Obstetric Anesthesia Research Articles

Norepinephrine or phenylephrine during spinal anaesthesia for Caesarean delivery: a randomised double-blind pragmatic non-inferiority study of neonatal outcome

BackgroundNorepinephrine is an effective vasopressor during spinal anaesthesia for Caesarean delivery. However, before it can be fully recommended, possible adverse effects on neonatal outcome should be excluded. We aimed to test the hypothesis that umbilical arterial cord pH is at least as good (non-inferior) when norepinephrine is used compared with phenylephrine for treatment of hypotension. MethodsWe enrolled 668 subjects having elective and non-elective Caesarean delivery under spinal or combined spinal–epidural anaesthesia in this randomised, double-blind, two-arm parallel, non-inferiority clinical trial. Arterial blood pressure was maintained using norepinephrine 6 μg ml−1 or phenylephrine 100 μg ml−1 according to the practice of the anaesthetist, either prophylactically or therapeutically, as an infusion or bolus. The primary outcome was umbilical arterial pH with a chosen non-inferiority margin of 0.01 units. ResultsOf 664 subjects (531 elective and 133 non-elective) who completed the study, umbilical arterial cord blood was analysed for 351 samples from 332 subjects in the norepinephrine group and 343 samples from 332 subjects in the phenylephrine group. Umbilical arterial pH was non-inferior in the norepinephrine group (mean, 7.289; 95% confidence interval [CI], 7.284–7.294) compared with the phenylephrine group (mean, 7.287; 95% CI, 7.281–7.292) (mean difference between groups, 0.002; 95% CI, –0.005 to 0.009; P=0.017). Subgroup analysis confirmed the non-inferiority of norepinephrine for elective cases but was inconclusive for non-elective cases. ConclusionsNorepinephrine was non-inferior to phenylephrine for neonatal outcome assessed by umbilical arterial pH. These results provide high-quality evidence supporting the fetal safety of norepinephrine in obstetric anaesthesia. Clinical trial registrationChiCTR-IPR-15006235.

Incidence and Causes of Failed Spinal Anesthesia

Introduction: Spinal anesthesia (SA) is one of the most frequently applied anesthesia procedures today. However, SA failure rate varies between 1 and 17%. The age of the patient, the position at which the procedure is performed, or the characteristics of the technical operation can affect success. In this study, we aimed to compare the most frequent SA failures according to the types of surgery and causes of failure. The results of SA procedures performed in a university hospital were compare to those published in the current literature. Materials and Methods: After obtaining ethics committee ­approval for our study, the hospital archives were examined retrospectively for 1 year with respect to SA procedures. SA application and failure rates were examined. Three or more SA attempts, failed dural puncture, or unsuccessful injection, and anesthesia applications that did not provide sufficient sensory block for surgery despite successful drug treatment were defined as failure. Results: Of all anesthesia procedures, SA was applied at a rate of 23.5%. Our SA failure rate was calculated as 16.6%. Considering a single surgical procedure, obstetric anesthesia was the most common surgery with failed SA (28.7%). The most common cause of failure was insufficient analgesia (32.9%). Discussion: SA failure rates were observed to be in a variable distribution range in the literature, and in some studies, SA failure was defined as a block that did not occur despite a full dose and successful injection, and this rate was found to be 3.9%. The high rate in our study group may be explained by differences in the definition of SA: blocks performed with several trials and any block that could not be applied were also recorded as SA failure. The reasons for failing to apply this procedure is an issue that is worth examining also in terms of patient satisfaction and safety, which is an important issue. Conclusion: Although the definition of unsuccessful SA is confusing, SA failure rates are worth examining and improving for each hospital.

The Future of Obstetric Anesthesiology: Looking for Answers in the History of Our Field

