Safe obstetric anaesthesia in low- and middle-income countries—a perspective from Africa

Learning objectivesBy reading this article, you should be able to:•Discuss the impact of resource limitation on the practice of obstetric anaesthesia.•Identify patients at high risk for adverse maternal outcomes in these settings.•Outline key areas where context-sensitive management might improve maternal outcomes.Key points•Perioperative maternal mortality rates are significantly higher in low- and middle-income countries than in high-income countries.•Evidence-based practice from these settings is limited and data are lacking.•The lack of trained anaesthetists is a key barrier to safe obstetric anaesthesia.•Identifying high-risk patients in advance may enable better use of limited resources.•Context-sensitive management may prevent complications in an accessible and safe manner. By reading this article, you should be able to:•Discuss the impact of resource limitation on the practice of obstetric anaesthesia.•Identify patients at high risk for adverse maternal outcomes in these settings.•Outline key areas where context-sensitive management might improve maternal outcomes. •Perioperative maternal mortality rates are significantly higher in low- and middle-income countries than in high-income countries.•Evidence-based practice from these settings is limited and data are lacking.•The lack of trained anaesthetists is a key barrier to safe obstetric anaesthesia.•Identifying high-risk patients in advance may enable better use of limited resources.•Context-sensitive management may prevent complications in an accessible and safe manner. Maternal and neonatal outcomes in low- and middle-income countries (LMICs) remain poor, despite gradual improvement. The global maternal mortality ratio (MMR) has declined from 339 to 223 deaths per 100,000 live births during the period 2000 to 2020, an annual reduction of 2.1% per year.1World Health OrganizationTrends in Maternal Mortality 2000 to 2020: Estimates by WHO, UNICEF, UNFPA, World Bank Group and UNDESA/Population Division. World Health Organization, Geneva2023Google Scholar However, the MMR in sub-Saharan Africa in 2020 was 545 (from 807 in 2000), with a lifetime risk of maternal death of 1 in 40 (compared to 1 in 16,000 in Australia and New Zealand). In 2020, sub-Saharan Africa still accounted for 70% of the global mortality. These poor outcomes are the result of complex and multifactorial health systems deficiencies. A recent review in this journal outlined the causes and contributors to higher MMRs in LMICs.2Pelland A. George R.B. Safe obstetric anaesthesia in low- and middle-income countries.BJA Educ. 2017; 17: 194-197Abstract Full Text Full Text PDF Google Scholar It discussed elements that are still relevant today, including the 3-delays model (transport, training and treatment), challenges related to systems and infrastructure, and the choice of anaesthesia for Caesarean section (CS), and methods for labour analgesia.2Pelland A. George R.B. Safe obstetric anaesthesia in low- and middle-income countries.BJA Educ. 2017; 17: 194-197Abstract Full Text Full Text PDF Google Scholar The safe provision of anaesthesia remains a key goal to improve maternal and neonatal outcomes, although it is just one aspect within a complex, interconnected and interdependent obstetric healthcare system. There may be marked differences between the levels of accessible care even within LMIC. For example, in South Africa major referral hospitals provide suitable care for complex obstetric anaesthesia, but in peripheral areas, there are often inadequate anaesthesia skills and resources to provide routine care during CS. Labour epidural rates remain unacceptably low in state hospitals, even in referral centres.3van Zyl S.F. Burke J.L. Increasing the labour epidural rate in a state hospital in South Africa: challenges and opportunities.South Afr J Anaesth Analg. 