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

Abstract

Background: A 2012 audit on labour epidural analgesia rates in Tygerberg Hospital (TBH) revealed that only 2.2% of labouring parturients received epidural analgesia. This unacceptably low number necessitated a dedicated epidural service that was subsequently initiated in June 2014 by the Department of Anaesthesiology and Critical Care to improve the quality of care in labouring patients.

Methods: A retrospective follow-up audit was conducted from June 2014 to December 2015 and included data on epidural rates, indications, complications and patient satisfaction. Comparison was made with the 2012 data to evaluate the impact of change on care provided and to recommend future changes.

Results: Labour epidural rates improved to 5.16% for the audit period, with 2014 and 2015 rates of 7.44% and 3.89% respectively. Daytime epidurals doubled in 2014/2015 and complication rates decreased from 32.3% in 2012 to 16%. Primary indications for epidural analgesia included pre-eclampsia, morbid obesity, primigravidity and cardiac conditions. Although 99.8% of the complications were minor and transient, one fatality was reported during the audit period. This mortality emphasises the importance of team training in every aspect of epidural analgesia, so that the desired increase in epidural rate is associated with safe practice.

Conclusions: An important increase in epidural rates as well as a decrease in minor complications was observed. The fatality indicates that the expansion of the service should be accompanied by in-depth training of the entire team, so that the process becomes routine and complications are reduced. A fatal drug error, a ‘never event’, should not occur.

Keywords: analgesia, audit, complications, epidural, labour