Articles| July 2020 The Future of Obstetric Anesthesiology: Looking for Answers in the History of Our Field Cesar R. Padilla, MD; Cesar R. Padilla, MD Search for other works by this author on: This Site PubMed Google Scholar Andrew D. Miller, MD; Andrew D. Miller, MD Search for other works by this author on: This Site PubMed Google Scholar William Camann, MD William Camann, MD Search for other works by this author on: This Site PubMed Google Scholar ASA Monitor July 2020, Vol. 84, 40. https://doi.org/10.1097/01.M99.0000688696.17744.04 Views Icon Views Article contents Figures & tables Video Audio Supplementary Data Share Icon Share Facebook Twitter LinkedIn Email Cite Icon Cite Get Permissions Search Site Citation Cesar R. Padilla, Andrew D. Miller, William Camann; The Future of Obstetric Anesthesiology: Looking for Answers in the History of Our Field. ASA Monitor 2020; 84:40 doi: https://doi.org/10.1097/01.M99.0000688696.17744.04 Download citation file: Ris (Zotero) Reference Manager EasyBib Bookends Mendeley Papers EndNote RefWorks BibTex toolbar search Search nav search search input Search input auto suggest search filter All ContentAll PublicationsASA Monitor Search Advanced Search Topics: obstetrics Obstetric anesthesiology, a field rich in history, is currently in transition. Maternal mortality has been increasing in the United States in the last 25 years and as medical advances continue, a more complex patient population is forcing doctors to re-evaluate the optimal approach to these patients. Historical acknowledgement, however, may be the key to our future. Obstetric anesthesiology has faced challenges, and through ingenuity and multidisciplinary collaboration, it has undergone remarkable transformations, becoming a field central to the birthing experience for women across the world. Historical remembrance is an ageless universal truth spanning multiple disciplines. Obstetric anesthesiology, facing challenges in maternal mortality, is an ideal example where history provides valuable lessons in strategy and collaboration. A rebirth through innovation is a hallmark of medicine. Medical advances seem to occur in bursts, thrusting the field considerably forward in seemingly short... © 2020 American Society of Anesthesiologists (ASA), All Rights Reserved.2020 You do not currently have access to this content.

The incidence and causes of failed spinal anesthesia in a tertiary care Hospital: A retrospective observational study

Introduction: Spinal anesthesia (SA) is one of the most frequently applied anesthesia procedures today. However, SA failure rate varies between 1 and 17%. The age of the patient, the position at which the procedure is performed, or the characteristics of the technical operation can affect success. In this study, we aimed to compare the most frequent SA failures according to the types of surgery and causes of failure. The results of SA procedures performed in a Hospital were comparing to those published in the current literature. Material and Method: This study was conducted in Department of Anesthesia, MGMMC and M Y Hospital, Indore, Madhya Pradesh, India. It was a one year retrospective study from January 2019 to December 2019. All the parturient undergoing surgery section was included in the study. Results: Of all anesthesia procedures, SA was applied at a rate of 25.97%. Our SA failure rate was calculated as 17.14%. Considering a single surgical procedure, obstetric anesthesia was the most common surgery with failed SA (27.77%). The most common cause of failure was insufficient analgesia (31.25%) and Unsuccessful lumbar puncture (27.07%) Conclusion: the incidence of failed spinal anesthesia was found to be higher compared to previous studies with the implication that we should give attention for this disgusting event. Since the study tried to identify risk factors for failure, we should act accordingly to minimize the failure rate.

COVID-19 and obstetric anesthesia

COVID-19 and obstetric anesthesia

The impact of the Safer Anaesthesia from Education (SAFE) Obstetric Anaesthesia training course in Ethiopia: A mixed methods longitudinal cohort study.

SummaryReducing maternal mortality remains a global priority, particularly in low- and middle-income countries (LMICs). The Safer Anaesthesia from Education (SAFE) Obstetric Anaesthesia (OB) course is a three-day refresher course for trained anaesthesia providers addressing common causes of maternal mortality in LMICs. This aim of this study was to investigate the impact of SAFE training for a cohort of anaesthesia providers in Ethiopia.We conducted a mixed methods longitudinal cohort study incorporating a behavioural questionnaire, multiple-choice questionnaires (MCQs), structured observational skills tests and structured interviews for anaesthesia providers who attended one of four SAFE-OB courses conducted in two regions of Ethiopia from October 2017 to May 2018.Some 149 participants from 60 facilities attended training. Behavioural questionnaires were completed at baseline (n = 101, 69% response rate). Pre- and post-course MCQs (n = 121, n = 123 respectively) and pre- and post-course skills tests (n = 123, n = 105 respectively) were completed, with repeat MCQ and skills tests, and semi-structured interviews completed at follow-up (n = 88, n = 76, n = 49 respectively). The mean MCQ scores for all participants improved from 80.3% prior to training to 85.4% following training (P < 0.0001) and skills test scores improved from 56.5% to 83.2% (P < 0.0001). Improvements in MCQs and skills were maintained at follow-up 3-11 months post-training compared to baseline (P = 0.0006, < 0.0001 respectively). Participants reported improved confidence, teamwork and communication at follow-up.This study suggests that the SAFE-OB course can have a sustained impact on knowledge and skills and can improve the confidence of anaesthesia providers and communication within surgical teams.

