The Queen Elizabeth Hospital King’s Lynn NHS Foundation Trust Clinical Guideline for Anaesthesia for Caesarean Section
Clinical Guideline Anaesthesia for caesarean section Author/s: R Jones, A Surendran Author/s title: Specialty Doctor, Consultant Anaesthetist Approved by: Anaesthetic Clinical Governance Committee Date approved: 18/06/2017 Review date: 18/06/202 Page 1 of 24
A Clinical Guideline For use in:
Theatres and Central Delivery Suite
By: Anaesthetists, Obstetricians, Midwives and Theatre Staff
For: Women who need caesarean delivery
Division responsible for document: Core Services
Key words: Anaesthesia, Caesarean section
Name of document author: R. Jones, A.Surendran
Job title of document author: Specialty Doctor, Consultant Anaesthetist
Name of document author’s Line Manager:
Sue Abdy
Job title of author’s Line Manager: Clinical Director, Theatre Services Group
Supported by: Anaesthetic Department
Assessed and approved by the: Clinical Guidelines Group
Date of approval: 18/06/2017
Ratified by or reported as approved to:
Anaesthetic Clinical Governance Committee, Obstetrics and Gynaecology Guidelines Group
To be reviewed before: This document remains current after this date but will be under review
18/06/2020
To be reviewed by: Lead Obstetric Anaesthetist
Reference: L33
Version No: V2
Description of changes: Entire guideline has been re-written with inclusion of charts
Compliance links: NICE, OAA, AAGBI
If Yes - does the guidance deviate from the recommendations of NICE? If so why?
Not applicable
This guideline has been approved by the Trust's Clinical Guidelines Group as an aid to the diagnosis and management of relevant patients and clinical circumstances. Not every patient or situation fits neatly into a standard guideline scenario and the guideline must be interpreted and applied in practice in the light of prevailing clinical circumstances, the diagnostic and treatment options available and the professional judgement, knowledge and expertise of relevant clinicians. It is advised that the rationale for any departure from relevant guidance should be documented in the patient's case notes. The Trust's guidelines are made publicly available as part of the collective endeavour to continuously improve the quality of healthcare through sharing medical experience and knowledge. The Trust accepts no responsibility for any misunderstanding or misapplication of this document.
The Queen Elizabeth Hospital King’s Lynn NHS Foundation Trust Clinical Guideline for Anaesthesia for Caesarean Section
Clinical Guideline Anaesthesia for caesarean section Author/s: R Jones, A Surendran Author/s title: Specialty Doctor, Consultant Anaesthetist Approved by: Anaesthetic Clinical Governance Committee Date approved: 18/06/2017 Review date: 18/06/202 Page 2 of 24
Contents page
1. Definitions of terms used
2. Anaesthesia for Caesarean Section
3. Pre- operative assessment
4. Consent
5. Pre Medication
6. Choice of technique
7. Preparation for all types of anaesthesia
8. Single shot spinal anaesthesia
9. Epidural top up anaesthesia
10. Spinal anaesthesia following inadequate epidural analgesia
11. General anaesthesia
12. Post-delivery measures
13. Post-operative analgesia
14. Post-operative care
15. Complications
16. Foetal Distress
17. Birthing partner in theatre
18. References
19. Appendix 1 Flow chart - OAA/ DAS failed tracheal intubation
20. Appendix 2 Flow chart – Anaesthesia options for caesarean section
21. Appendix 3 Flow chart – Anaesthetic considerations
22. Appendix 4 Regime for post-operative analgesia
23. Appendix 5 Monitoring compliance
24. Appendix 6 Equality impact
The Queen Elizabeth Hospital King’s Lynn NHS Foundation Trust Clinical Guideline for Anaesthesia for Caesarean Section
Clinical Guideline Anaesthesia for caesarean section Author/s: R Jones, A Surendran Author/s title: Specialty Doctor, Consultant Anaesthetist Approved by: Anaesthetic Clinical Governance Committee Date approved: 18/06/2017 Review date: 18/06/202 Page 3 of 24
1. Definitions of Terms Used
Anaesthesia is the loss of bodily feeling
Caesarean Section is a surgical incision into the uterus to deliver a baby.
2. Anaesthesia for Caesarean Section
The vast majority of Caesarean sections in the UK, both elective and emergency, are
performed under regional anaesthesia. General anaesthesia however is often indicated for
category one sections (i.e. when there is immediate threat to life of mother or foetus) and
when a regional technique is absolutely contra-indicated or has failed. Spinal anaesthesia
is often appropriate for urgent Caesarean section, although a previous Confidential
Enquiry into Stillbirths and Deaths in Infancy (CESDI) had deemed repeated attempts
inadvisable in the absence of significant risk factors for general anaesthesia.
All anaesthetic procedures and their follow-ups must be entered on the BadgerNet
electronic maternity records.
Classification of the urgency of Caesarean Sections:
Category Definition (at time of decision) Time standard from decision to delivery
1 Immediate threat to life of woman or foetus e.g.
Haemorrhage, cord prolapse, severe foetal
bradycardia
<30mins
2 Maternal or foetal compromise, not immediately life-
threatening, e.g. Breech contracting, obstructive
labour
Up to 75mins
3 Needing early delivery but no maternal or foetal
compromise e.g. Failure to progress Up to 24hrs
4 At a time to suit the woman and maternity team Elective
3. Pre-operative assessment
Even if the anaesthetist is presented with an unknown patient whose foetus is in extremis,
a focused assessment must not be omitted. Important points are:
Previous anaesthetics and family history of significant anaesthetic problems
Present and past medical history
Present and past obstetric history e.g.
o Pre-eclampsia
o Placental position in this pregnancy
o Past history of post-partum haemorrhage
Drug history and allergies.
