Obstetric Anesthesia Digest

Published by Lippincott, Williams & Wilkins
Online ISSN: 0275-665X
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Article
Although induction of labor in pregnant women at term with gestational hypertension or mild preeclampsia is already recommended and practiced in the United States and other developed countries, no randomized clinical trials have been carried out comparing induction of labor versus expectant monitoring. This multicenter, parallel, randomized, unblinded controlled trial compared the effect of labor induction or expectant management on maternal morbidity in singleton women with gestational hypertension or mild preeclampsia at term. A total of 776 women were randomized to undergo induction of labor (n = 377) or expectant monitoring (n = 379). The study was conducted between 2005 and 2008 at 38 hospitals in the Netherlands. The primary outcome measure was a composite of adverse maternal outcomes: maternal mortality, maternal morbidity (eclampsia, HELLP syndrome, pulmonary edema, thromboembolic disease, or placental abruption), progression to severe disease or proteinuria, and major postpartum hemorrhage (blood loss of more than 1000 mL within 24 hour of delivery). Data were analyzed according to an intention-to-treat basis. The composite adverse primary outcome occurred in fewer women who were induced compared to those receiving expectant monitoring (31% [117/377] vs. 44% [166/379]; the relative risk was 0.71, with a 95% confidence interval of 0.59–0.86, P < 0.0001). No fetal or neonatal deaths or cases of eclampsia or placental abruption occurred in either group. The investigators conclude from these findings that women with mild hypertensive disease beyond 37 weeks’ gestation should be advised to undergo induction.
 
Article
Objective The purpose of this study was to examine predictors associated with cesarean delivery (CD) among extremely obese women undergoing a trial of labor (TOL). Study design Using a delivery database, we identified all pregnant women delivering at our institution from Jan. 1, 2008, through July 31, 2010, weighing >275 lb at the time of delivery who attempted a TOL with a singleton gestation >34 weeks' gestation. Demographic and obstetrical factors were compared for those having a successful vaginal delivery to those having a CD. Results During the study period, there were 357 pregnant women who weighed >275 lb (all with body mass index [BMI] >40 kg/m2), and among these, 248 (69.5%) attempted a TOL. Women having a CD had a greater BMI (51.6 vs 49.9 kg/m2, P = .038), were less likely to be parous (32.2% vs 65.8%, P < .0001), and were more likely to be induced (80.5% vs 57.8%) compared to those having a vaginal delivery. Using a multivariable logistic regression model, among nulliparous women, maternal age, parity, and cervical dilation at time of admission were independent predictors for CD. Furthermore, an increase in BMI of 10 kg/m2 was associated with a 3.5 increased odds (P = .002) for CD. Conclusion Among nulliparous extremely obese women attempting a TOL, BMI was an independent predictor of CD, with the rate of CD increasing further with increasing BMI. The underlying mechanisms for failed TOL in the setting of maternal obesity remain largely unknown.
 
Article
A series of healthy nulliparous women with term singleton fetuses in the vertex presentation were pre-hydrated and had a lumbar epidural catheter inserted cephalad at L3-4. All patients received a test dose of 3 ml of 0.5% bupivacaine with 1:200,000 epinephrine followed, after 5 minutes, by 6 ml of either 0.125% bupivacaine with 0.0008% fentanyl or 0.25% bupivacaine alone. Thereafter, patients received a continuous epidural infusion at 12.5 ml/hr of 0.0625% bupivacaine with 0.0002% fentanyl or 0.125% bupivacaine. Uterine displacement was maintained and drug added to maintain a sensory level of T10, by either bolus or increased rate of infusion. The patient, anesthesiologist, obstetrician, pediatrician and nurses were unaware of the nature of the administered solution in each patient. Epidural infusion was discontinued when the cervix was fully dilated and only some boluses of bupivacaine given if perineal analgesia was inadequate. No elective instrumental deliveries were performed. Periodic assessment was made of pain employing a visual analog scale as well as patient assessment of analgesia during the first and second stages of labor. Record was made of duration of the first and second stages of labor, extent of motor block, incidence of maternal pruritus, nausea, emesis and urinary retention, and neonatal condition. (C) Williams & Wilkins 1989. All Rights Reserved.
 
