This lecture is dedicated to my Wife, Gloria and our two girls – Soala and Orafiri, whom I love very dearly.
To my late parents Elder Fyneface Sotonye-Ogan and Madam Elizabeth Erebulo Sotonye-Ogan for their uncompromising principles that charted the lives of their children.
To all the parturients who passed through my hands during learning the art of painless labour and childbirth.
And finally, to God Almighty who brought me out of nothing to where I am today.
The Vice Chancellor
Members of the Governing council
Deputy Vice Chancellor (Admin)
Deputy Vice Chancellor (Academic)
Deputy Vice Chancellor (Research & Development)
Registrar and other Principal Officers of the University
Provost, College of Health Sciences
Dean, School of Graduate Studies
Dean of Faculties
Distinguished Professors and Scholars
Directors of Institutes and Units
Head of Departments
My Lords both Spiritual and Temporal
Distinguished Guests and friends
Our Unique Uniport Students
Members of the Press
Ladies and Gentlemen
Mr. Vice Chancellor Sir, history is being made today, not because this is the second inaugural lecture from the Department of Anaesthesiology, but it is the first time many in this audience will understand what mothers go through to deliver their babies and the efforts made to reduce the suffering these women go through during childbirth. In this lecture also many seated here will come to realise that it is no longer sinful to alleviate the pain of childbirth, but rather it is a fundamental right of every pregnant woman to ask for pain relief during labour and childbirth. Importantly, this is the first time an obstetric anaesthesiologist would deliver an inaugural lecture to tell a mixed audience the pain and relief associated with labour and delivery.
Mr. Vice Chancellor Sir, need I say that an inaugural lecture is a once in a lifetime opportunity given to a professor to showcase his/her works to the university community and the general public. Still, some say that it is the payment of some form of debt the community owes the inaugural lecturer. Nonetheless, it is patent from both views, it is a gain-gain situation where both parties have a romance of knowledge with each other.
In the meantime, standing here before you all is a dream fulfilled; a dream that was dreamt about 29 years ago. Worthy of note is the fact that I was a product of a painful labour and delivery; I was admitted into The College 36 years ago and subsequently struggled through thick and thin to become a Surgeon-Physician, seven years after. While still in the Medical school, I took up the challenge to study the art of Pain Relief.
Surprisingly, till today many see pain as a sweetener or the icing on the cake of labour and childbirth. Mr. Vice Chancellor Sir, then, it is apropos that I have been empowered by your office to present to this audience the …th inaugural lecture, titled PAIN OF CHILDBIRTH: THE CURSE, THE RELIEF AND THE SURGEON ANAESTHESIOLOGIST. Distinguished audience, I want you to take cognisance of the fact that the Anaesthetist is not just a PHYSICIAN, he is also a SURGEON. Consequently, throughout this lecture, I shall be talking as a SURGEON ANAESTHESIOLOGIST as we are now frequently addressed.
Permit me to highlight the curse associated with labour and childbirth as recorded in the Holy Scriptures – The Eve’s Curse; Genesis Chapter 3:16 enunciates that: Unto the woman He said, I will greatly multiply thy sorrow and thy conception; in sorrow thou shalt bring forth children; and thy desire shall be to thy husband, and he shall rule over thee (Holy Bible KJV). Since then, labour and delivery have been associated with intense pain and distress. This, according to the Scriptures was a result of disobedience to the laid down principles of the Creator.
There is no gainsaying that pregnancy is associated with intense distress. Likewise it cannot be disputed that this physiological state is supported by the massive release of the stress hormone (cortisol).Even from the time of Hippocrates to Aristotle, many people throughout history, leaders of the Grecian School of Medicine, all wrote about childbirth but short of associating it with pain in their notes of normal births. However, following the close of 200 AD, animosity against women began to gain momentum. Then, pregnancy was linked to carnal sin and practitioners of medicine were not allowed to give attention to women in labour and delivery.
Over time, at the close of the 15th century the practice of midwifery began to gain popularity and acceptance. Notwithstanding this discovery, Genesis 3 verse 16 still generated a belief that God had cursed the process of labour and childbirth. This is evidenced in the assertion made by a reformer, (Martin Luther, 1521) who said, “If women become tired, even die, it does not matter. Let them die in childbirth. That’s what they are there for.”
Per se, in the face of the advent of the Renaissance, there was still a belief that God wanted childbirth to be painful. Following this stance, the administration of chloroform was met with a stiff resistance. Hence, one New England Minister was quoted as saying, “God would be deprived of the pleasure of their deep and earnest cries for help”. Correspondingly, women in the Christian world feared birth and the associative pain God had cursed it with.
Slowly, birthing became institutionalised and women trudged off to the hospital to birth their babies. Subsequently, this move increased women’s fear of birth. No wonder women still fear the birthing process, even with the high margin of safety associated with it.
Physiological changes in pregnancy
Maternal physiological changes in pregnancy are the normal adaptations that a woman undergoes during pregnancy to better accommodate the embryo or foetus. The body must necessarily change its physiological and homeostatic mechanisms in pregnancy to ensure that the foetus is provided for. Accordingly, some of these changes influence normal biochemical values while others may mimic symptoms of medical disease. It is important to differentiate between normal physiological changes and disease pathology.
Changes in the Blood
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Pain of Childbirth: The mother’s view
Largely, women have described the pain experienced during childbirth as severe and frequent (Onah et al, 2007); these parturients, especially those in the developing countries have few or no options for labour pain relief during childbirth.
The physiology of labour pain
Labour is a complex and subjective experience. On account of this, a parturient’s perception of labour is influenced by several factors making each experience a unique one. However, research findings consistently evince that labour pain is ranked high on the pain rating scale when compared to other painful life experiences (Melzack R, 1984). The memory of this pain however is short lived and as a result, out of the parturients who experienced severe pain in labour, 90% found the experience satisfactory three months later (Morgan et al, 1982). This short term memory may be related to the positive outcome that often occurs at the end of labour.
The perception of labour pain varies between nulliparous and multiparous women and it is well known and documented that pain scores are higher in the nulliparous compared to the multiparous woman especially if there has been no antenatal education. Congruently, the factors associated with these variations include antenatal education, parturient’s level of education, availability of caregiver support, presence of spouse, ethnic inclinations, etc.
However, besides the fact that labour pain is unpleasant for the mother, in point of fact, it can also have deleterious effects on the foetus.
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Labour being an active process of delivering a foetus, is a product of regular, painful uterine contraction that increases in frequency and intensity associated with a progressive dilatation of the cervical os. The pain associated with labour and delivery has two components: visceral and somatic.
The visceral labour pain occurs during the early first stage and the second stage of childbirth. With each contraction, pressure is transmitted to the cervix causing stretching, distension, and activating excitatory nocioceptive afferents. These afferent innervate the endocervix and lower segment from T10-L1.
Small unmyelinated ‘C’ fibres that travel with sympathetic fibres and pass through the uterine, cervical and hypogastric nerve plexuses into the main sympathetic chain transmit visceral pain. The pain fibres from the sympathetic chain enter the white rami communicantes associated with T10 to L1 spinal nerves and pass via their posterior nerve roots to synapse in the dorsal horn of the spinal cord. Some fibres cross over at the level of the dorsal horn with extensive rostral and caudal extension resulting in poorly localised pain. Chemical mediators involved include bradykinin, leukotrienes, prostaglandins, serotonin, substance P and lactic acid.
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The pain of early labour is referred to as T10-T12 dermatomes, such that pain is felt in the lower abdomen, sacrum and back. This pain is dull in character and is not always sensitive to opioid drugs; the response to opioids depends on the route of administration.
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Fine, myelinated rapidly transmitting ‘A delta’ fibres transmit somatic pain. Transmission occurs via the pudendal nerves and perineal branches of the posterior cutaneous nerve of the thigh to S2 – S4 nerve roots. Somatic fibres from the cutaneous branches of the ilioinguinal and genitofemoral nerves also carry afferent fibres to L1 and L2.
Somatic pain occurs closer to delivery; it is sharp in character and easily localised to the vagina, rectum and perineum. It radiates to the adjacent dermatomes T10 and L1 and compared to visceral pain, is more resistant to opioid drugs.
All resulting nerve impulses (visceral and somatic) pass to dorsal horn cells where they are processed and transmitted to the brain via the spino-thalamic tract. Transmission to the hypothalamic and limbic systems accounts for the emotional and autonomic responses associated with pain.
Anatomy of Labour Pain
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Labour pain is an emotional experience and presents a psychological challenge for many parturients. Indeed a recent Cochrane review concluded that women who had continuous intra-partum support were less likely to have intra-partum analgesia or to report dissatisfaction. Other groups have suggested that an underlying anxiety trait can both result in a higher uptake of epidural analgesia as well as influence the analgesic effect of the epidural block. There is current interest in determining whether the Pain Catastrophizing Score has any influence on either labour outcome or analgesic uptake.
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The anatomy of labour pain
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It is well known that an unrelieved pain is a stressor that can threaten homeostasis. The body’s response to this stress involves bio-physiological changes that initially are useful and subsequently become potentially life threatening.
However, one of the biochemical changes in response to the unrelieved pain is the production of endogenous opioids known as encephalins and endorphins found in the central nervous system. These bind to opioid receptor sites, prevent the release of neurotransmitters such as substance P, and thereby inhibit the transmission of pain impulses. Unfortunately, these endogenous opioids according to McCaffery and Pasero, 1999, degrade easily and cannot be considered as useful analgesics.
The sympathetic nervous system is involved in the immediate bodily response to emergencies, such as severe, acute pain. The initial effects of the sympathetic response allow survival of individual, for prolonged response activation can be detrimental (Marieb, 2001).
As aforementioned, the experience of pain in labour is subjective and differs from woman to woman (NICE, 2014), given this basic truth, every woman should have a choice according to her preference and individual circumstances. For instance, in low and middle-income countries (LMIC), the most common form of pain relief is the continuous support of a companion during labour. Likewise, the provision of pain relief in labour is often neglected against a background of controversy over the need, advantages and disadvantages of pain relief especially the pharmacological options (Olayemi et al, 2003). This lack of awareness, misunderstanding regarding acceptability, safety and availability of pain relief options could be considered as reasons women in many LMIC such as Nigeria, do not receive adequate pain relief (Olayemi et al, 2006).
According to the Nigerian Demographic and Health Survey findings in 2008, about 60% of pregnant Nigerian women attended antenatal care but only 35% of deliveries was in health care facilities.14 In this context, pain relief during labour could be a critical incentive for increasing facility deliveries.Nonetheless, only a few published studies have addressed the prevalence, determinants, and severity of labour pains and the role of pain relief agents (Olayemi et al 2005; Huntley et al, 2004). The majority of childbirth occurs at home and is largely attended by unskilled providers. With the strong belief grounded in culture and religion that pain is acceptable during labour, women who deliver at home rarely benefit from any modern pain relief.
Labour pain presents an emotional experience and complex psychological challenge for many parturients. One review concluded that women who had continuous intra-partum support were less likely to have intra-partum analgesia or to report dissatisfaction. Interestingly there appears to be a circadian variation in labour pain perception and one group have demonstrated lower mean daytime visual analogue pain score compared to nocturnal scores.
Evidence also suggests that attitudes to pain relief in labour depend on personal aspirations, cultural factors and peer group influences. As a result, the ability to cope with pain may be rated as more important than the level of pain experienced. In one survey, only 9% of women wanted ‘the most pain free labour that drugs can give me’. Conversely, the majority, 67%, wanted ‘the minimum quantity of drugs to keep the pain manageable (Green et al, 1990). Evidently, what seems to be important is that women are more likely to be satisfied with pain relief if they felt they had been in control during their labour. Childbirth, however fulfilling, can be a very painful experience for women. Ipso facto, in many high-income countries (HIC), pain relief in labour is considered an essential part of intra-partum care and all women have the choice of and access to a range of pain relief options for labour and delivery (NICE, 2014).
Prof. Richard Feynman, a Physics Nobel laureate once said that a research process must be based on the scientific culture. Scientific culture would not exist if there is no scientific integrity, and scientific integrity will not be formed if there is no good research practice. Accordingly, there are several principles in good research practices:
• Good research practice requires proper supervision and training.
• Good research practice encourages openness and dissemination of results.
• Good research practice requires proper maintaining and storing of records.
• Good research practice requires high quality outputs and good publication
Based on these considerations, one could argue that it is indeed very difficult to be a famous scientist compared with other jobs such as television host and a Nollywood star.
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The relief – My Scientific Contributions
Mr. Vice Chancellor Sir, with reference to the Holy Scriptures, in St. John’s Gospel, Chapter 19 verse 30, categorically avowed that, “When Jesus therefore had received the vinegar, he said, “It is finished”: and he bowed his head, and gave up the ghost.” Consequently, that avowal was the end of the curse on childbirth, thus marking the beginning of advancement in knowledge of science and technology.
The relief of pain during childbirth can be non-pharmacological and pharmacological (Fyneface-Ogan S, 2009). However, the ideal pain relief method must be timely, safe, efficient, effective, equitable, the woman-centred and ideally should not interfere with labour or the mobility of the labouring women (WHO, 2017).
On the one hand, non-pharmacological options include the continuous support of a companion, directed breathing and relaxation techniques, massage, labouring in water and the use of transcutaneous electrical nerve stimulation (TENS) in early labour. On the other, pharmacological options include oral tablets (paracetamol, codeine or tramadol), inhalation analgesia (Entonox® – a 50:50 mixtures of oxygen and nitrous oxide), intravenous and intramuscular opioids (pethidine or diamorphine) and various types of local (para-cervical or pudendal block) and regional analgesia (epidural or spinal analgesia).
Numerous non-pharmacologic methods of pain relief can be initiated during labour. Although labour pain is a subjective multidimensional experience not one specific technique or combination of interventions helps all women or even the same woman throughout the labour experience. Pain and suffering often occur together; one may suffer without pain or have pain without suffering. Furthermore, one can have pain coexisting with satisfaction, enjoyment, and empowerment. Loneliness, ignorance, unkind or insensitive treatment during labour, along with unresolved past psychological or physical distress, increase the chance that the woman will suffer. The physical sensation of pain is magnified and frequently becomes suffering when it coexists with these negative psychological influences (Simkin and Klaus, 2004).
