The Effect of Prolonged Face Mask Ventilation on Gastric Insufflation: A Prospective Observational Study.

BACKGROUND: Pulmonary aspiration is a potentially lethal perioperative complication that can be precipitated by gastric insufflation. Face mask ventilation (FMV), a ubiquitous anesthetic procedure, can cause gastric insufflation. FMV with an inspiratory pressure of 15 cm H2O provides the best balance between adequate pulmonary ventilation and a low probability of gastric insufflation. There is no data about the effects of FMV > 120 seconds. OBJECTIVES: To investigate the effect of prolonged FMV on gastric insufflation. METHODS: We conducted a prospective observational study at a tertiary medical center with female patients who underwent oocyte retrieval surgery under general anesthesia FMV. Pre- and postoperative gastric ultrasound examinations measured the gastric antral cross-sectional area to detect gastric insufflation. Pressure-controlled FMV with an inspiratory pressure of 15 cm H2O was continued from the anesthesia induction until the end of the surgery. RESULTS: The study comprised 49 patients. Baseline preoperative gastric ultrasound demonstrated optimal and good image quality. All supine measurements were feasible. The median duration of FMV was 13 minutes (interquartile range 9-18). In the postoperative period, gastric insufflation was detected in only 2 of 49 patients (4.1%). There was no association between the duration of FMV and delta gastric antral cross-sectional area (ß -0.01; 95% confidence interval -0.04 to 0.01, P = 0.31). CONCLUSIONS: Pressure-controlled FMV with an inspiratory pressure of 15 cm H2O carries a low incidence of gastric insufflations, not only as a bridge to a definitive airway but as an alternative ventilation method for relatively short procedures in selective populations.

Incidence of conversion to general anaesthesia and need for intravenous supplementation in parturients undergoing caesarean section under spinal anaesthesia: A retrospective observational study.

BACKGROUND: Conversion from spinal anaesthesia to general anaesthesia (GA) was shown to be associated with more complications. It has been postulated that spinal injection of a low dose of local anaesthetic is a risk factor. We aimed to discover the rate of conversion from spinal anaesthesia to GA in women who received at least 10 mg heavy bupivacaine and opioids and assess its risk factors. METHODS: All women that underwent spinal anaesthesia for caesarean section from 1 January 2017 to 31 December 2020 were included in this analysis. Spinal anaesthesia was performed according to department protocol using heavy bupivacaine 0.5% 10-13 mg, fentanyl 20 µg, and morphine 0.1 mg. We examined rate of conversion from spinal anaesthesia to GA and rate of need for analgesia/sedation. RESULTS: There were 1.7% of women that required conversion to GA. Bupivacaine dose (OR 0.54 [95% CI 0.38 to 0.75], p < 0.001), surgery time (OR 1.03 [95% CI 1.02 to 1.04], p < 0.001), emergency caesarean section (OR 1.06 [95% CI 1.16 to 3.76], p = 0.015), and postpartum haemorrhage (OR 5.96 [95% CI 1.09 to 25.18], p = 0.025) were independent predictors of need for conversion to GA. Of the women who had CS under spinal anaesthesia, 4.1% of parturients required intraoperative analgesics/sedatives and 9.1% required anxiolysis. CONCLUSIONS: A small proportion of women required conversion to GA. This conversion occurred especially with emergency caesarean section and when low spinal bupivacaine doses were used.

Fetal surgery using fetoscopic endoluminal tracheal occlusion for severe congenital diaphragmatic hernia: a single-center experience.

PURPOSE: To provide a comprehensive report of the experience gained in the prenatal treatment of congenital diaphragmatic hernia (CDH) using fetoscopic endoluminal tracheal occlusion (FETO) following its implementation at a newly established specialized fetal medicine center. METHODS: Mothers of fetuses with severe CDH were offered prenatal treatment by FETO. RESULTS: Between 2018 and 2021, 16 cases of severe CDH underwent FETO. The median gestational age (GA) at balloon insertion was 28.4 weeks (IQR 27.8-28.6). The median GA at delivery was 37 weeks (IQR 34.4-37.8). The survival rate was 8/16 cases (50%). None of the survivors required home oxygen therapy at 6 months of age. Comparison between the survivors and deceased showed that survivors had balloon insertion 1 week earlier (27.8 vs. 28.4 weeks, p = 0.007), a higher amniotic fluid level change between pre- to post-FETO (3.4 vs 1.3, p = 0.024), a higher O/E LHR change between pre- to post-FETO (50.8 vs. 37.5, p = 0.047), and a GA at delivery that was 2 weeks later (37.6 vs. 35.4 weeks, p = 0.032). CONCLUSIONS: The survival rate at 6 months of age in cases of severe CDH treated with FETO in our center was 50%. Our new fetal medicine center matches the performance of other leading international centers.

