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 Table of Contents  
EDITORIAL
Year : 2022  |  Volume : 12  |  Issue : 2  |  Page : 82-84

Patient safety in obstetric anesthesia


Department of Anaesthesiology, Pain Medicine and Critical Care, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, India

Date of Submission26-Jul-2022
Date of Acceptance27-Jul-2022
Date of Web Publication02-Sep-2022

Correspondence Address:
Dr. Sana Y Hussain
5th Floor, Anaesthesia office, Academic Block, Department of Anaesthesiology, Pain Medicine and Critical Care, All India Institute of Medical Sciences, Ansari Nagar, New Delhi - 110 029
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/JOACC.JOACC_47_22

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How to cite this article:
Rewari V, Hussain SY. Patient safety in obstetric anesthesia. J Obstet Anaesth Crit Care 2022;12:82-4

How to cite this URL:
Rewari V, Hussain SY. Patient safety in obstetric anesthesia. J Obstet Anaesth Crit Care [serial online] 2022 [cited 2022 Dec 9];12:82-4. Available from: https://www.joacc.com/text.asp?2022/12/2/82/355350



The overarching principal of medical care is to provide safe and quality care to all patients. The World Health Organization defines patient safety as 'prevention of errors and adverse events to patients associated with health care'.[1] Maternal safety, especially during childbirth is one of the top priorities and is emphasized by the theme of the World Patient Safety Day 2021 being 'Safe Maternal and Newborn Care'.

The maternal mortality rate in India declined from 398/100,000 live births in 1997-1998 to 99/100,000 in 2020.[2] Anesthesia-related maternal deaths account for approximately 2.8% of all maternal deaths in lower-middle income countries.[3] These data highlight the need for increased maternal care including robust perioperative care. During delivery of obstetric anesthesia and analgesia services, one should strive toward prevention and reduction of potential errors which could compromise the safety of the mother and the fetus. Obstetric care not only presents with clinical challenges but also poses enormous medico-legal liabilities. A closed malpractice claims analysis shows that majority of medicolegal issues arise from maternal nerve injury and maternal/fetal death.[4]

Medical errors leading to patient harm can be due to reasons ranging from individual to system failures. As explained by the Swiss cheese model of health care,[5] a catastrophic event occurs when a series of unlikely errors come in line. Preventing harm by barriers at various levels is hence important [Figure 1].
Figure 1: Swiss cheese model of patient safety in anesthesia

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Anesthesiology has always essentially been a safety centric speciality and obstetric anesthesiologists play a pivotal role in delivering safe maternal care. Obstetric patients have changes in physiology and anatomy compared to non-parturients which places them at a higher risk during anesthesia care.[6]

Obstetric anesthesia presents unique sets of challenges not only due to patient physiology, higher rate of emergency surgeries but also due to the need to balance anesthetic techniques to provide safe anesthesia to 'two lives' at risk. Any delayed or suboptimal maternal care directly impacts the well-being of fetus and can lead to significant morbidity and mortality. The presence of two lives at stake makes it extremely important to minimize and avoid all preventable errors and provide the best and the safest care possible.

Patient harm can be due to multiple causes including difficulty in securing the airway, aspiration, high spinal, hemorrhage,[7] drug errors, inadequate facilities for high-risk cases, improper documentation, incomplete evaluation during emergency sections, risks during patient transfer, and ineffective teamwork and communication due to different specialties involved.

Anesthesiologists are responsible for the safe and effective provision of anesthesia, labor analgesia, and also play a role as intensivists of the obstetric suite. They can contribute in maternal safety in various ways.

  1. Following general safety measures – The Joint Commission endorses universal methods of safety and updates it regularly. It has three basic components – pre-procedure verification, site marking, and time out. The surgical safety checklist addresses these basic tenets of safety including correct patient, correct site, and correct procedure.[8] The anesthesiologist, obstetrician, and nurse discuss specific patient concerns and decide for plan of management.
  2. Increasing safety during general anesthesia – Difficult airway and aspiration pneumonia have been implicated as major causes of anesthesia-related maternal deaths.[9] Despite the development of various advanced airway equipment and better techniques, incidence of failed obstetric intubation remains higher than in the non-obstetric population. A recent review stated an incidence of failed tracheal intubation of 2.6 per 1000 obstetric general anesthetics and associated maternal mortality of 2.3 per 100,000 general anesthesia.[10]