Psychological preparation for the non-pharmacological method is also extremely important due to the close link between pain and anxiety. It has been shown that confidence is greater after childbirth education and that confidence is powerfully related to decreased pain perception and decreased medication/analgesia use during labour (Lowe NK, 1996).
The non-pharmacologic approach to pain includes a wide variety of techniques to address not only the physical sensations of pain but also to prevent suffering by enhancing the psycho-emotional and spiritual components of care. Pain is perceived as a side effect of a normal process of labour, not a sign of damage, injury, or abnormality. To this end, rather than making the pain disappear, the caregivers assist the woman to cope with it, build her self-confidence, and maintain a sense of mastery and well-being. In fact, the element that best predicts a woman’s experience of labour pain is her level of confidence in her ability to cope with labour (Lowe NK, 2002). Reassurance, guidance, encouragement, and unconditional acceptance of her coping style are used. The woman and her partner or support persons are guided and supported in using self-comforting techniques and non-pharmacologic methods to relieve pain and enhance labour progress. With this kind of care, women perceive that they coped successfully with the pain and stress of labour and state that they were able to transcend their pain and experience a sense of strength and profound psychologic and spiritual comfort during labour (Lowe NK, 2002).
Despite a large number of published articles, there are relatively few prospective trials of effectiveness of many of the techniques of non-pharmacologic pain relief.
Continuous Labour Support
The term “continuous labour support” refers to non-medical care of the labouring woman throughout labour and birth by a trained person. Labour support includes continuous presence, emotional support (reassurance, encouragement, and guidance); physical comforting (assistance in carrying out coping techniques, use of touch, massage, heat and cold, hydrotherapy, positioning, and movement); information and guidance for the woman and her partner; facilitation of communication (assisting the woman to express her needs and wishes); and nonmedical information and advice, anticipatory guidance, and explanations of procedures.
Two recent systematic reviews of continuous labour support, a Cochrane Review (Hodnett et al, 2003) of all randomized controlled trials (RCTs), and a review of North American trials only (Simkin and O’Hara, 2002) reached similar conclusions.
The Cochrane Review examined 15 RCTs, including 12,791 women. Labour support was provided by a variety of people — staff nurses (in 2 trials), staff midwives (4 trials), staff student midwives (2 trials), retired nurses and trained lay women (1 trial), trained lay women (doulas 3 trials, lay midwives (1 trial), childbirth educators (1 trial), and untrained female relatives (1 trial). Despite the variety of caregivers and settings in which the trials took place, the meta-analysis revealed that women who received continuous labour support were less likely to experience analgesia or anaesthesia (including epidurals and opioids); instrumental delivery; Caesarean birth; and were less likely to report dissatisfaction or a negative rating of their birth experience. An analysis of the results showed greater benefit if the labour support provider was not a hospital staff. Women receiving support from non-hospital staff, compared to women who received no extra support, had 26% fewer caesarean births and 41% fewer instrumental deliveries. They were also 28% less likely to use any analgesia or anaesthesia and 33% less likely to be dissatisfied or to rate their birth experience negatively.
Baths in Child birth
Immersion in warm water deep enough to cover the woman’s abdomen is used to enhance relaxation, reduce labour pain, and promote labour progress. Baths are becoming a popular option in many countries, except in Nigeria. Women usually remain in the bath for a few minutes to a few hours during the first stage of labour.
A recent systematic review analysed findings of 2 prospective cohort studies and 7 RCTs of bathing published between 1987 and 2001 (Simkin and O’Hara, 2002). A total of 3496 women participated in these trials, while sample sizes in the individual trials ranged from 18 to 1237. The trials varied widely in study designs and quality, timing of entry into the water, water temperature, and in baseline rates of epidural analgesia and other interventions, as reflected by the rates in the control (“usual care”) groups. Out of the 3 best designed RCTs, 2 found a reduction in pain indicators in the bath groups (Cammu et al, 1994; Rush et al, 1996), 24, 25 while one did not (Ohlsson et al, 2001).26 Amidst the 2 that found decreases in pain in the bath group, 1 (Cammu et al, 1994) (N = 109) found an initial decrease in pain upon entering the water, followed by a slower rise in pain scores during the 1-hour study period than the control group, whose pain rose continually and more rapidly to higher levels. Maternal satisfaction was high in the bath group, with 89% stating they would like to use the bath in a future labour. In the other (Rush et al, 1996) (N = 785), the women randomised to the bath group required fewer epidurals (59.8% vs 66%, P < 0.02), even though almost half in the bath group opted for an epidural rather than the bath!
Intradermal Water Blocks
Intradermal water blocks, also called intracutaneous sterile water injections, decrease low back pain during labour. The block consists of 4 intradermal injections of 0.05- to 0.1-ml sterile water (using a 1-ml syringe with a 25-gauge needle) to form 4 small blebs, 1 over each posterior superior iliac spine and 2 others placed 3 cm below and 1 cm medial to each of the first sites. Exact locations of these do not appear to be critical to its success (Reynolds J, 1998). Studies show that the intradermal water blocks were effective in decreasing severe low back pain in most labouring women within minutes. Pain relief lasted between 45 and 120 minutes, and most women stated that they would want to use intradermal water blocks again during subsequent births (Martensson & Wallin, 1999; Ader et al, 1990). The studies demonstrated that intradermal water blocks reduce severe low back pain in most labouring women without any identified side effects on the foetus or mother, except for the transient, though extreme pain, with administration.
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Touch and Massage
Touching another human being can communicate positive messages such as caring, concern, reassurance, or love. Massage, “the intentional and systematic manipulation of the soft tissues of the body to enhance health and healing (Tappan & Benjamin, 1998) is used during labour to enhance relaxation and reduce pain and suffering.
Effectiveness of Touch and Massage in Reducing Pain and Suffering during Labour
A study of touch and massage described in a systematic review (N = 28) randomised women to receive either usual care (control group) or massage of head, back, hands, and feet by their partners for 20 minutes per hour for 5 hours during labour. The frequent massage reduced the women’s pain and anxiety and improved their mood (Field et al, 1997).
Acupuncture and Acupressure (Shiatsu)
Acupuncture, an important and ancient component of traditional Chinese medicine, is fast becoming integrated with conventional medicine worldwide. It is believed to initiate, control, or accelerate physiologic functions, and thus, correct organ malfunctions, heal illnesses, or relieve discomforting symptoms through insertion of fine needles into the skin at a combination of specific points along meridians (channels of energy, called “Qi,” pronounced “chee”) in the body, followed by rotation, heating, or electrical stimulation (electro-acupuncture) of the needles.
Acupuncture provides an effective alternative to pharmacologic pain relief. It may be useful for those women who want to avoid or delay pain medications or in settings where pain medications are not available. Satisfaction was high with acupuncture, but this was also true in the control groups. Additionally, because extra surveillance of the foetus and assistance from anaesthesiologists are not needed, care of the labouring woman is simpler and less expensive with acupuncture than neuraxial blocks.
Hypnosis has been used to reduce childbirth pain since the early 19th century. Hypnosis is “a state of deep physical relaxation with an alert mind producing alpha waves, and it is in this state that critical faculties are suspended and the subconscious mind can be more readily accessed” (Mantle F, 2000). In this state, the individual has increased suggestibility. Hypnosis for childbirth is almost always self-hypnosis; in other words, the hypnotherapist teaches the woman to induce the hypnotic state in her during labour.
Effectiveness of Hypnosis in Reducing Labour Pain and Preventing Suffering
While one study (Freeman et al, 1986) recorded no difference between hypnosis and control groups, another study found a decrease in use of anaesthesia and narcotics following the use of hypnosis (Martin et al, 2001).Nevertheless, current evidence suggests hypnosis may be effective in reducing pain in labour.
Transcutaneous Electrical Nerve Stimulation
Transcutaneous electrical nerve stimulation (TENS) is the transmission of low-voltage electrical impulses from a hand-held battery-powered generator to the skin via surface electrodes.
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TENS was introduced into maternity care in Scandinavia in the 1970s. Today, it is widely used and rated highly by users in the developed world except in the United States. It is not widely used for labour pain in the ….., although physical therapists can provide TENS units and teach expectant parents how to use them.
Music and Pain of Childbirth
Audio-analgesia is the use of auditory stimulation, such as music, white noise, or environmental sounds to decrease pain perception. Its use is popular for the relief of pain during childbirth, post-surgery, and for other painful situations. One study showed that the use of music therapy during labour decreased pain perception, increased the satisfaction with childbirth, postpartum anxiety, and reduced early postpartum depression rate. Music therapy can be clinically recommended as an alternative, safe, easy and enjoyable nonpharmacological method of pain relief in labour and an overall postpartum well-being (Simavli et al, 2014). All other studies, however, have suffered from small sample sizes, inadequate controls, or lack of true differences between control and experimental groups (DiFranco J, 2000). It has not been clearly demonstrated that audio-analgesia has any of the benefits claimed for it. There are no known drawbacks to using music or sound during labour.
Relaxation and Breathing
Most childbirth education classes and most literatures on childbirth present relaxation techniques, along with a variety of rhythmic breathing patterns intended to complement and promote relaxation or to provide distraction from labour pain.
Effectiveness of relaxation in reducing pain and suffering during labour
A survey of American women who gave birth between 2000 and 2002 divulged that 61% of the respondents used breathing techniques, and of those, 69% rated them as “very” or “somewhat” helpful, while 30% rated them as “not very helpful” or “not helpful at all.” This finding may be a reflection of the quality of the teaching received by the women, or the fact that breathing techniques are not helpful for everyone (DeClerq et al, 2002).
Take home notes on the use of non-pharmacologic pain relief methods during childbirth
All the techniques share several common properties:
Exhibit capacity to reduce pain sensations.
Can be combined safely or used sequentially to increase their total effect.
May be used instead of or as an adjunct to pain relief medications.
Are inexpensive and most are relatively easy to use.
The burden of pain control is not borne solely by the caregiver, but jointly by the woman, her labour support, and her caregivers.
The woman is less dependent, and, in turn, the caregivers are able to assume more of a supportive and assistive role and less of a directive role during her labour.
Encourages active participation by the woman in the birthing process.
She chooses the self-comfort measures and uses her own capabilities and support team to follow through.
Maintains or restores a sense of control to the labouring woman. When given encouragement, support, and unconditional acceptance of her coping style, her self-confidence grows. A woman who is confident in using her own resources can cope with labour better, which leads to a sense of well-being and mastery and less likelihood of suffering.
They tend to be rated highly in terms of satisfaction and a desire to repeat them in a future labour. Even though their pain-relieving capability is modest or short-lived, they contribute positively to the psycho-emotional, spiritual, social, and cultural aspects of her birth experience. When all aspects of the labour and birth are considered and respected, the likelihood of the woman suffering may significantly decrease.
Pharmacological method of pain relief during childbirth
Labour and childbirth result in severe pain for many women. According to the American College of Obstetricians and Gynaecologists (ACOG), there is no other circumstance in which it is considered acceptable for a parturient to experience untreated severe pain, amenable to safe intervention, while under a physician’s care. In the absence of a medical contraindication, maternal request is a sufficient medical indication for pain relief during labour. Pain management should be provided whenever it is medically indicated (Goetzl LM, 2002).
Eugen Bogdan Aburel first described the use of a catheter placed into the caudal epidural space in 1931 (Curelaru & Sandu, 1982). Aburel introduced a needle at the caudal level, then a soft catheter was advanced through the needle, after which the needle was removed, leaving the catheter in situ. This allowed repeated injections throughout labour without the need to repeat the procedure. Since then, the use of a modified form of this technique has become increasingly popular for pain relief during childbirth.
In Nigeria, data on the overall patterns of pain management during childbirth are lacking and are limited to surveys concerning service provision rather than genuine patient demand (Olayemi et al, 2003; Akpan et al, 2003). Anecdotal experience also shows that the rate of request for epidural analgesia in labour is low in Nigeria.
In one prospective study we enrolled 50 ASA Class I-II consecutive multiparous women in labour requesting pain relief (Fyneface-Ogan, Mato & Anya, 2009). After providing description of the options of pain relief available to them, they were allocated into two groups according to their request – to receive either parenteral opioid/sedative (Sedo-analgesia) or epidural pain relief. Subsequently, this study showed that the two groups were comparable in their socio-demographic data.
Bio-demographic data Labour characteristics and outcome
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Maternal questionnaire 1-hour post-delivery
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In obstetrics, acute postparturm perineal pain is quite common immediately after childbirth (MacArthur & MacArthur, 2004). It could be due to the extensive stretching of the perineal tissues, spontaneous perineal tear (unintended laceration of the skin and other soft tissue structures which, in women, separate the vagina from the anus) or from an episiotomy (intended surgical incision to widen the introitus to facilitate delivery). It has also been reported (Klein et al, 1994) that both episiotomy and perineal laceration are strongly associated with the presence of perineal pain during the immediate postpartum period and at 3 months for 11% of women. A research (East & Sherburn, 2012) submitted that over a third of women experienced moderate to severe perineal pain, particularly when walking or sitting to breastfeed their babies and while over one half of the women noted pain interfered with their ability to sleep. The prevalence of perineal pain and the associated impact on parturient’s recovery from childbirth warrant the proactive care in offering a range of effective pain relief options to them.
The incidence of post-episiotomy perineal pain relief was studied in primiparous parturients after repairing with two local anaesthetic agents. It was demonstrated that the use of 0.25% plain bupivacaine was tolerable and produced over a 7-hour period of complete pain relief than those who received 1% plain lidocaine. Most of the women depended less on the attending nurses and were able carry out bedside chores (Fyneface-Ogan, Mato ; Enyindah, 2006). It is well known that an individual’s pain response seems to be the most relevant factor in the development of persistent pain. The prevalence of chronic pain directly related to childbirth, at 6 months post-delivery, is however very low (< 2%) compared to chronic pain which occurs after other types of tissue trauma as in common surgical procedures (Lavand’homme ; Roelants, 2016).
