Anaesthesia praCtice for Caesarean dElivery Snapshot Study (ACCESS): Protocol and baseline characteristics of registered centres.

BACKGROUND: Specific guidelines to manage caesarean delivery anaesthesia are lacking. A European multicentre study, ACCESS investigates caesarean delivery anaesthesia management in European centres. In order to identify ACCESS participating centres, a registration survey was created. OBJECTIVE: The aim of the current report is to describe the characteristics of ACCESS study participating centres, the rationale for the ACCESS study and the study methodology. DESIGN AND SETTING: The ACCESS study is a European multicentre cross-sectional study to describe anaesthesia management for caesarean delivery (CD) using a snapshot (2-week) design. The ACCESS registration survey gathered: contact details for National Coordinators (NC); Lead Investigators (LI) per centre; centre annual CD volume; expected no. of CD during 2-week snapshot window; centre practice information; data collection language. The ACCESS registration survey was launched July 2022 (Google Forms, Google Inc., Mountain View, CA, USA) and distributed through personal connections, national and international societies, social media networks, during Euroanaesthesia 2023, through the European Society of Anaesthesiology and Intensive Care newsletter. RESULTS: The ACCESS registration survey identified Lead Investigators for 418 centres, in 32 countries, representing an anticipated number of 15,073 CD cases over the planned 12-month study period. A median (range) of 20 (2 to 400) CD cases are anticipated per centre during the 2-week snapshot window. Most 366/418 (87.6%) centres are small, ≤2000 annual CD cases, 42 are medium 2000-5000 cases and 10 are large, ≥5000 annual CD cases. Registered centres reported in 134 (32.0%) centres that anaesthesia for caesarean delivery is performed mostly by a specialist obstetric anaesthesiologist. CONCLUSION: The ACCESS registration survey revealed variability in volume and CD practice as well as training-levels and staffing among European countries. The ACCESS study (https://www.access-study.org/) aims to generate practice data to guide CD anaesthetic management strategies.

Obstetric anaesthesia manpower and service provision issues (introduction and European perspective).

Global health is an important and far-reaching concept in which health and access to surgical and anaesthetic care is crucial. Universal access to anaesthesia is a challenge in many countries. Manpower shortages are an important cause of difficulties and each European country has found different ways of facing a lack of healthcare professionals. In obstetric anaesthesia, the availability of competent anaesthesiologists has been related to the morbidity and mortality outcomes of patients. In this narrative review, authors from different European countries explain how manpower is managed in obstetric anaesthesia in delivery suites and obstetric operating rooms in different settings. To address manpower difficulties and issues, the goals are to achieve a minimum standard of care and at the same time, to promote clinical excellence through training, delegation to younger or less experienced colleagues, direct or at-a-distance supervision, or other means. The experience of sharing knowledge about the way in which manpower and service provision are organised in other healthcare settings is a significant opportunity to develop strategies for advancing tomorrow's obstetric anaesthesia in the world. While taking into account the level of socio-economic development in different countries, the aim is to standardise practice and workload organisation. Co-operative international projects in training and education in obstetric anaesthesia are ways in which better obstetric patient care can be achieved in the future.

Guidelines for the management of urgent obstetric situations in emergency medicine, 2022

To provide recommendations on the management of urgent obstetrical emergencies outside the maternity ward. A group of 24 experts from the French Society of Emergency Medicine (SFMU), the French Society of Anaesthesia and Intensive Care Medicine (SFAR) and the French College of Gynaecologists and Obstetricians (CNGOF) was convened. Potential conflicts of interest were formally declared at the outset of the guideline development process, which was conducted independently of industry funding. The authors followed the GRADE (Grading of Recommendations Assessment, Development and Evaluation) method to assess the level of evidence in the literature. The potential drawbacks of strong recommendations in the presence of low-level evidence were highlighted. Some recommendations with an insufficient level of evidence were not graded. Eight areas were defined: imminent delivery, postpartum haemorrhage (prevention and management), threat of premature delivery, hypertensive disorders in pregnancy, trauma, imaging, cardiopulmonary arrest, and emergency obstetric training. For each field, the expert panel formulated questions according to the PICO model (population, intervention, comparison, outcomes) and an extensive literature search was conducted. Analysis of the literature and formulation of recommendations were conducted according to the GRADE method. Fifteen recommendations on the management of obstetrical emergencies were issued by the SFMU/SFAR/CNGOF panel of experts, and 4 recommendations from formalised expert recommendations (RFE) established by the same societies were taken up to answer 4 PICO questions dealing with the pre-hospital context. After two rounds of voting and several amendments, strong agreement was reached for all the recommendations. For two questions (cardiopulmonary arrest and inter-hospital transfer), no recommendation could be made. There was significant agreement among the experts on strong recommendations to improve practice in the management of urgent obstetric complications in emergency medicine.

