Delivery Floor Research Articles

Implementing a Labor and Delivery Cell Salvage Protocol in Patients at Increased Risk of Hemorrhage: A Pilot Study.

Postpartum hemorrhage (PPH) contributes significantly to maternal morbidity and mortality. The use of cell salvage has been implemented in operating rooms across the world, but only a limited number of institutions have protocols for use of cell salvage during vaginal hemorrhage at the time of vaginal delivery. Observations suggest that blood salvaged from vaginal delivery is comparable to blood salvaged during cesarean delivery. Using pre-validated protocols of cell salvage, we sought to assess the feasibility and potential benefit of implementing cell salvage in our Labor and Delivery unit in all patients at high risk of hemorrhage. This was a prospective pilot study conducted from April 2022 to December 2022 on the Labor and Delivery floor at Mount Sinai Hospital in New York City. A total of 50 participants were identified for cell salvage after vaginal delivery during the study period.The mean age of participants was 34.4 years (SD 5.5).We utilized acell salvage technique at the time of vaginal delivery in patients at high risk of PPH. We employed simple descriptive statistics and examined sums and percentages (and means and standard deviations, where appropriate). A simple equation was used to determine the average cell salvaged volume in each delivery and describe potential values. The HEMAsavR™device (Ecomed Solutions, Mundelein, IL, USA) was used as a standby system to be used at the time of the vaginal delivery. Fifty participants were identified for the cell salvage protocol as described. Despite a diversity of clinical risk factors, the sample consisted ofpredominately non-Hispanic White patients. The mean quantitative blood lossof cell salvaged samples was 157.2 mL(SD 153.0). We identified that, on average, >33% of vaginally shed blood could be used for cell salvage and improve patient blood management. The implementation of cell salvage in our Labor and Delivery unit was feasible and easy to perform. We identified that a significant volume of blood would be available for cell salvage. Further studies should be done to evaluate the benefit of cell salvage to improve postpartum recovery.

Impact of cell salvage on hematocrit and post-partum anemia in low hemorrhage risk elective cesarean delivery

BackgroundPostpartum anemia is a significant contributor to peripartum morbidity. The utilization of cell salvage in low risk cases and its impact on postpartum anemia has not been investigated. We therefore aimed to examine the impact of autologous blood transfusion/cell salvage in routine cesarean delivery on postoperative hematocrit and anemia. Study design and methodsRetrospective cohort study from a perfusion database from a large academic center where cell salvage is performed at the discretion of the obstetrical team. Data from 99 patients was obtained. All patients were scheduled elective cesarean deliveries that took place on the labor and delivery floor. Thirty patients in the cohort had access to cell salvage where autologous blood was transfused after surgery. Pre-procedural hemoglobin/hematocrit measurements were obtained along will postpartum samples that were collected on post-partum day one. ResultsThe median amount of blood returned to cell salvage patients was 250 mL [206–250]. Hematocrit changes in cell salvage patients was significantly smaller than controls (−1.85 [−3.87, −0.925] vs −6.4 [−8.3, −4.75]; p < 0.001). The odds of developing new anemia following surgery were cut by 74% for the cell salvage treatment group, compared to the odds for the control group (OR = 0.26 (0.07–0.78); p = 0.028) DiscussionDespite losing more blood on average, patients with access to cell salvage had higher postoperative HCT, less postpartum anemia, and no difference in complications related to transfusion. The utilization of cell salvage for routine cesarean delivery warrants further research.

Mean distance from skin to epiglottis in parturients as measured by airway ultrasound.

There is an increasing interest in using airway ultrasound to predict difficult intubation. Studies to date have excluded pregnant women in reporting airway measurements. We performed this study to compare the mean distance from skin to epiglottis in parturients to that reported in previously published studies. We also assessed the correlation of mean distance from skin to epiglottis with other elements of the airway examination. A total of 100 parturients were recruited from a tertiary hospital's labor and delivery floor. Standard physical examination parameters were recorded in addition to the mean distance from skin to epiglottis for all subjects. The ratio of height-to-thyromental distance was used to classify airways as potentially favorable or unfavorable. The average mean distance from skin to epiglottis in parturients was 19.9 ± 3.3 mm and followed a normal distribution. The mean distance from skin to epiglottis was moderately correlated with height and body mass index. There was no difference in mean distance from skin to epiglottis between subjects with favorable versus unfavorable airways as classified by ratio of height-to-thyromental distance. The typical mean distance from skin to epiglottis in parturients falls between previously published values in mixed populations. Previously published cut-off values using airway ultrasound to predict difficult intubation are not likely to apply to parturients.

