obstetric anaesthesia in level 1 and 2 hospitals in the free state. a study and audit and remedial

213 Pages·2010·1.43 MB·English

OBSTETRIC ANAESTHESIA IN LEVEL 1 AND 2
HOSPITALS IN THE FREE STATE.
A STUDY AND AUDIT AND REMEDIAL
INTERVENTIONS

by G. LAMACRAFT

Thesis submitted in fulfillment of the requirements for the degree
Philosophiae Doctor in Anaesthesiology
(Ph.D. Anaes)

In the
DEPARTMENT OF ANAESTHESIOLGY
FACULTY OF HEALTH SCIENCES
UNIVERSITY OF THE FREE STATE
BLOEMFONTEIN

March 24th 2010

PROMOTER: Prof. BJS Diedericks
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DECLARATION
I hereby declare that this study which is submitted here is the result of my own independent
investigation. Where assistance was given, this has been acknowledged.

I declare that this study is submitted for the first time at this university and faculty, towards a
Ph.D in Anaesthesiology and that it has never been submitted to any other university or
faculty for the purpose of obtaining a degree.

I declare that I have no conflicts of interest regarding this study.

Permission for this study was obtained from the Free State Department of Health.
Ethics Committee approval was granted by the University of the Free State
(ETOVS NR 251/02).

…………………………… …………………..
G. LAMACRAFT DATE
I hereby cede copyright of this product in favour of the University of the Free State

…………………………… ………………….
G. LAMACRAFT DATE
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DEDICATION
This study is dedicated to all the children in the Free State, whose mothers died as a result of
obstetric anaesthesia.

A motherless soft lambkin
Along upon a hill;
No mother’s fleece to shelter him
And wrap him from the cold:
I’ll run to him and comfort him,
I’ll fetch him, that I will;
I’ll care for him and feed him
Until he’s strong and bold.
Christina Rossetti (1830-94)
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ACKNOWLEDGEMENTS
Thanks is given to:
• The Free State Provincial Government, for permitting this study to be performed and
partially funding the project (travel and accommodation expenses for Phase 1 of the
study).
• The Managers and Medical Staff of the Free State Level 1 and 2 Hospitals involved in
this study, for permitting the investigators to visit their hospital(s) and collect data.
• The University of the Free State Department of Anaesthesiology, for permitting me to
be relieved of my clinical duties so I could perform the hospital visits required in this
study.
• All the co-investigators (see below), who assisted with the process of driving to each
hospital and collecting data.
• Prof G. Joubert and the Department of Biostatistics of the University of the Free State,
for their assistance in design of the study and data analysis.

Role of the Co-Investigators:
The co-investigators were Dr S. Hollingworth, Dr M.J. Schmidt, Dr P. Kenny and Dr .J
Dowie.

Data collection was performed by me, with the assistance of the co-investigators:
In Phase 1 of the study I visited 50% of the hospitals myself, accompanied by one co-
investigator. I was unable to travel to all the hospitals myself at that time, as I was seven
months pregnant. The remaining, more distant hospitals were visited by the senior co-
investigator (Dr J Dowie), with another of the co-investigators. In Phase 2 of the study, I
visited all the hospitals myself, accompanied by one co-investigator.
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TABLE OF CONTENTS Page

CHAPTER 1
INTRODUCTION

1.1 BACKGROUND TO THE STUDY………………………………………………….......1
1.1.1 The Problem of maternal deaths due to anaesthesia……………………………….…..1
1.1.2 Monitoring maternal deaths due to anaesthesia…………………………………….….3
1.1.2.1 The South African maternal death notification system………………………….……4
1.1.2.1.1 Reporting a maternal death to the Provincial Coordinator…………………………........5
1.1.2.1.2 Problems of reporting…………………………………………………………….......5
1.1.2.1.3 Confidentiality…………………………………………………………………..…....6
1.1.2.1.4 Problems arising from a confidential system……………………….……………..……7
1.1.2.1.5 Role of the Provincial Maternal Health Department Coordinator…..…………………....7
1.1.2.1.6 Role of the Provincial Assessor for Anaesthesia……………………………………….8
1.1.2.1.7 The NCCEMD ………………………………………………………………………9
1.1.2.2 The United Kingdom confidential enquiries into maternal deaths……………...….10
1.1.2.3 Monitoring maternal deaths in other countries………………………………….….14
1.1.2.3.1 The USA………………………………………………………………………….…15
1.1.2.3.2 France………………………………………………………………………..……...16
1.1.2.3.3 Japan………………………………………………………………………….….…16
1.1.2.3.4 Botswana…………………………………………………………………...……….17
1.1.2.3.5 Malawi……………………………………………………………………………….19
1.1.2.3.6 Ghana……………………………………………………………………………….20
1.1.2.3.7 Nigeria………………………………………………………………………………21
1.1.2.3.8 Egypt………………………………………………………………………………..22

