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Contraindications to regional anaesthesia in obstetrics: a survey of German

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Article  in  International Journal of Obstetric Anesthesia · October 2007

DOI: 10.1016/j.ijoa.2007.05.011 · Source: PubMed

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International Journal of Obstetric Anesthesia (2007) 16, 328–335
 2007 Elsevier Ltd. All rights reserved.
doi:10.1016/j.ijoa.2007.05.011

ORIGINAL ARTICLE

Contraindications to regional anaesthesia in obstetrics:

a survey of German practice
U. M. Stamer, F. Stuber, R. Wiese, H. Wulf, T. Meuser
Departments of Anaesthesiology and Intensive Care Medicine, University of Bonn,
University of Marburg and Marien-Krankenhaus, Bergisch Gladbach, Germany

Background: We assessed current practice regarding indications and contraindications to regional analgesia and
anaesthesia for labour and delivery in Germany.
Methods: Questionnaires were mailed to the directors of 918 German departments of anaesthesiology.
Results: A total of 397 completed replies were received representing 41.3% of all deliveries in Germany. More than
half of the respondents never perform spinal or epidural anaesthesia when the platelet count falls below 65 · 109/L.
Preeclampsia, which was not graded for severity, was considered an absolute contraindication to regional block by
15% and placenta praevia by 30% of respondents. If a woman had taken aspirin three days before, the numbers of
respondents considering epidural anaesthesia contraindicated (40.2%) were nearly double those considering spinal
anaesthesia contraindicated (21.7%) (P < 0.001). For a platelet count of 79 · 109/L, epidural anaesthesia was thought
to be contraindicated by 37% and spinal anaesthesia by 22.2% (P = 0.001). In departments with <500 deliveries/year,
reluctance to use regional blockade was more pronounced than in departments with >1000 deliveries/year.
Conclusion: Clinical practice varies considerably in Germany. Concerns regarding the use of regional blockade were
more prevalent in hospitals with small delivery units. Indications and contraindications are not consistent in Germany
and some recommendations or guidelines are needed.
 2007 Elsevier Ltd. All rights reserved.

Keywords: Survey; Obstetrics; Epidural analgesia; Spinal anaesthesia; Contraindications

INTRODUCTION in obstetrics has become more widespread only in the

Recent years have seen a dramatic shift away from gen-
eral anaesthesia in obstetrics in favour of regional anaes-
thesia. In the UK, anaesthetists have been influenced by
the findings of the Confidential Enquiries into Maternal
Deaths, which have repeatedly highlighted the advanta-
ges of using regional anaesthesia in pregnancy. Further-
more many women wish to remain awake during
childbirth. In Germany, the use of regional anaesthesia
Accepted May 2007
UM Stamer, F Stuber, R Wiese, Department of Anaesthesiology and
Intensive Care Medicine, University of Bonn, Germany, H Wulf,
Department of Anaesthesiology and Intensive Care Medicine,
University of Marburg, Germany, T Meuser, Department of
Anaesthesiology and Intensive Care Medicine, Marien-Krankenhaus,
Bergisch Gladbach, Germany.
Correspondence to: PD Dr. Ulrike M. Stamer, Department of
Anaesthesiology and Intensive Care Medicine, University of Bonn,
Sigmund-Freud-Str. 25 53105 Bonn, Germany. Tel.: +49 228/287
14114; fax: +49 228/287 14125.
E-mail: ulrike.stamer@ukb.uni-bonn.de.
last decade. A survey conducted in 1996 revealed that
general anaesthesia was still the preferred technique
for caesarean section, although it had decreased in pop-
ularity since the 1980s.1 The 2002 re-evaluation indi-
cated that the rate of regional anaesthesia for elective
caesarean section had increased to 73.5% from a value
of 39% six years previously.2 Spinal anaesthesia became
the preferred technique and was performed in 50%, 35%
and 5% of the patients presenting for elective, urgent
and emergency caesarean delivery, respectively.
Epidural analgesia is the most effective way to re-
lieve labour pain. However, in Germany there has been
considerable variation in epidural rates; figures being
significantly influenced by the annual number of deliv-
eries.3 Data from the 1990s revealed that for vaginal
delivery 43% of departments had epidural rates of
<10%, 22% had rates between 10-19%, 14% 20-29%
and only 15% had rates in excess of 30%.1,3
For emergency caesarean section, an epidural block
can readily be extended to provide surgical anaesthesia.
Furthermore, where rapid onset of blockade is best

