Maternal Body Mass Index and Use of Labor Neuraxial Analgesia: A Population-based Retrospective Cohort Study

Behavioural and neuropsychological outcomes in children exposed in utero to maternal labour epidural analgesia

BACKGROUND

Recent studies report conflicting results regarding the relationship between labour epidural analgesia (LEA) in mothers and neurodevelopmental disorders in their offspring. We evaluated behavioural and neuropsychological test scores in children of mothers who used LEA.

METHODS

Children enrolled in the Raine Study from Western Australia and delivered vaginally from a singleton pregnancy between 1989 and 1992 were evaluated. Children exposed to LEA were compared with unexposed children. The primary outcome was the parent-reported Child Behaviour Checklist (CBCL) reporting total, internalising, and externalising behavioural problem scores at age 10 yr. Score differences, an increased risk of clinical deficit, and a dose-response based on the duration of LEA exposure were assessed. Secondary outcomes included language, motor function, cognition, and autistic traits.

RESULTS

Of 2180 children, 850 (39.0%) were exposed to LEA. After adjustment for covariates, exposed children had minimally increased CBCL total scores (+1.41 points; 95% confidence interval [CI] 0.09 to 2.73; P=0.037), but not internalising (+1.13 points; 95% CI -0.08 to 2.34; P=0.066) or externalising (+1.08 points; 95% CI -0.08 to 2.24; P=0.068) subscale subscores. Increased risk of clinical deficit was not observed for any CBCL score. For secondary outcomes, score differences were inconsistently observed in motor function and cognition. Increased exposure duration was not associated with worse scores in any outcomes.

CONCLUSIONS

Although LEA exposure was associated with slightly higher total behavioural scores, there was no difference in subscores, increased risk of clinical deficits, or dose-response relationship. These results argue against LEA exposure being associated with consistent, clinically significant neurodevelopmental deficits in children.

0.75% ropivacaine may be a suitable drug in pregnant women undergoing urgent cesarean delivery during labor analgesia period

BACKGROUND

3% chloroprocaine (CP) has been reported as the common local anesthetic used in pregnant women undergoing urgent cesarean delivery during labor analgesia period. However, 0.75% ropivacaine is considered a promising and effective alternative. Therefore, we conducted a randomized controlled trial to compare the effectiveness and safety of 0.75% ropivacaine with 3% chloroprocaine for extended epidural anesthesia in pregnant women.

METHODS

We conducted a double-blind, randomized, controlled, single-center study from November 1, 2022, to April 30, 2023. We selected forty-five pregnant women undergoing urgent cesarean delivery during labor analgesia period and randomized them to receive either 0.75% ropivacaine or 3% chloroprocaine in a 1:1 ratio. The primary outcome was the time to loss of cold sensation at the T4 level.

RESULTS

There was a significant difference between the two groups in the time to achieve loss of cold sensation (303, 95%CI 255 to 402 S vs. 372, 95%CI 297 to 630 S, p = 0.024). There was no significant difference the degree of motor block (p = 0.185) at the Th4 level. Fewer pregnant women required additional local anesthetics in the ropivacaine group compared to the chloroprocaine group (4.5% VS. 34.8%, p = 0.011). The ropivacaine group had lower intraoperative VAS scores (p = 0.023) and higher patient satisfaction scores (p = 0.040) than the chloroprocaine group. The incidence of intraoperative complications was similar between the two groups, and no serious complications were observed.

CONCLUSIONS

Our study found that 0.75% ropivacaine was associated with less intraoperative pain treatment, higher patient satisfaction and reduced the onset time compared to 3% chloroprocaine in pregnant women undergoing urgent cesarean delivery during labor analgesia period. Therefore, 0.75% ropivacaine may be a suitable drug in pregnant women undergoing urgent cesarean delivery during labor analgesia period.

CLINICAL TRIAL NUMBER AND REGISTRY URL

The registration number: ChiCTR2200065201; http://www.chictr.org.cn , Principal investigator: MEN, Date of registration: 31/10/2022.

