Anaesthesia services in developing countries: defining the problems

We describe the use of a questionnaire to define the difficulties in providing anaesthesia in Uganda. The results show that 23% of anaesthetists have the facilities to deliver safe anaesthesia to an adult, 13% to deliver safe anaesthesia to a child and 6% to deliver safe anaesthesia for a Caesarean section. The questionnaire identified shortages of personnel, drugs, equipment and training that have not been quantified or accurately described before. The method used provides an easy and effective way to gain essential data for any country or national anaesthesia society wishing to investigate anaesthesia services in its hospitals. Solutions require improvements in local management, finance and logistics, and action to ensure that the importance of anaesthesia within acute sector healthcare is fully recognised. Major investment in terms of personnel and equipment is required to modernise and improve the safety of anaesthesia for patients in Uganda.

Analgesia and satisfaction in childbirth (the Queen Charlotte's 1000 Mother Survey)

Maternal satisfaction with the experience of childbirth was investigated in 1000 women having a vaginal delivery of a live child. Effective pain relief did not ensure a satisfactory birth experience. Epidural block produced the most effective analgesia but there were more dissatisfied women among the epidural patients than among those who did not receive this analgesia (p less than 0.05). Bad experience scores were evaluated one year later and were clearly related to a forceps delivery and long labour, both of which were more common in the epidural group. The desirability of an "epidural on demand" service should be tested against an "epidural when necessary" service.

Advantage or disadvantage of episiotomy compared with spontaneous perineal laceration

In a prospective clinical investigation of 2,144 deliveries, we elucidate the indications for episiotomy and how different methods of anesthesia affect the frequency of episiotomy and the perineal problems after episiotomy compared with those after spontaneous perineal laceration. We found a significantly higher infection rate (p less than 0.001) and a longer healing period in the episiotomy group. These differences remain even if only primigravida or the indication, imminent perineal laceration, is studied. The results indicate that many women will unnecessarily suffer after an episiotomy. The patient's subjective problems are significantly increased, both immediately and at the 3-month postoperative follow-up.

Maternal mortality in resource-poor settings: policy barriers to care

Maternal mortality remains one of the most daunting public health problems in resource-poor settings, and reductions in maternal mortality have been identified as a prominent component of the United Nations Millennium Development Goals. The World Health Organization estimates that 515000 women die each year from pregnancy-related causes, and almost all of these deaths occur in developing countries. Evidence has shown that access to and utilization of high-quality emergency obstetric care (EmOC) is central to efforts aimed at reducing maternal mortality. We analyzed health care policies that restrict access to life-saving EmOC in most resource-poor settings, focusing on examples from rural India, a country of more than 1 billion people that contributes approximately 20% to 24% of the world's maternal deaths.

Emergency Caesarean section: best practice*

Good multidisciplinary communication is crucial to the safe management of women requiring non-elective Caesarean section. Anaesthetists should participate actively in resuscitation of the fetus in utero; relief of aortocaval compression is paramount. Epidural top-up with levobupivacaine 0.5% is the anaesthetic of choice for women who have been receiving labour epidural analgesia. If epidural top-up fails to provide bilateral light touch anaesthesia from S5 - T5, a combined spinal-epidural technique with small intrathecal dose of local anaesthetic is a useful approach. Pre-eclampsia is not a contra-indication to single-shot spinal anaesthesia, which is the technique of choice for most women presenting for Caesarean section without an epidural catheter in situ. Induction and maintenance doses of drugs for general anaesthesia should not be reduced in the belief that the baby will be harmed. Early postoperative observations are geared towards the detection of overt or covert haemorrhage.

A national survey of obstetric anaesthetic handovers

The handover of patient information between shifts enables continuity of care and increases patient safety. We surveyed UK practice during handovers in obstetric anaesthesia. A questionnaire was sent to 239 lead consultant obstetric anaesthetists to record routine practice in their unit and individual opinion about handover procedures. Responses were received from 168 anaesthetists, a 70% response rate. Handover policies were available in 10% of units. Most (76%) responding units had an allocated time for handover. In most units (76%), the duration of handover was reported as being < 15 min but the actual duration and depth of any discussion involved were not specified. Handovers were rarely documented in writing (7%). Consultant anaesthetists were most likely to be present at the morning handover and few handovers were multidisciplinary. Four percent of units reported critical incidents following inadequate handovers in the past 12 months. We identify features in handover procedures that could be improved.

