It is recognised that to gain experience and competence in providing a safe general anaesthetic for a Category 1 Caesarean section can be difficult for a trainee new to the speciality



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It is recognised that to gain experience and competence in providing a safe general anaesthetic for a Category 1 Caesarean section can be difficult for a trainee new to the speciality. Discuss ways in which this difficulty can be overcome.
Obstetric anaesthesia is regarded by many as being a particularly stressful subspecialty, and few situations epitomise that opinion better than a category 1 caesarean section under general anaesthesia (GA). To be the anaesthetist attending such an emergency, a trainee must possess the clinical resourcefulness and mental stamina to deal with the crisis at hand, while displaying a modicum of calm in the presence of an often terrified patient. As a current core training level 2 (CT2) doctor, I spent most of my first year in anaesthesia wondering how I could ever survive the world of obstetrics, where emotions run high and fear of lawsuits lurk behind the smallest of mistakes. However, my senior colleagues appreciated my apprehension, and showed enormous attention to my clinical progression during training. By the time I began to work obstetric on-calls independently, I felt cautiously prepared for the challenge of the job. My heart rate still doubles when I attend a category 1 GA section but I no longer worry about my ability to cope. I now take this opportunity to reflect on a few particular aspects of my training that helped me develop my confidence, and to consider the broader reasons for why gaining this confidence can be a major challenge for trainees. The key areas I have identified are that (1) general training in obstetrics is time-limited, (2) the opportunities for GA are infrequent, (3) the GA technique is unfamiliar, and (4) the negative attitudes surrounding obstetrics can have a detrimental effect towards learning. I will discuss these factors in turn, and share my thoughts for how each challenge can be mitigated, at times drawing from my own personal training experience.
Core training in anaesthetics has a steep learning curve and a formidable list of expectations to achieve within twenty-four European Working Time Directive (EWTD)-compliant months. Prior to appointment to an ST3 post, we must be able to independently provide obstetric anaesthetic services, including emergency GA, with senior support being up to thirty minutes away. However, most of us are only introduced to obstetrics in our CT2 year, often at a point when we are also under pressure to complete our e-portfolio, produce audits and quality improvement projects, and succeed in the Primary FRCA exam. Even with the best intentions and motivation, these other professional commitments can become mental distractions when trying to learn a new job. In some hospitals, the regimen for obstetric training is that each trainee is assigned one or two supervised sessions per week until the pre-written rota says that it is time for them to go solo. The OAA / AAGBI Guidelines for Obstetric Anaesthetic Services 2013 recommends a minimum of 20 supervised sessions within a 4-month period before immediate supervision can be removed.1 In reality, most trainees are likely to need more sessions and longer time, in part because intermittent exposure to a new specialty does not lend well to the retention of newly acquired knowledge and skills. A better training strategy is full immersion of the trainee into obstetric work. This was the approach that was adopted at my hospital and for two months, I worked exclusively within the delivery suite and obstetric theatre. My ability to perform epidurals and spinals improved quickly because I practiced them almost every day. I also became acquainted with nearly every obstetrician, midwife, and operating department practitioner (ODP), and I knew the contents of all the relevant cupboards in the anaesthetic room and delivery suite. This familiarity with colleagues and work environment proved to be invaluable during future disaster situations. Immersion learning is a teaching strategy that was originally introduced for learning foreign languages.2 Developed in Canada in the mid 1960s to encourage English-French bilingualism,2 it has been repeatedly shown to achieve better and faster fluency of speech compared to enrolling in language classes.3 While there are minimal formal studies which examine the efficacy of immersion learning in the context of medical education, my anecdotal experience of it has lead to a positive opinion of its merits.
Unfortunately, despite the learning benefits of my two-month immersion, I still only encountered one GA caesarean section during that time. There were two occasions where a patient was rushed to theatre for a category 1 section but the consultant anaesthetist insisted that we perform a spinal instead. Regional anaesthesia is becoming ever more dominant in obstetric practice and in 2013, the Hospital Episode Statistics (HES) data reported that only 8% of all caesarean sections in England and Wales were performed under GA.4 In 2014, the 5th National Audit Project (NAP5) published an unflattering association between obstetrics and accidental awareness during GA.5 Since then, there seems to have been an even greater push to avoid GA if at all possible. Regrettably, for a trainee who knows that GA is sometimes the only option, it is unhelpful to find that the opportunities to learn it under supervision are being actively pushed away. My strategy to combat this deficit in clinical experience was to repeatedly visualise the scenario of giving a GA for a category 1 section, and to mentally play out each sequential task that would be required. A typical mental drill occurred as follows:

  • Obstetric bleep buzzes and reads: “Category 1 LSCS to delivery suite”

  • Run to obstetric theatre, remove emergency drugs from fridge, draw up thiopental and suxamethonium

  • Greet the patient, take a succinct history (allergies, significant health problems, problems with GA), quickly assess mouth opening, and offer reassurance

  • Coordinate transfer to operating table and tilt to the left by 15 degrees

  • Secure and confirm IV access

  • Pre-oxygenate, place suction under pillow, and communicate details of rapid sequence induction to ODP (cricoid pressure, short handle laryngoscope, size 3 blade, size 7 tube, bougie at hand)

  • Verify that all team members are prepared to proceed

  • Induce anaesthesia, intubate, confirm tube position, and maintain anaesthesia

  • Inform obstetrician to commence surgery

This type of mental rehearsal, formally defined as the “cognitive rehearsal of a task in the absence of overt physical movement”,6 is a strategy that athletes and performing artists have used for decades to enhance the acquisition of particular skills in their disciplines.6,7 For instance, a ballet dancer who imagines herself performing the infamous thirty-two fouetté turns in Swan Lake has a better chance of succeeding compared to if she were to rely on physical practice alone. Mental rehearsal has been formally introduced in some surgical training curricula, and the results of two different randomised control studies show that the surgeons who engage in mental rehearsal perform better in laparoscopic simulations than their colleagues in the control groups.8,9 With the ever diminishing number of real-life opportunities to practice GA in obstetrics, anaesthetic trainees should be strongly encouraged to entertain frequent mental rehearsal of the situation to supplement their limited clinical exposure. As a learning resource, it has no financial costs, and can be practiced at any time or place. My daily habit of vividly imagining a category 1 section helped me gain a degree of emotional readiness to manage the situation in real life. The meticulous attention to detail during these mental rehearsals also meant that basic but crucial tasks such as tilting the table and placing suction under the pillow became ingrained into my subconscious. As a result, I could almost perform the “little things” on auto-pilot, leaving my headspace uncluttered, panic-free, and available to focus on the bigger picture at hand.
Another challenge for trainees in obstetrics is that not only is GA an uncommon occurrence, but the prescribed technique for GA is now rarely practiced elsewhere in anaesthetics. In the UK, the convention is to perform a rapid sequence induction using thiopental and suxamethonium.10,11 However, in non-obstetric practice, the use of thiopental has rapidly declined,11 and prior to beginning my obstetric training, every patient I had ever anaesthetised had been induced with propofol. With little to no experience in the use of thiopental, a pressurised category 1 section is the last scenario in which any trainee would wish to start experimenting. An easy solution to this problem would be to either encourage more practice with thiopental outside of obstetric work, thereby increasing confidence in its use, or to switch to the use of propofol within obstetrics. Arguments for staying with thiopental are its faster onset of action and its slower redistribution (and therefore longer duration of action) compared to propofol.12 Additionally, it is associated with less post-induction hypotension,13 and is therefore less likely to disrupt placental perfusion. One counter-argument is that thiopental requires dissolution and reconstitution, which consumes precious time in a situation where the difference between life and death could be a matter of minutes. NAP5 also reported an unnerving drug administration error where, due to their similar appearances in a syringe, antibiotics were given instead of thiopental5 – a problem that is far less likely to occur with propofol. Propofol is cheaper than thiopental13 and outside of the UK, it is believed to already be the primary induction drug of choice in obstetrics.14 Despite theoretical concerns about placental perfusion with propofol, studies which compare Apgar scores after GA caesarean sections show no statistically significant difference between inductions with thiopental versus propofol.15,16 Although this drug debate is a topic of much enthusiasm, it is probable that we will not achieve a nationally agreed consensus within the near future. In the meantime, anaesthetic departments at individual hospitals should make a local commitment to one drug or the other, and train their junior anaesthetists accordingly. Departments which advocate the use of thiopentone should encourage trainees to use it non-obstetric emergencies as well, thereby allowing more opportunities for them to gain a feel for the drug.