Overcoming Obstacles: The Legacy of Fidel Pagés, Founder of the Epidural, 100 Years After His Passing

Fidel Pagés, a Spanish surgeon, tragically died in 1923 at the age of 37, just 2 years after his publication "Anestesia Metamérica," the first description of human thoracolumbar epidural anesthesia. In the intervening 100 years, epidural anesthesia has faced countless obstacles, starting with the dissemination of his initial report, which was not widely read nor appreciated at the time. However, the merits of the technique have fueled innovations to meet these challenges over the years. Even today, while epidural anesthesia is widely embraced, particularly in obstetric and chronic pain medicine, the pressures of the operating room for efficiency and a low tolerance for failure, pose modern-day challenges. Here, we revisit Pagés' original report and highlight the key innovations that have allowed for the evolution of this essential anesthesia technique.

The Effect of Adolescent Idiopathic Scoliosis on Natural Delivery and Epidural Use in Pregnant Females: A Matched Cohort Study

STUDY DESIGN

Retrospective matched cohort study.

OBJECTIVE

The aim of this study was to determine whether females with idiopathic scoliosis (IS), both with and without spine fusion, experience different rates of cesarean section (CS) and epidural anesthesia (EA) than females without scoliosis.

SUMMARY OF BACKGROUND DATA

IS is a common spine condition with a higher prevalence in females. It is unclear whether females with scoliosis, treated nonoperatively or operatively, have different rates of cesarean delivery or EA.

MATERIALS AND METHODS

Patients with IS who delivered in our integrated health care system during a 6-year period were identified (N = 1810). They were matched with a group without scoliosis who delivered during the same period (N = 1810). Rates and relative risk (RR) of CS and EA between cohorts and subgroups were calculated.

RESULTS

The scoliosis cohort had significantly higher rates and RR of EA ( P = 0.002 and P = 0.004, respectively). Scoliosis patients treated nonoperatively had an 8% greater RR of EA ( P = 0.004) and had a significantly lower rate of CS (23.2% vs . 26%, P = 0.048) compared with the control group. Among only scoliosis patients, those treated with spine fusion had a 38% decreased RR of EA ( P < 0.001). Distal fusion level did not seem to influence the RR of EA or CS.

CONCLUSIONS

Females with scoliosis were significantly more likely to receive EA at delivery compared with females without scoliosis. Rates and RR of cesarean delivery were not significantly lower among women with scoliosis, but females treated nonoperatively for scoliosis had a significantly lower CS rate than those without scoliosis. Females treated with spine fusion for scoliosis were far less likely to receive EA than both females without scoliosis and females with scoliosis treated nonoperatively.

Intrapartum Cesarean Section and Perinatal Outcomes after Epidural Analgesia or Remifentanil-PCA in Breech and Twin Deliveries

Comparative data on the potential impact of various forms of labor analgesia on the mode of delivery and neonatal complications in vaginal deliveries of singleton breech and twin fetuses are lacking. The present study aimed to determine the associations between type of labor analgesia (epidural analgesia (EA) vs. remifentanil patient-controlled analgesia (PCA)) and intrapartum cesarean sections (CS), and maternal and neonatal adverse outcomes in breech and twin vaginal births. A retrospective analysis of planned vaginal breech and twin deliveries at the Department of Perinatology, University Medical Centre Ljubljana, was performed for the period 2013-2021, using data obtained from the Slovenian National Perinatal Information System. The pre-specified outcomes studied were the rates of CS in labor, postpartum hemorrhage, obstetric anal sphincter injury (OASI), an Apgar score of <7 at 5 min after birth, birth asphyxia, and neonatal intensive care admission. A total of 371 deliveries were analyzed, including 127 term breech and 244 twin births. There were no statistically significant nor clinically relevant differences between the EA and remifentanil-PCA groups in any of the outcomes studied. Our findings suggest that both EA and remifentanil-PCA are safe and comparable in terms of labor outcomes in singleton breech and twin deliveries.

