After briefly expounding the principles of an audit, this article focusses on the role of obstetric audit and how it can influence, and even shape, obstetric anaesthetic practice. The impact may be on service delivery, anaesthetic practice or the generation of new information. The relevance of maternal mortality reporting and of obstetric haemorrhage audit to anaesthetic practice is used to illustrate these concepts. Further examples include how different types of audit of pregnancy outcome, obstetric practice or areas of cross-interest to both obstetricians and anaesthetists are used by anaesthetists to evaluate health-care delivery, their own practices and to generate new audit and research agendas. Audits drive change and, hopefully, improvements that continue to make pregnancy a safer and more satisfying event for the mother and child.
Obstetric audit – benefits and issues
An obstetric audit is a component of clinical governance designed to monitor standards of care amongst pregnant women. It forms part of a quality-improvement process that has the objective of maintaining and progressively improving standards of patient care and staff training.
Criterion-based clinical practice audit allows benchmarking and is considered to be a rigorous means of measurement and improvement of the quality of health care against an agreed standard, at the local or national level. It is “A quality improvement process that seeks to improve patient care and outcomes through systematic review against explicit criteria and the implementation of change”. Following feedback of findings to stakeholders such as obstetricians, midwives, nurses, anaesthetists, intensivists, general or family practitioners and other physicians, the identification of gaps between practice and standards allows implementation of changes followed by monitoring of clinical practice to (hopefully) gain incremental improvement in health-care delivery. This process commences with the preparation and review of evidence-based best practice, including the selection of appropriate criteria for standards, followed by measurement of performance, identification of deficiencies, implementation of best-practice changes and, finally, monitoring (by means of either continuous or ‘one-off’ repeat audit) so that any improvements can be sustained. The process should be cyclical or spiral ( Fig. 1 ).
An audit can be used to demonstrate competency, identify deficiencies in staff training and suggest areas for development, but it also serves other purposes. In obstetrics, maternal mortality, maternal morbidity or critical incident monitoring captures information about infrequent events with a view to improving the safety of pregnancy. Outcome audits may address research questions not easily tested by conventional research methodologies (e.g., the safety and effectiveness of recombinant activated factor VIIa in life-threatening post-partum haemorrhage) or may assess the implementation of research findings. Audits can be used to document service patterns, such as the provision of caesarean section (CS) or critical care, or to support the effective use of resources. Although there is a certain overlap with research, audit differs in three principal ways – it examines accepted practice rather than generating or testing new ideas, it does not definitively indicate a direct relationship between the change of practice and the new outcomes (although it can be persuasive) and findings are specific to the population audited, thus lacking external validity. Whilst criterion-based clinical audit is often seen as a tool to perfect care in the developed world, limited experience in the developing world suggests it can also be effective in areas with limited health-care resources.
In many countries, obstetric critical incident monitoring (and, on a broader scale, maternal and perinatal morbidity and mortality reporting) or similar types of clinical outcome audit have been integrated into clinical governance activities to systematically evaluate changes in maternal and infant health-care delivery. A long-standing commitment to clinical obstetric audit is most clearly evident in the United Kingdom (UK), where the Confidential Enquiries into Maternal Death represent the longest running large-scale clinical audit in medicine. The directive of the World Health Organization (WHO) in 1985 was influential in Europe and, at present, many countries have extensive experience. In the UK, medical and, subsequently, clinical audits evolved during the 1990s and, by 2001, the government had mandated audit of the application of National Institute of Clinical Excellence (NICE) guidelines and recommendations. Doctors in the UK are expected to perform an audit in the first 2 years following graduation. The Royal College of Obstetricians and Gynaecologists (RCOG) has a clinical audit unit, which has audited audit activities across time, showing improvement in the number of audit programmes, especially the number of hospitals performing critical incident monitoring, patient-satisfaction surveys and re-audit. Other countries have also audited the implementation of audit, finding major barriers such as insufficient understanding of, or training in, the audit process and lack of administrative support. The same level of integration does not appear to apply in countries where the health system does not have a strong centralised government leadership system or where different quality-improvement strategies, involving both public and private systems, self-regulation and non-governmental organisations, are used.
