Obstetrics and perioperative medicine
In this article Dr Reshma Patel, National Institute of Academic Anaesthesia Research Fellow, explores how perioperative medicine can be used as a framework to improve care for obstetric patients.
Perioperative care in obstetrics has three primary aims:
- Detection and management of high-risk pregnancies
- Identifying areas of potential pre-optimisation
- Minimise length of stay and post-partum complications
In their recent editorial, Alicia Dennis and Nicole Sheridan make a compelling case for why perioperative medicine must prioritise pregnant women to improve their perioperative outcomes:
Caesarean section surgery is an essential surgical operation and makes up approximately 30% of all operations in low middle-income countries each year. Despite this, the 131 million pregnant women who might require this major abdominal surgery each year are rarely specifically highlighted in the discourse on perioperative medicine.
Pregnant women are an integral peri-operative medicine population…Optimisation of maternal health is essential to reduce both maternal and neonatal morbidity and mortality…Pre-existing comorbid conditions are increasing: increased body mass index, hypertensive disorders of pregnancy, endocrine disorders and cardiovascular disease, with cardiac disease now the leading cause of maternal death.
Lastly that perioperative medicine has made such advances in recent years: ‘recognition and risk stratification of the high‐risk patients; development of peri‐operative risk scoring systems; collaborative decision making; pre‐operative optimisation; standardisation of in‐hospital care and enhanced recovery and rehabilitation’ and pregnant women must be able to take advantage of, and benefit from, these advances.
The authors of the paper have developed a novel approach to maternal perioperative care known as ‘The PARRCEL approach’
P: Pre-pregnancy counselling
A: Antenatal care
R: Risk stratification and modification
C: Collaborative Decision Making
E: Enhanced recovery
L: Linkage to community support.
This approach should be adopted for all all pregnant women, and we will now briefly consider some of these strands of care, specifically antenatal care and enhanced recovery.
Imagine that you are seeing a patient in a pre-assessment clinic. What specific factors should be considered in Obstetrics?
- Not everyone gets surgery but you should prepare as though they do.
- Time limited pre-optimisation – about 9 months max!
- High risk for blood loss.
- There can be limited scope for cancellation or delay of surgery if patient not fit.
- Not all drugs used to pre-optimise patients are appropriate in pregnancy.
- There is a limit to how much you can plan what anaesthetic, what labour analgesia, or what drugs they will require in the peri-partum period
- Patients present with high risk features that cannot be changed – eg multiparity, advanced maternal age.
- Optimisation of maternal health is essential to reduce both maternal and neonatal morbidity and mortality.
High Risk Anaesthetic clinics – who should be referred?
The Obstetric Anaesthetic Association (OAA) state that: Timely antenatal anaesthetic assessment services should be provided for women who:`
-Might present difficulties should anaesthesia or regional analgesia be required
-Are at high risk of obstetric complications
-Have a body mass index (BMI) greater than 40 kg.m-2 at booking
-Have had previous difficulties with, or complications of, regional or general anaesthesia
-Have significant medical conditions.
They provide examples of good referral processes. Here’s a great example of the referral flow chart from King’s Lynn Hospital.
In obstetrics, the perioperative physician is responsible for optimising chronic and newly diagnosed maternal conditions as well as instigating early treatment of correctable conditions (See Figure 1).
Figure 1: The perioperative physician in obstetrics
The perioperative management of commonly presenting problems is beyond the scope of this article. However if you would like to read in more detail about current thoughts on management of cardiac disease, obesity, anaemia and maternal sleep apnoea, please do read this article in our Downlaods section where Dr Patel gives a brief overview and sign posts some very interesting recent papers.
Enhanced Recovery in Obstetrics
We look at Enhanced Recovery in much greater detail in Week 3 but as a brief introduction let us compare the principles of Enhanced Recovery in obstetrics and non-obstetric patients.
- Aims to reduce the stress response to surgery
- A co-ordinated perioperative care pathway that is designed and managed by a multidisciplinary team
- Benefits: decreasing length of hospital stay, increasing patient satisfaction, increasing elective (Caesearean) list efficiency, financial benefits
- Obstetric Enhanced Recovery patients usually have no medical pathology: the vast majority are fit and healthy patients who are motivated to return to normal and go home as soon as possible.