328
 German survey of contraindications to regional blocks 329
avoided epidural anaesthesia may be preferred. How-
ever, regional anaesthesia rates remain low in Germany,
at 48.3% and 5.8% for urgent and emergency surgery
respectively.2
Despite the benefits of regional anaesthesia, the tech-
nique is not without side effects, consequently there are
a number of recognised contraindications to its use.
There is no consensus view in Germany at present on
the minimum platelet count at which regional blocks
can be performed safely.4,5 Similarly, the use of regional
anaesthesia is controversial in patients with placenta
praevia in whom significant haemorrhage is likely or
where there is chorioamnionitis and the possibility of
infectious complications. Consequently we conducted
a questionnaire to evaluate German anaesthetists’ atti-
tudes to the use of regional blocks in high-risk
pregnancy.
METHODS
A survey was mailed to all 918 directors of anaesthesi-
ology departments in hospitals with obstetric units.
Mailing addresses were provided by the German Hospi-
tal Registry. To increase the number of responses, re-
plies were anonymous. The questionnaire contained a
number of multiple choice questions with additional
space allowing for written comments (Appendix). In
addition to demographic data, information was re-
quested on delivery rates and obstetric anaesthesia work-
load during 2002 and 2003. The questionnaire asked
specifically about a number of clinical scenarios in
which the use of regional blocks was controversial such
as preeclampsia, placenta praevia and chorioamnionitis.
Responders were asked whether such conditions repre-
sented absolute, relative or no contraindication to the
use of epidural or spinal anaesthesia.
The results were analysed using Statistica for
Windows 6.0. Hospitals were divided into small units
200-500, medium units 500-1000 and large units > 1000
deliveries/year. For comparison of groups ANOVA
and v2 tests were used, adopted for multiple testing.
A P value of <0.05 was considered significant.
RESULTS
Of the 918 questionnaires mailed, 432 were returned; a
response rate of 47.1%. Of these, 397 were suitable
for analysis. A total of 35 questionnaires were not com-
pleted sufficiently or the obstetric department had been
closed. Of the responding departments, 323 (81.3%)
were in the western part and 74 (18.6%) in the eastern
part of Germany. According to data from the Federal
Office of Statistics (Statistisches Bundesamt, edition
4/2003) this corresponds to the population distribution
of Germany (west 83.3%; east 16.7%). Of those who re-
plied, 30 (7.6%) were from university hospitals, 123
(31.0%) academic teaching hospitals and 167 (42.1%)
other hospitals. Seventy-seven (19.4%) did not indicate
their category. Mean annual delivery rate amongst
responders was 749 (SD 407), a value similar to that
for all obstetric departments in Germany (Table 1).
For labour analgesia 18% (IQR: 7.3-26.5) of the par-
turients received a regional block. There was a signifi-
cant difference in the use of regional analgesia with
the size of the unit. Regional analgesia was used in
12.8%, 18.6% and 21.6% (P < 0.001) of the parturients
in small, medium sized and large units, respectively.
For elective caesarean section spinal, epidural and gen-
eral anaesthesia were used in 50.5%, 21.6% and 26.6%
of the patients.2 In case of urgent caesarean delivery,
half of the cases were performed using general anaesthe-
sia, with this figure rising to 93.5% in the case of an
emergency.2
When managing a caesarean section for multiple
pregnancies or repeat caesarean section, less than 10%
regarded this as a contraindication (Table 2). However,
communication difficulties arising from foreign lan-
guage speaking patients leading to failure to obtain con-
sent was reported as a relative contraindication by more
than half of respondents. When the preoperative haemo-
globin was less than 8 g/dL, half of responders were
happy to use a regional block. However, about 10% per-
form neither spinal nor epidural anaesthesia with a hae-
moglobin less than 8 g/dL. Ingestion of aspirin three
days before of surgery increased the percentage of
anaesthetists who would not perform spinal or epidural
anaesthesia to 20.7% and 40.2%, respectively (Table
2). There were no differences between small, medium
and large obstetric units in the numbers considering
epidural anaesthesia to be absolutely contraindicated
(42%, 39% and 41%, respectively). There was a slightly
more liberal opinion towards spinal anaesthesia, with
24%, 22% and 16% of the small, medium and large
obstetric units respectively considering it contraindi-
cated (P > 0.05).
Table 1. Number (%) of the 397 hospitals responding allocated to
deliveries/year
Deliveries/year Departments responding Total number of
to survey German departments
<250 16 (4.0) 63 (6.4)
251-500 112 (28.2) 324 (33.1)
501-750 105 (26.4) 254 (25.9)
751-1000 72 (18.1) 132 (13.5)
1001-1250 44 (11.1) 94 (9.6)
1251-1500 27 (6.8) 52 (5.3)
1501-2000 16 (4.0) 43 (4.4)
>2000 5 (1.3) 16 (1.6)
Data are numbers (%).
330 International Journal of Obstetric Anesthesia

