Obstetric anaesthesia is considered a specific and difficult field of medicine. Many countries have published the evidence-based guidelines for care of parturients to avoid malpractice.

In Poland, the first congress concerning obstetric anaesthesia-related issues was organized in 2009 and guidelines for obstetric extradural analgesia were published.

The objective of the present study was to determine the methods of anaesthesia used for Caesarean sections in Poland. 

METHODS

A survey questionnaire was sent to hospitals listed on www.rejestrzoz.gov.pl and anaesthesiologists registered on www.polanest.web.pl. in January and February 2009. Additionally, data were collected by phone in randomly chosen hospitals. In total, questionnaires were sent to 398 hospitals with maternity units and to 34 anaesthesiologists interested in the survey.

The questionnaire consisted of three parts: the first one concerned hospital characteristics, the second – anaesthesia for Caesarean sections, and the third one – obstetric anaesthesia (the questionnaire available from the author). 

RESULTS

Ninety-eight (24%) questionnaires were answered, including 77 in writing and 21 by phone. The analysis of answers according to the specificity of hospitals is presented in Table 1.

Only 10 regional hospitals employed obstetric anaesthesiologists. Amongst the hospitals with 500-1000 deliveries a year, which was the biggest group represented in the survey, only one employs anaesthesiologists at the maternity unit. In the group of hospitals with 1000-2000 deliveries/year, anaesthesiologists are employed in 6 hospitals (19%), in centres with >2000 deliveries/year – only in 3 (12%).

Before elective Caesarean sections, premedication is routinely used in 37 hospitals (38%), in 34 – always, in 2 before general anaesthesia and in 1 – only when time permits. In cases of emergency Caesarean sections, premedication is used in 32 hospitals (33%): in 30 – always, in 1 – only before general anaesthesia and in 1 – when there is enough time.

In hospitals where premedication is applied, the commonest drugs used were: ranitidine – 19 (51%), sodium citrate – 16 (43%), metoclopramide – 14 (37%) and benzodiazepines – 4. In few hospitals, atropine, omeprazole, ondansetron and hydroxyzine were used. The commonest combination was ranitidine with metoclopramide – 10 (27%) and metoclopramide with sodium citrate – 5 (13%) hospitals. In 5 questionnaires, the respondents additionally stressed that premedication was ordered by obstetricians.

In 91 hospitals (93%), additional examinations are ordered before elective Caesarean sections, in 2 – data from pregnancy charts are used, in 5 – no examinations are required. The most frequently performed tests include TBC (100%), concentration of electrolytes (25%), clotting parameters (25%), blood glucose levels (21%). Before emergency Caesarean sections, examinations are carried out in 76 hospitals (77%), in 20 (20%) hospitals, no examinations are required and in two – pregnancy charts are used. The examinations concern TBC (100%), electrolytes (72%), clotting parameters (12%), and glucose (10%).

The commonest set of examinations includes TBC, clotting parameters and concentration of electrolytes: in 67 hospitals for elective sections and in 59 for emergency sections. TBC and clotting parameters were assessed in 11 hospitals prior to elective Caesarean sections and in 8 – for emergency procedures; TBC with electrolytes were tested in 8 hospitals before elective and in 5 before emergency sections. The selected blood tests were performed in 8 hospitals before elective procedures and in 8 before emergency sections.

Additional tests were conducted: on surgery day in 12 hospitals (13%), within 3 preoperative days – in 13 (14%), within 1 week – in 26 (28%), within 2 preoperative weeks – in 19 (21%) and within 1 month – in 10 (11%).

According to over half of respondents, the lowest acceptable platelet count to perform regional anaesthesia was 100 G L-1. Interestingly, 30% of hospitals perform anaesthesia at 50 – 100 G L-1 (Fig. 1).

Only in few hospitals, Caesarean sections were performed under epidural or combined subarachnoid-epidural anaesthesia, both for elective and emergency procedures. The majority of elective surgeries were performed with subarachnoid anaesthesia (Fig. 2).  

According to the respondents, the commonest drugs for subarachnoid anaesthesia were as follows: 0.5% bupivacaine – 57 (58%) hospitals, bupivacaine and fentanyl – 34 (35%), bupivacaine and morphine – 3 (3%) and 5% lidocaine – 3 (3%) hospitals. Epidural anaesthesia for Caesarean sections was most frequently performed using 0.5% bupivacaine (83%), 0.75% ropivacaine (6%) and 2% lidocaine (6%). Additionally, fentanyl (22%) and adrenaline (6%) were used.

In the postoperative period, the decisions regarding pain management, fasting or length of remaining in the flat supine position were made by gynaecologists and midwives. However, there are also some differences in management within the anaesthetic team (answers “at the anaesthetist’s discretion”). 

