|Year : 2019 | Volume
| Issue : 3 | Page : 412-417
An appraisal of anaesthetic technique for caesarean delivery in a tertiary Institution North Central Nigeria
MB Adegboye1, CI Oyewopo1, KA Adegboye2, J Josiah1, EO Ibegbula1
1 Department of Anesthesia, University of Ilorin Teaching Hospital, Ilorin, Kwara, Nigeria
2 Department of Anesthesia, General Hospital, Ilorin, Kwara, Nigeria
|Date of Submission||19-Jun-2019|
|Date of Decision||09-Oct-2019|
|Date of Acceptance||07-Nov-2019|
|Date of Web Publication||22-Jan-2020|
Dr. M B Adegboye
Department of Anesthesia, University of Ilorin Teaching Hospital, Ilorin, Kwara
Source of Support: None, Conflict of Interest: None
Background: The rate of caesarean delivery is on the rise globally and our institution is not left out. Therefore we set out to assess the trends, indications and anaesthetic techniques for caesarean delivery in our environment.
Methods: This was a retrospective review of all caesarean deliveries between 1st January 2015 and 31st December 2017 from the anaesthetic chart, anaesthetic theatre records and labour ward record of the University of Ilorin Teaching Hospital (UITH). Patient's demographic data, indication for caesarean section, nature of caesarean section, ASA physical status, anaesthetic technique used, cadre of anaesthetist and the total number of deliveries were recorded. Data were analysed and presented as frequencies and percentages using statistical package for social sciences (SPSS software version 22).
Results: During the study period a total of 7940 patients delivered and 1822 patients had undergone caesarean delivery. The caesarean section rate at the institution is around 22.9%. The commonest indication for caesarean delivery was previous caesarean section (31.6%) followed by hypertensive disorder in pregnancy(14.7%). Most of the caesarean section was performed as emergency (80%). Regional anaesthesia was the most frequently used for both emergency(91.3%) and elective (98.7%) caesarean section, and spinal anaesthesia(88.9%) was the commonest regional anaesthetic technique used.
Conclusion: The rate of caesarean section is high in our institution, with majority being performed under spinal anaesthesia. We need to improve on other regional anaesthetic technique so that our parturients can have the best and safest option.
Keywords: Anesthetic technique; cesarean section; spinal anesthesia.
|How to cite this article:|
Adegboye M B, Oyewopo C I, Adegboye K A, Josiah J, Ibegbula E O. An appraisal of anaesthetic technique for caesarean delivery in a tertiary Institution North Central Nigeria. Trop J Obstet Gynaecol 2019;36:412-7
|How to cite this URL:|
Adegboye M B, Oyewopo C I, Adegboye K A, Josiah J, Ibegbula E O. An appraisal of anaesthetic technique for caesarean delivery in a tertiary Institution North Central Nigeria. Trop J Obstet Gynaecol [serial online] 2019 [cited 2020 Feb 19];36:412-7. Available from: http://www.tjogonline.com/text.asp?2019/36/3/412/276448
| Introduction|| |
Cesarean section (CS) is one of the oldest and most common obstetric surgical procedure that is performed by an obstetrician. CS involves the delivery of the fetus, placenta, and membranes after the age of viability through an abdominal and uterine incision.
The incidence of cesarean section varies globally from about 5% to 25% with a higher rate in the developed countries like the United States of America while most developing countries the rate is still relatively low., In Nigeria, the rate of cesarean delivery varies from center to center with 11.3% in Sokoto, 15.5% in Makurdi, 21.4% Gwagwalada, 23% Zaria, and Port Harcourt 30.3%.
