|ORIGINAL RESEARCH REPORT
|Year : 2017 | Volume
| Issue : 4 | Page : 173-177
A snap-shot survey of spinal anaesthesia for caesarean section: The Nigeria experience
Charles Imarengiaye1, Felicia Asudo2, Allen Akinmola3, Bode Lawal4
1 Department of Anaesthesiology, University of Benin Teaching Hospital, Benin City, Nigeria
2 Department of Anaesthesia, University of Abuja Teaching Hospital, Gwagwalada, Nigeria
3 Department of Anaesthesia and Intensive Care, National Hospital, Abuja, Nigeria
4 Department of Anaesthesia, Lagos Island Maternity Hospital, Victoria Island, Lagos, Nigeria
|Date of Web Publication||8-Nov-2017|
Department of Anaesthesiology, University of Benin Teaching Hospital, PMB 1111, Benin City
Source of Support: None, Conflict of Interest: None
Background and Objective: In the last several decades, there has been a shift from general anaesthesia to regional anaesthesia for caesarean section worldwide. This rise notwithstanding, it is pertinent to determine the factors associated with the wholesome application of spinal anaesthesia for caesarean section in Nigeria. Method: A snap-shot survey was conducted in some selected hospitals in Nigeria. The survey determined the sociodemographic characteristics of patients, indication for surgery, grade of anaesthesia provider, contraindication to spinal anaesthesia and any other factor that may be noticed in the selected hospital (lack of appropriate drugs, spinal needles, absence of relevant expertise etc). Result: A total of 99 patients were attended to in four of the selected six hospitals within the study period. Thirty six (36.4%) women were nulliparous and maternal factors (82.8%) were the leading indications for caesarean section. Consultant anaesthetists (23.2%) and Senior Registrars (35.4%) were the leading anaesthesia providers for the caesarean sections. Eighty five (85.9%) patients received spinal anaesthesia and 14 (14.1%) had general anaesthesia for the Caesarean section. Fetal indication for Caesarean section was associated with a 3-fold chance of using general anaesthesia for the surgery (p = 0.0138, RR = 3.6, 95%CI 1.44 – 9.1). Conclusion: Over 85% of Caesarean sections in some hospitals in Nigeria were conducted under spinal anaesthesia. Fetal indications for caesarean section provoked over a 3-fold increase in general anaesthesia for caesarean section. The use of general anaesthesia for caesarean delivery was due to fetal indications for surgery, antepartum haemorrhage and failed spinal anaesthesia.
Keywords: Cesarean section, obstetric anesthesia, snapshot survey, spinal anesthesia
|How to cite this article:|
Imarengiaye C, Asudo F, Akinmola A, Lawal B. A snap-shot survey of spinal anaesthesia for caesarean section: The Nigeria experience. J Clin Sci 2017;14:173-7
|How to cite this URL:|
Imarengiaye C, Asudo F, Akinmola A, Lawal B. A snap-shot survey of spinal anaesthesia for caesarean section: The Nigeria experience. J Clin Sci [serial online] 2017 [cited 2017 Dec 11];14:173-7. Available from: http://www.jcsjournal.org/text.asp?2017/14/4/173/217817
| Introduction|| |
There has been a consistent increase in the rate of spinal anesthesia for cesarean section in many hospitals worldwide and had been advocated as the preferred technique for cesarean delivery. In the United Kingdom, the Confidential Enquiry into Maternal Deaths has been a major reason for the change in practice. However, there is no similar report in Nigeria, and any shift in practice is often provoked by evidence in the literature. There has been a consistent increase in the rate of spinal anesthesia for cesarean section in many hospitals in Nigeria.,
Despite the increasing use of spinal anesthesia for cesarean section in Nigeria, the rate has not reached 90% in the available reports.,, There are no clear reasons against the wholesome application of this technique for cesarean sections. Nevertheless, there are recognized contraindications for the use of spinal anesthesia for cesarean section. Specifically, there is no consensus on the use of spinal anesthesia for potential hemorhagic scenarios such as placenta praevia. Thus, the rate of such controversial clinical situations may influence the use of spinal anesthesia for cesarean section. It is pertinent, therefore, to determine such factors that may encourage widespread use of spinal anesthesia for cesarean section. The determination of such factors would document the realistic expectation of the use of regional anesthesia for cesarean section. Thus, this study evaluated the clinical utilization of spinal anesthesia for cesarean section in some hospitals in Nigeria.
| Methods|| |
This was a prospective, multicenter snapshot survey of consecutive patients undergoing cesarean section. The indications for the cesarean section were entirely as documented by the attending obstetrician and in accordance with the standards of good clinical practice in the respective hospitals.
A snapshot survey was conducted in some selected tertiary hospitals in Nigeria. Lead anesthetists and members of League of Obstetric Anaesthetists of Nigeria were approached to participate in the snapshot survey. The lead anesthetist obtained approval from the local institutional ethics committees. The logistics and date of commencement of data collection were discussed and agreed on. At each designated center, a lead anesthetist coordinated the data collection which was planned to last for 14 consecutive days.
