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 Table of Contents  
Year : 2021  |  Volume : 11  |  Issue : 1  |  Page : 20-24

Evaluating anesthesia practice for caesarean section: A prospective cross-sectional study from a tertiary care institution of low- and middle-income country

Department of Anaesthesiology, Aga Khan University Hospital, Karachi, Pakistan

Date of Submission25-Sep-2020
Date of Acceptance21-Dec-2020
Date of Web Publication16-Apr-2021

Correspondence Address:
Dr. Samina Ismail
Department of Anaesthesiology, Aga Khan University Hospital, Stadium Road P. O. Box - 3500, Karachi - 74800
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/JOACC.JOACC_103_20

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Background and Objective: In low and middle-income countries (LMICs), general anesthesia for cesarean section has shown to increase the odds of maternal mortality. Use of regional anesthesia for cesarean section is an indicator for safe practice of anesthesia; therefore, this study aims to evaluate the current practice of use of regional anesthesia and its failure rate for cesarean section. The current practice is analyzed in the light of previously published data from the same institution of LMIC. Methods: After hospital ethics committee approval, this prospective cross-sectional study was performed from January 1 to June 30, 2019. Prospective data collected on predesigned form included technique of anesthesia employed for different category of cesarean section, failure of regional anesthesia, and other related data. The cesarean section rate and trends of technique of anesthesia over last 10 years were collected from hospital record system. Results: Compared to the published data from the year 2012 from the same institution, the results from this prospective data have shown an increase rate of cesarean section rate from 31% to 52% with an overall decline in the use of general anesthesia from 49% to 12.3%. In addition, rate of regional anesthesia for category 1–3 cesarean section has increased from 46.4% to 79.8% and for category 1 from 37.1% to 63.4%. Decline in failure rate of regional technique was observed from 6.7% to 2.4%. Conclusion: Assessing and analyzing practices helps in taking initiative to implement safe practices which are needed to achieve the target for best practice.

Keywords: Anesthesia practice, cesarean section, low and middle-income country, regional anesthesia

How to cite this article:
Ismail S, Hameed M. Evaluating anesthesia practice for caesarean section: A prospective cross-sectional study from a tertiary care institution of low- and middle-income country. J Obstet Anaesth Crit Care 2021;11:20-4

How to cite this URL:
Ismail S, Hameed M. Evaluating anesthesia practice for caesarean section: A prospective cross-sectional study from a tertiary care institution of low- and middle-income country. J Obstet Anaesth Crit Care [serial online] 2021 [cited 2021 Oct 24];11:20-4. Available from: https://www.joacc.com/text.asp?2021/11/1/20/313903

  Introduction Top

There is a rising trend in the rate cesarean section (CS), not just in the high-income countries but also in the low and middle-income countries (LMIC).[1] Anesthesia has been implicated in about one in seven maternal deaths during or after CS with a disproportionately high maternal mortality in LMIC.[2],[3] Therefore, implications of rising trend in CS are more likely to affect LMIC.

World Health Organization has issued a statement in 2016, which states: “Cesarean section should be undertaken when medically necessary, and rather than striving to achieve a specific rate, efforts should focus on providing cesarean section to all women in need.”[4] The Royal College of Anaesthetists audit guidelines suggest that 85% of emergency CS should be conducted under regional anesthesia (RA), and conversion rate to general anesthesia (GA) should be less than 3% for emergency, and less than 1% for elective surgery.[5]

The present study aims to evaluate the current practice of use of RA and its failure rate of different categories of CS in a tertiary care hospital from LMIC. The authors of the present study published data on technique of anesthesia from the same institution in 2012,[6] which stated that GA was the choice of anesthesia in 49% for category 2–4 CS and 63% for category 1 CS. The previous published study further stated that failure rate and conversion rate to GA from RA was 6.7%.[6] Soon after this published data, a multidisciplinary approach was undertaken by different stakeholders with support from the institution to improve RA rate and decrease its failure rate in CS. Efforts were directed to improve overall clinical practice and changes were implemented in terms of improvement in patients/health-care education regarding the benefits of RA, enhancement of training for RA skills for residents, and introduction of rapid sequence spinal for category 1 CS.