    It is important to have a protocolized and stepwise approach to difficult airway management, focusing more on ways to maintain oxygenation in case of difficult intubation. Difficult airway cart should always be present inside the maternity OT including supraglottic airways, videolaryngoscope, etc. Availability of expert help, simulation training, aspiration prophylaxis, continuous oxygen saturation, and capnography monitoring is of paramount importance to reduce maternal complications related to difficult airway. Safe extubation and provision of postoperative care should be planned.
  3. Improving safety in neuraxial anesthesia – Spinal anesthesia is the most common technique used for caesarean sections. Although the incidence of complications like spinal hematoma, high spinal is less, they do occur leading to significant morbidity and mortality.[7] Low local anesthetic volume with adjuvants, careful epidural drug administration, complying by regional anesthesia guidelines in the presence of coagulopathy or for patients on anticoagulants is important. Hypotension not only affects the mother, but can be deleterious to the fetus as well. Hence, it should be prevented and managed by placing a wedge under the right buttock to prevent supine hypotension, fluid administration, and use of vasopressors like phenylephrine. Post-dural puncture headache is one of the most common complications of spinal block. Use of pencil point needles should be encouraged, patients should be followed postoperatively and if the condition does not respond to conservative methods, treatment options should move to epidural blood patch taking care of strict asepsis. Different alternatives like greater occipital nerve block or transnasal sphenopalatine block may also be tried.[11],[12]
  4. Safety in labor analgesia – Painless labor is every woman's right. Patient safety should be a priority when planning pain relief during labor. Utmost vigilance is required to confirm epidural catheter placement and to rule out intrathecal migration of catheter. Care should be taken to avoid inadvertent dural puncture. Dilute concentrations of local anesthetics should be used and presence of an accompanying person should be ensured during ambulatory epidurals to avoid patient fall. Labor analgesia suite should be well equipped with all resuscitation equipment, monitors, and trained personnel.
  5. Avoiding drug errors – Multiple drugs are used during anesthetic care of obstetric patients and errors can occur during drug prescription, preparation, or administration. These include errors like wrong drug administration, inaccurate dosages, and incorrect routes. A review by Kaur et al.[13] in this issue highlights the literature on drug errors and their consequences in obstetric anesthesia practice. Wrong drug administration in spinal route has been reported leading to significant patient harm. Oxytocin and magnesium sulphate are commonly used drugs in obstetric practice which need close monitoring of vitals and drug dosages. Simple methods like clear prescription, use of color coded labels and double checking by a second person before administration should be followed. Continuous vigilance in all steps of drug handling is necessary to minimize complications due to drug errors.
  6. Managing high-risk patients – Proper screening and evaluation of high-risk patients should be done. Recognizing the early warning signs of changing physiological parameters before the occurrence of critical or fatal event is important. To address this, use of Modified Early Obstetric Warning System has been recommended.[14] High-risk cases include, but are not limited to patients with hypertensive disorders of pregnancy, cardiac diseases, severe systemic illness, placenta accreta, postpartum hemorrhage.

    Establishing antenatal anesthesia clinics can help in timely predelivery optimization, patient counselling, education, and formulation of plan in case of operative delivery.

    Quick but complete anesthetic evaluation and examination should also be done prior to emergency surgeries. Protocols for managing high-risk patients should be in place, facility for swift arrangement of blood and blood products and a postoperative unit with critical monitoring should be present. Lack of obstetric ICUs leads to inadequate management of high-risk parturients. Efforts should be directed to establish maternal critical care units. In places with inadequate setup, a smooth and sound referral system to higher centres and safe patient transfer should be ensured.
  7. Safe hospital system – Hospitals should develop and propagate systems with patient safety at its core. A dedicated maternity OT with well-equipped labor analgesia suite and trained staff is a must. Triage and early management of obstetric emergencies and safe transfer of patients should be arranged. Poorly organized patient transfer can lead to significant morbidity. Hence, the logistics of patient transfer including equipment and personnel for both in-hospital and interhospital transfers should be preplanned. The most important goal during patient shifting is to ensure continuity of care. Policies should be formulated around medication safety, medication orders, avoiding unapproved abbreviations, proper documentation, informed consents, infection control, blood transfusion, and implementation of surgical safety checklist. Regular audits should be done to ensure strict compliance to patient safety policies, increase accountability and to find gaps in safe healthcare delivery with plans and actions to bridge them. Effective ways of adverse event reporting should be done. Based on feedbacks, formulation and dissemination of continuous quality improvement programs should be done. A close interaction between individuals and system provides better patient outcome [Figure 2].
  8. Training, teamwork, and communication – Obstetric anesthesia has its own challenges and requires expertize and balanced decision-making. Anesthesiologists should lay focus on obstetric anesthesia and obstetric critical care training for better maternal care. Simulated training should be encouraged for different conditions like difficult airway during general anesthesia for caesarean sections, maternal cardiac arrest, etc.
Figure 2: Interaction between individual and system factors for safer maternal outcomes

