Conversion of regional to general anaesthesia at caesarean section: increasing the use of regional anaesthesia through continuous prospective audit

Background: Anaesthetic-related maternal deaths have largely been attributed to complications of general anaesthesia. In our unit a retrospective audit conducted between 1997 and 2002 showed a 9.4% conversion rate to general anaesthesia for caesarean sections amongst women with epidural catheters in-situ. The Royal College of Anaesthetists has stated that <3% of cases should need conversion to general anaesthesia. To improve our figures, from 2004 to 2007 we prospectively audited all caesarean sections requiring general anaesthesia. Methods: Data were collected on the number of caesarean sections, initial anaesthetic technique used, need for conversion either pre- or intra-operatively and the use of labour epidural analgesia, where an epidural had been in-situ. Results: There were 2273 caesarean sections during the audit period. Neuraxial anaesthesia rates were for elective cases 95.3% (2004), 96.3% (2005), 98.3% (2006) and 98.2% (2007) and for emergency cases 82.3% (2004), 88.6% (2005), 87.0% (2006) and 85.7/0 (2007). Common reasons given for not using a regional technique were urgency of delivery (category 1) or anticipated large blood loss. Conversion rates from regional to general anaesthesia for elective cases were 0.8% (2004), 2.5% (2005), 0.5% (2006) and 0% (2007), and for emergencies 7.8%, (2004), 2.7% (2005), 3.7% (2006) and 5.4% (2007). Improvements were seen in all but category-1 caesarean sections. Conclusions: Prospective audit has been associated with improved rates for neuraxial anaesthesia and reduced need for conversion to general anaesthesia in all but category-1 caesarean sections. The Royal College of Anaesthetists standards may need to be reviewed to become category-specific. (C) 2009 Elsevier Ltd. All rights reserved.