Cesarean section can be performed either as an emergency or elective procedure and previously general anesthesia (GA) was the preferred method of anesthesia but presently there has been an increasing trend worldwide to the use of regional anesthesia. The reasons for the shift from GA is because of some complications of GA such as difficult intubation, aspiration pneumonitis, and hypoxemia which may lead to major anesthetic mortality. Regional anesthesia for cesarean section is usually spinal anesthesia, epidural anesthesia, or combined spinal-epidural anesthesia (CSE), all these regional anesthetic techniques have the advantage of reduced risk of gastric aspiration, less effect of anesthetic drugs on the fetus, excellent analgesia, and no respiratory depressant effects. Another significant advantage is that both parents can be present and conscious during the cesarean delivery of their child. Single-shot spinal anesthesia is particularly the most cost-effective and logical option for cesarean section in the developing counties. Earlier studies done in obstetric tertiary institutions in Nigeria showed that regional anesthetic technique was infrequently used for cesarean delivery, despite the rise in cesarean section rate in Nigeria. Recently, a few studies have shown a change in pattern with the majority of cesarean delivery been done under subarachnoid block while a few were performed under the epidural or combined spinal-epidural block.,
The aim of this study was to review the changing trend in obstetric anesthesia for cesarean delivery in a tertiary institution in Nigeria.
| Materials and Method|| |
This was a retrospective review of all cesarean deliveries between 1st January 2015 and 31st December 2017 derived from the anesthetic chart, anesthetic theatre records, and labor ward record of the University of Ilorin Teaching Hospital (UITH).
Patient's demographic data, parity, gestational age, indication for cesarean section, nature of cesarean section, ASA physical status, the anesthetic technique used, a cadre of an anesthetist, and a total number of deliveries were recorded.
Data were analyzed and presented as frequencies and percentages using statistical package for social sciences (IBM SPSS Statistics for Windows, Version 22.0, Armonk, NY. IBM Corp).
| Result|| |
A total of 7940 parturients delivered during the study period out of which 1822 patients were delivered by cesarean section. The annual distribution of deliveries through the cesarean section from 2015 to 2017 is shown in [Table 1]. The cesarean section rate of our institution from this present study is 22.9% [Table 1].
The demographic analysis showed that the highest age range of parturients that had cesarean section was between ages 21–30 years (53.7%). While those below 20 years were 4% and those above 40 years were 2.1% [Table 2].
Most of the parturients that had a cesarean section were American society of anesthesiologist (ASA) II (71.2%) out of which 80% were done as emergency cases. All ASA IV (100%) were performed as emergency cesarean section [Table 3].
|Table 3: American Society of anesthesiologist (ASA) physical status with nature of the cesarean section|
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Previous cesarean delivery (31.6%) accounted for the commonest indication for cesarean section, followed by hypertensive disorder in pregnancy (14.7%) [Table 4].
Majority of the cesarean section was done as an emergency procedure (80%) and regional anesthetic technique was the most frequently used method for both emergency (91.3%) and elective (98.7%) cesarean section [Table 5].
|Table 5: Type of anesthesia used in emergency and elective cesarean section|
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The annual distribution of the anesthetic technique used in cesarean deliveries during the study period is presented in [Table 6]. It can be observed that the rate of spinal anesthesia for cesarean section dropped from 91.3% in 2015 to 86% and 88.6% in 2016 and 2017, respectively this was due to an increase in the use of epidural and combined spinal-epidural anesthesia as an anesthetic option for cesarean section. The overall rate of regional anesthetic technique for cesarean section is 92.8% [Table 5] with spinal anesthesia accounting for the most common technique 88.9% while epidural and combined spinal-epidural accounted for 3.2% and 0.7%, respectively [Table 6].
The most indication for the use of the general anesthetic technique was cord prolapse in which 78.6% of the cases recorded were performed under GA followed by antepartum hemorrhage in which 44.6% of the recorded cases were done under GA [Table 7].
[Table 8] shows that all the 1822 parturients that had a cesarean section under various anesthetic techniques were anesthetized by the physician anesthetist. It also shows that the senior registrar performed most of the anesthesia 54.8%.
