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35ОСОБЕННОСТИ АКУШЕРСКОЙ АНЕСТЕЗИОЛОГИИ В ИНДИИ
Доктор (профессор) Джотсна Пундж1, доктор Тилака Мутиа1
1. Отделение анестезиологии и интенсивной терапии, Всеиндийского института медицинских наук, Дели, Индия
Для корреспонденции: [email protected] Резюме
Доступность и повышение качества помощи в акушерской анестезиологии играет важную роль в общем улучшении здоровья матери. Индия - многоликая страна с разнообразной инфраструктурой и услугами в области здравоохранения не только между штатами, но и внутри них с точки зрения сельских и городских районов. В этой статье делается попытка охватить в целом практику акушерской анестезиологии, которой придерживаются в Индии, с выделением различий между городской и сельской местностью. Рассмотрены вопросы роли анестезиолога при физиологических родах; препятствия в обеспечении обезболивания родов, особенности при операции кесарева сечения, текущее состояние интенсивной терапии в акушерстве, а также обучение и подготовка акушерских анестезиологов в Индии.
OBSTETRIC ANAESTHESIA PRACTICE IN INDIA
Dr (Prof) Jyotsna Punj1, Dr Thilaka Muthiah1
1. Department of Anesthesiology, Pain Medicine and Critical Care, All India Institute of Medical Sciences, India For correspondence: [email protected]
Abstract
Availability and improvement in obstetric anaesthesia services play an important role in the overall enhancement of maternal health. India is a diverse country with varied infrastructure and services in health care not only between the states, but also within them in terms of rural and urban areas. This article attempts to cover by large the practice of obstetric anaesthesia followed in India, highlighting the distinctions between the urban and rural areas. Role of the anesthesiologist in normal labor; practice, acceptance and barriers in the provision of labor analgesia, challenges faced in handling patients who present for caesarean section, current status of obstetric critical care and teaching and training of obstetric anaesthesia in India have been addressed.
Introduction
Maternal healthcare continues to remain a major challenge in the developing countries. Maternal mortality rate (MMR) is one of the key healthcare indicators that defines a country's progress and development in the health sector. The Safe motherhood WHO training manual considers anesthetic accidents as preventable causes of maternal deaths and thus obstetric anaesthesia plays a significant role in improving the quality of maternal health and thus in reducing MMR. Anesthesiologists, with their wide experience in critical illnesses, resuscitation, fluids, pain management and knowledge of maternal
physiology play a significant role in managing the complications in obstetric patients like hemorrhage, sepsis and hypertensive disorders. In India, there is shortage of anesthetists and this is now identified and recognized by the government as one of the major causes of high MMR. This led to inclusion of anaesthesia as an important component of «Comprehensive essential obstetric care» in the safe motherhood programs of the country, which is in line with the guidelines of WHO.
India is a huge and diverse country. It has a population of over 135 crores but the distribution of population in its 29 states and 7 union territories
is not uniform. Close to 30% of the India's population lives in the urban areas, while rural population constitute close to 70%. There is a gross difference in health parameters of the country according to the urban/rural population.
Though the MMR of the country declined from 556/100,000 live births in 1990 to 122/100,000 live births in 2015-2017, India currently ranks at 129 among 184 nations on MMR. However, MMR in India is not uniform through the country and varies between different states. States like Assam and Rajasthan have significantly higher MMR close to 200/100,000 live births and more educated states like Kerala have MMR of close to 50/100,000 live births which is closer to developed nations [1]. The reasons of this are multiple, like diversity in culture, local customs, percentage of people living in rural and urban areas, literacy, socioeconomic status, age of marriage, preference to home deliveries, awareness and access to healthcare.
The non-uniform composition of the country resulted in different health practices in each region and thus cannot be generalized. To make health care available to all people in the country especially to the rural population, government initiated Primary Health Centers (PHC) for preventive and promotive aspects of health care, right from its independence in 1947. These are state-owned rural health care facilities and are essentially single-physician clinics usually with facilities for minor surgeries. They are part of the government-funded public health system in India and are the most basic units. Considered the backbone of the health services in the country, presently more than 23,000 PHCs are functioning in the country. Each PHC caters to a population of 30,000. Approximately 34 PHCs refer patients to one Community Health Centers (CHC) and each CHC caters to a population of 1,20,000 in urban areas and 80,000 in remote areas.
This article will aim to understand the complex current obstetric anaesthesia practices in India.
