Use of Postpartum Hemorrhage Checklist during Vaginal Deliveries: A Quality Improvement Study.

OBJECTIVE: Postpartum hemorrhage (PPH) protocols improve patient safety and reduce utilization of blood products; however, few data exist on sustainability of PPH checklist use, how use affects care delivery, and variation of use among patient subgroups. This study aimed to (1) examine compliance with PPH checklist use during vaginal deliveries, (2) evaluate whether checklist use varied by patient and/or care team characteristics, and (3) evaluate whether checklist use was associated with increased use of recommended medications/interventions. STUDY DESIGN: This was a quality improvement study performed from April 2021 through June 2023. A multidisciplinary team developed a revised PPH checklist and used quality improvement methodology to increase checklist use following vaginal birth. Data were collected from medical records and clinician survey. Control charts were generated to track checklist use and evaluate special cause variation. Chi-square tests and logistic regression were used to evaluate variation in medications/interventions and across subgroups. RESULTS: During the study period, there were 342 cases of PPH at the time of vaginal birth. The checklist was used in 67% of PPH cases during the 20-month period after implementation in a setting where no checklist was previously being used. We found no statistically significant differences in checklist use by patient or health care team characteristics. Use of tranexamic acid, carboprost, and misoprostol were significantly associated with checklist use. CONCLUSION: This study demonstrated successful implementation of a checklist protocol where no checklist was previously being used, with sustained use in an average of 67% of PPH cases over 20 months. Checklist use was consistent across subgroups and was associated with higher use of interventions shown to lower blood loss. KEY POINTS: · Our study showed sustainability of PPH checklist use over a 20-month period.. · PPH checklist use was associated with increased use of interventions known to reduce blood loss.. · Checklist was used consistently across patient subgroups; may help address inequities in obstetric outcomes..

A positive effect of cumulative intergroup threat on reproductive success.

Outgroup conflict is a powerful selective force across all social taxa. While it is well documented that individual outgroup contests can have a range of direct and indirect fitness consequences, the cumulative pressure of outgroup threats could also potentially impact reproductive success. Here, we use long-term life-history data from a wild population of dwarf mongooses (Helogale parvula) to investigate how intergroup interaction (IGI) rate might influence breeding and offspring survival. IGI rate did not predict the number of litters produced in a season or the inter-litter interval. Unexpectedly, IGI rate was positively associated with the number of pups alive three months after emergence from the breeding burrow. This was not due to a difference in how many pups emerged but because those in groups experiencing more IGIs had a higher survival likelihood post-emergence. Detailed natural observations revealed that both IGI occurrence and the threat of intergroup conflict led to more sentinel behaviour by adults, probably reducing the predation risk to young. Our results contrast the previously documented negative effects of outgroup interactions on reproductive success and highlight the need to assess cumulative threat, rather than just the impact of physical contests, when considering outgroup conflict as a social driver of fitness.

A Quality Improvement Effort to Reduce Inpatient Opioid Consumption following Cesarean Delivery.

