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Obstetric audit is multidisciplinary, but maternal mortality data represent the only national obstetric anaesthetic audit currently available in the UK. Maternity and neonatal audit is progressing towards the collection of both numerator and denominator data in order to compare local, regional and national figures. Obstetric anaesthetists as a professional group play a significant role in maternity care and have in the past developed a minimum data set. Such a set now requires revision of items, agreement on definitions and integration with national projects. Since local and regional obstetric anaesthesia data collection systems are available, albeit in various manual or computerized forms, this is an achievable target. A standard maternity and neonatal data set which incorporates obstetric anaesthetic clinical items could offer a qualitative comparison of process variables and outcome, but should be under professional anaesthetic control. In addition, the process may enable professional standards to be defined and tested so that high quality obstetric anaesthetic care can be maintained.

In september 2006 kwamen de leden van de belangengroepering (SIG) sekse- en genderspecifieke pijn van de International Association for the Study of Pain (IASP, de internationele associatie voor pijnonderzoek) bijeen om over de volgende onderwerpen te discussieren: 1) Wat is er bekend over sekse- en genderverschillen op het gebied van pijn en analgesie; en 2) Wat zijn de ‘best practice’-richtlijnen voor sekse- en genderspecifiek pijnonderzoek? Dit verslag is de consensus van deze bijeenkomst en omvat bijdragen uit algemeen wetenschappelijke hoek, van onderzoekers op het gebied van klinische en psychosociale pijn en van erkende deskundigen op het gebied van seksuele differentiatie en reproductieve endocrinologie.

A 20-year-old primiparous woman, with a history of type 1 hereditary angioneurotic oedema, presented for induction of labour. She was hirsute, obese and presented technical difficulties for both general and epidural/spinal anaesthesia. Her management included prophylactic C1 esterase inhibitors and epidural analgesia for pain relief. A spontaneous vaginal delivery was achieved and no adverse complications occurred. Five days after delivery she had abdominal pain which was investigated and resolved spontaneously. The management of this condition is discussed.

Previous research has shown that post-partum abdominal pain is greater in multiparous than primiparous women (Murray and Holdcroft, 1989). Although breast feeding in the immediate post-partum period induces uterine contractions and abdominal pain, it is unknown how parity influences the contractions. Here, a structured questionnaire that included the McGill Pain Questionnaire (total pain intensity index, TPI) and visual analog scales (VAS) was used to evaluate the intensity, location, referred tenderness (hyperalgesia), descriptor, and temporal characteristics of pain during breast feeding up to three days after uncomplicated vaginal delivery. Three groups of women were studied: primiparous (n=25); low parity (1-2 prior births; n=14); high parity (3-5 prior births; n=11). Uterine contractions during breast feeding were recorded using tocodynamometry in some women from each group (n=17, 6, 7, respectively). For comparison, an identical questionnaire was used to evaluate pains the women remembered experiencing during menstruation in the year immediately preceding the current pregnancy. During breast feeding, nearly all women (96%) reported deep pain primarily at three sites: lower abdomen, low back, and breast, with associated referred hyperalgesia in 62% of them. The intensity of these pains increased significantly with parity (P

The Confidential Enquiries into Stillbirths and Deaths in Infancy (CESDI) were established in 1992 to determine how death in late fetal life and infancy (from 20 weeks’ gestation to one year after birth) could be decreased. Patterns of care and service provision have been monitored in defined areas so that recommendations can be made to attempt to improve fetal and neonatal outcome. The scale of mortality is much larger than for mothers, as reported by the Confidential Enquiries into Maternal Deaths (CEMD); the overlap of deficiencies that include maternal care has previously been reported by CESDI.1 In this latest report for the two-year period 1998– 2000 (Project 27/28),2 babies delivered at 27–28 weeks’ gestation who died within 28 days and a cohort of surviving babies matched for gestation and plurality (single and multiple births) were investigated. Multidisciplinary regional panels, independent of the case and hospital, assessed anonymised case notes. The members of these panels included obstetricians, neonatologists, public health medicine specialists, anaesthetists, midwives and other maternity health care workers. The objective of the panels was to identify areas of sub-optimal care and to score overall quality of care.