CHAPTER 2
LITERATURE REVIEW

2.1 MATERNAL MORTALITY DUE TO ANAESTHESIA IN SOUTH AFRICA……….25
2.1.1 Early descriptive studies of South African maternal healthcare and deaths……..……25
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2.1.2 Maternal Death Survey (1980 – 1982)………………………………………………...29
2.1.3 Reports of confidential enquiries into maternal deaths in South Africa………………30
2.1.3.1 1998 The first Saving Mothers report……………………………………………….30
2.1.3.2 1999 -2001 The second Saving Mothers report……………………………………..31
2.1.3.2 2002-2004 The third Saving Mothers report………………………………………..35

CHAPTER 3
CONCEPTUALISATION OF THE STUDY

3.1 INTRODUCTION……………………………………………………………………….38
3.2 AIM OF THE STUDY…………………………………………………………………..39
3.3 DESIGN OF THE STUDY……………………………………………………………...40
3.4 HOSPITALS STUDIED………………………………………………………………...40
3.5 FACTORS STUDIED…………………………………………………………………...41
3.5.1 Manpower……………………………………………………………………………..41
3.5.2 Use of regional anaesthesia……………………………………………………………41
3.5.3 Anaesthetic Drugs and Equipment…………………………………………………….42
3.5.4 Resuscitation protocols…………………………………………………......................42
3.5.5 Referral system………………………………………………………………………...43

CHAPTER 4
STUDY METHOD: OVERVIEW

4.1 INCLUSION AND EXCLUSION CRITERIA………………...……………………….44
4.2 PHASE 1 METHOD…………………………………………………………………….44
4.3 PHASE 2 METHOD………………………………………………………………….....45
4.4 STATISTICAL ANALYSIS…………………………………………………………….45

CHAPTER 5
REMEDIAL INTERVENTIONS

5.1 INVESTIGATOR INTERVENTIONS………………………………………………….46
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5.1.1 Resuscitation protocols……………………………………………………...………...46
5.1.2 Anaesthetic drugs and equipment……………………………………………...……...46
5.1.2.1 On-site…………………………………………………………………………….....46
5.1.2.2 Letters to Hospital Management…………………………………………………….47
5.1.3 Presentations and publications………………………………………………………...47
5.1.3.1 Disseminating information gathered from Phase 1 of study……………………...…47
5.1.3.1.1 Presentations………………………………………………………………………...47
5.1.3.1.2 Publication……………………………………………………………………….......48
5.4.1.3.2 Increasing awareness of problems associated with spinal anaesthesia for CS…....48
5.1.3.2.1 Conference lecture……………………………………………………………….......48
5.1.3.2.2 Publications………………………………………………………………………….48
5.2 FREE STATE DEPARTMENT OF HEALTH………………………………………….48
5.3 UNIVERSITY OF THE FREE STATE DEPARTMENT OF ANAESTHESIA……….49
5.3.1 iCAM lectures…………………………………………………………………...…….49
5.3.2 Workshop for General Practitioners…………………………………………………...50
5.4 COINCIDENTAL INTERVENTIONS……………………………………………...….50
5.4.1 Intern training………………………………………………………………………….50
5.4.2 COHSASA…………………………………………………………………………….51

CHAPTER 6
MANPOWER
6.1 OVERVIEW…………………………………………………………………...………..52
6.2 PILOT STUDY…………………………………………………………………...……..52
6.3. PHASE 1 MANPOWER STUDY………………………………………...……………53
6.3.1 Introduction……………………………………………………………………………53
6.3.2 Method………………………………………………………………………...………53
6.3.3 Results…………………………………………………………………………………53
6.3.4 Discussion……………………………………………………………………………..54
6.4 PHASE 2 MANPOWER STUDY………………………………………………………56
6.4.1 Method…………………………………………………………………………...……56
6.4.2 Results…………………………………………………………………………………56
6.4.2.1 Rank of respondents and duration in post…………………………………………..58
6.4.2.2 Previous training and experience…………………………………………...………58
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6.4.2.2.1 Internship……………………………………………………………………..….….58
6.4.2.2.2 Anaesthesia experience post Internship, before present post…………………………..59
6.4.2.2.3 Obstetric anaesthesia experience…………………………………………...………..59
6.5.4.2.3 Postgraduate qualifications…………………………………………………....….60
6.4.2.4 Other duties required whilst administering anaesthesia……………………...…….61
6.4.2.5 Senior anaesthetic supervision ……………………………………………………...62
6.4.2.6”Any suggestions”………………………………………………………………...…62
6.4.3 Discussion……………………………………………………………………...……...63
6.4.3.1 Inexperience and lack of supervision………………………………………………..63
6.4.3.2 Lack of training and postgraduate qualifications…………………………………...64
6.4.3.3 Other duties required whilst administering obstetric anaesthesia…………...……..67
6.4.3.4 Strategies to reduce maternal deaths from anaesthesia………………………...…..67
6.4.4 Conclusion……………………………………………………………………………..73
6.4.5 Limitations of manpower study……………………………………………………….73

