Neuraxial Anesthesia Following Thrombocyte Transfusion in Women with Severe Thrombocytopenia Prior to a Cesarean Delivery: A Retrospective Study and Literature Review.

BACKGROUND: Cesarean delivery (CD) is one of the most common surgeries performed worldwide, with increasing yearly rates. Although neuraxial techniques remain the preferred anesthesia method for CD, maternal thrombocytopenia remains a prominent contraindication. Formation of spinal\epidural hematomas are extremely rare, however the minimal thrombocyte count required for safe neuraxial anesthesia is still under debate. Although transfusion of thrombocytes for the purpose of neuraxial anesthesia is still not recommended, patients with severe thrombocytopenia (less than 50 × 103/uL) are given thrombocyte transfusion for surgical hemostasis. OBJECTIVES: To evaluate the anesthetic approach to caesarean deliveries in parturients with severe thrombocytopenia who received thrombocyte transfusion aimed for improved surgical hemostasis. METHODS: We conducted a single center, retrospective cohort study. Results: A total of five cases were found, four of which were given spinal anesthesia immediately following thrombocyte transfusion. One patient was denied spinal anesthesia because her thrombocyte count following transfusion failed to reach safe levels. None of our cases had anesthesia-related complications recorded. CONCLUSIONS: We examined the anesthetic management parturients with severe thrombocytopenia who needed cesarean delivery and were transfused with thrombocytes for surgical hemostasis. In such cases, spinal anesthesia may be considered due to the serious risks associated with general anesthesia.

Automating medical simulations.

OBJECTIVE: This study aims to explore speech as an alternative modality for human activity recognition (HAR) in medical settings. While current HAR technologies rely on video and sensory modalities, they are often unsuitable for the medical environment due to interference from medical personnel, privacy concerns, and environmental limitations. Therefore, we propose an end-to-end, fully automatic objective checklist validation framework that utilizes medical personnel's uttered speech to recognize and document the executed actions in a checklist format. METHODS: Our framework records, processes, and analyzes medical personnel's speech to extract valuable information about performed actions. This information is then used to fill the corresponding rubrics in the checklist automatically. RESULTS: Our approach to activity recognition outperformed the online expert examiner, achieving an F1 score of 0.869 on verbal tasks and an ICC score of 0.822 with an offline examiner. Furthermore, the framework successfully identified communication failures and medical errors made by physicians and nurses. CONCLUSION: Implementing a speech-based framework in medical settings, such as the emergency room and operation room, holds promise for improving care delivery and enabling the development of automated assistive technologies in various medical domains. By leveraging speech as a modality for HAR, we can overcome the limitations of existing technologies and enhance workflow efficiency and patient safety.

Incidence of conversion to general anaesthesia and need for intravenous supplementation in parturients undergoing caesarean section under spinal anaesthesia: A retrospective observational study.

BACKGROUND: Conversion from spinal anaesthesia to general anaesthesia (GA) was shown to be associated with more complications. It has been postulated that spinal injection of a low dose of local anaesthetic is a risk factor. We aimed to discover the rate of conversion from spinal anaesthesia to GA in women who received at least 10 mg heavy bupivacaine and opioids and assess its risk factors. METHODS: All women that underwent spinal anaesthesia for caesarean section from 1 January 2017 to 31 December 2020 were included in this analysis. Spinal anaesthesia was performed according to department protocol using heavy bupivacaine 0.5% 10-13 mg, fentanyl 20 µg, and morphine 0.1 mg. We examined rate of conversion from spinal anaesthesia to GA and rate of need for analgesia/sedation. RESULTS: There were 1.7% of women that required conversion to GA. Bupivacaine dose (OR 0.54 [95% CI 0.38 to 0.75], p < 0.001), surgery time (OR 1.03 [95% CI 1.02 to 1.04], p < 0.001), emergency caesarean section (OR 1.06 [95% CI 1.16 to 3.76], p = 0.015), and postpartum haemorrhage (OR 5.96 [95% CI 1.09 to 25.18], p = 0.025) were independent predictors of need for conversion to GA. Of the women who had CS under spinal anaesthesia, 4.1% of parturients required intraoperative analgesics/sedatives and 9.1% required anxiolysis. CONCLUSIONS: A small proportion of women required conversion to GA. This conversion occurred especially with emergency caesarean section and when low spinal bupivacaine doses were used.

Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) in the Multidisciplinary Management of Morbidly Adherent Placenta.

BACKGROUND: Morbidly adherent placentation (MAP) increases the risk for obstetric hemorrhage. Cesarean hysterectomy is the prevalent perioperative approach. Resuscitative endovascular balloon occlusion of the aorta (REBOA) is a minimally invasive and relatively simple endovascular procedure to temporarily occlude the aorta and control below diaphragm bleeding in trauma. It has been effectively used to reduce obstetric hemorrhage. OBJECTIVES: To evaluate whether REBOA during cesarean delivery (CD) in women with morbidly adherent placentation is a safe and effective treatment modality. METHODS: We introduced REBOA for CD with antepartum diagnosis of MAP in 2019 and compared these patients (RG) to a standard approach group (SAG) treated in our center over the preceding year, as a control. All relevant data were collected from patient electronic files. RESULTS: Estimated blood loss and transfusion rates were significantly higher in SAG; 54.5% of SAG patients received four RBC units or more vs. one administered in RG. No fresh frozen plasma, cryoprecipitate, or platelets were administered in RG vs. mean 3.63, 6, and 3.62 units, respectively in SAG. Ten SAG patients (90.9%) underwent hysterectomy vs. 3 RG patients (30%). Five SAG patients (45%) required post-surgical intensive care unit (ICU) admission vs. no RG patients. Bladder injury occurred in five SAG cases (45%) vs. 2 RG (20%). One RG patient had a thromboembolic event. Perioperative lactate levels were significantly higher in SAG patients. CONCLUSIONS: Use of REBOA during CD in women with MAP is safe and effective in preventing massive bleeding, reducing the rate of hysterectomy, and improving patient outcome.

The anesthetic approach to a patient with placenta accreta spectrum.

PURPOSE OF REVIEW: Placenta accreta poses significant risk of morbidity and mortality to a laboring patient. Here we review available treatment options, highlight trends in bleeding prevention and diagnosis that have been shown to improve patient outcome, and provide best practice suggestions. We also discuss the decision-making process for choice of anesthesia, as it is not based on a gold-standard paradigm. RECENT FINDINGS: The use of resuscitative endovascular balloon occlusion of the aorta has been gaining popularity around the world. It has been shown to cause an equivocal reduction in perioperative bleeding in placenta accreta spectrum (PAS), reduce the rate of hysterectomies, and is a safe and relatively easy technique. There are other invasive radiology techniques that have also proven to be beneficial in bleeding prevention: balloon occlusion of hypogastric arteries intraoperatively, internal iliac artery embolization, and intraoperative ligation of the hypogastric or uterine arteries. SUMMARY: Optimal management of PAS begins with early and definitive diagnosis. A multidisciplinary approach along with preparation of special equipment and the use of a check-list maximize the chance for success. Anesthesia could be done with all types of regional or under general, considering case-by-case factors but most importantly choosing according to the institution's best facility and skill.

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.

Long-term psychological and physical outcomes of women after postdural puncture headache: A retrospective, cohort study.

