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Obstetric Anaesthesia & Analgesia - Meena Nathan Cherian
Training in Reproducti=
ve
Health Research
Geneva 2006
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Obstetric Anaesthesia & Analgesia - Meena Nathan Cherian
How is obstetric anaes=
thesia
(OA) linked to maternal deaths?
What is the evidence f=
or the
role of obstetric anaesthesia in reducing maternal
deaths?
What special skills are
required to provide safe obstetric anaesthesia &
analgesia?
Can these skills be ma=
de
available at the first referral health facilities?
=
;
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Obstetric Anaesthesia & Analgesia - Meena Nathan Cherian
Complications of pregn=
ancy
& childbirth: leading causes of death =
among wom=
en of
reproductive age.
=
At least 40% of women
experience complications during pregnancy, childbirt=
h &
after delivery.
=
An estima=
ted
15% of these women develop potentially life threatening =
complication
that calls for skilled care; some will require a major obstetrical
intervention to survive (emergency & surgical procedures).
=
Health personnel at th=
e 1st
referral health facilities are required to perform emergency life saving procedures, ofte=
n with
inadequate training & limited resources
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Obstetric Anaesthesia & Analgesia - Meena Nathan Cherian
Causes of maternal
mortality. Other direct: 8% (anesthesia, ectopic, =
embolism)=
'Anaesthesia' is a com=
ponent
of the 'Comprehensive Essential Obstetric Care' in the=
safe
motherhood programmes
Majority of anaesthetic
deaths & obstetric haemorrhage at level 1 =
hospitals=
*.
Key recommendations:
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Obstetric Anaesthesia & Analgesia - Meena Nathan Cherian
Design & Methods: =
Results:
Conclusion:
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Obstetric Anaesthesia & Analgesia - Meena Nathan Cherian
Methods & Results:
district & 2 central hospitals in Malawi
Quantifiable risk fact=
ors:
Higher maternal mortality:
Obstetric Anaesthesia & Analgesia - Meena Nathan Cherian
Evidence for the role of OA in reduci= ng maternal deaths?
Standards & awaren=
ess of
OA in healthcare professionals, general public & political=
ly: Obstetrics
Association of Anaesthesia
<=
span
lang=3DEN-GB style=3D'mso-hansi-font-family:Arial;font-size:63%;display:no=
ne'>
Changes in practice &a=
mp;
teaching of anaesthesia & analgesia techniques:
Postoperative Pain
Management: impact on mothers & newborns:
=
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Obstetric Anaesthesia & Analgesia - Meena Nathan Cherian
Weight gain & uter=
ine
enlargement:
Difficult airway
(intubation): enlarged =
tongue,
breasts
Difficulty with nasal
breathing & ↑ nasal bleeding:
Denitrogenation: 100% oxygen is mandato=
ry
before GA
Full stomach: <=
span
lang=3DEN-GB style=3D'mso-hansi-font-family:Arial;font-size:56%'>Rapid seq=
uence
induction of GA:
Obstetric Anaesthesia & Analgesia - Meena Nathan Cherian
Resuscita=
tion
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Obstetric Anaesthesia & Analgesia - Meena Nathan Cherian
Most Caesarean sections =
are
performed as emergencies without preoperative
preparation:
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Obstetric Anaesthesia & Analgesia - Meena Nathan Cherian
Basic minimum requirem=
ent at
1st referral health facilities
Ensure patient safety:=
needs
assessment, & monitoring & evaluation of quality of =
=
clinical
procedures & equipment
Recommendations &
guidelines on best practice protocols for emergency & surgical =
procedure=
s &
equipment
Training tools: effect=
ive
interventions in management of emergency procedures
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Obstetric Anaesthesia & Analgesia - Meena Nathan Cherian
Can t=
hese
skills be made available at the first referral health
facilities?