CHAPTER 7
DRUGS AND EQUIPMENT

7.1 PHASE 1 DRUGS AND EQUIPMENT STUDY………………………………...…….75
7.1.1 Introduction……………………………………………………………………………75
7.1.2 Method………………………………………………………………………………...75
7.1.3 Results…………………………………………………………………………………76
7.2 PHASE 2 DRUGS AND EQUIPMENT STUDY………………………………...…….76
7.2.1 Introduction……………………………………………………………………………76
7.2.2 Method…………………………………………………………………………….......76
7.2.3 Results…………………………………………………………………………………77
7.2.3.1 Resuscitation…………………………………………………………...……………77
7.2.3.2 Haemorrhage……………………………………………………………...………...78
7.2.3.3 Spinal anaesthesia…………………………………………………………………...79
7.2.3.4 Post spinal hypotension……………………………………………………………...80
7.2.3.5 General anaesthesia…………………………………………………………………80
7.2.3.6 Acid aspiration prophylaxis………………………………………………………....81
7.2.3.7 Failed/difficult intubation equipment………………………………………………..81
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7.2.3.8 Anaesthetic monitors………………………………………………………………...82
7.2.3.9 Other equipment problems…………………………………………………………..83
7.2.3.9.1 Operating tables……………………………………………………………………..83
7.2.3.9.2 Anaesthetic machines………………………………………………………………..83
7.2.3.9.3 Servicing of anaesthetic machines……………………………………………………84
7.2.3.9.4 Laryngoscopes…………………………………………………………………...….84
7.2.3.9.5 Anaesthetic machine failure………………………………………………………….84
7.2.3.10 Other drug problems……………………………………………………………….85
7.2.3.11 Recovery areas……………………………………………………………………..86
7.2.3.12 Summary of results…………………………………………………………………87
7.2.4 Discussion……………………………………………………………………………..87
7.2.4.1 Resuscitation drugs and equipment………………………………...……………….90
7.2.4.2 Obstetric haemorrhage……………………………………………...………………90
7.2.4.3 Pre-eclampsia………………………………………………………...……………..91
7.2.4.4 Treatment of hypotension from spinal anaesthesia………………………………….91
7.2.4.5 Failed intubation equipment……………………………………………...…………91
7.2.4.6 Anaesthetic machine failure/malfunction……………………………………………92
7.2.4.7 Equipment for general anaesthesia………………………………………………….92
7.2.4.8 Anaesthetic monitors………………………………………………………………...93
7.2.4.9 Anaesthetic machines………………………………………………………………..93
7.2.4.10 Treatment of malignant hyperthermia…………………………………………......94
7.2.5 Conclusion……………………………………………………………………………..95

CHAPTER 8
USE OF REGIONAL ANAESTHESIA

8.1 PHASE 1 REGIONAL ANAESTHESIA STUDY……………………………………...96
8.1.1 Introduction……………………………………………………………………………96
8.1.2 Method……………………………………………………………………………...…97
8.1.3 Results…………………………………………………………………………………98
8.1.4 Discussion…………………………………………………………………...……….100
8.2 PHASE 2 REGIONAL ANAESTHESIA STUDY…………………………………….103
8.2.1 Method………………………..…………………………………………………...…103
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8.2.2 Results………………………..………………………………………………………103
8.2.3 Discussion……………………………………………………………………………104
8.2.4 Conclusion……………………………………………………………………………112

CHAPTER 9
RESUSCITATION PROTOCOLS

9.1 INTRODUCTION……………………………………………………………...………113
9.2 METHOD………………………………………………………………………………113
9.3 RESULTS…………………………………………………………………………...…114
9.4 DISCUSSION…………………………………………………………………..……...116
9.5 CONCLUSION…………………………………………………………………...……118

CHAPTER 10
REFERRAL SYSTEM

10.1 INTRODUCTION…………………………………………………………………….119
10.2 METHOD……………………………………………………………………………..119
10.3 RESULTS……………………………………………………...……………………..120
10.4 DISCUSSION…………………………………………………...……………………121
10.5 CONCLUSION………………………………….………………….………………...123

CHAPTER 11
FACTORS PERTAINING TO OBSTETRIC ANAESTHESIA DEATHS:
SYNOPSIS AND CONCLUSION

11.1 MANPOWER………………………………………………..………….……………124
11.2 DRUGS AND EQUIPMENT…………………………………………...……………125
11.3 USE OF REGIONAL ANAESTHESIA…………………………………...…………126
11.4 RESUSCITATION PROTOCOLS…………………………………………...………127
11.5 REFERRAL SYSTEM………………………………………………………………..127
11.6 CONCLUSION OF INVESTIGATION OF THE FACTORS……………………….128