Epidural Analgesia for Labour: Comparing the Effects of Continuous Epidural Infusion (CEI) and Programmed Intermittent Epidural Bolus (PIEB) on Obstetric Outcomes

Objective

In the last few years there is a trend of transiting from the continuous epidural infusion (CEI) method for epidural analgesia to a new method - programmed intermittent epidural analgesia (PIEB). This change improves the quality of epidural analgesia, thanks to an increased spread of the anaesthetic in the epidural space and higher maternal satisfaction. Nevertheless, we must make sure that such change of method does not lead to worse obstetric and neonatal outcomes.

Materials and Methods

This is a retrospective observational case control study. We compared several obstetrical outcomes between the CEI and PIEB groups, such as the rates of instrumental delivery, rates of caesarean section, duration of first and second stages of labour well as APGAR scores. We further segmented the subjects and examined them in groups of nulliparous and multiparous parturients.

Results

2696 parturients were included in this study: 1387 (51.4%) parturients in the CEI group and 1309 (48.6%) parturients in the PIEB group. No significant difference was found in instrumental or caesarean section delivery rates between groups. This result held even when the groups were differentiated between nulliparous and multiparous. No differences were revealed regarding first and second stage duration or APGAR scores.

Conclusion

Our study demonstrates transition from the CEI to the PIEB method does not lead to any statistically significant effects on either obstetric or neonatal outcomes.

SATISFACTION OF PARTURIENTS WITH EPIDURAL ANALGESIA DURING DELIVERY: ANALYSIS OF QUESTIONNAIRE AT A SINGLE HOSPITAL CENTER

Epidural analgesia is one of the most common methods of relieving labor pain. The objective of this study was to examine the effectiveness of epidural analgesia, maternal satisfaction and relationship between the effectiveness of epidural analgesia and various factors. Data were analyzed retrospectively and collected during 2022. A total of 60 parturients participated in the study. Data were collected through a questionnaire before the parturient was discharged from the hospital. The mean assessment of pain on a 1-10 numeric rating scale before epidural analgesia was 7.7 and 3.4 after administration of epidural analgesia. The median assessment of pain before epidural analgesia was 8 (7¬¬-8), and the median assessment of pain after epidural analgesia was 3 (2-5). The average satisfaction with epidural analgesia on a 1-10 scale was 8.11, and the median satisfaction was 10 (7-10). Total of 35 (58.3%) parturients rated satisfaction with 10. Statistically significant association between the effectiveness of epidural analgesia and parity, dilution of administered levobupivacaine, fentanyl administration, and level of education was not found. Childbirth pain is significantly alleviated by the application of epidural analgesia and the satisfaction of parturients is very high.

Role of MRI and CT in the Evaluation of Headache in Pregnancy and the Postpartum Period

Approximately 35% of acute headaches in pregnant women are secondary to an underlying condition. Headaches are also common in the postpartum period where they occur in 30% to 40% of patients. The majority of secondary headaches are due to hypertensive disorders: preeclampsia-eclampsia, posterior reversible encephalopathy syndrome, and acute arterial hypertension. Other causes include reversible cerebral vasoconstriction syndrome and pituitary apoplexy, as well as life-threatening conditions such as cerebral venous thrombosis. In this article, we review general recommendations for imaging the pregnant patients and discuss the imaging findings of common causes of headaches in pregnancy and the postpartum period.

Factors associated with women's preferences for labor epidural analgesia in Singapore: a survey approach

Epidural analgesia provides effective pain relief during labor. However, there is limited information on the factors associated with pregnant women’s preferences for labor epidural analgesia (LEA) prior to labor onset. We performed a secondary analysis of a clinical trial to identify demographic characteristics, pain and psychological vulnerability factors associated with preferences for LEA. Pregnant women at ≥ 36 weeks’ gestation prior to labor and delivery were recruited and given questionnaires on their LEA preferences, psychological and pain vulnerabilities. The primary outcome was the association between pre-delivery Edinburgh Postnatal Depression Scale (EPDS) with cut-off ≥ 10 and LEA preference. Of the 250 women recruited, 51.6% (n = 129) indicated “yes to LEA”. Amongst those considering LEA as an option to reduce labor pain, women who preferred to use LEA (n = 129) indicated favorable or neutral opinion. Additionally, 68% (n = 82) from those “no to LEA” or “not sure about LEA” still gave either favorable or neutral opinion for LEA (p < 0.0001). The multivariate logistic regression analysis found that EPDS ≥ 10 (p < 0.01), occupation (p = 0.03), ethnicity (p < 0.01), state anxiety (p = 0.02), mode of current pregnancy (unplanned; planned, assisted; planned, natural; p = 0.03) and premenstrual anger/irritability before current pregnancy (p = 0.02) were associated with LEA preference. The findings may help to define the population that may require further education on considering LEA and allow early identification on different LEA preferences to provide patient centric care prior to labor and delivery.

