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A case is described in which a Jehovah's Witness patient who refused blood transfusion suffered massive antepartum haemorrhage, her haemoglobin falling as low as 2.0 g.dl(-1). She was treated on an intensive care unit with intermittent positive pressure ventilation and general supportive measures, pulsed hyperbaric oxygen therapy and recombinant human erythropoietin.

Summary A postal survqy of all maternity units in the United Key wordsAnaesthesia; obstetric. Anaesthetic techniques, regional; epidural. Labour; analgesia.Epidural analgesia is well recognised as effective and relatively safe, and has been used increasingly in the United Kingdom not only for pain relief in labour but also for operative delivery. Since the introduction of continuous epidural blockade, there have been numerous techniques described for establishing and maintaining epidural analgesia. The aim of this survey was to establish the current practice of epidural analgesia for labour in maternity units in the United Kingdom. MethodsA mailing list of maternity units in the United Kingdom was supplied by the Royal College of Obstetricians and Gynaecologists, and each of the 272 obstetric units was sent a questionnaire, a stamped, self-addressed envelope and a covering letter. The survey was conducted between September 1991 and February 1992. The questionnaire asked for details concerning epidural analgesia as shown in Appendix I. The questions were answered by selecting the appropriate answer, and space was provided for additional comments. ResultsOf the 272 questionnaires sent, 234 were returned, representing a reply rate of 86%. Three replies were from units which no longer received obstetric patients and were excluded from further analysis. The epidural rate varied between 0 and 51% (Fig. I), with a n average epidural rate of 19.7%. The epidural rate vaned with size of unit (Table I), as did the epidural service that was offered (Table 2). Of the units offering an epidural service, 132 (59%) had a stable rate, whereas 82 (37%) ha1 increasing rates and only eight (4%) had decreasing rates.The methods used for epidural placement are shown in Table 3. The choices of local anaesthetic agents, average volumes given, the use of adrenaline, the use of opioids, and the use of midwife top-ups are shown in Table 4. Not all the units that completed the questionnaires answered every section.Infusions were used in 88 (40%) units, with 62 (28%) using them as their main technique and 26 (12%) using them occasionally. Of the units using infusions, the concentration of agent varied (Table 5) as did the use of opioid supplement, with 27 out of the 88 (31%) using opioids, the most commonly used being fentanyl. Of the 88 units using infusions, 41 (47%) used them because midwife top-ups were not allowed in their units. . It would appear that the above recommendations are slowly being implemented, with very few units (4%) offering no epidural service at all. Of the units offering a limited service there was a twofold difference (1 1 % compared to 22%) in the average epidural rate compared to units offering a 24-h service, and this was largely due to lack of trained staff to manage the service rather than differences in local demands. A significant number of units (22%) now require written consent before insertion of an epidural; the value of this in women under the influence of opioids, Entonox, or physically or emotionally ...