[Maternal deaths due to haemorrhage in France 2013-2015]. / Mortalité maternelle par hémorragie en France 2013­2015.

Maternal death from haemorrhage is decreasing: in the last 15 years the number of deaths has been halved. This improvement demonstrates the progress made in hemorrhage management as a result of collective efforts. The number of deaths in this triennium is 22, representing 8.4% of maternal deaths and a maternal mortality ratio by haemorrhage of 1.0/100,000 live births. Nevertheless, there is a worrying proportion of deaths from occult haemorrhage. These occult haemorrhages most often occurred after caesarean sections. A lack of surveillance in the immediate follow-up was generally associated. One or more factors of sub-optimal care were present in 84% of the cases, and 88.9% of deaths were considered possibly or probably preventable. Delay in the diagnosis of haemorrhage, delay in surgical treatment, an insufficient transfusion strategy and inappropriate locations of care were the most frequently reported factors. The experts suggest that risk factors for haemorrhage should be identified in order to propose the most appropriate facility for childbirth. They encourage the strategies for early diagnosis of haemorrhage (attentive and regular monitoring, rapid haemoglobin measurement, abdominal ultrasound) and surgical intervention in case of hemoperitoneum.

[Maternal mortality due to cardiovascular disease in France 2013-2015]. / Mortalité maternelle par maladies cardiovasculaires en France 2013­2015.

Between 2013 and 2015, cardiovascular diseases became one of the two leading causes of maternal mortality, with 36 deaths (13.7% of maternal deaths). The overall maternal mortality ratio for cardiovascular diseases is 1.5 per 100,000 live births, stable compared to the 2010-2012 period. The etiologies in order of decreasing frequency are: pre-existing cardiomyopathies (n=10), aortic dissections (n=9), peripartum cardiomyopathies (n=6), myocardial infarction (n=4), valvular cardiopathies (n=4). Non-optimal care occurred in 72% of cases, increasing since the previous triennium (50%). Similarly, there is a significant increase in the proportion of preventable deaths (possibly or probably) from 35% to 66%. In women with known cardiovascular disease, the lack of multidisciplinary prepregnancy assessment and pregnancy follow-up is most frequent. In patients with unknown cardiovascular disease, the lack of diagnosis of a cardiac event is the most common failure. Cardiovascular conditions or cardiovascular risk factors should be investigated in early pregnancy in order to monitor and refer women to appropriate maternity hospitals. Recent dyspnea, worsening at the end of pregnancy and postpartum, should suggest a cardiac complication. In presence of chest pain, aortic dissection should be considered with the same degree of emergency as myocardial infarction or pulmonary embolism. Cardiac ultrasonography, chest CT, Nt-proBNP and troponin should be considered in case of chest pain or recent dyspnea. Women with cardiac symptoms should be referred to an emergency department (not necessarily to the local maternity) for a complete cardiovascular check-up.

[Maternal Deaths due to Amniotic Fluid Embolism in France 2013-2015]. / Mortalité maternelle par embolie amniotique en France 2013­2015.

