key: cord-0861731-uovliaxf
authors: Rimmer, A.A.; Thomas, E.; Thomas, O.D.; Helme, D.; Tozer, J.
title: P.43 Impact of the COVID-19 pandemic on obstetric anaesthesia: A service evaluation
date: 2021-06-09
journal: Int J Obstet Anesth
DOI: 10.1016/j.ijoa.2021.103041
sha: 84715c76b5a3d0df09d6ce3e3c9c3e411da327bb
doc_id: 861731
cord_uid: uovliaxf

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Introduction: Following caesarean section (CS), women are now routinely discharged earlier (often on the day after surgery) with simple analgesia only, in line with current PROSPECT guidance to minimise opioid use. 1 We aimed to review patients presenting to their GP for stronger analgesia soon after discharge and establish associations that may predict additional analgesic requirements.

Methods: All CS at our hospital in 2019 were included. Retrospective review of community pharmacy electronic records identified those who received a new GP prescription within 2 weeks of discharge for: opioids, lidocaine and gabapentinoids. Discharge prescriptions were reviewed alongside patient characteristics. These data were then compared with the remainder of CS in 2019. Logistic regression was used to examine any associations with community analgesia prescriptions.

Results: In 2019, 1081 CS were performed and 77 (7.1%) women received a GP prescription within 2 weeks for additional strong analgesia: weak opioids 69 (90.7%), strong opioids 3 (3.6%) gabapentinoids 3 (3.6%) and lidocaine patch 2 (2.3%). Sixteen (21%) women were not prescribed a NSAID on discharge and 34 (44.2%) had a postoperative complication diagnosed: infection 21 (27.3%), psychiatric 10 (13%), others 3 (3.9%). Patient characteristics found to have no association with additional analgesia included: pre-op haemoglobin, number of previous CS, type of anaesthesia, grade of surgeon, urgency of CS and blood loss. Data for women with increased likelihood of requiring additional analgesia are presented in the Table. Discussion: From these data we found that a small proportion of women receive additional analgesia following discharge and simple analgesia appears to be adequate for the majority. However, inability to take NSAIDs may be an indication to consider the use of weak opioids on discharge. The correlation of raised BMI and smoking with increased analgesic requirements may be explained by the associated increased risk of wound infection causing pain. Using this methodology on a multicentre population in the future may more clearly elucidate associations to guide discharge prescribing. Introduction: The effectiveness of intrathecal (IT) morphine for post caesarean delivery (CD) analgesia is well established internationally as part of a multimodal analgesic regimen. 1 UK obstetric anaesthetic practice has favoured IT diamorphine. Our institution adopted IT morphine and fentanyl (morphine+fentanyl) as an adjuvant to hyperbaric bupivacaine for CD from 2019 due to supply issues. Given differences in lipid solubility of the two drugs, IT morphine could have prolonged effects, resulting in superior analgesia at 24 h post CD, but at the risk of worse side effects (nausea, pruritus). Given the multidimensional nature of post-CD recovery, IT morphine could result in poorer overall quality of recovery.

Methods: We retrospectively analysed audit data for elective CD over six weeks in early 2017 for the IT diamorphine protocol (300-350 lg); n = 119, and over 10 weeks from July-Sept 2020 for IT morphine (125-150 lg) +fentanyl (15 lg); n = 100. Both groups followed the same enhanced recovery (ER) protocol except for IT opioids. Women received IV ondansetron 4mg. At 24 h post-CD, women were interviewed on the ward using the ObsQoR-10 recovery scoring tool (ObsQoR-11 in 2017, data adjusted for comparison), which includes relevant recovery items (pain, nausea). 2 Number of nights hospital stay was recorded.

Results: Clinical characteristics of women were similar between groups. Morphine+fentanyl was associated with lower ObsQoR-10 scores at 24 h compared to diamorphine, indicating poorer recovery (Table) . Greater ObsQoR pain item scores (i.e. less pain) were found with morphine+fentanyl at 24 h. ObsQoR nausea and vomiting item scores were worse (lower score) in the morphine+fentanyl group. Number of nights hospital stay was similar between groups.

Discussion: Our data suggest that IT morphine+fentanyl was associated with improved analgesia at 24 h post-CD compared to diamorphine, but with worse side effects leading to a reduced quality of recovery at 24 h. This did not, however, impact length of stay. Our data are observational and so can suffer from bias. Morphine data were collected during the Covid-19 pandemic, which could be a confounding factor. However, we believe IT diamorphine may have advantages over IT morphine to promote ER, but we require higher quality studies with prospective randomised controlled trials.

