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.

A multicenter interdisciplinary survey of practices and opinions regarding oral intake during labor.

INTRODUCTION: Different society guidelines diverge regarding oral intake in labor. Our goal was to assess practices and opinions in Israeli labor and delivery units, comparing different disciplines. METHODS: An anonymous Google Forms survey was sent to anesthesiologists, obstetricians and midwives in all Israeli labor and delivery units. RESULTS: Responses were collected from all 27 labor and delivery units contacted, with a total of 501 respondents comprising 161 anesthesiologists, 102 obstetricians and 238 midwives. Forty-eight per cent stated there were no institutional guidelines for oral intake. The most common oral intake permitted was light food (60%). Midwives were significantly more likely than anesthesiologists and obstetricians to consider that women who are both low risk for cesarean delivery (P <0.00001) and high risk for cesarean delivery (P=0.001) should eat. Epidural analgesia did not impact recommendations regarding oral intake. The most common reasons for restricting oral intake were obstetric. Sixty-two per cent identified aspiration as the main risk associated with eating during labor, but 19% of midwives compared with 4% of anesthesiologists and obstetricians stated there were no risks (P <0.00001). The annual delivery volume of the unit did not impact staff practices. CONCLUSIONS: There was a discrepancy between opinions and practices across all disciplines. Permissive practices identified in this survey should be addressed to find the safe middle ground between restrictive and permissive policies for low- and high-risk women.

A national Israeli survey of neuraxial anesthesia for cesarean delivery: pre-operative block assessment and intra-operative pain management.

BACKGROUND: Neuraxial protocols for cesarean delivery differ among institutions, with various means of assessing the block prior to incision and managing breakthrough intra-operative pain. The different approaches used to deal with these issues in Israel have not been assessed. METHODS: Questionnaires were distributed to all anesthesiologists working in obstetric units in Israeli hospitals. The survey included several non-identifying respondent details intended to allow a description of the study population as a whole and multiple-choice questions addressing neuraxial techniques, method of pre-operative block assessment and medications used to treat intra-operative pain. RESULTS: Three hundred and sixty-one doctors completed the survey in 24 medical centers, an 81.1% response rate. Thirteen different protocols for spinal anesthesia and 20 different protocols for epidural anesthesia were described. Nine different protocols for assessment of the block prior to incision were identified, with significant inter-institutional differences (P <0.001). For treatment of intra-operative pain prior to delivery, 35.7% of spinals given and 40% of epidurals given were converted to general anesthesia whereas, after delivery, conversion of spinal to general anesthesia was 18% and epidural to general anesthesia was 18.6%. CONCLUSIONS: There were a variety of spinal and epidural regimens used as well as different methods for assessing the block and managing intra-operative pain. Further studies should be performed to identify optimal techniques for neuraxial anesthesia for pre-operative block assessment and for management of intra-operative pain.

A 10-year update: national survey questionnaire of obstetric anesthesia units in Israel.

BACKGROUND: This nationwide survey was conducted to provide data about the obstetric anesthesia services in Israeli labor and delivery units in 2016. METHODS: Prospective survey questionnaire was emailed to obstetric anesthesia unit directors/chairperson of all 25 labor and delivery services units within the jurisdiction of the Israeli Ministry of Health. RESULTS: The response rate was 100%. Nineteen (76%) units have dedicated anesthesiologist cover. Fifteen (60%) units offered nitrous oxide, four units (16%) offered patient-controlled intravenous fentanyl and six units (24%) offered patient-controlled intravenous remifentanil for alternative labor analgesia. The median (range) epidural rate was 60% (22-85%). The median (range) cesarean delivery rate was 20% (10-26%). Overall, general anesthesia was performed for median (range) 10% (1-25%) of cesarean deliveries. Neuraxial anesthesia was performed for 95% (40-99%) of elective and 60% (0-90%) of urgent cesarean deliveries. Intrathecal morphine was administered routinely for spinal anesthesia for post-cesarean delivery analgesia in 11 (44%) units. Nineteen (72%) units had a written aspiration prophylaxis protocol; 20 (80%) had a written labor analgesia protocol; 19 (76%) had a postdural puncture headache management protocol; 20 (80%) had a local anesthetic toxicity protocol; 24 units had Intralipid available in the unit. CONCLUSION: No new labor units have opened since 2005, despite huge increases in delivery volume in many units. These units manage increased numbers of epidurals and cesarean deliveries. Use of intrathecal morphine for spinal anesthesia has become more widespread. Future efforts should focus on availability of emergency equipment, separate obstetric anesthesia staffing, and establishing emergency protocols.