Article
(Anaesthesia. 2018;73:459–465) The use of programmed intermittent epidural bolus (PIEB) to provide labor analgesia has been increasing in popularity as commercially available pumps have become available. A variety of dosing strategies have been evaluated but the optimal settings for PIEB have not yet been established. The majority of studies have included PIEB in conjunction with patient controlled epidural analgesia (PCEA). The current investigators had previously investigated which PIEB dosing strategy would minimize breakthrough pain and the need for PCEA boluses. They determined the optimal regimen was 10 mL of bupivacaine 0.0625% with fentanyl 2 µg/ml administered every 40 minutes. However, 34% of women exhibited a sensory block to ice above T6, which might indicate an unnecessarily high spread of local anesthetic. Therefore, they conducted this prospective, double-blind, dose-finding study to investigate whether it was possible to reduce the PIEB volume without compromising the efficacy of the technique.
 
Article
Seventy-three females requesting epidural analgesia for labor were randomly allocated to one of two groups. Following appropriate fluid preloading, all patients had lumbar epidural catheters placed and confirmed to be appropriately located. Each patient then received a total bupivacaine dose of 6-8 ml of 0.5% solution, including test dose. One group then received top-up doses of 0.5% bupivacaine as requested during labor, whereas the other patients received a continuous epidural infusion of 15 ml/hr of 0.075% bupivacaine begun 30 minutes after the initial bolus dose. Top-up doses of 0.5% bupivacaine were given if analgesia was inadequate. Assessment consisted of maternal evaluation of pain by means of a visual analog scale (no pain to worst pain imaginable), level of sensory blockade, degree of motor blockade, incidence of hypotension, total drug dose, and nature of delivery. (C) Williams & Wilkins 1989. All Rights Reserved.
 
Article
(Can J Anesth. 2019 66:1075–1081) Programmed intermittent epidural bolus (PIEB) for labor analgesia has garnered a lot of attention and is the focus of ongoing research. PIEB when compared with continuous epidural infusion results in higher maternal satisfaction, reduced local anesthetic consumption, lower incidence of motor block, fewer unilateral blocks, and less breakthrough pain. The optimal epidural solution and PIEB settings for labor analgesia have yet to be decided. This study aimed to determine the effective PIEB time interval when using 5 mL boluses of bupivacaine 0.125% with fentanyl 2 mcg/mL.
 
Article
(Acta Anaesthesiol Scand. 2019;63(6):775–780) The method of photoplethysmography measures blood flow in the skin through the use of infrared light to gage nervous system activity during both peripheral and central anesthesia blocks. Experts today believe that ropivacaine and levobupivacaine carry varying levels of cardiovascular safety, with ropivacaine being less dangerous, despite a lack of data supporting this opinion. These investigators hypothesized that these 2 local anesthetics actually carry the same cardiovascular safety risk, and aimed to measure the effects of both ropivacaine and levobupivacaine using photoplethysmography.
 
Article
(Can J Anaesth. 2021;68:653–660. doi: 10.1007/s12630-021-01922-6. Epub February 2, 2021) Programmed intermittent epidural bolus (PIEB) has been increasingly recommended and used during labor analgesia. This study aimed to determine the recommended time interval between boluses of 2.5 mL of bupivacaine 0.25% plus fentanyl 8 µ/mL to provide effective analgesia in 90% of pregnant women (EI90) during the first stage of labor.
 
Article
(Int J Obstet Anesth. 2020;41:53–58) Epidural analgesia is considered the gold standard for labor analgesia. However, there are times when this technique fails to provide adequate analgesia and inadequate and/or failed epidural analgesia predicts failed conversion to anesthesia for cesarean delivery. The effectiveness of epidural analgesia can be determined early via verbal pain scores and testing the upper limit of the sensory block using cold sensation. Unfortunately, these methods are relatively subjective and can be unreliable. Thus, an objective tool for assessment of epidural spread of local anesthetic would be invaluable. This preliminary cohort study aimed to assess whether lumbar epidural analgesia brought forth significant change in cutaneous temperature (as measured by infrared thermography). In addition, the study also assessed whether the use of infrared thermography could aid in the prediction of failed epidural analgesia.
 
Article
(Anaesthesia. 2019;74:976–983) Over the last 20 years, obstetric hemorrhage has remained a dominant cause of maternal death; this trend shows no sign of changing in the near future. A standard treatment for obstetric hemorrhage is allogeneic (donor) blood transfusion, but autologous (cell salvaged) blood transfusion is becoming a more viable alternative to allogeneic blood transfusion. On the basis of a recent multicenter randomized trial that concluded the routine use of cell salvage during cesarean section was not cost-effective, updated guidelines from the Association of Anaesthetists no longer recommend routine cell salvage during cesarean section. They do encourage autologous blood transfusion when significant blood loss is expected. The authors of this article reported on their use of cell salvage during cesarean section and based on their results argued that cell salvage can be a safe and economically feasible option for patients undergoing cesarean section.
 