Operative delivery and Anaesthesia
In Western society, women for the most part were barred from carrying out Caesarean sections until the late nineteenth century, because they were largely denied admission to medical schools. A woman, however, conducted the first recorded successful Caesarean in the British Empire. Sometime between 1815 and 1821, James Miranda Stuart Barry performed the operation while masquerading as a man and serving as a physician to the British army in South Africa. While Barry applied Western surgical techniques, nineteenth-century travellers in Africa reported instances of indigenous people successfully carrying out the procedure with their own medical practices.
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Mr. Vice Chancellor Sir, history suggested that the early European travellers in the Great Lakes region of Africa during the 19th century observed Caesarean sections, which was equally performed on a regular basis. Evenly, in 1879, one British traveller, R.W. Felkin, witnessed Caesarean section performed by Ugandans. The healer reportedly used banana wine to semi-intoxicate the woman and to cleanse his hands and her prior to surgery. Afterward, he used a midline incision and applied cautery with a piece of iron roasted in the fire to minimize haemorrhaging. Then, he massaged the uterus to make it contract but did not suture it; the abdominal wound was pinned with iron needles and dressed with a paste prepared from roots. The patient recovered well, and Felkin concluded that this technique was well-developed and had clearly been employed for a long time. Similar reports come from Rwanda, where botanical preparations were also used to anaesthetize the patient and promote wound healing (US-NIH, 2009).
Likewise, it is on record that one Dr. James Barry, a European doctor who was a Military Surgeon carried out the first successful Caesarean section in Africa in Cape Town, while posted there between 1817 and 1828 (www.newscientist.com – accessed 2018).
Mr. Vice Chancellor, Sir, Caesarean section is now frequently regarded as part of a normal birthing process. Consequently, Caesarean section rates have been increasing progressively worldwide (Bragg et al, 2010), with a wide variability amongst various countries and regions (Althabe et al, 2006). Thus, with this global trend, the need for anaesthesia is also increasing along with great challenges (Fyneface-Ogan, 2012).
Before the year 2000, 80 – 90% of the Caesarean sections in the sub-Saharan Africa were frequently performed under general anaesthesia. Equivalently, at the University of Port Harcourt Teaching Hospital, the finding was not different. It is a universal knowledge that general anaesthesia for Caesarean section is frequently associated with airway manipulation, pulmonary aspiration, awareness, poor maternal bonding, deep venous thrombosis, delayed hospital discharge and neonatal depression. A review of Anaesthesia for Caesarean section carried out showed that …% of the surgeries were performed under general anaesthesia while regional anaesthesia constituted ….% (Fyneface-Ogan, Mato ; Odagme, 2005). However, the use of general anaesthesia has fallen dramatically in the past few decades following the numerous untoward effects on both mother and the newborn.
To that end, the upsurge in the use of regional anaesthesia for Caesarean section opened another frontier of complications, including post-dural puncture headache (PDPH). Meantime, before the twentieth century (1898), the incidence of post?dural puncture headache was 66% (Wulf HF, 1998). Withal this alarmingly high incidence of post?spinal headache was likely attributable to the use of large gauge, medium bevel, cutting spinal needles (17G Barkers Spinal Needle and 18G Crawford spinal Needle). Nevertheless, in 1956, with the introduction of 22G and 24G needles, the incidence was estimated to be 11% (Vandam ; Dripps, 1956).
Today the use of fine gauge pencil?point needles, such as the Whitacre and Sprotte® has produced a greater reduction in the incidence of post?dural puncture headache, which varies with the type of procedure and patients involved. It is related to the size and design of the spinal needle used and the experience of the personnel performing the dural puncture, age and sex of the patient. Comparing the incidence of PDPH using various designs and sizes of spinal needles in women undergoing Caesarean section, our study was able to show that “needle size still matters” even if the needle tips are of different configurations (Fyneface-Ogan, Mato ; Odagme, 2006). More women who had a larger needle size developed more PDPH than those with smaller gauge needles.
Caring and compassion were once often the only “treatment” available to clinicians. Even though over time, advances in medical science have provided new options, often improving outcomes, yet the advancement have inadvertently distanced physicians from their patients. The result is a health care environment in which patients and their families are often excluded from important discussions and left in the dark about how their problems are being managed and how to navigate the overwhelming array of diagnostic and treatment options available to them.
As a matter of necessity, clinicians, in turn, need to relinquish their role as the single, paternalistic authority and train to become more effective coaches or co-players, in other words, how to ask, “What matters to you?” as well as “What is the matter?” In addition, novel patient-centred health information technologies that deliver information in a more timely fashion can help clinicians identify patients who are facing fateful health care decisions and to more efficiently elicit their preferences.
In one study (Mato, Fyneface-Ogan ; Edem, 2007) where hospital workers were interviewed to identify their anaesthetic preferences, it was discovered that most of the staff preferred to remain awake during surgery. The study population opted for regional anaesthesia for fear of dying during general anaesthesia. This preference by patients could pose a great challenge to young anaesthetists who may not be well knowledgeable of the options requested by their patients
Evidence supports the shift in trends of practice towards shared decision-making, where patients are encouraged to express their views and participate in making clinical decisions (Frosch ; Kaplan, 1999). Patients are also becoming more informed about the various options available in anaesthetic care and their participatory role in treatment outcome. Their demand for involvement in such decision-making processes for a particular anaesthetic technique may cause an increased demand in regional anaesthesia for Caesarean section. This could be a reflection of satisfaction for that form of anaesthetic care with a tendency to have the same experience again.
The significance of shared decision-making cannot be downplayed because it can improve the satisfaction outcome in the birthing process. Maternal satisfaction was studied in women undergoing anaesthesia for Caesarean section. Effectually, the outcome of this cross-over study showed that the mothers were more satisfied with being awake (Epidural anaesthesia) than general anaesthesia during the surgery (Fyneface-Ogan, Mato ; Ogunbiyi, 2009). Using a modified 29-item questionnaire developed from the Likert’s scale of satisfaction, the tool showed that maternal satisfaction during childbirth can be influenced by many factors such as mood changes and other psychological make-ups that are not within the control of the caregiver. Factors such as pain control, nausea, and vomiting are however within the control of the team.
Intraoperative events can greatly influence satisfaction scores of patients under anaesthesia. In this study the feeling of sense of control and maintenance of verbal contact with staff (communication) impacted a positive influence on the level of satisfaction in the epidural group. This finding seems to correlate with that of other workers in which women showed satisfaction with the ability to make some input in their management during the delivery process and also, afforded them an earlier contact with their newborn (Green & Baston, 2003; De Andres et al, 1995).
Safe and timely administration of anaesthesia for Caesarean section is key in reducing the morbidity and mortality of both the parturient and child. Although the risk factors contributing to maternal mortality from anaesthesia in low-income and middle-income countries and the burden of the problem are still obscure, difficult airway management during general anaesthesia, inadequate supervision of trainee anaesthetists and a lack of appropriate monitors have been demonstrated in one study as the major anaesthetic reasons for maternal mortality (Enohumah & Imarengiaye, 2006).
However, a delay in the interval between decision and operative delivery could have adverse effects on both mother and child. Although the decision-to-delivery interval (DDI) of 30 minutes for emergency Caesarean sections (CS) has been widely recommended, there is little evidence to support it. In the sub-Saharan Africa, the delay in operative delivery could be multifactorial. In a one-year prospective audit one study (Fyneface-Ogan, Mato & Enyindah, 2009) at the University of Port Harcourt Teaching Hospital, the DDI was evaluated in 200 consecutive women who had emergency caesarean section. Out of the number recruited, 71.5% had received antenatal care. The mean maternal age was 27.5±4.54 years and mean parity was 1.95± 1.61. The mean transit time during transfer of patient from labour ward to theatre was 47±3.81 seconds over a distance of 48.16 metres. The mean DDI was 4.2±0.7hours. Reasons for the delay included busy theatre suites, need for counselling from spiritual leaders, unwillingness to sign consent for surgery (waiting for spouse to be available to sign consent for surgery), and delayed laboratory results in 36%, 24%, 13% and 11% women respectively (Table 4). The study concluded that the intrinsic socio-econo-cultural and religious inclinations of the parturients can influence the DDI. A prolonged DDI could negatively impact on APGAR scores of babies, an indication of the state of health of the newborn baby and an important measure of our perinatal morbidity and mortality index, and may contribute to maternal mortality.
Any anaesthetic technique, either regional or general, has potential for complications. Moreover, it has been seen that in obstetric patients, the complications are potentiated due to pregnancy-related changes in physiology and due to various other factors. Increasing trend of Caesarean section in the setting of increasing maternal age, obesity and other concomitant diseases will continue to challenge the attending anaesthetist in the task of providing safe regional and general anaesthesia.
One of such complications following regional anaesthesia is hypotension. Hypotension following neuraxial blockade is due to sympathetic inhibition, which causes a significant decrease in the venous return due to dilatation of the resistance and capacitance vessels (Baron & Decaux-Jacolot, 1986). This complication, if untreated before the delivery could lead to severe morbidity and mortality of either mother or child or both. Some of the methods of preventing hypotension during anaesthesia for Caesarean section include the administration of vasopressors, appropriate positioning of the parturient and a rapid administration of intravenous fluids. The administration of vasopressors appears to be mainstay in the treatment of hypotension. We compared the prophylactic infusion of two vasopressors – phenylephrine and ephedrine during combined spinal epidural for Caesarean section at the UPTH. The study showed that ephedrine and ?-adrenergic agonists (phenylephrine) appear to be equally efficacious in the treatment outcome (Odagme, Fyneface-Ogan & Mato, 2013).
By influencing spread of local anaesthetic, maternal position may affect the speed of onset of sensory block and thus the haemodynamic effects. We studied if the influence of maternal position on spread of plain bupivacaine during spinal anaesthesia for caesarean section using plain bupivacaine in the lateral position would result in less hypotension compared with the sitting position (Obasuyi BI, Fyneface-Ogan S & Mato CN, 2013). The result showed that although the onset of hypotension was similar between groups, the lowest recorded mean arterial pressure was greater in those in lateral position (72.9±11.2 mmHg) than in sitting group (68.2±9.6 mmHg; P=0.025). The incidence of hypotension was also lower in patients in the lateral position (17/50, 34%) than those in the sitting position (28/50, 56%; P=0.027).
Cardiopulmonary arrest in pregnancy is rare occurring in 1 in 30,000 pregnancies (Datner & Promes, 2006). When it does occur, it is important for a Physician Care giver to be familiar with the features peculiar to the pregnant state. Knowledge of the anatomic and physiologic changes of pregnancy is helpful in the treatment and diagnosis. Although the main focus should be on the mother, it should not be forgotten that there is another potential life at stake. Resuscitation of the mother is performed in the same manner as in any other patient, except for a few minor adjustments because of the changes of pregnancy. The specialties of obstetrics and neonatology should be involved early in the process to ensure appropriate treatment of both mother and the newborn.
There are many causes of cardiac arrest in the general population; pregnancy increases the risks to both the mother and the foetus. Changes in maternal anatomy and physiology during pregnancy can affect both the incidence of certain diseases as well as the mother’s ability to adapt to illness (Morrison, 2006). Trauma, pulmonary embolism; haemorrhage, hypertension, and infection are the leading causes of maternal death in pregnancy.
We sought to carry out an interview schedule to assess the knowledge of cardiopulmonary resuscitation amongst Physician care givers in all the major hospitals in South-south Nigeria (Fyneface-Ogan ; Mato, 2011). The result of the study showed that the only 3% of the study population is knowledgeable in resuscitation skills. Only about 1.5% of the Physicians have received some training in cardiopulmonary resuscitation of the pregnant woman. It is a shocking revelation of the unpreparedness of the Physician Care-giver when confronted with this challenge.
With medical care becoming more accessible, many parturients with intercurrent diseases are now beginning to seek intervention. According to Wikipedia, an intercurrent (or concurrent, concomitant or, in most cases, pre-existing) disease in pregnancy is a disease that is not directly caused by the pregnancy (in contrast to a complication of pregnancy), but which may become worse or be a potential risk to the pregnancy (such as causing pregnancy complications).
In such circumstances, women who wish to continue with a pregnancy require extra medical care, often from an interdisciplinary team. Such a team might include (besides an obstetrician) a specialist in the disorder and other practitioners (for example, Obstetric Anaesthetists, Neonatologists, Physicians etc.).
Thyroid disease in pregnancy can, if uncorrected, cause adverse effects on foetal and maternal well-being. The deleterious effects of thyroid dysfunction can also extend beyond pregnancy and delivery to affect neuro-intellectual development in the early life of the child. Demand for thyroid hormones is increased during pregnancy which may cause a previously unnoticed thyroid disorder to worsen (Spencer et al, 2015). The most effective way of screening for thyroid dysfunction is not known. The review by Spencer et al, found that more women were diagnosed with thyroid dysfunction when all pregnant women were tested instead of just testing those at ‘high-risk’ of thyroid problems (those with family history, signs or symptoms). Finding more women with thyroid dysfunction meant that the women could have treatment and management through their pregnancies.
It is a well-known fact that any hyperthyroid patient should be rendered euthyroid before elective surgery. But Anaesthesiologists can encounter inadequately treated patients during emergency situation, for example emergency caesarean section. Such patients have hypermetabolic and hyperdynamic states which need to be optimized as far as possible with intravenous beta blockers and antithyroid drugs. We reported a similar clinical scenario (Fyneface-Ogan S, Fiebai P ; Obasuyi BI, 2011). The parturient was delivered by Caesarean section under spinal anaesthesia in the face of hyperdynamic circulation leading to high output cardiac failure, cardiac dysrhythmias and the difficult airway associated with huge goitre.
In a pregnant patient presenting with goitre, airway can be difficult because of accompanying pregnancy induced changes like generalized weight gain, increase in breast size, respiratory mucosal oedema and increased risk of pulmonary aspiration. Haemodynamic responses to laryngoscopy and intubation can be exaggerated and detrimental. Inadequate depth during general anaesthesia can lead to hypertensive crisis and dysrhythmias which can cause considerable morbidity.
As reported in our patient, regional anaesthesia is preferred for Caesarean section since it is easier and safer in such patients. It also avoids manipulation of a potential difficult airway and cardiovascular problems due to inadequate depth.
