The critical role of obstetric anaesthesia in low-income and middle-income countries
Authors: Jill M Mhyre
Journal: The Lancet Global Health (2016)

In the current issue of The Lancet Global Health, Soha Sobhy and colleagues1Sobhy S Zamora J Dharmarajah K et al.Anaesthesia-related maternal mortality in low-income and middle-income countries: a systematic review and meta-analysis.Lancet Glob Health. 2016; 4: e320-e327Scopus (92) Google Scholar have compiled the first systematic review and meta-analysis of anaesthesia-related maternal mortality in low-income and middle-income countries. They find that anaesthesia contributes 2·8% of all maternal deaths in these settings. Although this percentage is small, the overall frequency of anaesthesia-related maternal death is 300-fold higher for neuraxial anaesthesia and 900-fold higher for general anaesthesia than that reported for the USA (1·2 per 1000 women undergoing an obstetric procedure vs 3·8 per million, and 5·9 per 1000 vs 6·5 per million, respectively).2Hawkins JL Chang J Palmer SK Gibbs CP Callaghan WM Anesthesia-related maternal mortality in the United States: 1979–2002.Obstet Gynecol. 2011; 117: 69-74Crossref PubMed Scopus (212) Google Scholar This disparity highlights a significant opportunity for improvement in safe childbirth worldwide, because anaesthesia-related maternal mortality is almost always preventable. Sobhy and colleagues' study emphasises the relative safety of spinal anaesthesia when compared with general anaesthesia. When all goes well, spinal anaesthesia is the most straightforward anaesthetic technique for caesarean delivery. But occasionally spinal anaesthesia can lead to disaster. The South African National Confidential Enquiry into Maternal Deaths recently reported an increasing proportion of maternal deaths attributed to spinal anaesthesia.3Farina Z Rout C ‘But it's just a spinal’: combating increasing rates of maternal death related to spinal anaesthesia.S Afr Med J. 2013; 103: 81-82Crossref Google Scholar Furthermore, case reviewers noted that many general anaesthetic deaths actually occur in women for whom spinal anaesthesia was first attempted.3Farina Z Rout C ‘But it's just a spinal’: combating increasing rates of maternal death related to spinal anaesthesia.S Afr Med J. 2013; 103: 81-82Crossref Google Scholar Why is spinal anaesthesia so hazardous? Even in elective caesarean delivery, careful attention to haemodynamic stability is essential; left unattended, mounting hypotension can trigger fatal dysrhythmia and haemodynamic collapse. Haemorrhage, dehydration, and sepsis compound the risk of haemodynamic collapse with spinal anaesthesia, and general anaesthesia is often safer for women with these conditions. When spinal anaesthesia produces an insufficient or excessively high blockade, general anaesthesia is indicated as a rescue technique. Certainly general anaesthesia presents substantial risk. Half of maternal deaths in the current study were attributed to complications of airway management during general anaesthesia,1Sobhy S Zamora J Dharmarajah K et al.Anaesthesia-related maternal mortality in low-income and middle-income countries: a systematic review and meta-analysis.Lancet Glob Health. 2016; 4: e320-e327Scopus (92) Google Scholar with additional consequences for infant survival. Technologies to detect oesophageal intubation (eg, auscultation, capnography, and pulse oximetry) must be universally available and applied, but alone will be insufficient to ensure maternal safety. Maternal airway management is notoriously difficult; the physiological changes of pregnancy lead to airway oedema, mucosal friability, difficult positioning, decreased oxygen reserves, and accelerated oxygen consumption and depletion. Multiple unsuccessful attempts to insert an endotracheal tube can worsen airway oedema to the point that facemask ventilation becomes impossible. Although endotracheal intubation is preferred for general anaesthesia in pregnancy, contemporary airway management guidelines recommend no more than two attempts to insert an endotracheal tube; when both attempts fail, a supraglottic airway (eg, laryngeal mask airway) can be inserted to provide ventilation and oxygenation until the caesarean delivery is complete.4Mushambi MC Kinsella SM Popat M et al.Obstetric Anaesthetists' Association and Difficult Airway Society guidelines for the management of difficult and failed tracheal intubation in obstetrics.Anaesthesia. 