connection pointbetween the spinal needle and the syringe at injectionfor spinal anaesthesia.1 This loss of local anaestheticmay lead to inadequate anaesthesia, possibly resultingin an inferior block. It was our clinical impression thatlocal anaesthetic was lost less frequently if the syringewas attached to the spinal needle before the spinalfluid had been allowed to enter the hub of the spinalneedle. We investigated this using the Rouilly LPsimulator.

Method: The Rouilly LP simulator for lumbar punctureinjection contained saline 0.9% representing cerebro-spinal fluid. A series of spinal injections were performedusing 25-gauge Sprotte needles. A 5-mL syringe wasthen firmly connected to the hub of the needle and 3 mLof 0.9% saline injected over 10 s. On 10 occasions salinewas allowed to flow freely from the hub of the needlebefore connecting the syringe, whereas on another 10occasions the syringe was connected to a dry needle hub.Any loss of the injectate from the connection site wasthen recorded.

Statistics: Fischer’s Exact Test was used (SPSS pro-gramme) assuming significance at P < 0.05.

Results: Significantly more drops of injectate were lostfrom the wet hub connection (P < 0.02).

Discussion: We have shown that it is possible toreduce significantly the incidence of loss of injectatefrom the hub of the spinal needle by using “dryconnection” to the syringe. This is a simple techniquethat should help ensure that all of the local anaes-thetic solution is instilled so that a satisfactory spinalblock is achieved.

References1. Randall K, Yentis SM. Every little drop counts. International

Journal of Obstetric Anesthesia 2002; 11: 23 (abstract P13).2. Levy JH, Islas JA, Ghia JN, Turnbull C. A retrospective study of

incidence and causes of failed spinal anesthetics in a universityhospital. Anesth Analg 1985; 64: 705–710.

Fluid loss Total

Loss No loss

Spinal hub dry 3 7 10Connection wet 9 1 10Total 12 8 20


P45. Mechanism of epidural paresthesia: is it thecatheter or the needle?M. Allen, G. Vasdev, C. Burkle, R. MacKenzie,P. SouthornDepartment of Anesthesia, Mayo Clinic, Rochester,MN, USAIntroduction: The incidence of paresthesia with epidu-ral catheter placement in the obstetric population is re-ported as high as 44%. Clinically, such paresthesiasmostly occur as the catheter tip initially emerges from thetip of the needle. We postulated that the stiffness of thecatheter and the angle of the epidural needle tip determinethe force an epidural catheter exerts on surrounding tis-sues as it exits the needle. To test this hypothesis, weconstructed a model to test in vitro the force exerted whena variety of epidural catheters are passed through differentepidural needles.

Methods: Force was measured with a compressiongauge and angle at the tip of an epidural catheter identifiedwith a 4· magnified protractor. The maximum forceacting on the compression plate with catheter advance-ment was measured 10 times for each catheter/needlecombination. Catheters studied were: 20-gauge KendallSafeTrak� bullet tip (kbt) (copolymer), 20-gauge Ken-dall SafeTrak� open tip (Teflon�) (kut), 20-gauge Portexbullet tip (nylon) (pbt), and the 19-gaugeArrow�FlexTipPlusTM (wire spiral polyurethane) (s). Epidural needleswere 18-gauge Husted� (h), 18-gauge winged Weiss�(w), 18-gaugewinged Espocan� (e), and 17-gauge Tuohy(winged) (t).Mean and standard errorwere determined foreach catheter/needle combination and compared by AN-OVAR and Dunnett’s Multiple Comparison Test withP = 0.05 as significant (JMP 4.04 software).

Results: The angle of needle tip was e = 22�, h = 2�0, t= 25�, w = 18�.

Discussion: Our study demonstrated that there is an as-sociation between needle type and catheter combinationand the force exerted on tissues with catheter advance-ment. The Kendall Bullet tip catheter pushed through anEspocan needle and Portex Bullet tip catheter advancedthrough Husted needle combinations were significantlybetter than the other polyamide catheter/needle combi-nations. When compared with the Arrow/Tuohy, only theKendall Bullet Tip/Espocan combinations were similar.This in vitro study implies that both the needle and cath-eter chosen are important determinants in reducing therisk of paresthesia.

P46. Is S1 motor block a reliable indicator ofaccidental intrathecal injection of levobupivacaine?S. Babu, B. Balhmann, W. W. Mapleson, R. E. CollisDepartment of Anaesthetics, University Hospital ofWales, Cardiff, UKIntroduction: In a recent paper1 it was shown that S1motor block, that developed 10 min after neuraxial in-jection, could be used as part of the initial assessment todetermine if bupivacaine had been inadvertently injectedintrathecally during epidural analgesia. The aim of thisstudy was to compare bupivacaine with levobupivacaineto determine if S1 motor block develops in a similar waywith latter.