BACKGROUND: Postdural puncture headache after accidental dural puncture during labour may lead to chronic sequalae. OBJECTIVES: We aimed to measure the incidence of postpartum depression, posttraumatic stress disorder, chronic headache, backache and breastfeeding rates after a postdural puncture headache. DESIGN: A retrospective, case-matched cohort study. SETTING: A review of documented cases of dural puncture and matched case controls occurring at Rabin Medical Center and Shamir Medical Center from 01 January 2012 to 30 September 2018. PATIENTS: The study cohort consisted of women with a documented postdural puncture headache and the controls were women with uneventful labour epidurals in the same 24-h period. Women were interviewed by telephone. PRIMARY OUTCOMES MEASURE: The primary outcome measure was the incidence of postpartum depression after a postdural puncture headache. RESULTS: Women with postdural puncture headache (n = 132) and controls (n = 276) had similar demographic data. The incidence of postpartum depression was 67/128 (52.3%) versus 31/276 (11.2%) for controls, P < 0.0001, 95% confidence intervals of the difference 31.5 to 50.2. Posttraumatic stress disorder was more frequent among women with postdural puncture headache, 17/132 (12.8%) versus controls 1/276 (0.4%), P < 0.0001, 95% confidence intervals of the difference 7.6 to 19.5. Women with postdural puncture headache breastfed less, 74/126 (54.5%) versus controls 212/276 (76.8%), P < 0.0001, 95% confidence intervals of the difference 33.1 to 55.2. Current headache and backache were significantly more frequent among women with postdural puncture headache [current headache 42/129 (32.6%) versus controls 42/276 (15.2%) P < 0.00001, 95% confidence intervals 0.085 to 0.266; current backache 58/129 (43.9%) versus controls 58/275 (21%) P < 0.0001, 95% confidence intervals 14.1 to 33.5]. CONCLUSION: We report an increased incidence of postpartum depression, posttraumatic stress disorder, chronic headache and backache and decreased breastfeeding following a postdural puncture headache. Our findings emphasise the need for postpartum follow-up for women with postdural puncture headache. TRIAL REGISTRY NUMBER: Clinical trial registry number: NCT03550586.

A Retrospective Investigation of Neuraxial Anesthesia Rates for Elective Cesarean Delivery Before and During the SARS-CoV-2 Pandemic.

BACKGROUND: Our hospital used to perform cesarean delivery under general anesthesia rather than neuraxial anesthesia, mostly because of patient refusal of members of the conservative Bedouin society. According to recommendations implemented by the Israeli Obstetric Anesthesia Society, which were implemented due to the severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) pandemic, we increased the rate of neuraxial anesthesia among deliveries. OBJECTIVES: To compare the rates of neuraxial anesthesia in our cesarean population before and during SARS-CoV-2 pandemic. METHODS: We included consecutive women undergoing an elective cesarean delivery from two time periods: pre-SARS-CoV-2 pandemic (15 February 2019 to 14 April 2019) and during the SARS-CoV-2 pandemic (15 February 2020 to 15 April 2020). We collected demographic data, details about cesarean delivery, and anesthesia complications. RESULTS: We included 413 parturients undergoing consecutive elective cesarean delivery identified during the study periods: 205 before the SARS-CoV-2 pandemic and 208 during SARS-CoV-2 pandemic. We found a statistically significant difference in neuraxial anesthesia rates between the groups: before the pandemic (92/205, 44.8%) and during (165/208, 79.3%; P < 0.0001). CONCLUSIONS: We demonstrated that patient and provider education about neuraxial anesthesia can increase its utilization. The addition of a trained obstetric anesthesiologist to the team may have facilitated this transition.

European minimum standards for obstetric analgesia and anaesthesia departments: An experts' consensus.

: An important variability of anaesthetic standards of care was discovered in the obstetric departments of many European Union countries. After discussing this issue in various meetings of the European Society of Anaesthesiology (ESA) board and its obstetric subcommittee, European Board of Anaesthesiology of the European Union of Medical Specialists (EBA-UEMS) executive members, ESA obstetric subcommittee members and European experts in obstetric anaesthesiology have participated in the elaboration of this document. This experts' opinion is focused mainly on obstetric patients and safety concerns in terms of minimum standards of practice. An initial bibliographical search was performed in medical databases and general literature, searching for obstetric anaesthesiology standards to select the most important safety issues. After the initial presentation of the project during EBA-UEMS and ESA obstetric subcommittee meetings, participants were asked to review the document; several rounds of revisions were performed by the experts, to reach a common opinion concerning the topics considered central to patient safety in the obstetric setting. After three rounds of revision, a consensus was reached and is presented in this document, which includes the list of topics considered relevant by the involved areas, and the respective recommendations. These recommendations covered some EBA-UEMS strategic key areas, in addition to several clinical aspects of common obstetric practice.