Guidelines to the practice of anesthesia revised edition 2013

OVERVIEW

The Guidelines to the Practice of Anesthesia Revised Edition 2013 (the guidelines) were prepared by the Canadian Anesthesiologists' Society (CAS), which reserves the right to determine their publication and distribution. Because the guidelines are subject to revision, updated versions are published annually. The Guidelines to the Practice of Anesthesia Revised Edition 2013 supersedes all previously published versions of this document. Although the CAS encourages Canadian anesthesiologists to adhere to its practice guidelines to ensure high-quality patient care, the society cannot guarantee any specific patient outcome. Each anesthesiologist should exercise his or her own professional judgement in determining the proper course of action for any patient's circumstances. The CAS assumes no responsibility or liability for any error or omission arising from the use of any information contained in its Guidelines to the Practice of Anesthesia.

ACOG practice bulletin. Obstetric analgesia and anesthesia. Number 36, July 2002. American College of Obstetrics and Gynecology

Labor results in severe pain for many women. There is no other circumstance in which it is considered acceptable for a person to experience untreated severe pain, amenable to safe intervention, while under a physician's care. In the absence of a medical contraindication, maternal request is a sufficient medical indication for pain relief during labor. Pain management should be provided whenever it is medically indicated. The purpose of this document is to help obstetrician-gynecologists understand the available methods of pain relief to facilitate communication with their colleagues in the field of anesthesia, thereby, optimizing patient comfort while minimizing the potential for maternal and neonatal morbidity and mortality.

A Mixed-Method Design Evaluation of the SAFE Obstetric Anaesthesia Course at 4 and 12-18 Months After Training in the Republic of Congo and Madagascar

BACKGROUND

Maternal mortality in low- and middle-income countries (LMICs) is higher than in high-income countries (HICs), and poor anesthesia care is a contributing factor. Many anesthesia complications are considered preventable with adequate training. The Safer Anaesthesia From Education Obstetric Anaesthesia (SAFE-OB) course was designed as a refresher course to upgrade the skills of anesthesia providers in low-income countries, but little is known about the long-term impact of the course on changes in practice. We report changes in practice at 4 and 12-18 months after SAFE-OB courses in Madagascar and the Republic of Congo.

METHODS

We used a concurrent embedded mixed-methods design based on the Kirkpatrick model for evaluating educational training courses. The primary outcome was qualitative determination of personal and organizational change at 4 months and 12-18 months. Secondary outcomes were quantitative evaluations of knowledge and skill retention over time. From 2014 to 2016, 213 participants participated in 5 SAFE-OB courses in 2 countries. Semistructured interviews were conducted at 4 and 12-18 months using purposive sampling and analyzed using thematic content analysis. Participants underwent baseline knowledge and skill assessment, with 1 cohort reevaluated using repeat knowledge and skills tests at 4 months and another at 12-18 months.

RESULTS

At 4 months, 2 themes of practice change (Kirkpatrick level 3) emerged that were not present at 12-18 months: neonatal resuscitation and airway management. At 12-18 months, 4 themes emerged: management of obstetric hemorrhage, management of eclampsia, using a structured approach to assessing a pregnant woman, and management of spinal anesthesia. With respect to organizational culture change (Kirkpatrick level 4), the same 3 themes emerged at both 4 and 12-18 months: improved teamwork, communication, and preparation. Resistance from peers, lack of senior support, and lack of resources were cited as barriers to change at 4 months, but at 12-18 months, very few interviewees mentioned lack of resources. Identified catalysts for change were self-motivation, credibility, peer support, and senior support. Knowledge and skills tests both showed an immediate improvement after the course that was sustained. This supports the qualitative responses suggesting personal and organizational change.