Amniotic fluid embolism remains the 3rd cause of maternal death in France, with a stable rate and 28 deaths in this triennium, representing 10.7% of maternal deaths and a maternal mortality ratio of 1.2/100,000 live births. Cases are characterized by the suddenness of symptoms: the median delay between symptoms and death was 4h [0.75-696] with 20/28 patients did not reach the intensive care unit. Initial circulatory failure or cataclysmic haemorrhage was the two modes of presentation. Prodromes were reported in 17 (63%) cases and induction of labour was present in 12/27 (44%). One or more factors of sub-optimal care were present in 72% of the cases, and 52% of deaths were considered possibly or probably preventable. This preventability most often concerned the content of care but also the organisation of care (including human resources, communication, sites of care and referrals). The delay in establishing a well-conducted cardio-circulatory resuscitation or the delay in setting up an optimal transfusion strategy were the most frequent elements of substandard care. Absence or delay at hysterectomy during haemorrhagic situations was reported in 15/20 cases. The experts suggest being on the alert to diagnose amniotic embolism at an early stage, initiating intense resuscitation "outside the walls", envisaging a hysterectomy without delay if the haemorrhage is intense. On an organisational level, a "vital emergency maternity care" plan, specific to each establishment could be proposed.

[Normal childbirth: physiologic labor support and medical procedures. Guidelines of the French National Authority for Health (HAS) with the collaboration of the French College of Gynaecologists and Obstetricians (CNGOF) and the French College of Midwives (CNSF) -- Text of the Guidelines (short text)]. / Accouchement normal : accompagnement de la physiologie et interventions médicales. Recommandations de la Haute Autorité de Santé (HAS) avec la collaboration du Collège National des Gynécologues Obstétriciens Français (CNGOF) et du Collège National des Sages-Femmes de France (CNSF) ­ Texte des recommandations (texte court).

OBJECTIVE: The objective of these guidelines is to define for women at low obstetric risk modalities that respect the physiology of delivery and guarantee the quality and safety of maternal and newborn care. METHODS: These guidelines were made by a consensus of experts based on an analysis of the scientific literature and the French and international recommendations available on the subject. RESULTS: It is recommended to conduct a complete initial examination of the woman in labor at admission (consensus agreement). The labor will be monitored using a partogram that is a useful traceability tool (consensus agreement). A transvaginal examination may be offered every two to four hours during the first stage of labor and every hour during the second stage of labor or before if the patient requests it, or in case of a warning sign. It is recommended that if anesthesia is required, epidural or spinal anesthesia should be used to prevent bronchial inhalation (grade A). The consumption of clear fluids is permitted throughout labor in patients with a low risk of general anesthesia (grade B). It is recommended to carry out a "low dose" epidural analgesia that respects the experience of delivery (grade A). It is recommended to maintain the epidural analgesia through a woman's self-administration pump (grade A). It is recommended to give the woman the choice of continuous (by cardiotocography) or discontinuous (by cardiotocography or intermittent auscultation) monitoring if the conditions of maternity organization and the permanent availability of staff allow it and, after having informed the woman of the benefits and risks of each technique (consensus agreement). In the active phase of the first stage of labor, the dilation rate is considered abnormal if it is less than 1cm/4h between 5 and 7cm or less than 1cm/2h above 7cm (level of Evidence 2). It is then recommended to propose an amniotomy if the membranes are intact or an oxytocin administration if the membranes are already ruptured, and the uterine contractions considered insufficient (consensus agreement). It is recommended not to start expulsive efforts as soon as complete dilation is identified, but to let the presentation of the fetus drop (grade A). It is recommended to inform the gynecologist-obstetrician in case of nonprogression of the fetus after two hours of complete dilation with sufficient uterine dynamics (consensus agreement). It is recommended not to use abdominal expression (grade B). It is recommended to carry out preventive administration of oxytocin at 5 or 10 IU to prevent PPH after vaginal delivery (grade A). In the case of placental retention, it is recommended to perform a manual removal of the placenta (grade A). In the absence of bleeding, it should be performed 30minutes but not more than 60minutes after delivery (consensus agreement). It is recommended to assess at birth the breathing or screaming, and tone of the newborn to quickly determine if resuscitation is required (consensus agreement). If the parameters are satisfactory (breathing present, screaming frankly, and normal tonicity), it is recommended to propose to the mother that she immediately place the newborn skin-to-skin with her mother if she wishes, with a monitoring protocol (grade B). Delayed cord clamping is recommended beyond the first 30seconds in neonates, not requiring resuscitation (grade C). It is recommended that the first oral dose (2mg) of vitamin K (consensus agreement) be given systematically within two hours of birth. CONCLUSION: These guidelines allow women at low obstetric risk to benefit from a better quality of care and optimal safety conditions while respecting the physiology of delivery.