OBJECTIVE: The amount of opioid prescribed following cesarean delivery (CD) is commonly in excess of patients' needs. An additional concern in a breastfeeding mother is neonatal opioid exposure. A maximum daily dose of 30 mg of oxycodone is recommended in breastfeeding women. Inadequate pain control can inhibit breastfeeding, as well as other negative consequences. We aimed to evaluate the effect of reducing the as-needed opioid ordered following CD on inpatient opioid consumption and analgesia. STUDY DESIGN: At our tertiary-care institution, our standard as-needed opioid order was reduced from oxycodone 5 to 10 mg every 4 hours to oxycodone 5 mg every 6 hours, in May 2019. Orders for scheduled acetaminophen and nonsteroidal anti-inflammatory drugs were unchanged. We compared opioid use and pain scores before (February 2019-April 2019) and after (May 2019-July 2019) the order modification. Our primary outcome was the proportion of patients using >30 mg of oxycodone in the 24 hours prior to hospital discharge. We further assessed 48-hour opioid consumption and patient-reported verbal pain scores. RESULTS: There were 559 patients who met inclusion criteria; 241 preintervention patients and 318 postintervention patients. In the preintervention group, 14.5% (35/241) used >30-mg oxycodone in the 24 hours before discharge, compared with 5.0% (16/318) after the order set change (relative risk [RR] = 0.34, 95% confidence interval [CI]: 0.19, 0.61; number needed to treat [NNT] = 10.5). There was no change in the proportion of women with one or more pain score >7 (preintervention: 44.4% [107/241], postintervention: 43.1% [137/318], p = 0.756) or >4 and ≤7 (preintervention: 36.9% [89/241], postintervention: 36.9% [125/318], p = 0.567), nor was there a change in mean pain score (mean ± standard deviation [SD]: preintervention = 2.8 ± 1.6 and postintervention = 2.7 ± 1.4, p = 0.464). CONCLUSION: Reducing the amount of opioid ordered after CD reduced the proportion of post-CD patients exceeding the maximum recommended daily oxycodone dose for breastfeeding women. KEY POINTS: · Inpatient opioid prescribing influences usage.. · Opioid orders influence consumption.. · Reducing opioids may not increase pain..

Access to CKD Care in Rural Communities of India: a qualitative study exploring the barriers and potential facilitators.

BACKGROUND: Despite the high and rising burden of chronic kidney disease (CKD) in South Asia, factors that influence access to CKD care at the community level have not been studied previously, especially in the rural areas. We conducted a mixed methods study and interviewed key stakeholders to explore the views and experiences of key stakeholders, and identify barriers and potential facilitators that influence access to CKD care at the primary care level in rural India. METHODS: A total of 21 stakeholders participated in the study. We conducted 15 in-depth interviews on a purposive sample of stakeholders (CKD patients, healthcare providers and health planners) and one focus group discussion with 6 community health workers. The interviews were audio-recorded and transcribed verbatim. We employed the Lévesque's framework for access to care to base interview guides and structure the initial codes. By inductive and deductive approaches, thematic analysis was undertaken using QSR NVivo version 11. RESULTS: The major patient-level barriers to CKD care as reported by the most patients and healthcare providers was poor knowledge and awareness of CKD. Health system-level barriers included shortages of skilled healthcare professionals and medicines, fragmented referrals pathways to the specialists at the hospitals with inadequate follow up care. Many patients and healthcare providers, when asked about areas for improving access to CKD care, reported educational initiatives to increase awareness of CKD among healthcare providers and patients, provision of CKD related supplies, and a systems-level approach to care coordination including task shifting by engaging community health workers in CKD care, as potential facilitators. CONCLUSIONS: We identified several barriers to access CKD care at the primary care level in rural India that need urgent attention. Targeted CKD screening programs and CKD specific educational initiatives may improve awareness of CKD. Additionally, primary care infrastructure needs to be strengthened for CKD care, ensuring trained staff, availability of essential diagnostics and medications, and creating efficient referral pathways for quality CKD care.

Anesthesiologist Specialization and Use of General Anesthesia for Cesarean Delivery.