2017; 23: 156-161Crossref Scopus (5) Google Scholar Similarly, there may be considerable differences in resources between countries classified as LMIC. This article focuses on specific anaesthesia practices that may contribute to improved outcomes, rather than the systems-level issues covered previously in this journal.2Pelland A. George R.B. Safe obstetric anaesthesia in low- and middle-income countries.BJA Educ. 2017; 17: 194-197Abstract Full Text Full Text PDF Google Scholar Although we concentrate on Africa, we believe that the underlying principles and contextual similarities make these suggestions globally applicable to resource-limited settings. Literature informing practice in LMICs originates from vastly different contexts.4du Toit L. Bougard H. Biccard B.M. The developing world of pre-operative optimisation: a systematic review of Cochrane reviews.Anaesthesia. 2019; 74: 89-99Crossref Scopus (7) Google Scholar Although this is to be expected given resource constraints that may preclude labour-intensive research, it highlights the need for context-sensitive solutions developed in conjunction with clinicians in that setting. We will discuss clinical anaesthetic approaches to LMIC concerns, based on the limited research available. We will also provide an update on anaesthesia-related morbidity and mortality in LMICs, including data from the South African National Committee for Confidential Enquiry into Maternal Deaths (NCCEMD).5NCCEMD. SavingMothers 2011–2013: Sixth Report on the Confidential Enquiries into Maternal Deaths in South Africa. Compiled by the National Committee for Confidential Enquiry into Maternal Deaths, 2014Google Scholar,6Lundgren A.C. Trends in maternal deaths associated with anaesthesia in the triennium 2017–2019.O&G Forum. 2020; 30: 46-47Google Scholar Many high-income countries (HICs) have processes that evaluate maternal outcomes, through confidential enquiries into maternal deaths. Until recently, South Africa was the only country that conducted this process in Africa. Kenya completed its first report in October 2016 (relating to deaths in 2014), although <15% of the actual deaths were reported and only half of these were assessed. The South African and the Kenyan processes highlighted similar problems: poor antenatal care, and a high number of avoidable deaths, particularly driven by obstetric haemorrhage and hypertensive disorders. Limited analysis of anaesthesia-related outcomes was available in the Kenyan report.7Mgamb E. Maua J.M. Okoro D. et al.Lives Saving Mothers 2017First Confidential Report into Maternal Deaths in Kenya.2017Google Scholar In contrast the 2017–2019 South African data suggested that anaesthesia contributed to 205/921 (22%) of maternal deaths after CS. In 66/921 (7%) of patients, deaths resulted primarily from complications of anaesthesia, whereas in a further 139/921 (15%), anaesthesia was contributory (mortality from another cause, such as obstetric haemorrhage, but action or inaction by the anaesthetist might have contributed significantly to the death or events ultimately leading to death).6Lundgren A.C. Trends in maternal deaths associated with anaesthesia in the triennium 2017–2019.O&G Forum. 2020; 30: 46-47Google Scholar Thus anaesthesia contributed to one in five perioperative maternal deaths, often including an avoidable component such as delayed or poor resuscitation, delay in recognition of complications and inappropriate method of anaesthesia. The African Surgical Outcomes Study (ASOS) showed that many regions in Africa have inadequate workforce density, and maternal and neonatal mortality remain unacceptably high, driven largely by haemorrhage and anaesthesia complications.8Biccard B.M. Madiba T.E. Kluyts H.-L. et al.Perioperative patient outcomes in the African Surgical Outcomes Study: a 7-day prospective observational cohort study.Lancet. 2018; 391: 1589-1598Abstract Full Text Full Text PDF PubMed Scopus (326) Google Scholar,9Bishop D. Dyer R.A. Maswime S. et al.Maternal and neonatal outcomes after caesarean delivery in the African Surgical Outcomes Study: a 7-day prospective observational cohort study.Lancet Glob Health. 