OBSTETRIC ANAESTHESIA COURSE Report

OBSTETRIC ANAESTHESIA COURSE Report Sylhet, Bangladesh 13-17th May 2017 Course developed by: Association of Anaesthetists of Great Britain and Ireland (AAGBI) World Federation of Societies of Anaesthesiologists (WFSA) Run in collaboration with: Bangladesh Society of Anaesthesiologists (BSA) Report Authors: Dr Noman Mahmood Dr James Leedham

Acknowledgements We are deeply grateful to the Bangladesh Society of Anaesthesiologists who offered a dynamic teaching Faculty and our wonderful hosts, the Sylhet MAG Osmani medical College. They provided splendid food and accommodation, whilst contributing many enthusiastic course delegates from amongst their own clinical staff and excellent educational facilities and air conditioned classrooms. We are grateful to the World Federation of Societies of Anaesthesiologists (WFSA) for their financial support and the Association Anaesthetists of Great Britain and Ireland (AAGBI) for their guidance. The Faculty worked hard, through long and humid days and were rejuvenated almost every evening with delightful cultural programs performed by the host medical school students. Finally we are indebted to our course delegates, a large contingent of whom travelled for many hours from the remotest hospitals of Bangladesh to attend the course. They made the whole course a pleasure to teach due to their inquisitive enthusiasm and as the final results prove, their dedication to learning. Delegates and Faculty

Executive Summary Safer Anaesthesia From Education (SAFE) courses have been held annually in Bangladesh since 2013. This paper details the fourth SAFE Obstetrics course held in Bangladesh which took place in May 2017 in the district of Sylhet. Regionally Sylhet Division has the highest maternal mortality rate [1]. The purpose of the 4 day course was to enhance the delegates training to work in obstetric environments and improve their knowledge and skills in safely managing peripartum women. Funding for the course was provided by the AAGBI Foundation s SAFE steering group. The course was attended by 47 delegates on the first day and 44 delegates on the subsequent days; comprising of junior to middle grade anaesthetic doctors and obstetricians. Dr James Leedham, Consultant anaesthetist from Worcester, UK directed the course. The Bangladesh Society of Anaesthesiologists provided local logistical coordination and an experienced teaching faculty led by Professor Abdur Rahman, Head of anaesthesia at Dhaka Medical College. The UK faculty consisted of three consultant and two trainee anaesthetists. Training equipment including adult and neonatal resuscitation models, airway and spinal trainers and course materials were donated by the WFSA for use on the course and subsequent teaching by the local faculty in their respective government districts. Lifebox pulse oximeters were provided by the Lifebox charity to responsible delegates for distribution and use in resource poor anaesthetic settings. All candidates received printed course manuals. We assessed delegates prior to and on completion of the course in the topics covered by the course. In all cases; delegates had improved scores following completion of the course compared to their initial test scores. Candidates thought to be particularly adept at teaching and sharing ideas with their peers were selected for the Training of Trainers course and the second group selected for training on the use of Lifebox pulse oximeters. The contents of this course can make a valuable impact in the training of anaesthetists and obstetricians and we would recommend this course continues to be funded in Bangladesh in the coming years.

Skills Lab: Cricothyroidotomy Resuscitation Lectures

Multidisciplinary Role Play Classroom teaching

Background/ Context Bangladesh has made significant progress in the areas of reducing poverty, reducing the prevalence of underweight children, increasing primary school enrolment, and lowering the infant mortality and maternal mortality rates [2]. As such it is regarded globally as an example of remarkable progress in poverty reduction and human development, despite daunting challenges [3]. In 2014, Bangladesh was designated as being of Low Middle Income Country status. The World Bank Group s new Country Partnership Framework (CPF) 2016-2020 will support Bangladesh to achieve its vision of reaching middle income status by its 50 th birthday in 2021 [4]. In 2015 Bangladesh became one of only a handful of countries to achieve one of the United Nations' key development targets by sharply decreasing its maternal mortality ratio (MMR), the number of mothers who die per 100,000 live births [5]. The MMR fell from 322 deaths per 100 000 livebirths (95% CI 253 391) in 1998 2001 to 194 deaths per 100 000 livebirths (149 238) in 2007 10, an annual rate of decrease of 5 6%. This decrease rate is slightly higher than that required (5 5%) to achieve the MDG target between 1990 and 2015 [6]. It is thought that the main reasons for this decline is due to improved access to health facilities as well as a reduction in fertility and proportion of births classified as high risk. The Bangladesh Maternal Health Services and Maternal Mortality Survey (BMMS) 2010 found that the overall maternal mortality rate and the mortality due to direct obstetric deaths are lower in urban areas. Regionally, Sylhet division has the highest maternal mortality rate and Khulna lowest [1]. Almost two-thirds of infant and child deaths in Bangladesh occur in the neonatal period, and more than 90% of all births occur at home, generally attended by a traditional birth attendant [7]. Course Poster