Table 2. Percent of respondents indicating no contraindication, a relative or an absolute contraindication to obstetric spinal anaesthesia or
epidural anaesthesia/analgesia

Spinal Epidural P value

No Relative Absolute No Relative Absolute

Coagulation problem
Aspirin 3 days before 34.5 43.8 20.7 16.9 42.9 40.2 <0.001
Platelets 79 · 109/L 32.3 45.5 22.2 21.5 41.5 37.0 0.001
Platelets 65 · 109/L 14.3 34.4 51.3 6.0 29.5 64.5 0.01
HELLP syndrome 9.0 49.3 41.7 10.3 38.1 50.6 NS
Preeclampsia 43.0 42.1 14.9 43.6 40.9 15.5 NS
Chorioamnionitis 46.1 39.7 14.2 33.6 48.1 18.3 NS
Placenta praevia 32.1 37.8 30.1 33.0 36.3 30.7 NS
Foreign language 23.4 62.7 13.9 18.5 66.8 14.7 NS
Repeat caesarean section 95.1 4.9 0.0 92.9 7.1 0.0 NS
Multiple pregnancy 89.5 9.9 0.6 92.3 7.1 0.6 NS
Haemoglobin <8 g/dL 46.9 41.6 11.5 51.2 38.9 9.9 NS

P values are given for comparison of spinal versus epidural anaesthesia; NS = not significant.