Obstetric Anaesthesia & Analgesia - Meena Nathan Cherian
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Content-Location: file:///C:/2209C636/Obstetric_Anaesthesia_Cherian_2006_files/script.js
Content-Transfer-Encoding: quoted-printable
Content-Type: application/javascript; charset="windows-1252"
function LoadSld()
{
var sld=3DGetObj("SlideObj")
if( !g_supportsPPTHTML ) { =09
sld.style.visibility=3D"visible"
return
}
if( MakeNotesVis() ) return
runAnimations =3D _InitAnimations();
=09
if( IsWin("PPTSld") )
parent.SldUpdated(GetSldId())
g_origSz=3DparseInt(SlideObj.style.fontSize)
g_origH=3Dsld.style.posHeight
g_origW=3Dsld.style.posWidth
g_scaleHyperlinks=3D(document.all.tags("AREA").length>0)
if( g_scaleHyperlinks )
InitHLinkArray()
if( g_scaleInFrame||(IsWin("PPTSld") && parent.IsFullScrMode() ) )
document.body.scroll=3D"no"
_RSW()
if( IsWin("PPTSld") && parent.IsFullScrMode() )
FullScrInit();
=09
MakeSldVis();
ChkAutoAdv()
if( runAnimations )
{
if( document.all("NSPlay") )
document.all("NSPlay").autoStart =3D false;
if( sld.filters && sld.filters.revealtrans )
setTimeout( "document.body.start()", sld.filters.revealtrans.duration * =
1000 );
else
document.body.start();
}
}
function MakeSldVis()=20
{
var fTrans=3Dg_showAnimation && SldHasTrans()
if( fTrans )=09
{
if( g_bgSound ) {
idx=3Dg_bgSound.indexOf(",");
pptSound.src=3Dg_bgSound.substr( 0, idx );
pptSound.loop=3D -(parseInt(g_bgSound.substr(idx+1)));
}
SlideObj.filters.revealtrans.Apply()=09
}
SlideObj.style.visibility=3D"visible"
if( fTrans )
SlideObj.filters.revealtrans.Play()
}
function MakeNotesVis()=20
{
if( !IsNts() ) return false=20
SlideObj.style.display=3D"none"
nObj =3D document.all.item("NotesObj")
parent.SetHasNts(0)
if( nObj ) {=20
nObj.style.display=3D""
parent.SetHasNts(1)
}
return 1
}
function ChkAutoAdv()
{
if(SldHasTrans())
SlideObj.onfilterchange=3DAutoAdv
else
AutoAdv()
}
function AutoAdv()
{
if(!IsWin("PPTSld") || !gUseSldTimings )return
var sld=3DGetCurSld()
if( (sld.mAdvDelay>0) && !parent.IsFramesMode() )
setTimeout("parent.GoToNextSld()",sld.mAdvDelay)
}
function GetObj(id)
{
if(g_supportsPPTHTML) return document.all(id);
else return document.getElementById(id);
}
function SldHasTrans() { return SlideObj.style.filter !=3D ""; }
function GetSldId() { return sId=3Dlocation.href.substring(location.href.la=
stIndexOf('/')+1) }
function HideMenu() { if( frames["PPTSld"] && PPTSld.document.all.item("ctx=
tmenu") && PPTSld.ctxtmenu.style.display!=3D"none" ) { PPTSld.ctxtmenu.styl=
e.display=3D'none'; return true } return false }
function IsWin( name ) { return window.name =3D=3D name }
function IsNts() { return IsWin("PPTNts") }
function IsSldOrNts() { return( IsWin("PPTSld")||IsWin("PPTNts") ) }
function SupportsPPTAnimation() { return( navigator.platform =3D=3D "Win32"=
&& navigator.appVersion.indexOf("Windows")>0 ) }
function SupportsPPTHTML()
{
var appVer=3Dnavigator.appVersion, msie=3DappVer.indexOf("MSIE "), ver=3D0
if( msie >=3D 0 )
ver=3DparseFloat( appVer.substring( msie+5, appVer.indexOf(";",msie) ) )
else
ver=3DparseInt(appVer)
return( ver >=3D 4 && msie >=3D 0 )
}
function _RSW()
{
if( !g_supportsPPTHTML || IsNts() ||
( !g_scaleInFrame && (!IsWin("PPTSld") || !parent.IsFullScrMode()) ) )
return
var padding=3D0;
if( IsWin("PPTSld") && parent.IsFramesMode() ) padding=3D6
cltWidth=3Ddocument.body.clientWidth-padding
cltHeight=3Ddocument.body.clientHeight-padding
factor=3D(1.0*cltWidth)/g_origW
if( cltHeight < g_origH*factor )
factor=3D(1.0*cltHeight)/g_origH
newSize =3D g_origSz * factor
if( newSize < 1 ) newSize=3D1
s=3DSlideObj.style
s.fontSize=3DnewSize+"px"
s.posWidth=3Dg_origW*factor
s.posHeight=3Dg_origH*factor
s.posLeft=3D(cltWidth-s.posWidth+padding)/2
s.posTop=3D(cltHeight-s.posHeight+padding)/2
if( g_scaleHyperlinks )
ScaleHyperlinks( factor )
}
function _InitAnimations()
{
animRuntimeInstalled =3D ''+document.body.localTime !=3D 'undefined';
isFullScreen =3D (window.name =3D=3D "PPTSld") && !parent.IsFramesMode();
