Saving mothers' lives
Cambridge, UK
E-mail: drkrishnanmr{at}gmail.com
Editor—I wish to respond to the special article1 on the Confidential Enquiries into Maternal and Child Health (CEMACH) triennium report 2003–05. I would like to add some comments regarding obese pregnant patients, the use of premixed 500 ml bags of bupivacaine 0.1% and fentanyl 2 µg ml–1 for epidural analgesia and practical problems that occur out of hours.
I fully agree with the comments by the authors on the anaesthetic management of obese pregnant patients and the need for a protocol driven approach for their management. It is also important to change our practice of handovers in the obstetric unit, with a common handover between doctors and midwives. This will enable all of us to highlight problems and plan care.
The midwives also need to contribute actively in the management of high-risk cases and alert the anaesthetist to patients who may be heading towards operative intervention, so that adequate preoperative assessment can be made to identify any anaesthetic related problems earlier.
I feel it is unsafe to continue the practice of using premixed 500 ml bags of bupivacaine and fentanyl for labour analgesia. These bags look similar to other i.v. fluids and it is only on close examination that the words ‘for epidural use only’ can be seen. It is very easy for anyone to miss this warning in an emergency scenario. There is no need for 500 ml bags as most of the solution is thrown away. It would be sensible that manufacturers prepare bags of less volume. Also, it would be ideal for these bags to be colour coded so that they can be distinguished from other i.v. fluids or an entirely different type of giving set produced which cannot be compatible with normal i.v. fluid bags.
I would like some feedback on what do the authors feel regarding these issues to ensure a safe anaesthetic practice especially with regards to obstetric anaesthesia.
Birmingham and Edinburgh, UK
* E-mail: gcooper{at}rcanae.org.uk
Editor—We thank Dr Melarkode for his interest in the recent chapter from Saving Mothers' Lives that was reprinted in the British Journal of Anaesthesia.1 We are largely in agreement with his comments, but to take them individually.
- The management of obese women is challenging and is likely to become even more so as the prevalence continues to increase. One of our aims was to increase awareness of the problems before arriving on the labour ward to allow forward planning. The suggestion of the anaesthetist attending the midwifery handover is a positive one and would improve team working and communication. Nevertheless, there is always the possibility that the anaesthetist is in theatre and unable to attend and the anaesthetists must communicate with each other.
- The benefit of good communication about high-risk cases is self-evident. It takes long persistence to make it happen consistently and has to be continually reinforced at a local level until it becomes routine.
- The use of premixed local anaesthetic with fentanyl is preferable to it being made up by the anaesthetist because of the issues of errors and sterility. However, we commented that it was not clear why 500 ml bags of such a solution were being used when the potential for confusion with i.v. fluids is obvious. In our units, 100 ml bags are used. Colour coding is one useful suggestion but misapplication would still be possible.
Reference
1 Cooper GM, McClure JH. Anaesthesia chapter from Saving Mothers' Lives; reviewing maternal deaths to make pregnancy safer. Br J Anaesth (2008) 100:17–22.
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