REMEMBER TO ASK: HAS THE PATIENT HAD CLEXANE? TIME AND DOSE
The Queen Elizabeth Hospital King’s Lynn NHS Foundation Trust Clinical Guideline for Anaesthesia for Caesarean Section
Clinical Guideline Anaesthesia for caesarean section Author/s: R Jones, A Surendran Author/s title: Specialty Doctor, Consultant Anaesthetist Approved by: Anaesthetic Clinical Governance Committee Date approved: 18/06/2017 Review date: 18/06/202 Page 4 of 24
Airway assessment
Starvation time and antacid prophylaxis. It is appropriate in category 1 and 2 sections to administer an anaesthetic even when the patient is not starved
Blood results as appropriate
o FBC o U & Es and Coagulation tests are indicated only if there is any suggestion of
pre-existing kidney disease, pre-existing clotting anomalies or PET.
o G & S / Fast issue / Cross match as appropriate
o Where clinically appropriate DO NOT DELAY CATEGORY 1 AND SOME
CATEGORY 2 SECTIONS waiting for the blood results, but do ensure that
samples have been sent
4. CONSENT
Women must receive an explanation of the proposed anaesthetic technique, its limitations
and the possible complications and side effects as deemed acceptable by any reasonable
person. It must include the possibility of regional anaesthesia proving inadequate and the
measures that will be taken to remedy the situation. Written consent is not essential,
although the risks/benefits that have been discussed and the fact that oral consent was
obtained should be documented. A patient with capacity has an absolute right to refuse to
consent to medical treatment for any reason (rational or irrational). This pertains even
though the consequence may be her own death or serious handicap of the child she bears
(please see Trust guidelines on Consent)
1. Consent for general anaesthesia should include:
Sore throat
Muscle pains
Awareness
Dental damage
2. Consent for regional technique should include:
Failure
Inadequate block requiring conversion to general anaesthetic
Sensations to be expected
Hypotension
Nausea and vomiting
Shivering
Itching
Post dural puncture headache
Nerve injury
3. For either technique discuss
Analgesic suppository if used
Post-operative analgesic plan
The Queen Elizabeth Hospital King’s Lynn NHS Foundation Trust Clinical Guideline for Anaesthesia for Caesarean Section
Clinical Guideline Anaesthesia for caesarean section Author/s: R Jones, A Surendran Author/s title: Specialty Doctor, Consultant Anaesthetist Approved by: Anaesthetic Clinical Governance Committee Date approved: 18/06/2017 Review date: 18/06/202 Page 5 of 24
5. PRE-MEDICATION (see ‘L31 Antacid prophylaxis in Labour’ guideline)
Elective Caesarean Section Morning Cases
i. Ranitidine 150mg tablet orally at 2200 hrs the night before surgery
ii. Ranitidine 150mg tablet orally at 0700 hrs on the day of surgery
iii. 30mls of 0.3 Molar Sodium Citrate orally prior to start, confirmed as part of
the WHO checklist Afternoon Cases
iv. Treat as for morning cases with the addition of Ranitidine 150mg tablet
orally at 1200 hrs. (Total 3 doses)
Emergency Caesarean Section
Either
i. Ranitidine 50mg IM given at time of decision (takes 45mins to work)
unless Ranitidine 150mg orally has been given within the last 6 hours
Or
ii. Ranitidine 50mg IV diluted to 20mls with normal saline given over 5-
10mins (preferably with ECG monitoring)
And
iii. 30mls of 0.3 Molar Sodium Citrate orally just prior to entering
theatre/ start
iv. Metoclopramide 10mg IV is indicated if the patient had a meal
6. CHOICE OF ANAESTHETIC TECHNIQUE
The preferred technique, where not contraindicated, is spinal anaesthesia or epidural
extension where appropriate (see reference J: NICE Guideline 132). There are a number of
conditions where general anaesthesia may be preferred, these include:
Obstetric indications
Actual or anticipated major haemorrhage
o Severe fibroid uterus
o Placenta accreta, increta or percreta
o Grade 4 placenta praevia
Inverted uterus
Ruptured uterus
Cord prolapse
Pre-eclampsia with coagulopathy
Profound foetal distress
Non-Obstetric indications for general anaesthetic include:
Absolute:
Maternal refusal of regional anaesthesia
The need for rapid delivery of the baby e.g. severe foetal distress
Maternal coagulopathy (see guidelines for anti-coagulation and neuroaxial
blockade)
Severe uncorrected hypovolaemia
The Queen Elizabeth Hospital King’s Lynn NHS Foundation Trust Clinical Guideline for Anaesthesia for Caesarean Section
Clinical Guideline Anaesthesia for caesarean section Author/s: R Jones, A Surendran Author/s title: Specialty Doctor, Consultant Anaesthetist Approved by: Anaesthetic Clinical Governance Committee Date approved: 18/06/2017 Review date: 18/06/202 Page 6 of 24
Local infection of the lower back
Raised intracranial pressure
Failed regional anaesthetic
Relative:
Maternal haemodynamic instability (e.g. severe valvular stenosis)
Sepsis; providing the mother is not cardiovascularly compromised a single shot
spinal may be acceptable)
Gross spinal deformity
HIV is NOT a contraindication for regional anaesthesia. BUT, use universal precautions;
consider eye protection and double gloving.
Always consult with the operating obstetrician regarding category and urgency, so a
mutually agreed plan can be formulated. IS THERE ENOUGH TIME TO PERFORM A REGIONAL BLOCK WITHOUT COMPROMISING MOTHER OR BABY? Seek senior help if you are in doubt You should remember that your prime duty is to the mother and it is not appropriate to take untoward and excessive risks with her life in an attempt to prevent harm to the foetus Always document the time anaesthetic services are requested but bear in mind this may differ from the decision to deliver time We should aim to deliver the baby within the specified time from decision, not request
7. PREPARATION for ALL types of Anaesthesia:
1) Ensure the anaesthetic machine and all equipment has been checked, including
suction and tilting function of operating table.
2) Secure adequate IV access;14G-16G cannula (2 x 16 or 14G cannulas in the event of
haemorrhage or anticipated haemorrhage)
3) Attach routine monitoring; BP, ECG and pulse oximetry
4) Complete the WHO checklist;
5) Ensure antacid prophylaxis has been given
6) Once IV access has been secured commence IV Hartmann’s infusion. IV antibiotics
should be given in line with Trust (and National guidelines); in our Trust, at the time of
writing, this is 1.5g Cefuroxime IV and 500mg Metronidazole IV. In the case of
confirmed penicillin allergy; both antibiotics should be replaced with Clindamycin
600mg IV. No additional antibiotics are needed for those women who require
antibiotic prophylaxis for cardiac problems.
A pregnant patient under any form of anaesthetic must be tilted to the left whilst supine
to avoid aorto-caval compression until the baby is delivered.
The Queen Elizabeth Hospital King’s Lynn NHS Foundation Trust Clinical Guideline for Anaesthesia for Caesarean Section
Clinical Guideline Anaesthesia for caesarean section Author/s: R Jones, A Surendran Author/s title: Specialty Doctor, Consultant Anaesthetist Approved by: Anaesthetic Clinical Governance Committee Date approved: 18/06/2017 Review date: 18/06/202 Page 7 of 24
8. SINGLE SHOT SPINAL ANAESTHESIA
Spinal anaesthesia is the preferred technique, where not contraindicated. (Consider the
value of CSE in cases where surgery may be prolonged or where epidural analgesia is
considered for the post-operative period.)
