Teaching Neuraxial Anesthesia Techniques for Obstetric Care in a Ghanaian Referral Hospital: Achievements and Obstacles

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E Special Article Teaching Neuraxial Anesthesia Techniques for Obstetric Care in a Ghanaian Referral Hospital: Achievements and Obstacles

Adeyemi J. Olufolabi, MB BS, Evans Atito-Narh, MD, Millicent Eshun, CRNA, Vernon H. Ross, MD, Holly A. Muir, MD, and Medge D. Owen, MD * † † ‡ * ‡ Anesthesia providers in low-income countries may infrequently provide regional anesthesia techniques for obstetrics due to insufficient training and supplies, limited manpower, and a lack of perceived need. In 2007, Kybele, Inc. began a 5-year collaboration in Ghana to improve obstetric anesthesia services. A program was designed to teach spinal anesthesia for cesarean delivery and spinal labor analgesia at Ridge Regional Hospital, Accra, the second largest obstetric unit in Ghana. The use of spinal anesthesia for cesarean delivery increased significantly from 6% in 2006 to 89% in 2009. By 2012, >90% of cesarean deliveries were conducted with spinal anesthesia, despite a doubling of the number performed. A trial of spinal labor analgesia was assessed in a small cohort of parturients with minimal complications; however, protocol deviations were observed. Although subsequent efforts to provide spinal analgesia in the labor ward were hampered by anesthesia provider shortages, spinal anesthesia for cesarean delivery proved to be practical and sustainable. (Anesth Analg 2015;120:1317–22)

euraxial anesthesia techniques for cesarean deliv- preoperative assessment before surgery.4,10,11 Many low- ery have become commonplace in high-income income country labor wards do not provide analgesia or Ncountries.1–3 Preference for the use of neuraxial companion support to women in labor.10,12–14 Small doses anesthesia has resulted, in part, from recognition that gen- of IV/IM opioids may be infrequently used for analge- eral anesthesia may increase maternal risk.3,4 Unfortunately, sia early in labor, although the effectiveness is variable at many low- and middle-income countries continue to use best.4,14 Surveys suggest that women in low-income coun- general anesthesia for cesarean delivery, contributing to tries desire labor pain relief;15 however, many are unaware maternal deaths in both healthy and medically complicated of the options or their availability. patients.4–9 Mishaps include pulmonary aspiration of gastric Kybele, Inc. (www.kybeleworldwide.org) is a North contents and/or hypoxemia related to difficult intubation, Carolina-based 501(c)(3) humanitarian organization that unrecognized esophageal intubation, hypoventilation, or partners with institutions or governments in low-income premature extubation. These problems may account for 3% countries to improve maternal and neonatal care stan- 16 to 9% of hospital-based maternal deaths.4–9 dards. An invitation in 2004 by a Ghanaian anesthesiolo- Anesthesia providers in low-income countries are few gist led to Kybele’s exploratory visit to understand the local 10 and rarely care for obstetric patients outside the operat- medical culture and needs. Observations and focus group ing room.10 The first encounter between the parturient discussions at numerous facilities revealed a staff preference and anesthesia provider is usually in the operating room for the use of general anesthesia for cesarean delivery due to immediately before induction of anesthesia. The absence unfamiliarity with neuraxial techniques, lack of training in of anesthesia coverage on the labor ward may contribute treating side effects and complications, and an inconsistent supply of spinal needles and drugs.10 Kybele’s initial inter- to inadequate maternal and neonatal resuscitation, anal- ventions consisted of didactic lectures given to nurse anes- gesia provision, airway management, intensive care, and thetists and anesthesiologists by multidisciplinary experts at local conferences. In January 2007, Kybele signed a 5-year From the Department of Anesthesiology, Duke University School of memorandum of understanding with the Ghana Health Medicine, Durham, North Carolina; Department of Anesthesiology, Ridge Regional Hospital,* Ghana Health Service, Accra, Ghana; and Department Service to strengthen hospital capacity in delivering mater- of Anesthesiology, Wake