Retrospective study to investigate fresh frozen plasma and packed cell ratios when administered for women with postpartum hemorrhage, before and after introduction of a massive transfusion protocol.

BACKGROUND: Administration of packed red blood cells (PRBC) and fresh frozen plasma (FFP) to women with postpartum hemorrhage (PPH) before and after introduction of a massive transfusion protocol. METHODS: The retrospective PPH study cohort of two tertiary centers was identified using blood bank records, verified by patient electronic medical records. We identified women transfused with ≥3 units PRBC in a short time period within 24 hours of delivery. Since 2010, both centers have used a protocol using 1:1 FFP:PRBC ratios. Demographic, obstetric, and blood management data were retrieved from medical records. Outcome measures included estimated blood loss, blood product administration, and hematologic variables. RESULTS: 273 women were included, 112 (41.0%) prior to introduction of the protocol (2004-2009) and 161 (59.0%) afterwards (2010-2014). The frequency of women managed with 1:1 FFP:PRBC ratios was similar before 55/112 (49.1%) and after 83/161 (51.6%) introduction of the protocol (P=0.69). There was strong correlation between PRBC units transfused and the FFP:PRBC transfusion ratio (R-square 0.866, P <0.0001), demonstrating that as the number of transfused PRBC units increased, FFP:PRBC ratios became closer to 1:1. There were no outcome differences between women managed before and after introduction of the protocol. CONCLUSIONS: Among women with PPH receiving ≥3 PRBC units within a short period of time, it appears that factors other than the existence of our massive transfusion protocol influence the number and ratio of PRBC and FFP units transfused. Blood products were not transfused according to exact ratios, even when guided by a protocol.

Preoperative sleep quality predicts postoperative pain after planned caesarean delivery.

BACKGROUND: Severe post-caesarean pain remains an important issue associated with persistent pain and postpartum depression. Women's sleep quality prior to caesarean delivery and its influence on postoperative pain and analgesic intake have not been evaluated yet. METHODS: Women undergoing caesarean delivery with spinal anaesthesia (bupivacaine 12 mg, fentanyl 20 µg, morphine 100 µg) were evaluated preoperatively for sleep quality using the Pittsburgh Sleep Quality Index (PSQI) questionnaire (PSQI 0-5 indicating good sleep quality, PSQI 6-21 poor sleep quality). Peak and average postoperative pain scores at rest, movement and uterine cramping were evaluated during 24 h using a verbal numerical pain score (VNPS; 0 indicating no pain and 100 indicating worst pain imaginable), and analgesic intake was recorded. Primary outcome was peak pain upon movement during the first 24 h. RESULTS: Seventy-eight of 245 women reported good sleep quality (31.2%; average PSQI 3.5 ± 1.2) and 167 poor sleep quality (68.2%; average PSQI 16.0 ± 3.4; p < 0.001). Women with poor sleep quality had significantly higher peak pain scores upon movement (46.7 ± 28.8 vs. 36.2 ± 25.6, respectively; p = 0.006). With multivariable logistic regression analysis, poor sleep quality significantly increased the risk for severe peak pain upon movement (VNPS ≥70; OR 2.64; 95% CI 1.2-6.0; p = 0.02). DISCUSSION: A significant proportion of women scheduled for caesarean delivery were identified preoperatively as having poor sleep quality, which was associated with more severe pain and increased analgesic intake after delivery. The PSQI score may therefore be a useful tool to predict increased risk for acute post-caesarean pain and higher analgesic requirements, and help tailor anaesthetic management. SIGNIFICANCE: Multiple studies have evaluated predictors for severe acute pain after caesarean delivery that may be performed in a clinical setting, however, sleep quality prior to delivery has not been included in predictive models for post-caesarean pain. The PSQI questionnaire, a simple test to administer preoperatively, identified that up to 70% of women report poor sleep quality before delivery, and poor sleep quality was associated with increased post-caesarean pain scores and analgesic intake, indicating that PSQI could help identify preoperatively women at risk for severe pain after caesarean delivery.

