Epidural analgesia in labour: separating fact from fiction for autism and neurodevelopment.

Having epidural analgesia in labour has been associated with a later diagnosis of autism spectrum disorder in the offspring, resulting in concerns about childhood wellbeing. Neurodevelopmental changes are inconsistently reported in the literature, creating challenges in the interpretation of these findings. Here we explore the limitations of the current evidence base, and why findings differ between studies, concluding that the current body of evidence does not support a causal association between use of epidural analgesia in labour and autism spectrum disorder.

ObsTIVA-UK: a service evaluation of obstetric total intravenous anaesthesia in the United Kingdom.

We conducted a prospective observational service evaluation across the United Kingdom on the use of total intravenous anaesthesia (TIVA) for obstetric surgery between November 2022 and June 2023. The primary aim was to describe the incidence of TIVA for obstetric surgery within participating units, with secondary aims to describe maternal and neonatal postoperative recovery indicators. Of 184 maternity units in the United Kingdom, 30 (16%) contributed data to the service evaluation. There were 104 patients who underwent caesarean delivery under TIVA and 19 patients had TIVA for other reasons. Infusions of propofol and remifentanil were used in 100% and 84% of cases, respectively. Fifty-nine out of 103 live neonates (57%) required some form of respiratory support. Of the neonates with recorded data, 73% and 17% had Apgar scores < 7 at 1 and 5 min respectively. No neonates were recorded to have Apgar scores < 7 at 10 min. Further prospective research is required to investigate the impact of obstetric TIVA on maternal and neonatal outcomes and inform best practice recommendations.

Behavioural and neuropsychological outcomes in children exposed in utero to maternal labour epidural analgesia.

BACKGROUND: Recent studies report conflicting results regarding the relationship between labour epidural analgesia (LEA) in mothers and neurodevelopmental disorders in their offspring. We evaluated behavioural and neuropsychological test scores in children of mothers who used LEA. METHODS: Children enrolled in the Raine Study from Western Australia and delivered vaginally from a singleton pregnancy between 1989 and 1992 were evaluated. Children exposed to LEA were compared with unexposed children. The primary outcome was the parent-reported Child Behaviour Checklist (CBCL) reporting total, internalising, and externalising behavioural problem scores at age 10 yr. Score differences, an increased risk of clinical deficit, and a dose-response based on the duration of LEA exposure were assessed. Secondary outcomes included language, motor function, cognition, and autistic traits. RESULTS: Of 2180 children, 850 (39.0%) were exposed to LEA. After adjustment for covariates, exposed children had minimally increased CBCL total scores (+1.41 points; 95% confidence interval [CI] 0.09 to 2.73; P=0.037), but not internalising (+1.13 points; 95% CI -0.08 to 2.34; P=0.066) or externalising (+1.08 points; 95% CI -0.08 to 2.24; P=0.068) subscale subscores. Increased risk of clinical deficit was not observed for any CBCL score. For secondary outcomes, score differences were inconsistently observed in motor function and cognition. Increased exposure duration was not associated with worse scores in any outcomes. CONCLUSIONS: Although LEA exposure was associated with slightly higher total behavioural scores, there was no difference in subscores, increased risk of clinical deficits, or dose-response relationship. These results argue against LEA exposure being associated with consistent, clinically significant neurodevelopmental deficits in children.

Agreement between three noninvasive temperature monitoring devices during spinal anaesthesia for caesarean delivery: a prospective observational study.

Hypothermia during obstetric spinal anaesthesia is a common and important problem, yet temperature monitoring is often not performed due to the lack of a suitable, cost-effective monitor. This study aimed to compare a noninvasive core temperature monitor with two readily available peripheral temperature monitors during obstetric spinal anaesthesia. We undertook a prospective observational study including elective and emergency caesarean deliveries, to determine the agreement between affordable reusable surface temperature monitors (Welch Allyn SureTemp® Plus oral thermometer and the Braun 3-in-1 No Touch infrared thermometer) and the Dräger T-core© (using dual-sensor heat flux technology), in detecting thermoregulatory changes during obstetric spinal anaesthesia. Predetermined clinically relevant limits of agreement (LOA) were set at ± 0.5 °C. We included 166 patients in our analysis. Hypothermia (heat flux temperature < 36 °C) occurred in 67% (95% CI 49 to 78%). There was poor agreement between devices. In the Bland-Altman analysis, LOA for the heat flux monitor vs. oral thermometer were 1.8 °C (CI 1.7 to 2.0 °C; bias 0.5 °C), for heat flux monitor vs. infrared thermometer LOA were 2.3 °C (CI 2.1 to 2.4 °C; bias 0.4 °C) and for infrared vs. oral thermometer, LOA were 2.0 °C (CI 1.9 to 2.2 °C; bias 0.1 °C). Error grid analysis highlighted a large amount of clinical disagreement between methods. While monitoring of core temperature during obstetric spinal anaesthesia is clinically important, agreement between monitors was below clinically acceptable limits. Future research with gold-standard temperature monitors and exploration of causes of sensor divergence is needed.