Forest School† of Medicine, Winston-Salem, North nal and newborn care.16 Kybele was granted approval by Carolina. ‡ the Ghana Health Service to conduct training and to collect Accepted for publication August 8, 2014 data within the program. Funding: This work was supported by the Ghana Health Service, Kybele, Inc. Kybele selected Ridge Regional Hospital, a busy referral and educational grants from the Obstetric Anesthetists’ Association (OAA) and the International Association for the Study of Pain (IASP). center in Accra, as the training site. The hospital is among the Conflict of Interest: See Disclosures at the end of the article. largest hospitals in Ghana with a 900-patient capacity. The Supplemental digital content is available for this article. Direct URL citations maternity unit had grown from 1900 deliveries per year in appear in the printed text and are provided in the HTML and PDF versions of 2004 to 11,000 deliveries in 2012; approximately 60% of which this article on the journal’s website (www.anesthesia-analgesia.org). were deemed high risk. At the program onset, Ridge Regional Reprints will not be available from the authors. Hospital had 3 anesthesia physicians and 4 nurse anesthetists Address correspondence to Adeyemi J. Olufolabi, MD, Department of An- esthesiology, Duke University Hospital, Erwin Rd., Durham, NC 27710. Ad- to cover 3 to 4 operating rooms for the hospital. Anesthesia dress e-mail to [email protected]. services were not provided outside the operating rooms. The Copyright © 2015 International Anesthesia Research Society labor ward consisted of 6 labor and 2 delivery beds located a DOI: 10.1213/ANE.0000000000000464 considerable distance from the operating rooms.

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The Kybele teams comprised 6 to 17 medical volunteers September 2012, 553 (97%) of 570 cesarean deliveries were per visit. They traveled to Ghana 2 to 3 times per year from conducted with spinal anesthesia. There were 11,007 deliv- 2007 to 2011 to provide 1 to 2 weeks of intensive on-site, eries at Ridge Regional Hospital in 2012; of these, 13.6% locally relevant training and follow-up. The volunteers and 2.7% had pregnancy-induced hypertension and hem- were obstetricians, anesthesiologists, nurse anesthetists, orrhage, respectively. There were 3851 cesarean deliveries neonatologists, nurses, and midwives from Canada, (35%). Data analysis revealed that cases of severe hemor- England, and the United States, all experienced in the care rhage were predominantly conducted with general anesthe- of high-risk parturients and newborns. The following is an sia, but the vast majority of hypertension-related cesarean account of the activities undertaken, challenges, and out- deliveries used spinal anesthesia. comes achieved in working with the anesthesia department Spinal anesthesia continued to be used for cesarean at Ridge Regional Hospital to introduce the use of neuraxial delivery, even though the number of cesarean deliver- anesthesia techniques in obstetric patients. ies increased significantly after the program commenced (Table 1). Despite the large increase in patient admissions PROGRAM IMPLEMENTATION and the number of cesarean deliveries, the overall cesarean Spinal Anesthesia for Cesarean Delivery delivery rate remained relatively constant between 29% and Observations revealed deficiencies in the local standards 36% (Table 1). Kybele trainers and other external partners of anesthesia practice. Standard monitors such as electro- initially provided monitors, airway equipment, and dispos- cardiogram, pulse oximeter, capnograph, peripheral nerve able equipment; subsequently, local colleagues engaged hos- stimulators, and noninvasive arterial blood pressure devices pital administrators to provide ongoing equipment needs. were frequently unavailable or not used. Surprisingly, the The collaboration spawned other clinical activities and availability of anesthesia drugs was generally adequate; accomplishments: a preanesthesia clinic, recruitment of however, an incomplete understanding of pharmacologic additional anesthesia staff, initiation of a nurse anesthesia effects occasionally resulted in adverse patient outcomes. training program, and the creation of a dedicated obstet- For example, sedation was administered to a compromised ric operating and postanesthesia