The performance of an audit requires data collection and, increasingly, databases are used to store data for audit purposes. These databases require financial, computer and manpower input and, thus, may not be feasible in some developing countries. Decisions regarding which indicators of quality should be collected require discussion at local, regional and national levels. Clinicians and administrators often focus on different aspects and outcome or quality indicators may differ in developing, compared with developed, countries. The UK National Obstetric Anaesthetic Database (NOAD) was established in 1998, with support from the Obstetric Anaesthetists Association (OAA), the Royal College of Anaesthetists (RCoA), the RCOG and the Royal College of Midwives and established a framework for the collection of national obstetric anaesthetic data.
Obstetric audit may provide the collective impetus to establish better administrative systems (e.g., for high-dependency or critical care admissions and management), better training (e.g., multidisciplinary courses for the management of critical events in pregnant women) or better facilities and resources (e.g., cell-savers or access to interventional radiology for the management of obstetric haemorrhage). Obstetric audits can highlight areas of obstetric (or obstetric anaesthetic) practice that warrant attention. While an audit has the capacity to enhance professional satisfaction, it is sometimes driven by financial incentives or medico-legal considerations. The Clinical Negligence Scheme for Trusts (CNST) in the UK is a means by which National Health Service Trusts fund the cost of clinical negligence litigation. A significant proportion of sums dispersed are directed to litigation arising from maternity services. In order to reduce the number of claims against maternity services, the CNST has introduced eight standards. If individual trusts accomplish these standards, discounts to premiums are obtained based on the level of compliance. Audit is the tool by which compliance is demonstrated. In addition to the financial incentives, improved maternity care and less litigation are potential benefits.
It must also be acknowledged that there are a number of barriers and limitations to the value of clinical audit. Audits increase workload, need to be driven by those who feel they have clinical ownership and may cause territorial disputes and professional isolation. Criticisms of local audits, compared with a national audit, include that they may be too small, of poor design or analysis, do not allow external comparison and may not affect change if retained internally or not re-audited. A poorly performed audit is unlikely to affect change; effort needs to be applied to planning, the accuracy and relevancy of measurements and benchmarking, the feedback of results to all relevant clinicians and administrators and, especially, to the effective implementation of subsequent change, including monitoring of practice to determine the impact of change, that is, re-audit. There are many examples of the failure of application of audit recommendations or for the effect of audit to be small to moderate at best, despite effective implementation.
Obstetric audit – impact on obstetric anaesthesia
Similar to obstetricians, obstetric anaesthetists are a group of medical professionals that are intimately involved in maternity care. In many cases, an obstetric audit has multidisciplinary interest, with implications for anaesthetists, midwives, nurses and other health professionals involved in the care of pregnant women. The nexus between obstetrics and anaesthesia is such that an obstetric audit can impact very significantly on anaesthesia and pain medicine. It may directly stimulate changes in anaesthetic service delivery, by directing attention to service requirements or requisite facilities. It can influence clinical practice or highlight areas suitable for obstetric anaesthetic audit or research. For example, an audit of the rate and outcome of vaginal birth after CS may prove of relevance because it indicates the need for increased anaesthetic or analgesic services or more efficient deployment of existing services. An audit of labour analgesia showing a trend to the increasing popularity of epidural analgesia will flag the likelihood of increased workload for the department of anaesthesia in the future.
Obstetric audits of topics or practice that involve or impact on anaesthetists may have additional benefits. Clinical audits can improve communication between professions and colleagues, a matter of critical importance in obstetrics where early and sound channels of communication can modify outcome in life-threatening situations for the foetus and, occasionally, the mother. There are many examples of audits that relate to patterns and quality of communication, for example, audit of referral by obstetricians of high-risk medical or anaesthetic patients (e.g., those with cardiac, respiratory, neurological, musculoskeletal, haematological disorders, known difficult intubation, morbid obesity) for antenatal anaesthetic review. Other examples are the notification of anaesthetists regarding the presence of women in labour who are at high risk of operative delivery and audit of the speed of notification of an anaesthetist with regard to the need for an emergency CS. The quality of professional relationships and the systems in place to optimise channels of communication impact profoundly on team (obstetric, midwifery and anaesthetic) management and sometimes patient outcome during critical events (e.g., eclampsia, massive haemorrhage and cardiac arrest). Good communication is crucial to obstetric anaesthetic practice, where the time available prior to delivery is a critical factor in the decision regarding the safest anaesthetic technique for non-elective CS.
