Method of Anesthesia and Perioperative Risk Factors, Maternal Anesthesia Complications, and Neonatal Mortality Following Cesarean Delivery in Africa: A Substudy of a 7-Day Prospective Observational Cohort Study.

BACKGROUND: The African Surgical Outcomes Study (ASOS) found that maternal mortality following cesarean delivery in Africa is 50 times higher than in high-income countries, and associated with obstetric hemorrhage and anesthesia complications. Mothers who died were more likely to receive general anesthesia (GA). The associations between GA versus spinal anesthesia (SA) and preoperative risk factors, maternal anesthesia complications, and neonatal outcomes following cesarean delivery in Africa are unknown. METHODS: This is a secondary explanatory analysis of 3792 patients undergoing cesarean delivery in ASOS, a prospective observational cohort study, across 22 African countries. The primary aim was to estimate the association between preoperative risk factors and the outcome of the method of anesthesia delivered. Secondary aims were to estimate the association between the method of anesthesia and the outcomes (1) maternal intraoperative hypotension, (2) severe maternal anesthesia complications, and (3) neonatal mortality. Generalized linear mixed models adjusting for obstetric gravidity and gestation, American Society of Anesthesiologists (ASA) category, urgency of surgery, maternal comorbidities, fetal distress, and level of anesthesia provider were used. RESULTS: Of 3709 patients, SA was performed in 2968 (80%) and GA in 741 (20%). Preoperative factors independently associated with GA for cesarean delivery were gestational age (adjusted odds ratio [aOR], 1.093; 95% confidence interval [CI], 1.052-1.135), ASA categories III (aOR, 11.84; 95% CI, 2.93-46.31) and IV (aOR, 11.48; 95% CI, 2.93-44.93), eclampsia (aOR, 3.92; 95% CI, 2.18-7.06), placental abruption (aOR, 6.23; 95% CI, 3.36-11.54), and ruptured uterus (aOR, 3.61; 95% CI, 1.36-9.63). SA was administered to 48 of 94 (51.1%) patients with eclampsia, 12 of 28 (42.9%) with cardiac disease, 14 of 19 (73.7%) with preoperative sepsis, 48 of 76 (63.2%) with antepartum hemorrhage, 30 of 55 (54.5%) with placenta previa, 33 of 78 (42.3%) with placental abruption, and 12 of 29 (41.4%) with a ruptured uterus. The composite maternal outcome "all anesthesia complications" was more frequent in GA than SA (9/741 [1.2%] vs 3/2968 [0.1%], P < .001). The unadjusted neonatal mortality was higher with GA than SA (65/662 [9.8%] vs 73/2669 [2.7%], P < .001). The adjusted analyses demonstrated no association between method of anesthesia and (1) intraoperative maternal hypotension and (2) neonatal mortality. CONCLUSIONS: Analysis of patients undergoing anesthesia for cesarean delivery in Africa indicated patients more likely to receive GA. Anesthesia complications and neonatal mortality were more frequent following GA. SA was often administered to high-risk patients, including those with eclampsia or obstetric hemorrhage. Training in the principles of selection of method of anesthesia, and the skills of safe GA and neonatal resuscitation, is recommended.

Retos durante la realización de cesáreas perimorten / Challenges during the performance of perimortem cesarean section

Introducción: El paro cardiaco en gestantes y la cesárea perimorten son infrecuentes. Estas constituyen catástrofes médicas que precisan atención inmediata. Realizar este proceder según normas adecuadas brinda mejores opciones a la madre y el feto. Cuba presta especial atención al binomio materno fetal, para ello emplea grandes recursos humanos y tecnológicos. Objetivo: Actualizar la información acerca de cesárea perimorten. Métodos: Se realizó una revisión en bases de datos que permitiese encontrar descripciones epidemiológicas, informes de casos, series de casos, comunicaciones personales, y estudios en diferentes contextos sanitarios, los cuales sirvieran de evidencia científica del tema. Resultados: El paro cardiaco en embarazadas es un evento infrecuente, la realización de una cesárea perimorten con tiempo reducido (4-5 min) resultó una opción efectiva. El trabajo del equipo multidisciplinario basado en protocolos tiene una función que beneficia tanto a la madre como al feto. Actualmente se recomienda el concepto de histerotomía resucitadora que refleja la optimización de los esfuerzos realizados en la reanimación. La muerte materna por anestesia es una emergencia médica que requiere especial atención. Existen asociaciones médicas que preconizan las escalas de cuidados precoces en gestantes graves, con un entrenamiento actualizado y con estrategias novedosas para obtener mejores resultados. Conclusiones: El estudio del paro cardiaco en gestantes, la cesárea perimorten y la muerte materna relacionada con la anestesia son importantes. La creación de grupos multidisciplinarios y grupos bien entrenados son la mejor opción en estas circunstancias. Se recomienda incrementar el estudio y entrenamiento para ofrecer las mejores opciones al binomio materno-fetal(AU)

