The association between the introduction of quantitative assessment of postpartum blood loss and institutional changes in clinical practice: an observational study.

BACKGROUND: Imprecise visual estimates of blood loss contribute to morbidity from postpartum hemorrhage. We examined the impact of quantitative assessment of postpartum blood loss on clinical practice and outcomes. METHODS: An observational study comparing blood loss, management and outcomes between two historical cohorts (August 2016 to January 2017 and August 2017 to January 2018) at an academic tertiary care center. Patients in the intervention group (second period) had blood loss quantified compared with visual estimation for controls. RESULTS: We included 7618 deliveries (intervention group n=3807; control group n=3811). There was an increase in the incidence of hemorrhage (blood loss >1 L) in the intervention group for both vaginal (2.2% vs 0.5%, P <0.001) and cesarean delivery (12.6% vs 6.4%, P <0.001). There was also a difference in median blood loss for vaginal (258 mL [151-384] vs 300 mL [300-350], P <0.001); and for cesarean delivery (702 mL [501-857] vs 800 mL [800-900], P <0.001). The median red blood cell units transfused was different in the intervention group having cesarean delivery (2 units [1-2] vs 2 units [2-2], P=0.043). Secondary uterotonic usage was greater in the intervention group for vaginal (22% vs 17.3%, P <0.001) but not cesarean delivery (7.0% vs 6.0%, P=0.177). Laboratory costs were different, but not the re-admission rate or length of stay. CONCLUSIONS: Quantifying blood loss may result in increased vigilance for vaginal and cesarean delivery. We identified an association between quantifying blood loss and improved identification of postpartum hemorrhage, patient management steps and cost savings.

Systemic adjunct analgesics for cesarean delivery: a narrative review.

It is critical to adequately treat postoperative cesarean delivery pain. The use of parenteral or neuraxial opioids has been a mainstay, but opioids have side effects that can be troubling and the opioid crisis in the United States has highlighted the necessity to utilize analgesics other than opioids. Other analgesic options include neuraxial analgesics, nerve blocks such as the transversus abdominis plane block, and non-opioid parenteral and oral medications. The goal of this article is to review non-opioid systemic analgesic adjuncts following cesarean delivery, focusing on their efficacy and side effects as well as their impact on reduction of opioid requirements after surgery.

Disorders of coagulation in pregnancy.

The process of haemostasis is complex and is further complicated in the parturient because of the physiological changes of pregnancy. Understanding these changes and the impact that they have on the safety profile of the anaesthetic options for labour and delivery is crucial to any anaesthetist caring for the parturient. This article analyses current theories on coagulation and reviews the physiological changes to coagulation that occur during pregnancy and the best methods with which to evaluate coagulation. Finally, we examine some of the more common disorders of coagulation that occur during pregnancy, including von Willebrand disease, common factor deficiencies, platelet disorders, the parturient on anticoagulants, and the more rare acute fatty liver of pregnancy, with a focus on their implications for neuraxial anaesthesia.

An ex utero intrapartum treatment procedure in a patient with a family history of malignant hyperthermia.

In the EXIT (ex utero intrapartum treatment) procedure, after uterine incision, uterine relaxation is maintained to prevent placental separation and the fetus is supported via the placenta until the airway is successfully established. The traditional method to maintain uterine relaxation is with the use of high-dose potent inhaled anesthetics during general anesthesia. A patient with a family history of malignant hyperthermia required an EXIT procedure. The history of malignant hyperthermia precluded the use of potent inhaled anesthetics and an alternate plan using propofol and remifentanil infusions for anesthesia and nitroglycerin 16 µg/kg/min for uterine relaxation allowed for good surgical conditions. The presence of malignant hyperthermia required an alternate plan and close collaboration in order to ensure good patient outcome.

A survey of anesthesiologists' and nurses' attitudes toward the implementation of an Anesthesia Information Management System on a labor and delivery floor.