As a subspecialty, obstetric anaesthesia possesses many unique and rewarding qualities, but it is not every anaesthetist’s cup of tea. Although the discussion thus far has focused on time and experience limitations, sometimes it can be our own attitudes that become the greatest detriment to our learning. It is common knowledge with medicine that tensions exist between anaesthetists, obstetricians, and midwives, and these can lead to stress, conflict, and a negative emotional work environment. Stories about midwifery inadequacies are an unfortunately popular topic of corridor and coffee room gossip, and anaesthetists contribute their fair share toward this pastime. While venting frustrations is a common way of dealing with stress, hearing too many derogatory comments about midwives can breed notions of disrespect and even contempt in an impressionable trainee. Trainees who categorically decide that they hate obstetrics often attempt to avoid the delivery suite, an effort which some non-obstetric anaesthetists will even jokingly encourage. This “see no evil, hear no evil” behaviour is especially dangerous because when disasters like a category 1 section strike, the trainee will have no warning. This problem stems from a longstanding inter-disciplinary rivalry and while gossip is unprofessional and discouraged, being exposed to it as a trainee is unavoidable. However, obstetric anaesthetists and people in roles of training responsibility could lead by example and demonstrate a non-cynical approach toward obstetrics. Trainees should also be reminded of the GMC duties of a doctor, which state that patient care is their first concern,17 and it takes precedence over petty conflicts with other staff. As part of providing a good standard of care, trainees must be held accountable for their own learning, and this may require them to be selective about which colleagues and attitudes they choose to emulate. During my obstetric training, I had the pleasure of frequently working with one particular consultant who also happened to be the lead clinician for obstetric anaesthesia. Under her mentorship, I copied her dedicated and proactive work ethic, and forged friendly relations with the obstetricians and midwives. Now, whenever I work an obstetric on-call, I make regular visits to delivery suite to touch base with the shift co-ordinator, and I pre-emptively check the blood results, scan reports, and old anaesthetic charts of any potentially complex patient. I never argue when asked to site a cannula (no matter how easy the veins look), and I use the opportunity to ask a few pertinent anaesthetic questions. As a result of these industrious habits, I have rarely been caught off guard when a category 1 section occurs, and I will endeavor to maintain these habits for the remainder of my career.
Giving a GA during an obstetric emergency is and always will be a stressful situation for a new trainee. With the reducing frequency of GA cases and training time being squeezed by the EWTD, it is statistically improbable that trainees will experience an adequate number of category 1 caesarean sections before they start working independently. In the face of certain unavoidable difficulties, gaining competence in obstetric anaesthesia requires active commitment and dedication from both trainers and trainees alike. My self-taught rituals of mentally rehearsing a category 1 section helped me develop a high panic threshold and emotional steel for the job. Clinical vigilance during obstetric on-calls meant that I was mentally prepared for most obstetric crises. There were attentive and conscientious colleagues in my department who earned my respect and taught me the value of a positive and professional attitude. My training was delivered as an immersive experience, which lead to the rapid acquisition of technical skills, inter-professional relationships, and environmental familiarity. Reflecting on my training has given me new insight into the process of learning and an appreciation for all the effort that my department has invested in me. As my career progresses, I will eventually have trainees of my own to educate. I will aspire to be for them the type of mentor that my current colleagues have been for me, and I will aim to set good examples of professional behaviour to motivate future trainees to succeed.