Article
(Br J Anaesth. 2020;125:e360–e361) A recent paper by Sanilipo et al, studied simulated airway management while wearing personal protective equipment. There is a need to study this issue, as personal protective equipment (PPE) can cause discomfort and potentially make airway management more challenging. PPE may do this by impairing vision, limiting communication, restricting movement and limiting tactile sensitivity. However, there are some concerning aspects of this study itself.
 
Article
(Br J Anaesth. 2020;125:e452–e453) Airway management conditions are affected by many factors, including the anesthetic induction drugs used. A recent study by Bonnett and colleagues in patients undergoing non-elective Cesarean delivery found co-administering propofol with succinylcholine resulted in superior intubating conditions compared with the co-administration of thiopental with succinylcholine. These results support the use of propofol rather than thiopental in obstetric general anesthesia.
 
Relative contribution of key groups of complications by outcome severity.  
Identified problems* associated with deficiencies in care for women with life-threatening conditions
Article
BJOG. 2016 May;123(6):928-38. doi: 10.1111/1471-0528.13450. Epub 2015 May 14. When getting there is not enough: a nationwide cross-sectional study of 998 maternal deaths and 1451 near-misses in public tertiary hospitals in a low-income country. Oladapo OT1, Adetoro OO2, Ekele BA3, Chama C4, Etuk SJ5, Aboyeji AP6, Onah HE7, Abasiattai AM8, Adamu AN9, Adegbola O10, Adeniran AS6, Aimakhu CO11, Akinsanya O12, Aliyu LD13, Ande AB14, Ashimi A15, Bwala M16, Fabamwo A17, Geidam AD4, Ikechebelu JI18, Imaralu JO19, Kuti O19, Nwachukwu D20, Omo-Aghoja L21, Tunau K22, Tukur J23, Umeora O24, Umezulike AC25, Dada OA26, Tunçalp Ӧ1, Vogel JP1, Gülmezoglu AM1; Nigeria Near-miss and Maternal Death Surveillance Network. Collaborators (24) Author information Abstract OBJECTIVE: To investigate the burden and causes of life-threatening maternal complications and the quality of emergency obstetric care in Nigerian public tertiary hospitals. DESIGN: Nationwide cross-sectional study. SETTING: Forty-two tertiary hospitals. POPULATION: Women admitted for pregnancy, childbirth and puerperal complications. METHODS: All cases of severe maternal outcome (SMO: maternal near-miss or maternal death) were prospectively identified using the WHO criteria over a 1-year period. MAIN OUTCOME MEASURES: Incidence and causes of SMO, health service events, case fatality rate, and mortality index (% of maternal death/SMO). RESULTS: Participating hospitals recorded 91 724 live births and 5910 stillbirths. A total of 2449 women had an SMO, including 1451 near-misses and 998 maternal deaths (2.7, 1.6 and 1.1% of live births, respectively). The majority (91.8%) of SMO cases were admitted in critical condition. Leading causes of SMO were pre-eclampsia/eclampsia (23.4%) and postpartum haemorrhage (14.4%). The overall mortality index for life-threatening conditions was 40.8%. For all SMOs, the median time between diagnosis and critical intervention was 60 minutes (IQR: 21-215 minutes) but in 21.9% of cases, it was over 4 hours. Late presentation (35.3%), lack of health insurance (17.5%) and non-availability of blood/blood products (12.7%) were the most frequent problems associated with deficiencies in care. CONCLUSIONS: Improving the chances of maternal survival would not only require timely application of life-saving interventions but also their safe, efficient and equitable use. Maternal mortality reduction strategies in Nigeria should address the deficiencies identified in tertiary hospital care and prioritise the prevention of severe complications at lower levels of care. TWEETABLE ABSTRACT: Of 998 maternal deaths and 1451 near-misses reported in a network of 42 Nigerian tertiary hospitals in 1 year. © 2015 World Health Organization; licensed by John Wiley & Sons Ltd on behalf of Royal College of Obstetricians and Gynaecologists. KEYWORDS: Clinical audit; WHO near-miss criteria; maternal death; maternal near miss; quality of care; severe acute maternal morbidity Comment in We can eliminate maternal deaths in resource-poor countries. [BJOG. 2016
 
Top-cited authors
Lale Say
  • World Health Organization WHO
Hannah Blencowe
  • London School of Hygiene and Tropical Medicine
Rajesh Narwal
  • World Health Organization WHO
Alma J Adler
  • London School of Hygiene and Tropical Medicine
Ronald Wapner
  • Columbia University