Severe Maternal Morbidity Cases in Israel in a High-Volume High-Resource Referral Center: A Retrospective Cohort Study.

BACKGROUND: Admission to an intensive care unit (ICU) is an objective marker of severe maternal morbidity (SMM). OBJECTIVES: To determine the prevalence of obstetric ICU admissions in one medical center in Israel and to characterize this population. METHODS: In this retrospective study the files of women coded for pregnancy, birth, or the perinatal period and admission to the ICU were pulled for data extraction (2005-2013). RESULTS: During the study period, 111 women were admitted to the ICU among 120,279 women who delivered babies (0.09%). Their average age was 30 ± 6 years, most were multigravida, a few had undergone fertility treatments, and only 27% had complicated previous pregnancies. Most pregnancies (71.2%) were uneventful prior to admission. ICU admissions were divided equally between direct (usually hemorrhage) and indirect (usually cardiac disease) obstetric causes. CONCLUSIONS: The indications for obstetrics ICU admission correlated with the proximate causes of maternal arrest observed worldwide. While obstetric hemorrhage is often unpredictable, deterioration of heart disease is foreseeable. Attention should be directed specifically toward improving the diagnosis and treatment of maternal heart disease during pregnancy in Israel.

Anesthetic considerations for repeat cesarean section.

PURPOSE OF REVIEW: The prevalence of cesarean delivery is increasing worldwide despite the advance of Trial of Labor After Cesarean section. In many countries, a history of previous cesarean section is an almost absolute indication for a repeat cesarean section. The purpose of this review was to examine if the perioperative anesthetic management of patients with repeat cesarean section is different from the anesthetic management of patients with primary cesarean section. RECENT FINDINGS: This review discusses important topics, such as early diagnosis of cases with a potentially high risk for complications; the need for assessment of patients diagnosed with abnormal placentation; the importance of a multidisciplinary approach that includes interaction of the anesthesiologist, gynaecologist, and invasive radiologist; emphasizing the need for reinforcement of new methods of invasive procedures; management of massive bleeding, use of new technologies, and development of an institutional protocol for management of patients with abnormal placentation. SUMMARY: According to this review, we show that the management of patients with repeat cesarean section without abnormal placentation is almost the same as the management of patients for primary cesarean section. Timely diagnosis of patient with abnormal placentation and multidisciplinary approach is crucial for prevention of morbidity or even mortality.

[ABDOMINAL WALL BLOCKS FOR POST CESAREAN DELIVERY ANALGESIA].

INTRODUCTION: Intrathecal morphine administration at the time of neuraxial anesthesia performance is the gold standard for post-cesarean delivery (CD) analgesia. When intrathecal morphine administration is inappropriate or contraindicated, the use of systemic analgesic options increase side effects and risks to both the parturient and the breastfeeding neonate. Moreover, systemic analgesia is often inadequate. The increased clinical use of ultrasound has made way for regional analgesia techniques, mostly in the form of local anesthesia injected between muscular planes. The transversus abdominis plane (TAP) block is the most well-known and the most commonly used for Cesarean delivery. It has been shown to be effective in the absence of intrathecal morphine administration. It has however, not been shown to be beneficial when intrathecal morphine has been administered. Other, newer techniques are being increasingly used and investigated. Some may prove to be superior to the TAP block. These techniques include: ilioinguinal/ilio-hypogastric nerve blocks (II-IH), the quadratus lumborum (QL) blocks and the erector spinae plane (ESP) block. In this review, we will discuss and assess these techniques regarding analgesia following CD.

[PROSPECTIVE INVESTIGATION OF POSTOPERATIVE NAUSEA AND VOMITING FOLLOWING DUAL PROPHYLAXIS AND LOW DOSE NEURAXIAL MORPHINE FOR CESAREAN DELIVERY].