Women typically report more pain than men, as well as exhibit specific sex differences in the perception and emotional expression of pain. We present evidence that sex is a significant variable in the evolution of facial expression of pain.

Visceromotor responses and vasopressin release before and after colonic visceral distension were compared between male (n=5 (n=4 for vasopressin)) and female rats and between females during the oestrous cycle (proestrus n=6, oestrus n=5, metestrus n=5, diestrus n=6) at a controlled depth of anaesthesia. Pre-stimulation vasopressin and blood pressures demonstrated oestrous cycle variability. The mean (SEM) colonic balloon pressure triggering visceromotor responses was significantly higher in males (64 (4) mm Hg) than females (41 (1) mm Hg), P=0.002 and within females, proestrus rats had the lowest thresholds, (29 (1) mm Hg, P0.01). Post-stimulation, vasopressin concentrations increased significantly in all groups (males 1.34 (0.39) to 2.24 (0.74) pmol litre(-1); females 1.54 (0.24) to 2.88 (0.58) pmol litre(-1); P=0.002). Within groups statistically significant differences were measured in proestrus 2.06 (0.56) to 3.42 (1.12) and oestrus 1.16 (0.38) to 2.76 (0.60) pmol litre(-1) (P0.05). High vasopressin concentrations coupled with low-pressure stimulation during proestrus shows sex-hormone dependent integration of the neuroendocrine response to noxious visceral stimulation.

Summary A new classification for caesarean section was developed in a two-part study conducted at six hospitals. Initially, 90 anaesthetists and obstetricians graded ten clinical scenarios according to five different classification methods—visual analogue scale; suitable anaesthetic technique; maximum time to delivery; clinical definitions; and a 1-5 rating scale. Clinical definitions was the most consistent and useful, and this method was then applied prospectively to 407 caesarean sections at the same six hospitals. There was close agreement (86%) between anaesthetists and obstetricians for the five-point scale (weighted kappa 0.89), increasing to 90% if two categories were combined (weighted kappa 0.91). We suggest that the resultant four-grade classification system—(i) immediate threat to life of woman or fetus; (ii) maternal or fetal compromise which is not immediately life-threatening; (iii) needing early delivery but no maternal or fetal compromise; (iv) at a time to suit the patient and maternity team—should be adopted by multidisciplinary groups with an interest in maternity data collection.

When pregnant women are asked what they consider to be the risks of epidural analgesia, up to half volunteer nerve paralysis.1 Anaesthetists in Britain and Ireland in contrast have been reluctant to mention the possibility of nerve damage because it is so rare.2 This is not the case in the USA where 71% of anaesthetists regularly discuss neurological sequelae before epidural analgesia compared with 20% in the UK.3 The requirement for consent and the duty to inform the patient of material risks4,5 does not differ substantially between the USA and the UK. The likely difference then is not medicolegal, but possibly a result of cultural variations.