With increase in westernized habits, cardiac diseases in pregnancy are on upward trend. His disease condition poses a great challenge to the attending anaesthetist. It is important to understand that even in normal parturients; pregnancy imposes some dramatic physiologic changes upon the cardiovascular system. These include an increase in plasma volume by 50%, an increase in resting pulse by 17%, and an increase in cardiac output by 50%. After delivery, the heart rate normalizes within 10 days; by 3 months postpartum, stroke volume, cardiac output, and systemic vascular resistance return to the pre-pregnancy state.
The Cardiac Disease in Pregnancy (CARPREG) Risk Score (Table ) can be calculated to estimate a woman’s cardiac risk during pregnancy (Siu et al, 2001). One point is assigned for each of the following risk factors: a history of cardiac event or arrhythmia, New York Heart Association functional class greater than II or cyanosis, left-heart obstruction (mitral valve area <2 cm2, aortic valve area <1.5 cm2, or left ventricular outflow tract gradient >30 mmHg), and left ventricular ejection fraction (LVEF) < 0.40. Zero points confers a 5% risk of cardiac complications, 1 point a 27% risk, and 2 or more points a 75% risk
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The University of Port Harcourt Teaching Hospital is beginning to attend to these high risk patients undergoing anaesthesia for Caesarean section. One of these cases that posed a great challenge to attending anaesthetist was a 24-year old booked primigravida, with rheumatic heart disease in heart failure and lobar pneumonia who presented in active labour. The patient was immediately prepared for an emergency caesarean section under epidural anaesthesia (Mato CN, Fyneface-Ogan S & Aggo AT, 2003). The patient was co-managed with the Cardiovascular and respiratory Physicians until she was discharged home. The management of such patient highlights the importance of proper follow up and treatment and, the need to perform more epidural techniques to meet the ever increasing challenges to the Anaesthetist.
Myasthenia gravis is a complex autoimmune disorder. It causes antibodies to destroy the connections between your muscles and nerves. Myasthenia gravis may be of special concern during pregnancy especially as its effect varies immensely among parturients and in between pregnancies in the same woman. More women with this autoimmune disease are now presenting for treatment. The challenges in the management of the disease during pregnancy are enormous especially to the anaesthetist. One case (Fyneface-Ogan & Alagbe-Briggs, 2013) highlighted the need for the anaesthetist to be knowledgeable in the management of this disease. The patient did not have routine antenatal care but presented for an emergency caesarean section. In general, myasthenia gravis does not have any adverse effects on pregnancy (Ferrero et al, 2008). However, during labour assistance might be required in the second stage with the help of forceps or vacuum extraction, as striated muscles are involved during this stage and these muscles can be affected by the acetylcholine (Ach) receptor antibodies. Caesarean section should be performed exclusively for obstetric indications, as surgery can be stressful for women with MG (Berlit et al, 2012). General anaesthesia should be avoided as neuromuscular drugs and narcotics can potentiate ACh receptor antibodies’ effects on the neuromuscular junction. Regional anaesthesia is advocated for Caesarean section in these women.
Maternal deaths in developing countries like Nigeria are still very high (3rd in ranking) and this could be due to many factors. It is well known that maternal mortality rate in Nigeria is 814/100,000 live births. Among the several causes of maternal death in sub-Saharan Africa is Eclampsia. One study (Uzoigwe ; John, 2004) showed that the high mortality was common among the unregistered primigravidas who usually present late with pre-eclampsia/eclampsia. The study showed that there were 45 maternal deaths; 40 (88.9%) among the unregistered and 5 (11%) among the registered mothers constituting a maternal mortality ratio of 23, 121.4 and 339.7 per 100,000 deliveries respectively. The combined mortality ratio was 2735.6 per 100, 000 deliveries. Fifteen (37.5%) unregistered primigravida died of severe pre-eclampsia/eclampsia. A total 1645 mothers delivered, 1472 (89.5%) were registered while 173 (10.5%) were unregistered with the hospital.
Preeclampsia/eclampsia has been described centuries ago despite lack of complete understanding of its pathophysiology. Around 400 BC, Hippocrates described that headache, convulsion and drowsiness are ominous signs associated with some pregnancies. Ancient civilizations of China, Egypt and India have all recognized and described the disease well.
However, management of the eclamptic patient requires a multidisciplinary approach involving the obstetrician, anaesthetist, intensivist, physician, paediatrician and the nurses. Anaesthesia for eclamptic undergoing caesarean section is one of the anaesthetist’s nightmares. These patients have multiple systemic challenges including the cardiovascular and respiratory systems. Following a poor maternal and perinatal outcome, we (Fyneface-Ogan & Uzoigwe, 2008) compared the use of infiltrative anaesthesia with general anaesthesia in 76 eclamptic patients undergoing caesarean section. The outcome of the study showed that twenty-one (60.0%) in gLA had mean Apgar scores of 8 compared to 10 (27.0%) in the gGA. The duration of hospital stay was longer in the gGA (17.1±4.1 days) than the gLA (13.0±1.6 days) with a statistically significant difference (p<0.0001). There were 5 (12.5%) maternal deaths in the gGA and 2 (5.0%) in the gLA. Intraoperatively, the mean arterial pressure and mean systolic pressure at skin incision were consistently and significantly higher in the gGA group than in gLA group. It was concluded therefore, that local infiltrative anaesthesia appears to have a better maternal and perinatal outcome than general anaesthesia for eclamptic patients undergoing caesarean section. This protocol has since been adopted and in use for the management of eclamptics with a better outcome.
Normal pregnancy is often associated with a progressive increase in circulating CRH and ACTH and in the third trimester also in free cortisol levels. A recent longitudinal study in 20 healthy pregnant women demonstrated a gradual increase in total plasma cortisol, corticosteroid-binding globulin (CBG) and 24-h urinary free cortisol, with circulating levels peaking during the third trimester to levels threefold higher than those in non-pregnant controls (Jung et al, 2011). The increase in total plasma cortisol concentration is primarily due to the oestrogen-stimulated increase in CBG concentrations, whereas the mechanisms underlying the rise in free cortisol during the later stages of pregnancy are less well understood. This increase may reflect alterations in the set point of the hypothalamic–pituitary–adrenal axis during pregnancy or an anti-glucocorticoid effect exerted by the increasing progesterone levels, which have been shown to correlate with increases in salivary cortisol (Allolio et al, 1990).
Cortisol is released in response to fear or stress by the adrenal glands as part of the fight-or-flight mechanism. Pregnancy and childbirth are stressful. The stress of painful labour could cause further elevation of cortisol level and could increase the risk for depression (post-delivery stress disorder), elevation of blood pressure, interference with memory, potentially trigger for mental illness and decreased resilience.
Pain of childbirth being a complex stimulus known to trigger and enhance adaptive responses in both mother and foetus, we sought to determine whether, or not, alleviation of pain with single-shot spinal analgesia has an influence on cortisol levels during the birthing process in 40 parturients (Fyneface-Ogan, John & Enyindah, 2013). While one group of labouring women had sedo-analgesia (intravenous pentazocine 30 mg with promethazine 25 mg), the other group received intrathecal bupivacaine 2.5 mg with fentanyl 25 mcg. The maternal cortisol levels were measured before and after administration of analgesia at intervals during labour and in the postpartum period.
The study showed that while there was no difference in the baseline cortisol levels (SA – 338.05±8.24 ng/dl and SSA – 340.14±6.29 ng/dl), p=0.124. At the 1st hour of labour, the cortisol level in the SA group showed a steep rise compared to the SSA group, (p=0.0001). The difference in the cortisol levels at 2nd and 3rd hours between the groups was statistically significant (P=0.0001). Following delivery, both groups showed stepwise fall in cortisol levels. The differences in the levels remained statistically significant (p=0.0001) until the 18th hour after onset of labour. It was concluded that single shot spinal analgesia provided a short duration but profound pain relief with lower maternal cortisol levels during labour and in the immediate postpartum period. Although in a heterogeneous study population, we also compared the differential impact on two anaesthetic techniques on cortisol levels in Nigerian surgical patients. The study (Aggo, Fyneface-Ogan & Mato, 2012) highlighted the complexity of stress response characterised by neurohumoral, immunologic and metabolic alterations following surgical procedures. Results of their findings showed that the baseline mean plasma cortisol level was 88.70 ± 3.85 ng/ml for group A and 85.55 ± 2.29 ng/ml for group B, P=0.148. At 30 minutes after the start of surgery the plasma cortisol level in the GA group was 361.60 ± 31.27 ng/ml while it was 147.45 ± 22.36 ng/ml in the EA group, showing a significant difference, P=0.001. At skin closure the mean plasma cortisol value of 384.65 ± 48.04 ng/ml recorded in the GA group was found to be significantly higher than the value of 140.20 ± 10.74 ng/ml in the GA group, P<0.002. With a conclusion that using plasma cortisol as a measure, bupivacaine-based epidural anaesthesia significantly reduces the stress response to surgical stimuli when compared with isoflurane-based tracheal general anaesthesia. This finding and that of a previous study (Fyneface-Ogan, John & Enyindah, 2013) show that neuraxial blocks in general, reduce the stress response to painful stimulus.
Childbirth is now well recognized as the most painful experience ever known to women of child bearing age and, regional anaesthesia/analgesia is considered the optimal technique for obstetric patients; nevertheless, the optimal method of regional anaesthesia for delivery remains to be determined. However, very many different potent agents injected into the subarachnoid space have been used to produce profound analgesia in obstetrics. A study aimed at finding the efficacy and safety of the single shot spinal analgesia for pain relief in labour was conducted by some workers (Adeyemi, Vernon & Medge, 2009) which was further corroborated by another group of workers (Otokwala, Fyneface-Ogan & Mato, 2013) in which the effects of single shot low dose spinal bupivacaine only and bupivacaine with fentanyl on labour outcome was demonstrated.
In their study of one hundred and twelve parturients in labour Otokwala et al randomized the parturients into two groups of 55 parturients each. While one group received 2.5 mg of spinal plain bupivacaine only the other had 2.5 mg plain bupivacaine with 25 mcg of fentanyl. The numeric rating pain scores for groups B and BF were significantly reduced from a mean pre-spinal score of 8.17 +/- 0.96 cm and 8.30 +/- 0.23 cm respectively to a mean post-spinal pain score of 0.23 +/- 0.45 cm and 0.09 +/- 0.47 cm respectively, p = 0.000. The mean duration of analgesia in Group B was 61.60 +/- 6.47 mins while it was 128.98 +/- 21.61 mins in Group BF, p = 0.000. The study showed that low dose spinal bupivacaine either alone or in combination with fentanyl is safe for labour analgesia, but the combination of bupivacaine with fentanyl provided much more prolonged pain relief
In a similar prospective, randomized, and controlled study (Fyneface-Ogan, Otokwala & Enyindah, 2012), we evaluated the efficacy of single shot intrathecal bupivacaine with dexmedetomidine and bupivacaine with fentanyl on labour outcome.
Ninety labouring multiparous women were studied and made to receive single shot intrathecal bupivacaine alone (B), bupivacaine with fentanyl (BF), or bupivacaine with dexmedetomidine (BD). Sensory and motor block characteristics; time from injection to two dermatome sensory regression, sensory regression to S1 dermatome, and motor block regression to Bromage 1 were recorded. Labour pain was assessed with a 10 cm verbal pain scale. Peak sensory block levels in the three groups were essentially the same (p=0.56). The time for sensory and motor blocks to reach T10 dermatome and Bromage 1, respectively, was faster in group BD than in the other groups (p-0.0001). The time for sensory regression to S1 was significantly prolonged in the group BD (p=0.0001). Motor block regression time to Bromage 1 was also prolonged in the group BD (p=0.0001). Neonatal outcome was normal in all groups. The study showed that single shot intrathecal bupivacaine/dexmedetomidine significantly prolonged sensory block in labouring women.
The effective relief of pain is of the utmost importance to physician treating patients undergoing surgery. Pain relief has significant physiological benefits; hence, monitoring of pain relief is increasingly becoming an important postoperative quality measure. The goal for postoperative pain management is to reduce or eliminate pain and discomfort with a minimum of side effects. Various agents (opioid vs. non-opioid), routes (oral, intravenous, neuraxial, regional) and modes (patient controlled vs. “as needed”) for the treatment of postoperative pain exist. Although traditionally the mainstay of postoperative analgesia is opioid based, increasingly more evidence exists to support a multimodal approach with the intent to reduce opioid side effects (such as nausea and ileus) and improve pain scores.
However, analgesia administered before the painful stimulus occurs may prevent or substantially reduce subsequent pain or analgesic requirements. This hypothesis has prompted numerous clinical studies, but few robust studies have clearly demonstrated its efficacy. Pre-emptive analgesia is a treatment that is initiated before and is operational during the surgical procedure in order to reduce the physiological consequences of nociceptive transmission provoked by that procedure. Owing to this ‘protective’ effect on the nociceptive pathways, preemptive analgesia has the potential to be more effective than a similar analgesic treatment initiated after surgery. Consequently, immediate postoperative pain may be reduced and the development of chronic pain may be prevented.
Effective pre-emptive analgesic techniques use multiple pharmacological agents to reduce nociceptor activation by blocking or decreasing receptor activation, and inhibiting the production or activity of pain neurotransmitters. Pre-emptive analgesia can be administered via local wound infiltration, epidural or systemic administration prior to surgical incision. A meta-analysis of randomized trials reported patients receiving pre-emptive local anaesthetic wound infiltration and nonsteroidal anti-inflammatory administration experience a decrease in analgesic consumption, but no decrease in postoperative pain scores. Pre-emptive epidural analgesia did show a decrease in pain scores as well as analgesic consumption (Ong et al, 2005). Pre-emptive local anaesthetic injection around small laparoscopic port incision sites was not effective in terms of managing postoperative visceral pain (Leung et al, 2000). Overall, pre-emptive analgesia may offer some short-term benefits, particularly in ambulatory surgery patients.
However, inadequate pain relief following a Caesarean delivery may impair the mother’s ability to optimally care for her infant in the immediate postpartum period and adversely affect early interactions between mother and infant. Pain and anxiety may also reduce the ability of a mother to breast-feed effectively. It is necessary that pain relief be safe and effective, that it does not interfere with the mother’s ability to move around and care for her infant, and that it results in no adverse neonatal effects in breast-feeding women.