In the following sections, several examples of the obstetric audit that are of direct relevance to anaesthetic practice will be explored in greater detail.
Obstetric audit – impact on obstetric anaesthesia
Similar to obstetricians, obstetric anaesthetists are a group of medical professionals that are intimately involved in maternity care. In many cases, an obstetric audit has multidisciplinary interest, with implications for anaesthetists, midwives, nurses and other health professionals involved in the care of pregnant women. The nexus between obstetrics and anaesthesia is such that an obstetric audit can impact very significantly on anaesthesia and pain medicine. It may directly stimulate changes in anaesthetic service delivery, by directing attention to service requirements or requisite facilities. It can influence clinical practice or highlight areas suitable for obstetric anaesthetic audit or research. For example, an audit of the rate and outcome of vaginal birth after CS may prove of relevance because it indicates the need for increased anaesthetic or analgesic services or more efficient deployment of existing services. An audit of labour analgesia showing a trend to the increasing popularity of epidural analgesia will flag the likelihood of increased workload for the department of anaesthesia in the future.
Obstetric audits of topics or practice that involve or impact on anaesthetists may have additional benefits. Clinical audits can improve communication between professions and colleagues, a matter of critical importance in obstetrics where early and sound channels of communication can modify outcome in life-threatening situations for the foetus and, occasionally, the mother. There are many examples of audits that relate to patterns and quality of communication, for example, audit of referral by obstetricians of high-risk medical or anaesthetic patients (e.g., those with cardiac, respiratory, neurological, musculoskeletal, haematological disorders, known difficult intubation, morbid obesity) for antenatal anaesthetic review. Other examples are the notification of anaesthetists regarding the presence of women in labour who are at high risk of operative delivery and audit of the speed of notification of an anaesthetist with regard to the need for an emergency CS. The quality of professional relationships and the systems in place to optimise channels of communication impact profoundly on team (obstetric, midwifery and anaesthetic) management and sometimes patient outcome during critical events (e.g., eclampsia, massive haemorrhage and cardiac arrest). Good communication is crucial to obstetric anaesthetic practice, where the time available prior to delivery is a critical factor in the decision regarding the safest anaesthetic technique for non-elective CS.
In the following sections, several examples of the obstetric audit that are of direct relevance to anaesthetic practice will be explored in greater detail.
Obstetric audit of relevance to anaesthetists
Maternal mortality audit
The estimated number of maternal deaths per annum worldwide is over half a million and 99% occur in developing countries where the life-time risk that a woman will die of pregnancy-related complications is approximately 1 in 16, compared with 1 in 2800 in developed countries (individual country range: 1 in 7 to 1 in 47 600). The WHO document ‘Beyond the Numbers’ offers “diagnostic tools that shed light on what needs to be done to prevent maternal deaths” and includes both criterion-based clinical audit and maternal death audit (e.g., death surveillance, confidential enquiries and case reviews).
Following the first national maternal mortality and morbidity surveillance cycle performed in England and Wales in 1952, the triennial ‘confidential enquires’ have been undertaken continuously in the UK. These have had a profound influence on obstetric anaesthesia. The enquiry process determines which deaths require review, identifies cases, collects and assesses relevant information, collates it and makes practice recommendations. The intent is not only to quantify rates but also to stimulate and promote beneficial clinical actions and health and social service changes that will save future lives. National enquiries – either continuous or intermittent but at regular intervals – or regional or state-based enquiries are also made in many other countries, for example, Australia, Canada, some states of the USA, some European countries. They have been started in countries such as Suriname, Malaysia, Israel, Indonesia and South Africa based on the UK methodology and ‘snap shot’ time-limited enquiries have been reported from Jamaica, the Netherlands and Egypt. In some cases, these enquiries extend to clinical commentary and practice recommendations, none more comprehensively than those in the UK.
