Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin)

48 Pages·2012·0.62 MB·English

Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin) P1
P101 A modified WHO surgical safety checklist for P102 A parturient with phocomelia and severe needle
category 1 caesarean sections phobia: the challenges faced
A Lahkar,  A Cooney,  G Massolini   R Sinha,  K Howard,  N Bhandal  
Anaesthetics, Milton Keynes NHS Foundation Trust, Milton Department of Anaesthesia, Nottingham University Hospitals
Keynes, UK NHS Trust, Nottingham, UK
Introduction: In June 2008, WHO introduced a surgical safety Introduction: Parturients with phocomelia are rarely seen and
checklist to be used in every operating theatre to improve present anaesthetic and obstetric challenges. We present a
patients' safety. In 2010 a WHO surgical safety checklist for case of a parturient with phocomelia and severe needle phobia.
maternity was created in response to requests from maternity Case report: A 33 year old woman with phocomelia and severe
services and clinicians. Nevertheless, in some emergency needle phobia presented to the obstetric anaesthetic clinic at
situations like category 1 Caesarean sections, this checklist 20 weeks for pre-assessment.
could still be quite a difficult task to achieve due to Her phocomelia was thought to be idiopathic, she had been
understandable time limit constrains to safely deliver the baby adopted when young and no family/drug history was
and/or save the mother's life. available. Examination revealed four limb phocomelia. There
Whilst there is still no international consensus or any specific were absent upper limb bones on the right and a fused hand
recommendation from WHO concerning these specific attached directly to her body. Her left upper limb was
situations, the Anaesthetic Department in Milton Keynes shortened with a primitive hand and fused fingers. Both lower
hospital has managed to devise a checklist for cat 1 LSCS limbs were extremely shortened with primitive feet with fused
which is 100% compliant both in terms of content with WHO toes. Her head, neck and torso appeared normal. She was able
guidelines and adherence by hospital staff. to mobilize with a wheelchair and significant assistance from
Method: After considerations and inputs from the Consultant her partner. The problems faced in clinic were numerous and
Anaesthetists, a simplified checklist was introduced in our focused on her severe needle phobia, difficult venous access
emergency obstetric theatre in June 2013 by way of an ad hoc and monitoring, positioning, mobilization and
poster hanged on the wall. It spells out the most 10 salient thromboprophylaxis as well as the challenges posed by the
questions to be read by one of the theatre staff before the start preganancy itself. The anaesthetic plan consisted of non-
of a category 1 Caesarean section. These questions translate invasive blood pressure monitoring on her left lower extremity;
the original 32 WHO ones that were spread across 3 sections pulse oximetry via an ear probe or toe and standard
in a simpler, quicker format. electrocardiogram. These were tested prior to labour. Due to
Results: After the introduction of the modified WHO checklist the impossibility of standard intravenous access and extreme
in June 2013, compliance is 100%. needle phobia several discussions were had about obtaining
Discussion: By putting the combined know-how and intravenous access prior to labour. A right subclavian
experience of many Consultant Anaesthetists to the task, we Hickman line was inserted at 39 weeks facilitated by the use of
managed to simplify the original WHO narrative into a sharper entonox. Regional analgesia was refused for labour so the
tool that is quickly and effectively utilised for a better and option of intravenous fentanyl via a midwife controlled
safer quality of care in what has become a "normal routine" analgesia pump was discussed. Should a caesarean section be
during extraordinary times in the emergency theatre. required a neuroaxial anaesthetic was refused and so a general
anaesthetic was planned.
Reference At 40+2 weeks spontaneous rupture of membranes occurred
1. WHO surgical safety checklist: for maternity cases only, and labour established. However, due to failure to progress a
http://www.nrls.npsa.nhs.uk/resources/?entryid45=83972 decision was made to perform a caesarean section.
In theatre the challenges related to positioning and achieving
a satisfactory left lateral tilt. A rapid sequence induction was
conducted following pre-oxygenation to an end-tidal oxygen
concentration of 92%. Anaesthesia was induced with
thiopentone 350mg and suxamethonium 100mg. Soon after
induction she desaturated rapidly to the high 60s. This
resolved after tracheal intubation and ventilation. She was
hypotensive intra-operatively, with an estimated blood loss of
1300mL After fluid and blood resuscitation, recovery was
unremarkable. Postoperative pain was managed with
transversus abdominus plane blocks and morphine
patient/midwife controlled analgesia.
Discussion: There is little literature about managing delivery
in women with phocomelia, but sucessful regional techniques
have been described although this was refused here. Early
discussion of anaethesia and analgesia options, and plans for
vascular access and monitoring are needed, There is a reduced
vascular reservior and skeletal muscle mass.
As a consequence faster inductions, emergences and
responses to titrated drugs are observed.

P2 Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin)
P103 A questionnaire to evaluate and aid future development P104 A retrospective descriptive analysis of anaesthesia for
of the AAGBI's SAFE obstetric anaesthesia course in successful cervical cerclage in pregnancy
Liberia J Modha,  G Burul*,  F Forya*,  CP James*,  AL David*,  J
JCO Fox,  CE Richards*,  T Sheraton*,  A Sonah†   Dick,  L Wee  
†Department of Anaesthetics, Phebe Hospital, Bong County,  Department of Anaesthesia, University College London
Liberia, *Department of Anaesthetics, Royal Gwent Hospital, Hospitals NHS Foundation, London, UK, *Department of
Newport, UK, Department of Anaesthetics, University Obstetrics, University College London Hospitals NHS
Hospital of Wales, Cardiff, UK Foundation, London, UK
Introduction: Dr Kate Grady has developed this three-day Introduction: Cervical cerclage is a common operation which
refresher course in obstetric anaesthesia on behalf of the requires an anaesthetic. There are no studies on the type of
AAGBI. The course is aimed at non-physician anaesthetists in anaesthesia used for this procedure.1
developing countries. It consists of short lectures, interactive Aim: To determine the type of anaesthesia used for vaginal
sessions and workshops that focus on the recognition and cervical cerclage.
management of leading causes of maternal death in resource
Method: Ethical approval waived. Women having any vaginal
poor settings. The course has been taught in Uganda,
cervical cerclage (Macdonald or Shirodkar) during pregnancy
Bangladesh, Liberia and Ghana. It includes the principles of
between January 2005 and December 2012 were identified
the WHO Safe Surgery and training of trainers. Mothers of
using the hospital obstetric anaesthesia database and cross-
Africa, a medical educational charity, has led delivery of 2
referenced with data from the Preterm Birth clinic where women
courses for nurse anaesthetists (NAs) in Liberia - supported
at risk of preterm birth are seen antenatally. Data was obtained
by the AAGBI IRC. Liberia has approximately 60 nurse
by examination of obstetric case notes and the ultrasound
anaesthetists and no medically qualified anaesthetists for a
scan records and analysis conducted using Microsoft Excel.
population of 4.2 million people1. Access to CPD is difficult.
Results: There were 190 cases. Twenty-five patients were
The MMR in Liberia is 770 per 100,000 live births1. In order to
excluded due to incomplete data, hence 165 included in
plan future development of the course in Liberia, which will be
analysis. The mean gestational age was 16.6 weeks (range 9-
led by Liberian trainers, feedback data was collected.
23.6 weeks). The table below shows that both general
Methods: A follow up questionnaire was given to 35 NAs who
anaesthesia (GA) and regional anaesthesia (RA) were used.
had previously attended a SAFE obstetric anaesthesia course
The majority of regional anaesthetics were spinals (95.7%), the
held in Liberia (March 2012 or March 2013). We aimed to
rest combined spinal and epidural (CSE) (3.6%) and epidural
assess; 1) the quality, usefulness and appropriateness of the
top up (0.7%).
material taught during the course, 2) the effect on motivation
to improve local services/care delivery, 3) the effect on the GA RA

confidence levels of NAs in managing obstetric anaesthetic n (%) n (%)
emergencies. Spinal n = 133
Results: A 70% follow up rate was achieved. 97% reported Total n=165 26 (16%) 139 (84%) CSE n = 5
positive changes in their attitude to work and their clinical Epidural n = 1
practice and 94% reported improvements in interactions with Five patients who had a spinal anaesthetic required second
colleagues. Many NAs gave details of cases where the skills procedures (3 GA, 1 spinal, 1 CSE). Of those converted to GA,
and knowledge they learnt on the course helped save lives one patient had a block to T6 (the reason for conversion to GA
and improve clinical outcomes. 11 NAs requested continued was not documented), one patient had a block to T12 and the
education and training. Other suggestions for course third patient had 3 failed spinal attempts. In all cases there
improvement included; additional sessions in preoperative were no major anaesthetic complications and cervical cerclage
assessment and TAP blocks, and the inclusion of midwives in was placed successfully.
the training sessions. The following table illustrates the mean
Discussion: In this series, the majority of vaginal cervical
subjective confidence scores (between 0 and 10) of the NAs in
cerclage surgery was performed safely and effectively under
various clinical scenarios before and after the course.
RA. There are no specific guidelines regarding the type of
  Before After anaesthesia for cervical cerclage.1 Anaesthetic considerations
General anaesthesia LSCS 6.3 9.2 favouring a regional anaesthetic in pregnancy include the risk
Spinal anaesthesia LSCS 7.6 9.8 of aspiration and difficult airway management in patients over
Management of severe eclampsia/preeclampsia 5.7 9.2 20 weeks gestation and those under 20 weeks gestation if at
Management of obstetric haemorrhage 5.9 9.4 high risk for example those with a high BMI. The majority of
women in our data set were less than 20 weeks (88.5%). Other
Discussion: Our results indicate that the SAFE obstetric
considerations include patient and surgeon choice. Women in
anaesthesia course in Liberia has been well received with
this series were given the option of GA or RA. In certain cases
subjective evidence of empowerment and improved methods
for example rescue and abdominal cerclages, the patient may
of working. This is promising in the context of increasing the
need to be in a deep Trendelenberg position to aid reduction
reach of future courses and enabling local faculty to lead
of membrane prolapse to avoid membrane rupture or to aid
training. Further data from logbooks provided as part of the
access to the pelvis.2
course were not obtained and more work is needed to
encourage completion of the logbooks. Objective evidence is References
required to demonstrate impact on patient outcomes. 1. Cervical Cerclage, Green-top Guideline No 60, Royal College of
Reference Obstetricians and Gynaecologists, May 2011.
2. Olatunbosun OA, Dyck F. Cervical cerclage operation for a dilated
1. http://data.worldbank.org/indicator/SH.STA.MMRT/countries/1W-
cervix. Obstet Gynecol. Feb 1981;57(2):166-70.
LR?display=graph
Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin) P3
P105 A retrospective descriptive analysis of dose of P106 A step towards improving theatre productivity for
intrathecal anaesthesia and adjuncts for successful elective caesarean sections
cervical cerclage in pregnancy S Kale,  C Farrow,  N Owen,  K Miltsios  
J Modha,  G Burul*,  F Forya*,  CP James*,  AL David*,  J Department of Anaesthesia, Whittington Hospital, London,
Dick,  L Wee   UK
Department of Anaesthesia , University College London Introduction: NHS Institute for Innovation and Improvement
Hospitals NHS Foundation, London, UK, *Department of developed The Productive Operating Theatre Programme to
Obstetrics, University College London Hospitals NHS improve effective use of theatre time, staff and patient
Foundation, London, UK experience.1 Good administrative system and organisation is
Introduction: Cervical cerclage is a common operation, which essential to ensure theatre efficiency.2On this background,
requires either a general or regional anaesthetic aiming for a with the rational of making existing system more productive,
block height of T10. There are no studies determining the dose safe and reliable, we evaluated current practice in one of our
that should be used to achieve this or describing additional main theatres, designated for elective sections, in a DGH set
drugs used for successful surgery. up.
Aim: To determine the dose of local anaesthesia used for Methods: Evaluation was carried out over a 4-week period, for
intrathecal injection and the block height achieved in women planned caesarean sections. The data was collected
undergoing cervical cerclage. In addition to determine the use concurrently by the anaesthetist for that case and from the
and dose of adjuncts. theatre database. The exact time for all significant events, such
Method: Ethical approval waived. Women having vaginal as when patient was sent for or when theatre was clean and
cervical cerclage during pregnancy between January 2005 and ready for the next patient, was recorded. Reasons for delays,
December 2012 were identified using the hospital obstetric duration of anaesthesia, surgery and problems encountered
anaesthesia database and cross-referenced with data from the were also recorded. Time spent at and between different
Preterm Birth clinic. Data was obtained by examination of crucial stages in theatre was calculated from the data. Results
obstetric case notes and the ultrasound scan records and are presented in the form of time in minutes, median [range]
analysis conducted using Microsoft Excel. and % (absolute numbers of cases).
Results: In all cases, cervical cerclage was achieved Results: We had 25 completed forms. Our analysis showed,
successfully. There were 138 cases of intrathecal anaesthesia median time interval from patient sent for to arrival in theatre
(133 spinals and 5 combined spinal epidurals) in whom 67.4% as 5 min [1-29]. Reasons for delay were due to obstetric team
(93/138) had documented intrathecal anaesthetic dose and busy in meeting, midwife busy preparing the patient and
were included for final analysis. Hyperbaric bupivacaine 0.5% midwife busy completing paperwork for previous patient in
was used (mean dose 10.9mg, median 10.8mg and mode 10mg, recovery. Median time interval between patient's arrival and
range 6.5–15mg). Block height and dose of intrathecal neuraxial block was 18 min [10-70], prolonged in 8% of cases
anaesthetic was documented in 54/93 cases (58%). The block (2/25) due to failed and repeat block. Bladder catheterisation
height ranged from T2 to T12 with similar doses of local after block was delayed by ≥30 min in 8% of cases (2/25) due
anaesthetic given in each group and of similar gestation and to unavailability of midwife. Median anaesthetic time for
body mass index (BMI). satisfactory block was 12 min. Interval between block ready
and knife to skin (KTS) was 6 min [1-12]. Median surgery
Block height T2-4 T5-8 T10 T12 duration was 45 min [31-141]. PPH, high BMI, and previous
Frequency 7 31 13 3 laparotomies resulted in longer operations in 16% of cases
Mean dose mg (4/25). Median turnaround time between the cases was 10 min
11 11 11 8
hyperbaric bupivacaine 0.5% [6-15]. Total time patients spent in theatre was 89 min [74-183].
Mean gestation (weeks) 17.4 17.7 15.6 19.1
Discussion: We noted that unavailability of obstetric team
Mean BMI kg/m2 27.3 26.6 26.1 32
and busy midwives at times has resulted in late starts and
In 3 patients that had block heights of T12 only one was delay in some procedures in theatres. Delay in starting the
converted to GA. Opiates were used in 73/93 (78.5%), the most surgery after a satisfactory block and prolonged turnaround
frequent being fentanyl. time have also affected the overall theatre productivity. We
have put forth some recommendations to working group such
Mean dose Range
Opiate used Number (%) as offering administrative support to midwives, ensuring
(mcg) (mcg)
senior obstetrician and anaesthetist are present for difficult
Fentanyl 69 (95) 20 10-75
cases, making use of anaesthetic room to improve patient
Diamorphine 3 (4) 300 250-350
turnaround time and most importantly encouraging staff
Fentanyl & Diamorphine 1 (1) 20/300 N/A
nurses to take the lead role in increasing theatre efficiency.
Vasopressors were used in 26 cases (23 phenylephrine, 3 This could be a big step towards enhancing theatre output as
ephedrine). Other drugs included 3 cases of intravenous well as increasing patient and staff satisfaction. We aim to
midazolam, 1 case propofol and in 1 case salbutamol (as a introduce these changes soon and re-evaluate the practice in
tocolytic agent). the near future.
Discussion: In our case series there is a wide dose range of References
both hyperbaric bupivacaine 0.5% and opiate given. To 1. The Productive Operating Theatre programme,
achieve a block height of T10 or above a minimum dose of http://www.institute.nhs.uk/quality_and_value/productivity_series/the
11mg (2.2ml) is recommended which may be independent of _productive_operating_theatre.html
other factors. There is a wide variation in block height but 2. Theatre Efficiency,
http://www.aagbi.org/sites/default/files/theatreefficiency03.pdf
even a low block (T12) was found to be adequate.

P4 Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin)
P107 A year in the "maternity" life of an increasingly busy P108 Abstracts on the antenatal anaesthetic clinic
new build district general teaching hospital - coping presented to the Obstetric Anaesthetists' Association,
with training and service provision - 2013 1991-2013
H Wrigley,  PF Yoxall,  Janet Slee   AJ Wickham,  SM Yentis*  
Anaesthetics, St Helens & Knowsley NHS Trust, Liverpool, Anaesthetic department, St Mary’s Hospital, London, UK,
UK *Anaesthetic department, Chelsea & Westminster Hospital,
Introduction: Since moving to a new PFI built hospital in 2010 London, UK
our maternity unit has become more busy. Delivery rates/year Introduction: National reports1 and guidelines2 recommend
have increased from 2900 to 3700 pa (up 27.6% in 3 years) assessment of women with ‘high-risk’ pregnancies and
increasing demands upon anaesthetic services. potentially serious co-morbid disease in an antenatal
Methods: We reviewed all our maternity cases during 2013, anaesthetic clinic (AAC). We reviewed trends and themes in
both epidural and caesarean sections. We also surveyed our abstracts on this topic presented to the OAA.
CT2 trainees to assess their experience in terms of case Methods: Full-text records of abstracts (excluding case reports)
numbers during a newly introduced modular training block. presented at OAA meetings (1991-2013; see www.oaa-
Lastly consultant cover on labour ward was audited for CNST anaes.ac.uk) were searched using the terms ‘antenatal’,
purposes. ‘clinic’, ‘risk’ and ‘refer’. Relevant abstracts were reviewed for
Results themes and conclusions.
Results: Forty abstracts were presented at 14 Annual
n %
Meetings (Fig. 1); 3 were unavailable in full-text (2008) but 1
Total Deliveries 3700
was provided by the author on request. 35 were from single
LSCS 838 22.6
departments and 5 were surveys (4 national). Common topics
Grade I-III LSCS 464 12.5
were obesity (12, 30%), referral reason (7, 18%) and
Grade IV LSCS 374 10.1
appropriateness (4, 10%), and outcomes (5, 13%). Nine (23%)
LSCS - SAB 666 79.5
described single patient cohorts, e.g. cardiac. AAC workload
LSCS - Epidural 123 14.7
has increased from 2.3 to 28.6 patients per month over 22
LSCS - CSE 14 1.7
years, albeit at different centres. Obesity has replaced
LSCS - GA 119 14.2
musculoskeletal disease as the most frequent reason for
RA to GA 34 4.2
referral. Common concluding themes include the need to
Average BMI LSCS (Range) 28.3 (16.7-59.9)  
improve the timeliness and appropriateness of referrals, and
Epidurals 895 24.2
ensuring anaesthetic plans are both prominent and followed.
Epidural Resites 32 3.7
PDPH - Epidural 15 1.7
PDPH - SAB 2 0.3
Epidural Blood Patches 21
Average BMI Epidural (Range) 27.1 (16-62.8)  
CT2 Training One of our requirements is to teach at least 4
CT2s per annum obstetric basic competencies. Our trainees
receive a 4 week long daytime block covered by an anaesthetic
ST3-7 and a consultant. They attend 40 sessions, the majority
siting 15 epidurals and anaesthetise 30 caesarean sections
before embarking on daytime on calls. They attend our in-
Figure 1: number of abstracts on the AAC presented per year
house MODSS (Obstetric Simulation Day) run by one of our
Consultant Obstetricians. Discussion: Abstracts relating to AACs have become more
frequent in the last decade, presumably reflecting their
Consultant Input The number of funded Consultant labour
increasing provision and perceived usefulness (and
ward sessions has risen 7 to 10 sessions (7 elective lists per
recommendation in the 2002-04 CEMACH report3). Increased
week). A “High Risk Obstetric clinic” runs weekly to pre-
demand for this service is exacerbated by inappropriate
assess all potentially difficult patients (250-300 per annum).
referrals and budgetary constraints. Referral processes,
Discussion: Despite a significant increase in workload we
facilities, and documentation and inconsistent use of plans are
have managed to maintain levels of cover (both junior and
areas for development. Future work should focus on quality
consultant) whilst allowing for CT2 training in obstetric basic
improvement and assessment of cost-effectiveness. Nationally
competencies as required at both national and local levels.
agreed referral criteria and a national ‘anaesthetic plan’
This has been achieved by increasing our core of obstetric
document, complemented by referrer education, may enhance
consultant anaesthetists, increasing obstetric PAs and
the process. Multidisciplinary ‘one-stop-shop’ or midwifery
changing to a modular CT2 training programme.
led clinics for common problems, such as obesity, may be
beneficial.
References
1. Centre for Maternal and Child Enquiries. Saving Mothers’ Lives:
reviewing maternal deaths to make motherhood safer: 2006-08.
The Eighth Report on Confidential Enquiries into Maternal Deaths
in the UK. BJOG. 2011; 118(Suppl.1): 1-203.
2. OAA & AAGBI Guidelines for Obstetric Anaesthetic Services.
Revised Edition 2005. London: OAA/ AAGBI
3. CEMACH. Why Mothers Die 2000-2002. Report on Confidential
Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin) P5
P109 Accuracy of a new electronic obstetric anaesthetic P110 Accuracy of landmark approach to central neuraxial
database blocks in obstetric patients
Rohit Rohit,  R Abraham,  GNB Jackson   J Lie,  K Bhatia,  A Venkataraju,  P Kochhar  
Anaesthetic department, Royal Berkshire Hospital, Reading, Anaesthesia, St Mary's Hospital, Manchester, UK
UK Introduction: Correct identification of vertebral level could
Introduction: We have introduced a new electronic database prevent damage to the spinal cord during a central neuraxial
'ROAD' (Reading Obstetric Anaesthetic Database) to record block (CNB). Evidence suggests that ultrasound (US) imaging
obstetric anaesthetic data. Written & designed by one of our of the spine by an experienced operator leads to correct
anaesthetists it is secure, password protected & able to identification of vertebral level in 90% of the patients and
produce reports on patient data & the activity of individual decrease the number of attempts required for a successful
anaesthetists. More than 70% obstetric anaesthetic units use CNB1. National Institute for Health and Care Excellence
electronic data collection system in the UK but there is little suggests US could be a useful tool for epidural catheter
agreement as to the best format.1 We audited the accuracy of insertion2. Our aim was to determine the discrepancy between
data entry, as a marker of ease of use by the anaesthetists, landmark technique and US to identify level of insertion of
before auditing the content of the database. CNB.
Methods: This was a retrospective audit, analysing data for Methods: Two experienced US operators who were blinded to
one month period (June 2013). The data in 'ROAD' was the initial procedure retrospectively performed US imaging of
compared to 1) our handwritten anaesthetic record book spine post-operatively after elective caesarean section in 51
(ARB); 2) Midwifery led labour ward logbook (LWLB); 3) obstetric patients with their consent from January to March
Operating theatre electronic log 'Bluespier'. Data entered on 2013 in St Mary’s Hospital. All the patients had a lumbar CNB
the 'ROAD' was manually checked against all these three done by landmark approach. The documented vertebral level
sources and the results tabulated and analysed. at which CNB was performed was noted. This was then
Results: 253 records were found in the ARB. The ARB missed compared with the actual vertebral level identified by bedside
one case (found in Bluespier), Bluespier missed one case US imaging of spine.
(found in the ARB) and LWLB missed 6 cases (found in the
Results: 29 patients had a spinal, 20 had an epidural and two
ARB & Bluespier). The results show that 'ROAD' was 96%
had combined spinal-epidural anaesthesia. The median body
accurate compared to any of the other systems.
mass index (BMI) was 28.6kg/m2. Landmark technique was
No. of cases missing on only accurate in 39.2% of patients. There was no statistically
Total 'ROAD' accuracy against
  'ROAD 'compared to significant correlation between the experience of operator and
no. other data sources as %
others accuracy. 3% of patients had a CNB at the level of L or above.
2
ARB 10 253 96.047% Documentation of the level performed was excellent. Raised
Bluespier 7 174 95.977% BMI and difficulty in palpation of landmarks resulted in
LWLB 10 247 95.951% statistically significant decrease in the accuracy (p<0.05
'ROAD'   243   Fisher’s Exact Test).
Discussion: Pinder et al considered an accuracy of 89% for Discussions: Our findings co-relate well with other studies
their electronic record adequate enough to adopt computer which have found that the vertebral level identified by
based data collection system.2We used three different landmark approach was at least 1 interspace higher than the
methods of data collection already in regular use, to compare level located by US in 40% of the pregnant population 3. Our
with our electronic database and showed it to have a high audit further confirms that the use of traditional landmark
degree of accuracy. This suggests that the database is easy to technique is highly inaccurate with potential increase risk of
use and consistently completed by our anaesthetists. We wish needle injury to the spinal cord especially in the high-risk
to use our database to produce reports on anaesthetic service patient groups (morbid obesity and musculoskeletal
provision (including the quality & safety of that service) as problems). We propose that all elective obstetric patients,
well as for auditing individual anaesthetist activity patients having a lumbar epidural, and high risk patients
(particularly our novice obstetric anaesthetists to ensure having a lumbar CNB should have US imaging of the of their
appropriate case mix & experience during their obstetric spines to identify the correct vertebral level and other relevant
attachments). Before using any database to audit these anatomy. The main reasons being that US imaging does not
aspects it is important to ensure that the data being audited is involve any radiation, is compact, portable and readily
a true reflection of anaesthetic activity, we believe our new available at the point of care. Better US equipment availability,
database is sufficiently accurate to audit the data within it. The staff awareness with appropriate training and improved
limitation of our audit is that we only audited the data from one documentation would aid in providing safer patient care.
month but we believe that the data entry practice of all months
References
is similar. We conclude that our electronic database is accurate
1. Chin KJ, Perlas A, Chan V, Brown-Shreves D, Koshkin A, Vaishnav
& the data entered can be used to audit our obstetric V: Ultrasound imaging facilitates spinal anesthesia in adults with
anaesthetic service. difficult surface anatomical landmarks. Anaesthesiology 2011; 115
(1): 94-101
References
2. Ultrasound-guided catherisation of epidural space. National Institute
1. Campbell NJ, Youngs P, Anderson I. A national survey of obstetric for Health and Care Excellence January 2008
anaesthetic data collection methods in the UK. Int J Obstet Anesth
2012; 21: S53. 3. Lee AJ, Ranasinghe S, Chehade JM, Arheart K, Saltzman BS,
Penning DH & Bimbach DJ. Ultrasound Assessment of the Vertebral
2. Pinder A, Wrench I, Shepherd D, Freeman R. Assessment of a Level of the Intercristal Line in Pregnancy. Anaesth Analg 2011;
handheld computer to collect obstetric epidural audit data. Int J
113: 559-564
Obstet Anesth 2002; 11: 8.
P6 Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin)
P111 Adherence to antenatal anaesthetic advice in P112 An evaluation of anaesthetic antenatal clinics in the
labouring morbidly obese parturients. obese obstetric population
S Halliday,  LC Robertson ,  HM du Plessis   PR El-Dalil,  DS Cochran,  R Ganapathy*  
Anaesthesia, Princess Royal Maternity Hospital, Glasgow, Department of Anaesthesia, Sandwell and West Birmingham
UK NHS Trust, Birmingham, UK, *Obstetrics and Fetal Medicine,
Introduction: Morbidly obese parturients pose a high Sandwell and West Birmingham NHS Trust, Birmingham, UK
anaesthetic risk1. Antenatal anaesthetic assessment for Introduction: Maternal obesity is increasingly common, with a
women with a body mass index (BMI) ≥40 kg.m-2 at booking is BMI 35 found in 5% of pregnancies. Current CMACE / RCOG
advised2. Early establishment of epidural analgesia is often guidelines advocate the referral of patients with a BMI 40 to
advocated. We sought to determine if this advice is adhered to an anaesthetic antenatal clinic. This study aimed to evaluate
in our centre. the outcomes following the implementation of such a clinic in a
Methods: A retrospective case note review of 49 morbidly busy inner city district general hospital.
obese patients (BMI ≥40) assessed antenatally was Method: High-risk patients were referred to a multidisciplinary
conducted. As a control, data from 23 patients with a BMI <40 antenatal clinic involving Anaesthetics, Obstetrics and
who had a labour epidural was collected. We compared the Haematology; patients with a BMI 40 were referred to the
timing of epidural request from labour ward admission, cervical clinic and included in the evaluation. Data was collected
dilation and syntocinon administration at request and the time retrospectively on the reason for attending, the past medical
from epidural insertion to delivery. Mode of delivery was also and obstetric history as well as any anaesthetic or surgical
noted. intervention provided in the perinatal period.
Results: Mean BMI for the control group was 23.6 (range 17- Results: In 2011, 72 women were referred to the clinic with a
32) and for the morbidly obese group 44.6 (40-60). Eleven BMI 40, although there were often other relevant co -
morbidly obese parturients had an elective caesarean section morbidities. The BMIs ranged from 40 to 80 (mean = 44). 44
(CS). Nineteen of the remaining morbidly obese parturients patients (61%) had a normal vaginal delivery, 3 women (4%)
requested labour epidurals. Two parturients delivered prior to required assisted vaginal delivery, 17 (24%) had an elective
insertion. caesarean section (CS), whilst 8 (11%) had a non-elective CS.
Of these patients, 38 (53%) required no anaesthetic
Time to Syntocinon Insertion to
Cervical dilation intervention.
request administration n delivery
  Centimetres
Minutes (%) Minutes Table: Anaesthetic intervention and failure rates in obese
(range)
(range) (range) parturients compared to previously published failure rates1 in
BMI Yes 12 (52.2) the general obstetric population
375 (110-
<40 169 (0-435) 3.7 (1-7) No 11 (47.8) Spinal Epidural CSE GA
915)
(n=23) Number attempted 19 12 4 1
BMI Yes 13 (68.4) % Failure rate 5 17 0 0
334 (12-702)
≥40  261 (0-555) 3.65 (2-8) No 6 ( 31.6) Published % failure rates1 6 24 18 <1
(n=17)
(n=19)
Discussion: The results demonstrated low regional
Table: Timing of epidural request, cervical dilation and anaesthesia failure rates, with only 1 unsuccessful spinal (5%)
syntocinon use at request, and time from insertion to delivery. and 2 failed epidurals (17%); figures comparable to those
In the control group with a BMI <40 that had a labour epidural found in the general obstetric population (Table). There is little
(n=23), the number of spontaneous vaginal deliveries (SVD), available data for regional anaesthetic failure rates in the obese
trial of forceps (TOF) and lower uterine segment CS (LUSCS) obstetric population precluding a direct comparison, but a
were 13 (56.5%), 5 (21.7%), and 5 (21.7%), respectively. For higher failure rate would be expected. A previous study of 677
those with a BMI ≥40 with an epidural (n=17) there were 6 women with a BMI 30 found an emergency CS rate of 24%, 2
(35.3%) SVD, 3 (17.7%) TOF and 8 (47.1%) LUSCS. The significantly higher than the 11% demonstrated in this cohort
number of SVD in the BMI ≥40 without an epidural group was of BMI 40. This robust multidisciplinary approach in the
18 (85.7%) and there were no TOF and 3 (14.3%) LUSCS. antenatal period allows for adequate planning and early
Discussion: Despite antenatal review, the time to epidural institution of optimised perinatal management. The service
request was longer in the morbidly obese group, indicating a provided was predominantly consultant led, with the on-call
need for ongoing education. The time between epidural Anaesthetist required to attend out of hours for parturients
insertion and delivery was shorter in the morbidly obese group with a BMI 45, and to be informed of patients with a BMI
which had a significantly increased chance of CS, signifying 40; significantly 73% of the on-call consultants are dedicated
the importance of establishing a working epidural early in this Obstetric Anaesthetists. We feel these systems may account
cohort. for our findings, as well as promote early and effective
communication with patients. Whilst the sample was relatively
References small the results are sufficiently encouraging to suggest that a
1. Soens MA, Birnbach DJ, Ranasinghe JS, van Zundert A. Obstetric multidisciplinary approach significantly improves perinatal
anesthesia for the obese and morbidly obese patient: an ounce of outcomes in the obese obstetric population.
prevention is worth more than a pound of treatment. Acta
Anaesthtesiol Scan 2008; 52: 6-19 References
2. OAA/AABGI Guidelines for Obstetric Anaesthetic Services 2013. 1. Kinsella SM. A prospective audit of regional anaesthesia failure in
Association of Anaesthetists' of Great Britain and Ireland and the 5080 caesarean sections. Anaesthesia 2008; 63(8): 822-832.
Obstetric Anaesthetists' Association. London, 2013. 2. Usha Kiran TS, Hemmadi S, Bethel J, Evans J. Outcome of
pregnancy in a woman with an increased body mass index. BJOG
2005; 112(6): 768-772.
Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin) P7
P113 An evaluation of fasting times for elective caesarean P114 An evaluation of intrathecal diamorphine versus
section surgery fentanyl for lower segment Caesarean section in a
J Ghoshdastidar,  KM Sherratt,  M Seneviratne*,  A medium-sized district general hospital
McGlennan   K Ramm,  LT Fenton-May,  S Naresh  
Anaesthetics, Royal Free Hospital, London, UK, Department of Anaesthesia, Good Hope Hospital, Heart of
*Anaesthetics, University College Hospital, London, UK England Trust, Birmingham, UK
Introduction: Enhanced Recovery Programmes have shown Introduction: Intrathecal diamorphine is now recommended by
increasing evidence for the benefits of reducing fasting times the National Institute for Health and Clinical Excellence (NICE)
for those undergoing elective surgery1. Many of these as the opioid of choice for lower segment Caesarean section as
benefits could be applicable to the elective caesarean section it provides improved post-operative pain relief.1 However, it is
patient. We evaluated the fasting times of our elective also associated with a dose-dependent increase in the
caesarean section patients to assess whether we could make incidence of pruritus2 and nausea3 which may be more
improvements to patient care. significant with diamorphine given its longer duration of
Methods: The evaluation included all patients undergoing action. Having arranged appropriate protocols for post-
elective caesarean section surgery at the Royal Free Hospital operative monitoring of women receiving intrathecal
over a 3 month period.. Patients received standard instructions diamorphine, we introduced the therapy in late 2012.
to stop eating at midnight on the day of surgery and to stop Methods: The evaluation took place over a six-week period. A
drinking clear fluids at 6 am. Data was collected by anaesthetic small number of women were still receiving intrathecal fentanyl
staff using a standardised data collection sheet.. Patients were due to clinician choice, and these provided a useful
questioned about the time they last consumed solid food and comparator. Women who were still present in the hospital on a
when they last drank liquid. follow-up round on the first day post-op were asked questions
Results: In total 77 patients underwent elective caesarean about post-operative pain, nausea and pruritus. We also
sections during the period of evaluation. We obtained data assessed total oral morphine and codeine doses and time to
from 71 patients for fasting times for fluids and 72 patients for first dose.
fasting times for solids. Results: Basic data is presented in the chart.

  Fentanyl Diamorphine
Pre-op fasting % of Pre-op fasting % of
Number 15 36
times FLUIDS patients times SOLIDS patients
Time to first morphine (hrs) 5.29 8.9
(hr) (n=71) (hr) (n=72)
Mean morphine dose (mg) 65.4 30
2 - 4 5.6 6 - 12 15.3
No morphine required 1 (6.6%) 11 (30.6%)
4 - 6 15.5 12 - 18 66.7
Mean codeine dose (mg) 123 119
6 - 8 14.1 18 - 24 16.7

8 - 10 8.5 over 24 1.4
Time to mobilisation (hrs) 21.17 15.21
over 10 56.3    
Time to catheter removal (hrs) 20.3 16.6

Discussion: There are no fasting recommendations specific to
Pruritus 8 (53.3%) 24 (66.7%)
elective caesarean sections but the standard surgical
- requiring treatment - 0 (0%) - 8 (22.2%)
guidelines of 6 hours for solids and 2 hours for clear fluids are
Nausea 5 (33%) 13 (36.1%)
usually applied. Periods longer than 12 hours without fluid
- requiring treatment - 3 (20%) - 7 (19.4%)
have correlated with significant dehydration
in patients having elective caesarean sections2. There is also
Discussion: Our results replicate previous work demonstrating
some evidence to suggest that gastric fluid volume is
a reduction in immediate post-operative analgesia
increased with prolonged starvation in the pregnant patient3.
requirements following a switch from fentanyl to diamorphine,
Over fifty per cent of our patients went without fluids for
but an associated increase in side effects requiring
longer than ten hours prior to surgery, and almost eighty-five
intervention. There was also a reduction in times to first
per cent of patients went without food for greater than 12
mobilisation and catheter removal, which is worth closer
hours. Our results show that there is a need to introduce
inspection. It is likely to be multi-factorial: the patients having
methods to reduce fasting times. These could include pre-
superior analgesia and feeling ready to move sooner, but also
operative letters with individualised times to stop eating and
the proforma for the ward indicating the patient had received
drinking. Also patients lower down the surgical list could be
diamorphine. This required the anaesthetist to specify a time
actively encouraged to consume clear fluids, or even
after which she would be ready to mobilise, which might have
carbohydrate drinks as used in many Enhanced Recovery
improved motivation amongst the midwives and mothers to
programmes.
achieve mobilisation.

References
References
1. Aguilar-Nascimento JE, Dock-Nascimento DB. Reducing
preoperative fasting time: A trend based on evidence. World J 1. NICE clinical guideline 132: Caesarean section
Gastrintest Surg. 2010 March 27;2(3): 57-60 2. Wrench IJ, Sanghera S, Pinder A et al, Dose response to intrathecal
2. Mackenzie M, Yentis S, Woolnough M and Johnson M. Fasting diamorphine for elective caesarean section and compliance with a
periods and dehydration before elective caesarean section. national audit standard, Int J Obstet Anesth. 2007;16(1):17-21
Anaesthesia, 2010 Vol 65:99 3. Sibilla C, Albertazzi P, Zatelli R, et al, Perioperative analgesia for
3. Maltby JR, Sutherland AD, Sale JP, Shaffer EA. Preoperative oral caesarean section: Comparison of intrathecal morphine and
fluids: is a five hour fast justified prior to elective surgery?. Anesth fentanyl alone or in combination, Int J Obstet Anesth. 1997; 6(1):
Analg. 1986 Nov;65(11):1112-6 43-48
P8 Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin)
P115 An evaluation of obstetric critical care admissions in a P116 An evaluation of standards of informed consent and
district general hospital documentation for labour epidural analgesia
VL Williams,  M Greene,  D Saul   S Chaudhari,  N Smith,  P Prasad  
Department of Anaesthesia, Leighton Hospital, Crewe, Anaesthetic Department, George Eliot Hospital, Nuneaton,
Cheshire, UK Nuneaton, UK
Introduction: CMACE has provided doctors with excellent
Introduction : It is both medico legally and ethically important
data over the past 50 years about maternal mortality, but
that the patient is made aware of the nature and risks
unfortunately no data about maternal morbidity. In December
associated with a labour epidural. No national standardised
2013, the Intensive Care National Audit & Research Centre
information card for informed consent is available, although
(ICNARC) produced a second report that analysed critical care
the OAA does publish a epidural information card1 with
admissions of women who were pregnant or recently pregnant
specific risks and incidence rates. At our hospital, the
in 2009-2012 inclusive.1 A comparison was made between the
documentation is made on part of the epidural chart as an
hospital ICNARC data and the national ICNARC data.
open entry. Our study looked to ascertain whether appropriate
Methods: Data were collected from the hospitals ICNARC
details of the epidural and informed consent were made. This
database over a four year period from 2009 to 2012. The data
was with a view to find whether a total redesign of the epidural
was analysed from the categories in the table below.
chart (at a level of standard suggested by the OAA website2)
Results: Data from 388 patients were evaluated.
was needed to improve our practice.
  Hospital ICNARC
Methods : We evaluated a total of 100 completed epidural
Total no. of patients admitted, female 16-50 years 388 55,791
charts over a 4-month period in mid-2012 at our obstetric unit.
Currently pregnant 3.6% 2.1%
The epidural notes were retrospectively analysed on our
Recently pregnant 9.3% 10.0%
scanned patient electronic notes. Documentation was
Obstetric reason for admission - currently pregnant 0% 8.7%
analysed for: details of the patient, anaesthetist and patient
Non-obstetric reason for admission - currently
100% 91.3% assessment, explanation of the risks and incidence given,
pregnant
details of the epidural technique and post epidural
Obstetric reason for admission - recently pregnant 50% 69.7%
management. Our main focus was on standards of consent.
Non-obstetric reason for admission - recently
50% 30.3% Results:
pregnant
%of patients Rate of risk
Discussion: The proportions of patients admitted to the Range of risk discussed
Risk discussed informed documented (no.
critical care area were comparable with the ICNARC report. (no. in total)
(n=100) in total)
The leading indication for admission in the currently pregnant
1in100:13,1in200:8
group was for sepsis. This corresponds with the ICNARC Headache 69 25
<1%:3,1in500:1
report and most recent CMACE report in which sepsis was the
Hypotension 45
leading direct cause of maternal death.2
Failure 59 4 1in8:2, 1in4000:2
The leading obstetric cause for currently pregnant admissions
Nerve 1in13k:21,1in10k:8
nationally, was for pre-eclampsia. However, there were no 65 31
damage 1in15k:1, 1 in19k:1
admissions in this category at the hospital. This is most likely
Itching 14    
because pre-eclampsia is diagnosed and treated effectively on
Infection 37  
the labour ward and rarely needs input from critical care.
Motor block 28    
In the recently pregnant group, there were equal proportions
Urinary
of patients admitted for obstetric and non-obstetric reasons, 28    
retention
this is quite different from the ICNARC report. The leading
indication for admission of recently pregnant patients in the The other areas of documentation studied showed an
ICNARC report was for post partum haemorrhage, by a long acceptable standard.
way. When looking at the hospital database, it showed that in Discussion : Several studies have looked at standards of
the period 2010-12, only 3 of 42 patients with a significant post informed consent in UK practice3and which risks and
partum haemorrhage of 2.5 litres or more were admitted to incidences were discussed and the range of risk quoted. Our
critical care. Therefore the question needs to be asked as to study showed rates generally to be slightly lower than that
whether these patients should have been admitted to the quoted in these studies. This is likely due to limited space and
critical care area? The hospital does not have an obstetric open entry nature of our current chart. The OAA has set
HDU, but in hospitals that do have an obstetric HDU facility, guidelines and advice for both epidural charts2 and risks and
these patients would certainly have been admitted there, had incidence1. Following this evaluation, a full redesign of our
closer monitoring and possibly goal directed therapy. All of epidural charts with prompts and guidance of risks and
these patients survived, but could admission to critical care incidence is warranted. In addition, the OAA had
have improved patient outcomes or reduced hospital stay? overwhelming support for a national standardised information
References card that could be implemented3.
1. Female admissions to adult, general critical care units in England,
Wales and Northern Ireland reported as 'currently pregnant'
References
or 'recently pregnant'. http://www.icnarc.org/documents/Obstetric%
20admissions%20to%20critical%20care%202009-2012.pdf 1. OAA epidural information card : http://www.oaa-
anaes.ac.uk/content.asp?ContentID=185
2. The eighth report on confidential enquiries into maternal deaths in
the United Kingdom. BJOG 2011, 118(Suppl 2):1-203 2. OAA epidural charts : http://www.oaa-anaes.ac.uk/content.asp?
ContentID=522
3. Informed consent for epidural analgesia in labour: A survey of UK
practice: Anaesthesia 2009, 64 p161-164
Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin) P9
P117 An unusual cause of post-partum sepsis P118 Anaesthetic management of a parturient with severe
F A Corcoran,  C Brennan,  A J Downs   systemic scleroderma
Anaesthetics, Dudley Group NHS Foundation Trust, Dudley, P Thomas,  A Varvinskiy,  M Human  
UK Anaesthetics, South Devon Healthcare NHS Foundation
Introduction: Leiomyomas are common in women of Trust, Torquay, UK
reproductive age and have been linked to spontaneous Introduction: Scleroderma is a chronic systemic autoimmune
abortion, retention of the placenta and post-partum disease. Successful pregnancy in patients with severe
haemorrhage.1 It is however rare for them to be the primary systemic scleroderma is very rare. We report the anaesthetic
cause of post-partum sepsis. We describe the case of a post management of such a case in a patient with a difficult airway,
partum patient presenting with painful fibroids and sepsis. severe pulmonary dysfunction and oesophageal dysmotility.
Case report: A 37 year old woman (P1), 5 days post partum Case report: A 29 year old woman (G1P0) with severe
presented with a history of fever, abdominal pain and systemic scleroderma presented to the hospital at 36 weeks
distention. She had a past medical history of fibroids but there gestation with dyspnoea and tachypnoea. Prior to pregnancy
had been no problems during pregnancy. She had an her exercise tolerance was poor, managing just 400 metres in a
uneventful labour with a normal vaginal delivery. On initial six minute walk test with resultant oxygen saturations of 72%.
assessment she was apyrexial with normal observations. She Her Forced Expiratory Volume (FEV1), Forced Vital Capacity
had mild tenderness on palpation of her abdomen. She was on (FVC) and Diffusing Capacity for Carbon Dioxide (DLCO) had
regular analgesics and had been commenced on oral each worsened steadily by five percent year on year over the
antibiotics by her GP. An ultrasound scan (USS) was booked last decade. The most recently measured values from 2007
to investigate the abdominal pain. Within 4 hours she had were FEV1 30%, FVC 28% and DLCO 24% of predicted values
deteriorated and developed a pyrexia, tachycardia, tachypnoea although the patient reported that her pulmonary function had
and decreased oxygen saturations. Initial impression was deteriorated significantly during pregnancy. On admission the
sepsis secondary to retained products so blood cultures and patient was breathless at rest with a p02 of 7.63 on room air
swabs were taken and intravenous antibiotics, oxygen and and it was felt that natural labour would not be possible due to
fluid resuscitation commenced. She was transferred to the poor physiological reserve. Severe reflux secondary to
Maternity High Dependency Unit. CRP was elevated but oesophageal dysmotility rendered her unable to recline more
lactate was normal. She improved over 6 hours but than 45 degrees and she could therefore not lie flat for awake
deteriorated again. Antibiotic coverage was amended caesarean section. Airway assessment revealed microstomia of
following microbiology advice but she continued to have a less than one centimetre, mallampati four, bucked teeth, sub
swinging pyrexia. USS detailed a bulky uterus with a large mental skin scleroderma and a narrow hooked nose with small
fibroid at the fundus and no retained products. 36 hours after nostrils. Oral intubation was therefore ruled out. Awake Fibre
admission she developed peritonitis and a CT abdomen which Optic Intubation (AFOI) appeared technically challenging due
suggested findings of a pedunculated fibroid measuring to nasal anatomy. Preoperative, bedside nasendoscopy
17.5cm that might have twisted on its pedicle. She had an revealed that AFOI would be possible should the need to
emergency laparotomy which revealed a degenerative, secure the airway arise mid operation. This avoided the need
necrotic, infected fibroid. She required ionotropic support and to perform an AFOI or awake tracheostomy pre-operatively.
was difficult to ventilate intra-operatively. Post-operatively The patient was positioned at 45 degrees on the operating
she was transferred to intensive care where she was sedated table. Surgeons confirmed that they could operate in this
and ventilated overnight. She was successfully extubated the position. A low dose spinal followed by an epidural which was
following morning and continued with intravenous antibiotics topped up gradually over 30 minutes using small incremental
and analgesia. She made a full recovery. Histology confirmed boluses achieved adequate block without compromising
the fibroid had extensive areas of coagulative necrosis, respiratory function. Surgery was completed without issue and
hyalinisation and inflammation. All microbiological both mother and baby did well post-operatively.
investigations were negative. Discussion: There are only three reports in the literature
Discussion: Sepsis in pregnant and post-partum women describing general anaesthesia for caesarean section in
remains a significant cause of maternal morbidity and patients with scleroderma and two using neuraxial blockade.1-5
mortality.2Sepsis is a clinical diagnosis and microbiological Of those who were intubated, one died and another required
investigations may be negative. Early recognition, timely three months ventilation. We demostrated how careful bedside
diagnosis and active treatment assists an optimum outcome. airway assessment and the use of a slow top up epidural were
Fibroids are common in pregnancy but sepsis secondary to successfully used to manage this challenging case.
infected, necrotic fibroid tissue post-partum is very rare. To References
our knowledge there have been no reported cases of this. It is
1. D'Angelo R, Miller R. Pregnancy complicated by severe
therefore essential to consider this in the differential causes of preeclampsia and thrombocytopenia in a patient with scleroderma.
obstetric sepsis when reviewing pregnant women with a Anesth Analg 1997; 85: 839-41
history of fibroids. 2. Hseu SS, Sung CS, Mao CC, Tsai SK, Lee TK. Anesthetic
management in a parturient with progressive systemic sclerosis
References during cesarean section. Acta Anaesthesiol Sing 1997; 35: 161-7
1. Mason T. Red Degeneration of a leiomyoma masquerading as 3. Younker D, Harrison B. Scleroderma and pregnancy. Br J Anaeth
retained products of conception. Journal of the National Medical 1985; 57: 1136-9
Association. 2002; 94: 124-6 4. Thompson J, Conklin KA. Anesthetic management of a pregnant
2. Lucas DN, Robinson PN, Nel MR. Sepsis in obstetrics and the role patient with scleroderma. Anaesthesiology 1983; 59: 69-71
of the anaesthetist. International Journal of Obstetric Anaesthesia. 5. Bailey AR, Wolmarans M, Rhodes S. Spinal anaesthesia for
2012; 21: 56-67 caesarean section in a patient with systemic sclerosis. Anaesth
1999; 54(4): 355-8
P10 Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin)
P119 Anaesthetic management of arrhythmogenic right P120 Anaesthetic management of obese parturients at a
ventricular cardiomyopathy during labour and tertiary centre - meeting the standard?
caesarean section: a case series L Kelliher,  J Teare,  E Evans  
J Eccles,  A Jain,  K Bhatia   Anaesthesia, St George's Healthcare NHS Trust, London, UK
Department of Anaesthesia, St Mary's Hospital, Manchester, Introduction: Obese women are at increased risk of perinatal
UK morbidity and mortality. In 2010 CMACE and RCOG published
Introduction: Arrhythmogenic right ventricular joint guidelines for the management of the obese parturient
cardiomyopathy (ARVC) is mainly a genetically determined including recommendations that patients with a booking BMI
autosomal dominant disease characterised by cardiomyocytes ≥40 should attend an antenatal anaesthetic clinic (AAC) and a
being replaced by fibrofatty tissue in the right ventricle.1 Specialist Trainee year 6 anaesthetist (ST6) or above should
ARVC has an incidence of 1:5000 and may account for as be informed and available to attend labour and operative
many as 5% of unexpected sudden deaths. The Eighth Report delivery1. Our unit is a tertiary centre with over 5,000
of the Confidential Enquiries into Maternal Deaths in the deliveries/year. A previous audit over 2 years showed that of
United Kingdom (2006-2008) highlighted that ARVC was the 120 women with BMI ≥40 attending our AAC, 76% required a
underlying cause in two of the 53 reported cardiac deaths. We peripartum anaesthetic intervention, with only 34% of these
describe the anaesthetic management of two parturients with performed by an anaesthetist ≥ST62. Awareness of the
ARVC who presented at our tertiary centre. guidelines was raised and anaesthetic plans for these women
Case reports: The maternal demographics, the cardiac signs, now state care should be managed by a senior anaesthetist.
symptoms and interventions along with the anaesthetic We examined our obese population following these changes.
management in the peri-partum period are briefly summarised Methods: A retrospective analysis over 1 year (2011-12) of
in the table below. hospital records for patients with a booking BMI ≥ 40. Records
were examined for referral and attendance at AAC, anaesthetic
Category Case 1 Case 2
intervention (regional/GA), grade of anaesthetist and
Age 27 23
anaesthetic complication (difficult/impossible regional, dural
BMI 25.8 27.2
tap, other).
Parity 0 0
Family history None Sudden death Results: In total there were 74 women with a booking BMI
Cardiac signs and Palpitations with spurts of Paroxysmal VT ≥40. 73% were referred to AAC, only 58% attended. Out of all
symptoms ventricular tachycardia (VT) patients, 69% had a peripartum anaesthetic intervention, 43%
Cardiac Cardiac ablation therapy and ICD insertion of which were performed by an anaesthetist ≥ST6 with a
intervention prior implantable cardioverter complication rate of 16%. Of those attending AAC, 67% had
to pregnancy defibrillator (ICD) insertion an anaesthetic intervention, 41% of which were performed by a
Mode of delivery Elective caesarean section Urgent LSCS for ≥ST6 with a complication rate of 17%. Of those patients not
(LSCS) for breech foetal distress attending AAC, 71% had an anaesthetic intervention and 36%
Anaesthesia and General anaesthesia, with Labour epidural of these were performed by ≥ST6 with a complication rate of
analgesia bilateral transversus analgesia, followed by 14%.
abdominal plane blocks top up for LSCS
Table 1. Incidence of complications by grade of anaesthetist
Maternal length of Three days Four days
stay Group ≥ST6 <ST6 p value (Fisher's Exact)
Neonatal APGAR 8 and 10 9 and 10 All 9.1% 20.7% 0.440
scores AAC 16.7% 17.6% 0.945
Discussion: The main implications of ARVC in parturients No AAC 0% 21.4% 0.273
include fatal arrhythmias, heart failure worsened by Discussion: This audit shows a significant number of obese
physiological changes of pregnancy and sudden adult death parturients were not seen in our AAC. A proportion of these
syndrome.1 Both our patients had VT diagnosed after 24 hour were referred, but did not attend however 27% were not
Holter monitoring, and an ICD was implanted in addition to referred. Despite this, there was no significant difference in the
beta blocker medical therapy to control the symptoms of VT as requirement for anaesthetic intervention or the incidence of
well as to prevent sudden death. The patients were seen in the anaesthesia-related complications between attenders and non-
joint cardiac, obstetric and anaesthesia antenatal clinic and a attenders. The incidence of senior anaesthetic involvement in
peri-partum plan formulated to facilitate safe delivery. Both care has risen from 34% to 41% but there is still room for
had serial echocardiograms, serum electrolytes monitored, improvement. This highlights the resource difficulties faced in
invasive blood pressure monitoring and ICD deactivated providing 24 hour senior anaesthetic cover. The on-call rota at
during their LSCS. Our case series highlights that both general our unit is staffed by junior and senior anaesthetists. The
and regional anaesthesia can be safely provided and we absence of a senior anaesthetist did not lead to a significant
recommend a multidisciplinary approach with close co- rise in anaesthesia-related complications, although there was a
operation between anaesthetists, cardiologists and t rend toward this (Table 1).
obstetricians to provide optimum care of these patients. References
Reference 1. Centre for Maternal and Child Enquiries & Royal College of
Obstetricians and Gynaecologists Joint Guideline. Management of
1. Alexoudis AK, Spyridonidou AG, Vogiatzaki TD, Iatrou CA.
Anaesthetic implications of arrhythmogenic right ventricular women with obesity in pregnancy. London: CMACE & RCOG; 2010
dysplasia/cardiomyopathy. Anaesthesia 2009; 64: 73-8. 2. Fulton L, Evans E, Schroeder F, Wendler R. Antenatal anaesthetic
assessment of morbidly obese women - a useful resource? 2013,
http://epostersonline.s3.amazonaws.com/oaa2013/oaa2013.0690195
.NORMAL.pdf
Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin) P11
P121 Anaesthetic management of the labouring patient with P122 Anesthetic implications  of heart disease in pregnancy
multiple sclerosis S Francés,  S Manrique,  M Goya,  M García,  R Perera,  N
J Li Wan Po,  K Maclennan   Montferrer  
Anaesthesia, St Mary's Hospital, Manchester, UK Anaesthetics, Vall d'Hebron University Hospital, Barcelona,
Introduction: Multiple Sclerosis (MS), an autoimmune Spain
inflammatory disease affecting the central nervous system, is Introduction: Despite advances in its diagnosis and treatment,
estimated to affect 20,000 or more UK women of childbearing heart disease (HD) in pregnancy remains a major cause of non-
age1. Controversy exists regarding the management of obstetric maternal and neonatal mortality and morbidity (it
anaesthesia and analgesia in labouring parturients with MS. complicates around 1-3% of pregnancies in developed
Following analysis of our practice at St Mary's Hospital, a countries). Accurate multidisciplinary assessment and
tertiary referral obstetric unit with over 8500 deliveries per management of individual maternal and fetal risks in pregnant
annum, and recent evidence in the literature; our women with HD provides the best opportunity to substantially
recommendations for the peri-partum management of improve outcomes for mother and baby. (1).
parturients with MS are presented. Methods: We present a prospective cohort study that
Methods: Interrogation of the St Mary's Hospital antenatal analyzed outcomes in women with HD, the majority of whom
clinic database, from 1999 to 2012, identified 21 pregnant had had corrective surgery and delivery between 2007 and
women diagnosed with MS. We reviewed antenatal advice, 2013. Baseline characteristics and adverse events during
intrapartum management and postpartum complications. delivery and postpartum were assessed. Intensive monitoring
Results: Over 50% of patients were nulliparous. The majority of the delivery and postpartum were planned beforehand in all
had mild sensory or motor deficit. Three relapsed during cases.
pregnancy, one improved in symptoms and one relapsed Results: One hundred and seventy-four patients with 179
postpartum. There were twelve normal vaginal deliveries, two pregnancies were included in the study. 127 women (72,98%)
instrumental deliveries, six Caesarean sections and one presented congenital heart disease (CHD), 47 acquired heart
unspecified delivered at another hospital. Five women opted disease (27,02%): 27 acquired rheumatic valve disease
for epidural analgesia, two were topped up for operative (19,98%), one Marfan syndrome (0,54%), 3 coronary heart
delivery. Five had spinal anaesthesia with 0.5% heavy disease (1,6%) and 9 primary myocardial disease (4,9%).
bupivacaine and one had a general anaesthetic. There were no
Pregnancy complications were presented in 21, 2% of CHD,
complications following regional technique.
14,8% of acquired rheumatic valve disease and 100% of
Discussion: A recent national survey reported that within a 10 women with arrhythmias.
year period, 91% of anaesthetists have encountered <ten
The type of delivery was vaginal in 124 women ( 72,1%) and
cases of MS2 and have little experience in their management
cesarean section in 50 women (27,9%).
during pregnancy. Recent evidence available supports our
168 women had analgesia during delivery (93,8%); 5 women,
current management of MS patients undergoing labour. The
general anesthesia (2,79%), 6 women, local anesthesia (3,35%)
low incidence of the disease makes it difficult to attain
and 87,5% of women had regional analgesia.
significant figures to determine the optimal management plan.
To standardize care, we made the following recommendations Delivery complications were 7% (uterine atony 2,7%, vaginal
based on the latest evidence and our own experience: hematoma 2,2%, chorioamnionitis 0,5%, cesarean hematoma
- Patients to be reviewed in an antenatal anaesthetic clinic. 0,5% and hemoperitoneum 0,5%). The only anesthesia
Document disease severity and discuss analgesia and complication was one dural puncture (0.5%). No maternal
anaesthetic options. death, one fetal death (0.5%) and one neonatal death (0.5%).
The maternal average hospital stay was 3 days.
- Use of 0.1% bupivacaine with 2mcg/ml fentanyl mixture for
epidural labour analgesia2 . For an operative intervention, top Discussion: Pregnancy and delivery are associated with
up with a higher concentration of local anaesthetic. substantial physiological changes, which require the
adaptation of the cardiovascular system and can expose
- Regional rather than general anaesthetic for caesarean
women with HD to significant risks. If regional anesthesia is
sections. Spinal anaesthesia is the most simple and reliable
selected, the addition of an opioid, when dosing any neuraxial
technique although consider combined spinal-epidural on an
anesthetic, will reduce the amount of local anesthetic required
individual basis.
and subsequent hemodynamic effects, while improve
- If a general anaesthetic is necessary, avoid suxamethonium
intraoperative and postoperative analgesia. The avoidance of
and monitor neuromuscular block to titrate dose of non-
epinephrine from the epidural dose will eliminate the possible
depolarizing muscle relaxant3.
deleterious effects of systemic epinephrine. Maintaining
These recommendations will be available for clinicians on the uterine blood flow is important for fetal well-being.
trust intranet and a patient information leaflet on the effects of Maintaining systemic vascular resistance in patients with
pregnancy and anaesthesia on MS has been produced. intravascular shunting, is important to avoid inducing or
exacerbating pre-existing cyanosis due to increased right- to –
References
left shunting. Cautious intravenous hydration and gentle
1. Brookings W, Lee M. Management of multiple sclerosis during
titration of phenylephrine or ephedrine are options to
pregnancy. Prog Neurol Psychiatry. 2009; 3(6): 9-11
counteract the hemodynamic effects of surgical neuraxial block
2. Drake E, Drake M, Bird J, Russell R. Obstetric regional blocks for
women with multiple sclerosis: a survey of UK experience. Int J (1,2). We observed a predominance of neuraxial anaesthetic
Obstet Anaesth. 2006; 15(2): 115-23 techniques, increased caesarean and operative delivery rates,
3. Griffiths S, Durbridge JA. Anaesthetic implications of neurological and favourable maternal and neonatal outcomes.
disease in pregnancy. Contin Educ Anaesth Crit Care Pain. 2011; 11
(5): 157-61 References
P12 Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin)
P123 Angle of tilt achieved with automated operating table P124 Antenatal anaesthetic information given to women
in elective caesarean sections: a comparison with tilt with obesity
achieved with an inflatable balloon wedge  C R Thomas,  C Busby  
PN Nair,  L Dyal,  B Grewal,  I Suri   Anaesthetics, Airedale General Hospital, Keighley, UK
Department of Anaesthesia, Warwick Hospital, Warwick, UK Introduction:Antenatal obesity is defined as a BMI of ≥30at
Introduction: A previous study1 done on patients undergoing booking. Its prevalence in England increased from 7% in 1990
elective caesarean sections looked into measuring the angle of to 16% in 2007.1Women with a BMI ≥40 are often provided
tilt of the operating table with an inflatable balloon wedge. with anaesthetic information antenatally. Those with lower
This showed that the visual estimation of angle proved levels of obesity also have an increased anaesthetic risk but
accurate in the achievement of near 150 tilt. Here we present these women may receive little or no information about this
the results of a similar study using a different technique of during pregnancy. 2The RCoA have produced standards
automated table tilt instead of the inflatable balloon wedge regarding care for these women: 90% of patients with a
device. The premise being is our visual actuation of tilt angle booking BMI ≥ 30 should receive a leaflet containing
accurate. information about anaesthesia and analgesia. 90% of patients
Methods: The study was similar to the previous one. We with a booking BMI ≥40 should have an anaesthetic consult.
prospectively selected 26 patients at random who were Booking BMI should be documented in 100% of maternity
undergoing elective lower segment caesarean section under hand-held notes. An audit of the above standards was carried
spinal anaesthesia over a six week period. Ethical committee out as summarised below.
approval was obtained. Verbal consent was obtained from all Methods:A list of all deliveries in January 2013 was generated.
participants and the booking Body Mass Index (BMI) was Notes were reviewed for adherance to the above three
noted. We used the same protractor device for measuring the standards. Change to practice was recommended based on
angle of tilt. This is similar to the one used by Kinsella et al2. audit findings. Following the implementation of change, the
Results: The measured angles ranged from 10 to 18 degrees, a audit cycle was completed by auditing notes of all deliveries in
mean angle of 13.70 with a mean difference of -1.3 and standard November 2013.
deviation of 2.32. This compared very closely to the angles Results:
between 10 to 17.5 degrees, mean angle of 13.650, mean Table: Recording of booking BMI, patient count by raised
difference of -1.35 and a standard deviation of 2.06 in the BMI category and number given anaesthetic information.
previous study. BMIs ranged from 19 to 37 with a mean of 24.
Discussion: The visual estimation of angle using the
BMI 30 - BMI 35 - BMI
automated table tilt proved accurate in achieving the near 150 No
Number of Unavailable 34.9; 39.9; ≥40; 
tilt and is comparable with that obtained with the inflatable   booking
deliveries casenotes info info info
balloon wedge device in the previous study. The standard BMI
given given given
deviation of 2.32 indicates that 95.4% of cases could achieve
Jan 195 6 2 20; 0 7; 1 7; 7
within 4.60 of the required 150 tilt i.e. 10.4 to 19.6 degrees tilt.
Nov 173 3 2 17; 2 7; 7 3; 3
The automated table tilt provides an easy and accurate means
of providing left lateral tilt in pregnant patients. Discussion: Booking BMI was recorded in 99% of the notes in
both audit cycles. In 100% of cases where BMI was ≥40, a
consultant anaesthetist discussed risk and made a plan with
References
the patient. However, the audit of January deliveries indicates
1. Grewal B, Suri I. Is visual actuation a valid predictor of angle of tilt?
that few women who have a BMI 30-39.9 receive anaesthetic
Int J Obstet Anaesth Vol 18 2009; pS1-64- supplement
information.; this occurred in only one case. Reaching this
2. Kinsella SM. A device for measuring the degree of lateral pelvic tilt
during supine recumbency. Anesth Analg 1995; 80: 204-5 population to provide information is difficult especially where
BMI is 30-34.9 as all antenatal care for this group may be
provided by community midwives. In collaboration with
Obstetrics, a patient information leaflet was written which
included both obstetric and anaesthetic information. The
leaflet was approved by the Women's Integrated Governance
group and has been in use since October 2013. It is available
on the Trust intranet which is accessible by some community
midwives. The leaflet is given to all those with a BMI ≥ 35
when they attend obstetric high risk clinic. The results of the
November audit indicate improvement has been made; 44.4%
of those with obesity now receive anaesthetic information.
Greater access to the leaflet is needed however.
References
1. Royal College of Anaesthetists 2012,
http://www.rcoa.ac.uk/document-store/audit-recipe-book-3rd-edition-
2012
2. Centre for Maternal and Child Enquiries 2010, http://www.oaa-
anaes.ac.uk/assets/_managed/editor/
File/CMACE/CMACE_Obesity_Report_2010_Final%20for%
20printing.pdf
Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin) P13
P125 Antenatal management of morbidly obese parturients: P126 Audit of temperature for patients undergoing elective
A multicentre evaluation. caesarean section
H Aladin,  A Khandhia,  K Pottinger   N J Truman,  I Clegg,  K Maclennan  
Anaesthetics, Good Hope Hospital, Birmingham, UK anaethetics, St Mary's Womens Hospital, Manchester, UK
Introduction: Women with a body mass index (BMI) of ≥30 Introduction: Perioperative Hypothermia is associated with
kg/m2 at the time of antenatal booking are classed as being poor outcomes and adverse events for patients; including
obese in pregnancy, accounting for around 39,000 maternities surgical site infection increased length of stay, blood loss,
per year1. Obesity is associated with increased risk of shivering, increased anaesthetic recovery time and cardiac
anaesthetic morbidity and mortality. National guidance have events. Risk factors for the occurrence of hypothermia include
been developed following the Confidential Enquiry into regional anaesthesia, fluid deprivation, blood loss, and cold
Maternal and Child Health report concerning obesity in fluid administration, all of which are common to obstetric
pregnancy. At two different hospitals, five indicators of best patients. 2008 Nice guidelines CG651 on perioperative
practice2 were analysed: (1) Recording of maternal BMI. (2) hypothermia do not include parturients, despite being an at
BMI ≥ 30 women receive information about risk group. An audit performed in 2011 at St Mary's Hospital
anaesthesia/analgesia. (3) Women with a BMI ≥ 40 have demonstrated that 92.5% of elective section patients were not
antenatal anaesthetic review. (4) Duty anaesthetist should be 'comfortably warm' on arrival in recovery, with 65% defined as
informed when women with a BMI ≥ 40 are admitted. (5) hypothermic. A repeat audit was performed following
Anaesthesia for women with a BMI ≥ 40 should be provided commencement of a trial of an air free conductive fabric patient
by a senior anaesthetist. warming system (Hot Dog®).

Methods: Women who had undergone a lower segment Method: A prospective audit of elective caesarean section
caesarean section (LSCS) during a 6 month period (Jan 2013- patients was conducted from April-June 2013 at St Mary's
Jun 2013) at a District General Hospital (DGH) and a Hospital. Theatre staff completed the audit proforma. Data
Foundation Hospital (FH) were evaluated. Data was collected collected included; ambient theatre temperature (ideal target
retrospectively from an electronic data archive and anaesthetic 21ºC), anaesthetic type, estimated blood loss (EBL),
charts. Evidence of BMI calculations, provision of temperature pre, intra, post operative and prior to discharge
anaesthesia/analgesia information, ante-natal anaesthetic from recovery (measured using a tympanic membrane
appointments, and anaesthetic care in the labour ward and thermometer) and details of which Hot Dog® warming
theatre were identified. products were used. Hypothermia was defined as a core
Results: 309 women who underwent a LSCS were identified temperature <36ºC with desirable temperature being defined as
with a having a BMI 30 (median 34, range 30-59). 51% of 36.5-37.5ºC. Comparison of the results from the 2011 audit
these were elective cases. 56% of women with a BMI ≥30 enabled conclusions to be drawn regarding the effectiveness
received anaesthesia/analgesia information, of which 2 were of the warming product.

given literature on anaesthesia in obesity. 32% of women with
Results: A total of 33 patients were audited who underwent
a BMI 40 underwent an antenatal anaesthetic review, with an
elective caesarean section, [n=79, 2011audit], 94% had spinal
additional 4 women failing to attend their appointments. In
anaesthetic (87%, 2011 audit). Mean (S.D) theatre temp was
those women with a BMI ≥40, the duty anaesthetist was
22.8 (± 0.6) [22.3 (± 0.6), 2011 audit], mean duration of
informed of admission in 19% of cases and in 56% of LSCS,
procedure was 51 minutes. 94% of patients had an additional
the anaesthetic care was provided by an appropriately graded
fluid warmer intra-op (72%, 2011 audit). The mean EBL was 574
anaesthetist .
ml (± 213) [653 (± 431), 2011 audit] and only 6% of patients had
Table: Women with BMI 30 having anaesthetic care at a DGH an EBL over 1L (20% 2011 audit). Only 12% (n=4 of 33) of
and FH. patients warmed with the HotDog® were hypothermic on
arrival to recovery (compared to 65% (n=51 of 79), 2011 audit)
  DGH FH
figure 1.
Total LSCS 32% (99/309) 68% (210/309)
Discussion: efforts have been to reduce perioperative
BMI Median (range) 33 (30-59) 34 (30-52)
hypothermia in elective caesarean sections. Almost all patients
Maternal height, weight + BMI recorded 100% 100%
received warmed fluids via a 3M™ Ranger™ fluid warming
Conclusion: This audit has identified that more than half the
system. Forced air warming devices applied to the upper body
women with a BMI ≥30 received analgesia/anaesthesia
are not well tolerated by our awake patient population and
information and more than half were anaesthetised by a senior
allow only a limited area to be heated. introduction of
anaesthetist. However, in all the areas of practice, the target
HotDog® with an under patient warming mattress and
percentage of women meeting the identified standards were
separate over patient warming blanket (for upper and lower
not achieved. Recommendations included revision of the
limb) proved to be of benefit in perioperative maintenance
referral guidelines for antenatal anaesthetic assessment,
when compared to our standard warming measures. A
improved communication within the multidisciplinary team
HotDog® warming mattress placed on the patient chair in the
during admissions and increased presence of senior
pre theatre waiting area helped prevent hypothermia pre arrival
anaesthetists on delivery suite.
in theatre.
References
Reference
1. Centre for Maternal and Child Enquiries (CMACE). Maternal
1. CG 65 Management of inadvertent perioperative hypothermia in
obesity in the UK: Findings from a national project. London:
adults. NICE April 2008.
CMACE, 2010
2. The Royal College of Anaesthetists. Raising the Standard. A
compendium of audit recipes for continuous quality improvement in
anaesthesia. 3rd Edition 2012
P14 Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin)
P127 Availability of chlorhexidine handwash for regional P128 Caesarean section in a rhesus null parturient with a
analgesia on the labour ward uterine fibroid
K Chima,  T Strickland,  F Plaat   P J Stewart,  R Laird,  J Cartmill  
Anaesthetics , Queen Charlotte's and Chelsea Hospital, Anaesthetics, Altnagelvin Area Hospital, Londonderry, UK
London, UK Introduction: The anaesthetic management of a Caesarean
Introduction: Many patients request regional analgesia during section is made more challenging by the combination of pre-
labour and therefore central neuraxial blocks are performed in operative anaemia, a large uterine fibroid and the presence of a
the delivery room. For central neuraxial blocks an aseptic very rare blood group Rhesus null.
technique should be standard. In the Third National Audit Case report: A forty-year lady with a past medical history of
Project of the Royal College of Anaesthetists the incidence of psoriatic arthritis presented to antenatal booking at 10 weeks
iatrogenic infection was reported as being 8/707 000 gestation. Booking investigations revealed a haemoglobin of
procedures1. However the consequence of any infection is 10.3g/dL, and a blood group O Rhesus null. Her 20-week
potentially devastating, and a 'scrupulous' aseptic technique ultrasound scan revealed no foetal anomalies but did
was therefore stated to be mandatory in the report1. demonstrate an anterior uterine fibroid. This was confirmed
Chlorhexidene gluconate 4% is used for hand decontamination with magnetic resonance imaging which showed a
in our department. It was noticed that not all delivery rooms heterogeneous mass measuring 188x139x159mm, in keeping
were equipped with both chlorhexidene and a hands free with a degenerating fibroid. At 21+3 days she presented with
method for application. dizziness and right upper quadrant pain. Her haemoglobin
Methods: All delivery rooms on labour ward were inspected to level was 7.6g/dL and she was treated for iron deficiency
ascertain the presence of chlorhexidene and a hands free anaemia. Due to a transverse lie and the large fibroid an
dispenser. elective Caesarean section at 38 weeks was planned. As a team
we anticipated a difficult Caesarean delivery with greater blood
The audit was repeated after one and twelve months to assess
loss in a patient with anaemia and a very rare blood group.
if there had been any improvement in the service.
Antenatal management focused on maximising the patient's
Results: Originally, 12 of the 16 delivery rooms had
haemoglobin levels and sourcing compatible blood. The
chlorhexidene available (75%). Of the 12 rooms with
Northern Ireland blood transfusion service and National frozen
chlorhexidene only three were equipped with a hands free
red cell bank in Liverpool secured two units of packed red cells
dispenser (25%), and five containers were uncovered (42%).
in England. Unfortunately, one week prior to the section this
After one month all 16 rooms were equipped with wall blood was issued in an emergency, making it unavailable to us.
mounted chlorhexidene with a hands free dispenser (100%). A new donor was found in South Africa and a further unit was
After a further 12 months it was found that 12 of the 14 secured in Brazil. Both units were couriered to our hospital
delivery rooms had chlorhexidene available (86%). (Two of the prior to the Caesarean delivery which was performed at 38+6
rooms had been converted to a post delivery high dependency days under spinal anaesthesia. Pre-operative haemoglobin was
unit). Eleven of the 12 containers were equipped with a hands 9.1g/dL. The patient was discharged home on day three post-
free dispenser (92%). operatively and her haemoglobin was 7.2g/dl on discharge. No
Discussion: The results of the initial data collected, as well as blood transfusion was required.
anaesthetists' concerns regarding the unavailability of Discussion: Red blood cells from people who have the Rhesus
chlorhexidine and dispensers in each room, was reported to null phenotype lack Rhesus proteins, and thus, Rhesus
managerial staff, who ensured all rooms were adequately antigens. This phenotype occurs in approximately 1 in 6x106
stocked. Results were therefore better when re-auditing was individuals1. When these patients are transfused they may
performed at one month. However, after 12 months standards form antibodies to high frequency rhesus antigens, which can
had declined, although they were still improved from the make it extremely difficult to process compatible blood. Rhesus
initital audit. This decline could be attributed to the fact that null blood is available from the National frozen cell bank,
neither a team nor a named individual was made responsible however it may not be available when required due to limited
for sustaining the initial improvement, which if introduced, we supplies, as in our case. There is very limited literature
feel would encourage a sense of ownership and enable the regarding the management of the rhesus null parturient and
improvement in this area of patient safety to be sustained. our management was guided by our regional Haematology
Reference unit. This case demonstrates the importance of good
communication with all members of the multi-disciplinary team
1. National Audit of Major Complications of Central Neuraxial Block
in the United Kingdom 2009, http://rcoa.ac.uk/system/files/CSQ- and the detailed preparations required in a complex case.
NAP3-Full_1.pdf
Reference
1. Avent ND, Reid, ME. The Rh blood system: a review. Blood 2000
95: 375-387.
Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin) P15
P129 Category one caesarean sections in a district general P130 Comparison of two non-invasive cardiac output
hospital:  Improving the decision to delivery time monitoring devices in a parturient with complex
VK Wroe,  AM Troy   cardiac disease.
Department of Anaesthesia, Countess of Chester Hospital, PJ Rose,  V Misra,  S Quasim  
Chester, UK Anaesthesia, UHCW, Coventry, UK
Introduction: National Guidelines state that the interval from Introduction: The management of valvular lesions during
decision to delivery (DDI) in a category one caesarean section pregnancy and labour can present a clinical conundrum. We
should be less than 30 minutes1, and that a duty anaesthetist present the use of two cardiac output (CO) monitoring devices
should be immediately available for emergency work on the in a parturient with complex valvular heart disease undergoing
delivery suite 24 hours a day2. a caesarean section under epidural anaesthesia.
A 2008 departmental audit found that 85% of category one Case Report: A 37 year old primiparous woman with history of
sections had a DDI of under 30 minutes, a figure marginally ASD repair aged 4, severe mitral regurgitation, severe tricuspid
under the audit standard of 90%. Anaesthetic service regurgitation, moderate aortic stenosis (AS) secondary to a
provision in our trust was expanded in July 2012, with the congenital bicuspid valve and moderate pulmonary
addition of a dedicated obstetric anaesthetist 24 hours a day. hypertension presented for elective caesarean section.
This re-audit aimed to assess the proportion of category one Echocardiography showed moderately dilated right ventricle
caesarean sections with a DDI <30 minutes and analyse the with good bi-ventricular systolic function, bi-atrial dilatation,
factors contributing to any delay. moderate to severe AS (mean gradient 34mmHg, peak gradient
Methods: After audit department approval, a retrospective 53mmHg, estimated valve area 0.74cm2). Pulmonary artery
analysis of category one caesarean sections between August pressures were estimated at 42-47mmHg. LiDCO rapid and
and December 2012 was performed. Data collected included Cheetah NICOM devices were used to monitor CO.
DDI and reason for delay, indication for section, type of Anaesthesia was established with 32mL 2% lignocaine and 100
anaesthesia and cord pHs. micrograms of epinephrine via epidural. Compound sodium
lactate was infused at 60mL/hr, and increased to 100mL/hr after
Results: 69 category one caesarean sections were analysed.
epidural anaesthesia. Fluid boluses of 200mL and 100mL were
The mean DDI was 23 minutes (range 3-120 minutes). 84% had
delivered via the pump at 13 and 28 minutes after delivery of a
a DDI of under 30 minutes, with a mean time from decision to
live infant. Metaraminol infusion was titrated to effect.
effective anaesthesia of 14.5 minutes. The indication for
Syntocinon infusion was started upon delivery (20 units in
caesarean section was abnormal CTG in 87% of cases (2008:
48mL 0.9% saline) at 15mL/hr and tapered post-operatively
77%). General anaesthesia was performed in 43% (2008: 85%),
over 4 hours. Mean arterial pressure was maintained at 91 to
spinal anaesthesia in 55% (2008: 15%) and extension of
97mmHg until delivery (78 minutes) and then decreased to
epidural blockade in 2%. In 11 cases, DDI was over 30
67mmHg at the end of surgery. Cardiac output was maintained
minutes; these cases were all performed under spinal
throughout surgery with an increase at the time of concurrent
anaesthesia. The following table shows the reasons identified
fall in MAP. Fluid challenge had negligible effect although
that contributed to delay:
there was a small reduction in heart rate (84 to 59bpm).

Arrival in
Discussion: NICE has advocated the use of cardiac output
theatre Incision to
Spinal monitoring in high risk non-obstetric surgery to improve
10 delivery Staff Theatre
  placement outcome.1 In this case we utilised both a non-calibrated pulse-
minutes time 10 unavailable unavailable
10 minutes contour waveform analysis and bioreactance system to
from minutes
compare both values measured and response to fluid
decision
challenge. Although the values produced were different, the
Number
trends were broadly similar. This, once again, highlights the
of 4 6 1 1 1
importance of analysing trends rather than absolute values to
patients
guide management. Interestingly, both devices demonstrated
Arterial cord blood analysis was carried out in 10/11 cases. pH
that a fall in MAP correlated with an increase in cardiac
was less than 7.2 in 30%, and base excess was less than -8 in
output, similar to previous investigators.3 Given that cardiac
20%.
disease is the leading cause of death in the most recent
Conclusion: The proportion of cases with a DDI of over 30 triennialreport2, monitoring cardiac output enables one to
minutes has remained constant at around 15%, despite an maintain physiological homeostasis, and ultimately aids
improvement in anaesthetic staffing. Our results suggest that clinical decision-making leading to good clinical outcome, as in
the causes for this delay are multifactorial, and the results are our case.
not benign- the delay in delivery led to a cord pH of <7.2 in
References
almost one third of cases. We intend to improve our practice
1. MTG3 CardioQ-ODM (oesophageal Doppler monitor): guidance
by regular practice drills, use of preprepared spinal packs to
2011, http://www.nice.org/nicemedia/live/13312/52624/52624.pdf
reduce spinal placement time, clear procedures to follow in the
2. Centre for Maternal and Child Enquires (CMACE). Saving Mothers'
case of staff or theatre unavailability and reaudit. Lives: Reviewing maternal deaths to make motherhood safer: 2006-
2008. The Eighth Report of the Confidential Enquires into
References
Maternal Deaths in the United Kingdom. BJOG 2011;118(Suppl
1. Caesarean section. NICE Clinical Guideline 132. NICE, London 1):1-203
2011. (http://publications.nice.org.uk/caesarean-section-cg-132).
3. Fanning NP, Sermer M, Colman J, Carvalho JC, Cordovani D. Non-
2. OAA/AAGBI guidelines for obstetric anaesthetic services- 3rd invasive Hemodynamic monitoring with bioreactance for cesarean
edition. AAGBI and OAA, London, 2012 delivery. A more relaxed look at tight aortic stenosis? Abstract
(http://www.aagbi.org/publication/publication-guidelines/M/R) SOAP 2011, http://www.soap.org/display_2011_abstract.php?id=58
P16 Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin)
P131 Comparsion of slow and rapid bolus of ephedrine in P132 Continuous spinal anaesthesia for a primigravida with
patients undergoing planned caesarean section under severe tricuspid regurgitation, Harrington rods and
spinal anaestheisa WITHDRAWN FROM  thrombocytopenia.
PRESENTATION AM Walton,  I Mettam  
PG Sekar,  LB Ellakumanan,  H Balachander,  MVS Obstetric Anaesthetic Department, University Hospital
Satyaprakash   Southampton, Southampton, UK
Anaesthesiology, JIPMER, Puducherry, India Introduction: We present the successful use of continuous
spinal anaesthesia (CSA) for caesarean delivery in a parturient
with severe tricuspid regurgitation and pregnancy-induced
thrombocytopenia in addition to Harrington rod placement for
scoliosis spinal surgery.
Case history: A 40 year old primigravida presented at 37
weeks gestation. She had undergone a tricuspid valve repair
previously for endocarditis. The patient had developed severe
tricuspid regurgitation and had heart failure. Harrington rods
were placed in her thoracic and lumbar spine for repair of a
congenital scoliosis. Blood tests revealed a pregnancy related
thrombocytopenia with platelets of 85x109/L. An
echocardiogram showed a severly dilated right atrium with
intra-atrial septal bowing to the left, severe free flowing
regurgitation and right ventricular systolic pressure
32mmHg.The case was discussed with obstetricians,
anaesthetists and cardiologists and a decision was made for
an elective caesarean section under CSA, if the final platelet
count remained stable. The patient expressed a preference to
remain awake and avoid a general anaesthetic. At surgery a
cannula and radial arterial line were inserted. In the sitting
position a 22G spinal needle was inserted below the level of
the scar tissue at L3/4, and a spinal catheter threaded into the
subarachnoid space. A total of 10mg bupivacaine and 250mcg
diamorphine were required over 20 minutes to establish a block
to T4. The blood pressure dropped from 135/70 to 90/50mmHg
and required only 5mcg of epinephrine to return to baseline
values. Blood loss was 720mls. Syntocinon was given as an
infusion only. A live male infant was delivered.
Discussion: An obstetric anaesthetist has to take many
factors into account when deciding on the best choice of
anaesthetic for a particular case; anaesthetic expertise,
maternal co-morbidities, fetal well-being and maternal
preferences all play a part. Cardiac disease in pregnancy is still
the leading cause of indirect maternal mortality in the UK.1 The
choice of anaesthetic and delivery had to ensure the least
amount of strain on an already compromised heart. The
advantages of CSA are that a block can be established
gradually with small incremental doses of local anaesthetic,
which reduces the likelihood of cardiovascular instability.2
The concerns with a CSA are principally neurological
complications and post-dural puncture headache. CSA is
proving an option to be considered for patients with
significant cardiac disease and previous spinal surgery
provided the anaesthetist has experience with the technique.
In this case it provided a cardiovascularly stable anaesthetic
with excellent analgesia and maximal maternal satisfaction.
References
1. Saving mothers lives.The Eighth Report of the Confidential
Enquires into Maternal Deaths in the UK. March 2011
2. DennyNM, Selender DE. Continuous spinal anaesthesia. Br J
Anaesth 1998;81:590-7
Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin) P17
P133 Does pre-operative anxiety predict post-operative pain P134 Early epidural analgesia may increase caesarean
scores in parturients undergoing caesarean section? section rate in spontaneously  labouring nulliparous 
BM Daly,  N Weidenhammer,  R Junkin,  L Riddell,  J Dolan,  J women: a retrospective study
Kinsella*,  R Marla,  S Young   R Anil Kumar,  Roger Mc Morrow  
Anaesthesia, Princess Royal Maternity, Glasgow, UK, Anaesthesia, National Maternity Hospital , Dublin, Ireland
*Anaesthesia, Pain & Critical Care Medicine, University of Introduction:.Epidural analgesia offers the most effective
Glasgow, Glasgow, UK method of intra-artum pain relief. The effect of epidural
Introduction: Pregnancy, childbirth, and undergoing a surgical analgesia on the progression of labour and the mode is often
procedure are all likely to induce anxiety. The relationship debated in multiple studies. This study aims to show the effect
between anxiety, pain and pregnancy is complex.1Childbirth is of timing of epidural analgesia on the mode of delivery.
a time of high anxiety, and Caesarean section is known to be Method: Data such as women's age, gestational age, cervical
associated with significant pain post-op. Here we ask can dilatation before epidural insertion and duration of labour was
anxiety scoring predict post LSCS pain? collected from a total of 2029 nulliparous women in
Methods: After ethical approval and consent, pre-operative spontaneous labour. Epidural analgesic was defined as early at
data and a single 24hr post-op 10cm VAS were collected from a cervical dilatation of 3cms or less and late at a cervical
108 women, with 9 having missing data. Spielberger2 State and dilatation of 4 or more cm
Trait anxiety forms were completed prior to surgery. We Results: Of the 2029 women, 1423 ( 70.1%) received epidural
present secondary end points powered post hoc for 0.8 analgesia. Out of the 2029 women, 1403 ( 69.2%) had
probability of 2cm VAS difference. A standardised anaesthetic spontenous vaginal delivery, 478 (23.6%) had assisted
(spinal including diamorphine) and analgesic regime was used. delivery and 146 ( 7.2%) had caeserean section.
The cohort was divided into "high"- above the mean and
The data was anaylsed according to the timing of epidural
"low"- below the mean anxiety and compared using Student's
analgesia or no epidural analgesia and modes of delivery.
t-test.
Anaesthetic Delivery method
Results:
intervention Spontaneous Assisted Caesarean
Table 1: State anxiety compared to VAS
No epidural 537 (88.9%) 51 (8.4%) 16(2.6%) 604
Low anxiety High anxiety Early epidural 757 (62.2%) 379 126 (10.0%) 1262
  Significance
(n=45) (n=54) (30.0%)
24 hr VAS mean Late epidural 109 (67.7) 48 (29.8%) 4(2.5%) 161
5.0 (2.2) 5.3 (2.0) P= 0.40
(SD) cm
Epidural Assisted delivery C-Section
Table 2: Trait anxiety compared to VAS analgesia OR 95% CI p-value OR 95% CI p-value
Low anxiety High anxiety Early 5.27 3.86, 7.21 <0.001 5.59 3.28, 9.51 <0.001
  Significance
(n=48) (n=55) epidural
24hr VAS mean (SD) Late 4.64 2.97,7.23 <0.001 1.23 0.40,3.76 0.71
4.8 (1.9) 5.5 (2.2) P= 0.15
cm epidural
Table 3: State +Trait anxiety compared to VAS Conclusion: The results from the study show that the
Low anxiety High anxiety likelihood of having caeserean section in the early epidural
  Significance
(n=48) (n=51) group is significantly higher compared to the late epidural
24hr VAS mean (SD) group, but the incidence of assisted delivery between the early
cm 4.8 (1.9) 5.6 (2.1) P=0.072 and late epidural group were similar. This study also shows
that there is an increased likelihood of having assisted
Discussion: While the higher anxiety groups displayed a delivery and caeserean section delivery with epidural
higher mean VAS in all the analysis, this was not statistically analgesia compared to without from the study group.
significant. The separation between the two groups was better
References
with the State than the Trait anxiety score and best of all when
1..Gonen Ohel. Early versus late initiation of epidural analgesia in
the two scores were combined. Further reasearch could look at
labour: Does it increasethe risk of cesarean section. A randomised
anxiety scoring as part of a bundle of other measures verus trial. American journal of Obstretrics and Gynaecology (2006) 194,
pain. 600-5
2. Wassen et al. Early versus late epidural analgesia and risk of
References
instrumental delivery in nulliparous women: a systemic review.
1..Waldenstrom U: Experience of labor and birth in 1111 women. J British Journal of Obstretrics and Gynaecology (2010) 1471, 655-
Psychosom Res.1999: 47(5):471-82 661
2..www.mindgarden.com
P18 Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin)
P135 Efficacy of midwife led epidural top ups in labour–Are P136 Emergency obstetric and neonatal care in Kenya:
programmable pumps really the way forward? Addressing millennium development goals
E Traer,  G Waters,  GNB Jackson   D B Pachter,  C A Ameh*  
Anaesthetic department, Royal Berkshire NHS Trust, Anaesthesia, Cumberland Infirmary, Carlisle, UK, *Maternal
Reading, UK and Neonatal Health, Liverpool School of Tropical
Introduction: There are an increasing number of automated Medicine, Liverpool, UK
techniques by which labour epidurals can be managed1,2,3,4. Introduction: In 2008, an estimated 358,000 women died from
Comparison reports of programmable epidural pumps regimens complications of pregnancy and childbirth. The overwhelming
have shown lower total volumes of local anaesthetic may be burden of this mortality occurs in the developing world, with
associated with reduced rates of instrumental delivery and almost 60% of deaths occurring in sub saharan Africa.1There
improved maternal satisfaction1,2. Extended intervals between are also some 3.6 million neonatal deaths each year, and once
boluses with larger volume boluses was shown to use less again the developing world is disproportionately represented.2
total local anaesthetic3. These reports have led us to In 2006, the Liverpool School of Tropical Medicine (LSTM)
investigate similar outcomes our unit where we have a midwife developed a training package entitled "Life Saving Skills,
led top up (MLTU) practice. Emergency Obstetric and Neonatal Care" (LSS EOC-NCC) to
Method: First epidural bolus administered by the anaesthetist try and address these huge public health issues. Courses now
of 20ml 0.1% bupivicaine+2µg/ml fentanyl . Data recorded at run in 11 countries worldwide. In October 2013, I was fortunate
each subsequent midwife administered bolus (MLTU): bolus e nough to teach on a course in Nyeri, Kenya.
interval time, motor block (Bromage score of 2-4 taken as motor Methods: A variety of teaching methods were used on the
block), any change to the standard dose 20ml 0.1% course. Didactic lecture based teaching had a limited role, with
bupivicaine+2µg/ml fentanyl and if analgesia was effective or more emphasis placed on small group "break out sessions"
ineffective. and scenario based teaching. Pre and post course simulation
Results: 50 patients audited based testing was undertaken, with results collated and sent
back to Liverpool for analysis and assessment of efficacy of
Midwife led epidural Top Up Data  
teaching.
Mean bolus interval time (min) 105 (sd 26)
Mean rate bupivicaine mg/hr 10.56 (sd 3.6) Results: Participant feedback suggested a high level of
Motor block (Bromage score 2-4) 11/48 (22.9%) satisfaction with the course. The impact of courses in terms of
Mean time to motor block (min) 237 (sd 135) reduction in maternal and neonatal mortality remains the
NVD 14/48 (29.1%) subject of ongoing scrutiny. One study from Somaliland
Instrumental 18/48 (37.5%) demonstrated improved knowledge and skills and evidence of
LSCS 16/48 (33.3%) positive behaviour change post introduction of the course.3

Satisfaction excellent/good 46/48 (95%)
Conclusions: Maternal morbidity and mortality remains a huge
Discussion: In this study we found the mean interval in problem in Kenya. In 2008 it's Maternal Mortality Ratio was
minutes between epidural boluses to be 105minutes. This is 488 per 100,000, one of the highest in the world.4Great efforts
greater than the average 60minute interval of the are being made by the Kenyan government to reduce this. An
programmable intermittent bolus(PIB) regimens. An average ambitious target to reduce MMR to 91 per 100,000 by 2018 has
rate of bupivicaine 10.56mg/hr was similar to that reported with been set. One step has been the introduction of the Liverpool
PIB and patient controlled epidural bolus(PCEA) regimens4, LSS EOC-NCC course.
while we report a lower rate of motor block. Given the practice Acknowledgements: I would like to thank the maternal and
of MLTU in effect is much like a PIB without PCEA, it is neonatal health unit at LSTM for the opportunity to become
notable that the time between epidural boluses is longer with involved, and look forward to teaching on my next course. I
MLTU with less maternal motor block and high maternal would also recommend the course to any obstetric
satisfaction. We feel our practice promotes close epidural anaesthetists with an interest in international health.
assessment as the midwives assess motor block and maternal
References
satisfaction before each “top-up” and avoids the cost of the
1. World Health Organization, UNICEF, UNFPA and The World
PIB/PCEA pumps.
Bank. Trends in Maternal Mortality 1990-2008. 2010.
References 2. Lawn JE, Kerber K, Enweronu-Laryea C, et al. 3.6 million neonatal
deaths–what is progressing and what is not? Seminars in
1. Capogna G Camorica M, Stirparo S, Farcomeni A. Programmed Perinatology 2010;34:371–386.
Intermittent Epidural Bolus Versus Continuous Epidural Infusion for
Labor Analgesia: The Effects on Maternal Motor Function and 3. Ameh C, Adegoke A, Hofman J, et al. The impact of emergency
obstetric care training in Somaliland, Somalia. International Journal
Labor Outcome. A Randomized Double-Blind Study in Nulliparous
of Gynecology & Obstetrics. 2012;117:283-7.
WomenAnesth Analg July Oct 2011; 113(4): 826-831
4. Kenya National Bureau of Statistics. Kenya Demographic and
2. George RB, Allen T, Habib A. Intermittent Epidural Bolus
Health Survey (KDHS) 2008-09. June 2010.
Compared with Continuous Epidural Infusion for Labour Analgesia:
A Systematic Review and Meta Analysis. Anesth Analg Jan 2013;
Vol 116: 133-144
3. Wong C, MacCarthy RJ, Hewlett Bl. The effect of manipulation of
the programmed intermittent bolus time interval and injection
volume on total drug use for labour epidural analgesia: a randomized
controlled trial. Anest Analg 2011; 112: 904-11
4. Husain T, Mavridou I, Fernando R, El-Wahab N, Stewart A, Dick J,
Columb M. A study of a programmed intermittent bolus and patient-
controlled epidural regimen for labour analgesia. Int J Obstet
Anaesth May 2013: P85 Abstracts OAA Bournemouth 2013
Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin) P19
P137 Enhanced recovery after elective caesarean section: P138 Epidural analgesia in obese parturients: can kneeling
Service evaluation and quality improvement be the answer to our prayers.
GJ Lilley,  M Adamson,  A Miskin*,  M Turner   S De Silva,  L Kelliher*,  R Mottaleb*,  E Combeer  
Anaesthetics, Royal Gwent Hospital, Newport, UK, Anaesthetics, Frimley Park Hospital, Frimley, UK,
*Obstetrics and gynaecology, Royal Gwent Hospital, *Anaesthetics, Royal Surrey County Hospital, Guildford, UK
Newport, UK Severe pain is not life-threatening in healthy parturient women,
Introduction: Enhanced recovery (ER), a concept widely it is however shown to have neuropsychological
recognised within many surgical specialties, is now a subject consequences. Postnatal depression may be more common
of interest within obstetrics. The core principles comprise when effective analgesia is not used1 and pain during labour
speeding up recovery and improving patient outcomes, with has been linked with the development of post-traumatic stress
associated benefits for staff and healthcare systems1. The disorder2.There is an increasing number of obese parturients3
most logical starting point for the introduction of ER principles and identification and placement of the epidural can be
are elective caesarean section lists. Delayed surgery may lead difficult in these women.
to prolonged fasting, followed by delayed mobilization, Classically the sitting or the lateral position is used during
delayed removal of catheter and delayed discharge. A pilot siting of labour epidurals. The kneeling position was first
audit in our hospital demonstrated a mean stay after elective described in 19934, where 34/35 women had their labour
caesarean section of 3.6 days, and mean preoperative fasting epidural sited whilst in the kneeling position and 88.5% of the
period of 12.4 hours. Current guidance for ER in obstetrics mothers were happy with this position.
suggests minimal interruption to oral intake, pre-operative
I elected to try the kneeling position in an obese lady with a
energy drinks, catheter removal at 12 hours post-surgery
BMI 50 after adjustments in the sitting position and two
regardless of time of day, and the option of discharge home 24
separate failed attempts to confidently palpate the lumbar
hours after caesarean section where appropriate2.
spine. Once the lady was in the kneeling position, the lumbar
Methods: All elective caesarean sections were included in this spine was not only palpable but also visible and the epidural
service evaluation after introduction of preoperative space was identified with ease. With Departmental approval I
carbohydrate drinks. Data collection included fasting time, in performed my labour epidurals in this manner and found it not
addition to time to mobilization, to catheter removal and to only to be easy to site epidurals but also tolerated well. Some
discharge. After an initial 6 week period of data collection, the women complained of paraesthesia in their feet, but this was
data was presented to anaesthetic and obstetric staff. Posters, rare and eased swiftly. We decided to survey our Deanery to
a discharge proforma and a patient information leaflet were ascertain what positions were being utilised.
produced, and specific guidance was developed regarding
Survey: An e-survey was sent to trainees and Consultants in
preoperative carbohydrate drinks. A further 6 weeks of data
the South West London Deanery into what their ideal first and
collection then took place.
second choice positions used for siting epidurals would be for
Results: A total of 78 consecutive patients were included, all labouring parturients. We then posed the same question for
of whom received a regional anaesthetic technique for elective obese parturients (BMI 40). They were asked if they had
caesarean section. The following table illustrates the timing of heard of the kneeling position and if anyone had tried it. For
pre- and post-operative events before and after our those who had not, we questioned why they had not tried it.
interventions.
Results: We received 53 responses, 96.2% of whom were
Time period / hour 2nd 6 week Initial 6 week
trainees. 64.2% chose to position the parturient sitting as their
mean(SD) period period
first choice and 60.4% chose lateral as their second choice in
Pre-op fasting 4.8 (2.8) 3.8 (2.5)
non-obese parturients. In comparison 84.9% opted for the
Post-op fasting 4.2 (3.5) 3.4 (3.5)
sitting position in obese parturients with 56.9% using the
Total interruption to oral
9.0 (4.5) 7.1 (4.6) lateral as their second choice. The only positions utilised were
intake
sitting and lateral. 94.9% of respondents had not heard of the
Delivery to mobilization 10.2 (4.5) 9.0 (3.3)
kneeling position to site labour epidurals.
Delivery to catheter removal 14.8 (6.6) 13.5 (3.5)
Conclusion: Each position used for the placement of labour
Delivery to discharge 67.3 (40.1) 63.3 (27.6)
epidurals has their own advantages and disadvantages. With
Discussion: The introduction of patient information leaflet
the rising incidence of maternal obesity and its associated
offering guidance regarding post-operative oral intake,
risks to not only the mother but also the unborn child, we need
mobilization, catheter removal and early discharge, along with
to be continuing in our development and advancement in the
staff education and introduction of pre-operative carbohydrate
provision of good care. We suggest that the kneeling position
drinks, has resulted in improvement in the timing of a number
is a safe and viable alternative for siting epidural catheters in
of peri-operative interventions, and a small reduction in
labouring parturients.
duration of hospital admission. However, possibly due to
References
obstetric, midwifery, paediatric and organisational reasons,
discharge is rarely achieved at the potential target of 24 hours 1. Hiltunen P, Raudaskoski T, Ebeling H, Moilanen I Does pain relief
during delivery decrease the risk of postnatal depression? Acta
after elective caesarean section. Obstet Gynecol Scand 2004;83:257-261
References 2. Soet JE, Brack GA, Dilorio C Prevalence and predictors of women's
1. Lucas DN, Gough KL. Enhanced recovery in obstetrics - a new experience of psychological trauma during childbirth. Birth
frontier? Int J Obstet Anaesth 2013; 22: 92-95 2003;30:36-46
2. Enhanced recovery partnership: A better journey for patients and a 3. Centre for Maternal and Child Enquiries (CMACE). Saving
better deal for the NHS. Available at: Mothers'. Lives: reviewing maternal deaths to make motherhood
http://www.improvement.nhs.uk/documents/er_better_journey.pdf safer: 2006–2008. The Eighth Report of the Confidential Enquiries
into Maternal Deaths in the United Kingdom. BJOG 2011;118:1-203
P20 Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin)
P139 Epidural labour analgesia and risk of instrumental P140 Estimation of blood loss during caesarean sections -
delivery discrepancy between visual and laboratory estimation
R Carvalho,  T Ferreira,  M Duque,  D Catré,  I Guedes,  J P A Nowicka,  A Amasakera,  C Ferdinand,  I Suri  
Assunção   Anaesthesia, Warwick Hospital, South Warwickshire NHS
Anaesthesiology, Centro Hospitalar Tondela Viseu EPE, Foundatio, Warwick, UK

Viseu, Portugal
Introduction: Excessive blood loss is a major threat to women
Introduction: Epidural analgesia (EA) is a worldwide effective undergoing casearean sections. Accurate visual estimation of
method used for pain relief during labour. Nevertheless, its use blood loss is difficult due to dispersion of blood lost and the
and evolution to instrumental vaginal (forceps or vacuum blood being mixed with amniotic fluid(1). Therefore the blood
extraction) or operative deliveries remains controversial loss often gets under or overestimated(2). A number of
between experts,1 either anesthesiologists or obstetricians. methods exist to estimate the blood loss, the commonly used
We aimed to analyze the relation between EA and instrumental being: visual estimation by the attending staff, weighing of the
v aginal deliveries in a sample of our obstetric population. blood soaked surgical swabs and calculation based on the pre-
and post-operative haemoglobin concentrations(3). The aim of
Methods: A retrospective study included all pregnant women
this audit was to compare the visually estimated blood loss by
who delivered on our labour Room, between 1-January-2011
both the surgeons (vEBLs) and anaesthetists (vEBLa) against
and 31-December-2012, excluding those who underwent
the calculated estimated blood loss (cEBL).
caesarean section. We reviewed the data of demographical
characteristics, type of gestation and labour, the use of EA Methods: Data was collected on thirty five caesarean sections.
and the newborn APGAR score. Descriptive analysis of Operating surgeona and anaesthetists were asked to visually
variables was used to summarize data and Chi-Square test was estimate the blood loss in each case. The circulating blood
used. Multivariate analysis was done with logistic regression, volume was calculated for each patient based on the body
with calculation of corrected Odds Ratio (OR) and its 95% weight and height. Then, the blood loss during caesarean
confidence interval (95% CI). section was calculated using the circulating blood volume and
the pre- and post-operative haemoglobin concentrations.
Results: 2901 pregnant women were included in this study, Correction was made for the haemodilution by intravenous
with mean age of 29,7 years. 81% underwent EA and 30% fluid administered.
instrumental vaginal delivery. 51% were nulliparous. Applying
Results: Twenty six complete forms were included in the
Chi-Square test to independent variables, we obtained
analysis. None of the patients received blood or blood
significant associations with dystocic delivery for EA, normal
products intraoperatively. Mean volume of intravenous fluid
maternal age (NMA; 20-35 years) and parity (p<0,001).
infused was 1304mL±421. Mean vEBLs, vEBLa and cEBL was
Applying logistic regression to our model, including parity,
590mL±300, 623mL±372 and 821mL±1004 respectively. The
NMA and EA with dystocic deliveries, we obtained corrected
tendency for anaesthetists to give a higher estimate of blood
OR (95%CI) for EA 2,459 (1,884-3,210) and for parity 3,4
loss was not statistically signifficant (p=0,12). There was a
(2,867-4,121), with NMA loosing significance. However, this
clear discrepancy between the visual estimate given by both
result may still be biased by other factors, such as labour
the surgeons and the anaesthetists, ant the cEBL, however, it
stage at the time of the EA beginning, drugs used in epidural
did not reach statistical significance (p=0,11 and p=014
space, use of oxytocin during labour, among others.
respectively). Compared to the cEBL the vEBL was
Additionally we found that, in our population of term
overestimated when the blood loss was low (12 cases) and
pregnancies, NMA and eutocic deliveries, there was no
underestimated when the blood loss was higher than 500mL
significant relation between EA and APGAR score <8 at the
(14 cases). There was a linear relationship between the degree
first minute (p=0,079).
of underestimation and the blood loss, with high levels of
Conclusion: It's generally assent that EA provides the most blood loss being most underestimated.
effective pain relief in labour. However, it's associated to Conclusions: In this audit, the standard procedure for
prolonged labour and risk of instrumental or caesarean estimation of blood (visual estimation by the obstetrician) loss
deliveries.2 Our study has drawn the conclusion that both was found to be unreliable. We demonstrated a tendency of
having EA for labour pain relief and being nulliparous increase anaesthetists and surgeons to overestimate the blood loss, if
the chance of instrumental delivery, respectively in 2,459 and actual blood loss was less than 500mL, and underestimate if
3,43 times, however without significant impact on newborn the blood loss exceeded 500mL. As a result of the audit, it has
APGAR score. Bigger prospective studies correcting for more been made compulsory in our unit to check haemoglobin
risk factors are advised. concentration in recovery whenever the vEBL exceeds
References 1 000mL.
1. BMC Pregnancy and Childbirth 2008, 8:45. References
2. Acta Obstet Gynecol Scand 2002, 8:1033-1039. 1. Khan FA, Khan M, Ali A, Chohan U Estimation of blood loss during
Caesarean section: an audit. J Pak Med Assoc. 2006 Dec;56(12):572-
5.
2. Larsson C, Saltvedt S, Wiklund I, Pahlen S, Andolf E Estimation of
blood loss after cesarean section and vaginal delivery has low
validity with a tendency to exaggeration. Acta Obstet Gynecol
Scand. 2006;85(12):1448-52.
3. Stafford I, Dildy GA, Clark SL, Belfort MA, Visually estimated and
calculated blood loss in vaginal and cesarean delivery. Am J Obstet
Gynecol. 2008 Nov;199(5):519.e1-7
Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin) P21
P141 Ethnic variations in use of labour analgesia P142 Factors associated with the use of spinal anaesthesia
LMD MacDarby,  CMC McCaul   for caesarean section in Nigeria
Delivery Suite, The Rotunda Hospital, Dublin, Ireland C Imarengiaye,  F Asudo*,  A Akinmola†,  B Lawal§  
Introduction; This retrospective cohort study was compiled to Anaesthesiology, University of Benin Teaching Hospital,
establish the wide variety of nationalities presenting to The Benin City, Nigeria, *Anaesthesia, University of Abuja
Rotunda Hospital for delivery during a one month period and Teaching Hospital, Gwagwalada, Nigeria, †Anaesthesia, 
to determine the labour analgesia preferences amongst this National Hospital, Abuja, Nigeria, §Anaesthesia, Lagos 
population. Island Maternity Hospital, Victoria Island, Nigeria

Introduction: There has been a consistent increase in the rate
Methods; Details of all deliveries occurring during the month
of spinal anaesthesia for caesarean section in many hospitals
of October 2013 were collected. Any patients undergoing
worldwide and had been advocated as the preferred technique
elective caesarean section and those with failed inductions
for caesarean delivery.1 Recent evidence suggests increasing
were excluded from the study. A demographic of patients’
use of spinal anaesthesia for caesarean sections in reports
nationality and ethnic background was compiled. Data relating
from a teaching hospital.2 The rise in spinal anaesthesia
to these patients’ use of labour analgesia was recorded i.e.
caesarean section notwithstanding, it is pertinent to determine
epidural uptake, pethidine administration and remifentanil
the factors limiting the wholesome application of spinal
infusion use. We then established the frequency of use of
anaesthesia for caesarean section in Nigeria.
each of these methods of analgesia in each population

Methods: A snap-shot survey was conducted in some
Results; There were 767 deliveries in Oct 2013. 104 elective
selected hospitals in Nigeria. The survey determined the
caesarean sections were carried out and there were 8 patients
sociodemographic characteristics of patients, indication for
who failed induction.
surgery, grade of anaesthesia provider, contraindication to
Therefore a total of 655 patients laboured during this time. spinal anaesthesia and any other factor that may be noticed in
This number was made up by 50 different nationalities. Of the selected hospital. The survey was to be conducted over a
these 414 patients were Irish, the majority being white but 2-week period but was truncated by the nation-wide strike
including small numbers of Asian or Black background. action by doctors after 9 days.
Amongst the Irish patients the rate of epidural uptake was
Results: A total of 99 patients were attended to in 4 of the
43.47% (234) and the rate of pethidine use was 17.87% (74)
selected 6 hospitals within the study period. 36/99 women
Patients of other white background, including many eastern
were nulliparous and maternal factors (82/99) were the leading
european countries made up 134 of the patients. These
indications for caesarean section. Consultant anaesthetists
patients as a group had a 52.98% epidural uptake rate. Black
(23/99), Senior Registrars (35/99), Medical Officers (36/99) and
Africans were found to have a 39.13% (9) uptake rate and
others (5/99) provided anaesthesia for the caesarean sections.
those of Asian background had the highest rate at 54.83%
85/99 patients received spinal anaesthesia and 14/99 had
(17). The use of pethidine was significantly lower than the rate
general anaesthesia for the c-section. Fetal indication for
of epidural in all of these groups. Pethidine was used by
caesarean section had a 3-fold risk of general anaesthesia for
18.19% of Black Africans, 12.9% of Asians and 23.13% in
the surgery (p = 0.037, RR = 3.1, 95%CI 1.2 – 8). 25/99 and
those of other white backgrounds. There were only 3 cases of
74/99 were performed as elective or emergency procedure.
remifentanil use during the month
Nature of caesarean section was not a factor for the use of
Discussion; The highest incidence of epidural uptake during spinal anaesthesia (p =0.51, RR = 2.0, 95%CI = 0.5).
Oct was found to be amongst the Asian population, the lowest Discussion: Over 85% of caesarean sections in Nigeria were
being amongst Black Africans. Pethidine use was less than conducted under spinal anaesthesia. Fetal indications for
25% in all groups. The reasons for these trends is unknown caesarean section provoked a 3-fold increase in general
though previous studies have suggested that cultural and anaesthesia for caesarean section. The use of general
educational factors may play a part. anaesthesia for caesarean delivery was due to fetal indications
A prospective survey of patients post delivery detailing the for surgery, antepartum haemorrhage and failed spinal
reasons for their choices of labour analgesia would be anaesthesia. Improved practical conduct of the spinal
worthwhile. Establishing the factors influencing their technique may enhance great application of spinal anaesthesia
decisions may allow us to provide an unbiased and fully for caesarean section.
comprehensive service to ensure patient satisfaction. References

1..Morgan BM, Magni V, Goroszenuik T. Anaesthesia for emergency
caesarenc section. BrJ Obstet Gynaecol 1990; 97: 420-424
2..Amadasun FE, Idehen HO, Edomwonyi NP. Evolving pattern of
anaesthesia for caesarean section: Experience at the university of
Benin Teaching Hospital West Afr J Med 2013; 32: 196-9
P22 Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin)
P143 Failed intubation for a category 1 caesarean section in P144 Fasting dilemmas: A rare case of a patient with non-
a patient with undiagnosed spina bifida ketotic hyperglycinaemia presenting for caesarean
CR Deane,  E Lewis,  J Spargo   section
Department of Anaesthetics, Singleton Hospital, Swansea, M Behravesh,  S Dawson,  G McClune,  S Atkinson  
UK Anaesthetics, Royal Jubilee Maternity Hospital, Belfast, UK
Introduction: Non-ketotic hyperglycinaemia (NKH) is a rare
Introduction: Spina Bifida Occulta (SBO) is part of a spectrum
autosomal recessive metabolic disease caused by a defect in
of neural tube defects and is common. We present the case of
the glycine cleavage system. This case report describes the
a patient with previously undiagnosed SBO who required a
management of a patient who presented for caesarean section.
category 1 caesarean section (CS). Despite an unremarkable
To our knowledge there are no other published case reports of
airway assessment she had a failed intubation on rapid
this type.
sequence induction (RSI) and subsequently required an awake
fibre optic intubation (AFOI). Case Report: A 32 year old Para 1 presented for elective
caesarean section of twins at 37 weeks gestation. She had a
Case report: A 37 year old para 0 patient presented to labour
history of atypical non-ketotic hyperglycinaemia. Following
ward labouring with a single live foetus at 37 weeks gestation.
advice from clinical chemistry, during her 6 hours preoperative
She was admitted under consultant obstetric care with
fast she received an inceased dose of sodium benzoate and an
asymptomatic hypertension. When considering an epidural
intravenous infusion of 10% dextrose at 3mls/kg/hour which
she was examined and had a vascular naevus, associated with
was continued perioperatively. Caesarean section was
skin tethering, over lumbar vertebrae. She was asymptomatic,
performed under spinal anaesthesia and twin baby boys were
had never been investigated, and had no definitive diagnosis
delivered successfully. Post delivery of the second twin she
of SBO. Airway assessment included a Mallampatti score of 3,
received a bolus of 5 units of syntocinon followed by an
but was otherwise unremarkable. An epidural was declined to
infusion at 10 units per hour. Due to uterine atony and an
the patient, with a remifentanil PCA provided instead. A plan
operative blood loss of 1000mls she also received ergometrine
was agreed for a RSI GA if operative intervention was
carboprost intramuscularly to good effect. Sodium benzoate
required. Several hours later she required a category 1 CS.
was administered orally in recovery and the 10% dextrose
Initial laryngoscopy with a Mackintosh blade yielded a
infusion was continued until the patient was establised on an
Cormack and Lehane grade 3 view. Manipulation of the cricoid
oral regimen prescribed by the dieticians. This involved a
cartilage, long and McCoy blades did not improve the view.
series of high calorie drinks up to every 2 hours for 48 hours.
Two failed attempts were made to intubate using a bougie. The
No dietary protein was allowed for 24 hours post delivery.
patient was ventilated using a face mask and a Guedel airway
Glycine levels were monitored daily and were raised on day 5
with oxygen saturations above 97% throughout. She was
while dietary protien was being gradually reintroduced.
woken up without further incident and an AFOI was
performed. Her child was delivered by LSCS without further Discussion: NKH has an incidence of 1 in 60,000 with 3
incident or obvious deficit. The APGAR scores were 8 and 10 distinct presentations. Classically neonates present with
at one and five minutes. A grade 3 view was confirmed before lethergy, hypotonia and seizures. These symptoms can
the patient was woken. Recovery from anaesthesia was proceed to apnoea requiring ventilation and 30% of patients
uneventful. The patient was appropriately counselled. An do not survive the neonatal period. Severe psychomotor
Airway Alert Letter was issued and follow up appointment retardation is common in those who survive. A second,
made. An MRI was carried out subsequently and showed a atypical and very rare form presents with mild baseline
neural arch defect and dural tethering. Significantly the conus hyperglycinaemia and intermittent encephalopathy
lay as low as L4 with diastematomyelia as far as L2. assosciated with periods of illness. Transient neonatal
hyperglycinaemia has also been described. Biochemically,
Discussion: SBO is common and without prior imaging
NKH is characterized by elevated glycine concentrations in
presents the clinician with a difficult decision. Regional
plasma, CSF, and brain with a CSF glycine to plasma glycine
techniques risk neural or dural injury due to a low lying or
ratio greater than 0.08.1 Standard treatment strategies include
tethered cord.1 Abnormal spread of the analgesic agents may
protein restriction to reduce exogenous glycine,
give rise to either excessive cranial spread or inadequate
supplementation of one-carbon pool donors and
caudal spread. This patient population provides further issues
administration of sodium benzoate. NMDA antagonists have
for the anaesthetist given the high risk of operative delivery or
been shown to raise the developmental quotient, improve
other intervention (due to pelvic structural abnormalities) and
muscle tone and reduce seizures in these patients.2
the association of spina bifida with difficult intubation.2,3
Patients with spina bifida require careful preop assessment Prolonged periods of fasting predispose these patients to
and MRI imaging and careful airway consideration is essential glycine build up and its toxic neurological effects. This has
in order to inform anaesthetic planning. major implications for the anaesthetist in the perioperative
period. This case demonstrates the safe use of regional
References
anaesthesia in conjunction with careful nutritional planning.
1. Reynolds F. Damage to the conus medullaris following spinal
anaesthesia. Anaesthesia 2001; 56: 235-247. References
2. Richmond D, Zaharierski I, Bond A. Management of pregnancy in 1. Chang YT, Lin WD, Chin ZN et al. Nonketotic hyperglycinemia: A
mothers with spina bifida. Eur J Obstet Gynecol Reprod Biol 1987; case report and brief review. Biomedicine 2012; 2(2):80-82
25: 341-5. 2. Van Hove JL, Vande Kerckhove K, Hennermann JB et al. Benzoate
3. May A, Fombon F, Francis S. UK registry of high-risk obstetric treatment and the glycine index in nonketotic hyperglycinaemia.
anaesthesia: report on neurological disease. Int J Obstet Anaesth Journal of Inherited Metabolic Diseases. 2005;28:651–663
2008; 17: 31-6.
Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin) P23
P145 Fetal bradycardia following regional anaesthesia for P146 Further increase in hysterectomy rates - and the
emergency caesarean section and instrumental reason why
delivery: a service evaluation JS Campbell,  M Molloy,  C Thompson,  D Fogarty  
JK Sidana,  K Jadhav-Smith,  J Corfe   Royal-Jubilee Maternity Service, Belfast HSC Trust, Belfast,
Anaesthetics, Norfolk and Norwich University Hospital, UK
Norwich, UK Introduction: RJMS is the tertiary obstetric service for
Introduction: Fetal heart rate abnormalities, such as late Northern Ireland. As part of a service review of use of uterine
decelerations or fetal bradycardia, are known to occur after artery balloon catheters, we retrieved data from several
neuraxial anaesthesia.1 These may be due to maternal sources. We found a large proportion of these patients still
sympathetic blockade or an increase in the uterine tone caused required hysterectomy. Further interrogation of our data
by intrathecal opioids. The objective of this service evaluation showed some unexpected trends.
was to evaluate the incidence and management of fetal Methods: With approval of the Trust's Data Guardian we used
bradycardia following regional anaesthesia for emergency data from several hospital systems, including a local maternity
caesarean section and instrumental deliveries. care database and histology records.
Methods: 15 patients with an episode of fetal bradycardia Results: We found 30 hysterectomies from 37,088 deliveries in
following regional anaesthesia were identified by reviewing 6 years. This is a rate of 0.8 per 1000 - significantly higher than
the daily obstetric handover sheets from January to December our prior rates which was near the NICE-quoted rate of up to 3
2011. The medical notes of these patients were reviewed for per 1000. Of these cases, 23 (76%) were due to morbidly
peripartum obstetric management, cardiotocographic (CTG) adherent placenta.
findings, perioperative anaesthetic management and
Not all these cases of morbidly adherent placenta were
management of fetal bradycardia. Neonatal outcome was
diagnosed antenatally, which perhaps made hysterectomy
assessed by APGAR scores, umbilical cord gases and NICU.
more likely since facilities such as intra-arterial balloon
Results: 10 patients had an assisted delivery and 5 had an catheters could not be available to us in an emergency.
emergency category-2 LSCS. The peripartum CTG findings Unanticipated cases suffered greater blood loss. Despite no
were either suspicious or pathological. Timing of fetal diagnosis, the majority (16/23) were placenta percreta on
bradycardia following regional anaesthesia ranged from 2 to 15 histology. These percreta cases again had greater blood loss,
min. 13 patients received spinal anaesthesia and 2 received and were more likely to require ICU care post-operatively. Yet
epidural top up. Maternal haemodynamics stability was there were no cases of percreta in the 6 years prior, and less
maintained with left uterine displacement, intravenous fluids than half the number of hysterectomies in that period. This
and phenylephrine infusion. One patient had an episode of seems to be a dangerous and dramatic change in recent years.
maternal bradycardia below 50 beats/min which was treated
Conclusion: We found a recent and significant increase in
with anticholinergics. Comparing the baseline maternal heart
peripartum hysterectomy, associated with a large increase in
rate with the lowest perioperative heart rate, 3 patients had a
the number and degree of morbidly adherent placenta. Patients
greater than 40% drop in the heart rate. 5 patients had a blood
with placenta percreta had a greater blood loss, and more
pressure drop of more than 20% below the baseline, which was
commonly required hysterectomy and ICU care.
treated with phenylephrine. The highest level of block to
Reference
temperature was T3. Syntocinon was stopped in all but one
case in the event of fetal bradycardia. Significant delays 1. National Institute for Health and Clinical Excellence. Caesarean
section: NICE Clinical Guideline 132 2012,
occurred in transferring these patients to theatre after the
http://www.nice.org.uk/nicemedia/live/13620/57163/57163.pdf
decision for surgical intervention were taken, maximum 35 min
(median 17 min). 6 cases had poor neonatal outcomes with low
5 minute APGAR and abnormal cord gases.
Discussion: We could not find any direct cause which can be
solely attributed to regional anaesthesia for the occurrence of
fetal bradycardia in these patients. Significant delay in patient
transfer to theatre may have a causal relationship but cannot
be confirmed. Studies in elective patients have shown that
maternal bradycardia causes a drop in maternal cardiac output.
2 Relative maternal bradycardia occurred in several of our
cases and this would have led to drop in cardiac output and
therefore oxygen delivery. This is most likely a side effect of
phenylephrine use. We plan to introduce a care bundle to
implement pre-operative and intra-operative fetal resuscitation.
This will include steps to improve fetal condition at the time of
regional anaesthesia and to ensure adequate maternal cardiac
output and oxygen delivery.
References
1. Reynolds F, Seed PT. Anaesthesia for Caesarean section and
neonatal acid-base status: a meta-analysis. Anaesthesia 2005; 60:
636–653
2. Stewart A, Fernando R et al. The dose-dependent effects of
phenylephrine for elective caesarean delivery under spinal
anaesthesia. Anesthesia & Analgesia 2010; 111: 1230-7.
P24 Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin)
P147 Impact of workload on accidental dural puncture P148 Implantable cardioverter defibrillator in
(ADP) rate pregnancy WITHDRAWN FROM PRESENTATION
W Mon,  YM Liu,  A Stewart,  R Fernando,  M Columb*   S Chaudhari,  S Quasim  
Anaesthetics, University College London Hospital, London, Anaesthetic Department, University Hospital Coventry and
UK, *Intensive Care Unit, University Hospital of South Warwickshire , Coventry, UK
Manchester, Manchester, UK
Introduction: Post dural puncture headache is an important
cause of morbidity. We audit our ADP rates annually against
the national standard.1Between 2005 and 2008, our ADP rate
was stable at approximately 0.5%. However, from 2008 to 2010,
our rate rose to above the 1% national standard.1Therefore, we
audited factors that may have contributed to this increase.
Methods: Information for this audit was obtained from a
computerised database. Data collection included day, month
and time of ADP and the grade of anaesthetist. We also
collected annual data of number of deliveries, epidurals and
combined spinal epidurals (CSEs) for labour, caesarean section
(CS) data, and the proportion of single shot spinals (SSS) to
CSEs performed. Data were analysed using chi-square
multinomial and trend tests with P value <0.05 defined as
significant.
Results: There was a 40% increase in deliveries between 2008-
2010. CSs and regional blocks for analgesia increased by 36%
and 40% respectively. Although the ADP rate increased, we
could not demonstrate a statistically significant trend due to
small numbers. From 2010 to 2012, a non-significant fall in the
ADP rate was seen. There was no significant association
between ADPs and day, month or time. We did see a
significant non-linear trend (P = 0.0012) in the proportions of
SSSs to CSEs performed, with the peak occurring in 2010.
Table 1. Trend of activity and ADP rate from 2008 to 2012
  2008 2009 2010 2011 2012 P value
Maternities (n) 4032 5039 5647 5841 5953 < 0.0001
Epidurals for labour (n) 1306 1600 1839 2029 2132 < 0.0001
CSs (n) 1370 1562 1861 1862 1773 < 0.0001
SSSs for CS (n) 282 274 356 326 347 0.0015
CSEs for CS (n) 797 644 714 833 915 < 0.0001
Proportion of SSS to CSE (%) 26 30 33 28 27 0.0012
ADP rate (%) 0.57 0.98 1.05 1.01 0.82 0.31
Discussion: We observed an increase in ADPs until 2010, with
significant rises in deliveries and anaesthetic procedures
performed. The significant non-linear trend in the proportions
of SSSs to CSEs performed for CSs peaked in 2010. A fall in the
ADP rate between 2010-2012, occurred despite exposing more
women to the risk of ADP, as during this time we performed
significantly more CSEs than SSSs proportionally. We believe
that the rise in the ADP rate resulted from a significant
increase in our workload between 2008 and 2010, without any
increase in anaesthetic staffing. From 2010 onwards, daytime
anaesthetic consultant sessions increased by 50%, and there
was a higher presence on the labour ward out of hours by
senior registrars covering non-obstetric theatres. Both factors
may have contributed to the subsequent fall in the ADP rate.
This audit supports the recent OAA/AAGBI guideline
recommending increased anaesthetic staffing on labour ward.2
References
1. Royal College of Anaesthetists. Epidural analgesia during labour.
Raising the standard: a compendium of audit recipes. 2012;218-219
2. Association of Anaesthetists of Great Britain and Ireland and
Obstetric Anaesthetists' Association. OAA/AAGBI guidelines for
obstetric anaesthetic services. 2013
Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin) P25
P149 Inadvertent hypothermia during elective caesarean P150 Inter professional relationships on labour ward- how
sections well do anaesthetists and midwives get along?
S Botros,  R Labib,  T Ramhew,  M Baban,  Y Poonawala   M Salman,  P Kumar,  G Graham  
Selwyn Crawford Department of Anaesthesia , Birmingham Anaesthetics, St. Thomas' Hospital, London, UK
Women's Hospital, Birmingham, UK Introduction: Anaesthetists and midwives are part of the
Introduction: The National Institute for Health and Care multi-professional team that provides care for parturients.
Excellence (NICE) defines inadvertent perioperative They work together in close collaboration in the unique and
hypothermia as a core body temperature below 36°C.1 It is a often highly charged environment of labour ward. In such
common complication of regional anaesthesia, and is the settings, effective inter professional relationships are key to
leading cause of perioperative shivering. Hypothermia is the delivery of high quality care and consequently better
associated with increased risk of wound infection and patient outcomes. Successful collaborative practice can be
increased blood loss.1 Shivering can be associated with negatively impacted by barriers such as lack of clarity on the
increased oxygen consumption and hypoxaemia in vulnerable scope of roles of team members, poor communication, or
patients. Although the NICE guideline on the management of stereotyping. We conducted a survey amongst obstetric
perioperative hypothermia did not cover pregnant women,1 it anaesthetists and midwives in our hospital to reflect upon this
has been adopted by many obstetric units. In our unit, working relationship and to see how it may be improved.
intravenous (IV) fluid is not routinely warmed for elective
Methods: A questionnaire was designed and distributed to
caesarean sections (CS). Hence, we audited our practice to
midwives and anaesthetists of all grades. Questions were
evaluate the incidence of hypothermia.
asked on their understanding of each other's professional role
Methods: Over a three month period, we prospectively audited
and on their perception of the quality and effectiveness of
our practice in 47 women who had elective CS under
their working relationship. A total of 43 responses were
subarachnoid anaesthesia without active warming. We
collected (24 anaesthetists and 19 midwives) in an ongoing
measured their tympanic temperature prior to anaesthesia (T )
1 survey.
and at the end of surgery (T ). We also collected data that may
2 Results: Of the anaesthetists who completed the
influence the results like the volume of IV fluid infused,
questionnaire, 16.6% were consultants, 58.3% were ST5-ST7,
estimated blood loss (EBL) and duration of surgery. We also
20.8% were ST3-4 and 4.1% were CT1-2. When asked whether
assessed the incidence of perioperative shivering. We
they felt they understood the scope of responsibilities of
repeated the audit in 42 parturients using an IV fluid warming
midwives on labour ward, only 27% of anaesthetists felt they
device. The data were analysed using Microsoft Excel 2007®.
understood it fully. In contrast, 63% of midwives believed they
Data from both audits were compared and p-values were
fully understood the scope of the anaesthetist's
calculated using unpaired t-test by GraphPad software®.
responsibilities.
Results: In the initial audit, 20 patients (42.55%) were
hypothermic at the end of surgery (T < 36°C). Shivering Thirty percent of midwives felt that collaboration with
2
occurred in 14 patients (29.79%). No correlation was found anaesthetists was 'very easy', in contrast to only 5.5% of
between T and the IV fluid volume, EBL, duration of surgery anaesthetists who felt the same about collaboration with their
1-2
or the dose of intrathecal Bupivacaine. In the re-audit, only 3 midwife colleagues. While 16% of anaesthetists found this
(7.14%) patients experienced hypothermia. There was no collaboration 'difficult', none of the midwives did (0%).
statistical difference in T between the two audits (p = 0.781). Seventy two percent of anaesthetists felt their input was
1
usually well-received by their midwife colleagues, compared to
  Initial Audit (n=47) Re-audit (n=42) p-value
only 40% of midwives who thought their input was well-
Fluid (ml) 1116.67(±369.43) 1233.33 (±483.59) 0.2236
received by the anaesthetist. Both professions were asked
EBL (ml) 523.75 (±152.33) 582.5 (±491.67) 0.474
how they perceived the general quality of communication
T1 36.84 (±0.37) 36.81 (±0.37) 0.781
between them. The majority of anaesthetists (47%) perceived it
T2 36.08 (±0.4) 36.3 (±0.29) 0.004
as 'fair', while 15% regarded it as 'poor'. Ninety percent of
T 0.76 (±0.34) 0.52 (±0.41) 0.0032
1-2 midwives felt it was either 'very good' or 'good'. None of the
Discussion: Our audit highlights the effect of warm IV fluid midwives (0%) felt it to be 'poor'.
therapy on reducing the incidence of inadvertent perioperative
Questions were asked on the types of obstacles they
hypothermia during elective CS. Our audit recommends the
encountered in their professional interaction with each other.
routine warming of IV fluid during elective CS. The Enhanced
Most anaesthetists (72%) agreed that they found fixation on
Recovery Partnership Programme considers patient warming
tasks and exclusion of others to be a challenge, followed by
as a key factor in accelerating patient recovery.2 Following our
delayed or non-communication of important issues (57%). A
results and as part of developing a new pathway for enhanced
third of the anaesthetists felt they rarely got a comprehensive
recovery post CS; our trust is currently looking to invest in a
handover from the midwife while only 29% of midwives felt
cost-effective IV fluid warming device.
they understood the rationale behind the anaesthetists'
References decisions.
1. NICE (2008) Perioperative hypothermia (inadvertent): full Conclusion: Despite both specialties working in close
guideline (CG65). Full Guideline. London: National Institute for proximity, the survey identified several gaps in
Health and Care Excellence.
communication. Working towards enhancement of the
2. Enhanced Recovery Partnership (2012) Fulfilling the potential: a
professional relationship between members of the team
better journey for patients and a better deal for the NHS. Leicester:
NHS Improvement. Available at http://www.improvement.nhs.uk providing maternity services will help facilitate their
(accessed 14/12/2013) collaboration and will reflect positively on the performance of
both professions.

P26 Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin)
P151 Intra-arterial balloon catheters: A service evaluation P152 Intrathecal diamorphine for cesarian section following
JS Campbell,  M Molloy,  D Fogarty   intramuscular diamorphine during labour: a cause for
Royal-Jubilee Maternity Service, Belfast HSC Trust, Belfast, concern?
UK RC Barr,  L Parks  
Introduction: Intra-arterial balloon catheters have become Anaesthetics and Intensive Care, Southern Health and Care
widely used and predominantly accepted in cases where Trust, Northern Ireland, UK
massive haemorrhage is anticipated, especially with morbidly Introduction: Diamorphine has largely replaced pethidine for
adherent placenta . However, the benefits are still intramuscular (IM) analgesia during labour in our obstetric
1,2
controversial. While our unit is not stand-alone, our building unit. We also routinely give diamorphine (250-300 micrograms)
is physically separated from other departments including intrathecally (IT) for cesarian sections. A recent case of
radiology, so the logistics of balloon catheters are difficult2. meiosis and drowsiness, in a lady presenting for a category 2
Our objective was to identify the impact of balloon catheters cesarian section having received IM diamorphine in labour,
on management of morbidly adherent placenta. Associated highlighted the potential for side effects when diamorphine is
anaesthetic issues include massive transfusion, cell salvage, used IM and then IT. Should we therefore consider adjusting
type of anaesthetic and post-operative care. our IT dose of diamorphine in women presenting for
Methods: With permission of the Trust's Data Guardian, we emergency cesarian sections? To our knowledge there are no
retrieved data from multiple sources to identify and review guidelines on this subject and clinical practice appears
cases where balloon catheters where used. These included variable.
radiology logs, maternity records and histology. Methods: We conducted a survey of all anaesthetists working
Results: Ten cases were identifed via these systems. Seven in the Southern Health and Social Care Trust who partake in
were for morbidly adherent placenta, of which 5 required obstetric anaesthesia. Questions focused on; current
hysterectomy despite balloon inflation. Many of these were diamorphine practice, diamorphine dose adjustments, factors
cases of placenta percreta, despite antenatal diagnosis of influencing our dose decisions and concerns regarding
accreta. However, blood loss was lower by around 20% potential side-effects with IT diamorphine.
(1078ml) using balloons, when compared to other Results: We received 24 replies; 14 consultants and 10
hysterectomies in the same time period. experienced trainees who regularly perform obstetric
Other indications were for intra-abdominal pregnancy and anaesthesia. There was a wide variation in diamorphine
persistent post-partum haemorrhage. Another case was practice amongst our anaesthetists. The majority (76%)
abandoned due to logistical reasons (unable to organise consider reducing their IT dose following IM diamorphine.
theatre time in same building), a decision felt to be open to Factors influencing this dose reduction include timing (88%)
medicolegal criticism after preparation and planning for and dose (29%) of the last IM diamorphine and clinical signs
balloons. of toxicity (76%). In particular anaesthetists were concerned
about postoperative respiratory depression (94%) and
Limitations particularly reflected the limitations and
drowsiness (88%), although no one surveyed reported
inconsistency of the systems used, for example no coding in
experience of these or other adverse effects associated with IT
records for morbidly adherent placenta. Local presentation
diamorphine.
highlighted these problems, which are being taken forward.
Discussion: There is variability regarding the IT diamorphine
Conclusion: Our review, and subsequent MDT discussion,
dose given to women for emergency cesarian section who
has confirmed the place of intra-arterial balloon catheters
have already received IM diamorphine in labour. This practice
within local guidelines for management of morbidly adherent
is based on limited evidence. Given the lack of adverse effects
placenta, and other occasional indications. We had decreased
reported from our survey and evidence from other specialties
blood loss in cases using balloons, but still saw a large
where diamorphine is used in higher doses 1,2,, we see no
proportion requiring hysterectomy.
reason to routinely reduce the IT diamorphine dose unless
References
there are clinical signs of opiate toxicity. Consideration should
1. Beilin Y, Halpern SH. Placenta accreta: successful outcome is all in be given to prolonged postoperative monitoring of all women
the planning. Int J Obstet Anesth. 2013;22:269–271.
who have received both IM and IT diamorphine, especially
2. Sadashivaiah J, Wilson R, Thein A. Role of prophylactic uterine
artery balloon catheters in the management of women with those in whom the interval between IM and IT diamorphine is
suspected placenta accreta. Int J Obstet Anesth. 2011;20:282-287 short or where there are signs of toxicity.
References
1. Fogarty DJ, Milligan KR. Postoperative analgesia following total
hip replacement ; a comparison of intrathecal morphine and
diamorphine. Journal of the Royal Society of Medicine 1995; 88:
70-72
2. Jacobson L, Kokri MS, Pridie AK. Intrathecal diamorphine: a dose-
response study. Annals of the Royal College of Surgeons of England
1989; 71: 289-292
Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin) P27
P153 Introducing self-administration of medication after P154 Is Remifentanil patient controlled analgesia an
caesarean section: a Robert The Bruce story effective alternative to epidural for labour analgesia?
A R Sajayan,  K Ramm,  T Yates,  Y Chikermane   V Betharia,  K Peckitt  
Anaesthesia, Heartlands Hospital, Birmingham, UK Anaesthesia, Stepping Hill Hospital, Stockport, UK
Introduction: We were involved in the introduction of the local Introduction: Remifentanil patient controlled analgesia (PCA)
protocol for self-administration of postoperative medications was introduced for pain relief in labour at our institution in
(SAM) after elective LSCS at a large obstetric unit. In the past, 2007. Since then its demand has steadily increased, gaining
several attempts to implement this have failed.We conducted a favour with midwives and patients due to simplicity of use,
pilot study to identify the obstacles and develop ways to effective analgesia¹ and good safety profile². We have
overcome the same standardised protocols for administration and monitoring of
Methods:A pilot project was conducted to find out the Remifentanil PCA and patient controlled epidural analgesia
obstacles in the process by obtaining feedback from the staff (PCEA) during labour which are strictly adhered to. Aim of our
and patient involved in the care of 10 patients who underwent audit was to assess both Remifentanil PCA and epidural PCEA
elective LSCS over a week’s time. Obstetric, anaesthetic, for labour analgesia and make recommendations for improved
recovery and ward staff were informed beforehand about this care of mothers and infants.
pilot by emails and personal discussion. The patients were Methods: This was a prospectively done, questionnaire based
given information leaflet during preoperative assessment and audit. Data was collected over 2 months from November 2013 -
were informed again on the day of operation. Interested January 2014. We looked at mode of delivery,
patients enrolled in the pilot with due consent. The self- cardiotocographic abnormalities, APGAR scores, maternal
administration pack contained analgesics and enoxparin and cardio-respiratory complications, conversion to alternative
was dispensed by the recovery staff. Exclusions were: methods of analgesia and patient satisfaction.
language barrier, patient refusal, lack of capacity and any co Results: There were 610 deliveries during the 2 months.
morbidities. Feedback was collected from patients and staff Remifentanil PCA was used in 102 (17%) and epidural PCEA in
using the standardized proforma during the postoperative 85 (12.2%) patients for labour analgesia.
visit. Mode of delivery:
Results:Two of the patients felt that on the first day it was
  Normal Assisted LSCS
difficult to use SAM due to mobility restrictions. One patient
Remifentanil PCA 69 (67%) 20 (19.6%) 13 (12.7%)
did not receive SAM pack due to communication problem
Epidural PCEA 29 (34%) 35 (41%) 21 (24.7%)
involving midwives and staff. The remaining seven patients
were satisfied with SAM. The obstacles we identified in the There was a higher incidence of cardiotocographic
pilot and also from the past experience and the way we tackled abnormality in the epidural group (61%) as opposed to
them are as below: Remifentanil group (34%). APGAR scores in both groups were
more than 8 at 5 minutes. None of the patients in either group
Obstacle Strategy
had respiratory depression or cardiovascular instability. Eight
Personal & email reminder
(7.8%) patients converted from Remifentanil to epidural due to
Promotional posters in clinical areas
inadequate analgesia whereas 4 (4.7%) patients in the epidural
Communication Reminder notices in operating room and recovery
group used alternative analgesia (3 switched to Remifentanil
Meeting with stakeholders (doctors, midwives&
and 1 to entonox). Patient satisfaction was similar in both
pharmacist)
groups at 95%.
Involving all staff in guideline preparation
Discussion: From our experience, Remifentanil PCA is a safe
Staff engagement Process simplified and paper work streamlined
and effective method of labour analgesia. We found no
Standardized SAM package and delivery
evidence of worsening cardiotocography or neonatal
Guideline Fully prepared guideline after extensive consultation
outcomes with its use. We also found that patients using
Time Pre-printed forms to increase efficiency and to avoid
Remifentanil have increased rate of vaginal deliveries as
management time delays and work duplication
compared to those on epidural. While epidural analgesia
Discussion: Self-administrationof medications after caesarean remains the gold standard and will be preferable in certain
provides better patient centered care. It improves patient and groups of patients, Remifentanil PCA is certainly an excellent
staff satisfaction, improves clinical efficiency and eases alternative to consider. In our institution its uptake has
staffworkload at hospital and at community level1. It empowers steadily increased to approximately 50 patients per month with
the mother in their own care, potentially reduces length of patients consistently report ing high levels of satisfaction.
stay, and facilitates seamless flow ofcare. Although staff and References
patients liked the concept alike, the process had failedthree
1. Blair JM, Dobson JT, Hill DA, McCracken GR, Fee JP. Patient
times before because of certain obstacles. This pilot helped us controlled analgesia for labour: a comparison of remifentanil with
to highlight the areas we needed to focus on with our new pethidine. Anaesthesia 2005; 60 (1) : 22-7
strategies and the results have been encouraging. After fully 2. Volikas I, Butwick A, Wilkinson C, Pleming A, Nicholson G.
Maternal and neonatal side-effects of remifentanil patient
implementing the project, the uptake is gradually getting better
controlled analgesia in labour. Br J Anaes 2005; 95(4): 504-9
and we continue to audit the outcome.
References
1. Snell P M, Bowden M I, Viira D J, Chilvers J P. An observational
study of self-medication of analgesic drugs after caesarean section.
Int J Obstet Anesth 2002; 11: S29
2. Change management good practice guideline-NHS Direct
P28 Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin)
P155 Is the existing local hospital guideline, 'Management P156 Klippel-Feil syndrome: management of anticipated
of women who decline blood products', being adhered difficult airway for caesarean delivery 
to? TM Price,  MT Qureshi,  ROK Laird  
J Houston,  R Burns   Department of Anaesthesia, Altnagelvin Area Hospital,
Simpson Centre for Reproductive Health, Royal Infirmary of Derry, UK
Edinburgh, Edinburgh, UK Introduction: Klippel-Feil syndrome (KFS) is a rare genetic
Introduction: An estimated 150000 Jehovah's Witnesses disorder affecting around 1 in 40,000 live births and is
(JWs) live in the UK1. JWs may not accept blood product (BP) characterised by the congenital fusion of any two of the
transfusion1, and have up to 130 times increased risk of cervical vertebrae1. In addition to the abnormalities of the
maternal death from major obstetric haemorrhage2. This cervical spine, patients may have thoracolumbar scoliosis,
retrospective case note review aims to establish how closely spina bifida and congenital heart defects. The classical
the hospital guideline, 'Management of women who decline phenotypic presentation is described as low hairline, short
blood products' (the Guideline), has been followed since its neck and limited neck and head movement. These patients can
May 2012 introduction, and to identify areas for improvement. therefore present a considerable challenge to the anaesthetist.
Methods: JWs managed at the Anaesthetic Antenatal Clinic The safest method of providing anaesthesia for operative
(AAC) since the Guideline's introduction were identified, and delivery of a parturient with KFS is controversial. We would
their medical records accessed. Information surrounding like to share our experience in managing four elective
aspects of patient management addressed by the Guideline caesarean deliveries in two parturients using awake oral fibre
was extracted. The findings were then audited against the optic intubation (AOFOI) and general anaesthesia.
Guideline to establish how closely it had been followed. Case Reports: The first patient had KFS Type II with fusion of
Approval was obtained from the Medical School and the cervical vertebrae and underwent elective caesarean deliveries
Regional Research Ethics Service. aged 35 and 37 years old. The second patient had KFS Type
Results: Of the patients referred (N=26), 92.3% were reviewed III with fused cervical vertebrae in conjunction with fusions in
at the AAC, and had management plans created, at 31.0 weeks' the thoracolumbar spine, and underwent elective caesarean
gestation on average (Guideline target: 28.0 weeks). 88.5% deliveries aged 31 and 39 years old. Our patients were both
completed a BP checklist before admission in labour, and pre-assessed by a consultant anaesthetist at a high-risk
96.2% by time of delivery. 7.7% agreed to accept BPs at clinic pregnancy clinic prior to delivery. This allowed time to discuss
and were discharged, so women studied became N=24. BP the anaesthetic options with each patient and plan for elective
refusal of 12.5% was not appropriately recorded in the notes, or emergency delivery. Both patients had the classical
and contrary to the Guideline, serum ferritin was not checked phenotypic features of KFS. Airway assessments revealed
in any woman. During pregnancy, 29.2% were not recorded as Mallampati class 4, thyromental distances less than 6cm and
having taken iron, and Hb was measured in 95.8%. Excluding severely limited neck flexion and extension. The trachea was
elective caesarean sections (CS), Obstetric consultants were not palpable in either patient. We anticipated difficult direct
documented as informed of admission in 13.6% of cases, and laryngoscopy in both patients and elected to manage the
54.5% of labours and deliveries were reviewed or supervised airway with an AOFOI followed by general anaesthesia. The
by senior Obstetric staff (ST6-consultant). 20.8% of total oral route was chosen as both patients had small nares in
deliveries were by CS: cell salvage was set up in 100.0% of keeping with KFS. Sugammadex ensured complete reversal of
these, and used in 80.0%. rocuronium induced neuromuscular blockade and smooth
Discussion: This study found the Guideline was closely emergence. Caesarean delivery and postoperative recovery
followed in some areas: completion of acceptable BP checklists was uneventful in all four cases.
before delivery, and availability and use of cell salvage in CS,
Discussion: As obstetric anaesthetists we are constantly
compare favourably to previous UK studies1,3. Areas to be
trying to minimise the risk to our mothers. Klippel-Feil
improved include that BP refusal must be appropriately
syndrome affects both the airway and the spine, making the
recorded in patient notes to ensure clarity upon presentation
choice of anaesthetic technique a difficult decision. Successful
in labour or an emergency. It is vital that iron supplementation
use of regional techniques including spinal, epidural and
is commenced early in JWs, and ferritin levels are monitored,
combined spinal-epidural anaesthesia, have all been described
to maximise iron stores. In light of this study's findings,
in the literature1. However, we feel that embarking upon a
hospital blood transfusion Haematologists, in the future, will
regional technique in patients with distorted neuroaxial
review JWs antenatally. The Guideline should quantify how
anatomy would expose patients to unnecessary risk of high
often Hb should be monitored, so anaemia can be detected
spinal block and/or inadequate regional anaesthesia. Should
and treated before delivery. Crucially, consultant staff must be
general anaesthesia be needed intra-operatively, attempting an
documented as informed upon admission of JWs in labour, in
AOFOI in an already distressed parturient would be
order that deliveries can be supervised by senior staff to
challenging. We therefore planned an AOFOI to secure the
reduce potential morbidity and mortality.
airway prior to general anaesthesia, in a controlled manner and
References
thus avoid a potentially difficult and emergent intraoperative
1. Massiah N, Athimulam S, Loo C, Okolo S, Yoong W. Obstetric care intubation. In summary, these are difficult cases that we
of Jehovah's Witnesses: a 14-year observational study. Arch
believe benefit from good antenatal planning and can be
Gynecol Obstet 2007; 276(4):330-343.
managed with a planned AOFOI and general anaesthesia.
2. Van Wolfswinkel ME, Zwart JJ, Schutte JM, Duvekot JJ, Pel M, Van
Roosmalen J. Maternal mortality and serious maternal morbidity in
Jehovah's witnesses in the Netherlands. BJOG 2009; 116(8): 1103- Reference
1108. 1. T. Kavanagh, R. Jee, N. Kilpatrick, J. Douglas. Elective cesarean
3. Nawaz YM, Atkinson S. Peripartum care of Jehovah's witness delivery in a parturient with Klippel–Feil syndrome. Int J Obstet
parturients: A five year review. Int J Obstet Anesth 2013; 22(S1): Anesth 2013; 22(4): 343-8
S22.
Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin) P29
P157 Labour and delivery in long QTsyndrome P158 Local anaesthetic toxicity audit: are workshops the
BJ Vowles,  FMM Bryden   best educational tool across the MDT?   
Anaesthetic department, Princess Royal Maternity, Glasgow, WITHDRAWN FROM PRESENTATION
UK JL Lambert,  D Chitre,  L Evans  
Introduction: A 22 year old primigravida presented to the high Anaesthesia, Southend Hospital, Southend, UK
risk clinic at 22 weeks gestation. She had been diagnosed with
long QT syndrome (LQTS) after her family had been
investigated following a sudden early cardiac death and was
found to be heterozygous for the KCNQ1 gene, responsible
for Long QT1. She was under regular review by the
cardiologists who had advised β blockade with bisoprolol
2.5mg orally (PO) for 9 months post partum due to an increase
in arrhythmia risk during this period. She had also been given
a list from Azcert Inc., advising drugs that should be avoided
and included on this list was syntocinon.
Labour and delivery: She was admitted in labour at term and
the decision was made by the obstetric team, not to administer
syntocinon to augment labour. They also felt that epidural
analgesia was unsuitable because it would slow the progress
of labour. However following an initial dose of intramuscular
(IM) diamorphine, the parturient requested epidural analgesia.
We felt this would be beneficial for minimising her arrhythmia
risk and so she obtained a working epidural with a bilateral T10
block. ECG monitoring was commenced on admission and
.
initially showed bigeminy. A 12 lead ECG demonstrated a QTc
of 460ms. Electrolytes checked at this time were in the normal
range. Over the subsequent 8 hours she failed to progress and
underwent a caesarean section with an effective epidural top
up of 20ml 0.5% L-bupivacaine. At delivery syntocinon was
administered as a slow infusion of 5 units in 100mls 0.9%
saline over 20 minutes, followed by 500µg ergometrine IM to
maintain uterine tone. 50mg IM cyclizine and 10mg
intravenous (IV) metoclopramide were used for anti-emesis.
She was monitored in the Obstetric high dependency unit
(HDU) for the following 48 hours, where an initial ECG
demonstrated frequent ventricular ectopics, with a QTc 432ms.
Electrolytes were again normal at this time.
Discussion: There are many lists of drugs available on the
internet with differing advice as to which drugs to avoid in
long QT syndrome. The one which our patient had been given
clearly stated syntocinon should not be administered, despite
no definitive evidence of harm with this drug in patients with
LQTS. In addition we found no guidance in published case
reports, on oxytocic drugs administered to patients with LQTS
in labour or at delivery1. There are case reports of ventricular
tachycardia after administration of syntocinon in long
QTsyndrome2 and one report of a pateint receiving it with no
sequelae3 Ideally the authors feel that this lady merited a case
conference prior to admission so that informed decisions
could be made. Whilst the outcome of this patient's labour and
delivery may not have been different, a short trial of
syntocinon with ECG monitoring may have altered her mode of
delivery.
References
1. Drake E, Preston R, Douglas J. Brief review: anaesthetics
implications of long QT syndrome in pregnancy. Can J Anaesth.
2007; 54(7): 561-72
2. Liou SC, Chen C, Wong SY, Wong KM. Ventricular tachycardia
after oxytocin injection in patients with prolonged Q-T syndrome -
report of two cases. Acta Anaesthesiol Sin 1998; 36: 49-52
3. Charbit B, Funck-Bretano C, Samain E, Jannier-Guillou V,
Albaladejo P, Marty J. Qt interval prolongation after oxytocin bolus
during surgical induced abortion. Clin Pharmacol Ther 2004; 76:
359-64
P30 Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin)
P159 Lymphangioleiomyomatosis and Pregnancy: A Case P160 Major obstetric bleeds-are we doing the right thing?-
Report A multi-centre study in west midlands
M Cole,  S Petkov,  J Pickett   A R Sajayan,  M McLoughlin,  S Dinesh,  A Walunj*,  J
Anaesthetics, Addenbrookes Hospital, Cambridge, UK Karattuparambil †,  M Ravindran†  
Introduction: Anaesthesia, Heartlands Hospital, Birmingham, UK,
Lymphangioleiomyomatosis (LAM) is a rare condition causing *Anaesthesia, Good Hope Hospital, Sutton Coldfield, UK,
proliferation of smooth muscle in the respiratory system, †Anaesthesia, George Eliot Hospital, Nuneaton, UK 
which can cavitate leading to degradation of lung parenchyma Introduction:Guidelines1 exist on the definitions of massive
and cystic lung disease1. Because of the risk of progression, bleed, the proposed management pathway and the safe time
women with LAM are frequently advised to avoid pregnancy2. frame for obtaining the blood and products. This multi-centre
We present a case of LAM where multidisciplinary audit looks at the average time taken for the blood/products to
management led to a successful outcome of pregnancy, with a be available in major bleed situations in obstetrics
focus on anaesthetic considerations. Aim: To find out the incidence and reasons for delays in
Case Study: issuing the blood/products, if any, from the blood bank and to
A 35 year old woman presented with bilateral spontaneous compare the existing practices and experience with the other
pneumothoraces in the first trimester of her 2nd pregnancy. hospitals in the area
Both required surgical correction and a lung biopsy revealed a Methods: We collected the data from three participating
diagnosis of LAM. Computerised tomography of her thorax hospital in west midlands using a standard proforma which
showed multiple small lung cysts. Past history included an included the number of massive obstetric bleed calls during a
uncomplicated first pregnancy and emergency caesarean six months period in 2013, the estimated blood loss, the time
section for foetal distress, aged 33; and a spontaneous taken for the first unit of blood/ product to be issued and the
pneumothorax aged 34, requiring surgery. The patient was number of products used among other data.
referred to a tertiary centre for multidisciplinary management.
Results: The results suggested that there is ambiguity in the
Care was shared between obstetrics and respiratory medicine
way major haemorrhage was defined in different situations
and she attended the high risk anaesthetic clinic. Elective
which led to unnecessary calls where blood products were not
caesarean delivery at 38 weeks was agreed upon. She had
urgently needed. Also, the time for getting the products varied
three further small pneumothoraces, treated conservatively
widely the longest being 200 minutes. The documentation of
with no marked deterioration in respiratory function. Elective
the details of the bleeding, time of calls and time of
caesarean section was performed at 38/40 gestation.
blood/product administration were incomplete and inaccurate
Respiratory assessment and examination on the morning of
in some cases.In one hospital, major bleed calls were only put
surgery were normal. A two-space combined spinal epidural
out in two out of 17 cases where blood loss was more than
was sited, administering intrathecal hyperbaric bupivacaine
1500ml.
and diamorphine. A respiratory physician was present at
delivery in case of deterioration. Delivery was uneventful, with   Hospital1 Hospital2 Hospital 3
no immediate complications. The patient spent 24 hours in an Number of MOH calls 58 41 2
obstetric close observation unit post-operatively. Her post- Full data available 13 18 2
natal period was uneventful and required no further obstetric, Average time for group specific (min) 59 NA 33
respiratory or anaesthetic intervention. Average time for X match blood (min) 63.45 42.27 0
Longest delay (min) 200 104 33
Discussion: LAM is a rare condition with an estimated UK
prevalence of 1per million3. Hypotheses suggest oestrogen
Discussion: The definitions of massive blood loss are:
accelerates disease progression and pregnancy may result in
Transfusion of a volume equal to the patient’s total blood
new diagnosis or exacerbation4, therefore obstetric
volume in less than 24 hours / 50% loss of blood volume
anaesthetists should have awareness of this disease. There is
within 3 hours / rate of blood loss 150ml/minute. Though the
sparse literature for anaesthetic management of pregnancy
circumstances of individual episodes of major bleed could
with LAM, consisting mainly of case reports. Considerations
vary, there was no consistency in the trigger of activating
suggested include; avoiding excessive Valsalva manoeuvre
major bleed calls. There were also unacceptable delays in
via instrumental or elective caesarean delivery, avoid nitrous
obtaining the first unit of blood in some cases. The first set of
oxide, early epidural analgesia, obtunding intubation response
uncross matched group specific blood should be available in
and lung protective ventilation strategies if general
20minutes and cross matched blood in 40minutes2. The study
anaesthesia. This case report supports that pregnancy in
suggest that there is a need for the reinforcement of major
LAM patients can progress successfully and highlights the
bleeds definition and also a need for a clearer pathway and
importance of a MDT approach, early anaesthetic assessment
consistency in issuing blood and products in major bleed
and a well considered anaesthetic and obstetric plan.
situations. This audit results will be used to formulate a
References uniform policy in the participating hospitals and a re-audit will
1. Rosendal T. A Case of Diffuse Myomatosis and Cyst Formation in be done in six month time
the Lung. Acta Radiaology. 1942; 23: 138-146
2. Cohen MM, Freyer AM, Johnson SR. Pregnancy Experiences References
Among Women With Lymphangioleiomyomatosis. Respiratory
1. D Thomas etal,Blood transfusion and the anaesthetist: management
Medicine. 2009; 103: 766-772
of massive haemorrhage, Anaesthesia 2010 November; 65(11):
3. Johnson SR, Tattersfield AE. Clinical Experience of 1153–1161
Lymphangioleiomyomatosis in the UK. Thorax. 2000; 55:1-5
2. Guidelines on the management of massive blood loss.
4. McLoughlin L, Thomas G, Hasan K. Pregnancy and BJHaematology 2006; 135(5): 634-641
Lymphangioleiomyomatosis: Anaesthetic Management.
International Journal of Obstetric Anaesthesia. 2003; 12: 40-44
Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin) P31
P161 Management of labour and delivery using  minimally  P162 Management of manual removal of placenta and third
invasive FlotracTM system in a parturient with  and fourth degree tear repair: pathway analysis
congenitally corrected transposition, dextrocardia P Jegendirabose,  J Subramanya*,  S Watkinson*,  J Short  
and systemic ventricular dysfunction Anaesthesia, Queen Elizabeth Hospital, Woolwich, London,
R Vedagiri Sai,  S Dhir,  J Racine   UK, *Obstetrics & Gynaecology, Queen Elizabeth Hospital,
Anesthesia, Western University, London Ontario, Canada Woolwich, London, UK
Introduction: More women with congenital heart disease now Introduction: Guidelines suggest that repair of obstetric anal
survive to reproductive age due to advances in modern sphincter injuries (OASIS) and manual removal of retained
medicine. Obstetric management is challenging in these placenta (MROP) should be undertaken as soon as possible to
complex cases. We present the anaesthetic management of minimise the risk of infection, blood loss and maternal
labour and delivery in a woman with congenitally corrected morbidity1,2. Anal incontinence and perineal pain can impact
transposition of great vessels, dextrocardia, systemic significantly on maternal quality of life and mother-child
ventricular dysfunction and junctional tachycardia using bonding.
minimally invasive continuous haemodynamic monitoring and Methods: We conduced a retrospective audit which showed
optimisation. shortcomings in our management of MROP and OASIS and we
Case report: A 28 year old primigravida presented with a undertook an analysis of a full calendar year's cases. All cases
diagnosis of congenitally corrected transposition of great of MROP and OASIS were identified over January 2012 to
vessels and dextrocardia. The atrial septal defect had been December 2012 using both theatre electronic records and
repaired in childhood. Her medications included folate and maternal records. Time from delivery of fetus to MROP or
multivitamins. She had good exercise tolerance, stable vital OASIS repair, blood loss and blood transfusion requirement
signs and was followed up by Cardiology team throughout her were reviewed.
pregancy. ECHO showed 50% ejection fraction (EF) and mildly Due to lack of nationally set standards, we set a local standard
reduced systemic (morphologic right) ventricle. A multi- of no more than one hundred and twenty minutes from
disciplinary meeting between Obstetrics, Cardiology, delivery to repair for OASIS.
Anaesthesia and Intensive care unit (ICU) team was held to
Results: Our institute is a secondary obstetric centre with
decide on optimal obstetric management. Induction of labour
4800 deliveries per annum. During the twelve month period,
was planned.
105 patients sustained OASIS. The mean delay from delivery
At 37 weeks she developed palpitations, increasing shortness to surgery was 136 minutes. The average blood loss was 501
of breath and peripheral oedema. Repeat ECHO showed millilitres and 3% of patients required blood transfusion. Total
moderate ventricular dysfunction with EF 40%, severe of 42 patients required manual removal of placenta with
systemic atrioventricular regurgitation and severely enlarged regional or general anaesthesia. The mean delay from delivery
left atrium. Prior to labour induction, an arterial line was to surgery was 178 minutes. The mean blood loss was 790
inserted and continuous cardiac output monitoring was millilitres and 5% of the patients required blood transfusion.
performed using arterial pressure waveform analysis with the
FloTracTM monitor. Haemodynamic optimization was guided OASIS repairs n=105 Time (minutes)
by stroke volume variation and goal directed fluid therapy. A Delivery to booking 81 (Cl 70-92)
lumbar epidural was then inserted followed by rupture of Booking to surgery 68 (Cl 40-95)
membranes and oxytocin infusion. Fluid balance was closely Delivery to surgery 136 (Cl 122-150)
monitored continuously using FloTracTM. 1st stage of labour MROP n=42 Time (minutes)
was uneventful and 2nd stage was shortened using vacuum Delivery to booking 138 (Cl 115- 160)
assisted delivery of a healthy baby. She had a second degree Booking to surgery 39 (Cl 32-46)
tear which was repaired. Post partum haemorrhage due to Delivery to surgery 178 (Cl 152-204)
uterine atony was treated with 400µg Misoprostol rectally and
Incidentally, 78% of the patients did not have electronic record
intravenous infusion of 20 IU of Oxytocin. Estimated blood
of estimated blood loss on the theatre system.
loss was 800 mL. Cardiac condition was stable apart from
Discussion: In our institution, these cases are booked onto
persistent tachycardia throughout labour. Postpartum, she
the general emergency theatre, and not in the designated
spent 24 hours in ICU with similar monitoring. Her tachycardia
emergency obstetric theatre. We have identified that this has
settled spontaneously. She was discharged home on day 4.
resulted in significant delay in surgery and increased blood
Discussion: Patients with congenitally corrected transposition
transfusion requirement. We are now changing the patient
have a thin-walled right ventricle as the systemic circulatory
pathway to include urgent utilisation of the emergency
pump. The stress of increased cardiac output can cause
obstetric theatre for these procedures. Since the presentation
failure, atrioventricular regurgitation and arrhythmias1. We
of this audit, we have included the estimation of blood loss in
used minimally invasive continuous cardiac output
the surgical sign out process, thus improving communication
monitoring, fluid balance optimisation and good maternal pain
and patient care.
control to prevent decompensation and achieve vaginal
References
delivery with a good feto-maternal outcome.
1. National Institute for Health and Care Excellence. 2007.
Reference Intrapartum care. Care of healthy women and their babies during
childbirth. Clinical guideline 55
1. Dob DP, Naguib MA, Gatzoullis MA. A functional understanding of
moderate to complex congenital heart disease and the impact of 2. Fernando RJ, Sultan AH, Kettle C, Thakar R. Methods of repair for
pregnancy. Part I: the transposition complexes.Int J Obstet Anesth. obstetric anal sphincter injury. Cochrane Database Syst Rev. 2013
2010 Jul;19(3):298-305 Dec 8;12:CD002866.
P32 Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin)
P163 Multidisciplinary involvement of the high risk P164 National Obstetric Anaesthetic Database: a useful tool
parturient to benchmark maternity units in the UK
S De Silva,  P Gregory,  E Combeer   G Keightley,  N Tailor,  R Baraz,  L De Lloyd  
Anaesthetics, Frimley Park Hospital, Frimley, UK Anaesthetics, University Hospital of Wales, Cardiff, UK

Our Hospital offers a high risk Obstetric Anaesthetic Clinic for Introduction: The National Obstetric Anaesthetic Database
review of parturients with anticipated Anaesthetic or Medical (NOAD) was set up in 1998 to establish a framework for
problems where a checklist referral form is used. We audited collecting national obstetric anaesthetic data considered
whether women were appropriately referred or inappropriately relevant to obstetric anaesthetists. Whilst preparing the
not referred. An alert sticker was created to encourage NOAD survey for 2012, we explored the usefulness of this
healthcare providers to alert the oncall Obstetric Anaesthetist data in benchmarking our units' performance at the University
when the high risk parturient presented to labour ward. We Hospital of Wales (UHW) in relation to NOAD published
went onto audit the effectiveness of this alert sticker. figures from the previous year.

Methods: Data was collected according to the NOAD 2012
Methods: We looked at 200 consecutive births during October
survey and therefore, ethical approval was not required. Due
2010 and ascertained how many of these women had referrals
to the large number of deliveries in our unit, data regarding
to the High Risk Clinic. In the referred cases, we asked whether
labour analgesia, mode of delivery, caesarean section rate and
referral criteria were met and also determined if any mothers
type of anaesthesia was based on six months period (Jan to
were inappropriately not referred. In 2012 we retrospectively
June 2012) and then doubled. Exceptions were critical care
inspected all notes of mothers seen in High Risk Clinic with an
admissions and patients with accidental dural puncture (ADP);
estimated delivery date of March to May 2012. We checked
these were collected and reviewed individually for the entire
whether an alert sticker was present in their notes and also the
year. Microsoft Excel was used to analyse the data.
time taken for the Obstetric Anaesthetist to be contacted once
the mother had presented to Labour Ward. Results: The number of total deliveries in our unit for 2012

was 6138, of which 3060 required anaesthetic procedure(s).
Results: In 2010, 178 of 200 notes were reviewed and 14
The table below compares performance and quality indicators
women met referral criteria and 12 of these were referred.
at UHW in 2012 with the NOAD averages from 2011.
Fourteen percent were therefore inappropriately not referred,
however no women were inappropriately referred. Indicator UHW 2012 NOAD 2011

Caesarean section (CS) rate 22% 24.8%
In 2012, 42 notes were inspected where only 8 had the alert
Elective CS rate 46% 39.1%
sticker in place, with only 5 in the correct position. Two
De novo general anaesthesia (GA) for CS 4.5% 4.7%
mothers with the alert had elective caesarean sections. In five
Conversion to GA (CS) 1.8% 3.5%
of the six remaning mothers, the oncall Anaesthetist was
Labour regional analgesia 27% 22.7%
informed of their presence on labour ward. The average time
Epidural re-site rate 7.7% 9%
taken for this was four hours and 45 minutes (range 10 minutes
Accidental dural puncture rate 0.9% 1.2%
to 10 hours and 50 minutes). On review of the Clinic letters, it
was felt that 30 of the 42 parturients should have had an alert In 2012, three cases were transferred to critical care unit as
present in their notes, which is 71% not 19% as shown by our level 2 care (two with sepsis and one adult respiratory distress
audit. syndrome) and six cases as level 3 care (two with sepsis, three

post partum haemorrhage and one case of amniotic fluid
Discussion: In many cases of substandard care assessed by
embolus).
CMACE, there were major failures of communication between
Discussion: Our unit is classified as a large maternity unit
healthcare workers that may have contributed to the woman’s
compared to the national average. The elective CS rate and
death in some cases1. Our audits demonstrated that local
labour regional analgesia rates in our unit are higher than the
guidelines for referral were followed in 99% of cases, therefore
national average, possibly related to the complexity of a
high risk mothers were identified early. However, there still
tertiary centre. Despite this, our total CS rate is well below the
lacks effective communication of concerns within teams and
average with very low conversion to GA. In addition, our
poor involvement of other specialties early.
epidural re-site rate is lower than the national average, as is
Reference our ADP rate. Current facilities include two theatres serving
1. Centre for Maternal and Child Enquiries (CMACE). Saving both emergency and elective streams, and a mixed
Mothers'. Lives: reviewing maternal deaths to make motherhood recovery/high dependancy unit (HDU) for up to 5 patients.
safer: 2006–2008. The Eighth Report of the Confidential Enquiries
Our unit has a low transfer rate as level 2 care in general HDU,
into Maternal Deaths in the United Kingdom. BJOG 2011;118:1-203
due to the ability to care for these patients on our unit. We
find the NOAD data a useful tool to benchmark our
performance and set standards of care. More units should
contribute to the annual NOAD survey and consider using the
data as a way of identifying shortfalls and improving patient
care and services.
Reference
1. National Obstetric Anaesthetic Database report 2011.
http://www.oaa-anaes.ac.uk/content.asp?ContentID=586
Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin) P33
P165 Obstetric admissions to the Intensive Care Unit: a 6 P166 Obstetric outcomes with programmed intermittent
year review at a UK tertiary maternity centre epidural bolus labour analgesia
R Labib,  K Cullis   JTE Cremin,  CH Papageorgiou  
Selwyn Crawford Department of Anaesthesia, Birmingham Department of Anaesthesia, Hillingdon Hospital, Uxbridge,
Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin) P1
P101 A modified WHO surgical safety checklist for P102 A parturient with phocomelia and severe needle
category 1 caesarean sections phobia: the challenges faced
A Lahkar,  A Cooney,  G Massolini   R Sinha,  K Howard,  N Bhandal  
Anaesthetics, Milton Keynes NHS Foundation Trust, Milton Department of Anaesthesia, Nottingham University Hospitals
Keynes, UK NHS Trust, Nottingham, UK
Introduction: In June 2008, WHO introduced a surgical safety Introduction: Parturients with phocomelia are rarely seen and
checklist to be used in every operating theatre to improve present anaesthetic and obstetric challenges. We present a
patients' safety. In 2010 a WHO surgical safety checklist for case of a parturient with phocomelia and severe needle phobia.
maternity was created in response to requests from maternity Case report: A 33 year old woman with phocomelia and severe
services and clinicians. Nevertheless, in some emergency needle phobia presented to the obstetric anaesthetic clinic at
situations like category 1 Caesarean sections, this checklist 20 weeks for pre-assessment.
could still be quite a difficult task to achieve due to Her phocomelia was thought to be idiopathic, she had been
understandable time limit constrains to safely deliver the baby adopted when young and no family/drug history was
and/or save the mother's life. available. Examination revealed four limb phocomelia. There
Whilst there is still no international consensus or any specific were absent upper limb bones on the right and a fused hand
recommendation from WHO concerning these specific attached directly to her body. Her left upper limb was
situations, the Anaesthetic Department in Milton Keynes shortened with a primitive hand and fused fingers. Both lower
hospital has managed to devise a checklist for cat 1 LSCS limbs were extremely shortened with primitive feet with fused
which is 100% compliant both in terms of content with WHO toes. Her head, neck and torso appeared normal. She was able
guidelines and adherence by hospital staff. to mobilize with a wheelchair and significant assistance from
Method: After considerations and inputs from the Consultant her partner. The problems faced in clinic were numerous and
Anaesthetists, a simplified checklist was introduced in our focused on her severe needle phobia, difficult venous access
emergency obstetric theatre in June 2013 by way of an ad hoc and monitoring, positioning, mobilization and
poster hanged on the wall. It spells out the most 10 salient thromboprophylaxis as well as the challenges posed by the
questions to be read by one of the theatre staff before the start preganancy itself. The anaesthetic plan consisted of non-
of a category 1 Caesarean section. These questions translate invasive blood pressure monitoring on her left lower extremity;
the original 32 WHO ones that were spread across 3 sections pulse oximetry via an ear probe or toe and standard
in a simpler, quicker format. electrocardiogram. These were tested prior to labour. Due to
Results: After the introduction of the modified WHO checklist the impossibility of standard intravenous access and extreme
in June 2013, compliance is 100%. needle phobia several discussions were had about obtaining
Discussion: By putting the combined know-how and intravenous access prior to labour. A right subclavian
experience of many Consultant Anaesthetists to the task, we Hickman line was inserted at 39 weeks facilitated by the use of
managed to simplify the original WHO narrative into a sharper entonox. Regional analgesia was refused for labour so the
tool that is quickly and effectively utilised for a better and option of intravenous fentanyl via a midwife controlled
safer quality of care in what has become a "normal routine" analgesia pump was discussed. Should a caesarean section be
during extraordinary times in the emergency theatre. required a neuroaxial anaesthetic was refused and so a general
anaesthetic was planned.
Reference At 40+2 weeks spontaneous rupture of membranes occurred
1. WHO surgical safety checklist: for maternity cases only, and labour established. However, due to failure to progress a
http://www.nrls.npsa.nhs.uk/resources/?entryid45=83972 decision was made to perform a caesarean section.
In theatre the challenges related to positioning and achieving
a satisfactory left lateral tilt. A rapid sequence induction was
conducted following pre-oxygenation to an end-tidal oxygen
concentration of 92%. Anaesthesia was induced with
thiopentone 350mg and suxamethonium 100mg. Soon after
induction she desaturated rapidly to the high 60s. This
resolved after tracheal intubation and ventilation. She was
hypotensive intra-operatively, with an estimated blood loss of
1300mL After fluid and blood resuscitation, recovery was
unremarkable. Postoperative pain was managed with
transversus abdominus plane blocks and morphine
patient/midwife controlled analgesia.
Discussion: There is little literature about managing delivery
in women with phocomelia, but sucessful regional techniques
have been described although this was refused here. Early
discussion of anaethesia and analgesia options, and plans for
vascular access and monitoring are needed, There is a reduced
vascular reservior and skeletal muscle mass.
As a consequence faster inductions, emergences and
responses to titrated drugs are observed.

P2 Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin)
P103 A questionnaire to evaluate and aid future development P104 A retrospective descriptive analysis of anaesthesia for
of the AAGBI's SAFE obstetric anaesthesia course in successful cervical cerclage in pregnancy
Liberia J Modha,  G Burul*,  F Forya*,  CP James*,  AL David*,  J
JCO Fox,  CE Richards*,  T Sheraton*,  A Sonah†   Dick,  L Wee  
†Department of Anaesthetics, Phebe Hospital, Bong County,  Department of Anaesthesia, University College London
Liberia, *Department of Anaesthetics, Royal Gwent Hospital, Hospitals NHS Foundation, London, UK, *Department of
Newport, UK, Department of Anaesthetics, University Obstetrics, University College London Hospitals NHS
Hospital of Wales, Cardiff, UK Foundation, London, UK
Introduction: Dr Kate Grady has developed this three-day Introduction: Cervical cerclage is a common operation which
refresher course in obstetric anaesthesia on behalf of the requires an anaesthetic. There are no studies on the type of
AAGBI. The course is aimed at non-physician anaesthetists in anaesthesia used for this procedure.1
developing countries. It consists of short lectures, interactive Aim: To determine the type of anaesthesia used for vaginal
sessions and workshops that focus on the recognition and cervical cerclage.
management of leading causes of maternal death in resource
Method: Ethical approval waived. Women having any vaginal
poor settings. The course has been taught in Uganda,
cervical cerclage (Macdonald or Shirodkar) during pregnancy
Bangladesh, Liberia and Ghana. It includes the principles of
between January 2005 and December 2012 were identified
the WHO Safe Surgery and training of trainers. Mothers of
using the hospital obstetric anaesthesia database and cross-
Africa, a medical educational charity, has led delivery of 2
referenced with data from the Preterm Birth clinic where women
courses for nurse anaesthetists (NAs) in Liberia - supported
at risk of preterm birth are seen antenatally. Data was obtained
by the AAGBI IRC. Liberia has approximately 60 nurse
by examination of obstetric case notes and the ultrasound
anaesthetists and no medically qualified anaesthetists for a
scan records and analysis conducted using Microsoft Excel.
population of 4.2 million people1. Access to CPD is difficult.
Results: There were 190 cases. Twenty-five patients were
The MMR in Liberia is 770 per 100,000 live births1. In order to
excluded due to incomplete data, hence 165 included in
plan future development of the course in Liberia, which will be
analysis. The mean gestational age was 16.6 weeks (range 9-
led by Liberian trainers, feedback data was collected.
23.6 weeks). The table below shows that both general
Methods: A follow up questionnaire was given to 35 NAs who
anaesthesia (GA) and regional anaesthesia (RA) were used.
had previously attended a SAFE obstetric anaesthesia course
The majority of regional anaesthetics were spinals (95.7%), the
held in Liberia (March 2012 or March 2013). We aimed to
rest combined spinal and epidural (CSE) (3.6%) and epidural
assess; 1) the quality, usefulness and appropriateness of the
top up (0.7%).
material taught during the course, 2) the effect on motivation
to improve local services/care delivery, 3) the effect on the GA RA

confidence levels of NAs in managing obstetric anaesthetic n (%) n (%)
emergencies. Spinal n = 133
Results: A 70% follow up rate was achieved. 97% reported Total n=165 26 (16%) 139 (84%) CSE n = 5
positive changes in their attitude to work and their clinical Epidural n = 1
practice and 94% reported improvements in interactions with Five patients who had a spinal anaesthetic required second
colleagues. Many NAs gave details of cases where the skills procedures (3 GA, 1 spinal, 1 CSE). Of those converted to GA,
and knowledge they learnt on the course helped save lives one patient had a block to T6 (the reason for conversion to GA
and improve clinical outcomes. 11 NAs requested continued was not documented), one patient had a block to T12 and the
education and training. Other suggestions for course third patient had 3 failed spinal attempts. In all cases there
improvement included; additional sessions in preoperative were no major anaesthetic complications and cervical cerclage
assessment and TAP blocks, and the inclusion of midwives in was placed successfully.
the training sessions. The following table illustrates the mean
Discussion: In this series, the majority of vaginal cervical
subjective confidence scores (between 0 and 10) of the NAs in
cerclage surgery was performed safely and effectively under
various clinical scenarios before and after the course.
RA. There are no specific guidelines regarding the type of
  Before After anaesthesia for cervical cerclage.1 Anaesthetic considerations
General anaesthesia LSCS 6.3 9.2 favouring a regional anaesthetic in pregnancy include the risk
Spinal anaesthesia LSCS 7.6 9.8 of aspiration and difficult airway management in patients over
Management of severe eclampsia/preeclampsia 5.7 9.2 20 weeks gestation and those under 20 weeks gestation if at
Management of obstetric haemorrhage 5.9 9.4 high risk for example those with a high BMI. The majority of
women in our data set were less than 20 weeks (88.5%). Other
Discussion: Our results indicate that the SAFE obstetric
considerations include patient and surgeon choice. Women in
anaesthesia course in Liberia has been well received with
this series were given the option of GA or RA. In certain cases
subjective evidence of empowerment and improved methods
for example rescue and abdominal cerclages, the patient may
of working. This is promising in the context of increasing the
need to be in a deep Trendelenberg position to aid reduction
reach of future courses and enabling local faculty to lead
of membrane prolapse to avoid membrane rupture or to aid
training. Further data from logbooks provided as part of the
access to the pelvis.2
course were not obtained and more work is needed to
encourage completion of the logbooks. Objective evidence is References
required to demonstrate impact on patient outcomes. 1. Cervical Cerclage, Green-top Guideline No 60, Royal College of
Reference Obstetricians and Gynaecologists, May 2011.
2. Olatunbosun OA, Dyck F. Cervical cerclage operation for a dilated
1. http://data.worldbank.org/indicator/SH.STA.MMRT/countries/1W-
cervix. Obstet Gynecol. Feb 1981;57(2):166-70.
LR?display=graph
Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin) P3
P105 A retrospective descriptive analysis of dose of P106 A step towards improving theatre productivity for
intrathecal anaesthesia and adjuncts for successful elective caesarean sections
cervical cerclage in pregnancy S Kale,  C Farrow,  N Owen,  K Miltsios  
J Modha,  G Burul*,  F Forya*,  CP James*,  AL David*,  J Department of Anaesthesia, Whittington Hospital, London,
Dick,  L Wee   UK
Department of Anaesthesia , University College London Introduction: NHS Institute for Innovation and Improvement
Hospitals NHS Foundation, London, UK, *Department of developed The Productive Operating Theatre Programme to
Obstetrics, University College London Hospitals NHS improve effective use of theatre time, staff and patient
Foundation, London, UK experience.1 Good administrative system and organisation is
Introduction: Cervical cerclage is a common operation, which essential to ensure theatre efficiency.2On this background,
requires either a general or regional anaesthetic aiming for a with the rational of making existing system more productive,
block height of T10. There are no studies determining the dose safe and reliable, we evaluated current practice in one of our
that should be used to achieve this or describing additional main theatres, designated for elective sections, in a DGH set
drugs used for successful surgery. up.
Aim: To determine the dose of local anaesthesia used for Methods: Evaluation was carried out over a 4-week period, for
intrathecal injection and the block height achieved in women planned caesarean sections. The data was collected
undergoing cervical cerclage. In addition to determine the use concurrently by the anaesthetist for that case and from the
and dose of adjuncts. theatre database. The exact time for all significant events, such
Method: Ethical approval waived. Women having vaginal as when patient was sent for or when theatre was clean and
cervical cerclage during pregnancy between January 2005 and ready for the next patient, was recorded. Reasons for delays,
December 2012 were identified using the hospital obstetric duration of anaesthesia, surgery and problems encountered
anaesthesia database and cross-referenced with data from the were also recorded. Time spent at and between different
Preterm Birth clinic. Data was obtained by examination of crucial stages in theatre was calculated from the data. Results
obstetric case notes and the ultrasound scan records and are presented in the form of time in minutes, median [range]
analysis conducted using Microsoft Excel. and % (absolute numbers of cases).
Results: In all cases, cervical cerclage was achieved Results: We had 25 completed forms. Our analysis showed,
successfully. There were 138 cases of intrathecal anaesthesia median time interval from patient sent for to arrival in theatre
(133 spinals and 5 combined spinal epidurals) in whom 67.4% as 5 min [1-29]. Reasons for delay were due to obstetric team
(93/138) had documented intrathecal anaesthetic dose and busy in meeting, midwife busy preparing the patient and
were included for final analysis. Hyperbaric bupivacaine 0.5% midwife busy completing paperwork for previous patient in
was used (mean dose 10.9mg, median 10.8mg and mode 10mg, recovery. Median time interval between patient's arrival and
range 6.5–15mg). Block height and dose of intrathecal neuraxial block was 18 min [10-70], prolonged in 8% of cases
anaesthetic was documented in 54/93 cases (58%). The block (2/25) due to failed and repeat block. Bladder catheterisation
height ranged from T2 to T12 with similar doses of local after block was delayed by ≥30 min in 8% of cases (2/25) due
anaesthetic given in each group and of similar gestation and to unavailability of midwife. Median anaesthetic time for
body mass index (BMI). satisfactory block was 12 min. Interval between block ready
and knife to skin (KTS) was 6 min [1-12]. Median surgery
Block height T2-4 T5-8 T10 T12 duration was 45 min [31-141]. PPH, high BMI, and previous
Frequency 7 31 13 3 laparotomies resulted in longer operations in 16% of cases
Mean dose mg (4/25). Median turnaround time between the cases was 10 min
11 11 11 8
hyperbaric bupivacaine 0.5% [6-15]. Total time patients spent in theatre was 89 min [74-183].
Mean gestation (weeks) 17.4 17.7 15.6 19.1
Discussion: We noted that unavailability of obstetric team
Mean BMI kg/m2 27.3 26.6 26.1 32
and busy midwives at times has resulted in late starts and
In 3 patients that had block heights of T12 only one was delay in some procedures in theatres. Delay in starting the
converted to GA. Opiates were used in 73/93 (78.5%), the most surgery after a satisfactory block and prolonged turnaround
frequent being fentanyl. time have also affected the overall theatre productivity. We
have put forth some recommendations to working group such
Mean dose Range
Opiate used Number (%) as offering administrative support to midwives, ensuring
(mcg) (mcg)
senior obstetrician and anaesthetist are present for difficult
Fentanyl 69 (95) 20 10-75
cases, making use of anaesthetic room to improve patient
Diamorphine 3 (4) 300 250-350
turnaround time and most importantly encouraging staff
Fentanyl & Diamorphine 1 (1) 20/300 N/A
nurses to take the lead role in increasing theatre efficiency.
Vasopressors were used in 26 cases (23 phenylephrine, 3 This could be a big step towards enhancing theatre output as
ephedrine). Other drugs included 3 cases of intravenous well as increasing patient and staff satisfaction. We aim to
midazolam, 1 case propofol and in 1 case salbutamol (as a introduce these changes soon and re-evaluate the practice in
tocolytic agent). the near future.
Discussion: In our case series there is a wide dose range of References
both hyperbaric bupivacaine 0.5% and opiate given. To 1. The Productive Operating Theatre programme,
achieve a block height of T10 or above a minimum dose of http://www.institute.nhs.uk/quality_and_value/productivity_series/the
11mg (2.2ml) is recommended which may be independent of _productive_operating_theatre.html
other factors. There is a wide variation in block height but 2. Theatre Efficiency,
http://www.aagbi.org/sites/default/files/theatreefficiency03.pdf
even a low block (T12) was found to be adequate.

P4 Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin)
P107 A year in the "maternity" life of an increasingly busy P108 Abstracts on the antenatal anaesthetic clinic
new build district general teaching hospital - coping presented to the Obstetric Anaesthetists' Association,
with training and service provision - 2013 1991-2013
H Wrigley,  PF Yoxall,  Janet Slee   AJ Wickham,  SM Yentis*  
Anaesthetics, St Helens & Knowsley NHS Trust, Liverpool, Anaesthetic department, St Mary’s Hospital, London, UK,
UK *Anaesthetic department, Chelsea & Westminster Hospital,
Introduction: Since moving to a new PFI built hospital in 2010 London, UK
our maternity unit has become more busy. Delivery rates/year Introduction: National reports1 and guidelines2 recommend
have increased from 2900 to 3700 pa (up 27.6% in 3 years) assessment of women with ‘high-risk’ pregnancies and
increasing demands upon anaesthetic services. potentially serious co-morbid disease in an antenatal
Methods: We reviewed all our maternity cases during 2013, anaesthetic clinic (AAC). We reviewed trends and themes in
both epidural and caesarean sections. We also surveyed our abstracts on this topic presented to the OAA.
CT2 trainees to assess their experience in terms of case Methods: Full-text records of abstracts (excluding case reports)
numbers during a newly introduced modular training block. presented at OAA meetings (1991-2013; see www.oaa-
Lastly consultant cover on labour ward was audited for CNST anaes.ac.uk) were searched using the terms ‘antenatal’,
purposes. ‘clinic’, ‘risk’ and ‘refer’. Relevant abstracts were reviewed for
Results themes and conclusions.
Results: Forty abstracts were presented at 14 Annual
n %
Meetings (Fig. 1); 3 were unavailable in full-text (2008) but 1
Total Deliveries 3700
was provided by the author on request. 35 were from single
LSCS 838 22.6
departments and 5 were surveys (4 national). Common topics
Grade I-III LSCS 464 12.5
were obesity (12, 30%), referral reason (7, 18%) and
Grade IV LSCS 374 10.1
appropriateness (4, 10%), and outcomes (5, 13%). Nine (23%)
LSCS - SAB 666 79.5
described single patient cohorts, e.g. cardiac. AAC workload
LSCS - Epidural 123 14.7
has increased from 2.3 to 28.6 patients per month over 22
LSCS - CSE 14 1.7
years, albeit at different centres. Obesity has replaced
LSCS - GA 119 14.2
musculoskeletal disease as the most frequent reason for
RA to GA 34 4.2
referral. Common concluding themes include the need to
Average BMI LSCS (Range) 28.3 (16.7-59.9)  
improve the timeliness and appropriateness of referrals, and
Epidurals 895 24.2
ensuring anaesthetic plans are both prominent and followed.
Epidural Resites 32 3.7
PDPH - Epidural 15 1.7
PDPH - SAB 2 0.3
Epidural Blood Patches 21
Average BMI Epidural (Range) 27.1 (16-62.8)  
CT2 Training One of our requirements is to teach at least 4
CT2s per annum obstetric basic competencies. Our trainees
receive a 4 week long daytime block covered by an anaesthetic
ST3-7 and a consultant. They attend 40 sessions, the majority
siting 15 epidurals and anaesthetise 30 caesarean sections
before embarking on daytime on calls. They attend our in-
Figure 1: number of abstracts on the AAC presented per year
house MODSS (Obstetric Simulation Day) run by one of our
Consultant Obstetricians. Discussion: Abstracts relating to AACs have become more
frequent in the last decade, presumably reflecting their
Consultant Input The number of funded Consultant labour
increasing provision and perceived usefulness (and
ward sessions has risen 7 to 10 sessions (7 elective lists per
recommendation in the 2002-04 CEMACH report3). Increased
week). A “High Risk Obstetric clinic” runs weekly to pre-
demand for this service is exacerbated by inappropriate
assess all potentially difficult patients (250-300 per annum).
referrals and budgetary constraints. Referral processes,
Discussion: Despite a significant increase in workload we
facilities, and documentation and inconsistent use of plans are
have managed to maintain levels of cover (both junior and
areas for development. Future work should focus on quality
consultant) whilst allowing for CT2 training in obstetric basic
improvement and assessment of cost-effectiveness. Nationally
competencies as required at both national and local levels.
agreed referral criteria and a national ‘anaesthetic plan’
This has been achieved by increasing our core of obstetric
document, complemented by referrer education, may enhance
consultant anaesthetists, increasing obstetric PAs and
the process. Multidisciplinary ‘one-stop-shop’ or midwifery
changing to a modular CT2 training programme.
led clinics for common problems, such as obesity, may be
beneficial.
References
1. Centre for Maternal and Child Enquiries. Saving Mothers’ Lives:
reviewing maternal deaths to make motherhood safer: 2006-08.
The Eighth Report on Confidential Enquiries into Maternal Deaths
in the UK. BJOG. 2011; 118(Suppl.1): 1-203.
2. OAA & AAGBI Guidelines for Obstetric Anaesthetic Services.
Revised Edition 2005. London: OAA/ AAGBI
3. CEMACH. Why Mothers Die 2000-2002. Report on Confidential
Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin) P5
P109 Accuracy of a new electronic obstetric anaesthetic P110 Accuracy of landmark approach to central neuraxial
database blocks in obstetric patients
Rohit Rohit,  R Abraham,  GNB Jackson   J Lie,  K Bhatia,  A Venkataraju,  P Kochhar  
Anaesthetic department, Royal Berkshire Hospital, Reading, Anaesthesia, St Mary's Hospital, Manchester, UK
UK Introduction: Correct identification of vertebral level could
Introduction: We have introduced a new electronic database prevent damage to the spinal cord during a central neuraxial
'ROAD' (Reading Obstetric Anaesthetic Database) to record block (CNB). Evidence suggests that ultrasound (US) imaging
obstetric anaesthetic data. Written & designed by one of our of the spine by an experienced operator leads to correct
anaesthetists it is secure, password protected & able to identification of vertebral level in 90% of the patients and
produce reports on patient data & the activity of individual decrease the number of attempts required for a successful
anaesthetists. More than 70% obstetric anaesthetic units use CNB1. National Institute for Health and Care Excellence
electronic data collection system in the UK but there is little suggests US could be a useful tool for epidural catheter
agreement as to the best format.1 We audited the accuracy of insertion2. Our aim was to determine the discrepancy between
data entry, as a marker of ease of use by the anaesthetists, landmark technique and US to identify level of insertion of
before auditing the content of the database. CNB.
Methods: This was a retrospective audit, analysing data for Methods: Two experienced US operators who were blinded to
one month period (June 2013). The data in 'ROAD' was the initial procedure retrospectively performed US imaging of
compared to 1) our handwritten anaesthetic record book spine post-operatively after elective caesarean section in 51
(ARB); 2) Midwifery led labour ward logbook (LWLB); 3) obstetric patients with their consent from January to March
Operating theatre electronic log 'Bluespier'. Data entered on 2013 in St Mary’s Hospital. All the patients had a lumbar CNB
the 'ROAD' was manually checked against all these three done by landmark approach. The documented vertebral level
sources and the results tabulated and analysed. at which CNB was performed was noted. This was then
Results: 253 records were found in the ARB. The ARB missed compared with the actual vertebral level identified by bedside
one case (found in Bluespier), Bluespier missed one case US imaging of spine.
(found in the ARB) and LWLB missed 6 cases (found in the
Results: 29 patients had a spinal, 20 had an epidural and two
ARB & Bluespier). The results show that 'ROAD' was 96%
had combined spinal-epidural anaesthesia. The median body
accurate compared to any of the other systems.
mass index (BMI) was 28.6kg/m2. Landmark technique was
No. of cases missing on only accurate in 39.2% of patients. There was no statistically
Total 'ROAD' accuracy against
  'ROAD 'compared to significant correlation between the experience of operator and
no. other data sources as %
others accuracy. 3% of patients had a CNB at the level of L or above.
2
ARB 10 253 96.047% Documentation of the level performed was excellent. Raised
Bluespier 7 174 95.977% BMI and difficulty in palpation of landmarks resulted in
LWLB 10 247 95.951% statistically significant decrease in the accuracy (p<0.05
'ROAD'   243   Fisher’s Exact Test).
Discussion: Pinder et al considered an accuracy of 89% for Discussions: Our findings co-relate well with other studies
their electronic record adequate enough to adopt computer which have found that the vertebral level identified by
based data collection system.2We used three different landmark approach was at least 1 interspace higher than the
methods of data collection already in regular use, to compare level located by US in 40% of the pregnant population 3. Our
with our electronic database and showed it to have a high audit further confirms that the use of traditional landmark
degree of accuracy. This suggests that the database is easy to technique is highly inaccurate with potential increase risk of
use and consistently completed by our anaesthetists. We wish needle injury to the spinal cord especially in the high-risk
to use our database to produce reports on anaesthetic service patient groups (morbid obesity and musculoskeletal
provision (including the quality & safety of that service) as problems). We propose that all elective obstetric patients,
well as for auditing individual anaesthetist activity patients having a lumbar epidural, and high risk patients
(particularly our novice obstetric anaesthetists to ensure having a lumbar CNB should have US imaging of the of their
appropriate case mix & experience during their obstetric spines to identify the correct vertebral level and other relevant
attachments). Before using any database to audit these anatomy. The main reasons being that US imaging does not
aspects it is important to ensure that the data being audited is involve any radiation, is compact, portable and readily
a true reflection of anaesthetic activity, we believe our new available at the point of care. Better US equipment availability,
database is sufficiently accurate to audit the data within it. The staff awareness with appropriate training and improved
limitation of our audit is that we only audited the data from one documentation would aid in providing safer patient care.
month but we believe that the data entry practice of all months
References
is similar. We conclude that our electronic database is accurate
1. Chin KJ, Perlas A, Chan V, Brown-Shreves D, Koshkin A, Vaishnav
& the data entered can be used to audit our obstetric V: Ultrasound imaging facilitates spinal anesthesia in adults with
anaesthetic service. difficult surface anatomical landmarks. Anaesthesiology 2011; 115
(1): 94-101
References
2. Ultrasound-guided catherisation of epidural space. National Institute
1. Campbell NJ, Youngs P, Anderson I. A national survey of obstetric for Health and Care Excellence January 2008
anaesthetic data collection methods in the UK. Int J Obstet Anesth
2012; 21: S53. 3. Lee AJ, Ranasinghe S, Chehade JM, Arheart K, Saltzman BS,
Penning DH & Bimbach DJ. Ultrasound Assessment of the Vertebral
2. Pinder A, Wrench I, Shepherd D, Freeman R. Assessment of a Level of the Intercristal Line in Pregnancy. Anaesth Analg 2011;
handheld computer to collect obstetric epidural audit data. Int J
113: 559-564
Obstet Anesth 2002; 11: 8.
P6 Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin)
P111 Adherence to antenatal anaesthetic advice in P112 An evaluation of anaesthetic antenatal clinics in the
labouring morbidly obese parturients. obese obstetric population
S Halliday,  LC Robertson ,  HM du Plessis   PR El-Dalil,  DS Cochran,  R Ganapathy*  
Anaesthesia, Princess Royal Maternity Hospital, Glasgow, Department of Anaesthesia, Sandwell and West Birmingham
UK NHS Trust, Birmingham, UK, *Obstetrics and Fetal Medicine,
Introduction: Morbidly obese parturients pose a high Sandwell and West Birmingham NHS Trust, Birmingham, UK
anaesthetic risk1. Antenatal anaesthetic assessment for Introduction: Maternal obesity is increasingly common, with a
women with a body mass index (BMI) ≥40 kg.m-2 at booking is BMI 35 found in 5% of pregnancies. Current CMACE / RCOG
advised2. Early establishment of epidural analgesia is often guidelines advocate the referral of patients with a BMI 40 to
advocated. We sought to determine if this advice is adhered to an anaesthetic antenatal clinic. This study aimed to evaluate
in our centre. the outcomes following the implementation of such a clinic in a
Methods: A retrospective case note review of 49 morbidly busy inner city district general hospital.
obese patients (BMI ≥40) assessed antenatally was Method: High-risk patients were referred to a multidisciplinary
conducted. As a control, data from 23 patients with a BMI <40 antenatal clinic involving Anaesthetics, Obstetrics and
who had a labour epidural was collected. We compared the Haematology; patients with a BMI 40 were referred to the
timing of epidural request from labour ward admission, cervical clinic and included in the evaluation. Data was collected
dilation and syntocinon administration at request and the time retrospectively on the reason for attending, the past medical
from epidural insertion to delivery. Mode of delivery was also and obstetric history as well as any anaesthetic or surgical
noted. intervention provided in the perinatal period.
Results: Mean BMI for the control group was 23.6 (range 17- Results: In 2011, 72 women were referred to the clinic with a
32) and for the morbidly obese group 44.6 (40-60). Eleven BMI 40, although there were often other relevant co -
morbidly obese parturients had an elective caesarean section morbidities. The BMIs ranged from 40 to 80 (mean = 44). 44
(CS). Nineteen of the remaining morbidly obese parturients patients (61%) had a normal vaginal delivery, 3 women (4%)
requested labour epidurals. Two parturients delivered prior to required assisted vaginal delivery, 17 (24%) had an elective
insertion. caesarean section (CS), whilst 8 (11%) had a non-elective CS.
Of these patients, 38 (53%) required no anaesthetic
Time to Syntocinon Insertion to
Cervical dilation intervention.
request administration n delivery
  Centimetres
Minutes (%) Minutes Table: Anaesthetic intervention and failure rates in obese
(range)
(range) (range) parturients compared to previously published failure rates1 in
BMI Yes 12 (52.2) the general obstetric population
375 (110-
<40 169 (0-435) 3.7 (1-7) No 11 (47.8) Spinal Epidural CSE GA
915)
(n=23) Number attempted 19 12 4 1
BMI Yes 13 (68.4) % Failure rate 5 17 0 0
334 (12-702)
≥40  261 (0-555) 3.65 (2-8) No 6 ( 31.6) Published % failure rates1 6 24 18 <1
(n=17)
(n=19)
Discussion: The results demonstrated low regional
Table: Timing of epidural request, cervical dilation and anaesthesia failure rates, with only 1 unsuccessful spinal (5%)
syntocinon use at request, and time from insertion to delivery. and 2 failed epidurals (17%); figures comparable to those
In the control group with a BMI <40 that had a labour epidural found in the general obstetric population (Table). There is little
(n=23), the number of spontaneous vaginal deliveries (SVD), available data for regional anaesthetic failure rates in the obese
trial of forceps (TOF) and lower uterine segment CS (LUSCS) obstetric population precluding a direct comparison, but a
were 13 (56.5%), 5 (21.7%), and 5 (21.7%), respectively. For higher failure rate would be expected. A previous study of 677
those with a BMI ≥40 with an epidural (n=17) there were 6 women with a BMI 30 found an emergency CS rate of 24%, 2
(35.3%) SVD, 3 (17.7%) TOF and 8 (47.1%) LUSCS. The significantly higher than the 11% demonstrated in this cohort
number of SVD in the BMI ≥40 without an epidural group was of BMI 40. This robust multidisciplinary approach in the
18 (85.7%) and there were no TOF and 3 (14.3%) LUSCS. antenatal period allows for adequate planning and early
Discussion: Despite antenatal review, the time to epidural institution of optimised perinatal management. The service
request was longer in the morbidly obese group, indicating a provided was predominantly consultant led, with the on-call
need for ongoing education. The time between epidural Anaesthetist required to attend out of hours for parturients
insertion and delivery was shorter in the morbidly obese group with a BMI 45, and to be informed of patients with a BMI
which had a significantly increased chance of CS, signifying 40; significantly 73% of the on-call consultants are dedicated
the importance of establishing a working epidural early in this Obstetric Anaesthetists. We feel these systems may account
cohort. for our findings, as well as promote early and effective
communication with patients. Whilst the sample was relatively
References small the results are sufficiently encouraging to suggest that a
1. Soens MA, Birnbach DJ, Ranasinghe JS, van Zundert A. Obstetric multidisciplinary approach significantly improves perinatal
anesthesia for the obese and morbidly obese patient: an ounce of outcomes in the obese obstetric population.
prevention is worth more than a pound of treatment. Acta
Anaesthtesiol Scan 2008; 52: 6-19 References
2. OAA/AABGI Guidelines for Obstetric Anaesthetic Services 2013. 1. Kinsella SM. A prospective audit of regional anaesthesia failure in
Association of Anaesthetists' of Great Britain and Ireland and the 5080 caesarean sections. Anaesthesia 2008; 63(8): 822-832.
Obstetric Anaesthetists' Association. London, 2013. 2. Usha Kiran TS, Hemmadi S, Bethel J, Evans J. Outcome of
pregnancy in a woman with an increased body mass index. BJOG
2005; 112(6): 768-772.
Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin) P7
P113 An evaluation of fasting times for elective caesarean P114 An evaluation of intrathecal diamorphine versus
section surgery fentanyl for lower segment Caesarean section in a
J Ghoshdastidar,  KM Sherratt,  M Seneviratne*,  A medium-sized district general hospital
McGlennan   K Ramm,  LT Fenton-May,  S Naresh  
Anaesthetics, Royal Free Hospital, London, UK, Department of Anaesthesia, Good Hope Hospital, Heart of
*Anaesthetics, University College Hospital, London, UK England Trust, Birmingham, UK
Introduction: Enhanced Recovery Programmes have shown Introduction: Intrathecal diamorphine is now recommended by
increasing evidence for the benefits of reducing fasting times the National Institute for Health and Clinical Excellence (NICE)
for those undergoing elective surgery1. Many of these as the opioid of choice for lower segment Caesarean section as
benefits could be applicable to the elective caesarean section it provides improved post-operative pain relief.1 However, it is
patient. We evaluated the fasting times of our elective also associated with a dose-dependent increase in the
caesarean section patients to assess whether we could make incidence of pruritus2 and nausea3 which may be more
improvements to patient care. significant with diamorphine given its longer duration of
Methods: The evaluation included all patients undergoing action. Having arranged appropriate protocols for post-
elective caesarean section surgery at the Royal Free Hospital operative monitoring of women receiving intrathecal
over a 3 month period.. Patients received standard instructions diamorphine, we introduced the therapy in late 2012.
to stop eating at midnight on the day of surgery and to stop Methods: The evaluation took place over a six-week period. A
drinking clear fluids at 6 am. Data was collected by anaesthetic small number of women were still receiving intrathecal fentanyl
staff using a standardised data collection sheet.. Patients were due to clinician choice, and these provided a useful
questioned about the time they last consumed solid food and comparator. Women who were still present in the hospital on a
when they last drank liquid. follow-up round on the first day post-op were asked questions
Results: In total 77 patients underwent elective caesarean about post-operative pain, nausea and pruritus. We also
sections during the period of evaluation. We obtained data assessed total oral morphine and codeine doses and time to
from 71 patients for fasting times for fluids and 72 patients for first dose.
fasting times for solids. Results: Basic data is presented in the chart.

  Fentanyl Diamorphine
Pre-op fasting % of Pre-op fasting % of
Number 15 36
times FLUIDS patients times SOLIDS patients
Time to first morphine (hrs) 5.29 8.9
(hr) (n=71) (hr) (n=72)
Mean morphine dose (mg) 65.4 30
2 - 4 5.6 6 - 12 15.3
No morphine required 1 (6.6%) 11 (30.6%)
4 - 6 15.5 12 - 18 66.7
Mean codeine dose (mg) 123 119
6 - 8 14.1 18 - 24 16.7

8 - 10 8.5 over 24 1.4
Time to mobilisation (hrs) 21.17 15.21
over 10 56.3    
Time to catheter removal (hrs) 20.3 16.6

Discussion: There are no fasting recommendations specific to
Pruritus 8 (53.3%) 24 (66.7%)
elective caesarean sections but the standard surgical
- requiring treatment - 0 (0%) - 8 (22.2%)
guidelines of 6 hours for solids and 2 hours for clear fluids are
Nausea 5 (33%) 13 (36.1%)
usually applied. Periods longer than 12 hours without fluid
- requiring treatment - 3 (20%) - 7 (19.4%)
have correlated with significant dehydration
in patients having elective caesarean sections2. There is also
Discussion: Our results replicate previous work demonstrating
some evidence to suggest that gastric fluid volume is
a reduction in immediate post-operative analgesia
increased with prolonged starvation in the pregnant patient3.
requirements following a switch from fentanyl to diamorphine,
Over fifty per cent of our patients went without fluids for
but an associated increase in side effects requiring
longer than ten hours prior to surgery, and almost eighty-five
intervention. There was also a reduction in times to first
per cent of patients went without food for greater than 12
mobilisation and catheter removal, which is worth closer
hours. Our results show that there is a need to introduce
inspection. It is likely to be multi-factorial: the patients having
methods to reduce fasting times. These could include pre-
superior analgesia and feeling ready to move sooner, but also
operative letters with individualised times to stop eating and
the proforma for the ward indicating the patient had received
drinking. Also patients lower down the surgical list could be
diamorphine. This required the anaesthetist to specify a time
actively encouraged to consume clear fluids, or even
after which she would be ready to mobilise, which might have
carbohydrate drinks as used in many Enhanced Recovery
improved motivation amongst the midwives and mothers to
programmes.
achieve mobilisation.