Methods: ACSE technique with sequential allocation ofa varying intrathecal dose was used for elective caesareansection. Thirty-five patients received bupivacaine withfentanyl in a fixed ratio of bupivacaine 1 mg to fentanyl 2lg. A study responder had motor block of ankle planter-flexion 10 min after injection. The next patient after aresponder received 1 mg less of bupivacaine, the nextpatient after a non-responder received 1 mg more. Thestudy was then repeated on a further 25 patients using thesame study design with levobupivacaine and fentanyl inthe same ratio.

Results: Calculations of the ED50 and confidence limitsfor S1motor block 10min after intrathecal injection usinglogistic regression were performed for both drugs. ED50for bupivacaine with fentanyl: 8.4 mg (95% CI 7–10) andfor levobupivacaine with fentanyl: 8.2 mg (95% CI 7.3–9.4).

The study was terminated slightly prematurely becauseof problems of pain during the caesarean section usingthese small intrathecal doses, despite using the epiduralcatheter in many cases.

Conclusion: We have shown that when bupivacaineand levobupivacaine are given intrathecally, S1 motorblock develops in a similar way and therefore this test isa valuable assessment for either drug.

Reference1. Daoud Z, Collis RE, Ateleanu B, Mapleson WW. Evaluation of S1

motor block to determine a safe reliable test dose for epiduralanalgesia. Br J Anaesth 2002; 89: 442–445.

Figure: Force vs catheter-needle combination.


P47. In vitro changes in heparin resistance duringpregnancy using thrombolelastography (TEGsR )J. Cropp, H. Gorton, G. LyonsDepartment of Obstetric Anaesthesia, St. JamesUniversity Hospital, Leeds, UKIntroduction: Guidelines recommend that regionalblockade is not performed for 12 h following an injec-tion of low molecular weight heparin. This is an arbi-trary time which is not evidence based. Duringpregnancy, women become hypercoaguable and evi-dence suggests that pregnant women are resistant toheparin at >36 weeks’ gestation.1 We conducted an invitro observational study in pregnant women to deter-mine at which stage of pregnancy heparin resistanceoccurs.

Materials and methods: Venous blood was taken us-ing a 22-gauge cannula from five pregnant staff volun-teers (ASA I) at various stages of pregnancy. Two nativeblood samples were taken (the first 3 mL discarded) andthromboelastographs performed, in accordance with theHemoscope manual. The first sample (control) consistedof 0.36 mL of native blood. The second sample con-sisted of 0.33 mL of native blood and 0.03 mL of hep-arinised saline resulting in 0.0083 units/mL ofunfractionated heparin. Heparin effect was defined asheparin r-time minus control r-time. r-time is normallyprolonged by heparin.

Results: Mean heparin effect at less than 20 weeks’gestation was 31.3 mm (95% CI 13.9 to 38.8). Meanheparin effect at more than 24 weeks’ gestation was 8.82mm (95% CI 3.1 to 14.5).

Conclusion: Heparin resistance may occur between 20and 22 weeks’ gestation. The heparin concentration usedin this study is below peak therapeutic range and wasused as it demonstrates the maximum difference.

Reference1. Lansbury AL, Monte S, Lyons GR. Evidence of heparin resistance

in pregnancy: an in vitro study. European Journal of Anaesthesia2002; 19: Abstract 586.

P48. Luer lock versus bayonette lock for spinalanesthesia during a combined spinal epidural techniqueF. Choudhry, K. Scott, B. Harrison, G. VasdevDepartment of Anesthesia, Mayo Clinic, Rochester,MN, USAIntroduction: Failures of the spinal component of thecombined spinal epidural (CSE) technique have been at-tributed to inability to aspirate CSF, movement of thespinal needle during spinal injection resulting in loss ofinjectate and loss at the syringe/spinal needle hub inter-face. Luer lock (LL) syringes have the advantage of at-taching securely to the spinal needle hub thus decreasingthe chance of fluid loss at this site. The main advantage ofthe bayonet lock (BL) syringe is that it requires verysimple manipulation to secure it to the hub.We conductedan in vitro study to examine which syringe resulted in theleast amount of spinal needle tip movement when injec-tate is delivered in a CSE technique.

Methods: A model was constructed using 3 cm of in-flexible tape to simulate the interspinal ligament. Thespinal needle was attached to a compression/strain gauge.The gauge was set to measure maximal compression/strain for each simulated intrathecal injection. A 3-mLLLsyringe and a 3-mL BL syringe were used to simulate aspinal injection. The maximal force exerted on the strain/compression gauge by the syringes was recorded for thefollowing CSE kits: matched needle through needle (18-gauge Weiss, 27-gauge Whitacre, Dura SafeTM), un-matched (18-gauge Hustead, 5¢¢ 27-gauge Gertie-Marxneedle), matched straight needle through needle (Espo-can� B. Braun). Ten sets of measurements for each kitwere analyzed usingANOVA and {ıt t}-test withPO0.05as significant.