g_animUseRuntime =3D g_showAnimation && animRuntimeInstalled && !(isFullSc=
reen && parent.IsSldVisited());
if( g_animUseRuntime ) {
collSeq =3D document.all.tags("seq");
if( collSeq !=3D null ) {
for(ii=3D0;ii numSlds )
gSldJumpIdx =3D numSlds;
if ( gSldJumpIdx >=3D 0 ) {
if ( gSldJumpIdx =3D=3D 0 )
gSldJumpIdx =3D 1;
var jumpTo =3D parseInt(gSldJumpIdx);
gSldJump =3D 0; gSldJumpIdx =3D "";
win.GoToSld( parent.GetSldList().mList[jumpTo-1].mSldHref )
}
}
}
function _KDH()
{
if( event.keyCode =3D=3D 8 ) {
event.returnValue =3D 0;
parent.GoToPrevSld();
}
}
function DocumentOnClick()
{
if( IsNts() || parent.HideMenu() ) return;
if( ( g_allowAdvOnClick && !parent.IsFramesMode() ) ||
(event && (event.keyCode=3D=3D32) ) )
parent.GoToNextSld();
}
var g_supportsPPTHTML =3D SupportsPPTHTML(), g_scaleInFrame =3D 1, gId=3D""=
, g_bgSound=3D"",
g_scaleHyperlinks =3D false, g_allowAdvOnClick =3D 1, g_showInBrowser =
=3D 0, gLoopCont =3D 0, gUseSldTimings =3D 1;
var g_showAnimation =3D g_supportsPPTHTML && SupportsPPTAnimation() && ( (w=
indow.name=3D=3D"PPTSld" && !parent.IsFramesMode()) || g_showInBrowser );va=
r g_animManager =3D null;
var g_animUseRuntime =3D false;
var g_animItemsToHide, g_animInteractiveItems, g_animSlideTime;
var g_animMainSequence =3D null;
var ENDSHOW_MESG=3D"End of slide show, click to exit.", SCREEN_MODE=3D"Fram=
es", gIsEndShow=3D0, NUM_VIS_SLDS=3D13, SCRIPT_HREF=3D"script.js", FULLSCR_=
HREF=3D"fullscreen.htm";
var gCurSld =3D gPrevSld =3D 1, g_offset =3D 0, gNtsOpen =3D gHasNts =3D gO=
tlTxtExp =3D 0, gHasNarration =3D 0, gOtlOpen =3D true
window.gPPTHTML=3DSupportsPPTHTML()
var gMainDoc=3Dnew Array(new hrefList("slide0001.htm",1,-1,1),new hrefList(=
"slide0010.htm",1,-1,1),new hrefList("slide0002.htm",1,-1,1),new hrefList("=
slide0004.htm",1,-1,1),new hrefList("slide0006.htm",1,-1,1),new hrefList("s=
lide0007.htm",1,-1,1),new hrefList("slide0009.htm",1,-1,1),new hrefList("sl=
ide0011.htm",1,-1,1),new hrefList("slide0017.htm",1,-1,1),new hrefList("sli=
de0013.htm",1,-1,1),new hrefList("slide0015.htm",1,-1,1),new hrefList("slid=
e0018.htm",1,-1,1),new hrefList("slide0016.htm",1,-1,1));
/*********************************************
Frameset functions
These functions control slide navigation
and state of the frameset.
**********************************************/
function FullScrInit()
{
g_allowAdvOnClick =3D GetCurSld().mAdvOnClk
document.body.style.backgroundColor=3D"black"
document.oncontextmenu=3Dparent._CM;
document.onkeydown =3D _KDH;
document.ondragstart=3DCancel
document.onselectstart=3DCancel
self.focus()
}
function Redirect( frmId )
{=09
var str=3Ddocument.location.hash,idx=3Dstr.indexOf('#'), sId=3DGetSldId()
if(idx>=3D0) str=3Dstr.substr(1);
if( window.name !=3D frmId && ( sId !=3D str) ) {
obj =3D GetObj("Main-File")
window.location.href=3Dobj.href+"#"+sId
return 1
}
return 0
}
var MHTMLPrefix =3D CalculateMHTMLPrefix();=20
function CalculateMHTMLPrefix()
{
if ( document.location.protocol =3D=3D 'mhtml:') {=20
href=3Dnew String(document.location.href)=20
Start=3Dhref.indexOf('!')+1=20
End=3Dhref.lastIndexOf('/')+1=20
if (End < Start)=20
return href.substring(0, Start)=20
else=20
return href.substring(0, End)=20
}
return '';
}
function GetTags(base,tag)
{
if(g_supportsPPTHTML) return base.all.tags(tag);
else return base.getElementsByTagName(tag);
}
function UpdNtsPane(){ if(frames["PPTNts"]) PPTNts.location.replace( MHTMLP=
refix+GetHrefObj( gCurSld ).mNtsHref ) }
function UpdNavPane( sldIndex ){ if(gNavLoaded) PPTNav.UpdNav() }
function UpdOtNavPane(){ if(gOtlNavLoaded) PPTOtlNav.UpdOtlNav() }
function UpdOtlPane(){ if(gOtlLoaded) PPTOtl.UpdOtl() }
function SetHasNts( fVal )
{
if( gHasNts !=3D fVal ) {
gHasNts=3DfVal
UpdNavPane()
}
}
function ToggleOtlText()
{
gOtlTxtExp=3D!gOtlTxtExp
UpdOtlPane()
}
function ClearMedia()
{
// Clear any sounds playing before launching another browser window. Other=
wise,
// in fullscreen mode, you'll continue to hear the sound in the frames mod=
e.
