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External Endorsements



Royal College of AnaesthatistsSTANDARD There is a policy for the management of morbidly obese patients 

EVIDENCE REQUIRED A copy of the policy should be provided PRIORITY 1 CQC KLoEs Safe Responsive 

GPAS REFERENCES 9.2.12 The maximum weight that the operating table can support must be known and alternative provision made for women who exceed this. It is recommended that the obstetric operating table should be able to safely support a minimum weight of 160 kilograms in all positions. 

9.2.13 Equipment to facilitate the care of the morbidly obese parturient including specialised electrically operated beds, aids to assist patient positioning, for example Oxford head elevating laryngoscopy pillow (HELP), weighing scales, sliding sheets and hoists, should be readily available and staff should receive training on how to use the specialist equipment.

HELPNOTE See Note 2 for an explanation of what is meant by the term ‘policies’.

Oxford Case Histories in Anaesthesia

Edited by Jon McCormack, Keith Kelly

OUP 2015

Morbid Obesity in Obstetrics

P.151 Case 5.3

Use a head-up tilt, with a pillow ramp or a proprietary device such as the Oxford HELP pillows, even with regional anaesthesia. This will help the block from spreading to cephalid and also places the patient in an ideal ramped position, should she require a general anaesthesia.



Oxford Textbook of Obstetric Anaesthesia

OUP 2016


Obstetric Anaesthesia

Elsevier 2016


Core Topics in Basic Anaesthesia

Elsevier 2016


Core Topics in Obstetric Anaesthesia

CUP 2015


Textbook of Anaesthesia

Elsevier 2013

ABC of Transfer and Retrieval Medicine

Wiley Blackwell 2015

Sheffield Teaching Hospitals


Royal Berkshire NHS Trust

Royal BerkshireObstetric failed intubation (GL774) 2016

Overview: The incidence of failed intubation is 1:3902 in obstetric patients. However, morbidity and mortality is caused not by failure to intubate but by failure to oxygenate. The causes for the increased incidence of failed intubation in the obstetric population cf. non-obstetric population is multifactorial and the new OAA/DAS guidelines address many of these challenges, emphasising the influence of human factors and the value of greater simplicity in decision-making. The focus in the guidelines is on planning and preparation, with the importance of pre-oxygenation and positioning emphasised. Factors to consider when deciding whether to continue general anaesthetic (GA) or wake patient up postfailedintubation are helpfully summarised in table 1 in the OAA/DAS guidelines1 . 

5. Ensure optimal positioning of patient. Consider use of the Oxford HELP Pillow, 3- 5 ‘normal’ pillows, ramping using the theatre table and head up.


Nottingham University HospitalHANDBOOK 2014

Revision date March 2019

p. 22

OBSTETRIC ANAESTHETIC HANDBOOK 22 Caesarean section in morbidly obese ·Senior help · Appropriately sized equipment and staff available for moving · Preoperative ranitidine · Increased risk of bleeding so consider two large-bore cannulae · Difficult intubation ≥ 10% so avoid if possible · Consider CSE if no epidural in situ o In the morbidly obese consider inserting epidural first and securing and then performing spinal at different interspace (To reduce risk of dislodging epidural during positioning) · Ramped intubating position may be useful in morbidly obese (see fig. 1) · Use Oxford HELP pillow which is now available at both sites (see fig. 2) · Consider uncut size 7 ETT · Consider arterial line for BP monitoring Figure 2. The Oxford HELP pillow in the high position

Challenging Concepts in Anaesthesia:

Challenging ConceptsCases with Expert Commentary

Editors: Dr Phoebe Syme, Dr Robert Jackson, Dr Tim Cook

OUP 2014

Chapter 5, P 157

Other relevant adjuncts include the range of head and neck supports to aid ideal positioning of the patients, particularly the obese, prior to intubation, the Oxford HELP (Head Elevating Laryngoscopy Pillow, Alma Medical, UK) being one such device (Figure 5.5).

Implementation of NAP4 in a DGH

Royal United BathFiona Kelly, Bath, 2013

NAP4 Findings:

Aspiration biggest cause of death

Obesity major risk factor for airway complications

Planning and assessment – airway assessment – planning for failure

Issues with…– Multiple repeated attempts at intubation – Awake fibreoptic intubation – Obstructed airway – Capnography trace interpretation – Needle cricothyroidotomy

Emergence or recovery – one third of events • ICU and ED – Continuous capnography – Displaced tracheostomies and tracheal tubes – Rapid sequence induction

2.9 million anaesthetics per year • Risk of airway complication resulting in death or brain death – 1 in 151 000 overall

Risk of death or brain death depending on location: Theatres 14% ED 33% ICU 61%

In Bath Hospital ED and ICU:

Airway complications more common • Airway complications more likely to lead to harm


True emergency – less time for planning and preparation • Full stomach • Equipment • Staff – Junior doctors – Consultants – ICU and ED nurses

Out of hours work.


Pages 41,42,43

• Preop assessment – anaesthetic review if BMI > 40 +other comorbidities • Oxford Head Elevation Laryngoscopy Pillow (HELP) • Videolaryngoscopy

Obstetric anaesthesia

Page 47

• Dedicated CMAC • Dedicated HELP pillow • Manujet plugged in at all times

Mid Essex Hospital Services NHS Trust

Management of Failed Adult Intubation on the Maternity Unit 2013

4.4 Full monitoring should be established and the patient positioned in the optimal intubating position (“sniffing the morning air”, ideally with two pillows). The OXFORD HELP pillow must be used in obese patients to aid optimal positioning.

PROMPT Course Manual

CUP 2012


In pregnant women, and in particular those with large breasts or who are obese, it can be useful to adopt the ‘ramped’ position. This has been shown to improve the view of the vocal cords at laryngoscopy, making intubation easier. The ramped position aims to create a horizontal line between the sternal notch and the external auditory meatus, as shown in figure 4.2. The position can be achieved using purpose-made pillows such as the Oxford HELP (Head Elevating Laryngoscopy Pillow)





NICEACSA standards with full GPAS references 2016 [PDF]

Remove:  Royal College of Anaesthetists source – 31 August 2016

…assist patient positioning, for example Oxford head elevating laryngoscopy pillow (HELP), weighing scales, sliding sheets and hoists…undertaken in the main theatre suite. This arrangement may be more flexible for complex work and avoids duplicating theatre skills and…

See below for full citation

Guidelines for the Provision of Anaesthetic Services (GPAS) 2014 [PDF]

Remove:  Royal College of Anaesthetists source – 18 June 2014

…suite. This arrangement may be more flexible for complex work and avoids duplicating…positioning, for example Oxford head elevating laryngoscopy pillow