References
References
1. Aguilar-Nascimento JE, Dock-Nascimento DB. Reducing
preoperative fasting time: A trend based on evidence. World J 1. NICE clinical guideline 132: Caesarean section
Gastrintest Surg. 2010 March 27;2(3): 57-60 2. Wrench IJ, Sanghera S, Pinder A et al, Dose response to intrathecal
2. Mackenzie M, Yentis S, Woolnough M and Johnson M. Fasting diamorphine for elective caesarean section and compliance with a
periods and dehydration before elective caesarean section. national audit standard, Int J Obstet Anesth. 2007;16(1):17-21
Anaesthesia, 2010 Vol 65:99 3. Sibilla C, Albertazzi P, Zatelli R, et al, Perioperative analgesia for
3. Maltby JR, Sutherland AD, Sale JP, Shaffer EA. Preoperative oral caesarean section: Comparison of intrathecal morphine and
fluids: is a five hour fast justified prior to elective surgery?. Anesth fentanyl alone or in combination, Int J Obstet Anesth. 1997; 6(1):
Analg. 1986 Nov;65(11):1112-6 43-48
P8 Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin)
P115 An evaluation of obstetric critical care admissions in a P116 An evaluation of standards of informed consent and
district general hospital documentation for labour epidural analgesia
VL Williams,  M Greene,  D Saul   S Chaudhari,  N Smith,  P Prasad  
Department of Anaesthesia, Leighton Hospital, Crewe, Anaesthetic Department, George Eliot Hospital, Nuneaton,
Cheshire, UK Nuneaton, UK
Introduction: CMACE has provided doctors with excellent
Introduction : It is both medico legally and ethically important
data over the past 50 years about maternal mortality, but
that the patient is made aware of the nature and risks
unfortunately no data about maternal morbidity. In December
associated with a labour epidural. No national standardised
2013, the Intensive Care National Audit & Research Centre
information card for informed consent is available, although
(ICNARC) produced a second report that analysed critical care
the OAA does publish a epidural information card1 with
admissions of women who were pregnant or recently pregnant
specific risks and incidence rates. At our hospital, the
in 2009-2012 inclusive.1 A comparison was made between the
documentation is made on part of the epidural chart as an
hospital ICNARC data and the national ICNARC data.
open entry. Our study looked to ascertain whether appropriate
Methods: Data were collected from the hospitals ICNARC
details of the epidural and informed consent were made. This
database over a four year period from 2009 to 2012. The data
was with a view to find whether a total redesign of the epidural
was analysed from the categories in the table below.
chart (at a level of standard suggested by the OAA website2)
Results: Data from 388 patients were evaluated.
was needed to improve our practice.
  Hospital ICNARC
Methods : We evaluated a total of 100 completed epidural
Total no. of patients admitted, female 16-50 years 388 55,791
charts over a 4-month period in mid-2012 at our obstetric unit.
Currently pregnant 3.6% 2.1%
The epidural notes were retrospectively analysed on our
Recently pregnant 9.3% 10.0%
scanned patient electronic notes. Documentation was
Obstetric reason for admission - currently pregnant 0% 8.7%
analysed for: details of the patient, anaesthetist and patient
Non-obstetric reason for admission - currently
100% 91.3% assessment, explanation of the risks and incidence given,
pregnant
details of the epidural technique and post epidural
Obstetric reason for admission - recently pregnant 50% 69.7%
management. Our main focus was on standards of consent.
Non-obstetric reason for admission - recently
50% 30.3% Results:
pregnant
%of patients Rate of risk
Discussion: The proportions of patients admitted to the Range of risk discussed
Risk discussed informed documented (no.
critical care area were comparable with the ICNARC report. (no. in total)
(n=100) in total)
The leading indication for admission in the currently pregnant
1in100:13,1in200:8
group was for sepsis. This corresponds with the ICNARC Headache 69 25
<1%:3,1in500:1
report and most recent CMACE report in which sepsis was the
Hypotension 45
leading direct cause of maternal death.2
Failure 59 4 1in8:2, 1in4000:2
The leading obstetric cause for currently pregnant admissions
Nerve 1in13k:21,1in10k:8
nationally, was for pre-eclampsia. However, there were no 65 31
damage 1in15k:1, 1 in19k:1
admissions in this category at the hospital. This is most likely
Itching 14    
because pre-eclampsia is diagnosed and treated effectively on
Infection 37  
the labour ward and rarely needs input from critical care.
Motor block 28    
In the recently pregnant group, there were equal proportions
Urinary
of patients admitted for obstetric and non-obstetric reasons, 28    
retention
this is quite different from the ICNARC report. The leading
indication for admission of recently pregnant patients in the The other areas of documentation studied showed an
ICNARC report was for post partum haemorrhage, by a long acceptable standard.
way. When looking at the hospital database, it showed that in Discussion : Several studies have looked at standards of
the period 2010-12, only 3 of 42 patients with a significant post informed consent in UK practice3and which risks and
partum haemorrhage of 2.5 litres or more were admitted to incidences were discussed and the range of risk quoted. Our
critical care. Therefore the question needs to be asked as to study showed rates generally to be slightly lower than that
whether these patients should have been admitted to the quoted in these studies. This is likely due to limited space and
critical care area? The hospital does not have an obstetric open entry nature of our current chart. The OAA has set
HDU, but in hospitals that do have an obstetric HDU facility, guidelines and advice for both epidural charts2 and risks and
these patients would certainly have been admitted there, had incidence1. Following this evaluation, a full redesign of our
closer monitoring and possibly goal directed therapy. All of epidural charts with prompts and guidance of risks and
these patients survived, but could admission to critical care incidence is warranted. In addition, the OAA had
have improved patient outcomes or reduced hospital stay? overwhelming support for a national standardised information
References card that could be implemented3.
1. Female admissions to adult, general critical care units in England,
Wales and Northern Ireland reported as 'currently pregnant'
References
or 'recently pregnant'. http://www.icnarc.org/documents/Obstetric%
20admissions%20to%20critical%20care%202009-2012.pdf 1. OAA epidural information card : http://www.oaa-
anaes.ac.uk/content.asp?ContentID=185
2. The eighth report on confidential enquiries into maternal deaths in
the United Kingdom. BJOG 2011, 118(Suppl 2):1-203 2. OAA epidural charts : http://www.oaa-anaes.ac.uk/content.asp?
ContentID=522
3. Informed consent for epidural analgesia in labour: A survey of UK
practice: Anaesthesia 2009, 64 p161-164
Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin) P9
P117 An unusual cause of post-partum sepsis P118 Anaesthetic management of a parturient with severe
F A Corcoran,  C Brennan,  A J Downs   systemic scleroderma
Anaesthetics, Dudley Group NHS Foundation Trust, Dudley, P Thomas,  A Varvinskiy,  M Human  
UK Anaesthetics, South Devon Healthcare NHS Foundation
Introduction: Leiomyomas are common in women of Trust, Torquay, UK
reproductive age and have been linked to spontaneous Introduction: Scleroderma is a chronic systemic autoimmune
abortion, retention of the placenta and post-partum disease. Successful pregnancy in patients with severe
haemorrhage.1 It is however rare for them to be the primary systemic scleroderma is very rare. We report the anaesthetic
cause of post-partum sepsis. We describe the case of a post management of such a case in a patient with a difficult airway,
partum patient presenting with painful fibroids and sepsis. severe pulmonary dysfunction and oesophageal dysmotility.
Case report: A 37 year old woman (P1), 5 days post partum Case report: A 29 year old woman (G1P0) with severe
presented with a history of fever, abdominal pain and systemic scleroderma presented to the hospital at 36 weeks
distention. She had a past medical history of fibroids but there gestation with dyspnoea and tachypnoea. Prior to pregnancy
had been no problems during pregnancy. She had an her exercise tolerance was poor, managing just 400 metres in a
uneventful labour with a normal vaginal delivery. On initial six minute walk test with resultant oxygen saturations of 72%.
assessment she was apyrexial with normal observations. She Her Forced Expiratory Volume (FEV1), Forced Vital Capacity
had mild tenderness on palpation of her abdomen. She was on (FVC) and Diffusing Capacity for Carbon Dioxide (DLCO) had
regular analgesics and had been commenced on oral each worsened steadily by five percent year on year over the
antibiotics by her GP. An ultrasound scan (USS) was booked last decade. The most recently measured values from 2007
to investigate the abdominal pain. Within 4 hours she had were FEV1 30%, FVC 28% and DLCO 24% of predicted values
deteriorated and developed a pyrexia, tachycardia, tachypnoea although the patient reported that her pulmonary function had
and decreased oxygen saturations. Initial impression was deteriorated significantly during pregnancy. On admission the
sepsis secondary to retained products so blood cultures and patient was breathless at rest with a p02 of 7.63 on room air
swabs were taken and intravenous antibiotics, oxygen and and it was felt that natural labour would not be possible due to
fluid resuscitation commenced. She was transferred to the poor physiological reserve. Severe reflux secondary to
Maternity High Dependency Unit. CRP was elevated but oesophageal dysmotility rendered her unable to recline more
lactate was normal. She improved over 6 hours but than 45 degrees and she could therefore not lie flat for awake
deteriorated again. Antibiotic coverage was amended caesarean section. Airway assessment revealed microstomia of
following microbiology advice but she continued to have a less than one centimetre, mallampati four, bucked teeth, sub
swinging pyrexia. USS detailed a bulky uterus with a large mental skin scleroderma and a narrow hooked nose with small
fibroid at the fundus and no retained products. 36 hours after nostrils. Oral intubation was therefore ruled out. Awake Fibre
admission she developed peritonitis and a CT abdomen which Optic Intubation (AFOI) appeared technically challenging due
suggested findings of a pedunculated fibroid measuring to nasal anatomy. Preoperative, bedside nasendoscopy
17.5cm that might have twisted on its pedicle. She had an revealed that AFOI would be possible should the need to
emergency laparotomy which revealed a degenerative, secure the airway arise mid operation. This avoided the need
necrotic, infected fibroid. She required ionotropic support and to perform an AFOI or awake tracheostomy pre-operatively.
was difficult to ventilate intra-operatively. Post-operatively The patient was positioned at 45 degrees on the operating
she was transferred to intensive care where she was sedated table. Surgeons confirmed that they could operate in this
and ventilated overnight. She was successfully extubated the position. A low dose spinal followed by an epidural which was
following morning and continued with intravenous antibiotics topped up gradually over 30 minutes using small incremental
and analgesia. She made a full recovery. Histology confirmed boluses achieved adequate block without compromising
the fibroid had extensive areas of coagulative necrosis, respiratory function. Surgery was completed without issue and
hyalinisation and inflammation. All microbiological both mother and baby did well post-operatively.
investigations were negative. Discussion: There are only three reports in the literature
Discussion: Sepsis in pregnant and post-partum women describing general anaesthesia for caesarean section in
remains a significant cause of maternal morbidity and patients with scleroderma and two using neuraxial blockade.1-5
mortality.2Sepsis is a clinical diagnosis and microbiological Of those who were intubated, one died and another required
investigations may be negative. Early recognition, timely three months ventilation. We demostrated how careful bedside
diagnosis and active treatment assists an optimum outcome. airway assessment and the use of a slow top up epidural were
Fibroids are common in pregnancy but sepsis secondary to successfully used to manage this challenging case.
infected, necrotic fibroid tissue post-partum is very rare. To References
our knowledge there have been no reported cases of this. It is
1. D'Angelo R, Miller R. Pregnancy complicated by severe
therefore essential to consider this in the differential causes of preeclampsia and thrombocytopenia in a patient with scleroderma.
obstetric sepsis when reviewing pregnant women with a Anesth Analg 1997; 85: 839-41
history of fibroids. 2. Hseu SS, Sung CS, Mao CC, Tsai SK, Lee TK. Anesthetic
management in a parturient with progressive systemic sclerosis
References during cesarean section. Acta Anaesthesiol Sing 1997; 35: 161-7
1. Mason T. Red Degeneration of a leiomyoma masquerading as 3. Younker D, Harrison B. Scleroderma and pregnancy. Br J Anaeth
retained products of conception. Journal of the National Medical 1985; 57: 1136-9
Association. 2002; 94: 124-6 4. Thompson J, Conklin KA. Anesthetic management of a pregnant
2. Lucas DN, Robinson PN, Nel MR. Sepsis in obstetrics and the role patient with scleroderma. Anaesthesiology 1983; 59: 69-71
of the anaesthetist. International Journal of Obstetric Anaesthesia. 5. Bailey AR, Wolmarans M, Rhodes S. Spinal anaesthesia for
2012; 21: 56-67 caesarean section in a patient with systemic sclerosis. Anaesth
1999; 54(4): 355-8
P10 Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin)
P119 Anaesthetic management of arrhythmogenic right P120 Anaesthetic management of obese parturients at a
ventricular cardiomyopathy during labour and tertiary centre - meeting the standard?
caesarean section: a case series L Kelliher,  J Teare,  E Evans  
J Eccles,  A Jain,  K Bhatia   Anaesthesia, St George's Healthcare NHS Trust, London, UK
Department of Anaesthesia, St Mary's Hospital, Manchester, Introduction: Obese women are at increased risk of perinatal
UK morbidity and mortality. In 2010 CMACE and RCOG published
Introduction: Arrhythmogenic right ventricular joint guidelines for the management of the obese parturient
cardiomyopathy (ARVC) is mainly a genetically determined including recommendations that patients with a booking BMI
autosomal dominant disease characterised by cardiomyocytes ≥40 should attend an antenatal anaesthetic clinic (AAC) and a
being replaced by fibrofatty tissue in the right ventricle.1 Specialist Trainee year 6 anaesthetist (ST6) or above should
ARVC has an incidence of 1:5000 and may account for as be informed and available to attend labour and operative
many as 5% of unexpected sudden deaths. The Eighth Report delivery1. Our unit is a tertiary centre with over 5,000
of the Confidential Enquiries into Maternal Deaths in the deliveries/year. A previous audit over 2 years showed that of
United Kingdom (2006-2008) highlighted that ARVC was the 120 women with BMI ≥40 attending our AAC, 76% required a
underlying cause in two of the 53 reported cardiac deaths. We peripartum anaesthetic intervention, with only 34% of these
describe the anaesthetic management of two parturients with performed by an anaesthetist ≥ST62. Awareness of the
ARVC who presented at our tertiary centre. guidelines was raised and anaesthetic plans for these women
Case reports: The maternal demographics, the cardiac signs, now state care should be managed by a senior anaesthetist.
symptoms and interventions along with the anaesthetic We examined our obese population following these changes.
management in the peri-partum period are briefly summarised Methods: A retrospective analysis over 1 year (2011-12) of
in the table below. hospital records for patients with a booking BMI ≥ 40. Records
were examined for referral and attendance at AAC, anaesthetic
Category Case 1 Case 2
intervention (regional/GA), grade of anaesthetist and
Age 27 23
anaesthetic complication (difficult/impossible regional, dural
BMI 25.8 27.2
tap, other).
Parity 0 0
Family history None Sudden death Results: In total there were 74 women with a booking BMI
Cardiac signs and Palpitations with spurts of Paroxysmal VT ≥40. 73% were referred to AAC, only 58% attended. Out of all
symptoms ventricular tachycardia (VT) patients, 69% had a peripartum anaesthetic intervention, 43%
Cardiac Cardiac ablation therapy and ICD insertion of which were performed by an anaesthetist ≥ST6 with a
intervention prior implantable cardioverter complication rate of 16%. Of those attending AAC, 67% had
to pregnancy defibrillator (ICD) insertion an anaesthetic intervention, 41% of which were performed by a
Mode of delivery Elective caesarean section Urgent LSCS for ≥ST6 with a complication rate of 17%. Of those patients not
(LSCS) for breech foetal distress attending AAC, 71% had an anaesthetic intervention and 36%
Anaesthesia and General anaesthesia, with Labour epidural of these were performed by ≥ST6 with a complication rate of
analgesia bilateral transversus analgesia, followed by 14%.
abdominal plane blocks top up for LSCS
Table 1. Incidence of complications by grade of anaesthetist
Maternal length of Three days Four days
stay Group ≥ST6 <ST6 p value (Fisher's Exact)
Neonatal APGAR 8 and 10 9 and 10 All 9.1% 20.7% 0.440
scores AAC 16.7% 17.6% 0.945
Discussion: The main implications of ARVC in parturients No AAC 0% 21.4% 0.273
include fatal arrhythmias, heart failure worsened by Discussion: This audit shows a significant number of obese
physiological changes of pregnancy and sudden adult death parturients were not seen in our AAC. A proportion of these
syndrome.1 Both our patients had VT diagnosed after 24 hour were referred, but did not attend however 27% were not
Holter monitoring, and an ICD was implanted in addition to referred. Despite this, there was no significant difference in the
beta blocker medical therapy to control the symptoms of VT as requirement for anaesthetic intervention or the incidence of
well as to prevent sudden death. The patients were seen in the anaesthesia-related complications between attenders and non-
joint cardiac, obstetric and anaesthesia antenatal clinic and a attenders. The incidence of senior anaesthetic involvement in
peri-partum plan formulated to facilitate safe delivery. Both care has risen from 34% to 41% but there is still room for
had serial echocardiograms, serum electrolytes monitored, improvement. This highlights the resource difficulties faced in
invasive blood pressure monitoring and ICD deactivated providing 24 hour senior anaesthetic cover. The on-call rota at
during their LSCS. Our case series highlights that both general our unit is staffed by junior and senior anaesthetists. The
and regional anaesthesia can be safely provided and we absence of a senior anaesthetist did not lead to a significant
recommend a multidisciplinary approach with close co- rise in anaesthesia-related complications, although there was a
operation between anaesthetists, cardiologists and t rend toward this (Table 1).
obstetricians to provide optimum care of these patients. References
Reference 1. Centre for Maternal and Child Enquiries & Royal College of
Obstetricians and Gynaecologists Joint Guideline. Management of
1. Alexoudis AK, Spyridonidou AG, Vogiatzaki TD, Iatrou CA.
Anaesthetic implications of arrhythmogenic right ventricular women with obesity in pregnancy. London: CMACE & RCOG; 2010
dysplasia/cardiomyopathy. Anaesthesia 2009; 64: 73-8. 2. Fulton L, Evans E, Schroeder F, Wendler R. Antenatal anaesthetic
assessment of morbidly obese women - a useful resource? 2013,
http://epostersonline.s3.amazonaws.com/oaa2013/oaa2013.0690195
.NORMAL.pdf
Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin) P11
P121 Anaesthetic management of the labouring patient with P122 Anesthetic implications  of heart disease in pregnancy
multiple sclerosis S Francés,  S Manrique,  M Goya,  M García,  R Perera,  N
J Li Wan Po,  K Maclennan   Montferrer  
Anaesthesia, St Mary's Hospital, Manchester, UK Anaesthetics, Vall d'Hebron University Hospital, Barcelona,
Introduction: Multiple Sclerosis (MS), an autoimmune Spain
inflammatory disease affecting the central nervous system, is Introduction: Despite advances in its diagnosis and treatment,
estimated to affect 20,000 or more UK women of childbearing heart disease (HD) in pregnancy remains a major cause of non-
age1. Controversy exists regarding the management of obstetric maternal and neonatal mortality and morbidity (it
anaesthesia and analgesia in labouring parturients with MS. complicates around 1-3% of pregnancies in developed
Following analysis of our practice at St Mary's Hospital, a countries). Accurate multidisciplinary assessment and
tertiary referral obstetric unit with over 8500 deliveries per management of individual maternal and fetal risks in pregnant
annum, and recent evidence in the literature; our women with HD provides the best opportunity to substantially
recommendations for the peri-partum management of improve outcomes for mother and baby. (1).
parturients with MS are presented. Methods: We present a prospective cohort study that
Methods: Interrogation of the St Mary's Hospital antenatal analyzed outcomes in women with HD, the majority of whom
clinic database, from 1999 to 2012, identified 21 pregnant had had corrective surgery and delivery between 2007 and
women diagnosed with MS. We reviewed antenatal advice, 2013. Baseline characteristics and adverse events during
intrapartum management and postpartum complications. delivery and postpartum were assessed. Intensive monitoring
Results: Over 50% of patients were nulliparous. The majority of the delivery and postpartum were planned beforehand in all
had mild sensory or motor deficit. Three relapsed during cases.
pregnancy, one improved in symptoms and one relapsed Results: One hundred and seventy-four patients with 179
postpartum. There were twelve normal vaginal deliveries, two pregnancies were included in the study. 127 women (72,98%)
instrumental deliveries, six Caesarean sections and one presented congenital heart disease (CHD), 47 acquired heart
unspecified delivered at another hospital. Five women opted disease (27,02%): 27 acquired rheumatic valve disease
for epidural analgesia, two were topped up for operative (19,98%), one Marfan syndrome (0,54%), 3 coronary heart
delivery. Five had spinal anaesthesia with 0.5% heavy disease (1,6%) and 9 primary myocardial disease (4,9%).
bupivacaine and one had a general anaesthetic. There were no
Pregnancy complications were presented in 21, 2% of CHD,
complications following regional technique.
14,8% of acquired rheumatic valve disease and 100% of
Discussion: A recent national survey reported that within a 10 women with arrhythmias.
year period, 91% of anaesthetists have encountered <ten
The type of delivery was vaginal in 124 women ( 72,1%) and
cases of MS2 and have little experience in their management
cesarean section in 50 women (27,9%).
during pregnancy. Recent evidence available supports our
168 women had analgesia during delivery (93,8%); 5 women,
current management of MS patients undergoing labour. The
general anesthesia (2,79%), 6 women, local anesthesia (3,35%)
low incidence of the disease makes it difficult to attain
and 87,5% of women had regional analgesia.
significant figures to determine the optimal management plan.
To standardize care, we made the following recommendations Delivery complications were 7% (uterine atony 2,7%, vaginal
based on the latest evidence and our own experience: hematoma 2,2%, chorioamnionitis 0,5%, cesarean hematoma
- Patients to be reviewed in an antenatal anaesthetic clinic. 0,5% and hemoperitoneum 0,5%). The only anesthesia
Document disease severity and discuss analgesia and complication was one dural puncture (0.5%). No maternal
anaesthetic options. death, one fetal death (0.5%) and one neonatal death (0.5%).
The maternal average hospital stay was 3 days.
- Use of 0.1% bupivacaine with 2mcg/ml fentanyl mixture for
epidural labour analgesia2 . For an operative intervention, top Discussion: Pregnancy and delivery are associated with
up with a higher concentration of local anaesthetic. substantial physiological changes, which require the
adaptation of the cardiovascular system and can expose
- Regional rather than general anaesthetic for caesarean
women with HD to significant risks. If regional anesthesia is
sections. Spinal anaesthesia is the most simple and reliable
selected, the addition of an opioid, when dosing any neuraxial
technique although consider combined spinal-epidural on an
anesthetic, will reduce the amount of local anesthetic required
individual basis.
and subsequent hemodynamic effects, while improve
- If a general anaesthetic is necessary, avoid suxamethonium
intraoperative and postoperative analgesia. The avoidance of
and monitor neuromuscular block to titrate dose of non-
epinephrine from the epidural dose will eliminate the possible
depolarizing muscle relaxant3.
deleterious effects of systemic epinephrine. Maintaining
These recommendations will be available for clinicians on the uterine blood flow is important for fetal well-being.
trust intranet and a patient information leaflet on the effects of Maintaining systemic vascular resistance in patients with
pregnancy and anaesthesia on MS has been produced. intravascular shunting, is important to avoid inducing or
exacerbating pre-existing cyanosis due to increased right- to –
References
left shunting. Cautious intravenous hydration and gentle
1. Brookings W, Lee M. Management of multiple sclerosis during
titration of phenylephrine or ephedrine are options to
pregnancy. Prog Neurol Psychiatry. 2009; 3(6): 9-11
counteract the hemodynamic effects of surgical neuraxial block
2. Drake E, Drake M, Bird J, Russell R. Obstetric regional blocks for
women with multiple sclerosis: a survey of UK experience. Int J (1,2). We observed a predominance of neuraxial anaesthetic
Obstet Anaesth. 2006; 15(2): 115-23 techniques, increased caesarean and operative delivery rates,
3. Griffiths S, Durbridge JA. Anaesthetic implications of neurological and favourable maternal and neonatal outcomes.
disease in pregnancy. Contin Educ Anaesth Crit Care Pain. 2011; 11
(5): 157-61 References
P12 Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin)
P123 Angle of tilt achieved with automated operating table P124 Antenatal anaesthetic information given to women
in elective caesarean sections: a comparison with tilt with obesity
achieved with an inflatable balloon wedge  C R Thomas,  C Busby  
PN Nair,  L Dyal,  B Grewal,  I Suri   Anaesthetics, Airedale General Hospital, Keighley, UK
Department of Anaesthesia, Warwick Hospital, Warwick, UK Introduction:Antenatal obesity is defined as a BMI of ≥30at
Introduction: A previous study1 done on patients undergoing booking. Its prevalence in England increased from 7% in 1990
elective caesarean sections looked into measuring the angle of to 16% in 2007.1Women with a BMI ≥40 are often provided
tilt of the operating table with an inflatable balloon wedge. with anaesthetic information antenatally. Those with lower
This showed that the visual estimation of angle proved levels of obesity also have an increased anaesthetic risk but
accurate in the achievement of near 150 tilt. Here we present these women may receive little or no information about this
the results of a similar study using a different technique of during pregnancy. 2The RCoA have produced standards
automated table tilt instead of the inflatable balloon wedge regarding care for these women: 90% of patients with a
device. The premise being is our visual actuation of tilt angle booking BMI ≥ 30 should receive a leaflet containing
accurate. information about anaesthesia and analgesia. 90% of patients
Methods: The study was similar to the previous one. We with a booking BMI ≥40 should have an anaesthetic consult.
prospectively selected 26 patients at random who were Booking BMI should be documented in 100% of maternity
undergoing elective lower segment caesarean section under hand-held notes. An audit of the above standards was carried
spinal anaesthesia over a six week period. Ethical committee out as summarised below.
approval was obtained. Verbal consent was obtained from all Methods:A list of all deliveries in January 2013 was generated.
participants and the booking Body Mass Index (BMI) was Notes were reviewed for adherance to the above three
noted. We used the same protractor device for measuring the standards. Change to practice was recommended based on
angle of tilt. This is similar to the one used by Kinsella et al2. audit findings. Following the implementation of change, the
Results: The measured angles ranged from 10 to 18 degrees, a audit cycle was completed by auditing notes of all deliveries in
mean angle of 13.70 with a mean difference of -1.3 and standard November 2013.
deviation of 2.32. This compared very closely to the angles Results:
between 10 to 17.5 degrees, mean angle of 13.650, mean Table: Recording of booking BMI, patient count by raised
difference of -1.35 and a standard deviation of 2.06 in the BMI category and number given anaesthetic information.
previous study. BMIs ranged from 19 to 37 with a mean of 24.
Discussion: The visual estimation of angle using the
BMI 30 - BMI 35 - BMI
automated table tilt proved accurate in achieving the near 150 No
Number of Unavailable 34.9; 39.9; ≥40; 
tilt and is comparable with that obtained with the inflatable   booking
deliveries casenotes info info info
balloon wedge device in the previous study. The standard BMI
given given given
deviation of 2.32 indicates that 95.4% of cases could achieve
Jan 195 6 2 20; 0 7; 1 7; 7
within 4.60 of the required 150 tilt i.e. 10.4 to 19.6 degrees tilt.
Nov 173 3 2 17; 2 7; 7 3; 3
The automated table tilt provides an easy and accurate means
of providing left lateral tilt in pregnant patients. Discussion: Booking BMI was recorded in 99% of the notes in
both audit cycles. In 100% of cases where BMI was ≥40, a
consultant anaesthetist discussed risk and made a plan with
References
the patient. However, the audit of January deliveries indicates
1. Grewal B, Suri I. Is visual actuation a valid predictor of angle of tilt?
that few women who have a BMI 30-39.9 receive anaesthetic
Int J Obstet Anaesth Vol 18 2009; pS1-64- supplement
information.; this occurred in only one case. Reaching this
2. Kinsella SM. A device for measuring the degree of lateral pelvic tilt
during supine recumbency. Anesth Analg 1995; 80: 204-5 population to provide information is difficult especially where
BMI is 30-34.9 as all antenatal care for this group may be
provided by community midwives. In collaboration with
Obstetrics, a patient information leaflet was written which
included both obstetric and anaesthetic information. The
leaflet was approved by the Women's Integrated Governance
group and has been in use since October 2013. It is available
on the Trust intranet which is accessible by some community
midwives. The leaflet is given to all those with a BMI ≥ 35
when they attend obstetric high risk clinic. The results of the
November audit indicate improvement has been made; 44.4%
of those with obesity now receive anaesthetic information.
Greater access to the leaflet is needed however.
References
1. Royal College of Anaesthetists 2012,
http://www.rcoa.ac.uk/document-store/audit-recipe-book-3rd-edition-
2012
2. Centre for Maternal and Child Enquiries 2010, http://www.oaa-
anaes.ac.uk/assets/_managed/editor/
File/CMACE/CMACE_Obesity_Report_2010_Final%20for%
20printing.pdf
Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin) P13
P125 Antenatal management of morbidly obese parturients: P126 Audit of temperature for patients undergoing elective
A multicentre evaluation. caesarean section
H Aladin,  A Khandhia,  K Pottinger   N J Truman,  I Clegg,  K Maclennan  
Anaesthetics, Good Hope Hospital, Birmingham, UK anaethetics, St Mary's Womens Hospital, Manchester, UK
Introduction: Women with a body mass index (BMI) of ≥30 Introduction: Perioperative Hypothermia is associated with
kg/m2 at the time of antenatal booking are classed as being poor outcomes and adverse events for patients; including
obese in pregnancy, accounting for around 39,000 maternities surgical site infection increased length of stay, blood loss,
per year1. Obesity is associated with increased risk of shivering, increased anaesthetic recovery time and cardiac
anaesthetic morbidity and mortality. National guidance have events. Risk factors for the occurrence of hypothermia include
been developed following the Confidential Enquiry into regional anaesthesia, fluid deprivation, blood loss, and cold
Maternal and Child Health report concerning obesity in fluid administration, all of which are common to obstetric
pregnancy. At two different hospitals, five indicators of best patients. 2008 Nice guidelines CG651 on perioperative
practice2 were analysed: (1) Recording of maternal BMI. (2) hypothermia do not include parturients, despite being an at
BMI ≥ 30 women receive information about risk group. An audit performed in 2011 at St Mary's Hospital
anaesthesia/analgesia. (3) Women with a BMI ≥ 40 have demonstrated that 92.5% of elective section patients were not
antenatal anaesthetic review. (4) Duty anaesthetist should be 'comfortably warm' on arrival in recovery, with 65% defined as
informed when women with a BMI ≥ 40 are admitted. (5) hypothermic. A repeat audit was performed following
Anaesthesia for women with a BMI ≥ 40 should be provided commencement of a trial of an air free conductive fabric patient
by a senior anaesthetist. warming system (Hot Dog®).

Methods: Women who had undergone a lower segment Method: A prospective audit of elective caesarean section
caesarean section (LSCS) during a 6 month period (Jan 2013- patients was conducted from April-June 2013 at St Mary's
Jun 2013) at a District General Hospital (DGH) and a Hospital. Theatre staff completed the audit proforma. Data
Foundation Hospital (FH) were evaluated. Data was collected collected included; ambient theatre temperature (ideal target
retrospectively from an electronic data archive and anaesthetic 21ºC), anaesthetic type, estimated blood loss (EBL),
charts. Evidence of BMI calculations, provision of temperature pre, intra, post operative and prior to discharge
anaesthesia/analgesia information, ante-natal anaesthetic from recovery (measured using a tympanic membrane
appointments, and anaesthetic care in the labour ward and thermometer) and details of which Hot Dog® warming
theatre were identified. products were used. Hypothermia was defined as a core
Results: 309 women who underwent a LSCS were identified temperature <36ºC with desirable temperature being defined as
with a having a BMI 30 (median 34, range 30-59). 51% of 36.5-37.5ºC. Comparison of the results from the 2011 audit
these were elective cases. 56% of women with a BMI ≥30 enabled conclusions to be drawn regarding the effectiveness
received anaesthesia/analgesia information, of which 2 were of the warming product.

given literature on anaesthesia in obesity. 32% of women with
Results: A total of 33 patients were audited who underwent
a BMI 40 underwent an antenatal anaesthetic review, with an
elective caesarean section, [n=79, 2011audit], 94% had spinal
additional 4 women failing to attend their appointments. In
anaesthetic (87%, 2011 audit). Mean (S.D) theatre temp was
those women with a BMI ≥40, the duty anaesthetist was
22.8 (± 0.6) [22.3 (± 0.6), 2011 audit], mean duration of
informed of admission in 19% of cases and in 56% of LSCS,
procedure was 51 minutes. 94% of patients had an additional
the anaesthetic care was provided by an appropriately graded
fluid warmer intra-op (72%, 2011 audit). The mean EBL was 574
anaesthetist .
ml (± 213) [653 (± 431), 2011 audit] and only 6% of patients had
Table: Women with BMI 30 having anaesthetic care at a DGH an EBL over 1L (20% 2011 audit). Only 12% (n=4 of 33) of
and FH. patients warmed with the HotDog® were hypothermic on
arrival to recovery (compared to 65% (n=51 of 79), 2011 audit)
  DGH FH
figure 1.
Total LSCS 32% (99/309) 68% (210/309)
Discussion: efforts have been to reduce perioperative
BMI Median (range) 33 (30-59) 34 (30-52)
hypothermia in elective caesarean sections. Almost all patients
Maternal height, weight + BMI recorded 100% 100%
received warmed fluids via a 3M™ Ranger™ fluid warming
Conclusion: This audit has identified that more than half the
system. Forced air warming devices applied to the upper body
women with a BMI ≥30 received analgesia/anaesthesia
are not well tolerated by our awake patient population and
information and more than half were anaesthetised by a senior
allow only a limited area to be heated. introduction of
anaesthetist. However, in all the areas of practice, the target
HotDog® with an under patient warming mattress and
percentage of women meeting the identified standards were
separate over patient warming blanket (for upper and lower
not achieved. Recommendations included revision of the
limb) proved to be of benefit in perioperative maintenance
referral guidelines for antenatal anaesthetic assessment,
when compared to our standard warming measures. A
improved communication within the multidisciplinary team
HotDog® warming mattress placed on the patient chair in the
during admissions and increased presence of senior
pre theatre waiting area helped prevent hypothermia pre arrival
anaesthetists on delivery suite.
in theatre.
References
Reference
1. Centre for Maternal and Child Enquiries (CMACE). Maternal
1. CG 65 Management of inadvertent perioperative hypothermia in
obesity in the UK: Findings from a national project. London:
adults. NICE April 2008.
CMACE, 2010
2. The Royal College of Anaesthetists. Raising the Standard. A
compendium of audit recipes for continuous quality improvement in
anaesthesia. 3rd Edition 2012
P14 Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin)
P127 Availability of chlorhexidine handwash for regional P128 Caesarean section in a rhesus null parturient with a
analgesia on the labour ward uterine fibroid
K Chima,  T Strickland,  F Plaat   P J Stewart,  R Laird,  J Cartmill  
Anaesthetics , Queen Charlotte's and Chelsea Hospital, Anaesthetics, Altnagelvin Area Hospital, Londonderry, UK
London, UK Introduction: The anaesthetic management of a Caesarean
Introduction: Many patients request regional analgesia during section is made more challenging by the combination of pre-
labour and therefore central neuraxial blocks are performed in operative anaemia, a large uterine fibroid and the presence of a
the delivery room. For central neuraxial blocks an aseptic very rare blood group Rhesus null.
technique should be standard. In the Third National Audit Case report: A forty-year lady with a past medical history of
Project of the Royal College of Anaesthetists the incidence of psoriatic arthritis presented to antenatal booking at 10 weeks
iatrogenic infection was reported as being 8/707 000 gestation. Booking investigations revealed a haemoglobin of
procedures1. However the consequence of any infection is 10.3g/dL, and a blood group O Rhesus null. Her 20-week
potentially devastating, and a 'scrupulous' aseptic technique ultrasound scan revealed no foetal anomalies but did
was therefore stated to be mandatory in the report1. demonstrate an anterior uterine fibroid. This was confirmed
Chlorhexidene gluconate 4% is used for hand decontamination with magnetic resonance imaging which showed a
in our department. It was noticed that not all delivery rooms heterogeneous mass measuring 188x139x159mm, in keeping
were equipped with both chlorhexidene and a hands free with a degenerating fibroid. At 21+3 days she presented with
method for application. dizziness and right upper quadrant pain. Her haemoglobin
Methods: All delivery rooms on labour ward were inspected to level was 7.6g/dL and she was treated for iron deficiency
ascertain the presence of chlorhexidene and a hands free anaemia. Due to a transverse lie and the large fibroid an
dispenser. elective Caesarean section at 38 weeks was planned. As a team
we anticipated a difficult Caesarean delivery with greater blood
The audit was repeated after one and twelve months to assess
loss in a patient with anaemia and a very rare blood group.
if there had been any improvement in the service.
Antenatal management focused on maximising the patient's
Results: Originally, 12 of the 16 delivery rooms had
haemoglobin levels and sourcing compatible blood. The
chlorhexidene available (75%). Of the 12 rooms with
Northern Ireland blood transfusion service and National frozen
chlorhexidene only three were equipped with a hands free
red cell bank in Liverpool secured two units of packed red cells
dispenser (25%), and five containers were uncovered (42%).
in England. Unfortunately, one week prior to the section this
After one month all 16 rooms were equipped with wall blood was issued in an emergency, making it unavailable to us.
mounted chlorhexidene with a hands free dispenser (100%). A new donor was found in South Africa and a further unit was
After a further 12 months it was found that 12 of the 14 secured in Brazil. Both units were couriered to our hospital
delivery rooms had chlorhexidene available (86%). (Two of the prior to the Caesarean delivery which was performed at 38+6
rooms had been converted to a post delivery high dependency days under spinal anaesthesia. Pre-operative haemoglobin was
unit). Eleven of the 12 containers were equipped with a hands 9.1g/dL. The patient was discharged home on day three post-
free dispenser (92%). operatively and her haemoglobin was 7.2g/dl on discharge. No
Discussion: The results of the initial data collected, as well as blood transfusion was required.
anaesthetists' concerns regarding the unavailability of Discussion: Red blood cells from people who have the Rhesus
chlorhexidine and dispensers in each room, was reported to null phenotype lack Rhesus proteins, and thus, Rhesus
managerial staff, who ensured all rooms were adequately antigens. This phenotype occurs in approximately 1 in 6x106
stocked. Results were therefore better when re-auditing was individuals1. When these patients are transfused they may
performed at one month. However, after 12 months standards form antibodies to high frequency rhesus antigens, which can
had declined, although they were still improved from the make it extremely difficult to process compatible blood. Rhesus
initital audit. This decline could be attributed to the fact that null blood is available from the National frozen cell bank,
neither a team nor a named individual was made responsible however it may not be available when required due to limited
for sustaining the initial improvement, which if introduced, we supplies, as in our case. There is very limited literature
feel would encourage a sense of ownership and enable the regarding the management of the rhesus null parturient and
improvement in this area of patient safety to be sustained. our management was guided by our regional Haematology
Reference unit. This case demonstrates the importance of good
communication with all members of the multi-disciplinary team
1. National Audit of Major Complications of Central Neuraxial Block
in the United Kingdom 2009, http://rcoa.ac.uk/system/files/CSQ- and the detailed preparations required in a complex case.
NAP3-Full_1.pdf
Reference
1. Avent ND, Reid, ME. The Rh blood system: a review. Blood 2000
95: 375-387.
Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin) P15
P129 Category one caesarean sections in a district general P130 Comparison of two non-invasive cardiac output
hospital:  Improving the decision to delivery time monitoring devices in a parturient with complex
VK Wroe,  AM Troy   cardiac disease.
Department of Anaesthesia, Countess of Chester Hospital, PJ Rose,  V Misra,  S Quasim  
Chester, UK Anaesthesia, UHCW, Coventry, UK
Introduction: National Guidelines state that the interval from Introduction: The management of valvular lesions during
decision to delivery (DDI) in a category one caesarean section pregnancy and labour can present a clinical conundrum. We
should be less than 30 minutes1, and that a duty anaesthetist present the use of two cardiac output (CO) monitoring devices
should be immediately available for emergency work on the in a parturient with complex valvular heart disease undergoing
delivery suite 24 hours a day2. a caesarean section under epidural anaesthesia.
A 2008 departmental audit found that 85% of category one Case Report: A 37 year old primiparous woman with history of
sections had a DDI of under 30 minutes, a figure marginally ASD repair aged 4, severe mitral regurgitation, severe tricuspid
under the audit standard of 90%. Anaesthetic service regurgitation, moderate aortic stenosis (AS) secondary to a
provision in our trust was expanded in July 2012, with the congenital bicuspid valve and moderate pulmonary
addition of a dedicated obstetric anaesthetist 24 hours a day. hypertension presented for elective caesarean section.
This re-audit aimed to assess the proportion of category one Echocardiography showed moderately dilated right ventricle
caesarean sections with a DDI <30 minutes and analyse the with good bi-ventricular systolic function, bi-atrial dilatation,
factors contributing to any delay. moderate to severe AS (mean gradient 34mmHg, peak gradient
Methods: After audit department approval, a retrospective 53mmHg, estimated valve area 0.74cm2). Pulmonary artery
analysis of category one caesarean sections between August pressures were estimated at 42-47mmHg. LiDCO rapid and
and December 2012 was performed. Data collected included Cheetah NICOM devices were used to monitor CO.
DDI and reason for delay, indication for section, type of Anaesthesia was established with 32mL 2% lignocaine and 100
anaesthesia and cord pHs. micrograms of epinephrine via epidural. Compound sodium
lactate was infused at 60mL/hr, and increased to 100mL/hr after
Results: 69 category one caesarean sections were analysed.
epidural anaesthesia. Fluid boluses of 200mL and 100mL were
The mean DDI was 23 minutes (range 3-120 minutes). 84% had
delivered via the pump at 13 and 28 minutes after delivery of a
a DDI of under 30 minutes, with a mean time from decision to
live infant. Metaraminol infusion was titrated to effect.
effective anaesthesia of 14.5 minutes. The indication for
Syntocinon infusion was started upon delivery (20 units in
caesarean section was abnormal CTG in 87% of cases (2008:
48mL 0.9% saline) at 15mL/hr and tapered post-operatively
77%). General anaesthesia was performed in 43% (2008: 85%),
over 4 hours. Mean arterial pressure was maintained at 91 to
spinal anaesthesia in 55% (2008: 15%) and extension of
97mmHg until delivery (78 minutes) and then decreased to
epidural blockade in 2%. In 11 cases, DDI was over 30
67mmHg at the end of surgery. Cardiac output was maintained
minutes; these cases were all performed under spinal
throughout surgery with an increase at the time of concurrent
anaesthesia. The following table shows the reasons identified
fall in MAP. Fluid challenge had negligible effect although
that contributed to delay:
there was a small reduction in heart rate (84 to 59bpm).

Arrival in
Discussion: NICE has advocated the use of cardiac output
theatre Incision to
Spinal monitoring in high risk non-obstetric surgery to improve
10 delivery Staff Theatre
  placement outcome.1 In this case we utilised both a non-calibrated pulse-
minutes time 10 unavailable unavailable
10 minutes contour waveform analysis and bioreactance system to
from minutes
compare both values measured and response to fluid
decision
challenge. Although the values produced were different, the
Number
trends were broadly similar. This, once again, highlights the
of 4 6 1 1 1
importance of analysing trends rather than absolute values to
patients
guide management. Interestingly, both devices demonstrated
Arterial cord blood analysis was carried out in 10/11 cases. pH
that a fall in MAP correlated with an increase in cardiac
was less than 7.2 in 30%, and base excess was less than -8 in
output, similar to previous investigators.3 Given that cardiac
20%.
disease is the leading cause of death in the most recent
Conclusion: The proportion of cases with a DDI of over 30 triennialreport2, monitoring cardiac output enables one to
minutes has remained constant at around 15%, despite an maintain physiological homeostasis, and ultimately aids
improvement in anaesthetic staffing. Our results suggest that clinical decision-making leading to good clinical outcome, as in
the causes for this delay are multifactorial, and the results are our case.
not benign- the delay in delivery led to a cord pH of <7.2 in
References
almost one third of cases. We intend to improve our practice
1. MTG3 CardioQ-ODM (oesophageal Doppler monitor): guidance
by regular practice drills, use of preprepared spinal packs to
2011, http://www.nice.org/nicemedia/live/13312/52624/52624.pdf
reduce spinal placement time, clear procedures to follow in the
2. Centre for Maternal and Child Enquires (CMACE). Saving Mothers'
case of staff or theatre unavailability and reaudit. Lives: Reviewing maternal deaths to make motherhood safer: 2006-
2008. The Eighth Report of the Confidential Enquires into
References
Maternal Deaths in the United Kingdom. BJOG 2011;118(Suppl
1. Caesarean section. NICE Clinical Guideline 132. NICE, London 1):1-203
2011. (http://publications.nice.org.uk/caesarean-section-cg-132).
3. Fanning NP, Sermer M, Colman J, Carvalho JC, Cordovani D. Non-
2. OAA/AAGBI guidelines for obstetric anaesthetic services- 3rd invasive Hemodynamic monitoring with bioreactance for cesarean
edition. AAGBI and OAA, London, 2012 delivery. A more relaxed look at tight aortic stenosis? Abstract
(http://www.aagbi.org/publication/publication-guidelines/M/R) SOAP 2011, http://www.soap.org/display_2011_abstract.php?id=58
P16 Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin)
P131 Comparsion of slow and rapid bolus of ephedrine in P132 Continuous spinal anaesthesia for a primigravida with
patients undergoing planned caesarean section under severe tricuspid regurgitation, Harrington rods and
spinal anaestheisa WITHDRAWN FROM  thrombocytopenia.
PRESENTATION AM Walton,  I Mettam  
PG Sekar,  LB Ellakumanan,  H Balachander,  MVS Obstetric Anaesthetic Department, University Hospital
Satyaprakash   Southampton, Southampton, UK
Anaesthesiology, JIPMER, Puducherry, India Introduction: We present the successful use of continuous
spinal anaesthesia (CSA) for caesarean delivery in a parturient
with severe tricuspid regurgitation and pregnancy-induced
thrombocytopenia in addition to Harrington rod placement for
scoliosis spinal surgery.
Case history: A 40 year old primigravida presented at 37
weeks gestation. She had undergone a tricuspid valve repair
previously for endocarditis. The patient had developed severe
tricuspid regurgitation and had heart failure. Harrington rods
were placed in her thoracic and lumbar spine for repair of a
congenital scoliosis. Blood tests revealed a pregnancy related
thrombocytopenia with platelets of 85x109/L. An
echocardiogram showed a severly dilated right atrium with
intra-atrial septal bowing to the left, severe free flowing
regurgitation and right ventricular systolic pressure
32mmHg.The case was discussed with obstetricians,
anaesthetists and cardiologists and a decision was made for
an elective caesarean section under CSA, if the final platelet
count remained stable. The patient expressed a preference to
remain awake and avoid a general anaesthetic. At surgery a
cannula and radial arterial line were inserted. In the sitting
position a 22G spinal needle was inserted below the level of
the scar tissue at L3/4, and a spinal catheter threaded into the
subarachnoid space. A total of 10mg bupivacaine and 250mcg
diamorphine were required over 20 minutes to establish a block
to T4. The blood pressure dropped from 135/70 to 90/50mmHg
and required only 5mcg of epinephrine to return to baseline
values. Blood loss was 720mls. Syntocinon was given as an
infusion only. A live male infant was delivered.
Discussion: An obstetric anaesthetist has to take many
factors into account when deciding on the best choice of
anaesthetic for a particular case; anaesthetic expertise,
maternal co-morbidities, fetal well-being and maternal
preferences all play a part. Cardiac disease in pregnancy is still
the leading cause of indirect maternal mortality in the UK.1 The
choice of anaesthetic and delivery had to ensure the least
amount of strain on an already compromised heart. The
advantages of CSA are that a block can be established
gradually with small incremental doses of local anaesthetic,
which reduces the likelihood of cardiovascular instability.2
The concerns with a CSA are principally neurological
complications and post-dural puncture headache. CSA is
proving an option to be considered for patients with
significant cardiac disease and previous spinal surgery
provided the anaesthetist has experience with the technique.
In this case it provided a cardiovascularly stable anaesthetic
with excellent analgesia and maximal maternal satisfaction.
References
1. Saving mothers lives.The Eighth Report of the Confidential
Enquires into Maternal Deaths in the UK. March 2011
2. DennyNM, Selender DE. Continuous spinal anaesthesia. Br J
Anaesth 1998;81:590-7
Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin) P17
P133 Does pre-operative anxiety predict post-operative pain P134 Early epidural analgesia may increase caesarean
scores in parturients undergoing caesarean section? section rate in spontaneously  labouring nulliparous 
BM Daly,  N Weidenhammer,  R Junkin,  L Riddell,  J Dolan,  J women: a retrospective study
Kinsella*,  R Marla,  S Young   R Anil Kumar,  Roger Mc Morrow  
Anaesthesia, Princess Royal Maternity, Glasgow, UK, Anaesthesia, National Maternity Hospital , Dublin, Ireland
*Anaesthesia, Pain & Critical Care Medicine, University of Introduction:.Epidural analgesia offers the most effective
Glasgow, Glasgow, UK method of intra-artum pain relief. The effect of epidural
Introduction: Pregnancy, childbirth, and undergoing a surgical analgesia on the progression of labour and the mode is often
procedure are all likely to induce anxiety. The relationship debated in multiple studies. This study aims to show the effect
between anxiety, pain and pregnancy is complex.1Childbirth is of timing of epidural analgesia on the mode of delivery.
a time of high anxiety, and Caesarean section is known to be Method: Data such as women's age, gestational age, cervical
associated with significant pain post-op. Here we ask can dilatation before epidural insertion and duration of labour was
anxiety scoring predict post LSCS pain? collected from a total of 2029 nulliparous women in
Methods: After ethical approval and consent, pre-operative spontaneous labour. Epidural analgesic was defined as early at
data and a single 24hr post-op 10cm VAS were collected from a cervical dilatation of 3cms or less and late at a cervical
108 women, with 9 having missing data. Spielberger2 State and dilatation of 4 or more cm
Trait anxiety forms were completed prior to surgery. We Results: Of the 2029 women, 1423 ( 70.1%) received epidural
present secondary end points powered post hoc for 0.8 analgesia. Out of the 2029 women, 1403 ( 69.2%) had
probability of 2cm VAS difference. A standardised anaesthetic spontenous vaginal delivery, 478 (23.6%) had assisted
(spinal including diamorphine) and analgesic regime was used. delivery and 146 ( 7.2%) had caeserean section.
The cohort was divided into "high"- above the mean and
The data was anaylsed according to the timing of epidural
"low"- below the mean anxiety and compared using Student's
analgesia or no epidural analgesia and modes of delivery.
t-test.
Anaesthetic Delivery method
Results:
intervention Spontaneous Assisted Caesarean
Table 1: State anxiety compared to VAS
No epidural 537 (88.9%) 51 (8.4%) 16(2.6%) 604
Low anxiety High anxiety Early epidural 757 (62.2%) 379 126 (10.0%) 1262
  Significance
(n=45) (n=54) (30.0%)
24 hr VAS mean Late epidural 109 (67.7) 48 (29.8%) 4(2.5%) 161
5.0 (2.2) 5.3 (2.0) P= 0.40
(SD) cm
Epidural Assisted delivery C-Section
Table 2: Trait anxiety compared to VAS analgesia OR 95% CI p-value OR 95% CI p-value
Low anxiety High anxiety Early 5.27 3.86, 7.21 <0.001 5.59 3.28, 9.51 <0.001
  Significance
(n=48) (n=55) epidural
24hr VAS mean (SD) Late 4.64 2.97,7.23 <0.001 1.23 0.40,3.76 0.71
4.8 (1.9) 5.5 (2.2) P= 0.15
cm epidural
Table 3: State +Trait anxiety compared to VAS Conclusion: The results from the study show that the
Low anxiety High anxiety likelihood of having caeserean section in the early epidural
  Significance
(n=48) (n=51) group is significantly higher compared to the late epidural
24hr VAS mean (SD) group, but the incidence of assisted delivery between the early
cm 4.8 (1.9) 5.6 (2.1) P=0.072 and late epidural group were similar. This study also shows
that there is an increased likelihood of having assisted
Discussion: While the higher anxiety groups displayed a delivery and caeserean section delivery with epidural
higher mean VAS in all the analysis, this was not statistically analgesia compared to without from the study group.
significant. The separation between the two groups was better
References
with the State than the Trait anxiety score and best of all when
1..Gonen Ohel. Early versus late initiation of epidural analgesia in
the two scores were combined. Further reasearch could look at
labour: Does it increasethe risk of cesarean section. A randomised
anxiety scoring as part of a bundle of other measures verus trial. American journal of Obstretrics and Gynaecology (2006) 194,
pain. 600-5
2. Wassen et al. Early versus late epidural analgesia and risk of
References
instrumental delivery in nulliparous women: a systemic review.
1..Waldenstrom U: Experience of labor and birth in 1111 women. J British Journal of Obstretrics and Gynaecology (2010) 1471, 655-
Psychosom Res.1999: 47(5):471-82 661
2..www.mindgarden.com
P18 Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin)
P135 Efficacy of midwife led epidural top ups in labour–Are P136 Emergency obstetric and neonatal care in Kenya:
programmable pumps really the way forward? Addressing millennium development goals
E Traer,  G Waters,  GNB Jackson   D B Pachter,  C A Ameh*  
Anaesthetic department, Royal Berkshire NHS Trust, Anaesthesia, Cumberland Infirmary, Carlisle, UK, *Maternal
Reading, UK and Neonatal Health, Liverpool School of Tropical
Introduction: There are an increasing number of automated Medicine, Liverpool, UK
techniques by which labour epidurals can be managed1,2,3,4. Introduction: In 2008, an estimated 358,000 women died from
Comparison reports of programmable epidural pumps regimens complications of pregnancy and childbirth. The overwhelming
have shown lower total volumes of local anaesthetic may be burden of this mortality occurs in the developing world, with
associated with reduced rates of instrumental delivery and almost 60% of deaths occurring in sub saharan Africa.1There
improved maternal satisfaction1,2. Extended intervals between are also some 3.6 million neonatal deaths each year, and once
boluses with larger volume boluses was shown to use less again the developing world is disproportionately represented.2
total local anaesthetic3. These reports have led us to In 2006, the Liverpool School of Tropical Medicine (LSTM)
investigate similar outcomes our unit where we have a midwife developed a training package entitled "Life Saving Skills,
led top up (MLTU) practice. Emergency Obstetric and Neonatal Care" (LSS EOC-NCC) to
Method: First epidural bolus administered by the anaesthetist try and address these huge public health issues. Courses now
of 20ml 0.1% bupivicaine+2µg/ml fentanyl . Data recorded at run in 11 countries worldwide. In October 2013, I was fortunate
each subsequent midwife administered bolus (MLTU): bolus e nough to teach on a course in Nyeri, Kenya.
interval time, motor block (Bromage score of 2-4 taken as motor Methods: A variety of teaching methods were used on the
block), any change to the standard dose 20ml 0.1% course. Didactic lecture based teaching had a limited role, with
bupivicaine+2µg/ml fentanyl and if analgesia was effective or more emphasis placed on small group "break out sessions"
ineffective. and scenario based teaching. Pre and post course simulation
Results: 50 patients audited based testing was undertaken, with results collated and sent
back to Liverpool for analysis and assessment of efficacy of
Midwife led epidural Top Up Data  
teaching.
Mean bolus interval time (min) 105 (sd 26)
Mean rate bupivicaine mg/hr 10.56 (sd 3.6) Results: Participant feedback suggested a high level of
Motor block (Bromage score 2-4) 11/48 (22.9%) satisfaction with the course. The impact of courses in terms of
Mean time to motor block (min) 237 (sd 135) reduction in maternal and neonatal mortality remains the
NVD 14/48 (29.1%) subject of ongoing scrutiny. One study from Somaliland
Instrumental 18/48 (37.5%) demonstrated improved knowledge and skills and evidence of
LSCS 16/48 (33.3%) positive behaviour change post introduction of the course.3

Satisfaction excellent/good 46/48 (95%)
Conclusions: Maternal morbidity and mortality remains a huge
Discussion: In this study we found the mean interval in problem in Kenya. In 2008 it's Maternal Mortality Ratio was
minutes between epidural boluses to be 105minutes. This is 488 per 100,000, one of the highest in the world.4Great efforts
greater than the average 60minute interval of the are being made by the Kenyan government to reduce this. An
programmable intermittent bolus(PIB) regimens. An average ambitious target to reduce MMR to 91 per 100,000 by 2018 has
rate of bupivicaine 10.56mg/hr was similar to that reported with been set. One step has been the introduction of the Liverpool
PIB and patient controlled epidural bolus(PCEA) regimens4, LSS EOC-NCC course.
while we report a lower rate of motor block. Given the practice Acknowledgements: I would like to thank the maternal and
of MLTU in effect is much like a PIB without PCEA, it is neonatal health unit at LSTM for the opportunity to become
notable that the time between epidural boluses is longer with involved, and look forward to teaching on my next course. I
MLTU with less maternal motor block and high maternal would also recommend the course to any obstetric
satisfaction. We feel our practice promotes close epidural anaesthetists with an interest in international health.
assessment as the midwives assess motor block and maternal
References
satisfaction before each “top-up” and avoids the cost of the
1. World Health Organization, UNICEF, UNFPA and The World
PIB/PCEA pumps.
Bank. Trends in Maternal Mortality 1990-2008. 2010.
References 2. Lawn JE, Kerber K, Enweronu-Laryea C, et al. 3.6 million neonatal
deaths–what is progressing and what is not? Seminars in
1. Capogna G Camorica M, Stirparo S, Farcomeni A. Programmed Perinatology 2010;34:371–386.
Intermittent Epidural Bolus Versus Continuous Epidural Infusion for
Labor Analgesia: The Effects on Maternal Motor Function and 3. Ameh C, Adegoke A, Hofman J, et al. The impact of emergency
obstetric care training in Somaliland, Somalia. International Journal
Labor Outcome. A Randomized Double-Blind Study in Nulliparous
of Gynecology & Obstetrics. 2012;117:283-7.
WomenAnesth Analg July Oct 2011; 113(4): 826-831
4. Kenya National Bureau of Statistics. Kenya Demographic and
2. George RB, Allen T, Habib A. Intermittent Epidural Bolus
Health Survey (KDHS) 2008-09. June 2010.
Compared with Continuous Epidural Infusion for Labour Analgesia:
A Systematic Review and Meta Analysis. Anesth Analg Jan 2013;
Vol 116: 133-144
3. Wong C, MacCarthy RJ, Hewlett Bl. The effect of manipulation of
the programmed intermittent bolus time interval and injection
volume on total drug use for labour epidural analgesia: a randomized
controlled trial. Anest Analg 2011; 112: 904-11
4. Husain T, Mavridou I, Fernando R, El-Wahab N, Stewart A, Dick J,
Columb M. A study of a programmed intermittent bolus and patient-
controlled epidural regimen for labour analgesia. Int J Obstet
Anaesth May 2013: P85 Abstracts OAA Bournemouth 2013
Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin) P19
P137 Enhanced recovery after elective caesarean section: P138 Epidural analgesia in obese parturients: can kneeling
Service evaluation and quality improvement be the answer to our prayers.
GJ Lilley,  M Adamson,  A Miskin*,  M Turner   S De Silva,  L Kelliher*,  R Mottaleb*,  E Combeer  
Anaesthetics, Royal Gwent Hospital, Newport, UK, Anaesthetics, Frimley Park Hospital, Frimley, UK,
*Obstetrics and gynaecology, Royal Gwent Hospital, *Anaesthetics, Royal Surrey County Hospital, Guildford, UK
Newport, UK Severe pain is not life-threatening in healthy parturient women,
Introduction: Enhanced recovery (ER), a concept widely it is however shown to have neuropsychological
recognised within many surgical specialties, is now a subject consequences. Postnatal depression may be more common
of interest within obstetrics. The core principles comprise when effective analgesia is not used1 and pain during labour
speeding up recovery and improving patient outcomes, with has been linked with the development of post-traumatic stress
associated benefits for staff and healthcare systems1. The disorder2.There is an increasing number of obese parturients3
most logical starting point for the introduction of ER principles and identification and placement of the epidural can be
are elective caesarean section lists. Delayed surgery may lead difficult in these women.
to prolonged fasting, followed by delayed mobilization, Classically the sitting or the lateral position is used during
delayed removal of catheter and delayed discharge. A pilot siting of labour epidurals. The kneeling position was first
audit in our hospital demonstrated a mean stay after elective described in 19934, where 34/35 women had their labour
caesarean section of 3.6 days, and mean preoperative fasting epidural sited whilst in the kneeling position and 88.5% of the
period of 12.4 hours. Current guidance for ER in obstetrics mothers were happy with this position.
suggests minimal interruption to oral intake, pre-operative
I elected to try the kneeling position in an obese lady with a
energy drinks, catheter removal at 12 hours post-surgery
BMI 50 after adjustments in the sitting position and two
regardless of time of day, and the option of discharge home 24
separate failed attempts to confidently palpate the lumbar
hours after caesarean section where appropriate2.
spine. Once the lady was in the kneeling position, the lumbar
Methods: All elective caesarean sections were included in this spine was not only palpable but also visible and the epidural
service evaluation after introduction of preoperative space was identified with ease. With Departmental approval I
carbohydrate drinks. Data collection included fasting time, in performed my labour epidurals in this manner and found it not
addition to time to mobilization, to catheter removal and to only to be easy to site epidurals but also tolerated well. Some
discharge. After an initial 6 week period of data collection, the women complained of paraesthesia in their feet, but this was
data was presented to anaesthetic and obstetric staff. Posters, rare and eased swiftly. We decided to survey our Deanery to
a discharge proforma and a patient information leaflet were ascertain what positions were being utilised.
produced, and specific guidance was developed regarding
Survey: An e-survey was sent to trainees and Consultants in
preoperative carbohydrate drinks. A further 6 weeks of data
the South West London Deanery into what their ideal first and
collection then took place.
second choice positions used for siting epidurals would be for
Results: A total of 78 consecutive patients were included, all labouring parturients. We then posed the same question for
of whom received a regional anaesthetic technique for elective obese parturients (BMI 40). They were asked if they had
caesarean section. The following table illustrates the timing of heard of the kneeling position and if anyone had tried it. For
pre- and post-operative events before and after our those who had not, we questioned why they had not tried it.
interventions.
Results: We received 53 responses, 96.2% of whom were
Time period / hour 2nd 6 week Initial 6 week
trainees. 64.2% chose to position the parturient sitting as their
mean(SD) period period
first choice and 60.4% chose lateral as their second choice in
Pre-op fasting 4.8 (2.8) 3.8 (2.5)
non-obese parturients. In comparison 84.9% opted for the
Post-op fasting 4.2 (3.5) 3.4 (3.5)
sitting position in obese parturients with 56.9% using the
Total interruption to oral
9.0 (4.5) 7.1 (4.6) lateral as their second choice. The only positions utilised were
intake
sitting and lateral. 94.9% of respondents had not heard of the
Delivery to mobilization 10.2 (4.5) 9.0 (3.3)
kneeling position to site labour epidurals.
Delivery to catheter removal 14.8 (6.6) 13.5 (3.5)
Conclusion: Each position used for the placement of labour
Delivery to discharge 67.3 (40.1) 63.3 (27.6)
epidurals has their own advantages and disadvantages. With
Discussion: The introduction of patient information leaflet
the rising incidence of maternal obesity and its associated
offering guidance regarding post-operative oral intake,
risks to not only the mother but also the unborn child, we need
mobilization, catheter removal and early discharge, along with
to be continuing in our development and advancement in the
staff education and introduction of pre-operative carbohydrate
provision of good care. We suggest that the kneeling position
drinks, has resulted in improvement in the timing of a number
is a safe and viable alternative for siting epidural catheters in
of peri-operative interventions, and a small reduction in
labouring parturients.
duration of hospital admission. However, possibly due to
References
obstetric, midwifery, paediatric and organisational reasons,
discharge is rarely achieved at the potential target of 24 hours 1. Hiltunen P, Raudaskoski T, Ebeling H, Moilanen I Does pain relief
during delivery decrease the risk of postnatal depression? Acta
after elective caesarean section. Obstet Gynecol Scand 2004;83:257-261
References 2. Soet JE, Brack GA, Dilorio C Prevalence and predictors of women's
1. Lucas DN, Gough KL. Enhanced recovery in obstetrics - a new experience of psychological trauma during childbirth. Birth
frontier? Int J Obstet Anaesth 2013; 22: 92-95 2003;30:36-46
2. Enhanced recovery partnership: A better journey for patients and a 3. Centre for Maternal and Child Enquiries (CMACE). Saving
better deal for the NHS. Available at: Mothers'. Lives: reviewing maternal deaths to make motherhood
http://www.improvement.nhs.uk/documents/er_better_journey.pdf safer: 2006–2008. The Eighth Report of the Confidential Enquiries
into Maternal Deaths in the United Kingdom. BJOG 2011;118:1-203
P20 Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin)
P139 Epidural labour analgesia and risk of instrumental P140 Estimation of blood loss during caesarean sections -
delivery discrepancy between visual and laboratory estimation
R Carvalho,  T Ferreira,  M Duque,  D Catré,  I Guedes,  J P A Nowicka,  A Amasakera,  C Ferdinand,  I Suri  
Assunção   Anaesthesia, Warwick Hospital, South Warwickshire NHS
Anaesthesiology, Centro Hospitalar Tondela Viseu EPE, Foundatio, Warwick, UK

Viseu, Portugal
Introduction: Excessive blood loss is a major threat to women
Introduction: Epidural analgesia (EA) is a worldwide effective undergoing casearean sections. Accurate visual estimation of
method used for pain relief during labour. Nevertheless, its use blood loss is difficult due to dispersion of blood lost and the
and evolution to instrumental vaginal (forceps or vacuum blood being mixed with amniotic fluid(1). Therefore the blood
extraction) or operative deliveries remains controversial loss often gets under or overestimated(2). A number of
between experts,1 either anesthesiologists or obstetricians. methods exist to estimate the blood loss, the commonly used
We aimed to analyze the relation between EA and instrumental being: visual estimation by the attending staff, weighing of the
v aginal deliveries in a sample of our obstetric population. blood soaked surgical swabs and calculation based on the pre-
and post-operative haemoglobin concentrations(3). The aim of
Methods: A retrospective study included all pregnant women
this audit was to compare the visually estimated blood loss by
who delivered on our labour Room, between 1-January-2011
both the surgeons (vEBLs) and anaesthetists (vEBLa) against
and 31-December-2012, excluding those who underwent
the calculated estimated blood loss (cEBL).
caesarean section. We reviewed the data of demographical
characteristics, type of gestation and labour, the use of EA Methods: Data was collected on thirty five caesarean sections.
and the newborn APGAR score. Descriptive analysis of Operating surgeona and anaesthetists were asked to visually
variables was used to summarize data and Chi-Square test was estimate the blood loss in each case. The circulating blood
used. Multivariate analysis was done with logistic regression, volume was calculated for each patient based on the body
with calculation of corrected Odds Ratio (OR) and its 95% weight and height. Then, the blood loss during caesarean
confidence interval (95% CI). section was calculated using the circulating blood volume and
the pre- and post-operative haemoglobin concentrations.
Results: 2901 pregnant women were included in this study, Correction was made for the haemodilution by intravenous
with mean age of 29,7 years. 81% underwent EA and 30% fluid administered.
instrumental vaginal delivery. 51% were nulliparous. Applying
Results: Twenty six complete forms were included in the
Chi-Square test to independent variables, we obtained
analysis. None of the patients received blood or blood
significant associations with dystocic delivery for EA, normal
products intraoperatively. Mean volume of intravenous fluid
maternal age (NMA; 20-35 years) and parity (p<0,001).
infused was 1304mL±421. Mean vEBLs, vEBLa and cEBL was
Applying logistic regression to our model, including parity,
590mL±300, 623mL±372 and 821mL±1004 respectively. The
NMA and EA with dystocic deliveries, we obtained corrected
tendency for anaesthetists to give a higher estimate of blood
OR (95%CI) for EA 2,459 (1,884-3,210) and for parity 3,4
loss was not statistically signifficant (p=0,12). There was a
(2,867-4,121), with NMA loosing significance. However, this
clear discrepancy between the visual estimate given by both
result may still be biased by other factors, such as labour
the surgeons and the anaesthetists, ant the cEBL, however, it
stage at the time of the EA beginning, drugs used in epidural
did not reach statistical significance (p=0,11 and p=014
space, use of oxytocin during labour, among others.
respectively). Compared to the cEBL the vEBL was
Additionally we found that, in our population of term
overestimated when the blood loss was low (12 cases) and
pregnancies, NMA and eutocic deliveries, there was no
underestimated when the blood loss was higher than 500mL
significant relation between EA and APGAR score <8 at the
(14 cases). There was a linear relationship between the degree
first minute (p=0,079).
of underestimation and the blood loss, with high levels of
Conclusion: It's generally assent that EA provides the most blood loss being most underestimated.
effective pain relief in labour. However, it's associated to Conclusions: In this audit, the standard procedure for
prolonged labour and risk of instrumental or caesarean estimation of blood (visual estimation by the obstetrician) loss
deliveries.2 Our study has drawn the conclusion that both was found to be unreliable. We demonstrated a tendency of
having EA for labour pain relief and being nulliparous increase anaesthetists and surgeons to overestimate the blood loss, if
the chance of instrumental delivery, respectively in 2,459 and actual blood loss was less than 500mL, and underestimate if
3,43 times, however without significant impact on newborn the blood loss exceeded 500mL. As a result of the audit, it has
APGAR score. Bigger prospective studies correcting for more been made compulsory in our unit to check haemoglobin
risk factors are advised. concentration in recovery whenever the vEBL exceeds
References 1 000mL.
1. BMC Pregnancy and Childbirth 2008, 8:45. References
2. Acta Obstet Gynecol Scand 2002, 8:1033-1039. 1. Khan FA, Khan M, Ali A, Chohan U Estimation of blood loss during
Caesarean section: an audit. J Pak Med Assoc. 2006 Dec;56(12):572-
5.
2. Larsson C, Saltvedt S, Wiklund I, Pahlen S, Andolf E Estimation of
blood loss after cesarean section and vaginal delivery has low
validity with a tendency to exaggeration. Acta Obstet Gynecol
Scand. 2006;85(12):1448-52.
3. Stafford I, Dildy GA, Clark SL, Belfort MA, Visually estimated and
calculated blood loss in vaginal and cesarean delivery. Am J Obstet
Gynecol. 2008 Nov;199(5):519.e1-7
Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin) P21
P141 Ethnic variations in use of labour analgesia P142 Factors associated with the use of spinal anaesthesia
LMD MacDarby,  CMC McCaul   for caesarean section in Nigeria
Delivery Suite, The Rotunda Hospital, Dublin, Ireland C Imarengiaye,  F Asudo*,  A Akinmola†,  B Lawal§  
Introduction; This retrospective cohort study was compiled to Anaesthesiology, University of Benin Teaching Hospital,
establish the wide variety of nationalities presenting to The Benin City, Nigeria, *Anaesthesia, University of Abuja
Rotunda Hospital for delivery during a one month period and Teaching Hospital, Gwagwalada, Nigeria, †Anaesthesia, 
to determine the labour analgesia preferences amongst this National Hospital, Abuja, Nigeria, §Anaesthesia, Lagos 
population. Island Maternity Hospital, Victoria Island, Nigeria

Introduction: There has been a consistent increase in the rate
Methods; Details of all deliveries occurring during the month
of spinal anaesthesia for caesarean section in many hospitals
of October 2013 were collected. Any patients undergoing
worldwide and had been advocated as the preferred technique
elective caesarean section and those with failed inductions
for caesarean delivery.1 Recent evidence suggests increasing
were excluded from the study. A demographic of patients’
use of spinal anaesthesia for caesarean sections in reports
nationality and ethnic background was compiled. Data relating
from a teaching hospital.2 The rise in spinal anaesthesia
to these patients’ use of labour analgesia was recorded i.e.
caesarean section notwithstanding, it is pertinent to determine
epidural uptake, pethidine administration and remifentanil
the factors limiting the wholesome application of spinal
infusion use. We then established the frequency of use of
anaesthesia for caesarean section in Nigeria.
each of these methods of analgesia in each population

Methods: A snap-shot survey was conducted in some
Results; There were 767 deliveries in Oct 2013. 104 elective
selected hospitals in Nigeria. The survey determined the
caesarean sections were carried out and there were 8 patients
sociodemographic characteristics of patients, indication for
who failed induction.
surgery, grade of anaesthesia provider, contraindication to
Therefore a total of 655 patients laboured during this time. spinal anaesthesia and any other factor that may be noticed in
This number was made up by 50 different nationalities. Of the selected hospital. The survey was to be conducted over a
these 414 patients were Irish, the majority being white but 2-week period but was truncated by the nation-wide strike
including small numbers of Asian or Black background. action by doctors after 9 days.
Amongst the Irish patients the rate of epidural uptake was
Results: A total of 99 patients were attended to in 4 of the
43.47% (234) and the rate of pethidine use was 17.87% (74)
selected 6 hospitals within the study period. 36/99 women
Patients of other white background, including many eastern
were nulliparous and maternal factors (82/99) were the leading
european countries made up 134 of the patients. These
indications for caesarean section. Consultant anaesthetists
patients as a group had a 52.98% epidural uptake rate. Black
(23/99), Senior Registrars (35/99), Medical Officers (36/99) and
Africans were found to have a 39.13% (9) uptake rate and
others (5/99) provided anaesthesia for the caesarean sections.
those of Asian background had the highest rate at 54.83%
85/99 patients received spinal anaesthesia and 14/99 had
(17). The use of pethidine was significantly lower than the rate
general anaesthesia for the c-section. Fetal indication for
of epidural in all of these groups. Pethidine was used by
caesarean section had a 3-fold risk of general anaesthesia for
18.19% of Black Africans, 12.9% of Asians and 23.13% in
the surgery (p = 0.037, RR = 3.1, 95%CI 1.2 – 8). 25/99 and
those of other white backgrounds. There were only 3 cases of
74/99 were performed as elective or emergency procedure.
remifentanil use during the month
Nature of caesarean section was not a factor for the use of
Discussion; The highest incidence of epidural uptake during spinal anaesthesia (p =0.51, RR = 2.0, 95%CI = 0.5).
Oct was found to be amongst the Asian population, the lowest Discussion: Over 85% of caesarean sections in Nigeria were
being amongst Black Africans. Pethidine use was less than conducted under spinal anaesthesia. Fetal indications for
25% in all groups. The reasons for these trends is unknown caesarean section provoked a 3-fold increase in general
though previous studies have suggested that cultural and anaesthesia for caesarean section. The use of general
educational factors may play a part. anaesthesia for caesarean delivery was due to fetal indications
A prospective survey of patients post delivery detailing the for surgery, antepartum haemorrhage and failed spinal
reasons for their choices of labour analgesia would be anaesthesia. Improved practical conduct of the spinal
worthwhile. Establishing the factors influencing their technique may enhance great application of spinal anaesthesia
decisions may allow us to provide an unbiased and fully for caesarean section.
comprehensive service to ensure patient satisfaction. References

1..Morgan BM, Magni V, Goroszenuik T. Anaesthesia for emergency
caesarenc section. BrJ Obstet Gynaecol 1990; 97: 420-424
2..Amadasun FE, Idehen HO, Edomwonyi NP. Evolving pattern of
anaesthesia for caesarean section: Experience at the university of
Benin Teaching Hospital West Afr J Med 2013; 32: 196-9
P22 Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin)
P143 Failed intubation for a category 1 caesarean section in P144 Fasting dilemmas: A rare case of a patient with non-
a patient with undiagnosed spina bifida ketotic hyperglycinaemia presenting for caesarean
CR Deane,  E Lewis,  J Spargo   section
Department of Anaesthetics, Singleton Hospital, Swansea, M Behravesh,  S Dawson,  G McClune,  S Atkinson  
UK Anaesthetics, Royal Jubilee Maternity Hospital, Belfast, UK
Introduction: Non-ketotic hyperglycinaemia (NKH) is a rare
Introduction: Spina Bifida Occulta (SBO) is part of a spectrum
autosomal recessive metabolic disease caused by a defect in
of neural tube defects and is common. We present the case of
the glycine cleavage system. This case report describes the
a patient with previously undiagnosed SBO who required a
management of a patient who presented for caesarean section.
category 1 caesarean section (CS). Despite an unremarkable
To our knowledge there are no other published case reports of
airway assessment she had a failed intubation on rapid
this type.
sequence induction (RSI) and subsequently required an awake
fibre optic intubation (AFOI). Case Report: A 32 year old Para 1 presented for elective
caesarean section of twins at 37 weeks gestation. She had a
Case report: A 37 year old para 0 patient presented to labour
history of atypical non-ketotic hyperglycinaemia. Following
ward labouring with a single live foetus at 37 weeks gestation.
advice from clinical chemistry, during her 6 hours preoperative
She was admitted under consultant obstetric care with
fast she received an inceased dose of sodium benzoate and an
asymptomatic hypertension. When considering an epidural
intravenous infusion of 10% dextrose at 3mls/kg/hour which
she was examined and had a vascular naevus, associated with
was continued perioperatively. Caesarean section was
skin tethering, over lumbar vertebrae. She was asymptomatic,
performed under spinal anaesthesia and twin baby boys were
had never been investigated, and had no definitive diagnosis
delivered successfully. Post delivery of the second twin she
of SBO. Airway assessment included a Mallampatti score of 3,
received a bolus of 5 units of syntocinon followed by an
but was otherwise unremarkable. An epidural was declined to
infusion at 10 units per hour. Due to uterine atony and an
the patient, with a remifentanil PCA provided instead. A plan
operative blood loss of 1000mls she also received ergometrine
was agreed for a RSI GA if operative intervention was
carboprost intramuscularly to good effect. Sodium benzoate
required. Several hours later she required a category 1 CS.
was administered orally in recovery and the 10% dextrose
Initial laryngoscopy with a Mackintosh blade yielded a
infusion was continued until the patient was establised on an
Cormack and Lehane grade 3 view. Manipulation of the cricoid
oral regimen prescribed by the dieticians. This involved a
cartilage, long and McCoy blades did not improve the view.
series of high calorie drinks up to every 2 hours for 48 hours.
Two failed attempts were made to intubate using a bougie. The
No dietary protein was allowed for 24 hours post delivery.
patient was ventilated using a face mask and a Guedel airway
Glycine levels were monitored daily and were raised on day 5
with oxygen saturations above 97% throughout. She was
while dietary protien was being gradually reintroduced.
woken up without further incident and an AFOI was
performed. Her child was delivered by LSCS without further Discussion: NKH has an incidence of 1 in 60,000 with 3
incident or obvious deficit. The APGAR scores were 8 and 10 distinct presentations. Classically neonates present with
at one and five minutes. A grade 3 view was confirmed before lethergy, hypotonia and seizures. These symptoms can
the patient was woken. Recovery from anaesthesia was proceed to apnoea requiring ventilation and 30% of patients
uneventful. The patient was appropriately counselled. An do not survive the neonatal period. Severe psychomotor
Airway Alert Letter was issued and follow up appointment retardation is common in those who survive. A second,
made. An MRI was carried out subsequently and showed a atypical and very rare form presents with mild baseline
neural arch defect and dural tethering. Significantly the conus hyperglycinaemia and intermittent encephalopathy
lay as low as L4 with diastematomyelia as far as L2. assosciated with periods of illness. Transient neonatal
hyperglycinaemia has also been described. Biochemically,
Discussion: SBO is common and without prior imaging
NKH is characterized by elevated glycine concentrations in
presents the clinician with a difficult decision. Regional
plasma, CSF, and brain with a CSF glycine to plasma glycine
techniques risk neural or dural injury due to a low lying or
ratio greater than 0.08.1 Standard treatment strategies include
tethered cord.1 Abnormal spread of the analgesic agents may
protein restriction to reduce exogenous glycine,
give rise to either excessive cranial spread or inadequate
supplementation of one-carbon pool donors and
caudal spread. This patient population provides further issues
administration of sodium benzoate. NMDA antagonists have
for the anaesthetist given the high risk of operative delivery or
been shown to raise the developmental quotient, improve
other intervention (due to pelvic structural abnormalities) and
muscle tone and reduce seizures in these patients.2
the association of spina bifida with difficult intubation.2,3
Patients with spina bifida require careful preop assessment Prolonged periods of fasting predispose these patients to
and MRI imaging and careful airway consideration is essential glycine build up and its toxic neurological effects. This has
in order to inform anaesthetic planning. major implications for the anaesthetist in the perioperative
period. This case demonstrates the safe use of regional
References
anaesthesia in conjunction with careful nutritional planning.
1. Reynolds F. Damage to the conus medullaris following spinal
anaesthesia. Anaesthesia 2001; 56: 235-247. References
2. Richmond D, Zaharierski I, Bond A. Management of pregnancy in 1. Chang YT, Lin WD, Chin ZN et al. Nonketotic hyperglycinemia: A
mothers with spina bifida. Eur J Obstet Gynecol Reprod Biol 1987; case report and brief review. Biomedicine 2012; 2(2):80-82
25: 341-5. 2. Van Hove JL, Vande Kerckhove K, Hennermann JB et al. Benzoate
3. May A, Fombon F, Francis S. UK registry of high-risk obstetric treatment and the glycine index in nonketotic hyperglycinaemia.
anaesthesia: report on neurological disease. Int J Obstet Anaesth Journal of Inherited Metabolic Diseases. 2005;28:651–663
2008; 17: 31-6.
Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin) P23
P145 Fetal bradycardia following regional anaesthesia for P146 Further increase in hysterectomy rates - and the
emergency caesarean section and instrumental reason why
delivery: a service evaluation JS Campbell,  M Molloy,  C Thompson,  D Fogarty  
JK Sidana,  K Jadhav-Smith,  J Corfe   Royal-Jubilee Maternity Service, Belfast HSC Trust, Belfast,
Anaesthetics, Norfolk and Norwich University Hospital, UK
Norwich, UK Introduction: RJMS is the tertiary obstetric service for
Introduction: Fetal heart rate abnormalities, such as late Northern Ireland. As part of a service review of use of uterine
decelerations or fetal bradycardia, are known to occur after artery balloon catheters, we retrieved data from several
neuraxial anaesthesia.1 These may be due to maternal sources. We found a large proportion of these patients still
sympathetic blockade or an increase in the uterine tone caused required hysterectomy. Further interrogation of our data
by intrathecal opioids. The objective of this service evaluation showed some unexpected trends.
was to evaluate the incidence and management of fetal Methods: With approval of the Trust's Data Guardian we used
bradycardia following regional anaesthesia for emergency data from several hospital systems, including a local maternity
caesarean section and instrumental deliveries. care database and histology records.
Methods: 15 patients with an episode of fetal bradycardia Results: We found 30 hysterectomies from 37,088 deliveries in
following regional anaesthesia were identified by reviewing 6 years. This is a rate of 0.8 per 1000 - significantly higher than
the daily obstetric handover sheets from January to December our prior rates which was near the NICE-quoted rate of up to 3
2011. The medical notes of these patients were reviewed for per 1000. Of these cases, 23 (76%) were due to morbidly
peripartum obstetric management, cardiotocographic (CTG) adherent placenta.
findings, perioperative anaesthetic management and
Not all these cases of morbidly adherent placenta were
management of fetal bradycardia. Neonatal outcome was
diagnosed antenatally, which perhaps made hysterectomy
assessed by APGAR scores, umbilical cord gases and NICU.
more likely since facilities such as intra-arterial balloon
Results: 10 patients had an assisted delivery and 5 had an catheters could not be available to us in an emergency.
emergency category-2 LSCS. The peripartum CTG findings Unanticipated cases suffered greater blood loss. Despite no
were either suspicious or pathological. Timing of fetal diagnosis, the majority (16/23) were placenta percreta on
bradycardia following regional anaesthesia ranged from 2 to 15 histology. These percreta cases again had greater blood loss,
min. 13 patients received spinal anaesthesia and 2 received and were more likely to require ICU care post-operatively. Yet
epidural top up. Maternal haemodynamics stability was there were no cases of percreta in the 6 years prior, and less
maintained with left uterine displacement, intravenous fluids than half the number of hysterectomies in that period. This
and phenylephrine infusion. One patient had an episode of seems to be a dangerous and dramatic change in recent years.
maternal bradycardia below 50 beats/min which was treated
Conclusion: We found a recent and significant increase in
with anticholinergics. Comparing the baseline maternal heart
peripartum hysterectomy, associated with a large increase in
rate with the lowest perioperative heart rate, 3 patients had a
the number and degree of morbidly adherent placenta. Patients
greater than 40% drop in the heart rate. 5 patients had a blood
with placenta percreta had a greater blood loss, and more
pressure drop of more than 20% below the baseline, which was
commonly required hysterectomy and ICU care.
treated with phenylephrine. The highest level of block to
Reference
temperature was T3. Syntocinon was stopped in all but one
case in the event of fetal bradycardia. Significant delays 1. National Institute for Health and Clinical Excellence. Caesarean
section: NICE Clinical Guideline 132 2012,
occurred in transferring these patients to theatre after the
http://www.nice.org.uk/nicemedia/live/13620/57163/57163.pdf
decision for surgical intervention were taken, maximum 35 min
(median 17 min). 6 cases had poor neonatal outcomes with low
5 minute APGAR and abnormal cord gases.
Discussion: We could not find any direct cause which can be
solely attributed to regional anaesthesia for the occurrence of
fetal bradycardia in these patients. Significant delay in patient
transfer to theatre may have a causal relationship but cannot
be confirmed. Studies in elective patients have shown that
maternal bradycardia causes a drop in maternal cardiac output.
2 Relative maternal bradycardia occurred in several of our
cases and this would have led to drop in cardiac output and
therefore oxygen delivery. This is most likely a side effect of
phenylephrine use. We plan to introduce a care bundle to
implement pre-operative and intra-operative fetal resuscitation.
This will include steps to improve fetal condition at the time of
regional anaesthesia and to ensure adequate maternal cardiac
output and oxygen delivery.
References
1. Reynolds F, Seed PT. Anaesthesia for Caesarean section and
neonatal acid-base status: a meta-analysis. Anaesthesia 2005; 60:
636–653
2. Stewart A, Fernando R et al. The dose-dependent effects of
phenylephrine for elective caesarean delivery under spinal
anaesthesia. Anesthesia & Analgesia 2010; 111: 1230-7.
P24 Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin)
P147 Impact of workload on accidental dural puncture P148 Implantable cardioverter defibrillator in
(ADP) rate pregnancy WITHDRAWN FROM PRESENTATION
W Mon,  YM Liu,  A Stewart,  R Fernando,  M Columb*   S Chaudhari,  S Quasim  
Anaesthetics, University College London Hospital, London, Anaesthetic Department, University Hospital Coventry and
UK, *Intensive Care Unit, University Hospital of South Warwickshire , Coventry, UK
Manchester, Manchester, UK
Introduction: Post dural puncture headache is an important
cause of morbidity. We audit our ADP rates annually against
the national standard.1Between 2005 and 2008, our ADP rate
was stable at approximately 0.5%. However, from 2008 to 2010,
our rate rose to above the 1% national standard.1Therefore, we
audited factors that may have contributed to this increase.
Methods: Information for this audit was obtained from a
computerised database. Data collection included day, month
and time of ADP and the grade of anaesthetist. We also
collected annual data of number of deliveries, epidurals and
combined spinal epidurals (CSEs) for labour, caesarean section
(CS) data, and the proportion of single shot spinals (SSS) to
CSEs performed. Data were analysed using chi-square
multinomial and trend tests with P value <0.05 defined as
significant.
Results: There was a 40% increase in deliveries between 2008-
2010. CSs and regional blocks for analgesia increased by 36%
and 40% respectively. Although the ADP rate increased, we
could not demonstrate a statistically significant trend due to
small numbers. From 2010 to 2012, a non-significant fall in the
ADP rate was seen. There was no significant association
between ADPs and day, month or time. We did see a
significant non-linear trend (P = 0.0012) in the proportions of
SSSs to CSEs performed, with the peak occurring in 2010.
Table 1. Trend of activity and ADP rate from 2008 to 2012
  2008 2009 2010 2011 2012 P value
Maternities (n) 4032 5039 5647 5841 5953 < 0.0001
Epidurals for labour (n) 1306 1600 1839 2029 2132 < 0.0001
CSs (n) 1370 1562 1861 1862 1773 < 0.0001
SSSs for CS (n) 282 274 356 326 347 0.0015
CSEs for CS (n) 797 644 714 833 915 < 0.0001
Proportion of SSS to CSE (%) 26 30 33 28 27 0.0012
ADP rate (%) 0.57 0.98 1.05 1.01 0.82 0.31
Discussion: We observed an increase in ADPs until 2010, with
significant rises in deliveries and anaesthetic procedures
performed. The significant non-linear trend in the proportions
of SSSs to CSEs performed for CSs peaked in 2010. A fall in the
ADP rate between 2010-2012, occurred despite exposing more
women to the risk of ADP, as during this time we performed
significantly more CSEs than SSSs proportionally. We believe
that the rise in the ADP rate resulted from a significant
increase in our workload between 2008 and 2010, without any
increase in anaesthetic staffing. From 2010 onwards, daytime
anaesthetic consultant sessions increased by 50%, and there
was a higher presence on the labour ward out of hours by
senior registrars covering non-obstetric theatres. Both factors
may have contributed to the subsequent fall in the ADP rate.
This audit supports the recent OAA/AAGBI guideline
recommending increased anaesthetic staffing on labour ward.2
References
1. Royal College of Anaesthetists. Epidural analgesia during labour.
Raising the standard: a compendium of audit recipes. 2012;218-219
2. Association of Anaesthetists of Great Britain and Ireland and
Obstetric Anaesthetists' Association. OAA/AAGBI guidelines for
obstetric anaesthetic services. 2013
Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin) P25
P149 Inadvertent hypothermia during elective caesarean P150 Inter professional relationships on labour ward- how
sections well do anaesthetists and midwives get along?
S Botros,  R Labib,  T Ramhew,  M Baban,  Y Poonawala   M Salman,  P Kumar,  G Graham  
Selwyn Crawford Department of Anaesthesia , Birmingham Anaesthetics, St. Thomas' Hospital, London, UK
Women's Hospital, Birmingham, UK Introduction: Anaesthetists and midwives are part of the
Introduction: The National Institute for Health and Care multi-professional team that provides care for parturients.
Excellence (NICE) defines inadvertent perioperative They work together in close collaboration in the unique and
hypothermia as a core body temperature below 36°C.1 It is a often highly charged environment of labour ward. In such
common complication of regional anaesthesia, and is the settings, effective inter professional relationships are key to
leading cause of perioperative shivering. Hypothermia is the delivery of high quality care and consequently better
associated with increased risk of wound infection and patient outcomes. Successful collaborative practice can be
increased blood loss.1 Shivering can be associated with negatively impacted by barriers such as lack of clarity on the
increased oxygen consumption and hypoxaemia in vulnerable scope of roles of team members, poor communication, or
patients. Although the NICE guideline on the management of stereotyping. We conducted a survey amongst obstetric
perioperative hypothermia did not cover pregnant women,1 it anaesthetists and midwives in our hospital to reflect upon this
has been adopted by many obstetric units. In our unit, working relationship and to see how it may be improved.
intravenous (IV) fluid is not routinely warmed for elective
Methods: A questionnaire was designed and distributed to
caesarean sections (CS). Hence, we audited our practice to
midwives and anaesthetists of all grades. Questions were
evaluate the incidence of hypothermia.
asked on their understanding of each other's professional role
Methods: Over a three month period, we prospectively audited
and on their perception of the quality and effectiveness of
our practice in 47 women who had elective CS under
their working relationship. A total of 43 responses were
subarachnoid anaesthesia without active warming. We
collected (24 anaesthetists and 19 midwives) in an ongoing
measured their tympanic temperature prior to anaesthesia (T )
1 survey.
and at the end of surgery (T ). We also collected data that may
2 Results: Of the anaesthetists who completed the
influence the results like the volume of IV fluid infused,
questionnaire, 16.6% were consultants, 58.3% were ST5-ST7,
estimated blood loss (EBL) and duration of surgery. We also
20.8% were ST3-4 and 4.1% were CT1-2. When asked whether
assessed the incidence of perioperative shivering. We
they felt they understood the scope of responsibilities of
repeated the audit in 42 parturients using an IV fluid warming
midwives on labour ward, only 27% of anaesthetists felt they
device. The data were analysed using Microsoft Excel 2007®.
understood it fully. In contrast, 63% of midwives believed they
Data from both audits were compared and p-values were
fully understood the scope of the anaesthetist's
calculated using unpaired t-test by GraphPad software®.
responsibilities.
Results: In the initial audit, 20 patients (42.55%) were
hypothermic at the end of surgery (T < 36°C). Shivering Thirty percent of midwives felt that collaboration with
2
occurred in 14 patients (29.79%). No correlation was found anaesthetists was 'very easy', in contrast to only 5.5% of
between T and the IV fluid volume, EBL, duration of surgery anaesthetists who felt the same about collaboration with their
1-2
or the dose of intrathecal Bupivacaine. In the re-audit, only 3 midwife colleagues. While 16% of anaesthetists found this
(7.14%) patients experienced hypothermia. There was no collaboration 'difficult', none of the midwives did (0%).
statistical difference in T between the two audits (p = 0.781). Seventy two percent of anaesthetists felt their input was
1
usually well-received by their midwife colleagues, compared to
  Initial Audit (n=47) Re-audit (n=42) p-value
only 40% of midwives who thought their input was well-
Fluid (ml) 1116.67(±369.43) 1233.33 (±483.59) 0.2236
received by the anaesthetist. Both professions were asked
EBL (ml) 523.75 (±152.33) 582.5 (±491.67) 0.474
how they perceived the general quality of communication
T1 36.84 (±0.37) 36.81 (±0.37) 0.781
between them. The majority of anaesthetists (47%) perceived it
T2 36.08 (±0.4) 36.3 (±0.29) 0.004
as 'fair', while 15% regarded it as 'poor'. Ninety percent of
T 0.76 (±0.34) 0.52 (±0.41) 0.0032
1-2 midwives felt it was either 'very good' or 'good'. None of the
Discussion: Our audit highlights the effect of warm IV fluid midwives (0%) felt it to be 'poor'.
therapy on reducing the incidence of inadvertent perioperative
Questions were asked on the types of obstacles they
hypothermia during elective CS. Our audit recommends the
encountered in their professional interaction with each other.
routine warming of IV fluid during elective CS. The Enhanced
Most anaesthetists (72%) agreed that they found fixation on
Recovery Partnership Programme considers patient warming
tasks and exclusion of others to be a challenge, followed by
as a key factor in accelerating patient recovery.2 Following our
delayed or non-communication of important issues (57%). A
results and as part of developing a new pathway for enhanced
third of the anaesthetists felt they rarely got a comprehensive
recovery post CS; our trust is currently looking to invest in a
handover from the midwife while only 29% of midwives felt
cost-effective IV fluid warming device.
they understood the rationale behind the anaesthetists'
References decisions.
1. NICE (2008) Perioperative hypothermia (inadvertent): full Conclusion: Despite both specialties working in close
guideline (CG65). Full Guideline. London: National Institute for proximity, the survey identified several gaps in
Health and Care Excellence.
communication. Working towards enhancement of the
2. Enhanced Recovery Partnership (2012) Fulfilling the potential: a
professional relationship between members of the team
better journey for patients and a better deal for the NHS. Leicester:
NHS Improvement. Available at http://www.improvement.nhs.uk providing maternity services will help facilitate their
(accessed 14/12/2013) collaboration and will reflect positively on the performance of
both professions.

P26 Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin)
P151 Intra-arterial balloon catheters: A service evaluation P152 Intrathecal diamorphine for cesarian section following
JS Campbell,  M Molloy,  D Fogarty   intramuscular diamorphine during labour: a cause for
Royal-Jubilee Maternity Service, Belfast HSC Trust, Belfast, concern?
UK RC Barr,  L Parks  
Introduction: Intra-arterial balloon catheters have become Anaesthetics and Intensive Care, Southern Health and Care
widely used and predominantly accepted in cases where Trust, Northern Ireland, UK
massive haemorrhage is anticipated, especially with morbidly Introduction: Diamorphine has largely replaced pethidine for
adherent placenta . However, the benefits are still intramuscular (IM) analgesia during labour in our obstetric
1,2
controversial. While our unit is not stand-alone, our building unit. We also routinely give diamorphine (250-300 micrograms)
is physically separated from other departments including intrathecally (IT) for cesarian sections. A recent case of
radiology, so the logistics of balloon catheters are difficult2. meiosis and drowsiness, in a lady presenting for a category 2
Our objective was to identify the impact of balloon catheters cesarian section having received IM diamorphine in labour,
on management of morbidly adherent placenta. Associated highlighted the potential for side effects when diamorphine is
anaesthetic issues include massive transfusion, cell salvage, used IM and then IT. Should we therefore consider adjusting
type of anaesthetic and post-operative care. our IT dose of diamorphine in women presenting for
Methods: With permission of the Trust's Data Guardian, we emergency cesarian sections? To our knowledge there are no
retrieved data from multiple sources to identify and review guidelines on this subject and clinical practice appears
cases where balloon catheters where used. These included variable.
radiology logs, maternity records and histology. Methods: We conducted a survey of all anaesthetists working
Results: Ten cases were identifed via these systems. Seven in the Southern Health and Social Care Trust who partake in
were for morbidly adherent placenta, of which 5 required obstetric anaesthesia. Questions focused on; current
hysterectomy despite balloon inflation. Many of these were diamorphine practice, diamorphine dose adjustments, factors
cases of placenta percreta, despite antenatal diagnosis of influencing our dose decisions and concerns regarding
accreta. However, blood loss was lower by around 20% potential side-effects with IT diamorphine.
(1078ml) using balloons, when compared to other Results: We received 24 replies; 14 consultants and 10
hysterectomies in the same time period. experienced trainees who regularly perform obstetric
Other indications were for intra-abdominal pregnancy and anaesthesia. There was a wide variation in diamorphine
persistent post-partum haemorrhage. Another case was practice amongst our anaesthetists. The majority (76%)
abandoned due to logistical reasons (unable to organise consider reducing their IT dose following IM diamorphine.
theatre time in same building), a decision felt to be open to Factors influencing this dose reduction include timing (88%)
medicolegal criticism after preparation and planning for and dose (29%) of the last IM diamorphine and clinical signs
balloons. of toxicity (76%). In particular anaesthetists were concerned
about postoperative respiratory depression (94%) and
Limitations particularly reflected the limitations and
drowsiness (88%), although no one surveyed reported
inconsistency of the systems used, for example no coding in
experience of these or other adverse effects associated with IT
records for morbidly adherent placenta. Local presentation
diamorphine.
highlighted these problems, which are being taken forward.
Discussion: There is variability regarding the IT diamorphine
Conclusion: Our review, and subsequent MDT discussion,
dose given to women for emergency cesarian section who
has confirmed the place of intra-arterial balloon catheters
have already received IM diamorphine in labour. This practice
within local guidelines for management of morbidly adherent
is based on limited evidence. Given the lack of adverse effects
placenta, and other occasional indications. We had decreased
reported from our survey and evidence from other specialties
blood loss in cases using balloons, but still saw a large
where diamorphine is used in higher doses 1,2,, we see no
proportion requiring hysterectomy.
reason to routinely reduce the IT diamorphine dose unless
References
there are clinical signs of opiate toxicity. Consideration should
1. Beilin Y, Halpern SH. Placenta accreta: successful outcome is all in be given to prolonged postoperative monitoring of all women
the planning. Int J Obstet Anesth. 2013;22:269–271.
who have received both IM and IT diamorphine, especially
2. Sadashivaiah J, Wilson R, Thein A. Role of prophylactic uterine
artery balloon catheters in the management of women with those in whom the interval between IM and IT diamorphine is
suspected placenta accreta. Int J Obstet Anesth. 2011;20:282-287 short or where there are signs of toxicity.
References
1. Fogarty DJ, Milligan KR. Postoperative analgesia following total
hip replacement ; a comparison of intrathecal morphine and
diamorphine. Journal of the Royal Society of Medicine 1995; 88:
70-72
2. Jacobson L, Kokri MS, Pridie AK. Intrathecal diamorphine: a dose-
response study. Annals of the Royal College of Surgeons of England
1989; 71: 289-292
Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin) P27
P153 Introducing self-administration of medication after P154 Is Remifentanil patient controlled analgesia an
caesarean section: a Robert The Bruce story effective alternative to epidural for labour analgesia?
A R Sajayan,  K Ramm,  T Yates,  Y Chikermane   V Betharia,  K Peckitt  
Anaesthesia, Heartlands Hospital, Birmingham, UK Anaesthesia, Stepping Hill Hospital, Stockport, UK
Introduction: We were involved in the introduction of the local Introduction: Remifentanil patient controlled analgesia (PCA)
protocol for self-administration of postoperative medications was introduced for pain relief in labour at our institution in
(SAM) after elective LSCS at a large obstetric unit. In the past, 2007. Since then its demand has steadily increased, gaining
several attempts to implement this have failed.We conducted a favour with midwives and patients due to simplicity of use,
pilot study to identify the obstacles and develop ways to effective analgesia¹ and good safety profile². We have
overcome the same standardised protocols for administration and monitoring of
Methods:A pilot project was conducted to find out the Remifentanil PCA and patient controlled epidural analgesia
obstacles in the process by obtaining feedback from the staff (PCEA) during labour which are strictly adhered to. Aim of our
and patient involved in the care of 10 patients who underwent audit was to assess both Remifentanil PCA and epidural PCEA
elective LSCS over a week’s time. Obstetric, anaesthetic, for labour analgesia and make recommendations for improved
recovery and ward staff were informed beforehand about this care of mothers and infants.
pilot by emails and personal discussion. The patients were Methods: This was a prospectively done, questionnaire based
given information leaflet during preoperative assessment and audit. Data was collected over 2 months from November 2013 -
were informed again on the day of operation. Interested January 2014. We looked at mode of delivery,
patients enrolled in the pilot with due consent. The self- cardiotocographic abnormalities, APGAR scores, maternal
administration pack contained analgesics and enoxparin and cardio-respiratory complications, conversion to alternative
was dispensed by the recovery staff. Exclusions were: methods of analgesia and patient satisfaction.
language barrier, patient refusal, lack of capacity and any co Results: There were 610 deliveries during the 2 months.
morbidities. Feedback was collected from patients and staff Remifentanil PCA was used in 102 (17%) and epidural PCEA in
using the standardized proforma during the postoperative 85 (12.2%) patients for labour analgesia.
visit. Mode of delivery:
Results:Two of the patients felt that on the first day it was
  Normal Assisted LSCS
difficult to use SAM due to mobility restrictions. One patient
Remifentanil PCA 69 (67%) 20 (19.6%) 13 (12.7%)
did not receive SAM pack due to communication problem
Epidural PCEA 29 (34%) 35 (41%) 21 (24.7%)
involving midwives and staff. The remaining seven patients
were satisfied with SAM. The obstacles we identified in the There was a higher incidence of cardiotocographic
pilot and also from the past experience and the way we tackled abnormality in the epidural group (61%) as opposed to
them are as below: Remifentanil group (34%). APGAR scores in both groups were
more than 8 at 5 minutes. None of the patients in either group
Obstacle Strategy
had respiratory depression or cardiovascular instability. Eight
Personal & email reminder
(7.8%) patients converted from Remifentanil to epidural due to
Promotional posters in clinical areas
inadequate analgesia whereas 4 (4.7%) patients in the epidural
Communication Reminder notices in operating room and recovery
group used alternative analgesia (3 switched to Remifentanil
Meeting with stakeholders (doctors, midwives&
and 1 to entonox). Patient satisfaction was similar in both
pharmacist)
groups at 95%.
Involving all staff in guideline preparation
Discussion: From our experience, Remifentanil PCA is a safe
Staff engagement Process simplified and paper work streamlined
and effective method of labour analgesia. We found no
Standardized SAM package and delivery
evidence of worsening cardiotocography or neonatal
Guideline Fully prepared guideline after extensive consultation
outcomes with its use. We also found that patients using
Time Pre-printed forms to increase efficiency and to avoid
Remifentanil have increased rate of vaginal deliveries as
management time delays and work duplication
compared to those on epidural. While epidural analgesia
Discussion: Self-administrationof medications after caesarean remains the gold standard and will be preferable in certain
provides better patient centered care. It improves patient and groups of patients, Remifentanil PCA is certainly an excellent
staff satisfaction, improves clinical efficiency and eases alternative to consider. In our institution its uptake has
staffworkload at hospital and at community level1. It empowers steadily increased to approximately 50 patients per month with
the mother in their own care, potentially reduces length of patients consistently report ing high levels of satisfaction.
stay, and facilitates seamless flow ofcare. Although staff and References
patients liked the concept alike, the process had failedthree
1. Blair JM, Dobson JT, Hill DA, McCracken GR, Fee JP. Patient
times before because of certain obstacles. This pilot helped us controlled analgesia for labour: a comparison of remifentanil with
to highlight the areas we needed to focus on with our new pethidine. Anaesthesia 2005; 60 (1) : 22-7
strategies and the results have been encouraging. After fully 2. Volikas I, Butwick A, Wilkinson C, Pleming A, Nicholson G.
Maternal and neonatal side-effects of remifentanil patient
implementing the project, the uptake is gradually getting better
controlled analgesia in labour. Br J Anaes 2005; 95(4): 504-9
and we continue to audit the outcome.
References
1. Snell P M, Bowden M I, Viira D J, Chilvers J P. An observational
study of self-medication of analgesic drugs after caesarean section.
Int J Obstet Anesth 2002; 11: S29
2. Change management good practice guideline-NHS Direct
P28 Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin)
P155 Is the existing local hospital guideline, 'Management P156 Klippel-Feil syndrome: management of anticipated
of women who decline blood products', being adhered difficult airway for caesarean delivery 
to? TM Price,  MT Qureshi,  ROK Laird  
J Houston,  R Burns   Department of Anaesthesia, Altnagelvin Area Hospital,
Simpson Centre for Reproductive Health, Royal Infirmary of Derry, UK
Edinburgh, Edinburgh, UK Introduction: Klippel-Feil syndrome (KFS) is a rare genetic
Introduction: An estimated 150000 Jehovah's Witnesses disorder affecting around 1 in 40,000 live births and is
(JWs) live in the UK1. JWs may not accept blood product (BP) characterised by the congenital fusion of any two of the
transfusion1, and have up to 130 times increased risk of cervical vertebrae1. In addition to the abnormalities of the
maternal death from major obstetric haemorrhage2. This cervical spine, patients may have thoracolumbar scoliosis,
retrospective case note review aims to establish how closely spina bifida and congenital heart defects. The classical
the hospital guideline, 'Management of women who decline phenotypic presentation is described as low hairline, short
blood products' (the Guideline), has been followed since its neck and limited neck and head movement. These patients can
May 2012 introduction, and to identify areas for improvement. therefore present a considerable challenge to the anaesthetist.
Methods: JWs managed at the Anaesthetic Antenatal Clinic The safest method of providing anaesthesia for operative
(AAC) since the Guideline's introduction were identified, and delivery of a parturient with KFS is controversial. We would
their medical records accessed. Information surrounding like to share our experience in managing four elective
aspects of patient management addressed by the Guideline caesarean deliveries in two parturients using awake oral fibre
was extracted. The findings were then audited against the optic intubation (AOFOI) and general anaesthesia.
Guideline to establish how closely it had been followed. Case Reports: The first patient had KFS Type II with fusion of
Approval was obtained from the Medical School and the cervical vertebrae and underwent elective caesarean deliveries
Regional Research Ethics Service. aged 35 and 37 years old. The second patient had KFS Type
Results: Of the patients referred (N=26), 92.3% were reviewed III with fused cervical vertebrae in conjunction with fusions in
at the AAC, and had management plans created, at 31.0 weeks' the thoracolumbar spine, and underwent elective caesarean
gestation on average (Guideline target: 28.0 weeks). 88.5% deliveries aged 31 and 39 years old. Our patients were both
completed a BP checklist before admission in labour, and pre-assessed by a consultant anaesthetist at a high-risk
96.2% by time of delivery. 7.7% agreed to accept BPs at clinic pregnancy clinic prior to delivery. This allowed time to discuss
and were discharged, so women studied became N=24. BP the anaesthetic options with each patient and plan for elective
refusal of 12.5% was not appropriately recorded in the notes, or emergency delivery. Both patients had the classical
and contrary to the Guideline, serum ferritin was not checked phenotypic features of KFS. Airway assessments revealed
in any woman. During pregnancy, 29.2% were not recorded as Mallampati class 4, thyromental distances less than 6cm and
having taken iron, and Hb was measured in 95.8%. Excluding severely limited neck flexion and extension. The trachea was
elective caesarean sections (CS), Obstetric consultants were not palpable in either patient. We anticipated difficult direct
documented as informed of admission in 13.6% of cases, and laryngoscopy in both patients and elected to manage the
54.5% of labours and deliveries were reviewed or supervised airway with an AOFOI followed by general anaesthesia. The
by senior Obstetric staff (ST6-consultant). 20.8% of total oral route was chosen as both patients had small nares in
deliveries were by CS: cell salvage was set up in 100.0% of keeping with KFS. Sugammadex ensured complete reversal of
these, and used in 80.0%. rocuronium induced neuromuscular blockade and smooth
Discussion: This study found the Guideline was closely emergence. Caesarean delivery and postoperative recovery
followed in some areas: completion of acceptable BP checklists was uneventful in all four cases.
before delivery, and availability and use of cell salvage in CS,
Discussion: As obstetric anaesthetists we are constantly
compare favourably to previous UK studies1,3. Areas to be
trying to minimise the risk to our mothers. Klippel-Feil
improved include that BP refusal must be appropriately
syndrome affects both the airway and the spine, making the
recorded in patient notes to ensure clarity upon presentation
choice of anaesthetic technique a difficult decision. Successful
in labour or an emergency. It is vital that iron supplementation
use of regional techniques including spinal, epidural and
is commenced early in JWs, and ferritin levels are monitored,
combined spinal-epidural anaesthesia, have all been described
to maximise iron stores. In light of this study's findings,
in the literature1. However, we feel that embarking upon a
hospital blood transfusion Haematologists, in the future, will
regional technique in patients with distorted neuroaxial
review JWs antenatally. The Guideline should quantify how
anatomy would expose patients to unnecessary risk of high
often Hb should be monitored, so anaemia can be detected
spinal block and/or inadequate regional anaesthesia. Should
and treated before delivery. Crucially, consultant staff must be
general anaesthesia be needed intra-operatively, attempting an
documented as informed upon admission of JWs in labour, in
AOFOI in an already distressed parturient would be
order that deliveries can be supervised by senior staff to
challenging. We therefore planned an AOFOI to secure the
reduce potential morbidity and mortality.
airway prior to general anaesthesia, in a controlled manner and
References
thus avoid a potentially difficult and emergent intraoperative
1. Massiah N, Athimulam S, Loo C, Okolo S, Yoong W. Obstetric care intubation. In summary, these are difficult cases that we
of Jehovah's Witnesses: a 14-year observational study. Arch
believe benefit from good antenatal planning and can be
Gynecol Obstet 2007; 276(4):330-343.
managed with a planned AOFOI and general anaesthesia.
2. Van Wolfswinkel ME, Zwart JJ, Schutte JM, Duvekot JJ, Pel M, Van
Roosmalen J. Maternal mortality and serious maternal morbidity in
Jehovah's witnesses in the Netherlands. BJOG 2009; 116(8): 1103- Reference
1108. 1. T. Kavanagh, R. Jee, N. Kilpatrick, J. Douglas. Elective cesarean
3. Nawaz YM, Atkinson S. Peripartum care of Jehovah's witness delivery in a parturient with Klippel–Feil syndrome. Int J Obstet
parturients: A five year review. Int J Obstet Anesth 2013; 22(S1): Anesth 2013; 22(4): 343-8
S22.
Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin) P29
P157 Labour and delivery in long QTsyndrome P158 Local anaesthetic toxicity audit: are workshops the
BJ Vowles,  FMM Bryden   best educational tool across the MDT?   
Anaesthetic department, Princess Royal Maternity, Glasgow, WITHDRAWN FROM PRESENTATION
UK JL Lambert,  D Chitre,  L Evans  
Introduction: A 22 year old primigravida presented to the high Anaesthesia, Southend Hospital, Southend, UK
risk clinic at 22 weeks gestation. She had been diagnosed with
long QT syndrome (LQTS) after her family had been
investigated following a sudden early cardiac death and was
found to be heterozygous for the KCNQ1 gene, responsible
for Long QT1. She was under regular review by the
cardiologists who had advised β blockade with bisoprolol
2.5mg orally (PO) for 9 months post partum due to an increase
in arrhythmia risk during this period. She had also been given
a list from Azcert Inc., advising drugs that should be avoided
and included on this list was syntocinon.
Labour and delivery: She was admitted in labour at term and
the decision was made by the obstetric team, not to administer
syntocinon to augment labour. They also felt that epidural
analgesia was unsuitable because it would slow the progress
of labour. However following an initial dose of intramuscular
(IM) diamorphine, the parturient requested epidural analgesia.
We felt this would be beneficial for minimising her arrhythmia
risk and so she obtained a working epidural with a bilateral T10
block. ECG monitoring was commenced on admission and
.
initially showed bigeminy. A 12 lead ECG demonstrated a QTc
of 460ms. Electrolytes checked at this time were in the normal
range. Over the subsequent 8 hours she failed to progress and
underwent a caesarean section with an effective epidural top
up of 20ml 0.5% L-bupivacaine. At delivery syntocinon was
administered as a slow infusion of 5 units in 100mls 0.9%
saline over 20 minutes, followed by 500µg ergometrine IM to
maintain uterine tone. 50mg IM cyclizine and 10mg
intravenous (IV) metoclopramide were used for anti-emesis.
She was monitored in the Obstetric high dependency unit
(HDU) for the following 48 hours, where an initial ECG
demonstrated frequent ventricular ectopics, with a QTc 432ms.
Electrolytes were again normal at this time.
Discussion: There are many lists of drugs available on the
internet with differing advice as to which drugs to avoid in
long QT syndrome. The one which our patient had been given
clearly stated syntocinon should not be administered, despite
no definitive evidence of harm with this drug in patients with
LQTS. In addition we found no guidance in published case
reports, on oxytocic drugs administered to patients with LQTS
in labour or at delivery1. There are case reports of ventricular
tachycardia after administration of syntocinon in long
QTsyndrome2 and one report of a pateint receiving it with no
sequelae3 Ideally the authors feel that this lady merited a case
conference prior to admission so that informed decisions
could be made. Whilst the outcome of this patient's labour and
delivery may not have been different, a short trial of
syntocinon with ECG monitoring may have altered her mode of
delivery.
References
1. Drake E, Preston R, Douglas J. Brief review: anaesthetics
implications of long QT syndrome in pregnancy. Can J Anaesth.
2007; 54(7): 561-72
2. Liou SC, Chen C, Wong SY, Wong KM. Ventricular tachycardia
after oxytocin injection in patients with prolonged Q-T syndrome -
report of two cases. Acta Anaesthesiol Sin 1998; 36: 49-52
3. Charbit B, Funck-Bretano C, Samain E, Jannier-Guillou V,
Albaladejo P, Marty J. Qt interval prolongation after oxytocin bolus
during surgical induced abortion. Clin Pharmacol Ther 2004; 76:
359-64
P30 Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin)
P159 Lymphangioleiomyomatosis and Pregnancy: A Case P160 Major obstetric bleeds-are we doing the right thing?-
Report A multi-centre study in west midlands
M Cole,  S Petkov,  J Pickett   A R Sajayan,  M McLoughlin,  S Dinesh,  A Walunj*,  J
Anaesthetics, Addenbrookes Hospital, Cambridge, UK Karattuparambil †,  M Ravindran†  
Introduction: Anaesthesia, Heartlands Hospital, Birmingham, UK,
Lymphangioleiomyomatosis (LAM) is a rare condition causing *Anaesthesia, Good Hope Hospital, Sutton Coldfield, UK,
proliferation of smooth muscle in the respiratory system, †Anaesthesia, George Eliot Hospital, Nuneaton, UK 
which can cavitate leading to degradation of lung parenchyma Introduction:Guidelines1 exist on the definitions of massive
and cystic lung disease1. Because of the risk of progression, bleed, the proposed management pathway and the safe time
women with LAM are frequently advised to avoid pregnancy2. frame for obtaining the blood and products. This multi-centre
We present a case of LAM where multidisciplinary audit looks at the average time taken for the blood/products to
management led to a successful outcome of pregnancy, with a be available in major bleed situations in obstetrics
focus on anaesthetic considerations. Aim: To find out the incidence and reasons for delays in
Case Study: issuing the blood/products, if any, from the blood bank and to
A 35 year old woman presented with bilateral spontaneous compare the existing practices and experience with the other
pneumothoraces in the first trimester of her 2nd pregnancy. hospitals in the area
Both required surgical correction and a lung biopsy revealed a Methods: We collected the data from three participating
diagnosis of LAM. Computerised tomography of her thorax hospital in west midlands using a standard proforma which
showed multiple small lung cysts. Past history included an included the number of massive obstetric bleed calls during a
uncomplicated first pregnancy and emergency caesarean six months period in 2013, the estimated blood loss, the time
section for foetal distress, aged 33; and a spontaneous taken for the first unit of blood/ product to be issued and the
pneumothorax aged 34, requiring surgery. The patient was number of products used among other data.
referred to a tertiary centre for multidisciplinary management.
Results: The results suggested that there is ambiguity in the
Care was shared between obstetrics and respiratory medicine
way major haemorrhage was defined in different situations
and she attended the high risk anaesthetic clinic. Elective
which led to unnecessary calls where blood products were not
caesarean delivery at 38 weeks was agreed upon. She had
urgently needed. Also, the time for getting the products varied
three further small pneumothoraces, treated conservatively
widely the longest being 200 minutes. The documentation of
with no marked deterioration in respiratory function. Elective
the details of the bleeding, time of calls and time of
caesarean section was performed at 38/40 gestation.
blood/product administration were incomplete and inaccurate
Respiratory assessment and examination on the morning of
in some cases.In one hospital, major bleed calls were only put
surgery were normal. A two-space combined spinal epidural
out in two out of 17 cases where blood loss was more than
was sited, administering intrathecal hyperbaric bupivacaine
1500ml.
and diamorphine. A respiratory physician was present at
delivery in case of deterioration. Delivery was uneventful, with   Hospital1 Hospital2 Hospital 3
no immediate complications. The patient spent 24 hours in an Number of MOH calls 58 41 2
obstetric close observation unit post-operatively. Her post- Full data available 13 18 2
natal period was uneventful and required no further obstetric, Average time for group specific (min) 59 NA 33
respiratory or anaesthetic intervention. Average time for X match blood (min) 63.45 42.27 0
Longest delay (min) 200 104 33
Discussion: LAM is a rare condition with an estimated UK
prevalence of 1per million3. Hypotheses suggest oestrogen
Discussion: The definitions of massive blood loss are:
accelerates disease progression and pregnancy may result in
Transfusion of a volume equal to the patient’s total blood
new diagnosis or exacerbation4, therefore obstetric
volume in less than 24 hours / 50% loss of blood volume
anaesthetists should have awareness of this disease. There is
within 3 hours / rate of blood loss 150ml/minute. Though the
sparse literature for anaesthetic management of pregnancy
circumstances of individual episodes of major bleed could
with LAM, consisting mainly of case reports. Considerations
vary, there was no consistency in the trigger of activating
suggested include; avoiding excessive Valsalva manoeuvre
major bleed calls. There were also unacceptable delays in
via instrumental or elective caesarean delivery, avoid nitrous
obtaining the first unit of blood in some cases. The first set of
oxide, early epidural analgesia, obtunding intubation response
uncross matched group specific blood should be available in
and lung protective ventilation strategies if general
20minutes and cross matched blood in 40minutes2. The study
anaesthesia. This case report supports that pregnancy in
suggest that there is a need for the reinforcement of major
LAM patients can progress successfully and highlights the
bleeds definition and also a need for a clearer pathway and
importance of a MDT approach, early anaesthetic assessment
consistency in issuing blood and products in major bleed
and a well considered anaesthetic and obstetric plan.
situations. This audit results will be used to formulate a
References uniform policy in the participating hospitals and a re-audit will
1. Rosendal T. A Case of Diffuse Myomatosis and Cyst Formation in be done in six month time
the Lung. Acta Radiaology. 1942; 23: 138-146
2. Cohen MM, Freyer AM, Johnson SR. Pregnancy Experiences References
Among Women With Lymphangioleiomyomatosis. Respiratory
1. D Thomas etal,Blood transfusion and the anaesthetist: management
Medicine. 2009; 103: 766-772
of massive haemorrhage, Anaesthesia 2010 November; 65(11):
3. Johnson SR, Tattersfield AE. Clinical Experience of 1153–1161
Lymphangioleiomyomatosis in the UK. Thorax. 2000; 55:1-5
2. Guidelines on the management of massive blood loss.
4. McLoughlin L, Thomas G, Hasan K. Pregnancy and BJHaematology 2006; 135(5): 634-641
Lymphangioleiomyomatosis: Anaesthetic Management.
International Journal of Obstetric Anaesthesia. 2003; 12: 40-44
Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin) P31
P161 Management of labour and delivery using  minimally  P162 Management of manual removal of placenta and third
invasive FlotracTM system in a parturient with  and fourth degree tear repair: pathway analysis
congenitally corrected transposition, dextrocardia P Jegendirabose,  J Subramanya*,  S Watkinson*,  J Short  
and systemic ventricular dysfunction Anaesthesia, Queen Elizabeth Hospital, Woolwich, London,
R Vedagiri Sai,  S Dhir,  J Racine   UK, *Obstetrics & Gynaecology, Queen Elizabeth Hospital,
Anesthesia, Western University, London Ontario, Canada Woolwich, London, UK
Introduction: More women with congenital heart disease now Introduction: Guidelines suggest that repair of obstetric anal
survive to reproductive age due to advances in modern sphincter injuries (OASIS) and manual removal of retained
medicine. Obstetric management is challenging in these placenta (MROP) should be undertaken as soon as possible to
complex cases. We present the anaesthetic management of minimise the risk of infection, blood loss and maternal
labour and delivery in a woman with congenitally corrected morbidity1,2. Anal incontinence and perineal pain can impact
transposition of great vessels, dextrocardia, systemic significantly on maternal quality of life and mother-child
ventricular dysfunction and junctional tachycardia using bonding.
minimally invasive continuous haemodynamic monitoring and Methods: We conduced a retrospective audit which showed
optimisation. shortcomings in our management of MROP and OASIS and we
Case report: A 28 year old primigravida presented with a undertook an analysis of a full calendar year's cases. All cases
diagnosis of congenitally corrected transposition of great of MROP and OASIS were identified over January 2012 to
vessels and dextrocardia. The atrial septal defect had been December 2012 using both theatre electronic records and
repaired in childhood. Her medications included folate and maternal records. Time from delivery of fetus to MROP or
multivitamins. She had good exercise tolerance, stable vital OASIS repair, blood loss and blood transfusion requirement
signs and was followed up by Cardiology team throughout her were reviewed.
pregancy. ECHO showed 50% ejection fraction (EF) and mildly Due to lack of nationally set standards, we set a local standard
reduced systemic (morphologic right) ventricle. A multi- of no more than one hundred and twenty minutes from
disciplinary meeting between Obstetrics, Cardiology, delivery to repair for OASIS.
Anaesthesia and Intensive care unit (ICU) team was held to
Results: Our institute is a secondary obstetric centre with
decide on optimal obstetric management. Induction of labour
4800 deliveries per annum. During the twelve month period,
was planned.
105 patients sustained OASIS. The mean delay from delivery
At 37 weeks she developed palpitations, increasing shortness to surgery was 136 minutes. The average blood loss was 501
of breath and peripheral oedema. Repeat ECHO showed millilitres and 3% of patients required blood transfusion. Total
moderate ventricular dysfunction with EF 40%, severe of 42 patients required manual removal of placenta with
systemic atrioventricular regurgitation and severely enlarged regional or general anaesthesia. The mean delay from delivery
left atrium. Prior to labour induction, an arterial line was to surgery was 178 minutes. The mean blood loss was 790
inserted and continuous cardiac output monitoring was millilitres and 5% of the patients required blood transfusion.
performed using arterial pressure waveform analysis with the
FloTracTM monitor. Haemodynamic optimization was guided OASIS repairs n=105 Time (minutes)
by stroke volume variation and goal directed fluid therapy. A Delivery to booking 81 (Cl 70-92)
lumbar epidural was then inserted followed by rupture of Booking to surgery 68 (Cl 40-95)
membranes and oxytocin infusion. Fluid balance was closely Delivery to surgery 136 (Cl 122-150)
monitored continuously using FloTracTM. 1st stage of labour MROP n=42 Time (minutes)
was uneventful and 2nd stage was shortened using vacuum Delivery to booking 138 (Cl 115- 160)
assisted delivery of a healthy baby. She had a second degree Booking to surgery 39 (Cl 32-46)
tear which was repaired. Post partum haemorrhage due to Delivery to surgery 178 (Cl 152-204)
uterine atony was treated with 400µg Misoprostol rectally and
Incidentally, 78% of the patients did not have electronic record
intravenous infusion of 20 IU of Oxytocin. Estimated blood
of estimated blood loss on the theatre system.
loss was 800 mL. Cardiac condition was stable apart from
Discussion: In our institution, these cases are booked onto
persistent tachycardia throughout labour. Postpartum, she
the general emergency theatre, and not in the designated
spent 24 hours in ICU with similar monitoring. Her tachycardia
emergency obstetric theatre. We have identified that this has
settled spontaneously. She was discharged home on day 4.
resulted in significant delay in surgery and increased blood
Discussion: Patients with congenitally corrected transposition
transfusion requirement. We are now changing the patient
have a thin-walled right ventricle as the systemic circulatory
pathway to include urgent utilisation of the emergency
pump. The stress of increased cardiac output can cause
obstetric theatre for these procedures. Since the presentation
failure, atrioventricular regurgitation and arrhythmias1. We
of this audit, we have included the estimation of blood loss in
used minimally invasive continuous cardiac output
the surgical sign out process, thus improving communication
monitoring, fluid balance optimisation and good maternal pain
and patient care.
control to prevent decompensation and achieve vaginal
References
delivery with a good feto-maternal outcome.
1. National Institute for Health and Care Excellence. 2007.
Reference Intrapartum care. Care of healthy women and their babies during
childbirth. Clinical guideline 55
1. Dob DP, Naguib MA, Gatzoullis MA. A functional understanding of
moderate to complex congenital heart disease and the impact of 2. Fernando RJ, Sultan AH, Kettle C, Thakar R. Methods of repair for
pregnancy. Part I: the transposition complexes.Int J Obstet Anesth. obstetric anal sphincter injury. Cochrane Database Syst Rev. 2013
2010 Jul;19(3):298-305 Dec 8;12:CD002866.
P32 Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin)
P163 Multidisciplinary involvement of the high risk P164 National Obstetric Anaesthetic Database: a useful tool
parturient to benchmark maternity units in the UK
S De Silva,  P Gregory,  E Combeer   G Keightley,  N Tailor,  R Baraz,  L De Lloyd  
Anaesthetics, Frimley Park Hospital, Frimley, UK Anaesthetics, University Hospital of Wales, Cardiff, UK

Our Hospital offers a high risk Obstetric Anaesthetic Clinic for Introduction: The National Obstetric Anaesthetic Database
review of parturients with anticipated Anaesthetic or Medical (NOAD) was set up in 1998 to establish a framework for
problems where a checklist referral form is used. We audited collecting national obstetric anaesthetic data considered
whether women were appropriately referred or inappropriately relevant to obstetric anaesthetists. Whilst preparing the
not referred. An alert sticker was created to encourage NOAD survey for 2012, we explored the usefulness of this
healthcare providers to alert the oncall Obstetric Anaesthetist data in benchmarking our units' performance at the University
when the high risk parturient presented to labour ward. We Hospital of Wales (UHW) in relation to NOAD published
went onto audit the effectiveness of this alert sticker. figures from the previous year.

Methods: Data was collected according to the NOAD 2012
Methods: We looked at 200 consecutive births during October
survey and therefore, ethical approval was not required. Due
2010 and ascertained how many of these women had referrals
to the large number of deliveries in our unit, data regarding
to the High Risk Clinic. In the referred cases, we asked whether
labour analgesia, mode of delivery, caesarean section rate and
referral criteria were met and also determined if any mothers
type of anaesthesia was based on six months period (Jan to
were inappropriately not referred. In 2012 we retrospectively
June 2012) and then doubled. Exceptions were critical care
inspected all notes of mothers seen in High Risk Clinic with an
admissions and patients with accidental dural puncture (ADP);
estimated delivery date of March to May 2012. We checked
these were collected and reviewed individually for the entire
whether an alert sticker was present in their notes and also the
year. Microsoft Excel was used to analyse the data.
time taken for the Obstetric Anaesthetist to be contacted once
the mother had presented to Labour Ward. Results: The number of total deliveries in our unit for 2012

was 6138, of which 3060 required anaesthetic procedure(s).
Results: In 2010, 178 of 200 notes were reviewed and 14
The table below compares performance and quality indicators
women met referral criteria and 12 of these were referred.
at UHW in 2012 with the NOAD averages from 2011.
Fourteen percent were therefore inappropriately not referred,
however no women were inappropriately referred. Indicator UHW 2012 NOAD 2011

Caesarean section (CS) rate 22% 24.8%
In 2012, 42 notes were inspected where only 8 had the alert
Elective CS rate 46% 39.1%
sticker in place, with only 5 in the correct position. Two
De novo general anaesthesia (GA) for CS 4.5% 4.7%
mothers with the alert had elective caesarean sections. In five
Conversion to GA (CS) 1.8% 3.5%
of the six remaning mothers, the oncall Anaesthetist was
Labour regional analgesia 27% 22.7%
informed of their presence on labour ward. The average time
Epidural re-site rate 7.7% 9%
taken for this was four hours and 45 minutes (range 10 minutes
Accidental dural puncture rate 0.9% 1.2%
to 10 hours and 50 minutes). On review of the Clinic letters, it
was felt that 30 of the 42 parturients should have had an alert In 2012, three cases were transferred to critical care unit as
present in their notes, which is 71% not 19% as shown by our level 2 care (two with sepsis and one adult respiratory distress
audit. syndrome) and six cases as level 3 care (two with sepsis, three

post partum haemorrhage and one case of amniotic fluid
Discussion: In many cases of substandard care assessed by
embolus).
CMACE, there were major failures of communication between
Discussion: Our unit is classified as a large maternity unit
healthcare workers that may have contributed to the woman’s
compared to the national average. The elective CS rate and
death in some cases1. Our audits demonstrated that local
labour regional analgesia rates in our unit are higher than the
guidelines for referral were followed in 99% of cases, therefore
national average, possibly related to the complexity of a
high risk mothers were identified early. However, there still
tertiary centre. Despite this, our total CS rate is well below the
lacks effective communication of concerns within teams and
average with very low conversion to GA. In addition, our
poor involvement of other specialties early.
epidural re-site rate is lower than the national average, as is
Reference our ADP rate. Current facilities include two theatres serving
1. Centre for Maternal and Child Enquiries (CMACE). Saving both emergency and elective streams, and a mixed
Mothers'. Lives: reviewing maternal deaths to make motherhood recovery/high dependancy unit (HDU) for up to 5 patients.
safer: 2006–2008. The Eighth Report of the Confidential Enquiries
Our unit has a low transfer rate as level 2 care in general HDU,
into Maternal Deaths in the United Kingdom. BJOG 2011;118:1-203
due to the ability to care for these patients on our unit. We
find the NOAD data a useful tool to benchmark our
performance and set standards of care. More units should
contribute to the annual NOAD survey and consider using the
data as a way of identifying shortfalls and improving patient
care and services.
Reference
1. National Obstetric Anaesthetic Database report 2011.
http://www.oaa-anaes.ac.uk/content.asp?ContentID=586
Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin) P33
P165 Obstetric admissions to the Intensive Care Unit: a 6 P166 Obstetric outcomes with programmed intermittent
year review at a UK tertiary maternity centre epidural bolus labour analgesia
R Labib,  K Cullis   JTE Cremin,  CH Papageorgiou  
Selwyn Crawford Department of Anaesthesia, Birmingham Department of Anaesthesia, Hillingdon Hospital, Uxbridge,
Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin) P1
P101 A modified WHO surgical safety checklist for P102 A parturient with phocomelia and severe needle
category 1 caesarean sections phobia: the challenges faced
A Lahkar,  A Cooney,  G Massolini   R Sinha,  K Howard,  N Bhandal  
Anaesthetics, Milton Keynes NHS Foundation Trust, Milton Department of Anaesthesia, Nottingham University Hospitals
Keynes, UK NHS Trust, Nottingham, UK
Introduction: In June 2008, WHO introduced a surgical safety Introduction: Parturients with phocomelia are rarely seen and
checklist to be used in every operating theatre to improve present anaesthetic and obstetric challenges. We present a
patients' safety. In 2010 a WHO surgical safety checklist for case of a parturient with phocomelia and severe needle phobia.
maternity was created in response to requests from maternity Case report: A 33 year old woman with phocomelia and severe
services and clinicians. Nevertheless, in some emergency needle phobia presented to the obstetric anaesthetic clinic at
situations like category 1 Caesarean sections, this checklist 20 weeks for pre-assessment.
could still be quite a difficult task to achieve due to Her phocomelia was thought to be idiopathic, she had been
understandable time limit constrains to safely deliver the baby adopted when young and no family/drug history was
and/or save the mother's life. available. Examination revealed four limb phocomelia. There
Whilst there is still no international consensus or any specific were absent upper limb bones on the right and a fused hand
recommendation from WHO concerning these specific attached directly to her body. Her left upper limb was
situations, the Anaesthetic Department in Milton Keynes shortened with a primitive hand and fused fingers. Both lower
hospital has managed to devise a checklist for cat 1 LSCS limbs were extremely shortened with primitive feet with fused
which is 100% compliant both in terms of content with WHO toes. Her head, neck and torso appeared normal. She was able
guidelines and adherence by hospital staff. to mobilize with a wheelchair and significant assistance from
Method: After considerations and inputs from the Consultant her partner. The problems faced in clinic were numerous and
Anaesthetists, a simplified checklist was introduced in our focused on her severe needle phobia, difficult venous access
emergency obstetric theatre in June 2013 by way of an ad hoc and monitoring, positioning, mobilization and
poster hanged on the wall. It spells out the most 10 salient thromboprophylaxis as well as the challenges posed by the
questions to be read by one of the theatre staff before the start preganancy itself. The anaesthetic plan consisted of non-
of a category 1 Caesarean section. These questions translate invasive blood pressure monitoring on her left lower extremity;
the original 32 WHO ones that were spread across 3 sections pulse oximetry via an ear probe or toe and standard
in a simpler, quicker format. electrocardiogram. These were tested prior to labour. Due to
Results: After the introduction of the modified WHO checklist the impossibility of standard intravenous access and extreme
in June 2013, compliance is 100%. needle phobia several discussions were had about obtaining
Discussion: By putting the combined know-how and intravenous access prior to labour. A right subclavian
experience of many Consultant Anaesthetists to the task, we Hickman line was inserted at 39 weeks facilitated by the use of
managed to simplify the original WHO narrative into a sharper entonox. Regional analgesia was refused for labour so the
tool that is quickly and effectively utilised for a better and option of intravenous fentanyl via a midwife controlled
safer quality of care in what has become a "normal routine" analgesia pump was discussed. Should a caesarean section be
during extraordinary times in the emergency theatre. required a neuroaxial anaesthetic was refused and so a general
anaesthetic was planned.
Reference At 40+2 weeks spontaneous rupture of membranes occurred
1. WHO surgical safety checklist: for maternity cases only, and labour established. However, due to failure to progress a
http://www.nrls.npsa.nhs.uk/resources/?entryid45=83972 decision was made to perform a caesarean section.
In theatre the challenges related to positioning and achieving
a satisfactory left lateral tilt. A rapid sequence induction was
conducted following pre-oxygenation to an end-tidal oxygen
concentration of 92%. Anaesthesia was induced with
thiopentone 350mg and suxamethonium 100mg. Soon after
induction she desaturated rapidly to the high 60s. This
resolved after tracheal intubation and ventilation. She was
hypotensive intra-operatively, with an estimated blood loss of
1300mL After fluid and blood resuscitation, recovery was
unremarkable. Postoperative pain was managed with
transversus abdominus plane blocks and morphine
patient/midwife controlled analgesia.
Discussion: There is little literature about managing delivery
in women with phocomelia, but sucessful regional techniques
have been described although this was refused here. Early
discussion of anaethesia and analgesia options, and plans for
vascular access and monitoring are needed, There is a reduced
vascular reservior and skeletal muscle mass.
As a consequence faster inductions, emergences and
responses to titrated drugs are observed.

P2 Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin)
P103 A questionnaire to evaluate and aid future development P104 A retrospective descriptive analysis of anaesthesia for
of the AAGBI's SAFE obstetric anaesthesia course in successful cervical cerclage in pregnancy
Liberia J Modha,  G Burul*,  F Forya*,  CP James*,  AL David*,  J
JCO Fox,  CE Richards*,  T Sheraton*,  A Sonah†   Dick,  L Wee  
†Department of Anaesthetics, Phebe Hospital, Bong County,  Department of Anaesthesia, University College London
Liberia, *Department of Anaesthetics, Royal Gwent Hospital, Hospitals NHS Foundation, London, UK, *Department of
Newport, UK, Department of Anaesthetics, University Obstetrics, University College London Hospitals NHS
Hospital of Wales, Cardiff, UK Foundation, London, UK
Introduction: Dr Kate Grady has developed this three-day Introduction: Cervical cerclage is a common operation which
refresher course in obstetric anaesthesia on behalf of the requires an anaesthetic. There are no studies on the type of
AAGBI. The course is aimed at non-physician anaesthetists in anaesthesia used for this procedure.1
developing countries. It consists of short lectures, interactive Aim: To determine the type of anaesthesia used for vaginal
sessions and workshops that focus on the recognition and cervical cerclage.
management of leading causes of maternal death in resource
Method: Ethical approval waived. Women having any vaginal
poor settings. The course has been taught in Uganda,
cervical cerclage (Macdonald or Shirodkar) during pregnancy
Bangladesh, Liberia and Ghana. It includes the principles of
between January 2005 and December 2012 were identified
the WHO Safe Surgery and training of trainers. Mothers of
using the hospital obstetric anaesthesia database and cross-
Africa, a medical educational charity, has led delivery of 2
referenced with data from the Preterm Birth clinic where women
courses for nurse anaesthetists (NAs) in Liberia - supported
at risk of preterm birth are seen antenatally. Data was obtained
by the AAGBI IRC. Liberia has approximately 60 nurse
by examination of obstetric case notes and the ultrasound
anaesthetists and no medically qualified anaesthetists for a
scan records and analysis conducted using Microsoft Excel.
population of 4.2 million people1. Access to CPD is difficult.
Results: There were 190 cases. Twenty-five patients were
The MMR in Liberia is 770 per 100,000 live births1. In order to
excluded due to incomplete data, hence 165 included in
plan future development of the course in Liberia, which will be
analysis. The mean gestational age was 16.6 weeks (range 9-
led by Liberian trainers, feedback data was collected.
23.6 weeks). The table below shows that both general
Methods: A follow up questionnaire was given to 35 NAs who
anaesthesia (GA) and regional anaesthesia (RA) were used.
had previously attended a SAFE obstetric anaesthesia course
The majority of regional anaesthetics were spinals (95.7%), the
held in Liberia (March 2012 or March 2013). We aimed to
rest combined spinal and epidural (CSE) (3.6%) and epidural
assess; 1) the quality, usefulness and appropriateness of the
top up (0.7%).
material taught during the course, 2) the effect on motivation
to improve local services/care delivery, 3) the effect on the GA RA

confidence levels of NAs in managing obstetric anaesthetic n (%) n (%)
emergencies. Spinal n = 133
Results: A 70% follow up rate was achieved. 97% reported Total n=165 26 (16%) 139 (84%) CSE n = 5
positive changes in their attitude to work and their clinical Epidural n = 1
practice and 94% reported improvements in interactions with Five patients who had a spinal anaesthetic required second
colleagues. Many NAs gave details of cases where the skills procedures (3 GA, 1 spinal, 1 CSE). Of those converted to GA,
and knowledge they learnt on the course helped save lives one patient had a block to T6 (the reason for conversion to GA
and improve clinical outcomes. 11 NAs requested continued was not documented), one patient had a block to T12 and the
education and training. Other suggestions for course third patient had 3 failed spinal attempts. In all cases there
improvement included; additional sessions in preoperative were no major anaesthetic complications and cervical cerclage
assessment and TAP blocks, and the inclusion of midwives in was placed successfully.
the training sessions. The following table illustrates the mean
Discussion: In this series, the majority of vaginal cervical
subjective confidence scores (between 0 and 10) of the NAs in
cerclage surgery was performed safely and effectively under
various clinical scenarios before and after the course.
RA. There are no specific guidelines regarding the type of
  Before After anaesthesia for cervical cerclage.1 Anaesthetic considerations
General anaesthesia LSCS 6.3 9.2 favouring a regional anaesthetic in pregnancy include the risk
Spinal anaesthesia LSCS 7.6 9.8 of aspiration and difficult airway management in patients over
Management of severe eclampsia/preeclampsia 5.7 9.2 20 weeks gestation and those under 20 weeks gestation if at
Management of obstetric haemorrhage 5.9 9.4 high risk for example those with a high BMI. The majority of
women in our data set were less than 20 weeks (88.5%). Other
Discussion: Our results indicate that the SAFE obstetric
considerations include patient and surgeon choice. Women in
anaesthesia course in Liberia has been well received with
this series were given the option of GA or RA. In certain cases
subjective evidence of empowerment and improved methods
for example rescue and abdominal cerclages, the patient may
of working. This is promising in the context of increasing the
need to be in a deep Trendelenberg position to aid reduction
reach of future courses and enabling local faculty to lead
of membrane prolapse to avoid membrane rupture or to aid
training. Further data from logbooks provided as part of the
access to the pelvis.2
course were not obtained and more work is needed to
encourage completion of the logbooks. Objective evidence is References
required to demonstrate impact on patient outcomes. 1. Cervical Cerclage, Green-top Guideline No 60, Royal College of
Reference Obstetricians and Gynaecologists, May 2011.
2. Olatunbosun OA, Dyck F. Cervical cerclage operation for a dilated
1. http://data.worldbank.org/indicator/SH.STA.MMRT/countries/1W-
cervix. Obstet Gynecol. Feb 1981;57(2):166-70.
LR?display=graph
Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin) P3
P105 A retrospective descriptive analysis of dose of P106 A step towards improving theatre productivity for
intrathecal anaesthesia and adjuncts for successful elective caesarean sections
cervical cerclage in pregnancy S Kale,  C Farrow,  N Owen,  K Miltsios  
J Modha,  G Burul*,  F Forya*,  CP James*,  AL David*,  J Department of Anaesthesia, Whittington Hospital, London,
Dick,  L Wee   UK
Department of Anaesthesia , University College London Introduction: NHS Institute for Innovation and Improvement
Hospitals NHS Foundation, London, UK, *Department of developed The Productive Operating Theatre Programme to
Obstetrics, University College London Hospitals NHS improve effective use of theatre time, staff and patient
Foundation, London, UK experience.1 Good administrative system and organisation is
Introduction: Cervical cerclage is a common operation, which essential to ensure theatre efficiency.2On this background,
requires either a general or regional anaesthetic aiming for a with the rational of making existing system more productive,
block height of T10. There are no studies determining the dose safe and reliable, we evaluated current practice in one of our
that should be used to achieve this or describing additional main theatres, designated for elective sections, in a DGH set
drugs used for successful surgery. up.
Aim: To determine the dose of local anaesthesia used for Methods: Evaluation was carried out over a 4-week period, for
intrathecal injection and the block height achieved in women planned caesarean sections. The data was collected
undergoing cervical cerclage. In addition to determine the use concurrently by the anaesthetist for that case and from the
and dose of adjuncts. theatre database. The exact time for all significant events, such
Method: Ethical approval waived. Women having vaginal as when patient was sent for or when theatre was clean and
cervical cerclage during pregnancy between January 2005 and ready for the next patient, was recorded. Reasons for delays,
December 2012 were identified using the hospital obstetric duration of anaesthesia, surgery and problems encountered
anaesthesia database and cross-referenced with data from the were also recorded. Time spent at and between different
Preterm Birth clinic. Data was obtained by examination of crucial stages in theatre was calculated from the data. Results
obstetric case notes and the ultrasound scan records and are presented in the form of time in minutes, median [range]
analysis conducted using Microsoft Excel. and % (absolute numbers of cases).
Results: In all cases, cervical cerclage was achieved Results: We had 25 completed forms. Our analysis showed,
successfully. There were 138 cases of intrathecal anaesthesia median time interval from patient sent for to arrival in theatre
(133 spinals and 5 combined spinal epidurals) in whom 67.4% as 5 min [1-29]. Reasons for delay were due to obstetric team
(93/138) had documented intrathecal anaesthetic dose and busy in meeting, midwife busy preparing the patient and
were included for final analysis. Hyperbaric bupivacaine 0.5% midwife busy completing paperwork for previous patient in
was used (mean dose 10.9mg, median 10.8mg and mode 10mg, recovery. Median time interval between patient's arrival and
range 6.5–15mg). Block height and dose of intrathecal neuraxial block was 18 min [10-70], prolonged in 8% of cases
anaesthetic was documented in 54/93 cases (58%). The block (2/25) due to failed and repeat block. Bladder catheterisation
height ranged from T2 to T12 with similar doses of local after block was delayed by ≥30 min in 8% of cases (2/25) due
anaesthetic given in each group and of similar gestation and to unavailability of midwife. Median anaesthetic time for
body mass index (BMI). satisfactory block was 12 min. Interval between block ready
and knife to skin (KTS) was 6 min [1-12]. Median surgery
Block height T2-4 T5-8 T10 T12 duration was 45 min [31-141]. PPH, high BMI, and previous
Frequency 7 31 13 3 laparotomies resulted in longer operations in 16% of cases
Mean dose mg (4/25). Median turnaround time between the cases was 10 min
11 11 11 8
hyperbaric bupivacaine 0.5% [6-15]. Total time patients spent in theatre was 89 min [74-183].
Mean gestation (weeks) 17.4 17.7 15.6 19.1
Discussion: We noted that unavailability of obstetric team
Mean BMI kg/m2 27.3 26.6 26.1 32
and busy midwives at times has resulted in late starts and
In 3 patients that had block heights of T12 only one was delay in some procedures in theatres. Delay in starting the
converted to GA. Opiates were used in 73/93 (78.5%), the most surgery after a satisfactory block and prolonged turnaround
frequent being fentanyl. time have also affected the overall theatre productivity. We
have put forth some recommendations to working group such
Mean dose Range
Opiate used Number (%) as offering administrative support to midwives, ensuring
(mcg) (mcg)
senior obstetrician and anaesthetist are present for difficult
Fentanyl 69 (95) 20 10-75
cases, making use of anaesthetic room to improve patient
Diamorphine 3 (4) 300 250-350
turnaround time and most importantly encouraging staff
Fentanyl & Diamorphine 1 (1) 20/300 N/A
nurses to take the lead role in increasing theatre efficiency.
Vasopressors were used in 26 cases (23 phenylephrine, 3 This could be a big step towards enhancing theatre output as
ephedrine). Other drugs included 3 cases of intravenous well as increasing patient and staff satisfaction. We aim to
midazolam, 1 case propofol and in 1 case salbutamol (as a introduce these changes soon and re-evaluate the practice in
tocolytic agent). the near future.
Discussion: In our case series there is a wide dose range of References
both hyperbaric bupivacaine 0.5% and opiate given. To 1. The Productive Operating Theatre programme,
achieve a block height of T10 or above a minimum dose of http://www.institute.nhs.uk/quality_and_value/productivity_series/the
11mg (2.2ml) is recommended which may be independent of _productive_operating_theatre.html
other factors. There is a wide variation in block height but 2. Theatre Efficiency,
http://www.aagbi.org/sites/default/files/theatreefficiency03.pdf
even a low block (T12) was found to be adequate.

P4 Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin)
P107 A year in the "maternity" life of an increasingly busy P108 Abstracts on the antenatal anaesthetic clinic
new build district general teaching hospital - coping presented to the Obstetric Anaesthetists' Association,
with training and service provision - 2013 1991-2013
H Wrigley,  PF Yoxall,  Janet Slee   AJ Wickham,  SM Yentis*  
Anaesthetics, St Helens & Knowsley NHS Trust, Liverpool, Anaesthetic department, St Mary’s Hospital, London, UK,
UK *Anaesthetic department, Chelsea & Westminster Hospital,
Introduction: Since moving to a new PFI built hospital in 2010 London, UK
our maternity unit has become more busy. Delivery rates/year Introduction: National reports1 and guidelines2 recommend
have increased from 2900 to 3700 pa (up 27.6% in 3 years) assessment of women with ‘high-risk’ pregnancies and
increasing demands upon anaesthetic services. potentially serious co-morbid disease in an antenatal
Methods: We reviewed all our maternity cases during 2013, anaesthetic clinic (AAC). We reviewed trends and themes in
both epidural and caesarean sections. We also surveyed our abstracts on this topic presented to the OAA.
CT2 trainees to assess their experience in terms of case Methods: Full-text records of abstracts (excluding case reports)
numbers during a newly introduced modular training block. presented at OAA meetings (1991-2013; see www.oaa-
Lastly consultant cover on labour ward was audited for CNST anaes.ac.uk) were searched using the terms ‘antenatal’,
purposes. ‘clinic’, ‘risk’ and ‘refer’. Relevant abstracts were reviewed for
Results themes and conclusions.
Results: Forty abstracts were presented at 14 Annual
n %
Meetings (Fig. 1); 3 were unavailable in full-text (2008) but 1
Total Deliveries 3700
was provided by the author on request. 35 were from single
LSCS 838 22.6
departments and 5 were surveys (4 national). Common topics
Grade I-III LSCS 464 12.5
were obesity (12, 30%), referral reason (7, 18%) and
Grade IV LSCS 374 10.1
appropriateness (4, 10%), and outcomes (5, 13%). Nine (23%)
LSCS - SAB 666 79.5
described single patient cohorts, e.g. cardiac. AAC workload
LSCS - Epidural 123 14.7
has increased from 2.3 to 28.6 patients per month over 22
LSCS - CSE 14 1.7
years, albeit at different centres. Obesity has replaced
LSCS - GA 119 14.2
musculoskeletal disease as the most frequent reason for
RA to GA 34 4.2
referral. Common concluding themes include the need to
Average BMI LSCS (Range) 28.3 (16.7-59.9)  
improve the timeliness and appropriateness of referrals, and
Epidurals 895 24.2
ensuring anaesthetic plans are both prominent and followed.
Epidural Resites 32 3.7
PDPH - Epidural 15 1.7
PDPH - SAB 2 0.3
Epidural Blood Patches 21
Average BMI Epidural (Range) 27.1 (16-62.8)  
CT2 Training One of our requirements is to teach at least 4
CT2s per annum obstetric basic competencies. Our trainees
receive a 4 week long daytime block covered by an anaesthetic
ST3-7 and a consultant. They attend 40 sessions, the majority
siting 15 epidurals and anaesthetise 30 caesarean sections
before embarking on daytime on calls. They attend our in-
Figure 1: number of abstracts on the AAC presented per year
house MODSS (Obstetric Simulation Day) run by one of our
Consultant Obstetricians. Discussion: Abstracts relating to AACs have become more
frequent in the last decade, presumably reflecting their
Consultant Input The number of funded Consultant labour
increasing provision and perceived usefulness (and
ward sessions has risen 7 to 10 sessions (7 elective lists per
recommendation in the 2002-04 CEMACH report3). Increased
week). A “High Risk Obstetric clinic” runs weekly to pre-
demand for this service is exacerbated by inappropriate
assess all potentially difficult patients (250-300 per annum).
referrals and budgetary constraints. Referral processes,
Discussion: Despite a significant increase in workload we
facilities, and documentation and inconsistent use of plans are
have managed to maintain levels of cover (both junior and
areas for development. Future work should focus on quality
consultant) whilst allowing for CT2 training in obstetric basic
improvement and assessment of cost-effectiveness. Nationally
competencies as required at both national and local levels.
agreed referral criteria and a national ‘anaesthetic plan’
This has been achieved by increasing our core of obstetric
document, complemented by referrer education, may enhance
consultant anaesthetists, increasing obstetric PAs and
the process. Multidisciplinary ‘one-stop-shop’ or midwifery
changing to a modular CT2 training programme.
led clinics for common problems, such as obesity, may be
beneficial.
References
1. Centre for Maternal and Child Enquiries. Saving Mothers’ Lives:
reviewing maternal deaths to make motherhood safer: 2006-08.
The Eighth Report on Confidential Enquiries into Maternal Deaths
in the UK. BJOG. 2011; 118(Suppl.1): 1-203.
2. OAA & AAGBI Guidelines for Obstetric Anaesthetic Services.
Revised Edition 2005. London: OAA/ AAGBI
3. CEMACH. Why Mothers Die 2000-2002. Report on Confidential
Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin) P5
P109 Accuracy of a new electronic obstetric anaesthetic P110 Accuracy of landmark approach to central neuraxial
database blocks in obstetric patients
Rohit Rohit,  R Abraham,  GNB Jackson   J Lie,  K Bhatia,  A Venkataraju,  P Kochhar  
Anaesthetic department, Royal Berkshire Hospital, Reading, Anaesthesia, St Mary's Hospital, Manchester, UK
UK Introduction: Correct identification of vertebral level could
Introduction: We have introduced a new electronic database prevent damage to the spinal cord during a central neuraxial
'ROAD' (Reading Obstetric Anaesthetic Database) to record block (CNB). Evidence suggests that ultrasound (US) imaging
obstetric anaesthetic data. Written & designed by one of our of the spine by an experienced operator leads to correct
anaesthetists it is secure, password protected & able to identification of vertebral level in 90% of the patients and
produce reports on patient data & the activity of individual decrease the number of attempts required for a successful
anaesthetists. More than 70% obstetric anaesthetic units use CNB1. National Institute for Health and Care Excellence
electronic data collection system in the UK but there is little suggests US could be a useful tool for epidural catheter
agreement as to the best format.1 We audited the accuracy of insertion2. Our aim was to determine the discrepancy between
data entry, as a marker of ease of use by the anaesthetists, landmark technique and US to identify level of insertion of
before auditing the content of the database. CNB.
Methods: This was a retrospective audit, analysing data for Methods: Two experienced US operators who were blinded to
one month period (June 2013). The data in 'ROAD' was the initial procedure retrospectively performed US imaging of
compared to 1) our handwritten anaesthetic record book spine post-operatively after elective caesarean section in 51
(ARB); 2) Midwifery led labour ward logbook (LWLB); 3) obstetric patients with their consent from January to March
Operating theatre electronic log 'Bluespier'. Data entered on 2013 in St Mary’s Hospital. All the patients had a lumbar CNB
the 'ROAD' was manually checked against all these three done by landmark approach. The documented vertebral level
sources and the results tabulated and analysed. at which CNB was performed was noted. This was then
Results: 253 records were found in the ARB. The ARB missed compared with the actual vertebral level identified by bedside
one case (found in Bluespier), Bluespier missed one case US imaging of spine.
(found in the ARB) and LWLB missed 6 cases (found in the
Results: 29 patients had a spinal, 20 had an epidural and two
ARB & Bluespier). The results show that 'ROAD' was 96%
had combined spinal-epidural anaesthesia. The median body
accurate compared to any of the other systems.
mass index (BMI) was 28.6kg/m2. Landmark technique was
No. of cases missing on only accurate in 39.2% of patients. There was no statistically
Total 'ROAD' accuracy against
  'ROAD 'compared to significant correlation between the experience of operator and
no. other data sources as %
others accuracy. 3% of patients had a CNB at the level of L or above.
2
ARB 10 253 96.047% Documentation of the level performed was excellent. Raised
Bluespier 7 174 95.977% BMI and difficulty in palpation of landmarks resulted in
LWLB 10 247 95.951% statistically significant decrease in the accuracy (p<0.05
'ROAD'   243   Fisher’s Exact Test).
Discussion: Pinder et al considered an accuracy of 89% for Discussions: Our findings co-relate well with other studies
their electronic record adequate enough to adopt computer which have found that the vertebral level identified by
based data collection system.2We used three different landmark approach was at least 1 interspace higher than the
methods of data collection already in regular use, to compare level located by US in 40% of the pregnant population 3. Our
with our electronic database and showed it to have a high audit further confirms that the use of traditional landmark
degree of accuracy. This suggests that the database is easy to technique is highly inaccurate with potential increase risk of
use and consistently completed by our anaesthetists. We wish needle injury to the spinal cord especially in the high-risk
to use our database to produce reports on anaesthetic service patient groups (morbid obesity and musculoskeletal
provision (including the quality & safety of that service) as problems). We propose that all elective obstetric patients,
well as for auditing individual anaesthetist activity patients having a lumbar epidural, and high risk patients
(particularly our novice obstetric anaesthetists to ensure having a lumbar CNB should have US imaging of the of their
appropriate case mix & experience during their obstetric spines to identify the correct vertebral level and other relevant
attachments). Before using any database to audit these anatomy. The main reasons being that US imaging does not
aspects it is important to ensure that the data being audited is involve any radiation, is compact, portable and readily
a true reflection of anaesthetic activity, we believe our new available at the point of care. Better US equipment availability,
database is sufficiently accurate to audit the data within it. The staff awareness with appropriate training and improved
limitation of our audit is that we only audited the data from one documentation would aid in providing safer patient care.
month but we believe that the data entry practice of all months
References
is similar. We conclude that our electronic database is accurate
1. Chin KJ, Perlas A, Chan V, Brown-Shreves D, Koshkin A, Vaishnav
& the data entered can be used to audit our obstetric V: Ultrasound imaging facilitates spinal anesthesia in adults with
anaesthetic service. difficult surface anatomical landmarks. Anaesthesiology 2011; 115
(1): 94-101
References
2. Ultrasound-guided catherisation of epidural space. National Institute
1. Campbell NJ, Youngs P, Anderson I. A national survey of obstetric for Health and Care Excellence January 2008
anaesthetic data collection methods in the UK. Int J Obstet Anesth
2012; 21: S53. 3. Lee AJ, Ranasinghe S, Chehade JM, Arheart K, Saltzman BS,
Penning DH & Bimbach DJ. Ultrasound Assessment of the Vertebral
2. Pinder A, Wrench I, Shepherd D, Freeman R. Assessment of a Level of the Intercristal Line in Pregnancy. Anaesth Analg 2011;
handheld computer to collect obstetric epidural audit data. Int J
113: 559-564
Obstet Anesth 2002; 11: 8.
P6 Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin)
P111 Adherence to antenatal anaesthetic advice in P112 An evaluation of anaesthetic antenatal clinics in the
labouring morbidly obese parturients. obese obstetric population
S Halliday,  LC Robertson ,  HM du Plessis   PR El-Dalil,  DS Cochran,  R Ganapathy*  
Anaesthesia, Princess Royal Maternity Hospital, Glasgow, Department of Anaesthesia, Sandwell and West Birmingham
UK NHS Trust, Birmingham, UK, *Obstetrics and Fetal Medicine,
Introduction: Morbidly obese parturients pose a high Sandwell and West Birmingham NHS Trust, Birmingham, UK
anaesthetic risk1. Antenatal anaesthetic assessment for Introduction: Maternal obesity is increasingly common, with a
women with a body mass index (BMI) ≥40 kg.m-2 at booking is BMI 35 found in 5% of pregnancies. Current CMACE / RCOG
advised2. Early establishment of epidural analgesia is often guidelines advocate the referral of patients with a BMI 40 to
advocated. We sought to determine if this advice is adhered to an anaesthetic antenatal clinic. This study aimed to evaluate
in our centre. the outcomes following the implementation of such a clinic in a
Methods: A retrospective case note review of 49 morbidly busy inner city district general hospital.
obese patients (BMI ≥40) assessed antenatally was Method: High-risk patients were referred to a multidisciplinary
conducted. As a control, data from 23 patients with a BMI <40 antenatal clinic involving Anaesthetics, Obstetrics and
who had a labour epidural was collected. We compared the Haematology; patients with a BMI 40 were referred to the
timing of epidural request from labour ward admission, cervical clinic and included in the evaluation. Data was collected
dilation and syntocinon administration at request and the time retrospectively on the reason for attending, the past medical
from epidural insertion to delivery. Mode of delivery was also and obstetric history as well as any anaesthetic or surgical
noted. intervention provided in the perinatal period.
Results: Mean BMI for the control group was 23.6 (range 17- Results: In 2011, 72 women were referred to the clinic with a
32) and for the morbidly obese group 44.6 (40-60). Eleven BMI 40, although there were often other relevant co -
morbidly obese parturients had an elective caesarean section morbidities. The BMIs ranged from 40 to 80 (mean = 44). 44
(CS). Nineteen of the remaining morbidly obese parturients patients (61%) had a normal vaginal delivery, 3 women (4%)
requested labour epidurals. Two parturients delivered prior to required assisted vaginal delivery, 17 (24%) had an elective
insertion. caesarean section (CS), whilst 8 (11%) had a non-elective CS.
Of these patients, 38 (53%) required no anaesthetic
Time to Syntocinon Insertion to
Cervical dilation intervention.
request administration n delivery
  Centimetres
Minutes (%) Minutes Table: Anaesthetic intervention and failure rates in obese
(range)
(range) (range) parturients compared to previously published failure rates1 in
BMI Yes 12 (52.2) the general obstetric population
375 (110-
<40 169 (0-435) 3.7 (1-7) No 11 (47.8) Spinal Epidural CSE GA
915)
(n=23) Number attempted 19 12 4 1
BMI Yes 13 (68.4) % Failure rate 5 17 0 0
334 (12-702)
≥40  261 (0-555) 3.65 (2-8) No 6 ( 31.6) Published % failure rates1 6 24 18 <1
(n=17)
(n=19)
Discussion: The results demonstrated low regional
Table: Timing of epidural request, cervical dilation and anaesthesia failure rates, with only 1 unsuccessful spinal (5%)
syntocinon use at request, and time from insertion to delivery. and 2 failed epidurals (17%); figures comparable to those
In the control group with a BMI <40 that had a labour epidural found in the general obstetric population (Table). There is little
(n=23), the number of spontaneous vaginal deliveries (SVD), available data for regional anaesthetic failure rates in the obese
trial of forceps (TOF) and lower uterine segment CS (LUSCS) obstetric population precluding a direct comparison, but a
were 13 (56.5%), 5 (21.7%), and 5 (21.7%), respectively. For higher failure rate would be expected. A previous study of 677
those with a BMI ≥40 with an epidural (n=17) there were 6 women with a BMI 30 found an emergency CS rate of 24%, 2
(35.3%) SVD, 3 (17.7%) TOF and 8 (47.1%) LUSCS. The significantly higher than the 11% demonstrated in this cohort
number of SVD in the BMI ≥40 without an epidural group was of BMI 40. This robust multidisciplinary approach in the
18 (85.7%) and there were no TOF and 3 (14.3%) LUSCS. antenatal period allows for adequate planning and early
Discussion: Despite antenatal review, the time to epidural institution of optimised perinatal management. The service
request was longer in the morbidly obese group, indicating a provided was predominantly consultant led, with the on-call
need for ongoing education. The time between epidural Anaesthetist required to attend out of hours for parturients
insertion and delivery was shorter in the morbidly obese group with a BMI 45, and to be informed of patients with a BMI
which had a significantly increased chance of CS, signifying 40; significantly 73% of the on-call consultants are dedicated
the importance of establishing a working epidural early in this Obstetric Anaesthetists. We feel these systems may account
cohort. for our findings, as well as promote early and effective
communication with patients. Whilst the sample was relatively
References small the results are sufficiently encouraging to suggest that a
1. Soens MA, Birnbach DJ, Ranasinghe JS, van Zundert A. Obstetric multidisciplinary approach significantly improves perinatal
anesthesia for the obese and morbidly obese patient: an ounce of outcomes in the obese obstetric population.
prevention is worth more than a pound of treatment. Acta
Anaesthtesiol Scan 2008; 52: 6-19 References
2. OAA/AABGI Guidelines for Obstetric Anaesthetic Services 2013. 1. Kinsella SM. A prospective audit of regional anaesthesia failure in
Association of Anaesthetists' of Great Britain and Ireland and the 5080 caesarean sections. Anaesthesia 2008; 63(8): 822-832.
Obstetric Anaesthetists' Association. London, 2013. 2. Usha Kiran TS, Hemmadi S, Bethel J, Evans J. Outcome of
pregnancy in a woman with an increased body mass index. BJOG
2005; 112(6): 768-772.
Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin) P7
P113 An evaluation of fasting times for elective caesarean P114 An evaluation of intrathecal diamorphine versus
section surgery fentanyl for lower segment Caesarean section in a
J Ghoshdastidar,  KM Sherratt,  M Seneviratne*,  A medium-sized district general hospital
McGlennan   K Ramm,  LT Fenton-May,  S Naresh  
Anaesthetics, Royal Free Hospital, London, UK, Department of Anaesthesia, Good Hope Hospital, Heart of
*Anaesthetics, University College Hospital, London, UK England Trust, Birmingham, UK
Introduction: Enhanced Recovery Programmes have shown Introduction: Intrathecal diamorphine is now recommended by
increasing evidence for the benefits of reducing fasting times the National Institute for Health and Clinical Excellence (NICE)
for those undergoing elective surgery1. Many of these as the opioid of choice for lower segment Caesarean section as
benefits could be applicable to the elective caesarean section it provides improved post-operative pain relief.1 However, it is
patient. We evaluated the fasting times of our elective also associated with a dose-dependent increase in the
caesarean section patients to assess whether we could make incidence of pruritus2 and nausea3 which may be more
improvements to patient care. significant with diamorphine given its longer duration of
Methods: The evaluation included all patients undergoing action. Having arranged appropriate protocols for post-
elective caesarean section surgery at the Royal Free Hospital operative monitoring of women receiving intrathecal
over a 3 month period.. Patients received standard instructions diamorphine, we introduced the therapy in late 2012.
to stop eating at midnight on the day of surgery and to stop Methods: The evaluation took place over a six-week period. A
drinking clear fluids at 6 am. Data was collected by anaesthetic small number of women were still receiving intrathecal fentanyl
staff using a standardised data collection sheet.. Patients were due to clinician choice, and these provided a useful
questioned about the time they last consumed solid food and comparator. Women who were still present in the hospital on a
when they last drank liquid. follow-up round on the first day post-op were asked questions
Results: In total 77 patients underwent elective caesarean about post-operative pain, nausea and pruritus. We also
sections during the period of evaluation. We obtained data assessed total oral morphine and codeine doses and time to
from 71 patients for fasting times for fluids and 72 patients for first dose.
fasting times for solids. Results: Basic data is presented in the chart.

  Fentanyl Diamorphine
Pre-op fasting % of Pre-op fasting % of
Number 15 36
times FLUIDS patients times SOLIDS patients
Time to first morphine (hrs) 5.29 8.9
(hr) (n=71) (hr) (n=72)
Mean morphine dose (mg) 65.4 30
2 - 4 5.6 6 - 12 15.3
No morphine required 1 (6.6%) 11 (30.6%)
4 - 6 15.5 12 - 18 66.7
Mean codeine dose (mg) 123 119
6 - 8 14.1 18 - 24 16.7

8 - 10 8.5 over 24 1.4
Time to mobilisation (hrs) 21.17 15.21
over 10 56.3    
Time to catheter removal (hrs) 20.3 16.6

Discussion: There are no fasting recommendations specific to
Pruritus 8 (53.3%) 24 (66.7%)
elective caesarean sections but the standard surgical
- requiring treatment - 0 (0%) - 8 (22.2%)
guidelines of 6 hours for solids and 2 hours for clear fluids are
Nausea 5 (33%) 13 (36.1%)
usually applied. Periods longer than 12 hours without fluid
- requiring treatment - 3 (20%) - 7 (19.4%)
have correlated with significant dehydration
in patients having elective caesarean sections2. There is also
Discussion: Our results replicate previous work demonstrating
some evidence to suggest that gastric fluid volume is
a reduction in immediate post-operative analgesia
increased with prolonged starvation in the pregnant patient3.
requirements following a switch from fentanyl to diamorphine,
Over fifty per cent of our patients went without fluids for
but an associated increase in side effects requiring
longer than ten hours prior to surgery, and almost eighty-five
intervention. There was also a reduction in times to first
per cent of patients went without food for greater than 12
mobilisation and catheter removal, which is worth closer
hours. Our results show that there is a need to introduce
inspection. It is likely to be multi-factorial: the patients having
methods to reduce fasting times. These could include pre-
superior analgesia and feeling ready to move sooner, but also
operative letters with individualised times to stop eating and
the proforma for the ward indicating the patient had received
drinking. Also patients lower down the surgical list could be
diamorphine. This required the anaesthetist to specify a time
actively encouraged to consume clear fluids, or even
after which she would be ready to mobilise, which might have
carbohydrate drinks as used in many Enhanced Recovery
improved motivation amongst the midwives and mothers to
programmes.
achieve mobilisation.

References
References
1. Aguilar-Nascimento JE, Dock-Nascimento DB. Reducing
preoperative fasting time: A trend based on evidence. World J 1. NICE clinical guideline 132: Caesarean section
Gastrintest Surg. 2010 March 27;2(3): 57-60 2. Wrench IJ, Sanghera S, Pinder A et al, Dose response to intrathecal
2. Mackenzie M, Yentis S, Woolnough M and Johnson M. Fasting diamorphine for elective caesarean section and compliance with a
periods and dehydration before elective caesarean section. national audit standard, Int J Obstet Anesth. 2007;16(1):17-21
Anaesthesia, 2010 Vol 65:99 3. Sibilla C, Albertazzi P, Zatelli R, et al, Perioperative analgesia for
3. Maltby JR, Sutherland AD, Sale JP, Shaffer EA. Preoperative oral caesarean section: Comparison of intrathecal morphine and
fluids: is a five hour fast justified prior to elective surgery?. Anesth fentanyl alone or in combination, Int J Obstet Anesth. 1997; 6(1):
Analg. 1986 Nov;65(11):1112-6 43-48
P8 Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin)
P115 An evaluation of obstetric critical care admissions in a P116 An evaluation of standards of informed consent and
district general hospital documentation for labour epidural analgesia
VL Williams,  M Greene,  D Saul   S Chaudhari,  N Smith,  P Prasad  
Department of Anaesthesia, Leighton Hospital, Crewe, Anaesthetic Department, George Eliot Hospital, Nuneaton,
Cheshire, UK Nuneaton, UK
Introduction: CMACE has provided doctors with excellent
Introduction : It is both medico legally and ethically important
data over the past 50 years about maternal mortality, but
that the patient is made aware of the nature and risks
unfortunately no data about maternal morbidity. In December
associated with a labour epidural. No national standardised
2013, the Intensive Care National Audit & Research Centre
information card for informed consent is available, although
(ICNARC) produced a second report that analysed critical care
the OAA does publish a epidural information card1 with
admissions of women who were pregnant or recently pregnant
specific risks and incidence rates. At our hospital, the
in 2009-2012 inclusive.1 A comparison was made between the
documentation is made on part of the epidural chart as an
hospital ICNARC data and the national ICNARC data.
open entry. Our study looked to ascertain whether appropriate
Methods: Data were collected from the hospitals ICNARC
details of the epidural and informed consent were made. This
database over a four year period from 2009 to 2012. The data
was with a view to find whether a total redesign of the epidural
was analysed from the categories in the table below.
chart (at a level of standard suggested by the OAA website2)
Results: Data from 388 patients were evaluated.
was needed to improve our practice.
  Hospital ICNARC
Methods : We evaluated a total of 100 completed epidural
Total no. of patients admitted, female 16-50 years 388 55,791
charts over a 4-month period in mid-2012 at our obstetric unit.
Currently pregnant 3.6% 2.1%
The epidural notes were retrospectively analysed on our
Recently pregnant 9.3% 10.0%
scanned patient electronic notes. Documentation was
Obstetric reason for admission - currently pregnant 0% 8.7%
analysed for: details of the patient, anaesthetist and patient
Non-obstetric reason for admission - currently
100% 91.3% assessment, explanation of the risks and incidence given,
pregnant
details of the epidural technique and post epidural
Obstetric reason for admission - recently pregnant 50% 69.7%
management. Our main focus was on standards of consent.
Non-obstetric reason for admission - recently
50% 30.3% Results:
pregnant
%of patients Rate of risk
Discussion: The proportions of patients admitted to the Range of risk discussed
Risk discussed informed documented (no.
critical care area were comparable with the ICNARC report. (no. in total)
(n=100) in total)
The leading indication for admission in the currently pregnant
1in100:13,1in200:8
group was for sepsis. This corresponds with the ICNARC Headache 69 25
<1%:3,1in500:1
report and most recent CMACE report in which sepsis was the
Hypotension 45
leading direct cause of maternal death.2
Failure 59 4 1in8:2, 1in4000:2
The leading obstetric cause for currently pregnant admissions
Nerve 1in13k:21,1in10k:8
nationally, was for pre-eclampsia. However, there were no 65 31
damage 1in15k:1, 1 in19k:1
admissions in this category at the hospital. This is most likely
Itching 14    
because pre-eclampsia is diagnosed and treated effectively on
Infection 37  
the labour ward and rarely needs input from critical care.
Motor block 28    
In the recently pregnant group, there were equal proportions
Urinary
of patients admitted for obstetric and non-obstetric reasons, 28    
retention
this is quite different from the ICNARC report. The leading
indication for admission of recently pregnant patients in the The other areas of documentation studied showed an
ICNARC report was for post partum haemorrhage, by a long acceptable standard.
way. When looking at the hospital database, it showed that in Discussion : Several studies have looked at standards of
the period 2010-12, only 3 of 42 patients with a significant post informed consent in UK practice3and which risks and
partum haemorrhage of 2.5 litres or more were admitted to incidences were discussed and the range of risk quoted. Our
critical care. Therefore the question needs to be asked as to study showed rates generally to be slightly lower than that
whether these patients should have been admitted to the quoted in these studies. This is likely due to limited space and
critical care area? The hospital does not have an obstetric open entry nature of our current chart. The OAA has set
HDU, but in hospitals that do have an obstetric HDU facility, guidelines and advice for both epidural charts2 and risks and
these patients would certainly have been admitted there, had incidence1. Following this evaluation, a full redesign of our
closer monitoring and possibly goal directed therapy. All of epidural charts with prompts and guidance of risks and
these patients survived, but could admission to critical care incidence is warranted. In addition, the OAA had
have improved patient outcomes or reduced hospital stay? overwhelming support for a national standardised information
References card that could be implemented3.
1. Female admissions to adult, general critical care units in England,
Wales and Northern Ireland reported as 'currently pregnant'
References
or 'recently pregnant'. http://www.icnarc.org/documents/Obstetric%
20admissions%20to%20critical%20care%202009-2012.pdf 1. OAA epidural information card : http://www.oaa-
anaes.ac.uk/content.asp?ContentID=185
2. The eighth report on confidential enquiries into maternal deaths in
the United Kingdom. BJOG 2011, 118(Suppl 2):1-203 2. OAA epidural charts : http://www.oaa-anaes.ac.uk/content.asp?
ContentID=522
3. Informed consent for epidural analgesia in labour: A survey of UK
practice: Anaesthesia 2009, 64 p161-164
Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin) P9
P117 An unusual cause of post-partum sepsis P118 Anaesthetic management of a parturient with severe
F A Corcoran,  C Brennan,  A J Downs   systemic scleroderma
Anaesthetics, Dudley Group NHS Foundation Trust, Dudley, P Thomas,  A Varvinskiy,  M Human  
UK Anaesthetics, South Devon Healthcare NHS Foundation
Introduction: Leiomyomas are common in women of Trust, Torquay, UK
reproductive age and have been linked to spontaneous Introduction: Scleroderma is a chronic systemic autoimmune
abortion, retention of the placenta and post-partum disease. Successful pregnancy in patients with severe
haemorrhage.1 It is however rare for them to be the primary systemic scleroderma is very rare. We report the anaesthetic
cause of post-partum sepsis. We describe the case of a post management of such a case in a patient with a difficult airway,
partum patient presenting with painful fibroids and sepsis. severe pulmonary dysfunction and oesophageal dysmotility.
Case report: A 37 year old woman (P1), 5 days post partum Case report: A 29 year old woman (G1P0) with severe
presented with a history of fever, abdominal pain and systemic scleroderma presented to the hospital at 36 weeks
distention. She had a past medical history of fibroids but there gestation with dyspnoea and tachypnoea. Prior to pregnancy
had been no problems during pregnancy. She had an her exercise tolerance was poor, managing just 400 metres in a
uneventful labour with a normal vaginal delivery. On initial six minute walk test with resultant oxygen saturations of 72%.
assessment she was apyrexial with normal observations. She Her Forced Expiratory Volume (FEV1), Forced Vital Capacity
had mild tenderness on palpation of her abdomen. She was on (FVC) and Diffusing Capacity for Carbon Dioxide (DLCO) had
regular analgesics and had been commenced on oral each worsened steadily by five percent year on year over the
antibiotics by her GP. An ultrasound scan (USS) was booked last decade. The most recently measured values from 2007
to investigate the abdominal pain. Within 4 hours she had were FEV1 30%, FVC 28% and DLCO 24% of predicted values
deteriorated and developed a pyrexia, tachycardia, tachypnoea although the patient reported that her pulmonary function had
and decreased oxygen saturations. Initial impression was deteriorated significantly during pregnancy. On admission the
sepsis secondary to retained products so blood cultures and patient was breathless at rest with a p02 of 7.63 on room air
swabs were taken and intravenous antibiotics, oxygen and and it was felt that natural labour would not be possible due to
fluid resuscitation commenced. She was transferred to the poor physiological reserve. Severe reflux secondary to
Maternity High Dependency Unit. CRP was elevated but oesophageal dysmotility rendered her unable to recline more
lactate was normal. She improved over 6 hours but than 45 degrees and she could therefore not lie flat for awake
deteriorated again. Antibiotic coverage was amended caesarean section. Airway assessment revealed microstomia of
following microbiology advice but she continued to have a less than one centimetre, mallampati four, bucked teeth, sub
swinging pyrexia. USS detailed a bulky uterus with a large mental skin scleroderma and a narrow hooked nose with small
fibroid at the fundus and no retained products. 36 hours after nostrils. Oral intubation was therefore ruled out. Awake Fibre
admission she developed peritonitis and a CT abdomen which Optic Intubation (AFOI) appeared technically challenging due
suggested findings of a pedunculated fibroid measuring to nasal anatomy. Preoperative, bedside nasendoscopy
17.5cm that might have twisted on its pedicle. She had an revealed that AFOI would be possible should the need to
emergency laparotomy which revealed a degenerative, secure the airway arise mid operation. This avoided the need
necrotic, infected fibroid. She required ionotropic support and to perform an AFOI or awake tracheostomy pre-operatively.
was difficult to ventilate intra-operatively. Post-operatively The patient was positioned at 45 degrees on the operating
she was transferred to intensive care where she was sedated table. Surgeons confirmed that they could operate in this
and ventilated overnight. She was successfully extubated the position. A low dose spinal followed by an epidural which was
following morning and continued with intravenous antibiotics topped up gradually over 30 minutes using small incremental
and analgesia. She made a full recovery. Histology confirmed boluses achieved adequate block without compromising
the fibroid had extensive areas of coagulative necrosis, respiratory function. Surgery was completed without issue and
hyalinisation and inflammation. All microbiological both mother and baby did well post-operatively.
investigations were negative. Discussion: There are only three reports in the literature
Discussion: Sepsis in pregnant and post-partum women describing general anaesthesia for caesarean section in
remains a significant cause of maternal morbidity and patients with scleroderma and two using neuraxial blockade.1-5
mortality.2Sepsis is a clinical diagnosis and microbiological Of those who were intubated, one died and another required
investigations may be negative. Early recognition, timely three months ventilation. We demostrated how careful bedside
diagnosis and active treatment assists an optimum outcome. airway assessment and the use of a slow top up epidural were
Fibroids are common in pregnancy but sepsis secondary to successfully used to manage this challenging case.
infected, necrotic fibroid tissue post-partum is very rare. To References
our knowledge there have been no reported cases of this. It is
1. D'Angelo R, Miller R. Pregnancy complicated by severe
therefore essential to consider this in the differential causes of preeclampsia and thrombocytopenia in a patient with scleroderma.
obstetric sepsis when reviewing pregnant women with a Anesth Analg 1997; 85: 839-41
history of fibroids. 2. Hseu SS, Sung CS, Mao CC, Tsai SK, Lee TK. Anesthetic
management in a parturient with progressive systemic sclerosis
References during cesarean section. Acta Anaesthesiol Sing 1997; 35: 161-7
1. Mason T. Red Degeneration of a leiomyoma masquerading as 3. Younker D, Harrison B. Scleroderma and pregnancy. Br J Anaeth
retained products of conception. Journal of the National Medical 1985; 57: 1136-9
Association. 2002; 94: 124-6 4. Thompson J, Conklin KA. Anesthetic management of a pregnant
2. Lucas DN, Robinson PN, Nel MR. Sepsis in obstetrics and the role patient with scleroderma. Anaesthesiology 1983; 59: 69-71
of the anaesthetist. International Journal of Obstetric Anaesthesia. 5. Bailey AR, Wolmarans M, Rhodes S. Spinal anaesthesia for
2012; 21: 56-67 caesarean section in a patient with systemic sclerosis. Anaesth
1999; 54(4): 355-8
P10 Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin)
P119 Anaesthetic management of arrhythmogenic right P120 Anaesthetic management of obese parturients at a
ventricular cardiomyopathy during labour and tertiary centre - meeting the standard?
caesarean section: a case series L Kelliher,  J Teare,  E Evans  
J Eccles,  A Jain,  K Bhatia   Anaesthesia, St George's Healthcare NHS Trust, London, UK
Department of Anaesthesia, St Mary's Hospital, Manchester, Introduction: Obese women are at increased risk of perinatal
UK morbidity and mortality. In 2010 CMACE and RCOG published
Introduction: Arrhythmogenic right ventricular joint guidelines for the management of the obese parturient
cardiomyopathy (ARVC) is mainly a genetically determined including recommendations that patients with a booking BMI
autosomal dominant disease characterised by cardiomyocytes ≥40 should attend an antenatal anaesthetic clinic (AAC) and a
being replaced by fibrofatty tissue in the right ventricle.1 Specialist Trainee year 6 anaesthetist (ST6) or above should
ARVC has an incidence of 1:5000 and may account for as be informed and available to attend labour and operative
many as 5% of unexpected sudden deaths. The Eighth Report delivery1. Our unit is a tertiary centre with over 5,000
of the Confidential Enquiries into Maternal Deaths in the deliveries/year. A previous audit over 2 years showed that of
United Kingdom (2006-2008) highlighted that ARVC was the 120 women with BMI ≥40 attending our AAC, 76% required a
underlying cause in two of the 53 reported cardiac deaths. We peripartum anaesthetic intervention, with only 34% of these
describe the anaesthetic management of two parturients with performed by an anaesthetist ≥ST62. Awareness of the
ARVC who presented at our tertiary centre. guidelines was raised and anaesthetic plans for these women
Case reports: The maternal demographics, the cardiac signs, now state care should be managed by a senior anaesthetist.
symptoms and interventions along with the anaesthetic We examined our obese population following these changes.
management in the peri-partum period are briefly summarised Methods: A retrospective analysis over 1 year (2011-12) of
in the table below. hospital records for patients with a booking BMI ≥ 40. Records
were examined for referral and attendance at AAC, anaesthetic
Category Case 1 Case 2
intervention (regional/GA), grade of anaesthetist and
Age 27 23
anaesthetic complication (difficult/impossible regional, dural
BMI 25.8 27.2
tap, other).
Parity 0 0
Family history None Sudden death Results: In total there were 74 women with a booking BMI
Cardiac signs and Palpitations with spurts of Paroxysmal VT ≥40. 73% were referred to AAC, only 58% attended. Out of all
symptoms ventricular tachycardia (VT) patients, 69% had a peripartum anaesthetic intervention, 43%
Cardiac Cardiac ablation therapy and ICD insertion of which were performed by an anaesthetist ≥ST6 with a
intervention prior implantable cardioverter complication rate of 16%. Of those attending AAC, 67% had
to pregnancy defibrillator (ICD) insertion an anaesthetic intervention, 41% of which were performed by a
Mode of delivery Elective caesarean section Urgent LSCS for ≥ST6 with a complication rate of 17%. Of those patients not
(LSCS) for breech foetal distress attending AAC, 71% had an anaesthetic intervention and 36%
Anaesthesia and General anaesthesia, with Labour epidural of these were performed by ≥ST6 with a complication rate of
analgesia bilateral transversus analgesia, followed by 14%.
abdominal plane blocks top up for LSCS
Table 1. Incidence of complications by grade of anaesthetist
Maternal length of Three days Four days
stay Group ≥ST6 <ST6 p value (Fisher's Exact)
Neonatal APGAR 8 and 10 9 and 10 All 9.1% 20.7% 0.440
scores AAC 16.7% 17.6% 0.945
Discussion: The main implications of ARVC in parturients No AAC 0% 21.4% 0.273
include fatal arrhythmias, heart failure worsened by Discussion: This audit shows a significant number of obese
physiological changes of pregnancy and sudden adult death parturients were not seen in our AAC. A proportion of these
syndrome.1 Both our patients had VT diagnosed after 24 hour were referred, but did not attend however 27% were not
Holter monitoring, and an ICD was implanted in addition to referred. Despite this, there was no significant difference in the
beta blocker medical therapy to control the symptoms of VT as requirement for anaesthetic intervention or the incidence of
well as to prevent sudden death. The patients were seen in the anaesthesia-related complications between attenders and non-
joint cardiac, obstetric and anaesthesia antenatal clinic and a attenders. The incidence of senior anaesthetic involvement in
peri-partum plan formulated to facilitate safe delivery. Both care has risen from 34% to 41% but there is still room for
had serial echocardiograms, serum electrolytes monitored, improvement. This highlights the resource difficulties faced in
invasive blood pressure monitoring and ICD deactivated providing 24 hour senior anaesthetic cover. The on-call rota at
during their LSCS. Our case series highlights that both general our unit is staffed by junior and senior anaesthetists. The
and regional anaesthesia can be safely provided and we absence of a senior anaesthetist did not lead to a significant
recommend a multidisciplinary approach with close co- rise in anaesthesia-related complications, although there was a
operation between anaesthetists, cardiologists and t rend toward this (Table 1).
obstetricians to provide optimum care of these patients. References
Reference 1. Centre for Maternal and Child Enquiries & Royal College of
Obstetricians and Gynaecologists Joint Guideline. Management of
1. Alexoudis AK, Spyridonidou AG, Vogiatzaki TD, Iatrou CA.
Anaesthetic implications of arrhythmogenic right ventricular women with obesity in pregnancy. London: CMACE & RCOG; 2010
dysplasia/cardiomyopathy. Anaesthesia 2009; 64: 73-8. 2. Fulton L, Evans E, Schroeder F, Wendler R. Antenatal anaesthetic
assessment of morbidly obese women - a useful resource? 2013,
http://epostersonline.s3.amazonaws.com/oaa2013/oaa2013.0690195
.NORMAL.pdf
Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin) P11
P121 Anaesthetic management of the labouring patient with P122 Anesthetic implications  of heart disease in pregnancy
multiple sclerosis S Francés,  S Manrique,  M Goya,  M García,  R Perera,  N
J Li Wan Po,  K Maclennan   Montferrer  
Anaesthesia, St Mary's Hospital, Manchester, UK Anaesthetics, Vall d'Hebron University Hospital, Barcelona,
Introduction: Multiple Sclerosis (MS), an autoimmune Spain
inflammatory disease affecting the central nervous system, is Introduction: Despite advances in its diagnosis and treatment,
estimated to affect 20,000 or more UK women of childbearing heart disease (HD) in pregnancy remains a major cause of non-
age1. Controversy exists regarding the management of obstetric maternal and neonatal mortality and morbidity (it
anaesthesia and analgesia in labouring parturients with MS. complicates around 1-3% of pregnancies in developed
Following analysis of our practice at St Mary's Hospital, a countries). Accurate multidisciplinary assessment and
tertiary referral obstetric unit with over 8500 deliveries per management of individual maternal and fetal risks in pregnant
annum, and recent evidence in the literature; our women with HD provides the best opportunity to substantially
recommendations for the peri-partum management of improve outcomes for mother and baby. (1).
parturients with MS are presented. Methods: We present a prospective cohort study that
Methods: Interrogation of the St Mary's Hospital antenatal analyzed outcomes in women with HD, the majority of whom
clinic database, from 1999 to 2012, identified 21 pregnant had had corrective surgery and delivery between 2007 and
women diagnosed with MS. We reviewed antenatal advice, 2013. Baseline characteristics and adverse events during
intrapartum management and postpartum complications. delivery and postpartum were assessed. Intensive monitoring
Results: Over 50% of patients were nulliparous. The majority of the delivery and postpartum were planned beforehand in all
had mild sensory or motor deficit. Three relapsed during cases.
pregnancy, one improved in symptoms and one relapsed Results: One hundred and seventy-four patients with 179
postpartum. There were twelve normal vaginal deliveries, two pregnancies were included in the study. 127 women (72,98%)
instrumental deliveries, six Caesarean sections and one presented congenital heart disease (CHD), 47 acquired heart
unspecified delivered at another hospital. Five women opted disease (27,02%): 27 acquired rheumatic valve disease
for epidural analgesia, two were topped up for operative (19,98%), one Marfan syndrome (0,54%), 3 coronary heart
delivery. Five had spinal anaesthesia with 0.5% heavy disease (1,6%) and 9 primary myocardial disease (4,9%).
bupivacaine and one had a general anaesthetic. There were no
Pregnancy complications were presented in 21, 2% of CHD,
complications following regional technique.
14,8% of acquired rheumatic valve disease and 100% of
Discussion: A recent national survey reported that within a 10 women with arrhythmias.
year period, 91% of anaesthetists have encountered <ten
The type of delivery was vaginal in 124 women ( 72,1%) and
cases of MS2 and have little experience in their management
cesarean section in 50 women (27,9%).
during pregnancy. Recent evidence available supports our
168 women had analgesia during delivery (93,8%); 5 women,
current management of MS patients undergoing labour. The
general anesthesia (2,79%), 6 women, local anesthesia (3,35%)
low incidence of the disease makes it difficult to attain
and 87,5% of women had regional analgesia.
significant figures to determine the optimal management plan.
To standardize care, we made the following recommendations Delivery complications were 7% (uterine atony 2,7%, vaginal
based on the latest evidence and our own experience: hematoma 2,2%, chorioamnionitis 0,5%, cesarean hematoma
- Patients to be reviewed in an antenatal anaesthetic clinic. 0,5% and hemoperitoneum 0,5%). The only anesthesia
Document disease severity and discuss analgesia and complication was one dural puncture (0.5%). No maternal
anaesthetic options. death, one fetal death (0.5%) and one neonatal death (0.5%).
The maternal average hospital stay was 3 days.
- Use of 0.1% bupivacaine with 2mcg/ml fentanyl mixture for
epidural labour analgesia2 . For an operative intervention, top Discussion: Pregnancy and delivery are associated with
up with a higher concentration of local anaesthetic. substantial physiological changes, which require the
adaptation of the cardiovascular system and can expose
- Regional rather than general anaesthetic for caesarean
women with HD to significant risks. If regional anesthesia is
sections. Spinal anaesthesia is the most simple and reliable
selected, the addition of an opioid, when dosing any neuraxial
technique although consider combined spinal-epidural on an
anesthetic, will reduce the amount of local anesthetic required
individual basis.
and subsequent hemodynamic effects, while improve
- If a general anaesthetic is necessary, avoid suxamethonium
intraoperative and postoperative analgesia. The avoidance of
and monitor neuromuscular block to titrate dose of non-
epinephrine from the epidural dose will eliminate the possible
depolarizing muscle relaxant3.
deleterious effects of systemic epinephrine. Maintaining
These recommendations will be available for clinicians on the uterine blood flow is important for fetal well-being.
trust intranet and a patient information leaflet on the effects of Maintaining systemic vascular resistance in patients with
pregnancy and anaesthesia on MS has been produced. intravascular shunting, is important to avoid inducing or
exacerbating pre-existing cyanosis due to increased right- to –
References
left shunting. Cautious intravenous hydration and gentle
1. Brookings W, Lee M. Management of multiple sclerosis during
titration of phenylephrine or ephedrine are options to
pregnancy. Prog Neurol Psychiatry. 2009; 3(6): 9-11
counteract the hemodynamic effects of surgical neuraxial block
2. Drake E, Drake M, Bird J, Russell R. Obstetric regional blocks for
women with multiple sclerosis: a survey of UK experience. Int J (1,2). We observed a predominance of neuraxial anaesthetic
Obstet Anaesth. 2006; 15(2): 115-23 techniques, increased caesarean and operative delivery rates,
3. Griffiths S, Durbridge JA. Anaesthetic implications of neurological and favourable maternal and neonatal outcomes.
disease in pregnancy. Contin Educ Anaesth Crit Care Pain. 2011; 11
(5): 157-61 References
P12 Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin)
P123 Angle of tilt achieved with automated operating table P124 Antenatal anaesthetic information given to women
in elective caesarean sections: a comparison with tilt with obesity
achieved with an inflatable balloon wedge  C R Thomas,  C Busby  
PN Nair,  L Dyal,  B Grewal,  I Suri   Anaesthetics, Airedale General Hospital, Keighley, UK
Department of Anaesthesia, Warwick Hospital, Warwick, UK Introduction:Antenatal obesity is defined as a BMI of ≥30at
Introduction: A previous study1 done on patients undergoing booking. Its prevalence in England increased from 7% in 1990
elective caesarean sections looked into measuring the angle of to 16% in 2007.1Women with a BMI ≥40 are often provided
tilt of the operating table with an inflatable balloon wedge. with anaesthetic information antenatally. Those with lower
This showed that the visual estimation of angle proved levels of obesity also have an increased anaesthetic risk but
accurate in the achievement of near 150 tilt. Here we present these women may receive little or no information about this
the results of a similar study using a different technique of during pregnancy. 2The RCoA have produced standards
automated table tilt instead of the inflatable balloon wedge regarding care for these women: 90% of patients with a
device. The premise being is our visual actuation of tilt angle booking BMI ≥ 30 should receive a leaflet containing
accurate. information about anaesthesia and analgesia. 90% of patients
Methods: The study was similar to the previous one. We with a booking BMI ≥40 should have an anaesthetic consult.
prospectively selected 26 patients at random who were Booking BMI should be documented in 100% of maternity
undergoing elective lower segment caesarean section under hand-held notes. An audit of the above standards was carried
spinal anaesthesia over a six week period. Ethical committee out as summarised below.
approval was obtained. Verbal consent was obtained from all Methods:A list of all deliveries in January 2013 was generated.
participants and the booking Body Mass Index (BMI) was Notes were reviewed for adherance to the above three
noted. We used the same protractor device for measuring the standards. Change to practice was recommended based on
angle of tilt. This is similar to the one used by Kinsella et al2. audit findings. Following the implementation of change, the
Results: The measured angles ranged from 10 to 18 degrees, a audit cycle was completed by auditing notes of all deliveries in
mean angle of 13.70 with a mean difference of -1.3 and standard November 2013.
deviation of 2.32. This compared very closely to the angles Results:
between 10 to 17.5 degrees, mean angle of 13.650, mean Table: Recording of booking BMI, patient count by raised
difference of -1.35 and a standard deviation of 2.06 in the BMI category and number given anaesthetic information.
previous study. BMIs ranged from 19 to 37 with a mean of 24.
Discussion: The visual estimation of angle using the
BMI 30 - BMI 35 - BMI
automated table tilt proved accurate in achieving the near 150 No
Number of Unavailable 34.9; 39.9; ≥40; 
tilt and is comparable with that obtained with the inflatable   booking
deliveries casenotes info info info
balloon wedge device in the previous study. The standard BMI
given given given
deviation of 2.32 indicates that 95.4% of cases could achieve
Jan 195 6 2 20; 0 7; 1 7; 7
within 4.60 of the required 150 tilt i.e. 10.4 to 19.6 degrees tilt.
Nov 173 3 2 17; 2 7; 7 3; 3
The automated table tilt provides an easy and accurate means
of providing left lateral tilt in pregnant patients. Discussion: Booking BMI was recorded in 99% of the notes in
both audit cycles. In 100% of cases where BMI was ≥40, a
consultant anaesthetist discussed risk and made a plan with
References
the patient. However, the audit of January deliveries indicates
1. Grewal B, Suri I. Is visual actuation a valid predictor of angle of tilt?
that few women who have a BMI 30-39.9 receive anaesthetic
Int J Obstet Anaesth Vol 18 2009; pS1-64- supplement
information.; this occurred in only one case. Reaching this
2. Kinsella SM. A device for measuring the degree of lateral pelvic tilt
during supine recumbency. Anesth Analg 1995; 80: 204-5 population to provide information is difficult especially where
BMI is 30-34.9 as all antenatal care for this group may be
provided by community midwives. In collaboration with
Obstetrics, a patient information leaflet was written which
included both obstetric and anaesthetic information. The
leaflet was approved by the Women's Integrated Governance
group and has been in use since October 2013. It is available
on the Trust intranet which is accessible by some community
midwives. The leaflet is given to all those with a BMI ≥ 35
when they attend obstetric high risk clinic. The results of the
November audit indicate improvement has been made; 44.4%
of those with obesity now receive anaesthetic information.
Greater access to the leaflet is needed however.
References
1. Royal College of Anaesthetists 2012,
http://www.rcoa.ac.uk/document-store/audit-recipe-book-3rd-edition-
2012
2. Centre for Maternal and Child Enquiries 2010, http://www.oaa-
anaes.ac.uk/assets/_managed/editor/
File/CMACE/CMACE_Obesity_Report_2010_Final%20for%
20printing.pdf
Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin) P13
P125 Antenatal management of morbidly obese parturients: P126 Audit of temperature for patients undergoing elective
A multicentre evaluation. caesarean section
H Aladin,  A Khandhia,  K Pottinger   N J Truman,  I Clegg,  K Maclennan  
Anaesthetics, Good Hope Hospital, Birmingham, UK anaethetics, St Mary's Womens Hospital, Manchester, UK
Introduction: Women with a body mass index (BMI) of ≥30 Introduction: Perioperative Hypothermia is associated with
kg/m2 at the time of antenatal booking are classed as being poor outcomes and adverse events for patients; including
obese in pregnancy, accounting for around 39,000 maternities surgical site infection increased length of stay, blood loss,
per year1. Obesity is associated with increased risk of shivering, increased anaesthetic recovery time and cardiac
anaesthetic morbidity and mortality. National guidance have events. Risk factors for the occurrence of hypothermia include
been developed following the Confidential Enquiry into regional anaesthesia, fluid deprivation, blood loss, and cold
Maternal and Child Health report concerning obesity in fluid administration, all of which are common to obstetric
pregnancy. At two different hospitals, five indicators of best patients. 2008 Nice guidelines CG651 on perioperative
practice2 were analysed: (1) Recording of maternal BMI. (2) hypothermia do not include parturients, despite being an at
BMI ≥ 30 women receive information about risk group. An audit performed in 2011 at St Mary's Hospital
anaesthesia/analgesia. (3) Women with a BMI ≥ 40 have demonstrated that 92.5% of elective section patients were not
antenatal anaesthetic review. (4) Duty anaesthetist should be 'comfortably warm' on arrival in recovery, with 65% defined as
informed when women with a BMI ≥ 40 are admitted. (5) hypothermic. A repeat audit was performed following
Anaesthesia for women with a BMI ≥ 40 should be provided commencement of a trial of an air free conductive fabric patient
by a senior anaesthetist. warming system (Hot Dog®).

Methods: Women who had undergone a lower segment Method: A prospective audit of elective caesarean section
caesarean section (LSCS) during a 6 month period (Jan 2013- patients was conducted from April-June 2013 at St Mary's
Jun 2013) at a District General Hospital (DGH) and a Hospital. Theatre staff completed the audit proforma. Data
Foundation Hospital (FH) were evaluated. Data was collected collected included; ambient theatre temperature (ideal target
retrospectively from an electronic data archive and anaesthetic 21ºC), anaesthetic type, estimated blood loss (EBL),
charts. Evidence of BMI calculations, provision of temperature pre, intra, post operative and prior to discharge
anaesthesia/analgesia information, ante-natal anaesthetic from recovery (measured using a tympanic membrane
appointments, and anaesthetic care in the labour ward and thermometer) and details of which Hot Dog® warming
theatre were identified. products were used. Hypothermia was defined as a core
Results: 309 women who underwent a LSCS were identified temperature <36ºC with desirable temperature being defined as
with a having a BMI 30 (median 34, range 30-59). 51% of 36.5-37.5ºC. Comparison of the results from the 2011 audit
these were elective cases. 56% of women with a BMI ≥30 enabled conclusions to be drawn regarding the effectiveness
received anaesthesia/analgesia information, of which 2 were of the warming product.

given literature on anaesthesia in obesity. 32% of women with
Results: A total of 33 patients were audited who underwent
a BMI 40 underwent an antenatal anaesthetic review, with an
elective caesarean section, [n=79, 2011audit], 94% had spinal
additional 4 women failing to attend their appointments. In
anaesthetic (87%, 2011 audit). Mean (S.D) theatre temp was
those women with a BMI ≥40, the duty anaesthetist was
22.8 (± 0.6) [22.3 (± 0.6), 2011 audit], mean duration of
informed of admission in 19% of cases and in 56% of LSCS,
procedure was 51 minutes. 94% of patients had an additional
the anaesthetic care was provided by an appropriately graded
fluid warmer intra-op (72%, 2011 audit). The mean EBL was 574
anaesthetist .
ml (± 213) [653 (± 431), 2011 audit] and only 6% of patients had
Table: Women with BMI 30 having anaesthetic care at a DGH an EBL over 1L (20% 2011 audit). Only 12% (n=4 of 33) of
and FH. patients warmed with the HotDog® were hypothermic on
arrival to recovery (compared to 65% (n=51 of 79), 2011 audit)
  DGH FH
figure 1.
Total LSCS 32% (99/309) 68% (210/309)
Discussion: efforts have been to reduce perioperative
BMI Median (range) 33 (30-59) 34 (30-52)
hypothermia in elective caesarean sections. Almost all patients
Maternal height, weight + BMI recorded 100% 100%
received warmed fluids via a 3M™ Ranger™ fluid warming
Conclusion: This audit has identified that more than half the
system. Forced air warming devices applied to the upper body
women with a BMI ≥30 received analgesia/anaesthesia
are not well tolerated by our awake patient population and
information and more than half were anaesthetised by a senior
allow only a limited area to be heated. introduction of
anaesthetist. However, in all the areas of practice, the target
HotDog® with an under patient warming mattress and
percentage of women meeting the identified standards were
separate over patient warming blanket (for upper and lower
not achieved. Recommendations included revision of the
limb) proved to be of benefit in perioperative maintenance
referral guidelines for antenatal anaesthetic assessment,
when compared to our standard warming measures. A
improved communication within the multidisciplinary team
HotDog® warming mattress placed on the patient chair in the
during admissions and increased presence of senior
pre theatre waiting area helped prevent hypothermia pre arrival
anaesthetists on delivery suite.
in theatre.
References
Reference
1. Centre for Maternal and Child Enquiries (CMACE). Maternal
1. CG 65 Management of inadvertent perioperative hypothermia in
obesity in the UK: Findings from a national project. London:
adults. NICE April 2008.
CMACE, 2010
2. The Royal College of Anaesthetists. Raising the Standard. A
compendium of audit recipes for continuous quality improvement in
anaesthesia. 3rd Edition 2012
P14 Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin)
P127 Availability of chlorhexidine handwash for regional P128 Caesarean section in a rhesus null parturient with a
analgesia on the labour ward uterine fibroid
K Chima,  T Strickland,  F Plaat   P J Stewart,  R Laird,  J Cartmill  
Anaesthetics , Queen Charlotte's and Chelsea Hospital, Anaesthetics, Altnagelvin Area Hospital, Londonderry, UK
London, UK Introduction: The anaesthetic management of a Caesarean
Introduction: Many patients request regional analgesia during section is made more challenging by the combination of pre-
labour and therefore central neuraxial blocks are performed in operative anaemia, a large uterine fibroid and the presence of a
the delivery room. For central neuraxial blocks an aseptic very rare blood group Rhesus null.
technique should be standard. In the Third National Audit Case report: A forty-year lady with a past medical history of
Project of the Royal College of Anaesthetists the incidence of psoriatic arthritis presented to antenatal booking at 10 weeks
iatrogenic infection was reported as being 8/707 000 gestation. Booking investigations revealed a haemoglobin of
procedures1. However the consequence of any infection is 10.3g/dL, and a blood group O Rhesus null. Her 20-week
potentially devastating, and a 'scrupulous' aseptic technique ultrasound scan revealed no foetal anomalies but did
was therefore stated to be mandatory in the report1. demonstrate an anterior uterine fibroid. This was confirmed
Chlorhexidene gluconate 4% is used for hand decontamination with magnetic resonance imaging which showed a
in our department. It was noticed that not all delivery rooms heterogeneous mass measuring 188x139x159mm, in keeping
were equipped with both chlorhexidene and a hands free with a degenerating fibroid. At 21+3 days she presented with
method for application. dizziness and right upper quadrant pain. Her haemoglobin
Methods: All delivery rooms on labour ward were inspected to level was 7.6g/dL and she was treated for iron deficiency
ascertain the presence of chlorhexidene and a hands free anaemia. Due to a transverse lie and the large fibroid an
dispenser. elective Caesarean section at 38 weeks was planned. As a team
we anticipated a difficult Caesarean delivery with greater blood
The audit was repeated after one and twelve months to assess
loss in a patient with anaemia and a very rare blood group.
if there had been any improvement in the service.
Antenatal management focused on maximising the patient's
Results: Originally, 12 of the 16 delivery rooms had
haemoglobin levels and sourcing compatible blood. The
chlorhexidene available (75%). Of the 12 rooms with
Northern Ireland blood transfusion service and National frozen
chlorhexidene only three were equipped with a hands free
red cell bank in Liverpool secured two units of packed red cells
dispenser (25%), and five containers were uncovered (42%).
in England. Unfortunately, one week prior to the section this
After one month all 16 rooms were equipped with wall blood was issued in an emergency, making it unavailable to us.
mounted chlorhexidene with a hands free dispenser (100%). A new donor was found in South Africa and a further unit was
After a further 12 months it was found that 12 of the 14 secured in Brazil. Both units were couriered to our hospital
delivery rooms had chlorhexidene available (86%). (Two of the prior to the Caesarean delivery which was performed at 38+6
rooms had been converted to a post delivery high dependency days under spinal anaesthesia. Pre-operative haemoglobin was
unit). Eleven of the 12 containers were equipped with a hands 9.1g/dL. The patient was discharged home on day three post-
free dispenser (92%). operatively and her haemoglobin was 7.2g/dl on discharge. No
Discussion: The results of the initial data collected, as well as blood transfusion was required.
anaesthetists' concerns regarding the unavailability of Discussion: Red blood cells from people who have the Rhesus
chlorhexidine and dispensers in each room, was reported to null phenotype lack Rhesus proteins, and thus, Rhesus
managerial staff, who ensured all rooms were adequately antigens. This phenotype occurs in approximately 1 in 6x106
stocked. Results were therefore better when re-auditing was individuals1. When these patients are transfused they may
performed at one month. However, after 12 months standards form antibodies to high frequency rhesus antigens, which can
had declined, although they were still improved from the make it extremely difficult to process compatible blood. Rhesus
initital audit. This decline could be attributed to the fact that null blood is available from the National frozen cell bank,
neither a team nor a named individual was made responsible however it may not be available when required due to limited
for sustaining the initial improvement, which if introduced, we supplies, as in our case. There is very limited literature
feel would encourage a sense of ownership and enable the regarding the management of the rhesus null parturient and
improvement in this area of patient safety to be sustained. our management was guided by our regional Haematology
Reference unit. This case demonstrates the importance of good
communication with all members of the multi-disciplinary team
1. National Audit of Major Complications of Central Neuraxial Block
in the United Kingdom 2009, http://rcoa.ac.uk/system/files/CSQ- and the detailed preparations required in a complex case.
NAP3-Full_1.pdf
Reference
1. Avent ND, Reid, ME. The Rh blood system: a review. Blood 2000
95: 375-387.
Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin) P15
P129 Category one caesarean sections in a district general P130 Comparison of two non-invasive cardiac output
hospital:  Improving the decision to delivery time monitoring devices in a parturient with complex
VK Wroe,  AM Troy   cardiac disease.
Department of Anaesthesia, Countess of Chester Hospital, PJ Rose,  V Misra,  S Quasim  
Chester, UK Anaesthesia, UHCW, Coventry, UK
Introduction: National Guidelines state that the interval from Introduction: The management of valvular lesions during
decision to delivery (DDI) in a category one caesarean section pregnancy and labour can present a clinical conundrum. We
should be less than 30 minutes1, and that a duty anaesthetist present the use of two cardiac output (CO) monitoring devices
should be immediately available for emergency work on the in a parturient with complex valvular heart disease undergoing
delivery suite 24 hours a day2. a caesarean section under epidural anaesthesia.
A 2008 departmental audit found that 85% of category one Case Report: A 37 year old primiparous woman with history of
sections had a DDI of under 30 minutes, a figure marginally ASD repair aged 4, severe mitral regurgitation, severe tricuspid
under the audit standard of 90%. Anaesthetic service regurgitation, moderate aortic stenosis (AS) secondary to a
provision in our trust was expanded in July 2012, with the congenital bicuspid valve and moderate pulmonary
addition of a dedicated obstetric anaesthetist 24 hours a day. hypertension presented for elective caesarean section.
This re-audit aimed to assess the proportion of category one Echocardiography showed moderately dilated right ventricle
caesarean sections with a DDI <30 minutes and analyse the with good bi-ventricular systolic function, bi-atrial dilatation,
factors contributing to any delay. moderate to severe AS (mean gradient 34mmHg, peak gradient
Methods: After audit department approval, a retrospective 53mmHg, estimated valve area 0.74cm2). Pulmonary artery
analysis of category one caesarean sections between August pressures were estimated at 42-47mmHg. LiDCO rapid and
and December 2012 was performed. Data collected included Cheetah NICOM devices were used to monitor CO.
DDI and reason for delay, indication for section, type of Anaesthesia was established with 32mL 2% lignocaine and 100
anaesthesia and cord pHs. micrograms of epinephrine via epidural. Compound sodium
lactate was infused at 60mL/hr, and increased to 100mL/hr after
Results: 69 category one caesarean sections were analysed.
epidural anaesthesia. Fluid boluses of 200mL and 100mL were
The mean DDI was 23 minutes (range 3-120 minutes). 84% had
delivered via the pump at 13 and 28 minutes after delivery of a
a DDI of under 30 minutes, with a mean time from decision to
live infant. Metaraminol infusion was titrated to effect.
effective anaesthesia of 14.5 minutes. The indication for
Syntocinon infusion was started upon delivery (20 units in
caesarean section was abnormal CTG in 87% of cases (2008:
48mL 0.9% saline) at 15mL/hr and tapered post-operatively
77%). General anaesthesia was performed in 43% (2008: 85%),
over 4 hours. Mean arterial pressure was maintained at 91 to
spinal anaesthesia in 55% (2008: 15%) and extension of
97mmHg until delivery (78 minutes) and then decreased to
epidural blockade in 2%. In 11 cases, DDI was over 30
67mmHg at the end of surgery. Cardiac output was maintained
minutes; these cases were all performed under spinal
throughout surgery with an increase at the time of concurrent
anaesthesia. The following table shows the reasons identified
fall in MAP. Fluid challenge had negligible effect although
that contributed to delay:
there was a small reduction in heart rate (84 to 59bpm).