BACKGROUND: Guidelines for obstetric anesthesia recommend neuraxial anesthesia (i.e., spinal or epidural block) for cesarean delivery in most patients. Little is known about the association of anesthesiologist specialization in obstetric anesthesia with a patient's likelihood of receiving general anesthesia. The authors conducted a retrospective cohort study to compare utilization of general anesthesia for cesarean delivery among patients treated by generalist versus obstetric-specialized anesthesiologists. METHODS: The authors studied patients undergoing cesarean delivery for live singleton pregnancies from 2013 through 2017 at one academic medical center. Data were extracted from the electronic medical record. The authors estimated the association of anesthesiologist specialization in obstetric anesthesia with the odds of receiving general anesthesia for cesarean delivery. RESULTS: Of the cesarean deliveries in our sample, 2,649 of 4,052 (65.4%) were performed by obstetric-specialized anesthesiologists, and 1,403 of 4,052 (34.6%) by generalists. Use of general anesthesia differed for patients treated by specialists and generalists (7.3% vs. 12.1%; P < 0.001). After adjustment, the odds of receiving general anesthesia were lower among patients treated by obstetric-specialized anesthesiologists among all patients (adjusted odds ratio, 0.71; 95% CI, 0.55 to 0.92; P = 0.011), and in a subgroup analysis restricted to urgent or emergent cesarean deliveries (adjusted odds ratio, 0.75; 95% CI, 0.56 to 0.99; P = 0.049). There was no association between provider specialization and the odds of receiving general anesthesia in a subgroup analysis restricted to evening or weekend deliveries (adjusted odds ratio, 0.76; 95% CI, 0.56 to 1.03; P = 0.085). CONCLUSIONS: Treatment by an obstetric anesthesiologist was associated with lower odds of receiving general anesthesia for cesarean delivery; however, this finding did not persist in a subgroup analysis restricted to evening and weekend deliveries.

Observational Study Using Ultrasound to Assess Midline Labor Epidural Analgesia Placement and Analgesic Efficacy.

OBJECTIVES: Labor epidural analgesia failure may relate to nonmidline placement of epidural catheters. We hypothesized that greater deviations of the epidural catheter insertion point from the ultrasound (US)-determined midline would be associated with less effective labor analgesia. METHODS: A prospective ethically approved cohort study was conducted. Fifty-two healthy average-sized women receiving labor epidural analgesia, inserted by the landmark technique, were approached after delivery. Immediately after removing the epidural catheter, we determined the epidural space midline using US and compared it to the epidural catheter insertion point and to the patient-identified midline (assessed by a pinprick in 1-mm increments). Correlations between the US midline-to-catheter insertion point distance and additional epidural local anesthetic requirements (primary outcome), pain verbal numeric rating scale scores (0-10) 1 hour after epidural insertion, and maternal satisfaction with analgesia were determined. The differences in distances were assessed by a Bland-Altman analysis. RESULTS: There were no significant correlations between the US midline-to-epidural catheter insertion point distance and additional epidural local anesthetic requirements (R2 = 0.138; P = .33), pain verbal numeric rating scale scores 1 hour after the epidural (R2 = 0.121; P = .40) or maternal satisfaction (R2 = 0.085; P = .57). The Bland-Altman analysis revealed that the mean ± SD US midline-to-epidural catheter insertion point distance and patient-identified midline distances were 0.38 ± 0.31 and 0.35 ± 0.46 cm, respectively. CONCLUSIONS: In our laboring population, the hypothesis that nonmidline epidural insertion is associated with less-effective labor analgesia was not confirmed in this study cohort. We found minimal differences in distances between the US midline to epidural catheter insertion point and US midline to patient-identified midline.

Cardiac Arrest: Obstetric CPR/ACLS.

In contrast with other high-resource countries, maternal mortality has seen an increase in the United States. Caring for pregnant women in cardiac arrest may prove uniquely challenging given the rarity of the event coupled by the physiological changes of pregnancy. Optimization of resuscitative efforts warrants special attention as described in the 2015 American Heart Association's "Scientific Statement on Maternal Cardiac Arrest." Current recommendations address a variety of topics ranging from the basic components of chest compressions and airway management to some of the logistical complexities and operational challenges involved in maternal cardiac arrest.

Active Warming Utilizing Combined IV Fluid and Forced-Air Warming Decreases Hypothermia and Improves Maternal Comfort During Cesarean Delivery: A Randomized Control Trial.

