A qualitative analysis of parturients' experiences using nitrous oxide for labor analgesia: It is not just about pain relief.

BACKGROUND: A vast majority of women who choose nitrous oxide for labor report high satisfaction despite variable analgesic effectiveness. We analyzed comments provided by women who used nitrous oxide for labor, to identify determinants of satisfaction in this population, and to better understand reasons for continuing with nitrous oxide despite variable analgesic effectiveness. METHODS: We conducted qualitative content analysis of comments in a quality improvement database of routine follow-up assessments of women who delivered vaginally, using nitrous oxide as the sole labor analgesic. An inductive grounded approach was used and emergent themes and subthemes were identified. RESULTS: Of 6507 vaginal deliveries over 34 months in 2011-2014, 753 (12%) used nitrous oxide as their sole analgesic. Analysis of 264 clarifying comments yielded six emergent themes. Parturients cited nonanalgesic benefits of nitrous oxide use (relaxation, distraction, focus on breathing), as well as partial analgesic effects that they deemed to be sufficient, or consistent with their expectations. Numerous women described their nitrous oxide experience as consistent with their birth plan, including 14 who equated it with natural childbirth. Several comments described nitrous oxide as a vital component of the parturients' birth experience. Some described using nitrous oxide when neuraxial analgesia was not possible. Side effects were identified, as were difficulties using the apparatus/mask. Analysis highlighted importance of timely administration upon request and attention to technical aspects. CONCLUSIONS: Among parturients who choose nitrous oxide as their sole labor analgesic, determinants of satisfaction are more variable than previously understood, and extend beyond analgesia.

Nitrous Oxide During Labor: Maternal Satisfaction Does Not Depend Exclusively on Analgesic Effectiveness.

BACKGROUND: Evidence on the analgesic effectiveness of nitrous oxide for labor pain is limited. Even fewer studies have looked at patient satisfaction. Although nitrous oxide appears less effective than neuraxial analgesia, it is unclear whether labor analgesic effectiveness is the most important factor in patient satisfaction. We sought to compare the relationship between analgesic effectiveness and patient satisfaction with analgesia in women who delivered vaginally using nitrous oxide, neuraxial analgesia (epidural or combined spinal-epidural [CSE]), or both (neuraxial after a trial of nitrous oxide). METHODS: A standardized survey was recorded on the first postpartum day for all women who received anesthetic care for labor and delivery. Data were queried for women who delivered vaginally with nitrous oxide and/or neuraxial labor analgesia over a 34-month period in 2011 to 2014. Parturients with complete data for analgesia quality and patient satisfaction were included. Analgesia and satisfaction scores were grouped into 8 to 10 high, 5 to 7 intermediate, and 0 to 4 low. These scores were compared with the use of ordinal logistic regression across 3 groups: nitrous oxide alone, epidural or CSE alone, or nitrous oxide followed by neuraxial (epidural or CSE) analgesia. RESULTS: A total of 6507 women received anesthesia care and delivered vaginally. Complete data were available for 6242 (96%) women; 5261 (81%) chose neuraxial analgesia and 1246 (19%) chose nitrous oxide. Of the latter, 753 (60%) went on to deliver with nitrous oxide alone, and 493 (40%) switched to neuraxial analgesia. Most parturients who received neuraxial analgesia (>90%) reported high analgesic effectiveness. Those who used nitrous oxide alone experienced variable analgesic effectiveness, with only one-half reporting high effectiveness. Among all women who reported poor analgesia effectiveness (0-4; n = 257), those who received nitrous oxide alone were more likely to report high satisfaction (8-10) than women who received epidural analgesia alone (OR 2.5; 95% CI 1.4-4.5; P = .002). Women who reported moderate analgesia (5-7) and received nitrous oxide only were more likely to report high satisfaction compared with the other groups. Among women who reported a high level of analgesic effectiveness, satisfaction with anesthesia was high and not different among groups. CONCLUSIONS: Patients who received nitrous oxide alone were as likely to express satisfaction with anesthesia care as those who received neuraxial analgesia, even though they were less likely to report excellent analgesia. Although pain relief contributes to the satisfaction with labor analgesia care, our results suggest that analgesia is not the only contributor to maternal satisfaction.

Recent advances of simulation in obstetric anesthesia.