Arrival in
Discussion: NICE has advocated the use of cardiac output
theatre Incision to
Spinal monitoring in high risk non-obstetric surgery to improve
10 delivery Staff Theatre
  placement outcome.1 In this case we utilised both a non-calibrated pulse-
minutes time 10 unavailable unavailable
10 minutes contour waveform analysis and bioreactance system to
from minutes
compare both values measured and response to fluid
decision
challenge. Although the values produced were different, the
Number
trends were broadly similar. This, once again, highlights the
of 4 6 1 1 1
importance of analysing trends rather than absolute values to
patients
guide management. Interestingly, both devices demonstrated
Arterial cord blood analysis was carried out in 10/11 cases. pH
that a fall in MAP correlated with an increase in cardiac
was less than 7.2 in 30%, and base excess was less than -8 in
output, similar to previous investigators.3 Given that cardiac
20%.
disease is the leading cause of death in the most recent
Conclusion: The proportion of cases with a DDI of over 30 triennialreport2, monitoring cardiac output enables one to
minutes has remained constant at around 15%, despite an maintain physiological homeostasis, and ultimately aids
improvement in anaesthetic staffing. Our results suggest that clinical decision-making leading to good clinical outcome, as in
the causes for this delay are multifactorial, and the results are our case.
not benign- the delay in delivery led to a cord pH of <7.2 in
References
almost one third of cases. We intend to improve our practice
1. MTG3 CardioQ-ODM (oesophageal Doppler monitor): guidance
by regular practice drills, use of preprepared spinal packs to
2011, http://www.nice.org/nicemedia/live/13312/52624/52624.pdf
reduce spinal placement time, clear procedures to follow in the
2. Centre for Maternal and Child Enquires (CMACE). Saving Mothers'
case of staff or theatre unavailability and reaudit. Lives: Reviewing maternal deaths to make motherhood safer: 2006-
2008. The Eighth Report of the Confidential Enquires into
References
Maternal Deaths in the United Kingdom. BJOG 2011;118(Suppl
1. Caesarean section. NICE Clinical Guideline 132. NICE, London 1):1-203
2011. (http://publications.nice.org.uk/caesarean-section-cg-132).
3. Fanning NP, Sermer M, Colman J, Carvalho JC, Cordovani D. Non-
2. OAA/AAGBI guidelines for obstetric anaesthetic services- 3rd invasive Hemodynamic monitoring with bioreactance for cesarean
edition. AAGBI and OAA, London, 2012 delivery. A more relaxed look at tight aortic stenosis? Abstract
(http://www.aagbi.org/publication/publication-guidelines/M/R) SOAP 2011, http://www.soap.org/display_2011_abstract.php?id=58
P16 Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin)
P131 Comparsion of slow and rapid bolus of ephedrine in P132 Continuous spinal anaesthesia for a primigravida with
patients undergoing planned caesarean section under severe tricuspid regurgitation, Harrington rods and
spinal anaestheisa WITHDRAWN FROM  thrombocytopenia.
PRESENTATION AM Walton,  I Mettam  
PG Sekar,  LB Ellakumanan,  H Balachander,  MVS Obstetric Anaesthetic Department, University Hospital
Satyaprakash   Southampton, Southampton, UK
Anaesthesiology, JIPMER, Puducherry, India Introduction: We present the successful use of continuous
spinal anaesthesia (CSA) for caesarean delivery in a parturient
with severe tricuspid regurgitation and pregnancy-induced
thrombocytopenia in addition to Harrington rod placement for
scoliosis spinal surgery.
Case history: A 40 year old primigravida presented at 37
weeks gestation. She had undergone a tricuspid valve repair
previously for endocarditis. The patient had developed severe
tricuspid regurgitation and had heart failure. Harrington rods
were placed in her thoracic and lumbar spine for repair of a
congenital scoliosis. Blood tests revealed a pregnancy related
thrombocytopenia with platelets of 85x109/L. An
echocardiogram showed a severly dilated right atrium with
intra-atrial septal bowing to the left, severe free flowing
regurgitation and right ventricular systolic pressure
32mmHg.The case was discussed with obstetricians,
anaesthetists and cardiologists and a decision was made for
an elective caesarean section under CSA, if the final platelet
count remained stable. The patient expressed a preference to
remain awake and avoid a general anaesthetic. At surgery a
cannula and radial arterial line were inserted. In the sitting
position a 22G spinal needle was inserted below the level of
the scar tissue at L3/4, and a spinal catheter threaded into the
subarachnoid space. A total of 10mg bupivacaine and 250mcg
diamorphine were required over 20 minutes to establish a block
to T4. The blood pressure dropped from 135/70 to 90/50mmHg
and required only 5mcg of epinephrine to return to baseline
values. Blood loss was 720mls. Syntocinon was given as an
infusion only. A live male infant was delivered.
Discussion: An obstetric anaesthetist has to take many
factors into account when deciding on the best choice of
anaesthetic for a particular case; anaesthetic expertise,
maternal co-morbidities, fetal well-being and maternal
preferences all play a part. Cardiac disease in pregnancy is still
the leading cause of indirect maternal mortality in the UK.1 The
choice of anaesthetic and delivery had to ensure the least
amount of strain on an already compromised heart. The
advantages of CSA are that a block can be established
gradually with small incremental doses of local anaesthetic,
which reduces the likelihood of cardiovascular instability.2
The concerns with a CSA are principally neurological
complications and post-dural puncture headache. CSA is
proving an option to be considered for patients with
significant cardiac disease and previous spinal surgery
provided the anaesthetist has experience with the technique.
In this case it provided a cardiovascularly stable anaesthetic
with excellent analgesia and maximal maternal satisfaction.
References
1. Saving mothers lives.The Eighth Report of the Confidential
Enquires into Maternal Deaths in the UK. March 2011
2. DennyNM, Selender DE. Continuous spinal anaesthesia. Br J
Anaesth 1998;81:590-7
Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin) P17
P133 Does pre-operative anxiety predict post-operative pain P134 Early epidural analgesia may increase caesarean
scores in parturients undergoing caesarean section? section rate in spontaneously  labouring nulliparous 
BM Daly,  N Weidenhammer,  R Junkin,  L Riddell,  J Dolan,  J women: a retrospective study
Kinsella*,  R Marla,  S Young   R Anil Kumar,  Roger Mc Morrow  
Anaesthesia, Princess Royal Maternity, Glasgow, UK, Anaesthesia, National Maternity Hospital , Dublin, Ireland
*Anaesthesia, Pain & Critical Care Medicine, University of Introduction:.Epidural analgesia offers the most effective
Glasgow, Glasgow, UK method of intra-artum pain relief. The effect of epidural
Introduction: Pregnancy, childbirth, and undergoing a surgical analgesia on the progression of labour and the mode is often
procedure are all likely to induce anxiety. The relationship debated in multiple studies. This study aims to show the effect
between anxiety, pain and pregnancy is complex.1Childbirth is of timing of epidural analgesia on the mode of delivery.
a time of high anxiety, and Caesarean section is known to be Method: Data such as women's age, gestational age, cervical
associated with significant pain post-op. Here we ask can dilatation before epidural insertion and duration of labour was
anxiety scoring predict post LSCS pain? collected from a total of 2029 nulliparous women in
Methods: After ethical approval and consent, pre-operative spontaneous labour. Epidural analgesic was defined as early at
data and a single 24hr post-op 10cm VAS were collected from a cervical dilatation of 3cms or less and late at a cervical
108 women, with 9 having missing data. Spielberger2 State and dilatation of 4 or more cm
Trait anxiety forms were completed prior to surgery. We Results: Of the 2029 women, 1423 ( 70.1%) received epidural
present secondary end points powered post hoc for 0.8 analgesia. Out of the 2029 women, 1403 ( 69.2%) had
probability of 2cm VAS difference. A standardised anaesthetic spontenous vaginal delivery, 478 (23.6%) had assisted
(spinal including diamorphine) and analgesic regime was used. delivery and 146 ( 7.2%) had caeserean section.
The cohort was divided into "high"- above the mean and
The data was anaylsed according to the timing of epidural
"low"- below the mean anxiety and compared using Student's
analgesia or no epidural analgesia and modes of delivery.
t-test.
Anaesthetic Delivery method
Results:
intervention Spontaneous Assisted Caesarean
Table 1: State anxiety compared to VAS
No epidural 537 (88.9%) 51 (8.4%) 16(2.6%) 604
Low anxiety High anxiety Early epidural 757 (62.2%) 379 126 (10.0%) 1262
  Significance
(n=45) (n=54) (30.0%)
24 hr VAS mean Late epidural 109 (67.7) 48 (29.8%) 4(2.5%) 161
5.0 (2.2) 5.3 (2.0) P= 0.40
(SD) cm
Epidural Assisted delivery C-Section
Table 2: Trait anxiety compared to VAS analgesia OR 95% CI p-value OR 95% CI p-value
Low anxiety High anxiety Early 5.27 3.86, 7.21 <0.001 5.59 3.28, 9.51 <0.001
  Significance
(n=48) (n=55) epidural
24hr VAS mean (SD) Late 4.64 2.97,7.23 <0.001 1.23 0.40,3.76 0.71
4.8 (1.9) 5.5 (2.2) P= 0.15
cm epidural
Table 3: State +Trait anxiety compared to VAS Conclusion: The results from the study show that the
Low anxiety High anxiety likelihood of having caeserean section in the early epidural
  Significance
(n=48) (n=51) group is significantly higher compared to the late epidural
24hr VAS mean (SD) group, but the incidence of assisted delivery between the early
cm 4.8 (1.9) 5.6 (2.1) P=0.072 and late epidural group were similar. This study also shows
that there is an increased likelihood of having assisted
Discussion: While the higher anxiety groups displayed a delivery and caeserean section delivery with epidural
higher mean VAS in all the analysis, this was not statistically analgesia compared to without from the study group.
significant. The separation between the two groups was better
References
with the State than the Trait anxiety score and best of all when
1..Gonen Ohel. Early versus late initiation of epidural analgesia in
the two scores were combined. Further reasearch could look at
labour: Does it increasethe risk of cesarean section. A randomised
anxiety scoring as part of a bundle of other measures verus trial. American journal of Obstretrics and Gynaecology (2006) 194,
pain. 600-5
2. Wassen et al. Early versus late epidural analgesia and risk of
References
instrumental delivery in nulliparous women: a systemic review.
1..Waldenstrom U: Experience of labor and birth in 1111 women. J British Journal of Obstretrics and Gynaecology (2010) 1471, 655-
Psychosom Res.1999: 47(5):471-82 661
2..www.mindgarden.com
P18 Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin)
P135 Efficacy of midwife led epidural top ups in labour–Are P136 Emergency obstetric and neonatal care in Kenya:
programmable pumps really the way forward? Addressing millennium development goals
E Traer,  G Waters,  GNB Jackson   D B Pachter,  C A Ameh*  
Anaesthetic department, Royal Berkshire NHS Trust, Anaesthesia, Cumberland Infirmary, Carlisle, UK, *Maternal
Reading, UK and Neonatal Health, Liverpool School of Tropical
Introduction: There are an increasing number of automated Medicine, Liverpool, UK
techniques by which labour epidurals can be managed1,2,3,4. Introduction: In 2008, an estimated 358,000 women died from
Comparison reports of programmable epidural pumps regimens complications of pregnancy and childbirth. The overwhelming
have shown lower total volumes of local anaesthetic may be burden of this mortality occurs in the developing world, with
associated with reduced rates of instrumental delivery and almost 60% of deaths occurring in sub saharan Africa.1There
improved maternal satisfaction1,2. Extended intervals between are also some 3.6 million neonatal deaths each year, and once
boluses with larger volume boluses was shown to use less again the developing world is disproportionately represented.2
total local anaesthetic3. These reports have led us to In 2006, the Liverpool School of Tropical Medicine (LSTM)
investigate similar outcomes our unit where we have a midwife developed a training package entitled "Life Saving Skills,
led top up (MLTU) practice. Emergency Obstetric and Neonatal Care" (LSS EOC-NCC) to
Method: First epidural bolus administered by the anaesthetist try and address these huge public health issues. Courses now
of 20ml 0.1% bupivicaine+2µg/ml fentanyl . Data recorded at run in 11 countries worldwide. In October 2013, I was fortunate
each subsequent midwife administered bolus (MLTU): bolus e nough to teach on a course in Nyeri, Kenya.
interval time, motor block (Bromage score of 2-4 taken as motor Methods: A variety of teaching methods were used on the
block), any change to the standard dose 20ml 0.1% course. Didactic lecture based teaching had a limited role, with
bupivicaine+2µg/ml fentanyl and if analgesia was effective or more emphasis placed on small group "break out sessions"
ineffective. and scenario based teaching. Pre and post course simulation
Results: 50 patients audited based testing was undertaken, with results collated and sent
back to Liverpool for analysis and assessment of efficacy of
Midwife led epidural Top Up Data  
teaching.
Mean bolus interval time (min) 105 (sd 26)
Mean rate bupivicaine mg/hr 10.56 (sd 3.6) Results: Participant feedback suggested a high level of
Motor block (Bromage score 2-4) 11/48 (22.9%) satisfaction with the course. The impact of courses in terms of
Mean time to motor block (min) 237 (sd 135) reduction in maternal and neonatal mortality remains the
NVD 14/48 (29.1%) subject of ongoing scrutiny. One study from Somaliland
Instrumental 18/48 (37.5%) demonstrated improved knowledge and skills and evidence of
LSCS 16/48 (33.3%) positive behaviour change post introduction of the course.3

Satisfaction excellent/good 46/48 (95%)
Conclusions: Maternal morbidity and mortality remains a huge
Discussion: In this study we found the mean interval in problem in Kenya. In 2008 it's Maternal Mortality Ratio was
minutes between epidural boluses to be 105minutes. This is 488 per 100,000, one of the highest in the world.4Great efforts
greater than the average 60minute interval of the are being made by the Kenyan government to reduce this. An
programmable intermittent bolus(PIB) regimens. An average ambitious target to reduce MMR to 91 per 100,000 by 2018 has
rate of bupivicaine 10.56mg/hr was similar to that reported with been set. One step has been the introduction of the Liverpool
PIB and patient controlled epidural bolus(PCEA) regimens4, LSS EOC-NCC course.
while we report a lower rate of motor block. Given the practice Acknowledgements: I would like to thank the maternal and
of MLTU in effect is much like a PIB without PCEA, it is neonatal health unit at LSTM for the opportunity to become
notable that the time between epidural boluses is longer with involved, and look forward to teaching on my next course. I
MLTU with less maternal motor block and high maternal would also recommend the course to any obstetric
satisfaction. We feel our practice promotes close epidural anaesthetists with an interest in international health.
assessment as the midwives assess motor block and maternal
References
satisfaction before each “top-up” and avoids the cost of the
1. World Health Organization, UNICEF, UNFPA and The World
PIB/PCEA pumps.
Bank. Trends in Maternal Mortality 1990-2008. 2010.
References 2. Lawn JE, Kerber K, Enweronu-Laryea C, et al. 3.6 million neonatal
deaths–what is progressing and what is not? Seminars in
1. Capogna G Camorica M, Stirparo S, Farcomeni A. Programmed Perinatology 2010;34:371–386.
Intermittent Epidural Bolus Versus Continuous Epidural Infusion for
Labor Analgesia: The Effects on Maternal Motor Function and 3. Ameh C, Adegoke A, Hofman J, et al. The impact of emergency
obstetric care training in Somaliland, Somalia. International Journal
Labor Outcome. A Randomized Double-Blind Study in Nulliparous
of Gynecology & Obstetrics. 2012;117:283-7.
WomenAnesth Analg July Oct 2011; 113(4): 826-831
4. Kenya National Bureau of Statistics. Kenya Demographic and
2. George RB, Allen T, Habib A. Intermittent Epidural Bolus
Health Survey (KDHS) 2008-09. June 2010.
Compared with Continuous Epidural Infusion for Labour Analgesia:
A Systematic Review and Meta Analysis. Anesth Analg Jan 2013;
Vol 116: 133-144
3. Wong C, MacCarthy RJ, Hewlett Bl. The effect of manipulation of
the programmed intermittent bolus time interval and injection
volume on total drug use for labour epidural analgesia: a randomized
controlled trial. Anest Analg 2011; 112: 904-11
4. Husain T, Mavridou I, Fernando R, El-Wahab N, Stewart A, Dick J,
Columb M. A study of a programmed intermittent bolus and patient-
controlled epidural regimen for labour analgesia. Int J Obstet
Anaesth May 2013: P85 Abstracts OAA Bournemouth 2013
Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin) P19
P137 Enhanced recovery after elective caesarean section: P138 Epidural analgesia in obese parturients: can kneeling
Service evaluation and quality improvement be the answer to our prayers.
GJ Lilley,  M Adamson,  A Miskin*,  M Turner   S De Silva,  L Kelliher*,  R Mottaleb*,  E Combeer  
Anaesthetics, Royal Gwent Hospital, Newport, UK, Anaesthetics, Frimley Park Hospital, Frimley, UK,
*Obstetrics and gynaecology, Royal Gwent Hospital, *Anaesthetics, Royal Surrey County Hospital, Guildford, UK
Newport, UK Severe pain is not life-threatening in healthy parturient women,
Introduction: Enhanced recovery (ER), a concept widely it is however shown to have neuropsychological
recognised within many surgical specialties, is now a subject consequences. Postnatal depression may be more common
of interest within obstetrics. The core principles comprise when effective analgesia is not used1 and pain during labour
speeding up recovery and improving patient outcomes, with has been linked with the development of post-traumatic stress
associated benefits for staff and healthcare systems1. The disorder2.There is an increasing number of obese parturients3
most logical starting point for the introduction of ER principles and identification and placement of the epidural can be
are elective caesarean section lists. Delayed surgery may lead difficult in these women.
to prolonged fasting, followed by delayed mobilization, Classically the sitting or the lateral position is used during
delayed removal of catheter and delayed discharge. A pilot siting of labour epidurals. The kneeling position was first
audit in our hospital demonstrated a mean stay after elective described in 19934, where 34/35 women had their labour
caesarean section of 3.6 days, and mean preoperative fasting epidural sited whilst in the kneeling position and 88.5% of the
period of 12.4 hours. Current guidance for ER in obstetrics mothers were happy with this position.
suggests minimal interruption to oral intake, pre-operative
I elected to try the kneeling position in an obese lady with a
energy drinks, catheter removal at 12 hours post-surgery
BMI 50 after adjustments in the sitting position and two
regardless of time of day, and the option of discharge home 24
separate failed attempts to confidently palpate the lumbar
hours after caesarean section where appropriate2.
spine. Once the lady was in the kneeling position, the lumbar
Methods: All elective caesarean sections were included in this spine was not only palpable but also visible and the epidural
service evaluation after introduction of preoperative space was identified with ease. With Departmental approval I
carbohydrate drinks. Data collection included fasting time, in performed my labour epidurals in this manner and found it not
addition to time to mobilization, to catheter removal and to only to be easy to site epidurals but also tolerated well. Some
discharge. After an initial 6 week period of data collection, the women complained of paraesthesia in their feet, but this was
data was presented to anaesthetic and obstetric staff. Posters, rare and eased swiftly. We decided to survey our Deanery to
a discharge proforma and a patient information leaflet were ascertain what positions were being utilised.
produced, and specific guidance was developed regarding
Survey: An e-survey was sent to trainees and Consultants in
preoperative carbohydrate drinks. A further 6 weeks of data
the South West London Deanery into what their ideal first and
collection then took place.
second choice positions used for siting epidurals would be for
Results: A total of 78 consecutive patients were included, all labouring parturients. We then posed the same question for
of whom received a regional anaesthetic technique for elective obese parturients (BMI 40). They were asked if they had
caesarean section. The following table illustrates the timing of heard of the kneeling position and if anyone had tried it. For
pre- and post-operative events before and after our those who had not, we questioned why they had not tried it.
interventions.
Results: We received 53 responses, 96.2% of whom were
Time period / hour 2nd 6 week Initial 6 week
trainees. 64.2% chose to position the parturient sitting as their
mean(SD) period period
first choice and 60.4% chose lateral as their second choice in
Pre-op fasting 4.8 (2.8) 3.8 (2.5)
non-obese parturients. In comparison 84.9% opted for the
Post-op fasting 4.2 (3.5) 3.4 (3.5)
sitting position in obese parturients with 56.9% using the
Total interruption to oral
9.0 (4.5) 7.1 (4.6) lateral as their second choice. The only positions utilised were
intake
sitting and lateral. 94.9% of respondents had not heard of the
Delivery to mobilization 10.2 (4.5) 9.0 (3.3)
kneeling position to site labour epidurals.
Delivery to catheter removal 14.8 (6.6) 13.5 (3.5)
Conclusion: Each position used for the placement of labour
Delivery to discharge 67.3 (40.1) 63.3 (27.6)
epidurals has their own advantages and disadvantages. With
Discussion: The introduction of patient information leaflet
the rising incidence of maternal obesity and its associated
offering guidance regarding post-operative oral intake,
risks to not only the mother but also the unborn child, we need
mobilization, catheter removal and early discharge, along with
to be continuing in our development and advancement in the
staff education and introduction of pre-operative carbohydrate
provision of good care. We suggest that the kneeling position
drinks, has resulted in improvement in the timing of a number
is a safe and viable alternative for siting epidural catheters in
of peri-operative interventions, and a small reduction in
labouring parturients.
duration of hospital admission. However, possibly due to
References
obstetric, midwifery, paediatric and organisational reasons,
discharge is rarely achieved at the potential target of 24 hours 1. Hiltunen P, Raudaskoski T, Ebeling H, Moilanen I Does pain relief
during delivery decrease the risk of postnatal depression? Acta
after elective caesarean section. Obstet Gynecol Scand 2004;83:257-261
References 2. Soet JE, Brack GA, Dilorio C Prevalence and predictors of women's
1. Lucas DN, Gough KL. Enhanced recovery in obstetrics - a new experience of psychological trauma during childbirth. Birth
frontier? Int J Obstet Anaesth 2013; 22: 92-95 2003;30:36-46
2. Enhanced recovery partnership: A better journey for patients and a 3. Centre for Maternal and Child Enquiries (CMACE). Saving
better deal for the NHS. Available at: Mothers'. Lives: reviewing maternal deaths to make motherhood
http://www.improvement.nhs.uk/documents/er_better_journey.pdf safer: 2006–2008. The Eighth Report of the Confidential Enquiries
into Maternal Deaths in the United Kingdom. BJOG 2011;118:1-203
P20 Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin)
P139 Epidural labour analgesia and risk of instrumental P140 Estimation of blood loss during caesarean sections -
delivery discrepancy between visual and laboratory estimation
R Carvalho,  T Ferreira,  M Duque,  D Catré,  I Guedes,  J P A Nowicka,  A Amasakera,  C Ferdinand,  I Suri  
Assunção   Anaesthesia, Warwick Hospital, South Warwickshire NHS
Anaesthesiology, Centro Hospitalar Tondela Viseu EPE, Foundatio, Warwick, UK

Viseu, Portugal
Introduction: Excessive blood loss is a major threat to women
Introduction: Epidural analgesia (EA) is a worldwide effective undergoing casearean sections. Accurate visual estimation of
method used for pain relief during labour. Nevertheless, its use blood loss is difficult due to dispersion of blood lost and the
and evolution to instrumental vaginal (forceps or vacuum blood being mixed with amniotic fluid(1). Therefore the blood
extraction) or operative deliveries remains controversial loss often gets under or overestimated(2). A number of
between experts,1 either anesthesiologists or obstetricians. methods exist to estimate the blood loss, the commonly used
We aimed to analyze the relation between EA and instrumental being: visual estimation by the attending staff, weighing of the
v aginal deliveries in a sample of our obstetric population. blood soaked surgical swabs and calculation based on the pre-
and post-operative haemoglobin concentrations(3). The aim of
Methods: A retrospective study included all pregnant women
this audit was to compare the visually estimated blood loss by
who delivered on our labour Room, between 1-January-2011
both the surgeons (vEBLs) and anaesthetists (vEBLa) against
and 31-December-2012, excluding those who underwent
the calculated estimated blood loss (cEBL).
caesarean section. We reviewed the data of demographical
characteristics, type of gestation and labour, the use of EA Methods: Data was collected on thirty five caesarean sections.
and the newborn APGAR score. Descriptive analysis of Operating surgeona and anaesthetists were asked to visually
variables was used to summarize data and Chi-Square test was estimate the blood loss in each case. The circulating blood
used. Multivariate analysis was done with logistic regression, volume was calculated for each patient based on the body
with calculation of corrected Odds Ratio (OR) and its 95% weight and height. Then, the blood loss during caesarean
confidence interval (95% CI). section was calculated using the circulating blood volume and
the pre- and post-operative haemoglobin concentrations.
Results: 2901 pregnant women were included in this study, Correction was made for the haemodilution by intravenous
with mean age of 29,7 years. 81% underwent EA and 30% fluid administered.
instrumental vaginal delivery. 51% were nulliparous. Applying
Results: Twenty six complete forms were included in the
Chi-Square test to independent variables, we obtained
analysis. None of the patients received blood or blood
significant associations with dystocic delivery for EA, normal
products intraoperatively. Mean volume of intravenous fluid
maternal age (NMA; 20-35 years) and parity (p<0,001).
infused was 1304mL±421. Mean vEBLs, vEBLa and cEBL was
Applying logistic regression to our model, including parity,
590mL±300, 623mL±372 and 821mL±1004 respectively. The
NMA and EA with dystocic deliveries, we obtained corrected
tendency for anaesthetists to give a higher estimate of blood
OR (95%CI) for EA 2,459 (1,884-3,210) and for parity 3,4
loss was not statistically signifficant (p=0,12). There was a
(2,867-4,121), with NMA loosing significance. However, this
clear discrepancy between the visual estimate given by both
result may still be biased by other factors, such as labour
the surgeons and the anaesthetists, ant the cEBL, however, it
stage at the time of the EA beginning, drugs used in epidural
did not reach statistical significance (p=0,11 and p=014
space, use of oxytocin during labour, among others.
respectively). Compared to the cEBL the vEBL was
Additionally we found that, in our population of term
overestimated when the blood loss was low (12 cases) and
pregnancies, NMA and eutocic deliveries, there was no
underestimated when the blood loss was higher than 500mL
significant relation between EA and APGAR score <8 at the
(14 cases). There was a linear relationship between the degree
first minute (p=0,079).
of underestimation and the blood loss, with high levels of
Conclusion: It's generally assent that EA provides the most blood loss being most underestimated.
effective pain relief in labour. However, it's associated to Conclusions: In this audit, the standard procedure for
prolonged labour and risk of instrumental or caesarean estimation of blood (visual estimation by the obstetrician) loss
deliveries.2 Our study has drawn the conclusion that both was found to be unreliable. We demonstrated a tendency of
having EA for labour pain relief and being nulliparous increase anaesthetists and surgeons to overestimate the blood loss, if
the chance of instrumental delivery, respectively in 2,459 and actual blood loss was less than 500mL, and underestimate if
3,43 times, however without significant impact on newborn the blood loss exceeded 500mL. As a result of the audit, it has
APGAR score. Bigger prospective studies correcting for more been made compulsory in our unit to check haemoglobin
risk factors are advised. concentration in recovery whenever the vEBL exceeds
References 1 000mL.
1. BMC Pregnancy and Childbirth 2008, 8:45. References
2. Acta Obstet Gynecol Scand 2002, 8:1033-1039. 1. Khan FA, Khan M, Ali A, Chohan U Estimation of blood loss during
Caesarean section: an audit. J Pak Med Assoc. 2006 Dec;56(12):572-
5.
2. Larsson C, Saltvedt S, Wiklund I, Pahlen S, Andolf E Estimation of
blood loss after cesarean section and vaginal delivery has low
validity with a tendency to exaggeration. Acta Obstet Gynecol
Scand. 2006;85(12):1448-52.
3. Stafford I, Dildy GA, Clark SL, Belfort MA, Visually estimated and
calculated blood loss in vaginal and cesarean delivery. Am J Obstet
Gynecol. 2008 Nov;199(5):519.e1-7
Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin) P21
P141 Ethnic variations in use of labour analgesia P142 Factors associated with the use of spinal anaesthesia
LMD MacDarby,  CMC McCaul   for caesarean section in Nigeria
Delivery Suite, The Rotunda Hospital, Dublin, Ireland C Imarengiaye,  F Asudo*,  A Akinmola†,  B Lawal§  
Introduction; This retrospective cohort study was compiled to Anaesthesiology, University of Benin Teaching Hospital,
establish the wide variety of nationalities presenting to The Benin City, Nigeria, *Anaesthesia, University of Abuja
Rotunda Hospital for delivery during a one month period and Teaching Hospital, Gwagwalada, Nigeria, †Anaesthesia, 
to determine the labour analgesia preferences amongst this National Hospital, Abuja, Nigeria, §Anaesthesia, Lagos 
population. Island Maternity Hospital, Victoria Island, Nigeria

Introduction: There has been a consistent increase in the rate
Methods; Details of all deliveries occurring during the month
of spinal anaesthesia for caesarean section in many hospitals
of October 2013 were collected. Any patients undergoing
worldwide and had been advocated as the preferred technique
elective caesarean section and those with failed inductions
for caesarean delivery.1 Recent evidence suggests increasing
were excluded from the study. A demographic of patients’
use of spinal anaesthesia for caesarean sections in reports
nationality and ethnic background was compiled. Data relating
from a teaching hospital.2 The rise in spinal anaesthesia
to these patients’ use of labour analgesia was recorded i.e.
caesarean section notwithstanding, it is pertinent to determine
epidural uptake, pethidine administration and remifentanil
the factors limiting the wholesome application of spinal
infusion use. We then established the frequency of use of
anaesthesia for caesarean section in Nigeria.
each of these methods of analgesia in each population

Methods: A snap-shot survey was conducted in some
Results; There were 767 deliveries in Oct 2013. 104 elective
selected hospitals in Nigeria. The survey determined the
caesarean sections were carried out and there were 8 patients
sociodemographic characteristics of patients, indication for
who failed induction.
surgery, grade of anaesthesia provider, contraindication to
Therefore a total of 655 patients laboured during this time. spinal anaesthesia and any other factor that may be noticed in
This number was made up by 50 different nationalities. Of the selected hospital. The survey was to be conducted over a
these 414 patients were Irish, the majority being white but 2-week period but was truncated by the nation-wide strike
including small numbers of Asian or Black background. action by doctors after 9 days.
Amongst the Irish patients the rate of epidural uptake was
Results: A total of 99 patients were attended to in 4 of the
43.47% (234) and the rate of pethidine use was 17.87% (74)
selected 6 hospitals within the study period. 36/99 women
Patients of other white background, including many eastern
were nulliparous and maternal factors (82/99) were the leading
european countries made up 134 of the patients. These
indications for caesarean section. Consultant anaesthetists
patients as a group had a 52.98% epidural uptake rate. Black
(23/99), Senior Registrars (35/99), Medical Officers (36/99) and
Africans were found to have a 39.13% (9) uptake rate and
others (5/99) provided anaesthesia for the caesarean sections.
those of Asian background had the highest rate at 54.83%
85/99 patients received spinal anaesthesia and 14/99 had
(17). The use of pethidine was significantly lower than the rate
general anaesthesia for the c-section. Fetal indication for
of epidural in all of these groups. Pethidine was used by
caesarean section had a 3-fold risk of general anaesthesia for
18.19% of Black Africans, 12.9% of Asians and 23.13% in
the surgery (p = 0.037, RR = 3.1, 95%CI 1.2 – 8). 25/99 and
those of other white backgrounds. There were only 3 cases of
74/99 were performed as elective or emergency procedure.
remifentanil use during the month
Nature of caesarean section was not a factor for the use of
Discussion; The highest incidence of epidural uptake during spinal anaesthesia (p =0.51, RR = 2.0, 95%CI = 0.5).
Oct was found to be amongst the Asian population, the lowest Discussion: Over 85% of caesarean sections in Nigeria were
being amongst Black Africans. Pethidine use was less than conducted under spinal anaesthesia. Fetal indications for
25% in all groups. The reasons for these trends is unknown caesarean section provoked a 3-fold increase in general
though previous studies have suggested that cultural and anaesthesia for caesarean section. The use of general
educational factors may play a part. anaesthesia for caesarean delivery was due to fetal indications
A prospective survey of patients post delivery detailing the for surgery, antepartum haemorrhage and failed spinal
reasons for their choices of labour analgesia would be anaesthesia. Improved practical conduct of the spinal
worthwhile. Establishing the factors influencing their technique may enhance great application of spinal anaesthesia
decisions may allow us to provide an unbiased and fully for caesarean section.
comprehensive service to ensure patient satisfaction. References

1..Morgan BM, Magni V, Goroszenuik T. Anaesthesia for emergency
caesarenc section. BrJ Obstet Gynaecol 1990; 97: 420-424
2..Amadasun FE, Idehen HO, Edomwonyi NP. Evolving pattern of
anaesthesia for caesarean section: Experience at the university of
Benin Teaching Hospital West Afr J Med 2013; 32: 196-9
P22 Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin)
P143 Failed intubation for a category 1 caesarean section in P144 Fasting dilemmas: A rare case of a patient with non-
a patient with undiagnosed spina bifida ketotic hyperglycinaemia presenting for caesarean
CR Deane,  E Lewis,  J Spargo   section
Department of Anaesthetics, Singleton Hospital, Swansea, M Behravesh,  S Dawson,  G McClune,  S Atkinson  
UK Anaesthetics, Royal Jubilee Maternity Hospital, Belfast, UK
Introduction: Non-ketotic hyperglycinaemia (NKH) is a rare
Introduction: Spina Bifida Occulta (SBO) is part of a spectrum
autosomal recessive metabolic disease caused by a defect in
of neural tube defects and is common. We present the case of
the glycine cleavage system. This case report describes the
a patient with previously undiagnosed SBO who required a
management of a patient who presented for caesarean section.
category 1 caesarean section (CS). Despite an unremarkable
To our knowledge there are no other published case reports of
airway assessment she had a failed intubation on rapid
this type.
sequence induction (RSI) and subsequently required an awake
fibre optic intubation (AFOI). Case Report: A 32 year old Para 1 presented for elective
caesarean section of twins at 37 weeks gestation. She had a
Case report: A 37 year old para 0 patient presented to labour
history of atypical non-ketotic hyperglycinaemia. Following
ward labouring with a single live foetus at 37 weeks gestation.
advice from clinical chemistry, during her 6 hours preoperative
She was admitted under consultant obstetric care with
fast she received an inceased dose of sodium benzoate and an
asymptomatic hypertension. When considering an epidural
intravenous infusion of 10% dextrose at 3mls/kg/hour which
she was examined and had a vascular naevus, associated with
was continued perioperatively. Caesarean section was
skin tethering, over lumbar vertebrae. She was asymptomatic,
performed under spinal anaesthesia and twin baby boys were
had never been investigated, and had no definitive diagnosis
delivered successfully. Post delivery of the second twin she
of SBO. Airway assessment included a Mallampatti score of 3,
received a bolus of 5 units of syntocinon followed by an
but was otherwise unremarkable. An epidural was declined to
infusion at 10 units per hour. Due to uterine atony and an
the patient, with a remifentanil PCA provided instead. A plan
operative blood loss of 1000mls she also received ergometrine
was agreed for a RSI GA if operative intervention was
carboprost intramuscularly to good effect. Sodium benzoate
required. Several hours later she required a category 1 CS.
was administered orally in recovery and the 10% dextrose
Initial laryngoscopy with a Mackintosh blade yielded a
infusion was continued until the patient was establised on an
Cormack and Lehane grade 3 view. Manipulation of the cricoid
oral regimen prescribed by the dieticians. This involved a
cartilage, long and McCoy blades did not improve the view.
series of high calorie drinks up to every 2 hours for 48 hours.
Two failed attempts were made to intubate using a bougie. The
No dietary protein was allowed for 24 hours post delivery.
patient was ventilated using a face mask and a Guedel airway
Glycine levels were monitored daily and were raised on day 5
with oxygen saturations above 97% throughout. She was
while dietary protien was being gradually reintroduced.
woken up without further incident and an AFOI was
performed. Her child was delivered by LSCS without further Discussion: NKH has an incidence of 1 in 60,000 with 3
incident or obvious deficit. The APGAR scores were 8 and 10 distinct presentations. Classically neonates present with
at one and five minutes. A grade 3 view was confirmed before lethergy, hypotonia and seizures. These symptoms can
the patient was woken. Recovery from anaesthesia was proceed to apnoea requiring ventilation and 30% of patients
uneventful. The patient was appropriately counselled. An do not survive the neonatal period. Severe psychomotor
Airway Alert Letter was issued and follow up appointment retardation is common in those who survive. A second,
made. An MRI was carried out subsequently and showed a atypical and very rare form presents with mild baseline
neural arch defect and dural tethering. Significantly the conus hyperglycinaemia and intermittent encephalopathy
lay as low as L4 with diastematomyelia as far as L2. assosciated with periods of illness. Transient neonatal
hyperglycinaemia has also been described. Biochemically,
Discussion: SBO is common and without prior imaging
NKH is characterized by elevated glycine concentrations in
presents the clinician with a difficult decision. Regional
plasma, CSF, and brain with a CSF glycine to plasma glycine
techniques risk neural or dural injury due to a low lying or
ratio greater than 0.08.1 Standard treatment strategies include
tethered cord.1 Abnormal spread of the analgesic agents may
protein restriction to reduce exogenous glycine,
give rise to either excessive cranial spread or inadequate
supplementation of one-carbon pool donors and
caudal spread. This patient population provides further issues
administration of sodium benzoate. NMDA antagonists have
for the anaesthetist given the high risk of operative delivery or
been shown to raise the developmental quotient, improve
other intervention (due to pelvic structural abnormalities) and
muscle tone and reduce seizures in these patients.2
the association of spina bifida with difficult intubation.2,3
Patients with spina bifida require careful preop assessment Prolonged periods of fasting predispose these patients to
and MRI imaging and careful airway consideration is essential glycine build up and its toxic neurological effects. This has
in order to inform anaesthetic planning. major implications for the anaesthetist in the perioperative
period. This case demonstrates the safe use of regional
References
anaesthesia in conjunction with careful nutritional planning.
1. Reynolds F. Damage to the conus medullaris following spinal
anaesthesia. Anaesthesia 2001; 56: 235-247. References
2. Richmond D, Zaharierski I, Bond A. Management of pregnancy in 1. Chang YT, Lin WD, Chin ZN et al. Nonketotic hyperglycinemia: A
mothers with spina bifida. Eur J Obstet Gynecol Reprod Biol 1987; case report and brief review. Biomedicine 2012; 2(2):80-82
25: 341-5. 2. Van Hove JL, Vande Kerckhove K, Hennermann JB et al. Benzoate
3. May A, Fombon F, Francis S. UK registry of high-risk obstetric treatment and the glycine index in nonketotic hyperglycinaemia.
anaesthesia: report on neurological disease. Int J Obstet Anaesth Journal of Inherited Metabolic Diseases. 2005;28:651–663
2008; 17: 31-6.
Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin) P23
P145 Fetal bradycardia following regional anaesthesia for P146 Further increase in hysterectomy rates - and the
emergency caesarean section and instrumental reason why
delivery: a service evaluation JS Campbell,  M Molloy,  C Thompson,  D Fogarty  
JK Sidana,  K Jadhav-Smith,  J Corfe   Royal-Jubilee Maternity Service, Belfast HSC Trust, Belfast,
Anaesthetics, Norfolk and Norwich University Hospital, UK
Norwich, UK Introduction: RJMS is the tertiary obstetric service for
Introduction: Fetal heart rate abnormalities, such as late Northern Ireland. As part of a service review of use of uterine
decelerations or fetal bradycardia, are known to occur after artery balloon catheters, we retrieved data from several
neuraxial anaesthesia.1 These may be due to maternal sources. We found a large proportion of these patients still
sympathetic blockade or an increase in the uterine tone caused required hysterectomy. Further interrogation of our data
by intrathecal opioids. The objective of this service evaluation showed some unexpected trends.
was to evaluate the incidence and management of fetal Methods: With approval of the Trust's Data Guardian we used
bradycardia following regional anaesthesia for emergency data from several hospital systems, including a local maternity
caesarean section and instrumental deliveries. care database and histology records.
Methods: 15 patients with an episode of fetal bradycardia Results: We found 30 hysterectomies from 37,088 deliveries in
following regional anaesthesia were identified by reviewing 6 years. This is a rate of 0.8 per 1000 - significantly higher than
the daily obstetric handover sheets from January to December our prior rates which was near the NICE-quoted rate of up to 3
2011. The medical notes of these patients were reviewed for per 1000. Of these cases, 23 (76%) were due to morbidly
peripartum obstetric management, cardiotocographic (CTG) adherent placenta.
findings, perioperative anaesthetic management and
Not all these cases of morbidly adherent placenta were
management of fetal bradycardia. Neonatal outcome was
diagnosed antenatally, which perhaps made hysterectomy
assessed by APGAR scores, umbilical cord gases and NICU.
more likely since facilities such as intra-arterial balloon
Results: 10 patients had an assisted delivery and 5 had an catheters could not be available to us in an emergency.
emergency category-2 LSCS. The peripartum CTG findings Unanticipated cases suffered greater blood loss. Despite no
were either suspicious or pathological. Timing of fetal diagnosis, the majority (16/23) were placenta percreta on
bradycardia following regional anaesthesia ranged from 2 to 15 histology. These percreta cases again had greater blood loss,
min. 13 patients received spinal anaesthesia and 2 received and were more likely to require ICU care post-operatively. Yet
epidural top up. Maternal haemodynamics stability was there were no cases of percreta in the 6 years prior, and less
maintained with left uterine displacement, intravenous fluids than half the number of hysterectomies in that period. This
and phenylephrine infusion. One patient had an episode of seems to be a dangerous and dramatic change in recent years.
maternal bradycardia below 50 beats/min which was treated
Conclusion: We found a recent and significant increase in
with anticholinergics. Comparing the baseline maternal heart
peripartum hysterectomy, associated with a large increase in
rate with the lowest perioperative heart rate, 3 patients had a
the number and degree of morbidly adherent placenta. Patients
greater than 40% drop in the heart rate. 5 patients had a blood
with placenta percreta had a greater blood loss, and more
pressure drop of more than 20% below the baseline, which was
commonly required hysterectomy and ICU care.
treated with phenylephrine. The highest level of block to
Reference
temperature was T3. Syntocinon was stopped in all but one
case in the event of fetal bradycardia. Significant delays 1. National Institute for Health and Clinical Excellence. Caesarean
section: NICE Clinical Guideline 132 2012,
occurred in transferring these patients to theatre after the
http://www.nice.org.uk/nicemedia/live/13620/57163/57163.pdf
decision for surgical intervention were taken, maximum 35 min
(median 17 min). 6 cases had poor neonatal outcomes with low
5 minute APGAR and abnormal cord gases.
Discussion: We could not find any direct cause which can be
solely attributed to regional anaesthesia for the occurrence of
fetal bradycardia in these patients. Significant delay in patient
transfer to theatre may have a causal relationship but cannot
be confirmed. Studies in elective patients have shown that
maternal bradycardia causes a drop in maternal cardiac output.
2 Relative maternal bradycardia occurred in several of our
cases and this would have led to drop in cardiac output and
therefore oxygen delivery. This is most likely a side effect of
phenylephrine use. We plan to introduce a care bundle to
implement pre-operative and intra-operative fetal resuscitation.
This will include steps to improve fetal condition at the time of
regional anaesthesia and to ensure adequate maternal cardiac
output and oxygen delivery.
References
1. Reynolds F, Seed PT. Anaesthesia for Caesarean section and
neonatal acid-base status: a meta-analysis. Anaesthesia 2005; 60:
636–653
2. Stewart A, Fernando R et al. The dose-dependent effects of
phenylephrine for elective caesarean delivery under spinal
anaesthesia. Anesthesia & Analgesia 2010; 111: 1230-7.
P24 Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin)
P147 Impact of workload on accidental dural puncture P148 Implantable cardioverter defibrillator in
(ADP) rate pregnancy WITHDRAWN FROM PRESENTATION
W Mon,  YM Liu,  A Stewart,  R Fernando,  M Columb*   S Chaudhari,  S Quasim  
Anaesthetics, University College London Hospital, London, Anaesthetic Department, University Hospital Coventry and
UK, *Intensive Care Unit, University Hospital of South Warwickshire , Coventry, UK
Manchester, Manchester, UK
Introduction: Post dural puncture headache is an important
cause of morbidity. We audit our ADP rates annually against
the national standard.1Between 2005 and 2008, our ADP rate
was stable at approximately 0.5%. However, from 2008 to 2010,
our rate rose to above the 1% national standard.1Therefore, we
audited factors that may have contributed to this increase.
Methods: Information for this audit was obtained from a
computerised database. Data collection included day, month
and time of ADP and the grade of anaesthetist. We also
collected annual data of number of deliveries, epidurals and
combined spinal epidurals (CSEs) for labour, caesarean section
(CS) data, and the proportion of single shot spinals (SSS) to
CSEs performed. Data were analysed using chi-square
multinomial and trend tests with P value <0.05 defined as
significant.
Results: There was a 40% increase in deliveries between 2008-
2010. CSs and regional blocks for analgesia increased by 36%
and 40% respectively. Although the ADP rate increased, we
could not demonstrate a statistically significant trend due to
small numbers. From 2010 to 2012, a non-significant fall in the
ADP rate was seen. There was no significant association
between ADPs and day, month or time. We did see a
significant non-linear trend (P = 0.0012) in the proportions of
SSSs to CSEs performed, with the peak occurring in 2010.
Table 1. Trend of activity and ADP rate from 2008 to 2012
  2008 2009 2010 2011 2012 P value
Maternities (n) 4032 5039 5647 5841 5953 < 0.0001
Epidurals for labour (n) 1306 1600 1839 2029 2132 < 0.0001
CSs (n) 1370 1562 1861 1862 1773 < 0.0001
SSSs for CS (n) 282 274 356 326 347 0.0015
CSEs for CS (n) 797 644 714 833 915 < 0.0001
Proportion of SSS to CSE (%) 26 30 33 28 27 0.0012
ADP rate (%) 0.57 0.98 1.05 1.01 0.82 0.31
Discussion: We observed an increase in ADPs until 2010, with
significant rises in deliveries and anaesthetic procedures
performed. The significant non-linear trend in the proportions
of SSSs to CSEs performed for CSs peaked in 2010. A fall in the
ADP rate between 2010-2012, occurred despite exposing more
women to the risk of ADP, as during this time we performed
significantly more CSEs than SSSs proportionally. We believe
that the rise in the ADP rate resulted from a significant
increase in our workload between 2008 and 2010, without any
increase in anaesthetic staffing. From 2010 onwards, daytime
anaesthetic consultant sessions increased by 50%, and there
was a higher presence on the labour ward out of hours by
senior registrars covering non-obstetric theatres. Both factors
may have contributed to the subsequent fall in the ADP rate.
This audit supports the recent OAA/AAGBI guideline
recommending increased anaesthetic staffing on labour ward.2
References
1. Royal College of Anaesthetists. Epidural analgesia during labour.
Raising the standard: a compendium of audit recipes. 2012;218-219
2. Association of Anaesthetists of Great Britain and Ireland and
Obstetric Anaesthetists' Association. OAA/AAGBI guidelines for
obstetric anaesthetic services. 2013
Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin) P25
P149 Inadvertent hypothermia during elective caesarean P150 Inter professional relationships on labour ward- how
sections well do anaesthetists and midwives get along?
S Botros,  R Labib,  T Ramhew,  M Baban,  Y Poonawala   M Salman,  P Kumar,  G Graham  
Selwyn Crawford Department of Anaesthesia , Birmingham Anaesthetics, St. Thomas' Hospital, London, UK
Women's Hospital, Birmingham, UK Introduction: Anaesthetists and midwives are part of the
Introduction: The National Institute for Health and Care multi-professional team that provides care for parturients.
Excellence (NICE) defines inadvertent perioperative They work together in close collaboration in the unique and
hypothermia as a core body temperature below 36°C.1 It is a often highly charged environment of labour ward. In such
common complication of regional anaesthesia, and is the settings, effective inter professional relationships are key to
leading cause of perioperative shivering. Hypothermia is the delivery of high quality care and consequently better
associated with increased risk of wound infection and patient outcomes. Successful collaborative practice can be
increased blood loss.1 Shivering can be associated with negatively impacted by barriers such as lack of clarity on the
increased oxygen consumption and hypoxaemia in vulnerable scope of roles of team members, poor communication, or
patients. Although the NICE guideline on the management of stereotyping. We conducted a survey amongst obstetric
perioperative hypothermia did not cover pregnant women,1 it anaesthetists and midwives in our hospital to reflect upon this
has been adopted by many obstetric units. In our unit, working relationship and to see how it may be improved.
intravenous (IV) fluid is not routinely warmed for elective
Methods: A questionnaire was designed and distributed to
caesarean sections (CS). Hence, we audited our practice to
midwives and anaesthetists of all grades. Questions were
evaluate the incidence of hypothermia.
asked on their understanding of each other's professional role
Methods: Over a three month period, we prospectively audited
and on their perception of the quality and effectiveness of
our practice in 47 women who had elective CS under
their working relationship. A total of 43 responses were
subarachnoid anaesthesia without active warming. We
collected (24 anaesthetists and 19 midwives) in an ongoing
measured their tympanic temperature prior to anaesthesia (T )
1 survey.
and at the end of surgery (T ). We also collected data that may
2 Results: Of the anaesthetists who completed the
influence the results like the volume of IV fluid infused,
questionnaire, 16.6% were consultants, 58.3% were ST5-ST7,
estimated blood loss (EBL) and duration of surgery. We also
20.8% were ST3-4 and 4.1% were CT1-2. When asked whether
assessed the incidence of perioperative shivering. We
they felt they understood the scope of responsibilities of
repeated the audit in 42 parturients using an IV fluid warming
midwives on labour ward, only 27% of anaesthetists felt they
device. The data were analysed using Microsoft Excel 2007®.
understood it fully. In contrast, 63% of midwives believed they
Data from both audits were compared and p-values were
fully understood the scope of the anaesthetist's
calculated using unpaired t-test by GraphPad software®.
responsibilities.
Results: In the initial audit, 20 patients (42.55%) were
hypothermic at the end of surgery (T < 36°C). Shivering Thirty percent of midwives felt that collaboration with
2
occurred in 14 patients (29.79%). No correlation was found anaesthetists was 'very easy', in contrast to only 5.5% of
between T and the IV fluid volume, EBL, duration of surgery anaesthetists who felt the same about collaboration with their
1-2
or the dose of intrathecal Bupivacaine. In the re-audit, only 3 midwife colleagues. While 16% of anaesthetists found this
(7.14%) patients experienced hypothermia. There was no collaboration 'difficult', none of the midwives did (0%).
statistical difference in T between the two audits (p = 0.781). Seventy two percent of anaesthetists felt their input was
1
usually well-received by their midwife colleagues, compared to
  Initial Audit (n=47) Re-audit (n=42) p-value
only 40% of midwives who thought their input was well-
Fluid (ml) 1116.67(±369.43) 1233.33 (±483.59) 0.2236
received by the anaesthetist. Both professions were asked
EBL (ml) 523.75 (±152.33) 582.5 (±491.67) 0.474
how they perceived the general quality of communication
T1 36.84 (±0.37) 36.81 (±0.37) 0.781
between them. The majority of anaesthetists (47%) perceived it
T2 36.08 (±0.4) 36.3 (±0.29) 0.004
as 'fair', while 15% regarded it as 'poor'. Ninety percent of
T 0.76 (±0.34) 0.52 (±0.41) 0.0032
1-2 midwives felt it was either 'very good' or 'good'. None of the
Discussion: Our audit highlights the effect of warm IV fluid midwives (0%) felt it to be 'poor'.
therapy on reducing the incidence of inadvertent perioperative
Questions were asked on the types of obstacles they
hypothermia during elective CS. Our audit recommends the
encountered in their professional interaction with each other.
routine warming of IV fluid during elective CS. The Enhanced
Most anaesthetists (72%) agreed that they found fixation on
Recovery Partnership Programme considers patient warming
tasks and exclusion of others to be a challenge, followed by
as a key factor in accelerating patient recovery.2 Following our
delayed or non-communication of important issues (57%). A
results and as part of developing a new pathway for enhanced
third of the anaesthetists felt they rarely got a comprehensive
recovery post CS; our trust is currently looking to invest in a
handover from the midwife while only 29% of midwives felt
cost-effective IV fluid warming device.
they understood the rationale behind the anaesthetists'
References decisions.
1. NICE (2008) Perioperative hypothermia (inadvertent): full Conclusion: Despite both specialties working in close
guideline (CG65). Full Guideline. London: National Institute for proximity, the survey identified several gaps in
Health and Care Excellence.
communication. Working towards enhancement of the
2. Enhanced Recovery Partnership (2012) Fulfilling the potential: a
professional relationship between members of the team
better journey for patients and a better deal for the NHS. Leicester:
NHS Improvement. Available at http://www.improvement.nhs.uk providing maternity services will help facilitate their
(accessed 14/12/2013) collaboration and will reflect positively on the performance of
both professions.

P26 Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin)
P151 Intra-arterial balloon catheters: A service evaluation P152 Intrathecal diamorphine for cesarian section following
JS Campbell,  M Molloy,  D Fogarty   intramuscular diamorphine during labour: a cause for
Royal-Jubilee Maternity Service, Belfast HSC Trust, Belfast, concern?
UK RC Barr,  L Parks  
Introduction: Intra-arterial balloon catheters have become Anaesthetics and Intensive Care, Southern Health and Care
widely used and predominantly accepted in cases where Trust, Northern Ireland, UK
massive haemorrhage is anticipated, especially with morbidly Introduction: Diamorphine has largely replaced pethidine for
adherent placenta . However, the benefits are still intramuscular (IM) analgesia during labour in our obstetric
1,2
controversial. While our unit is not stand-alone, our building unit. We also routinely give diamorphine (250-300 micrograms)
is physically separated from other departments including intrathecally (IT) for cesarian sections. A recent case of
radiology, so the logistics of balloon catheters are difficult2. meiosis and drowsiness, in a lady presenting for a category 2
Our objective was to identify the impact of balloon catheters cesarian section having received IM diamorphine in labour,
on management of morbidly adherent placenta. Associated highlighted the potential for side effects when diamorphine is
anaesthetic issues include massive transfusion, cell salvage, used IM and then IT. Should we therefore consider adjusting
type of anaesthetic and post-operative care. our IT dose of diamorphine in women presenting for
Methods: With permission of the Trust's Data Guardian, we emergency cesarian sections? To our knowledge there are no
retrieved data from multiple sources to identify and review guidelines on this subject and clinical practice appears
cases where balloon catheters where used. These included variable.
radiology logs, maternity records and histology. Methods: We conducted a survey of all anaesthetists working
Results: Ten cases were identifed via these systems. Seven in the Southern Health and Social Care Trust who partake in
were for morbidly adherent placenta, of which 5 required obstetric anaesthesia. Questions focused on; current
hysterectomy despite balloon inflation. Many of these were diamorphine practice, diamorphine dose adjustments, factors
cases of placenta percreta, despite antenatal diagnosis of influencing our dose decisions and concerns regarding
accreta. However, blood loss was lower by around 20% potential side-effects with IT diamorphine.
(1078ml) using balloons, when compared to other Results: We received 24 replies; 14 consultants and 10
hysterectomies in the same time period. experienced trainees who regularly perform obstetric
Other indications were for intra-abdominal pregnancy and anaesthesia. There was a wide variation in diamorphine
persistent post-partum haemorrhage. Another case was practice amongst our anaesthetists. The majority (76%)
abandoned due to logistical reasons (unable to organise consider reducing their IT dose following IM diamorphine.
theatre time in same building), a decision felt to be open to Factors influencing this dose reduction include timing (88%)
medicolegal criticism after preparation and planning for and dose (29%) of the last IM diamorphine and clinical signs
balloons. of toxicity (76%). In particular anaesthetists were concerned
about postoperative respiratory depression (94%) and
Limitations particularly reflected the limitations and
drowsiness (88%), although no one surveyed reported
inconsistency of the systems used, for example no coding in
experience of these or other adverse effects associated with IT
records for morbidly adherent placenta. Local presentation
diamorphine.
highlighted these problems, which are being taken forward.
Discussion: There is variability regarding the IT diamorphine
Conclusion: Our review, and subsequent MDT discussion,
dose given to women for emergency cesarian section who
has confirmed the place of intra-arterial balloon catheters
have already received IM diamorphine in labour. This practice
within local guidelines for management of morbidly adherent
is based on limited evidence. Given the lack of adverse effects
placenta, and other occasional indications. We had decreased
reported from our survey and evidence from other specialties
blood loss in cases using balloons, but still saw a large
where diamorphine is used in higher doses 1,2,, we see no
proportion requiring hysterectomy.
reason to routinely reduce the IT diamorphine dose unless
References
there are clinical signs of opiate toxicity. Consideration should
1. Beilin Y, Halpern SH. Placenta accreta: successful outcome is all in be given to prolonged postoperative monitoring of all women
the planning. Int J Obstet Anesth. 2013;22:269–271.
who have received both IM and IT diamorphine, especially
2. Sadashivaiah J, Wilson R, Thein A. Role of prophylactic uterine
artery balloon catheters in the management of women with those in whom the interval between IM and IT diamorphine is
suspected placenta accreta. Int J Obstet Anesth. 2011;20:282-287 short or where there are signs of toxicity.
References
1. Fogarty DJ, Milligan KR. Postoperative analgesia following total
hip replacement ; a comparison of intrathecal morphine and
diamorphine. Journal of the Royal Society of Medicine 1995; 88:
70-72
2. Jacobson L, Kokri MS, Pridie AK. Intrathecal diamorphine: a dose-
response study. Annals of the Royal College of Surgeons of England
1989; 71: 289-292
Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin) P27
P153 Introducing self-administration of medication after P154 Is Remifentanil patient controlled analgesia an
caesarean section: a Robert The Bruce story effective alternative to epidural for labour analgesia?
A R Sajayan,  K Ramm,  T Yates,  Y Chikermane   V Betharia,  K Peckitt  
Anaesthesia, Heartlands Hospital, Birmingham, UK Anaesthesia, Stepping Hill Hospital, Stockport, UK
Introduction: We were involved in the introduction of the local Introduction: Remifentanil patient controlled analgesia (PCA)
protocol for self-administration of postoperative medications was introduced for pain relief in labour at our institution in
(SAM) after elective LSCS at a large obstetric unit. In the past, 2007. Since then its demand has steadily increased, gaining
several attempts to implement this have failed.We conducted a favour with midwives and patients due to simplicity of use,
pilot study to identify the obstacles and develop ways to effective analgesia¹ and good safety profile². We have
overcome the same standardised protocols for administration and monitoring of
Methods:A pilot project was conducted to find out the Remifentanil PCA and patient controlled epidural analgesia
obstacles in the process by obtaining feedback from the staff (PCEA) during labour which are strictly adhered to. Aim of our
and patient involved in the care of 10 patients who underwent audit was to assess both Remifentanil PCA and epidural PCEA
elective LSCS over a week’s time. Obstetric, anaesthetic, for labour analgesia and make recommendations for improved
recovery and ward staff were informed beforehand about this care of mothers and infants.
pilot by emails and personal discussion. The patients were Methods: This was a prospectively done, questionnaire based
given information leaflet during preoperative assessment and audit. Data was collected over 2 months from November 2013 -
were informed again on the day of operation. Interested January 2014. We looked at mode of delivery,
patients enrolled in the pilot with due consent. The self- cardiotocographic abnormalities, APGAR scores, maternal
administration pack contained analgesics and enoxparin and cardio-respiratory complications, conversion to alternative
was dispensed by the recovery staff. Exclusions were: methods of analgesia and patient satisfaction.
language barrier, patient refusal, lack of capacity and any co Results: There were 610 deliveries during the 2 months.
morbidities. Feedback was collected from patients and staff Remifentanil PCA was used in 102 (17%) and epidural PCEA in
using the standardized proforma during the postoperative 85 (12.2%) patients for labour analgesia.
visit. Mode of delivery:
Results:Two of the patients felt that on the first day it was
  Normal Assisted LSCS
difficult to use SAM due to mobility restrictions. One patient
Remifentanil PCA 69 (67%) 20 (19.6%) 13 (12.7%)
did not receive SAM pack due to communication problem
Epidural PCEA 29 (34%) 35 (41%) 21 (24.7%)
involving midwives and staff. The remaining seven patients
were satisfied with SAM. The obstacles we identified in the There was a higher incidence of cardiotocographic
pilot and also from the past experience and the way we tackled abnormality in the epidural group (61%) as opposed to
them are as below: Remifentanil group (34%). APGAR scores in both groups were
more than 8 at 5 minutes. None of the patients in either group
Obstacle Strategy
had respiratory depression or cardiovascular instability. Eight
Personal & email reminder
(7.8%) patients converted from Remifentanil to epidural due to
Promotional posters in clinical areas
inadequate analgesia whereas 4 (4.7%) patients in the epidural
Communication Reminder notices in operating room and recovery
group used alternative analgesia (3 switched to Remifentanil
Meeting with stakeholders (doctors, midwives&
and 1 to entonox). Patient satisfaction was similar in both
pharmacist)
groups at 95%.
Involving all staff in guideline preparation
Discussion: From our experience, Remifentanil PCA is a safe
Staff engagement Process simplified and paper work streamlined
and effective method of labour analgesia. We found no
Standardized SAM package and delivery
evidence of worsening cardiotocography or neonatal
Guideline Fully prepared guideline after extensive consultation
outcomes with its use. We also found that patients using
Time Pre-printed forms to increase efficiency and to avoid
Remifentanil have increased rate of vaginal deliveries as
management time delays and work duplication
compared to those on epidural. While epidural analgesia
Discussion: Self-administrationof medications after caesarean remains the gold standard and will be preferable in certain
provides better patient centered care. It improves patient and groups of patients, Remifentanil PCA is certainly an excellent
staff satisfaction, improves clinical efficiency and eases alternative to consider. In our institution its uptake has
staffworkload at hospital and at community level1. It empowers steadily increased to approximately 50 patients per month with
the mother in their own care, potentially reduces length of patients consistently report ing high levels of satisfaction.
stay, and facilitates seamless flow ofcare. Although staff and References
patients liked the concept alike, the process had failedthree
1. Blair JM, Dobson JT, Hill DA, McCracken GR, Fee JP. Patient
times before because of certain obstacles. This pilot helped us controlled analgesia for labour: a comparison of remifentanil with
to highlight the areas we needed to focus on with our new pethidine. Anaesthesia 2005; 60 (1) : 22-7
strategies and the results have been encouraging. After fully 2. Volikas I, Butwick A, Wilkinson C, Pleming A, Nicholson G.
Maternal and neonatal side-effects of remifentanil patient
implementing the project, the uptake is gradually getting better
controlled analgesia in labour. Br J Anaes 2005; 95(4): 504-9
and we continue to audit the outcome.
References
1. Snell P M, Bowden M I, Viira D J, Chilvers J P. An observational
study of self-medication of analgesic drugs after caesarean section.
Int J Obstet Anesth 2002; 11: S29
2. Change management good practice guideline-NHS Direct
P28 Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin)
P155 Is the existing local hospital guideline, 'Management P156 Klippel-Feil syndrome: management of anticipated
of women who decline blood products', being adhered difficult airway for caesarean delivery 
to? TM Price,  MT Qureshi,  ROK Laird  
J Houston,  R Burns   Department of Anaesthesia, Altnagelvin Area Hospital,
Simpson Centre for Reproductive Health, Royal Infirmary of Derry, UK
Edinburgh, Edinburgh, UK Introduction: Klippel-Feil syndrome (KFS) is a rare genetic
Introduction: An estimated 150000 Jehovah's Witnesses disorder affecting around 1 in 40,000 live births and is
(JWs) live in the UK1. JWs may not accept blood product (BP) characterised by the congenital fusion of any two of the
transfusion1, and have up to 130 times increased risk of cervical vertebrae1. In addition to the abnormalities of the
maternal death from major obstetric haemorrhage2. This cervical spine, patients may have thoracolumbar scoliosis,
retrospective case note review aims to establish how closely spina bifida and congenital heart defects. The classical
the hospital guideline, 'Management of women who decline phenotypic presentation is described as low hairline, short
blood products' (the Guideline), has been followed since its neck and limited neck and head movement. These patients can
May 2012 introduction, and to identify areas for improvement. therefore present a considerable challenge to the anaesthetist.
Methods: JWs managed at the Anaesthetic Antenatal Clinic The safest method of providing anaesthesia for operative
(AAC) since the Guideline's introduction were identified, and delivery of a parturient with KFS is controversial. We would
their medical records accessed. Information surrounding like to share our experience in managing four elective
aspects of patient management addressed by the Guideline caesarean deliveries in two parturients using awake oral fibre
was extracted. The findings were then audited against the optic intubation (AOFOI) and general anaesthesia.
Guideline to establish how closely it had been followed. Case Reports: The first patient had KFS Type II with fusion of
Approval was obtained from the Medical School and the cervical vertebrae and underwent elective caesarean deliveries
Regional Research Ethics Service. aged 35 and 37 years old. The second patient had KFS Type
Results: Of the patients referred (N=26), 92.3% were reviewed III with fused cervical vertebrae in conjunction with fusions in
at the AAC, and had management plans created, at 31.0 weeks' the thoracolumbar spine, and underwent elective caesarean
gestation on average (Guideline target: 28.0 weeks). 88.5% deliveries aged 31 and 39 years old. Our patients were both
completed a BP checklist before admission in labour, and pre-assessed by a consultant anaesthetist at a high-risk
96.2% by time of delivery. 7.7% agreed to accept BPs at clinic pregnancy clinic prior to delivery. This allowed time to discuss
and were discharged, so women studied became N=24. BP the anaesthetic options with each patient and plan for elective
refusal of 12.5% was not appropriately recorded in the notes, or emergency delivery. Both patients had the classical
and contrary to the Guideline, serum ferritin was not checked phenotypic features of KFS. Airway assessments revealed
in any woman. During pregnancy, 29.2% were not recorded as Mallampati class 4, thyromental distances less than 6cm and
having taken iron, and Hb was measured in 95.8%. Excluding severely limited neck flexion and extension. The trachea was
elective caesarean sections (CS), Obstetric consultants were not palpable in either patient. We anticipated difficult direct
documented as informed of admission in 13.6% of cases, and laryngoscopy in both patients and elected to manage the
54.5% of labours and deliveries were reviewed or supervised airway with an AOFOI followed by general anaesthesia. The
by senior Obstetric staff (ST6-consultant). 20.8% of total oral route was chosen as both patients had small nares in
deliveries were by CS: cell salvage was set up in 100.0% of keeping with KFS. Sugammadex ensured complete reversal of
these, and used in 80.0%. rocuronium induced neuromuscular blockade and smooth
Discussion: This study found the Guideline was closely emergence. Caesarean delivery and postoperative recovery
followed in some areas: completion of acceptable BP checklists was uneventful in all four cases.
before delivery, and availability and use of cell salvage in CS,
Discussion: As obstetric anaesthetists we are constantly
compare favourably to previous UK studies1,3. Areas to be
trying to minimise the risk to our mothers. Klippel-Feil
improved include that BP refusal must be appropriately
syndrome affects both the airway and the spine, making the
recorded in patient notes to ensure clarity upon presentation
choice of anaesthetic technique a difficult decision. Successful
in labour or an emergency. It is vital that iron supplementation
use of regional techniques including spinal, epidural and
is commenced early in JWs, and ferritin levels are monitored,
combined spinal-epidural anaesthesia, have all been described
to maximise iron stores. In light of this study's findings,
in the literature1. However, we feel that embarking upon a
hospital blood transfusion Haematologists, in the future, will
regional technique in patients with distorted neuroaxial
review JWs antenatally. The Guideline should quantify how
anatomy would expose patients to unnecessary risk of high
often Hb should be monitored, so anaemia can be detected
spinal block and/or inadequate regional anaesthesia. Should
and treated before delivery. Crucially, consultant staff must be
general anaesthesia be needed intra-operatively, attempting an
documented as informed upon admission of JWs in labour, in
AOFOI in an already distressed parturient would be
order that deliveries can be supervised by senior staff to
challenging. We therefore planned an AOFOI to secure the
reduce potential morbidity and mortality.
airway prior to general anaesthesia, in a controlled manner and
References
thus avoid a potentially difficult and emergent intraoperative
1. Massiah N, Athimulam S, Loo C, Okolo S, Yoong W. Obstetric care intubation. In summary, these are difficult cases that we
of Jehovah's Witnesses: a 14-year observational study. Arch
believe benefit from good antenatal planning and can be
Gynecol Obstet 2007; 276(4):330-343.
managed with a planned AOFOI and general anaesthesia.
2. Van Wolfswinkel ME, Zwart JJ, Schutte JM, Duvekot JJ, Pel M, Van
Roosmalen J. Maternal mortality and serious maternal morbidity in
Jehovah's witnesses in the Netherlands. BJOG 2009; 116(8): 1103- Reference
1108. 1. T. Kavanagh, R. Jee, N. Kilpatrick, J. Douglas. Elective cesarean
3. Nawaz YM, Atkinson S. Peripartum care of Jehovah's witness delivery in a parturient with Klippel–Feil syndrome. Int J Obstet
parturients: A five year review. Int J Obstet Anesth 2013; 22(S1): Anesth 2013; 22(4): 343-8
S22.
Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin) P29
P157 Labour and delivery in long QTsyndrome P158 Local anaesthetic toxicity audit: are workshops the
BJ Vowles,  FMM Bryden   best educational tool across the MDT?   
Anaesthetic department, Princess Royal Maternity, Glasgow, WITHDRAWN FROM PRESENTATION
UK JL Lambert,  D Chitre,  L Evans  
Introduction: A 22 year old primigravida presented to the high Anaesthesia, Southend Hospital, Southend, UK
risk clinic at 22 weeks gestation. She had been diagnosed with
long QT syndrome (LQTS) after her family had been
investigated following a sudden early cardiac death and was
found to be heterozygous for the KCNQ1 gene, responsible
for Long QT1. She was under regular review by the
cardiologists who had advised β blockade with bisoprolol
2.5mg orally (PO) for 9 months post partum due to an increase
in arrhythmia risk during this period. She had also been given
a list from Azcert Inc., advising drugs that should be avoided
and included on this list was syntocinon.
Labour and delivery: She was admitted in labour at term and
the decision was made by the obstetric team, not to administer
syntocinon to augment labour. They also felt that epidural
analgesia was unsuitable because it would slow the progress
of labour. However following an initial dose of intramuscular
(IM) diamorphine, the parturient requested epidural analgesia.
We felt this would be beneficial for minimising her arrhythmia
risk and so she obtained a working epidural with a bilateral T10
block. ECG monitoring was commenced on admission and
.
initially showed bigeminy. A 12 lead ECG demonstrated a QTc
of 460ms. Electrolytes checked at this time were in the normal
range. Over the subsequent 8 hours she failed to progress and
underwent a caesarean section with an effective epidural top
up of 20ml 0.5% L-bupivacaine. At delivery syntocinon was
administered as a slow infusion of 5 units in 100mls 0.9%
saline over 20 minutes, followed by 500µg ergometrine IM to
maintain uterine tone. 50mg IM cyclizine and 10mg
intravenous (IV) metoclopramide were used for anti-emesis.
She was monitored in the Obstetric high dependency unit
(HDU) for the following 48 hours, where an initial ECG
demonstrated frequent ventricular ectopics, with a QTc 432ms.
Electrolytes were again normal at this time.
Discussion: There are many lists of drugs available on the
internet with differing advice as to which drugs to avoid in
long QT syndrome. The one which our patient had been given
clearly stated syntocinon should not be administered, despite
no definitive evidence of harm with this drug in patients with
LQTS. In addition we found no guidance in published case
reports, on oxytocic drugs administered to patients with LQTS
in labour or at delivery1. There are case reports of ventricular
tachycardia after administration of syntocinon in long
QTsyndrome2 and one report of a pateint receiving it with no
sequelae3 Ideally the authors feel that this lady merited a case
conference prior to admission so that informed decisions
could be made. Whilst the outcome of this patient's labour and
delivery may not have been different, a short trial of
syntocinon with ECG monitoring may have altered her mode of
delivery.
References
1. Drake E, Preston R, Douglas J. Brief review: anaesthetics
implications of long QT syndrome in pregnancy. Can J Anaesth.
2007; 54(7): 561-72
2. Liou SC, Chen C, Wong SY, Wong KM. Ventricular tachycardia
after oxytocin injection in patients with prolonged Q-T syndrome -
report of two cases. Acta Anaesthesiol Sin 1998; 36: 49-52
3. Charbit B, Funck-Bretano C, Samain E, Jannier-Guillou V,
Albaladejo P, Marty J. Qt interval prolongation after oxytocin bolus
during surgical induced abortion. Clin Pharmacol Ther 2004; 76:
359-64
P30 Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin)
P159 Lymphangioleiomyomatosis and Pregnancy: A Case P160 Major obstetric bleeds-are we doing the right thing?-
Report A multi-centre study in west midlands
M Cole,  S Petkov,  J Pickett   A R Sajayan,  M McLoughlin,  S Dinesh,  A Walunj*,  J
Anaesthetics, Addenbrookes Hospital, Cambridge, UK Karattuparambil †,  M Ravindran†  
Introduction: Anaesthesia, Heartlands Hospital, Birmingham, UK,
Lymphangioleiomyomatosis (LAM) is a rare condition causing *Anaesthesia, Good Hope Hospital, Sutton Coldfield, UK,
proliferation of smooth muscle in the respiratory system, †Anaesthesia, George Eliot Hospital, Nuneaton, UK 
which can cavitate leading to degradation of lung parenchyma Introduction:Guidelines1 exist on the definitions of massive
and cystic lung disease1. Because of the risk of progression, bleed, the proposed management pathway and the safe time
women with LAM are frequently advised to avoid pregnancy2. frame for obtaining the blood and products. This multi-centre
We present a case of LAM where multidisciplinary audit looks at the average time taken for the blood/products to
management led to a successful outcome of pregnancy, with a be available in major bleed situations in obstetrics
focus on anaesthetic considerations. Aim: To find out the incidence and reasons for delays in
Case Study: issuing the blood/products, if any, from the blood bank and to
A 35 year old woman presented with bilateral spontaneous compare the existing practices and experience with the other
pneumothoraces in the first trimester of her 2nd pregnancy. hospitals in the area
Both required surgical correction and a lung biopsy revealed a Methods: We collected the data from three participating
diagnosis of LAM. Computerised tomography of her thorax hospital in west midlands using a standard proforma which
showed multiple small lung cysts. Past history included an included the number of massive obstetric bleed calls during a
uncomplicated first pregnancy and emergency caesarean six months period in 2013, the estimated blood loss, the time
section for foetal distress, aged 33; and a spontaneous taken for the first unit of blood/ product to be issued and the
pneumothorax aged 34, requiring surgery. The patient was number of products used among other data.
referred to a tertiary centre for multidisciplinary management.
Results: The results suggested that there is ambiguity in the
Care was shared between obstetrics and respiratory medicine
way major haemorrhage was defined in different situations
and she attended the high risk anaesthetic clinic. Elective
which led to unnecessary calls where blood products were not
caesarean delivery at 38 weeks was agreed upon. She had
urgently needed. Also, the time for getting the products varied
three further small pneumothoraces, treated conservatively
widely the longest being 200 minutes. The documentation of
with no marked deterioration in respiratory function. Elective
the details of the bleeding, time of calls and time of
caesarean section was performed at 38/40 gestation.
blood/product administration were incomplete and inaccurate
Respiratory assessment and examination on the morning of
in some cases.In one hospital, major bleed calls were only put
surgery were normal. A two-space combined spinal epidural
out in two out of 17 cases where blood loss was more than
was sited, administering intrathecal hyperbaric bupivacaine
1500ml.
and diamorphine. A respiratory physician was present at
delivery in case of deterioration. Delivery was uneventful, with   Hospital1 Hospital2 Hospital 3
no immediate complications. The patient spent 24 hours in an Number of MOH calls 58 41 2
obstetric close observation unit post-operatively. Her post- Full data available 13 18 2
natal period was uneventful and required no further obstetric, Average time for group specific (min) 59 NA 33
respiratory or anaesthetic intervention. Average time for X match blood (min) 63.45 42.27 0
Longest delay (min) 200 104 33
Discussion: LAM is a rare condition with an estimated UK
prevalence of 1per million3. Hypotheses suggest oestrogen
Discussion: The definitions of massive blood loss are:
accelerates disease progression and pregnancy may result in
Transfusion of a volume equal to the patient’s total blood
new diagnosis or exacerbation4, therefore obstetric
volume in less than 24 hours / 50% loss of blood volume
anaesthetists should have awareness of this disease. There is
within 3 hours / rate of blood loss 150ml/minute. Though the
sparse literature for anaesthetic management of pregnancy
circumstances of individual episodes of major bleed could
with LAM, consisting mainly of case reports. Considerations
vary, there was no consistency in the trigger of activating
suggested include; avoiding excessive Valsalva manoeuvre
major bleed calls. There were also unacceptable delays in
via instrumental or elective caesarean delivery, avoid nitrous
obtaining the first unit of blood in some cases. The first set of
oxide, early epidural analgesia, obtunding intubation response
uncross matched group specific blood should be available in
and lung protective ventilation strategies if general
20minutes and cross matched blood in 40minutes2. The study
anaesthesia. This case report supports that pregnancy in
suggest that there is a need for the reinforcement of major
LAM patients can progress successfully and highlights the
bleeds definition and also a need for a clearer pathway and
importance of a MDT approach, early anaesthetic assessment
consistency in issuing blood and products in major bleed
and a well considered anaesthetic and obstetric plan.
situations. This audit results will be used to formulate a
References uniform policy in the participating hospitals and a re-audit will
1. Rosendal T. A Case of Diffuse Myomatosis and Cyst Formation in be done in six month time
the Lung. Acta Radiaology. 1942; 23: 138-146
2. Cohen MM, Freyer AM, Johnson SR. Pregnancy Experiences References
Among Women With Lymphangioleiomyomatosis. Respiratory
1. D Thomas etal,Blood transfusion and the anaesthetist: management
Medicine. 2009; 103: 766-772
of massive haemorrhage, Anaesthesia 2010 November; 65(11):
3. Johnson SR, Tattersfield AE. Clinical Experience of 1153–1161
Lymphangioleiomyomatosis in the UK. Thorax. 2000; 55:1-5
2. Guidelines on the management of massive blood loss.
4. McLoughlin L, Thomas G, Hasan K. Pregnancy and BJHaematology 2006; 135(5): 634-641
Lymphangioleiomyomatosis: Anaesthetic Management.
International Journal of Obstetric Anaesthesia. 2003; 12: 40-44
Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin) P31
P161 Management of labour and delivery using  minimally  P162 Management of manual removal of placenta and third
invasive FlotracTM system in a parturient with  and fourth degree tear repair: pathway analysis
congenitally corrected transposition, dextrocardia P Jegendirabose,  J Subramanya*,  S Watkinson*,  J Short  
and systemic ventricular dysfunction Anaesthesia, Queen Elizabeth Hospital, Woolwich, London,
R Vedagiri Sai,  S Dhir,  J Racine   UK, *Obstetrics & Gynaecology, Queen Elizabeth Hospital,
Anesthesia, Western University, London Ontario, Canada Woolwich, London, UK
Introduction: More women with congenital heart disease now Introduction: Guidelines suggest that repair of obstetric anal
survive to reproductive age due to advances in modern sphincter injuries (OASIS) and manual removal of retained
medicine. Obstetric management is challenging in these placenta (MROP) should be undertaken as soon as possible to
complex cases. We present the anaesthetic management of minimise the risk of infection, blood loss and maternal
labour and delivery in a woman with congenitally corrected morbidity1,2. Anal incontinence and perineal pain can impact
transposition of great vessels, dextrocardia, systemic significantly on maternal quality of life and mother-child
ventricular dysfunction and junctional tachycardia using bonding.
minimally invasive continuous haemodynamic monitoring and Methods: We conduced a retrospective audit which showed
optimisation. shortcomings in our management of MROP and OASIS and we
Case report: A 28 year old primigravida presented with a undertook an analysis of a full calendar year's cases. All cases
diagnosis of congenitally corrected transposition of great of MROP and OASIS were identified over January 2012 to
vessels and dextrocardia. The atrial septal defect had been December 2012 using both theatre electronic records and
repaired in childhood. Her medications included folate and maternal records. Time from delivery of fetus to MROP or
multivitamins. She had good exercise tolerance, stable vital OASIS repair, blood loss and blood transfusion requirement
signs and was followed up by Cardiology team throughout her were reviewed.
pregancy. ECHO showed 50% ejection fraction (EF) and mildly Due to lack of nationally set standards, we set a local standard
reduced systemic (morphologic right) ventricle. A multi- of no more than one hundred and twenty minutes from
disciplinary meeting between Obstetrics, Cardiology, delivery to repair for OASIS.
Anaesthesia and Intensive care unit (ICU) team was held to
Results: Our institute is a secondary obstetric centre with
decide on optimal obstetric management. Induction of labour
4800 deliveries per annum. During the twelve month period,
was planned.
105 patients sustained OASIS. The mean delay from delivery
At 37 weeks she developed palpitations, increasing shortness to surgery was 136 minutes. The average blood loss was 501
of breath and peripheral oedema. Repeat ECHO showed millilitres and 3% of patients required blood transfusion. Total
moderate ventricular dysfunction with EF 40%, severe of 42 patients required manual removal of placenta with
systemic atrioventricular regurgitation and severely enlarged regional or general anaesthesia. The mean delay from delivery
left atrium. Prior to labour induction, an arterial line was to surgery was 178 minutes. The mean blood loss was 790
inserted and continuous cardiac output monitoring was millilitres and 5% of the patients required blood transfusion.
performed using arterial pressure waveform analysis with the
FloTracTM monitor. Haemodynamic optimization was guided OASIS repairs n=105 Time (minutes)
by stroke volume variation and goal directed fluid therapy. A Delivery to booking 81 (Cl 70-92)
lumbar epidural was then inserted followed by rupture of Booking to surgery 68 (Cl 40-95)
membranes and oxytocin infusion. Fluid balance was closely Delivery to surgery 136 (Cl 122-150)
monitored continuously using FloTracTM. 1st stage of labour MROP n=42 Time (minutes)
was uneventful and 2nd stage was shortened using vacuum Delivery to booking 138 (Cl 115- 160)
assisted delivery of a healthy baby. She had a second degree Booking to surgery 39 (Cl 32-46)
tear which was repaired. Post partum haemorrhage due to Delivery to surgery 178 (Cl 152-204)
uterine atony was treated with 400µg Misoprostol rectally and
Incidentally, 78% of the patients did not have electronic record
intravenous infusion of 20 IU of Oxytocin. Estimated blood
of estimated blood loss on the theatre system.
loss was 800 mL. Cardiac condition was stable apart from
Discussion: In our institution, these cases are booked onto
persistent tachycardia throughout labour. Postpartum, she
the general emergency theatre, and not in the designated
spent 24 hours in ICU with similar monitoring. Her tachycardia
emergency obstetric theatre. We have identified that this has
settled spontaneously. She was discharged home on day 4.
resulted in significant delay in surgery and increased blood
Discussion: Patients with congenitally corrected transposition
transfusion requirement. We are now changing the patient
have a thin-walled right ventricle as the systemic circulatory
pathway to include urgent utilisation of the emergency
pump. The stress of increased cardiac output can cause
obstetric theatre for these procedures. Since the presentation
failure, atrioventricular regurgitation and arrhythmias1. We
of this audit, we have included the estimation of blood loss in
used minimally invasive continuous cardiac output
the surgical sign out process, thus improving communication
monitoring, fluid balance optimisation and good maternal pain
and patient care.
control to prevent decompensation and achieve vaginal
References
delivery with a good feto-maternal outcome.
1. National Institute for Health and Care Excellence. 2007.
Reference Intrapartum care. Care of healthy women and their babies during
childbirth. Clinical guideline 55
1. Dob DP, Naguib MA, Gatzoullis MA. A functional understanding of
moderate to complex congenital heart disease and the impact of 2. Fernando RJ, Sultan AH, Kettle C, Thakar R. Methods of repair for
pregnancy. Part I: the transposition complexes.Int J Obstet Anesth. obstetric anal sphincter injury. Cochrane Database Syst Rev. 2013
2010 Jul;19(3):298-305 Dec 8;12:CD002866.
P32 Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin)
P163 Multidisciplinary involvement of the high risk P164 National Obstetric Anaesthetic Database: a useful tool
parturient to benchmark maternity units in the UK
S De Silva,  P Gregory,  E Combeer   G Keightley,  N Tailor,  R Baraz,  L De Lloyd  
Anaesthetics, Frimley Park Hospital, Frimley, UK Anaesthetics, University Hospital of Wales, Cardiff, UK

Our Hospital offers a high risk Obstetric Anaesthetic Clinic for Introduction: The National Obstetric Anaesthetic Database
review of parturients with anticipated Anaesthetic or Medical (NOAD) was set up in 1998 to establish a framework for
problems where a checklist referral form is used. We audited collecting national obstetric anaesthetic data considered
whether women were appropriately referred or inappropriately relevant to obstetric anaesthetists. Whilst preparing the
not referred. An alert sticker was created to encourage NOAD survey for 2012, we explored the usefulness of this
healthcare providers to alert the oncall Obstetric Anaesthetist data in benchmarking our units' performance at the University
when the high risk parturient presented to labour ward. We Hospital of Wales (UHW) in relation to NOAD published
went onto audit the effectiveness of this alert sticker. figures from the previous year.

Methods: Data was collected according to the NOAD 2012
Methods: We looked at 200 consecutive births during October
survey and therefore, ethical approval was not required. Due
2010 and ascertained how many of these women had referrals
to the large number of deliveries in our unit, data regarding
to the High Risk Clinic. In the referred cases, we asked whether
labour analgesia, mode of delivery, caesarean section rate and
referral criteria were met and also determined if any mothers
type of anaesthesia was based on six months period (Jan to
were inappropriately not referred. In 2012 we retrospectively
June 2012) and then doubled. Exceptions were critical care
inspected all notes of mothers seen in High Risk Clinic with an
admissions and patients with accidental dural puncture (ADP);
estimated delivery date of March to May 2012. We checked
these were collected and reviewed individually for the entire
whether an alert sticker was present in their notes and also the
year. Microsoft Excel was used to analyse the data.
time taken for the Obstetric Anaesthetist to be contacted once
the mother had presented to Labour Ward. Results: The number of total deliveries in our unit for 2012

was 6138, of which 3060 required anaesthetic procedure(s).
Results: In 2010, 178 of 200 notes were reviewed and 14
The table below compares performance and quality indicators
women met referral criteria and 12 of these were referred.
at UHW in 2012 with the NOAD averages from 2011.
Fourteen percent were therefore inappropriately not referred,
however no women were inappropriately referred. Indicator UHW 2012 NOAD 2011

Caesarean section (CS) rate 22% 24.8%
In 2012, 42 notes were inspected where only 8 had the alert
Elective CS rate 46% 39.1%
sticker in place, with only 5 in the correct position. Two
De novo general anaesthesia (GA) for CS 4.5% 4.7%
mothers with the alert had elective caesarean sections. In five
Conversion to GA (CS) 1.8% 3.5%
of the six remaning mothers, the oncall Anaesthetist was
Labour regional analgesia 27% 22.7%
informed of their presence on labour ward. The average time
Epidural re-site rate 7.7% 9%
taken for this was four hours and 45 minutes (range 10 minutes
Accidental dural puncture rate 0.9% 1.2%
to 10 hours and 50 minutes). On review of the Clinic letters, it
was felt that 30 of the 42 parturients should have had an alert In 2012, three cases were transferred to critical care unit as
present in their notes, which is 71% not 19% as shown by our level 2 care (two with sepsis and one adult respiratory distress
audit. syndrome) and six cases as level 3 care (two with sepsis, three

post partum haemorrhage and one case of amniotic fluid
Discussion: In many cases of substandard care assessed by
embolus).
CMACE, there were major failures of communication between
Discussion: Our unit is classified as a large maternity unit
healthcare workers that may have contributed to the woman’s
compared to the national average. The elective CS rate and
death in some cases1. Our audits demonstrated that local
labour regional analgesia rates in our unit are higher than the
guidelines for referral were followed in 99% of cases, therefore
national average, possibly related to the complexity of a
high risk mothers were identified early. However, there still
tertiary centre. Despite this, our total CS rate is well below the
lacks effective communication of concerns within teams and
average with very low conversion to GA. In addition, our
poor involvement of other specialties early.
epidural re-site rate is lower than the national average, as is
Reference our ADP rate. Current facilities include two theatres serving
1. Centre for Maternal and Child Enquiries (CMACE). Saving both emergency and elective streams, and a mixed
Mothers'. Lives: reviewing maternal deaths to make motherhood recovery/high dependancy unit (HDU) for up to 5 patients.
safer: 2006–2008. The Eighth Report of the Confidential Enquiries
Our unit has a low transfer rate as level 2 care in general HDU,
into Maternal Deaths in the United Kingdom. BJOG 2011;118:1-203
due to the ability to care for these patients on our unit. We
find the NOAD data a useful tool to benchmark our
performance and set standards of care. More units should
contribute to the annual NOAD survey and consider using the
data as a way of identifying shortfalls and improving patient
care and services.
Reference
1. National Obstetric Anaesthetic Database report 2011.
http://www.oaa-anaes.ac.uk/content.asp?ContentID=586
Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin) P33
P165 Obstetric admissions to the Intensive Care Unit: a 6 P166 Obstetric outcomes with programmed intermittent
year review at a UK tertiary maternity centre epidural bolus labour analgesia
R Labib,  K Cullis   JTE Cremin,  CH Papageorgiou  
Selwyn Crawford Department of Anaesthesia, Birmingham Department of Anaesthesia, Hillingdon Hospital, Uxbridge,
Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin) P1
P101 A modified WHO surgical safety checklist for P102 A parturient with phocomelia and severe needle
category 1 caesarean sections phobia: the challenges faced
A Lahkar,  A Cooney,  G Massolini   R Sinha,  K Howard,  N Bhandal  
Anaesthetics, Milton Keynes NHS Foundation Trust, Milton Department of Anaesthesia, Nottingham University Hospitals
Keynes, UK NHS Trust, Nottingham, UK
Introduction: In June 2008, WHO introduced a surgical safety Introduction: Parturients with phocomelia are rarely seen and
checklist to be used in every operating theatre to improve present anaesthetic and obstetric challenges. We present a
patients' safety. In 2010 a WHO surgical safety checklist for case of a parturient with phocomelia and severe needle phobia.
maternity was created in response to requests from maternity Case report: A 33 year old woman with phocomelia and severe
services and clinicians. Nevertheless, in some emergency needle phobia presented to the obstetric anaesthetic clinic at
situations like category 1 Caesarean sections, this checklist 20 weeks for pre-assessment.
could still be quite a difficult task to achieve due to Her phocomelia was thought to be idiopathic, she had been
understandable time limit constrains to safely deliver the baby adopted when young and no family/drug history was
and/or save the mother's life. available. Examination revealed four limb phocomelia. There
Whilst there is still no international consensus or any specific were absent upper limb bones on the right and a fused hand
recommendation from WHO concerning these specific attached directly to her body. Her left upper limb was
situations, the Anaesthetic Department in Milton Keynes shortened with a primitive hand and fused fingers. Both lower
hospital has managed to devise a checklist for cat 1 LSCS limbs were extremely shortened with primitive feet with fused
which is 100% compliant both in terms of content with WHO toes. Her head, neck and torso appeared normal. She was able
guidelines and adherence by hospital staff. to mobilize with a wheelchair and significant assistance from
Method: After considerations and inputs from the Consultant her partner. The problems faced in clinic were numerous and
Anaesthetists, a simplified checklist was introduced in our focused on her severe needle phobia, difficult venous access
emergency obstetric theatre in June 2013 by way of an ad hoc and monitoring, positioning, mobilization and
poster hanged on the wall. It spells out the most 10 salient thromboprophylaxis as well as the challenges posed by the
questions to be read by one of the theatre staff before the start preganancy itself. The anaesthetic plan consisted of non-
of a category 1 Caesarean section. These questions translate invasive blood pressure monitoring on her left lower extremity;
the original 32 WHO ones that were spread across 3 sections pulse oximetry via an ear probe or toe and standard
in a simpler, quicker format. electrocardiogram. These were tested prior to labour. Due to
Results: After the introduction of the modified WHO checklist the impossibility of standard intravenous access and extreme
in June 2013, compliance is 100%. needle phobia several discussions were had about obtaining
Discussion: By putting the combined know-how and intravenous access prior to labour. A right subclavian
experience of many Consultant Anaesthetists to the task, we Hickman line was inserted at 39 weeks facilitated by the use of
managed to simplify the original WHO narrative into a sharper entonox. Regional analgesia was refused for labour so the
tool that is quickly and effectively utilised for a better and option of intravenous fentanyl via a midwife controlled
safer quality of care in what has become a "normal routine" analgesia pump was discussed. Should a caesarean section be
during extraordinary times in the emergency theatre. required a neuroaxial anaesthetic was refused and so a general
anaesthetic was planned.
Reference At 40+2 weeks spontaneous rupture of membranes occurred
1. WHO surgical safety checklist: for maternity cases only, and labour established. However, due to failure to progress a
http://www.nrls.npsa.nhs.uk/resources/?entryid45=83972 decision was made to perform a caesarean section.
In theatre the challenges related to positioning and achieving
a satisfactory left lateral tilt. A rapid sequence induction was
conducted following pre-oxygenation to an end-tidal oxygen
concentration of 92%. Anaesthesia was induced with
thiopentone 350mg and suxamethonium 100mg. Soon after
induction she desaturated rapidly to the high 60s. This
resolved after tracheal intubation and ventilation. She was
hypotensive intra-operatively, with an estimated blood loss of
1300mL After fluid and blood resuscitation, recovery was
unremarkable. Postoperative pain was managed with
transversus abdominus plane blocks and morphine
patient/midwife controlled analgesia.
Discussion: There is little literature about managing delivery
in women with phocomelia, but sucessful regional techniques
have been described although this was refused here. Early
discussion of anaethesia and analgesia options, and plans for
vascular access and monitoring are needed, There is a reduced
vascular reservior and skeletal muscle mass.
As a consequence faster inductions, emergences and
responses to titrated drugs are observed.

P2 Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin)
P103 A questionnaire to evaluate and aid future development P104 A retrospective descriptive analysis of anaesthesia for
of the AAGBI's SAFE obstetric anaesthesia course in successful cervical cerclage in pregnancy
Liberia J Modha,  G Burul*,  F Forya*,  CP James*,  AL David*,  J
JCO Fox,  CE Richards*,  T Sheraton*,  A Sonah†   Dick,  L Wee  
†Department of Anaesthetics, Phebe Hospital, Bong County,  Department of Anaesthesia, University College London
Liberia, *Department of Anaesthetics, Royal Gwent Hospital, Hospitals NHS Foundation, London, UK, *Department of
Newport, UK, Department of Anaesthetics, University Obstetrics, University College London Hospitals NHS
Hospital of Wales, Cardiff, UK Foundation, London, UK
Introduction: Dr Kate Grady has developed this three-day Introduction: Cervical cerclage is a common operation which
refresher course in obstetric anaesthesia on behalf of the requires an anaesthetic. There are no studies on the type of
AAGBI. The course is aimed at non-physician anaesthetists in anaesthesia used for this procedure.1
developing countries. It consists of short lectures, interactive Aim: To determine the type of anaesthesia used for vaginal
sessions and workshops that focus on the recognition and cervical cerclage.
management of leading causes of maternal death in resource
Method: Ethical approval waived. Women having any vaginal
poor settings. The course has been taught in Uganda,
cervical cerclage (Macdonald or Shirodkar) during pregnancy
Bangladesh, Liberia and Ghana. It includes the principles of
between January 2005 and December 2012 were identified
the WHO Safe Surgery and training of trainers. Mothers of
using the hospital obstetric anaesthesia database and cross-
Africa, a medical educational charity, has led delivery of 2
referenced with data from the Preterm Birth clinic where women
courses for nurse anaesthetists (NAs) in Liberia - supported
at risk of preterm birth are seen antenatally. Data was obtained
by the AAGBI IRC. Liberia has approximately 60 nurse
by examination of obstetric case notes and the ultrasound
anaesthetists and no medically qualified anaesthetists for a
scan records and analysis conducted using Microsoft Excel.
population of 4.2 million people1. Access to CPD is difficult.
Results: There were 190 cases. Twenty-five patients were
The MMR in Liberia is 770 per 100,000 live births1. In order to
excluded due to incomplete data, hence 165 included in
plan future development of the course in Liberia, which will be
analysis. The mean gestational age was 16.6 weeks (range 9-
led by Liberian trainers, feedback data was collected.
23.6 weeks). The table below shows that both general
Methods: A follow up questionnaire was given to 35 NAs who
anaesthesia (GA) and regional anaesthesia (RA) were used.
had previously attended a SAFE obstetric anaesthesia course
The majority of regional anaesthetics were spinals (95.7%), the
held in Liberia (March 2012 or March 2013). We aimed to
rest combined spinal and epidural (CSE) (3.6%) and epidural
assess; 1) the quality, usefulness and appropriateness of the
top up (0.7%).
material taught during the course, 2) the effect on motivation
to improve local services/care delivery, 3) the effect on the GA RA

confidence levels of NAs in managing obstetric anaesthetic n (%) n (%)
emergencies. Spinal n = 133
Results: A 70% follow up rate was achieved. 97% reported Total n=165 26 (16%) 139 (84%) CSE n = 5
positive changes in their attitude to work and their clinical Epidural n = 1
practice and 94% reported improvements in interactions with Five patients who had a spinal anaesthetic required second
colleagues. Many NAs gave details of cases where the skills procedures (3 GA, 1 spinal, 1 CSE). Of those converted to GA,
and knowledge they learnt on the course helped save lives one patient had a block to T6 (the reason for conversion to GA
and improve clinical outcomes. 11 NAs requested continued was not documented), one patient had a block to T12 and the
education and training. Other suggestions for course third patient had 3 failed spinal attempts. In all cases there
improvement included; additional sessions in preoperative were no major anaesthetic complications and cervical cerclage
assessment and TAP blocks, and the inclusion of midwives in was placed successfully.
the training sessions. The following table illustrates the mean
Discussion: In this series, the majority of vaginal cervical
subjective confidence scores (between 0 and 10) of the NAs in
cerclage surgery was performed safely and effectively under
various clinical scenarios before and after the course.
RA. There are no specific guidelines regarding the type of
  Before After anaesthesia for cervical cerclage.1 Anaesthetic considerations
General anaesthesia LSCS 6.3 9.2 favouring a regional anaesthetic in pregnancy include the risk
Spinal anaesthesia LSCS 7.6 9.8 of aspiration and difficult airway management in patients over
Management of severe eclampsia/preeclampsia 5.7 9.2 20 weeks gestation and those under 20 weeks gestation if at
Management of obstetric haemorrhage 5.9 9.4 high risk for example those with a high BMI. The majority of
women in our data set were less than 20 weeks (88.5%). Other
Discussion: Our results indicate that the SAFE obstetric
considerations include patient and surgeon choice. Women in
anaesthesia course in Liberia has been well received with
this series were given the option of GA or RA. In certain cases
subjective evidence of empowerment and improved methods
for example rescue and abdominal cerclages, the patient may
of working. This is promising in the context of increasing the
need to be in a deep Trendelenberg position to aid reduction
reach of future courses and enabling local faculty to lead
of membrane prolapse to avoid membrane rupture or to aid
training. Further data from logbooks provided as part of the
access to the pelvis.2
course were not obtained and more work is needed to
encourage completion of the logbooks. Objective evidence is References
required to demonstrate impact on patient outcomes. 1. Cervical Cerclage, Green-top Guideline No 60, Royal College of
Reference Obstetricians and Gynaecologists, May 2011.
2. Olatunbosun OA, Dyck F. Cervical cerclage operation for a dilated
1. http://data.worldbank.org/indicator/SH.STA.MMRT/countries/1W-
cervix. Obstet Gynecol. Feb 1981;57(2):166-70.
LR?display=graph
Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin) P3
P105 A retrospective descriptive analysis of dose of P106 A step towards improving theatre productivity for
intrathecal anaesthesia and adjuncts for successful elective caesarean sections
cervical cerclage in pregnancy S Kale,  C Farrow,  N Owen,  K Miltsios  
J Modha,  G Burul*,  F Forya*,  CP James*,  AL David*,  J Department of Anaesthesia, Whittington Hospital, London,
Dick,  L Wee   UK
Department of Anaesthesia , University College London Introduction: NHS Institute for Innovation and Improvement
Hospitals NHS Foundation, London, UK, *Department of developed The Productive Operating Theatre Programme to
Obstetrics, University College London Hospitals NHS improve effective use of theatre time, staff and patient
Foundation, London, UK experience.1 Good administrative system and organisation is
Introduction: Cervical cerclage is a common operation, which essential to ensure theatre efficiency.2On this background,
requires either a general or regional anaesthetic aiming for a with the rational of making existing system more productive,
block height of T10. There are no studies determining the dose safe and reliable, we evaluated current practice in one of our
that should be used to achieve this or describing additional main theatres, designated for elective sections, in a DGH set
drugs used for successful surgery. up.
Aim: To determine the dose of local anaesthesia used for Methods: Evaluation was carried out over a 4-week period, for
intrathecal injection and the block height achieved in women planned caesarean sections. The data was collected
undergoing cervical cerclage. In addition to determine the use concurrently by the anaesthetist for that case and from the
and dose of adjuncts. theatre database. The exact time for all significant events, such
Method: Ethical approval waived. Women having vaginal as when patient was sent for or when theatre was clean and
cervical cerclage during pregnancy between January 2005 and ready for the next patient, was recorded. Reasons for delays,
December 2012 were identified using the hospital obstetric duration of anaesthesia, surgery and problems encountered
anaesthesia database and cross-referenced with data from the were also recorded. Time spent at and between different
Preterm Birth clinic. Data was obtained by examination of crucial stages in theatre was calculated from the data. Results
obstetric case notes and the ultrasound scan records and are presented in the form of time in minutes, median [range]
analysis conducted using Microsoft Excel. and % (absolute numbers of cases).
Results: In all cases, cervical cerclage was achieved Results: We had 25 completed forms. Our analysis showed,
successfully. There were 138 cases of intrathecal anaesthesia median time interval from patient sent for to arrival in theatre
(133 spinals and 5 combined spinal epidurals) in whom 67.4% as 5 min [1-29]. Reasons for delay were due to obstetric team
(93/138) had documented intrathecal anaesthetic dose and busy in meeting, midwife busy preparing the patient and
were included for final analysis. Hyperbaric bupivacaine 0.5% midwife busy completing paperwork for previous patient in
was used (mean dose 10.9mg, median 10.8mg and mode 10mg, recovery. Median time interval between patient's arrival and
range 6.5–15mg). Block height and dose of intrathecal neuraxial block was 18 min [10-70], prolonged in 8% of cases
anaesthetic was documented in 54/93 cases (58%). The block (2/25) due to failed and repeat block. Bladder catheterisation
height ranged from T2 to T12 with similar doses of local after block was delayed by ≥30 min in 8% of cases (2/25) due
anaesthetic given in each group and of similar gestation and to unavailability of midwife. Median anaesthetic time for
body mass index (BMI). satisfactory block was 12 min. Interval between block ready
and knife to skin (KTS) was 6 min [1-12]. Median surgery
Block height T2-4 T5-8 T10 T12 duration was 45 min [31-141]. PPH, high BMI, and previous
Frequency 7 31 13 3 laparotomies resulted in longer operations in 16% of cases
Mean dose mg (4/25). Median turnaround time between the cases was 10 min
11 11 11 8
hyperbaric bupivacaine 0.5% [6-15]. Total time patients spent in theatre was 89 min [74-183].
Mean gestation (weeks) 17.4 17.7 15.6 19.1
Discussion: We noted that unavailability of obstetric team
Mean BMI kg/m2 27.3 26.6 26.1 32
and busy midwives at times has resulted in late starts and
In 3 patients that had block heights of T12 only one was delay in some procedures in theatres. Delay in starting the
converted to GA. Opiates were used in 73/93 (78.5%), the most surgery after a satisfactory block and prolonged turnaround
frequent being fentanyl. time have also affected the overall theatre productivity. We
have put forth some recommendations to working group such
Mean dose Range
Opiate used Number (%) as offering administrative support to midwives, ensuring
(mcg) (mcg)
senior obstetrician and anaesthetist are present for difficult
Fentanyl 69 (95) 20 10-75
cases, making use of anaesthetic room to improve patient
Diamorphine 3 (4) 300 250-350
turnaround time and most importantly encouraging staff
Fentanyl & Diamorphine 1 (1) 20/300 N/A
nurses to take the lead role in increasing theatre efficiency.
Vasopressors were used in 26 cases (23 phenylephrine, 3 This could be a big step towards enhancing theatre output as
ephedrine). Other drugs included 3 cases of intravenous well as increasing patient and staff satisfaction. We aim to
midazolam, 1 case propofol and in 1 case salbutamol (as a introduce these changes soon and re-evaluate the practice in
tocolytic agent). the near future.
Discussion: In our case series there is a wide dose range of References
both hyperbaric bupivacaine 0.5% and opiate given. To 1. The Productive Operating Theatre programme,
achieve a block height of T10 or above a minimum dose of http://www.institute.nhs.uk/quality_and_value/productivity_series/the
11mg (2.2ml) is recommended which may be independent of _productive_operating_theatre.html
other factors. There is a wide variation in block height but 2. Theatre Efficiency,
http://www.aagbi.org/sites/default/files/theatreefficiency03.pdf
even a low block (T12) was found to be adequate.

P4 Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin)
P107 A year in the "maternity" life of an increasingly busy P108 Abstracts on the antenatal anaesthetic clinic
new build district general teaching hospital - coping presented to the Obstetric Anaesthetists' Association,
with training and service provision - 2013 1991-2013
H Wrigley,  PF Yoxall,  Janet Slee   AJ Wickham,  SM Yentis*  
Anaesthetics, St Helens & Knowsley NHS Trust, Liverpool, Anaesthetic department, St Mary’s Hospital, London, UK,
UK *Anaesthetic department, Chelsea & Westminster Hospital,
Introduction: Since moving to a new PFI built hospital in 2010 London, UK
our maternity unit has become more busy. Delivery rates/year Introduction: National reports1 and guidelines2 recommend
have increased from 2900 to 3700 pa (up 27.6% in 3 years) assessment of women with ‘high-risk’ pregnancies and
increasing demands upon anaesthetic services. potentially serious co-morbid disease in an antenatal
Methods: We reviewed all our maternity cases during 2013, anaesthetic clinic (AAC). We reviewed trends and themes in
both epidural and caesarean sections. We also surveyed our abstracts on this topic presented to the OAA.
CT2 trainees to assess their experience in terms of case Methods: Full-text records of abstracts (excluding case reports)
numbers during a newly introduced modular training block. presented at OAA meetings (1991-2013; see www.oaa-
Lastly consultant cover on labour ward was audited for CNST anaes.ac.uk) were searched using the terms ‘antenatal’,
purposes. ‘clinic’, ‘risk’ and ‘refer’. Relevant abstracts were reviewed for
Results themes and conclusions.
Results: Forty abstracts were presented at 14 Annual
n %
Meetings (Fig. 1); 3 were unavailable in full-text (2008) but 1
Total Deliveries 3700
was provided by the author on request. 35 were from single
LSCS 838 22.6
departments and 5 were surveys (4 national). Common topics
Grade I-III LSCS 464 12.5
were obesity (12, 30%), referral reason (7, 18%) and
Grade IV LSCS 374 10.1
appropriateness (4, 10%), and outcomes (5, 13%). Nine (23%)
LSCS - SAB 666 79.5
described single patient cohorts, e.g. cardiac. AAC workload
LSCS - Epidural 123 14.7
has increased from 2.3 to 28.6 patients per month over 22
LSCS - CSE 14 1.7
years, albeit at different centres. Obesity has replaced
LSCS - GA 119 14.2
musculoskeletal disease as the most frequent reason for
RA to GA 34 4.2
referral. Common concluding themes include the need to
Average BMI LSCS (Range) 28.3 (16.7-59.9)  
improve the timeliness and appropriateness of referrals, and
Epidurals 895 24.2
ensuring anaesthetic plans are both prominent and followed.
Epidural Resites 32 3.7
PDPH - Epidural 15 1.7
PDPH - SAB 2 0.3
Epidural Blood Patches 21
Average BMI Epidural (Range) 27.1 (16-62.8)  
CT2 Training One of our requirements is to teach at least 4
CT2s per annum obstetric basic competencies. Our trainees
receive a 4 week long daytime block covered by an anaesthetic
ST3-7 and a consultant. They attend 40 sessions, the majority
siting 15 epidurals and anaesthetise 30 caesarean sections
before embarking on daytime on calls. They attend our in-
Figure 1: number of abstracts on the AAC presented per year
house MODSS (Obstetric Simulation Day) run by one of our
Consultant Obstetricians. Discussion: Abstracts relating to AACs have become more
frequent in the last decade, presumably reflecting their
Consultant Input The number of funded Consultant labour
increasing provision and perceived usefulness (and
ward sessions has risen 7 to 10 sessions (7 elective lists per
recommendation in the 2002-04 CEMACH report3). Increased
week). A “High Risk Obstetric clinic” runs weekly to pre-
demand for this service is exacerbated by inappropriate
assess all potentially difficult patients (250-300 per annum).
referrals and budgetary constraints. Referral processes,
Discussion: Despite a significant increase in workload we
facilities, and documentation and inconsistent use of plans are
have managed to maintain levels of cover (both junior and
areas for development. Future work should focus on quality
consultant) whilst allowing for CT2 training in obstetric basic
improvement and assessment of cost-effectiveness. Nationally
competencies as required at both national and local levels.
agreed referral criteria and a national ‘anaesthetic plan’
This has been achieved by increasing our core of obstetric
document, complemented by referrer education, may enhance
consultant anaesthetists, increasing obstetric PAs and
the process. Multidisciplinary ‘one-stop-shop’ or midwifery
changing to a modular CT2 training programme.
led clinics for common problems, such as obesity, may be
beneficial.
References
1. Centre for Maternal and Child Enquiries. Saving Mothers’ Lives:
reviewing maternal deaths to make motherhood safer: 2006-08.
The Eighth Report on Confidential Enquiries into Maternal Deaths
in the UK. BJOG. 2011; 118(Suppl.1): 1-203.
2. OAA & AAGBI Guidelines for Obstetric Anaesthetic Services.
Revised Edition 2005. London: OAA/ AAGBI
3. CEMACH. Why Mothers Die 2000-2002. Report on Confidential
Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin) P5
P109 Accuracy of a new electronic obstetric anaesthetic P110 Accuracy of landmark approach to central neuraxial
database blocks in obstetric patients
Rohit Rohit,  R Abraham,  GNB Jackson   J Lie,  K Bhatia,  A Venkataraju,  P Kochhar  
Anaesthetic department, Royal Berkshire Hospital, Reading, Anaesthesia, St Mary's Hospital, Manchester, UK
UK Introduction: Correct identification of vertebral level could
Introduction: We have introduced a new electronic database prevent damage to the spinal cord during a central neuraxial
'ROAD' (Reading Obstetric Anaesthetic Database) to record block (CNB). Evidence suggests that ultrasound (US) imaging
obstetric anaesthetic data. Written & designed by one of our of the spine by an experienced operator leads to correct
anaesthetists it is secure, password protected & able to identification of vertebral level in 90% of the patients and
produce reports on patient data & the activity of individual decrease the number of attempts required for a successful
anaesthetists. More than 70% obstetric anaesthetic units use CNB1. National Institute for Health and Care Excellence
electronic data collection system in the UK but there is little suggests US could be a useful tool for epidural catheter
agreement as to the best format.1 We audited the accuracy of insertion2. Our aim was to determine the discrepancy between
data entry, as a marker of ease of use by the anaesthetists, landmark technique and US to identify level of insertion of
before auditing the content of the database. CNB.
Methods: This was a retrospective audit, analysing data for Methods: Two experienced US operators who were blinded to
one month period (June 2013). The data in 'ROAD' was the initial procedure retrospectively performed US imaging of
compared to 1) our handwritten anaesthetic record book spine post-operatively after elective caesarean section in 51
(ARB); 2) Midwifery led labour ward logbook (LWLB); 3) obstetric patients with their consent from January to March
Operating theatre electronic log 'Bluespier'. Data entered on 2013 in St Mary’s Hospital. All the patients had a lumbar CNB
the 'ROAD' was manually checked against all these three done by landmark approach. The documented vertebral level
sources and the results tabulated and analysed. at which CNB was performed was noted. This was then
Results: 253 records were found in the ARB. The ARB missed compared with the actual vertebral level identified by bedside
one case (found in Bluespier), Bluespier missed one case US imaging of spine.
(found in the ARB) and LWLB missed 6 cases (found in the
Results: 29 patients had a spinal, 20 had an epidural and two
ARB & Bluespier). The results show that 'ROAD' was 96%
had combined spinal-epidural anaesthesia. The median body
accurate compared to any of the other systems.
mass index (BMI) was 28.6kg/m2. Landmark technique was
No. of cases missing on only accurate in 39.2% of patients. There was no statistically
Total 'ROAD' accuracy against
  'ROAD 'compared to significant correlation between the experience of operator and
no. other data sources as %
others accuracy. 3% of patients had a CNB at the level of L or above.
2
ARB 10 253 96.047% Documentation of the level performed was excellent. Raised
Bluespier 7 174 95.977% BMI and difficulty in palpation of landmarks resulted in
LWLB 10 247 95.951% statistically significant decrease in the accuracy (p<0.05
'ROAD'   243   Fisher’s Exact Test).
Discussion: Pinder et al considered an accuracy of 89% for Discussions: Our findings co-relate well with other studies
their electronic record adequate enough to adopt computer which have found that the vertebral level identified by
based data collection system.2We used three different landmark approach was at least 1 interspace higher than the
methods of data collection already in regular use, to compare level located by US in 40% of the pregnant population 3. Our
with our electronic database and showed it to have a high audit further confirms that the use of traditional landmark
degree of accuracy. This suggests that the database is easy to technique is highly inaccurate with potential increase risk of
use and consistently completed by our anaesthetists. We wish needle injury to the spinal cord especially in the high-risk
to use our database to produce reports on anaesthetic service patient groups (morbid obesity and musculoskeletal
provision (including the quality & safety of that service) as problems). We propose that all elective obstetric patients,
well as for auditing individual anaesthetist activity patients having a lumbar epidural, and high risk patients
(particularly our novice obstetric anaesthetists to ensure having a lumbar CNB should have US imaging of the of their
appropriate case mix & experience during their obstetric spines to identify the correct vertebral level and other relevant
attachments). Before using any database to audit these anatomy. The main reasons being that US imaging does not
aspects it is important to ensure that the data being audited is involve any radiation, is compact, portable and readily
a true reflection of anaesthetic activity, we believe our new available at the point of care. Better US equipment availability,
database is sufficiently accurate to audit the data within it. The staff awareness with appropriate training and improved
limitation of our audit is that we only audited the data from one documentation would aid in providing safer patient care.
month but we believe that the data entry practice of all months
References
is similar. We conclude that our electronic database is accurate
1. Chin KJ, Perlas A, Chan V, Brown-Shreves D, Koshkin A, Vaishnav
& the data entered can be used to audit our obstetric V: Ultrasound imaging facilitates spinal anesthesia in adults with
anaesthetic service. difficult surface anatomical landmarks. Anaesthesiology 2011; 115
(1): 94-101
References
2. Ultrasound-guided catherisation of epidural space. National Institute
1. Campbell NJ, Youngs P, Anderson I. A national survey of obstetric for Health and Care Excellence January 2008
anaesthetic data collection methods in the UK. Int J Obstet Anesth
2012; 21: S53. 3. Lee AJ, Ranasinghe S, Chehade JM, Arheart K, Saltzman BS,
Penning DH & Bimbach DJ. Ultrasound Assessment of the Vertebral
2. Pinder A, Wrench I, Shepherd D, Freeman R. Assessment of a Level of the Intercristal Line in Pregnancy. Anaesth Analg 2011;
handheld computer to collect obstetric epidural audit data. Int J
113: 559-564
Obstet Anesth 2002; 11: 8.
P6 Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin)
P111 Adherence to antenatal anaesthetic advice in P112 An evaluation of anaesthetic antenatal clinics in the
labouring morbidly obese parturients. obese obstetric population
S Halliday,  LC Robertson ,  HM du Plessis   PR El-Dalil,  DS Cochran,  R Ganapathy*  
Anaesthesia, Princess Royal Maternity Hospital, Glasgow, Department of Anaesthesia, Sandwell and West Birmingham
UK NHS Trust, Birmingham, UK, *Obstetrics and Fetal Medicine,
Introduction: Morbidly obese parturients pose a high Sandwell and West Birmingham NHS Trust, Birmingham, UK
anaesthetic risk1. Antenatal anaesthetic assessment for Introduction: Maternal obesity is increasingly common, with a
women with a body mass index (BMI) ≥40 kg.m-2 at booking is BMI 35 found in 5% of pregnancies. Current CMACE / RCOG
advised2. Early establishment of epidural analgesia is often guidelines advocate the referral of patients with a BMI 40 to
advocated. We sought to determine if this advice is adhered to an anaesthetic antenatal clinic. This study aimed to evaluate
in our centre. the outcomes following the implementation of such a clinic in a
Methods: A retrospective case note review of 49 morbidly busy inner city district general hospital.
obese patients (BMI ≥40) assessed antenatally was Method: High-risk patients were referred to a multidisciplinary
conducted. As a control, data from 23 patients with a BMI <40 antenatal clinic involving Anaesthetics, Obstetrics and
who had a labour epidural was collected. We compared the Haematology; patients with a BMI 40 were referred to the
timing of epidural request from labour ward admission, cervical clinic and included in the evaluation. Data was collected
dilation and syntocinon administration at request and the time retrospectively on the reason for attending, the past medical
from epidural insertion to delivery. Mode of delivery was also and obstetric history as well as any anaesthetic or surgical
noted. intervention provided in the perinatal period.
Results: Mean BMI for the control group was 23.6 (range 17- Results: In 2011, 72 women were referred to the clinic with a
32) and for the morbidly obese group 44.6 (40-60). Eleven BMI 40, although there were often other relevant co -
morbidly obese parturients had an elective caesarean section morbidities. The BMIs ranged from 40 to 80 (mean = 44). 44
(CS). Nineteen of the remaining morbidly obese parturients patients (61%) had a normal vaginal delivery, 3 women (4%)
requested labour epidurals. Two parturients delivered prior to required assisted vaginal delivery, 17 (24%) had an elective
insertion. caesarean section (CS), whilst 8 (11%) had a non-elective CS.
Of these patients, 38 (53%) required no anaesthetic
Time to Syntocinon Insertion to
Cervical dilation intervention.
request administration n delivery
  Centimetres
Minutes (%) Minutes Table: Anaesthetic intervention and failure rates in obese
(range)
(range) (range) parturients compared to previously published failure rates1 in
BMI Yes 12 (52.2) the general obstetric population
375 (110-
<40 169 (0-435) 3.7 (1-7) No 11 (47.8) Spinal Epidural CSE GA
915)
(n=23) Number attempted 19 12 4 1
BMI Yes 13 (68.4) % Failure rate 5 17 0 0
334 (12-702)
≥40  261 (0-555) 3.65 (2-8) No 6 ( 31.6) Published % failure rates1 6 24 18 <1
(n=17)
(n=19)
Discussion: The results demonstrated low regional
Table: Timing of epidural request, cervical dilation and anaesthesia failure rates, with only 1 unsuccessful spinal (5%)
syntocinon use at request, and time from insertion to delivery. and 2 failed epidurals (17%); figures comparable to those
In the control group with a BMI <40 that had a labour epidural found in the general obstetric population (Table). There is little
(n=23), the number of spontaneous vaginal deliveries (SVD), available data for regional anaesthetic failure rates in the obese
trial of forceps (TOF) and lower uterine segment CS (LUSCS) obstetric population precluding a direct comparison, but a
were 13 (56.5%), 5 (21.7%), and 5 (21.7%), respectively. For higher failure rate would be expected. A previous study of 677
those with a BMI ≥40 with an epidural (n=17) there were 6 women with a BMI 30 found an emergency CS rate of 24%, 2
(35.3%) SVD, 3 (17.7%) TOF and 8 (47.1%) LUSCS. The significantly higher than the 11% demonstrated in this cohort
number of SVD in the BMI ≥40 without an epidural group was of BMI 40. This robust multidisciplinary approach in the
18 (85.7%) and there were no TOF and 3 (14.3%) LUSCS. antenatal period allows for adequate planning and early
Discussion: Despite antenatal review, the time to epidural institution of optimised perinatal management. The service
request was longer in the morbidly obese group, indicating a provided was predominantly consultant led, with the on-call
need for ongoing education. The time between epidural Anaesthetist required to attend out of hours for parturients
insertion and delivery was shorter in the morbidly obese group with a BMI 45, and to be informed of patients with a BMI
which had a significantly increased chance of CS, signifying 40; significantly 73% of the on-call consultants are dedicated
the importance of establishing a working epidural early in this Obstetric Anaesthetists. We feel these systems may account
cohort. for our findings, as well as promote early and effective
communication with patients. Whilst the sample was relatively
References small the results are sufficiently encouraging to suggest that a
1. Soens MA, Birnbach DJ, Ranasinghe JS, van Zundert A. Obstetric multidisciplinary approach significantly improves perinatal
anesthesia for the obese and morbidly obese patient: an ounce of outcomes in the obese obstetric population.
prevention is worth more than a pound of treatment. Acta
Anaesthtesiol Scan 2008; 52: 6-19 References
2. OAA/AABGI Guidelines for Obstetric Anaesthetic Services 2013. 1. Kinsella SM. A prospective audit of regional anaesthesia failure in
Association of Anaesthetists' of Great Britain and Ireland and the 5080 caesarean sections. Anaesthesia 2008; 63(8): 822-832.
Obstetric Anaesthetists' Association. London, 2013. 2. Usha Kiran TS, Hemmadi S, Bethel J, Evans J. Outcome of
pregnancy in a woman with an increased body mass index. BJOG
2005; 112(6): 768-772.
Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin) P7
P113 An evaluation of fasting times for elective caesarean P114 An evaluation of intrathecal diamorphine versus
section surgery fentanyl for lower segment Caesarean section in a
J Ghoshdastidar,  KM Sherratt,  M Seneviratne*,  A medium-sized district general hospital
McGlennan   K Ramm,  LT Fenton-May,  S Naresh  
Anaesthetics, Royal Free Hospital, London, UK, Department of Anaesthesia, Good Hope Hospital, Heart of
*Anaesthetics, University College Hospital, London, UK England Trust, Birmingham, UK
Introduction: Enhanced Recovery Programmes have shown Introduction: Intrathecal diamorphine is now recommended by
increasing evidence for the benefits of reducing fasting times the National Institute for Health and Clinical Excellence (NICE)
for those undergoing elective surgery1. Many of these as the opioid of choice for lower segment Caesarean section as
benefits could be applicable to the elective caesarean section it provides improved post-operative pain relief.1 However, it is
patient. We evaluated the fasting times of our elective also associated with a dose-dependent increase in the
caesarean section patients to assess whether we could make incidence of pruritus2 and nausea3 which may be more
improvements to patient care. significant with diamorphine given its longer duration of
Methods: The evaluation included all patients undergoing action. Having arranged appropriate protocols for post-
elective caesarean section surgery at the Royal Free Hospital operative monitoring of women receiving intrathecal
over a 3 month period.. Patients received standard instructions diamorphine, we introduced the therapy in late 2012.
to stop eating at midnight on the day of surgery and to stop Methods: The evaluation took place over a six-week period. A
drinking clear fluids at 6 am. Data was collected by anaesthetic small number of women were still receiving intrathecal fentanyl
staff using a standardised data collection sheet.. Patients were due to clinician choice, and these provided a useful
questioned about the time they last consumed solid food and comparator. Women who were still present in the hospital on a
when they last drank liquid. follow-up round on the first day post-op were asked questions
Results: In total 77 patients underwent elective caesarean about post-operative pain, nausea and pruritus. We also
sections during the period of evaluation. We obtained data assessed total oral morphine and codeine doses and time to
from 71 patients for fasting times for fluids and 72 patients for first dose.
fasting times for solids. Results: Basic data is presented in the chart.

  Fentanyl Diamorphine
Pre-op fasting % of Pre-op fasting % of
Number 15 36
times FLUIDS patients times SOLIDS patients
Time to first morphine (hrs) 5.29 8.9
(hr) (n=71) (hr) (n=72)
Mean morphine dose (mg) 65.4 30
2 - 4 5.6 6 - 12 15.3
No morphine required 1 (6.6%) 11 (30.6%)
4 - 6 15.5 12 - 18 66.7
Mean codeine dose (mg) 123 119
6 - 8 14.1 18 - 24 16.7

8 - 10 8.5 over 24 1.4
Time to mobilisation (hrs) 21.17 15.21
over 10 56.3    
Time to catheter removal (hrs) 20.3 16.6

Discussion: There are no fasting recommendations specific to
Pruritus 8 (53.3%) 24 (66.7%)
elective caesarean sections but the standard surgical
- requiring treatment - 0 (0%) - 8 (22.2%)
guidelines of 6 hours for solids and 2 hours for clear fluids are
Nausea 5 (33%) 13 (36.1%)
usually applied. Periods longer than 12 hours without fluid
- requiring treatment - 3 (20%) - 7 (19.4%)
have correlated with significant dehydration
in patients having elective caesarean sections2. There is also
Discussion: Our results replicate previous work demonstrating
some evidence to suggest that gastric fluid volume is
a reduction in immediate post-operative analgesia
increased with prolonged starvation in the pregnant patient3.
requirements following a switch from fentanyl to diamorphine,
Over fifty per cent of our patients went without fluids for
but an associated increase in side effects requiring
longer than ten hours prior to surgery, and almost eighty-five
intervention. There was also a reduction in times to first
per cent of patients went without food for greater than 12
mobilisation and catheter removal, which is worth closer
hours. Our results show that there is a need to introduce
inspection. It is likely to be multi-factorial: the patients having
methods to reduce fasting times. These could include pre-
superior analgesia and feeling ready to move sooner, but also
operative letters with individualised times to stop eating and
the proforma for the ward indicating the patient had received
drinking. Also patients lower down the surgical list could be
diamorphine. This required the anaesthetist to specify a time
actively encouraged to consume clear fluids, or even
after which she would be ready to mobilise, which might have
carbohydrate drinks as used in many Enhanced Recovery
improved motivation amongst the midwives and mothers to
programmes.
achieve mobilisation.

References
References
1. Aguilar-Nascimento JE, Dock-Nascimento DB. Reducing
preoperative fasting time: A trend based on evidence. World J 1. NICE clinical guideline 132: Caesarean section
Gastrintest Surg. 2010 March 27;2(3): 57-60 2. Wrench IJ, Sanghera S, Pinder A et al, Dose response to intrathecal
2. Mackenzie M, Yentis S, Woolnough M and Johnson M. Fasting diamorphine for elective caesarean section and compliance with a
periods and dehydration before elective caesarean section. national audit standard, Int J Obstet Anesth. 2007;16(1):17-21
Anaesthesia, 2010 Vol 65:99 3. Sibilla C, Albertazzi P, Zatelli R, et al, Perioperative analgesia for
3. Maltby JR, Sutherland AD, Sale JP, Shaffer EA. Preoperative oral caesarean section: Comparison of intrathecal morphine and
fluids: is a five hour fast justified prior to elective surgery?. Anesth fentanyl alone or in combination, Int J Obstet Anesth. 1997; 6(1):
Analg. 1986 Nov;65(11):1112-6 43-48
P8 Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin)
P115 An evaluation of obstetric critical care admissions in a P116 An evaluation of standards of informed consent and
district general hospital documentation for labour epidural analgesia
VL Williams,  M Greene,  D Saul   S Chaudhari,  N Smith,  P Prasad  
Department of Anaesthesia, Leighton Hospital, Crewe, Anaesthetic Department, George Eliot Hospital, Nuneaton,
Cheshire, UK Nuneaton, UK
Introduction: CMACE has provided doctors with excellent
Introduction : It is both medico legally and ethically important
data over the past 50 years about maternal mortality, but
that the patient is made aware of the nature and risks
unfortunately no data about maternal morbidity. In December
associated with a labour epidural. No national standardised
2013, the Intensive Care National Audit & Research Centre
information card for informed consent is available, although
(ICNARC) produced a second report that analysed critical care
the OAA does publish a epidural information card1 with
admissions of women who were pregnant or recently pregnant
specific risks and incidence rates. At our hospital, the
in 2009-2012 inclusive.1 A comparison was made between the
documentation is made on part of the epidural chart as an
hospital ICNARC data and the national ICNARC data.
open entry. Our study looked to ascertain whether appropriate
Methods: Data were collected from the hospitals ICNARC
details of the epidural and informed consent were made. This
database over a four year period from 2009 to 2012. The data
was with a view to find whether a total redesign of the epidural
was analysed from the categories in the table below.
chart (at a level of standard suggested by the OAA website2)
Results: Data from 388 patients were evaluated.
was needed to improve our practice.
  Hospital ICNARC
Methods : We evaluated a total of 100 completed epidural
Total no. of patients admitted, female 16-50 years 388 55,791
charts over a 4-month period in mid-2012 at our obstetric unit.
Currently pregnant 3.6% 2.1%
The epidural notes were retrospectively analysed on our
Recently pregnant 9.3% 10.0%
scanned patient electronic notes. Documentation was
Obstetric reason for admission - currently pregnant 0% 8.7%
analysed for: details of the patient, anaesthetist and patient
Non-obstetric reason for admission - currently
100% 91.3% assessment, explanation of the risks and incidence given,
pregnant
details of the epidural technique and post epidural
Obstetric reason for admission - recently pregnant 50% 69.7%
management. Our main focus was on standards of consent.
Non-obstetric reason for admission - recently
50% 30.3% Results:
pregnant
%of patients Rate of risk
Discussion: The proportions of patients admitted to the Range of risk discussed
Risk discussed informed documented (no.
critical care area were comparable with the ICNARC report. (no. in total)
(n=100) in total)
The leading indication for admission in the currently pregnant
1in100:13,1in200:8
group was for sepsis. This corresponds with the ICNARC Headache 69 25
<1%:3,1in500:1
report and most recent CMACE report in which sepsis was the
Hypotension 45
leading direct cause of maternal death.2
Failure 59 4 1in8:2, 1in4000:2
The leading obstetric cause for currently pregnant admissions
Nerve 1in13k:21,1in10k:8
nationally, was for pre-eclampsia. However, there were no 65 31
damage 1in15k:1, 1 in19k:1
admissions in this category at the hospital. This is most likely
Itching 14    
because pre-eclampsia is diagnosed and treated effectively on
Infection 37  
the labour ward and rarely needs input from critical care.
Motor block 28    
In the recently pregnant group, there were equal proportions
Urinary
of patients admitted for obstetric and non-obstetric reasons, 28    
retention
this is quite different from the ICNARC report. The leading
indication for admission of recently pregnant patients in the The other areas of documentation studied showed an
ICNARC report was for post partum haemorrhage, by a long acceptable standard.
way. When looking at the hospital database, it showed that in Discussion : Several studies have looked at standards of
the period 2010-12, only 3 of 42 patients with a significant post informed consent in UK practice3and which risks and
partum haemorrhage of 2.5 litres or more were admitted to incidences were discussed and the range of risk quoted. Our
critical care. Therefore the question needs to be asked as to study showed rates generally to be slightly lower than that
whether these patients should have been admitted to the quoted in these studies. This is likely due to limited space and
critical care area? The hospital does not have an obstetric open entry nature of our current chart. The OAA has set
HDU, but in hospitals that do have an obstetric HDU facility, guidelines and advice for both epidural charts2 and risks and
these patients would certainly have been admitted there, had incidence1. Following this evaluation, a full redesign of our
closer monitoring and possibly goal directed therapy. All of epidural charts with prompts and guidance of risks and
these patients survived, but could admission to critical care incidence is warranted. In addition, the OAA had
have improved patient outcomes or reduced hospital stay? overwhelming support for a national standardised information
References card that could be implemented3.
1. Female admissions to adult, general critical care units in England,
Wales and Northern Ireland reported as 'currently pregnant'
References
or 'recently pregnant'. http://www.icnarc.org/documents/Obstetric%
20admissions%20to%20critical%20care%202009-2012.pdf 1. OAA epidural information card : http://www.oaa-
anaes.ac.uk/content.asp?ContentID=185
2. The eighth report on confidential enquiries into maternal deaths in
the United Kingdom. BJOG 2011, 118(Suppl 2):1-203 2. OAA epidural charts : http://www.oaa-anaes.ac.uk/content.asp?
ContentID=522
3. Informed consent for epidural analgesia in labour: A survey of UK
practice: Anaesthesia 2009, 64 p161-164
Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin) P9
P117 An unusual cause of post-partum sepsis P118 Anaesthetic management of a parturient with severe
F A Corcoran,  C Brennan,  A J Downs   systemic scleroderma
Anaesthetics, Dudley Group NHS Foundation Trust, Dudley, P Thomas,  A Varvinskiy,  M Human  
UK Anaesthetics, South Devon Healthcare NHS Foundation
Introduction: Leiomyomas are common in women of Trust, Torquay, UK
reproductive age and have been linked to spontaneous Introduction: Scleroderma is a chronic systemic autoimmune
abortion, retention of the placenta and post-partum disease. Successful pregnancy in patients with severe
haemorrhage.1 It is however rare for them to be the primary systemic scleroderma is very rare. We report the anaesthetic
cause of post-partum sepsis. We describe the case of a post management of such a case in a patient with a difficult airway,
partum patient presenting with painful fibroids and sepsis. severe pulmonary dysfunction and oesophageal dysmotility.
Case report: A 37 year old woman (P1), 5 days post partum Case report: A 29 year old woman (G1P0) with severe
presented with a history of fever, abdominal pain and systemic scleroderma presented to the hospital at 36 weeks
distention. She had a past medical history of fibroids but there gestation with dyspnoea and tachypnoea. Prior to pregnancy
had been no problems during pregnancy. She had an her exercise tolerance was poor, managing just 400 metres in a
uneventful labour with a normal vaginal delivery. On initial six minute walk test with resultant oxygen saturations of 72%.
assessment she was apyrexial with normal observations. She Her Forced Expiratory Volume (FEV1), Forced Vital Capacity
had mild tenderness on palpation of her abdomen. She was on (FVC) and Diffusing Capacity for Carbon Dioxide (DLCO) had
regular analgesics and had been commenced on oral each worsened steadily by five percent year on year over the
antibiotics by her GP. An ultrasound scan (USS) was booked last decade. The most recently measured values from 2007
to investigate the abdominal pain. Within 4 hours she had were FEV1 30%, FVC 28% and DLCO 24% of predicted values
deteriorated and developed a pyrexia, tachycardia, tachypnoea although the patient reported that her pulmonary function had
and decreased oxygen saturations. Initial impression was deteriorated significantly during pregnancy. On admission the
sepsis secondary to retained products so blood cultures and patient was breathless at rest with a p02 of 7.63 on room air
swabs were taken and intravenous antibiotics, oxygen and and it was felt that natural labour would not be possible due to
fluid resuscitation commenced. She was transferred to the poor physiological reserve. Severe reflux secondary to
Maternity High Dependency Unit. CRP was elevated but oesophageal dysmotility rendered her unable to recline more
lactate was normal. She improved over 6 hours but than 45 degrees and she could therefore not lie flat for awake
deteriorated again. Antibiotic coverage was amended caesarean section. Airway assessment revealed microstomia of
following microbiology advice but she continued to have a less than one centimetre, mallampati four, bucked teeth, sub
swinging pyrexia. USS detailed a bulky uterus with a large mental skin scleroderma and a narrow hooked nose with small
fibroid at the fundus and no retained products. 36 hours after nostrils. Oral intubation was therefore ruled out. Awake Fibre
admission she developed peritonitis and a CT abdomen which Optic Intubation (AFOI) appeared technically challenging due
suggested findings of a pedunculated fibroid measuring to nasal anatomy. Preoperative, bedside nasendoscopy
17.5cm that might have twisted on its pedicle. She had an revealed that AFOI would be possible should the need to
emergency laparotomy which revealed a degenerative, secure the airway arise mid operation. This avoided the need
necrotic, infected fibroid. She required ionotropic support and to perform an AFOI or awake tracheostomy pre-operatively.
was difficult to ventilate intra-operatively. Post-operatively The patient was positioned at 45 degrees on the operating
she was transferred to intensive care where she was sedated table. Surgeons confirmed that they could operate in this
and ventilated overnight. She was successfully extubated the position. A low dose spinal followed by an epidural which was
following morning and continued with intravenous antibiotics topped up gradually over 30 minutes using small incremental
and analgesia. She made a full recovery. Histology confirmed boluses achieved adequate block without compromising
the fibroid had extensive areas of coagulative necrosis, respiratory function. Surgery was completed without issue and
hyalinisation and inflammation. All microbiological both mother and baby did well post-operatively.
investigations were negative. Discussion: There are only three reports in the literature
Discussion: Sepsis in pregnant and post-partum women describing general anaesthesia for caesarean section in
remains a significant cause of maternal morbidity and patients with scleroderma and two using neuraxial blockade.1-5
mortality.2Sepsis is a clinical diagnosis and microbiological Of those who were intubated, one died and another required
investigations may be negative. Early recognition, timely three months ventilation. We demostrated how careful bedside
diagnosis and active treatment assists an optimum outcome. airway assessment and the use of a slow top up epidural were
Fibroids are common in pregnancy but sepsis secondary to successfully used to manage this challenging case.
infected, necrotic fibroid tissue post-partum is very rare. To References
our knowledge there have been no reported cases of this. It is
1. D'Angelo R, Miller R. Pregnancy complicated by severe
therefore essential to consider this in the differential causes of preeclampsia and thrombocytopenia in a patient with scleroderma.
obstetric sepsis when reviewing pregnant women with a Anesth Analg 1997; 85: 839-41
history of fibroids. 2. Hseu SS, Sung CS, Mao CC, Tsai SK, Lee TK. Anesthetic
management in a parturient with progressive systemic sclerosis
References during cesarean section. Acta Anaesthesiol Sing 1997; 35: 161-7
1. Mason T. Red Degeneration of a leiomyoma masquerading as 3. Younker D, Harrison B. Scleroderma and pregnancy. Br J Anaeth
retained products of conception. Journal of the National Medical 1985; 57: 1136-9
Association. 2002; 94: 124-6 4. Thompson J, Conklin KA. Anesthetic management of a pregnant
2. Lucas DN, Robinson PN, Nel MR. Sepsis in obstetrics and the role patient with scleroderma. Anaesthesiology 1983; 59: 69-71
of the anaesthetist. International Journal of Obstetric Anaesthesia. 5. Bailey AR, Wolmarans M, Rhodes S. Spinal anaesthesia for
2012; 21: 56-67 caesarean section in a patient with systemic sclerosis. Anaesth
1999; 54(4): 355-8
P10 Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin)
P119 Anaesthetic management of arrhythmogenic right P120 Anaesthetic management of obese parturients at a
ventricular cardiomyopathy during labour and tertiary centre - meeting the standard?
caesarean section: a case series L Kelliher,  J Teare,  E Evans  
J Eccles,  A Jain,  K Bhatia   Anaesthesia, St George's Healthcare NHS Trust, London, UK
Department of Anaesthesia, St Mary's Hospital, Manchester, Introduction: Obese women are at increased risk of perinatal
UK morbidity and mortality. In 2010 CMACE and RCOG published
Introduction: Arrhythmogenic right ventricular joint guidelines for the management of the obese parturient
cardiomyopathy (ARVC) is mainly a genetically determined including recommendations that patients with a booking BMI
autosomal dominant disease characterised by cardiomyocytes ≥40 should attend an antenatal anaesthetic clinic (AAC) and a
being replaced by fibrofatty tissue in the right ventricle.1 Specialist Trainee year 6 anaesthetist (ST6) or above should
ARVC has an incidence of 1:5000 and may account for as be informed and available to attend labour and operative
many as 5% of unexpected sudden deaths. The Eighth Report delivery1. Our unit is a tertiary centre with over 5,000
of the Confidential Enquiries into Maternal Deaths in the deliveries/year. A previous audit over 2 years showed that of
United Kingdom (2006-2008) highlighted that ARVC was the 120 women with BMI ≥40 attending our AAC, 76% required a
underlying cause in two of the 53 reported cardiac deaths. We peripartum anaesthetic intervention, with only 34% of these
describe the anaesthetic management of two parturients with performed by an anaesthetist ≥ST62. Awareness of the
ARVC who presented at our tertiary centre. guidelines was raised and anaesthetic plans for these women
Case reports: The maternal demographics, the cardiac signs, now state care should be managed by a senior anaesthetist.
symptoms and interventions along with the anaesthetic We examined our obese population following these changes.
management in the peri-partum period are briefly summarised Methods: A retrospective analysis over 1 year (2011-12) of
in the table below. hospital records for patients with a booking BMI ≥ 40. Records
were examined for referral and attendance at AAC, anaesthetic
Category Case 1 Case 2
intervention (regional/GA), grade of anaesthetist and
Age 27 23
anaesthetic complication (difficult/impossible regional, dural
BMI 25.8 27.2
tap, other).
Parity 0 0
Family history None Sudden death Results: In total there were 74 women with a booking BMI
Cardiac signs and Palpitations with spurts of Paroxysmal VT ≥40. 73% were referred to AAC, only 58% attended. Out of all
symptoms ventricular tachycardia (VT) patients, 69% had a peripartum anaesthetic intervention, 43%
Cardiac Cardiac ablation therapy and ICD insertion of which were performed by an anaesthetist ≥ST6 with a
intervention prior implantable cardioverter complication rate of 16%. Of those attending AAC, 67% had
to pregnancy defibrillator (ICD) insertion an anaesthetic intervention, 41% of which were performed by a
Mode of delivery Elective caesarean section Urgent LSCS for ≥ST6 with a complication rate of 17%. Of those patients not
(LSCS) for breech foetal distress attending AAC, 71% had an anaesthetic intervention and 36%
Anaesthesia and General anaesthesia, with Labour epidural of these were performed by ≥ST6 with a complication rate of
analgesia bilateral transversus analgesia, followed by 14%.
abdominal plane blocks top up for LSCS
Table 1. Incidence of complications by grade of anaesthetist
Maternal length of Three days Four days
stay Group ≥ST6 <ST6 p value (Fisher's Exact)
Neonatal APGAR 8 and 10 9 and 10 All 9.1% 20.7% 0.440
scores AAC 16.7% 17.6% 0.945
Discussion: The main implications of ARVC in parturients No AAC 0% 21.4% 0.273
include fatal arrhythmias, heart failure worsened by Discussion: This audit shows a significant number of obese
physiological changes of pregnancy and sudden adult death parturients were not seen in our AAC. A proportion of these
syndrome.1 Both our patients had VT diagnosed after 24 hour were referred, but did not attend however 27% were not
Holter monitoring, and an ICD was implanted in addition to referred. Despite this, there was no significant difference in the
beta blocker medical therapy to control the symptoms of VT as requirement for anaesthetic intervention or the incidence of
well as to prevent sudden death. The patients were seen in the anaesthesia-related complications between attenders and non-
joint cardiac, obstetric and anaesthesia antenatal clinic and a attenders. The incidence of senior anaesthetic involvement in
peri-partum plan formulated to facilitate safe delivery. Both care has risen from 34% to 41% but there is still room for
had serial echocardiograms, serum electrolytes monitored, improvement. This highlights the resource difficulties faced in
invasive blood pressure monitoring and ICD deactivated providing 24 hour senior anaesthetic cover. The on-call rota at
during their LSCS. Our case series highlights that both general our unit is staffed by junior and senior anaesthetists. The
and regional anaesthesia can be safely provided and we absence of a senior anaesthetist did not lead to a significant
recommend a multidisciplinary approach with close co- rise in anaesthesia-related complications, although there was a
operation between anaesthetists, cardiologists and t rend toward this (Table 1).
obstetricians to provide optimum care of these patients. References
Reference 1. Centre for Maternal and Child Enquiries & Royal College of
Obstetricians and Gynaecologists Joint Guideline. Management of
1. Alexoudis AK, Spyridonidou AG, Vogiatzaki TD, Iatrou CA.
Anaesthetic implications of arrhythmogenic right ventricular women with obesity in pregnancy. London: CMACE & RCOG; 2010
dysplasia/cardiomyopathy. Anaesthesia 2009; 64: 73-8. 2. Fulton L, Evans E, Schroeder F, Wendler R. Antenatal anaesthetic
assessment of morbidly obese women - a useful resource? 2013,
http://epostersonline.s3.amazonaws.com/oaa2013/oaa2013.0690195
.NORMAL.pdf
Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin) P11
P121 Anaesthetic management of the labouring patient with P122 Anesthetic implications  of heart disease in pregnancy
multiple sclerosis S Francés,  S Manrique,  M Goya,  M García,  R Perera,  N
J Li Wan Po,  K Maclennan   Montferrer  
Anaesthesia, St Mary's Hospital, Manchester, UK Anaesthetics, Vall d'Hebron University Hospital, Barcelona,
Introduction: Multiple Sclerosis (MS), an autoimmune Spain
inflammatory disease affecting the central nervous system, is Introduction: Despite advances in its diagnosis and treatment,
estimated to affect 20,000 or more UK women of childbearing heart disease (HD) in pregnancy remains a major cause of non-
age1. Controversy exists regarding the management of obstetric maternal and neonatal mortality and morbidity (it
anaesthesia and analgesia in labouring parturients with MS. complicates around 1-3% of pregnancies in developed
Following analysis of our practice at St Mary's Hospital, a countries). Accurate multidisciplinary assessment and
tertiary referral obstetric unit with over 8500 deliveries per management of individual maternal and fetal risks in pregnant
annum, and recent evidence in the literature; our women with HD provides the best opportunity to substantially
recommendations for the peri-partum management of improve outcomes for mother and baby. (1).
parturients with MS are presented. Methods: We present a prospective cohort study that
Methods: Interrogation of the St Mary's Hospital antenatal analyzed outcomes in women with HD, the majority of whom
clinic database, from 1999 to 2012, identified 21 pregnant had had corrective surgery and delivery between 2007 and
women diagnosed with MS. We reviewed antenatal advice, 2013. Baseline characteristics and adverse events during
intrapartum management and postpartum complications. delivery and postpartum were assessed. Intensive monitoring
Results: Over 50% of patients were nulliparous. The majority of the delivery and postpartum were planned beforehand in all
had mild sensory or motor deficit. Three relapsed during cases.
pregnancy, one improved in symptoms and one relapsed Results: One hundred and seventy-four patients with 179
postpartum. There were twelve normal vaginal deliveries, two pregnancies were included in the study. 127 women (72,98%)
instrumental deliveries, six Caesarean sections and one presented congenital heart disease (CHD), 47 acquired heart
unspecified delivered at another hospital. Five women opted disease (27,02%): 27 acquired rheumatic valve disease
for epidural analgesia, two were topped up for operative (19,98%), one Marfan syndrome (0,54%), 3 coronary heart
delivery. Five had spinal anaesthesia with 0.5% heavy disease (1,6%) and 9 primary myocardial disease (4,9%).
bupivacaine and one had a general anaesthetic. There were no
Pregnancy complications were presented in 21, 2% of CHD,
complications following regional technique.
14,8% of acquired rheumatic valve disease and 100% of
Discussion: A recent national survey reported that within a 10 women with arrhythmias.
year period, 91% of anaesthetists have encountered <ten
The type of delivery was vaginal in 124 women ( 72,1%) and
cases of MS2 and have little experience in their management
cesarean section in 50 women (27,9%).
during pregnancy. Recent evidence available supports our
168 women had analgesia during delivery (93,8%); 5 women,
current management of MS patients undergoing labour. The
general anesthesia (2,79%), 6 women, local anesthesia (3,35%)
low incidence of the disease makes it difficult to attain
and 87,5% of women had regional analgesia.
significant figures to determine the optimal management plan.
To standardize care, we made the following recommendations Delivery complications were 7% (uterine atony 2,7%, vaginal
based on the latest evidence and our own experience: hematoma 2,2%, chorioamnionitis 0,5%, cesarean hematoma
- Patients to be reviewed in an antenatal anaesthetic clinic. 0,5% and hemoperitoneum 0,5%). The only anesthesia
Document disease severity and discuss analgesia and complication was one dural puncture (0.5%). No maternal
anaesthetic options. death, one fetal death (0.5%) and one neonatal death (0.5%).
The maternal average hospital stay was 3 days.
- Use of 0.1% bupivacaine with 2mcg/ml fentanyl mixture for
epidural labour analgesia2 . For an operative intervention, top Discussion: Pregnancy and delivery are associated with
up with a higher concentration of local anaesthetic. substantial physiological changes, which require the
adaptation of the cardiovascular system and can expose
- Regional rather than general anaesthetic for caesarean
women with HD to significant risks. If regional anesthesia is
sections. Spinal anaesthesia is the most simple and reliable
selected, the addition of an opioid, when dosing any neuraxial
technique although consider combined spinal-epidural on an
anesthetic, will reduce the amount of local anesthetic required
individual basis.
and subsequent hemodynamic effects, while improve
- If a general anaesthetic is necessary, avoid suxamethonium
intraoperative and postoperative analgesia. The avoidance of
and monitor neuromuscular block to titrate dose of non-
epinephrine from the epidural dose will eliminate the possible
depolarizing muscle relaxant3.
deleterious effects of systemic epinephrine. Maintaining
These recommendations will be available for clinicians on the uterine blood flow is important for fetal well-being.
trust intranet and a patient information leaflet on the effects of Maintaining systemic vascular resistance in patients with
pregnancy and anaesthesia on MS has been produced. intravascular shunting, is important to avoid inducing or
exacerbating pre-existing cyanosis due to increased right- to –
References
left shunting. Cautious intravenous hydration and gentle
1. Brookings W, Lee M. Management of multiple sclerosis during
titration of phenylephrine or ephedrine are options to
pregnancy. Prog Neurol Psychiatry. 2009; 3(6): 9-11
counteract the hemodynamic effects of surgical neuraxial block
2. Drake E, Drake M, Bird J, Russell R. Obstetric regional blocks for
women with multiple sclerosis: a survey of UK experience. Int J (1,2). We observed a predominance of neuraxial anaesthetic
Obstet Anaesth. 2006; 15(2): 115-23 techniques, increased caesarean and operative delivery rates,
3. Griffiths S, Durbridge JA. Anaesthetic implications of neurological and favourable maternal and neonatal outcomes.
disease in pregnancy. Contin Educ Anaesth Crit Care Pain. 2011; 11
(5): 157-61 References
P12 Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin)
P123 Angle of tilt achieved with automated operating table P124 Antenatal anaesthetic information given to women
in elective caesarean sections: a comparison with tilt with obesity
achieved with an inflatable balloon wedge  C R Thomas,  C Busby  
PN Nair,  L Dyal,  B Grewal,  I Suri   Anaesthetics, Airedale General Hospital, Keighley, UK
Department of Anaesthesia, Warwick Hospital, Warwick, UK Introduction:Antenatal obesity is defined as a BMI of ≥30at
Introduction: A previous study1 done on patients undergoing booking. Its prevalence in England increased from 7% in 1990
elective caesarean sections looked into measuring the angle of to 16% in 2007.1Women with a BMI ≥40 are often provided
tilt of the operating table with an inflatable balloon wedge. with anaesthetic information antenatally. Those with lower
This showed that the visual estimation of angle proved levels of obesity also have an increased anaesthetic risk but
accurate in the achievement of near 150 tilt. Here we present these women may receive little or no information about this
the results of a similar study using a different technique of during pregnancy. 2The RCoA have produced standards
automated table tilt instead of the inflatable balloon wedge regarding care for these women: 90% of patients with a
device. The premise being is our visual actuation of tilt angle booking BMI ≥ 30 should receive a leaflet containing
accurate. information about anaesthesia and analgesia. 90% of patients
Methods: The study was similar to the previous one. We with a booking BMI ≥40 should have an anaesthetic consult.
prospectively selected 26 patients at random who were Booking BMI should be documented in 100% of maternity
undergoing elective lower segment caesarean section under hand-held notes. An audit of the above standards was carried
spinal anaesthesia over a six week period. Ethical committee out as summarised below.
approval was obtained. Verbal consent was obtained from all Methods:A list of all deliveries in January 2013 was generated.
participants and the booking Body Mass Index (BMI) was Notes were reviewed for adherance to the above three
noted. We used the same protractor device for measuring the standards. Change to practice was recommended based on
angle of tilt. This is similar to the one used by Kinsella et al2. audit findings. Following the implementation of change, the
Results: The measured angles ranged from 10 to 18 degrees, a audit cycle was completed by auditing notes of all deliveries in
mean angle of 13.70 with a mean difference of -1.3 and standard November 2013.
deviation of 2.32. This compared very closely to the angles Results:
between 10 to 17.5 degrees, mean angle of 13.650, mean Table: Recording of booking BMI, patient count by raised
difference of -1.35 and a standard deviation of 2.06 in the BMI category and number given anaesthetic information.
previous study. BMIs ranged from 19 to 37 with a mean of 24.
Discussion: The visual estimation of angle using the
BMI 30 - BMI 35 - BMI
automated table tilt proved accurate in achieving the near 150 No
Number of Unavailable 34.9; 39.9; ≥40; 
tilt and is comparable with that obtained with the inflatable   booking
deliveries casenotes info info info
balloon wedge device in the previous study. The standard BMI
given given given
deviation of 2.32 indicates that 95.4% of cases could achieve
Jan 195 6 2 20; 0 7; 1 7; 7
within 4.60 of the required 150 tilt i.e. 10.4 to 19.6 degrees tilt.
Nov 173 3 2 17; 2 7; 7 3; 3
The automated table tilt provides an easy and accurate means
of providing left lateral tilt in pregnant patients. Discussion: Booking BMI was recorded in 99% of the notes in
both audit cycles. In 100% of cases where BMI was ≥40, a
consultant anaesthetist discussed risk and made a plan with
References
the patient. However, the audit of January deliveries indicates
1. Grewal B, Suri I. Is visual actuation a valid predictor of angle of tilt?
that few women who have a BMI 30-39.9 receive anaesthetic
Int J Obstet Anaesth Vol 18 2009; pS1-64- supplement
information.; this occurred in only one case. Reaching this
2. Kinsella SM. A device for measuring the degree of lateral pelvic tilt
during supine recumbency. Anesth Analg 1995; 80: 204-5 population to provide information is difficult especially where
BMI is 30-34.9 as all antenatal care for this group may be
provided by community midwives. In collaboration with
Obstetrics, a patient information leaflet was written which
included both obstetric and anaesthetic information. The
leaflet was approved by the Women's Integrated Governance
group and has been in use since October 2013. It is available
on the Trust intranet which is accessible by some community
midwives. The leaflet is given to all those with a BMI ≥ 35
when they attend obstetric high risk clinic. The results of the
November audit indicate improvement has been made; 44.4%
of those with obesity now receive anaesthetic information.
Greater access to the leaflet is needed however.
References
1. Royal College of Anaesthetists 2012,
http://www.rcoa.ac.uk/document-store/audit-recipe-book-3rd-edition-
2012
2. Centre for Maternal and Child Enquiries 2010, http://www.oaa-
anaes.ac.uk/assets/_managed/editor/
File/CMACE/CMACE_Obesity_Report_2010_Final%20for%
20printing.pdf
Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin) P13
P125 Antenatal management of morbidly obese parturients: P126 Audit of temperature for patients undergoing elective
A multicentre evaluation. caesarean section
H Aladin,  A Khandhia,  K Pottinger   N J Truman,  I Clegg,  K Maclennan  
Anaesthetics, Good Hope Hospital, Birmingham, UK anaethetics, St Mary's Womens Hospital, Manchester, UK
Introduction: Women with a body mass index (BMI) of ≥30 Introduction: Perioperative Hypothermia is associated with
kg/m2 at the time of antenatal booking are classed as being poor outcomes and adverse events for patients; including
obese in pregnancy, accounting for around 39,000 maternities surgical site infection increased length of stay, blood loss,
per year1. Obesity is associated with increased risk of shivering, increased anaesthetic recovery time and cardiac
anaesthetic morbidity and mortality. National guidance have events. Risk factors for the occurrence of hypothermia include
been developed following the Confidential Enquiry into regional anaesthesia, fluid deprivation, blood loss, and cold
Maternal and Child Health report concerning obesity in fluid administration, all of which are common to obstetric
pregnancy. At two different hospitals, five indicators of best patients. 2008 Nice guidelines CG651 on perioperative
practice2 were analysed: (1) Recording of maternal BMI. (2) hypothermia do not include parturients, despite being an at
BMI ≥ 30 women receive information about risk group. An audit performed in 2011 at St Mary's Hospital
anaesthesia/analgesia. (3) Women with a BMI ≥ 40 have demonstrated that 92.5% of elective section patients were not
antenatal anaesthetic review. (4) Duty anaesthetist should be 'comfortably warm' on arrival in recovery, with 65% defined as
informed when women with a BMI ≥ 40 are admitted. (5) hypothermic. A repeat audit was performed following
Anaesthesia for women with a BMI ≥ 40 should be provided commencement of a trial of an air free conductive fabric patient
by a senior anaesthetist. warming system (Hot Dog®).

Methods: Women who had undergone a lower segment Method: A prospective audit of elective caesarean section
caesarean section (LSCS) during a 6 month period (Jan 2013- patients was conducted from April-June 2013 at St Mary's
Jun 2013) at a District General Hospital (DGH) and a Hospital. Theatre staff completed the audit proforma. Data
Foundation Hospital (FH) were evaluated. Data was collected collected included; ambient theatre temperature (ideal target
retrospectively from an electronic data archive and anaesthetic 21ºC), anaesthetic type, estimated blood loss (EBL),
charts. Evidence of BMI calculations, provision of temperature pre, intra, post operative and prior to discharge
anaesthesia/analgesia information, ante-natal anaesthetic from recovery (measured using a tympanic membrane
appointments, and anaesthetic care in the labour ward and thermometer) and details of which Hot Dog® warming
theatre were identified. products were used. Hypothermia was defined as a core
Results: 309 women who underwent a LSCS were identified temperature <36ºC with desirable temperature being defined as
with a having a BMI 30 (median 34, range 30-59). 51% of 36.5-37.5ºC. Comparison of the results from the 2011 audit
these were elective cases. 56% of women with a BMI ≥30 enabled conclusions to be drawn regarding the effectiveness
received anaesthesia/analgesia information, of which 2 were of the warming product.

given literature on anaesthesia in obesity. 32% of women with
Results: A total of 33 patients were audited who underwent
a BMI 40 underwent an antenatal anaesthetic review, with an
elective caesarean section, [n=79, 2011audit], 94% had spinal
additional 4 women failing to attend their appointments. In
anaesthetic (87%, 2011 audit). Mean (S.D) theatre temp was
those women with a BMI ≥40, the duty anaesthetist was
22.8 (± 0.6) [22.3 (± 0.6), 2011 audit], mean duration of
informed of admission in 19% of cases and in 56% of LSCS,
procedure was 51 minutes. 94% of patients had an additional
the anaesthetic care was provided by an appropriately graded
fluid warmer intra-op (72%, 2011 audit). The mean EBL was 574
anaesthetist .
ml (± 213) [653 (± 431), 2011 audit] and only 6% of patients had
Table: Women with BMI 30 having anaesthetic care at a DGH an EBL over 1L (20% 2011 audit). Only 12% (n=4 of 33) of
and FH. patients warmed with the HotDog® were hypothermic on
arrival to recovery (compared to 65% (n=51 of 79), 2011 audit)
  DGH FH
figure 1.
Total LSCS 32% (99/309) 68% (210/309)
Discussion: efforts have been to reduce perioperative
BMI Median (range) 33 (30-59) 34 (30-52)
hypothermia in elective caesarean sections. Almost all patients
Maternal height, weight + BMI recorded 100% 100%
received warmed fluids via a 3M™ Ranger™ fluid warming
Conclusion: This audit has identified that more than half the
system. Forced air warming devices applied to the upper body
women with a BMI ≥30 received analgesia/anaesthesia
are not well tolerated by our awake patient population and
information and more than half were anaesthetised by a senior
allow only a limited area to be heated. introduction of
anaesthetist. However, in all the areas of practice, the target
HotDog® with an under patient warming mattress and
percentage of women meeting the identified standards were
separate over patient warming blanket (for upper and lower
not achieved. Recommendations included revision of the
limb) proved to be of benefit in perioperative maintenance
referral guidelines for antenatal anaesthetic assessment,
when compared to our standard warming measures. A
improved communication within the multidisciplinary team
HotDog® warming mattress placed on the patient chair in the
during admissions and increased presence of senior
pre theatre waiting area helped prevent hypothermia pre arrival
anaesthetists on delivery suite.
in theatre.
References
Reference
1. Centre for Maternal and Child Enquiries (CMACE). Maternal
1. CG 65 Management of inadvertent perioperative hypothermia in
obesity in the UK: Findings from a national project. London:
adults. NICE April 2008.
CMACE, 2010
2. The Royal College of Anaesthetists. Raising the Standard. A
compendium of audit recipes for continuous quality improvement in
anaesthesia. 3rd Edition 2012
P14 Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin)
P127 Availability of chlorhexidine handwash for regional P128 Caesarean section in a rhesus null parturient with a
analgesia on the labour ward uterine fibroid
K Chima,  T Strickland,  F Plaat   P J Stewart,  R Laird,  J Cartmill  
Anaesthetics , Queen Charlotte's and Chelsea Hospital, Anaesthetics, Altnagelvin Area Hospital, Londonderry, UK
London, UK Introduction: The anaesthetic management of a Caesarean
Introduction: Many patients request regional analgesia during section is made more challenging by the combination of pre-
labour and therefore central neuraxial blocks are performed in operative anaemia, a large uterine fibroid and the presence of a
the delivery room. For central neuraxial blocks an aseptic very rare blood group Rhesus null.
technique should be standard. In the Third National Audit Case report: A forty-year lady with a past medical history of
Project of the Royal College of Anaesthetists the incidence of psoriatic arthritis presented to antenatal booking at 10 weeks
iatrogenic infection was reported as being 8/707 000 gestation. Booking investigations revealed a haemoglobin of
procedures1. However the consequence of any infection is 10.3g/dL, and a blood group O Rhesus null. Her 20-week
potentially devastating, and a 'scrupulous' aseptic technique ultrasound scan revealed no foetal anomalies but did
was therefore stated to be mandatory in the report1. demonstrate an anterior uterine fibroid. This was confirmed
Chlorhexidene gluconate 4% is used for hand decontamination with magnetic resonance imaging which showed a
in our department. It was noticed that not all delivery rooms heterogeneous mass measuring 188x139x159mm, in keeping
were equipped with both chlorhexidene and a hands free with a degenerating fibroid. At 21+3 days she presented with
method for application. dizziness and right upper quadrant pain. Her haemoglobin
Methods: All delivery rooms on labour ward were inspected to level was 7.6g/dL and she was treated for iron deficiency
ascertain the presence of chlorhexidene and a hands free anaemia. Due to a transverse lie and the large fibroid an
dispenser. elective Caesarean section at 38 weeks was planned. As a team
we anticipated a difficult Caesarean delivery with greater blood
The audit was repeated after one and twelve months to assess
loss in a patient with anaemia and a very rare blood group.
if there had been any improvement in the service.
Antenatal management focused on maximising the patient's
Results: Originally, 12 of the 16 delivery rooms had
haemoglobin levels and sourcing compatible blood. The
chlorhexidene available (75%). Of the 12 rooms with
Northern Ireland blood transfusion service and National frozen
chlorhexidene only three were equipped with a hands free
red cell bank in Liverpool secured two units of packed red cells
dispenser (25%), and five containers were uncovered (42%).
in England. Unfortunately, one week prior to the section this
After one month all 16 rooms were equipped with wall blood was issued in an emergency, making it unavailable to us.
mounted chlorhexidene with a hands free dispenser (100%). A new donor was found in South Africa and a further unit was
After a further 12 months it was found that 12 of the 14 secured in Brazil. Both units were couriered to our hospital
delivery rooms had chlorhexidene available (86%). (Two of the prior to the Caesarean delivery which was performed at 38+6
rooms had been converted to a post delivery high dependency days under spinal anaesthesia. Pre-operative haemoglobin was
unit). Eleven of the 12 containers were equipped with a hands 9.1g/dL. The patient was discharged home on day three post-
free dispenser (92%). operatively and her haemoglobin was 7.2g/dl on discharge. No
Discussion: The results of the initial data collected, as well as blood transfusion was required.
anaesthetists' concerns regarding the unavailability of Discussion: Red blood cells from people who have the Rhesus
chlorhexidine and dispensers in each room, was reported to null phenotype lack Rhesus proteins, and thus, Rhesus
managerial staff, who ensured all rooms were adequately antigens. This phenotype occurs in approximately 1 in 6x106
stocked. Results were therefore better when re-auditing was individuals1. When these patients are transfused they may
performed at one month. However, after 12 months standards form antibodies to high frequency rhesus antigens, which can
had declined, although they were still improved from the make it extremely difficult to process compatible blood. Rhesus
initital audit. This decline could be attributed to the fact that null blood is available from the National frozen cell bank,
neither a team nor a named individual was made responsible however it may not be available when required due to limited
for sustaining the initial improvement, which if introduced, we supplies, as in our case. There is very limited literature
feel would encourage a sense of ownership and enable the regarding the management of the rhesus null parturient and
improvement in this area of patient safety to be sustained. our management was guided by our regional Haematology
Reference unit. This case demonstrates the importance of good
communication with all members of the multi-disciplinary team
1. National Audit of Major Complications of Central Neuraxial Block
in the United Kingdom 2009, http://rcoa.ac.uk/system/files/CSQ- and the detailed preparations required in a complex case.
NAP3-Full_1.pdf
Reference
1. Avent ND, Reid, ME. The Rh blood system: a review. Blood 2000
95: 375-387.
Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin) P15
P129 Category one caesarean sections in a district general P130 Comparison of two non-invasive cardiac output
hospital:  Improving the decision to delivery time monitoring devices in a parturient with complex
VK Wroe,  AM Troy   cardiac disease.
Department of Anaesthesia, Countess of Chester Hospital, PJ Rose,  V Misra,  S Quasim  
Chester, UK Anaesthesia, UHCW, Coventry, UK
Introduction: National Guidelines state that the interval from Introduction: The management of valvular lesions during
decision to delivery (DDI) in a category one caesarean section pregnancy and labour can present a clinical conundrum. We
should be less than 30 minutes1, and that a duty anaesthetist present the use of two cardiac output (CO) monitoring devices
should be immediately available for emergency work on the in a parturient with complex valvular heart disease undergoing
delivery suite 24 hours a day2. a caesarean section under epidural anaesthesia.
A 2008 departmental audit found that 85% of category one Case Report: A 37 year old primiparous woman with history of
sections had a DDI of under 30 minutes, a figure marginally ASD repair aged 4, severe mitral regurgitation, severe tricuspid
under the audit standard of 90%. Anaesthetic service regurgitation, moderate aortic stenosis (AS) secondary to a
provision in our trust was expanded in July 2012, with the congenital bicuspid valve and moderate pulmonary
addition of a dedicated obstetric anaesthetist 24 hours a day. hypertension presented for elective caesarean section.
This re-audit aimed to assess the proportion of category one Echocardiography showed moderately dilated right ventricle
caesarean sections with a DDI <30 minutes and analyse the with good bi-ventricular systolic function, bi-atrial dilatation,
factors contributing to any delay. moderate to severe AS (mean gradient 34mmHg, peak gradient
Methods: After audit department approval, a retrospective 53mmHg, estimated valve area 0.74cm2). Pulmonary artery
analysis of category one caesarean sections between August pressures were estimated at 42-47mmHg. LiDCO rapid and
and December 2012 was performed. Data collected included Cheetah NICOM devices were used to monitor CO.
DDI and reason for delay, indication for section, type of Anaesthesia was established with 32mL 2% lignocaine and 100
anaesthesia and cord pHs. micrograms of epinephrine via epidural. Compound sodium
lactate was infused at 60mL/hr, and increased to 100mL/hr after
Results: 69 category one caesarean sections were analysed.
epidural anaesthesia. Fluid boluses of 200mL and 100mL were
The mean DDI was 23 minutes (range 3-120 minutes). 84% had
delivered via the pump at 13 and 28 minutes after delivery of a
a DDI of under 30 minutes, with a mean time from decision to
live infant. Metaraminol infusion was titrated to effect.
effective anaesthesia of 14.5 minutes. The indication for
Syntocinon infusion was started upon delivery (20 units in
caesarean section was abnormal CTG in 87% of cases (2008:
48mL 0.9% saline) at 15mL/hr and tapered post-operatively
77%). General anaesthesia was performed in 43% (2008: 85%),
over 4 hours. Mean arterial pressure was maintained at 91 to
spinal anaesthesia in 55% (2008: 15%) and extension of
97mmHg until delivery (78 minutes) and then decreased to
epidural blockade in 2%. In 11 cases, DDI was over 30
67mmHg at the end of surgery. Cardiac output was maintained
minutes; these cases were all performed under spinal
throughout surgery with an increase at the time of concurrent
anaesthesia. The following table shows the reasons identified
fall in MAP. Fluid challenge had negligible effect although
that contributed to delay:
there was a small reduction in heart rate (84 to 59bpm).

Arrival in
Discussion: NICE has advocated the use of cardiac output
theatre Incision to
Spinal monitoring in high risk non-obstetric surgery to improve
10 delivery Staff Theatre
  placement outcome.1 In this case we utilised both a non-calibrated pulse-
minutes time 10 unavailable unavailable
10 minutes contour waveform analysis and bioreactance system to
from minutes
compare both values measured and response to fluid
decision
challenge. Although the values produced were different, the
Number
trends were broadly similar. This, once again, highlights the
of 4 6 1 1 1
importance of analysing trends rather than absolute values to
patients
guide management. Interestingly, both devices demonstrated
Arterial cord blood analysis was carried out in 10/11 cases. pH
that a fall in MAP correlated with an increase in cardiac
was less than 7.2 in 30%, and base excess was less than -8 in
output, similar to previous investigators.3 Given that cardiac
20%.
disease is the leading cause of death in the most recent
Conclusion: The proportion of cases with a DDI of over 30 triennialreport2, monitoring cardiac output enables one to
minutes has remained constant at around 15%, despite an maintain physiological homeostasis, and ultimately aids
improvement in anaesthetic staffing. Our results suggest that clinical decision-making leading to good clinical outcome, as in
the causes for this delay are multifactorial, and the results are our case.
not benign- the delay in delivery led to a cord pH of <7.2 in
References
almost one third of cases. We intend to improve our practice
1. MTG3 CardioQ-ODM (oesophageal Doppler monitor): guidance
by regular practice drills, use of preprepared spinal packs to
2011, http://www.nice.org/nicemedia/live/13312/52624/52624.pdf
reduce spinal placement time, clear procedures to follow in the
2. Centre for Maternal and Child Enquires (CMACE). Saving Mothers'
case of staff or theatre unavailability and reaudit. Lives: Reviewing maternal deaths to make motherhood safer: 2006-
2008. The Eighth Report of the Confidential Enquires into
References
Maternal Deaths in the United Kingdom. BJOG 2011;118(Suppl
1. Caesarean section. NICE Clinical Guideline 132. NICE, London 1):1-203
2011. (http://publications.nice.org.uk/caesarean-section-cg-132).
3. Fanning NP, Sermer M, Colman J, Carvalho JC, Cordovani D. Non-
2. OAA/AAGBI guidelines for obstetric anaesthetic services- 3rd invasive Hemodynamic monitoring with bioreactance for cesarean
edition. AAGBI and OAA, London, 2012 delivery. A more relaxed look at tight aortic stenosis? Abstract
(http://www.aagbi.org/publication/publication-guidelines/M/R) SOAP 2011, http://www.soap.org/display_2011_abstract.php?id=58
P16 Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin)
P131 Comparsion of slow and rapid bolus of ephedrine in P132 Continuous spinal anaesthesia for a primigravida with
patients undergoing planned caesarean section under severe tricuspid regurgitation, Harrington rods and
spinal anaestheisa WITHDRAWN FROM  thrombocytopenia.
PRESENTATION AM Walton,  I Mettam  
PG Sekar,  LB Ellakumanan,  H Balachander,  MVS Obstetric Anaesthetic Department, University Hospital
Satyaprakash   Southampton, Southampton, UK
Anaesthesiology, JIPMER, Puducherry, India Introduction: We present the successful use of continuous
spinal anaesthesia (CSA) for caesarean delivery in a parturient
with severe tricuspid regurgitation and pregnancy-induced
thrombocytopenia in addition to Harrington rod placement for
scoliosis spinal surgery.
Case history: A 40 year old primigravida presented at 37
weeks gestation. She had undergone a tricuspid valve repair
previously for endocarditis. The patient had developed severe
tricuspid regurgitation and had heart failure. Harrington rods
were placed in her thoracic and lumbar spine for repair of a
congenital scoliosis. Blood tests revealed a pregnancy related
thrombocytopenia with platelets of 85x109/L. An
echocardiogram showed a severly dilated right atrium with
intra-atrial septal bowing to the left, severe free flowing
regurgitation and right ventricular systolic pressure
32mmHg.The case was discussed with obstetricians,
anaesthetists and cardiologists and a decision was made for
an elective caesarean section under CSA, if the final platelet
count remained stable. The patient expressed a preference to
remain awake and avoid a general anaesthetic. At surgery a
cannula and radial arterial line were inserted. In the sitting
position a 22G spinal needle was inserted below the level of
the scar tissue at L3/4, and a spinal catheter threaded into the
subarachnoid space. A total of 10mg bupivacaine and 250mcg
diamorphine were required over 20 minutes to establish a block
to T4. The blood pressure dropped from 135/70 to 90/50mmHg
and required only 5mcg of epinephrine to return to baseline
values. Blood loss was 720mls. Syntocinon was given as an
infusion only. A live male infant was delivered.
Discussion: An obstetric anaesthetist has to take many
factors into account when deciding on the best choice of
anaesthetic for a particular case; anaesthetic expertise,
maternal co-morbidities, fetal well-being and maternal
preferences all play a part. Cardiac disease in pregnancy is still
the leading cause of indirect maternal mortality in the UK.1 The
choice of anaesthetic and delivery had to ensure the least
amount of strain on an already compromised heart. The
advantages of CSA are that a block can be established
gradually with small incremental doses of local anaesthetic,
which reduces the likelihood of cardiovascular instability.2
The concerns with a CSA are principally neurological
complications and post-dural puncture headache. CSA is
proving an option to be considered for patients with
significant cardiac disease and previous spinal surgery
provided the anaesthetist has experience with the technique.
In this case it provided a cardiovascularly stable anaesthetic
with excellent analgesia and maximal maternal satisfaction.
References
1. Saving mothers lives.The Eighth Report of the Confidential
Enquires into Maternal Deaths in the UK. March 2011
2. DennyNM, Selender DE. Continuous spinal anaesthesia. Br J
Anaesth 1998;81:590-7
Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin) P17
P133 Does pre-operative anxiety predict post-operative pain P134 Early epidural analgesia may increase caesarean
scores in parturients undergoing caesarean section? section rate in spontaneously  labouring nulliparous 
BM Daly,  N Weidenhammer,  R Junkin,  L Riddell,  J Dolan,  J women: a retrospective study
Kinsella*,  R Marla,  S Young   R Anil Kumar,  Roger Mc Morrow  
Anaesthesia, Princess Royal Maternity, Glasgow, UK, Anaesthesia, National Maternity Hospital , Dublin, Ireland
*Anaesthesia, Pain & Critical Care Medicine, University of Introduction:.Epidural analgesia offers the most effective
Glasgow, Glasgow, UK method of intra-artum pain relief. The effect of epidural
Introduction: Pregnancy, childbirth, and undergoing a surgical analgesia on the progression of labour and the mode is often
procedure are all likely to induce anxiety. The relationship debated in multiple studies. This study aims to show the effect
between anxiety, pain and pregnancy is complex.1Childbirth is of timing of epidural analgesia on the mode of delivery.
a time of high anxiety, and Caesarean section is known to be Method: Data such as women's age, gestational age, cervical
associated with significant pain post-op. Here we ask can dilatation before epidural insertion and duration of labour was
anxiety scoring predict post LSCS pain? collected from a total of 2029 nulliparous women in
Methods: After ethical approval and consent, pre-operative spontaneous labour. Epidural analgesic was defined as early at
data and a single 24hr post-op 10cm VAS were collected from a cervical dilatation of 3cms or less and late at a cervical
108 women, with 9 having missing data. Spielberger2 State and dilatation of 4 or more cm
Trait anxiety forms were completed prior to surgery. We Results: Of the 2029 women, 1423 ( 70.1%) received epidural
present secondary end points powered post hoc for 0.8 analgesia. Out of the 2029 women, 1403 ( 69.2%) had
probability of 2cm VAS difference. A standardised anaesthetic spontenous vaginal delivery, 478 (23.6%) had assisted
(spinal including diamorphine) and analgesic regime was used. delivery and 146 ( 7.2%) had caeserean section.
The cohort was divided into "high"- above the mean and
The data was anaylsed according to the timing of epidural
"low"- below the mean anxiety and compared using Student's
analgesia or no epidural analgesia and modes of delivery.
t-test.
Anaesthetic Delivery method
Results:
intervention Spontaneous Assisted Caesarean
Table 1: State anxiety compared to VAS
No epidural 537 (88.9%) 51 (8.4%) 16(2.6%) 604
Low anxiety High anxiety Early epidural 757 (62.2%) 379 126 (10.0%) 1262
  Significance
(n=45) (n=54) (30.0%)
24 hr VAS mean Late epidural 109 (67.7) 48 (29.8%) 4(2.5%) 161
5.0 (2.2) 5.3 (2.0) P= 0.40
(SD) cm
Epidural Assisted delivery C-Section
Table 2: Trait anxiety compared to VAS analgesia OR 95% CI p-value OR 95% CI p-value
Low anxiety High anxiety Early 5.27 3.86, 7.21 <0.001 5.59 3.28, 9.51 <0.001
  Significance
(n=48) (n=55) epidural
24hr VAS mean (SD) Late 4.64 2.97,7.23 <0.001 1.23 0.40,3.76 0.71
4.8 (1.9) 5.5 (2.2) P= 0.15
cm epidural
Table 3: State +Trait anxiety compared to VAS Conclusion: The results from the study show that the
Low anxiety High anxiety likelihood of having caeserean section in the early epidural
  Significance
(n=48) (n=51) group is significantly higher compared to the late epidural
24hr VAS mean (SD) group, but the incidence of assisted delivery between the early
cm 4.8 (1.9) 5.6 (2.1) P=0.072 and late epidural group were similar. This study also shows
that there is an increased likelihood of having assisted
Discussion: While the higher anxiety groups displayed a delivery and caeserean section delivery with epidural
higher mean VAS in all the analysis, this was not statistically analgesia compared to without from the study group.
significant. The separation between the two groups was better
References
with the State than the Trait anxiety score and best of all when
1..Gonen Ohel. Early versus late initiation of epidural analgesia in
the two scores were combined. Further reasearch could look at
labour: Does it increasethe risk of cesarean section. A randomised
anxiety scoring as part of a bundle of other measures verus trial. American journal of Obstretrics and Gynaecology (2006) 194,
pain. 600-5
2. Wassen et al. Early versus late epidural analgesia and risk of
References
instrumental delivery in nulliparous women: a systemic review.
1..Waldenstrom U: Experience of labor and birth in 1111 women. J British Journal of Obstretrics and Gynaecology (2010) 1471, 655-
Psychosom Res.1999: 47(5):471-82 661
2..www.mindgarden.com
P18 Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin)
P135 Efficacy of midwife led epidural top ups in labour–Are P136 Emergency obstetric and neonatal care in Kenya:
programmable pumps really the way forward? Addressing millennium development goals
E Traer,  G Waters,  GNB Jackson   D B Pachter,  C A Ameh*  
Anaesthetic department, Royal Berkshire NHS Trust, Anaesthesia, Cumberland Infirmary, Carlisle, UK, *Maternal
Reading, UK and Neonatal Health, Liverpool School of Tropical
Introduction: There are an increasing number of automated Medicine, Liverpool, UK
techniques by which labour epidurals can be managed1,2,3,4. Introduction: In 2008, an estimated 358,000 women died from
Comparison reports of programmable epidural pumps regimens complications of pregnancy and childbirth. The overwhelming
have shown lower total volumes of local anaesthetic may be burden of this mortality occurs in the developing world, with
associated with reduced rates of instrumental delivery and almost 60% of deaths occurring in sub saharan Africa.1There
improved maternal satisfaction1,2. Extended intervals between are also some 3.6 million neonatal deaths each year, and once
boluses with larger volume boluses was shown to use less again the developing world is disproportionately represented.2
total local anaesthetic3. These reports have led us to In 2006, the Liverpool School of Tropical Medicine (LSTM)
investigate similar outcomes our unit where we have a midwife developed a training package entitled "Life Saving Skills,
led top up (MLTU) practice. Emergency Obstetric and Neonatal Care" (LSS EOC-NCC) to
Method: First epidural bolus administered by the anaesthetist try and address these huge public health issues. Courses now
of 20ml 0.1% bupivicaine+2µg/ml fentanyl . Data recorded at run in 11 countries worldwide. In October 2013, I was fortunate
each subsequent midwife administered bolus (MLTU): bolus e nough to teach on a course in Nyeri, Kenya.
interval time, motor block (Bromage score of 2-4 taken as motor Methods: A variety of teaching methods were used on the
block), any change to the standard dose 20ml 0.1% course. Didactic lecture based teaching had a limited role, with
bupivicaine+2µg/ml fentanyl and if analgesia was effective or more emphasis placed on small group "break out sessions"
ineffective. and scenario based teaching. Pre and post course simulation
Results: 50 patients audited based testing was undertaken, with results collated and sent
back to Liverpool for analysis and assessment of efficacy of
Midwife led epidural Top Up Data  
teaching.
Mean bolus interval time (min) 105 (sd 26)
Mean rate bupivicaine mg/hr 10.56 (sd 3.6) Results: Participant feedback suggested a high level of
Motor block (Bromage score 2-4) 11/48 (22.9%) satisfaction with the course. The impact of courses in terms of
Mean time to motor block (min) 237 (sd 135) reduction in maternal and neonatal mortality remains the
NVD 14/48 (29.1%) subject of ongoing scrutiny. One study from Somaliland
Instrumental 18/48 (37.5%) demonstrated improved knowledge and skills and evidence of
LSCS 16/48 (33.3%) positive behaviour change post introduction of the course.3

Satisfaction excellent/good 46/48 (95%)
Conclusions: Maternal morbidity and mortality remains a huge
Discussion: In this study we found the mean interval in problem in Kenya. In 2008 it's Maternal Mortality Ratio was
minutes between epidural boluses to be 105minutes. This is 488 per 100,000, one of the highest in the world.4Great efforts
greater than the average 60minute interval of the are being made by the Kenyan government to reduce this. An
programmable intermittent bolus(PIB) regimens. An average ambitious target to reduce MMR to 91 per 100,000 by 2018 has
rate of bupivicaine 10.56mg/hr was similar to that reported with been set. One step has been the introduction of the Liverpool
PIB and patient controlled epidural bolus(PCEA) regimens4, LSS EOC-NCC course.
while we report a lower rate of motor block. Given the practice Acknowledgements: I would like to thank the maternal and
of MLTU in effect is much like a PIB without PCEA, it is neonatal health unit at LSTM for the opportunity to become
notable that the time between epidural boluses is longer with involved, and look forward to teaching on my next course. I
MLTU with less maternal motor block and high maternal would also recommend the course to any obstetric
satisfaction. We feel our practice promotes close epidural anaesthetists with an interest in international health.
assessment as the midwives assess motor block and maternal
References
satisfaction before each “top-up” and avoids the cost of the
1. World Health Organization, UNICEF, UNFPA and The World
PIB/PCEA pumps.
Bank. Trends in Maternal Mortality 1990-2008. 2010.
References 2. Lawn JE, Kerber K, Enweronu-Laryea C, et al. 3.6 million neonatal
deaths–what is progressing and what is not? Seminars in
1. Capogna G Camorica M, Stirparo S, Farcomeni A. Programmed Perinatology 2010;34:371–386.
Intermittent Epidural Bolus Versus Continuous Epidural Infusion for
Labor Analgesia: The Effects on Maternal Motor Function and 3. Ameh C, Adegoke A, Hofman J, et al. The impact of emergency
obstetric care training in Somaliland, Somalia. International Journal
Labor Outcome. A Randomized Double-Blind Study in Nulliparous
of Gynecology & Obstetrics. 2012;117:283-7.
WomenAnesth Analg July Oct 2011; 113(4): 826-831
4. Kenya National Bureau of Statistics. Kenya Demographic and
2. George RB, Allen T, Habib A. Intermittent Epidural Bolus
Health Survey (KDHS) 2008-09. June 2010.
Compared with Continuous Epidural Infusion for Labour Analgesia:
A Systematic Review and Meta Analysis. Anesth Analg Jan 2013;
Vol 116: 133-144
3. Wong C, MacCarthy RJ, Hewlett Bl. The effect of manipulation of
the programmed intermittent bolus time interval and injection
volume on total drug use for labour epidural analgesia: a randomized
controlled trial. Anest Analg 2011; 112: 904-11
4. Husain T, Mavridou I, Fernando R, El-Wahab N, Stewart A, Dick J,
Columb M. A study of a programmed intermittent bolus and patient-
controlled epidural regimen for labour analgesia. Int J Obstet
Anaesth May 2013: P85 Abstracts OAA Bournemouth 2013
Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin) P19
P137 Enhanced recovery after elective caesarean section: P138 Epidural analgesia in obese parturients: can kneeling
Service evaluation and quality improvement be the answer to our prayers.
GJ Lilley,  M Adamson,  A Miskin*,  M Turner   S De Silva,  L Kelliher*,  R Mottaleb*,  E Combeer  
Anaesthetics, Royal Gwent Hospital, Newport, UK, Anaesthetics, Frimley Park Hospital, Frimley, UK,
*Obstetrics and gynaecology, Royal Gwent Hospital, *Anaesthetics, Royal Surrey County Hospital, Guildford, UK
Newport, UK Severe pain is not life-threatening in healthy parturient women,
Introduction: Enhanced recovery (ER), a concept widely it is however shown to have neuropsychological
recognised within many surgical specialties, is now a subject consequences. Postnatal depression may be more common
of interest within obstetrics. The core principles comprise when effective analgesia is not used1 and pain during labour
speeding up recovery and improving patient outcomes, with has been linked with the development of post-traumatic stress
associated benefits for staff and healthcare systems1. The disorder2.There is an increasing number of obese parturients3
most logical starting point for the introduction of ER principles and identification and placement of the epidural can be
are elective caesarean section lists. Delayed surgery may lead difficult in these women.
to prolonged fasting, followed by delayed mobilization, Classically the sitting or the lateral position is used during
delayed removal of catheter and delayed discharge. A pilot siting of labour epidurals. The kneeling position was first
audit in our hospital demonstrated a mean stay after elective described in 19934, where 34/35 women had their labour
caesarean section of 3.6 days, and mean preoperative fasting epidural sited whilst in the kneeling position and 88.5% of the
period of 12.4 hours. Current guidance for ER in obstetrics mothers were happy with this position.
suggests minimal interruption to oral intake, pre-operative
I elected to try the kneeling position in an obese lady with a
energy drinks, catheter removal at 12 hours post-surgery
BMI 50 after adjustments in the sitting position and two
regardless of time of day, and the option of discharge home 24
separate failed attempts to confidently palpate the lumbar
hours after caesarean section where appropriate2.
spine. Once the lady was in the kneeling position, the lumbar
Methods: All elective caesarean sections were included in this spine was not only palpable but also visible and the epidural
service evaluation after introduction of preoperative space was identified with ease. With Departmental approval I
carbohydrate drinks. Data collection included fasting time, in performed my labour epidurals in this manner and found it not
addition to time to mobilization, to catheter removal and to only to be easy to site epidurals but also tolerated well. Some
discharge. After an initial 6 week period of data collection, the women complained of paraesthesia in their feet, but this was
data was presented to anaesthetic and obstetric staff. Posters, rare and eased swiftly. We decided to survey our Deanery to
a discharge proforma and a patient information leaflet were ascertain what positions were being utilised.
produced, and specific guidance was developed regarding
Survey: An e-survey was sent to trainees and Consultants in
preoperative carbohydrate drinks. A further 6 weeks of data
the South West London Deanery into what their ideal first and
collection then took place.
second choice positions used for siting epidurals would be for
Results: A total of 78 consecutive patients were included, all labouring parturients. We then posed the same question for
of whom received a regional anaesthetic technique for elective obese parturients (BMI 40). They were asked if they had
caesarean section. The following table illustrates the timing of heard of the kneeling position and if anyone had tried it. For
pre- and post-operative events before and after our those who had not, we questioned why they had not tried it.
interventions.
Results: We received 53 responses, 96.2% of whom were
Time period / hour 2nd 6 week Initial 6 week
trainees. 64.2% chose to position the parturient sitting as their
mean(SD) period period
first choice and 60.4% chose lateral as their second choice in
Pre-op fasting 4.8 (2.8) 3.8 (2.5)
non-obese parturients. In comparison 84.9% opted for the
Post-op fasting 4.2 (3.5) 3.4 (3.5)
sitting position in obese parturients with 56.9% using the
Total interruption to oral
9.0 (4.5) 7.1 (4.6) lateral as their second choice. The only positions utilised were
intake
sitting and lateral. 94.9% of respondents had not heard of the
Delivery to mobilization 10.2 (4.5) 9.0 (3.3)
kneeling position to site labour epidurals.
Delivery to catheter removal 14.8 (6.6) 13.5 (3.5)
Conclusion: Each position used for the placement of labour
Delivery to discharge 67.3 (40.1) 63.3 (27.6)
epidurals has their own advantages and disadvantages. With
Discussion: The introduction of patient information leaflet
the rising incidence of maternal obesity and its associated
offering guidance regarding post-operative oral intake,
risks to not only the mother but also the unborn child, we need
mobilization, catheter removal and early discharge, along with
to be continuing in our development and advancement in the
staff education and introduction of pre-operative carbohydrate
provision of good care. We suggest that the kneeling position
drinks, has resulted in improvement in the timing of a number
is a safe and viable alternative for siting epidural catheters in
of peri-operative interventions, and a small reduction in
labouring parturients.
duration of hospital admission. However, possibly due to
References
obstetric, midwifery, paediatric and organisational reasons,
discharge is rarely achieved at the potential target of 24 hours 1. Hiltunen P, Raudaskoski T, Ebeling H, Moilanen I Does pain relief
during delivery decrease the risk of postnatal depression? Acta
after elective caesarean section. Obstet Gynecol Scand 2004;83:257-261
References 2. Soet JE, Brack GA, Dilorio C Prevalence and predictors of women's
1. Lucas DN, Gough KL. Enhanced recovery in obstetrics - a new experience of psychological trauma during childbirth. Birth
frontier? Int J Obstet Anaesth 2013; 22: 92-95 2003;30:36-46
2. Enhanced recovery partnership: A better journey for patients and a 3. Centre for Maternal and Child Enquiries (CMACE). Saving
better deal for the NHS. Available at: Mothers'. Lives: reviewing maternal deaths to make motherhood
http://www.improvement.nhs.uk/documents/er_better_journey.pdf safer: 2006–2008. The Eighth Report of the Confidential Enquiries
into Maternal Deaths in the United Kingdom. BJOG 2011;118:1-203
P20 Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin)
P139 Epidural labour analgesia and risk of instrumental P140 Estimation of blood loss during caesarean sections -
delivery discrepancy between visual and laboratory estimation
R Carvalho,  T Ferreira,  M Duque,  D Catré,  I Guedes,  J P A Nowicka,  A Amasakera,  C Ferdinand,  I Suri  
Assunção   Anaesthesia, Warwick Hospital, South Warwickshire NHS
Anaesthesiology, Centro Hospitalar Tondela Viseu EPE, Foundatio, Warwick, UK

Viseu, Portugal
Introduction: Excessive blood loss is a major threat to women
Introduction: Epidural analgesia (EA) is a worldwide effective undergoing casearean sections. Accurate visual estimation of
method used for pain relief during labour. Nevertheless, its use blood loss is difficult due to dispersion of blood lost and the
and evolution to instrumental vaginal (forceps or vacuum blood being mixed with amniotic fluid(1). Therefore the blood
extraction) or operative deliveries remains controversial loss often gets under or overestimated(2). A number of
between experts,1 either anesthesiologists or obstetricians. methods exist to estimate the blood loss, the commonly used
We aimed to analyze the relation between EA and instrumental being: visual estimation by the attending staff, weighing of the
v aginal deliveries in a sample of our obstetric population. blood soaked surgical swabs and calculation based on the pre-
and post-operative haemoglobin concentrations(3). The aim of
Methods: A retrospective study included all pregnant women
this audit was to compare the visually estimated blood loss by
who delivered on our labour Room, between 1-January-2011
both the surgeons (vEBLs) and anaesthetists (vEBLa) against
and 31-December-2012, excluding those who underwent
the calculated estimated blood loss (cEBL).
caesarean section. We reviewed the data of demographical
characteristics, type of gestation and labour, the use of EA Methods: Data was collected on thirty five caesarean sections.
and the newborn APGAR score. Descriptive analysis of Operating surgeona and anaesthetists were asked to visually
variables was used to summarize data and Chi-Square test was estimate the blood loss in each case. The circulating blood
used. Multivariate analysis was done with logistic regression, volume was calculated for each patient based on the body
with calculation of corrected Odds Ratio (OR) and its 95% weight and height. Then, the blood loss during caesarean
confidence interval (95% CI). section was calculated using the circulating blood volume and
the pre- and post-operative haemoglobin concentrations.
Results: 2901 pregnant women were included in this study, Correction was made for the haemodilution by intravenous
with mean age of 29,7 years. 81% underwent EA and 30% fluid administered.
instrumental vaginal delivery. 51% were nulliparous. Applying
Results: Twenty six complete forms were included in the
Chi-Square test to independent variables, we obtained
analysis. None of the patients received blood or blood
significant associations with dystocic delivery for EA, normal
products intraoperatively. Mean volume of intravenous fluid
maternal age (NMA; 20-35 years) and parity (p<0,001).
infused was 1304mL±421. Mean vEBLs, vEBLa and cEBL was
Applying logistic regression to our model, including parity,
590mL±300, 623mL±372 and 821mL±1004 respectively. The
NMA and EA with dystocic deliveries, we obtained corrected
tendency for anaesthetists to give a higher estimate of blood
OR (95%CI) for EA 2,459 (1,884-3,210) and for parity 3,4
loss was not statistically signifficant (p=0,12). There was a
(2,867-4,121), with NMA loosing significance. However, this
clear discrepancy between the visual estimate given by both
result may still be biased by other factors, such as labour
the surgeons and the anaesthetists, ant the cEBL, however, it
stage at the time of the EA beginning, drugs used in epidural
did not reach statistical significance (p=0,11 and p=014
space, use of oxytocin during labour, among others.
respectively). Compared to the cEBL the vEBL was
Additionally we found that, in our population of term
overestimated when the blood loss was low (12 cases) and
pregnancies, NMA and eutocic deliveries, there was no
underestimated when the blood loss was higher than 500mL
significant relation between EA and APGAR score <8 at the
(14 cases). There was a linear relationship between the degree
first minute (p=0,079).
of underestimation and the blood loss, with high levels of
Conclusion: It's generally assent that EA provides the most blood loss being most underestimated.
effective pain relief in labour. However, it's associated to Conclusions: In this audit, the standard procedure for
prolonged labour and risk of instrumental or caesarean estimation of blood (visual estimation by the obstetrician) loss
deliveries.2 Our study has drawn the conclusion that both was found to be unreliable. We demonstrated a tendency of
having EA for labour pain relief and being nulliparous increase anaesthetists and surgeons to overestimate the blood loss, if
the chance of instrumental delivery, respectively in 2,459 and actual blood loss was less than 500mL, and underestimate if
3,43 times, however without significant impact on newborn the blood loss exceeded 500mL. As a result of the audit, it has
APGAR score. Bigger prospective studies correcting for more been made compulsory in our unit to check haemoglobin
risk factors are advised. concentration in recovery whenever the vEBL exceeds
References 1 000mL.
1. BMC Pregnancy and Childbirth 2008, 8:45. References
2. Acta Obstet Gynecol Scand 2002, 8:1033-1039. 1. Khan FA, Khan M, Ali A, Chohan U Estimation of blood loss during
Caesarean section: an audit. J Pak Med Assoc. 2006 Dec;56(12):572-
5.
2. Larsson C, Saltvedt S, Wiklund I, Pahlen S, Andolf E Estimation of
blood loss after cesarean section and vaginal delivery has low
validity with a tendency to exaggeration. Acta Obstet Gynecol
Scand. 2006;85(12):1448-52.
3. Stafford I, Dildy GA, Clark SL, Belfort MA, Visually estimated and
calculated blood loss in vaginal and cesarean delivery. Am J Obstet
Gynecol. 2008 Nov;199(5):519.e1-7
Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin) P21
P141 Ethnic variations in use of labour analgesia P142 Factors associated with the use of spinal anaesthesia
LMD MacDarby,  CMC McCaul   for caesarean section in Nigeria
Delivery Suite, The Rotunda Hospital, Dublin, Ireland C Imarengiaye,  F Asudo*,  A Akinmola†,  B Lawal§  
Introduction; This retrospective cohort study was compiled to Anaesthesiology, University of Benin Teaching Hospital,
establish the wide variety of nationalities presenting to The Benin City, Nigeria, *Anaesthesia, University of Abuja
Rotunda Hospital for delivery during a one month period and Teaching Hospital, Gwagwalada, Nigeria, †Anaesthesia, 
to determine the labour analgesia preferences amongst this National Hospital, Abuja, Nigeria, §Anaesthesia, Lagos 
population. Island Maternity Hospital, Victoria Island, Nigeria

Introduction: There has been a consistent increase in the rate
Methods; Details of all deliveries occurring during the month
of spinal anaesthesia for caesarean section in many hospitals
of October 2013 were collected. Any patients undergoing
worldwide and had been advocated as the preferred technique
elective caesarean section and those with failed inductions
for caesarean delivery.1 Recent evidence suggests increasing
were excluded from the study. A demographic of patients’
use of spinal anaesthesia for caesarean sections in reports
nationality and ethnic background was compiled. Data relating
from a teaching hospital.2 The rise in spinal anaesthesia
to these patients’ use of labour analgesia was recorded i.e.
caesarean section notwithstanding, it is pertinent to determine
epidural uptake, pethidine administration and remifentanil
the factors limiting the wholesome application of spinal
infusion use. We then established the frequency of use of
anaesthesia for caesarean section in Nigeria.
each of these methods of analgesia in each population

Methods: A snap-shot survey was conducted in some
Results; There were 767 deliveries in Oct 2013. 104 elective
selected hospitals in Nigeria. The survey determined the
caesarean sections were carried out and there were 8 patients
sociodemographic characteristics of patients, indication for
who failed induction.
surgery, grade of anaesthesia provider, contraindication to
Therefore a total of 655 patients laboured during this time. spinal anaesthesia and any other factor that may be noticed in
This number was made up by 50 different nationalities. Of the selected hospital. The survey was to be conducted over a
these 414 patients were Irish, the majority being white but 2-week period but was truncated by the nation-wide strike
including small numbers of Asian or Black background. action by doctors after 9 days.
Amongst the Irish patients the rate of epidural uptake was
Results: A total of 99 patients were attended to in 4 of the
43.47% (234) and the rate of pethidine use was 17.87% (74)
selected 6 hospitals within the study period. 36/99 women
Patients of other white background, including many eastern
were nulliparous and maternal factors (82/99) were the leading
european countries made up 134 of the patients. These
indications for caesarean section. Consultant anaesthetists
patients as a group had a 52.98% epidural uptake rate. Black
(23/99), Senior Registrars (35/99), Medical Officers (36/99) and
Africans were found to have a 39.13% (9) uptake rate and
others (5/99) provided anaesthesia for the caesarean sections.
those of Asian background had the highest rate at 54.83%
85/99 patients received spinal anaesthesia and 14/99 had
(17). The use of pethidine was significantly lower than the rate
general anaesthesia for the c-section. Fetal indication for
of epidural in all of these groups. Pethidine was used by
caesarean section had a 3-fold risk of general anaesthesia for
18.19% of Black Africans, 12.9% of Asians and 23.13% in
the surgery (p = 0.037, RR = 3.1, 95%CI 1.2 – 8). 25/99 and
those of other white backgrounds. There were only 3 cases of
74/99 were performed as elective or emergency procedure.
remifentanil use during the month
Nature of caesarean section was not a factor for the use of
Discussion; The highest incidence of epidural uptake during spinal anaesthesia (p =0.51, RR = 2.0, 95%CI = 0.5).
Oct was found to be amongst the Asian population, the lowest Discussion: Over 85% of caesarean sections in Nigeria were
being amongst Black Africans. Pethidine use was less than conducted under spinal anaesthesia. Fetal indications for
25% in all groups. The reasons for these trends is unknown caesarean section provoked a 3-fold increase in general
though previous studies have suggested that cultural and anaesthesia for caesarean section. The use of general
educational factors may play a part. anaesthesia for caesarean delivery was due to fetal indications
A prospective survey of patients post delivery detailing the for surgery, antepartum haemorrhage and failed spinal
reasons for their choices of labour analgesia would be anaesthesia. Improved practical conduct of the spinal
worthwhile. Establishing the factors influencing their technique may enhance great application of spinal anaesthesia
decisions may allow us to provide an unbiased and fully for caesarean section.
comprehensive service to ensure patient satisfaction. References

1..Morgan BM, Magni V, Goroszenuik T. Anaesthesia for emergency
caesarenc section. BrJ Obstet Gynaecol 1990; 97: 420-424
2..Amadasun FE, Idehen HO, Edomwonyi NP. Evolving pattern of
anaesthesia for caesarean section: Experience at the university of
Benin Teaching Hospital West Afr J Med 2013; 32: 196-9
P22 Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin)
P143 Failed intubation for a category 1 caesarean section in P144 Fasting dilemmas: A rare case of a patient with non-
a patient with undiagnosed spina bifida ketotic hyperglycinaemia presenting for caesarean
CR Deane,  E Lewis,  J Spargo   section
Department of Anaesthetics, Singleton Hospital, Swansea, M Behravesh,  S Dawson,  G McClune,  S Atkinson  
UK Anaesthetics, Royal Jubilee Maternity Hospital, Belfast, UK
Introduction: Non-ketotic hyperglycinaemia (NKH) is a rare
Introduction: Spina Bifida Occulta (SBO) is part of a spectrum
autosomal recessive metabolic disease caused by a defect in
of neural tube defects and is common. We present the case of
the glycine cleavage system. This case report describes the
a patient with previously undiagnosed SBO who required a
management of a patient who presented for caesarean section.
category 1 caesarean section (CS). Despite an unremarkable
To our knowledge there are no other published case reports of
airway assessment she had a failed intubation on rapid
this type.
sequence induction (RSI) and subsequently required an awake
fibre optic intubation (AFOI). Case Report: A 32 year old Para 1 presented for elective
caesarean section of twins at 37 weeks gestation. She had a
Case report: A 37 year old para 0 patient presented to labour
history of atypical non-ketotic hyperglycinaemia. Following
ward labouring with a single live foetus at 37 weeks gestation.
advice from clinical chemistry, during her 6 hours preoperative
She was admitted under consultant obstetric care with
fast she received an inceased dose of sodium benzoate and an
asymptomatic hypertension. When considering an epidural
intravenous infusion of 10% dextrose at 3mls/kg/hour which
she was examined and had a vascular naevus, associated with
was continued perioperatively. Caesarean section was
skin tethering, over lumbar vertebrae. She was asymptomatic,
performed under spinal anaesthesia and twin baby boys were
had never been investigated, and had no definitive diagnosis
delivered successfully. Post delivery of the second twin she
of SBO. Airway assessment included a Mallampatti score of 3,
received a bolus of 5 units of syntocinon followed by an
but was otherwise unremarkable. An epidural was declined to
infusion at 10 units per hour. Due to uterine atony and an
the patient, with a remifentanil PCA provided instead. A plan
operative blood loss of 1000mls she also received ergometrine
was agreed for a RSI GA if operative intervention was
carboprost intramuscularly to good effect. Sodium benzoate
required. Several hours later she required a category 1 CS.
was administered orally in recovery and the 10% dextrose
Initial laryngoscopy with a Mackintosh blade yielded a
infusion was continued until the patient was establised on an
Cormack and Lehane grade 3 view. Manipulation of the cricoid
oral regimen prescribed by the dieticians. This involved a
cartilage, long and McCoy blades did not improve the view.
series of high calorie drinks up to every 2 hours for 48 hours.
Two failed attempts were made to intubate using a bougie. The
No dietary protein was allowed for 24 hours post delivery.
patient was ventilated using a face mask and a Guedel airway
Glycine levels were monitored daily and were raised on day 5
with oxygen saturations above 97% throughout. She was
while dietary protien was being gradually reintroduced.
woken up without further incident and an AFOI was
performed. Her child was delivered by LSCS without further Discussion: NKH has an incidence of 1 in 60,000 with 3
incident or obvious deficit. The APGAR scores were 8 and 10 distinct presentations. Classically neonates present with
at one and five minutes. A grade 3 view was confirmed before lethergy, hypotonia and seizures. These symptoms can
the patient was woken. Recovery from anaesthesia was proceed to apnoea requiring ventilation and 30% of patients
uneventful. The patient was appropriately counselled. An do not survive the neonatal period. Severe psychomotor
Airway Alert Letter was issued and follow up appointment retardation is common in those who survive. A second,
made. An MRI was carried out subsequently and showed a atypical and very rare form presents with mild baseline
neural arch defect and dural tethering. Significantly the conus hyperglycinaemia and intermittent encephalopathy
lay as low as L4 with diastematomyelia as far as L2. assosciated with periods of illness. Transient neonatal
hyperglycinaemia has also been described. Biochemically,
Discussion: SBO is common and without prior imaging
NKH is characterized by elevated glycine concentrations in
presents the clinician with a difficult decision. Regional
plasma, CSF, and brain with a CSF glycine to plasma glycine
techniques risk neural or dural injury due to a low lying or
ratio greater than 0.08.1 Standard treatment strategies include
tethered cord.1 Abnormal spread of the analgesic agents may
protein restriction to reduce exogenous glycine,
give rise to either excessive cranial spread or inadequate
supplementation of one-carbon pool donors and
caudal spread. This patient population provides further issues
administration of sodium benzoate. NMDA antagonists have
for the anaesthetist given the high risk of operative delivery or
been shown to raise the developmental quotient, improve
other intervention (due to pelvic structural abnormalities) and
muscle tone and reduce seizures in these patients.2
the association of spina bifida with difficult intubation.2,3
Patients with spina bifida require careful preop assessment Prolonged periods of fasting predispose these patients to
and MRI imaging and careful airway consideration is essential glycine build up and its toxic neurological effects. This has
in order to inform anaesthetic planning. major implications for the anaesthetist in the perioperative
period. This case demonstrates the safe use of regional
References
anaesthesia in conjunction with careful nutritional planning.
1. Reynolds F. Damage to the conus medullaris following spinal
anaesthesia. Anaesthesia 2001; 56: 235-247. References
2. Richmond D, Zaharierski I, Bond A. Management of pregnancy in 1. Chang YT, Lin WD, Chin ZN et al. Nonketotic hyperglycinemia: A
mothers with spina bifida. Eur J Obstet Gynecol Reprod Biol 1987; case report and brief review. Biomedicine 2012; 2(2):80-82
25: 341-5. 2. Van Hove JL, Vande Kerckhove K, Hennermann JB et al. Benzoate
3. May A, Fombon F, Francis S. UK registry of high-risk obstetric treatment and the glycine index in nonketotic hyperglycinaemia.
anaesthesia: report on neurological disease. Int J Obstet Anaesth Journal of Inherited Metabolic Diseases. 2005;28:651–663
2008; 17: 31-6.
Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin) P23
P145 Fetal bradycardia following regional anaesthesia for P146 Further increase in hysterectomy rates - and the
emergency caesarean section and instrumental reason why
delivery: a service evaluation JS Campbell,  M Molloy,  C Thompson,  D Fogarty  
JK Sidana,  K Jadhav-Smith,  J Corfe   Royal-Jubilee Maternity Service, Belfast HSC Trust, Belfast,
Anaesthetics, Norfolk and Norwich University Hospital, UK
Norwich, UK Introduction: RJMS is the tertiary obstetric service for
Introduction: Fetal heart rate abnormalities, such as late Northern Ireland. As part of a service review of use of uterine
decelerations or fetal bradycardia, are known to occur after artery balloon catheters, we retrieved data from several
neuraxial anaesthesia.1 These may be due to maternal sources. We found a large proportion of these patients still
sympathetic blockade or an increase in the uterine tone caused required hysterectomy. Further interrogation of our data
by intrathecal opioids. The objective of this service evaluation showed some unexpected trends.
was to evaluate the incidence and management of fetal Methods: With approval of the Trust's Data Guardian we used
bradycardia following regional anaesthesia for emergency data from several hospital systems, including a local maternity
caesarean section and instrumental deliveries. care database and histology records.
Methods: 15 patients with an episode of fetal bradycardia Results: We found 30 hysterectomies from 37,088 deliveries in
following regional anaesthesia were identified by reviewing 6 years. This is a rate of 0.8 per 1000 - significantly higher than
the daily obstetric handover sheets from January to December our prior rates which was near the NICE-quoted rate of up to 3
2011. The medical notes of these patients were reviewed for per 1000. Of these cases, 23 (76%) were due to morbidly
peripartum obstetric management, cardiotocographic (CTG) adherent placenta.
findings, perioperative anaesthetic management and
Not all these cases of morbidly adherent placenta were
management of fetal bradycardia. Neonatal outcome was
diagnosed antenatally, which perhaps made hysterectomy
assessed by APGAR scores, umbilical cord gases and NICU.
more likely since facilities such as intra-arterial balloon
Results: 10 patients had an assisted delivery and 5 had an catheters could not be available to us in an emergency.
emergency category-2 LSCS. The peripartum CTG findings Unanticipated cases suffered greater blood loss. Despite no
were either suspicious or pathological. Timing of fetal diagnosis, the majority (16/23) were placenta percreta on
bradycardia following regional anaesthesia ranged from 2 to 15 histology. These percreta cases again had greater blood loss,
min. 13 patients received spinal anaesthesia and 2 received and were more likely to require ICU care post-operatively. Yet
epidural top up. Maternal haemodynamics stability was there were no cases of percreta in the 6 years prior, and less
maintained with left uterine displacement, intravenous fluids than half the number of hysterectomies in that period. This
and phenylephrine infusion. One patient had an episode of seems to be a dangerous and dramatic change in recent years.
maternal bradycardia below 50 beats/min which was treated
Conclusion: We found a recent and significant increase in
with anticholinergics. Comparing the baseline maternal heart
peripartum hysterectomy, associated with a large increase in
rate with the lowest perioperative heart rate, 3 patients had a
the number and degree of morbidly adherent placenta. Patients
greater than 40% drop in the heart rate. 5 patients had a blood
with placenta percreta had a greater blood loss, and more
pressure drop of more than 20% below the baseline, which was
commonly required hysterectomy and ICU care.
treated with phenylephrine. The highest level of block to
Reference
temperature was T3. Syntocinon was stopped in all but one
case in the event of fetal bradycardia. Significant delays 1. National Institute for Health and Clinical Excellence. Caesarean
section: NICE Clinical Guideline 132 2012,
occurred in transferring these patients to theatre after the
http://www.nice.org.uk/nicemedia/live/13620/57163/57163.pdf
decision for surgical intervention were taken, maximum 35 min
(median 17 min). 6 cases had poor neonatal outcomes with low
5 minute APGAR and abnormal cord gases.
Discussion: We could not find any direct cause which can be
solely attributed to regional anaesthesia for the occurrence of
fetal bradycardia in these patients. Significant delay in patient
transfer to theatre may have a causal relationship but cannot
be confirmed. Studies in elective patients have shown that
maternal bradycardia causes a drop in maternal cardiac output.
2 Relative maternal bradycardia occurred in several of our
cases and this would have led to drop in cardiac output and
therefore oxygen delivery. This is most likely a side effect of
phenylephrine use. We plan to introduce a care bundle to
implement pre-operative and intra-operative fetal resuscitation.
This will include steps to improve fetal condition at the time of
regional anaesthesia and to ensure adequate maternal cardiac
output and oxygen delivery.
References
1. Reynolds F, Seed PT. Anaesthesia for Caesarean section and
neonatal acid-base status: a meta-analysis. Anaesthesia 2005; 60:
636–653
2. Stewart A, Fernando R et al. The dose-dependent effects of
phenylephrine for elective caesarean delivery under spinal
anaesthesia. Anesthesia & Analgesia 2010; 111: 1230-7.
P24 Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin)
P147 Impact of workload on accidental dural puncture P148 Implantable cardioverter defibrillator in
(ADP) rate pregnancy WITHDRAWN FROM PRESENTATION
W Mon,  YM Liu,  A Stewart,  R Fernando,  M Columb*   S Chaudhari,  S Quasim  
Anaesthetics, University College London Hospital, London, Anaesthetic Department, University Hospital Coventry and
UK, *Intensive Care Unit, University Hospital of South Warwickshire , Coventry, UK
Manchester, Manchester, UK
Introduction: Post dural puncture headache is an important
cause of morbidity. We audit our ADP rates annually against
the national standard.1Between 2005 and 2008, our ADP rate
was stable at approximately 0.5%. However, from 2008 to 2010,
our rate rose to above the 1% national standard.1Therefore, we
audited factors that may have contributed to this increase.
Methods: Information for this audit was obtained from a
computerised database. Data collection included day, month
and time of ADP and the grade of anaesthetist. We also
collected annual data of number of deliveries, epidurals and
combined spinal epidurals (CSEs) for labour, caesarean section
(CS) data, and the proportion of single shot spinals (SSS) to
CSEs performed. Data were analysed using chi-square
multinomial and trend tests with P value <0.05 defined as
significant.
Results: There was a 40% increase in deliveries between 2008-
2010. CSs and regional blocks for analgesia increased by 36%
and 40% respectively. Although the ADP rate increased, we
could not demonstrate a statistically significant trend due to
small numbers. From 2010 to 2012, a non-significant fall in the
ADP rate was seen. There was no significant association
between ADPs and day, month or time. We did see a
significant non-linear trend (P = 0.0012) in the proportions of
SSSs to CSEs performed, with the peak occurring in 2010.
Table 1. Trend of activity and ADP rate from 2008 to 2012
  2008 2009 2010 2011 2012 P value
Maternities (n) 4032 5039 5647 5841 5953 < 0.0001
Epidurals for labour (n) 1306 1600 1839 2029 2132 < 0.0001
CSs (n) 1370 1562 1861 1862 1773 < 0.0001
SSSs for CS (n) 282 274 356 326 347 0.0015
CSEs for CS (n) 797 644 714 833 915 < 0.0001
Proportion of SSS to CSE (%) 26 30 33 28 27 0.0012
ADP rate (%) 0.57 0.98 1.05 1.01 0.82 0.31
Discussion: We observed an increase in ADPs until 2010, with
significant rises in deliveries and anaesthetic procedures
performed. The significant non-linear trend in the proportions
of SSSs to CSEs performed for CSs peaked in 2010. A fall in the
ADP rate between 2010-2012, occurred despite exposing more
women to the risk of ADP, as during this time we performed
significantly more CSEs than SSSs proportionally. We believe
that the rise in the ADP rate resulted from a significant
increase in our workload between 2008 and 2010, without any
increase in anaesthetic staffing. From 2010 onwards, daytime
anaesthetic consultant sessions increased by 50%, and there
was a higher presence on the labour ward out of hours by
senior registrars covering non-obstetric theatres. Both factors
may have contributed to the subsequent fall in the ADP rate.
This audit supports the recent OAA/AAGBI guideline
recommending increased anaesthetic staffing on labour ward.2
References
1. Royal College of Anaesthetists. Epidural analgesia during labour.
Raising the standard: a compendium of audit recipes. 2012;218-219
2. Association of Anaesthetists of Great Britain and Ireland and
Obstetric Anaesthetists' Association. OAA/AAGBI guidelines for
obstetric anaesthetic services. 2013
Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin) P25
P149 Inadvertent hypothermia during elective caesarean P150 Inter professional relationships on labour ward- how
sections well do anaesthetists and midwives get along?
S Botros,  R Labib,  T Ramhew,  M Baban,  Y Poonawala   M Salman,  P Kumar,  G Graham  
Selwyn Crawford Department of Anaesthesia , Birmingham Anaesthetics, St. Thomas' Hospital, London, UK
Women's Hospital, Birmingham, UK Introduction: Anaesthetists and midwives are part of the
Introduction: The National Institute for Health and Care multi-professional team that provides care for parturients.
Excellence (NICE) defines inadvertent perioperative They work together in close collaboration in the unique and
hypothermia as a core body temperature below 36°C.1 It is a often highly charged environment of labour ward. In such
common complication of regional anaesthesia, and is the settings, effective inter professional relationships are key to
leading cause of perioperative shivering. Hypothermia is the delivery of high quality care and consequently better
associated with increased risk of wound infection and patient outcomes. Successful collaborative practice can be
increased blood loss.1 Shivering can be associated with negatively impacted by barriers such as lack of clarity on the
increased oxygen consumption and hypoxaemia in vulnerable scope of roles of team members, poor communication, or
patients. Although the NICE guideline on the management of stereotyping. We conducted a survey amongst obstetric
perioperative hypothermia did not cover pregnant women,1 it anaesthetists and midwives in our hospital to reflect upon this
has been adopted by many obstetric units. In our unit, working relationship and to see how it may be improved.
intravenous (IV) fluid is not routinely warmed for elective
Methods: A questionnaire was designed and distributed to
caesarean sections (CS). Hence, we audited our practice to
midwives and anaesthetists of all grades. Questions were
evaluate the incidence of hypothermia.
asked on their understanding of each other's professional role
Methods: Over a three month period, we prospectively audited
and on their perception of the quality and effectiveness of
our practice in 47 women who had elective CS under
their working relationship. A total of 43 responses were
subarachnoid anaesthesia without active warming. We
collected (24 anaesthetists and 19 midwives) in an ongoing
measured their tympanic temperature prior to anaesthesia (T )
1 survey.
and at the end of surgery (T ). We also collected data that may
2 Results: Of the anaesthetists who completed the
influence the results like the volume of IV fluid infused,
questionnaire, 16.6% were consultants, 58.3% were ST5-ST7,
estimated blood loss (EBL) and duration of surgery. We also
20.8% were ST3-4 and 4.1% were CT1-2. When asked whether
assessed the incidence of perioperative shivering. We
they felt they understood the scope of responsibilities of
repeated the audit in 42 parturients using an IV fluid warming
midwives on labour ward, only 27% of anaesthetists felt they
device. The data were analysed using Microsoft Excel 2007®.
understood it fully. In contrast, 63% of midwives believed they
Data from both audits were compared and p-values were
fully understood the scope of the anaesthetist's
calculated using unpaired t-test by GraphPad software®.
responsibilities.
Results: In the initial audit, 20 patients (42.55%) were
hypothermic at the end of surgery (T < 36°C). Shivering Thirty percent of midwives felt that collaboration with
2
occurred in 14 patients (29.79%). No correlation was found anaesthetists was 'very easy', in contrast to only 5.5% of
between T and the IV fluid volume, EBL, duration of surgery anaesthetists who felt the same about collaboration with their
1-2
or the dose of intrathecal Bupivacaine. In the re-audit, only 3 midwife colleagues. While 16% of anaesthetists found this
(7.14%) patients experienced hypothermia. There was no collaboration 'difficult', none of the midwives did (0%).
statistical difference in T between the two audits (p = 0.781). Seventy two percent of anaesthetists felt their input was
1
usually well-received by their midwife colleagues, compared to
  Initial Audit (n=47) Re-audit (n=42) p-value
only 40% of midwives who thought their input was well-
Fluid (ml) 1116.67(±369.43) 1233.33 (±483.59) 0.2236
received by the anaesthetist. Both professions were asked
EBL (ml) 523.75 (±152.33) 582.5 (±491.67) 0.474
how they perceived the general quality of communication
T1 36.84 (±0.37) 36.81 (±0.37) 0.781
between them. The majority of anaesthetists (47%) perceived it
T2 36.08 (±0.4) 36.3 (±0.29) 0.004
as 'fair', while 15% regarded it as 'poor'. Ninety percent of
T 0.76 (±0.34) 0.52 (±0.41) 0.0032
1-2 midwives felt it was either 'very good' or 'good'. None of the
Discussion: Our audit highlights the effect of warm IV fluid midwives (0%) felt it to be 'poor'.
therapy on reducing the incidence of inadvertent perioperative
Questions were asked on the types of obstacles they
hypothermia during elective CS. Our audit recommends the
encountered in their professional interaction with each other.
routine warming of IV fluid during elective CS. The Enhanced
Most anaesthetists (72%) agreed that they found fixation on
Recovery Partnership Programme considers patient warming
tasks and exclusion of others to be a challenge, followed by
as a key factor in accelerating patient recovery.2 Following our
delayed or non-communication of important issues (57%). A
results and as part of developing a new pathway for enhanced
third of the anaesthetists felt they rarely got a comprehensive
recovery post CS; our trust is currently looking to invest in a
handover from the midwife while only 29% of midwives felt
cost-effective IV fluid warming device.
they understood the rationale behind the anaesthetists'
References decisions.
1. NICE (2008) Perioperative hypothermia (inadvertent): full Conclusion: Despite both specialties working in close
guideline (CG65). Full Guideline. London: National Institute for proximity, the survey identified several gaps in
Health and Care Excellence.
communication. Working towards enhancement of the
2. Enhanced Recovery Partnership (2012) Fulfilling the potential: a
professional relationship between members of the team
better journey for patients and a better deal for the NHS. Leicester:
NHS Improvement. Available at http://www.improvement.nhs.uk providing maternity services will help facilitate their
(accessed 14/12/2013) collaboration and will reflect positively on the performance of
both professions.