BACKGROUND: Spinal morphine provides the optimal treatment for post-cesarean analgesia, despite frequent nausea and vomiting. We investigated the incidence of nausea and vomiting 24 hours after cesarean delivery in women receiving intrathecal morphine 100 µcg and intravenous prophylactic dexamethasone and ondansetron. METHODS: In a prospective, observational, Institutional Review Board (IRB) approved study of women undergoing cesarean delivery according to a standardized anesthetic protocol, the subjects were approached preoperatively and underwent standardized interviews regarding prior anesthesia experience and history of postoperative nausea and vomiting. In the post anesthesia care unit and 24 hours postoperatively, the women were interviewed regarding the incidence of nausea and vomiting, Women with and without nausea at 24 hours were compared for potential associated risk factors. RESULTS: Among 201 women recruited, 29 (14.5%) had nausea and 7 (3.5%) vomited in the postoperative care unit. During the first 24 hours, 36 (17.9%) had experienced nausea and 19 (9.5%) had vomited when interviewed at the 24-hours postoperatively. Women who had nausea 24 hours postoperatively were more likely to have nausea in the post anesthesia care unit than women without nausea during 24 hours after cesarean delivery (41.7% versus 1.2%, p<0.001). We did not find preoperative risk factors for postoperative nausea and vomiting. CONCLUSIONS: We report that almost 20% of the women managed with prophylactic dual therapy of ondansetron and dexamethasone had nausea during the 24 hours after administration of low dose intrathecal morphine. Our findings suggested that women who experience nausea or vomiting in the immediate postoperative period are at increased risk of nausea and vomiting in the 24-hour postoperative period.

Delaying laparoscopic surgery in pregnant patients with an equivocal acute appendicitis: a step-wise approach does not affect maternal or fetal safety.

BACKGROUND: Accurate and timely diagnoses of acute appendicitis (AA) during pregnancy avoids maternal and fetal morbidity and mortality. We present our experience of using an initial transabdominal ultrasound (US) performed at presentation to diagnose AA in pregnant patients as well as the value of a delayed repeat study in those who remain equivocal. We explore the sensitivity and specificity of this algorithm as well as the maternal and fetal safety of this approach. METHODS: Of the 225 patients identified within the study period who underwent laparoscopic appendectomy, 216 met the inclusion criteria and were retrospectively analyzed. If the US performed on presentation revealed AA, surgery was performed. Patients with a non-diagnostic US were admitted with surgery performed if there was clinical and/or biochemical deterioration. Patients who remained equivocal underwent a repeat delayed study. The results of the initial versus delayed studies were compared. Maternal and fetal complications were recorded and contrasted. RESULTS: Of the 216 patients included, 164 (75.9%) had AA, 14 (6.5%) had complicated AA and 38 (17.6%) had a normal appendix. Initial US was diagnostic for 125/216 (57.9%) of patients and 19/34 (55.8%) of patients who underwent a delayed repeat study. The remaining patients underwent empirical surgery. The pooled sensitivity and specificity of US for the cohort was 79.2% and 92.1%, respectively. There was no difference in proxies of maternal or fetal safety between the groups. CONCLUSION: US is a useful tool for diagnosing AA in pregnancy. In this cohort, performing a delayed repeat US during a period of observation in those patients who remained otherwise equivocal increased the diagnostic yield of the US. Delaying surgery in this specific group of patients does not affect maternal or fetal safety.

The Effect of Labor Epidural Analgesia on Breastfeeding Outcomes: A Prospective Observational Cohort Study in a Mixed-Parity Cohort.