Development and validation of a Spanish version of the Obstetric Quality of Recovery-10 item score (ObsQoR-10-Spanish).

Background: Spanish is the second most spoken language globally with around 475 million native speakers. We aimed to validate a Spanish version of the Obstetric Quality of Recovery-10 item (ObsQoR-10) patient-reported outcome measure. Methods: ObsQoR-10-Spanish was developed using EuroQoL methodology. ObsQoR-10-Spanish was assessed in 100 Spanish-speaking patients undergoing elective Caesarean or vaginal delivery. Patients <38 weeks, undergoing an intrapartum Caesarean delivery, intrauterine death, or maternal admission to the intensive care unit (ICU) were excluded. Validity was assessed by evaluating (i) convergent validity-correlation with 24-h EuroQoL and global health visual analogue scale (GHVAS) scores (0-100); (ii) discriminant validity-difference in ObsQoR-10-Spanish score for patients with GHVAS scores >70 vs <70; (iii) hypothesis testing-correlation of ObsQoR score with maternal and neonatal factors; and (iv) cross-cultural validity assessed using differential item functioning analysis. Reliability was assessed by evaluating: (i) internal consistency; (ii) split-half reliability and (iii) test-retest reliability; and (iv) floor and ceiling effects. Results: One hundred patients were approached, recruited, and completed surveys. Validity: (i) convergent validity: the ObsQoR 24-h score correlated moderately with the 24-h EuroQoL (r=-0.632) and GHVAS scores (r=0.590); (ii) discriminant validity: the ObsQoR-10-Spanish 24-h scores were higher in women who delivered vaginally compared to via Caesarean delivery, (mean [standard deviation] scores were 89 [9] vs 81 [12]; P<0.001). The 24-h ObsQoR-Spanish scores were lower in patients experiencing a poor vs a good recovery (mean [standard deviation] scores were 76 [12.3] vs 87.1 [10.6]; P=0.001); (iii) hypothesis testing: the ObsQoR-10 score correlated negatively with age (r=-0.207) and positively with 5-min (r=0.204) and 10-min (r=0.243) Apgar scores. Remaining correlations were not significant; and (iv) differential item functioning analysis suggested no potential bias among the 10 items. Reliability: (i) internal consistency was good (Cronbach alpha=0.763); (ii) split-half reliability was good (Spearman-Brown prophesy reliability estimate of 0.866); (iii) test-retest reliability was excellent with an intra-class correlation coefficient of 0.90; and (iv) floor and ceiling effects: six patients scored a maximum total ObsQoR-10 score. Conclusions: The ObsQoR-10-Spanish patient-reported outcome measure is valid, reliable, and clinically feasible, and should be considered for use in Spanish-speaking women to assess quality of inpatient postpartum recovery.

Comparative evaluation of nebulised dexmedetomidine vs fentanyl for the treatment of post-dural puncture headache (PDPH) in parturients after caesarean section under spinal anaesthesia: A randomised controlled study.

