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SummaryEpidural mixtures containing lidocaine with or without additives are commonly used to convert epidural analgesia in labour to anaesthesia for emergency Caesarean section, but direct comparisons with alternative, single agents in this situation are few. In a prospective double-blinded trial, we compared a freshly prepared lidocaine-bicarbonate-adrenaline mixture (final concentrations 1.8%, 0.76% and 1 : 200,000, respectively) with our standard agent, levobupivacaine 0.5%, for extending epidural blockade for emergency Caesarean section. Using a sequential analysis technique, with data analysed in blocks of 40, women receiving epidural analgesia in labour who required top-up for Caesarean section were randomly assigned to receive 20 ml of epidural solution over 3 min. The first analysis (n = 40) indicated that the study should be stopped, as significant differences were found in our primary outcome data. Median (IQR [range]) times to reach a block to touch to T5 and cold to T4 were, respectively, 7 (6-9 [5-17]) min and 7 (5-8 [4-17]) min for lidocainebicarbonate-adrenaline, and 14 (10 )17 [9-31]) min and 11 (9-14 [6-30]) min for levobupivacaine (p = 0.00004 and 0.001, respectively). Pre-and intra-operative supplementation ⁄ pain, maternal side-effects and neonatal outcomes (excluding five women who underwent instrumental delivery) were similar between the groups. Intra-operative maternal sedation (scored by the mother on a 10-point scale) was greater with lidocaine-bicarbonate-adrenaline (4.5 (3-8 [1-9])) than with levobupivacaine (3 (1-4 [1-7])), but not significantly so (p = 0.07). We conclude that epidural lidocaine-bicarbonate-adrenaline halves the onset time when extending epidural analgesia for Caesarean section although there is a possibility of increased maternal sedation. When extending epidural analgesia in labour for emergency Caesarean section, the most appropriate choice of local anaesthetic for achieving rapid and reliable epidural anaesthesia remains unclear. A recent survey of leading UK obstetric anaesthetists [1] found that 13 combinations of local anaesthetics and adjuncts are used in this situation, with 2% lidocaine (alone or in combination) used by 40% of respondents and 0.5% levobupivacaine or bupivacaine used by 72% of respondents (some respondents using more than one in their practice). In our unit, levobupivacaine is the standard agent used in this situation and was adopted as a result of previous studies that showed no consistent advantage of alternatives [2][3][4], and because of the superior safety profile of levobupivacaine compared with bupivacaine [5,6]. Use of levobupivacaine has recently been recommended as best practice when extending epidural analgesia for emergency Caesarean section [7].We have found that trainees rotating to our unit often report the use of a lidocaine-bicarbonate-adrenaline mixture in other units when a faster onset of block is required, for example when there is fetal compromise.

thrombophilia, antenatal and postpartum prophylaxis should be used. Prophylactic treatment with LMWH or UFH can be stopped at 12 to 24 hours before induction or elective CS; full anticoagulation should be withheld for 24 hours.For asymptomatic women with no prior VTE or APO but with thrombophilia, there is not enough evidence to recommend anticoagulant drug treatment during pregnancy, unless there are other risk factors. Those with AT-III deficiency, or who are homozygotes, or compound heterozygotes for factor V Leiden and prothrombin G20210A mutations require therapeutic UFH or LMWH throughout pregnancy. Fitted compression stockings, calcium, and vitamin D supplementation may be of benefit. Women with no history of thrombophilia or VTE but with other risk factors can be treated with intermittent compression devices and/or UFH or LMWH prophylaxis. Women who are AT-III deficient may require AT-III concentrate in addition to anticoagulation.Management of infants in at-risk pregnancies includes avoidance of maternal anticoagulation with warfarin before delivery, screening of infants with known thrombophilic conditions, examination of the placenta and umbilical cord by a pathologist (for counseling in future pregnancies), and evaluation and prompt treatment, as necessary, for additional risk factors (eg, asphyxia, polycythemia, dehydration, septicemia, and cardiac diseases).Specific recommendations for anesthesia for women with VTE include general anesthesia for CS if delivery is within 12 hours of taking a prophylactic dose of LMWH. Epidural and spinal anesthesia should be delayed for 10 to 12 hours after the last dose of prophylactic LMWH and for 24 hours with full anticoagulation. Patients on LMWH should receive the next dose 10 to 12 hours after removal of the catheter. Epidural anesthesia should be avoided during peak heparin concentrations to reduce the risk of epidural hematoma.In summary, thrombophilia and the development of VTE during pregnancy can have serious repercussions for mother and fetus. Antithrombotic treatments all have limitations in pregnant women and management of thromboprophylaxis during pregnancy requires extensive interaction between patients and clinicians. Treatment plans have to be individualized and require frequent modification over the course of pregnancy, labor, delivery, and postpartum. Due to a lack of evidence-based guidelines, the authors recommended large, prospective, randomized studies of women with risks for VTE.

General anaesthesia for obstetric surgery has distinct characteristics that may contribute towards a higher risk of accidental awareness during general anaesthesia. The primary aim of this study was to investigate the incidence, experience and psychological implications of unintended conscious awareness during general anaesthesia in obstetric patients. From May 2017 to August 2018, 3115 consenting patients receiving general anaesthesia for obstetric surgery in 72 hospitals in England were recruited to the study. Patients received three repetitions of standardised questioning over 30 days, with responses indicating memories during general anaesthesia that were verified using interviews and record interrogation. A total of 12 patients had certain/ probable or possible awareness, an incidence of 1 in 256 (95%CI 149-500) for all obstetric surgery. The incidence was 1 in 212 (95%CI 122-417) for caesarean section surgery. Distressing experiences were reported by seven (58.3%) patients, paralysis by five (41.7%) and paralysis with pain by two (16.7%). Accidental awareness occurred during induction and emergence in nine (75%) of the patients who reported awareness. Factors associated with accidental awareness during general anaesthesia were: high BMI (25-30 kg.m -2 ); low BMI (<18.5 kg.m -2 ); out-of-hours surgery; and use of ketamine or thiopental for induction. Standardised psychological impact scores at 30 days were significantly higher in awareness patients (median (IQR [range]) 15 (2.7-52.0 [2-56]) than in patients without awareness 3 (1-9 [0-64]), p = 0.010. Four patients had a provisional diagnosis of post-traumatic stress disorder. We conclude that direct postoperative questioning reveals high rates of accidental awareness during general anaesthesia for obstetric surgery, which has implications for anaesthetic practice, consent and follow-up.