BACKGROUND: The effect of labor epidural analgesia (LEA) on successful breastfeeding has been evaluated in several studies with divergent results. We hypothesized that LEA would not influence breastfeeding status 6 weeks postpartum in women who intended to breastfeed in an environment that encourages breastfeeding. METHODS: In this prospective observational cohort study, a total of 1204 women intending to breastfeed, delivering vaginally with or without LEA, were included; breastfeeding was recorded at 3 days and 6 weeks postpartum. Primary outcome was breastfeeding at 6 weeks, and the χ test was used for comparisons between women delivering with and without LEA, according to parity status and previous breastfeeding experience. Total epidural fentanyl dose and oxytocin use (yes/no) were recorded. A multivariable logistic regression was performed to assess factors affecting breastfeeding at 6 weeks. RESULTS: The overall breastfeeding rate at 6 weeks was 76.9%; it was significantly lower among women delivering with LEA (74.0%) compared with women delivering without LEA (83.4%; P < .001). Among 398 nulliparous women, 84.9% delivered with LEA, compared with 61.8% of multiparous women (P < .001). Multiparous women (N = 806) were more likely to breastfeed at 6 weeks (80.0% vs 70.6% nullipara; P < .001). Using multivariable logistic regression that accounted for 14 covariates including parity, and an interaction term between parity and LEA use, LEA was significantly associated with reduced breastfeeding at 6 weeks (odds ratio, 0.60; 95% confidence interval, 0.40-0.90; P = .015). In a modified multivariable logistic regression where parity was replaced with previous breastfeeding experience, both as a covariate and in the interaction term, only previous breastfeeding experience was associated with increased breastfeeding at 6 weeks (odds ratio, 3.17; 95% confidence interval, 1.72-5.80; P < .001). CONCLUSIONS: In our mixed-parity cohort, delivering with LEA was associated with reduced likelihood of breastfeeding at 6 weeks. However, integrating women's previous breastfeeding experience, the breastfeeding rate was not different between women delivering with and without LEA among the subset of multiparous women with previous breastfeeding experience. Therefore, our findings suggest that offering lactation support to the subset of women with no previous breastfeeding experience may be a simple approach to improve breastfeeding success. This concept subscribes to the notion that women at risk for an undesired outcome be offered tailored interventions with a personalized approach.

[INTERVENTIONS TO IMPROVE THE QUALITY OF THE INTERNSHIP YEAR].

AIMS: To describe three interventions that have improved the quality of the internship. BACKGROUND: All medical school graduates are required to take a one year internship, rotating through various hospital departments. By various objective and subjective measures, the quality, benefit and efficacy of the internship varies significantly between departments and hospitals and also depends on where the interns studied. METHODS: The interventions were: First, all graduates of foreign medical schools (FMG) were required to interview and present a patient, demonstrating practical knowledge of spoken and written Hebrew and basic medical terminology prior to the start of the internship. Second, on the first day of their internship in internal medicine the new interns participate in an orientation day, addressing multiple clinical, administrative and other components. Third, upon the completion of their rotation in internal medicine, the interns participate in an interactive session to help them prepare for their future career. RESULTS: First, during the first 3 years after introducing the Hebrew test, 101 FMGs took the test, 89 (88%) passed the first time, the remainder passed the 2nd or 3rd test after another 1-3 months of studying Hebrew. Of 31 women, 30 (97%) passed the first time, compared to 59/70 (84%) of the men (p=0.065); 27/28 (96%) of Jewish interns passed the first time compared to 62/73 (85%) non-Jewish interns (p=0.99). Physicians report on the significantly increased ability of FMGs to participate in all activities from the onset of their internship. Second, upon completion of the orientation, 137 interns provided feedback of its 12 components; satisfaction was marked on a Likert scale (ranging from 1 [low] to 5 [high]) and ranged from 4.2±0.1 to 4.7±0.6; high/very high satisfaction with the various components ranged from 79% to 96%. Third, feedback was provided by 96 interns after participating in the interactive session helping to prepare for the future; satisfaction with the 5 components of the session ranged from 3.8±0.8 (on the acquired insight into the possibilities, scope and limitations regarding their future career) to 4.5±0.7 (regarding the relevance of such sessions). Sub-analysis revealed several statistically significant differences between male and female interns (male interns indicated these sessions to be more important to them than females, p<0.01), and FMG (as compared to graduates from Israeli medical schools) indicated that they had acquired relevant information more often (p<0.001). CONCLUSIONS: Various interventions positively impact the quality, benefit and efficacy of the internship as observed by physicians working with the residents, as well as perceived by the interns themselves.