BACKGROUND: An anesthesia information management system (AIMS) is most frequently used in the operating room, but not on labor and delivery (L&D). The purpose of this study is to describe the implementation of an AIMS on L&D and the attitudes of practitioners (anesthesiologists and nurses) toward the system. METHODS: The anesthesiology survey focused on satisfaction with the L&D AIMS, comparison of the L&D AIMS with a handwritten anesthesia record, and comparison of the L&D AIMS with the operating room AIMS. The nursing survey focused on nursing satisfaction with the L&D AIMS and comparison of the L&D AIMS with a handwritten anesthesia record. RESULTS: Most anesthesiologists (76%) were satisfied with the L&D AIMS and 73% would not want to revert back to the paper record. However, most anesthesiologists felt the operating room AIMS was either superior or equal to the L&D AIMS. Although few nurses (4%) preferred the anesthesiologists revert back to the handwritten record overall, the nurses were neutral in their assessment of the AIMS. Most of the criticism related to the location of the system; 56% believed it was not in a convenient location and 74% thought the AIMS equipment "got in their way". CONCLUSIONS: Overall, the anesthesiologists and nurses are satisfied with the L&D AIMS and would not want to switch back to a handwritten record. We conclude that AIMS should not be limited to the operating room setting and can successfully be used in L&D.

Delayed diagnosis of posterior reversible encephalopathy syndrome (PRES) in a parturient with preeclampsia after inadvertent dural puncture.

Posterior reversible encephalopathy syndrome is a rare complication generally associated with headache and acute changes in blood pressure. We present a case of posterior reversible encephalopathy syndrome where diagnosis was delayed because the patient also had preeclampsia and an inadvertent dural puncture, both associated with headache. The clinical challenge and the need for prompt diagnosis and treatment are emphasized.

Evaluation of the platelet function analyzer (PFA-100) vs. the thromboelastogram (TEG) in the parturient.

BACKGROUND: The platelet function analyzer (PFA-100) is a bedside test of coagulation designed to evaluate platelet function. It measures the time required for whole blood to occlude a membrane impregnated with either epinephrine (EPI) or adenosine 5'diphosphate (ADP). The results are reported as closure time (CT-EPI or CT-ADP) in seconds. The thromboelastogram (TEG) measures whole blood clotting and the maximum amplitude (MA) correlates with platelet count and function. We wished to establish whether there is a correlation between the CT and platelet count, between the CT and MA, and between the MA and platelet count. METHODS: Platelet count, CT, and MA were measured in blood drawn from 172 healthy term parturients using the PFA-100. RESULTS: We were unable to detect a significant correlation between the CT-EPI and platelet count (r=-0.1, P=0.21), or the CT-ADP and platelet count (r=-0.02, P=0.83). We also did not find a correlation between the CT-EPI and MA (r=-0.13, P=0.12) or between the CT-ADP and MA (r=-0.11, P=0.19). However, we found a significant correlation between platelet count and MA (r=0.33, P<0.001). CONCLUSIONS: We conclude that the CT does not correlate with the platelet count or MA in the parturient, but the TEG does. Therefore the TEG may be a better tool to evaluate coagulation in the parturient with thrombocytopenia.

The visual analog scale for pain: clinical significance in postoperative patients.

BACKGROUND: The visual analog scale is widely used in research studies, but its connection with clinical experience outside the research setting and the best way to administer the VAS forms are not well established. This study defines changes in dosing of intravenous patient-controlled analgesia as a clinically relevant outcome and compares it with VAS measures of postoperative pain. METHODS: Visual analog scale measurements were obtained from 150 patients on the morning after intraabdominal surgery. On the same afternoon, 50 of the patients provided a VAS score on the same form used in the morning, 50 on a new form, and 50 were not asked for a second VAS measurement. RESULTS: Visual analog scale values and changes in value were similar for patients who were given a new VAS form in the afternoon and those who used the form that showed the morning value. The proportions of patients requesting additional analgesia were 4, 43, and 80%, corresponding to afternoon VAS scores of 30 or less, 31-70, and greater than 70, respectively. Change from morning VAS score had no apparent influence on patient-controlled analgesic dosing for patients with afternoon values of 30 or less or greater than 70, but changes in VAS scores of at least 10 did discriminate among patients whose afternoon values were between 31 and 70. CONCLUSIONS: When pain is an outcome measure in research studies, grouping final VAS scores into a small number of categories provides greater clinical relevance for comparisons than using the full spectrum of measured values or changes in value. Seeing an earlier VAS form has no apparent influence on later values.

