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Audit of near misses in obstetric anaesthesia
Starting on:
Sep 18, 2026
Ending on:
Sep 18, 2026
Moderator(s):
Venue:
KUTRRH
Max Credits:
3 Points

Provider:
Kenyatta University Teaching and Referral Hospital
Claim Points

Audit of near misses in obstetric anaesthesia

Starting on:
Sep 18, 2026
Ending on:
Sep 18, 2026
Venue:
KUTRRH

Description

The session examined six near-miss cases involving antepartum haemorrhage (APH), postpartum haemorrhage (PPH), placenta accreta spectrum disorders, HELLP syndrome, disseminated intravascular coagulation (DIC), and massive transfusion requirements. Through a retrospective audit, participants analyzed clinical management, anaesthetic approaches, escalation processes, blood product availability, theatre capacity, and system-related factors contributing to adverse maternal outcomes. The findings were compared against national and international standards, including WHO and RCOG guidelines, to identify quality improvement opportunities and develop actionable recommendations.

Objectives

Identify recurring clinical near-miss themes associated with major obstetric haemorrhage and obstetric anaesthesia. Identify systems-level gaps contributing to maternal near-miss events, including delays in diagnosis, escalation, blood product access, medication availability, and theatre capacity. Evaluate clinical practice against established standards and guidelines, including WHO recommendations and RCOG Green-top Guidelines for APH, PPH, and blood transfusion in obstetrics. Assess anaesthetic management strategies in major obstetric haemorrhage cases, including conversion from regional to general anaesthesia and management of haemodynamically unstable patients. Analyze causes of maternal near misses and determine opportunities for improving recognition, escalation, multidisciplinary coordination, and transfusion practices. Generate evidence-based recommendations to reduce future maternal morbidity and prevent avoidable harm. Develop an action plan and re-audit framework to measure improvements in obstetric haemorrhage management, including uterotonic availability, timely theatre access, and antenatal diagnosis of placenta accreta spectrum disorders.

Presenters

  1. Dr. Jeremy Githome


  2. Dr. Ronald Ombaka


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