Discussion: In an ideal needle-through-needle CSEtechnique, the operator should feel a dural pop when thespinal needle is placed, CSF should easily be aspirated,then injectate delivered. Unmatched needles may bemoreeconomical and versatile. Once CSF is located, unneces-sary manipulation of the spinal needle should be avoidedto assure continued intrathecal position. Our study appliesto CSEwhere the needle hubs are not locked together.Wedemonstrate that LL causesmost force to be transmitted tothe needle tip during attachment of the syringewhen usingEspocan needles, probably because the Teflon-coatedcentering sleeve allows smoother placement of the spinalneedle through the epidural needle. We also found thatunmatched needles transmitted the least force during sy-ringe manipulation, due to the forced curve of the GertieMarx needle through the Husted. In summary, we advo-cate the use of BL needles in the CSE technique, espe-cially when low resistance needles are used.

DuraSafen = 10

Unmatchedn = 10

EspocanN = 10

ANOVA2-sided

BL mean €SEM in Newtons

1.14 € 0.12 0.89 € 0.14 0.94 € 0.15 0.47

LL mean €SE in Newtons

1.24 € 0.12 1.03 € 0.14++ 1.55 € 0.15++ 0.04*

t-test P 0.56 0.48 0.01*

*Significant; ++t-test P = 0.02*

Figure: Box plot at less than 20 and more than 22 weeks’ ges-tation.


P49. Use of the pulse contour cardiac output(PiCCO) monitor in caesarean section in a parturientwith mitral stenosisT. M. L. Chan, P. GrovesDepartment of Anaesthesia, King’s College Hospital,Bessemer Road, London, UKIntroduction: We report the case of a 46-year-oldwoman with severe mitral stenosis undergoing electivecaesarean section and tubal ligation under general an-aesthesia at 36 weeks’ gestation in her ninth pregnancy.We present the use of the less invasive pulse contourcardiac output (PiCCO) monitor throughout the peri-operative period.

Methods: Non-invasive monitoring was establishedbefore insertion of the invasive monitoring lines underlocal anaesthesia. A right internal jugular triple lumencatheter was introduced and a thermodilution catheter(PULSIOCATH PV2015L13) inserted into the rightfemoral artery. These lines were then connected to thepulse contour cardiac output monitor (PiCCO) andbaseline haemodynamic variables were obtained beforeinduction of anaesthesia.

Results: Throughout the peri-operative period continu-ous monitoring of blood pressure, cardiac output, strokevolume and systemic vascular resistance was possiblewith the use of the PiCCOmonitor. With this informationjudicious use of fluid and vasoactive drugs maintainedcardiovascular stability. Both mother and baby made anuneventful recovery.

Conclusion: Although the PiCCO has not been widelyused in these groups of patients, the values obtainedwere not dissimilar to those of the pulmonary arteryfloatation catheter used in other investigators’ case re-ports.1 The continuous capability of the monitor allowedus to keep track of the changing trend of systemic ar-terial blood pressure, cardiac output and systemic vas-cular resistance during the operation and thepostoperative period and to adjust treatment accordinglyin real time.

Reference1. Hemmings GT, Whalley DG, O’Connor PJ, Benjamin A, Dunn C.

Invasive monitoring and anaesthetic management of a parturientwith mitral stenosis. Can J Anaesth 1987; 34: 182–185.

P50. Caesarean section for severe preeclampsia: asurvey of UK consultant obstetric anaestheticpracticeW. J. Wight, V. Bythell*

Department of Anaesthesia, Women’s College Hospital,Toronto, Canada and *Royal Victoria Infirmary,Newcastle upon Tyne, UKIntroduction: There is no accepted standard anaes-thetic management of caesarean section in the severelypre-eclamptic patient.1 We performed a postal survey ofall UK consultant anaesthetist members of the ObstetricAnaesthetists Association (OAA) about their beliefsregarding this issue.

Method: A questionnaire was mailed in April 2002 toall consultant anaesthetists identified by the OAA. Allnon-responders were followed up with a second mailing.The questionnaire asked about the preferred anaesthetictechnique for caesarean section in the severely pre-eclamptic patient, coagulation tests and results requiredbefore performing a regional technique, and the drugschosen when performing general anaesthesia in thispopulation.