Background and Aims: The incidence of post-dural puncture headache (PDPH) following spinal anaesthesia in the obstetric population is around 0.5%-2%. Hydration, bed rest, caffeine, paracetamol, non-steroid anti-inflammatory drugs, epidural blood patches, etc., are the various modalities used for its management. This study aims to compare nebulised dexmedetomidine versus fentanyl for the treatment of PDPH in parturients after caesarean section under spinal anaesthesia. Methods: Ninety obstetric patients aged 18-35 years with American Society of Anesthesiologists (ASA) physical status II/III and suffering from PDPH as per the criteria of the International Headache Society after caesarean section under spinal anaesthesia were recruited in this double-blinded randomised study. Patients were randomised to Group D (dexmedetomidine 1 µg/kg nebulisation), Group F (fentanyl 1 µg/kg nebulisation), and Group S (saline nebulisation 4mL). The nebulisation was done 12 hourly for 72 hours. Assessment parameters included pain score and the requirement of additional treatment such as paracetamol, caffeine, and epidural blood patch. Analysis of variance test was used for continuous quantitative variables, and the Kruskal-Wallis test was used for quantitative discrete data. Results: The pain scores at 1, 6, 12, 24, 48, and 72 hours following nebulisation were significantly lower in Group D in comparison to groups F and S (P < 0.001). The number of patients requiring additional analgesic therapy was lower in Group D in comparison to patients in other groups (P < 0.001). Conclusion: Dexmedetomidine nebulisation resulted in effective reduction in PDPH symptoms and pain scores. Nebulisation with fentanyl did not alleviate PDPH symptoms when compared to the control group.

Observational study of peripheral skin temperature changes following spinal anaesthesia for caesarean birth.

BACKGROUND: Spinal anaesthesia is widely used in obstetric anaesthesia practice but there is limited knowledge about the development of sympathetic blockade following spinal anaesthesia for caesarean birth. This study investigated the characteristics of sympathetic blockade by measuring peripheral skin temperature changes in the feet of patients given spinal anaesthesia for elective caesarean birth. METHODS: A prospective observational study was conducted involving 60 eligible parturients scheduled for elective caesarean birth with spinal anaesthesia. Skin temperature probes were attached to the dorsum of both feet, and temperature measurements were recorded every minute. The dose of spinal anaesthesia given, and other relevant patient data, were collected. RESULTS: All participants had successful spinal anaesthesia. Following spinal anaesthesia, a sustained rise in skin temperature of both feet was observed, indicating the presence of sympathetic blockade. The maximum rate of temperature increase occurred between 6 and 15 min after the intrathecal injection and plateaued from 22 min after the injection. Control participants did not show any changes in foot temperature. CONCLUSIONS: This study demonstrates that successful spinal anaesthesia for caesarean birth results in a consistent and reliable rise in skin temperature of the feet that is evident after six minutes from intrathecal injection. The observed temperature changes provide indirect objective evidence of bilateral sympathetic blockade. Measurement of feet skin temperatures may serve as an additional objective indicator of successful spinal anaesthesia, along with tests of lower limb motor block and sensory block height. These findings contribute to the understanding of sympathetic blockade during spinal anaesthesia.

Association of free maternal and fetal ropivacaine after epidural analgesia for intrapartum caesarean delivery: a prospective observational trial.

BACKGROUND: Ropivacaine is present in plasma in both protein-bound and free forms. The free form is responsible for the occurrence of toxic side effects. During obstetric epidural analgesia, free ropivacaine enters the fetal circulation depending on various factors. The aim of this study was to analyse a potential association between ropivacaine concentrations in maternal and fetal plasma and hence the extent of fetal exposure to ropivacaine. METHODS: In this prospective monocentre study, parturients who met the following criteria were included in the study: 1. epidural administration as part of obstetric anaesthesia, and 2. subsequent intrapartum caesarean delivery, which 3. was performed after an epidural bolus administration of ropivacaine within the existing epidural analgesia. Total and free ropivacaine concentrations were analysed in maternal blood at baseline, prior to epidural bolus administration for caesarean delivery, and in maternal and fetal (umbilical venous, oxygenated) blood at delivery. The results are presented as mean ±â€¯SD or median (25/75th percentile). RESULTS: We screened 128 parturients who went into labour at term and requested epidural analgesia, of whom 39 were ultimately included in the study. An intrapartum caesarean delivery was performed after the epidural application of 207 (166/276) mg ropivacaine during an epidural treatment period of 577 (360/1010) min. Total and free ropivacaine concentrations were 1402 ±â€¯357 ng/ml and 53 ±â€¯46 ng/ml, respectively, in maternal venous blood and 457 ±â€¯243 ng/ml and 43 ±â€¯27 ng/ml, respectively, in fetal blood. The maternal total and free ropivacaine concentrations were significantly correlated (r = 0.873; P < 0.0001). CONCLUSION: The results of the present study suggest that determining the concentration of free ropivacaine in maternal blood may be a feasible option for estimating neonatal exposure to ropivacaine.

Online Group Consultation on Labor Analgesia for Pregnant Women: Is It Feasible?