Many of the recommendations from maternal death reporting pertain to anaesthetic care because of the integral role of the obstetric anaesthetist in peripartum and multidisciplinary obstetric care. Deaths from hypertensive disease, obstetric haemorrhage or cardiac disease usually involve an obstetric anaesthetist. The UK triennial reports contain a chapter dedicated to maternal mortality associated with anaesthesia and a dramatic reduction in the number of maternal deaths directly as a result of anaesthesia has been a success story of these reports. From 30 to 50 such deaths per triennium until 1981, the number fell to 19 deaths in the 1982–84 triennium and a similar number across all the following triennia from 1985 to 1996. The predominant cause of anaesthetic-related death was failed airway management, either through failure to oxygenate while trying to achieve tracheal intubation or aspiration of gastric contents with immediate hypoxic arrest or, subsequently, adult respiratory distress syndrome and respiratory failure. This information became a key driver of practice change, leading to the predominant use of regional anaesthesia for CS. Since the late 1960s, very few deaths have resulted from a complication of regional anaesthesia. Criterion-based clinical audit is being used to promote the use of regional anaesthesia for CS. In 2007, a Joint College working party in the UK set an auditable ‘best practice’ standard that 95% of elective CS and 85% of emergency CS should be performed under regional anaesthesia.
Maternal morbidity and critical incident audit
Although the lessons learned through mortality reporting are instructive, deaths are so infrequent in many developed countries that lessons learned cannot be used to support more specific clinical decisions or formulation of practice guidelines. Serious maternal morbidity is up to 50 times more common than mortality in developed countries and ‘near misses’ (also termed ‘adverse events’, ‘critical incidents’ or ‘near-miss events’) are much more common again. Audits of these should provide a more clinically relevant indication of standards of care and greater clinical insights, especially for units other than tertiary referral centres.
Currently, severe morbidity audit mainly occurs at a local level but wider ascertainment is increasing. In 1997–99, the UK triennial report included a chapter on ‘near-miss and severe maternal morbidity’ and the Scottish experience was described in recent reports. Definitions, sources of data and assessment of quality of care vary. What constitutes ‘severe maternal morbidity’ can be variously defined, but, by means of large population-based cohort studies, national databases or even larger regional database initiatives, such as that in Europe, it is possible to quantify severe maternal morbidities and to identify risk factors and suboptimal care. In addition to Scotland, countries such as Canada, South Africa, the USA and those of the European Union have implemented programmes to examine aspects of maternal morbidity. In the developing world, criterion-based clinical audits focussing on the management of life-threatening obstetric complications have been studied in Ghana and Jamaica. The authors concluded that it was a feasible and acceptable method of quality assurance, which appeared to have improved the management of these complications.
In general, morbidity rates (5 per 1000 maternities for severe morbidity in Scotland) parallel mortality rates and a number of morbidity sets are suitable for audit. One criterion used to identify severe maternal morbidity, but which misses approximately two-thirds of cases of life-threatening illness or events, is admission to an intensive care unit (ICU). In the UK, the Intensive Care National Audit and Research Centre (ICNARC), has, since 1994, attempted to improve the organisation and servicing of critical care and provides population-based data for benchmarking. There are a number of problems related to the obstetric ICU audit, particularly under-ascertainment of pregnancy and variation in transfer rates to ICU depending on the local availability of tertiary centres and high-dependency units. However, most ICU admissions occur post partum and involve haemorrhage, hypertensive disease and multi-organ failure. Complementary audits of clinically defined disease-entities, such as severe sepsis or obstetric haemorrhage, can maximise ascertainment.