Quality of analgesia when air versus saline is used for identification of the epidural space in the parturient.

BACKGROUND AND OBJECTIVES: Identification of the epidural space is often performed using the loss-of-resistance technique (LOR), commonly with air or saline. The effect of air or saline on the quality of labor epidural analgesia has not been adequately studied. METHODS: Women who requested labor epidural analgesia were randomly assigned to 1 of 2 groups depending on the syringe contents used for the LOR technique and injected into the epidural space. In the air group (n = 80) the anesthesiologist used 2 mL of air, and in the saline group (n = 80) the anesthesiologist used 2 mL of 0.9% saline. After LOR was obtained, a multiorifice epidural catheter was threaded 5 cm into the epidural space and 13 mL of bupivacaine 0.25% was administered in divided doses. The success of the epidural block was determined by asking the patient if she required additional medication 15 minutes later. The occurrence of paresthesias and intravascular or subarachnoid catheters was noted. RESULTS: In the air group, 36% of patients requested additional pain medication, and in the saline group 19% requested additional medication (P =.022). We were not able to find a statistically significant difference between groups in the incidence of paresthesias (42% air v 51% saline), intravascular catheters (5% air v 8% saline), or subarachnoid catheters (0 in both groups). CONCLUSIONS: Using 0.9% saline for the LOR technique is associated with better analgesia as compared with air for labor analgesia, and this advantage should be considered when selecting the syringe contents for the LOR technique.

The effect of the obstetrician group and epidural analgesia on the risk for cesarean delivery in nulliparous women.

BACKGROUND: The effects of regional anesthesia and of the obstetrician on the risk of cesarean delivery remain controversial. The purpose of this study was to determine whether epidural analgesia or the obstetrician group is associated with an increase in the risk for cesarean delivery in nulliparous women. METHODS: Data were collected for a two-year period from the medical records of all nulliparous women who had a private obstetrician who delivered >20 babies per year, and who presented with a singleton gestation in the vertex presentation for a trial of labor. RESULTS: Data were collected for 3699 women of whom 1832 were nulliparous. Of the 1832 nulliparous women, data were analyzed for the 1278 women who met our study criteria, representing 14 separate obstetrician groups. Excluding the 50 women whose babies were delivered for fetal distress (leaving 1228 women for analysis), the epidural rate was 93%, range 81-98%, and the cesarean delivery rate was 14%, range 8-34%. Logistic regression analyses revealed that (odds ratio, 95% confidence interval) patient age (1.7, 1.2-2.4), birth weight (1.001, 1.001-1.002), induction of labor (1.9, 1.3-2.7), non-Caucasian (1.9, 1.2-2.9) and the obstetrician group, (P=0.002), were independently associated with the risk of cesarean delivery, but epidural analgesia was not (1.6, 0.7-3.6). CONCLUSIONS: The obstetrician group is independently associated with the risk of cesarean delivery in nulliparous women, but we could not demonstrate this association with epidural analgesia. We suggest that in future studies regarding epidural analgesia and cesarean delivery, the obstetrician group should be included as a variable.

Improved epidural analgesia in the parturient in the 30 degree tilt position.

