Maternal critical care is not a formalized discipline and, as such, access to this scarce resource constitutes a major concern. The situation in South Africa is illustrative of the issues elsewhere. Critical care provision is not considered to be a major priority as the focus is instead on primary healthcare provision. Providing regular supply of oxygen cylinders to any hospital in rural Africa is both expensive and difficult. Early identification of the critically ill woman in developing regions is equally important as focusing, for critically ill obstetric patients, on basic infrastructure (facilities, transport, and electricity), accessibility, and basic equipment, essential drugs for advanced life support, blood, human resources, and quality of care. The challenge in the management of the critically ill antenatal or peripartum patient in poorly resourced settings is the need to tailor treatment around the significant cardiorespiratory, immunological, hematological, and metabolic alterations that accompany the gravid state.

Neuraxial analgesia techniques are commonly performed to relieve pain during labor and to provide analgesia during cesarean section. When combined spinal-epidural (CSE) is used for labor analgesia it provides a faster onset with minimal motor block. This chapter describes the history and use of CSE techniques in laboring patients and for cesarean section. It discusses the advantages and disadvantages of these techniques compared to traditional spinal and epidural techniques. The chapter outlines the use of continuous spinal anesthesia (CSA) in obstetric patients. The catheter appears to be at least as effective as with the epidural technique; however, CSE has a higher rate of complications (e.g. nerve damage, infection) and side effects (e.g. pruritus, fetal heart rate (FHR) abnormalities) compared to epidural analgesia. The theoretical advantages of hemodynamic stability and prolonged block can be easily achieved with other techniques such as CSE at much lower complication rates.

Hypotension following spinal anesthesia in obstetric patients is commonplace. Spinal anesthesia induces a sympathectomy, leading to vasodilation, increased venous capacitance, and decreased venous return. High levels of sympathetic blockade can decrease maternal cardiac output although with lesser height and degrees of sympathetic blockade a compensatory increase in cardiac output may be seen secondary to reductions in cardiac afterload. Risk factors associated with spinal-induced hypotension include: increasing age, pre-existing hypertension, higher infant birth weight and obesity. Many studies have been carried out to determine the role of ephedrine and phenylephrine during spinal anesthesia for cesarean section. Chronic hypotension, especially if accompanied by decreased cardiac output, may reduce placental perfusion and impair fetal oxygenation. Drawbacks to ephedrine include variable efficacy at prophylaxis of hypotension secondary to spinal anesthesia in low doses or in doses normally used in the clinical setting.

This chapter provides an overview of the normal changes in coagulation associated with pregnancy. It discusses the most common challenges experienced by anesthesiologists in the coagulopathic pregnant woman. The result is a hypercoagulable state that maintains placental function during pregnancy and protects the parturient from hemorrhagic complications during delivery but increases the risk of thromboembolism. The risks of neuraxial anesthesia in the coagulopathic parturient must be weighed against the risks of the alternatives and the gravity of the situation. Normal pregnancy imparts an increased tendency toward thrombus formation, extension, and stability. Epidural or spinal hematoma are rare and devastating complications of neuraxial anesthesia in parturients. Their occurrence is almost invariably associated with clinical coagulopathy or the use of anticoagulants. Decisions regarding the most appropriate anesthetic management for obstetric patients can be difficult and fraught with pitfalls.