care unit. Maternal mor- patient with respiratory distress, leading to cardiac arrest, tality decreased by 23% overall, from 496 to 380 maternal and swallowing had been used as criteria for tracheal extu- deaths/100,000 live births, over the 5-year period despite bation, resulting in airway obstruction. Frequent electrical an increase in patient volume and high-risk disease acu- power outages and an inconsistent supply of clean water ity. In 2008, the World Health Organization estimated the contributed significantly to disruption of service. These maternal mortality ratio in Ghana was 409 maternal deaths observations reinforced the advantages spinal anesthe- per 100,000 live births with an uncertainty interval ranging sia could provide within the resource-restricted environ- from 248 to 633.17 ment, including less cleaning of reusable items (e.g., airway devices), avoidance of airway manipulation, less postop- Single-Shot Spinal Labor Analgesia erative pain, less nausea and vomiting, earlier breastfeed- After the introduction of spinal anesthesia for cesarean ing (thus decreasing the risk for neonatal hypoglycemia), delivery, a literature review and focus group discussions reduced nurse workload, and possibly, lower costs. with Ridge Regional Hospital anesthesia leaders led to the Ridge Regional Hospital anesthesia providers received development of a locally relevant single-shot spinal labor didactic and practical training in the use of spinal anesthe- analgesia protocol (Supplemental Digital Content 1, http:// sia for cesarean delivery over 3 consecutive 1- to 2-week links.lww.com/AA/B14). Epidural analgesia was deemed visits between 2006 and 2007. Patient eligibility, sterile inappropriate because of safety concerns and equipment preparation, needle selection, lumbar spinal interspace limitations. In addition, a resuscitation box, equipment trol- identification, local anesthetic dosage, sensory block assess- ley, and a patient data record were developed (Supplemental ment, hemodynamic monitoring, treatment of side effects, Digital Content 2, http://links.lww.com/AA/B15; and and complications were reviewed. Pencil point (25-gauge) Supplemental Digital Content 3, http://links.lww.com/ needles were available for use, and 10 mg hyperbaric 0.5% AA/B16). The patient data record and a logbook recorded bupivacaine was the preferred spinal dose. Opioid (fentanyl all patients who received spinal labor analgesia. 25 μg) was rarely added because of lack of availability. A A demonstration/training program was undertaken to review of operating room logbooks (2004–2006) revealed determine feasibility, staff, and patient acceptance of single- prior limited use of spinal anesthesia for cesarean delivery shot spinal labor analgesia in June 2007. This was conducted (Fig. 1). Over the course of the program, the following areas over 1 week during which 10 healthy, low-risk patients were were addressed and re-emphasized: preanesthetic evalua- recruited for training purposes. Risks and benefits were tion and assessment of patients, customer care behavior, the explained to patients before the procedure, and spinal anal- spinal anesthesia technique, treatment of hypotension, and gesia was conducted with the customary sterile technique management of suboptimal neuraxial block. including skin preparation, hat, mask, and sterile gloves. After training in 2007, the use of spinal anesthe- Pencil-point (25-gauge) needles were used; plain bupi- sia increased significantly from 6% to 89% over 3 years vacaine 2.5 mg was the preferred spinal dose. An opioid, (2008–2010) (Fig. 1). Reviews conducted in 2011 and 2012 fentanyl 25 μg, was added if available. Reinforcement of confirmed a continued change in practice. In August to training also occurred with subsequent Kybele visits. Two September 2011, 528 (95%) of 559 cesarean deliveries were local nurse anesthetists had become proficient with spinal performed using spinal anesthesia. Similarly, in August to anesthesia for cesarean delivery and agreed to work in the

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Figure 1. Anesthesia for cesarean delivery at Ridge Regional Hospital after a training program. Spinal anesthesia for cesarean delivery significantly increased after training in the use of regional anesthesia. Comparison is made between 2006 (baseline) and 2009 (P < 0.001; χ2).