Systems-Level Factors Affecting Registered Nurses During Care of Women in Labor Experiencing Clinical Deterioration

Maternal morbidity and mortality are at their highest recorded levels in the United States, with more than 50% of maternal deaths deemed preventable. Women in labor often experience gradual morbidity, but signs of worsening condition may not be noticed by clinicians. Nurses are well-positioned to notice these signs, but performance obstacles inhibit nurses' work. There is scant literature describing the obstetric work system. This study sought to identify the systems-level factors affecting registered nurses during care of women in labor experiencing clinical deterioration. A convergent parallel mixed methods design combining survey data from the adapted Performance Obstacles for ICU Nurses instrument and semistructured interviews with registered nurses, certified nurse midwives, and physicians was used. Data were collected on the labor and delivery floor of a tertiary care center in Boston from July 2021 through August 2021. Interviews were coded using Bradley's integrated deductive and inductive methods and the Systems Engineering Initiative for Patient Safety (SEIPS) categories. Data included 46 surveys and 16 interviews. Identified performance obstacles were in the categories of tasks, tools and technology, and physical environment. Emergent themes included swamped, feeling inadequate, and is this safe? Issues with task overload, tools, and technology inhibit nurses' abilities to respond appropriately to women in labor who experience clinical deterioration. Emergent themes imply a relationship between task overload and burnout. Health care administrators should improve staffing, decrease nurse task load, and include bedside nurses in the redesign of tools and technology to mitigate the harms of performance obstacles.

Black Women Watchers

Black Women Watchers Wendy M. Thompson (bio) I remember the first time I went into labor. It was as though I was being forced to dance to a new choreography. The pain gripped and twisted the whole of my body, my lower back folding inward, my five-foot body contorting to music only I could hear, moving on a stage only I could access. Each sudden lightning strike of pain reminded me that in that moment, my body was not my own but was shared by the small thing—a girl, they told me, who might have a congenital anomaly, so we were on high alert—pushing inside. My mother, who had given birth multiple times without anesthesia, reminded me of her mother, who had also given birth multiple (nine) times without anesthesia in a foreign country, and told me I was not the first woman to go into labor. She said this to me while panicked and driving to a hospital in Fremont at night, where I had intentionally chosen a young Asian American female doctor and knew that there would be Black female medical staff present, among many other nurses of color who would at the very least, see me and attend to my body. Unlike in the videos and manuals I was given by the birthing center, there was no defining marker between the beginning of real labor and the moment when pain arrived to fight me for my body. There was no breaking of water. There was no voice outside of me that gently guided me into the golden meadow of motherhood. Just sharp violent pains that, if I were to describe it to a counselor later, had no color, no smell, and weren't even five minutes apart. I barely remember standing in front of two panicked male front desk staff with swollen legs and feet, wearing a loose-flowing housedress while I struggled to pull my driver's license out of my wallet. One of the staff [End Page 165] members, a young Chinese man, ran—literally, ran!—to get me a wheelchair and quickly wheeled me up to my room. Then someone helped me onto the bed before leaving me alone. Everything that came after that, the breathing, the rotating nursing staff, the pushing, the family members who stopped by, the white female doctor who came in to get my signature in the event that I died during delivery, ran together like watching a movie in fast-forward. Everything except for the Black nurse who I never saw at first but who came to me after I let out what I can only now describe as a wild animal sound. Alone in a room on the labor and delivery floor in this hospital, a cry was heard through my open door by another Black woman, a nurse, who wasn't even assigned to me but was conveniently (or divinely) right outside my room and who I would never see again during the rest of my stay at the hospital. I will never forget how she came in, looked at me, and immediately said, "Don't worry, honey. I'm going to go call the anesthesiologist to come right now." No need to explain on a scale of one to ten. No need to prove my pain according to a white man's threshold. Just a matter-of-fact acknowledgment that a baby was coming, her mama was in great pain, and there needed to be some immediate action taken. With a little sugar on top. Honey. ________ I thought about this birthing experience and the traumatic one that would follow seven years later in Minnesota after reading a post made by writer Kiese Laymon on social media on January 4, 2021. Kiese wrote: My mother had major spine surgery. It was terrifying. She's still trying to recover. When she finally woke up, all she could talk about was this Haitian nurse who told her it would be okay because there would be a Black resident in the operation room watching. We talked more and she made it clear that even if she would have had a Black surgeon, she really wanted a...

