Obstetric Anaesthesia Services 2012 1 Membership of the working party 1. Dr David Bogod – OAA 2. Val Bythell – AAGBI 3. Dr Paul Clyburn – AAGBI 4. Dr Sarah Gibb – GAT 5. Dr Ian Johnston – AAGBI 6. Dr Nuala Lucas – OAA 7. Dr Mary Mushambi – OAA 8. Dr Iftikhar Parvez – AAGBI 9. Dr Felicity Plaat – AAGBI 10. Dr Anne Thornberry - RCoA 2 Contents Section 1 Key recommendations Section 2 Introduction Section 3 Staffing Section 4 Services and standards Section 5 Training and education Section 6 The labour ward team Section 7 Support services, equipment, facilities and accommodation Section 8 The future Section 9 List of recommended guidelines Section 10 References 3 Section 1 Key recommendations 1. A duty anaesthetist must be immediately available for emergency work on the Delivery suite 24 hours a day. 2. There must be a nominated consultant in charge of obstetric anaesthesia with time allocated for this role. 3. There should be a clear line of communication from the duty anaesthetist to the supervising consultant at all times. 4. The workload of the obstetric anaesthetist continues to increase. As a basic minimum there must be 10 consultant PAs/ sessions per week to cover emergency work on Delivery suite. 5. Scheduled obstetric anaesthetic activities (e.g. elective Caesarean section lists, clinic), require additional consultant sessions over and above the 10 for emergency cover. 6. Women should have antenatal access to evidence based information about the availability and provision of all types of analgesia and anaesthesia. This information should be provided or at least ratified by the department of obstetric anaesthesia. 7. There should be an agreed system whereby the anaesthetist is given sufficient advance notice of all potentially high risk patients. 8. When a 24-hour epidural service is offered, the time from the anaesthetist being informed that a woman is requesting an epidural and ready to receive one, until attending the mother should not normally exceed 30 minutes. This period should only exceed 1 hour in exceptional circumstances. 9. Provision should be made for those who cover the Delivery suite on-call, but do not have regular sessions there to spend time on Delivery suite in a supernumerary capacity with one of the regular obstetric anaesthetic consultants. 10. There must be separate provision of staffing and resources to enable elective work to run independently of emergency work, in particular to prevent delays to both emergency and elective procedures and provision of analgesia in labour. 11. The person assisting the anaesthetist must have no other conflicting duties, must be trained to a nationally recognized standard and must work regularly and frequently in the obstetric unit. 12. The training undergone by staff and the facilities provided in the maternity recovery unit must be of the same standard as for general recovery, as defined in current, published guidelines. 13. Appropriate facilities should be available for the antenatal and peri-partum management of the sick obstetric patient as defined in the document ‘Providing equity of critical and maternity care for the critically ill pregnant or recently pregnant patient’. 4 Section 2 Introduction This is the third version of the joint Association of Great Britain & Ireland/ Obstetric Anaesthetists’ Association (AAGBI/OAA), guidelines. [1,2] A major change from the last revision in 2005 is the inclusion of a chapter on critical care in maternity. This reflects the belated recognition of this increasingly important area of obstetrics. [3] The number of women requiring advanced levels of care is set to increase as the trend towards an older obstetric population with increasing morbidities and levels of obesity shows no sign of abating. As a result obstetric anaesthetists will continue to be required to take on the role of peri-partum physician, (paralleling a growing enthusiasm for that of peri-operative physician in non-obstetric practice [4]). This will inevitably mean involvement in training of staff caring for high-risk parturients and adoption of management roles to develop and maintain critical care facilities. These guidelines recommend a further increase in the minimum number of weekly anaesthetic consultant session to 10 in order to provide Delivery Suite cover plus further sessions for scheduled work (Caesarean section lists/ clinic etc). This arises from three developments. Firstly, recent surveys have confirmed that the workload of obstetric anaesthetists is increasingly onerous and complex [5, 6] Secondly the presence of the obstetric consultant on delivery suite is now mandatory, with the number of hours per week determined by number of deliveries [7]; this must be reflected in anaesthetic input. Thirdly the Clinical Negligence Scheme for Trusts circulated a draft standard that elective work should be independently staffed in order that it can run uninterrupted by emergencies; this is likely to have been adopted as a full standard by the time this document is published. On-call rooms are disappearing from many maternity units despite the well described benefits of enabling periods of proper rest during night time working. [8] Even when working to a shift-based rota, the most common pattern for trainees, fatigue is more likely to affect performance and thus patient safety at night. Even short periods of sleep can help mitigate these effects and we have therefore recommended that appropriate facilities be made available. Effective team working is crucial to maternity care as highlighted in a recent report on safety in maternity services. [9]. Obstetric anaesthetists play a pivotal role in the team itself and in delivering training in team working. This is reflected in our recommendations for anaesthetic representation on all Maternity committees. As noted in the previous version of these guidelines, we realise that our recommendations potentially have major financial and organisational implications. However they are based on consideration of the safety of the women who deliver in our units and their babies. We have therefore stressed yet again that consideration should be given to amalgamating units that are too small to support the costs of providing these services. 