Audit of severe morbidity often identifies issues or outcomes relevant to multiple professions. It can help support organisational change and even major health-care restructuring, such as the integration of free-standing maternity hospitals with general hospital intensive care facilities. Audit of specific clinical events or rare conditions (e.g., amniotic fluid embolism, eclampsia) requires audit at regional or national level. The UK registry of high-risk obstetric anaesthesia, a national registry initially confined to women with cardiac and respiratory disease, was an example of an attempt to guide practice through this type of audit. The UK Obstetric Surveillance system, established in 2005, represents an extension of the confidential enquiries to enable the study of severe maternal ‘near-miss’ morbidity. The Australian Maternity Outcomes Surveillance System commenced in 2009. Information generated by these systems can be used to estimate incidence, allow case-control studies to identify risk factors and evaluate the quality of care.
Disease during pregnancy
More than 50% of women entering a delivery unit require the services of an anaesthetist. Where and when anaesthetists are deployed and the level of seniority warranted is strongly influenced by obstetric practice. Obstetric procedures (e.g., external cephalic version, foetal procedures and surgery, insertion of devices to prevent uterine haemorrhage) will impact if anaesthetic care or pain management are prerequisites or useful adjuncts. An audit of the rate and outcome of vaginal birth after CS is of relevance if it indicates the need for an increasing number of anaesthetic services or more efficient deployment of existing services. An audit of wound infection following CS that leads to a change in policy regarding the timing of prophylactic antibiotics will change anaesthetic work patterns, because these drugs are usually administered by the anaesthetist. When new management strategies that involve or impact on both obstetricians and anaesthetists are introduced, an audit is important in checking compliance.
Some obstetric audit will immediately justify new or repeat obstetric anaesthetic audit. For example, an audit of perineal trauma after vaginal delivery may reveal poor pain management. This aspect can then be audited by the anaesthetic department, new analgesia protocols introduced and compliance checked, hopefully resulting in better pain control that is maintained when a repeat audit is performed.
Indirect causes of maternal death, particularly cardiac disease, are now more common than direct causes in many developed countries. Multidisciplinary care, including anaesthesia and pain-medicine assessment and service provision, is accepted as a standard for the management of pregnant women with significant or poorly controlled medical disease. Multidisciplinary audit of these cases has been attempted at the national level. The ‘obesity epidemic’ in many countries is associated with a rapid rise in the prevalence of morbid obesity during pregnancy. This has multiple impacts on antepartum health and intra- and post-partum risks. From the anaesthetic perspective, problems relate to medical co-morbidities (diabetes, hypertension, ischaemic heart disease, sleep apnoea, etc.), difficult venous access and physiological monitoring, difficulty and increased technical complications associated with epidural analgesia and regional anaesthesia, difficult airway management with general anaesthesia and post-partum complications such as haemorrhage, thrombo-embolism and respiratory compromise. Although very rare, deaths due to complications of anaesthesia are clearly of paramount importance to the obstetric anaesthetist and, thus, good preoperative assessment and planning are essential elements in minimising the risks associated with difficult airway management, in particular. Consequently, many maternity units dealing with high-risk pregnant women now run antenatal anaesthetic or medical clinics. The success of these is dependent on early referral by knowledgeable obstetricians who are aware of the types of patients likely to benefit from such evaluation. Audit of pregnant women with cardiac disease can identify patterns of disease, risk factors for complications, such as pulmonary oedema and morbidity, and mortality rates. Audits of the anaesthetic or multidisciplinary obstetric referral clinic itself, particularly cross-tabulating attendees against cases meeting the referral criteria but missed, may help improve compliance with referral and, subsequently, with patient care and resource allocation.
Obstetric haemorrhage
A challenge of the maternal morbidity audit is the conversion of knowledge gained into less frequent or severe morbidity and safer patient management. For the obstetric anaesthetist, this might involve adjustments to practice, development of practice guidelines or management protocols, participation in drills or simulations or the acquisition of new drugs or equipment. Obstetric haemorrhage is an excellent example of an obstetric topic that is also of great clinical relevance to anaesthetists. Audit of blood loss and transfusion patterns at CS has resulted in most units changing preoperative blood-ordering practice, thus reducing workload, costs and wastage of precious resources. Audit of severe post-partum haemorrhage can identify factors leading to suboptimal care, thus permitting a systematic evaluation of system failures, inadequate facilities and service errors.