The association between epidural analgesia during labor and mother-infant bonding

STUDY OBJECTIVE

This study was aimed to assess the association between the use of epidural analgesia during labor and mother-infant bonding.

DESIGN

A cross-sectional study.

SETTING

Maternity ward at Soroka University Medical Center during 2020.

PATIENTS

Women who delivered a singleton live-born infant vaginally in their immediate post-partum period.

INTERVENTIONS

Women completed questionnaires. 25 items post-partum bonding questionnaire (PBQ) to assess mother-infant bonding (A high score on the PBQ indicates impaired mother-infant bonding) and the Edinburgh postnatal depression scale (EPDS) questionnaire to assess risk for post-partum depression.

MEASUREMENTS

The study used PBQ questionnaire and four sub-scales to assess mother-infant bonding and the EPDS questionnaire to assess risk for post- partum depression. Generalized linear regression models (gamma) were constructed to examine the association between epidural analgesia and mother-infant bonding total score and impaired bonding sub- scale, while adjusting for confounders Additional information such as pregnancy complications and sociodemographic data was drawn from women's medical records.

MAIN RESULTS

A total of 234 women were included in the final analysis, of them 126 (53.8%) delivered with epidural analgesia. The total PBQ score was significantly lower among women who received epidural analgesia compared to women without epidural analgesia (7.6 vs. 10.2, p = 0.024), demonstrating a better mother -infant bonding. Using two multivariable linear regression models, controlling for confounders such as maternal age and educational status, epidural analgesia during labor was independently associated with a better mother -infant bonding total score and better impaired bonding sub-scale score (Beta coefficient-0.252, 95% CI -0.5; -0.006, p = 0.045 and Beta coefficient - 0.34, 95% CI -0.52; -0.08, p = 0.01 for mother-infant bonding total score and sub-scale score, respectively). No differences in post-partum depression risks were found between the groups (EDPS≥13, 5.7% vs. 13%, p = 0.058).

CONCLUSION

Our study demonstrated better mother -infant bonding among women delivering with epidural analgesia.

Did she have an epidural? The long-term consequences of postdural puncture headache and the role of unintended dural puncture

OBJECTIVE

This narrative literature review examines the long-term impact of postdural puncture headache (PDPH) in postpartum women following an unintended dural puncture (UDP) with a large bore needle commonly used for epidural catheter placement. It seeks to bridge the knowledge gap for the neurologist as to the mounting body of obstetric anesthesia literature on the development of chronic headache after PDPH with this unique needle.

BACKGROUND

Headache is the most common complication of dural puncture, and the risk is greatest in the parturient population. Preexisting risk factors for this population include youth and sex, and after UDP with a large bore needle, almost 70%-80% report a headache. Additionally, there appears to be a significant cohort who experience long-term, persistent headache after UDP.

METHODS

We performed a narrative review of literature using PubMed, searching terms that included long-term follow-up after UDP with a large bore needle in the postpartum population.

RESULTS

In women who had UDP with a large bore needle used for epidural catheter placement at delivery, the rate of chronic debilitating headache is around 30% in the months following delivery and may persist for up to a year or longer.

CONCLUSION

Based on the existing literature, we have mounting evidence that UDP with the large bore needle used to place an epidural catheter should be understood as a high-risk inciting event for the development of long-term headaches not simply a high risk of acute PDPH. Additionally, consideration should be given to stratifying the etiology of PDPH, based on needle type, and recognizing the entity of chronic PDPH, thus allowing for improvements in research and diagnosis.