Introduction: Cardiac arrest in pregnant women and perimortem cesarean section are rare. These are medical catastrophes that require immediate attention. Performing this procedure according to adequate standards provides better options for both the mother and the fetus. Cuba pays special attention to the maternal-fetal binomial, for which large amounts of human and technological resources are used. Objective: To update the information about perimortem cesarean section. Methods: A database review was carried out to find epidemiological descriptions, case reports, case series, personal communications, and studies in different health contexts, which would serve as scientific evidence on the subject. Results: Cardiac arrest in pregnant women is a rare event; the performance of a perimortem cesarean section with reduced time (4-5 min) was an effective option. The work of the multidisciplinary team based on protocols has a function that benefits both the mother and the fetus. Currently, the concept of resuscitative hysterotomy is recommended, which reflects the optimization of the resuscitation efforts. Maternal death by anesthesia is a medical emergency that requires special attention. There are medical associations that advocate the scales of early care in pregnant women, with updated training and innovative strategies to obtain better outcomes. Conclusions: The study of cardiac arrest in pregnant women, perimortem caesarean section and anesthesia-related maternal death are important. The creation of multidisciplinary groups and well-trained groups are the best option in these circumstances. It is recommended to increase the study and training to offer the best options to the maternal-fetal binomial(AU)

Development and Pilot Testing of a Context-Relevant Safe Anesthesia Checklist for Cesarean Delivery in East Africa.

BACKGROUND: Maternal mortality rate in developing countries is 20 times higher than in developed countries. Detailed reports surrounding maternal deaths have noted an association between substandard management during emergency events and death. In parallel with these findings, there is increasing evidence for cognitive aids as a means to prevent errors during perioperative crises. However, previously published findings are not directly applicable to cesarean delivery in low-income settings. Our hypothesis was that the use of obstetric anesthesia checklists in the management of high-fidelity simulated obstetrical emergency scenarios would improve adherence to best practice guidelines in low- and middle-income countries. METHODS: Accordingly, with input from East African health care professionals, we created a context-relevant obstetric anesthesia checklist for cesarean delivery. Second, clinical observations were performed to assess in a real-world setting. Third, a pilot testing of the cognitive aid was undertaken. RESULTS: Clinical observation data highlighted significant deficiencies in the management of obstetric emergencies. The use of the cesarean delivery checklist during simulations of peripartum hemorrhage and preeclampsia showed significant improvement in the percentage of completed actions (pretraining 23% ± 6% for preeclampsia and 22% ± 13% for peripartum hemorrhage, posttraining 75% ± 9% for preeclampsia, and 69% ± 9% for peripartum hemorrhage [P < .0001, both scenarios; data as mean ± standard deviation]). CONCLUSIONS: We developed, evaluated, and begun implementation of a context-relevant checklist for the management of obstetric crisis in low- and middle-income countries. We demonstrated not only the need for this tool in a real-world setting but also confirmed its potential efficacy through a pilot simulation study.

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

BACKGROUND: Despite 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. METHODS: We 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. RESULTS: Response 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. CONCLUSION: We 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.

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

BACKGROUND: 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. METHODS: 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). RESULTS: 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. CONCLUSIONS: 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.

Anaesthesia-related maternal mortality in low-income and middle-income countries: a systematic review and meta-analysis.