[Normal childbirth: physiologic labor support and medical procedures. Guidelines of the French National Authority for Health (HAS) with the collaboration of the French College of Gynaecologists and Obstetricians (CNGOF) and the French College of Midwives (CNSF) - Mother's wellbeing and regional or systemic analgesia for labor]. / Accouchement normal : accompagnement de la physiologie et interventions médicales. Recommandations de la Haute Autorité de Santé (HAS) avec la collaboration du Collège National des Gynécologues Obstétriciens Français (CNGOF) et du Collège National des Sages-Femmes de France (CNSF) ­ Bien être maternel et prise en charge médicamenteuse de la douleur.

INTRODUCTION: These guidelines deal with the parturient wellbeing in terms of hydration and regional and systemic pain management during labour. METHOD: Guidelines were established based on literature analysis and experts consensus. RESULTS: Clear liquids consumption is permitted all along labor and postpartum, without volume limitation, in patients at low risk of general anesthesia (grade B). The consumption of solid foods is not recommended during the active stage of labor (consensus agreement). It is recommended to promote on regional analgesia to prevent inhalation (grade A). Pain relief using regional analgesia is a part of normal childbirth. It is recommended to provide regional analgesia to parturient who wish these technics. Regional analgesia is the safest and most effective analgesic method for the mother (grade A) and the child (grade B). It is recommended to inform women on the analgesic technics, to respect their choice and consider the right for a parturient to change her strategy in obstetrical circumstances or in cases of untractable pain (consensus agreement). It is recommended to perform a "low-dose" regional analgesia that respects the experience of childbirth (grade A) and maintain it with a patient controlled epidural analgesia technics (grade A). There is no minimum cervical dilation to allow epidural analgesia (grade A). In cases of rapid labor or after delivery for revision, spinal or combined spinal epidural can be used (grade C). Epidural has not to be ended before birth (consensus agreement). Blood pressure and fetal heart rate must be monitored every 3minutes after induction and/or each 10mL bolus then hourly (consensus agreement). Systematic and preventive fluid loading is not needed if only due to regional analgesia (grade B). Deambulation or postures are allowed in the absence of motor block and must be traced and do not alter the distribution of the regional analgesia (grade C). The postures of childbirth do not alter regional analgesia spread (NP2). There is no effect low dose regional analgesia on the duration of obstetric labor, nor the rate of instrumental births or caesarean section (NP1). Systematic use of oxytocin due to epidural analgesia is neither useful nor recommended (AE). Regional analgesia has no side effect on the fetus or newborn (NP1). If regional analgesia is contraindicated or during the waiting time, alternatives analgesic drugs (entonox, nalbuphine and tramadol or pudendal block) can be used but their analgesic efficiency remains mediocre to moderate and they are associated with adverse maternal and especially neonatal side effects (NP2). Remifentanil, ketamine and volatile anesthetics are excluded from these recommendations. CONCLUSION: The present guidelines were established to update wellbeing of normal parturient during normal labor: hydration is recommended and low dose patient-controlled regional (epidural and spinal) analgesia is the most effective and safest analgesic method.

[Maternal death by venous thromboembolic disease]. / Morts maternelles par thromboembolies veineuses.