Flouroscopic versus conventional epidural blood patch in obstetrics: A retrospective cohort study.

BACKGROUND: Epidural blood patch is a common effective treatment for postdural puncture headache after accidental dural puncture during labor and may be done in conventional or fluoroscopy-guided methods. The aim of this study was to compare intensity of headache at the time of discharge from the hospital and to compare blood volumes injected in conventional epidural blood patches versus fluoroscopic-guided blood patches and evaluate the side effects of both method of treatment. METHODS: Between the years 2010 and 2020, 84 patients who were diagnosed with postdural puncture headache received either a conventional epidural blood patch or a fluoroscopic-guided blood patch. Blood volumes were compared and evaluation of side effects was made based on data collected during and after the procedure. RESULTS: Eighty-four patients were included in this study. Fifty-two women in the conventional epidural blood patch group and 32 in the fluoroscopic-guided blood patch group. Women in the conventional epidural blood patch group received statistically significantly higher doses of blood than women in the fluoroscopic-guided blood patch group: conventional method 29 ml IQR [23-36] versus fluoroscopic method 16 ml, IQR [12-18], p < .001 with no difference in headache pain intensity at hospital release. There was no difference between groups in hospital length of stay, or persistent PDPH. There was also no difference chronic headache or backache between the two groups. CONCLUSIONS: Women who received fluoroscopic epidural blood patch required a much lower volume of blood injected while there was no difference between groups in headache pain intensity at discharge.

Chronic pain in parturients with an accidental dural puncture: A case-controlled prospective observational study.

BACKGROUND: We set out to examine incidence of chronic headache and back pain in women with PDPH after accidental dural puncture during labor. METHODS: Chronic headache, backache, and disability were assessed 18-24 months postpartum. Women with PDPH treated with epidural blood patch (PDPH-EBP) were identified and matched with women who had a PDPH without epidural blood patch (PDPH-no EBP), with women with uncomplicated epidural analgesia and with women without epidural analgesia. Our primary outcome was incidence of chronic headache and backache. Secondary outcome was the effect of epidural blood patch on chronic pain development. We used Chi-square or Fisher's exact test to calculate odds ratios. RESULTS: There was no statistically significant difference in demographic characteristics between groups. In the no epidural group, no women reported chronic headache and 2/116 (1.7%) reported chronic backache. In the uncomplicated epidural group, no women reported chronic headache and 7/116 (6.0%) reported chronic backache. In the PDPH-no EBP group, 9/56 (16.1%) women reported chronic headache and 10/56 (17.9%) reported chronic backache. In the PDPH-EBP group, 12/59 (20.3%) had chronic headache and 14/59 (23.7%) had chronic backache. No women in the no epidural or uncomplicated epidural group reported disability (chronic pain score of 3 or 4). High disability was reported by 8.9% of women in the PDPH-no EBP group and by 8.4% in the PDPH-EBP group. CONCLUSION: Women with PDPH had a high incidence of chronic headache, back pain, and disability. We did not find a statistically significant difference in chronic pain development between conservatively treated and EBP-treated patients.

The relationship between resited epidural catheters after secondary epidural catheter failure and vaginal delivery: A retrospective case-control study.

BACKGROUND: There are cases where epidural analgesia is initially effective but subsequently fails and needs to be resited. We evaluated the rate of normal vaginal delivery and operative delivery among parturients who had resited epidurals compared to parturients with epidurals that were not resited. METHODS: A retrospective electronic medical review of parturients with a singleton gestation attempting normal vaginal delivery under epidural analgesia between the years 2012-2016 was conducted. Resited epidurals were defined as epidurals that were considered effective but subsequently removed and reinserted. For each resited epidural, two previous and two consecutive deliveries of parturients with normally functioning epidural catheter inserted by the same anesthesiologist were matched controls (non-resited epidurals). RESULTS: There were 35,984 attempted vaginal deliveries with 118 resited epidurals and 472 non-resited epidurals. When adjusted for nulliparity, oxytocin administration, sex and weight of the baby, and maternal BMI, labor epidural catheter replacement was not associated with need for instrumental or caesarean delivery, (OR 1.5, 95% CI 0.91-2.49, P = .11). CONCLUSIONS: Need for labor epidural catheter replacement does not appear to be associated with need for operative delivery based on this single-centre cohort analysis.