For women with preeclampsia, most respondents in
all sizes of unit were prepared to use regional blocks,
whereas HELLP syndrome was considered to be a rela-
tive or absolute contraindication for both regional tech-
niques (Table 2), depending on the size of the obstetric
unit (Fig. 1). HELLP syndrome was an absolute contra-
indication to performing epidural anaesthesia in 61.2%,
47.6% and 41.2% (P = 0.001) and spinal anaesthesia in
44.6%, 41.7% and 37.7% (P > 0.05) of the small, med-
ium and large delivery units, respectively.
A platelet count of 79 · 109/L was considered an
absolute contraindication to spinal anaesthesia by 22%
and epidural anaesthesia by 37% of the respondents,
with no significant difference between units of different
size. However, clinical practice was related to the num-
ber of epidurals performed for labour analgesia. In hos-
pitals that would perform an epidural for labour when
the platelet count was 79 · 109/L, epidural rates were
higher (21.4%) than in those regarding this platelet
count as a contraindication (16.9%, P = 0.02).
The majority of anaesthetists would not perform an
epidural when the platelet count was 65 · 109/L; the
technique was considered contraindicated by 72%,
Deliveries / year
80
Percent of responders
60% and 63% in small, medium and large delivery units,
respectively (NS). For spinal anaesthesia values were
49%, 66% and 41% (NS).
For women with placenta praevia, replies were
approximately equal for absolute, relative and no contra-
indication to regional blocks (Table 2). Chorioamnioni-
tis was considered an absolute contraindication to
regional blocks by the minority (Table 2). Anaesthetists
working in units with > 1000 deliveries/year were more
likely to use regional blocks than those in small units
(P = 0.02 and P = 0.03; Fig. 2).
Obstetric departments in the western part of Germany
were larger than in the eastern part, with annual deliver-
ies of 775 (SD 403) versus 634 (SD 379) (P = 0.006).
There were significant geographical differences in the
use of epidural analgesia. Of women delivering vagi-
nally, 19.8% and 8.5% received epidural analgesia in
western and eastern Germany, respectively (P < 0.001).
Overall, anaesthetists working in the eastern part of Ger-
many were more reluctant to use a regional block
(Fig. 3). Significant differences were identified for both
spinal and epidural anaesthesia for repeat caesarean sec-
tion and a foreign language speaking patient. Practice
also differed for the use of epidural anaesthesia in
patients with a haemoglobin <8 g/dL and HELLP syn-
drome. Although there was greater reluctance to use
<500 500-1000 >1000

60 Deliveries / year: <500 500-1000 >1000

30
Percent of responders

40
* *
20 20

0
10
Platelets Platelets Placenta HELLP Aspirin 3
79 × 109/L 65 × 109/L praevia syndrome days before
0
Fig. 1 Percent of responders who considered epidural block Spinal anaesthesia Epidural anaesthesia
0absolutely contraindicated with platelet counts of 79 · 109/L and
65 · 109/L, placenta praevia, HELLP syndrome and an intake of Fig. 2 Percent of responders who considered chorioamnionitis an
aspirin three days before. absolute contraindication to spinal or epidural block. *P < 0.05.