A. Drugs:
Phenylephrine infusion prepared at a concentration of 50mcg/ml in a 60ml
syringe loaded in a syringe driver
1% Lidocaine for skin infiltration
0.5% Heavy Bupivacaine
Spinal opioid - diamorphine 300 micrograms.
B. Equipment:
Monitoring and machine prepared
Spinal pack
Conduct of the anaesthetic: 1) Follow steps for preparation 7 (above)
2) After IV access start phenylephrine infusion immediately at a rate of 20mls /hour. This
could be titrated depending on the haemodynamic response.
3) Position the patient either sitting or in the lateral (ideally left) position
4) Scrub and use full aseptic technique including wearing a facemask
5) Prepare the patients back with 0.5% chlorhexidine in alcohol and allow this to dry
6) Draw up an appropriate dose of local anaesthetic and opioid using filter needles
a. The amount of local anaesthetic required to produce a reliably adequate spinal
block is dependent on multiple factors; including patient factors, anaesthetist’s
technique and drug choice. If 0.5% heavy bupivacaine is used the required dose
normally lies between 10-14mg (2 – 2.8mL)
b. The chosen type and total dose of local anaesthetic and opioid used should be
one that the individual anaesthetist and/or supervising anaesthetist is familiar
with
c. Choice of opioid
i. Intrathecal diamorphine 0.3mg provides excellent post-op analgesia and
facilitates enhanced recovery process 7) Choose a suitable lumbar interspace, preferably L3/L4
8) Use a pencil point needle such as a 24/25G Sprotte needle
9) Once the intrathecal injection has been performed:
a. Spray the injection site with a plastic dressing (Opsite)
b. Immediately position the patient supine with 15 degrees left lateral tilt
10) For all obstetric cases NIBP should be set at 3 minutes interval
a. Any undue hypotension should be treated with titrated infusion of
phenylephrine
Faintness, dizziness, nausea and vomiting, tachycardia, sweating is almost always due to
hypotension, and early vasopressors may be considered, even before a blood pressure
reading has been obtained
The Queen Elizabeth Hospital King’s Lynn NHS Foundation Trust Clinical Guideline for Anaesthesia for Caesarean Section
Clinical Guideline Anaesthesia for caesarean section Author/s: R Jones, A Surendran Author/s title: Specialty Doctor, Consultant Anaesthetist Approved by: Anaesthetic Clinical Governance Committee Date approved: 18/06/2017 Review date: 18/06/202 Page 8 of 24
b. Profound bradycardia due to vasovagal reflex or cardiac sympathetic blockade
should be promptly treated with either glycopyrrolate 300–600mcgmcg or
atropine 600mcg.
c. It may be necessary to increase left lateral tilt or in rare circumstances reverse tilt
to right lateral in order to prevent aortocaval compression
11) Consider administering oxygen by mask if there is foetal distress (see later guidance),
12) Whilst waiting for the anaesthetic to establish, urine catheterisation can be carried out
by the midwife or a suitably trained person.
13) Check both the upper and lower end of the block with both cold and light touch. This
should be clearly documented on the anaesthetic chart. Do not start surgery unless
there is:
a. A bilateral sensory block to T4 when tested with cold (ice pack or ethyl chloride
spray)
b. A bilateral sensory block to T5 when tested with light touch (piece of cloth or
paper tissue)
c. A bilateral sacral block (test lateral aspect of both feet S1)
14) When confident, clearly communicate with the surgeon and declare to the whole
team that “patient is ready for surgery”
At delivery, proceed to follow guidelines for post-delivery (page 7)
The Queen Elizabeth Hospital King’s Lynn NHS Foundation Trust Clinical Guideline for Anaesthesia for Caesarean Section
Clinical Guideline Anaesthesia for caesarean section Author/s: R Jones, A Surendran Author/s title: Specialty Doctor, Consultant Anaesthetist Approved by: Anaesthetic Clinical Governance Committee Date approved: 18/06/2017 Review date: 18/06/202 Page 9 of 24
9. EPIDURAL TOP-UP ANAESTHESIA
If an epidural has been used for analgesia in labour and has been effective, it should be
topped up for surgery (time allowing). This is only reliably effective when the epidural has
been problem free, if not consider siting a spinal anaesthetic
A. Topping-up the epidural:
1) Follow steps for preparation
2) Check the block has been trouble free during labour
3) Assess the height of the block and ensure it is bilateral
4) Ensure IV access is still patent and adequate
5) Assess and consent the patient, remembering to warn of the possibility of discomfort
or pain and the possibility of conversion to general anaesthesia
6) Once you have commenced topping the epidural up DO NOT leave the patient and
monitor the blood pressure every 3 minutes
7) The CTG should be monitored throughout until surgery is about to start
8) 15° left lateral tilt (or wedge) should be maintained throughout the top-up procedure
9) Suggested top-up solution:
a. Mix 50 -100 micrograms fentanyl in 10mls of 0.5% Levobupivacaine. Bolus in 5ml
increments. This may be carried out in the delivery room during or prior to
transfer, provided the anaesthetist remains with the patient. Up on arrival to
theatre reassess the sensory and motor block. A further 10ml of 0.5%
levobupivicaine without fentanyl may be required. A total volume of up to 25ml
may be required to reach T4 block.
10) If, at any stage, you suspect subarachnoid block, stop injecting and re-assess. Or, if
after administering 20ml there is inadequate block consider all options available and
seek advice if appropriate
11) Treat hypotension as for spinal anaesthesia
12) If a high block is produced but the patient is conscious and breathing adequately give
supplemental oxygen by facemask
13) If a total spinal is produced DON’T PANIC. See total spinal guidelines.