In addition to identifying practical issues related to specific and shared aspects of care, such as transfusion practices or cell salvage, an obstetric haemorrhage audit often highlights where there are service deficiencies or changing service needs. In Scotland, between 2003 and 2005, a specialist obstetrician attended 71% of cases of major haemorrhage but a specialist anaesthetist was present at only 50%. An audit demonstrated that post-partum haemorrhage increased in incidence by 25–30% in some jurisdictions, probably as a result of changing population demographics (increasing maternal age, obesity and CS rates). Obstetric haemorrhage is the leading cause of direct maternal death in most countries, as well as the most common reason for admission to a high-dependency unit and possibly the ICU and the leading cause of peripartum hysterectomy. Thus, audits play a vital role in directing attention to where additional resources are most needed or appropriately located. Past recommendations from the UK confidential enquiries have considered the type of facilities that should be available in specialist-led obstetric units, such as access to a blood bank or ICU and to hospital protocols for the management of severe haemorrhage. How effective audit has been in relation to this is unknown, although an audit of the implementation of recommendations from the confidential enquiries conducted some 15 years ago found fragmentary compliance. Cell salvage and other interventional management services (e.g., uterine artery embolisation) impact on operating-room and out-of-theatre anaesthetic workload. Cell salvage for the management of intra-operative obstetric blood loss has been endorsed by organisations in Europe and North America (the OAA, the NICE, the Association of Anaesthetists of Great Britain and Ireland (AAGBI) and the American College of Obstetricians and Gynecologists (ACOG)) and the first audits of this service have now been reported.
Post-partum neurological complications
Another topic of relevance to both obstetricians and anaesthetists is post-partum neurological deficit. Parturients having a central neuraxial blockade (spinal, epidural or combined spinal/epidural analgesia or anaesthesia) are at risk of neurological complications such as post-dural puncture headache, meningitis, direct nerve root or spinal cord trauma, epidural and subdural haematoma or vertebral canal abscess. However, lumbosacral spine and lower extremity nerve injuries unrelated to anaesthesia occur during labour and delivery, irrespective of delivery mode or regional techniques. Presentation of pre-existing conditions and obstetric, surgical or other peripheral nerve injuries are more common than anaesthesia-related complications. A prospective audit helps determine the incidence and aetiology of these complications. A multidisciplinary regional prospective audit of neurological complications associated with pregnancy and delivery found an incidence of neurological complications associated with pregnancy and delivery of 1 in 2500 deliveries and an incidence of neurological injuries to which epidural analgesia was considered contributory of 1 in 13 000. A prospective audit of complications in a tertiary centre associated with 10 995 epidural blocks for labour and delivery found a similar incidence of epidural related neuropathy of 1 in 11 000. Obstetric care providers should be aware that significant post-partum neurological dysfunction is common, with one centre reporting an incidence of 1 in 100.
In discussing rare events, such as permanent neurological complications, it is worth considering the differing contributions of audits of local, regional or national practice. Single-centre audits assist with quality assurance and the consent process when discussing analgesic or anaesthetic options but estimations of associated risks are limited by small numbers of cases over a lengthy time period. It is invalid to extrapolate incidence figures to other institutions because of variations in staffing, trainee numbers, teaching and clinical practices. Large databases can provide denominator data and more precise estimations of incidence. In the UK, the first National Obstetric Anaesthetic Database opened in 1999, focussed on post-partum headache and is an example of national audit of a sub-category of neurological complication. The third National Audit Project of the RCoA has provided comprehensive data on the incidence of serious complications of central neuraxial block, including in an obstetric population of over 320 000. Community-based audit is also valuable as it may detect complications missed by hospital-based audit systems because of early-discharge policies, late presentation or poor symptom recognition.
