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 Table of Contents  
EDITORIAL
Year : 2018  |  Volume : 8  |  Issue : 2  |  Page : 63-65

Training initiatives for safe obstetric anesthesia care


1 Department of Anaesthesiology, Dayanand Medical College and Hospital, Ludhiana, Punjab, India
2 Department of Anesthesia and Intensive Care, Postgraduate Institute of Medical Education and Research, Chandigarh, India

Date of Web Publication3-Oct-2018

Correspondence Address:
Prof. Anju Grewal
Department of Anaesthesiology, Dayanand Medical College and Hospital, Ludhiana - 141 001, Punjab
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/joacc.JOACC_54_18

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How to cite this article:
Grewal A, Bhatia N. Training initiatives for safe obstetric anesthesia care. J Obstet Anaesth Crit Care 2018;8:63-5

How to cite this URL:
Grewal A, Bhatia N. Training initiatives for safe obstetric anesthesia care. J Obstet Anaesth Crit Care [serial online] 2018 [cited 2018 Dec 16];8:63-5. Available from: http://www.joacc.com/text.asp?2018/8/2/63/242631



Lack of access to safe anesthesia and surgery threatens 5 of the 7 billion people who occupy this planet.[1] There is a wide disparity in the availability of safe surgical anesthesia between populations residing in metropolitan cities and small towns or villages across the length and breadth of our country. Indeed, the more you travel into hinterland areas of India, the scarcer is the availability of safe obstetric anesthesia care for our mothers. This indeed deters a significant reduction in maternal mortality rates across various states of India. Obstetric anesthesia is an integral part of practice of a majority of anesthesiologists especially those practicing in far-flung outreach areas and resource-limited settings. The crucial role that anesthesia plays in enhancing the safety of obstetric care and thus reducing maternal mortality cannot be undermined.[1],[2]

Various governmental and nongovernmental organizations have pitched in facilities, finances, and training initiatives to ensure safe obstetric anesthesia delivery. However, these efforts are rather too scarce in numbers and wanting in quality care. This lack of quality initiatives has been aptly highlighted in an editorial from New England Journal of Medicine[3] which describes the inadequacy of an ambitious project – Janani Suraksha Yojana, to result in no change in the maternal mortality or morbidity. It is indeed imperative that quality enhancement should be the main feature of all such initiatives “...doing more isn't better. Doing better is better.”[2.3]

In our quest to improve quality of obstetric anesthesia care, we need to take the first few steps of identifying the deficiencies and bottlenecks in our systems, understanding our situational realities, formulating safe anesthesia practice standards, educating, training, and retraining ourselves and all anesthesia providers. A follow-up auditing of our strengths and pitfalls can help enhancement in quality of care further. Improving and maintaining safety in anesthesia is complex and requires attention to training, continuing education, and provision of appropriate monitoring equipment, drugs, and an interplay of a myriad of human factors.[4] Empowering the new and existing anesthesia providers comes from training and practice.

The current training modules of training encompass national conferences, continuing medical education (CME) programs, or day-long workshops which are instrumental in executing training programs for local anesthesiologists of all cadres.[5] Despite their popularity and innovative approach, they do lack structure, rigor, and quality initiatives interwoven into their structure. Moreover, anesthesia providers in low-resource settings or residing at outreach locations either do not have access to such CMEs nor are motivated enough to attend them rigorously as they find translating the cognitive knowledge learnt at CMEs to clinical daily practice an uphill task. Wilkinson[2] aptly states that all teaching and humanitarian aid should have sustainability for the receiving population. Therefore, all standards, guidelines, teaching, and care modules should be adaptable to local needs despite being evidence-based which makes them practical, achievable, and sustainable.[2],[6]

The first ever, recently introduced 3-day Safer Anesthesia From Education (SAFE) obstetric anesthesia course in India at Hyderabad in May 2018 aims to fulfil this gap. This course originally created by Kate Grady from the United Kingdom is supported by the Association of Anaesthetists of Great Britain and Ireland as well as by the World Federation of Societies of Anesthesiologists (WFSA).[2],[7],[8]The aim of the course is to improve the quality and safety of obstetric anesthesia along with the management of critical complications that are often encountered by the delegates in their routine daily work”.[2] The faculty chosen for these courses is a mix of trained international experts, course coordinators, and local faculty. The local faculty attend a train-the-trainer session ahead of the course and then enhance their course delivery skills while being monitored by the expert SAFE faculty. The local faculty indeed add an indigenous flavor to the course by assisting in adapting the course content to local environment, available resources, and unique clinical situations. The SAFE obstetric anesthesia structured course imparts training by lectures, group discussion, and break-out sessions along with hands-on practical activity using low or medium fidelity simulation on various aspects of obstetric analgesia, regional anesthesia, and general endotracheal anesthesia.[2],[7],[8] The SAFE course offers flexibility of adding other high-quality practical ancillary learning programs. For example, in Uganda, a Lifebox teaching program that incorporates use of the World Health Organization surgical checklist was recently added to the SAFE obstetric course.[2],[9]

Exchange of information and communication skills in the complex and dynamic environment of labor and delivery is essential for safe outcome[10] The value of the course can be further enhanced by adding practice mock drills dealing with obstetric emergencies, near-miss situations, dynamic elements of team work, communication skills, and an understanding of human factors in decision-making as an integral part of these courses.[2] Team work and debriefing are essential skills which one needs to impart and imbibe during the conduct of various simulation scenarios.