Spinal anaesthesia
60
East West
40
Percent of responders
* et al. found epidural rates ranging between 17%(<500
20
* deliveries/year) and 51%(>1500 deliveries/year) in US
0 hospitals in 1992.6,7 More recent data revealed epidural
Epidural anaesthesia *
60
40
* of regional versus general anaesthesia for caesarean
20 * *
0
at ign ge dL LP ta
pe re gua g/ L en via
e
R CS o 8 HE ac e
F an < Pl pra
l Hb
Fig. 3 Percent of responders who considered spinal or epidural
anaesthesia absolutely contraindicated in repeat caesarean section,
foreign language speaking women, Hb < 8 g/dL, HELLP syndrome,
placenta praevia and a platelet count of 65 · 109/L in the eastern and
western part of Germany. *P < 0.05.
regional blocks in a number of circumstances, after
adjusting for multiple testing these differences were
not statistically significant.
DISCUSSION
The response rate to our survey was only 47%. Previous
response rates to obstetric surveys have varied between
35 and 100%; compared to former German investiga-
tions the survey showed a satisfactory number of re-
sponses.1 Reasons for failure to respond are a lack of
tradition and culture for audit and quality control in Ger-
many, lack of familiarity with such questionnaires,
expenditure of time and high workload as well as volun-
tary participation. Response rates did not differ between
the 16 German states, which suggests a comparable rep-
resentation of the western and eastern parts of Germany.
Replies were anonymous to encourage participation in
the survey. Additionally, making replies anonymous
might have reduced self-reporting bias. Other problems
of survey data are that answers may reflect national
and international trends such that responses are given
in favour of regional anaesthesia from respondents
aware of this development in anaesthetic practice. Final-
ly, departments not engaged in regional anaesthetic tech-
niques may be less likely to respond. Consequently data
might look more favourable than they actually are.
The use of regional anaesthesia for labour and deliv-
ery in Germany has significantly increased since 1996,
although it is still less popular than in many other coun-
tries.1,2 For labour 18% of the women received regional
analgesia (range: 0-60%) with a significant difference
between the western and eastern part of Germany. In
contrast, the 1992 survey of Davies and co-workers
German survey of contraindications to regional blocks 331
revealed a frequency of epidural analgesia for labour
in the UK of 12% with <1500 deliveries/year and
23.1% with > 3000 deliveries/year, whereas Hawkins
rates of 20.6% in Norway, 61.6% in France, 65% in Flan-
ders (Belgium) and 98.9% in Catalonia (Spain).8–11
Comparable differences have been reported in the use
section.1,2 There are several possible reasons for these
differences. First, in smaller obstetric units there may
t s 9 /L be less obstetric commitment from anaesthetists; there
ele 0
at 1
Pl 5 x is also a long standing tradition of general anaesthesia;
6
publications on obstetric anaesthesia in the German
language are rare; and there is little statistical analysis
of obstetric anaesthesia data on outcome, morbidity and
mortality when compared with the UK.
Different practice in regional anaesthesia between the
two geographical regions in Germany might be at least
in part due to the smaller delivery units in the east. Spe-
cifically, there seems to be more reluctance to use regio-
nal blocks, either spinal or epidural, in any woman with
pregnancy-associated co-morbidity. Most high-risk pa-
tients are referred to major delivery centres early in
pregnancy. However, others may present for emergency
delivery in smaller units and therefore each unit has to
be able to care for these cases and must have obstetric
and anaesthesia personnel continuously available. Never-
theless, anaesthetists in smaller units might be less
experienced and motivated to employ a regional tech-
nique. Although it is beyond the scope of this survey
to judge best practice, the data provide valuable infor-
mation on what are considered to be contraindications
to regional anaesthesia.
Coagulation problems
National and international guidelines recommend that if
there are no symptoms or signs of a bleeding disorder,
no laboratory blood analysis is necessary in obstetric
patients.12,13 In contrast, coagulation disorders and
medication with anticoagulants or antiplatelet drugs
increase the risk of regional anaesthesia. The antiplatelet
activity of aspirin produces an irreversible blockade of
platelet aggregation and the fear is that it may increase
the risk of spinal haematoma. After discontinuing aspi-
rin it takes three days for the bone marrow to replace
30-50% of the platelets. But anti-platelet medication is
designed to be antithrombotic rather than anticoagulant
and low-dose aspirin is not usually considered a contra-
indication to regional anaesthesia, if no additional anti-
thrombotic substances are administered and no further
additional bleeding risks exist.4,12,14,15 Low-dose aspirin
does not appear to produce enhanced bleeding problems
332 International Journal of Obstetric Anesthesia