Although there are varied opinions on the role of ketamine as an agent for pre-emptive analgesia, some workers (Kwok et al, 2004) confirm the pre-emptive effect of ketamine, others claim that it only delays time to request for supplemental analgesic (Oliveira et al, 2004). In one study (Ebong, Mato & Fyneface-Ogan, 2011) we evaluated the effect of low dose intravenous ketamine as a pre-emptive analgesic in patients undergoing Caesarean section under spinal anaesthesia. This prospective, randomised, double blind, placebo-controlled study showed that the time for first analgesia request (time from institution of subarachnoid block to when patient requests for pain relief) in the ketamine group had a significantly more prolonged mean analgesia request time of 193.44±26.53 mins while than the non-ketamine group – 140.14±22.34 mins. The difference in the mean analgesia request time was statistically significant, p=0.0001. The study showed that the pre-incisional administration of low dose intravenous ketamine delayed the time to first analgesic request in women who had Caesarean section under bupivacaine/fentanyl spinal anaesthesia. However, the study could not substantially demonstrate the pre-emptive analgesic property of ketamine. The failure of this study to show the desired effect of ketamine has increased the on-going controversy regarding the concept of pre-emptive analgesia thought to be exhibited by ketamine.
Continuous spinal anaesthesia (CSA) is an underutilized technique in modern anaesthesia practice. Compared with other techniques of neuraxial anaesthesia, CSA allows incremental dosing of an intrathecal local anaesthetic for an indefinite duration, whereas traditional single-shot spinal anaesthesia usually involves larger doses, a finite, unpredictable duration, and greater potential for detrimental haemodynamic effects including hypotension, and epidural anaesthesia via a catheter may produce lesser motor block and suboptimal anaesthesia in sacral nerve root distributions. After case reports of cauda equina syndrome were reported with the use of spinal microcatheters for CSA, these microcatheters were withdrawn from clinical practice in the United States but continued to be used in Europe with no further neurologic sequelae.
The main advantages of CSA over epidural anaesthesia and single shot spinal anaesthesia are its easier technique and the possibility of providing an adequate level and duration of anaesthesia with small intermittent doses of local anaesthetic, which also minimizes the risks of cardiovascular and respiratory disturbances. These qualities are of special value for lower abdominal and lower limb surgery in elderly and high-risk patients; they constitute the primary indication for CSA.
In one prospective study (Fyneface-Ogan & Job, 2013), we demonstrated the usefulness of this technique of regional anaesthesia in 30 women undergoing repeat caesarean sections. In the study we determined the difference between priming and non-priming of the Wik-Wire extension set with local anaesthetic on the induction-incision interval. The outcome showed that the primed Wik-wire extension set had a shorter induction-incision interval, hence reducing the induction-delivery interval following the use of continuous spinal anaesthesia for repeat Caesarean section. Continuous spinal anaesthesia has been shown to be a useful technique of anaesthesia for high-risk parturients especially those with cardiomyopathy coexisting with pregnancy scheduled for caesarean section. Parturients with peripartum cardiomyopathy present with the typical signs and symptoms of left ventricular failure. The majority of cases occur after delivery and the immediate postpartum period. However, when the disease develops during the last month of pregnancy the diagnosis of cardiac failure is difficult to make by signs and symptoms alone since some of those symptoms, such as fatigue, orthopnoea, and pedal oedema, are common among normal parturients during late pregnancy.
Parturients with peripartum cardiomyopathy require special anaesthetic care during labour and delivery. Invasive monitoring, including an arterial line and pulmonary artery catheter, should be utilized to assess the patient’s haemodynamic status and guide management. The cardiovascular stress of labour and delivery may lead to cardiac decompensation. When that situation occurs, the anaesthesiologist may need to administer vasoactive agents, such as nitroglycerin or nitroprusside for preload and afterload reduction and dopamine, dobutamine or milrinone for inotropic support. Data from the pulmonary artery catheter is essential to determine the appropriate pharmacologic therapy for each patient.
Early administration of labour analgesia to minimize further cardiac stress associated with pain is paramount in the anaesthetic management of these patients. Various analgesic techniques provide unique advantages in the haemodynamic management of the parturient while also providing excellent analgesia. A continuous spinal catheter technique permits intermittent intrathecal opioid injection for analgesia throughout the first stage of labour. Supplementation with a small dose of intrathecal local anaesthetic is sometimes needed to provide adequate analgesia for the second stage of labour and delivery. A significant advantage of this technique is that haemodynamic stability is more easily achieved because a local anaesthetic-induced sympathectomy is avoided for the majority or all of the labour process.
A case of peripartum cardiomyopathy that was successfully managed with a continuous spinal anaesthesia for Caesarean section was reported (Fyneface-Ogan ; Ojule, 2014). In that report, a 27-year-old Nigerian woman that presented at 31 weeks’ gestation with no previous history of hypertension heart disease, but super morbidly obese (body mass index of 42 kg/m2), with uncontrolled hypertension, severe pulmonary oedema who required an urgent Caesarean section. The patient was stabilized in the hospital’s Intensive Care Unit. She was placed on oxygen by non-rebreathing facemask while receiving intravenous labetalol and frusemide. Following a worsening clinical state, an urgent Caesarean section was conducted under continuous spinal anaesthesia using 7.5 mg intrathecal 0.5% isobaric bupivacaine and was delivered of a 1.8 Kg live female baby with good Apgar scores. The patient’s haemodynamic status was carefully monitored and fluid management guided by data from the non-invasive monitors while the anaesthetic level was slowly increased At the end of the surgery, mother and baby were transferred to the ICU and SCBU respectively. After a 7-day intensive treatment, she was discharged home.
This case report illustrated the recognition of peripartum cardiomyopathy and the use of a more haemodynamic stable anaesthetic technique. It also described the need for collaboration with multiple medical specialists before, during delivery and after delivery to provide the best possible outcome for both mother and infant.
From time to time, the anaesthetist is met with some unavoidable nightmares. These nightmares challenge his competency in terms of skill and adequate knowledge of his basic anatomy, physiology and anaesthetic skills. One of these challenges is administering anaesthesia on an achodroplastic parturient. Anaesthetic management in dwarfism is challenging, for it is often complicated by conditions such as deformed spine, limited neck mobility, and narrowed pharynx, leading to high-risk in both general anaesthesia and regional anaesthesia. However, a …..year old dwarf was successfully managed for anaesthesia for emergency Caesarean section (Otokwala & Fyneface-Ogan, 2018).
However, it may be technically difficult to perform regional anaesthesia in the patients with significant physical abnormalities, such as severe lumber lordosis, spinal deformity, and potential cord compression. In addition, the risk of intrathecal anaesthesia for pregnant patients with dwarfism is high due to a lack of X-ray examination, which is not usually indicated for pregnant patients. The patient in this index case was successfully managed with a low volume (dose) single shot spinal anaesthesia. Both mother and child were released home on the 7th day postoperative.
Administering anaesthesia to paediatric patients can always be herculean, especially for the non-paediatric anaesthetist. Some clinical states, their anatomic features and non-operating room settings can make these cases even more herculean, even for the most skilled paediatric anaesthetist (Mato, Fyneface-Ogan & Aggo, 2017).
Paediatric patients undergoing surgery are required to undergo some period of fasting. Preoperative fasting is defined as a prescribed period before a procedure when patients are not allowed the oral intake of liquids or solids. The purpose of fasting guidelines are to enhance the quality and efficiency of anaesthesia care, stimulate evaluation of clinical practices, and reduce the severity of complications related to perioperative pulmonary aspiration of gastric contents (Ljungqvist & Søreide, 2003). Children, like adults, are required to fast before anaesthesia.
Many professional societies have issued their guidelines on preoperative fasting. The American Society of Anesthesiologists (ASA) (1999), Association of Paediatric Anaesthetists of Great Britain and Ireland (APAGBI) (2003), Royal College of Nursing (RCN) (2005) and European Society of Anaesthesia (ESA) (2005) have all recommended preoperative fasting of 2 h for clear fluids, 4 h for breast milk and 6 h for solids, nonhuman and formula milk in children (2-4-6 rule).
Clinical practice however is usually slow to change. We conducted a 6-month closed audit in two medical facilities to determine the length of preoperative fasting on 109 elective paediatric surgical patients and the cause for non-adherence to standard guidelines (Fyneface-Ogan, Aggo & Otokwala, 2011). Surprisingly all the children had their last meal by 22.00 hrs the day before the scheduled surgery. We found that the children were fasted much more (mean duration of fasting 14.7±0.8 hrs (range 12 – 20 hrs)) than the recommended period (3-6hrs). The children were overzealously fasted and appeared dehydrated before the scheduled surgery from lack of clear preoperative fasting guidelines.
Paediatric postoperative pain management has developed rapidly accompanying the development of new drugs. However, children have remained undertreated for postoperative pain because of the difficulty of pain assessment, apprehension regarding cardiorespiratory depression, etc.
Anaesthesia and operative fields are unfamiliar and unpleasant environments for children. In addition, separation from caregivers, hunger, fear of strange places, and perioperative pain can cause stress and result in indistinct behavioural and physiological changes. Although pain is often regarded as an inevitable consequence of operative procedures, its control is important to improve both clinical outcome and patient comfort. Postoperative pain in children who had surgery is frequently under-treated. One large scale survey reported that 40% of paediatric surgical patients experienced moderate or severe postoperative pain and that 75% had insufficient analgesia (Alönnqvist & Morton, 2005).
One of the multimodal approaches of pain management is the use of local infiltration of the wound edges (Kehlet & Holte, 2001). Local infiltration of surgical wounds with either lignocaine or bupivacaine will provide analgesia for a few hours postoperatively. The toxic dose for each drug (3 mg/kg for lignocaine, 2 mg/kg for bupivacaine or ropivacaine) should not be exceeded. This is very useful for abdominal surgery and herniotomies.
However, there is a substantial body of literature suggesting that LA infiltration can have deleterious effects on wound healing. These reports are spread across a wide range of literature, including surgical, anaesthetic, ophthalmologic, pharmacologic, and cellular biochemistry and are often not appreciated in total. Problems with wound healing are dif?cult to assess in human studies: tensile strength is not easily measured by non-destructive methods, and long-term follow-up required to assess late sequelae, such as incisional hernias, is expensive and dif?cult. Although the impression from earlier studies is that “no untoward effects, evident from clinical examination, have been observed on wound healing in any study published”, almost all clinical studies of local in?ltration have reported only general, subjective impressions of wound healing over a limited time–their focus has been the analgesic ef?cacy of wound in?ltration.
Diverse animal models have tested the effect of local infiltration or topical application, on surgical wounds or corneal epithelium, using healing time, tensile strength, collagen synthesis, bone healing, infection, or inflammation as measures. Extrapolation to clinical practice must be made cautiously and confirmed by whole animal and human studies. However, the wound healing following infiltration with lidocaine with epinephrine was studied in 48 children who had herniotomies (Fyneface-Ogan & Gbobo, 2010). In this prospective randomized double-blind study two groups of children were allocated to have either lidocaine plain infiltration or lidocaine with epinephrine wound infiltration at the end of surgery. The result showed that while the mean duration of analgesia in Lidocaine plain group was 68.9 ± 11.8 mins the lidocaine with epinephrine had 89.0 ± 17.4 mins (p=0.01). Wounds healed by primary intention by the 7th postoperative day in both groups. It was therefore, concluded that wound infiltration with lidocaine with or without epinephrine did not impair wound healing in humans.
Pain is perhaps the most feared symptom of disease, which a man is always trying to alleviate and conquer since ages. It is defined by the international association for study of pain as an “unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage (IASP, 1979).
Historically, children have been under treated for pain and for painful procedures because of the wrong notion that they neither, suffer or feel pain, nor responded to or remembered the painful experiences to the same degree that adult did. An unproved safety and efficacy of the analgesics and worries about the risk of opioid induced respiratory depression, added more reasons for the under treatment of pain in children. It has been shown that under treatment of post-operative pain even in the children and newborns may trigger biochemical and physiologic stress response and cause impairments in pulmonary, cardiovascular, neuro endocrinal, gastrointestinal, immunological, and metabolic functions (Rawal et al, 1984). It has been reported that many types of the so called “minor” surgery can cause significant pain in children and that, parents have a number of misconceptions concerning pain treatment (Finley et al, 1996).
The Society of Paediatric Anaesthesia, at its 15th annual meeting at New Orleans, Louisiana (2001) clearly defined the alleviation of pain as a “basic human right”, irrespective of age, medical condition, treatment, primary service response for the patient care or medical institution (Frank, 2002). It has been suggested that the postoperative pain treatment must be included in the anaesthetic planning even before induction of anaesthesia, adopting the idea of ‘managing pain before it occurs’ (Langlade & Kriegel, 1997). It is now well known that acute pain is the pain associated with a brief episode of tissue injury or inflammation, such as that caused by surgery, burns, or trauma. In most of such cases, the intensity of pain diminishes steadily over a period of time. Following this, post-operative pain management is now an integral part of practice of paediatric anaesthesia in all major hospitals (Fyneface-Ogan, 2014).
Various postoperative pain treatment modalities have been advocated in children. The aim is to make the intensity of the postoperative pain in children to kept at the most tolerable level. In our study, the duration of postoperative analgesia and possible adverse effects produced by caudal bupivacaine 0.25% at 1 ml/kg with or without 1.5 µg/kg of neostigmine in children undergoing unilateral herniotomy was compared (Tobin, Fyneface-Ogan & Mato, 2014).
In this study, 66 children aged 1-6 years, of American Society of Anaesthesiologists physical status classes I or II for elective unilateral herniotomy under general anaesthesia without premedication were compared. The patients were randomly allocated into two groups of 33 each. One group received caudal analgesia with plain bupivacaine 0.25% at 1 ml/kg alone, while the other group received caudal analgesia using a mixture of plain bupivacaine 0.25% at 1 ml/kg and neostigmine 1.5 µg/Kg. Postoperatively, monitoring of pain scores and time to first analgesic request and, total dose of analgesics administered in both within the first 24 hours were recorded.
The result of the study showed that all the patients participated throughout the study. There were no differences in the demographic characteristics (age, weight, ASA status) between the two groups. The mean duration of effective analgesia was significantly longer in the bupivacaine/neostigmine group, 460 ± 60.2 min. compared to bupivacaine alone group, 286.4 ± 47.8 mins; (p < 0.001). The analgesic requirements within the first 24 hours postoperatively significantly reduced in bupivacaine/neostigmine group, p < 0.001.
