Does the addition of active body warming to in-line intravenous fluid warming prevent maternal hypothermia during elective caesarean section? A randomised controlled trial.

INTRODUCTION: Inadvertent perioperative hypothermia occurs frequently during elective caesarean section but perioperative active body warming is not widely used. There is a paucity of evidence of its use in the obstetric population, and no applicable guidelines. We set out to identify a superior active warming method for preventing inadvertent perioperative hypothermia. METHODS: Following ethical approval, 132 women presenting for uncomplicated elective caesarean section under spinal anaesthesia were recruited. All participants received in-line intravenous fluid warming and were randomised to one of three parallel groups: no active body warming; forced air warming; and conduction mattress warming. The primary outcome was the difference in mean core temperature, measured on admission to the recovery room, between study groups. Core temperature and thermal comfort were measured perioperatively at 15-min intervals. Estimated blood loss, haemoglobin change, length of hospital stay and neonatal core temperature were also recorded. RESULTS: One-hundred-and-thirty-one women completed the study. There was no significant difference in mean core temperature on admission to the recovery room (36.6°C vs. 36.6°C vs. 36.6°C, η2=0.005, P=0.74). Maternal hypothermia was prevented in all groups with only 0.3% hypothermic at any of the temperature measurements (3/1016). There was no difference in mean neonatal core temperature (36.3°C vs. 36.3°C vs. 36.3°C, η2=0.003, P=0.82); however, 59.4% (76/128) of all neonates were hypothermic. CONCLUSION: In-line intravenous fluid warming is sufficient to prevent maternal hypothermia and maintain core temperature. The addition of active body warming conferred no added benefit.

The feasibility of using 'bring your own device' (BYOD) technology for electronic data capture in multicentre medical audit and research.

Large-scale audit and research projects demand robust, efficient systems for accurate data collection, handling and analysis. We utilised a multiplatform 'bring your own device' (BYOD) electronic data collection app to capture observational audit data on theatre efficiency across seven hospital Trusts in South Yorkshire in June-August 2013. None of the participating hospitals had a dedicated information governance policy for bring your own device. Data were collected by 17 investigators for 392 individual theatre lists, capturing 14,148 individual data points, 12, 852 (91%) of which were transmitted to a central database on the day of collection without any loss of data. BYOD technology enabled accurate collection of a large volume of secure data across multiple NHS organisations over a short period of time. Bring your own device technology provides a method for collecting real-time audit, research and quality improvement data within healthcare systems without compromising patient data protection.

Introduction of enhanced recovery for elective caesarean section enabling next day discharge: a tertiary centre experience.

BACKGROUND: The widespread adoption of enhanced recovery programmes in various surgical specialties has resulted in patient benefits including reduced morbidity, reduced length of stay and an earlier return to normal activities. This evidence, along with the increased financial pressures in the UK National Health Service, has led many units to consider introducing such a programme for obstetric surgery. We report our experience in setting up an enhanced recovery programme for women undergoing elective caesarean section and a prospective analysis of factors that influence length of stay. METHODS: An enhanced recovery pathway was designed by a multidisciplinary team and introduced in March 2012. Factors influencing length of stay were determined using a log normal model. RESULTS: The proportion of women discharged on Day 1 increased from 1.6% in the first quarter of 2012 to 25.2% in the first quarter of 2014. The 30-day readmission rate was 4.4% for those discharged on Day 1 and 5.6% for Day 2. Earlier gestation, multiple birth, intention to breast feed, longer surgery and more time in the post-anaesthesia recovery unit were all independently associated with a longer postoperative stay. Women presenting for obstetric surgery with the indication "one previous caesarean section" were more likely to leave hospital earlier compared to most other indications. CONCLUSION: An enhanced recovery programme was successfully introduced into our unit. Many of the interventions were straightforward and could be adopted easily elsewhere.

Enhanced recovery from obstetric surgery: a U.K. survey of practice.

BACKGROUND: In the UK earlier discharge of patients following elective caesarean section would require that more patients are discharged the day after surgery. The introduction of enhanced recovery in other specialties has resulted in shorter postoperative stay. We surveyed current U.K. practice to find whether this was consistent with enhanced recovery and what changes units would need to introduce to establish such a programme. METHODS: We conducted an Obstetric Anaesthetists' Association approved electronic survey of all the U.K. lead obstetric anaesthetists between March and May 2013. RESULTS: A response rate of 81% was achieved with 96% of those who responded supporting the concept of enhanced recovery. Only 4% of units routinely discharged their patients on day one. There were a number of practices consistent with enhanced recovery. Postoperative pain was controlled by regular paracetamol (97%) and non-steroidal anti-inflammatory drugs (100% when not contraindicated), with oral opioids (68%) being used for breakthrough pain. Over 70% of units allowed minimal interruption of perioperative oral intake and 72% of units mobilised their patients within 12h of surgery or when the neuraxial block had worn off. In contrast, a minority of units monitored patient temperature in theatre (27%) or used active warming (18%), and 28% routinely removed the urinary catheter within 12h of surgery or when the neuraxial block had worn off. Regarding neonatal recovery, only 23% reported using delayed cord clamping and 53% used skin-to-skin contact in theatre. CONCLUSION: Most obstetric units support the concept of enhanced recovery following caesarean section and many could introduce a programme for elective surgery with relatively small changes in patient care.

