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Obstetric anaesthesia in low-resource settings

https://doi.org/10.1016/j.bpobgyn.2009.11.005Get rights and content

Close co-operation between obstetricians and obstetric anaesthesia providers is crucial for the safety and comfort of parturients, particularly in low-resource environments. Maternal and foetal mortality is unacceptably high, and the practice of obstetric anaesthesia has an important influence on outcome. Well-conducted national audits have identified the contributing factors to anaesthesia-related deaths. Spinal anaesthesia for caesarean section is the method of choice in the absence of contraindications, but is associated with significant morbidity and mortality. Minimum requirements for safe practice are adequate skills, anaesthesia monitors, disposables and drugs and relevant management protocols for each level of care. The importance of current outreach initiatives is emphasised, and educational resources and the available financial sources discussed. The difficulties of efficient procurement of equipment and drugs are outlined. Guiding principles for the practice of analgesia for labour, anaesthesia for caesarean section and the management of obstetric emergencies, where the anaesthetist also has a central role, are suggested.

Section snippets

The role of the obstetric anaesthetist

Closer co-operation between obstetricians and obstetric anaesthetists is crucial if we are to improve maternal health and reduce maternal mortality by 75% between 1990 and 2015, as in the Millennium Development Goal 5. Obstetricians should appreciate that a well-trained obstetric anaesthetist not only provides safe analgesia and anaesthesia for labour and caesarean section, but also brings a detailed knowledge of the physiology of pregnancy and makes a crucial contribution in maternal and

Maternal mortality

The World Health Organization estimates that 515 000 women die every year from pregnancy-related causes, predominantly in developing countries.3 The lifetime risk of dying during pregnancy is one in six in the poorest parts of the world,4 due to a high incidence of severe pre-eclampsia, cardiac disease and infectious diseases such as tuberculosis, malaria and HIV/AIDS.

After the first significant reductions in maternal mortality in the late 19th century in Europe and USA, there were still 441

The influence of obstetric anaesthesia on maternal mortality

Obstetric anaesthesia practice has had an important influence on maternal mortality. Early awareness of the risks of pulmonary aspiration resulted in widespread acceptance of rapid sequence induction techniques. This initially resulted in an increase in direct anaesthesia-related maternal mortality, reaching 20 per million deliveries in the triennium 1967–1969 in the United Kingdom, due to failed intubation.8 Subsequent interventions, such as better training, supervision, sub-specialisation and

Factors contributing to anaesthesia mortality

The CEMD in the United Kingdom has clearly shown the factors contributing to anaesthesia mortality in a First World environment. Such valuable audits lead to recommendations and monitoring of their effectiveness; “the audit loop is closed.” 13 Clearly, implicated factors are inexperience of the anaesthetist, failed airway management, obesity and the administration of oxytocin.*10, 14 The increasing proportion of patients managed under regional anaesthesia, together with the reduction of hours

Minimum requirements for safe obstetric anaesthesia

In an important recent initiative, a questionnaire explored the problems faced by anaesthetists in low-resource settings. The results are intended to guide national anaesthesia societies and health authorities to improve anaesthesia services, to make better use of limited resources and identify areas requiring support from the World Federation of Societies of Anaesthesiologists (WFSA). Minimum requirements for the provision of safe anaesthesia, including general and spinal anaesthesia for

Summary

Maternal mortality is appallingly high in the developing world. Improved teamwork and understanding between the obstetric anaesthesia provider and obstetrician is essential to improve maternal and neonatal outcome. Valuable audits in the United Kingdom, and more recently South Africa, have identified specific risk factors for maternal death due to anaesthesia. The first steps towards a reduction in mortality should be attention to the minimum requirements for safe anaesthesia. These are

Conflict of interest statement

There are no conflicts of interest and no funding was required.

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