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Rapid Responses: Rapid Responses published:
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need for basic surgical skills program
- peter h reemst (17 September 2003)
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Caesarean section in Malawi
- Jos van Roosmalen (14 October 2003)
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Should all patients have spinal anaesthesia for Caesarean sections in Malawi?
- Dr Mandy Rees, Dr David Male Consultant Anaesthetist Epsom and St Helier NHS Trust (16 October 2003)
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Re: need for basic surgical skills program
- Paul M Fenton (27 October 2003)
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Re: Caesarean section in Malawi
- Paul M Fenton (31 October 2003)
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Re: Should all patients have spinal anaesthesia for Caesarean sections in Malawi?
- Paul M Fenton (31 October 2003)
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Unconcious Birth
- Susan Bewley, Geraldine O'Sullivan (16 December 2003)
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peter h reemst, surgeon eindhoven
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With great interest I read your article about mortality after caesarian sections. Your article again underscores the urgent need to set up a worldwide program for a basic surgical skills program in order to diminish morbidity and mortality because of lacking surgical facilities. This program should be led by the WHO (World Health Organisation) in the same way as there are programs on AIDS (Acquired Immune Deficiency Syndrome), TB (Tuberculosis) and other communicable diseases. It is a shame that in our world we do spend billions of dollars to improve medical and surgical results with marginal effects whereas at the same time billions of people lack access to very basic surgical services like caesarian section, laparotomy for acute abdomen, trauma care. We need to train general surgeons with a wide armamentarium of basic surgical skills who can work in units where good basic surgical care can be provided. There is an international task to be performed. peter reemst, general surgeon
Competing interests: None declared |
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Jos van Roosmalen, consultant obstetrician Leiden University Medical Centre, Department of Obstetrics, Box 9600, 2300 RC Leiden The Netherlands
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Fenton et al reported in a very important paper on the high maternal and perinatal mortality associated with caesarean section in less privileged circumstances.1 This is especially important because of the worldwide ever increasing caesarean section rates, often for futile indications. They, however, consider an intervention for the repair of uterine rupture similar to caesarean section, while caesarean section for cephalopelvic disproportion amongst others is performed to prevent uterine rupture to occur. The a priori risk of uterine rupture is much higher than the a priori risk of caesarean section (by definition without uterine rupture). This can also be deducted from Fenton's data as the case fatality rate (CFR) of uterine rupture was 11% in their study as compared to a 0.65% case fatality rate of caesarean section. This 0.65% CFR of caesarean section is still more than ten times as high as the CFR in the more privileged part of this world. It, however, seems to be somewhat lower than reported before. In the eighties of the last century 151 maternal deaths occurred after 8.446 caesarean sections in different hospitals, mainly in eastern Africa.2 This CFR of 1.8% had a range of 0.6 – 5.0%. In 2071 caesarean sections performed in the nineties in the University Hospital in Maputo in Mozambique, the CFR was 17/2071 (0.82%).3 Fenton's study points at anaesthesia and postoperative surveillance and resuscitation as factors which would lower this CFR even more when properly addressed. Apart from this one also has to address the issue of uterine scar rupture in subsequent deliveries. In the eighties this occurred in 271 women out of 7.018 women with a previous Caesarean Section: 3.9% (range 0.3 –6.8%).2 Of those 7.018 women 3.482 had a repeat caesarean birth (50%; range 30- 80%). This indicates that approximately half of all women with a previous caesarean will be exposed to the same risk in a further pregnancy. Being strict with the indication to perform the first caesarean section will thus always be to the benefit of women's health. Jos van Roosmalen, consultant obstetrician
1. Fenton PM, Whitty CJM, Reynolds F. Caesarean section in Malawi: prospective study of early maternal and perinatal mortality. BMJ 2003; 327: 587-90. 2. Van Roosmalen J. Safe motherhood: Cesarean section or symphysiotomy? Am J Obstet Gynecol 1990; 163: 1-4. Pereira C, Bugalho A, Bergstrom S, Vaz F, Cotiro M. Br J Obstet Gynaecol 1996; 103: 508-12 Competing interests: None declared |
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Dr Mandy Rees, Specialist registrar in Anaesthetics Epsom and St Helier NHS Trust, Carshalton, Surrey Uk SM5 1AA, Dr David Male Consultant Anaesthetist Epsom and St Helier NHS Trust