P26 Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin)
P151 Intra-arterial balloon catheters: A service evaluation P152 Intrathecal diamorphine for cesarian section following
JS Campbell,  M Molloy,  D Fogarty   intramuscular diamorphine during labour: a cause for
Royal-Jubilee Maternity Service, Belfast HSC Trust, Belfast, concern?
UK RC Barr,  L Parks  
Introduction: Intra-arterial balloon catheters have become Anaesthetics and Intensive Care, Southern Health and Care
widely used and predominantly accepted in cases where Trust, Northern Ireland, UK
massive haemorrhage is anticipated, especially with morbidly Introduction: Diamorphine has largely replaced pethidine for
adherent placenta . However, the benefits are still intramuscular (IM) analgesia during labour in our obstetric
1,2
controversial. While our unit is not stand-alone, our building unit. We also routinely give diamorphine (250-300 micrograms)
is physically separated from other departments including intrathecally (IT) for cesarian sections. A recent case of
radiology, so the logistics of balloon catheters are difficult2. meiosis and drowsiness, in a lady presenting for a category 2
Our objective was to identify the impact of balloon catheters cesarian section having received IM diamorphine in labour,
on management of morbidly adherent placenta. Associated highlighted the potential for side effects when diamorphine is
anaesthetic issues include massive transfusion, cell salvage, used IM and then IT. Should we therefore consider adjusting
type of anaesthetic and post-operative care. our IT dose of diamorphine in women presenting for
Methods: With permission of the Trust's Data Guardian, we emergency cesarian sections? To our knowledge there are no
retrieved data from multiple sources to identify and review guidelines on this subject and clinical practice appears
cases where balloon catheters where used. These included variable.
radiology logs, maternity records and histology. Methods: We conducted a survey of all anaesthetists working
Results: Ten cases were identifed via these systems. Seven in the Southern Health and Social Care Trust who partake in
were for morbidly adherent placenta, of which 5 required obstetric anaesthesia. Questions focused on; current
hysterectomy despite balloon inflation. Many of these were diamorphine practice, diamorphine dose adjustments, factors
cases of placenta percreta, despite antenatal diagnosis of influencing our dose decisions and concerns regarding
accreta. However, blood loss was lower by around 20% potential side-effects with IT diamorphine.
(1078ml) using balloons, when compared to other Results: We received 24 replies; 14 consultants and 10
hysterectomies in the same time period. experienced trainees who regularly perform obstetric
Other indications were for intra-abdominal pregnancy and anaesthesia. There was a wide variation in diamorphine
persistent post-partum haemorrhage. Another case was practice amongst our anaesthetists. The majority (76%)
abandoned due to logistical reasons (unable to organise consider reducing their IT dose following IM diamorphine.
theatre time in same building), a decision felt to be open to Factors influencing this dose reduction include timing (88%)
medicolegal criticism after preparation and planning for and dose (29%) of the last IM diamorphine and clinical signs
balloons. of toxicity (76%). In particular anaesthetists were concerned
about postoperative respiratory depression (94%) and
Limitations particularly reflected the limitations and
drowsiness (88%), although no one surveyed reported
inconsistency of the systems used, for example no coding in
experience of these or other adverse effects associated with IT
records for morbidly adherent placenta. Local presentation
diamorphine.
highlighted these problems, which are being taken forward.
Discussion: There is variability regarding the IT diamorphine
Conclusion: Our review, and subsequent MDT discussion,
dose given to women for emergency cesarian section who
has confirmed the place of intra-arterial balloon catheters
have already received IM diamorphine in labour. This practice
within local guidelines for management of morbidly adherent
is based on limited evidence. Given the lack of adverse effects
placenta, and other occasional indications. We had decreased
reported from our survey and evidence from other specialties
blood loss in cases using balloons, but still saw a large
where diamorphine is used in higher doses 1,2,, we see no
proportion requiring hysterectomy.
reason to routinely reduce the IT diamorphine dose unless
References
there are clinical signs of opiate toxicity. Consideration should
1. Beilin Y, Halpern SH. Placenta accreta: successful outcome is all in be given to prolonged postoperative monitoring of all women
the planning. Int J Obstet Anesth. 2013;22:269–271.
who have received both IM and IT diamorphine, especially
2. Sadashivaiah J, Wilson R, Thein A. Role of prophylactic uterine
artery balloon catheters in the management of women with those in whom the interval between IM and IT diamorphine is
suspected placenta accreta. Int J Obstet Anesth. 2011;20:282-287 short or where there are signs of toxicity.
References
1. Fogarty DJ, Milligan KR. Postoperative analgesia following total
hip replacement ; a comparison of intrathecal morphine and
diamorphine. Journal of the Royal Society of Medicine 1995; 88:
70-72
2. Jacobson L, Kokri MS, Pridie AK. Intrathecal diamorphine: a dose-
response study. Annals of the Royal College of Surgeons of England
1989; 71: 289-292
Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin) P27
P153 Introducing self-administration of medication after P154 Is Remifentanil patient controlled analgesia an
caesarean section: a Robert The Bruce story effective alternative to epidural for labour analgesia?
A R Sajayan,  K Ramm,  T Yates,  Y Chikermane   V Betharia,  K Peckitt  
Anaesthesia, Heartlands Hospital, Birmingham, UK Anaesthesia, Stepping Hill Hospital, Stockport, UK
Introduction: We were involved in the introduction of the local Introduction: Remifentanil patient controlled analgesia (PCA)
protocol for self-administration of postoperative medications was introduced for pain relief in labour at our institution in
(SAM) after elective LSCS at a large obstetric unit. In the past, 2007. Since then its demand has steadily increased, gaining
several attempts to implement this have failed.We conducted a favour with midwives and patients due to simplicity of use,
pilot study to identify the obstacles and develop ways to effective analgesia¹ and good safety profile². We have
overcome the same standardised protocols for administration and monitoring of
Methods:A pilot project was conducted to find out the Remifentanil PCA and patient controlled epidural analgesia
obstacles in the process by obtaining feedback from the staff (PCEA) during labour which are strictly adhered to. Aim of our
and patient involved in the care of 10 patients who underwent audit was to assess both Remifentanil PCA and epidural PCEA
elective LSCS over a week’s time. Obstetric, anaesthetic, for labour analgesia and make recommendations for improved
recovery and ward staff were informed beforehand about this care of mothers and infants.
pilot by emails and personal discussion. The patients were Methods: This was a prospectively done, questionnaire based
given information leaflet during preoperative assessment and audit. Data was collected over 2 months from November 2013 -
were informed again on the day of operation. Interested January 2014. We looked at mode of delivery,
patients enrolled in the pilot with due consent. The self- cardiotocographic abnormalities, APGAR scores, maternal
administration pack contained analgesics and enoxparin and cardio-respiratory complications, conversion to alternative
was dispensed by the recovery staff. Exclusions were: methods of analgesia and patient satisfaction.
language barrier, patient refusal, lack of capacity and any co Results: There were 610 deliveries during the 2 months.
morbidities. Feedback was collected from patients and staff Remifentanil PCA was used in 102 (17%) and epidural PCEA in
using the standardized proforma during the postoperative 85 (12.2%) patients for labour analgesia.
visit. Mode of delivery:
Results:Two of the patients felt that on the first day it was
  Normal Assisted LSCS
difficult to use SAM due to mobility restrictions. One patient
Remifentanil PCA 69 (67%) 20 (19.6%) 13 (12.7%)
did not receive SAM pack due to communication problem
Epidural PCEA 29 (34%) 35 (41%) 21 (24.7%)
involving midwives and staff. The remaining seven patients
were satisfied with SAM. The obstacles we identified in the There was a higher incidence of cardiotocographic
pilot and also from the past experience and the way we tackled abnormality in the epidural group (61%) as opposed to
them are as below: Remifentanil group (34%). APGAR scores in both groups were
more than 8 at 5 minutes. None of the patients in either group
Obstacle Strategy
had respiratory depression or cardiovascular instability. Eight
Personal & email reminder
(7.8%) patients converted from Remifentanil to epidural due to
Promotional posters in clinical areas
inadequate analgesia whereas 4 (4.7%) patients in the epidural
Communication Reminder notices in operating room and recovery
group used alternative analgesia (3 switched to Remifentanil
Meeting with stakeholders (doctors, midwives&
and 1 to entonox). Patient satisfaction was similar in both
pharmacist)
groups at 95%.
Involving all staff in guideline preparation
Discussion: From our experience, Remifentanil PCA is a safe
Staff engagement Process simplified and paper work streamlined
and effective method of labour analgesia. We found no
Standardized SAM package and delivery
evidence of worsening cardiotocography or neonatal
Guideline Fully prepared guideline after extensive consultation
outcomes with its use. We also found that patients using
Time Pre-printed forms to increase efficiency and to avoid
Remifentanil have increased rate of vaginal deliveries as
management time delays and work duplication
compared to those on epidural. While epidural analgesia
Discussion: Self-administrationof medications after caesarean remains the gold standard and will be preferable in certain
provides better patient centered care. It improves patient and groups of patients, Remifentanil PCA is certainly an excellent
staff satisfaction, improves clinical efficiency and eases alternative to consider. In our institution its uptake has
staffworkload at hospital and at community level1. It empowers steadily increased to approximately 50 patients per month with
the mother in their own care, potentially reduces length of patients consistently report ing high levels of satisfaction.
stay, and facilitates seamless flow ofcare. Although staff and References
patients liked the concept alike, the process had failedthree
1. Blair JM, Dobson JT, Hill DA, McCracken GR, Fee JP. Patient
times before because of certain obstacles. This pilot helped us controlled analgesia for labour: a comparison of remifentanil with
to highlight the areas we needed to focus on with our new pethidine. Anaesthesia 2005; 60 (1) : 22-7
strategies and the results have been encouraging. After fully 2. Volikas I, Butwick A, Wilkinson C, Pleming A, Nicholson G.
Maternal and neonatal side-effects of remifentanil patient
implementing the project, the uptake is gradually getting better
controlled analgesia in labour. Br J Anaes 2005; 95(4): 504-9
and we continue to audit the outcome.
References
1. Snell P M, Bowden M I, Viira D J, Chilvers J P. An observational
study of self-medication of analgesic drugs after caesarean section.
Int J Obstet Anesth 2002; 11: S29
2. Change management good practice guideline-NHS Direct
P28 Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin)
P155 Is the existing local hospital guideline, 'Management P156 Klippel-Feil syndrome: management of anticipated
of women who decline blood products', being adhered difficult airway for caesarean delivery 
to? TM Price,  MT Qureshi,  ROK Laird  
J Houston,  R Burns   Department of Anaesthesia, Altnagelvin Area Hospital,
Simpson Centre for Reproductive Health, Royal Infirmary of Derry, UK
Edinburgh, Edinburgh, UK Introduction: Klippel-Feil syndrome (KFS) is a rare genetic
Introduction: An estimated 150000 Jehovah's Witnesses disorder affecting around 1 in 40,000 live births and is
(JWs) live in the UK1. JWs may not accept blood product (BP) characterised by the congenital fusion of any two of the
transfusion1, and have up to 130 times increased risk of cervical vertebrae1. In addition to the abnormalities of the
maternal death from major obstetric haemorrhage2. This cervical spine, patients may have thoracolumbar scoliosis,
retrospective case note review aims to establish how closely spina bifida and congenital heart defects. The classical
the hospital guideline, 'Management of women who decline phenotypic presentation is described as low hairline, short
blood products' (the Guideline), has been followed since its neck and limited neck and head movement. These patients can
May 2012 introduction, and to identify areas for improvement. therefore present a considerable challenge to the anaesthetist.
Methods: JWs managed at the Anaesthetic Antenatal Clinic The safest method of providing anaesthesia for operative
(AAC) since the Guideline's introduction were identified, and delivery of a parturient with KFS is controversial. We would
their medical records accessed. Information surrounding like to share our experience in managing four elective
aspects of patient management addressed by the Guideline caesarean deliveries in two parturients using awake oral fibre
was extracted. The findings were then audited against the optic intubation (AOFOI) and general anaesthesia.
Guideline to establish how closely it had been followed. Case Reports: The first patient had KFS Type II with fusion of
Approval was obtained from the Medical School and the cervical vertebrae and underwent elective caesarean deliveries
Regional Research Ethics Service. aged 35 and 37 years old. The second patient had KFS Type
Results: Of the patients referred (N=26), 92.3% were reviewed III with fused cervical vertebrae in conjunction with fusions in
at the AAC, and had management plans created, at 31.0 weeks' the thoracolumbar spine, and underwent elective caesarean
gestation on average (Guideline target: 28.0 weeks). 88.5% deliveries aged 31 and 39 years old. Our patients were both
completed a BP checklist before admission in labour, and pre-assessed by a consultant anaesthetist at a high-risk
96.2% by time of delivery. 7.7% agreed to accept BPs at clinic pregnancy clinic prior to delivery. This allowed time to discuss
and were discharged, so women studied became N=24. BP the anaesthetic options with each patient and plan for elective
refusal of 12.5% was not appropriately recorded in the notes, or emergency delivery. Both patients had the classical
and contrary to the Guideline, serum ferritin was not checked phenotypic features of KFS. Airway assessments revealed
in any woman. During pregnancy, 29.2% were not recorded as Mallampati class 4, thyromental distances less than 6cm and
having taken iron, and Hb was measured in 95.8%. Excluding severely limited neck flexion and extension. The trachea was
elective caesarean sections (CS), Obstetric consultants were not palpable in either patient. We anticipated difficult direct
documented as informed of admission in 13.6% of cases, and laryngoscopy in both patients and elected to manage the
54.5% of labours and deliveries were reviewed or supervised airway with an AOFOI followed by general anaesthesia. The
by senior Obstetric staff (ST6-consultant). 20.8% of total oral route was chosen as both patients had small nares in
deliveries were by CS: cell salvage was set up in 100.0% of keeping with KFS. Sugammadex ensured complete reversal of
these, and used in 80.0%. rocuronium induced neuromuscular blockade and smooth
Discussion: This study found the Guideline was closely emergence. Caesarean delivery and postoperative recovery
followed in some areas: completion of acceptable BP checklists was uneventful in all four cases.
before delivery, and availability and use of cell salvage in CS,
Discussion: As obstetric anaesthetists we are constantly
compare favourably to previous UK studies1,3. Areas to be
trying to minimise the risk to our mothers. Klippel-Feil
improved include that BP refusal must be appropriately
syndrome affects both the airway and the spine, making the
recorded in patient notes to ensure clarity upon presentation
choice of anaesthetic technique a difficult decision. Successful
in labour or an emergency. It is vital that iron supplementation
use of regional techniques including spinal, epidural and
is commenced early in JWs, and ferritin levels are monitored,
combined spinal-epidural anaesthesia, have all been described
to maximise iron stores. In light of this study's findings,
in the literature1. However, we feel that embarking upon a
hospital blood transfusion Haematologists, in the future, will
regional technique in patients with distorted neuroaxial
review JWs antenatally. The Guideline should quantify how
anatomy would expose patients to unnecessary risk of high
often Hb should be monitored, so anaemia can be detected
spinal block and/or inadequate regional anaesthesia. Should
and treated before delivery. Crucially, consultant staff must be
general anaesthesia be needed intra-operatively, attempting an
documented as informed upon admission of JWs in labour, in
AOFOI in an already distressed parturient would be
order that deliveries can be supervised by senior staff to
challenging. We therefore planned an AOFOI to secure the
reduce potential morbidity and mortality.
airway prior to general anaesthesia, in a controlled manner and
References
thus avoid a potentially difficult and emergent intraoperative
1. Massiah N, Athimulam S, Loo C, Okolo S, Yoong W. Obstetric care intubation. In summary, these are difficult cases that we
of Jehovah's Witnesses: a 14-year observational study. Arch
believe benefit from good antenatal planning and can be
Gynecol Obstet 2007; 276(4):330-343.
managed with a planned AOFOI and general anaesthesia.
2. Van Wolfswinkel ME, Zwart JJ, Schutte JM, Duvekot JJ, Pel M, Van
Roosmalen J. Maternal mortality and serious maternal morbidity in
Jehovah's witnesses in the Netherlands. BJOG 2009; 116(8): 1103- Reference
1108. 1. T. Kavanagh, R. Jee, N. Kilpatrick, J. Douglas. Elective cesarean
3. Nawaz YM, Atkinson S. Peripartum care of Jehovah's witness delivery in a parturient with Klippel–Feil syndrome. Int J Obstet
parturients: A five year review. Int J Obstet Anesth 2013; 22(S1): Anesth 2013; 22(4): 343-8
S22.
Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin) P29
P157 Labour and delivery in long QTsyndrome P158 Local anaesthetic toxicity audit: are workshops the
BJ Vowles,  FMM Bryden   best educational tool across the MDT?   
Anaesthetic department, Princess Royal Maternity, Glasgow, WITHDRAWN FROM PRESENTATION
UK JL Lambert,  D Chitre,  L Evans  
Introduction: A 22 year old primigravida presented to the high Anaesthesia, Southend Hospital, Southend, UK
risk clinic at 22 weeks gestation. She had been diagnosed with
long QT syndrome (LQTS) after her family had been
investigated following a sudden early cardiac death and was
found to be heterozygous for the KCNQ1 gene, responsible
for Long QT1. She was under regular review by the
cardiologists who had advised β blockade with bisoprolol
2.5mg orally (PO) for 9 months post partum due to an increase
in arrhythmia risk during this period. She had also been given
a list from Azcert Inc., advising drugs that should be avoided
and included on this list was syntocinon.
Labour and delivery: She was admitted in labour at term and
the decision was made by the obstetric team, not to administer
syntocinon to augment labour. They also felt that epidural
analgesia was unsuitable because it would slow the progress
of labour. However following an initial dose of intramuscular
(IM) diamorphine, the parturient requested epidural analgesia.
We felt this would be beneficial for minimising her arrhythmia
risk and so she obtained a working epidural with a bilateral T10
block. ECG monitoring was commenced on admission and
.
initially showed bigeminy. A 12 lead ECG demonstrated a QTc
of 460ms. Electrolytes checked at this time were in the normal
range. Over the subsequent 8 hours she failed to progress and
underwent a caesarean section with an effective epidural top
up of 20ml 0.5% L-bupivacaine. At delivery syntocinon was
administered as a slow infusion of 5 units in 100mls 0.9%
saline over 20 minutes, followed by 500µg ergometrine IM to
maintain uterine tone. 50mg IM cyclizine and 10mg
intravenous (IV) metoclopramide were used for anti-emesis.
She was monitored in the Obstetric high dependency unit
(HDU) for the following 48 hours, where an initial ECG
demonstrated frequent ventricular ectopics, with a QTc 432ms.
Electrolytes were again normal at this time.
Discussion: There are many lists of drugs available on the
internet with differing advice as to which drugs to avoid in
long QT syndrome. The one which our patient had been given
clearly stated syntocinon should not be administered, despite
no definitive evidence of harm with this drug in patients with
LQTS. In addition we found no guidance in published case
reports, on oxytocic drugs administered to patients with LQTS
in labour or at delivery1. There are case reports of ventricular
tachycardia after administration of syntocinon in long
QTsyndrome2 and one report of a pateint receiving it with no
sequelae3 Ideally the authors feel that this lady merited a case
conference prior to admission so that informed decisions
could be made. Whilst the outcome of this patient's labour and
delivery may not have been different, a short trial of
syntocinon with ECG monitoring may have altered her mode of
delivery.
References
1. Drake E, Preston R, Douglas J. Brief review: anaesthetics
implications of long QT syndrome in pregnancy. Can J Anaesth.
2007; 54(7): 561-72
2. Liou SC, Chen C, Wong SY, Wong KM. Ventricular tachycardia
after oxytocin injection in patients with prolonged Q-T syndrome -
report of two cases. Acta Anaesthesiol Sin 1998; 36: 49-52
3. Charbit B, Funck-Bretano C, Samain E, Jannier-Guillou V,
Albaladejo P, Marty J. Qt interval prolongation after oxytocin bolus
during surgical induced abortion. Clin Pharmacol Ther 2004; 76:
359-64
P30 Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin)
P159 Lymphangioleiomyomatosis and Pregnancy: A Case P160 Major obstetric bleeds-are we doing the right thing?-
Report A multi-centre study in west midlands
M Cole,  S Petkov,  J Pickett   A R Sajayan,  M McLoughlin,  S Dinesh,  A Walunj*,  J
Anaesthetics, Addenbrookes Hospital, Cambridge, UK Karattuparambil †,  M Ravindran†  
Introduction: Anaesthesia, Heartlands Hospital, Birmingham, UK,
Lymphangioleiomyomatosis (LAM) is a rare condition causing *Anaesthesia, Good Hope Hospital, Sutton Coldfield, UK,
proliferation of smooth muscle in the respiratory system, †Anaesthesia, George Eliot Hospital, Nuneaton, UK 
which can cavitate leading to degradation of lung parenchyma Introduction:Guidelines1 exist on the definitions of massive
and cystic lung disease1. Because of the risk of progression, bleed, the proposed management pathway and the safe time
women with LAM are frequently advised to avoid pregnancy2. frame for obtaining the blood and products. This multi-centre
We present a case of LAM where multidisciplinary audit looks at the average time taken for the blood/products to
management led to a successful outcome of pregnancy, with a be available in major bleed situations in obstetrics
focus on anaesthetic considerations. Aim: To find out the incidence and reasons for delays in
Case Study: issuing the blood/products, if any, from the blood bank and to
A 35 year old woman presented with bilateral spontaneous compare the existing practices and experience with the other
pneumothoraces in the first trimester of her 2nd pregnancy. hospitals in the area
Both required surgical correction and a lung biopsy revealed a Methods: We collected the data from three participating
diagnosis of LAM. Computerised tomography of her thorax hospital in west midlands using a standard proforma which
showed multiple small lung cysts. Past history included an included the number of massive obstetric bleed calls during a
uncomplicated first pregnancy and emergency caesarean six months period in 2013, the estimated blood loss, the time
section for foetal distress, aged 33; and a spontaneous taken for the first unit of blood/ product to be issued and the
pneumothorax aged 34, requiring surgery. The patient was number of products used among other data.
referred to a tertiary centre for multidisciplinary management.
Results: The results suggested that there is ambiguity in the
Care was shared between obstetrics and respiratory medicine
way major haemorrhage was defined in different situations
and she attended the high risk anaesthetic clinic. Elective
which led to unnecessary calls where blood products were not
caesarean delivery at 38 weeks was agreed upon. She had
urgently needed. Also, the time for getting the products varied
three further small pneumothoraces, treated conservatively
widely the longest being 200 minutes. The documentation of
with no marked deterioration in respiratory function. Elective
the details of the bleeding, time of calls and time of
caesarean section was performed at 38/40 gestation.
blood/product administration were incomplete and inaccurate
Respiratory assessment and examination on the morning of
in some cases.In one hospital, major bleed calls were only put
surgery were normal. A two-space combined spinal epidural
out in two out of 17 cases where blood loss was more than
was sited, administering intrathecal hyperbaric bupivacaine
1500ml.
and diamorphine. A respiratory physician was present at
delivery in case of deterioration. Delivery was uneventful, with   Hospital1 Hospital2 Hospital 3
no immediate complications. The patient spent 24 hours in an Number of MOH calls 58 41 2
obstetric close observation unit post-operatively. Her post- Full data available 13 18 2
natal period was uneventful and required no further obstetric, Average time for group specific (min) 59 NA 33
respiratory or anaesthetic intervention. Average time for X match blood (min) 63.45 42.27 0
Longest delay (min) 200 104 33
Discussion: LAM is a rare condition with an estimated UK
prevalence of 1per million3. Hypotheses suggest oestrogen
Discussion: The definitions of massive blood loss are:
accelerates disease progression and pregnancy may result in
Transfusion of a volume equal to the patient’s total blood
new diagnosis or exacerbation4, therefore obstetric
volume in less than 24 hours / 50% loss of blood volume
anaesthetists should have awareness of this disease. There is
within 3 hours / rate of blood loss 150ml/minute. Though the
sparse literature for anaesthetic management of pregnancy
circumstances of individual episodes of major bleed could
with LAM, consisting mainly of case reports. Considerations
vary, there was no consistency in the trigger of activating
suggested include; avoiding excessive Valsalva manoeuvre
major bleed calls. There were also unacceptable delays in
via instrumental or elective caesarean delivery, avoid nitrous
obtaining the first unit of blood in some cases. The first set of
oxide, early epidural analgesia, obtunding intubation response
uncross matched group specific blood should be available in
and lung protective ventilation strategies if general
20minutes and cross matched blood in 40minutes2. The study
anaesthesia. This case report supports that pregnancy in
suggest that there is a need for the reinforcement of major
LAM patients can progress successfully and highlights the
bleeds definition and also a need for a clearer pathway and
importance of a MDT approach, early anaesthetic assessment
consistency in issuing blood and products in major bleed
and a well considered anaesthetic and obstetric plan.
situations. This audit results will be used to formulate a
References uniform policy in the participating hospitals and a re-audit will
1. Rosendal T. A Case of Diffuse Myomatosis and Cyst Formation in be done in six month time
the Lung. Acta Radiaology. 1942; 23: 138-146
2. Cohen MM, Freyer AM, Johnson SR. Pregnancy Experiences References
Among Women With Lymphangioleiomyomatosis. Respiratory
1. D Thomas etal,Blood transfusion and the anaesthetist: management
Medicine. 2009; 103: 766-772
of massive haemorrhage, Anaesthesia 2010 November; 65(11):
3. Johnson SR, Tattersfield AE. Clinical Experience of 1153–1161
Lymphangioleiomyomatosis in the UK. Thorax. 2000; 55:1-5
2. Guidelines on the management of massive blood loss.
4. McLoughlin L, Thomas G, Hasan K. Pregnancy and BJHaematology 2006; 135(5): 634-641
Lymphangioleiomyomatosis: Anaesthetic Management.
International Journal of Obstetric Anaesthesia. 2003; 12: 40-44
Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin) P31
P161 Management of labour and delivery using  minimally  P162 Management of manual removal of placenta and third
invasive FlotracTM system in a parturient with  and fourth degree tear repair: pathway analysis
congenitally corrected transposition, dextrocardia P Jegendirabose,  J Subramanya*,  S Watkinson*,  J Short  
and systemic ventricular dysfunction Anaesthesia, Queen Elizabeth Hospital, Woolwich, London,
R Vedagiri Sai,  S Dhir,  J Racine   UK, *Obstetrics & Gynaecology, Queen Elizabeth Hospital,
Anesthesia, Western University, London Ontario, Canada Woolwich, London, UK
Introduction: More women with congenital heart disease now Introduction: Guidelines suggest that repair of obstetric anal
survive to reproductive age due to advances in modern sphincter injuries (OASIS) and manual removal of retained
medicine. Obstetric management is challenging in these placenta (MROP) should be undertaken as soon as possible to
complex cases. We present the anaesthetic management of minimise the risk of infection, blood loss and maternal
labour and delivery in a woman with congenitally corrected morbidity1,2. Anal incontinence and perineal pain can impact
transposition of great vessels, dextrocardia, systemic significantly on maternal quality of life and mother-child
ventricular dysfunction and junctional tachycardia using bonding.
minimally invasive continuous haemodynamic monitoring and Methods: We conduced a retrospective audit which showed
optimisation. shortcomings in our management of MROP and OASIS and we
Case report: A 28 year old primigravida presented with a undertook an analysis of a full calendar year's cases. All cases
diagnosis of congenitally corrected transposition of great of MROP and OASIS were identified over January 2012 to
vessels and dextrocardia. The atrial septal defect had been December 2012 using both theatre electronic records and
repaired in childhood. Her medications included folate and maternal records. Time from delivery of fetus to MROP or
multivitamins. She had good exercise tolerance, stable vital OASIS repair, blood loss and blood transfusion requirement
signs and was followed up by Cardiology team throughout her were reviewed.
pregancy. ECHO showed 50% ejection fraction (EF) and mildly Due to lack of nationally set standards, we set a local standard
reduced systemic (morphologic right) ventricle. A multi- of no more than one hundred and twenty minutes from
disciplinary meeting between Obstetrics, Cardiology, delivery to repair for OASIS.
Anaesthesia and Intensive care unit (ICU) team was held to
Results: Our institute is a secondary obstetric centre with
decide on optimal obstetric management. Induction of labour
4800 deliveries per annum. During the twelve month period,
was planned.
105 patients sustained OASIS. The mean delay from delivery
At 37 weeks she developed palpitations, increasing shortness to surgery was 136 minutes. The average blood loss was 501
of breath and peripheral oedema. Repeat ECHO showed millilitres and 3% of patients required blood transfusion. Total
moderate ventricular dysfunction with EF 40%, severe of 42 patients required manual removal of placenta with
systemic atrioventricular regurgitation and severely enlarged regional or general anaesthesia. The mean delay from delivery
left atrium. Prior to labour induction, an arterial line was to surgery was 178 minutes. The mean blood loss was 790
inserted and continuous cardiac output monitoring was millilitres and 5% of the patients required blood transfusion.
performed using arterial pressure waveform analysis with the
FloTracTM monitor. Haemodynamic optimization was guided OASIS repairs n=105 Time (minutes)
by stroke volume variation and goal directed fluid therapy. A Delivery to booking 81 (Cl 70-92)
lumbar epidural was then inserted followed by rupture of Booking to surgery 68 (Cl 40-95)
membranes and oxytocin infusion. Fluid balance was closely Delivery to surgery 136 (Cl 122-150)
monitored continuously using FloTracTM. 1st stage of labour MROP n=42 Time (minutes)
was uneventful and 2nd stage was shortened using vacuum Delivery to booking 138 (Cl 115- 160)
assisted delivery of a healthy baby. She had a second degree Booking to surgery 39 (Cl 32-46)
tear which was repaired. Post partum haemorrhage due to Delivery to surgery 178 (Cl 152-204)
uterine atony was treated with 400µg Misoprostol rectally and
Incidentally, 78% of the patients did not have electronic record
intravenous infusion of 20 IU of Oxytocin. Estimated blood
of estimated blood loss on the theatre system.
loss was 800 mL. Cardiac condition was stable apart from
Discussion: In our institution, these cases are booked onto
persistent tachycardia throughout labour. Postpartum, she
the general emergency theatre, and not in the designated
spent 24 hours in ICU with similar monitoring. Her tachycardia
emergency obstetric theatre. We have identified that this has
settled spontaneously. She was discharged home on day 4.
resulted in significant delay in surgery and increased blood
Discussion: Patients with congenitally corrected transposition
transfusion requirement. We are now changing the patient
have a thin-walled right ventricle as the systemic circulatory
pathway to include urgent utilisation of the emergency
pump. The stress of increased cardiac output can cause
obstetric theatre for these procedures. Since the presentation
failure, atrioventricular regurgitation and arrhythmias1. We
of this audit, we have included the estimation of blood loss in
used minimally invasive continuous cardiac output
the surgical sign out process, thus improving communication
monitoring, fluid balance optimisation and good maternal pain
and patient care.
control to prevent decompensation and achieve vaginal
References
delivery with a good feto-maternal outcome.
1. National Institute for Health and Care Excellence. 2007.
Reference Intrapartum care. Care of healthy women and their babies during
childbirth. Clinical guideline 55
1. Dob DP, Naguib MA, Gatzoullis MA. A functional understanding of
moderate to complex congenital heart disease and the impact of 2. Fernando RJ, Sultan AH, Kettle C, Thakar R. Methods of repair for
pregnancy. Part I: the transposition complexes.Int J Obstet Anesth. obstetric anal sphincter injury. Cochrane Database Syst Rev. 2013
2010 Jul;19(3):298-305 Dec 8;12:CD002866.
P32 Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin)
P163 Multidisciplinary involvement of the high risk P164 National Obstetric Anaesthetic Database: a useful tool
parturient to benchmark maternity units in the UK
S De Silva,  P Gregory,  E Combeer   G Keightley,  N Tailor,  R Baraz,  L De Lloyd  
Anaesthetics, Frimley Park Hospital, Frimley, UK Anaesthetics, University Hospital of Wales, Cardiff, UK

Our Hospital offers a high risk Obstetric Anaesthetic Clinic for Introduction: The National Obstetric Anaesthetic Database
review of parturients with anticipated Anaesthetic or Medical (NOAD) was set up in 1998 to establish a framework for
problems where a checklist referral form is used. We audited collecting national obstetric anaesthetic data considered
whether women were appropriately referred or inappropriately relevant to obstetric anaesthetists. Whilst preparing the
not referred. An alert sticker was created to encourage NOAD survey for 2012, we explored the usefulness of this
healthcare providers to alert the oncall Obstetric Anaesthetist data in benchmarking our units' performance at the University
when the high risk parturient presented to labour ward. We Hospital of Wales (UHW) in relation to NOAD published
went onto audit the effectiveness of this alert sticker. figures from the previous year.

Methods: Data was collected according to the NOAD 2012
Methods: We looked at 200 consecutive births during October
survey and therefore, ethical approval was not required. Due
2010 and ascertained how many of these women had referrals
to the large number of deliveries in our unit, data regarding
to the High Risk Clinic. In the referred cases, we asked whether
labour analgesia, mode of delivery, caesarean section rate and
referral criteria were met and also determined if any mothers
type of anaesthesia was based on six months period (Jan to
were inappropriately not referred. In 2012 we retrospectively
June 2012) and then doubled. Exceptions were critical care
inspected all notes of mothers seen in High Risk Clinic with an
admissions and patients with accidental dural puncture (ADP);
estimated delivery date of March to May 2012. We checked
these were collected and reviewed individually for the entire
whether an alert sticker was present in their notes and also the
year. Microsoft Excel was used to analyse the data.
time taken for the Obstetric Anaesthetist to be contacted once
the mother had presented to Labour Ward. Results: The number of total deliveries in our unit for 2012

was 6138, of which 3060 required anaesthetic procedure(s).
Results: In 2010, 178 of 200 notes were reviewed and 14
The table below compares performance and quality indicators
women met referral criteria and 12 of these were referred.
at UHW in 2012 with the NOAD averages from 2011.
Fourteen percent were therefore inappropriately not referred,
however no women were inappropriately referred. Indicator UHW 2012 NOAD 2011

Caesarean section (CS) rate 22% 24.8%
In 2012, 42 notes were inspected where only 8 had the alert
Elective CS rate 46% 39.1%
sticker in place, with only 5 in the correct position. Two
De novo general anaesthesia (GA) for CS 4.5% 4.7%
mothers with the alert had elective caesarean sections. In five
Conversion to GA (CS) 1.8% 3.5%
of the six remaning mothers, the oncall Anaesthetist was
Labour regional analgesia 27% 22.7%
informed of their presence on labour ward. The average time
Epidural re-site rate 7.7% 9%
taken for this was four hours and 45 minutes (range 10 minutes
Accidental dural puncture rate 0.9% 1.2%
to 10 hours and 50 minutes). On review of the Clinic letters, it
was felt that 30 of the 42 parturients should have had an alert In 2012, three cases were transferred to critical care unit as
present in their notes, which is 71% not 19% as shown by our level 2 care (two with sepsis and one adult respiratory distress
audit. syndrome) and six cases as level 3 care (two with sepsis, three

post partum haemorrhage and one case of amniotic fluid
Discussion: In many cases of substandard care assessed by
embolus).
CMACE, there were major failures of communication between
Discussion: Our unit is classified as a large maternity unit
healthcare workers that may have contributed to the woman’s
compared to the national average. The elective CS rate and
death in some cases1. Our audits demonstrated that local
labour regional analgesia rates in our unit are higher than the
guidelines for referral were followed in 99% of cases, therefore
national average, possibly related to the complexity of a
high risk mothers were identified early. However, there still
tertiary centre. Despite this, our total CS rate is well below the
lacks effective communication of concerns within teams and
average with very low conversion to GA. In addition, our
poor involvement of other specialties early.
epidural re-site rate is lower than the national average, as is
Reference our ADP rate. Current facilities include two theatres serving
1. Centre for Maternal and Child Enquiries (CMACE). Saving both emergency and elective streams, and a mixed
Mothers'. Lives: reviewing maternal deaths to make motherhood recovery/high dependancy unit (HDU) for up to 5 patients.
safer: 2006–2008. The Eighth Report of the Confidential Enquiries
Our unit has a low transfer rate as level 2 care in general HDU,
into Maternal Deaths in the United Kingdom. BJOG 2011;118:1-203
due to the ability to care for these patients on our unit. We
find the NOAD data a useful tool to benchmark our
performance and set standards of care. More units should
contribute to the annual NOAD survey and consider using the
data as a way of identifying shortfalls and improving patient
care and services.
Reference
1. National Obstetric Anaesthetic Database report 2011.
http://www.oaa-anaes.ac.uk/content.asp?ContentID=586
Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin) P33
P165 Obstetric admissions to the Intensive Care Unit: a 6 P166 Obstetric outcomes with programmed intermittent
year review at a UK tertiary maternity centre epidural bolus labour analgesia
R Labib,  K Cullis   JTE Cremin,  CH Papageorgiou  
Selwyn Crawford Department of Anaesthesia, Birmingham Department of Anaesthesia, Hillingdon Hospital, Uxbridge,
Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin) P1
P101 A modified WHO surgical safety checklist for P102 A parturient with phocomelia and severe needle
category 1 caesarean sections phobia: the challenges faced
A Lahkar,  A Cooney,  G Massolini   R Sinha,  K Howard,  N Bhandal  
Anaesthetics, Milton Keynes NHS Foundation Trust, Milton Department of Anaesthesia, Nottingham University Hospitals
Keynes, UK NHS Trust, Nottingham, UK
Introduction: In June 2008, WHO introduced a surgical safety Introduction: Parturients with phocomelia are rarely seen and
checklist to be used in every operating theatre to improve present anaesthetic and obstetric challenges. We present a
patients' safety. In 2010 a WHO surgical safety checklist for case of a parturient with phocomelia and severe needle phobia.
maternity was created in response to requests from maternity Case report: A 33 year old woman with phocomelia and severe
services and clinicians. Nevertheless, in some emergency needle phobia presented to the obstetric anaesthetic clinic at
situations like category 1 Caesarean sections, this checklist 20 weeks for pre-assessment.
could still be quite a difficult task to achieve due to Her phocomelia was thought to be idiopathic, she had been
understandable time limit constrains to safely deliver the baby adopted when young and no family/drug history was
and/or save the mother's life. available. Examination revealed four limb phocomelia. There
Whilst there is still no international consensus or any specific were absent upper limb bones on the right and a fused hand
recommendation from WHO concerning these specific attached directly to her body. Her left upper limb was
situations, the Anaesthetic Department in Milton Keynes shortened with a primitive hand and fused fingers. Both lower
hospital has managed to devise a checklist for cat 1 LSCS limbs were extremely shortened with primitive feet with fused
which is 100% compliant both in terms of content with WHO toes. Her head, neck and torso appeared normal. She was able
guidelines and adherence by hospital staff. to mobilize with a wheelchair and significant assistance from
Method: After considerations and inputs from the Consultant her partner. The problems faced in clinic were numerous and
Anaesthetists, a simplified checklist was introduced in our focused on her severe needle phobia, difficult venous access
emergency obstetric theatre in June 2013 by way of an ad hoc and monitoring, positioning, mobilization and
poster hanged on the wall. It spells out the most 10 salient thromboprophylaxis as well as the challenges posed by the
questions to be read by one of the theatre staff before the start preganancy itself. The anaesthetic plan consisted of non-
of a category 1 Caesarean section. These questions translate invasive blood pressure monitoring on her left lower extremity;
the original 32 WHO ones that were spread across 3 sections pulse oximetry via an ear probe or toe and standard
in a simpler, quicker format. electrocardiogram. These were tested prior to labour. Due to
Results: After the introduction of the modified WHO checklist the impossibility of standard intravenous access and extreme
in June 2013, compliance is 100%. needle phobia several discussions were had about obtaining
Discussion: By putting the combined know-how and intravenous access prior to labour. A right subclavian
experience of many Consultant Anaesthetists to the task, we Hickman line was inserted at 39 weeks facilitated by the use of
managed to simplify the original WHO narrative into a sharper entonox. Regional analgesia was refused for labour so the
tool that is quickly and effectively utilised for a better and option of intravenous fentanyl via a midwife controlled
safer quality of care in what has become a "normal routine" analgesia pump was discussed. Should a caesarean section be
during extraordinary times in the emergency theatre. required a neuroaxial anaesthetic was refused and so a general
anaesthetic was planned.
Reference At 40+2 weeks spontaneous rupture of membranes occurred
1. WHO surgical safety checklist: for maternity cases only, and labour established. However, due to failure to progress a
http://www.nrls.npsa.nhs.uk/resources/?entryid45=83972 decision was made to perform a caesarean section.
In theatre the challenges related to positioning and achieving
a satisfactory left lateral tilt. A rapid sequence induction was
conducted following pre-oxygenation to an end-tidal oxygen
concentration of 92%. Anaesthesia was induced with
thiopentone 350mg and suxamethonium 100mg. Soon after
induction she desaturated rapidly to the high 60s. This
resolved after tracheal intubation and ventilation. She was
hypotensive intra-operatively, with an estimated blood loss of
1300mL After fluid and blood resuscitation, recovery was
unremarkable. Postoperative pain was managed with
transversus abdominus plane blocks and morphine
patient/midwife controlled analgesia.
Discussion: There is little literature about managing delivery
in women with phocomelia, but sucessful regional techniques
have been described although this was refused here. Early
discussion of anaethesia and analgesia options, and plans for
vascular access and monitoring are needed, There is a reduced
vascular reservior and skeletal muscle mass.
As a consequence faster inductions, emergences and
responses to titrated drugs are observed.

P2 Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin)
P103 A questionnaire to evaluate and aid future development P104 A retrospective descriptive analysis of anaesthesia for
of the AAGBI's SAFE obstetric anaesthesia course in successful cervical cerclage in pregnancy
Liberia J Modha,  G Burul*,  F Forya*,  CP James*,  AL David*,  J
JCO Fox,  CE Richards*,  T Sheraton*,  A Sonah†   Dick,  L Wee  
†Department of Anaesthetics, Phebe Hospital, Bong County,  Department of Anaesthesia, University College London
Liberia, *Department of Anaesthetics, Royal Gwent Hospital, Hospitals NHS Foundation, London, UK, *Department of
Newport, UK, Department of Anaesthetics, University Obstetrics, University College London Hospitals NHS
Hospital of Wales, Cardiff, UK Foundation, London, UK
Introduction: Dr Kate Grady has developed this three-day Introduction: Cervical cerclage is a common operation which
refresher course in obstetric anaesthesia on behalf of the requires an anaesthetic. There are no studies on the type of
AAGBI. The course is aimed at non-physician anaesthetists in anaesthesia used for this procedure.1
developing countries. It consists of short lectures, interactive Aim: To determine the type of anaesthesia used for vaginal
sessions and workshops that focus on the recognition and cervical cerclage.
management of leading causes of maternal death in resource
Method: Ethical approval waived. Women having any vaginal
poor settings. The course has been taught in Uganda,
cervical cerclage (Macdonald or Shirodkar) during pregnancy
Bangladesh, Liberia and Ghana. It includes the principles of
between January 2005 and December 2012 were identified
the WHO Safe Surgery and training of trainers. Mothers of
using the hospital obstetric anaesthesia database and cross-
Africa, a medical educational charity, has led delivery of 2
referenced with data from the Preterm Birth clinic where women
courses for nurse anaesthetists (NAs) in Liberia - supported
at risk of preterm birth are seen antenatally. Data was obtained
by the AAGBI IRC. Liberia has approximately 60 nurse
by examination of obstetric case notes and the ultrasound
anaesthetists and no medically qualified anaesthetists for a
scan records and analysis conducted using Microsoft Excel.
population of 4.2 million people1. Access to CPD is difficult.
Results: There were 190 cases. Twenty-five patients were
The MMR in Liberia is 770 per 100,000 live births1. In order to
excluded due to incomplete data, hence 165 included in
plan future development of the course in Liberia, which will be
analysis. The mean gestational age was 16.6 weeks (range 9-
led by Liberian trainers, feedback data was collected.
23.6 weeks). The table below shows that both general
Methods: A follow up questionnaire was given to 35 NAs who
anaesthesia (GA) and regional anaesthesia (RA) were used.
had previously attended a SAFE obstetric anaesthesia course
The majority of regional anaesthetics were spinals (95.7%), the
held in Liberia (March 2012 or March 2013). We aimed to
rest combined spinal and epidural (CSE) (3.6%) and epidural
assess; 1) the quality, usefulness and appropriateness of the
top up (0.7%).
material taught during the course, 2) the effect on motivation
to improve local services/care delivery, 3) the effect on the GA RA

confidence levels of NAs in managing obstetric anaesthetic n (%) n (%)
emergencies. Spinal n = 133
Results: A 70% follow up rate was achieved. 97% reported Total n=165 26 (16%) 139 (84%) CSE n = 5
positive changes in their attitude to work and their clinical Epidural n = 1
practice and 94% reported improvements in interactions with Five patients who had a spinal anaesthetic required second
colleagues. Many NAs gave details of cases where the skills procedures (3 GA, 1 spinal, 1 CSE). Of those converted to GA,
and knowledge they learnt on the course helped save lives one patient had a block to T6 (the reason for conversion to GA
and improve clinical outcomes. 11 NAs requested continued was not documented), one patient had a block to T12 and the
education and training. Other suggestions for course third patient had 3 failed spinal attempts. In all cases there
improvement included; additional sessions in preoperative were no major anaesthetic complications and cervical cerclage
assessment and TAP blocks, and the inclusion of midwives in was placed successfully.
the training sessions. The following table illustrates the mean
Discussion: In this series, the majority of vaginal cervical
subjective confidence scores (between 0 and 10) of the NAs in
cerclage surgery was performed safely and effectively under
various clinical scenarios before and after the course.
RA. There are no specific guidelines regarding the type of
  Before After anaesthesia for cervical cerclage.1 Anaesthetic considerations
General anaesthesia LSCS 6.3 9.2 favouring a regional anaesthetic in pregnancy include the risk
Spinal anaesthesia LSCS 7.6 9.8 of aspiration and difficult airway management in patients over
Management of severe eclampsia/preeclampsia 5.7 9.2 20 weeks gestation and those under 20 weeks gestation if at
Management of obstetric haemorrhage 5.9 9.4 high risk for example those with a high BMI. The majority of
women in our data set were less than 20 weeks (88.5%). Other
Discussion: Our results indicate that the SAFE obstetric
considerations include patient and surgeon choice. Women in
anaesthesia course in Liberia has been well received with
this series were given the option of GA or RA. In certain cases
subjective evidence of empowerment and improved methods
for example rescue and abdominal cerclages, the patient may
of working. This is promising in the context of increasing the
need to be in a deep Trendelenberg position to aid reduction
reach of future courses and enabling local faculty to lead
of membrane prolapse to avoid membrane rupture or to aid
training. Further data from logbooks provided as part of the
access to the pelvis.2
course were not obtained and more work is needed to
encourage completion of the logbooks. Objective evidence is References
required to demonstrate impact on patient outcomes. 1. Cervical Cerclage, Green-top Guideline No 60, Royal College of
Reference Obstetricians and Gynaecologists, May 2011.
2. Olatunbosun OA, Dyck F. Cervical cerclage operation for a dilated
1. http://data.worldbank.org/indicator/SH.STA.MMRT/countries/1W-
cervix. Obstet Gynecol. Feb 1981;57(2):166-70.
LR?display=graph
Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin) P3
P105 A retrospective descriptive analysis of dose of P106 A step towards improving theatre productivity for
intrathecal anaesthesia and adjuncts for successful elective caesarean sections
cervical cerclage in pregnancy S Kale,  C Farrow,  N Owen,  K Miltsios  
J Modha,  G Burul*,  F Forya*,  CP James*,  AL David*,  J Department of Anaesthesia, Whittington Hospital, London,
Dick,  L Wee   UK
Department of Anaesthesia , University College London Introduction: NHS Institute for Innovation and Improvement
Hospitals NHS Foundation, London, UK, *Department of developed The Productive Operating Theatre Programme to
Obstetrics, University College London Hospitals NHS improve effective use of theatre time, staff and patient
Foundation, London, UK experience.1 Good administrative system and organisation is
Introduction: Cervical cerclage is a common operation, which essential to ensure theatre efficiency.2On this background,
requires either a general or regional anaesthetic aiming for a with the rational of making existing system more productive,
block height of T10. There are no studies determining the dose safe and reliable, we evaluated current practice in one of our
that should be used to achieve this or describing additional main theatres, designated for elective sections, in a DGH set
drugs used for successful surgery. up.
Aim: To determine the dose of local anaesthesia used for Methods: Evaluation was carried out over a 4-week period, for
intrathecal injection and the block height achieved in women planned caesarean sections. The data was collected
undergoing cervical cerclage. In addition to determine the use concurrently by the anaesthetist for that case and from the
and dose of adjuncts. theatre database. The exact time for all significant events, such
Method: Ethical approval waived. Women having vaginal as when patient was sent for or when theatre was clean and
cervical cerclage during pregnancy between January 2005 and ready for the next patient, was recorded. Reasons for delays,
December 2012 were identified using the hospital obstetric duration of anaesthesia, surgery and problems encountered
anaesthesia database and cross-referenced with data from the were also recorded. Time spent at and between different
Preterm Birth clinic. Data was obtained by examination of crucial stages in theatre was calculated from the data. Results
obstetric case notes and the ultrasound scan records and are presented in the form of time in minutes, median [range]
analysis conducted using Microsoft Excel. and % (absolute numbers of cases).
Results: In all cases, cervical cerclage was achieved Results: We had 25 completed forms. Our analysis showed,
successfully. There were 138 cases of intrathecal anaesthesia median time interval from patient sent for to arrival in theatre
(133 spinals and 5 combined spinal epidurals) in whom 67.4% as 5 min [1-29]. Reasons for delay were due to obstetric team
(93/138) had documented intrathecal anaesthetic dose and busy in meeting, midwife busy preparing the patient and
were included for final analysis. Hyperbaric bupivacaine 0.5% midwife busy completing paperwork for previous patient in
was used (mean dose 10.9mg, median 10.8mg and mode 10mg, recovery. Median time interval between patient's arrival and
range 6.5–15mg). Block height and dose of intrathecal neuraxial block was 18 min [10-70], prolonged in 8% of cases
anaesthetic was documented in 54/93 cases (58%). The block (2/25) due to failed and repeat block. Bladder catheterisation
height ranged from T2 to T12 with similar doses of local after block was delayed by ≥30 min in 8% of cases (2/25) due
anaesthetic given in each group and of similar gestation and to unavailability of midwife. Median anaesthetic time for
body mass index (BMI). satisfactory block was 12 min. Interval between block ready
and knife to skin (KTS) was 6 min [1-12]. Median surgery
Block height T2-4 T5-8 T10 T12 duration was 45 min [31-141]. PPH, high BMI, and previous
Frequency 7 31 13 3 laparotomies resulted in longer operations in 16% of cases
Mean dose mg (4/25). Median turnaround time between the cases was 10 min
11 11 11 8
hyperbaric bupivacaine 0.5% [6-15]. Total time patients spent in theatre was 89 min [74-183].
Mean gestation (weeks) 17.4 17.7 15.6 19.1
Discussion: We noted that unavailability of obstetric team
Mean BMI kg/m2 27.3 26.6 26.1 32
and busy midwives at times has resulted in late starts and
In 3 patients that had block heights of T12 only one was delay in some procedures in theatres. Delay in starting the
converted to GA. Opiates were used in 73/93 (78.5%), the most surgery after a satisfactory block and prolonged turnaround
frequent being fentanyl. time have also affected the overall theatre productivity. We
have put forth some recommendations to working group such
Mean dose Range
Opiate used Number (%) as offering administrative support to midwives, ensuring
(mcg) (mcg)
senior obstetrician and anaesthetist are present for difficult
Fentanyl 69 (95) 20 10-75
cases, making use of anaesthetic room to improve patient
Diamorphine 3 (4) 300 250-350
turnaround time and most importantly encouraging staff
Fentanyl & Diamorphine 1 (1) 20/300 N/A
nurses to take the lead role in increasing theatre efficiency.
Vasopressors were used in 26 cases (23 phenylephrine, 3 This could be a big step towards enhancing theatre output as
ephedrine). Other drugs included 3 cases of intravenous well as increasing patient and staff satisfaction. We aim to
midazolam, 1 case propofol and in 1 case salbutamol (as a introduce these changes soon and re-evaluate the practice in
tocolytic agent). the near future.
Discussion: In our case series there is a wide dose range of References
both hyperbaric bupivacaine 0.5% and opiate given. To 1. The Productive Operating Theatre programme,
achieve a block height of T10 or above a minimum dose of http://www.institute.nhs.uk/quality_and_value/productivity_series/the
11mg (2.2ml) is recommended which may be independent of _productive_operating_theatre.html
other factors. There is a wide variation in block height but 2. Theatre Efficiency,
http://www.aagbi.org/sites/default/files/theatreefficiency03.pdf
even a low block (T12) was found to be adequate.

P4 Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin)
P107 A year in the "maternity" life of an increasingly busy P108 Abstracts on the antenatal anaesthetic clinic
new build district general teaching hospital - coping presented to the Obstetric Anaesthetists' Association,
with training and service provision - 2013 1991-2013
H Wrigley,  PF Yoxall,  Janet Slee   AJ Wickham,  SM Yentis*  
Anaesthetics, St Helens & Knowsley NHS Trust, Liverpool, Anaesthetic department, St Mary’s Hospital, London, UK,
UK *Anaesthetic department, Chelsea & Westminster Hospital,
Introduction: Since moving to a new PFI built hospital in 2010 London, UK
our maternity unit has become more busy. Delivery rates/year Introduction: National reports1 and guidelines2 recommend
have increased from 2900 to 3700 pa (up 27.6% in 3 years) assessment of women with ‘high-risk’ pregnancies and
increasing demands upon anaesthetic services. potentially serious co-morbid disease in an antenatal
Methods: We reviewed all our maternity cases during 2013, anaesthetic clinic (AAC). We reviewed trends and themes in
both epidural and caesarean sections. We also surveyed our abstracts on this topic presented to the OAA.
CT2 trainees to assess their experience in terms of case Methods: Full-text records of abstracts (excluding case reports)
numbers during a newly introduced modular training block. presented at OAA meetings (1991-2013; see www.oaa-
Lastly consultant cover on labour ward was audited for CNST anaes.ac.uk) were searched using the terms ‘antenatal’,
purposes. ‘clinic’, ‘risk’ and ‘refer’. Relevant abstracts were reviewed for
Results themes and conclusions.
Results: Forty abstracts were presented at 14 Annual
n %
Meetings (Fig. 1); 3 were unavailable in full-text (2008) but 1
Total Deliveries 3700
was provided by the author on request. 35 were from single
LSCS 838 22.6
departments and 5 were surveys (4 national). Common topics
Grade I-III LSCS 464 12.5
were obesity (12, 30%), referral reason (7, 18%) and
Grade IV LSCS 374 10.1
appropriateness (4, 10%), and outcomes (5, 13%). Nine (23%)
LSCS - SAB 666 79.5
described single patient cohorts, e.g. cardiac. AAC workload
LSCS - Epidural 123 14.7
has increased from 2.3 to 28.6 patients per month over 22
LSCS - CSE 14 1.7
years, albeit at different centres. Obesity has replaced
LSCS - GA 119 14.2
musculoskeletal disease as the most frequent reason for
RA to GA 34 4.2
referral. Common concluding themes include the need to
Average BMI LSCS (Range) 28.3 (16.7-59.9)  
improve the timeliness and appropriateness of referrals, and
Epidurals 895 24.2
ensuring anaesthetic plans are both prominent and followed.
Epidural Resites 32 3.7
PDPH - Epidural 15 1.7
PDPH - SAB 2 0.3
Epidural Blood Patches 21
Average BMI Epidural (Range) 27.1 (16-62.8)  
CT2 Training One of our requirements is to teach at least 4
CT2s per annum obstetric basic competencies. Our trainees
receive a 4 week long daytime block covered by an anaesthetic
ST3-7 and a consultant. They attend 40 sessions, the majority
siting 15 epidurals and anaesthetise 30 caesarean sections
before embarking on daytime on calls. They attend our in-
Figure 1: number of abstracts on the AAC presented per year
house MODSS (Obstetric Simulation Day) run by one of our
Consultant Obstetricians. Discussion: Abstracts relating to AACs have become more
frequent in the last decade, presumably reflecting their
Consultant Input The number of funded Consultant labour
increasing provision and perceived usefulness (and
ward sessions has risen 7 to 10 sessions (7 elective lists per
recommendation in the 2002-04 CEMACH report3). Increased
week). A “High Risk Obstetric clinic” runs weekly to pre-
demand for this service is exacerbated by inappropriate
assess all potentially difficult patients (250-300 per annum).
referrals and budgetary constraints. Referral processes,
Discussion: Despite a significant increase in workload we
facilities, and documentation and inconsistent use of plans are
have managed to maintain levels of cover (both junior and
areas for development. Future work should focus on quality
consultant) whilst allowing for CT2 training in obstetric basic
improvement and assessment of cost-effectiveness. Nationally
competencies as required at both national and local levels.
agreed referral criteria and a national ‘anaesthetic plan’
This has been achieved by increasing our core of obstetric
document, complemented by referrer education, may enhance
consultant anaesthetists, increasing obstetric PAs and
the process. Multidisciplinary ‘one-stop-shop’ or midwifery
changing to a modular CT2 training programme.
led clinics for common problems, such as obesity, may be
beneficial.
References
1. Centre for Maternal and Child Enquiries. Saving Mothers’ Lives:
reviewing maternal deaths to make motherhood safer: 2006-08.
The Eighth Report on Confidential Enquiries into Maternal Deaths
in the UK. BJOG. 2011; 118(Suppl.1): 1-203.
2. OAA & AAGBI Guidelines for Obstetric Anaesthetic Services.
Revised Edition 2005. London: OAA/ AAGBI
3. CEMACH. Why Mothers Die 2000-2002. Report on Confidential
Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin) P5
P109 Accuracy of a new electronic obstetric anaesthetic P110 Accuracy of landmark approach to central neuraxial
database blocks in obstetric patients
Rohit Rohit,  R Abraham,  GNB Jackson   J Lie,  K Bhatia,  A Venkataraju,  P Kochhar  
Anaesthetic department, Royal Berkshire Hospital, Reading, Anaesthesia, St Mary's Hospital, Manchester, UK
UK Introduction: Correct identification of vertebral level could
Introduction: We have introduced a new electronic database prevent damage to the spinal cord during a central neuraxial
'ROAD' (Reading Obstetric Anaesthetic Database) to record block (CNB). Evidence suggests that ultrasound (US) imaging
obstetric anaesthetic data. Written & designed by one of our of the spine by an experienced operator leads to correct
anaesthetists it is secure, password protected & able to identification of vertebral level in 90% of the patients and
produce reports on patient data & the activity of individual decrease the number of attempts required for a successful
anaesthetists. More than 70% obstetric anaesthetic units use CNB1. National Institute for Health and Care Excellence
electronic data collection system in the UK but there is little suggests US could be a useful tool for epidural catheter
agreement as to the best format.1 We audited the accuracy of insertion2. Our aim was to determine the discrepancy between
data entry, as a marker of ease of use by the anaesthetists, landmark technique and US to identify level of insertion of
before auditing the content of the database. CNB.
Methods: This was a retrospective audit, analysing data for Methods: Two experienced US operators who were blinded to
one month period (June 2013). The data in 'ROAD' was the initial procedure retrospectively performed US imaging of
compared to 1) our handwritten anaesthetic record book spine post-operatively after elective caesarean section in 51
(ARB); 2) Midwifery led labour ward logbook (LWLB); 3) obstetric patients with their consent from January to March
Operating theatre electronic log 'Bluespier'. Data entered on 2013 in St Mary’s Hospital. All the patients had a lumbar CNB
the 'ROAD' was manually checked against all these three done by landmark approach. The documented vertebral level
sources and the results tabulated and analysed. at which CNB was performed was noted. This was then
Results: 253 records were found in the ARB. The ARB missed compared with the actual vertebral level identified by bedside
one case (found in Bluespier), Bluespier missed one case US imaging of spine.
(found in the ARB) and LWLB missed 6 cases (found in the
Results: 29 patients had a spinal, 20 had an epidural and two
ARB & Bluespier). The results show that 'ROAD' was 96%
had combined spinal-epidural anaesthesia. The median body
accurate compared to any of the other systems.
mass index (BMI) was 28.6kg/m2. Landmark technique was
No. of cases missing on only accurate in 39.2% of patients. There was no statistically
Total 'ROAD' accuracy against
  'ROAD 'compared to significant correlation between the experience of operator and
no. other data sources as %
others accuracy. 3% of patients had a CNB at the level of L or above.
2
ARB 10 253 96.047% Documentation of the level performed was excellent. Raised
Bluespier 7 174 95.977% BMI and difficulty in palpation of landmarks resulted in
LWLB 10 247 95.951% statistically significant decrease in the accuracy (p<0.05
'ROAD'   243   Fisher’s Exact Test).
Discussion: Pinder et al considered an accuracy of 89% for Discussions: Our findings co-relate well with other studies
their electronic record adequate enough to adopt computer which have found that the vertebral level identified by
based data collection system.2We used three different landmark approach was at least 1 interspace higher than the
methods of data collection already in regular use, to compare level located by US in 40% of the pregnant population 3. Our
with our electronic database and showed it to have a high audit further confirms that the use of traditional landmark
degree of accuracy. This suggests that the database is easy to technique is highly inaccurate with potential increase risk of
use and consistently completed by our anaesthetists. We wish needle injury to the spinal cord especially in the high-risk
to use our database to produce reports on anaesthetic service patient groups (morbid obesity and musculoskeletal
provision (including the quality & safety of that service) as problems). We propose that all elective obstetric patients,
well as for auditing individual anaesthetist activity patients having a lumbar epidural, and high risk patients
(particularly our novice obstetric anaesthetists to ensure having a lumbar CNB should have US imaging of the of their
appropriate case mix & experience during their obstetric spines to identify the correct vertebral level and other relevant
attachments). Before using any database to audit these anatomy. The main reasons being that US imaging does not
aspects it is important to ensure that the data being audited is involve any radiation, is compact, portable and readily
a true reflection of anaesthetic activity, we believe our new available at the point of care. Better US equipment availability,
database is sufficiently accurate to audit the data within it. The staff awareness with appropriate training and improved
limitation of our audit is that we only audited the data from one documentation would aid in providing safer patient care.
month but we believe that the data entry practice of all months
References
is similar. We conclude that our electronic database is accurate
1. Chin KJ, Perlas A, Chan V, Brown-Shreves D, Koshkin A, Vaishnav
& the data entered can be used to audit our obstetric V: Ultrasound imaging facilitates spinal anesthesia in adults with
anaesthetic service. difficult surface anatomical landmarks. Anaesthesiology 2011; 115
(1): 94-101
References
2. Ultrasound-guided catherisation of epidural space. National Institute
1. Campbell NJ, Youngs P, Anderson I. A national survey of obstetric for Health and Care Excellence January 2008
anaesthetic data collection methods in the UK. Int J Obstet Anesth
2012; 21: S53. 3. Lee AJ, Ranasinghe S, Chehade JM, Arheart K, Saltzman BS,
Penning DH & Bimbach DJ. Ultrasound Assessment of the Vertebral
2. Pinder A, Wrench I, Shepherd D, Freeman R. Assessment of a Level of the Intercristal Line in Pregnancy. Anaesth Analg 2011;
handheld computer to collect obstetric epidural audit data. Int J
113: 559-564
Obstet Anesth 2002; 11: 8.
P6 Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin)
P111 Adherence to antenatal anaesthetic advice in P112 An evaluation of anaesthetic antenatal clinics in the
labouring morbidly obese parturients. obese obstetric population
S Halliday,  LC Robertson ,  HM du Plessis   PR El-Dalil,  DS Cochran,  R Ganapathy*  
Anaesthesia, Princess Royal Maternity Hospital, Glasgow, Department of Anaesthesia, Sandwell and West Birmingham
UK NHS Trust, Birmingham, UK, *Obstetrics and Fetal Medicine,
Introduction: Morbidly obese parturients pose a high Sandwell and West Birmingham NHS Trust, Birmingham, UK
anaesthetic risk1. Antenatal anaesthetic assessment for Introduction: Maternal obesity is increasingly common, with a
women with a body mass index (BMI) ≥40 kg.m-2 at booking is BMI 35 found in 5% of pregnancies. Current CMACE / RCOG
advised2. Early establishment of epidural analgesia is often guidelines advocate the referral of patients with a BMI 40 to
advocated. We sought to determine if this advice is adhered to an anaesthetic antenatal clinic. This study aimed to evaluate
in our centre. the outcomes following the implementation of such a clinic in a
Methods: A retrospective case note review of 49 morbidly busy inner city district general hospital.
obese patients (BMI ≥40) assessed antenatally was Method: High-risk patients were referred to a multidisciplinary
conducted. As a control, data from 23 patients with a BMI <40 antenatal clinic involving Anaesthetics, Obstetrics and
who had a labour epidural was collected. We compared the Haematology; patients with a BMI 40 were referred to the
timing of epidural request from labour ward admission, cervical clinic and included in the evaluation. Data was collected
dilation and syntocinon administration at request and the time retrospectively on the reason for attending, the past medical
from epidural insertion to delivery. Mode of delivery was also and obstetric history as well as any anaesthetic or surgical
noted. intervention provided in the perinatal period.
Results: Mean BMI for the control group was 23.6 (range 17- Results: In 2011, 72 women were referred to the clinic with a
32) and for the morbidly obese group 44.6 (40-60). Eleven BMI 40, although there were often other relevant co -
morbidly obese parturients had an elective caesarean section morbidities. The BMIs ranged from 40 to 80 (mean = 44). 44
(CS). Nineteen of the remaining morbidly obese parturients patients (61%) had a normal vaginal delivery, 3 women (4%)
requested labour epidurals. Two parturients delivered prior to required assisted vaginal delivery, 17 (24%) had an elective
insertion. caesarean section (CS), whilst 8 (11%) had a non-elective CS.
Of these patients, 38 (53%) required no anaesthetic
Time to Syntocinon Insertion to
Cervical dilation intervention.
request administration n delivery
  Centimetres
Minutes (%) Minutes Table: Anaesthetic intervention and failure rates in obese
(range)
(range) (range) parturients compared to previously published failure rates1 in
BMI Yes 12 (52.2) the general obstetric population
375 (110-
<40 169 (0-435) 3.7 (1-7) No 11 (47.8) Spinal Epidural CSE GA
915)
(n=23) Number attempted 19 12 4 1
BMI Yes 13 (68.4) % Failure rate 5 17 0 0
334 (12-702)
≥40  261 (0-555) 3.65 (2-8) No 6 ( 31.6) Published % failure rates1 6 24 18 <1
(n=17)
(n=19)
Discussion: The results demonstrated low regional
Table: Timing of epidural request, cervical dilation and anaesthesia failure rates, with only 1 unsuccessful spinal (5%)
syntocinon use at request, and time from insertion to delivery. and 2 failed epidurals (17%); figures comparable to those
In the control group with a BMI <40 that had a labour epidural found in the general obstetric population (Table). There is little
(n=23), the number of spontaneous vaginal deliveries (SVD), available data for regional anaesthetic failure rates in the obese
trial of forceps (TOF) and lower uterine segment CS (LUSCS) obstetric population precluding a direct comparison, but a
were 13 (56.5%), 5 (21.7%), and 5 (21.7%), respectively. For higher failure rate would be expected. A previous study of 677
those with a BMI ≥40 with an epidural (n=17) there were 6 women with a BMI 30 found an emergency CS rate of 24%, 2
(35.3%) SVD, 3 (17.7%) TOF and 8 (47.1%) LUSCS. The significantly higher than the 11% demonstrated in this cohort
number of SVD in the BMI ≥40 without an epidural group was of BMI 40. This robust multidisciplinary approach in the
18 (85.7%) and there were no TOF and 3 (14.3%) LUSCS. antenatal period allows for adequate planning and early
Discussion: Despite antenatal review, the time to epidural institution of optimised perinatal management. The service
request was longer in the morbidly obese group, indicating a provided was predominantly consultant led, with the on-call
need for ongoing education. The time between epidural Anaesthetist required to attend out of hours for parturients
insertion and delivery was shorter in the morbidly obese group with a BMI 45, and to be informed of patients with a BMI
which had a significantly increased chance of CS, signifying 40; significantly 73% of the on-call consultants are dedicated
the importance of establishing a working epidural early in this Obstetric Anaesthetists. We feel these systems may account
cohort. for our findings, as well as promote early and effective
communication with patients. Whilst the sample was relatively
References small the results are sufficiently encouraging to suggest that a
1. Soens MA, Birnbach DJ, Ranasinghe JS, van Zundert A. Obstetric multidisciplinary approach significantly improves perinatal
anesthesia for the obese and morbidly obese patient: an ounce of outcomes in the obese obstetric population.
prevention is worth more than a pound of treatment. Acta
Anaesthtesiol Scan 2008; 52: 6-19 References
2. OAA/AABGI Guidelines for Obstetric Anaesthetic Services 2013. 1. Kinsella SM. A prospective audit of regional anaesthesia failure in
Association of Anaesthetists' of Great Britain and Ireland and the 5080 caesarean sections. Anaesthesia 2008; 63(8): 822-832.
Obstetric Anaesthetists' Association. London, 2013. 2. Usha Kiran TS, Hemmadi S, Bethel J, Evans J. Outcome of
pregnancy in a woman with an increased body mass index. BJOG
2005; 112(6): 768-772.
Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin) P7
P113 An evaluation of fasting times for elective caesarean P114 An evaluation of intrathecal diamorphine versus
section surgery fentanyl for lower segment Caesarean section in a
J Ghoshdastidar,  KM Sherratt,  M Seneviratne*,  A medium-sized district general hospital
McGlennan   K Ramm,  LT Fenton-May,  S Naresh  
Anaesthetics, Royal Free Hospital, London, UK, Department of Anaesthesia, Good Hope Hospital, Heart of
*Anaesthetics, University College Hospital, London, UK England Trust, Birmingham, UK
Introduction: Enhanced Recovery Programmes have shown Introduction: Intrathecal diamorphine is now recommended by
increasing evidence for the benefits of reducing fasting times the National Institute for Health and Clinical Excellence (NICE)
for those undergoing elective surgery1. Many of these as the opioid of choice for lower segment Caesarean section as
benefits could be applicable to the elective caesarean section it provides improved post-operative pain relief.1 However, it is
patient. We evaluated the fasting times of our elective also associated with a dose-dependent increase in the
caesarean section patients to assess whether we could make incidence of pruritus2 and nausea3 which may be more
improvements to patient care. significant with diamorphine given its longer duration of
Methods: The evaluation included all patients undergoing action. Having arranged appropriate protocols for post-
elective caesarean section surgery at the Royal Free Hospital operative monitoring of women receiving intrathecal
over a 3 month period.. Patients received standard instructions diamorphine, we introduced the therapy in late 2012.
to stop eating at midnight on the day of surgery and to stop Methods: The evaluation took place over a six-week period. A
drinking clear fluids at 6 am. Data was collected by anaesthetic small number of women were still receiving intrathecal fentanyl
staff using a standardised data collection sheet.. Patients were due to clinician choice, and these provided a useful
questioned about the time they last consumed solid food and comparator. Women who were still present in the hospital on a
when they last drank liquid. follow-up round on the first day post-op were asked questions
Results: In total 77 patients underwent elective caesarean about post-operative pain, nausea and pruritus. We also
sections during the period of evaluation. We obtained data assessed total oral morphine and codeine doses and time to
from 71 patients for fasting times for fluids and 72 patients for first dose.
fasting times for solids. Results: Basic data is presented in the chart.

  Fentanyl Diamorphine
Pre-op fasting % of Pre-op fasting % of
Number 15 36
times FLUIDS patients times SOLIDS patients
Time to first morphine (hrs) 5.29 8.9
(hr) (n=71) (hr) (n=72)
Mean morphine dose (mg) 65.4 30
2 - 4 5.6 6 - 12 15.3
No morphine required 1 (6.6%) 11 (30.6%)
4 - 6 15.5 12 - 18 66.7
Mean codeine dose (mg) 123 119
6 - 8 14.1 18 - 24 16.7

8 - 10 8.5 over 24 1.4
Time to mobilisation (hrs) 21.17 15.21
over 10 56.3    
Time to catheter removal (hrs) 20.3 16.6

Discussion: There are no fasting recommendations specific to
Pruritus 8 (53.3%) 24 (66.7%)
elective caesarean sections but the standard surgical
- requiring treatment - 0 (0%) - 8 (22.2%)
guidelines of 6 hours for solids and 2 hours for clear fluids are
Nausea 5 (33%) 13 (36.1%)
usually applied. Periods longer than 12 hours without fluid
- requiring treatment - 3 (20%) - 7 (19.4%)
have correlated with significant dehydration
in patients having elective caesarean sections2. There is also
Discussion: Our results replicate previous work demonstrating
some evidence to suggest that gastric fluid volume is
a reduction in immediate post-operative analgesia
increased with prolonged starvation in the pregnant patient3.
requirements following a switch from fentanyl to diamorphine,
Over fifty per cent of our patients went without fluids for
but an associated increase in side effects requiring
longer than ten hours prior to surgery, and almost eighty-five
intervention. There was also a reduction in times to first
per cent of patients went without food for greater than 12
mobilisation and catheter removal, which is worth closer
hours. Our results show that there is a need to introduce
inspection. It is likely to be multi-factorial: the patients having
methods to reduce fasting times. These could include pre-
superior analgesia and feeling ready to move sooner, but also
operative letters with individualised times to stop eating and
the proforma for the ward indicating the patient had received
drinking. Also patients lower down the surgical list could be
diamorphine. This required the anaesthetist to specify a time
actively encouraged to consume clear fluids, or even
after which she would be ready to mobilise, which might have
carbohydrate drinks as used in many Enhanced Recovery
improved motivation amongst the midwives and mothers to
programmes.
achieve mobilisation.

References
References
1. Aguilar-Nascimento JE, Dock-Nascimento DB. Reducing
preoperative fasting time: A trend based on evidence. World J 1. NICE clinical guideline 132: Caesarean section
Gastrintest Surg. 2010 March 27;2(3): 57-60 2. Wrench IJ, Sanghera S, Pinder A et al, Dose response to intrathecal
2. Mackenzie M, Yentis S, Woolnough M and Johnson M. Fasting diamorphine for elective caesarean section and compliance with a
periods and dehydration before elective caesarean section. national audit standard, Int J Obstet Anesth. 2007;16(1):17-21
Anaesthesia, 2010 Vol 65:99 3. Sibilla C, Albertazzi P, Zatelli R, et al, Perioperative analgesia for
3. Maltby JR, Sutherland AD, Sale JP, Shaffer EA. Preoperative oral caesarean section: Comparison of intrathecal morphine and
fluids: is a five hour fast justified prior to elective surgery?. Anesth fentanyl alone or in combination, Int J Obstet Anesth. 1997; 6(1):
Analg. 1986 Nov;65(11):1112-6 43-48
P8 Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin)
P115 An evaluation of obstetric critical care admissions in a P116 An evaluation of standards of informed consent and
district general hospital documentation for labour epidural analgesia
VL Williams,  M Greene,  D Saul   S Chaudhari,  N Smith,  P Prasad  
Department of Anaesthesia, Leighton Hospital, Crewe, Anaesthetic Department, George Eliot Hospital, Nuneaton,
Cheshire, UK Nuneaton, UK
Introduction: CMACE has provided doctors with excellent
Introduction : It is both medico legally and ethically important
data over the past 50 years about maternal mortality, but
that the patient is made aware of the nature and risks
unfortunately no data about maternal morbidity. In December
associated with a labour epidural. No national standardised
2013, the Intensive Care National Audit & Research Centre
information card for informed consent is available, although
(ICNARC) produced a second report that analysed critical care
the OAA does publish a epidural information card1 with
admissions of women who were pregnant or recently pregnant
specific risks and incidence rates. At our hospital, the
in 2009-2012 inclusive.1 A comparison was made between the
documentation is made on part of the epidural chart as an
hospital ICNARC data and the national ICNARC data.
open entry. Our study looked to ascertain whether appropriate
Methods: Data were collected from the hospitals ICNARC
details of the epidural and informed consent were made. This
database over a four year period from 2009 to 2012. The data
was with a view to find whether a total redesign of the epidural
was analysed from the categories in the table below.
chart (at a level of standard suggested by the OAA website2)
Results: Data from 388 patients were evaluated.
was needed to improve our practice.
  Hospital ICNARC
Methods : We evaluated a total of 100 completed epidural
Total no. of patients admitted, female 16-50 years 388 55,791
charts over a 4-month period in mid-2012 at our obstetric unit.
Currently pregnant 3.6% 2.1%
The epidural notes were retrospectively analysed on our
Recently pregnant 9.3% 10.0%
scanned patient electronic notes. Documentation was
Obstetric reason for admission - currently pregnant 0% 8.7%
analysed for: details of the patient, anaesthetist and patient
Non-obstetric reason for admission - currently
100% 91.3% assessment, explanation of the risks and incidence given,
pregnant
details of the epidural technique and post epidural
Obstetric reason for admission - recently pregnant 50% 69.7%
management. Our main focus was on standards of consent.
Non-obstetric reason for admission - recently
50% 30.3% Results:
pregnant
%of patients Rate of risk
Discussion: The proportions of patients admitted to the Range of risk discussed
Risk discussed informed documented (no.
critical care area were comparable with the ICNARC report. (no. in total)
(n=100) in total)
The leading indication for admission in the currently pregnant
1in100:13,1in200:8
group was for sepsis. This corresponds with the ICNARC Headache 69 25
<1%:3,1in500:1
report and most recent CMACE report in which sepsis was the
Hypotension 45
leading direct cause of maternal death.2
Failure 59 4 1in8:2, 1in4000:2
The leading obstetric cause for currently pregnant admissions
Nerve 1in13k:21,1in10k:8
nationally, was for pre-eclampsia. However, there were no 65 31
damage 1in15k:1, 1 in19k:1
admissions in this category at the hospital. This is most likely
Itching 14    
because pre-eclampsia is diagnosed and treated effectively on
Infection 37  
the labour ward and rarely needs input from critical care.
Motor block 28    
In the recently pregnant group, there were equal proportions
Urinary
of patients admitted for obstetric and non-obstetric reasons, 28    
retention
this is quite different from the ICNARC report. The leading
indication for admission of recently pregnant patients in the The other areas of documentation studied showed an
ICNARC report was for post partum haemorrhage, by a long acceptable standard.
way. When looking at the hospital database, it showed that in Discussion : Several studies have looked at standards of
the period 2010-12, only 3 of 42 patients with a significant post informed consent in UK practice3and which risks and
partum haemorrhage of 2.5 litres or more were admitted to incidences were discussed and the range of risk quoted. Our
critical care. Therefore the question needs to be asked as to study showed rates generally to be slightly lower than that
whether these patients should have been admitted to the quoted in these studies. This is likely due to limited space and
critical care area? The hospital does not have an obstetric open entry nature of our current chart. The OAA has set
HDU, but in hospitals that do have an obstetric HDU facility, guidelines and advice for both epidural charts2 and risks and
these patients would certainly have been admitted there, had incidence1. Following this evaluation, a full redesign of our
closer monitoring and possibly goal directed therapy. All of epidural charts with prompts and guidance of risks and
these patients survived, but could admission to critical care incidence is warranted. In addition, the OAA had
have improved patient outcomes or reduced hospital stay? overwhelming support for a national standardised information
References card that could be implemented3.
1. Female admissions to adult, general critical care units in England,
Wales and Northern Ireland reported as 'currently pregnant'
References
or 'recently pregnant'. http://www.icnarc.org/documents/Obstetric%
20admissions%20to%20critical%20care%202009-2012.pdf 1. OAA epidural information card : http://www.oaa-
anaes.ac.uk/content.asp?ContentID=185
2. The eighth report on confidential enquiries into maternal deaths in
the United Kingdom. BJOG 2011, 118(Suppl 2):1-203 2. OAA epidural charts : http://www.oaa-anaes.ac.uk/content.asp?
ContentID=522
3. Informed consent for epidural analgesia in labour: A survey of UK
practice: Anaesthesia 2009, 64 p161-164
Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin) P9
P117 An unusual cause of post-partum sepsis P118 Anaesthetic management of a parturient with severe
F A Corcoran,  C Brennan,  A J Downs   systemic scleroderma
Anaesthetics, Dudley Group NHS Foundation Trust, Dudley, P Thomas,  A Varvinskiy,  M Human  
UK Anaesthetics, South Devon Healthcare NHS Foundation
Introduction: Leiomyomas are common in women of Trust, Torquay, UK
reproductive age and have been linked to spontaneous Introduction: Scleroderma is a chronic systemic autoimmune
abortion, retention of the placenta and post-partum disease. Successful pregnancy in patients with severe
haemorrhage.1 It is however rare for them to be the primary systemic scleroderma is very rare. We report the anaesthetic
cause of post-partum sepsis. We describe the case of a post management of such a case in a patient with a difficult airway,
partum patient presenting with painful fibroids and sepsis. severe pulmonary dysfunction and oesophageal dysmotility.
Case report: A 37 year old woman (P1), 5 days post partum Case report: A 29 year old woman (G1P0) with severe
presented with a history of fever, abdominal pain and systemic scleroderma presented to the hospital at 36 weeks
distention. She had a past medical history of fibroids but there gestation with dyspnoea and tachypnoea. Prior to pregnancy
had been no problems during pregnancy. She had an her exercise tolerance was poor, managing just 400 metres in a
uneventful labour with a normal vaginal delivery. On initial six minute walk test with resultant oxygen saturations of 72%.
assessment she was apyrexial with normal observations. She Her Forced Expiratory Volume (FEV1), Forced Vital Capacity
had mild tenderness on palpation of her abdomen. She was on (FVC) and Diffusing Capacity for Carbon Dioxide (DLCO) had
regular analgesics and had been commenced on oral each worsened steadily by five percent year on year over the
antibiotics by her GP. An ultrasound scan (USS) was booked last decade. The most recently measured values from 2007
to investigate the abdominal pain. Within 4 hours she had were FEV1 30%, FVC 28% and DLCO 24% of predicted values
deteriorated and developed a pyrexia, tachycardia, tachypnoea although the patient reported that her pulmonary function had
and decreased oxygen saturations. Initial impression was deteriorated significantly during pregnancy. On admission the
sepsis secondary to retained products so blood cultures and patient was breathless at rest with a p02 of 7.63 on room air
swabs were taken and intravenous antibiotics, oxygen and and it was felt that natural labour would not be possible due to
fluid resuscitation commenced. She was transferred to the poor physiological reserve. Severe reflux secondary to
Maternity High Dependency Unit. CRP was elevated but oesophageal dysmotility rendered her unable to recline more
lactate was normal. She improved over 6 hours but than 45 degrees and she could therefore not lie flat for awake
deteriorated again. Antibiotic coverage was amended caesarean section. Airway assessment revealed microstomia of
following microbiology advice but she continued to have a less than one centimetre, mallampati four, bucked teeth, sub
swinging pyrexia. USS detailed a bulky uterus with a large mental skin scleroderma and a narrow hooked nose with small
fibroid at the fundus and no retained products. 36 hours after nostrils. Oral intubation was therefore ruled out. Awake Fibre
admission she developed peritonitis and a CT abdomen which Optic Intubation (AFOI) appeared technically challenging due
suggested findings of a pedunculated fibroid measuring to nasal anatomy. Preoperative, bedside nasendoscopy
17.5cm that might have twisted on its pedicle. She had an revealed that AFOI would be possible should the need to
emergency laparotomy which revealed a degenerative, secure the airway arise mid operation. This avoided the need
necrotic, infected fibroid. She required ionotropic support and to perform an AFOI or awake tracheostomy pre-operatively.
was difficult to ventilate intra-operatively. Post-operatively The patient was positioned at 45 degrees on the operating
she was transferred to intensive care where she was sedated table. Surgeons confirmed that they could operate in this
and ventilated overnight. She was successfully extubated the position. A low dose spinal followed by an epidural which was
following morning and continued with intravenous antibiotics topped up gradually over 30 minutes using small incremental
and analgesia. She made a full recovery. Histology confirmed boluses achieved adequate block without compromising
the fibroid had extensive areas of coagulative necrosis, respiratory function. Surgery was completed without issue and
hyalinisation and inflammation. All microbiological both mother and baby did well post-operatively.
investigations were negative. Discussion: There are only three reports in the literature
Discussion: Sepsis in pregnant and post-partum women describing general anaesthesia for caesarean section in
remains a significant cause of maternal morbidity and patients with scleroderma and two using neuraxial blockade.1-5
mortality.2Sepsis is a clinical diagnosis and microbiological Of those who were intubated, one died and another required
investigations may be negative. Early recognition, timely three months ventilation. We demostrated how careful bedside
diagnosis and active treatment assists an optimum outcome. airway assessment and the use of a slow top up epidural were
Fibroids are common in pregnancy but sepsis secondary to successfully used to manage this challenging case.
infected, necrotic fibroid tissue post-partum is very rare. To References
our knowledge there have been no reported cases of this. It is
1. D'Angelo R, Miller R. Pregnancy complicated by severe
therefore essential to consider this in the differential causes of preeclampsia and thrombocytopenia in a patient with scleroderma.
obstetric sepsis when reviewing pregnant women with a Anesth Analg 1997; 85: 839-41
history of fibroids. 2. Hseu SS, Sung CS, Mao CC, Tsai SK, Lee TK. Anesthetic
management in a parturient with progressive systemic sclerosis
References during cesarean section. Acta Anaesthesiol Sing 1997; 35: 161-7
1. Mason T. Red Degeneration of a leiomyoma masquerading as 3. Younker D, Harrison B. Scleroderma and pregnancy. Br J Anaeth
retained products of conception. Journal of the National Medical 1985; 57: 1136-9
Association. 2002; 94: 124-6 4. Thompson J, Conklin KA. Anesthetic management of a pregnant
2. Lucas DN, Robinson PN, Nel MR. Sepsis in obstetrics and the role patient with scleroderma. Anaesthesiology 1983; 59: 69-71
of the anaesthetist. International Journal of Obstetric Anaesthesia. 5. Bailey AR, Wolmarans M, Rhodes S. Spinal anaesthesia for
2012; 21: 56-67 caesarean section in a patient with systemic sclerosis. Anaesth
1999; 54(4): 355-8
P10 Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin)
P119 Anaesthetic management of arrhythmogenic right P120 Anaesthetic management of obese parturients at a
ventricular cardiomyopathy during labour and tertiary centre - meeting the standard?
caesarean section: a case series L Kelliher,  J Teare,  E Evans  
J Eccles,  A Jain,  K Bhatia   Anaesthesia, St George's Healthcare NHS Trust, London, UK
Department of Anaesthesia, St Mary's Hospital, Manchester, Introduction: Obese women are at increased risk of perinatal
UK morbidity and mortality. In 2010 CMACE and RCOG published
Introduction: Arrhythmogenic right ventricular joint guidelines for the management of the obese parturient
cardiomyopathy (ARVC) is mainly a genetically determined including recommendations that patients with a booking BMI
autosomal dominant disease characterised by cardiomyocytes ≥40 should attend an antenatal anaesthetic clinic (AAC) and a
being replaced by fibrofatty tissue in the right ventricle.1 Specialist Trainee year 6 anaesthetist (ST6) or above should
ARVC has an incidence of 1:5000 and may account for as be informed and available to attend labour and operative
many as 5% of unexpected sudden deaths. The Eighth Report delivery1. Our unit is a tertiary centre with over 5,000
of the Confidential Enquiries into Maternal Deaths in the deliveries/year. A previous audit over 2 years showed that of
United Kingdom (2006-2008) highlighted that ARVC was the 120 women with BMI ≥40 attending our AAC, 76% required a
underlying cause in two of the 53 reported cardiac deaths. We peripartum anaesthetic intervention, with only 34% of these
describe the anaesthetic management of two parturients with performed by an anaesthetist ≥ST62. Awareness of the
ARVC who presented at our tertiary centre. guidelines was raised and anaesthetic plans for these women
Case reports: The maternal demographics, the cardiac signs, now state care should be managed by a senior anaesthetist.
symptoms and interventions along with the anaesthetic We examined our obese population following these changes.
management in the peri-partum period are briefly summarised Methods: A retrospective analysis over 1 year (2011-12) of
in the table below. hospital records for patients with a booking BMI ≥ 40. Records
were examined for referral and attendance at AAC, anaesthetic
Category Case 1 Case 2
intervention (regional/GA), grade of anaesthetist and
Age 27 23
anaesthetic complication (difficult/impossible regional, dural
BMI 25.8 27.2
tap, other).
Parity 0 0
Family history None Sudden death Results: In total there were 74 women with a booking BMI
Cardiac signs and Palpitations with spurts of Paroxysmal VT ≥40. 73% were referred to AAC, only 58% attended. Out of all
symptoms ventricular tachycardia (VT) patients, 69% had a peripartum anaesthetic intervention, 43%
Cardiac Cardiac ablation therapy and ICD insertion of which were performed by an anaesthetist ≥ST6 with a
intervention prior implantable cardioverter complication rate of 16%. Of those attending AAC, 67% had
to pregnancy defibrillator (ICD) insertion an anaesthetic intervention, 41% of which were performed by a
Mode of delivery Elective caesarean section Urgent LSCS for ≥ST6 with a complication rate of 17%. Of those patients not
(LSCS) for breech foetal distress attending AAC, 71% had an anaesthetic intervention and 36%
Anaesthesia and General anaesthesia, with Labour epidural of these were performed by ≥ST6 with a complication rate of
analgesia bilateral transversus analgesia, followed by 14%.
abdominal plane blocks top up for LSCS
Table 1. Incidence of complications by grade of anaesthetist
Maternal length of Three days Four days
stay Group ≥ST6 <ST6 p value (Fisher's Exact)
Neonatal APGAR 8 and 10 9 and 10 All 9.1% 20.7% 0.440
scores AAC 16.7% 17.6% 0.945
Discussion: The main implications of ARVC in parturients No AAC 0% 21.4% 0.273
include fatal arrhythmias, heart failure worsened by Discussion: This audit shows a significant number of obese
physiological changes of pregnancy and sudden adult death parturients were not seen in our AAC. A proportion of these
syndrome.1 Both our patients had VT diagnosed after 24 hour were referred, but did not attend however 27% were not
Holter monitoring, and an ICD was implanted in addition to referred. Despite this, there was no significant difference in the
beta blocker medical therapy to control the symptoms of VT as requirement for anaesthetic intervention or the incidence of
well as to prevent sudden death. The patients were seen in the anaesthesia-related complications between attenders and non-
joint cardiac, obstetric and anaesthesia antenatal clinic and a attenders. The incidence of senior anaesthetic involvement in
peri-partum plan formulated to facilitate safe delivery. Both care has risen from 34% to 41% but there is still room for
had serial echocardiograms, serum electrolytes monitored, improvement. This highlights the resource difficulties faced in
invasive blood pressure monitoring and ICD deactivated providing 24 hour senior anaesthetic cover. The on-call rota at
during their LSCS. Our case series highlights that both general our unit is staffed by junior and senior anaesthetists. The
and regional anaesthesia can be safely provided and we absence of a senior anaesthetist did not lead to a significant
recommend a multidisciplinary approach with close co- rise in anaesthesia-related complications, although there was a
operation between anaesthetists, cardiologists and t rend toward this (Table 1).
obstetricians to provide optimum care of these patients. References
Reference 1. Centre for Maternal and Child Enquiries & Royal College of
Obstetricians and Gynaecologists Joint Guideline. Management of
1. Alexoudis AK, Spyridonidou AG, Vogiatzaki TD, Iatrou CA.
Anaesthetic implications of arrhythmogenic right ventricular women with obesity in pregnancy. London: CMACE & RCOG; 2010
dysplasia/cardiomyopathy. Anaesthesia 2009; 64: 73-8. 2. Fulton L, Evans E, Schroeder F, Wendler R. Antenatal anaesthetic
assessment of morbidly obese women - a useful resource? 2013,
http://epostersonline.s3.amazonaws.com/oaa2013/oaa2013.0690195
.NORMAL.pdf
Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin) P11
P121 Anaesthetic management of the labouring patient with P122 Anesthetic implications  of heart disease in pregnancy
multiple sclerosis S Francés,  S Manrique,  M Goya,  M García,  R Perera,  N
J Li Wan Po,  K Maclennan   Montferrer  
Anaesthesia, St Mary's Hospital, Manchester, UK Anaesthetics, Vall d'Hebron University Hospital, Barcelona,
Introduction: Multiple Sclerosis (MS), an autoimmune Spain
inflammatory disease affecting the central nervous system, is Introduction: Despite advances in its diagnosis and treatment,
estimated to affect 20,000 or more UK women of childbearing heart disease (HD) in pregnancy remains a major cause of non-
age1. Controversy exists regarding the management of obstetric maternal and neonatal mortality and morbidity (it
anaesthesia and analgesia in labouring parturients with MS. complicates around 1-3% of pregnancies in developed
Following analysis of our practice at St Mary's Hospital, a countries). Accurate multidisciplinary assessment and
tertiary referral obstetric unit with over 8500 deliveries per management of individual maternal and fetal risks in pregnant
annum, and recent evidence in the literature; our women with HD provides the best opportunity to substantially
recommendations for the peri-partum management of improve outcomes for mother and baby. (1).
parturients with MS are presented. Methods: We present a prospective cohort study that
Methods: Interrogation of the St Mary's Hospital antenatal analyzed outcomes in women with HD, the majority of whom
clinic database, from 1999 to 2012, identified 21 pregnant had had corrective surgery and delivery between 2007 and
women diagnosed with MS. We reviewed antenatal advice, 2013. Baseline characteristics and adverse events during
intrapartum management and postpartum complications. delivery and postpartum were assessed. Intensive monitoring
Results: Over 50% of patients were nulliparous. The majority of the delivery and postpartum were planned beforehand in all
had mild sensory or motor deficit. Three relapsed during cases.
pregnancy, one improved in symptoms and one relapsed Results: One hundred and seventy-four patients with 179
postpartum. There were twelve normal vaginal deliveries, two pregnancies were included in the study. 127 women (72,98%)
instrumental deliveries, six Caesarean sections and one presented congenital heart disease (CHD), 47 acquired heart
unspecified delivered at another hospital. Five women opted disease (27,02%): 27 acquired rheumatic valve disease
for epidural analgesia, two were topped up for operative (19,98%), one Marfan syndrome (0,54%), 3 coronary heart
delivery. Five had spinal anaesthesia with 0.5% heavy disease (1,6%) and 9 primary myocardial disease (4,9%).
bupivacaine and one had a general anaesthetic. There were no
Pregnancy complications were presented in 21, 2% of CHD,
complications following regional technique.
14,8% of acquired rheumatic valve disease and 100% of
Discussion: A recent national survey reported that within a 10 women with arrhythmias.
year period, 91% of anaesthetists have encountered <ten
The type of delivery was vaginal in 124 women ( 72,1%) and
cases of MS2 and have little experience in their management
cesarean section in 50 women (27,9%).
during pregnancy. Recent evidence available supports our
168 women had analgesia during delivery (93,8%); 5 women,
current management of MS patients undergoing labour. The
general anesthesia (2,79%), 6 women, local anesthesia (3,35%)
low incidence of the disease makes it difficult to attain
and 87,5% of women had regional analgesia.
significant figures to determine the optimal management plan.
To standardize care, we made the following recommendations Delivery complications were 7% (uterine atony 2,7%, vaginal
based on the latest evidence and our own experience: hematoma 2,2%, chorioamnionitis 0,5%, cesarean hematoma
- Patients to be reviewed in an antenatal anaesthetic clinic. 0,5% and hemoperitoneum 0,5%). The only anesthesia
Document disease severity and discuss analgesia and complication was one dural puncture (0.5%). No maternal
anaesthetic options. death, one fetal death (0.5%) and one neonatal death (0.5%).
The maternal average hospital stay was 3 days.
- Use of 0.1% bupivacaine with 2mcg/ml fentanyl mixture for
epidural labour analgesia2 . For an operative intervention, top Discussion: Pregnancy and delivery are associated with
up with a higher concentration of local anaesthetic. substantial physiological changes, which require the
adaptation of the cardiovascular system and can expose
- Regional rather than general anaesthetic for caesarean
women with HD to significant risks. If regional anesthesia is
sections. Spinal anaesthesia is the most simple and reliable
selected, the addition of an opioid, when dosing any neuraxial
technique although consider combined spinal-epidural on an
anesthetic, will reduce the amount of local anesthetic required
individual basis.
and subsequent hemodynamic effects, while improve
- If a general anaesthetic is necessary, avoid suxamethonium
intraoperative and postoperative analgesia. The avoidance of
and monitor neuromuscular block to titrate dose of non-
epinephrine from the epidural dose will eliminate the possible
depolarizing muscle relaxant3.
deleterious effects of systemic epinephrine. Maintaining
These recommendations will be available for clinicians on the uterine blood flow is important for fetal well-being.
trust intranet and a patient information leaflet on the effects of Maintaining systemic vascular resistance in patients with
pregnancy and anaesthesia on MS has been produced. intravascular shunting, is important to avoid inducing or
exacerbating pre-existing cyanosis due to increased right- to –
References
left shunting. Cautious intravenous hydration and gentle
1. Brookings W, Lee M. Management of multiple sclerosis during
titration of phenylephrine or ephedrine are options to
pregnancy. Prog Neurol Psychiatry. 2009; 3(6): 9-11
counteract the hemodynamic effects of surgical neuraxial block
2. Drake E, Drake M, Bird J, Russell R. Obstetric regional blocks for
women with multiple sclerosis: a survey of UK experience. Int J (1,2). We observed a predominance of neuraxial anaesthetic
Obstet Anaesth. 2006; 15(2): 115-23 techniques, increased caesarean and operative delivery rates,
3. Griffiths S, Durbridge JA. Anaesthetic implications of neurological and favourable maternal and neonatal outcomes.
disease in pregnancy. Contin Educ Anaesth Crit Care Pain. 2011; 11
(5): 157-61 References
P12 Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin)
P123 Angle of tilt achieved with automated operating table P124 Antenatal anaesthetic information given to women
in elective caesarean sections: a comparison with tilt with obesity
achieved with an inflatable balloon wedge  C R Thomas,  C Busby  
PN Nair,  L Dyal,  B Grewal,  I Suri   Anaesthetics, Airedale General Hospital, Keighley, UK
Department of Anaesthesia, Warwick Hospital, Warwick, UK Introduction:Antenatal obesity is defined as a BMI of ≥30at
Introduction: A previous study1 done on patients undergoing booking. Its prevalence in England increased from 7% in 1990
elective caesarean sections looked into measuring the angle of to 16% in 2007.1Women with a BMI ≥40 are often provided
tilt of the operating table with an inflatable balloon wedge. with anaesthetic information antenatally. Those with lower
This showed that the visual estimation of angle proved levels of obesity also have an increased anaesthetic risk but
accurate in the achievement of near 150 tilt. Here we present these women may receive little or no information about this
the results of a similar study using a different technique of during pregnancy. 2The RCoA have produced standards
automated table tilt instead of the inflatable balloon wedge regarding care for these women: 90% of patients with a
device. The premise being is our visual actuation of tilt angle booking BMI ≥ 30 should receive a leaflet containing
accurate. information about anaesthesia and analgesia. 90% of patients
Methods: The study was similar to the previous one. We with a booking BMI ≥40 should have an anaesthetic consult.
prospectively selected 26 patients at random who were Booking BMI should be documented in 100% of maternity
undergoing elective lower segment caesarean section under hand-held notes. An audit of the above standards was carried
spinal anaesthesia over a six week period. Ethical committee out as summarised below.
approval was obtained. Verbal consent was obtained from all Methods:A list of all deliveries in January 2013 was generated.
participants and the booking Body Mass Index (BMI) was Notes were reviewed for adherance to the above three
noted. We used the same protractor device for measuring the standards. Change to practice was recommended based on
angle of tilt. This is similar to the one used by Kinsella et al2. audit findings. Following the implementation of change, the
Results: The measured angles ranged from 10 to 18 degrees, a audit cycle was completed by auditing notes of all deliveries in
mean angle of 13.70 with a mean difference of -1.3 and standard November 2013.
deviation of 2.32. This compared very closely to the angles Results:
between 10 to 17.5 degrees, mean angle of 13.650, mean Table: Recording of booking BMI, patient count by raised
difference of -1.35 and a standard deviation of 2.06 in the BMI category and number given anaesthetic information.
previous study. BMIs ranged from 19 to 37 with a mean of 24.
Discussion: The visual estimation of angle using the
BMI 30 - BMI 35 - BMI
automated table tilt proved accurate in achieving the near 150 No
Number of Unavailable 34.9; 39.9; ≥40; 
tilt and is comparable with that obtained with the inflatable   booking
deliveries casenotes info info info
balloon wedge device in the previous study. The standard BMI
given given given
deviation of 2.32 indicates that 95.4% of cases could achieve
Jan 195 6 2 20; 0 7; 1 7; 7
within 4.60 of the required 150 tilt i.e. 10.4 to 19.6 degrees tilt.
Nov 173 3 2 17; 2 7; 7 3; 3
The automated table tilt provides an easy and accurate means
of providing left lateral tilt in pregnant patients. Discussion: Booking BMI was recorded in 99% of the notes in
both audit cycles. In 100% of cases where BMI was ≥40, a
consultant anaesthetist discussed risk and made a plan with
References
the patient. However, the audit of January deliveries indicates
1. Grewal B, Suri I. Is visual actuation a valid predictor of angle of tilt?
that few women who have a BMI 30-39.9 receive anaesthetic
Int J Obstet Anaesth Vol 18 2009; pS1-64- supplement
information.; this occurred in only one case. Reaching this
2. Kinsella SM. A device for measuring the degree of lateral pelvic tilt
during supine recumbency. Anesth Analg 1995; 80: 204-5 population to provide information is difficult especially where
BMI is 30-34.9 as all antenatal care for this group may be
provided by community midwives. In collaboration with
Obstetrics, a patient information leaflet was written which
included both obstetric and anaesthetic information. The
leaflet was approved by the Women's Integrated Governance
group and has been in use since October 2013. It is available
on the Trust intranet which is accessible by some community
midwives. The leaflet is given to all those with a BMI ≥ 35
when they attend obstetric high risk clinic. The results of the
November audit indicate improvement has been made; 44.4%
of those with obesity now receive anaesthetic information.
Greater access to the leaflet is needed however.
References
1. Royal College of Anaesthetists 2012,
http://www.rcoa.ac.uk/document-store/audit-recipe-book-3rd-edition-
2012
2. Centre for Maternal and Child Enquiries 2010, http://www.oaa-
anaes.ac.uk/assets/_managed/editor/
File/CMACE/CMACE_Obesity_Report_2010_Final%20for%
20printing.pdf
Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin) P13
P125 Antenatal management of morbidly obese parturients: P126 Audit of temperature for patients undergoing elective
A multicentre evaluation. caesarean section
H Aladin,  A Khandhia,  K Pottinger   N J Truman,  I Clegg,  K Maclennan  
Anaesthetics, Good Hope Hospital, Birmingham, UK anaethetics, St Mary's Womens Hospital, Manchester, UK
Introduction: Women with a body mass index (BMI) of ≥30 Introduction: Perioperative Hypothermia is associated with
kg/m2 at the time of antenatal booking are classed as being poor outcomes and adverse events for patients; including
obese in pregnancy, accounting for around 39,000 maternities surgical site infection increased length of stay, blood loss,
per year1. Obesity is associated with increased risk of shivering, increased anaesthetic recovery time and cardiac
anaesthetic morbidity and mortality. National guidance have events. Risk factors for the occurrence of hypothermia include
been developed following the Confidential Enquiry into regional anaesthesia, fluid deprivation, blood loss, and cold
Maternal and Child Health report concerning obesity in fluid administration, all of which are common to obstetric
pregnancy. At two different hospitals, five indicators of best patients. 2008 Nice guidelines CG651 on perioperative
practice2 were analysed: (1) Recording of maternal BMI. (2) hypothermia do not include parturients, despite being an at
BMI ≥ 30 women receive information about risk group. An audit performed in 2011 at St Mary's Hospital
anaesthesia/analgesia. (3) Women with a BMI ≥ 40 have demonstrated that 92.5% of elective section patients were not
antenatal anaesthetic review. (4) Duty anaesthetist should be 'comfortably warm' on arrival in recovery, with 65% defined as
informed when women with a BMI ≥ 40 are admitted. (5) hypothermic. A repeat audit was performed following
Anaesthesia for women with a BMI ≥ 40 should be provided commencement of a trial of an air free conductive fabric patient
by a senior anaesthetist. warming system (Hot Dog®).

Methods: Women who had undergone a lower segment Method: A prospective audit of elective caesarean section
caesarean section (LSCS) during a 6 month period (Jan 2013- patients was conducted from April-June 2013 at St Mary's
Jun 2013) at a District General Hospital (DGH) and a Hospital. Theatre staff completed the audit proforma. Data
Foundation Hospital (FH) were evaluated. Data was collected collected included; ambient theatre temperature (ideal target
retrospectively from an electronic data archive and anaesthetic 21ºC), anaesthetic type, estimated blood loss (EBL),
charts. Evidence of BMI calculations, provision of temperature pre, intra, post operative and prior to discharge
anaesthesia/analgesia information, ante-natal anaesthetic from recovery (measured using a tympanic membrane
appointments, and anaesthetic care in the labour ward and thermometer) and details of which Hot Dog® warming
theatre were identified. products were used. Hypothermia was defined as a core
Results: 309 women who underwent a LSCS were identified temperature <36ºC with desirable temperature being defined as
with a having a BMI 30 (median 34, range 30-59). 51% of 36.5-37.5ºC. Comparison of the results from the 2011 audit
these were elective cases. 56% of women with a BMI ≥30 enabled conclusions to be drawn regarding the effectiveness
received anaesthesia/analgesia information, of which 2 were of the warming product.

given literature on anaesthesia in obesity. 32% of women with
Results: A total of 33 patients were audited who underwent
a BMI 40 underwent an antenatal anaesthetic review, with an
elective caesarean section, [n=79, 2011audit], 94% had spinal
additional 4 women failing to attend their appointments. In
anaesthetic (87%, 2011 audit). Mean (S.D) theatre temp was
those women with a BMI ≥40, the duty anaesthetist was
22.8 (± 0.6) [22.3 (± 0.6), 2011 audit], mean duration of
informed of admission in 19% of cases and in 56% of LSCS,
procedure was 51 minutes. 94% of patients had an additional
the anaesthetic care was provided by an appropriately graded
fluid warmer intra-op (72%, 2011 audit). The mean EBL was 574
anaesthetist .
ml (± 213) [653 (± 431), 2011 audit] and only 6% of patients had
Table: Women with BMI 30 having anaesthetic care at a DGH an EBL over 1L (20% 2011 audit). Only 12% (n=4 of 33) of
and FH. patients warmed with the HotDog® were hypothermic on
arrival to recovery (compared to 65% (n=51 of 79), 2011 audit)
  DGH FH
figure 1.
Total LSCS 32% (99/309) 68% (210/309)
Discussion: efforts have been to reduce perioperative
BMI Median (range) 33 (30-59) 34 (30-52)
hypothermia in elective caesarean sections. Almost all patients
Maternal height, weight + BMI recorded 100% 100%
received warmed fluids via a 3M™ Ranger™ fluid warming
Conclusion: This audit has identified that more than half the
system. Forced air warming devices applied to the upper body
women with a BMI ≥30 received analgesia/anaesthesia
are not well tolerated by our awake patient population and
information and more than half were anaesthetised by a senior
allow only a limited area to be heated. introduction of
anaesthetist. However, in all the areas of practice, the target
HotDog® with an under patient warming mattress and
percentage of women meeting the identified standards were
separate over patient warming blanket (for upper and lower
not achieved. Recommendations included revision of the
limb) proved to be of benefit in perioperative maintenance
referral guidelines for antenatal anaesthetic assessment,
when compared to our standard warming measures. A
improved communication within the multidisciplinary team
HotDog® warming mattress placed on the patient chair in the
during admissions and increased presence of senior
pre theatre waiting area helped prevent hypothermia pre arrival
anaesthetists on delivery suite.
in theatre.
References
Reference
1. Centre for Maternal and Child Enquiries (CMACE). Maternal
1. CG 65 Management of inadvertent perioperative hypothermia in
obesity in the UK: Findings from a national project. London:
adults. NICE April 2008.
CMACE, 2010
2. The Royal College of Anaesthetists. Raising the Standard. A
compendium of audit recipes for continuous quality improvement in
anaesthesia. 3rd Edition 2012
P14 Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin)
P127 Availability of chlorhexidine handwash for regional P128 Caesarean section in a rhesus null parturient with a
analgesia on the labour ward uterine fibroid
K Chima,  T Strickland,  F Plaat   P J Stewart,  R Laird,  J Cartmill  
Anaesthetics , Queen Charlotte's and Chelsea Hospital, Anaesthetics, Altnagelvin Area Hospital, Londonderry, UK
London, UK Introduction: The anaesthetic management of a Caesarean
Introduction: Many patients request regional analgesia during section is made more challenging by the combination of pre-
labour and therefore central neuraxial blocks are performed in operative anaemia, a large uterine fibroid and the presence of a
the delivery room. For central neuraxial blocks an aseptic very rare blood group Rhesus null.
technique should be standard. In the Third National Audit Case report: A forty-year lady with a past medical history of
Project of the Royal College of Anaesthetists the incidence of psoriatic arthritis presented to antenatal booking at 10 weeks
iatrogenic infection was reported as being 8/707 000 gestation. Booking investigations revealed a haemoglobin of
procedures1. However the consequence of any infection is 10.3g/dL, and a blood group O Rhesus null. Her 20-week
potentially devastating, and a 'scrupulous' aseptic technique ultrasound scan revealed no foetal anomalies but did
was therefore stated to be mandatory in the report1. demonstrate an anterior uterine fibroid. This was confirmed
Chlorhexidene gluconate 4% is used for hand decontamination with magnetic resonance imaging which showed a
in our department. It was noticed that not all delivery rooms heterogeneous mass measuring 188x139x159mm, in keeping
were equipped with both chlorhexidene and a hands free with a degenerating fibroid. At 21+3 days she presented with
method for application. dizziness and right upper quadrant pain. Her haemoglobin
Methods: All delivery rooms on labour ward were inspected to level was 7.6g/dL and she was treated for iron deficiency
ascertain the presence of chlorhexidene and a hands free anaemia. Due to a transverse lie and the large fibroid an
dispenser. elective Caesarean section at 38 weeks was planned. As a team
we anticipated a difficult Caesarean delivery with greater blood
The audit was repeated after one and twelve months to assess
loss in a patient with anaemia and a very rare blood group.
if there had been any improvement in the service.
Antenatal management focused on maximising the patient's
Results: Originally, 12 of the 16 delivery rooms had
haemoglobin levels and sourcing compatible blood. The
chlorhexidene available (75%). Of the 12 rooms with
Northern Ireland blood transfusion service and National frozen
chlorhexidene only three were equipped with a hands free
red cell bank in Liverpool secured two units of packed red cells
dispenser (25%), and five containers were uncovered (42%).
in England. Unfortunately, one week prior to the section this
After one month all 16 rooms were equipped with wall blood was issued in an emergency, making it unavailable to us.
mounted chlorhexidene with a hands free dispenser (100%). A new donor was found in South Africa and a further unit was
After a further 12 months it was found that 12 of the 14 secured in Brazil. Both units were couriered to our hospital
delivery rooms had chlorhexidene available (86%). (Two of the prior to the Caesarean delivery which was performed at 38+6
rooms had been converted to a post delivery high dependency days under spinal anaesthesia. Pre-operative haemoglobin was
unit). Eleven of the 12 containers were equipped with a hands 9.1g/dL. The patient was discharged home on day three post-
free dispenser (92%). operatively and her haemoglobin was 7.2g/dl on discharge. No
Discussion: The results of the initial data collected, as well as blood transfusion was required.
anaesthetists' concerns regarding the unavailability of Discussion: Red blood cells from people who have the Rhesus
chlorhexidine and dispensers in each room, was reported to null phenotype lack Rhesus proteins, and thus, Rhesus
managerial staff, who ensured all rooms were adequately antigens. This phenotype occurs in approximately 1 in 6x106
stocked. Results were therefore better when re-auditing was individuals1. When these patients are transfused they may
performed at one month. However, after 12 months standards form antibodies to high frequency rhesus antigens, which can
had declined, although they were still improved from the make it extremely difficult to process compatible blood. Rhesus
initital audit. This decline could be attributed to the fact that null blood is available from the National frozen cell bank,
neither a team nor a named individual was made responsible however it may not be available when required due to limited
for sustaining the initial improvement, which if introduced, we supplies, as in our case. There is very limited literature
feel would encourage a sense of ownership and enable the regarding the management of the rhesus null parturient and
improvement in this area of patient safety to be sustained. our management was guided by our regional Haematology
Reference unit. This case demonstrates the importance of good
communication with all members of the multi-disciplinary team
1. National Audit of Major Complications of Central Neuraxial Block
in the United Kingdom 2009, http://rcoa.ac.uk/system/files/CSQ- and the detailed preparations required in a complex case.
NAP3-Full_1.pdf
Reference
1. Avent ND, Reid, ME. The Rh blood system: a review. Blood 2000
95: 375-387.
Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin) P15
P129 Category one caesarean sections in a district general P130 Comparison of two non-invasive cardiac output
hospital:  Improving the decision to delivery time monitoring devices in a parturient with complex
VK Wroe,  AM Troy   cardiac disease.
Department of Anaesthesia, Countess of Chester Hospital, PJ Rose,  V Misra,  S Quasim  
Chester, UK Anaesthesia, UHCW, Coventry, UK
Introduction: National Guidelines state that the interval from Introduction: The management of valvular lesions during
decision to delivery (DDI) in a category one caesarean section pregnancy and labour can present a clinical conundrum. We
should be less than 30 minutes1, and that a duty anaesthetist present the use of two cardiac output (CO) monitoring devices
should be immediately available for emergency work on the in a parturient with complex valvular heart disease undergoing
delivery suite 24 hours a day2. a caesarean section under epidural anaesthesia.
A 2008 departmental audit found that 85% of category one Case Report: A 37 year old primiparous woman with history of
sections had a DDI of under 30 minutes, a figure marginally ASD repair aged 4, severe mitral regurgitation, severe tricuspid
under the audit standard of 90%. Anaesthetic service regurgitation, moderate aortic stenosis (AS) secondary to a
provision in our trust was expanded in July 2012, with the congenital bicuspid valve and moderate pulmonary
addition of a dedicated obstetric anaesthetist 24 hours a day. hypertension presented for elective caesarean section.
This re-audit aimed to assess the proportion of category one Echocardiography showed moderately dilated right ventricle
caesarean sections with a DDI <30 minutes and analyse the with good bi-ventricular systolic function, bi-atrial dilatation,
factors contributing to any delay. moderate to severe AS (mean gradient 34mmHg, peak gradient
Methods: After audit department approval, a retrospective 53mmHg, estimated valve area 0.74cm2). Pulmonary artery
analysis of category one caesarean sections between August pressures were estimated at 42-47mmHg. LiDCO rapid and
and December 2012 was performed. Data collected included Cheetah NICOM devices were used to monitor CO.
DDI and reason for delay, indication for section, type of Anaesthesia was established with 32mL 2% lignocaine and 100
anaesthesia and cord pHs. micrograms of epinephrine via epidural. Compound sodium
lactate was infused at 60mL/hr, and increased to 100mL/hr after
Results: 69 category one caesarean sections were analysed.
epidural anaesthesia. Fluid boluses of 200mL and 100mL were
The mean DDI was 23 minutes (range 3-120 minutes). 84% had
delivered via the pump at 13 and 28 minutes after delivery of a
a DDI of under 30 minutes, with a mean time from decision to
live infant. Metaraminol infusion was titrated to effect.
effective anaesthesia of 14.5 minutes. The indication for
Syntocinon infusion was started upon delivery (20 units in
caesarean section was abnormal CTG in 87% of cases (2008:
48mL 0.9% saline) at 15mL/hr and tapered post-operatively
77%). General anaesthesia was performed in 43% (2008: 85%),
over 4 hours. Mean arterial pressure was maintained at 91 to
spinal anaesthesia in 55% (2008: 15%) and extension of
97mmHg until delivery (78 minutes) and then decreased to
epidural blockade in 2%. In 11 cases, DDI was over 30
67mmHg at the end of surgery. Cardiac output was maintained
minutes; these cases were all performed under spinal
throughout surgery with an increase at the time of concurrent
anaesthesia. The following table shows the reasons identified
fall in MAP. Fluid challenge had negligible effect although
that contributed to delay:
there was a small reduction in heart rate (84 to 59bpm).

Arrival in
Discussion: NICE has advocated the use of cardiac output
theatre Incision to
Spinal monitoring in high risk non-obstetric surgery to improve
10 delivery Staff Theatre
  placement outcome.1 In this case we utilised both a non-calibrated pulse-
minutes time 10 unavailable unavailable
10 minutes contour waveform analysis and bioreactance system to
from minutes
compare both values measured and response to fluid
decision
challenge. Although the values produced were different, the
Number
trends were broadly similar. This, once again, highlights the
of 4 6 1 1 1
importance of analysing trends rather than absolute values to
patients
guide management. Interestingly, both devices demonstrated
Arterial cord blood analysis was carried out in 10/11 cases. pH
that a fall in MAP correlated with an increase in cardiac
was less than 7.2 in 30%, and base excess was less than -8 in
output, similar to previous investigators.3 Given that cardiac
20%.
disease is the leading cause of death in the most recent
Conclusion: The proportion of cases with a DDI of over 30 triennialreport2, monitoring cardiac output enables one to
minutes has remained constant at around 15%, despite an maintain physiological homeostasis, and ultimately aids
improvement in anaesthetic staffing. Our results suggest that clinical decision-making leading to good clinical outcome, as in
the causes for this delay are multifactorial, and the results are our case.
not benign- the delay in delivery led to a cord pH of <7.2 in
References
almost one third of cases. We intend to improve our practice
1. MTG3 CardioQ-ODM (oesophageal Doppler monitor): guidance
by regular practice drills, use of preprepared spinal packs to
2011, http://www.nice.org/nicemedia/live/13312/52624/52624.pdf
reduce spinal placement time, clear procedures to follow in the
2. Centre for Maternal and Child Enquires (CMACE). Saving Mothers'
case of staff or theatre unavailability and reaudit. Lives: Reviewing maternal deaths to make motherhood safer: 2006-
2008. The Eighth Report of the Confidential Enquires into
References
Maternal Deaths in the United Kingdom. BJOG 2011;118(Suppl
1. Caesarean section. NICE Clinical Guideline 132. NICE, London 1):1-203
2011. (http://publications.nice.org.uk/caesarean-section-cg-132).
3. Fanning NP, Sermer M, Colman J, Carvalho JC, Cordovani D. Non-
2. OAA/AAGBI guidelines for obstetric anaesthetic services- 3rd invasive Hemodynamic monitoring with bioreactance for cesarean
edition. AAGBI and OAA, London, 2012 delivery. A more relaxed look at tight aortic stenosis? Abstract
(http://www.aagbi.org/publication/publication-guidelines/M/R) SOAP 2011, http://www.soap.org/display_2011_abstract.php?id=58
P16 Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin)
P131 Comparsion of slow and rapid bolus of ephedrine in P132 Continuous spinal anaesthesia for a primigravida with
patients undergoing planned caesarean section under severe tricuspid regurgitation, Harrington rods and
spinal anaestheisa WITHDRAWN FROM  thrombocytopenia.
PRESENTATION AM Walton,  I Mettam  
PG Sekar,  LB Ellakumanan,  H Balachander,  MVS Obstetric Anaesthetic Department, University Hospital
Satyaprakash   Southampton, Southampton, UK
Anaesthesiology, JIPMER, Puducherry, India Introduction: We present the successful use of continuous
spinal anaesthesia (CSA) for caesarean delivery in a parturient
with severe tricuspid regurgitation and pregnancy-induced
thrombocytopenia in addition to Harrington rod placement for
scoliosis spinal surgery.
Case history: A 40 year old primigravida presented at 37
weeks gestation. She had undergone a tricuspid valve repair
previously for endocarditis. The patient had developed severe
tricuspid regurgitation and had heart failure. Harrington rods
were placed in her thoracic and lumbar spine for repair of a
congenital scoliosis. Blood tests revealed a pregnancy related
thrombocytopenia with platelets of 85x109/L. An
echocardiogram showed a severly dilated right atrium with
intra-atrial septal bowing to the left, severe free flowing
regurgitation and right ventricular systolic pressure
32mmHg.The case was discussed with obstetricians,
anaesthetists and cardiologists and a decision was made for
an elective caesarean section under CSA, if the final platelet
count remained stable. The patient expressed a preference to
remain awake and avoid a general anaesthetic. At surgery a
cannula and radial arterial line were inserted. In the sitting
position a 22G spinal needle was inserted below the level of
the scar tissue at L3/4, and a spinal catheter threaded into the
subarachnoid space. A total of 10mg bupivacaine and 250mcg
diamorphine were required over 20 minutes to establish a block
to T4. The blood pressure dropped from 135/70 to 90/50mmHg
and required only 5mcg of epinephrine to return to baseline
values. Blood loss was 720mls. Syntocinon was given as an
infusion only. A live male infant was delivered.
Discussion: An obstetric anaesthetist has to take many
factors into account when deciding on the best choice of
anaesthetic for a particular case; anaesthetic expertise,
maternal co-morbidities, fetal well-being and maternal
preferences all play a part. Cardiac disease in pregnancy is still
the leading cause of indirect maternal mortality in the UK.1 The
choice of anaesthetic and delivery had to ensure the least
amount of strain on an already compromised heart. The
advantages of CSA are that a block can be established
gradually with small incremental doses of local anaesthetic,
which reduces the likelihood of cardiovascular instability.2
The concerns with a CSA are principally neurological
complications and post-dural puncture headache. CSA is
proving an option to be considered for patients with
significant cardiac disease and previous spinal surgery
provided the anaesthetist has experience with the technique.
In this case it provided a cardiovascularly stable anaesthetic
with excellent analgesia and maximal maternal satisfaction.
References
1. Saving mothers lives.The Eighth Report of the Confidential
Enquires into Maternal Deaths in the UK. March 2011
2. DennyNM, Selender DE. Continuous spinal anaesthesia. Br J
Anaesth 1998;81:590-7
Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin) P17
P133 Does pre-operative anxiety predict post-operative pain P134 Early epidural analgesia may increase caesarean
scores in parturients undergoing caesarean section? section rate in spontaneously  labouring nulliparous 
BM Daly,  N Weidenhammer,  R Junkin,  L Riddell,  J Dolan,  J women: a retrospective study
Kinsella*,  R Marla,  S Young   R Anil Kumar,  Roger Mc Morrow  
Anaesthesia, Princess Royal Maternity, Glasgow, UK, Anaesthesia, National Maternity Hospital , Dublin, Ireland
*Anaesthesia, Pain & Critical Care Medicine, University of Introduction:.Epidural analgesia offers the most effective
Glasgow, Glasgow, UK method of intra-artum pain relief. The effect of epidural
Introduction: Pregnancy, childbirth, and undergoing a surgical analgesia on the progression of labour and the mode is often
procedure are all likely to induce anxiety. The relationship debated in multiple studies. This study aims to show the effect
between anxiety, pain and pregnancy is complex.1Childbirth is of timing of epidural analgesia on the mode of delivery.
a time of high anxiety, and Caesarean section is known to be Method: Data such as women's age, gestational age, cervical
associated with significant pain post-op. Here we ask can dilatation before epidural insertion and duration of labour was
anxiety scoring predict post LSCS pain? collected from a total of 2029 nulliparous women in
Methods: After ethical approval and consent, pre-operative spontaneous labour. Epidural analgesic was defined as early at
data and a single 24hr post-op 10cm VAS were collected from a cervical dilatation of 3cms or less and late at a cervical
108 women, with 9 having missing data. Spielberger2 State and dilatation of 4 or more cm
Trait anxiety forms were completed prior to surgery. We Results: Of the 2029 women, 1423 ( 70.1%) received epidural
present secondary end points powered post hoc for 0.8 analgesia. Out of the 2029 women, 1403 ( 69.2%) had
probability of 2cm VAS difference. A standardised anaesthetic spontenous vaginal delivery, 478 (23.6%) had assisted
(spinal including diamorphine) and analgesic regime was used. delivery and 146 ( 7.2%) had caeserean section.
The cohort was divided into "high"- above the mean and
The data was anaylsed according to the timing of epidural
"low"- below the mean anxiety and compared using Student's
analgesia or no epidural analgesia and modes of delivery.
t-test.
Anaesthetic Delivery method
Results:
intervention Spontaneous Assisted Caesarean
Table 1: State anxiety compared to VAS
No epidural 537 (88.9%) 51 (8.4%) 16(2.6%) 604
Low anxiety High anxiety Early epidural 757 (62.2%) 379 126 (10.0%) 1262
  Significance
(n=45) (n=54) (30.0%)
24 hr VAS mean Late epidural 109 (67.7) 48 (29.8%) 4(2.5%) 161
5.0 (2.2) 5.3 (2.0) P= 0.40
(SD) cm
Epidural Assisted delivery C-Section
Table 2: Trait anxiety compared to VAS analgesia OR 95% CI p-value OR 95% CI p-value
Low anxiety High anxiety Early 5.27 3.86, 7.21 <0.001 5.59 3.28, 9.51 <0.001
  Significance
(n=48) (n=55) epidural
24hr VAS mean (SD) Late 4.64 2.97,7.23 <0.001 1.23 0.40,3.76 0.71
4.8 (1.9) 5.5 (2.2) P= 0.15
cm epidural
Table 3: State +Trait anxiety compared to VAS Conclusion: The results from the study show that the
Low anxiety High anxiety likelihood of having caeserean section in the early epidural
  Significance
(n=48) (n=51) group is significantly higher compared to the late epidural
24hr VAS mean (SD) group, but the incidence of assisted delivery between the early
cm 4.8 (1.9) 5.6 (2.1) P=0.072 and late epidural group were similar. This study also shows
that there is an increased likelihood of having assisted
Discussion: While the higher anxiety groups displayed a delivery and caeserean section delivery with epidural
higher mean VAS in all the analysis, this was not statistically analgesia compared to without from the study group.
significant. The separation between the two groups was better
References
with the State than the Trait anxiety score and best of all when
1..Gonen Ohel. Early versus late initiation of epidural analgesia in
the two scores were combined. Further reasearch could look at
labour: Does it increasethe risk of cesarean section. A randomised
anxiety scoring as part of a bundle of other measures verus trial. American journal of Obstretrics and Gynaecology (2006) 194,
pain. 600-5
2. Wassen et al. Early versus late epidural analgesia and risk of
References
instrumental delivery in nulliparous women: a systemic review.
1..Waldenstrom U: Experience of labor and birth in 1111 women. J British Journal of Obstretrics and Gynaecology (2010) 1471, 655-
Psychosom Res.1999: 47(5):471-82 661
2..www.mindgarden.com
P18 Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin)
P135 Efficacy of midwife led epidural top ups in labour–Are P136 Emergency obstetric and neonatal care in Kenya:
programmable pumps really the way forward? Addressing millennium development goals
E Traer,  G Waters,  GNB Jackson   D B Pachter,  C A Ameh*  
Anaesthetic department, Royal Berkshire NHS Trust, Anaesthesia, Cumberland Infirmary, Carlisle, UK, *Maternal
Reading, UK and Neonatal Health, Liverpool School of Tropical
Introduction: There are an increasing number of automated Medicine, Liverpool, UK
techniques by which labour epidurals can be managed1,2,3,4. Introduction: In 2008, an estimated 358,000 women died from
Comparison reports of programmable epidural pumps regimens complications of pregnancy and childbirth. The overwhelming
have shown lower total volumes of local anaesthetic may be burden of this mortality occurs in the developing world, with
associated with reduced rates of instrumental delivery and almost 60% of deaths occurring in sub saharan Africa.1There
improved maternal satisfaction1,2. Extended intervals between are also some 3.6 million neonatal deaths each year, and once
boluses with larger volume boluses was shown to use less again the developing world is disproportionately represented.2
total local anaesthetic3. These reports have led us to In 2006, the Liverpool School of Tropical Medicine (LSTM)
investigate similar outcomes our unit where we have a midwife developed a training package entitled "Life Saving Skills,
led top up (MLTU) practice. Emergency Obstetric and Neonatal Care" (LSS EOC-NCC) to
Method: First epidural bolus administered by the anaesthetist try and address these huge public health issues. Courses now
of 20ml 0.1% bupivicaine+2µg/ml fentanyl . Data recorded at run in 11 countries worldwide. In October 2013, I was fortunate
each subsequent midwife administered bolus (MLTU): bolus e nough to teach on a course in Nyeri, Kenya.
interval time, motor block (Bromage score of 2-4 taken as motor Methods: A variety of teaching methods were used on the
block), any change to the standard dose 20ml 0.1% course. Didactic lecture based teaching had a limited role, with
bupivicaine+2µg/ml fentanyl and if analgesia was effective or more emphasis placed on small group "break out sessions"
ineffective. and scenario based teaching. Pre and post course simulation
Results: 50 patients audited based testing was undertaken, with results collated and sent
back to Liverpool for analysis and assessment of efficacy of
Midwife led epidural Top Up Data  
teaching.
Mean bolus interval time (min) 105 (sd 26)
Mean rate bupivicaine mg/hr 10.56 (sd 3.6) Results: Participant feedback suggested a high level of
Motor block (Bromage score 2-4) 11/48 (22.9%) satisfaction with the course. The impact of courses in terms of
Mean time to motor block (min) 237 (sd 135) reduction in maternal and neonatal mortality remains the
NVD 14/48 (29.1%) subject of ongoing scrutiny. One study from Somaliland
Instrumental 18/48 (37.5%) demonstrated improved knowledge and skills and evidence of
LSCS 16/48 (33.3%) positive behaviour change post introduction of the course.3

Satisfaction excellent/good 46/48 (95%)
Conclusions: Maternal morbidity and mortality remains a huge
Discussion: In this study we found the mean interval in problem in Kenya. In 2008 it's Maternal Mortality Ratio was
minutes between epidural boluses to be 105minutes. This is 488 per 100,000, one of the highest in the world.4Great efforts
greater than the average 60minute interval of the are being made by the Kenyan government to reduce this. An
programmable intermittent bolus(PIB) regimens. An average ambitious target to reduce MMR to 91 per 100,000 by 2018 has
rate of bupivicaine 10.56mg/hr was similar to that reported with been set. One step has been the introduction of the Liverpool
PIB and patient controlled epidural bolus(PCEA) regimens4, LSS EOC-NCC course.
while we report a lower rate of motor block. Given the practice Acknowledgements: I would like to thank the maternal and
of MLTU in effect is much like a PIB without PCEA, it is neonatal health unit at LSTM for the opportunity to become
notable that the time between epidural boluses is longer with involved, and look forward to teaching on my next course. I
MLTU with less maternal motor block and high maternal would also recommend the course to any obstetric
satisfaction. We feel our practice promotes close epidural anaesthetists with an interest in international health.
assessment as the midwives assess motor block and maternal
References
satisfaction before each “top-up” and avoids the cost of the
1. World Health Organization, UNICEF, UNFPA and The World
PIB/PCEA pumps.
Bank. Trends in Maternal Mortality 1990-2008. 2010.
References 2. Lawn JE, Kerber K, Enweronu-Laryea C, et al. 3.6 million neonatal
deaths–what is progressing and what is not? Seminars in
1. Capogna G Camorica M, Stirparo S, Farcomeni A. Programmed Perinatology 2010;34:371–386.
Intermittent Epidural Bolus Versus Continuous Epidural Infusion for
Labor Analgesia: The Effects on Maternal Motor Function and 3. Ameh C, Adegoke A, Hofman J, et al. The impact of emergency
obstetric care training in Somaliland, Somalia. International Journal
Labor Outcome. A Randomized Double-Blind Study in Nulliparous
of Gynecology & Obstetrics. 2012;117:283-7.
WomenAnesth Analg July Oct 2011; 113(4): 826-831
4. Kenya National Bureau of Statistics. Kenya Demographic and
2. George RB, Allen T, Habib A. Intermittent Epidural Bolus
Health Survey (KDHS) 2008-09. June 2010.
Compared with Continuous Epidural Infusion for Labour Analgesia:
A Systematic Review and Meta Analysis. Anesth Analg Jan 2013;
Vol 116: 133-144
3. Wong C, MacCarthy RJ, Hewlett Bl. The effect of manipulation of
the programmed intermittent bolus time interval and injection
volume on total drug use for labour epidural analgesia: a randomized
controlled trial. Anest Analg 2011; 112: 904-11
4. Husain T, Mavridou I, Fernando R, El-Wahab N, Stewart A, Dick J,
Columb M. A study of a programmed intermittent bolus and patient-
controlled epidural regimen for labour analgesia. Int J Obstet
Anaesth May 2013: P85 Abstracts OAA Bournemouth 2013
Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin) P19
P137 Enhanced recovery after elective caesarean section: P138 Epidural analgesia in obese parturients: can kneeling
Service evaluation and quality improvement be the answer to our prayers.
GJ Lilley,  M Adamson,  A Miskin*,  M Turner   S De Silva,  L Kelliher*,  R Mottaleb*,  E Combeer  
Anaesthetics, Royal Gwent Hospital, Newport, UK, Anaesthetics, Frimley Park Hospital, Frimley, UK,
*Obstetrics and gynaecology, Royal Gwent Hospital, *Anaesthetics, Royal Surrey County Hospital, Guildford, UK
Newport, UK Severe pain is not life-threatening in healthy parturient women,
Introduction: Enhanced recovery (ER), a concept widely it is however shown to have neuropsychological
recognised within many surgical specialties, is now a subject consequences. Postnatal depression may be more common
of interest within obstetrics. The core principles comprise when effective analgesia is not used1 and pain during labour
speeding up recovery and improving patient outcomes, with has been linked with the development of post-traumatic stress
associated benefits for staff and healthcare systems1. The disorder2.There is an increasing number of obese parturients3
most logical starting point for the introduction of ER principles and identification and placement of the epidural can be
are elective caesarean section lists. Delayed surgery may lead difficult in these women.
to prolonged fasting, followed by delayed mobilization, Classically the sitting or the lateral position is used during
delayed removal of catheter and delayed discharge. A pilot siting of labour epidurals. The kneeling position was first
audit in our hospital demonstrated a mean stay after elective described in 19934, where 34/35 women had their labour
caesarean section of 3.6 days, and mean preoperative fasting epidural sited whilst in the kneeling position and 88.5% of the
period of 12.4 hours. Current guidance for ER in obstetrics mothers were happy with this position.
suggests minimal interruption to oral intake, pre-operative
I elected to try the kneeling position in an obese lady with a
energy drinks, catheter removal at 12 hours post-surgery
BMI 50 after adjustments in the sitting position and two
regardless of time of day, and the option of discharge home 24
separate failed attempts to confidently palpate the lumbar
hours after caesarean section where appropriate2.
spine. Once the lady was in the kneeling position, the lumbar
Methods: All elective caesarean sections were included in this spine was not only palpable but also visible and the epidural
service evaluation after introduction of preoperative space was identified with ease. With Departmental approval I
carbohydrate drinks. Data collection included fasting time, in performed my labour epidurals in this manner and found it not
addition to time to mobilization, to catheter removal and to only to be easy to site epidurals but also tolerated well. Some
discharge. After an initial 6 week period of data collection, the women complained of paraesthesia in their feet, but this was
data was presented to anaesthetic and obstetric staff. Posters, rare and eased swiftly. We decided to survey our Deanery to
a discharge proforma and a patient information leaflet were ascertain what positions were being utilised.
produced, and specific guidance was developed regarding
Survey: An e-survey was sent to trainees and Consultants in
preoperative carbohydrate drinks. A further 6 weeks of data
the South West London Deanery into what their ideal first and
collection then took place.
second choice positions used for siting epidurals would be for
Results: A total of 78 consecutive patients were included, all labouring parturients. We then posed the same question for
of whom received a regional anaesthetic technique for elective obese parturients (BMI 40). They were asked if they had
caesarean section. The following table illustrates the timing of heard of the kneeling position and if anyone had tried it. For
pre- and post-operative events before and after our those who had not, we questioned why they had not tried it.
interventions.
Results: We received 53 responses, 96.2% of whom were
Time period / hour 2nd 6 week Initial 6 week
trainees. 64.2% chose to position the parturient sitting as their
mean(SD) period period
first choice and 60.4% chose lateral as their second choice in
Pre-op fasting 4.8 (2.8) 3.8 (2.5)
non-obese parturients. In comparison 84.9% opted for the
Post-op fasting 4.2 (3.5) 3.4 (3.5)
sitting position in obese parturients with 56.9% using the
Total interruption to oral
9.0 (4.5) 7.1 (4.6) lateral as their second choice. The only positions utilised were
intake
sitting and lateral. 94.9% of respondents had not heard of the
Delivery to mobilization 10.2 (4.5) 9.0 (3.3)
kneeling position to site labour epidurals.
Delivery to catheter removal 14.8 (6.6) 13.5 (3.5)
Conclusion: Each position used for the placement of labour
Delivery to discharge 67.3 (40.1) 63.3 (27.6)
epidurals has their own advantages and disadvantages. With
Discussion: The introduction of patient information leaflet
the rising incidence of maternal obesity and its associated
offering guidance regarding post-operative oral intake,
risks to not only the mother but also the unborn child, we need
mobilization, catheter removal and early discharge, along with
to be continuing in our development and advancement in the
staff education and introduction of pre-operative carbohydrate
provision of good care. We suggest that the kneeling position
drinks, has resulted in improvement in the timing of a number
is a safe and viable alternative for siting epidural catheters in
of peri-operative interventions, and a small reduction in
labouring parturients.
duration of hospital admission. However, possibly due to
References
obstetric, midwifery, paediatric and organisational reasons,
discharge is rarely achieved at the potential target of 24 hours 1. Hiltunen P, Raudaskoski T, Ebeling H, Moilanen I Does pain relief
during delivery decrease the risk of postnatal depression? Acta
after elective caesarean section. Obstet Gynecol Scand 2004;83:257-261
References 2. Soet JE, Brack GA, Dilorio C Prevalence and predictors of women's
1. Lucas DN, Gough KL. Enhanced recovery in obstetrics - a new experience of psychological trauma during childbirth. Birth
frontier? Int J Obstet Anaesth 2013; 22: 92-95 2003;30:36-46
2. Enhanced recovery partnership: A better journey for patients and a 3. Centre for Maternal and Child Enquiries (CMACE). Saving
better deal for the NHS. Available at: Mothers'. Lives: reviewing maternal deaths to make motherhood
http://www.improvement.nhs.uk/documents/er_better_journey.pdf safer: 2006–2008. The Eighth Report of the Confidential Enquiries
into Maternal Deaths in the United Kingdom. BJOG 2011;118:1-203
P20 Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin)
P139 Epidural labour analgesia and risk of instrumental P140 Estimation of blood loss during caesarean sections -
delivery discrepancy between visual and laboratory estimation
R Carvalho,  T Ferreira,  M Duque,  D Catré,  I Guedes,  J P A Nowicka,  A Amasakera,  C Ferdinand,  I Suri  
Assunção   Anaesthesia, Warwick Hospital, South Warwickshire NHS
Anaesthesiology, Centro Hospitalar Tondela Viseu EPE, Foundatio, Warwick, UK

Viseu, Portugal
Introduction: Excessive blood loss is a major threat to women
Introduction: Epidural analgesia (EA) is a worldwide effective undergoing casearean sections. Accurate visual estimation of
method used for pain relief during labour. Nevertheless, its use blood loss is difficult due to dispersion of blood lost and the
and evolution to instrumental vaginal (forceps or vacuum blood being mixed with amniotic fluid(1). Therefore the blood
extraction) or operative deliveries remains controversial loss often gets under or overestimated(2). A number of
between experts,1 either anesthesiologists or obstetricians. methods exist to estimate the blood loss, the commonly used
We aimed to analyze the relation between EA and instrumental being: visual estimation by the attending staff, weighing of the
v aginal deliveries in a sample of our obstetric population. blood soaked surgical swabs and calculation based on the pre-
and post-operative haemoglobin concentrations(3). The aim of
Methods: A retrospective study included all pregnant women
this audit was to compare the visually estimated blood loss by
who delivered on our labour Room, between 1-January-2011
both the surgeons (vEBLs) and anaesthetists (vEBLa) against
and 31-December-2012, excluding those who underwent
the calculated estimated blood loss (cEBL).
caesarean section. We reviewed the data of demographical
characteristics, type of gestation and labour, the use of EA Methods: Data was collected on thirty five caesarean sections.
and the newborn APGAR score. Descriptive analysis of Operating surgeona and anaesthetists were asked to visually
variables was used to summarize data and Chi-Square test was estimate the blood loss in each case. The circulating blood
used. Multivariate analysis was done with logistic regression, volume was calculated for each patient based on the body
with calculation of corrected Odds Ratio (OR) and its 95% weight and height. Then, the blood loss during caesarean
confidence interval (95% CI). section was calculated using the circulating blood volume and
the pre- and post-operative haemoglobin concentrations.
Results: 2901 pregnant women were included in this study, Correction was made for the haemodilution by intravenous
with mean age of 29,7 years. 81% underwent EA and 30% fluid administered.
instrumental vaginal delivery. 51% were nulliparous. Applying
Results: Twenty six complete forms were included in the
Chi-Square test to independent variables, we obtained
analysis. None of the patients received blood or blood
significant associations with dystocic delivery for EA, normal
products intraoperatively. Mean volume of intravenous fluid
maternal age (NMA; 20-35 years) and parity (p<0,001).
infused was 1304mL±421. Mean vEBLs, vEBLa and cEBL was
Applying logistic regression to our model, including parity,
590mL±300, 623mL±372 and 821mL±1004 respectively. The
NMA and EA with dystocic deliveries, we obtained corrected
tendency for anaesthetists to give a higher estimate of blood
OR (95%CI) for EA 2,459 (1,884-3,210) and for parity 3,4
loss was not statistically signifficant (p=0,12). There was a
(2,867-4,121), with NMA loosing significance. However, this
clear discrepancy between the visual estimate given by both
result may still be biased by other factors, such as labour
the surgeons and the anaesthetists, ant the cEBL, however, it
stage at the time of the EA beginning, drugs used in epidural
did not reach statistical significance (p=0,11 and p=014
space, use of oxytocin during labour, among others.
respectively). Compared to the cEBL the vEBL was
Additionally we found that, in our population of term
overestimated when the blood loss was low (12 cases) and
pregnancies, NMA and eutocic deliveries, there was no
underestimated when the blood loss was higher than 500mL
significant relation between EA and APGAR score <8 at the
(14 cases). There was a linear relationship between the degree
first minute (p=0,079).
of underestimation and the blood loss, with high levels of
Conclusion: It's generally assent that EA provides the most blood loss being most underestimated.
effective pain relief in labour. However, it's associated to Conclusions: In this audit, the standard procedure for
prolonged labour and risk of instrumental or caesarean estimation of blood (visual estimation by the obstetrician) loss
deliveries.2 Our study has drawn the conclusion that both was found to be unreliable. We demonstrated a tendency of
having EA for labour pain relief and being nulliparous increase anaesthetists and surgeons to overestimate the blood loss, if
the chance of instrumental delivery, respectively in 2,459 and actual blood loss was less than 500mL, and underestimate if
3,43 times, however without significant impact on newborn the blood loss exceeded 500mL. As a result of the audit, it has
APGAR score. Bigger prospective studies correcting for more been made compulsory in our unit to check haemoglobin
risk factors are advised. concentration in recovery whenever the vEBL exceeds
References 1 000mL.
1. BMC Pregnancy and Childbirth 2008, 8:45. References
2. Acta Obstet Gynecol Scand 2002, 8:1033-1039. 1. Khan FA, Khan M, Ali A, Chohan U Estimation of blood loss during
Caesarean section: an audit. J Pak Med Assoc. 2006 Dec;56(12):572-
5.
2. Larsson C, Saltvedt S, Wiklund I, Pahlen S, Andolf E Estimation of
blood loss after cesarean section and vaginal delivery has low
validity with a tendency to exaggeration. Acta Obstet Gynecol
Scand. 2006;85(12):1448-52.
3. Stafford I, Dildy GA, Clark SL, Belfort MA, Visually estimated and
calculated blood loss in vaginal and cesarean delivery. Am J Obstet
Gynecol. 2008 Nov;199(5):519.e1-7
Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin) P21
P141 Ethnic variations in use of labour analgesia P142 Factors associated with the use of spinal anaesthesia
LMD MacDarby,  CMC McCaul   for caesarean section in Nigeria
Delivery Suite, The Rotunda Hospital, Dublin, Ireland C Imarengiaye,  F Asudo*,  A Akinmola†,  B Lawal§  
Introduction; This retrospective cohort study was compiled to Anaesthesiology, University of Benin Teaching Hospital,
establish the wide variety of nationalities presenting to The Benin City, Nigeria, *Anaesthesia, University of Abuja
Rotunda Hospital for delivery during a one month period and Teaching Hospital, Gwagwalada, Nigeria, †Anaesthesia, 
to determine the labour analgesia preferences amongst this National Hospital, Abuja, Nigeria, §Anaesthesia, Lagos 
population. Island Maternity Hospital, Victoria Island, Nigeria

Introduction: There has been a consistent increase in the rate
Methods; Details of all deliveries occurring during the month
of spinal anaesthesia for caesarean section in many hospitals
of October 2013 were collected. Any patients undergoing
worldwide and had been advocated as the preferred technique
elective caesarean section and those with failed inductions
for caesarean delivery.1 Recent evidence suggests increasing
were excluded from the study. A demographic of patients’
use of spinal anaesthesia for caesarean sections in reports
nationality and ethnic background was compiled. Data relating
from a teaching hospital.2 The rise in spinal anaesthesia
to these patients’ use of labour analgesia was recorded i.e.
caesarean section notwithstanding, it is pertinent to determine
epidural uptake, pethidine administration and remifentanil
the factors limiting the wholesome application of spinal
infusion use. We then established the frequency of use of
anaesthesia for caesarean section in Nigeria.
each of these methods of analgesia in each population

Methods: A snap-shot survey was conducted in some
Results; There were 767 deliveries in Oct 2013. 104 elective
selected hospitals in Nigeria. The survey determined the
caesarean sections were carried out and there were 8 patients
sociodemographic characteristics of patients, indication for
who failed induction.
surgery, grade of anaesthesia provider, contraindication to
Therefore a total of 655 patients laboured during this time. spinal anaesthesia and any other factor that may be noticed in
This number was made up by 50 different nationalities. Of the selected hospital. The survey was to be conducted over a
these 414 patients were Irish, the majority being white but 2-week period but was truncated by the nation-wide strike
including small numbers of Asian or Black background. action by doctors after 9 days.
Amongst the Irish patients the rate of epidural uptake was
Results: A total of 99 patients were attended to in 4 of the
43.47% (234) and the rate of pethidine use was 17.87% (74)
selected 6 hospitals within the study period. 36/99 women
Patients of other white background, including many eastern
were nulliparous and maternal factors (82/99) were the leading
european countries made up 134 of the patients. These
indications for caesarean section. Consultant anaesthetists
patients as a group had a 52.98% epidural uptake rate. Black
(23/99), Senior Registrars (35/99), Medical Officers (36/99) and
Africans were found to have a 39.13% (9) uptake rate and
others (5/99) provided anaesthesia for the caesarean sections.
those of Asian background had the highest rate at 54.83%
85/99 patients received spinal anaesthesia and 14/99 had
(17). The use of pethidine was significantly lower than the rate
general anaesthesia for the c-section. Fetal indication for
of epidural in all of these groups. Pethidine was used by
caesarean section had a 3-fold risk of general anaesthesia for
18.19% of Black Africans, 12.9% of Asians and 23.13% in
the surgery (p = 0.037, RR = 3.1, 95%CI 1.2 – 8). 25/99 and
those of other white backgrounds. There were only 3 cases of
74/99 were performed as elective or emergency procedure.
remifentanil use during the month
Nature of caesarean section was not a factor for the use of
Discussion; The highest incidence of epidural uptake during spinal anaesthesia (p =0.51, RR = 2.0, 95%CI = 0.5).
Oct was found to be amongst the Asian population, the lowest Discussion: Over 85% of caesarean sections in Nigeria were
being amongst Black Africans. Pethidine use was less than conducted under spinal anaesthesia. Fetal indications for
25% in all groups. The reasons for these trends is unknown caesarean section provoked a 3-fold increase in general
though previous studies have suggested that cultural and anaesthesia for caesarean section. The use of general
educational factors may play a part. anaesthesia for caesarean delivery was due to fetal indications
A prospective survey of patients post delivery detailing the for surgery, antepartum haemorrhage and failed spinal
reasons for their choices of labour analgesia would be anaesthesia. Improved practical conduct of the spinal
worthwhile. Establishing the factors influencing their technique may enhance great application of spinal anaesthesia
decisions may allow us to provide an unbiased and fully for caesarean section.
comprehensive service to ensure patient satisfaction. References

1..Morgan BM, Magni V, Goroszenuik T. Anaesthesia for emergency
caesarenc section. BrJ Obstet Gynaecol 1990; 97: 420-424
2..Amadasun FE, Idehen HO, Edomwonyi NP. Evolving pattern of
anaesthesia for caesarean section: Experience at the university of
Benin Teaching Hospital West Afr J Med 2013; 32: 196-9
P22 Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin)
P143 Failed intubation for a category 1 caesarean section in P144 Fasting dilemmas: A rare case of a patient with non-
a patient with undiagnosed spina bifida ketotic hyperglycinaemia presenting for caesarean
CR Deane,  E Lewis,  J Spargo   section
Department of Anaesthetics, Singleton Hospital, Swansea, M Behravesh,  S Dawson,  G McClune,  S Atkinson  
UK Anaesthetics, Royal Jubilee Maternity Hospital, Belfast, UK
Introduction: Non-ketotic hyperglycinaemia (NKH) is a rare
Introduction: Spina Bifida Occulta (SBO) is part of a spectrum
autosomal recessive metabolic disease caused by a defect in
of neural tube defects and is common. We present the case of
the glycine cleavage system. This case report describes the
a patient with previously undiagnosed SBO who required a
management of a patient who presented for caesarean section.
category 1 caesarean section (CS). Despite an unremarkable
To our knowledge there are no other published case reports of
airway assessment she had a failed intubation on rapid
this type.
sequence induction (RSI) and subsequently required an awake
fibre optic intubation (AFOI). Case Report: A 32 year old Para 1 presented for elective
caesarean section of twins at 37 weeks gestation. She had a
Case report: A 37 year old para 0 patient presented to labour
history of atypical non-ketotic hyperglycinaemia. Following
ward labouring with a single live foetus at 37 weeks gestation.
advice from clinical chemistry, during her 6 hours preoperative
She was admitted under consultant obstetric care with
fast she received an inceased dose of sodium benzoate and an
asymptomatic hypertension. When considering an epidural
intravenous infusion of 10% dextrose at 3mls/kg/hour which
she was examined and had a vascular naevus, associated with
was continued perioperatively. Caesarean section was
skin tethering, over lumbar vertebrae. She was asymptomatic,
performed under spinal anaesthesia and twin baby boys were
had never been investigated, and had no definitive diagnosis
delivered successfully. Post delivery of the second twin she
of SBO. Airway assessment included a Mallampatti score of 3,
received a bolus of 5 units of syntocinon followed by an
but was otherwise unremarkable. An epidural was declined to
infusion at 10 units per hour. Due to uterine atony and an
the patient, with a remifentanil PCA provided instead. A plan
operative blood loss of 1000mls she also received ergometrine
was agreed for a RSI GA if operative intervention was
carboprost intramuscularly to good effect. Sodium benzoate
required. Several hours later she required a category 1 CS.
was administered orally in recovery and the 10% dextrose
Initial laryngoscopy with a Mackintosh blade yielded a
infusion was continued until the patient was establised on an
Cormack and Lehane grade 3 view. Manipulation of the cricoid
oral regimen prescribed by the dieticians. This involved a
cartilage, long and McCoy blades did not improve the view.
series of high calorie drinks up to every 2 hours for 48 hours.
Two failed attempts were made to intubate using a bougie. The
No dietary protein was allowed for 24 hours post delivery.
patient was ventilated using a face mask and a Guedel airway
Glycine levels were monitored daily and were raised on day 5
with oxygen saturations above 97% throughout. She was
while dietary protien was being gradually reintroduced.
woken up without further incident and an AFOI was
performed. Her child was delivered by LSCS without further Discussion: NKH has an incidence of 1 in 60,000 with 3
incident or obvious deficit. The APGAR scores were 8 and 10 distinct presentations. Classically neonates present with
at one and five minutes. A grade 3 view was confirmed before lethergy, hypotonia and seizures. These symptoms can
the patient was woken. Recovery from anaesthesia was proceed to apnoea requiring ventilation and 30% of patients
uneventful. The patient was appropriately counselled. An do not survive the neonatal period. Severe psychomotor
Airway Alert Letter was issued and follow up appointment retardation is common in those who survive. A second,
made. An MRI was carried out subsequently and showed a atypical and very rare form presents with mild baseline
neural arch defect and dural tethering. Significantly the conus hyperglycinaemia and intermittent encephalopathy
lay as low as L4 with diastematomyelia as far as L2. assosciated with periods of illness. Transient neonatal
hyperglycinaemia has also been described. Biochemically,
Discussion: SBO is common and without prior imaging
NKH is characterized by elevated glycine concentrations in
presents the clinician with a difficult decision. Regional
plasma, CSF, and brain with a CSF glycine to plasma glycine
techniques risk neural or dural injury due to a low lying or
ratio greater than 0.08.1 Standard treatment strategies include
tethered cord.1 Abnormal spread of the analgesic agents may
protein restriction to reduce exogenous glycine,
give rise to either excessive cranial spread or inadequate
supplementation of one-carbon pool donors and
caudal spread. This patient population provides further issues
administration of sodium benzoate. NMDA antagonists have
for the anaesthetist given the high risk of operative delivery or
been shown to raise the developmental quotient, improve
other intervention (due to pelvic structural abnormalities) and
muscle tone and reduce seizures in these patients.2
the association of spina bifida with difficult intubation.2,3
Patients with spina bifida require careful preop assessment Prolonged periods of fasting predispose these patients to
and MRI imaging and careful airway consideration is essential glycine build up and its toxic neurological effects. This has
in order to inform anaesthetic planning. major implications for the anaesthetist in the perioperative
period. This case demonstrates the safe use of regional
References
anaesthesia in conjunction with careful nutritional planning.
1. Reynolds F. Damage to the conus medullaris following spinal
anaesthesia. Anaesthesia 2001; 56: 235-247. References
2. Richmond D, Zaharierski I, Bond A. Management of pregnancy in 1. Chang YT, Lin WD, Chin ZN et al. Nonketotic hyperglycinemia: A
mothers with spina bifida. Eur J Obstet Gynecol Reprod Biol 1987; case report and brief review. Biomedicine 2012; 2(2):80-82
25: 341-5. 2. Van Hove JL, Vande Kerckhove K, Hennermann JB et al. Benzoate
3. May A, Fombon F, Francis S. UK registry of high-risk obstetric treatment and the glycine index in nonketotic hyperglycinaemia.
anaesthesia: report on neurological disease. Int J Obstet Anaesth Journal of Inherited Metabolic Diseases. 2005;28:651–663
2008; 17: 31-6.
Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin) P23
P145 Fetal bradycardia following regional anaesthesia for P146 Further increase in hysterectomy rates - and the
emergency caesarean section and instrumental reason why
delivery: a service evaluation JS Campbell,  M Molloy,  C Thompson,  D Fogarty  
JK Sidana,  K Jadhav-Smith,  J Corfe   Royal-Jubilee Maternity Service, Belfast HSC Trust, Belfast,
Anaesthetics, Norfolk and Norwich University Hospital, UK
Norwich, UK Introduction: RJMS is the tertiary obstetric service for
Introduction: Fetal heart rate abnormalities, such as late Northern Ireland. As part of a service review of use of uterine
decelerations or fetal bradycardia, are known to occur after artery balloon catheters, we retrieved data from several
neuraxial anaesthesia.1 These may be due to maternal sources. We found a large proportion of these patients still
sympathetic blockade or an increase in the uterine tone caused required hysterectomy. Further interrogation of our data
by intrathecal opioids. The objective of this service evaluation showed some unexpected trends.
was to evaluate the incidence and management of fetal Methods: With approval of the Trust's Data Guardian we used
bradycardia following regional anaesthesia for emergency data from several hospital systems, including a local maternity
caesarean section and instrumental deliveries. care database and histology records.
Methods: 15 patients with an episode of fetal bradycardia Results: We found 30 hysterectomies from 37,088 deliveries in
following regional anaesthesia were identified by reviewing 6 years. This is a rate of 0.8 per 1000 - significantly higher than
the daily obstetric handover sheets from January to December our prior rates which was near the NICE-quoted rate of up to 3
2011. The medical notes of these patients were reviewed for per 1000. Of these cases, 23 (76%) were due to morbidly
peripartum obstetric management, cardiotocographic (CTG) adherent placenta.
findings, perioperative anaesthetic management and
Not all these cases of morbidly adherent placenta were
management of fetal bradycardia. Neonatal outcome was
diagnosed antenatally, which perhaps made hysterectomy
assessed by APGAR scores, umbilical cord gases and NICU.
more likely since facilities such as intra-arterial balloon
Results: 10 patients had an assisted delivery and 5 had an catheters could not be available to us in an emergency.
emergency category-2 LSCS. The peripartum CTG findings Unanticipated cases suffered greater blood loss. Despite no
were either suspicious or pathological. Timing of fetal diagnosis, the majority (16/23) were placenta percreta on
bradycardia following regional anaesthesia ranged from 2 to 15 histology. These percreta cases again had greater blood loss,
min. 13 patients received spinal anaesthesia and 2 received and were more likely to require ICU care post-operatively. Yet
epidural top up. Maternal haemodynamics stability was there were no cases of percreta in the 6 years prior, and less
maintained with left uterine displacement, intravenous fluids than half the number of hysterectomies in that period. This
and phenylephrine infusion. One patient had an episode of seems to be a dangerous and dramatic change in recent years.
maternal bradycardia below 50 beats/min which was treated
Conclusion: We found a recent and significant increase in
with anticholinergics. Comparing the baseline maternal heart
peripartum hysterectomy, associated with a large increase in
rate with the lowest perioperative heart rate, 3 patients had a
the number and degree of morbidly adherent placenta. Patients
greater than 40% drop in the heart rate. 5 patients had a blood
with placenta percreta had a greater blood loss, and more
pressure drop of more than 20% below the baseline, which was
commonly required hysterectomy and ICU care.
treated with phenylephrine. The highest level of block to
Reference
temperature was T3. Syntocinon was stopped in all but one
case in the event of fetal bradycardia. Significant delays 1. National Institute for Health and Clinical Excellence. Caesarean
section: NICE Clinical Guideline 132 2012,
occurred in transferring these patients to theatre after the
http://www.nice.org.uk/nicemedia/live/13620/57163/57163.pdf
decision for surgical intervention were taken, maximum 35 min
(median 17 min). 6 cases had poor neonatal outcomes with low
5 minute APGAR and abnormal cord gases.
Discussion: We could not find any direct cause which can be
solely attributed to regional anaesthesia for the occurrence of
fetal bradycardia in these patients. Significant delay in patient
transfer to theatre may have a causal relationship but cannot
be confirmed. Studies in elective patients have shown that
maternal bradycardia causes a drop in maternal cardiac output.
2 Relative maternal bradycardia occurred in several of our
cases and this would have led to drop in cardiac output and
therefore oxygen delivery. This is most likely a side effect of
phenylephrine use. We plan to introduce a care bundle to
implement pre-operative and intra-operative fetal resuscitation.
This will include steps to improve fetal condition at the time of
regional anaesthesia and to ensure adequate maternal cardiac
output and oxygen delivery.
References
1. Reynolds F, Seed PT. Anaesthesia for Caesarean section and
neonatal acid-base status: a meta-analysis. Anaesthesia 2005; 60:
636–653
2. Stewart A, Fernando R et al. The dose-dependent effects of
phenylephrine for elective caesarean delivery under spinal
anaesthesia. Anesthesia & Analgesia 2010; 111: 1230-7.
P24 Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin)
P147 Impact of workload on accidental dural puncture P148 Implantable cardioverter defibrillator in
(ADP) rate pregnancy WITHDRAWN FROM PRESENTATION
W Mon,  YM Liu,  A Stewart,  R Fernando,  M Columb*   S Chaudhari,  S Quasim  
Anaesthetics, University College London Hospital, London, Anaesthetic Department, University Hospital Coventry and
UK, *Intensive Care Unit, University Hospital of South Warwickshire , Coventry, UK
Manchester, Manchester, UK
Introduction: Post dural puncture headache is an important
cause of morbidity. We audit our ADP rates annually against
the national standard.1Between 2005 and 2008, our ADP rate
was stable at approximately 0.5%. However, from 2008 to 2010,
our rate rose to above the 1% national standard.1Therefore, we
audited factors that may have contributed to this increase.
Methods: Information for this audit was obtained from a
computerised database. Data collection included day, month
and time of ADP and the grade of anaesthetist. We also
collected annual data of number of deliveries, epidurals and
combined spinal epidurals (CSEs) for labour, caesarean section
(CS) data, and the proportion of single shot spinals (SSS) to
CSEs performed. Data were analysed using chi-square
multinomial and trend tests with P value <0.05 defined as
significant.
Results: There was a 40% increase in deliveries between 2008-
2010. CSs and regional blocks for analgesia increased by 36%
and 40% respectively. Although the ADP rate increased, we
could not demonstrate a statistically significant trend due to
small numbers. From 2010 to 2012, a non-significant fall in the
ADP rate was seen. There was no significant association
between ADPs and day, month or time. We did see a
significant non-linear trend (P = 0.0012) in the proportions of
SSSs to CSEs performed, with the peak occurring in 2010.
Table 1. Trend of activity and ADP rate from 2008 to 2012
  2008 2009 2010 2011 2012 P value
Maternities (n) 4032 5039 5647 5841 5953 < 0.0001
Epidurals for labour (n) 1306 1600 1839 2029 2132 < 0.0001
CSs (n) 1370 1562 1861 1862 1773 < 0.0001
SSSs for CS (n) 282 274 356 326 347 0.0015
CSEs for CS (n) 797 644 714 833 915 < 0.0001
Proportion of SSS to CSE (%) 26 30 33 28 27 0.0012
ADP rate (%) 0.57 0.98 1.05 1.01 0.82 0.31
Discussion: We observed an increase in ADPs until 2010, with
significant rises in deliveries and anaesthetic procedures
performed. The significant non-linear trend in the proportions
of SSSs to CSEs performed for CSs peaked in 2010. A fall in the
ADP rate between 2010-2012, occurred despite exposing more
women to the risk of ADP, as during this time we performed
significantly more CSEs than SSSs proportionally. We believe
that the rise in the ADP rate resulted from a significant
increase in our workload between 2008 and 2010, without any
increase in anaesthetic staffing. From 2010 onwards, daytime
anaesthetic consultant sessions increased by 50%, and there
was a higher presence on the labour ward out of hours by
senior registrars covering non-obstetric theatres. Both factors
may have contributed to the subsequent fall in the ADP rate.
This audit supports the recent OAA/AAGBI guideline
recommending increased anaesthetic staffing on labour ward.2
References
1. Royal College of Anaesthetists. Epidural analgesia during labour.
Raising the standard: a compendium of audit recipes. 2012;218-219
2. Association of Anaesthetists of Great Britain and Ireland and
Obstetric Anaesthetists' Association. OAA/AAGBI guidelines for
obstetric anaesthetic services. 2013
Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin) P25
P149 Inadvertent hypothermia during elective caesarean P150 Inter professional relationships on labour ward- how
sections well do anaesthetists and midwives get along?
S Botros,  R Labib,  T Ramhew,  M Baban,  Y Poonawala   M Salman,  P Kumar,  G Graham  
Selwyn Crawford Department of Anaesthesia , Birmingham Anaesthetics, St. Thomas' Hospital, London, UK
Women's Hospital, Birmingham, UK Introduction: Anaesthetists and midwives are part of the
Introduction: The National Institute for Health and Care multi-professional team that provides care for parturients.
Excellence (NICE) defines inadvertent perioperative They work together in close collaboration in the unique and
hypothermia as a core body temperature below 36°C.1 It is a often highly charged environment of labour ward. In such
common complication of regional anaesthesia, and is the settings, effective inter professional relationships are key to
leading cause of perioperative shivering. Hypothermia is the delivery of high quality care and consequently better
associated with increased risk of wound infection and patient outcomes. Successful collaborative practice can be
increased blood loss.1 Shivering can be associated with negatively impacted by barriers such as lack of clarity on the
increased oxygen consumption and hypoxaemia in vulnerable scope of roles of team members, poor communication, or
patients. Although the NICE guideline on the management of stereotyping. We conducted a survey amongst obstetric
perioperative hypothermia did not cover pregnant women,1 it anaesthetists and midwives in our hospital to reflect upon this
has been adopted by many obstetric units. In our unit, working relationship and to see how it may be improved.
intravenous (IV) fluid is not routinely warmed for elective
Methods: A questionnaire was designed and distributed to
caesarean sections (CS). Hence, we audited our practice to
midwives and anaesthetists of all grades. Questions were
evaluate the incidence of hypothermia.
asked on their understanding of each other's professional role
Methods: Over a three month period, we prospectively audited
and on their perception of the quality and effectiveness of
our practice in 47 women who had elective CS under
their working relationship. A total of 43 responses were
subarachnoid anaesthesia without active warming. We
collected (24 anaesthetists and 19 midwives) in an ongoing
measured their tympanic temperature prior to anaesthesia (T )
1 survey.
and at the end of surgery (T ). We also collected data that may
2 Results: Of the anaesthetists who completed the
influence the results like the volume of IV fluid infused,
questionnaire, 16.6% were consultants, 58.3% were ST5-ST7,
estimated blood loss (EBL) and duration of surgery. We also
20.8% were ST3-4 and 4.1% were CT1-2. When asked whether
assessed the incidence of perioperative shivering. We
they felt they understood the scope of responsibilities of
repeated the audit in 42 parturients using an IV fluid warming
midwives on labour ward, only 27% of anaesthetists felt they
device. The data were analysed using Microsoft Excel 2007®.
understood it fully. In contrast, 63% of midwives believed they
Data from both audits were compared and p-values were
fully understood the scope of the anaesthetist's
calculated using unpaired t-test by GraphPad software®.
responsibilities.
Results: In the initial audit, 20 patients (42.55%) were
hypothermic at the end of surgery (T < 36°C). Shivering Thirty percent of midwives felt that collaboration with
2
occurred in 14 patients (29.79%). No correlation was found anaesthetists was 'very easy', in contrast to only 5.5% of
between T and the IV fluid volume, EBL, duration of surgery anaesthetists who felt the same about collaboration with their
1-2
or the dose of intrathecal Bupivacaine. In the re-audit, only 3 midwife colleagues. While 16% of anaesthetists found this
(7.14%) patients experienced hypothermia. There was no collaboration 'difficult', none of the midwives did (0%).
statistical difference in T between the two audits (p = 0.781). Seventy two percent of anaesthetists felt their input was
1
usually well-received by their midwife colleagues, compared to
  Initial Audit (n=47) Re-audit (n=42) p-value
only 40% of midwives who thought their input was well-
Fluid (ml) 1116.67(±369.43) 1233.33 (±483.59) 0.2236
received by the anaesthetist. Both professions were asked
EBL (ml) 523.75 (±152.33) 582.5 (±491.67) 0.474
how they perceived the general quality of communication
T1 36.84 (±0.37) 36.81 (±0.37) 0.781
between them. The majority of anaesthetists (47%) perceived it
T2 36.08 (±0.4) 36.3 (±0.29) 0.004
as 'fair', while 15% regarded it as 'poor'. Ninety percent of
T 0.76 (±0.34) 0.52 (±0.41) 0.0032
1-2 midwives felt it was either 'very good' or 'good'. None of the
Discussion: Our audit highlights the effect of warm IV fluid midwives (0%) felt it to be 'poor'.
therapy on reducing the incidence of inadvertent perioperative
Questions were asked on the types of obstacles they
hypothermia during elective CS. Our audit recommends the
encountered in their professional interaction with each other.
routine warming of IV fluid during elective CS. The Enhanced
Most anaesthetists (72%) agreed that they found fixation on
Recovery Partnership Programme considers patient warming
tasks and exclusion of others to be a challenge, followed by
as a key factor in accelerating patient recovery.2 Following our
delayed or non-communication of important issues (57%). A
results and as part of developing a new pathway for enhanced
third of the anaesthetists felt they rarely got a comprehensive
recovery post CS; our trust is currently looking to invest in a
handover from the midwife while only 29% of midwives felt
cost-effective IV fluid warming device.
they understood the rationale behind the anaesthetists'
References decisions.
1. NICE (2008) Perioperative hypothermia (inadvertent): full Conclusion: Despite both specialties working in close
guideline (CG65). Full Guideline. London: National Institute for proximity, the survey identified several gaps in
Health and Care Excellence.
communication. Working towards enhancement of the
2. Enhanced Recovery Partnership (2012) Fulfilling the potential: a
professional relationship between members of the team
better journey for patients and a better deal for the NHS. Leicester:
NHS Improvement. Available at http://www.improvement.nhs.uk providing maternity services will help facilitate their
(accessed 14/12/2013) collaboration and will reflect positively on the performance of
both professions.

P26 Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin)
P151 Intra-arterial balloon catheters: A service evaluation P152 Intrathecal diamorphine for cesarian section following
JS Campbell,  M Molloy,  D Fogarty   intramuscular diamorphine during labour: a cause for
Royal-Jubilee Maternity Service, Belfast HSC Trust, Belfast, concern?
UK RC Barr,  L Parks  
Introduction: Intra-arterial balloon catheters have become Anaesthetics and Intensive Care, Southern Health and Care
widely used and predominantly accepted in cases where Trust, Northern Ireland, UK
massive haemorrhage is anticipated, especially with morbidly Introduction: Diamorphine has largely replaced pethidine for
adherent placenta . However, the benefits are still intramuscular (IM) analgesia during labour in our obstetric
1,2
controversial. While our unit is not stand-alone, our building unit. We also routinely give diamorphine (250-300 micrograms)
is physically separated from other departments including intrathecally (IT) for cesarian sections. A recent case of
radiology, so the logistics of balloon catheters are difficult2. meiosis and drowsiness, in a lady presenting for a category 2
Our objective was to identify the impact of balloon catheters cesarian section having received IM diamorphine in labour,
on management of morbidly adherent placenta. Associated highlighted the potential for side effects when diamorphine is
anaesthetic issues include massive transfusion, cell salvage, used IM and then IT. Should we therefore consider adjusting
type of anaesthetic and post-operative care. our IT dose of diamorphine in women presenting for
Methods: With permission of the Trust's Data Guardian, we emergency cesarian sections? To our knowledge there are no
retrieved data from multiple sources to identify and review guidelines on this subject and clinical practice appears
cases where balloon catheters where used. These included variable.
radiology logs, maternity records and histology. Methods: We conducted a survey of all anaesthetists working
Results: Ten cases were identifed via these systems. Seven in the Southern Health and Social Care Trust who partake in
were for morbidly adherent placenta, of which 5 required obstetric anaesthesia. Questions focused on; current
hysterectomy despite balloon inflation. Many of these were diamorphine practice, diamorphine dose adjustments, factors
cases of placenta percreta, despite antenatal diagnosis of influencing our dose decisions and concerns regarding
accreta. However, blood loss was lower by around 20% potential side-effects with IT diamorphine.
(1078ml) using balloons, when compared to other Results: We received 24 replies; 14 consultants and 10
hysterectomies in the same time period. experienced trainees who regularly perform obstetric
Other indications were for intra-abdominal pregnancy and anaesthesia. There was a wide variation in diamorphine
persistent post-partum haemorrhage. Another case was practice amongst our anaesthetists. The majority (76%)
abandoned due to logistical reasons (unable to organise consider reducing their IT dose following IM diamorphine.
theatre time in same building), a decision felt to be open to Factors influencing this dose reduction include timing (88%)
medicolegal criticism after preparation and planning for and dose (29%) of the last IM diamorphine and clinical signs
balloons. of toxicity (76%). In particular anaesthetists were concerned
about postoperative respiratory depression (94%) and
Limitations particularly reflected the limitations and
drowsiness (88%), although no one surveyed reported
inconsistency of the systems used, for example no coding in
experience of these or other adverse effects associated with IT
records for morbidly adherent placenta. Local presentation
diamorphine.
highlighted these problems, which are being taken forward.
Discussion: There is variability regarding the IT diamorphine
Conclusion: Our review, and subsequent MDT discussion,
dose given to women for emergency cesarian section who
has confirmed the place of intra-arterial balloon catheters
have already received IM diamorphine in labour. This practice
within local guidelines for management of morbidly adherent
is based on limited evidence. Given the lack of adverse effects
placenta, and other occasional indications. We had decreased
reported from our survey and evidence from other specialties
blood loss in cases using balloons, but still saw a large
where diamorphine is used in higher doses 1,2,, we see no
proportion requiring hysterectomy.
reason to routinely reduce the IT diamorphine dose unless
References
there are clinical signs of opiate toxicity. Consideration should
1. Beilin Y, Halpern SH. Placenta accreta: successful outcome is all in be given to prolonged postoperative monitoring of all women
the planning. Int J Obstet Anesth. 2013;22:269–271.
who have received both IM and IT diamorphine, especially
2. Sadashivaiah J, Wilson R, Thein A. Role of prophylactic uterine
artery balloon catheters in the management of women with those in whom the interval between IM and IT diamorphine is
suspected placenta accreta. Int J Obstet Anesth. 2011;20:282-287 short or where there are signs of toxicity.
References
1. Fogarty DJ, Milligan KR. Postoperative analgesia following total
hip replacement ; a comparison of intrathecal morphine and
diamorphine. Journal of the Royal Society of Medicine 1995; 88:
70-72
2. Jacobson L, Kokri MS, Pridie AK. Intrathecal diamorphine: a dose-
response study. Annals of the Royal College of Surgeons of England
1989; 71: 289-292
Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin) P27
P153 Introducing self-administration of medication after P154 Is Remifentanil patient controlled analgesia an
caesarean section: a Robert The Bruce story effective alternative to epidural for labour analgesia?
A R Sajayan,  K Ramm,  T Yates,  Y Chikermane   V Betharia,  K Peckitt  
Anaesthesia, Heartlands Hospital, Birmingham, UK Anaesthesia, Stepping Hill Hospital, Stockport, UK
Introduction: We were involved in the introduction of the local Introduction: Remifentanil patient controlled analgesia (PCA)
protocol for self-administration of postoperative medications was introduced for pain relief in labour at our institution in
(SAM) after elective LSCS at a large obstetric unit. In the past, 2007. Since then its demand has steadily increased, gaining
several attempts to implement this have failed.We conducted a favour with midwives and patients due to simplicity of use,
pilot study to identify the obstacles and develop ways to effective analgesia¹ and good safety profile². We have
overcome the same standardised protocols for administration and monitoring of
Methods:A pilot project was conducted to find out the Remifentanil PCA and patient controlled epidural analgesia
obstacles in the process by obtaining feedback from the staff (PCEA) during labour which are strictly adhered to. Aim of our
and patient involved in the care of 10 patients who underwent audit was to assess both Remifentanil PCA and epidural PCEA
elective LSCS over a week’s time. Obstetric, anaesthetic, for labour analgesia and make recommendations for improved
recovery and ward staff were informed beforehand about this care of mothers and infants.
pilot by emails and personal discussion. The patients were Methods: This was a prospectively done, questionnaire based
given information leaflet during preoperative assessment and audit. Data was collected over 2 months from November 2013 -
were informed again on the day of operation. Interested January 2014. We looked at mode of delivery,
patients enrolled in the pilot with due consent. The self- cardiotocographic abnormalities, APGAR scores, maternal
administration pack contained analgesics and enoxparin and cardio-respiratory complications, conversion to alternative
was dispensed by the recovery staff. Exclusions were: methods of analgesia and patient satisfaction.
language barrier, patient refusal, lack of capacity and any co Results: There were 610 deliveries during the 2 months.
morbidities. Feedback was collected from patients and staff Remifentanil PCA was used in 102 (17%) and epidural PCEA in
using the standardized proforma during the postoperative 85 (12.2%) patients for labour analgesia.
visit. Mode of delivery:
Results:Two of the patients felt that on the first day it was
  Normal Assisted LSCS
difficult to use SAM due to mobility restrictions. One patient
Remifentanil PCA 69 (67%) 20 (19.6%) 13 (12.7%)
did not receive SAM pack due to communication problem
Epidural PCEA 29 (34%) 35 (41%) 21 (24.7%)
involving midwives and staff. The remaining seven patients
were satisfied with SAM. The obstacles we identified in the There was a higher incidence of cardiotocographic
pilot and also from the past experience and the way we tackled abnormality in the epidural group (61%) as opposed to
them are as below: Remifentanil group (34%). APGAR scores in both groups were
more than 8 at 5 minutes. None of the patients in either group
Obstacle Strategy
had respiratory depression or cardiovascular instability. Eight
Personal & email reminder
(7.8%) patients converted from Remifentanil to epidural due to
Promotional posters in clinical areas
inadequate analgesia whereas 4 (4.7%) patients in the epidural
Communication Reminder notices in operating room and recovery
group used alternative analgesia (3 switched to Remifentanil
Meeting with stakeholders (doctors, midwives&
and 1 to entonox). Patient satisfaction was similar in both
pharmacist)
groups at 95%.
Involving all staff in guideline preparation
Discussion: From our experience, Remifentanil PCA is a safe
Staff engagement Process simplified and paper work streamlined
and effective method of labour analgesia. We found no
Standardized SAM package and delivery
evidence of worsening cardiotocography or neonatal
Guideline Fully prepared guideline after extensive consultation
outcomes with its use. We also found that patients using
Time Pre-printed forms to increase efficiency and to avoid
Remifentanil have increased rate of vaginal deliveries as
management time delays and work duplication
compared to those on epidural. While epidural analgesia
Discussion: Self-administrationof medications after caesarean remains the gold standard and will be preferable in certain
provides better patient centered care. It improves patient and groups of patients, Remifentanil PCA is certainly an excellent
staff satisfaction, improves clinical efficiency and eases alternative to consider. In our institution its uptake has
staffworkload at hospital and at community level1. It empowers steadily increased to approximately 50 patients per month with
the mother in their own care, potentially reduces length of patients consistently report ing high levels of satisfaction.
stay, and facilitates seamless flow ofcare. Although staff and References
patients liked the concept alike, the process had failedthree
1. Blair JM, Dobson JT, Hill DA, McCracken GR, Fee JP. Patient
times before because of certain obstacles. This pilot helped us controlled analgesia for labour: a comparison of remifentanil with
to highlight the areas we needed to focus on with our new pethidine. Anaesthesia 2005; 60 (1) : 22-7
strategies and the results have been encouraging. After fully 2. Volikas I, Butwick A, Wilkinson C, Pleming A, Nicholson G.
Maternal and neonatal side-effects of remifentanil patient
implementing the project, the uptake is gradually getting better
controlled analgesia in labour. Br J Anaes 2005; 95(4): 504-9
and we continue to audit the outcome.
References
1. Snell P M, Bowden M I, Viira D J, Chilvers J P. An observational
study of self-medication of analgesic drugs after caesarean section.
Int J Obstet Anesth 2002; 11: S29
2. Change management good practice guideline-NHS Direct
P28 Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin)
P155 Is the existing local hospital guideline, 'Management P156 Klippel-Feil syndrome: management of anticipated
of women who decline blood products', being adhered difficult airway for caesarean delivery 
to? TM Price,  MT Qureshi,  ROK Laird  
J Houston,  R Burns   Department of Anaesthesia, Altnagelvin Area Hospital,
Simpson Centre for Reproductive Health, Royal Infirmary of Derry, UK
Edinburgh, Edinburgh, UK Introduction: Klippel-Feil syndrome (KFS) is a rare genetic
Introduction: An estimated 150000 Jehovah's Witnesses disorder affecting around 1 in 40,000 live births and is
(JWs) live in the UK1. JWs may not accept blood product (BP) characterised by the congenital fusion of any two of the
transfusion1, and have up to 130 times increased risk of cervical vertebrae1. In addition to the abnormalities of the
maternal death from major obstetric haemorrhage2. This cervical spine, patients may have thoracolumbar scoliosis,
retrospective case note review aims to establish how closely spina bifida and congenital heart defects. The classical
the hospital guideline, 'Management of women who decline phenotypic presentation is described as low hairline, short
blood products' (the Guideline), has been followed since its neck and limited neck and head movement. These patients can
May 2012 introduction, and to identify areas for improvement. therefore present a considerable challenge to the anaesthetist.
Methods: JWs managed at the Anaesthetic Antenatal Clinic The safest method of providing anaesthesia for operative
(AAC) since the Guideline's introduction were identified, and delivery of a parturient with KFS is controversial. We would
their medical records accessed. Information surrounding like to share our experience in managing four elective
aspects of patient management addressed by the Guideline caesarean deliveries in two parturients using awake oral fibre
was extracted. The findings were then audited against the optic intubation (AOFOI) and general anaesthesia.
Guideline to establish how closely it had been followed. Case Reports: The first patient had KFS Type II with fusion of
Approval was obtained from the Medical School and the cervical vertebrae and underwent elective caesarean deliveries
Regional Research Ethics Service. aged 35 and 37 years old. The second patient had KFS Type
Results: Of the patients referred (N=26), 92.3% were reviewed III with fused cervical vertebrae in conjunction with fusions in
at the AAC, and had management plans created, at 31.0 weeks' the thoracolumbar spine, and underwent elective caesarean
gestation on average (Guideline target: 28.0 weeks). 88.5% deliveries aged 31 and 39 years old. Our patients were both
completed a BP checklist before admission in labour, and pre-assessed by a consultant anaesthetist at a high-risk
96.2% by time of delivery. 7.7% agreed to accept BPs at clinic pregnancy clinic prior to delivery. This allowed time to discuss
and were discharged, so women studied became N=24. BP the anaesthetic options with each patient and plan for elective
refusal of 12.5% was not appropriately recorded in the notes, or emergency delivery. Both patients had the classical
and contrary to the Guideline, serum ferritin was not checked phenotypic features of KFS. Airway assessments revealed
in any woman. During pregnancy, 29.2% were not recorded as Mallampati class 4, thyromental distances less than 6cm and
having taken iron, and Hb was measured in 95.8%. Excluding severely limited neck flexion and extension. The trachea was
elective caesarean sections (CS), Obstetric consultants were not palpable in either patient. We anticipated difficult direct
documented as informed of admission in 13.6% of cases, and laryngoscopy in both patients and elected to manage the
54.5% of labours and deliveries were reviewed or supervised airway with an AOFOI followed by general anaesthesia. The
by senior Obstetric staff (ST6-consultant). 20.8% of total oral route was chosen as both patients had small nares in
deliveries were by CS: cell salvage was set up in 100.0% of keeping with KFS. Sugammadex ensured complete reversal of
these, and used in 80.0%. rocuronium induced neuromuscular blockade and smooth
Discussion: This study found the Guideline was closely emergence. Caesarean delivery and postoperative recovery
followed in some areas: completion of acceptable BP checklists was uneventful in all four cases.
before delivery, and availability and use of cell salvage in CS,
Discussion: As obstetric anaesthetists we are constantly
compare favourably to previous UK studies1,3. Areas to be
trying to minimise the risk to our mothers. Klippel-Feil
improved include that BP refusal must be appropriately
syndrome affects both the airway and the spine, making the
recorded in patient notes to ensure clarity upon presentation
choice of anaesthetic technique a difficult decision. Successful
in labour or an emergency. It is vital that iron supplementation
use of regional techniques including spinal, epidural and
is commenced early in JWs, and ferritin levels are monitored,
combined spinal-epidural anaesthesia, have all been described
to maximise iron stores. In light of this study's findings,
in the literature1. However, we feel that embarking upon a
hospital blood transfusion Haematologists, in the future, will
regional technique in patients with distorted neuroaxial
review JWs antenatally. The Guideline should quantify how
anatomy would expose patients to unnecessary risk of high
often Hb should be monitored, so anaemia can be detected
spinal block and/or inadequate regional anaesthesia. Should
and treated before delivery. Crucially, consultant staff must be
general anaesthesia be needed intra-operatively, attempting an
documented as informed upon admission of JWs in labour, in
AOFOI in an already distressed parturient would be
order that deliveries can be supervised by senior staff to
challenging. We therefore planned an AOFOI to secure the
reduce potential morbidity and mortality.
airway prior to general anaesthesia, in a controlled manner and
References
thus avoid a potentially difficult and emergent intraoperative
1. Massiah N, Athimulam S, Loo C, Okolo S, Yoong W. Obstetric care intubation. In summary, these are difficult cases that we
of Jehovah's Witnesses: a 14-year observational study. Arch
believe benefit from good antenatal planning and can be
Gynecol Obstet 2007; 276(4):330-343.
managed with a planned AOFOI and general anaesthesia.
2. Van Wolfswinkel ME, Zwart JJ, Schutte JM, Duvekot JJ, Pel M, Van
Roosmalen J. Maternal mortality and serious maternal morbidity in
Jehovah's witnesses in the Netherlands. BJOG 2009; 116(8): 1103- Reference
1108. 1. T. Kavanagh, R. Jee, N. Kilpatrick, J. Douglas. Elective cesarean
3. Nawaz YM, Atkinson S. Peripartum care of Jehovah's witness delivery in a parturient with Klippel–Feil syndrome. Int J Obstet
parturients: A five year review. Int J Obstet Anesth 2013; 22(S1): Anesth 2013; 22(4): 343-8
S22.
Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin) P29
P157 Labour and delivery in long QTsyndrome P158 Local anaesthetic toxicity audit: are workshops the
BJ Vowles,  FMM Bryden   best educational tool across the MDT?   
Anaesthetic department, Princess Royal Maternity, Glasgow, WITHDRAWN FROM PRESENTATION
UK JL Lambert,  D Chitre,  L Evans  
Introduction: A 22 year old primigravida presented to the high Anaesthesia, Southend Hospital, Southend, UK
risk clinic at 22 weeks gestation. She had been diagnosed with
long QT syndrome (LQTS) after her family had been
investigated following a sudden early cardiac death and was
found to be heterozygous for the KCNQ1 gene, responsible
for Long QT1. She was under regular review by the
cardiologists who had advised β blockade with bisoprolol
2.5mg orally (PO) for 9 months post partum due to an increase
in arrhythmia risk during this period. She had also been given
a list from Azcert Inc., advising drugs that should be avoided
and included on this list was syntocinon.
Labour and delivery: She was admitted in labour at term and
the decision was made by the obstetric team, not to administer
syntocinon to augment labour. They also felt that epidural
analgesia was unsuitable because it would slow the progress
of labour. However following an initial dose of intramuscular
(IM) diamorphine, the parturient requested epidural analgesia.
We felt this would be beneficial for minimising her arrhythmia
risk and so she obtained a working epidural with a bilateral T10
block. ECG monitoring was commenced on admission and
.
initially showed bigeminy. A 12 lead ECG demonstrated a QTc
of 460ms. Electrolytes checked at this time were in the normal
range. Over the subsequent 8 hours she failed to progress and
underwent a caesarean section with an effective epidural top
up of 20ml 0.5% L-bupivacaine. At delivery syntocinon was
administered as a slow infusion of 5 units in 100mls 0.9%
saline over 20 minutes, followed by 500µg ergometrine IM to
maintain uterine tone. 50mg IM cyclizine and 10mg
intravenous (IV) metoclopramide were used for anti-emesis.
She was monitored in the Obstetric high dependency unit
(HDU) for the following 48 hours, where an initial ECG
demonstrated frequent ventricular ectopics, with a QTc 432ms.
Electrolytes were again normal at this time.
Discussion: There are many lists of drugs available on the
internet with differing advice as to which drugs to avoid in
long QT syndrome. The one which our patient had been given
clearly stated syntocinon should not be administered, despite
no definitive evidence of harm with this drug in patients with
LQTS. In addition we found no guidance in published case
reports, on oxytocic drugs administered to patients with LQTS
in labour or at delivery1. There are case reports of ventricular
tachycardia after administration of syntocinon in long
QTsyndrome2 and one report of a pateint receiving it with no
sequelae3 Ideally the authors feel that this lady merited a case
conference prior to admission so that informed decisions
could be made. Whilst the outcome of this patient's labour and
delivery may not have been different, a short trial of
syntocinon with ECG monitoring may have altered her mode of
delivery.
References
1. Drake E, Preston R, Douglas J. Brief review: anaesthetics
implications of long QT syndrome in pregnancy. Can J Anaesth.
2007; 54(7): 561-72
2. Liou SC, Chen C, Wong SY, Wong KM. Ventricular tachycardia
after oxytocin injection in patients with prolonged Q-T syndrome -
report of two cases. Acta Anaesthesiol Sin 1998; 36: 49-52
3. Charbit B, Funck-Bretano C, Samain E, Jannier-Guillou V,
Albaladejo P, Marty J. Qt interval prolongation after oxytocin bolus
during surgical induced abortion. Clin Pharmacol Ther 2004; 76:
359-64
P30 Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin)
P159 Lymphangioleiomyomatosis and Pregnancy: A Case P160 Major obstetric bleeds-are we doing the right thing?-
Report A multi-centre study in west midlands
M Cole,  S Petkov,  J Pickett   A R Sajayan,  M McLoughlin,  S Dinesh,  A Walunj*,  J
Anaesthetics, Addenbrookes Hospital, Cambridge, UK Karattuparambil †,  M Ravindran†  
Introduction: Anaesthesia, Heartlands Hospital, Birmingham, UK,
Lymphangioleiomyomatosis (LAM) is a rare condition causing *Anaesthesia, Good Hope Hospital, Sutton Coldfield, UK,
proliferation of smooth muscle in the respiratory system, †Anaesthesia, George Eliot Hospital, Nuneaton, UK 
which can cavitate leading to degradation of lung parenchyma Introduction:Guidelines1 exist on the definitions of massive
and cystic lung disease1. Because of the risk of progression, bleed, the proposed management pathway and the safe time
women with LAM are frequently advised to avoid pregnancy2. frame for obtaining the blood and products. This multi-centre
We present a case of LAM where multidisciplinary audit looks at the average time taken for the blood/products to
management led to a successful outcome of pregnancy, with a be available in major bleed situations in obstetrics
focus on anaesthetic considerations. Aim: To find out the incidence and reasons for delays in
Case Study: issuing the blood/products, if any, from the blood bank and to
A 35 year old woman presented with bilateral spontaneous compare the existing practices and experience with the other
pneumothoraces in the first trimester of her 2nd pregnancy. hospitals in the area
Both required surgical correction and a lung biopsy revealed a Methods: We collected the data from three participating
diagnosis of LAM. Computerised tomography of her thorax hospital in west midlands using a standard proforma which
showed multiple small lung cysts. Past history included an included the number of massive obstetric bleed calls during a
uncomplicated first pregnancy and emergency caesarean six months period in 2013, the estimated blood loss, the time
section for foetal distress, aged 33; and a spontaneous taken for the first unit of blood/ product to be issued and the
pneumothorax aged 34, requiring surgery. The patient was number of products used among other data.
referred to a tertiary centre for multidisciplinary management.
Results: The results suggested that there is ambiguity in the
Care was shared between obstetrics and respiratory medicine
way major haemorrhage was defined in different situations
and she attended the high risk anaesthetic clinic. Elective
which led to unnecessary calls where blood products were not
caesarean delivery at 38 weeks was agreed upon. She had
urgently needed. Also, the time for getting the products varied
three further small pneumothoraces, treated conservatively
widely the longest being 200 minutes. The documentation of
with no marked deterioration in respiratory function. Elective
the details of the bleeding, time of calls and time of
caesarean section was performed at 38/40 gestation.
blood/product administration were incomplete and inaccurate
Respiratory assessment and examination on the morning of
in some cases.In one hospital, major bleed calls were only put
surgery were normal. A two-space combined spinal epidural
out in two out of 17 cases where blood loss was more than
was sited, administering intrathecal hyperbaric bupivacaine
1500ml.
and diamorphine. A respiratory physician was present at
delivery in case of deterioration. Delivery was uneventful, with   Hospital1 Hospital2 Hospital 3
no immediate complications. The patient spent 24 hours in an Number of MOH calls 58 41 2
obstetric close observation unit post-operatively. Her post- Full data available 13 18 2
natal period was uneventful and required no further obstetric, Average time for group specific (min) 59 NA 33
respiratory or anaesthetic intervention. Average time for X match blood (min) 63.45 42.27 0
Longest delay (min) 200 104 33
Discussion: LAM is a rare condition with an estimated UK
prevalence of 1per million3. Hypotheses suggest oestrogen
Discussion: The definitions of massive blood loss are:
accelerates disease progression and pregnancy may result in
Transfusion of a volume equal to the patient’s total blood
new diagnosis or exacerbation4, therefore obstetric
volume in less than 24 hours / 50% loss of blood volume
anaesthetists should have awareness of this disease. There is
within 3 hours / rate of blood loss 150ml/minute. Though the
sparse literature for anaesthetic management of pregnancy
circumstances of individual episodes of major bleed could
with LAM, consisting mainly of case reports. Considerations
vary, there was no consistency in the trigger of activating
suggested include; avoiding excessive Valsalva manoeuvre
major bleed calls. There were also unacceptable delays in
via instrumental or elective caesarean delivery, avoid nitrous
obtaining the first unit of blood in some cases. The first set of
oxide, early epidural analgesia, obtunding intubation response
uncross matched group specific blood should be available in
and lung protective ventilation strategies if general
20minutes and cross matched blood in 40minutes2. The study
anaesthesia. This case report supports that pregnancy in
suggest that there is a need for the reinforcement of major
LAM patients can progress successfully and highlights the
bleeds definition and also a need for a clearer pathway and
importance of a MDT approach, early anaesthetic assessment
consistency in issuing blood and products in major bleed
and a well considered anaesthetic and obstetric plan.
situations. This audit results will be used to formulate a
References uniform policy in the participating hospitals and a re-audit will
1. Rosendal T. A Case of Diffuse Myomatosis and Cyst Formation in be done in six month time
the Lung. Acta Radiaology. 1942; 23: 138-146
2. Cohen MM, Freyer AM, Johnson SR. Pregnancy Experiences References
Among Women With Lymphangioleiomyomatosis. Respiratory
1. D Thomas etal,Blood transfusion and the anaesthetist: management
Medicine. 2009; 103: 766-772
of massive haemorrhage, Anaesthesia 2010 November; 65(11):
3. Johnson SR, Tattersfield AE. Clinical Experience of 1153–1161
Lymphangioleiomyomatosis in the UK. Thorax. 2000; 55:1-5
2. Guidelines on the management of massive blood loss.
4. McLoughlin L, Thomas G, Hasan K. Pregnancy and BJHaematology 2006; 135(5): 634-641
Lymphangioleiomyomatosis: Anaesthetic Management.
International Journal of Obstetric Anaesthesia. 2003; 12: 40-44
Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin) P31
P161 Management of labour and delivery using  minimally  P162 Management of manual removal of placenta and third
invasive FlotracTM system in a parturient with  and fourth degree tear repair: pathway analysis
congenitally corrected transposition, dextrocardia P Jegendirabose,  J Subramanya*,  S Watkinson*,  J Short  
and systemic ventricular dysfunction Anaesthesia, Queen Elizabeth Hospital, Woolwich, London,
R Vedagiri Sai,  S Dhir,  J Racine   UK, *Obstetrics & Gynaecology, Queen Elizabeth Hospital,
Anesthesia, Western University, London Ontario, Canada Woolwich, London, UK
Introduction: More women with congenital heart disease now Introduction: Guidelines suggest that repair of obstetric anal
survive to reproductive age due to advances in modern sphincter injuries (OASIS) and manual removal of retained
medicine. Obstetric management is challenging in these placenta (MROP) should be undertaken as soon as possible to
complex cases. We present the anaesthetic management of minimise the risk of infection, blood loss and maternal
labour and delivery in a woman with congenitally corrected morbidity1,2. Anal incontinence and perineal pain can impact
transposition of great vessels, dextrocardia, systemic significantly on maternal quality of life and mother-child
ventricular dysfunction and junctional tachycardia using bonding.
minimally invasive continuous haemodynamic monitoring and Methods: We conduced a retrospective audit which showed
optimisation. shortcomings in our management of MROP and OASIS and we
Case report: A 28 year old primigravida presented with a undertook an analysis of a full calendar year's cases. All cases
diagnosis of congenitally corrected transposition of great of MROP and OASIS were identified over January 2012 to
vessels and dextrocardia. The atrial septal defect had been December 2012 using both theatre electronic records and
repaired in childhood. Her medications included folate and maternal records. Time from delivery of fetus to MROP or
multivitamins. She had good exercise tolerance, stable vital OASIS repair, blood loss and blood transfusion requirement
signs and was followed up by Cardiology team throughout her were reviewed.
pregancy. ECHO showed 50% ejection fraction (EF) and mildly Due to lack of nationally set standards, we set a local standard
reduced systemic (morphologic right) ventricle. A multi- of no more than one hundred and twenty minutes from
disciplinary meeting between Obstetrics, Cardiology, delivery to repair for OASIS.
Anaesthesia and Intensive care unit (ICU) team was held to
Results: Our institute is a secondary obstetric centre with
decide on optimal obstetric management. Induction of labour
4800 deliveries per annum. During the twelve month period,
was planned.
105 patients sustained OASIS. The mean delay from delivery
At 37 weeks she developed palpitations, increasing shortness to surgery was 136 minutes. The average blood loss was 501
of breath and peripheral oedema. Repeat ECHO showed millilitres and 3% of patients required blood transfusion. Total
moderate ventricular dysfunction with EF 40%, severe of 42 patients required manual removal of placenta with
systemic atrioventricular regurgitation and severely enlarged regional or general anaesthesia. The mean delay from delivery
left atrium. Prior to labour induction, an arterial line was to surgery was 178 minutes. The mean blood loss was 790
inserted and continuous cardiac output monitoring was millilitres and 5% of the patients required blood transfusion.
performed using arterial pressure waveform analysis with the
FloTracTM monitor. Haemodynamic optimization was guided OASIS repairs n=105 Time (minutes)
by stroke volume variation and goal directed fluid therapy. A Delivery to booking 81 (Cl 70-92)
lumbar epidural was then inserted followed by rupture of Booking to surgery 68 (Cl 40-95)
membranes and oxytocin infusion. Fluid balance was closely Delivery to surgery 136 (Cl 122-150)
monitored continuously using FloTracTM. 1st stage of labour MROP n=42 Time (minutes)
was uneventful and 2nd stage was shortened using vacuum Delivery to booking 138 (Cl 115- 160)
assisted delivery of a healthy baby. She had a second degree Booking to surgery 39 (Cl 32-46)
tear which was repaired. Post partum haemorrhage due to Delivery to surgery 178 (Cl 152-204)
uterine atony was treated with 400µg Misoprostol rectally and
Incidentally, 78% of the patients did not have electronic record
intravenous infusion of 20 IU of Oxytocin. Estimated blood
of estimated blood loss on the theatre system.
loss was 800 mL. Cardiac condition was stable apart from
Discussion: In our institution, these cases are booked onto
persistent tachycardia throughout labour. Postpartum, she
the general emergency theatre, and not in the designated
spent 24 hours in ICU with similar monitoring. Her tachycardia
emergency obstetric theatre. We have identified that this has
settled spontaneously. She was discharged home on day 4.
resulted in significant delay in surgery and increased blood
Discussion: Patients with congenitally corrected transposition
transfusion requirement. We are now changing the patient
have a thin-walled right ventricle as the systemic circulatory
pathway to include urgent utilisation of the emergency
pump. The stress of increased cardiac output can cause
obstetric theatre for these procedures. Since the presentation
failure, atrioventricular regurgitation and arrhythmias1. We
of this audit, we have included the estimation of blood loss in
used minimally invasive continuous cardiac output
the surgical sign out process, thus improving communication
monitoring, fluid balance optimisation and good maternal pain
and patient care.
control to prevent decompensation and achieve vaginal
References
delivery with a good feto-maternal outcome.
1. National Institute for Health and Care Excellence. 2007.
Reference Intrapartum care. Care of healthy women and their babies during
childbirth. Clinical guideline 55
1. Dob DP, Naguib MA, Gatzoullis MA. A functional understanding of
moderate to complex congenital heart disease and the impact of 2. Fernando RJ, Sultan AH, Kettle C, Thakar R. Methods of repair for
pregnancy. Part I: the transposition complexes.Int J Obstet Anesth. obstetric anal sphincter injury. Cochrane Database Syst Rev. 2013
2010 Jul;19(3):298-305 Dec 8;12:CD002866.
P32 Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin)
P163 Multidisciplinary involvement of the high risk P164 National Obstetric Anaesthetic Database: a useful tool
parturient to benchmark maternity units in the UK
S De Silva,  P Gregory,  E Combeer   G Keightley,  N Tailor,  R Baraz,  L De Lloyd  
Anaesthetics, Frimley Park Hospital, Frimley, UK Anaesthetics, University Hospital of Wales, Cardiff, UK

Our Hospital offers a high risk Obstetric Anaesthetic Clinic for Introduction: The National Obstetric Anaesthetic Database
review of parturients with anticipated Anaesthetic or Medical (NOAD) was set up in 1998 to establish a framework for
problems where a checklist referral form is used. We audited collecting national obstetric anaesthetic data considered
whether women were appropriately referred or inappropriately relevant to obstetric anaesthetists. Whilst preparing the
not referred. An alert sticker was created to encourage NOAD survey for 2012, we explored the usefulness of this
healthcare providers to alert the oncall Obstetric Anaesthetist data in benchmarking our units' performance at the University
when the high risk parturient presented to labour ward. We Hospital of Wales (UHW) in relation to NOAD published
went onto audit the effectiveness of this alert sticker. figures from the previous year.

