GUIDELINES FOR OBSTETRIC ANAESTHESIA SERVICES Published by The Association of Anaesthetists of Great Britain and Ireland The Obstetric Anaesthetists Association MEMBERS OF THE WORKING PARTY Dr T A Thomas Joint Chairman/President OAA Dr W L M Baird Joint Chairman/President AAGBI Dr J H W Ballance Secretary Dr R J S Birks AAGBI Dr G C McDowell AAGBI Dr T H Madej Honorary Secretary OAA Dr D G Bogod OAA Professor M Harmer OAA Dr N L A Hickman Group of Anaesthetists in Training Ex Officio Dr M Morgan President elect/Editor Dr D A Saunders Honorary Treasurer Dr D J Wilkinson Honorary Secretary Dr P G M Wallace Assistant Honorary Secretary Dr A F Naylor Honorary Membership Secretary September 1998 © Copyright of the Association of Anaesthetists of Great Britain and Ireland and the Obstetric Anaesthetists Association. No part of this book may be reproduced without the written permission of the Association of Anaesthetists. The Association of Anaesthetists The Obstetric Anaesthetists Association of Great Britain and Ireland PO Box 3219 9 Bedford Square, London WC1B 3RA London SW13 9XR Telephone: 0171 631 1650 Telephone: 0181 741 1311 Fax: 0171 631 4352 Fax: 0181 741 0611 Email: [email protected] Email: [email protected] CONTENTS page Section 1 Recommendations............................................1 Section 2 Introduction......................................................2 Section 3 General considerations.....................................3 Section 4 Requirements of an obstetric anaesthesia service..............................................................4 Section 5 Guidelines for an anaesthesia service...............6 Section 6 Professional relationships.................................16 References ..........................................................................19 SECTION 1 - RECOMMENDATIONS Parturients requiring anaesthesia have a right to the same facilities and standards of peri-operative care as all surgical patients. Women and purchasers should be informed of the level of availability of regional analgesia in each unit. At least one consultant obstetric anaesthesia session should be allocated for every 500 deliveries. Extra 'fixed' sessions above this minimum are required in units with a frequent turnover of inexperienced trainees, with a higher than average epidural or Caesarean section rate and/or a substantial number of high risk cases. Criteria for midwife-led care should be followed. The person assisting the anaesthetist during anaesthesia should have no other duties at that time. They should have been trained to NVQ level 3 in Operating Department Practice or possess the appropriate ENB qualification. To maintain relevant skills, they should act as an anaesthesia assistant on a regular basis. There should be a list of problems about which the anaesthetist should be informed. The conditions to be included should be agreed jointly between the departments of anaesthesia, obstetrics and midwifery. 1 SECTION 2 - INTRODUCTION In 1986, the Report on the Confidential Enquiries into Maternal Deaths (CEMD) in England and Wales for 1979-81 [1] showed that anaesthesia was the third commonest cause of maternal death. In the same year, the Association of Anaesthetists of Great Britain and Ireland (AAGBI), in conjunction with the Obstetric Anaesthetists Association (OAA), published a report [2] outlining far-sighted proposals for improving the quality and safety of obstetric anaesthesia in the UK. In the ensuing decade, there have been major changes in the provision of maternity services and obstetric anaesthesia, many of which have reflected the recommendations made in the Associations' report and by the continuing Confidential Enquiries. The number of women delivering in larger units rose from 67% to 83% over the same period. An epidural service that was only available in 56.5% of all units in 1984 had increased to 70% by 1990 [3]. The Caesarean section rate increased but the use of general anaesthesia for Caesarean section fell rapidly, from 77% in 1982 to 44% in 1992 [4]. Over the same period, maternal mortality due to anaesthesia had declined markedly so that, in 1991-93, anaesthesia had fallen to eighth position as a cause of maternal death. This improvement coincided with a decrease in the use of general anaesthesia for Caesarean section, although other important contributing factors probably include improved staffing levels and the availability of senior anaesthesia and obstetric staff, together with better facilities in obstetric theatres and improvements in patient monitoring. These improvements have, of course, necessitated considerable expenditure. The temptation to economise in the face of the reduction in maternal mortality must be resisted and only continued vigilance will maintain the enviable standards achieved in the last decade. The OAA published its 'Recommended Minimum Standards for Obstetric Anaesthesia Services' in 1995 [5]. This joint report by the AAGBI and the OAA updates the 1987 edition and the OAA's 1995 publication and aims to advance the provision of obstetric anaesthesia services in the UK into the next millennium. 