INTRODUCTION: Our department of anesthesiology has been conducting weekly, for several years, a group consultation to educate childbearing people about labor analgesia. The emergence of the COVID-19 pandemic forced an adaptation to a virtual consultation format. Since there are no studies about online group consultation on labor analgesia in order to understand its role, an anonymous questionnaire was created and applied. The objective was to evaluate this new consultation format, namely the ease of access, usefulness of the content provided, and its impact on the satisfaction and experience of childbirth. MATERIALS AND METHODS: An observational prospective study was conducted. A questionnaire was sent by e-mail after childbirth to all childbearing people participating in the online consultation from January 20, 2021, to March 2, 2022. SPSS Statistics version 28.0 (IBM Corp. Released 2021. IBM SPSS Statistics for Windows, Version 28.0. Armonk, NY: IBM Corp) was used for statistical analysis. Internal consistency was analyzed using Cronbach's alpha. RESULTS: A total of 563 participants were eligible, and 404 (71.8%) completed questionnaires were analyzed. A few technical problems were reported. The participants considered their privacy respected, and more than 90% were satisfied with the content of the online consultation, the opportunity to pose questions, and the help managing expectations. Considering face-to-face consultation, 89.6% of patients considered the online format an effective alternative, 63.2% believed it could replace the old model, and 96.3% would recommend it. CONCLUSIONS: Our study demonstrates that online consultation on labor analgesia was a good strategy during the COVID-19 pandemic and has the potential to be used in this format in the future.

Anesthetic Management of Cesarean Section in the Case of a Sextuplet Pregnancy and Polycystic Ovarian Syndrome.

Cesarean section in a mother with a sextuplet pregnancy is challenging for an anesthesiologist. Several perioperative complications are likely because of the overdistended uterus and associated changes in the mother. We are reporting the case of a woman with a sextuplet pregnancy who came for an emergency cesarean. She also had a background history of polycystic ovarian syndrome (PCOS) and ovulation induction for conception. Early pregnancy was complicated by ovarian hyperstimulation syndrome. She required cervical cerclage in early pregnancy. The emergency cesarean was done as she went into preterm labor and six premature babies were delivered at 29 weeks of gestation. Cesarean was done under spinal anesthesia. Preeclampsia and postpartum hemorrhage complicated the perioperative period.

Anaesthetic subspecialties and sustainable healthcare: a narrative review.

The principles of environmentally sustainable healthcare as applied to anaesthesia and peri-operative care are well documented. Associated recommendations focus on generic principles that can be applied to all areas of practice. These include reducing the use of inhalational anaesthetic agents and carbon dioxide equivalent emissions of modern peri-operative care. However, four areas of practice have specific patient, surgical and anaesthetic factors that present barriers to the implementation of some of these principles, namely: neuroanaesthesia; obstetric; paediatric; and cardiac anaesthesia. This narrative review describes these factors and synthesises the available evidence to highlight areas of sustainable practice clinicians can address today, as well as posing several unanswered questions for the future. In neuroanaesthesia, improvements can be made by undertaking awake surgery, moving towards more reusables and embracing telemedicine in quaternary services. Obstetric anaesthesia continues to present questions regarding how services can move away from nitrous oxide use or limit its release to the environment. The focus for paediatric anaesthesia is addressing the barriers to total intravenous and regional anaesthesia. For cardiac anaesthesia, a significant emphasis is determining how to focus the substantial resources required on those who will benefit from cardiac interventions, rather than universal implementation. Whilst the landscape of evidence-based sustainable practice is evolving, there remains an urgent need for further original evidence in healthcare sustainability targeting these four clinical areas.

Effect of Intravenous Ketamine Infusion on Hemodynamics of Patients Undergoing Cesarean Delivery after Spinal Anaesthesia: A Randomized, Double-Blind, Controlled Trial.