The evidence basis of medicine may be fundamentally flawed because there is an ongoing failure of research tools to include sex differences in study design and analysis. The reporting bias which this methodology maintains creates a situation where guidelines based on the study of one sex may be generalized and applied to both. In fact, study design in the 1970s in response to sex discrimination legislation made efforts to mix gender within study groups since this was considered the best approach to equality. Although significant social progress has been made since then, the application of the principles behind the legislation to women's health and gender-based research have not been so positive. Those who research gender issues in clinical and laboratory medicine are aware of significant barriers both for researchers and for subjects entering studies. This is one illustration of continuing deep-seated patterns of disadvantage that triggered an equalities review by the UK Cabinet Office in November 2005. For example, research funding for coronary artery disease in men is far greater than for women, yet the at risk population of women, which is an older age group, suffers more morbidity and mortality. The lack of funding for women's disease in effect maintains women's lower economic status. It can also hinder research into gender medicine where significant advances in the diagnosis and management of coronary artery disease have built up from small differences into major gender medicine issues.1 Clinical research also exhibits gender bias in other areas. One of these is in recruitment into clinical trials;2 another is the reporting of gender-related data.3 However, there is a dearth of gender-based clinical research from within the UK. Thus it is pertinent to use studies from North America and Europe where these issues have been investigated. It was in 1994 that the US National Institutes of Health (NIH) issued a guideline for the study and evaluation of gender differences in clinical trials to ensure that the safety and efficacy of drugs would be adequately investigated in the full range of patients who would use the therapy.4 Prior to this policy, women had been excluded from early studies of most drugs—mainly for safety reasons, but this prohibition meant there was little information about the effects of drugs in women. For example, women may have a different drug efficacy or side effect profile to men.5 It was reported in 2005 that eight out of ten prescription drugs were withdrawn from the US market because of women's health issues.6 This represents an enormous waste of research money as a consequence of neglecting gender research. The aims of the NIH guidance were to recruit enough women into studies to be able to allow valid analyses of differences in intervention effect, to evaluate the risks and benefits in women, and to provide opportunities for women to contribute to research through active participation in clinical trials while preventing exposure of a fetus to a toxic drug. Since then, in the USA, women can enter phase one, two and three clinical trials. Furthermore, training for and monitoring adherence to this policy has been undertaken by the NIH through the review process for research funding. However there has not been a dramatic recruitment of women's data into trial results.7 Monitoring for gender in NIH research has been reported from the US Congress Office. In 1997, 94% of grant proposals included women as research subjects.8 This high figure, however, belies the underlying Society for Women's Health Research data that the richest charities (as distinct from government funded bodies) were not progressing with the inclusion of women as researchers and subjects and that only 3% of grant proposals measured sex differences.6 One important methodological barrier appears to be that women using hormonal contraception must be considered as a separate group for purposes of analysis.9 However, even the basic concept of including women, whatever their hormonal status, has been brought into focus by recent studies that identified significant barriers to the inclusion of women in clinical trials. Questions concerning contraceptive use in clinical trials were investigated by an Institutional Board survey. These trials were mainly government sponsored in the years after gender discrimination was outlawed. It was found that certification of contraceptive use was required in 42% of protocols without explanation and in 36% of protocols because of the study drug used.10 Almost 10% of protocols allowed no exclusions for contraceptive use (e.g. celibacy or sexual orientation). In addition, for the inclusion of women, up to four counter-signatures were required in some studies to confirm contraceptive use, whereas for men no signatures were required. The study concluded that access to studies by women created burdens that were disproportionate to men. Aspects of contraceptive requirements for studies that did not appear to have been considered by researchers or ethics committees included the risks of contraceptives, interference with drug metabolism by hormonal contraception,11 that partners may be sterile, that fetal harm may also affect men, that the risk of fetal exposure to one dose of a drug was minimal and that women could make their own decisions. A similar study in Sweden from 1997-1999 investigated why researchers excluded women from clinical trials.2 The scientific reasons for excluding women were a lack of physiological data, repeat of studies that had previously used only men so as to obtain comparable data, and the economic costs of research in women. This latter problem has been highlighted in a recent publication by the Society for Women's Health Research, where the guidelines advise that for research into sex differences the best standards for women are to use different hormonal states.11 The economic costs of this ‘gold standard’ methodology have the potential to quadruple medical research grant costs.12 Another facet of gender bias in research is in the lack of incorporation of gender data into evidence-based medicine. For example, despite well recognized gender differences in coronary heart disease management in UK critical care units,13 the UK NHS guidelines for management are not gender specific.14 If research lacks or excludes female subjects then the guidelines should clearly state that the evidence has been obtained mainly from men. In addition, the context in which the evidence basis for medicine is drawn is also questionable because the factors that contribute to women's health (or lack of it) such as poverty and social deprivation will not be the same as for men. These differences need to be defined in order for guidance to reflect the social context of disease. Furthermore, the outputs of biased guidance can influence education, both in terms of what is taught (i.e. maintenance of the status quo) and who teaches it (e.g. gender bias in training) so that inequality is perpetuated. In a recent NHS and Medical Research Council assessment of the causes and effects of socio-demographic exclusions of women from clinical trials, statins and nonsteroidal anti-inflammatory drugs (NSAIDs) were investigated.15 The two drugs demonstrated a dramatic difference in the gender of subjects included in trials. Whereas studies of NSAIDs reflected the population in which they were used, those for statins did not and only 16% of women were included in trials compared with 45% who were using statins. The authors of this study identified the neglect of gender issues in UK research and recommended facilitators to be identified to remove barriers to researchers and women. Including women in clinical studies recognizes that the population is not homogenous, research should benefit all people, protective policies may exclude the people most at risk and exclusion accords a lower status to women. With the advent of gender medicine as a specialty that is developing across the world, a woman's reproductive status, menstrual cycle and contraceptive history has become significant in studying health, disease and pharmacology. In the UK we should seize the opportunity to implement best practices for health care research across genders and to establish gender specific evidence based guidance.