14) If you get signs of local anaesthetic toxicity STOP INJECTING see local anaesthetic
toxicity guidelines
15) Ensure an adequate block has been achieved prior to commencing surgery
16) Treat intra-operative pain as for spinal anaesthesia (see complications)
17) Once the baby has been born follow the post-delivery guidelines (page 7)
The Queen Elizabeth Hospital King’s Lynn NHS Foundation Trust Clinical Guideline for Anaesthesia for Caesarean Section
Clinical Guideline Anaesthesia for caesarean section Author/s: R Jones, A Surendran Author/s title: Specialty Doctor, Consultant Anaesthetist Approved by: Anaesthetic Clinical Governance Committee Date approved: 18/06/2017 Review date: 18/06/202 Page 10 of 24
10. SPINAL ANAESTHESIA FOLLOWING INADEQUATE EPIDURAL ANALGESIA
A spinal anaesthetic following epidural analgesia can result in an unpredictably high or
low block, with the possibility of a total spinal. Any mother having this procedure should
be warned of the need for general anaesthetic either due to inadequate block or high
block. The resulting spinal block is likely to be higher with a higher starting epidural block
and if a large volume of local anaesthetic has been injected down the epidural catheter i.e.
after a failed epidural extension, just prior to performing the spinal. Removing or leaving
the catheter in situ for a spinal is a personal preference. It can be useful to extend spinal
block but this should be attempted only if comfortable to do so. Smaller doses of local
anaesthetic have been recommended to avoid producing a total spinal.
A. Performing the spinal:
1) Perform steps for preparation
2) Check the existing block height
3) Check the drip is patent and adequate
4) Position the patient either in the lateral or sitting position. If the patient has a
significant block then the sitting position is inappropriate
5) Carefully remove the epidural catheter dressing, leaving the catheter in place and
disinfect the back with 0.5% chlorhexidine in alcohol, allowing it to dry
6) Choose a suitable local anaesthetic agent and opioid (see spinal anaesthetic),
approximately two thirds of your normal dose is recommended. Do not exceed 2ml
and inject the fluid very slowly
7) Perform the spinal as per spinal anaesthetic protocol
8) Re-secure the epidural catheter and commence monitoring the blood pressure every 1-
2 minutes
9) Maintain continuous verbal contact with the patient and assess the extent of the block
10) Treat hypotension as per spinal anaesthetic protocol
11) If an excessively high block is produced but the patient is still conscious and breathing
adequately reassure the patient, give supplemental oxygen by face mask and
frequently monitor the block height
12) If a total spinal is produced DON’T PANIC. See total spinal guidelines
13) Allow surgery to commence when the block is adequate and proceed as for spinal
anaesthesia for LSCS.
The Queen Elizabeth Hospital King’s Lynn NHS Foundation Trust Clinical Guideline for Anaesthesia for Caesarean Section
Clinical Guideline Anaesthesia for caesarean section Author/s: R Jones, A Surendran Author/s title: Specialty Doctor, Consultant Anaesthetist Approved by: Anaesthetic Clinical Governance Committee Date approved: 18/06/2017 Review date: 18/06/202 Page 11 of 24
11. GENERAL ANAESTHESIA
All women undergoing general anaesthesia must be considered for RSI until 14 days post-partum
Drugs:
Emergency drugs are immediately available, and checked on a daily basis by the ODA/P
covering obstetric theatres. These comprise of:
Propofol (minimum 200mg)
Suxamethonium 100mg x 2
Atropine 600mcg
Atracurium 50mg OR Rocuronium 50mg
Phenylephrine infusion (as above)
These are kept locked in the fridge in the obstetric theatre. It is ultimately the
anaesthetist’s responsibility to check these are available. If the anaesthetist has a
preference to use specific induction agents, this should be his or her responsibility to check
and ensure their immediate availability.
Equipment:
The Obstetric theatre is stocked with all the usual equipment needed for general and
regional anaesthesia with additional equipment for difficult intubation and major
haemorrhage. All anaesthetists should be familiar with the equipment that is normally
available and check it is present
Additional airway equipment on the Obstetric difficult intubation trolley includes:
Short handled laryngoscope
Polio blade laryngoscope
McCoy laryngoscope
Laryngeal mask airways including intubating laryngeal masks and proseal
laryngeal masks
ETT down to size 6
High flow ‘THRIVE’ oxygen and a free-standing glidescope are available in the CDS theatre
Oxford ‘HELP’ pillow which is kept in Room J (obstetric recovery room)
Conduct of the anaesthetic:
Follow steps for preparation
The patient should have been catheterised and prepped prior to induction and the
surgeon should be scrubbed and ready to commence
Pre-oxygenate the patient by attaching the ‘THRIVE’ high flow nasal oxygen as soon
as the patient has entered theatre
Have suction ready and switched on
All patients with a BMI over 40 should be positioned with a slight head up tilt or
ramp position with the use of Oxford pillow
Large breasts can interfere with laryngoscopy. Ensure a person is free to push the
breasts down in case of difficult with laryngoscopy.
Induce the patient with a rapid sequence induction. Consider use of cricoid pressure
performed by a trained ODP. Be aware that cricoid pressure can make laryngoscopy
more difficult. If difficult intubation is encountered, prepare to fully release the
cricoid.
The Queen Elizabeth Hospital King’s Lynn NHS Foundation Trust Clinical Guideline for Anaesthesia for Caesarean Section
Clinical Guideline Anaesthesia for caesarean section Author/s: R Jones, A Surendran Author/s title: Specialty Doctor, Consultant Anaesthetist Approved by: Anaesthetic Clinical Governance Committee Date approved: 18/06/2017 Review date: 18/06/202 Page 12 of 24
o Propofol 1.5-2.5mg/kg (use an appropriately small dose if haemorrhage has
occurred). Other agents are available in main theatres in extreme
circumstances
o Suxamethonium 1-1.5mg/kg or RSI dose (1.0-1.2mg/kg) of Rocuronium
o 1mg of Alfentanil or 100mcg of Fentanyl is recommended to obtund the
vasopressor response to intubation and possibly skin incision for all GA
caesarean sections. Alert the neonatal team of the neonatal effect.
Confirm correct tube placement by ensuring capnograph trace is present and
listening to the chest prior to release of cricoid pressure
The risk of failed intubation in the obstetric patient has been reported as 1:200, eight times that of the general population. It is therefore important if general anaesthesia is to be undertaken that a proper airway assessment is done, even in
the emergency situation Remember patients do not die from failure to intubate. They do die from
prolonged attempts to intubate in the face of hypoxia and from unrecognised oesophageal intubation
“IF IN DOUBT, TAKE IT OUT”
In the event of a failed intubation resort to the failed intubation drill (see OAA/
DAS guidelines 2015 - appendix)
In preference use Sevoflurane in 50% Oxygen and 50% Nitrous oxide, unless higher
oxygen concentrations are required clinically. Alternatively, Desflurane may be used
as volatile anaesthetic vapour. The inhalation agent should be over pressured
initially and good communication maintained with surgeon to ensure surgery
commences once MAC >1 has been achieved
Be aware that obstetric general anaesthesia is a risk factor for accidental
awareness during anaesthesia due to the increased incidence of obesity and
protracted airway management and high rates of emergency surgery.