|Table 8: The anesthetic technique used and a cadre of an anesthetist who administered the anesthesia|
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| Discussion|| |
Worldwide there has been an increasing trend in the rate of cesarean section deliveries.,, In this study, the cesarean section rate was 22.9% which is higher than the previously reported rate of 9.1% in 1999 from this institution. The cesarean section rate in this present study is much lower than that of the southern region of Nigeria, Igberase et al. in Eku, Delta state and Deniel et al. in Osogbo south-west Nigeria, who reported 34.5% and 35.9%, respectively. However, the cesarean section rate still falls within the range (6.4%-33.2%) documented in Nigeria by various studies.,, In the united states of America, the proportion of cesarean birth to total birth increased from 20.7% in 1996 to 31.1% in 2006. Also in India, Banerjee et al. reported an increase in the cesarean section from 27.5% in 2010 to 39.6% in 2017. There is generally a wide variation in the incidence of the cesarean section from region to region within a country and also from one country to another. In 1985, the World Health Organization (WHO) stated: “There is no justification for any region to have cesarean section rates higher than 10–15%”, and that new studies reveal that when cesarean section rates rise towards 10% across population, the number of maternal newborn deaths decreases but when the rate goes above 10%, there is no evidence that mortality rate improves and that countries with cesarean section rate <10% are considered to show underuse, while those with rates from 10% to 15% are considered to have adequate use of cesarean section. The real cause for the rise in cesarean section rate is because of rapid socioeconomic changes, altered family structure, changing the role of women in the society and the biological urge to have good off-springs in this competitive world. Therefore, the current rate of cesarean section in many developed and developing country as Nigeria has far exceeded the tolerable limit specified by WHO thus indicating unnecessary use of this intervention. The cesarean section rate in our institution is high because it is a referral tertiary institution with a large proportion of high-risk parturients attending our facility.
In this study, the highest cesarean section rate of 53.7% was recorded among the age group 21–30 years which is consistent with the findings of Deniel et al. and Geidam et al. in Nigeria who reported 50.3% and 52.8%, respectively but lower than 73.2% reported in India. This age group has the highest cesarean section rate probably because the age group represents the most active reproductive age group.
The commonest indication for cesarean delivery in this study is previous cesarean delivery (31.6%) this differs from what was previously documented in this institution in 1999 as cephalopelvic disproportion (30.8%) by Ijaiya and Aboyeji. This may be due to increasing rates of cesarean section over the years thus reversing the pattern of cephalopelvic disproportion as the commonest indication in the previous study. Our present finding is in accordance with studies conducted by Ogboli-Nwasor and Yannus, and Saxena et al. which were 34.1% and 33%, respectively. Some other studies , have however reported cephalopelvic disproportion (CPD) as the commonest indication for cesarean section.
Most of our cesarean section was done as emergency (80%) cases this finding is comparable with that of Isah et al., Saxena et al. and Banerjee et al. which were 80.2%, 84.4% and 75.6%, respectively. However, Sari et al. in their study had more cases of elective (59.2%) cesarean section than emergency (40.8%) cesarean section. Majority of the emergency cesarean section in this study was done under regional anesthesia. Thus, the rate of regional anesthesia for emergency cesarean section increased from 90.3% in 2015 to 92.2% in 2017 while the rate of GA administration for emergency cesarean section decreased from 9.7% in 2015 to 7.8% in 2017. This is similar to the pattern seen in developed countries in which regional anesthesia for emergency cesarean section was 49.3% in 1992 and increased to 86.6% in 2002. In our institution, a regional anesthetic technique for elective cesarean delivery is 98.7% which is higher than that reported by Banerjee et al. and Sari et al. which was 84.2% and 82%, respectively. Today, GA is preferred in emergency obstetric situations such as cord prolapse, in which there is a need for swift and reliable induction and also in antepartum hemorrhage and uterus inversion. This is in agreement with our study, where most of the indication for GA for cesarean section were in cases of cord prolapse (78.6%) and antepartum hemorrhage (44%).
