Retrospective Evaluation of Anaesthesia Care for Caesarean Delivery in a Secondary Healthcare Facility in Saudi Arabia

Retrospective Evaluation of Anaesthesia Care for Caesarean Delivery in a Secondary Healthcare Facility in Saudi Arabia

*¹Dr. Nnaji, Chimaobi Tim, ²Dr. Ahlamessam Mohammed Saba

¹Mbbch, Fmca, Fwacs, Fics Consultant Anaesthetist, Department Of Anaesthesia, Quaryyat General Hospital, Al Jawf Region, Saudi Arabia

² Mbbs, Anaesthesia Resident, Department Of Anaesthesia, Quaryyat General Hospital, Al Jawf Region, Saudi Arabia

*Corresponding Author

DOI: https://doi.org/10.51244/IJRSI.2025.12010031

Received: 03 January 2025; Accepted: 07 January 2025; Published: 05 February 2025

ABSTRACT

Background: Anaesthesia for Caesarean section has increased globally in the last two decades with increasing rate of Caesarean delivery. Despite the observed scientific reports of rising rate of single shot SA and decreasing rate of GA for Caesarean delivery, no scientific record has supported or disprove these findings from our healthcare institution.

Objective: This study aimed to audit the type and trend of anaesthesia care provided to the expectant mothers who had Caesarean deliveries in our healthcare facility.

Methods: With the approval of Research Ethics Committee, we retrospectively retrieved data from the hospital’s EMR database regarding the type of anaesthetic care and their yearly total for both elective and emergent Caesarean deliveries during the period of 5 years (January 2018 to December 2022). We excluded obstetric patients who received anaesthesia for other surgical indications that are not Caesarean section. Data collected were entered into Excel Spread sheet version 2019 (Microsoft Corp, Redmond, WA). Figures were used to present the result, and expressed as, proportion, frequencies and numbers.

Results: In 2018, 88.3% of the Caesarean deliveries were conducted with GA, but in 2022, the prevalence rate of GA reduced to 44%. The graph also showed that SA service prevalence rate increased from 16.7% in 2018 to 56% in 2022.

Conclusion: This study demonstrated that general anaesthesia and spinal anaesthesia were the prevalent anaesthesia techniques offered to parturient who has Caesarean section and it detected that although general anaesthesia and spinal anaesthesia were used for Caesarean delivery, there has been a declining rate of utilization of general anaesthesia technique and increasing rate of spinal anaesthesia technique utilization in our healthcare facility

Keywords: Anaesthesia services, Caesarean delivery, Obstetrics.

INTRODUCTION

Anaesthesia for Caesarean section has increased globally in the last two decades with increasing rate of Caesarean delivery (CD)¹. Caesarean delivery or section is defined as surgical extraction of one or more foetus from the uterus through an incision made on the abdominal (laparotomy) and the uterine (hysterotomy) walls of an obstetric patient². In a recent World Health Organization (WHO) study, CD had a global ratio of 1 in 5 (21%) of all childbirths¹. But studies conducted in Saudi Arabia, United Arab Emirate and Egypt reported higher rates of 27.6%, 33% and 55% respectively^{3, 4, 5}. Another study conducted in Nigeria reported a lower rate of 17.6% due to inequitable access to CD linked to cultural beliefs and social determinants of health (SDoH)⁶. Cesarean delivery can be done as an elective, urgent or emergent procedure, nevertheless, the decision for urgent or emergent CD is often made on consideration of either maternal, fetal or maternofetal well-being, and the anaesthesia care which includes patient’s evaluation, preparation and planning is fast-tracked to enable rapid progression from decision making to CD⁷.

In the present clime of advancement of patient safety in the care of obstetric patients, multidisciplinary team approach is required and there should be clear and open communication between the obstetrician, anaesthetist, neonatologist, perioperative nurses and midwives, with the goal of ensuring safe anaesthetic, obstetric and neonatal outcomes. Caesarean section was historically performed under general anaesthesia (GA), but in recent years, the trend is favoring neuraxial blocks like spinal, epidural and combined spinal-epidural anaesthesia, however spinal anaesthesia (SA) has been shown to be the dominating neuraxial block^{3, 8}. This could be due to single shot SA related improved safety margin and patient outcomes reported by most studies on CD^{3, 9, 10}. Nevertheless, anaesthesia for CD can be influenced by different considerations that ranges from physiological changes in pregnancy, urgency of the surgery, surgical indication, maternal preference, to coexisting maternal co-morbidity. Physiological changes during pregnancy results from the alterations in maternal hormone balance, biochemical shifts and its related larger metabolic demands by the foetus and placenta, in addition to the effects of the mechanical forces from the gravid uterus¹¹. Cardiovascular diseases have been reported as the major cause of global maternal morbidity and mortality, with heart disease accounting for 0.2 to 3% of all pregnancy related morbidities⁷. Thus, adequate anaesthesia planning and care from the preconception or early part of the pregnancy is needed to enhance the best outcome for the expectant mother.

