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.

In the triennium 2006-2008, 261 women in the UK died directly or indirectly related to pregnancy. The overall maternal mortality rate was 11.39 per 100,000 maternities. Direct deaths decreased from 6.24 per 100,000 maternities in 2003-2005 to 4.67 per 100,000 maternities in 2006­2008 (p = 0.02). This decline is predominantly due to the reduction in deaths from thromboembolism and, to a lesser extent, haemorrhage. For the first time there has been a reduction in the inequalities gap, with a significant decrease in maternal mortality rates among those living in the most deprived areas and those in the lowest socio-economic group. Despite a decline in the overall UK maternal mortality rate, there has been an increase in deaths related to genital tract sepsis, particularly from community acquired Group A streptococcal disease. The mortality rate related to sepsis increased from 0.85 deaths per 100,000 maternities in 2003-2005 to 1.13 deaths in 2006-2008, and sepsis is now the most common cause of Direct maternal death. Cardiac disease is the most common cause of Indirect death; the Indirect maternal mortality rate has not changed significantly since 2003-2005. This Confidential Enquiry identified substandard care in 70% of Direct deaths and 55% of Indirect deaths. Many of the identified avoidable factors remain the same as those identified in previous Enquiries. Recommendations for improving care have been developed and are highlighted in this report. Implementing the Top ten recommendations should be prioritised in order to ensure the overall UK maternal mortality rate continues to decline.

Obstetric anaesthetic deaths in context.

PURPOSE OF REVIEW: Although there have been few recent publications about obstetric deaths due to anaesthesia, it is timely to review their occurrence and put them into context. Health services are under constant review and a recent Department of Health publication highlights the need for safer care. Changes, including those related to training and permitted hours of work, may impact on safety. Without knowing where we are now, we cannot know whether these changes are an improvement or not. RECENT FINDINGS: The UK Confidential Enquiry reports have tracked anaesthetic-related deaths since 1952. During the 1990 s, the numbers became almost irreducible: the last report gave six deaths caused by anaesthesia. This review puts these into a global perspective. SUMMARY: Medical intervention undoubtedly saves many lives. Concerns about a possible increase in anaesthetic maternal mortality must be kept in perspective with the overall benefits. The growing complexity of problems such as maternal disease, obesity, and the increasing age of motherhood, nevertheless, increases the challenges presented. Multidisciplinary working is all-important.

The challenges of obesity and obstetric anaesthesia.

PURPOSE OF REVIEW: The aim of this article is to review the clinical challenges of obesity in obstetrics from the anaesthetist's viewpoint. RECENT FINDINGS: The prevalence of obesity continues to increase both in the community and on the labour ward. Women who have undergone bariatric surgery are also on rise. During pregnancy, obesity is associated with hypertensive disease (chronic hypertension and preeclampsia), diabetes mellitus (pregestational and gestational), respiratory disorders (asthma and sleep apnoea), thromboembolic disease, caesarean section and infections (primarily urinary tract infections, wound infections and endometritis). Obesity is a risk factor for anaesthesia-related maternal mortality. Obese women are not only at high-risk of airway complications, cardiopulmonary dysfunction, perioperative morbidity and mortality but also pose technical challenges. Obesity also influences the fetal outcomes. Increasing use of regional techniques contributes to the reduced anaesthesia-related maternal mortality. Preconception counselling, antenatal screening and anaesthetic assessment are strongly encouraged. SUMMARY: Effective communication and good teamwork between an anaesthetist and an obstetrician are essential for the care of obese parturients. A more liberalized use of regional techniques may be a means of further reducing the anaesthesia-related maternal mortality.

Randomized controlled trial comparing traditional with two "mobile" epidural techniques: anesthetic and analgesic efficacy.

BACKGROUND: The authors recently showed that "mobile" epidural analgesia, using low-dose local anesthetic-opioid mixtures, reduces the impact of epidural analgesia on instrumental vaginal delivery, relative to a traditional technique. The main prespecified assessment of pain relief efficacy, women's postpartum estimates of labor pain after epidural insertion, did not differ. The detailed analgesic efficacy and the anesthetic characteristics of the techniques are reported here. METHODS: A total of 1,054 nulliparous women were randomized, in labor, to receive boluses of 10 ml 0.25% bupivacaine (traditional), combined spinal-epidural (CSE) analgesia, or low-dose infusion (LDI), the latter groups utilizing 0.1% bupivacaine with 2 microg/ml fentanyl. Visual analog scale pain assessments were collected throughout labor and delivery and 24 h later. Details of the conduct of epidural analgesia, drug utilization, and requirement for anesthesiologist reattendance were recorded. RESULTS: A total of 353 women were randomized to receive traditional epidural analgesia, 351 received CSE, and 350 received LDI. CSE was associated with a more rapid onset of analgesia, lower median visual analog scale pain scores than traditional in the first hour after epidural insertion, and a significant reduction in bupivacaine dose given during labor. Pain scores reported by women receiving LDI were similar to those in the traditional group throughout labor and delivery. Anesthesiologist reattendance was low but greater with each mobile technique. CONCLUSIONS: Relative to traditional epidural analgesia, LDI is at least as effective and CSE provided better pain relief in the early stages after insertion. The proven efficacy of mobile epidurals and their beneficial impact on delivery mode make them the preferred techniques for epidural pain relief in labor.