BACKGROUND: The aim of this study was to apply both IV fluid and forced-air warming to decrease perioperative hypothermia in women undergoing cesarean delivery with spinal anesthesia. The authors hypothesize that combined-modality active warming (AW) would increase maternal temperature on arrival at the postanesthesia care unit (PACU) and decrease the incidence of maternal perioperative hypothermia (<36°C) compared with no AW. METHODS: Forty-six healthy women (n = 23 per group) undergoing scheduled cesarean delivery with spinal anesthesia (10-12 mg bupivacaine + 10 µg fentanyl) were enrolled in this double-blinded, randomized controlled trial. Women were randomly assigned to receive either AW (warmed IV fluid and lower body forced-air warmer) or no warming (NW; blankets only). SpotOn Monitoring System was used to measure core temperature intraoperatively and for 1 hour postoperatively. The primary outcome measure was maternal temperature on arrival at the PACU. Secondary outcome measures included incidence of maternal perioperative hypothermia (<36°C), incidence of shivering, thermal comfort scores (0-100 scale), Apgar scores, and umbilical cord blood gas analysis. RESULTS: Demographic, obstetric, and surgical data were similar between study groups. The AW group (35.9°C ± 0.5°C) had a significantly higher temperature on arrival at the PACU compared with the NW group (35.5°C ± 0.5°C, P = 0.006; 95% confidence interval of mean difference, 0.1°C-0.7°C). Fourteen (64%) women in the AW group and 20 (91%) in the NW group were hypothermic during the study period (P = 0.031). Median (interquartile range) thermal comfort scores were 100 (95-100) in the AW group and 90 (70-100) in the NW group (P = 0.008). There were no significant differences in the incidence of intraoperative shivering (22% in the AW and 45% in the NW groups; P = 0.11), Apgar scores, or umbilical vein blood gas values between the study groups. CONCLUSIONS: Fluid combined with forced-air warming is effective in decreasing the incidence of perioperative hypothermia and improving maternal thermal comfort. However, despite multimodal AW, the majority of women became hypothermic, and shivering was not prevented. The findings suggest that combined AW for cesarean delivery with spinal anesthesia is difficult, and only modest benefit should be expected.

Implementation of Programmed Intermittent Epidural Bolus for the Maintenance of Labor Analgesia.

Programmed intermittent epidural bolus (PIEB) is an exciting new technology that has the potential to improve the maintenance of epidural labor analgesia. PIEB compared with a continuous epidural infusion (CEI) has the potential advantage of greater spread within the epidural space and therefore better sensory blockade. Studies have demonstrated a local anesthetic-sparing effect, fewer instrumental vaginal deliveries, less motor blockade, and improvements in maternal satisfaction with PIEB compared with CEI. However, the optimal PIEB regimen and pump settings remain unknown, and there are a number of logistical issues and practical considerations that should be considered when implementing PIEB. The PIEB bolus size and interval, PIEB start time delay period, and patient-controlled epidural analgesia bolus size and lockout time can influence the efficacy of PIEB used for epidural labor analgesia. Educating all members of the health care team is critical to the success of the technique. This review summarizes the role of PIEB for the maintenance of labor analgesia, outlines implementation strategies, suggests optimal settings, and presents potential limitations of the technique.

Point-of-care system for detection of Mycobacterium tuberculosis and rifampin resistance in sputum samples.