Obstetric outcome audit
Caesarean delivery
In many parts of the world, audits show that CS rates continue to increase. This increases the burden on health services with limited resources, not only in terms of direct costs, but also due to the need to deploy staff effectively in the face of extra after-hours workload and time pressures. Patient prioritisation is imperative and most hospitals have adopted systems by which the urgency of CS is categorised. The system used should be agreed on locally by obstetricians, midwives, anaesthetists and operating-room staff. The anaesthetist must be notified in individual cases as soon as possible. If definitions of the type of CS are standardised, comparison of local, regional and national data becomes feasible. A number of learned bodies have recommended that maternity units should be capable of performing a CS within 30 min of the decision when an immediate threat to the life of the woman or foetus is present (i.e., category 1 CS). Although clinical outcome benefits from applying this standard are unproven, it has become a medico-legal benchmark, and, in the UK, an auditable standard.
Despite achieving improvements in time to delivery, a number of clinical practice audit cycles indicate that most hospitals cannot achieve high compliance with a decision to delivery interval of <30 min for a category 1 CS. One audit demonstrated an improvement in the proportion of ‘urgent’ cases achieving a 30-min decision to delivery interval from 41% to 66% across three audit cycles over 4 years and then during a continuous audit over 32 months. The practice changes implemented that resulted in improvements in these audits had been agreed on by a collaborative multidisciplinary group and focussed on processes affecting system efficiencies. Delays in providing anaesthesia were one of many contributing factors to failure to achieve targets and were a consequence of insufficient anaesthetic cover or difficulty in establishing adequate anaesthesia. Other units have failed to achieve an improvement in reaching target decision-to-delivery times, despite implementing changes. This was attributed to frequent turnover of medical and midwifery staff during the audit cycle period and an inadequate education service with respect to birthing unit protocols.
The targeted decision-to-delivery time is important with respect to the method of anaesthesia chosen. In the case of the urgent CS, multidisciplinary audit has emphasised the importance of direct and clear communication amongst obstetrician, midwives and anaesthetists in determining whether regional or general anaesthesia can be used appropriately. Irrespective of whether general anaesthesia, spinal anaesthesia or ‘top-up’ of epidural analgesia is employed, a skilful anaesthetist is paramount in achieving prompt and safe anaesthesia delivery. Resorting to general anaesthesia to expedite delivery in the case of foetal distress has not been shown to significantly improve foetal outcome but confers greater maternal risk. However, if spinal anaesthesia is attempted in such situations, a Confidential Enquiry into Stillbirths and Deaths in Infancy advised against repeated attempts when there were no significant patient risk factors for general anaesthesia. A single-centre outcome audit found that epidural bolus or ‘top-up’ of effective labour epidural analgesia can result in decision-to-delivery intervals almost as short as those associated with conversion to general anaesthesia.
Demands on obstetric anaesthetic services are increasing both in quantity and in complexity due to the introduction of new technologies and rising intervention rates. Adequate anaesthetic staffing levels are fundamental to meeting response time standards when considering CS decision to delivery time. Successive confidential enquiries and a working party in the UK have emphasised the need for dedicated obstetric anaesthetic services in all consultant-led obstetric units, with early involvement of consultant anaesthetists in the care of high-risk patients and the availability of a designated consultant anaesthetist at all times to give prompt advice and help to trainee anaesthetists. Several countries have recommended minimal standards with respect to the provision of obstetric anaesthetic services, consultant cover and appropriate levels of experience of trainees covering birthing units. A suitably trained anaesthetic assistant is considered a mandatory part of the anaesthetic team.
The UK National Sentinel Caesarean Section Audit (NSCSA) demonstrated that 100% of units met the criteria of 24 h-a-day immediate provision of a duty anaesthetist but several audits in British hospitals found that the grade of the out-of-hours duty anaesthetist often indicated relative inexperience. The UK confidential enquiries also highlighted that trainees may not have sufficient experience or skill to recognise the seriously ill woman and that they (and their specialist supervisors) should acknowledge their competency limits and be willing to call for assistance when needed.