The study therefore showed that the addition of low dose neostigmine to caudal isobaric bupivacaine significantly prolonged the time to first analgesic request and hence significantly reduced postoperative analgesic requirement.
The significance of this study is that children ought to be pain free as much as possible. In addition, children should be made comfortable and less distressed, before, during and after surgery as well as during hospital stay. These measures include presence of parent with the child, nursing in a comfortable environment, allowing the child to adopt most comfortable position and feeding if permissible.
Since the first administered spinal anaesthetic in 19…the use of regional anaesthesia has revolutionized the practice of anaesthesia. The use of this technique makes a specific part of the body numb to relieve pain or allow surgical procedures to be performed. Types of regional anaesthesia include spinal anaesthesia (also called subarachnoid block), epidural anaesthesia, and nerve blocks. Regional anaesthesia is often used for orthopaedic surgery on an extremity (arm, leg, hand, or foot), for female reproductive surgery (gynaecological procedures and Caesarean section) or male reproductive surgery, and for operations on the bladder and urinary tract. Epidural analgesia (pain relief) is commonly used to ease the pain of labour and childbirth but can also be used to provide anaesthesia for other types of surgeries.
However, this form of anaesthesia as compared to general anaesthesia is also associated with some complications. Although spinal anaesthesia is easy and safe, it is not without life-threatening complications. In one study (Jebbin, Fyneface-Ogan & Johnson, 2007) of 98 consecutive elective surgical and gynaecological patients were recruited to study the pattern of complications following spinal anaesthesia. About 47.5% of the patients suffered shivering while about 12.5% had hypotension as a complication. Shivering appeared to be the commonest form of morbidity. A good conduct of subarachnoid block and meticulous monitoring are critical to a good outcome
Surgery and anaesthesia cause shivering due to thermal dysregulation as a compensatory mechanism and is worsened by vasodilatation from spinal anaesthesia that redistributes core body heat. Post spinal shivering is an unpleasant, thoroughly discomforting and frequent complication after surgery with many grades i.e. from a mild form of having skin eruptions to a severe form with generalised continuous skeletal muscle contractions with prevalence of up to 50–80 % 6. Exact causes of post spinal shivering are still unclear though various mechanisms have been postulated with some attributing it to a thermoregulatory response to hypothermia that causes temperature-induced changes of neurons in the mesencephalic reticular formation and dorsolateral pontine and medullary reticular formation 7. This increased muscular activity leads to increased oxygen consumption and carbon dioxide production that results in hypoxaemia, hypercarbia and lactic acidosis which are not only discomforting but also worsens pain sensation 6.
Shivering can be prevented by maintaining intraoperative normothermia, giving warm fluids, using warm clothing covers sites or by administering pharmacologic treatments like tramadol, clonidine and pethidine (meperidine). In one study (Mato, Isa & Fyneface-Ogan, 2002) the antishivering effect of tramadol was compared with that of ketamine, a relatively cheap and easily assessable agent. In this study, 60 surgical patients were randomly assigned to three groups. While one group had a low (sub-anaesthetic) dose, the other groups received tramadol and placebo for the treatment of postspinal shivering. There was no significant difference between the group that received tramadol and ketamine; (p= 0.201 Kruskal Wallis Anova). Both tramadol and ketamine aborted postspinal shivering while shivering continued in those who received placebo. The department of anaesthesia has since been using low dose ketamine to treat postspinal shivering without sedation and hallucination as side effects.
Regional anaesthesia is associated with reduction of blood loss during surgery. This is frequently seen as one of the advantages of using this technique for lower abdominal and limb surgeries. However, there are conflicting reports on the influence of different anaesthetic techniques, such as regional versus general anaesthesia, on intraoperative blood loss. While one study (Shir et al, 1995) concluded that epidural anaesthesia did not reduce bleeding but, rather general anaesthesia increased blood loss during prostatectomy, a study (Fyneface-Ogan & Eke, 2004) we conducted showed a significant reduction in blood loss by % (p=00000) compared to general anaesthesia. Following the finding from our study, most of the lower abdominal and urologic surgeries including transurethral resection of the prostate (TURP) are now performed under regional anaesthesia with good sensorimotor blockade and recovery profile of the patients (Nnaji, Mato & Fyneface-Ogan, 2014; Uwandu, Fyneface-Ogan & Ebirim, 2016) .
This is another form of regional anaesthesia that has gained wide popularity in pain management (labour and childbirth or postoperative pain management), anaesthesia, etc.
Identification of epidural space
The gold standard for pain relief during childbirth is the use of epidural analgesia. However, the location of the epidural space for local anaesthetic injection could be a very challenging one. It is frequently described as one of the anaesthetists’ “nightmare”.
Anatomy of the epidural space
The epidural space is one of the most explored areas of the human body. This exploration demands a good knowledge of the relevant anatomy and contents of the space. First described in 1901 (Corning, 1901), the epidural space is an anatomic compartment between the dural sheath and the spinal canal. In some areas it is a real space and in others only a potential space (Fyneface-Ogan, 2012).
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Methods of locating the epidural space depend on the negative pressure exhibited during the introduction of the epidural needle into the space (e.g., hanging drop, Macintosh balloon, Vygon® Epidural Balloon). The two frequently used methods rely on loss of resistance to injection of saline, local anaesthetic or air as the needle advances through the ligamentum flavum and lodge the epidural space. Each of these techniques has its own benefits and drawbacks. Compared with air, loss of resistance to saline or local anaesthetic has the advantage of providing a more obvious tactile endpoint when the needle is situated within the epidural space. However, because saline is a clear fluid, it may be confused with cerebrospinal fluid and dural puncture may be masked. Large volumes of air or saline may result in inadequate analgesia or patchy block. Large volumes of saline may result in inadequate analgesia because of dilution.
Many methods have been used in the past to correctly identify the epidural space. Recently, we tested a modification of the Macintosh balloon and found it was quicker than traditional LOR (Fyneface-Ogan and Mato, 2008). It consists of a Y-shaped connector attached to the epidural needle with one end having a balloon and the other end attached to a syringe for charging the balloon with air. This technique provides a visual cue on entering EDS and thus provides objective evidence.
Other methods of Various methods such as the use of ultrasound guided technique, epidural space localization with CO2 and compliance, and the dual technique for identification of the epidural space have been tried at different times but with variable application by anaesthetist. It is well known that pressures applied on the plunger of the epidural syringe during space identification could be intermittent or continuous which also depends on the administrator.
The current incidence of inadvertent dural puncture (IDP) during epidural anaesthesia in obstetrics is about 1% with a possible postdural puncture headache. The IDP could be due to inability to correctly identify the end-point of the epidural space localisation. A study (Fyneface-Ogan, 2014) however was designed to find a better and more reliable method of identifying the epidural space. This study describes the sling-shot technique to identify pressure changes in the syringe during puncture of the ligamentum flavum in identifying the epidural space. Knowledge of pressure changes might be of help to the anaesthetist who attempts to ascertain the location of the needle tip using a designed sling-shot epidural syringe.
To design the sling-shot epidural syringe, the length and thickness and to determine force applied to the rubber band at the interface of the intra-epidural negative pressure. The sling-shot syringe is made up of three parts namely; barrel, grooved plunger and a rubber band (see Figs. 1 and 2).
Figure 1: Showing syringe without mounted rubber band Figure 2: Showing pulled plunger without mounted rubber band
The rubber band applies a continuous force on the plunger when the latter is pulled (see Fig. 3 below).
Figure 3: Showing pulled plunger with mounted rubber band Figure 4: Showing proximal end (plunger base) of syringe
While Fig. 4 above shows the distal end of the syringe displaying the grooved plunger into which the rubber band fits, Fig. 5 shows the proximal end or the tip of the syringe
Figure 5: Showing distal end (tip) of syringe
The force applied on the rubber band was determined based on the Hooke’s Law (states that the extension of a spring is directly proportionate to the load applied to it – F= k ?L). Hooke’s Law (below) is classically applied to spring systems. However, it can also, to some extent, describe the stretch patterns observed for rubber bands.
F = Force applied to elastic material
k = spring constant
?L = change in length of the elastic material.
Where, F is the force applied to the rubber band, k is the spring constant and ?L is the change in length of the rubber band. The spring constant is the constant that makes the Hooke’s Law mathematically correct and is usually found by experimentation. So the more the rubber band is stretched the more force it applies to return to equilibrium. So intuitively the farther it is pulled, the farther it would go.
The mass of water needed to pull the rubber from an initial length of 0.075 m to 0.12 m to produce a 5 ml displacement of the syringe plunger is 0.1 kg. Therefore, the difference in ?L from 0.075 to 0.12 m = 0.045m
Mass needed to change length = 0.100 kg
Weight = Mass x acceleration due to gravity = 0.100 x 9.8 = 0.98N
If F = k ?L, then k = F/ ?L
Therefore, 0.98/0.045 = 21.8 N/m
The spring constant (k) of the rubber band = 21.8 N/m
However, the pressure exerted by the plunger is calculated using: Pressure = Force (F) exerted by the plunger/Surface area (A) of the plunger.
A 10-ml Becton Dickinson (BD) plastic syringe has a 1.45 cm-diameter plunger.
For the purpose of this study, the pressure exerted by the rubber band on the plunger is calculated in kilopascal (kPa).
It is important to note that the Atmospheric pressure = 740 torr = 101.3 kPa x (740 torr/760 torr) = 98.6 kPa.
The syringe plunger has an area A =?r2. Where ? = 3.142
A = (3.142) x (1.45/2)2 = 1.60 cm2.
This is an area of 1.60 cm2 x (10-4 m2/cm2) = 1.60 x 10-4 m2
The acceleration due to gravity is 9.8 m/s2. Multiplying the mass (needed to cause a change in 0.045 m length of the rubber band) by the acceleration due to gravity gives the force (in newton).
F exerted by rubber band = (9.8 m/s2) x (0.10 kg) = 0.98 N
Dividing the force by the area of the plunger face gives the pressure in Pascal.
Pressure (P) = (Force (F) exerted by rubber band/Area
(A) of plunger) = (0.98 N/1.60 x 10-4 m2) = 0.61 x 104 Pa or 6.1KPa or 45.75 mmHg
It is worthy of note that the pressure exerted on the plunger in the sling-shot plastic syringe (Becton Dickinson (BD)) described in this study was generated by the rubber band. Although the resistive (frictional) force was not determined, it has been shown in one study that a 10-ml BD syringe has a mean static (fs) force of 2.22 X 10(-3) +/- 0.48 X 10(-3) N and a mean dynamic force (fd) = 1.46 X 10(-3) +/- 0.37 X 10(-3) N; a value higher than that of a 10-ml glass syringe. It is concluded that glass syringes are favoured over plastic for locating the epidural space because frictional forces developed with glass syringes were significantly lower than with plastic.
Table: Characteristics of epidural space localisation
Number (%) Mean ± SD
Attempts at insertion
1 28 (93.3)
>1 2 (6.7)
Duration to reach end point (secs) 17.3 (2.5)
Accidental dural puncture –
Ease of passage of catheter
Difficult 1 (3.3)
Easy 29 (96.7)
The study showed that the duration to reach the end point of correct space identification was 17.3 seconds. The passage of epidural catheter into the epidural space was easy in 29 out of 30 patients recruited into the study. It confirms that the sling-shot epidural syringe is a very valuable tool in the hands of the anaesthetist and further reduces the challenges fraught with the identification of the space.
With the increasing use of epidural techniques in the treatment of pain, the need for a more efficient technique in identifying the epidural space correctly cannot be overemphasized. The sling-shot epidural syringe provides a one-stop method of correctly identifying the epidural space. Although this study adds to the current knowledge on methods of epidural space identification, further studies may be needed. However this study has shown that the sling-shot syringe has great potential in facilitating the identification of the epidural space. The use of fluid (saline or local anaesthetic agent) could still produce the same effect with air. Again this still needs further evaluation.
Difficult Airway versus difficult tracheal intubation
One of the anaesthetist’s nightmares is being confronted with the challenge of establishing a patent airway in an unconscious patient. The difficulty in securing a patent airway and oxygenation portends a mortal danger to the patient. Difficult airway could be defined as the situation in which the anaesthesia clinician experiences a great challenge with ventilation by mask or supraglottic airway (SGA), difficulty with tracheal intubation, or both. This situation is a dare emergency, where the life of the patient is “hanging in the balance”.
Structured communication between anaesthetists and anaesthetic assistants could help prepare for and deal with emergency airway difficulties. Talking before every patient, or at least before every surgical list, about the plan to manage difficulties should they develop is good practice. At a minimum, this involves thinking about the challenges that might be encountered and checking that the appropriate equipment is available. However difficult intubation is a situation when a normally trained anaesthetist needs more than 3 attempts or more than 10 min for a successful endotracheal intubation. The incidence of difficult intubation depends on the degree of difficulty encountered showing a range of 1-18% of all intubations to about 2:10000 – 1: million for “cannot ventilate-cannot intubate” situations (Benumof, 1991).
Difficult airway can be assessed and classified using a bedside technique. The classification, introduced in 1983 by an Indian-born American Anaesthetist Seshagiri Mallampati, is one of the most accepted and commonly used predictors for difficult airway wherein lower classes are associated with easier intubation. In addition to the 4 classes described in its modified scoring system (I, II, III and IV), a new class was proposed by (Ezri et al, 2003) in which the epiglottis is visible on mouth opening or tongue protrusion, which was labelled class zero (0).
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Class 0: Ability to see any part of the epiglottis upon mouth opening and tongue protrusion
Class I: Soft palate, fauces, uvula, pillars visible
Class II: Soft palate, fauces, uvula visible
Class III: Soft palate, base of uvula visible
Class IV: Soft palate not visible at all
Difficult tracheal intubation can be a major source of morbidity and mortality in clinical practice, particularly in emergency situations. The complexity of intubation is often referred to in the literature, but unfortunately, no uniform method of description of the “difficult intubation” exists. Following the lack of a standard definition of difficult intubation, the incidence and factors associated with difficult intubation vary drastically from one institution or time period to another and are virtually impossible to compare directly.