Editorial introductions

Editorial introductions

Simulation in obstetric anesthesia: an update.

Simulation training (crew resource management training and scenario training) has become an important tool in the education of anesthesiologists. This review summarizes recent research performed in this area, focusing more specifically on obstetric anesthesia. Simulation training is becoming more integrated in the modern education of anesthesiologists. Research regarding the most effective way to perform simulation training in terms of learning outcomes and long-term skill retention has started to appear. Scenarios which are played independently and that allow for simulated mortality, as well as relaxation techniques before debriefing might have positive effects in this regard. Furthermore, simulation has been investigated as a tool to improve patient safety in low-resource settings. In addition, simulation training in the domain of obstetrics has been rapidly expanding and has an important role in this field of medicine as well. Simulation training has acquired a central role in modern education of anesthesiologists. Further research regarding elements to optimize simulation training in terms of learning outcomes and long-term skill retention is desirable. In addition, little data exist concerning the effect of simulation training on possible improvement of patient outcomes in anesthesia.

Editorial: Current and future challenges in obstetric anesthesia: are we ready?

Editorial: Current and future challenges in obstetric anesthesia: are we ready?

In Response.

In Response.

Staying Ahead of the Curve: Modified Approach to Emergency Caesarean Section Under General Anaesthesia in COVID-19 Pandemic

The recent outbreak of SARS-CoV-2 has prompted healthcare professionals to re-design and modify the standards of care and operating procedures relevant to dealing with suspected or confirmed cases of COVID-19. The aim of this review is to highlight the key recommendations related to obstetric anaesthesia from scientific bodies in the United Kingdom and United States and to summarize recently developed and implemented clinical pathways for care of obstetric patients – specifically those requiring urgent general anaesthesia for caesarean section within a large maternity unit in London. The need to perform an emergency operative delivery in a timely manner while ensuring clinicians are suitably equipped and protected represents a uniquely challenging scenario, given the higher risk of viral transmission with aerosol generating procedures. In these settings, emphasis needs to be put on meticulous preparation, safety checklists and specific equipment and staffing adjustments. We present a structured framework comprised of four critical steps aimed to facilitate the development of local strategies and protocols.

Spinal versus general anesthesia for elective cesarean section: immediate outcome

Background: Recent interest has focused on the influence of obstetric anesthesia types on the immediate neonatal and maternal outcome. Aim of the work: The study was intended to assess the immediate neonatal and maternal outcome in relation to the maternal anesthesia type during cesarean section.Patients and methods: the present study included 200 full term neonates whose mothers underwent elective cesarean section (CS). They were grouped according to type of anesthesia given to mothers into group 1: included 100 newborns whose mothers had general anesthesia and group 2: included 100 newborns whose mothers had spinal anesthesia. Each newborn evaluated for short-term outcome including Apgar score, need for NICU admission and blood gas analysis. Mothers assessed for postoperative outcome. Results: No significant differences were discovered between the types of anesthesia used in regard to the general maternal characteristics. Neonatal outcomes on the other hand showed no significant differences as regard Apgar score (P=0.33) and NICU admission (P= 0.57), PaCO2, HCO3, Na and K; while PH and PaO2 were significantly lower with spinal anesthesia (P= 0.02 and 0.008 respectively). Additionally, spinal anesthesia was associated with rapid recovery of bowel and less need for postoperative analgesia. Conclusion: The type of anesthesia used in mothers undergoing full term elective cesarean deliveries does not seem to affect the immediate neonatal outcome. Both may be safely used in full term elective cesarean deliveries. However, spinal anesthesia had the advantage of lower need for postoperative analgesia with rapid recovery of bowel

Efficacy of Intrathecal Fentanyl for Cesarean Delivery: A Systematic Review and Meta-analysis of Randomized Controlled Trials With Trial Sequential Analysis

(Anesth Analg. 2020;130:111–125) Cesarean delivery procedures have become more popular over the past few decades, and spinal anesthesia is a commonly used method of anesthesia for that operation. A majority of surveyed members of the Society for Obstetric Anesthesia and Perinatology stated that they preferred to administer hyperbaric 0.75% bupivacaine spinal anesthesia for cesarean deliveries, while a smaller percentage of anesthesiologists reported adding fentanyl, morphine, or a combination of both to an intrathecal bupivacaine solution. The addition of intrathecal opioids to spinal anesthesia medication has been reported to be effective for pain relief in some cases, but researchers are still unsure of the benefits, drawbacks, and optimal dosages of these medications. These investigators conducted their systematic review and meta-anlaysis to analyze the effectiveness of fentanyl both alone and in combination with morphine when added to intrathecal bupivacaine anesthesia during a cesarean delivery.