Long-term psychological and physical outcomes of women after postdural puncture headache: A retrospective, cohort study.

BACKGROUND: Postdural puncture headache after accidental dural puncture during labour may lead to chronic sequalae. OBJECTIVES: We aimed to measure the incidence of postpartum depression, posttraumatic stress disorder, chronic headache, backache and breastfeeding rates after a postdural puncture headache. DESIGN: A retrospective, case-matched cohort study. SETTING: A review of documented cases of dural puncture and matched case controls occurring at Rabin Medical Center and Shamir Medical Center from 01 January 2012 to 30 September 2018. PATIENTS: The study cohort consisted of women with a documented postdural puncture headache and the controls were women with uneventful labour epidurals in the same 24-h period. Women were interviewed by telephone. PRIMARY OUTCOMES MEASURE: The primary outcome measure was the incidence of postpartum depression after a postdural puncture headache. RESULTS: Women with postdural puncture headache (n = 132) and controls (n = 276) had similar demographic data. The incidence of postpartum depression was 67/128 (52.3%) versus 31/276 (11.2%) for controls, P < 0.0001, 95% confidence intervals of the difference 31.5 to 50.2. Posttraumatic stress disorder was more frequent among women with postdural puncture headache, 17/132 (12.8%) versus controls 1/276 (0.4%), P < 0.0001, 95% confidence intervals of the difference 7.6 to 19.5. Women with postdural puncture headache breastfed less, 74/126 (54.5%) versus controls 212/276 (76.8%), P < 0.0001, 95% confidence intervals of the difference 33.1 to 55.2. Current headache and backache were significantly more frequent among women with postdural puncture headache [current headache 42/129 (32.6%) versus controls 42/276 (15.2%) P < 0.00001, 95% confidence intervals 0.085 to 0.266; current backache 58/129 (43.9%) versus controls 58/275 (21%) P < 0.0001, 95% confidence intervals 14.1 to 33.5]. CONCLUSION: We report an increased incidence of postpartum depression, posttraumatic stress disorder, chronic headache and backache and decreased breastfeeding following a postdural puncture headache. Our findings emphasise the need for postpartum follow-up for women with postdural puncture headache. TRIAL REGISTRY NUMBER: Clinical trial registry number: NCT03550586.

A Retrospective Investigation of Neuraxial Anesthesia Rates for Elective Cesarean Delivery Before and During the SARS-CoV-2 Pandemic.

BACKGROUND: Our hospital used to perform cesarean delivery under general anesthesia rather than neuraxial anesthesia, mostly because of patient refusal of members of the conservative Bedouin society. According to recommendations implemented by the Israeli Obstetric Anesthesia Society, which were implemented due to the severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) pandemic, we increased the rate of neuraxial anesthesia among deliveries. OBJECTIVES: To compare the rates of neuraxial anesthesia in our cesarean population before and during SARS-CoV-2 pandemic. METHODS: We included consecutive women undergoing an elective cesarean delivery from two time periods: pre-SARS-CoV-2 pandemic (15 February 2019 to 14 April 2019) and during the SARS-CoV-2 pandemic (15 February 2020 to 15 April 2020). We collected demographic data, details about cesarean delivery, and anesthesia complications. RESULTS: We included 413 parturients undergoing consecutive elective cesarean delivery identified during the study periods: 205 before the SARS-CoV-2 pandemic and 208 during SARS-CoV-2 pandemic. We found a statistically significant difference in neuraxial anesthesia rates between the groups: before the pandemic (92/205, 44.8%) and during (165/208, 79.3%; P < 0.0001). CONCLUSIONS: We demonstrated that patient and provider education about neuraxial anesthesia can increase its utilization. The addition of a trained obstetric anesthesiologist to the team may have facilitated this transition.

Epidural/spinal anesthesia during delivery in women with factor XI deficiency, a single center experience.

