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Year : 2013  |  Volume : 3  |  Issue : 2  |  Page : 67-69

Sustaining two lives…

Department of Anesthesiology and Intensive Care, Faculty of Medicine, University of Malaya, 59100 Kuala Lumpur, Malaysia

Date of Web Publication19-Dec-2013

Correspondence Address:
Yoo Kuen Chan
Department of Anesthesiology and Intensive Care, Faculty of Medicine, University of Malaya, 59100 Kuala Lumpur
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/2249-4472.123296

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How to cite this article:
Chan YK. Sustaining two lives…. J Obstet Anaesth Crit Care 2013;3:67-9

How to cite this URL:
Chan YK. Sustaining two lives…. J Obstet Anaesth Crit Care [serial online] 2013 [cited 2021 Aug 1];3:67-9. Available from: https://www.joacc.com/text.asp?2013/3/2/67/123296

Every year half a million parturients around the world [1] die as a result of their pregnancies. Another 3 million babies die as stillbirths and a further 3.8 million die as neonatal deaths. [1] These huge numbers of unnecessary deaths are probably not obvious to their care-providers, much less to the public in general. Obstetric providers, administrators and all who are involved in the care of this population, have a huge responsibility to bring these staggering numbers down.

From a physiological point of view, lives are sustained [2] through ensuring the tissue needs of the parturient or the fetus are met. The parturient's life is usually threatened [3],[4],[5] by massive hemorrhage, pre-eclampsia, [6] sepsis, thromboembolism and amniotic fluid embolism - all of which affect the delivery of oxygen to the maternal tissues. Interestingly when one moves from one country [4],[5] to another regardless of economic levels, the life-threat to the parturient remains the same. Even when the causes of maternal deaths are examined over a few decades of care in the same country [4],[5],[7] the predominant life-threats remain fairly unchanged.

The fetus is without question more at risk of death since the pathway of oxygen from the environment to the fetal tissue is an even longer one. It is dependent on obtaining oxygen from the parturient [8] through the uterine blood flow, placental transfer and the intact fetal circulation. [9] This may explain the greater ratio of five stillbirths to every maternal death globally. All fetuses compensate for this hypoxia [10] by increasing their hemoglobin level, by producing fetal hemoglobin with its higher oxygen affinity and by the special phenomenon of "double Bohr" on the maternal and fetal oxygen dissociation curves to increase the gradient for better oxygen diffusion from parturient to the fetus. The hypoxia in the fetal tissue is in addition compensated for by a redesign of the fetal circulation [11] compared with the adult circulation to ensure more favorable oxygen flow to the brain [12] in preference to the other organs.

As a provider (albeit in a more limited manner than the obstetrician) of obstetric care, the well-being of both should be within our purview. Any threat to the life of the parturient might ultimately translate to a threat to the life of the fetus. Death [13] is part of the continuum of outcome we see in our obstetric care provision. Lesser forms of life-threat can be seen in the intensive care admissions of these parturients [14] or their newborn or the cerebral palsies [15] detected very much later in the lives of the newborn.

Strengthening care in the areas that has been flagged to be recurring annually seems like a simple measure. In reality, the lessons from these never seem to be learnt. If the lesson learnt from each maternal death is used to strengthen the systems in a hospital or a district, ultimately the level of care will definitely improve. The next parturient need not suffer the same fate as her predecessor through the same failure in the system. Protocols of care should be written and updated for these recurring events. We do know of well-written protocols/guidelines for hemorrhage, [16] for sepsis, [17] for the management of pre-eclampsia [18] and for cardiac disease in pregnancy which can be adapted and modified for local consumption. Drills to make providers understand how they can better perform as a team [19],[20] during such life-threatening events are encouraged as a measure of improving the level of care. Senior help should be obtained sooner than later and consultants of the two disciplines, i.e., obstetric and anesthesia should be involved earlier than often is the case. Administrators can institute better support through a variety of forms including - better paging system, 24 h blood banking and instituting sepsis bundles in the hospital setting. In countries where parturients face poor access to care, [21] the challenge in sustaining the parturient's life may be even more daunting. Increasing the use of skilled birth attendants for parturients may potentially improve outcome.

Education and continued education to improve the culture of appropriate care [22],[23] remain the mainstay. These strategies should not be limited to the providers but be extended to the education of patients [24] as well. Timely care [25] in most of these life-threats to the parturient may determine the outcome. In situations where parturients have been warned of the risk but are not acceding to the needs of admission, senior involvement to further educate the parturients of the risk is essential. Failure on the part of the parturients to cooperate with care may be due to fear of medical intervention, [25] lack of financial resources [26] and lack of faith in modern care.