PURPOSE OF REVIEW: Simulation training in obstetric anesthesia has become widespread in recent years. Simulations are used to train staff and trainees, assess and improve team performance, and evaluate the work environment. This review summarizes current research in these categories. RECENT FINDINGS: Simulation to improve individual technical skills has focused on induction of general anesthesia for emergent cesarean delivery, an infrequently encountered scenario by anesthesia trainees. Low- and high-fidelity simulation devices for the learning and practicing neuraxial and non-neuraxial procedures have been described, and both are equally effective. The use of checklists in obstetric emergencies has become common as and post-scenario debriefing techniques have improved. Although participant task performance improves, whether participants retain learned skills or whether simulation improves patient outcomes has not yet been established. Tools to assess teamwork during simulation have been developed, but none have been rigorously validated. In-situ vs. offsite simulations do not differ in effectiveness. SUMMARY: Simulation allows for practice of tasks and teamwork in a controlled manner. There is little data whether simulation improves patient outcomes and metrics to predict the long-term retention of skills by simulation participants have not been developed.

The Effects of Vasopressin and Oxytocin on the Fetoplacental Distal Stem Arteriolar Vascular Resistance of the Dual-Perfused, Single, Isolated, Human Placental Cotyledon.

BACKGROUND: Vasoactive agents administered to counter maternal hypotension at cesarean delivery may theoretically intensify the hypoxemic fetoplacental vasoconstrictor response and, hence, negatively impact transplacental oxygen delivery to the fetus. Yet, this aspect of their pharmacodynamic profiles is seldom mentioned, let alone investigated. We hypothesized that vasopressin, a potent systemic vasoconstrictor, and oxytocin, a uterotonic agent administered routinely at cesarean delivery, which, in contrast to vasopressin, possesses significant systemic vasodilator properties, would not influence distal stem villous arteriolar resistance. METHODS: The dual-perfused, single, isolated cotyledon, human placental perfusion model was used to examine the resistance response of the fetoplacental circulation to oxytocin and vasopressin in placentae harvested from healthy women. Twelve of a total of 17 individual experiments were conducted successfully during which either oxytocin (n = 6) or vasopressin (n = 6) was introduced into the fetal reservoir in concentration increments of 10 M. Fetoplacental distal stem villous arteriolar perfusion pressure (FAP) was measured continuously. The fetal circuit concentration of either oxytocin or vasopressin was raised in a stepwise fashion from 10 to 10 M or 10 to 10 M, respectively. Both reservoirs were then purged of drug, after which 1-mL 1.0 mM 5-hydroxytryptamine (2.5 µM), an agent well known to manifestly increase fetoplacental distal stem villous arteriolar resistance, was introduced into the fetal circuit. A significant increase in FAP from baseline in response to exposure to 5-hydroxytryptamine confirmed that the fetoplacental vasoconstrictor response remained reactive. The primary outcome of this study was changes in FAP after incremental dosing of vasopressin and oxytocin. RESULTS: No changes in FAP were observed with either oxytocin or vasopressin regardless of the drug concentration tested. For each drug and concentration, a mean pressure change greater than ±10 mm Hg was excluded with 95% confidence. In contrast, 5-hydroxytryptamine significantly increased perfusion pressure in all 12 successful experiments. CONCLUSIONS: Oxytocin and vasopressin do not influence human fetoplacental distal stem villous arteriolar resistance. The neutral impact of vasopressin noted here is thus analogous to the reported negligible influence of the drug on human pulmonary arteriolar resistance. Neither drug seems likely to adversely influence the compensatory hypoxemic fetoplacental vasoconstrictor response.

Imaging during pregnancy.

The use of imaging techniques in women who are pregnant has increased greatly over the past decade. This focused review discusses the risks and indications of ultrasonography, magnetic resonance imaging, computed tomographic scanning, and fluoroscopy for the evaluation of the parturient with non-obstetric disorders. Diagnostic imaging of the pregnant woman for the evaluation of disorders not related to pregnancy is evolving, and protocols will vary from institution to institution. The potential benefit from indicated diagnostic radiological procedures in the parturient nearly always outweighs risk to the fetus because radiation exposure from a single procedure conveys little fetal risk.

Post Partum Death in a Patient Diagnosed With COVID-19.

Background: There are few case reports describing maternal mortality and intensive care of the pregnant patient with COVID-19 infection. Case: A 27-year-old patient at 34 weeks of gestation was admitted for the evaluation of cough, fever, tachypnea, and oligohydramnios. The day of admission she underwent cesarean delivery for a non-reassuring fetal heart rate tracing. Over the next 6 days her clinical condition deteriorated, she developed multi organ system failure, and died despite aggressive supportive care. Conclusion: Although mortality related to COVID-19 in pregnancy has been rarely reported to date, we describe a case of progressive clinical deterioration postpartum despite aggressive supportive care. Management strategies specific for pregnant women have not been developed. In timing delivery, the obstetrician must consider the possibility that the inflammatory response associated with CD may increase the risk for multiorgan system failure in parturients with COVID-19 while recognizing that risks to the fetus may be higher in patients with COVID-19 than in other critically ill parturients. Vertical transmission of infection to the neonate did not occur in our case and has not been demonstrated in other pregnancies with COVID-19 disease.