Quality Assurance and Quality Improvement in the Labor and Delivery Setting.

Quality assurance (QA) is the maintenance of a desired level of quality, whereas quality improvement (QI) is the continuous process of creating systems to make things better. Implementation science promotes the systematic uptake of best practices. Bundles are a structured list of best practices whereas toolkits provide the necessary details, rationale, and implementation materials, such as sample policies and protocols. Metrics that can guide care on the labor and delivery (L&D) floor may be related to team structure (obstetric, multidisciplinary, anesthetic), processes (patient monitoring, team effects), and outcomes (postpartum hemorrhage, venous thromboembolism). Multiple anesthetic quality metrics have been proposed, including the mode of anesthesia for cesarean delivery.

An Intelligent Actuator of an Indoor Logistics System Based on Multi-Sensor Fusion

Integration technologies of artificial intelligence (AI) and autonomous vehicles play important roles in intelligent transportation systems (ITS). In order to achieve better logistics distribution efficiency, this paper proposes an intelligent actuator of an indoor logistics system by fusing multiple involved sensors. Firstly, an actuator based on a four-wheel differential chassis is equipped with sensors, including an RGB camera, a lidar and an indoor inertial navigation system, by which autonomous driving can be realized. Secondly, cross-floor positioning can be realized by multi-node simultaneous localization and mappings (SLAM) based on the Cartographer algorithm Thirdly the actuator can communicate with elevators and take the elevator to the designated delivery floor. Finally, a novel indoor route planning strategy is designed based on an A* algorithm and genetic algorithm (GA) and an actual building is tested as a scenario. The experimental results have shown that the actuator can model the indoor mapping and develop the optimal route effectively. At the same time, the actuator displays its superiority in detecting the dynamic obstacles and actively avoiding the collision in the indoor scenario. Through communicating with indoor elevators, the final delivery task can be completed accurately by autonomous driving.

The interval between births and the risk of recurrent preeclampsia among predominantly high risk women in urban tertiary care center

Women with a history of preeclampsia have a higher risk of recurrent preeclampsia. This study sought to ascertain the relationship between the interbirth interval and the risk of recurrent preeclampsia and difference in angiogenic markers between the two groups. Data was collected from an ongoing cohort study of women with hypertensive disorders of pregnancy (HDP) enrolled at the admission to the labor and delivery floor. From this dataset, multigravida women with a prior diagnosis of preeclampsia were identified and compared to women with no prior history of preeclampsia. Of the 375 women with HDP who were predominantly African American, 245 were multigravida and 44 (18.0%) had a prior history of preeclampsia. Women with prior preeclampsia had an earlier gestational age of delivery, higher rates of preterm delivery and a higher incidence of preeclampsia with severe features (56.8% vs 29.8%) in the index pregnancy (p-values≤0.001) than those without. The median number of years between history of preeclampsia in previous pregnancy and current pregnancy was 6years (IQR 3, 8). Among patients with a prior history of preeclampsia, the interbirth interval was not associated with severe preeclampsia (p=0.60) and there was no difference in angiogenic factors between patients with a prior history of preeclampsia compared to those without. In this study, the duration of the interbirth interval was not identified as a risk factor of developing severe preeclampsia in a subsequent pregnancy and angiogenic factors are not a reflection of maternal predisposition to recurrent preeclampsia.

Management of Pre-eclampsia and Eclampsia: A Simulation.