Ventilate with an appropriate minute volume to maintain an end tidal CO2
between 4.0 to 5.0 kPa
Prolonged neuro muscular blockade is less desirable to facilitate rapid recovery
after surgery. But if necessary paralysis can be maintained with aliquots of non-
depolarising muscle relaxant e.g. 10mg boluses of Atracurium or Rocuronium
If the blood pressure falls consider:
Speeding up the maintenance fluid infusion
Titrating increments of a vasoconstrictor
Increasing lateral tilt, or in some circumstances reverse it
Using fluid or blood as appropriate
New guidelines suggest opioids should be given at induction. Communication of
opioid use should be made with the neonatal team
Follow post-delivery guidance
Oxytocin infusion is recommended in ALL patients undergoing general anaesthetic
A nerve stimulator should be used to assess neuromuscular blockade. Reverse as
appropriate using; intravenous Neostigmine 2.5mg with Glycopyrrolate 0.5mg.
Sugammadex should only be considered for exceptional circumstances eg. Morbid
obesity, difficult intubation. Reversing dose of intravenous Sugammadex after an
intubating dose of Rocuronium is 2-4mg/kg
The Queen Elizabeth Hospital King’s Lynn NHS Foundation Trust Clinical Guideline for Anaesthesia for Caesarean Section
Clinical Guideline Anaesthesia for caesarean section Author/s: R Jones, A Surendran Author/s title: Specialty Doctor, Consultant Anaesthetist Approved by: Anaesthetic Clinical Governance Committee Date approved: 18/06/2017 Review date: 18/06/202 Page 13 of 24
12. POST DELIVERY MEASURES
1) Once the baby has been born (in line with new delayed cord clamping protocol):
a. Administer Oxytocin 5 IU (Syntocinon) usually given as a slow intravenous bolus.
Side effects, as for other utero-tonic drugs, may include nausea and
hypotension, which should be treated as described
b. Commence an oxytocin infusion (20 IU of oxytocin made up to 20mls with
normal saline) at a rate of 10mls/hour over two hours if indicated (usually
agreed with the surgeon)
c. The lateral tilt should be removed
2) Intravenous Ondansetron 4 should be given in theatre to all mothers receiving
parenteral opioids
3) Diclofenac 100mg PR if consent from the mother has been obtained. Intravenous
Diclofenac 7mg is a suitable alternative. Contra-indications include:
Intolerance to NSAID e.g. some asthmatics and patients with PMHx of a GI
bleed
Allergy to NSAID
Significant PET
Coagulopathies
Significant haemorrhage
Renal impairment 13. POST-OPERATIVE ANALGESIA
1) Prescribe an appropriate analgesic regimen e.g.
a. Oral morphine 20mg given 2 – 4 hourly PRN (buprenorphine 200-400mcg every 6 hours
if morphine intolerant)
b. Paracetamol 1g QDS PO regularly
c. Ibuprofen 400mg 6 hourly regularly (if no contra indications)
2) With epidural in situ administer 3mg diamorphine via epidural, flushed with 2mls of
Normal Saline
3) TAP block can be performed under ultrasound guidance with 40ml of 0.25% L-
bupivacaine immediately after the surgery, prior to extubation. An equally effective
alternative would be direct rectus sheath infiltration of the same amount of local
anaesthetic under direct vision by the surgeon at the time of wound closure. They can
reduce opiate requirements postoperatively.
4) During general anaesthetic, administer 10mg morphine IV intra-operatively and
commence IV PCA in recovery (1mg/ml) with 1mg bolus and a lockout time of 3
minutes. It is the responsibility of the anaesthetist to ensure that the PCA is set up
correctly. The PCA connector should go directly to the cannula and there should be no
three-way tap downstream of the bifurcation point. Fluids must run constantly to
maintain PCA line patency. Where syntocinon is running, a three way tap may be added
at the insertion point of the fluid line to PCA connector and run from there. However,
an additional cannula is equally advised where possible.
The Queen Elizabeth Hospital King’s Lynn NHS Foundation Trust Clinical Guideline for Anaesthesia for Caesarean Section
Clinical Guideline Anaesthesia for caesarean section Author/s: R Jones, A Surendran Author/s title: Specialty Doctor, Consultant Anaesthetist Approved by: Anaesthetic Clinical Governance Committee Date approved: 18/06/2017 Review date: 18/06/202 Page 14 of 24
5) Prescribe an anti-emetic e.g. Cyclizine 50mg 8hrly PRN for PONV
6) Central opioid induced itching: Chlorpheniramine 4 mg orally 4-6 hourly for itch
Limit intravenous fluids to 1 litre if suitable for enhanced recovery pathway.
Ensure that appropriate thromboprophylaxis risk assessment is entered on the
BadgerNet and appropriate dose is prescribed
14. POST-OPERATIVE GUIDELINES (see Trust guidelines FOR OBSTETRIC RECOVERY AND ENHANCED RECOVERY IN OBSTETRICS)
Ensure safe transfer of patient to recovery and ensure accurate handover to recovery staff.
Please ensure documentation is complete with the minimum information required being:
Urgency (category of the section)
Timings of the procedure; knife to skin, delivery of the baby
Blood loss
Routine observations and drugs administered
All epidural and spinal interventions should be documented on a
epidural/spinal chart including doses of opiates used Indications for post-delivery Syntocinon infusion:
This should be started routinely in the following circumstances:
a. Over-distended uterus
Multiple pregnancy
Large baby
Polyhydramnios
b. Bleeding tendency
Past history of PPH
Antepartum haemorrhage in this pregnancy
Anticoagulant/antithrombotic therapy or Coagulopathy
Placenta praevia
Fibroid uterus
High BMI
c. Abnormal contractility
Prolonged and/or obstructed labour
Use of Syntocinon infusion during labour
Failure of the uterus to contract adequately
Pre-eclampsia
Pyrexia
15. COMPLICATIONS
Insufficient block following epidural top-up:
If 20mls of solution do not achieve a block approaching T4 then it is unlikely that further
increments will help. Under these circumstances carefully consider other options with the
obstetrician and patient. Take into account the CTG. If you are unsure seek senior advice.