All consecutive women for cesarean sections during the survey were included. The primary objective of the snapshot survey was to collect patient and hospital-based information on the perioperative anesthetic management of cesarean section to identify the prevailing procedural routines for cesarean section in Nigeria hospitals. The survey determined the demographic characteristics of patients, indication for surgery, grade of anesthesia provider, contraindication to spinal anesthesia, and any other factor that may be noticed in the selected hospital. The study commenced on the common date agreed by all research participants and was to be conducted over a 2-week period (September 23 to October 7, 2013). The data collection tools were pretested and validated in each center. Data collection was truncated by the nationwide strike action by doctors after 9 days.
The structured questionnaire collected clinical information on all cesarean sections done in each of the participating center within the period. The patients' characteristics were determined from the hospital records. The indication for cesarean section was determined and characterized as maternal (repeat cesarean section, placenta praevia, preeclampsia/eclampsia, cephalopelvic disproportion, intercurrent medical diseases, etc.) or fetal (macrosomic fetus, fetal distress, intrauterine growth retardation, fetal anomalies, etc.). The anesthetic provider was graded as Consultant, Senior Registrar, Registrar, Medical Officer or Nurse Anaesthetist. The technique of anesthesia was categorized as general anesthesia, spinal anesthesia, epidural anesthesia, combined spinal epidural, Ketamine TIVA, and infiltration with local anesthetic agent. Other factors that may limit the use of a regional technique like the non-availability of the relevant materials, clinical diagnosis, or local problems in the hospital were also determined.
Data analyses were performed with Instat GraphPad™. All tests were two-sided with a type 1 error rate of 5%. Continuous variables were summarized using means (standard deviation). Dichotomous variables were presented as frequencies. The association between variables (fetal indication and anesthetic technique) and outcome were tested using Fisher's exact test.
| Results|| |
Eight tertiary hospitals were approached to participate in the study. Two of these centers could not commence data collection due to logistic problems in their hospitals. Four of the six hospitals (with a response rate of 66.7%) that started the snapshot survey completed data acquisition, entry and analysis. A total of 99 patients were attended to in 4 hospitals within the study period. Spinal anesthesia and general anesthesia were the main anesthetic techniques for the cesarean sections. No patient received epidural anesthesia, combined spinal epidural anesthesia, total intravenous anesthesia with Ketamine. There were no institutional problems such as lack of spinal needles, relevant local anesthetic agents, patient's refusal of regional anesthesia or lack of will of the surgeon to operate on an awake patient.
[Table 1] shows the levels of anesthesia providers: Consultant anesthetists 23 (23.2%), senior registrars 35 (35.4%), medical officers 36 (36.4%), and nurse anesthetists 5 (5.1%) provided anesthesia for the cesarean sections. Spinal anesthesia was the leading technique of anesthesia for cesarean section. Eighty-five patients received spinal anesthesia (85.9%), and 14 women had general anesthesia (14.1%) for the cesarean section. The general anesthesia was for placenta praevia (2), ruptured uterus (1) preeclampsia/eclampsia (3), fetal distress (4), failed spinal (2), and retained second twin (2).
[Table 2] indicates that 36 (36.4%) women were nulliparous and maternal factors 82 (82.8%) were the leading indications for cesarean section. Elective cesarean sections were performed for 25 women (25.3%) 74 women (74.4%) had emergency procedure. The type of cesarean section (elective or emergency) was not a factor for the use of spinal anesthesia (P = 0.51, relative risk [RR] = 2.0, 95% confidence interval [CI] = 0.5).
|Table 2: Maternal characteristics, indications and techniques of anesthesia for cesarean section|
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General anesthesia was employed for the delivery of 8 (8.1%) women who had fetal indication for the cesarean section [Table 3]. Fetal indication for cesarean section had over a 3-fold chance for the use of general anesthesia for the surgery (P = 0.037, RR = 3.1, 95% CI 1.2–8, Fisher's exact test).
| Discussion|| |
This study shows that spinal anesthesia is the favored technique of anesthesia for cesarean section in some Nigerian hospitals with a rate of 85.9%. In addition, the use of general anesthesia was more likely following fetal indications for cesarean section, maternal antepartum hemorrhage, or failed spinal anesthesia. Several studies in Nigeria and worldwide have demonstrated spinal anesthesia as the preferred technique for cesarean delivery.,,,, However, the reasons for the increased use of this technique is due to the relative safety for mother and the baby when compared with general anesthesia. However, the factors in favor of the preference of spinal anesthesia over general anesthesia for cesarean section have not been explored. This study shows that spinal anesthesia is the main technique for cesarean section in some tertiary centers in Nigeria in keeping with global practices. In addition, the limited application in some patients was due to some specific indications such as fetal indication (fetal distress, retained the second twin) for cesarean section, maternal antepartum hemorrhage, or failed spinal anesthesia thus resulting in the use of general anesthesia.
