Unpublished Posters: Obstetric Anaesthesia 2010 (Newcastle) P1
P R Madhivathanan,  P Jatoth,*  A Rodin,*  M K Balasubramanian   Department of Anaesthesia, Barnet General Hospital, London, UK, *Department of Obstetrics & Gynaecology, Barnet General Hospital, London, UK Introduction: Uterine inversion is a rare and potentially life threatening complication of pregnancy that can be associated with massive haemorrhage. We describe a recent case where uterine inversion occurred following vaginal birth after previous caesarean section (VBAC).
Case report : A 27 -year-old healthy woman (G2P1) with previous history of one caesarean section presented with spontaneous onset of labour at 37 weeks of gestation. She was very keen on vaginal delivery. After a prolonged labour with entonox and intramuscular pethidine for analgesia, she gave birth to a baby girl. Active management of the third stage was instituted. Following the delivery of the placenta , brisk blood loss of 500ml was noted and the patient complained of severe back pain. She appeared pale and shocked, with a heart rate of 131 beats/ min and BP of 78/49 mmHg. Active fluid resuscitation improved BP and heart rate. The obstetrician suspected uterine scar dehiscence in the first place given the history of previous caesarean. Uterus was well contracted on  examination of the abdomen. Vaginal examination was difficult as the patient was in severe pain. Decision was made to examine under anaesthesia. In the operating theatre a rapid sequence induction with thiopental and suxamethonium was performed and anaesthesia was maintained with sevoflurane in 50% oxygen and nitrous oxide. Vaginal examination under anaesthesia revealed incomplete uterine inversion (fundus not extending beyond external os) with large amounts of blood clots. The uterine scar from previous caesarean was intact. The uterus was reduced without any difficulty with the volatile anaesthetic providing excellent tocolysis. The estimated blood loss was 2500ml. Intraoperative fluid management included 2 litres of crystalloid, 1 l i tre of colloid and 2 units of blood. Postoperative haemoglobin was 6.1g/dl and further 2 units of blood were transfused. Subsequent recovery of the patient  was uneventful. 
Discussion: Acute uterine inversion occurs between 1:2000 and 1:6400 deliveries.  In our case, as vaginal examination proved difficult,  and the uterine inversion was incomplete, it was difficult to make a diagnosis in the labour room. Examination under anaesthesia not only helped to diagnose but also promptly treat uterine inversion. Although the classical description of shock out of proportion to blood loss was initially noted in our case , this was probably due
to underestimation of blood loss.
 
 
 
References
P81 Acute uterine inversion following vaginal birth  after caesarean (VBAC): a case report
1
1
2
1. Sarna MC, Hess P, Takoudes T C, Chaudhury A K. Postpartum hemorrhage. In: Datta S, ed. Anesthetic and obstetric managment of high risk pregnancy. 3rd ed. New York: Springer; 2004: 123, 129.
2. Beringer R M, Patterill M. Puerperal uterine inversion and shock. Br J Anaesth 2004; 92: 439-441.
 
 
 
 
Conclusion: Difficulties could be encountered in the event of power failure due to a lack of charged equipment. Reasons may include lack of knowledge of  issues and solutions during testing and lack of communication between engineers and staff highlighting potential local problems. It i s   no t   e nough   t o   a nnounce   t h e   d a t e   o f   t e s t i ng . Communication between departments is vital to plan for and hopefully avoid deleterious consequences. Written test procedures could provide a framework to ensure quality preparation and safe testing procedures. Drills to familiarise staff with failure procedures may improve performance in this area
Reference
.1 
1. Stymiest DL. Managing hospital emergency power testing programs. American Society for Healthcare Engineering of American Hospital Association.
P2 Unpublished Posters: Obstetric Anaesthesia 2010 (Newcastle)
Irfan Mansur,  Ajay Swami   Department of Anaesthesia, Kettering General Hospital, Kettering, UK Introduction: Carboprost is used in refractory cases of atonic post partum haemorrhage. Pulmonary oedema is a known complication after the administration of carboprost (1,2,3). We describe a case of a healthy primigravida needing  mechanical ventilation for pulmonary oedema after the administration of carboprost .
Case History : 17-year-old primigravida at 37 weeks gestation was admitted after spontaneous rupture of membranes.  There was no significant past medical or antenatal history. Labour was induced with dinoprostone and oxytocin infusion. Patient requested epidural analgesia, which provided good pain relief. Patient was transferred to theatre for trial of instrumental delivery due to failure to progress . The t r ia l o f ins t rumenta l de l ivery was unsuccessful and caesarean section was indicated. Both the procedures were carried out under epidural anaesthesia with 10mls 0.5% Bupivacaine , 8mls 2% Lignocaine and 50mcg of fentanyl. After delivery and removal of placenta uterine a t o n y was unsuccessful ly treated w i t h m a n u a l compression, intravenous oxytocin and intrauterine misoprostol. The estimated blood loss was approximately 2000mls which was replaced with   3 units of blood and 1
litre of crystalloids. Anaesthetist gave three doses of 250 mcg intramuscular carboprost 15 minutes apart and bleeding stopped. After 5 minutes of 3rd dose of carboprost patient developed sinus tachycardia of 130/min, dyspnoea and oxygen saturation fell to 80% with bilateral wheeze and crepitations on chest auscultation . T h e p a t i e n t w a s intubated needing high airway pressures and the chest radiograph showed acute pulmonary oedema. Treatment for pulmonary oedema was started and patient transferred to intensive care unit where she was extubated  6  hours later. Patient was discharged home on the third postoperative day
Discussion: Carboprost is useful for treating uterine atony which does not respond to other drugs, but side effects are not uncommon (1,2). Hypoxia related to carboprost could b e d u e t o p u l m o n a r y o e d e m a ( a s i n t h i s c a s e ) , bronchoconstriction(1)e v e n i n n o n a s t h m a t i c s ( 2 ) o r pulmonary shunting leading to ventilation/perfusion mismatch. CEMACH case report "Why Mothers Die 1997- 1999" indicated that the lack of understanding of side effects of carboprost including bronchospasm and pulmonary oedema was one of the contributing factors to a patient’s death.(3).We emphasize caution in prescribing carboprost with special attention to minimum dosage interval of 15 minutes with minimising the maximum dosage of  2mg. Patient reactions to drug administration should be carefully monitored during and after anaesthesia and unnecessary over hydration should be avoided to prevent the occurrence of pulmonary oedema
References
P83 Carboprost induced pulmonary oedema during caesarean section
1. Harber C,Levy D,Chidambaram S,Macpherson M. Life-threatening bronchospasm after intramuscular carboprost for postpartum haemorrhage. BJOG 2007; 114(3):366-8.
2. Cooley DM, Glosten B, Roberts JR, Eppes PD, Barnes RB. Bronchospasm after intramuscular 15-methyl prostaglandin F2 alpha in a nonasthmatic patient. Anesth Analg 1991; 73:87–9
3. Thomas TA, Cooper G. Why Mothers Die 1997–1999 (Chapter 9: Anaesthesia).TheConfidentialEnquiries into Maternal Deaths in the United Kingdom. London: Royal College of Obstetricians & Gynecologists, 2001; 134-49
 