CONCLUSIONS

Participation at a SAFE-OB course in the Republic of Congo and in Madagascar was associated with personal and organizational changes in practice and sustained improvements in knowledge and skill at 12-18 months.

Lumbar epidural analgesia--the pursuit of perfection. With special reference to midwife participation

Lumbar epidural block for the relief of pain in labour has been reported as having a variable frequency of success. Analysis of a personal series of 1544 epidurals carried out with the close co-operation of midwives shows that, with attention to details of management, satisfactory analgesia can be assured in well over 90% of all labours. Total failure should be a rare event and the causes of more than half the partial failures can be traced to errors of management.

Updated Australian consensus statement on management of inherited bleeding disorders in pregnancy

INTRODUCTION

There have been significant advances in the understanding of the management of inherited bleeding disorders in pregnancy since the last Australian Haemophilia Centre Directors' Organisation (AHCDO) consensus statement was published in 2009. This updated consensus statement provides practical information for clinicians managing pregnant women who have, or carry a gene for, inherited bleeding disorders, and their potentially affected infants. It represents the consensus opinion of all AHCDO members; where evidence was lacking, recommendations have been based on clinical experience and consensus opinion.

MAIN RECOMMENDATIONS

During pregnancy and delivery, women with inherited bleeding disorders may be exposed to haemostatic challenges. Women with inherited bleeding disorders, and their potentially affected infants, need specialised care during pregnancy, delivery, and postpartum, and should be managed by a multidisciplinary team that includes at a minimum an obstetrician, anaesthetist, paediatrician or neonatologist, and haematologist. Recommendations on management of pregnancy, labour, delivery, obstetric anaesthesia and postpartum care, including reducing and treating postpartum haemorrhage, are included. The management of infants known to have or be at risk of an inherited bleeding disorder is also covered.

CHANGES IN MANAGEMENT AS A RESULT OF THIS STATEMENT

Key changes in this update include the addition of a summary of the expected physiological changes in coagulation factors and phenotypic severity of bleeding disorders in pregnancy; a flow chart for the recommended clinical management during pregnancy and delivery; guidance for the use of regional anaesthetic; and prophylactic treatment recommendations including concomitant tranexamic acid.

Beneficial effect of epidural anesthesia on oxygen consumption in a parturient with adult respiratory distress syndrome

Multifactorial increases in oxygen consumption during labor may exceed available oxygen supply. Cumulative subclinical oxygen debt could be clinically detrimental to both patient and fetus. We have reported the use of continuous mixed venous oxygen saturation monitoring to identify changes in oxygen consumption after painful uterine contractions in a critically ill parturient. We used continuous venous saturation monitoring to document the effects of epidural analgesia on oxygen balance in our patient. The absence of venous desaturation with contractions after abatement of labor pains confirmed that pain was the major cause of increased oxygen consumption in this critically ill parturient. Broader use of mixed venous saturation monitoring may allow detection of oxygen deficits during labor and direct appropriate therapy in other critically ill parturients. Similar applications and results have been noted for other disease states in nonpregnant patients.

Where is T5? A survey of anaesthetists

The extent of a regional block for Caesarean section must be tested and documented before surgery commences. In recent years a block to 'touch' that includes T5 has increasingly been considered the best predictive test for a pain-free Caesarean section. Our survey examines the consistency with which different anaesthetists identified the location of the T5 dermatome. Seventy-three anaesthetists were asked to mark a point on an anatomical picture to indicate where they would test for T5. Overall there was good agreement on the location of the T5 dermatome, but one in seven anaesthetists were inaccurate by two or more dermatomes. There were no statistically significant differences between the subgroups of senior house officer, specialist registrar and consultant anaesthetists. The knowledge of relevant dermatome levels should be an integral part of obstetric anaesthetic training.