Chronic disabling postpartum headache after unintentional dural puncture during epidural anaesthesia: a prospective cohort study

BACKGROUND

Unintentional dural puncture with an epidural needle complicates approximately 1% of epidural anaesthetics and causes an acute headache in 60-80% of these patients. Several retrospective studies suggest an increased risk of chronic headache. We assessed the relationship between unintentional dural puncture and chronic disabling headache, defined as one or more functionally limiting headaches within a 2-week interval ending 2, 6, and 12 months postpartum.

METHODS

In this prospective observational study, parturients who experienced unintentional dural puncture were matched 1:4 with control patients. Patients completed questionnaires regarding characteristics of headache and back pain pre-pregnancy, during pregnancy, immediately postpartum, and at 2, 6, and 12 months postpartum. The primary outcome was prevalence of disabling headache in the past 2 weeks, assessed at 2 months postpartum. Secondary outcomes included prevalence and characteristics of headache and back pain at these time points.

RESULTS

We enrolled 99 patients. At 2 and 6 months postpartum, the prevalence of disabling headache was greater among patients with unintentional dural puncture than matched controls (2 months, 74% vs 38%, relative risk 1.9, 95% confidence interval 1.2-2.9, P=0.009; 6 months, 56% vs 25%, relative risk 2.1, 95% confidence interval 1.1-4.0, P=0.033). There was no difference in the prevalence of back pain at any time point.

CONCLUSIONS

Our prospective trial confirms retrospective studies that chronic headache is more prevalent among women who experienced unintentional dural puncture compared with controls who received uncomplicated neuraxial anaesthesia. This finding has implications for the. patient consent process and recommendations for long-term follow-up of patients who experience unintentional dural puncture.

Chronic pain in parturients with an accidental dural puncture: A case-controlled prospective observational study

BACKGROUND

We set out to examine incidence of chronic headache and back pain in women with PDPH after accidental dural puncture during labor.

METHODS

Chronic headache, backache, and disability were assessed 18-24 months postpartum. Women with PDPH treated with epidural blood patch (PDPH-EBP) were identified and matched with women who had a PDPH without epidural blood patch (PDPH-no EBP), with women with uncomplicated epidural analgesia and with women without epidural analgesia. Our primary outcome was incidence of chronic headache and backache. Secondary outcome was the effect of epidural blood patch on chronic pain development. We used Chi-square or Fisher's exact test to calculate odds ratios.

RESULTS

There was no statistically significant difference in demographic characteristics between groups. In the no epidural group, no women reported chronic headache and 2/116 (1.7%) reported chronic backache. In the uncomplicated epidural group, no women reported chronic headache and 7/116 (6.0%) reported chronic backache. In the PDPH-no EBP group, 9/56 (16.1%) women reported chronic headache and 10/56 (17.9%) reported chronic backache. In the PDPH-EBP group, 12/59 (20.3%) had chronic headache and 14/59 (23.7%) had chronic backache. No women in the no epidural or uncomplicated epidural group reported disability (chronic pain score of 3 or 4). High disability was reported by 8.9% of women in the PDPH-no EBP group and by 8.4% in the PDPH-EBP group.

CONCLUSION

Women with PDPH had a high incidence of chronic headache, back pain, and disability. We did not find a statistically significant difference in chronic pain development between conservatively treated and EBP-treated patients.

Comparison of Chloroprocaine Versus Lidocaine With Epinephrine, Sodium Bicarbonate, and Fentanyl for Epidural Extension Anesthesia in Elective Cesarean Delivery: A Randomized, Triple-Blind, Noninferiority Study

BACKGROUND

For emergent intrapartum cesarean delivery (CD), the literature does not support the use of any particular local anesthetic solution to extend epidural analgesia to cesarean anesthesia. We hypothesized that 3% chloroprocaine (CP) would be noninferior to a mixture of 2% lidocaine, 150 µg of epinephrine, 2 mL of 8.4% bicarbonate, and 100 µg of fentanyl (LEBF) in terms of onset time to surgical anesthesia.