2019; 7: e513-e522Abstract Full Text Full Text PDF PubMed Scopus (115) Google Scholar Whereas the complication rate of CS is only two to three times higher in women in Africa, maternal mortality is 50 times higher than in their HIC counterparts. This illustrates the concept of ‘failure-to-rescue’: when perioperative complications occur, the ‘rescue’ of these patients requires resources that are lacking, such as monitoring, skilled practitioners, blood products and intensive care support. The prevention and early detection of complications, in tandem with context-sensitive management solutions, are therefore a key priority. Poor maternal outcomes are compounded by inadequate CS rates, which should be up to 19%,10Molina G. Weiser T.G. Lipsitz S.R. et al.Relationship between Cesarean delivery rate and maternal and neonatal mortality.JAMA. 2015; 314: 2263-2270Crossref PubMed Google Scholar but are <10% in more than half of African countries, indicating a deficiency in access to surgery.11Sobhy S. Arroyo-Manzano D. Murugesu N. et al.Maternal and perinatal mortality and complications associated with caesarean section in low-income and middle-income countries: a systematic review and meta-analysis.Lancet. 2019; 393: 1973-1982Abstract Full Text Full Text PDF PubMed Scopus (167) Google Scholar There is also an increased morbidity and mortality that occurs in the absence of adequate numbers of trained anaesthesia providers.12Sobhy S. Zamora J. Dharmarajah K. et al.Anaesthesia-related maternal mortality in low-income and middle-income countries: a systematic review and meta-analysis.Lancet Glob Health. 2016; 4: e320-e327Abstract Full Text Full Text PDF PubMed Google Scholar In LMICs, obstetric anaesthesia deaths occur at rate of 1.2 per 1000, and represent 13.8% of all deaths after CS—compared with 3.8–6.5 per million in the USA. Anaesthesia is responsible for 2.8% of all maternal deaths in LMICs, with general anaesthesia (GA) resulting in a five-fold higher mortality rate than spinal anaesthesia.12Sobhy S. Zamora J. Dharmarajah K. et al.Anaesthesia-related maternal mortality in low-income and middle-income countries: a systematic review and meta-analysis.Lancet Glob Health. 2016; 4: e320-e327Abstract Full Text Full Text PDF PubMed Google Scholar In Malawi, poorly trained anaesthesia providers have been found to have almost three times higher maternal mortality rates compared with trained anaesthesia providers.13Fenton P.M. Whitty C.J. Reynolds F. Caesarean section in Malawi: prospective study of early maternal and perinatal mortality.BMJ. 2003; 327: 587Crossref PubMed Google Scholar A lack of robust data makes it impossible to determine whether non-physician anaesthesia providers (NPAPs) are associated with worse maternal outcomes than physician anaesthesia providers (PAPs) within any particular jurisdiction.12Sobhy S. Zamora J. Dharmarajah K. et al.Anaesthesia-related maternal mortality in low-income and middle-income countries: a systematic review and meta-analysis.Lancet Glob Health. 2016; 4: e320-e327Abstract Full Text Full Text PDF PubMed Google Scholar An inflection point regarding optimal number of anaesthetists has been described, below which maternal mortality increases precipitously.14Davies J.I. Vreede E. Onajin-Obembe B. Morriss W.W. What is the minimum number of specialist anaesthetists needed in low-income and middle-income countries?.BMJ Glob Health. 2018; 3e001005Crossref Scopus (31) Google Scholar The authors suggest that a minimum of four specialist anaesthetists per 100,000 of the population are required to achieve a minimum standard of healthcare. Only five African countries have more than one PAP per 100,000 of the population (Fig. 1), and HICs have 90 times the number of PAPs compared with low-income countries (LICs).15Kempthorne P. Morriss W.W. Mellin-Olsen J. Gore-Booth J. The WFSA global anesthesia workforce survey.Anesth Analg. 2017; 125: 981-990Crossref PubMed Scopus (168) Google Scholar Despite the fact that this proportion is exceeded in South Africa, the South African confidential enquiry process confirmed that in some areas, unqualified junior doctors and clinical associates were providing anaesthesia care in unsupervised settings, and that in 2.5% of deaths the designated anaesthetist was also an assistant at surgery.6Lundgren A.C. Trends in maternal deaths associated with anaesthesia in the triennium 2017–2019.O&G Forum. 2020; 30: 46-47Google Scholar Workforce deficiencies usually coexist with poor operative capacity. One study in LMICs, including three African countries, suggested that one-third of hospitals do not have access to reliable electricity, one-quarter do not have access to oxygen, three-quarters do not have pulse oximetry for routine monitoring and half of hospitals do not have a recovery area.16LeBrun D.G. Chackungal S. Chao T.E. et al.Prioritizing essential surgery and safe anesthesia for the Post-2015 Development Agenda: operative capacities of 78 district hospitals in 7 low- and middle-income countries.Surgery. 