A survey of obstetric anaesthesia practice in British Columbia

Hospitals and anaesthetists in British Columbia were surveyed by means of questionnaires to assess patterns of obstetric anaesthesia practice, qualifications and numbers of obstetric anaesthesia personnel, hospital obstetric facilities and facilities and protocols for neonatal resuscitation. It was apparent that a large proportion of the obstetric anaesthesia service in this province was being provided by physicians who were not trained, nor certified, as anaesthesia specialists. Preanaesthetic assessment in the obstetric units differed in attitude and practice from the standards expected in the general operating rooms. There was also in community hospitals a significant incidence of failure to follow certain accepted safe practices (in obstetric patients), such as preinduction hydration and oxygenation, cricoid pressure during intubation and prevention of aortocaval compression. However, administration of general anaesthesia without endotracheal intubation, was rare in this survey. Post-anaesthetic recovery facilities in obstetric units were conspicuously deficient, even in the larger hospitals. The majority of community hospitals lacked written protocols for neonatal resuscitation; and the number of institutions reporting that the neonatal heart rates and temperatures were not routinely monitored is of concern. It is recommended that minimum standards for training in obstetric anaesthesia should be clearly defined; and provision should be made for revision and upgrading of knowledge and skills for physicians practicing anaesthesia in smaller community hospitals.

Caesarean section provision and readiness in Tanzania: analysis of cross-sectional surveys of women and health facilities over time

OBJECTIVES

To describe trends in caesarean sections and facilities performing caesareans over time in Tanzania and examine the readiness of such facilities in terms of infrastructure, equipment and staffing.

DESIGN

Nationally representative, repeated cross-sectional surveys of women and health facilities.

SETTING

Tanzania.

PARTICIPANTS

Women of reproductive age and health facility staff.

MAIN OUTCOME MEASURES

Population-based caesarean rate, absolute annual number of caesareans, percentage of facilities reporting to perform caesareans and three readiness indicators for safe caesarean care: availability of consistent electricity, 24 hour schedule for caesarean and anaesthesia providers, and availability of all general anaesthesia equipment.

RESULTS

The caesarean rate in Tanzania increased threefold from 2% in 1996 to 6% in 2015-16, while the total number of births increased by 60%. As a result, the absolute number of caesareans increased almost fivefold to 120 000 caesareans per year. The main mechanism sustaining the increase in caesareans was the doubling of median caesarean volume among public hospitals, from 17 caesareans per month in 2006 to 35 in 2014-15. The number of facilities performing caesareans increased only modestly over the same period. Less than half (43%) of caesareans in Tanzania in 2014-15 were performed in facilities meeting the three readiness indicators. Consistent electricity was widely available, and 24 hour schedules for caesarean and (less systematically) anaesthesia providers were observed in most facilities; however, the availability of all general anaesthesia equipment was the least commonly reported indicator, present in only 44% of all facilities (34% of public hospitals).

CONCLUSIONS

Given the rising trend in numbers of caesareans, urgent improvements in the availability of general anaesthesia equipment and trained anaesthesia staff should be made to ensure the safety of caesareans. Initial efforts should focus on improving anaesthesia provision in public and faith-based organisation hospitals, which together perform more than 90% of all caesareans in Tanzania.

Correlating obstetric epidural anaesthesia performance and psychomotor aptitude

We investigated the correlation between the scores attained on computerised psychometric tests, measuring psychomotor and information processing aptitudes, and learning obstetric epidural anaesthesia. Ten anaesthetic trainees performed an adaptive tracking task (ADTRACK 3) and one information management task (MAZE) from the MICROPAT testing system. They then embarked on a standardised obstetric anaesthesia training programme prior to performing obstetric on-call duties. The success or failure of their first 50 obstetric epidurals was recorded. There was a significant correlation between mean obstetric epidural failure rate for the second 25 consecutive epidurals and ADTRACK 3 (r = -0.579, p = 0.04) scores. The correlation between the means of the first 25 and 50 consecutive epidurals and ADTRACK 3 scores was not significant. There was no significant correlation between epidural failure rate and MAZE scores. The ratios of the mean epidural failure rate for the last 25 epidurals to the mean for the first 25 epidurals were not significantly correlated with ADTRACK 3 or MAZE scores. Psychomotor abilities appear to be poor determinants of trainees' initial proficiency at obstetric epidural anaesthesia or of trainees' rates of progress during early obstetric epidural training, but may be determinants of an individual's performance after the initial training phase.