if (PPTSld.pptSound) PPTSld.pptSound.loop =3D 0;
}
function FullScreen()
{=20
if ( PPTSld.g_animUseRuntime )
PPTSld.document.body.pause();
ClearMedia();
var href =3D ( document.location.protocol =3D=3D 'mhtml:') ? FULLSCR_HREF =
: FULLSCR_HREF+"#"+GetHrefObj(gCurSld).mSldHref;
if(PPTNav.event.ctrlKey) {
var w =3D (window.screen.availWidth * 1.0) / 2.0
var h =3D w * (PPTSld.g_origH * 1.0) / PPTSld.g_origW
win =3D window.open( MHTMLPrefix+href,null,"toolbar=3D0,resizable=3D1,top=
=3D0,left=3D0," + "width=3D"+ w + ",height=3D" + h );
if( win.document.body && PPTSld.g_animUseRuntime )
win.document.body.PPTSldFrameset=3Dwindow;
}
else
{
win =3D window.open( MHTMLPrefix+href,null,"fullscreen=3Dyes" );
if( win.document.body && PPTSld.g_animUseRuntime )
win.document.body.PPTSldFrameset=3Dwindow;
}
}
function ToggleVNarration()
{
rObj=3DPPTSld.document.all("NSPlay")
if( rObj && !PPTSld.g_animUseRuntime ) {
if( (rObj.playState =3D=3D 1)||(rObj.playState =3D=3D 0) )
rObj.Play()
else if( rObj.playState =3D=3D 2 )
rObj.Pause()
else
return;
}
else if( PPTSld.g_animUseRuntime )
{
narObj =3D PPTSld.document.all("narrationID")
if( narObj )
narObj.togglePause()
}
}
function GetCurSldNum()
{ =20
obj=3DGetHrefObj(gCurSld)
if( obj.mOrigVis =3D=3D 1 )
return obj.mSldIdx
else =20
return gCurSld
}
function GetNumSlds()
{ =20
if( GetHrefObj(gCurSld).mOrigVis =3D=3D 1 )
return GetSldList().mNumVisSlds;
else
return GetSldList().mList.length
}
function GetSldNum( href )
{
for(ii=3D0; ii 1 )
PopSldList();
else if( !IsFramesMode() ) {
if( gLoopCont )
GoToFirst()
else
EndShow()
}
}
function GoToPrevSld()
{
ii=3DgCurSld-1
if( ii > 0 ) {
obj=3DGetHrefObj(ii)
while ( obj && ( obj.mVis =3D=3D 0 ) && ( ii>0 ) )
obj=3DGetHrefObj(--ii)
if( ii =3D=3D 0 ) ii=3D1
GoToSldNum(ii)
}
}
function GoToFirst(){ GoToSld( GetHrefObj(1).mSldHref ) }
function GoToLast()
{
ii=3DGetSldList().mList.length
if( ii !=3D gCurSld )
GoToSld( GetHrefObj(ii).mSldHref )
}
function GoToSldNum( num )
{
if( PPTSld.event ) PPTSld.event.cancelBubble=3Dtrue
obj =3D GetHrefObj( num )
obj.mVis=3D1
gPrevSld=3DgCurSld
gCurSld =3D num;
PPTSld.location.replace(MHTMLPrefix+obj.mSldHref)
if( IsFramesMode() ) {
UpdNavPane(); UpdOtlPane(); UpdNtsPane()
}
}
function GoToSld( href )
{
if( PPTSld.event ) PPTSld.event.cancelBubble=3Dtrue
GetHrefObj( GetSldNum(href) ).mVis=3D1
PPTSld.location.replace(MHTMLPrefix+href)
}
function SldUpdated( id )
{
if( id =3D=3D GetHrefObj(gCurSld).mSldHref ) return
gPrevSld=3DgCurSld
gCurSld=3DGetSldNum(id)
if( IsFramesMode() ) {
UpdNavPane(); UpdOtlPane(); UpdNtsPane()
}
}
function PrevSldViewed(){ GoToSld( GetHrefObj(gPrevSld).mSldHref ) }
function HasPrevSld() { return ( gIsEndShow || ( gCurSld !=3D 1 && GetHrefO=
bj( gCurSld-1 ).mVis =3D=3D 1 )||( GetCurSldNum() > 1 ) ) }
function HasNextSld() { return (GetCurSldNum() !=3D GetNumSlds()) }
function CloseWindow() {
if( HideMenu() ) return;
=09
var event =3D PPTSld.event;
if( !IsFramesMode() && event && (event.keyCode=3D=3D27 || event.keyCode=3D=
=3D32 || event.type=3D=3D"click" ) )
window.close( self );
CatchNumKeys( self, event );
}
function Unload() { gIsEndShow=3D0; }
function SetupEndShow() {
gIsEndShow=3D1;
PPTSld.document.body.scroll=3D"no";
PPTSld.document.onkeypress=3DCloseWindow;
PPTSld.document.onclick=3DCloseWindow;
PPTSld.document.oncontextmenu=3D_CM;
}
function EndShow()
{
if( IsFramesMode() ) return
if( PPTSld.event ) PPTSld.event.cancelBubble=3Dtrue
doc=3DPPTSld.document
var dir =3D doc.body.dir
if( dir !=3D "rtl" ) dir =3D "ltr";
doc.open()
doc.writeln(' 0) {
PushSldList(sldList,fEnd);
gCurSld =3D 1;
}
else
if( PPTSld.event ) PPTSld.event.cancelBubble=3Dtrue
}
function PushSldList(arr,fEnd) {
var ii =3D gSldStack.length;
gSldStack[ii] =3D new SldList(arr,gCurSld,fEnd);
GoToSld( gSldStack[ii].mList[0].mSldHref );
}
function PopSldList() {
if (gSldStack[gSldStack.length-1].fEndShow)
EndShow()
else {
gCurSld =3D gSldStack[gSldStack.length-1].mCurSld;
gSldStack[gSldStack.length-1] =3D null;
gSldStack.length--;
var sldList =3D gSldStack[gSldStack.length-1];
GoToSld( sldList.mList[gCurSld - 1].mSldHref );
}
}
var custShowList=3Dnew Array();
/*********************************************
Navigation button implementation
There are 2 types of buttons: ImgBtn, TxtBtn
implemented as function objects. They share
a similiar interface so the event handlers
can call SetActive, for example, on a button=20
object without needing to know exactly=20
what type of button it is.