Objective: Hypotension is the most frequent side effect of intrathecal anaesthesia, with an incidence of more than 80%. Following neuraxial anaesthesia, perioperative shivering is a serious complication affecting 40-60% of patients undergoing surgery. This study aimed to determine the effectiveness of low-dose ketamine on blood pressure in patients undergoing cesarean delivery after spinal anaesthesia. Methods: We included 126 female patients undergoing cesarean deliveries, American Society of Anesthesiologists (ASA)-(II and III), and aged 21-40 selected from the outpatient clinics of the anaesthesia department. Patients were randomized to two groups; Group K (63 patients), who received 0.3 mg kg-1 of ketamine IV diluted to 10 mL, followed by an infusion of 0.1 mg kg-1 h-1. Group C (Controlled) (63 patients) received 10 mL of normal saline, followed by an infusion of 0.1 mL kg-1 h-1, which started before spinal anaesthesia. Results: Compared with the saline group, the average heart rate, blood pressure, and level of sedation were significantly higher in the ketamine group (P < 0.05). The ketamine group reported a significantly lower incidence of shivering (P < 0.01). The ketamine groups exhibited significantly less mild or severe hypotension (P < 0.05). There was no significant difference between the two groups in terms of nystagmus, diplopia, hallucinations, or neonatal outcomes (P > 0.05). Conclusion: Ketamine decreases the incidence of hypotension and shivering in patients undergoing spinal anaesthesia during cesarean delivery. In addition, it resulted in improved sedation for the mother and prolonged postoperative analgesia without neonatal illness.

Effect of Intrathecal Morphine on Postdural Puncture Headache in Obstetric Anaesthesia.

Objective: Intrathecal morphine is used as an effective component of multimodal analgesia in postoperative analgesia in cesarean section patients. We aimed to analyze the relationship between intrathecal morphine administration and postdural puncture headache (PDPH), pain score and analgesia consumption in the postoperative period, and maternal fetal effects. Methods: One hundred four pregnant women aged ≥18 years (American Society of Anesthesiology physical status I or II, >36 weeks gestation) who were scheduled for elective cesarean section under spinal anaesthesia were included in this study. Spinal anesthesia consisted of bupivacaine with or without morphine (Group M: 10 mg heavy marcaine + 25 mcg fentanyl + 100 mcg morphine; Group F: 10 mg heavy marcaine + 25 mcg fentanyl). The effect of intrathecal morphine on PDPH, postoperative pain score, analgesia consumption, and maternal and fetal effects were recorded for 5 days. Results: PDPH developed in a total of 33 patients (Group M: 18 and Group F: 15, P=0.274). When we evaluated PDPH with the VAS, there was no significant difference between the groups. The postoperative visual analogue scale (VAS) was lower in the morphine group, and no statistically significant difference was found in the VAS 1st hr and VAS 2nd hr, whereas the VAS 6th hr and VAS 24th hr were found to be statistically significant. There was no difference in terms of PDPH, the first analgesic requirement and postoperative nausea-vomiting, but meperidine consumption was lower in the morphine group. Conclusion: Low-dose intrathecal morphine did not affect the incidence of PDPH. It is an effective method that can be used in cesarean section patients without increasing the maternal and fetal side effects from postoperative analgesia.

The Efficacy of Dural Puncture Epidural Performed by 27-gauge Whitacre Needle in Labour Epidural Analgesia: Randomized Single-Blinded Controlled Study.

Objective: Dural puncture epidural technique is refinement of standard epidural technique. Its goal is to overcome drawbacks of standard epidural. We assessed whether dural puncture epidural technique performed by 27-gauge spinal needle would provide higher quality of labour epidural analgesia by using 10 mL epidural bolus of 0.125% bupivacaine. Additionally, the impact of dural puncture epidural on epidural analgesia onset, course of labour and occurrence of maternal side effects was examined. Methods: We designed prospective, randomized, single-blind study. A total of 76 healthy nulliparous parturients were randomly allocated to dural puncture or standard epidural group. After identification of epidural space, spinal Whitacre needle was used for dural puncture. Intrathecal drug administration was omitted at that point. Both groups received a bolus of local anaesthetic mixture, followed by a continuous infusion of diluted local anaesthetic via epidural catheter. Pain was assessed by numeric pain rating scale. The number of top-ups and mode of delivery were recorded in both groups. Results: After 10 minutes, there was a statistically significant difference in numeric pain rating scale ≤3 reported (P=0.028), with 97.4% subjects in dural puncture epidural group achieving adequate analgesia after 10 minutes. There was no statistically significant difference in the number of additional boluses, time to delivery, Bromage scale achieved or maternal outcomes between groups. Conclusion: Dural puncture epidural technique appears to be effective in providing faster onset of epidural analgesia. However, the need for additional boluses remains unchanged. It can be safely used in obstetrics, without deleterious effect on the course of labour.