Xandra Schyns-van den Berg
Worldwide, 15% of pregnancies require emergency obstetric care in order to prevent life threatening maternal complications for which anaesthesia care is often needed. And while from its origins in the 19th century anaesthesia and obstetrics have been intensively related, modern day anaesthesia involvement in obstetric practice varies widely.
In many countries and/or institutions the contribution of anaesthesia is limited to the provision of anaesthesia interventions on a consultative basis, while elsewhere sophisticated super-specialization in obstetric anaesthesia has developed, with obstetric anaesthetists collaborating actively in clinical obstetric care. The Helsinki Declaration on Patient Safety in Anaesthesiology recommends the highest standards: parturients deserve the same safe practice. Since anaesthesia and analgesia provision for obstetric patients is an essential part of anaesthesia, a more structured participation in obstetric care in countries/institutions lagging behind seems justified.
The physiologic changes of pregnancy, pregnancy-related diseases, complications, and the presence of an unborn infant all have implications for anaesthesia provision. Maternal age and BMI are rising worldwide, resulting in more non-obstetric causes of pregnancy complications. Anaesthetic skills may contribute to improved safety in the maternity units, while the development and provision of labour analgesia techniques alleviate maternal pain and suffering. Obstetric knowledge is essential for anaesthetists in order to provide value-based maternal care with quality and safety for both mother and child, and both specialties should understand each other’s expertise, tools, and challenges in order to optimize multidisciplinary collaboration.
Present day situation
Among the different European countries, specialty training in anaesthesia still varies, both in content and duration, with varying emphasis on obstetric anaesthesia.To optimize training in obstetric anaesthesia and to prepare the next generation of anaesthetists in Europe, this variation in training in obstetric anaesthesia care should be reduced, with the syllabus of requirements for the European Diploma in Anaesthesiology and Intensive Care (EDAIC®) serving as guidance.
This syllabus contains extensive descriptions of both knowledge and skills needed in the care for pregnant women. It provides a perfect framework for harmonization of training in Obstetric anaesthesia, but until now Malta is the only European country where all the components of the EDAIC examinations are mandatory. Elsewhere the different components are often comparable to the national board exams, part 1 is mandatory or there is a mutual recognition between national diplomas and EDAIC.
It is not only a matter of training. At present, the provision of obstetric anaesthesia services also differs between the different countries. The European Board of Anaesthesiology (EBA) is currently preparing a consensus on minimum standards and recommendations for obstetric analgesia and anaesthesia, to be endorsed by all National Societies.
The objective is to provide a document, made by medical specialists, to be used throughout Europe to improve safety and quality of standard obstetric anaesthesia practice and to harmonize European provision of obstetric anaesthesia care.
Training in Obstetric Anaesthesia provides a variety of challenges.
Residents’ exposure to complicated obstetric cases can be reduced due to an increased number of trainees and reduced working hours. There is the increased complexity of high-risk parturients, the expansion of labour analgesia possibilities and demand, and the preference for regional anaesthesia for C-Section.
When GA is needed, it is often during a stressful emergency, which does not provide the ideal scenario to train in the skills of general obstetric anaesthesia and of the difficult obstetric airway.
Anaesthesia presence in the labour ward provides optimal conditions for teaching and learning safe obstetric anaesthesia. If absent it is also a missed opportunity to develop multidisciplinary collaboration skills and mutual understanding.
Traditional knowledge-based education with clinical apprenticeship is no longer sufficient. It is being supplemented with competency-based training (skills, training, and attitude) and assessments, using learning curves that allow the resident and teacher to have an objective evaluation of progress.
Individualized learning processes and inter-professional teamwork education contribute to training. Active (e-)learning tools and simulation-based learning techniques are increasingly important in achieving competency.
Simulation-based training of airway and epidural insertion prepare unexperienced residents for unanticipated airway difficulties and improve their skills before being allowed to provide epidural analgesia in the parturient.
Multidisciplinary teamwork is essential for safe obstetric care; during obstetric crises both technical and non-technical skills are essential for effective and optimal collaboration. Many multidisciplinary simulation training programs (local, national, and international) have been developed, in which participants of emergency response teams simulate emergency scenarios and train in the different skills and components essential for optimal performance. But anaesthetists are not always involved. For instance, in some countries the MOET (Managing Obstetric Emergencies and Trauma) courses are well-attended by obstetricians but have varying participation of anaesthetists.
Digital technology is transforming healthcare worldwide. New opportunities arise, connecting patients and healthcare providers and empowering patients with evidence-based information. E-learning strategies are evolving at an accelerating pace, and augmented reality will become one of the effective tools to improve skills and training of young professionals, not only in the industrialized world but everywhere, thus contributing to the solution of the lack of training in lower resource countries as well.
Realistic scenarios using augmented reality have been developed online for gaming (World of Warcraft, Fortnite) and could serve as examples for online healthcare simulation games. These could provide a worldwide training platform for the different health care professionals involved. The possibilities seem endless: different levels (resembling the resources available locally) would provide realistic training conditions, with different care providers joining to play an online simulated scenario (game). Afterwards, online discussion of options and solutions would facilitate evaluation. Evidence-based background information could be included and many more options would be possible, as most of our young gaming colleagues will know.
- To optimize anaesthesia’s contribution to safe and qualitative obstetric care, our role as peripartum physicians should be encouraged and future colleagues be trained accordingly.
- Modern e-learning tools and harmonization of care can contribute to improved training and result in better peripartum outcomes related to anaesthesia care.
- Applying the Standards of the Helsinki Declaration on Patient Safety in Anaesthesiology is essential for safe maternity care.
The various national societies should work together towards a safer and more standardized practice of obstetric anaesthesia.
- Last but not least (if willing to think out of the box): worldwide organizations active in providing and promoting safe maternal healthcare could contribute to the development of an adventurous professional simulation gaming platform for training and expanding knowledge of safe (maternal) healthcare provision.