I have followed the correspondence relating to the rapid sequence spinal technique with some incredulity that we are discussing it at all. What is it that happens to us when the word obstetric prefixes anaesthesia? If one were to propose a new anaesthetic technique with a rate of awareness of pain starting at 10%, one would not expect to be taken seriously; nor would one expect to get ethical approval to study it (not in my hospital anyway). Add to that, not bothering to scrub up and not adding an opioid to the local anaesthetic; the 'no win, no fee' lawyers must be getting quite excited. 

Category one caesarean sections are a challenge, we all know that. The anaesthetic we provide has to be safe, effective and fast. When we reduce standards on any of these three, we may be criticised. I suggest that it is precisely when we cut corners that the problems arise. This certainly applies to general anaesthesia in obstetric practice, and may actually explain a great many of the failed intubations. Perhaps we may attempt to stratify and deal with the risks of general anaesthesia in obstetric practice.  Incidentally, converting a failed spinal to general anaesthesia during surgery must be one of the most uncontrolled and hazardous general anaesthetics to adminster in obstetrics. I do not think that a technique which relies heavily on this in order to get out of trouble can be safe, for that reason alone.

Is it time to take a step back and reconsider what we assume to be acceptable practice in the obstetric setting? Maybe we could even ask women what they think. They have been known to have opinions of their own!

F Knox

Consultant Anaesthetist

Aberdeen Royal Infirmary 

We have described a carefully defined approach to providing safer anaesthesia for the category-1 caesarean section, rather than an aspiration to stratify and deal with the risks. In obstetric practice, corners are cut by all the staff involved in order to achieve rapid delivery; but that is the nature of dealing with life-threatening pathology.

As ours being an observational study, we did not get ethical approval. However, ethics approval has been granted to study, for instance, elective spinal anaesthesia for caesarean section with a rate of pain of 12-32% [1] and non-elective epidural top-up anaesthesia with a rate of pain of 21-34% [2].

We published results on small numbers, and may have been fortunate with the early cases. However, going by a previous definition of pain during caesarean section as that requiring pharmacological treatment [3], we had a rate of pain for rapid sequence spinal anaesthesia at category 1 caesarean section of 0% i.e. none of our cases required treatment for transient discomfort or pain. It did not seem sensible to headline such a figure, and we accept that the true rate of pain with rapid sequence spinal is likely to exceed the rate that we have recorded previously in our unit for all category-1 caesarean sections using spinal anaesthesia of 6% [3].

Women do have opinions of their own. Almost two and a half thousand women were surveyed as part of the Sentinel caesarean section audit. The safety of their baby and their own safety far outweighed concerns over pain [4].

1.      Ackerman N, Saxena S, Wilson R, Colomb M, Lyons G. Effect of intrathecal diamorphine on block height during spinal anaesthesia for caesarean section with bupivacaine. British Journal of Anaesthesia 2005; 94: 843-7.

2.      Lucas DN, Ciccone GK, Yentis SM. Extending low-dose epidural analgesia for emergency Caesarean section. A comparison of three solutions. Anaesthesia 1999; 54: 1173-7.

3.      Kinsella SM. A prospective audit of regional anaesthesia failure in 5080 Caesarean sections. Anaesthesia 2008; 63: 822-32.

4.      Thomas J, Paranjothy S. Royal College of Obstetricians & Gynaecologists Clinical Effectiveness Support Unit. The national sentinel caesarean section audit report. London: Royal College of Obstetricians and Gynaecologists Press, 2001.