APPENDIX 12
Memorandum by the Royal College of Anaesthetists
(RCA)
1. INTRODUCTION
1.1 The Royal College of Anaesthetists (RCA)
is a registered charity and is independent of the State and the
National Health Service. Its Charter commits it to set and maintain
the standards of anaesthetic training and to work for the benefit
of patients. It also plays a major role in the postgraduate education
of doctors in all fields of anaesthesia. The Royal College of
Anaesthetists has nearly 12,000 Fellows or members, of whom 9,281
are practicing anaesthetists within the UK.
1.2 Anaesthesia is a key component of many
hospital services and is integral to the safe provision of maternity
services.
1.3 The Royal College of Anaesthetists has
supported and been involved in many safety initiatives and service
issues involving obstetric anaesthesia. These include
— guides to training in anaesthesia1,2,3
— the Confidential Enquiries into Maternal
Deaths, since its inception in 19524
— the Confidential Enquiries into Stillbirths
and deaths in infancy
— the newly formed Confidential Enquiry
into Maternal and Child Health
— the National Caesarean Section audit5
— the Maternity and Neonatal Workforce
working group reporting to Ministers
— the external working group (maternity
services) reporting to the National Children's Service Framework
— a joint liaison committee with the
Royal College of Obstetricians and Gynaecologists
1.4 The membership of College Council includes
four anaesthetists with particular interest in obstetric anaesthesia.
2. PLACE OF
BIRTH
2.1 Anaesthesia is an integral part of the
safe delivery of maternity services and is most often needed at
the time of delivery. Anaesthesia is given of necessity for Caesarean
Section (rate of 21% nationally5), and for complications such
as retained placenta. Regional anaesthesia (such as spinal or
epidural) is most commonly used but general anaesthesia is also
necessary on occasion.
2.2 Staffing shortages within anaesthesia
mean that there will be difficulties staffing the current numbers
of maternity units once the European Working Time Directive reduces
working hours to 56 hours in August 2004. This fact has been appreciated
for some time and has been flagged up as an important issue through
the Neonatal and Maternity Workforce Group that reported to Ministers,
as well as through other routes. The Government's current initiative
to bring in more doctors, including anaesthetists, is targeted
at waiting lists, rather than the provision of obstetric anaesthetic
or emergency services.
2.3 The RCA supports the fact that women
should have a choice in the place of delivery although it recognises
that the choice may be limited in sparsely populated areas. That
choice must be an informed one bearing in mind the wishes of the
mother, any risks anticipated and the staffing that can be provided.
The choices involved include home delivery, or delivery in a midwifery-led
unit, a consultant-led unit or a tertiary referral centre.
2.4 Women should be fully informed about
the services that are available (and those that are not available)
when making their choice of place of birth. They should be able
to change their mind in their choice.
2.5 Where a woman presents with particular
problems (be they obstetric or medical or concerning the baby)
she should be advised of any limitations or risks involved, should
she choose a birth location that cannot provide the services that
it is anticipated she will require.
2.6 Where the need for anaesthesia is anticipated,
the woman must be able to choose a unit where these services are
available.
2.7 Epidural analgesia is undoubtedly the
most effective method of analgesia in labour and is chosen by
24% women nationally5. For some women there are medical indications
for epidural analgesia. If a woman wants epidural analgesia she
should be able to choose a unit where this is available. If the
service is only available on a limited basis (eg day-time only)
the mother should be informed of this. Currently, only anaesthetists
provide epidural analgesia. Although there is a pilot scheme (in
Nottingham) evaluating the feasibility of non-medical personnel
being trained to provide epidural analgesia it is not envisaged,
even if successful, that this would be appropriate on isolated
sites away from anaesthetists who could deal with any complications,
or provide anaesthesia for urgent delivery.
2.8 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. These
factors need to be to receive strong consideration in the choice
of birth-place when problems pre-exist or develop during pregnancy.
2.9 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. The proportion of caesarean Sections that fell
into this category was 16% in the National Sentinel Caesarean
Section Audit5. The urgency of anaesthesia requirement cannot
always be anticipated and it is therefore important that the mother
is aware if anaesthesia services are not immediately available.
It should be noted that this immediacy of requirement of anaesthetists
is a source of the staffing difficulties within anaesthesia.
2.10 Appropriate selection of low-risk mothers
should allow those who wish to choose units that cannot supply
anaesthesia services, reasonably safely, since there are also
benefits in demedicalising pregnancy and birth. On the rare occasion
when anaesthesia 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. This situation illustrates the benefits of a
midwifery unit attached to a hospital unit, such that transfer
can be effected rapidly and safely.
2.11 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 guides1,2,3 and the future training of anaesthetists
in this area must be assured.
2.12 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.
2.13 The provision of safe anaesthesia is
dependent on good training, adequate monitoring6, properly maintained
modern anaesthetic machines and availability of blood and blood
products. Equally important is the presence of trained assistance7.
This implies that the number of maternity sites with these services
cannot be limitless.
2.14 Safety is paramount. We must not forget
the huge advances in maternity care that have taken place: in
the years 1952-546 one in 1,500 women died in pregnancy or childbirth
compared with only one in nearly 10,000 in 1997-99.8 Furthermore
there are significant numbers of women known to be at high-risk
who choose to become pregnant (eg those with congenital heart
disease) some of whom contribute to the current mortality.
June 2003
REFERENCES
1. The Royal College of Anaesthetists. The
CCST in Anaesthesia. II: Competency based Senior House Officer
Training and Assessment. 2000.
2. The Royal College of Anaesthetists. The
CCST in Anaesthesia. III: Competency based Specialist Registrar
Years 1 and 2 Training and Assessment. 2002.
3. The Royal College of Anaesthetists. The
CCST in Anaesthesia. IV: Competency based Specialist Registrar
Years 3, 4 and 5 Training and Assessment. 2003.
4. Ministry of Health. Reports on Public
Health and Medical Subjects No 97. Report on Confidential Enquiries
into Maternal Deaths in England and Wales 1952-54. London: HMSO
1957.
5. J Thomas, S Paranjothy. Royal College
of Obstetricians and Gynaecologists Clinical Effectiveness Support
Unit. National Sentinel Caesarean Section Audit Report. RCOG press;
2001.
6. Association of Anaesthetists of Great
Britain and Ireland. Recommendations for standards of monitoring
during anaesthesia and recovery. 2000.
7. Association of Anaesthetists of Great
Britain and Ireland. Guidelines for Obstetric Anaesthesia Services.
1998.
8. Why Mothers Die. Report on Confidential
Enquiries into maternal deaths in the United Kingdom 1997-99.
London: RCOG press 2001.
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