METHODS

In this single-center randomized noninferiority trial, adult healthy women undergoing CD were randomly assigned to epidural anesthesia with either CP or LEBF. Sensory blockade (pinprick) to T10 was established before operating room (OR) entry for elective CD. On arrival to the OR, participants received the epidural study medications in a standardized manner to simulate the conversion of "epidural labor analgesia to surgical anesthesia." The primary outcome was the time to loss of touch sensation at the T7 level. A noninferiority margin was set at 3 minutes. The secondary outcome was the need for intraoperative analgesia supplementation.

RESULTS

In total, 70 women were enrolled in the study. The mean onset time to achieve a bilateral sensory block to touch at the T7 dermatome level was 655 (standard deviation [SD] = 258) seconds for group CP and 558 (269) seconds for group LEBF, a difference in means of 97 seconds (90% confidence interval [CI], SD = -10.6 to 204; P = .10 for noninferiority). The upper limit of the 90% CI for the mean difference exceeded the prespecified 3-minute noninferiority margin. There was no meaningful difference in the requirement for intraoperative analgesia between the 2 groups.

CONCLUSION

Both anesthetic solutions have a rapid onset of anesthesia when used to extend low-dose epidural sensory block to surgical anesthesia. Data from the current study provide insufficient evidence to confirm that CP is noninferior to LEBF for rapid epidural extension anesthesia for CD, and further research is required to determine noninferiority.

Development of Unity Simulator for Epidural Insertion Training for Replacing Current Lumbar Puncture Simulators

We have recently developed the Unity Simulator for Epidural Insertion Training (USEIT) system that provides an innovative and relatively inexpensive virtual simulation approach for epidural training. This report describes the design and development process to produce the USEIT system.

Morphine acts on spinal dynorphin neurons to cause itch through disinhibition

Morphine-induced itch is a very common and debilitating side effect that occurs in laboring women who receive epidural analgesia and in patients who receive spinal morphine for relief of perioperative pain. Although antihistamines are still widely prescribed for the treatment of morphine-induced itch, their use is controversial because the cellular basis for morphine-induced itch remains unclear. Here, we used animal models and show that neuraxial morphine causes itch through neurons and not mast cells. In particular, we found that spinal dynorphin (Pdyn) neurons are both necessary and sufficient for morphine-induced itch in mice. Agonism of the kappa-opioid receptor alleviated morphine-induced itch in mice and nonhuman primates. Thus, our findings not only reveal that morphine causes itch through a mechanism of disinhibition but also challenge the long-standing use of antihistamines, thereby informing the treatment of millions worldwide.

Birth signalling hormones and the developmental consequences of caesarean delivery

Rates of delivery by caesarean section (CS) are increasing around the globe and, although several epidemiological associations have already been observed between CS and health outcomes in later life, more are sure to be discovered as this practice continues to gain popularity. The components of vaginal delivery that protect offspring from the negative consequences of CS delivery in later life are currently unknown, although much attention to date has focused on differences in microbial colonisation. Here, we present the case that differing hormonal experiences at birth may also contribute to the neurodevelopmental consequences of CS delivery. Levels of each of the 'birth signalling hormones' (oxytocin, arginine vasopressin, epinephrine, norepinephrine and the glucocorticoids) are lower following CS compared to vaginal delivery, and there is substantial evidence for each that manipulations in early life results in long-term neurodevelopmental consequences. We draw from the research traditions of neuroendocrinology and developmental psychobiology to suggest that the perinatal period is a sensitive period, during which hormones achieve organisational effects. Furthermore, there is much to be learned from research on developmental programming by early-life stress that may inform research on CS, as a result of shared neuroendocrine mechanisms at work. We compare and contrast the effects of early-life stress with those of CS delivery and propose new avenues of research based on the links between the two bodies of literature. The research conducted to date suggests that the differences in hormone signalling seen in CS neonates may produce long-term neurodevelopmental consequences.

Analgesia for vaginal birth: Secondary analysis from the WHO Multicountry Survey on Maternal and Newborn Health

OBJECTIVE

To evaluate the use of analgesia during labor in women who had a vaginal birth and to determine the factors associated with its use.

