APPENDIX 51
Memorandum by Royal College of Anaesthetists
(MS 15)
1. COLLECTION
OF DATA
FROM MATERNITY
UNITS
1.1 It is not clear whether this relates
to how the data is collected or what is collected. Assuming it
is what is collected it would be sensible to know how many anaesthetics
are given.
1.2 The type of anaesthetic given is relevant
and should at least give broad categories of general anaesthetic
or regional anaesthetic.
1.3 The use of epidural analgesia in labour
1.4 Anaesthetics given for procedures such
as evacuation of retained products of conception (miscarriage)
and for ectopic pregnancy. These anaesthetics may not be given
in the maternity unit but are pregnancy-related and are of relevance
to the Confidential Enquiries into Maternal Deaths.
1.5 The committee presumably will want to
discuss whether to collect outcome data in terms of efficacy (eg
epidural analgesia) and complications related to the anaesthetic
procedures.
2. STAFFING STRUCTURE
OF MATERNITY
CARE TEAMS
2.1 Anaesthesia is an integral part of the
safe delivery of maternity services. Anaesthesia is given of necessity
for Caesarean Section (rate of 21% nationally1), retained placenta,
insertion of Shirodkhar suture. Epidural analgesia is undoubtedly
the most effective method of analgesia in labour and is chosen
by 24% women nationally1. In some women there are medical indications
for epidural analgesia.
2.2 Anaesthetists are also crucial to the
care of pregnant women who become seriously ill (such as through
severe pre-eclampsia, massive haemorrhage or through intercurrent
illness such as sepsis or through pre-existing disease such as
congenital cardiac disease or asthma to give but a few examples).
These women are managed either on high-dependency units within
the maternity unit or are transferred to intensive care units
either on or off site, depending on local circumstances.
2.3 In a proportion of cases anaesthesia
is required within minutes, such that the presence of an anaesthetist
within the maternity unit is necessary for the safety of the baby
or the mother.
2.4 In units that select low-risk cases
and have small numbers of deliveries it is not practicable for
anaesthesia to be provided routinely. On the rare occasion it
will be necessary (such as retained placenta) local circumstances
will prevail but it will often entail a woman being transferred
to a site where anaesthesia can be given with relative safety.
2.5 Although the majority of pregnant women
are inherently young and healthy the physiological changes of
normal pregnancy mean that there are special considerations for
anaesthesia. This requires that anaesthetists are specially trained
for obstetric anaesthesia. This is recognised in the RCA competency-based
training guides2,3
2.6 * * * The RCA promotes the relocation
of isolated maternity units to within a main hospital. The RCA
would not support a proliferation of isolated maternity units
where anaesthetists would be requested to bale out potential disasters.
2.7 The provision of safe anaesthesia is
dependent on good training, adequate monitoring4, properly maintained
modern anaesthetic machines and availability of blood and blood
products. Equally important is the presence of trained assistance5.
2.8 The recommended number of anaesthetists
in an obstetric unit is problematic as is highlighted in the Neonatal
and Maternity Working Group report that has been submitted to
Ministers. Elective work is more easily timetabled to when staff
are available. However there is a requirement for an anaesthetist
24 hours/day. This is compounded by the fact that the unscheduled
work, in busier units, frequently needs a second anaesthetist
and occasionally a third (or more) at unpredictable times. Women
sometimes have to wait for an epidural but waiting is not acceptable
where urgent delivery of the baby is required.
2.9 The historical recommendation has been
that there should be a day-time session from a consultant anaesthetist
for every 500 deliveries. Trainee anaesthetists who have worked
72 hours or more/week have provided round-the-clock cover, consultants
being available on-call for emergencies. Since that recommendation
the workload has increased substantially with a doubling of the
Caesarean Section rate and increased numbers of women with complex
medical problems becoming pregnant and requiring specialist care.
In specialist units it is quite clear that two consultants are
needed for the majority of daytime sessions. Flexible sessions
are also needed for cover during leave.
2.10 The European Working Time Directive
has had two important effects. Firstly, it has reduced the amount
of time that trainees can work and hence the rotas have had to
change. This has reduced the amount of time that trainees can
provide emergency anaesthesia cover but thus far the clinical
areas of service that have been protected are obstetric anaesthesia
and Intensive Care. The second and consequent effect is that trainees
are spending a disproportionate time in service to obstetric anaesthesia
and Intensive Care to the detriment of their training and experience
in general and specialist anaesthetic practice.
2.11 The solution eventually will be to
provide a much higher proportion of the service by consultant
anaesthetists. However good they are, they can only be in one
place at a time and therefore backup will continue to be required.
We are still a long way short of the numbers of anaesthetists
that are required by the National Health Service. Further information
on workforce planning can be obtained from Dr David Saunders,
Council Member RCA.
2.12 It is important to appreciate that
obstetric anaesthetists require sessions in other areas of anaesthetic
practice in order to maintain their skills (and their sanity)
in procedures that may only be occasionally required within obstetrics
but nevertheless are essential to safe outcome. This would include
airway management skills and invasive vascular monitoring.
2.13 The RCA is aware of a pilot scheme
to assess the feasibility of training non-anaesthetists to insert
and manage epidural analgesia. Appointments to the scheme have
only just been made and so it is too early to comment on possible
contributions that might be made. However it must be appreciated
that the scheme relies on having back up and supervision from
an anaesthetist on site for the treatment of emergencies related
to the epidural, and hence it should not be seen as a potential
solution to providing epidural analgesia in isolated sites.
3. CAESAREAN
SECTION RATES
3.1 Advice on factors that can be shown
to affect Caesarean section rates can best be obtained from Ms
Jane Thomas at the RCOG. She co-ordinated the National Caesarean
Section Audit1.
3.2 In our own hospital the Caesarean section
rate has been reduced by the dedicated input of one of the obstetric
consultants (Mr Peter Thompson).
3.3 The litigation factor cannot be ignored.
4. PROVISION
OF TRAINING
FOR HEALTH
PROFESSIONALS WHO
ADVISE PREGNANT
WOMEN AND
NEW MOTHERS
4.1 Training for anaesthetists is provided
within the RCA curriculum2,3,6.
4.2 The provision of leaflets explaining
the various forms of analgesia for labour and the choices of form
of anaesthesia for Caesarean Section are very useful. Funding
for providing them is sometimes problematic.
4.3 My personal view is that people other
than anaesthetists could be trained (and supervised) by anaesthetists
to impart the necessary information about choices of analgesia
and anaesthesia. Such people could also usefully perform some
of the routine follow-up of women after anaesthesia.
4.4 Translations and translators are essential.
* * *
12 February 2003
REFERENCES1. J
Thomas, S Paranjothy. Royal College of Obstetricians and Gynaecologists
Clinical Effectiveness Support Unit. National Sentinel Caesarean
Section Audit Report. RCOG press; 2001.
2. The Royal College of Anaesthetists. The CCST
in Anaesthesia. II: Competency based Senior House Officer Training
and Assessment. 2000.
3. The Royal College of Anaesthetists. The CCST
in Anaesthesia. III: Competency based Specialist Registrar Years
1 and 2 Training and Assessment. 2002.
4. Association of Anaesthetists of Great Britain
and Ireland. Recommendations for standards of monitoring during
anaesthesia and recovery. 2000.
5. Association of Anaesthetists of Great Britain
and Ireland. Guidelines for Obstetric Anaesthesia Services. 1998.
6. The Royal College of Anaesthetists. The CCST
in Anaesthesia. IV: Competency based Specialist Registrar Years
3, 4 and 5 Training and Assessment. 2003.
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