Increasing the labour epidural rate in a state hospital in South Africa: challenges and opportunities

Abstract

Background: A 2012 audit on labour epidural analgesia rates in Tygerberg Hospital (TBH) revealed that only 2.2% of labouring parturients received epidural analgesia. This unacceptably low number necessitated a dedicated epidural service that was subsequently initiated in June 2014 by the Department of Anaesthesiology and Critical Care to improve the quality of care in labouring patients. Methods: A retrospective follow-up audit was conducted from June 2014 to December 2015 and included data on epidural rates, indications, complications and patient satisfaction. Comparison was made with the 2012 data to evaluate the impact of change on care provided and to recommend future changes. Results: Labour epidural rates improved to 5.16% for the audit period, with 2014 and 2015 rates of 7.44% and 3.89% respectively. Daytime epidurals doubled in 2014/2015 and complication rates decreased from 32.3% in 2012 to 16%. Primary indications for epidural analgesia included pre-eclampsia, morbid obesity, primigravidity and cardiac conditions. Although 99.8% of the complications were minor and transient, one fatality was reported during the audit period. This mortality emphasises the importance of team training in every aspect of epidural analgesia, so that the desired increase in epidural rate is associated with safe practice. Conclusions: An important increase in epidural rates as well as a decrease in minor complications was observed. The fatality indicates that the expansion of the service should be accompanied by in-depth training of the entire team, so that the process becomes routine and complications are reduced. A fatal drug error, a 'never event' , should not occur.

An audit of the labour epidural analgesia service at a regional hospital in Gauteng Province, South Africa

“…[16] This increased to 5.2% after the establishment of a dedicated epidural service. [17] The reasons for the low epidural rate in our study are multifactorial and include a limited number of anaesthetists available to provide labour epidurals. During the study period, there was a single anaesthetist on call for labour epidurals from Monday to Friday during the daytime (07h00 to 16h00) only.…”

“…[16] A follow-up study in 2014, after the establishment of a dedicated epidural service at the same hospital, revealed that the epidural rate had increased to 5.2%. [17] Epidurals are considered safe, but when serious complications occur, they can be fatal or lead to permanent harm. [6] An audit by the Royal College of Anaesthetists in 2009 [18] found the incidence of permanent harm after epidural to be 0.6 per 100 000 cases (95% confidence interval 0 -3.4), and a survey in France found an incidence of serious events related to obstetric epidural to be less than 5 in 10 000.…”

Labour epidurals in Gauteng Province, South Africa

“…[1,10,[14][15][16][17] Very few public training hospitals offered labour epidural services, but the epidural rates in public hospitals in GP were similar to those in public hospitals in Western Cape Province. [19][20] This may be a result of similar limitations in service delivery in most public maternity hospitals, but further research is needed to determine this. The epidural rates were higher in public hospitals in 2015 than those reported in a study conducted by Leonard et al [21] This is most likely a result of the initiation of a 24/7 labour epidural service in 2015 at the same GP academic hospital initially evaluated by Leonard et al [21] in 2014.…”

“…Factors limiting the provision and uptake of labour epidural services in SA have not been fully elucidated. [20] However, insufficient knowledge, poor awareness and inadequate exposure of healthcare workers to the analgesic modality during their academic training may be contributing factors to poor rates in both the public and private sector and requires further study. [18] CS rates in GP private and public hospitals in 2015 were higher than the CS rates of 10 -15% recommended by the WHO.…”

“…Data available from two isolated public hospital audits suggest that the epidural frequency in public hospitals is <10%, and may be as low as 2.5%. [19][20][21] The highest number of births (n=296 621) were registered in Gauteng Province (GP) in 2015, [22] and represented 27% of the registered births in SA at the time. [22] Given the high number of births in the province and the lack of information on the provision of labour epidurals, to our knowledge, we conducted the first multisite survey of labour epidural provision in the private and public sector hospitals in GP.…”