Table Of ContentCrises in Childbirth
Why Mothers Survive
LESSONS FROM THE CONFIDENTIAL
ENQUIRIES INTO MATERNAL DEATHS
Edited by
Daryl Dob BSc MB BS FRCA
Consultant Obstetric Anaesthetist
Chelsea and Westminster Hospital
Griselda Cooper OBE FRCA FRCOG
Senior Lecturer in Anaesthesia and Honorary Consultant Anaesthetist
Birmingham Women’s Hospital
and
Anita Holdcroft MB ChB MD FRCA
Reader in Anaesthesia and Honorary Consultant Anaesthetist
Imperial College London and Chelsea and Westminster Hospital
Foreword by
Professor Philip Steer BSc MB BS MD FRCOG
Includes an Introduction by
Gwyneth Lewis MSc MRCGP FFPH FRCOG
Director, UK Confi dential Enquiries into Maternal Deaths on behalf of the CEMACH
Radcliffe Publishing Ltd
18 Marcham Road
Abingdon
Oxon OX14 1AA
United Kingdom
www.radcliffe-oxford.com
Electronic catalogue and worldwide online ordering facility.
© 2007 Daryl Dob, Griselda Cooper and Anita Holdcroft
Daryl Dob, Griselda Cooper and Anita Holdcroft have asserted their right under
the Copyright, Designs and Patents Act 1998 to be identifi ed as the authors of
this work.
All rights reserved. No part of this publication may be reproduced, stored
in a retrieval system or transmitted, in any form or by any means, electronic,
mechanical, photocopying, recording or otherwise without the prior permission
of the copyright owner.
British Library Cataloguing in Publication Data
A catalogue record for this book is available from the British Library.
ISBN-13: 978 1 84619 049 0
Typeset by Egan Reid, Auckland, New Zealand
Printed and bound by TJI Digital, Padstow, Cornwall
This book is dedicated to the families of the
mothers who died, and to the anaesthetists who
prevent maternal death, past, present and future.
Contents
Foreword vi
Preface vii
About the editors viii
List of contributors x
List of abbreviations xiii
1 Saving mothers’ lives: the contribution of the Confi dential
Enquiries into Maternal Deaths to improving maternal
health in the UK 1
GWYNETH LEWIS
2 General anaesthesia and failure to ventilate 19
MARK STACEY
3 General anaesthesia and acid aspiration 47
MICHELLE SCOTT AND MICHAEL WEE
4 Regional anaesthesia 67
MICHAEL KINSELLA, DARYL DOB AND ANITA HOLDCROFT
5 Haemorrhage 87
BERNARD NORMAN
6 Hypertension 110
MICHAEL KINSELLA AND MARK SCRUTTON
7 Cardiac disease 130
ROBIN RUSSELL
8A Thromboembolism 147
GORDON LYONS AND MITKO KOCAREV
8B Amniotic fl uid embolism 159
MITKO KOCAREV AND GORDON LYONS
9 Sepsis 168
MICHELLE HAYES
10 Intensive care 187
TOM CLUTTON-BROCK
References 201
Index 219
v
Foreword
When I began my training in obstetrics, anaesthetists were not often seen on the
average delivery suite. They were called only to give the general anaesthetic for the
one or two Caesarean sections per week that then took place, and for one or two
Caesarean hysterectomies a year. Regional anaesthesia was very uncommon and was
often seen as the job of the obstetrician (as, in those days, was neonatal care).
Since then, the specialty of obstetric anaesthesia has come of age, and it is
even rumoured that consultant obstetric anaesthetists now outnumber consultant
obstet ricians. Major advances in anaesthetic techniques and improvements in the
understanding of pathophysiology have resulted in the suggestion that obstetric
anaesthetists might restyle themselves as ‘peripartum physicians.’ This book refl ects
and recognises the growing input that obstetric anaesthetists have made not only
in the care of normal labour in respect of analgesia, but also in the management of
complications, be they medical or surgical. The reductions in maternal mortality over
the last half century are an eloquent testimony to the value of the technical expertise
in life support that anaesthetists bring to the management of labour complications.
Many direct causes of maternal death have been substantially reduced as a result of
anaesthetic innovations ranging from advances in regional anaesthesia to the panoply
of techniques used in intensive care. However, obstetric anaesthetists face new chal-
lenges – not least, for example, from the rapidly growing cohort of women with
surgically ameliorated congenital heart disease. The latter group now represents almost
1% of all pregnant women, and together with the frequent acquired lesions seen in
the growing number of refugees, death associated with cardiac disease in pregnancy
has become one of the major contributors to maternal mortality in the UK. Moreo ver,
the numbers of such deaths have doubled over the last 15 years. There is never any
place for complacency – every maternal death should be considered one too many.
So this book is essential reading for every obstetric anaesthetist, and obstetric ians
would also benefi t greatly from carefully studying the lessons that it contains.
