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 sectionunder 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 inanaesthesiawondering 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 colleaguesappreciated my apprehension, and showed enormous attention to my clinical progression during training. Bythe time I began to work obstetric on-calls independently, I felt cautiously prepared for the challenge of the job. My heart rate still doubleswhen I attenda 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 techniqueis unfamiliar, and (4) the negative attitudes surrounding obstetricscan 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 curveand 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-writtenrota 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 specialtydoes 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 foreignlanguages.2 Developed in Canada in the mid 1960s to encourage English-French bilingualism,2it has been repeatedly shown to achieve better and faster fluency of speech compared to enrolling inlanguage 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 thelearningbenefits of my two-month immersion, I still only encountered one GA caesareansection 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 anaesthesiais 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) publishedan unflattering association between obstetrics and accidental awareness during GA.5 Since then, there seems to have been an even greater push to avoid GAif 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 supervisionare being actively pushed away. My strategy to combat this deficit in clinical experience was to repeatedly visualise the scenario of giving a GA for acategory 1 section, and to mentally play out each sequential task that would be required. A typical mental drill occurred as follows:

  • Obstetricbleepbuzzes 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 ofrapid 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 ofparticularskillsin their disciplines.6,7 For instance, a ballet dancer who imagines herself performing the infamous thirty-twofouetté turns inSwan Lakehas 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 oftwo different randomised control studiesshow that the surgeons who engage in mental rehearsal performbetter 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 situationin real life. The meticulous attention to detail during these mental rehearsalsalso 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, leavingmy 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 useof 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 withthiopental 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,13and is therefore less likely to disrupt placental perfusion. One counter-argument is that thiopental requires dissolution and reconstitution, which consumesprecious 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, antibioticsweregiven 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 primaryinduction 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 betweeninductions with thiopental versus propofol.15,16 Although this drug debateis 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 thiopentoneshould 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 hasfocused on timeand experience limitations, sometimes it can beour own attitudes that become the greatest detriment to our learning. It is commonknowledge with medicine thattensions exist between anaesthetists, obstetricians, and midwives, and these can lead to stress, conflict, and a negative emotional work environment. Stories about midwifery inadequaciesare an unfortunately popular topic of corridor and coffee room gossip, and anaesthetists contribute their fair share toward thispastime. 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 whichsome 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. Thisproblem 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 responsibilitycouldlead by example and demonstrate anon-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 herdedicated 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 theseindustrious habits, I have rarely been caught off guard when a category 1 section occurs, and I will endeavor tomaintainthese 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 sectionhelped medevelopa high panic threshold and emotional steel for the job. Clinical vigilance during obstetric on-calls meant that I wasmentally prepared for most obstetric crises. There were attentive and conscientiouscolleagues 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 traininghasgiven me new insight into the processof learning and an appreciation for all the effort that my department has invested in me. As my career progresses, Iwilleventually 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:

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