The Relationship Between Women's Intention to Request a Labor Epidural Analgesia, Actually Delivering With Labor Epidural Analgesia, and Postpartum Depression at 6 Weeks: A Prospective Observational Study.

BACKGROUND: Postpartum depression (PPD) is associated with pain during and after delivery, with studies showing reduced rates among women delivering with labor epidural analgesia (LEA). We hypothesized that women who intend to deliver with LEA but do not receive it are at higher risk for PPD at 6 weeks due to the combined experience of untreated labor pain and unmatched expectations during labor, and evaluated the interaction between labor plans related to LEA, satisfaction with pain control when actually delivering with LEA, and PPD at 6 weeks after delivery. METHODS: A total of 1497 women with a vaginal delivery were enrolled into this prospective longitudinal study. Women's initial intention to deliver with or without LEA, how they subsequently delivered, and satisfaction with pain relief were recorded on postpartum day 1. Primary aim was selected as PPD at 6 weeks among women intending to deliver with but subsequently delivering without LEA compared with the rest of the cohort. Primary outcome was PPD at 6 weeks using the Edinburgh Postnatal Depression Scale; PPD was defined with a score ≥10 (scale from 0 to 30). Demographic and obstetric data were recorded. Fisher exact test was used for comparisons between groups. The interaction between intention and actual delivery with regard to LEA and PPD was tested. RESULTS: Overall, 87 of 1326 women completing the study at 6 weeks had PPD (6.6%). For the primary aim, 439 (29.3%) delivered without LEA, of which 193 (12.9%) had intended to deliver with LEA; the PPD rate among these women was 8.1%, which was not statistically different from the rest of the cohort (6.3%; odds ratio [OR], 1.30; 95% confidence interval [CI], 0.72-2.38; P = .41). A total of 1058 women (70.7%) delivered with LEA and 439 (29.3%) delivered without; therefore, 1169 (78.1%) delivered as intended and 328 (21.9%) did not (unmatched expectations). Evaluating the interaction between effects, there was a strong negative additive interaction between intending to deliver without LEA and actually delivering with LEA (risk difference = -8.6%, 95% CI, 16.2%-1.6%; P = .014) suggesting that unmatched intention effect is significantly associated with negative outcome. In multiple regression analysis, while intending to deliver with LEA (OR, 1.06; 95% CI, 1.01-1.11; P = .029) and actually delivering with LEA (OR, 1.07; 95% CI, 1.01-1.13; P = .018) both increased the odds for PPD, the multiplicative interaction was protective (OR, 0.92; 95% CI, 0.86-0.99; P = .022), after adjusting for cofactors. CONCLUSIONS: Our study results did not demonstrate a significant increase in the odds for PPD at 6 weeks among women who intended to deliver with LEA but subsequently delivered without. However, we identified a protective interaction between intended LEA use and actual use on the incidence of PPD. Our data suggest an increased risk when women do not deliver as intended, particularly when not initially intending to deliver with LEA. The relationship between unplanned LEA and PPD may be mediated by a physically difficult delivery rather than or in addition to negative emotions related to unmet expectations or a sense of personal failure; therefore, counseling women after delivery to address any negative perceptions may be useful.

Anesthetic approach to postdural puncture headache in the peripartum period: An Israeli national survey.