**********************************************/
//----------------------------------
function ImgBtn( oId,bId,w,action )
//----------------------------------
{
var t=3Dthis
t.Perform =3D _IBP
t.SetActive =3D _IBSetA
t.SetInactive=3D _IBSetI
t.SetPressed =3D _IBSetP
t.SetDisabled=3D _IBSetD
t.Enabled =3D _IBSetE
t.ChangeIcon =3D null
t.UserAction =3D action
t.ChgState =3D _IBUI
t.mObjId =3D oId
t.mBorderId=3D bId
t.mWidth =3D w
t.mIsOn =3D t.mCurState =3D 0
}
function _IBSetA()
{
if( this.mIsOn ) {
obj=3Dthis.ChgState( gHiliteClr,gShadowClr,2 )
obj.style.posTop=3D0
}
}
function _IBSetI()
{
if( this.mIsOn ) {
obj=3Dthis.ChgState( gFaceClr,gFaceClr,1 )
obj.style.posTop=3D0=20
}
}
function _IBSetP()
{
if( this.mIsOn ) {
obj=3Dthis.ChgState( gShadowClr,gHiliteClr,2 )
obj.style.posLeft+=3D1; obj.style.posTop+=3D1
}
}
function _IBSetD()
{ =20
obj=3Dthis.ChgState( gFaceClr,gFaceClr,0 )
obj.style.posTop=3D0=20
}
function _IBSetE( state )
{
var t=3Dthis
GetObj( t.mBorderId ).style.visibility=3D"visible"
if( state !=3D t.mIsOn ) {
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t.SetDisabled()
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var t=3Dthis
if( t.mIsOn ) {
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obj=3DGetObj(t.mObjId)
if( t.ChangeIcon() )
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else
obj.style.posLeft=3Dobj.style.posLeft+(t.mCurState-0)*t.mWidth
}
t.SetActive()
} =20
}
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var t=3Dthis
SetBorder( GetObj( t.mBorderId ),clr1,clr2 )
obj=3DGetObj( t.mObjId )
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t.mCurState=3DnextState
return obj
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//-----------------------------------------
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//-----------------------------------------
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var t=3Dthis
t.Perform =3D _TBP
t.SetActive =3D _TBSetA
t.SetInactive=3D _TBSetI
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t.SetDisabled=3D _TBSetD
t.SetEnabled =3D _TBSetE
t.GetState =3D chkState
t.UserAction =3D action
t.ChgState =3D _TBUI
t.mObjId =3D oId
t.m_elementsId=3D oeId
t.mIsOn =3D 1
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{
var t=3Dthis
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var t=3Dthis
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function _TBSetE()
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var t=3Dthis
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t.mIsOn =3D 1
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t.SetPressed()
else
t.SetActive()
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b=3DGetBtnObj()
if( b !=3D null )
b.Perform()
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Upd()
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function _BSetI_Border(){ b =3D gBtnArr[this.mObjId]; if( b !=3D null ) b.S=
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function _BSetP_Border(){ b =3D gBtnArr[this.mObjId]; if( b !=3D null ) b.S=
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function _BSetA_BorderImg()
{=20
b =3D gBtnArr[this.mBorderId]=20
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obj=3Dthis.ChgState( gHiliteClr,gShadowClr,2 )
obj.style.posTop=3D0
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}
function _BSetI_BorderImg()
{=20
b =3D gBtnArr[this.mBorderId]
if( b !=3D null && this.mIsOn && !b.GetState() ) {
obj=3Dthis.ChgState( gFaceClr,gFaceClr,1 )
obj.style.posTop=3D0
}
}
var gHiliteClr=3D"THREEDHIGHLIGHT",gShadowClr=3D"THREEDSHADOW",gFaceClr=3D"=
THREEDFACE"
var gBtnArr =3D new Array()
gBtnArr["nb_otl"] =3D new TxtBtn( "nb_otl","nb_otlElem",parent.ToggleOtlPan=
e,GetOtlState )
gBtnArr["nb_otlElem"] =3D new TxtBtn( "nb_otl","nb_otlElem",parent.ToggleOt=
lPane,GetOtlState )
gBtnArr["nb_nts"] =3D new ImgBtn( "nb_nts","nb_ntsBorder",10,parent.ToggleN=
tsPane )
gBtnArr["nb_nts"].SetActive =3D _BSetA_BorderImg;
gBtnArr["nb_nts"].SetInactive =3D _BSetI_BorderImg;
gBtnArr["nb_ntsBorder"] =3D new TxtBtn( "nb_ntsBorder","nb_ntsElem",parent.=
ToggleNtsPane,GetNtsState )
gBtnArr["nb_ntsElem"] =3D new TxtBtn( "nb_ntsBorder","nb_ntsElem",parent.To=
ggleNtsPane,GetNtsState )
gBtnArr["nb_prevBorder"] =3D gBtnArr["nb_prev"]=3D new ImgBtn( "nb_prev","n=
b_prevBorder",30,parent.GoToPrevSld )
gBtnArr["nb_nextBorder"] =3D gBtnArr["nb_next"]=3D new ImgBtn( "nb_next","n=
b_nextBorder",30,parent.GoToNextSld )
gBtnArr["nb_sldshw"]=3D new ImgBtn( "nb_sldshw","nb_sldshwBorder",18,parent=