Methods: Data was collected according to the NOAD 2012
Methods: We looked at 200 consecutive births during October
survey and therefore, ethical approval was not required. Due
2010 and ascertained how many of these women had referrals
to the large number of deliveries in our unit, data regarding
to the High Risk Clinic. In the referred cases, we asked whether
labour analgesia, mode of delivery, caesarean section rate and
referral criteria were met and also determined if any mothers
type of anaesthesia was based on six months period (Jan to
were inappropriately not referred. In 2012 we retrospectively
June 2012) and then doubled. Exceptions were critical care
inspected all notes of mothers seen in High Risk Clinic with an
admissions and patients with accidental dural puncture (ADP);
estimated delivery date of March to May 2012. We checked
these were collected and reviewed individually for the entire
whether an alert sticker was present in their notes and also the
year. Microsoft Excel was used to analyse the data.
time taken for the Obstetric Anaesthetist to be contacted once
the mother had presented to Labour Ward. Results: The number of total deliveries in our unit for 2012

was 6138, of which 3060 required anaesthetic procedure(s).
Results: In 2010, 178 of 200 notes were reviewed and 14
The table below compares performance and quality indicators
women met referral criteria and 12 of these were referred.
at UHW in 2012 with the NOAD averages from 2011.
Fourteen percent were therefore inappropriately not referred,
however no women were inappropriately referred. Indicator UHW 2012 NOAD 2011

Caesarean section (CS) rate 22% 24.8%
In 2012, 42 notes were inspected where only 8 had the alert
Elective CS rate 46% 39.1%
sticker in place, with only 5 in the correct position. Two
De novo general anaesthesia (GA) for CS 4.5% 4.7%
mothers with the alert had elective caesarean sections. In five
Conversion to GA (CS) 1.8% 3.5%
of the six remaning mothers, the oncall Anaesthetist was
Labour regional analgesia 27% 22.7%
informed of their presence on labour ward. The average time
Epidural re-site rate 7.7% 9%
taken for this was four hours and 45 minutes (range 10 minutes
Accidental dural puncture rate 0.9% 1.2%
to 10 hours and 50 minutes). On review of the Clinic letters, it
was felt that 30 of the 42 parturients should have had an alert In 2012, three cases were transferred to critical care unit as
present in their notes, which is 71% not 19% as shown by our level 2 care (two with sepsis and one adult respiratory distress
audit. syndrome) and six cases as level 3 care (two with sepsis, three

post partum haemorrhage and one case of amniotic fluid
Discussion: In many cases of substandard care assessed by
embolus).
CMACE, there were major failures of communication between
Discussion: Our unit is classified as a large maternity unit
healthcare workers that may have contributed to the woman’s
compared to the national average. The elective CS rate and
death in some cases1. Our audits demonstrated that local
labour regional analgesia rates in our unit are higher than the
guidelines for referral were followed in 99% of cases, therefore
national average, possibly related to the complexity of a
high risk mothers were identified early. However, there still
tertiary centre. Despite this, our total CS rate is well below the
lacks effective communication of concerns within teams and
average with very low conversion to GA. In addition, our
poor involvement of other specialties early.
epidural re-site rate is lower than the national average, as is
Reference our ADP rate. Current facilities include two theatres serving
1. Centre for Maternal and Child Enquiries (CMACE). Saving both emergency and elective streams, and a mixed
Mothers'. Lives: reviewing maternal deaths to make motherhood recovery/high dependancy unit (HDU) for up to 5 patients.
safer: 2006–2008. The Eighth Report of the Confidential Enquiries
Our unit has a low transfer rate as level 2 care in general HDU,
into Maternal Deaths in the United Kingdom. BJOG 2011;118:1-203
due to the ability to care for these patients on our unit. We
find the NOAD data a useful tool to benchmark our
performance and set standards of care. More units should
contribute to the annual NOAD survey and consider using the
data as a way of identifying shortfalls and improving patient
care and services.
Reference
1. National Obstetric Anaesthetic Database report 2011.
http://www.oaa-anaes.ac.uk/content.asp?ContentID=586
Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin) P33
P165 Obstetric admissions to the Intensive Care Unit: a 6 P166 Obstetric outcomes with programmed intermittent
year review at a UK tertiary maternity centre epidural bolus labour analgesia
R Labib,  K Cullis   JTE Cremin,  CH Papageorgiou  
Selwyn Crawford Department of Anaesthesia, Birmingham Department of Anaesthesia, Hillingdon Hospital, Uxbridge,
Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin) P1
P101 A modified WHO surgical safety checklist for P102 A parturient with phocomelia and severe needle
category 1 caesarean sections phobia: the challenges faced
A Lahkar,  A Cooney,  G Massolini   R Sinha,  K Howard,  N Bhandal  
Anaesthetics, Milton Keynes NHS Foundation Trust, Milton Department of Anaesthesia, Nottingham University Hospitals
Keynes, UK NHS Trust, Nottingham, UK
Introduction: In June 2008, WHO introduced a surgical safety Introduction: Parturients with phocomelia are rarely seen and
checklist to be used in every operating theatre to improve present anaesthetic and obstetric challenges. We present a
patients' safety. In 2010 a WHO surgical safety checklist for case of a parturient with phocomelia and severe needle phobia.
maternity was created in response to requests from maternity Case report: A 33 year old woman with phocomelia and severe
services and clinicians. Nevertheless, in some emergency needle phobia presented to the obstetric anaesthetic clinic at
situations like category 1 Caesarean sections, this checklist 20 weeks for pre-assessment.
could still be quite a difficult task to achieve due to Her phocomelia was thought to be idiopathic, she had been
understandable time limit constrains to safely deliver the baby adopted when young and no family/drug history was
and/or save the mother's life. available. Examination revealed four limb phocomelia. There
Whilst there is still no international consensus or any specific were absent upper limb bones on the right and a fused hand
recommendation from WHO concerning these specific attached directly to her body. Her left upper limb was
situations, the Anaesthetic Department in Milton Keynes shortened with a primitive hand and fused fingers. Both lower
hospital has managed to devise a checklist for cat 1 LSCS limbs were extremely shortened with primitive feet with fused
which is 100% compliant both in terms of content with WHO toes. Her head, neck and torso appeared normal. She was able
guidelines and adherence by hospital staff. to mobilize with a wheelchair and significant assistance from
Method: After considerations and inputs from the Consultant her partner. The problems faced in clinic were numerous and
Anaesthetists, a simplified checklist was introduced in our focused on her severe needle phobia, difficult venous access
emergency obstetric theatre in June 2013 by way of an ad hoc and monitoring, positioning, mobilization and
poster hanged on the wall. It spells out the most 10 salient thromboprophylaxis as well as the challenges posed by the
questions to be read by one of the theatre staff before the start preganancy itself. The anaesthetic plan consisted of non-
of a category 1 Caesarean section. These questions translate invasive blood pressure monitoring on her left lower extremity;
the original 32 WHO ones that were spread across 3 sections pulse oximetry via an ear probe or toe and standard
in a simpler, quicker format. electrocardiogram. These were tested prior to labour. Due to
Results: After the introduction of the modified WHO checklist the impossibility of standard intravenous access and extreme
in June 2013, compliance is 100%. needle phobia several discussions were had about obtaining
Discussion: By putting the combined know-how and intravenous access prior to labour. A right subclavian
experience of many Consultant Anaesthetists to the task, we Hickman line was inserted at 39 weeks facilitated by the use of
managed to simplify the original WHO narrative into a sharper entonox. Regional analgesia was refused for labour so the
tool that is quickly and effectively utilised for a better and option of intravenous fentanyl via a midwife controlled
safer quality of care in what has become a "normal routine" analgesia pump was discussed. Should a caesarean section be
during extraordinary times in the emergency theatre. required a neuroaxial anaesthetic was refused and so a general
anaesthetic was planned.
Reference At 40+2 weeks spontaneous rupture of membranes occurred
1. WHO surgical safety checklist: for maternity cases only, and labour established. However, due to failure to progress a
http://www.nrls.npsa.nhs.uk/resources/?entryid45=83972 decision was made to perform a caesarean section.
In theatre the challenges related to positioning and achieving
a satisfactory left lateral tilt. A rapid sequence induction was
conducted following pre-oxygenation to an end-tidal oxygen
concentration of 92%. Anaesthesia was induced with
thiopentone 350mg and suxamethonium 100mg. Soon after
induction she desaturated rapidly to the high 60s. This
resolved after tracheal intubation and ventilation. She was
hypotensive intra-operatively, with an estimated blood loss of
1300mL After fluid and blood resuscitation, recovery was
unremarkable. Postoperative pain was managed with
transversus abdominus plane blocks and morphine
patient/midwife controlled analgesia.
Discussion: There is little literature about managing delivery
in women with phocomelia, but sucessful regional techniques
have been described although this was refused here. Early
discussion of anaethesia and analgesia options, and plans for
vascular access and monitoring are needed, There is a reduced
vascular reservior and skeletal muscle mass.
As a consequence faster inductions, emergences and
responses to titrated drugs are observed.

P2 Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin)
P103 A questionnaire to evaluate and aid future development P104 A retrospective descriptive analysis of anaesthesia for
of the AAGBI's SAFE obstetric anaesthesia course in successful cervical cerclage in pregnancy
Liberia J Modha,  G Burul*,  F Forya*,  CP James*,  AL David*,  J
JCO Fox,  CE Richards*,  T Sheraton*,  A Sonah†   Dick,  L Wee  
†Department of Anaesthetics, Phebe Hospital, Bong County,  Department of Anaesthesia, University College London
Liberia, *Department of Anaesthetics, Royal Gwent Hospital, Hospitals NHS Foundation, London, UK, *Department of
Newport, UK, Department of Anaesthetics, University Obstetrics, University College London Hospitals NHS
Hospital of Wales, Cardiff, UK Foundation, London, UK
Introduction: Dr Kate Grady has developed this three-day Introduction: Cervical cerclage is a common operation which
refresher course in obstetric anaesthesia on behalf of the requires an anaesthetic. There are no studies on the type of
AAGBI. The course is aimed at non-physician anaesthetists in anaesthesia used for this procedure.1
developing countries. It consists of short lectures, interactive Aim: To determine the type of anaesthesia used for vaginal
sessions and workshops that focus on the recognition and cervical cerclage.
management of leading causes of maternal death in resource
Method: Ethical approval waived. Women having any vaginal
poor settings. The course has been taught in Uganda,
cervical cerclage (Macdonald or Shirodkar) during pregnancy
Bangladesh, Liberia and Ghana. It includes the principles of
between January 2005 and December 2012 were identified
the WHO Safe Surgery and training of trainers. Mothers of
using the hospital obstetric anaesthesia database and cross-
Africa, a medical educational charity, has led delivery of 2
referenced with data from the Preterm Birth clinic where women
courses for nurse anaesthetists (NAs) in Liberia - supported
at risk of preterm birth are seen antenatally. Data was obtained
by the AAGBI IRC. Liberia has approximately 60 nurse
by examination of obstetric case notes and the ultrasound
anaesthetists and no medically qualified anaesthetists for a
scan records and analysis conducted using Microsoft Excel.
population of 4.2 million people1. Access to CPD is difficult.
Results: There were 190 cases. Twenty-five patients were
The MMR in Liberia is 770 per 100,000 live births1. In order to
excluded due to incomplete data, hence 165 included in
plan future development of the course in Liberia, which will be
analysis. The mean gestational age was 16.6 weeks (range 9-
led by Liberian trainers, feedback data was collected.
23.6 weeks). The table below shows that both general
Methods: A follow up questionnaire was given to 35 NAs who
anaesthesia (GA) and regional anaesthesia (RA) were used.
had previously attended a SAFE obstetric anaesthesia course
The majority of regional anaesthetics were spinals (95.7%), the
held in Liberia (March 2012 or March 2013). We aimed to
rest combined spinal and epidural (CSE) (3.6%) and epidural
assess; 1) the quality, usefulness and appropriateness of the
top up (0.7%).
material taught during the course, 2) the effect on motivation
to improve local services/care delivery, 3) the effect on the GA RA

confidence levels of NAs in managing obstetric anaesthetic n (%) n (%)
emergencies. Spinal n = 133
Results: A 70% follow up rate was achieved. 97% reported Total n=165 26 (16%) 139 (84%) CSE n = 5
positive changes in their attitude to work and their clinical Epidural n = 1
practice and 94% reported improvements in interactions with Five patients who had a spinal anaesthetic required second
colleagues. Many NAs gave details of cases where the skills procedures (3 GA, 1 spinal, 1 CSE). Of those converted to GA,
and knowledge they learnt on the course helped save lives one patient had a block to T6 (the reason for conversion to GA
and improve clinical outcomes. 11 NAs requested continued was not documented), one patient had a block to T12 and the
education and training. Other suggestions for course third patient had 3 failed spinal attempts. In all cases there
improvement included; additional sessions in preoperative were no major anaesthetic complications and cervical cerclage
assessment and TAP blocks, and the inclusion of midwives in was placed successfully.
the training sessions. The following table illustrates the mean
Discussion: In this series, the majority of vaginal cervical
subjective confidence scores (between 0 and 10) of the NAs in
cerclage surgery was performed safely and effectively under
various clinical scenarios before and after the course.
RA. There are no specific guidelines regarding the type of
  Before After anaesthesia for cervical cerclage.1 Anaesthetic considerations
General anaesthesia LSCS 6.3 9.2 favouring a regional anaesthetic in pregnancy include the risk
Spinal anaesthesia LSCS 7.6 9.8 of aspiration and difficult airway management in patients over
Management of severe eclampsia/preeclampsia 5.7 9.2 20 weeks gestation and those under 20 weeks gestation if at
Management of obstetric haemorrhage 5.9 9.4 high risk for example those with a high BMI. The majority of
women in our data set were less than 20 weeks (88.5%). Other
Discussion: Our results indicate that the SAFE obstetric
considerations include patient and surgeon choice. Women in
anaesthesia course in Liberia has been well received with
this series were given the option of GA or RA. In certain cases
subjective evidence of empowerment and improved methods
for example rescue and abdominal cerclages, the patient may
of working. This is promising in the context of increasing the
need to be in a deep Trendelenberg position to aid reduction
reach of future courses and enabling local faculty to lead
of membrane prolapse to avoid membrane rupture or to aid
training. Further data from logbooks provided as part of the
access to the pelvis.2
course were not obtained and more work is needed to
encourage completion of the logbooks. Objective evidence is References
required to demonstrate impact on patient outcomes. 1. Cervical Cerclage, Green-top Guideline No 60, Royal College of
Reference Obstetricians and Gynaecologists, May 2011.
2. Olatunbosun OA, Dyck F. Cervical cerclage operation for a dilated
1. http://data.worldbank.org/indicator/SH.STA.MMRT/countries/1W-
cervix. Obstet Gynecol. Feb 1981;57(2):166-70.
LR?display=graph
Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin) P3
P105 A retrospective descriptive analysis of dose of P106 A step towards improving theatre productivity for
intrathecal anaesthesia and adjuncts for successful elective caesarean sections
cervical cerclage in pregnancy S Kale,  C Farrow,  N Owen,  K Miltsios  
J Modha,  G Burul*,  F Forya*,  CP James*,  AL David*,  J Department of Anaesthesia, Whittington Hospital, London,
Dick,  L Wee   UK
Department of Anaesthesia , University College London Introduction: NHS Institute for Innovation and Improvement
Hospitals NHS Foundation, London, UK, *Department of developed The Productive Operating Theatre Programme to
Obstetrics, University College London Hospitals NHS improve effective use of theatre time, staff and patient
Foundation, London, UK experience.1 Good administrative system and organisation is
Introduction: Cervical cerclage is a common operation, which essential to ensure theatre efficiency.2On this background,
requires either a general or regional anaesthetic aiming for a with the rational of making existing system more productive,
block height of T10. There are no studies determining the dose safe and reliable, we evaluated current practice in one of our
that should be used to achieve this or describing additional main theatres, designated for elective sections, in a DGH set
drugs used for successful surgery. up.
Aim: To determine the dose of local anaesthesia used for Methods: Evaluation was carried out over a 4-week period, for
intrathecal injection and the block height achieved in women planned caesarean sections. The data was collected
undergoing cervical cerclage. In addition to determine the use concurrently by the anaesthetist for that case and from the
and dose of adjuncts. theatre database. The exact time for all significant events, such
Method: Ethical approval waived. Women having vaginal as when patient was sent for or when theatre was clean and
cervical cerclage during pregnancy between January 2005 and ready for the next patient, was recorded. Reasons for delays,
December 2012 were identified using the hospital obstetric duration of anaesthesia, surgery and problems encountered
anaesthesia database and cross-referenced with data from the were also recorded. Time spent at and between different
Preterm Birth clinic. Data was obtained by examination of crucial stages in theatre was calculated from the data. Results
obstetric case notes and the ultrasound scan records and are presented in the form of time in minutes, median [range]
analysis conducted using Microsoft Excel. and % (absolute numbers of cases).
Results: In all cases, cervical cerclage was achieved Results: We had 25 completed forms. Our analysis showed,
successfully. There were 138 cases of intrathecal anaesthesia median time interval from patient sent for to arrival in theatre
(133 spinals and 5 combined spinal epidurals) in whom 67.4% as 5 min [1-29]. Reasons for delay were due to obstetric team
(93/138) had documented intrathecal anaesthetic dose and busy in meeting, midwife busy preparing the patient and
were included for final analysis. Hyperbaric bupivacaine 0.5% midwife busy completing paperwork for previous patient in
was used (mean dose 10.9mg, median 10.8mg and mode 10mg, recovery. Median time interval between patient's arrival and
range 6.5–15mg). Block height and dose of intrathecal neuraxial block was 18 min [10-70], prolonged in 8% of cases
anaesthetic was documented in 54/93 cases (58%). The block (2/25) due to failed and repeat block. Bladder catheterisation
height ranged from T2 to T12 with similar doses of local after block was delayed by ≥30 min in 8% of cases (2/25) due
anaesthetic given in each group and of similar gestation and to unavailability of midwife. Median anaesthetic time for
body mass index (BMI). satisfactory block was 12 min. Interval between block ready
and knife to skin (KTS) was 6 min [1-12]. Median surgery
Block height T2-4 T5-8 T10 T12 duration was 45 min [31-141]. PPH, high BMI, and previous
Frequency 7 31 13 3 laparotomies resulted in longer operations in 16% of cases
Mean dose mg (4/25). Median turnaround time between the cases was 10 min
11 11 11 8
hyperbaric bupivacaine 0.5% [6-15]. Total time patients spent in theatre was 89 min [74-183].
Mean gestation (weeks) 17.4 17.7 15.6 19.1
Discussion: We noted that unavailability of obstetric team
Mean BMI kg/m2 27.3 26.6 26.1 32
and busy midwives at times has resulted in late starts and
In 3 patients that had block heights of T12 only one was delay in some procedures in theatres. Delay in starting the
converted to GA. Opiates were used in 73/93 (78.5%), the most surgery after a satisfactory block and prolonged turnaround
frequent being fentanyl. time have also affected the overall theatre productivity. We
have put forth some recommendations to working group such
Mean dose Range
Opiate used Number (%) as offering administrative support to midwives, ensuring
(mcg) (mcg)
senior obstetrician and anaesthetist are present for difficult
Fentanyl 69 (95) 20 10-75
cases, making use of anaesthetic room to improve patient
Diamorphine 3 (4) 300 250-350
turnaround time and most importantly encouraging staff
Fentanyl & Diamorphine 1 (1) 20/300 N/A
nurses to take the lead role in increasing theatre efficiency.
Vasopressors were used in 26 cases (23 phenylephrine, 3 This could be a big step towards enhancing theatre output as
ephedrine). Other drugs included 3 cases of intravenous well as increasing patient and staff satisfaction. We aim to
midazolam, 1 case propofol and in 1 case salbutamol (as a introduce these changes soon and re-evaluate the practice in
tocolytic agent). the near future.
Discussion: In our case series there is a wide dose range of References
both hyperbaric bupivacaine 0.5% and opiate given. To 1. The Productive Operating Theatre programme,
achieve a block height of T10 or above a minimum dose of http://www.institute.nhs.uk/quality_and_value/productivity_series/the
11mg (2.2ml) is recommended which may be independent of _productive_operating_theatre.html
other factors. There is a wide variation in block height but 2. Theatre Efficiency,
http://www.aagbi.org/sites/default/files/theatreefficiency03.pdf
even a low block (T12) was found to be adequate.

P4 Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin)
P107 A year in the "maternity" life of an increasingly busy P108 Abstracts on the antenatal anaesthetic clinic
new build district general teaching hospital - coping presented to the Obstetric Anaesthetists' Association,
with training and service provision - 2013 1991-2013
H Wrigley,  PF Yoxall,  Janet Slee   AJ Wickham,  SM Yentis*  
Anaesthetics, St Helens & Knowsley NHS Trust, Liverpool, Anaesthetic department, St Mary’s Hospital, London, UK,
UK *Anaesthetic department, Chelsea & Westminster Hospital,
Introduction: Since moving to a new PFI built hospital in 2010 London, UK
our maternity unit has become more busy. Delivery rates/year Introduction: National reports1 and guidelines2 recommend
have increased from 2900 to 3700 pa (up 27.6% in 3 years) assessment of women with ‘high-risk’ pregnancies and
increasing demands upon anaesthetic services. potentially serious co-morbid disease in an antenatal
Methods: We reviewed all our maternity cases during 2013, anaesthetic clinic (AAC). We reviewed trends and themes in
both epidural and caesarean sections. We also surveyed our abstracts on this topic presented to the OAA.
CT2 trainees to assess their experience in terms of case Methods: Full-text records of abstracts (excluding case reports)
numbers during a newly introduced modular training block. presented at OAA meetings (1991-2013; see www.oaa-
Lastly consultant cover on labour ward was audited for CNST anaes.ac.uk) were searched using the terms ‘antenatal’,
purposes. ‘clinic’, ‘risk’ and ‘refer’. Relevant abstracts were reviewed for
Results themes and conclusions.
Results: Forty abstracts were presented at 14 Annual
n %
Meetings (Fig. 1); 3 were unavailable in full-text (2008) but 1
Total Deliveries 3700
was provided by the author on request. 35 were from single
LSCS 838 22.6
departments and 5 were surveys (4 national). Common topics
Grade I-III LSCS 464 12.5
were obesity (12, 30%), referral reason (7, 18%) and
Grade IV LSCS 374 10.1
appropriateness (4, 10%), and outcomes (5, 13%). Nine (23%)
LSCS - SAB 666 79.5
described single patient cohorts, e.g. cardiac. AAC workload
LSCS - Epidural 123 14.7
has increased from 2.3 to 28.6 patients per month over 22
LSCS - CSE 14 1.7
years, albeit at different centres. Obesity has replaced
LSCS - GA 119 14.2
musculoskeletal disease as the most frequent reason for
RA to GA 34 4.2
referral. Common concluding themes include the need to
Average BMI LSCS (Range) 28.3 (16.7-59.9)  
improve the timeliness and appropriateness of referrals, and
Epidurals 895 24.2
ensuring anaesthetic plans are both prominent and followed.
Epidural Resites 32 3.7
PDPH - Epidural 15 1.7
PDPH - SAB 2 0.3
Epidural Blood Patches 21
Average BMI Epidural (Range) 27.1 (16-62.8)  
CT2 Training One of our requirements is to teach at least 4
CT2s per annum obstetric basic competencies. Our trainees
receive a 4 week long daytime block covered by an anaesthetic
ST3-7 and a consultant. They attend 40 sessions, the majority
siting 15 epidurals and anaesthetise 30 caesarean sections
before embarking on daytime on calls. They attend our in-
Figure 1: number of abstracts on the AAC presented per year
house MODSS (Obstetric Simulation Day) run by one of our
Consultant Obstetricians. Discussion: Abstracts relating to AACs have become more
frequent in the last decade, presumably reflecting their
Consultant Input The number of funded Consultant labour
increasing provision and perceived usefulness (and
ward sessions has risen 7 to 10 sessions (7 elective lists per
recommendation in the 2002-04 CEMACH report3). Increased
week). A “High Risk Obstetric clinic” runs weekly to pre-
demand for this service is exacerbated by inappropriate
assess all potentially difficult patients (250-300 per annum).
referrals and budgetary constraints. Referral processes,
Discussion: Despite a significant increase in workload we
facilities, and documentation and inconsistent use of plans are
have managed to maintain levels of cover (both junior and
areas for development. Future work should focus on quality
consultant) whilst allowing for CT2 training in obstetric basic
improvement and assessment of cost-effectiveness. Nationally
competencies as required at both national and local levels.
agreed referral criteria and a national ‘anaesthetic plan’
This has been achieved by increasing our core of obstetric
document, complemented by referrer education, may enhance
consultant anaesthetists, increasing obstetric PAs and
the process. Multidisciplinary ‘one-stop-shop’ or midwifery
changing to a modular CT2 training programme.
led clinics for common problems, such as obesity, may be
beneficial.
References
1. Centre for Maternal and Child Enquiries. Saving Mothers’ Lives:
reviewing maternal deaths to make motherhood safer: 2006-08.
The Eighth Report on Confidential Enquiries into Maternal Deaths
in the UK. BJOG. 2011; 118(Suppl.1): 1-203.
2. OAA & AAGBI Guidelines for Obstetric Anaesthetic Services.
Revised Edition 2005. London: OAA/ AAGBI
3. CEMACH. Why Mothers Die 2000-2002. Report on Confidential
Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin) P5
P109 Accuracy of a new electronic obstetric anaesthetic P110 Accuracy of landmark approach to central neuraxial
database blocks in obstetric patients
Rohit Rohit,  R Abraham,  GNB Jackson   J Lie,  K Bhatia,  A Venkataraju,  P Kochhar  
Anaesthetic department, Royal Berkshire Hospital, Reading, Anaesthesia, St Mary's Hospital, Manchester, UK
UK Introduction: Correct identification of vertebral level could
Introduction: We have introduced a new electronic database prevent damage to the spinal cord during a central neuraxial
'ROAD' (Reading Obstetric Anaesthetic Database) to record block (CNB). Evidence suggests that ultrasound (US) imaging
obstetric anaesthetic data. Written & designed by one of our of the spine by an experienced operator leads to correct
anaesthetists it is secure, password protected & able to identification of vertebral level in 90% of the patients and
produce reports on patient data & the activity of individual decrease the number of attempts required for a successful
anaesthetists. More than 70% obstetric anaesthetic units use CNB1. National Institute for Health and Care Excellence
electronic data collection system in the UK but there is little suggests US could be a useful tool for epidural catheter
agreement as to the best format.1 We audited the accuracy of insertion2. Our aim was to determine the discrepancy between
data entry, as a marker of ease of use by the anaesthetists, landmark technique and US to identify level of insertion of
before auditing the content of the database. CNB.
Methods: This was a retrospective audit, analysing data for Methods: Two experienced US operators who were blinded to
one month period (June 2013). The data in 'ROAD' was the initial procedure retrospectively performed US imaging of
compared to 1) our handwritten anaesthetic record book spine post-operatively after elective caesarean section in 51
(ARB); 2) Midwifery led labour ward logbook (LWLB); 3) obstetric patients with their consent from January to March
Operating theatre electronic log 'Bluespier'. Data entered on 2013 in St Mary’s Hospital. All the patients had a lumbar CNB
the 'ROAD' was manually checked against all these three done by landmark approach. The documented vertebral level
sources and the results tabulated and analysed. at which CNB was performed was noted. This was then
Results: 253 records were found in the ARB. The ARB missed compared with the actual vertebral level identified by bedside
one case (found in Bluespier), Bluespier missed one case US imaging of spine.
(found in the ARB) and LWLB missed 6 cases (found in the
Results: 29 patients had a spinal, 20 had an epidural and two
ARB & Bluespier). The results show that 'ROAD' was 96%
had combined spinal-epidural anaesthesia. The median body
accurate compared to any of the other systems.
mass index (BMI) was 28.6kg/m2. Landmark technique was
No. of cases missing on only accurate in 39.2% of patients. There was no statistically
Total 'ROAD' accuracy against
  'ROAD 'compared to significant correlation between the experience of operator and
no. other data sources as %
others accuracy. 3% of patients had a CNB at the level of L or above.
2
ARB 10 253 96.047% Documentation of the level performed was excellent. Raised
Bluespier 7 174 95.977% BMI and difficulty in palpation of landmarks resulted in
LWLB 10 247 95.951% statistically significant decrease in the accuracy (p<0.05
'ROAD'   243   Fisher’s Exact Test).
Discussion: Pinder et al considered an accuracy of 89% for Discussions: Our findings co-relate well with other studies
their electronic record adequate enough to adopt computer which have found that the vertebral level identified by
based data collection system.2We used three different landmark approach was at least 1 interspace higher than the
methods of data collection already in regular use, to compare level located by US in 40% of the pregnant population 3. Our
with our electronic database and showed it to have a high audit further confirms that the use of traditional landmark
degree of accuracy. This suggests that the database is easy to technique is highly inaccurate with potential increase risk of
use and consistently completed by our anaesthetists. We wish needle injury to the spinal cord especially in the high-risk
to use our database to produce reports on anaesthetic service patient groups (morbid obesity and musculoskeletal
provision (including the quality & safety of that service) as problems). We propose that all elective obstetric patients,
well as for auditing individual anaesthetist activity patients having a lumbar epidural, and high risk patients
(particularly our novice obstetric anaesthetists to ensure having a lumbar CNB should have US imaging of the of their
appropriate case mix & experience during their obstetric spines to identify the correct vertebral level and other relevant
attachments). Before using any database to audit these anatomy. The main reasons being that US imaging does not
aspects it is important to ensure that the data being audited is involve any radiation, is compact, portable and readily
a true reflection of anaesthetic activity, we believe our new available at the point of care. Better US equipment availability,
database is sufficiently accurate to audit the data within it. The staff awareness with appropriate training and improved
limitation of our audit is that we only audited the data from one documentation would aid in providing safer patient care.
month but we believe that the data entry practice of all months
References
is similar. We conclude that our electronic database is accurate
1. Chin KJ, Perlas A, Chan V, Brown-Shreves D, Koshkin A, Vaishnav
& the data entered can be used to audit our obstetric V: Ultrasound imaging facilitates spinal anesthesia in adults with
anaesthetic service. difficult surface anatomical landmarks. Anaesthesiology 2011; 115
(1): 94-101
References
2. Ultrasound-guided catherisation of epidural space. National Institute
1. Campbell NJ, Youngs P, Anderson I. A national survey of obstetric for Health and Care Excellence January 2008
anaesthetic data collection methods in the UK. Int J Obstet Anesth
2012; 21: S53. 3. Lee AJ, Ranasinghe S, Chehade JM, Arheart K, Saltzman BS,
Penning DH & Bimbach DJ. Ultrasound Assessment of the Vertebral
2. Pinder A, Wrench I, Shepherd D, Freeman R. Assessment of a Level of the Intercristal Line in Pregnancy. Anaesth Analg 2011;
handheld computer to collect obstetric epidural audit data. Int J
113: 559-564
Obstet Anesth 2002; 11: 8.
P6 Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin)
P111 Adherence to antenatal anaesthetic advice in P112 An evaluation of anaesthetic antenatal clinics in the
labouring morbidly obese parturients. obese obstetric population
S Halliday,  LC Robertson ,  HM du Plessis   PR El-Dalil,  DS Cochran,  R Ganapathy*  
Anaesthesia, Princess Royal Maternity Hospital, Glasgow, Department of Anaesthesia, Sandwell and West Birmingham
UK NHS Trust, Birmingham, UK, *Obstetrics and Fetal Medicine,
Introduction: Morbidly obese parturients pose a high Sandwell and West Birmingham NHS Trust, Birmingham, UK
anaesthetic risk1. Antenatal anaesthetic assessment for Introduction: Maternal obesity is increasingly common, with a
women with a body mass index (BMI) ≥40 kg.m-2 at booking is BMI 35 found in 5% of pregnancies. Current CMACE / RCOG
advised2. Early establishment of epidural analgesia is often guidelines advocate the referral of patients with a BMI 40 to
advocated. We sought to determine if this advice is adhered to an anaesthetic antenatal clinic. This study aimed to evaluate
in our centre. the outcomes following the implementation of such a clinic in a
Methods: A retrospective case note review of 49 morbidly busy inner city district general hospital.
obese patients (BMI ≥40) assessed antenatally was Method: High-risk patients were referred to a multidisciplinary
conducted. As a control, data from 23 patients with a BMI <40 antenatal clinic involving Anaesthetics, Obstetrics and
who had a labour epidural was collected. We compared the Haematology; patients with a BMI 40 were referred to the
timing of epidural request from labour ward admission, cervical clinic and included in the evaluation. Data was collected
dilation and syntocinon administration at request and the time retrospectively on the reason for attending, the past medical
from epidural insertion to delivery. Mode of delivery was also and obstetric history as well as any anaesthetic or surgical
noted. intervention provided in the perinatal period.
Results: Mean BMI for the control group was 23.6 (range 17- Results: In 2011, 72 women were referred to the clinic with a
32) and for the morbidly obese group 44.6 (40-60). Eleven BMI 40, although there were often other relevant co -
morbidly obese parturients had an elective caesarean section morbidities. The BMIs ranged from 40 to 80 (mean = 44). 44
(CS). Nineteen of the remaining morbidly obese parturients patients (61%) had a normal vaginal delivery, 3 women (4%)
requested labour epidurals. Two parturients delivered prior to required assisted vaginal delivery, 17 (24%) had an elective
insertion. caesarean section (CS), whilst 8 (11%) had a non-elective CS.
Of these patients, 38 (53%) required no anaesthetic
Time to Syntocinon Insertion to
Cervical dilation intervention.
request administration n delivery
  Centimetres
Minutes (%) Minutes Table: Anaesthetic intervention and failure rates in obese
(range)
(range) (range) parturients compared to previously published failure rates1 in
BMI Yes 12 (52.2) the general obstetric population
375 (110-
<40 169 (0-435) 3.7 (1-7) No 11 (47.8) Spinal Epidural CSE GA
915)
(n=23) Number attempted 19 12 4 1
BMI Yes 13 (68.4) % Failure rate 5 17 0 0
334 (12-702)
≥40  261 (0-555) 3.65 (2-8) No 6 ( 31.6) Published % failure rates1 6 24 18 <1
(n=17)
(n=19)
Discussion: The results demonstrated low regional
Table: Timing of epidural request, cervical dilation and anaesthesia failure rates, with only 1 unsuccessful spinal (5%)
syntocinon use at request, and time from insertion to delivery. and 2 failed epidurals (17%); figures comparable to those
In the control group with a BMI <40 that had a labour epidural found in the general obstetric population (Table). There is little
(n=23), the number of spontaneous vaginal deliveries (SVD), available data for regional anaesthetic failure rates in the obese
trial of forceps (TOF) and lower uterine segment CS (LUSCS) obstetric population precluding a direct comparison, but a
were 13 (56.5%), 5 (21.7%), and 5 (21.7%), respectively. For higher failure rate would be expected. A previous study of 677
those with a BMI ≥40 with an epidural (n=17) there were 6 women with a BMI 30 found an emergency CS rate of 24%, 2
(35.3%) SVD, 3 (17.7%) TOF and 8 (47.1%) LUSCS. The significantly higher than the 11% demonstrated in this cohort
number of SVD in the BMI ≥40 without an epidural group was of BMI 40. This robust multidisciplinary approach in the
18 (85.7%) and there were no TOF and 3 (14.3%) LUSCS. antenatal period allows for adequate planning and early
Discussion: Despite antenatal review, the time to epidural institution of optimised perinatal management. The service
request was longer in the morbidly obese group, indicating a provided was predominantly consultant led, with the on-call
need for ongoing education. The time between epidural Anaesthetist required to attend out of hours for parturients
insertion and delivery was shorter in the morbidly obese group with a BMI 45, and to be informed of patients with a BMI
which had a significantly increased chance of CS, signifying 40; significantly 73% of the on-call consultants are dedicated
the importance of establishing a working epidural early in this Obstetric Anaesthetists. We feel these systems may account
cohort. for our findings, as well as promote early and effective
communication with patients. Whilst the sample was relatively
References small the results are sufficiently encouraging to suggest that a
1. Soens MA, Birnbach DJ, Ranasinghe JS, van Zundert A. Obstetric multidisciplinary approach significantly improves perinatal
anesthesia for the obese and morbidly obese patient: an ounce of outcomes in the obese obstetric population.
prevention is worth more than a pound of treatment. Acta
Anaesthtesiol Scan 2008; 52: 6-19 References
2. OAA/AABGI Guidelines for Obstetric Anaesthetic Services 2013. 1. Kinsella SM. A prospective audit of regional anaesthesia failure in
Association of Anaesthetists' of Great Britain and Ireland and the 5080 caesarean sections. Anaesthesia 2008; 63(8): 822-832.
Obstetric Anaesthetists' Association. London, 2013. 2. Usha Kiran TS, Hemmadi S, Bethel J, Evans J. Outcome of
pregnancy in a woman with an increased body mass index. BJOG
2005; 112(6): 768-772.
Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin) P7
P113 An evaluation of fasting times for elective caesarean P114 An evaluation of intrathecal diamorphine versus
section surgery fentanyl for lower segment Caesarean section in a
J Ghoshdastidar,  KM Sherratt,  M Seneviratne*,  A medium-sized district general hospital
McGlennan   K Ramm,  LT Fenton-May,  S Naresh  
Anaesthetics, Royal Free Hospital, London, UK, Department of Anaesthesia, Good Hope Hospital, Heart of
*Anaesthetics, University College Hospital, London, UK England Trust, Birmingham, UK
Introduction: Enhanced Recovery Programmes have shown Introduction: Intrathecal diamorphine is now recommended by
increasing evidence for the benefits of reducing fasting times the National Institute for Health and Clinical Excellence (NICE)
for those undergoing elective surgery1. Many of these as the opioid of choice for lower segment Caesarean section as
benefits could be applicable to the elective caesarean section it provides improved post-operative pain relief.1 However, it is
patient. We evaluated the fasting times of our elective also associated with a dose-dependent increase in the
caesarean section patients to assess whether we could make incidence of pruritus2 and nausea3 which may be more
improvements to patient care. significant with diamorphine given its longer duration of
Methods: The evaluation included all patients undergoing action. Having arranged appropriate protocols for post-
elective caesarean section surgery at the Royal Free Hospital operative monitoring of women receiving intrathecal
over a 3 month period.. Patients received standard instructions diamorphine, we introduced the therapy in late 2012.
to stop eating at midnight on the day of surgery and to stop Methods: The evaluation took place over a six-week period. A
drinking clear fluids at 6 am. Data was collected by anaesthetic small number of women were still receiving intrathecal fentanyl
staff using a standardised data collection sheet.. Patients were due to clinician choice, and these provided a useful
questioned about the time they last consumed solid food and comparator. Women who were still present in the hospital on a
when they last drank liquid. follow-up round on the first day post-op were asked questions
Results: In total 77 patients underwent elective caesarean about post-operative pain, nausea and pruritus. We also
sections during the period of evaluation. We obtained data assessed total oral morphine and codeine doses and time to
from 71 patients for fasting times for fluids and 72 patients for first dose.
fasting times for solids. Results: Basic data is presented in the chart.

  Fentanyl Diamorphine
Pre-op fasting % of Pre-op fasting % of
Number 15 36
times FLUIDS patients times SOLIDS patients
Time to first morphine (hrs) 5.29 8.9
(hr) (n=71) (hr) (n=72)
Mean morphine dose (mg) 65.4 30
2 - 4 5.6 6 - 12 15.3
No morphine required 1 (6.6%) 11 (30.6%)
4 - 6 15.5 12 - 18 66.7
Mean codeine dose (mg) 123 119
6 - 8 14.1 18 - 24 16.7

8 - 10 8.5 over 24 1.4
Time to mobilisation (hrs) 21.17 15.21
over 10 56.3    
Time to catheter removal (hrs) 20.3 16.6

Discussion: There are no fasting recommendations specific to
Pruritus 8 (53.3%) 24 (66.7%)
elective caesarean sections but the standard surgical
- requiring treatment - 0 (0%) - 8 (22.2%)
guidelines of 6 hours for solids and 2 hours for clear fluids are
Nausea 5 (33%) 13 (36.1%)
usually applied. Periods longer than 12 hours without fluid
- requiring treatment - 3 (20%) - 7 (19.4%)
have correlated with significant dehydration
in patients having elective caesarean sections2. There is also
Discussion: Our results replicate previous work demonstrating
some evidence to suggest that gastric fluid volume is
a reduction in immediate post-operative analgesia
increased with prolonged starvation in the pregnant patient3.
requirements following a switch from fentanyl to diamorphine,
Over fifty per cent of our patients went without fluids for
but an associated increase in side effects requiring
longer than ten hours prior to surgery, and almost eighty-five
intervention. There was also a reduction in times to first
per cent of patients went without food for greater than 12
mobilisation and catheter removal, which is worth closer
hours. Our results show that there is a need to introduce
inspection. It is likely to be multi-factorial: the patients having
methods to reduce fasting times. These could include pre-
superior analgesia and feeling ready to move sooner, but also
operative letters with individualised times to stop eating and
the proforma for the ward indicating the patient had received
drinking. Also patients lower down the surgical list could be
diamorphine. This required the anaesthetist to specify a time
actively encouraged to consume clear fluids, or even
after which she would be ready to mobilise, which might have
carbohydrate drinks as used in many Enhanced Recovery
improved motivation amongst the midwives and mothers to
programmes.
achieve mobilisation.

References
References
1. Aguilar-Nascimento JE, Dock-Nascimento DB. Reducing
preoperative fasting time: A trend based on evidence. World J 1. NICE clinical guideline 132: Caesarean section
Gastrintest Surg. 2010 March 27;2(3): 57-60 2. Wrench IJ, Sanghera S, Pinder A et al, Dose response to intrathecal
2. Mackenzie M, Yentis S, Woolnough M and Johnson M. Fasting diamorphine for elective caesarean section and compliance with a
periods and dehydration before elective caesarean section. national audit standard, Int J Obstet Anesth. 2007;16(1):17-21
Anaesthesia, 2010 Vol 65:99 3. Sibilla C, Albertazzi P, Zatelli R, et al, Perioperative analgesia for
3. Maltby JR, Sutherland AD, Sale JP, Shaffer EA. Preoperative oral caesarean section: Comparison of intrathecal morphine and
fluids: is a five hour fast justified prior to elective surgery?. Anesth fentanyl alone or in combination, Int J Obstet Anesth. 1997; 6(1):
Analg. 1986 Nov;65(11):1112-6 43-48
P8 Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin)
P115 An evaluation of obstetric critical care admissions in a P116 An evaluation of standards of informed consent and
district general hospital documentation for labour epidural analgesia
VL Williams,  M Greene,  D Saul   S Chaudhari,  N Smith,  P Prasad  
Department of Anaesthesia, Leighton Hospital, Crewe, Anaesthetic Department, George Eliot Hospital, Nuneaton,
Cheshire, UK Nuneaton, UK
Introduction: CMACE has provided doctors with excellent
Introduction : It is both medico legally and ethically important
data over the past 50 years about maternal mortality, but
that the patient is made aware of the nature and risks
unfortunately no data about maternal morbidity. In December
associated with a labour epidural. No national standardised
2013, the Intensive Care National Audit & Research Centre
information card for informed consent is available, although
(ICNARC) produced a second report that analysed critical care
the OAA does publish a epidural information card1 with
admissions of women who were pregnant or recently pregnant
specific risks and incidence rates. At our hospital, the
in 2009-2012 inclusive.1 A comparison was made between the
documentation is made on part of the epidural chart as an
hospital ICNARC data and the national ICNARC data.
open entry. Our study looked to ascertain whether appropriate
Methods: Data were collected from the hospitals ICNARC
details of the epidural and informed consent were made. This
database over a four year period from 2009 to 2012. The data
was with a view to find whether a total redesign of the epidural
was analysed from the categories in the table below.
chart (at a level of standard suggested by the OAA website2)
Results: Data from 388 patients were evaluated.
was needed to improve our practice.
  Hospital ICNARC
Methods : We evaluated a total of 100 completed epidural
Total no. of patients admitted, female 16-50 years 388 55,791
charts over a 4-month period in mid-2012 at our obstetric unit.
Currently pregnant 3.6% 2.1%
The epidural notes were retrospectively analysed on our
Recently pregnant 9.3% 10.0%
scanned patient electronic notes. Documentation was
Obstetric reason for admission - currently pregnant 0% 8.7%
analysed for: details of the patient, anaesthetist and patient
Non-obstetric reason for admission - currently
100% 91.3% assessment, explanation of the risks and incidence given,
pregnant
details of the epidural technique and post epidural
Obstetric reason for admission - recently pregnant 50% 69.7%
management. Our main focus was on standards of consent.
Non-obstetric reason for admission - recently
50% 30.3% Results:
pregnant
%of patients Rate of risk
Discussion: The proportions of patients admitted to the Range of risk discussed
Risk discussed informed documented (no.
critical care area were comparable with the ICNARC report. (no. in total)
(n=100) in total)
The leading indication for admission in the currently pregnant
1in100:13,1in200:8
group was for sepsis. This corresponds with the ICNARC Headache 69 25
<1%:3,1in500:1
report and most recent CMACE report in which sepsis was the
Hypotension 45
leading direct cause of maternal death.2
Failure 59 4 1in8:2, 1in4000:2
The leading obstetric cause for currently pregnant admissions
Nerve 1in13k:21,1in10k:8
nationally, was for pre-eclampsia. However, there were no 65 31
damage 1in15k:1, 1 in19k:1
admissions in this category at the hospital. This is most likely
Itching 14    
because pre-eclampsia is diagnosed and treated effectively on
Infection 37  
the labour ward and rarely needs input from critical care.
Motor block 28    
In the recently pregnant group, there were equal proportions
Urinary
of patients admitted for obstetric and non-obstetric reasons, 28    
retention
this is quite different from the ICNARC report. The leading
indication for admission of recently pregnant patients in the The other areas of documentation studied showed an
ICNARC report was for post partum haemorrhage, by a long acceptable standard.
way. When looking at the hospital database, it showed that in Discussion : Several studies have looked at standards of
the period 2010-12, only 3 of 42 patients with a significant post informed consent in UK practice3and which risks and
partum haemorrhage of 2.5 litres or more were admitted to incidences were discussed and the range of risk quoted. Our
critical care. Therefore the question needs to be asked as to study showed rates generally to be slightly lower than that
whether these patients should have been admitted to the quoted in these studies. This is likely due to limited space and
critical care area? The hospital does not have an obstetric open entry nature of our current chart. The OAA has set
HDU, but in hospitals that do have an obstetric HDU facility, guidelines and advice for both epidural charts2 and risks and
these patients would certainly have been admitted there, had incidence1. Following this evaluation, a full redesign of our
closer monitoring and possibly goal directed therapy. All of epidural charts with prompts and guidance of risks and
these patients survived, but could admission to critical care incidence is warranted. In addition, the OAA had
have improved patient outcomes or reduced hospital stay? overwhelming support for a national standardised information
References card that could be implemented3.
1. Female admissions to adult, general critical care units in England,
Wales and Northern Ireland reported as 'currently pregnant'
References
or 'recently pregnant'. http://www.icnarc.org/documents/Obstetric%
20admissions%20to%20critical%20care%202009-2012.pdf 1. OAA epidural information card : http://www.oaa-
anaes.ac.uk/content.asp?ContentID=185
2. The eighth report on confidential enquiries into maternal deaths in
the United Kingdom. BJOG 2011, 118(Suppl 2):1-203 2. OAA epidural charts : http://www.oaa-anaes.ac.uk/content.asp?
ContentID=522
3. Informed consent for epidural analgesia in labour: A survey of UK
practice: Anaesthesia 2009, 64 p161-164
Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin) P9
P117 An unusual cause of post-partum sepsis P118 Anaesthetic management of a parturient with severe
F A Corcoran,  C Brennan,  A J Downs   systemic scleroderma
Anaesthetics, Dudley Group NHS Foundation Trust, Dudley, P Thomas,  A Varvinskiy,  M Human  
UK Anaesthetics, South Devon Healthcare NHS Foundation
Introduction: Leiomyomas are common in women of Trust, Torquay, UK
reproductive age and have been linked to spontaneous Introduction: Scleroderma is a chronic systemic autoimmune
abortion, retention of the placenta and post-partum disease. Successful pregnancy in patients with severe
haemorrhage.1 It is however rare for them to be the primary systemic scleroderma is very rare. We report the anaesthetic
cause of post-partum sepsis. We describe the case of a post management of such a case in a patient with a difficult airway,
partum patient presenting with painful fibroids and sepsis. severe pulmonary dysfunction and oesophageal dysmotility.
Case report: A 37 year old woman (P1), 5 days post partum Case report: A 29 year old woman (G1P0) with severe
presented with a history of fever, abdominal pain and systemic scleroderma presented to the hospital at 36 weeks
distention. She had a past medical history of fibroids but there gestation with dyspnoea and tachypnoea. Prior to pregnancy
had been no problems during pregnancy. She had an her exercise tolerance was poor, managing just 400 metres in a
uneventful labour with a normal vaginal delivery. On initial six minute walk test with resultant oxygen saturations of 72%.
assessment she was apyrexial with normal observations. She Her Forced Expiratory Volume (FEV1), Forced Vital Capacity
had mild tenderness on palpation of her abdomen. She was on (FVC) and Diffusing Capacity for Carbon Dioxide (DLCO) had
regular analgesics and had been commenced on oral each worsened steadily by five percent year on year over the
antibiotics by her GP. An ultrasound scan (USS) was booked last decade. The most recently measured values from 2007
to investigate the abdominal pain. Within 4 hours she had were FEV1 30%, FVC 28% and DLCO 24% of predicted values
deteriorated and developed a pyrexia, tachycardia, tachypnoea although the patient reported that her pulmonary function had
and decreased oxygen saturations. Initial impression was deteriorated significantly during pregnancy. On admission the
sepsis secondary to retained products so blood cultures and patient was breathless at rest with a p02 of 7.63 on room air
swabs were taken and intravenous antibiotics, oxygen and and it was felt that natural labour would not be possible due to
fluid resuscitation commenced. She was transferred to the poor physiological reserve. Severe reflux secondary to
Maternity High Dependency Unit. CRP was elevated but oesophageal dysmotility rendered her unable to recline more
lactate was normal. She improved over 6 hours but than 45 degrees and she could therefore not lie flat for awake
deteriorated again. Antibiotic coverage was amended caesarean section. Airway assessment revealed microstomia of
following microbiology advice but she continued to have a less than one centimetre, mallampati four, bucked teeth, sub
swinging pyrexia. USS detailed a bulky uterus with a large mental skin scleroderma and a narrow hooked nose with small
fibroid at the fundus and no retained products. 36 hours after nostrils. Oral intubation was therefore ruled out. Awake Fibre
admission she developed peritonitis and a CT abdomen which Optic Intubation (AFOI) appeared technically challenging due
suggested findings of a pedunculated fibroid measuring to nasal anatomy. Preoperative, bedside nasendoscopy
17.5cm that might have twisted on its pedicle. She had an revealed that AFOI would be possible should the need to
emergency laparotomy which revealed a degenerative, secure the airway arise mid operation. This avoided the need
necrotic, infected fibroid. She required ionotropic support and to perform an AFOI or awake tracheostomy pre-operatively.
was difficult to ventilate intra-operatively. Post-operatively The patient was positioned at 45 degrees on the operating
she was transferred to intensive care where she was sedated table. Surgeons confirmed that they could operate in this
and ventilated overnight. She was successfully extubated the position. A low dose spinal followed by an epidural which was
following morning and continued with intravenous antibiotics topped up gradually over 30 minutes using small incremental
and analgesia. She made a full recovery. Histology confirmed boluses achieved adequate block without compromising
the fibroid had extensive areas of coagulative necrosis, respiratory function. Surgery was completed without issue and
hyalinisation and inflammation. All microbiological both mother and baby did well post-operatively.
investigations were negative. Discussion: There are only three reports in the literature
Discussion: Sepsis in pregnant and post-partum women describing general anaesthesia for caesarean section in
remains a significant cause of maternal morbidity and patients with scleroderma and two using neuraxial blockade.1-5
mortality.2Sepsis is a clinical diagnosis and microbiological Of those who were intubated, one died and another required
investigations may be negative. Early recognition, timely three months ventilation. We demostrated how careful bedside
diagnosis and active treatment assists an optimum outcome. airway assessment and the use of a slow top up epidural were
Fibroids are common in pregnancy but sepsis secondary to successfully used to manage this challenging case.
infected, necrotic fibroid tissue post-partum is very rare. To References
our knowledge there have been no reported cases of this. It is
1. D'Angelo R, Miller R. Pregnancy complicated by severe
therefore essential to consider this in the differential causes of preeclampsia and thrombocytopenia in a patient with scleroderma.
obstetric sepsis when reviewing pregnant women with a Anesth Analg 1997; 85: 839-41
history of fibroids. 2. Hseu SS, Sung CS, Mao CC, Tsai SK, Lee TK. Anesthetic
management in a parturient with progressive systemic sclerosis
References during cesarean section. Acta Anaesthesiol Sing 1997; 35: 161-7
1. Mason T. Red Degeneration of a leiomyoma masquerading as 3. Younker D, Harrison B. Scleroderma and pregnancy. Br J Anaeth
retained products of conception. Journal of the National Medical 1985; 57: 1136-9
Association. 2002; 94: 124-6 4. Thompson J, Conklin KA. Anesthetic management of a pregnant
2. Lucas DN, Robinson PN, Nel MR. Sepsis in obstetrics and the role patient with scleroderma. Anaesthesiology 1983; 59: 69-71
of the anaesthetist. International Journal of Obstetric Anaesthesia. 5. Bailey AR, Wolmarans M, Rhodes S. Spinal anaesthesia for
2012; 21: 56-67 caesarean section in a patient with systemic sclerosis. Anaesth
1999; 54(4): 355-8
P10 Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin)
P119 Anaesthetic management of arrhythmogenic right P120 Anaesthetic management of obese parturients at a
ventricular cardiomyopathy during labour and tertiary centre - meeting the standard?
caesarean section: a case series L Kelliher,  J Teare,  E Evans  
J Eccles,  A Jain,  K Bhatia   Anaesthesia, St George's Healthcare NHS Trust, London, UK
Department of Anaesthesia, St Mary's Hospital, Manchester, Introduction: Obese women are at increased risk of perinatal
UK morbidity and mortality. In 2010 CMACE and RCOG published
Introduction: Arrhythmogenic right ventricular joint guidelines for the management of the obese parturient
cardiomyopathy (ARVC) is mainly a genetically determined including recommendations that patients with a booking BMI
autosomal dominant disease characterised by cardiomyocytes ≥40 should attend an antenatal anaesthetic clinic (AAC) and a
being replaced by fibrofatty tissue in the right ventricle.1 Specialist Trainee year 6 anaesthetist (ST6) or above should
ARVC has an incidence of 1:5000 and may account for as be informed and available to attend labour and operative
many as 5% of unexpected sudden deaths. The Eighth Report delivery1. Our unit is a tertiary centre with over 5,000
of the Confidential Enquiries into Maternal Deaths in the deliveries/year. A previous audit over 2 years showed that of
United Kingdom (2006-2008) highlighted that ARVC was the 120 women with BMI ≥40 attending our AAC, 76% required a
underlying cause in two of the 53 reported cardiac deaths. We peripartum anaesthetic intervention, with only 34% of these
describe the anaesthetic management of two parturients with performed by an anaesthetist ≥ST62. Awareness of the
ARVC who presented at our tertiary centre. guidelines was raised and anaesthetic plans for these women
Case reports: The maternal demographics, the cardiac signs, now state care should be managed by a senior anaesthetist.
symptoms and interventions along with the anaesthetic We examined our obese population following these changes.
management in the peri-partum period are briefly summarised Methods: A retrospective analysis over 1 year (2011-12) of
in the table below. hospital records for patients with a booking BMI ≥ 40. Records
were examined for referral and attendance at AAC, anaesthetic
Category Case 1 Case 2
intervention (regional/GA), grade of anaesthetist and
Age 27 23
anaesthetic complication (difficult/impossible regional, dural
BMI 25.8 27.2
tap, other).
Parity 0 0
Family history None Sudden death Results: In total there were 74 women with a booking BMI
Cardiac signs and Palpitations with spurts of Paroxysmal VT ≥40. 73% were referred to AAC, only 58% attended. Out of all
symptoms ventricular tachycardia (VT) patients, 69% had a peripartum anaesthetic intervention, 43%
Cardiac Cardiac ablation therapy and ICD insertion of which were performed by an anaesthetist ≥ST6 with a
intervention prior implantable cardioverter complication rate of 16%. Of those attending AAC, 67% had
to pregnancy defibrillator (ICD) insertion an anaesthetic intervention, 41% of which were performed by a
Mode of delivery Elective caesarean section Urgent LSCS for ≥ST6 with a complication rate of 17%. Of those patients not
(LSCS) for breech foetal distress attending AAC, 71% had an anaesthetic intervention and 36%
Anaesthesia and General anaesthesia, with Labour epidural of these were performed by ≥ST6 with a complication rate of
analgesia bilateral transversus analgesia, followed by 14%.
abdominal plane blocks top up for LSCS
Table 1. Incidence of complications by grade of anaesthetist
Maternal length of Three days Four days
stay Group ≥ST6 <ST6 p value (Fisher's Exact)
Neonatal APGAR 8 and 10 9 and 10 All 9.1% 20.7% 0.440
scores AAC 16.7% 17.6% 0.945
Discussion: The main implications of ARVC in parturients No AAC 0% 21.4% 0.273
include fatal arrhythmias, heart failure worsened by Discussion: This audit shows a significant number of obese
physiological changes of pregnancy and sudden adult death parturients were not seen in our AAC. A proportion of these
syndrome.1 Both our patients had VT diagnosed after 24 hour were referred, but did not attend however 27% were not
Holter monitoring, and an ICD was implanted in addition to referred. Despite this, there was no significant difference in the
beta blocker medical therapy to control the symptoms of VT as requirement for anaesthetic intervention or the incidence of
well as to prevent sudden death. The patients were seen in the anaesthesia-related complications between attenders and non-
joint cardiac, obstetric and anaesthesia antenatal clinic and a attenders. The incidence of senior anaesthetic involvement in
peri-partum plan formulated to facilitate safe delivery. Both care has risen from 34% to 41% but there is still room for
had serial echocardiograms, serum electrolytes monitored, improvement. This highlights the resource difficulties faced in
invasive blood pressure monitoring and ICD deactivated providing 24 hour senior anaesthetic cover. The on-call rota at
during their LSCS. Our case series highlights that both general our unit is staffed by junior and senior anaesthetists. The
and regional anaesthesia can be safely provided and we absence of a senior anaesthetist did not lead to a significant
recommend a multidisciplinary approach with close co- rise in anaesthesia-related complications, although there was a
operation between anaesthetists, cardiologists and t rend toward this (Table 1).
obstetricians to provide optimum care of these patients. References
Reference 1. Centre for Maternal and Child Enquiries & Royal College of
Obstetricians and Gynaecologists Joint Guideline. Management of
1. Alexoudis AK, Spyridonidou AG, Vogiatzaki TD, Iatrou CA.
Anaesthetic implications of arrhythmogenic right ventricular women with obesity in pregnancy. London: CMACE & RCOG; 2010
dysplasia/cardiomyopathy. Anaesthesia 2009; 64: 73-8. 2. Fulton L, Evans E, Schroeder F, Wendler R. Antenatal anaesthetic
assessment of morbidly obese women - a useful resource? 2013,
http://epostersonline.s3.amazonaws.com/oaa2013/oaa2013.0690195
.NORMAL.pdf
Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin) P11
P121 Anaesthetic management of the labouring patient with P122 Anesthetic implications  of heart disease in pregnancy
multiple sclerosis S Francés,  S Manrique,  M Goya,  M García,  R Perera,  N
J Li Wan Po,  K Maclennan   Montferrer  
Anaesthesia, St Mary's Hospital, Manchester, UK Anaesthetics, Vall d'Hebron University Hospital, Barcelona,
Introduction: Multiple Sclerosis (MS), an autoimmune Spain
inflammatory disease affecting the central nervous system, is Introduction: Despite advances in its diagnosis and treatment,
estimated to affect 20,000 or more UK women of childbearing heart disease (HD) in pregnancy remains a major cause of non-
age1. Controversy exists regarding the management of obstetric maternal and neonatal mortality and morbidity (it
anaesthesia and analgesia in labouring parturients with MS. complicates around 1-3% of pregnancies in developed
Following analysis of our practice at St Mary's Hospital, a countries). Accurate multidisciplinary assessment and
tertiary referral obstetric unit with over 8500 deliveries per management of individual maternal and fetal risks in pregnant
annum, and recent evidence in the literature; our women with HD provides the best opportunity to substantially
recommendations for the peri-partum management of improve outcomes for mother and baby. (1).
parturients with MS are presented. Methods: We present a prospective cohort study that
Methods: Interrogation of the St Mary's Hospital antenatal analyzed outcomes in women with HD, the majority of whom
clinic database, from 1999 to 2012, identified 21 pregnant had had corrective surgery and delivery between 2007 and
women diagnosed with MS. We reviewed antenatal advice, 2013. Baseline characteristics and adverse events during
intrapartum management and postpartum complications. delivery and postpartum were assessed. Intensive monitoring
Results: Over 50% of patients were nulliparous. The majority of the delivery and postpartum were planned beforehand in all
had mild sensory or motor deficit. Three relapsed during cases.
pregnancy, one improved in symptoms and one relapsed Results: One hundred and seventy-four patients with 179
postpartum. There were twelve normal vaginal deliveries, two pregnancies were included in the study. 127 women (72,98%)
instrumental deliveries, six Caesarean sections and one presented congenital heart disease (CHD), 47 acquired heart
unspecified delivered at another hospital. Five women opted disease (27,02%): 27 acquired rheumatic valve disease
for epidural analgesia, two were topped up for operative (19,98%), one Marfan syndrome (0,54%), 3 coronary heart
delivery. Five had spinal anaesthesia with 0.5% heavy disease (1,6%) and 9 primary myocardial disease (4,9%).
bupivacaine and one had a general anaesthetic. There were no
Pregnancy complications were presented in 21, 2% of CHD,
complications following regional technique.
14,8% of acquired rheumatic valve disease and 100% of
Discussion: A recent national survey reported that within a 10 women with arrhythmias.
year period, 91% of anaesthetists have encountered <ten
The type of delivery was vaginal in 124 women ( 72,1%) and
cases of MS2 and have little experience in their management
cesarean section in 50 women (27,9%).
during pregnancy. Recent evidence available supports our
168 women had analgesia during delivery (93,8%); 5 women,
current management of MS patients undergoing labour. The
general anesthesia (2,79%), 6 women, local anesthesia (3,35%)
low incidence of the disease makes it difficult to attain
and 87,5% of women had regional analgesia.
significant figures to determine the optimal management plan.
To standardize care, we made the following recommendations Delivery complications were 7% (uterine atony 2,7%, vaginal
based on the latest evidence and our own experience: hematoma 2,2%, chorioamnionitis 0,5%, cesarean hematoma
- Patients to be reviewed in an antenatal anaesthetic clinic. 0,5% and hemoperitoneum 0,5%). The only anesthesia
Document disease severity and discuss analgesia and complication was one dural puncture (0.5%). No maternal
anaesthetic options. death, one fetal death (0.5%) and one neonatal death (0.5%).
The maternal average hospital stay was 3 days.
- Use of 0.1% bupivacaine with 2mcg/ml fentanyl mixture for
epidural labour analgesia2 . For an operative intervention, top Discussion: Pregnancy and delivery are associated with
up with a higher concentration of local anaesthetic. substantial physiological changes, which require the
adaptation of the cardiovascular system and can expose
- Regional rather than general anaesthetic for caesarean
women with HD to significant risks. If regional anesthesia is
sections. Spinal anaesthesia is the most simple and reliable
selected, the addition of an opioid, when dosing any neuraxial
technique although consider combined spinal-epidural on an
anesthetic, will reduce the amount of local anesthetic required
individual basis.
and subsequent hemodynamic effects, while improve
- If a general anaesthetic is necessary, avoid suxamethonium
intraoperative and postoperative analgesia. The avoidance of
and monitor neuromuscular block to titrate dose of non-
epinephrine from the epidural dose will eliminate the possible
depolarizing muscle relaxant3.
deleterious effects of systemic epinephrine. Maintaining
These recommendations will be available for clinicians on the uterine blood flow is important for fetal well-being.
trust intranet and a patient information leaflet on the effects of Maintaining systemic vascular resistance in patients with
pregnancy and anaesthesia on MS has been produced. intravascular shunting, is important to avoid inducing or
exacerbating pre-existing cyanosis due to increased right- to –
References
left shunting. Cautious intravenous hydration and gentle
1. Brookings W, Lee M. Management of multiple sclerosis during
titration of phenylephrine or ephedrine are options to
pregnancy. Prog Neurol Psychiatry. 2009; 3(6): 9-11
counteract the hemodynamic effects of surgical neuraxial block
2. Drake E, Drake M, Bird J, Russell R. Obstetric regional blocks for
women with multiple sclerosis: a survey of UK experience. Int J (1,2). We observed a predominance of neuraxial anaesthetic
Obstet Anaesth. 2006; 15(2): 115-23 techniques, increased caesarean and operative delivery rates,
3. Griffiths S, Durbridge JA. Anaesthetic implications of neurological and favourable maternal and neonatal outcomes.
disease in pregnancy. Contin Educ Anaesth Crit Care Pain. 2011; 11
(5): 157-61 References
P12 Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin)
P123 Angle of tilt achieved with automated operating table P124 Antenatal anaesthetic information given to women
in elective caesarean sections: a comparison with tilt with obesity
achieved with an inflatable balloon wedge  C R Thomas,  C Busby  
PN Nair,  L Dyal,  B Grewal,  I Suri   Anaesthetics, Airedale General Hospital, Keighley, UK
Department of Anaesthesia, Warwick Hospital, Warwick, UK Introduction:Antenatal obesity is defined as a BMI of ≥30at
Introduction: A previous study1 done on patients undergoing booking. Its prevalence in England increased from 7% in 1990
elective caesarean sections looked into measuring the angle of to 16% in 2007.1Women with a BMI ≥40 are often provided
tilt of the operating table with an inflatable balloon wedge. with anaesthetic information antenatally. Those with lower
This showed that the visual estimation of angle proved levels of obesity also have an increased anaesthetic risk but
accurate in the achievement of near 150 tilt. Here we present these women may receive little or no information about this
the results of a similar study using a different technique of during pregnancy. 2The RCoA have produced standards
automated table tilt instead of the inflatable balloon wedge regarding care for these women: 90% of patients with a
device. The premise being is our visual actuation of tilt angle booking BMI ≥ 30 should receive a leaflet containing
accurate. information about anaesthesia and analgesia. 90% of patients
Methods: The study was similar to the previous one. We with a booking BMI ≥40 should have an anaesthetic consult.
prospectively selected 26 patients at random who were Booking BMI should be documented in 100% of maternity
undergoing elective lower segment caesarean section under hand-held notes. An audit of the above standards was carried
spinal anaesthesia over a six week period. Ethical committee out as summarised below.
approval was obtained. Verbal consent was obtained from all Methods:A list of all deliveries in January 2013 was generated.
participants and the booking Body Mass Index (BMI) was Notes were reviewed for adherance to the above three
noted. We used the same protractor device for measuring the standards. Change to practice was recommended based on
angle of tilt. This is similar to the one used by Kinsella et al2. audit findings. Following the implementation of change, the
Results: The measured angles ranged from 10 to 18 degrees, a audit cycle was completed by auditing notes of all deliveries in
mean angle of 13.70 with a mean difference of -1.3 and standard November 2013.
deviation of 2.32. This compared very closely to the angles Results:
between 10 to 17.5 degrees, mean angle of 13.650, mean Table: Recording of booking BMI, patient count by raised
difference of -1.35 and a standard deviation of 2.06 in the BMI category and number given anaesthetic information.
previous study. BMIs ranged from 19 to 37 with a mean of 24.
Discussion: The visual estimation of angle using the
BMI 30 - BMI 35 - BMI
automated table tilt proved accurate in achieving the near 150 No
Number of Unavailable 34.9; 39.9; ≥40; 
tilt and is comparable with that obtained with the inflatable   booking
deliveries casenotes info info info
balloon wedge device in the previous study. The standard BMI
given given given
deviation of 2.32 indicates that 95.4% of cases could achieve
Jan 195 6 2 20; 0 7; 1 7; 7
within 4.60 of the required 150 tilt i.e. 10.4 to 19.6 degrees tilt.
Nov 173 3 2 17; 2 7; 7 3; 3
The automated table tilt provides an easy and accurate means
of providing left lateral tilt in pregnant patients. Discussion: Booking BMI was recorded in 99% of the notes in
both audit cycles. In 100% of cases where BMI was ≥40, a
consultant anaesthetist discussed risk and made a plan with
References
the patient. However, the audit of January deliveries indicates
1. Grewal B, Suri I. Is visual actuation a valid predictor of angle of tilt?
that few women who have a BMI 30-39.9 receive anaesthetic
Int J Obstet Anaesth Vol 18 2009; pS1-64- supplement
information.; this occurred in only one case. Reaching this
2. Kinsella SM. A device for measuring the degree of lateral pelvic tilt
during supine recumbency. Anesth Analg 1995; 80: 204-5 population to provide information is difficult especially where
BMI is 30-34.9 as all antenatal care for this group may be
provided by community midwives. In collaboration with
Obstetrics, a patient information leaflet was written which
included both obstetric and anaesthetic information. The
leaflet was approved by the Women's Integrated Governance
group and has been in use since October 2013. It is available
on the Trust intranet which is accessible by some community
midwives. The leaflet is given to all those with a BMI ≥ 35
when they attend obstetric high risk clinic. The results of the
November audit indicate improvement has been made; 44.4%
of those with obesity now receive anaesthetic information.
Greater access to the leaflet is needed however.
References
1. Royal College of Anaesthetists 2012,
http://www.rcoa.ac.uk/document-store/audit-recipe-book-3rd-edition-
2012
2. Centre for Maternal and Child Enquiries 2010, http://www.oaa-
anaes.ac.uk/assets/_managed/editor/
File/CMACE/CMACE_Obesity_Report_2010_Final%20for%
20printing.pdf
Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin) P13
P125 Antenatal management of morbidly obese parturients: P126 Audit of temperature for patients undergoing elective
A multicentre evaluation. caesarean section
H Aladin,  A Khandhia,  K Pottinger   N J Truman,  I Clegg,  K Maclennan  
Anaesthetics, Good Hope Hospital, Birmingham, UK anaethetics, St Mary's Womens Hospital, Manchester, UK
Introduction: Women with a body mass index (BMI) of ≥30 Introduction: Perioperative Hypothermia is associated with
kg/m2 at the time of antenatal booking are classed as being poor outcomes and adverse events for patients; including
obese in pregnancy, accounting for around 39,000 maternities surgical site infection increased length of stay, blood loss,
per year1. Obesity is associated with increased risk of shivering, increased anaesthetic recovery time and cardiac
anaesthetic morbidity and mortality. National guidance have events. Risk factors for the occurrence of hypothermia include
been developed following the Confidential Enquiry into regional anaesthesia, fluid deprivation, blood loss, and cold
Maternal and Child Health report concerning obesity in fluid administration, all of which are common to obstetric
pregnancy. At two different hospitals, five indicators of best patients. 2008 Nice guidelines CG651 on perioperative
practice2 were analysed: (1) Recording of maternal BMI. (2) hypothermia do not include parturients, despite being an at
BMI ≥ 30 women receive information about risk group. An audit performed in 2011 at St Mary's Hospital
anaesthesia/analgesia. (3) Women with a BMI ≥ 40 have demonstrated that 92.5% of elective section patients were not
antenatal anaesthetic review. (4) Duty anaesthetist should be 'comfortably warm' on arrival in recovery, with 65% defined as
informed when women with a BMI ≥ 40 are admitted. (5) hypothermic. A repeat audit was performed following
Anaesthesia for women with a BMI ≥ 40 should be provided commencement of a trial of an air free conductive fabric patient
by a senior anaesthetist. warming system (Hot Dog®).

Methods: Women who had undergone a lower segment Method: A prospective audit of elective caesarean section
caesarean section (LSCS) during a 6 month period (Jan 2013- patients was conducted from April-June 2013 at St Mary's
Jun 2013) at a District General Hospital (DGH) and a Hospital. Theatre staff completed the audit proforma. Data
Foundation Hospital (FH) were evaluated. Data was collected collected included; ambient theatre temperature (ideal target
retrospectively from an electronic data archive and anaesthetic 21ºC), anaesthetic type, estimated blood loss (EBL),
charts. Evidence of BMI calculations, provision of temperature pre, intra, post operative and prior to discharge
anaesthesia/analgesia information, ante-natal anaesthetic from recovery (measured using a tympanic membrane
appointments, and anaesthetic care in the labour ward and thermometer) and details of which Hot Dog® warming
theatre were identified. products were used. Hypothermia was defined as a core
Results: 309 women who underwent a LSCS were identified temperature <36ºC with desirable temperature being defined as
with a having a BMI 30 (median 34, range 30-59). 51% of 36.5-37.5ºC. Comparison of the results from the 2011 audit
these were elective cases. 56% of women with a BMI ≥30 enabled conclusions to be drawn regarding the effectiveness
received anaesthesia/analgesia information, of which 2 were of the warming product.

given literature on anaesthesia in obesity. 32% of women with
Results: A total of 33 patients were audited who underwent
a BMI 40 underwent an antenatal anaesthetic review, with an
elective caesarean section, [n=79, 2011audit], 94% had spinal
additional 4 women failing to attend their appointments. In
anaesthetic (87%, 2011 audit). Mean (S.D) theatre temp was
those women with a BMI ≥40, the duty anaesthetist was
22.8 (± 0.6) [22.3 (± 0.6), 2011 audit], mean duration of
informed of admission in 19% of cases and in 56% of LSCS,
procedure was 51 minutes. 94% of patients had an additional
the anaesthetic care was provided by an appropriately graded
fluid warmer intra-op (72%, 2011 audit). The mean EBL was 574
anaesthetist .
ml (± 213) [653 (± 431), 2011 audit] and only 6% of patients had
Table: Women with BMI 30 having anaesthetic care at a DGH an EBL over 1L (20% 2011 audit). Only 12% (n=4 of 33) of
and FH. patients warmed with the HotDog® were hypothermic on
arrival to recovery (compared to 65% (n=51 of 79), 2011 audit)
  DGH FH
figure 1.
Total LSCS 32% (99/309) 68% (210/309)
Discussion: efforts have been to reduce perioperative
BMI Median (range) 33 (30-59) 34 (30-52)
hypothermia in elective caesarean sections. Almost all patients
Maternal height, weight + BMI recorded 100% 100%
received warmed fluids via a 3M™ Ranger™ fluid warming
Conclusion: This audit has identified that more than half the
system. Forced air warming devices applied to the upper body
women with a BMI ≥30 received analgesia/anaesthesia
are not well tolerated by our awake patient population and
information and more than half were anaesthetised by a senior
allow only a limited area to be heated. introduction of
anaesthetist. However, in all the areas of practice, the target
HotDog® with an under patient warming mattress and
percentage of women meeting the identified standards were
separate over patient warming blanket (for upper and lower
not achieved. Recommendations included revision of the
limb) proved to be of benefit in perioperative maintenance
referral guidelines for antenatal anaesthetic assessment,
when compared to our standard warming measures. A
improved communication within the multidisciplinary team
HotDog® warming mattress placed on the patient chair in the
during admissions and increased presence of senior
pre theatre waiting area helped prevent hypothermia pre arrival
anaesthetists on delivery suite.
in theatre.
References
Reference
1. Centre for Maternal and Child Enquiries (CMACE). Maternal
1. CG 65 Management of inadvertent perioperative hypothermia in
obesity in the UK: Findings from a national project. London:
adults. NICE April 2008.
CMACE, 2010
2. The Royal College of Anaesthetists. Raising the Standard. A
compendium of audit recipes for continuous quality improvement in
anaesthesia. 3rd Edition 2012
P14 Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin)
P127 Availability of chlorhexidine handwash for regional P128 Caesarean section in a rhesus null parturient with a
analgesia on the labour ward uterine fibroid
K Chima,  T Strickland,  F Plaat   P J Stewart,  R Laird,  J Cartmill  
Anaesthetics , Queen Charlotte's and Chelsea Hospital, Anaesthetics, Altnagelvin Area Hospital, Londonderry, UK
London, UK Introduction: The anaesthetic management of a Caesarean
Introduction: Many patients request regional analgesia during section is made more challenging by the combination of pre-
labour and therefore central neuraxial blocks are performed in operative anaemia, a large uterine fibroid and the presence of a
the delivery room. For central neuraxial blocks an aseptic very rare blood group Rhesus null.
technique should be standard. In the Third National Audit Case report: A forty-year lady with a past medical history of
Project of the Royal College of Anaesthetists the incidence of psoriatic arthritis presented to antenatal booking at 10 weeks
iatrogenic infection was reported as being 8/707 000 gestation. Booking investigations revealed a haemoglobin of
procedures1. However the consequence of any infection is 10.3g/dL, and a blood group O Rhesus null. Her 20-week
potentially devastating, and a 'scrupulous' aseptic technique ultrasound scan revealed no foetal anomalies but did
was therefore stated to be mandatory in the report1. demonstrate an anterior uterine fibroid. This was confirmed
Chlorhexidene gluconate 4% is used for hand decontamination with magnetic resonance imaging which showed a
in our department. It was noticed that not all delivery rooms heterogeneous mass measuring 188x139x159mm, in keeping
were equipped with both chlorhexidene and a hands free with a degenerating fibroid. At 21+3 days she presented with
method for application. dizziness and right upper quadrant pain. Her haemoglobin
Methods: All delivery rooms on labour ward were inspected to level was 7.6g/dL and she was treated for iron deficiency
ascertain the presence of chlorhexidene and a hands free anaemia. Due to a transverse lie and the large fibroid an
dispenser. elective Caesarean section at 38 weeks was planned. As a team
we anticipated a difficult Caesarean delivery with greater blood
The audit was repeated after one and twelve months to assess
loss in a patient with anaemia and a very rare blood group.
if there had been any improvement in the service.
Antenatal management focused on maximising the patient's
Results: Originally, 12 of the 16 delivery rooms had
haemoglobin levels and sourcing compatible blood. The
chlorhexidene available (75%). Of the 12 rooms with
Northern Ireland blood transfusion service and National frozen
chlorhexidene only three were equipped with a hands free
red cell bank in Liverpool secured two units of packed red cells
dispenser (25%), and five containers were uncovered (42%).
in England. Unfortunately, one week prior to the section this
After one month all 16 rooms were equipped with wall blood was issued in an emergency, making it unavailable to us.
mounted chlorhexidene with a hands free dispenser (100%). A new donor was found in South Africa and a further unit was
After a further 12 months it was found that 12 of the 14 secured in Brazil. Both units were couriered to our hospital
delivery rooms had chlorhexidene available (86%). (Two of the prior to the Caesarean delivery which was performed at 38+6
rooms had been converted to a post delivery high dependency days under spinal anaesthesia. Pre-operative haemoglobin was
unit). Eleven of the 12 containers were equipped with a hands 9.1g/dL. The patient was discharged home on day three post-
free dispenser (92%). operatively and her haemoglobin was 7.2g/dl on discharge. No
Discussion: The results of the initial data collected, as well as blood transfusion was required.
anaesthetists' concerns regarding the unavailability of Discussion: Red blood cells from people who have the Rhesus
chlorhexidine and dispensers in each room, was reported to null phenotype lack Rhesus proteins, and thus, Rhesus
managerial staff, who ensured all rooms were adequately antigens. This phenotype occurs in approximately 1 in 6x106
stocked. Results were therefore better when re-auditing was individuals1. When these patients are transfused they may
performed at one month. However, after 12 months standards form antibodies to high frequency rhesus antigens, which can
had declined, although they were still improved from the make it extremely difficult to process compatible blood. Rhesus
initital audit. This decline could be attributed to the fact that null blood is available from the National frozen cell bank,
neither a team nor a named individual was made responsible however it may not be available when required due to limited
for sustaining the initial improvement, which if introduced, we supplies, as in our case. There is very limited literature
feel would encourage a sense of ownership and enable the regarding the management of the rhesus null parturient and
improvement in this area of patient safety to be sustained. our management was guided by our regional Haematology
Reference unit. This case demonstrates the importance of good
communication with all members of the multi-disciplinary team
1. National Audit of Major Complications of Central Neuraxial Block
in the United Kingdom 2009, http://rcoa.ac.uk/system/files/CSQ- and the detailed preparations required in a complex case.
NAP3-Full_1.pdf
Reference
1. Avent ND, Reid, ME. The Rh blood system: a review. Blood 2000
95: 375-387.
Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin) P15
P129 Category one caesarean sections in a district general P130 Comparison of two non-invasive cardiac output
hospital:  Improving the decision to delivery time monitoring devices in a parturient with complex
VK Wroe,  AM Troy   cardiac disease.
Department of Anaesthesia, Countess of Chester Hospital, PJ Rose,  V Misra,  S Quasim  
Chester, UK Anaesthesia, UHCW, Coventry, UK
Introduction: National Guidelines state that the interval from Introduction: The management of valvular lesions during
decision to delivery (DDI) in a category one caesarean section pregnancy and labour can present a clinical conundrum. We
should be less than 30 minutes1, and that a duty anaesthetist present the use of two cardiac output (CO) monitoring devices
should be immediately available for emergency work on the in a parturient with complex valvular heart disease undergoing
delivery suite 24 hours a day2. a caesarean section under epidural anaesthesia.
A 2008 departmental audit found that 85% of category one Case Report: A 37 year old primiparous woman with history of
sections had a DDI of under 30 minutes, a figure marginally ASD repair aged 4, severe mitral regurgitation, severe tricuspid
under the audit standard of 90%. Anaesthetic service regurgitation, moderate aortic stenosis (AS) secondary to a
provision in our trust was expanded in July 2012, with the congenital bicuspid valve and moderate pulmonary
addition of a dedicated obstetric anaesthetist 24 hours a day. hypertension presented for elective caesarean section.
This re-audit aimed to assess the proportion of category one Echocardiography showed moderately dilated right ventricle
caesarean sections with a DDI <30 minutes and analyse the with good bi-ventricular systolic function, bi-atrial dilatation,
factors contributing to any delay. moderate to severe AS (mean gradient 34mmHg, peak gradient
Methods: After audit department approval, a retrospective 53mmHg, estimated valve area 0.74cm2). Pulmonary artery
analysis of category one caesarean sections between August pressures were estimated at 42-47mmHg. LiDCO rapid and
and December 2012 was performed. Data collected included Cheetah NICOM devices were used to monitor CO.
DDI and reason for delay, indication for section, type of Anaesthesia was established with 32mL 2% lignocaine and 100
anaesthesia and cord pHs. micrograms of epinephrine via epidural. Compound sodium
lactate was infused at 60mL/hr, and increased to 100mL/hr after
Results: 69 category one caesarean sections were analysed.
epidural anaesthesia. Fluid boluses of 200mL and 100mL were
The mean DDI was 23 minutes (range 3-120 minutes). 84% had
delivered via the pump at 13 and 28 minutes after delivery of a
a DDI of under 30 minutes, with a mean time from decision to
live infant. Metaraminol infusion was titrated to effect.
effective anaesthesia of 14.5 minutes. The indication for
Syntocinon infusion was started upon delivery (20 units in
caesarean section was abnormal CTG in 87% of cases (2008:
48mL 0.9% saline) at 15mL/hr and tapered post-operatively
77%). General anaesthesia was performed in 43% (2008: 85%),
over 4 hours. Mean arterial pressure was maintained at 91 to
spinal anaesthesia in 55% (2008: 15%) and extension of
97mmHg until delivery (78 minutes) and then decreased to
epidural blockade in 2%. In 11 cases, DDI was over 30
67mmHg at the end of surgery. Cardiac output was maintained
minutes; these cases were all performed under spinal
throughout surgery with an increase at the time of concurrent
anaesthesia. The following table shows the reasons identified
fall in MAP. Fluid challenge had negligible effect although
that contributed to delay:
there was a small reduction in heart rate (84 to 59bpm).

Arrival in
Discussion: NICE has advocated the use of cardiac output
theatre Incision to
Spinal monitoring in high risk non-obstetric surgery to improve
10 delivery Staff Theatre
  placement outcome.1 In this case we utilised both a non-calibrated pulse-
minutes time 10 unavailable unavailable
10 minutes contour waveform analysis and bioreactance system to
from minutes
compare both values measured and response to fluid
decision
challenge. Although the values produced were different, the
Number
trends were broadly similar. This, once again, highlights the
of 4 6 1 1 1
importance of analysing trends rather than absolute values to
patients
guide management. Interestingly, both devices demonstrated
Arterial cord blood analysis was carried out in 10/11 cases. pH
that a fall in MAP correlated with an increase in cardiac
was less than 7.2 in 30%, and base excess was less than -8 in
output, similar to previous investigators.3 Given that cardiac
20%.
disease is the leading cause of death in the most recent
Conclusion: The proportion of cases with a DDI of over 30 triennialreport2, monitoring cardiac output enables one to
minutes has remained constant at around 15%, despite an maintain physiological homeostasis, and ultimately aids
improvement in anaesthetic staffing. Our results suggest that clinical decision-making leading to good clinical outcome, as in
the causes for this delay are multifactorial, and the results are our case.
not benign- the delay in delivery led to a cord pH of <7.2 in
References
almost one third of cases. We intend to improve our practice
1. MTG3 CardioQ-ODM (oesophageal Doppler monitor): guidance
by regular practice drills, use of preprepared spinal packs to
2011, http://www.nice.org/nicemedia/live/13312/52624/52624.pdf
reduce spinal placement time, clear procedures to follow in the
2. Centre for Maternal and Child Enquires (CMACE). Saving Mothers'
case of staff or theatre unavailability and reaudit. Lives: Reviewing maternal deaths to make motherhood safer: 2006-
2008. The Eighth Report of the Confidential Enquires into
References
Maternal Deaths in the United Kingdom. BJOG 2011;118(Suppl
1. Caesarean section. NICE Clinical Guideline 132. NICE, London 1):1-203
2011. (http://publications.nice.org.uk/caesarean-section-cg-132).
3. Fanning NP, Sermer M, Colman J, Carvalho JC, Cordovani D. Non-
2. OAA/AAGBI guidelines for obstetric anaesthetic services- 3rd invasive Hemodynamic monitoring with bioreactance for cesarean
edition. AAGBI and OAA, London, 2012 delivery. A more relaxed look at tight aortic stenosis? Abstract
(http://www.aagbi.org/publication/publication-guidelines/M/R) SOAP 2011, http://www.soap.org/display_2011_abstract.php?id=58
P16 Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin)
P131 Comparsion of slow and rapid bolus of ephedrine in P132 Continuous spinal anaesthesia for a primigravida with
patients undergoing planned caesarean section under severe tricuspid regurgitation, Harrington rods and
spinal anaestheisa WITHDRAWN FROM  thrombocytopenia.
PRESENTATION AM Walton,  I Mettam  
PG Sekar,  LB Ellakumanan,  H Balachander,  MVS Obstetric Anaesthetic Department, University Hospital
Satyaprakash   Southampton, Southampton, UK
Anaesthesiology, JIPMER, Puducherry, India Introduction: We present the successful use of continuous
spinal anaesthesia (CSA) for caesarean delivery in a parturient
with severe tricuspid regurgitation and pregnancy-induced
thrombocytopenia in addition to Harrington rod placement for
scoliosis spinal surgery.
Case history: A 40 year old primigravida presented at 37
weeks gestation. She had undergone a tricuspid valve repair
previously for endocarditis. The patient had developed severe
tricuspid regurgitation and had heart failure. Harrington rods
were placed in her thoracic and lumbar spine for repair of a
congenital scoliosis. Blood tests revealed a pregnancy related
thrombocytopenia with platelets of 85x109/L. An
echocardiogram showed a severly dilated right atrium with
intra-atrial septal bowing to the left, severe free flowing
regurgitation and right ventricular systolic pressure
32mmHg.The case was discussed with obstetricians,
anaesthetists and cardiologists and a decision was made for
an elective caesarean section under CSA, if the final platelet
count remained stable. The patient expressed a preference to
remain awake and avoid a general anaesthetic. At surgery a
cannula and radial arterial line were inserted. In the sitting
position a 22G spinal needle was inserted below the level of
the scar tissue at L3/4, and a spinal catheter threaded into the
subarachnoid space. A total of 10mg bupivacaine and 250mcg
diamorphine were required over 20 minutes to establish a block
to T4. The blood pressure dropped from 135/70 to 90/50mmHg
and required only 5mcg of epinephrine to return to baseline
values. Blood loss was 720mls. Syntocinon was given as an
infusion only. A live male infant was delivered.
Discussion: An obstetric anaesthetist has to take many
factors into account when deciding on the best choice of
anaesthetic for a particular case; anaesthetic expertise,
maternal co-morbidities, fetal well-being and maternal
preferences all play a part. Cardiac disease in pregnancy is still
the leading cause of indirect maternal mortality in the UK.1 The
choice of anaesthetic and delivery had to ensure the least
amount of strain on an already compromised heart. The
advantages of CSA are that a block can be established
gradually with small incremental doses of local anaesthetic,
which reduces the likelihood of cardiovascular instability.2
The concerns with a CSA are principally neurological
complications and post-dural puncture headache. CSA is
proving an option to be considered for patients with
significant cardiac disease and previous spinal surgery
provided the anaesthetist has experience with the technique.
In this case it provided a cardiovascularly stable anaesthetic
with excellent analgesia and maximal maternal satisfaction.
References
1. Saving mothers lives.The Eighth Report of the Confidential
Enquires into Maternal Deaths in the UK. March 2011
2. DennyNM, Selender DE. Continuous spinal anaesthesia. Br J
Anaesth 1998;81:590-7
Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin) P17
P133 Does pre-operative anxiety predict post-operative pain P134 Early epidural analgesia may increase caesarean
scores in parturients undergoing caesarean section? section rate in spontaneously  labouring nulliparous 
BM Daly,  N Weidenhammer,  R Junkin,  L Riddell,  J Dolan,  J women: a retrospective study
Kinsella*,  R Marla,  S Young   R Anil Kumar,  Roger Mc Morrow  
Anaesthesia, Princess Royal Maternity, Glasgow, UK, Anaesthesia, National Maternity Hospital , Dublin, Ireland
*Anaesthesia, Pain & Critical Care Medicine, University of Introduction:.Epidural analgesia offers the most effective
Glasgow, Glasgow, UK method of intra-artum pain relief. The effect of epidural
Introduction: Pregnancy, childbirth, and undergoing a surgical analgesia on the progression of labour and the mode is often
procedure are all likely to induce anxiety. The relationship debated in multiple studies. This study aims to show the effect
between anxiety, pain and pregnancy is complex.1Childbirth is of timing of epidural analgesia on the mode of delivery.
a time of high anxiety, and Caesarean section is known to be Method: Data such as women's age, gestational age, cervical
associated with significant pain post-op. Here we ask can dilatation before epidural insertion and duration of labour was
anxiety scoring predict post LSCS pain? collected from a total of 2029 nulliparous women in
Methods: After ethical approval and consent, pre-operative spontaneous labour. Epidural analgesic was defined as early at
data and a single 24hr post-op 10cm VAS were collected from a cervical dilatation of 3cms or less and late at a cervical
108 women, with 9 having missing data. Spielberger2 State and dilatation of 4 or more cm
Trait anxiety forms were completed prior to surgery. We Results: Of the 2029 women, 1423 ( 70.1%) received epidural
present secondary end points powered post hoc for 0.8 analgesia. Out of the 2029 women, 1403 ( 69.2%) had
probability of 2cm VAS difference. A standardised anaesthetic spontenous vaginal delivery, 478 (23.6%) had assisted
(spinal including diamorphine) and analgesic regime was used. delivery and 146 ( 7.2%) had caeserean section.
The cohort was divided into "high"- above the mean and
The data was anaylsed according to the timing of epidural
"low"- below the mean anxiety and compared using Student's
analgesia or no epidural analgesia and modes of delivery.
t-test.
Anaesthetic Delivery method
Results:
intervention Spontaneous Assisted Caesarean
Table 1: State anxiety compared to VAS
No epidural 537 (88.9%) 51 (8.4%) 16(2.6%) 604
Low anxiety High anxiety Early epidural 757 (62.2%) 379 126 (10.0%) 1262
  Significance
(n=45) (n=54) (30.0%)
24 hr VAS mean Late epidural 109 (67.7) 48 (29.8%) 4(2.5%) 161
5.0 (2.2) 5.3 (2.0) P= 0.40
(SD) cm
Epidural Assisted delivery C-Section
Table 2: Trait anxiety compared to VAS analgesia OR 95% CI p-value OR 95% CI p-value
Low anxiety High anxiety Early 5.27 3.86, 7.21 <0.001 5.59 3.28, 9.51 <0.001
  Significance
(n=48) (n=55) epidural
24hr VAS mean (SD) Late 4.64 2.97,7.23 <0.001 1.23 0.40,3.76 0.71
4.8 (1.9) 5.5 (2.2) P= 0.15
cm epidural
Table 3: State +Trait anxiety compared to VAS Conclusion: The results from the study show that the
Low anxiety High anxiety likelihood of having caeserean section in the early epidural
  Significance
(n=48) (n=51) group is significantly higher compared to the late epidural
24hr VAS mean (SD) group, but the incidence of assisted delivery between the early
cm 4.8 (1.9) 5.6 (2.1) P=0.072 and late epidural group were similar. This study also shows
that there is an increased likelihood of having assisted
Discussion: While the higher anxiety groups displayed a delivery and caeserean section delivery with epidural
higher mean VAS in all the analysis, this was not statistically analgesia compared to without from the study group.
significant. The separation between the two groups was better
References
with the State than the Trait anxiety score and best of all when
1..Gonen Ohel. Early versus late initiation of epidural analgesia in
the two scores were combined. Further reasearch could look at
labour: Does it increasethe risk of cesarean section. A randomised
anxiety scoring as part of a bundle of other measures verus trial. American journal of Obstretrics and Gynaecology (2006) 194,
pain. 600-5
2. Wassen et al. Early versus late epidural analgesia and risk of
References
instrumental delivery in nulliparous women: a systemic review.
1..Waldenstrom U: Experience of labor and birth in 1111 women. J British Journal of Obstretrics and Gynaecology (2010) 1471, 655-
Psychosom Res.1999: 47(5):471-82 661
2..www.mindgarden.com
P18 Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin)
P135 Efficacy of midwife led epidural top ups in labour–Are P136 Emergency obstetric and neonatal care in Kenya:
programmable pumps really the way forward? Addressing millennium development goals
E Traer,  G Waters,  GNB Jackson   D B Pachter,  C A Ameh*  
Anaesthetic department, Royal Berkshire NHS Trust, Anaesthesia, Cumberland Infirmary, Carlisle, UK, *Maternal
Reading, UK and Neonatal Health, Liverpool School of Tropical
Introduction: There are an increasing number of automated Medicine, Liverpool, UK
techniques by which labour epidurals can be managed1,2,3,4. Introduction: In 2008, an estimated 358,000 women died from
Comparison reports of programmable epidural pumps regimens complications of pregnancy and childbirth. The overwhelming
have shown lower total volumes of local anaesthetic may be burden of this mortality occurs in the developing world, with
associated with reduced rates of instrumental delivery and almost 60% of deaths occurring in sub saharan Africa.1There
improved maternal satisfaction1,2. Extended intervals between are also some 3.6 million neonatal deaths each year, and once
boluses with larger volume boluses was shown to use less again the developing world is disproportionately represented.2
total local anaesthetic3. These reports have led us to In 2006, the Liverpool School of Tropical Medicine (LSTM)
investigate similar outcomes our unit where we have a midwife developed a training package entitled "Life Saving Skills,
led top up (MLTU) practice. Emergency Obstetric and Neonatal Care" (LSS EOC-NCC) to
Method: First epidural bolus administered by the anaesthetist try and address these huge public health issues. Courses now
of 20ml 0.1% bupivicaine+2µg/ml fentanyl . Data recorded at run in 11 countries worldwide. In October 2013, I was fortunate
each subsequent midwife administered bolus (MLTU): bolus e nough to teach on a course in Nyeri, Kenya.
interval time, motor block (Bromage score of 2-4 taken as motor Methods: A variety of teaching methods were used on the
block), any change to the standard dose 20ml 0.1% course. Didactic lecture based teaching had a limited role, with
bupivicaine+2µg/ml fentanyl and if analgesia was effective or more emphasis placed on small group "break out sessions"
ineffective. and scenario based teaching. Pre and post course simulation
Results: 50 patients audited based testing was undertaken, with results collated and sent
back to Liverpool for analysis and assessment of efficacy of
Midwife led epidural Top Up Data  
teaching.
Mean bolus interval time (min) 105 (sd 26)
Mean rate bupivicaine mg/hr 10.56 (sd 3.6) Results: Participant feedback suggested a high level of
Motor block (Bromage score 2-4) 11/48 (22.9%) satisfaction with the course. The impact of courses in terms of
Mean time to motor block (min) 237 (sd 135) reduction in maternal and neonatal mortality remains the
NVD 14/48 (29.1%) subject of ongoing scrutiny. One study from Somaliland
Instrumental 18/48 (37.5%) demonstrated improved knowledge and skills and evidence of
LSCS 16/48 (33.3%) positive behaviour change post introduction of the course.3

Satisfaction excellent/good 46/48 (95%)
Conclusions: Maternal morbidity and mortality remains a huge
Discussion: In this study we found the mean interval in problem in Kenya. In 2008 it's Maternal Mortality Ratio was
minutes between epidural boluses to be 105minutes. This is 488 per 100,000, one of the highest in the world.4Great efforts
greater than the average 60minute interval of the are being made by the Kenyan government to reduce this. An
programmable intermittent bolus(PIB) regimens. An average ambitious target to reduce MMR to 91 per 100,000 by 2018 has
rate of bupivicaine 10.56mg/hr was similar to that reported with been set. One step has been the introduction of the Liverpool
PIB and patient controlled epidural bolus(PCEA) regimens4, LSS EOC-NCC course.
while we report a lower rate of motor block. Given the practice Acknowledgements: I would like to thank the maternal and
of MLTU in effect is much like a PIB without PCEA, it is neonatal health unit at LSTM for the opportunity to become
notable that the time between epidural boluses is longer with involved, and look forward to teaching on my next course. I
MLTU with less maternal motor block and high maternal would also recommend the course to any obstetric
satisfaction. We feel our practice promotes close epidural anaesthetists with an interest in international health.
assessment as the midwives assess motor block and maternal
References
satisfaction before each “top-up” and avoids the cost of the
1. World Health Organization, UNICEF, UNFPA and The World
PIB/PCEA pumps.
Bank. Trends in Maternal Mortality 1990-2008. 2010.
References 2. Lawn JE, Kerber K, Enweronu-Laryea C, et al. 3.6 million neonatal
deaths–what is progressing and what is not? Seminars in
1. Capogna G Camorica M, Stirparo S, Farcomeni A. Programmed Perinatology 2010;34:371–386.
Intermittent Epidural Bolus Versus Continuous Epidural Infusion for
Labor Analgesia: The Effects on Maternal Motor Function and 3. Ameh C, Adegoke A, Hofman J, et al. The impact of emergency
obstetric care training in Somaliland, Somalia. International Journal
Labor Outcome. A Randomized Double-Blind Study in Nulliparous
of Gynecology & Obstetrics. 2012;117:283-7.
WomenAnesth Analg July Oct 2011; 113(4): 826-831
4. Kenya National Bureau of Statistics. Kenya Demographic and
2. George RB, Allen T, Habib A. Intermittent Epidural Bolus
Health Survey (KDHS) 2008-09. June 2010.
Compared with Continuous Epidural Infusion for Labour Analgesia:
A Systematic Review and Meta Analysis. Anesth Analg Jan 2013;
Vol 116: 133-144
3. Wong C, MacCarthy RJ, Hewlett Bl. The effect of manipulation of
the programmed intermittent bolus time interval and injection
volume on total drug use for labour epidural analgesia: a randomized
controlled trial. Anest Analg 2011; 112: 904-11
4. Husain T, Mavridou I, Fernando R, El-Wahab N, Stewart A, Dick J,
Columb M. A study of a programmed intermittent bolus and patient-
controlled epidural regimen for labour analgesia. Int J Obstet
Anaesth May 2013: P85 Abstracts OAA Bournemouth 2013
Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin) P19
P137 Enhanced recovery after elective caesarean section: P138 Epidural analgesia in obese parturients: can kneeling
Service evaluation and quality improvement be the answer to our prayers.
GJ Lilley,  M Adamson,  A Miskin*,  M Turner   S De Silva,  L Kelliher*,  R Mottaleb*,  E Combeer  
Anaesthetics, Royal Gwent Hospital, Newport, UK, Anaesthetics, Frimley Park Hospital, Frimley, UK,
*Obstetrics and gynaecology, Royal Gwent Hospital, *Anaesthetics, Royal Surrey County Hospital, Guildford, UK
Newport, UK Severe pain is not life-threatening in healthy parturient women,
Introduction: Enhanced recovery (ER), a concept widely it is however shown to have neuropsychological
recognised within many surgical specialties, is now a subject consequences. Postnatal depression may be more common
of interest within obstetrics. The core principles comprise when effective analgesia is not used1 and pain during labour
speeding up recovery and improving patient outcomes, with has been linked with the development of post-traumatic stress
associated benefits for staff and healthcare systems1. The disorder2.There is an increasing number of obese parturients3
most logical starting point for the introduction of ER principles and identification and placement of the epidural can be
are elective caesarean section lists. Delayed surgery may lead difficult in these women.
to prolonged fasting, followed by delayed mobilization, Classically the sitting or the lateral position is used during
delayed removal of catheter and delayed discharge. A pilot siting of labour epidurals. The kneeling position was first
audit in our hospital demonstrated a mean stay after elective described in 19934, where 34/35 women had their labour
caesarean section of 3.6 days, and mean preoperative fasting epidural sited whilst in the kneeling position and 88.5% of the
period of 12.4 hours. Current guidance for ER in obstetrics mothers were happy with this position.
suggests minimal interruption to oral intake, pre-operative
I elected to try the kneeling position in an obese lady with a
energy drinks, catheter removal at 12 hours post-surgery
BMI 50 after adjustments in the sitting position and two
regardless of time of day, and the option of discharge home 24
separate failed attempts to confidently palpate the lumbar
hours after caesarean section where appropriate2.
spine. Once the lady was in the kneeling position, the lumbar
Methods: All elective caesarean sections were included in this spine was not only palpable but also visible and the epidural
service evaluation after introduction of preoperative space was identified with ease. With Departmental approval I
carbohydrate drinks. Data collection included fasting time, in performed my labour epidurals in this manner and found it not
addition to time to mobilization, to catheter removal and to only to be easy to site epidurals but also tolerated well. Some
discharge. After an initial 6 week period of data collection, the women complained of paraesthesia in their feet, but this was
data was presented to anaesthetic and obstetric staff. Posters, rare and eased swiftly. We decided to survey our Deanery to
a discharge proforma and a patient information leaflet were ascertain what positions were being utilised.
produced, and specific guidance was developed regarding
Survey: An e-survey was sent to trainees and Consultants in
preoperative carbohydrate drinks. A further 6 weeks of data
the South West London Deanery into what their ideal first and
collection then took place.
second choice positions used for siting epidurals would be for
Results: A total of 78 consecutive patients were included, all labouring parturients. We then posed the same question for
of whom received a regional anaesthetic technique for elective obese parturients (BMI 40). They were asked if they had
caesarean section. The following table illustrates the timing of heard of the kneeling position and if anyone had tried it. For
pre- and post-operative events before and after our those who had not, we questioned why they had not tried it.
interventions.
Results: We received 53 responses, 96.2% of whom were
Time period / hour 2nd 6 week Initial 6 week
trainees. 64.2% chose to position the parturient sitting as their
mean(SD) period period
first choice and 60.4% chose lateral as their second choice in
Pre-op fasting 4.8 (2.8) 3.8 (2.5)
non-obese parturients. In comparison 84.9% opted for the
Post-op fasting 4.2 (3.5) 3.4 (3.5)
sitting position in obese parturients with 56.9% using the
Total interruption to oral
9.0 (4.5) 7.1 (4.6) lateral as their second choice. The only positions utilised were
intake
sitting and lateral. 94.9% of respondents had not heard of the
Delivery to mobilization 10.2 (4.5) 9.0 (3.3)
kneeling position to site labour epidurals.
Delivery to catheter removal 14.8 (6.6) 13.5 (3.5)
Conclusion: Each position used for the placement of labour
Delivery to discharge 67.3 (40.1) 63.3 (27.6)
epidurals has their own advantages and disadvantages. With
Discussion: The introduction of patient information leaflet
the rising incidence of maternal obesity and its associated
offering guidance regarding post-operative oral intake,
risks to not only the mother but also the unborn child, we need
mobilization, catheter removal and early discharge, along with
to be continuing in our development and advancement in the
staff education and introduction of pre-operative carbohydrate
provision of good care. We suggest that the kneeling position
drinks, has resulted in improvement in the timing of a number
is a safe and viable alternative for siting epidural catheters in
of peri-operative interventions, and a small reduction in
labouring parturients.
duration of hospital admission. However, possibly due to
References
obstetric, midwifery, paediatric and organisational reasons,
discharge is rarely achieved at the potential target of 24 hours 1. Hiltunen P, Raudaskoski T, Ebeling H, Moilanen I Does pain relief
during delivery decrease the risk of postnatal depression? Acta
after elective caesarean section. Obstet Gynecol Scand 2004;83:257-261
References 2. Soet JE, Brack GA, Dilorio C Prevalence and predictors of women's
1. Lucas DN, Gough KL. Enhanced recovery in obstetrics - a new experience of psychological trauma during childbirth. Birth
frontier? Int J Obstet Anaesth 2013; 22: 92-95 2003;30:36-46
2. Enhanced recovery partnership: A better journey for patients and a 3. Centre for Maternal and Child Enquiries (CMACE). Saving
better deal for the NHS. Available at: Mothers'. Lives: reviewing maternal deaths to make motherhood
http://www.improvement.nhs.uk/documents/er_better_journey.pdf safer: 2006–2008. The Eighth Report of the Confidential Enquiries
into Maternal Deaths in the United Kingdom. BJOG 2011;118:1-203
P20 Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin)
P139 Epidural labour analgesia and risk of instrumental P140 Estimation of blood loss during caesarean sections -
delivery discrepancy between visual and laboratory estimation
R Carvalho,  T Ferreira,  M Duque,  D Catré,  I Guedes,  J P A Nowicka,  A Amasakera,  C Ferdinand,  I Suri  
Assunção   Anaesthesia, Warwick Hospital, South Warwickshire NHS
Anaesthesiology, Centro Hospitalar Tondela Viseu EPE, Foundatio, Warwick, UK

Viseu, Portugal
Introduction: Excessive blood loss is a major threat to women
Introduction: Epidural analgesia (EA) is a worldwide effective undergoing casearean sections. Accurate visual estimation of
method used for pain relief during labour. Nevertheless, its use blood loss is difficult due to dispersion of blood lost and the
and evolution to instrumental vaginal (forceps or vacuum blood being mixed with amniotic fluid(1). Therefore the blood
extraction) or operative deliveries remains controversial loss often gets under or overestimated(2). A number of
between experts,1 either anesthesiologists or obstetricians. methods exist to estimate the blood loss, the commonly used
We aimed to analyze the relation between EA and instrumental being: visual estimation by the attending staff, weighing of the
v aginal deliveries in a sample of our obstetric population. blood soaked surgical swabs and calculation based on the pre-
and post-operative haemoglobin concentrations(3). The aim of
Methods: A retrospective study included all pregnant women
this audit was to compare the visually estimated blood loss by
who delivered on our labour Room, between 1-January-2011
both the surgeons (vEBLs) and anaesthetists (vEBLa) against
and 31-December-2012, excluding those who underwent
the calculated estimated blood loss (cEBL).
caesarean section. We reviewed the data of demographical
characteristics, type of gestation and labour, the use of EA Methods: Data was collected on thirty five caesarean sections.
and the newborn APGAR score. Descriptive analysis of Operating surgeona and anaesthetists were asked to visually
variables was used to summarize data and Chi-Square test was estimate the blood loss in each case. The circulating blood
used. Multivariate analysis was done with logistic regression, volume was calculated for each patient based on the body
with calculation of corrected Odds Ratio (OR) and its 95% weight and height. Then, the blood loss during caesarean
confidence interval (95% CI). section was calculated using the circulating blood volume and
the pre- and post-operative haemoglobin concentrations.
Results: 2901 pregnant women were included in this study, Correction was made for the haemodilution by intravenous
with mean age of 29,7 years. 81% underwent EA and 30% fluid administered.
instrumental vaginal delivery. 51% were nulliparous. Applying
Results: Twenty six complete forms were included in the
Chi-Square test to independent variables, we obtained
analysis. None of the patients received blood or blood
significant associations with dystocic delivery for EA, normal
products intraoperatively. Mean volume of intravenous fluid
maternal age (NMA; 20-35 years) and parity (p<0,001).
infused was 1304mL±421. Mean vEBLs, vEBLa and cEBL was
Applying logistic regression to our model, including parity,
590mL±300, 623mL±372 and 821mL±1004 respectively. The
NMA and EA with dystocic deliveries, we obtained corrected
tendency for anaesthetists to give a higher estimate of blood
OR (95%CI) for EA 2,459 (1,884-3,210) and for parity 3,4
loss was not statistically signifficant (p=0,12). There was a
(2,867-4,121), with NMA loosing significance. However, this
clear discrepancy between the visual estimate given by both
result may still be biased by other factors, such as labour
the surgeons and the anaesthetists, ant the cEBL, however, it
stage at the time of the EA beginning, drugs used in epidural
did not reach statistical significance (p=0,11 and p=014
space, use of oxytocin during labour, among others.
respectively). Compared to the cEBL the vEBL was
Additionally we found that, in our population of term
overestimated when the blood loss was low (12 cases) and
pregnancies, NMA and eutocic deliveries, there was no
underestimated when the blood loss was higher than 500mL
significant relation between EA and APGAR score <8 at the
(14 cases). There was a linear relationship between the degree
first minute (p=0,079).
of underestimation and the blood loss, with high levels of
Conclusion: It's generally assent that EA provides the most blood loss being most underestimated.
effective pain relief in labour. However, it's associated to Conclusions: In this audit, the standard procedure for
prolonged labour and risk of instrumental or caesarean estimation of blood (visual estimation by the obstetrician) loss
deliveries.2 Our study has drawn the conclusion that both was found to be unreliable. We demonstrated a tendency of
having EA for labour pain relief and being nulliparous increase anaesthetists and surgeons to overestimate the blood loss, if
the chance of instrumental delivery, respectively in 2,459 and actual blood loss was less than 500mL, and underestimate if
3,43 times, however without significant impact on newborn the blood loss exceeded 500mL. As a result of the audit, it has
APGAR score. Bigger prospective studies correcting for more been made compulsory in our unit to check haemoglobin
risk factors are advised. concentration in recovery whenever the vEBL exceeds
References 1 000mL.
1. BMC Pregnancy and Childbirth 2008, 8:45. References
2. Acta Obstet Gynecol Scand 2002, 8:1033-1039. 1. Khan FA, Khan M, Ali A, Chohan U Estimation of blood loss during
Caesarean section: an audit. J Pak Med Assoc. 2006 Dec;56(12):572-
5.
2. Larsson C, Saltvedt S, Wiklund I, Pahlen S, Andolf E Estimation of
blood loss after cesarean section and vaginal delivery has low
validity with a tendency to exaggeration. Acta Obstet Gynecol
Scand. 2006;85(12):1448-52.
3. Stafford I, Dildy GA, Clark SL, Belfort MA, Visually estimated and
calculated blood loss in vaginal and cesarean delivery. Am J Obstet
Gynecol. 2008 Nov;199(5):519.e1-7
Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin) P21
P141 Ethnic variations in use of labour analgesia P142 Factors associated with the use of spinal anaesthesia
LMD MacDarby,  CMC McCaul   for caesarean section in Nigeria
Delivery Suite, The Rotunda Hospital, Dublin, Ireland C Imarengiaye,  F Asudo*,  A Akinmola†,  B Lawal§  
Introduction; This retrospective cohort study was compiled to Anaesthesiology, University of Benin Teaching Hospital,
establish the wide variety of nationalities presenting to The Benin City, Nigeria, *Anaesthesia, University of Abuja
Rotunda Hospital for delivery during a one month period and Teaching Hospital, Gwagwalada, Nigeria, †Anaesthesia, 
to determine the labour analgesia preferences amongst this National Hospital, Abuja, Nigeria, §Anaesthesia, Lagos 
population. Island Maternity Hospital, Victoria Island, Nigeria

Introduction: There has been a consistent increase in the rate
Methods; Details of all deliveries occurring during the month
of spinal anaesthesia for caesarean section in many hospitals
of October 2013 were collected. Any patients undergoing
worldwide and had been advocated as the preferred technique
elective caesarean section and those with failed inductions
for caesarean delivery.1 Recent evidence suggests increasing
were excluded from the study. A demographic of patients’
use of spinal anaesthesia for caesarean sections in reports
nationality and ethnic background was compiled. Data relating
from a teaching hospital.2 The rise in spinal anaesthesia
to these patients’ use of labour analgesia was recorded i.e.
caesarean section notwithstanding, it is pertinent to determine
epidural uptake, pethidine administration and remifentanil
the factors limiting the wholesome application of spinal
infusion use. We then established the frequency of use of
anaesthesia for caesarean section in Nigeria.
each of these methods of analgesia in each population

Methods: A snap-shot survey was conducted in some
Results; There were 767 deliveries in Oct 2013. 104 elective
selected hospitals in Nigeria. The survey determined the
caesarean sections were carried out and there were 8 patients
sociodemographic characteristics of patients, indication for
who failed induction.
surgery, grade of anaesthesia provider, contraindication to
Therefore a total of 655 patients laboured during this time. spinal anaesthesia and any other factor that may be noticed in
This number was made up by 50 different nationalities. Of the selected hospital. The survey was to be conducted over a
these 414 patients were Irish, the majority being white but 2-week period but was truncated by the nation-wide strike
including small numbers of Asian or Black background. action by doctors after 9 days.
Amongst the Irish patients the rate of epidural uptake was
Results: A total of 99 patients were attended to in 4 of the
43.47% (234) and the rate of pethidine use was 17.87% (74)
selected 6 hospitals within the study period. 36/99 women
Patients of other white background, including many eastern
were nulliparous and maternal factors (82/99) were the leading
european countries made up 134 of the patients. These
indications for caesarean section. Consultant anaesthetists
patients as a group had a 52.98% epidural uptake rate. Black
(23/99), Senior Registrars (35/99), Medical Officers (36/99) and
Africans were found to have a 39.13% (9) uptake rate and
others (5/99) provided anaesthesia for the caesarean sections.
those of Asian background had the highest rate at 54.83%
85/99 patients received spinal anaesthesia and 14/99 had
(17). The use of pethidine was significantly lower than the rate
general anaesthesia for the c-section. Fetal indication for
of epidural in all of these groups. Pethidine was used by
caesarean section had a 3-fold risk of general anaesthesia for
18.19% of Black Africans, 12.9% of Asians and 23.13% in
the surgery (p = 0.037, RR = 3.1, 95%CI 1.2 – 8). 25/99 and
those of other white backgrounds. There were only 3 cases of
74/99 were performed as elective or emergency procedure.
remifentanil use during the month
Nature of caesarean section was not a factor for the use of
Discussion; The highest incidence of epidural uptake during spinal anaesthesia (p =0.51, RR = 2.0, 95%CI = 0.5).
Oct was found to be amongst the Asian population, the lowest Discussion: Over 85% of caesarean sections in Nigeria were
being amongst Black Africans. Pethidine use was less than conducted under spinal anaesthesia. Fetal indications for
25% in all groups. The reasons for these trends is unknown caesarean section provoked a 3-fold increase in general
though previous studies have suggested that cultural and anaesthesia for caesarean section. The use of general
educational factors may play a part. anaesthesia for caesarean delivery was due to fetal indications
A prospective survey of patients post delivery detailing the for surgery, antepartum haemorrhage and failed spinal
reasons for their choices of labour analgesia would be anaesthesia. Improved practical conduct of the spinal
worthwhile. Establishing the factors influencing their technique may enhance great application of spinal anaesthesia
decisions may allow us to provide an unbiased and fully for caesarean section.
comprehensive service to ensure patient satisfaction. References

1..Morgan BM, Magni V, Goroszenuik T. Anaesthesia for emergency
caesarenc section. BrJ Obstet Gynaecol 1990; 97: 420-424
2..Amadasun FE, Idehen HO, Edomwonyi NP. Evolving pattern of
anaesthesia for caesarean section: Experience at the university of
Benin Teaching Hospital West Afr J Med 2013; 32: 196-9
P22 Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin)
P143 Failed intubation for a category 1 caesarean section in P144 Fasting dilemmas: A rare case of a patient with non-
a patient with undiagnosed spina bifida ketotic hyperglycinaemia presenting for caesarean
CR Deane,  E Lewis,  J Spargo   section
Department of Anaesthetics, Singleton Hospital, Swansea, M Behravesh,  S Dawson,  G McClune,  S Atkinson  
UK Anaesthetics, Royal Jubilee Maternity Hospital, Belfast, UK
Introduction: Non-ketotic hyperglycinaemia (NKH) is a rare
Introduction: Spina Bifida Occulta (SBO) is part of a spectrum
autosomal recessive metabolic disease caused by a defect in
of neural tube defects and is common. We present the case of
the glycine cleavage system. This case report describes the
a patient with previously undiagnosed SBO who required a
management of a patient who presented for caesarean section.
category 1 caesarean section (CS). Despite an unremarkable
To our knowledge there are no other published case reports of
airway assessment she had a failed intubation on rapid
this type.
sequence induction (RSI) and subsequently required an awake
fibre optic intubation (AFOI). Case Report: A 32 year old Para 1 presented for elective
caesarean section of twins at 37 weeks gestation. She had a
Case report: A 37 year old para 0 patient presented to labour
history of atypical non-ketotic hyperglycinaemia. Following
ward labouring with a single live foetus at 37 weeks gestation.
advice from clinical chemistry, during her 6 hours preoperative
She was admitted under consultant obstetric care with
fast she received an inceased dose of sodium benzoate and an
asymptomatic hypertension. When considering an epidural
intravenous infusion of 10% dextrose at 3mls/kg/hour which
she was examined and had a vascular naevus, associated with
was continued perioperatively. Caesarean section was
skin tethering, over lumbar vertebrae. She was asymptomatic,
performed under spinal anaesthesia and twin baby boys were
had never been investigated, and had no definitive diagnosis
delivered successfully. Post delivery of the second twin she
of SBO. Airway assessment included a Mallampatti score of 3,
received a bolus of 5 units of syntocinon followed by an
but was otherwise unremarkable. An epidural was declined to
infusion at 10 units per hour. Due to uterine atony and an
the patient, with a remifentanil PCA provided instead. A plan
operative blood loss of 1000mls she also received ergometrine
was agreed for a RSI GA if operative intervention was
carboprost intramuscularly to good effect. Sodium benzoate
required. Several hours later she required a category 1 CS.
was administered orally in recovery and the 10% dextrose
Initial laryngoscopy with a Mackintosh blade yielded a
infusion was continued until the patient was establised on an
Cormack and Lehane grade 3 view. Manipulation of the cricoid
oral regimen prescribed by the dieticians. This involved a
cartilage, long and McCoy blades did not improve the view.
series of high calorie drinks up to every 2 hours for 48 hours.
Two failed attempts were made to intubate using a bougie. The
No dietary protein was allowed for 24 hours post delivery.
patient was ventilated using a face mask and a Guedel airway
Glycine levels were monitored daily and were raised on day 5
with oxygen saturations above 97% throughout. She was
while dietary protien was being gradually reintroduced.
woken up without further incident and an AFOI was
performed. Her child was delivered by LSCS without further Discussion: NKH has an incidence of 1 in 60,000 with 3
incident or obvious deficit. The APGAR scores were 8 and 10 distinct presentations. Classically neonates present with
at one and five minutes. A grade 3 view was confirmed before lethergy, hypotonia and seizures. These symptoms can
the patient was woken. Recovery from anaesthesia was proceed to apnoea requiring ventilation and 30% of patients
uneventful. The patient was appropriately counselled. An do not survive the neonatal period. Severe psychomotor
Airway Alert Letter was issued and follow up appointment retardation is common in those who survive. A second,
made. An MRI was carried out subsequently and showed a atypical and very rare form presents with mild baseline
neural arch defect and dural tethering. Significantly the conus hyperglycinaemia and intermittent encephalopathy
lay as low as L4 with diastematomyelia as far as L2. assosciated with periods of illness. Transient neonatal
hyperglycinaemia has also been described. Biochemically,
Discussion: SBO is common and without prior imaging
NKH is characterized by elevated glycine concentrations in
presents the clinician with a difficult decision. Regional
plasma, CSF, and brain with a CSF glycine to plasma glycine
techniques risk neural or dural injury due to a low lying or
ratio greater than 0.08.1 Standard treatment strategies include
tethered cord.1 Abnormal spread of the analgesic agents may
protein restriction to reduce exogenous glycine,
give rise to either excessive cranial spread or inadequate
supplementation of one-carbon pool donors and
caudal spread. This patient population provides further issues
administration of sodium benzoate. NMDA antagonists have
for the anaesthetist given the high risk of operative delivery or
been shown to raise the developmental quotient, improve
other intervention (due to pelvic structural abnormalities) and
muscle tone and reduce seizures in these patients.2
the association of spina bifida with difficult intubation.2,3
Patients with spina bifida require careful preop assessment Prolonged periods of fasting predispose these patients to
and MRI imaging and careful airway consideration is essential glycine build up and its toxic neurological effects. This has
in order to inform anaesthetic planning. major implications for the anaesthetist in the perioperative
period. This case demonstrates the safe use of regional
References
anaesthesia in conjunction with careful nutritional planning.
1. Reynolds F. Damage to the conus medullaris following spinal
anaesthesia. Anaesthesia 2001; 56: 235-247. References
2. Richmond D, Zaharierski I, Bond A. Management of pregnancy in 1. Chang YT, Lin WD, Chin ZN et al. Nonketotic hyperglycinemia: A
mothers with spina bifida. Eur J Obstet Gynecol Reprod Biol 1987; case report and brief review. Biomedicine 2012; 2(2):80-82
25: 341-5. 2. Van Hove JL, Vande Kerckhove K, Hennermann JB et al. Benzoate
3. May A, Fombon F, Francis S. UK registry of high-risk obstetric treatment and the glycine index in nonketotic hyperglycinaemia.
anaesthesia: report on neurological disease. Int J Obstet Anaesth Journal of Inherited Metabolic Diseases. 2005;28:651–663
2008; 17: 31-6.
Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin) P23
P145 Fetal bradycardia following regional anaesthesia for P146 Further increase in hysterectomy rates - and the
emergency caesarean section and instrumental reason why
delivery: a service evaluation JS Campbell,  M Molloy,  C Thompson,  D Fogarty  
JK Sidana,  K Jadhav-Smith,  J Corfe   Royal-Jubilee Maternity Service, Belfast HSC Trust, Belfast,
Anaesthetics, Norfolk and Norwich University Hospital, UK
Norwich, UK Introduction: RJMS is the tertiary obstetric service for
Introduction: Fetal heart rate abnormalities, such as late Northern Ireland. As part of a service review of use of uterine
decelerations or fetal bradycardia, are known to occur after artery balloon catheters, we retrieved data from several
neuraxial anaesthesia.1 These may be due to maternal sources. We found a large proportion of these patients still
sympathetic blockade or an increase in the uterine tone caused required hysterectomy. Further interrogation of our data
by intrathecal opioids. The objective of this service evaluation showed some unexpected trends.
was to evaluate the incidence and management of fetal Methods: With approval of the Trust's Data Guardian we used
bradycardia following regional anaesthesia for emergency data from several hospital systems, including a local maternity
caesarean section and instrumental deliveries. care database and histology records.
Methods: 15 patients with an episode of fetal bradycardia Results: We found 30 hysterectomies from 37,088 deliveries in
following regional anaesthesia were identified by reviewing 6 years. This is a rate of 0.8 per 1000 - significantly higher than
the daily obstetric handover sheets from January to December our prior rates which was near the NICE-quoted rate of up to 3
2011. The medical notes of these patients were reviewed for per 1000. Of these cases, 23 (76%) were due to morbidly
peripartum obstetric management, cardiotocographic (CTG) adherent placenta.
findings, perioperative anaesthetic management and
Not all these cases of morbidly adherent placenta were
management of fetal bradycardia. Neonatal outcome was
diagnosed antenatally, which perhaps made hysterectomy
assessed by APGAR scores, umbilical cord gases and NICU.
more likely since facilities such as intra-arterial balloon
Results: 10 patients had an assisted delivery and 5 had an catheters could not be available to us in an emergency.
emergency category-2 LSCS. The peripartum CTG findings Unanticipated cases suffered greater blood loss. Despite no
were either suspicious or pathological. Timing of fetal diagnosis, the majority (16/23) were placenta percreta on
bradycardia following regional anaesthesia ranged from 2 to 15 histology. These percreta cases again had greater blood loss,
min. 13 patients received spinal anaesthesia and 2 received and were more likely to require ICU care post-operatively. Yet
epidural top up. Maternal haemodynamics stability was there were no cases of percreta in the 6 years prior, and less
maintained with left uterine displacement, intravenous fluids than half the number of hysterectomies in that period. This
and phenylephrine infusion. One patient had an episode of seems to be a dangerous and dramatic change in recent years.
maternal bradycardia below 50 beats/min which was treated
Conclusion: We found a recent and significant increase in
with anticholinergics. Comparing the baseline maternal heart
peripartum hysterectomy, associated with a large increase in
rate with the lowest perioperative heart rate, 3 patients had a
the number and degree of morbidly adherent placenta. Patients
greater than 40% drop in the heart rate. 5 patients had a blood
with placenta percreta had a greater blood loss, and more
pressure drop of more than 20% below the baseline, which was
commonly required hysterectomy and ICU care.
treated with phenylephrine. The highest level of block to
Reference
temperature was T3. Syntocinon was stopped in all but one
case in the event of fetal bradycardia. Significant delays 1. National Institute for Health and Clinical Excellence. Caesarean
section: NICE Clinical Guideline 132 2012,
occurred in transferring these patients to theatre after the
http://www.nice.org.uk/nicemedia/live/13620/57163/57163.pdf
decision for surgical intervention were taken, maximum 35 min
(median 17 min). 6 cases had poor neonatal outcomes with low
5 minute APGAR and abnormal cord gases.
Discussion: We could not find any direct cause which can be
solely attributed to regional anaesthesia for the occurrence of
fetal bradycardia in these patients. Significant delay in patient
transfer to theatre may have a causal relationship but cannot
be confirmed. Studies in elective patients have shown that
maternal bradycardia causes a drop in maternal cardiac output.
2 Relative maternal bradycardia occurred in several of our
cases and this would have led to drop in cardiac output and
therefore oxygen delivery. This is most likely a side effect of
phenylephrine use. We plan to introduce a care bundle to
implement pre-operative and intra-operative fetal resuscitation.
This will include steps to improve fetal condition at the time of
regional anaesthesia and to ensure adequate maternal cardiac
output and oxygen delivery.
References
1. Reynolds F, Seed PT. Anaesthesia for Caesarean section and
neonatal acid-base status: a meta-analysis. Anaesthesia 2005; 60:
636–653
2. Stewart A, Fernando R et al. The dose-dependent effects of
phenylephrine for elective caesarean delivery under spinal
anaesthesia. Anesthesia & Analgesia 2010; 111: 1230-7.
P24 Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin)
P147 Impact of workload on accidental dural puncture P148 Implantable cardioverter defibrillator in
(ADP) rate pregnancy WITHDRAWN FROM PRESENTATION
W Mon,  YM Liu,  A Stewart,  R Fernando,  M Columb*   S Chaudhari,  S Quasim  
Anaesthetics, University College London Hospital, London, Anaesthetic Department, University Hospital Coventry and
UK, *Intensive Care Unit, University Hospital of South Warwickshire , Coventry, UK
Manchester, Manchester, UK
Introduction: Post dural puncture headache is an important
cause of morbidity. We audit our ADP rates annually against
the national standard.1Between 2005 and 2008, our ADP rate
was stable at approximately 0.5%. However, from 2008 to 2010,
our rate rose to above the 1% national standard.1Therefore, we
audited factors that may have contributed to this increase.
Methods: Information for this audit was obtained from a
computerised database. Data collection included day, month
and time of ADP and the grade of anaesthetist. We also
collected annual data of number of deliveries, epidurals and
combined spinal epidurals (CSEs) for labour, caesarean section
(CS) data, and the proportion of single shot spinals (SSS) to
CSEs performed. Data were analysed using chi-square
multinomial and trend tests with P value <0.05 defined as
significant.
Results: There was a 40% increase in deliveries between 2008-
2010. CSs and regional blocks for analgesia increased by 36%
and 40% respectively. Although the ADP rate increased, we
could not demonstrate a statistically significant trend due to
small numbers. From 2010 to 2012, a non-significant fall in the
ADP rate was seen. There was no significant association
between ADPs and day, month or time. We did see a
significant non-linear trend (P = 0.0012) in the proportions of
SSSs to CSEs performed, with the peak occurring in 2010.
Table 1. Trend of activity and ADP rate from 2008 to 2012
  2008 2009 2010 2011 2012 P value
Maternities (n) 4032 5039 5647 5841 5953 < 0.0001
Epidurals for labour (n) 1306 1600 1839 2029 2132 < 0.0001
CSs (n) 1370 1562 1861 1862 1773 < 0.0001
SSSs for CS (n) 282 274 356 326 347 0.0015
CSEs for CS (n) 797 644 714 833 915 < 0.0001
Proportion of SSS to CSE (%) 26 30 33 28 27 0.0012
ADP rate (%) 0.57 0.98 1.05 1.01 0.82 0.31
Discussion: We observed an increase in ADPs until 2010, with
significant rises in deliveries and anaesthetic procedures
performed. The significant non-linear trend in the proportions
of SSSs to CSEs performed for CSs peaked in 2010. A fall in the
ADP rate between 2010-2012, occurred despite exposing more
women to the risk of ADP, as during this time we performed
significantly more CSEs than SSSs proportionally. We believe
that the rise in the ADP rate resulted from a significant
increase in our workload between 2008 and 2010, without any
increase in anaesthetic staffing. From 2010 onwards, daytime
anaesthetic consultant sessions increased by 50%, and there
was a higher presence on the labour ward out of hours by
senior registrars covering non-obstetric theatres. Both factors
may have contributed to the subsequent fall in the ADP rate.
This audit supports the recent OAA/AAGBI guideline
recommending increased anaesthetic staffing on labour ward.2
References
1. Royal College of Anaesthetists. Epidural analgesia during labour.
Raising the standard: a compendium of audit recipes. 2012;218-219
2. Association of Anaesthetists of Great Britain and Ireland and
Obstetric Anaesthetists' Association. OAA/AAGBI guidelines for
obstetric anaesthetic services. 2013
Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin) P25
P149 Inadvertent hypothermia during elective caesarean P150 Inter professional relationships on labour ward- how
sections well do anaesthetists and midwives get along?
S Botros,  R Labib,  T Ramhew,  M Baban,  Y Poonawala   M Salman,  P Kumar,  G Graham  
Selwyn Crawford Department of Anaesthesia , Birmingham Anaesthetics, St. Thomas' Hospital, London, UK
Women's Hospital, Birmingham, UK Introduction: Anaesthetists and midwives are part of the
Introduction: The National Institute for Health and Care multi-professional team that provides care for parturients.
Excellence (NICE) defines inadvertent perioperative They work together in close collaboration in the unique and
hypothermia as a core body temperature below 36°C.1 It is a often highly charged environment of labour ward. In such
common complication of regional anaesthesia, and is the settings, effective inter professional relationships are key to
leading cause of perioperative shivering. Hypothermia is the delivery of high quality care and consequently better
associated with increased risk of wound infection and patient outcomes. Successful collaborative practice can be
increased blood loss.1 Shivering can be associated with negatively impacted by barriers such as lack of clarity on the
increased oxygen consumption and hypoxaemia in vulnerable scope of roles of team members, poor communication, or
patients. Although the NICE guideline on the management of stereotyping. We conducted a survey amongst obstetric
perioperative hypothermia did not cover pregnant women,1 it anaesthetists and midwives in our hospital to reflect upon this
has been adopted by many obstetric units. In our unit, working relationship and to see how it may be improved.
intravenous (IV) fluid is not routinely warmed for elective
Methods: A questionnaire was designed and distributed to
caesarean sections (CS). Hence, we audited our practice to
midwives and anaesthetists of all grades. Questions were
evaluate the incidence of hypothermia.
asked on their understanding of each other's professional role
Methods: Over a three month period, we prospectively audited
and on their perception of the quality and effectiveness of
our practice in 47 women who had elective CS under
their working relationship. A total of 43 responses were
subarachnoid anaesthesia without active warming. We
collected (24 anaesthetists and 19 midwives) in an ongoing
measured their tympanic temperature prior to anaesthesia (T )
1 survey.
and at the end of surgery (T ). We also collected data that may
2 Results: Of the anaesthetists who completed the
influence the results like the volume of IV fluid infused,
questionnaire, 16.6% were consultants, 58.3% were ST5-ST7,
estimated blood loss (EBL) and duration of surgery. We also
20.8% were ST3-4 and 4.1% were CT1-2. When asked whether
assessed the incidence of perioperative shivering. We
they felt they understood the scope of responsibilities of
repeated the audit in 42 parturients using an IV fluid warming
midwives on labour ward, only 27% of anaesthetists felt they
device. The data were analysed using Microsoft Excel 2007®.
understood it fully. In contrast, 63% of midwives believed they
Data from both audits were compared and p-values were
fully understood the scope of the anaesthetist's
calculated using unpaired t-test by GraphPad software®.
responsibilities.
Results: In the initial audit, 20 patients (42.55%) were
hypothermic at the end of surgery (T < 36°C). Shivering Thirty percent of midwives felt that collaboration with
2
occurred in 14 patients (29.79%). No correlation was found anaesthetists was 'very easy', in contrast to only 5.5% of
between T and the IV fluid volume, EBL, duration of surgery anaesthetists who felt the same about collaboration with their
1-2
or the dose of intrathecal Bupivacaine. In the re-audit, only 3 midwife colleagues. While 16% of anaesthetists found this
(7.14%) patients experienced hypothermia. There was no collaboration 'difficult', none of the midwives did (0%).
statistical difference in T between the two audits (p = 0.781). Seventy two percent of anaesthetists felt their input was
1
usually well-received by their midwife colleagues, compared to
  Initial Audit (n=47) Re-audit (n=42) p-value
only 40% of midwives who thought their input was well-
Fluid (ml) 1116.67(±369.43) 1233.33 (±483.59) 0.2236
received by the anaesthetist. Both professions were asked
EBL (ml) 523.75 (±152.33) 582.5 (±491.67) 0.474
how they perceived the general quality of communication
T1 36.84 (±0.37) 36.81 (±0.37) 0.781
between them. The majority of anaesthetists (47%) perceived it
T2 36.08 (±0.4) 36.3 (±0.29) 0.004
as 'fair', while 15% regarded it as 'poor'. Ninety percent of
T 0.76 (±0.34) 0.52 (±0.41) 0.0032
1-2 midwives felt it was either 'very good' or 'good'. None of the
Discussion: Our audit highlights the effect of warm IV fluid midwives (0%) felt it to be 'poor'.
therapy on reducing the incidence of inadvertent perioperative
Questions were asked on the types of obstacles they
hypothermia during elective CS. Our audit recommends the
encountered in their professional interaction with each other.
routine warming of IV fluid during elective CS. The Enhanced
Most anaesthetists (72%) agreed that they found fixation on
Recovery Partnership Programme considers patient warming
tasks and exclusion of others to be a challenge, followed by
as a key factor in accelerating patient recovery.2 Following our
delayed or non-communication of important issues (57%). A
results and as part of developing a new pathway for enhanced
third of the anaesthetists felt they rarely got a comprehensive
recovery post CS; our trust is currently looking to invest in a
handover from the midwife while only 29% of midwives felt
cost-effective IV fluid warming device.
they understood the rationale behind the anaesthetists'
References decisions.
1. NICE (2008) Perioperative hypothermia (inadvertent): full Conclusion: Despite both specialties working in close
guideline (CG65). Full Guideline. London: National Institute for proximity, the survey identified several gaps in
Health and Care Excellence.
communication. Working towards enhancement of the
2. Enhanced Recovery Partnership (2012) Fulfilling the potential: a
professional relationship between members of the team
better journey for patients and a better deal for the NHS. Leicester:
NHS Improvement. Available at http://www.improvement.nhs.uk providing maternity services will help facilitate their
(accessed 14/12/2013) collaboration and will reflect positively on the performance of
both professions.

P26 Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin)
P151 Intra-arterial balloon catheters: A service evaluation P152 Intrathecal diamorphine for cesarian section following
JS Campbell,  M Molloy,  D Fogarty   intramuscular diamorphine during labour: a cause for
Royal-Jubilee Maternity Service, Belfast HSC Trust, Belfast, concern?
UK RC Barr,  L Parks  
Introduction: Intra-arterial balloon catheters have become Anaesthetics and Intensive Care, Southern Health and Care
widely used and predominantly accepted in cases where Trust, Northern Ireland, UK
massive haemorrhage is anticipated, especially with morbidly Introduction: Diamorphine has largely replaced pethidine for
adherent placenta . However, the benefits are still intramuscular (IM) analgesia during labour in our obstetric
1,2
controversial. While our unit is not stand-alone, our building unit. We also routinely give diamorphine (250-300 micrograms)
is physically separated from other departments including intrathecally (IT) for cesarian sections. A recent case of
radiology, so the logistics of balloon catheters are difficult2. meiosis and drowsiness, in a lady presenting for a category 2
Our objective was to identify the impact of balloon catheters cesarian section having received IM diamorphine in labour,
on management of morbidly adherent placenta. Associated highlighted the potential for side effects when diamorphine is
anaesthetic issues include massive transfusion, cell salvage, used IM and then IT. Should we therefore consider adjusting
type of anaesthetic and post-operative care. our IT dose of diamorphine in women presenting for
Methods: With permission of the Trust's Data Guardian, we emergency cesarian sections? To our knowledge there are no
retrieved data from multiple sources to identify and review guidelines on this subject and clinical practice appears
cases where balloon catheters where used. These included variable.
radiology logs, maternity records and histology. Methods: We conducted a survey of all anaesthetists working
Results: Ten cases were identifed via these systems. Seven in the Southern Health and Social Care Trust who partake in
were for morbidly adherent placenta, of which 5 required obstetric anaesthesia. Questions focused on; current
hysterectomy despite balloon inflation. Many of these were diamorphine practice, diamorphine dose adjustments, factors
cases of placenta percreta, despite antenatal diagnosis of influencing our dose decisions and concerns regarding
accreta. However, blood loss was lower by around 20% potential side-effects with IT diamorphine.
(1078ml) using balloons, when compared to other Results: We received 24 replies; 14 consultants and 10
hysterectomies in the same time period. experienced trainees who regularly perform obstetric
Other indications were for intra-abdominal pregnancy and anaesthesia. There was a wide variation in diamorphine
persistent post-partum haemorrhage. Another case was practice amongst our anaesthetists. The majority (76%)
abandoned due to logistical reasons (unable to organise consider reducing their IT dose following IM diamorphine.
theatre time in same building), a decision felt to be open to Factors influencing this dose reduction include timing (88%)
medicolegal criticism after preparation and planning for and dose (29%) of the last IM diamorphine and clinical signs
balloons. of toxicity (76%). In particular anaesthetists were concerned
about postoperative respiratory depression (94%) and
Limitations particularly reflected the limitations and
drowsiness (88%), although no one surveyed reported
inconsistency of the systems used, for example no coding in
experience of these or other adverse effects associated with IT
records for morbidly adherent placenta. Local presentation
diamorphine.
highlighted these problems, which are being taken forward.
Discussion: There is variability regarding the IT diamorphine
Conclusion: Our review, and subsequent MDT discussion,
dose given to women for emergency cesarian section who
has confirmed the place of intra-arterial balloon catheters
have already received IM diamorphine in labour. This practice
within local guidelines for management of morbidly adherent
is based on limited evidence. Given the lack of adverse effects
placenta, and other occasional indications. We had decreased
reported from our survey and evidence from other specialties
blood loss in cases using balloons, but still saw a large
where diamorphine is used in higher doses 1,2,, we see no
proportion requiring hysterectomy.
reason to routinely reduce the IT diamorphine dose unless
References
there are clinical signs of opiate toxicity. Consideration should
1. Beilin Y, Halpern SH. Placenta accreta: successful outcome is all in be given to prolonged postoperative monitoring of all women
the planning. Int J Obstet Anesth. 2013;22:269–271.
who have received both IM and IT diamorphine, especially
2. Sadashivaiah J, Wilson R, Thein A. Role of prophylactic uterine
artery balloon catheters in the management of women with those in whom the interval between IM and IT diamorphine is
suspected placenta accreta. Int J Obstet Anesth. 2011;20:282-287 short or where there are signs of toxicity.
References
1. Fogarty DJ, Milligan KR. Postoperative analgesia following total
hip replacement ; a comparison of intrathecal morphine and
diamorphine. Journal of the Royal Society of Medicine 1995; 88:
70-72
2. Jacobson L, Kokri MS, Pridie AK. Intrathecal diamorphine: a dose-
response study. Annals of the Royal College of Surgeons of England
1989; 71: 289-292
Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin) P27
P153 Introducing self-administration of medication after P154 Is Remifentanil patient controlled analgesia an
caesarean section: a Robert The Bruce story effective alternative to epidural for labour analgesia?
A R Sajayan,  K Ramm,  T Yates,  Y Chikermane   V Betharia,  K Peckitt  
Anaesthesia, Heartlands Hospital, Birmingham, UK Anaesthesia, Stepping Hill Hospital, Stockport, UK
Introduction: We were involved in the introduction of the local Introduction: Remifentanil patient controlled analgesia (PCA)
protocol for self-administration of postoperative medications was introduced for pain relief in labour at our institution in
(SAM) after elective LSCS at a large obstetric unit. In the past, 2007. Since then its demand has steadily increased, gaining
several attempts to implement this have failed.We conducted a favour with midwives and patients due to simplicity of use,
pilot study to identify the obstacles and develop ways to effective analgesia¹ and good safety profile². We have
overcome the same standardised protocols for administration and monitoring of
Methods:A pilot project was conducted to find out the Remifentanil PCA and patient controlled epidural analgesia
obstacles in the process by obtaining feedback from the staff (PCEA) during labour which are strictly adhered to. Aim of our
and patient involved in the care of 10 patients who underwent audit was to assess both Remifentanil PCA and epidural PCEA
elective LSCS over a week’s time. Obstetric, anaesthetic, for labour analgesia and make recommendations for improved
recovery and ward staff were informed beforehand about this care of mothers and infants.
pilot by emails and personal discussion. The patients were Methods: This was a prospectively done, questionnaire based
given information leaflet during preoperative assessment and audit. Data was collected over 2 months from November 2013 -
were informed again on the day of operation. Interested January 2014. We looked at mode of delivery,
patients enrolled in the pilot with due consent. The self- cardiotocographic abnormalities, APGAR scores, maternal
administration pack contained analgesics and enoxparin and cardio-respiratory complications, conversion to alternative
was dispensed by the recovery staff. Exclusions were: methods of analgesia and patient satisfaction.
language barrier, patient refusal, lack of capacity and any co Results: There were 610 deliveries during the 2 months.
morbidities. Feedback was collected from patients and staff Remifentanil PCA was used in 102 (17%) and epidural PCEA in
using the standardized proforma during the postoperative 85 (12.2%) patients for labour analgesia.
visit. Mode of delivery:
Results:Two of the patients felt that on the first day it was
  Normal Assisted LSCS
difficult to use SAM due to mobility restrictions. One patient
Remifentanil PCA 69 (67%) 20 (19.6%) 13 (12.7%)
did not receive SAM pack due to communication problem
Epidural PCEA 29 (34%) 35 (41%) 21 (24.7%)
involving midwives and staff. The remaining seven patients
were satisfied with SAM. The obstacles we identified in the There was a higher incidence of cardiotocographic
pilot and also from the past experience and the way we tackled abnormality in the epidural group (61%) as opposed to
them are as below: Remifentanil group (34%). APGAR scores in both groups were
more than 8 at 5 minutes. None of the patients in either group
Obstacle Strategy
had respiratory depression or cardiovascular instability. Eight
Personal & email reminder
(7.8%) patients converted from Remifentanil to epidural due to
Promotional posters in clinical areas
inadequate analgesia whereas 4 (4.7%) patients in the epidural
Communication Reminder notices in operating room and recovery
group used alternative analgesia (3 switched to Remifentanil
Meeting with stakeholders (doctors, midwives&
and 1 to entonox). Patient satisfaction was similar in both
pharmacist)
groups at 95%.
Involving all staff in guideline preparation
Discussion: From our experience, Remifentanil PCA is a safe
Staff engagement Process simplified and paper work streamlined
and effective method of labour analgesia. We found no
Standardized SAM package and delivery
evidence of worsening cardiotocography or neonatal
Guideline Fully prepared guideline after extensive consultation
outcomes with its use. We also found that patients using
Time Pre-printed forms to increase efficiency and to avoid
Remifentanil have increased rate of vaginal deliveries as
management time delays and work duplication
compared to those on epidural. While epidural analgesia
Discussion: Self-administrationof medications after caesarean remains the gold standard and will be preferable in certain
provides better patient centered care. It improves patient and groups of patients, Remifentanil PCA is certainly an excellent
staff satisfaction, improves clinical efficiency and eases alternative to consider. In our institution its uptake has
staffworkload at hospital and at community level1. It empowers steadily increased to approximately 50 patients per month with
the mother in their own care, potentially reduces length of patients consistently report ing high levels of satisfaction.
stay, and facilitates seamless flow ofcare. Although staff and References
patients liked the concept alike, the process had failedthree
1. Blair JM, Dobson JT, Hill DA, McCracken GR, Fee JP. Patient
times before because of certain obstacles. This pilot helped us controlled analgesia for labour: a comparison of remifentanil with
to highlight the areas we needed to focus on with our new pethidine. Anaesthesia 2005; 60 (1) : 22-7
strategies and the results have been encouraging. After fully 2. Volikas I, Butwick A, Wilkinson C, Pleming A, Nicholson G.
Maternal and neonatal side-effects of remifentanil patient
implementing the project, the uptake is gradually getting better
controlled analgesia in labour. Br J Anaes 2005; 95(4): 504-9
and we continue to audit the outcome.
References
1. Snell P M, Bowden M I, Viira D J, Chilvers J P. An observational
study of self-medication of analgesic drugs after caesarean section.
Int J Obstet Anesth 2002; 11: S29
2. Change management good practice guideline-NHS Direct
P28 Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin)
P155 Is the existing local hospital guideline, 'Management P156 Klippel-Feil syndrome: management of anticipated
of women who decline blood products', being adhered difficult airway for caesarean delivery 
to? TM Price,  MT Qureshi,  ROK Laird  
J Houston,  R Burns   Department of Anaesthesia, Altnagelvin Area Hospital,
Simpson Centre for Reproductive Health, Royal Infirmary of Derry, UK
Edinburgh, Edinburgh, UK Introduction: Klippel-Feil syndrome (KFS) is a rare genetic
Introduction: An estimated 150000 Jehovah's Witnesses disorder affecting around 1 in 40,000 live births and is
(JWs) live in the UK1. JWs may not accept blood product (BP) characterised by the congenital fusion of any two of the
transfusion1, and have up to 130 times increased risk of cervical vertebrae1. In addition to the abnormalities of the
maternal death from major obstetric haemorrhage2. This cervical spine, patients may have thoracolumbar scoliosis,
retrospective case note review aims to establish how closely spina bifida and congenital heart defects. The classical
the hospital guideline, 'Management of women who decline phenotypic presentation is described as low hairline, short
blood products' (the Guideline), has been followed since its neck and limited neck and head movement. These patients can
May 2012 introduction, and to identify areas for improvement. therefore present a considerable challenge to the anaesthetist.
Methods: JWs managed at the Anaesthetic Antenatal Clinic The safest method of providing anaesthesia for operative
(AAC) since the Guideline's introduction were identified, and delivery of a parturient with KFS is controversial. We would
their medical records accessed. Information surrounding like to share our experience in managing four elective
aspects of patient management addressed by the Guideline caesarean deliveries in two parturients using awake oral fibre
was extracted. The findings were then audited against the optic intubation (AOFOI) and general anaesthesia.
Guideline to establish how closely it had been followed. Case Reports: The first patient had KFS Type II with fusion of
Approval was obtained from the Medical School and the cervical vertebrae and underwent elective caesarean deliveries
Regional Research Ethics Service. aged 35 and 37 years old. The second patient had KFS Type
Results: Of the patients referred (N=26), 92.3% were reviewed III with fused cervical vertebrae in conjunction with fusions in
at the AAC, and had management plans created, at 31.0 weeks' the thoracolumbar spine, and underwent elective caesarean
gestation on average (Guideline target: 28.0 weeks). 88.5% deliveries aged 31 and 39 years old. Our patients were both
completed a BP checklist before admission in labour, and pre-assessed by a consultant anaesthetist at a high-risk
96.2% by time of delivery. 7.7% agreed to accept BPs at clinic pregnancy clinic prior to delivery. This allowed time to discuss
and were discharged, so women studied became N=24. BP the anaesthetic options with each patient and plan for elective
refusal of 12.5% was not appropriately recorded in the notes, or emergency delivery. Both patients had the classical
and contrary to the Guideline, serum ferritin was not checked phenotypic features of KFS. Airway assessments revealed
in any woman. During pregnancy, 29.2% were not recorded as Mallampati class 4, thyromental distances less than 6cm and
having taken iron, and Hb was measured in 95.8%. Excluding severely limited neck flexion and extension. The trachea was
elective caesarean sections (CS), Obstetric consultants were not palpable in either patient. We anticipated difficult direct
documented as informed of admission in 13.6% of cases, and laryngoscopy in both patients and elected to manage the
54.5% of labours and deliveries were reviewed or supervised airway with an AOFOI followed by general anaesthesia. The
by senior Obstetric staff (ST6-consultant). 20.8% of total oral route was chosen as both patients had small nares in
deliveries were by CS: cell salvage was set up in 100.0% of keeping with KFS. Sugammadex ensured complete reversal of
these, and used in 80.0%. rocuronium induced neuromuscular blockade and smooth
Discussion: This study found the Guideline was closely emergence. Caesarean delivery and postoperative recovery
followed in some areas: completion of acceptable BP checklists was uneventful in all four cases.
before delivery, and availability and use of cell salvage in CS,
Discussion: As obstetric anaesthetists we are constantly
compare favourably to previous UK studies1,3. Areas to be
trying to minimise the risk to our mothers. Klippel-Feil
improved include that BP refusal must be appropriately
syndrome affects both the airway and the spine, making the
recorded in patient notes to ensure clarity upon presentation
choice of anaesthetic technique a difficult decision. Successful
in labour or an emergency. It is vital that iron supplementation
use of regional techniques including spinal, epidural and
is commenced early in JWs, and ferritin levels are monitored,
combined spinal-epidural anaesthesia, have all been described
to maximise iron stores. In light of this study's findings,
in the literature1. However, we feel that embarking upon a
hospital blood transfusion Haematologists, in the future, will
regional technique in patients with distorted neuroaxial
review JWs antenatally. The Guideline should quantify how
anatomy would expose patients to unnecessary risk of high
often Hb should be monitored, so anaemia can be detected
spinal block and/or inadequate regional anaesthesia. Should
and treated before delivery. Crucially, consultant staff must be
general anaesthesia be needed intra-operatively, attempting an
documented as informed upon admission of JWs in labour, in
AOFOI in an already distressed parturient would be
order that deliveries can be supervised by senior staff to
challenging. We therefore planned an AOFOI to secure the
reduce potential morbidity and mortality.
airway prior to general anaesthesia, in a controlled manner and
References
thus avoid a potentially difficult and emergent intraoperative
1. Massiah N, Athimulam S, Loo C, Okolo S, Yoong W. Obstetric care intubation. In summary, these are difficult cases that we
of Jehovah's Witnesses: a 14-year observational study. Arch
believe benefit from good antenatal planning and can be
Gynecol Obstet 2007; 276(4):330-343.
managed with a planned AOFOI and general anaesthesia.
2. Van Wolfswinkel ME, Zwart JJ, Schutte JM, Duvekot JJ, Pel M, Van
Roosmalen J. Maternal mortality and serious maternal morbidity in
Jehovah's witnesses in the Netherlands. BJOG 2009; 116(8): 1103- Reference
1108. 1. T. Kavanagh, R. Jee, N. Kilpatrick, J. Douglas. Elective cesarean
3. Nawaz YM, Atkinson S. Peripartum care of Jehovah's witness delivery in a parturient with Klippel–Feil syndrome. Int J Obstet
parturients: A five year review. Int J Obstet Anesth 2013; 22(S1): Anesth 2013; 22(4): 343-8
S22.
Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin) P29
P157 Labour and delivery in long QTsyndrome P158 Local anaesthetic toxicity audit: are workshops the
BJ Vowles,  FMM Bryden   best educational tool across the MDT?   
Anaesthetic department, Princess Royal Maternity, Glasgow, WITHDRAWN FROM PRESENTATION
UK JL Lambert,  D Chitre,  L Evans  
Introduction: A 22 year old primigravida presented to the high Anaesthesia, Southend Hospital, Southend, UK
risk clinic at 22 weeks gestation. She had been diagnosed with
long QT syndrome (LQTS) after her family had been
investigated following a sudden early cardiac death and was
found to be heterozygous for the KCNQ1 gene, responsible
for Long QT1. She was under regular review by the
cardiologists who had advised β blockade with bisoprolol
2.5mg orally (PO) for 9 months post partum due to an increase
in arrhythmia risk during this period. She had also been given
a list from Azcert Inc., advising drugs that should be avoided
and included on this list was syntocinon.
Labour and delivery: She was admitted in labour at term and
the decision was made by the obstetric team, not to administer
syntocinon to augment labour. They also felt that epidural
analgesia was unsuitable because it would slow the progress
of labour. However following an initial dose of intramuscular
(IM) diamorphine, the parturient requested epidural analgesia.
We felt this would be beneficial for minimising her arrhythmia
risk and so she obtained a working epidural with a bilateral T10
block. ECG monitoring was commenced on admission and
.
initially showed bigeminy. A 12 lead ECG demonstrated a QTc
of 460ms. Electrolytes checked at this time were in the normal
range. Over the subsequent 8 hours she failed to progress and
underwent a caesarean section with an effective epidural top
up of 20ml 0.5% L-bupivacaine. At delivery syntocinon was
administered as a slow infusion of 5 units in 100mls 0.9%
saline over 20 minutes, followed by 500µg ergometrine IM to
maintain uterine tone. 50mg IM cyclizine and 10mg
intravenous (IV) metoclopramide were used for anti-emesis.
She was monitored in the Obstetric high dependency unit
(HDU) for the following 48 hours, where an initial ECG
demonstrated frequent ventricular ectopics, with a QTc 432ms.
Electrolytes were again normal at this time.
Discussion: There are many lists of drugs available on the
internet with differing advice as to which drugs to avoid in
long QT syndrome. The one which our patient had been given
clearly stated syntocinon should not be administered, despite
no definitive evidence of harm with this drug in patients with
LQTS. In addition we found no guidance in published case
reports, on oxytocic drugs administered to patients with LQTS
in labour or at delivery1. There are case reports of ventricular
tachycardia after administration of syntocinon in long
QTsyndrome2 and one report of a pateint receiving it with no
sequelae3 Ideally the authors feel that this lady merited a case
conference prior to admission so that informed decisions
could be made. Whilst the outcome of this patient's labour and
delivery may not have been different, a short trial of
syntocinon with ECG monitoring may have altered her mode of
delivery.
References
1. Drake E, Preston R, Douglas J. Brief review: anaesthetics
implications of long QT syndrome in pregnancy. Can J Anaesth.
2007; 54(7): 561-72
2. Liou SC, Chen C, Wong SY, Wong KM. Ventricular tachycardia
after oxytocin injection in patients with prolonged Q-T syndrome -
report of two cases. Acta Anaesthesiol Sin 1998; 36: 49-52
3. Charbit B, Funck-Bretano C, Samain E, Jannier-Guillou V,
Albaladejo P, Marty J. Qt interval prolongation after oxytocin bolus
during surgical induced abortion. Clin Pharmacol Ther 2004; 76:
359-64
P30 Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin)
P159 Lymphangioleiomyomatosis and Pregnancy: A Case P160 Major obstetric bleeds-are we doing the right thing?-
Report A multi-centre study in west midlands
M Cole,  S Petkov,  J Pickett   A R Sajayan,  M McLoughlin,  S Dinesh,  A Walunj*,  J
Anaesthetics, Addenbrookes Hospital, Cambridge, UK Karattuparambil †,  M Ravindran†  
Introduction: Anaesthesia, Heartlands Hospital, Birmingham, UK,
Lymphangioleiomyomatosis (LAM) is a rare condition causing *Anaesthesia, Good Hope Hospital, Sutton Coldfield, UK,
proliferation of smooth muscle in the respiratory system, †Anaesthesia, George Eliot Hospital, Nuneaton, UK 
which can cavitate leading to degradation of lung parenchyma Introduction:Guidelines1 exist on the definitions of massive
and cystic lung disease1. Because of the risk of progression, bleed, the proposed management pathway and the safe time
women with LAM are frequently advised to avoid pregnancy2. frame for obtaining the blood and products. This multi-centre
We present a case of LAM where multidisciplinary audit looks at the average time taken for the blood/products to
management led to a successful outcome of pregnancy, with a be available in major bleed situations in obstetrics
focus on anaesthetic considerations. Aim: To find out the incidence and reasons for delays in
Case Study: issuing the blood/products, if any, from the blood bank and to
A 35 year old woman presented with bilateral spontaneous compare the existing practices and experience with the other
pneumothoraces in the first trimester of her 2nd pregnancy. hospitals in the area
Both required surgical correction and a lung biopsy revealed a Methods: We collected the data from three participating
diagnosis of LAM. Computerised tomography of her thorax hospital in west midlands using a standard proforma which
showed multiple small lung cysts. Past history included an included the number of massive obstetric bleed calls during a
uncomplicated first pregnancy and emergency caesarean six months period in 2013, the estimated blood loss, the time
section for foetal distress, aged 33; and a spontaneous taken for the first unit of blood/ product to be issued and the
pneumothorax aged 34, requiring surgery. The patient was number of products used among other data.
referred to a tertiary centre for multidisciplinary management.
Results: The results suggested that there is ambiguity in the
Care was shared between obstetrics and respiratory medicine
way major haemorrhage was defined in different situations
and she attended the high risk anaesthetic clinic. Elective
which led to unnecessary calls where blood products were not
caesarean delivery at 38 weeks was agreed upon. She had
urgently needed. Also, the time for getting the products varied
three further small pneumothoraces, treated conservatively
widely the longest being 200 minutes. The documentation of
with no marked deterioration in respiratory function. Elective
the details of the bleeding, time of calls and time of
caesarean section was performed at 38/40 gestation.
blood/product administration were incomplete and inaccurate
Respiratory assessment and examination on the morning of
in some cases.In one hospital, major bleed calls were only put
surgery were normal. A two-space combined spinal epidural
out in two out of 17 cases where blood loss was more than
was sited, administering intrathecal hyperbaric bupivacaine
1500ml.
and diamorphine. A respiratory physician was present at
delivery in case of deterioration. Delivery was uneventful, with   Hospital1 Hospital2 Hospital 3
no immediate complications. The patient spent 24 hours in an Number of MOH calls 58 41 2
obstetric close observation unit post-operatively. Her post- Full data available 13 18 2
natal period was uneventful and required no further obstetric, Average time for group specific (min) 59 NA 33
respiratory or anaesthetic intervention. Average time for X match blood (min) 63.45 42.27 0
Longest delay (min) 200 104 33
Discussion: LAM is a rare condition with an estimated UK
prevalence of 1per million3. Hypotheses suggest oestrogen
Discussion: The definitions of massive blood loss are:
accelerates disease progression and pregnancy may result in
Transfusion of a volume equal to the patient’s total blood
new diagnosis or exacerbation4, therefore obstetric
volume in less than 24 hours / 50% loss of blood volume
anaesthetists should have awareness of this disease. There is
within 3 hours / rate of blood loss 150ml/minute. Though the
sparse literature for anaesthetic management of pregnancy
circumstances of individual episodes of major bleed could
with LAM, consisting mainly of case reports. Considerations
vary, there was no consistency in the trigger of activating
suggested include; avoiding excessive Valsalva manoeuvre
major bleed calls. There were also unacceptable delays in
via instrumental or elective caesarean delivery, avoid nitrous
obtaining the first unit of blood in some cases. The first set of
oxide, early epidural analgesia, obtunding intubation response
uncross matched group specific blood should be available in
and lung protective ventilation strategies if general
20minutes and cross matched blood in 40minutes2. The study
anaesthesia. This case report supports that pregnancy in
suggest that there is a need for the reinforcement of major
LAM patients can progress successfully and highlights the
bleeds definition and also a need for a clearer pathway and
importance of a MDT approach, early anaesthetic assessment
consistency in issuing blood and products in major bleed
and a well considered anaesthetic and obstetric plan.
situations. This audit results will be used to formulate a
References uniform policy in the participating hospitals and a re-audit will
1. Rosendal T. A Case of Diffuse Myomatosis and Cyst Formation in be done in six month time
the Lung. Acta Radiaology. 1942; 23: 138-146
2. Cohen MM, Freyer AM, Johnson SR. Pregnancy Experiences References
Among Women With Lymphangioleiomyomatosis. Respiratory
1. D Thomas etal,Blood transfusion and the anaesthetist: management
Medicine. 2009; 103: 766-772
of massive haemorrhage, Anaesthesia 2010 November; 65(11):
3. Johnson SR, Tattersfield AE. Clinical Experience of 1153–1161
Lymphangioleiomyomatosis in the UK. Thorax. 2000; 55:1-5
2. Guidelines on the management of massive blood loss.
4. McLoughlin L, Thomas G, Hasan K. Pregnancy and BJHaematology 2006; 135(5): 634-641
Lymphangioleiomyomatosis: Anaesthetic Management.
International Journal of Obstetric Anaesthesia. 2003; 12: 40-44
Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin) P31
P161 Management of labour and delivery using  minimally  P162 Management of manual removal of placenta and third
invasive FlotracTM system in a parturient with  and fourth degree tear repair: pathway analysis
congenitally corrected transposition, dextrocardia P Jegendirabose,  J Subramanya*,  S Watkinson*,  J Short  
and systemic ventricular dysfunction Anaesthesia, Queen Elizabeth Hospital, Woolwich, London,
R Vedagiri Sai,  S Dhir,  J Racine   UK, *Obstetrics & Gynaecology, Queen Elizabeth Hospital,
Anesthesia, Western University, London Ontario, Canada Woolwich, London, UK
Introduction: More women with congenital heart disease now Introduction: Guidelines suggest that repair of obstetric anal
survive to reproductive age due to advances in modern sphincter injuries (OASIS) and manual removal of retained
medicine. Obstetric management is challenging in these placenta (MROP) should be undertaken as soon as possible to
complex cases. We present the anaesthetic management of minimise the risk of infection, blood loss and maternal
labour and delivery in a woman with congenitally corrected morbidity1,2. Anal incontinence and perineal pain can impact
transposition of great vessels, dextrocardia, systemic significantly on maternal quality of life and mother-child
ventricular dysfunction and junctional tachycardia using bonding.
minimally invasive continuous haemodynamic monitoring and Methods: We conduced a retrospective audit which showed
optimisation. shortcomings in our management of MROP and OASIS and we
Case report: A 28 year old primigravida presented with a undertook an analysis of a full calendar year's cases. All cases
diagnosis of congenitally corrected transposition of great of MROP and OASIS were identified over January 2012 to
vessels and dextrocardia. The atrial septal defect had been December 2012 using both theatre electronic records and
repaired in childhood. Her medications included folate and maternal records. Time from delivery of fetus to MROP or
multivitamins. She had good exercise tolerance, stable vital OASIS repair, blood loss and blood transfusion requirement
signs and was followed up by Cardiology team throughout her were reviewed.
pregancy. ECHO showed 50% ejection fraction (EF) and mildly Due to lack of nationally set standards, we set a local standard
reduced systemic (morphologic right) ventricle. A multi- of no more than one hundred and twenty minutes from
disciplinary meeting between Obstetrics, Cardiology, delivery to repair for OASIS.
Anaesthesia and Intensive care unit (ICU) team was held to
Results: Our institute is a secondary obstetric centre with
decide on optimal obstetric management. Induction of labour
4800 deliveries per annum. During the twelve month period,
was planned.
105 patients sustained OASIS. The mean delay from delivery
At 37 weeks she developed palpitations, increasing shortness to surgery was 136 minutes. The average blood loss was 501
of breath and peripheral oedema. Repeat ECHO showed millilitres and 3% of patients required blood transfusion. Total
moderate ventricular dysfunction with EF 40%, severe of 42 patients required manual removal of placenta with
systemic atrioventricular regurgitation and severely enlarged regional or general anaesthesia. The mean delay from delivery
left atrium. Prior to labour induction, an arterial line was to surgery was 178 minutes. The mean blood loss was 790
inserted and continuous cardiac output monitoring was millilitres and 5% of the patients required blood transfusion.
performed using arterial pressure waveform analysis with the
FloTracTM monitor. Haemodynamic optimization was guided OASIS repairs n=105 Time (minutes)
by stroke volume variation and goal directed fluid therapy. A Delivery to booking 81 (Cl 70-92)
lumbar epidural was then inserted followed by rupture of Booking to surgery 68 (Cl 40-95)
membranes and oxytocin infusion. Fluid balance was closely Delivery to surgery 136 (Cl 122-150)
monitored continuously using FloTracTM. 1st stage of labour MROP n=42 Time (minutes)
was uneventful and 2nd stage was shortened using vacuum Delivery to booking 138 (Cl 115- 160)
assisted delivery of a healthy baby. She had a second degree Booking to surgery 39 (Cl 32-46)
tear which was repaired. Post partum haemorrhage due to Delivery to surgery 178 (Cl 152-204)
uterine atony was treated with 400µg Misoprostol rectally and
Incidentally, 78% of the patients did not have electronic record
intravenous infusion of 20 IU of Oxytocin. Estimated blood
of estimated blood loss on the theatre system.
loss was 800 mL. Cardiac condition was stable apart from
Discussion: In our institution, these cases are booked onto
persistent tachycardia throughout labour. Postpartum, she
the general emergency theatre, and not in the designated
spent 24 hours in ICU with similar monitoring. Her tachycardia
emergency obstetric theatre. We have identified that this has
settled spontaneously. She was discharged home on day 4.
resulted in significant delay in surgery and increased blood
Discussion: Patients with congenitally corrected transposition
transfusion requirement. We are now changing the patient
have a thin-walled right ventricle as the systemic circulatory
pathway to include urgent utilisation of the emergency
pump. The stress of increased cardiac output can cause
obstetric theatre for these procedures. Since the presentation
failure, atrioventricular regurgitation and arrhythmias1. We
of this audit, we have included the estimation of blood loss in
used minimally invasive continuous cardiac output
the surgical sign out process, thus improving communication
monitoring, fluid balance optimisation and good maternal pain
and patient care.
control to prevent decompensation and achieve vaginal
References
delivery with a good feto-maternal outcome.
1. National Institute for Health and Care Excellence. 2007.
Reference Intrapartum care. Care of healthy women and their babies during
childbirth. Clinical guideline 55
1. Dob DP, Naguib MA, Gatzoullis MA. A functional understanding of
moderate to complex congenital heart disease and the impact of 2. Fernando RJ, Sultan AH, Kettle C, Thakar R. Methods of repair for
pregnancy. Part I: the transposition complexes.Int J Obstet Anesth. obstetric anal sphincter injury. Cochrane Database Syst Rev. 2013
2010 Jul;19(3):298-305 Dec 8;12:CD002866.
P32 Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin)
P163 Multidisciplinary involvement of the high risk P164 National Obstetric Anaesthetic Database: a useful tool
parturient to benchmark maternity units in the UK
S De Silva,  P Gregory,  E Combeer   G Keightley,  N Tailor,  R Baraz,  L De Lloyd  
Anaesthetics, Frimley Park Hospital, Frimley, UK Anaesthetics, University Hospital of Wales, Cardiff, UK

Our Hospital offers a high risk Obstetric Anaesthetic Clinic for Introduction: The National Obstetric Anaesthetic Database
review of parturients with anticipated Anaesthetic or Medical (NOAD) was set up in 1998 to establish a framework for
problems where a checklist referral form is used. We audited collecting national obstetric anaesthetic data considered
whether women were appropriately referred or inappropriately relevant to obstetric anaesthetists. Whilst preparing the
not referred. An alert sticker was created to encourage NOAD survey for 2012, we explored the usefulness of this
healthcare providers to alert the oncall Obstetric Anaesthetist data in benchmarking our units' performance at the University
when the high risk parturient presented to labour ward. We Hospital of Wales (UHW) in relation to NOAD published
went onto audit the effectiveness of this alert sticker. figures from the previous year.

Methods: Data was collected according to the NOAD 2012
Methods: We looked at 200 consecutive births during October
survey and therefore, ethical approval was not required. Due
2010 and ascertained how many of these women had referrals
to the large number of deliveries in our unit, data regarding
to the High Risk Clinic. In the referred cases, we asked whether
labour analgesia, mode of delivery, caesarean section rate and
referral criteria were met and also determined if any mothers
type of anaesthesia was based on six months period (Jan to
were inappropriately not referred. In 2012 we retrospectively
June 2012) and then doubled. Exceptions were critical care
inspected all notes of mothers seen in High Risk Clinic with an
admissions and patients with accidental dural puncture (ADP);
estimated delivery date of March to May 2012. We checked
these were collected and reviewed individually for the entire
whether an alert sticker was present in their notes and also the
year. Microsoft Excel was used to analyse the data.
time taken for the Obstetric Anaesthetist to be contacted once
the mother had presented to Labour Ward. Results: The number of total deliveries in our unit for 2012

was 6138, of which 3060 required anaesthetic procedure(s).
Results: In 2010, 178 of 200 notes were reviewed and 14
The table below compares performance and quality indicators
women met referral criteria and 12 of these were referred.
at UHW in 2012 with the NOAD averages from 2011.
Fourteen percent were therefore inappropriately not referred,
however no women were inappropriately referred. Indicator UHW 2012 NOAD 2011

Caesarean section (CS) rate 22% 24.8%
In 2012, 42 notes were inspected where only 8 had the alert
Elective CS rate 46% 39.1%
sticker in place, with only 5 in the correct position. Two
De novo general anaesthesia (GA) for CS 4.5% 4.7%
mothers with the alert had elective caesarean sections. In five
Conversion to GA (CS) 1.8% 3.5%
of the six remaning mothers, the oncall Anaesthetist was
Labour regional analgesia 27% 22.7%
informed of their presence on labour ward. The average time
Epidural re-site rate 7.7% 9%
taken for this was four hours and 45 minutes (range 10 minutes
Accidental dural puncture rate 0.9% 1.2%
to 10 hours and 50 minutes). On review of the Clinic letters, it
was felt that 30 of the 42 parturients should have had an alert In 2012, three cases were transferred to critical care unit as
present in their notes, which is 71% not 19% as shown by our level 2 care (two with sepsis and one adult respiratory distress
audit. syndrome) and six cases as level 3 care (two with sepsis, three

post partum haemorrhage and one case of amniotic fluid
Discussion: In many cases of substandard care assessed by
embolus).
CMACE, there were major failures of communication between
Discussion: Our unit is classified as a large maternity unit
healthcare workers that may have contributed to the woman’s
compared to the national average. The elective CS rate and
death in some cases1. Our audits demonstrated that local
labour regional analgesia rates in our unit are higher than the
guidelines for referral were followed in 99% of cases, therefore
national average, possibly related to the complexity of a
high risk mothers were identified early. However, there still
tertiary centre. Despite this, our total CS rate is well below the
lacks effective communication of concerns within teams and
average with very low conversion to GA. In addition, our
poor involvement of other specialties early.
epidural re-site rate is lower than the national average, as is
Reference our ADP rate. Current facilities include two theatres serving
1. Centre for Maternal and Child Enquiries (CMACE). Saving both emergency and elective streams, and a mixed
Mothers'. Lives: reviewing maternal deaths to make motherhood recovery/high dependancy unit (HDU) for up to 5 patients.
safer: 2006–2008. The Eighth Report of the Confidential Enquiries
Our unit has a low transfer rate as level 2 care in general HDU,
into Maternal Deaths in the United Kingdom. BJOG 2011;118:1-203
due to the ability to care for these patients on our unit. We
find the NOAD data a useful tool to benchmark our
performance and set standards of care. More units should
contribute to the annual NOAD survey and consider using the
data as a way of identifying shortfalls and improving patient
care and services.
Reference
1. National Obstetric Anaesthetic Database report 2011.
http://www.oaa-anaes.ac.uk/content.asp?ContentID=586
Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin) P33
P165 Obstetric admissions to the Intensive Care Unit: a 6 P166 Obstetric outcomes with programmed intermittent
year review at a UK tertiary maternity centre epidural bolus labour analgesia
R Labib,  K Cullis   JTE Cremin,  CH Papageorgiou  
Selwyn Crawford Department of Anaesthesia, Birmingham Department of Anaesthesia, Hillingdon Hospital, Uxbridge,
Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin) P1
P101 A modified WHO surgical safety checklist for P102 A parturient with phocomelia and severe needle
category 1 caesarean sections phobia: the challenges faced
A Lahkar,  A Cooney,  G Massolini   R Sinha,  K Howard,  N Bhandal  
Anaesthetics, Milton Keynes NHS Foundation Trust, Milton Department of Anaesthesia, Nottingham University Hospitals
Keynes, UK NHS Trust, Nottingham, UK
Introduction: In June 2008, WHO introduced a surgical safety Introduction: Parturients with phocomelia are rarely seen and
checklist to be used in every operating theatre to improve present anaesthetic and obstetric challenges. We present a
patients' safety. In 2010 a WHO surgical safety checklist for case of a parturient with phocomelia and severe needle phobia.
maternity was created in response to requests from maternity Case report: A 33 year old woman with phocomelia and severe
services and clinicians. Nevertheless, in some emergency needle phobia presented to the obstetric anaesthetic clinic at
situations like category 1 Caesarean sections, this checklist 20 weeks for pre-assessment.
could still be quite a difficult task to achieve due to Her phocomelia was thought to be idiopathic, she had been
understandable time limit constrains to safely deliver the baby adopted when young and no family/drug history was
and/or save the mother's life. available. Examination revealed four limb phocomelia. There
Whilst there is still no international consensus or any specific were absent upper limb bones on the right and a fused hand
recommendation from WHO concerning these specific attached directly to her body. Her left upper limb was
situations, the Anaesthetic Department in Milton Keynes shortened with a primitive hand and fused fingers. Both lower
hospital has managed to devise a checklist for cat 1 LSCS limbs were extremely shortened with primitive feet with fused
which is 100% compliant both in terms of content with WHO toes. Her head, neck and torso appeared normal. She was able
guidelines and adherence by hospital staff. to mobilize with a wheelchair and significant assistance from
Method: After considerations and inputs from the Consultant her partner. The problems faced in clinic were numerous and
Anaesthetists, a simplified checklist was introduced in our focused on her severe needle phobia, difficult venous access
emergency obstetric theatre in June 2013 by way of an ad hoc and monitoring, positioning, mobilization and
poster hanged on the wall. It spells out the most 10 salient thromboprophylaxis as well as the challenges posed by the
questions to be read by one of the theatre staff before the start preganancy itself. The anaesthetic plan consisted of non-
of a category 1 Caesarean section. These questions translate invasive blood pressure monitoring on her left lower extremity;
the original 32 WHO ones that were spread across 3 sections pulse oximetry via an ear probe or toe and standard
in a simpler, quicker format. electrocardiogram. These were tested prior to labour. Due to
Results: After the introduction of the modified WHO checklist the impossibility of standard intravenous access and extreme
in June 2013, compliance is 100%. needle phobia several discussions were had about obtaining
Discussion: By putting the combined know-how and intravenous access prior to labour. A right subclavian
experience of many Consultant Anaesthetists to the task, we Hickman line was inserted at 39 weeks facilitated by the use of
managed to simplify the original WHO narrative into a sharper entonox. Regional analgesia was refused for labour so the
tool that is quickly and effectively utilised for a better and option of intravenous fentanyl via a midwife controlled
safer quality of care in what has become a "normal routine" analgesia pump was discussed. Should a caesarean section be
during extraordinary times in the emergency theatre. required a neuroaxial anaesthetic was refused and so a general
anaesthetic was planned.
Reference At 40+2 weeks spontaneous rupture of membranes occurred
1. WHO surgical safety checklist: for maternity cases only, and labour established. However, due to failure to progress a
http://www.nrls.npsa.nhs.uk/resources/?entryid45=83972 decision was made to perform a caesarean section.
In theatre the challenges related to positioning and achieving
a satisfactory left lateral tilt. A rapid sequence induction was
conducted following pre-oxygenation to an end-tidal oxygen
concentration of 92%. Anaesthesia was induced with
thiopentone 350mg and suxamethonium 100mg. Soon after
induction she desaturated rapidly to the high 60s. This
resolved after tracheal intubation and ventilation. She was
hypotensive intra-operatively, with an estimated blood loss of
1300mL After fluid and blood resuscitation, recovery was
unremarkable. Postoperative pain was managed with
transversus abdominus plane blocks and morphine
patient/midwife controlled analgesia.
Discussion: There is little literature about managing delivery
in women with phocomelia, but sucessful regional techniques
have been described although this was refused here. Early
discussion of anaethesia and analgesia options, and plans for
vascular access and monitoring are needed, There is a reduced
vascular reservior and skeletal muscle mass.
As a consequence faster inductions, emergences and
responses to titrated drugs are observed.

P2 Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin)
P103 A questionnaire to evaluate and aid future development P104 A retrospective descriptive analysis of anaesthesia for
of the AAGBI's SAFE obstetric anaesthesia course in successful cervical cerclage in pregnancy
Liberia J Modha,  G Burul*,  F Forya*,  CP James*,  AL David*,  J
JCO Fox,  CE Richards*,  T Sheraton*,  A Sonah†   Dick,  L Wee  
†Department of Anaesthetics, Phebe Hospital, Bong County,  Department of Anaesthesia, University College London
Liberia, *Department of Anaesthetics, Royal Gwent Hospital, Hospitals NHS Foundation, London, UK, *Department of
Newport, UK, Department of Anaesthetics, University Obstetrics, University College London Hospitals NHS
Hospital of Wales, Cardiff, UK Foundation, London, UK
Introduction: Dr Kate Grady has developed this three-day Introduction: Cervical cerclage is a common operation which
refresher course in obstetric anaesthesia on behalf of the requires an anaesthetic. There are no studies on the type of
AAGBI. The course is aimed at non-physician anaesthetists in anaesthesia used for this procedure.1
developing countries. It consists of short lectures, interactive Aim: To determine the type of anaesthesia used for vaginal
sessions and workshops that focus on the recognition and cervical cerclage.
management of leading causes of maternal death in resource
Method: Ethical approval waived. Women having any vaginal
poor settings. The course has been taught in Uganda,
cervical cerclage (Macdonald or Shirodkar) during pregnancy
Bangladesh, Liberia and Ghana. It includes the principles of
between January 2005 and December 2012 were identified
the WHO Safe Surgery and training of trainers. Mothers of
using the hospital obstetric anaesthesia database and cross-
Africa, a medical educational charity, has led delivery of 2
referenced with data from the Preterm Birth clinic where women
courses for nurse anaesthetists (NAs) in Liberia - supported
at risk of preterm birth are seen antenatally. Data was obtained
by the AAGBI IRC. Liberia has approximately 60 nurse
by examination of obstetric case notes and the ultrasound
anaesthetists and no medically qualified anaesthetists for a
scan records and analysis conducted using Microsoft Excel.
population of 4.2 million people1. Access to CPD is difficult.
Results: There were 190 cases. Twenty-five patients were
The MMR in Liberia is 770 per 100,000 live births1. In order to
excluded due to incomplete data, hence 165 included in
plan future development of the course in Liberia, which will be
analysis. The mean gestational age was 16.6 weeks (range 9-
led by Liberian trainers, feedback data was collected.
23.6 weeks). The table below shows that both general
Methods: A follow up questionnaire was given to 35 NAs who
anaesthesia (GA) and regional anaesthesia (RA) were used.
had previously attended a SAFE obstetric anaesthesia course
The majority of regional anaesthetics were spinals (95.7%), the
held in Liberia (March 2012 or March 2013). We aimed to
rest combined spinal and epidural (CSE) (3.6%) and epidural
assess; 1) the quality, usefulness and appropriateness of the
top up (0.7%).
material taught during the course, 2) the effect on motivation
to improve local services/care delivery, 3) the effect on the GA RA

confidence levels of NAs in managing obstetric anaesthetic n (%) n (%)
emergencies. Spinal n = 133
Results: A 70% follow up rate was achieved. 97% reported Total n=165 26 (16%) 139 (84%) CSE n = 5
positive changes in their attitude to work and their clinical Epidural n = 1
practice and 94% reported improvements in interactions with Five patients who had a spinal anaesthetic required second
colleagues. Many NAs gave details of cases where the skills procedures (3 GA, 1 spinal, 1 CSE). Of those converted to GA,
and knowledge they learnt on the course helped save lives one patient had a block to T6 (the reason for conversion to GA
and improve clinical outcomes. 11 NAs requested continued was not documented), one patient had a block to T12 and the
education and training. Other suggestions for course third patient had 3 failed spinal attempts. In all cases there
improvement included; additional sessions in preoperative were no major anaesthetic complications and cervical cerclage
assessment and TAP blocks, and the inclusion of midwives in was placed successfully.
the training sessions. The following table illustrates the mean
Discussion: In this series, the majority of vaginal cervical
subjective confidence scores (between 0 and 10) of the NAs in
cerclage surgery was performed safely and effectively under
various clinical scenarios before and after the course.
RA. There are no specific guidelines regarding the type of
  Before After anaesthesia for cervical cerclage.1 Anaesthetic considerations
General anaesthesia LSCS 6.3 9.2 favouring a regional anaesthetic in pregnancy include the risk
Spinal anaesthesia LSCS 7.6 9.8 of aspiration and difficult airway management in patients over
Management of severe eclampsia/preeclampsia 5.7 9.2 20 weeks gestation and those under 20 weeks gestation if at
Management of obstetric haemorrhage 5.9 9.4 high risk for example those with a high BMI. The majority of
women in our data set were less than 20 weeks (88.5%). Other
Discussion: Our results indicate that the SAFE obstetric
considerations include patient and surgeon choice. Women in
anaesthesia course in Liberia has been well received with
this series were given the option of GA or RA. In certain cases
subjective evidence of empowerment and improved methods
for example rescue and abdominal cerclages, the patient may
of working. This is promising in the context of increasing the
need to be in a deep Trendelenberg position to aid reduction
reach of future courses and enabling local faculty to lead
of membrane prolapse to avoid membrane rupture or to aid
training. Further data from logbooks provided as part of the
access to the pelvis.2
course were not obtained and more work is needed to
encourage completion of the logbooks. Objective evidence is References
required to demonstrate impact on patient outcomes. 1. Cervical Cerclage, Green-top Guideline No 60, Royal College of
Reference Obstetricians and Gynaecologists, May 2011.
2. Olatunbosun OA, Dyck F. Cervical cerclage operation for a dilated
1. http://data.worldbank.org/indicator/SH.STA.MMRT/countries/1W-
cervix. Obstet Gynecol. Feb 1981;57(2):166-70.
LR?display=graph
Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin) P3
P105 A retrospective descriptive analysis of dose of P106 A step towards improving theatre productivity for
intrathecal anaesthesia and adjuncts for successful elective caesarean sections
cervical cerclage in pregnancy S Kale,  C Farrow,  N Owen,  K Miltsios  
J Modha,  G Burul*,  F Forya*,  CP James*,  AL David*,  J Department of Anaesthesia, Whittington Hospital, London,
Dick,  L Wee   UK
Department of Anaesthesia , University College London Introduction: NHS Institute for Innovation and Improvement
Hospitals NHS Foundation, London, UK, *Department of developed The Productive Operating Theatre Programme to
Obstetrics, University College London Hospitals NHS improve effective use of theatre time, staff and patient
Foundation, London, UK experience.1 Good administrative system and organisation is
Introduction: Cervical cerclage is a common operation, which essential to ensure theatre efficiency.2On this background,
requires either a general or regional anaesthetic aiming for a with the rational of making existing system more productive,
block height of T10. There are no studies determining the dose safe and reliable, we evaluated current practice in one of our
that should be used to achieve this or describing additional main theatres, designated for elective sections, in a DGH set
drugs used for successful surgery. up.
Aim: To determine the dose of local anaesthesia used for Methods: Evaluation was carried out over a 4-week period, for
intrathecal injection and the block height achieved in women planned caesarean sections. The data was collected
undergoing cervical cerclage. In addition to determine the use concurrently by the anaesthetist for that case and from the
and dose of adjuncts. theatre database. The exact time for all significant events, such
Method: Ethical approval waived. Women having vaginal as when patient was sent for or when theatre was clean and
cervical cerclage during pregnancy between January 2005 and ready for the next patient, was recorded. Reasons for delays,
December 2012 were identified using the hospital obstetric duration of anaesthesia, surgery and problems encountered
anaesthesia database and cross-referenced with data from the were also recorded. Time spent at and between different
Preterm Birth clinic. Data was obtained by examination of crucial stages in theatre was calculated from the data. Results
obstetric case notes and the ultrasound scan records and are presented in the form of time in minutes, median [range]
analysis conducted using Microsoft Excel. and % (absolute numbers of cases).
Results: In all cases, cervical cerclage was achieved Results: We had 25 completed forms. Our analysis showed,
successfully. There were 138 cases of intrathecal anaesthesia median time interval from patient sent for to arrival in theatre
(133 spinals and 5 combined spinal epidurals) in whom 67.4% as 5 min [1-29]. Reasons for delay were due to obstetric team
(93/138) had documented intrathecal anaesthetic dose and busy in meeting, midwife busy preparing the patient and
were included for final analysis. Hyperbaric bupivacaine 0.5% midwife busy completing paperwork for previous patient in
was used (mean dose 10.9mg, median 10.8mg and mode 10mg, recovery. Median time interval between patient's arrival and
range 6.5–15mg). Block height and dose of intrathecal neuraxial block was 18 min [10-70], prolonged in 8% of cases
anaesthetic was documented in 54/93 cases (58%). The block (2/25) due to failed and repeat block. Bladder catheterisation
height ranged from T2 to T12 with similar doses of local after block was delayed by ≥30 min in 8% of cases (2/25) due
anaesthetic given in each group and of similar gestation and to unavailability of midwife. Median anaesthetic time for
body mass index (BMI). satisfactory block was 12 min. Interval between block ready
and knife to skin (KTS) was 6 min [1-12]. Median surgery
Block height T2-4 T5-8 T10 T12 duration was 45 min [31-141]. PPH, high BMI, and previous
Frequency 7 31 13 3 laparotomies resulted in longer operations in 16% of cases
Mean dose mg (4/25). Median turnaround time between the cases was 10 min
11 11 11 8
hyperbaric bupivacaine 0.5% [6-15]. Total time patients spent in theatre was 89 min [74-183].
Mean gestation (weeks) 17.4 17.7 15.6 19.1
Discussion: We noted that unavailability of obstetric team
Mean BMI kg/m2 27.3 26.6 26.1 32
and busy midwives at times has resulted in late starts and
In 3 patients that had block heights of T12 only one was delay in some procedures in theatres. Delay in starting the
converted to GA. Opiates were used in 73/93 (78.5%), the most surgery after a satisfactory block and prolonged turnaround
frequent being fentanyl. time have also affected the overall theatre productivity. We
have put forth some recommendations to working group such
Mean dose Range
Opiate used Number (%) as offering administrative support to midwives, ensuring
(mcg) (mcg)
senior obstetrician and anaesthetist are present for difficult
Fentanyl 69 (95) 20 10-75
cases, making use of anaesthetic room to improve patient
Diamorphine 3 (4) 300 250-350
turnaround time and most importantly encouraging staff
Fentanyl & Diamorphine 1 (1) 20/300 N/A
nurses to take the lead role in increasing theatre efficiency.
Vasopressors were used in 26 cases (23 phenylephrine, 3 This could be a big step towards enhancing theatre output as
ephedrine). Other drugs included 3 cases of intravenous well as increasing patient and staff satisfaction. We aim to
midazolam, 1 case propofol and in 1 case salbutamol (as a introduce these changes soon and re-evaluate the practice in
tocolytic agent). the near future.
Discussion: In our case series there is a wide dose range of References
both hyperbaric bupivacaine 0.5% and opiate given. To 1. The Productive Operating Theatre programme,
achieve a block height of T10 or above a minimum dose of http://www.institute.nhs.uk/quality_and_value/productivity_series/the
11mg (2.2ml) is recommended which may be independent of _productive_operating_theatre.html
other factors. There is a wide variation in block height but 2. Theatre Efficiency,
http://www.aagbi.org/sites/default/files/theatreefficiency03.pdf
even a low block (T12) was found to be adequate.

P4 Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin)
P107 A year in the "maternity" life of an increasingly busy P108 Abstracts on the antenatal anaesthetic clinic
new build district general teaching hospital - coping presented to the Obstetric Anaesthetists' Association,
with training and service provision - 2013 1991-2013
H Wrigley,  PF Yoxall,  Janet Slee   AJ Wickham,  SM Yentis*  
Anaesthetics, St Helens & Knowsley NHS Trust, Liverpool, Anaesthetic department, St Mary’s Hospital, London, UK,
UK *Anaesthetic department, Chelsea & Westminster Hospital,
Introduction: Since moving to a new PFI built hospital in 2010 London, UK
our maternity unit has become more busy. Delivery rates/year Introduction: National reports1 and guidelines2 recommend
have increased from 2900 to 3700 pa (up 27.6% in 3 years) assessment of women with ‘high-risk’ pregnancies and
increasing demands upon anaesthetic services. potentially serious co-morbid disease in an antenatal
Methods: We reviewed all our maternity cases during 2013, anaesthetic clinic (AAC). We reviewed trends and themes in
both epidural and caesarean sections. We also surveyed our abstracts on this topic presented to the OAA.
CT2 trainees to assess their experience in terms of case Methods: Full-text records of abstracts (excluding case reports)
numbers during a newly introduced modular training block. presented at OAA meetings (1991-2013; see www.oaa-
Lastly consultant cover on labour ward was audited for CNST anaes.ac.uk) were searched using the terms ‘antenatal’,
purposes. ‘clinic’, ‘risk’ and ‘refer’. Relevant abstracts were reviewed for
Results themes and conclusions.
Results: Forty abstracts were presented at 14 Annual
n %
Meetings (Fig. 1); 3 were unavailable in full-text (2008) but 1
Total Deliveries 3700
was provided by the author on request. 35 were from single
LSCS 838 22.6
departments and 5 were surveys (4 national). Common topics
Grade I-III LSCS 464 12.5
were obesity (12, 30%), referral reason (7, 18%) and
Grade IV LSCS 374 10.1
appropriateness (4, 10%), and outcomes (5, 13%). Nine (23%)
LSCS - SAB 666 79.5
described single patient cohorts, e.g. cardiac. AAC workload
LSCS - Epidural 123 14.7
has increased from 2.3 to 28.6 patients per month over 22
LSCS - CSE 14 1.7
years, albeit at different centres. Obesity has replaced
LSCS - GA 119 14.2
musculoskeletal disease as the most frequent reason for
RA to GA 34 4.2
referral. Common concluding themes include the need to
Average BMI LSCS (Range) 28.3 (16.7-59.9)  
improve the timeliness and appropriateness of referrals, and
Epidurals 895 24.2
ensuring anaesthetic plans are both prominent and followed.
Epidural Resites 32 3.7
PDPH - Epidural 15 1.7
PDPH - SAB 2 0.3
Epidural Blood Patches 21
Average BMI Epidural (Range) 27.1 (16-62.8)  
CT2 Training One of our requirements is to teach at least 4
CT2s per annum obstetric basic competencies. Our trainees
receive a 4 week long daytime block covered by an anaesthetic
ST3-7 and a consultant. They attend 40 sessions, the majority
siting 15 epidurals and anaesthetise 30 caesarean sections
before embarking on daytime on calls. They attend our in-
Figure 1: number of abstracts on the AAC presented per year
house MODSS (Obstetric Simulation Day) run by one of our
Consultant Obstetricians. Discussion: Abstracts relating to AACs have become more
frequent in the last decade, presumably reflecting their
Consultant Input The number of funded Consultant labour
increasing provision and perceived usefulness (and
ward sessions has risen 7 to 10 sessions (7 elective lists per
recommendation in the 2002-04 CEMACH report3). Increased
week). A “High Risk Obstetric clinic” runs weekly to pre-
demand for this service is exacerbated by inappropriate
assess all potentially difficult patients (250-300 per annum).
referrals and budgetary constraints. Referral processes,
Discussion: Despite a significant increase in workload we
facilities, and documentation and inconsistent use of plans are
have managed to maintain levels of cover (both junior and
areas for development. Future work should focus on quality
consultant) whilst allowing for CT2 training in obstetric basic
improvement and assessment of cost-effectiveness. Nationally
competencies as required at both national and local levels.
agreed referral criteria and a national ‘anaesthetic plan’
This has been achieved by increasing our core of obstetric
document, complemented by referrer education, may enhance
consultant anaesthetists, increasing obstetric PAs and
the process. Multidisciplinary ‘one-stop-shop’ or midwifery
changing to a modular CT2 training programme.
led clinics for common problems, such as obesity, may be
beneficial.
References
1. Centre for Maternal and Child Enquiries. Saving Mothers’ Lives:
reviewing maternal deaths to make motherhood safer: 2006-08.
The Eighth Report on Confidential Enquiries into Maternal Deaths
in the UK. BJOG. 2011; 118(Suppl.1): 1-203.
2. OAA & AAGBI Guidelines for Obstetric Anaesthetic Services.
Revised Edition 2005. London: OAA/ AAGBI
3. CEMACH. Why Mothers Die 2000-2002. Report on Confidential
Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin) P5
P109 Accuracy of a new electronic obstetric anaesthetic P110 Accuracy of landmark approach to central neuraxial
database blocks in obstetric patients
Rohit Rohit,  R Abraham,  GNB Jackson   J Lie,  K Bhatia,  A Venkataraju,  P Kochhar  
Anaesthetic department, Royal Berkshire Hospital, Reading, Anaesthesia, St Mary's Hospital, Manchester, UK
UK Introduction: Correct identification of vertebral level could
Introduction: We have introduced a new electronic database prevent damage to the spinal cord during a central neuraxial
'ROAD' (Reading Obstetric Anaesthetic Database) to record block (CNB). Evidence suggests that ultrasound (US) imaging
obstetric anaesthetic data. Written & designed by one of our of the spine by an experienced operator leads to correct
anaesthetists it is secure, password protected & able to identification of vertebral level in 90% of the patients and
produce reports on patient data & the activity of individual decrease the number of attempts required for a successful
anaesthetists. More than 70% obstetric anaesthetic units use CNB1. National Institute for Health and Care Excellence
electronic data collection system in the UK but there is little suggests US could be a useful tool for epidural catheter
agreement as to the best format.1 We audited the accuracy of insertion2. Our aim was to determine the discrepancy between
data entry, as a marker of ease of use by the anaesthetists, landmark technique and US to identify level of insertion of
before auditing the content of the database. CNB.
Methods: This was a retrospective audit, analysing data for Methods: Two experienced US operators who were blinded to
one month period (June 2013). The data in 'ROAD' was the initial procedure retrospectively performed US imaging of
compared to 1) our handwritten anaesthetic record book spine post-operatively after elective caesarean section in 51
(ARB); 2) Midwifery led labour ward logbook (LWLB); 3) obstetric patients with their consent from January to March
Operating theatre electronic log 'Bluespier'. Data entered on 2013 in St Mary’s Hospital. All the patients had a lumbar CNB
the 'ROAD' was manually checked against all these three done by landmark approach. The documented vertebral level
sources and the results tabulated and analysed. at which CNB was performed was noted. This was then
Results: 253 records were found in the ARB. The ARB missed compared with the actual vertebral level identified by bedside
one case (found in Bluespier), Bluespier missed one case US imaging of spine.
(found in the ARB) and LWLB missed 6 cases (found in the
Results: 29 patients had a spinal, 20 had an epidural and two
ARB & Bluespier). The results show that 'ROAD' was 96%
had combined spinal-epidural anaesthesia. The median body
accurate compared to any of the other systems.
mass index (BMI) was 28.6kg/m2. Landmark technique was
No. of cases missing on only accurate in 39.2% of patients. There was no statistically
Total 'ROAD' accuracy against
  'ROAD 'compared to significant correlation between the experience of operator and
no. other data sources as %
others accuracy. 3% of patients had a CNB at the level of L or above.
2
ARB 10 253 96.047% Documentation of the level performed was excellent. Raised
Bluespier 7 174 95.977% BMI and difficulty in palpation of landmarks resulted in
LWLB 10 247 95.951% statistically significant decrease in the accuracy (p<0.05
'ROAD'   243   Fisher’s Exact Test).
Discussion: Pinder et al considered an accuracy of 89% for Discussions: Our findings co-relate well with other studies
their electronic record adequate enough to adopt computer which have found that the vertebral level identified by
based data collection system.2We used three different landmark approach was at least 1 interspace higher than the
methods of data collection already in regular use, to compare level located by US in 40% of the pregnant population 3. Our
with our electronic database and showed it to have a high audit further confirms that the use of traditional landmark
degree of accuracy. This suggests that the database is easy to technique is highly inaccurate with potential increase risk of
use and consistently completed by our anaesthetists. We wish needle injury to the spinal cord especially in the high-risk
to use our database to produce reports on anaesthetic service patient groups (morbid obesity and musculoskeletal
provision (including the quality & safety of that service) as problems). We propose that all elective obstetric patients,
well as for auditing individual anaesthetist activity patients having a lumbar epidural, and high risk patients
(particularly our novice obstetric anaesthetists to ensure having a lumbar CNB should have US imaging of the of their
appropriate case mix & experience during their obstetric spines to identify the correct vertebral level and other relevant
attachments). Before using any database to audit these anatomy. The main reasons being that US imaging does not
aspects it is important to ensure that the data being audited is involve any radiation, is compact, portable and readily
a true reflection of anaesthetic activity, we believe our new available at the point of care. Better US equipment availability,
database is sufficiently accurate to audit the data within it. The staff awareness with appropriate training and improved
limitation of our audit is that we only audited the data from one documentation would aid in providing safer patient care.
month but we believe that the data entry practice of all months
References
is similar. We conclude that our electronic database is accurate
1. Chin KJ, Perlas A, Chan V, Brown-Shreves D, Koshkin A, Vaishnav
& the data entered can be used to audit our obstetric V: Ultrasound imaging facilitates spinal anesthesia in adults with
anaesthetic service. difficult surface anatomical landmarks. Anaesthesiology 2011; 115
(1): 94-101
References
2. Ultrasound-guided catherisation of epidural space. National Institute
1. Campbell NJ, Youngs P, Anderson I. A national survey of obstetric for Health and Care Excellence January 2008
anaesthetic data collection methods in the UK. Int J Obstet Anesth
2012; 21: S53. 3. Lee AJ, Ranasinghe S, Chehade JM, Arheart K, Saltzman BS,
Penning DH & Bimbach DJ. Ultrasound Assessment of the Vertebral
2. Pinder A, Wrench I, Shepherd D, Freeman R. Assessment of a Level of the Intercristal Line in Pregnancy. Anaesth Analg 2011;
handheld computer to collect obstetric epidural audit data. Int J
113: 559-564
Obstet Anesth 2002; 11: 8.
P6 Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin)
P111 Adherence to antenatal anaesthetic advice in P112 An evaluation of anaesthetic antenatal clinics in the
labouring morbidly obese parturients. obese obstetric population
S Halliday,  LC Robertson ,  HM du Plessis   PR El-Dalil,  DS Cochran,  R Ganapathy*  
Anaesthesia, Princess Royal Maternity Hospital, Glasgow, Department of Anaesthesia, Sandwell and West Birmingham
UK NHS Trust, Birmingham, UK, *Obstetrics and Fetal Medicine,
Introduction: Morbidly obese parturients pose a high Sandwell and West Birmingham NHS Trust, Birmingham, UK
anaesthetic risk1. Antenatal anaesthetic assessment for Introduction: Maternal obesity is increasingly common, with a
women with a body mass index (BMI) ≥40 kg.m-2 at booking is BMI 35 found in 5% of pregnancies. Current CMACE / RCOG
advised2. Early establishment of epidural analgesia is often guidelines advocate the referral of patients with a BMI 40 to
advocated. We sought to determine if this advice is adhered to an anaesthetic antenatal clinic. This study aimed to evaluate
in our centre. the outcomes following the implementation of such a clinic in a
Methods: A retrospective case note review of 49 morbidly busy inner city district general hospital.
obese patients (BMI ≥40) assessed antenatally was Method: High-risk patients were referred to a multidisciplinary
conducted. As a control, data from 23 patients with a BMI <40 antenatal clinic involving Anaesthetics, Obstetrics and
who had a labour epidural was collected. We compared the Haematology; patients with a BMI 40 were referred to the
timing of epidural request from labour ward admission, cervical clinic and included in the evaluation. Data was collected
dilation and syntocinon administration at request and the time retrospectively on the reason for attending, the past medical
from epidural insertion to delivery. Mode of delivery was also and obstetric history as well as any anaesthetic or surgical
noted. intervention provided in the perinatal period.
Results: Mean BMI for the control group was 23.6 (range 17- Results: In 2011, 72 women were referred to the clinic with a
32) and for the morbidly obese group 44.6 (40-60). Eleven BMI 40, although there were often other relevant co -
morbidly obese parturients had an elective caesarean section morbidities. The BMIs ranged from 40 to 80 (mean = 44). 44
(CS). Nineteen of the remaining morbidly obese parturients patients (61%) had a normal vaginal delivery, 3 women (4%)
requested labour epidurals. Two parturients delivered prior to required assisted vaginal delivery, 17 (24%) had an elective
insertion. caesarean section (CS), whilst 8 (11%) had a non-elective CS.
Of these patients, 38 (53%) required no anaesthetic
Time to Syntocinon Insertion to
Cervical dilation intervention.
request administration n delivery
  Centimetres
Minutes (%) Minutes Table: Anaesthetic intervention and failure rates in obese
(range)
(range) (range) parturients compared to previously published failure rates1 in
BMI Yes 12 (52.2) the general obstetric population
375 (110-
<40 169 (0-435) 3.7 (1-7) No 11 (47.8) Spinal Epidural CSE GA
915)
(n=23) Number attempted 19 12 4 1
BMI Yes 13 (68.4) % Failure rate 5 17 0 0
334 (12-702)
≥40  261 (0-555) 3.65 (2-8) No 6 ( 31.6) Published % failure rates1 6 24 18 <1
(n=17)
(n=19)
Discussion: The results demonstrated low regional
Table: Timing of epidural request, cervical dilation and anaesthesia failure rates, with only 1 unsuccessful spinal (5%)
syntocinon use at request, and time from insertion to delivery. and 2 failed epidurals (17%); figures comparable to those
In the control group with a BMI <40 that had a labour epidural found in the general obstetric population (Table). There is little
(n=23), the number of spontaneous vaginal deliveries (SVD), available data for regional anaesthetic failure rates in the obese
trial of forceps (TOF) and lower uterine segment CS (LUSCS) obstetric population precluding a direct comparison, but a
were 13 (56.5%), 5 (21.7%), and 5 (21.7%), respectively. For higher failure rate would be expected. A previous study of 677
those with a BMI ≥40 with an epidural (n=17) there were 6 women with a BMI 30 found an emergency CS rate of 24%, 2
(35.3%) SVD, 3 (17.7%) TOF and 8 (47.1%) LUSCS. The significantly higher than the 11% demonstrated in this cohort
number of SVD in the BMI ≥40 without an epidural group was of BMI 40. This robust multidisciplinary approach in the
18 (85.7%) and there were no TOF and 3 (14.3%) LUSCS. antenatal period allows for adequate planning and early
Discussion: Despite antenatal review, the time to epidural institution of optimised perinatal management. The service
request was longer in the morbidly obese group, indicating a provided was predominantly consultant led, with the on-call
need for ongoing education. The time between epidural Anaesthetist required to attend out of hours for parturients
insertion and delivery was shorter in the morbidly obese group with a BMI 45, and to be informed of patients with a BMI
which had a significantly increased chance of CS, signifying 40; significantly 73% of the on-call consultants are dedicated
the importance of establishing a working epidural early in this Obstetric Anaesthetists. We feel these systems may account
cohort. for our findings, as well as promote early and effective
communication with patients. Whilst the sample was relatively
References small the results are sufficiently encouraging to suggest that a
1. Soens MA, Birnbach DJ, Ranasinghe JS, van Zundert A. Obstetric multidisciplinary approach significantly improves perinatal
anesthesia for the obese and morbidly obese patient: an ounce of outcomes in the obese obstetric population.
prevention is worth more than a pound of treatment. Acta
Anaesthtesiol Scan 2008; 52: 6-19 References
2. OAA/AABGI Guidelines for Obstetric Anaesthetic Services 2013. 1. Kinsella SM. A prospective audit of regional anaesthesia failure in
Association of Anaesthetists' of Great Britain and Ireland and the 5080 caesarean sections. Anaesthesia 2008; 63(8): 822-832.
Obstetric Anaesthetists' Association. London, 2013. 2. Usha Kiran TS, Hemmadi S, Bethel J, Evans J. Outcome of
pregnancy in a woman with an increased body mass index. BJOG
2005; 112(6): 768-772.
Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin) P7
P113 An evaluation of fasting times for elective caesarean P114 An evaluation of intrathecal diamorphine versus
section surgery fentanyl for lower segment Caesarean section in a
J Ghoshdastidar,  KM Sherratt,  M Seneviratne*,  A medium-sized district general hospital
McGlennan   K Ramm,  LT Fenton-May,  S Naresh  
Anaesthetics, Royal Free Hospital, London, UK, Department of Anaesthesia, Good Hope Hospital, Heart of
*Anaesthetics, University College Hospital, London, UK England Trust, Birmingham, UK
Introduction: Enhanced Recovery Programmes have shown Introduction: Intrathecal diamorphine is now recommended by
increasing evidence for the benefits of reducing fasting times the National Institute for Health and Clinical Excellence (NICE)
for those undergoing elective surgery1. Many of these as the opioid of choice for lower segment Caesarean section as
benefits could be applicable to the elective caesarean section it provides improved post-operative pain relief.1 However, it is
patient. We evaluated the fasting times of our elective also associated with a dose-dependent increase in the
caesarean section patients to assess whether we could make incidence of pruritus2 and nausea3 which may be more
improvements to patient care. significant with diamorphine given its longer duration of
Methods: The evaluation included all patients undergoing action. Having arranged appropriate protocols for post-
elective caesarean section surgery at the Royal Free Hospital operative monitoring of women receiving intrathecal
over a 3 month period.. Patients received standard instructions diamorphine, we introduced the therapy in late 2012.
to stop eating at midnight on the day of surgery and to stop Methods: The evaluation took place over a six-week period. A
drinking clear fluids at 6 am. Data was collected by anaesthetic small number of women were still receiving intrathecal fentanyl
staff using a standardised data collection sheet.. Patients were due to clinician choice, and these provided a useful
questioned about the time they last consumed solid food and comparator. Women who were still present in the hospital on a
when they last drank liquid. follow-up round on the first day post-op were asked questions
Results: In total 77 patients underwent elective caesarean about post-operative pain, nausea and pruritus. We also
sections during the period of evaluation. We obtained data assessed total oral morphine and codeine doses and time to
from 71 patients for fasting times for fluids and 72 patients for first dose.
fasting times for solids. Results: Basic data is presented in the chart.

  Fentanyl Diamorphine
Pre-op fasting % of Pre-op fasting % of
Number 15 36
times FLUIDS patients times SOLIDS patients
Time to first morphine (hrs) 5.29 8.9
(hr) (n=71) (hr) (n=72)
Mean morphine dose (mg) 65.4 30
2 - 4 5.6 6 - 12 15.3
No morphine required 1 (6.6%) 11 (30.6%)
4 - 6 15.5 12 - 18 66.7
Mean codeine dose (mg) 123 119
6 - 8 14.1 18 - 24 16.7

8 - 10 8.5 over 24 1.4
Time to mobilisation (hrs) 21.17 15.21
over 10 56.3    
Time to catheter removal (hrs) 20.3 16.6

Discussion: There are no fasting recommendations specific to
Pruritus 8 (53.3%) 24 (66.7%)
elective caesarean sections but the standard surgical
- requiring treatment - 0 (0%) - 8 (22.2%)
guidelines of 6 hours for solids and 2 hours for clear fluids are
Nausea 5 (33%) 13 (36.1%)
usually applied. Periods longer than 12 hours without fluid
- requiring treatment - 3 (20%) - 7 (19.4%)
have correlated with significant dehydration
in patients having elective caesarean sections2. There is also
Discussion: Our results replicate previous work demonstrating
some evidence to suggest that gastric fluid volume is
a reduction in immediate post-operative analgesia
increased with prolonged starvation in the pregnant patient3.
requirements following a switch from fentanyl to diamorphine,
Over fifty per cent of our patients went without fluids for
but an associated increase in side effects requiring
longer than ten hours prior to surgery, and almost eighty-five
intervention. There was also a reduction in times to first
per cent of patients went without food for greater than 12
mobilisation and catheter removal, which is worth closer
hours. Our results show that there is a need to introduce
inspection. It is likely to be multi-factorial: the patients having
methods to reduce fasting times. These could include pre-
superior analgesia and feeling ready to move sooner, but also
operative letters with individualised times to stop eating and
the proforma for the ward indicating the patient had received
drinking. Also patients lower down the surgical list could be
diamorphine. This required the anaesthetist to specify a time
actively encouraged to consume clear fluids, or even
after which she would be ready to mobilise, which might have
carbohydrate drinks as used in many Enhanced Recovery
improved motivation amongst the midwives and mothers to
programmes.
achieve mobilisation.

