Follow-up of mothers after obstetric analgesia and anaesthesia is important for the woman, the individual anaesthetist and the hospital - and for obstetric anaesthesia as a whole. In an ideal world, all anaesthetists would aim to follow up their own patients. This ideal is often not practical; there fore follow-up has to become part of the routine of an obstetric anaesthetic service. At local, national and international levels, data collection enables anaesthetists to assess risk and monitor standards of care.
Problems and special considerations
The purpose of routine follow-up is to provide feedback on the anaesthetic care received, and to identify complications. Follow-up of women who have had analgesia or anaesthesia administered by the anaesthetist should ideally be carried out within 24 hours. However, it may be difficult to see all women before they are discharged from hospital. This early discharge to the community means that anaesthetists must rely on midwifery, obstetric and general practitioner colleagues to refer back any problems. Areas that anaesthetists might wish to follow up can be divided into anaesthetic interventions perceived to be uncomplicated, and those where there was a problem.
Management options
After an uncomplicated intervention
Follow-up of this group is important, to ensure that women are satisfied with their treatment and, if not, why not. The follow-up interview gives the woman a chance to voice her opinion of the treatment she received. The anaesthetist should be responsive to criticisms of the service as a whole, since many women make their comments in order to help improve the service to others.
Questions to be asked at follow-up could include the following:
• Relating to analgesia in labour - Were you satisfied with the pain relief you received for the first and second stages of your labour? Were you able to mobilise during labour where appropriate? Has your sensation returned to normal? Have you a headache? Have you any comments about the care that you received?
• Relating to regional anaesthesia - Were you satisfied with the anaesthesia that you received? Did you feel any discomfort or pain at any time during the caesarean section? Have you had good postoperative pain relief? Are you mobile? Are you able to pass urine? Has your sensation returned to normal? Have you a headache? Have you any comments about the treatment that you received?
• Relating to general anaesthesia - Did you have a good sleep? Do you remember going to sleep? Do you remember waking up? Do you remember dreaming or waking up during the operation? Do you have a sore throat, sore muscles or headache? Were you in pain when you woke up? Has the postoperative pain relief been adequate (at rest and on movement)? Have you had nausea or vomiting? Have you any comments about your treatment?
After a problem with anaesthesia or analgesia
The most common problems associated with an anaesthetic intervention are:
• Difficulty in siting a regional analgesic
• Accidental dural puncture
• Paraesthesia during insertion of a spinal or epidural, and/or neurological symptoms afterwards
• Poor analgesia in labour (especially in the second stage if the epidural was inadequately topped up)
• Pain during caesarean section or operative delivery
Patients with the above problems should always be followed up, ideally by a consultant obstetric anaesthetist. Continuity of care is important for these patients, and involvement of other specialists, where appropriate, should occur at an early stage. For example, neurological consultation should be sought when there is any doubt as to the cause of a headache or neurological deficit. Early involvement of a clinical psychologist with a special interest in post-traumatic stress disorder following childbirth (if one is available) may be useful when there has been a painful experience during delivery.
Communication with the women, their partners and the midwifery and obstetric staff is essential to ensure that any problems, however small, are dealt with quickly and comprehensively. All women who have had a problem should have the opportunity to see the consultant obstetric anaesthetist after discharge from hospital. A follow-up visit at around 6-8 weeks post-delivery is useful for both the women and the obstetric anaesthetist. This consultation allows the lines of communication to remain open and offers the opportunity for a frank and open dialogue about any problems.
Key points
• Follow-up is important in both straightforward and complicated cases.
• Follow-up does not end when the woman leaves hospital.
• Consultant anaesthetic involvement is important.
• Communication is vital between all the professional groups involved.
Further reading
Cook TM, Counsell D, Wildsmith JA; Royal College of Anaesthetists Third National Audit Project. Major complications of central neuraxial block: report on the 3rd National Audit Project of the Royal College of Anaesthetists. Br J Anaesth 2009; 102: 179-90.
Jenkins JG. Some immediate serious complications of obstetric epidural analgesia and anaesthesia: a prospective study of 145,550 epidurals. Int J Obstet Anesth 2005; 14: 37-42.
Nguyen T, Slater P, Cyna AM. Open vs specific questioning during anaesthetic follow-up after Caesarean section. Anaesthesia 2009; 64: 156-60.