Pain Management in Labor.

A patient's sense of empowerment and control is most predictive of maternal satisfaction with childbirth. Analgesia during labor greatly affects this experience. Individual patient priorities for labor pain management should be explored as part of routine prenatal care. Continuous labor support, water immersion, and upright positioning in the first stage of labor are associated with decreased use of pharmacologic analgesia. Despite the increased risk of adverse effects, self-administered inhaled nitrous oxide appears to be safe and effective for pain relief; however, its negative environmental impact as a greenhouse gas is a drawback. Evidence is lacking that any one opioid is superior in maximizing pain relief while minimizing adverse effects. Neuraxial anesthesia provides the most effective pharmacologic analgesia and is used in nearly three-fourths of labors in the United States. Neuraxial regional anesthesia is not associated with increased rates of cesarean delivery or assisted vaginal delivery, and it has only a small effect on the length of the second stage of labor. Epidural, spinal, combined spinal-epidural, and dural puncture epidural anesthesia are commonly used neuraxial techniques. Paracervical and pudendal blocks are safe and effective pain management options in specific circumstances. Both transversus abdominis plane block and subcutaneous wound infiltration with local anesthetic can decrease the use of postoperative analgesia. Patients with opioid use disorder require individualized pain management plans throughout perinatal care, and judicious opioid prescribing practices are encouraged for all patients.

Development of theory-based knowledge translation interventions to facilitate the implementation of evidence-based guidelines on the early management of adults with traumatic spinal cord injury.

RATIONALE: Optimal, early management following a spinal cord injury (SCI) can limit individuals' disabilities and costs related to their care. Several knowledge syntheses were recently published to guide health care professionals with regard to early interventions in SCI patients. However, no knowledge translation (KT) intervention, selected according to a behaviour change theory, has been proposed to facilitate the use of SCI guidelines in an acute care setting. OBJECTIVES: To develop theory-informed KT interventions to promote the application of evidence-based recommendations on the acute care management of SCI patients. METHODS: The first four phases of the knowledge-to-action model were used to establish the study design. Knowledge selection was based on the Grading of Recommendations Assessment, Development and Evaluation system. Knowledge adaptation to the local context was sourced from the ADAPTE process. The theoretical domains framework oriented the selection and development of the interventions based on an assessment of barriers and enablers to knowledge application. RESULTS: Twenty-nine recommendations were chosen and operationalized in measurable clinical indicators. Barriers related to knowledge, skills, perceived capacities, beliefs about consequences, social influences, and the environmental context and resources theoretical domains were identified. The mapping of behaviour change techniques associated with those barriers led to the development of an online educational curriculum, interdisciplinary clinical pathways as well as policies and procedures. CONCLUSIONS: This research project allowed us developing KT interventions according to a thorough behavioural change methodology. Exposure to the generated interventions will support health care professionals in providing the best care to SCI patients.

Maternal hemoglobin concentration and pregnancy outcome: a study of the effects of elevation in el alto, bolivia.

Iron-deficiency anemia is often under-diagnosed in developing countries, specifically in pregnant populations in regions of high altitude. Hemoglobin levels are not consistently adjusted for elevation, and therefore many anemic patients are left undiagnosed. The purpose of this study was to incorporate current parameters for diagnosing anemia in pregnancy at high altitudes, and to evaluate the effects of appropriately adjusted hemoglobin concentrations on pregnancy outcome. A few studies have examined the effect of elevation on hemoglobin status, and other studies have considered the effects of anemia of pregnancy; however, there is a lack of data demonstrating that altitude-adjusted hemoglobin levels accurately predict pregnancy outcome. Using the Student t-Test, multiple linear regression, and ANOVA statistical analyses, various factors of pregnancy outcome were compared between anemic and non-anemic groups, as defined by hemoglobin cut-off levels adjusted for trimester of pregnancy and altitude. When appropriate adjustments were used, maternal anemia was associated with lower infant Apgar scores at both one minute and five minutes after birth, as well as complication of labor, lower gestational age at birth, and higher parity. This study demonstrates the importance of altitude and trimester specific adjustments to maternal hemoglobin levels in order to accurately diagnose anemia in pregnancy. In addition, a clear correlation is seen between maternal hemoglobin level and pregnancy outcome.