NAP7 and obstetric activity: important and measured

We thank Drs Bamber and Christmas [1] for their interest in the work of the NAP7 project. The activity survey aims to provide denominator data relevant to the project's overall theme: capturing data regarding patients at risk of peri-operative cardiac arrest [2]. It allows us to contextualise the case reporting data within the ‘big picture’. As Bamber and Christmas observe, large-scale data on national anaesthesia activity are lacking, and national coding of anaesthetic interventions would be helpful [3]. They suggest there is no reference to “assisted vaginal births, removal of placenta and repair of perineal tears”. However, this is not quite correct; the supplementary material references ‘obstetrics: other’, which would include these procedures when an anaesthetist is involved [4]. Together, total obstetric activity captured was: caesarean sections (7%) + labour analgesia (4%) + other (2%) = 13% of all activity in the survey [4]. This activity is indeed greater than elective orthopaedics on absolute numbers. However, there are many ways to divide or add activities and elective orthopaedics (10%) + orthopaedic trauma (9%) = 19%. Similarly, general surgery and its subspecialities (upper gastrointestinal, hepatobiliary and ‘other’) represent 18% of the overall workload. The difficulties of defining and measuring obstetric anaesthetic workload have been described previously. Yentis and Robinson applied various definitions of obstetric anaesthetic activity to maternity data from two units, demonstrating that activity rates differed widely according to the definition used [5]. We feel it may not be constructive to consider the absolute number of procedures undertaken by anaesthetists or staffed sessions to be a marker of workload. As Bamber and Christmas note, anaesthetists perform many activities beyond operating theatre and labour ward sessions, which are not captured in the NAP7 activity survey, or by previous national activity surveys; procedural activities represent only a proportion of the work undertaken by anaesthetists. Obstetric anaesthetists run high-risk pregnancy clinics and, in common with all anaesthetists, may have managerial, governance, educational and research roles. Many others will have other subspecialist anaesthesia roles, such as pain management, critical care, sleep medicine or management positions. The aim of the NAP activity surveys is not to capture all individuals' activity but rather to report data relevant to procedural activity. We plan to publish speciality-specific data in due course. Important findings of relevance to obstetrics include the volume of out-of-hours activity and median BMI of the obstetric population, both of which have increased substantially [4]. We feel these are highly important, especially in the wake of the Ockenden report [6]. Individual departments must ensure that staffing numbers and skill mix are adequate for these challenges.