Small dose spinal bupivacaine for Cesarean delivery does not reduce hypotension but accelerates motor recovery.

BACKGROUND: Maternal hypotension occurs in 60-94% of Cesarean deliveries with 10-15 mg spinal bupivacaine. Reduced doses of bupivacaine may decrease the incidence of hypotension, nausea, and vasopressor use. The primary objective of this study was to compare 4.5 mg and 12 mg doses of intrathecal bupivacaine on maternal hemodynamics. The secondary objective was to determine if anticipated reductions in side effects were reflected in increased patient satisfaction. METHODS: Following Research Ethics Board approval and informed consent 52 term parturients undergoing elective Cesarean delivery were randomly assigned to isobaric bupivacaine 4.5 mg or hyperbaric bupivacaine 12 mg for spinal anesthesia. All patients received fentanyl 50 microg and morphine 200 microg intrathecally. Intravenous fluid and vasopressor administration were standardized. Maternal hemodynamics, and sensorimotor levels were recorded at regular intervals. Side effects and patient satisfaction were documented. RESULTS: Median cepahalad sensory block was C8 in both groups (NS) but the intensity of motor block was significantly less (P < 0.001) and of shorter duration (P < 0.001) with bupivacaine 4.5 mg. The proportion of patients requiring ephedrine (> 70%) and the quantities of ephedrine used were similar in both groups (NS). Use of supplemental analgesia, side effects, and measures of patient satisfaction were comparable in both groups. DISCUSSION: Intrathecal bupivacaine 4.5 and 12 mg yielded similar sensory block and side effects during Cesarean delivery. Patients receiving 4.5 mg did, however, experience significantly less motor blockade of shorter duration.

Epidural analgesia does not prolong the third stage of labour.

PURPOSE: To investigate whether there is an association between epidural analgesia and duration of third stage of labour, and between epidural analgesia and type of placental delivery (spontaneous vs expressed vs manual). METHODS: We examined, retrospectively, the computerized labour and delivery data of all 7,468 parturients who had vaginal deliveries from 1996 to 1999 at the Civic Campus of the Ottawa Hospital. RESULTS: There was no difference in duration of third stage of labour between women with and without epidural pain relief who had spontaneous or expressed (fundal pressure/gentle cord traction) placental delivery. Duration of third stage of labour was shorter in women with epidural analgesia requiring manual removal of placenta. (25.3 min vs 40.1 min, P < 0.0001). The incidence of expressed placental delivery or manual removal of placenta was not different between the groups. CONCLUSIONS: We conclude that there is no clinically important difference in duration of third stage of labour between women with or without epidural analgesia who have spontaneous placental delivery or placental expulsion with fundal pressure/gentle cord traction. However, duration of third stage of labour was shorter in women who received epidural analgesia and required manual removal of the placenta.

Anesthetic management of a parturient with Ehlers Danlos syndrome type IV.

PURPOSE: To describe the anesthetic management of a parturient with Ehlers Danlos syndrome (EDS) type IV. CLINICAL FEATURES: A 29-yr-old pregnant woman with EDS type IV was seen in the Obstetric Anesthesia Pre-assessment Clinic at 30 weeks gestation. She had a history of vertebral artery dissection, resulting in a transient neurological deficit at 22 yr of age. She had a normal vaginal delivery with continuous epidural analgesia for the delivery of her first child at 27 yr of age, before the diagnosis of EDS was made. Recent fibroblast culture demonstrated the production of abnormal procollagen type III, which is pathognomonic for EDS type IV. The patient and obstetrician preferred a repeat vaginal birth with instrumental delivery in the second stage. Analgesia for labour and delivery was provided with a continuous epidural infusion of ropivacaine and fentanyl. She delivered a healthy female infant with the use of outlet forceps, without complications. CONCLUSION: A pre-delivery, multidisciplinary, individualized management plan is required in patients with EDS, a rare disease with variable clinical features. In the case described, continuous epidural analgesia was effective and associated with excellent maternal and fetal outcomes.