Pregnancy and postpartum are very high-risk periods for venous thromboembolism events (TEE), which seems to extend far beyond the classical 6-8 weeks after childbirth. Pulmonary embolism (PE) is one of the 3 main causes of direct maternal death in western countries. Between 2010 an 2012 in France, 24 deaths were related to PE giving a maternal mortality ratio of 1/100,000, which is not different from the former report (2007-2009). PE is responsible of 9% of maternal deaths, in equal position with postpartum hemorrhage and amniotic fluid embolism. Four deaths (16%) occurred after pregnancy interruption (1 abortion, 3 medical interruptions), 7 (30%) during ongoing pregnancy (before 22 weeks of pregnancy) and 13 (54%) in the postpartum period (9 to 60 days after childbirth). Among these deaths, 9 occurred in extra hospital setting (at home or in the street). Fifty percent of these deaths seem to be avoidable, as it was in the former report. Main avoidability criteria were: diagnostic delay; mobilization before effective anticoagulation of proximal deep venous thrombosis; insufficient preventive treatment with low molecular weight heparin [duration and/or dose (obesity)]; unjustified induction of labor. Analyzing those deaths allow to remind that in case of high suspicion of TEE, effective anticoagulation should be started without delay, and that angio-TDM is not contraindicated in pregnant women. Low molecular weight heparin regiment should be adapted to real weight. Monitoring of anti-Xa activity, if not routinely recommended, is probably useful in case of obesity or renal insufficiency. Anticipating birth by induction of labor, in the absence of abnormal fetal heart rhythm, should not delay effective anticoagulation of near-term TEE.

[Maternal deaths due to amniotic fluid embolism. Results from the French confidential enquiry into maternal deaths, 2010-2012]. / Mortalité maternelle par embolie amniotique. Résultats de l'ENCMM, France 2010­2012.

Amniotic fluid embolism (AFE) is an unpredictable, dreadful complication of pregnancy or childbirth. EA typically includes in the same lapse of time respiratory, haemodynamic, neurological and hemorrhagic symptoms (from early and severe coagulopathy). Immediate supportive treatment by a multidisciplinary team is the cornerstone of the management. Between 2010 an 2012 in France, 24 deaths were related to AFE giving a maternal mortality ratio of 1/100,000 live births (CI 95% 0.6-1.4). AFE ranks as the second leading cause of direct maternal death. Eight cases over 23 were classified as having some degree of substandard care. Substandard care included delays in performing aggressive surgical treatment or delays in the diagnosis and the treatment of the coagulopathy. Learning points focus on the importance to pay attention on premonitory symptoms, to early assess the clotting status and to train in multidisciplinary team.

[Maternal deaths due to sudden death. Results from the French confidential enquiry into maternal deaths, 2010-2012]. / Mortalité maternelle par mort subite. Résultats de l'enquête nationale française confidentielle sur la mortalité maternelle, 2010­2012.

Sudden death is defined as unexpected cardiac arrest occurring less than one hour after the onset of the first symptoms. Between 2010 and 2012, 23 maternal deaths were considered as unexplained sudden deaths and three of them were not evaluated due to a lack of clinical data. In addition, 13 maternal deaths with an identified cause occurred in a clinical context of sudden death (7 cases of pulmonary embolism, 2 cases of epilepsy, and 2 cases of cardiomyopathy). The first maneuvers of resuscitation in the presence of bystanders were attempted in 8 of 22 cases (36%). This emphasizes the importance of teaching the non-medical resuscitation modalities of cardiac arrest in pregnant women. Pregnant women must receive accurate resuscitation as the whole population. An autopsy was performed in 10 of 33 cases (30%) and was considered incomplete in 3 patients. This result emphasizes the necessity to perform a systematic and specialized autopsy in the context of sudden maternal death, which is mostly unexplained.

[Maternal deaths due to haemorrhage: Results from the French confidential enquiry into maternal deaths, 2010-2012]. / Mortalité maternelle par hémorragie, résultats de l'ENCMM, France 2010­2012.

Haemorrhage is the first cause of maternal mortality and morbidity in France and a quality of care marker. Haemorrhage rate in France is around 5 to 10% of deliveries. PPH is defined as a post-partum blood loss≥500mL whatever the delivery route and sometime blood can be concealed inside the pelvis. Between 2010 and 2012 in France, 29 deaths were related to haemorrhage giving a maternal mortality ratio of 1.2/100,000 live births (CI 95% 0.8-1.7). Haemorrhage cases decreased from last triennium (2007-2009) especially for uterine atony cases (12/29) but remains the first leading cause of direct maternal death. Patients with previous cesarean birth were more represented than in general obstetrical population (11/23). Substandard care were mainly due to delays in diagnosis of hemoperitoneum, delays in adequate resuscitation because of reassuring vital signs (normal blood pressure or normal hematocrite at the initial stage of bleeding) or organisational mistakes.