 
Conclusion: A combination of numerical and colour coded MEOWS is an unique and invaluable tool to aid admission and discharge of the sick parturient to OHDU. We believe that it is a simple, convenient and robust early warning system   to al low t imely  inst i tut ion of  appropriate management. In addition, we recommend that  the presence of a clearly documented discharge summary would allow better follow up and after care of the patients on the ward. We are in the process of introducing the discharge summary form in our unit.  Reference
P84 Introduction of modified early obstetric warning score chart
1
1. Lewis G (ed). Saving mothers' lives: reviewing maternal deaths to make motherhood safer -2003-2005. London: CEMACH; 2007
Unpublished Posters: Obstetric Anaesthesia 2010 (Newcastle) P3
K O'Connor,  J Robertson,  J Reid   Anaesthetic Department, Queen Mothers Hospital, Glasgow, UK Introduction: MEOWS scoring systems are a newly introduced method of recognising and monitoring the sick obstetric patient and have been recommended by CEMACH . Our unit (3000 deliveries) recently introduced this
observation system and we aimed to assess the mode of delivery and anaesthetic type associated with red and yellow triggers.
Methods: All patients who delivered in our 70 bed unit over a 4 week period were identified and case notes analysed retrospectively for details of abnormal observations recorded, type of anaesthetic and mode of delivery.
Results: 264 patients delivered in the 4 weeks with 247 (94%) of case notes available for review. Of these, 54 (21.9%) had no MEOWS chart and 4 (1.6%) had only one set of observations documented. 189 (77%) had a MEOWS chart with >1 recording with and average duration of 48.6 hours (range 0-216 hours). 31 patients triggered a red score while 90 triggered a yellow. Details of red and yellow scores are summarised in table below:
FVD= Forceps or vacuum delivery
Discussion:  Patients who underwent general anaesthesia trigger a higher mean red and yellow score than other modes of delivery emphasising their high risk status. Interestingly patients who received an epidural triggered almost double the mean red score compared with patients who underwent spinal anaesthesia. Of epidural patients who triggered a red score, 33% had a caesarean section and 66% delivered vaginally. Caesarean section patients trigger more than double the number of red scores than mothers who had a spontaneous vaginal delivery. However, once a score is triggered, all modes of delivery have similar mean red scores. This suggests that patients not undergoing caesarean section are less likely to become unwell but once they do become sick they are as unstable as post-operative patients. Vaginal instrumental deliveries trigger scores similar to caesarean section patients.
Reference
P85 Mode of delivery and type of anaesthetic associated with triggering modified early obstetric warning scoring (MEOWS) system
1
SVD, n=125  6 (4.8) 24 (4) 35(28)  125 (3.6)
FVD , n=84 *  11 (13.1) 53 (4.8) 18 (21.4) 117 (6.5)
LSCS, n=38 14 (36.8) 60 (4.3) 37 (97.4) 261 (7.1)
Anaesthetic
*
1. Confidential Enquiry into Maternal and Child Health. Saving Mothers' Lives- 2003-2005 - the 7th report of the confidential enquiries into maternal deaths in the UK. London: CEMACH; 2007
S Friar,  S Kanakarajan   Department of Anaesthesia, Aberdeen Maternity Hospital, Aberdeen, UK
Introduction: National reports have recommended the use of Obstetric Early Warning Scores (OEWS) for the detection and management of critically ill patients . Our hospital uses an adapted chart for the obstetric population, with abnormal physiological observations generating an OEWS score which potentially triggers a predetermined action or response. This scoring system however lacks validation as the physiological ranges used are a best guess. Furthermore an OEWS chart will only be useful if applied effectively. We planned to describe the pragmatic use of an OEWS chart in our clinical practice.
Method: One hundred case notes were randomly selected from the daily discharge list over a period of three months from February 2009 to April 2009. Abnormal parameters which were scored, triggering a response were noted and any action taken was recorded. Abnormal parameters which were not scored and did not trigger a response were also noted.
Results: Ninety of the one hundred case notes contained a completed chart. Overall 1008 observations were recorded of which 779 (77.2%) observations were scored. From 195 actual triggering events 110 (56.4%) triggering events were recorded by midwifery staff.  Of these triggering events 105 (53.8%) had a response recorded. The majority of actual trigger events were yellow events i.e. less abnormal changes.  The parameter most likely to trigger an event was systolic blood pressure. No events were triggered by  SpO2 or respiratory rate.
Discussion: The efficacy of an OEWS chart to 'track and trigger' a response depends on accurate scoring and improving the sensitivity and specificity of the chart itself. We noted a high incidence of triggering due to systolic blood pressure which may represent over sensitivity of this parameter. No triggering for SpO2 and respiratory rate may represent a lack of specificity however it is more likely that this is confounded by the relatively well population audited as opposed to a true lack of predictive power of these parameters .  We have shown that in practice the use of an OEWS chart is prone to inadequate recording of observations, incomplete scoring and failure to document or act on the trigger itself. The human factors af fec t ing the use of these char t s warran t fur ther investigation.
  References
P86 Not so trigger happy? A retrospective audit of the use of an obstetric early warning score chart
1
Heart Rate               36               12
Temperature                4                2
Lochia                3                0
Proteinuria                2                4
2
1. Lewis G. (ed) 2007. The confidential enquiry into maternal and child health (CEMACH). Saving mothers ’ lives; reviewing maternal deaths to make motherhood safer -2003-2005.
P4 Unpublished Posters: Obstetric Anaesthesia 2010 (Newcastle)
HM King,  PJ Youngs   Department of Anaesthesia, Derriford Hospital, Plymouth, UK Introduction: The National Institute for Clinical Excellence (NICE) have produced guidel ines  on  inadver tent perioperative hypothermia (temperature <36ºC) as there is evidence that this may increase the risk of perioperative
morbidity. However, this guidance excludes parturients. W e   a s s e s s e d   t h e   c h a n g e   i n   p a t i e n t temperature during elective caesarean section in order to ascertain whether there was a need for active warming. Method: Data from 43 patients was collected prospectively over a two month period. Core temperature was measured u s i n g t h e s a m e i n f r a r e d t y m p a n i c t h e r m o m e t e r (Thermoscan, Braun) which has an accuracy of ±0.2ºC (manufacturers data). Temperature was measured in the right ear prior to anaesthetic and on arrival in the recovery suite. Ambient operating theatre temperature and humidity were recorded.
Results: The mean postoperative temperature in recovery was 36.3ºC (35.2-36.9ºC). The mean temperature decrease was 0 .6 ºC ( 0 -1.6ºC).  6 women had a postoperative temperature below 36 ºC (35.2 -35.8ºC). Th is was no t related to theatre temperature, humidity or duration of surgery. Three patients started with temperatures below 36.5ºC, two of which then had post operative temperatures below 36ºC. One patient had warmed intravenous fluids and none had forced air warmers. There was no significant difference in postoperative temperature between the 8 patients who had standard hospital blankets and the 34 who did not.  There was no significant difference in temperature decrease in patients that had spinal anaesthesia (n=17) or combined spinal-epidural anaesthesia (n=26).
Discussion: Inadvertent hypothermia occurred in 14% of patients. The risk of hypothermia could be reduced with the use of warmed intravenous fluids as this has been shown to mitigate the decrease in maternal temperature during elective caesarean section under combined spinal-epidural anaesthesia. Care should also be taken on the admission ward to ensure that patients are kept warm prior to surgery. Consideration should be given for inclusion of pregnant women in the NICE guideline.
References
1 
2
1. Perioperative hypothermia (inadvertent): full guideline. National Institute for Health and Clinical Excellence clinical guideline CG65. April 2008. http://www.nice.org.uk/nicemedia/pdf/CG65Guidance.pdf
2. Woolnough M, Allam J, Hemingway C, Cox M, Yentis SM. Intra- operative fluid warming in elective caesarean section: a blinded randomised controlled trial. Int J Obstet Anesth 2009; 18, 346-351.
E De Silva,  B Pigera,  LC Karunaratna   Anesthetics, Basildon & Thurrock University Hospital, Basildon, UK Background: Post -operative observation after caesarean section is of utmost importance to reduce post operative complications and improve patient satisfaction.There are specific NICE guidelines for post -operative observation following caesarean sections.Some obstetric units in the UK have introduced MEOWS charts  as an early warning system.
Aim::The current practise of post -operative recovery following caesarean section on our obstetric unit was compared with the NICE guidelines.We also looked at the effectiveness of the MEOWS chart as an early warning tool.
Methodology:Data was collected retrospectively using a questionnaire which was fi l led in by the obstetric anaesthetic registrar and recovery nurses.We analysed data from 52 patients who had undergone both elective and emergency sections.We also looked at the MEOWS chart which should have been filled in by the midwifery and nursing staff on the ward.
Results:All post section patients were observed on a 1  to 1 basis on the post anaesthetic care unit.100% compliance with NICE guidelines
-Al l   pos t   s e c t i on  pa t i en t s  we re   l ooked   a f t e r   on PACU  by   properly qualified nurses  (band 5 or 6) 
-All post -section patients had regular monitoring of RR,HR,BP,pa in   and   seda t ion   sco res   and  a i rway control .100% compliance with guidelines.
-49/52 patients had 1/2 hourly monitoring for two hours on PACU/post-operative wards.94% compliance with guidelines
-2/48 patients were monitored for 12 hours after receiving   intrathecal or epidural diamorphine.2% compliance with NICE guidelines
 - Though all patients had MEOWS charts attached to their post-opera t ive ca re p lan ,no char t was comple ted appropriately by the nursing staff.
Conclusion:Immediate post-operative care at PACU  is compliant with current NICE guidelines.Monitoring of patients after intrathecal and epidural opioids is not satisfactory and needs improving.
           