Israeli survey of anesthesia practice related to placenta previa and accreta.

BACKGROUND: Anesthesia practices for placenta previa (PP) and accreta (PA) impact hemorrhage management and other supportive strategies. We conducted a survey to assess reported management of PP and PA in all Israeli labor and delivery units. METHODS: After Institutional Review Board waiver, we surveyed all 26 Israeli hospitals with a labor and delivery unit by directly contacting the representatives of obstetric anesthesiology services in every department (unit director or department chair). Each director surveyed provided information about the anesthetic and transfusion management in their labor and delivery units for three types of abnormal placentation based on antenatal placental imaging: PP, low suspicion for PA, and high suspicion for PA. The primary outcome was use of neuraxial or general anesthesia for PP and PA Cesarean delivery. Univariate statistics were used for survey responses using counts and percentages. RESULTS: The response rate was 100%. Spinal anesthesia is the preferred anesthetic mode for PP cases, used in 17/26 (65.4%) of labor and delivery units. By comparison, most representatives reported that they perform general anesthesia for patients with PA: 18/26 (69.2%) for all low suspicion cases of PA and 25/26 (96.2%) for all high suspicion cases of PA. Although a massive transfusion protocol was available in the majority of hospitals (84.6%), the availability of thromboelastography and cell salvage was much lower (53.8% and 19.2% hospitals respectively). CONCLUSIONS: In our survey, representatives of anesthesia labor and delivery services in Israel are almost exclusively using general anesthesia for women with high suspicion for PA; however, almost two-thirds use spinal anesthesia for PP without suspicion of PA. Among representatives, we found wide variations in anesthesia practice patterns with regard to anesthesia mode, multidisciplinary management, and hemorrhage anticipation strategies.

Severe pain during local infiltration for spinal anaesthesia predicts post-caesarean pain.

BACKGROUND: Quantitative sensory testing (QST) measures response to painful stimuli and has been used to predict post-caesarean pain. Pain reported upon intravenous cannulation was shown to predict epidural analgesic use and pain intensity during labour. We hypothesized that pain intensity reported by women upon local anaesthesia injection (ILA) for spinal anaesthesia may predict acute pain after caesarean delivery (CD). METHODS: In a prospective observational trial, 229 women undergoing elective CD under spinal anaesthesia were enrolled. Using standardized script before ILA, women received ILA (lidocaine 1% 2.5 mL via 25 G needle), and provided an ILA score after the injection [verbal numeric pain scale (VNPS); 0-100]. Demographic data, average, peak pain (at rest, with movement and uterine cramping) and analgesic requests were recorded for the first 24 h. RESULTS: Fourteen percent of women experienced severe pain (VNPS ≥70) upon ILA. Good correlation was noted between ILA and pain scores at rest and upon mobilization during the 24 h following surgery (average resting pain r = 0.529, p < 0.001, average pain at mobilization r = 0.483, p < 0.0001). Severe acute postoperative pain (VNPS ≥70) was predicted by severe ILA pain with a sensitivity of 91.6% and specificity of 93.3%. CONCLUSION: This is the first study evaluating a clinical measure to predict post-caesarean pain. Our main findings were that 14% of women experience severe pain upon ILA, which was associated with increased pain during the first 24 h.

Peripartum anesthetic management of renal transplant patients--a multicenter cohort study.

