United Bristol Healthcare

NHS Trust Surname: Unit No:

OBSTETRIC ANALGESIA/ANAESTHESIA Forenames:

Name: ...........................................................

Date: .............................................................
Signed: .........................................................

Time: ............................................................
CHART Address:

I confirm that the epidural catheter

Anaesthetic Assessment
Date:............... Assessing Anaesthetist:....................................... Date of Birth: Consultant:

was intact on removal

Catheter Removal
Previous G A / regional technique:
Risks Discussed
RA: Information card reviewed Y/N
Headache Y/N
Backache Y/N
Neurological damage Y/N
Failure Y/N
Obstetric History:
Risk of inoperative pain Y/N

Given by / Checked by

........................./.........................

........................./.........................

........................./.........................
........................./.........................

........................./.........................

........................./.........................

........................./.........................
Risk of G A being needed Y/N
Assisted Delivery: Y/N
GA: Difficult Intubation Y/N
Aspiration Y/N
Awareness Y/N
Medical History: Other .....................................................................

Signature ..............................................................

Witnessed ..............................................................

Drugs:

Effect of top-up
Airway/Fasting:

Allergies:

Insertion of regional anaesthesia / analgesia

30
Date: Anaesthetist: Indication:

20
Blood Pressure
Regional Block Insertion Details
Epidural / Spinal / Combined Epidural Spinal. Needle through needle / 2 insertions [ Epi -Spi / Spi - Epi ]

15
Aseptic technique / No touch Patient Position........................................ Local Infiltration......................................

Epidural

10
Level .............................................................. Midline / Paramedian Needle Size ......................................... LOR Air / Saline
Depth of Space ............................................... CSF Seen Y / N Blood in Catheter Y / N

5
Catheter Mark at Skin .................................... Parasthesiae Y / N

Spinal

0
Level ............................................. Midline / Paramedian Needle Size .................................... Type: Pencil Point / ............................
CSF Y / N Clear Y / N Free Aspiration Y / N Parasthesiae Y / N

ml
Catheter inserted Y / N Catheter mark at skin ............................. CSF aspirated Y / N Blood aspirated Y / N

ANALGESIA FOR LABOUR

Details of Paraesthesiae:

INITIAL DOSE & TOP UP RECORD

Agent
Problems of Insertion: 200

80
60
180
160
140
120
100

40
Time

Pain Score (0 - 10)

Block level - upper (R/L)
Block level - lower (R/L)
Motorblock (R/L)
Resp. rate
Inf rate ml/hr
Vol. Infused ml
Initial Assessment of Block

Cervix
mm Hg

Time ........................ Pain Score 0-10...................................... b.p.m

H.R
B.P

R L Motor Block ( See Guidelines ): 0 / 1 / 2 / 3

Sensory limit (Upper) ....................... .......................

Time
Sensory limit (Lower) ....................... ....................... Sympathetic Block R: Y / N L: Y / N

How Tested ......................................................

Anaesthesia in theatre record
Date: Operation: Category: 1 2 3 4 Drug Unit

Anaesthetist: Surgeon:

Time anaesthetist aware .............................. Wt

Time arrival in theatre .................................. BP

Time anaes commenced .............................. Pulse

Time of adequate anaes ............................... ASA

Nitrous Oxide / Air l/min
Time of KTS................................................... Hb Oxygen l/min
% Volatile
Time of del..................................................... G+S :
Anaesthetic
Time
Supervising Consultant....................................................Level of supervision 1 2 3 4 Case discussed Y / N
Event No.
Advice given: Position

Events Block Prior to Surgery 220

220
R L 200 200
Sensory limit (Upper) .................. .................. 180
180
Sensory limit (Lower) .................. ..................
160 160
How Tested ............................................................
Motor Block Y/N Y/N 140 140
Sympathetic Block Y/N Y/N 120 120

Quality of Intraoperative Block 100 100

80 80

60 60

Supplements Offered 40 40
Na citrate Time 20 20
Premed: Ranitidine Time Oral / IV 0 0
Metoclopramide Time Oral / IV Sp O2

GA technique or 2nd regional anaesthetic Monitoring: FI O2

ECG ET CO2
BP
Temp
SpO2
FIO2 CVP
Blood Loss :
ETCO2 Suction (ml)

Inhalational agent Blood Loss :

Swabs (ml)
Nerve stimulator
Urine (ml)
Ventilator disconnect
IVI 1
Temp site:
CVP IVI 2
Fluid warmer
Warming blanket

Post-op anaesthetic instructions Eye protection Fluid Vol (ml)
Other A............................... : .............
iv access & invasive B............................... : .............
lines
C............................... : .............
D............................... : .............
E............................... : .............
F............................... : .............
Fluid Vol (ml) Totals Pre- recovery
H............................... : ............. Blood Loss : ....................................ml
I................................. : ............. Urine Output : ....................................ml
J................................ : .............
K............................... : .............
Crystalloid In : ....................................ml
L................................ : .............
M............................... : ............. Colloid In : ....................................ml

G.............................. : ............. N................................ : ............. Blood Products In : ....................................ml

Signature .......................................................