Documentation of spinal anaesthesia technique and block level at caesarean section at a secondary-level obstetrics hospital in South Africa

Abstract

Background: The ease of administration and relative safety of spinal anaesthesia have made this the preferred technique for both elective and many emergency caesarean sections. Complications include incomplete sensory block, resulting in intraoperative breakthrough pain, which is commonly associated with a successful medicolegal claim. If documentation of the spinal anaesthesia technique was found to be inadequate during the course of the medicolegal proceedings, it is likely that the decision would be against the anaesthetist. The purpose of this study was to evaluate documentation by anaesthetists relating to the establishment of surgical anaesthesia utilising subarachnoid block. 
Methods: A retrospective folder analysis was conducted at Mowbray Maternity Hospital in Cape Town, South Africa. One hundred consecutive spinal anaesthesia charts, each completed by a different anaesthetist, either a registrar or specialist, were analysed. Starting from 31 December 2018 and proceeding retrospectively in time, charts were included until the desired sample size was achieved. 
Results: Of the 100 cases of spinal anaesthesia for caesarean section analysed, 68 were emergency and 32 were elective operations. Following a literature review, 12 variables were identified that required documentation so that adequate information would be available in the event of medicolegal action. Of these variables, 7 and 8 were recorded in 23% and 32% of the charts, respectively. Ninety per cent of the anaesthesia charts had inadequate documentation, defined as information on fewer than 10 of the specified variables. 
Conclusion: The quality of documentation of both the procedure and block level during spinal anaesthesia for caesarean section was inadequate. National guidelines should be drafted and standardised to improve the quality of these records, both for quality of care and medicolegal purposes.