Description of current Obstetric Anesthesia Practices
Normal labor, labor analgesia and the anesthesiologist
Normal labor and the anesthesiologist: Increased utilization of institutional facilities for delivery is recognized as a major factor for improved maternal health and reduction in MMR [2]. However, in India only urban women are more likely to deliver in institutions. Major concern in the rural set up is to motivate the parturient to report to the PHCs for antenatal care which is hugely related to their economic status and accessibility of delivery services [3, 4]. The data of the number of women delivering in institutions with the help of skilled birth attendants shows an encouraging trend from 43% in 2004 to 83% in 2014 [5]. This has mainly been possible due to increased health awareness programmes of the government like the Janani Shishu Suraksha Karyakram that allows free transport and no expense delivery including caesarean section, to all pregnant women delivering in public health institutions. Another effective government scheme is the Pradhan Mantri Surakshit Matritva Abhiyan, that allows greater access to antenatal check-ups and helps obstetricians track and refer high risk pregnancies at the right time. The success of these programmes has been mainly due to early recognition of anemia, a significant problem in our country among women of child bearing age group, and recognition of other obstetric complications, at the level of the PHCs where the parturient reports. These women are then timely referred to higher CHC centers for further management. In the CHCs, presence of blood bank and round the clock operation theatres ensure good peri-partum care for these patients.
Obstetricians and Anesthesiologist: Earlier studies conducted about 15 years ago showed considerable neglect among obstetricians in teaching and training of labor analgesia in the Indian setup [6]. Increased incidence of instrumental deliveries and concern of increased
time required to initiate labor analgesia were the main concerns in obstetricians to not agree for it [7]. A recent study in 2018 showed that in about 71% parturients, labor analgesia was administered by anesthesiologists with majority not believing in myths surrounding labor analgesia [8].
Labor analgesia and the anesthesiologist: The Federation of Obstetric and Gynecological Societies of India (FOGSI) emphasizes that labor management should be individualized according to the needs of the laboring woman trying to achieve a successful and safe vaginal delivery, along with the ability to intervene with a cesarean delivery, if necessary, to prevent morbidity and mortality [9].
a) Labor analgesia in rural areas: Awareness about labor analgesia in rural areas is next to nil. In a survey that involved participants primarily from rural areas, about 98% of the participants had no awareness about labor analgesia, though majority expressed interest in learning about how it will be provided and the advantages [10]. On the other hand, a study conducted in a tertiary care teaching hospital which sees a mixture of rural and urban women reporting for antenatal care, majority were found to express desire in opting for labor analgesia if it would be effective and safe. However, increased cost was a concern that led to almost half the interested parturients drop the option of labor analgesia [11];
b) Labor analgesia in urban areas: In urban women acceptance to labor analgesia has come about gradually. The main reasons against labor analgesia were that it is felt that pain during labor is a good aspect as it helps in allowing the mother push the baby, as it is a is a natural process pain has to be tolerated and fear that pain relief might lead to some delivery problems [10]. As family members have a major say in a married couple's life in the country, opinion of other family members, especially the elderly ladies are respected and obeyed and as these people are mostly unaware of labor analgesia, permission for the same is usually not given due
to ignorance. This prevented most women for asking for labor analgesia. Recent studies show a remarkable increase in the willingness, awareness as well as intent among obstetricians and anesthesiologists in the practice of labor analgesia [7, 8, 11]. A study conducted in the year 2018 showed that among anesthesiologists throughout India, labor analgesia is maximally practiced by those in the corporate and private hospitals, primarily catering to the urban population, followed by the ones practicing in government medical colleges. This could be because pregnant women reporting to the government medical colleges for antenatal care usually belong to lower socioeconomic state. This survey might also be underrepresented of practices in tertiary medical colleges and teaching institutions, due to low response rate of 16.47% to the survey [8];
c) Services of labor analgesia: Presently, labor analgesia is practiced in majority of the tertiary teaching institutes, which is reflected by numerous studies on labor analgesia published from teaching institutions, though data of all the whole country practices is not compiled presently [12-15];
d) Techniques of labor analgesia practiced in India: In a recent study (2018), the most common indication for the initiation of labor analgesia among 74.38% of respondents was request for pain relief. Amongst all the modalities of labor analgesia, regional techniques were the most common of which epidural analgesia with intermittent boluses was the most preferred. 8% of respondents considered using ultrasound for the placement of epidural. Systemic analgesia was generally reserved for early stages and as adjuvant to regional. Bupivacaine was the local anesthetic of choice for epidural in 64.10% of respondents, followed by ropivacaine. Lower concentrations of local anesthetic were preferred as walking epidural was considered by 67% of anesthetists. Myths surrounding labor analgesia were dismissed by majority of the respondents [8].