The hypothesis of this study is that the data from this current prospective study will show a rise in the rate of use of RA for CS and decrease in its failure rate compared to published data of 2012 from the same institution.[6] Therefore, the rationale of the study is to evaluate the current practice of use of RA and it is failure rate for different categories of CS and to assess if it is meeting the target for best practice.

The objective of this prospective cross-sectional study is to evaluate the current practice of technique of anesthesia for different grades of CS and failure rate of RA from a tertiary care hospital of LMIC.

  Methods Top

After taking approval from the hospital's ethics committee and consent from anesthesiologists providing anesthesia in the obstetric unit of tertiary care hospital from LMIC, this prospective cross-sectional study was carried for a period of 6 months from January 1 to June 30, 2019. The institution where this study was conducted is a tertiary care hospital from LMIC, having an average delivery rate of 4000–4500 per year. The inclusion criteria for this study were all CS done during the study period; however, cases where the primary anesthesiologist did not give consent to share the details required for data collection were excluded from the study.

Data collection procedure required the anesthesiologist performing the procedure to fill out the required data on the predesigned collection form. All anesthesiologists assigned in the operating room of obstetric unit were explained the purpose of the study by one of the investigator and asked for written informed consent. Those consenting to participate were explained the process of data entry in the predesigned collection form. The data included the urgency of CS as classified by Lucas et al.,[7] into four categories, technique of anesthesia chosen by the anesthesiologists either as primary GA (where patient has not received any other regional technique) or primary RA (all cases where needle is inserted in the patient's back and included single-shot spinal, epidural, combined epidural spinal or extension of labor epidural analgesia for CS), reasons for choosing primary GA, failure and reason of failure of RA (need to convert RA to GA), level of anesthesiologists providing anesthesia, need to call for help, number of attempts at RA (number of skin punctures), and number of patients complaining of discomfort during surgery under RA requiring rescue analgesia only and not conversion to GA. All predesigned data collection forms were available in the operating room, which were deposited after completion of data entry in the dropbox placed in the operating room. One of the investigators checked the completion and accuracy of forms every second day and handed the forms to the statistician for data entry. In addition, data of rate of CS and rate of RA for CS from the years 2010 to 2018 were taken from hospital record system by one of the investigator.

The statistical package of social sciences (SPSS 19) was used for data entry and its analysis. Frequencies and percentages were generated to tabulate the data.

  Results Top

During the study period from January 1 to June 30, 2019, total number of deliveries in the obstetric unit of Aga Khan University hospital was 1989 with CS rate of 52.1%. [Figure 1] is showing mode of delivery for all 1989 patients and technique of anesthesia used for 938 patients undergoing CS during the study period and included in the study. The data on 100 (10.6%) patients that could not be collected for reasons, mentioned in [Figure 1], were more or less equally distributed between the four categories of CS (29% in category 1, 31% in category 2, 18% in category 3, and 22% in category 4). The trend of CS rate and technique of anesthesia as available from hospital record system from the years 2010 to 2019 is presented in [Figure 2].
Figure 1: Mode of delivery and technique of anesthesia (n = number) used for patients undergoing CS during the study period

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Figure 2: The trend of CS rate and technique of anesthesia over 10 years' time period from 2010 to 2019

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The prospective data during the study period of 2019 on technique of anesthesia and failure rate of RA in four categories according to Lucas's classification of CS urgency (7) are shown in [Table 1]. RA failed and was converted to GA in 2.4% (n = 20/822) of CS; either due to inability to institute the block (1.58%; n = 13), failure to achieve the adequate level of block before the start of surgery (0.36%, n = 3), and patient complaining of pain after the start of surgery (0.48%, n = 4).
Table 1: Technique of anesthesia and failure rate of regional anesthesia among different categories of cesarean section urgency

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Anatomical deformity, obesity, and non-cooperation of patient due to labor pains were the most common reasons for the failure of RA. Out of 20 failed RA, six patients had epidural placed for labor analgesia and could not be used for CS due to inadequate block after top-up in one patient, time constraint due to category 1 CS in one patient and in four patients labor epidurals were not topped up as epidural was assessed to be inadequate during labor analgesia. During RA 5.4% (n = 44/802) patients reported discomfort during surgery and successfully managed with rescue analgesia and did not require conversion to GA. Out of these 44 patients requiring rescue analgesia and not conversion to GA, 13 (29.5%) belonged to category 1, 12 (27.2%) to category 2, 10 (22.7%) to category 3, and 9 (20.4%) to category 4.