Introduction: The first wave of the COVID-19 pandemic, between March and May 2020, affected provision of anaesthetic services across the country. At its peak, critical care capacity exceeded 300% at Royal Gwent Hospital (RGH). Anaesthetic rotas were upscaled, trainees worked a 1 in 5 rota, and there was 24-h resident consultant anaesthetist cover. An obstetric COVID-19 contingency plan was introduced from 15 March 2020. We explored the impact of the pandemic on the provision of obstetric anaesthesia in RGH. 1 Methods: We compared the demand and quality of care provided between March and May of 2019 and 2020. Measures of demand used were: total number of deliveries, caesarean deliveries (CD), epidurals and non-CD theatre interventions. Measures of quality used were: rate of post-dural puncture headache (PDPH), anaesthetic technique for CD, number of post-partum haemorrhages (PPH) >1500 mL, rate of obstetric high dependency unit (HDU) admissions, special care baby unit (SCBU) admissions and anaesthetic follow-up. Sources of data included the local obstetric anaesthetic database and diary, PDPH follow-up record, delivery unit admission record and birth register.

Results: There was a reduction in workload, particularly in the earlier weeks of the pandemic, compared to 2019. Rates of successful regional anaesthesia (RA) for operative delivery were higher and HDU admissions were lower. In 2020 a lower percentage of women received follow up after anaesthetic intervention.

Discussion: There was a reduction in the number of deliveries in 2020, most elective CDs occurred in another hospital within the health board. The measures used suggest high quality care was maintained at RGH during the first wave of the pandemic; the CD rate under RA and PDPH rate were improved, and the rate of PPH >1500 mL and obstetric HDU admissions were reduced. Fewer women received anaesthetic follow-up, which could be improved through post-discharge telephone review. Since the first wave, obstetric services across the health board have been centralised. We plan to compare data in this new setting during the current COVID-19 wave. Introduction: The COVID-19 pandemic has necessitated rapid changes to services to minimise the risk of viral transmission, including widespread adoption of remote consultation methods. 1 From April 2020, we changed our pre-operative assessment service for elective caesarean section (CS) patients from a face-to-face consultation 1-3 days before admission to a telephone-based service. This included signposting to an electronic version of our patient information leaflet (PIL), which was previously poorly accessed. 2 A service evaluation was conducted to assess patient satisfaction of this new approach.

Methods: A voluntary, anonymous, 15-point questionnaire was offered on admission to elective caesarean section patients from May to October 2020. Distribution continued until fifty responses were received. Responses were collected post-operatively.

Results: 98% of respondents (49) rated the care provided during the consultation as very good or excellent. 92% (46) expressed either no preference or would prefer a telephone consultation if given a choice, whilst only 8% (4) said they would prefer to attend hospital for faceto-face consultation. Two respondents reported hearing impairment, though still rated the consultation as very good or excellent. 82% (41) of respondents felt better prepared for their CS than prior to the consultation. 68% (34) were aware of the patient information leaflet (compared with 21-35% previously) 2 and 80% of these had found it useful.

Discussion: The telephone preoperative consultation appears overall effective and satisfactory for most patients, however a formal pathway for patients with language or communication needs that preclude telephone consultation is required. Holding the consultation prior to admission appears to help women feel more prepared for admission, and awareness of the PIL has improved. The service evaluation was limited by its convenience sampling. Introduction: Pregnant women with mechanical prosthetic heart valves (MPHV) are at a significant risk of thromboembolic, haemorrhagic and cardiac complications. Maternal mortality of 9%, morbidity of 41% and adverse fetal outcomes were reported in 47% of the 58 MPHV women in the UKOSS study. 1 NICE now recommends a multi-disciplinary (MDT) approach in the peripartum management of women with MPHV. 2 Methods: We conducted a retrospective review of all pregnant women with MPHV who had MDT input as per NICE/RCOG guidance over a five-year period (2015-2019) in our tertiary unit. Maternal, anaesthetic and neonatal outcomes were evaluated as part of this audit.

PROSPECT guideline for elective caesarean section: updated systematic review and procedure-specific postoperative pain management recommendations

Optimal pain management after cesarean delivery

Development and evaluation of an obstetric quality-of-recovery score (ObsQoR-11) after elective caesarean delivery

Guidelines for Provision of Anaesthetic Services

et␣al Maternity services in the UK during the coronavirus disease 2019 pandemic: a national survey of modifications to standard care

Patient information leaflets for elective caesarean sections: print or digital? OAA conference 2020 P132