Another study in year 2018 also revealed epidural to be the first choice of technique for providing labor analgesia among 77% of anesthesiologists. Obstetricians on the contrary used parenteral drugs for labor analgesia (LA). The reasons for providing LA were better maternal outcome in anesthesiologists and a cooperative parturient who helped in delivery and vaginal examination in obstetricians [7].
Anaesthesia for caesarean section
FOGSI recognized increase in the rate of caesarean section (CS) in the country which has doubled in a decade, from 9% in 2005-06 to 17% in 2015-16. The various reasons that an anesthesiologist has to administer anesthesia for CS to the parturient are varied. On one hand, are the planned elective patients who are well prepared and adequately fasted for CS, and on the other hand are parturient for emergency CS due to last minute referrals and are inadequately fasted and non-optimized ( which may include blood pressure, hemoglobin values, sugars and other comorbid conditions like valvular heart diseases, liver and renal dysfunctions). The urgency of fetal distress and the anticipated difficulty in the pregnant airway with the risk of regurgitation are true tests of the skills and knowledge of even the most experienced of anesthesiologists.
In a 30 year survey from California, spinal anesthesia was found to be the most preferred technique for CS among all regional anesthesia techniques [16]. The ease of administration combined with the rapid onset and cost effectiveness has made it the most popular choice among regional techniques [17] Introduction of «rapid sequence spinal anesthesia» (RSSA), where spinal anesthesia can be established in 6-8 minutes in suitable parturient has made spinal anesthesia a popular option in patients undergoing emergency CS where not much time can be spent on administration of anesthesia [18, 19]. Epidural and combined spinal epidural (CSE) have also been used for CS. Epidural anesthesia is mostly administered when a patient has an indwelling epidural catheter placed for purposes of labor
analgesia, and a decision to convert to CS has been taken due to non-progress or any other cause that allows time of at least 15- 20 minutes for the activation of epidural. CSE combines the benefits of both a rapid onset block along with prolonged duration of anesthesia and the flexibility of extending the block height and is particularly used in the high-risk cardiac patients and obese patients. [19]. Emergency CS with fetal distress in the presence of a difficult airway of parturient, especially during nights is particularly challenging, especially in the hands of a not too experienced anesthesiologist [20]. The choice of RSSA versus GA depends on expertise of the anesthetist and institutional practices.
Due to the vast population of the country and diversity in geography the country lacks data of total number of CS conducted under regional or general anaesthesia. One retrospective study from the eastern part of the country found that administration of regional anaesthesia for CS has consistently increased over the years, both in elective and emergency scenarios and spinal anesthesia is the most frequently used type of regional anaesthesia [21].
Similar to the practice in most parts of the world, general anaesthesia (GA) for CS is not the first choice in India mainly due to the risk of potential difficult airway and risk of aspiration. It is used in conditions when regional anaesthesia is contraindicated, failure of regional anaesthesia and in emergency CS for acute conditions where spending more time on CS may jeopardize safety of mother and child (19) A study involving 60 patients undergoing category 1 emergency CS carried out in India, found shorter anaesthesia to delivery time with RSSA, and found the technique to be equivalent to GA [22]. Another observational study involving 123 patients from a tertiary care center in India, comparing spinal anaesthesia vs GA for category 1 emergency CS found no difference in decision to delivery time, uterine incision to delivery interval and fetal heart rate among both the groups. However, on subgroup analysis of parturient who presented with fetal bradycardia, lower cord blood pH and lower 1-
minute Apgar scores was found compared to parturient who received GA [23].
The All India Difficult Airway Association (AIDAA) brought out five guidelines for the management of difficult airway, that included a separate algorithm to deal with obstetric difficult airways, tailor made for the Indian scenario, which can be followed irrespective of the level of experience of the anesthesiologist [24]. These guidelines have some differences from the the international guidelines. The DAS guideline for obstetric difficult airway has 3 distinct steps in an algorithmic form detailing sub steps for the provision of safe obstetric general anaesthesia, obstetric failed intubation and cannot oxygenate situation compared to 4 steps recommended by AIDAA for the obstetric difficult airway which include: 1) laryngoscopy and intubation, 2) insertion of supraglottic airway device to maintain oxygenation, 3) rescue face mask ventilation and 4) emergency cricothyroidotomy. Also, perimortem caesarean section is included as part of the algorithm when condition deteriorates into maternal cardiac arrest. Human factors and efforts to avoid mistakes due to human errors have been included and are emphasized in the guidelines. Terms like front of neck access and cannot ventilate and cannot intubate were replaced with «emergency cricothyroidotomy» and «complete ventilation failure» to aid in better and clearer communication [25].