2014; 155: 365-373Abstract Full Text Full Text PDF PubMed Scopus (91) Google Scholar A survey conducted in referral hospitals in East Africa showed that none of the hospitals had all the necessary requirements to provide safe obstetric anaesthesia (based on the availability of drugs, equipment, monitoring and anaesthesia machines), and only 7% reported adequate staffing.17Epiu I. Tindimwebwa J.V. Mijumbi C. et al.Challenges of anesthesia in low- and middle-income countries: a cross-sectional survey of access to safe obstetric anesthesia in East Africa.Anesth Analg. 2017; 124: 290-299Crossref PubMed Scopus (66) Google Scholar Providing guidance to inexperienced anaesthetists is challenging in the absence of these minimum standards. Single-shot spinal anaesthesia remains the safest choice for CS in most patients in LMICs. However, it is probably true that spinal anaesthesia is performed inappropriately in many patients in variable resource countries, resulting from concerns about the ability to perform a safe general anaesthetic, because of the lack of availability of trained staff or basic equipment. Data from Africa have shown that spinal anaesthesia is often performed in patients with conditions such as abnormal placentation or even a ruptured uterus, or eclampsia associated with a low Glasgow Coma Scale (GCS).9Bishop D. Dyer R.A. Maswime S. et al.Maternal and neonatal outcomes after caesarean delivery in the African Surgical Outcomes Study: a 7-day prospective observational cohort study.Lancet Glob Health. 2019; 7: e513-e522Abstract Full Text Full Text PDF PubMed Scopus (115) Google Scholar Most practitioners are comfortable with performing spinal anaesthesia in healthy patients, but often cannot manage complications should they arise, whether in healthy or compromised patients.Clinical scenario 1In a district hospital in Uganda, a woman is scheduled for CS as a result of obstructed labour. She is assessed by an NPAP, who decides to perform spinal anaesthesia. The patient has a mild tachycardia and is experiencing uterine contractions while the spinal anaesthetic is performed. Soon after commencement of surgery, the patient complains of numbness in the hands, and subsequently becomes drowsy. The NPAP notices a slow heart rate, but the blood pressure is undetectable, and there is no pulse oximetry available. After checking the blood pressure cuff and restarting the machine, the NPAP notices that the patient is unconscious and is not breathing. Mask ventilation is commenced, but the patient quickly progresses to a cardiac arrest. The surgeon (a general practitioner) assists with a full resuscitation. Following treatment with adrenaline (epinephrine) and fluids there is a return of spontaneous circulation, but both the mother and neonate have suffered significant neurological injury. In a district hospital in Uganda, a woman is scheduled for CS as a result of obstructed labour. She is assessed by an NPAP, who decides to perform spinal anaesthesia. The patient has a mild tachycardia and is experiencing uterine contractions while the spinal anaesthetic is performed. Soon after commencement of surgery, the patient complains of numbness in the hands, and subsequently becomes drowsy. The NPAP notices a slow heart rate, but the blood pressure is undetectable, and there is no pulse oximetry available. After checking the blood pressure cuff and restarting the machine, the NPAP notices that the patient is unconscious and is not breathing. Mask ventilation is commenced, but the patient quickly progresses to a cardiac arrest. The surgeon (a general practitioner) assists with a full resuscitation. Following treatment with adrenaline (epinephrine) and fluids there is a return of spontaneous circulation, but both the mother and neonate have suffered significant neurological injury. Spinal hypotension is usually a consequence of sympathectomy, and rarely may result from a high spinal anaesthetic (manifesting as hypotension, bradycardia and a high spinal sensory level to the cervical dermatomes). Guidelines for the management of high spinal anaesthesia are available, which include suggestions for emergency inotrope infusions in the absence of a syringe pump (adrenaline [epinephrine] 1 mg in 1 L modified Ringer's lactate solution).18van Rensburg G. van Dyk D. Bishop D.G. et al.The management of high spinal anaesthesia in obstetrics: suggested clinical guideline in the South African context.South Afr J Anaesth Analg. 