PURPOSE: To compare the incidence of incomplete analgesia when epidural local anesthetic is administered with the parturient supine in a 30 degree leftward tilt or in the left lateral decubitus position. METHODS: After placement of a multiorifice catheter 5 cm into the epidural space, 293 women in active labour were randomly positioned either to the left lateral decubitus position (lateral group) or supine with a 30 degree leftward tilt (tilt group) and then received 13 mL bupivacaine 0.25%. The success of the epidural block was determined by asking the patient if she required additional medication 15 min later. The incidence of complications (fetal heart rate decelerations, hypotension, and ephedrine usage) was noted. RESULTS: In the lateral group, 38% required additional medication compared with 24% in the tilt group (P = 0.006). There were no differences between groups in the incidence of maternal hypotension or fetal heart rate decelerations, but more women (10%) received ephedrine in the lateral than in the tilt group (4%), P = 0.035. CONCLUSIONS: Placing the parturient supine with a 30 degree leftward tilt is associated with a greater success rate of labour epidural analgesia without an increase in complications than in women in the left lateral decubitus position. This advantage should be considered when positioning the parturient after epidural catheter placement.

Comparison of non-invasive blood pressure measurements on the arm and calf during cesarean delivery.

OBJECTIVE: Shivering may occur in 75% of women undergoing spinal anesthesia for cesarean delivery and may render an automated noninvasive blood pressure (ANIBP) device incapable of determining blood pressurc (BP). When patients shiver under spinal anesthesia, the lower extremities do not exhibit the same involuntary muscle movements as do the upper extremities. This study was undertaken to determine if a correlation exists between ANIBP measurements in the arm and calf of women undergoing cesarean delivery under spinal anesthesia. METHODS: We enrolled 73 women in this blinded, prospective study. Simultaneous arm and calf BP were measured with an ANIBP and differences between the two were determined. RESULTS: We found significant differences between the average difference in systolic and in diastolic BP, no significant difference between the average mean BP, and a tendency for the systolic BP to be higher and the diastolic BP to be lower in the calf than in the arm; however, there was a large degree of variability among patients. CONCLUSION: We conclude that there is a poor correlation between the BP measured by an ANIBP on the calf and one on the arm. In the parturient undergoing cesarean section, lower extremity BP as measured by an ANIBP does not correlate with the arm ANIBP and should not be used to assure fetal well being.

Epidural ropivacaine for the initiation of labor epidural analgesia: a dose finding study.

UNLABELLED: The purpose of our study was to determine the lowest concentration of ropivacaine that offers pain relief for the initiation of labor epidural analgesia. Women in active labor were enrolled in this prospective, randomized, double-blinded study to receive either ropivacaine 0.20% (Group I), ropivacaine 0.15% (Group II), or ropivacaine 0.10% (Group III). After placement of the epidural catheter, 13 mL of the study medication was administered. Fifteen minutes later, the adequacy of analgesia was assessed. If the woman reported that her degree of analgesia was not adequate, an additional 5 mL of the study medication was given, the degree of pain relief was reassessed 15 min later, and the study was concluded. A sequential study design was used to assess the success rates. We found that 26 of 28 (93%) women in Group I had adequate analgesia, compared with only 18 of 28 (64%) in Group II (P = 0.014) and 4 of 12 (33%) in Group III (P = 0.003). We conclude that ropivacaine 0.20% offers adequate analgesia significantly more often than either ropivacaine 0.15% or ropivacaine 0.10%. If one selects ropivacaine as the sole local anesthetic for the initiation of labor epidural analgesia, the minimal concentration should be 0.20%. IMPLICATIONS: The lowest effective concentration of ropivacaine for the initiation of labor epidural analgesia has not been determined. We found that ropivacaine 0.20% offers adequate analgesia significantly more often than either ropivacaine 0.15% or ropivacaine 0.10%. If one selects ropivacaine as the sole local anesthetic for the initiation of labor epidural analgesia, the minimal concentration should be 0.20%.

The use of propofol, nitrous oxide, or isoflurane does not affect the reproductive success rate following gamete intrafallopian transfer (GIFT): a multicenter pilot trial/survey.