Special population like parturient with heart disease, obese parturient, uncontrolled hypertensives and parturient with liver dysfunction, renal dysfunction or any other comorbidity that poses threat to the life of the mother or the fetus are referred to higher centers as soon as diagnosed, so that adequate optimization and management of the specific condition can be done. Majority of the tertiary care centers in India, corporate hospitals and medical colleges in capitals of states have state- of the art facilities and experienced anesthesiologists for the management of complicated obstetric cases. Management of complicated patients, along with measures to improve quality of care, like implementation of
enhanced recovery after surgery (ERAS) in obstetric population is undertaken in few of the Institutes including the authors Institute. Implementation on a larger scale has barriers like poor literacy, inadequate telecommunication and networking, urban rural divide and inability to identify early warning signs [26].
With expanding fetal medicine services in India, anesthetists are also involved in procedures like oocyte retrieval for in vitro fertilization and assisted reproductive techniques, intrauterine transfusions and fetal reduction procedures. They also form part of the team of ex utero intra partum (EXIT) procedure performed in tertiary and apex centers [27].
Critical care services and the anesthesiologist
Admission rates of obstetric patients to intensive care unit (ICU) in India is not uniform and ranges between 3-8% which is more than the rate of admissions in developed nations 0.9-1% [28]. General critical care units are available in the country for the admission and treatment of obstetric patients but dedicated obstetric critical care units is not present. Similar number of critical care units and obstetric ICUs were found in states both with lower MMR and higher MMR. On analyzing it was found that success of lower MMR was attributed to systematic referral system in these states which helped in timely ICU admission to get care and treatment at the right time.
Our future direction aims at creating a greater number of dedicated obstetric critical care units, encouraging use of early warning signs in obstetrics to aid in early referral and management, involving multidisciplinary approach with active involvement from policy makers and government and increasing awareness among the society and public to utilize these services.
Simulation based training (SBT)
SBT to teach and enhance basic and advanced skills has become part of the curriculum in many teaching institutes. The traditional concept of «see one, do one, teach one» in imparting skills to students is not acceptable anymore, as it puts
patients at potential risk. SBT is transforming training and teaching not only in anaesthesia, but also in surgical specialties. Skills like epidural placement, difficult airway management, team work and crisis resource management are efficiently imparted to students through SBT. Training programmed in simulation, involving international agencies have been organized in India to enhance training in obstetric anaesthesia among students and PR actioners [29]. Presently, SBT is present in only few of the leading teaching institutes of the country though many are actively pursuing it due to the proactive involvement of the teachers and consultants in taking it forwards to reach the students and PR actioners.
Conclusion
India is a developing country, where the primary focus is still on MMR, in contrast to the developed nations where the focus has shifted to near misses in obstetric practices. Audits with data analysis and publication definitely help in shaping obstetric anaesthesia practices better and should be a mandate to move forward. India faces shortage of anesthesiologists, with a ratio of 1 anesthesiologist per 50,000 population against the WHO recommendation of 1 per 5000 population. Data collection and auditing for quality control purposes require sufficient manpower, finances and
equipment. Using dashboard as a dynamic audit tool to simplify complex data, and aid in easy sharing, analysis and addressal of potential problems has been suggested [30]. Despite the manpower shortage and paucity of published data, majority of the teaching hospitals, government hospitals and tertiary care centers conduct regular maternal and perinatal morbidity and mortality meets involving obstetricians, anesthesiologists, pediatricians and hospital administrators to address lacunae in care and to avoid preventable complications. In India, teaching and training of postgraduates, clinical practices and research resonates with evidence-based practices followed worldwide.
To conclude, obstetric anaesthesia practices vary between rural and urban areas in India. In the rural areas it is primarily aimed at reducing MMR. In urban areas, anesthesiologists are involved in the provision of labor analgesia and in providing and constantly improving quality of care in anaesthesia services for caesarean section and high-risk pregnancies. Formation of dedicated obstetric critical care services, creation and maintenance of robust data collection and auditing and establishing and implementing simulation-based teaching to enhance teaching and training in obstetric anaesthesia is the way forward and is being led by the premier institutes of the country.
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