P88 Post caesarean section observations.Are we compliant with NICE guidelines?
1. NICE guideline-care of the woman after CS (ref CG 13)1.6
Unpublished Posters: Obstetric Anaesthesia 2010 (Newcastle) P5
 
 
Results:
 
Conclusions: Currently 25.3% consultant anaesthetists either do not use alcoholic chlorhexidine or do not know which disinfectant they use. There is evidence that alcoholic chlorhexidine is   the most  effective skin disinfective and should be the agent of choice. Many anaesthetists keep the disinfectant on the same surface as the spinal equipment and a large proportion do not always allow the solution to dry prior to commencing the spinal anaesthetic. Although the risk of contamination remains small, it could be eliminated by changing these practices.
Reference
P89 Skin disinfection prior to spinal anaesthesia: a survey of current UK practice
1
isopropyl alcohol 285 49.8% 
2% chlorhexidine gluconate in 70% isopropyl alcohol
149  26% 
Iodine plus alcoholic chlorhexidine 8 1.4% Other disinfectant 7 1.2%
Unknown 5 0.9%
1. Pratt RJ, Pellowe CM, Wilson JA et al. epic2: national evidence- based guidelines for preventing healthcare-associated infections in NHS hospitals in England. J Hosp Infect 2007; 65 suppl 1:s1-64
RJ Kearns,  V Uppal,  J Bonner,*  EM McGrady   Princess Royal Maternity Unit, Glasgow Royal Infirmary, Glasgow, UK, *Department of Anaesthesia, Ninewells Hospital, Dundee, UK Introduction: The provision of safe and procedurally robust peri-operative care should be a fundamental goal of any surgical team. Surgical safety checklists have been shown to improve teamwork, safety and minimise list disruption . In keeping with National Patient Safety Agency guidance , we introduced a surgical safety checklist for patients undergoing elective caesarean section. Such patients are usually awake and  pre -operative anxiety is common .  We wished to evaluate the effects of such checks on our patients.
 Methods: Local ethics committee approval was sought and deemed not to be necessary. Patients undergoing elective caesarean section during August to November 2009 were asked 3 questions relating to the performance of the surgical safety checklist. Responses were recorded as yes or no for the first question, and with a Likert scale (strongly disagree, disagree, neither, agree, strongly agree) for the subsequent 2 questions.
 Results: 58 randomly selected patients undergoing elective caesarean section were asked the following: "The theatre team performed a series of checks at the start and end of the operation. Did you notice this?"    45 patients (75%) remembered the checks being performed. 11 patients (19%) remembered when prompted and 2 (3%) did not remember even when prompted. The 56 patients who recalled the checks being performed were asked a further 2 questions;
"If I said the checks made you worried, how would you reply?" All patients either disagreed or strongly disagreed with this statement.
"If I said the checks were reassuring, how would you reply?" 52 patients (93%) either agreed or strongly agreed with this statement. 4 patients (7%) neither agreed nor disagreed.
 Conclusion: One of the arguments against the use of surgical safety checklists is the concern that patients may find it worrying or "unprofessional" that staff expected to be familiar with their case, ask fundamental questions such as their name and procedure to be performed. In obstetric thea t re , the pa t ien t i s o f ten awake making th i s a particularly pertinent issue. Our results suggest that although the majority of patients are aware of the checks being performed, they do not find this worrying and may find it reassuring. Perceived effects on patient anxiety should not constitute a reason to abandon surgical safety checklists.
References
1,2
3
4
1. Lingard L, Regehr G, Orser B et al. Evaluation of a pre-operative checklist and team briefing among surgeons, nurses, and anaesthesiologists to reduce failures in communication. Arch Surg 2008;143:12-7
2. Nundy S, Mukherjee A, Sexton JB et al. Impact of preoperative briefings on operating room delays: a preliminary report. Arch Surg 2008; 143:1068-72
3. National Patient Safety Agency. Patient safety alert. WHO surgical safety checklist 2009. www.npsa.nhs.uk/nrls/alerts-and- directives/alerts/safer-surgery-alert/
4. Holdcroft A, Parshall Am, Knowles MG, Waite KE, Morgan BM. Factors associated with mothers selecting general anaesthesia for lower segment caesarian section. J Psychosom Obstet Gynaecol 1995;16:167-70
P6 Unpublished Posters: Obstetric Anaesthesia 2010 (Newcastle)
RJ Kearns,  J Bonner,*  V Uppal,  M Mackenzie,  M Young,  EM McGrady   Princess Royal Maternity Unit, Glasgow Royal Infirmary, Glasgow, UK, *Department of Anaesthesia, Ninewells Hospital, Dundee, UK Introduction: Provision of care in the operating theatre involves complex interactions between organisational, procedural and inter -personal components. Surgical safety checklists have been shown to improve efficiency and team work as well as reducing morbidity and mortality. National guidelines recommend that such checklists be performed for all theatre cases by 2010.   We introduced pre and post - operative surgical safety checklists for elective caesarean sections in obstetric theatre. After a 3 month introductory period, an evaluation of compliance was performed.
Methods: An independent, impartial anaesthetist (JB) attended elective   caesarean sections during November 2009. Completion of the pre-operative checklist  (patient identity, indication for caesarean section, allergies, neonatology presence), and post -operative check (analgesia, oxytocics, antibiotics, thromboprophylaxis, skin to skin) was examined. Staff participation, roles assumed and adverse events were reviewed. 
Results: Audit forms were completed for 34 of the 44 elective caesarean sections in the 1 month evaluation  period, giving an audit compliance rate of 77%.  Results are tabulated below:
Unforeseen adverse events occurred in 2 patients (high spinal block  and failed regional block) These were not felt to have been preventable from the pre-operative check. Conclusion: Our compliance rates with pre and post - operative checks were 61% and 68% respectively. Benchmark data on this topic is scarce, though in a procedure so integral to patient safety, one could argue that the target should be 100%. Although safety checklists should take minutes and not cause delay, it is not always possible for all staff to attend due to clinical demands. Working patterns may need to be reviewed in order to improve this. Achieving a sustained change in practice is challenging, particularly in the complex and dynamic environment of the operating theatre. If we are  to continue to develop in our practice, we must recognise the importance of the function of the team as a unit and accept our limitations as individuals. We plan to re-audit compliance after a period of further education and consultation with staff. 
References
1,2
3
Professional group most often leading
check
 midwives
(48%)
 midwives
(57%) Midwife present during check  21 (100%)  23 (100%)
Anaesthetic nurse present during check  21 (100%)  23 (100%)
Anaesthetist present during check 21 (100%) 23 (100%) Obstetrician present during check 20 (95%) 20 (87%)
1. Lingard L, Regehr G, Orser B, Reznick R, Baker GR, Doran D, et al. Evaluation of a preoperative checklist and team briefing among surgeons, nurses, and anesthesiologists to reduce failures in communication. Arch Surg 2008;143:12-7
2. Haynes AB, Weiser TG, Berry WR, Lipsitz SR, Breizat AH,Dellinger EP. A surgical safety checklist to reduce morbidity and mortality in a global population. N Engl J Med 2009;360:491 -9
3. National Patient Safety Agency. Patient safety alert. WHO surgical safety checklist. 2009. www.npsa.nhs.uk/nrls/alerts -and- directives/alerts/safer-surgery- alert/
TR Christmas,  SM Kinsella,  FC Forrest ,*   Anaesthesia, St Michael's Hospital, Bristol, UK, *Anaesthesia, University Hospitals Bristol NHS Foundation Trust, Bristol, UK  
 
 
 
 
 
 
1
2
Baby and mother labels complete?
US scan to confirm fetal
lie/placental position?
* Category 1 LSCS
1. Haynes AB, Weiser TG, Berry WR et al. A surgical safety checklist to reduce morbidity and mortality in a global population. N Engl J Med 2009; 360: 491-499.
2. National Patient Safety Agency. Patient Safety Alert Update: WHO surgical safety checklist (January 2009).
Unpublished Posters: Obstetric Anaesthesia 2010 (Newcastle) P7
P Smith,  C Phillips,  G Allan   Anaesthetics, Worthing Hospital, Worthing, UK Introduction: Ob ta in ing in fo rmed consen t f rom a labouring woman can be challenging. This is an audit to compare adequacy of consent for obstetric epidural analgesia to the standards set by the Royal College of Anaesthetists.
 