BACKGROUND: The risk factors contributing to maternal mortality from anaesthesia in low-income and middle-income countries and the burden of the problem have not been comprehensively studied up to now. We aimed to obtain precise estimates of anaesthesia-attributed deaths in pregnant women exposed to anaesthesia and to identify the factors linked to adverse outcomes in pregnant women exposed to anaesthesia in low-income and middle-income countries. METHODS: In this systematic review and meta-analysis, we searched major electronic databases from inception until Oct 1, 2015, for studies reporting risks of maternal death from anaesthesia in low-income and middle-income countries. Studies were included if they assessed maternal and perinatal outcomes in pregnant women exposed to anaesthesia for an obstetric procedure in countries categorised as low-income or middle-income by the World Bank. We excluded studies in high-income countries, those involving non-pregnant women, case reports, and studies published before 1990 to ensure that the estimates reflect the current burden of the condition. Two independent reviewers undertook quality assessment and data extraction. We computed odds ratios for risk factors and anaesthesia-related complications, and pooled them using a random effects model. This study is registered with PROSPERO, number CRD42015015805. FINDINGS: 44 studies (632,556 pregnancies) reported risks of death from anaesthesia in women who had an obstetric surgical procedure; 95 (32,149,636 pregnancies and 36,144 deaths) provided rates of anaesthesia-attributed deaths as a proportion of maternal deaths. The risk of death from anaesthesia in women undergoing obstetric procedures was 1·2 per 1000 women undergoing obstetric procedures (95% CI 0·8-1·7, I(2)=83%). Anaesthesia accounted for 2·8% (2·4-3·4, I(2)=75%) of all maternal deaths, 3·5% (2·9-4·3, I(2)=79%) of direct maternal deaths (ie, those that resulted from obstetric complications), and 13·8% (9·0-20·7, I(2)=84%) of deaths after caesarean section. Exposure to general anaesthesia increased the odds of maternal (odds ratio [OR] 3·3, 95% CI 1·2-9·0, I(2)=58%), and perinatal deaths (2·3, 1·2-4·1, I(2)=73%) compared with neuraxial anaesthesia. The rate of any maternal death was 9·8 per 1000 anaesthetics (5·2-15·7, I(2)=92%) when managed by non-physician anaesthetists compared with 5·2 per 1000 (0·9-12·6, I(2)=95%) when managed by physician anaesthetists. INTERPRETATION: The current international priority on strengthening health systems should address the risk factors such as general anaesthesia and rural setting for improving anaesthetic care in pregnant women. FUNDING: Ammalife Charity and ELLY Appeal, Bart's Charity.

Physician anaesthetists versus non-physician providers of anaesthesia for surgical patients.

BACKGROUND: With increasing demand for surgery, pressure on healthcare providers to reduce costs, and a predicted shortfall in the number of medically qualified anaesthetists it is important to consider whether non-physician anaesthetists (NPAs), who do not have a medical qualification, are able to provide equivalent anaesthetic services to medically qualified anaesthesia providers. OBJECTIVES: To assess the safety and effectiveness of different anaesthetic providers for patients undergoing surgical procedures under general, regional or epidural anaesthesia. We planned to consider results from studies across countries worldwide (including developed and developing countries). SEARCH METHODS: We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE and CINAHL on 13 February 2014. Our search terms were relevant to the review question and not limited by study design or outcomes. We also carried out searches of clinical trials registers, forward and backward citation tracking and grey literature searching. SELECTION CRITERIA: We considered all randomized controlled trials (RCTs), non-randomized studies (NRS), non-randomized cluster trials and observational study designs which had a comparison group. We included studies which compared an anaesthetic administered by a NPA working independently with an anaesthetic administered by either a physician anaesthetist working independently or by a NPA working in a team supervised or directed by a physician anaesthetist. DATA COLLECTION AND ANALYSIS: Three review authors independently assessed trial quality and extracted data, contacting study authors for additional information where required. In addition to the standard methodological procedures, we based our risk of bias assessment for NRS on the specific NRS risk of bias tool presented at the UK Cochrane Contributors' Meeting in March 2012. We considered case-mix and type of surgical procedure, patient co-morbidity, type of anaesthetic given, and hospital characteristics as possible confounders in the studies, and judged how well the authors had adjusted for these confounders. MAIN RESULTS: We included six NRS with 1,563,820 participants. Five were large retrospective cohort studies using routinely collected hospital or administrative data from the United States (US). The sixth was a smaller cohort study based on emergency medical care in Haiti. Two were restricted to obstetric patients whilst the others included a range of surgical procedures. It was not possible to combine data as there was a degree of heterogeneity between the included studies.Two studies failed to find a difference in the risk of death in women undergoing caesarean section when given anaesthesia by NPAs compared with physician anaesthetists, both working independently. One study reported there was no difference in mortality between independently working provider groups. One compared mortality risks between US states that had, or had not, 'opted-out' of federal insurance requirements for physician anaesthetists to supervise or direct NPAs. This study reported a lower mortality risk for NPAs working independently compared with physician anaesthetists working independently in both 'opt-out' and 'non-opt out' states.One study reported a lower mortality risk for NPAs working independently compared with supervised or directed NPAs. One reported a higher mortality risk for NPAs working independently than in a supervised or directed NPA group but no statistical testing was presented. One reported a lower mortality risk in the NPA group working independently compared with the supervised or directed NPA group in both 'opt-out' and 'non-opt out' states before the 'opt-out' rule was introduced, but a higher mortality risk in 'opt-out' states after the 'opt-out' rule was introduced. One reported only one death and was unable to detect a risk in mortality. One reported that the risk of mortality and failure to rescue was higher for NPAs who were categorized as undirected than for directed NPAs.Three studies reported the risk of anaesthesia-related complications for NPAs working independently compared to physician anaesthetists working independently. Two failed to find a difference in the risk of complications in women undergoing caesarean section. One failed to find a difference in risk of complications between groups in 'non-opt out' states. This study reported a lower risk of complications for NPAs working independently than for physician anaesthetists working independently in 'opt-out' states before the 'opt-out' rule was introduced, but a higher risk after, although these differences were not tested statistically.Two studies reported that the risk of complications was generally lower for NPAs working independently than in the NPA supervised or team group but no statistical testing was reported. One reported no evidence of increased risk of postoperative complications in an undirected NPA group versus a directed NPA group.The risk of bias and assessment of confounders was particularly important for this review. We were concerned about the use of routine data for research and the likely accuracy of such databases to determine the intervention and control groups, thus judging four studies at medium risk of inaccuracy, one at low and one, for which there was insufficient detail, at an unclear risk. Whilst we expected that mortality would have been accurately reported in record systems, we thought reporting may not be as accurate for complications, which relied on the use of codes. Studies were therefore judged as at high risk or an unclear risk of bias for the reporting of complications data. Four of the six studies received funding, which could have influenced the reporting and interpretation of study results. Studies considered confounders of case-mix, co-morbidity and hospital characteristics with varying degrees of detail and again we were concerned about the accuracy of the coding of data in records and the variables considered during assessment. Five of the studies used multivariate logistic regression models to account for these confounders. We judged three as being at low risk, one at medium risk and one at high risk of incomplete adjustment in analysis. AUTHORS' CONCLUSIONS: No definitive statement can be made about the possible superiority of one type of anaesthesia care over another. The complexity of perioperative care, the low intrinsic rate of complications relating directly to anaesthesia, and the potential confounding effects within the studies reviewed, all of which were non-randomized, make it impossible to provide a definitive answer to the review question.