After Caesarean sections, flat positioning is not required in 25 of all hospitals involved. In 22 hospitals patients have to lie flat for 6 h, in 29 – for 12 h whereas in 13 – for 24 h. The “until block has subsided” answers were obtained from 4 hospitals; in single cases, this depended on the decision of an anaesthesiologist or gynaecologist. 

The question whether the patients should be fasting after surgery was positively answered by 73 (74%) hospitals, negative answers were given by 13 (13%). In 3 hospitals (3%), patients may receive water for drinking. In 9 cases, there were no answers to this question. The parturients are left without food or drink for 24 h in 20 (27%) hospitals, for 6 h – in 10 (14%), until block subsidence – in 3 (4%) and for 48 h – in 2 (3%). In one hospital, water is allowed after 2 h and solid food after 6 h; in still another one – water after 6 h and solid food after 24 h. According to one respondent, patients are fed orally once peristalsis has returned.

Analgesics are injected in the postoperative period in 88% of hospitals. In 25% – they are used for 1 day, in 28% – for 2 days; 10% of respondents did not give answers.

Rectal suppositories are used in 8% and tablets in 13% of hospitals. Noteworthy, in 23% of hospitals, obstetricians decide about postoperative pain management; petidine is preferred in 36% of hospitals. The commonest combinations of drugs used are paracetamol and ketoprofen administered regularly and pethidine on patient`s demand – 17% as well as ketoprofen and metamizole with or without pethidine – 16% of hospitals (Fig. 3).

DISCUSSION

Only a few hospitals, even those with a high number of deliveries, employ obstetric anaesthesiologists. In many Polish hospitals, Caesarean sections are not performed on an elective basis and anaesthesiologists are informed on short notice. Therefore, patients are not thoroughly prepared and the method of anaesthesia cannot be properly chosen.

According to the American guidelines, pregnant women before elective Caesarean sections may receive solid food 6-8 h before the procedure and fluids without solid particles should be stopped 2 h before surgery, unless there are specific contraindications, e.g. morbid obesity or diabetes mellitus delaying gastric emptying. Moreover, before the procedure, agents neutralizing the gastric contents without particles, e.g. sodium citrate, blockers of H2 receptors and/or metoclopramide should be considered [1].

According to the British guidelines, women should receive neutralizing agents, blockers of H2 receptors or proton pump inhibitors and anti-emetics [2].

In Poland, premedication before Caesarean section is applied only in some hospitals, which increases the risk of regurgitation, particularly when general anaesthesia is needed. In risk groups, premedication before emergency Caesarean sections can be administered orally at regular intervals (e.g. ranitidine every 12 h and metoclopramide every 8 h).

Due to the lack of clear guidelines regarding necessary pre-surgery laboratory tests in healthy women, the examinations are mostly ordered (according to international standards) unnecessarily as in many cases, the data from pregnancy charts might be used.

According to the American guidelines, the platelet count and blood cross-matching tests are not required in healthy pregnant women; following the British guidelines, pregnant women should have haemoglobin levels determined [1, 2]. In cases of healthy women with normal pregnancy, clotting tests and cross-matching tests should not be performed or blood groups determined. According to the Polish National Health Fund guidelines, in the last trimester of pregnancy, gynaecological appointments should be made every 3 weeks and TBC performed every second visit (every 6 weeks) [3]. The blood group is commonly determined at the beginning of pregnancy and results are recorded in pregnancy charts.

To date, it has been thought that the safe number of blood platelets is 100 G L-1; recently, lower values have also been accepted (75 G L-1), unless symptoms of haemorrhagic diaphesis are observed or the history is positive [4].

At present, the commonest anaesthesia for both elective and emergency Caesarean sections in the developed countries is block anaesthesia (considered the method of choice), mainly due to higher safety for a parturient and a newborn compared to general anaesthesia [1, 2].

Many anaesthesiologists and obstetricians believe that general anaesthesia should be administered in conditions threatening the foetus, as its time is shorter than that of block anaesthesia. Yet the experienced anaesthetist performs the block anaesthesia quickly; in the majority of cases, the method is safer, results in lower incidence of thromboembolic complications and reduced postoperative pain. General anaesthesia requires the preparation of a large number of agents in short time, which is likely to be associated with errors. This method increases the risk of regurgitation, blood loss, and creates a high risk of wakening during the procedure; moreover, the risk of intubation failure in pregnant women is 10 times higher than in non-pregnant patients.

Nowadays, in the developed countries the commonest agent of subarachnoid anaesthesia for Caesarean section is 0.5% bupivacaine. Opioids, preferably of long-lasting action are also recommended, which improves the quality of anaesthesia and reduces postoperative pain [1, 2, 5]. According to respondents, less than 50% of hospitals use adjuvants to local anaesthetics during anaesthesia for Caesarean sections.

