Obstetric Anaesthetic Services Research Articles

A Survey of Obstetric Anaesthesia Services and Practices in the United Kingdom.

Background Variability in obstetric anaesthetia practice and care delivered within the UK is under-explored. The ObsQoR study explored structures, processes, and outcomes of obstetric anaesthesia in 107 hospitals within the UK's National Health Service, and the results of the hospital-level survey are reported here. Methods Hospitals were surveyed to assess obstetric anaesthesia provision, practice, and care delivery. Questions explored staffing, service provision and training, facilities present, clinical practices, outcome measurement, and key indicators of quality in obstetric anaesthesia. Results We received responses from 106 participating hospitals, representing 69% of all UK obstetric units. One hundred (94%) hospitals had a dedicated consultant obstetric anaesthetist within working hours, with 27 (25%) of hospitals' duty anaesthetists having additional clinical responsibilities outside the care of obstetric patients outside of working hours. Around 102 hospitals (98%) offer multidisciplinary team training, of which 95 (93%) use a simulation-based method. Dedicated high-risk antenatal clinics were present in 50 (47%) hospitals. The majority of hospitals provide written patient information in multiple languages for discussing obstetric anaesthesia options (77, 82%). Seventy-three hospitals (69%) use point-of-care testing to estimate haemoglobin concentration. Labour epidural analgesia is most commonly delivered via patient-controlled epidural analgesia in 80 (76%) hospitals, and the incidence of post-dural puncture headaches was recorded by 80 (76%) hospitals. Conclusions These results demonstrate variation in the provision of staffing, facilities, clinical practices, and outcome measurements across the UK. To deliver safe and equitable care across the UK, there needs to be standardisation of anaesthetic peripartum care based on national recommendations and the benchmarking and measurement of appropriate markers of quality.

Effective Epidural Analgesia during Labor: A Feasible Method to Decrease Unnecessary Cesarean Deliveries in Thailand

Thailand has reported a high rate of cesarean delivery (45%–55%), prompting global concern about an increase in cesarean delivery rates. Fear of labor pains is one of the most common reasons pregnant women opt for cesarean delivery. Labor pain is associated with cervix dilation and fetal descent into the birth canal, which is exacerbated by ischemic pain caused by uterine contraction. Modern medical and non-medical techniques have demonstrated efficacy in reducing pain and ensuring safety during labor and delivery. Neuraxial labor analgesia is a highly effective medical pain relief method but has no effect on the rate of cesarean or assisted vaginal delivery. Medication administration for pain relief during labor, using a combination of a local anesthetic and an opioid, was observed to be transmitted across the placenta to the fetus, but had no significant effects on fetal outcomes in mothers who chose epidural analgesia. There are several techniques for administering neuraxial labor analgesia that can be customized for each pregnant woman. To achieve the most wonderful feasible labor and delivery experience, effective epidural labor analgesia is a crucial technique for reducing anxiety and suffering about labor pain. It is safe, widely used world-wide, and effective. Implementing a policy to increase public and medical providers awareness and acceptance of labor pain relief, as well as establishing a safe obstetric anesthesia service provided by obstetric anesthesiologists, could improve maternal and neonatal safety while significantly lowering the rate of unnecessary cesarean deliveries.

Obstetric Anesthesia Manpower and Service Provision Issues: Introduction and European Perspective

Obstetric Anesthesia Manpower and Service Provision Issues: Introduction and European Perspective

The Delivery of Obstetric Anesthetic Care in UK Maternity Units: A Survey of Practice in 2021

(Int J Obstet Anesth. 2023;53:103618) Anesthesiologists play an integral role in the care provided to patients in maternity units by administering peripartum anesthesia and analgesia and sharing the responsibility of safe care. Yet the efficacy of their role is dependent on the organization of anesthesia services and how they are resourced. As the information on how obstetric anesthetic resources are lacking in the United Kingdom, the aim of this survey was to determine current obstetric anesthesia service delivery and staffing resources in the United Kingdom to guide care teams and achieve key national recommendations and benchmarks.

Racial and ethnic disparities in obstetric anesthesia: a scoping review.