INTRODUCTION: The safety of neuro-axial anaesthesia (epidural/spinal) at labour of women with partial factor XI (FXI) deficiency is uncertain. Although FXI deficiency is frequent in Ashkenazi Jews, it is not routinely measured before labour. Our institute serves a large Ashkenazi population. We assumed that 10% of them have undiagnosed FXI deficiency. AIM: Assess the incidence, bleeding tendency and coagulation status among Jewish Ashkenazi women with FXI deficiency that underwent neuro-axial anaesthesia at delivery. METHODS: Jewish Ashkenazi women who underwent neuro-axial anaesthesia at labour completed the SSC ISTH bleeding assessment tool (BAT) and had blood drawn for coagulation tests, FXI and thrombin generation after labour. Estimation for 10 years was calculated from the 1-year sample. RESULTS: We recruited 261 women during 12 months. Among them, 39 (15%) had FXI deficiency (<70%) with median FXI levels of 63% (range: 33%-70%). Around 50% of them underwent amniocentesis in the current pregnancy and prior neuro-axial anaesthesia with no bleeding complications. BAT score and thrombin generation did not differ between women regardless of FXI status. aPTT was longer in women with partial FXI deficiency (median - 28.6 sec vs 26.3 sec, P < .001, Table 2), although within the normal range in all women. No bleeding complications after neuro-axial anaesthesia at delivery were reported in our centre in the last decade though, and according to our estimation, at least 2150 women had partial FXI deficiency. CONCLUSIONS: A significant number of Jewish Ashkenazi women with undiagnosed partial FXI deficiency undergo neuro-axial anaesthesia at labour without bleeding complications.

The effect of preoperative anxiety on phenylephrine dose during cesarean delivery: An open controlled one-arm clinical trial.

BACKGROUND: We performed an open controlled one-arm clinical trial to assess whether preoperative anxiety influences phenylephrine dosage required to maintain normotension during cesarean section under spinal anesthesia. METHODS: Ninety-four parturients undergoing elective cesarean delivery under spinal anesthesia were included. Anxiety levels were measured using a verbal numerical scale anxiety score (0-10). Phenylephrine infusion to prevent hypotension was adjusted by a standard algorithm. The primary outcome was total phenylephrine dose. Linear uni- and multivariate regressions were performed to assess the relationship between preoperative anxiety and the outcome. P < .05 was considered statistically significant. RESULTS: We found no association between preoperative anxiety and phenylephrine dosage (R2  = 0.05). Taking the number of attempts for spinal anesthesia and surgical time into account did not lead to a significant improvement of the regression model. CONCLUSION: In conclusion, we did not find a large independent effect of preoperative anxiety on phenylephrine dose required to maintain normotension in our cohort. We believe that spinal hypotension and phenylephrine dose requirement are multifactorial and anxiety is only one of the factors in this complex interaction.

Prediction of Adnexal Torsion by Ultrasound in Women with Acute Abdominal Pain.

PURPOSE: To investigate the accuracy of ultrasound in the diagnosis of adnexal torsion. MATERIALS AND METHODS: Retrospective cohort analysis of 322 women, presenting to a tertiary medical center with acute abdominal pain, who underwent gynecological examination, sonographic evaluation and laparoscopic surgery, between 2010 and 2016. Findings for adnexal torsion were compared among three groups: positive sonographic findings consistent with surgically confirmed adnexal torsion (true positive, n = 228); negative sonographic findings inconsistent with surgically confirmed adnexal torsion (false negative, n = 42); and positive sonographic findings inconsistent with a surgical diagnosis other than adnexal torsion (false positive, n = 52). Outcome measures were sensitivity and positive predictive value of ultrasound, and its specific features, for the diagnosis of adnexal torsion. RESULTS: The sensitivity of ultrasound for adnexal torsion diagnosis was 84.4 %, and the positive predictive value was 81.4 %. Edematous ovary and/or tube, as well as positive whirlpool sign had the highest sensitivity and positive predictive value. The false-negative group had the highest frequency of ovarian cysts (p = 0.0086) and the lowest frequency of ovarian edema (p < 0.0001). The false-positive group had the lowest proportion of pregnant women (p = 0.0022). Significantly more women in the true-positive group had a prior event of adnexal torsion (p = 0.026). CONCLUSION: Ultrasound examination is highly accurate in the diagnosis of adnexal torsion. Clinicians should be aware of the presence of demographic and clinical characteristics that may positively or negatively affect sonographic diagnostic accuracy.