References
References
1. Aguilar-Nascimento JE, Dock-Nascimento DB. Reducing
preoperative fasting time: A trend based on evidence. World J 1. NICE clinical guideline 132: Caesarean section
Gastrintest Surg. 2010 March 27;2(3): 57-60 2. Wrench IJ, Sanghera S, Pinder A et al, Dose response to intrathecal
2. Mackenzie M, Yentis S, Woolnough M and Johnson M. Fasting diamorphine for elective caesarean section and compliance with a
periods and dehydration before elective caesarean section. national audit standard, Int J Obstet Anesth. 2007;16(1):17-21
Anaesthesia, 2010 Vol 65:99 3. Sibilla C, Albertazzi P, Zatelli R, et al, Perioperative analgesia for
3. Maltby JR, Sutherland AD, Sale JP, Shaffer EA. Preoperative oral caesarean section: Comparison of intrathecal morphine and
fluids: is a five hour fast justified prior to elective surgery?. Anesth fentanyl alone or in combination, Int J Obstet Anesth. 1997; 6(1):
Analg. 1986 Nov;65(11):1112-6 43-48
P8 Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin)
P115 An evaluation of obstetric critical care admissions in a P116 An evaluation of standards of informed consent and
district general hospital documentation for labour epidural analgesia
VL Williams,  M Greene,  D Saul   S Chaudhari,  N Smith,  P Prasad  
Department of Anaesthesia, Leighton Hospital, Crewe, Anaesthetic Department, George Eliot Hospital, Nuneaton,
Cheshire, UK Nuneaton, UK
Introduction: CMACE has provided doctors with excellent
Introduction : It is both medico legally and ethically important
data over the past 50 years about maternal mortality, but
that the patient is made aware of the nature and risks
unfortunately no data about maternal morbidity. In December
associated with a labour epidural. No national standardised
2013, the Intensive Care National Audit & Research Centre
information card for informed consent is available, although
(ICNARC) produced a second report that analysed critical care
the OAA does publish a epidural information card1 with
admissions of women who were pregnant or recently pregnant
specific risks and incidence rates. At our hospital, the
in 2009-2012 inclusive.1 A comparison was made between the
documentation is made on part of the epidural chart as an
hospital ICNARC data and the national ICNARC data.
open entry. Our study looked to ascertain whether appropriate
Methods: Data were collected from the hospitals ICNARC
details of the epidural and informed consent were made. This
database over a four year period from 2009 to 2012. The data
was with a view to find whether a total redesign of the epidural
was analysed from the categories in the table below.
chart (at a level of standard suggested by the OAA website2)
Results: Data from 388 patients were evaluated.
was needed to improve our practice.
  Hospital ICNARC
Methods : We evaluated a total of 100 completed epidural
Total no. of patients admitted, female 16-50 years 388 55,791
charts over a 4-month period in mid-2012 at our obstetric unit.
Currently pregnant 3.6% 2.1%
The epidural notes were retrospectively analysed on our
Recently pregnant 9.3% 10.0%
scanned patient electronic notes. Documentation was
Obstetric reason for admission - currently pregnant 0% 8.7%
analysed for: details of the patient, anaesthetist and patient
Non-obstetric reason for admission - currently
100% 91.3% assessment, explanation of the risks and incidence given,
pregnant
details of the epidural technique and post epidural
Obstetric reason for admission - recently pregnant 50% 69.7%
management. Our main focus was on standards of consent.
Non-obstetric reason for admission - recently
50% 30.3% Results:
pregnant
%of patients Rate of risk
Discussion: The proportions of patients admitted to the Range of risk discussed
Risk discussed informed documented (no.
critical care area were comparable with the ICNARC report. (no. in total)
(n=100) in total)
The leading indication for admission in the currently pregnant
1in100:13,1in200:8
group was for sepsis. This corresponds with the ICNARC Headache 69 25
<1%:3,1in500:1
report and most recent CMACE report in which sepsis was the
Hypotension 45
leading direct cause of maternal death.2
Failure 59 4 1in8:2, 1in4000:2
The leading obstetric cause for currently pregnant admissions
Nerve 1in13k:21,1in10k:8
nationally, was for pre-eclampsia. However, there were no 65 31
damage 1in15k:1, 1 in19k:1
admissions in this category at the hospital. This is most likely
Itching 14    
because pre-eclampsia is diagnosed and treated effectively on
Infection 37  
the labour ward and rarely needs input from critical care.
Motor block 28    
In the recently pregnant group, there were equal proportions
Urinary
of patients admitted for obstetric and non-obstetric reasons, 28    
retention
this is quite different from the ICNARC report. The leading
indication for admission of recently pregnant patients in the The other areas of documentation studied showed an
ICNARC report was for post partum haemorrhage, by a long acceptable standard.
way. When looking at the hospital database, it showed that in Discussion : Several studies have looked at standards of
the period 2010-12, only 3 of 42 patients with a significant post informed consent in UK practice3and which risks and
partum haemorrhage of 2.5 litres or more were admitted to incidences were discussed and the range of risk quoted. Our
critical care. Therefore the question needs to be asked as to study showed rates generally to be slightly lower than that
whether these patients should have been admitted to the quoted in these studies. This is likely due to limited space and
critical care area? The hospital does not have an obstetric open entry nature of our current chart. The OAA has set
HDU, but in hospitals that do have an obstetric HDU facility, guidelines and advice for both epidural charts2 and risks and
these patients would certainly have been admitted there, had incidence1. Following this evaluation, a full redesign of our
closer monitoring and possibly goal directed therapy. All of epidural charts with prompts and guidance of risks and
these patients survived, but could admission to critical care incidence is warranted. In addition, the OAA had
have improved patient outcomes or reduced hospital stay? overwhelming support for a national standardised information
References card that could be implemented3.
1. Female admissions to adult, general critical care units in England,
Wales and Northern Ireland reported as 'currently pregnant'
References
or 'recently pregnant'. http://www.icnarc.org/documents/Obstetric%
20admissions%20to%20critical%20care%202009-2012.pdf 1. OAA epidural information card : http://www.oaa-
anaes.ac.uk/content.asp?ContentID=185
2. The eighth report on confidential enquiries into maternal deaths in
the United Kingdom. BJOG 2011, 118(Suppl 2):1-203 2. OAA epidural charts : http://www.oaa-anaes.ac.uk/content.asp?
ContentID=522
3. Informed consent for epidural analgesia in labour: A survey of UK
practice: Anaesthesia 2009, 64 p161-164
Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin) P9
P117 An unusual cause of post-partum sepsis P118 Anaesthetic management of a parturient with severe
F A Corcoran,  C Brennan,  A J Downs   systemic scleroderma
Anaesthetics, Dudley Group NHS Foundation Trust, Dudley, P Thomas,  A Varvinskiy,  M Human  
UK Anaesthetics, South Devon Healthcare NHS Foundation
Introduction: Leiomyomas are common in women of Trust, Torquay, UK
reproductive age and have been linked to spontaneous Introduction: Scleroderma is a chronic systemic autoimmune
abortion, retention of the placenta and post-partum disease. Successful pregnancy in patients with severe
haemorrhage.1 It is however rare for them to be the primary systemic scleroderma is very rare. We report the anaesthetic
cause of post-partum sepsis. We describe the case of a post management of such a case in a patient with a difficult airway,
partum patient presenting with painful fibroids and sepsis. severe pulmonary dysfunction and oesophageal dysmotility.
Case report: A 37 year old woman (P1), 5 days post partum Case report: A 29 year old woman (G1P0) with severe
presented with a history of fever, abdominal pain and systemic scleroderma presented to the hospital at 36 weeks
distention. She had a past medical history of fibroids but there gestation with dyspnoea and tachypnoea. Prior to pregnancy
had been no problems during pregnancy. She had an her exercise tolerance was poor, managing just 400 metres in a
uneventful labour with a normal vaginal delivery. On initial six minute walk test with resultant oxygen saturations of 72%.
assessment she was apyrexial with normal observations. She Her Forced Expiratory Volume (FEV1), Forced Vital Capacity
had mild tenderness on palpation of her abdomen. She was on (FVC) and Diffusing Capacity for Carbon Dioxide (DLCO) had
regular analgesics and had been commenced on oral each worsened steadily by five percent year on year over the
antibiotics by her GP. An ultrasound scan (USS) was booked last decade. The most recently measured values from 2007
to investigate the abdominal pain. Within 4 hours she had were FEV1 30%, FVC 28% and DLCO 24% of predicted values
deteriorated and developed a pyrexia, tachycardia, tachypnoea although the patient reported that her pulmonary function had
and decreased oxygen saturations. Initial impression was deteriorated significantly during pregnancy. On admission the
sepsis secondary to retained products so blood cultures and patient was breathless at rest with a p02 of 7.63 on room air
swabs were taken and intravenous antibiotics, oxygen and and it was felt that natural labour would not be possible due to
fluid resuscitation commenced. She was transferred to the poor physiological reserve. Severe reflux secondary to
Maternity High Dependency Unit. CRP was elevated but oesophageal dysmotility rendered her unable to recline more
lactate was normal. She improved over 6 hours but than 45 degrees and she could therefore not lie flat for awake
deteriorated again. Antibiotic coverage was amended caesarean section. Airway assessment revealed microstomia of
following microbiology advice but she continued to have a less than one centimetre, mallampati four, bucked teeth, sub
swinging pyrexia. USS detailed a bulky uterus with a large mental skin scleroderma and a narrow hooked nose with small
fibroid at the fundus and no retained products. 36 hours after nostrils. Oral intubation was therefore ruled out. Awake Fibre
admission she developed peritonitis and a CT abdomen which Optic Intubation (AFOI) appeared technically challenging due
suggested findings of a pedunculated fibroid measuring to nasal anatomy. Preoperative, bedside nasendoscopy
17.5cm that might have twisted on its pedicle. She had an revealed that AFOI would be possible should the need to
emergency laparotomy which revealed a degenerative, secure the airway arise mid operation. This avoided the need
necrotic, infected fibroid. She required ionotropic support and to perform an AFOI or awake tracheostomy pre-operatively.
was difficult to ventilate intra-operatively. Post-operatively The patient was positioned at 45 degrees on the operating
she was transferred to intensive care where she was sedated table. Surgeons confirmed that they could operate in this
and ventilated overnight. She was successfully extubated the position. A low dose spinal followed by an epidural which was
following morning and continued with intravenous antibiotics topped up gradually over 30 minutes using small incremental
and analgesia. She made a full recovery. Histology confirmed boluses achieved adequate block without compromising
the fibroid had extensive areas of coagulative necrosis, respiratory function. Surgery was completed without issue and
hyalinisation and inflammation. All microbiological both mother and baby did well post-operatively.
investigations were negative. Discussion: There are only three reports in the literature
Discussion: Sepsis in pregnant and post-partum women describing general anaesthesia for caesarean section in
remains a significant cause of maternal morbidity and patients with scleroderma and two using neuraxial blockade.1-5
mortality.2Sepsis is a clinical diagnosis and microbiological Of those who were intubated, one died and another required
investigations may be negative. Early recognition, timely three months ventilation. We demostrated how careful bedside
diagnosis and active treatment assists an optimum outcome. airway assessment and the use of a slow top up epidural were
Fibroids are common in pregnancy but sepsis secondary to successfully used to manage this challenging case.
infected, necrotic fibroid tissue post-partum is very rare. To References
our knowledge there have been no reported cases of this. It is
1. D'Angelo R, Miller R. Pregnancy complicated by severe
therefore essential to consider this in the differential causes of preeclampsia and thrombocytopenia in a patient with scleroderma.
obstetric sepsis when reviewing pregnant women with a Anesth Analg 1997; 85: 839-41
history of fibroids. 2. Hseu SS, Sung CS, Mao CC, Tsai SK, Lee TK. Anesthetic
management in a parturient with progressive systemic sclerosis
References during cesarean section. Acta Anaesthesiol Sing 1997; 35: 161-7
1. Mason T. Red Degeneration of a leiomyoma masquerading as 3. Younker D, Harrison B. Scleroderma and pregnancy. Br J Anaeth
retained products of conception. Journal of the National Medical 1985; 57: 1136-9
Association. 2002; 94: 124-6 4. Thompson J, Conklin KA. Anesthetic management of a pregnant
2. Lucas DN, Robinson PN, Nel MR. Sepsis in obstetrics and the role patient with scleroderma. Anaesthesiology 1983; 59: 69-71
of the anaesthetist. International Journal of Obstetric Anaesthesia. 5. Bailey AR, Wolmarans M, Rhodes S. Spinal anaesthesia for
2012; 21: 56-67 caesarean section in a patient with systemic sclerosis. Anaesth
1999; 54(4): 355-8
P10 Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin)
P119 Anaesthetic management of arrhythmogenic right P120 Anaesthetic management of obese parturients at a
ventricular cardiomyopathy during labour and tertiary centre - meeting the standard?
caesarean section: a case series L Kelliher,  J Teare,  E Evans  
J Eccles,  A Jain,  K Bhatia   Anaesthesia, St George's Healthcare NHS Trust, London, UK
Department of Anaesthesia, St Mary's Hospital, Manchester, Introduction: Obese women are at increased risk of perinatal
UK morbidity and mortality. In 2010 CMACE and RCOG published
Introduction: Arrhythmogenic right ventricular joint guidelines for the management of the obese parturient
cardiomyopathy (ARVC) is mainly a genetically determined including recommendations that patients with a booking BMI
autosomal dominant disease characterised by cardiomyocytes ≥40 should attend an antenatal anaesthetic clinic (AAC) and a
being replaced by fibrofatty tissue in the right ventricle.1 Specialist Trainee year 6 anaesthetist (ST6) or above should
ARVC has an incidence of 1:5000 and may account for as be informed and available to attend labour and operative
many as 5% of unexpected sudden deaths. The Eighth Report delivery1. Our unit is a tertiary centre with over 5,000
of the Confidential Enquiries into Maternal Deaths in the deliveries/year. A previous audit over 2 years showed that of
United Kingdom (2006-2008) highlighted that ARVC was the 120 women with BMI ≥40 attending our AAC, 76% required a
underlying cause in two of the 53 reported cardiac deaths. We peripartum anaesthetic intervention, with only 34% of these
describe the anaesthetic management of two parturients with performed by an anaesthetist ≥ST62. Awareness of the
ARVC who presented at our tertiary centre. guidelines was raised and anaesthetic plans for these women
Case reports: The maternal demographics, the cardiac signs, now state care should be managed by a senior anaesthetist.
symptoms and interventions along with the anaesthetic We examined our obese population following these changes.
management in the peri-partum period are briefly summarised Methods: A retrospective analysis over 1 year (2011-12) of
in the table below. hospital records for patients with a booking BMI ≥ 40. Records
were examined for referral and attendance at AAC, anaesthetic
Category Case 1 Case 2
intervention (regional/GA), grade of anaesthetist and
Age 27 23
anaesthetic complication (difficult/impossible regional, dural
BMI 25.8 27.2
tap, other).
Parity 0 0
Family history None Sudden death Results: In total there were 74 women with a booking BMI
Cardiac signs and Palpitations with spurts of Paroxysmal VT ≥40. 73% were referred to AAC, only 58% attended. Out of all
symptoms ventricular tachycardia (VT) patients, 69% had a peripartum anaesthetic intervention, 43%
Cardiac Cardiac ablation therapy and ICD insertion of which were performed by an anaesthetist ≥ST6 with a
intervention prior implantable cardioverter complication rate of 16%. Of those attending AAC, 67% had
to pregnancy defibrillator (ICD) insertion an anaesthetic intervention, 41% of which were performed by a
Mode of delivery Elective caesarean section Urgent LSCS for ≥ST6 with a complication rate of 17%. Of those patients not
(LSCS) for breech foetal distress attending AAC, 71% had an anaesthetic intervention and 36%
Anaesthesia and General anaesthesia, with Labour epidural of these were performed by ≥ST6 with a complication rate of
analgesia bilateral transversus analgesia, followed by 14%.
abdominal plane blocks top up for LSCS
Table 1. Incidence of complications by grade of anaesthetist
Maternal length of Three days Four days
stay Group ≥ST6 <ST6 p value (Fisher's Exact)
Neonatal APGAR 8 and 10 9 and 10 All 9.1% 20.7% 0.440
scores AAC 16.7% 17.6% 0.945
Discussion: The main implications of ARVC in parturients No AAC 0% 21.4% 0.273
include fatal arrhythmias, heart failure worsened by Discussion: This audit shows a significant number of obese
physiological changes of pregnancy and sudden adult death parturients were not seen in our AAC. A proportion of these
syndrome.1 Both our patients had VT diagnosed after 24 hour were referred, but did not attend however 27% were not
Holter monitoring, and an ICD was implanted in addition to referred. Despite this, there was no significant difference in the
beta blocker medical therapy to control the symptoms of VT as requirement for anaesthetic intervention or the incidence of
well as to prevent sudden death. The patients were seen in the anaesthesia-related complications between attenders and non-
joint cardiac, obstetric and anaesthesia antenatal clinic and a attenders. The incidence of senior anaesthetic involvement in
peri-partum plan formulated to facilitate safe delivery. Both care has risen from 34% to 41% but there is still room for
had serial echocardiograms, serum electrolytes monitored, improvement. This highlights the resource difficulties faced in
invasive blood pressure monitoring and ICD deactivated providing 24 hour senior anaesthetic cover. The on-call rota at
during their LSCS. Our case series highlights that both general our unit is staffed by junior and senior anaesthetists. The
and regional anaesthesia can be safely provided and we absence of a senior anaesthetist did not lead to a significant
recommend a multidisciplinary approach with close co- rise in anaesthesia-related complications, although there was a
operation between anaesthetists, cardiologists and t rend toward this (Table 1).
obstetricians to provide optimum care of these patients. References
Reference 1. Centre for Maternal and Child Enquiries & Royal College of
Obstetricians and Gynaecologists Joint Guideline. Management of
1. Alexoudis AK, Spyridonidou AG, Vogiatzaki TD, Iatrou CA.
Anaesthetic implications of arrhythmogenic right ventricular women with obesity in pregnancy. London: CMACE & RCOG; 2010
dysplasia/cardiomyopathy. Anaesthesia 2009; 64: 73-8. 2. Fulton L, Evans E, Schroeder F, Wendler R. Antenatal anaesthetic
assessment of morbidly obese women - a useful resource? 2013,
http://epostersonline.s3.amazonaws.com/oaa2013/oaa2013.0690195
.NORMAL.pdf
Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin) P11
P121 Anaesthetic management of the labouring patient with P122 Anesthetic implications  of heart disease in pregnancy
multiple sclerosis S Francés,  S Manrique,  M Goya,  M García,  R Perera,  N
J Li Wan Po,  K Maclennan   Montferrer  
Anaesthesia, St Mary's Hospital, Manchester, UK Anaesthetics, Vall d'Hebron University Hospital, Barcelona,
Introduction: Multiple Sclerosis (MS), an autoimmune Spain
inflammatory disease affecting the central nervous system, is Introduction: Despite advances in its diagnosis and treatment,
estimated to affect 20,000 or more UK women of childbearing heart disease (HD) in pregnancy remains a major cause of non-
age1. Controversy exists regarding the management of obstetric maternal and neonatal mortality and morbidity (it
anaesthesia and analgesia in labouring parturients with MS. complicates around 1-3% of pregnancies in developed
Following analysis of our practice at St Mary's Hospital, a countries). Accurate multidisciplinary assessment and
tertiary referral obstetric unit with over 8500 deliveries per management of individual maternal and fetal risks in pregnant
annum, and recent evidence in the literature; our women with HD provides the best opportunity to substantially
recommendations for the peri-partum management of improve outcomes for mother and baby. (1).
parturients with MS are presented. Methods: We present a prospective cohort study that
Methods: Interrogation of the St Mary's Hospital antenatal analyzed outcomes in women with HD, the majority of whom
clinic database, from 1999 to 2012, identified 21 pregnant had had corrective surgery and delivery between 2007 and
women diagnosed with MS. We reviewed antenatal advice, 2013. Baseline characteristics and adverse events during
intrapartum management and postpartum complications. delivery and postpartum were assessed. Intensive monitoring
Results: Over 50% of patients were nulliparous. The majority of the delivery and postpartum were planned beforehand in all
had mild sensory or motor deficit. Three relapsed during cases.
pregnancy, one improved in symptoms and one relapsed Results: One hundred and seventy-four patients with 179
postpartum. There were twelve normal vaginal deliveries, two pregnancies were included in the study. 127 women (72,98%)
instrumental deliveries, six Caesarean sections and one presented congenital heart disease (CHD), 47 acquired heart
unspecified delivered at another hospital. Five women opted disease (27,02%): 27 acquired rheumatic valve disease
for epidural analgesia, two were topped up for operative (19,98%), one Marfan syndrome (0,54%), 3 coronary heart
delivery. Five had spinal anaesthesia with 0.5% heavy disease (1,6%) and 9 primary myocardial disease (4,9%).
bupivacaine and one had a general anaesthetic. There were no
Pregnancy complications were presented in 21, 2% of CHD,
complications following regional technique.
14,8% of acquired rheumatic valve disease and 100% of
Discussion: A recent national survey reported that within a 10 women with arrhythmias.
year period, 91% of anaesthetists have encountered <ten
The type of delivery was vaginal in 124 women ( 72,1%) and
cases of MS2 and have little experience in their management
cesarean section in 50 women (27,9%).
during pregnancy. Recent evidence available supports our
168 women had analgesia during delivery (93,8%); 5 women,
current management of MS patients undergoing labour. The
general anesthesia (2,79%), 6 women, local anesthesia (3,35%)
low incidence of the disease makes it difficult to attain
and 87,5% of women had regional analgesia.
significant figures to determine the optimal management plan.
To standardize care, we made the following recommendations Delivery complications were 7% (uterine atony 2,7%, vaginal
based on the latest evidence and our own experience: hematoma 2,2%, chorioamnionitis 0,5%, cesarean hematoma
- Patients to be reviewed in an antenatal anaesthetic clinic. 0,5% and hemoperitoneum 0,5%). The only anesthesia
Document disease severity and discuss analgesia and complication was one dural puncture (0.5%). No maternal
anaesthetic options. death, one fetal death (0.5%) and one neonatal death (0.5%).
The maternal average hospital stay was 3 days.
- Use of 0.1% bupivacaine with 2mcg/ml fentanyl mixture for
epidural labour analgesia2 . For an operative intervention, top Discussion: Pregnancy and delivery are associated with
up with a higher concentration of local anaesthetic. substantial physiological changes, which require the
adaptation of the cardiovascular system and can expose
- Regional rather than general anaesthetic for caesarean
women with HD to significant risks. If regional anesthesia is
sections. Spinal anaesthesia is the most simple and reliable
selected, the addition of an opioid, when dosing any neuraxial
technique although consider combined spinal-epidural on an
anesthetic, will reduce the amount of local anesthetic required
individual basis.
and subsequent hemodynamic effects, while improve
- If a general anaesthetic is necessary, avoid suxamethonium
intraoperative and postoperative analgesia. The avoidance of
and monitor neuromuscular block to titrate dose of non-
epinephrine from the epidural dose will eliminate the possible
depolarizing muscle relaxant3.
deleterious effects of systemic epinephrine. Maintaining
These recommendations will be available for clinicians on the uterine blood flow is important for fetal well-being.
trust intranet and a patient information leaflet on the effects of Maintaining systemic vascular resistance in patients with
pregnancy and anaesthesia on MS has been produced. intravascular shunting, is important to avoid inducing or
exacerbating pre-existing cyanosis due to increased right- to –
References
left shunting. Cautious intravenous hydration and gentle
1. Brookings W, Lee M. Management of multiple sclerosis during
titration of phenylephrine or ephedrine are options to
pregnancy. Prog Neurol Psychiatry. 2009; 3(6): 9-11
counteract the hemodynamic effects of surgical neuraxial block
2. Drake E, Drake M, Bird J, Russell R. Obstetric regional blocks for
women with multiple sclerosis: a survey of UK experience. Int J (1,2). We observed a predominance of neuraxial anaesthetic
Obstet Anaesth. 2006; 15(2): 115-23 techniques, increased caesarean and operative delivery rates,
3. Griffiths S, Durbridge JA. Anaesthetic implications of neurological and favourable maternal and neonatal outcomes.
disease in pregnancy. Contin Educ Anaesth Crit Care Pain. 2011; 11
(5): 157-61 References
P12 Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin)
P123 Angle of tilt achieved with automated operating table P124 Antenatal anaesthetic information given to women
in elective caesarean sections: a comparison with tilt with obesity
achieved with an inflatable balloon wedge  C R Thomas,  C Busby  
PN Nair,  L Dyal,  B Grewal,  I Suri   Anaesthetics, Airedale General Hospital, Keighley, UK
Department of Anaesthesia, Warwick Hospital, Warwick, UK Introduction:Antenatal obesity is defined as a BMI of ≥30at
Introduction: A previous study1 done on patients undergoing booking. Its prevalence in England increased from 7% in 1990
elective caesarean sections looked into measuring the angle of to 16% in 2007.1Women with a BMI ≥40 are often provided
tilt of the operating table with an inflatable balloon wedge. with anaesthetic information antenatally. Those with lower
This showed that the visual estimation of angle proved levels of obesity also have an increased anaesthetic risk but
accurate in the achievement of near 150 tilt. Here we present these women may receive little or no information about this
the results of a similar study using a different technique of during pregnancy. 2The RCoA have produced standards
automated table tilt instead of the inflatable balloon wedge regarding care for these women: 90% of patients with a
device. The premise being is our visual actuation of tilt angle booking BMI ≥ 30 should receive a leaflet containing
accurate. information about anaesthesia and analgesia. 90% of patients
Methods: The study was similar to the previous one. We with a booking BMI ≥40 should have an anaesthetic consult.
prospectively selected 26 patients at random who were Booking BMI should be documented in 100% of maternity
undergoing elective lower segment caesarean section under hand-held notes. An audit of the above standards was carried
spinal anaesthesia over a six week period. Ethical committee out as summarised below.
approval was obtained. Verbal consent was obtained from all Methods:A list of all deliveries in January 2013 was generated.
participants and the booking Body Mass Index (BMI) was Notes were reviewed for adherance to the above three
noted. We used the same protractor device for measuring the standards. Change to practice was recommended based on
angle of tilt. This is similar to the one used by Kinsella et al2. audit findings. Following the implementation of change, the
Results: The measured angles ranged from 10 to 18 degrees, a audit cycle was completed by auditing notes of all deliveries in
mean angle of 13.70 with a mean difference of -1.3 and standard November 2013.
deviation of 2.32. This compared very closely to the angles Results:
between 10 to 17.5 degrees, mean angle of 13.650, mean Table: Recording of booking BMI, patient count by raised
difference of -1.35 and a standard deviation of 2.06 in the BMI category and number given anaesthetic information.
previous study. BMIs ranged from 19 to 37 with a mean of 24.
Discussion: The visual estimation of angle using the
BMI 30 - BMI 35 - BMI
automated table tilt proved accurate in achieving the near 150 No
Number of Unavailable 34.9; 39.9; ≥40; 
tilt and is comparable with that obtained with the inflatable   booking
deliveries casenotes info info info
balloon wedge device in the previous study. The standard BMI
given given given
deviation of 2.32 indicates that 95.4% of cases could achieve
Jan 195 6 2 20; 0 7; 1 7; 7
within 4.60 of the required 150 tilt i.e. 10.4 to 19.6 degrees tilt.
Nov 173 3 2 17; 2 7; 7 3; 3
The automated table tilt provides an easy and accurate means
of providing left lateral tilt in pregnant patients. Discussion: Booking BMI was recorded in 99% of the notes in
both audit cycles. In 100% of cases where BMI was ≥40, a
consultant anaesthetist discussed risk and made a plan with
References
the patient. However, the audit of January deliveries indicates
1. Grewal B, Suri I. Is visual actuation a valid predictor of angle of tilt?
that few women who have a BMI 30-39.9 receive anaesthetic
Int J Obstet Anaesth Vol 18 2009; pS1-64- supplement
information.; this occurred in only one case. Reaching this
2. Kinsella SM. A device for measuring the degree of lateral pelvic tilt
during supine recumbency. Anesth Analg 1995; 80: 204-5 population to provide information is difficult especially where
BMI is 30-34.9 as all antenatal care for this group may be
provided by community midwives. In collaboration with
Obstetrics, a patient information leaflet was written which
included both obstetric and anaesthetic information. The
leaflet was approved by the Women's Integrated Governance
group and has been in use since October 2013. It is available
on the Trust intranet which is accessible by some community
midwives. The leaflet is given to all those with a BMI ≥ 35
when they attend obstetric high risk clinic. The results of the
November audit indicate improvement has been made; 44.4%
of those with obesity now receive anaesthetic information.
Greater access to the leaflet is needed however.
References
1. Royal College of Anaesthetists 2012,
http://www.rcoa.ac.uk/document-store/audit-recipe-book-3rd-edition-
2012
2. Centre for Maternal and Child Enquiries 2010, http://www.oaa-
anaes.ac.uk/assets/_managed/editor/
File/CMACE/CMACE_Obesity_Report_2010_Final%20for%
20printing.pdf
Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin) P13
P125 Antenatal management of morbidly obese parturients: P126 Audit of temperature for patients undergoing elective
A multicentre evaluation. caesarean section
H Aladin,  A Khandhia,  K Pottinger   N J Truman,  I Clegg,  K Maclennan  
Anaesthetics, Good Hope Hospital, Birmingham, UK anaethetics, St Mary's Womens Hospital, Manchester, UK
Introduction: Women with a body mass index (BMI) of ≥30 Introduction: Perioperative Hypothermia is associated with
kg/m2 at the time of antenatal booking are classed as being poor outcomes and adverse events for patients; including
obese in pregnancy, accounting for around 39,000 maternities surgical site infection increased length of stay, blood loss,
per year1. Obesity is associated with increased risk of shivering, increased anaesthetic recovery time and cardiac
anaesthetic morbidity and mortality. National guidance have events. Risk factors for the occurrence of hypothermia include
been developed following the Confidential Enquiry into regional anaesthesia, fluid deprivation, blood loss, and cold
Maternal and Child Health report concerning obesity in fluid administration, all of which are common to obstetric
pregnancy. At two different hospitals, five indicators of best patients. 2008 Nice guidelines CG651 on perioperative
practice2 were analysed: (1) Recording of maternal BMI. (2) hypothermia do not include parturients, despite being an at
BMI ≥ 30 women receive information about risk group. An audit performed in 2011 at St Mary's Hospital
anaesthesia/analgesia. (3) Women with a BMI ≥ 40 have demonstrated that 92.5% of elective section patients were not
antenatal anaesthetic review. (4) Duty anaesthetist should be 'comfortably warm' on arrival in recovery, with 65% defined as
informed when women with a BMI ≥ 40 are admitted. (5) hypothermic. A repeat audit was performed following
Anaesthesia for women with a BMI ≥ 40 should be provided commencement of a trial of an air free conductive fabric patient
by a senior anaesthetist. warming system (Hot Dog®).

Methods: Women who had undergone a lower segment Method: A prospective audit of elective caesarean section
caesarean section (LSCS) during a 6 month period (Jan 2013- patients was conducted from April-June 2013 at St Mary's
Jun 2013) at a District General Hospital (DGH) and a Hospital. Theatre staff completed the audit proforma. Data
Foundation Hospital (FH) were evaluated. Data was collected collected included; ambient theatre temperature (ideal target
retrospectively from an electronic data archive and anaesthetic 21ºC), anaesthetic type, estimated blood loss (EBL),
charts. Evidence of BMI calculations, provision of temperature pre, intra, post operative and prior to discharge
anaesthesia/analgesia information, ante-natal anaesthetic from recovery (measured using a tympanic membrane
appointments, and anaesthetic care in the labour ward and thermometer) and details of which Hot Dog® warming
theatre were identified. products were used. Hypothermia was defined as a core
Results: 309 women who underwent a LSCS were identified temperature <36ºC with desirable temperature being defined as
with a having a BMI 30 (median 34, range 30-59). 51% of 36.5-37.5ºC. Comparison of the results from the 2011 audit
these were elective cases. 56% of women with a BMI ≥30 enabled conclusions to be drawn regarding the effectiveness
received anaesthesia/analgesia information, of which 2 were of the warming product.

given literature on anaesthesia in obesity. 32% of women with
Results: A total of 33 patients were audited who underwent
a BMI 40 underwent an antenatal anaesthetic review, with an
elective caesarean section, [n=79, 2011audit], 94% had spinal
additional 4 women failing to attend their appointments. In
anaesthetic (87%, 2011 audit). Mean (S.D) theatre temp was
those women with a BMI ≥40, the duty anaesthetist was
22.8 (± 0.6) [22.3 (± 0.6), 2011 audit], mean duration of
informed of admission in 19% of cases and in 56% of LSCS,
procedure was 51 minutes. 94% of patients had an additional
the anaesthetic care was provided by an appropriately graded
fluid warmer intra-op (72%, 2011 audit). The mean EBL was 574
anaesthetist .
ml (± 213) [653 (± 431), 2011 audit] and only 6% of patients had
Table: Women with BMI 30 having anaesthetic care at a DGH an EBL over 1L (20% 2011 audit). Only 12% (n=4 of 33) of
and FH. patients warmed with the HotDog® were hypothermic on
arrival to recovery (compared to 65% (n=51 of 79), 2011 audit)
  DGH FH
figure 1.
Total LSCS 32% (99/309) 68% (210/309)
Discussion: efforts have been to reduce perioperative
BMI Median (range) 33 (30-59) 34 (30-52)
hypothermia in elective caesarean sections. Almost all patients
Maternal height, weight + BMI recorded 100% 100%
received warmed fluids via a 3M™ Ranger™ fluid warming
Conclusion: This audit has identified that more than half the
system. Forced air warming devices applied to the upper body
women with a BMI ≥30 received analgesia/anaesthesia
are not well tolerated by our awake patient population and
information and more than half were anaesthetised by a senior
allow only a limited area to be heated. introduction of
anaesthetist. However, in all the areas of practice, the target
HotDog® with an under patient warming mattress and
percentage of women meeting the identified standards were
separate over patient warming blanket (for upper and lower
not achieved. Recommendations included revision of the
limb) proved to be of benefit in perioperative maintenance
referral guidelines for antenatal anaesthetic assessment,
when compared to our standard warming measures. A
improved communication within the multidisciplinary team
HotDog® warming mattress placed on the patient chair in the
during admissions and increased presence of senior
pre theatre waiting area helped prevent hypothermia pre arrival
anaesthetists on delivery suite.
in theatre.
References
Reference
1. Centre for Maternal and Child Enquiries (CMACE). Maternal
1. CG 65 Management of inadvertent perioperative hypothermia in
obesity in the UK: Findings from a national project. London:
adults. NICE April 2008.
CMACE, 2010
2. The Royal College of Anaesthetists. Raising the Standard. A
compendium of audit recipes for continuous quality improvement in
anaesthesia. 3rd Edition 2012
P14 Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin)
P127 Availability of chlorhexidine handwash for regional P128 Caesarean section in a rhesus null parturient with a
analgesia on the labour ward uterine fibroid
K Chima,  T Strickland,  F Plaat   P J Stewart,  R Laird,  J Cartmill  
Anaesthetics , Queen Charlotte's and Chelsea Hospital, Anaesthetics, Altnagelvin Area Hospital, Londonderry, UK
London, UK Introduction: The anaesthetic management of a Caesarean
Introduction: Many patients request regional analgesia during section is made more challenging by the combination of pre-
labour and therefore central neuraxial blocks are performed in operative anaemia, a large uterine fibroid and the presence of a
the delivery room. For central neuraxial blocks an aseptic very rare blood group Rhesus null.
technique should be standard. In the Third National Audit Case report: A forty-year lady with a past medical history of
Project of the Royal College of Anaesthetists the incidence of psoriatic arthritis presented to antenatal booking at 10 weeks
iatrogenic infection was reported as being 8/707 000 gestation. Booking investigations revealed a haemoglobin of
procedures1. However the consequence of any infection is 10.3g/dL, and a blood group O Rhesus null. Her 20-week
potentially devastating, and a 'scrupulous' aseptic technique ultrasound scan revealed no foetal anomalies but did
was therefore stated to be mandatory in the report1. demonstrate an anterior uterine fibroid. This was confirmed
Chlorhexidene gluconate 4% is used for hand decontamination with magnetic resonance imaging which showed a
in our department. It was noticed that not all delivery rooms heterogeneous mass measuring 188x139x159mm, in keeping
were equipped with both chlorhexidene and a hands free with a degenerating fibroid. At 21+3 days she presented with
method for application. dizziness and right upper quadrant pain. Her haemoglobin
Methods: All delivery rooms on labour ward were inspected to level was 7.6g/dL and she was treated for iron deficiency
ascertain the presence of chlorhexidene and a hands free anaemia. Due to a transverse lie and the large fibroid an
dispenser. elective Caesarean section at 38 weeks was planned. As a team
we anticipated a difficult Caesarean delivery with greater blood
The audit was repeated after one and twelve months to assess
loss in a patient with anaemia and a very rare blood group.
if there had been any improvement in the service.
Antenatal management focused on maximising the patient's
Results: Originally, 12 of the 16 delivery rooms had
haemoglobin levels and sourcing compatible blood. The
chlorhexidene available (75%). Of the 12 rooms with
Northern Ireland blood transfusion service and National frozen
chlorhexidene only three were equipped with a hands free
red cell bank in Liverpool secured two units of packed red cells
dispenser (25%), and five containers were uncovered (42%).
in England. Unfortunately, one week prior to the section this
After one month all 16 rooms were equipped with wall blood was issued in an emergency, making it unavailable to us.
mounted chlorhexidene with a hands free dispenser (100%). A new donor was found in South Africa and a further unit was
After a further 12 months it was found that 12 of the 14 secured in Brazil. Both units were couriered to our hospital
delivery rooms had chlorhexidene available (86%). (Two of the prior to the Caesarean delivery which was performed at 38+6
rooms had been converted to a post delivery high dependency days under spinal anaesthesia. Pre-operative haemoglobin was
unit). Eleven of the 12 containers were equipped with a hands 9.1g/dL. The patient was discharged home on day three post-
free dispenser (92%). operatively and her haemoglobin was 7.2g/dl on discharge. No
Discussion: The results of the initial data collected, as well as blood transfusion was required.
anaesthetists' concerns regarding the unavailability of Discussion: Red blood cells from people who have the Rhesus
chlorhexidine and dispensers in each room, was reported to null phenotype lack Rhesus proteins, and thus, Rhesus
managerial staff, who ensured all rooms were adequately antigens. This phenotype occurs in approximately 1 in 6x106
stocked. Results were therefore better when re-auditing was individuals1. When these patients are transfused they may
performed at one month. However, after 12 months standards form antibodies to high frequency rhesus antigens, which can
had declined, although they were still improved from the make it extremely difficult to process compatible blood. Rhesus
initital audit. This decline could be attributed to the fact that null blood is available from the National frozen cell bank,
neither a team nor a named individual was made responsible however it may not be available when required due to limited
for sustaining the initial improvement, which if introduced, we supplies, as in our case. There is very limited literature
feel would encourage a sense of ownership and enable the regarding the management of the rhesus null parturient and
improvement in this area of patient safety to be sustained. our management was guided by our regional Haematology
Reference unit. This case demonstrates the importance of good
communication with all members of the multi-disciplinary team
1. National Audit of Major Complications of Central Neuraxial Block
in the United Kingdom 2009, http://rcoa.ac.uk/system/files/CSQ- and the detailed preparations required in a complex case.
NAP3-Full_1.pdf
Reference
1. Avent ND, Reid, ME. The Rh blood system: a review. Blood 2000
95: 375-387.
Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin) P15
P129 Category one caesarean sections in a district general P130 Comparison of two non-invasive cardiac output
hospital:  Improving the decision to delivery time monitoring devices in a parturient with complex
VK Wroe,  AM Troy   cardiac disease.
Department of Anaesthesia, Countess of Chester Hospital, PJ Rose,  V Misra,  S Quasim  
Chester, UK Anaesthesia, UHCW, Coventry, UK
Introduction: National Guidelines state that the interval from Introduction: The management of valvular lesions during
decision to delivery (DDI) in a category one caesarean section pregnancy and labour can present a clinical conundrum. We
should be less than 30 minutes1, and that a duty anaesthetist present the use of two cardiac output (CO) monitoring devices
should be immediately available for emergency work on the in a parturient with complex valvular heart disease undergoing
delivery suite 24 hours a day2. a caesarean section under epidural anaesthesia.
A 2008 departmental audit found that 85% of category one Case Report: A 37 year old primiparous woman with history of
sections had a DDI of under 30 minutes, a figure marginally ASD repair aged 4, severe mitral regurgitation, severe tricuspid
under the audit standard of 90%. Anaesthetic service regurgitation, moderate aortic stenosis (AS) secondary to a
provision in our trust was expanded in July 2012, with the congenital bicuspid valve and moderate pulmonary
addition of a dedicated obstetric anaesthetist 24 hours a day. hypertension presented for elective caesarean section.
This re-audit aimed to assess the proportion of category one Echocardiography showed moderately dilated right ventricle
caesarean sections with a DDI <30 minutes and analyse the with good bi-ventricular systolic function, bi-atrial dilatation,
factors contributing to any delay. moderate to severe AS (mean gradient 34mmHg, peak gradient
Methods: After audit department approval, a retrospective 53mmHg, estimated valve area 0.74cm2). Pulmonary artery
analysis of category one caesarean sections between August pressures were estimated at 42-47mmHg. LiDCO rapid and
and December 2012 was performed. Data collected included Cheetah NICOM devices were used to monitor CO.
DDI and reason for delay, indication for section, type of Anaesthesia was established with 32mL 2% lignocaine and 100
anaesthesia and cord pHs. micrograms of epinephrine via epidural. Compound sodium
lactate was infused at 60mL/hr, and increased to 100mL/hr after
Results: 69 category one caesarean sections were analysed.
epidural anaesthesia. Fluid boluses of 200mL and 100mL were
The mean DDI was 23 minutes (range 3-120 minutes). 84% had
delivered via the pump at 13 and 28 minutes after delivery of a
a DDI of under 30 minutes, with a mean time from decision to
live infant. Metaraminol infusion was titrated to effect.
effective anaesthesia of 14.5 minutes. The indication for
Syntocinon infusion was started upon delivery (20 units in
caesarean section was abnormal CTG in 87% of cases (2008:
48mL 0.9% saline) at 15mL/hr and tapered post-operatively
77%). General anaesthesia was performed in 43% (2008: 85%),
over 4 hours. Mean arterial pressure was maintained at 91 to
spinal anaesthesia in 55% (2008: 15%) and extension of
97mmHg until delivery (78 minutes) and then decreased to
epidural blockade in 2%. In 11 cases, DDI was over 30
67mmHg at the end of surgery. Cardiac output was maintained
minutes; these cases were all performed under spinal
throughout surgery with an increase at the time of concurrent
anaesthesia. The following table shows the reasons identified
fall in MAP. Fluid challenge had negligible effect although
that contributed to delay:
there was a small reduction in heart rate (84 to 59bpm).

Arrival in
Discussion: NICE has advocated the use of cardiac output
theatre Incision to
Spinal monitoring in high risk non-obstetric surgery to improve
10 delivery Staff Theatre
  placement outcome.1 In this case we utilised both a non-calibrated pulse-
minutes time 10 unavailable unavailable
10 minutes contour waveform analysis and bioreactance system to
from minutes
compare both values measured and response to fluid
decision
challenge. Although the values produced were different, the
Number
trends were broadly similar. This, once again, highlights the
of 4 6 1 1 1
importance of analysing trends rather than absolute values to
patients
guide management. Interestingly, both devices demonstrated
Arterial cord blood analysis was carried out in 10/11 cases. pH
that a fall in MAP correlated with an increase in cardiac
was less than 7.2 in 30%, and base excess was less than -8 in
output, similar to previous investigators.3 Given that cardiac
20%.
disease is the leading cause of death in the most recent
Conclusion: The proportion of cases with a DDI of over 30 triennialreport2, monitoring cardiac output enables one to
minutes has remained constant at around 15%, despite an maintain physiological homeostasis, and ultimately aids
improvement in anaesthetic staffing. Our results suggest that clinical decision-making leading to good clinical outcome, as in
the causes for this delay are multifactorial, and the results are our case.
not benign- the delay in delivery led to a cord pH of <7.2 in
References
almost one third of cases. We intend to improve our practice
1. MTG3 CardioQ-ODM (oesophageal Doppler monitor): guidance
by regular practice drills, use of preprepared spinal packs to
2011, http://www.nice.org/nicemedia/live/13312/52624/52624.pdf
reduce spinal placement time, clear procedures to follow in the
2. Centre for Maternal and Child Enquires (CMACE). Saving Mothers'
case of staff or theatre unavailability and reaudit. Lives: Reviewing maternal deaths to make motherhood safer: 2006-
2008. The Eighth Report of the Confidential Enquires into
References
Maternal Deaths in the United Kingdom. BJOG 2011;118(Suppl
1. Caesarean section. NICE Clinical Guideline 132. NICE, London 1):1-203
2011. (http://publications.nice.org.uk/caesarean-section-cg-132).
3. Fanning NP, Sermer M, Colman J, Carvalho JC, Cordovani D. Non-
2. OAA/AAGBI guidelines for obstetric anaesthetic services- 3rd invasive Hemodynamic monitoring with bioreactance for cesarean
edition. AAGBI and OAA, London, 2012 delivery. A more relaxed look at tight aortic stenosis? Abstract
(http://www.aagbi.org/publication/publication-guidelines/M/R) SOAP 2011, http://www.soap.org/display_2011_abstract.php?id=58
P16 Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin)
P131 Comparsion of slow and rapid bolus of ephedrine in P132 Continuous spinal anaesthesia for a primigravida with
patients undergoing planned caesarean section under severe tricuspid regurgitation, Harrington rods and
spinal anaestheisa WITHDRAWN FROM  thrombocytopenia.
PRESENTATION AM Walton,  I Mettam  
PG Sekar,  LB Ellakumanan,  H Balachander,  MVS Obstetric Anaesthetic Department, University Hospital
Satyaprakash   Southampton, Southampton, UK
Anaesthesiology, JIPMER, Puducherry, India Introduction: We present the successful use of continuous
spinal anaesthesia (CSA) for caesarean delivery in a parturient
with severe tricuspid regurgitation and pregnancy-induced
thrombocytopenia in addition to Harrington rod placement for
scoliosis spinal surgery.
Case history: A 40 year old primigravida presented at 37
weeks gestation. She had undergone a tricuspid valve repair
previously for endocarditis. The patient had developed severe
tricuspid regurgitation and had heart failure. Harrington rods
were placed in her thoracic and lumbar spine for repair of a
congenital scoliosis. Blood tests revealed a pregnancy related
thrombocytopenia with platelets of 85x109/L. An
echocardiogram showed a severly dilated right atrium with
intra-atrial septal bowing to the left, severe free flowing
regurgitation and right ventricular systolic pressure
32mmHg.The case was discussed with obstetricians,
anaesthetists and cardiologists and a decision was made for
an elective caesarean section under CSA, if the final platelet
count remained stable. The patient expressed a preference to
remain awake and avoid a general anaesthetic. At surgery a
cannula and radial arterial line were inserted. In the sitting
position a 22G spinal needle was inserted below the level of
the scar tissue at L3/4, and a spinal catheter threaded into the
subarachnoid space. A total of 10mg bupivacaine and 250mcg
diamorphine were required over 20 minutes to establish a block
to T4. The blood pressure dropped from 135/70 to 90/50mmHg
and required only 5mcg of epinephrine to return to baseline
values. Blood loss was 720mls. Syntocinon was given as an
infusion only. A live male infant was delivered.
Discussion: An obstetric anaesthetist has to take many
factors into account when deciding on the best choice of
anaesthetic for a particular case; anaesthetic expertise,
maternal co-morbidities, fetal well-being and maternal
preferences all play a part. Cardiac disease in pregnancy is still
the leading cause of indirect maternal mortality in the UK.1 The
choice of anaesthetic and delivery had to ensure the least
amount of strain on an already compromised heart. The
advantages of CSA are that a block can be established
gradually with small incremental doses of local anaesthetic,
which reduces the likelihood of cardiovascular instability.2
The concerns with a CSA are principally neurological
complications and post-dural puncture headache. CSA is
proving an option to be considered for patients with
significant cardiac disease and previous spinal surgery
provided the anaesthetist has experience with the technique.
In this case it provided a cardiovascularly stable anaesthetic
with excellent analgesia and maximal maternal satisfaction.
References
1. Saving mothers lives.The Eighth Report of the Confidential
Enquires into Maternal Deaths in the UK. March 2011
2. DennyNM, Selender DE. Continuous spinal anaesthesia. Br J
Anaesth 1998;81:590-7
Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin) P17
P133 Does pre-operative anxiety predict post-operative pain P134 Early epidural analgesia may increase caesarean
scores in parturients undergoing caesarean section? section rate in spontaneously  labouring nulliparous 
BM Daly,  N Weidenhammer,  R Junkin,  L Riddell,  J Dolan,  J women: a retrospective study
Kinsella*,  R Marla,  S Young   R Anil Kumar,  Roger Mc Morrow  
Anaesthesia, Princess Royal Maternity, Glasgow, UK, Anaesthesia, National Maternity Hospital , Dublin, Ireland
*Anaesthesia, Pain & Critical Care Medicine, University of Introduction:.Epidural analgesia offers the most effective
Glasgow, Glasgow, UK method of intra-artum pain relief. The effect of epidural
Introduction: Pregnancy, childbirth, and undergoing a surgical analgesia on the progression of labour and the mode is often
procedure are all likely to induce anxiety. The relationship debated in multiple studies. This study aims to show the effect
between anxiety, pain and pregnancy is complex.1Childbirth is of timing of epidural analgesia on the mode of delivery.
a time of high anxiety, and Caesarean section is known to be Method: Data such as women's age, gestational age, cervical
associated with significant pain post-op. Here we ask can dilatation before epidural insertion and duration of labour was
anxiety scoring predict post LSCS pain? collected from a total of 2029 nulliparous women in
Methods: After ethical approval and consent, pre-operative spontaneous labour. Epidural analgesic was defined as early at
data and a single 24hr post-op 10cm VAS were collected from a cervical dilatation of 3cms or less and late at a cervical
108 women, with 9 having missing data. Spielberger2 State and dilatation of 4 or more cm
Trait anxiety forms were completed prior to surgery. We Results: Of the 2029 women, 1423 ( 70.1%) received epidural
present secondary end points powered post hoc for 0.8 analgesia. Out of the 2029 women, 1403 ( 69.2%) had
probability of 2cm VAS difference. A standardised anaesthetic spontenous vaginal delivery, 478 (23.6%) had assisted
(spinal including diamorphine) and analgesic regime was used. delivery and 146 ( 7.2%) had caeserean section.
The cohort was divided into "high"- above the mean and
The data was anaylsed according to the timing of epidural
"low"- below the mean anxiety and compared using Student's
analgesia or no epidural analgesia and modes of delivery.
t-test.
Anaesthetic Delivery method
Results:
intervention Spontaneous Assisted Caesarean
Table 1: State anxiety compared to VAS
No epidural 537 (88.9%) 51 (8.4%) 16(2.6%) 604
Low anxiety High anxiety Early epidural 757 (62.2%) 379 126 (10.0%) 1262
  Significance
(n=45) (n=54) (30.0%)
24 hr VAS mean Late epidural 109 (67.7) 48 (29.8%) 4(2.5%) 161
5.0 (2.2) 5.3 (2.0) P= 0.40
(SD) cm
Epidural Assisted delivery C-Section
Table 2: Trait anxiety compared to VAS analgesia OR 95% CI p-value OR 95% CI p-value
Low anxiety High anxiety Early 5.27 3.86, 7.21 <0.001 5.59 3.28, 9.51 <0.001
  Significance
(n=48) (n=55) epidural
24hr VAS mean (SD) Late 4.64 2.97,7.23 <0.001 1.23 0.40,3.76 0.71
4.8 (1.9) 5.5 (2.2) P= 0.15
cm epidural
Table 3: State +Trait anxiety compared to VAS Conclusion: The results from the study show that the
Low anxiety High anxiety likelihood of having caeserean section in the early epidural
  Significance
(n=48) (n=51) group is significantly higher compared to the late epidural
24hr VAS mean (SD) group, but the incidence of assisted delivery between the early
cm 4.8 (1.9) 5.6 (2.1) P=0.072 and late epidural group were similar. This study also shows
that there is an increased likelihood of having assisted
Discussion: While the higher anxiety groups displayed a delivery and caeserean section delivery with epidural
higher mean VAS in all the analysis, this was not statistically analgesia compared to without from the study group.
significant. The separation between the two groups was better
References
with the State than the Trait anxiety score and best of all when
1..Gonen Ohel. Early versus late initiation of epidural analgesia in
the two scores were combined. Further reasearch could look at
labour: Does it increasethe risk of cesarean section. A randomised
anxiety scoring as part of a bundle of other measures verus trial. American journal of Obstretrics and Gynaecology (2006) 194,
pain. 600-5
2. Wassen et al. Early versus late epidural analgesia and risk of
References
instrumental delivery in nulliparous women: a systemic review.
1..Waldenstrom U: Experience of labor and birth in 1111 women. J British Journal of Obstretrics and Gynaecology (2010) 1471, 655-
Psychosom Res.1999: 47(5):471-82 661
2..www.mindgarden.com
P18 Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin)
P135 Efficacy of midwife led epidural top ups in labour–Are P136 Emergency obstetric and neonatal care in Kenya:
programmable pumps really the way forward? Addressing millennium development goals
E Traer,  G Waters,  GNB Jackson   D B Pachter,  C A Ameh*  
Anaesthetic department, Royal Berkshire NHS Trust, Anaesthesia, Cumberland Infirmary, Carlisle, UK, *Maternal
Reading, UK and Neonatal Health, Liverpool School of Tropical
Introduction: There are an increasing number of automated Medicine, Liverpool, UK
techniques by which labour epidurals can be managed1,2,3,4. Introduction: In 2008, an estimated 358,000 women died from
Comparison reports of programmable epidural pumps regimens complications of pregnancy and childbirth. The overwhelming
have shown lower total volumes of local anaesthetic may be burden of this mortality occurs in the developing world, with
associated with reduced rates of instrumental delivery and almost 60% of deaths occurring in sub saharan Africa.1There
improved maternal satisfaction1,2. Extended intervals between are also some 3.6 million neonatal deaths each year, and once
boluses with larger volume boluses was shown to use less again the developing world is disproportionately represented.2
total local anaesthetic3. These reports have led us to In 2006, the Liverpool School of Tropical Medicine (LSTM)
investigate similar outcomes our unit where we have a midwife developed a training package entitled "Life Saving Skills,
led top up (MLTU) practice. Emergency Obstetric and Neonatal Care" (LSS EOC-NCC) to
Method: First epidural bolus administered by the anaesthetist try and address these huge public health issues. Courses now
of 20ml 0.1% bupivicaine+2µg/ml fentanyl . Data recorded at run in 11 countries worldwide. In October 2013, I was fortunate
each subsequent midwife administered bolus (MLTU): bolus e nough to teach on a course in Nyeri, Kenya.
interval time, motor block (Bromage score of 2-4 taken as motor Methods: A variety of teaching methods were used on the
block), any change to the standard dose 20ml 0.1% course. Didactic lecture based teaching had a limited role, with
bupivicaine+2µg/ml fentanyl and if analgesia was effective or more emphasis placed on small group "break out sessions"
ineffective. and scenario based teaching. Pre and post course simulation
Results: 50 patients audited based testing was undertaken, with results collated and sent
back to Liverpool for analysis and assessment of efficacy of
Midwife led epidural Top Up Data  
teaching.
Mean bolus interval time (min) 105 (sd 26)
Mean rate bupivicaine mg/hr 10.56 (sd 3.6) Results: Participant feedback suggested a high level of
Motor block (Bromage score 2-4) 11/48 (22.9%) satisfaction with the course. The impact of courses in terms of
Mean time to motor block (min) 237 (sd 135) reduction in maternal and neonatal mortality remains the
NVD 14/48 (29.1%) subject of ongoing scrutiny. One study from Somaliland
Instrumental 18/48 (37.5%) demonstrated improved knowledge and skills and evidence of
LSCS 16/48 (33.3%) positive behaviour change post introduction of the course.3

Satisfaction excellent/good 46/48 (95%)
Conclusions: Maternal morbidity and mortality remains a huge
Discussion: In this study we found the mean interval in problem in Kenya. In 2008 it's Maternal Mortality Ratio was
minutes between epidural boluses to be 105minutes. This is 488 per 100,000, one of the highest in the world.4Great efforts
greater than the average 60minute interval of the are being made by the Kenyan government to reduce this. An
programmable intermittent bolus(PIB) regimens. An average ambitious target to reduce MMR to 91 per 100,000 by 2018 has
rate of bupivicaine 10.56mg/hr was similar to that reported with been set. One step has been the introduction of the Liverpool
PIB and patient controlled epidural bolus(PCEA) regimens4, LSS EOC-NCC course.
while we report a lower rate of motor block. Given the practice Acknowledgements: I would like to thank the maternal and
of MLTU in effect is much like a PIB without PCEA, it is neonatal health unit at LSTM for the opportunity to become
notable that the time between epidural boluses is longer with involved, and look forward to teaching on my next course. I
MLTU with less maternal motor block and high maternal would also recommend the course to any obstetric
satisfaction. We feel our practice promotes close epidural anaesthetists with an interest in international health.
assessment as the midwives assess motor block and maternal
References
satisfaction before each “top-up” and avoids the cost of the
1. World Health Organization, UNICEF, UNFPA and The World
PIB/PCEA pumps.
Bank. Trends in Maternal Mortality 1990-2008. 2010.
References 2. Lawn JE, Kerber K, Enweronu-Laryea C, et al. 3.6 million neonatal
deaths–what is progressing and what is not? Seminars in
1. Capogna G Camorica M, Stirparo S, Farcomeni A. Programmed Perinatology 2010;34:371–386.
Intermittent Epidural Bolus Versus Continuous Epidural Infusion for
Labor Analgesia: The Effects on Maternal Motor Function and 3. Ameh C, Adegoke A, Hofman J, et al. The impact of emergency
obstetric care training in Somaliland, Somalia. International Journal
Labor Outcome. A Randomized Double-Blind Study in Nulliparous
of Gynecology & Obstetrics. 2012;117:283-7.
WomenAnesth Analg July Oct 2011; 113(4): 826-831
4. Kenya National Bureau of Statistics. Kenya Demographic and
2. George RB, Allen T, Habib A. Intermittent Epidural Bolus
Health Survey (KDHS) 2008-09. June 2010.
Compared with Continuous Epidural Infusion for Labour Analgesia:
A Systematic Review and Meta Analysis. Anesth Analg Jan 2013;
Vol 116: 133-144
3. Wong C, MacCarthy RJ, Hewlett Bl. The effect of manipulation of
the programmed intermittent bolus time interval and injection
volume on total drug use for labour epidural analgesia: a randomized
controlled trial. Anest Analg 2011; 112: 904-11
4. Husain T, Mavridou I, Fernando R, El-Wahab N, Stewart A, Dick J,
Columb M. A study of a programmed intermittent bolus and patient-
controlled epidural regimen for labour analgesia. Int J Obstet
Anaesth May 2013: P85 Abstracts OAA Bournemouth 2013
Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin) P19
P137 Enhanced recovery after elective caesarean section: P138 Epidural analgesia in obese parturients: can kneeling
Service evaluation and quality improvement be the answer to our prayers.
GJ Lilley,  M Adamson,  A Miskin*,  M Turner   S De Silva,  L Kelliher*,  R Mottaleb*,  E Combeer  
Anaesthetics, Royal Gwent Hospital, Newport, UK, Anaesthetics, Frimley Park Hospital, Frimley, UK,
*Obstetrics and gynaecology, Royal Gwent Hospital, *Anaesthetics, Royal Surrey County Hospital, Guildford, UK
Newport, UK Severe pain is not life-threatening in healthy parturient women,
Introduction: Enhanced recovery (ER), a concept widely it is however shown to have neuropsychological
recognised within many surgical specialties, is now a subject consequences. Postnatal depression may be more common
of interest within obstetrics. The core principles comprise when effective analgesia is not used1 and pain during labour
speeding up recovery and improving patient outcomes, with has been linked with the development of post-traumatic stress
associated benefits for staff and healthcare systems1. The disorder2.There is an increasing number of obese parturients3
most logical starting point for the introduction of ER principles and identification and placement of the epidural can be
are elective caesarean section lists. Delayed surgery may lead difficult in these women.
to prolonged fasting, followed by delayed mobilization, Classically the sitting or the lateral position is used during
delayed removal of catheter and delayed discharge. A pilot siting of labour epidurals. The kneeling position was first
audit in our hospital demonstrated a mean stay after elective described in 19934, where 34/35 women had their labour
caesarean section of 3.6 days, and mean preoperative fasting epidural sited whilst in the kneeling position and 88.5% of the
period of 12.4 hours. Current guidance for ER in obstetrics mothers were happy with this position.
suggests minimal interruption to oral intake, pre-operative
I elected to try the kneeling position in an obese lady with a
energy drinks, catheter removal at 12 hours post-surgery
BMI 50 after adjustments in the sitting position and two
regardless of time of day, and the option of discharge home 24
separate failed attempts to confidently palpate the lumbar
hours after caesarean section where appropriate2.
spine. Once the lady was in the kneeling position, the lumbar
Methods: All elective caesarean sections were included in this spine was not only palpable but also visible and the epidural
service evaluation after introduction of preoperative space was identified with ease. With Departmental approval I
carbohydrate drinks. Data collection included fasting time, in performed my labour epidurals in this manner and found it not
addition to time to mobilization, to catheter removal and to only to be easy to site epidurals but also tolerated well. Some
discharge. After an initial 6 week period of data collection, the women complained of paraesthesia in their feet, but this was
data was presented to anaesthetic and obstetric staff. Posters, rare and eased swiftly. We decided to survey our Deanery to
a discharge proforma and a patient information leaflet were ascertain what positions were being utilised.
produced, and specific guidance was developed regarding
Survey: An e-survey was sent to trainees and Consultants in
preoperative carbohydrate drinks. A further 6 weeks of data
the South West London Deanery into what their ideal first and
collection then took place.
second choice positions used for siting epidurals would be for
Results: A total of 78 consecutive patients were included, all labouring parturients. We then posed the same question for
of whom received a regional anaesthetic technique for elective obese parturients (BMI 40). They were asked if they had
caesarean section. The following table illustrates the timing of heard of the kneeling position and if anyone had tried it. For
pre- and post-operative events before and after our those who had not, we questioned why they had not tried it.
interventions.
Results: We received 53 responses, 96.2% of whom were
Time period / hour 2nd 6 week Initial 6 week
trainees. 64.2% chose to position the parturient sitting as their
mean(SD) period period
first choice and 60.4% chose lateral as their second choice in
Pre-op fasting 4.8 (2.8) 3.8 (2.5)
non-obese parturients. In comparison 84.9% opted for the
Post-op fasting 4.2 (3.5) 3.4 (3.5)
sitting position in obese parturients with 56.9% using the
Total interruption to oral
9.0 (4.5) 7.1 (4.6) lateral as their second choice. The only positions utilised were
intake
sitting and lateral. 94.9% of respondents had not heard of the
Delivery to mobilization 10.2 (4.5) 9.0 (3.3)
kneeling position to site labour epidurals.
Delivery to catheter removal 14.8 (6.6) 13.5 (3.5)
Conclusion: Each position used for the placement of labour
Delivery to discharge 67.3 (40.1) 63.3 (27.6)
epidurals has their own advantages and disadvantages. With
Discussion: The introduction of patient information leaflet
the rising incidence of maternal obesity and its associated
offering guidance regarding post-operative oral intake,
risks to not only the mother but also the unborn child, we need
mobilization, catheter removal and early discharge, along with
to be continuing in our development and advancement in the
staff education and introduction of pre-operative carbohydrate
provision of good care. We suggest that the kneeling position
drinks, has resulted in improvement in the timing of a number
is a safe and viable alternative for siting epidural catheters in
of peri-operative interventions, and a small reduction in
labouring parturients.
duration of hospital admission. However, possibly due to
References
obstetric, midwifery, paediatric and organisational reasons,
discharge is rarely achieved at the potential target of 24 hours 1. Hiltunen P, Raudaskoski T, Ebeling H, Moilanen I Does pain relief
during delivery decrease the risk of postnatal depression? Acta
after elective caesarean section. Obstet Gynecol Scand 2004;83:257-261
References 2. Soet JE, Brack GA, Dilorio C Prevalence and predictors of women's
1. Lucas DN, Gough KL. Enhanced recovery in obstetrics - a new experience of psychological trauma during childbirth. Birth
frontier? Int J Obstet Anaesth 2013; 22: 92-95 2003;30:36-46
2. Enhanced recovery partnership: A better journey for patients and a 3. Centre for Maternal and Child Enquiries (CMACE). Saving
better deal for the NHS. Available at: Mothers'. Lives: reviewing maternal deaths to make motherhood
http://www.improvement.nhs.uk/documents/er_better_journey.pdf safer: 2006–2008. The Eighth Report of the Confidential Enquiries
into Maternal Deaths in the United Kingdom. BJOG 2011;118:1-203
P20 Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin)
P139 Epidural labour analgesia and risk of instrumental P140 Estimation of blood loss during caesarean sections -
delivery discrepancy between visual and laboratory estimation
R Carvalho,  T Ferreira,  M Duque,  D Catré,  I Guedes,  J P A Nowicka,  A Amasakera,  C Ferdinand,  I Suri  
Assunção   Anaesthesia, Warwick Hospital, South Warwickshire NHS
Anaesthesiology, Centro Hospitalar Tondela Viseu EPE, Foundatio, Warwick, UK

Viseu, Portugal
Introduction: Excessive blood loss is a major threat to women
Introduction: Epidural analgesia (EA) is a worldwide effective undergoing casearean sections. Accurate visual estimation of
method used for pain relief during labour. Nevertheless, its use blood loss is difficult due to dispersion of blood lost and the
and evolution to instrumental vaginal (forceps or vacuum blood being mixed with amniotic fluid(1). Therefore the blood
extraction) or operative deliveries remains controversial loss often gets under or overestimated(2). A number of
between experts,1 either anesthesiologists or obstetricians. methods exist to estimate the blood loss, the commonly used
We aimed to analyze the relation between EA and instrumental being: visual estimation by the attending staff, weighing of the
v aginal deliveries in a sample of our obstetric population. blood soaked surgical swabs and calculation based on the pre-
and post-operative haemoglobin concentrations(3). The aim of
Methods: A retrospective study included all pregnant women
this audit was to compare the visually estimated blood loss by
who delivered on our labour Room, between 1-January-2011
both the surgeons (vEBLs) and anaesthetists (vEBLa) against
and 31-December-2012, excluding those who underwent
the calculated estimated blood loss (cEBL).
caesarean section. We reviewed the data of demographical
characteristics, type of gestation and labour, the use of EA Methods: Data was collected on thirty five caesarean sections.
and the newborn APGAR score. Descriptive analysis of Operating surgeona and anaesthetists were asked to visually
variables was used to summarize data and Chi-Square test was estimate the blood loss in each case. The circulating blood
used. Multivariate analysis was done with logistic regression, volume was calculated for each patient based on the body
with calculation of corrected Odds Ratio (OR) and its 95% weight and height. Then, the blood loss during caesarean
confidence interval (95% CI). section was calculated using the circulating blood volume and
the pre- and post-operative haemoglobin concentrations.
Results: 2901 pregnant women were included in this study, Correction was made for the haemodilution by intravenous
with mean age of 29,7 years. 81% underwent EA and 30% fluid administered.
instrumental vaginal delivery. 51% were nulliparous. Applying
Results: Twenty six complete forms were included in the
Chi-Square test to independent variables, we obtained
analysis. None of the patients received blood or blood
significant associations with dystocic delivery for EA, normal
products intraoperatively. Mean volume of intravenous fluid
maternal age (NMA; 20-35 years) and parity (p<0,001).
infused was 1304mL±421. Mean vEBLs, vEBLa and cEBL was
Applying logistic regression to our model, including parity,
590mL±300, 623mL±372 and 821mL±1004 respectively. The
NMA and EA with dystocic deliveries, we obtained corrected
tendency for anaesthetists to give a higher estimate of blood
OR (95%CI) for EA 2,459 (1,884-3,210) and for parity 3,4
loss was not statistically signifficant (p=0,12). There was a
(2,867-4,121), with NMA loosing significance. However, this
clear discrepancy between the visual estimate given by both
result may still be biased by other factors, such as labour
the surgeons and the anaesthetists, ant the cEBL, however, it
stage at the time of the EA beginning, drugs used in epidural
did not reach statistical significance (p=0,11 and p=014
space, use of oxytocin during labour, among others.
respectively). Compared to the cEBL the vEBL was
Additionally we found that, in our population of term
overestimated when the blood loss was low (12 cases) and
pregnancies, NMA and eutocic deliveries, there was no
underestimated when the blood loss was higher than 500mL
significant relation between EA and APGAR score <8 at the
(14 cases). There was a linear relationship between the degree
first minute (p=0,079).
of underestimation and the blood loss, with high levels of
Conclusion: It's generally assent that EA provides the most blood loss being most underestimated.
effective pain relief in labour. However, it's associated to Conclusions: In this audit, the standard procedure for
prolonged labour and risk of instrumental or caesarean estimation of blood (visual estimation by the obstetrician) loss
deliveries.2 Our study has drawn the conclusion that both was found to be unreliable. We demonstrated a tendency of
having EA for labour pain relief and being nulliparous increase anaesthetists and surgeons to overestimate the blood loss, if
the chance of instrumental delivery, respectively in 2,459 and actual blood loss was less than 500mL, and underestimate if
3,43 times, however without significant impact on newborn the blood loss exceeded 500mL. As a result of the audit, it has
APGAR score. Bigger prospective studies correcting for more been made compulsory in our unit to check haemoglobin
risk factors are advised. concentration in recovery whenever the vEBL exceeds
References 1 000mL.
1. BMC Pregnancy and Childbirth 2008, 8:45. References
2. Acta Obstet Gynecol Scand 2002, 8:1033-1039. 1. Khan FA, Khan M, Ali A, Chohan U Estimation of blood loss during
Caesarean section: an audit. J Pak Med Assoc. 2006 Dec;56(12):572-
5.
2. Larsson C, Saltvedt S, Wiklund I, Pahlen S, Andolf E Estimation of
blood loss after cesarean section and vaginal delivery has low
validity with a tendency to exaggeration. Acta Obstet Gynecol
Scand. 2006;85(12):1448-52.
3. Stafford I, Dildy GA, Clark SL, Belfort MA, Visually estimated and
calculated blood loss in vaginal and cesarean delivery. Am J Obstet
Gynecol. 2008 Nov;199(5):519.e1-7
Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin) P21
P141 Ethnic variations in use of labour analgesia P142 Factors associated with the use of spinal anaesthesia
LMD MacDarby,  CMC McCaul   for caesarean section in Nigeria
Delivery Suite, The Rotunda Hospital, Dublin, Ireland C Imarengiaye,  F Asudo*,  A Akinmola†,  B Lawal§  
Introduction; This retrospective cohort study was compiled to Anaesthesiology, University of Benin Teaching Hospital,
establish the wide variety of nationalities presenting to The Benin City, Nigeria, *Anaesthesia, University of Abuja
Rotunda Hospital for delivery during a one month period and Teaching Hospital, Gwagwalada, Nigeria, †Anaesthesia, 
to determine the labour analgesia preferences amongst this National Hospital, Abuja, Nigeria, §Anaesthesia, Lagos 
population. Island Maternity Hospital, Victoria Island, Nigeria

Introduction: There has been a consistent increase in the rate
Methods; Details of all deliveries occurring during the month
of spinal anaesthesia for caesarean section in many hospitals
of October 2013 were collected. Any patients undergoing
worldwide and had been advocated as the preferred technique
elective caesarean section and those with failed inductions
for caesarean delivery.1 Recent evidence suggests increasing
were excluded from the study. A demographic of patients’
use of spinal anaesthesia for caesarean sections in reports
nationality and ethnic background was compiled. Data relating
from a teaching hospital.2 The rise in spinal anaesthesia
to these patients’ use of labour analgesia was recorded i.e.
caesarean section notwithstanding, it is pertinent to determine
epidural uptake, pethidine administration and remifentanil
the factors limiting the wholesome application of spinal
infusion use. We then established the frequency of use of
anaesthesia for caesarean section in Nigeria.
each of these methods of analgesia in each population

Methods: A snap-shot survey was conducted in some
Results; There were 767 deliveries in Oct 2013. 104 elective
selected hospitals in Nigeria. The survey determined the
caesarean sections were carried out and there were 8 patients
sociodemographic characteristics of patients, indication for
who failed induction.
surgery, grade of anaesthesia provider, contraindication to
Therefore a total of 655 patients laboured during this time. spinal anaesthesia and any other factor that may be noticed in
This number was made up by 50 different nationalities. Of the selected hospital. The survey was to be conducted over a
these 414 patients were Irish, the majority being white but 2-week period but was truncated by the nation-wide strike
including small numbers of Asian or Black background. action by doctors after 9 days.
Amongst the Irish patients the rate of epidural uptake was
Results: A total of 99 patients were attended to in 4 of the
43.47% (234) and the rate of pethidine use was 17.87% (74)
selected 6 hospitals within the study period. 36/99 women
Patients of other white background, including many eastern
were nulliparous and maternal factors (82/99) were the leading
european countries made up 134 of the patients. These
indications for caesarean section. Consultant anaesthetists
patients as a group had a 52.98% epidural uptake rate. Black
(23/99), Senior Registrars (35/99), Medical Officers (36/99) and
Africans were found to have a 39.13% (9) uptake rate and
others (5/99) provided anaesthesia for the caesarean sections.
those of Asian background had the highest rate at 54.83%
85/99 patients received spinal anaesthesia and 14/99 had
(17). The use of pethidine was significantly lower than the rate
general anaesthesia for the c-section. Fetal indication for
of epidural in all of these groups. Pethidine was used by
caesarean section had a 3-fold risk of general anaesthesia for
18.19% of Black Africans, 12.9% of Asians and 23.13% in
the surgery (p = 0.037, RR = 3.1, 95%CI 1.2 – 8). 25/99 and
those of other white backgrounds. There were only 3 cases of
74/99 were performed as elective or emergency procedure.
remifentanil use during the month
Nature of caesarean section was not a factor for the use of
Discussion; The highest incidence of epidural uptake during spinal anaesthesia (p =0.51, RR = 2.0, 95%CI = 0.5).
Oct was found to be amongst the Asian population, the lowest Discussion: Over 85% of caesarean sections in Nigeria were
being amongst Black Africans. Pethidine use was less than conducted under spinal anaesthesia. Fetal indications for
25% in all groups. The reasons for these trends is unknown caesarean section provoked a 3-fold increase in general
though previous studies have suggested that cultural and anaesthesia for caesarean section. The use of general
educational factors may play a part. anaesthesia for caesarean delivery was due to fetal indications
A prospective survey of patients post delivery detailing the for surgery, antepartum haemorrhage and failed spinal
reasons for their choices of labour analgesia would be anaesthesia. Improved practical conduct of the spinal
worthwhile. Establishing the factors influencing their technique may enhance great application of spinal anaesthesia
decisions may allow us to provide an unbiased and fully for caesarean section.
comprehensive service to ensure patient satisfaction. References

1..Morgan BM, Magni V, Goroszenuik T. Anaesthesia for emergency
caesarenc section. BrJ Obstet Gynaecol 1990; 97: 420-424
2..Amadasun FE, Idehen HO, Edomwonyi NP. Evolving pattern of
anaesthesia for caesarean section: Experience at the university of
Benin Teaching Hospital West Afr J Med 2013; 32: 196-9
P22 Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin)
P143 Failed intubation for a category 1 caesarean section in P144 Fasting dilemmas: A rare case of a patient with non-
a patient with undiagnosed spina bifida ketotic hyperglycinaemia presenting for caesarean
CR Deane,  E Lewis,  J Spargo   section
Department of Anaesthetics, Singleton Hospital, Swansea, M Behravesh,  S Dawson,  G McClune,  S Atkinson  
UK Anaesthetics, Royal Jubilee Maternity Hospital, Belfast, UK
Introduction: Non-ketotic hyperglycinaemia (NKH) is a rare
Introduction: Spina Bifida Occulta (SBO) is part of a spectrum
autosomal recessive metabolic disease caused by a defect in
of neural tube defects and is common. We present the case of
the glycine cleavage system. This case report describes the
a patient with previously undiagnosed SBO who required a
management of a patient who presented for caesarean section.
category 1 caesarean section (CS). Despite an unremarkable
To our knowledge there are no other published case reports of
airway assessment she had a failed intubation on rapid
this type.
sequence induction (RSI) and subsequently required an awake
fibre optic intubation (AFOI). Case Report: A 32 year old Para 1 presented for elective
caesarean section of twins at 37 weeks gestation. She had a
Case report: A 37 year old para 0 patient presented to labour
history of atypical non-ketotic hyperglycinaemia. Following
ward labouring with a single live foetus at 37 weeks gestation.
advice from clinical chemistry, during her 6 hours preoperative
She was admitted under consultant obstetric care with
fast she received an inceased dose of sodium benzoate and an
asymptomatic hypertension. When considering an epidural
intravenous infusion of 10% dextrose at 3mls/kg/hour which
she was examined and had a vascular naevus, associated with
was continued perioperatively. Caesarean section was
skin tethering, over lumbar vertebrae. She was asymptomatic,
performed under spinal anaesthesia and twin baby boys were
had never been investigated, and had no definitive diagnosis
delivered successfully. Post delivery of the second twin she
of SBO. Airway assessment included a Mallampatti score of 3,
received a bolus of 5 units of syntocinon followed by an
but was otherwise unremarkable. An epidural was declined to
infusion at 10 units per hour. Due to uterine atony and an
the patient, with a remifentanil PCA provided instead. A plan
operative blood loss of 1000mls she also received ergometrine
was agreed for a RSI GA if operative intervention was
carboprost intramuscularly to good effect. Sodium benzoate
required. Several hours later she required a category 1 CS.
was administered orally in recovery and the 10% dextrose
Initial laryngoscopy with a Mackintosh blade yielded a
infusion was continued until the patient was establised on an
Cormack and Lehane grade 3 view. Manipulation of the cricoid
oral regimen prescribed by the dieticians. This involved a
cartilage, long and McCoy blades did not improve the view.
series of high calorie drinks up to every 2 hours for 48 hours.
Two failed attempts were made to intubate using a bougie. The
No dietary protein was allowed for 24 hours post delivery.
patient was ventilated using a face mask and a Guedel airway
Glycine levels were monitored daily and were raised on day 5
with oxygen saturations above 97% throughout. She was
while dietary protien was being gradually reintroduced.
woken up without further incident and an AFOI was
performed. Her child was delivered by LSCS without further Discussion: NKH has an incidence of 1 in 60,000 with 3
incident or obvious deficit. The APGAR scores were 8 and 10 distinct presentations. Classically neonates present with
at one and five minutes. A grade 3 view was confirmed before lethergy, hypotonia and seizures. These symptoms can
the patient was woken. Recovery from anaesthesia was proceed to apnoea requiring ventilation and 30% of patients
uneventful. The patient was appropriately counselled. An do not survive the neonatal period. Severe psychomotor
Airway Alert Letter was issued and follow up appointment retardation is common in those who survive. A second,
made. An MRI was carried out subsequently and showed a atypical and very rare form presents with mild baseline
neural arch defect and dural tethering. Significantly the conus hyperglycinaemia and intermittent encephalopathy
lay as low as L4 with diastematomyelia as far as L2. assosciated with periods of illness. Transient neonatal
hyperglycinaemia has also been described. Biochemically,
Discussion: SBO is common and without prior imaging
NKH is characterized by elevated glycine concentrations in
presents the clinician with a difficult decision. Regional
plasma, CSF, and brain with a CSF glycine to plasma glycine
techniques risk neural or dural injury due to a low lying or
ratio greater than 0.08.1 Standard treatment strategies include
tethered cord.1 Abnormal spread of the analgesic agents may
protein restriction to reduce exogenous glycine,
give rise to either excessive cranial spread or inadequate
supplementation of one-carbon pool donors and
caudal spread. This patient population provides further issues
administration of sodium benzoate. NMDA antagonists have
for the anaesthetist given the high risk of operative delivery or
been shown to raise the developmental quotient, improve
other intervention (due to pelvic structural abnormalities) and
muscle tone and reduce seizures in these patients.2
the association of spina bifida with difficult intubation.2,3
Patients with spina bifida require careful preop assessment Prolonged periods of fasting predispose these patients to
and MRI imaging and careful airway consideration is essential glycine build up and its toxic neurological effects. This has
in order to inform anaesthetic planning. major implications for the anaesthetist in the perioperative
period. This case demonstrates the safe use of regional
References
anaesthesia in conjunction with careful nutritional planning.
1. Reynolds F. Damage to the conus medullaris following spinal
anaesthesia. Anaesthesia 2001; 56: 235-247. References
2. Richmond D, Zaharierski I, Bond A. Management of pregnancy in 1. Chang YT, Lin WD, Chin ZN et al. Nonketotic hyperglycinemia: A
mothers with spina bifida. Eur J Obstet Gynecol Reprod Biol 1987; case report and brief review. Biomedicine 2012; 2(2):80-82
25: 341-5. 2. Van Hove JL, Vande Kerckhove K, Hennermann JB et al. Benzoate
3. May A, Fombon F, Francis S. UK registry of high-risk obstetric treatment and the glycine index in nonketotic hyperglycinaemia.
anaesthesia: report on neurological disease. Int J Obstet Anaesth Journal of Inherited Metabolic Diseases. 2005;28:651–663
2008; 17: 31-6.
Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin) P23
P145 Fetal bradycardia following regional anaesthesia for P146 Further increase in hysterectomy rates - and the
emergency caesarean section and instrumental reason why
delivery: a service evaluation JS Campbell,  M Molloy,  C Thompson,  D Fogarty  
JK Sidana,  K Jadhav-Smith,  J Corfe   Royal-Jubilee Maternity Service, Belfast HSC Trust, Belfast,
Anaesthetics, Norfolk and Norwich University Hospital, UK
Norwich, UK Introduction: RJMS is the tertiary obstetric service for
Introduction: Fetal heart rate abnormalities, such as late Northern Ireland. As part of a service review of use of uterine
decelerations or fetal bradycardia, are known to occur after artery balloon catheters, we retrieved data from several
neuraxial anaesthesia.1 These may be due to maternal sources. We found a large proportion of these patients still
sympathetic blockade or an increase in the uterine tone caused required hysterectomy. Further interrogation of our data
by intrathecal opioids. The objective of this service evaluation showed some unexpected trends.
was to evaluate the incidence and management of fetal Methods: With approval of the Trust's Data Guardian we used
bradycardia following regional anaesthesia for emergency data from several hospital systems, including a local maternity
caesarean section and instrumental deliveries. care database and histology records.
Methods: 15 patients with an episode of fetal bradycardia Results: We found 30 hysterectomies from 37,088 deliveries in
following regional anaesthesia were identified by reviewing 6 years. This is a rate of 0.8 per 1000 - significantly higher than
the daily obstetric handover sheets from January to December our prior rates which was near the NICE-quoted rate of up to 3
2011. The medical notes of these patients were reviewed for per 1000. Of these cases, 23 (76%) were due to morbidly
peripartum obstetric management, cardiotocographic (CTG) adherent placenta.
findings, perioperative anaesthetic management and
Not all these cases of morbidly adherent placenta were
management of fetal bradycardia. Neonatal outcome was
diagnosed antenatally, which perhaps made hysterectomy
assessed by APGAR scores, umbilical cord gases and NICU.
more likely since facilities such as intra-arterial balloon
Results: 10 patients had an assisted delivery and 5 had an catheters could not be available to us in an emergency.
emergency category-2 LSCS. The peripartum CTG findings Unanticipated cases suffered greater blood loss. Despite no
were either suspicious or pathological. Timing of fetal diagnosis, the majority (16/23) were placenta percreta on
bradycardia following regional anaesthesia ranged from 2 to 15 histology. These percreta cases again had greater blood loss,
min. 13 patients received spinal anaesthesia and 2 received and were more likely to require ICU care post-operatively. Yet
epidural top up. Maternal haemodynamics stability was there were no cases of percreta in the 6 years prior, and less
maintained with left uterine displacement, intravenous fluids than half the number of hysterectomies in that period. This
and phenylephrine infusion. One patient had an episode of seems to be a dangerous and dramatic change in recent years.
maternal bradycardia below 50 beats/min which was treated
Conclusion: We found a recent and significant increase in
with anticholinergics. Comparing the baseline maternal heart
peripartum hysterectomy, associated with a large increase in
rate with the lowest perioperative heart rate, 3 patients had a
the number and degree of morbidly adherent placenta. Patients
greater than 40% drop in the heart rate. 5 patients had a blood
with placenta percreta had a greater blood loss, and more
pressure drop of more than 20% below the baseline, which was
commonly required hysterectomy and ICU care.
treated with phenylephrine. The highest level of block to
Reference
temperature was T3. Syntocinon was stopped in all but one
case in the event of fetal bradycardia. Significant delays 1. National Institute for Health and Clinical Excellence. Caesarean
section: NICE Clinical Guideline 132 2012,
occurred in transferring these patients to theatre after the
http://www.nice.org.uk/nicemedia/live/13620/57163/57163.pdf
decision for surgical intervention were taken, maximum 35 min
(median 17 min). 6 cases had poor neonatal outcomes with low
5 minute APGAR and abnormal cord gases.
Discussion: We could not find any direct cause which can be
solely attributed to regional anaesthesia for the occurrence of
fetal bradycardia in these patients. Significant delay in patient
transfer to theatre may have a causal relationship but cannot
be confirmed. Studies in elective patients have shown that
maternal bradycardia causes a drop in maternal cardiac output.
2 Relative maternal bradycardia occurred in several of our
cases and this would have led to drop in cardiac output and
therefore oxygen delivery. This is most likely a side effect of
phenylephrine use. We plan to introduce a care bundle to
implement pre-operative and intra-operative fetal resuscitation.
This will include steps to improve fetal condition at the time of
regional anaesthesia and to ensure adequate maternal cardiac
output and oxygen delivery.
References
1. Reynolds F, Seed PT. Anaesthesia for Caesarean section and
neonatal acid-base status: a meta-analysis. Anaesthesia 2005; 60:
636–653
2. Stewart A, Fernando R et al. The dose-dependent effects of
phenylephrine for elective caesarean delivery under spinal
anaesthesia. Anesthesia & Analgesia 2010; 111: 1230-7.
P24 Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin)
P147 Impact of workload on accidental dural puncture P148 Implantable cardioverter defibrillator in
(ADP) rate pregnancy WITHDRAWN FROM PRESENTATION
W Mon,  YM Liu,  A Stewart,  R Fernando,  M Columb*   S Chaudhari,  S Quasim  
Anaesthetics, University College London Hospital, London, Anaesthetic Department, University Hospital Coventry and
UK, *Intensive Care Unit, University Hospital of South Warwickshire , Coventry, UK
Manchester, Manchester, UK
Introduction: Post dural puncture headache is an important
cause of morbidity. We audit our ADP rates annually against
the national standard.1Between 2005 and 2008, our ADP rate
was stable at approximately 0.5%. However, from 2008 to 2010,
our rate rose to above the 1% national standard.1Therefore, we
audited factors that may have contributed to this increase.
Methods: Information for this audit was obtained from a
computerised database. Data collection included day, month
and time of ADP and the grade of anaesthetist. We also
collected annual data of number of deliveries, epidurals and
combined spinal epidurals (CSEs) for labour, caesarean section
(CS) data, and the proportion of single shot spinals (SSS) to
CSEs performed. Data were analysed using chi-square
multinomial and trend tests with P value <0.05 defined as
significant.
Results: There was a 40% increase in deliveries between 2008-
2010. CSs and regional blocks for analgesia increased by 36%
and 40% respectively. Although the ADP rate increased, we
could not demonstrate a statistically significant trend due to
small numbers. From 2010 to 2012, a non-significant fall in the
ADP rate was seen. There was no significant association
between ADPs and day, month or time. We did see a
significant non-linear trend (P = 0.0012) in the proportions of
SSSs to CSEs performed, with the peak occurring in 2010.
Table 1. Trend of activity and ADP rate from 2008 to 2012
  2008 2009 2010 2011 2012 P value
Maternities (n) 4032 5039 5647 5841 5953 < 0.0001
Epidurals for labour (n) 1306 1600 1839 2029 2132 < 0.0001
CSs (n) 1370 1562 1861 1862 1773 < 0.0001
SSSs for CS (n) 282 274 356 326 347 0.0015
CSEs for CS (n) 797 644 714 833 915 < 0.0001
Proportion of SSS to CSE (%) 26 30 33 28 27 0.0012
ADP rate (%) 0.57 0.98 1.05 1.01 0.82 0.31
Discussion: We observed an increase in ADPs until 2010, with
significant rises in deliveries and anaesthetic procedures
performed. The significant non-linear trend in the proportions
of SSSs to CSEs performed for CSs peaked in 2010. A fall in the
ADP rate between 2010-2012, occurred despite exposing more
women to the risk of ADP, as during this time we performed
significantly more CSEs than SSSs proportionally. We believe
that the rise in the ADP rate resulted from a significant
increase in our workload between 2008 and 2010, without any
increase in anaesthetic staffing. From 2010 onwards, daytime
anaesthetic consultant sessions increased by 50%, and there
was a higher presence on the labour ward out of hours by
senior registrars covering non-obstetric theatres. Both factors
may have contributed to the subsequent fall in the ADP rate.
This audit supports the recent OAA/AAGBI guideline
recommending increased anaesthetic staffing on labour ward.2
References
1. Royal College of Anaesthetists. Epidural analgesia during labour.
Raising the standard: a compendium of audit recipes. 2012;218-219
2. Association of Anaesthetists of Great Britain and Ireland and
Obstetric Anaesthetists' Association. OAA/AAGBI guidelines for
obstetric anaesthetic services. 2013
Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin) P25
P149 Inadvertent hypothermia during elective caesarean P150 Inter professional relationships on labour ward- how
sections well do anaesthetists and midwives get along?
S Botros,  R Labib,  T Ramhew,  M Baban,  Y Poonawala   M Salman,  P Kumar,  G Graham  
Selwyn Crawford Department of Anaesthesia , Birmingham Anaesthetics, St. Thomas' Hospital, London, UK
Women's Hospital, Birmingham, UK Introduction: Anaesthetists and midwives are part of the
Introduction: The National Institute for Health and Care multi-professional team that provides care for parturients.
Excellence (NICE) defines inadvertent perioperative They work together in close collaboration in the unique and
hypothermia as a core body temperature below 36°C.1 It is a often highly charged environment of labour ward. In such
common complication of regional anaesthesia, and is the settings, effective inter professional relationships are key to
leading cause of perioperative shivering. Hypothermia is the delivery of high quality care and consequently better
associated with increased risk of wound infection and patient outcomes. Successful collaborative practice can be
increased blood loss.1 Shivering can be associated with negatively impacted by barriers such as lack of clarity on the
increased oxygen consumption and hypoxaemia in vulnerable scope of roles of team members, poor communication, or
patients. Although the NICE guideline on the management of stereotyping. We conducted a survey amongst obstetric
perioperative hypothermia did not cover pregnant women,1 it anaesthetists and midwives in our hospital to reflect upon this
has been adopted by many obstetric units. In our unit, working relationship and to see how it may be improved.
intravenous (IV) fluid is not routinely warmed for elective
Methods: A questionnaire was designed and distributed to
caesarean sections (CS). Hence, we audited our practice to
midwives and anaesthetists of all grades. Questions were
evaluate the incidence of hypothermia.
asked on their understanding of each other's professional role
Methods: Over a three month period, we prospectively audited
and on their perception of the quality and effectiveness of
our practice in 47 women who had elective CS under
their working relationship. A total of 43 responses were
subarachnoid anaesthesia without active warming. We
collected (24 anaesthetists and 19 midwives) in an ongoing
measured their tympanic temperature prior to anaesthesia (T )
1 survey.
and at the end of surgery (T ). We also collected data that may
2 Results: Of the anaesthetists who completed the
influence the results like the volume of IV fluid infused,
questionnaire, 16.6% were consultants, 58.3% were ST5-ST7,
estimated blood loss (EBL) and duration of surgery. We also
20.8% were ST3-4 and 4.1% were CT1-2. When asked whether
assessed the incidence of perioperative shivering. We
they felt they understood the scope of responsibilities of
repeated the audit in 42 parturients using an IV fluid warming
midwives on labour ward, only 27% of anaesthetists felt they
device. The data were analysed using Microsoft Excel 2007®.
understood it fully. In contrast, 63% of midwives believed they
Data from both audits were compared and p-values were
fully understood the scope of the anaesthetist's
calculated using unpaired t-test by GraphPad software®.
responsibilities.
Results: In the initial audit, 20 patients (42.55%) were
hypothermic at the end of surgery (T < 36°C). Shivering Thirty percent of midwives felt that collaboration with
2
occurred in 14 patients (29.79%). No correlation was found anaesthetists was 'very easy', in contrast to only 5.5% of
between T and the IV fluid volume, EBL, duration of surgery anaesthetists who felt the same about collaboration with their
1-2
or the dose of intrathecal Bupivacaine. In the re-audit, only 3 midwife colleagues. While 16% of anaesthetists found this
(7.14%) patients experienced hypothermia. There was no collaboration 'difficult', none of the midwives did (0%).
statistical difference in T between the two audits (p = 0.781). Seventy two percent of anaesthetists felt their input was
1
usually well-received by their midwife colleagues, compared to
  Initial Audit (n=47) Re-audit (n=42) p-value
only 40% of midwives who thought their input was well-
Fluid (ml) 1116.67(±369.43) 1233.33 (±483.59) 0.2236
received by the anaesthetist. Both professions were asked
EBL (ml) 523.75 (±152.33) 582.5 (±491.67) 0.474
how they perceived the general quality of communication
T1 36.84 (±0.37) 36.81 (±0.37) 0.781
between them. The majority of anaesthetists (47%) perceived it
T2 36.08 (±0.4) 36.3 (±0.29) 0.004
as 'fair', while 15% regarded it as 'poor'. Ninety percent of
T 0.76 (±0.34) 0.52 (±0.41) 0.0032
1-2 midwives felt it was either 'very good' or 'good'. None of the
Discussion: Our audit highlights the effect of warm IV fluid midwives (0%) felt it to be 'poor'.
therapy on reducing the incidence of inadvertent perioperative
Questions were asked on the types of obstacles they
hypothermia during elective CS. Our audit recommends the
encountered in their professional interaction with each other.
routine warming of IV fluid during elective CS. The Enhanced
Most anaesthetists (72%) agreed that they found fixation on
Recovery Partnership Programme considers patient warming
tasks and exclusion of others to be a challenge, followed by
as a key factor in accelerating patient recovery.2 Following our
delayed or non-communication of important issues (57%). A
results and as part of developing a new pathway for enhanced
third of the anaesthetists felt they rarely got a comprehensive
recovery post CS; our trust is currently looking to invest in a
handover from the midwife while only 29% of midwives felt
cost-effective IV fluid warming device.
they understood the rationale behind the anaesthetists'
References decisions.
1. NICE (2008) Perioperative hypothermia (inadvertent): full Conclusion: Despite both specialties working in close
guideline (CG65). Full Guideline. London: National Institute for proximity, the survey identified several gaps in
Health and Care Excellence.
communication. Working towards enhancement of the
2. Enhanced Recovery Partnership (2012) Fulfilling the potential: a
professional relationship between members of the team
better journey for patients and a better deal for the NHS. Leicester:
NHS Improvement. Available at http://www.improvement.nhs.uk providing maternity services will help facilitate their
(accessed 14/12/2013) collaboration and will reflect positively on the performance of
both professions.

P26 Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin)
P151 Intra-arterial balloon catheters: A service evaluation P152 Intrathecal diamorphine for cesarian section following
JS Campbell,  M Molloy,  D Fogarty   intramuscular diamorphine during labour: a cause for
Royal-Jubilee Maternity Service, Belfast HSC Trust, Belfast, concern?
UK RC Barr,  L Parks  
Introduction: Intra-arterial balloon catheters have become Anaesthetics and Intensive Care, Southern Health and Care
widely used and predominantly accepted in cases where Trust, Northern Ireland, UK
massive haemorrhage is anticipated, especially with morbidly Introduction: Diamorphine has largely replaced pethidine for
adherent placenta . However, the benefits are still intramuscular (IM) analgesia during labour in our obstetric
1,2
controversial. While our unit is not stand-alone, our building unit. We also routinely give diamorphine (250-300 micrograms)
is physically separated from other departments including intrathecally (IT) for cesarian sections. A recent case of
radiology, so the logistics of balloon catheters are difficult2. meiosis and drowsiness, in a lady presenting for a category 2
Our objective was to identify the impact of balloon catheters cesarian section having received IM diamorphine in labour,
on management of morbidly adherent placenta. Associated highlighted the potential for side effects when diamorphine is
anaesthetic issues include massive transfusion, cell salvage, used IM and then IT. Should we therefore consider adjusting
type of anaesthetic and post-operative care. our IT dose of diamorphine in women presenting for
Methods: With permission of the Trust's Data Guardian, we emergency cesarian sections? To our knowledge there are no
retrieved data from multiple sources to identify and review guidelines on this subject and clinical practice appears
cases where balloon catheters where used. These included variable.
radiology logs, maternity records and histology. Methods: We conducted a survey of all anaesthetists working
Results: Ten cases were identifed via these systems. Seven in the Southern Health and Social Care Trust who partake in
were for morbidly adherent placenta, of which 5 required obstetric anaesthesia. Questions focused on; current
hysterectomy despite balloon inflation. Many of these were diamorphine practice, diamorphine dose adjustments, factors
cases of placenta percreta, despite antenatal diagnosis of influencing our dose decisions and concerns regarding
accreta. However, blood loss was lower by around 20% potential side-effects with IT diamorphine.
(1078ml) using balloons, when compared to other Results: We received 24 replies; 14 consultants and 10
hysterectomies in the same time period. experienced trainees who regularly perform obstetric
Other indications were for intra-abdominal pregnancy and anaesthesia. There was a wide variation in diamorphine
persistent post-partum haemorrhage. Another case was practice amongst our anaesthetists. The majority (76%)
abandoned due to logistical reasons (unable to organise consider reducing their IT dose following IM diamorphine.
theatre time in same building), a decision felt to be open to Factors influencing this dose reduction include timing (88%)
medicolegal criticism after preparation and planning for and dose (29%) of the last IM diamorphine and clinical signs
balloons. of toxicity (76%). In particular anaesthetists were concerned
about postoperative respiratory depression (94%) and
Limitations particularly reflected the limitations and
drowsiness (88%), although no one surveyed reported
inconsistency of the systems used, for example no coding in
experience of these or other adverse effects associated with IT
records for morbidly adherent placenta. Local presentation
diamorphine.
highlighted these problems, which are being taken forward.
Discussion: There is variability regarding the IT diamorphine
Conclusion: Our review, and subsequent MDT discussion,
dose given to women for emergency cesarian section who
has confirmed the place of intra-arterial balloon catheters
have already received IM diamorphine in labour. This practice
within local guidelines for management of morbidly adherent
is based on limited evidence. Given the lack of adverse effects
placenta, and other occasional indications. We had decreased
reported from our survey and evidence from other specialties
blood loss in cases using balloons, but still saw a large
where diamorphine is used in higher doses 1,2,, we see no
proportion requiring hysterectomy.
reason to routinely reduce the IT diamorphine dose unless
References
there are clinical signs of opiate toxicity. Consideration should
1. Beilin Y, Halpern SH. Placenta accreta: successful outcome is all in be given to prolonged postoperative monitoring of all women
the planning. Int J Obstet Anesth. 2013;22:269–271.
who have received both IM and IT diamorphine, especially
2. Sadashivaiah J, Wilson R, Thein A. Role of prophylactic uterine
artery balloon catheters in the management of women with those in whom the interval between IM and IT diamorphine is
suspected placenta accreta. Int J Obstet Anesth. 2011;20:282-287 short or where there are signs of toxicity.
References
1. Fogarty DJ, Milligan KR. Postoperative analgesia following total
hip replacement ; a comparison of intrathecal morphine and
diamorphine. Journal of the Royal Society of Medicine 1995; 88:
70-72
2. Jacobson L, Kokri MS, Pridie AK. Intrathecal diamorphine: a dose-
response study. Annals of the Royal College of Surgeons of England
1989; 71: 289-292
Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin) P27
P153 Introducing self-administration of medication after P154 Is Remifentanil patient controlled analgesia an
caesarean section: a Robert The Bruce story effective alternative to epidural for labour analgesia?
A R Sajayan,  K Ramm,  T Yates,  Y Chikermane   V Betharia,  K Peckitt  
Anaesthesia, Heartlands Hospital, Birmingham, UK Anaesthesia, Stepping Hill Hospital, Stockport, UK
Introduction: We were involved in the introduction of the local Introduction: Remifentanil patient controlled analgesia (PCA)
protocol for self-administration of postoperative medications was introduced for pain relief in labour at our institution in
(SAM) after elective LSCS at a large obstetric unit. In the past, 2007. Since then its demand has steadily increased, gaining
several attempts to implement this have failed.We conducted a favour with midwives and patients due to simplicity of use,
pilot study to identify the obstacles and develop ways to effective analgesia¹ and good safety profile². We have
overcome the same standardised protocols for administration and monitoring of
Methods:A pilot project was conducted to find out the Remifentanil PCA and patient controlled epidural analgesia
obstacles in the process by obtaining feedback from the staff (PCEA) during labour which are strictly adhered to. Aim of our
and patient involved in the care of 10 patients who underwent audit was to assess both Remifentanil PCA and epidural PCEA
elective LSCS over a week’s time. Obstetric, anaesthetic, for labour analgesia and make recommendations for improved
recovery and ward staff were informed beforehand about this care of mothers and infants.
pilot by emails and personal discussion. The patients were Methods: This was a prospectively done, questionnaire based
given information leaflet during preoperative assessment and audit. Data was collected over 2 months from November 2013 -
were informed again on the day of operation. Interested January 2014. We looked at mode of delivery,
patients enrolled in the pilot with due consent. The self- cardiotocographic abnormalities, APGAR scores, maternal
administration pack contained analgesics and enoxparin and cardio-respiratory complications, conversion to alternative
was dispensed by the recovery staff. Exclusions were: methods of analgesia and patient satisfaction.
language barrier, patient refusal, lack of capacity and any co Results: There were 610 deliveries during the 2 months.
morbidities. Feedback was collected from patients and staff Remifentanil PCA was used in 102 (17%) and epidural PCEA in
using the standardized proforma during the postoperative 85 (12.2%) patients for labour analgesia.
visit. Mode of delivery:
Results:Two of the patients felt that on the first day it was
  Normal Assisted LSCS
difficult to use SAM due to mobility restrictions. One patient
Remifentanil PCA 69 (67%) 20 (19.6%) 13 (12.7%)
did not receive SAM pack due to communication problem
Epidural PCEA 29 (34%) 35 (41%) 21 (24.7%)
involving midwives and staff. The remaining seven patients
were satisfied with SAM. The obstacles we identified in the There was a higher incidence of cardiotocographic
pilot and also from the past experience and the way we tackled abnormality in the epidural group (61%) as opposed to
them are as below: Remifentanil group (34%). APGAR scores in both groups were
more than 8 at 5 minutes. None of the patients in either group
Obstacle Strategy
had respiratory depression or cardiovascular instability. Eight
Personal & email reminder
(7.8%) patients converted from Remifentanil to epidural due to
Promotional posters in clinical areas
inadequate analgesia whereas 4 (4.7%) patients in the epidural
Communication Reminder notices in operating room and recovery
group used alternative analgesia (3 switched to Remifentanil
Meeting with stakeholders (doctors, midwives&
and 1 to entonox). Patient satisfaction was similar in both
pharmacist)
groups at 95%.
Involving all staff in guideline preparation
Discussion: From our experience, Remifentanil PCA is a safe
Staff engagement Process simplified and paper work streamlined
and effective method of labour analgesia. We found no
Standardized SAM package and delivery
evidence of worsening cardiotocography or neonatal
Guideline Fully prepared guideline after extensive consultation
outcomes with its use. We also found that patients using
Time Pre-printed forms to increase efficiency and to avoid
Remifentanil have increased rate of vaginal deliveries as
management time delays and work duplication
compared to those on epidural. While epidural analgesia
Discussion: Self-administrationof medications after caesarean remains the gold standard and will be preferable in certain
provides better patient centered care. It improves patient and groups of patients, Remifentanil PCA is certainly an excellent
staff satisfaction, improves clinical efficiency and eases alternative to consider. In our institution its uptake has
staffworkload at hospital and at community level1. It empowers steadily increased to approximately 50 patients per month with
the mother in their own care, potentially reduces length of patients consistently report ing high levels of satisfaction.
stay, and facilitates seamless flow ofcare. Although staff and References
patients liked the concept alike, the process had failedthree
1. Blair JM, Dobson JT, Hill DA, McCracken GR, Fee JP. Patient
times before because of certain obstacles. This pilot helped us controlled analgesia for labour: a comparison of remifentanil with
to highlight the areas we needed to focus on with our new pethidine. Anaesthesia 2005; 60 (1) : 22-7
strategies and the results have been encouraging. After fully 2. Volikas I, Butwick A, Wilkinson C, Pleming A, Nicholson G.
Maternal and neonatal side-effects of remifentanil patient
implementing the project, the uptake is gradually getting better
controlled analgesia in labour. Br J Anaes 2005; 95(4): 504-9
and we continue to audit the outcome.
References
1. Snell P M, Bowden M I, Viira D J, Chilvers J P. An observational
study of self-medication of analgesic drugs after caesarean section.
Int J Obstet Anesth 2002; 11: S29
2. Change management good practice guideline-NHS Direct
P28 Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin)
P155 Is the existing local hospital guideline, 'Management P156 Klippel-Feil syndrome: management of anticipated
of women who decline blood products', being adhered difficult airway for caesarean delivery 
to? TM Price,  MT Qureshi,  ROK Laird  
J Houston,  R Burns   Department of Anaesthesia, Altnagelvin Area Hospital,
Simpson Centre for Reproductive Health, Royal Infirmary of Derry, UK
Edinburgh, Edinburgh, UK Introduction: Klippel-Feil syndrome (KFS) is a rare genetic
Introduction: An estimated 150000 Jehovah's Witnesses disorder affecting around 1 in 40,000 live births and is
(JWs) live in the UK1. JWs may not accept blood product (BP) characterised by the congenital fusion of any two of the
transfusion1, and have up to 130 times increased risk of cervical vertebrae1. In addition to the abnormalities of the
maternal death from major obstetric haemorrhage2. This cervical spine, patients may have thoracolumbar scoliosis,
retrospective case note review aims to establish how closely spina bifida and congenital heart defects. The classical
the hospital guideline, 'Management of women who decline phenotypic presentation is described as low hairline, short
blood products' (the Guideline), has been followed since its neck and limited neck and head movement. These patients can
May 2012 introduction, and to identify areas for improvement. therefore present a considerable challenge to the anaesthetist.
Methods: JWs managed at the Anaesthetic Antenatal Clinic The safest method of providing anaesthesia for operative
(AAC) since the Guideline's introduction were identified, and delivery of a parturient with KFS is controversial. We would
their medical records accessed. Information surrounding like to share our experience in managing four elective
aspects of patient management addressed by the Guideline caesarean deliveries in two parturients using awake oral fibre
was extracted. The findings were then audited against the optic intubation (AOFOI) and general anaesthesia.
Guideline to establish how closely it had been followed. Case Reports: The first patient had KFS Type II with fusion of
Approval was obtained from the Medical School and the cervical vertebrae and underwent elective caesarean deliveries
Regional Research Ethics Service. aged 35 and 37 years old. The second patient had KFS Type
Results: Of the patients referred (N=26), 92.3% were reviewed III with fused cervical vertebrae in conjunction with fusions in
at the AAC, and had management plans created, at 31.0 weeks' the thoracolumbar spine, and underwent elective caesarean
gestation on average (Guideline target: 28.0 weeks). 88.5% deliveries aged 31 and 39 years old. Our patients were both
completed a BP checklist before admission in labour, and pre-assessed by a consultant anaesthetist at a high-risk
96.2% by time of delivery. 7.7% agreed to accept BPs at clinic pregnancy clinic prior to delivery. This allowed time to discuss
and were discharged, so women studied became N=24. BP the anaesthetic options with each patient and plan for elective
refusal of 12.5% was not appropriately recorded in the notes, or emergency delivery. Both patients had the classical
and contrary to the Guideline, serum ferritin was not checked phenotypic features of KFS. Airway assessments revealed
in any woman. During pregnancy, 29.2% were not recorded as Mallampati class 4, thyromental distances less than 6cm and
having taken iron, and Hb was measured in 95.8%. Excluding severely limited neck flexion and extension. The trachea was
elective caesarean sections (CS), Obstetric consultants were not palpable in either patient. We anticipated difficult direct
documented as informed of admission in 13.6% of cases, and laryngoscopy in both patients and elected to manage the
54.5% of labours and deliveries were reviewed or supervised airway with an AOFOI followed by general anaesthesia. The
by senior Obstetric staff (ST6-consultant). 20.8% of total oral route was chosen as both patients had small nares in
deliveries were by CS: cell salvage was set up in 100.0% of keeping with KFS. Sugammadex ensured complete reversal of
these, and used in 80.0%. rocuronium induced neuromuscular blockade and smooth
Discussion: This study found the Guideline was closely emergence. Caesarean delivery and postoperative recovery
followed in some areas: completion of acceptable BP checklists was uneventful in all four cases.
before delivery, and availability and use of cell salvage in CS,
Discussion: As obstetric anaesthetists we are constantly
compare favourably to previous UK studies1,3. Areas to be
trying to minimise the risk to our mothers. Klippel-Feil
improved include that BP refusal must be appropriately
syndrome affects both the airway and the spine, making the
recorded in patient notes to ensure clarity upon presentation
choice of anaesthetic technique a difficult decision. Successful
in labour or an emergency. It is vital that iron supplementation
use of regional techniques including spinal, epidural and
is commenced early in JWs, and ferritin levels are monitored,
combined spinal-epidural anaesthesia, have all been described
to maximise iron stores. In light of this study's findings,
in the literature1. However, we feel that embarking upon a
hospital blood transfusion Haematologists, in the future, will
regional technique in patients with distorted neuroaxial
review JWs antenatally. The Guideline should quantify how
anatomy would expose patients to unnecessary risk of high
often Hb should be monitored, so anaemia can be detected
spinal block and/or inadequate regional anaesthesia. Should
and treated before delivery. Crucially, consultant staff must be
general anaesthesia be needed intra-operatively, attempting an
documented as informed upon admission of JWs in labour, in
AOFOI in an already distressed parturient would be
order that deliveries can be supervised by senior staff to
challenging. We therefore planned an AOFOI to secure the
reduce potential morbidity and mortality.
airway prior to general anaesthesia, in a controlled manner and
References
thus avoid a potentially difficult and emergent intraoperative
1. Massiah N, Athimulam S, Loo C, Okolo S, Yoong W. Obstetric care intubation. In summary, these are difficult cases that we
of Jehovah's Witnesses: a 14-year observational study. Arch
believe benefit from good antenatal planning and can be
Gynecol Obstet 2007; 276(4):330-343.
managed with a planned AOFOI and general anaesthesia.
2. Van Wolfswinkel ME, Zwart JJ, Schutte JM, Duvekot JJ, Pel M, Van
Roosmalen J. Maternal mortality and serious maternal morbidity in
Jehovah's witnesses in the Netherlands. BJOG 2009; 116(8): 1103- Reference
1108. 1. T. Kavanagh, R. Jee, N. Kilpatrick, J. Douglas. Elective cesarean
3. Nawaz YM, Atkinson S. Peripartum care of Jehovah's witness delivery in a parturient with Klippel–Feil syndrome. Int J Obstet
parturients: A five year review. Int J Obstet Anesth 2013; 22(S1): Anesth 2013; 22(4): 343-8
S22.
Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin) P29
P157 Labour and delivery in long QTsyndrome P158 Local anaesthetic toxicity audit: are workshops the
BJ Vowles,  FMM Bryden   best educational tool across the MDT?   
Anaesthetic department, Princess Royal Maternity, Glasgow, WITHDRAWN FROM PRESENTATION
UK JL Lambert,  D Chitre,  L Evans  
Introduction: A 22 year old primigravida presented to the high Anaesthesia, Southend Hospital, Southend, UK
risk clinic at 22 weeks gestation. She had been diagnosed with
long QT syndrome (LQTS) after her family had been
investigated following a sudden early cardiac death and was
found to be heterozygous for the KCNQ1 gene, responsible
for Long QT1. She was under regular review by the
cardiologists who had advised β blockade with bisoprolol
2.5mg orally (PO) for 9 months post partum due to an increase
in arrhythmia risk during this period. She had also been given
a list from Azcert Inc., advising drugs that should be avoided
and included on this list was syntocinon.
Labour and delivery: She was admitted in labour at term and
the decision was made by the obstetric team, not to administer
syntocinon to augment labour. They also felt that epidural
analgesia was unsuitable because it would slow the progress
of labour. However following an initial dose of intramuscular
(IM) diamorphine, the parturient requested epidural analgesia.
We felt this would be beneficial for minimising her arrhythmia
risk and so she obtained a working epidural with a bilateral T10
block. ECG monitoring was commenced on admission and
.
initially showed bigeminy. A 12 lead ECG demonstrated a QTc
of 460ms. Electrolytes checked at this time were in the normal
range. Over the subsequent 8 hours she failed to progress and
underwent a caesarean section with an effective epidural top
up of 20ml 0.5% L-bupivacaine. At delivery syntocinon was
administered as a slow infusion of 5 units in 100mls 0.9%
saline over 20 minutes, followed by 500µg ergometrine IM to
maintain uterine tone. 50mg IM cyclizine and 10mg
intravenous (IV) metoclopramide were used for anti-emesis.
She was monitored in the Obstetric high dependency unit
(HDU) for the following 48 hours, where an initial ECG
demonstrated frequent ventricular ectopics, with a QTc 432ms.
Electrolytes were again normal at this time.
Discussion: There are many lists of drugs available on the
internet with differing advice as to which drugs to avoid in
long QT syndrome. The one which our patient had been given
clearly stated syntocinon should not be administered, despite
no definitive evidence of harm with this drug in patients with
LQTS. In addition we found no guidance in published case
reports, on oxytocic drugs administered to patients with LQTS
in labour or at delivery1. There are case reports of ventricular
tachycardia after administration of syntocinon in long
QTsyndrome2 and one report of a pateint receiving it with no
sequelae3 Ideally the authors feel that this lady merited a case
conference prior to admission so that informed decisions
could be made. Whilst the outcome of this patient's labour and
delivery may not have been different, a short trial of
syntocinon with ECG monitoring may have altered her mode of
delivery.
References
1. Drake E, Preston R, Douglas J. Brief review: anaesthetics
implications of long QT syndrome in pregnancy. Can J Anaesth.
2007; 54(7): 561-72
2. Liou SC, Chen C, Wong SY, Wong KM. Ventricular tachycardia
after oxytocin injection in patients with prolonged Q-T syndrome -
report of two cases. Acta Anaesthesiol Sin 1998; 36: 49-52
3. Charbit B, Funck-Bretano C, Samain E, Jannier-Guillou V,
Albaladejo P, Marty J. Qt interval prolongation after oxytocin bolus
during surgical induced abortion. Clin Pharmacol Ther 2004; 76:
359-64
P30 Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin)
P159 Lymphangioleiomyomatosis and Pregnancy: A Case P160 Major obstetric bleeds-are we doing the right thing?-
Report A multi-centre study in west midlands
M Cole,  S Petkov,  J Pickett   A R Sajayan,  M McLoughlin,  S Dinesh,  A Walunj*,  J
Anaesthetics, Addenbrookes Hospital, Cambridge, UK Karattuparambil †,  M Ravindran†  
Introduction: Anaesthesia, Heartlands Hospital, Birmingham, UK,
Lymphangioleiomyomatosis (LAM) is a rare condition causing *Anaesthesia, Good Hope Hospital, Sutton Coldfield, UK,
proliferation of smooth muscle in the respiratory system, †Anaesthesia, George Eliot Hospital, Nuneaton, UK 
which can cavitate leading to degradation of lung parenchyma Introduction:Guidelines1 exist on the definitions of massive
and cystic lung disease1. Because of the risk of progression, bleed, the proposed management pathway and the safe time
women with LAM are frequently advised to avoid pregnancy2. frame for obtaining the blood and products. This multi-centre
We present a case of LAM where multidisciplinary audit looks at the average time taken for the blood/products to
management led to a successful outcome of pregnancy, with a be available in major bleed situations in obstetrics
focus on anaesthetic considerations. Aim: To find out the incidence and reasons for delays in
Case Study: issuing the blood/products, if any, from the blood bank and to
A 35 year old woman presented with bilateral spontaneous compare the existing practices and experience with the other
pneumothoraces in the first trimester of her 2nd pregnancy. hospitals in the area
Both required surgical correction and a lung biopsy revealed a Methods: We collected the data from three participating
diagnosis of LAM. Computerised tomography of her thorax hospital in west midlands using a standard proforma which
showed multiple small lung cysts. Past history included an included the number of massive obstetric bleed calls during a
uncomplicated first pregnancy and emergency caesarean six months period in 2013, the estimated blood loss, the time
section for foetal distress, aged 33; and a spontaneous taken for the first unit of blood/ product to be issued and the
pneumothorax aged 34, requiring surgery. The patient was number of products used among other data.
referred to a tertiary centre for multidisciplinary management.
Results: The results suggested that there is ambiguity in the
Care was shared between obstetrics and respiratory medicine
way major haemorrhage was defined in different situations
and she attended the high risk anaesthetic clinic. Elective
which led to unnecessary calls where blood products were not
caesarean delivery at 38 weeks was agreed upon. She had
urgently needed. Also, the time for getting the products varied
three further small pneumothoraces, treated conservatively
widely the longest being 200 minutes. The documentation of
with no marked deterioration in respiratory function. Elective
the details of the bleeding, time of calls and time of
caesarean section was performed at 38/40 gestation.
blood/product administration were incomplete and inaccurate
Respiratory assessment and examination on the morning of
in some cases.In one hospital, major bleed calls were only put
surgery were normal. A two-space combined spinal epidural
out in two out of 17 cases where blood loss was more than
was sited, administering intrathecal hyperbaric bupivacaine
1500ml.
and diamorphine. A respiratory physician was present at
delivery in case of deterioration. Delivery was uneventful, with   Hospital1 Hospital2 Hospital 3
no immediate complications. The patient spent 24 hours in an Number of MOH calls 58 41 2
obstetric close observation unit post-operatively. Her post- Full data available 13 18 2
natal period was uneventful and required no further obstetric, Average time for group specific (min) 59 NA 33
respiratory or anaesthetic intervention. Average time for X match blood (min) 63.45 42.27 0
Longest delay (min) 200 104 33
Discussion: LAM is a rare condition with an estimated UK
prevalence of 1per million3. Hypotheses suggest oestrogen
Discussion: The definitions of massive blood loss are:
accelerates disease progression and pregnancy may result in
Transfusion of a volume equal to the patient’s total blood
new diagnosis or exacerbation4, therefore obstetric
volume in less than 24 hours / 50% loss of blood volume
anaesthetists should have awareness of this disease. There is
within 3 hours / rate of blood loss 150ml/minute. Though the
sparse literature for anaesthetic management of pregnancy
circumstances of individual episodes of major bleed could
with LAM, consisting mainly of case reports. Considerations
vary, there was no consistency in the trigger of activating
suggested include; avoiding excessive Valsalva manoeuvre
major bleed calls. There were also unacceptable delays in
via instrumental or elective caesarean delivery, avoid nitrous
obtaining the first unit of blood in some cases. The first set of
oxide, early epidural analgesia, obtunding intubation response
uncross matched group specific blood should be available in
and lung protective ventilation strategies if general
20minutes and cross matched blood in 40minutes2. The study
anaesthesia. This case report supports that pregnancy in
suggest that there is a need for the reinforcement of major
LAM patients can progress successfully and highlights the
bleeds definition and also a need for a clearer pathway and
importance of a MDT approach, early anaesthetic assessment
consistency in issuing blood and products in major bleed
and a well considered anaesthetic and obstetric plan.
situations. This audit results will be used to formulate a
References uniform policy in the participating hospitals and a re-audit will
1. Rosendal T. A Case of Diffuse Myomatosis and Cyst Formation in be done in six month time
the Lung. Acta Radiaology. 1942; 23: 138-146
2. Cohen MM, Freyer AM, Johnson SR. Pregnancy Experiences References
Among Women With Lymphangioleiomyomatosis. Respiratory
1. D Thomas etal,Blood transfusion and the anaesthetist: management
Medicine. 2009; 103: 766-772
of massive haemorrhage, Anaesthesia 2010 November; 65(11):
3. Johnson SR, Tattersfield AE. Clinical Experience of 1153–1161
Lymphangioleiomyomatosis in the UK. Thorax. 2000; 55:1-5
2. Guidelines on the management of massive blood loss.
4. McLoughlin L, Thomas G, Hasan K. Pregnancy and BJHaematology 2006; 135(5): 634-641
Lymphangioleiomyomatosis: Anaesthetic Management.
International Journal of Obstetric Anaesthesia. 2003; 12: 40-44
Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin) P31
P161 Management of labour and delivery using  minimally  P162 Management of manual removal of placenta and third
invasive FlotracTM system in a parturient with  and fourth degree tear repair: pathway analysis
congenitally corrected transposition, dextrocardia P Jegendirabose,  J Subramanya*,  S Watkinson*,  J Short  
and systemic ventricular dysfunction Anaesthesia, Queen Elizabeth Hospital, Woolwich, London,
R Vedagiri Sai,  S Dhir,  J Racine   UK, *Obstetrics & Gynaecology, Queen Elizabeth Hospital,
Anesthesia, Western University, London Ontario, Canada Woolwich, London, UK
Introduction: More women with congenital heart disease now Introduction: Guidelines suggest that repair of obstetric anal
survive to reproductive age due to advances in modern sphincter injuries (OASIS) and manual removal of retained
medicine. Obstetric management is challenging in these placenta (MROP) should be undertaken as soon as possible to
complex cases. We present the anaesthetic management of minimise the risk of infection, blood loss and maternal
labour and delivery in a woman with congenitally corrected morbidity1,2. Anal incontinence and perineal pain can impact
transposition of great vessels, dextrocardia, systemic significantly on maternal quality of life and mother-child
ventricular dysfunction and junctional tachycardia using bonding.
minimally invasive continuous haemodynamic monitoring and Methods: We conduced a retrospective audit which showed
optimisation. shortcomings in our management of MROP and OASIS and we
Case report: A 28 year old primigravida presented with a undertook an analysis of a full calendar year's cases. All cases
diagnosis of congenitally corrected transposition of great of MROP and OASIS were identified over January 2012 to
vessels and dextrocardia. The atrial septal defect had been December 2012 using both theatre electronic records and
repaired in childhood. Her medications included folate and maternal records. Time from delivery of fetus to MROP or
multivitamins. She had good exercise tolerance, stable vital OASIS repair, blood loss and blood transfusion requirement
signs and was followed up by Cardiology team throughout her were reviewed.
pregancy. ECHO showed 50% ejection fraction (EF) and mildly Due to lack of nationally set standards, we set a local standard
reduced systemic (morphologic right) ventricle. A multi- of no more than one hundred and twenty minutes from
disciplinary meeting between Obstetrics, Cardiology, delivery to repair for OASIS.
Anaesthesia and Intensive care unit (ICU) team was held to
Results: Our institute is a secondary obstetric centre with
decide on optimal obstetric management. Induction of labour
4800 deliveries per annum. During the twelve month period,
was planned.
105 patients sustained OASIS. The mean delay from delivery
At 37 weeks she developed palpitations, increasing shortness to surgery was 136 minutes. The average blood loss was 501
of breath and peripheral oedema. Repeat ECHO showed millilitres and 3% of patients required blood transfusion. Total
moderate ventricular dysfunction with EF 40%, severe of 42 patients required manual removal of placenta with
systemic atrioventricular regurgitation and severely enlarged regional or general anaesthesia. The mean delay from delivery
left atrium. Prior to labour induction, an arterial line was to surgery was 178 minutes. The mean blood loss was 790
inserted and continuous cardiac output monitoring was millilitres and 5% of the patients required blood transfusion.
performed using arterial pressure waveform analysis with the
FloTracTM monitor. Haemodynamic optimization was guided OASIS repairs n=105 Time (minutes)
by stroke volume variation and goal directed fluid therapy. A Delivery to booking 81 (Cl 70-92)
lumbar epidural was then inserted followed by rupture of Booking to surgery 68 (Cl 40-95)
membranes and oxytocin infusion. Fluid balance was closely Delivery to surgery 136 (Cl 122-150)
monitored continuously using FloTracTM. 1st stage of labour MROP n=42 Time (minutes)
was uneventful and 2nd stage was shortened using vacuum Delivery to booking 138 (Cl 115- 160)
assisted delivery of a healthy baby. She had a second degree Booking to surgery 39 (Cl 32-46)
tear which was repaired. Post partum haemorrhage due to Delivery to surgery 178 (Cl 152-204)
uterine atony was treated with 400µg Misoprostol rectally and
Incidentally, 78% of the patients did not have electronic record
intravenous infusion of 20 IU of Oxytocin. Estimated blood
of estimated blood loss on the theatre system.
loss was 800 mL. Cardiac condition was stable apart from
Discussion: In our institution, these cases are booked onto
persistent tachycardia throughout labour. Postpartum, she
the general emergency theatre, and not in the designated
spent 24 hours in ICU with similar monitoring. Her tachycardia
emergency obstetric theatre. We have identified that this has
settled spontaneously. She was discharged home on day 4.
resulted in significant delay in surgery and increased blood
Discussion: Patients with congenitally corrected transposition
transfusion requirement. We are now changing the patient
have a thin-walled right ventricle as the systemic circulatory
pathway to include urgent utilisation of the emergency
pump. The stress of increased cardiac output can cause
obstetric theatre for these procedures. Since the presentation
failure, atrioventricular regurgitation and arrhythmias1. We
of this audit, we have included the estimation of blood loss in
used minimally invasive continuous cardiac output
the surgical sign out process, thus improving communication
monitoring, fluid balance optimisation and good maternal pain
and patient care.
control to prevent decompensation and achieve vaginal
References
delivery with a good feto-maternal outcome.
1. National Institute for Health and Care Excellence. 2007.
Reference Intrapartum care. Care of healthy women and their babies during
childbirth. Clinical guideline 55
1. Dob DP, Naguib MA, Gatzoullis MA. A functional understanding of
moderate to complex congenital heart disease and the impact of 2. Fernando RJ, Sultan AH, Kettle C, Thakar R. Methods of repair for
pregnancy. Part I: the transposition complexes.Int J Obstet Anesth. obstetric anal sphincter injury. Cochrane Database Syst Rev. 2013
2010 Jul;19(3):298-305 Dec 8;12:CD002866.
P32 Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin)
P163 Multidisciplinary involvement of the high risk P164 National Obstetric Anaesthetic Database: a useful tool
parturient to benchmark maternity units in the UK
S De Silva,  P Gregory,  E Combeer   G Keightley,  N Tailor,  R Baraz,  L De Lloyd  
Anaesthetics, Frimley Park Hospital, Frimley, UK Anaesthetics, University Hospital of Wales, Cardiff, UK

Our Hospital offers a high risk Obstetric Anaesthetic Clinic for Introduction: The National Obstetric Anaesthetic Database
review of parturients with anticipated Anaesthetic or Medical (NOAD) was set up in 1998 to establish a framework for
problems where a checklist referral form is used. We audited collecting national obstetric anaesthetic data considered
whether women were appropriately referred or inappropriately relevant to obstetric anaesthetists. Whilst preparing the
not referred. An alert sticker was created to encourage NOAD survey for 2012, we explored the usefulness of this
healthcare providers to alert the oncall Obstetric Anaesthetist data in benchmarking our units' performance at the University
when the high risk parturient presented to labour ward. We Hospital of Wales (UHW) in relation to NOAD published
went onto audit the effectiveness of this alert sticker. figures from the previous year.

Methods: Data was collected according to the NOAD 2012
Methods: We looked at 200 consecutive births during October
survey and therefore, ethical approval was not required. Due
2010 and ascertained how many of these women had referrals
to the large number of deliveries in our unit, data regarding
to the High Risk Clinic. In the referred cases, we asked whether
labour analgesia, mode of delivery, caesarean section rate and
referral criteria were met and also determined if any mothers
type of anaesthesia was based on six months period (Jan to
were inappropriately not referred. In 2012 we retrospectively
June 2012) and then doubled. Exceptions were critical care
inspected all notes of mothers seen in High Risk Clinic with an
admissions and patients with accidental dural puncture (ADP);
estimated delivery date of March to May 2012. We checked
these were collected and reviewed individually for the entire
whether an alert sticker was present in their notes and also the
year. Microsoft Excel was used to analyse the data.
time taken for the Obstetric Anaesthetist to be contacted once
the mother had presented to Labour Ward. Results: The number of total deliveries in our unit for 2012

was 6138, of which 3060 required anaesthetic procedure(s).
Results: In 2010, 178 of 200 notes were reviewed and 14
The table below compares performance and quality indicators
women met referral criteria and 12 of these were referred.
at UHW in 2012 with the NOAD averages from 2011.
Fourteen percent were therefore inappropriately not referred,
however no women were inappropriately referred. Indicator UHW 2012 NOAD 2011

Caesarean section (CS) rate 22% 24.8%
In 2012, 42 notes were inspected where only 8 had the alert
Elective CS rate 46% 39.1%
sticker in place, with only 5 in the correct position. Two
De novo general anaesthesia (GA) for CS 4.5% 4.7%
mothers with the alert had elective caesarean sections. In five
Conversion to GA (CS) 1.8% 3.5%
of the six remaning mothers, the oncall Anaesthetist was
Labour regional analgesia 27% 22.7%
informed of their presence on labour ward. The average time
Epidural re-site rate 7.7% 9%
taken for this was four hours and 45 minutes (range 10 minutes
Accidental dural puncture rate 0.9% 1.2%
to 10 hours and 50 minutes). On review of the Clinic letters, it
was felt that 30 of the 42 parturients should have had an alert In 2012, three cases were transferred to critical care unit as
present in their notes, which is 71% not 19% as shown by our level 2 care (two with sepsis and one adult respiratory distress
audit. syndrome) and six cases as level 3 care (two with sepsis, three

post partum haemorrhage and one case of amniotic fluid
Discussion: In many cases of substandard care assessed by
embolus).
CMACE, there were major failures of communication between
Discussion: Our unit is classified as a large maternity unit
healthcare workers that may have contributed to the woman’s
compared to the national average. The elective CS rate and
death in some cases1. Our audits demonstrated that local
labour regional analgesia rates in our unit are higher than the
guidelines for referral were followed in 99% of cases, therefore
national average, possibly related to the complexity of a
high risk mothers were identified early. However, there still
tertiary centre. Despite this, our total CS rate is well below the
lacks effective communication of concerns within teams and
average with very low conversion to GA. In addition, our
poor involvement of other specialties early.
epidural re-site rate is lower than the national average, as is
Reference our ADP rate. Current facilities include two theatres serving
1. Centre for Maternal and Child Enquiries (CMACE). Saving both emergency and elective streams, and a mixed
Mothers'. Lives: reviewing maternal deaths to make motherhood recovery/high dependancy unit (HDU) for up to 5 patients.
safer: 2006–2008. The Eighth Report of the Confidential Enquiries
Our unit has a low transfer rate as level 2 care in general HDU,
into Maternal Deaths in the United Kingdom. BJOG 2011;118:1-203
due to the ability to care for these patients on our unit. We
find the NOAD data a useful tool to benchmark our
performance and set standards of care. More units should
contribute to the annual NOAD survey and consider using the
data as a way of identifying shortfalls and improving patient
care and services.
Reference
1. National Obstetric Anaesthetic Database report 2011.
http://www.oaa-anaes.ac.uk/content.asp?ContentID=586
Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin) P33
P165 Obstetric admissions to the Intensive Care Unit: a 6 P166 Obstetric outcomes with programmed intermittent
year review at a UK tertiary maternity centre epidural bolus labour analgesia
R Labib,  K Cullis   JTE Cremin,  CH Papageorgiou  
Selwyn Crawford Department of Anaesthesia, Birmingham Department of Anaesthesia, Hillingdon Hospital, Uxbridge,
Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin) P1
P101 A modified WHO surgical safety checklist for P102 A parturient with phocomelia and severe needle
category 1 caesarean sections phobia: the challenges faced
A Lahkar,  A Cooney,  G Massolini   R Sinha,  K Howard,  N Bhandal  
Anaesthetics, Milton Keynes NHS Foundation Trust, Milton Department of Anaesthesia, Nottingham University Hospitals
Keynes, UK NHS Trust, Nottingham, UK
Introduction: In June 2008, WHO introduced a surgical safety Introduction: Parturients with phocomelia are rarely seen and
checklist to be used in every operating theatre to improve present anaesthetic and obstetric challenges. We present a
patients' safety. In 2010 a WHO surgical safety checklist for case of a parturient with phocomelia and severe needle phobia.
maternity was created in response to requests from maternity Case report: A 33 year old woman with phocomelia and severe
services and clinicians. Nevertheless, in some emergency needle phobia presented to the obstetric anaesthetic clinic at
situations like category 1 Caesarean sections, this checklist 20 weeks for pre-assessment.
could still be quite a difficult task to achieve due to Her phocomelia was thought to be idiopathic, she had been
understandable time limit constrains to safely deliver the baby adopted when young and no family/drug history was
and/or save the mother's life. available. Examination revealed four limb phocomelia. There
Whilst there is still no international consensus or any specific were absent upper limb bones on the right and a fused hand
recommendation from WHO concerning these specific attached directly to her body. Her left upper limb was
situations, the Anaesthetic Department in Milton Keynes shortened with a primitive hand and fused fingers. Both lower
hospital has managed to devise a checklist for cat 1 LSCS limbs were extremely shortened with primitive feet with fused
which is 100% compliant both in terms of content with WHO toes. Her head, neck and torso appeared normal. She was able
guidelines and adherence by hospital staff. to mobilize with a wheelchair and significant assistance from
Method: After considerations and inputs from the Consultant her partner. The problems faced in clinic were numerous and
Anaesthetists, a simplified checklist was introduced in our focused on her severe needle phobia, difficult venous access
emergency obstetric theatre in June 2013 by way of an ad hoc and monitoring, positioning, mobilization and
poster hanged on the wall. It spells out the most 10 salient thromboprophylaxis as well as the challenges posed by the
questions to be read by one of the theatre staff before the start preganancy itself. The anaesthetic plan consisted of non-
of a category 1 Caesarean section. These questions translate invasive blood pressure monitoring on her left lower extremity;
the original 32 WHO ones that were spread across 3 sections pulse oximetry via an ear probe or toe and standard
in a simpler, quicker format. electrocardiogram. These were tested prior to labour. Due to
Results: After the introduction of the modified WHO checklist the impossibility of standard intravenous access and extreme
in June 2013, compliance is 100%. needle phobia several discussions were had about obtaining
Discussion: By putting the combined know-how and intravenous access prior to labour. A right subclavian
experience of many Consultant Anaesthetists to the task, we Hickman line was inserted at 39 weeks facilitated by the use of
managed to simplify the original WHO narrative into a sharper entonox. Regional analgesia was refused for labour so the
tool that is quickly and effectively utilised for a better and option of intravenous fentanyl via a midwife controlled
safer quality of care in what has become a "normal routine" analgesia pump was discussed. Should a caesarean section be
during extraordinary times in the emergency theatre. required a neuroaxial anaesthetic was refused and so a general
anaesthetic was planned.
Reference At 40+2 weeks spontaneous rupture of membranes occurred
1. WHO surgical safety checklist: for maternity cases only, and labour established. However, due to failure to progress a
http://www.nrls.npsa.nhs.uk/resources/?entryid45=83972 decision was made to perform a caesarean section.
In theatre the challenges related to positioning and achieving
a satisfactory left lateral tilt. A rapid sequence induction was
conducted following pre-oxygenation to an end-tidal oxygen
concentration of 92%. Anaesthesia was induced with
thiopentone 350mg and suxamethonium 100mg. Soon after
induction she desaturated rapidly to the high 60s. This
resolved after tracheal intubation and ventilation. She was
hypotensive intra-operatively, with an estimated blood loss of
1300mL After fluid and blood resuscitation, recovery was
unremarkable. Postoperative pain was managed with
transversus abdominus plane blocks and morphine
patient/midwife controlled analgesia.
Discussion: There is little literature about managing delivery
in women with phocomelia, but sucessful regional techniques
have been described although this was refused here. Early
discussion of anaethesia and analgesia options, and plans for
vascular access and monitoring are needed, There is a reduced
vascular reservior and skeletal muscle mass.
As a consequence faster inductions, emergences and
responses to titrated drugs are observed.

P2 Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin)
P103 A questionnaire to evaluate and aid future development P104 A retrospective descriptive analysis of anaesthesia for
of the AAGBI's SAFE obstetric anaesthesia course in successful cervical cerclage in pregnancy
Liberia J Modha,  G Burul*,  F Forya*,  CP James*,  AL David*,  J
JCO Fox,  CE Richards*,  T Sheraton*,  A Sonah†   Dick,  L Wee  
†Department of Anaesthetics, Phebe Hospital, Bong County,  Department of Anaesthesia, University College London
Liberia, *Department of Anaesthetics, Royal Gwent Hospital, Hospitals NHS Foundation, London, UK, *Department of
Newport, UK, Department of Anaesthetics, University Obstetrics, University College London Hospitals NHS
Hospital of Wales, Cardiff, UK Foundation, London, UK
Introduction: Dr Kate Grady has developed this three-day Introduction: Cervical cerclage is a common operation which
refresher course in obstetric anaesthesia on behalf of the requires an anaesthetic. There are no studies on the type of
AAGBI. The course is aimed at non-physician anaesthetists in anaesthesia used for this procedure.1
developing countries. It consists of short lectures, interactive Aim: To determine the type of anaesthesia used for vaginal
sessions and workshops that focus on the recognition and cervical cerclage.
management of leading causes of maternal death in resource
Method: Ethical approval waived. Women having any vaginal
poor settings. The course has been taught in Uganda,
cervical cerclage (Macdonald or Shirodkar) during pregnancy
Bangladesh, Liberia and Ghana. It includes the principles of
between January 2005 and December 2012 were identified
the WHO Safe Surgery and training of trainers. Mothers of
using the hospital obstetric anaesthesia database and cross-
Africa, a medical educational charity, has led delivery of 2
referenced with data from the Preterm Birth clinic where women
courses for nurse anaesthetists (NAs) in Liberia - supported
at risk of preterm birth are seen antenatally. Data was obtained
by the AAGBI IRC. Liberia has approximately 60 nurse
by examination of obstetric case notes and the ultrasound
anaesthetists and no medically qualified anaesthetists for a
scan records and analysis conducted using Microsoft Excel.
population of 4.2 million people1. Access to CPD is difficult.
Results: There were 190 cases. Twenty-five patients were
The MMR in Liberia is 770 per 100,000 live births1. In order to
excluded due to incomplete data, hence 165 included in
plan future development of the course in Liberia, which will be
analysis. The mean gestational age was 16.6 weeks (range 9-
led by Liberian trainers, feedback data was collected.
23.6 weeks). The table below shows that both general
Methods: A follow up questionnaire was given to 35 NAs who
anaesthesia (GA) and regional anaesthesia (RA) were used.
had previously attended a SAFE obstetric anaesthesia course
The majority of regional anaesthetics were spinals (95.7%), the
held in Liberia (March 2012 or March 2013). We aimed to
rest combined spinal and epidural (CSE) (3.6%) and epidural
assess; 1) the quality, usefulness and appropriateness of the
top up (0.7%).
material taught during the course, 2) the effect on motivation
to improve local services/care delivery, 3) the effect on the GA RA

confidence levels of NAs in managing obstetric anaesthetic n (%) n (%)
emergencies. Spinal n = 133
Results: A 70% follow up rate was achieved. 97% reported Total n=165 26 (16%) 139 (84%) CSE n = 5
positive changes in their attitude to work and their clinical Epidural n = 1
practice and 94% reported improvements in interactions with Five patients who had a spinal anaesthetic required second
colleagues. Many NAs gave details of cases where the skills procedures (3 GA, 1 spinal, 1 CSE). Of those converted to GA,
and knowledge they learnt on the course helped save lives one patient had a block to T6 (the reason for conversion to GA
and improve clinical outcomes. 11 NAs requested continued was not documented), one patient had a block to T12 and the
education and training. Other suggestions for course third patient had 3 failed spinal attempts. In all cases there
improvement included; additional sessions in preoperative were no major anaesthetic complications and cervical cerclage
assessment and TAP blocks, and the inclusion of midwives in was placed successfully.
the training sessions. The following table illustrates the mean
Discussion: In this series, the majority of vaginal cervical
subjective confidence scores (between 0 and 10) of the NAs in
cerclage surgery was performed safely and effectively under
various clinical scenarios before and after the course.
RA. There are no specific guidelines regarding the type of
  Before After anaesthesia for cervical cerclage.1 Anaesthetic considerations
General anaesthesia LSCS 6.3 9.2 favouring a regional anaesthetic in pregnancy include the risk
Spinal anaesthesia LSCS 7.6 9.8 of aspiration and difficult airway management in patients over
Management of severe eclampsia/preeclampsia 5.7 9.2 20 weeks gestation and those under 20 weeks gestation if at
Management of obstetric haemorrhage 5.9 9.4 high risk for example those with a high BMI. The majority of
women in our data set were less than 20 weeks (88.5%). Other
Discussion: Our results indicate that the SAFE obstetric
considerations include patient and surgeon choice. Women in
anaesthesia course in Liberia has been well received with
this series were given the option of GA or RA. In certain cases
subjective evidence of empowerment and improved methods
for example rescue and abdominal cerclages, the patient may
of working. This is promising in the context of increasing the
need to be in a deep Trendelenberg position to aid reduction
reach of future courses and enabling local faculty to lead
of membrane prolapse to avoid membrane rupture or to aid
training. Further data from logbooks provided as part of the
access to the pelvis.2
course were not obtained and more work is needed to
encourage completion of the logbooks. Objective evidence is References
required to demonstrate impact on patient outcomes. 1. Cervical Cerclage, Green-top Guideline No 60, Royal College of
Reference Obstetricians and Gynaecologists, May 2011.
2. Olatunbosun OA, Dyck F. Cervical cerclage operation for a dilated
1. http://data.worldbank.org/indicator/SH.STA.MMRT/countries/1W-
cervix. Obstet Gynecol. Feb 1981;57(2):166-70.
LR?display=graph
Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin) P3
P105 A retrospective descriptive analysis of dose of P106 A step towards improving theatre productivity for
intrathecal anaesthesia and adjuncts for successful elective caesarean sections
cervical cerclage in pregnancy S Kale,  C Farrow,  N Owen,  K Miltsios  
J Modha,  G Burul*,  F Forya*,  CP James*,  AL David*,  J Department of Anaesthesia, Whittington Hospital, London,
Dick,  L Wee   UK
Department of Anaesthesia , University College London Introduction: NHS Institute for Innovation and Improvement
Hospitals NHS Foundation, London, UK, *Department of developed The Productive Operating Theatre Programme to
Obstetrics, University College London Hospitals NHS improve effective use of theatre time, staff and patient
Foundation, London, UK experience.1 Good administrative system and organisation is
Introduction: Cervical cerclage is a common operation, which essential to ensure theatre efficiency.2On this background,
requires either a general or regional anaesthetic aiming for a with the rational of making existing system more productive,
block height of T10. There are no studies determining the dose safe and reliable, we evaluated current practice in one of our
that should be used to achieve this or describing additional main theatres, designated for elective sections, in a DGH set
drugs used for successful surgery. up.
Aim: To determine the dose of local anaesthesia used for Methods: Evaluation was carried out over a 4-week period, for
intrathecal injection and the block height achieved in women planned caesarean sections. The data was collected
undergoing cervical cerclage. In addition to determine the use concurrently by the anaesthetist for that case and from the
and dose of adjuncts. theatre database. The exact time for all significant events, such
Method: Ethical approval waived. Women having vaginal as when patient was sent for or when theatre was clean and
cervical cerclage during pregnancy between January 2005 and ready for the next patient, was recorded. Reasons for delays,
December 2012 were identified using the hospital obstetric duration of anaesthesia, surgery and problems encountered
anaesthesia database and cross-referenced with data from the were also recorded. Time spent at and between different
Preterm Birth clinic. Data was obtained by examination of crucial stages in theatre was calculated from the data. Results
obstetric case notes and the ultrasound scan records and are presented in the form of time in minutes, median [range]
analysis conducted using Microsoft Excel. and % (absolute numbers of cases).
Results: In all cases, cervical cerclage was achieved Results: We had 25 completed forms. Our analysis showed,
successfully. There were 138 cases of intrathecal anaesthesia median time interval from patient sent for to arrival in theatre
(133 spinals and 5 combined spinal epidurals) in whom 67.4% as 5 min [1-29]. Reasons for delay were due to obstetric team
(93/138) had documented intrathecal anaesthetic dose and busy in meeting, midwife busy preparing the patient and
were included for final analysis. Hyperbaric bupivacaine 0.5% midwife busy completing paperwork for previous patient in
was used (mean dose 10.9mg, median 10.8mg and mode 10mg, recovery. Median time interval between patient's arrival and
range 6.5–15mg). Block height and dose of intrathecal neuraxial block was 18 min [10-70], prolonged in 8% of cases
anaesthetic was documented in 54/93 cases (58%). The block (2/25) due to failed and repeat block. Bladder catheterisation
height ranged from T2 to T12 with similar doses of local after block was delayed by ≥30 min in 8% of cases (2/25) due
anaesthetic given in each group and of similar gestation and to unavailability of midwife. Median anaesthetic time for
body mass index (BMI). satisfactory block was 12 min. Interval between block ready
and knife to skin (KTS) was 6 min [1-12]. Median surgery
Block height T2-4 T5-8 T10 T12 duration was 45 min [31-141]. PPH, high BMI, and previous
Frequency 7 31 13 3 laparotomies resulted in longer operations in 16% of cases
Mean dose mg (4/25). Median turnaround time between the cases was 10 min
11 11 11 8
hyperbaric bupivacaine 0.5% [6-15]. Total time patients spent in theatre was 89 min [74-183].
Mean gestation (weeks) 17.4 17.7 15.6 19.1
Discussion: We noted that unavailability of obstetric team
Mean BMI kg/m2 27.3 26.6 26.1 32
and busy midwives at times has resulted in late starts and
In 3 patients that had block heights of T12 only one was delay in some procedures in theatres. Delay in starting the
converted to GA. Opiates were used in 73/93 (78.5%), the most surgery after a satisfactory block and prolonged turnaround
frequent being fentanyl. time have also affected the overall theatre productivity. We
have put forth some recommendations to working group such
Mean dose Range
Opiate used Number (%) as offering administrative support to midwives, ensuring
(mcg) (mcg)
senior obstetrician and anaesthetist are present for difficult
Fentanyl 69 (95) 20 10-75
cases, making use of anaesthetic room to improve patient
Diamorphine 3 (4) 300 250-350
turnaround time and most importantly encouraging staff
Fentanyl & Diamorphine 1 (1) 20/300 N/A
nurses to take the lead role in increasing theatre efficiency.
Vasopressors were used in 26 cases (23 phenylephrine, 3 This could be a big step towards enhancing theatre output as
ephedrine). Other drugs included 3 cases of intravenous well as increasing patient and staff satisfaction. We aim to
midazolam, 1 case propofol and in 1 case salbutamol (as a introduce these changes soon and re-evaluate the practice in
tocolytic agent). the near future.
Discussion: In our case series there is a wide dose range of References
both hyperbaric bupivacaine 0.5% and opiate given. To 1. The Productive Operating Theatre programme,
achieve a block height of T10 or above a minimum dose of http://www.institute.nhs.uk/quality_and_value/productivity_series/the
11mg (2.2ml) is recommended which may be independent of _productive_operating_theatre.html
other factors. There is a wide variation in block height but 2. Theatre Efficiency,
http://www.aagbi.org/sites/default/files/theatreefficiency03.pdf
even a low block (T12) was found to be adequate.

P4 Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin)
P107 A year in the "maternity" life of an increasingly busy P108 Abstracts on the antenatal anaesthetic clinic
new build district general teaching hospital - coping presented to the Obstetric Anaesthetists' Association,
with training and service provision - 2013 1991-2013
H Wrigley,  PF Yoxall,  Janet Slee   AJ Wickham,  SM Yentis*  
Anaesthetics, St Helens & Knowsley NHS Trust, Liverpool, Anaesthetic department, St Mary’s Hospital, London, UK,
UK *Anaesthetic department, Chelsea & Westminster Hospital,
Introduction: Since moving to a new PFI built hospital in 2010 London, UK
our maternity unit has become more busy. Delivery rates/year Introduction: National reports1 and guidelines2 recommend
have increased from 2900 to 3700 pa (up 27.6% in 3 years) assessment of women with ‘high-risk’ pregnancies and
increasing demands upon anaesthetic services. potentially serious co-morbid disease in an antenatal
Methods: We reviewed all our maternity cases during 2013, anaesthetic clinic (AAC). We reviewed trends and themes in
both epidural and caesarean sections. We also surveyed our abstracts on this topic presented to the OAA.
CT2 trainees to assess their experience in terms of case Methods: Full-text records of abstracts (excluding case reports)
numbers during a newly introduced modular training block. presented at OAA meetings (1991-2013; see www.oaa-
Lastly consultant cover on labour ward was audited for CNST anaes.ac.uk) were searched using the terms ‘antenatal’,
purposes. ‘clinic’, ‘risk’ and ‘refer’. Relevant abstracts were reviewed for
Results themes and conclusions.
Results: Forty abstracts were presented at 14 Annual
n %
Meetings (Fig. 1); 3 were unavailable in full-text (2008) but 1
Total Deliveries 3700
was provided by the author on request. 35 were from single
LSCS 838 22.6
departments and 5 were surveys (4 national). Common topics
Grade I-III LSCS 464 12.5
were obesity (12, 30%), referral reason (7, 18%) and
Grade IV LSCS 374 10.1
appropriateness (4, 10%), and outcomes (5, 13%). Nine (23%)
LSCS - SAB 666 79.5
described single patient cohorts, e.g. cardiac. AAC workload
LSCS - Epidural 123 14.7
has increased from 2.3 to 28.6 patients per month over 22
LSCS - CSE 14 1.7
years, albeit at different centres. Obesity has replaced
LSCS - GA 119 14.2
musculoskeletal disease as the most frequent reason for
RA to GA 34 4.2
referral. Common concluding themes include the need to
Average BMI LSCS (Range) 28.3 (16.7-59.9)  
improve the timeliness and appropriateness of referrals, and
Epidurals 895 24.2
ensuring anaesthetic plans are both prominent and followed.
Epidural Resites 32 3.7
PDPH - Epidural 15 1.7
PDPH - SAB 2 0.3
Epidural Blood Patches 21
Average BMI Epidural (Range) 27.1 (16-62.8)  
CT2 Training One of our requirements is to teach at least 4
CT2s per annum obstetric basic competencies. Our trainees
receive a 4 week long daytime block covered by an anaesthetic
ST3-7 and a consultant. They attend 40 sessions, the majority
siting 15 epidurals and anaesthetise 30 caesarean sections
before embarking on daytime on calls. They attend our in-
Figure 1: number of abstracts on the AAC presented per year
house MODSS (Obstetric Simulation Day) run by one of our
Consultant Obstetricians. Discussion: Abstracts relating to AACs have become more
frequent in the last decade, presumably reflecting their
Consultant Input The number of funded Consultant labour
increasing provision and perceived usefulness (and
ward sessions has risen 7 to 10 sessions (7 elective lists per
recommendation in the 2002-04 CEMACH report3). Increased
week). A “High Risk Obstetric clinic” runs weekly to pre-
demand for this service is exacerbated by inappropriate
assess all potentially difficult patients (250-300 per annum).
referrals and budgetary constraints. Referral processes,
Discussion: Despite a significant increase in workload we
facilities, and documentation and inconsistent use of plans are
have managed to maintain levels of cover (both junior and
areas for development. Future work should focus on quality
consultant) whilst allowing for CT2 training in obstetric basic
improvement and assessment of cost-effectiveness. Nationally
competencies as required at both national and local levels.
agreed referral criteria and a national ‘anaesthetic plan’
This has been achieved by increasing our core of obstetric
document, complemented by referrer education, may enhance
consultant anaesthetists, increasing obstetric PAs and
the process. Multidisciplinary ‘one-stop-shop’ or midwifery
changing to a modular CT2 training programme.
led clinics for common problems, such as obesity, may be
beneficial.
References
1. Centre for Maternal and Child Enquiries. Saving Mothers’ Lives:
reviewing maternal deaths to make motherhood safer: 2006-08.
The Eighth Report on Confidential Enquiries into Maternal Deaths
in the UK. BJOG. 2011; 118(Suppl.1): 1-203.
2. OAA & AAGBI Guidelines for Obstetric Anaesthetic Services.
Revised Edition 2005. London: OAA/ AAGBI
3. CEMACH. Why Mothers Die 2000-2002. Report on Confidential
Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin) P5
P109 Accuracy of a new electronic obstetric anaesthetic P110 Accuracy of landmark approach to central neuraxial
database blocks in obstetric patients
Rohit Rohit,  R Abraham,  GNB Jackson   J Lie,  K Bhatia,  A Venkataraju,  P Kochhar  
Anaesthetic department, Royal Berkshire Hospital, Reading, Anaesthesia, St Mary's Hospital, Manchester, UK
UK Introduction: Correct identification of vertebral level could
Introduction: We have introduced a new electronic database prevent damage to the spinal cord during a central neuraxial
'ROAD' (Reading Obstetric Anaesthetic Database) to record block (CNB). Evidence suggests that ultrasound (US) imaging
obstetric anaesthetic data. Written & designed by one of our of the spine by an experienced operator leads to correct
anaesthetists it is secure, password protected & able to identification of vertebral level in 90% of the patients and
produce reports on patient data & the activity of individual decrease the number of attempts required for a successful
anaesthetists. More than 70% obstetric anaesthetic units use CNB1. National Institute for Health and Care Excellence
electronic data collection system in the UK but there is little suggests US could be a useful tool for epidural catheter
agreement as to the best format.1 We audited the accuracy of insertion2. Our aim was to determine the discrepancy between
data entry, as a marker of ease of use by the anaesthetists, landmark technique and US to identify level of insertion of
before auditing the content of the database. CNB.
Methods: This was a retrospective audit, analysing data for Methods: Two experienced US operators who were blinded to
one month period (June 2013). The data in 'ROAD' was the initial procedure retrospectively performed US imaging of
compared to 1) our handwritten anaesthetic record book spine post-operatively after elective caesarean section in 51
(ARB); 2) Midwifery led labour ward logbook (LWLB); 3) obstetric patients with their consent from January to March
Operating theatre electronic log 'Bluespier'. Data entered on 2013 in St Mary’s Hospital. All the patients had a lumbar CNB
the 'ROAD' was manually checked against all these three done by landmark approach. The documented vertebral level
sources and the results tabulated and analysed. at which CNB was performed was noted. This was then
Results: 253 records were found in the ARB. The ARB missed compared with the actual vertebral level identified by bedside
one case (found in Bluespier), Bluespier missed one case US imaging of spine.
(found in the ARB) and LWLB missed 6 cases (found in the
Results: 29 patients had a spinal, 20 had an epidural and two
ARB & Bluespier). The results show that 'ROAD' was 96%
had combined spinal-epidural anaesthesia. The median body
accurate compared to any of the other systems.
mass index (BMI) was 28.6kg/m2. Landmark technique was
No. of cases missing on only accurate in 39.2% of patients. There was no statistically
Total 'ROAD' accuracy against
  'ROAD 'compared to significant correlation between the experience of operator and
no. other data sources as %
others accuracy. 3% of patients had a CNB at the level of L or above.
2
ARB 10 253 96.047% Documentation of the level performed was excellent. Raised
Bluespier 7 174 95.977% BMI and difficulty in palpation of landmarks resulted in
LWLB 10 247 95.951% statistically significant decrease in the accuracy (p<0.05
'ROAD'   243   Fisher’s Exact Test).
Discussion: Pinder et al considered an accuracy of 89% for Discussions: Our findings co-relate well with other studies
their electronic record adequate enough to adopt computer which have found that the vertebral level identified by
based data collection system.2We used three different landmark approach was at least 1 interspace higher than the
methods of data collection already in regular use, to compare level located by US in 40% of the pregnant population 3. Our
with our electronic database and showed it to have a high audit further confirms that the use of traditional landmark
degree of accuracy. This suggests that the database is easy to technique is highly inaccurate with potential increase risk of
use and consistently completed by our anaesthetists. We wish needle injury to the spinal cord especially in the high-risk
to use our database to produce reports on anaesthetic service patient groups (morbid obesity and musculoskeletal
provision (including the quality & safety of that service) as problems). We propose that all elective obstetric patients,
well as for auditing individual anaesthetist activity patients having a lumbar epidural, and high risk patients
(particularly our novice obstetric anaesthetists to ensure having a lumbar CNB should have US imaging of the of their
appropriate case mix & experience during their obstetric spines to identify the correct vertebral level and other relevant
attachments). Before using any database to audit these anatomy. The main reasons being that US imaging does not
aspects it is important to ensure that the data being audited is involve any radiation, is compact, portable and readily
a true reflection of anaesthetic activity, we believe our new available at the point of care. Better US equipment availability,
database is sufficiently accurate to audit the data within it. The staff awareness with appropriate training and improved
limitation of our audit is that we only audited the data from one documentation would aid in providing safer patient care.
month but we believe that the data entry practice of all months
References
is similar. We conclude that our electronic database is accurate
1. Chin KJ, Perlas A, Chan V, Brown-Shreves D, Koshkin A, Vaishnav
& the data entered can be used to audit our obstetric V: Ultrasound imaging facilitates spinal anesthesia in adults with
anaesthetic service. difficult surface anatomical landmarks. Anaesthesiology 2011; 115
(1): 94-101
References
2. Ultrasound-guided catherisation of epidural space. National Institute
1. Campbell NJ, Youngs P, Anderson I. A national survey of obstetric for Health and Care Excellence January 2008
anaesthetic data collection methods in the UK. Int J Obstet Anesth
2012; 21: S53. 3. Lee AJ, Ranasinghe S, Chehade JM, Arheart K, Saltzman BS,
Penning DH & Bimbach DJ. Ultrasound Assessment of the Vertebral
2. Pinder A, Wrench I, Shepherd D, Freeman R. Assessment of a Level of the Intercristal Line in Pregnancy. Anaesth Analg 2011;
handheld computer to collect obstetric epidural audit data. Int J
113: 559-564
Obstet Anesth 2002; 11: 8.
P6 Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin)
P111 Adherence to antenatal anaesthetic advice in P112 An evaluation of anaesthetic antenatal clinics in the
labouring morbidly obese parturients. obese obstetric population
S Halliday,  LC Robertson ,  HM du Plessis   PR El-Dalil,  DS Cochran,  R Ganapathy*  
Anaesthesia, Princess Royal Maternity Hospital, Glasgow, Department of Anaesthesia, Sandwell and West Birmingham
UK NHS Trust, Birmingham, UK, *Obstetrics and Fetal Medicine,
Introduction: Morbidly obese parturients pose a high Sandwell and West Birmingham NHS Trust, Birmingham, UK
anaesthetic risk1. Antenatal anaesthetic assessment for Introduction: Maternal obesity is increasingly common, with a
women with a body mass index (BMI) ≥40 kg.m-2 at booking is BMI 35 found in 5% of pregnancies. Current CMACE / RCOG
advised2. Early establishment of epidural analgesia is often guidelines advocate the referral of patients with a BMI 40 to
advocated. We sought to determine if this advice is adhered to an anaesthetic antenatal clinic. This study aimed to evaluate
in our centre. the outcomes following the implementation of such a clinic in a
Methods: A retrospective case note review of 49 morbidly busy inner city district general hospital.
obese patients (BMI ≥40) assessed antenatally was Method: High-risk patients were referred to a multidisciplinary
conducted. As a control, data from 23 patients with a BMI <40 antenatal clinic involving Anaesthetics, Obstetrics and
who had a labour epidural was collected. We compared the Haematology; patients with a BMI 40 were referred to the
timing of epidural request from labour ward admission, cervical clinic and included in the evaluation. Data was collected
dilation and syntocinon administration at request and the time retrospectively on the reason for attending, the past medical
from epidural insertion to delivery. Mode of delivery was also and obstetric history as well as any anaesthetic or surgical
noted. intervention provided in the perinatal period.
Results: Mean BMI for the control group was 23.6 (range 17- Results: In 2011, 72 women were referred to the clinic with a
32) and for the morbidly obese group 44.6 (40-60). Eleven BMI 40, although there were often other relevant co -
morbidly obese parturients had an elective caesarean section morbidities. The BMIs ranged from 40 to 80 (mean = 44). 44
(CS). Nineteen of the remaining morbidly obese parturients patients (61%) had a normal vaginal delivery, 3 women (4%)
requested labour epidurals. Two parturients delivered prior to required assisted vaginal delivery, 17 (24%) had an elective
insertion. caesarean section (CS), whilst 8 (11%) had a non-elective CS.
Of these patients, 38 (53%) required no anaesthetic
Time to Syntocinon Insertion to
Cervical dilation intervention.
request administration n delivery
  Centimetres
Minutes (%) Minutes Table: Anaesthetic intervention and failure rates in obese
(range)
(range) (range) parturients compared to previously published failure rates1 in
BMI Yes 12 (52.2) the general obstetric population
375 (110-
<40 169 (0-435) 3.7 (1-7) No 11 (47.8) Spinal Epidural CSE GA
915)
(n=23) Number attempted 19 12 4 1
BMI Yes 13 (68.4) % Failure rate 5 17 0 0
334 (12-702)
≥40  261 (0-555) 3.65 (2-8) No 6 ( 31.6) Published % failure rates1 6 24 18 <1
(n=17)
(n=19)
Discussion: The results demonstrated low regional
Table: Timing of epidural request, cervical dilation and anaesthesia failure rates, with only 1 unsuccessful spinal (5%)
syntocinon use at request, and time from insertion to delivery. and 2 failed epidurals (17%); figures comparable to those
In the control group with a BMI <40 that had a labour epidural found in the general obstetric population (Table). There is little
(n=23), the number of spontaneous vaginal deliveries (SVD), available data for regional anaesthetic failure rates in the obese
trial of forceps (TOF) and lower uterine segment CS (LUSCS) obstetric population precluding a direct comparison, but a
were 13 (56.5%), 5 (21.7%), and 5 (21.7%), respectively. For higher failure rate would be expected. A previous study of 677
those with a BMI ≥40 with an epidural (n=17) there were 6 women with a BMI 30 found an emergency CS rate of 24%, 2
(35.3%) SVD, 3 (17.7%) TOF and 8 (47.1%) LUSCS. The significantly higher than the 11% demonstrated in this cohort
number of SVD in the BMI ≥40 without an epidural group was of BMI 40. This robust multidisciplinary approach in the
18 (85.7%) and there were no TOF and 3 (14.3%) LUSCS. antenatal period allows for adequate planning and early
Discussion: Despite antenatal review, the time to epidural institution of optimised perinatal management. The service
request was longer in the morbidly obese group, indicating a provided was predominantly consultant led, with the on-call
need for ongoing education. The time between epidural Anaesthetist required to attend out of hours for parturients
insertion and delivery was shorter in the morbidly obese group with a BMI 45, and to be informed of patients with a BMI
which had a significantly increased chance of CS, signifying 40; significantly 73% of the on-call consultants are dedicated
the importance of establishing a working epidural early in this Obstetric Anaesthetists. We feel these systems may account
cohort. for our findings, as well as promote early and effective
communication with patients. Whilst the sample was relatively
References small the results are sufficiently encouraging to suggest that a
1. Soens MA, Birnbach DJ, Ranasinghe JS, van Zundert A. Obstetric multidisciplinary approach significantly improves perinatal
anesthesia for the obese and morbidly obese patient: an ounce of outcomes in the obese obstetric population.
prevention is worth more than a pound of treatment. Acta
Anaesthtesiol Scan 2008; 52: 6-19 References
2. OAA/AABGI Guidelines for Obstetric Anaesthetic Services 2013. 1. Kinsella SM. A prospective audit of regional anaesthesia failure in
Association of Anaesthetists' of Great Britain and Ireland and the 5080 caesarean sections. Anaesthesia 2008; 63(8): 822-832.
Obstetric Anaesthetists' Association. London, 2013. 2. Usha Kiran TS, Hemmadi S, Bethel J, Evans J. Outcome of
pregnancy in a woman with an increased body mass index. BJOG
2005; 112(6): 768-772.
Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin) P7
P113 An evaluation of fasting times for elective caesarean P114 An evaluation of intrathecal diamorphine versus
section surgery fentanyl for lower segment Caesarean section in a
J Ghoshdastidar,  KM Sherratt,  M Seneviratne*,  A medium-sized district general hospital
McGlennan   K Ramm,  LT Fenton-May,  S Naresh  
Anaesthetics, Royal Free Hospital, London, UK, Department of Anaesthesia, Good Hope Hospital, Heart of
*Anaesthetics, University College Hospital, London, UK England Trust, Birmingham, UK
Introduction: Enhanced Recovery Programmes have shown Introduction: Intrathecal diamorphine is now recommended by
increasing evidence for the benefits of reducing fasting times the National Institute for Health and Clinical Excellence (NICE)
for those undergoing elective surgery1. Many of these as the opioid of choice for lower segment Caesarean section as
benefits could be applicable to the elective caesarean section it provides improved post-operative pain relief.1 However, it is
patient. We evaluated the fasting times of our elective also associated with a dose-dependent increase in the
caesarean section patients to assess whether we could make incidence of pruritus2 and nausea3 which may be more
improvements to patient care. significant with diamorphine given its longer duration of
Methods: The evaluation included all patients undergoing action. Having arranged appropriate protocols for post-
elective caesarean section surgery at the Royal Free Hospital operative monitoring of women receiving intrathecal
over a 3 month period.. Patients received standard instructions diamorphine, we introduced the therapy in late 2012.
to stop eating at midnight on the day of surgery and to stop Methods: The evaluation took place over a six-week period. A
drinking clear fluids at 6 am. Data was collected by anaesthetic small number of women were still receiving intrathecal fentanyl
staff using a standardised data collection sheet.. Patients were due to clinician choice, and these provided a useful
questioned about the time they last consumed solid food and comparator. Women who were still present in the hospital on a
when they last drank liquid. follow-up round on the first day post-op were asked questions
Results: In total 77 patients underwent elective caesarean about post-operative pain, nausea and pruritus. We also
sections during the period of evaluation. We obtained data assessed total oral morphine and codeine doses and time to
from 71 patients for fasting times for fluids and 72 patients for first dose.
fasting times for solids. Results: Basic data is presented in the chart.

  Fentanyl Diamorphine
Pre-op fasting % of Pre-op fasting % of
Number 15 36
times FLUIDS patients times SOLIDS patients
Time to first morphine (hrs) 5.29 8.9
(hr) (n=71) (hr) (n=72)
Mean morphine dose (mg) 65.4 30
2 - 4 5.6 6 - 12 15.3
No morphine required 1 (6.6%) 11 (30.6%)
4 - 6 15.5 12 - 18 66.7
Mean codeine dose (mg) 123 119
6 - 8 14.1 18 - 24 16.7

8 - 10 8.5 over 24 1.4
Time to mobilisation (hrs) 21.17 15.21
over 10 56.3    
Time to catheter removal (hrs) 20.3 16.6

Discussion: There are no fasting recommendations specific to
Pruritus 8 (53.3%) 24 (66.7%)
elective caesarean sections but the standard surgical
- requiring treatment - 0 (0%) - 8 (22.2%)
guidelines of 6 hours for solids and 2 hours for clear fluids are
Nausea 5 (33%) 13 (36.1%)
usually applied. Periods longer than 12 hours without fluid
- requiring treatment - 3 (20%) - 7 (19.4%)
have correlated with significant dehydration
in patients having elective caesarean sections2. There is also
Discussion: Our results replicate previous work demonstrating
some evidence to suggest that gastric fluid volume is
a reduction in immediate post-operative analgesia
increased with prolonged starvation in the pregnant patient3.
requirements following a switch from fentanyl to diamorphine,
Over fifty per cent of our patients went without fluids for
but an associated increase in side effects requiring
longer than ten hours prior to surgery, and almost eighty-five
intervention. There was also a reduction in times to first
per cent of patients went without food for greater than 12
mobilisation and catheter removal, which is worth closer
hours. Our results show that there is a need to introduce
inspection. It is likely to be multi-factorial: the patients having
methods to reduce fasting times. These could include pre-
superior analgesia and feeling ready to move sooner, but also
operative letters with individualised times to stop eating and
the proforma for the ward indicating the patient had received
drinking. Also patients lower down the surgical list could be
diamorphine. This required the anaesthetist to specify a time
actively encouraged to consume clear fluids, or even
after which she would be ready to mobilise, which might have
carbohydrate drinks as used in many Enhanced Recovery
improved motivation amongst the midwives and mothers to
programmes.
achieve mobilisation.

References
References
1. Aguilar-Nascimento JE, Dock-Nascimento DB. Reducing
preoperative fasting time: A trend based on evidence. World J 1. NICE clinical guideline 132: Caesarean section
Gastrintest Surg. 2010 March 27;2(3): 57-60 2. Wrench IJ, Sanghera S, Pinder A et al, Dose response to intrathecal
2. Mackenzie M, Yentis S, Woolnough M and Johnson M. Fasting diamorphine for elective caesarean section and compliance with a
periods and dehydration before elective caesarean section. national audit standard, Int J Obstet Anesth. 2007;16(1):17-21
Anaesthesia, 2010 Vol 65:99 3. Sibilla C, Albertazzi P, Zatelli R, et al, Perioperative analgesia for
3. Maltby JR, Sutherland AD, Sale JP, Shaffer EA. Preoperative oral caesarean section: Comparison of intrathecal morphine and
fluids: is a five hour fast justified prior to elective surgery?. Anesth fentanyl alone or in combination, Int J Obstet Anesth. 1997; 6(1):
Analg. 1986 Nov;65(11):1112-6 43-48
P8 Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin)
P115 An evaluation of obstetric critical care admissions in a P116 An evaluation of standards of informed consent and
district general hospital documentation for labour epidural analgesia
VL Williams,  M Greene,  D Saul   S Chaudhari,  N Smith,  P Prasad  
Department of Anaesthesia, Leighton Hospital, Crewe, Anaesthetic Department, George Eliot Hospital, Nuneaton,
Cheshire, UK Nuneaton, UK
Introduction: CMACE has provided doctors with excellent
Introduction : It is both medico legally and ethically important
data over the past 50 years about maternal mortality, but
that the patient is made aware of the nature and risks
unfortunately no data about maternal morbidity. In December
associated with a labour epidural. No national standardised
2013, the Intensive Care National Audit & Research Centre
information card for informed consent is available, although
(ICNARC) produced a second report that analysed critical care
the OAA does publish a epidural information card1 with
admissions of women who were pregnant or recently pregnant
specific risks and incidence rates. At our hospital, the
in 2009-2012 inclusive.1 A comparison was made between the
documentation is made on part of the epidural chart as an
hospital ICNARC data and the national ICNARC data.
open entry. Our study looked to ascertain whether appropriate
Methods: Data were collected from the hospitals ICNARC
details of the epidural and informed consent were made. This
database over a four year period from 2009 to 2012. The data
was with a view to find whether a total redesign of the epidural
was analysed from the categories in the table below.
chart (at a level of standard suggested by the OAA website2)
Results: Data from 388 patients were evaluated.
was needed to improve our practice.
  Hospital ICNARC
Methods : We evaluated a total of 100 completed epidural
Total no. of patients admitted, female 16-50 years 388 55,791
charts over a 4-month period in mid-2012 at our obstetric unit.
Currently pregnant 3.6% 2.1%
The epidural notes were retrospectively analysed on our
Recently pregnant 9.3% 10.0%
scanned patient electronic notes. Documentation was
Obstetric reason for admission - currently pregnant 0% 8.7%
analysed for: details of the patient, anaesthetist and patient
Non-obstetric reason for admission - currently
100% 91.3% assessment, explanation of the risks and incidence given,
pregnant
details of the epidural technique and post epidural
Obstetric reason for admission - recently pregnant 50% 69.7%
management. Our main focus was on standards of consent.
Non-obstetric reason for admission - recently
50% 30.3% Results:
pregnant
%of patients Rate of risk
Discussion: The proportions of patients admitted to the Range of risk discussed
Risk discussed informed documented (no.
critical care area were comparable with the ICNARC report. (no. in total)
(n=100) in total)
The leading indication for admission in the currently pregnant
1in100:13,1in200:8
group was for sepsis. This corresponds with the ICNARC Headache 69 25
<1%:3,1in500:1
report and most recent CMACE report in which sepsis was the
Hypotension 45
leading direct cause of maternal death.2
Failure 59 4 1in8:2, 1in4000:2
The leading obstetric cause for currently pregnant admissions
Nerve 1in13k:21,1in10k:8
nationally, was for pre-eclampsia. However, there were no 65 31
damage 1in15k:1, 1 in19k:1
admissions in this category at the hospital. This is most likely
Itching 14    
because pre-eclampsia is diagnosed and treated effectively on
Infection 37  
the labour ward and rarely needs input from critical care.
Motor block 28    
In the recently pregnant group, there were equal proportions
Urinary
of patients admitted for obstetric and non-obstetric reasons, 28    
retention
this is quite different from the ICNARC report. The leading
indication for admission of recently pregnant patients in the The other areas of documentation studied showed an
ICNARC report was for post partum haemorrhage, by a long acceptable standard.
way. When looking at the hospital database, it showed that in Discussion : Several studies have looked at standards of
the period 2010-12, only 3 of 42 patients with a significant post informed consent in UK practice3and which risks and
partum haemorrhage of 2.5 litres or more were admitted to incidences were discussed and the range of risk quoted. Our
critical care. Therefore the question needs to be asked as to study showed rates generally to be slightly lower than that
whether these patients should have been admitted to the quoted in these studies. This is likely due to limited space and
critical care area? The hospital does not have an obstetric open entry nature of our current chart. The OAA has set
HDU, but in hospitals that do have an obstetric HDU facility, guidelines and advice for both epidural charts2 and risks and
these patients would certainly have been admitted there, had incidence1. Following this evaluation, a full redesign of our
closer monitoring and possibly goal directed therapy. All of epidural charts with prompts and guidance of risks and
these patients survived, but could admission to critical care incidence is warranted. In addition, the OAA had
have improved patient outcomes or reduced hospital stay? overwhelming support for a national standardised information
References card that could be implemented3.
1. Female admissions to adult, general critical care units in England,
Wales and Northern Ireland reported as 'currently pregnant'
References
or 'recently pregnant'. http://www.icnarc.org/documents/Obstetric%
20admissions%20to%20critical%20care%202009-2012.pdf 1. OAA epidural information card : http://www.oaa-
anaes.ac.uk/content.asp?ContentID=185
2. The eighth report on confidential enquiries into maternal deaths in
the United Kingdom. BJOG 2011, 118(Suppl 2):1-203 2. OAA epidural charts : http://www.oaa-anaes.ac.uk/content.asp?
ContentID=522
3. Informed consent for epidural analgesia in labour: A survey of UK
practice: Anaesthesia 2009, 64 p161-164
Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin) P9
P117 An unusual cause of post-partum sepsis P118 Anaesthetic management of a parturient with severe
F A Corcoran,  C Brennan,  A J Downs   systemic scleroderma
Anaesthetics, Dudley Group NHS Foundation Trust, Dudley, P Thomas,  A Varvinskiy,  M Human  
UK Anaesthetics, South Devon Healthcare NHS Foundation
Introduction: Leiomyomas are common in women of Trust, Torquay, UK
reproductive age and have been linked to spontaneous Introduction: Scleroderma is a chronic systemic autoimmune
abortion, retention of the placenta and post-partum disease. Successful pregnancy in patients with severe
haemorrhage.1 It is however rare for them to be the primary systemic scleroderma is very rare. We report the anaesthetic
cause of post-partum sepsis. We describe the case of a post management of such a case in a patient with a difficult airway,
partum patient presenting with painful fibroids and sepsis. severe pulmonary dysfunction and oesophageal dysmotility.
Case report: A 37 year old woman (P1), 5 days post partum Case report: A 29 year old woman (G1P0) with severe
presented with a history of fever, abdominal pain and systemic scleroderma presented to the hospital at 36 weeks
distention. She had a past medical history of fibroids but there gestation with dyspnoea and tachypnoea. Prior to pregnancy
had been no problems during pregnancy. She had an her exercise tolerance was poor, managing just 400 metres in a
uneventful labour with a normal vaginal delivery. On initial six minute walk test with resultant oxygen saturations of 72%.
assessment she was apyrexial with normal observations. She Her Forced Expiratory Volume (FEV1), Forced Vital Capacity
had mild tenderness on palpation of her abdomen. She was on (FVC) and Diffusing Capacity for Carbon Dioxide (DLCO) had
regular analgesics and had been commenced on oral each worsened steadily by five percent year on year over the
antibiotics by her GP. An ultrasound scan (USS) was booked last decade. The most recently measured values from 2007
to investigate the abdominal pain. Within 4 hours she had were FEV1 30%, FVC 28% and DLCO 24% of predicted values
deteriorated and developed a pyrexia, tachycardia, tachypnoea although the patient reported that her pulmonary function had
and decreased oxygen saturations. Initial impression was deteriorated significantly during pregnancy. On admission the
sepsis secondary to retained products so blood cultures and patient was breathless at rest with a p02 of 7.63 on room air
swabs were taken and intravenous antibiotics, oxygen and and it was felt that natural labour would not be possible due to
fluid resuscitation commenced. She was transferred to the poor physiological reserve. Severe reflux secondary to
Maternity High Dependency Unit. CRP was elevated but oesophageal dysmotility rendered her unable to recline more
lactate was normal. She improved over 6 hours but than 45 degrees and she could therefore not lie flat for awake
deteriorated again. Antibiotic coverage was amended caesarean section. Airway assessment revealed microstomia of
following microbiology advice but she continued to have a less than one centimetre, mallampati four, bucked teeth, sub
swinging pyrexia. USS detailed a bulky uterus with a large mental skin scleroderma and a narrow hooked nose with small
fibroid at the fundus and no retained products. 36 hours after nostrils. Oral intubation was therefore ruled out. Awake Fibre
admission she developed peritonitis and a CT abdomen which Optic Intubation (AFOI) appeared technically challenging due
suggested findings of a pedunculated fibroid measuring to nasal anatomy. Preoperative, bedside nasendoscopy
17.5cm that might have twisted on its pedicle. She had an revealed that AFOI would be possible should the need to
emergency laparotomy which revealed a degenerative, secure the airway arise mid operation. This avoided the need
necrotic, infected fibroid. She required ionotropic support and to perform an AFOI or awake tracheostomy pre-operatively.
was difficult to ventilate intra-operatively. Post-operatively The patient was positioned at 45 degrees on the operating
she was transferred to intensive care where she was sedated table. Surgeons confirmed that they could operate in this
and ventilated overnight. She was successfully extubated the position. A low dose spinal followed by an epidural which was
following morning and continued with intravenous antibiotics topped up gradually over 30 minutes using small incremental
and analgesia. She made a full recovery. Histology confirmed boluses achieved adequate block without compromising
the fibroid had extensive areas of coagulative necrosis, respiratory function. Surgery was completed without issue and
hyalinisation and inflammation. All microbiological both mother and baby did well post-operatively.
investigations were negative. Discussion: There are only three reports in the literature
Discussion: Sepsis in pregnant and post-partum women describing general anaesthesia for caesarean section in
remains a significant cause of maternal morbidity and patients with scleroderma and two using neuraxial blockade.1-5
mortality.2Sepsis is a clinical diagnosis and microbiological Of those who were intubated, one died and another required
investigations may be negative. Early recognition, timely three months ventilation. We demostrated how careful bedside
diagnosis and active treatment assists an optimum outcome. airway assessment and the use of a slow top up epidural were
Fibroids are common in pregnancy but sepsis secondary to successfully used to manage this challenging case.
infected, necrotic fibroid tissue post-partum is very rare. To References
our knowledge there have been no reported cases of this. It is
1. D'Angelo R, Miller R. Pregnancy complicated by severe
therefore essential to consider this in the differential causes of preeclampsia and thrombocytopenia in a patient with scleroderma.
obstetric sepsis when reviewing pregnant women with a Anesth Analg 1997; 85: 839-41
history of fibroids. 2. Hseu SS, Sung CS, Mao CC, Tsai SK, Lee TK. Anesthetic
management in a parturient with progressive systemic sclerosis
References during cesarean section. Acta Anaesthesiol Sing 1997; 35: 161-7
1. Mason T. Red Degeneration of a leiomyoma masquerading as 3. Younker D, Harrison B. Scleroderma and pregnancy. Br J Anaeth
retained products of conception. Journal of the National Medical 1985; 57: 1136-9
Association. 2002; 94: 124-6 4. Thompson J, Conklin KA. Anesthetic management of a pregnant
2. Lucas DN, Robinson PN, Nel MR. Sepsis in obstetrics and the role patient with scleroderma. Anaesthesiology 1983; 59: 69-71
of the anaesthetist. International Journal of Obstetric Anaesthesia. 5. Bailey AR, Wolmarans M, Rhodes S. Spinal anaesthesia for
2012; 21: 56-67 caesarean section in a patient with systemic sclerosis. Anaesth
1999; 54(4): 355-8
P10 Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin)
P119 Anaesthetic management of arrhythmogenic right P120 Anaesthetic management of obese parturients at a
ventricular cardiomyopathy during labour and tertiary centre - meeting the standard?
caesarean section: a case series L Kelliher,  J Teare,  E Evans  
J Eccles,  A Jain,  K Bhatia   Anaesthesia, St George's Healthcare NHS Trust, London, UK
Department of Anaesthesia, St Mary's Hospital, Manchester, Introduction: Obese women are at increased risk of perinatal
UK morbidity and mortality. In 2010 CMACE and RCOG published
Introduction: Arrhythmogenic right ventricular joint guidelines for the management of the obese parturient
cardiomyopathy (ARVC) is mainly a genetically determined including recommendations that patients with a booking BMI
autosomal dominant disease characterised by cardiomyocytes ≥40 should attend an antenatal anaesthetic clinic (AAC) and a
being replaced by fibrofatty tissue in the right ventricle.1 Specialist Trainee year 6 anaesthetist (ST6) or above should
ARVC has an incidence of 1:5000 and may account for as be informed and available to attend labour and operative
many as 5% of unexpected sudden deaths. The Eighth Report delivery1. Our unit is a tertiary centre with over 5,000
of the Confidential Enquiries into Maternal Deaths in the deliveries/year. A previous audit over 2 years showed that of
United Kingdom (2006-2008) highlighted that ARVC was the 120 women with BMI ≥40 attending our AAC, 76% required a
underlying cause in two of the 53 reported cardiac deaths. We peripartum anaesthetic intervention, with only 34% of these
describe the anaesthetic management of two parturients with performed by an anaesthetist ≥ST62. Awareness of the
ARVC who presented at our tertiary centre. guidelines was raised and anaesthetic plans for these women
Case reports: The maternal demographics, the cardiac signs, now state care should be managed by a senior anaesthetist.
symptoms and interventions along with the anaesthetic We examined our obese population following these changes.
management in the peri-partum period are briefly summarised Methods: A retrospective analysis over 1 year (2011-12) of
in the table below. hospital records for patients with a booking BMI ≥ 40. Records
were examined for referral and attendance at AAC, anaesthetic
Category Case 1 Case 2
intervention (regional/GA), grade of anaesthetist and
Age 27 23
anaesthetic complication (difficult/impossible regional, dural
BMI 25.8 27.2
tap, other).
Parity 0 0
Family history None Sudden death Results: In total there were 74 women with a booking BMI
Cardiac signs and Palpitations with spurts of Paroxysmal VT ≥40. 73% were referred to AAC, only 58% attended. Out of all
symptoms ventricular tachycardia (VT) patients, 69% had a peripartum anaesthetic intervention, 43%
Cardiac Cardiac ablation therapy and ICD insertion of which were performed by an anaesthetist ≥ST6 with a
intervention prior implantable cardioverter complication rate of 16%. Of those attending AAC, 67% had
to pregnancy defibrillator (ICD) insertion an anaesthetic intervention, 41% of which were performed by a
Mode of delivery Elective caesarean section Urgent LSCS for ≥ST6 with a complication rate of 17%. Of those patients not
(LSCS) for breech foetal distress attending AAC, 71% had an anaesthetic intervention and 36%
Anaesthesia and General anaesthesia, with Labour epidural of these were performed by ≥ST6 with a complication rate of
analgesia bilateral transversus analgesia, followed by 14%.
abdominal plane blocks top up for LSCS
Table 1. Incidence of complications by grade of anaesthetist
Maternal length of Three days Four days
stay Group ≥ST6 <ST6 p value (Fisher's Exact)
Neonatal APGAR 8 and 10 9 and 10 All 9.1% 20.7% 0.440
scores AAC 16.7% 17.6% 0.945
Discussion: The main implications of ARVC in parturients No AAC 0% 21.4% 0.273
include fatal arrhythmias, heart failure worsened by Discussion: This audit shows a significant number of obese
physiological changes of pregnancy and sudden adult death parturients were not seen in our AAC. A proportion of these
syndrome.1 Both our patients had VT diagnosed after 24 hour were referred, but did not attend however 27% were not
Holter monitoring, and an ICD was implanted in addition to referred. Despite this, there was no significant difference in the
beta blocker medical therapy to control the symptoms of VT as requirement for anaesthetic intervention or the incidence of
well as to prevent sudden death. The patients were seen in the anaesthesia-related complications between attenders and non-
joint cardiac, obstetric and anaesthesia antenatal clinic and a attenders. The incidence of senior anaesthetic involvement in
peri-partum plan formulated to facilitate safe delivery. Both care has risen from 34% to 41% but there is still room for
had serial echocardiograms, serum electrolytes monitored, improvement. This highlights the resource difficulties faced in
invasive blood pressure monitoring and ICD deactivated providing 24 hour senior anaesthetic cover. The on-call rota at
during their LSCS. Our case series highlights that both general our unit is staffed by junior and senior anaesthetists. The
and regional anaesthesia can be safely provided and we absence of a senior anaesthetist did not lead to a significant
recommend a multidisciplinary approach with close co- rise in anaesthesia-related complications, although there was a
operation between anaesthetists, cardiologists and t rend toward this (Table 1).
obstetricians to provide optimum care of these patients. References
Reference 1. Centre for Maternal and Child Enquiries & Royal College of
Obstetricians and Gynaecologists Joint Guideline. Management of
1. Alexoudis AK, Spyridonidou AG, Vogiatzaki TD, Iatrou CA.
Anaesthetic implications of arrhythmogenic right ventricular women with obesity in pregnancy. London: CMACE & RCOG; 2010
dysplasia/cardiomyopathy. Anaesthesia 2009; 64: 73-8. 2. Fulton L, Evans E, Schroeder F, Wendler R. Antenatal anaesthetic
assessment of morbidly obese women - a useful resource? 2013,
http://epostersonline.s3.amazonaws.com/oaa2013/oaa2013.0690195
.NORMAL.pdf
Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin) P11
P121 Anaesthetic management of the labouring patient with P122 Anesthetic implications  of heart disease in pregnancy
multiple sclerosis S Francés,  S Manrique,  M Goya,  M García,  R Perera,  N
J Li Wan Po,  K Maclennan   Montferrer  
Anaesthesia, St Mary's Hospital, Manchester, UK Anaesthetics, Vall d'Hebron University Hospital, Barcelona,
Introduction: Multiple Sclerosis (MS), an autoimmune Spain
inflammatory disease affecting the central nervous system, is Introduction: Despite advances in its diagnosis and treatment,
estimated to affect 20,000 or more UK women of childbearing heart disease (HD) in pregnancy remains a major cause of non-
age1. Controversy exists regarding the management of obstetric maternal and neonatal mortality and morbidity (it
anaesthesia and analgesia in labouring parturients with MS. complicates around 1-3% of pregnancies in developed
Following analysis of our practice at St Mary's Hospital, a countries). Accurate multidisciplinary assessment and
tertiary referral obstetric unit with over 8500 deliveries per management of individual maternal and fetal risks in pregnant
annum, and recent evidence in the literature; our women with HD provides the best opportunity to substantially
recommendations for the peri-partum management of improve outcomes for mother and baby. (1).
parturients with MS are presented. Methods: We present a prospective cohort study that
Methods: Interrogation of the St Mary's Hospital antenatal analyzed outcomes in women with HD, the majority of whom
clinic database, from 1999 to 2012, identified 21 pregnant had had corrective surgery and delivery between 2007 and
women diagnosed with MS. We reviewed antenatal advice, 2013. Baseline characteristics and adverse events during
intrapartum management and postpartum complications. delivery and postpartum were assessed. Intensive monitoring
Results: Over 50% of patients were nulliparous. The majority of the delivery and postpartum were planned beforehand in all
had mild sensory or motor deficit. Three relapsed during cases.
pregnancy, one improved in symptoms and one relapsed Results: One hundred and seventy-four patients with 179
postpartum. There were twelve normal vaginal deliveries, two pregnancies were included in the study. 127 women (72,98%)
instrumental deliveries, six Caesarean sections and one presented congenital heart disease (CHD), 47 acquired heart
unspecified delivered at another hospital. Five women opted disease (27,02%): 27 acquired rheumatic valve disease
for epidural analgesia, two were topped up for operative (19,98%), one Marfan syndrome (0,54%), 3 coronary heart
delivery. Five had spinal anaesthesia with 0.5% heavy disease (1,6%) and 9 primary myocardial disease (4,9%).
bupivacaine and one had a general anaesthetic. There were no
Pregnancy complications were presented in 21, 2% of CHD,
complications following regional technique.
14,8% of acquired rheumatic valve disease and 100% of
Discussion: A recent national survey reported that within a 10 women with arrhythmias.
year period, 91% of anaesthetists have encountered <ten
The type of delivery was vaginal in 124 women ( 72,1%) and
cases of MS2 and have little experience in their management
cesarean section in 50 women (27,9%).
during pregnancy. Recent evidence available supports our
168 women had analgesia during delivery (93,8%); 5 women,
current management of MS patients undergoing labour. The
general anesthesia (2,79%), 6 women, local anesthesia (3,35%)
low incidence of the disease makes it difficult to attain
and 87,5% of women had regional analgesia.
significant figures to determine the optimal management plan.
To standardize care, we made the following recommendations Delivery complications were 7% (uterine atony 2,7%, vaginal
based on the latest evidence and our own experience: hematoma 2,2%, chorioamnionitis 0,5%, cesarean hematoma
- Patients to be reviewed in an antenatal anaesthetic clinic. 0,5% and hemoperitoneum 0,5%). The only anesthesia
Document disease severity and discuss analgesia and complication was one dural puncture (0.5%). No maternal
anaesthetic options. death, one fetal death (0.5%) and one neonatal death (0.5%).
The maternal average hospital stay was 3 days.
- Use of 0.1% bupivacaine with 2mcg/ml fentanyl mixture for
epidural labour analgesia2 . For an operative intervention, top Discussion: Pregnancy and delivery are associated with
up with a higher concentration of local anaesthetic. substantial physiological changes, which require the
adaptation of the cardiovascular system and can expose
- Regional rather than general anaesthetic for caesarean
women with HD to significant risks. If regional anesthesia is
sections. Spinal anaesthesia is the most simple and reliable
selected, the addition of an opioid, when dosing any neuraxial
technique although consider combined spinal-epidural on an
anesthetic, will reduce the amount of local anesthetic required
individual basis.
and subsequent hemodynamic effects, while improve
- If a general anaesthetic is necessary, avoid suxamethonium
intraoperative and postoperative analgesia. The avoidance of
and monitor neuromuscular block to titrate dose of non-
epinephrine from the epidural dose will eliminate the possible
depolarizing muscle relaxant3.
deleterious effects of systemic epinephrine. Maintaining
These recommendations will be available for clinicians on the uterine blood flow is important for fetal well-being.
trust intranet and a patient information leaflet on the effects of Maintaining systemic vascular resistance in patients with
pregnancy and anaesthesia on MS has been produced. intravascular shunting, is important to avoid inducing or
exacerbating pre-existing cyanosis due to increased right- to –
References
left shunting. Cautious intravenous hydration and gentle
1. Brookings W, Lee M. Management of multiple sclerosis during
titration of phenylephrine or ephedrine are options to
pregnancy. Prog Neurol Psychiatry. 2009; 3(6): 9-11
counteract the hemodynamic effects of surgical neuraxial block
2. Drake E, Drake M, Bird J, Russell R. Obstetric regional blocks for
women with multiple sclerosis: a survey of UK experience. Int J (1,2). We observed a predominance of neuraxial anaesthetic
Obstet Anaesth. 2006; 15(2): 115-23 techniques, increased caesarean and operative delivery rates,
3. Griffiths S, Durbridge JA. Anaesthetic implications of neurological and favourable maternal and neonatal outcomes.
disease in pregnancy. Contin Educ Anaesth Crit Care Pain. 2011; 11
(5): 157-61 References
P12 Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin)
P123 Angle of tilt achieved with automated operating table P124 Antenatal anaesthetic information given to women
in elective caesarean sections: a comparison with tilt with obesity
achieved with an inflatable balloon wedge  C R Thomas,  C Busby  
PN Nair,  L Dyal,  B Grewal,  I Suri   Anaesthetics, Airedale General Hospital, Keighley, UK
Department of Anaesthesia, Warwick Hospital, Warwick, UK Introduction:Antenatal obesity is defined as a BMI of ≥30at
Introduction: A previous study1 done on patients undergoing booking. Its prevalence in England increased from 7% in 1990
elective caesarean sections looked into measuring the angle of to 16% in 2007.1Women with a BMI ≥40 are often provided
tilt of the operating table with an inflatable balloon wedge. with anaesthetic information antenatally. Those with lower
This showed that the visual estimation of angle proved levels of obesity also have an increased anaesthetic risk but
accurate in the achievement of near 150 tilt. Here we present these women may receive little or no information about this
the results of a similar study using a different technique of during pregnancy. 2The RCoA have produced standards
automated table tilt instead of the inflatable balloon wedge regarding care for these women: 90% of patients with a
device. The premise being is our visual actuation of tilt angle booking BMI ≥ 30 should receive a leaflet containing
accurate. information about anaesthesia and analgesia. 90% of patients
Methods: The study was similar to the previous one. We with a booking BMI ≥40 should have an anaesthetic consult.
prospectively selected 26 patients at random who were Booking BMI should be documented in 100% of maternity
undergoing elective lower segment caesarean section under hand-held notes. An audit of the above standards was carried
spinal anaesthesia over a six week period. Ethical committee out as summarised below.
approval was obtained. Verbal consent was obtained from all Methods:A list of all deliveries in January 2013 was generated.
participants and the booking Body Mass Index (BMI) was Notes were reviewed for adherance to the above three
noted. We used the same protractor device for measuring the standards. Change to practice was recommended based on
angle of tilt. This is similar to the one used by Kinsella et al2. audit findings. Following the implementation of change, the
Results: The measured angles ranged from 10 to 18 degrees, a audit cycle was completed by auditing notes of all deliveries in
mean angle of 13.70 with a mean difference of -1.3 and standard November 2013.
deviation of 2.32. This compared very closely to the angles Results:
between 10 to 17.5 degrees, mean angle of 13.650, mean Table: Recording of booking BMI, patient count by raised
difference of -1.35 and a standard deviation of 2.06 in the BMI category and number given anaesthetic information.
previous study. BMIs ranged from 19 to 37 with a mean of 24.
Discussion: The visual estimation of angle using the
BMI 30 - BMI 35 - BMI
automated table tilt proved accurate in achieving the near 150 No
Number of Unavailable 34.9; 39.9; ≥40; 
tilt and is comparable with that obtained with the inflatable   booking
deliveries casenotes info info info
balloon wedge device in the previous study. The standard BMI
given given given
deviation of 2.32 indicates that 95.4% of cases could achieve
Jan 195 6 2 20; 0 7; 1 7; 7
within 4.60 of the required 150 tilt i.e. 10.4 to 19.6 degrees tilt.
Nov 173 3 2 17; 2 7; 7 3; 3
The automated table tilt provides an easy and accurate means
of providing left lateral tilt in pregnant patients. Discussion: Booking BMI was recorded in 99% of the notes in
both audit cycles. In 100% of cases where BMI was ≥40, a
consultant anaesthetist discussed risk and made a plan with
References
the patient. However, the audit of January deliveries indicates
1. Grewal B, Suri I. Is visual actuation a valid predictor of angle of tilt?
that few women who have a BMI 30-39.9 receive anaesthetic
Int J Obstet Anaesth Vol 18 2009; pS1-64- supplement
information.; this occurred in only one case. Reaching this
2. Kinsella SM. A device for measuring the degree of lateral pelvic tilt
during supine recumbency. Anesth Analg 1995; 80: 204-5 population to provide information is difficult especially where
BMI is 30-34.9 as all antenatal care for this group may be
provided by community midwives. In collaboration with
Obstetrics, a patient information leaflet was written which
included both obstetric and anaesthetic information. The
leaflet was approved by the Women's Integrated Governance
group and has been in use since October 2013. It is available
on the Trust intranet which is accessible by some community
midwives. The leaflet is given to all those with a BMI ≥ 35
when they attend obstetric high risk clinic. The results of the
November audit indicate improvement has been made; 44.4%
of those with obesity now receive anaesthetic information.
Greater access to the leaflet is needed however.
References
1. Royal College of Anaesthetists 2012,
http://www.rcoa.ac.uk/document-store/audit-recipe-book-3rd-edition-
2012
2. Centre for Maternal and Child Enquiries 2010, http://www.oaa-
anaes.ac.uk/assets/_managed/editor/
File/CMACE/CMACE_Obesity_Report_2010_Final%20for%
20printing.pdf
Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin) P13
P125 Antenatal management of morbidly obese parturients: P126 Audit of temperature for patients undergoing elective
A multicentre evaluation. caesarean section
H Aladin,  A Khandhia,  K Pottinger   N J Truman,  I Clegg,  K Maclennan  
Anaesthetics, Good Hope Hospital, Birmingham, UK anaethetics, St Mary's Womens Hospital, Manchester, UK
Introduction: Women with a body mass index (BMI) of ≥30 Introduction: Perioperative Hypothermia is associated with
kg/m2 at the time of antenatal booking are classed as being poor outcomes and adverse events for patients; including
obese in pregnancy, accounting for around 39,000 maternities surgical site infection increased length of stay, blood loss,
per year1. Obesity is associated with increased risk of shivering, increased anaesthetic recovery time and cardiac
anaesthetic morbidity and mortality. National guidance have events. Risk factors for the occurrence of hypothermia include
been developed following the Confidential Enquiry into regional anaesthesia, fluid deprivation, blood loss, and cold
Maternal and Child Health report concerning obesity in fluid administration, all of which are common to obstetric
pregnancy. At two different hospitals, five indicators of best patients. 2008 Nice guidelines CG651 on perioperative
practice2 were analysed: (1) Recording of maternal BMI. (2) hypothermia do not include parturients, despite being an at
BMI ≥ 30 women receive information about risk group. An audit performed in 2011 at St Mary's Hospital
anaesthesia/analgesia. (3) Women with a BMI ≥ 40 have demonstrated that 92.5% of elective section patients were not
antenatal anaesthetic review. (4) Duty anaesthetist should be 'comfortably warm' on arrival in recovery, with 65% defined as
informed when women with a BMI ≥ 40 are admitted. (5) hypothermic. A repeat audit was performed following
Anaesthesia for women with a BMI ≥ 40 should be provided commencement of a trial of an air free conductive fabric patient
by a senior anaesthetist. warming system (Hot Dog®).

Methods: Women who had undergone a lower segment Method: A prospective audit of elective caesarean section
caesarean section (LSCS) during a 6 month period (Jan 2013- patients was conducted from April-June 2013 at St Mary's
Jun 2013) at a District General Hospital (DGH) and a Hospital. Theatre staff completed the audit proforma. Data
Foundation Hospital (FH) were evaluated. Data was collected collected included; ambient theatre temperature (ideal target
retrospectively from an electronic data archive and anaesthetic 21ºC), anaesthetic type, estimated blood loss (EBL),
charts. Evidence of BMI calculations, provision of temperature pre, intra, post operative and prior to discharge
anaesthesia/analgesia information, ante-natal anaesthetic from recovery (measured using a tympanic membrane
appointments, and anaesthetic care in the labour ward and thermometer) and details of which Hot Dog® warming
theatre were identified. products were used. Hypothermia was defined as a core
Results: 309 women who underwent a LSCS were identified temperature <36ºC with desirable temperature being defined as
with a having a BMI 30 (median 34, range 30-59). 51% of 36.5-37.5ºC. Comparison of the results from the 2011 audit
these were elective cases. 56% of women with a BMI ≥30 enabled conclusions to be drawn regarding the effectiveness
received anaesthesia/analgesia information, of which 2 were of the warming product.

given literature on anaesthesia in obesity. 32% of women with
Results: A total of 33 patients were audited who underwent
a BMI 40 underwent an antenatal anaesthetic review, with an
elective caesarean section, [n=79, 2011audit], 94% had spinal
additional 4 women failing to attend their appointments. In
anaesthetic (87%, 2011 audit). Mean (S.D) theatre temp was
those women with a BMI ≥40, the duty anaesthetist was
22.8 (± 0.6) [22.3 (± 0.6), 2011 audit], mean duration of
informed of admission in 19% of cases and in 56% of LSCS,
procedure was 51 minutes. 94% of patients had an additional
the anaesthetic care was provided by an appropriately graded
fluid warmer intra-op (72%, 2011 audit). The mean EBL was 574
anaesthetist .
ml (± 213) [653 (± 431), 2011 audit] and only 6% of patients had
Table: Women with BMI 30 having anaesthetic care at a DGH an EBL over 1L (20% 2011 audit). Only 12% (n=4 of 33) of
and FH. patients warmed with the HotDog® were hypothermic on
arrival to recovery (compared to 65% (n=51 of 79), 2011 audit)
  DGH FH
figure 1.
Total LSCS 32% (99/309) 68% (210/309)
Discussion: efforts have been to reduce perioperative
BMI Median (range) 33 (30-59) 34 (30-52)
hypothermia in elective caesarean sections. Almost all patients
Maternal height, weight + BMI recorded 100% 100%
received warmed fluids via a 3M™ Ranger™ fluid warming
Conclusion: This audit has identified that more than half the
system. Forced air warming devices applied to the upper body
women with a BMI ≥30 received analgesia/anaesthesia
are not well tolerated by our awake patient population and
information and more than half were anaesthetised by a senior
allow only a limited area to be heated. introduction of
anaesthetist. However, in all the areas of practice, the target
HotDog® with an under patient warming mattress and
percentage of women meeting the identified standards were
separate over patient warming blanket (for upper and lower
not achieved. Recommendations included revision of the
limb) proved to be of benefit in perioperative maintenance
referral guidelines for antenatal anaesthetic assessment,
when compared to our standard warming measures. A
improved communication within the multidisciplinary team
HotDog® warming mattress placed on the patient chair in the
during admissions and increased presence of senior
pre theatre waiting area helped prevent hypothermia pre arrival
anaesthetists on delivery suite.
in theatre.
References
Reference
1. Centre for Maternal and Child Enquiries (CMACE). Maternal
1. CG 65 Management of inadvertent perioperative hypothermia in
obesity in the UK: Findings from a national project. London:
adults. NICE April 2008.
CMACE, 2010
2. The Royal College of Anaesthetists. Raising the Standard. A
compendium of audit recipes for continuous quality improvement in
anaesthesia. 3rd Edition 2012
P14 Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin)
P127 Availability of chlorhexidine handwash for regional P128 Caesarean section in a rhesus null parturient with a
analgesia on the labour ward uterine fibroid
K Chima,  T Strickland,  F Plaat   P J Stewart,  R Laird,  J Cartmill  
Anaesthetics , Queen Charlotte's and Chelsea Hospital, Anaesthetics, Altnagelvin Area Hospital, Londonderry, UK
London, UK Introduction: The anaesthetic management of a Caesarean
Introduction: Many patients request regional analgesia during section is made more challenging by the combination of pre-
labour and therefore central neuraxial blocks are performed in operative anaemia, a large uterine fibroid and the presence of a
the delivery room. For central neuraxial blocks an aseptic very rare blood group Rhesus null.
technique should be standard. In the Third National Audit Case report: A forty-year lady with a past medical history of
Project of the Royal College of Anaesthetists the incidence of psoriatic arthritis presented to antenatal booking at 10 weeks
iatrogenic infection was reported as being 8/707 000 gestation. Booking investigations revealed a haemoglobin of
procedures1. However the consequence of any infection is 10.3g/dL, and a blood group O Rhesus null. Her 20-week
potentially devastating, and a 'scrupulous' aseptic technique ultrasound scan revealed no foetal anomalies but did
was therefore stated to be mandatory in the report1. demonstrate an anterior uterine fibroid. This was confirmed
Chlorhexidene gluconate 4% is used for hand decontamination with magnetic resonance imaging which showed a
in our department. It was noticed that not all delivery rooms heterogeneous mass measuring 188x139x159mm, in keeping
were equipped with both chlorhexidene and a hands free with a degenerating fibroid. At 21+3 days she presented with
method for application. dizziness and right upper quadrant pain. Her haemoglobin
Methods: All delivery rooms on labour ward were inspected to level was 7.6g/dL and she was treated for iron deficiency
ascertain the presence of chlorhexidene and a hands free anaemia. Due to a transverse lie and the large fibroid an
dispenser. elective Caesarean section at 38 weeks was planned. As a team
we anticipated a difficult Caesarean delivery with greater blood
The audit was repeated after one and twelve months to assess
loss in a patient with anaemia and a very rare blood group.
if there had been any improvement in the service.
Antenatal management focused on maximising the patient's
Results: Originally, 12 of the 16 delivery rooms had
haemoglobin levels and sourcing compatible blood. The
chlorhexidene available (75%). Of the 12 rooms with
Northern Ireland blood transfusion service and National frozen
chlorhexidene only three were equipped with a hands free
red cell bank in Liverpool secured two units of packed red cells
dispenser (25%), and five containers were uncovered (42%).
in England. Unfortunately, one week prior to the section this
After one month all 16 rooms were equipped with wall blood was issued in an emergency, making it unavailable to us.
mounted chlorhexidene with a hands free dispenser (100%). A new donor was found in South Africa and a further unit was
After a further 12 months it was found that 12 of the 14 secured in Brazil. Both units were couriered to our hospital
delivery rooms had chlorhexidene available (86%). (Two of the prior to the Caesarean delivery which was performed at 38+6
rooms had been converted to a post delivery high dependency days under spinal anaesthesia. Pre-operative haemoglobin was
unit). Eleven of the 12 containers were equipped with a hands 9.1g/dL. The patient was discharged home on day three post-
free dispenser (92%). operatively and her haemoglobin was 7.2g/dl on discharge. No
Discussion: The results of the initial data collected, as well as blood transfusion was required.
anaesthetists' concerns regarding the unavailability of Discussion: Red blood cells from people who have the Rhesus
chlorhexidine and dispensers in each room, was reported to null phenotype lack Rhesus proteins, and thus, Rhesus
managerial staff, who ensured all rooms were adequately antigens. This phenotype occurs in approximately 1 in 6x106
stocked. Results were therefore better when re-auditing was individuals1. When these patients are transfused they may
performed at one month. However, after 12 months standards form antibodies to high frequency rhesus antigens, which can
had declined, although they were still improved from the make it extremely difficult to process compatible blood. Rhesus
initital audit. This decline could be attributed to the fact that null blood is available from the National frozen cell bank,
neither a team nor a named individual was made responsible however it may not be available when required due to limited
for sustaining the initial improvement, which if introduced, we supplies, as in our case. There is very limited literature
feel would encourage a sense of ownership and enable the regarding the management of the rhesus null parturient and
improvement in this area of patient safety to be sustained. our management was guided by our regional Haematology
Reference unit. This case demonstrates the importance of good
communication with all members of the multi-disciplinary team
1. National Audit of Major Complications of Central Neuraxial Block
in the United Kingdom 2009, http://rcoa.ac.uk/system/files/CSQ- and the detailed preparations required in a complex case.
NAP3-Full_1.pdf
Reference
1. Avent ND, Reid, ME. The Rh blood system: a review. Blood 2000
95: 375-387.
Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin) P15
P129 Category one caesarean sections in a district general P130 Comparison of two non-invasive cardiac output
hospital:  Improving the decision to delivery time monitoring devices in a parturient with complex
VK Wroe,  AM Troy   cardiac disease.
Department of Anaesthesia, Countess of Chester Hospital, PJ Rose,  V Misra,  S Quasim  
Chester, UK Anaesthesia, UHCW, Coventry, UK
Introduction: National Guidelines state that the interval from Introduction: The management of valvular lesions during
decision to delivery (DDI) in a category one caesarean section pregnancy and labour can present a clinical conundrum. We
should be less than 30 minutes1, and that a duty anaesthetist present the use of two cardiac output (CO) monitoring devices
should be immediately available for emergency work on the in a parturient with complex valvular heart disease undergoing
delivery suite 24 hours a day2. a caesarean section under epidural anaesthesia.
A 2008 departmental audit found that 85% of category one Case Report: A 37 year old primiparous woman with history of
sections had a DDI of under 30 minutes, a figure marginally ASD repair aged 4, severe mitral regurgitation, severe tricuspid
under the audit standard of 90%. Anaesthetic service regurgitation, moderate aortic stenosis (AS) secondary to a
provision in our trust was expanded in July 2012, with the congenital bicuspid valve and moderate pulmonary
addition of a dedicated obstetric anaesthetist 24 hours a day. hypertension presented for elective caesarean section.
This re-audit aimed to assess the proportion of category one Echocardiography showed moderately dilated right ventricle
caesarean sections with a DDI <30 minutes and analyse the with good bi-ventricular systolic function, bi-atrial dilatation,
factors contributing to any delay. moderate to severe AS (mean gradient 34mmHg, peak gradient
Methods: After audit department approval, a retrospective 53mmHg, estimated valve area 0.74cm2). Pulmonary artery
analysis of category one caesarean sections between August pressures were estimated at 42-47mmHg. LiDCO rapid and
and December 2012 was performed. Data collected included Cheetah NICOM devices were used to monitor CO.
DDI and reason for delay, indication for section, type of Anaesthesia was established with 32mL 2% lignocaine and 100
anaesthesia and cord pHs. micrograms of epinephrine via epidural. Compound sodium
lactate was infused at 60mL/hr, and increased to 100mL/hr after
Results: 69 category one caesarean sections were analysed.
epidural anaesthesia. Fluid boluses of 200mL and 100mL were
The mean DDI was 23 minutes (range 3-120 minutes). 84% had
delivered via the pump at 13 and 28 minutes after delivery of a
a DDI of under 30 minutes, with a mean time from decision to
live infant. Metaraminol infusion was titrated to effect.
effective anaesthesia of 14.5 minutes. The indication for
Syntocinon infusion was started upon delivery (20 units in
caesarean section was abnormal CTG in 87% of cases (2008:
48mL 0.9% saline) at 15mL/hr and tapered post-operatively
77%). General anaesthesia was performed in 43% (2008: 85%),
over 4 hours. Mean arterial pressure was maintained at 91 to
spinal anaesthesia in 55% (2008: 15%) and extension of
97mmHg until delivery (78 minutes) and then decreased to
epidural blockade in 2%. In 11 cases, DDI was over 30
67mmHg at the end of surgery. Cardiac output was maintained
minutes; these cases were all performed under spinal
throughout surgery with an increase at the time of concurrent
anaesthesia. The following table shows the reasons identified
fall in MAP. Fluid challenge had negligible effect although
that contributed to delay:
there was a small reduction in heart rate (84 to 59bpm).