2016; 22: S1-S5Google Scholar Pattern recognition should be taught of the haemodynamic presentations of all the causes of spinal hypotension. This is particularly important where anaesthesia providers with minimal experience are practicing without supervision by a senior anaesthetist.19van Dyk D. Dyer R.A. Bishop D.G. Spinal hypotension in obstetrics: context-sensitive prevention and management.Best Pract Res Clin Anaesthesiol. 2022; 36: 69-82Crossref PubMed Scopus (0) Google Scholar It is crucial that spinal anaesthesia is given only to appropriate patients, avoiding patients in whom a sympathectomy could cause rapid decompensation, such as those with hypovolaemia, or when major haemorrhage is present or expected. Unexplained tachycardia (heart rate >120–140 beats min−1) should be a relative contraindication to spinal anaesthesia and requires discussion with the best qualified anaesthesia provider, and further investigation as indicated. The management of spinal hypotension should include fluids and early initiation of appropriate vasopressor drugs, optimally phenylephrine if available, or other agents such as ephedrine, etilefrine, metaraminol or adrenaline.20Heesen M. Carvalho B. Carvalho J.C.A. et al.International consensus statement on the use of uterotonic agents during caesarean section.Anaesthesia. 2019; 74: 1305-1319Crossref PubMed Scopus (71) Google Scholar In the setting of precipitous hypotension unresponsive to phenylephrine or ephedrine, adrenaline boluses may be required (10–50 μg), in conjunction with airway management if needed. Hypotension during routine spinal anaesthesia is both likely and predictable and should be managed proactively if possible. Given that hypotension occurs in >70% of patients and is severe in >20%, the use of prophylactic vasopressor infusions is advised. A titrated phenylephrine infusion remains the gold standard,21Kinsella S.M. Carvalho B. Dyer R.A. et al.International consensus statement on the management of hypotension with vasopressors during caesarean section under spinal anaesthesia.Anaesthesia. 2018; 73: 71-92Crossref PubMed Scopus (247) Google Scholar but fixed-rate, low-dose infusions have been shown to be effective in variable resource settings in the hands of junior doctors.22Bishop D.G. Cairns C. Grobbelaar M. Rodseth R.N. Prophylactic phenylephrine infusions to reduce severe spinal anesthesia hypotension during Cesarean delivery in a resource-constrained environment.Anesth Analg. 2017; 125: 904-906Crossref Scopus (23) Google Scholar Where infusion pumps are unavailable, adding vasopressor (phenylephrine 500 μg) to the first litre of fluid after spinal anaesthesia may also be safe and effective.23Buthelezi A.S. Bishop D.G. Rodseth R.N. Dyer R.A. Prophylactic phenylephrine and fluid co-administration to reduce spinal hypotension during elective caesarean section in a resource-limited setting: a prospective alternating intervention study.Anaesthesia. 2020; 75: 487-492Crossref Scopus (5) Google Scholar A recent review of these practices in LMICs deals with the subject in more detail.19van Dyk D. Dyer R.A. Bishop D.G. Spinal hypotension in obstetrics: context-sensitive prevention and management.Best Pract Res Clin Anaesthesiol. 