 Worryingly, 10 women (16%) did not remember being given any antenatal education about epidural analgesia.  However, overall 56 (89%) felt that they had given fully informed consent. In 9 (14%) sets of notes there was poor documentation of the consent obtained, although in some of these cases the epidural sheet had been lost.
Discussion: 63% of mothers questioned recalled antenatal education regarding epidural analgesia, this is less than the 80% currently recommended by the Royal College of Anaesthetists. Documentation of consent was 86% (recommendation 100%), and 89% of mothers were s a t i s f i e d t h a t t h e y h a d g i v e n i n f o r m e d c o n s e n t (recommendation 100%). The fact that 65% reported seeking extra information on epidurals suggests that there is currently insufficient antenatal education. The importance of this is illustrated by the fact that 38% of women did not feel able to think clearly at the time of giving consent. Potential areas for improving antenatal education are provision of the OAA leaflet at  the 36 week clinic rather instead of at the booking visit, and more coverage of epidural analgesia in antenatal classes. Our hospital has recently expanded provision for the high risk obstetric clinic such that 10% of all women will now be seen  - this is an opportunity to better educate them. In addition, the introduction of a new electronic audit system should improve the rates of documentation of consent.
P93 Audit of consent for epidural analgesia in labour in Worthing hospital P R Greig,  S Muddle,  P Patel  
Nuffield Department of Anaesthetics, John Radcliffe Hospital, Oxford, UK Background: Consent for procedures in labour is a challenging aspect of anaesthetic practice. Consent is best regarded a multistage process and some question if labouring women are capable of fully informed consent.  Here we review the obstetric anaesthetic literature for current opinions with respect to consent in labour and report the results of a post-natal survey of women's recall of the consent process for anaesthetic intervention in labour.
Methods: Women were surveyed 24 -48 hours post delivery with data recorded for: anaesthetic procedure and indication, timing of consent and recall of various points discussed as part of the routine consent process. Statistical analysis was conducted using chi-squared tests.
Results: The survey was completed by 94 women: 60 had received labour analgesia; 18 underwent non -elective surgery and 16 underwent elective surgery. The majority of surgery was performed under regional anaesthesia. Recall o f a p r e -proedure conversation, specifically with an anaesthetist, was found in 94%, and this did not vary between groups (p=0.474); 83% of women were satisfied with the level of detail provided. Stage of labour (p=0.162) and urgency of intervention (p=0.294) did not affect their degree of satisfaction with the consent process. Birth plans were drafted by 59 women, fewer than half of whom had expressly planned for epidural analgesia. Recall of the consent process was best in the elective surgery group (p=0.027).
Discussion: In the group of women surveyed, all had at least some degree of recall of the consent process but a clinically significant number remembered less than 50% of the details provided. Whilst there is no evidence that women in labour lack capacity to offer informed consent, this finding has medico-legal implications. There is evidence that antenatal education can impact on recall and improve consent.   A review of recent national guidelines on the issue of consent suggest it is less appropriate to "just put it in". We conclude women even in advanced labour retain capacity, but advise that consent is most effectively taken at the earliest practicable stage.
References
1
2
3 4 5
1. Saunders TA, Stein DJ, Dilger JP. Informed consent for labor epidurals: a survey of society for obstetric anesthesia and perinatology anesthesiologists from the United States. International Journal of Obstetric Anesthesia 2006; 15: 98-103.
2. Bush DJ. A comparison of informed consent for obstetric anaesthesia in the USA and UK. International Journal of Obstetric Anesthesia 1995; 4:1-6.
3. Swan HD, Borshhoff DC. Informed consent - recall of risk information following epidural analgesia in labour. Anaesthesia and Intensive Care 1994; 22: 139-141.
4. White LA, Gorton P, Wee MYK, Mandal N. Written information about epidural analgesia for women in labour: did it improve knowledge? International Journal of Obstetric Anesthesia 2003; 12: 93-97.
5. Anonymous. Making decisions about investigations and treatment. In: Consent: Patients and Doctors making decisions together. 1st ed. London: General Medical Council; 2008: 9-25.
P8 Unpublished Posters: Obstetric Anaesthesia 2010 (Newcastle)
J M Dolan,  S J Young,  J Kinsella,*   Department of Anaesthesia, Princess Royal Maternity, Glasgow, UK, *University Department of Anaesthesia, University of Glasgow, Glasgow, UK Introduction: In our obstetric anaesthetic practice we have recognised that many of our patients are anxious when they appear on the labour suite. This suggests that perhaps we are not targeting antenatal education at the correct groups. We speculated that one group at risk of anxiety would be those for whom there were concerns about fetal well-being. The aim of this study was to compare anxiety levels in primiparous patients undergoing induction of labour for fetal concerns, with anxiety levels in primiparous patients undergoing induction of labour for uncomplicated post dates pregnancies or for concerns over maternal health.
Methods: The Beck Anxiety Inventory (BAI)- a 21 item validated questionnaire - w a s g i v e n t o 2 5 0 consenting primiparous induction patients after obtaining local Research Ethics Committee approval. the indication for induction was also recorded and categorised as: postdates, maternal concerns ( e.g. hypertension, diabetes, previous thromboembolism), or fetal (e.g .reduced growth, reduced movement, oligohydramnios). Data was analysed using the Kruskal-Wallis test.
 