[PROSPECTIVE INVESTIGATION OF POSTOPERATIVE NAUSEA AND VOMITING FOLLOWING DUAL PROPHYLAXIS AND LOW DOSE NEURAXIAL MORPHINE FOR CESAREAN DELIVERY].

BACKGROUND: Spinal morphine provides the optimal treatment for post-cesarean analgesia, despite frequent nausea and vomiting. We investigated the incidence of nausea and vomiting 24 hours after cesarean delivery in women receiving intrathecal morphine 100 µcg and intravenous prophylactic dexamethasone and ondansetron. METHODS: In a prospective, observational, Institutional Review Board (IRB) approved study of women undergoing cesarean delivery according to a standardized anesthetic protocol, the subjects were approached preoperatively and underwent standardized interviews regarding prior anesthesia experience and history of postoperative nausea and vomiting. In the post anesthesia care unit and 24 hours postoperatively, the women were interviewed regarding the incidence of nausea and vomiting, Women with and without nausea at 24 hours were compared for potential associated risk factors. RESULTS: Among 201 women recruited, 29 (14.5%) had nausea and 7 (3.5%) vomited in the postoperative care unit. During the first 24 hours, 36 (17.9%) had experienced nausea and 19 (9.5%) had vomited when interviewed at the 24-hours postoperatively. Women who had nausea 24 hours postoperatively were more likely to have nausea in the post anesthesia care unit than women without nausea during 24 hours after cesarean delivery (41.7% versus 1.2%, p<0.001). We did not find preoperative risk factors for postoperative nausea and vomiting. CONCLUSIONS: We report that almost 20% of the women managed with prophylactic dual therapy of ondansetron and dexamethasone had nausea during the 24 hours after administration of low dose intrathecal morphine. Our findings suggested that women who experience nausea or vomiting in the immediate postoperative period are at increased risk of nausea and vomiting in the 24-hour postoperative period.

Distribution of Extreme Vital Signs and Complete Blood Count Values of Healthy Parturients: A Retrospective Database Analysis and Review of the Literature.

BACKGROUND: The impact of physiological adjustments throughout pregnancy on maternal vital signs and laboratory values has yet to be fully defined. The present study was designed to determine the normal range of these parameters among healthy pregnant women during the peripartum period. METHODS: This is a retrospective analysis of data collected during real-time deliveries in a single medical center. Vital signs and laboratory results from the 24 hours preceding delivery room admission and up to 72 hours postpartum were collected. Only pregnant women at term (37 to 41 weeks' gestation) with a liveborn, singleton gestation, and no chronic disease or obstetric complication that could affect the physiological parameters under study were included. The mean, range, and standard deviations of the extremes of all parameters at 3 distinct time points (prelabor, intrapartum, and postpartum) were calculated. The 2.5 and 97.5 percentiles for each parameter were reported as the normal range. RESULTS: A total of 32,161 cases fulfilled inclusion criteria. The average gestational age at delivery was 39 weeks ± 8 days, and one-third of the cases were primiparous. During labor and after delivery, the upper limits of normal blood pressure values were 147/94 and 145/94 mm Hg, respectively. The lower limits were 83/43 and 83/42 mm Hg, respectively. Normal heart rates were 60-115 beats/min prelabor, 51-120 beats/min intrapartum, and 50-120 beats/min postpartum. Lowest normal temperatures ranged between 36.0°C and 36.3°C in the 3 study time points, and highest normal temperatures were 37.2°C prelabor and 37.6°C intra- and postpartum. The normal ranges of white blood cell counts were 6.1-16.8 prelabor, 6.5-22.5 intrapartum, and 6.4-23.9 K/µL postpartum. Normal low values of hemoglobin were 9.7, 8.7, and 7.1 g/dL and of platelets were 117, 113, and 105 K/µL, respectively. CONCLUSIONS: Our findings justify the practice of using ≥2 repeated measurements for diagnosing hypertensive disorders of pregnancy. Lower normal blood pressure limits may be below those defining hypotensive shock. Normal heart rates exceed the accepted definitions of both tachy- and bradycardia. Normal temperatures at all times have a more narrow range than previously thought, and the normal range of white blood cell count has outliers exceeding the current definitions of leukocytosis or leukopenia at all times. The normal lower range of hemoglobin was constantly below 10 g/dL, and normal platelet counts were considerably lower than those previously described. The vital signs and complete blood count values thus far considered normal for the peripartum period may require some adjustment. New definitions for hypotension, tachy- and bradycardia, fever, and leukocyte quantitative disorders should be considered.