As the number and success of renal transplantation has grown, there has been an increase in the number of renal transplant patients giving birth. To date, there has been no data on obstetric anesthesia management of these patients. The purpose of this study was to build an Israeli national database on parturients after renal transplant. A sixteen-year (calendar years 1996-2011) retrospective study was conducted at three major tertiary centers with a combined current birth rate of approximately 25,000 deliveries annually. We found 83 labors in 64 women. Forty-two percent of this population suffered from hypertension while 12.5% had diabetes. Forty-seven percent of women had a vaginal delivery while 53% of women had a cesarean section. The rate of epidural analgesia for labor was 59%, and rate of regional anesthesia during cesarean section was 75%. There were no anesthetic complications in any cases. Standard ASA monitoring was used in all cases except for one woman with severe hypertension who required an arterial line during her cesarean section. Forty-seven percent of newborn were under 37 weeks with average gestational week 36 ± 3 days and birth weight 2.5 ± 0.7 kg. Average Apgar was 8.4 ± 1.3 at one minute and 9.3 ± 0.7 at five minutes. There was one neonatal death in the CS group due to placental abruption. Patients after renal transplant can safely undergo birth and obstetric analgesia.

Severe heart disease complicating pregnancy does not preclude a favourable pregnancy outcome: 15 years' experience in a single centre.

Heart disease (HD) in pregnancy remains a major cause of non-obstetric maternal and neonatal mortality and morbidity. This study describes the outcome in 164 pregnant women with HD (158 deliveries in women in New York Heart Association (NYHA) Classes 1 and 2; 17 in NYHA Classes 3 and 4) who received good antenatal care and benefitted from a specific protocol and experience of a dedicated staff. There were no maternal or neonatal deaths; 46 women were diagnosed peripartum. Based on a sub-division into NYHA categories, and when sub-divided by HD, there were no statistically significant differences between groups with regard to maternal age, gestational age at admission or at delivery, birth weight, 5 min Apgar scores, mode of delivery (caesarean delivery), senior obstetric/anaesthesiology staff in attendance or delivery during day/working hours. There was a higher incidence of pre-term deliveries in women with rheumatic heart disease and Marfan syndrome (p = 0.06) relative to others. Babies of women with coronary heart disease had prolonged postpartum course in the NICU (p = 0.0001) and longer total hospital stays for the mother. In conclusion, well-managed, motivated mothers with HD who benefit from comprehensive antenatal care, and are managed primarily by their obstetric and anaesthesia teams, can aspire to a good outcome for themselves and their babies.

Peripartum anesthetic management of a patient with brittle cornea syndrome.

Brittle cornea syndrome (BCS) is a rare autosomal recessive disease that affects the connective tissue. The syndrome is caused by genetic changes in the 4.7-Mb interval between the D16S3423 and D16S3425 markers on the 16q24 chromosome and mutations in the Zinc-Finger 469 gene (ZNF469). BCS is characterized by thin and fragile cornea that tends to perforate spontaneously or as a result of minor trauma to the eye. In addition, the patient usually suffers from hearing loss, mental retardation, hyperextensibility of skin and joints, as well as varying degrees of scoliosis. This phenotypical expression presents an interesting challenge to anesthetic care. We briefly present the perioperative management of a patient with BCS who underwent three cesarean sections.

Obstetric anesthesia units in Israel: a national questionnaire-based survey.