Assessment of interdisciplinary communication for Category 1 caesarean sections.

We assessed how often the urgency of Category 1 caesarean sections was incorrectly recorded by the anaesthetic and theatre teams. Category 1 caesarean sections were identified over a 15-month period (September 2010 to November 2011), from the daily audit of emergency caesarean sections undertaken by the obstetric team. The categories of urgency as recorded by the attending anaesthetist and theatre team were noted for each case. There were 236 Category 1 caesarean sections identified, of which 47 were incorrectly recorded as Category 2 by either the anaesthetist alone (34), the theatre team alone (1) or both (12). Where the category of urgency was correctly recorded, 11.6% of cases had a decision-to-delivery interval of more than 30 min compared with 27.7% of cases recorded as Category 2 (p = 0.01, Fisher's exact test).

Improved survival in pregnancy and pulmonary hypertension using a multiprofessional approach.

OBJECTIVE: Pregnancy in women with pulmonary hypertension (PH) is reported to carry a maternal mortality rate of 30-56%. We report our experience of the management of pregnancies using a strategy of early introduction of targeted pulmonary vascular therapy and early planned delivery under regional anaesthesia. DESIGN: Retrospective observational study. SETTING: Specialist quaternary referral pulmonary vascular unit. POPULATION: Nine women with PH who chose to proceed with ten pregnancies. METHODS: A retrospective review of the management of all women who chose to continue with their pregnancy in our unit during 2002-2009. MAIN OUTCOME MEASURES: Maternal and fetal survival. RESULTS: All women commenced nebulised targeted therapy at 8-34 weeks of gestation. Four women required additional treatment or conversion to intravenous prostanoid therapy. All women were delivered between 26 and 37 weeks of gestation. Delivery was by planned caesarean section in nine cases. All women received regional anaesthesia and were monitored during the peripartum period in a critical care setting. There was no maternal mortality during pregnancy and all infants were free from congenital abnormalities. One woman died 4 weeks after delivery following patient-initiated discontinuation of therapy. All remaining women and infants were alive after a median of 3.2 years (range, 0.8-6.5 years) of follow-up. CONCLUSION: Although the risk of mortality in pregnant women with PH remains significant, we describe improved outcomes in fully counselled women who chose to continue with pregnancy and were managed with a tailored multiprofessional approach involving early introduction of targeted therapy, early planned delivery and regional anaesthetic techniques.

Introduction of cell salvage to a large obstetric unit: the first six months.

BACKGROUND: We introduced red-cell salvage to our obstetric unit following a two-month period of training and education. We report a service evaluation of the first six months of activity from May to October 2007. METHODS: The indications for using cell salvage were: placenta praevia, suspected placental abruption, multiple pregnancy, multiple repeat caesarean, previous history of post partum haemorrhage, refusal of blood transfusion, caesarean section at full dilatation, low preoperative haemoglobin and at the discretion of the theatre team. RESULTS: The cell saver was used for 46 patients with a blood loss (median; range) of 800 (200-2000) mL and a heterologous transfusion rate of 22% (10 cases). Blood was processed and returned in 19 cases of which nine were emergency and 10 elective. The median volume (range) of blood returned was 390 (200-800) mL. For the unit as a whole the percentage of all theatre cases who received a heterologous transfusion fell from 10.2% for the equivalent time period in the preceding year to 7.9% during the six month period that cell salvage was in use (P=0.126, chi(2)). There were no adverse reactions following the administration of processed blood. CONCLUSION: We have successfully introduced cell salvage to our unit in a relatively short period of time and have used it for the largest series of patients reported in the UK.

Pre-oxygenation in pregnancy: the effect of fresh gas flow rates within a circle breathing system.

We have investigated the effect of oxygen flow rate on pre-oxygenation in pregnant patients at term using a circle system. Twenty patients presenting for elective Caesarean section maintained tidal volume breathing through a standard circle system for 3 min. Subjects were pre-oxygenated using oxygen flow rates of 5 l.min(-1), 10 l.min(-1) and 15 l.min(-1) presented in random order. The mean (SD) fractional end-tidal oxygen at the end of 3 min was 0.86 (0.07) for 5 l.min(-1), 0.92 (0.05) for 10 l.min(-1)and 0.90 (0.09) for 15 l.min(-1) (p < 0.001). Entrainment of air occurred in 22% of pre-oxygenation sessions. Oxygen flow rates of 10 l.min(-1) or above provide optimal pre-oxygenation using a circle system in term parturients. In our study, entrainment of air occurred in a surprisingly high percentage of cases.