Results: Of the 936 consultant anaesthetists surveyed,637 replies were received (71.3%). The most frequentlyused anaesthetic technique for caesarean section in se-vere preeclampsia was single shot spinal anaesthesia(46.1%), 26.2% choosing combined spinal and epiduralanaesthesia (CSE), 15.6% epidural anaesthesia, and7.6% general anaesthesia. The median platelet countbelow which respondents would not perform regionalanaesthesia was 80 · 109/L (47.1%), with 16.5%choosing a cut-off below 70 · 109/L. The most popularinduction agent for general anaesthesia was thiopentone(86.6%). A wide range of drugs is used to attenuate thehypertensive response to intubation, with many usingmore than one agent. The most frequently used drug wasalfentanil (75.2%), whilst labetalol (35.0%), magnesiumsulphate (33.6%), and fentanyl (14.2%) are also popularchoices; 5.8% are now using remifentanil for this pur-pose.

Conclusion: Despite an apparent lack of consensus inthe literature regarding the superiority of one regionaltechnique over another in severe preeclampsia, thissurvey demonstrates that in practice a majority of UKanaesthetists use spinal or CSE in this situation. A ma-jority of anaesthetists would perform a regional tech-nique for caesarean section when the platelet count is80 · 109/L or greater, which broadly reflects the prac-tice represented in a similar survey performed in 1998.2

When general anaesthesia is performed in this popula-tion a wide range of drugs is used in the attenuation ofthe hypertensive response to intubation.

References1. Hood DD, Curry R. Spinal versus epidural anesthesia for cesarean

section in severely preeclamptic patients: a retrospective survey.Anesthesiology 1999; 90: 1276–1282.

2. Wee L, Sinha P, Lewis M. Central nerve block and coagulation: asurvey of obstetric anaesthetists. International Journal of ObstetricAnesthesia 2002; 11: 170–175.

Events Ind SI Oxy End

Heart rate (bpm) 98 107 120 98Blood pressure (mmHg): systolic 117 85 104 100Diastolic 74 57 60 65Central venous pressure (mmHg) 1 5 12 7Cardiac index (L min)1 m)2) 2.35 1.3 2.24 2.79Systemic vascular resistanceindex (dynes s cm)5 m)2)

3158 3551 2950 2105

Ind: induction, SI: skin incision, Oxy: oxytocin, End: end of sur-gery.


P51. Vasodilatation by magnesium in the dorsalhand veinR. Landau, J. A. Scott, R. M. SmileyColumbia University, New York, USAIntroduction: Magnesium affects blood pressure bymodulating vascular tone and reactivity. In obstetrics,magnesium is administered to women to preventeclamptic seizures and for tocolysis. Prior to studying a-and ß-adrenergic vascular sensitivity in women withpreeclampsia, we sought to determine the effect ofmagnesium on venous tone.

Methods: Ten healthy non-pregnant women of child-bearing age were studied. Response to magnesium sul-fate (MgSO4) was measured in a dorsal hand vein usingthe linear variable differential transformer (LVDT)technique.1 Complete dose-response curves to MgSO4(0.625–2 g/h) were determined after 50% preconstric-tion of the vein with phenylephrine Total plasma mag-nesium concentrations at baseline and at the highestinfused dose of MgSO4 were determined. ED50 resultsare expressed as geometric mean (95% confidence in-terval). Emax results and magnesium concentrations areexpressed as mean € SD.

Results: The ED50 of MgSO4 was116 lg/min (52,252 lg/min) and Emax was 102% € 20%, where 100%indicates a return to pre-phenylephrine baseline (Fig-ure). Systemic magnesium levels were increased by theinfusion (from 2.0 to 2.3 mg/dL, P < 0.001 by pairedt-test) but concentrations remained normal.

Conclusions: This is the first in vivo demonstration ofmagnesium-induced venodilatation. The MgSO4 doseresulting in vasodilatation using the LVDT/hand veintechnique is two to three orders of magnitude less thanthe therapeutic doses of magnesium used for tocolysis orseizure prophylaxis. The vascular effects of systemicallyadministered therapeutic doses of magnesium on vas-cular reactivity and drug response in preeclampsia willbe of interest.

Reference1. Aellig W H. Clinical pharmacology, physiology and

pathophysiology of superficial veins–1. Br J Clin Pharmacol1994; 38: 181–196.

P52. Ambulatory epidural analgesia and the durationof laborM. KarrazPolyclinique de Beauvaisis, Beauvais, FranceBackground and goals: Some obstetrical studies haveshown the benefits of ambulation without epidural an-algesia- on labor.1,2 We tested the hypothesis that thedevelopment of an original method of ambulatory epi-dural analgesia (AEA) which allowed all parturients towalk3 has specific advantages on mode of delivery(spontaneous vaginal, cesarean, forceps), consumptionof local anesthetic (LA), oxytocin requirement, Apgarscore and labor duration.