The Queen Elizabeth Hospital King’s Lynn NHS Foundation Trust Clinical Guideline for Anaesthesia for Caesarean Section
Clinical Guideline Anaesthesia for caesarean section Author/s: R Jones, A Surendran Author/s title: Specialty Doctor, Consultant Anaesthetist Approved by: Anaesthetic Clinical Governance Committee Date approved: 18/06/2017 Review date: 18/06/202 Page 15 of 24
Available options are:
a. Insert a spinal anaesthetic (see guidelines for spinal anaesthetic following
epidural analgesia or failed epidural anaesthesia)
b. Providing the patient is showing no signs of toxicity and the block is progressing
satisfactorily, the use of a further 5-10mls of 0.5% levobupivacaine is permitted.
Do not exceed the safe maximum dose of bupivacaine of 2mg/kg
c. Conversion to general anaesthetic
Pain during regional anaesthetic
Pain during LSCS under regional block has replaced awareness during general anaesthesia
as the main reason for litigation associated with this procedure. The patient who feels pain
during the operation is not necessarily the victim of negligence, however, to have a good
defence your documentation must demonstrate you took reasonable steps to minimise the
chance of pain and treated it promptly and effectively when it arose
a. Mothers should always be warned of the possibility of intra-operative pain or
discomfort and, in the event that this cannot be relieved, the need for
conversion to general anaesthesia
b. The complaint of pain or discomfort should be taken seriously, dealt with
promptly and documented
c. Reassure the mother and her partner
d. Assess the degree of pain / discomfort, bearing in mind the stage of the
procedure
e. If the discomfort is deemed severe or the mother indicates she is not happy to
remain awake then offer a general anaesthetic in the first instance
f. Consider temporarily stopping the surgery until treatment has been given. This
will not be possible if the uterus has been incised but the baby not yet delivered
and in cases of severe foetal distress and maternal haemorrhage
g. If the Mother is happy to stay awake the following treatment options can be
tried as appropriate:
i. A 50:50 mixture of nitrous oxide and oxygen given through the
anaesthetic machine
ii. Fentanyl 25 microgram increments IV
iii. Alfentanil 250 microgram increments IV
iv. Ketamine 10-20mg IV
v. Midazolam 2mg IV
vi. Local anaesthetic infiltration of the wound. This is usually only
appropriate if the procedure is nearing completion
h. If intravenous opioids or benzodiazepenes are given before the baby is
delivered then you must inform the paediatrician
i. Document accurately:
The time the patient complained of pain
How severe the discomfort was
Whether a GA was offered
What treatment options where used to remedy the situation
Whether this was satisfactory
j. Provide follow-up and support (referral to clinical psychologist, or obstetric
anaesthetic clinic) to the patient who felt pain during the operation
The Queen Elizabeth Hospital King’s Lynn NHS Foundation Trust Clinical Guideline for Anaesthesia for Caesarean Section
Clinical Guideline Anaesthesia for caesarean section Author/s: R Jones, A Surendran Author/s title: Specialty Doctor, Consultant Anaesthetist Approved by: Anaesthetic Clinical Governance Committee Date approved: 18/06/2017 Review date: 18/06/202 Page 16 of 24
16. FETAL DISTRESS
If a decision has been made to deliver the baby via Caesarean section with evidence on the
CTG that there is foetal distress there are a few steps that should be taken to help
physiological stresses on both mother and baby. These include:
1) Alteration of maternal position – left lateral position
2) Maternal oxygenation – 10-15L/min of oxygen via face mask or nasal high-flow
oxygen
3) Correction of hypotension
4) Fluid resuscitation – 1L of Hartmann’s
5) Tocolysis – turn off syntocinon, consider terbutaline 250mcg SC or a GTN spray.
Acute tocolysis during Caesarean section may also be required when surgeon
experiences extreme difficulty to extract the baby or if the uterus goes in to
hypertonic contraction during caesarean section. GTN is available in the
obstetric theatre as a Sublingual spray. Usual recommended dose for
sublingual route is 200-400mcg, which can be repeated after 5 minutes.
17. BIRTHING PARTNER IN THEATRE
The mother is entitled to be accompanied by a birthing partner in theatre throughout the
procedure when regional anaesthesia is used. They should be briefed on what to expect
inside an operating theatre. The birthing partner must be clearly instructed that they may
only be allowed to watch the birth of the baby on discretion of the surgeon and the
anaesthetist. They may be asked to leave if any member of theatre team feels they pose a
risk to clinical performance or patient safety.
The Queen Elizabeth Hospital King’s Lynn NHS Foundation Trust Clinical Guideline for Anaesthesia for Caesarean Section
Clinical Guideline Anaesthesia for caesarean section Author/s: R Jones, A Surendran Author/s title: Specialty Doctor, Consultant Anaesthetist Approved by: Anaesthetic Clinical Governance Committee Date approved: 18/06/2017 Review date: 18/06/202 Page 17 of 24
18. REFERENCES
1. Analgesia, Anaesthesia and Pregnancy A Practical Guide, chapter 36; S. M. Yentis, D.
Brighouse, A. May, D. Bogod, C. Elton.
2. Information and consent for anaesthesia. AAGBI; London 1999
3. MBRRACE 2016
4. Comparison of intrathecal fentanyl and diamorphine in addition to bupivacaine for
Caesarean section under spinal anaesthesia. Cown C.M, Kendall J.B, Wilkes R.G. BJA 2002;
89: 452-8.
5. Comparison of plain and alkalinised local anaesthetic mixtures of lignocaine and
bupivacaine for elective extradural Caesarean section. Fernando R, Jones H.M.BJA 1991; 67:
699-703.
6. Side effects of intrathecal and epidural opioids. Can J Anaesth 1995; 42: 891-903.
7. Levels of anaesthesia and intraoperative pain at Caesarean section under regional block.
Russell I.F. IJOA 1995; 4: 71-7.