BACKGROUND: Whether anesthetic agents administered during gamete intrafallopian transfer (GIFT) affect reproductive outcome is controversial. This multicenter pilot trial and survey had two purposes: to evaluate the effect of propofol, nitrous oxide, midazolam, and isoflurane on pregnancy outcome after GIFT, and to determine if a larger prospective, randomized study is warranted. METHODS: A written invitation was mailed to all 50 fertility programs in the United States that are members of the Society for Assisted Reproductive Technology and perform more than 30 GIFT procedures per year. They were invited to contribute information from the medical records of women who underwent GIFT during the calendar years 1993 and 1994. They were asked to document whether propofol, nitrous oxide, midazolam, a potent inhaled anesthetic agent was used during the GIFT procedure; if the woman became pregnant; and if she delivered at least one live neonate. RESULTS: Seven medical centers participated and contributed data from 455 women. The clinical pregnancy rate (number of pregnancies/total number of GIFT procedures) and the delivery rate (number of women who delivered at least one live baby/total number of GIFT procedures) were 35% and 32%, respectively. A statistically significant difference could not be found in the clinical pregnancy or delivery rates between those women who received propofol, nitrous oxide, midazolam, or isoflurane during GIFT and those who did not. CONCLUSIONS: No agent-related differences in pregnancy rates were found when propofol, nitrous oxide, isoflurane, or midazolam was used as part of the anesthetic technique for GIFT. Therefore, a more extensive prospective trial does not appear to be warranted.

Anesthesia for nonobstetric surgery during pregnancy.

Approximately 50,000 pregnant women undergo nonobstetric surgery each year in the United States. Administering anesthesia during such surgery is one of the only situations in which anesthesia impacts on more than one individual (mother and fetus) at the same time. Providing a safe anesthetic to the pregnant woman requires an understanding of the physiologic changes of pregnancy and the impact of anesthesia and surgery on the developing fetus. The following review will consider the risks of the mother and to the fetus during nonobstetric surgery.

Treatment of incomplete analgesia after placement of an epidural catheter and administration of local anesthetic for women in labor.

BACKGROUND: Approximately 15% of women still have pain after placement of an epidural catheter and administration of local anesthetic for labor analgesia. Two techniques frequently used to treat this pain were compared: (1) withdrawal of the catheter 1 cm and repeated dosing with additional local anesthetic, and (2) repeated dosing with additional local anesthetic without any catheter manipulation. METHODS: Fifteen minutes after placement of a multiple-orifice epidural catheter 5 cm into the epidural space and administration of 13 ml 0.25% bupivacaine to the parturient in labor, the adequacy of analgesia was assessed. All women who had incomplete analgesia were randomized (first intervention) to receive an additional 5 ml 0.25% bupivacaine (local-anestheticonly group) or to receive 5 ml 0.25% bupivacaine after first withdrawing the epidural catheter 1 cm (catheter-manipulation group). If after 15 min the woman still had pain, then (second intervention) the catheter was withdrawn 1 cm and an additional 5 ml 0.25% bupivacaine was administered to the local-anesthetic-only group, whereas 5 ml 0.25% bupivacaine was given to the catheter-manipulation group without further catheter manipulation. The success rate of the second intervention was assessed 15 min later. RESULTS: Seventy-eight women were enrolled in the study, 39 to each group. In the local-anesthetic-only group, 29 (74%) women were successfully treated with the first intervention and the remaining 10 (100%) were successfully treated with the second intervention. In the catheter-manipulation group, 30 (77%) were successfully treated with the first intervention and 7 (100%; 2 patients were not studied because of investigator error) were successfully treated with the second intervention (P=NS). CONCLUSIONS: Administration of additional local anesthetic without first withdrawing the epidural catheter will effectively treat most women for whom analgesia is incomplete after the placement of an epidural catheter during labor.