.FullScreen )
gBtnArr["nb_sldshwBorder"] =3D new TxtBtn( "nb_sldshw","nb_sldshwBorder",pa=
rent.FullScreen,null )
gBtnArr["nb_sldshwBorder"].SetActive =3D _BSetA_Border;
gBtnArr["nb_sldshwBorder"].SetInactive =3D _BSetI_Border;
gBtnArr["nb_sldshwText"] =3D new TxtBtn( "nb_sldshw","nb_sldshwText",parent=
.FullScreen,null )
gBtnArr["nb_sldshwText"].SetActive =3D _BSetA_Border;
gBtnArr["nb_sldshwText"].SetInactive =3D _BSetI_Border;
gBtnArr["nb_voice"] =3D gBtnArr["nb_voiceBorder"] =3D new ImgBtn( "nb_voice=
","nb_voiceBorder",18,parent.ToggleVNarration )
gBtnArr["nb_otlTxtBorder"] =3D gBtnArr["nb_otlTxt"]=3D new ImgBtn( "nb_otlT=
xt","nb_otlTxtBorder",23,parent.ToggleOtlText )
gBtnArr["nb_ntsBorder"].m_flagId=3D "nb_nts"
gBtnArr["nb_ntsBorder"].SetFlag =3D NtsBtnSetFlag
gBtnArr["nb_otlTxt"].ChangeIcon=3D GetOtlTxtState
/*********************************************
Context menu implementation
_CM() is the function that's hooked up to
the oncontextmenu event. Once we're asked to
show the menu, we first build it by creating
DIVs on-the-fly. Then we position it=20
within the screen area so it doesn't get
clipped.
Creating the DIVs using createElement() means
we don't have to write out any extra HTML
into the slide HTML files.
**********************************************/
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BuildMenu();
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m.style.pixelLeft=3Dx
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m.style.display=3D""
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mObj.id=3D"ctxtmenu"
mObj.style.visibility=3D"hidden"
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SetCMBorder(mObj,"menu","black")
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SetCMBorder( iObj, "threedhighlight","threedshadow" )
iObj.style.padding=3D2
CreateMenuItem( iObj,sNext,M_GoNextSld,M_True )
CreateMenuItem( iObj,sPrev,M_GoPrevSld,M_HasPrevSld )
=09
CreateSeparator( iObj )
CreateMenuItem( iObj,sEnd,M_End,M_True )
mObj.style.visibility=3D"visible"
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function Cancel() { window.event.cancelBubble=3Dtrue; window.event.returnVa=
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function Highlight() { ChangeClr("activecaption","threedhighlight") }
function Deselect() { ChangeClr("threedface","menutext") }
function Perform()
{
e=3DPPTSld.event.srcElement
if( e.type=3D=3D"menuitem" && e.IsActive() )
e.Action()
else
PPTSld.event.cancelBubble=3Dtrue
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function ChangeClr( bg,clr )
{
e=3DPPTSld.event.srcElement
if( e.type=3D=3D"menuitem" && e.IsActive() ) {
e.style.backgroundColor=3Dbg
e.style.color=3Dclr
}
}
function M_HasPrevSld() { return( parent.HasPrevSld() ) }
function M_GoNextSld() { if( gIsEndShow ) M_End(); else GoToNextSld() }
function M_GoPrevSld() { if( gIsEndShow ) { gIsEndShow=3D0; history.back();=
PPTSld.event.cancelBubble=3Dtrue; } else GoToPrevSld() }
function M_True() { return true }
function M_End() { window.close( self ) }
function CreateMenuItem( node,text,action,eval )
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var e=3DCreateItem( node )
e.type=3D"menuitem"
e.Action=3Daction
e.IsActive=3Deval
e.innerHTML=3Dtext
if( !e.IsActive() )
e.style.color=3D"threedshadow"
e.onclick=3DPerform
e.onmouseover=3DHighlight
e.onmouseout=3DDeselect
s=3De.style;
s.fontFamily=3DsFont
s.fontSize=3D"9pt"
s.paddingLeft=3D2
}
function CreateSeparator( node )
{
var sObj=3DCreateItem( node )
SetCMBorder(sObj,"menu","menu")
var s=3DsObj.style
s.borderTopColor=3D"threedshadow"
s.borderBottomColor=3D"threedhighlight"
s.height=3D1
s.fontSize=3D"0px"
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function CreateItem( node )
{
var elem=3DPPTSld.document.createElement("DIV")
node.insertBefore( elem )
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function SetCMBorder( o,ltClr,rbClr )
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var s=3Do.style
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Obstetric Anaesthesia & Analgesia - Meena Nathan Cherian
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le
‹date/time›
‹footer›
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Obstetric Anaesthesia & Analgesia
Dr Meena =
Nathan
Cherian
Clinical
Procedures
Department
Essential Health Technologies
WHO, Gene=
va,
Switzerland
Geneva 2006
Obstetric Anaesthesia & Analgesia
How is obstetric anaes=
thesia
(OA) linked to maternal deaths?