 
There was no significant difference in the BAI scores between the 3 groups (p=0.135).
Conclusions: Contrary to our expectations we did not see any difference in anxiety levels in either the fetal concern or the maternal concern groups compared with our control population. This work suggests that there would not be any gain in terms of anxiety by refocusing antenatal education towards mothers with maternal health or fetal wellbeing concerns.
Reference
1
 Post dates  13  0-44  Maternal Concerns  15  3-45
 Fetal Concerns  12  3-34      
1. Beck AT, Epstein N, Brown G, Steer RA. An inventory for measuring clinical anxiety. Psychometric properties. J Consult Clin Psychol 1988;56:893-897
A Kumar,  S Rhodes   Department of Anaesthesia, James Paget University Hospital NHS Trust, Great Yarmouth, UK Background: Informed consent about pain relief in labour and regional anaesthesia for caesarian section can be challenging. It is uncertain on the amount of information retained by women due to the effects of pain and drugs. Currently information about the complications of central neuraxial blockade is provided by Obstetric Anaesthetists Association (OAA) leaflets, discussion with midwives and anaesthetists.
Method: 50 women were interviewed 24 to 72 hours post natal during May-June 2009. The women had either epidural (n=26), combined spinal epidural (n=4) for labour pain or spinal anaesthesia for caesarian section. Information collected included age, parity, previous CNAB, source of information, satisfaction with the information provided (scale of 1-10) and recollection of complication by open and closed questions. The closed questions are as shown in Chart 1.
Results: 27 (54%) & 16 (32%) of the 50 women were unable to recall any of the complications by open and closed questions respectively. Of the 16 women who were unable to recall complications by closed questions, 14 were primiparas and 13 were having the procedure for the first time. Only 2 women obtained the information through OAA leaflets. The mean satisfaction with the information provided was 8.5 (range 7-10). 
Discussion: A considerable proportion of women were unable to recall the complications, but they were well satisfied with the amount of information provided. None of the women developed any complication and the perception may have been different if they had developed one. Also it was the younger women and first t ime mothers who appeared less informed. Following Chester vs Afsar case, the Dept of Health recommended that health care professionals give information about all possible adverse outcomes. Alternate sources of information like the internet can be utilized to provide information to the target women (younger mothers and primiparas). There is a need for a retrospective audit on women who have developed complication after CNAB. References
P96 Information recalled by women about the complications of central neuraxial blockade (CNAB) in labour and childbirth 
1,2
3
1. Kelly GD, Blunt C, Moore PAS, Lewis M. Consent for regional anaesthesia in the United Kingdom: what is material risk? Int J of Obstet Anesth 2004; 13: 71-4.
2. Bethune L, Harper N, Lucas ND, Robinson NP, Cox M, Lilley A, Yentis SM. Complications of obstetric regional analgesia: how much information is enough? Int J of Obstet Anesth 2004; 13: 30-4.
3. http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/ PublicationsPolicyAndGuidance/DH_103643
Unpublished Posters: Obstetric Anaesthesia 2010 (Newcastle) P9
J Humphreys,  S J Moss ,*   Anaesthetics, Royal Oldham Hospital, Oldham, UK, *Anaesthetics, Royal Bolton Hospital, Bolton, UK Introduction: Patients must receive accurate, up to date information so they can make an informed decision about medical interventions and provide consent. We undertook an audit on information about obstetric analgesia as per the college compendium of audit recipes . Out of 50 women audited at greater than 36 weeks gestation, only 24% had received the hospital booklet on pain relief in labour. We found most women obtained information from parenting books, midwives, friends and the internet.
Methods: The purpose of this survey was to assess accuracy of information in current UK parenting books, and on UK websites. The information provided in the OAA Pain Relief in Labour leaflet was summarised. From this a survey form was devised to collect the following data from books and the internet: types of non-pharmacological pain relief options; types of pharmacological pain relief; epidural side effects and complications. 4 different internet search engines were used inputting the words: Pain relief; epidural; and labour.
Results: We looked at 20 books published in the UK between 1997 and 2009, and 20 websites. A total of 14 p o s s i b l e m e t h o d s o f n o n -pharmacological and pharmacological pain relief were searched for. 25% of books and 50% of the websites mention 10 or more methods. The most commonly quoted forms of analgesia are TENS, entonox, pethidine and epidurals. Table 1
For epidural analgesia we looked for reference to the 21 possible side effects/complications listed in the OAA leaflet. Just 1 book and only 4 websites discuss greater than 10 associated problems. This includes the OAA website. The most frequently documented side effects are: A fall in blood pressure; post dural puncture headache (PDPH); failure; and increased risk of instrumental delivery. Table 2
3 books and 2 websites have inaccurate information. They state that epidurals increase the risk of caesarean section and cause long term backache.
Discussion: Although women may be given the OAA leaflet during their pregnancy, a lot of their information is gained from reading parenting books and searching the internet. These sources contain varied details that can be misleading and false. We found that the internet offers more accurate information, with some sites written by consultant anaesthetists or referencing the OAA or the Royal College of Anaesthetists. The OAA website accessing the pain relief in labour leaflet is found on the fourth page of Google. As it provides the most concise and accurate text, we believe it should be made more visible to the public.
Reference
P97 Survey of the accuracy of information available in non medical books and on the internet, compared with the Obstetric Anaesthetists' Association pain relief  in labour leaflet 
1
Books 80%     70%     90% 90%
Internet 100%   100%  100%  100%
 Table 
Nerve Damage
 Books   65%  55%  60% 15% 45% 20% Internet90% 80% 45% 70% 70% 25%
1. Royal College of Anaesthetists. Raising the Standard: A compendium of audit recipes. Information about obstetric anaesthesia and analgesia. RCoA, London 2000.
N Patel,  R Padmagirison,  W Justin,  D Chitre   Anaesthetic, Southend Hospital, Southend, UK Introduction: Peri-partum cardiomyopathy (PPC) is a rare and life -threatening condition. We describe a case of unrecognised PPC with superimposed pre-eclampsia and the dangers of fluid therapy in these patients. Case Report: A 38-year-old G5P3 with a previous history of gestational hypertension, asthma and thoracic scoliosis, had a history of reducing exercise tolerance in the latter stages of her pregnancy; this had not been elicited antenatally. At 37 weeks she had an uneventful caesarean section for breech presentation and pre -eclampsia (high blood pressure, proteinuria and severe peripheral oedema) under spinal anaesthetic. Post-operatively she was treated for pre-eclamptic hypertension with oral labetolol and was fluid restricted. The SpO2 was noted to be 90% in the supine position, which corrected with 2L/min oxygen. She was oliguric for 6hrs and was given a fluid challenge of 500ml of normal saline over 1 hour. Once this had been administered, the SpO2 was recorded as low. The patient then became unresponsive and no pulse was detected. CPR was initiated immediately. After 2 cycles of CPR with adrenaline and atropine, there was a return of spontaneous circulation (ROSC). The patient was intubated, sedated and transferred to the ICU. A transthoracic echo (TTE) showed mild concentric left ventricular hypertrophy and an undilated left ventricle. There was severe systolic dysfunction with an ejection fraction (EF) of 25-30%. The chest X -ray showed signs of pulmonary oedema. She stabilised very  quickly with  Fi02 requirements reducing from 1.0 to 0.4 within a couple of hours post -arrest. No further inotropes were needed on ROSC. She was cooled for 24 hours and received magnesium sulphate. She had a failed extubation after 2 days due to recurrent pulmonary oedema and severe hypertension. Frusemide was given and a GTN and esmolol infusion were started, which lead to a successful extubation after 4 days in ICU. She was dischargd home from CCU 6 days after delivery on 3 anti- hypertenive agents. A repeat TTE at this time showed moderately impaired global LV systolic dysfunction with an EF of 35-45%. The right ventricle was mildly dilated.
Discussion: PPC is a relatively rare condition occuring in 1 in 1,300 to 1 in 15,000 pregnancies , presenting with signs and symptoms of left ventricular dysfunction. These patients can be difficult to manage despite early diagnosis and treatment. In this case the  condition was undiagnosed, and was superimposed with  pre-eclampsia which enhanced the hazardous nature of the situation. A relatively small bolus of fluid in a vasoconstricted circulation with a poorly contracting myocardium, lead to pulmonary oedema, hypoxia and cardiac arrest. Modified Early Warning Scores (MOEWS) had been used to summon medical help prior to the cardiac arrest. This enabled prompt and effective advanced life support to lead to a successful outcome for our patient. This case highlights the fact that fluid therapy in a small group of patients can be catastophic. Other risk factors that reduce cardio-respiratory reserve must be taken into account before initiating a fluid challenge. We discuss the haemodynamics, monitoring and fluid therapy in such patients.
Reference
1
1. Abboud J, Murad Y, Chen- Scarabelli C, Saravolatz L, Scarabelli TM. Peripartum Cardiomyopathy: a comprehensive review. Int J Cardiology 2007; 118: 295-303.
P10 Unpublished Posters: Obstetric Anaesthesia 2010 (Newcastle)
 
 
 
 
Reference
P99 More frequent measurement of non-invasive blood pressure at onset of spinal anaesthesia is not associated with a lower incidence of hypotension
1
1. Cyna AM, Andrew M, Emmett RS, Middleton P, Simmons SW. Techniques for preventing hypotension during spinal anaesthesia for caesarean section. Cochrane Database of Systematic Reviews 2006, Issue 4. Art. No.: CD002251. DOI: 10.1002/14651858.CD002251.pub2.
V Sharma,  A Swinson,  C Spencer,  S Mokashi,*  R Russell   Department of Anaesthesia, John Radcliffe Hospital, Oxford, UK, *Department of Anaesthesia, Singapore General Hospital, Singapore, Singapore Introduction: During the last decade two thirds of the increasing birth rate has been attributed to women born outside the UK. Hence there is an increasing ethnic diversity among women giving birth and requesting neuraxial analgesia in UK maternity units. During this time the prevalence of obes i ty in par tur ients has a lso increased.    Previous s tudies  have demonstrated a relationship between body mass index (BMI) and distance from skin to the lumbar epidural space.  Reports of ethnic influence on the distance from skin to epidural space have
been conflicting. The effect of ethnici ty and BMI upon epidural space depth has not been studied in UK parturients. The aim of this study was to establish if ethnicity or BMI or both influence epidural space depth.
Methods: Following ethical approval, data on ethnicity, height, weight and epidural space depth were prospectively obtained from 1210 labouring women requesting epidural analgesia. ANOVA was used to analyse effect of BMI on epidural space depth. The influence of ethnicity and BMI on epidural space depth were tested in a multiple linear regression model. Ineffective epidurals and those performed in lateral position and mixed race parturients were excluded from analysis.
Results : The mean epidural space depth was 5.4 cm (range 3-10 cm). Epidural depth increased with an increasing BMI. The distance to epidural space differed among ethnic groups even after controlling for BMI (ANOVA p<0.001). The skin to epidural space depth was significantly greater in Black/British Black (BB) and Caucasians as compared with Asians and Chinese (p<0.001).  At BMI of 25, difference in mean depth between BB and Chinese patients was greater than 1 cm. At BMI of 30 or above, difference in mean depth increased up to 1 cm or more in BB and Caucasian patients as compared with Asian and Chinese.
 