Early detection of Mycobacterium tuberculosis complex (MTBC) and markers conveying drug resistance can have a beneficial impact on preventive public health actions. We describe here a new molecular point-of-care (POC) system, the Genedrive, which is based on simple sample preparation combined with PCR to detect MTBC and simultaneously detect mutation markers in the rpoB gene directly from raw sputum sample. Hybridization probes were used to detect the presence of the key mutations in codons 516, 526, and 531 of the rpoB gene. The sensitivities for MTBC and rpoB detection from sputum samples were assessed using model samples spiked with known numbers of bacteria prepared from liquid cultures of M. tuberculosis. The overall sensitivities were 90.8% (95% confidence interval [CI], 81, 96.5) for MTBC detection and 72.3% (95% CI, 59.8, 82.7) for rpoB detection. For samples containing ≥1,000 CFU/ml, the sensitivities were 100% for MTBC and 85.7% for rpoB detection, while for samples containing ≤100 CFU/ml, the sensitivities were 86.4% and 65.9% for MTBC and rpoB detection, respectively. The specificity was shown to be 100% (95% CI, 83.2, 100) for MTBC and rpoB. The clinical sputum samples were processed using the same protocol and showed good concordance with the data generated from the model. Tuberculosis-infected subjects with smear samples assessed as scanty or negative were detectable by the Genedrive system. In these paucibacillary patients, the performance of the Genedrive system was comparable to that of the GeneXpert assay. The characteristics of the Genedrive platform make it particularly useful for detecting MTBC and rifampin resistance in low-resource settings and for reducing the burden of tuberculosis disease.

Maternal outcomes in women supplemented with a high-protein drink in labour.

BACKGROUND: Because of the potential aspiration risk, oral intake is restricted during labour. AIMS: To determine whether high-protein drink supplementation in labour decreases nausea and emesis and promotes patient satisfaction. MATERIALS AND METHODS: The study was registered with www.clinicaltrials.gov (NCT01414478). Labouring women were randomised into two groups: Group P received a high-protein drink (325 mL) with ice chips/water PRN; and Group C served as control and received only ice chips/water PRN (Study 1). Incidences of nausea and emesis were measured hourly until delivery and at 1 h postdelivery. Patient satisfaction was measured the following day. A secondary aim was to evaluate the rate of gastric emptying (t½ ) in women who ingested either 325 mL of a high-protein drink or ice chips/water (Study 2) using ultrasound. RESULTS: In Study 1, 150 women were recruited (Group P = 75; Group C = 75). There were no differences in the overall incidences of nausea (P = 0.14), emesis (P = 0.15) or in the incidences at the measured time periods (MANOVA, P > 0.05). Median patient satisfaction scores were higher in Group P than in Group C (P = 0.007). In Study 2, 18 additional patients (Group PG = 9; Group CG = 9) were analysed to determine US gastric emptying t½ rates (PG : 25.56 ± 15.90 min [95% CI: 15.17 - 35.94] compared with CG : 20.00 ± 8.70 min [95% CI: 14.34 - 25.66], P = 0.19). CONCLUSION: In labour, patient satisfaction is improved with high-protein drink supplementation compared with ice chips/water with comparable gastric emptying rates.

Efficacy of the bilateral ilioinguinal-iliohypogastric block with intrathecal morphine for postoperative cesarean delivery analgesia.

The ilioinguinal-iliohypogastric (IIIH) block is frequently used as multimodal analgesia for lower abdominal surgeries. The aim of this study is to compare the efficacy of IIIH block using ultrasound visualization for reducing postoperative pain after caesarean delivery (CD) in patients receiving intrathecal morphine (ITM) under spinal anesthesia. Participants were randomly assigned to 1 of 3 treatment groups for the bilateral IIIH block: Group A = 10 mL of 0.5% bupivacaine, Group B = 10 mL of 0.5% bupivacaine on one side and 10 mL of a normal saline (NSS) placebo block on the opposite side, and Group C = 10 mL of NSS placebo per side. Pain and nausea scores, treatment for pain and nausea, and patient satisfaction were recorded for 48 hours after CD. No differences were noted with respect to pain scores or treatment for pain over the 48 hours. There were no differences to the presence of nausea (P = 0.64), treatment for nausea (P = 0.21), pruritus (P = 0.39), emesis (P = 0.35), or patient satisfaction (P = 0.29). There were no differences in pain and nausea scores over the measured time periods (MANOVA, P > 0.05). In parturients receiving ITM for elective CD, IIIH block offers no additional postoperative benefit for up to 48 hours.

Anesthetic Management for Combined Anterior Cervical Spinal Decompression and Fusion and Cesarean Delivery: A Case Report.

