P.155 When the patient would rather run for the hills than encounter the anaesthetist

ABSTRACT

Introduction: It is estimated that needle phobia is present in up to 10% of the population.1 We present the antenatal anaesthetic management of a pregnant woman initially refusing any blood tests or cannulation but ultimately requiring emergency caesarean delivery. Case Report The high risk antenatal anaesthetic clinic became aware of a 26-year-old woman (G1P0) of 30 weeks’ gestation with extreme needle phobia. She had no medical history, the pregnancy was low risk and a midwifery-led delivery was planned. The woman declined blood tests in pregnancy. We met the woman with her community midwife. She stated she would run for the hills rather than have a cannula or would lock herself in the bathroom if the need arose. She was indifferent on hearing that a cannula is required for anaesthesia or that refusing one may be life-threatening. Her phobia possibly stemmed from a childhood experience but she had no recall of this. Although sceptical, the woman worked with us on a multifaceted plan. We emphasised the importance of her engagement. A referral for cognitive behavioural therapy failed due to the Covid-19 pandemic. Instead we suggested hypno-birthing techniques and mindfulness apps to manage anxiety. We taught applied tension although doubtful of its use as the woman did not suffer vasovagal symptoms with her phobia. We described graded exposure and gave resources, however she did not manage any of these. We devised distractions involving her partner and media, for example FaceTiming her mother and using headphones to listen to music or watch videos. We asked her to work on positive visualisation, focusing on gains, empowerment and rewards. Medical strategies were planned, specifically topical anaesthesia before cannulation and Entonox. In the event of an emergency caesarean we ruled out inhalational induction before cannulation. In turn, we agreed to be empathetic to her phobia and respect her choices. We agreed to minimise interventions but would not be influenced into deviating from safe protocol. Following initial consultation we remained in telephone contact. She remained unsure if she would consent. Hospital legal services were contacted for advice and a discussion with a QC was arranged. We were advised to create advance consent documents to avoid applying to the courts. After a few hesitant weeks the woman turned a corner and the community midwife reported improvement in mindset. We discussed the legal paperwork but the woman decided it was not necessary. An action plan was attached to her notes. Ultimately she required a cannula for antibiotics, induction of labour, epidural and caesarean delivery under epidural top-up. She was compliant and coped by using varying degrees of the above outlined strategies. On follow-up in the community the midwifery team reported a happy mother looking forward to future pregnancies and being able to keep her phobia under check. Discussion: This case demonstrates the importance of developing a management plan for the extreme needle phobic parturient. A pregnant woman’s greatest fear was controlled in order to facilitate safe delivery.