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Nowhere is redundancy more indispensable than extended range cave diving. Training and practice in this discipline ensure divers are equipped with backup regulators, gauges, lights, and adequate breathing gas for a safe exit, emergencies, and decompression. Depending on penetration distances and depth, open circuit cave diving may require carrying more gas cylinders than can be logistically managed by the diver themselves while maintaining safe gas supply margins. Consequently, divers are forced to either stage cylinders in the cave prior to the dive or rely on resupply from support divers. Both scenarios have significant drawbacks. Due to the improved efficiency of breathing gas utilisation and other advantages, closed circuit rebreathers (CCR) have enabled extended range cave diving. With increasing depths, penetration distances, and bottom times, these divers must also plan for an increasing amount of open circuit bail-out gas in the event of CCR failure. Staged cylinders have traditionally been utilised, but this strategy has limitations due to the advanced dives needed to place them and equipment degradation due to prolonged water immersion, which can often result in cylinder and regulator corrosion with consequent leakage of contents over time. Consequently, a growing number of CCR divers are foregoing open-circuit bailout altogether by carrying an additional CCR system for bailout. Although these bailout rebreathers may facilitate further exploration and have certain advantages, the risks of diving with two complex machines remain to be clearly defined.

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OBJECTIVE: To gather multicenter data on the incidence of second-stage cesarean sections and suggest alternative methods by which the data can be represented. METHODS: Retrospective, observational study over a 12-month study period. Numbers of term, singleton live births were collated from each of six maternity units. Data were separated by mode of delivery-unassisted vaginal birth, assisted (instrumental) vaginal delivery and elective, first-stage, and second-stage cesarean sections. Second-stage cesarean sections were expressed as a proportion of all deliveries, of all laboring women (i.e. excluding elective cesarean sections), and all women who reach full dilatation (i.e. excluding elective and first-stage cesarean sections). RESULTS: Of the 28 867 deliveries included in the analysis, 493 of these were second-stage cesarean sections. This represented an incidence of 1.7% of all deliveries, 2.0% of all women in labor, and 2.5% of all women who reach full dilatation. CONCLUSION: Second-stage cesarean sections continue to be common. Safe delivery of a deeply impacted fetal vertex is essential in modern obstetric practice.

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The surgical setting is a highly complex environment where, in ideal conditions, everything should be under control to ensure a positive outcome. However, the existing complexity opens the possibility for multiple failures along the process and many of those failures are related to what is call the non-technical skills of the members of the team. We cannot eradicate human error, but we can try to avoid future mistakes in our daily practice introducing the awareness for providing a high-quality care in which patient safety is crucial. This paper presents an easy approach to concepts and teaching possibilities of those non-technical skills.

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The recent outbreak of SARS-CoV-2 has prompted healthcare professionals to re-design and modify the standards of care and operating procedures relevant to dealing with suspected or confirmed cases of COVID-19. The aim of this review is to highlight the key recommendations related to obstetric anaesthesia from scientific bodies in the United Kingdom and United States and to summarize recently developed and implemented clinical pathways for care of obstetric patients - specifically those requiring urgent general anaesthesia for caesarean section within a large maternity unit in London. The need to perform an emergency operative delivery in a timely manner while ensuring clinicians are suitably equipped and protected represents a uniquely challenging scenario, given the higher risk of viral transmission with aerosol generating procedures. In these settings, emphasis needs to be put on meticulous preparation, safety checklists and specific equipment and staffing adjustments. We present a structured framework comprised of four critical steps aimed to facilitate the development of local strategies and protocols.

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The improvement of surgical outcomes has been achieved working under the assumption that they are mainly the result of technical skills. This model, although correct, is not exhaustive and has left out many variables that affect outcomes, of which a number can be grouped under the label of non-technical skills, which is a subset of human factors. Non-technical skills are developed to facilitate a shared mental model between team members, teams and their operational environment. They include situation awareness, decision-making, communication, teamwork, leadership and performance-shaping factors. The importance of these non-technical skills has been highlighted during the investigations of severe accidents in many high-risk industries and healthcare. There is an almost untapped opportunity to improve outcomes focusing on non-technical skills because until recently there has been an under-investment of time and resources in this area compared with technical skills. This theoretical paper supports the adoption of a broader model of human performance as a function of technical and non-technical skills and the cultural and organisational context where these are at play. We also aim to highlight a pathway to increase the investment in non-technical skills following the most updated evidence.

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