or increase the frequency of spinal haematoma.16–18 A
time interval of more than two days after the last intake
is recommended in Germany, if additional prophylactic
heparin is administered.19 A smaller time interval should
only be used after individual risk-benefit assessment.
Although these recommendations exist, German anaes-
thetists’ concerns about the use of regional anaesthesia
are widespread.
There is no clear evidence for an absolute threshold
for the platelet count for regional anaesthesia to be con-
sidered safe. In 1996, Schneider and Alon4 suggested a
platelet count of 100 · 109/L, but reports of uncompli-
cated epidural anaesthesia in parturients with lower
counts have been published.20,21 More recently Douglas
suggested a platelet count of 75 · 109/L as a reasonable
cut off for epidural anaesthesia,5 and a USA survey re-
vealed that 60% of the American anaesthesiologists
would perform a block without further laboratory inves-
tigation in otherwise healthy pregnant women if the
platelet count was between 80 and 100 · 109/L.3,22 Ger-
man anaesthesiologists are more reluctant to use epidu-
ral anaesthesia. Interestingly, attitudes towards siting an
epidural in a woman with a compromised platelet count
were more liberal in hospitals with higher epidural and
delivery rates.3 Their experience with epidural anaesthe-
sia might influence the more individualized use of this
technique.
Although a case report described a spinal haematoma
requiring emergency laminectomy after epidural anaes-
thesia for caesarean section in a woman with severe pre-
eclampsia and rapidly decreasing platelets,23 other
authors have reported uncomplicated epidural anaesthe-
sia in pregnant women with profound thrombocytopenia.
In 30 patients with platelet counts ranging between 69
and 98 · 109/L, epidural anaesthesia was performed
without bleeding complications.20 From published data,
it can be concluded that a neuraxial block for labour and
operative delivery can be offered to preeclamptic
patients provided the platelet count and coagulation pro-
file are within acceptable limits.
HELLP syndrome is seen in 2-12% of women with
preeclampsia. As the only treatment is termination of
pregnancy, the rate of operative delivery is high. As with
preeclampsia, a regional technique might be advanta-
geous. However, this is advisable only in stable cases
with adequate platelet counts.24 In contrast, rapidly
decreasing platelets are a feature of HELLP syndrome.
Disseminated intravascular coagulation is associated
with a rapidly developing and fulminant hyperfibrinoly-
sis. General anaesthesia is the technique of choice in
these cases and was reflected by the respondents’
answers.
In our survey there was no classification of severity
of preeclampsia and HELLP syndrome, as we assumed
that there was a considerable number of anaesthetists
who never perform a regional block in these women,
irrespective of the severity of preeclampsia. This is in
contrast to practice in many other countries and German
anaesthetists should perhaps reconsider their manage-
ment of preeclamptic patients. A long tradition of gen-
eral anaesthesia and a lack of German language
articles and national guidelines might have contributed
to the lack of popularity of regional blocks. Responders
who wished to base their decision on using a regional
block on the severity of the disease were able to com-
ment on platelet counts of 79 and 65 · 109/L. The two
levels were chosen because they both fell below the gen-
erally accepted safety threshold of 100 · 109/L recom-
mended in a German language publication.4 However,
nowadays many experienced anaesthetists would per-
form a regional block at platelet counts of 80 · 109/L.
The second value mentioned in the questionnaire was,
however, lower than the 75 · 109/L discussed in some
publications.5
Haemodynamic stability
In the past, spinal anaesthesia has been considered haz-
ardous in patients with hypertensive disorders.25 Con-
cerns focused on a possible profound decrease in mean
arterial blood pressure enhanced by a pre-existing con-
tracted blood volume, common in preeclampsia. Admin-
istration of large volumes of intravenous fluid increases
the risk of pulmonary oedema, whilst increased sensitiv-
ity to vasopressors can compromise uteroplacental blood
flow.19,26 More recently, spinal anaesthesia has been
recommended for urgent caesarean section, specifically
when there is no epidural catheter in situ.27 Blocking
neuroendocrine and haemodynamic stress responses
with regional anaesthesia has proved to be advantageous
in preeclampsia.28 Clinical trials have demonstrated that
excessive hypotension during spinal anaesthesia is rare,
with comparable frequency under general and regional
anaesthesia.29–33 When vasopressor support was neces-
sary, doses required were less than in normal parturi-
ents.30 Our survey revealed no difference in the use of
spinal and epidural anaesthesia in preeclampsia.
Although the majority of German anaesthetists use
regional techniques in these patients, about 15% of
responders remain to be convinced of its suitablity.
Risk of haemorrhage
Women presenting with placenta praevia are at risk of