dilation, and patients maintained the ability to ambulate to Table 1. Patient Number and Delivery Trends an adjacent room for delivery once leg strength was tested at Ridge Regional Hospital, Accra, Ghana at bedside. One patient had a paresthesia during spinal (2004–2011) administration without further complication. All patients Cesarean deliveries were seen the following day, and no postpartum complica- Mean cesarean Year Deliveries (N) Number Percent deliveries/day tions were identified. Unfortunately, efforts to sustain ser- 2004 1905 591 31.0 1.6 vice delivery were hampered by prolonged anesthesia staff 2005 2971 868 29.2 2.3 shortages that required the nurse anesthetists to work in the 2006 4793 1555 32.4 4.2 operating room. 2007 6049 2161 35.7 5.9 Twelve months after the preliminary labor analgesia 2008 7465 2454 32.9 6.7 program, 65 patients (17% nulliparous) were randomly sur- 2009 8230 2826 34.3 7.7 veyed the day after vaginal delivery to assess their expe- 2010 8133 2917 35.9 8.0 2011 9357 3361 35.9 9.2 rience before, during, and after delivery (Supplemental Digital Content 4, http://links.lww.com/AA/B17). Sixty- one percent of patients reported pain and anxiety before, labor ward. They recruited patients after the departure of 29% during and 13% after delivery. Only 51% of patients the Kybele team. The department altered the daily schedule were asked about the severity of the labor pain by hospital to allow the nurse anesthetists to be on duty in the labor staff. Patients reported being offered the following modali- ward during the morning shift (8 am–2 pm). Procedure ties for labor pain control: nothing (44%), reassurance (22%), complications and adherence to the protocol were assessed IV injection (22%), spinal medication (7%), and could not at subsequent Kybele visits by interviewing nurse anesthe- remember (5%). When asked which aspects of care could tists and midwives and reviewing the patient record sheets improve the labor and delivery experience, 46% reported and procedure logbook. the provision of pain relief, followed by 29% desiring com- Forty-six women (mean age 28 years) received spinal panion support. labor analgesia; of these, 6 patients requested a second dose when the initial analgesia waned. Fifty percent of the DISCUSSION patients were nulliparous. The median verbal pain scale There has been a steady and sustained increase in the use of (0–10 scale) score was 9 (range 5–10) before and 0 (range spinal anesthesia for operative delivery at Ridge Regional 0–4) after analgesia. The mean cervical dilation was 5 cm Hospital. The anesthesia providers continue to use the spi- (range 3–8 cm) immediately before initiation of analge- nal technique despite a rapid increase in the number of sia. Ephedrine (10 mg) was available to treat hypoten- cesarean deliveries performed and staff shortages. This is sion, but was not needed because systolic blood pressure commendable since other countries with sufficient numbers remained within 10% of baseline in all patients. Protocol of trained anesthesia providers and readily available spinal deviations were noted in 26 patients who received higher anesthesia supplies still report more frequent use of gen- than the recommended dose of 2.5 mg bupivacaine (range eral anesthesia for cesarean delivery.18,19 Fear of neuraxial 3–6 mg). Opioid availability was limited such that only 4 anesthesia by patients, reluctance of surgeons to operate patients received bupivacaine/opioid combination, 3 fen- on “awake” patients, and unfamiliarity of anesthesiologists tanyl (maximum 25 μg) and 1 meperidine (10 mg). Overall, using neuraxial techniques for obstetric patients were rec- motor block was minimal by the time of complete cervical ognized factors.18–20

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At Ridge Regional Hospital, spinal anesthesia use for welfare in relation to the procedure. It is important to note that cesarean delivery has been sustained due to support by the even though guidelines were developed, protocol deviations obstetric and nursing staff, as well as administrators who occurred. Larger than recommended local anesthetic doses ensure an adequate supply of 25-gauge pencil-point spinal were sometimes administered to extend analgesia duration. needles and local anesthetics. This support was achieved Fortunately, there were no untoward effects. Efforts must be through concerted and sustained advocacy efforts at indi- made to emphasize and reinforce strict protocol adherence. vidual and departmental levels. Spinal anesthesia con- Spinal analgesia has risks, complications, and benefits, sumes fewer resources than general anesthesia for operative and these must be anticipated and discussed with the deliveries. Furthermore, a