We found that there was a yearly increase in the use of regional anesthesia for all our cesarean deliveries in 2015 (91.6%), 2016 (93.1%) and in 2017 (94%), making the regional anesthesia rate within the study period to be 92.8%. Okafor et al. in Enugu, Eastern Nigeria also reported a yearly increase in the use of regional anesthesia for their cesarean deliveries from 18% in2003 to 48% in 2004 and 72.6% in 2005 but fell to 71% in 2006. Ogboli-Nwasor and Yannus  in Zaria North-Central Nigeria conducted a retrospective study from January 2006 to December 2009 and reported that even though the majority of their cesarean section were done under regional anesthesia (54%) there was still a large number of cases performed under GA (48%). The use of regional anesthesia for cesarean section has increased globally over the years because of increased knowledge and skills of the anesthetist to the use of different regional anesthetic techniques. Rukewe et al. in a study to investigate potential trends and rate of maternal complications associated with general or regional anesthesia in a Nigerian teaching hospital from 1st January 2008 to 31st December 2010 showed that 34.5% of parturients who had GA in contrast to 6.7% who had regional anesthesia had anesthesia-related complications, postoperative intensive care admission rather than recovery room care and they concluded that GA was a significant risk factor for maternal complications during cesarean section. In Germany after 2002, it was reported that the most frequently used anesthetic method for cesarean section was spinal anesthesia with a rate of 90.8% which is in accordance to our spinal anesthesia rate of 88.9% in this study. While in Spain 98% of the cesarean section was done under regional anesthesia which is slightly higher than our own finding of 92.8%.
The use of epidural for cesarean section in our center was 3.2% which is higher than that reported by Okafor et al. (1.1%) and Benergee et al. (0.87%). Combined spinal-epidural anesthesia (CSEA) for cesarean section was not used at all in any of our cesarean in 2015. The highest rate for the use of CSEA for our cesarean section was in 2016 which was 1.8%, however, the overall rate of CSEA for cesarean section during the study period was 0.7% which is similar to that reported by Benergee, et al. (0.68%). Blandsheard and colleagues  reported a high rate of CSEA (65%) for cesarean section in their institution. Studies done has demonstrated that the use of CSEA for cesarean section has increased worldwide because it provides better maternal hemodynamic stability, provides sufficient anesthesia in prolonged surgeries and safe postoperative analgesia in comparison to spinal anesthesia, however, it is not superior to spinal anesthesia in terms of intraoperative anesthesia quality.
Finally, in a previous study conducted in our institution by Ijaiya and Aboyeji, they attributed the high mortality rate in their study to the use of GA for all cases of cesarean section irrespective of the indication and that 89.2% of the patients were anesthetized by nurse anesthetist and that the high mortality recorded were preventable in skilled hands by using alternative forms of anesthesia such as regional anesthesia. Our present study shows that 100% of our cesarean section were anesthetized by physician anesthetist using the predominantly regional anesthetic technique with a highly skilled hand such as the senior registrar performing 54.8% of the anesthesia for cesarean delivery in our institution.
| Conclusion|| |
The rate of cesarean section is high in our institution, with the majority being performed under single-shot spinal anesthesia. However, we need to improve on other regional anesthetic techniques so that our parturients can have the best and safest option of anesthesia to choose from. A follow-up review is also needed to compare the maternal and fetal outcomes for the various anesthetic techniques used for cesarean section.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Barber EL, Lundsberg L, Belanger K, Pettker CM, Funai EF, Illuzzi JL. Contributing indications to the rising caesarean delivery rate. Obstet Gynecol 2011;118:29-38.
Incerpi MH. Caesarean section. In: Decherney AH, Goodwin TM, Nathan L, Laufer N, editors. Current Diagnosis and Treatment Obstetrics and Gynaecology. 10th
ed. New York: McGraw Hill; 2007. p. 469-75.
Jaiyesinmi RA, Ojo O. Caesarean section. In: Okonofua F, Odunsi K, editor. Contemporary Obstetrics and Gynaecology for Developing Countries. Benin City: Women's Health and Action Research Centre; 2003. p. 592-621.
Daniel CN, Singh S. Caesarean delivery: An experience from a tertiary institution in north western Nigeria. Niger J Clin Pract 2016;19:18-24.
] [Full text]
Bassey EE, Stephen DN, Donald UO, Stephen AA. Trends in obstetric anaesthesia in a tertiary hospital in Nigeria: A four year review. IOSR J Dent Med Sci 2015;14:72-6.
Isah AD, Adewole N, Zaman J. A five-year survey of cesarean delivery at a Nigerian tertiary hospital. Trop J Obstet Gynaecol 2018;35:14-7.
