The State of Obstetric Anaesthesiology

With 20 years’ experience in obstetric anaesthesia behind him, consultant anaesthetist Dr Roshan Fernando from University College Hospital London (UCLH) has seen many changes – mostly for the better. Here, he talks to Pat Hogan about progress in pain relief for mothers, on-going staffing challenges and the fact that he’s busier than ever.

During Dr Fernando’s training days at Queen Charlotte’s Hospital in London, specialising as a consultant in obstetric anaesthesia was not as popular as specialties such as cardiac and paediatric anaesthesia, even though it is such an important field. Things have since improved and many delivery suites within hospitals are better staffed and equipped than ever before. But the rising workload means there are often resource issues, he says.

Under-availability of anaesthetists

“I regard our delivery suite at UCLH as one of the best. We have very motivated staff and good resources for certain things. But we are still under resourced in terms of obstetric anaesthetists who need to cover both the emergency and elective workload. I used to work at the Royal Free Hospital in London, where annual deliveries are about 3,000 a year.

‘Here at UCLH we deliver 6,500 mothers each year, so double the workload. We often have three anaesthetists working extremely hard, sometimes from 8am to 5pm without a break. The challenge is obviously obtaining funding to provide a safe and high quality service to our mothers.”

However, as every politician, health professional and member of the public knows, the NHS does not have enough funding to deliver the service most patients expect these days.   But in a perfect world, he says,x he would staff all delivery suites  with a consultant obstetric anaesthetist present 24/7.  Many years ago, it was rare to see any type of consultant outside of normal daily working hours. Things have changed and now some of the busy obstetric hospitals have consultant obstetricians available up to 10pm and during weekends or even 24 hours a day.

But anaesthetists are lagging behind in terms of providing consultant cover, says Dr Fernando. “We are usually present from 8am to 6pm, but rarely beyond that and certainly not at weekends. The ideal model in my opinion would be to have a consultant obstetrician and consultant obstetric anaesthetist working together on the delivery suite throughout the day and night.”

Cutting-edge epidural research

But while the ideal staffing formula has yet to be perfected, technological innovation marches on. Dr Fernando is currently at the forefront of new research on the use of epidural pain relief pumps that provide a programmed intermittent epidural bolus, or PIEB function, which first came into use at UCLH a few years ago.

A clinical research trial is planned for this summer where women opting for an epidural will be randomised to various PIEB protocols involving different bolus volumes and intervals. Dr Fernando says: “I think the PIEB pumps could be one of the most important things to have been developed recently to provide epidural pain relief to mothers. There are many hospitals in the UK which are now starting to look at these new PIEB pumps.”

UCLH has already run a pilot study involving epidural PCA pumps with a PIEB protocol capacity. “About a year or so ago we had a short trial of the PIEB and it worked quite well,” he adds. The upcoming trial will be bigger and more in-depth and, hopefully, shed more light on best practice for using the PIEB technology.

“At the last UK meeting on obstetric anaesthesia there were quite a lot of research abstracts on PIEB. It’s early days to see if it’s going to reduce motor block in the mothers legs (a well known side effect of epidural analgesia) and improve instrumental delivery rates but it’s an interesting development.”

In the long-run, says Dr Fernando, these ground-breaking pumps may all be linked to Wi-Fi so that consultants can remotely check how much epidural drug each patient is receiving. In Singapore this type of technology has already been in use for several years. Naturally, these pumps can’t be seen as a substitute for qualified staff – especially not in areas such as the delivery suite or in the high dependency care area.

Home birth risks from the anaesthetist’s perspective

Against the backdrop of hospital-based treatments, in Dr Fernando’s view, is the on-going controversy over the safety of home births.

In December, the National Institute for Health and Care Excellence (NICE) issued new guidelines stating births at home or in midwife-led units were better for certain mothers and often just as safe for babies as being born in hospital.

But Dr Fernando believes many women are not currently properly informed about the likely risks of home births. “It’s very difficult to quantify the absolute risks.

“Let’s imagine you live in central London and your hospital is UCLH. If things do not go according to plan and you have to get to the hospital urgently, how quickly can you get there and how? Patients need to understand all the potential risks involved”

Obstetrics and obstetric anaesthesia has significantly advanced over the course of Dr Fernando’s career, with major improvements in caring for mothers, however perhaps the best is yet to come.

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