l
l
What is the evidence f=
or the
role of obstetric anaesthesia in reducing maternal
deaths?
l
l
What special skills are
required to provide safe obstetric anaesthesia &
analgesia?
l
l
Can these skills be ma=
de
available at the first referral health facilities?
=
;l
Obstetric anaesthesia
linked to maternal deaths?
Developing countries scenarios
Developing countries scenarios
l
Complications of pregn=
ancy
& childbirth: leading causes of death =
among wom=
en of
reproductive age.
=
At least 40% of women
experience complications during pregnancy, childbirt=
h &
after delivery.
=
An estima=
ted
15% of these women develop potentially life threatening =
complication
that calls for skilled care; some will require a major obstetrical
intervention to survive (emergency & surgical procedures).
=
l
Health personnel at th=
e 1st
referral health facilities are required to performl
l
•* Safe Mo=
therhood
Fact Sheet: Maternal Mortality
=
l* WHO tra=
ining
manuals for health personnel at first referral health facilities:
=
l- Managing
Complications in Pregnancy and Childbirth
=
l- Surgica=
l Care
at the District Hospital
Obstetric anaesthesia
linked to maternal deaths?
Causes of maternal
mortality. Other direct: 8% (anesthesia, ectopic, =
embolism)=
l
'Anaesthesia' is a com=
ponent
of the 'Comprehensive Essential Obstetric Care' in the=
safe
motherhood programmes
l
l
Majority of anaesthetic
deaths & obstetric haemorrhage at level 1 =
hospitals=
*.
l
=
l - AIDS at level 2; hypertensive diseases at level 3
hospitals.
l <=
span
lang=3DEN-GB style=3D'mso-hansi-font-family:Arial;font-size:57%;color:yell=
ow'>-
Anaesthetic accidents (4.8%) are an important preventable cause of maternal
deaths.
l - Lack of
training & infrequent use of regional anaesthesia
l
Key recommendations:
l -
Regional anaesthesia should be promoted in all sites
l performing
Caesarean sections
l
l
•
•
•
•*Interim =
Report
on the Confidential Enquiry into Maternal Deaths in S. Africa,
•March 199=
8,1999
by the National Committee for the Confidential Enquiry
•into Mate=
rnal
Deaths (NCCEMD).
l
l
l
l
l
l
Evidence for the role of OA in reducing maternal deaths?
=
lEvaluatio=
n of the
quality of care for severe obstetrical haemorrhage in
=
l3 French =
regions
(n=3D165)
=
l
Design & Methods: =
l Retrospective questionnaire survey=
3;
l 51% vaginal, 19% operat=
ive
vaginal, 30% caesarean.
l Expert commit=
tee
established a framework for qualitative assessment (blood loss > or =3D1500 m=
l)
l
Results:
=
l <=
span
lang=3DEN-GB style=3D'mso-hansi-font-family:Arial;font-size:50%'> <=
span
lang=3DEN-GB style=3D'mso-hansi-font-family:Arial;font-size:56%'>62% recei=
ved
appropriate care
l 24% received totally
inadequate care
=
l 14% mixed care
l
l
Conclusion:
l - Organi=
zation
of obstetric services for good clinical practices for safer =
=
motherhoo=
d
l -
Presence of an anaesthetist is shown to have a measurable effect on the quality
of care for women giving birth
l
l* BJOG 2001,108(9): 898-903
Evidence for the role =
of OA
in reducing maternal deaths?
lC-section in Malawi: Prospective study of early maternal
& perinatal
mortality
l
Methods & Results:
district & 2 central hospitals in Malawi
l n=3D 8070 C-sections, 85
(1.05%) died & of these, 68 (80%) died in the 72 hrs
l
Quantifiable risk fact=
ors:
Higher maternal mortality:
l- Ruptured uterus
-Little
anaesthesia training
-GA as opposed to spinal
anaesthesia
-Blood loss requiring
transfusion > or =3D 2 units
l Perinatal
mortality 11.2%: Ruptured uterus; GA
l
qConclusion:
l - Improv=
ed
training in anaesthetics
l - Wider u=
se of
spinal anaesthesia
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l -
Improved surveillance & resuscitation in postoperative wards might red=
uce mortality:
=
l
l* BMJ 2003 13;327 (7415);587
Evidence for the role of OA in reduci= ng maternal deaths?