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We read with interest the recent paper 'Caesarean section in Malawi ; prospective study of early maternal and perinatal mortality' (1) In the United Kingdom over the past 30 years there has been a dramatic decrease in mortality associated with anaesthesia.The latest Confidential Enquiry into Maternal Deaths in the United Kingdom (2)quotes 1.4 deaths per million maternities even though the number of caesarean sections performed with general anaesthesia as opposed to regional techniques has remained static. This decrease in mortality is mainly due to improved training and teaching, the presence of consultant anaesthetists available on labour ward and the introduction of guidelines. In their conclusions the authors state that increasing use of spinal anaesthesia would decrease the mortality rate.However the majority of deaths were associated with pre/intra operative hypovolaemia that the authors identify as a contraindication to spinal anaesthesia.Therefore it is doubtful that this approach would make a large impact on the mortality rate. The high mortality rate in Malawi suggests that more training is needed in general anaesthesia for the paramedics already in position and also for more specialist anaesthetists to be available ideally having been trained to UK standards. We agree that it would be interesting to undertake a randomised trial comparing caesarean sections performed under general and spinal anaesthesia but would the authors be happy randomising hypovolaemic patients to the spinal group? Furthermore could such a study be justified before the mortality rates from general anaesthesia be brought closer to UK levels ? An alternative pragmatic 'greatest good for the greatest number'approach would be to perform all caesarean sections under spinal anaesthesia regardless of volume status.While spinal anaesthesia in the presence of hypovolaemia is contraindicated in the UK it may only rarely result in death so whilst not entirely 'safe'it may be 'safer'than the alternative in Malawi. It would be interesting to see if the mortality rate declined. (1) Caesarean Section in Malawi : prospective study in early maternal and perinatal mortality Paul M Fenton,Christopher J M Whitty,Felicity Reynolds (2) Why Mothers Die 1997 - 1999 The Confidential Enquiries into Maternal Deaths in the United Kingdom Competing interests: None declared |
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Paul M Fenton, retired France 47800
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Dr Reemst is so right. The need is desperate, the costs are low and the effect proven and sustainable. The people are queueing up to be trained. Is World Health Organisation interested in this, after AIDS, TB and Smoking? Probably not. The last time I asked a member of the now defunct WHO SafeMotherhood Initiative team why they did nothing about hospital based initiatives to reduce maternal deaths he replied that: "the clinicians all go off to the private sector" Apparently to prove this point, shortly after that he himself went off to the World Bank! Paul Fenton Competing interests: None declared |
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Paul M Fenton, retired France 47800
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Your interest in the subject is of value in itself - it is increasingly scarce in the West whether in academic circles, among politicians, official health development agencies or the average popular perception of Africa's health troubles. I understand that the British Government aid agency DFID has dropped safe motherhood from its agenda, despite its declared goal of reducing the level of 1990 maternal deaths by 75% by the year 2015. However, of the many contributions to the woes of African Health, one is the perception that C/section is somehow a wicked medical intervention that disturbs the 'natural' process of childbirth. This is a northern position, though stretching as far south as Geneva, but really it has little relevance to poorly resourced public hospitals in Africa where the conduct of labour, the shape of the pelvis and the attendant health delivery system problems are very different. It is true that at a private hospital just down the road from the Government hospital in Blantyre, Malawi the CS rate is 75-80% - mainly for 'futile' financial reasons - but the numbers are tiny and the problem for the vast majority of African women is not too much surgery but too little. We counted ruptured uterus with c/section because the diagnostic facilities (both human and technical) did not permit a realistic distinction preoperatively and indeed many ruptures were found only at surgery for cs, sometimes with a surviving baby. We considered it therefore to be a medical artifice to make the distinction. It is pleasing to note that Malawi in 1998-2000 does better than East Africa in the 1980's. The figures probably do not show that surgical care has improved in one country, however, since the same differences in outcome could be demonstrated today. It seems there is little interest in conducting such audit. Malawi has consistently trained clinical officers in Anaesthesia and Surgery and deployed these people in the rural areas. The service they offer may not be excellent in the western sense but it is free and reaches the people and could, with time, money and evolution, improve further. Places such as Kenya which sought to be 'more developed' depend on doctors many of who stay in town or have emigrated to greener pastures outside Africa. Unsurprisingly, with such a shortage of clinicians, little data comes out of Kenya. The problem with paramedical training is not in the quality of the service that a non-physician surgeon or anaesthetist can provide but in the solid resistance against the cadre, both from within Africa and outside. Paul M Fenton Competing interests: None declared |
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Paul M Fenton, retired France 47800
