I read with interest the article by Kinsella et al [1] on rapid sequence spinals for category one caesarean sections. From my experience of being the anaesthetist on call for 4 obstetric units over the past few years, the category one sections, especially those which occur out of hours are very dramatic affairs, with the patient being wheeled down the theatre by the obstetric team and myself meeting them just before they enter the theatre. There is no time to establish a rapport with the patient, or obtain anything other than a quick history and basic consent. The patient is understandably very anxious, as are the midwives and the obstetric trainees. If I were to suggest a regional, I would not receive any support from the rest of the team, other than from the operating department practitioner. For the rapid sequence spinal to succeed, a team effort is essential. This may be possible in the daytime where senior staff are around, and also there are more pairs of hands to help attach monitoring, position patient, etc. During out of hours, the obstetricians rush to scrub up as soon as the patient is in theatre, and helping the anaesthetist is the last thing on their minds. Furthermore, a spinal done in a hurry, with an anxious, less than cooperative patient, is more likely to fail.

I am a firm believer of regional anaesthesia for obstetrics, but unless there is a change in the way category one sections are viewed by the rest of the team, it is very difficult to suggest regional anaesthesia, at least as a trainee. If the patient has factors suggesting a difficult airway, such as morbid obesity, then I would suggest a regional regardless of the urgency. In all other cases, in the current climate of the obstetric units that I have worked in, a general anaesthetic is probably the easiest option.

Rashmi Menon

ST5 Anaesthetics

St James University Hospital

Leeds

References

1. Kinsella SM, Girgirah K, Scrutton MJL. Rapid sequence spina lanaesthesia for category-1 urgency caesarean section: a case series. Anaesthesia 2010; 65: 664–669. 

Dr Menon is absolutely correct when describing the importance of the team approach to the category 1 caesarean section. It has been shown that team training can reduce the decision to delivery interval while increasing the proportionate use of regional anaesthesia in cord prolapse - a classic category 1 situation [1]. We would argue that in most cases general anaesthesia is not the safest option for mother or baby, but that safety is being sacrificed for speed in spite of the oft-repeated statement "don't jeopardise the mother for the sake of the baby".

In our series of 25 cases of rapid sequence spinal, 19 were performed by a trainee anaesthetist in the absence of a consultant anaesthetist, 19 were performed by a solo anaesthetist and 15 were performed between the hours of 18.00-08.00. We support our own trainees in the use of spinal for category 1 caesarean section and the adaptations required for the rapid sequence spinal, and they quickly become comfortable with thisapproach. This is therefore not a technique used just in ideal circumstances by senior staff. What is the difference between the units that Dr Menon has worked in and St Michael's Hospital Bristol? We emphasise good communication between all specialities on the delivery suite and an understanding of the need to work as a team in order to provide the best result for mother and baby. We have multidisciplinary ward rounds that include the anaesthetist, midwives and obstetrician. We encourage the regular use of intra-uterine fetal resuscitation in the event of fetal distress and review fetal status after transfer from the delivery room to the operating theatre. There is a commitment by the anaesthetist when performing a regional technique that any attempts will be time-limited according to the circumstances, and following on from this the acceptance by the obstetricians that we will consider regional anaesthesia as an option in many cases.

The rapid sequence spinal is only one part of a package of care that we aim to deliver in the category 1 situation. We agree that the anaesthetist should not work in conflict with the practices of a maternity unit, but hope that improved team functioning will allow such developments in the units where Dr Menon goes.

MJL Scrutton

SM Kinsella

K Girgirah

1. Siassakos D, Hasafa Z, Sibanda T, et al. Retrospective cohort study of diagnosis-delivery interval with umbilical cord prolapse: the effect of team training. British Journal of Obstetrics and Gynaecology 2009; 116: 1089-96.

It is with interest that I read the correspondence by Dr Menon regarding the article by Kinsella et al [1]. There has been significant progress in the multiprofessional management of women in labour over the last few years. First, by training staff in the team management of obstetric emergencies [2,3]; a process that has improved perinatal outcomes in several units worldwide [2]. Second, by changing focus from speed to physical and psychological safety, for patients and staff alike. It is relevant that the cord prolapse guideline from the Royal College of Obstetricians and Gynaecologists states that category-1 urgency caesarean sections should "not unduly risk maternal safety"; "regional anaesthesia may be considered in consultation with an experienced anaesthetist" [4]. The focus on safety rather than on fixation with time targets is re-iterated in a recent guideline for all caesarean sections [5].

The answer to Dr Menon's concerns may be to insist not on performing general anaesthesia for all category 1 caesarean sections, but on improving teamwork and individual skills with appropriate evidence-based training for all staff in every unit. Perhaps then no one would ever have to face the same climate that Dr Menon describes, of anxious staff and patients who fail to communicate or support each other.

D Siassakos

Clinical Lecturer, Obstetrics and Gynaecology and Medical Education

Southmead Hospital, Bristol

References

1. Kinsella SM, Girgirah K, Scrutton MJL. Rapid sequence spina lanaesthesia for category-1 urgency caesarean section: a case series. Anaesthesia 2010; 65: 664-669. 

2. Siassakos D, Crofts J, Winter C, Weiner C, Draycott T. The active components of effective team training in obstetric emergencies. British Journal of Obstetrics and Gynaecology 2009;116:1028-32.

3. Siassakos D, Hasafa Z, Sibanda T, et al. Retrospective cohort study of diagnosis-delivery interval with umbilical cord prolapse: the effect of team training. British Journal of Obstetrics and Gynaecology 2009;116:1089-1096.

4. Royal College of Obstetricians and Gynaecologists. Umbilical cord prolapse. Clinical Guideline Green-Top Guideline No.26. London: RCOG, 2008.

5. Royal College of Obstetricians and Gynaecologists and Royal College of Anaesthetists. Classification of urgency of caesarean section - a continuum of risk. Good Practice No.11. London: RCOG, 2010.