Anaesthesia chapter from Saving mothers' lives; reviewing maternal deaths to make pregnancy safer.

This chapter concerning maternal mortality due to anaesthesia, reprinted with permission from Saving Mothers' Lives, is the 18th in a series of reports within the Confidential Enquiries into Maternal and Child Health (CEMACH) in the UK. In the years 2003-05 there were six women who died from problems directly related to anaesthesia, which is the same as the 2000-02 triennium. Obesity was a factor in four of these women who died. Two of these deaths were in women in early pregnancy, who received general anaesthesia for gynaecological surgery by inexperienced anaesthetists who failed to manage the airway and ventilation adequately. When trainee anaesthetists are relatively inexperienced their consultants must know the limits of their competence and when close supervision and help may be needed. One death was due to bupivacaine toxicity due to a drug administration error when a bag of dilute local anaesthetic was thought to be intravenous fluid. In a further 31 cases poor perioperative management may have contributed to death. Obesity was again a relevant factor. Other cases could be categorized into poor recognition of women being sick and poor clinical management of haemorrhage, sepsis and of pre-eclampsia. Early warning scores of vital signs may help identify the mother who is seriously ill. Learning points are highlighted in relation to the clinical management of these obstetric complications.

Maternal and fetal outcome of anaesthesia for caesarean delivery in preeclampsia/eclampsia in Enugu, Nigeria: a retrospective observational study.

BACKGROUND: Maternal mortality, for which preeclampsia is a major cause, is a problem in Nigeria. Accurate data are available for caesarean sections in the University of Nigeria Teaching Hospital, Enugu. We therefore studied the outcome of caesarean section among these high-risk patients. METHOD: We conducted a retrospective survey of hospital records of patients with preeclampsia/eclampsia who had caesarean delivery in this unit over a four-year span from July 1998 to June 2002. RESULTS: There were 3926 deliveries and 4036 births (3611 live births), with 898 women (23%) delivered by caesarean section. Of these, 125 (14%) had preeclampsia/eclampsia, 103 (82.4%) presenting for emergency caesarean delivery and 22 (17.6%) elective. General anaesthesia was used in 116 patients (92.8%) and spinal in nine. The major indications for surgery were severe preeclampsia/eclampsia in patients with unfavourable cervix (68%), fetal distress/intrauterine growth restriction (7.2%) and previous caesarean section (6.4%). There were six maternal deaths, all with general anaesthesia, giving a case fatality rate of 5.2% of general anaesthetics or 4.8% of caesarean deliveries. The cause of death was anaesthetic in three patients, cerebrovascular accident and pulmonary oedema in two and intraoperative haemorrhage in one. There were 13 stillbirths and 10 neonatal deaths. CONCLUSION: Maternal and fetal mortality were high. Poverty, late presentation, lack of equipment and inexperienced management were major contributory factors. Use of spinal anaesthesia should be encouraged in view of recent favourable reviews and cheaper cost.