The Effect of Labor Epidural Analgesia on Breastfeeding Outcomes: A Prospective Observational Cohort Study in a Mixed-Parity Cohort.

BACKGROUND: The effect of labor epidural analgesia (LEA) on successful breastfeeding has been evaluated in several studies with divergent results. We hypothesized that LEA would not influence breastfeeding status 6 weeks postpartum in women who intended to breastfeed in an environment that encourages breastfeeding. METHODS: In this prospective observational cohort study, a total of 1204 women intending to breastfeed, delivering vaginally with or without LEA, were included; breastfeeding was recorded at 3 days and 6 weeks postpartum. Primary outcome was breastfeeding at 6 weeks, and the χ test was used for comparisons between women delivering with and without LEA, according to parity status and previous breastfeeding experience. Total epidural fentanyl dose and oxytocin use (yes/no) were recorded. A multivariable logistic regression was performed to assess factors affecting breastfeeding at 6 weeks. RESULTS: The overall breastfeeding rate at 6 weeks was 76.9%; it was significantly lower among women delivering with LEA (74.0%) compared with women delivering without LEA (83.4%; P < .001). Among 398 nulliparous women, 84.9% delivered with LEA, compared with 61.8% of multiparous women (P < .001). Multiparous women (N = 806) were more likely to breastfeed at 6 weeks (80.0% vs 70.6% nullipara; P < .001). Using multivariable logistic regression that accounted for 14 covariates including parity, and an interaction term between parity and LEA use, LEA was significantly associated with reduced breastfeeding at 6 weeks (odds ratio, 0.60; 95% confidence interval, 0.40-0.90; P = .015). In a modified multivariable logistic regression where parity was replaced with previous breastfeeding experience, both as a covariate and in the interaction term, only previous breastfeeding experience was associated with increased breastfeeding at 6 weeks (odds ratio, 3.17; 95% confidence interval, 1.72-5.80; P < .001). CONCLUSIONS: In our mixed-parity cohort, delivering with LEA was associated with reduced likelihood of breastfeeding at 6 weeks. However, integrating women's previous breastfeeding experience, the breastfeeding rate was not different between women delivering with and without LEA among the subset of multiparous women with previous breastfeeding experience. Therefore, our findings suggest that offering lactation support to the subset of women with no previous breastfeeding experience may be a simple approach to improve breastfeeding success. This concept subscribes to the notion that women at risk for an undesired outcome be offered tailored interventions with a personalized approach.

No longer rare diseases and obstetric anesthesia.

PURPOSE OF REVIEW: With new medical technologies and changing life styles, maternal demographics has changes and consequently older and sicker women are becoming pregnant.In this review, we present these different high-risk parturient populations, which were once considered rare for the practicing obstetric anesthesiologist. RECENT FINDINGS: With lifestyle and medical advances, older and sicker women are getting pregnant. Older women are more prone to pregnancy complications. Cancer survivors are becoming pregnant and more pregnant women are being diagnosed with cancer. Previous neurological and cardiac conditions considered not compatible with pregnancy are now seen more frequently. As the rate of obesity increases so does the rate of obstructive sleep apnea, which is known to be associated with many adverse maternal and neonatal sequalae. Finally, increased use of both opioids and marijuana has led to increased number of pregnant women using these illicit substances. SUMMARY: Future research and implementation of international guidelines for management of these high-risk parturient population is necessary in order to reduce maternal and neonatal morbidity.

The Relationship Between Women's Intention to Request a Labor Epidural Analgesia, Actually Delivering With Labor Epidural Analgesia, and Postpartum Depression at 6 Weeks: A Prospective Observational Study.