8. Chemical stability of bupivacaine, lidocaine and epinephrine in pH adjusted solutions.
Robinson J, Fernando R, Sun Wai Y.W, Reynolds F. Anaesthesia 2000; 55: 835-8
9. Urgency of Caesarean section: anew classification. Lucas D.N, Yentis S.M, Kinsella S.M. et al.
J R Soc Med 2000; 93: 346-50
10. NICE clinical guideline 132: Caesarean Section, /issued November 2011. Last modified August
2012
11. NAP4 Major complications of airway management in the United Kingdom March 2011
12. NAP5 Accidental Awareness during General Anaesthesia in the United Kingdom and Ireland
September 2014
13. Sugammadex reversal of rocuronium-induced neuromuscular block in Caesarean section
patients: a series of seven cases F. K. Pühringer, P. Kristen, C. Rex; BJA: British Journal of
Anaesthesia, Volume 105, Issue 5, 1 November 2010; 657–660,
14. AAGBI guideline: The Anaesthetic Team; Section 6; Recovery Post-Anaesthetic Care Unit.
15. ‘Reproduced from Mushambi MC , Kinsella SM, Popat M, Swales H, Ramaswamy KK, Winton
AL, Quinn AC. Obstetric Anaesthetists' Association and Difficult Airway Society guidelines
for the management of difficult and failed tracheal intubation in obstetrics. Anaesthesia
2015; 70: 1286 – 1306, with permission from Obstetric Anaesthetists’ Association / Difficult
Airway Society’
The Queen Elizabeth Hospital King’s Lynn NHS Foundation Trust Clinical Guideline for Anaesthesia for Caesarean Section
Clinical Guideline Anaesthesia for caesarean section Author/s: R Jones, A Surendran Author/s title: Specialty Doctor, Consultant Anaesthetist Approved by: Anaesthetic Clinical Governance Committee Date approved: 18/06/2017 Review date: 18/06/202 Page 18 of 24
16. Appendix 1
Fail
Fail
*See Table 1, §See Table 2
© Obstetric Anaesthetists’ Association / Diffic
u
l t Airway Society (2015)
Master algorithm – obstetric general anaesthesia and failed tracheal intubation
Verify successful tracheal intubation
and proceed
Plan extubation
Pre-induction planning and preparation
Team discussion
Algorithm 1
Safe obstetric
general anaesthesia
Algorithm 2
Obstetric failed
tracheal intubation
Algorithm 3
Can’t intubate,
can’t oxygenate
Rapid sequence induction
Consider facemask ventilation (Pmax
20 cmH2O)
Laryngoscopy
(maximum 2 intubation attempts; 3rd intubation
attempt only by experienced colleague)
Declare failed intubation
Call for help
Maintain oxygenation
Supraglottic airway device (maximum 2 attempts) or facemask
Declare CICO
Give 100% oxygen
Exclude laryngospasm – ensure
neuromuscular blockade
Front-of-neck access
Success
Success
Wake§ Proceed with surgery§
Is it essential / safe
to proceed with surgery
immediately?*
YesNo
Full guidelines can be found at: http://www.oaa-anaes.ac.uk/ui/content/content.aspx?id=3447
The Queen Elizabeth Hospital King’s Lynn NHS Foundation Trust Clinical Guideline for Anaesthesia for Caesarean Section
Clinical Guideline Anaesthesia for caesarean section Author/s: R Jones, A Surendran Author/s title: Specialty Doctor, Consultant Anaesthetist Approved by: Anaesthetic Clinical Governance Committee Date approved: 18/06/2017 Review date: 18/06/202 Page 19 of 24
17. Appendix 2
Gen
eralAna
esthe&
c(GA)
Obstetric
•
• • •
• • • • • Non
-obstetric
• • • • • • • • • •
Combine
dSpinalEpidural(C
SE)
New
procedu
re
Exis4ng
epidu
ralcathe
ter
Spinal not
not
NEV
ER
Epiduraltop
-up
MUST
twothirds
The Queen Elizabeth Hospital King’s Lynn NHS Foundation Trust Clinical Guideline for Anaesthesia for Caesarean Section
Clinical Guideline Anaesthesia for caesarean section Author/s: R Jones, A Surendran Author/s title: Specialty Doctor, Consultant Anaesthetist Approved by: Anaesthetic Clinical Governance Committee Date approved: 18/06/2017 Review date: 18/06/202 Page 20 of 24
18. Appendix 3
ObstetricAnaesthesiaforCaesareanSec
on
Prepara
onforan
aesthesia:
• Fullpre-assessm
ent,checkantacidstaken,consent
form
,bloodstatus
• Machineandequipmen
tcheck
• Monitoring
• IVaccess,runHartm
ann’s,
preparephen
ylep
hrine
• IVan
bio
cs
Post-delivery:
• Slowbolus5IUsyntocinon
• Syntocinoninfusionifindicated
(ALLGA’s)
• Correct
lt
• Diclofenac100
mgPR
ifconsentedandnocontra-
indica
on
• Prescribethromboprophylaxis
• Documen
tbloodloss
• Oramoprh15-25
mg2-4hrly
• Paracetamol1gPO
QDS
• Diclofenac50m
gTD
SPO
•
+/-Ep
iduralbolusdiamorphine3m
g,2mlflu
sh
• PC
AforGA’s1mgbolus,3minlockout
• An
-eme
cse.g.cyclizine50
mgTD
S•
Fluids80
ml/hrun
lE&D
RegionalAnaesthesia(recommen
ded
):
• Spinal–si
ngorle
lateral
• Asep
ctechnique(0.5%chrlohexidinetoskin)
• 1%
lignocaineforskin
• 2-2.8m
l0.5%heavybupivicainewith0.3mgdiamorphineat
L3/4
• Commen
cephen
ylep
hrine
• Supinewithle
lateral
lt
• Ep
iduraltop-up–supinewithle
lateral
lt
• ONLYifperfectlyhap
pywithepidural
• 10
ml0.5%levobupivicainewith50microgram
fen
tanylin5m
l
boluses,m
onitorBPandpa
ent
• Further10m
lof0.5%
levobupivicaineonly
• Assessblock*further5-10m
l0.5%levoifdesperatelyneeded
•
STOPifhighblockortotalspinal–converttoGA
• Adeq
uateblock=T4;ensuresacralblockpresent
• Catheterwillberequired
•
Documen
tonspinal/ep
iduralchart
• Ifunsa
sfactoryblockatanypointofferGAorconvert;consider
rescuedosesofopioid(inform
neo
natesifgiven
priortodelivery)
• 2/3doses(<2m
l)inspinala
erepidural–leavingep
iduralcatheter
ispersonalpreference–injectslowlyashighriskforhighspinal!