2022; 36: 69-82Crossref PubMed Scopus (0) Google Scholar Regardless of how they are given, the early use of vasopressors is recommended. Recently, there has been considerable research in HICs into noradrenaline (norepinephrine) for both prophylaxis and treatment of spinal hypotension, predominantly motivated by the mild beta-adrenergic activity of noradrenaline. However, research has been conducted predominantly in resource-rich contexts. Current evidence is unconvincing even in HICs for any clinically significant benefits of potent agents such as noradrenaline. In LMICs this agent should be avoided as clinicians are unfamiliar with the drug and unable to monitor for adverse effects. In addition, syringe pumps are often unavailable, and the risk of catastrophic dose error is significant. In the rare situation in which phenylephrine is associated with bradycardia and hypotension, small doses of anticholinergic agents or ephedrine would suffice. Spinal anaesthesia may require conversion to GA, either because of complete or partial failure of the block, protracted surgery, or haemodynamic instability. The decision to convert to GA because of pain should be guided by the risk associated with GA in that context. This is likely increased in proportion to the shortage of equipment available to anaesthesia providers, and their lack of training. Recent guidelines have been published for the management of intraoperative pain and include modifications for variable resource countries.24Plaat F. Stanford S.E.R. Lucas D.N. et al.Prevention and management of intra-operative pain during caesarean section under neuraxial anaesthesia: a technical and interpersonal approach.Anaesthesia. 2022; 77: 588-597Crossref PubMed Scopus (17) Google Scholar Conversion to GA either for protracted surgery or haemodynamic instability requires a higher level of anaesthesia expertise, particularly with respect to airway management. Tracheal intubation may be technically more challenging in a patient draped and prepared for surgery. Whereas exact details of the practice of GA for CS in Africa are unavailable, in Sierra Leone, the use of ketamine without intubation is commonly performed.25Lonnee H.A. Taule K. Knoph Sandvand J. et al.A survey of anaesthesia practices at all hospitals performing caesarean sections in Sierra Leone.Acta Anaesthesiol Scand. 2021; 65: 404-419Crossref Scopus (1) Google Scholar It is likely that i.v. or i.m. ketamine is often used without definitive airway management. Recently, a prospective case-series from Kenya analysed 401 emergency CS that were conducted by 54 non-anaesthesia providers using ketamine-based anaesthesia (ESM-Ketamine), in circumstances where no anaesthetist was available.26Burke T.F. Mantena S. Opondo K. Orero S. Rogo K. A ketamine package for use in emergency cesarean delivery when no anesthetist is available: an analysis of 401 consecutive operations.Int J Gynaecol Obstet. 2022; 158: 377-384Crossref Scopus (3) Google Scholar There were no serious adverse maternal events and all mothers survived to hospital discharge. Further data related to the prevalence and safety of the various practices used for GA in LMICs are urgently required, and currently under investigation in the ASOS studies. Following the World Health Organization's recommendation to use tranexamic acid early in the management of obstetric haemorrhage at CS, there has been a concerning increase in the number of intrathecal tranexamic acid injections, associated with a high mortality.27Moran N.F. Bishop D.G. Fawcus S. et al.Tranexamic acid at caesarean delivery: drug error deaths.Am J Obstet Gynecol. 2023; 228: 1-4Abstract Full Text Full Text PDF PubMed Google Scholar Clinical presentation typically follows initial failure of the spinal anaesthesia, proceeding to a seizure and sympathetic hyperactivity, which may be mistaken for eclampsia. This arises because of a drug error caused by similarities in the size and appearance of tranexamic acid and bupivacaine ampoules, compounded by storage of the two drugs in close proximity to each other. Systems are necessary that allow for timely use of tranexamic acid, but reduce the risk of drug error. Improved procedures for checking of ampoules, and ultimately re-design of the ampoules so that they are clearly distinguishable, are recommended. Tranexamic acid should be stored in a separate location to bupivacaine, either in a sealed box containing drugs used specifically for obstetric haemorrhage, or just outside the operating theatre, where the drug can be accessed quickly for use when required.27Moran N.F. Bishop D.G. Fawcus S. et al.Tranexamic acid at caesarean delivery: drug error deaths.Am J Obstet Gynecol. 