Spinal Cord Trauma During Subarachnoid Anesthesia for Cesarean Delivery: A Case Report.

Spinal cord trauma can occur during subarachnoid blockade and can result in significant morbidity for the patient. Careful attention to lumbar insertion level is essential to prevent injury.

A Survey of Enhanced Recovery After Surgery Protocols for Cesarean Delivery in Serbia.

Enhanced recovery after surgery (ERAS) protocols have been described for patients undergoing colon surgery. Similar protocols for cesarean delivery (CD) have been developed recently. CD is one of the most commonly performed surgical procedures, and adoption of ERAS protocols following CD might benefit patients and the health-care system. We aimed to determine which Serbian hospitals reported ERAS protocols, which elements of ERAS protocols were used in CD patients, and whether ERAS and non-ERAS hospitals differed. The survey was sent to all hospitals with obstetric services and 46 of 49 responded. The questionnaire asked whether ERAS protocols had been formally adopted for surgical patients and about their use in CD patients. Specific questions on elements described in other obstetric ERAS protocols for CD included preoperative patient preparation, type of anesthesia and temperature monitoring used for CD, maternal/neonatal contact, and time to discharge. ERAS protocols are used in 24% of surveyed hospitals, 84% admit the patient the day before elective CDs, 87% use a maternal bowel preparation morning on the day of CD, and 80% administer maternal deep venous thrombosis prophylaxis. Only 33% remove IV in the first postoperative day, and 89% of women do not eat solid food until the day following their CD. Neuraxial anesthesia is used in 46% of elective CDs in ERAS hospitals compared to 9% in non-ERAS hospitals (P < 0.01), and neuraxial narcotics for post CD analgesia are given more often in ERAS hospitals. Thirty-six percentage of ERAS patients are discharged within 3 days vs. none in the non-ERAS group. Few elements of ERAS protocols reported from other centers outside Serbia are employed in Serbian hospitals performing CD. Despite significant changes that have been made recently in CD care, enhanced recovery after CD could be significantly improved in Serbian hospitals.

Should Nitrous Oxide Be Used for Laboring Patients?

Nitrous oxide, long used during labor in Europe, is gaining popularity in the United States. It offers many beneficial attributes, with few drawbacks. Cost, safety, and side effect profiles are favorable. Analgesic effectiveness is highly variable, yet maternal satisfaction is often high among the women who choose to use it. Despite being less effective in treating labor pain than neuraxial analgesic modalities, nitrous oxide serves the needs and preferences of a subset of laboring parturients. Nitrous oxide should, therefore, be considered for inclusion in the repertoire of modalities used to alleviate pain and facilitate effective coping during labor.

Continuous Spinal Anesthesia for Obstetric Anesthesia and Analgesia.

The widespread use of continuous spinal anesthesia (CSA) in obstetrics has been slow because of the high risk for post-dural puncture headache (PDPH) associated with epidural needles and catheters. New advances in equipment and technique have not significantly overcome this disadvantage. However, CSA offers an alternative to epidural anesthesia in morbidly obese women, women with severe cardiac disease, and patients with prior spinal surgery. It should be strongly considered in parturients who receive an accidental dural puncture with a large bore needle, on the basis of recent work suggesting significant reduction in PDPH when intrathecal catheters are used. Small doses of drug can be administered and extension of labor analgesia for emergency cesarean delivery may occur more rapidly compared to continuous epidural techniques.

Increasing Regional Anesthesia Use in a Serbian Teaching Hospital through an International Collaboration.

Many low- and middle-income countries (LMICs) report low rates of regional anesthesia (RA) use for cesarean delivery (CD), despite its association with lower maternal major morbidity and mortality. Also, the prevalence of neuraxial analgesia for labor (NAL) is often low in LMICs. We report on the results of a collaboration in clinical education over a multi-year period between Kybele Inc., an international non-profit organization, and Klinicki Centar Vojvodine (CCV), a teaching hospital in Novi Sad, Serbia, to increase RA use for CD and NAL at CCV. From late 2011 through 2015, teams from Kybele participated in annual to biannual didactic conferences and week-long bedside teaching efforts involving obstetric and anesthesia staff from CCV and surrounding hospitals. Ongoing contact occurred at least weekly between Kybele and the host to discuss progress. De-identified quality improvement data on total deliveries, numbers of elective and non-elective CDs, number of vaginal deliveries, type of anesthesia for CD, and the number of NALs were collected. RA use for CD increased to 25% in year 2015 versus 14% in base year 2011 [odds ratio (OR): 2.05; 95% confidence interval (CI): 1.73,2.42; p < 0.001]. NAL increased to 10.5% of laboring women in 2015 versus 1.2% in 2011 (OR: 9.6; 95% CI: 7.2, 12.8; p < 0.001). Greater increases for RA use during non-elective CD were observed between 2011 and 2015 (1.4 versus 7.5% of total CD; OR: 5.52; 95% CI: 2.63, 8.41; p < 0.001) relative to elective CD (12.5 versus 17.5% of total CD; OR: 1.48; 95% CI: 1.23, 1.77; p < 0.001). Overall, RA for CD increased during the 4 year collaboration but was not as great as reported in other countries with similar health-care demographics utilizing a similar program. Detailed descriptions of program interventions and barriers to change at CCV are presented.