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Good teamwork and effective communication among anesthesiologists, obstetrician, nurses, and other stakeholders is of utmost importance. Careful documentation and meticulous handing and taking over should be done to avoid missing any critical history or event.

To conclude, with increasing scientific and technical advances, we have come a long way in providing better care and decreasing maternal morbidity and mortality, still there is a long journey ahead to reach the goal of providing completely safe anesthesia and healthcare. Continuous training, skill acquisition, learning from errors, quality improvement, and inculcating young minds with the significance of providing safe and effective care so that they can carry the legacy of this 'culture of safety' should be our priority.



 
  References Top

1.
World Health Organization, G. The conceptual framework for the international classification for patient safety. In: Version 1.1 final technical report January 2009.  Back to cited text no. 1
    
2.
Meh C, Sharma A, Ram U, Fadel S, Correa N, Snelgrove JW, et al. Trends in maternal mortality in India over two decades in nationally representative surveys. BJOG 2022;129:550-61.  Back to cited text no. 2
    
3.
Flin R, Fioratou E, Frerk C, Trotter C, Cook TM. Human factors in the development of complications of airway management: Preliminary evaluation of an interview tool. Anaesthesia 2013;68:817-25.  Back to cited text no. 3
    
4.
Kovacheva VP, Brovman EY, Greenberg P, Song E, Palanisamy A, Urman RD. A contemporary analysis of medicolegal issues in obstetric anesthesia between 2005 and 2015. Anesth Analg 2019;128:1199-207.  Back to cited text no. 4
    
5.
Reason J. Human error: Models and management. BMJ 2000;320:768-70.  Back to cited text no. 5
    
6.
Bhatia P, Chhabra S. Physiological and anatomical changes of pregnancy: Implications for anaesthesia. Indian J Anaesth 2018;62:651-7.  Back to cited text no. 6
[PUBMED]  [Full text]  
7.
D'Angelo R, Smiley RM, Riley ET, Segal S. Serious complications related to obstetric anesthesia: The serious complication repository project of the society for obstetric anesthesia and perinatology. Anesthesiology 2014;120:1505-12.  Back to cited text no. 7
    
8.
Hospital: 2022 National Patient Safety Goals | The Joint Commission. Available from: https://www.jointcommission.org/standards/national-patient-safety-goals/hospital-national-patient-safety-goals. [Last accessed on 2022 Jun 28].  Back to cited text no. 8
    
9.
Rudra A, Mondal M, Acharya A, Nayak S, Mukherjee S. Anaesthesia-related maternal mortality. J Indian Med Assoc 2006;104:312-6.  Back to cited text no. 9
    
10.
Kinsella SM, Winton AL, Mushambi MC, Ramaswamy K, Swales H, Quinn AC, et al. Failed tracheal intubation during obstetric general anaesthesia: A literature review. Int J Obstet Anesth 2015;24:356-74.  Back to cited text no. 10
    
11.
Kwak KH. Postdural puncture headache. Korean J Anesthesiol 2017;70:136-43.  Back to cited text no. 11
    
12.
Nair AS, Rayani BK. Sphenopalatine ganglion block for relieving postdural puncture headache: Technique and mechanism of action of block with a narrative review of efficacy. Korean J Pain 2017;30:93-7.  Back to cited text no. 12
    
13.
Kaur M, Yalla B, Trikha A. Medication errors in a parturient: A huge cost to two lives. J Obstet Anaesth Crit Care 2022.  Back to cited text no. 13
  [Full text]  
14.
Lewis G, editors. Saving Mothers' Lives: Reviewing maternal Deaths to make Motherhood Safer 2003–2005. The Seventh Confidential Enquiry into Maternal Deaths in the United Kingdom. London: CEMACH; 2007.  Back to cited text no. 14
    


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