significant haemorrhage. Such women might be hypovo-
laemic with a low haemoglobin at presentation. In our
survey, in the absence of further clinical information, a
haemoglobin value of less than 8 g/dL was considered
an absolute contraindication to regional anaesthesia by
10% of the respondents. However, the decision regarding
 German survey of contraindications to regional blocks 333
anaesthetic technique depends on individual circum-
stances. Placental position influences choice with regio-
nal anaesthesia producing less concern with a fundal
placenta than with placenta praevia.
Placenta praevia complicates approximately 0.3-
0.8% of pregnancies, with multiparae and those who
have previously undergone caesarean section showing
an increased risk.34,35 Anaesthetic technique for delivery
should be chosen depending on bleeding status and hae-
modynamic stability. In the absence of hypovolaemia,
continuous bleeding and coagulopathy, a regional tech-
nique may be considered safe.34 In the present survey,
a third of the respondents were prepared to use regional
blockade and one third felt that placenta praevia was an
absolute contraindication. However, there was no differ-
entiation related to degree of bleeding, haemoglobin and
urgency of delivery. A previous UK survey also re-
vealed a wide variety of clinical practice, demonstrating
that there was no consensus view.35 Furthermore, famil-
iarity with technique in different clinical situations
proved to be of relevance, with a greater willingness
to use regional anaesthesia among anaesthetists with
more frequent obstetric commitments.35
Risk of infection
Controversy regarding the use of regional blocks in par-
turients with chorioamnionitis stems from concerns for
infectious complications in the epidural or subarachnoid
space.36 Intra-amniotic infection mainly develops as an
ascending process after prolonged rupture of the mem-
branes and labour. Other cases may be haematogenous
in origin or complicate intrauterine procedures. Bader
et al. identified 319 parturients (3%) with chorioamnioni-
tis from a total of 10 047 deliveries over a one-year per-
iod.37 Bacteraemia was found in eight of these patients.
Small case series have reported on bacteraemic parturi-
ents receiving uncomplicated epidural blocks without
antibiotics.37,38 However, published data are not suffi-
cient to indicate the safety of epidural blocks.37 Epidural
abscess or meningitis is not always due to regional block-
ade but, as stated by Loo et al., “unfortunately the con-
ventional wisdom deems the anaesthetist to be guilty
until proven otherwise.”39 This might explain the restric-
tive use of a regional technique in patients with suspected
chorioamnionitis in some German departments.
There is wide variation in the clinical practice of re-
gional anaesthesia in obstetrics in Germany. Anaesthe-
tists working in hospitals with low delivery rates have
a greater reluctance to use regional anaesthesia. It is pos-
sible that concerns regarding regional blocks hold true
for many other countries where general anaesthesia still
predominates. This is probably influenced by traditional
departmental policy and change will only take place
with the advent of a new generation of anaesthetists.
Since many variables affect the appropriate clinical
decision for a given obstetric patient, evidence-based
or at least expert-based recommendations will be help-
ful. Refusal to use regional anaesthesia in cases of pre-
eclampsia, aspirin prophylaxis or placenta praevia is
not supported by published data.
ACKNOWLEDGEMENT
We thank all participants who completed the survey.
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Appendix: Items in the questionnaire relevant for this evaluation
1. In which German state is your hospital located?..................
2. Type of hospital University hospital
University affiliated teaching hospital
Other hospital, e.g. primary care, private hospital
3. Deliveries / Year
Total number of deliveries
Number of spontaneous vaginal deliveries
Number of vacuum extractions
Number of forceps deliveries
Number of Caesarean sections
4. Number of patients receiving epidural analgesia for vaginal delivery
Single shot epidural
Epidural catheter
CSE (combined spinal/epidural analgesia)
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2002 2003
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 German survey of contraindications to regional blocks 335

Appendix (continued)
5. Anaesthetic technique for Caesarean section
General Spinal Epidural Combined Total
anaesthesia anaesthesia anaesthesia spinal-epidural
Elective cases 100%
Urgent cases 100%
Emergency cases 100%

6. Contraindications for central regional block in obstetrics

Spinal anaesthesia contraindicated Epidural anaesthesia contraindicated

no relative absolute no relative absolute

Repeat Caesarean section
Multiple pregnancy
Foreign language
Haemoglobin < 8 g/dL
Aspirin intake 3 days before
Preeclampsia
HELLP Syndrome
Platelet count: 79 · 109/L
Platelet count: 65 · 109/L
Placenta praevia
Chorioamnionitis
Other (specify)

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