Course Venue The 4th obstetric SAFE course was held in the Sylhet, a city in the north eastern district of Bangladesh. It is located on the banks of the Surma river and surrounded by luscious tea estates. It is an important economic and cultural hub of Bangladesh. The obstetric workload in Sylhet is high as the total fertility rate is 3.7 versus the national average of 2.7. Antenatal care attendance with trained provider:47% in Sylhet vs 52% in the country overall (DHS 2007). The course was held in Sylhet MAG Osmani Medical College, a government medical university with associated teaching hospital established in 1948. Sylhet MAG Osmani Medical College Hospital

Course Details Thursday 11th May Friday 12th May Saturday 13th May Sunday 14th May Monday 15th May Tuesday 16th May Wednesday 17th May Flights from UK to Sylhet Preparation and Sylhet sightseeing Delegates arrive, SAFE Obs course Day 1 Safe Obs Course Day 2 Safe Obs Course Day 3 SAFE Training of Trainers and Lifebox course Rest and Preparation for Home The SAFE obstetric anaesthesia course lasted for three days. As the candidates arrived, they were assessed on the pre-course MCQ and skills test. An extensive syllabus was covered over the subsequent days through the variety of lectures, small group facilitated discussions, skill labs and teaching sessions. The main topics centered on maternal and newborn physiology and resuscitation, anaesthetic techniques including in depth discourse on general and regional anaesthesia and finally, managing the common and significant complications associated with childbirth. The post course tests were matched to the initial pre course assessments. The fourth day of the course was split into the Training of Trainers program and the Lifebox course. Course Participants Course Attendance Day day1 day2 day3 Delegate 47 45 45 number

Monitoring Course Success In order to measure whether the course successfully imparted knowledge on its participants; all participants were asked to complete a skills test before and on completion of the course in the key areas covered. Table 1 demonstrates that participants had better scores on their skills tests in Eclampsia; Maternal CPR; Neonatal Resus and RSI following the completion of the course compared to their test results prior to the course. Skills Tests Results Median (IQR) Table 1 Eclampsia Maternal CPR Neonatal Resus RSI Pre Post Pre Post Pre Post Pre Post 4 (4-6) 10 (9-10) 6 (4-8.3) 10 (10-10) 2.8 (2.1-5.5) 9 (8-9.8) 7 (6-8.8) 8 (8-9.5)

Table 2 MCQ Test Results (Median) n=44 (delegates tested) % correct 50 Questions % Correct 50 Identical Questions % Correct 30 Different Questions % Correct Total (80 Questions) Test Pre course Post course Post course Post course Median 75 88 83 86 The total percentage of correct MCQs went up by 11% between the candidates precourse and post course tests.

Course Feedback and Evaluation The following graphs show the delegate s course feedback. The diamonds show the medians and the error bars show the interquartile ranges.

Additional feedback comments This course is excellent. I am so pleased to have participated in this course. The sessions were very interesting and of a high quality. I will practise what I learnt here. Very enjoyable course but please increase duration. More video should be shown during lectures. Please arrange this course in my institution. Please increase the duration of this course. Without doubt it was a good course for us. I benefited much. Arrange repeatedly so more doctors can benefit and manage critical patients effectively. More videos and practical workshops will be more beneficial to participants. Repeat this effective training. This training should be done on a large scale throughout our country. I would like to learn about more safe anaesthesia practices on various subjects in the same manner. Please reduce duration of each day and increase number of course days.

Topics identified by delegates as NEW ideas emanating from the 3 day SAFE Obstetrics course: Topic Number of Delegates ABCDE Assessment 4 Left Lateral Tilt 4 Neonatal Resuscitation 4 WHO Checklist for Safer Surgery 4 Importance of Team Communication 3 Estimation of Blood Loss 3 How to perform surgical cricothyroidotomy 3 Obstetric emergency team 2 Bougie for difficult intubation 2 RSI 2 Airway assessment 2 Check sensory level after spinal before proceeding to 1 LSCS Maternal Trauma management 1 Spinal aseptic technique 1 Sepsis guidelines 1 Value of monitoring 1