BACKGROUND: Postpartum depression (PPD) is associated with pain during and after delivery, with studies showing reduced rates among women delivering with labor epidural analgesia (LEA). We hypothesized that women who intend to deliver with LEA but do not receive it are at higher risk for PPD at 6 weeks due to the combined experience of untreated labor pain and unmatched expectations during labor, and evaluated the interaction between labor plans related to LEA, satisfaction with pain control when actually delivering with LEA, and PPD at 6 weeks after delivery. METHODS: A total of 1497 women with a vaginal delivery were enrolled into this prospective longitudinal study. Women's initial intention to deliver with or without LEA, how they subsequently delivered, and satisfaction with pain relief were recorded on postpartum day 1. Primary aim was selected as PPD at 6 weeks among women intending to deliver with but subsequently delivering without LEA compared with the rest of the cohort. Primary outcome was PPD at 6 weeks using the Edinburgh Postnatal Depression Scale; PPD was defined with a score ≥10 (scale from 0 to 30). Demographic and obstetric data were recorded. Fisher exact test was used for comparisons between groups. The interaction between intention and actual delivery with regard to LEA and PPD was tested. RESULTS: Overall, 87 of 1326 women completing the study at 6 weeks had PPD (6.6%). For the primary aim, 439 (29.3%) delivered without LEA, of which 193 (12.9%) had intended to deliver with LEA; the PPD rate among these women was 8.1%, which was not statistically different from the rest of the cohort (6.3%; odds ratio [OR], 1.30; 95% confidence interval [CI], 0.72-2.38; P = .41). A total of 1058 women (70.7%) delivered with LEA and 439 (29.3%) delivered without; therefore, 1169 (78.1%) delivered as intended and 328 (21.9%) did not (unmatched expectations). Evaluating the interaction between effects, there was a strong negative additive interaction between intending to deliver without LEA and actually delivering with LEA (risk difference = -8.6%, 95% CI, 16.2%-1.6%; P = .014) suggesting that unmatched intention effect is significantly associated with negative outcome. In multiple regression analysis, while intending to deliver with LEA (OR, 1.06; 95% CI, 1.01-1.11; P = .029) and actually delivering with LEA (OR, 1.07; 95% CI, 1.01-1.13; P = .018) both increased the odds for PPD, the multiplicative interaction was protective (OR, 0.92; 95% CI, 0.86-0.99; P = .022), after adjusting for cofactors. CONCLUSIONS: Our study results did not demonstrate a significant increase in the odds for PPD at 6 weeks among women who intended to deliver with LEA but subsequently delivered without. However, we identified a protective interaction between intended LEA use and actual use on the incidence of PPD. Our data suggest an increased risk when women do not deliver as intended, particularly when not initially intending to deliver with LEA. The relationship between unplanned LEA and PPD may be mediated by a physically difficult delivery rather than or in addition to negative emotions related to unmet expectations or a sense of personal failure; therefore, counseling women after delivery to address any negative perceptions may be useful.

Anesthetic approach to postdural puncture headache in the peripartum period: An Israeli national survey.

BACKGROUND: Accidental dural puncture frequency among pregnant women is about 1.5%, while approximately 60% of these women will suffer from post-dural puncture headache (PDPH) that may be debilitating. METHODS: Following IRB approval, we conducted a national survey of the lead anesthesiologist in 23 labor and delivery rooms in Israel. Each survey inquired about medical center annual delivery volume, training program for residents, accidental dural puncture management, processing of information, and PDPH management strategies. RESULTS: Data were collected from all 23 surveyed hospitals. As for methods for PDPH prevention, in most hospitals (87%) a prophylactic epidural blood patch (EBP) is not considered. Injection of epidural normal saline after delivery as a preventive measure is never considered in most (78.3%) hospitals, while four (17.4%) hospitals reported of constitutive use of this technique and one hospital only occasionally. Duration of conservative treatment was 24-48 hours in 95.7% of PDPH cases. CONCLUSION: In this survey, different aspects of treatment and PDPH management were examined. EBP is considered the gold standard in treating PDPH, although prophylactic blood patch is ineffective. We observed a tendency of very low performance of both prophylactic EBP and epidural normal saline administration after delivery in most centers. Most hospitals perform EBP after 24-48 hours of conservative treatment, along with published recommendations that show increased EBP efficiency with this timeframe. In light of the survey information, we aim to reach a uniform literature-based management strategy across Israeli hospitals.

The impact of epidural analgesia on the duration of the second stage of labor.