BACKGROUND: Accidental dural puncture frequency among pregnant women is about 1.5%, while approximately 60% of these women will suffer from post-dural puncture headache (PDPH) that may be debilitating. METHODS: Following IRB approval, we conducted a national survey of the lead anesthesiologist in 23 labor and delivery rooms in Israel. Each survey inquired about medical center annual delivery volume, training program for residents, accidental dural puncture management, processing of information, and PDPH management strategies. RESULTS: Data were collected from all 23 surveyed hospitals. As for methods for PDPH prevention, in most hospitals (87%) a prophylactic epidural blood patch (EBP) is not considered. Injection of epidural normal saline after delivery as a preventive measure is never considered in most (78.3%) hospitals, while four (17.4%) hospitals reported of constitutive use of this technique and one hospital only occasionally. Duration of conservative treatment was 24-48 hours in 95.7% of PDPH cases. CONCLUSION: In this survey, different aspects of treatment and PDPH management were examined. EBP is considered the gold standard in treating PDPH, although prophylactic blood patch is ineffective. We observed a tendency of very low performance of both prophylactic EBP and epidural normal saline administration after delivery in most centers. Most hospitals perform EBP after 24-48 hours of conservative treatment, along with published recommendations that show increased EBP efficiency with this timeframe. In light of the survey information, we aim to reach a uniform literature-based management strategy across Israeli hospitals.

Five years' experience in an anesthesiology antenatal clinic for high-risk patients.

INTRODUCTION: The aim, of this study is to describe our approach and outcomes in an outpatient anesthesia/analgesia antepartum clinic among ambulatory high-risk obstetric patients. METHODS: This was a retrospective evaluation of the activity of the anesthesiology antenatal clinic from its inception in 2010 until 2016 (a 5-year period). The clinic works in collaboration with the Department of Obstetrics and Gynecology. The catchment area of the study University Affiliated Hospital attends a multiethnic population characterized by high parity. RESULTS: There were 241 referrals over the 5 years, each of whom was discharged with a consult and a delivery management plan and 228 (95%) of which were performed as planned. Mean gestational age at consultation was 34.4 weeks (range: 20-37). There were no preconceptional consultation. No limitations regarding mode of anesthesia/analgesia was considered for 47% of the referrals. Nulliparous women accounted for 50% of the referrals and 17% were in their second pregnancy. The greatest number of referrals (30%) was for musculoskeletal conditions. No maternal death encountered. The mode of delivery was vaginal in 139 (65%) women; elective cesarean section in 44 (21%) women; and emergent cesarean section in 30 (14%) women. The neonatal outcomes were unremarkable; 210 (87%) in hospital births, 97.1% had an a 5' Apgar score of 9. CONCLUSION: Our findings reveal the need for high-risk obstetric patients consult with a dedicated obstetric anesthesiologist to devise a management plan for labor and delivery that is tailored to their comorbidity and obstetric status, to ensure an optimum outcome for mother and child.

Epidural analgesia at trial of labor after cesarean (TOLAC): a significant adjunct to successful vaginal birth after cesarean (VBAC).

INTRODUCTION: Epidural analgesia has been considered a risk factor for labor dystocia at trial of labor after cesarean (TOLAC) and uterine rupture. We evaluated the association between exposure to epidural during TOLAC and mode of delivery and maternal-neonatal outcomes. MATERIALS AND METHODS: A single center retrospective study of women that consented to TOLAC within a strict protocol between 2006 and 2013. Epidural "users" were compared to "non-users". Primary outcome was the mode of delivery: repeat in-labor cesarean or vaginal birth after cesarean (VBAC). Secondary outcomes were maternal/neonatal morbidities. Univariate/multivariate analyses for associations between epidural and mode of delivery were adjusted for significant covariates/mediators. RESULTS: Of a total of 105,471 births registered, 9464 (9.0%) were eligible for TOLAC; 7149 (75.5%) women consented to TOLAC, among which 4081 (57.1%) had epidural analgesia. The in labor cesarean rate was significantly lower for the epidural "users" 8.7% vs. "non-users" 11.8%, P<0.0001, with a parallel increased rate of instrumental delivery. Uterine rupture rates were comparable: 0.4% and 0.29%, respectively (P=0.31). The adjusted multivariate model showed that epidural "users" were more likely to experience a VBAC, odds ratio (OR) 4.58 [3.67; 5.70]; P<0.0001 with a similar rate of adverse maternal-neonatal outcomes. CONCLUSION: Epidural analgesia at TOLAC may emerge as a safe and significant adjunct for VBAC.