Clinical Corner : Obstetric general anaesthetic training opportunities

Clinical Corner : Obstetric general anaesthetic training opportunities

  • Issue 62

Veena Daga (Leicester, UK) and Mary Mushambi (Leicester, UK)

Obstetric general anaesthetic training opportunities – comparison between the implementation period of the European Working Time Directive (EWTD) and 2012-2013

Studies have shown that the number of Caesarean Sections (CS) carried out under general anaesthesia (GA) have reduced significantly, which is attributed to the increased use of regional anaesthetic techniques for CS.1, 2 European Working Time directive (EWTD) was introduced in three phases between August 2004 and August 2009, resulting in reduction of total number of working hours for junior doctors to 48hrs per week.3 As a result of these two factors, the number of CS carried out under GA by trainees has decreased significantly. The consequent reduction of working hours has raised concerns about the delivery of high quality medical training in the UK. One study showed that the number of CS carried out under GA by trainees had decreased from 18 in 1982 to one in 20062. Reducing experience in GA for CS raises concerns for patient safety. In order to address the reduction in exposure to obstetric general anaesthetics, the Royal College of Anaesthetists (RCoA) has recommended that 100% of elective CS carried out under GA should be used for training.4

We have used training opportunities for general anaesthesia (GA) for caesarean sections (CS) as a surrogate marker to explore obstetric anaesthetic training. The purpose of this study was to look at how training opportunities of GA for elective CS were utilised at a university teaching hospital during different phases of EWTD introduction and more recently in 2012-13, following the RCoA recommendations.


This was a retrospective study in which data were obtained from obstetric electronic data collecting system (Euroking) which is used at the two obstetric units of the University Hospitals of Leicester (UHL) NHS Trust. The audit was approved by Clinical Audit and Quality Improvement Team at UHL NHS Trust.

Data were collected for one year at four different periods, firstly according to three different phases of EWTD implementation (2004-05, 2007-08 and 2009-10) and more recently for years 2012-13. The data were divided according to the time the procedures were carried out (elective weekday 08:00-18:00, emergency – during weekday working hours (08:00 to 18:00 hours) and out of hours (18:00-08:00 and weekends). Proportions of supervised CS carried out under GA were compared between years 2004-05 and 2012-13 using Fisher exact (2-tail) test (Graph Pad software).


The percentages of CS under GA remained relatively unchanged between 8 – 9.8% during study period. The proportions of elective cases done by trainees under supervision were: 4% in 2004/5, 7 % in 2007/8 and 0% in 2009/10 and 72% in 2012/13. The proportion of supervised emergency GA increased from 8.3 to 65.9% during normal hours and 6.4% to 17.4% during out of hours (between 2004/5 and 2012/13). The increase in the proportions of supervised CS carried out under GA between 2004/5 and 2012/13 were statistically significant for elective (P<0.0001, Fishers exact 2-tail test) and emergency-working hours (P < 0.0001, Fishers exact 2-tail test) and for emergency-out of hours (P <0.02, Fishers exact 2-tail test).


This is first study comparing the utilisation of training opportunities during the different phases of EWTD and following RCoA recommendation using GA for elective CS as surrogate marker for training opportunities in anaesthetics.

Our data from recent years (2012-13) shows a significant improvement in supervised training (72%) compared with 2004-05 data (4.3%) (P < 0.0001). According to The Department of Health figures, between years 2009-2012 there was 25% increase in the number of consultant anaesthetist in England.5 This, in addition to better rota design might have allowed better supervised training opportunities in years 2012-13. Despite this, our data shows that we have yet to achieve the goal of 100% supervision of elective CS as recommended by the RCoA .4

Although not a standard set by RCoA, we also looked at emergency GA CS during working hours. There was a small difference between the proportions of supervised CS carried out under GA elective and emergency-working hours (72% versus 66%).

The limitation of our study was the retrospective nature whereby completeness of data cannot be fully guaranteed. This may have underestimated numbers done jointly by a trainee and consultant grade doctors if only one anaesthetist was entered on the Euroking.

In conclusion, the current study shows significant improvement in supervised training for recent years (2012-13). There are many opportunities available for training of GA for CS but unfortunately, our department did not utilise all the available opportunities. It is accepted that this is a combined responsibility of trainee and consultant to achieve this 6 although rota design and working culture may often not allow this. It is hoped that in the future, with the implementation of consultant delivered service 24/7 will increase the training opportunities by the utilisation GA cases done out of hours.

  1. Johnson RV, Lyons GR, Wilson RC, Robinson AP. 2000 Feb;55(2):179-83
  2. Searle R D, Lyons G.. Int J Obst Anesth 2008; 17:233–237.
  3. European Community Directive 2000/34/EC of the European Parliament and of the Council. Official Journal of the European Community. 2000;L195:41
  4. Colvin JR, Peden C. Royal College of Anaesthetists. 2012; 3rd edition: 205-229.
  5. Shape of the medical workforce: Intensive Care Medicine: CfWI medical fact sheet and summary sheet – August 2011, Anaesthetics: CfWI medical fact sheet and summary sheet – August 2011, available at:
  6. Russell, R. Int J Obstet Anesth. 2007; 16: 1–3

Figure 1 : Percentage of elective caesarean sections carried out under general anaesthetic (supervised and un-supervised) during different study periods.