Incidence and Factors Associated with Postspinal Headache in Obstetric Mothers Who Underwent Spinal Anesthesia from a Tertiary Hospital in Western Uganda: A Prospective Cohort Study.

Background: The proportion of obstetric mothers reporting postspinal headache (PSH) in Uganda is high. The aim of this study is to determine the incidence and factors associated with postspinal headache among obstetric patients who underwent spinal anesthesia during cesarean section at a tertiary hospital in Western Uganda. Methods: A prospective cohort study was done on 274 consecutively enrolled obstetric patients at Fort Portal Regional Referral Hospital (FRRH) from August to November 2022. Pretested questionnaires were used to obtain the data needed for analysis. The data were entered into Microsoft Excel version 16, coded, and transported into SPSS version 22 for analysis. Descriptive statistics was used to determine the incidence of postspinal headache. Binary logistic regression was computed to obtain factors associated with postspinal headache. Results: The overall incidence of postspinal headache was 38.3% (95% CI: 32.5-44.4). Factors with higher odds of developing postspinal headache included using cutting needle (aOR 3.206, 95% CI: 1.408-7.299, p=0.006), having a previous history of chronic headache (aOR 3.326, 95% CI: 1.409-7.85, p=0.006), having lost >1500 mls of blood intraoperatively (aOR 6.618, 95% CI: 1.582-27.687, p=0.010), initiation of ambulation >24 h after spinal anesthesia (aOR 2.346, 95% CI: 1.079-5.102, p=0.032), allowing 2-3 drops of cerebrospinal fluid (CSF) to fall (aOR 3.278, 95% CI: 1.263-8.510, p=0.015), undergoing 2 puncture attempts (aOR 7.765, 95% CI: 3.48-17.326, p ≤ 0.001), 3 puncture attempts (aOR 27.61, 95% CI: 7.671-99.377, p ≤ 0.001) and >3 puncture attempts (aOR 20.17, 95% CI: 1.614-155.635, p=0.004), those prescribed weak opioids (aOR 20.745, 95% CI: 2.964-145.212, p=0.002), nonsteroidal anti-inflammatory drug (NSAID) with nonopioids (aOR 6.104, 95% CI: 1.257-29.651, p=0.025), and NSAID with weak opioids (aOR 5.149, 95% CI: 1.047-25.326, p=0.044). Women with a body mass index (BMI) of 25-29.9 kg/m2 (aOR 0.471, 95% CI: 0.224-0.989, p=0.047) and a level of puncture entry at L3-4 (aOR 0.381, 95% CI: 0.167-0.868, p=0.022) had lower odds of developing PSH. Conclusions: The incidence of postspinal headache is still high as compared to the global range. This was significantly associated with needle design, amount of cerebro-spinal fluid lost, number of puncture attempts, body mass index, previous diagnosis with chronic headache, amount of intraoperative blood loss, time at start of ambulation, level of puncture entry, and class of analgesic prescribed. We recommend the use of a smaller gauge needle, preventing CSF loss, deliberate attempts to ensure successful puncture with fewer attempts, puncture attempts at L3-4, reducing intraoperative blood loss, earlier ambulation, and prescribing adequate analgesia to reduce the incidence of postspinal headache.

Benefits and Barriers to Increasing Regional Anesthesia in Resource-Limited Settings.

Safe and accessible surgical and anesthetic care is critically limited for over half of the world's population, particularly in Sub-Saharan African and Southeast Asian countries. Increasing the use of regional anesthesia in these areas has potential benefits regarding access, safety, and cost-effectiveness. Perioperative anesthesia-related mortality is significantly higher in resource-limited countries and every effort should be made to encourage the use of anesthetic techniques in these countries that are safest under the present conditions. Studies from Sub-Saharan Africa, although limited in number, have shown a lower risk of death with regional compared to general anesthesia. Regional anesthesia has the further benefit of decreasing the risk of COVID-19 spread to healthcare providers by avoiding the aerosol-generating procedures that occur during general anesthesia. Neuraxial regional anesthesia is relatively easy to teach and perform and is considered the anesthetic of choice for surgeries below the umbilicus in resource-limited settings due to its safety, efficacy, and low cost. Although regional anesthesia has multiple potential advantages, education and training of anesthetic providers in low-and-middle-income countries (LMIC) are a significant barrier to growth. Anesthesia professionals, especially in Sub-Saharan Africa, are often poorly supported and undervalued, and recruitment and retention of adequate numbers of trained practitioners are a continuing problem. Greater use of regional anesthesia could be one way to safely increase anesthesia access and simultaneously create value and enthusiasm for the field. Deficits in anesthesia infrastructure, equipment, and drugs also limit anesthesia capacity in low-and middle-income countries. Ultrasound-guided regional anesthesia may be helpful in improving access to safe and reliable anesthesia in low-resource countries as it continues to become more user-friendly, durable, and affordable.

Health and sustainable development; strengthening peri-operative care in low income countries to improve maternal and neonatal outcomes.

BACKGROUND: Uganda is far from meeting the sustainable development goals on maternal and neonatal mortality with a maternal mortality ratio of 383/100,000 live births, and 33% of the women gave birth by 18 years. The neonatal mortality ratio was 29/1000 live births and 96 stillbirths occur every day due to placental abruption, and/or eclampsia - preeclampsia and other unkown causes. These deaths could be reduced with access to timely safe surgery and safe anaesthesia if the Comprehensive Emergency Obstetric and Newborn Care services (CEmONC), and appropriate intensive care post operatively were implemented. A 2013 multi-national survey by Epiu et al. showed that, the Safe Surgical Checklist was not available for use at main referral hospitals in East Africa. We, therefore, set out to further assess 64 government and private hospitals in Uganda for the availability and usage of the WHO Checklists, and investigate the post-operative care of paturients; to advocate for CEmONC implementation in similarly burdened low income countries. METHODS: The cross-sectional survey was conducted at 64 government and private hospitals in Uganda using preset questionnaires. RESULTS: We surveyed 41% of all hospitals in Uganda: 100% of the government regional referral hospitals, 16% of government district hospitals and 33% of all private hospitals. Only 22/64 (34.38%: 95% CI = 23.56-47.09) used the WHO Safe Surgical Checklist. Additionally, only 6% of the government hospitals and 14% not-for profit hospitals had access to Intensive Care Unit (ICU) services for postoperative care compared to 57% of the private hospitals. CONCLUSIONS: There is urgent need to make WHO checklists available and operationalized. Strengthening peri-operative care in obstetrics would decrease maternal and neonatal morbidity and move closer to the goal of safe motherhood working towards Universal Health Care.