There is a wide range of practice amongst obstetric anaesthetists when obtaining consent for women requesting labour epidural analgesia. This is the first prospective observational study recording the number and types of risks mentioned and whether the risk was quantified. Statements of benefits and alternatives to the procedure were also noted. Fourteen anaesthetists, each consulting a single patient, were recorded during the process of obtaining consent and inserting the epidural. The most commonly mentioned risks (median 7) were headache/dural puncture, failure/difficulty with insertion, nerve damage, bleeding/haematoma and infection/epidural abscess. There was no difference between consultants and trainees, although consultants showed greater variance. It was uncommon for anaesthetists to state a benefit (21%) or mention an alternative option (21%), but there was usually a quantitative statement of risk (71%). Data showed a deviation from the Australian and New Zealand College of Anaesthetists guidelines and these findings may encourage anaesthetists to reflect on their own practice and guide future research.

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.

SummaryWords with negative emotional content such as pain or itch may enhance perception of these symptoms. We assessed open and direct questioning for symptoms in 100 women following Caesarean section. Of the 65 women reporting pain, 25 (39%) did so only when questioned specifically. Similarly, three women with bothersome pain (5%), and two requesting analgesia (3%), failed to disclose pain until questioned specifically. None of the 46 women with pain scores < 6 on a verbal numerical rating scale requested additional analgesia. Of 31 women with pruritus, two (6%) stated it bothered them and requested treatment and one (3%) failed to disclose pruritus on open questioning. Most women with bothersome pain or who request analgesia reveal this with open questioning. However, specific questioning is required to elicit pain in all patients. Most patients are bothered by pain at pain scores ‡ 6, while those with scores < 6 are unlikely to request additional analgesia. Effective communication is increasingly being recognised as an essential skill in anaesthetic practice [1][2][3]. It allows practitioners to develop rapport and trust with patients whilst enabling co-operation with their care, which in turn facilitates clinical management [4]. Anaesthetistpatient communication can play a vital role in alleviating anxiety [5] and enhancing analgesia, and is widely considered to be a required skill in today's medicolegal environment [6]. Although suspected for some time, only recently has it been shown that the way medical practitioners communicate can influence clinical outcomes. Lang et al. have shown that the use of negative suggestion or language with negative emotional content during painful invasive radiological procedures increases patients' pain and anxiety scores compared with the use of neutral or positive language [7]. Similarly, a recent randomised controlled trial has shown that the inadvertent use of language with negative emotional content to describe a sensation when inserting an intravenous cannula may not be helpful when compared with the use of neutral language [8]. Our anecdotal experience is that the use of negative suggestions is ubiquitous in our institution. For example, many patients are warned of a 'sting' before the injection of local anaesthetic. This in itself may increase the perception of a 'sting' rather than a 'numbing' sensation to allow the procedure to be performed more comfortably than otherwise. Similarly, the process of asking patients about pain or pruritus may function as a negative suggestion where the likelihood of patients' experiencing these symptoms may be increased. In attempting to develop a way to avoid introducing the potential for such changes in perception, we use a standardised neutral approach to patients in the form of initial open questioning regarding the presence or absence of symptoms such as pain or itch, followed by more specific questions where indicated. The questions asked have been routinely used by anaesthetists on the post-anaesthetic ward round of our insti...

No abstract

Evidence suggests that anaesthetists' communication can affect patient experience. There is a lack of guidance for anaesthetists as to the optimal verbal communication to use during insertion of epidurals on the labour ward. We recorded the verbal communication used by 14 anaesthetists during the siting of epidural catheters in women on the labour ward; a classification of the language used was subsequently devised. We found that commands and information statements were the most common types of communication used. Individual anaesthetists differed markedly in their use of positive and negative verbal language. This classification of verbal communication that we produced may be of value in future training and research of verbal communication used by anaesthetists on the labour ward.