- Obstetric patients can be recruited to Enhanced Recovery after the fact. If an unplanned Caesarean section patient is medically fit, recovering well and apyrexial – she may benefit from accelerated discharge.
Figure 2: Central Principles of Obstetric Enhanced Recovery (Adapted from Ituk and Habib, 2018
Standardising end points for women undergoing obstetric surgery
Does Enhanced Recovery in obstetrics make any difference to patient outcomes? How do we measure patient outcomes in obstetrics? What validated tools are there?
The ObsQoR11 (Obstetric Quality of Recovery tool – an 11 part questionnaire) is one of the few validated tools to assess outcomes in obstetrics. In this paper, the team from University College London Hospital describe the development of this 11-item obstetric specific recovery assessment, where reliability, responsiveness, acceptability, and feasibility were tested. 146 women who had Caesarean sections completed the questionnaire, with ObsQoR11 score correlating to global health recovery, as well as being able to discriminate between good and poor recovery. It was also inversely correlated with length of hospital stay.
We look at outcome measures in more closely in Week 2 so do stay with us to learn more.
What next for Perioperative care in Obstetrics?
Collection and analysis of data on large national projects - including patient experiences, outcomes, and physiology - are the hallmark of a responsible, self reflective, and successful health system. National Clinical Audits produce data on outcomes at an institutional level, with the aim to assess quality of care and identify variation. A fantastic example of this are the National Audit Projects by the RCOA. Large data projects such as these help us to improve care by identifying target institutions or population groups, such as obstetric patients.
One of the headline results from NAP5, a RCOA national audit project looking at Accidental Awareness under General Anaesthesia (AAGA), was the disproportionately high incidence of AAGA in obstetric patients undergoing LSCS (~1:670 versus ~1:19,000 overall). Why might this be? General anaesthetics for obstetric patients recurrently typify many of the risk factors for AAGA identified by NAP5 and previous studies: rapid sequence induction, neuromuscular blockade, difficult airway management, obesity and frequent performance out-of-hours by non-consultant grade anaesthetists.
This combination of factors is particular, if not unique, to obstetric anaesthetic practice, and perhaps mandates that Obstetrics as a speciality could be classified as high risk for AAGA. Furthermore, 21% of NAP5 cases of obstetric AAGA reported new significant psychological morbidity. In one case the patient indicated a decision to litigate, which may also indicate further psychological harm. As a result of this further work is being done to determine incidence, risk factors, and impact of AAGA in the Obstetric population; this is the first step toward preventative measures.
Keep an eye out for a new patient centred outcomes project from the National Obstetric Anaesthesia Health Audit Research and patient Centred outcomes – NOAHs ARC. This collaborative effort from the OAA and the Health Services Research Centre (by the RCoA) will be looking at the incidence of, risk factors for, and impact of regional anaesthetic failure in obstetric surgery. We will be using validated patient-centred measures to assess endpoints and possibly developing novel ones too.
- Dennis, A. T. and Sheridan, N. (2019), Sex, suffering and silence – why peri‐operative medicine must prioritise pregnant women. Anaesthesia. doi:10.1111/anae.14702
- Ituk U and Habib AS. Enhanced recovery after cesarean delivery
- Ciechanowicz, S. et al.(2018) Development and evaluation of an obstetric quality-of-recovery score (ObsQoR-11) after elective Caesarean delivery.British Journal of Anaesthesia, Volume 122, Issue 1, 69 - 78
- Pandit, J.J., Andrade, J., Bogod, D.G., Hitchman, J.M., Jonker, W.R., Lucas, N., Mackay, J.H., Nimmo, A.F., O’Connor, K., O’Sullivan, E.P., Paul, R.G., Palmer, J.H.M.G., Plaat, F., Radcliffe, J.J., Sury, M.R.J., Torevell, H.E., Wang, M., Hainsworth, J., Cook, T.M., Royal College of Anaesthetists, Association of Anaesthetists of Great Britain and Ireland, 2014. 5th National Audit Project (NAP5) on accidental awareness during general anaesthesia: summary of main findings and risk factors. Br. J. Anaesth. 113, 549–559