Material and methods: 221 parturients with uncom-plicated, singleton and cephalic pregnancy, between 36–42 weeks’ gestation, who presented in spontaneous laboror who were scheduled for induced labor were randomlydivided to two groups: ambulatory group (AG) withambulation, sitting in chair or semi-supine position andnon-ambulatory group (NAG) with supine or lateralposition. Parturients with preeclampsia and those whohad had previous cesarean delivery were excluded. Bothgroups had intermittent epidural injection of 0.1% rop-ivacaine and sufentanil 0.6 lg/mL (R-S) for analgesiaduring labor. The first dose of R-S was determined ac-cording to the parturient’s stature (10-18 mL); all re-peated injections were 10 mL for all parturients.P < 0.05 was considered to be significant.

Results: Five parturients were excluded for fast de-livery (3 AG vs 2 NAG). All parturients walked in theAG group. No significant differences were noted be-tween AG and NAG in mode of delivery, consump-tion of LA, oxytocin requirement or Apgar scores inthe 1st and 5th minute. Significant difference wasnoted in labor duration (173.4 (SD 109.9) min vs236.4 (SD 130.6) min, P = 0.001).

Conclusion: Although walking with AEA shortens laborduration, it has no other effect on the outcome of labor.Even when using low doses of less concentrated LA thatallowed all parturients to walk, epidural analgesia seemsto deprive ambulation of its other benefits, perhaps be-cause we have not yet found the most appropriate con-centration or the best technique that would preserveambulatory advantages during labor, with the privilege ofpain relief, or maybe there are no real benefits of ambu-lation on labor.

References1. Flynn A M, Kelly J, Hollins G, Lynch P F. Ambulation in

labour. Br Med J 1978; 2: 591–593.2. Read J A, Miller F C, Paul R H. Randomized trial of ambulation

versus oxytocin for labor enhancement. Am J Obstet Gynecol 1981;139: 669–672.

3. Karraz M A, Karraz T A. Ambulatory labor analgesia: clinicalexperience. International Journal of Obstetric Anesthesia 2002; 11:143–144.

Figure: Dose-response curve for the 10 subjects. X axis: log of theMgSO4 dose, Y axis: % return to pre-consriction baseline. Error barsare SEM.


P53. Survey of audit practices in United Kingdomobstetric anaesthesiaM. DresnerLeeds General Infirmary, Leeds, UKIntroduction: Many obstetric anaesthetists have aninterest in data collection, of measures both of clinicalactivity and of quality. Methods of collating these datato produce national statistics have included postal sur-veys and the Obstetric Anaesthetists’ Association(OAA) National Obstetric Anaesthesia Database(NOAD). Both fall short of providing a national view,because response rates are incomplete. This survey wasperformed to assess how many units collect routine auditdata, how this is done, and to measure any appetite forthe development of a national audit program by theOAA.

Methods: A survey was emailed or posted to 245 leadanaesthetists in obstetric anaesthesia in the UK duringthe latter part of 2002. Replies were received from 156(64%) at the time of preparing this abstract.

Results: Of those units responding, 93% perform routineepidural audit and 86% collect follow-up data. Obstetrictheatre anaesthesia data is collected by 98%, and follow-up data by 83%. Methods include pen and paper (38%)and generic computer systems (48%), with only 12% us-ing purpose-designed audit software. As many as 96%were in favour of the OAA providing an audit adviceservice and 90% were in favour of the OAA developingand distributing an audit software package that allowsnational data to be pooled.

Discussion: Audit of clinical activity is useful for bothfinancial planning and the monitoring of clinical out-comes. It is an integral part of any clinical governanceprogram. UK obstetric anaesthetists can take satisfactionin the high level of audit activity in our specialty. Whilst Idoubt that there is a primary school student in the UK thatdoesn’t have computer access, 38% of obstetric anaes-thetists perform their audit with pen and paper! This fact,plus the widespread but disparate use of generic spread-sheets and databases, makes national data collection in theform of a database impossible at the current time. Thesurvey revealed a lack of enthusiasm towards the dupli-cation of effort and complexity involved in existing na-tional audit projects, but near universal interest in theOAA exploring an audit option that assists local effortsand allows national data to be pooled. The views revealedin this survey warrant further consideration by the OAA.