BACKGROUND: We aimed to describe the length of second stage of labor in a contemporary cohort. We calculated the 5th, 50th, and 95th percentiles for second-stage length stratified by parity and epidural analgesia use and evaluated the effect of labor induction and oxytocin augmentation in our cohort. METHODS: We did a retrospective analysis of all live, singleton, term vaginal deliveries in one tertiary hospital. Multivariate linear regression was used to evaluate second-stage duration confounders. First, we calculated the second-stage length and presented it as 5th, 50th, and 95th percentiles stratified by epidural analgesia and parity. Second, we evaluated the effect of labor induction and oxytocin augmentation on second-stage length, and third, we determined the demographic and obstetrical confounders that affected second-stage length. RESULTS: Overall, 15 500 deliveries were included. Nulliparity, oxytocin augmentation, epidural use, birthweight, labor induction, lower body mass index, and higher maternal age were found to be significantly associated with prolongation of the second stage. Epidural use was associated with an additional 82 minutes for the 95th percentile for both nulliparas and multiparas and tripled the rate of prolonged second stage for the entire cohort. Labor induction was associated with clinically significant prolongation of the second stage in nulliparas with epidural analgesia only. Oxytocin was associated with longer duration of the second stage for nulliparas, regardless of epidural use. DISCUSSION: Our findings suggest a significant prolongation of the second stage in women receiving epidural analgesia. Recommendations for management of second stage should be reconsidered by contemporary data.

The Hemodynamics of Labor in Women Undergoing Vaginal and Cesarean Deliveries as Determined by Whole Body Bioimpedance.

OBJECTIVE: The objective of this study was to assess the hemodynamics of labor, delivery, and 48 hours postpartum in women undergoing vaginal and cesarean deliveries by utilizing a whole body bioimpedance-based device. MATERIALS AND METHODS: A prospective longitudinal single-center observational study was performed between September 2014 and September 2015. The hemodynamics of low-risk women undergoing spontaneous vaginal delivery were compared with those undergoing elective cesarean sections. Cardiac index (CI), stroke index, total peripheral resistance index (TPRI), and mean arterial pressure (MAP) were assessed at different time points during delivery and in the immediate postpartum period (1, 24, and 48 hours postpartum). RESULTS: Eighty-seven women were evaluated, 63 parturients in the vaginal delivery group and 24 in the cesarean delivery group. Normal vaginal delivery was characterized by a reduction in MAP and CI after epidural anesthesia, whereas elective cesarean sections were characterized by a rise in MAP and CI after spinal anesthesia. As labor progressed, CI increased reaching its peak during the second stage. Immediately following delivery, TPRI declined to its nadir with no significant change in CI. As opposed to vaginal delivery, in cesarean delivery, TPRI peaked within 1-hour postpartum resulting in a significant decline in CI. CONCLUSION: Whole body bioimpedance can be used effectively to assess the hemodynamics of vaginal and cesarean deliveries.

Birthweight thresholds for increased risk for maternal and neonatal morbidity following vaginal delivery: a retrospective study.

PURPOSE: To determine neonatal birthweight (BW) thresholds for adverse maternal and neonatal outcome following vaginal delivery. METHODS: A retrospective cohort study of all women with singleton pregnancies who underwent vaginal delivery in a university-affiliated tertiary hospital (1996-2015). The association between BW and adverse outcome in neonates with BW ≥ 3500 g (> 90th centile BW at 37 weeks' gestation) with 100 g-increment groups was explored. Pregnancies complicated by diabetes mellitus, fetal anomalies or cesarean deliveries were excluded. The composite neonatal outcome was defined as shoulder dystocia or brachial plexus injury. The composite maternal outcome was defined as postpartum hemorrhage or third- or fourth-degree perineal tears. RESULTS: Of the 121,728 deliveries during the study period, 26,920 (22.1%) met inclusion criteria. Of these, 1024 (3.8%) had a composite adverse maternal outcome and 947 (3.5%) had a composite adverse neonatal outcome. The rates of composite maternal outcomes increased significantly only at a BW of 4800 g and above. The composite neonatal outcomes increased significantly only at a BW of 4400 g and above. In multivariate analysis, after subcategorizing our cohort into 3 BW groups [3500-3999 g (control, n = 23,030); 4000-4399 g (n = 3494); ≥ 4400 g (n = 396)], BW was associated with adverse neonatal outcomes in a dose-dependent manner. In the BW ≥ 4400 g group, to prevent one case of shoulder dystocia or Erb's palsy, 12 cesarean deliveries needed to be performed. CONCLUSION: For non-diabetic mothers who deliver vaginally, neonatal BW ≥ 4400 g was associated with a significant increase in adverse neonatal outcomes, whereas neonatal BW ≥ 4800 g was associated with a significant increase in adverse maternal outcomes.