Where there is no Anaesthetist- C- Section Under Local Anaesthesia

1. Where there is no Anaesthetist-C- Section Under Local Anaesthesia Dr N S Iyer MBBS;DGO Retd Civil Surgeon ,Kerala Govt health services, Former PO Safe Motherhood UNICEF,Chennai, Presently- Consultant ,Averting Maternal Death and Disability programme(AMDD) Indian Institute of management, Ahmedabad Good afternoon, Respected chairperson and dear colleagues As you all may be wondering, C Section under local anesthesia is definitely neither new nor experimental. Most of you would have had experience doing the procedure sometime in your career. So why we are discussing it nowGood afternoon, Respected chairperson and dear colleagues As you all may be wondering, C Section under local anesthesia is definitely neither new nor experimental. Most of you would have had experience doing the procedure sometime in your career. So why we are discussing it now

2. � Local anesthesia is a safe alternative to General, Ketamine or Spinal Anesthesia when these anesthetics are persons trained in their use are not available.� - Managing Complications in Pregnancy and Childbirth IMPAC, WHO Publication. I am not sure how many of the obstetricians providing services in the rural areas are aware that Word Health Organisation has endorsed the procedure as a safe alternative to General,Ketamine or spinal anaesthesia when these anesthetics or persons trained in their use are not available. In the WHO Publication -IMPAC series -Managing Complications in Pregnancy and Child Birth,as a Procedure (P7),CSLA is discussed in detail.I am not sure how many of the obstetricians providing services in the rural areas are aware that Word Health Organisation has endorsed the procedure as a safe alternative to General,Ketamine or spinal anaesthesia when these anesthetics or persons trained in their use are not available. In the WHO Publication -IMPAC series -Managing Complications in Pregnancy and Child Birth,as a Procedure (P7),CSLA is discussed in detail.

3. We are all aware that there is a wide gap (day after day widening) between developed countries and developing countries as far as MMR is concerned. MMR is indeed silent tsunamis in the developing countries The MMR of India is around 4.2 per 1000 where as that of Developed countries is only 0.12 per 1000. But India which is an example for Unity in Diversity,Kerala, a state in the southern India stand alone giving a comparable figure on MMR with that of the developed countries. In fact as per the report of the DHS, MMR in Kerala is around 0.4 per 1000 only, We are all aware that there is a wide gap (day after day widening) between developed countries and developing countries as far as MMR is concerned. MMR is indeed silent tsunamis in the developing countries The MMR of India is around 4.2 per 1000 where as that of Developed countries is only 0.12 per 1000. But India which is an example for Unity in Diversity,Kerala, a state in the southern India stand alone giving a comparable figure on MMR with that of the developed countries. In fact as per the report of the DHS, MMR in Kerala is around 0.4 per 1000 only,

4. On plotting the maternal mortality ratio against the C Section rates in 15 states in India the trend line gives a clear picture of the relationship. There is a drop when C section rate becomes more than 5% .It goes further down when the rate crosses 10%. . On plotting the maternal mortality ratio against the C Section rates in 15 states in India the trend line gives a clear picture of the relationship. There is a drop when C section rate becomes more than 5% .It goes further down when the rate crosses 10%. .

5. Demographic Profile -Kerala Here you see the demographic profile of Kerala Population 31m Sex ratio 1057 Female literacy 86.5% Institutional Deliveries 98% Maternal Mortality Ratio 87(40) Infant Mortality rate 10. Even in this state with very little rural urban divide women do not hesitate to have C section done under local if need arise. Here you see the demographic profile of Kerala Population 31m Sex ratio 1057 Female literacy 86.5% Institutional Deliveries 98% Maternal Mortality Ratio 87(40) Infant Mortality rate 10. Even in this state with very little rural urban divide women do not hesitate to have C section done under local if need arise.