Arrival in
Discussion: NICE has advocated the use of cardiac output
theatre Incision to
Spinal monitoring in high risk non-obstetric surgery to improve
10 delivery Staff Theatre
  placement outcome.1 In this case we utilised both a non-calibrated pulse-
minutes time 10 unavailable unavailable
10 minutes contour waveform analysis and bioreactance system to
from minutes
compare both values measured and response to fluid
decision
challenge. Although the values produced were different, the
Number
trends were broadly similar. This, once again, highlights the
of 4 6 1 1 1
importance of analysing trends rather than absolute values to
patients
guide management. Interestingly, both devices demonstrated
Arterial cord blood analysis was carried out in 10/11 cases. pH
that a fall in MAP correlated with an increase in cardiac
was less than 7.2 in 30%, and base excess was less than -8 in
output, similar to previous investigators.3 Given that cardiac
20%.
disease is the leading cause of death in the most recent
Conclusion: The proportion of cases with a DDI of over 30 triennialreport2, monitoring cardiac output enables one to
minutes has remained constant at around 15%, despite an maintain physiological homeostasis, and ultimately aids
improvement in anaesthetic staffing. Our results suggest that clinical decision-making leading to good clinical outcome, as in
the causes for this delay are multifactorial, and the results are our case.
not benign- the delay in delivery led to a cord pH of <7.2 in
References
almost one third of cases. We intend to improve our practice
1. MTG3 CardioQ-ODM (oesophageal Doppler monitor): guidance
by regular practice drills, use of preprepared spinal packs to
2011, http://www.nice.org/nicemedia/live/13312/52624/52624.pdf
reduce spinal placement time, clear procedures to follow in the
2. Centre for Maternal and Child Enquires (CMACE). Saving Mothers'
case of staff or theatre unavailability and reaudit. Lives: Reviewing maternal deaths to make motherhood safer: 2006-
2008. The Eighth Report of the Confidential Enquires into
References
Maternal Deaths in the United Kingdom. BJOG 2011;118(Suppl
1. Caesarean section. NICE Clinical Guideline 132. NICE, London 1):1-203
2011. (http://publications.nice.org.uk/caesarean-section-cg-132).
3. Fanning NP, Sermer M, Colman J, Carvalho JC, Cordovani D. Non-
2. OAA/AAGBI guidelines for obstetric anaesthetic services- 3rd invasive Hemodynamic monitoring with bioreactance for cesarean
edition. AAGBI and OAA, London, 2012 delivery. A more relaxed look at tight aortic stenosis? Abstract
(http://www.aagbi.org/publication/publication-guidelines/M/R) SOAP 2011, http://www.soap.org/display_2011_abstract.php?id=58
P16 Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin)
P131 Comparsion of slow and rapid bolus of ephedrine in P132 Continuous spinal anaesthesia for a primigravida with
patients undergoing planned caesarean section under severe tricuspid regurgitation, Harrington rods and
spinal anaestheisa WITHDRAWN FROM  thrombocytopenia.
PRESENTATION AM Walton,  I Mettam  
PG Sekar,  LB Ellakumanan,  H Balachander,  MVS Obstetric Anaesthetic Department, University Hospital
Satyaprakash   Southampton, Southampton, UK
Anaesthesiology, JIPMER, Puducherry, India Introduction: We present the successful use of continuous
spinal anaesthesia (CSA) for caesarean delivery in a parturient
with severe tricuspid regurgitation and pregnancy-induced
thrombocytopenia in addition to Harrington rod placement for
scoliosis spinal surgery.
Case history: A 40 year old primigravida presented at 37
weeks gestation. She had undergone a tricuspid valve repair
previously for endocarditis. The patient had developed severe
tricuspid regurgitation and had heart failure. Harrington rods
were placed in her thoracic and lumbar spine for repair of a
congenital scoliosis. Blood tests revealed a pregnancy related
thrombocytopenia with platelets of 85x109/L. An
echocardiogram showed a severly dilated right atrium with
intra-atrial septal bowing to the left, severe free flowing
regurgitation and right ventricular systolic pressure
32mmHg.The case was discussed with obstetricians,
anaesthetists and cardiologists and a decision was made for
an elective caesarean section under CSA, if the final platelet
count remained stable. The patient expressed a preference to
remain awake and avoid a general anaesthetic. At surgery a
cannula and radial arterial line were inserted. In the sitting
position a 22G spinal needle was inserted below the level of
the scar tissue at L3/4, and a spinal catheter threaded into the
subarachnoid space. A total of 10mg bupivacaine and 250mcg
diamorphine were required over 20 minutes to establish a block
to T4. The blood pressure dropped from 135/70 to 90/50mmHg
and required only 5mcg of epinephrine to return to baseline
values. Blood loss was 720mls. Syntocinon was given as an
infusion only. A live male infant was delivered.
Discussion: An obstetric anaesthetist has to take many
factors into account when deciding on the best choice of
anaesthetic for a particular case; anaesthetic expertise,
maternal co-morbidities, fetal well-being and maternal
preferences all play a part. Cardiac disease in pregnancy is still
the leading cause of indirect maternal mortality in the UK.1 The
choice of anaesthetic and delivery had to ensure the least
amount of strain on an already compromised heart. The
advantages of CSA are that a block can be established
gradually with small incremental doses of local anaesthetic,
which reduces the likelihood of cardiovascular instability.2
The concerns with a CSA are principally neurological
complications and post-dural puncture headache. CSA is
proving an option to be considered for patients with
significant cardiac disease and previous spinal surgery
provided the anaesthetist has experience with the technique.
In this case it provided a cardiovascularly stable anaesthetic
with excellent analgesia and maximal maternal satisfaction.
References
1. Saving mothers lives.The Eighth Report of the Confidential
Enquires into Maternal Deaths in the UK. March 2011
2. DennyNM, Selender DE. Continuous spinal anaesthesia. Br J
Anaesth 1998;81:590-7
Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin) P17
P133 Does pre-operative anxiety predict post-operative pain P134 Early epidural analgesia may increase caesarean
scores in parturients undergoing caesarean section? section rate in spontaneously  labouring nulliparous 
BM Daly,  N Weidenhammer,  R Junkin,  L Riddell,  J Dolan,  J women: a retrospective study
Kinsella*,  R Marla,  S Young   R Anil Kumar,  Roger Mc Morrow  
Anaesthesia, Princess Royal Maternity, Glasgow, UK, Anaesthesia, National Maternity Hospital , Dublin, Ireland
*Anaesthesia, Pain & Critical Care Medicine, University of Introduction:.Epidural analgesia offers the most effective
Glasgow, Glasgow, UK method of intra-artum pain relief. The effect of epidural
Introduction: Pregnancy, childbirth, and undergoing a surgical analgesia on the progression of labour and the mode is often
procedure are all likely to induce anxiety. The relationship debated in multiple studies. This study aims to show the effect
between anxiety, pain and pregnancy is complex.1Childbirth is of timing of epidural analgesia on the mode of delivery.
a time of high anxiety, and Caesarean section is known to be Method: Data such as women's age, gestational age, cervical
associated with significant pain post-op. Here we ask can dilatation before epidural insertion and duration of labour was
anxiety scoring predict post LSCS pain? collected from a total of 2029 nulliparous women in
Methods: After ethical approval and consent, pre-operative spontaneous labour. Epidural analgesic was defined as early at
data and a single 24hr post-op 10cm VAS were collected from a cervical dilatation of 3cms or less and late at a cervical
108 women, with 9 having missing data. Spielberger2 State and dilatation of 4 or more cm
Trait anxiety forms were completed prior to surgery. We Results: Of the 2029 women, 1423 ( 70.1%) received epidural
present secondary end points powered post hoc for 0.8 analgesia. Out of the 2029 women, 1403 ( 69.2%) had
probability of 2cm VAS difference. A standardised anaesthetic spontenous vaginal delivery, 478 (23.6%) had assisted
(spinal including diamorphine) and analgesic regime was used. delivery and 146 ( 7.2%) had caeserean section.
The cohort was divided into "high"- above the mean and
The data was anaylsed according to the timing of epidural
"low"- below the mean anxiety and compared using Student's
analgesia or no epidural analgesia and modes of delivery.
t-test.
Anaesthetic Delivery method
Results:
intervention Spontaneous Assisted Caesarean
Table 1: State anxiety compared to VAS
No epidural 537 (88.9%) 51 (8.4%) 16(2.6%) 604
Low anxiety High anxiety Early epidural 757 (62.2%) 379 126 (10.0%) 1262
  Significance
(n=45) (n=54) (30.0%)
24 hr VAS mean Late epidural 109 (67.7) 48 (29.8%) 4(2.5%) 161
5.0 (2.2) 5.3 (2.0) P= 0.40
(SD) cm
Epidural Assisted delivery C-Section
Table 2: Trait anxiety compared to VAS analgesia OR 95% CI p-value OR 95% CI p-value
Low anxiety High anxiety Early 5.27 3.86, 7.21 <0.001 5.59 3.28, 9.51 <0.001
  Significance
(n=48) (n=55) epidural
24hr VAS mean (SD) Late 4.64 2.97,7.23 <0.001 1.23 0.40,3.76 0.71
4.8 (1.9) 5.5 (2.2) P= 0.15
cm epidural
Table 3: State +Trait anxiety compared to VAS Conclusion: The results from the study show that the
Low anxiety High anxiety likelihood of having caeserean section in the early epidural
  Significance
(n=48) (n=51) group is significantly higher compared to the late epidural
24hr VAS mean (SD) group, but the incidence of assisted delivery between the early
cm 4.8 (1.9) 5.6 (2.1) P=0.072 and late epidural group were similar. This study also shows
that there is an increased likelihood of having assisted
Discussion: While the higher anxiety groups displayed a delivery and caeserean section delivery with epidural
higher mean VAS in all the analysis, this was not statistically analgesia compared to without from the study group.
significant. The separation between the two groups was better
References
with the State than the Trait anxiety score and best of all when
1..Gonen Ohel. Early versus late initiation of epidural analgesia in
the two scores were combined. Further reasearch could look at
labour: Does it increasethe risk of cesarean section. A randomised
anxiety scoring as part of a bundle of other measures verus trial. American journal of Obstretrics and Gynaecology (2006) 194,
pain. 600-5
2. Wassen et al. Early versus late epidural analgesia and risk of
References
instrumental delivery in nulliparous women: a systemic review.
1..Waldenstrom U: Experience of labor and birth in 1111 women. J British Journal of Obstretrics and Gynaecology (2010) 1471, 655-
Psychosom Res.1999: 47(5):471-82 661
2..www.mindgarden.com
P18 Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin)
P135 Efficacy of midwife led epidural top ups in labour–Are P136 Emergency obstetric and neonatal care in Kenya:
programmable pumps really the way forward? Addressing millennium development goals
E Traer,  G Waters,  GNB Jackson   D B Pachter,  C A Ameh*  
Anaesthetic department, Royal Berkshire NHS Trust, Anaesthesia, Cumberland Infirmary, Carlisle, UK, *Maternal
Reading, UK and Neonatal Health, Liverpool School of Tropical
Introduction: There are an increasing number of automated Medicine, Liverpool, UK
techniques by which labour epidurals can be managed1,2,3,4. Introduction: In 2008, an estimated 358,000 women died from
Comparison reports of programmable epidural pumps regimens complications of pregnancy and childbirth. The overwhelming
have shown lower total volumes of local anaesthetic may be burden of this mortality occurs in the developing world, with
associated with reduced rates of instrumental delivery and almost 60% of deaths occurring in sub saharan Africa.1There
improved maternal satisfaction1,2. Extended intervals between are also some 3.6 million neonatal deaths each year, and once
boluses with larger volume boluses was shown to use less again the developing world is disproportionately represented.2
total local anaesthetic3. These reports have led us to In 2006, the Liverpool School of Tropical Medicine (LSTM)
investigate similar outcomes our unit where we have a midwife developed a training package entitled "Life Saving Skills,
led top up (MLTU) practice. Emergency Obstetric and Neonatal Care" (LSS EOC-NCC) to
Method: First epidural bolus administered by the anaesthetist try and address these huge public health issues. Courses now
of 20ml 0.1% bupivicaine+2µg/ml fentanyl . Data recorded at run in 11 countries worldwide. In October 2013, I was fortunate
each subsequent midwife administered bolus (MLTU): bolus e nough to teach on a course in Nyeri, Kenya.
interval time, motor block (Bromage score of 2-4 taken as motor Methods: A variety of teaching methods were used on the
block), any change to the standard dose 20ml 0.1% course. Didactic lecture based teaching had a limited role, with
bupivicaine+2µg/ml fentanyl and if analgesia was effective or more emphasis placed on small group "break out sessions"
ineffective. and scenario based teaching. Pre and post course simulation
Results: 50 patients audited based testing was undertaken, with results collated and sent
back to Liverpool for analysis and assessment of efficacy of
Midwife led epidural Top Up Data  
teaching.
Mean bolus interval time (min) 105 (sd 26)
Mean rate bupivicaine mg/hr 10.56 (sd 3.6) Results: Participant feedback suggested a high level of
Motor block (Bromage score 2-4) 11/48 (22.9%) satisfaction with the course. The impact of courses in terms of
Mean time to motor block (min) 237 (sd 135) reduction in maternal and neonatal mortality remains the
NVD 14/48 (29.1%) subject of ongoing scrutiny. One study from Somaliland
Instrumental 18/48 (37.5%) demonstrated improved knowledge and skills and evidence of
LSCS 16/48 (33.3%) positive behaviour change post introduction of the course.3

Satisfaction excellent/good 46/48 (95%)
Conclusions: Maternal morbidity and mortality remains a huge
Discussion: In this study we found the mean interval in problem in Kenya. In 2008 it's Maternal Mortality Ratio was
minutes between epidural boluses to be 105minutes. This is 488 per 100,000, one of the highest in the world.4Great efforts
greater than the average 60minute interval of the are being made by the Kenyan government to reduce this. An
programmable intermittent bolus(PIB) regimens. An average ambitious target to reduce MMR to 91 per 100,000 by 2018 has
rate of bupivicaine 10.56mg/hr was similar to that reported with been set. One step has been the introduction of the Liverpool
PIB and patient controlled epidural bolus(PCEA) regimens4, LSS EOC-NCC course.
while we report a lower rate of motor block. Given the practice Acknowledgements: I would like to thank the maternal and
of MLTU in effect is much like a PIB without PCEA, it is neonatal health unit at LSTM for the opportunity to become
notable that the time between epidural boluses is longer with involved, and look forward to teaching on my next course. I
MLTU with less maternal motor block and high maternal would also recommend the course to any obstetric
satisfaction. We feel our practice promotes close epidural anaesthetists with an interest in international health.
assessment as the midwives assess motor block and maternal
References
satisfaction before each “top-up” and avoids the cost of the
1. World Health Organization, UNICEF, UNFPA and The World
PIB/PCEA pumps.
Bank. Trends in Maternal Mortality 1990-2008. 2010.
References 2. Lawn JE, Kerber K, Enweronu-Laryea C, et al. 3.6 million neonatal
deaths–what is progressing and what is not? Seminars in
1. Capogna G Camorica M, Stirparo S, Farcomeni A. Programmed Perinatology 2010;34:371–386.
Intermittent Epidural Bolus Versus Continuous Epidural Infusion for
Labor Analgesia: The Effects on Maternal Motor Function and 3. Ameh C, Adegoke A, Hofman J, et al. The impact of emergency
obstetric care training in Somaliland, Somalia. International Journal
Labor Outcome. A Randomized Double-Blind Study in Nulliparous
of Gynecology & Obstetrics. 2012;117:283-7.
WomenAnesth Analg July Oct 2011; 113(4): 826-831
4. Kenya National Bureau of Statistics. Kenya Demographic and
2. George RB, Allen T, Habib A. Intermittent Epidural Bolus
Health Survey (KDHS) 2008-09. June 2010.
Compared with Continuous Epidural Infusion for Labour Analgesia:
A Systematic Review and Meta Analysis. Anesth Analg Jan 2013;
Vol 116: 133-144
3. Wong C, MacCarthy RJ, Hewlett Bl. The effect of manipulation of
the programmed intermittent bolus time interval and injection
volume on total drug use for labour epidural analgesia: a randomized
controlled trial. Anest Analg 2011; 112: 904-11
4. Husain T, Mavridou I, Fernando R, El-Wahab N, Stewart A, Dick J,
Columb M. A study of a programmed intermittent bolus and patient-
controlled epidural regimen for labour analgesia. Int J Obstet
Anaesth May 2013: P85 Abstracts OAA Bournemouth 2013
Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin) P19
P137 Enhanced recovery after elective caesarean section: P138 Epidural analgesia in obese parturients: can kneeling
Service evaluation and quality improvement be the answer to our prayers.
GJ Lilley,  M Adamson,  A Miskin*,  M Turner   S De Silva,  L Kelliher*,  R Mottaleb*,  E Combeer  
Anaesthetics, Royal Gwent Hospital, Newport, UK, Anaesthetics, Frimley Park Hospital, Frimley, UK,
*Obstetrics and gynaecology, Royal Gwent Hospital, *Anaesthetics, Royal Surrey County Hospital, Guildford, UK
Newport, UK Severe pain is not life-threatening in healthy parturient women,
Introduction: Enhanced recovery (ER), a concept widely it is however shown to have neuropsychological
recognised within many surgical specialties, is now a subject consequences. Postnatal depression may be more common
of interest within obstetrics. The core principles comprise when effective analgesia is not used1 and pain during labour
speeding up recovery and improving patient outcomes, with has been linked with the development of post-traumatic stress
associated benefits for staff and healthcare systems1. The disorder2.There is an increasing number of obese parturients3
most logical starting point for the introduction of ER principles and identification and placement of the epidural can be
are elective caesarean section lists. Delayed surgery may lead difficult in these women.
to prolonged fasting, followed by delayed mobilization, Classically the sitting or the lateral position is used during
delayed removal of catheter and delayed discharge. A pilot siting of labour epidurals. The kneeling position was first
audit in our hospital demonstrated a mean stay after elective described in 19934, where 34/35 women had their labour
caesarean section of 3.6 days, and mean preoperative fasting epidural sited whilst in the kneeling position and 88.5% of the
period of 12.4 hours. Current guidance for ER in obstetrics mothers were happy with this position.
suggests minimal interruption to oral intake, pre-operative
I elected to try the kneeling position in an obese lady with a
energy drinks, catheter removal at 12 hours post-surgery
BMI 50 after adjustments in the sitting position and two
regardless of time of day, and the option of discharge home 24
separate failed attempts to confidently palpate the lumbar
hours after caesarean section where appropriate2.
spine. Once the lady was in the kneeling position, the lumbar
Methods: All elective caesarean sections were included in this spine was not only palpable but also visible and the epidural
service evaluation after introduction of preoperative space was identified with ease. With Departmental approval I
carbohydrate drinks. Data collection included fasting time, in performed my labour epidurals in this manner and found it not
addition to time to mobilization, to catheter removal and to only to be easy to site epidurals but also tolerated well. Some
discharge. After an initial 6 week period of data collection, the women complained of paraesthesia in their feet, but this was
data was presented to anaesthetic and obstetric staff. Posters, rare and eased swiftly. We decided to survey our Deanery to
a discharge proforma and a patient information leaflet were ascertain what positions were being utilised.
produced, and specific guidance was developed regarding
Survey: An e-survey was sent to trainees and Consultants in
preoperative carbohydrate drinks. A further 6 weeks of data
the South West London Deanery into what their ideal first and
collection then took place.
second choice positions used for siting epidurals would be for
Results: A total of 78 consecutive patients were included, all labouring parturients. We then posed the same question for
of whom received a regional anaesthetic technique for elective obese parturients (BMI 40). They were asked if they had
caesarean section. The following table illustrates the timing of heard of the kneeling position and if anyone had tried it. For
pre- and post-operative events before and after our those who had not, we questioned why they had not tried it.
interventions.
Results: We received 53 responses, 96.2% of whom were
Time period / hour 2nd 6 week Initial 6 week
trainees. 64.2% chose to position the parturient sitting as their
mean(SD) period period
first choice and 60.4% chose lateral as their second choice in
Pre-op fasting 4.8 (2.8) 3.8 (2.5)
non-obese parturients. In comparison 84.9% opted for the
Post-op fasting 4.2 (3.5) 3.4 (3.5)
sitting position in obese parturients with 56.9% using the
Total interruption to oral
9.0 (4.5) 7.1 (4.6) lateral as their second choice. The only positions utilised were
intake
sitting and lateral. 94.9% of respondents had not heard of the
Delivery to mobilization 10.2 (4.5) 9.0 (3.3)
kneeling position to site labour epidurals.
Delivery to catheter removal 14.8 (6.6) 13.5 (3.5)
Conclusion: Each position used for the placement of labour
Delivery to discharge 67.3 (40.1) 63.3 (27.6)
epidurals has their own advantages and disadvantages. With
Discussion: The introduction of patient information leaflet
the rising incidence of maternal obesity and its associated
offering guidance regarding post-operative oral intake,
risks to not only the mother but also the unborn child, we need
mobilization, catheter removal and early discharge, along with
to be continuing in our development and advancement in the
staff education and introduction of pre-operative carbohydrate
provision of good care. We suggest that the kneeling position
drinks, has resulted in improvement in the timing of a number
is a safe and viable alternative for siting epidural catheters in
of peri-operative interventions, and a small reduction in
labouring parturients.
duration of hospital admission. However, possibly due to
References
obstetric, midwifery, paediatric and organisational reasons,
discharge is rarely achieved at the potential target of 24 hours 1. Hiltunen P, Raudaskoski T, Ebeling H, Moilanen I Does pain relief
during delivery decrease the risk of postnatal depression? Acta
after elective caesarean section. Obstet Gynecol Scand 2004;83:257-261
References 2. Soet JE, Brack GA, Dilorio C Prevalence and predictors of women's
1. Lucas DN, Gough KL. Enhanced recovery in obstetrics - a new experience of psychological trauma during childbirth. Birth
frontier? Int J Obstet Anaesth 2013; 22: 92-95 2003;30:36-46
2. Enhanced recovery partnership: A better journey for patients and a 3. Centre for Maternal and Child Enquiries (CMACE). Saving
better deal for the NHS. Available at: Mothers'. Lives: reviewing maternal deaths to make motherhood
http://www.improvement.nhs.uk/documents/er_better_journey.pdf safer: 2006–2008. The Eighth Report of the Confidential Enquiries
into Maternal Deaths in the United Kingdom. BJOG 2011;118:1-203
P20 Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin)
P139 Epidural labour analgesia and risk of instrumental P140 Estimation of blood loss during caesarean sections -
delivery discrepancy between visual and laboratory estimation
R Carvalho,  T Ferreira,  M Duque,  D Catré,  I Guedes,  J P A Nowicka,  A Amasakera,  C Ferdinand,  I Suri  
Assunção   Anaesthesia, Warwick Hospital, South Warwickshire NHS
Anaesthesiology, Centro Hospitalar Tondela Viseu EPE, Foundatio, Warwick, UK

Viseu, Portugal
Introduction: Excessive blood loss is a major threat to women
Introduction: Epidural analgesia (EA) is a worldwide effective undergoing casearean sections. Accurate visual estimation of
method used for pain relief during labour. Nevertheless, its use blood loss is difficult due to dispersion of blood lost and the
and evolution to instrumental vaginal (forceps or vacuum blood being mixed with amniotic fluid(1). Therefore the blood
extraction) or operative deliveries remains controversial loss often gets under or overestimated(2). A number of
between experts,1 either anesthesiologists or obstetricians. methods exist to estimate the blood loss, the commonly used
We aimed to analyze the relation between EA and instrumental being: visual estimation by the attending staff, weighing of the
v aginal deliveries in a sample of our obstetric population. blood soaked surgical swabs and calculation based on the pre-
and post-operative haemoglobin concentrations(3). The aim of
Methods: A retrospective study included all pregnant women
this audit was to compare the visually estimated blood loss by
who delivered on our labour Room, between 1-January-2011
both the surgeons (vEBLs) and anaesthetists (vEBLa) against
and 31-December-2012, excluding those who underwent
the calculated estimated blood loss (cEBL).
caesarean section. We reviewed the data of demographical
characteristics, type of gestation and labour, the use of EA Methods: Data was collected on thirty five caesarean sections.
and the newborn APGAR score. Descriptive analysis of Operating surgeona and anaesthetists were asked to visually
variables was used to summarize data and Chi-Square test was estimate the blood loss in each case. The circulating blood
used. Multivariate analysis was done with logistic regression, volume was calculated for each patient based on the body
with calculation of corrected Odds Ratio (OR) and its 95% weight and height. Then, the blood loss during caesarean
confidence interval (95% CI). section was calculated using the circulating blood volume and
the pre- and post-operative haemoglobin concentrations.
Results: 2901 pregnant women were included in this study, Correction was made for the haemodilution by intravenous
with mean age of 29,7 years. 81% underwent EA and 30% fluid administered.
instrumental vaginal delivery. 51% were nulliparous. Applying
Results: Twenty six complete forms were included in the
Chi-Square test to independent variables, we obtained
analysis. None of the patients received blood or blood
significant associations with dystocic delivery for EA, normal
products intraoperatively. Mean volume of intravenous fluid
maternal age (NMA; 20-35 years) and parity (p<0,001).
infused was 1304mL±421. Mean vEBLs, vEBLa and cEBL was
Applying logistic regression to our model, including parity,
590mL±300, 623mL±372 and 821mL±1004 respectively. The
NMA and EA with dystocic deliveries, we obtained corrected
tendency for anaesthetists to give a higher estimate of blood
OR (95%CI) for EA 2,459 (1,884-3,210) and for parity 3,4
loss was not statistically signifficant (p=0,12). There was a
(2,867-4,121), with NMA loosing significance. However, this
clear discrepancy between the visual estimate given by both
result may still be biased by other factors, such as labour
the surgeons and the anaesthetists, ant the cEBL, however, it
stage at the time of the EA beginning, drugs used in epidural
did not reach statistical significance (p=0,11 and p=014
space, use of oxytocin during labour, among others.
respectively). Compared to the cEBL the vEBL was
Additionally we found that, in our population of term
overestimated when the blood loss was low (12 cases) and
pregnancies, NMA and eutocic deliveries, there was no
underestimated when the blood loss was higher than 500mL
significant relation between EA and APGAR score <8 at the
(14 cases). There was a linear relationship between the degree
first minute (p=0,079).
of underestimation and the blood loss, with high levels of
Conclusion: It's generally assent that EA provides the most blood loss being most underestimated.
effective pain relief in labour. However, it's associated to Conclusions: In this audit, the standard procedure for
prolonged labour and risk of instrumental or caesarean estimation of blood (visual estimation by the obstetrician) loss
deliveries.2 Our study has drawn the conclusion that both was found to be unreliable. We demonstrated a tendency of
having EA for labour pain relief and being nulliparous increase anaesthetists and surgeons to overestimate the blood loss, if
the chance of instrumental delivery, respectively in 2,459 and actual blood loss was less than 500mL, and underestimate if
3,43 times, however without significant impact on newborn the blood loss exceeded 500mL. As a result of the audit, it has
APGAR score. Bigger prospective studies correcting for more been made compulsory in our unit to check haemoglobin
risk factors are advised. concentration in recovery whenever the vEBL exceeds
References 1 000mL.
1. BMC Pregnancy and Childbirth 2008, 8:45. References
2. Acta Obstet Gynecol Scand 2002, 8:1033-1039. 1. Khan FA, Khan M, Ali A, Chohan U Estimation of blood loss during
Caesarean section: an audit. J Pak Med Assoc. 2006 Dec;56(12):572-
5.
2. Larsson C, Saltvedt S, Wiklund I, Pahlen S, Andolf E Estimation of
blood loss after cesarean section and vaginal delivery has low
validity with a tendency to exaggeration. Acta Obstet Gynecol
Scand. 2006;85(12):1448-52.
3. Stafford I, Dildy GA, Clark SL, Belfort MA, Visually estimated and
calculated blood loss in vaginal and cesarean delivery. Am J Obstet
Gynecol. 2008 Nov;199(5):519.e1-7
Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin) P21
P141 Ethnic variations in use of labour analgesia P142 Factors associated with the use of spinal anaesthesia
LMD MacDarby,  CMC McCaul   for caesarean section in Nigeria
Delivery Suite, The Rotunda Hospital, Dublin, Ireland C Imarengiaye,  F Asudo*,  A Akinmola†,  B Lawal§  
Introduction; This retrospective cohort study was compiled to Anaesthesiology, University of Benin Teaching Hospital,
establish the wide variety of nationalities presenting to The Benin City, Nigeria, *Anaesthesia, University of Abuja
Rotunda Hospital for delivery during a one month period and Teaching Hospital, Gwagwalada, Nigeria, †Anaesthesia, 
to determine the labour analgesia preferences amongst this National Hospital, Abuja, Nigeria, §Anaesthesia, Lagos 
population. Island Maternity Hospital, Victoria Island, Nigeria

Introduction: There has been a consistent increase in the rate
Methods; Details of all deliveries occurring during the month
of spinal anaesthesia for caesarean section in many hospitals
of October 2013 were collected. Any patients undergoing
worldwide and had been advocated as the preferred technique
elective caesarean section and those with failed inductions
for caesarean delivery.1 Recent evidence suggests increasing
were excluded from the study. A demographic of patients’
use of spinal anaesthesia for caesarean sections in reports
nationality and ethnic background was compiled. Data relating
from a teaching hospital.2 The rise in spinal anaesthesia
to these patients’ use of labour analgesia was recorded i.e.
caesarean section notwithstanding, it is pertinent to determine
epidural uptake, pethidine administration and remifentanil
the factors limiting the wholesome application of spinal
infusion use. We then established the frequency of use of
anaesthesia for caesarean section in Nigeria.
each of these methods of analgesia in each population

Methods: A snap-shot survey was conducted in some
Results; There were 767 deliveries in Oct 2013. 104 elective
selected hospitals in Nigeria. The survey determined the
caesarean sections were carried out and there were 8 patients
sociodemographic characteristics of patients, indication for
who failed induction.
surgery, grade of anaesthesia provider, contraindication to
Therefore a total of 655 patients laboured during this time. spinal anaesthesia and any other factor that may be noticed in
This number was made up by 50 different nationalities. Of the selected hospital. The survey was to be conducted over a
these 414 patients were Irish, the majority being white but 2-week period but was truncated by the nation-wide strike
including small numbers of Asian or Black background. action by doctors after 9 days.
Amongst the Irish patients the rate of epidural uptake was
Results: A total of 99 patients were attended to in 4 of the
43.47% (234) and the rate of pethidine use was 17.87% (74)
selected 6 hospitals within the study period. 36/99 women
Patients of other white background, including many eastern
were nulliparous and maternal factors (82/99) were the leading
european countries made up 134 of the patients. These
indications for caesarean section. Consultant anaesthetists
patients as a group had a 52.98% epidural uptake rate. Black
(23/99), Senior Registrars (35/99), Medical Officers (36/99) and
Africans were found to have a 39.13% (9) uptake rate and
others (5/99) provided anaesthesia for the caesarean sections.
those of Asian background had the highest rate at 54.83%
85/99 patients received spinal anaesthesia and 14/99 had
(17). The use of pethidine was significantly lower than the rate
general anaesthesia for the c-section. Fetal indication for
of epidural in all of these groups. Pethidine was used by
caesarean section had a 3-fold risk of general anaesthesia for
18.19% of Black Africans, 12.9% of Asians and 23.13% in
the surgery (p = 0.037, RR = 3.1, 95%CI 1.2 – 8). 25/99 and
those of other white backgrounds. There were only 3 cases of
74/99 were performed as elective or emergency procedure.
remifentanil use during the month
Nature of caesarean section was not a factor for the use of
Discussion; The highest incidence of epidural uptake during spinal anaesthesia (p =0.51, RR = 2.0, 95%CI = 0.5).
Oct was found to be amongst the Asian population, the lowest Discussion: Over 85% of caesarean sections in Nigeria were
being amongst Black Africans. Pethidine use was less than conducted under spinal anaesthesia. Fetal indications for
25% in all groups. The reasons for these trends is unknown caesarean section provoked a 3-fold increase in general
though previous studies have suggested that cultural and anaesthesia for caesarean section. The use of general
educational factors may play a part. anaesthesia for caesarean delivery was due to fetal indications
A prospective survey of patients post delivery detailing the for surgery, antepartum haemorrhage and failed spinal
reasons for their choices of labour analgesia would be anaesthesia. Improved practical conduct of the spinal
worthwhile. Establishing the factors influencing their technique may enhance great application of spinal anaesthesia
decisions may allow us to provide an unbiased and fully for caesarean section.
comprehensive service to ensure patient satisfaction. References

1..Morgan BM, Magni V, Goroszenuik T. Anaesthesia for emergency
caesarenc section. BrJ Obstet Gynaecol 1990; 97: 420-424
2..Amadasun FE, Idehen HO, Edomwonyi NP. Evolving pattern of
anaesthesia for caesarean section: Experience at the university of
Benin Teaching Hospital West Afr J Med 2013; 32: 196-9
P22 Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin)
P143 Failed intubation for a category 1 caesarean section in P144 Fasting dilemmas: A rare case of a patient with non-
a patient with undiagnosed spina bifida ketotic hyperglycinaemia presenting for caesarean
CR Deane,  E Lewis,  J Spargo   section
Department of Anaesthetics, Singleton Hospital, Swansea, M Behravesh,  S Dawson,  G McClune,  S Atkinson  
UK Anaesthetics, Royal Jubilee Maternity Hospital, Belfast, UK
Introduction: Non-ketotic hyperglycinaemia (NKH) is a rare
Introduction: Spina Bifida Occulta (SBO) is part of a spectrum
autosomal recessive metabolic disease caused by a defect in
of neural tube defects and is common. We present the case of
the glycine cleavage system. This case report describes the
a patient with previously undiagnosed SBO who required a
management of a patient who presented for caesarean section.
category 1 caesarean section (CS). Despite an unremarkable
To our knowledge there are no other published case reports of
airway assessment she had a failed intubation on rapid
this type.
sequence induction (RSI) and subsequently required an awake
fibre optic intubation (AFOI). Case Report: A 32 year old Para 1 presented for elective
caesarean section of twins at 37 weeks gestation. She had a
Case report: A 37 year old para 0 patient presented to labour
history of atypical non-ketotic hyperglycinaemia. Following
ward labouring with a single live foetus at 37 weeks gestation.
advice from clinical chemistry, during her 6 hours preoperative
She was admitted under consultant obstetric care with
fast she received an inceased dose of sodium benzoate and an
asymptomatic hypertension. When considering an epidural
intravenous infusion of 10% dextrose at 3mls/kg/hour which
she was examined and had a vascular naevus, associated with
was continued perioperatively. Caesarean section was
skin tethering, over lumbar vertebrae. She was asymptomatic,
performed under spinal anaesthesia and twin baby boys were
had never been investigated, and had no definitive diagnosis
delivered successfully. Post delivery of the second twin she
of SBO. Airway assessment included a Mallampatti score of 3,
received a bolus of 5 units of syntocinon followed by an
but was otherwise unremarkable. An epidural was declined to
infusion at 10 units per hour. Due to uterine atony and an
the patient, with a remifentanil PCA provided instead. A plan
operative blood loss of 1000mls she also received ergometrine
was agreed for a RSI GA if operative intervention was
carboprost intramuscularly to good effect. Sodium benzoate
required. Several hours later she required a category 1 CS.
was administered orally in recovery and the 10% dextrose
Initial laryngoscopy with a Mackintosh blade yielded a
infusion was continued until the patient was establised on an
Cormack and Lehane grade 3 view. Manipulation of the cricoid
oral regimen prescribed by the dieticians. This involved a
cartilage, long and McCoy blades did not improve the view.
series of high calorie drinks up to every 2 hours for 48 hours.
Two failed attempts were made to intubate using a bougie. The
No dietary protein was allowed for 24 hours post delivery.
patient was ventilated using a face mask and a Guedel airway
Glycine levels were monitored daily and were raised on day 5
with oxygen saturations above 97% throughout. She was
while dietary protien was being gradually reintroduced.
woken up without further incident and an AFOI was
performed. Her child was delivered by LSCS without further Discussion: NKH has an incidence of 1 in 60,000 with 3
incident or obvious deficit. The APGAR scores were 8 and 10 distinct presentations. Classically neonates present with
at one and five minutes. A grade 3 view was confirmed before lethergy, hypotonia and seizures. These symptoms can
the patient was woken. Recovery from anaesthesia was proceed to apnoea requiring ventilation and 30% of patients
uneventful. The patient was appropriately counselled. An do not survive the neonatal period. Severe psychomotor
Airway Alert Letter was issued and follow up appointment retardation is common in those who survive. A second,
made. An MRI was carried out subsequently and showed a atypical and very rare form presents with mild baseline
neural arch defect and dural tethering. Significantly the conus hyperglycinaemia and intermittent encephalopathy
lay as low as L4 with diastematomyelia as far as L2. assosciated with periods of illness. Transient neonatal
hyperglycinaemia has also been described. Biochemically,
Discussion: SBO is common and without prior imaging
NKH is characterized by elevated glycine concentrations in
presents the clinician with a difficult decision. Regional
plasma, CSF, and brain with a CSF glycine to plasma glycine
techniques risk neural or dural injury due to a low lying or
ratio greater than 0.08.1 Standard treatment strategies include
tethered cord.1 Abnormal spread of the analgesic agents may
protein restriction to reduce exogenous glycine,
give rise to either excessive cranial spread or inadequate
supplementation of one-carbon pool donors and
caudal spread. This patient population provides further issues
administration of sodium benzoate. NMDA antagonists have
for the anaesthetist given the high risk of operative delivery or
been shown to raise the developmental quotient, improve
other intervention (due to pelvic structural abnormalities) and
muscle tone and reduce seizures in these patients.2
the association of spina bifida with difficult intubation.2,3
Patients with spina bifida require careful preop assessment Prolonged periods of fasting predispose these patients to
and MRI imaging and careful airway consideration is essential glycine build up and its toxic neurological effects. This has
in order to inform anaesthetic planning. major implications for the anaesthetist in the perioperative
period. This case demonstrates the safe use of regional
References
anaesthesia in conjunction with careful nutritional planning.
1. Reynolds F. Damage to the conus medullaris following spinal
anaesthesia. Anaesthesia 2001; 56: 235-247. References
2. Richmond D, Zaharierski I, Bond A. Management of pregnancy in 1. Chang YT, Lin WD, Chin ZN et al. Nonketotic hyperglycinemia: A
mothers with spina bifida. Eur J Obstet Gynecol Reprod Biol 1987; case report and brief review. Biomedicine 2012; 2(2):80-82
25: 341-5. 2. Van Hove JL, Vande Kerckhove K, Hennermann JB et al. Benzoate
3. May A, Fombon F, Francis S. UK registry of high-risk obstetric treatment and the glycine index in nonketotic hyperglycinaemia.
anaesthesia: report on neurological disease. Int J Obstet Anaesth Journal of Inherited Metabolic Diseases. 2005;28:651–663
2008; 17: 31-6.
Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin) P23
P145 Fetal bradycardia following regional anaesthesia for P146 Further increase in hysterectomy rates - and the
emergency caesarean section and instrumental reason why
delivery: a service evaluation JS Campbell,  M Molloy,  C Thompson,  D Fogarty  
JK Sidana,  K Jadhav-Smith,  J Corfe   Royal-Jubilee Maternity Service, Belfast HSC Trust, Belfast,
Anaesthetics, Norfolk and Norwich University Hospital, UK
Norwich, UK Introduction: RJMS is the tertiary obstetric service for
Introduction: Fetal heart rate abnormalities, such as late Northern Ireland. As part of a service review of use of uterine
decelerations or fetal bradycardia, are known to occur after artery balloon catheters, we retrieved data from several
neuraxial anaesthesia.1 These may be due to maternal sources. We found a large proportion of these patients still
sympathetic blockade or an increase in the uterine tone caused required hysterectomy. Further interrogation of our data
by intrathecal opioids. The objective of this service evaluation showed some unexpected trends.
was to evaluate the incidence and management of fetal Methods: With approval of the Trust's Data Guardian we used
bradycardia following regional anaesthesia for emergency data from several hospital systems, including a local maternity
caesarean section and instrumental deliveries. care database and histology records.
Methods: 15 patients with an episode of fetal bradycardia Results: We found 30 hysterectomies from 37,088 deliveries in
following regional anaesthesia were identified by reviewing 6 years. This is a rate of 0.8 per 1000 - significantly higher than
the daily obstetric handover sheets from January to December our prior rates which was near the NICE-quoted rate of up to 3
2011. The medical notes of these patients were reviewed for per 1000. Of these cases, 23 (76%) were due to morbidly
peripartum obstetric management, cardiotocographic (CTG) adherent placenta.
findings, perioperative anaesthetic management and
Not all these cases of morbidly adherent placenta were
management of fetal bradycardia. Neonatal outcome was
diagnosed antenatally, which perhaps made hysterectomy
assessed by APGAR scores, umbilical cord gases and NICU.
more likely since facilities such as intra-arterial balloon
Results: 10 patients had an assisted delivery and 5 had an catheters could not be available to us in an emergency.
emergency category-2 LSCS. The peripartum CTG findings Unanticipated cases suffered greater blood loss. Despite no
were either suspicious or pathological. Timing of fetal diagnosis, the majority (16/23) were placenta percreta on
bradycardia following regional anaesthesia ranged from 2 to 15 histology. These percreta cases again had greater blood loss,
min. 13 patients received spinal anaesthesia and 2 received and were more likely to require ICU care post-operatively. Yet
epidural top up. Maternal haemodynamics stability was there were no cases of percreta in the 6 years prior, and less
maintained with left uterine displacement, intravenous fluids than half the number of hysterectomies in that period. This
and phenylephrine infusion. One patient had an episode of seems to be a dangerous and dramatic change in recent years.
maternal bradycardia below 50 beats/min which was treated
Conclusion: We found a recent and significant increase in
with anticholinergics. Comparing the baseline maternal heart
peripartum hysterectomy, associated with a large increase in
rate with the lowest perioperative heart rate, 3 patients had a
the number and degree of morbidly adherent placenta. Patients
greater than 40% drop in the heart rate. 5 patients had a blood
with placenta percreta had a greater blood loss, and more
pressure drop of more than 20% below the baseline, which was
commonly required hysterectomy and ICU care.
treated with phenylephrine. The highest level of block to
Reference
temperature was T3. Syntocinon was stopped in all but one
case in the event of fetal bradycardia. Significant delays 1. National Institute for Health and Clinical Excellence. Caesarean
section: NICE Clinical Guideline 132 2012,
occurred in transferring these patients to theatre after the
http://www.nice.org.uk/nicemedia/live/13620/57163/57163.pdf
decision for surgical intervention were taken, maximum 35 min
(median 17 min). 6 cases had poor neonatal outcomes with low
5 minute APGAR and abnormal cord gases.
Discussion: We could not find any direct cause which can be
solely attributed to regional anaesthesia for the occurrence of
fetal bradycardia in these patients. Significant delay in patient
transfer to theatre may have a causal relationship but cannot
be confirmed. Studies in elective patients have shown that
maternal bradycardia causes a drop in maternal cardiac output.
2 Relative maternal bradycardia occurred in several of our
cases and this would have led to drop in cardiac output and
therefore oxygen delivery. This is most likely a side effect of
phenylephrine use. We plan to introduce a care bundle to
implement pre-operative and intra-operative fetal resuscitation.
This will include steps to improve fetal condition at the time of
regional anaesthesia and to ensure adequate maternal cardiac
output and oxygen delivery.
References
1. Reynolds F, Seed PT. Anaesthesia for Caesarean section and
neonatal acid-base status: a meta-analysis. Anaesthesia 2005; 60:
636–653
2. Stewart A, Fernando R et al. The dose-dependent effects of
phenylephrine for elective caesarean delivery under spinal
anaesthesia. Anesthesia & Analgesia 2010; 111: 1230-7.
P24 Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin)
P147 Impact of workload on accidental dural puncture P148 Implantable cardioverter defibrillator in
(ADP) rate pregnancy WITHDRAWN FROM PRESENTATION
W Mon,  YM Liu,  A Stewart,  R Fernando,  M Columb*   S Chaudhari,  S Quasim  
Anaesthetics, University College London Hospital, London, Anaesthetic Department, University Hospital Coventry and
UK, *Intensive Care Unit, University Hospital of South Warwickshire , Coventry, UK
Manchester, Manchester, UK
Introduction: Post dural puncture headache is an important
cause of morbidity. We audit our ADP rates annually against
the national standard.1Between 2005 and 2008, our ADP rate
was stable at approximately 0.5%. However, from 2008 to 2010,
our rate rose to above the 1% national standard.1Therefore, we
audited factors that may have contributed to this increase.
Methods: Information for this audit was obtained from a
computerised database. Data collection included day, month
and time of ADP and the grade of anaesthetist. We also
collected annual data of number of deliveries, epidurals and
combined spinal epidurals (CSEs) for labour, caesarean section
(CS) data, and the proportion of single shot spinals (SSS) to
CSEs performed. Data were analysed using chi-square
multinomial and trend tests with P value <0.05 defined as
significant.
Results: There was a 40% increase in deliveries between 2008-
2010. CSs and regional blocks for analgesia increased by 36%
and 40% respectively. Although the ADP rate increased, we
could not demonstrate a statistically significant trend due to
small numbers. From 2010 to 2012, a non-significant fall in the
ADP rate was seen. There was no significant association
between ADPs and day, month or time. We did see a
significant non-linear trend (P = 0.0012) in the proportions of
SSSs to CSEs performed, with the peak occurring in 2010.
Table 1. Trend of activity and ADP rate from 2008 to 2012
  2008 2009 2010 2011 2012 P value
Maternities (n) 4032 5039 5647 5841 5953 < 0.0001
Epidurals for labour (n) 1306 1600 1839 2029 2132 < 0.0001
CSs (n) 1370 1562 1861 1862 1773 < 0.0001
SSSs for CS (n) 282 274 356 326 347 0.0015
CSEs for CS (n) 797 644 714 833 915 < 0.0001
Proportion of SSS to CSE (%) 26 30 33 28 27 0.0012
ADP rate (%) 0.57 0.98 1.05 1.01 0.82 0.31
Discussion: We observed an increase in ADPs until 2010, with
significant rises in deliveries and anaesthetic procedures
performed. The significant non-linear trend in the proportions
of SSSs to CSEs performed for CSs peaked in 2010. A fall in the
ADP rate between 2010-2012, occurred despite exposing more
women to the risk of ADP, as during this time we performed
significantly more CSEs than SSSs proportionally. We believe
that the rise in the ADP rate resulted from a significant
increase in our workload between 2008 and 2010, without any
increase in anaesthetic staffing. From 2010 onwards, daytime
anaesthetic consultant sessions increased by 50%, and there
was a higher presence on the labour ward out of hours by
senior registrars covering non-obstetric theatres. Both factors
may have contributed to the subsequent fall in the ADP rate.
This audit supports the recent OAA/AAGBI guideline
recommending increased anaesthetic staffing on labour ward.2
References
1. Royal College of Anaesthetists. Epidural analgesia during labour.
Raising the standard: a compendium of audit recipes. 2012;218-219
2. Association of Anaesthetists of Great Britain and Ireland and
Obstetric Anaesthetists' Association. OAA/AAGBI guidelines for
obstetric anaesthetic services. 2013
Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin) P25
P149 Inadvertent hypothermia during elective caesarean P150 Inter professional relationships on labour ward- how
sections well do anaesthetists and midwives get along?
S Botros,  R Labib,  T Ramhew,  M Baban,  Y Poonawala   M Salman,  P Kumar,  G Graham  
Selwyn Crawford Department of Anaesthesia , Birmingham Anaesthetics, St. Thomas' Hospital, London, UK
Women's Hospital, Birmingham, UK Introduction: Anaesthetists and midwives are part of the
Introduction: The National Institute for Health and Care multi-professional team that provides care for parturients.
Excellence (NICE) defines inadvertent perioperative They work together in close collaboration in the unique and
hypothermia as a core body temperature below 36°C.1 It is a often highly charged environment of labour ward. In such
common complication of regional anaesthesia, and is the settings, effective inter professional relationships are key to
leading cause of perioperative shivering. Hypothermia is the delivery of high quality care and consequently better
associated with increased risk of wound infection and patient outcomes. Successful collaborative practice can be
increased blood loss.1 Shivering can be associated with negatively impacted by barriers such as lack of clarity on the
increased oxygen consumption and hypoxaemia in vulnerable scope of roles of team members, poor communication, or
patients. Although the NICE guideline on the management of stereotyping. We conducted a survey amongst obstetric
perioperative hypothermia did not cover pregnant women,1 it anaesthetists and midwives in our hospital to reflect upon this
has been adopted by many obstetric units. In our unit, working relationship and to see how it may be improved.
intravenous (IV) fluid is not routinely warmed for elective
Methods: A questionnaire was designed and distributed to
caesarean sections (CS). Hence, we audited our practice to
midwives and anaesthetists of all grades. Questions were
evaluate the incidence of hypothermia.
asked on their understanding of each other's professional role
Methods: Over a three month period, we prospectively audited
and on their perception of the quality and effectiveness of
our practice in 47 women who had elective CS under
their working relationship. A total of 43 responses were
subarachnoid anaesthesia without active warming. We
collected (24 anaesthetists and 19 midwives) in an ongoing
measured their tympanic temperature prior to anaesthesia (T )
1 survey.
and at the end of surgery (T ). We also collected data that may
2 Results: Of the anaesthetists who completed the
influence the results like the volume of IV fluid infused,
questionnaire, 16.6% were consultants, 58.3% were ST5-ST7,
estimated blood loss (EBL) and duration of surgery. We also
20.8% were ST3-4 and 4.1% were CT1-2. When asked whether
assessed the incidence of perioperative shivering. We
they felt they understood the scope of responsibilities of
repeated the audit in 42 parturients using an IV fluid warming
midwives on labour ward, only 27% of anaesthetists felt they
device. The data were analysed using Microsoft Excel 2007®.
understood it fully. In contrast, 63% of midwives believed they
Data from both audits were compared and p-values were
fully understood the scope of the anaesthetist's
calculated using unpaired t-test by GraphPad software®.
responsibilities.
Results: In the initial audit, 20 patients (42.55%) were
hypothermic at the end of surgery (T < 36°C). Shivering Thirty percent of midwives felt that collaboration with
2
occurred in 14 patients (29.79%). No correlation was found anaesthetists was 'very easy', in contrast to only 5.5% of
between T and the IV fluid volume, EBL, duration of surgery anaesthetists who felt the same about collaboration with their
1-2
or the dose of intrathecal Bupivacaine. In the re-audit, only 3 midwife colleagues. While 16% of anaesthetists found this
(7.14%) patients experienced hypothermia. There was no collaboration 'difficult', none of the midwives did (0%).
statistical difference in T between the two audits (p = 0.781). Seventy two percent of anaesthetists felt their input was
1
usually well-received by their midwife colleagues, compared to
  Initial Audit (n=47) Re-audit (n=42) p-value
only 40% of midwives who thought their input was well-
Fluid (ml) 1116.67(±369.43) 1233.33 (±483.59) 0.2236
received by the anaesthetist. Both professions were asked
EBL (ml) 523.75 (±152.33) 582.5 (±491.67) 0.474
how they perceived the general quality of communication
T1 36.84 (±0.37) 36.81 (±0.37) 0.781
between them. The majority of anaesthetists (47%) perceived it
T2 36.08 (±0.4) 36.3 (±0.29) 0.004
as 'fair', while 15% regarded it as 'poor'. Ninety percent of
T 0.76 (±0.34) 0.52 (±0.41) 0.0032
1-2 midwives felt it was either 'very good' or 'good'. None of the
Discussion: Our audit highlights the effect of warm IV fluid midwives (0%) felt it to be 'poor'.
therapy on reducing the incidence of inadvertent perioperative
Questions were asked on the types of obstacles they
hypothermia during elective CS. Our audit recommends the
encountered in their professional interaction with each other.
routine warming of IV fluid during elective CS. The Enhanced
Most anaesthetists (72%) agreed that they found fixation on
Recovery Partnership Programme considers patient warming
tasks and exclusion of others to be a challenge, followed by
as a key factor in accelerating patient recovery.2 Following our
delayed or non-communication of important issues (57%). A
results and as part of developing a new pathway for enhanced
third of the anaesthetists felt they rarely got a comprehensive
recovery post CS; our trust is currently looking to invest in a
handover from the midwife while only 29% of midwives felt
cost-effective IV fluid warming device.
they understood the rationale behind the anaesthetists'
References decisions.
1. NICE (2008) Perioperative hypothermia (inadvertent): full Conclusion: Despite both specialties working in close
guideline (CG65). Full Guideline. London: National Institute for proximity, the survey identified several gaps in
Health and Care Excellence.
communication. Working towards enhancement of the
2. Enhanced Recovery Partnership (2012) Fulfilling the potential: a
professional relationship between members of the team
better journey for patients and a better deal for the NHS. Leicester:
NHS Improvement. Available at http://www.improvement.nhs.uk providing maternity services will help facilitate their
(accessed 14/12/2013) collaboration and will reflect positively on the performance of
both professions.

P26 Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin)
P151 Intra-arterial balloon catheters: A service evaluation P152 Intrathecal diamorphine for cesarian section following
JS Campbell,  M Molloy,  D Fogarty   intramuscular diamorphine during labour: a cause for
Royal-Jubilee Maternity Service, Belfast HSC Trust, Belfast, concern?
UK RC Barr,  L Parks  
Introduction: Intra-arterial balloon catheters have become Anaesthetics and Intensive Care, Southern Health and Care
widely used and predominantly accepted in cases where Trust, Northern Ireland, UK
massive haemorrhage is anticipated, especially with morbidly Introduction: Diamorphine has largely replaced pethidine for
adherent placenta . However, the benefits are still intramuscular (IM) analgesia during labour in our obstetric
1,2
controversial. While our unit is not stand-alone, our building unit. We also routinely give diamorphine (250-300 micrograms)
is physically separated from other departments including intrathecally (IT) for cesarian sections. A recent case of
radiology, so the logistics of balloon catheters are difficult2. meiosis and drowsiness, in a lady presenting for a category 2
Our objective was to identify the impact of balloon catheters cesarian section having received IM diamorphine in labour,
on management of morbidly adherent placenta. Associated highlighted the potential for side effects when diamorphine is
anaesthetic issues include massive transfusion, cell salvage, used IM and then IT. Should we therefore consider adjusting
type of anaesthetic and post-operative care. our IT dose of diamorphine in women presenting for
Methods: With permission of the Trust's Data Guardian, we emergency cesarian sections? To our knowledge there are no
retrieved data from multiple sources to identify and review guidelines on this subject and clinical practice appears
cases where balloon catheters where used. These included variable.
radiology logs, maternity records and histology. Methods: We conducted a survey of all anaesthetists working
Results: Ten cases were identifed via these systems. Seven in the Southern Health and Social Care Trust who partake in
were for morbidly adherent placenta, of which 5 required obstetric anaesthesia. Questions focused on; current
hysterectomy despite balloon inflation. Many of these were diamorphine practice, diamorphine dose adjustments, factors
cases of placenta percreta, despite antenatal diagnosis of influencing our dose decisions and concerns regarding
accreta. However, blood loss was lower by around 20% potential side-effects with IT diamorphine.
(1078ml) using balloons, when compared to other Results: We received 24 replies; 14 consultants and 10
hysterectomies in the same time period. experienced trainees who regularly perform obstetric
Other indications were for intra-abdominal pregnancy and anaesthesia. There was a wide variation in diamorphine
persistent post-partum haemorrhage. Another case was practice amongst our anaesthetists. The majority (76%)
abandoned due to logistical reasons (unable to organise consider reducing their IT dose following IM diamorphine.
theatre time in same building), a decision felt to be open to Factors influencing this dose reduction include timing (88%)
medicolegal criticism after preparation and planning for and dose (29%) of the last IM diamorphine and clinical signs
balloons. of toxicity (76%). In particular anaesthetists were concerned
about postoperative respiratory depression (94%) and
Limitations particularly reflected the limitations and
drowsiness (88%), although no one surveyed reported
inconsistency of the systems used, for example no coding in
experience of these or other adverse effects associated with IT
records for morbidly adherent placenta. Local presentation
diamorphine.
highlighted these problems, which are being taken forward.
Discussion: There is variability regarding the IT diamorphine
Conclusion: Our review, and subsequent MDT discussion,
dose given to women for emergency cesarian section who
has confirmed the place of intra-arterial balloon catheters
have already received IM diamorphine in labour. This practice
within local guidelines for management of morbidly adherent
is based on limited evidence. Given the lack of adverse effects
placenta, and other occasional indications. We had decreased
reported from our survey and evidence from other specialties
blood loss in cases using balloons, but still saw a large
where diamorphine is used in higher doses 1,2,, we see no
proportion requiring hysterectomy.
reason to routinely reduce the IT diamorphine dose unless
References
there are clinical signs of opiate toxicity. Consideration should
1. Beilin Y, Halpern SH. Placenta accreta: successful outcome is all in be given to prolonged postoperative monitoring of all women
the planning. Int J Obstet Anesth. 2013;22:269–271.
who have received both IM and IT diamorphine, especially
2. Sadashivaiah J, Wilson R, Thein A. Role of prophylactic uterine
artery balloon catheters in the management of women with those in whom the interval between IM and IT diamorphine is
suspected placenta accreta. Int J Obstet Anesth. 2011;20:282-287 short or where there are signs of toxicity.
References
1. Fogarty DJ, Milligan KR. Postoperative analgesia following total
hip replacement ; a comparison of intrathecal morphine and
diamorphine. Journal of the Royal Society of Medicine 1995; 88:
70-72
2. Jacobson L, Kokri MS, Pridie AK. Intrathecal diamorphine: a dose-
response study. Annals of the Royal College of Surgeons of England
1989; 71: 289-292
Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin) P27
P153 Introducing self-administration of medication after P154 Is Remifentanil patient controlled analgesia an
caesarean section: a Robert The Bruce story effective alternative to epidural for labour analgesia?
A R Sajayan,  K Ramm,  T Yates,  Y Chikermane   V Betharia,  K Peckitt  
Anaesthesia, Heartlands Hospital, Birmingham, UK Anaesthesia, Stepping Hill Hospital, Stockport, UK
Introduction: We were involved in the introduction of the local Introduction: Remifentanil patient controlled analgesia (PCA)
protocol for self-administration of postoperative medications was introduced for pain relief in labour at our institution in
(SAM) after elective LSCS at a large obstetric unit. In the past, 2007. Since then its demand has steadily increased, gaining
several attempts to implement this have failed.We conducted a favour with midwives and patients due to simplicity of use,
pilot study to identify the obstacles and develop ways to effective analgesia¹ and good safety profile². We have
overcome the same standardised protocols for administration and monitoring of
Methods:A pilot project was conducted to find out the Remifentanil PCA and patient controlled epidural analgesia
obstacles in the process by obtaining feedback from the staff (PCEA) during labour which are strictly adhered to. Aim of our
and patient involved in the care of 10 patients who underwent audit was to assess both Remifentanil PCA and epidural PCEA
elective LSCS over a week’s time. Obstetric, anaesthetic, for labour analgesia and make recommendations for improved
recovery and ward staff were informed beforehand about this care of mothers and infants.
pilot by emails and personal discussion. The patients were Methods: This was a prospectively done, questionnaire based
given information leaflet during preoperative assessment and audit. Data was collected over 2 months from November 2013 -
were informed again on the day of operation. Interested January 2014. We looked at mode of delivery,
patients enrolled in the pilot with due consent. The self- cardiotocographic abnormalities, APGAR scores, maternal
administration pack contained analgesics and enoxparin and cardio-respiratory complications, conversion to alternative
was dispensed by the recovery staff. Exclusions were: methods of analgesia and patient satisfaction.
language barrier, patient refusal, lack of capacity and any co Results: There were 610 deliveries during the 2 months.
morbidities. Feedback was collected from patients and staff Remifentanil PCA was used in 102 (17%) and epidural PCEA in
using the standardized proforma during the postoperative 85 (12.2%) patients for labour analgesia.
visit. Mode of delivery:
Results:Two of the patients felt that on the first day it was
  Normal Assisted LSCS
difficult to use SAM due to mobility restrictions. One patient
Remifentanil PCA 69 (67%) 20 (19.6%) 13 (12.7%)
did not receive SAM pack due to communication problem
Epidural PCEA 29 (34%) 35 (41%) 21 (24.7%)
involving midwives and staff. The remaining seven patients
were satisfied with SAM. The obstacles we identified in the There was a higher incidence of cardiotocographic
pilot and also from the past experience and the way we tackled abnormality in the epidural group (61%) as opposed to
them are as below: Remifentanil group (34%). APGAR scores in both groups were
more than 8 at 5 minutes. None of the patients in either group
Obstacle Strategy
had respiratory depression or cardiovascular instability. Eight
Personal & email reminder
(7.8%) patients converted from Remifentanil to epidural due to
Promotional posters in clinical areas
inadequate analgesia whereas 4 (4.7%) patients in the epidural
Communication Reminder notices in operating room and recovery
group used alternative analgesia (3 switched to Remifentanil
Meeting with stakeholders (doctors, midwives&
and 1 to entonox). Patient satisfaction was similar in both
pharmacist)
groups at 95%.
Involving all staff in guideline preparation
Discussion: From our experience, Remifentanil PCA is a safe
Staff engagement Process simplified and paper work streamlined
and effective method of labour analgesia. We found no
Standardized SAM package and delivery
evidence of worsening cardiotocography or neonatal
Guideline Fully prepared guideline after extensive consultation
outcomes with its use. We also found that patients using
Time Pre-printed forms to increase efficiency and to avoid
Remifentanil have increased rate of vaginal deliveries as
management time delays and work duplication
compared to those on epidural. While epidural analgesia
Discussion: Self-administrationof medications after caesarean remains the gold standard and will be preferable in certain
provides better patient centered care. It improves patient and groups of patients, Remifentanil PCA is certainly an excellent
staff satisfaction, improves clinical efficiency and eases alternative to consider. In our institution its uptake has
staffworkload at hospital and at community level1. It empowers steadily increased to approximately 50 patients per month with
the mother in their own care, potentially reduces length of patients consistently report ing high levels of satisfaction.
stay, and facilitates seamless flow ofcare. Although staff and References
patients liked the concept alike, the process had failedthree
1. Blair JM, Dobson JT, Hill DA, McCracken GR, Fee JP. Patient
times before because of certain obstacles. This pilot helped us controlled analgesia for labour: a comparison of remifentanil with
to highlight the areas we needed to focus on with our new pethidine. Anaesthesia 2005; 60 (1) : 22-7
strategies and the results have been encouraging. After fully 2. Volikas I, Butwick A, Wilkinson C, Pleming A, Nicholson G.
Maternal and neonatal side-effects of remifentanil patient
implementing the project, the uptake is gradually getting better
controlled analgesia in labour. Br J Anaes 2005; 95(4): 504-9
and we continue to audit the outcome.
References
1. Snell P M, Bowden M I, Viira D J, Chilvers J P. An observational
study of self-medication of analgesic drugs after caesarean section.
Int J Obstet Anesth 2002; 11: S29
2. Change management good practice guideline-NHS Direct
P28 Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin)
P155 Is the existing local hospital guideline, 'Management P156 Klippel-Feil syndrome: management of anticipated
of women who decline blood products', being adhered difficult airway for caesarean delivery 
to? TM Price,  MT Qureshi,  ROK Laird  
J Houston,  R Burns   Department of Anaesthesia, Altnagelvin Area Hospital,
Simpson Centre for Reproductive Health, Royal Infirmary of Derry, UK
Edinburgh, Edinburgh, UK Introduction: Klippel-Feil syndrome (KFS) is a rare genetic
Introduction: An estimated 150000 Jehovah's Witnesses disorder affecting around 1 in 40,000 live births and is
(JWs) live in the UK1. JWs may not accept blood product (BP) characterised by the congenital fusion of any two of the
transfusion1, and have up to 130 times increased risk of cervical vertebrae1. In addition to the abnormalities of the
maternal death from major obstetric haemorrhage2. This cervical spine, patients may have thoracolumbar scoliosis,
retrospective case note review aims to establish how closely spina bifida and congenital heart defects. The classical
the hospital guideline, 'Management of women who decline phenotypic presentation is described as low hairline, short
blood products' (the Guideline), has been followed since its neck and limited neck and head movement. These patients can
May 2012 introduction, and to identify areas for improvement. therefore present a considerable challenge to the anaesthetist.
Methods: JWs managed at the Anaesthetic Antenatal Clinic The safest method of providing anaesthesia for operative
(AAC) since the Guideline's introduction were identified, and delivery of a parturient with KFS is controversial. We would
their medical records accessed. Information surrounding like to share our experience in managing four elective
aspects of patient management addressed by the Guideline caesarean deliveries in two parturients using awake oral fibre
was extracted. The findings were then audited against the optic intubation (AOFOI) and general anaesthesia.
Guideline to establish how closely it had been followed. Case Reports: The first patient had KFS Type II with fusion of
Approval was obtained from the Medical School and the cervical vertebrae and underwent elective caesarean deliveries
Regional Research Ethics Service. aged 35 and 37 years old. The second patient had KFS Type
Results: Of the patients referred (N=26), 92.3% were reviewed III with fused cervical vertebrae in conjunction with fusions in
at the AAC, and had management plans created, at 31.0 weeks' the thoracolumbar spine, and underwent elective caesarean
gestation on average (Guideline target: 28.0 weeks). 88.5% deliveries aged 31 and 39 years old. Our patients were both
completed a BP checklist before admission in labour, and pre-assessed by a consultant anaesthetist at a high-risk
96.2% by time of delivery. 7.7% agreed to accept BPs at clinic pregnancy clinic prior to delivery. This allowed time to discuss
and were discharged, so women studied became N=24. BP the anaesthetic options with each patient and plan for elective
refusal of 12.5% was not appropriately recorded in the notes, or emergency delivery. Both patients had the classical
and contrary to the Guideline, serum ferritin was not checked phenotypic features of KFS. Airway assessments revealed
in any woman. During pregnancy, 29.2% were not recorded as Mallampati class 4, thyromental distances less than 6cm and
having taken iron, and Hb was measured in 95.8%. Excluding severely limited neck flexion and extension. The trachea was
elective caesarean sections (CS), Obstetric consultants were not palpable in either patient. We anticipated difficult direct
documented as informed of admission in 13.6% of cases, and laryngoscopy in both patients and elected to manage the
54.5% of labours and deliveries were reviewed or supervised airway with an AOFOI followed by general anaesthesia. The
by senior Obstetric staff (ST6-consultant). 20.8% of total oral route was chosen as both patients had small nares in
deliveries were by CS: cell salvage was set up in 100.0% of keeping with KFS. Sugammadex ensured complete reversal of
these, and used in 80.0%. rocuronium induced neuromuscular blockade and smooth
Discussion: This study found the Guideline was closely emergence. Caesarean delivery and postoperative recovery
followed in some areas: completion of acceptable BP checklists was uneventful in all four cases.
before delivery, and availability and use of cell salvage in CS,
Discussion: As obstetric anaesthetists we are constantly
compare favourably to previous UK studies1,3. Areas to be
trying to minimise the risk to our mothers. Klippel-Feil
improved include that BP refusal must be appropriately
syndrome affects both the airway and the spine, making the
recorded in patient notes to ensure clarity upon presentation
choice of anaesthetic technique a difficult decision. Successful
in labour or an emergency. It is vital that iron supplementation
use of regional techniques including spinal, epidural and
is commenced early in JWs, and ferritin levels are monitored,
combined spinal-epidural anaesthesia, have all been described
to maximise iron stores. In light of this study's findings,
in the literature1. However, we feel that embarking upon a
hospital blood transfusion Haematologists, in the future, will
regional technique in patients with distorted neuroaxial
review JWs antenatally. The Guideline should quantify how
anatomy would expose patients to unnecessary risk of high
often Hb should be monitored, so anaemia can be detected
spinal block and/or inadequate regional anaesthesia. Should
and treated before delivery. Crucially, consultant staff must be
general anaesthesia be needed intra-operatively, attempting an
documented as informed upon admission of JWs in labour, in
AOFOI in an already distressed parturient would be
order that deliveries can be supervised by senior staff to
challenging. We therefore planned an AOFOI to secure the
reduce potential morbidity and mortality.
airway prior to general anaesthesia, in a controlled manner and
References
thus avoid a potentially difficult and emergent intraoperative
1. Massiah N, Athimulam S, Loo C, Okolo S, Yoong W. Obstetric care intubation. In summary, these are difficult cases that we
of Jehovah's Witnesses: a 14-year observational study. Arch
believe benefit from good antenatal planning and can be
Gynecol Obstet 2007; 276(4):330-343.
managed with a planned AOFOI and general anaesthesia.
2. Van Wolfswinkel ME, Zwart JJ, Schutte JM, Duvekot JJ, Pel M, Van
Roosmalen J. Maternal mortality and serious maternal morbidity in
Jehovah's witnesses in the Netherlands. BJOG 2009; 116(8): 1103- Reference
1108. 1. T. Kavanagh, R. Jee, N. Kilpatrick, J. Douglas. Elective cesarean
3. Nawaz YM, Atkinson S. Peripartum care of Jehovah's witness delivery in a parturient with Klippel–Feil syndrome. Int J Obstet
parturients: A five year review. Int J Obstet Anesth 2013; 22(S1): Anesth 2013; 22(4): 343-8
S22.
Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin) P29
P157 Labour and delivery in long QTsyndrome P158 Local anaesthetic toxicity audit: are workshops the
BJ Vowles,  FMM Bryden   best educational tool across the MDT?   
Anaesthetic department, Princess Royal Maternity, Glasgow, WITHDRAWN FROM PRESENTATION
UK JL Lambert,  D Chitre,  L Evans  
Introduction: A 22 year old primigravida presented to the high Anaesthesia, Southend Hospital, Southend, UK
risk clinic at 22 weeks gestation. She had been diagnosed with
long QT syndrome (LQTS) after her family had been
investigated following a sudden early cardiac death and was
found to be heterozygous for the KCNQ1 gene, responsible
for Long QT1. She was under regular review by the
cardiologists who had advised β blockade with bisoprolol
2.5mg orally (PO) for 9 months post partum due to an increase
in arrhythmia risk during this period. She had also been given
a list from Azcert Inc., advising drugs that should be avoided
and included on this list was syntocinon.
Labour and delivery: She was admitted in labour at term and
the decision was made by the obstetric team, not to administer
syntocinon to augment labour. They also felt that epidural
analgesia was unsuitable because it would slow the progress
of labour. However following an initial dose of intramuscular
(IM) diamorphine, the parturient requested epidural analgesia.
We felt this would be beneficial for minimising her arrhythmia
risk and so she obtained a working epidural with a bilateral T10
block. ECG monitoring was commenced on admission and
.
initially showed bigeminy. A 12 lead ECG demonstrated a QTc
of 460ms. Electrolytes checked at this time were in the normal
range. Over the subsequent 8 hours she failed to progress and
underwent a caesarean section with an effective epidural top
up of 20ml 0.5% L-bupivacaine. At delivery syntocinon was
administered as a slow infusion of 5 units in 100mls 0.9%
saline over 20 minutes, followed by 500µg ergometrine IM to
maintain uterine tone. 50mg IM cyclizine and 10mg
intravenous (IV) metoclopramide were used for anti-emesis.
She was monitored in the Obstetric high dependency unit
(HDU) for the following 48 hours, where an initial ECG
demonstrated frequent ventricular ectopics, with a QTc 432ms.
Electrolytes were again normal at this time.
Discussion: There are many lists of drugs available on the
internet with differing advice as to which drugs to avoid in
long QT syndrome. The one which our patient had been given
clearly stated syntocinon should not be administered, despite
no definitive evidence of harm with this drug in patients with
LQTS. In addition we found no guidance in published case
reports, on oxytocic drugs administered to patients with LQTS
in labour or at delivery1. There are case reports of ventricular
tachycardia after administration of syntocinon in long
QTsyndrome2 and one report of a pateint receiving it with no
sequelae3 Ideally the authors feel that this lady merited a case
conference prior to admission so that informed decisions
could be made. Whilst the outcome of this patient's labour and
delivery may not have been different, a short trial of
syntocinon with ECG monitoring may have altered her mode of
delivery.
References
1. Drake E, Preston R, Douglas J. Brief review: anaesthetics
implications of long QT syndrome in pregnancy. Can J Anaesth.
2007; 54(7): 561-72
2. Liou SC, Chen C, Wong SY, Wong KM. Ventricular tachycardia
after oxytocin injection in patients with prolonged Q-T syndrome -
report of two cases. Acta Anaesthesiol Sin 1998; 36: 49-52
3. Charbit B, Funck-Bretano C, Samain E, Jannier-Guillou V,
Albaladejo P, Marty J. Qt interval prolongation after oxytocin bolus
during surgical induced abortion. Clin Pharmacol Ther 2004; 76:
359-64
P30 Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin)
P159 Lymphangioleiomyomatosis and Pregnancy: A Case P160 Major obstetric bleeds-are we doing the right thing?-
Report A multi-centre study in west midlands
M Cole,  S Petkov,  J Pickett   A R Sajayan,  M McLoughlin,  S Dinesh,  A Walunj*,  J
Anaesthetics, Addenbrookes Hospital, Cambridge, UK Karattuparambil †,  M Ravindran†  
Introduction: Anaesthesia, Heartlands Hospital, Birmingham, UK,
Lymphangioleiomyomatosis (LAM) is a rare condition causing *Anaesthesia, Good Hope Hospital, Sutton Coldfield, UK,
proliferation of smooth muscle in the respiratory system, †Anaesthesia, George Eliot Hospital, Nuneaton, UK 
which can cavitate leading to degradation of lung parenchyma Introduction:Guidelines1 exist on the definitions of massive
and cystic lung disease1. Because of the risk of progression, bleed, the proposed management pathway and the safe time
women with LAM are frequently advised to avoid pregnancy2. frame for obtaining the blood and products. This multi-centre
We present a case of LAM where multidisciplinary audit looks at the average time taken for the blood/products to
management led to a successful outcome of pregnancy, with a be available in major bleed situations in obstetrics
focus on anaesthetic considerations. Aim: To find out the incidence and reasons for delays in
Case Study: issuing the blood/products, if any, from the blood bank and to
A 35 year old woman presented with bilateral spontaneous compare the existing practices and experience with the other
pneumothoraces in the first trimester of her 2nd pregnancy. hospitals in the area
Both required surgical correction and a lung biopsy revealed a Methods: We collected the data from three participating
diagnosis of LAM. Computerised tomography of her thorax hospital in west midlands using a standard proforma which
showed multiple small lung cysts. Past history included an included the number of massive obstetric bleed calls during a
uncomplicated first pregnancy and emergency caesarean six months period in 2013, the estimated blood loss, the time
section for foetal distress, aged 33; and a spontaneous taken for the first unit of blood/ product to be issued and the
pneumothorax aged 34, requiring surgery. The patient was number of products used among other data.
referred to a tertiary centre for multidisciplinary management.
Results: The results suggested that there is ambiguity in the
Care was shared between obstetrics and respiratory medicine
way major haemorrhage was defined in different situations
and she attended the high risk anaesthetic clinic. Elective
which led to unnecessary calls where blood products were not
caesarean delivery at 38 weeks was agreed upon. She had
urgently needed. Also, the time for getting the products varied
three further small pneumothoraces, treated conservatively
widely the longest being 200 minutes. The documentation of
with no marked deterioration in respiratory function. Elective
the details of the bleeding, time of calls and time of
caesarean section was performed at 38/40 gestation.
blood/product administration were incomplete and inaccurate
Respiratory assessment and examination on the morning of
in some cases.In one hospital, major bleed calls were only put
surgery were normal. A two-space combined spinal epidural
out in two out of 17 cases where blood loss was more than
was sited, administering intrathecal hyperbaric bupivacaine
1500ml.
and diamorphine. A respiratory physician was present at
delivery in case of deterioration. Delivery was uneventful, with   Hospital1 Hospital2 Hospital 3
no immediate complications. The patient spent 24 hours in an Number of MOH calls 58 41 2
obstetric close observation unit post-operatively. Her post- Full data available 13 18 2
natal period was uneventful and required no further obstetric, Average time for group specific (min) 59 NA 33
respiratory or anaesthetic intervention. Average time for X match blood (min) 63.45 42.27 0
Longest delay (min) 200 104 33
Discussion: LAM is a rare condition with an estimated UK
prevalence of 1per million3. Hypotheses suggest oestrogen
Discussion: The definitions of massive blood loss are:
accelerates disease progression and pregnancy may result in
Transfusion of a volume equal to the patient’s total blood
new diagnosis or exacerbation4, therefore obstetric
volume in less than 24 hours / 50% loss of blood volume
anaesthetists should have awareness of this disease. There is
within 3 hours / rate of blood loss 150ml/minute. Though the
sparse literature for anaesthetic management of pregnancy
circumstances of individual episodes of major bleed could
with LAM, consisting mainly of case reports. Considerations
vary, there was no consistency in the trigger of activating
suggested include; avoiding excessive Valsalva manoeuvre
major bleed calls. There were also unacceptable delays in
via instrumental or elective caesarean delivery, avoid nitrous
obtaining the first unit of blood in some cases. The first set of
oxide, early epidural analgesia, obtunding intubation response
uncross matched group specific blood should be available in
and lung protective ventilation strategies if general
20minutes and cross matched blood in 40minutes2. The study
anaesthesia. This case report supports that pregnancy in
suggest that there is a need for the reinforcement of major
LAM patients can progress successfully and highlights the
bleeds definition and also a need for a clearer pathway and
importance of a MDT approach, early anaesthetic assessment
consistency in issuing blood and products in major bleed
and a well considered anaesthetic and obstetric plan.
situations. This audit results will be used to formulate a
References uniform policy in the participating hospitals and a re-audit will
1. Rosendal T. A Case of Diffuse Myomatosis and Cyst Formation in be done in six month time
the Lung. Acta Radiaology. 1942; 23: 138-146
2. Cohen MM, Freyer AM, Johnson SR. Pregnancy Experiences References
Among Women With Lymphangioleiomyomatosis. Respiratory
1. D Thomas etal,Blood transfusion and the anaesthetist: management
Medicine. 2009; 103: 766-772
of massive haemorrhage, Anaesthesia 2010 November; 65(11):
3. Johnson SR, Tattersfield AE. Clinical Experience of 1153–1161
Lymphangioleiomyomatosis in the UK. Thorax. 2000; 55:1-5
2. Guidelines on the management of massive blood loss.
4. McLoughlin L, Thomas G, Hasan K. Pregnancy and BJHaematology 2006; 135(5): 634-641
Lymphangioleiomyomatosis: Anaesthetic Management.
International Journal of Obstetric Anaesthesia. 2003; 12: 40-44
Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin) P31
P161 Management of labour and delivery using  minimally  P162 Management of manual removal of placenta and third
invasive FlotracTM system in a parturient with  and fourth degree tear repair: pathway analysis
congenitally corrected transposition, dextrocardia P Jegendirabose,  J Subramanya*,  S Watkinson*,  J Short  
and systemic ventricular dysfunction Anaesthesia, Queen Elizabeth Hospital, Woolwich, London,
R Vedagiri Sai,  S Dhir,  J Racine   UK, *Obstetrics & Gynaecology, Queen Elizabeth Hospital,
Anesthesia, Western University, London Ontario, Canada Woolwich, London, UK
Introduction: More women with congenital heart disease now Introduction: Guidelines suggest that repair of obstetric anal
survive to reproductive age due to advances in modern sphincter injuries (OASIS) and manual removal of retained
medicine. Obstetric management is challenging in these placenta (MROP) should be undertaken as soon as possible to
complex cases. We present the anaesthetic management of minimise the risk of infection, blood loss and maternal
labour and delivery in a woman with congenitally corrected morbidity1,2. Anal incontinence and perineal pain can impact
transposition of great vessels, dextrocardia, systemic significantly on maternal quality of life and mother-child
ventricular dysfunction and junctional tachycardia using bonding.
minimally invasive continuous haemodynamic monitoring and Methods: We conduced a retrospective audit which showed
optimisation. shortcomings in our management of MROP and OASIS and we
Case report: A 28 year old primigravida presented with a undertook an analysis of a full calendar year's cases. All cases
diagnosis of congenitally corrected transposition of great of MROP and OASIS were identified over January 2012 to
vessels and dextrocardia. The atrial septal defect had been December 2012 using both theatre electronic records and
repaired in childhood. Her medications included folate and maternal records. Time from delivery of fetus to MROP or
multivitamins. She had good exercise tolerance, stable vital OASIS repair, blood loss and blood transfusion requirement
signs and was followed up by Cardiology team throughout her were reviewed.
pregancy. ECHO showed 50% ejection fraction (EF) and mildly Due to lack of nationally set standards, we set a local standard
reduced systemic (morphologic right) ventricle. A multi- of no more than one hundred and twenty minutes from
disciplinary meeting between Obstetrics, Cardiology, delivery to repair for OASIS.
Anaesthesia and Intensive care unit (ICU) team was held to
Results: Our institute is a secondary obstetric centre with
decide on optimal obstetric management. Induction of labour
4800 deliveries per annum. During the twelve month period,
was planned.
105 patients sustained OASIS. The mean delay from delivery
At 37 weeks she developed palpitations, increasing shortness to surgery was 136 minutes. The average blood loss was 501
of breath and peripheral oedema. Repeat ECHO showed millilitres and 3% of patients required blood transfusion. Total
moderate ventricular dysfunction with EF 40%, severe of 42 patients required manual removal of placenta with
systemic atrioventricular regurgitation and severely enlarged regional or general anaesthesia. The mean delay from delivery
left atrium. Prior to labour induction, an arterial line was to surgery was 178 minutes. The mean blood loss was 790
inserted and continuous cardiac output monitoring was millilitres and 5% of the patients required blood transfusion.
performed using arterial pressure waveform analysis with the
FloTracTM monitor. Haemodynamic optimization was guided OASIS repairs n=105 Time (minutes)
by stroke volume variation and goal directed fluid therapy. A Delivery to booking 81 (Cl 70-92)
lumbar epidural was then inserted followed by rupture of Booking to surgery 68 (Cl 40-95)
membranes and oxytocin infusion. Fluid balance was closely Delivery to surgery 136 (Cl 122-150)
monitored continuously using FloTracTM. 1st stage of labour MROP n=42 Time (minutes)
was uneventful and 2nd stage was shortened using vacuum Delivery to booking 138 (Cl 115- 160)
assisted delivery of a healthy baby. She had a second degree Booking to surgery 39 (Cl 32-46)
tear which was repaired. Post partum haemorrhage due to Delivery to surgery 178 (Cl 152-204)
uterine atony was treated with 400µg Misoprostol rectally and
Incidentally, 78% of the patients did not have electronic record
intravenous infusion of 20 IU of Oxytocin. Estimated blood
of estimated blood loss on the theatre system.
loss was 800 mL. Cardiac condition was stable apart from
Discussion: In our institution, these cases are booked onto
persistent tachycardia throughout labour. Postpartum, she
the general emergency theatre, and not in the designated
spent 24 hours in ICU with similar monitoring. Her tachycardia
emergency obstetric theatre. We have identified that this has
settled spontaneously. She was discharged home on day 4.
resulted in significant delay in surgery and increased blood
Discussion: Patients with congenitally corrected transposition
transfusion requirement. We are now changing the patient
have a thin-walled right ventricle as the systemic circulatory
pathway to include urgent utilisation of the emergency
pump. The stress of increased cardiac output can cause
obstetric theatre for these procedures. Since the presentation
failure, atrioventricular regurgitation and arrhythmias1. We
of this audit, we have included the estimation of blood loss in
used minimally invasive continuous cardiac output
the surgical sign out process, thus improving communication
monitoring, fluid balance optimisation and good maternal pain
and patient care.
control to prevent decompensation and achieve vaginal
References
delivery with a good feto-maternal outcome.
1. National Institute for Health and Care Excellence. 2007.
Reference Intrapartum care. Care of healthy women and their babies during
childbirth. Clinical guideline 55
1. Dob DP, Naguib MA, Gatzoullis MA. A functional understanding of
moderate to complex congenital heart disease and the impact of 2. Fernando RJ, Sultan AH, Kettle C, Thakar R. Methods of repair for
pregnancy. Part I: the transposition complexes.Int J Obstet Anesth. obstetric anal sphincter injury. Cochrane Database Syst Rev. 2013
2010 Jul;19(3):298-305 Dec 8;12:CD002866.
P32 Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin)
P163 Multidisciplinary involvement of the high risk P164 National Obstetric Anaesthetic Database: a useful tool
parturient to benchmark maternity units in the UK
S De Silva,  P Gregory,  E Combeer   G Keightley,  N Tailor,  R Baraz,  L De Lloyd  
Anaesthetics, Frimley Park Hospital, Frimley, UK Anaesthetics, University Hospital of Wales, Cardiff, UK

Our Hospital offers a high risk Obstetric Anaesthetic Clinic for Introduction: The National Obstetric Anaesthetic Database
review of parturients with anticipated Anaesthetic or Medical (NOAD) was set up in 1998 to establish a framework for
problems where a checklist referral form is used. We audited collecting national obstetric anaesthetic data considered
whether women were appropriately referred or inappropriately relevant to obstetric anaesthetists. Whilst preparing the
not referred. An alert sticker was created to encourage NOAD survey for 2012, we explored the usefulness of this
healthcare providers to alert the oncall Obstetric Anaesthetist data in benchmarking our units' performance at the University
when the high risk parturient presented to labour ward. We Hospital of Wales (UHW) in relation to NOAD published
went onto audit the effectiveness of this alert sticker. figures from the previous year.

Methods: Data was collected according to the NOAD 2012
Methods: We looked at 200 consecutive births during October
survey and therefore, ethical approval was not required. Due
2010 and ascertained how many of these women had referrals
to the large number of deliveries in our unit, data regarding
to the High Risk Clinic. In the referred cases, we asked whether
labour analgesia, mode of delivery, caesarean section rate and
referral criteria were met and also determined if any mothers
type of anaesthesia was based on six months period (Jan to
were inappropriately not referred. In 2012 we retrospectively
June 2012) and then doubled. Exceptions were critical care
inspected all notes of mothers seen in High Risk Clinic with an
admissions and patients with accidental dural puncture (ADP);
estimated delivery date of March to May 2012. We checked
these were collected and reviewed individually for the entire
whether an alert sticker was present in their notes and also the
year. Microsoft Excel was used to analyse the data.
time taken for the Obstetric Anaesthetist to be contacted once
the mother had presented to Labour Ward. Results: The number of total deliveries in our unit for 2012

was 6138, of which 3060 required anaesthetic procedure(s).
Results: In 2010, 178 of 200 notes were reviewed and 14
The table below compares performance and quality indicators
women met referral criteria and 12 of these were referred.
at UHW in 2012 with the NOAD averages from 2011.
Fourteen percent were therefore inappropriately not referred,
however no women were inappropriately referred. Indicator UHW 2012 NOAD 2011

Caesarean section (CS) rate 22% 24.8%
In 2012, 42 notes were inspected where only 8 had the alert
Elective CS rate 46% 39.1%
sticker in place, with only 5 in the correct position. Two
De novo general anaesthesia (GA) for CS 4.5% 4.7%
mothers with the alert had elective caesarean sections. In five
Conversion to GA (CS) 1.8% 3.5%
of the six remaning mothers, the oncall Anaesthetist was
Labour regional analgesia 27% 22.7%
informed of their presence on labour ward. The average time
Epidural re-site rate 7.7% 9%
taken for this was four hours and 45 minutes (range 10 minutes
Accidental dural puncture rate 0.9% 1.2%
to 10 hours and 50 minutes). On review of the Clinic letters, it
was felt that 30 of the 42 parturients should have had an alert In 2012, three cases were transferred to critical care unit as
present in their notes, which is 71% not 19% as shown by our level 2 care (two with sepsis and one adult respiratory distress
audit. syndrome) and six cases as level 3 care (two with sepsis, three

post partum haemorrhage and one case of amniotic fluid
Discussion: In many cases of substandard care assessed by
embolus).
CMACE, there were major failures of communication between
Discussion: Our unit is classified as a large maternity unit
healthcare workers that may have contributed to the woman’s
compared to the national average. The elective CS rate and
death in some cases1. Our audits demonstrated that local
labour regional analgesia rates in our unit are higher than the
guidelines for referral were followed in 99% of cases, therefore
national average, possibly related to the complexity of a
high risk mothers were identified early. However, there still
tertiary centre. Despite this, our total CS rate is well below the
lacks effective communication of concerns within teams and
average with very low conversion to GA. In addition, our
poor involvement of other specialties early.
epidural re-site rate is lower than the national average, as is
Reference our ADP rate. Current facilities include two theatres serving
1. Centre for Maternal and Child Enquiries (CMACE). Saving both emergency and elective streams, and a mixed
Mothers'. Lives: reviewing maternal deaths to make motherhood recovery/high dependancy unit (HDU) for up to 5 patients.
safer: 2006–2008. The Eighth Report of the Confidential Enquiries
Our unit has a low transfer rate as level 2 care in general HDU,
into Maternal Deaths in the United Kingdom. BJOG 2011;118:1-203
due to the ability to care for these patients on our unit. We
find the NOAD data a useful tool to benchmark our
performance and set standards of care. More units should
contribute to the annual NOAD survey and consider using the
data as a way of identifying shortfalls and improving patient
care and services.
Reference
1. National Obstetric Anaesthetic Database report 2011.
http://www.oaa-anaes.ac.uk/content.asp?ContentID=586
Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin) P33
P165 Obstetric admissions to the Intensive Care Unit: a 6 P166 Obstetric outcomes with programmed intermittent
year review at a UK tertiary maternity centre epidural bolus labour analgesia
R Labib,  K Cullis   JTE Cremin,  CH Papageorgiou  
Selwyn Crawford Department of Anaesthesia, Birmingham Department of Anaesthesia, Hillingdon Hospital, Uxbridge,
Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin) P1
P101 A modified WHO surgical safety checklist for P102 A parturient with phocomelia and severe needle
category 1 caesarean sections phobia: the challenges faced
A Lahkar,  A Cooney,  G Massolini   R Sinha,  K Howard,  N Bhandal  
Anaesthetics, Milton Keynes NHS Foundation Trust, Milton Department of Anaesthesia, Nottingham University Hospitals
Keynes, UK NHS Trust, Nottingham, UK
Introduction: In June 2008, WHO introduced a surgical safety Introduction: Parturients with phocomelia are rarely seen and
checklist to be used in every operating theatre to improve present anaesthetic and obstetric challenges. We present a
patients' safety. In 2010 a WHO surgical safety checklist for case of a parturient with phocomelia and severe needle phobia.
maternity was created in response to requests from maternity Case report: A 33 year old woman with phocomelia and severe
services and clinicians. Nevertheless, in some emergency needle phobia presented to the obstetric anaesthetic clinic at
situations like category 1 Caesarean sections, this checklist 20 weeks for pre-assessment.
could still be quite a difficult task to achieve due to Her phocomelia was thought to be idiopathic, she had been
understandable time limit constrains to safely deliver the baby adopted when young and no family/drug history was
and/or save the mother's life. available. Examination revealed four limb phocomelia. There
Whilst there is still no international consensus or any specific were absent upper limb bones on the right and a fused hand
recommendation from WHO concerning these specific attached directly to her body. Her left upper limb was
situations, the Anaesthetic Department in Milton Keynes shortened with a primitive hand and fused fingers. Both lower
hospital has managed to devise a checklist for cat 1 LSCS limbs were extremely shortened with primitive feet with fused
which is 100% compliant both in terms of content with WHO toes. Her head, neck and torso appeared normal. She was able
guidelines and adherence by hospital staff. to mobilize with a wheelchair and significant assistance from
Method: After considerations and inputs from the Consultant her partner. The problems faced in clinic were numerous and
Anaesthetists, a simplified checklist was introduced in our focused on her severe needle phobia, difficult venous access
emergency obstetric theatre in June 2013 by way of an ad hoc and monitoring, positioning, mobilization and
poster hanged on the wall. It spells out the most 10 salient thromboprophylaxis as well as the challenges posed by the
questions to be read by one of the theatre staff before the start preganancy itself. The anaesthetic plan consisted of non-
of a category 1 Caesarean section. These questions translate invasive blood pressure monitoring on her left lower extremity;
the original 32 WHO ones that were spread across 3 sections pulse oximetry via an ear probe or toe and standard
in a simpler, quicker format. electrocardiogram. These were tested prior to labour. Due to
Results: After the introduction of the modified WHO checklist the impossibility of standard intravenous access and extreme
in June 2013, compliance is 100%. needle phobia several discussions were had about obtaining
Discussion: By putting the combined know-how and intravenous access prior to labour. A right subclavian
experience of many Consultant Anaesthetists to the task, we Hickman line was inserted at 39 weeks facilitated by the use of
managed to simplify the original WHO narrative into a sharper entonox. Regional analgesia was refused for labour so the
tool that is quickly and effectively utilised for a better and option of intravenous fentanyl via a midwife controlled
safer quality of care in what has become a "normal routine" analgesia pump was discussed. Should a caesarean section be
during extraordinary times in the emergency theatre. required a neuroaxial anaesthetic was refused and so a general
anaesthetic was planned.
Reference At 40+2 weeks spontaneous rupture of membranes occurred
1. WHO surgical safety checklist: for maternity cases only, and labour established. However, due to failure to progress a
http://www.nrls.npsa.nhs.uk/resources/?entryid45=83972 decision was made to perform a caesarean section.
In theatre the challenges related to positioning and achieving
a satisfactory left lateral tilt. A rapid sequence induction was
conducted following pre-oxygenation to an end-tidal oxygen
concentration of 92%. Anaesthesia was induced with
thiopentone 350mg and suxamethonium 100mg. Soon after
induction she desaturated rapidly to the high 60s. This
resolved after tracheal intubation and ventilation. She was
hypotensive intra-operatively, with an estimated blood loss of
1300mL After fluid and blood resuscitation, recovery was
unremarkable. Postoperative pain was managed with
transversus abdominus plane blocks and morphine
patient/midwife controlled analgesia.
Discussion: There is little literature about managing delivery
in women with phocomelia, but sucessful regional techniques
have been described although this was refused here. Early
discussion of anaethesia and analgesia options, and plans for
vascular access and monitoring are needed, There is a reduced
vascular reservior and skeletal muscle mass.
As a consequence faster inductions, emergences and
responses to titrated drugs are observed.

P2 Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin)
P103 A questionnaire to evaluate and aid future development P104 A retrospective descriptive analysis of anaesthesia for
of the AAGBI's SAFE obstetric anaesthesia course in successful cervical cerclage in pregnancy
Liberia J Modha,  G Burul*,  F Forya*,  CP James*,  AL David*,  J
JCO Fox,  CE Richards*,  T Sheraton*,  A Sonah†   Dick,  L Wee  
†Department of Anaesthetics, Phebe Hospital, Bong County,  Department of Anaesthesia, University College London
Liberia, *Department of Anaesthetics, Royal Gwent Hospital, Hospitals NHS Foundation, London, UK, *Department of
Newport, UK, Department of Anaesthetics, University Obstetrics, University College London Hospitals NHS
Hospital of Wales, Cardiff, UK Foundation, London, UK
Introduction: Dr Kate Grady has developed this three-day Introduction: Cervical cerclage is a common operation which
refresher course in obstetric anaesthesia on behalf of the requires an anaesthetic. There are no studies on the type of
AAGBI. The course is aimed at non-physician anaesthetists in anaesthesia used for this procedure.1
developing countries. It consists of short lectures, interactive Aim: To determine the type of anaesthesia used for vaginal
sessions and workshops that focus on the recognition and cervical cerclage.
management of leading causes of maternal death in resource
Method: Ethical approval waived. Women having any vaginal
poor settings. The course has been taught in Uganda,
cervical cerclage (Macdonald or Shirodkar) during pregnancy
Bangladesh, Liberia and Ghana. It includes the principles of
between January 2005 and December 2012 were identified
the WHO Safe Surgery and training of trainers. Mothers of
using the hospital obstetric anaesthesia database and cross-
Africa, a medical educational charity, has led delivery of 2
referenced with data from the Preterm Birth clinic where women
courses for nurse anaesthetists (NAs) in Liberia - supported
at risk of preterm birth are seen antenatally. Data was obtained
by the AAGBI IRC. Liberia has approximately 60 nurse
by examination of obstetric case notes and the ultrasound
anaesthetists and no medically qualified anaesthetists for a
scan records and analysis conducted using Microsoft Excel.
population of 4.2 million people1. Access to CPD is difficult.
Results: There were 190 cases. Twenty-five patients were
The MMR in Liberia is 770 per 100,000 live births1. In order to
excluded due to incomplete data, hence 165 included in
plan future development of the course in Liberia, which will be
analysis. The mean gestational age was 16.6 weeks (range 9-
led by Liberian trainers, feedback data was collected.
23.6 weeks). The table below shows that both general
Methods: A follow up questionnaire was given to 35 NAs who
anaesthesia (GA) and regional anaesthesia (RA) were used.
had previously attended a SAFE obstetric anaesthesia course
The majority of regional anaesthetics were spinals (95.7%), the
held in Liberia (March 2012 or March 2013). We aimed to
rest combined spinal and epidural (CSE) (3.6%) and epidural
assess; 1) the quality, usefulness and appropriateness of the
top up (0.7%).
material taught during the course, 2) the effect on motivation
to improve local services/care delivery, 3) the effect on the GA RA

confidence levels of NAs in managing obstetric anaesthetic n (%) n (%)
emergencies. Spinal n = 133
Results: A 70% follow up rate was achieved. 97% reported Total n=165 26 (16%) 139 (84%) CSE n = 5
positive changes in their attitude to work and their clinical Epidural n = 1
practice and 94% reported improvements in interactions with Five patients who had a spinal anaesthetic required second
colleagues. Many NAs gave details of cases where the skills procedures (3 GA, 1 spinal, 1 CSE). Of those converted to GA,
and knowledge they learnt on the course helped save lives one patient had a block to T6 (the reason for conversion to GA
and improve clinical outcomes. 11 NAs requested continued was not documented), one patient had a block to T12 and the
education and training. Other suggestions for course third patient had 3 failed spinal attempts. In all cases there
improvement included; additional sessions in preoperative were no major anaesthetic complications and cervical cerclage
assessment and TAP blocks, and the inclusion of midwives in was placed successfully.
the training sessions. The following table illustrates the mean
Discussion: In this series, the majority of vaginal cervical
subjective confidence scores (between 0 and 10) of the NAs in
cerclage surgery was performed safely and effectively under
various clinical scenarios before and after the course.
RA. There are no specific guidelines regarding the type of
  Before After anaesthesia for cervical cerclage.1 Anaesthetic considerations
General anaesthesia LSCS 6.3 9.2 favouring a regional anaesthetic in pregnancy include the risk
Spinal anaesthesia LSCS 7.6 9.8 of aspiration and difficult airway management in patients over
Management of severe eclampsia/preeclampsia 5.7 9.2 20 weeks gestation and those under 20 weeks gestation if at
Management of obstetric haemorrhage 5.9 9.4 high risk for example those with a high BMI. The majority of
women in our data set were less than 20 weeks (88.5%). Other
Discussion: Our results indicate that the SAFE obstetric
considerations include patient and surgeon choice. Women in
anaesthesia course in Liberia has been well received with
this series were given the option of GA or RA. In certain cases
subjective evidence of empowerment and improved methods
for example rescue and abdominal cerclages, the patient may
of working. This is promising in the context of increasing the
need to be in a deep Trendelenberg position to aid reduction
reach of future courses and enabling local faculty to lead
of membrane prolapse to avoid membrane rupture or to aid
training. Further data from logbooks provided as part of the
access to the pelvis.2
course were not obtained and more work is needed to
encourage completion of the logbooks. Objective evidence is References
required to demonstrate impact on patient outcomes. 1. Cervical Cerclage, Green-top Guideline No 60, Royal College of
Reference Obstetricians and Gynaecologists, May 2011.
2. Olatunbosun OA, Dyck F. Cervical cerclage operation for a dilated
1. http://data.worldbank.org/indicator/SH.STA.MMRT/countries/1W-
cervix. Obstet Gynecol. Feb 1981;57(2):166-70.
LR?display=graph
Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin) P3
P105 A retrospective descriptive analysis of dose of P106 A step towards improving theatre productivity for
intrathecal anaesthesia and adjuncts for successful elective caesarean sections
cervical cerclage in pregnancy S Kale,  C Farrow,  N Owen,  K Miltsios  
J Modha,  G Burul*,  F Forya*,  CP James*,  AL David*,  J Department of Anaesthesia, Whittington Hospital, London,
Dick,  L Wee   UK
Department of Anaesthesia , University College London Introduction: NHS Institute for Innovation and Improvement
Hospitals NHS Foundation, London, UK, *Department of developed The Productive Operating Theatre Programme to
Obstetrics, University College London Hospitals NHS improve effective use of theatre time, staff and patient
Foundation, London, UK experience.1 Good administrative system and organisation is
Introduction: Cervical cerclage is a common operation, which essential to ensure theatre efficiency.2On this background,
requires either a general or regional anaesthetic aiming for a with the rational of making existing system more productive,
block height of T10. There are no studies determining the dose safe and reliable, we evaluated current practice in one of our
that should be used to achieve this or describing additional main theatres, designated for elective sections, in a DGH set
drugs used for successful surgery. up.
Aim: To determine the dose of local anaesthesia used for Methods: Evaluation was carried out over a 4-week period, for
intrathecal injection and the block height achieved in women planned caesarean sections. The data was collected
undergoing cervical cerclage. In addition to determine the use concurrently by the anaesthetist for that case and from the
and dose of adjuncts. theatre database. The exact time for all significant events, such
Method: Ethical approval waived. Women having vaginal as when patient was sent for or when theatre was clean and
cervical cerclage during pregnancy between January 2005 and ready for the next patient, was recorded. Reasons for delays,
December 2012 were identified using the hospital obstetric duration of anaesthesia, surgery and problems encountered
anaesthesia database and cross-referenced with data from the were also recorded. Time spent at and between different
Preterm Birth clinic. Data was obtained by examination of crucial stages in theatre was calculated from the data. Results
obstetric case notes and the ultrasound scan records and are presented in the form of time in minutes, median [range]
analysis conducted using Microsoft Excel. and % (absolute numbers of cases).
Results: In all cases, cervical cerclage was achieved Results: We had 25 completed forms. Our analysis showed,
successfully. There were 138 cases of intrathecal anaesthesia median time interval from patient sent for to arrival in theatre
(133 spinals and 5 combined spinal epidurals) in whom 67.4% as 5 min [1-29]. Reasons for delay were due to obstetric team
(93/138) had documented intrathecal anaesthetic dose and busy in meeting, midwife busy preparing the patient and
were included for final analysis. Hyperbaric bupivacaine 0.5% midwife busy completing paperwork for previous patient in
was used (mean dose 10.9mg, median 10.8mg and mode 10mg, recovery. Median time interval between patient's arrival and
range 6.5–15mg). Block height and dose of intrathecal neuraxial block was 18 min [10-70], prolonged in 8% of cases
anaesthetic was documented in 54/93 cases (58%). The block (2/25) due to failed and repeat block. Bladder catheterisation
height ranged from T2 to T12 with similar doses of local after block was delayed by ≥30 min in 8% of cases (2/25) due
anaesthetic given in each group and of similar gestation and to unavailability of midwife. Median anaesthetic time for
body mass index (BMI). satisfactory block was 12 min. Interval between block ready
and knife to skin (KTS) was 6 min [1-12]. Median surgery
Block height T2-4 T5-8 T10 T12 duration was 45 min [31-141]. PPH, high BMI, and previous
Frequency 7 31 13 3 laparotomies resulted in longer operations in 16% of cases
Mean dose mg (4/25). Median turnaround time between the cases was 10 min
11 11 11 8
hyperbaric bupivacaine 0.5% [6-15]. Total time patients spent in theatre was 89 min [74-183].
Mean gestation (weeks) 17.4 17.7 15.6 19.1
Discussion: We noted that unavailability of obstetric team
Mean BMI kg/m2 27.3 26.6 26.1 32
and busy midwives at times has resulted in late starts and
In 3 patients that had block heights of T12 only one was delay in some procedures in theatres. Delay in starting the
converted to GA. Opiates were used in 73/93 (78.5%), the most surgery after a satisfactory block and prolonged turnaround
frequent being fentanyl. time have also affected the overall theatre productivity. We
have put forth some recommendations to working group such
Mean dose Range
Opiate used Number (%) as offering administrative support to midwives, ensuring
(mcg) (mcg)
senior obstetrician and anaesthetist are present for difficult
Fentanyl 69 (95) 20 10-75
cases, making use of anaesthetic room to improve patient
Diamorphine 3 (4) 300 250-350
turnaround time and most importantly encouraging staff
Fentanyl & Diamorphine 1 (1) 20/300 N/A
nurses to take the lead role in increasing theatre efficiency.
Vasopressors were used in 26 cases (23 phenylephrine, 3 This could be a big step towards enhancing theatre output as
ephedrine). Other drugs included 3 cases of intravenous well as increasing patient and staff satisfaction. We aim to
midazolam, 1 case propofol and in 1 case salbutamol (as a introduce these changes soon and re-evaluate the practice in
tocolytic agent). the near future.
Discussion: In our case series there is a wide dose range of References
both hyperbaric bupivacaine 0.5% and opiate given. To 1. The Productive Operating Theatre programme,
achieve a block height of T10 or above a minimum dose of http://www.institute.nhs.uk/quality_and_value/productivity_series/the
11mg (2.2ml) is recommended which may be independent of _productive_operating_theatre.html
other factors. There is a wide variation in block height but 2. Theatre Efficiency,
http://www.aagbi.org/sites/default/files/theatreefficiency03.pdf
even a low block (T12) was found to be adequate.

P4 Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin)
P107 A year in the "maternity" life of an increasingly busy P108 Abstracts on the antenatal anaesthetic clinic
new build district general teaching hospital - coping presented to the Obstetric Anaesthetists' Association,
with training and service provision - 2013 1991-2013
H Wrigley,  PF Yoxall,  Janet Slee   AJ Wickham,  SM Yentis*  
Anaesthetics, St Helens & Knowsley NHS Trust, Liverpool, Anaesthetic department, St Mary’s Hospital, London, UK,
UK *Anaesthetic department, Chelsea & Westminster Hospital,
Introduction: Since moving to a new PFI built hospital in 2010 London, UK
our maternity unit has become more busy. Delivery rates/year Introduction: National reports1 and guidelines2 recommend
have increased from 2900 to 3700 pa (up 27.6% in 3 years) assessment of women with ‘high-risk’ pregnancies and
increasing demands upon anaesthetic services. potentially serious co-morbid disease in an antenatal
Methods: We reviewed all our maternity cases during 2013, anaesthetic clinic (AAC). We reviewed trends and themes in
both epidural and caesarean sections. We also surveyed our abstracts on this topic presented to the OAA.
CT2 trainees to assess their experience in terms of case Methods: Full-text records of abstracts (excluding case reports)
numbers during a newly introduced modular training block. presented at OAA meetings (1991-2013; see www.oaa-
Lastly consultant cover on labour ward was audited for CNST anaes.ac.uk) were searched using the terms ‘antenatal’,
purposes. ‘clinic’, ‘risk’ and ‘refer’. Relevant abstracts were reviewed for
Results themes and conclusions.
Results: Forty abstracts were presented at 14 Annual
n %
Meetings (Fig. 1); 3 were unavailable in full-text (2008) but 1
Total Deliveries 3700
was provided by the author on request. 35 were from single
LSCS 838 22.6
departments and 5 were surveys (4 national). Common topics
Grade I-III LSCS 464 12.5
were obesity (12, 30%), referral reason (7, 18%) and
Grade IV LSCS 374 10.1
appropriateness (4, 10%), and outcomes (5, 13%). Nine (23%)
LSCS - SAB 666 79.5
described single patient cohorts, e.g. cardiac. AAC workload
LSCS - Epidural 123 14.7
has increased from 2.3 to 28.6 patients per month over 22
LSCS - CSE 14 1.7
years, albeit at different centres. Obesity has replaced
LSCS - GA 119 14.2
musculoskeletal disease as the most frequent reason for
RA to GA 34 4.2
referral. Common concluding themes include the need to
Average BMI LSCS (Range) 28.3 (16.7-59.9)  
improve the timeliness and appropriateness of referrals, and
Epidurals 895 24.2
ensuring anaesthetic plans are both prominent and followed.
Epidural Resites 32 3.7
PDPH - Epidural 15 1.7
PDPH - SAB 2 0.3
Epidural Blood Patches 21
Average BMI Epidural (Range) 27.1 (16-62.8)  
CT2 Training One of our requirements is to teach at least 4
CT2s per annum obstetric basic competencies. Our trainees
receive a 4 week long daytime block covered by an anaesthetic
ST3-7 and a consultant. They attend 40 sessions, the majority
siting 15 epidurals and anaesthetise 30 caesarean sections
before embarking on daytime on calls. They attend our in-
Figure 1: number of abstracts on the AAC presented per year
house MODSS (Obstetric Simulation Day) run by one of our
Consultant Obstetricians. Discussion: Abstracts relating to AACs have become more
frequent in the last decade, presumably reflecting their
Consultant Input The number of funded Consultant labour
increasing provision and perceived usefulness (and
ward sessions has risen 7 to 10 sessions (7 elective lists per
recommendation in the 2002-04 CEMACH report3). Increased
week). A “High Risk Obstetric clinic” runs weekly to pre-
demand for this service is exacerbated by inappropriate
assess all potentially difficult patients (250-300 per annum).
referrals and budgetary constraints. Referral processes,
Discussion: Despite a significant increase in workload we
facilities, and documentation and inconsistent use of plans are
have managed to maintain levels of cover (both junior and
areas for development. Future work should focus on quality
consultant) whilst allowing for CT2 training in obstetric basic
improvement and assessment of cost-effectiveness. Nationally
competencies as required at both national and local levels.
agreed referral criteria and a national ‘anaesthetic plan’
This has been achieved by increasing our core of obstetric
document, complemented by referrer education, may enhance
consultant anaesthetists, increasing obstetric PAs and
the process. Multidisciplinary ‘one-stop-shop’ or midwifery
changing to a modular CT2 training programme.
led clinics for common problems, such as obesity, may be
beneficial.
References
1. Centre for Maternal and Child Enquiries. Saving Mothers’ Lives:
reviewing maternal deaths to make motherhood safer: 2006-08.
The Eighth Report on Confidential Enquiries into Maternal Deaths
in the UK. BJOG. 2011; 118(Suppl.1): 1-203.
2. OAA & AAGBI Guidelines for Obstetric Anaesthetic Services.
Revised Edition 2005. London: OAA/ AAGBI
3. CEMACH. Why Mothers Die 2000-2002. Report on Confidential
Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin) P5
P109 Accuracy of a new electronic obstetric anaesthetic P110 Accuracy of landmark approach to central neuraxial
database blocks in obstetric patients
Rohit Rohit,  R Abraham,  GNB Jackson   J Lie,  K Bhatia,  A Venkataraju,  P Kochhar  
Anaesthetic department, Royal Berkshire Hospital, Reading, Anaesthesia, St Mary's Hospital, Manchester, UK
UK Introduction: Correct identification of vertebral level could
Introduction: We have introduced a new electronic database prevent damage to the spinal cord during a central neuraxial
'ROAD' (Reading Obstetric Anaesthetic Database) to record block (CNB). Evidence suggests that ultrasound (US) imaging
obstetric anaesthetic data. Written & designed by one of our of the spine by an experienced operator leads to correct
anaesthetists it is secure, password protected & able to identification of vertebral level in 90% of the patients and
produce reports on patient data & the activity of individual decrease the number of attempts required for a successful
anaesthetists. More than 70% obstetric anaesthetic units use CNB1. National Institute for Health and Care Excellence
electronic data collection system in the UK but there is little suggests US could be a useful tool for epidural catheter
agreement as to the best format.1 We audited the accuracy of insertion2. Our aim was to determine the discrepancy between
data entry, as a marker of ease of use by the anaesthetists, landmark technique and US to identify level of insertion of
before auditing the content of the database. CNB.
Methods: This was a retrospective audit, analysing data for Methods: Two experienced US operators who were blinded to
one month period (June 2013). The data in 'ROAD' was the initial procedure retrospectively performed US imaging of
compared to 1) our handwritten anaesthetic record book spine post-operatively after elective caesarean section in 51
(ARB); 2) Midwifery led labour ward logbook (LWLB); 3) obstetric patients with their consent from January to March
Operating theatre electronic log 'Bluespier'. Data entered on 2013 in St Mary’s Hospital. All the patients had a lumbar CNB
the 'ROAD' was manually checked against all these three done by landmark approach. The documented vertebral level
sources and the results tabulated and analysed. at which CNB was performed was noted. This was then
Results: 253 records were found in the ARB. The ARB missed compared with the actual vertebral level identified by bedside
one case (found in Bluespier), Bluespier missed one case US imaging of spine.
(found in the ARB) and LWLB missed 6 cases (found in the
Results: 29 patients had a spinal, 20 had an epidural and two
ARB & Bluespier). The results show that 'ROAD' was 96%
had combined spinal-epidural anaesthesia. The median body
accurate compared to any of the other systems.
mass index (BMI) was 28.6kg/m2. Landmark technique was
No. of cases missing on only accurate in 39.2% of patients. There was no statistically
Total 'ROAD' accuracy against
  'ROAD 'compared to significant correlation between the experience of operator and
no. other data sources as %
others accuracy. 3% of patients had a CNB at the level of L or above.
2
ARB 10 253 96.047% Documentation of the level performed was excellent. Raised
Bluespier 7 174 95.977% BMI and difficulty in palpation of landmarks resulted in
LWLB 10 247 95.951% statistically significant decrease in the accuracy (p<0.05
'ROAD'   243   Fisher’s Exact Test).
Discussion: Pinder et al considered an accuracy of 89% for Discussions: Our findings co-relate well with other studies
their electronic record adequate enough to adopt computer which have found that the vertebral level identified by
based data collection system.2We used three different landmark approach was at least 1 interspace higher than the
methods of data collection already in regular use, to compare level located by US in 40% of the pregnant population 3. Our
with our electronic database and showed it to have a high audit further confirms that the use of traditional landmark
degree of accuracy. This suggests that the database is easy to technique is highly inaccurate with potential increase risk of
use and consistently completed by our anaesthetists. We wish needle injury to the spinal cord especially in the high-risk
to use our database to produce reports on anaesthetic service patient groups (morbid obesity and musculoskeletal
provision (including the quality & safety of that service) as problems). We propose that all elective obstetric patients,
well as for auditing individual anaesthetist activity patients having a lumbar epidural, and high risk patients
(particularly our novice obstetric anaesthetists to ensure having a lumbar CNB should have US imaging of the of their
appropriate case mix & experience during their obstetric spines to identify the correct vertebral level and other relevant
attachments). Before using any database to audit these anatomy. The main reasons being that US imaging does not
aspects it is important to ensure that the data being audited is involve any radiation, is compact, portable and readily
a true reflection of anaesthetic activity, we believe our new available at the point of care. Better US equipment availability,
database is sufficiently accurate to audit the data within it. The staff awareness with appropriate training and improved
limitation of our audit is that we only audited the data from one documentation would aid in providing safer patient care.
month but we believe that the data entry practice of all months
References
is similar. We conclude that our electronic database is accurate
1. Chin KJ, Perlas A, Chan V, Brown-Shreves D, Koshkin A, Vaishnav
& the data entered can be used to audit our obstetric V: Ultrasound imaging facilitates spinal anesthesia in adults with
anaesthetic service. difficult surface anatomical landmarks. Anaesthesiology 2011; 115
(1): 94-101
References
2. Ultrasound-guided catherisation of epidural space. National Institute
1. Campbell NJ, Youngs P, Anderson I. A national survey of obstetric for Health and Care Excellence January 2008
anaesthetic data collection methods in the UK. Int J Obstet Anesth
2012; 21: S53. 3. Lee AJ, Ranasinghe S, Chehade JM, Arheart K, Saltzman BS,
Penning DH & Bimbach DJ. Ultrasound Assessment of the Vertebral
2. Pinder A, Wrench I, Shepherd D, Freeman R. Assessment of a Level of the Intercristal Line in Pregnancy. Anaesth Analg 2011;
handheld computer to collect obstetric epidural audit data. Int J
113: 559-564
Obstet Anesth 2002; 11: 8.
P6 Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin)
P111 Adherence to antenatal anaesthetic advice in P112 An evaluation of anaesthetic antenatal clinics in the
labouring morbidly obese parturients. obese obstetric population
S Halliday,  LC Robertson ,  HM du Plessis   PR El-Dalil,  DS Cochran,  R Ganapathy*  
Anaesthesia, Princess Royal Maternity Hospital, Glasgow, Department of Anaesthesia, Sandwell and West Birmingham
UK NHS Trust, Birmingham, UK, *Obstetrics and Fetal Medicine,
Introduction: Morbidly obese parturients pose a high Sandwell and West Birmingham NHS Trust, Birmingham, UK
anaesthetic risk1. Antenatal anaesthetic assessment for Introduction: Maternal obesity is increasingly common, with a
women with a body mass index (BMI) ≥40 kg.m-2 at booking is BMI 35 found in 5% of pregnancies. Current CMACE / RCOG
advised2. Early establishment of epidural analgesia is often guidelines advocate the referral of patients with a BMI 40 to
advocated. We sought to determine if this advice is adhered to an anaesthetic antenatal clinic. This study aimed to evaluate
in our centre. the outcomes following the implementation of such a clinic in a
Methods: A retrospective case note review of 49 morbidly busy inner city district general hospital.
obese patients (BMI ≥40) assessed antenatally was Method: High-risk patients were referred to a multidisciplinary
conducted. As a control, data from 23 patients with a BMI <40 antenatal clinic involving Anaesthetics, Obstetrics and
who had a labour epidural was collected. We compared the Haematology; patients with a BMI 40 were referred to the
timing of epidural request from labour ward admission, cervical clinic and included in the evaluation. Data was collected
dilation and syntocinon administration at request and the time retrospectively on the reason for attending, the past medical
from epidural insertion to delivery. Mode of delivery was also and obstetric history as well as any anaesthetic or surgical
noted. intervention provided in the perinatal period.
Results: Mean BMI for the control group was 23.6 (range 17- Results: In 2011, 72 women were referred to the clinic with a
32) and for the morbidly obese group 44.6 (40-60). Eleven BMI 40, although there were often other relevant co -
morbidly obese parturients had an elective caesarean section morbidities. The BMIs ranged from 40 to 80 (mean = 44). 44
(CS). Nineteen of the remaining morbidly obese parturients patients (61%) had a normal vaginal delivery, 3 women (4%)
requested labour epidurals. Two parturients delivered prior to required assisted vaginal delivery, 17 (24%) had an elective
insertion. caesarean section (CS), whilst 8 (11%) had a non-elective CS.
Of these patients, 38 (53%) required no anaesthetic
Time to Syntocinon Insertion to
Cervical dilation intervention.
request administration n delivery
  Centimetres
Minutes (%) Minutes Table: Anaesthetic intervention and failure rates in obese
(range)
(range) (range) parturients compared to previously published failure rates1 in
BMI Yes 12 (52.2) the general obstetric population
375 (110-
<40 169 (0-435) 3.7 (1-7) No 11 (47.8) Spinal Epidural CSE GA
915)
(n=23) Number attempted 19 12 4 1
BMI Yes 13 (68.4) % Failure rate 5 17 0 0
334 (12-702)
≥40  261 (0-555) 3.65 (2-8) No 6 ( 31.6) Published % failure rates1 6 24 18 <1
(n=17)
(n=19)
Discussion: The results demonstrated low regional
Table: Timing of epidural request, cervical dilation and anaesthesia failure rates, with only 1 unsuccessful spinal (5%)
syntocinon use at request, and time from insertion to delivery. and 2 failed epidurals (17%); figures comparable to those
In the control group with a BMI <40 that had a labour epidural found in the general obstetric population (Table). There is little
(n=23), the number of spontaneous vaginal deliveries (SVD), available data for regional anaesthetic failure rates in the obese
trial of forceps (TOF) and lower uterine segment CS (LUSCS) obstetric population precluding a direct comparison, but a
were 13 (56.5%), 5 (21.7%), and 5 (21.7%), respectively. For higher failure rate would be expected. A previous study of 677
those with a BMI ≥40 with an epidural (n=17) there were 6 women with a BMI 30 found an emergency CS rate of 24%, 2
(35.3%) SVD, 3 (17.7%) TOF and 8 (47.1%) LUSCS. The significantly higher than the 11% demonstrated in this cohort
number of SVD in the BMI ≥40 without an epidural group was of BMI 40. This robust multidisciplinary approach in the
18 (85.7%) and there were no TOF and 3 (14.3%) LUSCS. antenatal period allows for adequate planning and early
Discussion: Despite antenatal review, the time to epidural institution of optimised perinatal management. The service
request was longer in the morbidly obese group, indicating a provided was predominantly consultant led, with the on-call
need for ongoing education. The time between epidural Anaesthetist required to attend out of hours for parturients
insertion and delivery was shorter in the morbidly obese group with a BMI 45, and to be informed of patients with a BMI
which had a significantly increased chance of CS, signifying 40; significantly 73% of the on-call consultants are dedicated
the importance of establishing a working epidural early in this Obstetric Anaesthetists. We feel these systems may account
cohort. for our findings, as well as promote early and effective
communication with patients. Whilst the sample was relatively
References small the results are sufficiently encouraging to suggest that a
1. Soens MA, Birnbach DJ, Ranasinghe JS, van Zundert A. Obstetric multidisciplinary approach significantly improves perinatal
anesthesia for the obese and morbidly obese patient: an ounce of outcomes in the obese obstetric population.
prevention is worth more than a pound of treatment. Acta
Anaesthtesiol Scan 2008; 52: 6-19 References
2. OAA/AABGI Guidelines for Obstetric Anaesthetic Services 2013. 1. Kinsella SM. A prospective audit of regional anaesthesia failure in
Association of Anaesthetists' of Great Britain and Ireland and the 5080 caesarean sections. Anaesthesia 2008; 63(8): 822-832.
Obstetric Anaesthetists' Association. London, 2013. 2. Usha Kiran TS, Hemmadi S, Bethel J, Evans J. Outcome of
pregnancy in a woman with an increased body mass index. BJOG
2005; 112(6): 768-772.
Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin) P7
P113 An evaluation of fasting times for elective caesarean P114 An evaluation of intrathecal diamorphine versus
section surgery fentanyl for lower segment Caesarean section in a
J Ghoshdastidar,  KM Sherratt,  M Seneviratne*,  A medium-sized district general hospital
McGlennan   K Ramm,  LT Fenton-May,  S Naresh  
Anaesthetics, Royal Free Hospital, London, UK, Department of Anaesthesia, Good Hope Hospital, Heart of
*Anaesthetics, University College Hospital, London, UK England Trust, Birmingham, UK
Introduction: Enhanced Recovery Programmes have shown Introduction: Intrathecal diamorphine is now recommended by
increasing evidence for the benefits of reducing fasting times the National Institute for Health and Clinical Excellence (NICE)
for those undergoing elective surgery1. Many of these as the opioid of choice for lower segment Caesarean section as
benefits could be applicable to the elective caesarean section it provides improved post-operative pain relief.1 However, it is
patient. We evaluated the fasting times of our elective also associated with a dose-dependent increase in the
caesarean section patients to assess whether we could make incidence of pruritus2 and nausea3 which may be more
improvements to patient care. significant with diamorphine given its longer duration of
Methods: The evaluation included all patients undergoing action. Having arranged appropriate protocols for post-
elective caesarean section surgery at the Royal Free Hospital operative monitoring of women receiving intrathecal
over a 3 month period.. Patients received standard instructions diamorphine, we introduced the therapy in late 2012.
to stop eating at midnight on the day of surgery and to stop Methods: The evaluation took place over a six-week period. A
drinking clear fluids at 6 am. Data was collected by anaesthetic small number of women were still receiving intrathecal fentanyl
staff using a standardised data collection sheet.. Patients were due to clinician choice, and these provided a useful
questioned about the time they last consumed solid food and comparator. Women who were still present in the hospital on a
when they last drank liquid. follow-up round on the first day post-op were asked questions
Results: In total 77 patients underwent elective caesarean about post-operative pain, nausea and pruritus. We also
sections during the period of evaluation. We obtained data assessed total oral morphine and codeine doses and time to
from 71 patients for fasting times for fluids and 72 patients for first dose.
fasting times for solids. Results: Basic data is presented in the chart.

  Fentanyl Diamorphine
Pre-op fasting % of Pre-op fasting % of
Number 15 36
times FLUIDS patients times SOLIDS patients
Time to first morphine (hrs) 5.29 8.9
(hr) (n=71) (hr) (n=72)
Mean morphine dose (mg) 65.4 30
2 - 4 5.6 6 - 12 15.3
No morphine required 1 (6.6%) 11 (30.6%)
4 - 6 15.5 12 - 18 66.7
Mean codeine dose (mg) 123 119
6 - 8 14.1 18 - 24 16.7

8 - 10 8.5 over 24 1.4
Time to mobilisation (hrs) 21.17 15.21
over 10 56.3    
Time to catheter removal (hrs) 20.3 16.6

Discussion: There are no fasting recommendations specific to
Pruritus 8 (53.3%) 24 (66.7%)
elective caesarean sections but the standard surgical
- requiring treatment - 0 (0%) - 8 (22.2%)
guidelines of 6 hours for solids and 2 hours for clear fluids are
Nausea 5 (33%) 13 (36.1%)
usually applied. Periods longer than 12 hours without fluid
- requiring treatment - 3 (20%) - 7 (19.4%)
have correlated with significant dehydration
in patients having elective caesarean sections2. There is also
Discussion: Our results replicate previous work demonstrating
some evidence to suggest that gastric fluid volume is
a reduction in immediate post-operative analgesia
increased with prolonged starvation in the pregnant patient3.
requirements following a switch from fentanyl to diamorphine,
Over fifty per cent of our patients went without fluids for
but an associated increase in side effects requiring
longer than ten hours prior to surgery, and almost eighty-five
intervention. There was also a reduction in times to first
per cent of patients went without food for greater than 12
mobilisation and catheter removal, which is worth closer
hours. Our results show that there is a need to introduce
inspection. It is likely to be multi-factorial: the patients having
methods to reduce fasting times. These could include pre-
superior analgesia and feeling ready to move sooner, but also
operative letters with individualised times to stop eating and
the proforma for the ward indicating the patient had received
drinking. Also patients lower down the surgical list could be
diamorphine. This required the anaesthetist to specify a time
actively encouraged to consume clear fluids, or even
after which she would be ready to mobilise, which might have
carbohydrate drinks as used in many Enhanced Recovery
improved motivation amongst the midwives and mothers to
programmes.
achieve mobilisation.

References
References
1. Aguilar-Nascimento JE, Dock-Nascimento DB. Reducing
preoperative fasting time: A trend based on evidence. World J 1. NICE clinical guideline 132: Caesarean section
Gastrintest Surg. 2010 March 27;2(3): 57-60 2. Wrench IJ, Sanghera S, Pinder A et al, Dose response to intrathecal
2. Mackenzie M, Yentis S, Woolnough M and Johnson M. Fasting diamorphine for elective caesarean section and compliance with a
periods and dehydration before elective caesarean section. national audit standard, Int J Obstet Anesth. 2007;16(1):17-21
Anaesthesia, 2010 Vol 65:99 3. Sibilla C, Albertazzi P, Zatelli R, et al, Perioperative analgesia for
3. Maltby JR, Sutherland AD, Sale JP, Shaffer EA. Preoperative oral caesarean section: Comparison of intrathecal morphine and
fluids: is a five hour fast justified prior to elective surgery?. Anesth fentanyl alone or in combination, Int J Obstet Anesth. 1997; 6(1):
Analg. 1986 Nov;65(11):1112-6 43-48
P8 Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin)
P115 An evaluation of obstetric critical care admissions in a P116 An evaluation of standards of informed consent and
district general hospital documentation for labour epidural analgesia
VL Williams,  M Greene,  D Saul   S Chaudhari,  N Smith,  P Prasad  
Department of Anaesthesia, Leighton Hospital, Crewe, Anaesthetic Department, George Eliot Hospital, Nuneaton,
Cheshire, UK Nuneaton, UK
Introduction: CMACE has provided doctors with excellent
Introduction : It is both medico legally and ethically important
data over the past 50 years about maternal mortality, but
that the patient is made aware of the nature and risks
unfortunately no data about maternal morbidity. In December
associated with a labour epidural. No national standardised
2013, the Intensive Care National Audit & Research Centre
information card for informed consent is available, although
(ICNARC) produced a second report that analysed critical care
the OAA does publish a epidural information card1 with
admissions of women who were pregnant or recently pregnant
specific risks and incidence rates. At our hospital, the
in 2009-2012 inclusive.1 A comparison was made between the
documentation is made on part of the epidural chart as an
hospital ICNARC data and the national ICNARC data.
open entry. Our study looked to ascertain whether appropriate
Methods: Data were collected from the hospitals ICNARC
details of the epidural and informed consent were made. This
database over a four year period from 2009 to 2012. The data
was with a view to find whether a total redesign of the epidural
was analysed from the categories in the table below.
chart (at a level of standard suggested by the OAA website2)
Results: Data from 388 patients were evaluated.
was needed to improve our practice.
  Hospital ICNARC
Methods : We evaluated a total of 100 completed epidural
Total no. of patients admitted, female 16-50 years 388 55,791
charts over a 4-month period in mid-2012 at our obstetric unit.
Currently pregnant 3.6% 2.1%
The epidural notes were retrospectively analysed on our
Recently pregnant 9.3% 10.0%
scanned patient electronic notes. Documentation was
Obstetric reason for admission - currently pregnant 0% 8.7%
analysed for: details of the patient, anaesthetist and patient
Non-obstetric reason for admission - currently
100% 91.3% assessment, explanation of the risks and incidence given,
pregnant
details of the epidural technique and post epidural
Obstetric reason for admission - recently pregnant 50% 69.7%
management. Our main focus was on standards of consent.
Non-obstetric reason for admission - recently
50% 30.3% Results:
pregnant
%of patients Rate of risk
Discussion: The proportions of patients admitted to the Range of risk discussed
Risk discussed informed documented (no.
critical care area were comparable with the ICNARC report. (no. in total)
(n=100) in total)
The leading indication for admission in the currently pregnant
1in100:13,1in200:8
group was for sepsis. This corresponds with the ICNARC Headache 69 25
<1%:3,1in500:1
report and most recent CMACE report in which sepsis was the
Hypotension 45
leading direct cause of maternal death.2
Failure 59 4 1in8:2, 1in4000:2
The leading obstetric cause for currently pregnant admissions
Nerve 1in13k:21,1in10k:8
nationally, was for pre-eclampsia. However, there were no 65 31
damage 1in15k:1, 1 in19k:1
admissions in this category at the hospital. This is most likely
Itching 14    
because pre-eclampsia is diagnosed and treated effectively on
Infection 37  
the labour ward and rarely needs input from critical care.
Motor block 28    
In the recently pregnant group, there were equal proportions
Urinary
of patients admitted for obstetric and non-obstetric reasons, 28    
retention
this is quite different from the ICNARC report. The leading
indication for admission of recently pregnant patients in the The other areas of documentation studied showed an
ICNARC report was for post partum haemorrhage, by a long acceptable standard.
way. When looking at the hospital database, it showed that in Discussion : Several studies have looked at standards of
the period 2010-12, only 3 of 42 patients with a significant post informed consent in UK practice3and which risks and
partum haemorrhage of 2.5 litres or more were admitted to incidences were discussed and the range of risk quoted. Our
critical care. Therefore the question needs to be asked as to study showed rates generally to be slightly lower than that
whether these patients should have been admitted to the quoted in these studies. This is likely due to limited space and
critical care area? The hospital does not have an obstetric open entry nature of our current chart. The OAA has set
HDU, but in hospitals that do have an obstetric HDU facility, guidelines and advice for both epidural charts2 and risks and
these patients would certainly have been admitted there, had incidence1. Following this evaluation, a full redesign of our
closer monitoring and possibly goal directed therapy. All of epidural charts with prompts and guidance of risks and
these patients survived, but could admission to critical care incidence is warranted. In addition, the OAA had
have improved patient outcomes or reduced hospital stay? overwhelming support for a national standardised information
References card that could be implemented3.
1. Female admissions to adult, general critical care units in England,
Wales and Northern Ireland reported as 'currently pregnant'
References
or 'recently pregnant'. http://www.icnarc.org/documents/Obstetric%
20admissions%20to%20critical%20care%202009-2012.pdf 1. OAA epidural information card : http://www.oaa-
anaes.ac.uk/content.asp?ContentID=185
2. The eighth report on confidential enquiries into maternal deaths in
the United Kingdom. BJOG 2011, 118(Suppl 2):1-203 2. OAA epidural charts : http://www.oaa-anaes.ac.uk/content.asp?
ContentID=522
3. Informed consent for epidural analgesia in labour: A survey of UK
practice: Anaesthesia 2009, 64 p161-164
Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin) P9
P117 An unusual cause of post-partum sepsis P118 Anaesthetic management of a parturient with severe
F A Corcoran,  C Brennan,  A J Downs   systemic scleroderma
Anaesthetics, Dudley Group NHS Foundation Trust, Dudley, P Thomas,  A Varvinskiy,  M Human  
UK Anaesthetics, South Devon Healthcare NHS Foundation
Introduction: Leiomyomas are common in women of Trust, Torquay, UK
reproductive age and have been linked to spontaneous Introduction: Scleroderma is a chronic systemic autoimmune
abortion, retention of the placenta and post-partum disease. Successful pregnancy in patients with severe
haemorrhage.1 It is however rare for them to be the primary systemic scleroderma is very rare. We report the anaesthetic
cause of post-partum sepsis. We describe the case of a post management of such a case in a patient with a difficult airway,
partum patient presenting with painful fibroids and sepsis. severe pulmonary dysfunction and oesophageal dysmotility.
Case report: A 37 year old woman (P1), 5 days post partum Case report: A 29 year old woman (G1P0) with severe
presented with a history of fever, abdominal pain and systemic scleroderma presented to the hospital at 36 weeks
distention. She had a past medical history of fibroids but there gestation with dyspnoea and tachypnoea. Prior to pregnancy
had been no problems during pregnancy. She had an her exercise tolerance was poor, managing just 400 metres in a
uneventful labour with a normal vaginal delivery. On initial six minute walk test with resultant oxygen saturations of 72%.
assessment she was apyrexial with normal observations. She Her Forced Expiratory Volume (FEV1), Forced Vital Capacity
had mild tenderness on palpation of her abdomen. She was on (FVC) and Diffusing Capacity for Carbon Dioxide (DLCO) had
regular analgesics and had been commenced on oral each worsened steadily by five percent year on year over the
antibiotics by her GP. An ultrasound scan (USS) was booked last decade. The most recently measured values from 2007
to investigate the abdominal pain. Within 4 hours she had were FEV1 30%, FVC 28% and DLCO 24% of predicted values
deteriorated and developed a pyrexia, tachycardia, tachypnoea although the patient reported that her pulmonary function had
and decreased oxygen saturations. Initial impression was deteriorated significantly during pregnancy. On admission the
sepsis secondary to retained products so blood cultures and patient was breathless at rest with a p02 of 7.63 on room air
swabs were taken and intravenous antibiotics, oxygen and and it was felt that natural labour would not be possible due to
fluid resuscitation commenced. She was transferred to the poor physiological reserve. Severe reflux secondary to
Maternity High Dependency Unit. CRP was elevated but oesophageal dysmotility rendered her unable to recline more
lactate was normal. She improved over 6 hours but than 45 degrees and she could therefore not lie flat for awake
deteriorated again. Antibiotic coverage was amended caesarean section. Airway assessment revealed microstomia of
following microbiology advice but she continued to have a less than one centimetre, mallampati four, bucked teeth, sub
swinging pyrexia. USS detailed a bulky uterus with a large mental skin scleroderma and a narrow hooked nose with small
fibroid at the fundus and no retained products. 36 hours after nostrils. Oral intubation was therefore ruled out. Awake Fibre
admission she developed peritonitis and a CT abdomen which Optic Intubation (AFOI) appeared technically challenging due
suggested findings of a pedunculated fibroid measuring to nasal anatomy. Preoperative, bedside nasendoscopy
17.5cm that might have twisted on its pedicle. She had an revealed that AFOI would be possible should the need to
emergency laparotomy which revealed a degenerative, secure the airway arise mid operation. This avoided the need
necrotic, infected fibroid. She required ionotropic support and to perform an AFOI or awake tracheostomy pre-operatively.
was difficult to ventilate intra-operatively. Post-operatively The patient was positioned at 45 degrees on the operating
she was transferred to intensive care where she was sedated table. Surgeons confirmed that they could operate in this
and ventilated overnight. She was successfully extubated the position. A low dose spinal followed by an epidural which was
following morning and continued with intravenous antibiotics topped up gradually over 30 minutes using small incremental
and analgesia. She made a full recovery. Histology confirmed boluses achieved adequate block without compromising
the fibroid had extensive areas of coagulative necrosis, respiratory function. Surgery was completed without issue and
hyalinisation and inflammation. All microbiological both mother and baby did well post-operatively.
investigations were negative. Discussion: There are only three reports in the literature
Discussion: Sepsis in pregnant and post-partum women describing general anaesthesia for caesarean section in
remains a significant cause of maternal morbidity and patients with scleroderma and two using neuraxial blockade.1-5
mortality.2Sepsis is a clinical diagnosis and microbiological Of those who were intubated, one died and another required
investigations may be negative. Early recognition, timely three months ventilation. We demostrated how careful bedside
diagnosis and active treatment assists an optimum outcome. airway assessment and the use of a slow top up epidural were
Fibroids are common in pregnancy but sepsis secondary to successfully used to manage this challenging case.
infected, necrotic fibroid tissue post-partum is very rare. To References
our knowledge there have been no reported cases of this. It is
1. D'Angelo R, Miller R. Pregnancy complicated by severe
therefore essential to consider this in the differential causes of preeclampsia and thrombocytopenia in a patient with scleroderma.
obstetric sepsis when reviewing pregnant women with a Anesth Analg 1997; 85: 839-41
history of fibroids. 2. Hseu SS, Sung CS, Mao CC, Tsai SK, Lee TK. Anesthetic
management in a parturient with progressive systemic sclerosis
References during cesarean section. Acta Anaesthesiol Sing 1997; 35: 161-7
1. Mason T. Red Degeneration of a leiomyoma masquerading as 3. Younker D, Harrison B. Scleroderma and pregnancy. Br J Anaeth
retained products of conception. Journal of the National Medical 1985; 57: 1136-9
Association. 2002; 94: 124-6 4. Thompson J, Conklin KA. Anesthetic management of a pregnant
2. Lucas DN, Robinson PN, Nel MR. Sepsis in obstetrics and the role patient with scleroderma. Anaesthesiology 1983; 59: 69-71
of the anaesthetist. International Journal of Obstetric Anaesthesia. 5. Bailey AR, Wolmarans M, Rhodes S. Spinal anaesthesia for
2012; 21: 56-67 caesarean section in a patient with systemic sclerosis. Anaesth
1999; 54(4): 355-8
P10 Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin)
P119 Anaesthetic management of arrhythmogenic right P120 Anaesthetic management of obese parturients at a
ventricular cardiomyopathy during labour and tertiary centre - meeting the standard?
caesarean section: a case series L Kelliher,  J Teare,  E Evans  
J Eccles,  A Jain,  K Bhatia   Anaesthesia, St George's Healthcare NHS Trust, London, UK
Department of Anaesthesia, St Mary's Hospital, Manchester, Introduction: Obese women are at increased risk of perinatal
UK morbidity and mortality. In 2010 CMACE and RCOG published
Introduction: Arrhythmogenic right ventricular joint guidelines for the management of the obese parturient
cardiomyopathy (ARVC) is mainly a genetically determined including recommendations that patients with a booking BMI
autosomal dominant disease characterised by cardiomyocytes ≥40 should attend an antenatal anaesthetic clinic (AAC) and a
being replaced by fibrofatty tissue in the right ventricle.1 Specialist Trainee year 6 anaesthetist (ST6) or above should
ARVC has an incidence of 1:5000 and may account for as be informed and available to attend labour and operative
many as 5% of unexpected sudden deaths. The Eighth Report delivery1. Our unit is a tertiary centre with over 5,000
of the Confidential Enquiries into Maternal Deaths in the deliveries/year. A previous audit over 2 years showed that of
United Kingdom (2006-2008) highlighted that ARVC was the 120 women with BMI ≥40 attending our AAC, 76% required a
underlying cause in two of the 53 reported cardiac deaths. We peripartum anaesthetic intervention, with only 34% of these
describe the anaesthetic management of two parturients with performed by an anaesthetist ≥ST62. Awareness of the
ARVC who presented at our tertiary centre. guidelines was raised and anaesthetic plans for these women
Case reports: The maternal demographics, the cardiac signs, now state care should be managed by a senior anaesthetist.
symptoms and interventions along with the anaesthetic We examined our obese population following these changes.
management in the peri-partum period are briefly summarised Methods: A retrospective analysis over 1 year (2011-12) of
in the table below. hospital records for patients with a booking BMI ≥ 40. Records
were examined for referral and attendance at AAC, anaesthetic
Category Case 1 Case 2
intervention (regional/GA), grade of anaesthetist and
Age 27 23
anaesthetic complication (difficult/impossible regional, dural
BMI 25.8 27.2
tap, other).
Parity 0 0
Family history None Sudden death Results: In total there were 74 women with a booking BMI
Cardiac signs and Palpitations with spurts of Paroxysmal VT ≥40. 73% were referred to AAC, only 58% attended. Out of all
symptoms ventricular tachycardia (VT) patients, 69% had a peripartum anaesthetic intervention, 43%
Cardiac Cardiac ablation therapy and ICD insertion of which were performed by an anaesthetist ≥ST6 with a
intervention prior implantable cardioverter complication rate of 16%. Of those attending AAC, 67% had
to pregnancy defibrillator (ICD) insertion an anaesthetic intervention, 41% of which were performed by a
Mode of delivery Elective caesarean section Urgent LSCS for ≥ST6 with a complication rate of 17%. Of those patients not
(LSCS) for breech foetal distress attending AAC, 71% had an anaesthetic intervention and 36%
Anaesthesia and General anaesthesia, with Labour epidural of these were performed by ≥ST6 with a complication rate of
analgesia bilateral transversus analgesia, followed by 14%.
abdominal plane blocks top up for LSCS
Table 1. Incidence of complications by grade of anaesthetist
Maternal length of Three days Four days
stay Group ≥ST6 <ST6 p value (Fisher's Exact)
Neonatal APGAR 8 and 10 9 and 10 All 9.1% 20.7% 0.440
scores AAC 16.7% 17.6% 0.945
Discussion: The main implications of ARVC in parturients No AAC 0% 21.4% 0.273
include fatal arrhythmias, heart failure worsened by Discussion: This audit shows a significant number of obese
physiological changes of pregnancy and sudden adult death parturients were not seen in our AAC. A proportion of these
syndrome.1 Both our patients had VT diagnosed after 24 hour were referred, but did not attend however 27% were not
Holter monitoring, and an ICD was implanted in addition to referred. Despite this, there was no significant difference in the
beta blocker medical therapy to control the symptoms of VT as requirement for anaesthetic intervention or the incidence of
well as to prevent sudden death. The patients were seen in the anaesthesia-related complications between attenders and non-
joint cardiac, obstetric and anaesthesia antenatal clinic and a attenders. The incidence of senior anaesthetic involvement in
peri-partum plan formulated to facilitate safe delivery. Both care has risen from 34% to 41% but there is still room for
had serial echocardiograms, serum electrolytes monitored, improvement. This highlights the resource difficulties faced in
invasive blood pressure monitoring and ICD deactivated providing 24 hour senior anaesthetic cover. The on-call rota at
during their LSCS. Our case series highlights that both general our unit is staffed by junior and senior anaesthetists. The
and regional anaesthesia can be safely provided and we absence of a senior anaesthetist did not lead to a significant
recommend a multidisciplinary approach with close co- rise in anaesthesia-related complications, although there was a
operation between anaesthetists, cardiologists and t rend toward this (Table 1).
obstetricians to provide optimum care of these patients. References
Reference 1. Centre for Maternal and Child Enquiries & Royal College of
Obstetricians and Gynaecologists Joint Guideline. Management of
1. Alexoudis AK, Spyridonidou AG, Vogiatzaki TD, Iatrou CA.
Anaesthetic implications of arrhythmogenic right ventricular women with obesity in pregnancy. London: CMACE & RCOG; 2010
dysplasia/cardiomyopathy. Anaesthesia 2009; 64: 73-8. 2. Fulton L, Evans E, Schroeder F, Wendler R. Antenatal anaesthetic
assessment of morbidly obese women - a useful resource? 2013,
http://epostersonline.s3.amazonaws.com/oaa2013/oaa2013.0690195
.NORMAL.pdf
Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin) P11
P121 Anaesthetic management of the labouring patient with P122 Anesthetic implications  of heart disease in pregnancy
multiple sclerosis S Francés,  S Manrique,  M Goya,  M García,  R Perera,  N
J Li Wan Po,  K Maclennan   Montferrer  
Anaesthesia, St Mary's Hospital, Manchester, UK Anaesthetics, Vall d'Hebron University Hospital, Barcelona,
Introduction: Multiple Sclerosis (MS), an autoimmune Spain
inflammatory disease affecting the central nervous system, is Introduction: Despite advances in its diagnosis and treatment,
estimated to affect 20,000 or more UK women of childbearing heart disease (HD) in pregnancy remains a major cause of non-
age1. Controversy exists regarding the management of obstetric maternal and neonatal mortality and morbidity (it
anaesthesia and analgesia in labouring parturients with MS. complicates around 1-3% of pregnancies in developed
Following analysis of our practice at St Mary's Hospital, a countries). Accurate multidisciplinary assessment and
tertiary referral obstetric unit with over 8500 deliveries per management of individual maternal and fetal risks in pregnant
annum, and recent evidence in the literature; our women with HD provides the best opportunity to substantially
recommendations for the peri-partum management of improve outcomes for mother and baby. (1).
parturients with MS are presented. Methods: We present a prospective cohort study that
Methods: Interrogation of the St Mary's Hospital antenatal analyzed outcomes in women with HD, the majority of whom
clinic database, from 1999 to 2012, identified 21 pregnant had had corrective surgery and delivery between 2007 and
women diagnosed with MS. We reviewed antenatal advice, 2013. Baseline characteristics and adverse events during
intrapartum management and postpartum complications. delivery and postpartum were assessed. Intensive monitoring
Results: Over 50% of patients were nulliparous. The majority of the delivery and postpartum were planned beforehand in all
had mild sensory or motor deficit. Three relapsed during cases.
pregnancy, one improved in symptoms and one relapsed Results: One hundred and seventy-four patients with 179
postpartum. There were twelve normal vaginal deliveries, two pregnancies were included in the study. 127 women (72,98%)
instrumental deliveries, six Caesarean sections and one presented congenital heart disease (CHD), 47 acquired heart
unspecified delivered at another hospital. Five women opted disease (27,02%): 27 acquired rheumatic valve disease
for epidural analgesia, two were topped up for operative (19,98%), one Marfan syndrome (0,54%), 3 coronary heart
delivery. Five had spinal anaesthesia with 0.5% heavy disease (1,6%) and 9 primary myocardial disease (4,9%).
bupivacaine and one had a general anaesthetic. There were no
Pregnancy complications were presented in 21, 2% of CHD,
complications following regional technique.
14,8% of acquired rheumatic valve disease and 100% of
Discussion: A recent national survey reported that within a 10 women with arrhythmias.
year period, 91% of anaesthetists have encountered <ten
The type of delivery was vaginal in 124 women ( 72,1%) and
cases of MS2 and have little experience in their management
cesarean section in 50 women (27,9%).
during pregnancy. Recent evidence available supports our
168 women had analgesia during delivery (93,8%); 5 women,
current management of MS patients undergoing labour. The
general anesthesia (2,79%), 6 women, local anesthesia (3,35%)
low incidence of the disease makes it difficult to attain
and 87,5% of women had regional analgesia.
significant figures to determine the optimal management plan.
To standardize care, we made the following recommendations Delivery complications were 7% (uterine atony 2,7%, vaginal
based on the latest evidence and our own experience: hematoma 2,2%, chorioamnionitis 0,5%, cesarean hematoma
- Patients to be reviewed in an antenatal anaesthetic clinic. 0,5% and hemoperitoneum 0,5%). The only anesthesia
Document disease severity and discuss analgesia and complication was one dural puncture (0.5%). No maternal
anaesthetic options. death, one fetal death (0.5%) and one neonatal death (0.5%).
The maternal average hospital stay was 3 days.
- Use of 0.1% bupivacaine with 2mcg/ml fentanyl mixture for
epidural labour analgesia2 . For an operative intervention, top Discussion: Pregnancy and delivery are associated with
up with a higher concentration of local anaesthetic. substantial physiological changes, which require the
adaptation of the cardiovascular system and can expose
- Regional rather than general anaesthetic for caesarean
women with HD to significant risks. If regional anesthesia is
sections. Spinal anaesthesia is the most simple and reliable
selected, the addition of an opioid, when dosing any neuraxial
technique although consider combined spinal-epidural on an
anesthetic, will reduce the amount of local anesthetic required
individual basis.
and subsequent hemodynamic effects, while improve
- If a general anaesthetic is necessary, avoid suxamethonium
intraoperative and postoperative analgesia. The avoidance of
and monitor neuromuscular block to titrate dose of non-
epinephrine from the epidural dose will eliminate the possible
depolarizing muscle relaxant3.
deleterious effects of systemic epinephrine. Maintaining
These recommendations will be available for clinicians on the uterine blood flow is important for fetal well-being.
trust intranet and a patient information leaflet on the effects of Maintaining systemic vascular resistance in patients with
pregnancy and anaesthesia on MS has been produced. intravascular shunting, is important to avoid inducing or
exacerbating pre-existing cyanosis due to increased right- to –
References
left shunting. Cautious intravenous hydration and gentle
1. Brookings W, Lee M. Management of multiple sclerosis during
titration of phenylephrine or ephedrine are options to
pregnancy. Prog Neurol Psychiatry. 2009; 3(6): 9-11
counteract the hemodynamic effects of surgical neuraxial block
2. Drake E, Drake M, Bird J, Russell R. Obstetric regional blocks for
women with multiple sclerosis: a survey of UK experience. Int J (1,2). We observed a predominance of neuraxial anaesthetic
Obstet Anaesth. 2006; 15(2): 115-23 techniques, increased caesarean and operative delivery rates,
3. Griffiths S, Durbridge JA. Anaesthetic implications of neurological and favourable maternal and neonatal outcomes.
disease in pregnancy. Contin Educ Anaesth Crit Care Pain. 2011; 11
(5): 157-61 References
P12 Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin)
P123 Angle of tilt achieved with automated operating table P124 Antenatal anaesthetic information given to women
in elective caesarean sections: a comparison with tilt with obesity
achieved with an inflatable balloon wedge  C R Thomas,  C Busby  
PN Nair,  L Dyal,  B Grewal,  I Suri   Anaesthetics, Airedale General Hospital, Keighley, UK
Department of Anaesthesia, Warwick Hospital, Warwick, UK Introduction:Antenatal obesity is defined as a BMI of ≥30at
Introduction: A previous study1 done on patients undergoing booking. Its prevalence in England increased from 7% in 1990
elective caesarean sections looked into measuring the angle of to 16% in 2007.1Women with a BMI ≥40 are often provided
tilt of the operating table with an inflatable balloon wedge. with anaesthetic information antenatally. Those with lower
This showed that the visual estimation of angle proved levels of obesity also have an increased anaesthetic risk but
accurate in the achievement of near 150 tilt. Here we present these women may receive little or no information about this
the results of a similar study using a different technique of during pregnancy. 2The RCoA have produced standards
automated table tilt instead of the inflatable balloon wedge regarding care for these women: 90% of patients with a
device. The premise being is our visual actuation of tilt angle booking BMI ≥ 30 should receive a leaflet containing
accurate. information about anaesthesia and analgesia. 90% of patients
Methods: The study was similar to the previous one. We with a booking BMI ≥40 should have an anaesthetic consult.
prospectively selected 26 patients at random who were Booking BMI should be documented in 100% of maternity
undergoing elective lower segment caesarean section under hand-held notes. An audit of the above standards was carried
spinal anaesthesia over a six week period. Ethical committee out as summarised below.
approval was obtained. Verbal consent was obtained from all Methods:A list of all deliveries in January 2013 was generated.
participants and the booking Body Mass Index (BMI) was Notes were reviewed for adherance to the above three
noted. We used the same protractor device for measuring the standards. Change to practice was recommended based on
angle of tilt. This is similar to the one used by Kinsella et al2. audit findings. Following the implementation of change, the
Results: The measured angles ranged from 10 to 18 degrees, a audit cycle was completed by auditing notes of all deliveries in
mean angle of 13.70 with a mean difference of -1.3 and standard November 2013.
deviation of 2.32. This compared very closely to the angles Results:
between 10 to 17.5 degrees, mean angle of 13.650, mean Table: Recording of booking BMI, patient count by raised
difference of -1.35 and a standard deviation of 2.06 in the BMI category and number given anaesthetic information.
previous study. BMIs ranged from 19 to 37 with a mean of 24.
Discussion: The visual estimation of angle using the
BMI 30 - BMI 35 - BMI
automated table tilt proved accurate in achieving the near 150 No
Number of Unavailable 34.9; 39.9; ≥40; 
tilt and is comparable with that obtained with the inflatable   booking
deliveries casenotes info info info
balloon wedge device in the previous study. The standard BMI
given given given
deviation of 2.32 indicates that 95.4% of cases could achieve
Jan 195 6 2 20; 0 7; 1 7; 7
within 4.60 of the required 150 tilt i.e. 10.4 to 19.6 degrees tilt.
Nov 173 3 2 17; 2 7; 7 3; 3
The automated table tilt provides an easy and accurate means
of providing left lateral tilt in pregnant patients. Discussion: Booking BMI was recorded in 99% of the notes in
both audit cycles. In 100% of cases where BMI was ≥40, a
consultant anaesthetist discussed risk and made a plan with
References
the patient. However, the audit of January deliveries indicates
1. Grewal B, Suri I. Is visual actuation a valid predictor of angle of tilt?
that few women who have a BMI 30-39.9 receive anaesthetic
Int J Obstet Anaesth Vol 18 2009; pS1-64- supplement
information.; this occurred in only one case. Reaching this
2. Kinsella SM. A device for measuring the degree of lateral pelvic tilt
during supine recumbency. Anesth Analg 1995; 80: 204-5 population to provide information is difficult especially where
BMI is 30-34.9 as all antenatal care for this group may be
provided by community midwives. In collaboration with
Obstetrics, a patient information leaflet was written which
included both obstetric and anaesthetic information. The
leaflet was approved by the Women's Integrated Governance
group and has been in use since October 2013. It is available
on the Trust intranet which is accessible by some community
midwives. The leaflet is given to all those with a BMI ≥ 35
when they attend obstetric high risk clinic. The results of the
November audit indicate improvement has been made; 44.4%
of those with obesity now receive anaesthetic information.
Greater access to the leaflet is needed however.
References
1. Royal College of Anaesthetists 2012,
http://www.rcoa.ac.uk/document-store/audit-recipe-book-3rd-edition-
2012
2. Centre for Maternal and Child Enquiries 2010, http://www.oaa-
anaes.ac.uk/assets/_managed/editor/
File/CMACE/CMACE_Obesity_Report_2010_Final%20for%
20printing.pdf
Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin) P13
P125 Antenatal management of morbidly obese parturients: P126 Audit of temperature for patients undergoing elective
A multicentre evaluation. caesarean section
H Aladin,  A Khandhia,  K Pottinger   N J Truman,  I Clegg,  K Maclennan  
Anaesthetics, Good Hope Hospital, Birmingham, UK anaethetics, St Mary's Womens Hospital, Manchester, UK
Introduction: Women with a body mass index (BMI) of ≥30 Introduction: Perioperative Hypothermia is associated with
kg/m2 at the time of antenatal booking are classed as being poor outcomes and adverse events for patients; including
obese in pregnancy, accounting for around 39,000 maternities surgical site infection increased length of stay, blood loss,
per year1. Obesity is associated with increased risk of shivering, increased anaesthetic recovery time and cardiac
anaesthetic morbidity and mortality. National guidance have events. Risk factors for the occurrence of hypothermia include
been developed following the Confidential Enquiry into regional anaesthesia, fluid deprivation, blood loss, and cold
Maternal and Child Health report concerning obesity in fluid administration, all of which are common to obstetric
pregnancy. At two different hospitals, five indicators of best patients. 2008 Nice guidelines CG651 on perioperative
practice2 were analysed: (1) Recording of maternal BMI. (2) hypothermia do not include parturients, despite being an at
BMI ≥ 30 women receive information about risk group. An audit performed in 2011 at St Mary's Hospital
anaesthesia/analgesia. (3) Women with a BMI ≥ 40 have demonstrated that 92.5% of elective section patients were not
antenatal anaesthetic review. (4) Duty anaesthetist should be 'comfortably warm' on arrival in recovery, with 65% defined as
informed when women with a BMI ≥ 40 are admitted. (5) hypothermic. A repeat audit was performed following
Anaesthesia for women with a BMI ≥ 40 should be provided commencement of a trial of an air free conductive fabric patient
by a senior anaesthetist. warming system (Hot Dog®).

Methods: Women who had undergone a lower segment Method: A prospective audit of elective caesarean section
caesarean section (LSCS) during a 6 month period (Jan 2013- patients was conducted from April-June 2013 at St Mary's
Jun 2013) at a District General Hospital (DGH) and a Hospital. Theatre staff completed the audit proforma. Data
Foundation Hospital (FH) were evaluated. Data was collected collected included; ambient theatre temperature (ideal target
retrospectively from an electronic data archive and anaesthetic 21ºC), anaesthetic type, estimated blood loss (EBL),
charts. Evidence of BMI calculations, provision of temperature pre, intra, post operative and prior to discharge
anaesthesia/analgesia information, ante-natal anaesthetic from recovery (measured using a tympanic membrane
appointments, and anaesthetic care in the labour ward and thermometer) and details of which Hot Dog® warming
theatre were identified. products were used. Hypothermia was defined as a core
Results: 309 women who underwent a LSCS were identified temperature <36ºC with desirable temperature being defined as
with a having a BMI 30 (median 34, range 30-59). 51% of 36.5-37.5ºC. Comparison of the results from the 2011 audit
these were elective cases. 56% of women with a BMI ≥30 enabled conclusions to be drawn regarding the effectiveness
received anaesthesia/analgesia information, of which 2 were of the warming product.

given literature on anaesthesia in obesity. 32% of women with
Results: A total of 33 patients were audited who underwent
a BMI 40 underwent an antenatal anaesthetic review, with an
elective caesarean section, [n=79, 2011audit], 94% had spinal
additional 4 women failing to attend their appointments. In
anaesthetic (87%, 2011 audit). Mean (S.D) theatre temp was
those women with a BMI ≥40, the duty anaesthetist was
22.8 (± 0.6) [22.3 (± 0.6), 2011 audit], mean duration of
informed of admission in 19% of cases and in 56% of LSCS,
procedure was 51 minutes. 94% of patients had an additional
the anaesthetic care was provided by an appropriately graded
fluid warmer intra-op (72%, 2011 audit). The mean EBL was 574
anaesthetist .
ml (± 213) [653 (± 431), 2011 audit] and only 6% of patients had
Table: Women with BMI 30 having anaesthetic care at a DGH an EBL over 1L (20% 2011 audit). Only 12% (n=4 of 33) of
and FH. patients warmed with the HotDog® were hypothermic on
arrival to recovery (compared to 65% (n=51 of 79), 2011 audit)
  DGH FH
figure 1.
Total LSCS 32% (99/309) 68% (210/309)
Discussion: efforts have been to reduce perioperative
BMI Median (range) 33 (30-59) 34 (30-52)
hypothermia in elective caesarean sections. Almost all patients
Maternal height, weight + BMI recorded 100% 100%
received warmed fluids via a 3M™ Ranger™ fluid warming
Conclusion: This audit has identified that more than half the
system. Forced air warming devices applied to the upper body
women with a BMI ≥30 received analgesia/anaesthesia
are not well tolerated by our awake patient population and
information and more than half were anaesthetised by a senior
allow only a limited area to be heated. introduction of
anaesthetist. However, in all the areas of practice, the target
HotDog® with an under patient warming mattress and
percentage of women meeting the identified standards were
separate over patient warming blanket (for upper and lower
not achieved. Recommendations included revision of the
limb) proved to be of benefit in perioperative maintenance
referral guidelines for antenatal anaesthetic assessment,
when compared to our standard warming measures. A
improved communication within the multidisciplinary team
HotDog® warming mattress placed on the patient chair in the
during admissions and increased presence of senior
pre theatre waiting area helped prevent hypothermia pre arrival
anaesthetists on delivery suite.
in theatre.
References
Reference
1. Centre for Maternal and Child Enquiries (CMACE). Maternal
1. CG 65 Management of inadvertent perioperative hypothermia in
obesity in the UK: Findings from a national project. London:
adults. NICE April 2008.
CMACE, 2010
2. The Royal College of Anaesthetists. Raising the Standard. A
compendium of audit recipes for continuous quality improvement in
anaesthesia. 3rd Edition 2012
P14 Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin)
P127 Availability of chlorhexidine handwash for regional P128 Caesarean section in a rhesus null parturient with a
analgesia on the labour ward uterine fibroid
K Chima,  T Strickland,  F Plaat   P J Stewart,  R Laird,  J Cartmill  
Anaesthetics , Queen Charlotte's and Chelsea Hospital, Anaesthetics, Altnagelvin Area Hospital, Londonderry, UK
London, UK Introduction: The anaesthetic management of a Caesarean
Introduction: Many patients request regional analgesia during section is made more challenging by the combination of pre-
labour and therefore central neuraxial blocks are performed in operative anaemia, a large uterine fibroid and the presence of a
the delivery room. For central neuraxial blocks an aseptic very rare blood group Rhesus null.
technique should be standard. In the Third National Audit Case report: A forty-year lady with a past medical history of
Project of the Royal College of Anaesthetists the incidence of psoriatic arthritis presented to antenatal booking at 10 weeks
iatrogenic infection was reported as being 8/707 000 gestation. Booking investigations revealed a haemoglobin of
procedures1. However the consequence of any infection is 10.3g/dL, and a blood group O Rhesus null. Her 20-week
potentially devastating, and a 'scrupulous' aseptic technique ultrasound scan revealed no foetal anomalies but did
was therefore stated to be mandatory in the report1. demonstrate an anterior uterine fibroid. This was confirmed
Chlorhexidene gluconate 4% is used for hand decontamination with magnetic resonance imaging which showed a
in our department. It was noticed that not all delivery rooms heterogeneous mass measuring 188x139x159mm, in keeping
were equipped with both chlorhexidene and a hands free with a degenerating fibroid. At 21+3 days she presented with
method for application. dizziness and right upper quadrant pain. Her haemoglobin
Methods: All delivery rooms on labour ward were inspected to level was 7.6g/dL and she was treated for iron deficiency
ascertain the presence of chlorhexidene and a hands free anaemia. Due to a transverse lie and the large fibroid an
dispenser. elective Caesarean section at 38 weeks was planned. As a team
we anticipated a difficult Caesarean delivery with greater blood
The audit was repeated after one and twelve months to assess
loss in a patient with anaemia and a very rare blood group.
if there had been any improvement in the service.
Antenatal management focused on maximising the patient's
Results: Originally, 12 of the 16 delivery rooms had
haemoglobin levels and sourcing compatible blood. The
chlorhexidene available (75%). Of the 12 rooms with
Northern Ireland blood transfusion service and National frozen
chlorhexidene only three were equipped with a hands free
red cell bank in Liverpool secured two units of packed red cells
dispenser (25%), and five containers were uncovered (42%).
in England. Unfortunately, one week prior to the section this
After one month all 16 rooms were equipped with wall blood was issued in an emergency, making it unavailable to us.
mounted chlorhexidene with a hands free dispenser (100%). A new donor was found in South Africa and a further unit was
After a further 12 months it was found that 12 of the 14 secured in Brazil. Both units were couriered to our hospital
delivery rooms had chlorhexidene available (86%). (Two of the prior to the Caesarean delivery which was performed at 38+6
rooms had been converted to a post delivery high dependency days under spinal anaesthesia. Pre-operative haemoglobin was
unit). Eleven of the 12 containers were equipped with a hands 9.1g/dL. The patient was discharged home on day three post-
free dispenser (92%). operatively and her haemoglobin was 7.2g/dl on discharge. No
Discussion: The results of the initial data collected, as well as blood transfusion was required.
anaesthetists' concerns regarding the unavailability of Discussion: Red blood cells from people who have the Rhesus
chlorhexidine and dispensers in each room, was reported to null phenotype lack Rhesus proteins, and thus, Rhesus
managerial staff, who ensured all rooms were adequately antigens. This phenotype occurs in approximately 1 in 6x106
stocked. Results were therefore better when re-auditing was individuals1. When these patients are transfused they may
performed at one month. However, after 12 months standards form antibodies to high frequency rhesus antigens, which can
had declined, although they were still improved from the make it extremely difficult to process compatible blood. Rhesus
initital audit. This decline could be attributed to the fact that null blood is available from the National frozen cell bank,
neither a team nor a named individual was made responsible however it may not be available when required due to limited
for sustaining the initial improvement, which if introduced, we supplies, as in our case. There is very limited literature
feel would encourage a sense of ownership and enable the regarding the management of the rhesus null parturient and
improvement in this area of patient safety to be sustained. our management was guided by our regional Haematology
Reference unit. This case demonstrates the importance of good
communication with all members of the multi-disciplinary team
1. National Audit of Major Complications of Central Neuraxial Block
in the United Kingdom 2009, http://rcoa.ac.uk/system/files/CSQ- and the detailed preparations required in a complex case.
NAP3-Full_1.pdf
Reference
1. Avent ND, Reid, ME. The Rh blood system: a review. Blood 2000
95: 375-387.
Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin) P15
P129 Category one caesarean sections in a district general P130 Comparison of two non-invasive cardiac output
hospital:  Improving the decision to delivery time monitoring devices in a parturient with complex
VK Wroe,  AM Troy   cardiac disease.
Department of Anaesthesia, Countess of Chester Hospital, PJ Rose,  V Misra,  S Quasim  
Chester, UK Anaesthesia, UHCW, Coventry, UK
Introduction: National Guidelines state that the interval from Introduction: The management of valvular lesions during
decision to delivery (DDI) in a category one caesarean section pregnancy and labour can present a clinical conundrum. We
should be less than 30 minutes1, and that a duty anaesthetist present the use of two cardiac output (CO) monitoring devices
should be immediately available for emergency work on the in a parturient with complex valvular heart disease undergoing
delivery suite 24 hours a day2. a caesarean section under epidural anaesthesia.
A 2008 departmental audit found that 85% of category one Case Report: A 37 year old primiparous woman with history of
sections had a DDI of under 30 minutes, a figure marginally ASD repair aged 4, severe mitral regurgitation, severe tricuspid
under the audit standard of 90%. Anaesthetic service regurgitation, moderate aortic stenosis (AS) secondary to a
provision in our trust was expanded in July 2012, with the congenital bicuspid valve and moderate pulmonary
addition of a dedicated obstetric anaesthetist 24 hours a day. hypertension presented for elective caesarean section.
This re-audit aimed to assess the proportion of category one Echocardiography showed moderately dilated right ventricle
caesarean sections with a DDI <30 minutes and analyse the with good bi-ventricular systolic function, bi-atrial dilatation,
factors contributing to any delay. moderate to severe AS (mean gradient 34mmHg, peak gradient
Methods: After audit department approval, a retrospective 53mmHg, estimated valve area 0.74cm2). Pulmonary artery
analysis of category one caesarean sections between August pressures were estimated at 42-47mmHg. LiDCO rapid and
and December 2012 was performed. Data collected included Cheetah NICOM devices were used to monitor CO.
DDI and reason for delay, indication for section, type of Anaesthesia was established with 32mL 2% lignocaine and 100
anaesthesia and cord pHs. micrograms of epinephrine via epidural. Compound sodium
lactate was infused at 60mL/hr, and increased to 100mL/hr after
Results: 69 category one caesarean sections were analysed.
epidural anaesthesia. Fluid boluses of 200mL and 100mL were
The mean DDI was 23 minutes (range 3-120 minutes). 84% had
delivered via the pump at 13 and 28 minutes after delivery of a
a DDI of under 30 minutes, with a mean time from decision to
live infant. Metaraminol infusion was titrated to effect.
effective anaesthesia of 14.5 minutes. The indication for
Syntocinon infusion was started upon delivery (20 units in
caesarean section was abnormal CTG in 87% of cases (2008:
48mL 0.9% saline) at 15mL/hr and tapered post-operatively
77%). General anaesthesia was performed in 43% (2008: 85%),
over 4 hours. Mean arterial pressure was maintained at 91 to
spinal anaesthesia in 55% (2008: 15%) and extension of
97mmHg until delivery (78 minutes) and then decreased to
epidural blockade in 2%. In 11 cases, DDI was over 30
67mmHg at the end of surgery. Cardiac output was maintained
minutes; these cases were all performed under spinal
throughout surgery with an increase at the time of concurrent
anaesthesia. The following table shows the reasons identified
fall in MAP. Fluid challenge had negligible effect although
that contributed to delay:
there was a small reduction in heart rate (84 to 59bpm).

Arrival in
Discussion: NICE has advocated the use of cardiac output
theatre Incision to
Spinal monitoring in high risk non-obstetric surgery to improve
10 delivery Staff Theatre
  placement outcome.1 In this case we utilised both a non-calibrated pulse-
minutes time 10 unavailable unavailable
10 minutes contour waveform analysis and bioreactance system to
from minutes
compare both values measured and response to fluid
decision
challenge. Although the values produced were different, the
Number
trends were broadly similar. This, once again, highlights the
of 4 6 1 1 1
importance of analysing trends rather than absolute values to
patients
guide management. Interestingly, both devices demonstrated
Arterial cord blood analysis was carried out in 10/11 cases. pH
that a fall in MAP correlated with an increase in cardiac
was less than 7.2 in 30%, and base excess was less than -8 in
output, similar to previous investigators.3 Given that cardiac
20%.
disease is the leading cause of death in the most recent
Conclusion: The proportion of cases with a DDI of over 30 triennialreport2, monitoring cardiac output enables one to
minutes has remained constant at around 15%, despite an maintain physiological homeostasis, and ultimately aids
improvement in anaesthetic staffing. Our results suggest that clinical decision-making leading to good clinical outcome, as in
the causes for this delay are multifactorial, and the results are our case.
not benign- the delay in delivery led to a cord pH of <7.2 in
References
almost one third of cases. We intend to improve our practice
1. MTG3 CardioQ-ODM (oesophageal Doppler monitor): guidance
by regular practice drills, use of preprepared spinal packs to
2011, http://www.nice.org/nicemedia/live/13312/52624/52624.pdf
reduce spinal placement time, clear procedures to follow in the
2. Centre for Maternal and Child Enquires (CMACE). Saving Mothers'
case of staff or theatre unavailability and reaudit. Lives: Reviewing maternal deaths to make motherhood safer: 2006-
2008. The Eighth Report of the Confidential Enquires into
References
Maternal Deaths in the United Kingdom. BJOG 2011;118(Suppl
1. Caesarean section. NICE Clinical Guideline 132. NICE, London 1):1-203
2011. (http://publications.nice.org.uk/caesarean-section-cg-132).
3. Fanning NP, Sermer M, Colman J, Carvalho JC, Cordovani D. Non-
2. OAA/AAGBI guidelines for obstetric anaesthetic services- 3rd invasive Hemodynamic monitoring with bioreactance for cesarean
edition. AAGBI and OAA, London, 2012 delivery. A more relaxed look at tight aortic stenosis? Abstract
(http://www.aagbi.org/publication/publication-guidelines/M/R) SOAP 2011, http://www.soap.org/display_2011_abstract.php?id=58
P16 Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin)
P131 Comparsion of slow and rapid bolus of ephedrine in P132 Continuous spinal anaesthesia for a primigravida with
patients undergoing planned caesarean section under severe tricuspid regurgitation, Harrington rods and
spinal anaestheisa WITHDRAWN FROM  thrombocytopenia.
PRESENTATION AM Walton,  I Mettam  
PG Sekar,  LB Ellakumanan,  H Balachander,  MVS Obstetric Anaesthetic Department, University Hospital
Satyaprakash   Southampton, Southampton, UK
Anaesthesiology, JIPMER, Puducherry, India Introduction: We present the successful use of continuous
spinal anaesthesia (CSA) for caesarean delivery in a parturient
with severe tricuspid regurgitation and pregnancy-induced
thrombocytopenia in addition to Harrington rod placement for
scoliosis spinal surgery.
Case history: A 40 year old primigravida presented at 37
weeks gestation. She had undergone a tricuspid valve repair
previously for endocarditis. The patient had developed severe
tricuspid regurgitation and had heart failure. Harrington rods
were placed in her thoracic and lumbar spine for repair of a
congenital scoliosis. Blood tests revealed a pregnancy related
thrombocytopenia with platelets of 85x109/L. An
echocardiogram showed a severly dilated right atrium with
intra-atrial septal bowing to the left, severe free flowing
regurgitation and right ventricular systolic pressure
32mmHg.The case was discussed with obstetricians,
anaesthetists and cardiologists and a decision was made for
an elective caesarean section under CSA, if the final platelet
count remained stable. The patient expressed a preference to
remain awake and avoid a general anaesthetic. At surgery a
cannula and radial arterial line were inserted. In the sitting
position a 22G spinal needle was inserted below the level of
the scar tissue at L3/4, and a spinal catheter threaded into the
subarachnoid space. A total of 10mg bupivacaine and 250mcg
diamorphine were required over 20 minutes to establish a block
to T4. The blood pressure dropped from 135/70 to 90/50mmHg
and required only 5mcg of epinephrine to return to baseline
values. Blood loss was 720mls. Syntocinon was given as an
infusion only. A live male infant was delivered.
Discussion: An obstetric anaesthetist has to take many
factors into account when deciding on the best choice of
anaesthetic for a particular case; anaesthetic expertise,
maternal co-morbidities, fetal well-being and maternal
preferences all play a part. Cardiac disease in pregnancy is still
the leading cause of indirect maternal mortality in the UK.1 The
choice of anaesthetic and delivery had to ensure the least
amount of strain on an already compromised heart. The
advantages of CSA are that a block can be established
gradually with small incremental doses of local anaesthetic,
which reduces the likelihood of cardiovascular instability.2
The concerns with a CSA are principally neurological
complications and post-dural puncture headache. CSA is
proving an option to be considered for patients with
significant cardiac disease and previous spinal surgery
provided the anaesthetist has experience with the technique.
In this case it provided a cardiovascularly stable anaesthetic
with excellent analgesia and maximal maternal satisfaction.
References
1. Saving mothers lives.The Eighth Report of the Confidential
Enquires into Maternal Deaths in the UK. March 2011
2. DennyNM, Selender DE. Continuous spinal anaesthesia. Br J
Anaesth 1998;81:590-7
Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin) P17
P133 Does pre-operative anxiety predict post-operative pain P134 Early epidural analgesia may increase caesarean
scores in parturients undergoing caesarean section? section rate in spontaneously  labouring nulliparous 
BM Daly,  N Weidenhammer,  R Junkin,  L Riddell,  J Dolan,  J women: a retrospective study
Kinsella*,  R Marla,  S Young   R Anil Kumar,  Roger Mc Morrow  
Anaesthesia, Princess Royal Maternity, Glasgow, UK, Anaesthesia, National Maternity Hospital , Dublin, Ireland
*Anaesthesia, Pain & Critical Care Medicine, University of Introduction:.Epidural analgesia offers the most effective
Glasgow, Glasgow, UK method of intra-artum pain relief. The effect of epidural
Introduction: Pregnancy, childbirth, and undergoing a surgical analgesia on the progression of labour and the mode is often
procedure are all likely to induce anxiety. The relationship debated in multiple studies. This study aims to show the effect
between anxiety, pain and pregnancy is complex.1Childbirth is of timing of epidural analgesia on the mode of delivery.
a time of high anxiety, and Caesarean section is known to be Method: Data such as women's age, gestational age, cervical
associated with significant pain post-op. Here we ask can dilatation before epidural insertion and duration of labour was
anxiety scoring predict post LSCS pain? collected from a total of 2029 nulliparous women in
Methods: After ethical approval and consent, pre-operative spontaneous labour. Epidural analgesic was defined as early at
data and a single 24hr post-op 10cm VAS were collected from a cervical dilatation of 3cms or less and late at a cervical
108 women, with 9 having missing data. Spielberger2 State and dilatation of 4 or more cm
Trait anxiety forms were completed prior to surgery. We Results: Of the 2029 women, 1423 ( 70.1%) received epidural
present secondary end points powered post hoc for 0.8 analgesia. Out of the 2029 women, 1403 ( 69.2%) had
probability of 2cm VAS difference. A standardised anaesthetic spontenous vaginal delivery, 478 (23.6%) had assisted
(spinal including diamorphine) and analgesic regime was used. delivery and 146 ( 7.2%) had caeserean section.
The cohort was divided into "high"- above the mean and
The data was anaylsed according to the timing of epidural
"low"- below the mean anxiety and compared using Student's
analgesia or no epidural analgesia and modes of delivery.
t-test.
Anaesthetic Delivery method
Results:
intervention Spontaneous Assisted Caesarean
Table 1: State anxiety compared to VAS
No epidural 537 (88.9%) 51 (8.4%) 16(2.6%) 604
Low anxiety High anxiety Early epidural 757 (62.2%) 379 126 (10.0%) 1262
  Significance
(n=45) (n=54) (30.0%)
24 hr VAS mean Late epidural 109 (67.7) 48 (29.8%) 4(2.5%) 161
5.0 (2.2) 5.3 (2.0) P= 0.40
(SD) cm
Epidural Assisted delivery C-Section
Table 2: Trait anxiety compared to VAS analgesia OR 95% CI p-value OR 95% CI p-value
Low anxiety High anxiety Early 5.27 3.86, 7.21 <0.001 5.59 3.28, 9.51 <0.001
  Significance
(n=48) (n=55) epidural
24hr VAS mean (SD) Late 4.64 2.97,7.23 <0.001 1.23 0.40,3.76 0.71
4.8 (1.9) 5.5 (2.2) P= 0.15
cm epidural
Table 3: State +Trait anxiety compared to VAS Conclusion: The results from the study show that the
Low anxiety High anxiety likelihood of having caeserean section in the early epidural
  Significance
(n=48) (n=51) group is significantly higher compared to the late epidural
24hr VAS mean (SD) group, but the incidence of assisted delivery between the early
cm 4.8 (1.9) 5.6 (2.1) P=0.072 and late epidural group were similar. This study also shows
that there is an increased likelihood of having assisted
Discussion: While the higher anxiety groups displayed a delivery and caeserean section delivery with epidural
higher mean VAS in all the analysis, this was not statistically analgesia compared to without from the study group.
significant. The separation between the two groups was better
References
with the State than the Trait anxiety score and best of all when
1..Gonen Ohel. Early versus late initiation of epidural analgesia in
the two scores were combined. Further reasearch could look at
labour: Does it increasethe risk of cesarean section. A randomised
anxiety scoring as part of a bundle of other measures verus trial. American journal of Obstretrics and Gynaecology (2006) 194,
pain. 600-5
2. Wassen et al. Early versus late epidural analgesia and risk of
References
instrumental delivery in nulliparous women: a systemic review.
1..Waldenstrom U: Experience of labor and birth in 1111 women. J British Journal of Obstretrics and Gynaecology (2010) 1471, 655-
Psychosom Res.1999: 47(5):471-82 661
2..www.mindgarden.com
P18 Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin)
P135 Efficacy of midwife led epidural top ups in labour–Are P136 Emergency obstetric and neonatal care in Kenya:
programmable pumps really the way forward? Addressing millennium development goals
E Traer,  G Waters,  GNB Jackson   D B Pachter,  C A Ameh*  
Anaesthetic department, Royal Berkshire NHS Trust, Anaesthesia, Cumberland Infirmary, Carlisle, UK, *Maternal
Reading, UK and Neonatal Health, Liverpool School of Tropical
Introduction: There are an increasing number of automated Medicine, Liverpool, UK
techniques by which labour epidurals can be managed1,2,3,4. Introduction: In 2008, an estimated 358,000 women died from
Comparison reports of programmable epidural pumps regimens complications of pregnancy and childbirth. The overwhelming
have shown lower total volumes of local anaesthetic may be burden of this mortality occurs in the developing world, with
associated with reduced rates of instrumental delivery and almost 60% of deaths occurring in sub saharan Africa.1There
improved maternal satisfaction1,2. Extended intervals between are also some 3.6 million neonatal deaths each year, and once
boluses with larger volume boluses was shown to use less again the developing world is disproportionately represented.2
total local anaesthetic3. These reports have led us to In 2006, the Liverpool School of Tropical Medicine (LSTM)
investigate similar outcomes our unit where we have a midwife developed a training package entitled "Life Saving Skills,
led top up (MLTU) practice. Emergency Obstetric and Neonatal Care" (LSS EOC-NCC) to
Method: First epidural bolus administered by the anaesthetist try and address these huge public health issues. Courses now
of 20ml 0.1% bupivicaine+2µg/ml fentanyl . Data recorded at run in 11 countries worldwide. In October 2013, I was fortunate
each subsequent midwife administered bolus (MLTU): bolus e nough to teach on a course in Nyeri, Kenya.
interval time, motor block (Bromage score of 2-4 taken as motor Methods: A variety of teaching methods were used on the
block), any change to the standard dose 20ml 0.1% course. Didactic lecture based teaching had a limited role, with
bupivicaine+2µg/ml fentanyl and if analgesia was effective or more emphasis placed on small group "break out sessions"
ineffective. and scenario based teaching. Pre and post course simulation
Results: 50 patients audited based testing was undertaken, with results collated and sent
back to Liverpool for analysis and assessment of efficacy of
Midwife led epidural Top Up Data  
teaching.
Mean bolus interval time (min) 105 (sd 26)
Mean rate bupivicaine mg/hr 10.56 (sd 3.6) Results: Participant feedback suggested a high level of
Motor block (Bromage score 2-4) 11/48 (22.9%) satisfaction with the course. The impact of courses in terms of
Mean time to motor block (min) 237 (sd 135) reduction in maternal and neonatal mortality remains the
NVD 14/48 (29.1%) subject of ongoing scrutiny. One study from Somaliland
Instrumental 18/48 (37.5%) demonstrated improved knowledge and skills and evidence of
LSCS 16/48 (33.3%) positive behaviour change post introduction of the course.3

Satisfaction excellent/good 46/48 (95%)
Conclusions: Maternal morbidity and mortality remains a huge
Discussion: In this study we found the mean interval in problem in Kenya. In 2008 it's Maternal Mortality Ratio was
minutes between epidural boluses to be 105minutes. This is 488 per 100,000, one of the highest in the world.4Great efforts
greater than the average 60minute interval of the are being made by the Kenyan government to reduce this. An
programmable intermittent bolus(PIB) regimens. An average ambitious target to reduce MMR to 91 per 100,000 by 2018 has
rate of bupivicaine 10.56mg/hr was similar to that reported with been set. One step has been the introduction of the Liverpool
PIB and patient controlled epidural bolus(PCEA) regimens4, LSS EOC-NCC course.
while we report a lower rate of motor block. Given the practice Acknowledgements: I would like to thank the maternal and
of MLTU in effect is much like a PIB without PCEA, it is neonatal health unit at LSTM for the opportunity to become
notable that the time between epidural boluses is longer with involved, and look forward to teaching on my next course. I
MLTU with less maternal motor block and high maternal would also recommend the course to any obstetric
satisfaction. We feel our practice promotes close epidural anaesthetists with an interest in international health.
assessment as the midwives assess motor block and maternal
References
satisfaction before each “top-up” and avoids the cost of the
1. World Health Organization, UNICEF, UNFPA and The World
PIB/PCEA pumps.
Bank. Trends in Maternal Mortality 1990-2008. 2010.
References 2. Lawn JE, Kerber K, Enweronu-Laryea C, et al. 3.6 million neonatal
deaths–what is progressing and what is not? Seminars in
1. Capogna G Camorica M, Stirparo S, Farcomeni A. Programmed Perinatology 2010;34:371–386.
Intermittent Epidural Bolus Versus Continuous Epidural Infusion for
Labor Analgesia: The Effects on Maternal Motor Function and 3. Ameh C, Adegoke A, Hofman J, et al. The impact of emergency
obstetric care training in Somaliland, Somalia. International Journal
Labor Outcome. A Randomized Double-Blind Study in Nulliparous
of Gynecology & Obstetrics. 2012;117:283-7.
WomenAnesth Analg July Oct 2011; 113(4): 826-831
4. Kenya National Bureau of Statistics. Kenya Demographic and
2. George RB, Allen T, Habib A. Intermittent Epidural Bolus
Health Survey (KDHS) 2008-09. June 2010.
Compared with Continuous Epidural Infusion for Labour Analgesia:
A Systematic Review and Meta Analysis. Anesth Analg Jan 2013;
Vol 116: 133-144
3. Wong C, MacCarthy RJ, Hewlett Bl. The effect of manipulation of
the programmed intermittent bolus time interval and injection
volume on total drug use for labour epidural analgesia: a randomized
controlled trial. Anest Analg 2011; 112: 904-11
4. Husain T, Mavridou I, Fernando R, El-Wahab N, Stewart A, Dick J,
Columb M. A study of a programmed intermittent bolus and patient-
controlled epidural regimen for labour analgesia. Int J Obstet
Anaesth May 2013: P85 Abstracts OAA Bournemouth 2013
Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin) P19
P137 Enhanced recovery after elective caesarean section: P138 Epidural analgesia in obese parturients: can kneeling
Service evaluation and quality improvement be the answer to our prayers.
GJ Lilley,  M Adamson,  A Miskin*,  M Turner   S De Silva,  L Kelliher*,  R Mottaleb*,  E Combeer  
Anaesthetics, Royal Gwent Hospital, Newport, UK, Anaesthetics, Frimley Park Hospital, Frimley, UK,
*Obstetrics and gynaecology, Royal Gwent Hospital, *Anaesthetics, Royal Surrey County Hospital, Guildford, UK
Newport, UK Severe pain is not life-threatening in healthy parturient women,
Introduction: Enhanced recovery (ER), a concept widely it is however shown to have neuropsychological
recognised within many surgical specialties, is now a subject consequences. Postnatal depression may be more common
of interest within obstetrics. The core principles comprise when effective analgesia is not used1 and pain during labour
speeding up recovery and improving patient outcomes, with has been linked with the development of post-traumatic stress
associated benefits for staff and healthcare systems1. The disorder2.There is an increasing number of obese parturients3
most logical starting point for the introduction of ER principles and identification and placement of the epidural can be
are elective caesarean section lists. Delayed surgery may lead difficult in these women.
to prolonged fasting, followed by delayed mobilization, Classically the sitting or the lateral position is used during
delayed removal of catheter and delayed discharge. A pilot siting of labour epidurals. The kneeling position was first
audit in our hospital demonstrated a mean stay after elective described in 19934, where 34/35 women had their labour
caesarean section of 3.6 days, and mean preoperative fasting epidural sited whilst in the kneeling position and 88.5% of the
period of 12.4 hours. Current guidance for ER in obstetrics mothers were happy with this position.
suggests minimal interruption to oral intake, pre-operative
I elected to try the kneeling position in an obese lady with a
energy drinks, catheter removal at 12 hours post-surgery
BMI 50 after adjustments in the sitting position and two
regardless of time of day, and the option of discharge home 24
separate failed attempts to confidently palpate the lumbar
hours after caesarean section where appropriate2.
spine. Once the lady was in the kneeling position, the lumbar
Methods: All elective caesarean sections were included in this spine was not only palpable but also visible and the epidural
service evaluation after introduction of preoperative space was identified with ease. With Departmental approval I
carbohydrate drinks. Data collection included fasting time, in performed my labour epidurals in this manner and found it not
addition to time to mobilization, to catheter removal and to only to be easy to site epidurals but also tolerated well. Some
discharge. After an initial 6 week period of data collection, the women complained of paraesthesia in their feet, but this was
data was presented to anaesthetic and obstetric staff. Posters, rare and eased swiftly. We decided to survey our Deanery to
a discharge proforma and a patient information leaflet were ascertain what positions were being utilised.
produced, and specific guidance was developed regarding
Survey: An e-survey was sent to trainees and Consultants in
preoperative carbohydrate drinks. A further 6 weeks of data
the South West London Deanery into what their ideal first and
collection then took place.
second choice positions used for siting epidurals would be for
Results: A total of 78 consecutive patients were included, all labouring parturients. We then posed the same question for
of whom received a regional anaesthetic technique for elective obese parturients (BMI 40). They were asked if they had
caesarean section. The following table illustrates the timing of heard of the kneeling position and if anyone had tried it. For
pre- and post-operative events before and after our those who had not, we questioned why they had not tried it.
interventions.
Results: We received 53 responses, 96.2% of whom were
Time period / hour 2nd 6 week Initial 6 week
trainees. 64.2% chose to position the parturient sitting as their
mean(SD) period period
first choice and 60.4% chose lateral as their second choice in
Pre-op fasting 4.8 (2.8) 3.8 (2.5)
non-obese parturients. In comparison 84.9% opted for the
Post-op fasting 4.2 (3.5) 3.4 (3.5)
sitting position in obese parturients with 56.9% using the
Total interruption to oral
9.0 (4.5) 7.1 (4.6) lateral as their second choice. The only positions utilised were
intake
sitting and lateral. 94.9% of respondents had not heard of the
Delivery to mobilization 10.2 (4.5) 9.0 (3.3)
kneeling position to site labour epidurals.
Delivery to catheter removal 14.8 (6.6) 13.5 (3.5)
Conclusion: Each position used for the placement of labour
Delivery to discharge 67.3 (40.1) 63.3 (27.6)
epidurals has their own advantages and disadvantages. With
Discussion: The introduction of patient information leaflet
the rising incidence of maternal obesity and its associated
offering guidance regarding post-operative oral intake,
risks to not only the mother but also the unborn child, we need
mobilization, catheter removal and early discharge, along with
to be continuing in our development and advancement in the
staff education and introduction of pre-operative carbohydrate
provision of good care. We suggest that the kneeling position
drinks, has resulted in improvement in the timing of a number
is a safe and viable alternative for siting epidural catheters in
of peri-operative interventions, and a small reduction in
labouring parturients.
duration of hospital admission. However, possibly due to
References
obstetric, midwifery, paediatric and organisational reasons,
discharge is rarely achieved at the potential target of 24 hours 1. Hiltunen P, Raudaskoski T, Ebeling H, Moilanen I Does pain relief
during delivery decrease the risk of postnatal depression? Acta
after elective caesarean section. Obstet Gynecol Scand 2004;83:257-261
References 2. Soet JE, Brack GA, Dilorio C Prevalence and predictors of women's
1. Lucas DN, Gough KL. Enhanced recovery in obstetrics - a new experience of psychological trauma during childbirth. Birth
frontier? Int J Obstet Anaesth 2013; 22: 92-95 2003;30:36-46
2. Enhanced recovery partnership: A better journey for patients and a 3. Centre for Maternal and Child Enquiries (CMACE). Saving
better deal for the NHS. Available at: Mothers'. Lives: reviewing maternal deaths to make motherhood
http://www.improvement.nhs.uk/documents/er_better_journey.pdf safer: 2006–2008. The Eighth Report of the Confidential Enquiries
into Maternal Deaths in the United Kingdom. BJOG 2011;118:1-203
P20 Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin)
P139 Epidural labour analgesia and risk of instrumental P140 Estimation of blood loss during caesarean sections -
delivery discrepancy between visual and laboratory estimation
R Carvalho,  T Ferreira,  M Duque,  D Catré,  I Guedes,  J P A Nowicka,  A Amasakera,  C Ferdinand,  I Suri  
Assunção   Anaesthesia, Warwick Hospital, South Warwickshire NHS
Anaesthesiology, Centro Hospitalar Tondela Viseu EPE, Foundatio, Warwick, UK

Viseu, Portugal
Introduction: Excessive blood loss is a major threat to women
Introduction: Epidural analgesia (EA) is a worldwide effective undergoing casearean sections. Accurate visual estimation of
method used for pain relief during labour. Nevertheless, its use blood loss is difficult due to dispersion of blood lost and the
and evolution to instrumental vaginal (forceps or vacuum blood being mixed with amniotic fluid(1). Therefore the blood
extraction) or operative deliveries remains controversial loss often gets under or overestimated(2). A number of
between experts,1 either anesthesiologists or obstetricians. methods exist to estimate the blood loss, the commonly used
We aimed to analyze the relation between EA and instrumental being: visual estimation by the attending staff, weighing of the
v aginal deliveries in a sample of our obstetric population. blood soaked surgical swabs and calculation based on the pre-
and post-operative haemoglobin concentrations(3). The aim of
Methods: A retrospective study included all pregnant women
this audit was to compare the visually estimated blood loss by
who delivered on our labour Room, between 1-January-2011
both the surgeons (vEBLs) and anaesthetists (vEBLa) against
and 31-December-2012, excluding those who underwent
the calculated estimated blood loss (cEBL).
caesarean section. We reviewed the data of demographical
characteristics, type of gestation and labour, the use of EA Methods: Data was collected on thirty five caesarean sections.
and the newborn APGAR score. Descriptive analysis of Operating surgeona and anaesthetists were asked to visually
variables was used to summarize data and Chi-Square test was estimate the blood loss in each case. The circulating blood
used. Multivariate analysis was done with logistic regression, volume was calculated for each patient based on the body
with calculation of corrected Odds Ratio (OR) and its 95% weight and height. Then, the blood loss during caesarean
confidence interval (95% CI). section was calculated using the circulating blood volume and
the pre- and post-operative haemoglobin concentrations.
Results: 2901 pregnant women were included in this study, Correction was made for the haemodilution by intravenous
with mean age of 29,7 years. 81% underwent EA and 30% fluid administered.
instrumental vaginal delivery. 51% were nulliparous. Applying
Results: Twenty six complete forms were included in the
Chi-Square test to independent variables, we obtained
analysis. None of the patients received blood or blood
significant associations with dystocic delivery for EA, normal
products intraoperatively. Mean volume of intravenous fluid
maternal age (NMA; 20-35 years) and parity (p<0,001).
infused was 1304mL±421. Mean vEBLs, vEBLa and cEBL was
Applying logistic regression to our model, including parity,
590mL±300, 623mL±372 and 821mL±1004 respectively. The
NMA and EA with dystocic deliveries, we obtained corrected
tendency for anaesthetists to give a higher estimate of blood
OR (95%CI) for EA 2,459 (1,884-3,210) and for parity 3,4
loss was not statistically signifficant (p=0,12). There was a
(2,867-4,121), with NMA loosing significance. However, this
clear discrepancy between the visual estimate given by both
result may still be biased by other factors, such as labour
the surgeons and the anaesthetists, ant the cEBL, however, it
stage at the time of the EA beginning, drugs used in epidural
did not reach statistical significance (p=0,11 and p=014
space, use of oxytocin during labour, among others.
respectively). Compared to the cEBL the vEBL was
Additionally we found that, in our population of term
overestimated when the blood loss was low (12 cases) and
pregnancies, NMA and eutocic deliveries, there was no
underestimated when the blood loss was higher than 500mL
significant relation between EA and APGAR score <8 at the
(14 cases). There was a linear relationship between the degree
first minute (p=0,079).
of underestimation and the blood loss, with high levels of
Conclusion: It's generally assent that EA provides the most blood loss being most underestimated.
effective pain relief in labour. However, it's associated to Conclusions: In this audit, the standard procedure for
prolonged labour and risk of instrumental or caesarean estimation of blood (visual estimation by the obstetrician) loss
deliveries.2 Our study has drawn the conclusion that both was found to be unreliable. We demonstrated a tendency of
having EA for labour pain relief and being nulliparous increase anaesthetists and surgeons to overestimate the blood loss, if
the chance of instrumental delivery, respectively in 2,459 and actual blood loss was less than 500mL, and underestimate if
3,43 times, however without significant impact on newborn the blood loss exceeded 500mL. As a result of the audit, it has
APGAR score. Bigger prospective studies correcting for more been made compulsory in our unit to check haemoglobin
risk factors are advised. concentration in recovery whenever the vEBL exceeds
References 1 000mL.
1. BMC Pregnancy and Childbirth 2008, 8:45. References
2. Acta Obstet Gynecol Scand 2002, 8:1033-1039. 1. Khan FA, Khan M, Ali A, Chohan U Estimation of blood loss during
Caesarean section: an audit. J Pak Med Assoc. 2006 Dec;56(12):572-
5.
2. Larsson C, Saltvedt S, Wiklund I, Pahlen S, Andolf E Estimation of
blood loss after cesarean section and vaginal delivery has low
validity with a tendency to exaggeration. Acta Obstet Gynecol
Scand. 2006;85(12):1448-52.
3. Stafford I, Dildy GA, Clark SL, Belfort MA, Visually estimated and
calculated blood loss in vaginal and cesarean delivery. Am J Obstet
Gynecol. 2008 Nov;199(5):519.e1-7
Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin) P21
P141 Ethnic variations in use of labour analgesia P142 Factors associated with the use of spinal anaesthesia
LMD MacDarby,  CMC McCaul   for caesarean section in Nigeria
Delivery Suite, The Rotunda Hospital, Dublin, Ireland C Imarengiaye,  F Asudo*,  A Akinmola†,  B Lawal§  
Introduction; This retrospective cohort study was compiled to Anaesthesiology, University of Benin Teaching Hospital,
establish the wide variety of nationalities presenting to The Benin City, Nigeria, *Anaesthesia, University of Abuja
Rotunda Hospital for delivery during a one month period and Teaching Hospital, Gwagwalada, Nigeria, †Anaesthesia, 
to determine the labour analgesia preferences amongst this National Hospital, Abuja, Nigeria, §Anaesthesia, Lagos 
population. Island Maternity Hospital, Victoria Island, Nigeria

Introduction: There has been a consistent increase in the rate
Methods; Details of all deliveries occurring during the month
of spinal anaesthesia for caesarean section in many hospitals
of October 2013 were collected. Any patients undergoing
worldwide and had been advocated as the preferred technique
elective caesarean section and those with failed inductions
for caesarean delivery.1 Recent evidence suggests increasing
were excluded from the study. A demographic of patients’
use of spinal anaesthesia for caesarean sections in reports
nationality and ethnic background was compiled. Data relating
from a teaching hospital.2 The rise in spinal anaesthesia
to these patients’ use of labour analgesia was recorded i.e.
caesarean section notwithstanding, it is pertinent to determine
epidural uptake, pethidine administration and remifentanil
the factors limiting the wholesome application of spinal
infusion use. We then established the frequency of use of
anaesthesia for caesarean section in Nigeria.
each of these methods of analgesia in each population

Methods: A snap-shot survey was conducted in some
Results; There were 767 deliveries in Oct 2013. 104 elective
selected hospitals in Nigeria. The survey determined the
caesarean sections were carried out and there were 8 patients
sociodemographic characteristics of patients, indication for
who failed induction.
surgery, grade of anaesthesia provider, contraindication to
Therefore a total of 655 patients laboured during this time. spinal anaesthesia and any other factor that may be noticed in
This number was made up by 50 different nationalities. Of the selected hospital. The survey was to be conducted over a
these 414 patients were Irish, the majority being white but 2-week period but was truncated by the nation-wide strike
including small numbers of Asian or Black background. action by doctors after 9 days.
Amongst the Irish patients the rate of epidural uptake was
Results: A total of 99 patients were attended to in 4 of the
43.47% (234) and the rate of pethidine use was 17.87% (74)
selected 6 hospitals within the study period. 36/99 women
Patients of other white background, including many eastern
were nulliparous and maternal factors (82/99) were the leading
european countries made up 134 of the patients. These
indications for caesarean section. Consultant anaesthetists
patients as a group had a 52.98% epidural uptake rate. Black
(23/99), Senior Registrars (35/99), Medical Officers (36/99) and
Africans were found to have a 39.13% (9) uptake rate and
others (5/99) provided anaesthesia for the caesarean sections.
those of Asian background had the highest rate at 54.83%
85/99 patients received spinal anaesthesia and 14/99 had
(17). The use of pethidine was significantly lower than the rate
general anaesthesia for the c-section. Fetal indication for
of epidural in all of these groups. Pethidine was used by
caesarean section had a 3-fold risk of general anaesthesia for
18.19% of Black Africans, 12.9% of Asians and 23.13% in
the surgery (p = 0.037, RR = 3.1, 95%CI 1.2 – 8). 25/99 and
those of other white backgrounds. There were only 3 cases of
74/99 were performed as elective or emergency procedure.
remifentanil use during the month
Nature of caesarean section was not a factor for the use of
Discussion; The highest incidence of epidural uptake during spinal anaesthesia (p =0.51, RR = 2.0, 95%CI = 0.5).
Oct was found to be amongst the Asian population, the lowest Discussion: Over 85% of caesarean sections in Nigeria were
being amongst Black Africans. Pethidine use was less than conducted under spinal anaesthesia. Fetal indications for
25% in all groups. The reasons for these trends is unknown caesarean section provoked a 3-fold increase in general
though previous studies have suggested that cultural and anaesthesia for caesarean section. The use of general
educational factors may play a part. anaesthesia for caesarean delivery was due to fetal indications
A prospective survey of patients post delivery detailing the for surgery, antepartum haemorrhage and failed spinal
reasons for their choices of labour analgesia would be anaesthesia. Improved practical conduct of the spinal
worthwhile. Establishing the factors influencing their technique may enhance great application of spinal anaesthesia
decisions may allow us to provide an unbiased and fully for caesarean section.
comprehensive service to ensure patient satisfaction. References

1..Morgan BM, Magni V, Goroszenuik T. Anaesthesia for emergency
caesarenc section. BrJ Obstet Gynaecol 1990; 97: 420-424
2..Amadasun FE, Idehen HO, Edomwonyi NP. Evolving pattern of
anaesthesia for caesarean section: Experience at the university of
Benin Teaching Hospital West Afr J Med 2013; 32: 196-9
P22 Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin)
P143 Failed intubation for a category 1 caesarean section in P144 Fasting dilemmas: A rare case of a patient with non-
a patient with undiagnosed spina bifida ketotic hyperglycinaemia presenting for caesarean
CR Deane,  E Lewis,  J Spargo   section
Department of Anaesthetics, Singleton Hospital, Swansea, M Behravesh,  S Dawson,  G McClune,  S Atkinson  
UK Anaesthetics, Royal Jubilee Maternity Hospital, Belfast, UK
Introduction: Non-ketotic hyperglycinaemia (NKH) is a rare
Introduction: Spina Bifida Occulta (SBO) is part of a spectrum
autosomal recessive metabolic disease caused by a defect in
of neural tube defects and is common. We present the case of
the glycine cleavage system. This case report describes the
a patient with previously undiagnosed SBO who required a
management of a patient who presented for caesarean section.
category 1 caesarean section (CS). Despite an unremarkable
To our knowledge there are no other published case reports of
airway assessment she had a failed intubation on rapid
this type.
sequence induction (RSI) and subsequently required an awake
fibre optic intubation (AFOI). Case Report: A 32 year old Para 1 presented for elective
caesarean section of twins at 37 weeks gestation. She had a
Case report: A 37 year old para 0 patient presented to labour
history of atypical non-ketotic hyperglycinaemia. Following
ward labouring with a single live foetus at 37 weeks gestation.
advice from clinical chemistry, during her 6 hours preoperative
She was admitted under consultant obstetric care with
fast she received an inceased dose of sodium benzoate and an
asymptomatic hypertension. When considering an epidural
intravenous infusion of 10% dextrose at 3mls/kg/hour which
she was examined and had a vascular naevus, associated with
was continued perioperatively. Caesarean section was
skin tethering, over lumbar vertebrae. She was asymptomatic,
performed under spinal anaesthesia and twin baby boys were
had never been investigated, and had no definitive diagnosis
delivered successfully. Post delivery of the second twin she
of SBO. Airway assessment included a Mallampatti score of 3,
received a bolus of 5 units of syntocinon followed by an
but was otherwise unremarkable. An epidural was declined to
infusion at 10 units per hour. Due to uterine atony and an
the patient, with a remifentanil PCA provided instead. A plan
operative blood loss of 1000mls she also received ergometrine
was agreed for a RSI GA if operative intervention was
carboprost intramuscularly to good effect. Sodium benzoate
required. Several hours later she required a category 1 CS.
was administered orally in recovery and the 10% dextrose
Initial laryngoscopy with a Mackintosh blade yielded a
infusion was continued until the patient was establised on an
Cormack and Lehane grade 3 view. Manipulation of the cricoid
oral regimen prescribed by the dieticians. This involved a
cartilage, long and McCoy blades did not improve the view.
series of high calorie drinks up to every 2 hours for 48 hours.
Two failed attempts were made to intubate using a bougie. The
No dietary protein was allowed for 24 hours post delivery.
patient was ventilated using a face mask and a Guedel airway
Glycine levels were monitored daily and were raised on day 5
with oxygen saturations above 97% throughout. She was
while dietary protien was being gradually reintroduced.
woken up without further incident and an AFOI was
performed. Her child was delivered by LSCS without further Discussion: NKH has an incidence of 1 in 60,000 with 3
incident or obvious deficit. The APGAR scores were 8 and 10 distinct presentations. Classically neonates present with
at one and five minutes. A grade 3 view was confirmed before lethergy, hypotonia and seizures. These symptoms can
the patient was woken. Recovery from anaesthesia was proceed to apnoea requiring ventilation and 30% of patients
uneventful. The patient was appropriately counselled. An do not survive the neonatal period. Severe psychomotor
Airway Alert Letter was issued and follow up appointment retardation is common in those who survive. A second,
made. An MRI was carried out subsequently and showed a atypical and very rare form presents with mild baseline
neural arch defect and dural tethering. Significantly the conus hyperglycinaemia and intermittent encephalopathy
lay as low as L4 with diastematomyelia as far as L2. assosciated with periods of illness. Transient neonatal
hyperglycinaemia has also been described. Biochemically,
Discussion: SBO is common and without prior imaging
NKH is characterized by elevated glycine concentrations in
presents the clinician with a difficult decision. Regional
plasma, CSF, and brain with a CSF glycine to plasma glycine
techniques risk neural or dural injury due to a low lying or
ratio greater than 0.08.1 Standard treatment strategies include
tethered cord.1 Abnormal spread of the analgesic agents may
protein restriction to reduce exogenous glycine,
give rise to either excessive cranial spread or inadequate
supplementation of one-carbon pool donors and
caudal spread. This patient population provides further issues
administration of sodium benzoate. NMDA antagonists have
for the anaesthetist given the high risk of operative delivery or
been shown to raise the developmental quotient, improve
other intervention (due to pelvic structural abnormalities) and
muscle tone and reduce seizures in these patients.2
the association of spina bifida with difficult intubation.2,3
Patients with spina bifida require careful preop assessment Prolonged periods of fasting predispose these patients to
and MRI imaging and careful airway consideration is essential glycine build up and its toxic neurological effects. This has
in order to inform anaesthetic planning. major implications for the anaesthetist in the perioperative
period. This case demonstrates the safe use of regional
References
anaesthesia in conjunction with careful nutritional planning.
1. Reynolds F. Damage to the conus medullaris following spinal
anaesthesia. Anaesthesia 2001; 56: 235-247. References
2. Richmond D, Zaharierski I, Bond A. Management of pregnancy in 1. Chang YT, Lin WD, Chin ZN et al. Nonketotic hyperglycinemia: A
mothers with spina bifida. Eur J Obstet Gynecol Reprod Biol 1987; case report and brief review. Biomedicine 2012; 2(2):80-82
25: 341-5. 2. Van Hove JL, Vande Kerckhove K, Hennermann JB et al. Benzoate
3. May A, Fombon F, Francis S. UK registry of high-risk obstetric treatment and the glycine index in nonketotic hyperglycinaemia.
anaesthesia: report on neurological disease. Int J Obstet Anaesth Journal of Inherited Metabolic Diseases. 2005;28:651–663
2008; 17: 31-6.
Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin) P23
P145 Fetal bradycardia following regional anaesthesia for P146 Further increase in hysterectomy rates - and the
emergency caesarean section and instrumental reason why
delivery: a service evaluation JS Campbell,  M Molloy,  C Thompson,  D Fogarty  
JK Sidana,  K Jadhav-Smith,  J Corfe   Royal-Jubilee Maternity Service, Belfast HSC Trust, Belfast,
Anaesthetics, Norfolk and Norwich University Hospital, UK
Norwich, UK Introduction: RJMS is the tertiary obstetric service for
Introduction: Fetal heart rate abnormalities, such as late Northern Ireland. As part of a service review of use of uterine
decelerations or fetal bradycardia, are known to occur after artery balloon catheters, we retrieved data from several
neuraxial anaesthesia.1 These may be due to maternal sources. We found a large proportion of these patients still
sympathetic blockade or an increase in the uterine tone caused required hysterectomy. Further interrogation of our data
by intrathecal opioids. The objective of this service evaluation showed some unexpected trends.
was to evaluate the incidence and management of fetal Methods: With approval of the Trust's Data Guardian we used
bradycardia following regional anaesthesia for emergency data from several hospital systems, including a local maternity
caesarean section and instrumental deliveries. care database and histology records.
Methods: 15 patients with an episode of fetal bradycardia Results: We found 30 hysterectomies from 37,088 deliveries in
following regional anaesthesia were identified by reviewing 6 years. This is a rate of 0.8 per 1000 - significantly higher than
the daily obstetric handover sheets from January to December our prior rates which was near the NICE-quoted rate of up to 3
2011. The medical notes of these patients were reviewed for per 1000. Of these cases, 23 (76%) were due to morbidly
peripartum obstetric management, cardiotocographic (CTG) adherent placenta.
findings, perioperative anaesthetic management and
Not all these cases of morbidly adherent placenta were
management of fetal bradycardia. Neonatal outcome was
diagnosed antenatally, which perhaps made hysterectomy
assessed by APGAR scores, umbilical cord gases and NICU.
more likely since facilities such as intra-arterial balloon
Results: 10 patients had an assisted delivery and 5 had an catheters could not be available to us in an emergency.
emergency category-2 LSCS. The peripartum CTG findings Unanticipated cases suffered greater blood loss. Despite no
were either suspicious or pathological. Timing of fetal diagnosis, the majority (16/23) were placenta percreta on
bradycardia following regional anaesthesia ranged from 2 to 15 histology. These percreta cases again had greater blood loss,
min. 13 patients received spinal anaesthesia and 2 received and were more likely to require ICU care post-operatively. Yet
epidural top up. Maternal haemodynamics stability was there were no cases of percreta in the 6 years prior, and less
maintained with left uterine displacement, intravenous fluids than half the number of hysterectomies in that period. This
and phenylephrine infusion. One patient had an episode of seems to be a dangerous and dramatic change in recent years.
maternal bradycardia below 50 beats/min which was treated
Conclusion: We found a recent and significant increase in
with anticholinergics. Comparing the baseline maternal heart
peripartum hysterectomy, associated with a large increase in
rate with the lowest perioperative heart rate, 3 patients had a
the number and degree of morbidly adherent placenta. Patients
greater than 40% drop in the heart rate. 5 patients had a blood
with placenta percreta had a greater blood loss, and more
pressure drop of more than 20% below the baseline, which was
commonly required hysterectomy and ICU care.
treated with phenylephrine. The highest level of block to
Reference
temperature was T3. Syntocinon was stopped in all but one
case in the event of fetal bradycardia. Significant delays 1. National Institute for Health and Clinical Excellence. Caesarean
section: NICE Clinical Guideline 132 2012,
occurred in transferring these patients to theatre after the
http://www.nice.org.uk/nicemedia/live/13620/57163/57163.pdf
decision for surgical intervention were taken, maximum 35 min
(median 17 min). 6 cases had poor neonatal outcomes with low
5 minute APGAR and abnormal cord gases.
Discussion: We could not find any direct cause which can be
solely attributed to regional anaesthesia for the occurrence of
fetal bradycardia in these patients. Significant delay in patient
transfer to theatre may have a causal relationship but cannot
be confirmed. Studies in elective patients have shown that
maternal bradycardia causes a drop in maternal cardiac output.
2 Relative maternal bradycardia occurred in several of our
cases and this would have led to drop in cardiac output and
therefore oxygen delivery. This is most likely a side effect of
phenylephrine use. We plan to introduce a care bundle to
implement pre-operative and intra-operative fetal resuscitation.
This will include steps to improve fetal condition at the time of
regional anaesthesia and to ensure adequate maternal cardiac
output and oxygen delivery.
References
1. Reynolds F, Seed PT. Anaesthesia for Caesarean section and
neonatal acid-base status: a meta-analysis. Anaesthesia 2005; 60:
636–653
2. Stewart A, Fernando R et al. The dose-dependent effects of
phenylephrine for elective caesarean delivery under spinal
anaesthesia. Anesthesia & Analgesia 2010; 111: 1230-7.
P24 Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin)
P147 Impact of workload on accidental dural puncture P148 Implantable cardioverter defibrillator in
(ADP) rate pregnancy WITHDRAWN FROM PRESENTATION
W Mon,  YM Liu,  A Stewart,  R Fernando,  M Columb*   S Chaudhari,  S Quasim  
Anaesthetics, University College London Hospital, London, Anaesthetic Department, University Hospital Coventry and
UK, *Intensive Care Unit, University Hospital of South Warwickshire , Coventry, UK
Manchester, Manchester, UK
Introduction: Post dural puncture headache is an important
cause of morbidity. We audit our ADP rates annually against
the national standard.1Between 2005 and 2008, our ADP rate
was stable at approximately 0.5%. However, from 2008 to 2010,
our rate rose to above the 1% national standard.1Therefore, we
audited factors that may have contributed to this increase.
Methods: Information for this audit was obtained from a
computerised database. Data collection included day, month
and time of ADP and the grade of anaesthetist. We also
collected annual data of number of deliveries, epidurals and
combined spinal epidurals (CSEs) for labour, caesarean section
(CS) data, and the proportion of single shot spinals (SSS) to
CSEs performed. Data were analysed using chi-square
multinomial and trend tests with P value <0.05 defined as
significant.
Results: There was a 40% increase in deliveries between 2008-
2010. CSs and regional blocks for analgesia increased by 36%
and 40% respectively. Although the ADP rate increased, we
could not demonstrate a statistically significant trend due to
small numbers. From 2010 to 2012, a non-significant fall in the
ADP rate was seen. There was no significant association
between ADPs and day, month or time. We did see a
significant non-linear trend (P = 0.0012) in the proportions of
SSSs to CSEs performed, with the peak occurring in 2010.
Table 1. Trend of activity and ADP rate from 2008 to 2012
  2008 2009 2010 2011 2012 P value
Maternities (n) 4032 5039 5647 5841 5953 < 0.0001
Epidurals for labour (n) 1306 1600 1839 2029 2132 < 0.0001
CSs (n) 1370 1562 1861 1862 1773 < 0.0001
SSSs for CS (n) 282 274 356 326 347 0.0015
CSEs for CS (n) 797 644 714 833 915 < 0.0001
Proportion of SSS to CSE (%) 26 30 33 28 27 0.0012
ADP rate (%) 0.57 0.98 1.05 1.01 0.82 0.31
Discussion: We observed an increase in ADPs until 2010, with
significant rises in deliveries and anaesthetic procedures
performed. The significant non-linear trend in the proportions
of SSSs to CSEs performed for CSs peaked in 2010. A fall in the
ADP rate between 2010-2012, occurred despite exposing more
women to the risk of ADP, as during this time we performed
significantly more CSEs than SSSs proportionally. We believe
that the rise in the ADP rate resulted from a significant
increase in our workload between 2008 and 2010, without any
increase in anaesthetic staffing. From 2010 onwards, daytime
anaesthetic consultant sessions increased by 50%, and there
was a higher presence on the labour ward out of hours by
senior registrars covering non-obstetric theatres. Both factors
may have contributed to the subsequent fall in the ADP rate.
This audit supports the recent OAA/AAGBI guideline
recommending increased anaesthetic staffing on labour ward.2
References
1. Royal College of Anaesthetists. Epidural analgesia during labour.
Raising the standard: a compendium of audit recipes. 2012;218-219
2. Association of Anaesthetists of Great Britain and Ireland and
Obstetric Anaesthetists' Association. OAA/AAGBI guidelines for
obstetric anaesthetic services. 2013
Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin) P25
P149 Inadvertent hypothermia during elective caesarean P150 Inter professional relationships on labour ward- how
sections well do anaesthetists and midwives get along?
S Botros,  R Labib,  T Ramhew,  M Baban,  Y Poonawala   M Salman,  P Kumar,  G Graham  
Selwyn Crawford Department of Anaesthesia , Birmingham Anaesthetics, St. Thomas' Hospital, London, UK
Women's Hospital, Birmingham, UK Introduction: Anaesthetists and midwives are part of the
Introduction: The National Institute for Health and Care multi-professional team that provides care for parturients.
Excellence (NICE) defines inadvertent perioperative They work together in close collaboration in the unique and
hypothermia as a core body temperature below 36°C.1 It is a often highly charged environment of labour ward. In such
common complication of regional anaesthesia, and is the settings, effective inter professional relationships are key to
leading cause of perioperative shivering. Hypothermia is the delivery of high quality care and consequently better
associated with increased risk of wound infection and patient outcomes. Successful collaborative practice can be
increased blood loss.1 Shivering can be associated with negatively impacted by barriers such as lack of clarity on the
increased oxygen consumption and hypoxaemia in vulnerable scope of roles of team members, poor communication, or
patients. Although the NICE guideline on the management of stereotyping. We conducted a survey amongst obstetric
perioperative hypothermia did not cover pregnant women,1 it anaesthetists and midwives in our hospital to reflect upon this
has been adopted by many obstetric units. In our unit, working relationship and to see how it may be improved.
intravenous (IV) fluid is not routinely warmed for elective
Methods: A questionnaire was designed and distributed to
caesarean sections (CS). Hence, we audited our practice to
midwives and anaesthetists of all grades. Questions were
evaluate the incidence of hypothermia.
asked on their understanding of each other's professional role
Methods: Over a three month period, we prospectively audited
and on their perception of the quality and effectiveness of
our practice in 47 women who had elective CS under
their working relationship. A total of 43 responses were
subarachnoid anaesthesia without active warming. We
collected (24 anaesthetists and 19 midwives) in an ongoing
measured their tympanic temperature prior to anaesthesia (T )
1 survey.
and at the end of surgery (T ). We also collected data that may
2 Results: Of the anaesthetists who completed the
influence the results like the volume of IV fluid infused,
questionnaire, 16.6% were consultants, 58.3% were ST5-ST7,
estimated blood loss (EBL) and duration of surgery. We also
20.8% were ST3-4 and 4.1% were CT1-2. When asked whether
assessed the incidence of perioperative shivering. We
they felt they understood the scope of responsibilities of
repeated the audit in 42 parturients using an IV fluid warming
midwives on labour ward, only 27% of anaesthetists felt they
device. The data were analysed using Microsoft Excel 2007®.
understood it fully. In contrast, 63% of midwives believed they
Data from both audits were compared and p-values were
fully understood the scope of the anaesthetist's
calculated using unpaired t-test by GraphPad software®.
responsibilities.
Results: In the initial audit, 20 patients (42.55%) were
hypothermic at the end of surgery (T < 36°C). Shivering Thirty percent of midwives felt that collaboration with
2
occurred in 14 patients (29.79%). No correlation was found anaesthetists was 'very easy', in contrast to only 5.5% of
between T and the IV fluid volume, EBL, duration of surgery anaesthetists who felt the same about collaboration with their
1-2
or the dose of intrathecal Bupivacaine. In the re-audit, only 3 midwife colleagues. While 16% of anaesthetists found this
(7.14%) patients experienced hypothermia. There was no collaboration 'difficult', none of the midwives did (0%).
statistical difference in T between the two audits (p = 0.781). Seventy two percent of anaesthetists felt their input was
1
usually well-received by their midwife colleagues, compared to
  Initial Audit (n=47) Re-audit (n=42) p-value
only 40% of midwives who thought their input was well-
Fluid (ml) 1116.67(±369.43) 1233.33 (±483.59) 0.2236
received by the anaesthetist. Both professions were asked
EBL (ml) 523.75 (±152.33) 582.5 (±491.67) 0.474
how they perceived the general quality of communication
T1 36.84 (±0.37) 36.81 (±0.37) 0.781
between them. The majority of anaesthetists (47%) perceived it
T2 36.08 (±0.4) 36.3 (±0.29) 0.004
as 'fair', while 15% regarded it as 'poor'. Ninety percent of
T 0.76 (±0.34) 0.52 (±0.41) 0.0032
1-2 midwives felt it was either 'very good' or 'good'. None of the
Discussion: Our audit highlights the effect of warm IV fluid midwives (0%) felt it to be 'poor'.
therapy on reducing the incidence of inadvertent perioperative
Questions were asked on the types of obstacles they
hypothermia during elective CS. Our audit recommends the
encountered in their professional interaction with each other.
routine warming of IV fluid during elective CS. The Enhanced
Most anaesthetists (72%) agreed that they found fixation on
Recovery Partnership Programme considers patient warming
tasks and exclusion of others to be a challenge, followed by
as a key factor in accelerating patient recovery.2 Following our
delayed or non-communication of important issues (57%). A
results and as part of developing a new pathway for enhanced
third of the anaesthetists felt they rarely got a comprehensive
recovery post CS; our trust is currently looking to invest in a
handover from the midwife while only 29% of midwives felt
cost-effective IV fluid warming device.
they understood the rationale behind the anaesthetists'
References decisions.
1. NICE (2008) Perioperative hypothermia (inadvertent): full Conclusion: Despite both specialties working in close
guideline (CG65). Full Guideline. London: National Institute for proximity, the survey identified several gaps in
Health and Care Excellence.
communication. Working towards enhancement of the
2. Enhanced Recovery Partnership (2012) Fulfilling the potential: a
professional relationship between members of the team
better journey for patients and a better deal for the NHS. Leicester:
NHS Improvement. Available at http://www.improvement.nhs.uk providing maternity services will help facilitate their
(accessed 14/12/2013) collaboration and will reflect positively on the performance of
both professions.

