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In 2007 the Department of Health published Maternity Matters: Choice, Access and Continuity of Care in a Safe Service. The over-riding aim of any maternity service is to provide safe, high-quality care to women and their partners, thus enabling a safe pregnancy and birth for both mother and baby and to provide a confident start to family life.
For the majority of women, midwives and obstetricians will deliver care, but there are an increasing number of women whose pregnancy, labour or delivery require anaesthetic input.
Over the past decade the Centre for Maternal and Child Enquiries (CMACE), the Royal College of Obstetricians and Gynaecologists (RCOG), the Obstetric Anaesthetists’ Association (OAA) and the Association of Anaesthetists of Great Britain and Ireland (AAGBI) have all produced guidance emphasizing the need for good communication between all the speciality groups providing antenatal care. Antenatal anaesthetic assessment is pivotal in planning peripartum care, particularly for those with co-existing disease, to ensure the best outcome for these women. The most recent guidance from the OAA/AAGBI states there should be an agreed system whereby the anaesthetist is given sufficient notice of all potentially high-risk patients. In the majority of obstetric units this would be done as a referral to an antenatal anaesthetic assessment clinic.
Antenatal anaesthetic clinic
There are increasing numbers of parturients presenting with co-existing, complex medical conditions. This may, in part, result from the advances in medicine that have rendered such conditions more stable and have seen these women surviving to childbearing age. Many women are now choosing to have children later in life, resulting in an increase in acquired co-morbidity. The prevalence of morbid obesity has significantly increased in the UK (1.4% in 1993, 2.9% in 2005). This was echoed by data published by the World Health Organization, demonstrating that the prevalence of obesity has nearly doubled between 1998 and 2008.
The anaesthetic service not only provides intrapartum analgesia and anaesthesia, but also assists in the delivery of peripartum care to women with complications related to their pregnancy or co-existing medical disease.
The aim of the antenatal clinic is to carry out a review of the woman’s history, assess the impact of any co-morbidities and provide information. The outcome of the visit should be an individualized anaesthetic management plan for labour and delivery. Women with complex medical problems need to be discussed at a multidisciplinary forum, so that obstetricians, anaesthetists, midwives and other medical specialities are aware of the issues that might arise in the peripartum period.
In 1993 Rosaeg et al. published a review of patients seen in their anaesthetic clinic over a 6-year period. The review showed that the clinic provided a valuable service, not only to the pregnant woman, but also to the anaesthetist and other healthcare professionals involved in the woman’s care. Another highlighted benefit was the provision of consistent advice and information regarding anaesthetic management that may impact on obstetric care to the obstetricians.
When setting up an anaesthetic assessment service it is essential that there is suitable infrastructure to support the clinic:
Consultant time made available in job plans to run the clinics
Consultation room dedicated to the clinic
Setting appropriate referral criteria (see Table 7.1)
Consultant review of referrals prior to booking
Booking women into the clinic
Appointment and clinic letters
Point of contact for the women
Retrieval of notes from other hospitals
Dissemination of the findings from the clinic visit to all relevant personnel
A system that ensures there is easy access to the clinic letters if a woman is admitted to the delivery unit out of hours
Database of all the referrals
Audit of the clinic service.
Previous difficulties with general or regional anaesthesia
Severe reaction to drugs including anaesthetic agents or local anaesthetics
Congenital heart disease
Coronary heart disease
Previous cardiac surgery
Arrhythmias/pacemaker or ICD in situ
Restrictive lung disease
Previous spinal surgery/injury
History of brain injury/surgery
Any spinal cord abnormality
|• Endocrine||Thyroid disease/phaeochromocytoma/other endocrine disorder|
|• Obstetric||Risk of major obstetric haemorrhage|
Severe obesity – BMI > 40 kg/m2
Difficult venous access or needle phobia
Refusal of blood products
Learning difficulties or significant problems with consent
Other severe disease
Who should be seen?
In an ideal world, all parturients would be reviewed in the antenatal period; however, personnel and financial constraints make this unworkable.
Locally agreed referral criteria enable patients at higher risk and women who have had problems with previous pregnancies to be referred to the anaesthetic antenatal clinic.
The recent OAA/AAGBI guidance on provision of obstetric services recommends that referral criteria for antenatal anaesthetic clinics should include:
Women that might present difficulties should analgesia or anaesthesia be required (this could include women with poor venous access, e.g. due to intravenous drug use or severe burns, or those with learning difficulties or mental health problems)
Women at high risk of obstetric complications
BMI > 40 kg/m2 at booking (as recommended by Joint CMACE/RCOG guideline on the management of women with obesity in pregnancy)
Previous difficulty with or complications of regional or general anaesthesia
Women with significant medical conditions.
This list is not exhaustive and should be tailored to the needs of each individual obstetric unit.
It is important to have formal referral criteria, regardless of whether the parturient is seen in an anaesthetic clinic or on an ad hoc basis, as it will increase the number of appropriate referrals and highlight the presence of the service. When introducing or amending referral guidelines it is vital to ensure that they are communicated to the healthcare professionals making the referrals and to provide a point of contact should there be any uncertainty over which patients to refer.
Once guidelines have been agreed and circulated, referrals can be made through an electronic booking system, written referral or standardized proforma, whichever is suitable for each obstetric unit. Referrals can be made either at the time of the booking visit or later in pregnancy, it is essential that there is clear guidance where the referral is sent to be reviewed by an anaesthetic consultant.