ABC of labour care: induction

Dear Sir
We read with interest the informative articles in the ‘ABC of labour care’
series that has recently been completed in the BMJ. We wish to rectify an
important omission; namely the role of the obstetric anaesthetist on the
labour ward.

The most recent report on Confidential Enquiries into Maternal Deaths
in the UK, 1994-6 [1] has repeatedly highlighted the importance of
multidisciplinary care for pregnant women. The report specifically
establishes lack of teamwork as one of the identifiable causes of
substandard care. The leading causes of maternal death in the UK are
thromboembolism, pregnancy-induced hypertension, amniotic fluid embolism,
and haemorrhage. Not only does the anaesthetist have a key role to play in
clinical management when these emergencies arise, but he or she should
also be involved in the development of labour ward guidelines for dealing
with these situations.

There have been at least two publications from the Royal College of
Obstetricians and Gynaecologists emphasising the need for early
involvement of anaesthetists and haematologists in the management of major
haemorrhage [2,3].

Many sick mothers are now admitted to intensive or high dependency
care units, where an anaesthetist will be at least partly responsible for
clinical management. Early involvement of the anaesthetist on the labour
ward may facilitate earlier transfer of sick mothers; delay in such
transfer has been identified as a cause of substandard care in mothers who
die in childbirth.

The article on operative deliveries makes reference to the
desirability of regional anaesthesia, but fails to state the main risks of
general anaesthesia, namely the risk of difficult or failed endotracheal
intubation, with the consequent risks of hypoxia and aspiration of gastric
contents. The indications given for general anaesthesia are controversial,
and would be disputed by many obstetric anaesthetists. We believe that the
importance of early identification of mothers at risk of operative
delivery should be emphasised since this enables regional analgesia to be
instituted before the need for urgent Caesarean section arises. Similarly
our obstetricians believe that it is important to have an anaesthetist
present for all trials of instrumental delivery, and that such deliveries
should take place in the operating theatre so that immediate extension of
regional block can be provided should Caesarean section become necessary.

Finally we believe that the series should have mentioned the
increasing number of women who become pregnant despite significant
coexisting medical disease. Repeated reports have recommended early
identification of these women, so that they can be properly assessed
during the antenatal period, and so that plans for management of
pregnancy, delivery and the puerperium can be made. It is recognised that
care of these high risk women should be multidisciplinary if substandard
care is to be avoided. The most recent Confidential Enquiries report
recommends that better links be established between obstetricians and
other departments, and that more consultant anaesthetists with special
interest in pregnancy be appointed. For the past seven years our hospital
has held a regular antenatal clinic for women with medical and anaesthetic
problems in pregnancy. This clinic is run by a consultant anaesthetist,
and operates in parallel with the high-risk obstetrician-led antenatal
clinic. We suggest this as a possible model for improved communication
between disciplines in the management of women with coexisting disease.

The latest Confidential Enquiries report concludes by emphasising yet
again the importance of communication between all those responsible for
the care of women in childbirth. This view has been echoed in two recent
editorials [4,5], one of which also notes that in some centres 70%
parturients may require the services of the obstetric anaesthetist [4]. We
conclude by urging your readers to remember that the anaesthetist is one
of the key professionals involved in the care of pregnant women.
Yours faithfully

Dominic Aldington BSc MBBS

Specialist Anaesthetic Registrar

Diana Brighouse BM MA FRCA

Consultant Anaesthetist

References

1. Why mothers die. Report on Confidential Enquiries into Maternal Deaths
in the UK 1994-1996. London: HMSO; 1998

2. Patel N. (Ed) Maternal Mortality – The Way Forward. London: Royal
College of Obstetricians and Gynaecologists; 1992

3. Royal College of Obstetricians and Gynaecologists. Deriving Standards
from the Maternal Mortality Reports. London: Royal College of
Obstetricians and Gynaecologists; 1994

4. Crowhurst JA, Plaat F. Why Mothers Die – Report on Confidential
Enquiries into Maternal Deaths in the United Kingdom 1994-96. Anaesthesia
1999; 54:207-209

5. May AE. The Confidential Enquiry into Maternal Deaths 1994-1996.
International Journal of Obstetric Anesthesia 1999; 8:77-78