The high expectations and standards set for obstetric anaesthesia services have significant implications for anaesthetic training. Concern arises when audits demonstrate falling rates of obstetric general anaesthetic experience amongst trainees. Suggested strategies to improve competency and skill include competency-based assessment, simulation training, the development of practice guidelines and the running of protocol-based drills. It has been recommended that units regularly establish and update department protocols covering various aspects of obstetric anaesthetic management. The NSCSA found that units in England and Wales showed high compliance with provision of some written protocols, for example, for the management of major haemorrhage (98%) and difficult intubation (95%), but poor provision of guidelines for services such as admission and discharge to, and from, high-dependency units (23%), with less than 50% of guidelines reported to be evidence based. A more recent survey demonstrated improvements in provision of protocols but only 35% of units provided all recommended protocols.
Neonatal outcome
The routine collection of neonatal acid–base status data at birth allows the development of large population databases within which specific cohorts (e.g., women having elective CS or spontaneous vaginal delivery) can be examined. In this manner, the influence of factors such as type of anaesthesia, which ethically can never be evaluated by means of a large randomised trial, can be investigated. A meta-analysis has reported that spinal anaesthesia, which is safer for the mother than general anaesthesia, results in worse neonatal cord blood gas analyses than general anaesthesia. This begs the question ‘Why?’ with possibilities being the effects of spinal anaesthesia on maternal blood pressure, cardiac output, uteroplacental blood flow and foetal gas exchange or the effect of the vasopressor ephedrine on foetal metabolic state. Almost all the studies in the meta-analysis used ephedrine for blood pressure support, whereas, in the past several years, a major shift to direct alpha-adrenergic vasoactive drugs such as phenylephrine has occurred on the basis that foetal acid–base status is unaffected compared with ephedrine. Unpublished analysis of retrospective data from our unit suggests that spinal anaesthesia may not be detrimental, but prospective audit is now awaited.
The impact of category 1 CS on anaesthetic technique has been discussed. Although benefit is unproven, a consensus view is that intrauterine resuscitation strategies are harmless and may at least buy additional time to prepare the woman for delivery. In some cases, this will permit the use of regional, rather than general, anaesthesia. An audit of the implementation of various strategies in this setting (e.g., turning off oxytocin infusions or administration of tocolytic drugs) can show compliance levels with protocols or suggest what measures are needed to improve their application.
Other obstetric audits
Handover audit
In obstetrics, clinical risk management is particularly important because the cost of mistakes is high, both financially and in human terms. Poor staff communication is frequently identified as a major factor in claims and complaints. The care of a pregnant woman involves a large number of professionals and many countries have introduced work patterns such that the quality of clinical handover, an important component of safe medical practice, has attracted attention. Guidelines have been published as to the detail of medical handover. The formalisation of this process, with audit of compliance, is increasingly encouraged as a tool of risk management. The UK RCOG and the OAA recommend a standard that maternity units provide policies and work practices and are able to demonstrate effective, personal handover of care with adequate time for discussion. Ideally, work shifts should be arranged so that obstetric handover is multidisciplinary. This topic is suitable for audit but, to date, there do not appear to be any publications.
Maternal satisfaction audit
Measuring patient satisfaction and experience in hospital provides information on the standard of services and can be used to improve quality of care. In addition to mortality and morbidity, maternal satisfaction is now considered an important outcome measure that should be audited. The Victorian Surveys of Recent Mothers in Australia were a series of surveys that assessed maternal satisfaction, provided recommendations and then reassessed, seeking improvements. Similar cycles in a developing country have been conducted. After a multidisciplinary team had assessed current care and designed, implemented and evaluated a new maternity care model, women’s satisfaction levels were shown to improve. Studies of maternal satisfaction, including audits, have focussed on non-technical aspects of care such as control, choice, communication, understanding and continuity of care and carers, but rarely refer to the contribution of an anaesthetist or enquire about technical aspects of care such as provision of analgesia. ‘First Class Delivery’ was an independent review of maternity care by the UK Audit Commission that conducted a national survey of women’s views. A recommendation of relevance to the anaesthetist was that prospective mothers should have access to information in advance, allowing them to assess their options for pain relief. Many anaesthetists already contribute to antenatal education classes or Internet-based resources but examples of areas of anaesthetic service suitable for maternal satisfaction audit include the provision of information regarding labour analgesia or anaesthetic management at CS and the timeliness of analgesic service provision.
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