Despite the observed scientific reports of rising rate of single shot SA and decreasing rate of GA respectively for CD, and the established fact that the choice of anaesthesia for CD reflects on intraoperative foeto-maternal safety and post-operative course, these have not been established in our rural setting. Thus, this study aimed to retrospectively audit the techniques of anaesthesia care provided to the expectant mothers who had CD over the periods of 5 years in our secondary healthcare. Hence, we constructed the outcome measure to detect the associations between the type and trend of anaesthesia services for CD and results in our environment. The findings of our study will add to the wealth of obstetric anaesthesia knowledge.

METHODOLOGY

We obtained approval from Research Ethics Committee of Quaryyat Health Affairs (Reg No: H-13-S-071) for this study, which was designed as a retrospective method of research, to audit the trends of anaesthesia technique for CD, using the respective hospital electronic medical record (EMR) database, without any patient contact. The study population included all the patients that were anaesthesized for elective or emergency CD from January 2018 to December 2022 in Al Quaryyat General Hospital, Al Jouf, Saudi Arabia. Thus, ethics statement from the individual patients were not applicable. Our study excluded the pregnant women who received any form of anaesthesia for radiological diagnosis, gynaecological, general surgical or other form of procedure that are not elective or emergency Caesarean section. This study was initially structured for the period of 10 years, but we were unable to retrieve complete data for the periods of September 2014 to December 2017 and January to December 2023, due to inconsistencies accrued to the hospital’s migration from manual to electronic medical registration, hence, we excluded these periods of incomplete data from our study.

Data collected were entered into Excel Spread sheet version 2019 (Microsoft Corp, Redmond, WA). The type of anaesthesia technique and the proportion of different types of anaesthesia technique for the study periods were collected, and collated. Figures were used to present the result, and expressed as, proportion, frequencies and numbers.

RESULTS

Figure 1 compared the distribution of general and spinal anesthesia services for Cesarean section from the period of 2018 through 2022. The trend shows that GA service was more in 2018, 2019, 2020 and 2021 compared with SA, but in 2022, SA service predominated more than GA service. No patient utilized epidural anesthesia (EA) and combined spinal-epidural anesthesia (CSEA) services. The graph also shows that the volume of anesthesia services peaked in 2019 but declined more in 2020.

Figure 2 shows the trend in anesthesia services during the period of our evaluation. Most patients received GA for CD in 2018 and 2019. Subsequently, GA service for CD recorded its lowest rate in 2022. The distribution for SA service for CD shows the lowest rate in 2018 and recorded its highest rate in 2022. The comparative changes in the proportions of GA and SA services for CD in 2018 and 2022 is shown in figure 3. In 2018, 88.3% of the CD were conducted with GA, compared with 2022, where only 44% of the patients received GA. The graph also shows that SA services in 2018 was 16.7% but peaked in 2022 with the utilization rate of 56%.

Figure 1 – Comparative distribution of anesthesia services for Cesarean delivery.

Figure 2 – The trends in anesthesia services for Cesarean section.

Figure 3 – Comparative changes between the distributions of general and spinal anesthesia services for Cesarean delivery.

DISCUSSION

Global Cesarean section rate, obstetric anesthesia demand and population expectations of safer obstetric anesthesia continue to rise, as well as the global interest on the effect of anesthesia on climate change. The principal findings of our study were decreasing utilization rate of GA, and increasing utilization rate of SA service, as well as dearth of EA and CSEA services for CD in our secondary healthcare facility.

The proportion of CD performed under SA has increased in recent times globally amidst other form of neuraxial blocks like EA and CSEA with high safety profile in obstetric services ^{3, 8-10}. Single-shot SA for Cesarean section ranks the highest among the different types of neuraxial anesthesia used for CD^{3, 8, 12}.  This could be due to its predictability, rapid onset of anesthesia, and good immediate postoperative analgesia. Perhaps corroborating the rapid increase in the rate of SA uses from 16.7% in 2018 to 56% in year 2022, which was higher than GA service. This is like the report of Alshabibi et al³, that demonstrated an increased rate of SA service for CD, although 63.6%, which was higher than the rate we observed in our study. Other studies done in Botswana and Israel, also reported higher rates of 95.2% and 68% respectively^{12, 13}. The reasons for lower utilization rate of SA for CD in this region were clarified by Alfaifi et al¹⁴, to be associated with worries about developing chronic headache and back pain after CD and poor knowledge of SA for CD. Although it was not the focus of this study, but education of the women about SA for CD in the anesthesia clinic improved its utilisation rate from 16.7% of 2018 record to 56% in 2022.