P54. A critical analysis of the incidence of caesareansection in Latin America: a Colombian experienceC. Restrepo,*,� M. Arango,* N. Socha,*,� M. Campo,�

A. G\mez,� S. Ram]rez�

Department of Anaesthesia, Clinica Las Americas*,UPB�, GIAO, Medell8n, ColombiaIntroduction: Caesarean section increases the healthrisks for mothers and babies as well as the costs of healthcare. The rates for the Colombian Health Care Systemrange from 30% up to 80%,1 but there is a lack of infor-mation about the specific causes of caesarean section inColombia. Our aims were to evaluate the incidence ofcaesarean section in our local health care system and toexamine the main causes of it, and also determine theproportion of these that were not justified.

Method: After ethical approval, we reviewed the ob-stetrical records (from January to October 2002) of theHospital Manuel Uribe Angel; which is the main refer-ence centre for the north part of the City of Medell]n.The caesarean section patients were identified and 200cases were chosen randomly, looking for demographicand medical data, overall incidence of caesarean section,specific causes and the percentage of caesarean sectionsthat we judged not to be justified and the reasons forthem.

Results: 1067 deliveries were identified, with 438 bycaesarean section (41.04%). The age groups were 18–35years: 79.5%, >35 years: 10.5%, <18 years: 10%. All thepatients had some degree of school education and 50.5%were primigravidae, in 35% it was the second pregnancyand 14.5% had three or more pregnancies. The mainindications for caesarean section were dystocia (71%),fetal distress (12.5%), previous caesarean section(8.5%), pregnancy-induced hypertension (5%) and oth-ers (3%). We judged 37.5% of the caesarean section notto be justified and dystocia was given as the indicationfor 69.3% of these cases.

Conclusion: The overall incidence of caesarean sectionin our hospital is beyond the permissible range, andmore than one-third of caesarean section are not justi-fied. Since dystocia is the main cause, all our effortsmust be directed to improving the accuracy of this di-agnosis and also in the interventions to decrease theproblem. This audit will be repeated in June 2003 toevaluate the recommendations.

Acknowledgement: We are grateful to the staff of the HospitalManuel Uribe Angel who kindly provided this information.

Reference1. Metrosalud, Mortalidad Materna en Area Metropolitana, 2002.


P55. Urgency of caesarean section: do obstetriciansand anaesthetists agree?S. M. Kinsella, M. J. L. ScruttonSt. Michael’s Hospital, Bristol, UKIntroduction: A multi-centre assessment of a new ur-gency classification for caesarean section found a 90%correspondence between the obstetrician and anaesthe-tist if results were analysed using a four-point scale.1

Initial inspection of the results at our hospital indicated alower level of correspondence, and therefore a moreformal study was undertaken.

Methods: We studied 400 caesarean sections carriedout during Nov 00–Feb 01 and Apr–Jul 02. Urgencycategory was taken independently from the operationrecord (obstetrician) and from the anaesthetic audit re-cord (anaesthetist).

Results: There was correspondence between the ob-stetrician and anaesthetist in 72% overall (75% in 2000/1, 68% in 2002) (Table 1). This compares with 84% in180 cases in our hospital in 1999.1 When non-corre-spondence occurred, it was more common for anaes-thetists to give a lower urgency than obstetricians.

Table 1: Categories assigned by anaesthetists and ob-stetricians

Discussion: Ideally, there should be a high rate ofcorrespondence between obstetricians and anaesthetistson the urgency of caesarean section as a result of goodcommunication of clinical details,2 leaving few genuinedisagreements. Correspondence fell from initial valida-tion to 2000/1 and then 2002, despite increased famil-iarity. Non-correspondence occurs frequently withcertain clinical scenarios, possibly because of the brevityof definitions in the current classification. An alternativemight be to give examples for particular clinical situa-tions, although this approach may also incur problems.3

References1. Lucas D N, Yentis S M, Kinsella S M et al. Urgency of

caesarean section: a new classification. J Royal Soc Med 2000;93: 346–350.

2. Roberts N D, May A E. Prospective audit of non-electivecaesarean section referrals to anaesthetists July–Sept 2001 (O06).International Journal of Obstetric Anesthesia 2002; 11: S3.

3. Thomas J, Paranjothy S. Royal College of Obstetricians andGynaecologists Clinical Effectiveness Support Unit. The NationalSentinel Caesarean Section Audit Report. London: RCOG Press,2001.

P56. Survey of anaesthetic support staff in obstetricunits in England and WalesA. Qureshi, M. Stevens, F. PlaatDepartment of Anaesthesia, Queen Charlotte’s andChelsea Hospital, London, UKIntroduction: During obstetric emergencies, guide-lines mandate rapid response times (of less than30 min) from decision to operate and delivery. Par-turients requiring anaesthesia have a right to the samestandards of peri-operative care as all surgical pa-tients, including appropriate anaesthetic assistance.1,2

The aim of this survey was to assess the type ofsupport available to anaesthetists in maternity unitsand the impact on elective and emergency work.