patient immediately knowing the patient. It is reassuring that the incidence of postdural punc- sex of her baby has also become a positive practice. ture headache is low using small-gauge pencil-point spinal A limitation of the program was the lack of anesthesia- needles. The headache duration is usually self-limiting or related mortality data collected before the commencement of can be treated with simple analgesia, rehydration, and bed the Kybele collaboration. Deaths due to anesthesia are often rest. Resuscitative drugs (vasopressors, anesthesia drugs) unknown or underreported.5 In sub-Saharan Africa, periop- and equipment (facemasks, Ambu bag, tracheal tubes) erative maternal death rates are reported to be as high as should be readily available. Guidelines and prompt inter- 1% to 3.8%.4,6,8,11 Anesthesia complications were implicated vention of hemodynamic or respiratory compromise must in a number of the deaths.4,6,11,21 Airway complications that be taught. Although the duration of spinal analgesia using accompany general anesthesia are minimized when spinal this protocol is limited, its benefit was understood and anesthesia techniques are used for cesarean delivery.5,8,11 patients could receive a second spinal dose, if requested. A 2012 Ridge Regional Hospital internal audit identified In labor suites requiring parturients to walk to a separate 54 maternal deaths. Of these, 3 anesthesia-related deaths delivery room, motor weakness from residual spinal anal- were identified; 2 deaths were due to airway complications gesia must be considered; convertible labor and delivery during general anesthesia; and 1 death was related to high beds would help eliminate this potential risk. spinal anesthesia. Forty-one percent of the maternal deaths Patient acceptance of neuraxial labor analgesia is consis- occurred in the operating room and postanesthesia care unit. tent with other reports.25,26 An Indonesian study found that General or spinal anesthesia must be conducted or 81% of women were highly satisfied with spinal analge- closely supervised by experienced providers who ade- sia comprising bupivacaine 2.5 mg, morphine 250 μg, and quately monitor and treat complications as is summarized clonidine 45 μg.25 Similarly, in a Finnish study in which 229 in the triennial report on confidential enquiries of mater- parous women received single-shot spinal analgesia with nal deaths from South Africa.21 Although the number of bupivacaine 2.5 mg and fentanyl 25 μg, 85% of patients deaths related to spinal anesthesia were higher than general reported satisfactory analgesia and 81% would request the anesthesia (79% vs 17%) in this report, it is correctly stated same technique again.26 that, “no conclusion can be drawn on the safety of spinal The provision of labor analgesia in low-income coun- compared with general anesthesia as denominator data are tries requires further study. African women consistently not available.” Anesthesia accounted for 2.5% of deaths in rate childbirth as painful, similar to women in other coun- >580,000 cesarean deliveries. The majority of anesthesia- tries; however, they have few options for pain relief because related deaths occurred in smaller hospitals where super- labor analgesia is rarely provided.10,14,15,27,28 Interestingly, 94% vision was often inadequate. The trend towards neuraxial of health care workers surveyed in 1 African tertiary center anesthesia was obvious and appropriate because the avoid- believed women should be offered pain relief, yet less than ance of airway manipulation under general anesthesia has half had administered any form of analgesia in the 3 months been instrumental in reducing anesthesia-related maternal before the survey.14 The survey further confirmed that the pro- deaths.22,23 Correct standards of care, however, need to be vision of pain relief was the highest rated factor that patients emphasized during training to avoid deaths due to compli- felt would improve their delivery experience. Other African cations of spinal anesthesia.24 studies have similarly found that women would use labor We demonstrated that spinal labor analgesia can be pro- analgesia if given the opportunity.15,27,28 Our survey corrobo- vided in a low-resource setting with the development of rates these findings. Midwives at Ridge Regional Hospital appropriate protocols, staff education, and the availability appeared supportive of pain-reducing efforts, but the major- of a few basic drugs. Spinal labor analgesia was introduced ity of patients were not offered available analgesia. This due to staff familiarity and relative simplicity compared to discrepancy among midwives has many causes, including the epidural technique. We avoided epidural