There are many situations where the parturient's life may not be under threat but that of the fetus is. Most Anesthesiologists may not realize it but the life of the fetus is very much in our purview as much as it is in the obstetrician's. Recognizing the vulnerability of the fetus [15] and how they are compensating for the in utero hypoxic environment may be an excellent first step. Translating it further to good intrapartum monitoring [8],[13] and resuscitation [9],[10] especially when the signs of worsening hypoxia is occurring, would definitely go a long way to reducing the many still births, cerebral palsies and possibly peri-delivery newborn deaths. This is especially so when parturients present for high grade emergencies, prolapsed cords and abruptio placenta. Having the operation theatre in a perpetual ready state to receive the next emergency cesarean section and having a system to alert the team for a timely operative delivery would definitely cut down delays. Smaller measures [9],[10] that is within our own individual care delivery practices include putting parturients in the left lateral position [27] during transfers, administering oxygen to the parturient as a means to improve fetal oxygenation in the fetus with worsening hypoxia, terminating the use of uterotonic agents or possibly using the tocolytics like intravenous or subcutaneous terbutaline and correcting hypovolemia or hypotension appropriately in the parturients so that uterine blood flow is not compromised. Even if we are not handling emergencies, these measures should be internalized in providers as part of our care culture with the understanding that we are handling very vulnerable beings.

Our care if inadequate [15] leaves a lifetime of hardship for the affected parturient or the affected newborn. We have the skills in sustaining these lives and ensuring that hypoxia or asphyxia is avoided. We may not be able to do it alone - we need the determined effort of each and every provider who is involved in the field of obstetric care to play their part as a team. [19] As Anesthesiologists our role in this aspect may seemingly be limited to the time of delivery, but increasingly we are now involved early in high risk pregnancy discussions and assisting in formulating correct plans [28],[29] to thwart threats to the lives of both the parturient and her fetus. Encouraging the greater use of the modified early warning systems in obstetric care may also allow earlier recognition of the parturient who is unwell. [30]