[Distribution of anesthesia practice, types of anesthesia, and human resources in Catalonia, Spain, in 2003]

BACKGROUND AND OBJECTIVE

The aim of this arm of the ANESCAT 2003 study was to describe the temporal distribution and types of anesthesia used in Catalonia, Spain, in 2003, along with the associated human resources used.

PATIENTS AND METHOD

Data were used from a survey of 23,136 anesthetic procedures collected on 14 randomly selected days in 2003 and an individual questionnaire was completed by 765 anesthesiologists working in Catalonia.

RESULTS

Anesthesia practice was divided into that associated with surgery (78.4%), obstetrics (11.3%), and other nonsurgical procedures (10.4%). Of all anesthetic procedures performed, 84.3% took place in operating theaters and 7.0% in obstetric areas. Emergency procedures accounted for 20.3% of the total. Most procedures (71.2%) were undertaken within 08:00 and 16:00 h, and the lowest number of procedures performed on workdays took place on Fridays. The median duration of anesthesia was 60 minutes. The most common technique was regional anesthesia (41.4%), with spinal block being the most widely used. There were an estimated 12.5 anesthesiologists per 100,000 inhabitants, with a median (10th-90th percentile) age of 45 (34-57) years; women made up 47.2% of that group. The mean number of standard working hours was 46 hours per week and 65% of anesthesiologists also undertook on duty shifts. Anesthesiologists spent 77% of their time performing anesthesia and the remainder in postoperative recovery and critical care units and pain clinics.

CONCLUSIONS

Emergency anesthesia represents 20% of the total workload and obstetrics and nonsurgical procedures another 20%. The use of regional anesthesia was very widespread. The population density of anesthesiologists is comparable to that of other European countries, but with a higher proportion of women.

A complementary approach to outcome analysis in the parturient

As part of routine Quality Assurance (QA) activity in our Department, a quarterly audit of patient outcome after obstetric anaesthetic care is completed. Previously this consisted of a technical (criteria-based) audit and some assessment of patient satisfaction. The most recent audit was carried out by a volunteer providing a cost-effective and flexible means of data collection. In addition, the focus of this audit has shifted to emphasize the importance of 'Patient Described Outcome' (PDO). These data are gathered by means of an interview by the volunteer and a patient questionnaire (PDO factors) and a chart audit (technical details). Simple analysis of data is done to assess both technical and PDO information. Technical details allow comparison to internal and published standards. PDO data provide a complementary means of assessing Structure, Process and Outcome. Thus, the audit permits internal and external evaluation of departmental activities and feedback of QA information necessary to a comprehensive QA program.

An audit of the efficacy of a structured handover tool in obstetric anaesthesia

INTRODUCTION

The SAFE handover tool was developed to reduce critical omissions during handovers in obstetric anaesthesia. It comprises a simple proforma onto which the outgoing team documents patients who fall into one of four anaesthetically relevant categories: Sick patients; At-risk patients (of emergency caesarean section, major haemorrhage or anaesthetic problems); Follow-ups; and Epidurals. We hypothesised that its use would reduce the number of critical omissions at handover.

METHODS

The efficacy of the SAFE handover tool was assessed through several audit cycles in a single maternity unit. The four SAFE categories were considered the gold standard, since they encompassed the consensus opinion of senior obstetric anaesthetists with respect to parturients they most wanted to know about at handover. Against these criteria it was possible to compare the number of cases that should have been handed-over against the number that were actually handed-over.

RESULTS

After implementation of the handover tool, patients were four times more likely to be handed-over than without the use of the tool: an increase from 49% to 79% of relevant cases (P<0.0001, OR 4.1, 95% CI 2.19-7.6). The handover tool was particularly effective at increasing the handover rates of Sick and At-risk parturients, which increased from 21% to 67% (P<0.0001, OR 7.7, 95% CI 2.7-21.7) and 25% to 78% (P<0.01, OR 9.9, 95% CI 1.6-61.6), respectively.

CONCLUSION

The SAFE handover tool significantly increased handover rates of anaesthetically relevant parturients. It is easy to remember and consistent with UK National Health Service Litigation Authority's guidance on risk management in maternity units.