Patient-controlled oral analgesia versus nurse-controlled parenteral analgesia after caesarean section: a randomised controlled trial.

We assessed the effectiveness of early patient-controlled oral analgesia compared with parenteral analgesia in a randomised controlled non-inferiority trial of women undergoing elective caesarean section under regional anaesthesia. Seventy-seven women received multimodal paracetamol, ketoprofen and morphine analgesia. The woman having patient-controlled oral analgesia were administered four pillboxes on the postnatal ward containing tablets and instructions for self-medication, the first at 7 h after the spinal injection and then three more at 12-hourly intervals. Pain at rest and on movement was evaluated using an 11-point verbal rating scale at 2 h and then at 6-hourly intervals for 48 h. The pre-defined non-inferiority limit for the difference in mean pain scores (patient-controlled oral analgesia minus parenteral) was one. The one-sided 95% CI of the difference in mean pain scores was significantly lower than one at all time-points at rest and on movement, demonstrating non-inferiority of patient-controlled oral analgesia. More women used morphine in the patient-controlled oral analgesia group (22 (58%)) than in the parenteral group (9 (23%); p = 0.002). The median (IQR [range]) number of morphine doses in the patient-controlled oral analgesia group was 2 (1-3 [1-7]) compared with 1 (1-1 [1-2]); p = 0.006) in the parenteral group. Minor drug errors or omissions were identified in five (13%) women receiving patient-controlled oral analgesia. Pruritus was more frequent in the patient-controlled oral analgesia group (14 (37%) vs 6 (15%) respectively; p = 0.03), but no differences were noted for other adverse events and maternal satisfaction. After elective caesarean section, early patient-controlled oral analgesia is non-inferior to standard parenteral analgesia for pain management, and can be one of the steps of an enhanced recovery process.

Recombinant human FVIIa for reducing the need for invasive second-line therapies in severe refractory postpartum hemorrhage: a multicenter, randomized, open controlled trial.

BACKGROUND: Case reports on recombinant human factor VIIa (rhuFVIIa) use in women with severe postpartum hemorrhage (PPH) showed encouraging results, but no randomized controlled trial (RCT) is available. PATIENTS AND METHODS: Eighty-four women with severe PPH unresponsive to uterotonics were randomized to receive one early single rhuFVIIa infusion (n = 42) or standard care (no rhuFVIIa; n = 42). The primary efficacy outcome measure was the reduction of the need for specific second-line therapies, such as interventional hemostatic procedures, for blood loss and transfusions. The primary safety outcome measure was the number of deaths and thrombotic events during the 5 days following rhuFVIIa infusion. RESULTS: rhuFVIIa was associated with a reduction in the number of patients who needed second-line therapies compared with controls (standard care). Specifically, 39/42 (93%) patients in the standard care arm received second-line therapies and 22/42 (52%) patients in the rhuFVIIa arm (absolute difference, 41%; range, 18-63%; relative risk RR, 0.56 [0.42-0.76]). The delivery mode (vaginal or Cesarean section) did not affect the primary outcome. No death occurred. Two venous thrombotic events were recorded in the rhuFVIIa arm: one ovarian vein thrombosis and one deep vein thrombosis with a non-severe pulmonary embolism. CONCLUSION: This open RCT in women with severe PPH refractory to uterotonics shows that rhuFVIIa reduces the need for specific second-line therapies in about one in three patients, with the occurrence of non-fatal venous thrombotic events in one in 20 patients.

[Assessment of practices in postoperative analgesia in caesarean before and after implementation of an information program]. / Évaluation des pratiques de prise en charge analgésique en postopératoire de césarienne avant et après mesures d'amélioration.