BACKGROUND: This survey was performed to assess the organization and practice of obstetric anesthesia units in Israel. METHODS: A written questionnaire was mailed at the end of December 2005 to all Israeli anesthesia departments providing labor and delivery services in 2005 (n=25). RESULTS: A response rate of 100% accounted for 125,340 deliveries. All labor and delivery suites had on-site anesthesia department services. Data are presented as mean (range) or frequency. Eleven hospitals performed 2500-4999 deliveries/year, 6 hospitals 5000-7499 deliveries/year, and 4 hospitals 7500-9999 deliveries/year. The overall cesarean delivery rate was 20% (0-27). Anesthesia for cesarean delivery (elective and emergency combined) was provided by: general anesthesia 15% (0.5-50), epidural 14.5% (0-99.5), spinal 68% (0-98), or combined spinal-epidural technique 0% (0-30). There was an operating room within or immediately adjacent to the labor ward in 16/25 units, including 10/11 units with >5000 deliveries/year. Labor analgesia was provided by epidural techniques in 50% (4-93) and nitrous oxide in 0.5% (0-90) of deliveries. A total of 11 units had 24h dedicated anesthesiologist coverage, including all units >7500 deliveries but only 3/8 (38%) with 5000-7500 deliveries. Two of the 4 units with >7500 deliveries had no faculty member with formal training in obstetric anesthesia. Written protocols were available for labor analgesia (17/25), post-partum hemorrhage (12/25), aspiration prophylaxis (15/25) and maternal resuscitation (8/25). CONCLUSION: In this national appraisal of Israeli obstetric anesthesia services, a notable lack of written protocols, wide variations in staffing, and few specifically trained obstetric anesthesia personnel were observed.

Anesthetic management of a patient with cleidocranial dysplasia undergoing various obstetric procedures.

Patients with cleidocranial dysplasia, a rare autosomal dominant genetic syndrome, possess abnormal anatomical features of the head, mouth, neck and spinal column. These features may result in perioperative problems such as difficult airway and complicated regional anesthesia. We report the anesthetic management of a young woman with cleidocranial dysplasia undergoing four caesarean sections, one vaginal delivery and a dilatation and curettage, employing different modes of anesthesia. Anesthetic management in this disorder presents challenges for both general and neuraxial anesthesia.

Peripartum anesthetic management of patients with aortic valve stenosis: a retrospective study and literature review.

BACKGROUND: Anesthetic management of parturients with aortic stenosis is controversial. Early studies suggest maternal mortality was related to cardiac condition and anesthetic care. In this report, management of parturients with moderate or severe aortic stenosis in two institutions is compared, and published cases are reviewed. METHODS: Peripartum anesthetic management of all parturients with moderate or severe aortic stenosis who gave birth between 1990 and 2005 at our institutions, is described. Patients with mild or non-valvular aortic stenosis were excluded. RESULTS: There were 12 parturients, six with moderate and six with severe aortic stenosis. Two patients with moderate aortic stenosis were New York Heart Association (NYHA) classification II, the others were asymptomatic. Five patients with severe aortic stenosis were symptomatic (NYHA classification II or III). Two patients with moderate and three with severe aortic stenosis underwent cesarean delivery; epidural anesthesia was used for two. Two patients with moderate and all with serious aortic stenosis were observed postpartum for 24 to 48 h in a high-dependency unit. There were no severe maternal or neonatal complications. CONCLUSIONS: Carefully titrated regional analgesia is usually well tolerated in patients undergoing vaginal or cesarean delivery even in the presence of severe aortic stenosis. Standard monitoring is usually adequate for vaginal delivery, but invasive monitoring may facilitate management in some patients. An arterial line allows close monitoring of systemic blood pressure. Facilities for close 24-48-h post-partum observation should be available. A multidisciplinary approach is needed.

Perioperative anaesthetic management of high-order repeat caesarean section: audit of practice in a university-affiliated medical centre.

