OAA Large Project Grant

Background
Every year approximately 2% of women need to receive a general anaesthetic (GA) in order to safely deliver their babies by caesarean section. In 2015 a national audit project conducted by the Royal College of Anaesthetists (NAP5) revealed that 1 in 670 of such women reported that they were not fully asleep at some point during their surgery. This figure is much higher than the number of non-pregnant patients who report awareness under general anaesthesia, which is closer to 1 in 19,000. The reasons for the increased likelihood of awareness in pregnant women are incompletely understood.

NAP5 identified cases of awareness by relying on patients coming forward to self-report experiences. It may be that this method underestimates the true incidence of awareness under GA, because some patients might not present to health services again or not wish to disclose the information. Other research into this problem has involved directly questioning patients receiving a GA about what they can remember shortly afterwards, using a tool known as the Brice questionnaire. These studies have reported a much higher risk of recall of events whilst under anaesthesia of 1 in 600 in the non-pregnant population.

We do not currently know what proportion of pregnant women might recall events whilst under GA if screened using the Brice questionnaire. It may be much higher than reported in NAP5, as it is for the non-pregnant population. We also do not know what the psychological consequences of such awareness events are on mothers in the months following childbirth.

Aims
The aim of this research is to use the Brice questionnaire to determine the proportion of women who experience some form of awareness whilst under anaesthesia for childbirth-related surgery. This study also aims to explore the long term psychological impact of awareness under anaesthesia on mothers. This is important because we may be able to identify more women who experience awareness and offer better psychological support for them in the long term, potentially reducing harm.

Design
This is an observational study in which women receiving GA for childbirth-related surgery will be asked Brice questions at various intervals after their anaesthetic. They will be asked questions on the day of surgery (day 0) and on the next day (day 1) whilst still in hospital. They will be contacted by telephone on day 30 to complete the questionnaire again. Any women reporting awareness will be fed into a pathway of supportive care and receive screening for evidence of psychological harm at 1, 3, 6, 9 and 12 months after surgery. Individual cases will be reviewed by an expert panel to identify where lessons can be learnt and conclusions based on data in this population will be disseminated widely.

The implications of these results will be a greater understanding of the risks of awareness under anaesthesia for both clinicians and patients, and the development of robust pathways of care for these patients designed to reduce the risk of long term psychological harm.