Pre-eclampsia is a hypertensive disorder in pregnancy. Maternal sequelae that may occur include impaired liver function, disseminated intravascular coagulation, seizures (eclampsia), stroke, and death. Thus, providers should know how to recognize (diagnose) and treat pre-eclampsia and eclampsia. A simulator with noninvasive blood pressure monitoring was used. Transducers for fetal heart rate and contraction monitoring were placed on the simulator, which represented the patient. After obtaining a history and performing a physical examination, resident physician (postgraduate years 1-4) and nurse learners had to diagnose pre-eclampsia and treat this condition. They also had to treat severe-range blood pressures and manage eclampsia. Learner performance was assessed with a checklist. Debriefing followed the simulation. Thirty resident learners participated in the study. Nurses did not participate. All resident learners indicated familiarity with the diagnosis and management of pre-eclampsia and emergent hypertension and managed these conditions correctly. All resident learners reported not being confident in managing eclampsia. None of the learners were able to stop the eclamptic seizure. All resident learners were more confident in managing eclampsia after the scenario compared with before (mean confidence level 3.6 ± 0.5 vs. 1.1 ± 0.4, p < .001). Resident learners were familiar with the management of pre-eclampsia and emergent hypertension but not with eclampsia. We recommend that eclampsia simulations occur in a laboratory and in situ on the labor and delivery floor with interprofessional team members including obstetricians, nurses, anesthesiologists, emergency and family medicine physicians, nurse practitioners, and physician assistants.

Magnitude and frequency of debris and slush flows in the Khibiny mountain valleys, Kola Peninsula, NW Russia

Abstract. Available results for five studied valleys of the Khibiny Mountains, Kola Peninsula, suggest that slush flows and, possibly for some valleys, typical debris flows with lower frequency, are a leading mechanism for downstream sediment delivery and valley floor topographical formation. Typical fluvial topography in slush flow-affected basins is extremely suppressed or nonexistent, since under such conditions, stream channels are unable to rework slush flow deposits. The recovery phase of fluvial topography can serve as an indicator of the magnitude and time passed since the last extreme event. A combination of grain size analysis, radionuclide fingerprinting with the 232Th content in the finer-grained sediment matrix (size &lt;10 mm) and 14C dating, were applied to reveal the age and common structure of debris and slush flow environments and to investigate the main factors in their lithodynamics. Those helped to estimate transportation distances and capacities of the flows and the amount of fluvial reworking of its deposits with time. Application of radiocarbon dating to determine absolute ages (about 30 dates) of stabilization periods for the colluvial cones, mountain fans and valley bottoms and integration with other available chronological data provided a basis for distinguishing several stages of decreased activity of debris and slush flows and extreme slope failures through the second half of the Holocene. Field mapping and remote sensing data interpretation revealed spatial distribution patterns of debris and slush flows. Geomorphic analysis of large relic landforms in valley bottoms confirms, in general, the case for a significant reduction of debris flow magnitude since the last deglaciation and distinct shift to slush flow processes with much lower clastic content. A reliable chronology of the early events is yet to be obtained representing a challenging problem for future research.

Robotic assistance in the coordination of patient care

We conducted a study to investigate trust in and dependence upon robotic decision support among nurses and doctors on a labor and delivery floor. There is evidence that suggestions provided by embodied agents engender inappropriate degrees of trust and reliance among humans. This concern represents a critical barrier that must be addressed before fielding intelligent hospital service robots that take initiative to coordinate patient care. We conducted our experiment with nurses and physicians, and evaluated the subjects’ levels of trust in and dependence upon high- and low-quality recommendations issued by robotic versus computer-based decision support. The decision support, generated through action-driven learning from expert demonstration, produced high-quality recommendations that were accepted by nurses and physicians at a compliance rate of 90%. Rates of Type I and Type II errors were comparable between robotic and computer-based decision support. Furthermore, embodiment appeared to benefit performance, as indicated by a higher degree of appropriate dependence after the quality of recommendations changed over the course of the experiment. These results support the notion that a robotic assistant may be able to safely and effectively assist with patient care. Finally, we conducted a pilot demonstration in which a robot-assisted resource nurses on a labor and delivery floor at a tertiary care center.

565: Trends for a surgical center of excellence for morbidly adherent placenta (MAP)