2015; 70: 1286-1306Crossref PubMed Scopus (308) Google Scholar Supraglottic airway devices do not protect the trachea from the aspiration of gastric contents. Although 31% of maternal deaths in Sobhy and colleagues' systematic review were attributed to aspiration of gastric contents,1Sobhy S Zamora J Dharmarajah K et al.Anaesthesia-related maternal mortality in low-income and middle-income countries: a systematic review and meta-analysis.Lancet Glob Health. 2016; 4: e320-e327Scopus (92) Google Scholar WHO has endorsed unrestricted food and drink in labour.5WHOCare in normal birth: a practical guide. World Health Organization, Geneva1997Google Scholar Clear liquids (eg, clear apple juice) consumed in labour satiate thirst, avoid ketosis, and facilitate stomach emptying. A non-particulate antacid swallowed immediately prior to the induction of general anaesthesia neutralises stomach contents. Should aspiration of gastric contents occur, injury is least when stomach contents are both neutral and free of solid food particles.6Knight PR Rutter T Tait AR Coleman E Johnson K Pathogenesis of gastric particulate lung injury: a comparison and interaction with acidic pneumonitis.Anesth Analg. 1993; 77: 754-760Crossref PubMed Google Scholar The combination of universal pulse oximetry and supplemental oxygen, a diet restricted to clear liquids in labour, the administration of a non-particulate antacid prior to induction of anaesthesia, and airway management protocols that call for a maximum of two attempts at laryngoscopy followed by supraglottic airway rescue could go a long way towards reducing death from general anaesthesia. The equipment needed for such an approach might not be universally available, so context-specific alternatives must be defined. For example, with a skilled surgeon, caesarean delivery can be completed under local anaesthesia infiltration with intravenous ketamine supplementation. Sobhy and colleagues emphasise the importance of medical training to ensure safe anaesthesia for caesarean delivery, and contrast the outcomes reported for non-physician and physician providers of anaesthetic care.1Sobhy S Zamora J Dharmarajah K et al.Anaesthesia-related maternal mortality in low-income and middle-income countries: a systematic review and meta-analysis.Lancet Glob Health. 2016; 4: e320-e327Scopus (92) Google Scholar The essential skills needed for safe anaesthetic care include the safe provision of both neuraxial and general anaesthesia in the context of obstetric complications.3Farina Z Rout C ‘But it's just a spinal’: combating increasing rates of maternal death related to spinal anaesthesia.S Afr Med J. 2013; 103: 81-82Crossref Google Scholar Post-anaesthesia monitoring and management also requires specific nursing expertise; postoperative complications including hypoventilation and haemodynamic collapse have been described.7Mhyre JM Riesner MN Polley LS Naughton NN A series of anesthesia-related maternal deaths in Michigan, 1985–2003.Anesthesiology. 2007; 106: 1096-1104Crossref PubMed Scopus (141) Google Scholar Massive open online courses and open access electronic journals and textbooks show promise to rapidly expand access to information. Electronic networks that connect learners with technical experts may be an effective strategy to spread expertise around the globe. But investigations into specific clinical contexts are needed to identify and address local factors that impede and facilitate improvements in care, and at the same time, define generalisable principles of how to accelerate innovations in perioperative patient safety.8Kopic D Sedensky M Owen M The impact of a teaching program on obstetric anesthesia practices in Croatia.Int J Obstet Anesth. 2009; 18: 4-9Summary Full Text Full Text PDF PubMed Scopus (18) Google Scholar, 9Olufolabi AJ Atito-Narh E Eshun M Ross VH Muir HA Owen MD Teaching neuraxial anesthesia techniques for obstetric care in a Ghanaian referral hospital: achievements and obstacles.Anesth Analg. 2015; 120: 1317-1322Crossref PubMed Scopus (14) Google Scholar, 10Ramaswamy R Iracane S Srofenyoh E et al.Transforming maternal and neonatal outcomes in tertiary hospitals in Ghana: an integrated approach for systems change.J Obstet Gynaecol. 2015; 37: 905-914Scopus (21) Google Scholar It is gratifying that obstetric surgery has finally emerged as a global health priority, and that this systematic review published in The Lancet Global Health points to the critical role of obstetric anaesthesia in ensuring the safety of childbirth around the world. I declare no competing interests. Anaesthesia-related maternal mortality in low-income and middle-income countries: a systematic review and meta-analysisThe current international priority on strengthening health systems should address the risk factors such as general anaesthesia and rural setting for improving anaesthetic care in pregnant women. Full-Text PDF Open Access