Intubation difficulty is commonly identified as a risk factor for morbidity and mortality. Unfortunately, there is no generally accepted definition of difficult intubation. The American Society of Anesthesiologists (ASA) has defined difficult tracheal intubation as when “proper insertion of the endotracheal tube with conventional laryngoscopy requires more than three attempts, or more than ten minutes” (ASA, 1993). Other proposed definitions include failure to intubate, more than two laryngoscopies, more than three attempts in the modified Jackson position, poor visualization of the vocal cords, vocal cord movement, perception of jaw relaxation, subjective difficulty on the part of the operator, and combination of subjective evaluation and number of laryngoscopies.
In West Africa, difficult laryngoscopy is associated with 3.4% of the surgical population (Merah et al, 2005). When unanticipated, difficult airway can be a nightmare during laryngoscopy and tracheal intubation. However, in one study Fyneface-Ogan and Mato123 we described an experience with the use of a two-operator laryngoscopic technique (Fyneface-Ogan ; Mato 2006). In the technique described, the patient with a potentially difficult airway is placed in the modified Jackson position with a pillow 6 cm thick under the head, to allow alignment of the pharyngeal and laryngeal axes. The operators are trained anaesthetists.
Following the attainment of maximal intubating conditions, the first operator carries out the laryngoscopic manoeuvre using the Mackintosh laryngoscope while applying a downward and upward pressure to try to bring the laryngeal inlet into focus. With laryngoscopy, manipulation of the larynx, and successful visualization of the glottis, the first operator stoops down, while the second operator leans over to pass the tracheal tube with the aid of a flexible introducer into the larynx.
THE BODY MASS INDEX AND DIFFICULT AIRWAY PREDICTABILITY
It is well known that difficult tracheal intubation is a common source of mortality and morbidity in surgical and critical care settings. The adverse events related to difficult tracheal intubation include, but are not limited to: hypoxic brain injury, cardiopulmonary arrest, rescue tracheostomy, airway trauma, aspiration, damage to teeth, and death.
Various parameters have been studied in an attempt to establish a better predictor of potential difficult intubation. However, there is no strong consensus and the results are still unclear on true predictors and criteria to be used to predict potential difficult laryngoscopies.
Some anthropometric parameters (distances) have been implicated in predicting difficult airway and tracheal intubation. One of such distances is the thyromental distance. Thyromental distance (TMD) is measured along a straight line from the thyroid notch to the lower border of the mandibular mentum with the head fully extended and categorized as ; 6.5, 6.0–6.5 or ; 6.0 cm. The TMD gives us a clue regarding the mandibular space. In patients with a short mandibular space, the tongue cannot be accommodated anteriorly during laryngoscopy and is pushed posteriorly thus obscuring the glottic view. For practical purposes, a distance less than 3 finger breadths between the thyroid cartilage and the mandible is considered to indicate a receding mandible. Different distances have been suggested ranging from ;6 to 7 cm but neither the Sensitivity nor the Specificity of TMD has been high enough to employ this landmark as the only predictor of a difficult laryngoscopy.
However, sternomental distance (SMD) is measured as the distance between incisura jugularis of the sternal bone and symphysis of the mandible with the patient’s head in midline neutral position, neck fully extended and the patient lying supine. SMD may be a good indicator of maximum neck extension therefore enabling a more accurate assessment of head extension than any other subjective assessment and avoiding the need for radiological examination which in fact is an infringement on patient’s safety. Ramadhani and his colleagues (Ramadhani et al, 1996) have shown that SMD had a high sensitivity and specificity for predicting difficult laryngoscopy. Contrary to their observations of in which they concluded that SMD was not affected by age, we found that the SMD measurements were affected both by age and sex (Jaja ; Fyneface-Ogan, 2011). Although the BMI was statistically the same in both sexes, the SMD correlated positively with the TMD in both sexes (r = 0.86, p = 0.005 while BMI correlated negatively with SMD (r = 0.166, p = 0.108) as well as to the TMD (r = 0.147, p = 0.04) in both sexes. We concluded that in young healthy adult populations the SMD and TMD are strongly related to each other but unrelated to the BMI. In this study males tend to have on average longer SMD and TMD as compared to females. This finding is very useful during pre-anaesthetic airway assessment of patients scheduled for surgeries under general anaesthesia.
Obesity and Anaesthesia
Obesity is a metabolic disease that is on the increase all over the world. There are several classifications and definitions of obesity; however, the one commonly adopted is the definition by the World Health Organization (WHO, 1995), which defines obesity as a body mass index (BMI) of 30 kg/m2 or more. The extent of obesity is usually quantified through the body mass index (BMI), which is defined as the relationship between height and weight (weight in kilograms kg/height2 in metres m2).
Bray classified the BMI into five categories (Bray, 1992):
;25 kg/m2 = normal,
25–30 kg/m2 = overweight,
;30 kg/m2 = obesity,
;35 kg/m2 = morbid obesity,
;55 kg/m2 = super morbid obesity
While about 35% of the population in North America and 15-20% in Europe can be considered obese one systematic review by Chuwunonye et al.130 showed that the prevalence of overweight and obesity in Nigeria ranged from 20.3%–35.1%, and 8.1%–22.2%, respectively (Chuwunonye et al, 2013).
Since these patients are characterised by several systemic physio-pathological alterations, the perioperative management may present some problems, mainly related to their respiratory system. Body mass is an important determinant of respiratory function before and during anaesthesia not only in morbidly but also in moderately obese patients. These can manifest as:
(a) reduced lung volume with increased atelectasis;
(b) derangements in respiratory system, lung and chest wall compliance and increased resistance;
(c) moderate to severe hypoxaemia.
These physiological alterations are more marked in obese patients with hypercapnic syndrome or obstructive sleep apnoea syndrome.
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Using a lifter to transport a patient facilitates patient safety and safeguards medical team members. (http://www.anesthesiologynews.com)
Obesity is frequently associated with challenges during anaesthesia. Following this, the use of regional anaesthetic techniques for obese patients is increasing in popularity as this offers distinct advantages over general anaesthesia for these patients. Regional anaesthesia (RA) offers several advantages when treating obese patients, including minimal airway intervention, less cardiopulmonary depression, improved postoperative analgesia, decreased opioid consumption, decreased postoperative nausea and vomiting (PONV), and therefore reduced post-anaesthesia care unit (PACU) and hospital length of stay. Moreover, RA has been associated with improved postoperative analgesia, particularly when long-acting local anaesthetics, or continuous peripheral nerve blocks, are used. Despite these advantages, RA can be technically challenging in the obese. These challenges are related to difficulties in patient positioning, identifying the usual bony and muscular landmarks, and the depth of needle penetration. However, the limitations of regional anaesthesia and the technical difficulties encountered with its use in obese patients must be carefully considered.
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Showing the posterior view of the patient
One of the experiences was a 53 year old super morbidly obese female, total body weight 165 kg, with a height of 168cm (BMI=58.5), presented with a history of heavy menstrual bleeding and abdominal mass of 3 years duration (Fyneface-Ogan, Abam ; Numbere, 2012). On account of the massive weight, heavy bleeding, uncontrolled hypertension and diabetes, the decision to operate was reached. Some of the problems associated with this were establishing a venous access, epidural block and transportation of the patient to the ward. One of the lessons learnt from the management of this patient was the response of the morbidly obese to the use of opioids for both intraoperative and postoperative pain management. While the use of spinal bupivacaine/fentanyl is encouraged to extend the duration of sensory block, its use in the morbidly obese can be detrimental. The cephalad spread of opioids could potentiate an already existing obstructive sleep apnoea. Perioperative opioid-based pain management of patients suffering from obstructive sleep apnoea (OSA) may present challenges because of concerns over severe ventilatory compromise.
OSA is a chronic inflammatory state and intermittent hypoxia seems to be causally responsible (at least partially) for this outcome through a complex scheme of positive interactions between upregulation of hypoxia-inducible factor 1 alpha and increased production of reactive oxygen species by mitochondria (Lavie, 2003). The inflammatory products of these reactions, such as IL-6, IL-1?, and TNF? have been shown to be both hyperalgesic (Zhang ; An, 2007) and also potentiating the analgesic effect of opioids. Although the molecular basis for the effect of intermittent hypoxia on opioid sensitivity is less clear, recent experimental evidence suggests that the two, seemingly contrasting, phenotypes of increased pain and enhanced opioid potency, as emerging consequences of intermittent hypoxia, are not mutually exclusive.
The administration of oxygen and sedatives may stabilize ventilatory control and benefit OSA patients with increased chemosensory sensitivity and low arousal thresholds, whereas the same therapeutic measures could prolong the duration of airway obstruction, potentially leading to severe hypoxemia, in patients with decreased ventilatory responses to hypoxia/hypercapnia and high arousal thresholds. Although this latter group of patients represents a minority among OSA populations, they might be at a greater risk for opioid-related respiratory events in the postoperative period because they rely heavily on arousal to restore adequate airflow and oxygenation. Opioids, by inhibiting chemical, behavioural, and motor control of respiration, could further raise arousal thresholds; prolong airway obstruction, and precipitate hypoxemia.
INNOVATIONS IN SURGERY
Various types of surgical drains have been used for different surgical interventions for many years (Memon, Memon ; Donohue, 2001). It is often open to question whether they achieve their intended purpose despite many years of surgery. There is a paucity of evidence for the benefit of many types of surgical drainage and many surgeons still ‘follow their usual practice’. With better evidence, management of surgical patients should improve and surgeons should be able to practice based upon sound scientific principles rather than simply “How I do it”.
The aim of using a surgical drain is to decompress or drain either fluid (blood, pus, and infected fluid), air from the surgical field (dead space) or to characterize fluid (for example, early identification of anastomotic leakage (Makama ; Ameh, 2008). Surgical drains remove content of body organs, secretion of body cavities and tissue fluids such as blood, serum, lymph and other body fluid that accumulate in the wound bed after surgical procedures. Therefore, reduction of pressure to surgical site as well as adjacent organs, nerves and blood vessels, enhances wound perfusion and wound healing. Reduction of pain is also achieved. However, drains are now known not to be innocuous especially when they are poorly selected, wrongly used and left in situ for too long. Essentially, passive and active drains are the most practically useful type. Therefore, understanding the benefits and applications of surgical drains and tissue responses to constituent material is not only relevant to a practicing surgeon but would help to reduce the abuse of surgical drains.
Specific examples of drains and operations where they are commonly used include:
Plastic surgery including myocutaneous flap surgery
Breast surgery (to prevent collection of blood and lymph)
Orthopaedic procedures (associated with greater blood loss)
Chest surgery (with, for example, the associated risks of raised intrathoracic pressure and tamponade)
Infected cysts (to drain pus)
– Pancreatic surgery (to drain secretions)
Thyroid surgery (concern over haematoma and haemorrhage around the airway)
Neurosurgery (where there is a risk of raised intracranial pressure)
Surgical drains can be:
Open or closed
Open drains (Including corrugated rubber or plastic sheets) drain fluid on to a gauze pad or into a stoma bag. They are likely to increase the risk of infection.
Closed drains are formed by tubes draining into a bag or bottle. Examples include chest, abdominal and orthopaedic drains. Generally, the risk of infection is reduced.
Active or passive
Active drains are maintained under suction (which may be low or high pressure).
Passive drains have no suction and work according to the differential pressure between body cavities and the exterior.
We have described a novel closed passive surgical drain using the uribag (Fyneface-Ogan ; Jebbin, 2007). In this prospective study of the use of uribag as a drain (Figure 1) was carried out in 104 consecutive surgical and gynaecologic patients.
Figure 1 Uribag drain showing the blue tip Figure 2 Blue tip of uribag being cut-off
The drain was prepared by cutting off the blue tip of the uribag as shown in Figure 2 below. Two to four fenestrations, 2 cm apart, were made in the opposite sides of the cut end of the tubing shown in Figure 3.
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Figure 3 Fenestrations being made on tube of uribag
A 1 cm stab incision was made on the skin. With the aid of an artery forceps passed from inside the cavity, the tube drain was pulled through the incision into the cavity or tissue bed to be drained (Figure 4).
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Figure 4 Improvised drain prepared tube with Figure 5 Drain tube being anchored
It was anchored to the skin with the aid of nylon 0 suture (Figure 5). The collections into the bag were emptied as necessary the volume being noted. The drain was retained until it was no longer necessary, as judged by the quantity of the effluent (about 50–100 ml). The drain was pulled out after cutting the anchoring suture. This improvised drain has been used for a variety of surgical procedures and found to be very safe, efficient, simple, cheap and readily available (Figure 6).
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Figure 6 Improvised surgical drain in action
Patient safety is the cornerstone of good patient care. This is especially important in the operating room setup. Reporting of critical incidents and near misses is an established method of improving patient safety. In recent years, in spite of low mortality, anaesthesia is still associated with significant morbidity. There appears to be considerable conformity that anaesthesia risk is an important public health concern and that it is reducible. Further, there is reason to believe that a substantive portion of that risk is related to human error resulting from errors in management or deviation from accepted practice. If the frequency of error has to be decreased, a clearer understanding of that process is needed, the circumstances that encourage error should be identified and the relative frequencies of different classes of errors should be established.
Medication errors are common in anaesthesia. Some of the predisposing factors include fatigue on the part of the anaesthetists, poor vision, illegible inscriptions, and different medications with the same design on vials or ampoules (leading to swapping). The consequences of these errors could be far reaching with undesirable outcomes ranging from prolonged hospitalization to permanent disability or death (Cooper et al, 1978). The incidents may be due to human, mechanical errors or both and, sometimes following deviation from standard processes. We reported a series of drug errors in anaesthesia following a change in packaging of routine anaesthetic agents without notifying the end-user anaesthetists (Mato and Fyneface-Ogan, 2003).
The role of the Surgeon Anaesthetisiologist
If surgeons are the blood, anaesthetists are the brains – Anonymous. If this is true, then a Surgeon Anaesthetist is both blood and brain! The Anaesthetist is also known as a perioperative Physician (“peri-” meaning “all-around”) who provides medical care to each patient throughout his or her surgical experience. This includes medically evaluating the patient before surgery (preoperative), consulting with and advising the surgical team, providing pain control and supporting life functions during surgery (intraoperative), supervising care after surgery (postoperative), discharging the patient from the recovery unit and managing postoperative pain.