Comparison of indication of GA as primary technique among different categories of CS urgency is shown in [Table 2]. Maternal preference was found to be the reason in 33.6% (n = 39/116) of patients for choosing GA as primary technique of anesthesia among different categories CS [Table 2].
Table 2: Comparison of indications of general anesthesia as primary choice among different category of cesarean section urgency

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Overall anesthesia was provided by the attending anesthesiologists in 12.5% (n = 117), fellow in 18% (n = 169), and residents in 69.5% (n = 652) of cases. Regarding number of attempts or skin punctures, RA was successfully performed at first attempt in 82.6% (n = 663/802) while 11.7% (n = 94/802) patients had successful RA at second attempt, 4.6% (n = 37/802) patients required third attempt while 0.99 (n = 8/802) patients required more than three attempts at RA. Call for help for senior assistance for RA was given for 6.4% (n = 52/802) of cases.

  Discussion Top

The current study observed a rising trend of CS which is mirroring the world trend.[1] With an overwhelming evidence that RA is a safer technique than GA for CS,[8] percentage use of RA for CS has become a marker of quality for obstetric anesthesia service.[5] The institution where this study was conducted also observed an increase in the rate of RA for all grades of CS and decline in the failure rate of RA as compared to the previous published data from the same institution.[6]

In LMICs, anesthesia-related maternal mortality has shown to account for 13.8% of all deaths after CS and exposure to GA has shown to increase the odds of maternal mortality (odds ratio 3.3, 95% CI 1.2–9.0, I2 = 58%), compared with RA.[9] The institution where the current study was conducted is from LMIC, where the rate of CS under GA remained more than 50% over many years.[6] The published data from 2012[6] evaluated the possible reasons of failing to achieve the recommended RA rate for CS, which prompted various stakeholders with institutional support to form a multidisciplinary team. This team evaluated the data from the published study,[6] to direct efforts to increase the rate of RA and decrease its failure rate for CS. The multidisciplinary efforts were directed toward improving communication among health-care personnel and patients to bring awareness and benefits of RA for CS. In addition, the team worked to introduce rapid sequence spinal anesthesia for category 1 CS and also on enhancement of training of anesthesia trainee residents and other health-care personnel. Literature has shown that multidisciplinary effort at all levels are required to bring positive changes in the clinical practice.[10] In addition, evidence on the impact of effective communication and patient education in obstetric services has shown to improve outcomes.[11],[12]

The current prospective study has shown an overall decline in the rate of use of GA for CS to 12.3% compared to the quoted rate of 49% from the published data of year 2012 from the same institution.[6] This current rate of use of GA for CS is almost comparable to the data from developed countries where GA usage for CS is less than 5% in the United States of America, <10% in Germany, and <15% in Great Britain.[13],[14],[15]

In addition, a rise in the rate of RA for emergency CS was observed compared to the published data from same institution.[6] The use of RA for category 1–3 CS has increased to 79.8% from 46.6% and 63.4% from 37.1% for category 1 CS compared to the published data.[6] This rate of rise in the rate of RA is most probably due to the introduction of rapid sequence spinal anesthesia in the, which was introduced by Kinsella et al. in 2010.[16]

The other area that needed improvement was failure rate of RA and conversion to GA. The Royal College of Anaesthetists in UK has proposed that conversion rate from RA to GA should be <5% for emergency cases and <1% for elective cases.[13] The failure rate of RA in this prospective study was reduced to 2.4% compared to 6.7% quoted in the previously published data from the same institution.[6] In the current study, failure rate of emergency CS (category 1–3) was 3.8% and 1.1% in the category 4 CS, which is in accordance to the standard for best practices.[13]

Literature has advocated the role of ultrasound for difficult spinal anatomy,[17] which could help in improvement in failure rate of RA for difficult cases. In addition, introduction of “competency-based assessment tools” has shown improvement in better training of trainee residents,[18] which could further improve the failure rate of RA instituted by trainees. The multidisciplinary efforts where the study was conducted included arranging simulated training workshops for use of ultrasound, adding a module of RA in the anesthesia residency training curriculum and introduction of direct observational skills. In addition, competency-based assessment was also introduced in anesthesia residency training program to measure the performance of trainee residents.

