Best Practice & Research Clinical Obstetrics & Gynaecology
11Obstetric anaesthesia in low-resource settings
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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Cited by (36)
Pain management during labor and vaginal birth
2020, Best Practice and Research: Clinical Obstetrics and GynaecologyPreeclampsia in 2017: Obstetric and Anaesthesia Management
2017, Best Practice and Research: Clinical AnaesthesiologyCitation Excerpt :Once diagnosed, it is recognised that preeclampsia can rapidly progress from ‘mild’ disease to severe end-organ involvement [12]. Early detection and referral are crucial, especially in environments with limited resources and lack of timely access to advanced health care [5,14,15]. Even in high-resource settings, failure of early diagnosis of intrapartum hypertension was implicated in 60% of deaths [15,16].
Prolonging the duration of single-shot intrathecal labour analgesia with morphine: A systematic review
2016, Scandinavian Journal of PainSimulation in the operating room
2015, Best Practice and Research: Clinical AnaesthesiologyCitation Excerpt :The exodus through medical migration of the few trained physician anesthetists further compounds these issues. The biggest problems exist in the fields of obstetric and pediatric anesthesia, mirrored by an unacceptably high perinatal morbidity and mortality, and a common inability to provide safe anesthesia for pediatric patients [30,31]. Given the challenges providers face just in providing clinical care, it should come as no surprise that simulation remains uncommon in these regions [32].
Defining the anesthesia gap for reproductive health procedures in resource-limited settings
2014, International Journal of Gynecology and ObstetricsCitation Excerpt :In the deaths directly related to spinal anesthesia, the most common causes were a high spinal (41%) and intraoperative hypotension (14%). Possible causes include inadequate training [16,17,21]. A few studies have compared different anesthesia regimens for cesarean delivery to determine safety profiles in low-income countries [21,23].
Establishing an obstetric neuraxial service in low-resource areas
2014, International Journal of Obstetric Anesthesia