Safe Obstetric Anesthesia Research Articles

Effective Epidural Analgesia during Labor: A Feasible Method to Decrease Unnecessary Cesarean Deliveries in Thailand

Thailand has reported a high rate of cesarean delivery (45%–55%), prompting global concern about an increase in cesarean delivery rates. Fear of labor pains is one of the most common reasons pregnant women opt for cesarean delivery. Labor pain is associated with cervix dilation and fetal descent into the birth canal, which is exacerbated by ischemic pain caused by uterine contraction. Modern medical and non-medical techniques have demonstrated efficacy in reducing pain and ensuring safety during labor and delivery. Neuraxial labor analgesia is a highly effective medical pain relief method but has no effect on the rate of cesarean or assisted vaginal delivery. Medication administration for pain relief during labor, using a combination of a local anesthetic and an opioid, was observed to be transmitted across the placenta to the fetus, but had no significant effects on fetal outcomes in mothers who chose epidural analgesia. There are several techniques for administering neuraxial labor analgesia that can be customized for each pregnant woman. To achieve the most wonderful feasible labor and delivery experience, effective epidural labor analgesia is a crucial technique for reducing anxiety and suffering about labor pain. It is safe, widely used world-wide, and effective. Implementing a policy to increase public and medical providers awareness and acceptance of labor pain relief, as well as establishing a safe obstetric anesthesia service provided by obstetric anesthesiologists, could improve maternal and neonatal safety while significantly lowering the rate of unnecessary cesarean deliveries.

Impact of conflict and pandemic on women's health in Latin America: implementation to improve equity in the provision and access to safe obstetric anesthesia

Latin America is one of the regions with the most significant inequalities in women’s health as a result of factors such as social disparity, lack of work opportunities, unemployment, violence, and corruption. Adding a health crisis like the COVID-19 pandemic to these elements created a perfect storm that perpetuated extreme inequalities. The crisis negatively impacted Latin-American women, and economic recession in our region was one of the main consequences, resulting in women compared with men having higher rates of poverty, poorer access to and experience of healthcare, a wider gender gap, and adverse effects on well-being. This consequently made women more vulnerable. Several initiatives to allow better access and to provide safe anesthesia to pregnant patients have been taken in the region to improve obstetric patient care during the pandemic and beyond. Education has been pivotal and one of the most essential tools in bridging the gap in inequalities between men and women.

Anesthesia management in a post Covid-19 obstetric patient-What we need to know.

The outbreak of the coronavirus disease (COVID)-19 pandemic has led to unprecedented challenges globally. At the outset of the receding second wave and third wave of COVID-19, many patients who have recovered from the severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) are coming for elective/emergency surgery. This demands a noteworthy emphasis on the post-COVID-19 obstetric patients. The administration of quality and safe obstetric anesthesia are quite challenging in this mentioned subset due to the overlap of signs and symptoms of COVID-19 with the constitutional signs and symptoms of pregnancy. The physiological changes in normal pregnancy and vascular, metabolic alterations in high-risk pregnancy may affect or exacerbate the pathogenesis or clinical presentation of COVID-19, respectively. This article highlights the specific concerns in recovered COVID-19 pregnant patients with associated comorbidity posted for surgery and their repercussions on anesthesia management.

Considerations and strategies in the organisation of obstetric anaesthesia care during the 2019 COVID-19 outbreak in Singapore

The provision of safe obstetric anaesthesia services is essential during the COVID-19 global outbreak. The identification of the ‘high-infection risk’ parturient can be challenging especially with the rapidly changing risk criteria for COVID-19 ‘cases’. A multidisciplinary taskforce is required to review the infection control protocols and workflows for managing the parturient for labour analgesia and for caesarean section in order to minimize infection risk to healthcare staff and other parturients. A constant review of such processes is needed to enhance efficiency and to optimise use of finite resources. Good communication between health officials, institutional leadership and ground staff is essential for the dissemination of information.

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.

Training initiatives for safe obstetric anesthesia care

Training initiatives for safe obstetric anesthesia care

Key bottlenecks to the provision of safe obstetric anaesthesia in low- income countries; a cross-sectional survey of 64 hospitals in Uganda

BackgroundDespite recent advances in surgery and anaesthesia which significantly improve safety, many health facilities in low-and middle-income countries (LMICs) remain chronically under-resourced with inability to cope effectively with serious obstetric complications (Knight et al., PLoS One 8:e63846, 2013). As a result many of these countries still have unacceptably high maternal and neonatal mortality rates. Recent data at the national referral hospitals in East Africa reported that none of the national referral hospitals met the World Federation of Societies of Anesthesiologists (WFSA) international standards required to provide safe obstetric anaesthesia (Epiu I: Challenges of Anesthesia in Low-and Middle-Income Countries. WFSA; 2014 http://wfsa.newsweaver.com/Newsletter/p8c8ta4ri7a1wsacct9y3u?a=2&p=47730565&t=27996496). In spite of this evidence, factors contributing to maternal mortality related to anaesthesia in LMICs and the magnitude of these issues have not been comprehensively studied. We therefore set out to assess regional referral, district, private for profit and private not-for profit hospitals in Uganda.MethodsWe conducted a cross-sectional survey at 64 government and private hospitals in Uganda using pre-set questionnaires to the anaesthetists and hospital directors. Access to the minimum requirements for safe obstetric anaesthesia according to WFSA guidelines were also checked using a checklist for operating and recovery rooms.ResultsResponse rate was 100% following personal interviews of anaesthetists, and hospital directors. Only 3 of the 64 (5%) of the hospitals had all requirements available to meet the WFSA International guidelines for safe anaesthesia. Additionally, 54/64 (84%) did not have a trained physician anaesthetist and 5/64 (8%) had no trained providers for anaesthesia at all. Frequent shortages of drugs were reported for regional/neuroaxial anaesthesia, and other essential drugs were often lacking such as antacids and antihypertensives. We noted that many of the anaesthesia machines present were obsolete models without functional safety alarms and/or mechanical ventilators. Continuous ECG was only available in 3/64 (5%) of hospitals.ConclusionWe conclude that there is a significant lack of essential equipment for the delivery of safe anaesthesia across this region. This is compounded by the shortage of trained providers and inadequate supervision. It is therefore essential to strengthen anaesthesia services by addressing these specific deficiencies. This will include improved training of associate clinicians, training more physician anaesthetists and providing the basic equipment required to provide safe and effective care. These services are key components of comprehensive emergency obstetric care and anaesthetists are crucial in managing critically ill mothers and ensuring good surgical outcomes.