OBJECTIVE: To assess the improvement of practices in postoperative analgesia after a cesarean section post implementation of a corrective program. STUDY DESIGN: Prospective impact study. PATIENTS AND METHODS: After obtaining ethics approval, we included all patients undergoing a cesarean section at Montpellier University Hospital during February 2011 (PRE group) and March 2012 (POST group). The patients were interviewed on the fourth day postpartum about pain management and related data was collected from the chart. From March 2011 to February 2012, training sessions were held for the paramedical and medical teams. RESULTS: Sixty patients were included in each group. The two groups were not significantly different. The mean overall numeric rating scale worst pain score between Day 0 and Day 4 in POST group was lower (5.5±2.5 vs. 6.5±2.4 p<0.01) and impairment during mobilization decreased significantly. Compliance with protocols improved in the POST group: the number of women receiving full analgesia regiment increased from 12% to 68% between PRE and POST period. CONCLUSION: After an awareness campaign of the paramedical and medical staff, we succeeded in improving significantly the routine use of analgesics regardless of their level. Nevertheless healthcare professionals still seem reluctant to administer opioids.

Effect of epidural analgesia on change in Mallampati class during labour.

Mallampati class has been shown to increase during labour. Epidural analgesia might influence this change. The aim of our study was to compare the change in Mallampati class during labour in parturients who did and did not receive epidural analgesia and study the association of these changes with pre-defined clinical characteristics. We performed a prospective observational study of 190 parturients. Using standard methodology, photographs of the upper airway were taken with a digital camera during early labour and within 90 min of delivery. Two to three consultant anaesthetists, blinded to the origin of the photographs, evaluated the images obtained and assigned a Mallampati class to each. Overall, Mallampati class increased in 61 (32.1%), decreased in 18 (9.5%) and did not change in 111 (58.4%) parturients (p<0.001). The proportions of parturients in the epidural and non-epidural groups who demonstrated an increase, decrease and no change in Mallampati class were similar. Of the relationships between change in Mallampati class and the other factors studied, only the total dose of epidural levobupivacaine during labour demonstrated a weak positive correlation 0.17 (p=0.039) with Mallampati class. This study confirms that labour is associated with an increase in the Mallampati class in approximately one third of parturients. Our findings indicate that having an epidural does not influence the likelihood of a change in Mallampati class during labour.

Low-dose combined spinal-epidural anaesthesia for caesarean section in a patient with Eisenmenger's syndrome.

A 34-year-old woman (G3,P0) with Eisenmenger's syndrome and positive HIV serology presented to hospital at 16 weeks of pregnancy. She was hospitalised at 20 weeks under the care of a multidisciplinary team. At 33 weeks caesarean section was performed under low-dose combined spinal-epidural anaesthesia using a needle-through-needle technique. Over a period of 10 min, spinal anaesthesia produced a sensory block to T4 which did not alter oxygenation or blood pressure. Epidural supplementation was not required. The caesarean section proceeded uneventfully without pain or discomfort. The post-partum period was without major incident. Low-dose combined spinal-epidural techniques combine the advantages of spinal and epidural blockade; the versatility allows its use in a wide range of clinical conditions, combining effective anaesthesia with cardiovascular stability.

Amniotic fluid embolism with haemostasis complications: primary fibrinogenolysis or disseminated intravascular coagulation?

Amniotic fluid embolism (AFE) is characterized by the passage of amniotic fluid (AF) into the maternal circulation during or just after childbirth. AFE is a rare disorder occurring in 1/8,000 to 1/80,000 deliveries but with a maternal morbidity ranging from 26% in a recent report to 86% in earlier ones. In patients who survive, AFE may affect coagulation resulting in severe bleeding. While disseminated intravascular coagulation (DIC) is usually seen in such cases, we reported a case of AFE in which the hemostatic abnormalities were compatible with primary fibrinogenolysis rather than with DIC.

[Amniotic fluid embolism during labor]. / Embolie amniotique en cours de travail.

Amniotic fluid embolism is an unpredictable but dramatical complication of pregnancy that occurs when amniotic fluid enter into the maternal circulation. The classical clinical feature is acute respiratory distress, circulatory distress, seizures and coagulopathy. However there is no routine laboratory diagnosis, so that is a diagnosis of exclusion. We report here the case of a patient, on labor with an epidural analgesia who suddenly suffered from seizures, circulatory arrest, and haemorrhage. A symptomatic management was instituted and a caesarean section was performed. An haemostatic hysterectomy was required. The patient survived without any sequelae. Neurological outcome of the child is still reserved.