Methods: A postal questionnaire was sent to all thelead obstetric anaesthetic consultants in England andWales registered with the OAA in 2001. The questionsrelated to unit locality, residency status and on-callcommitments of the anaesthetic assistant. The source ofassistance for elective and emergency surgery and forlabour analgesia blocks was explored.

Results: 195 of 257 units (76%) returned a completedquestionnaire.

• 11% of units were isolated from the main hospital.• 95% had a designated operating department personresponsible for elective surgery.

• 58 (29%) experienced delays in managingemergencies, waiting for the anaesthetic assistant(regardless of whether the unit was within the mainhospital site or separate). This rarely caused delay toelective work.

• The anaesthetic assistant was resident on call in thehospital in 168 units (86%), but not exclusively for thematernity ward.

• The anaesthetist was usually (76%) assisted by themidwife when inserting blocks for analgesia.

• More than 1/3 thought that it would be appropriate tohave an anaesthetic assistant resident on 24-h callexclusively for labour ward (41%) and who could helpwith labour analgesia (36%).

Discussion: The results of this survey suggest thatcurrently the recommended standards of care in terms ofappropriate staffing are not being met consistently inobstetric units in England and Wales, and this has de-leterious affects on emergency work.

References1. Dwyer J P. Decision to delivery time in emergency caesarean

section. Abstract Book, Fourth International Scientific Meetingof the Royal College of Obstetrics and Gynaecology. Cape Town4–6 October 1999: 13.

2. Association of Anaesthetists of Great Britain and Ireland.Obstetric Anaesthetists Association. Guidelines for ObstetricAnaesthesia Services. London: 1998.

AnaesObs

1 2 3 4 Total

1 22 16 4 422 14 63 39 2 1183 16 58 12 864 1 8 145 154Total 37 95 109 159 400

1: immediate threat to life of woman or fetus; 2: maternal or fetalcompromise which is not immediately life-threatening; 3: needingearly delivery but no maternal or fetal compromise; 4: at a time to suitthe patient and maternity team.


P57. The role of the anaesthetist in mother’sexperiences of elective caesarean section: a pilotstudyS. Hughes,*,§ A. Holdcroft,* E. Keogh§*Magill Department of Anaesthesia, Chelsea &Westminster Hospital, London, §Department ofPsychology, Goldsmiths College, London, UK

Introduction: Midwives play a critical role in the birthexperiences of women. The expectations and experi-ences mothers have about their anaesthetist are lessclear. Our aim was to collect pilot data to determine therelative role of the anaesthetist in mothers’ experiencesof caesarean section because of the fears and concernassociated with it.

Method: After ethics committee approval, 40 healthywomen for elective surgery were recruited at 36 weeks’gestation. Mothers completed a series of self-reportmeasures before caesarean section, related to expecta-tions, anxiety and pain during and following the caesareansection. They rated their birth experiences post partum,with particular reference to the anaesthetist and painmanagement. Statistical analysis (SPSS) was conductedusing correlations.

Results: Pain expectations: Mothers expecting painreported more postoperative pain (r = 0.45, P < 0.05)but if they believed that the anaesthetist could controlpain effectively during caesarean section, they not onlyexpected less pain (r = )0.24, P < 0.05), but actuallyreported less pain during the caesarean section(r = )0.32, P < 0.05). Such perceived control by theanaesthetist over pain during the caesarean section wasalso related to pain relief (r = 0.60, P < 0.005), supportfrom the anaesthetist (r = 0.38, P < 0.01) and overallsatisfaction with the anaesthetist (r = 0.65, P < 0.001).Pre-operative fear:Mothers who were fearful of anxietyexpected more support (r = .29, P < 0.05), reportedmore fear (r = 0.37, P < 0.01) and postoperative (emo-tional) pain was greater (r = 0.45, P < 0.01). Fortu-nately though, mothers expecting more support, receiveit (r = 0.35, P < 0.05).Pain during caesarean section: The amount of painreported during the caesarean section (measured post-operatively) was positively correlated to postnatal(emotional) pain experiences (r = 0.37, P < 0.05) andnegatively with the belief that the anaesthetist couldcontrol pain during caesarean section (r = )0.58,P < 0.001). Pain relief during caesarean section wasreported as effective if mothers felt the anaesthetistsupported her (r = 0.44, P < 0.05) and did not ignoreher (r = )0.46, P < 0.05).Patient satisfaction: Anaesthetic rapport was reassuring(r = 0.57, P < 0.001) and less isolating (r = )0.46,P < 0.005).

Conclusion: The anaesthetist plays a critical role forthe mother during caesarean section. Specifically, itseems as if a greater focus on the patient by the anaes-thetist is associated with greater birth satisfaction by themother.

