Multidisciplinary perinatal management of the compromised airway on placental support: lessons learned.

OBJECTIVE: The aims of this study were to review fetal and maternal outcomes after management of the compromised perinatal airway via operation on placental support or ex utero intrapartum treatment and to discuss implications for future management of these complex and rare cases. METHODS: We have presented a retrospective case series of 12 neonates requiring airway management on placental support at a single tertiary care, academic center. RESULTS: One mother experienced significant blood loss. Operative recovery times were unremarkable. Eight neonates required airway management due to mass obstruction, two for removal of an endotracheal balloon for fetoscopic treatment of congenital diaphragmatic hernia, one for laryngeal atresia, and one for severe retrognathia. One of our series is an unusual case of management on placental support after vaginal delivery. Another child would have ideally been managed on placental support, but an extremely short umbilical cord prevented this. Even though the airway was secured in all 12 cases, five neonates died in the perinatal period. CONCLUSIONS: These procedures have a risk for substantial maternal blood loss. Despite excellent rates of success securing the neonatal airway, children who require management on placental support still have high mortality. A formalized multidisciplinary approach at our institution has enhanced preparedness for these cases.

The transversus abdominis plane block, when used as part of a multimodal regimen inclusive of intrathecal morphine, does not improve analgesia after cesarean delivery.

BACKGROUND AND OBJECTIVES: The transversus abdominis plane (TAP) block has been shown to provide analgesia for lower abdominal wall incisions. We evaluated the efficacy of the TAP block for post-cesarean delivery (CD) patients used as a part of a multimodal regimen. METHODS: Women undergoing elective CD under spinal anesthesia were randomized to receive the TAP block with ropivacaine (n = 50) or placebo (n = 50), in addition to a standard postoperative analgesic regimen inclusive of intrathecal opioids. At the end of the surgical procedure, all the patients received bilateral TAP blocks under real-time ultrasound guidance, with either 20 mL of ropivacaine 0.375% or saline, on each side. Each patient was assessed at 6, 12, 24, and 48 hrs postoperatively, and again 6 weeks after the surgical procedure. The primary outcome was the difference in visual analog scale pain scores with movement at 24 hrs postpartum. Other outcomes assessed were analgesic consumption, maternal satisfaction, and incidence of adverse effects. RESULTS: One hundred women were recruited, and 96 completed the study. The mean (SD) visual analog scale pain scores on movement at 24 hrs were not different between the ropivacaine and placebo groups (3.4 [2.4] and 3.2 [2.2] cm, respectively, P = 0.47). The pain scores at other times, and the supplemental opioid consumption, were also similar between the 2 groups. The overall incidence of pain at 6 weeks postpartum was 8.3%. CONCLUSIONS: The TAP block, when used as part of a multimodal regimen inclusive of intrathecal morphine, does not improve the quality of post-CD analgesia.

Incidence, severity, and determinants of perineal pain after vaginal delivery: a prospective cohort study.

OBJECTIVES: The purpose of this study was to determine the frequency of perineal pain in the 6 weeks after vaginal delivery and to assess the association between perineal trauma and perineal pain. Study design This was a prospective cohort study of parturients at 1 day, 7 days,' and 6 weeks' post partum in an academic tertiary obstetric unit in Toronto, Canada. Four hundred forty-four women were followed up, including women with an intact perineum (n=84), first-/second-degree tears (n=220), episiotomies (n=97), or third-/fourth-degree tears (n=46). Primary outcome was the incidence of perineal pain on day of interview; secondary outcomes were pain score measurements and interference with daily activities. RESULTS: Perineal trauma was more common among primiparous women, those with operative vaginal deliveries, and those with epidural analgesia during the second stage of labor. The incidence of perineal pain among the groups during the first week was intact perineum 75% (day 1) and 38% (day 7); first-/second-degree tears 95% and 60%; episiotomies 97% and 71%; and third-/fourth-degree tears 100% and 91%. By 6 weeks, the frequency of perineal pain was not statistically different between trauma groups. CONCLUSION: Acute postpartum perineal pain is common among all women. However, perineal pain was more frequent and severe for women with increased perineal trauma.

Anesthesia facilitation of external cephalic version: a meta-analysis.

OBJECTIVES: This study was undertaken to systematically review the medical literature to determine whether anesthesia facilitates the external cephalic version maneuver (ECV) for breech presentations. Study design A meta-analytic review of medical databases for randomized clinical trials comparing anesthesia with no anesthesia given for ECV attempts. The primary outcome was the immediate success of the ECV attempt. RESULTS: The literature search revealed only 4 articles that met inclusion criteria. Four hundred eighty women participated in the studies and the use of anesthesia increased the success of ECV attempts (119/238 with anesthesia; 82/242 without anesthesia). The relative risk for this beneficial effect was 1.5 (95% CI 1.12-1.98) and number needed to treat was 7 (95% CI 4-14). CONCLUSION: Further study is required to assess maternal and neonatal safety with anesthesia administered for ECV maneuvers.