To review management and maternal outcomes in pregnant women with MAP in a Surgical Center of Excellence at Columbia University Medical Center. The Mothers' Center provides a standardized approach to patients referred for suspected MAP. Management includes establishing a multi-disciplinary team and a standardized approach to management with a flow chart for early diagnosis, antepartum surveillance, preoperative consultation and preparation, intraoperative management, and postoperative care. (Image 1). Single-institution retrospective chart review from 2011 to 2017 comparing patients with diagnosis of MAP at the Mothers' Center. We reviewed our demographic and outcome data for the previous six years. Our statistical trends were analyzed using SAS. We delivered 82 pregnant women at a mean gestational age of 35 weeks with suspected MAP in which 95% had prior cesarean deliveries and 32% had prior D&Cs/D&Es. Women underwent cesarean deliveries in either a scheduled setting (85%) or emergent setting (15%). Of the emergent deliveries, 9% were delivered on the labor and delivery floor. Of the total deliveries, only 89% had confirmed pathology of MAP. Interestingly, 61 mothers were transferred directly from the operating room to a surgical step down unit, while 16 were transferred to a Surgical Intensive Care Unit (SICU) and 4 went directly to postpartum. There was 1 maternal death. (Table 1). Over the last three and a half years, the number of patients referred to our center has doubled from 28 to 54. As rates of caesarean section continue to increase, the frequency of MAP has been seen to increase. As the standard of care moves towards Centers of Excellence, we have seen an increasing number of patients presenting for management of MAP. We found that the majority of our patients underwent scheduled delivery with a multidisciplinary team with a disposition to surgical step down rather than ICU.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Impact of an Obstetrical Hospitalist Program on the Safety Events in a Mid-Sized Obstetrical Unit.

ObjectiveBecause internal medicine hospitalist programs were developed to address issues in medicine such as a need to improve quality, improve efficiency, and decrease healthcare cost, obstetrical (OB) hospitalist models were developed to address needs specific to the obstetrics and gynecology field. Our objective was to compare outcomes measured by occurrence of safety events before and after implementation of an OB hospitalist program in a mid-sized OB unit.MethodsFrom July 2012 to September 2014, 11 safety events occurred on the labor and delivery floor. A full-time OB hospitalist program was implemented in October 2014.ResultsFrom October 2014 to December 2016, there was 1 safety event associated with labor and delivery.ConclusionIt has been speculated that implementation of an OB hospitalist model would be associated with improved maternal and neonatal outcomes; our regional OB referral hospital demonstrated a statistically significant decrease in OB safety events after the OB hospitalist program implementation.

Impact of an Obstetrical Hospitalist Program on the Safety Events in a Midsized Obstetrical Unit [24N

INTRODUCTION: As internal medicine hospitalist programs were developed to address issues in medicine such as a need to improve quality, improve efficiency and decrease healthcare cost, obstetrical (OB) hospitalist models were developed to address needs specific to obstetrics and gynecology (OB/GYN). Though there is an increase of OB hospitalist model utilization in the U.S., there is currently no published studies available that report outcomes following the implementation of OB hospitalist programs. Our objective was to compare outcomes measured by occurrence of safety events prior to and after implementation of an OB hospitalist program in a mid-sized obstetrical unit. METHODS: Our regional obstetrical referral hospital has approximately 3500 deliveries per year. Safety events are regularly monitored and evaluated. Our full-time OB hospitalist program was implemented in October 2014, with continuous coverage of the labor and delivery (L/D) floor. Safety events from the pre-implementation period, July 2012-September 2014, were compared to the post-implementation period, October 2014-June 2016. RESULTS: From July 2012 through September 2014, 11 safety events occurred on the L/D floor. From October 2014 through June 2016, post-implementation, there was zero safety events associated with L/D. CONCLUSION: Full-time OB hospitalists provided patients with immediate evaluation, early recognition of critical clinical events, and provided management in high stakes clinical situations. While it has been speculated that implementation of an OB hospitalist model would be associated with improved maternal and neonatal outcomes, our regional obstetrical referral hospital demonstrated a significant decrease and elimination of obstetrical safety events following the OB hospitalist program implementation.

Does nitrous oxide labor analgesia influence the pattern of neuraxial analgesia usage? An impact study at an academic medical center

Study objectiveTo compare the rate of epidural use before and after the implementation of nitrous oxide (N2O). DesignData were obtained from a nursing database of N2O usage and our obstetric anesthesia database. We compared 8 months before and 8 months after the introduction of N2O. It was available 24 h/d, 7 d/wk, consistent with neuraxial analgesia availability. Epidural utilization before and after introduction of N2O was compared using χ2 analysis. SettingLabor and delivery floor. Main resultsTotal number of births over the study period was 8539: 4315 pre-N2O and 4224 post-N2O. The rate of epidural usage was 77% pre-N2O and 74% after N2O (P= not significant, χ2). A total of 762 patients used N2O. Monthly analysis showed no change in pattern of neuraxial analgesia use in post-N2O period compared with the pre-N2O period. ConclusionThe introduction of N2O for labor analgesia was not associated with any change in our rate of labor epidural utilization. Under the conditions of our study, these results suggest that N2O does not discourage neuraxial use for labor pain relief.