Professor Philip Steer BSc MB BS MD FRCOG
Professor of Obstetrics, Faculty of Medicine
Imperial College London
Honorary Consultant Obstetrician, Chelsea and Westminster Hospital
March 2007
vi
Preface
Those who do not remember the past are condemned to repeat it.
George Santayana (1863–1952)
For more than 50 years the Confi dential Enquiries into Maternal Deaths in the
UK have collected together invaluable information about why mothers die in
pregnancy and childbirth. Analysis of the reasons behind the deaths, suggested
protocols for avoidance of death in similar cases, and an often sympathetic view of
the diffi culties facing both mothers and healthcare professionals have led to each
triennial publication being essential reading for anyone involved in obstetrics and
perinatal medicine.
Often, however, it seemed that the new lessons were eagerly learned, and the old
ones quickly forgotten.
For the fi rst time ever, this unique book collects together all of the valuable lessons
from recent triennia into one volume. Experts in their fi elds provide a physiological,
pharmacological and evidence-based commentary on the events of each death.
The overall result pays homage to the value of collecting together lessons from
the past, and we hope that it will help people to avoid repetition of these situations
in the future.
We must thank the Confi dential Enquiries into Maternal and Child Health
(CEMACH), past and present, for their invaluable cooperation and wholehearted
support in the writing of this book, particularly the Chief Executive, Richard
Congdon.
Thanks also go to our fellow authors, who have contributed magnifi cently in such
a timely fashion, and fi nally to our publishers, Radcliffe Publishing, in Oxford, who
have turned this important idea into a reality.
Daryl Dob
Griselda Cooper
Anita Holdcroft
March 2007
vii
About the editors
Dr Daryl Dob is a consultant obstetric anaesthetist at Chelsea and Westminster
Hospital, London. He has studied, practised and taught obstetric anaesthesia for
many years. He is married to Lorraine, and has a daughter, Isis.
Dr Griselda Cooper is a Senior Lecturer in Anaesthesia at the University of
Birmingham, and is an honorary consultant anaesthetist at Birmingham Women’s
Hospital, the University Hospital Birmingham and Birmingham Children’s Hospital.
She was previously Senior Lecturer at the University of Bristol and a consultant
anaesthetist in Dunedin, New Zealand. Her main clinical and research interests are
in obstetric anaesthesia and analgesia, areas in which she has published widely. She is
a central assessor in anaesthesia for the Confi dential Enquiries into Maternal Deaths,
and is a Board and Consortium member of the Confi dential Enquiries into Maternal
and Child Health (CEMACH). She has been a Council member of the Royal College
of Anaesthetists (RCA) since 1998, and is currently one of their Vice-Presidents. She
has represented the RCA on several Royal College of Obstetrics and Gynaecology
(RCOG) and Department of Health working parties related to maternity care. In
2006, she was awarded an OBE for services to medicine in Birmingham. She is
married to Brian, a consultant physician, and they have a daughter, Charlotte.
Dr Anita Holdcroft is an academic anaesthetist working at Imperial College London
and Chelsea and Westminster Hospital. She completed her undergraduate training
at Sheffi eld University and then at the Royal Postgraduate Medical School and
Hammersmith Hospital, before taking up a Senior Lecturer appointment at Charing
Cross Medical School, where she completed her MD (in cardiovascular changes
during anaesthesia and analgesia) at the West London Hospital. She was appointed
Professor of Anaesthesia to the University of Jos, Nigeria and established a new
anaesthetic department there, focused on reducing mortality from eclampsia and
haemorrhage. She returned to the UK to lead the obstetric anaesthetic service at the
Hammersmith Hospital for many years, until the academic anaesthetic department
there was closed in 2000, when she relocated to her present post. Anita is known
for her work in pain medicine, especially in relation to women. She has written
a textbook entitled Principles and Practice of Obstetric Anaesthesia and has edited
Core Topics in Pain. She is on the Editorial Board of the International Journal for
Obstetric Anesthesia. In addition, she has served as President of the Section Forum
viii
ABOUT THE EDITORS ix
on Maternity and the Newborn of the Royal Society of Medicine, as the Co-Chair
of the International Association for the Study of Pain Special Interest Group on Sex,
Gender and Pain, and is the Deputy Chair of the Medical Academic Staff Committee
of the British Medical Association, where she leads developments in women’s careers.
Anita is the originator and lead of the Obstetric Anaesthetists’ Association and the
CEMACH Diabetes Project. She has published and presented many papers on
obstetric anaesthesia and pain in women, and her expertise is sought internationally
through grant-awarding bodies. Her doctoral students are working on the history of
obstetric anaesthesia in the UK, especially the role of the Confi dential Enquiries into
Maternal Deaths, and on the development of new drugs for labour analgesia. She is
married to Erasmus, and they have four daughters.