Development and Pilot Testing of a Context-Relevant Safe Anesthesia Checklist for Cesarean Delivery in East Africa

(Anesth Analg. 2019;128:993–998) The maternal mortality rate in low- and middle-income countries (LMICs) is 20 times higher than in developed countries, at a rate of 239 deaths per 100,000 live births. Sub-Saharan Africa in particular is considered by the World Health Organization (WHO) to be the most dangerous place in the world for women undergoing childbirth. On the basis of the success of WHO’s surgical checklist, this current study investigated the development and use of a context-sensitive obstetric anesthesia checklist for use during cesarean delivery (CD) in East Africa, with the goal that they could demonstrate an improvement in adherence to best practice guidelines for anesthesia for CD in LMICs.

Mixed methods analysis of factors influencing change in clinical behaviours of non-physician anaesthetists in Kenya following obstetric anaesthesia training.

Maternal mortality rates in low-middle income countries remain high, with sub-Saharan Africa accounting for two-thirds of global maternal deaths. Inadequate staff training is one of the main contributors to anaesthesia-related deaths and the Association of Anaesthetists developed the Safe Anaesthesia from Education course in collaboration with the World Federation of Societies of Anaesthesiologists to address this training gap. We aimed to evaluate the impact of this course among Kenyan participants. Mixed methodologies and secondary analyses of anonymised data were used to study translation of learning into practice. In total, 103 participants from 66 facilities who attended courses between 2016 and 2017 were analysed. Ninety (87%) participants who were followed up completed knowledge tests. Baseline median (IQR [range]) knowledge test score was 41 (37-43 [21-46]). There was a significant improvement in median (IQR [range]) knowledge test score immediately post-course (43 (41-45 [33-48]); p<0.001) which was sustained at 3-6month follow-up (43 (41-45 [32-50]); p<0.001 compared with baseline). Eighty-four of the 103 participants were observed in their workplace and capability, opportunity and motivation-behaviour framework was used to study the barriers and facilitators to practice change. Psychological capability and reflective motivation were the main factors enabling positive behaviour change such as team communication and pre-operative assessment, whereas physical and social opportunity accounted for the main barriers to behaviours such as performing the surgical safety checklist. Our study demonstrates that the Safe Anaesthesia from Education obstetric course is relevant in the low-resource setting and may lead to knowledge translation in clinical practice.

A retrospective review of 10-year trends in general anesthesia for cesarean delivery at a university hospital: the impact of a newly launched team on obstetric anesthesia practice

BackgroundThe indications for general anesthesia (GA) in obstetric settings, which are determined in consideration of maternal and fetal outcome, could be affected by local patterns of clinical practice grounded in unique situations and circumstances that vary among medical institutions. Although the use of GA for cesarean delivery has become less common with more frequent adoption of neuraxial anesthesia, GA was previously chosen for pregnancy with placenta previa at our institution in case of unexpected massive hemorrhage. However, the situation has been gradually changing since formation of a team dedicated to obstetric anesthesia practice. Here, we report the results of a review of all cesarean deliveries performed under GA, and assess the impact of our newly launched team on trends in clinical obstetric anesthesia practice at our institution.MethodsOur original database for obstetric GA during the period of 2010 to 2019 was analyzed. The medical records of all parturients who received GA for cesarean delivery were reviewed to collect detailed information. Interrupted time series analysis was used to evaluate the impact of the launch of our obstetric anesthesia team.ResultsAs recently as 2014, more than 10% of cesarean deliveries were performed under GA, with placenta previa accounting for the main indication in elective and emergent cases. Our obstetric anesthesia team was formed in 2015 to serve as a communication bridge between the department of anesthesiology and the department of obstetrics. Since then, there has been a steady decline in the percentage of cesarean deliveries performed under GA, decreasing to a low of less than 5% in the latest 2 years. Interrupted time series analysis revealed a significant reduction in obstetric GA after 2015 (P = 0.04), which was associated with decreased use of GA for pregnancy with placenta previa. On the other hand, every year has seen a number of urgent cesarean deliveries requiring GA.ConclusionsThere has been a trend towards fewer obstetric GA since 2015. The optimized use of GA for cesarean delivery was made possible mainly through strengthened partnerships between anesthesiologists and obstetricians with the support of our obstetric anesthesia team.