Standards & awaren=
ess of
OA in healthcare professionals, general public & political=
ly: Obstetrics
Association of Anaesthesia
l
<=
span
lang=3DEN-GB style=3D'mso-hansi-font-family:Arial;font-size:63%;display:no=
ne'>
Changes in practice &a=
mp;
teaching of anaesthesia & analgesia techniques:
l -General vs Spinal, Epi=
dural,
Combined spinal & epidural anaesthesia.
l -Labour analgesia
=
l - Analgesia for Caesarean
section
l - Pain relief following
Caesarean section
l - Balanced combination of
non-opiod & opiod medications, local anaesth.
l
l
Postoperative Pain
Management: impact on mothers & newborns:
l - Ambulation:
thromboembolism
l - Dietary intake: ileus=
l - Respiration: atelecta=
sis,
pneumonia
l - Nursing activities &a=
mp;
breast feeding
=
l*Journal of Clinical Anaesthesia 2004,16:57-65
l*Anaesthesia 2003, 58(12), 1186-9
Why special skills are
required for safe OA?
=
lAnaesthetic
risks in obstetric patients:
Weight gain & uter=
ine
enlargement:
=
l =
↓ functional residual capacity (FRC),
l =
↑ onset of hypoxemia during hypovent./ apnoea
=
l
Difficult airway
(intubation): enlarged =
tongue,
breasts
=
l
Difficulty with nasal
breathing & ↑ nasal bleeding:
- vasc. engorgement & oed=
ema of
nasal, oral pharynx, larynx, trachea
-
Denitrogenation: 100% oxygen is mandato=
ry
before GA
l =
↑ maternal oxygen consumption
Full stomach: <=
span
lang=3DEN-GB style=3D'mso-hansi-font-family:Arial;font-size:56%'>Rapid seq=
uence
induction of GA:
- =
↑ gastric acid content with ↓ pH,
=
;
- =
↓ function of gastro-esoph. sphincter
Supine Hypotensive Syn=
drome:
16
wks to term, in appx.12-15%.
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-
Supine Hypotensive Syn=
drome:
16
wks to term, in appx.12-15%.
l Gravid uterus may
compress the vena cava & aorta in the supine position:
l =
↓ cardiac output, B.P& uterine blood flow.
=
l
l*Journal of Clinical Anesthesia.2003; 15:522-3
What special skills a=
re
required for safe OA?
Resuscita=
tion
=
l - emergencies
=
l - coexisting
medical conditions
=
l - Skill, experience, resources
=
l
Managemen=
t of
complications
l - Side-effects &
toxicity of anaesthesia drugs
l - Difficult airway
What special skills a=
re
required for safe OA?
=
lHIV: anae=
sthetic
& obstetric considerations
l
Most Caesarean sections =
are
performed as emergencies without preoperative
preparation:
l - Anaemia, hypovolemia,
sepsis from obstructed labour & ruptured uterus are
l common
Prenatal anaesthesia
consultations
Team approach
Regional anaesthesia u=
sually
technique of choice (local infection, blood =
clotting
abnormalities; neuropathies)
GA (drug interactions =
&
impact on various organ systems)
Infection control (ase=
psis,
sterilization of equipment & standard =
precautio=
ns)
l
Prenatal anaesthesia
consultations
l
Team approach
Regional anaesthesia u=
sually
technique of choice (local infection, blood =
clotting
abnormalities; neuropathies)
GA (drug interactions =
&
impact on various organ systems)
Infection control (ase=
psis,
sterilization of equipment & standard =
precautio=
ns)
l
l * BMJ 2003 13;327 (7415);587
• *Anaesth=
esia
Analgesia 2004:98(2): 503-11
l* WHO training manual Surgical Care at the District Hospital
Can these skills be made available at the first =
referral health facilities?
Reduce maternal mortality due to preventable
anaes= thesia related complications
Reduce maternal mortality due to preventable
anaes= thesia related complications
l
lPolic=
y
Basic minimum requirem=
ent at
1st referral health facilities
-
-
lQuali=
ty &
Safety
Ensure patient safety:=
needs
assessment, & monitoring & evaluation of quality of =
=
clinical
procedures & equipment
=
l
=
l
lAccess
Recommendations &
guidelines on best practice protocols for emergency & surgical =
procedure=
s &
equipment
l
l
lUse
Training tools: effect=
ive
interventions in management of emergency procedures
lWHO Inte=
grated
Management for Emergency and Essential Surgical Care (IMEESC) toolkit
<=
/span>
=
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Best Practices for Clinical Procedures
Safety
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Safe obstetric anaesthesia & analgesia
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Collaborative Approach
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Right patient
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Right time
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Rightly trained health personnel
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Thank you
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