Health disparities continue to affect racial and ethnic marginalized obstetric patients disproportionally with increased risk of Cesarean delivery and pregnancy-related death. Yet, the literature on what influences such disparities in obstetric anesthesia service and its clinical outcomes is less well known. We set out to describe racial and ethnic disparities in obstetric anesthesia during the peripartum period in the USA via a scoping review of the recent literature. Using the Institute of Medicine's definition of disparities, we searched the National Library of Medicine's PubMed/Medline, Embase, Web of Science, APA PsycINFO, and Google Scholar for articles published between 1 January 2000 and 30 June 2022 to identify literature on racial and ethnic disparities in obstetric anesthesia. Out of 8,432 articles reviewed, 15 met our inclusion criteria. All but one study was observational. Seven studies were single-institutional while the remaining used multicentre data/databases. All studies compared two or more race and ethnicity classifications. Studies in this review described disparities in the use of labour epidural analgesia, labour epidural request timing, anesthesia for Cesarean deliveries, postpartum pain management, and epidural blood patch for postdural puncture headaches. Several studies reported disparities observed in the unadjusted models becoming no longer significant when adjusted for other covariates. Based on the findings of the present scoping review on racial and ethnic disparities in obstetric anesthesia, we present an evidence map identifying knowledge gaps and propose a future research agenda.

Obstetric anesthesia services profile in cesarean section in Indonesian population: A prospective, observational, multicenter study

Obstetric anesthesia services profile in cesarean section in Indonesian population: A prospective, observational, multicenter study

The delivery of obstetric anaesthetic care in UK maternity units: a survey of practice in 2021

BackgroundAnaesthetists are crucial members of the maternity unit team, providing peri-operative analgesia and anaesthesia, and supporting the delivery of medical care to high-risk women. The effective contribution from obstetric anaesthetists to safety in maternity units depends on how anaesthesia services are organised and resourced. There is a lack of information on how obstetric anaesthetic care is resourced in the UK. MethodsThe Obstetric Anaesthetists’ Association surveyed UK clinical leads for their hospital’s obstetric anaesthetic service and examined compliance with national recommendations. ResultsThere were 153 responses by lead obstetric anaesthetists from 184 maternity units in the UK (83%). The number of consultants per 1000 deliveries was 2.2 [1.6–2.7] (median [IQR]). In 20% of units, there was a dedicated on-call rota (on-call only for obstetric anaesthesia), whilst the remainder had a ‘combined’ on-call rota (on-call for other clinical areas in addition to obstetrics). Multidisciplinary ward rounds were held in 83% of units. Twenty-five (16%) units reported having no regular multidisciplinary ward rounds, of which nine (6%) did not have any multidisciplinary ward rounds. Planned operating lists for elective caesarean sections were provided in 77% of units. ConclusionsIn the largest survey of obstetric anaesthesia workload to be reported for any health system, we found significant disparities between obstetric anaesthesia service provision and current national recommendations for areas including consultant staffing, support for elective caesarean section lists, antenatal anaesthetic clinics, and consultant support for service development. Wide national variation in service provision was identified.

Obstetric Anesthesia Procedure-Based Workload and Facility Utilization of Society of Obstetric Anesthesia and Perinatology Centers of Excellence Designated Institutions.

Optimal workload and staffing for obstetric anesthesia services have yet to be determined. We surveyed Society of Obstetric Anesthesia and Perinatology (SOAP) Centers of Excellence (COE) for Obstetric Anesthesia Care institutions to evaluate procedure-based obstetric anesthesia workload and facility use. After institutional review board (IRB) exemption, an online survey instrument (REDCap) was sent by email (1 initial and 2 reminders) to all SOAP COEs. Survey data included the number of deliveries, cesarean delivery rate, neuraxial labor analgesia rate, the number of labor and operating rooms, and the number of in-house and backup obstetric anesthesia providers. Obstetric anesthesia activity was estimated using a time-based workload ratio per provider (Stanford Work Index, 1.0 = clinically working every minute of every hour on duty) during weekday, weeknight, and weekend shifts. We compared workload between academic and nonacademic centers and correlated operating and labor rooms with cesarean and vaginal delivery volume. Fifty-one of 53 surveys were returned (96% response rate). Data from 33 academic and 14 nonacademic US institutions were analyzed. For academic centers, median Stanford Work Index for all staff (included trainees and Certified Registered Nurse Anesthetists) was 0.20 (weekday) and 0.19 (weeknight and weekends); nonacademic centers were 0.33 (weekday, P < .001 versus academic), 0.23 (weeknight, P = .009 versus academic), and 0.23 (weekends, P = .03 versus academic practices). Attending-only Stanford Work Indices were similar between academic and nonacademic centers. Total number of rooms on the obstetric suite (operating, labor, or triage room) was strongly correlated with delivery volume ( R2 = 0.55). The results outline staffing procedure-based workload ratios and facility utilization at SOAP COEs in the United States. These data can be used by other institutions that provide obstetric anesthesia services to guide their obstetric anesthesia staffing. The importance of considering the workload associated with different shifts and between academic and nonacademic centers is also highlighted. The results show that approximately one-third of an obstetric anesthesiologist's workload is spent on performing procedures. We did not, however, measure the other tasks anesthesiologists practice as peripartum physicians (eg, managing critically ill parturients, doing pre- and postprocedural evaluations, or performing emergent and unexpected procedures), and future studies are required to determine the time required to perform these tasks. Studies to determine the optimal staffing models to handle workload fluctuations and improve outcomes are also required.

