Pregnancy: The Obstetrician's View

16.3.06

Causes of improved mortality
• Improved medical care
-Infection control.
-Medical knowledge.
-Anaethetics.
-Drugs (antibiotics, oxtocins, antihypertensives, MgSO¬4).
-Diagnostic ability.
• Availability of care (NHS/transport).
• Improved maternal health.
• Education.
• Audit.
• Changes in parity.

International situation
• Huge disparity in health outcomes.
• Worst in sub-Saharan Africa.

Causes of maternal mortality (global)
• Haemorrhage ~ 25%.
• Sepsis ~ 15%.
• Unsafe abortions ~ 15%.
• Hypertension/eclampsia ~ 12%.
• Prolonged labour ~ 8%.
• Pre-existing disorders ~ 20%.

Africa's problems
• Delays in treatment.
-Women do not seek care.
§Traditional treatments used.
-Transport.
§Inadequate.
§Huge distances.
-Delays at institution.
• Organisation.
-Work overload.
-Low morale.
• Lack of facilities and supplies.
-Finance.

Goal: access to quality care when needed.

Worst case - Sierra Leone
• Worst health indicators - UN WDI.
• Life expectancy = 37 years.

Work experience - South Africa
• 1998-1999.
• Obstetrics and gynaecology.
• Eastern Cape.
-Old "white" and township facilities.
• High-risk obstetrics.
-Eclampsia/antipartum haemorrhage/postpartum haemorrhage.
-High maternal mortality.

Philosophy of care
• "Pregnancy is a physiological process."
• WHO objectives for maternity care:
1. Healthy mother.
2. Healthy baby.
3. Good experience.
• Reality: "Pregnancy is only normal in retrospect."
• Risk assessment unhelpful.

Midwives see normal, obstetricians see abnormal
• Midwives better at screening.
• Gives obstetricians biased view.
• Labour becoming medicalised.

Medicalisation of birth
• Global rise in C-section rates.
• 90% in Brazil.
• At some time in some places, normal to have general anaesthetic to give birth.
• Upper class 30s women more at risk.
• Intervention leads of intervention.
• Academics tend to be medics not midwives.
• Power held with medical profession.
• Medics only see abnormal/complicated.
• Drives medicalisation and patient preference.

Reasons for caesarean section increase
• Society trends - convenience, control.
• Low threshold if foetal concerns.
• Safety of procedure.
• Patient preference.
• Medical ease.
• Litigation.
• Declining skills - complex vaginal deliveries.

Alternatives
• Hospital midwifery-led units.
• Community birth centres.
• Home birth.
• Birth Choice UK.
-Information on birth statistics.
-Different units.
Intervention rate.
• National Childbirth Trust.
-Established 1957.
-Independent.

Obstetrician's role in pregnancy
1. Pre-conceptual
• Counselling.
• Optimise medical conditions.
• Advise against pregnancy.
-Severe renal disease.
-Pulmonary hypertension.

2. Pre-natal
• Screening issues.
• Down's/spina bifida.
• Invasive testing.

3. Antenatal
• General obstetrics.
• Medical disorders.
• Foetal medicine.

4. Delivery
• IOL decisions.
• Manage abnormal labour.
• Operative delivery.
• HDU care.

5. Post-natal
• Counselling.
-Problems.
-IUFD.
-Referral.
• ?? Ongoing care eg. hypertension.

Liverpool Women's Hospital labour ward - tertiary care
• 24-hour cover.
• Multidisciplinary team.
-3 obstetricians.
-2 anaesthetists.
-12 midwives.

The future?
• Pre-natal implantation diagnosis.
• Non-invasive diagnosis.
-Genetic conditions.
-Free foetal DNA in maternal blood.
§Molecular genetics.
§Endless possibilities.
• Earlier identification of problems - USS 11-14 weeks.
• Effective interventions for:
-PET, preterm labour.
• Foetal surgery - spina bifida, diaphragmatic hernia, twin laser.
• Delivery by caesarean section??

Job in obstetrics?
• Recruitment crisis.
• Poor work-social balance.
• Consultant resident on-call.
• Fear of litigation.