Appendix 1- Faculty List BSA Sylhet MAG OSMANI Faculty Prof. Sabysachi Roy Dr Manas Kumar Basu (Executive Head Chef) Dr. Fuzayel Ahmed Dr H Ahmed Rubel BSA Visiting Faculty Prof. Md. Abdur Rahman Dr. Atiqul Islam Dr. Rabeya Begum Prof. Paresh Chandra Sarker Dr. Manas Kumar Basu Dr. Md. Sayedur Rahman Dr. (Col) Hasan Murshed Dr. Ahsan Habib Dr. Md. Amir Hossain Rahat Prof M. Khalilur Rahman Prof A.B.M Muksudul Alam Prof. Debabrata Banik Dr Masum Hasan (Coordinator) AAGBI UK Visiting Faculty Dr James Leedham, Consultant anaesthetist, Worcester Royal Hospital, SAFE Course Director Dr Michael Cowen, Emeritus Consultant Anaesthetist, Milton Keynes University Hospital Dr Elma Wong, Consultant Anaesthetist, Worcester Royal Hospital Dr Stephen Barrett, Trainee Anaesthetist, Royal Free Hospital, London Dr Noman Mahmood Trainee Anaesthetist, Royal Free Hospital, London

Faculty photos Appendix 2- Delegate List SAFE & Lifebox Dr. Afsana Sathi Dr. Nujhat Sharmin Urmi DR. Tanusree Bhattacharjee Dr. Mohammad Zahangir Alam Dr. Syed Ohidul Haque Dr. Md. Hasanur Rahman Chowdhury Dr. Hosne Ara Begum Dr. Syeda Sharmin Sarwar Dr. Preete Ranjan Roy DR. Deen Islam Mithu Dr. Nasren Akhter Nipa Dr. Farjana Haque Sony Dr. Shanta Rani Datta DR. Rafi Chowdhury DR. Jony Lal Das Dr. Md. Nazim Hossain Chowdhury Dr. Fateha Reswana Dr. Kamrul Gaffar Dr. Ayaz Mahmood

Dr. Sonia Latif Dr. Shakilur Rahman Dr. Sharmila Nath Dr. Sabina Akhter Dr. A.Z.M. Forhad Dr. Fuzael Ahmed DR. Susmita Roy Dr. Priyanka Paul Chowdhury Dr. Shahinara Islam Marine Dr. Mushfeka Jahan Dr. Shah Md Mukhlesur Rahman Dr. Md. Mosaddek Hossain Dr. Jannatul Fardous Dr. Jhumur Deb DR. Md. Ashfaq-ul Alam DR. Shahida Farhana Dr. Mumit Chowdhury Dr. Sayeedur Rahman SAFE & Training of Trainer Delegates Dr. Ebana Begum Dr. Md. Amir Hossain Rahat Dr. Anik Roy Dr. Nahida Parveen Nimmi Dr Ravi Ram Shrestha DR. Md. Mahmudur Rahman Md Shafiul Alam Shaheen Dr. Ridwanul Ferdous Dr. Amir Babu Shrestha Dr. Ishrat Jahan Karim Dr. Sabbysachi Roy Dr Parimol Kishore Dey Dr Hussain Ahmed

Training the Trainers

Evening Cultural Programs held by the local Sylhet medical schools

Sunset on the river Surma

References: Title photo: Lakkatura Tea Garden, Sylhet 12th May 2017. [1]. Bangladesh Health System Review (2015) Health Systems in Transition, Asia Pacific Observatory on Health Systems and Policies, Vol. 5 No. 3. [2]. Planning Commission (2008) Moving Ahead: National Strategy for Accelerated Poverty Reduction II (FY 2009-11). Dhaka: Planning Commission. [ 3]. Qimiao Fan, World Bank Country Director for Bangladesh, Bhutan and Nepal [4]. http://www.worldbank.org/en/news/feature/2016/04/07/world_bank_group_s_new_countr y_partnership_framework_helps_bangladesh_reach_middle_income_country_status [5] http://www.aljazeera.com/indepth/features/2014/09/maternal-deaths-decline-sharply-bangla desh-20149975534783651.html [6]. Prof Shams El Arifeen, DrPH, Prof Kenneth Hill, PhD, Karar Zunaid Ahsan, MIPH, Kanta Jamil, PhD, Quamrun Nahar, PhD, Peter Kim Streatfield, PhD (2014). Maternal mortality in Bangladesh: a Countdown to 2015 country case study. Lancet [7] Bangladesh Demographic and Health Survey (DHS 2007). Calverton, Maryland; National Institute for Population Research and Training (NIPORT) and Measure DHS Macro International.