Spinal anesthesia provide quicker onset of anesthesia, and it’s easy to perform with precise end point and high success rate and it provides improved intraoperative and postoperative analgesia, avoidance of the problem of difficult airway and multiple drugs administration often experienced during GA. Additionally, it accords the parturient the benefit of wakefulness and improved birthing experience during CD, thereby facilitating early maternal bonding with the new baby in the early moments of birth^{3, 12}. Literature search shows that SA is the preferred technique for CD unless there is any contraindication^13-15. For example, Ghaffari et al¹⁰ noted that single-shot SA improved safety margin, Health Related Quality of Life (HRQoL), mobility and self-care in 24 hours after Caesarean section, as well as the usual activities at one week and one month after CD time points, compared with GA. Furthermore, the Society for Obstetric Anesthesia and Perinatology and the National Institute for Health and Care Excellence (NICE) believed that SA improves maternal and neonatal outcomes after Cesarean delivery, and as such should be the gold-standard anesthesia technique for CD^{16, 17}. Nevertheless, in the event of CD anticipated to go beyond 2 hours, a neuraxial catheter-based technique like epidural or combined spinal–epidural anesthesia can be used. This helps to prolong the duration of analgesia and muscle relaxation, but our study observed the dearth of these techniques in our obstetric anesthesia practice. Notwithstanding, SA can be associated with cardiovascular system variabilities (bradycardia and hypotension), as well as other complications like headaches, shivering intraoperative nausea and vomiting and pruritus. But these complications are minimized by proper patient’s selection, anesthesia plan and conduct of SA by skilled personnel^18-19.

We observed a declining rate of GA service for CD in our institution during this study from 83.3% in 2018 to 44% in 2022. There is a global campaign to reduce the rate of GA for CD to as low as 1% for elective Cesarean delivery and < 5% for the emergent Cesarean section by the Royal College of Anaesthetists¹⁸. But Society for Obstetric Anesthesia and Perinatology has previously recommended that the overall GA rate for CD should be reduced to as low as ≤ 5%¹⁶. No wonder, in recent 2 decades, the rate of GA services for CD has declined globally^{8, 12, 13}. This could be inevitably linked to the poor maternal and fetal outcomes associated with GA for CD, which often results from difficult airway, aspiration of gastric content, awareness under GA, and impaired neonatal adaptation after Cesarean delivery^19-21. Elsewhere, Sung et al¹⁵ reported that GA was associated with increased maternal blood loss and poorer newborns outcome than SA during CD. Notwithstanding, GA provides the most rapid and reliable form of anesthesia for prompt delivery of fetus, and it can be indicated where neuraxial block is contraindicated, based on maternal preference, emergent circumstances when the obstetrician must deliver the baby immediately for maternal and/or fetal wellbeing and there is insufficient time to induce neuraxial anesthesia or when there is neuraxial failure concern. Furthermore, GA provides the benefit of maintaining patent airway, controlled ventilation, and less cardiovascular depression. Nevertheless, it can be complicated by difficult tracheal intubation, failed intubation, failed ventilation, aspiration of gastric content, awareness, pain, and fetal depression^22-24.

Safe and quality improvement in anesthesia care, good patient outcomes and experience, as well as sustainability of standard of care for the obstetric patients remains a continuing process for the anesthetists in obstetric services. Nevertheless, anesthesia as a discipline continue to play a vital role in providing the highest standard of care during CD and ensuring environment sustainability. Most inhalational agents used in GA services are air pollutants and greenhouse gases. They inadvertently contribute to global warming via long time degradation of the ozone layer, with sevoflurane and desflurane having a lifetime of 1.4 years and 21.4 years respectively in the atmosphere and 1 kg of sevoflurane emitting 440 kg CO₂ and 1 kg of desflurane emitting 6810 kg CO₂ to the earth’s ozone layer^{25, 26}. Additionally, when 500 ml of nitrous oxide was used per minute in a 1hour procedure, it had a moderate impact on global warming of the atmosphere by an equivalent of 16kg carbon-dioxide²⁶. Although this study was not designed to evaluate the impact of GA on global warming, but these reports connote that the impacts of GA on our environment outweigh its benefits. The anesthetist has the responsibility to minimize the unnecessary atmospheric pollution due to anesthetic gases and vapors by harnessing the benefit of scavenging system in the surgical theatre and where necessary use other arrays of alternative anesthesia techniques that can lessen the burden of air pollution and global warming like peripheral or neuraxial blocks.  The health crisis caused by climate change continue to surge, with great awareness for the healthcare to be transformed into a sustainable industry^{27, 28}.

CONCLUSION

This study which designed to retrospectively evaluate the type of anaesthesia technique provided to the expectant mothers who had Caesarean deliveries in our healthcare facility, demonstrated that general anaesthesia and spinal anaesthesia were the prevalent anaesthesia techniques offered for Caesarean section. Furthermore, the study detected that although general anaesthesia and spinal anaesthesia were used for this surgical procedure, there has been a declining rate of utilization of general anaesthesia and increasing rate of spinal anaesthesia utilization in our healthcare facility. Nevertheless, there was dearth of epidural and combined spinal-epidural anesthesia for Caesarean delivery in our institution.

We Declare That The Authors Have No Conflicts Of Interest Nor Any Financial Or Other Relationships That Might Lead To A Conflict Of Interest. Also, No Form Of Grant Nor Financial Support Was Received For This Research.

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