A 31-year-old G2P1 (gravida 2 para 1) woman at 34 weeks of gestation presented after a motor vehicle collision with an incomplete cervical spinal cord injury. The patient underwent emergent anterior cervical decompression and fusion (ACDF), immediately followed by cesarean delivery. We discuss the clinical decision making to perform ACDF first, weighing risks and benefits to both mother and baby. We also address important anesthetic considerations for this pregnant patient having emergent spine surgery, including positioning with left uterine displacement, rapid sequence intubation to minimize aspiration risk, choice of vasopressor, implications of total intravenous maintenance anesthetic, and the medical teams involved in this care.

Expectant management of a parturient with serotonin syndrome: A case report.

Serotonin syndrome is a potentially fatal condition caused by central nervous system serotonergic overactivity. The primary principle of managing serotonin syndrome in pregnancy focuses on discontinuation of offending agents and supportive care. In general, delivery should be avoided pending resolution of serotonin syndrome.

Conventional Hepatic Volumetry May Lead to Inaccurate Segmental Yttrium-90 Radiation Dosimetry.

OBJECTIVE: To compare radioembolization treatment zone volumes from mapping cone beam CT (CBCT) versus planning CT/MRI and to model their impact on dosimetry. METHODS: Y90 cases were retrospectively identified in which intra-procedural CBCT angiograms were performed. Segmental and lobar treatment zone volumes were calculated with semi-automated contouring using Couinaud venous anatomy (planning CT/MRI) or tumor angiosome enhancement (CBCT). Differences were compared with a Wilcoxon signed-rank test. Treatment zone-specific differences in segmental volumes by volumetric method were also calculated and used to model differences in delivered dose using medical internal radiation dosimetry (MIRD) at 200 and 120 Gy targets. Anatomic, pathologic, and technical factors likely affecting segmental volumes by volumetric method were evaluated. RESULTS: Forty segmental and 48 lobar CBCT angiograms and corresponding planning CT/MRI scans were included. Median Couinaud- and CBCT-derived segmental volumes were 281 and 243 mL, respectively (p = 0.005). Differences between Couinaud and CBCT lobar volumes (right, left) were not significant (p = 0.24, p = 0.07). Couinaud overestimated segmental volumes in 28 cases by a median of 98 mL (83%) and underestimated in 12 cases by median 69 mL (20%). At a 200 Gy dose target, Couinaud estimates produced median delivered doses of 367 and 160 Gy in these 28 and 12 cases. At a 120 Gy target, Couinaud produced doses of 220 and 96 Gy. Proximal vs. distal microcatheter positioning, variant arterial anatomy, and tumor location on or near segmental watersheds were leading factors linked to volumetric differences. CONCLUSION: Use of CBCT-based volumetry may allow more accurate, personalized dosimetry for segmental Y90 radioembolization.

Patients' experiences on accessing health care services for management of hypertension in rural Bangladesh, Pakistan and Sri Lanka: A qualitative study.

