Maternal heart rate variability patterns associated with maternal hypotension and non-reassuring fetal heart rate patterns following initiation of combined spinal-epidural labor analgesia: a prospective observational trial.

BACKGROUND: We evaluated whether baseline maternal heart rate variability (HRV), including the Analgesia Nociception Index (ANI), is associated with maternal hypotension and fetal heart rate (FHR) abnormalities following combined spinal-epidural (CSE) labor analgesia. METHODS: Laboring women were enrolled in this prospective observational study. The primary endpoint was maternal hypotension. The secondary endpoint was FHR abnormalities within 30 min following CSE analgesia initiated with intrathecal plain bupivacaine 1.0 mg and fentanyl 20 µg. The maternal ANI, electrocardiogram, blood pressure, heart rate, oxygen saturation, and FHR tracings were recorded 15 min before and 30 min after CSE. Parturients were grouped based on presence of hypotension and FHR abnormalities. Patient demographics and HRV metrics were compared. Receiver operating characteristics (ROC) curves were constructed for the prediction of hypotension and FHR abnormalities. RESULTS: No significant intergroup differences were detected in patient characteristics. Several baseline HRV metrics and ANI differed significantly between the normotensive (n = 50) and hypotensive (n = 31) groups and between parturients showing FHR abnormalities (n = 19) and those showing reassuring FHR traces (n = 62). The area under the ROC curve (AUC) for predicting hypotension of the baseline low-frequency (LF)/high-frequency (HF) ratio was 0.677 (95% CI 0.55 to 0.80), and that of the ANI was 0.858 (95% CI 0.78 to 0.94). For predicting non-reassuring FHR patterns, the AUC of the LF/HF ratio was 0.77 (95% CI 0.65 to 0.89), and that of the ANI was 0.833 (95% CI 0.72 to 0.94). CONCLUSIONS: The ANI can predict the propensity for maternal hypotension and non-reassuring FHR patterns following CSE.

Observational study evaluating obstetric anesthesiologist residents' well-being, anxiety and stress in a North American academic program.

BACKGROUND: The obstetric work environment has a unique set of stressors that may be associated with burnout. We investigated how well-being during the obstetric anesthesia (ObA) rotation compared to other rotations; which workplace environment characteristics precipitated the greatest stress; and whether anxiety and stress levels changed in trainees before and after an ObA rotation. METHODS: Using a survey, anesthesia residents (n=36) ranked their well-being on each anesthesia rotation and answered questions about their work environment. A separate survey measured anxiety and stress before and after an ObA rotation. Friedman's test was used to compare ranking data and Likert responses. T-tests were used to compare stress and anxiety scores. RESULTS: Residents' ranking of well-being on ObA was higher than that on another high demand rotation (cardiothoracic anesthesia, P=0.007). Work environment stress scores were significantly higher among community and fairness domains than for workload (P=0.002 and P=0.0001, respectively). While stress and anxiety scores did not significantly differ before and after the ObA rotation, they were higher than the reference population scores. CONCLUSIONS: We provide the first example of tools for assessing work environment stressors in ObA. Our study illustrates that beyond excessive workload, lack of fairness and community values are areas that impact physician well-being. Use of these tools can guide initiatives to address work environment concerns, and presents a need for a validated well-being instrument to gauge physician well-being, in order to create a cultural shift from burnout to one of well-being.