Finite Element Modeling in Female Pelvic Floor Medicine: a Literature Review

Female pelvic floor dysfunction (PFD) includes conditions such as urinary incontinence, pelvic organ prolapse, or fecal incontinence. One in every ten women will, at some point of their lives, suffer a form of PFD so severe that it will require surgery, with one third of these undergoing repeated surgical procedures. PFD occurs due to damage to levator ani muscle (LAM), endopelvic fascia, and nerves organized as a complex load-bearing apparatus in the pelvis. Our ability to understand treatment failure and prevention strategies necessitates an understanding of these tissue elements and their structural and functional interactions. Biomechanical engineering is a discipline that studies and analyzes structure-function relationships. Geometric and finite element modeling are tools that have been widely used by biomechanical engineers to computationally simulate vaginal delivery and pelvic floor function and dysfunction. The aim of this review was to discuss the role of computational modeling in female pelvic floor medicine.

The case for an electronic fetal heart rate monitoring credentialing examination

The Perinatal Quality Foundation has created an examination containing both knowledge-based and judgment questions relating to the interpretation of electronic fetal heart rate monitoring for credentialing all medical and nursing personnel working on a labor and delivery floor. A description of the examination and the rationale for its use throughout the United States is presented.

The Use of the Clinical Resource Nurse to Solve the Eternal Dilemma of Financial Responsibility Versus Staffing Requirements

Professional Issues Poster Presentation Purpose for the Program This pilot quality improvement project provides data to support a creative option that involves the use of a clinical resource nurse to support units with high percentages of new‐to‐practice staff, and also improves nursing satisfaction, complies with new staffing guidelines set by a professional organization, and improves patient flow. Proposed Change A 2‐week pilot project of the clinical resource nurse (CRN) was implemented on a labor and delivery floor in an academic medical center with 772 beds. This concept was tested for five main reasons: (a) increased acuity, (b) new staffing guidelines, (c) high percentages of new to practice staff, (d) high percentages of nurse turnover rates, and (e) low nurse satisfaction scores. To implement the pilot project, an extra registered nurse (RN) was assigned as the clinical resource nurse on every shift (excluding weekends) resulting in over budgeting (one extra RN was needed from 7 a.m. to 7 p.m. and from 7 p.m. to 7 a.m.) for a 2‐week period. Implementation, Outcomes, and Evaluation A core group of nurses were selected to continue the role of CRN 24 hours per day, 7 days per week. A PowerPoint presentation was created as a resource for all staff, and education continued surrounding the daily responsibilities of this nurse by a clinical level IV nurse. During the trial period this role focused on the use of the CRN on the labor and delivery floor, but upon implementation the scope of this role was expanded to be a resource for the newly developed antepartum unit (APU). This requires the CRN to assess the APU every 4 hours and assist with admissions and overseeing the management of nursing care for patients. A preimplementation and postimplementation survey was given to 32 nurses based on the Likert scale. Results showed increased perceived quality of care provided to patients and increased feelings of having the necessary resources for help when they need them. Furthermore, the results showed an increased perception of improved quality of patient care with 50% of respondents rating their care as excellent posttrial as opposed to only 16% pretrial. A decrease in incident reports was also noted. Implications for Nursing Practice This pilot indicated that a CRN may be useful in areas with high rates of new‐to‐practice nurses. In the short period of time, nurses reported increased perceived quality of care along with resources needed for complex patients. Patient flow was improved as well as possible improved quality of care related to the decrease in incident reports filed.

Resuscitation of the pregnant patient: What is the effect of patient positioning on inferior vena cava diameter?