5 Section 3 Staffing Background Anaesthetists are involved in the care of over 60% of pregnant women. The Audit Commission found a wide variability of anaesthetic staffing on labour wards [10] and a recent survey confirms this [6] Previous recommendations concerning anaesthetic staffing were based on delivery rates. Busy units were defined somewhat arbitrarily as those with > 5,000 deliveries/year, an epidural rate > 35%, Caesarean section rate > 25%, tertiary referral centres or centres with a high proportion of high risk cases. It was proposed that there should one consultant session per 500 deliveries with at least 10 sessions for units over 3000 deliveries [2]. However there are several problems with the use of such definitions [11]. The use of crude delivery rates: • Does not take into account the huge variation in case-mix that is exists between units • Does not take into account the impact of changing obstetric demographics, (increased maternal co-morbidities such as obesity, increased maternal age, increased assisted conception, increasing immigrant population) • Does not take account of the impact of the changes to training in anaesthesia. (In particular the effect of the European Working Time directive on training, associated paperwork and reduced trainee numbers). • Does not reflect the increased demand for the delivery of additional anaesthetic services such as anaesthetic clinics, maternity high dependency units, and support for intervention radiology etc. • Does not take into account changes in obstetric practice, such as trial of instrumental delivery, cervical cerclage and repair of complex tears which tend to increase theatre workload The calculation of consultant sessions will need to take into account the volume of clinical work, the contribution by consultants towards administration and other nonclinical activities, the numbers and experience of trainees. It is essential that the contribution made by non-consultant career grades anaesthetists is included. It is the unanimous opinion of this working party that a move towards obstetric anaesthetic services being fully consultant delivered is both desirable and inevitable. Obstetricians have already set this as an objective and are in the process of working towards it [12]. Recommendations Medical staff The term duty anaesthetist denotes an anaesthetist who has been assessed as competent to undertake duties on the delivery suite under a specified degree of supervision. The duty anaesthetist should be immediately* available to attend the obstetric unit 24 hours per day. The duty anaesthetist should not have other responsibilities out-with obstetrics as they must be able to attend immediately* a call to labour ward 24/ 7 6 In all units offering a 24-hour epidural service the duty anaesthetist must be resident on site. The duty anaesthetist must have been assessed as currently competent to provide obstetric anaesthetic services. If not a consultant, it follows that consultant support and on-call availability is essential 24 hours per day, and a clear line of communication from the duty anaesthetist to the on-call consultant is essential at all times. If the duty anaesthetist is a consultant, the workload of the unit may dictate a need for additional manpower in order to deliver a safe service, and contact details of a back up anaesthetist should be immediately available at all times. The name of the on-call consultant must be prominently displayed at all times. The names of all consultants who cover labour ward and contact numbers should be readily available. *Immediately available – able to attend within 5 minutes or less of being summoned except in exceptional circumstances. The duty anaesthetist should not be responsible for planned maternity work such as elective caesarean section lists, anaesthetic ante-natal clinics etc. Such activities should be able to continue uninterrupted in the face of non-elective activities (e.g. emergency CS, requests for regional labour analgesia). In consultant-led obstetric units where anaesthetic care is not primarily consultant-delivered, there should be 10 consultant anaesthetic sessions (direct clinical care), per week to cover non-elective activity. Where there is a high turnover of trainees, (i.e. a three-month interval or more frequent), in order to adequately train and supervise trainees a third evening session may be necessary. In addition, there must be further consultants sessions for direct clinical care to cover: • Elective caesarean section lists • Anaesthetic clinics There must be a nominated lead obstetric anaesthetist who has an active role in leading and managing services, with this adequately recognised in their job plan Induction All trainee and non-trainee anaesthetists, regardless of prior experience in obstetric anaesthesia, should receive a formal induction to the Obstetric Anaesthetic Unit before commencing duties there. This ideally should include: • Information regarding the obstetric anaesthetic clinical supervisor and if relevant the trainee/non-trainees educational supervisor for their attachment. • A physical tour of delivery suite, obstetric theatres, the learning environment and any other relevant areas. 