| Summary: | Reports from the maternal death notification system showed a high number of maternal
deaths from anaesthesia in the Free State. I initiated this study in order to investigate and
rectify factors identified as being associated with this problem.
The study method used was an audit cycle. I selected from the literature on maternal deaths
the five main factors most likely to be relevant ie manpower, use of regional anaesthesia,
anaesthetic drugs and equipment, resuscitation protocols and the referral system.
In the first part of the study (Phase 1), every level one and two hospital in the Free State in
which Caesarean sections (CSâs) were being performed was inspected to determine whether
the required standards for these factors were being met. The intention was to then implement
remedial interventions to correct any problems identified in Phase 1 and then in Phase 2 to
repeat the hospitals visits to assess the effect of the interventions.
Phase 1 showed deficiencies in essential anaesthetic drugs and equipment in most hospitals.
Hospital staff and managers were clearly informed regarding these problems but there was
only a slight overall improvement in standards when the audit was repeated in Phase 2 and
even a decline in certain aspects.
Anaesthetic manpower was studied using self-completed questionnaires. Only a third of
these questionnaires were returned and they showed that doctors were largely inadequately
trained and supervised whilst administering obstetric anaesthesia. These results were
presented to Free State Department of Health Top Management. Concern over possible bias
regarding the doctors who returned the forms was raised and it was requested this study
should be repeated using a different method to improve the response rate. This was done in
Phase 2, a 69% response rate was achieved and the results confirmed the Phase 1 findings. Management was presented with these findings and interventions to resolve these problems
was suggested to them.
Use of regional anaesthesia was studied via inspection of theatre record books. In Phase 1 it
was found that 71% of CSâs were performed using regional anaesthesia (RA), close to the
proposed goal of 75%. However, in some hospitals no or few CSâs were performed using
RA. There followed remedial interventions in which RA was promoted and in Phase 2 it was
found that 84% of CSâs had been performed using RA. Unfortunately there is now concern
that RA is being over utilised and general anaesthesia is not being administered when
appropriate.
In Phase 1, there were virtually no hospitals in which up-to-date resuscitation protocols were
displayed. Protocols were distributed to all and in Phase 2 more, but not all, hospitals had the
required protocols on display.
The referral system was studied in Phase 1 using data collection sheets which were to be
completed by the doctors when a patient had a CS. There was such poor compliance with
this part of the study that it was decided that to resolve this would require a completely
separate study utilizing greater research resources. Further investigation was therefore
abandoned.
Performing this audit had the desired result of improving the awareness of problems relating
to obstetric anaesthesia in the Free State, at a Provincial and National level amongst both
health care professionals and management. Although the remedial interventions did not
âcureâ some of the problems identified, progress was made and where progress was not
made there is now greater knowledge as to where the problems lie. It remains for those who
have the resources to tackle these issues, which are largely concerned with manpower, to
take cognisance of the results of this study and implement the suggested corrective
measures.
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