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Our point was clearly that several small improvements would have an effect, with the main concern being improved surveillance post op. There were 5 cases without pre-op complications who received a GA with halothane and were found dead in bed post operatively within 72hrs, cause not stated. I would reasonable sure that if they had received a spinal, not all 5 would have died, probably none would. Your paragraph about needing more UK trained anaesthetists in Malawi was followed by another which, if I got it right, proposed randomly allocating mothers for cs into two groups: to receive GA or spinal, regardless of their condition. Is not shock and severe sepsis a contraindication to spinal all over the world? I fear that UK trained anaesthetists may not live up to their promise, if they do seek to conduct such overzealous research into this (already known) fact outside the UK and will spend some time behind bars, or else - more likely in tolerant Malawi - on the first plane out! Paul Fenton Competing interests: None declared |
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Susan Bewley, Clinical Director, Womens Services Guys and St Thomas' Hospitals NHS Trust SE1 7EH, Geraldine O'Sullivan
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Although Fenton et al (BMJ 2003;327:587-0) consider that "improved training in anaesthetics, wider use of spinal anaesthesia, and improved surveillance and resuscitation in postoperative wards might reduce mortality" from Caesarean section in Malawi, we consider that there remain important anaesthetic issues even in developed countries. Analysis of the National Sentinel Caesarean Section Audit (NSCSA) shows that 1 in 29 of mothers in England and Wales are unconscious during childbirth. This was not reported directly or commented upon. The audit found that the overall caesarean section rate in England and Wales had risen to 21.5%. As general anaesthesia (GA) was used for 9.5% of the elective and 22.8% of the emergency cases (n = 10,923 and 18,534 respectively tables 7.1 p 51, and 11.2 p 86), we calculate that 5,244 (3.5%) of the 3-month cohort of 150,139 women (table 4.2 p 18) must have delivered under GA.(1) The reasons for persistent use of GA include a) maternal choice, b) failed regional anaesthesia, c) medical/obstetric contraindications to regional anaesthesia (e.g. HELLP/ septicaemia/ acute hypovolaemia) and d) the CS rate itself rising as fast as anaesthetic improvement. GA is associated with higher maternal mortality and morbidity, and not being "present" at the birth may have longer-term psychological sequelae. Even regional anaesthesia has complications such as inadequate pain relief, dural puncture and neurological sequelae. We were surprised to realise that over 20,000 pregnant women per year in the UK deliver unconcious, although it has been noted before that the total number of GAs has not significantly decreased consequent to the rising CS rate.(2,3) The rise in CSs has partly been considered justified by obstetricians due to the improved anaesthetic safety provided by modern regional anaesthesia and analgesia. Indeed anaesthetic deaths are now rare. (4) Generally however, safer anaesthesia does not justify nor lead to lower thresholds for performing major surgery. An important distinction between surgical and anaesthetic complications is that documented sequelae persist long after the anaesthetic wears off (e.g. lower future fecundity, repeat CS, placenta praevia, rupture of the uterus, scar and adhesions complicating future pelvic surgery etc.).(5) The NSCSA showed that obstetrics services failed to reach audit standards for many indications, including breech (only 33% of women who had CS for breech had been offered external cephalic version), fetal distress (non-use of fetal blood sampling) and failure to progress (non- use of oxytocic). The later two alone accounted for at least 6.8% of the overall CS rate. In addition, unexplained wide variability was found between units; for example vaginal birth after caesarean rates varied from 6-64%. Anaesthetists have a legitimate interest in the provision of midwifery services and the quality and context of obstetric decisions. Unnecessary caesareans mean they too are performing unnecessary interventions with inevitable risks and complications especially when out of hours and emergencies. Anaesthetists should not be technicians merely responding to surgical demands in either the private or public sectors, but medical colleagues who are part of the multidisciplinary team that aim to provide good quality evidence-based care to pregnant women. In the light of the NSCSA findings, it is beholden on them to question present day maternity practices. Yours Sincerely Dr Susan Bewley MD FRCOG Consultant in Maternal Fetal Medicine Geraldine O'Sullivan MD FRCA Consultant Anaesthetist ___________________________________ 1) National Sentinal Caesarean Section Audit. Royal College of Obstetricians and Gynaecologists. 2002 2) Shibli KU, Russell IF. A survey of anaesthetic techniques used for caesarean section in the UK in 1997. International Journal of Obstetric Anesthesia 2000;9:160-167. 3) Brown GW, Russel IF. A survey of anaesthesia for caesarean section. International Journal of Obstetric Anesthesia 1995;4:214-218. 4) Report on Confidential Enquiries into Maternal Deaths. 1994-1996 and 1997-1999. HMSO London. 5) Bewley S, Cockburn J. The unfacts of "request" Caesarean section. BJOG 2002; 109: 597-605. Competing interests: None declared |
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