Study objectivePatients in the third trimester of pregnancy presenting to the emergency department (ED) with hypotension are routinely placed in the left lateral tilt (LLT) position to relieve inferior vena cava (IVC) compression from the gravid uterus thereby increasing venous return. However, the relationship between patient position and proximal intrahepatic IVC filling has never assessed directly. This study set out to determine the effect of LLT position on intrahepatic IVC diameter in third trimester patients under real-time visualization with ultrasound. MethodsThis prospective observational study on the labor and delivery floor of a large urban academic teaching hospital enrolled patients between 30 and 42 weeks estimated gestational age from August 2011 to March 2012. Patients were placed in three different positions: supine, LLT, and right lateral tilt (RLT). After the patient was in each position for at least 3min, IVC ultrasound using the intercostal window was performed by one of three study sonologists. Maternal and fetal hemodynamics were also monitored and recorded in each position. ResultsA total of 26 patients were enrolled with one excluded from data analysis due to inability to obtain IVC measurements. The median IVC maximum diameter was 1.26cm (95% confidence interval [CI] 1.13–1.55) in LLT compared to 1.13cm (95% CI 0.89–1.41) in supine, p=0.01. When comparing each individual patient's LLT to supine measurement, LLT lead to an increase in maximum IVC diameter in 76% (19/25) of patients with the average LLT measurement 29% (95% confidence interval 10–48%) larger. Six patients had the largest maximum IVC measurement in the supine position. No patients experienced any hemodynamic instability or distress during the study. ConclusionIVC ultrasound is feasible in late pregnancy and demonstrates an increase in diameter with LLT positioning. However, a quarter of patients had a decrease in IVC diameter with tilting and, instead, had the largest IVC diameter in the supine position suggesting that uterine compression of the IVC may not occur universally. IVC assessment at the bedside may be a useful adjunct in determining optimal positioning for resuscitation of third trimester patients.

Obstetric Anesthesia

Northwestern University Feinberg School of Medicine, Northwestern Memorial Hospital, Chicago, Illinois. jason-farrer@fsm.northwestern.eduBy Craig M. Palmer, M.D., Robert D'Angelo, M.D., Michael J. Paech, F.A.N.Z.C.A. New York, Oxford University Press, Inc., 2011. Pages: 440. Price: $59.95.Providing appropriate and safe anesthetic care to the obstetric patient has long been a challenging and controversial endeavor, since the days of Queen Victoria and Fanny Longfellow. In the past, controversy surrounded the ethical and religious implications of providing pain relief for the laboring parturient. Although some of this sentiment lingers to present day, the continued education of the populace and excellent safety record of anesthetic practice is helping to make James Young Simpson's prediction that any opposition to the “superinduction of anesthesia in parturition will be in vain” a reality.The present challenge for obstetric anesthesiologists involves providing safe and effective labor analgesia and anesthesia in the context of the parturient's unique physiologic, mental, emotional, and social state, all the while trying to provide a nurturing, supportive, and enjoyable environment for delivery. This challenge is further complicated by new factors, such as advanced maternal age, increasing cesarean delivery rate, and the growing number of women with serious comorbid systemic diseases. These factors can confuse acute anesthetic care decisions in situations where a delay in appropriate management has the potential to result in permanent injury or mortality to both mother and baby. In this regard, the importance of evidence-based medical practice cannot be overestimated. Luckily for anesthesia providers, Obstetric Anesthesia by Palmer, D'Angelo, and Paech is available to be an excellent companion on the labor and delivery floor. Although too succinct to be a comprehensive primary text for students or new residents with no exposure to the field of obstetrical anesthesiology, it is a potentially powerful tool for anesthesia providers requiring a detailed, literature-supported overview of the most important areas of anesthetic concern involving the parturient.The brevity of the book should not be mistaken for incompleteness, as the chapters contain a surprising level of detail and can answer most of the practical questions a reader would pose. Read cover-to-cover, the book places the reader in the shoes of an obstetric anesthesiologist, as the flow of the chapters reflect the daily flow of events on the labor and deliver floor. Many days begin with providing routine neuraxial labor analgesia and anesthesia, which can become complicated by complex patients, unfamiliar diseases, and anesthetic complications, as well as occasional postdelivery management of a critically ill parturient. Taken individually, the chapters contain relevant statistics and facts, as well as many useful tables with practical, technical, and procedural advice one would expect from a face-to-face discussion with a consultant obstetrical anesthesiologist. The authors clearly understand that a one-size-fits-all approach to management of the obstetric patient is ineffective, and thus provide concise descriptions of multiple techniques and modalities that allow an anesthesia provider to personalize his or her practice while remaining safely within the confines of standard anesthetic care.I would highly recommend this text to any anesthesia provider who desires a portable, yet detailed, discussion of the most recent evidence-based obstetrical anesthesia techniques, theories, and practice. Whether used as a reference to solve an acute problem, or as a manageable method to reorient to the subspecialty, Obstetric Anesthesia will not disappoint. This book will make an excellent companion to anyone interested in navigating the challenging and rewarding field of obstetrical anesthesiology.