Cannabinoids have analgesic and, possibly, anti-inflammatory properties but their clinical use has been restricted by legislation. This is the first United Kingdom report of the controlled use of a standardised pharmaceutical preparation of cannabinoids in capsular form. The therapy was assessed in a patient with familial Mediterranean fever, who presented with chronic relapsing pain and inflammation of gastrointestinal origin. After determining a suitable analgesic dosage, a double-blind placebo-controlled cross-over trial was conducted using 50 mg tetrahydrocannabinol daily in five doses in the active weeks and measuring effects on parameters of inflammation and pain. Although no anti-inflammatory effects of tetrahydrocannabinol were detected during the trial, a highly significant reduction (p < 0.001) in additional analgesic requirements was achieved. Future study designs can now incorporate prescribable forms of cannabinoids but the choice of previous cannabis users only as patients has clinical limitations. Cannabis naive patients would tolerate controlled investigations but may generate medicolegal problems.

Tail-flick (TF) response latencies were measured in pentobarbitone-anaesthetized rats and variations with time, body and tail temperatures and 5 tail stimuli positions analysed with a mixed model analysis of variance. Variation with time was not significant. Highly significant differences (P < 0.001) were found between tail-flick latencies (TFLs) for tail temperatures and stimulus position. The most proximal tail position showed significantly different relationships for TFL with time and body temperature from other positions. The method described-allows multiple TFLs to be measured in 1 animal with the potential of reducing the total number of animals in an experiment. Tail stimuli positions from proximal to distal sites showed a variation in response from 4.3 sec (95% CI: 4.2, 4.4) to 6.7 sec (95% CI: 6.6, 6.9). Rat tail stimulus position should therefore be standardised to allow reproducible measures of TFL and body temperature maintained within normal limits. TFLs were found to be abnormal at body temperatures above 39 degrees C.

Your Editorial “Promoting women in science and medicine” (Nov 20, p 1712)1 is timely. The genSET science leaders panel2 analysed gender and sex bias in basic research and found that medical treatments for women are less evidence-based than for men. Pain research demonstrates this point well: 79% of animal studies published in the journal Pain over the past 10 years included males only, with a mere 8% of studies on females only, and another 4% explicitly designed to test for sex differences (the rest did not specify).3 Editors of peer-reviewed journals can require analysis of sex and gender effects when selecting papers for publication. The US Journal of the National Cancer Institute does it as a matter of “commitment to sound, scientific research”: “where appropriate, clinical and epidemiological studies should be analysed to see if there is an effect of sex or any of the major ethnic groups. If there is no effect, it should be so stated in Results”.4 The Journal of the American College of Cardiology and Circulation (the American Heart Association journal), also adopted this practice. Nature journals are at present considering whether to require the inclusion of such information.5 Could The Lancet adopt such guidelines as part of its gender equality and scientific quality policy?

