Artigo recomendado: Anaesthesia chapter from Saving Mothers’ Lives: reviewing maternal deaths to make pregnancy safer

G. M. Cooper and J. H. McClure

Br J Anaesth 2008; 100: 17–22

INTRODUCTION

This chapter concerning maternal mortality due to anaesthesia, reprinted with permission from Saving Mothers’ Lives, is the 18th in a series of reports within the Confidential Enquiries into Maternal and Child Health (CEMACH) in the UK. In the years 2003–05 there were six women who died from problems directly related to anaesthesia, which is the same as the 2000–02 triennium.

Obesity was a factor in four of these women who died. Two of these deaths were in women in early pregnancy, who received general anaesthesia for gynaecological surgery by inexperienced anaesthetists who failed to manage the airway and ventilation adequately. When trainee anaesthetists are relatively inexperienced their consultants must know the limits of their competence and when close supervision and help may be needed. One death was due to bupivacaine toxicity due to a drug administration error when a bag of dilute local anaesthetic was thought to be intravenous fluid. In a further 31 cases poor perioperative management may have contributed to death.

Obesity was again a relevant factor. Other cases could be categorized into poor recognition of women being sick and poor clinical management of haemorrhage, sepsis and of pre-eclampsia. Early warning scores of vital signs may help identify the mother who is seriously ill. Learning points are highlighted in relation to the clinical management of these obstetric complications.

Anaesthesia: specific recommendations

All patients, including women in early pregnancy whose treatment is generally managed by gynaecological services, require the same high standard of anaesthetic care. This includes early recovery from anaesthesia for which anaesthetic services have full responsibility. Recovery staff must be able to receive immediate effective assistance from an anaesthetist until the woman is fully conscious and has stable vital signs.

Trainee anaesthetists must be able to obtain prompt advice and help from a designated consultant anaesthetist at all times. They and their consultants must know the limits of their competence and when close supervision and help are needed. Morbidly obese women should not be anaesthetized by trainees without direct supervision.

Trainees across all specialties may not have the experience or skill to recognize a seriously ill woman. Referral to a consultant or senior trainee should occur if there is any doubt about a woman’s condition. Early warning scores may help identify the mother who is seriously ill. Bedside estimation of haemoglobin concentration is valuable. Many of these points are reiterated in the ‘top-ten’ Recommendations of this Report.

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