  References Top

1.Lawn JE, Lee AC, Kinney M, Sibley L, Carlo WA, Paul VK, et al. Two million intrapartum-related stillbirths and neonatal deaths: Where, why, and what can be done? Int J Gynaecol Obstet 2009;107 Suppl 1:S5-18, S19.  Back to cited text no. 1
2.Chan YK. Basis of life. In: Chan YK, Ng KP, editors. Physiological Basis of Acute Care. Singapore: Saunders Elsevier; 2012. p. 5-11.  Back to cited text no. 2
3.Cantwell R, Clutton-Brock T, Cooper G, Dawson A, Drife J, Garrod D, et al. Saving Mothers′ Lives: Reviewing maternal deaths to make motherhood safer: 2006-2008. The Eighth Report of the Confidential Enquiries into Maternal Deaths in the United Kingdom. BJOG 2011;118 Suppl 1:1-203.  Back to cited text no. 3
4.Report on the confidential enquiries into maternal deaths in Malaysia 2006-2008. Published by the Ministry of Health Malaysia. Available from: http://www.fh.moh.gov.my/v3/index.php/ms/component/jdownloads/finish/16-kesihatan-ibu/127-cemd/0. [Last accessed on 2013 Nov 21].  Back to cited text no. 4
5.Gupta S. Obstetric anaesthesia: Widening horizons? Indian J Anaesth 2010;54:376-9.  Back to cited text no. 5
[PUBMED]  Medknow Journal  
6.Moodley J. Maternal deaths associated with eclampsia in South Africa: Lessons to learn from the confidential enquiries into maternal deaths, 2005-2007. S Afr Med J 2010;100:717-9.  Back to cited text no. 6
7.Report on the confidential enquiries into maternal deaths in Malaysia 1995-1996. Published by the Ministry of Health Malaysia. Available from: http://www.fh.moh.gov.my/v3/index.php/ms/component/jdownloads/finish/16-kesihatan-ibu/129-1995/0. [Last accessed on 2013 Nov 21].  Back to cited text no. 7
8.Newton ER. The fetus as a patient. Med Clin North Am 1989;73:517-40.  Back to cited text no. 8
9.Kither H, Monaghan S. Intrauterine fetal resuscitation. Anaesth Intensive Care Med 2013;14:287-90.  Back to cited text no. 9
10.Weale NK, Kinsella SM. Intrauterine fetal resuscitation. Anaesth Intensive Care Med 2007;8:282-5.  Back to cited text no. 10
11.Vajiravelu V. Maternal and foetal physiology. In: Chan YK, Ng KP, editors. Physiological Basis of Acute Care. Singapore: Saunders Elsevier; 2012. p. 145-50.  Back to cited text no. 11
12.Parer JT, King T. Intrapartum evaluation of the fetus. In: Stevenson DK, Benitz WE, Sunshine P, editors. Fetal and Neonatal Brain Injury: Mechanisms, Management and Risks of Practice. 3 rd ed. Cambridge: Cambridge University Press; 2003. p. 226-43.  Back to cited text no. 12
13.Heazell A. Peripartum and intrapartum assessment of the fetus. Anaesth Intensive Care Med 2013;14:333-6.  Back to cited text no. 13
14.Trikha A, Singh P. The critically ill obstetric patient - Recent concepts. Indian J Anaesth 2010;54:421-7.  Back to cited text no. 14
[PUBMED]  Medknow Journal  
15.Chan Y. Better understanding needed of physiology of sustaining life in utero. Lancet 2011;378:878.  Back to cited text no. 15
16.Maclennan K, Croft R. Obstetric hemorrhage. Anaesth Intensive Care Med 2013;14:337-41.  Back to cited text no. 16
17.Royal College of Obstetricians and Gynaecologists (RCOG). Bacterial Sepsis in Pregnancy. London (UK): Royal College of Obstetricians and Gynaecologists (RCOG); 2012. p. (Green-top guideline; no. 64a). Available from: http://www.rcog.org.uk/files/rcog-corp/11.6.12GTG64b.pdf. [Last accessed on 2013 Nov 21].  Back to cited text no. 17
18.Sibai BM, Barton JR. Expectant management of severe preeclampsia remote from term: Patient selection, treatment, and delivery indications. Am J Obstet Gynecol 2007;196:514.e1-9.  Back to cited text no. 18
19.Merién AE, van de Ven J, Mol BW, Houterman S, Oei SG. Multidisciplinary team training in a simulation setting for acute obstetric emergencies: A systematic review. Obstet Gynecol 2010;115:1021-31.  Back to cited text no. 19
20.Birch L, Jones N, Doyle PM, Green P, McLaughlin A, Champney C, et al. Obstetric skills drills: Evaluation of teaching methods. Nurse Educ Today 2007;27:915-22.  Back to cited text no. 20
21.Mavalankar DV, Rosenfield A. Maternal mortality in resource-poor settings: Policy barriers to care. Am J Public Health 2005;95:200-3.  Back to cited text no. 21
22.Goldberg H. Informed decision making in maternity care. J Perinat Educ 2009;18:32-40.  Back to cited text no. 22
23.McAllister E. Transparency in maternity care: Empowering women to make educated choices. J Perinat Educ 2008;17:8-11.  Back to cited text no. 23
24.Blankson ML, Goldenberg RL, Keith B. Noncompliance of high-risk pregnant women in keeping appointments at an obstetric complications clinic. South Med J 1994;87:634-8.  Back to cited text no. 24
25.Nahar S, Banu M, Nasreen HE. Women-focused development intervention reduces delays in accessing emergency obstetric care in urban slums in Bangladesh: A cross-sectional study. BMC Pregnancy Childbirth 2011;11:11. Available from: http://www.biomedcentral.com/1471-2393/11/11 [Last accessed on 2013 Nov 21]  Back to cited text no. 25
26.Nwameme AU, Phillips JF, Adongo PB. Compliance with emergency obstetric care referrals among pregnant women in an urban informal settlement of Accra, Ghana. Matern Child Health J 2013;Nov 1 [Epub ahead of print].  Back to cited text no. 26
27.Stacey T, Thompson JM, Mitchell EA, Ekeroma AJ, Zuccollo JM, McCowan LM. Association between maternal sleep practices and risk of late stillbirth: A case-control study. BMJ 2011;342:d3403.  Back to cited text no. 27
28.Avila WS, Rossi EG, Ramires JA, Grinberg M, Bortolotto MR, Zugaib M, et al. Pregnancy in patients with heart disease: Experience with 1,000 cases. Clin Cardiol 2003;26:135-42.  Back to cited text no. 28
29.Stangl V, Schad J, Gossing G, Borges A, Baumann G, Stangl K. Maternal heart disease and pregnancy outcome: A single-centre experience. Eur J Heart Fail 2008;10:855-60.  Back to cited text no. 29
30.Singh S, McGlennan A, England A, Simons R. A validation study of the CEMACH recommended modified early obstetric warning system (MEOWS). Anaesthesia 2012;67:12-8.  Back to cited text no. 30


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