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Awareness after general anaesthesia for emergency caesareanActor: a 29-year-old woman, day 1 after a category 1 caesarean section under general anaesthesia

From memory: the diagnosis and the notes are hidden. Answer each question aloud, then press Show.

Know this first

  • Awareness with recall: about 1–2 per 1000 general anaesthetics when formally sought.
  • Caesarean under general anaesthesia: estimated awareness risk 1 in 256.
  • Higher risk with relaxants, caesarean section and rapid sequence induction.
  • Brice questions: last memory before sleep, first on waking, anything in between, dreams.
  • Awareness carries a high rate of later PTSD.

The patient

Actor: a 29-year-old woman, day 1 after a category 1 caesarean section under general anaesthesia. She told the midwife she heard voices and felt pain during the operation. She is frightened and has not slept. Task: take her account and plan the next steps.

The examiner asks

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  1. Open

    How do you start?

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    • I'm seeing her the day after her emergency caesarean under general anaesthetic, because she remembers part of it. Patient
    • Thank you for telling the midwife. I want to hear exactly what you remember. Communication
    • What is the last thing you recall before you went to sleep?
    • And the first thing on waking? Was there anything in between?
    • What did you hear or feel, and could you move at all?

  2. Explain

    Explain what you think happened.

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    • I believe you. This sounds like awareness: being partly awake during the operation. (Communication)
    • I've been through your anaesthetic chart minute by minute to see when it happened.
    • Emergency caesareans under general anaesthetic carry a higher risk, about 1 in 256.
    • The rush to start and the muscle relaxant both make awareness more likely.
    • I'm truly sorry this happened to you.

  3. Respond

    She asks: 'So I was really awake? Will it happen again?'

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    • Yes, it seems you were aware for part of it. It wasn't a dream. (Communication)
    • Future teams will know this and can plan to reduce the risk, including avoiding general anaesthesia if possible.
    • I'll put an alert in your records so every future anaesthetist sees it.

  4. Respond

    She is tearful and says she can't sleep and keeps hearing the voices.

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    • That sounds really distressing, and it makes sense after what you went through. (Communication)
    • Are you having flashbacks or nightmares, or avoiding reminders? These can follow awareness.
    • I'll ask a psychologist to see you before you go home.
    • Do you and your baby have support at home?

  5. Close

    How do you close?

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    • I'm reporting this as an incident so it is reviewed. Communication
    • I'll see you again tomorrow, and after discharge, to check how you're doing.
    • I'll write to your GP and give you a letter for any future anaesthetic.
    • I record her account in her own words, the chart review and the follow-up plan. After surgery

Fatal mistakes

  • Dismissing it as a dream.
  • Nothing documented.
  • No psychological or anaesthetic follow-up.

Checked against: Miller 10e · Mayo review

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