COVID-19: Obstetric anesthesia care considerations

• Pre-hospital COVID-19 screening should be implemented for all pregnant patients. • Limit the number of staff in a delivery room or operating room when feasible • Encourage the use of video messaging with other members of the patient's support system • An experienced provider should perform neuraxial procedures and intubations, whenever possible.

Obstetric Anaesthesia Challenges and Management in COVID - 19 Patients

Obstetric Anaesthesia Challenges and Management in COVID - 19 Patients

“I’m Not Going to Jail for This,” an Analysis of Anesthesia Providers’ Responses to Georgia’s 22-Week Abortion Ban [01I

INTRODUCTION: State-level legal regulations affect abortion provision in the United States. Anesthesia providers participate in abortion care, and their understanding of legal regulations may impact their willingness to participate in hospital-based abortion care. METHODS: In-depth qualitative interviews were conducted with currently-practicing anesthesia providers, who care for obstetric (OB) patients. A semi-structured interview guide elicited information on providers’ personal abortion attitudes through case-based examples and a discussion of Georgia’s (GA) 22-week abortion ban. Data were analyzed in an iterative fashion using both inductive and deductive approaches. RESULTS: Thematic saturation of the primary aim occurred after 15 interviews. Participants represented many provider types, including anesthesiologists, certified and student registered nurse anesthetists, certified anesthesiology assistants, and anesthesiology residents. Most participants practiced general or OB anesthesiology in a hospital setting (n=14). Two-thirds of participants reported prior participation in abortion (n=10). Most providers had little to no prior knowledge of GA’s 22-week abortion ban (n=11) and perceived an overall neutral or negative impact of the law on OB practice (n=13). Prominent themes that emerged from the data included “fear of criminality,” “transfer of responsibility to the law,” and “retroactive versus proactive medical care,” which described how anesthesia providers reacted to state-specific legislation on abortion. CONCLUSION: Anesthesia providers are not well-informed of state-specific abortion legislation and demonstrate a mixed response to such laws. After introduction of GA’s 22-week ban, many participants reported a more conservative approach to participating in hospital-based abortion care, which affects abortion access in this setting.

Prophylactic Low-Molecular-Weight Heparin Versus Unfractionated Heparin at the Time of Delivery [32L

INTRODUCTION: To compare the impact of two common dosing practices of antepartum prophylactic anticoagulation on peripartum management. METHODS: IRB approval was obtained for this retrospective cohort study of women receiving prophylactic anticoagulation from 2014 to 2019. Two strategies were reviewed: continuation of low-molecular weight heparin (LMWH) until delivery vs transitioning from LMWH to unfractionated heparin (UFH) at 36 weeks. Strategies were compared for impact on obstetric outcomes and anesthesia for delivery. RESULTS: Prophylactic anticoagulation was identified in 66 women; 48 (73%) remained on LMWH until delivery and 18 (27%) were transitioned to UFH. LMWH dosing ranged from 30 to 80 mg daily (88% at 40 mg). UFH was dosed at either 5,000 U twice daily (56%) or 10,000 U twice daily (44%). Comparing outcomes, both groups had similar rates of delivery during a scheduled admission (65% vs 50%, P=.40) and receiving neuraxial analgesia (79% vs 89% P=.50). Four women receiving LMWH (8%) did not receive neuraxial analgesia due to timing of their last dose (range 5-12 hours); one of these patients received general anesthesia for a cesarean, and the other three received intravenous analgesia for labor. In the LMWH group, seven women (15%) had an estimated blood loss (EBL) &gt;1000 cc compared to none in the UFH group (P=.18) A multiple regression model showed no effect of anticoagulation strategies on EBL when adjusted for route of delivery, maternal weight and birthweight (P=.18). CONCLUSION: Among women receiving prophylactic LMWH, transition to UFH before delivery did not significantly impact receipt of neuraxial analgesia or lower rates of postpartum hemorrhage.