anesthesia/ limited staff availability, other priorities, and complacency. analgesia due to potential complications (postdural puncture Another factor limiting the consistent availability of headaches after unintentional dural puncture, high spinal neuraxial labor analgesia is the lack of trained anesthesia anesthesia, neuraxial infection) and the lack of equipment providers.4,5,11 In our experience at Ridge Regional Hospital (epidural catheters, low-resistant syringes, infusion devices). in Ghana, limited manpower was the greatest challenge in Anesthesia providers, midwives, and obstetricians recog- establishing anesthesia provider presence on the labor ward. nized the immediate benefits of spinal labor analgesia by the Staff attrition and workload increase due to the increase of positive patient responses that ranged from falling asleep to cesarean deliveries became problematic. It was hoped that complete excitement over the unexpected experience of pain the nurse anesthesia training school, which opened in 2009, relief. The presence of fetal heartbeat before and after initia- would provide available nurse anesthetists; however, insuf- tion of analgesia reassured midwives and patients of fetal ficient physician anesthesia coverage, lack of a perceived

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role for anesthesia providers on the labor ward, and unfa- Name: Holly A. Muir, MD. miliarity of anesthesia providers with the labor and delivery Contribution: This author helped with protocol design, on-site environment continue to hamper progress. This situation at training, and manuscript preparation. Ridge Regional Hospital is not unique because labor ward Attestation: Holly A. Muir reviewed and approved the final presence of anesthesia personnel is uncommon in many low- manuscript. This author attests to the integrity of the original income countries.10,18,19 A practice paradigm shift is required. data and the analysis reported in the manuscript. The option for pain relief is considered a basic human Conflicts of Interest: This author serves on the Kybele board of right and is an index of health care quality and compas- directors but receives no financial compensation for activities sion.29 We must work to understand and address the mul- undertaken with regards to the organization. Name: tifactorial barriers that prevent women from receiving pain Medge D. Owen, MD. Contribution: This author helped with protocol design, data relief when they desire it. Providing analgesia during labor collection and analysis, and manuscript preparation. may encourage patients to seek earlier hospital admission Attestation: Medge D. Owen reviewed and approved the final and promote earlier multidisciplinary patient care. Earlier manuscript. This author attests to the integrity of the original intervention by anesthesia providers also has the potential data and the analysis reported in the manuscript. This author to improve patient outcome, especially in cases requiring will serve as the archival author and will maintain study 10,11 resuscitation and airway support. records. In conclusion, we have demonstrated that training anes- Conflicts of Interest: Medge D. Owen is founder and president thesia providers to conduct spinal anesthesia for cesarean of Kybele but receives no financial compensation for activities delivery in a low-income country can result in sustained undertaken with regards to the organization. use. Use of simple protocols for spinal labor analgesia can This manuscript was handled by: Cynthia A. Wong, MD. also provide effective pain relief; however, challenges due to manpower, cultural, and logistical constraints can cur- ACKNOWLEDGMENTS tail sustainability. Anesthesia providers bring a unique set The authors wish to extend our gratitude to the Kybele team of skills to the care of high-risk obstetric patients, well rec- members who participated in this program and Tobi Olufolabi ognized in high-resource countries. We must work to over- and Genny Olsen who conducted the patient survey. come barriers that prevent broader roles for involvement of anesthesia providers in maternal and neonatal care in low- REFERENCES resource countries. 1. Bucklin BA, Hawkins JL, Anderson JR, Ullrich FA. E Obstetric anesthesia workforce survey: twenty-year update. Anesthesiology 2005;103:645–53 DISCLOSURES 2. Benhamou D, Bouaziz H, Chassard D, Ducloy JC, Fuzier V, Name: Adeyemi J. Olufolabi, MBBS. Laffon M, Mercier F, Raucoules M, Samii K. Anaesthetic prac- Contribution: This author helped with protocol design, on-site tices for scheduled caesarean delivery: a 2005 French national training, conduct of the study, data analysis, and manuscript survey. 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