P.124 Analgesia post caesarean section: a fifth local re-audit of obstetric anaesthetic service and implementation of PROSPECT guidelines

P.124 Analgesia post caesarean section: a fifth local re-audit of obstetric anaesthetic service and implementation of PROSPECT guidelines

Adaptation of an Obstetric Anesthesia Service for the Severe Acute Respiratory Syndrome Coronavirus-2 Pandemic: Description of Checklists, Workflows, and Development Tools

(Anesth Analg. 2021;132:31–37) Health care workers have a significant risk of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) exposure and infection. Current guidelines detailing the management of patients with confirmed or suspected SARS-CoV-2 infection do not adequately address preparations aimed at mitigating SARS-CoV-2 infection risks associated with procedures specific to obstetric anesthesia. There is a need for workflows and checklists that maintain safety, provide effective care for patients with or without SARS-CoV-2 infection, and reduce waste during labor analgesia, cesarean neuraxial anesthesia, general anesthesia, and situations such as conversion of labor analgesia to cesarean anesthesia. This report discusses the COVID response workflows developed by the Beth Israel Deaconess Medical Center in Boston.

P.25 Improving antenatal anaesthetic assessment and dissemination of information to parturients with a high body mass index

Introduction: Parturients with a body mass index (BMI) greater than 40 kg/m2 should be referred to the anaesthetic clinic for antenatal assessment. [1] OAA/AAGBI Guidelines for Obstetric Anaesthetic Services 2013.https://www.oaa-anaes.ac.uk/assets/_managed/cms/files/Clinical%20Guidelines/obstetric_anaesthetic_services_2013.pdf. Google Scholar We assessed parturients’ understanding of high BMI and the additional risks posed to them in order to improve their anaesthetic assessment. This has particular importance due to COVID-19 when most assessments have taken place over the telephone.

P.118 Postoperative monitoring following neuraxial opioid administration for caesarean sections across maternity units in the Republic of Ireland: A national survey

Introduction: Neuraxial opioids are a well-recognised, effective means of providing post-operative analgesia following caesarean section (CS). Hydrophilic opioids e.g. morphine, can yield prolonged analgesia post-CS. Although rare in the obstetric population, delayed respiratory depression is a serious risk following neuraxial opioid use. The ASA Closed Claim database reports 16 cases of respiratory depression in first 24 h between 2001 and 2007 involving neuraxial opioid use, resulting in death or permanent brain damage in the majority of patients. [1] Weinger M. Dangers of postoperative opioids. APSF Newsletter 2007;21:61–8. Google Scholar Following intrathecal morphine administration for CS, hourly observations are advised in the first 12 h by the ASA Practice Guidelines. [2] American Society of Anesthesiologists Task Force on Neuraxial Opioids. Practice guidelines for the prevention, detection, and management of respiratory depression associated with neuraxial opioid administration. Anesthesiology 2016;124:535-52. Google Scholar The NICE clinical guideline advises hourly observations for the first 24 h. [3] NICE. Caesarean section Clinical guideline [CG132] 2011. https://www.nice.org.uk/guidance/cg132. Google Scholar The AAGBI Guidelines for Obstetric Anaesthetic Services do not advise a specific frequency for monitoring in this patient cohort. No standardised national policy exists across Irish Maternity Units for monitoring post neuraxial opioid administration. We have conducted a national survey of all units regarding monitoring policies following neuraxial opioid administration for CS.