METHODS

A secondary analysis was performed of the WHO Multicountry Survey on Maternal and Newborn Health, a cross-sectional, facility-based survey including 359 healthcare facilities in 29 countries. The prevalence of analgesia use for vaginal birth in different countries was reported according to the Human Development Index (HDI). Sociodemographic and obstetric characteristics of the participants with and without analgesia were compared. The prevalence ratios were compared across countries, HDI groups, and regions using a design-based χ² test.

RESULTS

Among the 221 345 women who had a vaginal birth, only 4% received labor analgesia, mainly epidural. The prevalence of women receiving analgesia was significantly higher in countries with a higher HDI than in countries with a lower HDI. Education was significantly associated with increased use of analgesia; nulliparous women and women undergoing previous cesarean delivery had a significantly increased likelihood of receiving analgesia.

CONCLUSION

Use of analgesia for women undergoing labor and vaginal delivery was low, specifically in low-HDI countries. Whether low use of analgesia reflects women's desire or an unmet need for pain relief requires further studies.

Gerard W. Ostheimer Lecture: What's New in Obstetric Anesthesia 2018

This article summarizes the Gerard W. Ostheimer Lecture given at the 2019 Society for Obstetric Anesthesia and Perinatology annual meeting. The article summarizes key articles published in 2018 that were presented in the 2019 Ostheimer Lecture, with a focus on maternal mortality, maternal complications, analgesic and anesthetic management of vaginal and cesarean deliveries, postpartum care, and the impact of anesthesia on maternal outcomes. The reviewed literature highlights many opportunities for anesthesiologists to impact maternal care and outcomes. The major themes presented in this manuscript are maternal mortality including amniotic fluid and cardiac arrest; postpartum hemorrhage; venous thromboembolism; management of spinal-induced hypotension; postpartum care including opioid use, postcesarean analgesia, and postpartum depression. A proposed list of action items and research topics based on the literature from 2018 is also presented. Specifically, anesthesiologists should use prophylactic vasopressor infusions during elective cesarean delivery; use a structured algorithm to diagnose pulmonary embolus, and reevaluate the use of D-dimer measurements; target postpartum opioid analgesia and prescribing; use multimodal postcesarean delivery analgesia, preferably with neuraxial hydrophilic opioids; and study any association between labor analgesia on postpartum depression.

Japanese parturient body mass index and the role in initial nerve block height of women undergoing cesarean delivery with spinal anesthesia

The present retrospective cohort study was designed to determine body mass index (BMI) at the delivery in women undergoing cesarean section in a Japanese urban area, and whether the nerve block height after spinal anesthesia upon the cesarean delivery relates to the lower maternal BMI, less gestational age, or underweight fetus at birth in the population.A total of 401 pregnant women undergoing cesarean delivery with spinal anesthesia were evaluated retrospectively. We examined background differences, including BMI at the delivery, gestational age, and fetal birth weight between the cases with and without the adequate initial nerve block height less than the sixth thoracic vertebral level (Th6) after the spinal dose administration.The data demonstrated advanced maternal age pregnancy (median 35.5 years) and normal BMI (median 24.7) at the delivery in the population. The patients with the inadequate initial nerve block height immediately after the spinal dose administration documented significantly lower block height compared with those with adequate block height (Th8 [n = 55] vs Th4 [n = 346], P < 0.001). There was a risk of the low initial block height caused by either preoperative BMI <23, gestational age <37 weeks, or fetal birth weight <2500 g in the population.In a Japanese urban area, parturient median BMI undergoing cesarean delivery is in the normal range. Such lower BMI, in addition to less gestational age or underweight fetus, seems one of the factors causing the low initial block height upon spinal anesthesia.

A Project to Increase Nurses' Comfort in Offering Bedpans to Women Laboring With Epidural Analgesia

OBJECTIVE

To improve nurses' comfort in helping laboring woman void on a bedpan after initiation of epidural analgesia, to increase the frequency of bedpan use in the labor and birth unit, and to decrease the use of continuous indwelling Foley catheters during the intrapartum period.