A questionnaire on the use of adrenaline in obstetric analgesia was completed by 87 obstetric anaesthetists: 71% of consultants in teaching hospitals were prepared to use adrenaline mixed with local anaesthetics compared with 33% of consultants in district hospitals; they had a similar duration of obstetric anaesthetic experience. Test doses containing adrenaline were not commonly used in labour, but were more often used prior to elective Caesarean section. Adrenaline was used with either lignocaine or bupivacaine; few consultants used both solutions. Contraindications to the use of adrenaline in the nonuser group were in decreasing order of rank: neurological damage, pregnancy-induced hypertension, stenotic valvular heart disease, sickle cell disease or trait of fetal distress. Overall, the contraindications related to the systemic absorption of adrenaline were most common.

Summary A case is described of a primiparous patient with Von Willebrand's type 1 disease and diabetes who presented at 36 weeks’gestation for Caesarean section. This was performed under epidural anaesthesia in the absence of any coagulation disorder. The effects of pregnancy on coagulation factors in this disorder are discussed.

A circle breathing system was connected by deadspace tubing to an open system valveless ventilator. The minimum volume of this tubing, required to prevent dilution of anaesthetic gas in the breathing system by the driving gas of the ventilator, was determined at frequencies of 15, 30, 60, 100 and 150 breaths/minute, with tidal volumes that ranged from 100 to 1100 ml and a fresh gas supply to the circle system of 1, 2 and 4 litres/minute. At 15 breaths/minute, tidal volumes equal to or less than the deadspace volume could be used safely without any mixing with the ventilator driving gas, when a fresh gas flow of 2 litres/minute or above is supplied to the circle system. At 1 litre/minute of fresh gas flow, mixing occurred at tidal volumes less than the deadspace volume. Mixing of gas occurred in the system at frequencies greater than 30 breaths/minute even when the tidal volume was much less than the deadspace volume. However, at high frequencies of ventilation, since the tidal volume requirement decreases, deadspace tubing with a safe internal volume, that is greater than 600 ml, may be used up to 100 breaths/minute.

Summary A prototype valveless ventilator was attached by open deadspace tubing to a circle system and used to ventilate the lungs of 12 patients with low flows of anaesthetic gases for periods between 60 and 120 minutes during intra-abdominal surgery. Anaesthesia was induced with thiopentone and maintained with nitrous oxide 50% in oxygen and enflurane. This was reduced to 2 litres/minute after a 10-minute period of nitrogen wash out and stabilisation of anaesthetic gas concentration, with an initial anaesthetic gas flow of 6 litres/minute. The concentration of oxygen, carbon dioxide, nitrous oxide and enflurane were measured in the outflow from both the anaesthetic machine and the inspiratory limb of the circle system. The measured mean inspired oxygen and nitrous oxide concentrations showed no significant variation throughout the low flow period of the study. This new low flow open circle ventilation system appears to offer some advantages in terms of safety and versatility over other systems which are discussed.

Editor—The question “Why is academic medicine failing?” could be rephrased “Why is academic medicine failing women?”1 One reason is the recruitment and retention of senior female academics, and the other is the application of gender issues to medical research. The failure of academic medicine to come to terms with clinical workforce interests and population healthcare issues is exemplified by the role and aspirations of female students, potential female clinical scientists, and women as patients. Recognition of the high quality skills of female science students and their subsequent loss during early postgraduate years has led to a reappraisal of the culture of a male dominated hierarchy in universities.2 The same process has yet to be applied to medicine. What exclusions are academic medical women facing, and to what extent does this impact on the crisis in academic medicine, where men dominate and the NHS is an alternative employer? The obstacles of childrearing are very clear. It is a myth that great discoveries are made by scientists before the age of 40 years. The biological clock for women may be different; “life starts at 40 years” may be an attitude to consider. Today's female doctors are demanding improved working conditions, better equity, and less hierarchy at work. They see their female counterparts in academic medicine with fewer resources and awards, less space, and lower salaries than male doctors. A BMA working paper identifies the monitoring tools required to support equity in the workforce and considers that a fair representation of women in scientific institutions can bring benefits to academic medicine.3 If women continue to be excluded in the university system, as the evidence from science faculties suggests, academic medicine will be unable to meet the challenges of medicine in the 21st century.