P.58 Use of video information to assist the consent process for epidural analgesia in labour

Introduction: The need for informed consent is firmly embedded in modern healthcare. Obtaining consent for epidural analgesia during labour can be challenging and information on labour analgesia should be provided for mothers in a variety of formats. [1] OAA / AAGBI Guidelines for Obstetric Anaesthetic Services 2013. https://www.oaa-anaes.ac.uk/assets/_managed/cms/files/Clinical% 20Guidelines/obstetric_anaesthetic_services_2013.pdf. Google Scholar Our hospital recently implemented an online patient education video on epidural anaesthesia. We conducted this study to assess video uptake and response, how patients receive information on epidurals and to determine preferred timing of epidural information delivery.

P.82 Improving anaesthetic maternity follow-up through adoption of electronic maternity records

Introduction: Routine follow-up of postnatal women who received an anaesthetic intervention during labour or delivery is vital for allowing patient feedback and assessment of complications. [1] Association of Anaesthetists of Great Britain and Ireland and Obstetric Anaesthetists’ Association. Guidelines for Obstetric Anaesthetic Services; 2013. https://www.oaa- anaes.ac.uk/assets/_managed/editor/File/Guidelines/obstetric_anaesthe tic_services_2013.pdf Google Scholar Until recently, Cumberland Infirmary, Carlisle, used a paper follow-up system in maternity. This system was isolated from the electronic record used by the midwifery and obstetric teams. Paper systems have limitations, such as loss of records and the potential for errors relating to poor penmanship. [2] Job O, Bachmann LM, Schmid MK, et al. Assessing the efficacy of the electronic patient record system EDeR: implementation study-study protocol. BMJ Open 2013;3(4):e002478. Google Scholar We assessed the effect of integrating anaesthetic documentation into an electronic maternity record and its impact on anaesthetic maternity follow-up.

Obstetric anesthesia services in Israel snapshot (OASIS) study: a 72 hour cross-sectional observational study of workforce supply and demand

BackgroundWe planned an observational study to assess obstetric anesthesia services nationwide. We aimed to assess the effect of the anesthesia workload/workforce ratio on quality and safety outcomes of obstetric anesthesia care.MethodsObservers prospectively collected data from labor units over 72 h (Wednesday, Thursday and Friday). Independent variables were workload (WL) and workforce (WF). WL was assessed by the Obstetric Anesthesia Activity Index (OAAI), which is the estimated time in a 24-h period spent on epidurals and all cesarean deliveries. Workforce (WF) was assessed by the number of anesthesiologists dedicated to the labor ward per week. Dependent variables were the time until anesthesiologist arrival for epidural (quality measure) and the occurrence of general anesthesia for urgent Cesarean section, CS, (safety measure). This census included vaginal deliveries and unscheduled (but not elective) CS.ResultsData on 575 deliveries are from 12 maternity units only, primarily because a major hospital chain chose not to participate; eight other hospitals lacked institutional review board approval. The epidural response rate was 94.4%; 321 of 340 parturients who requested epidural analgesia (EA) received it. Of the 19 women who requested EA but gave birth without it, 14 (77%) were due to late arrival of the anesthesiologist. Median waiting times for anesthesiologist arrival ranged from 5 to 28 min. The OAAI varied from 4.6 to 25.1 and WF ranged from 0 to 2 per shift. Request rates for EA in hospitals serving predominantly orthodox Jewish communities and in peripheral hospitals were similar to those of the entire sample. More than a fifth (13/62; 21%) of the unscheduled CS received general anesthesia, and of these almost a quarter (3/13; 23%) were attributed to delayed anesthesiologist arrival.ConclusionsInadequate WF allocations may impair quality and safety outcomes in obstetric anesthesia services. OAAI is a better predictor of WL than delivery numbers alone, especially concerning WF shortage. To assess the quality and safety of anesthetic services to labor units nationally, observational data on workforce, workload, and clinical outcomes should be collected prospectively in all labor units in Israel.

Adaptation of an Obstetric Anesthesia Service for the Severe Acute Respiratory Syndrome Coronavirus-2 Pandemic: Description of Checklists, Workflows, and Development Tools.