DESIGN

Quality improvement project.

SETTING

A single large, midwestern U.S. hospital (>3,000 births annually), where bedpans are infrequently used after epidural placement.

PARTICIPANTS

Registered nurses on a labor and birth unit.

INTERVENTION/MEASUREMENTS

A 20-minute educational presentation that included current urinary catheter evidence-based practice, preferential use of bedpans, and methods to help women void successfully was taught to all registered nurses in the author's labor unit. Nurses rated on a scale of 0 (not comfortable at all) to 10 (extremely comfortable) their comfort level at helping a woman with a bedpan. Primary data were collected through a convenience sample of anonymous surveys (n = 52) completed by registered nurses regarding their experience with bedpan and catheter use during labor and their comfort level helping women be successful with voiding. This was followed by a retrospective chart audit for women with term, singleton pregnancies who labored with epidural analgesia.

RESULTS

Nurses' comfort levels increased from an average of 5.7 to 7.2 (p = .067). Postepidural bedpan use increased from 5.5% (n = 12) to 19% overall (n = 20; p < .001), with five women using bedpans exclusively. When assisted with bedpan use, 38% (n = 12) of women were able to void 34 of the 53 times it was offered (64%). Use of continuous indwelling Foley catheters decreased from 61.7% (n = 137) to 54.7% (n = 58), and use of intermittent catheterization increased from 30.6% (n = 68) to 37.7% (n = 40).

CONCLUSION

When assisted by nurses educated in and comfortable with different voiding techniques, women may be able to avoid medically unnecessary use of urinary catheters during labor.

National survey of obstetric anaesthesia clinical practices in the republic of Austria

BACKGROUND

The aim of this study was to describe the current obstetric anaesthetic practices in Austria by performing a comprehensive questionnaire survey.

METHODS

A questionnaire was sent via email to key anaesthesiologists from obstetric anaesthesia departments of 81 hospitals registered at the Austrian Ministry of Health.

RESULTS

Of 81 departments contacted, 65 (80%), covering 84% of annual births in Austria, responded to the 82-question survey. Epidural analgesia was offered universally, at a rate under 30% in 56 (86%) of respondent hospitals. The caesarean section rate was under 30% in 44 (68%) respondent obstetric units. All respondents provided spinal anaesthesia as the primary anaesthetic technique for elective caesarean section. Three (5%) respondents administered long-acting intrathecal morphine and 18 (28%) respondents did not routinely administer any intrathecal opioid. Wound infiltration for acute postoperative pain control was practiced in two (3%) respondent units. A transversus abdominis plane block was offered as rescue analgesia in 14 (22%) departments. Spinal hypotension was treated using a prophylactic phenylephrine infusion in two (3%) respondent hospitals. Prophylactic antibiotics were administered prior to skin incision by 31 (48%) respondents.

CONCLUSION

This survey reveals that obstetric anaesthetic practices in Austria differ in part from current European and American guidelines. Findings will direct the national workforce on obstetric anaesthesia that aims to introduce into Austria practice guidelines, based on international collaborations and guideline recommendations.

Bearing the Pain: A Historic Review Exploring the Impact of Science and Culture on Pain Management for Childbirth in the United States

Scientific advances over the past 150 years have influenced pain management practices during childbirth. Cultural attitudes about pain in childbirth have also affected these practices. The objective of this work is to examine the history of pain management in childbirth in the United States and explore the relationship between cultural attitudes and care practices. A historic review was chosen as the research method. Included were records that described pain management practices and records that explored the relationship between care practices and American cultural attitudes about pain in childbirth. The health science reference databases of CINAHL (EBSCO host), PubMed and the Cochrane Library were searched for English language articles. There were no limitations in years searched. Twenty-five primary records and 42 secondary records met inclusion criteria and were used in this work. Scientific developments as well as ever-changing cultural attitudes have greatly impacted pain management practices for childbirth in America. A highly complex and parallel, relationship exists between science and culture in regards to this history. To promote positive birth experiences for women, it is essential that obstetrical practices are congruent with cultural views regarding appropriate pain management in childbirth.