Ogboli-Nwasor E, Yunus AA. Anesthesia for cesarean delivery in a low-resource setting, an initial review. Open J Anesthesiol 2014;4:217-22.
John CO, Alegbeleye O. Caesarean delivery at a teaching hospital South-South Nigeria: A five-year Review. Int J Tropical Dis Health 2017;21:1-6.
Lamina MA. Trends in regional anaesthesia for caesarean section in a Nigerian Tertiary health center. West Afr J Med 2009;28:380-3.
Ijaiya MA, Aboyeji AA. Caesarean delivery: The trend over a ten-year period at Ilorin, Nigeria. Nig JSurg Res 2011;3:11-8.
Igberase GO, Ebeigbe PN, Andrew B High Caesarean sectionrate: A ten year experience in a tertiary hospital in the Niger Delta, Nigeria. Niger J ClinPract 2009;12:294-7.
Adekanle DA, Adeyemi AS, Fasanu AO. Caesarean section at a tertiary institution in South-Western Nigeria – A 6-year audits. Open J Obstet Gnaecol 2013;3:357-61.
Gibbons L, Belizan JM, Lauer JA, Betran AP, Merialdi M, Althabe F. The global numbers and costs of additionally needed and unnecessary caesarean sections performed per year: Overuse as a barrier to universal coverage. World Health Report (2010) Background Paper, No 30.5; 2010.
Banerjee A, Sarkar D, Bhadra B. Evaluation of anaesthetic techniques for caesarean. Int J Res Med Sci 2018;6:1742-6.
Yakassai IA, Abubakar MY. Trends in elective caesarean section in Aminu Kano Teaching Hospital, Kano: A four (4) year review. Glob Adv Res J Med Med Sci 2014;3:80-3.
Radha K, Devi GP, Manjula RV, Chandrasekharan PA. Study on rising trends of caesarean section (C-Section): A bio-sociological effect. IOSR J Dent Med Sci 2015;14:10-3.
Kambale MJ. Social predictors of caesarean section births in Italy. Afr Health Sci 2011;11:560-5.
Geidam AD, Audu BM, Kawuwa BM, Obed JY. Rising trend and indications of caesarean section at the university of Maiduguri teaching hospital, Nigeria. Ann Afr Med 2009;8:127-32.
] [Full text]
Saxena N, Sharma B, Gupta V, Negi KS. A six year appraisal of caesarean delivery at a teaching hospital in Uttarakhand. Int J Reprod Contracept Obstet Gynecol 2016;5:4369-72.
Sarı MA, Küçükgüçlü S, Özbilgin Ş, Günenç FS, Mercan S, Esen A, et al
. Retrospective evaluation of anaesthetic techniques for caesarean. Turk J Anaesthesiol Reanim 2015;43:373-80.
Jenkins JG, Khan MM. Anaesthesia for caesarean section: A survey in a UK region from 1992 to 2002. Anaesthesia 2003;58:1114-8.
Reynolds F. General anesthesia is unacceptable for elective cesarean section. Int J Obstet Anesth 2010;19:212-7.
Okafor UV, Ezegwui HU, Ekwazi K. Trends of different forms of anaesthesia for caesarean section in South-eastern Nigeria. J Obstet Gynaecol 2009;29:392-5.
Prasad MK, Rani K. Retrospective evaluation of Anaesthetic method used in caesarean sections: Changing trends. Indian J App Res 2017;7:44-6.
Rukewe A, Fatiregun A, Adebayo K. Anaesthesia for caesarean deliveries and maternal complications in a Nigerian teaching hospital. Afr J Med Med Sci 2014;43:5-10.
Marcus HE, Behrend A, Schier R, Dagtekin O, Teschendorf P, Böttiger BW, et al
. Anesthesiological management of caesarean sections: Nationwide survey in Germany. Anaesthesist 2011;60:916-92.
Blanshard HJ, Cook TM. Use of combined spinal-epidural by obstetric anaesthetists. Anaesthesia 2004;59:922-5.
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8]