2 SECTION 3 - GENERAL CONSIDERATIONS Anaesthetists are involved with an increasing proportion of parturients as the use of regional analgesia increases and Caesarean section rates rise. The Audit Commission has shown that anaesthetists are involved in an average of 38% of labours, although this figure may be as high as 60% in some units [6]. Although this may be an overestimate - as it does not allow for the overlap between regional analgesia and Caesarean section - it clearly demonstrates the importance of the anaesthetist in maternity care. At the same time, the role of anaesthetists in the care of the parturient has expanded. They are regularly involved in antenatal clinics and classes, the delivery suite, the obstetric theatre and in the high dependency and intensive care units that care for the critically ill parturient. Their skills in the recognition and treatment of cardiovascular, respiratory and central nervous system problems are added to their responsibility for the provision of pain relief in labour and anaesthesia for operative obstetric interventions. Anaesthetists are an integral part of obstetric care teams. Their presence allows early consultation on the management of life-threatening obstetric complications such as haemorrhage or convulsions. Resuscitation of the mother is a rare but important responsibility for the obstetric anaesthetist and, although paediatric services are responsible for resuscitation of the newborn, anaesthetists are still called upon to assist. The role of the obstetrician in the provision of maternity care has altered in recent years, following the publication of 'Changing Childbirth' [7]. Midwives are becoming the lead providers for many women with normal, healthy pregnancies but many of these parturients still require anaesthesia services to be available [8]. The question of professional relationships between midwives and anaesthetists needs to be addressed with some degree of urgency, not least because of the rising tide of medical negligence litigation. 3 SECTION 4 – REQUIREMENTS OF AN OBSTETRIC ANAESTHESIA SERVICE The provision of a safe obstetric anaesthesia service is the responsibility of the individual trust and should be devolved to the directorate of anaesthesia. A comprehensive service can only be provided if anaesthetists who are skilled and experienced in obstetric anaesthesia and analgesia are immediately available at all times for elective operative deliveries, emergency calls and pain relief in labour. In most instances, the emergency, first on-call, obstetric anaesthesia service is provided by trainee anaesthetists but consultant support and on-call availability is essential throughout the 24 hour period, every day of the year. Standards in the obstetric operating theatre and recovery area should be the same as in other theatre suites and equal to those described by the AAGBI as necessary for all surgical patients [9]. Directorates of anaesthesia that offer a pain relief service in labour using regional analgesia undertake an increased commitment. Units offering regional analgesia at maternal request require extra anaesthesia staff in order to respond to requests in a reasonable time and to provide the continuous dedicated anaesthesia cover needed for patient safety. The CEMD report states that; "Epidural analgesia is entirely contra-indicated for safety reasons unless a trained anaesthetist is immediately available whenever the technique is in use" [10]. Women delivering in smaller units have a right to the same standard of care. However, in very small units (<500 deliveries per annum), provision of such care may be impractical and uneconomic. In such circumstances, women may require early transfer to a larger unit offering a comprehensive anaesthesia service. Every Maternity Service Liaison Committee or its equivalent should have a consultant obstetric anaesthetist as a member to ensure that expert anaesthetic advice is always available. Women and purchasers should be informed of the level of availability of anaesthesia and regional analgesia services in each unit. 4 The anaesthesia service is required to provide:- • the organisation and audit of anaesthesia care for operative delivery, including pre-anaesthesia assessment, pre-operative and postoperative care; • the administration, supervision and audit of regional analgesia; • anaesthesia skills as part of the team managing severe illness in the obstetric patient e.g. severe haemorrhage, fulminating pre-eclampsia and eclampsia. This may include the transfer of a sick patient to another unit. It should not include primary transfer from home or 'flying squads'. The CEMD state that; "We endorse the recommendations of the Joint