Essay 04 – Safe Anesthesia: Right of Every Mother and Child

Primum non nocere– “First, do no harm” is the fundamental aspect of ethics of Hippocratic oath we took on our first day of MBBS and throughout our journey as an Anaesthesiologist. This aspect became a core principle of our practice.

Maternal and neonatal safety are cornerstone of our healthcare system. Not long ago , majority of deliveries used to happen at homes. Overtime obstetric care became more institutionalised and anaesthesia started forming a critical part of essential obstetric services. In our past two decades, MMR( Maternal Mortality Rate) has fallen dramatically  by about 70% between 2000 and 2020. But we have long journey ahead of us. Safe anaesthesia remains a privilege, not a right.

Safe anaesthesia is an ethical and medical right of every mother and newborn and not just a luxury. Mother’s in remote or resource poor setting often undergo surgery or interventions without full monitoring, trained staff or emergency backup. In rural PHC, many women undergo tubal ligation procedure under Local anaesthesia without proper monitoring and anaesthesia backup. Their high endurance for pain is taken for granted regardless of effectiveness of local anaesthesia. Hypotension, shivering and nausea , these are manageable risks.

For safe obstetric anaesthesia, we need to have not just skilled workforce but timely access to trained personnel, appropriate monitoring equipment. We should be well trained to perform airway management, prevention of aspiration , emergency resuscitation. A well equipped infrastructure must include essential equipment and basic drugs. We must sensitise the administration to provide ECG,  SpO2 , NIBP, capnography monitors so as to provide standard of care. Blood banks  to issue blood on priority basis for postpartum hemorrhage.

Of course lacunae and gaps are present in giving anaesthesia services at primary as well as in tertiary setups. Many of which are attributed to regional differences in health infrastructure, workforce and protocols. These gaps can be reduced by making policy initiatives and setting up our own guidelines and advisory to set uniform standards. In our own setup we must display difficult airway charts, maternal and neonatal resuscitation guidelines, organise mock drills, guidelines for managing postpartum hemorrhage. Setup Simulation labs for training of anaesthetists , obstetricians as well as primary healthcare providers at rural and urban centers.

Thesis and Audits need to be done on regular basis so as to collect data and hence update protocols to act upon it. Just to highlight importance of research , we came to know the importance of Magnesium Sulphate in prevention and treatment of Eclampsia in pregnant females through various meta-analysis. With the help of research we came to know about importance of tranexamic acid in bleeding parturients. Various pressor agents like phenylephrine and ephedrine found their specific role in our day to day practice. A decision of what and when a drug is to be used in a particular situation is mostly decided on it.

Through research itself we have established that Regional anaesthesia for cesarean section is preferable to General anaesthesia to lessen the risk of aspiration, avoid depressant anaesthetic drugs, shorten recovery time and hence reduce maternal and fetal morbidity and mortality

Respectful care, informed consent and adequate pain relief is a right of every mother. For working class women seeking health insurance , most of the policies either do not cover vaginal or cesarean section or keep a 2-3 years waiting period; this itself create hurdels in providing basic healthcare, increasing financial burden on families. Policy makers in government must make some amendments towards this cause.

Policy initiatives in India have made programs focused on Maternal health. LaQshya programme is to improve quality of care for pregnant women during labour and immediate postpartum period. Whereas PMSMA( Pradhan Mantri Surakshit Matritva Abhiyan) is to provide free , assured and quality antenatal checkup services to all pregnant women. Just recently IMR(Infant Mortality Rate) in Kerala has dropped to 5/1000 live births in 2023. This achievement is a result of decades of investment in maternal and child healthcare. We all can draw instirations from it.

Safe Anaesthesia must be elevated from a technical concern to a rights issue. The history shows progress but we have a long way to go.