Previous studies in Nigeria have highlighted the pattern of anesthetic techniques for cesarean section.,,, Imarengiaye and colleagues  reported a low utilization of spinal anesthesia for cesarean section in their hospital in the 80 s and 90 s. Over the years, there has been a progressive increase in the rate of spinal anesthesia for cesarean section from 50% in 2002 to 89% in 2010 in this single center., Other studies have demonstrated a similar decline in the use of general anesthesia technique for cesarean section in Nigeria., Most of these studies, if not all, were results from a single center with institutional biases. Our result is the composite findings in selected hospitals with a good representation of the various practice patterns across the country. Thus, the findings can be generalized for the larger Nigerian society. Indeed, the hospitals are mainly tertiary institutions at many major cities and may be taken to be representative of the practice pattern of anesthesia in Nigeria: specialist anesthetists, trainee (registrar) anesthetists, medical officer anesthetists, and nurse anesthetists.
Globally, there is increased use of spinal anesthesia for cesarean section.,, Jenkins and Khan  showed a 95% spinal anesthesia rate for cesarean section by 2002. The authors highlighted the unacceptable failure rates for spinal anesthesia, especially in emergency deliveries. The failure rate in our study is low and within the set limits of 1% and 3% for elective and emergency cesarean sections, respectively. An audit of anesthetic practice in a large UK teaching hospital showed the overall techniques in the 5 years (1999–2004) to include general anesthesia (5%), spinal anesthesia (63%), epidural top-up (26%), and combined spinal epidural (5%).
Furthermore, similar rates of spinal anesthesia for cesarean sections have been reported in some other countries with similar economy. Specifically, the University Hospital of the West Indies achieved a change in practice resulting in the rate of 84% of spinal anesthesia for cesarean section by 2001. This change in practice was a deliberate shift in the departmental policy and procedure. However, the desired target of 60% rate of spinal anesthesia for cesarean section was achieved within 19 months. Similarly, Shrestha  demonstrated about 80% spinal anesthesia for cesarean section in a Nepalese hospital. The implication of this high rate of cesarean section under regional anesthesia has been identified to include the reduced teaching of general anesthesia for cesarean section.
The minimal use or lack of epidural technique in this survey may be due to the rudimentary stage of labor epidural analgesia in our country. Elsewhere, epidural block or Combined Spinal Epidural aneshesia formed about a quarter of the cesarean sections. The use of primary epidural anesthesia for cesarean section is not a common event. However, if the epidural technique was established for labor analgesia, this is usually topped-up for surgery. Therefore, some of our patients could have benefitted from the conversion of labor analgesia to anesthesia for cesarean section if epidural analgesia was established during labor. This may have further reduced the rate of general anesthesia for cesarean section and improve the overall use of regional technique. It is pertinent therefore that epidural analgesia in labor should be encouraged and this may further minimize the use of general anesthesia in some clinical situations.
The indications for cesarean section could be maternal, fetal or a combination of both factors. The Royal College of Obstetricians and Gynaecologists has rationalized the indications for cesarean section and the urgency of surgery. In particular, a threat to fetal survival demands urgent intervention and general anesthesia may be the best-considered option. This may have provoked the 3-fold increase in the use of general anesthesia when fetal considerations were the reasons for the cesarean section in this survey. The conduct of regional anesthesia may take additional time which often is not available in the urgent cesarean section for fetal concerns. Hence, general anesthesia is more favored in such urgent situations. However, some have suggested “rapid sequence” spinal anesthesia as a middle course to the anesthetic management of cesarean section for category – 1 cesarean section. This notwithstanding, the conduct of spinal anesthesia has its associated pitfalls, especially with respect to aseptic preparation of the skin.
The use of snapshot survey and not longitudinal surveys was to improve the quality of data and reduce institutional limitations. Snapshot surveys would produce high-quality data since the data entry is prospective and for a short time. This adds value to the quality of data as quasi-prospective data cannot be entered. Some of the selected hospitals could not commence data collection for peculiar institutional reasons. However, a national strike by a segment of the health sector limited the data collection to 9 of the planned 14 days. These are contemporary issues on any discussion on healthcare delivery in Nigeria today. All hospitals do not have a similar capacity for anesthesia service. However, the increasing cesarean section rate under regional anesthesia and the observation that fetal indication is a factor for general anesthesia for cesarean section remain the strength of this study. This may be of interest, particularly, to practitioners and trainers of anesthetists.
| Conclusion|| |
This snapshot survey of anesthetic practice in some Nigerian teaching hospitals demonstrated a high rate of spinal anesthesia for cesarean section. The use of general anesthesia is still common particularly when fetal concern is the indication for the cesarean section. Improved training in the use of spinal anesthesia as well as the establishment of labor analgesia service may improve further the rate of regional anesthesia for cesarean section. An organized labor analgesia service would allow the routine use of epidural analgesia and combined spinal epidural techniques in labor and possible activation at cesarean section.
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Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3]