P26 Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin)
P151 Intra-arterial balloon catheters: A service evaluation P152 Intrathecal diamorphine for cesarian section following
JS Campbell,  M Molloy,  D Fogarty   intramuscular diamorphine during labour: a cause for
Royal-Jubilee Maternity Service, Belfast HSC Trust, Belfast, concern?
UK RC Barr,  L Parks  
Introduction: Intra-arterial balloon catheters have become Anaesthetics and Intensive Care, Southern Health and Care
widely used and predominantly accepted in cases where Trust, Northern Ireland, UK
massive haemorrhage is anticipated, especially with morbidly Introduction: Diamorphine has largely replaced pethidine for
adherent placenta . However, the benefits are still intramuscular (IM) analgesia during labour in our obstetric
1,2
controversial. While our unit is not stand-alone, our building unit. We also routinely give diamorphine (250-300 micrograms)
is physically separated from other departments including intrathecally (IT) for cesarian sections. A recent case of
radiology, so the logistics of balloon catheters are difficult2. meiosis and drowsiness, in a lady presenting for a category 2
Our objective was to identify the impact of balloon catheters cesarian section having received IM diamorphine in labour,
on management of morbidly adherent placenta. Associated highlighted the potential for side effects when diamorphine is
anaesthetic issues include massive transfusion, cell salvage, used IM and then IT. Should we therefore consider adjusting
type of anaesthetic and post-operative care. our IT dose of diamorphine in women presenting for
Methods: With permission of the Trust's Data Guardian, we emergency cesarian sections? To our knowledge there are no
retrieved data from multiple sources to identify and review guidelines on this subject and clinical practice appears
cases where balloon catheters where used. These included variable.
radiology logs, maternity records and histology. Methods: We conducted a survey of all anaesthetists working
Results: Ten cases were identifed via these systems. Seven in the Southern Health and Social Care Trust who partake in
were for morbidly adherent placenta, of which 5 required obstetric anaesthesia. Questions focused on; current
hysterectomy despite balloon inflation. Many of these were diamorphine practice, diamorphine dose adjustments, factors
cases of placenta percreta, despite antenatal diagnosis of influencing our dose decisions and concerns regarding
accreta. However, blood loss was lower by around 20% potential side-effects with IT diamorphine.
(1078ml) using balloons, when compared to other Results: We received 24 replies; 14 consultants and 10
hysterectomies in the same time period. experienced trainees who regularly perform obstetric
Other indications were for intra-abdominal pregnancy and anaesthesia. There was a wide variation in diamorphine
persistent post-partum haemorrhage. Another case was practice amongst our anaesthetists. The majority (76%)
abandoned due to logistical reasons (unable to organise consider reducing their IT dose following IM diamorphine.
theatre time in same building), a decision felt to be open to Factors influencing this dose reduction include timing (88%)
medicolegal criticism after preparation and planning for and dose (29%) of the last IM diamorphine and clinical signs
balloons. of toxicity (76%). In particular anaesthetists were concerned
about postoperative respiratory depression (94%) and
Limitations particularly reflected the limitations and
drowsiness (88%), although no one surveyed reported
inconsistency of the systems used, for example no coding in
experience of these or other adverse effects associated with IT
records for morbidly adherent placenta. Local presentation
diamorphine.
highlighted these problems, which are being taken forward.
Discussion: There is variability regarding the IT diamorphine
Conclusion: Our review, and subsequent MDT discussion,
dose given to women for emergency cesarian section who
has confirmed the place of intra-arterial balloon catheters
have already received IM diamorphine in labour. This practice
within local guidelines for management of morbidly adherent
is based on limited evidence. Given the lack of adverse effects
placenta, and other occasional indications. We had decreased
reported from our survey and evidence from other specialties
blood loss in cases using balloons, but still saw a large
where diamorphine is used in higher doses 1,2,, we see no
proportion requiring hysterectomy.
reason to routinely reduce the IT diamorphine dose unless
References
there are clinical signs of opiate toxicity. Consideration should
1. Beilin Y, Halpern SH. Placenta accreta: successful outcome is all in be given to prolonged postoperative monitoring of all women
the planning. Int J Obstet Anesth. 2013;22:269–271.
who have received both IM and IT diamorphine, especially
2. Sadashivaiah J, Wilson R, Thein A. Role of prophylactic uterine
artery balloon catheters in the management of women with those in whom the interval between IM and IT diamorphine is
suspected placenta accreta. Int J Obstet Anesth. 2011;20:282-287 short or where there are signs of toxicity.
References
1. Fogarty DJ, Milligan KR. Postoperative analgesia following total
hip replacement ; a comparison of intrathecal morphine and
diamorphine. Journal of the Royal Society of Medicine 1995; 88:
70-72
2. Jacobson L, Kokri MS, Pridie AK. Intrathecal diamorphine: a dose-
response study. Annals of the Royal College of Surgeons of England
1989; 71: 289-292
Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin) P27
P153 Introducing self-administration of medication after P154 Is Remifentanil patient controlled analgesia an
caesarean section: a Robert The Bruce story effective alternative to epidural for labour analgesia?
A R Sajayan,  K Ramm,  T Yates,  Y Chikermane   V Betharia,  K Peckitt  
Anaesthesia, Heartlands Hospital, Birmingham, UK Anaesthesia, Stepping Hill Hospital, Stockport, UK
Introduction: We were involved in the introduction of the local Introduction: Remifentanil patient controlled analgesia (PCA)
protocol for self-administration of postoperative medications was introduced for pain relief in labour at our institution in
(SAM) after elective LSCS at a large obstetric unit. In the past, 2007. Since then its demand has steadily increased, gaining
several attempts to implement this have failed.We conducted a favour with midwives and patients due to simplicity of use,
pilot study to identify the obstacles and develop ways to effective analgesia¹ and good safety profile². We have
overcome the same standardised protocols for administration and monitoring of
Methods:A pilot project was conducted to find out the Remifentanil PCA and patient controlled epidural analgesia
obstacles in the process by obtaining feedback from the staff (PCEA) during labour which are strictly adhered to. Aim of our
and patient involved in the care of 10 patients who underwent audit was to assess both Remifentanil PCA and epidural PCEA
elective LSCS over a week’s time. Obstetric, anaesthetic, for labour analgesia and make recommendations for improved
recovery and ward staff were informed beforehand about this care of mothers and infants.
pilot by emails and personal discussion. The patients were Methods: This was a prospectively done, questionnaire based
given information leaflet during preoperative assessment and audit. Data was collected over 2 months from November 2013 -
were informed again on the day of operation. Interested January 2014. We looked at mode of delivery,
patients enrolled in the pilot with due consent. The self- cardiotocographic abnormalities, APGAR scores, maternal
administration pack contained analgesics and enoxparin and cardio-respiratory complications, conversion to alternative
was dispensed by the recovery staff. Exclusions were: methods of analgesia and patient satisfaction.
language barrier, patient refusal, lack of capacity and any co Results: There were 610 deliveries during the 2 months.
morbidities. Feedback was collected from patients and staff Remifentanil PCA was used in 102 (17%) and epidural PCEA in
using the standardized proforma during the postoperative 85 (12.2%) patients for labour analgesia.
visit. Mode of delivery:
Results:Two of the patients felt that on the first day it was
  Normal Assisted LSCS
difficult to use SAM due to mobility restrictions. One patient
Remifentanil PCA 69 (67%) 20 (19.6%) 13 (12.7%)
did not receive SAM pack due to communication problem
Epidural PCEA 29 (34%) 35 (41%) 21 (24.7%)
involving midwives and staff. The remaining seven patients
were satisfied with SAM. The obstacles we identified in the There was a higher incidence of cardiotocographic
pilot and also from the past experience and the way we tackled abnormality in the epidural group (61%) as opposed to
them are as below: Remifentanil group (34%). APGAR scores in both groups were
more than 8 at 5 minutes. None of the patients in either group
Obstacle Strategy
had respiratory depression or cardiovascular instability. Eight
Personal & email reminder
(7.8%) patients converted from Remifentanil to epidural due to
Promotional posters in clinical areas
inadequate analgesia whereas 4 (4.7%) patients in the epidural
Communication Reminder notices in operating room and recovery
group used alternative analgesia (3 switched to Remifentanil
Meeting with stakeholders (doctors, midwives&
and 1 to entonox). Patient satisfaction was similar in both
pharmacist)
groups at 95%.
Involving all staff in guideline preparation
Discussion: From our experience, Remifentanil PCA is a safe
Staff engagement Process simplified and paper work streamlined
and effective method of labour analgesia. We found no
Standardized SAM package and delivery
evidence of worsening cardiotocography or neonatal
Guideline Fully prepared guideline after extensive consultation
outcomes with its use. We also found that patients using
Time Pre-printed forms to increase efficiency and to avoid
Remifentanil have increased rate of vaginal deliveries as
management time delays and work duplication
compared to those on epidural. While epidural analgesia
Discussion: Self-administrationof medications after caesarean remains the gold standard and will be preferable in certain
provides better patient centered care. It improves patient and groups of patients, Remifentanil PCA is certainly an excellent
staff satisfaction, improves clinical efficiency and eases alternative to consider. In our institution its uptake has
staffworkload at hospital and at community level1. It empowers steadily increased to approximately 50 patients per month with
the mother in their own care, potentially reduces length of patients consistently report ing high levels of satisfaction.
stay, and facilitates seamless flow ofcare. Although staff and References
patients liked the concept alike, the process had failedthree
1. Blair JM, Dobson JT, Hill DA, McCracken GR, Fee JP. Patient
times before because of certain obstacles. This pilot helped us controlled analgesia for labour: a comparison of remifentanil with
to highlight the areas we needed to focus on with our new pethidine. Anaesthesia 2005; 60 (1) : 22-7
strategies and the results have been encouraging. After fully 2. Volikas I, Butwick A, Wilkinson C, Pleming A, Nicholson G.
Maternal and neonatal side-effects of remifentanil patient
implementing the project, the uptake is gradually getting better
controlled analgesia in labour. Br J Anaes 2005; 95(4): 504-9
and we continue to audit the outcome.
References
1. Snell P M, Bowden M I, Viira D J, Chilvers J P. An observational
study of self-medication of analgesic drugs after caesarean section.
Int J Obstet Anesth 2002; 11: S29
2. Change management good practice guideline-NHS Direct
P28 Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin)
P155 Is the existing local hospital guideline, 'Management P156 Klippel-Feil syndrome: management of anticipated
of women who decline blood products', being adhered difficult airway for caesarean delivery 
to? TM Price,  MT Qureshi,  ROK Laird  
J Houston,  R Burns   Department of Anaesthesia, Altnagelvin Area Hospital,
Simpson Centre for Reproductive Health, Royal Infirmary of Derry, UK
Edinburgh, Edinburgh, UK Introduction: Klippel-Feil syndrome (KFS) is a rare genetic
Introduction: An estimated 150000 Jehovah's Witnesses disorder affecting around 1 in 40,000 live births and is
(JWs) live in the UK1. JWs may not accept blood product (BP) characterised by the congenital fusion of any two of the
transfusion1, and have up to 130 times increased risk of cervical vertebrae1. In addition to the abnormalities of the
maternal death from major obstetric haemorrhage2. This cervical spine, patients may have thoracolumbar scoliosis,
retrospective case note review aims to establish how closely spina bifida and congenital heart defects. The classical
the hospital guideline, 'Management of women who decline phenotypic presentation is described as low hairline, short
blood products' (the Guideline), has been followed since its neck and limited neck and head movement. These patients can
May 2012 introduction, and to identify areas for improvement. therefore present a considerable challenge to the anaesthetist.
Methods: JWs managed at the Anaesthetic Antenatal Clinic The safest method of providing anaesthesia for operative
(AAC) since the Guideline's introduction were identified, and delivery of a parturient with KFS is controversial. We would
their medical records accessed. Information surrounding like to share our experience in managing four elective
aspects of patient management addressed by the Guideline caesarean deliveries in two parturients using awake oral fibre
was extracted. The findings were then audited against the optic intubation (AOFOI) and general anaesthesia.
Guideline to establish how closely it had been followed. Case Reports: The first patient had KFS Type II with fusion of
Approval was obtained from the Medical School and the cervical vertebrae and underwent elective caesarean deliveries
Regional Research Ethics Service. aged 35 and 37 years old. The second patient had KFS Type
Results: Of the patients referred (N=26), 92.3% were reviewed III with fused cervical vertebrae in conjunction with fusions in
at the AAC, and had management plans created, at 31.0 weeks' the thoracolumbar spine, and underwent elective caesarean
gestation on average (Guideline target: 28.0 weeks). 88.5% deliveries aged 31 and 39 years old. Our patients were both
completed a BP checklist before admission in labour, and pre-assessed by a consultant anaesthetist at a high-risk
96.2% by time of delivery. 7.7% agreed to accept BPs at clinic pregnancy clinic prior to delivery. This allowed time to discuss
and were discharged, so women studied became N=24. BP the anaesthetic options with each patient and plan for elective
refusal of 12.5% was not appropriately recorded in the notes, or emergency delivery. Both patients had the classical
and contrary to the Guideline, serum ferritin was not checked phenotypic features of KFS. Airway assessments revealed
in any woman. During pregnancy, 29.2% were not recorded as Mallampati class 4, thyromental distances less than 6cm and
having taken iron, and Hb was measured in 95.8%. Excluding severely limited neck flexion and extension. The trachea was
elective caesarean sections (CS), Obstetric consultants were not palpable in either patient. We anticipated difficult direct
documented as informed of admission in 13.6% of cases, and laryngoscopy in both patients and elected to manage the
54.5% of labours and deliveries were reviewed or supervised airway with an AOFOI followed by general anaesthesia. The
by senior Obstetric staff (ST6-consultant). 20.8% of total oral route was chosen as both patients had small nares in
deliveries were by CS: cell salvage was set up in 100.0% of keeping with KFS. Sugammadex ensured complete reversal of
these, and used in 80.0%. rocuronium induced neuromuscular blockade and smooth
Discussion: This study found the Guideline was closely emergence. Caesarean delivery and postoperative recovery
followed in some areas: completion of acceptable BP checklists was uneventful in all four cases.
before delivery, and availability and use of cell salvage in CS,
Discussion: As obstetric anaesthetists we are constantly
compare favourably to previous UK studies1,3. Areas to be
trying to minimise the risk to our mothers. Klippel-Feil
improved include that BP refusal must be appropriately
syndrome affects both the airway and the spine, making the
recorded in patient notes to ensure clarity upon presentation
choice of anaesthetic technique a difficult decision. Successful
in labour or an emergency. It is vital that iron supplementation
use of regional techniques including spinal, epidural and
is commenced early in JWs, and ferritin levels are monitored,
combined spinal-epidural anaesthesia, have all been described
to maximise iron stores. In light of this study's findings,
in the literature1. However, we feel that embarking upon a
hospital blood transfusion Haematologists, in the future, will
regional technique in patients with distorted neuroaxial
review JWs antenatally. The Guideline should quantify how
anatomy would expose patients to unnecessary risk of high
often Hb should be monitored, so anaemia can be detected
spinal block and/or inadequate regional anaesthesia. Should
and treated before delivery. Crucially, consultant staff must be
general anaesthesia be needed intra-operatively, attempting an
documented as informed upon admission of JWs in labour, in
AOFOI in an already distressed parturient would be
order that deliveries can be supervised by senior staff to
challenging. We therefore planned an AOFOI to secure the
reduce potential morbidity and mortality.
airway prior to general anaesthesia, in a controlled manner and
References
thus avoid a potentially difficult and emergent intraoperative
1. Massiah N, Athimulam S, Loo C, Okolo S, Yoong W. Obstetric care intubation. In summary, these are difficult cases that we
of Jehovah's Witnesses: a 14-year observational study. Arch
believe benefit from good antenatal planning and can be
Gynecol Obstet 2007; 276(4):330-343.
managed with a planned AOFOI and general anaesthesia.
2. Van Wolfswinkel ME, Zwart JJ, Schutte JM, Duvekot JJ, Pel M, Van
Roosmalen J. Maternal mortality and serious maternal morbidity in
Jehovah's witnesses in the Netherlands. BJOG 2009; 116(8): 1103- Reference
1108. 1. T. Kavanagh, R. Jee, N. Kilpatrick, J. Douglas. Elective cesarean
3. Nawaz YM, Atkinson S. Peripartum care of Jehovah's witness delivery in a parturient with Klippel–Feil syndrome. Int J Obstet
parturients: A five year review. Int J Obstet Anesth 2013; 22(S1): Anesth 2013; 22(4): 343-8
S22.
Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin) P29
P157 Labour and delivery in long QTsyndrome P158 Local anaesthetic toxicity audit: are workshops the
BJ Vowles,  FMM Bryden   best educational tool across the MDT?   
Anaesthetic department, Princess Royal Maternity, Glasgow, WITHDRAWN FROM PRESENTATION
UK JL Lambert,  D Chitre,  L Evans  
Introduction: A 22 year old primigravida presented to the high Anaesthesia, Southend Hospital, Southend, UK
risk clinic at 22 weeks gestation. She had been diagnosed with
long QT syndrome (LQTS) after her family had been
investigated following a sudden early cardiac death and was
found to be heterozygous for the KCNQ1 gene, responsible
for Long QT1. She was under regular review by the
cardiologists who had advised β blockade with bisoprolol
2.5mg orally (PO) for 9 months post partum due to an increase
in arrhythmia risk during this period. She had also been given
a list from Azcert Inc., advising drugs that should be avoided
and included on this list was syntocinon.
Labour and delivery: She was admitted in labour at term and
the decision was made by the obstetric team, not to administer
syntocinon to augment labour. They also felt that epidural
analgesia was unsuitable because it would slow the progress
of labour. However following an initial dose of intramuscular
(IM) diamorphine, the parturient requested epidural analgesia.
We felt this would be beneficial for minimising her arrhythmia
risk and so she obtained a working epidural with a bilateral T10
block. ECG monitoring was commenced on admission and
.
initially showed bigeminy. A 12 lead ECG demonstrated a QTc
of 460ms. Electrolytes checked at this time were in the normal
range. Over the subsequent 8 hours she failed to progress and
underwent a caesarean section with an effective epidural top
up of 20ml 0.5% L-bupivacaine. At delivery syntocinon was
administered as a slow infusion of 5 units in 100mls 0.9%
saline over 20 minutes, followed by 500µg ergometrine IM to
maintain uterine tone. 50mg IM cyclizine and 10mg
intravenous (IV) metoclopramide were used for anti-emesis.
She was monitored in the Obstetric high dependency unit
(HDU) for the following 48 hours, where an initial ECG
demonstrated frequent ventricular ectopics, with a QTc 432ms.
Electrolytes were again normal at this time.
Discussion: There are many lists of drugs available on the
internet with differing advice as to which drugs to avoid in
long QT syndrome. The one which our patient had been given
clearly stated syntocinon should not be administered, despite
no definitive evidence of harm with this drug in patients with
LQTS. In addition we found no guidance in published case
reports, on oxytocic drugs administered to patients with LQTS
in labour or at delivery1. There are case reports of ventricular
tachycardia after administration of syntocinon in long
QTsyndrome2 and one report of a pateint receiving it with no
sequelae3 Ideally the authors feel that this lady merited a case
conference prior to admission so that informed decisions
could be made. Whilst the outcome of this patient's labour and
delivery may not have been different, a short trial of
syntocinon with ECG monitoring may have altered her mode of
delivery.
References
1. Drake E, Preston R, Douglas J. Brief review: anaesthetics
implications of long QT syndrome in pregnancy. Can J Anaesth.
2007; 54(7): 561-72
2. Liou SC, Chen C, Wong SY, Wong KM. Ventricular tachycardia
after oxytocin injection in patients with prolonged Q-T syndrome -
report of two cases. Acta Anaesthesiol Sin 1998; 36: 49-52
3. Charbit B, Funck-Bretano C, Samain E, Jannier-Guillou V,
Albaladejo P, Marty J. Qt interval prolongation after oxytocin bolus
during surgical induced abortion. Clin Pharmacol Ther 2004; 76:
359-64
P30 Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin)
P159 Lymphangioleiomyomatosis and Pregnancy: A Case P160 Major obstetric bleeds-are we doing the right thing?-
Report A multi-centre study in west midlands
M Cole,  S Petkov,  J Pickett   A R Sajayan,  M McLoughlin,  S Dinesh,  A Walunj*,  J
Anaesthetics, Addenbrookes Hospital, Cambridge, UK Karattuparambil †,  M Ravindran†  
Introduction: Anaesthesia, Heartlands Hospital, Birmingham, UK,
Lymphangioleiomyomatosis (LAM) is a rare condition causing *Anaesthesia, Good Hope Hospital, Sutton Coldfield, UK,
proliferation of smooth muscle in the respiratory system, †Anaesthesia, George Eliot Hospital, Nuneaton, UK 
which can cavitate leading to degradation of lung parenchyma Introduction:Guidelines1 exist on the definitions of massive
and cystic lung disease1. Because of the risk of progression, bleed, the proposed management pathway and the safe time
women with LAM are frequently advised to avoid pregnancy2. frame for obtaining the blood and products. This multi-centre
We present a case of LAM where multidisciplinary audit looks at the average time taken for the blood/products to
management led to a successful outcome of pregnancy, with a be available in major bleed situations in obstetrics
focus on anaesthetic considerations. Aim: To find out the incidence and reasons for delays in
Case Study: issuing the blood/products, if any, from the blood bank and to
A 35 year old woman presented with bilateral spontaneous compare the existing practices and experience with the other
pneumothoraces in the first trimester of her 2nd pregnancy. hospitals in the area
Both required surgical correction and a lung biopsy revealed a Methods: We collected the data from three participating
diagnosis of LAM. Computerised tomography of her thorax hospital in west midlands using a standard proforma which
showed multiple small lung cysts. Past history included an included the number of massive obstetric bleed calls during a
uncomplicated first pregnancy and emergency caesarean six months period in 2013, the estimated blood loss, the time
section for foetal distress, aged 33; and a spontaneous taken for the first unit of blood/ product to be issued and the
pneumothorax aged 34, requiring surgery. The patient was number of products used among other data.
referred to a tertiary centre for multidisciplinary management.
Results: The results suggested that there is ambiguity in the
Care was shared between obstetrics and respiratory medicine
way major haemorrhage was defined in different situations
and she attended the high risk anaesthetic clinic. Elective
which led to unnecessary calls where blood products were not
caesarean delivery at 38 weeks was agreed upon. She had
urgently needed. Also, the time for getting the products varied
three further small pneumothoraces, treated conservatively
widely the longest being 200 minutes. The documentation of
with no marked deterioration in respiratory function. Elective
the details of the bleeding, time of calls and time of
caesarean section was performed at 38/40 gestation.
blood/product administration were incomplete and inaccurate
Respiratory assessment and examination on the morning of
in some cases.In one hospital, major bleed calls were only put
surgery were normal. A two-space combined spinal epidural
out in two out of 17 cases where blood loss was more than
was sited, administering intrathecal hyperbaric bupivacaine
1500ml.
and diamorphine. A respiratory physician was present at
delivery in case of deterioration. Delivery was uneventful, with   Hospital1 Hospital2 Hospital 3
no immediate complications. The patient spent 24 hours in an Number of MOH calls 58 41 2
obstetric close observation unit post-operatively. Her post- Full data available 13 18 2
natal period was uneventful and required no further obstetric, Average time for group specific (min) 59 NA 33
respiratory or anaesthetic intervention. Average time for X match blood (min) 63.45 42.27 0
Longest delay (min) 200 104 33
Discussion: LAM is a rare condition with an estimated UK
prevalence of 1per million3. Hypotheses suggest oestrogen
Discussion: The definitions of massive blood loss are:
accelerates disease progression and pregnancy may result in
Transfusion of a volume equal to the patient’s total blood
new diagnosis or exacerbation4, therefore obstetric
volume in less than 24 hours / 50% loss of blood volume
anaesthetists should have awareness of this disease. There is
within 3 hours / rate of blood loss 150ml/minute. Though the
sparse literature for anaesthetic management of pregnancy
circumstances of individual episodes of major bleed could
with LAM, consisting mainly of case reports. Considerations
vary, there was no consistency in the trigger of activating
suggested include; avoiding excessive Valsalva manoeuvre
major bleed calls. There were also unacceptable delays in
via instrumental or elective caesarean delivery, avoid nitrous
obtaining the first unit of blood in some cases. The first set of
oxide, early epidural analgesia, obtunding intubation response
uncross matched group specific blood should be available in
and lung protective ventilation strategies if general
20minutes and cross matched blood in 40minutes2. The study
anaesthesia. This case report supports that pregnancy in
suggest that there is a need for the reinforcement of major
LAM patients can progress successfully and highlights the
bleeds definition and also a need for a clearer pathway and
importance of a MDT approach, early anaesthetic assessment
consistency in issuing blood and products in major bleed
and a well considered anaesthetic and obstetric plan.
situations. This audit results will be used to formulate a
References uniform policy in the participating hospitals and a re-audit will
1. Rosendal T. A Case of Diffuse Myomatosis and Cyst Formation in be done in six month time
the Lung. Acta Radiaology. 1942; 23: 138-146
2. Cohen MM, Freyer AM, Johnson SR. Pregnancy Experiences References
Among Women With Lymphangioleiomyomatosis. Respiratory
1. D Thomas etal,Blood transfusion and the anaesthetist: management
Medicine. 2009; 103: 766-772
of massive haemorrhage, Anaesthesia 2010 November; 65(11):
3. Johnson SR, Tattersfield AE. Clinical Experience of 1153–1161
Lymphangioleiomyomatosis in the UK. Thorax. 2000; 55:1-5
2. Guidelines on the management of massive blood loss.
4. McLoughlin L, Thomas G, Hasan K. Pregnancy and BJHaematology 2006; 135(5): 634-641
Lymphangioleiomyomatosis: Anaesthetic Management.
International Journal of Obstetric Anaesthesia. 2003; 12: 40-44
Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin) P31
P161 Management of labour and delivery using  minimally  P162 Management of manual removal of placenta and third
invasive FlotracTM system in a parturient with  and fourth degree tear repair: pathway analysis
congenitally corrected transposition, dextrocardia P Jegendirabose,  J Subramanya*,  S Watkinson*,  J Short  
and systemic ventricular dysfunction Anaesthesia, Queen Elizabeth Hospital, Woolwich, London,
R Vedagiri Sai,  S Dhir,  J Racine   UK, *Obstetrics & Gynaecology, Queen Elizabeth Hospital,
Anesthesia, Western University, London Ontario, Canada Woolwich, London, UK
Introduction: More women with congenital heart disease now Introduction: Guidelines suggest that repair of obstetric anal
survive to reproductive age due to advances in modern sphincter injuries (OASIS) and manual removal of retained
medicine. Obstetric management is challenging in these placenta (MROP) should be undertaken as soon as possible to
complex cases. We present the anaesthetic management of minimise the risk of infection, blood loss and maternal
labour and delivery in a woman with congenitally corrected morbidity1,2. Anal incontinence and perineal pain can impact
transposition of great vessels, dextrocardia, systemic significantly on maternal quality of life and mother-child
ventricular dysfunction and junctional tachycardia using bonding.
minimally invasive continuous haemodynamic monitoring and Methods: We conduced a retrospective audit which showed
optimisation. shortcomings in our management of MROP and OASIS and we
Case report: A 28 year old primigravida presented with a undertook an analysis of a full calendar year's cases. All cases
diagnosis of congenitally corrected transposition of great of MROP and OASIS were identified over January 2012 to
vessels and dextrocardia. The atrial septal defect had been December 2012 using both theatre electronic records and
repaired in childhood. Her medications included folate and maternal records. Time from delivery of fetus to MROP or
multivitamins. She had good exercise tolerance, stable vital OASIS repair, blood loss and blood transfusion requirement
signs and was followed up by Cardiology team throughout her were reviewed.
pregancy. ECHO showed 50% ejection fraction (EF) and mildly Due to lack of nationally set standards, we set a local standard
reduced systemic (morphologic right) ventricle. A multi- of no more than one hundred and twenty minutes from
disciplinary meeting between Obstetrics, Cardiology, delivery to repair for OASIS.
Anaesthesia and Intensive care unit (ICU) team was held to
Results: Our institute is a secondary obstetric centre with
decide on optimal obstetric management. Induction of labour
4800 deliveries per annum. During the twelve month period,
was planned.
105 patients sustained OASIS. The mean delay from delivery
At 37 weeks she developed palpitations, increasing shortness to surgery was 136 minutes. The average blood loss was 501
of breath and peripheral oedema. Repeat ECHO showed millilitres and 3% of patients required blood transfusion. Total
moderate ventricular dysfunction with EF 40%, severe of 42 patients required manual removal of placenta with
systemic atrioventricular regurgitation and severely enlarged regional or general anaesthesia. The mean delay from delivery
left atrium. Prior to labour induction, an arterial line was to surgery was 178 minutes. The mean blood loss was 790
inserted and continuous cardiac output monitoring was millilitres and 5% of the patients required blood transfusion.
performed using arterial pressure waveform analysis with the
FloTracTM monitor. Haemodynamic optimization was guided OASIS repairs n=105 Time (minutes)
by stroke volume variation and goal directed fluid therapy. A Delivery to booking 81 (Cl 70-92)
lumbar epidural was then inserted followed by rupture of Booking to surgery 68 (Cl 40-95)
membranes and oxytocin infusion. Fluid balance was closely Delivery to surgery 136 (Cl 122-150)
monitored continuously using FloTracTM. 1st stage of labour MROP n=42 Time (minutes)
was uneventful and 2nd stage was shortened using vacuum Delivery to booking 138 (Cl 115- 160)
assisted delivery of a healthy baby. She had a second degree Booking to surgery 39 (Cl 32-46)
tear which was repaired. Post partum haemorrhage due to Delivery to surgery 178 (Cl 152-204)
uterine atony was treated with 400µg Misoprostol rectally and
Incidentally, 78% of the patients did not have electronic record
intravenous infusion of 20 IU of Oxytocin. Estimated blood
of estimated blood loss on the theatre system.
loss was 800 mL. Cardiac condition was stable apart from
Discussion: In our institution, these cases are booked onto
persistent tachycardia throughout labour. Postpartum, she
the general emergency theatre, and not in the designated
spent 24 hours in ICU with similar monitoring. Her tachycardia
emergency obstetric theatre. We have identified that this has
settled spontaneously. She was discharged home on day 4.
resulted in significant delay in surgery and increased blood
Discussion: Patients with congenitally corrected transposition
transfusion requirement. We are now changing the patient
have a thin-walled right ventricle as the systemic circulatory
pathway to include urgent utilisation of the emergency
pump. The stress of increased cardiac output can cause
obstetric theatre for these procedures. Since the presentation
failure, atrioventricular regurgitation and arrhythmias1. We
of this audit, we have included the estimation of blood loss in
used minimally invasive continuous cardiac output
the surgical sign out process, thus improving communication
monitoring, fluid balance optimisation and good maternal pain
and patient care.
control to prevent decompensation and achieve vaginal
References
delivery with a good feto-maternal outcome.
1. National Institute for Health and Care Excellence. 2007.
Reference Intrapartum care. Care of healthy women and their babies during
childbirth. Clinical guideline 55
1. Dob DP, Naguib MA, Gatzoullis MA. A functional understanding of
moderate to complex congenital heart disease and the impact of 2. Fernando RJ, Sultan AH, Kettle C, Thakar R. Methods of repair for
pregnancy. Part I: the transposition complexes.Int J Obstet Anesth. obstetric anal sphincter injury. Cochrane Database Syst Rev. 2013
2010 Jul;19(3):298-305 Dec 8;12:CD002866.
P32 Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin)
P163 Multidisciplinary involvement of the high risk P164 National Obstetric Anaesthetic Database: a useful tool
parturient to benchmark maternity units in the UK
S De Silva,  P Gregory,  E Combeer   G Keightley,  N Tailor,  R Baraz,  L De Lloyd  
Anaesthetics, Frimley Park Hospital, Frimley, UK Anaesthetics, University Hospital of Wales, Cardiff, UK

Our Hospital offers a high risk Obstetric Anaesthetic Clinic for Introduction: The National Obstetric Anaesthetic Database
review of parturients with anticipated Anaesthetic or Medical (NOAD) was set up in 1998 to establish a framework for
problems where a checklist referral form is used. We audited collecting national obstetric anaesthetic data considered
whether women were appropriately referred or inappropriately relevant to obstetric anaesthetists. Whilst preparing the
not referred. An alert sticker was created to encourage NOAD survey for 2012, we explored the usefulness of this
healthcare providers to alert the oncall Obstetric Anaesthetist data in benchmarking our units' performance at the University
when the high risk parturient presented to labour ward. We Hospital of Wales (UHW) in relation to NOAD published
went onto audit the effectiveness of this alert sticker. figures from the previous year.

Methods: Data was collected according to the NOAD 2012
Methods: We looked at 200 consecutive births during October
survey and therefore, ethical approval was not required. Due
2010 and ascertained how many of these women had referrals
to the large number of deliveries in our unit, data regarding
to the High Risk Clinic. In the referred cases, we asked whether
labour analgesia, mode of delivery, caesarean section rate and
referral criteria were met and also determined if any mothers
type of anaesthesia was based on six months period (Jan to
were inappropriately not referred. In 2012 we retrospectively
June 2012) and then doubled. Exceptions were critical care
inspected all notes of mothers seen in High Risk Clinic with an
admissions and patients with accidental dural puncture (ADP);
estimated delivery date of March to May 2012. We checked
these were collected and reviewed individually for the entire
whether an alert sticker was present in their notes and also the
year. Microsoft Excel was used to analyse the data.
time taken for the Obstetric Anaesthetist to be contacted once
the mother had presented to Labour Ward. Results: The number of total deliveries in our unit for 2012

was 6138, of which 3060 required anaesthetic procedure(s).
Results: In 2010, 178 of 200 notes were reviewed and 14
The table below compares performance and quality indicators
women met referral criteria and 12 of these were referred.
at UHW in 2012 with the NOAD averages from 2011.
Fourteen percent were therefore inappropriately not referred,
however no women were inappropriately referred. Indicator UHW 2012 NOAD 2011

Caesarean section (CS) rate 22% 24.8%
In 2012, 42 notes were inspected where only 8 had the alert
Elective CS rate 46% 39.1%
sticker in place, with only 5 in the correct position. Two
De novo general anaesthesia (GA) for CS 4.5% 4.7%
mothers with the alert had elective caesarean sections. In five
Conversion to GA (CS) 1.8% 3.5%
of the six remaning mothers, the oncall Anaesthetist was
Labour regional analgesia 27% 22.7%
informed of their presence on labour ward. The average time
Epidural re-site rate 7.7% 9%
taken for this was four hours and 45 minutes (range 10 minutes
Accidental dural puncture rate 0.9% 1.2%
to 10 hours and 50 minutes). On review of the Clinic letters, it
was felt that 30 of the 42 parturients should have had an alert In 2012, three cases were transferred to critical care unit as
present in their notes, which is 71% not 19% as shown by our level 2 care (two with sepsis and one adult respiratory distress
audit. syndrome) and six cases as level 3 care (two with sepsis, three

post partum haemorrhage and one case of amniotic fluid
Discussion: In many cases of substandard care assessed by
embolus).
CMACE, there were major failures of communication between
Discussion: Our unit is classified as a large maternity unit
healthcare workers that may have contributed to the woman’s
compared to the national average. The elective CS rate and
death in some cases1. Our audits demonstrated that local
labour regional analgesia rates in our unit are higher than the
guidelines for referral were followed in 99% of cases, therefore
national average, possibly related to the complexity of a
high risk mothers were identified early. However, there still
tertiary centre. Despite this, our total CS rate is well below the
lacks effective communication of concerns within teams and
average with very low conversion to GA. In addition, our
poor involvement of other specialties early.
epidural re-site rate is lower than the national average, as is
Reference our ADP rate. Current facilities include two theatres serving
1. Centre for Maternal and Child Enquiries (CMACE). Saving both emergency and elective streams, and a mixed
Mothers'. Lives: reviewing maternal deaths to make motherhood recovery/high dependancy unit (HDU) for up to 5 patients.
safer: 2006–2008. The Eighth Report of the Confidential Enquiries
Our unit has a low transfer rate as level 2 care in general HDU,
into Maternal Deaths in the United Kingdom. BJOG 2011;118:1-203
due to the ability to care for these patients on our unit. We
find the NOAD data a useful tool to benchmark our
performance and set standards of care. More units should
contribute to the annual NOAD survey and consider using the
data as a way of identifying shortfalls and improving patient
care and services.
Reference
1. National Obstetric Anaesthetic Database report 2011.
http://www.oaa-anaes.ac.uk/content.asp?ContentID=586
Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin) P33
P165 Obstetric admissions to the Intensive Care Unit: a 6 P166 Obstetric outcomes with programmed intermittent
year review at a UK tertiary maternity centre epidural bolus labour analgesia
R Labib,  K Cullis   JTE Cremin,  CH Papageorgiou  
Selwyn Crawford Department of Anaesthesia, Birmingham Department of Anaesthesia, Hillingdon Hospital, Uxbridge,
Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin) P1
P101 A modified WHO surgical safety checklist for P102 A parturient with phocomelia and severe needle
category 1 caesarean sections phobia: the challenges faced
A Lahkar,  A Cooney,  G Massolini   R Sinha,  K Howard,  N Bhandal  
Anaesthetics, Milton Keynes NHS Foundation Trust, Milton Department of Anaesthesia, Nottingham University Hospitals
Keynes, UK NHS Trust, Nottingham, UK
Introduction: In June 2008, WHO introduced a surgical safety Introduction: Parturients with phocomelia are rarely seen and
checklist to be used in every operating theatre to improve present anaesthetic and obstetric challenges. We present a
patients' safety. In 2010 a WHO surgical safety checklist for case of a parturient with phocomelia and severe needle phobia.
maternity was created in response to requests from maternity Case report: A 33 year old woman with phocomelia and severe
services and clinicians. Nevertheless, in some emergency needle phobia presented to the obstetric anaesthetic clinic at
situations like category 1 Caesarean sections, this checklist 20 weeks for pre-assessment.
could still be quite a difficult task to achieve due to Her phocomelia was thought to be idiopathic, she had been
understandable time limit constrains to safely deliver the baby adopted when young and no family/drug history was
and/or save the mother's life. available. Examination revealed four limb phocomelia. There
Whilst there is still no international consensus or any specific were absent upper limb bones on the right and a fused hand
recommendation from WHO concerning these specific attached directly to her body. Her left upper limb was
situations, the Anaesthetic Department in Milton Keynes shortened with a primitive hand and fused fingers. Both lower
hospital has managed to devise a checklist for cat 1 LSCS limbs were extremely shortened with primitive feet with fused
which is 100% compliant both in terms of content with WHO toes. Her head, neck and torso appeared normal. She was able
guidelines and adherence by hospital staff. to mobilize with a wheelchair and significant assistance from
Method: After considerations and inputs from the Consultant her partner. The problems faced in clinic were numerous and
Anaesthetists, a simplified checklist was introduced in our focused on her severe needle phobia, difficult venous access
emergency obstetric theatre in June 2013 by way of an ad hoc and monitoring, positioning, mobilization and
poster hanged on the wall. It spells out the most 10 salient thromboprophylaxis as well as the challenges posed by the
questions to be read by one of the theatre staff before the start preganancy itself. The anaesthetic plan consisted of non-
of a category 1 Caesarean section. These questions translate invasive blood pressure monitoring on her left lower extremity;
the original 32 WHO ones that were spread across 3 sections pulse oximetry via an ear probe or toe and standard
in a simpler, quicker format. electrocardiogram. These were tested prior to labour. Due to
Results: After the introduction of the modified WHO checklist the impossibility of standard intravenous access and extreme
in June 2013, compliance is 100%. needle phobia several discussions were had about obtaining
Discussion: By putting the combined know-how and intravenous access prior to labour. A right subclavian
experience of many Consultant Anaesthetists to the task, we Hickman line was inserted at 39 weeks facilitated by the use of
managed to simplify the original WHO narrative into a sharper entonox. Regional analgesia was refused for labour so the
tool that is quickly and effectively utilised for a better and option of intravenous fentanyl via a midwife controlled
safer quality of care in what has become a "normal routine" analgesia pump was discussed. Should a caesarean section be
during extraordinary times in the emergency theatre. required a neuroaxial anaesthetic was refused and so a general
anaesthetic was planned.
Reference At 40+2 weeks spontaneous rupture of membranes occurred
1. WHO surgical safety checklist: for maternity cases only, and labour established. However, due to failure to progress a
http://www.nrls.npsa.nhs.uk/resources/?entryid45=83972 decision was made to perform a caesarean section.
In theatre the challenges related to positioning and achieving
a satisfactory left lateral tilt. A rapid sequence induction was
conducted following pre-oxygenation to an end-tidal oxygen
concentration of 92%. Anaesthesia was induced with
thiopentone 350mg and suxamethonium 100mg. Soon after
induction she desaturated rapidly to the high 60s. This
resolved after tracheal intubation and ventilation. She was
hypotensive intra-operatively, with an estimated blood loss of
1300mL After fluid and blood resuscitation, recovery was
unremarkable. Postoperative pain was managed with
transversus abdominus plane blocks and morphine
patient/midwife controlled analgesia.
Discussion: There is little literature about managing delivery
in women with phocomelia, but sucessful regional techniques
have been described although this was refused here. Early
discussion of anaethesia and analgesia options, and plans for
vascular access and monitoring are needed, There is a reduced
vascular reservior and skeletal muscle mass.
As a consequence faster inductions, emergences and
responses to titrated drugs are observed.

P2 Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin)
P103 A questionnaire to evaluate and aid future development P104 A retrospective descriptive analysis of anaesthesia for
of the AAGBI's SAFE obstetric anaesthesia course in successful cervical cerclage in pregnancy
Liberia J Modha,  G Burul*,  F Forya*,  CP James*,  AL David*,  J
JCO Fox,  CE Richards*,  T Sheraton*,  A Sonah†   Dick,  L Wee  
†Department of Anaesthetics, Phebe Hospital, Bong County,  Department of Anaesthesia, University College London
Liberia, *Department of Anaesthetics, Royal Gwent Hospital, Hospitals NHS Foundation, London, UK, *Department of
Newport, UK, Department of Anaesthetics, University Obstetrics, University College London Hospitals NHS
Hospital of Wales, Cardiff, UK Foundation, London, UK
Introduction: Dr Kate Grady has developed this three-day Introduction: Cervical cerclage is a common operation which
refresher course in obstetric anaesthesia on behalf of the requires an anaesthetic. There are no studies on the type of
AAGBI. The course is aimed at non-physician anaesthetists in anaesthesia used for this procedure.1
developing countries. It consists of short lectures, interactive Aim: To determine the type of anaesthesia used for vaginal
sessions and workshops that focus on the recognition and cervical cerclage.
management of leading causes of maternal death in resource
Method: Ethical approval waived. Women having any vaginal
poor settings. The course has been taught in Uganda,
cervical cerclage (Macdonald or Shirodkar) during pregnancy
Bangladesh, Liberia and Ghana. It includes the principles of
between January 2005 and December 2012 were identified
the WHO Safe Surgery and training of trainers. Mothers of
using the hospital obstetric anaesthesia database and cross-
Africa, a medical educational charity, has led delivery of 2
referenced with data from the Preterm Birth clinic where women
courses for nurse anaesthetists (NAs) in Liberia - supported
at risk of preterm birth are seen antenatally. Data was obtained
by the AAGBI IRC. Liberia has approximately 60 nurse
by examination of obstetric case notes and the ultrasound
anaesthetists and no medically qualified anaesthetists for a
scan records and analysis conducted using Microsoft Excel.
population of 4.2 million people1. Access to CPD is difficult.
Results: There were 190 cases. Twenty-five patients were
The MMR in Liberia is 770 per 100,000 live births1. In order to
excluded due to incomplete data, hence 165 included in
plan future development of the course in Liberia, which will be
analysis. The mean gestational age was 16.6 weeks (range 9-
led by Liberian trainers, feedback data was collected.
23.6 weeks). The table below shows that both general
Methods: A follow up questionnaire was given to 35 NAs who
anaesthesia (GA) and regional anaesthesia (RA) were used.
had previously attended a SAFE obstetric anaesthesia course
The majority of regional anaesthetics were spinals (95.7%), the
held in Liberia (March 2012 or March 2013). We aimed to
rest combined spinal and epidural (CSE) (3.6%) and epidural
assess; 1) the quality, usefulness and appropriateness of the
top up (0.7%).
material taught during the course, 2) the effect on motivation
to improve local services/care delivery, 3) the effect on the GA RA

confidence levels of NAs in managing obstetric anaesthetic n (%) n (%)
emergencies. Spinal n = 133
Results: A 70% follow up rate was achieved. 97% reported Total n=165 26 (16%) 139 (84%) CSE n = 5
positive changes in their attitude to work and their clinical Epidural n = 1
practice and 94% reported improvements in interactions with Five patients who had a spinal anaesthetic required second
colleagues. Many NAs gave details of cases where the skills procedures (3 GA, 1 spinal, 1 CSE). Of those converted to GA,
and knowledge they learnt on the course helped save lives one patient had a block to T6 (the reason for conversion to GA
and improve clinical outcomes. 11 NAs requested continued was not documented), one patient had a block to T12 and the
education and training. Other suggestions for course third patient had 3 failed spinal attempts. In all cases there
improvement included; additional sessions in preoperative were no major anaesthetic complications and cervical cerclage
assessment and TAP blocks, and the inclusion of midwives in was placed successfully.
the training sessions. The following table illustrates the mean
Discussion: In this series, the majority of vaginal cervical
subjective confidence scores (between 0 and 10) of the NAs in
cerclage surgery was performed safely and effectively under
various clinical scenarios before and after the course.
RA. There are no specific guidelines regarding the type of
  Before After anaesthesia for cervical cerclage.1 Anaesthetic considerations
General anaesthesia LSCS 6.3 9.2 favouring a regional anaesthetic in pregnancy include the risk
Spinal anaesthesia LSCS 7.6 9.8 of aspiration and difficult airway management in patients over
Management of severe eclampsia/preeclampsia 5.7 9.2 20 weeks gestation and those under 20 weeks gestation if at
Management of obstetric haemorrhage 5.9 9.4 high risk for example those with a high BMI. The majority of
women in our data set were less than 20 weeks (88.5%). Other
Discussion: Our results indicate that the SAFE obstetric
considerations include patient and surgeon choice. Women in
anaesthesia course in Liberia has been well received with
this series were given the option of GA or RA. In certain cases
subjective evidence of empowerment and improved methods
for example rescue and abdominal cerclages, the patient may
of working. This is promising in the context of increasing the
need to be in a deep Trendelenberg position to aid reduction
reach of future courses and enabling local faculty to lead
of membrane prolapse to avoid membrane rupture or to aid
training. Further data from logbooks provided as part of the
access to the pelvis.2
course were not obtained and more work is needed to
encourage completion of the logbooks. Objective evidence is References
required to demonstrate impact on patient outcomes. 1. Cervical Cerclage, Green-top Guideline No 60, Royal College of
Reference Obstetricians and Gynaecologists, May 2011.
2. Olatunbosun OA, Dyck F. Cervical cerclage operation for a dilated
1. http://data.worldbank.org/indicator/SH.STA.MMRT/countries/1W-
cervix. Obstet Gynecol. Feb 1981;57(2):166-70.
LR?display=graph
Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin) P3
P105 A retrospective descriptive analysis of dose of P106 A step towards improving theatre productivity for
intrathecal anaesthesia and adjuncts for successful elective caesarean sections
cervical cerclage in pregnancy S Kale,  C Farrow,  N Owen,  K Miltsios  
J Modha,  G Burul*,  F Forya*,  CP James*,  AL David*,  J Department of Anaesthesia, Whittington Hospital, London,
Dick,  L Wee   UK
Department of Anaesthesia , University College London Introduction: NHS Institute for Innovation and Improvement
Hospitals NHS Foundation, London, UK, *Department of developed The Productive Operating Theatre Programme to
Obstetrics, University College London Hospitals NHS improve effective use of theatre time, staff and patient
Foundation, London, UK experience.1 Good administrative system and organisation is
Introduction: Cervical cerclage is a common operation, which essential to ensure theatre efficiency.2On this background,
requires either a general or regional anaesthetic aiming for a with the rational of making existing system more productive,
block height of T10. There are no studies determining the dose safe and reliable, we evaluated current practice in one of our
that should be used to achieve this or describing additional main theatres, designated for elective sections, in a DGH set
drugs used for successful surgery. up.
Aim: To determine the dose of local anaesthesia used for Methods: Evaluation was carried out over a 4-week period, for
intrathecal injection and the block height achieved in women planned caesarean sections. The data was collected
undergoing cervical cerclage. In addition to determine the use concurrently by the anaesthetist for that case and from the
and dose of adjuncts. theatre database. The exact time for all significant events, such
Method: Ethical approval waived. Women having vaginal as when patient was sent for or when theatre was clean and
cervical cerclage during pregnancy between January 2005 and ready for the next patient, was recorded. Reasons for delays,
December 2012 were identified using the hospital obstetric duration of anaesthesia, surgery and problems encountered
anaesthesia database and cross-referenced with data from the were also recorded. Time spent at and between different
Preterm Birth clinic. Data was obtained by examination of crucial stages in theatre was calculated from the data. Results
obstetric case notes and the ultrasound scan records and are presented in the form of time in minutes, median [range]
analysis conducted using Microsoft Excel. and % (absolute numbers of cases).
Results: In all cases, cervical cerclage was achieved Results: We had 25 completed forms. Our analysis showed,
successfully. There were 138 cases of intrathecal anaesthesia median time interval from patient sent for to arrival in theatre
(133 spinals and 5 combined spinal epidurals) in whom 67.4% as 5 min [1-29]. Reasons for delay were due to obstetric team
(93/138) had documented intrathecal anaesthetic dose and busy in meeting, midwife busy preparing the patient and
were included for final analysis. Hyperbaric bupivacaine 0.5% midwife busy completing paperwork for previous patient in
was used (mean dose 10.9mg, median 10.8mg and mode 10mg, recovery. Median time interval between patient's arrival and
range 6.5–15mg). Block height and dose of intrathecal neuraxial block was 18 min [10-70], prolonged in 8% of cases
anaesthetic was documented in 54/93 cases (58%). The block (2/25) due to failed and repeat block. Bladder catheterisation
height ranged from T2 to T12 with similar doses of local after block was delayed by ≥30 min in 8% of cases (2/25) due
anaesthetic given in each group and of similar gestation and to unavailability of midwife. Median anaesthetic time for
body mass index (BMI). satisfactory block was 12 min. Interval between block ready
and knife to skin (KTS) was 6 min [1-12]. Median surgery
Block height T2-4 T5-8 T10 T12 duration was 45 min [31-141]. PPH, high BMI, and previous
Frequency 7 31 13 3 laparotomies resulted in longer operations in 16% of cases
Mean dose mg (4/25). Median turnaround time between the cases was 10 min
11 11 11 8
hyperbaric bupivacaine 0.5% [6-15]. Total time patients spent in theatre was 89 min [74-183].
Mean gestation (weeks) 17.4 17.7 15.6 19.1
Discussion: We noted that unavailability of obstetric team
Mean BMI kg/m2 27.3 26.6 26.1 32
and busy midwives at times has resulted in late starts and
In 3 patients that had block heights of T12 only one was delay in some procedures in theatres. Delay in starting the
converted to GA. Opiates were used in 73/93 (78.5%), the most surgery after a satisfactory block and prolonged turnaround
frequent being fentanyl. time have also affected the overall theatre productivity. We
have put forth some recommendations to working group such
Mean dose Range
Opiate used Number (%) as offering administrative support to midwives, ensuring
(mcg) (mcg)
senior obstetrician and anaesthetist are present for difficult
Fentanyl 69 (95) 20 10-75
cases, making use of anaesthetic room to improve patient
Diamorphine 3 (4) 300 250-350
turnaround time and most importantly encouraging staff
Fentanyl & Diamorphine 1 (1) 20/300 N/A
nurses to take the lead role in increasing theatre efficiency.
Vasopressors were used in 26 cases (23 phenylephrine, 3 This could be a big step towards enhancing theatre output as
ephedrine). Other drugs included 3 cases of intravenous well as increasing patient and staff satisfaction. We aim to
midazolam, 1 case propofol and in 1 case salbutamol (as a introduce these changes soon and re-evaluate the practice in
tocolytic agent). the near future.
Discussion: In our case series there is a wide dose range of References
both hyperbaric bupivacaine 0.5% and opiate given. To 1. The Productive Operating Theatre programme,
achieve a block height of T10 or above a minimum dose of http://www.institute.nhs.uk/quality_and_value/productivity_series/the
11mg (2.2ml) is recommended which may be independent of _productive_operating_theatre.html
other factors. There is a wide variation in block height but 2. Theatre Efficiency,
http://www.aagbi.org/sites/default/files/theatreefficiency03.pdf
even a low block (T12) was found to be adequate.

P4 Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin)
P107 A year in the "maternity" life of an increasingly busy P108 Abstracts on the antenatal anaesthetic clinic
new build district general teaching hospital - coping presented to the Obstetric Anaesthetists' Association,
with training and service provision - 2013 1991-2013
H Wrigley,  PF Yoxall,  Janet Slee   AJ Wickham,  SM Yentis*  
Anaesthetics, St Helens & Knowsley NHS Trust, Liverpool, Anaesthetic department, St Mary’s Hospital, London, UK,
UK *Anaesthetic department, Chelsea & Westminster Hospital,
Introduction: Since moving to a new PFI built hospital in 2010 London, UK
our maternity unit has become more busy. Delivery rates/year Introduction: National reports1 and guidelines2 recommend
have increased from 2900 to 3700 pa (up 27.6% in 3 years) assessment of women with ‘high-risk’ pregnancies and
increasing demands upon anaesthetic services. potentially serious co-morbid disease in an antenatal
Methods: We reviewed all our maternity cases during 2013, anaesthetic clinic (AAC). We reviewed trends and themes in
both epidural and caesarean sections. We also surveyed our abstracts on this topic presented to the OAA.
CT2 trainees to assess their experience in terms of case Methods: Full-text records of abstracts (excluding case reports)
numbers during a newly introduced modular training block. presented at OAA meetings (1991-2013; see www.oaa-
Lastly consultant cover on labour ward was audited for CNST anaes.ac.uk) were searched using the terms ‘antenatal’,
purposes. ‘clinic’, ‘risk’ and ‘refer’. Relevant abstracts were reviewed for
Results themes and conclusions.
Results: Forty abstracts were presented at 14 Annual
n %
Meetings (Fig. 1); 3 were unavailable in full-text (2008) but 1
Total Deliveries 3700
was provided by the author on request. 35 were from single
LSCS 838 22.6
departments and 5 were surveys (4 national). Common topics
Grade I-III LSCS 464 12.5
were obesity (12, 30%), referral reason (7, 18%) and
Grade IV LSCS 374 10.1
appropriateness (4, 10%), and outcomes (5, 13%). Nine (23%)
LSCS - SAB 666 79.5
described single patient cohorts, e.g. cardiac. AAC workload
LSCS - Epidural 123 14.7
has increased from 2.3 to 28.6 patients per month over 22
LSCS - CSE 14 1.7
years, albeit at different centres. Obesity has replaced
LSCS - GA 119 14.2
musculoskeletal disease as the most frequent reason for
RA to GA 34 4.2
referral. Common concluding themes include the need to
Average BMI LSCS (Range) 28.3 (16.7-59.9)  
improve the timeliness and appropriateness of referrals, and
Epidurals 895 24.2
ensuring anaesthetic plans are both prominent and followed.
Epidural Resites 32 3.7
PDPH - Epidural 15 1.7
PDPH - SAB 2 0.3
Epidural Blood Patches 21
Average BMI Epidural (Range) 27.1 (16-62.8)  
CT2 Training One of our requirements is to teach at least 4
CT2s per annum obstetric basic competencies. Our trainees
receive a 4 week long daytime block covered by an anaesthetic
ST3-7 and a consultant. They attend 40 sessions, the majority
siting 15 epidurals and anaesthetise 30 caesarean sections
before embarking on daytime on calls. They attend our in-
Figure 1: number of abstracts on the AAC presented per year
house MODSS (Obstetric Simulation Day) run by one of our
Consultant Obstetricians. Discussion: Abstracts relating to AACs have become more
frequent in the last decade, presumably reflecting their
Consultant Input The number of funded Consultant labour
increasing provision and perceived usefulness (and
ward sessions has risen 7 to 10 sessions (7 elective lists per
recommendation in the 2002-04 CEMACH report3). Increased
week). A “High Risk Obstetric clinic” runs weekly to pre-
demand for this service is exacerbated by inappropriate
assess all potentially difficult patients (250-300 per annum).
referrals and budgetary constraints. Referral processes,
Discussion: Despite a significant increase in workload we
facilities, and documentation and inconsistent use of plans are
have managed to maintain levels of cover (both junior and
areas for development. Future work should focus on quality
consultant) whilst allowing for CT2 training in obstetric basic
improvement and assessment of cost-effectiveness. Nationally
competencies as required at both national and local levels.
agreed referral criteria and a national ‘anaesthetic plan’
This has been achieved by increasing our core of obstetric
document, complemented by referrer education, may enhance
consultant anaesthetists, increasing obstetric PAs and
the process. Multidisciplinary ‘one-stop-shop’ or midwifery
changing to a modular CT2 training programme.
led clinics for common problems, such as obesity, may be
beneficial.
References
1. Centre for Maternal and Child Enquiries. Saving Mothers’ Lives:
reviewing maternal deaths to make motherhood safer: 2006-08.
The Eighth Report on Confidential Enquiries into Maternal Deaths
in the UK. BJOG. 2011; 118(Suppl.1): 1-203.
2. OAA & AAGBI Guidelines for Obstetric Anaesthetic Services.
Revised Edition 2005. London: OAA/ AAGBI
3. CEMACH. Why Mothers Die 2000-2002. Report on Confidential
Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin) P5
P109 Accuracy of a new electronic obstetric anaesthetic P110 Accuracy of landmark approach to central neuraxial
database blocks in obstetric patients
Rohit Rohit,  R Abraham,  GNB Jackson   J Lie,  K Bhatia,  A Venkataraju,  P Kochhar  
Anaesthetic department, Royal Berkshire Hospital, Reading, Anaesthesia, St Mary's Hospital, Manchester, UK
UK Introduction: Correct identification of vertebral level could
Introduction: We have introduced a new electronic database prevent damage to the spinal cord during a central neuraxial
'ROAD' (Reading Obstetric Anaesthetic Database) to record block (CNB). Evidence suggests that ultrasound (US) imaging
obstetric anaesthetic data. Written & designed by one of our of the spine by an experienced operator leads to correct
anaesthetists it is secure, password protected & able to identification of vertebral level in 90% of the patients and
produce reports on patient data & the activity of individual decrease the number of attempts required for a successful
anaesthetists. More than 70% obstetric anaesthetic units use CNB1. National Institute for Health and Care Excellence
electronic data collection system in the UK but there is little suggests US could be a useful tool for epidural catheter
agreement as to the best format.1 We audited the accuracy of insertion2. Our aim was to determine the discrepancy between
data entry, as a marker of ease of use by the anaesthetists, landmark technique and US to identify level of insertion of
before auditing the content of the database. CNB.
Methods: This was a retrospective audit, analysing data for Methods: Two experienced US operators who were blinded to
one month period (June 2013). The data in 'ROAD' was the initial procedure retrospectively performed US imaging of
compared to 1) our handwritten anaesthetic record book spine post-operatively after elective caesarean section in 51
(ARB); 2) Midwifery led labour ward logbook (LWLB); 3) obstetric patients with their consent from January to March
Operating theatre electronic log 'Bluespier'. Data entered on 2013 in St Mary’s Hospital. All the patients had a lumbar CNB
the 'ROAD' was manually checked against all these three done by landmark approach. The documented vertebral level
sources and the results tabulated and analysed. at which CNB was performed was noted. This was then
Results: 253 records were found in the ARB. The ARB missed compared with the actual vertebral level identified by bedside
one case (found in Bluespier), Bluespier missed one case US imaging of spine.
(found in the ARB) and LWLB missed 6 cases (found in the
Results: 29 patients had a spinal, 20 had an epidural and two
ARB & Bluespier). The results show that 'ROAD' was 96%
had combined spinal-epidural anaesthesia. The median body
accurate compared to any of the other systems.
mass index (BMI) was 28.6kg/m2. Landmark technique was
No. of cases missing on only accurate in 39.2% of patients. There was no statistically
Total 'ROAD' accuracy against
  'ROAD 'compared to significant correlation between the experience of operator and
no. other data sources as %
others accuracy. 3% of patients had a CNB at the level of L or above.
2
ARB 10 253 96.047% Documentation of the level performed was excellent. Raised
Bluespier 7 174 95.977% BMI and difficulty in palpation of landmarks resulted in
LWLB 10 247 95.951% statistically significant decrease in the accuracy (p<0.05
'ROAD'   243   Fisher’s Exact Test).
Discussion: Pinder et al considered an accuracy of 89% for Discussions: Our findings co-relate well with other studies
their electronic record adequate enough to adopt computer which have found that the vertebral level identified by
based data collection system.2We used three different landmark approach was at least 1 interspace higher than the
methods of data collection already in regular use, to compare level located by US in 40% of the pregnant population 3. Our
with our electronic database and showed it to have a high audit further confirms that the use of traditional landmark
degree of accuracy. This suggests that the database is easy to technique is highly inaccurate with potential increase risk of
use and consistently completed by our anaesthetists. We wish needle injury to the spinal cord especially in the high-risk
to use our database to produce reports on anaesthetic service patient groups (morbid obesity and musculoskeletal
provision (including the quality & safety of that service) as problems). We propose that all elective obstetric patients,
well as for auditing individual anaesthetist activity patients having a lumbar epidural, and high risk patients
(particularly our novice obstetric anaesthetists to ensure having a lumbar CNB should have US imaging of the of their
appropriate case mix & experience during their obstetric spines to identify the correct vertebral level and other relevant
attachments). Before using any database to audit these anatomy. The main reasons being that US imaging does not
aspects it is important to ensure that the data being audited is involve any radiation, is compact, portable and readily
a true reflection of anaesthetic activity, we believe our new available at the point of care. Better US equipment availability,
database is sufficiently accurate to audit the data within it. The staff awareness with appropriate training and improved
limitation of our audit is that we only audited the data from one documentation would aid in providing safer patient care.
month but we believe that the data entry practice of all months
References
is similar. We conclude that our electronic database is accurate
1. Chin KJ, Perlas A, Chan V, Brown-Shreves D, Koshkin A, Vaishnav
& the data entered can be used to audit our obstetric V: Ultrasound imaging facilitates spinal anesthesia in adults with
anaesthetic service. difficult surface anatomical landmarks. Anaesthesiology 2011; 115
(1): 94-101
References
2. Ultrasound-guided catherisation of epidural space. National Institute
1. Campbell NJ, Youngs P, Anderson I. A national survey of obstetric for Health and Care Excellence January 2008
anaesthetic data collection methods in the UK. Int J Obstet Anesth
2012; 21: S53. 3. Lee AJ, Ranasinghe S, Chehade JM, Arheart K, Saltzman BS,
Penning DH & Bimbach DJ. Ultrasound Assessment of the Vertebral
2. Pinder A, Wrench I, Shepherd D, Freeman R. Assessment of a Level of the Intercristal Line in Pregnancy. Anaesth Analg 2011;
handheld computer to collect obstetric epidural audit data. Int J
113: 559-564
Obstet Anesth 2002; 11: 8.
P6 Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin)
P111 Adherence to antenatal anaesthetic advice in P112 An evaluation of anaesthetic antenatal clinics in the
labouring morbidly obese parturients. obese obstetric population
S Halliday,  LC Robertson ,  HM du Plessis   PR El-Dalil,  DS Cochran,  R Ganapathy*  
Anaesthesia, Princess Royal Maternity Hospital, Glasgow, Department of Anaesthesia, Sandwell and West Birmingham
UK NHS Trust, Birmingham, UK, *Obstetrics and Fetal Medicine,
Introduction: Morbidly obese parturients pose a high Sandwell and West Birmingham NHS Trust, Birmingham, UK
anaesthetic risk1. Antenatal anaesthetic assessment for Introduction: Maternal obesity is increasingly common, with a
women with a body mass index (BMI) ≥40 kg.m-2 at booking is BMI 35 found in 5% of pregnancies. Current CMACE / RCOG
advised2. Early establishment of epidural analgesia is often guidelines advocate the referral of patients with a BMI 40 to
advocated. We sought to determine if this advice is adhered to an anaesthetic antenatal clinic. This study aimed to evaluate
in our centre. the outcomes following the implementation of such a clinic in a
Methods: A retrospective case note review of 49 morbidly busy inner city district general hospital.
obese patients (BMI ≥40) assessed antenatally was Method: High-risk patients were referred to a multidisciplinary
conducted. As a control, data from 23 patients with a BMI <40 antenatal clinic involving Anaesthetics, Obstetrics and
who had a labour epidural was collected. We compared the Haematology; patients with a BMI 40 were referred to the
timing of epidural request from labour ward admission, cervical clinic and included in the evaluation. Data was collected
dilation and syntocinon administration at request and the time retrospectively on the reason for attending, the past medical
from epidural insertion to delivery. Mode of delivery was also and obstetric history as well as any anaesthetic or surgical
noted. intervention provided in the perinatal period.
Results: Mean BMI for the control group was 23.6 (range 17- Results: In 2011, 72 women were referred to the clinic with a
32) and for the morbidly obese group 44.6 (40-60). Eleven BMI 40, although there were often other relevant co -
morbidly obese parturients had an elective caesarean section morbidities. The BMIs ranged from 40 to 80 (mean = 44). 44
(CS). Nineteen of the remaining morbidly obese parturients patients (61%) had a normal vaginal delivery, 3 women (4%)
requested labour epidurals. Two parturients delivered prior to required assisted vaginal delivery, 17 (24%) had an elective
insertion. caesarean section (CS), whilst 8 (11%) had a non-elective CS.
Of these patients, 38 (53%) required no anaesthetic
Time to Syntocinon Insertion to
Cervical dilation intervention.
request administration n delivery
  Centimetres
Minutes (%) Minutes Table: Anaesthetic intervention and failure rates in obese
(range)
(range) (range) parturients compared to previously published failure rates1 in
BMI Yes 12 (52.2) the general obstetric population
375 (110-
<40 169 (0-435) 3.7 (1-7) No 11 (47.8) Spinal Epidural CSE GA
915)
(n=23) Number attempted 19 12 4 1
BMI Yes 13 (68.4) % Failure rate 5 17 0 0
334 (12-702)
≥40  261 (0-555) 3.65 (2-8) No 6 ( 31.6) Published % failure rates1 6 24 18 <1
(n=17)
(n=19)
Discussion: The results demonstrated low regional
Table: Timing of epidural request, cervical dilation and anaesthesia failure rates, with only 1 unsuccessful spinal (5%)
syntocinon use at request, and time from insertion to delivery. and 2 failed epidurals (17%); figures comparable to those
In the control group with a BMI <40 that had a labour epidural found in the general obstetric population (Table). There is little
(n=23), the number of spontaneous vaginal deliveries (SVD), available data for regional anaesthetic failure rates in the obese
trial of forceps (TOF) and lower uterine segment CS (LUSCS) obstetric population precluding a direct comparison, but a
were 13 (56.5%), 5 (21.7%), and 5 (21.7%), respectively. For higher failure rate would be expected. A previous study of 677
those with a BMI ≥40 with an epidural (n=17) there were 6 women with a BMI 30 found an emergency CS rate of 24%, 2
(35.3%) SVD, 3 (17.7%) TOF and 8 (47.1%) LUSCS. The significantly higher than the 11% demonstrated in this cohort
number of SVD in the BMI ≥40 without an epidural group was of BMI 40. This robust multidisciplinary approach in the
18 (85.7%) and there were no TOF and 3 (14.3%) LUSCS. antenatal period allows for adequate planning and early
Discussion: Despite antenatal review, the time to epidural institution of optimised perinatal management. The service
request was longer in the morbidly obese group, indicating a provided was predominantly consultant led, with the on-call
need for ongoing education. The time between epidural Anaesthetist required to attend out of hours for parturients
insertion and delivery was shorter in the morbidly obese group with a BMI 45, and to be informed of patients with a BMI
which had a significantly increased chance of CS, signifying 40; significantly 73% of the on-call consultants are dedicated
the importance of establishing a working epidural early in this Obstetric Anaesthetists. We feel these systems may account
cohort. for our findings, as well as promote early and effective
communication with patients. Whilst the sample was relatively
References small the results are sufficiently encouraging to suggest that a
1. Soens MA, Birnbach DJ, Ranasinghe JS, van Zundert A. Obstetric multidisciplinary approach significantly improves perinatal
anesthesia for the obese and morbidly obese patient: an ounce of outcomes in the obese obstetric population.
prevention is worth more than a pound of treatment. Acta
Anaesthtesiol Scan 2008; 52: 6-19 References
2. OAA/AABGI Guidelines for Obstetric Anaesthetic Services 2013. 1. Kinsella SM. A prospective audit of regional anaesthesia failure in
Association of Anaesthetists' of Great Britain and Ireland and the 5080 caesarean sections. Anaesthesia 2008; 63(8): 822-832.
Obstetric Anaesthetists' Association. London, 2013. 2. Usha Kiran TS, Hemmadi S, Bethel J, Evans J. Outcome of
pregnancy in a woman with an increased body mass index. BJOG
2005; 112(6): 768-772.
Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin) P7
P113 An evaluation of fasting times for elective caesarean P114 An evaluation of intrathecal diamorphine versus
section surgery fentanyl for lower segment Caesarean section in a
J Ghoshdastidar,  KM Sherratt,  M Seneviratne*,  A medium-sized district general hospital
McGlennan   K Ramm,  LT Fenton-May,  S Naresh  
Anaesthetics, Royal Free Hospital, London, UK, Department of Anaesthesia, Good Hope Hospital, Heart of
*Anaesthetics, University College Hospital, London, UK England Trust, Birmingham, UK
Introduction: Enhanced Recovery Programmes have shown Introduction: Intrathecal diamorphine is now recommended by
increasing evidence for the benefits of reducing fasting times the National Institute for Health and Clinical Excellence (NICE)
for those undergoing elective surgery1. Many of these as the opioid of choice for lower segment Caesarean section as
benefits could be applicable to the elective caesarean section it provides improved post-operative pain relief.1 However, it is
patient. We evaluated the fasting times of our elective also associated with a dose-dependent increase in the
caesarean section patients to assess whether we could make incidence of pruritus2 and nausea3 which may be more
improvements to patient care. significant with diamorphine given its longer duration of
Methods: The evaluation included all patients undergoing action. Having arranged appropriate protocols for post-
elective caesarean section surgery at the Royal Free Hospital operative monitoring of women receiving intrathecal
over a 3 month period.. Patients received standard instructions diamorphine, we introduced the therapy in late 2012.
to stop eating at midnight on the day of surgery and to stop Methods: The evaluation took place over a six-week period. A
drinking clear fluids at 6 am. Data was collected by anaesthetic small number of women were still receiving intrathecal fentanyl
staff using a standardised data collection sheet.. Patients were due to clinician choice, and these provided a useful
questioned about the time they last consumed solid food and comparator. Women who were still present in the hospital on a
when they last drank liquid. follow-up round on the first day post-op were asked questions
Results: In total 77 patients underwent elective caesarean about post-operative pain, nausea and pruritus. We also
sections during the period of evaluation. We obtained data assessed total oral morphine and codeine doses and time to
from 71 patients for fasting times for fluids and 72 patients for first dose.
fasting times for solids. Results: Basic data is presented in the chart.

  Fentanyl Diamorphine
Pre-op fasting % of Pre-op fasting % of
Number 15 36
times FLUIDS patients times SOLIDS patients
Time to first morphine (hrs) 5.29 8.9
(hr) (n=71) (hr) (n=72)
Mean morphine dose (mg) 65.4 30
2 - 4 5.6 6 - 12 15.3
No morphine required 1 (6.6%) 11 (30.6%)
4 - 6 15.5 12 - 18 66.7
Mean codeine dose (mg) 123 119
6 - 8 14.1 18 - 24 16.7

8 - 10 8.5 over 24 1.4
Time to mobilisation (hrs) 21.17 15.21
over 10 56.3    
Time to catheter removal (hrs) 20.3 16.6

Discussion: There are no fasting recommendations specific to
Pruritus 8 (53.3%) 24 (66.7%)
elective caesarean sections but the standard surgical
- requiring treatment - 0 (0%) - 8 (22.2%)
guidelines of 6 hours for solids and 2 hours for clear fluids are
Nausea 5 (33%) 13 (36.1%)
usually applied. Periods longer than 12 hours without fluid
- requiring treatment - 3 (20%) - 7 (19.4%)
have correlated with significant dehydration
in patients having elective caesarean sections2. There is also
Discussion: Our results replicate previous work demonstrating
some evidence to suggest that gastric fluid volume is
a reduction in immediate post-operative analgesia
increased with prolonged starvation in the pregnant patient3.
requirements following a switch from fentanyl to diamorphine,
Over fifty per cent of our patients went without fluids for
but an associated increase in side effects requiring
longer than ten hours prior to surgery, and almost eighty-five
intervention. There was also a reduction in times to first
per cent of patients went without food for greater than 12
mobilisation and catheter removal, which is worth closer
hours. Our results show that there is a need to introduce
inspection. It is likely to be multi-factorial: the patients having
methods to reduce fasting times. These could include pre-
superior analgesia and feeling ready to move sooner, but also
operative letters with individualised times to stop eating and
the proforma for the ward indicating the patient had received
drinking. Also patients lower down the surgical list could be
diamorphine. This required the anaesthetist to specify a time
actively encouraged to consume clear fluids, or even
after which she would be ready to mobilise, which might have
carbohydrate drinks as used in many Enhanced Recovery
improved motivation amongst the midwives and mothers to
programmes.
achieve mobilisation.

References
References
1. Aguilar-Nascimento JE, Dock-Nascimento DB. Reducing
preoperative fasting time: A trend based on evidence. World J 1. NICE clinical guideline 132: Caesarean section
Gastrintest Surg. 2010 March 27;2(3): 57-60 2. Wrench IJ, Sanghera S, Pinder A et al, Dose response to intrathecal
2. Mackenzie M, Yentis S, Woolnough M and Johnson M. Fasting diamorphine for elective caesarean section and compliance with a
periods and dehydration before elective caesarean section. national audit standard, Int J Obstet Anesth. 2007;16(1):17-21
Anaesthesia, 2010 Vol 65:99 3. Sibilla C, Albertazzi P, Zatelli R, et al, Perioperative analgesia for
3. Maltby JR, Sutherland AD, Sale JP, Shaffer EA. Preoperative oral caesarean section: Comparison of intrathecal morphine and
fluids: is a five hour fast justified prior to elective surgery?. Anesth fentanyl alone or in combination, Int J Obstet Anesth. 1997; 6(1):
Analg. 1986 Nov;65(11):1112-6 43-48
P8 Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin)
P115 An evaluation of obstetric critical care admissions in a P116 An evaluation of standards of informed consent and
district general hospital documentation for labour epidural analgesia
VL Williams,  M Greene,  D Saul   S Chaudhari,  N Smith,  P Prasad  
Department of Anaesthesia, Leighton Hospital, Crewe, Anaesthetic Department, George Eliot Hospital, Nuneaton,
Cheshire, UK Nuneaton, UK
Introduction: CMACE has provided doctors with excellent
Introduction : It is both medico legally and ethically important
data over the past 50 years about maternal mortality, but
that the patient is made aware of the nature and risks
unfortunately no data about maternal morbidity. In December
associated with a labour epidural. No national standardised
2013, the Intensive Care National Audit & Research Centre
information card for informed consent is available, although
(ICNARC) produced a second report that analysed critical care
the OAA does publish a epidural information card1 with
admissions of women who were pregnant or recently pregnant
specific risks and incidence rates. At our hospital, the
in 2009-2012 inclusive.1 A comparison was made between the
documentation is made on part of the epidural chart as an
hospital ICNARC data and the national ICNARC data.
open entry. Our study looked to ascertain whether appropriate
Methods: Data were collected from the hospitals ICNARC
details of the epidural and informed consent were made. This
database over a four year period from 2009 to 2012. The data
was with a view to find whether a total redesign of the epidural
was analysed from the categories in the table below.
chart (at a level of standard suggested by the OAA website2)
Results: Data from 388 patients were evaluated.
was needed to improve our practice.
  Hospital ICNARC
Methods : We evaluated a total of 100 completed epidural
Total no. of patients admitted, female 16-50 years 388 55,791
charts over a 4-month period in mid-2012 at our obstetric unit.
Currently pregnant 3.6% 2.1%
The epidural notes were retrospectively analysed on our
Recently pregnant 9.3% 10.0%
scanned patient electronic notes. Documentation was
Obstetric reason for admission - currently pregnant 0% 8.7%
analysed for: details of the patient, anaesthetist and patient
Non-obstetric reason for admission - currently
100% 91.3% assessment, explanation of the risks and incidence given,
pregnant
details of the epidural technique and post epidural
Obstetric reason for admission - recently pregnant 50% 69.7%
management. Our main focus was on standards of consent.
Non-obstetric reason for admission - recently
50% 30.3% Results:
pregnant
%of patients Rate of risk
Discussion: The proportions of patients admitted to the Range of risk discussed
Risk discussed informed documented (no.
critical care area were comparable with the ICNARC report. (no. in total)
(n=100) in total)
The leading indication for admission in the currently pregnant
1in100:13,1in200:8
group was for sepsis. This corresponds with the ICNARC Headache 69 25
<1%:3,1in500:1
report and most recent CMACE report in which sepsis was the
Hypotension 45
leading direct cause of maternal death.2
Failure 59 4 1in8:2, 1in4000:2
The leading obstetric cause for currently pregnant admissions
Nerve 1in13k:21,1in10k:8
nationally, was for pre-eclampsia. However, there were no 65 31
damage 1in15k:1, 1 in19k:1
admissions in this category at the hospital. This is most likely
Itching 14    
because pre-eclampsia is diagnosed and treated effectively on
Infection 37  
the labour ward and rarely needs input from critical care.
Motor block 28    
In the recently pregnant group, there were equal proportions
Urinary
of patients admitted for obstetric and non-obstetric reasons, 28    
retention
this is quite different from the ICNARC report. The leading
indication for admission of recently pregnant patients in the The other areas of documentation studied showed an
ICNARC report was for post partum haemorrhage, by a long acceptable standard.
way. When looking at the hospital database, it showed that in Discussion : Several studies have looked at standards of
the period 2010-12, only 3 of 42 patients with a significant post informed consent in UK practice3and which risks and
partum haemorrhage of 2.5 litres or more were admitted to incidences were discussed and the range of risk quoted. Our
critical care. Therefore the question needs to be asked as to study showed rates generally to be slightly lower than that
whether these patients should have been admitted to the quoted in these studies. This is likely due to limited space and
critical care area? The hospital does not have an obstetric open entry nature of our current chart. The OAA has set
HDU, but in hospitals that do have an obstetric HDU facility, guidelines and advice for both epidural charts2 and risks and
these patients would certainly have been admitted there, had incidence1. Following this evaluation, a full redesign of our
closer monitoring and possibly goal directed therapy. All of epidural charts with prompts and guidance of risks and
these patients survived, but could admission to critical care incidence is warranted. In addition, the OAA had
have improved patient outcomes or reduced hospital stay? overwhelming support for a national standardised information
References card that could be implemented3.
1. Female admissions to adult, general critical care units in England,
Wales and Northern Ireland reported as 'currently pregnant'
References
or 'recently pregnant'. http://www.icnarc.org/documents/Obstetric%
20admissions%20to%20critical%20care%202009-2012.pdf 1. OAA epidural information card : http://www.oaa-
anaes.ac.uk/content.asp?ContentID=185
2. The eighth report on confidential enquiries into maternal deaths in
the United Kingdom. BJOG 2011, 118(Suppl 2):1-203 2. OAA epidural charts : http://www.oaa-anaes.ac.uk/content.asp?
ContentID=522
3. Informed consent for epidural analgesia in labour: A survey of UK
practice: Anaesthesia 2009, 64 p161-164
Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin) P9
P117 An unusual cause of post-partum sepsis P118 Anaesthetic management of a parturient with severe
F A Corcoran,  C Brennan,  A J Downs   systemic scleroderma
Anaesthetics, Dudley Group NHS Foundation Trust, Dudley, P Thomas,  A Varvinskiy,  M Human  
UK Anaesthetics, South Devon Healthcare NHS Foundation
Introduction: Leiomyomas are common in women of Trust, Torquay, UK
reproductive age and have been linked to spontaneous Introduction: Scleroderma is a chronic systemic autoimmune
abortion, retention of the placenta and post-partum disease. Successful pregnancy in patients with severe
haemorrhage.1 It is however rare for them to be the primary systemic scleroderma is very rare. We report the anaesthetic
cause of post-partum sepsis. We describe the case of a post management of such a case in a patient with a difficult airway,
partum patient presenting with painful fibroids and sepsis. severe pulmonary dysfunction and oesophageal dysmotility.
Case report: A 37 year old woman (P1), 5 days post partum Case report: A 29 year old woman (G1P0) with severe
presented with a history of fever, abdominal pain and systemic scleroderma presented to the hospital at 36 weeks
distention. She had a past medical history of fibroids but there gestation with dyspnoea and tachypnoea. Prior to pregnancy
had been no problems during pregnancy. She had an her exercise tolerance was poor, managing just 400 metres in a
uneventful labour with a normal vaginal delivery. On initial six minute walk test with resultant oxygen saturations of 72%.
assessment she was apyrexial with normal observations. She Her Forced Expiratory Volume (FEV1), Forced Vital Capacity
had mild tenderness on palpation of her abdomen. She was on (FVC) and Diffusing Capacity for Carbon Dioxide (DLCO) had
regular analgesics and had been commenced on oral each worsened steadily by five percent year on year over the
antibiotics by her GP. An ultrasound scan (USS) was booked last decade. The most recently measured values from 2007
to investigate the abdominal pain. Within 4 hours she had were FEV1 30%, FVC 28% and DLCO 24% of predicted values
deteriorated and developed a pyrexia, tachycardia, tachypnoea although the patient reported that her pulmonary function had
and decreased oxygen saturations. Initial impression was deteriorated significantly during pregnancy. On admission the
sepsis secondary to retained products so blood cultures and patient was breathless at rest with a p02 of 7.63 on room air
swabs were taken and intravenous antibiotics, oxygen and and it was felt that natural labour would not be possible due to
fluid resuscitation commenced. She was transferred to the poor physiological reserve. Severe reflux secondary to
Maternity High Dependency Unit. CRP was elevated but oesophageal dysmotility rendered her unable to recline more
lactate was normal. She improved over 6 hours but than 45 degrees and she could therefore not lie flat for awake
deteriorated again. Antibiotic coverage was amended caesarean section. Airway assessment revealed microstomia of
following microbiology advice but she continued to have a less than one centimetre, mallampati four, bucked teeth, sub
swinging pyrexia. USS detailed a bulky uterus with a large mental skin scleroderma and a narrow hooked nose with small
fibroid at the fundus and no retained products. 36 hours after nostrils. Oral intubation was therefore ruled out. Awake Fibre
admission she developed peritonitis and a CT abdomen which Optic Intubation (AFOI) appeared technically challenging due
suggested findings of a pedunculated fibroid measuring to nasal anatomy. Preoperative, bedside nasendoscopy
17.5cm that might have twisted on its pedicle. She had an revealed that AFOI would be possible should the need to
emergency laparotomy which revealed a degenerative, secure the airway arise mid operation. This avoided the need
necrotic, infected fibroid. She required ionotropic support and to perform an AFOI or awake tracheostomy pre-operatively.
was difficult to ventilate intra-operatively. Post-operatively The patient was positioned at 45 degrees on the operating
she was transferred to intensive care where she was sedated table. Surgeons confirmed that they could operate in this
and ventilated overnight. She was successfully extubated the position. A low dose spinal followed by an epidural which was
following morning and continued with intravenous antibiotics topped up gradually over 30 minutes using small incremental
and analgesia. She made a full recovery. Histology confirmed boluses achieved adequate block without compromising
the fibroid had extensive areas of coagulative necrosis, respiratory function. Surgery was completed without issue and
hyalinisation and inflammation. All microbiological both mother and baby did well post-operatively.
investigations were negative. Discussion: There are only three reports in the literature
Discussion: Sepsis in pregnant and post-partum women describing general anaesthesia for caesarean section in
remains a significant cause of maternal morbidity and patients with scleroderma and two using neuraxial blockade.1-5
mortality.2Sepsis is a clinical diagnosis and microbiological Of those who were intubated, one died and another required
investigations may be negative. Early recognition, timely three months ventilation. We demostrated how careful bedside
diagnosis and active treatment assists an optimum outcome. airway assessment and the use of a slow top up epidural were
Fibroids are common in pregnancy but sepsis secondary to successfully used to manage this challenging case.
infected, necrotic fibroid tissue post-partum is very rare. To References
our knowledge there have been no reported cases of this. It is
1. D'Angelo R, Miller R. Pregnancy complicated by severe
therefore essential to consider this in the differential causes of preeclampsia and thrombocytopenia in a patient with scleroderma.
obstetric sepsis when reviewing pregnant women with a Anesth Analg 1997; 85: 839-41
history of fibroids. 2. Hseu SS, Sung CS, Mao CC, Tsai SK, Lee TK. Anesthetic
management in a parturient with progressive systemic sclerosis
References during cesarean section. Acta Anaesthesiol Sing 1997; 35: 161-7
1. Mason T. Red Degeneration of a leiomyoma masquerading as 3. Younker D, Harrison B. Scleroderma and pregnancy. Br J Anaeth
retained products of conception. Journal of the National Medical 1985; 57: 1136-9
Association. 2002; 94: 124-6 4. Thompson J, Conklin KA. Anesthetic management of a pregnant
2. Lucas DN, Robinson PN, Nel MR. Sepsis in obstetrics and the role patient with scleroderma. Anaesthesiology 1983; 59: 69-71
of the anaesthetist. International Journal of Obstetric Anaesthesia. 5. Bailey AR, Wolmarans M, Rhodes S. Spinal anaesthesia for
2012; 21: 56-67 caesarean section in a patient with systemic sclerosis. Anaesth
1999; 54(4): 355-8
P10 Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin)
P119 Anaesthetic management of arrhythmogenic right P120 Anaesthetic management of obese parturients at a
ventricular cardiomyopathy during labour and tertiary centre - meeting the standard?
caesarean section: a case series L Kelliher,  J Teare,  E Evans  
J Eccles,  A Jain,  K Bhatia   Anaesthesia, St George's Healthcare NHS Trust, London, UK
Department of Anaesthesia, St Mary's Hospital, Manchester, Introduction: Obese women are at increased risk of perinatal
UK morbidity and mortality. In 2010 CMACE and RCOG published
Introduction: Arrhythmogenic right ventricular joint guidelines for the management of the obese parturient
cardiomyopathy (ARVC) is mainly a genetically determined including recommendations that patients with a booking BMI
autosomal dominant disease characterised by cardiomyocytes ≥40 should attend an antenatal anaesthetic clinic (AAC) and a
being replaced by fibrofatty tissue in the right ventricle.1 Specialist Trainee year 6 anaesthetist (ST6) or above should
ARVC has an incidence of 1:5000 and may account for as be informed and available to attend labour and operative
many as 5% of unexpected sudden deaths. The Eighth Report delivery1. Our unit is a tertiary centre with over 5,000
of the Confidential Enquiries into Maternal Deaths in the deliveries/year. A previous audit over 2 years showed that of
United Kingdom (2006-2008) highlighted that ARVC was the 120 women with BMI ≥40 attending our AAC, 76% required a
underlying cause in two of the 53 reported cardiac deaths. We peripartum anaesthetic intervention, with only 34% of these
describe the anaesthetic management of two parturients with performed by an anaesthetist ≥ST62. Awareness of the
ARVC who presented at our tertiary centre. guidelines was raised and anaesthetic plans for these women
Case reports: The maternal demographics, the cardiac signs, now state care should be managed by a senior anaesthetist.
symptoms and interventions along with the anaesthetic We examined our obese population following these changes.
management in the peri-partum period are briefly summarised Methods: A retrospective analysis over 1 year (2011-12) of
in the table below. hospital records for patients with a booking BMI ≥ 40. Records
were examined for referral and attendance at AAC, anaesthetic
Category Case 1 Case 2
intervention (regional/GA), grade of anaesthetist and
Age 27 23
anaesthetic complication (difficult/impossible regional, dural
BMI 25.8 27.2
tap, other).
Parity 0 0
Family history None Sudden death Results: In total there were 74 women with a booking BMI
Cardiac signs and Palpitations with spurts of Paroxysmal VT ≥40. 73% were referred to AAC, only 58% attended. Out of all
symptoms ventricular tachycardia (VT) patients, 69% had a peripartum anaesthetic intervention, 43%
Cardiac Cardiac ablation therapy and ICD insertion of which were performed by an anaesthetist ≥ST6 with a
intervention prior implantable cardioverter complication rate of 16%. Of those attending AAC, 67% had
to pregnancy defibrillator (ICD) insertion an anaesthetic intervention, 41% of which were performed by a
Mode of delivery Elective caesarean section Urgent LSCS for ≥ST6 with a complication rate of 17%. Of those patients not
(LSCS) for breech foetal distress attending AAC, 71% had an anaesthetic intervention and 36%
Anaesthesia and General anaesthesia, with Labour epidural of these were performed by ≥ST6 with a complication rate of
analgesia bilateral transversus analgesia, followed by 14%.
abdominal plane blocks top up for LSCS
Table 1. Incidence of complications by grade of anaesthetist
Maternal length of Three days Four days
stay Group ≥ST6 <ST6 p value (Fisher's Exact)
Neonatal APGAR 8 and 10 9 and 10 All 9.1% 20.7% 0.440
scores AAC 16.7% 17.6% 0.945
Discussion: The main implications of ARVC in parturients No AAC 0% 21.4% 0.273
include fatal arrhythmias, heart failure worsened by Discussion: This audit shows a significant number of obese
physiological changes of pregnancy and sudden adult death parturients were not seen in our AAC. A proportion of these
syndrome.1 Both our patients had VT diagnosed after 24 hour were referred, but did not attend however 27% were not
Holter monitoring, and an ICD was implanted in addition to referred. Despite this, there was no significant difference in the
beta blocker medical therapy to control the symptoms of VT as requirement for anaesthetic intervention or the incidence of
well as to prevent sudden death. The patients were seen in the anaesthesia-related complications between attenders and non-
joint cardiac, obstetric and anaesthesia antenatal clinic and a attenders. The incidence of senior anaesthetic involvement in
peri-partum plan formulated to facilitate safe delivery. Both care has risen from 34% to 41% but there is still room for
had serial echocardiograms, serum electrolytes monitored, improvement. This highlights the resource difficulties faced in
invasive blood pressure monitoring and ICD deactivated providing 24 hour senior anaesthetic cover. The on-call rota at
during their LSCS. Our case series highlights that both general our unit is staffed by junior and senior anaesthetists. The
and regional anaesthesia can be safely provided and we absence of a senior anaesthetist did not lead to a significant
recommend a multidisciplinary approach with close co- rise in anaesthesia-related complications, although there was a
operation between anaesthetists, cardiologists and t rend toward this (Table 1).
obstetricians to provide optimum care of these patients. References
Reference 1. Centre for Maternal and Child Enquiries & Royal College of
Obstetricians and Gynaecologists Joint Guideline. Management of
1. Alexoudis AK, Spyridonidou AG, Vogiatzaki TD, Iatrou CA.
Anaesthetic implications of arrhythmogenic right ventricular women with obesity in pregnancy. London: CMACE & RCOG; 2010
dysplasia/cardiomyopathy. Anaesthesia 2009; 64: 73-8. 2. Fulton L, Evans E, Schroeder F, Wendler R. Antenatal anaesthetic
assessment of morbidly obese women - a useful resource? 2013,
http://epostersonline.s3.amazonaws.com/oaa2013/oaa2013.0690195
.NORMAL.pdf
Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin) P11
P121 Anaesthetic management of the labouring patient with P122 Anesthetic implications  of heart disease in pregnancy
multiple sclerosis S Francés,  S Manrique,  M Goya,  M García,  R Perera,  N
J Li Wan Po,  K Maclennan   Montferrer  
Anaesthesia, St Mary's Hospital, Manchester, UK Anaesthetics, Vall d'Hebron University Hospital, Barcelona,
Introduction: Multiple Sclerosis (MS), an autoimmune Spain
inflammatory disease affecting the central nervous system, is Introduction: Despite advances in its diagnosis and treatment,
estimated to affect 20,000 or more UK women of childbearing heart disease (HD) in pregnancy remains a major cause of non-
age1. Controversy exists regarding the management of obstetric maternal and neonatal mortality and morbidity (it
anaesthesia and analgesia in labouring parturients with MS. complicates around 1-3% of pregnancies in developed
Following analysis of our practice at St Mary's Hospital, a countries). Accurate multidisciplinary assessment and
tertiary referral obstetric unit with over 8500 deliveries per management of individual maternal and fetal risks in pregnant
annum, and recent evidence in the literature; our women with HD provides the best opportunity to substantially
recommendations for the peri-partum management of improve outcomes for mother and baby. (1).
parturients with MS are presented. Methods: We present a prospective cohort study that
Methods: Interrogation of the St Mary's Hospital antenatal analyzed outcomes in women with HD, the majority of whom
clinic database, from 1999 to 2012, identified 21 pregnant had had corrective surgery and delivery between 2007 and
women diagnosed with MS. We reviewed antenatal advice, 2013. Baseline characteristics and adverse events during
intrapartum management and postpartum complications. delivery and postpartum were assessed. Intensive monitoring
Results: Over 50% of patients were nulliparous. The majority of the delivery and postpartum were planned beforehand in all
had mild sensory or motor deficit. Three relapsed during cases.
pregnancy, one improved in symptoms and one relapsed Results: One hundred and seventy-four patients with 179
postpartum. There were twelve normal vaginal deliveries, two pregnancies were included in the study. 127 women (72,98%)
instrumental deliveries, six Caesarean sections and one presented congenital heart disease (CHD), 47 acquired heart
unspecified delivered at another hospital. Five women opted disease (27,02%): 27 acquired rheumatic valve disease
for epidural analgesia, two were topped up for operative (19,98%), one Marfan syndrome (0,54%), 3 coronary heart
delivery. Five had spinal anaesthesia with 0.5% heavy disease (1,6%) and 9 primary myocardial disease (4,9%).
bupivacaine and one had a general anaesthetic. There were no
Pregnancy complications were presented in 21, 2% of CHD,
complications following regional technique.
14,8% of acquired rheumatic valve disease and 100% of
Discussion: A recent national survey reported that within a 10 women with arrhythmias.
year period, 91% of anaesthetists have encountered <ten
The type of delivery was vaginal in 124 women ( 72,1%) and
cases of MS2 and have little experience in their management
cesarean section in 50 women (27,9%).
during pregnancy. Recent evidence available supports our
168 women had analgesia during delivery (93,8%); 5 women,
current management of MS patients undergoing labour. The
general anesthesia (2,79%), 6 women, local anesthesia (3,35%)
low incidence of the disease makes it difficult to attain
and 87,5% of women had regional analgesia.
significant figures to determine the optimal management plan.
To standardize care, we made the following recommendations Delivery complications were 7% (uterine atony 2,7%, vaginal
based on the latest evidence and our own experience: hematoma 2,2%, chorioamnionitis 0,5%, cesarean hematoma
- Patients to be reviewed in an antenatal anaesthetic clinic. 0,5% and hemoperitoneum 0,5%). The only anesthesia
Document disease severity and discuss analgesia and complication was one dural puncture (0.5%). No maternal
anaesthetic options. death, one fetal death (0.5%) and one neonatal death (0.5%).
The maternal average hospital stay was 3 days.
- Use of 0.1% bupivacaine with 2mcg/ml fentanyl mixture for
epidural labour analgesia2 . For an operative intervention, top Discussion: Pregnancy and delivery are associated with
up with a higher concentration of local anaesthetic. substantial physiological changes, which require the
adaptation of the cardiovascular system and can expose
- Regional rather than general anaesthetic for caesarean
women with HD to significant risks. If regional anesthesia is
sections. Spinal anaesthesia is the most simple and reliable
selected, the addition of an opioid, when dosing any neuraxial
technique although consider combined spinal-epidural on an
anesthetic, will reduce the amount of local anesthetic required
individual basis.
and subsequent hemodynamic effects, while improve
- If a general anaesthetic is necessary, avoid suxamethonium
intraoperative and postoperative analgesia. The avoidance of
and monitor neuromuscular block to titrate dose of non-
epinephrine from the epidural dose will eliminate the possible
depolarizing muscle relaxant3.
deleterious effects of systemic epinephrine. Maintaining
These recommendations will be available for clinicians on the uterine blood flow is important for fetal well-being.
trust intranet and a patient information leaflet on the effects of Maintaining systemic vascular resistance in patients with
pregnancy and anaesthesia on MS has been produced. intravascular shunting, is important to avoid inducing or
exacerbating pre-existing cyanosis due to increased right- to –
References
left shunting. Cautious intravenous hydration and gentle
1. Brookings W, Lee M. Management of multiple sclerosis during
titration of phenylephrine or ephedrine are options to
pregnancy. Prog Neurol Psychiatry. 2009; 3(6): 9-11
counteract the hemodynamic effects of surgical neuraxial block
2. Drake E, Drake M, Bird J, Russell R. Obstetric regional blocks for
women with multiple sclerosis: a survey of UK experience. Int J (1,2). We observed a predominance of neuraxial anaesthetic
Obstet Anaesth. 2006; 15(2): 115-23 techniques, increased caesarean and operative delivery rates,
3. Griffiths S, Durbridge JA. Anaesthetic implications of neurological and favourable maternal and neonatal outcomes.
disease in pregnancy. Contin Educ Anaesth Crit Care Pain. 2011; 11
(5): 157-61 References
P12 Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin)
P123 Angle of tilt achieved with automated operating table P124 Antenatal anaesthetic information given to women
in elective caesarean sections: a comparison with tilt with obesity
achieved with an inflatable balloon wedge  C R Thomas,  C Busby  
PN Nair,  L Dyal,  B Grewal,  I Suri   Anaesthetics, Airedale General Hospital, Keighley, UK
Department of Anaesthesia, Warwick Hospital, Warwick, UK Introduction:Antenatal obesity is defined as a BMI of ≥30at
Introduction: A previous study1 done on patients undergoing booking. Its prevalence in England increased from 7% in 1990
elective caesarean sections looked into measuring the angle of to 16% in 2007.1Women with a BMI ≥40 are often provided
tilt of the operating table with an inflatable balloon wedge. with anaesthetic information antenatally. Those with lower
This showed that the visual estimation of angle proved levels of obesity also have an increased anaesthetic risk but
accurate in the achievement of near 150 tilt. Here we present these women may receive little or no information about this
the results of a similar study using a different technique of during pregnancy. 2The RCoA have produced standards
automated table tilt instead of the inflatable balloon wedge regarding care for these women: 90% of patients with a
device. The premise being is our visual actuation of tilt angle booking BMI ≥ 30 should receive a leaflet containing
accurate. information about anaesthesia and analgesia. 90% of patients
Methods: The study was similar to the previous one. We with a booking BMI ≥40 should have an anaesthetic consult.
prospectively selected 26 patients at random who were Booking BMI should be documented in 100% of maternity
undergoing elective lower segment caesarean section under hand-held notes. An audit of the above standards was carried
spinal anaesthesia over a six week period. Ethical committee out as summarised below.
approval was obtained. Verbal consent was obtained from all Methods:A list of all deliveries in January 2013 was generated.
participants and the booking Body Mass Index (BMI) was Notes were reviewed for adherance to the above three
noted. We used the same protractor device for measuring the standards. Change to practice was recommended based on
angle of tilt. This is similar to the one used by Kinsella et al2. audit findings. Following the implementation of change, the
Results: The measured angles ranged from 10 to 18 degrees, a audit cycle was completed by auditing notes of all deliveries in
mean angle of 13.70 with a mean difference of -1.3 and standard November 2013.
deviation of 2.32. This compared very closely to the angles Results:
between 10 to 17.5 degrees, mean angle of 13.650, mean Table: Recording of booking BMI, patient count by raised
difference of -1.35 and a standard deviation of 2.06 in the BMI category and number given anaesthetic information.
previous study. BMIs ranged from 19 to 37 with a mean of 24.
Discussion: The visual estimation of angle using the
BMI 30 - BMI 35 - BMI
automated table tilt proved accurate in achieving the near 150 No
Number of Unavailable 34.9; 39.9; ≥40; 
tilt and is comparable with that obtained with the inflatable   booking
deliveries casenotes info info info
balloon wedge device in the previous study. The standard BMI
given given given
deviation of 2.32 indicates that 95.4% of cases could achieve
Jan 195 6 2 20; 0 7; 1 7; 7
within 4.60 of the required 150 tilt i.e. 10.4 to 19.6 degrees tilt.
Nov 173 3 2 17; 2 7; 7 3; 3
The automated table tilt provides an easy and accurate means
of providing left lateral tilt in pregnant patients. Discussion: Booking BMI was recorded in 99% of the notes in
both audit cycles. In 100% of cases where BMI was ≥40, a
consultant anaesthetist discussed risk and made a plan with
References
the patient. However, the audit of January deliveries indicates
1. Grewal B, Suri I. Is visual actuation a valid predictor of angle of tilt?
that few women who have a BMI 30-39.9 receive anaesthetic
Int J Obstet Anaesth Vol 18 2009; pS1-64- supplement
information.; this occurred in only one case. Reaching this
2. Kinsella SM. A device for measuring the degree of lateral pelvic tilt
during supine recumbency. Anesth Analg 1995; 80: 204-5 population to provide information is difficult especially where
BMI is 30-34.9 as all antenatal care for this group may be
provided by community midwives. In collaboration with
Obstetrics, a patient information leaflet was written which
included both obstetric and anaesthetic information. The
leaflet was approved by the Women's Integrated Governance
group and has been in use since October 2013. It is available
on the Trust intranet which is accessible by some community
midwives. The leaflet is given to all those with a BMI ≥ 35
when they attend obstetric high risk clinic. The results of the
November audit indicate improvement has been made; 44.4%
of those with obesity now receive anaesthetic information.
Greater access to the leaflet is needed however.
References
1. Royal College of Anaesthetists 2012,
http://www.rcoa.ac.uk/document-store/audit-recipe-book-3rd-edition-
2012
2. Centre for Maternal and Child Enquiries 2010, http://www.oaa-
anaes.ac.uk/assets/_managed/editor/
File/CMACE/CMACE_Obesity_Report_2010_Final%20for%
20printing.pdf
Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin) P13
P125 Antenatal management of morbidly obese parturients: P126 Audit of temperature for patients undergoing elective
A multicentre evaluation. caesarean section
H Aladin,  A Khandhia,  K Pottinger   N J Truman,  I Clegg,  K Maclennan  
Anaesthetics, Good Hope Hospital, Birmingham, UK anaethetics, St Mary's Womens Hospital, Manchester, UK
Introduction: Women with a body mass index (BMI) of ≥30 Introduction: Perioperative Hypothermia is associated with
kg/m2 at the time of antenatal booking are classed as being poor outcomes and adverse events for patients; including
obese in pregnancy, accounting for around 39,000 maternities surgical site infection increased length of stay, blood loss,
per year1. Obesity is associated with increased risk of shivering, increased anaesthetic recovery time and cardiac
anaesthetic morbidity and mortality. National guidance have events. Risk factors for the occurrence of hypothermia include
been developed following the Confidential Enquiry into regional anaesthesia, fluid deprivation, blood loss, and cold
Maternal and Child Health report concerning obesity in fluid administration, all of which are common to obstetric
pregnancy. At two different hospitals, five indicators of best patients. 2008 Nice guidelines CG651 on perioperative
practice2 were analysed: (1) Recording of maternal BMI. (2) hypothermia do not include parturients, despite being an at
BMI ≥ 30 women receive information about risk group. An audit performed in 2011 at St Mary's Hospital
anaesthesia/analgesia. (3) Women with a BMI ≥ 40 have demonstrated that 92.5% of elective section patients were not
antenatal anaesthetic review. (4) Duty anaesthetist should be 'comfortably warm' on arrival in recovery, with 65% defined as
informed when women with a BMI ≥ 40 are admitted. (5) hypothermic. A repeat audit was performed following
Anaesthesia for women with a BMI ≥ 40 should be provided commencement of a trial of an air free conductive fabric patient
by a senior anaesthetist. warming system (Hot Dog®).

Methods: Women who had undergone a lower segment Method: A prospective audit of elective caesarean section
caesarean section (LSCS) during a 6 month period (Jan 2013- patients was conducted from April-June 2013 at St Mary's
Jun 2013) at a District General Hospital (DGH) and a Hospital. Theatre staff completed the audit proforma. Data
Foundation Hospital (FH) were evaluated. Data was collected collected included; ambient theatre temperature (ideal target
retrospectively from an electronic data archive and anaesthetic 21ºC), anaesthetic type, estimated blood loss (EBL),
charts. Evidence of BMI calculations, provision of temperature pre, intra, post operative and prior to discharge
anaesthesia/analgesia information, ante-natal anaesthetic from recovery (measured using a tympanic membrane
appointments, and anaesthetic care in the labour ward and thermometer) and details of which Hot Dog® warming
theatre were identified. products were used. Hypothermia was defined as a core
Results: 309 women who underwent a LSCS were identified temperature <36ºC with desirable temperature being defined as
with a having a BMI 30 (median 34, range 30-59). 51% of 36.5-37.5ºC. Comparison of the results from the 2011 audit
these were elective cases. 56% of women with a BMI ≥30 enabled conclusions to be drawn regarding the effectiveness
received anaesthesia/analgesia information, of which 2 were of the warming product.

given literature on anaesthesia in obesity. 32% of women with
Results: A total of 33 patients were audited who underwent
a BMI 40 underwent an antenatal anaesthetic review, with an
elective caesarean section, [n=79, 2011audit], 94% had spinal
additional 4 women failing to attend their appointments. In
anaesthetic (87%, 2011 audit). Mean (S.D) theatre temp was
those women with a BMI ≥40, the duty anaesthetist was
22.8 (± 0.6) [22.3 (± 0.6), 2011 audit], mean duration of
informed of admission in 19% of cases and in 56% of LSCS,
procedure was 51 minutes. 94% of patients had an additional
the anaesthetic care was provided by an appropriately graded
fluid warmer intra-op (72%, 2011 audit). The mean EBL was 574
anaesthetist .
ml (± 213) [653 (± 431), 2011 audit] and only 6% of patients had
Table: Women with BMI 30 having anaesthetic care at a DGH an EBL over 1L (20% 2011 audit). Only 12% (n=4 of 33) of
and FH. patients warmed with the HotDog® were hypothermic on
arrival to recovery (compared to 65% (n=51 of 79), 2011 audit)
  DGH FH
figure 1.
Total LSCS 32% (99/309) 68% (210/309)
Discussion: efforts have been to reduce perioperative
BMI Median (range) 33 (30-59) 34 (30-52)
hypothermia in elective caesarean sections. Almost all patients
Maternal height, weight + BMI recorded 100% 100%
received warmed fluids via a 3M™ Ranger™ fluid warming
Conclusion: This audit has identified that more than half the
system. Forced air warming devices applied to the upper body
women with a BMI ≥30 received analgesia/anaesthesia
are not well tolerated by our awake patient population and
information and more than half were anaesthetised by a senior
allow only a limited area to be heated. introduction of
anaesthetist. However, in all the areas of practice, the target
HotDog® with an under patient warming mattress and
percentage of women meeting the identified standards were
separate over patient warming blanket (for upper and lower
not achieved. Recommendations included revision of the
limb) proved to be of benefit in perioperative maintenance
referral guidelines for antenatal anaesthetic assessment,
when compared to our standard warming measures. A
improved communication within the multidisciplinary team
HotDog® warming mattress placed on the patient chair in the
during admissions and increased presence of senior
pre theatre waiting area helped prevent hypothermia pre arrival
anaesthetists on delivery suite.
in theatre.
References
Reference
1. Centre for Maternal and Child Enquiries (CMACE). Maternal
1. CG 65 Management of inadvertent perioperative hypothermia in
obesity in the UK: Findings from a national project. London:
adults. NICE April 2008.
CMACE, 2010
2. The Royal College of Anaesthetists. Raising the Standard. A
compendium of audit recipes for continuous quality improvement in
anaesthesia. 3rd Edition 2012
P14 Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin)
P127 Availability of chlorhexidine handwash for regional P128 Caesarean section in a rhesus null parturient with a
analgesia on the labour ward uterine fibroid
K Chima,  T Strickland,  F Plaat   P J Stewart,  R Laird,  J Cartmill  
Anaesthetics , Queen Charlotte's and Chelsea Hospital, Anaesthetics, Altnagelvin Area Hospital, Londonderry, UK
London, UK Introduction: The anaesthetic management of a Caesarean
Introduction: Many patients request regional analgesia during section is made more challenging by the combination of pre-
labour and therefore central neuraxial blocks are performed in operative anaemia, a large uterine fibroid and the presence of a
the delivery room. For central neuraxial blocks an aseptic very rare blood group Rhesus null.
technique should be standard. In the Third National Audit Case report: A forty-year lady with a past medical history of
Project of the Royal College of Anaesthetists the incidence of psoriatic arthritis presented to antenatal booking at 10 weeks
iatrogenic infection was reported as being 8/707 000 gestation. Booking investigations revealed a haemoglobin of
procedures1. However the consequence of any infection is 10.3g/dL, and a blood group O Rhesus null. Her 20-week
potentially devastating, and a 'scrupulous' aseptic technique ultrasound scan revealed no foetal anomalies but did
was therefore stated to be mandatory in the report1. demonstrate an anterior uterine fibroid. This was confirmed
Chlorhexidene gluconate 4% is used for hand decontamination with magnetic resonance imaging which showed a
in our department. It was noticed that not all delivery rooms heterogeneous mass measuring 188x139x159mm, in keeping
were equipped with both chlorhexidene and a hands free with a degenerating fibroid. At 21+3 days she presented with
method for application. dizziness and right upper quadrant pain. Her haemoglobin
Methods: All delivery rooms on labour ward were inspected to level was 7.6g/dL and she was treated for iron deficiency
ascertain the presence of chlorhexidene and a hands free anaemia. Due to a transverse lie and the large fibroid an
dispenser. elective Caesarean section at 38 weeks was planned. As a team
we anticipated a difficult Caesarean delivery with greater blood
The audit was repeated after one and twelve months to assess
loss in a patient with anaemia and a very rare blood group.
if there had been any improvement in the service.
Antenatal management focused on maximising the patient's
Results: Originally, 12 of the 16 delivery rooms had
haemoglobin levels and sourcing compatible blood. The
chlorhexidene available (75%). Of the 12 rooms with
Northern Ireland blood transfusion service and National frozen
chlorhexidene only three were equipped with a hands free
red cell bank in Liverpool secured two units of packed red cells
dispenser (25%), and five containers were uncovered (42%).
in England. Unfortunately, one week prior to the section this
After one month all 16 rooms were equipped with wall blood was issued in an emergency, making it unavailable to us.
mounted chlorhexidene with a hands free dispenser (100%). A new donor was found in South Africa and a further unit was
After a further 12 months it was found that 12 of the 14 secured in Brazil. Both units were couriered to our hospital
delivery rooms had chlorhexidene available (86%). (Two of the prior to the Caesarean delivery which was performed at 38+6
rooms had been converted to a post delivery high dependency days under spinal anaesthesia. Pre-operative haemoglobin was
unit). Eleven of the 12 containers were equipped with a hands 9.1g/dL. The patient was discharged home on day three post-
free dispenser (92%). operatively and her haemoglobin was 7.2g/dl on discharge. No
Discussion: The results of the initial data collected, as well as blood transfusion was required.
anaesthetists' concerns regarding the unavailability of Discussion: Red blood cells from people who have the Rhesus
chlorhexidine and dispensers in each room, was reported to null phenotype lack Rhesus proteins, and thus, Rhesus
managerial staff, who ensured all rooms were adequately antigens. This phenotype occurs in approximately 1 in 6x106
stocked. Results were therefore better when re-auditing was individuals1. When these patients are transfused they may
performed at one month. However, after 12 months standards form antibodies to high frequency rhesus antigens, which can
had declined, although they were still improved from the make it extremely difficult to process compatible blood. Rhesus
initital audit. This decline could be attributed to the fact that null blood is available from the National frozen cell bank,
neither a team nor a named individual was made responsible however it may not be available when required due to limited
for sustaining the initial improvement, which if introduced, we supplies, as in our case. There is very limited literature
feel would encourage a sense of ownership and enable the regarding the management of the rhesus null parturient and
improvement in this area of patient safety to be sustained. our management was guided by our regional Haematology
Reference unit. This case demonstrates the importance of good
communication with all members of the multi-disciplinary team
1. National Audit of Major Complications of Central Neuraxial Block
in the United Kingdom 2009, http://rcoa.ac.uk/system/files/CSQ- and the detailed preparations required in a complex case.
NAP3-Full_1.pdf
Reference
1. Avent ND, Reid, ME. The Rh blood system: a review. Blood 2000
95: 375-387.
Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin) P15
P129 Category one caesarean sections in a district general P130 Comparison of two non-invasive cardiac output
hospital:  Improving the decision to delivery time monitoring devices in a parturient with complex
VK Wroe,  AM Troy   cardiac disease.
Department of Anaesthesia, Countess of Chester Hospital, PJ Rose,  V Misra,  S Quasim  
Chester, UK Anaesthesia, UHCW, Coventry, UK
Introduction: National Guidelines state that the interval from Introduction: The management of valvular lesions during
decision to delivery (DDI) in a category one caesarean section pregnancy and labour can present a clinical conundrum. We
should be less than 30 minutes1, and that a duty anaesthetist present the use of two cardiac output (CO) monitoring devices
should be immediately available for emergency work on the in a parturient with complex valvular heart disease undergoing
delivery suite 24 hours a day2. a caesarean section under epidural anaesthesia.
A 2008 departmental audit found that 85% of category one Case Report: A 37 year old primiparous woman with history of
sections had a DDI of under 30 minutes, a figure marginally ASD repair aged 4, severe mitral regurgitation, severe tricuspid
under the audit standard of 90%. Anaesthetic service regurgitation, moderate aortic stenosis (AS) secondary to a
provision in our trust was expanded in July 2012, with the congenital bicuspid valve and moderate pulmonary
addition of a dedicated obstetric anaesthetist 24 hours a day. hypertension presented for elective caesarean section.
This re-audit aimed to assess the proportion of category one Echocardiography showed moderately dilated right ventricle
caesarean sections with a DDI <30 minutes and analyse the with good bi-ventricular systolic function, bi-atrial dilatation,
factors contributing to any delay. moderate to severe AS (mean gradient 34mmHg, peak gradient
Methods: After audit department approval, a retrospective 53mmHg, estimated valve area 0.74cm2). Pulmonary artery
analysis of category one caesarean sections between August pressures were estimated at 42-47mmHg. LiDCO rapid and
and December 2012 was performed. Data collected included Cheetah NICOM devices were used to monitor CO.
DDI and reason for delay, indication for section, type of Anaesthesia was established with 32mL 2% lignocaine and 100
anaesthesia and cord pHs. micrograms of epinephrine via epidural. Compound sodium
lactate was infused at 60mL/hr, and increased to 100mL/hr after
Results: 69 category one caesarean sections were analysed.
epidural anaesthesia. Fluid boluses of 200mL and 100mL were
The mean DDI was 23 minutes (range 3-120 minutes). 84% had
delivered via the pump at 13 and 28 minutes after delivery of a
a DDI of under 30 minutes, with a mean time from decision to
live infant. Metaraminol infusion was titrated to effect.
effective anaesthesia of 14.5 minutes. The indication for
Syntocinon infusion was started upon delivery (20 units in
caesarean section was abnormal CTG in 87% of cases (2008:
48mL 0.9% saline) at 15mL/hr and tapered post-operatively
77%). General anaesthesia was performed in 43% (2008: 85%),
over 4 hours. Mean arterial pressure was maintained at 91 to
spinal anaesthesia in 55% (2008: 15%) and extension of
97mmHg until delivery (78 minutes) and then decreased to
epidural blockade in 2%. In 11 cases, DDI was over 30
67mmHg at the end of surgery. Cardiac output was maintained
minutes; these cases were all performed under spinal
throughout surgery with an increase at the time of concurrent
anaesthesia. The following table shows the reasons identified
fall in MAP. Fluid challenge had negligible effect although
that contributed to delay:
there was a small reduction in heart rate (84 to 59bpm).

Arrival in
Discussion: NICE has advocated the use of cardiac output
theatre Incision to
Spinal monitoring in high risk non-obstetric surgery to improve
10 delivery Staff Theatre
  placement outcome.1 In this case we utilised both a non-calibrated pulse-
minutes time 10 unavailable unavailable
10 minutes contour waveform analysis and bioreactance system to
from minutes
compare both values measured and response to fluid
decision
challenge. Although the values produced were different, the
Number
trends were broadly similar. This, once again, highlights the
of 4 6 1 1 1
importance of analysing trends rather than absolute values to
patients
guide management. Interestingly, both devices demonstrated
Arterial cord blood analysis was carried out in 10/11 cases. pH
that a fall in MAP correlated with an increase in cardiac
was less than 7.2 in 30%, and base excess was less than -8 in
output, similar to previous investigators.3 Given that cardiac
20%.
disease is the leading cause of death in the most recent
Conclusion: The proportion of cases with a DDI of over 30 triennialreport2, monitoring cardiac output enables one to
minutes has remained constant at around 15%, despite an maintain physiological homeostasis, and ultimately aids
improvement in anaesthetic staffing. Our results suggest that clinical decision-making leading to good clinical outcome, as in
the causes for this delay are multifactorial, and the results are our case.
not benign- the delay in delivery led to a cord pH of <7.2 in
References
almost one third of cases. We intend to improve our practice
1. MTG3 CardioQ-ODM (oesophageal Doppler monitor): guidance
by regular practice drills, use of preprepared spinal packs to
2011, http://www.nice.org/nicemedia/live/13312/52624/52624.pdf
reduce spinal placement time, clear procedures to follow in the
2. Centre for Maternal and Child Enquires (CMACE). Saving Mothers'
case of staff or theatre unavailability and reaudit. Lives: Reviewing maternal deaths to make motherhood safer: 2006-
2008. The Eighth Report of the Confidential Enquires into
References
Maternal Deaths in the United Kingdom. BJOG 2011;118(Suppl
1. Caesarean section. NICE Clinical Guideline 132. NICE, London 1):1-203
2011. (http://publications.nice.org.uk/caesarean-section-cg-132).
3. Fanning NP, Sermer M, Colman J, Carvalho JC, Cordovani D. Non-
2. OAA/AAGBI guidelines for obstetric anaesthetic services- 3rd invasive Hemodynamic monitoring with bioreactance for cesarean
edition. AAGBI and OAA, London, 2012 delivery. A more relaxed look at tight aortic stenosis? Abstract
(http://www.aagbi.org/publication/publication-guidelines/M/R) SOAP 2011, http://www.soap.org/display_2011_abstract.php?id=58
P16 Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin)
P131 Comparsion of slow and rapid bolus of ephedrine in P132 Continuous spinal anaesthesia for a primigravida with
patients undergoing planned caesarean section under severe tricuspid regurgitation, Harrington rods and
spinal anaestheisa WITHDRAWN FROM  thrombocytopenia.
PRESENTATION AM Walton,  I Mettam  
PG Sekar,  LB Ellakumanan,  H Balachander,  MVS Obstetric Anaesthetic Department, University Hospital
Satyaprakash   Southampton, Southampton, UK
Anaesthesiology, JIPMER, Puducherry, India Introduction: We present the successful use of continuous
spinal anaesthesia (CSA) for caesarean delivery in a parturient
with severe tricuspid regurgitation and pregnancy-induced
thrombocytopenia in addition to Harrington rod placement for
scoliosis spinal surgery.
Case history: A 40 year old primigravida presented at 37
weeks gestation. She had undergone a tricuspid valve repair
previously for endocarditis. The patient had developed severe
tricuspid regurgitation and had heart failure. Harrington rods
were placed in her thoracic and lumbar spine for repair of a
congenital scoliosis. Blood tests revealed a pregnancy related
thrombocytopenia with platelets of 85x109/L. An
echocardiogram showed a severly dilated right atrium with
intra-atrial septal bowing to the left, severe free flowing
regurgitation and right ventricular systolic pressure
32mmHg.The case was discussed with obstetricians,
anaesthetists and cardiologists and a decision was made for
an elective caesarean section under CSA, if the final platelet
count remained stable. The patient expressed a preference to
remain awake and avoid a general anaesthetic. At surgery a
cannula and radial arterial line were inserted. In the sitting
position a 22G spinal needle was inserted below the level of
the scar tissue at L3/4, and a spinal catheter threaded into the
subarachnoid space. A total of 10mg bupivacaine and 250mcg
diamorphine were required over 20 minutes to establish a block
to T4. The blood pressure dropped from 135/70 to 90/50mmHg
and required only 5mcg of epinephrine to return to baseline
values. Blood loss was 720mls. Syntocinon was given as an
infusion only. A live male infant was delivered.
Discussion: An obstetric anaesthetist has to take many
factors into account when deciding on the best choice of
anaesthetic for a particular case; anaesthetic expertise,
maternal co-morbidities, fetal well-being and maternal
preferences all play a part. Cardiac disease in pregnancy is still
the leading cause of indirect maternal mortality in the UK.1 The
choice of anaesthetic and delivery had to ensure the least
amount of strain on an already compromised heart. The
advantages of CSA are that a block can be established
gradually with small incremental doses of local anaesthetic,
which reduces the likelihood of cardiovascular instability.2
The concerns with a CSA are principally neurological
complications and post-dural puncture headache. CSA is
proving an option to be considered for patients with
significant cardiac disease and previous spinal surgery
provided the anaesthetist has experience with the technique.
In this case it provided a cardiovascularly stable anaesthetic
with excellent analgesia and maximal maternal satisfaction.
References
1. Saving mothers lives.The Eighth Report of the Confidential
Enquires into Maternal Deaths in the UK. March 2011
2. DennyNM, Selender DE. Continuous spinal anaesthesia. Br J
Anaesth 1998;81:590-7
Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin) P17
P133 Does pre-operative anxiety predict post-operative pain P134 Early epidural analgesia may increase caesarean
scores in parturients undergoing caesarean section? section rate in spontaneously  labouring nulliparous 
BM Daly,  N Weidenhammer,  R Junkin,  L Riddell,  J Dolan,  J women: a retrospective study
Kinsella*,  R Marla,  S Young   R Anil Kumar,  Roger Mc Morrow  
Anaesthesia, Princess Royal Maternity, Glasgow, UK, Anaesthesia, National Maternity Hospital , Dublin, Ireland
*Anaesthesia, Pain & Critical Care Medicine, University of Introduction:.Epidural analgesia offers the most effective
Glasgow, Glasgow, UK method of intra-artum pain relief. The effect of epidural
Introduction: Pregnancy, childbirth, and undergoing a surgical analgesia on the progression of labour and the mode is often
procedure are all likely to induce anxiety. The relationship debated in multiple studies. This study aims to show the effect
between anxiety, pain and pregnancy is complex.1Childbirth is of timing of epidural analgesia on the mode of delivery.
a time of high anxiety, and Caesarean section is known to be Method: Data such as women's age, gestational age, cervical
associated with significant pain post-op. Here we ask can dilatation before epidural insertion and duration of labour was
anxiety scoring predict post LSCS pain? collected from a total of 2029 nulliparous women in
Methods: After ethical approval and consent, pre-operative spontaneous labour. Epidural analgesic was defined as early at
data and a single 24hr post-op 10cm VAS were collected from a cervical dilatation of 3cms or less and late at a cervical
108 women, with 9 having missing data. Spielberger2 State and dilatation of 4 or more cm
Trait anxiety forms were completed prior to surgery. We Results: Of the 2029 women, 1423 ( 70.1%) received epidural
present secondary end points powered post hoc for 0.8 analgesia. Out of the 2029 women, 1403 ( 69.2%) had
probability of 2cm VAS difference. A standardised anaesthetic spontenous vaginal delivery, 478 (23.6%) had assisted
(spinal including diamorphine) and analgesic regime was used. delivery and 146 ( 7.2%) had caeserean section.
The cohort was divided into "high"- above the mean and
The data was anaylsed according to the timing of epidural
"low"- below the mean anxiety and compared using Student's
analgesia or no epidural analgesia and modes of delivery.
t-test.
Anaesthetic Delivery method
Results:
intervention Spontaneous Assisted Caesarean
Table 1: State anxiety compared to VAS
No epidural 537 (88.9%) 51 (8.4%) 16(2.6%) 604
Low anxiety High anxiety Early epidural 757 (62.2%) 379 126 (10.0%) 1262
  Significance
(n=45) (n=54) (30.0%)
24 hr VAS mean Late epidural 109 (67.7) 48 (29.8%) 4(2.5%) 161
5.0 (2.2) 5.3 (2.0) P= 0.40
(SD) cm
Epidural Assisted delivery C-Section
Table 2: Trait anxiety compared to VAS analgesia OR 95% CI p-value OR 95% CI p-value
Low anxiety High anxiety Early 5.27 3.86, 7.21 <0.001 5.59 3.28, 9.51 <0.001
  Significance
(n=48) (n=55) epidural
24hr VAS mean (SD) Late 4.64 2.97,7.23 <0.001 1.23 0.40,3.76 0.71
4.8 (1.9) 5.5 (2.2) P= 0.15
cm epidural
Table 3: State +Trait anxiety compared to VAS Conclusion: The results from the study show that the
Low anxiety High anxiety likelihood of having caeserean section in the early epidural
  Significance
(n=48) (n=51) group is significantly higher compared to the late epidural
24hr VAS mean (SD) group, but the incidence of assisted delivery between the early
cm 4.8 (1.9) 5.6 (2.1) P=0.072 and late epidural group were similar. This study also shows
that there is an increased likelihood of having assisted
Discussion: While the higher anxiety groups displayed a delivery and caeserean section delivery with epidural
higher mean VAS in all the analysis, this was not statistically analgesia compared to without from the study group.
significant. The separation between the two groups was better
References
with the State than the Trait anxiety score and best of all when
1..Gonen Ohel. Early versus late initiation of epidural analgesia in
the two scores were combined. Further reasearch could look at
labour: Does it increasethe risk of cesarean section. A randomised
anxiety scoring as part of a bundle of other measures verus trial. American journal of Obstretrics and Gynaecology (2006) 194,
pain. 600-5
2. Wassen et al. Early versus late epidural analgesia and risk of
References
instrumental delivery in nulliparous women: a systemic review.
1..Waldenstrom U: Experience of labor and birth in 1111 women. J British Journal of Obstretrics and Gynaecology (2010) 1471, 655-
Psychosom Res.1999: 47(5):471-82 661
2..www.mindgarden.com
P18 Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin)
P135 Efficacy of midwife led epidural top ups in labour–Are P136 Emergency obstetric and neonatal care in Kenya:
programmable pumps really the way forward? Addressing millennium development goals
E Traer,  G Waters,  GNB Jackson   D B Pachter,  C A Ameh*  
Anaesthetic department, Royal Berkshire NHS Trust, Anaesthesia, Cumberland Infirmary, Carlisle, UK, *Maternal
Reading, UK and Neonatal Health, Liverpool School of Tropical
Introduction: There are an increasing number of automated Medicine, Liverpool, UK
techniques by which labour epidurals can be managed1,2,3,4. Introduction: In 2008, an estimated 358,000 women died from
Comparison reports of programmable epidural pumps regimens complications of pregnancy and childbirth. The overwhelming
have shown lower total volumes of local anaesthetic may be burden of this mortality occurs in the developing world, with
associated with reduced rates of instrumental delivery and almost 60% of deaths occurring in sub saharan Africa.1There
improved maternal satisfaction1,2. Extended intervals between are also some 3.6 million neonatal deaths each year, and once
boluses with larger volume boluses was shown to use less again the developing world is disproportionately represented.2
total local anaesthetic3. These reports have led us to In 2006, the Liverpool School of Tropical Medicine (LSTM)
investigate similar outcomes our unit where we have a midwife developed a training package entitled "Life Saving Skills,
led top up (MLTU) practice. Emergency Obstetric and Neonatal Care" (LSS EOC-NCC) to
Method: First epidural bolus administered by the anaesthetist try and address these huge public health issues. Courses now
of 20ml 0.1% bupivicaine+2µg/ml fentanyl . Data recorded at run in 11 countries worldwide. In October 2013, I was fortunate
each subsequent midwife administered bolus (MLTU): bolus e nough to teach on a course in Nyeri, Kenya.
interval time, motor block (Bromage score of 2-4 taken as motor Methods: A variety of teaching methods were used on the
block), any change to the standard dose 20ml 0.1% course. Didactic lecture based teaching had a limited role, with
bupivicaine+2µg/ml fentanyl and if analgesia was effective or more emphasis placed on small group "break out sessions"
ineffective. and scenario based teaching. Pre and post course simulation
Results: 50 patients audited based testing was undertaken, with results collated and sent
back to Liverpool for analysis and assessment of efficacy of
Midwife led epidural Top Up Data  
teaching.
Mean bolus interval time (min) 105 (sd 26)
Mean rate bupivicaine mg/hr 10.56 (sd 3.6) Results: Participant feedback suggested a high level of
Motor block (Bromage score 2-4) 11/48 (22.9%) satisfaction with the course. The impact of courses in terms of
Mean time to motor block (min) 237 (sd 135) reduction in maternal and neonatal mortality remains the
NVD 14/48 (29.1%) subject of ongoing scrutiny. One study from Somaliland
Instrumental 18/48 (37.5%) demonstrated improved knowledge and skills and evidence of
LSCS 16/48 (33.3%) positive behaviour change post introduction of the course.3

Satisfaction excellent/good 46/48 (95%)
Conclusions: Maternal morbidity and mortality remains a huge
Discussion: In this study we found the mean interval in problem in Kenya. In 2008 it's Maternal Mortality Ratio was
minutes between epidural boluses to be 105minutes. This is 488 per 100,000, one of the highest in the world.4Great efforts
greater than the average 60minute interval of the are being made by the Kenyan government to reduce this. An
programmable intermittent bolus(PIB) regimens. An average ambitious target to reduce MMR to 91 per 100,000 by 2018 has
rate of bupivicaine 10.56mg/hr was similar to that reported with been set. One step has been the introduction of the Liverpool
PIB and patient controlled epidural bolus(PCEA) regimens4, LSS EOC-NCC course.
while we report a lower rate of motor block. Given the practice Acknowledgements: I would like to thank the maternal and
of MLTU in effect is much like a PIB without PCEA, it is neonatal health unit at LSTM for the opportunity to become
notable that the time between epidural boluses is longer with involved, and look forward to teaching on my next course. I
MLTU with less maternal motor block and high maternal would also recommend the course to any obstetric
satisfaction. We feel our practice promotes close epidural anaesthetists with an interest in international health.
assessment as the midwives assess motor block and maternal
References
satisfaction before each “top-up” and avoids the cost of the
1. World Health Organization, UNICEF, UNFPA and The World
PIB/PCEA pumps.
Bank. Trends in Maternal Mortality 1990-2008. 2010.
References 2. Lawn JE, Kerber K, Enweronu-Laryea C, et al. 3.6 million neonatal
deaths–what is progressing and what is not? Seminars in
1. Capogna G Camorica M, Stirparo S, Farcomeni A. Programmed Perinatology 2010;34:371–386.
Intermittent Epidural Bolus Versus Continuous Epidural Infusion for
Labor Analgesia: The Effects on Maternal Motor Function and 3. Ameh C, Adegoke A, Hofman J, et al. The impact of emergency
obstetric care training in Somaliland, Somalia. International Journal
Labor Outcome. A Randomized Double-Blind Study in Nulliparous
of Gynecology & Obstetrics. 2012;117:283-7.
WomenAnesth Analg July Oct 2011; 113(4): 826-831
4. Kenya National Bureau of Statistics. Kenya Demographic and
2. George RB, Allen T, Habib A. Intermittent Epidural Bolus
Health Survey (KDHS) 2008-09. June 2010.
Compared with Continuous Epidural Infusion for Labour Analgesia:
A Systematic Review and Meta Analysis. Anesth Analg Jan 2013;
Vol 116: 133-144
3. Wong C, MacCarthy RJ, Hewlett Bl. The effect of manipulation of
the programmed intermittent bolus time interval and injection
volume on total drug use for labour epidural analgesia: a randomized
controlled trial. Anest Analg 2011; 112: 904-11
4. Husain T, Mavridou I, Fernando R, El-Wahab N, Stewart A, Dick J,
Columb M. A study of a programmed intermittent bolus and patient-
controlled epidural regimen for labour analgesia. Int J Obstet
Anaesth May 2013: P85 Abstracts OAA Bournemouth 2013
Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin) P19
P137 Enhanced recovery after elective caesarean section: P138 Epidural analgesia in obese parturients: can kneeling
Service evaluation and quality improvement be the answer to our prayers.
GJ Lilley,  M Adamson,  A Miskin*,  M Turner   S De Silva,  L Kelliher*,  R Mottaleb*,  E Combeer  
Anaesthetics, Royal Gwent Hospital, Newport, UK, Anaesthetics, Frimley Park Hospital, Frimley, UK,
*Obstetrics and gynaecology, Royal Gwent Hospital, *Anaesthetics, Royal Surrey County Hospital, Guildford, UK
Newport, UK Severe pain is not life-threatening in healthy parturient women,
Introduction: Enhanced recovery (ER), a concept widely it is however shown to have neuropsychological
recognised within many surgical specialties, is now a subject consequences. Postnatal depression may be more common
of interest within obstetrics. The core principles comprise when effective analgesia is not used1 and pain during labour
speeding up recovery and improving patient outcomes, with has been linked with the development of post-traumatic stress
associated benefits for staff and healthcare systems1. The disorder2.There is an increasing number of obese parturients3
most logical starting point for the introduction of ER principles and identification and placement of the epidural can be
are elective caesarean section lists. Delayed surgery may lead difficult in these women.
to prolonged fasting, followed by delayed mobilization, Classically the sitting or the lateral position is used during
delayed removal of catheter and delayed discharge. A pilot siting of labour epidurals. The kneeling position was first
audit in our hospital demonstrated a mean stay after elective described in 19934, where 34/35 women had their labour
caesarean section of 3.6 days, and mean preoperative fasting epidural sited whilst in the kneeling position and 88.5% of the
period of 12.4 hours. Current guidance for ER in obstetrics mothers were happy with this position.
suggests minimal interruption to oral intake, pre-operative
I elected to try the kneeling position in an obese lady with a
energy drinks, catheter removal at 12 hours post-surgery
BMI 50 after adjustments in the sitting position and two
regardless of time of day, and the option of discharge home 24
separate failed attempts to confidently palpate the lumbar
hours after caesarean section where appropriate2.
spine. Once the lady was in the kneeling position, the lumbar
Methods: All elective caesarean sections were included in this spine was not only palpable but also visible and the epidural
service evaluation after introduction of preoperative space was identified with ease. With Departmental approval I
carbohydrate drinks. Data collection included fasting time, in performed my labour epidurals in this manner and found it not
addition to time to mobilization, to catheter removal and to only to be easy to site epidurals but also tolerated well. Some
discharge. After an initial 6 week period of data collection, the women complained of paraesthesia in their feet, but this was
data was presented to anaesthetic and obstetric staff. Posters, rare and eased swiftly. We decided to survey our Deanery to
a discharge proforma and a patient information leaflet were ascertain what positions were being utilised.
produced, and specific guidance was developed regarding
Survey: An e-survey was sent to trainees and Consultants in
preoperative carbohydrate drinks. A further 6 weeks of data
the South West London Deanery into what their ideal first and
collection then took place.
second choice positions used for siting epidurals would be for
Results: A total of 78 consecutive patients were included, all labouring parturients. We then posed the same question for
of whom received a regional anaesthetic technique for elective obese parturients (BMI 40). They were asked if they had
caesarean section. The following table illustrates the timing of heard of the kneeling position and if anyone had tried it. For
pre- and post-operative events before and after our those who had not, we questioned why they had not tried it.
interventions.
Results: We received 53 responses, 96.2% of whom were
Time period / hour 2nd 6 week Initial 6 week
trainees. 64.2% chose to position the parturient sitting as their
mean(SD) period period
first choice and 60.4% chose lateral as their second choice in
Pre-op fasting 4.8 (2.8) 3.8 (2.5)
non-obese parturients. In comparison 84.9% opted for the
Post-op fasting 4.2 (3.5) 3.4 (3.5)
sitting position in obese parturients with 56.9% using the
Total interruption to oral
9.0 (4.5) 7.1 (4.6) lateral as their second choice. The only positions utilised were
intake
sitting and lateral. 94.9% of respondents had not heard of the
Delivery to mobilization 10.2 (4.5) 9.0 (3.3)
kneeling position to site labour epidurals.
Delivery to catheter removal 14.8 (6.6) 13.5 (3.5)
Conclusion: Each position used for the placement of labour
Delivery to discharge 67.3 (40.1) 63.3 (27.6)
epidurals has their own advantages and disadvantages. With
Discussion: The introduction of patient information leaflet
the rising incidence of maternal obesity and its associated
offering guidance regarding post-operative oral intake,
risks to not only the mother but also the unborn child, we need
mobilization, catheter removal and early discharge, along with
to be continuing in our development and advancement in the
staff education and introduction of pre-operative carbohydrate
provision of good care. We suggest that the kneeling position
drinks, has resulted in improvement in the timing of a number
is a safe and viable alternative for siting epidural catheters in
of peri-operative interventions, and a small reduction in
labouring parturients.
duration of hospital admission. However, possibly due to
References
obstetric, midwifery, paediatric and organisational reasons,
discharge is rarely achieved at the potential target of 24 hours 1. Hiltunen P, Raudaskoski T, Ebeling H, Moilanen I Does pain relief
during delivery decrease the risk of postnatal depression? Acta
after elective caesarean section. Obstet Gynecol Scand 2004;83:257-261
References 2. Soet JE, Brack GA, Dilorio C Prevalence and predictors of women's
1. Lucas DN, Gough KL. Enhanced recovery in obstetrics - a new experience of psychological trauma during childbirth. Birth
frontier? Int J Obstet Anaesth 2013; 22: 92-95 2003;30:36-46
2. Enhanced recovery partnership: A better journey for patients and a 3. Centre for Maternal and Child Enquiries (CMACE). Saving
better deal for the NHS. Available at: Mothers'. Lives: reviewing maternal deaths to make motherhood
http://www.improvement.nhs.uk/documents/er_better_journey.pdf safer: 2006–2008. The Eighth Report of the Confidential Enquiries
into Maternal Deaths in the United Kingdom. BJOG 2011;118:1-203
P20 Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin)
P139 Epidural labour analgesia and risk of instrumental P140 Estimation of blood loss during caesarean sections -
delivery discrepancy between visual and laboratory estimation
R Carvalho,  T Ferreira,  M Duque,  D Catré,  I Guedes,  J P A Nowicka,  A Amasakera,  C Ferdinand,  I Suri  
Assunção   Anaesthesia, Warwick Hospital, South Warwickshire NHS
Anaesthesiology, Centro Hospitalar Tondela Viseu EPE, Foundatio, Warwick, UK

Viseu, Portugal
Introduction: Excessive blood loss is a major threat to women
Introduction: Epidural analgesia (EA) is a worldwide effective undergoing casearean sections. Accurate visual estimation of
method used for pain relief during labour. Nevertheless, its use blood loss is difficult due to dispersion of blood lost and the
and evolution to instrumental vaginal (forceps or vacuum blood being mixed with amniotic fluid(1). Therefore the blood
extraction) or operative deliveries remains controversial loss often gets under or overestimated(2). A number of
between experts,1 either anesthesiologists or obstetricians. methods exist to estimate the blood loss, the commonly used
We aimed to analyze the relation between EA and instrumental being: visual estimation by the attending staff, weighing of the
v aginal deliveries in a sample of our obstetric population. blood soaked surgical swabs and calculation based on the pre-
and post-operative haemoglobin concentrations(3). The aim of
Methods: A retrospective study included all pregnant women
this audit was to compare the visually estimated blood loss by
who delivered on our labour Room, between 1-January-2011
both the surgeons (vEBLs) and anaesthetists (vEBLa) against
and 31-December-2012, excluding those who underwent
the calculated estimated blood loss (cEBL).
caesarean section. We reviewed the data of demographical
characteristics, type of gestation and labour, the use of EA Methods: Data was collected on thirty five caesarean sections.
and the newborn APGAR score. Descriptive analysis of Operating surgeona and anaesthetists were asked to visually
variables was used to summarize data and Chi-Square test was estimate the blood loss in each case. The circulating blood
used. Multivariate analysis was done with logistic regression, volume was calculated for each patient based on the body
with calculation of corrected Odds Ratio (OR) and its 95% weight and height. Then, the blood loss during caesarean
confidence interval (95% CI). section was calculated using the circulating blood volume and
the pre- and post-operative haemoglobin concentrations.
Results: 2901 pregnant women were included in this study, Correction was made for the haemodilution by intravenous
with mean age of 29,7 years. 81% underwent EA and 30% fluid administered.
instrumental vaginal delivery. 51% were nulliparous. Applying
Results: Twenty six complete forms were included in the
Chi-Square test to independent variables, we obtained
analysis. None of the patients received blood or blood
significant associations with dystocic delivery for EA, normal
products intraoperatively. Mean volume of intravenous fluid
maternal age (NMA; 20-35 years) and parity (p<0,001).
infused was 1304mL±421. Mean vEBLs, vEBLa and cEBL was
Applying logistic regression to our model, including parity,
590mL±300, 623mL±372 and 821mL±1004 respectively. The
NMA and EA with dystocic deliveries, we obtained corrected
tendency for anaesthetists to give a higher estimate of blood
OR (95%CI) for EA 2,459 (1,884-3,210) and for parity 3,4
loss was not statistically signifficant (p=0,12). There was a
(2,867-4,121), with NMA loosing significance. However, this
clear discrepancy between the visual estimate given by both
result may still be biased by other factors, such as labour
the surgeons and the anaesthetists, ant the cEBL, however, it
stage at the time of the EA beginning, drugs used in epidural
did not reach statistical significance (p=0,11 and p=014
space, use of oxytocin during labour, among others.
respectively). Compared to the cEBL the vEBL was
Additionally we found that, in our population of term
overestimated when the blood loss was low (12 cases) and
pregnancies, NMA and eutocic deliveries, there was no
underestimated when the blood loss was higher than 500mL
significant relation between EA and APGAR score <8 at the
(14 cases). There was a linear relationship between the degree
first minute (p=0,079).
of underestimation and the blood loss, with high levels of
Conclusion: It's generally assent that EA provides the most blood loss being most underestimated.
effective pain relief in labour. However, it's associated to Conclusions: In this audit, the standard procedure for
prolonged labour and risk of instrumental or caesarean estimation of blood (visual estimation by the obstetrician) loss
deliveries.2 Our study has drawn the conclusion that both was found to be unreliable. We demonstrated a tendency of
having EA for labour pain relief and being nulliparous increase anaesthetists and surgeons to overestimate the blood loss, if
the chance of instrumental delivery, respectively in 2,459 and actual blood loss was less than 500mL, and underestimate if
3,43 times, however without significant impact on newborn the blood loss exceeded 500mL. As a result of the audit, it has
APGAR score. Bigger prospective studies correcting for more been made compulsory in our unit to check haemoglobin
risk factors are advised. concentration in recovery whenever the vEBL exceeds
References 1 000mL.
1. BMC Pregnancy and Childbirth 2008, 8:45. References
2. Acta Obstet Gynecol Scand 2002, 8:1033-1039. 1. Khan FA, Khan M, Ali A, Chohan U Estimation of blood loss during
Caesarean section: an audit. J Pak Med Assoc. 2006 Dec;56(12):572-
5.
2. Larsson C, Saltvedt S, Wiklund I, Pahlen S, Andolf E Estimation of
blood loss after cesarean section and vaginal delivery has low
validity with a tendency to exaggeration. Acta Obstet Gynecol
Scand. 2006;85(12):1448-52.
3. Stafford I, Dildy GA, Clark SL, Belfort MA, Visually estimated and
calculated blood loss in vaginal and cesarean delivery. Am J Obstet
Gynecol. 2008 Nov;199(5):519.e1-7
Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin) P21
P141 Ethnic variations in use of labour analgesia P142 Factors associated with the use of spinal anaesthesia
LMD MacDarby,  CMC McCaul   for caesarean section in Nigeria
Delivery Suite, The Rotunda Hospital, Dublin, Ireland C Imarengiaye,  F Asudo*,  A Akinmola†,  B Lawal§  
Introduction; This retrospective cohort study was compiled to Anaesthesiology, University of Benin Teaching Hospital,
establish the wide variety of nationalities presenting to The Benin City, Nigeria, *Anaesthesia, University of Abuja
Rotunda Hospital for delivery during a one month period and Teaching Hospital, Gwagwalada, Nigeria, †Anaesthesia, 
to determine the labour analgesia preferences amongst this National Hospital, Abuja, Nigeria, §Anaesthesia, Lagos 
population. Island Maternity Hospital, Victoria Island, Nigeria

Introduction: There has been a consistent increase in the rate
Methods; Details of all deliveries occurring during the month
of spinal anaesthesia for caesarean section in many hospitals
of October 2013 were collected. Any patients undergoing
worldwide and had been advocated as the preferred technique
elective caesarean section and those with failed inductions
for caesarean delivery.1 Recent evidence suggests increasing
were excluded from the study. A demographic of patients’
use of spinal anaesthesia for caesarean sections in reports
nationality and ethnic background was compiled. Data relating
from a teaching hospital.2 The rise in spinal anaesthesia
to these patients’ use of labour analgesia was recorded i.e.
caesarean section notwithstanding, it is pertinent to determine
epidural uptake, pethidine administration and remifentanil
the factors limiting the wholesome application of spinal
infusion use. We then established the frequency of use of
anaesthesia for caesarean section in Nigeria.
each of these methods of analgesia in each population

Methods: A snap-shot survey was conducted in some
Results; There were 767 deliveries in Oct 2013. 104 elective
selected hospitals in Nigeria. The survey determined the
caesarean sections were carried out and there were 8 patients
sociodemographic characteristics of patients, indication for
who failed induction.
surgery, grade of anaesthesia provider, contraindication to
Therefore a total of 655 patients laboured during this time. spinal anaesthesia and any other factor that may be noticed in
This number was made up by 50 different nationalities. Of the selected hospital. The survey was to be conducted over a
these 414 patients were Irish, the majority being white but 2-week period but was truncated by the nation-wide strike
including small numbers of Asian or Black background. action by doctors after 9 days.
Amongst the Irish patients the rate of epidural uptake was
Results: A total of 99 patients were attended to in 4 of the
43.47% (234) and the rate of pethidine use was 17.87% (74)
selected 6 hospitals within the study period. 36/99 women
Patients of other white background, including many eastern
were nulliparous and maternal factors (82/99) were the leading
european countries made up 134 of the patients. These
indications for caesarean section. Consultant anaesthetists
patients as a group had a 52.98% epidural uptake rate. Black
(23/99), Senior Registrars (35/99), Medical Officers (36/99) and
Africans were found to have a 39.13% (9) uptake rate and
others (5/99) provided anaesthesia for the caesarean sections.
those of Asian background had the highest rate at 54.83%
85/99 patients received spinal anaesthesia and 14/99 had
(17). The use of pethidine was significantly lower than the rate
general anaesthesia for the c-section. Fetal indication for
of epidural in all of these groups. Pethidine was used by
caesarean section had a 3-fold risk of general anaesthesia for
18.19% of Black Africans, 12.9% of Asians and 23.13% in
the surgery (p = 0.037, RR = 3.1, 95%CI 1.2 – 8). 25/99 and
those of other white backgrounds. There were only 3 cases of
74/99 were performed as elective or emergency procedure.
remifentanil use during the month
Nature of caesarean section was not a factor for the use of
Discussion; The highest incidence of epidural uptake during spinal anaesthesia (p =0.51, RR = 2.0, 95%CI = 0.5).
Oct was found to be amongst the Asian population, the lowest Discussion: Over 85% of caesarean sections in Nigeria were
being amongst Black Africans. Pethidine use was less than conducted under spinal anaesthesia. Fetal indications for
25% in all groups. The reasons for these trends is unknown caesarean section provoked a 3-fold increase in general
though previous studies have suggested that cultural and anaesthesia for caesarean section. The use of general
educational factors may play a part. anaesthesia for caesarean delivery was due to fetal indications
A prospective survey of patients post delivery detailing the for surgery, antepartum haemorrhage and failed spinal
reasons for their choices of labour analgesia would be anaesthesia. Improved practical conduct of the spinal
worthwhile. Establishing the factors influencing their technique may enhance great application of spinal anaesthesia
decisions may allow us to provide an unbiased and fully for caesarean section.
comprehensive service to ensure patient satisfaction. References

1..Morgan BM, Magni V, Goroszenuik T. Anaesthesia for emergency
caesarenc section. BrJ Obstet Gynaecol 1990; 97: 420-424
2..Amadasun FE, Idehen HO, Edomwonyi NP. Evolving pattern of
anaesthesia for caesarean section: Experience at the university of
Benin Teaching Hospital West Afr J Med 2013; 32: 196-9
P22 Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin)
P143 Failed intubation for a category 1 caesarean section in P144 Fasting dilemmas: A rare case of a patient with non-
a patient with undiagnosed spina bifida ketotic hyperglycinaemia presenting for caesarean
CR Deane,  E Lewis,  J Spargo   section
Department of Anaesthetics, Singleton Hospital, Swansea, M Behravesh,  S Dawson,  G McClune,  S Atkinson  
UK Anaesthetics, Royal Jubilee Maternity Hospital, Belfast, UK
Introduction: Non-ketotic hyperglycinaemia (NKH) is a rare
Introduction: Spina Bifida Occulta (SBO) is part of a spectrum
autosomal recessive metabolic disease caused by a defect in
of neural tube defects and is common. We present the case of
the glycine cleavage system. This case report describes the
a patient with previously undiagnosed SBO who required a
management of a patient who presented for caesarean section.
category 1 caesarean section (CS). Despite an unremarkable
To our knowledge there are no other published case reports of
airway assessment she had a failed intubation on rapid
this type.
sequence induction (RSI) and subsequently required an awake
fibre optic intubation (AFOI). Case Report: A 32 year old Para 1 presented for elective
caesarean section of twins at 37 weeks gestation. She had a
Case report: A 37 year old para 0 patient presented to labour
history of atypical non-ketotic hyperglycinaemia. Following
ward labouring with a single live foetus at 37 weeks gestation.
advice from clinical chemistry, during her 6 hours preoperative
She was admitted under consultant obstetric care with
fast she received an inceased dose of sodium benzoate and an
asymptomatic hypertension. When considering an epidural
intravenous infusion of 10% dextrose at 3mls/kg/hour which
she was examined and had a vascular naevus, associated with
was continued perioperatively. Caesarean section was
skin tethering, over lumbar vertebrae. She was asymptomatic,
performed under spinal anaesthesia and twin baby boys were
had never been investigated, and had no definitive diagnosis
delivered successfully. Post delivery of the second twin she
of SBO. Airway assessment included a Mallampatti score of 3,
received a bolus of 5 units of syntocinon followed by an
but was otherwise unremarkable. An epidural was declined to
infusion at 10 units per hour. Due to uterine atony and an
the patient, with a remifentanil PCA provided instead. A plan
operative blood loss of 1000mls she also received ergometrine
was agreed for a RSI GA if operative intervention was
carboprost intramuscularly to good effect. Sodium benzoate
required. Several hours later she required a category 1 CS.
was administered orally in recovery and the 10% dextrose
Initial laryngoscopy with a Mackintosh blade yielded a
infusion was continued until the patient was establised on an
Cormack and Lehane grade 3 view. Manipulation of the cricoid
oral regimen prescribed by the dieticians. This involved a
cartilage, long and McCoy blades did not improve the view.
series of high calorie drinks up to every 2 hours for 48 hours.
Two failed attempts were made to intubate using a bougie. The
No dietary protein was allowed for 24 hours post delivery.
patient was ventilated using a face mask and a Guedel airway
Glycine levels were monitored daily and were raised on day 5
with oxygen saturations above 97% throughout. She was
while dietary protien was being gradually reintroduced.
woken up without further incident and an AFOI was
performed. Her child was delivered by LSCS without further Discussion: NKH has an incidence of 1 in 60,000 with 3
incident or obvious deficit. The APGAR scores were 8 and 10 distinct presentations. Classically neonates present with
at one and five minutes. A grade 3 view was confirmed before lethergy, hypotonia and seizures. These symptoms can
the patient was woken. Recovery from anaesthesia was proceed to apnoea requiring ventilation and 30% of patients
uneventful. The patient was appropriately counselled. An do not survive the neonatal period. Severe psychomotor
Airway Alert Letter was issued and follow up appointment retardation is common in those who survive. A second,
made. An MRI was carried out subsequently and showed a atypical and very rare form presents with mild baseline
neural arch defect and dural tethering. Significantly the conus hyperglycinaemia and intermittent encephalopathy
lay as low as L4 with diastematomyelia as far as L2. assosciated with periods of illness. Transient neonatal
hyperglycinaemia has also been described. Biochemically,
Discussion: SBO is common and without prior imaging
NKH is characterized by elevated glycine concentrations in
presents the clinician with a difficult decision. Regional
plasma, CSF, and brain with a CSF glycine to plasma glycine
techniques risk neural or dural injury due to a low lying or
ratio greater than 0.08.1 Standard treatment strategies include
tethered cord.1 Abnormal spread of the analgesic agents may
protein restriction to reduce exogenous glycine,
give rise to either excessive cranial spread or inadequate
supplementation of one-carbon pool donors and
caudal spread. This patient population provides further issues
administration of sodium benzoate. NMDA antagonists have
for the anaesthetist given the high risk of operative delivery or
been shown to raise the developmental quotient, improve
other intervention (due to pelvic structural abnormalities) and
muscle tone and reduce seizures in these patients.2
the association of spina bifida with difficult intubation.2,3
Patients with spina bifida require careful preop assessment Prolonged periods of fasting predispose these patients to
and MRI imaging and careful airway consideration is essential glycine build up and its toxic neurological effects. This has
in order to inform anaesthetic planning. major implications for the anaesthetist in the perioperative
period. This case demonstrates the safe use of regional
References
anaesthesia in conjunction with careful nutritional planning.
1. Reynolds F. Damage to the conus medullaris following spinal
anaesthesia. Anaesthesia 2001; 56: 235-247. References
2. Richmond D, Zaharierski I, Bond A. Management of pregnancy in 1. Chang YT, Lin WD, Chin ZN et al. Nonketotic hyperglycinemia: A
mothers with spina bifida. Eur J Obstet Gynecol Reprod Biol 1987; case report and brief review. Biomedicine 2012; 2(2):80-82
25: 341-5. 2. Van Hove JL, Vande Kerckhove K, Hennermann JB et al. Benzoate
3. May A, Fombon F, Francis S. UK registry of high-risk obstetric treatment and the glycine index in nonketotic hyperglycinaemia.
anaesthesia: report on neurological disease. Int J Obstet Anaesth Journal of Inherited Metabolic Diseases. 2005;28:651–663
2008; 17: 31-6.
Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin) P23
P145 Fetal bradycardia following regional anaesthesia for P146 Further increase in hysterectomy rates - and the
emergency caesarean section and instrumental reason why
delivery: a service evaluation JS Campbell,  M Molloy,  C Thompson,  D Fogarty  
JK Sidana,  K Jadhav-Smith,  J Corfe   Royal-Jubilee Maternity Service, Belfast HSC Trust, Belfast,
Anaesthetics, Norfolk and Norwich University Hospital, UK
Norwich, UK Introduction: RJMS is the tertiary obstetric service for
Introduction: Fetal heart rate abnormalities, such as late Northern Ireland. As part of a service review of use of uterine
decelerations or fetal bradycardia, are known to occur after artery balloon catheters, we retrieved data from several
neuraxial anaesthesia.1 These may be due to maternal sources. We found a large proportion of these patients still
sympathetic blockade or an increase in the uterine tone caused required hysterectomy. Further interrogation of our data
by intrathecal opioids. The objective of this service evaluation showed some unexpected trends.
was to evaluate the incidence and management of fetal Methods: With approval of the Trust's Data Guardian we used
bradycardia following regional anaesthesia for emergency data from several hospital systems, including a local maternity
caesarean section and instrumental deliveries. care database and histology records.
Methods: 15 patients with an episode of fetal bradycardia Results: We found 30 hysterectomies from 37,088 deliveries in
following regional anaesthesia were identified by reviewing 6 years. This is a rate of 0.8 per 1000 - significantly higher than
the daily obstetric handover sheets from January to December our prior rates which was near the NICE-quoted rate of up to 3
2011. The medical notes of these patients were reviewed for per 1000. Of these cases, 23 (76%) were due to morbidly
peripartum obstetric management, cardiotocographic (CTG) adherent placenta.
findings, perioperative anaesthetic management and
Not all these cases of morbidly adherent placenta were
management of fetal bradycardia. Neonatal outcome was
diagnosed antenatally, which perhaps made hysterectomy
assessed by APGAR scores, umbilical cord gases and NICU.
more likely since facilities such as intra-arterial balloon
Results: 10 patients had an assisted delivery and 5 had an catheters could not be available to us in an emergency.
emergency category-2 LSCS. The peripartum CTG findings Unanticipated cases suffered greater blood loss. Despite no
were either suspicious or pathological. Timing of fetal diagnosis, the majority (16/23) were placenta percreta on
bradycardia following regional anaesthesia ranged from 2 to 15 histology. These percreta cases again had greater blood loss,
min. 13 patients received spinal anaesthesia and 2 received and were more likely to require ICU care post-operatively. Yet
epidural top up. Maternal haemodynamics stability was there were no cases of percreta in the 6 years prior, and less
maintained with left uterine displacement, intravenous fluids than half the number of hysterectomies in that period. This
and phenylephrine infusion. One patient had an episode of seems to be a dangerous and dramatic change in recent years.
maternal bradycardia below 50 beats/min which was treated
Conclusion: We found a recent and significant increase in
with anticholinergics. Comparing the baseline maternal heart
peripartum hysterectomy, associated with a large increase in
rate with the lowest perioperative heart rate, 3 patients had a
the number and degree of morbidly adherent placenta. Patients
greater than 40% drop in the heart rate. 5 patients had a blood
with placenta percreta had a greater blood loss, and more
pressure drop of more than 20% below the baseline, which was
commonly required hysterectomy and ICU care.
treated with phenylephrine. The highest level of block to
Reference
temperature was T3. Syntocinon was stopped in all but one
case in the event of fetal bradycardia. Significant delays 1. National Institute for Health and Clinical Excellence. Caesarean
section: NICE Clinical Guideline 132 2012,
occurred in transferring these patients to theatre after the
http://www.nice.org.uk/nicemedia/live/13620/57163/57163.pdf
decision for surgical intervention were taken, maximum 35 min
(median 17 min). 6 cases had poor neonatal outcomes with low
5 minute APGAR and abnormal cord gases.
Discussion: We could not find any direct cause which can be
solely attributed to regional anaesthesia for the occurrence of
fetal bradycardia in these patients. Significant delay in patient
transfer to theatre may have a causal relationship but cannot
be confirmed. Studies in elective patients have shown that
maternal bradycardia causes a drop in maternal cardiac output.
2 Relative maternal bradycardia occurred in several of our
cases and this would have led to drop in cardiac output and
therefore oxygen delivery. This is most likely a side effect of
phenylephrine use. We plan to introduce a care bundle to
implement pre-operative and intra-operative fetal resuscitation.
This will include steps to improve fetal condition at the time of
regional anaesthesia and to ensure adequate maternal cardiac
output and oxygen delivery.
References
1. Reynolds F, Seed PT. Anaesthesia for Caesarean section and
neonatal acid-base status: a meta-analysis. Anaesthesia 2005; 60:
636–653
2. Stewart A, Fernando R et al. The dose-dependent effects of
phenylephrine for elective caesarean delivery under spinal
anaesthesia. Anesthesia & Analgesia 2010; 111: 1230-7.
P24 Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin)
P147 Impact of workload on accidental dural puncture P148 Implantable cardioverter defibrillator in
(ADP) rate pregnancy WITHDRAWN FROM PRESENTATION
W Mon,  YM Liu,  A Stewart,  R Fernando,  M Columb*   S Chaudhari,  S Quasim  
Anaesthetics, University College London Hospital, London, Anaesthetic Department, University Hospital Coventry and
UK, *Intensive Care Unit, University Hospital of South Warwickshire , Coventry, UK
Manchester, Manchester, UK
Introduction: Post dural puncture headache is an important
cause of morbidity. We audit our ADP rates annually against
the national standard.1Between 2005 and 2008, our ADP rate
was stable at approximately 0.5%. However, from 2008 to 2010,
our rate rose to above the 1% national standard.1Therefore, we
audited factors that may have contributed to this increase.
Methods: Information for this audit was obtained from a
computerised database. Data collection included day, month
and time of ADP and the grade of anaesthetist. We also
collected annual data of number of deliveries, epidurals and
combined spinal epidurals (CSEs) for labour, caesarean section
(CS) data, and the proportion of single shot spinals (SSS) to
CSEs performed. Data were analysed using chi-square
multinomial and trend tests with P value <0.05 defined as
significant.
Results: There was a 40% increase in deliveries between 2008-
2010. CSs and regional blocks for analgesia increased by 36%
and 40% respectively. Although the ADP rate increased, we
could not demonstrate a statistically significant trend due to
small numbers. From 2010 to 2012, a non-significant fall in the
ADP rate was seen. There was no significant association
between ADPs and day, month or time. We did see a
significant non-linear trend (P = 0.0012) in the proportions of
SSSs to CSEs performed, with the peak occurring in 2010.
Table 1. Trend of activity and ADP rate from 2008 to 2012
  2008 2009 2010 2011 2012 P value
Maternities (n) 4032 5039 5647 5841 5953 < 0.0001
Epidurals for labour (n) 1306 1600 1839 2029 2132 < 0.0001
CSs (n) 1370 1562 1861 1862 1773 < 0.0001
SSSs for CS (n) 282 274 356 326 347 0.0015
CSEs for CS (n) 797 644 714 833 915 < 0.0001
Proportion of SSS to CSE (%) 26 30 33 28 27 0.0012
ADP rate (%) 0.57 0.98 1.05 1.01 0.82 0.31
Discussion: We observed an increase in ADPs until 2010, with
significant rises in deliveries and anaesthetic procedures
performed. The significant non-linear trend in the proportions
of SSSs to CSEs performed for CSs peaked in 2010. A fall in the
ADP rate between 2010-2012, occurred despite exposing more
women to the risk of ADP, as during this time we performed
significantly more CSEs than SSSs proportionally. We believe
that the rise in the ADP rate resulted from a significant
increase in our workload between 2008 and 2010, without any
increase in anaesthetic staffing. From 2010 onwards, daytime
anaesthetic consultant sessions increased by 50%, and there
was a higher presence on the labour ward out of hours by
senior registrars covering non-obstetric theatres. Both factors
may have contributed to the subsequent fall in the ADP rate.
This audit supports the recent OAA/AAGBI guideline
recommending increased anaesthetic staffing on labour ward.2
References
1. Royal College of Anaesthetists. Epidural analgesia during labour.
Raising the standard: a compendium of audit recipes. 2012;218-219
2. Association of Anaesthetists of Great Britain and Ireland and
Obstetric Anaesthetists' Association. OAA/AAGBI guidelines for
obstetric anaesthetic services. 2013
Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin) P25
P149 Inadvertent hypothermia during elective caesarean P150 Inter professional relationships on labour ward- how
sections well do anaesthetists and midwives get along?
S Botros,  R Labib,  T Ramhew,  M Baban,  Y Poonawala   M Salman,  P Kumar,  G Graham  
Selwyn Crawford Department of Anaesthesia , Birmingham Anaesthetics, St. Thomas' Hospital, London, UK
Women's Hospital, Birmingham, UK Introduction: Anaesthetists and midwives are part of the
Introduction: The National Institute for Health and Care multi-professional team that provides care for parturients.
Excellence (NICE) defines inadvertent perioperative They work together in close collaboration in the unique and
hypothermia as a core body temperature below 36°C.1 It is a often highly charged environment of labour ward. In such
common complication of regional anaesthesia, and is the settings, effective inter professional relationships are key to
leading cause of perioperative shivering. Hypothermia is the delivery of high quality care and consequently better
associated with increased risk of wound infection and patient outcomes. Successful collaborative practice can be
increased blood loss.1 Shivering can be associated with negatively impacted by barriers such as lack of clarity on the
increased oxygen consumption and hypoxaemia in vulnerable scope of roles of team members, poor communication, or
patients. Although the NICE guideline on the management of stereotyping. We conducted a survey amongst obstetric
perioperative hypothermia did not cover pregnant women,1 it anaesthetists and midwives in our hospital to reflect upon this
has been adopted by many obstetric units. In our unit, working relationship and to see how it may be improved.
intravenous (IV) fluid is not routinely warmed for elective
Methods: A questionnaire was designed and distributed to
caesarean sections (CS). Hence, we audited our practice to
midwives and anaesthetists of all grades. Questions were
evaluate the incidence of hypothermia.
asked on their understanding of each other's professional role
Methods: Over a three month period, we prospectively audited
and on their perception of the quality and effectiveness of
our practice in 47 women who had elective CS under
their working relationship. A total of 43 responses were
subarachnoid anaesthesia without active warming. We
collected (24 anaesthetists and 19 midwives) in an ongoing
measured their tympanic temperature prior to anaesthesia (T )
1 survey.
and at the end of surgery (T ). We also collected data that may
2 Results: Of the anaesthetists who completed the
influence the results like the volume of IV fluid infused,
questionnaire, 16.6% were consultants, 58.3% were ST5-ST7,
estimated blood loss (EBL) and duration of surgery. We also
20.8% were ST3-4 and 4.1% were CT1-2. When asked whether
assessed the incidence of perioperative shivering. We
they felt they understood the scope of responsibilities of
repeated the audit in 42 parturients using an IV fluid warming
midwives on labour ward, only 27% of anaesthetists felt they
device. The data were analysed using Microsoft Excel 2007®.
understood it fully. In contrast, 63% of midwives believed they
Data from both audits were compared and p-values were
fully understood the scope of the anaesthetist's
calculated using unpaired t-test by GraphPad software®.
responsibilities.
Results: In the initial audit, 20 patients (42.55%) were
hypothermic at the end of surgery (T < 36°C). Shivering Thirty percent of midwives felt that collaboration with
2
occurred in 14 patients (29.79%). No correlation was found anaesthetists was 'very easy', in contrast to only 5.5% of
between T and the IV fluid volume, EBL, duration of surgery anaesthetists who felt the same about collaboration with their
1-2
or the dose of intrathecal Bupivacaine. In the re-audit, only 3 midwife colleagues. While 16% of anaesthetists found this
(7.14%) patients experienced hypothermia. There was no collaboration 'difficult', none of the midwives did (0%).
statistical difference in T between the two audits (p = 0.781). Seventy two percent of anaesthetists felt their input was
1
usually well-received by their midwife colleagues, compared to
  Initial Audit (n=47) Re-audit (n=42) p-value
only 40% of midwives who thought their input was well-
Fluid (ml) 1116.67(±369.43) 1233.33 (±483.59) 0.2236
received by the anaesthetist. Both professions were asked
EBL (ml) 523.75 (±152.33) 582.5 (±491.67) 0.474
how they perceived the general quality of communication
T1 36.84 (±0.37) 36.81 (±0.37) 0.781
between them. The majority of anaesthetists (47%) perceived it
T2 36.08 (±0.4) 36.3 (±0.29) 0.004
as 'fair', while 15% regarded it as 'poor'. Ninety percent of
T 0.76 (±0.34) 0.52 (±0.41) 0.0032
1-2 midwives felt it was either 'very good' or 'good'. None of the
Discussion: Our audit highlights the effect of warm IV fluid midwives (0%) felt it to be 'poor'.
therapy on reducing the incidence of inadvertent perioperative
Questions were asked on the types of obstacles they
hypothermia during elective CS. Our audit recommends the
encountered in their professional interaction with each other.
routine warming of IV fluid during elective CS. The Enhanced
Most anaesthetists (72%) agreed that they found fixation on
Recovery Partnership Programme considers patient warming
tasks and exclusion of others to be a challenge, followed by
as a key factor in accelerating patient recovery.2 Following our
delayed or non-communication of important issues (57%). A
results and as part of developing a new pathway for enhanced
third of the anaesthetists felt they rarely got a comprehensive
recovery post CS; our trust is currently looking to invest in a
handover from the midwife while only 29% of midwives felt
cost-effective IV fluid warming device.
they understood the rationale behind the anaesthetists'
References decisions.
1. NICE (2008) Perioperative hypothermia (inadvertent): full Conclusion: Despite both specialties working in close
guideline (CG65). Full Guideline. London: National Institute for proximity, the survey identified several gaps in
Health and Care Excellence.
communication. Working towards enhancement of the
2. Enhanced Recovery Partnership (2012) Fulfilling the potential: a
professional relationship between members of the team
better journey for patients and a better deal for the NHS. Leicester:
NHS Improvement. Available at http://www.improvement.nhs.uk providing maternity services will help facilitate their
(accessed 14/12/2013) collaboration and will reflect positively on the performance of
both professions.

P26 Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin)
P151 Intra-arterial balloon catheters: A service evaluation P152 Intrathecal diamorphine for cesarian section following
JS Campbell,  M Molloy,  D Fogarty   intramuscular diamorphine during labour: a cause for
Royal-Jubilee Maternity Service, Belfast HSC Trust, Belfast, concern?
UK RC Barr,  L Parks  
Introduction: Intra-arterial balloon catheters have become Anaesthetics and Intensive Care, Southern Health and Care
widely used and predominantly accepted in cases where Trust, Northern Ireland, UK
massive haemorrhage is anticipated, especially with morbidly Introduction: Diamorphine has largely replaced pethidine for
adherent placenta . However, the benefits are still intramuscular (IM) analgesia during labour in our obstetric
1,2
controversial. While our unit is not stand-alone, our building unit. We also routinely give diamorphine (250-300 micrograms)
is physically separated from other departments including intrathecally (IT) for cesarian sections. A recent case of
radiology, so the logistics of balloon catheters are difficult2. meiosis and drowsiness, in a lady presenting for a category 2
Our objective was to identify the impact of balloon catheters cesarian section having received IM diamorphine in labour,
on management of morbidly adherent placenta. Associated highlighted the potential for side effects when diamorphine is
anaesthetic issues include massive transfusion, cell salvage, used IM and then IT. Should we therefore consider adjusting
type of anaesthetic and post-operative care. our IT dose of diamorphine in women presenting for
Methods: With permission of the Trust's Data Guardian, we emergency cesarian sections? To our knowledge there are no
retrieved data from multiple sources to identify and review guidelines on this subject and clinical practice appears
cases where balloon catheters where used. These included variable.
radiology logs, maternity records and histology. Methods: We conducted a survey of all anaesthetists working
Results: Ten cases were identifed via these systems. Seven in the Southern Health and Social Care Trust who partake in
were for morbidly adherent placenta, of which 5 required obstetric anaesthesia. Questions focused on; current
hysterectomy despite balloon inflation. Many of these were diamorphine practice, diamorphine dose adjustments, factors
cases of placenta percreta, despite antenatal diagnosis of influencing our dose decisions and concerns regarding
accreta. However, blood loss was lower by around 20% potential side-effects with IT diamorphine.
(1078ml) using balloons, when compared to other Results: We received 24 replies; 14 consultants and 10
hysterectomies in the same time period. experienced trainees who regularly perform obstetric
Other indications were for intra-abdominal pregnancy and anaesthesia. There was a wide variation in diamorphine
persistent post-partum haemorrhage. Another case was practice amongst our anaesthetists. The majority (76%)
abandoned due to logistical reasons (unable to organise consider reducing their IT dose following IM diamorphine.
theatre time in same building), a decision felt to be open to Factors influencing this dose reduction include timing (88%)
medicolegal criticism after preparation and planning for and dose (29%) of the last IM diamorphine and clinical signs
balloons. of toxicity (76%). In particular anaesthetists were concerned
about postoperative respiratory depression (94%) and
Limitations particularly reflected the limitations and
drowsiness (88%), although no one surveyed reported
inconsistency of the systems used, for example no coding in
experience of these or other adverse effects associated with IT
records for morbidly adherent placenta. Local presentation
diamorphine.
highlighted these problems, which are being taken forward.
Discussion: There is variability regarding the IT diamorphine
Conclusion: Our review, and subsequent MDT discussion,
dose given to women for emergency cesarian section who
has confirmed the place of intra-arterial balloon catheters
have already received IM diamorphine in labour. This practice
within local guidelines for management of morbidly adherent
is based on limited evidence. Given the lack of adverse effects
placenta, and other occasional indications. We had decreased
reported from our survey and evidence from other specialties
blood loss in cases using balloons, but still saw a large
where diamorphine is used in higher doses 1,2,, we see no
proportion requiring hysterectomy.
reason to routinely reduce the IT diamorphine dose unless
References
there are clinical signs of opiate toxicity. Consideration should
1. Beilin Y, Halpern SH. Placenta accreta: successful outcome is all in be given to prolonged postoperative monitoring of all women
the planning. Int J Obstet Anesth. 2013;22:269–271.
who have received both IM and IT diamorphine, especially
2. Sadashivaiah J, Wilson R, Thein A. Role of prophylactic uterine
artery balloon catheters in the management of women with those in whom the interval between IM and IT diamorphine is
suspected placenta accreta. Int J Obstet Anesth. 2011;20:282-287 short or where there are signs of toxicity.
References
1. Fogarty DJ, Milligan KR. Postoperative analgesia following total
hip replacement ; a comparison of intrathecal morphine and
diamorphine. Journal of the Royal Society of Medicine 1995; 88:
70-72
2. Jacobson L, Kokri MS, Pridie AK. Intrathecal diamorphine: a dose-
response study. Annals of the Royal College of Surgeons of England
1989; 71: 289-292
Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin) P27
P153 Introducing self-administration of medication after P154 Is Remifentanil patient controlled analgesia an
caesarean section: a Robert The Bruce story effective alternative to epidural for labour analgesia?
A R Sajayan,  K Ramm,  T Yates,  Y Chikermane   V Betharia,  K Peckitt  
Anaesthesia, Heartlands Hospital, Birmingham, UK Anaesthesia, Stepping Hill Hospital, Stockport, UK
Introduction: We were involved in the introduction of the local Introduction: Remifentanil patient controlled analgesia (PCA)
protocol for self-administration of postoperative medications was introduced for pain relief in labour at our institution in
(SAM) after elective LSCS at a large obstetric unit. In the past, 2007. Since then its demand has steadily increased, gaining
several attempts to implement this have failed.We conducted a favour with midwives and patients due to simplicity of use,
pilot study to identify the obstacles and develop ways to effective analgesia¹ and good safety profile². We have
overcome the same standardised protocols for administration and monitoring of
Methods:A pilot project was conducted to find out the Remifentanil PCA and patient controlled epidural analgesia
obstacles in the process by obtaining feedback from the staff (PCEA) during labour which are strictly adhered to. Aim of our
and patient involved in the care of 10 patients who underwent audit was to assess both Remifentanil PCA and epidural PCEA
elective LSCS over a week’s time. Obstetric, anaesthetic, for labour analgesia and make recommendations for improved
recovery and ward staff were informed beforehand about this care of mothers and infants.
pilot by emails and personal discussion. The patients were Methods: This was a prospectively done, questionnaire based
given information leaflet during preoperative assessment and audit. Data was collected over 2 months from November 2013 -
were informed again on the day of operation. Interested January 2014. We looked at mode of delivery,
patients enrolled in the pilot with due consent. The self- cardiotocographic abnormalities, APGAR scores, maternal
administration pack contained analgesics and enoxparin and cardio-respiratory complications, conversion to alternative
was dispensed by the recovery staff. Exclusions were: methods of analgesia and patient satisfaction.
language barrier, patient refusal, lack of capacity and any co Results: There were 610 deliveries during the 2 months.
morbidities. Feedback was collected from patients and staff Remifentanil PCA was used in 102 (17%) and epidural PCEA in
using the standardized proforma during the postoperative 85 (12.2%) patients for labour analgesia.
visit. Mode of delivery:
Results:Two of the patients felt that on the first day it was
  Normal Assisted LSCS
difficult to use SAM due to mobility restrictions. One patient
Remifentanil PCA 69 (67%) 20 (19.6%) 13 (12.7%)
did not receive SAM pack due to communication problem
Epidural PCEA 29 (34%) 35 (41%) 21 (24.7%)
involving midwives and staff. The remaining seven patients
were satisfied with SAM. The obstacles we identified in the There was a higher incidence of cardiotocographic
pilot and also from the past experience and the way we tackled abnormality in the epidural group (61%) as opposed to
them are as below: Remifentanil group (34%). APGAR scores in both groups were
more than 8 at 5 minutes. None of the patients in either group
Obstacle Strategy
had respiratory depression or cardiovascular instability. Eight
Personal & email reminder
(7.8%) patients converted from Remifentanil to epidural due to
Promotional posters in clinical areas
inadequate analgesia whereas 4 (4.7%) patients in the epidural
Communication Reminder notices in operating room and recovery
group used alternative analgesia (3 switched to Remifentanil
Meeting with stakeholders (doctors, midwives&
and 1 to entonox). Patient satisfaction was similar in both
pharmacist)
groups at 95%.
Involving all staff in guideline preparation
Discussion: From our experience, Remifentanil PCA is a safe
Staff engagement Process simplified and paper work streamlined
and effective method of labour analgesia. We found no
Standardized SAM package and delivery
evidence of worsening cardiotocography or neonatal
Guideline Fully prepared guideline after extensive consultation
outcomes with its use. We also found that patients using
Time Pre-printed forms to increase efficiency and to avoid
Remifentanil have increased rate of vaginal deliveries as
management time delays and work duplication
compared to those on epidural. While epidural analgesia
Discussion: Self-administrationof medications after caesarean remains the gold standard and will be preferable in certain
provides better patient centered care. It improves patient and groups of patients, Remifentanil PCA is certainly an excellent
staff satisfaction, improves clinical efficiency and eases alternative to consider. In our institution its uptake has
staffworkload at hospital and at community level1. It empowers steadily increased to approximately 50 patients per month with
the mother in their own care, potentially reduces length of patients consistently report ing high levels of satisfaction.
stay, and facilitates seamless flow ofcare. Although staff and References
patients liked the concept alike, the process had failedthree
1. Blair JM, Dobson JT, Hill DA, McCracken GR, Fee JP. Patient
times before because of certain obstacles. This pilot helped us controlled analgesia for labour: a comparison of remifentanil with
to highlight the areas we needed to focus on with our new pethidine. Anaesthesia 2005; 60 (1) : 22-7
strategies and the results have been encouraging. After fully 2. Volikas I, Butwick A, Wilkinson C, Pleming A, Nicholson G.
Maternal and neonatal side-effects of remifentanil patient
implementing the project, the uptake is gradually getting better
controlled analgesia in labour. Br J Anaes 2005; 95(4): 504-9
and we continue to audit the outcome.
References
1. Snell P M, Bowden M I, Viira D J, Chilvers J P. An observational
study of self-medication of analgesic drugs after caesarean section.
Int J Obstet Anesth 2002; 11: S29
2. Change management good practice guideline-NHS Direct
P28 Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin)
P155 Is the existing local hospital guideline, 'Management P156 Klippel-Feil syndrome: management of anticipated
of women who decline blood products', being adhered difficult airway for caesarean delivery 
to? TM Price,  MT Qureshi,  ROK Laird  
J Houston,  R Burns   Department of Anaesthesia, Altnagelvin Area Hospital,
Simpson Centre for Reproductive Health, Royal Infirmary of Derry, UK
Edinburgh, Edinburgh, UK Introduction: Klippel-Feil syndrome (KFS) is a rare genetic
Introduction: An estimated 150000 Jehovah's Witnesses disorder affecting around 1 in 40,000 live births and is
(JWs) live in the UK1. JWs may not accept blood product (BP) characterised by the congenital fusion of any two of the
transfusion1, and have up to 130 times increased risk of cervical vertebrae1. In addition to the abnormalities of the
maternal death from major obstetric haemorrhage2. This cervical spine, patients may have thoracolumbar scoliosis,
retrospective case note review aims to establish how closely spina bifida and congenital heart defects. The classical
the hospital guideline, 'Management of women who decline phenotypic presentation is described as low hairline, short
blood products' (the Guideline), has been followed since its neck and limited neck and head movement. These patients can
May 2012 introduction, and to identify areas for improvement. therefore present a considerable challenge to the anaesthetist.
Methods: JWs managed at the Anaesthetic Antenatal Clinic The safest method of providing anaesthesia for operative
(AAC) since the Guideline's introduction were identified, and delivery of a parturient with KFS is controversial. We would
their medical records accessed. Information surrounding like to share our experience in managing four elective
aspects of patient management addressed by the Guideline caesarean deliveries in two parturients using awake oral fibre
was extracted. The findings were then audited against the optic intubation (AOFOI) and general anaesthesia.
Guideline to establish how closely it had been followed. Case Reports: The first patient had KFS Type II with fusion of
Approval was obtained from the Medical School and the cervical vertebrae and underwent elective caesarean deliveries
Regional Research Ethics Service. aged 35 and 37 years old. The second patient had KFS Type
Results: Of the patients referred (N=26), 92.3% were reviewed III with fused cervical vertebrae in conjunction with fusions in
at the AAC, and had management plans created, at 31.0 weeks' the thoracolumbar spine, and underwent elective caesarean
gestation on average (Guideline target: 28.0 weeks). 88.5% deliveries aged 31 and 39 years old. Our patients were both
completed a BP checklist before admission in labour, and pre-assessed by a consultant anaesthetist at a high-risk
96.2% by time of delivery. 7.7% agreed to accept BPs at clinic pregnancy clinic prior to delivery. This allowed time to discuss
and were discharged, so women studied became N=24. BP the anaesthetic options with each patient and plan for elective
refusal of 12.5% was not appropriately recorded in the notes, or emergency delivery. Both patients had the classical
and contrary to the Guideline, serum ferritin was not checked phenotypic features of KFS. Airway assessments revealed
in any woman. During pregnancy, 29.2% were not recorded as Mallampati class 4, thyromental distances less than 6cm and
having taken iron, and Hb was measured in 95.8%. Excluding severely limited neck flexion and extension. The trachea was
elective caesarean sections (CS), Obstetric consultants were not palpable in either patient. We anticipated difficult direct
documented as informed of admission in 13.6% of cases, and laryngoscopy in both patients and elected to manage the
54.5% of labours and deliveries were reviewed or supervised airway with an AOFOI followed by general anaesthesia. The
by senior Obstetric staff (ST6-consultant). 20.8% of total oral route was chosen as both patients had small nares in
deliveries were by CS: cell salvage was set up in 100.0% of keeping with KFS. Sugammadex ensured complete reversal of
these, and used in 80.0%. rocuronium induced neuromuscular blockade and smooth
Discussion: This study found the Guideline was closely emergence. Caesarean delivery and postoperative recovery
followed in some areas: completion of acceptable BP checklists was uneventful in all four cases.
before delivery, and availability and use of cell salvage in CS,
Discussion: As obstetric anaesthetists we are constantly
compare favourably to previous UK studies1,3. Areas to be
trying to minimise the risk to our mothers. Klippel-Feil
improved include that BP refusal must be appropriately
syndrome affects both the airway and the spine, making the
recorded in patient notes to ensure clarity upon presentation
choice of anaesthetic technique a difficult decision. Successful
in labour or an emergency. It is vital that iron supplementation
use of regional techniques including spinal, epidural and
is commenced early in JWs, and ferritin levels are monitored,
combined spinal-epidural anaesthesia, have all been described
to maximise iron stores. In light of this study's findings,
in the literature1. However, we feel that embarking upon a
hospital blood transfusion Haematologists, in the future, will
regional technique in patients with distorted neuroaxial
review JWs antenatally. The Guideline should quantify how
anatomy would expose patients to unnecessary risk of high
often Hb should be monitored, so anaemia can be detected
spinal block and/or inadequate regional anaesthesia. Should
and treated before delivery. Crucially, consultant staff must be
general anaesthesia be needed intra-operatively, attempting an
documented as informed upon admission of JWs in labour, in
AOFOI in an already distressed parturient would be
order that deliveries can be supervised by senior staff to
challenging. We therefore planned an AOFOI to secure the
reduce potential morbidity and mortality.
airway prior to general anaesthesia, in a controlled manner and
References
thus avoid a potentially difficult and emergent intraoperative
1. Massiah N, Athimulam S, Loo C, Okolo S, Yoong W. Obstetric care intubation. In summary, these are difficult cases that we
of Jehovah's Witnesses: a 14-year observational study. Arch
believe benefit from good antenatal planning and can be
Gynecol Obstet 2007; 276(4):330-343.
managed with a planned AOFOI and general anaesthesia.
2. Van Wolfswinkel ME, Zwart JJ, Schutte JM, Duvekot JJ, Pel M, Van
Roosmalen J. Maternal mortality and serious maternal morbidity in
Jehovah's witnesses in the Netherlands. BJOG 2009; 116(8): 1103- Reference
1108. 1. T. Kavanagh, R. Jee, N. Kilpatrick, J. Douglas. Elective cesarean
3. Nawaz YM, Atkinson S. Peripartum care of Jehovah's witness delivery in a parturient with Klippel–Feil syndrome. Int J Obstet
parturients: A five year review. Int J Obstet Anesth 2013; 22(S1): Anesth 2013; 22(4): 343-8
S22.
Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin) P29
P157 Labour and delivery in long QTsyndrome P158 Local anaesthetic toxicity audit: are workshops the
BJ Vowles,  FMM Bryden   best educational tool across the MDT?   
Anaesthetic department, Princess Royal Maternity, Glasgow, WITHDRAWN FROM PRESENTATION
UK JL Lambert,  D Chitre,  L Evans  
Introduction: A 22 year old primigravida presented to the high Anaesthesia, Southend Hospital, Southend, UK
risk clinic at 22 weeks gestation. She had been diagnosed with
long QT syndrome (LQTS) after her family had been
investigated following a sudden early cardiac death and was
found to be heterozygous for the KCNQ1 gene, responsible
for Long QT1. She was under regular review by the
cardiologists who had advised β blockade with bisoprolol
2.5mg orally (PO) for 9 months post partum due to an increase
in arrhythmia risk during this period. She had also been given
a list from Azcert Inc., advising drugs that should be avoided
and included on this list was syntocinon.
Labour and delivery: She was admitted in labour at term and
the decision was made by the obstetric team, not to administer
syntocinon to augment labour. They also felt that epidural
analgesia was unsuitable because it would slow the progress
of labour. However following an initial dose of intramuscular
(IM) diamorphine, the parturient requested epidural analgesia.
We felt this would be beneficial for minimising her arrhythmia
risk and so she obtained a working epidural with a bilateral T10
block. ECG monitoring was commenced on admission and
.
initially showed bigeminy. A 12 lead ECG demonstrated a QTc
of 460ms. Electrolytes checked at this time were in the normal
range. Over the subsequent 8 hours she failed to progress and
underwent a caesarean section with an effective epidural top
up of 20ml 0.5% L-bupivacaine. At delivery syntocinon was
administered as a slow infusion of 5 units in 100mls 0.9%
saline over 20 minutes, followed by 500µg ergometrine IM to
maintain uterine tone. 50mg IM cyclizine and 10mg
intravenous (IV) metoclopramide were used for anti-emesis.
She was monitored in the Obstetric high dependency unit
(HDU) for the following 48 hours, where an initial ECG
demonstrated frequent ventricular ectopics, with a QTc 432ms.
Electrolytes were again normal at this time.
Discussion: There are many lists of drugs available on the
internet with differing advice as to which drugs to avoid in
long QT syndrome. The one which our patient had been given
clearly stated syntocinon should not be administered, despite
no definitive evidence of harm with this drug in patients with
LQTS. In addition we found no guidance in published case
reports, on oxytocic drugs administered to patients with LQTS
in labour or at delivery1. There are case reports of ventricular
tachycardia after administration of syntocinon in long
QTsyndrome2 and one report of a pateint receiving it with no
sequelae3 Ideally the authors feel that this lady merited a case
conference prior to admission so that informed decisions
could be made. Whilst the outcome of this patient's labour and
delivery may not have been different, a short trial of
syntocinon with ECG monitoring may have altered her mode of
delivery.
References
1. Drake E, Preston R, Douglas J. Brief review: anaesthetics
implications of long QT syndrome in pregnancy. Can J Anaesth.
2007; 54(7): 561-72
2. Liou SC, Chen C, Wong SY, Wong KM. Ventricular tachycardia
after oxytocin injection in patients with prolonged Q-T syndrome -
report of two cases. Acta Anaesthesiol Sin 1998; 36: 49-52
3. Charbit B, Funck-Bretano C, Samain E, Jannier-Guillou V,
Albaladejo P, Marty J. Qt interval prolongation after oxytocin bolus
during surgical induced abortion. Clin Pharmacol Ther 2004; 76:
359-64
P30 Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin)
P159 Lymphangioleiomyomatosis and Pregnancy: A Case P160 Major obstetric bleeds-are we doing the right thing?-
Report A multi-centre study in west midlands
M Cole,  S Petkov,  J Pickett   A R Sajayan,  M McLoughlin,  S Dinesh,  A Walunj*,  J
Anaesthetics, Addenbrookes Hospital, Cambridge, UK Karattuparambil †,  M Ravindran†  
Introduction: Anaesthesia, Heartlands Hospital, Birmingham, UK,
Lymphangioleiomyomatosis (LAM) is a rare condition causing *Anaesthesia, Good Hope Hospital, Sutton Coldfield, UK,
proliferation of smooth muscle in the respiratory system, †Anaesthesia, George Eliot Hospital, Nuneaton, UK 
which can cavitate leading to degradation of lung parenchyma Introduction:Guidelines1 exist on the definitions of massive
and cystic lung disease1. Because of the risk of progression, bleed, the proposed management pathway and the safe time
women with LAM are frequently advised to avoid pregnancy2. frame for obtaining the blood and products. This multi-centre
We present a case of LAM where multidisciplinary audit looks at the average time taken for the blood/products to
management led to a successful outcome of pregnancy, with a be available in major bleed situations in obstetrics
focus on anaesthetic considerations. Aim: To find out the incidence and reasons for delays in
Case Study: issuing the blood/products, if any, from the blood bank and to
A 35 year old woman presented with bilateral spontaneous compare the existing practices and experience with the other
pneumothoraces in the first trimester of her 2nd pregnancy. hospitals in the area
Both required surgical correction and a lung biopsy revealed a Methods: We collected the data from three participating
diagnosis of LAM. Computerised tomography of her thorax hospital in west midlands using a standard proforma which
showed multiple small lung cysts. Past history included an included the number of massive obstetric bleed calls during a
uncomplicated first pregnancy and emergency caesarean six months period in 2013, the estimated blood loss, the time
section for foetal distress, aged 33; and a spontaneous taken for the first unit of blood/ product to be issued and the
pneumothorax aged 34, requiring surgery. The patient was number of products used among other data.
referred to a tertiary centre for multidisciplinary management.
Results: The results suggested that there is ambiguity in the
Care was shared between obstetrics and respiratory medicine
way major haemorrhage was defined in different situations
and she attended the high risk anaesthetic clinic. Elective
which led to unnecessary calls where blood products were not
caesarean delivery at 38 weeks was agreed upon. She had
urgently needed. Also, the time for getting the products varied
three further small pneumothoraces, treated conservatively
widely the longest being 200 minutes. The documentation of
with no marked deterioration in respiratory function. Elective
the details of the bleeding, time of calls and time of
caesarean section was performed at 38/40 gestation.
blood/product administration were incomplete and inaccurate
Respiratory assessment and examination on the morning of
in some cases.In one hospital, major bleed calls were only put
surgery were normal. A two-space combined spinal epidural
out in two out of 17 cases where blood loss was more than
was sited, administering intrathecal hyperbaric bupivacaine
1500ml.
and diamorphine. A respiratory physician was present at
delivery in case of deterioration. Delivery was uneventful, with   Hospital1 Hospital2 Hospital 3
no immediate complications. The patient spent 24 hours in an Number of MOH calls 58 41 2
obstetric close observation unit post-operatively. Her post- Full data available 13 18 2
natal period was uneventful and required no further obstetric, Average time for group specific (min) 59 NA 33
respiratory or anaesthetic intervention. Average time for X match blood (min) 63.45 42.27 0
Longest delay (min) 200 104 33
Discussion: LAM is a rare condition with an estimated UK
prevalence of 1per million3. Hypotheses suggest oestrogen
Discussion: The definitions of massive blood loss are:
accelerates disease progression and pregnancy may result in
Transfusion of a volume equal to the patient’s total blood
new diagnosis or exacerbation4, therefore obstetric
volume in less than 24 hours / 50% loss of blood volume
anaesthetists should have awareness of this disease. There is
within 3 hours / rate of blood loss 150ml/minute. Though the
sparse literature for anaesthetic management of pregnancy
circumstances of individual episodes of major bleed could
with LAM, consisting mainly of case reports. Considerations
vary, there was no consistency in the trigger of activating
suggested include; avoiding excessive Valsalva manoeuvre
major bleed calls. There were also unacceptable delays in
via instrumental or elective caesarean delivery, avoid nitrous
obtaining the first unit of blood in some cases. The first set of
oxide, early epidural analgesia, obtunding intubation response
uncross matched group specific blood should be available in
and lung protective ventilation strategies if general
20minutes and cross matched blood in 40minutes2. The study
anaesthesia. This case report supports that pregnancy in
suggest that there is a need for the reinforcement of major
LAM patients can progress successfully and highlights the
bleeds definition and also a need for a clearer pathway and
importance of a MDT approach, early anaesthetic assessment
consistency in issuing blood and products in major bleed
and a well considered anaesthetic and obstetric plan.
situations. This audit results will be used to formulate a
References uniform policy in the participating hospitals and a re-audit will
1. Rosendal T. A Case of Diffuse Myomatosis and Cyst Formation in be done in six month time
the Lung. Acta Radiaology. 1942; 23: 138-146
2. Cohen MM, Freyer AM, Johnson SR. Pregnancy Experiences References
Among Women With Lymphangioleiomyomatosis. Respiratory
1. D Thomas etal,Blood transfusion and the anaesthetist: management
Medicine. 2009; 103: 766-772
of massive haemorrhage, Anaesthesia 2010 November; 65(11):
3. Johnson SR, Tattersfield AE. Clinical Experience of 1153–1161
Lymphangioleiomyomatosis in the UK. Thorax. 2000; 55:1-5
2. Guidelines on the management of massive blood loss.
4. McLoughlin L, Thomas G, Hasan K. Pregnancy and BJHaematology 2006; 135(5): 634-641
Lymphangioleiomyomatosis: Anaesthetic Management.
International Journal of Obstetric Anaesthesia. 2003; 12: 40-44
Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin) P31
P161 Management of labour and delivery using  minimally  P162 Management of manual removal of placenta and third
invasive FlotracTM system in a parturient with  and fourth degree tear repair: pathway analysis
congenitally corrected transposition, dextrocardia P Jegendirabose,  J Subramanya*,  S Watkinson*,  J Short  
and systemic ventricular dysfunction Anaesthesia, Queen Elizabeth Hospital, Woolwich, London,
R Vedagiri Sai,  S Dhir,  J Racine   UK, *Obstetrics & Gynaecology, Queen Elizabeth Hospital,
Anesthesia, Western University, London Ontario, Canada Woolwich, London, UK
Introduction: More women with congenital heart disease now Introduction: Guidelines suggest that repair of obstetric anal
survive to reproductive age due to advances in modern sphincter injuries (OASIS) and manual removal of retained
medicine. Obstetric management is challenging in these placenta (MROP) should be undertaken as soon as possible to
complex cases. We present the anaesthetic management of minimise the risk of infection, blood loss and maternal
labour and delivery in a woman with congenitally corrected morbidity1,2. Anal incontinence and perineal pain can impact
transposition of great vessels, dextrocardia, systemic significantly on maternal quality of life and mother-child
ventricular dysfunction and junctional tachycardia using bonding.
minimally invasive continuous haemodynamic monitoring and Methods: We conduced a retrospective audit which showed
optimisation. shortcomings in our management of MROP and OASIS and we
Case report: A 28 year old primigravida presented with a undertook an analysis of a full calendar year's cases. All cases
diagnosis of congenitally corrected transposition of great of MROP and OASIS were identified over January 2012 to
vessels and dextrocardia. The atrial septal defect had been December 2012 using both theatre electronic records and
repaired in childhood. Her medications included folate and maternal records. Time from delivery of fetus to MROP or
multivitamins. She had good exercise tolerance, stable vital OASIS repair, blood loss and blood transfusion requirement
signs and was followed up by Cardiology team throughout her were reviewed.
pregancy. ECHO showed 50% ejection fraction (EF) and mildly Due to lack of nationally set standards, we set a local standard
reduced systemic (morphologic right) ventricle. A multi- of no more than one hundred and twenty minutes from
disciplinary meeting between Obstetrics, Cardiology, delivery to repair for OASIS.
Anaesthesia and Intensive care unit (ICU) team was held to
Results: Our institute is a secondary obstetric centre with
decide on optimal obstetric management. Induction of labour
4800 deliveries per annum. During the twelve month period,
was planned.
105 patients sustained OASIS. The mean delay from delivery
At 37 weeks she developed palpitations, increasing shortness to surgery was 136 minutes. The average blood loss was 501
of breath and peripheral oedema. Repeat ECHO showed millilitres and 3% of patients required blood transfusion. Total
moderate ventricular dysfunction with EF 40%, severe of 42 patients required manual removal of placenta with
systemic atrioventricular regurgitation and severely enlarged regional or general anaesthesia. The mean delay from delivery
left atrium. Prior to labour induction, an arterial line was to surgery was 178 minutes. The mean blood loss was 790
inserted and continuous cardiac output monitoring was millilitres and 5% of the patients required blood transfusion.
performed using arterial pressure waveform analysis with the
FloTracTM monitor. Haemodynamic optimization was guided OASIS repairs n=105 Time (minutes)
by stroke volume variation and goal directed fluid therapy. A Delivery to booking 81 (Cl 70-92)
lumbar epidural was then inserted followed by rupture of Booking to surgery 68 (Cl 40-95)
membranes and oxytocin infusion. Fluid balance was closely Delivery to surgery 136 (Cl 122-150)
monitored continuously using FloTracTM. 1st stage of labour MROP n=42 Time (minutes)
was uneventful and 2nd stage was shortened using vacuum Delivery to booking 138 (Cl 115- 160)
assisted delivery of a healthy baby. She had a second degree Booking to surgery 39 (Cl 32-46)
tear which was repaired. Post partum haemorrhage due to Delivery to surgery 178 (Cl 152-204)
uterine atony was treated with 400µg Misoprostol rectally and
Incidentally, 78% of the patients did not have electronic record
intravenous infusion of 20 IU of Oxytocin. Estimated blood
of estimated blood loss on the theatre system.
loss was 800 mL. Cardiac condition was stable apart from
Discussion: In our institution, these cases are booked onto
persistent tachycardia throughout labour. Postpartum, she
the general emergency theatre, and not in the designated
spent 24 hours in ICU with similar monitoring. Her tachycardia
emergency obstetric theatre. We have identified that this has
settled spontaneously. She was discharged home on day 4.
resulted in significant delay in surgery and increased blood
Discussion: Patients with congenitally corrected transposition
transfusion requirement. We are now changing the patient
have a thin-walled right ventricle as the systemic circulatory
pathway to include urgent utilisation of the emergency
pump. The stress of increased cardiac output can cause
obstetric theatre for these procedures. Since the presentation
failure, atrioventricular regurgitation and arrhythmias1. We
of this audit, we have included the estimation of blood loss in
used minimally invasive continuous cardiac output
the surgical sign out process, thus improving communication
monitoring, fluid balance optimisation and good maternal pain
and patient care.
control to prevent decompensation and achieve vaginal
References
delivery with a good feto-maternal outcome.
1. National Institute for Health and Care Excellence. 2007.
Reference Intrapartum care. Care of healthy women and their babies during
childbirth. Clinical guideline 55
1. Dob DP, Naguib MA, Gatzoullis MA. A functional understanding of
moderate to complex congenital heart disease and the impact of 2. Fernando RJ, Sultan AH, Kettle C, Thakar R. Methods of repair for
pregnancy. Part I: the transposition complexes.Int J Obstet Anesth. obstetric anal sphincter injury. Cochrane Database Syst Rev. 2013
2010 Jul;19(3):298-305 Dec 8;12:CD002866.
P32 Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin)
P163 Multidisciplinary involvement of the high risk P164 National Obstetric Anaesthetic Database: a useful tool
parturient to benchmark maternity units in the UK
S De Silva,  P Gregory,  E Combeer   G Keightley,  N Tailor,  R Baraz,  L De Lloyd  
Anaesthetics, Frimley Park Hospital, Frimley, UK Anaesthetics, University Hospital of Wales, Cardiff, UK

Our Hospital offers a high risk Obstetric Anaesthetic Clinic for Introduction: The National Obstetric Anaesthetic Database
review of parturients with anticipated Anaesthetic or Medical (NOAD) was set up in 1998 to establish a framework for
problems where a checklist referral form is used. We audited collecting national obstetric anaesthetic data considered
whether women were appropriately referred or inappropriately relevant to obstetric anaesthetists. Whilst preparing the
not referred. An alert sticker was created to encourage NOAD survey for 2012, we explored the usefulness of this
healthcare providers to alert the oncall Obstetric Anaesthetist data in benchmarking our units' performance at the University
when the high risk parturient presented to labour ward. We Hospital of Wales (UHW) in relation to NOAD published
went onto audit the effectiveness of this alert sticker. figures from the previous year.

Methods: Data was collected according to the NOAD 2012
Methods: We looked at 200 consecutive births during October
survey and therefore, ethical approval was not required. Due
2010 and ascertained how many of these women had referrals
to the large number of deliveries in our unit, data regarding
to the High Risk Clinic. In the referred cases, we asked whether
labour analgesia, mode of delivery, caesarean section rate and
referral criteria were met and also determined if any mothers
type of anaesthesia was based on six months period (Jan to
were inappropriately not referred. In 2012 we retrospectively
June 2012) and then doubled. Exceptions were critical care
inspected all notes of mothers seen in High Risk Clinic with an
admissions and patients with accidental dural puncture (ADP);
estimated delivery date of March to May 2012. We checked
these were collected and reviewed individually for the entire
whether an alert sticker was present in their notes and also the
year. Microsoft Excel was used to analyse the data.
time taken for the Obstetric Anaesthetist to be contacted once
the mother had presented to Labour Ward. Results: The number of total deliveries in our unit for 2012

was 6138, of which 3060 required anaesthetic procedure(s).
Results: In 2010, 178 of 200 notes were reviewed and 14
The table below compares performance and quality indicators
women met referral criteria and 12 of these were referred.
at UHW in 2012 with the NOAD averages from 2011.
Fourteen percent were therefore inappropriately not referred,
however no women were inappropriately referred. Indicator UHW 2012 NOAD 2011

Caesarean section (CS) rate 22% 24.8%
In 2012, 42 notes were inspected where only 8 had the alert
Elective CS rate 46% 39.1%
sticker in place, with only 5 in the correct position. Two
De novo general anaesthesia (GA) for CS 4.5% 4.7%
mothers with the alert had elective caesarean sections. In five
Conversion to GA (CS) 1.8% 3.5%
of the six remaning mothers, the oncall Anaesthetist was
Labour regional analgesia 27% 22.7%
informed of their presence on labour ward. The average time
Epidural re-site rate 7.7% 9%
taken for this was four hours and 45 minutes (range 10 minutes
Accidental dural puncture rate 0.9% 1.2%
to 10 hours and 50 minutes). On review of the Clinic letters, it
was felt that 30 of the 42 parturients should have had an alert In 2012, three cases were transferred to critical care unit as
present in their notes, which is 71% not 19% as shown by our level 2 care (two with sepsis and one adult respiratory distress
audit. syndrome) and six cases as level 3 care (two with sepsis, three

post partum haemorrhage and one case of amniotic fluid
Discussion: In many cases of substandard care assessed by
embolus).
CMACE, there were major failures of communication between
Discussion: Our unit is classified as a large maternity unit
healthcare workers that may have contributed to the woman’s
compared to the national average. The elective CS rate and
death in some cases1. Our audits demonstrated that local
labour regional analgesia rates in our unit are higher than the
guidelines for referral were followed in 99% of cases, therefore
national average, possibly related to the complexity of a
high risk mothers were identified early. However, there still
tertiary centre. Despite this, our total CS rate is well below the
lacks effective communication of concerns within teams and
average with very low conversion to GA. In addition, our
poor involvement of other specialties early.
epidural re-site rate is lower than the national average, as is
Reference our ADP rate. Current facilities include two theatres serving
1. Centre for Maternal and Child Enquiries (CMACE). Saving both emergency and elective streams, and a mixed
Mothers'. Lives: reviewing maternal deaths to make motherhood recovery/high dependancy unit (HDU) for up to 5 patients.
safer: 2006–2008. The Eighth Report of the Confidential Enquiries
Our unit has a low transfer rate as level 2 care in general HDU,
into Maternal Deaths in the United Kingdom. BJOG 2011;118:1-203
due to the ability to care for these patients on our unit. We
find the NOAD data a useful tool to benchmark our
performance and set standards of care. More units should
contribute to the annual NOAD survey and consider using the
data as a way of identifying shortfalls and improving patient
care and services.
Reference
1. National Obstetric Anaesthetic Database report 2011.
http://www.oaa-anaes.ac.uk/content.asp?ContentID=586
Unpublished Posters: Obstetric Anaesthesia 2014 (Dublin) P33
P165 Obstetric admissions to the Intensive Care Unit: a 6 P166 Obstetric outcomes with programmed intermittent
year review at a UK tertiary maternity centre epidural bolus labour analgesia
R Labib,  K Cullis   JTE Cremin,  CH Papageorgiou  
Selwyn Crawford Department of Anaesthesia, Birmingham Department of Anaesthesia, Hillingdon Hospital, Uxbridge,