Hypertension is the leading risk factor for cardiovascular disease and leading cause of premature death globally. In 2008, approximately 40% of adults were diagnosed with hypertension, with more than 1.5 billion people estimated to be affected globally by 2025. Hypertension disproportionally affects low- and middle-income countries, where the prevalence is higher and where the health systems are more fragile. This qualitative study explored patients' experiences on the management and control of hypertension in rural Bangladesh, Sri Lanka and Pakistan. We conducted sixty semi-structured interviews, with 20 participants in each country. Hypertensive individuals were recruited based on age, gender and hypertensive status. Overall, patients' reported symptoms across the three countries were quite similar, although perceptions of hypertension were mixed. The majority of patients reported low knowledge on how to prevent or treat hypertension. The main barriers to accessing health services, as reported by participants, were inadequate services and poor quality of existing facilities, shortage of medicine supplies, busyness of doctors due to high patient load, long travel distance to facilities, and long waiting times once facilities were reached. Patients also mentioned that cost was a barrier to accessing services and adhering to medication. Many patients, when asked for areas of improvement, reported on the importance of the provider-patient relationship and mentioned valuing doctors who spent time with them, provided advice, and could be trusted. However, most patients reported that, especially at primary health care level and in government hospitals, the experience with their doctor did not meet their expectations. Patients in the three countries reported desire for good quality local medical services, the need for access to doctors, medicine and diagnostics and decreased cost for medication and medical services. Patients also described welcoming health care outreach activities near their homes. Areas of improvement could focus on reorienting community health workers' activities; involving family members in comprehensive counseling for medication adherence; providing appropriate training for health care staff to deliver effective information and services for controlling hypertension to patients; enhancing primary health care and specialist services; improving supplies of hypertensive medication in public facilities; taking into account patients' cultural and social background when providing services; and facilitating access and treatment to those who are most vulnerable.

Implementation Science in Perioperative Care.

There is a 17-year gap between the initial publication of scientific evidence and its uptake into widespread practice in health care. The field of implementation science (IS) emerged in the 1990s as an answer to this "evidence-to-practice gap." In this article, we present an overview of implementation science, focusing on the application of IS principles to perioperative care. We describe opportunities for additional training and discuss strategies for funding and publishing IS work. The objective is to demonstrate how IS can improve perioperative patient care, while highlighting perioperative IS studies and identifying areas in need of additional investigation.

Correlation of changes in hemodynamic response as measured by cerebral optical spectrometry with subjective pain ratings in volunteers and patients: a prospective cohort study.

PURPOSE: Noninvasive cerebral optical spectrometry is a promising candidate technology for the objective assessment physiological changes during pain perception. This study's primary objective was to test if there was a significant correlation between the changes in physiological parameters as measured by a cerebral optical spectrometry-based algorithm (real-time objective pain assessment [ROPA]) and subjective pain ratings obtained from volunteers and laboring women. Secondary aims were performance assessment using linear regression and receiver operating curve (ROC) analysis. PATIENTS AND METHODS: Prospective cohort study performed in Human Pain Laboratory and Labor and Delivery Unit. After institutional review board approval, we evaluated ROPA in volunteers undergoing the cold pressor test and in laboring women before and after epidural or combined spinal epidural placement. Linear regression was performed to measure correlations. ROCs and corresponding areas under the ROCs (AUC), as well as Youden's indices, as a measure of diagnostic effectiveness, were calculated. RESULTS: Correlations between numeric rating scale or visual analog scale and ROPA were significant for both volunteers and laboring women. AUCs for both volunteers and laboring women with numeric rating scale and visual analog scale subjective pain ratings as ground truth revealed at least good (AUC: 70%-79%) to excellent (AUC >90%) distinction between clinically meaningful pain severity differentiations (no/mild-moderate-severe). CONCLUSION: Cerebral Optical Spectrometry-based ROPA significantly correlated with subjectively reported pain in volunteers and laboring women, and could be a useful monitor for clinical circumstances where direct assessment is not available, or to complement patient-reported pain scores.

Breastfeeding after Anesthesia: A Review for Anesthesia Providers Regarding the Transfer of Medications into Breast Milk.

Doctors, nurses, and midwives often inform mothers to "pump and dump" their breast milk for 24 hours after receiving anesthesia to avoid passing medications to the infant. This advice, though cautious, is probably outdated. This review highlights the more recent literature regarding common anesthesia medications, their passage into breast milk, and medication effects observed in breastfed infants. We suggest continuing breastfeeding after anesthesia when the mother is awake, alert, and able to hold her infant. We recommend multiple types of medications for pain relief while minimizing sedating medications. Few medications can have sedating effects to the infant, but those medications are specifically outlined. For additional safety, anesthesia providers and patients may screen medications using the National Institute of Health' LactMed database.