Yet another unique feature of the SAFE course is the in-built evaluation which takes place in the months following completion of the course. This is achieved by a knowledge-to-action (KTA) cycle whereby local faculty continues relevant teaching interventions and takes on the role of a mentor to reinforce uptake of new knowledge into clinical practice.[7] Local trainers who have trained on previous courses are encouraged to be actively involved in the planning and organization of subsequent courses and are motivated to take over the full management of these courses eventually. This is the classical “teach the teachers” model which encompasses a great quality tool to propagate a spiral toward safe anesthesia care.[2],[7],[8]

In Rwanda, where the SAFE Obstetric anesthesia course was imparted as part of WFSA and Canadian Anesthesiologists' Society International Education Foundation project, “KTA meant carefully considering educational needs, revising curricula to suit the local context, employing active experiential learning during the SAFE Obstetric Anesthesia course, encouraging supportive relationships with peers and mentors, and using participant action plans for change, post-course logbooks, and follow-up interviews with participants six months after the course.”[7] During those interviews, participants reported improvements in clinical practice and greater confidence in coordinating team activities.[7]

The need of the hour is a proactive approach by National Obstetric Anesthesia societies like the Association of Obstetric Anesthesiologists (AOA) who should actively engage with these first batch of trained SAFE course instructors to review the curricula according to the local provider needs for formulating training protocols prior to administering both the provider and the trainer SAFE obstetric anesthesia courses widely across the nation. We must remember that obstetric anesthesia safety remains confronted by resource limitations and refusal to change by healthcare providers. Thus, we need to evolve training guidelines addressing the varying practices from one region to other, provider availability and motivation, skill level, infrastructure, and resources.[6],[7] Furthermore, reinforcement and sustenance of the change to safe obstetric anesthesia practice should be achieved with the help of experienced experts or mentors.

As a giant stride toward these goals of safe and high-quality obstetric anesthesia care, the AOA should take an enormous leap in translating the internationally accepted evidence-based practice guidelines, protocols, and standards of care to our local environment, clinical needs, and constraints so as to develop a safety culture for maternal and child healthcare across the various levels of healthcare facilities of our vast nation. Developing appropriate standards is challenging, and those involved in their creation need to be vigilant to ensure that standards are practical, reliable, robust, achievable, and affordable in low-resource settings while having the capability to be upgraded mandatorily in high-resource settings, thereby promoting advancement of anesthesia care at par with international standards. The key to safe obstetric anesthesia care lies in incorporating the goals and missions of global societies like WFSA and adapting them to suit our infrastructure.[2],[6],[11],[12] We need to raise our bar to a level that any parturient should have complete reassurance and trust of receiving high-quality obstetric anesthesia care from all levels of anesthesia provider working in any nook or corner of our vast nation. Are we ready to rise to this challenge? We hope the answer stays in affirmative always.



 
  References Top

1.
McDougall RJ, Enright AC. Safe surgery globally by 2030: The view from anesthesia. Anesth Analg 2018;126:1102-4.  Back to cited text no. 1
    
2.
Wilkinson DJ. Providing quality in anesthesia care in low- and middle-income countries. Can J Anaesth 2014;61:975-8.  Back to cited text no. 2
    
3.
Scott KW, Jha AK. Putting quality on the global health agenda. N Engl J Med 2014;371:3-5.  Back to cited text no. 3
    
4.
Dyer RA, Reed AR, James MF. Obstetric anaesthesia in low-resource settings. Best Pract Res Clin Obstet Gynaecol 2010;24:401-12.  Back to cited text no. 4
    
5.
Morriss WW, Milenovic MS, Evans FM. Education: The heart of the matter. Anesth Analg 2018;126:1298-304.  Back to cited text no. 5
    
6.
Yuill G, Amroyan A, Millar S, Vardapetyan E, Habib AS, Owen MD, et al. Establishing obstetric anesthesiology practice guidelines in the republic of Armenia: A global health collaboration. Anesthesiology 2017;127:220-6.  Back to cited text no. 6
    
7.
Livingston P, Evans F, Nsereko E, Nyirigira G, Ruhato P, Sargeant J, et al. Safer obstetric anesthesia through education and mentorship: A model for knowledge translation in Rwanda. Can J Anaesth 2014;61:1028-39.  Back to cited text no. 7
    
8.
Enright A, Grady K, Evans F. A new approach to teaching obstetric anaesthesia in low-resource areas. J Obstet Gynaecol Can 2015;37:880-4.  Back to cited text no. 8
    
9.
Finch LC, Kim RY, Ttendo S, Kiwanuka JK, Walker IA, Wilson IH, et al. Evaluation of a large-scale donation of lifebox pulse oximeters to non-physician anaesthetists in Uganda. Anaesthesia 2014;69:445-51.  Back to cited text no. 9
    
10.
Kuczkowski KM. Obstetric anesthesia: Past present and future. J Matern Fetal Neonatal Med 2009;22:819-22.  Back to cited text no. 10
    
11.
Walker IA, Shafer SL. The world federation of societies of anaesthesiologists, international anesthesia research society, and anesthesia and analgesia: A shared global vision. Anesth Analg 2015;120:721-4.  Back to cited text no. 11
    
12.
Practice Guidelines for Obstetric Anesthesia: An updated report by the American Society of Anesthesiologists task force on obstetric anesthesia and the society for obstetric anesthesia and perinatology. Anesthesiology 2016;124:270-300.  Back to cited text no. 12
    




 

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