6. In spite of having high level of literacy women in Kerala do not hesitate to give consent for CS to be done under Local if required. Though CSLA involves a certain amount of risk for the doctor and a little discomfort to the patient it is definitely a pleasure for the doctor to have saved the life of a mother especially with the available limited facilities

7. Why CSLA  In emergency situations when the next available institution is far away to save the mother and baby this is found to be a very good alternate solution.. In sub district hospitals when cases are referred from peripheral PHCs with Obstructed labour, undignosed Breech, APH etc ,it may be fatal to transfer the case again to another centre. The loss of either mother or the baby is certain

8. A study was done on 3487 cases of C sections in Gh thiroor in Kerala. Period of study April 1994-march 2002 Total births -23850 LSCS- 3487 CSLA- 3392 CSGA/SA -95

10. Indications.

15. Advantages Easy methodology No time lapse in starting the surgery Recovery is smooth-Post operative pain and vomiting is less when compared to other forms of anaesthesia.

16. Disadvantages No Proper relaxation. Bowel and omentum may interfere. More than 2 Previous section with adhesion may cause difficulty Pfannensteil incision may be difficult. Delivering the baby in deep transverse arrest may be difficult

17. Other Cases on LA Caesarean Hysterectomy -6 cases Abruptio Placentae-Acute abdomen �Successful CS -2 cases Rupture Uterus -2 cases Severe PIH-PPH-2 cases

18. Who Can doo Well experienced Confident surgeon To be done quickly Gentle and minimum handling of tissues Well trained assistant Proper counseling of patient and relatives and good rapport with them

19. How to do-The procedure Premedication- Inj Rantac 1 amp, Inj Reglan /Phenergan 25 mg . Inj Atropine Sulphate .6 mg,IV line, 2% Xylocaine-diluted up to 40 ml 200mg maximum. Inject Fortwin amp IM/IV TPR Chart. BP monitoring

20. Infiltrate the skin with 1%/0.5% Xylocaine. Sub umbilical vertical incision is preferred. Infiltrate on either side of the proposed incision. Incise the skin and the infiltrate rectal sheath. Infiltrate the parietal and visceral peritoneum over the site of incision. Once the baby is delivered and cord clamped 50 mg Pethidine given IV and 50 mg IM to the woman. Placenta expelled. Massage the uterus.The uterine and abdominal wound closed.

21. Can we provide anaesthesia service to all? There is an unmet need of C section in India. Facility surveys indicates poor availability of anaesthetist even in metros. Most of the sub district hospitals do not even have one anaesthetist Short training on anaesthesia even for MBBS doctors is not favoured by the persons concerned . Cannot even imagine to have nurse anaesthetist. The deficiency is perpetual Can we provide anaesthesia service to all? There is an unmet need of C section in India. Facility surveys indicates poor availability of anaesthetist even in metros. Most of the sub district hospitals do not even have one anaesthetist Short training on anaesthesia even for MBBS doctors is not favoured by the persons concerned . Cannot even imagine to have nurse anaesthetist. The deficiency is perpetual Can we provide anaesthesia service to all? There is an unmet need of C section in India. Facility surveys indicates poor availability of anaesthetist even in metros. Most of the sub district hospitals do not even have one anaesthetist Short training on anaesthesia even for MBBS doctors is not favoured by the persons concerned . Cannot even imagine to have nurse anaesthetist. The deficiency is perpetual

22. The issue We preach, but don�t practice CSLA not mentioned in any of the training programme for Emergency Obstetric Care Poor dissemination of WHO endorsement. Lack of support from Professional bodies The issue Teaching institutions do not practice the procedure.It is done only in exceptional cases There is no mention of CSLA in any of the training programme for Emergency Obstetric Care The endorsement of the procedure in WHO publication is not disseminated in wider dimension. There is no mention on the necessity of the procedure in resource poor settings in the Journals of professional bodies. Let us now have a view of the procedure being performed in a PHC In Kerala.PHC is at alower level than the SD hospitalsThe issue Teaching institutions do not practice the procedure.It is done only in exceptional cases There is no mention of CSLA in any of the training programme for Emergency Obstetric Care The endorsement of the procedure in WHO publication is not disseminated in wider dimension. There is no mention on the necessity of the procedure in resource poor settings in the Journals of professional bodies. Let us now have a view of the procedure being performed in a PHC In Kerala.PHC is at alower level than the SD hospitals