Adolescent gynaecology: anaesthetic and peri-operative care implications.

Adolescents represent a quarter of the world's population, yet their specific healthcare needs have often not been acknowledged. Whilst many operations in this population will be performed in specialist tertiary centres and children's hospitals, it is likely that care will be sought in a variety of healthcare settings, and so it is important to have an understanding of the particular approach to this age group. Paediatric and adolescent gynaecology emerged as a speciality in 2000 with the inauguration of the British Society for Paediatric and Adolescent Gynaecology, a specialist society of the Royal College of Obstetricians and Gynaecologists. This is a multidisciplinary group, comprising paediatricians, paediatric surgeons, psychologists and nurses, although the majority of the members are gynaecologists. In this review, we will describe the peri-operative implications of adolescent gynaecological surgery and the considerations that need to be applied to this specific age group, such as consent, the operative setting and key personnel. We will also discuss specialist situations which are likely to fall to an adolescent gynaecology setting, such as management of those with Mullerian abnormalities, which often present with pelvic pain in adolescence. We discuss those with a history of ritual female genital cutting (female genital mutilation), trans men and those with significant learning difficulties. In all circumstances, teamwork, reflection and pragmatism are key.

Anaesthetic management during labour of a manifesting carrier of Duchenne muscular dystrophy.

We describe the peripartum anaesthetic management of a 36-year-old woman who was a manifesting carrier of Duchenne muscular dystrophy. Duchenne muscular dystrophy is an X-linked recessive disorder affecting young males associated with severe complications during anaesthesia if depolarising neuromuscular blocking drugs and volatile agents are used. A manifesting carrier is a heterozygous female who demonstrates the disease in a milder form than in males. This probably occurs because of skewed X-inactivation. We planned to establish regional anaesthesia should an operation be necessary during labour or delivery and to use propofol total intravenous anaesthesia and rocuronium if general anaesthesia became unavoidable. At 37 weeks, the woman went into spontaneous labour, but fetal distress necessitated caesarean section for which combined spinal-epidural anaesthesia was used.

An organized approach to the control of hazards to health at work.

Shell U.K. has an approach which facilitates the implementation of its occupational hygiene programme in its many locations. The main elements of the system are Company Policy, Standards, Methods and Management. The Policy sets the scene and is rigorous in its aims. The new COSHH legislation has emphasized particular duties which have influenced the approach. The Company Occupational Health Guidelines [Guidelines on Health at Work for Shell in the U.K. Shell U.K. Ltd, London (1989)] set the standards for control of exposure, among other things, and the Company adopts appropriate methods to achieve them. Of particular note is the Company's COSHH Programme [Implementation of the Shell U.K. Policy on the Control of Substances Hazardous to Health. Shell U.K. Ltd, London (1989)] which applies to all hazards to health (including physical and biological agents) in the workplace. Its introduction has been given full corporate support and is in the process of implementation. Appropriate procedures have been introduced for assessments of risk and for work histories. Guidance has been given on competence, reflecting a philosphy based on a team approach using local resources to the full, supported by corporate resources as required. The awards of the British Examining and Registration Board in Occupational Hygiene (1987) are used as the professional standard. Because of difficulties in obtaining basic hazard data, an internal core hazard data system (CHADS) [Core Hazard Data System. Shell U.K Ltd, London (1989)] has been introduced. The whole programme is managed through Occupational Hygiene Focal Points (OHFP) which represent local activities but also participate in corporate strategy. Through them the multidisciplinary approach is promoted, working in conjunction with local and sector Medical Advisers. Work done by the central Occupational Hygiene Unit is recorded and the reports are used for time management and recovery of costs. In its entirety, the approach is being used successfully to implement a comprehensive occupational hygiene programme in a diversified and dispersed industrial organization.