 
References
P100 Effect of ethnicity and body mass index on the depth of the epidural space in parturients
1
3
1. D'Alonzo RC, White WD, Schultz JR, Jaklitsch PM, Habib AS. Ethnicity and the distance to the epidural space in parturients. Reg Anesth Pain Med 2008; 33: 24-9.
2. Segal S, Beach M, Eappen S. A multivariate model to predict the
Unpublished Posters: Obstetric Anaesthesia 2010 (Newcastle) P11
V Uppal,  MA Leonard,  SJ Young   Department of Anaesthesia, Princess Royal Maternity Hospital, Glasgow, UK Introduction: Recent reports from the UK Confidential Enquiry into Maternal and Child Health have highlighted inequalities in the rate of maternal death among different ethnic groups. A national cohort study using UK Obstetric Surveillance System (UKOSS) has reported similar trend for severe maternal morbidity. We aimed to find out what are the underlying factors that might be responsible for differences in these outcomes.
Methods: We conducted a retrospective cohort study using hospital maternity database from July 2007 to October 2009. Statistical analysis was performed using MINITAB 15.1 statistical software. Continuous variables were analysed using two-sample t -test. Categorical data was analysed using chi-squared test. One -way analysis of v a r i a n c e ( A N O V A ) w a s u s e d t o a n a l y s e continuous variables during subgroup analysis. P-value of <0.05 was considered significant.
Results : There were 13714 deliveries in our unit during this 27 months period. Ethnicity was recorded for 11306 parturients. 9653 parturients belonged to the non-ethnic group. There were 1653 deliveries recorded for ethnic population. This included African/Caribbean-Black (402), Chinese (254), Indian (140), Pakistani (240), Ethnic White (351) and unclassified Ethnics (266). Results are tabulated below. Values are expressed as mean or percentage
Discussion: In this study, we were able to demonstrate var ious d i f fe rences be tween the e thnic and non - ethnic groups. Gestation at first review was four weeks later for ethnic population, a factor that could be associated with poorer outcome. Other factors (like smoking, higher BMI and higher caesarean section rate) that could be associated with poorer outcome were actually found more often in non -ethnic mothers. Ethnic women were less likely than non-ethnic women to receive both epidural and opioid analgesia during labour. Subgroup analysis (data not shown) revealed that the Chinese women were least likely to use epidural analgesia during labour. Intention to breast feed was lowest for non -ethnic women and highest for African-black and Indian women. We conclude that poorer outcomes in ethnic population cannot be completely explained by the factors reviewed in this study.
References
P101 Factors responsible for inequalities in maternal  outcomes among different ethnic groups
1
2
 Weight (kg)  70.0  67.7  0.000
 Body Mass Index (BMI) (kg.m )-2  25.4  24.8  0.000
 Parity  0.78  0.93  0.011
 Currently smoker (%)  22.6  1.7  0.000
 Opioid use for labour analgesia (%)  53.4  44.7  0.000
 Epidural analgesia (%)  37.6  29.5  0.000
 Epidural failure rate (%)  5.9  4.7  0.412
 Caesarean section rate (%)  30.4  27.5  0.017
 Total blood loss (ml)  484  496  0.318
 Breast feeding intention (%)   36.5  76.0  0.000
1. Lewis G, ed. The Confidential Enquiry into Maternal and Child Health (CEMACH). Saving mothers ’ lives: reviewing maternal deaths to make childhood safer—2003-2005. London: CEMACH, 2007.
2. Knight M, Kurinczuk JJ, Spark P, Brocklehurst P. Inequalities in maternal health: national cohort study of ethnic variation in severe maternal morbidities UKOSS. BMJ 2009 Mar 3; 338: b542
DJG Milne,  A Quinn,  A Pinder,  H Gorton   Anaesthesia, Leeds General Infirmary, Leeds, UK Introduction: Reports from the Confidential Enquiry into Maternal and Child Health have shown a decrease in the number of anaesthetic related deaths over recent years. However, a consistent cause of death is hypoxia relating to a failure to intubate and ventilate. The incidence of failed intubation among the pregnant population has been estimated to be up to 8 times that of the non -pregnant population in previous studies . However, a more recent study had no cases of failed intubation in a set of 3430 general anaesthetic cases .  As yet, no national data exist. This study aims to calculate a national incidence for failed intubation in obstetric general anaesthesia.  
 
Results: 
 