This is the first volume of a series of reviews by international clinicians which analyses developments in the clinical management of critical illness. It presents a variety of topics, some of which are new, such as extracorporeal membrane oxygenation, and some of which are part of day-to-day care, such as weaning from ventilators and enteral nutrition. Management based on clinical science and investigation is discussed. The editor is a consultant clinical physiologist and director of intensive therapy in Newcastleupon-Tyne, UK. The opening chapter by Leo Bossaert, the Honorary Secretary of the European Resuscitation Council, on cardiopulmonary resuscitation, gives a glimpse of the persistent international differences in this field of clinical management. For the obstetric anaesthetist there is no specific information, yet the studies presented highlight aspects of resuscitation in obstetrics. These include teamwork, the necessity for a short intervention time, and problems of resuscitation outside the hospital, such as would present with home deliveries. Acute respiratory distress syndrome (ARDS) is the second topic, and is again of concern to obstetric anaesthetists. Maternal risk factors of aspiration of gastric contents, infection and overtransfusion are discussed in the context of basic science but without any consideration of alterations in physiology during parturition. However, the reviews of Starling’s equation and cellular mediators are helpful in understanding some of the pathological acute lung changes that occur. The management of ARDS, the reader is informed, requires pulmonary artery catheterization. Perhaps, again, international practice varies as do the causes of death associated with ARDS. Chapters on traumatic brain injury and the particular characteristics of intensive care beds may appear to have little interest for obstetric anaesthetists. However, the accompanying update of the regulation of the cerebral circulation and prevention of cerebral ischaemia could be usefully related to women with severe preeclampsia or eclampsia. The description of changes in lung function afforded by posture may also stimulate more investigations into lung function changes in pregnancy, particularly in relation to all the positions now adopted during labour. The book is to be commended for its clarity in presenting clinical physiology, and the editor has obviously encouraged all the contributors to achieve this form of presentation in all the subject areas. Perhaps the next edition will contain an account of the changes in maternal physiology which relate to aspects of intensive care and critical illness, particularly cardiorespiratory function, metabolism and fluid balance. Anita Holdcroft Royal Postgraduate Medical School Hammersmith Hospital, London, UK

SUMMARY Thirty patients for elective lower segment Caesarean section were randomly divided into two groups. One group received 50 litre/kg of Althesin for induction of anaesthesia and the other, 100 μlitre/kg. The two maternal groups were similar. There was no significant difference in the clinical or biochemical status of the infants except that infants in the low dose group had a significantly higher Po2 in the umbilical venous and arterial blood.