Gen
eralAnaesthesia(GA):
• Warnm
otherofriskofaw
aren
ess1:60
0•
HiFlownasaloxygenim
med
iatelya
erarrivingintheatre
• Pe
rform
RSI
• Propofol(minim
um200mg,cau
oninhaemorrhage)
• Opiate;alfen
tanil1m
gorfentanyl100
mcg(inform
neo
nates)
• SuxamethoniumorRSIdoserocuronium
• Onlyallowsurgeo
ntostartwhen
MAC>1andcap
nography
confirm
ed(DASguidelinesifdifficultairway)
• En
sureEtCO2agen
torMACalarm
isON
• Sevofluranewith50%
nitrousoxide,oxygen50%
•
Aim
EtCO24kPa
• Maintainparalysis
• Titratevasopressorsasrequired
•
Iniateoxytocininfusiona
erbolusinALLcases
• IVm
orphine10
mgintra-opera
velya
erdelivery
• Nerves
mulatortodetermineneu
romuscularblockade–
reverseaccordingly
Foetaldistress:
1. Le
latpo
sion
2.
Oxygen
3. 1Lfluid
4. To
colysis(terbu
taline/
GTN
,syntooff)
5.
Correcthypoten
sion
The Queen Elizabeth Hospital King’s Lynn NHS Foundation Trust Clinical Guideline for Anaesthesia for Caesarean Section
Clinical Guideline Anaesthesia for caesarean section Author/s: R Jones, A Surendran Author/s title: Specialty Doctor, Consultant Anaesthetist Approved by: Anaesthetic Clinical Governance Committee Date approved: 18/06/2017 Review date: 18/06/202 Page 21 of 24
19. Appendix 4
Post-operative analgesia regime for all caesarean sections
DRUG Dosage Maximum dose
in 24 hours
Caution
REGULAR
1. PARACETAMOL 1gm 6 hourly orally /
IV 4g
Liver impairment , caution in
severe pre-eclampsia – check
liver function tests
2. IBUPROFEN
400mg 6 hourly
2400mg
Check if patient received rectal suppository intra-operatively
prior to first dose.
AVOID
in severe pre-eclampsia, renal
impairment
(creatinine >70mmol/L), haemorrhage > 2000ml,
platelet count <75,
history of gastric intolerance,
severe asthma
CAUTION – previous history of
heart disease, morbid obesity
LACTATING MOTHERS MUST AVOID TRAMADOL or CODEINE PREPARATIONS
AS REQUIRED
3. ORAMORPH
(first choice for all cases performed
under regional anaesthesia)
OR
MORPHINE PCA
(preferably for all GA sections)
20mg 4 hourly
1mg bolus at
3minute lockout
120mg
60mg
Hourly MEOWS must be
carried out on all patients
receiving parenteral opioids
INTOLERANCE TO MORPHINE
4. BUPRENORPHINE 200mcg 6 hourly
as sublingual tablet
- as required
1200mcg Consult with on-call
anaesthetist.
Can be allowed to take home
if intolerant to NSAIDs
Limit use to maximum of 5
days
FOR ONGOING PAIN ISSUES CONTACT ON-CALL ANAESTHETIST ON BLEEP 1079
Management of common side effects:
NAUSEA and VOMITING
Intra-operatively all patients must receive a single intravenous dose of ONDANSETRON 4mg
As required PROCHLORPERAZINE 12.5mg IM and CYCLIZINE 50mg IM
PRURITUS
CHLORPHENIRAMINE 4mg orally or 10mg IM injection
The Queen Elizabeth Hospital King’s Lynn NHS Foundation Trust Clinical Guideline for Anaesthesia for Caesarean Section
Clinical Guideline Anaesthesia for caesarean section Author/s: R Jones, A Surendran Author/s title: Specialty Doctor, Consultant Anaesthetist Approved by: Anaesthetic Clinical Governance Committee Date approved: 18/06/2017 Review date: 18/06/202 Page 22 of 24
20. Appendix 5
MONITORING COMPLIANCE
Key elements Process for Monitoring
By Whom (Individual / group /committee)
Responsible Governance Committee /dept
Frequency of monitoring
Safe outcome for mum
and baby
Review of clinical
incidents
Anaesthetic
department
and O&G
clinical
governance
group
Anaesthetic
governance
group. O+G
group
All cases
Patient satisfaction Anaesthetists follow up
all women after
procedure
Anaesthetic
department
Anaesthetic
governance
All cases
GA caesarean section
rates
Annual review of audit
data from BadgerNet
Lead Obstetric
Anaesthetist
Anaesthetic
governance
Annually
The Queen Elizabeth Hospital King’s Lynn NHS Foundation Trust Clinical Guideline for Anaesthesia for Caesarean Section
Clinical Guideline Anaesthesia for caesarean section Author/s: R Jones, A Surendran Author/s title: Specialty Doctor, Consultant Anaesthetist Approved by: Anaesthetic Clinical Governance Committee Date approved: 18/06/2017 Review date: 18/06/202 Page 23 of 24
Appendix 6 EQUALITY IMPACT ASSESSMENT
STAGE 1 - SCREENING Name & Job Title of Assessor:
Date of Initial Screening: Date of Review:
Policy or Function to be assessed:
Yes/No Comments
1. Does the policy, function, service or project affect one group more or less favourably than another on the basis of:
Race & Ethnic background No
Gender including transgender Yes Female patients only
Disability:- This will include consideration in terms of impact to persons with learning disabilities, autism or on individuals who may have a cognitive impairment or lack capacity to make decisions about their care
No
Religion or belief No
Sexual orientation No
Age Yes Child bearing age
2. Does the public have a perception/concern regarding the potential for discrimination?
No
If the answer to any of the questions above is yes, please complete a full Stage 2 Equality Impact Assessment. Signature of Assessor: Date: Signature of Line Manager: Date:
The Queen Elizabeth Hospital King’s Lynn NHS Foundation Trust Clinical Guideline for Anaesthesia for Caesarean Section
Clinical Guideline Anaesthesia for caesarean section Author/s: R Jones, A Surendran Author/s title: Specialty Doctor, Consultant Anaesthetist Approved by: Anaesthetic Clinical Governance Committee Date approved: 18/06/2017 Review date: 18/06/202 Page 24 of 24
STAGE 2 – EQUALITY IMPACT ASSESSMENT If you have indicated that there is a negative impact on any group in part one please complete the following, is that impact:
Yes/No Comments
1. Legal/Lawful under current equality legislation?
Yes
2. Can the negative impact be avoided? N/A
3. Are there alternatives to achieving the policy/guidance without the impact?
N/A
4. Have you consulted with relevant stakeholders of potentially affected groups?
N/A
5. Is action required to address the issues?
No
It is essential that this Assessment is discussed by your management team and remains
readily available for inspection. A copy including completed action plan, if appropriate,
should also be forwarded to the Equality & Diversity Lead, c/o Human Resources
Department.