We would like to thank the OAA and UKOSS for their support. References
P102 Failed intubation in obstetric general anaesthesia - interim results of a national survey.
1
2,3
4
Previous difficult intubation 2 0 Predicted difficult airway (Mallampati 3-4) 9/26
(34%) 4/27 (15%)
Urgency - grade 1 24 (54%) 43 (54%) Urgency - grade 2 10 (23%) 16 (20%)
Urgency - grade 3 3 (7%) 5 (6%) Urgency - grade 4 5 (11%) 10 (13%) ICU admissions (majority not related to airway problems)
11 (25%) 7 (9%)
Cases managed with supraglottic airways   30 Cases managed with bag and facemask 3
Cases manages with surgical airway 1 Cases woken for alternative anaesthesia 10
2,3
4
1. Lewis G. (Ed) The Confidential Enquiry into Maternal and CHild Health (CEMACH). Saving Mothers Lives: reviewing maternal deaths to make childhood safer - 2003-2005. London: CEMACH, 2007.
2. Rahman K, Jenkins JG. Failed tracheal intubation in obstetrics: no more frequent but still managed badly. Anaesthesia 2005; 60: 168-71.
3. Hawthorne I, Wilson R, Lyons G, Dresner M.Failed intubation revisited: 17-yr experience in a teaching maternity unit. British Journal of Anaesthesia 1996; 76: 680-4.
4. Djabatey EA, Barclay PM. Difficult and failed intubation in 3430 obstetric general anaesthetics. Anaesthesia 2009, 64: 1168-1171
P12 Unpublished Posters: Obstetric Anaesthesia 2010 (Newcastle)
L de Lloyd,  R Baraz,  H Ankireddy,  R Collis,  M Stacey   Anaesthetic department, University Hospital of Wales, Cardiff, UK Introduction: Failed intubation during obstetric general anaesthesia is an extremely challenging situation with potentially devastating consequences. Algorithms have been developed as  a   t raining  tool  and  to guide  the management of  such a situation.  We discuss our experience of a failed intubation during general anaesthesia for category one caesarean section (CS), and reflect on the role and limitations of failed intubation algorithms in obstetrics.
Case history: A labour epidural was sited during normal working hours in a 40 year old primigravida, with moderate difficulty due to mild lumbar scoliosis. While establishing labour analgesia, prolonged fetal bradycardia occurred requiring immediate caesarean delivery.  Following airway assessment and appropriate head and neck positioning, anaes thes i a was induced us ing th iopen tone and suxamethonium. Direct laryngoscopy revealed grade 3 view with only the tip of the epiglottis visible. Attempts to intubate the trachea using bougie, standard and McCoy blades with release of cricoid by two senior anaesthetists failed. Ventilation using a guedel airway and 4 hands was extremely difficult but improved slightly with a Proseal LMA. Oxygen saturations were maintained above 90% at all times. The fetal heart remained at 80bpm. At this stage, whether to proceed with CS or wake the patient up was considered. CS using a spontaneously breathing technique was carried out uneventfully and a healthy  baby was delivered.
Discussion: When presented with a category one CS the anaesthetist is required to enable rapid delivery of a critically distressed fetus, whilst providing safe anaesthesia for the mother, in a highly time and emotionally pressurised situation. When faced with a failed intubation, the reality of ‘waking the patient up’   is not as easy as it may sound. Difficulties inherent in managing the airway of a supine pregnant patient, combined with laryngospasm often complicate the situation. The reality of managing the critical clinical situation is far removed from the fluent transitions of the algorithm. Waking the woman up in the face of profound fetal distress and a partially obstructed airway is an emotionally very difficult decision.  Everyone wants to ‘save the baby’ (but not to kill the mother).
Conclusion: How each case proceeds is influenced by unique patient factors, anaesthetist experience and level of support available at the time. Priority in the management of any failed intubation must always be oxygenation and preserving the safety of the mother. Anticipating the difficult middle ground, and the powerful emotional stresses of failed intubation in a category one CS, pose a significant challenge for the training of anaesthetists. Algorithms, while undoubtedly useful, fail to bridge the divide between theory and clinical practice.
References
P103 Failed intubation in obstetrics; translation of theory into practice
1,2
1. Nair A, Alderson JD. Failed intubation drill in Obstetrics. Int J Obstet Anesth 2006;15: 172-4.
2. Harmer M. Difficult and failed intubation in obstetrics. Int J Obstet Anesth 1997; 6: 25-31.
R Hartley,  S Labor   Department of Anaesthetics, Salford Royal NHS Foundation Trust, Salford, UK Introduction: Maternal obesity is an increasing problem and presen ts s ign i f ican t anaes the t ic cha l lenges . Recommendations from the most recent CEMACH report suggest that a consultant anaesthetist should be directly involved in the management of all morbidly obese parturients .    Elsewhere, a pragmatic approach to consultant involvement has been suggested . In view of increasing prevalence of obese parturients it may be appropriate to recommend direct consultant involvement in cases with risk factors identified by CAVE assessment (Co-morbidities, Airway, Venous access, Epidural and related techniques).    
Methods: We audited the anaesthetic management of parturients requiring intervention in theatre, between September and November 2009. Standards were taken from the latest CEMACH report . This recommends that all morbidly obese women should undergo antenatal assessment, and should be anaesthetised with the direct involvement of a consultant anaesthetist.
Retrospectively we applied the CAVE acronym to identify risk factors based on anaesthetic notes and recorded complications for all patients with BMI>35kg/m .  
Results: 1)      192 patients required intervention in theatre during the audit.
2)      Of these 18 had a BMI > 35kg/m  at booking, all were seen in antenatal clinic by a consultant anaesthetist.
3)      5 of these 18 patients with BMI>35kg/m had no direct or indirect consultant involvement during the theatre intervention.
4)      CAVE analysis identified 7 co-morbid conditions, no anticipated airway or venous access difficulties, and 8 possible cases of difficulty with regional techniques.
5)      There were no cases of difficult intubation or failed regional anaesthesia.  
Discussion: CAVE is a valuable tool for use by the multi- disciplinary team to aid in care of the obese parturient. Although our recommended standards are not being met, the findings and lack of documented complications suggest that it would be appropriate to recommend mandatory direct consultant involvement for identified patients only. 
It is anticipated that instituting CAVE assessment in our antenatal clinic and delivery unit would aid education, and the identification of high risk obese parturients. Following this, anaesthetic management will be re-audited.
References
P104 Anaesthetic management of the obese parturient in Salford - an audit of practice.
1
2
1
2
2
2
1. Lewis G, editor. The Confidential Enquiry into Maternal and Child Health (CEMACH). Saving Mothers ’ Lives: reviewing maternal deaths to make motherhood safer – 2003 – 2005. The Seventh Report on Confidential Enquiries into Maternal Deaths in the United Kingdom, London: CEMACH, 2007.
2. Morbidly obese patients should not be anaesthetised by trainees without supervision. Proposer A.F. McCrae; Opposer M. Dresner. Int J Obstet Anaesth 2009; 18; 373-378
Unpublished Posters: Obstetric Anaesthesia 2010 (Newcastle) P13
A Bhat,  J Barley,  SG Rao,  A Surendran   Department of Anaesthetics, The Queen Elizabeth Hospital, King's Lynn, UK Introduction: Obese parturients are at an increased risk of o b s t e t r i c a n d a n a e s t h e t i c c o m p l i c a t i o n s . CEMACH reported obesity as a contributory factor in 35% of all maternal deaths in the latest triennial report. Early insertion of epidural is recommended in these patients to minimise the risks of general anaesthesia . Previous studies have shown that obese parturients require less epidural local anaesthetic (LA) when compared to the non-obese. Large doses of LA can cause undesirable motor block and a higher incidence of operative deliveries.  Our audit aimed to compare the average hourly local anaesthetic consumption and the mode of delivery in the four body mass index (BMI) groups.
Methods: We established that an ethical committee approval was not required for this audit. Our unit uses continuous infusion with intermittent top-ups for labour epidural analgesia. Data was collected prospectively from 179 parturients with labour epidurals over a four month period.
Results: The results are tabulated below:
Discussion: Our audit has shown that epidural analgesia and high BMI can increase the incidence of operative deliveries. Obese parturients from our study group have received comparitively more LA dosage than the non obese. This is contradictory to existing evidence and could have contributed for the higher incidence of operative deliveries. The audit suggests the need for an alternative mode of labour epidural administration like intermittent boluses or patient controlled epidural analgesia (PCEA) which have been shown to decrease the epidural LA requirement.  This may possibly decrease the operative delivery rate with epidurals in not just the obese but also the non-obese population. The results have given us an incentive to change to PCEA mode for labour epidural analgesia and we  plan to repeat the study in future to complete the audit cycle.
References
P105 Labour epidural analgesia and delivery outcomes in obesity- a prospective audit
1
1
2
2
Group C (BMI 30-
Group D (BMI>35)
2
3
1. Saravankumar K, Rao SG, Cooper GM. Obesity and obstetric anaesthesia. Anaesthesia 2002; 61: 36-48.
2. Panni MK, Columb MO. Obese parturients have lower epidural local anaesthetic requirements for analgesia in labour. Br J Anaesth 2006; 96: 106-10.
3. http://www.nice.org.uk/nicemedia/pdf/IPCNICEGuidance.pdf
JA Cronje,  S Gowrie-Mohan,  A Suxena,  J Misra   Dept of Anaesthesia, Lister Hospital, Stevenage, UK Introduction: Accidental dural puncture is a recognised complication of epidural insertion. Post dural puncture headache (PDPH) subsequently develops in approximately 81% of parturients . A low incidence (25%) of PDPH has been reported in morbidly obese paturients after (18G) epidural anaesthesia . In this s tudy we compared the incidence of PDPH in morbidly obese parturients with non- morbidly obese parturients. Method:  Approval was obtained for this study from the local research ethics committee. A prospective audit was carried out on all patients known to have had an accidental dural puncture with a 16G Touhy needle or complaining of PDPH after epidural anaesthesia over an eleven year period at our institution. Data was collected prospectively using a standardised form. Demographic data included Body Mass Index (BMI), age and ASA status. Epidural details included reason for request, level of epidural placement, depth of epidural space, severity and associated symptoms of PDPH and subsequent treatment.
Results:  One hundred and sixteen patients were identified during the study period. Both groups were comparable in terms of age & ASA status. The incidence of inadvertent dural puncture was significantly higher in morbidly obese paturients than non-morbidly obese parturients - 7.8% (44/564) versus 1.1% (72/6540), respectively. There was a statistically significant lower incidence of severe PDPH (necessitating epidural blood patch) between morbidly obese (52.3%) and non-morbidly obese (86.1%) paturients.
Discussion: The combined risks of obesity and pregnancy are significant. Regional anaesthesia is the safest approach for morbidly obese obstetr ic pat ients , but may be technically challenging for the anaesthetist. Morbidly obese patients have poorly defined anatomical landmarks that can make identification of the epidural space difficult and increase the possibility of dural puncture. The decreased incidence of PDPH in morbidly obese paturients may relate to the large abdominal panniculus that functions as the equivalent of an abdominal binder, elevating intraabdominal pressures and retarding the degree of spinal fluid leakage through the dural puncture site.
References
1
2
Age  mean & 
BMI mean & range
 -
 -
1. Paech M, Banks S. An audit of accidental dural puncture during epidural insertion of a Touhy needle in obstetric patients. Int J Obstet Anesth 2001; 10: 162-7
2. Faure E, Moreno R. Incidence of postdural puncture headache in morbidly obese parturients. Regional Anesthesia 1994; 19: 361-3
P14 Unpublished Posters: Obstetric Anaesthesia 2010 (Newcastle)
PN Nair,  GC Dignam,  I Suri   Department of Anaesthesia, Warwick hospital, Warwick, UK Introduction: Regional anaesthesia is often the preferred technique in obstetric practice. However, in patients with raised BMI , relying on blind landmark techniques can make successful regional anaesthesia difficult. Multiple attempts in establishing a successful spinal anaesthetic increases pat ient d iscomfor t , infec t ion r i sk and damage to surrounding structures.
Methods: A prospective study of 23 patients undergoing elective caesarian section  for a 3 month period was done. Current BMI and number of attempts at spinal insertion were recorded. The depth of the spinal space was measured using Sonosite®  M-Turbo ultrasound machine before measuring the actual depth with a spinal needle. We analysed the relation between the ultrasound and actual depth, BMI and actual depth and BMI and needle reinsertions. Patients were followed up to identify adverse outcomes and patient satisfaction was determined on a six point verbal numerical score.
Results:  The mean difference in ultrasound and actual  depth was 0.23 cm (SD 0.56, range -0.02 to 1.99,  P >0.05) with a positive correlation coefficient of 0.85 (see figure). The correlation coefficient between BMI and  actual depth was 0.37. 21 patients received successful initial placement, including two patients with a BMI >40. Two patients (BMI 31 and 39) required two attempts. There were no reported adverse effects. Patient satisfaction scores ranged between 4-6: 13 patients (57 %) scored 6 [very satisfied]; 9 (39 %) scored 5 [satisfied] and 1 (4%) scored 4 [slightly less satisfied].  
      Conclusion: Greater numbers are required for significant results, however within this limitation depth of space does not appear to correlate with BMI, except for perhaps at extremes of BMI (patients with BMI <25 had depths below 4.8 cm and those with BMI > 40 had depths above 6 cm). There does appear to be positive correlation between ultrasound and actual depth. With ultrasound assistance 21 out of 23 patients received successful initial placement with a single further attempt for the remaining two. Ultrasound provides an accurate assessment of depth and also appears to aid efficient, safe placement with minimal attempts. High recorded satisfaction perhaps represents less discomfort from fewer attempts and/or reduced anxiety from patients' confidence in a guided rather than blind technique. Reference
P107 Accuracy and patient satisfaction with ultrasound facilitated spinal needle insertion for elective caesarean sections
1
1. Carvalho JCA. Ultrasound-facilitated epidurals and spinals in obstetrics. Anesthesiology Clin 2008; 26: 145-158.
A Morris,  R Leighton,  P Sharpe   Department of Anaesthesia, University Hospitals of Leicester NHS Trust, Leicester, UK Introduction: Ultrasound is now widely used throughout all areas of anaesthesia. Within obstetric anaesthesia it is becoming increasingly popular to guide placement of epidurals, in particular to measure the depth of the epidural space prior to needle puncture. It has been shown to reduce the number of needle punctures and improve the quality of analgesia produced. However, this requires the use of a different ultrasound technique and probe from that with which most anaesthetists were familiar with. We looked at the ability of anaesthetists to measure depth using ultrasound.
Method: A model was developed to allow measurement of the dep th of severa l s tandard ob jec t s by mul t ip le anaesthetists. The model comprised of a container of a gelatine solution with 10 standardised objects suspended within it. 10 anaesthetists, of different grades, performed an u l t r a s o u n d s c a n o f t h e g e l a t i n e s o l u t i o n . E a c h anaesthetist measured the depth of all the suspended objects 5 using a linear probe and 5 using a curved probe. The depth of the objects was measured directly using a ruler.
Results :  The   r u l e r  measu r ed  dep th   o f   t h e   ob j e c t s ranged between 0.3-6.7 cm. The mean ultrasound measured depths ranged between 0.36-5.86 cm, the standard deviations of the ultrasound measurements ranged between 0.06-0.4 cm. There is a good correlation between the ruler measured and ultrasound measured depths. 
Figure 1: Ruler measured vs ultrasound measured depth Discussion:  In this simple and innovative model depth measurements made by anaesthetists using ultrasound correlated well with the direct ruler measurements made. This model provides a useful mecahnism for training and for further research. References
P108 Measurement of depth by ultrasound in anaesthetic practice
1,2
1. Grau T, Leipold RW, Conradi R, Martin E, Motsch J. Efficacy of ultrasound imaging in obstetric epidural anaesthesia. J Clin Anaesth 2002; 14: 169-75.
2. Grau T, Leipold RW, Conradi R, Martin E. Ultrasound control for presumed difficult epidural puncture. Acta Anaesthesiol Scand 2001; 45: 766-71.
Unpublished Posters: Obstetric Anaesthesia 2010 (Newcastle) P15
S Kuthanur Natarajan,  K Nandakumar   Anaesthetics/Obstetrics, West Middlesex University Hospital, Isleworth, UK Aim:To determine the adequacy and maternal satisfaction of the pain relief following caesarean section.
Standards:Following are the standards set by Royal college of anaesthetists
More than 90% of women should have a worst pain score of  3 or less than 3 on Visual analogue scale (VAS)
More than 90% should be satisfied or very satisfied with the pain relief 
All should receive Non steroidal anti inflammatory agents (NSAID) unless contraindicated
Methods:It is a prospective audit conducted in 30 obstetric patients undergoing caesarean section. All these patients had epidural or spinal diamorphine or fentanyl, diclofenac 100mg PR at the end of the procedure, regular diclofenac and co-codamol. They can also have oromorph as required with maximum dose of 30 mg in 4 hours. Pain scores were recorded at 6  hours, 12 hours, 24 hours and 48 hours after the caesarean section. Maternal satisfaction about the pain relief was noted at the end of 48 hours. 
Observations:Only 18 patients (60%) of women had a worst pain score of 3 or less than 3  on VAS. Six patients had a pain score of 5, two of them had pain score of 7 and four of them had a worst pain score of 8.
Only 21 patients(70%) are satisfied or very satisfied with the pain relief. Out of remaining nine patients, six said they are not happy about the pain relief for initial 12 hours and the remaining three said they are not happy at all for whole 48 hours. 
All patients have received NSAIDs .
 