In many hospitals, oral feeding and pain management are rarely introduced during the first postoperative day; therefore, troublesome infusions and drips have to be administered. In many cases, ambulation of patients is delayed, which is unfavourable due to the risk of thromboembolic disease and care of a neonate.

Since the flat positioning brings relieve in post-puncture headaches, it is generally accepted that lying down after subarachnoid anaesthesia also prevents post-puncture headaches. However, this has not been confirmed by any studies and the management is no longer recommended [6].

At present, there are no contraindications for early oral feeding after abdominal surgery, unless the alimentary tract continuity has been disrupted; this also regards Caesarean sections. The beneficial effects of early feeding on the postoperative course are widely documented [7, 8, 9].

According to the guidelines of the Polish Society of Anaesthesiology and Intensive Therapy, pain management should be multimodal, i.e. various methods and various agents should be combined to achieve the best action and avoid side effects. It has been demonstrated that moderate and severe postoperative pain is experienced by about 80% of patients treated with intramuscular opioids on demand. The patient-controlled analgesia or epidural analgesia is much more effective [10]. In the United States and Europe, long-acting opioids (morphine or diamorphine) are mostly recommended for pain management after Caesarean section under block anaesthesia, subarachnoidally or epidurally [1, 2, 11, 12]. At the end of surgery, paracetamol and/or non-steroidal anti-inflammatory drugs (NSAIDs) are administered as rectal suppositories or intravenously [13]. In the postoperative period, patients receive regularly paracetamol and oral NSAIDs or intramuscular/oral opioids.

CONCLUSION

In Poland, there are no uniform guidelines for preparation, anaesthesia and treatment of parturients undergoing Caesarean sections.

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REFERENCES

1.     Practice guidelines for obstetric anesthesia. An updated report by the American Society of Anesthesiologists task force on obstetric anesthesia. Anesthesiology 2007; 106: 843–863.

2.     National Institute for Health an Clinical Excellence. Intrapartum care. Care of healthy women and their babies during childbirth,  http://www.nice.org.uk/nicemedia/pdf/CG013NICEguideline.pdf.

3.     Narodowy Fundusz Zdrowia, Mazowiecki Oddział Wojewódzki w Warszawie: Plan wizyt u lekarza i badań lekarskich, http://www.nfz-warszawa.pl/index/pacjent/mama/plan.

4.     Douglas MJ: Platelets, the parturient and regional anesthesia. Int J Obstet Anesth 2001; 10: 113-120.

5.     Cowan CM, Kendall JB, Barclay PM, Wilkes RG: Comparison of intrathecal fentanyl and diamorphine in addition to bupivacaine for Cesarean section under spinal anaesthesia, Br J Anaesth 2002; 89: 452-458.

6.     Sudlow CLM, Warlow CP: Posture and fluids for preventing post-dural puncture headache, Cochrane Database of Systematic Reviews 2001, Issue 2. Art No. CD001790.

7.     Mangesi L, Hofmeyr GJ: Early compared with delayed oral fluids and food after caesarean section. Cochrane Database of Systematic Reviews 2002, Issue 3. Art. No. CD003516.

8.     Kovavisarach E, Atthakom M: Early versus delayed oral feeding after cesarean delivery. Int J Gynecol Obstet 2005; 90: 31-34.

9.     Mulayim B, Celik NY, Kaya S, Yanik FF: Early oral hydration after cesarean delivery performed under regional anesthesia. Int J Gynecol Obstet 2008; 101: 273-276.

10.    Dolin SJ, Cashman JN, Bland JM: Effectiveness of acute postoperative pain management: I. Evidence from published data. Br J Anaesth 2002; 89: 409-423.

11.    Dahl JB, Jeppesen IS, Jørgensen H, Wetterslev J, Møiniche S: Intraoperative and postoperative analgesic efficacy and adverse effects of intrathecal opioids in patients undergoing cesarean section with spinal anesthesia: a qualitative and quantitative systematic review of randomized controlled trials. Anesthesiology. 1999; 91: 1919-1927.

12.    Weigl W, Bieryło A, Krzemień-Wiczyńska Ś, Mayzner-Zawadzka E: Analiza porównawcza podpajęczynówkowego zastosowania fentanylu lub morfiny w terapii bólu po operacji cięcia cesarskiego. Anaesthesiol Intensive Ther 2009; 39: 28-32.

13.    Lim NL, Lo WK, Chong JL, Pan AX: Single dose diclofenac suppository reduces post-Cesarean PCEA requirements. Can J Anaesth 2001; 48: 383-386.

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address:

*Jacek Furmanik
Oddział Anestezjologii i Intensywnej Terapii
Tczewskie Centrum Zdrowia
ul. 30-go Stycznia 57, 83-110 Tczew
tel.: 0-58 777-67-30

received: 22.12.2009
accepted: 25.02.2010