7 • Equipment: A demonstration of relevant equipment e.g. anaesthetic machine, epidural infusion o devices etc. Location of the difficult airway trolley and its contents, including the subglottic airway o kit. Depending on stage of training/prior experience location of other equipment such as o blood storage fridge, level one infusion device, cell salvage. • Resuscitation: Location of the cardiac arrest trolley with demonstration of defibrillator and any other o equipment if unfamiliar. Use of the resuscitaire and location of equipment required for new born resuscitation. o • A clear description of: Local arrangements for handover and contacting senior staff. o Local arrangements for contacting the obstetric anaesthetist in an emergency and for o a category one LSCS. The trainee/non-trainees responsibilities whilst covering delivery suite. o • The location of local guidelines for obstetric anaesthesia. Handover Time for formal hand-over between shifts must be built into the timetable. The shift pattern of different professional groups should be compatible: e.g., anaesthetic and obstetric shifts should start/ finish at the same times to allow multi-disciplinary handover. Anaesthetists not in training A survey has shown that, in 61% of units in the UK, SAS doctors contribute to the provision of obstetric anaesthetic services [6]. Any non-trainee anaesthetist who undertakes anaesthetic duties on Delivery Suite should have successfully completed the Initial Assessment of Competence in Obstetric Anaesthesia, (IACOA) and have been deemed by the consultant in charge of obstetric services to be competent to perform their duties in accordance with OAA and RCoA guidelines. The doctor must work regularly on Delivery Suite and must also regularly undertake non-obstetric anaesthetic work to ensure maintenance of a broad range of anaesthetic skills. Non trainee anaesthetists who are appointed directly from other countries may not be familiar with the protocols in the UK. The following recommendations are to ensure that they are safe and are supported in the new working environment: 1. There should be a defined period of directly supervised obstetric sessions. The duration of supervision will depend on individual circumstances and should be mutually agreed. 2. The anaesthetist must have successfully completed the IACOA before being allowed to work unsupervised. 8 Theatre staffing Many units still use midwifery staff to assist in the operating theatre and this has an impact on midwifery staff on the labour ward. Strategic Health Authorities and Health Boards have been urged to make significant progress in replacing midwifery staff in the scrub/instrument role [13]. Staffing for theatre recovery and anaesthetic assistance Parturients requiring anaesthesia have the right to the same standards of peri-operative care as any other surgical patient, including anaesthetic assistance. Training must be to the standards as defined If the person assisting the anaesthetist is a nurse or midwife, they must have current and effective registration and have received equivalent training acceptable to the consultant anaesthetist in charge of obstetric anaesthesia services. The person assisting the anaesthetist must be experienced, should assist the anaesthetist on labour ward on a regular basis in order to maintain competence. The assistant should have no other duties in the operating suite concurrently. Newly recruited assistants should undergo a period of induction prior to working on the maternity unit. The training undergone by staff in recovery, whether they are midwives, nurses or ODPs, must also be of the same standard as that required for general recovery facilities [15]. Midwives with no additional training are not equipped to recover patients following anaesthesia. Staff should work in a general theatre recovery unit on a regular basis to ensure competence is maintained. All staff must be given regular access to continuing professional development and complete all mandatory training as frequently as required. 9 Section 4 Services and standards General introduction In consultant-led as opposed to midwifery-led units, anaesthetic services should be available to all women. The exact nature and availability of the services offered should be clear both to women choosing to book in a particular unit and to commissioning bodies. Antenatal services Information for mothers Up to date, locally relevant information should be available for mothers, in a range of formats appropriate to their needs, (written, electronic, audio with translations as required), about the services offered, including as a minimum: • Analgesia for labour: benefits, (including efficacy), risks and availability of all options offered. • Anaesthesia for caesarean section: benefits, risks, relative merits of all options offered. • All women should be asked if they would be prepared to receive blood in the case of haemorrhage and this should be documented in the notes. Information should be given to mothers in a timely way – usually antenatally, as relevant to them. Anaesthetists must have central role in the development of all information about pain relief and anaesthesia. All mothers should be given and encouraged to read information about analgesia for labour and anaesthesia for Caesarean Section, as the need for these choices is unpredictable and may need to be made in an emergency. Antenatal assessment and multidisciplinary planning Timely antenatal anaesthetic assessment services should be provided for women who: • might present difficulties should anaesthesia or regional analgesia be required • are at high risk of obstetric complications • have a BMI greater than 40 at booking [16] • have had previous difficulties with or complications of regional or general anaesthesia • have significant medical conditions Locally-agreed referral criteria should be in place. Sample guidelines regarding referral to anaesthetic services and supporting information are available from the Obstetric Anaesthetists Association. [17] Reviewing women antenatally allows for communication between obstetric anaesthetists, obstetricians and other specialists as required, and enables planning for the safe provision of anaesthesia for high risk women. 10