Care of the pregnant patient during the severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) pandemic presents many challenges, including creating parallel workflows for infected and noninfected patients, minimizing waste of materials, and ensuring that clinicians can seamlessly transition between types of anesthesia. The exponential community spread of disease limited the time for development and training. The goals of our workflow and process development were to maximize safety for staff and patients, minimize the risk of contamination, and reduce the waste of unused supplies and materials. We used a cyclical improvement system and the plus/delta debriefing method to rapidly develop workflows consisting of sequential checklists and procedure-specific packs. We designed independent workflows for labor analgesia, neuraxial anesthesia for cesarean delivery, conversion of labor analgesia to cesarean anesthesia, and general anesthesia. In addition, we created procedure-specific material packs to optimize supplies and prevent wastage. Finally, we generated sequential checklists to allow staff to perform standard operating procedures without extensive training. Collectively, these workflows and tools allowed our staff to urgently care for patients in high-risk situations without prior experience. Over time, we refined the workflows using a cyclical improvement system. We present our checklists and workflows as well as the system we used for their development, so that others may use them to their benefit.

Considerations and strategies in the organisation of obstetric anaesthesia care during the 2019 COVID-19 outbreak in Singapore

The provision of safe obstetric anaesthesia services is essential during the COVID-19 global outbreak. The identification of the ‘high-infection risk’ parturient can be challenging especially with the rapidly changing risk criteria for COVID-19 ‘cases’. A multidisciplinary taskforce is required to review the infection control protocols and workflows for managing the parturient for labour analgesia and for caesarean section in order to minimize infection risk to healthcare staff and other parturients. A constant review of such processes is needed to enhance efficiency and to optimise use of finite resources. Good communication between health officials, institutional leadership and ground staff is essential for the dissemination of information.

Obstetric anesthesia in China: associated challenges and long-term goals.

Obstetric anesthesia in China: associated challenges and long-term goals.

Obstetric Anesthesiology in the United States: Current and Future Demand for Fellowship-trained Subspecialists

(Anesth Analg. 2018;127:1445–1447) Subspeciality training in obstetric anesthesiology is associated with improved patient outcomes (27% reduction in risk of maternal death). Therefore, it is no surprise that the 2015 American College of Obstetricians and Gynecologists (ACOG) and the Society for Maternal Fetal Medicine (SMFM) consensus document for improved referral and regionalization of high-risk obstetric services proposed defined levels of high-risk obstetric services with specific requirements. Level II centers require a board-certified anesthesiologist with special training or experience in obstetrics available for consultation, whereas in level III-IV centers, this board-certified anesthesiologist must also be “in charge of obstetric anesthesia services” (level I: birth centers, basic care; II: specialty care; III: subspecialty care; IV: regional perinatal health centers). Considering that the demand for obstetric anesthesia services has increased dramatically in the past few decades, the authors of the present article estimate the workforce demand for fellowship-trained obstetric anesthesiologists (FTOAs).

Current Status of Obstetric Anaesthesia Services (OASIS); A Cross-sectional Survey of Public Hospitals in Khartoum State, Sudan

Background: Medical services in general, and anaesthetic services in particular, in Sudan have been vulnerable to changes secondary to the socio-economic factors over the last few decades. Objective: This cross-state survey aims to identify the current set up of obstetric anaesthesia services in 19 hospitals - representing all public hospitals in Khartoum State with maternity units- and audit them against internationally set standards. Methodology: This is a cross-sectional descriptive non-interventional study. Questionnaires- based on the World Federation of Societies of Anaesthesiologists (WFSA) Safe Anaesthesia Standards- were distributed to Anaesthetic departments’ heads at the time of the study (first to fourteenth of May 2016) of 19 public hospitals. This is the total number of public hospitals delivering obstetric services in Khartoum State. All filled out questionnaires were returned (response rate 100%). Collected information/data provided were subsequently entered into an Excel sheet and analysed. Results were tabulated. Results: There was a considerable variation in the capacity of the surveyed hospitals in terms of human resources, caseload and set up. Improper utilisation of already deficient anaesthesiologist in covering high load obstetrics services was also noticed. All the hospitals fell short of recommendations for minimum standards set by the World Federation of Societies of Anaesthesiologists (WFSA). Conclusion: There is a vast gap between international set standards and the current set up of obstetric anaesthesia in Khartoum State public hospitals. Necessary concerted efforts from governmental, non-governmental and professional bodies are warranted to improve obstetric anaesthetic services in Khartoum State.