Use of the HemoCue near patient testing device to measure the concentration of haemoglobin in suction fluid at elective caesarean section.

We have investigated the suitability of the HemoCue photometer to measure the concentration of haemoglobin in suction fluid obtained at elective caesarean section in 30 women. Laboratory analysis was used as a gold standard against which values generated by the HemoCue were compared. We used the method of Bland and Altman to analyse the data. The bias and the limits of agreement were -0.013 and -0.39 to 0.36 mg x dl(-1) respectively, indicating a good level of agreement. Mean (SD) total blood loss calculated using these data, combined with the weight of the swabs, was consistently greater than clinical estimation: 768 (496) ml versus 506 (249) ml respectively (p < 0.001). We have found that the HemoCue near patient testing device may be used to estimate blood loss accurately in the suction fluid obtained at elective Caesarean section.

Dose response to intrathecal diamorphine for elective caesarean section and compliance with a national audit standard.

BACKGROUND: This double-blind randomised controlled trial investigated the most appropriate dose of intrathecal diamorphine to use with high-dose diclofenac as part of a multimodal analgesic regimen for caesarean section under subarachnoid block. We also wished to establish whether it was possible to satisfy the Royal College of Anaesthetists postoperative pain audit recommendation for this patient group. METHODS: One hundred and twenty patients presenting for elective caesarean section under subarachnoid block were recruited and divided into four groups. Treatment was standard except that patients were given either placebo or one of three different doses of intrathecal diamorphine (100 microg, 200 microg or 300 microg). All patients were given regular paracetamol, high-dose diclofenac and an hourly subcutaneous diamorphine regimen for breakthrough pain. RESULTS: There was a dose-dependent improvement in analgesia with intrathecal diamorphine. Only 37.9% of patients given 300 microg of intrathecal diamorphine had a visual analogue pain score of 3/10 or less throughout the study. There was a dose-dependent increase in the incidence of itching with intrathecal diamorphine although the incidence of nausea and vomiting was similar between groups. CONCLUSIONS: We found that for elective caesarean section under subarachnoid block with high dose diclofenac, analgesia was optimal with 300 microg of intrathecal diamorphine. Even the highest dose of intrathecal diamorphine did not achieve the Royal College of Anaesthetists postoperative audit target that 90% of patients should have a pain score of no more than 3/10. We believe that this target is too arduous.

Preoperative anxiety and postoperative satisfaction in women undergoing elective caesarean section.

BACKGROUND: The primary aim was to investigate whether preoperative anxiety in women undergoing elective caesarean section predicts postoperative maternal satisfaction with the process, perceptions of recovery, analgesic use or length of hospital stay. Other factors that might influence postoperative satisfaction were also explored. METHOD: In 85 women awaiting elective caesarean section, anxiety, social support and aspects of preparation were measured in the 24 hours preceding surgery. Maternal satisfaction and perceptions of recovery were assessed around the third postoperative day. Satisfaction with the preoperative information from the anaesthetist and postoperative pain relief were also measured at this time. Medical notes were used to gather information on analgesia use and length of hospital stay. RESULTS: Preoperative anxiety scores were comparable with those of general surgical/medical patients. Preoperative trait anxiety and state anxiety were inversely associated with postoperative maternal satisfaction. State anxiety was also inversely associated with better recovery. Preoperative anxiety was not associated with analgesic use or length of hospital stay. Linear regression analysis indicated the degree of satisfaction with information from the anaesthetist and perceived emotional support from the partner explained 52% of the variance in postoperative maternal satisfaction. CONCLUSION: Lower preoperative anxiety is associated with greater maternal satisfaction with elective caesarean section and better recovery. Information provided by anaesthetists and perceived emotional support are also of importance. It may be possible to identify women with high anxiety and facilitate satisfaction and recovery through providing additional supportive input.

Arm and ankle blood pressure during caesarean section.

BACKGROUND: We have previously reported that measurement of non-invasive blood pressure during caesarean section under spinal anaesthesia fails in over 50% of cases. We felt that errors would be less likely if blood pressure could be measured at the ankle as it is immobile during caesarean section. The purpose of our study was to determine whether blood pressure measurement at the ankle was equivalent to the arm. METHOD: Following ethical approval, informed consent was obtained from 30 women scheduled for elective caesarean section. Two non-invasive blood pressure cuffs, one on the upper arm and one on the ankle, were used to measure blood pressures at three timed intervals: before spinal insertion, before surgery and after delivery of the neonate. RESULTS: Using the method of Bland and Altman we found that there was only marginal agreement between the two methods. On eight out of 15 occasions where there was a greater than 20% fall in arm systolic blood pressure, this was not detected at the ankle. CONCLUSION: We cannot recommend the use of the ankle to measure blood pressure during caesarean section.