The strength of the study is the prospective design to evaluate the current practice of use RA and its failure rate for patients undergoing CS in an institution from LMIC. The observation from the current study in comparison to the data from the published study,[6] from the same institution, shows improvement in reaching the target for best practice. This should motivate the obstetric clinical caregivers to put effort in enhancement of trainee education, communication, patient education, and introduction of rapid sequence spinal to enhance RA rate and decrease its failure rate to improve obstetric anesthesia practice for CS. However, the year-wise detailed data from the time of introduction of the multidisciplinary efforts would have captured progression of improvement, which is the limitation of the current study.

In conclusion, the current study has highlighted the fact that evaluating obstetric anesthesia practice is needed to identify areas needing improvement and multidisciplinary efforts. Regular reevaluation of current clinical practice as done in this prospective study is needed to observe if target for best practice has been achieved or not. As RA technique for CS is considered to be a safer anesthesia technique, especially in resource-limited setting of LMIC, it is important for health-care institution to analyze their obstetric anesthesia practices. Regular reassessment of clinical practice helps in evaluating the outcomes of these efforts. In addition, there is a need to continue multidisciplinary communication and sharing of knowledge, which is crucial in implementation of good clinical practice.


We wish to acknowledge Mr. Syed Amir Raza and Ms. Seharish Sher Ali from the Department of Anesthesia, Aga Khan University, for their significant contributions in the statistical analysis of results and formatting of the manuscript.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

The Lancet. Stemming the global caesarean section epidemic. Lancet 2018;392:1279.  Back to cited text no. 1
McClure JH, Cooper GM, Clutton-Brock TH, Centre for maternal and child enquiries. Saving mothers' lives: Reviewing maternal deaths to make motherhood safer: 2006–8: A review. Br J Anaesth 2011;107:127-32.  Back to cited text no. 2
Say L, Chou D, Gemmill A, Tunçalp Ö, Moller AB, Daniels J, et al. Global causes of maternal death: A WHO systematic analysis. Lancet 2014;2:e323-33.  Back to cited text no. 3
Betran AP, Torloni MR, Zhang JJ, Gülmezoglu AM; WHO Working Group on Caesarean Section. WHO Statement on Caesarean Section Rates. BJOG 2016;123:667-70.   Back to cited text no. 4
Royal College of Anaesthetist. Technique of anaesthesia for Caesarean section. In: Raising the Standard: A Compendium of Audit Recipes 2012. Available from: www.rcoa.ac.uk/media/7156. [Last accessed on 2019 Dec 12].  Back to cited text no. 5
Ismail S, Shafiq F, Malik A. Technique of anaesthesia for different grades of caesarean section: A cross-sectional study. J Pak Med Assoc 2012;62:363-7.  Back to cited text no. 6
Lucas DN, Yentis SM, Kinsella SM, Holdcroft A, May AE, Wee M, et al. Urgency of caesarean section: A new classification. J Roy Soc Med 2000;93:346-50.  Back to cited text no. 7
Ghaffari S, Dehghanpisheh L, Tavakkoli F, Mahmoudi H. The effect of spinal versus general anesthesia on quality of life in women undergoing cesarean delivery on maternal request. Cureus 2018;10:e3715.  Back to cited text no. 8
Sobhy S, Zamora J, Dharmarajah K, Arroyo-Manzano D, Wilson M, Navaratnarajah R, et al. Anaesthesia-related maternal mortality in low-income and middle-income countries: A systematic review and meta-analysis. Lancet Glob Health 2016;4:e320-7.  Back to cited text no. 9
Nancarrow SA, Booth A, Ariss S, Smith T, Enderby P, Roots A. Ten principles of good interdisciplinary team work. Hum Resour Health 2013;11:19.  Back to cited text no. 10
Chang YS, Coxon K, Portela AG, Furuta M, Bick D. Interventions to support effective communication between maternity care staff and women in labour: A mixed methods systematic review. Midwifery 2017;59:4-16.  Back to cited text no. 11
Kalliyath AK, Korula SV, Mathew A, Abraham SP, Isac M. Effect of preoperative education about spinal anesthesia on anxiety and postoperative pain in parturients undergoing elective cesarean section: A randomized controlled trial. J Obstet Anaesth Crit Care 2019;9:14-7.  Back to cited text no. 12
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  [Figure 1], [Figure 2]

  [Table 1], [Table 2]


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