Review: Potential druggable targets for the treatment of early onset preeclampsia.

Placental delivery is the only known cure for early onset preeclampsia, a major cause of maternal and neonatal morbidity and mortality worldwide. Prolonging pregnancy beyond 25weeks without undue maternal risk favors fetal survival, improves neonatal outcome and saves money. In vitro experiments using human placental tissue and in vivo studies employing "preeclamptic" animal models reveal the presence of likely druggable targets, especially within the maladapted intracellular nucleotide transduction pathways of preeclampsia. This review focuses on some novel pharmacological treatment options targeting early onset severe preeclampsia. Human and animal derived experimental data support the possible roles of nitric oxide donors (glyceryltrinitrate), aspirin, dietary supplements (calcium, l-Arginine, anti-oxidant vitamins), phosphodiesterase-5 inhibitors, statins, carbon monoxide and most recently, hydrogen sulfide. Extension of pregnancy or improvement of the disorder using means applicable in under resourced areas of the world would have a major positive impact on women's health globally. We therefore advocate the immediate launch of clinical trials testing simple innovative therapies in large obstetric units of developing countries such as South Africa or Brazil where preeclampsia is endemic and a regular killer of both mothers and offspring.

Maintaining perioperative normothermia in the patient undergoing cesarean delivery.

Anesthesia and surgery interfere with normal thermoregulation, and nearly all patients will become hypothermic unless compensatory measures are used. Preoperative patient warming and intraoperative methods using forced air and warmed intravenous fluids are important methods for maintaining patient's core temperature during the perioperative period. The benefits of maintaining normothermia include reductions in postoperative wound infection, the risk of perioperative coagulopathy, and myocardial ischemia. These advantages, demonstrated in patients undergoing general surgery, would be expected in patients undergoing gynecological surgery but have not been specifically studied in that population. Few studies have examined the maternal and neonatal effects of hypothermia after cesarean delivery. The results conflict as to the effectiveness of maternal warming techniques used to prevent it and the effects on neonatal temperature and acid-base status at delivery. Large prospective studies will be required to show significant effects on rates of maternal wound infection after cesarean delivery. European and American national obstetrical organizations have not published recommendations regarding the perioperative thermal regulation for cesarean delivery. We review the physiology of thermal regulation and perioperative thermal management in surgical patients and the literature that has examined perioperative maternal warming for cesarean delivery.

Nitrous oxide for labor analgesia: expanding analgesic options for women in the United States.

Nitrous oxide (N2O) is a commonly used labor analgesic in many Western countries, but is used infrequently in the United States. The University of California at San Francisco has been offering N2O for labor analgesia for more than 30 years. Vanderbilt University Medical Center recently began offering N2O as an option for pain relief in laboring women. Many women report that N2O provides effective pain relief during labor and argue that it should be made more widely available in the United States. This article discusses the use of N2O for pain management during labor, including its history, properties, clinical indications, and use and environmental safety issues. Practical issues regarding implementation of N2O service in a medical center setting are also discussed.

The management of accidental dural puncture and postdural puncture headache: a North American survey.

STUDY OBJECTIVE: To evaluate the management of accidental dural puncture (ADP) and postdural puncture headache (PDPH) among obstetric anesthesiologists practicing in North America. DESIGN: Questionnaire survey of individual members of the Society for Obstetric Anesthesia and Perinatology (SOAP). SETTING: University hospital. MEASUREMENTS: In June 2008, a 4-part, 83-item electronic survey was distributed to all North American members of SOAP. It contained questions about respondent demographics, epidural catheter and intrathecal catheter management after ADP, PDPH management, epidural blood patch (EBP) management, and patient follow-up. MAIN RESULTS: Of the 843 United States and Canadian members of SOAP who were surveyed, 160 responses were collected. Respondents reported placing an epidural 75% of the time and an intrathecal catheter 25% of the time following ADP. Common prophylactic and conservative treatment strategies included hydration, caffeine, and opioids by mouth; 76% of respondents leave an intrathecal catheter in place for 24 hours to reduce the frequency of headache. Epidural blood patches are placed by 81% of practitioners less than 24 hours after headache onset. CONCLUSIONS: Protocols for ADP management are rare. There is wide variation in catheter management after dural puncture, measures used to prevent and treat a resultant headache, and EBP management.