Anaesthesia as a faculty has grown tremendously over the years after the first public demonstration of the administration of an anaesthetic by William Morton in 1846. Traditionally, the role of the anaesthetist has been viewed as behind the screen specialty and it is only in the last few decades, this specialty has grown beyond the four walls of the operation room and the role of the anaesthetist is being increasingly appreciated in pain clinic, labour room, accident and emergency, intensive care unit.
Anaesthesia is the art and science of relieving pain during surgery and safety is the most important priority achieved through eternal vigilance (Uma and Hanji, 2013). The general population’s view about the role of the anaesthetist is relatively poor. There have been surveys conducted on general public to assess knowledge of anaesthesia and the role of anaesthetists before (Edomwonyi et al, 1997 and Naithani et al 2007). Our study showed that most of the patients were not aware of the role of anaesthesia, types and techniques of anaesthesia, and the role of anaesthetists inside and outside OT despite the fact that most of them had previous surgery. Although this could be attributed to their lower level of formal education, the fraternity of anaesthetists has a very important responsibility to educate patients and surgeons about the role of anaesthesia, types, techniques, benefits, and also the very crucial role played by anaesthetists inside and outside operating theatre.
Being primarily a surgeon, the anaesthetisiologist has a good measure of knowledge of surgical extirpations. Many anaesthesiologists have been involved in the development of surgical devices and themselves assisted in many surgeries.
The anaesthesiologist plays a very vital role in the management of both surgical and non-surgical patients. Some of the roles played by the anaesthesiologist include preoperative evaluation, intraoperative care, postoperative care and postoperative pain management, management of critically ill patients in the ICU, pain management during labour and childbirth, pain clinics etc.
Surgeon Anaesthesiologist’s role is important in establishing the patient’s readiness for surgery. With a unique advantage of advanced knowledge of both the medical illnesses a patient undergoing surgery may suffer, as well as the effects on the body of the specific operation to be performed, the role of the Anaesthesiologist is indispensable. The surgeon anaesthesiologist’s preoperative evaluation may be very brief (such as in the case of a surgical emergency) or very prolonged (as in the case of a patient with multiple chronic medical problems who is to undergo an extensive operation). In all cases, however, the surgeon anaesthetist performs a focused history and physical examination, reviews available laboratory and special test results, and assesses the need for additional testing prior to proceeding with surgery.
It is estimated that nearly 500, 000 anaesthetics (both minor and major anaesthetics) are administered each year in Nigeria. Surgeon anaesthesiologists provide or participate in more than 70-90% of these procedures. In the operating room, the surgeon anaesthesiologists are responsible for the medical management; sometimes suggest techniques in difficult surgical situations to the attending surgeon and provide anaesthetic care of the patient throughout the duration of the surgery. The attending surgeon anaesthesiologist must carefully match the anaesthetic needs of each patient to that patient’s medical condition, responses to anaesthesia and the requirements of the surgery.
The Surgeon anaesthesiologists have important functions outside of the operating room, but the majority of their vital work takes place in the surgical suite. Their main roles during surgery are:
Provide continual medical assessment of the patient
Monitor and control the patient’s vital life functions, including heart rate and rhythm, breathing, blood pressure, body temperature and body fluid balance
Control the patient’s pain and level of consciousness to make conditions ideal for a safe and successful surgery
Delivery (Labour Room) Suite
It is very common for Surgeon anaesthesiologists to provide expectant mothers with pain relief during labour and delivery. While many mothers choose to use natural childbirth techniques, the demand for pain relief for labour and delivery has increased dramatically over the last several years due to the proven safety and benefits of this resource.
During childbirth, the Surgeon anaesthesiologist manages the care of two patients, providing effective pain relief for the mother while maintaining a high degree of safety for her unborn child. In the event of an emergency Caesarean section, the attending surgeon anaesthetist provides surgical anaesthesia while managing the life functions of both the mother and the baby.
The Postanaesthesia Care Unit (PACU) or “Recovery Room”
After surgery, patients are transferred to the PACU, where they continue to emerge from the effects of anaesthesia under the watchful eyes of the Surgeon anaesthesiologist. Evidence of recovery – including activity level, adequacy of breathing, circulation, level of consciousness and oxygen saturation – is continuously monitored. Pain control is optimized. In most cases, the Surgeon anaesthesiologist decides when the patient has recovered enough to be sent home following outpatient surgery or has been stabilized sufficiently to be moved to a regular room in the medical facility or transferred to an intensive care unit.
Critical Care and Trauma Medicine
As an outgrowth of the PACU, critical care units are now found in all major medical facilities throughout the United States. Surgeon anaesthesiologists are uniquely qualified to coordinate the care of patients in the intensive care unit because of their extensive training in clinical physiology/pharmacology and resuscitation. Some Surgeon anaesthesiologists pursue advanced fellowship training to subspecialize in critical care medicine in both adult and paediatric hospitals. In the intensive care unit, they direct the complete medical care for critically ill patients. The role of the surgeon anaesthetist in this setting includes the provision of medical assessment and diagnosis, respiratory and cardiovascular support, and infection control.
Anaesthetists also possess the medical knowledge and technical expertise to deal with many emergency and trauma situations. They provide airway management, cardiac and pulmonary resuscitation, advanced life support and pain control. As consultants, they play an active role in stabilizing and preparing the patient for emergency surgery.
Anaesthesia outside the operating room
As medical technology has advanced, so has the need for anaesthetists to become involved in caring for patients during uncomfortable or prolonged procedures in locations outside the traditional operating suite. These procedures include radiological imaging, gastrointestinal endoscopy (Ray-Offor and Fyneface-Ogan, 2017), placement and testing of cardiac pacemakers and defibrillators, lithotripsy and electroconvulsive therapy. In most institutions, Surgeon anaesthesiologists are available during cardiac catheterizations and angioplasty procedures should emergency airway management or resuscitation become necessary. It would be impossible to perform many of these tests on infants and young children without the use of anaesthesia or various sedation techniques provided by an anaesthetist.
Because of their specialty training and vast experience in controlling pain during surgery, Surgeon anaesthesiologists are uniquely qualified to prescribe and administer drug therapies or perform special techniques for acute, chronic and cancer pain. Here are two of the most common areas in which Surgeon anaesthesiologists treat pain:
Acute Pain Management
In addition to relief of a patient’s pain during a surgical procedure, it is equally important for the patient’s comfort and well-being to receive adequate pain relief postoperatively. Surgeon anaesthesiologists are responsible for ensuring that a patient’s pain is under control before they are discharged from the PACU. Surgeon anaesthesiologists may prescribe specific pain medications or perform specialized procedures to maximize patient comfort, which helps to minimize stress on the patient’s heart and blood pressure. The techniques that are best suited for each individual patient are chosen to allow for proper rest and healing.
Chronic and Cancer Pain Management
Surgeon anaesthesiologists are the vanguard of those who are developing new therapies for chronic pain syndromes and cancer-related pain. Surgeon anaesthesiologists who specialize in the treatment of chronic pain often dedicate their practices exclusively to a multidisciplinary approach to pain medicine, working collaboratively with other medical specialists in a pain clinic.
Ambulatory and Office-Based Anaesthesia
The number of operations performed in ambulatory surgical centres and doctors’ offices continues to rise. Many of the patients being treated in these facilities are from an increasingly elderly population with more complex medical problems. Patients deserve the same high standard of care in these facilities that they receive in the hospital setting. Surgeon anaesthesiologists are working with federal and state legislators and agencies and collaborating with other physicians and accrediting bodies to establish safety standards for such facilities.
Operating Room Management
In addition to providing patient care, the Surgeon anaesthesiologist often is responsible for managing the resources of the operating suite, including the efficient use of operating rooms, supplies, equipment and personnel. Unlike most surgeons, who spend much of their time seeing patients in private offices, Surgeon anaesthesiologists work in the operating suite every day. Their continuous presence, along with their wide-based appreciation for the needs of surgeons and other physicians who perform procedures requiring anaesthesia, uniquely qualifies anaesthesiologists for leadership positions in operating room administration and management.
Basic Science and Clinical Research
Some of the most significant strides in medicine and surgery are directly attributable to Surgeon anaesthesiologists’s advances in patient monitoring, improved anaesthetic agents and new drug therapy. Anaesthesia research at the clinical and basic science levels has been completed almost exclusively by Surgeon anaesthesiologists or Ph.D. scientists with the goal of continually improving patient care and safety. Research is conducted in each of the subspecialties of Paediatric, Geriatric, Obstetric, Critical Care, Cardiovascular, Neurosurgical and Ambulatory Anaesthesia. Other areas of active study include blood transfusions and fluid therapy, infection control, difficult airway management, cardiopulmonary resuscitation, complications, new devices and methods of monitoring, pharmacology, patient safety, pain therapy and organ transplantation.
Without the significant input of the Surgeon anaesthesiologists certain surgeries may not have been possible. There has been an increasing tendency for patients with a definitive diagnosis of phaeochromocytoma to be referred to specialist endocrine surgeons, who in turn work with Surgeon anaesthesiologists with specialist experience, and this can only be beneficial for such patients. Few Surgeon anaesthesiologists have substantial experience of anaesthetic management of patients with phaeochromocytoma. Pheochromocytoma although rare, presents challenges for the anaesthetist. By some estimates, 25 to 50 percent of hospital deaths of patients with unmanaged or unknown pheochromocytoma occur during induction of anaesthesia or during operative procedures for other conditions. Since treatment of phaeochromocytoma almost always includes surgical resection, most of these patients will require anaesthesia. While that 10% of pheochromocytomas are extra-adrenal, 10% are malignant.
Currently, there is no effective cure for malignant pheochromocytoma. There are also no reliable histopathological methods for distinguishing benign from malignant tumours. Instead, malignancy requires evidence of metastases at non-chromaffin sites distant from that of the primary tumour. Although extensive invasion of adjacent tissues can be considered an indicator of malignant potential, local invasiveness and malignant disease are not necessarily associated. The presence of metastases provides the only currently widely accepted means to define malignant pheochromocytoma. In one case of malignant phaechromocytoma with multiple deposits on the mesentry, liver and some parts of the stomach, a monoblock resection was performed through meticulous anaesthetic and surgical skills (Jamabo, Fyneface-Ogan & Eke, 2003).. In another experience, the tumour was solely suprarenal and was removed by simple excision (Fyneface-Ogan, Elenwo & Omodu, 2006).
Mr Vice Chancellor Sir, every year we celebrate MOTHERS’ DAY yet minimal efforts are made to relieve the extreme discomfort these women experience during the long hours of labour and delivery. The greatest gift that can be given to the parturient is to relieve her of the PAIN OF CHILDBIRTH
The following recommendations are made:
It is imperative that every pregnant woman registers with an approved facility with modern equipment to have a safe labour and childbirth
The Federal, State and Local Government should increase the budget on health with a target at reducing the current maternal morbidity/mortality rates
Government should make a legislation for the affordability, accessibility and availability of safe and painless labour and childbirth
A stringent law and legislation be passed to enforce the prevention of prayer houses and other religious homes from being involved in the management of the processes of childbirth
More funding should be made available to train more Surgeon Anaesthesiologists involved in painless birthing processes; the harvest is plenty but the workers are very few!
We are all products of very painful labour and delivery, therefore it should be a collective responsibility (involving the academia, politicians and other decision makers) to reduce burden on the LABOURER.
May I appreciate the Management of the University of Port Harcourt ably administered by the Vice Chancellor Professor Ndowa Laale for this privilege given to me to present the …th Inaugural Lecture of this Unique University.
Special appreciation goes to my dear wife and friend, Gloria and our two beautiful daughters – Soala and Orafiri who have been very prayerful and supportive in my academic exploits.
I am deeply and eternally grateful to my mentors – Prof. Christie Mato (Provost, College of Health Sciences) and Prof. Nosa Edomwonyi (Head, Department of Anaesthesiology, UBTH, Benin) who held my hands and taught me the secrets of the art. I am also indebted to my teachers, Prof. Ezri Tiberiu (The immediate past Head of Anaesthesia and WFSA Program Director at Wolfson Medical Centre) and, Prof. Shmuel Evron (Father of Obstetric Anaesthesia, Israel and Palestine) who taught me the way through the maze of Obstetric Anaesthesia and Pain Management at the Department of Anaesthesiology and Pain Studies, Elizabeth Wolfson Medical Centre, Halohamin – Holon, Israel.
The Head (Dr. OT Alagbe-Briggs) and entire Staff of Anaesthesia Departments of University of Port Harcourt and University of Port Harcourt Teaching Hospital have been wonderful and encouraging. God bless you all abundantly.
My special gratitude goes to my late parents, Elder and Mrs. Fyneface Sotonye-Ogan whose uncompromising principles charted a good path for me in life. I thank my beloved sisters Madonna, Sarah (Deceased), Bridget and Esther and, the head (Elder Daso I Ogan) and entire Tamuno’s family of Ogan Ama for all their sacrifices and faithfully supporting my endeavours.
I wish to thank my Big brother and friend, Chief (Dr.) Bernard Aprikaloku Aprioku Okome for being a well of wisdom to me. I remember all my friends who also like me, had the challenges of coming from a poor home during our studentship – Dr. Charles Ngeribara, Dr. Kodjo Willie Soroh, Eng. Christian Minasia, and Mr. Sylvester Ed Ogan for the support we gave to each other during those hard years of our lives. I wish to thank Mr. Ibitoroko S. Ogan for being my dear friend and brother. I thank you all for your kindness and support. I will not forget to mention my friend, small but mighty, Nsima Green and his family. You are a blessing to my family. I say thank you.
Millions of thanks to Professors Rollings Jamabo-Owu, Kanu EO Nkanginieme, Anthony Okpani, Celestine T. John and Sunny E. Uzoigwe for helping me to grow into an ‘adult’ today
Finally, and now unto Him who dwells and fills the entire Heavens and the Earth being able to do infinitely more than all I have ever asked or imagined, according to His power that is at work within me, to Him be all the glory and honour forever and ever. Amen
Sotonye Fyneface-Ogan FWACS, FICS, JP
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