References:



  1. Association of Anaesthetists of Great Britain & Ireland, Obstetric Anaesthetists’ Assocation. OAA / AAGBI guidelines for obstetric anaesthetic services 2013. https://www.aagbi.org/sites/default/files/obstetric_anaesthetic_services_2013.pdf [accessed February 2016].

  2. Genesee F. Second language learning through immersion: a review of U.S. programs. Rev Educ Res 1985;55;541-561.

  3. Freed BF, Segalowitz N, Dewey DP. Context of learning and second language fluency in French: comparing regular classroom, study abroad, and intensive domestic immersion programs. Stud Second Lang Acquis 2004;26:275-301.

  4. Health and Social Care Information Centre. NHS Maternity statistics – England 2012–13. www.hscic.gov.uk/catalogue/PUB12744 [accessed February 2016].

  5. Royal College of Anaesthetists. 5th National Audit Project of the Royal College of Anaesthetists. Accidental awareness during general anaesthesia in the United Kingdom and Ireland; 2014. http://nap5.org.uk/NAP5report [accessed February 2016].

  6. Rogers RG. Mental practice and acquisition of motor skills: examples from sports training and surgical education. Obstet Gynecol Clin North Am 2006;33:297-304.

  7. Lejeune M, Decker C. Mental rehearsal in table tennis performance. Percept Mot Skills 1994;79:627-641.

  8. Arora S, Aggarwal R, Sirimanna P, Moran A, Grantcharov T, Kneebone R, Sevdalis N, Darzi A. Mental practice enhances surgical technical skills: a randomized controlled study. Ann Surg 2011;253:265-270.

  9. Louridas M, Bonrath EM, Sinclaire DA, Dedy NJ, Grantcharov TP. Randomized clinical trail to evaluate mental practice in enhancing advanced laparoscopic surgical performance. Br J Surg 2015;102:37-44.

  10. McGlennan A, Mustafa A. General anaesthesia for caesarean section. Contin Educ Anaesth Crit Care Pain 2015;15:148-151.

  11. Murdoch H, Scrutton M, Laxton CM. Choice of anaesthetic agents for caesarean section: a UK survey of current practice. Int J Obstet Anesth 2013;22:31–35.

  12. Sørensen MK, Dolven TL, Rasmussen LS. Onset time and haemodynamic response after thiopental vs. propofol in the elderly: a randomized trial. Acta Anaesthesiol Scand 2011;55:429-434.

  13. Moore J, Bill KM, Flynn RJ, McKeating KT, Howard PJ. A comparison between propofol and thiopentone as induction agents in obstetric anaesthesia. Anaesthesia 1989;44:753–757.

  14. Rucklidge M. Up-to-date or out-of-date: does thiopentone have a future in obstetric general anaesthesia? Int J Obstet Anesth 2013;22:175–178.

  15. Tumukunde J, Lomangisi DD, Davidson O, Kintu A, Joseph E, Kwizera A. Effects of propofol versus thiopental on Apgar scores in newborns and peri-operative outcomes of women undergoing emergency cesarean section: a randomized clinical trail. BMC Anesthesiol 2015;15:63.

  16. Zamora E, Redondo JA, Catalán PA, Carrillo F. Effects on the newborn infant of thiopental and propofol used in anesthetic induction in cesarean section. Rev Esp Anestesiol Reanim 1994;41:20-22.

  17. General Medical Council. Good Medical Practice; 2013. http://www.gmc-uk.org/guidance/good_medical_practice.asp [accessed February 2016].


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