Committee of the Royal Colleges and Ambulance Service that the primary response for domiciliary emergencies such as eclampsia should be by the ambulance paramedics trained in cardiopulmonary resuscitation and the immediate management of obstetric complications" [11]. • a training programme for trainee anaesthetists [12]. Opportunities for appropriate continuing medical education for non-trainee grades contributing to the obstetric anaesthetic service; • education of midwives in training and in-service. Antenatal education of mothers so that they can make informed choices about analgesia and anaesthesia. Information and updating for obstetricians of the scope and limitations of obstetric anaesthesia services; • participation, if requested by the paediatric service, in resuscitation of the newborn. However, the primary responsibility of the anaesthetist rests with the mother. 5 SECTION 5 – GUIDELINES FOR AN ANAESTHESIA SERVICE 1. STAFFING OF OBSTETRIC ANAESTHESIA UNITS (i) Consultant Anaesthetist Each obstetric unit with an anaesthesia service should have a nominated consultant in charge of obstetric anaesthesia. The nominated consultant should organise the service, maintain or raise standards of practice, review facilities, audit the service and take responsibility for training anaesthetists. Sessional time should be granted for these responsibilities. For optimal levels of patient care, there should be a designated consultant anaesthetist available in the obstetric unit, during normal working hours, Monday to Friday. In smaller units, the workload may not justify this level of staffing, thus highlighting, once again, the need to rationalise obstetric services by closing smaller units. Previously, the recommended allocation of consultant anaesthetists to obstetric units was based on a least one 'fixed' session per 500 deliveries per annum. This ratio was first recommended by the House of Commons Social Services Committee in its Second Report of 1979/80. The Committee stated; "We recommend that every obstetric unit delivering more than 1,000 women should have attached to it a consultant anaesthetist with at least two sessions of his contract committed to obstetric anaesthesia. In units delivering more women, the number of sessions of anaesthesia should be proportionately increased" [13]. The Government responded to this particular point by stating that it did not doubt the desirability of the target described in the recommendation. It should be remembered that this recommendation was made 20 years ago when the responsibilities of consultants in obstetric anaesthesia were substantially less onerous than they are today. This recommendation must therefore now be regarded as a minimum provision, which should be reviewed to take account of the increased workload and 6 responsibilities that have been devolved to consultant anaesthetists. Sessional allocations must be greater in units with a fast turnover of trainees, a higher than average epidural or Caesarean section rate and/or a substantial throughput of high risk cases. During 'fixed' obstetric sessions, the consultant should be based on the delivery suite or obstetric operating theatre, with no other commitments. Consultants must have job plans which reflect their commitment to an obstetric anaesthesia service and which are reviewed and agreed annually [14]. In addition to the contracted consultant obstetric anaesthesia sessions, an obstetric unit with an anaesthesia service should have a consultant anaesthetist on call and responsible for the unit at all times, in the same way as a consultant anaesthetist is always available for other hospital emergency services. The CEMD state; "All obstetric patients should be regarded as high anaesthesia risks, especially when emergency procedures are required and there should be early involvement of consultant anaesthetists in the management of complex deliveries" [15]. These responsibilities should be shared between consultants and local departmental arrangements should prevail. Each unit should display prominently the name of the consultant responsible for the delivery suite at that time. That consultant should not be more than half an hour away from the delivery suite at any time, in keeping with the NHS terms and conditions of service. Elective Caesarean sections should be arranged at times when there is a dedicated team of anaesthesia, obstetric, midwifery and operating theatre staff available who are not, at the same time, required to cover other operating activities or emergencies. (ii) Duty Anaesthetist A duty anaesthetist should be available for the obstetric unit 24 hours a day. There should be time for a formal handover between shifts. All new staff should have a geographical orientation to the unit and access to local guidelines. Adequate accommodation, including provision for overnight stay, should be available, adjacent to the obstetric unit. If the duty 7