The National Committee on Confidential Enquiries into Maternal Deaths recently received notification of a death in South Africa caused by inadvertent intrathecal administration of tranexamic acid (TXA). TXA is increasingly used during caesarean delivery following updated recommendations from the World Health Organization in 2017. However, its greater availability has led to an international rise in drug errors during obstetric spinal anaesthesia. This case highlights a growing clinical risk, of which all operating theatre staff should be aware. Review of existing operating theatre drug handling practices is required in order to decrease this risk. Recommendations are made that aim to minimise drug errors associated with the use of this potentially life-saving intervention.

The sphenopalatine ganglion is a parasympathetic ganglion and has been blocked for various types of headaches and facial pain. We have reported a patient with severe post-dural puncture headache after cesarean section who showed rapid symptomatic improvement after a single sphenopalatine ganglion block.

A gestão de grávidas com histórico de vício ou abuso de substâncias pode ser desafiadora. Este tutorial foca nos efeitos patofisiológicos do vício em drogas, fornecendo cuidados perioperatório seguros e atingindo analgesia tanto durante o trabalho de parto quando após uma cesárea.

Update in Anaesthesia #34 Obstetrics Special

Update in Anaesthesia #34 Obstetrics Special

Maternal mortality rate in developing countries is 20 times higher than in developed countries. Detailed reports surrounding maternal deaths have noted an association between substandard management during emergency events and death. In parallel with these findings, there is increasing evidence for cognitive aids as a means to prevent errors during perioperative crises. However, previously published findings are not directly applicable to cesarean delivery in low-income settings. Our hypothesis was that the use of obstetric anesthesia checklists in the management of high-fidelity simulated obstetrical emergency scenarios would improve adherence to best practice guidelines in low- and middle-income countries.

It is unknown whether the implementation of an information video on spinal anesthesia for cesarean delivery, narrated in a patient’s first language, reduces anxiety, increases satisfaction, and improves doctor–patient communication if there is a language barrier. In South Africa, most doctors speak English, and patients speak Xhosa, with educational and cultural disparities existing in many doctor–patient interactions.

Maternal mortality in low- and middle-income countries (LMICs) is higher than in high-income countries (HICs), and poor anesthesia care is a contributing factor. Many anesthesia complications are considered preventable with adequate training. The Safer Anaesthesia From Education Obstetric Anaesthesia (SAFE-OB) course was designed as a refresher course to upgrade the skills of anesthesia providers in low-income countries, but little is known about the long-term impact of the course on changes in practice. We report changes in practice at 4 and 12–18 months after SAFE-OB courses in Madagascar and the Republic of Congo.

Maternal mortality is high in many low- and middle-income countries. Unsafe anaesthesia contributes to this, especially for women requiring Caesarean section. Anaesthesia providers with limited skills and poor resources are often faced with complicated obstetric patients. A new course called SAFE-OB teaches a systematic approach to anticipating, preparing for, and dealing with obstetric anaesthetic emergencies. The course has now been taught in many African, Asian, and Latin countries. Initial follow-up suggests improvement in skills and knowledge, and effective translation of these to the workplace. Efforts are made to make the course locally owned and sustainable. We feel that SAFE-OB is an effective method of improving obstetric anaesthesia care.

Postpartum hemorrhage remains the leading cause of maternal mortality and morbidity. Oxytocic drugs are the main stay in prevention as well as treatment. Oxytocin remains the drug of choice

Deaths of babies in the first 28 days of life in resource-limited countries can be significantly reduced with a small number of low-tech interventions. This article summarises the core equipment and skills needed for the resuscitation of newborns where equipment is limited and skilled paediatric support is not available.

Physiological changes in the parturient occur due to the needs of the developing foetus. Understanding these changes is important when administering anaesthesia to the obstetric patient. Additionally, understanding the physiological effects in the foetus allows for appropriate intrauterine monitoring and expedient delivery if there are signs of foetal hypoxia.

Sepsis remains one of the four main causes of maternal mortality. Common causes of severe sepsis & septic shock during pregnancy include pyelonephritis, infection during labour and peurpurium & respiratory infection.

Trauma during pregnancy is the leading non-obstetrical cause of maternal death and remains the most common cause of foetal demise. Trauma management needs multidisciplinary team of emergency physician, obstetrician, anesthesiologist & surgeons. Major trauma causes obstetric & fetal complications & may end by maternal death.

Obesity is one of the greatest public health challenges of the 21st century. Obesity during pregnancy puts the mother, fetus and neonate at higher risk of morbidity and mortality during the antenatal, intrapartum and postnatal periods.

The anaesthesiologist’s expertise in treatment of the parturient and massive haemorrhage resuscitation is a valuable component of the multidisciplinary care team’s capacity to reduce maternal and perinatal morbidity and mortality. This article reviews recent updates in the diagnosis and management of placental pathology and will present challenges facing today’s obstetric anesthesiologist.

Pre-eclampsia causes significant morbidity and mortality to both mother and foetus worldwide, the major causes being delayed diagnosis and poor management. Identifying the parturient at risk of developing pre-eclampsia is paramount and optimising this patient cohort is key. Early management of pre-eclampsia favours a better outcome with magnesium sulphate and anti-hypertensive medications being the mainstay of treatment.

The cause of maternal collapse and cardiorespiratory arrest is not always immediately apparent. A generic approach based on Basic and Advanced Adult Life Support is recommended. Key modifications to these algorithms are required in pregnancy. These include early intubation and the use of lateral tilt or uterine displacement.

The health of women correlates strongly with the social and economic well-being of a community. However, pain during childbirth is undertreated in variable resource environments Epidurals provide safe and efficient provision of anesthesia for unplanned or emergent cesarean delivery. This article focuses on establishing an epidural service to provide labour analgesia and anesthesia for nonscheduled cesarean delivery.

Labour epidurals provide safe, effective analgesia with minimal side effects to mother and fetus. Knowledge of anatomy and pain pathways are key to providing epidural analgesia to labouring parturients. Consent can be challenging during active labour.

Total spinal or a high neuraxial blockade is a recognised complication of central neuraxial techniques. A high number of incidents of a high neuraxial block are being reported in obstetrics following the increased use of neuraxial anaesthesia.

Caesarean section is the most frequently performed obstetric surgical procedure, and spinal anaesthesia is a common anaesthetic technique used across the world. It produces rapid, dense, predictable block, is relatively easy to perform with a definite end point and has a very high success rate.

General anaesthesia for caesarean section entails the risk of life-threatening complications such as difficult airway management and aspiration pneumonia, and it is therefore recommended that it be avoided whenever possible in favour of neuraxial anaesthesia.

Obstetric airway management has long been associated with an increased risk of failed tracheal intubation and airway-related morbidity and mortality. However, there is little evidence that failed intubation rates have fallen despite recent advances in airway equipment and techniques.

Members of WFSA's Obstetric anaesthesia committee and experts in obstetrics anaesthesia from around the globe, offers an important contribution to improve patient care and access to safe peripartum care.