PROSPECT guideline for elective caesarean section and the administration of dexamethasone

A narrative review of the literature relevant to obstetric anesthesiologists: the 2023 Gerard W. Ostheimer lecture

This narrative review of the 2023 Gerard W. Ostheimer lecture presented at the Society for Obstetric Anesthesia and Perinatology 2023 annual meeting summarizes 2022 literature relevant to obstetric anesthesiologists.

ANTENATAL STUDIES

Neonatal morbidity is reduced with antenatal maternal buprenorphine compared with methadone for treatment of opioid use disorder. Antenatal pregnancy allergy testing is safe and feasible.

ANALGESIA AND ANESTHESIA STUDIES

Intrathecal (IT) 3% chloroprocaine for cervical cerclage results in faster sensory block resolution and discharge readiness compared with bupivacaine. The ED90 of 3% chloroprocaine (with IT fentanyl 10 µg) is 49.5 mg. Dural puncture epidural technique does not improve the quality of labor analgesia in obese parturients compared with epidural analgesia. Low- (>0.08 to ≤0.1%) and ultra-low (<0.08%) concentrations of bupivacaine for epidural analgesia maintenance result in similar maternal and neonatal outcomes. Lower doses of first line uterotonic agents are non-inferior to higher doses (oxytocin 0.5 IU vs. 5 IU and carbetocin 20 vs. 100 µg) in patients at low risk for postpartum hemorrhage. Supplemental analgesia or conversion to general anesthesia is necessary in approximately 15% of elective cesarean deliveries. Intravenous dexamethasone improves analgesia outcomes, however optimal dosing and timing remain unclear; it may induce neonatal hypoglycemia in the setting of gestational diabetes.

POSTPARTUM STUDIES

A core outcome set may help evaluate enhanced recovery protocol implementation. History of migraine and accidental dural puncture (ADP) above the L3 level are associated with epidural blood patch (EBP) failure and ADP at or below L3 and >48 h interval between ADP and EBP are associated with success.