P58. Pre-operative anxiety and postoperativesatisfaction in women undergoing elective caesareansectionJ. A. Hobson, P. Slade,* I. Wrench,* L. PowerClinical Psychology, University of Sheffield,*Royal Hallamshire Hospital, Sheffield, UK

Introduction: The study aimed to quantify and de-scribe preoperative anxiety in women undergoing elec-tive caesarean section and its relationship withpostoperative maternal satisfaction.

Method: In 85 women awaiting elective caesareansection anxiety was measured in the 24 h precedingsurgery using the State-Trait Anxiety Inventory (STAI).1

Perceived social support was measured using the Sig-nificant Others Scale.2 Maternal satisfaction was as-sessed around the 3rd postoperative day using thematernal satisfactions scale for caesarean section(MSSCS),3 yielding a total satisfaction score and sub-scale scores for anaesthetic, insertion of the needle, sideeffects and the atmosphere in theatre. Satisfaction withthe pre-operative information from the anaesthetist wasalso measured at this time.

Results: Anxiety scores were comparable with those ofgeneral surgical/medical patients. Women were gener-ally satisfied with the procedure. Lower pre-operativetrait anxiety and state anxiety were associated withgreater maternal satisfaction. Lower state anxiety wasassociated with higher satisfaction with insertion of thespinal needle and greater satisfaction with the degree towhich they experienced side-effects of the anaesthesia.Lower trait anxiety was also associated with greatersatisfaction with side-effects. Linear regression analysisindicated satisfaction with information from the anaes-thetist and perceived emotional support from the partnerexplained 52% of the variance in postoperative maternalsatisfaction.

Conclusion: Lower preoperative anxiety is associatedwith greater maternal satisfaction with elective caesar-ean section. Information and perceived support are alsoof importance.

References1. Speilberger C D. State-Trait Anxiety Inventory Manual. Mind

Garden. C.A 1983.2. Power MJ, Champion LA, Aris SJ. The development of a measure of

social support: the significant others scale. Br J Clin Psychol 1988;27: 349–358.

3. Morgan PJ, Halpern S, Lo J. The development of a maternalsatisfaction scale for caesarean section. International Journal ofObstetric Anesthesia, 1999; 8: 165–170.


P59. Comparative obstetric mobile epidural trial(COMET): epidural fentanyl dose and neonataloutcomesM Lewis on behalf of The COMET Study GroupDepartments of Public Health and Epidemiology, andAnaesthetics, University of Birmingham andDepartments of Anaesthetics, Obstetrics, andGynaecology, University of Leicester, UK

Introduction: The Comparative Obstetric Mobile Epi-dural Trial (COMET1) randomised 1054 primiparouswomen requesting epidural analgesia to receive tradi-tional i.e. intermittent boluses of 0.25% bupivacaine,combined spinal epidural (CSE) or low dose infusion(LDI), both using 0.1% bupivacaine and fentanyl 2 lg/mL. Neonatal effects were secondary trial outcomes,measured by Apgar scores at delivery, requirements forresuscitation and admission to the neonatal unit. Five-minute Apgar scores were the main pre-specified as-sessment. The results demonstrated a significantlyhigher incidence of low Apgar scores (£7) at 1 min andof borderline significance at 5 min in the LDI group.High level resuscitation was also significantly greaterfor the LDI group. As the total epidural dose of fentanylwas highest in this group, this raised the possibility thatsystemic absorption was leading to fetal effects. Despitethis, admission to special care did not vary between thetrial groups.

Method: We performed regression analysis including anumber of relevant variables: CSE, LDI, instrumentaldelivery (Inst), caesarean section (C/S), total dose ofbupivacaine (tot bup) and total dose of fentanyl (totfent), to detect whether fentanyl or any other factorsindependently predict low Apgar scores at delivery.

Results: The table shows the P-values for factors con-sidered in the regression analyses as possibly predictiveof a low Apgar score. LDI and instrumental deliverywere independently predictive of low Apgar score at1 min, but not at 5 min. Total fentanyl was not predic-tive of low Apgar score at either 1 or 5 min.

Conclusion: We found no relationship between dose ofepidural fentanyl and low Apgar score. Within the doserange used, this provides reassurance over concerns re-garding the neonatal effects of epidural fentanyl in theprovision of labour analgesia.

Reference1. Comparative Obstetric Mobile Epidural Trial (COMET) Study

Group UK: Effect of low-dose mobile versus traditional epiduraltechniques on mode of delivery. Lancet 2001; 358: 19–23

Apgar<7

CSE LDI Inst C/S Totbup

Totfent

1 min 0.18 0.04* 0.05* 0.14 0.25 0.145 min 0.33 0.28 0.77 0.74 0.95 0.98

*P < 0.05.


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