Etomidate, (R-(+) ethyl-1-(phenylethyl) 1H-imidazole-5-carboxylate), when administered as drops to the eyes of normal New Zealand white rabbits in concentrations of 2%, 4% and 8% in arachis oil has been shown to significantly lower the intraocular pressure in these animals. The intraocular pressure was measured with the Perkins handheld applanation tonometer. The intraocular pressure reducing effect of the 2% and 4% were better than that of 1% pilocarpine; the two per cent etomidate solution reduced intraocular pressure from a pretreatment mean of 13.6mm Hg to a new mean of 7.7mm Hg after three weeks treatment, while the 4% etomidate solution lowered the intraocular pressure from a pretreatment mean of 14.4mm Hg to a new mean of 7.3mm Hg also after three weeks treatment. Pilocarpine (1%) reduced the intraocular pressure from a pretreatment mean of 13.7mm Hg to 10.7mmHg after three weeks treatment in the same group of rabbits. Etomidate (8%) solution also showed a more significant reduction of intraocular pressure than the 2% solution of pilocarpine. The eight percent etomidate reduced the pretreatment mean intraocular pressure of 14.0mm Hg to a new mean of 6.5mm Hg after three weeks treatment while 2% pilocarpine lowered a pretreatment mean of 13.9mm Hg to 9.0mm Hg after three weeks treatment in the same group of rabbits. There was a persistence of the low intraocular pressure produced by the various concentrations of etomidate in arachis oil after treatment with these drops was stopped. However, this feature was also shown by the two concentrations of pilocarpine used but not in as marked an extent as the etomidate solutions with regard to duration of effect and height of reduction of the intraocular pressure. During a three week period of topical application of drops to the rabbits eyes, the etomidate solutions were found to have no effect in the iris sphincter.

The superficial and deep body temperatures of 23 patients were studied during prolonged anaesthesia for microscopic surgery of the fallopian tubes. The patients were divided randomly into three groups, receiving either halothane 0.5%, halothane 1% or low-dose fentanyl as a supplement to nitrous oxide, oxygen and myoneural block. Other variables were kept constant, and the theatre temperature was maintained at 24 degrees C. Temperature changes were unrelated to both the type of anaesthesia and the percentage of subcutaneous fat to body weight. Halothane 1% decreased the rate of heat loss in the 3rd hour. Large heat losses occurred on transfer to the recovery room, where the total heat produced increased rapidly and was unrelated to shivering.

Observations were made on 26 infants delivered by elective caesarean section under general anaesthesia. A standard anaesthetic technique was employed using a methohexitone, relaxant, nitrous oxide-oxygen sequence with regulated ventilation and the administration of papaveretum after clamping the umbilical cord. In 12 patients the induction dose of methohexitone was 1·4mg/kg and in 14 it was reduced to 1·0 mg/kg. There were no significant differences between the two groups in the clinical status of the mothers, in operative technique and timing, or in the value of PO2, PCO2, and pH in the umbilical cord venous blood. The infants whose mothers received the lower dose of methohexitone were in better condition, as assessed by the number needing assisted ventilation, the time taken to establish regular respiration, the Apgar score, and the “Apgar minus colour” score.

The maternal complications associated with 1,000 consecutive obstetric epidurals are described. Although the analgesia provided was very satisfactory, complications were common. A dural puncture rate of 1·7 per cent resulted’ in 13 patients suffering from “spinal headache”. Blood vessel puncture occurred in 45 patients, while the presence of unblocked segments and unilateral block was troublesome. There were no serious sequelae, but it is suggested that the provision of an epidural service for women in labour requires the immediate availability of an experienced anaesthetist to attend the labour ward.

Epidural anaesthesia and high dose fentanyl (50 micrograms/kg) when used to supplement nitrous oxide and oxygen anaesthesia for a standard lower abdominal operation were associated with a mean fall in deep body temperature, as measured in the external auditory meatus, of 0.46 degrees C and 0.6 degrees C/hr respectively. This is significantly different from the mean values of 0.14 degrees C and 0.2 degrees C/hr which were recorded when moderate dose fentanyl (10 micrograms/kg) or 0.5% halothane were used to supplement anaesthesia. When mean skin temperature is combined with the core temperature to provide an estimate for total body heat, there is no difference between the groups. Redistribution of body heat occurs and this may be related to reduced adrenergic stimulation and altered regional blood flow. Where the facilities and environments are inadequate for the maintenance of normothermia, care should be taken in the choice of anaesthetic technique. In the recovery period mean body heat gain showed a wide scatter of results but those patients receiving epidural anaesthesia were slow to rewarm despite a high incidence of shivering in this group. The implications of this are discussed.