2023; 228: 1-4Abstract Full Text Full Text PDF PubMed Google Scholar With the increased use of spinal anaesthesia for CS, it is possible that junior clinicians have become less proficient in the management of the obstetric airway, as a consequence of a lack of regular exposure. Hypoxaemia (Spo2 <90%) is a relatively common event during the management of the obstetric airway in anaesthesia departments in South Africa, occurring in one in six patients.28Tomlinson J.M.B. Bishop D.G. Hofmeyr R. Cronje L. Rodseth R.N. The incidence and predictors of hypoxaemia during induction of general anaesthesia for caesarean delivery in two South African hospitals: a prospective, observational, dual-centre study.South Afr J Anaesth Analg. 2020; 26: 180-187Google Scholar Guidelines exist for the management of the difficult airway in obstetric anaesthesia.29Mushambi M.C. Kinsella S.M. Popat M. et al.Obstetric Anaesthetists’ Association and Difficult Airway Society guidelines for the management of difficult and failed tracheal intubation in obstetrics.Anaesthesia. 2015; 70: 1286-1306Crossref PubMed Scopus (338) Google Scholar Calls for the availability of a videolaryngoscope in all obstetric theatres are unlikely to be realised because of cost restraints. In addition, training in their use is in short supply. However, many of the basic principles of modern airway management are available and accessible in variable resource countries through education and training. These include the following practices29Mushambi M.C. Kinsella S.M. Popat M. et al.Obstetric Anaesthetists’ Association and Difficult Airway Society guidelines for the management of difficult and failed tracheal intubation in obstetrics.Anaesthesia. 2015; 70: 1286-1306Crossref PubMed Scopus (338) Google Scholar:•Adequate preoperative assessment of the airway•Elevation of the head by 25°•Ramping (horizontal alignment between the external auditory meatus and the sternal notch)•Preoxygenation (end-tidal oxygen fraction >0.9)•Apnoeic insufflation by face mask before tracheal intubation•Considering early mask ventilation at pressures ≤20 cmH2O during induction of anaesthesia, if there is a high risk of hypoxaemia, or in the event of difficult intubation Amendments to traditional rapid-sequence induction should be taught routinely, including the early release of cricoid pressure if laryngoscopy is difficult, and the use of low-pressure mask ventilation.29Mushambi M.C. Kinsella S.M. Popat M. et al.Obstetric Anaesthetists’ Association and Difficult Airway Society guidelines for the management of difficult and failed tracheal intubation in obstetrics.Anaesthesia. 2015; 70: 1286-1306Crossref PubMed Scopus (338) Google Scholar Appropriate teaching of the use of the Macintosh blade is essential, and should be supplemented with online teaching and simulation where necessary. These principles are essential in ensuring that an ‘easy airway’ is not converted to a ‘difficult airway’ through deficiencies in technique and positioning. Early use of a rescue airway such as the supraglottic airway device should be encouraged, as indicated in the most recent difficult airway algorithm.29Mushambi M.C. Kinsella S.M. Popat M. et al.Obstetric Anaesthetists’ Association and Difficult Airway Society guidelines for the management of difficult and failed tracheal intubation in obstetrics.Anaesthesia. 2015; 70: 1286-1306Crossref PubMed Scopus (338) Google Scholar Hypertensive disorders of pregnancy are a leading cause of mortality in LMICs.30van Dyk D. Dyer R.A. Fernandes N.L. Preeclampsia in 2021—a perioperative medical challenge for the anesthesiologist.Anesthesiol Clin. 2021; 39: 711-725Abstract Full Text Full Text PDF PubMed Google Scholar Late presentation and delayed treatment often compound the severity of this multisystem disorder. In preeclampsia with severe features, rapid clinical deterioration is possible, particularly where cardiovascular involvement is present. Point-of-care ultrasound evaluation of the heart and lungs has utility in the assessment of disease severity and strategic anaesthesia choices. However, although handheld devices are becoming more affordable and increasingly used in variable resource countries, this equipment and experience are unlikely to be routinely available in many LMICs. In the absence of a reliable measurement of stroke volume responsiveness, fluid restriction is likely the safer general strategy. Adequate control of the blood pressure on admission and before