BACKGROUND: High-order (five or more) repeat caesarean sections (HORCS) are associated with increased rates of placenta praevia, placenta accreta and peripartum hysterectomy and prolonged surgical time secondary to intra-abdominal adhesions. This study summarizes our experience in the anaesthetic management of HORCS. METHODS: The files of all parturients undergoing HORCS between January 1995 and August 2007 were reviewed to determine surgical times, rates and causes of conversion from neuraxial to general anaesthesia and the need to supplement neuraxial anaesthesia with intravenous sedation. RESULTS: Parturients (n=108) were 35+/-4.5 years old with a gestational age of 37.5+/-1.5 weeks, weighed 88+/-20 kg and had undergone 6+/-1 caesarean sections. Eighty-six (80%) were elective. Initial anaesthetic techniques included spinal (n=80, 74%), epidural (n=9, 8%), combined spinal-epidural (n=6, 6%) and general anaesthesia (n=13, 12%). Surgery lasted 38+/-19 min (median 34, range 9-120). Fourteen parturients (13%) underwent intraoperative manipulations other than caesarean section, including three hysterectomies for haemorrhage (two placenta accreta, one praevia). There were no ruptures or dehiscences of the uterine scar, intraoperative bladder/ bowel injuries or re-explorations. Apgar scores <9 at 1 (n=9, 13%) and 5 (n=6, 5%) min were related to non-anaesthetic causes. Anaesthesia was converted from neuraxial to general in five cases (5/95, 5%) but only two were due to haemorrhage. No epidural top-up doses or intravenous sedatives/analgesics were required for spinal anaesthesia. CONCLUSION: HORCS is not necessarily an indication for general anaesthesia provided uterine and placental abnormalities are sought preoperatively. In our practice single-shot spinal anaesthesia sufficed for uncomplicated HORCS.

Congenital diaphragmatic hernia: review of the literature in reflection of unresolved dilemmas.

BACKGROUND: Congenital diaphragmatic hernia (CDH) is a rare but clinically and scientifically challenging condition. The introduction of ultrasound has enabled early prenatal detection and consequently, hope of early therapeutic intervention. AIM: We undertook the task to review the recent developments in understanding the pathology of CDH as well as the history and current management strategies to aid perinatologists in consultations with parents of CDH-affected foetuses. STUDY DESIGN: A Medline search was undertaken of all reports and reviews published between 1980 and 2008 using MeSH search terms 'diaphragmatic hernia', 'congenital' and 'newborn'. RESULTS: The true incidence of CDH is still difficult to estimate because of the high incidence of hidden mortality of CDH. Complete case ascertainment also poses difficulties in assessment of the impact of new therapeutic modalities on overall survival. Recent improvements in prenatal detection are a milestone in affording time for re-assessments and parental counselling. The true benefit of antenatal therapy is circumscribed and should be offered only in selected cases of isolated severe CDH as defined by existing guidelines. Postnatal intensive respiratory supportive therapy and innovative surgical techniques within specialized tertiary centres has had a major impact on survival of babies with CDH. CONCLUSION: The high survival of 'selected cases' that are live births and benefit from optimal care will be difficult to improve by antenatal interventions. The multidisciplinary approach to basic research and randomized clinical trials will further define the best approach to the foetus and neonate with CDH.

Conversion of epidural labour analgesia to anaesthesia for Caesarean section: a prospective study of the incidence and determinants of failure.

BACKGROUND: The incidence of general anaesthesia (GA) has been used as a marker for the quality of obstetric anaesthesia care. Recent guidelines suggest the rate of GA for Caesarean section in parturients with pre-existing epidural analgesia for labour should be <3%. The primary purpose of this study is to determine whether or not this is an achievable standard in a university teaching hospital. We also wished to determine the factors influencing the incidence of inadequate anaesthesia. METHODS: We studied a consecutive cohort of 501 patients who had a Caesarean section after epidural labour analgesia. The incidence of GA, the total incidence of failure, and the factors previously associated with failure were recorded. Factors shown to be significant with univariate analysis were used in a binary logistic regression to determine the independent risk factors for failure. RESULTS: Twenty-one of 501 parturients required GA (4.1%, 95% confidence interval 2.6-6.3%), not significantly different from 3% (P=0.1). Fifteen of 21 (71%) of these occurred intraoperatively. The total rate of failure was 30/501 (5.9%, 95% confidence interval 4.0-8.4%). Maternal height and the number of clinician top-ups in labour were the significant independent risk factors for failure. CONCLUSIONS: Intraoperative conversion to GA may increase both maternal and fetal risks. Strategies to reduce the incidence may include early recognition of inadequate labour analgesia and reliable assessment of adequacy of surgical anaesthesia.