 
P109 Adequacy of post caesarean section pain relief - an audit
1
1. RCOA: Raising the Standard: A compendium of audit recipes (Second edition 2006) - 8.9 Pain relief after caesarean section
N Joshi,  N Boniface,  D Hurford,  C Hommers,  N Wharton,  M Scrutton    Obstetric Anaesthesia, St Michael's Hospital, Bristol, UK Introduction: A RCOA audit standard suggests that >90% women should have a visual analogue score (VAS) of ≤3cm for pain after caesarean section (CS). >90% women should be satisfied with their pain relief.  In 2008 an audit revealed a day 1 VAS score ≤3cm for only 29% of women despite regular oral paracetamol and NSAID. Patient satisfaction with analgesia was 69% on day 1. There were also significant levels of nausea and pruritus following CS. We p r e s e n t e d t h e r e s u l t s t o c o l l e a g u e s a l o n g w i t h recommendations to convert from supplemental PRN intramuscular morphine (10mg) to PRN oral morphine (10- 20mg oramorph) following success in other units. PRN codeine phosphate was omitted. One year later we re - audited.
Methods: Prospective data was collected from patients undergoing CS during a four -week period in March 2009.   .
Results: 100% of women received intra-thecal or epidural opioids when CS was performed under regional blockade. CS under general anaesthesia received PCA morphine init ial ly. 100% of women were prescribed regular paracetamol and NSAIDS (unless contra-indicated) along with PRN oral morphine.
Discussion: This audit confirms that a regimen substituting oral morphine for intramuscular morphine can improve pain control . Codeine phosphate (60mg NNT of 16.7) maintains a high side effect profile and was successfully eliminated from our analgesia prescription. Increased patient satisfaction was observed.
References
1
2
3
1. Raising the Standard: a compendium of audit recipes. The Royal College of Anaesthetists, 2006.
2. Antrobus H. Do-it-yourself pain control. ImpAct 4, 10th November 1999, http://www.jr2.ox.ac.uk/bandolier/impact/imp04/i4±05.html
3. Oxford Pain Internet Site. Easy targets aren't always the right ones, http://www.jr2.ox.ac.uk/bandolier/painres/combos/comboed/html
P16 Unpublished Posters: Obstetric Anaesthesia 2010 (Newcastle)
R Dumpala,  J Francis ,  M Jones,  JA Pickett   Anaesthesia, Addenbrooke's Hospital, Cambridge, UK Introduction: The Association of Anaesthetists of Great Britain and Ireland recommends that UK obstetric units have systems for referral and antenatal anaesthetic assessment of high -risk parturients. A survey of UK practice of antenatal anaesthetic assessment (2005) showed that only 30% of responding units had formal anaesthetic assessment clinics.  No regional information could be i n f e r r e d   f r o m   t h i s   s u r v e y .   W e   w i s h e d   t o investigate antenatal anaesthetic assessment in our region.
Methods: Questionnaires were sent to the lead anaesthetist for each obstetric unit in our region. This was followed by email or telephone reminder if no initial response. We asked about anaesthetic  clinic availability,  year of establishment, frequency, guidelines for referral, consultant cover on labour ward and joint clinics with other specialties. We also asked what value of  BMI would trigger review at a clinic since the Confidential Enquiries into Maternal and Child Health has identified pregnant women with BMI > 35 at greater risk from anaesthesia. 
Results: Replies were received from 15 out of 17 units (88%). Thirteen (87%) of the responding units had a dedicated antenatal anaesthetic clinic. Nine (60%) of these
were certainly established before the 2005 survey. Frequency of the clinics ranged from monthly to greater than once a week. The number of consultant sessions on labour ward ranged from 5 to 17 per week with larger units generally having more. Fourteen units (93%) had clear guidel ines on which women to refer  for  antenatal anaesthetic review. Fourteen units  (93%)  had a formal referral mechanism, usually by letter. Only 1 unit had a joint clinic (with cardiology and obstetrics).
The threshold BMIs for referral to a clinic are shown in the Table.
Two units reviewed women below their normal trigger value if there was other significant comorbidity.
Discussion: In East Anglia most obstetric units have formal antenatal anaesthetic assessment clinics. All responding units had some sort of system in place for referral of  high risk parturients. One unit which did not have a dedicated clinic felt that it would be beneficial. BMI thresholds for clinic review vary. This may reflect limited availability of clinic appointments or differing opinion on level of  BMI that requires clinic assessment. Joint clinics with other medical specialties are rare.
Reference
P111 Antenatal anaesthetic assessment: a survey of practice in East Anglia
1
1
 >35 4
>39 1
>40 6
>45 2
>50 1
No value given 1
1. Rai MR et al. Antenatal anaesthetic assessment of high-risk pregnancy: a survey of UK practice. International Journal of Obstetric Anesthesia 2005; 14: 21