Analysis of anaesthesia incidents during caesarean section reported to webAIRS between 2009 and 2022

Abstract

Anaesthesia for caesarean section occurs commonly and places specific demands on anaesthetists. We analysed 469 narratives concerning anaesthesia for caesarean section, entered by Australian and New Zealand anaesthetists into the webAIRS incident reporting system between 2009 and 2022. As expected, compared with the remaining 8978 database entries, the 469 incidents were more likely to be emergency cases (relative risk (RR) 1.95), more likely to occur between 18:00 and 22:00 hours (RR 1.81) and between 22:00 and 07:59 hours (RR 4.40) and more likely to be undertaken using neuraxial anaesthesia (RR 9.18). Most incidents involved more than one event. The most commonly reported incidents included intraoperative neuraxial anaesthesia complications (180, 38%), medication errors or issues (136, 29%), equipment issues (49, 10%), obstetric haemorrhage (38, 8%), maternal cardiac arrests (28, 6%), endotracheal tube issues (28, 6%) and neonatal resuscitation (24, 5%). Inadequate neuraxial block, reported in 95 incidents, was the most common intraoperative neuraxial complication. Allergic reactions, reported in 30 incidents, were the most common medication issue, followed by 17 associated with oxytocin and 16 syringe swaps. Thirty-eight reports included significant maternal haemorrhage, with eight of those incidents including maternal cardiac arrest. There was one maternal death and eight incidents with neonatal deaths reported, affecting nine neonates. Problems with intraoperative neuraxial anaesthesia were the most commonly reported events. Implementation of specific strategies are encouraged to enhance preparation for conversion to general anaesthesia and to mitigate medication errors, particularly those relating to oxytocic use and neuraxial anaesthesia medications.

High risk factors for massive haemorrhage during medical abortion patients with missed miscarriage

“…For patients experiencing signi cant vaginal bleeding, prompt surgical haemostasis is necessary. Such emergency surgeries, conducted without su cient preoperative preparation, heighten the risk of anaesthetic complications [23] and increase the likelihood of further complications such as infections [24] and organ damage. Patients often endure signi cant pain and suffering from suboptimal experiences during these emergency procedures, causing both physical and psychological distress.…”

Clinical incident reporting: Extending the learning opportunities through webAIRS

“…Eley et al report on 469 caesarean-related incidents reported to webAIRS between its inception in 2009 and early 2022. 2 Bright et al report on 684 adult cardiac arrests over a similar period. 3 Mistry and Endlich, drawing from the first 8000 webAIRS reports again over a similar period, discuss 26 incidents related to paediatric regional anaesthesia.…”