Safe obstetric anaesthesia in low- and middle-income countries

Safe obstetric anaesthesia in low- and middle-income countries

Challenges of Anesthesia in Low- and Middle-Income Countries: A Cross-Sectional Survey of Access to Safe Obstetric Anesthesia in East Africa.

The United Nations 2015 Millennium Development Goals targeted a 75% reduction in maternal mortality. However, in spite of this goal, the number of maternal deaths per 100,000 live births remains unacceptably high across Sub-Saharan Africa. Because many of these deaths could likely be averted with access to safe surgery, including cesarean delivery, we set out to assess the capacity to provide safe anesthetic care for mothers in the main referral hospitals in East Africa. A cross-sectional survey was conducted at 5 main referral hospitals in East Africa: Uganda, Kenya, Tanzania, Rwanda, and Burundi. Using a questionnaire based on the World Federation of the Societies of Anesthesiologists (WFSA) international guidelines for safe anesthesia, we interviewed anesthetists in these hospitals, key informants from the Ministry of Health and National Anesthesia Society of each country (Supplemental Digital Content, http://links.lww.com/AA/B561). Using the WFSA checklist as a guide, none of respondents had all the necessary requirements available to provide safe obstetric anesthesia, and only 7% reported adequate anesthesia staffing. Availability of monitors was limited, and those that were available were often nonfunctional. The paucity of local protocols, and lack of intensive care unit services, also contributed significantly to poor maternal outcomes. For a population of 142.9 million in the East African community, there were only 237 anesthesiologists, with a workforce density of 0.08 in Uganda, 0.39 in Kenya, 0.05 in Tanzania, 0.13 in Rwanda, and 0.02 anesthesiologists in Burundi per 100,000 population in each country. We identified significant shortages of both the personnel and equipment needed to provide safe anesthetic care for obstetric surgical cases across East Africa. There is a need to increase the number of physician anesthetists, to improve the training of nonphysician anesthesia providers, and to develop management protocols for obstetric patients requiring anesthesia. This will strengthen health systems and improve surgical outcomes in developing countries. More funding is required for training physician anesthetists if developing countries are to reach the targeted specialist workforce density of the Lancet Commission on Global Surgery of 20 surgical, anesthetic, and obstetric physicians per 100,000 population by 2030.

Safe obstetric anaesthesia: Time to face new challenges

Safe obstetric anaesthesia: Time to face new challenges

Effect Of Anaesthesia On Morbidity And Mortality In Emergency Caesarean Section Patients In Calabar, Nigeria

The outcome of obstetric anaesthesia following emergency Caesarean sections was studied retrospectively. The study which was carried out in the University of Calabar Teaching Hospital covered the period between 1st August 1995 – 31st August 2000. The aim was to evaluate the morbidity and mortality from anaesthesia during the period under review. Out of 1533 Caesarean sections performed 920 were emergency giving an emergency Caesearean section rate of 60%. The main indications for the emergency Caesearean sections were obstructed labour 220 (23.9%), foetal distress 193 (19.9%) and pre-eclampsia/eclampsia 142 (15.4%). General anaesthesia was employed in 555 (60.3%) while spinal was used in 365 (39.7%). Morbidity recorded in the spinal anaesthesia group were severe hypotension 110(30%), post dural puncture headache (PDPH) 46(2.6%) and transient neurologic symptoms (TNSs) 1 (0.022%). No mortality was recorded in the spinal anaesthesia group. Morbidity in the general anaesthesia group was mainly sore throat 364(65.6%) Five deaths were recorded in the general anaesthesia group. Four deaths occurred probably due to hypoxia following failed intubation, while the fifth death followed an unsuccessful cardiopulmonary resuscitation in an eclamptic patient, or due to eclampsia. From this study, mortality was recorded in the general anaesthesia group. Spinal anaesthesia, when there is no contra- indication is therefore recommended for safe obstetric anaesthesia. Brisk pre-operative evaluation, optimization of pre-operative clinical status of parturients and competent anaesthetist are of paramount importance. Key words: Obstetric anaesthesia; emergency caesarean section; morbidity and mortality. Nigerian Journal of Physiological Sciences Vol.18(1-2) 2003: 77-81

Safe obstetric anaesthesia—just an ideal?

Safe obstetric anaesthesia—just an ideal?