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Editor's Choice Articles
Global obstetric anaesthesia: bridging the gap in maternal health care inequities through partnership in education
The risk of death during, or as a result of, pregnancy remains unacceptably high. The Global Burden of Disease study reported that, in 2015, across 195 countries more than a quarter of a million women died during or after pregnancy, mostly from preventable or treatable causes.1 The majority of maternal deaths continue to occur in low- and middle-income countries (LMICs), with 415 maternal deaths per 100 000 live births in these regions compared with 7–10 maternal deaths per 100 000 live births in Europe, Australia and New Zealand.Clinical and ultrasonographic assessment of airway indices among non-pregnant, normotensive pregnant and pre-eclamptic patients: a prospective observational study
The first step in airway management is the assessment of various airway indices. This is particularly important in obstetric anaesthesia because failed airway management is one of the leading causes of maternal morbidity and mortality.1 Various anatomical and physiological factors place pregnant females at greater risk of airway management complications and difficult intubation.2 Hypertensive conditions of pregnancy are associated with aggravated changes in the airway, including a narrower upper airway compared with healthy pregnant females.Evaluation of ultrasound airway assessment parameters in pregnant patients and their comparison with that of non-pregnant women: a prospective cohort study
Encountering a difficult or failed tracheal intubation scenario is considered to be the most tarrying situation for all anesthesiologists, so attempts have been made to predict it. Expected or unexpected difficulty in managing the airway is more frequently encountered in emergencies, obstetric cases, and by inexperienced operators.1COVID-19 infection and maternal morbidity in critical care units in Scotland: a national cohort study
Risk factors for the development of severe COVID-19 disease such as multimorbidity, socio-economic deprivation, ethnicity and age, are well established.1,2 Ongoing research has also shown that, in comparison with non-pregnant women of reproductive age, pregnant women with COVID-19 are more likely to be admitted to critical care, receive invasive ventilation, and die.3,4 Despite this, the clinical course of pregnant and recently pregnant women admitted to critical care warrants further investigation, especially in relation to hospital outcomes and healthcare utilisation following hospital discharge.Investigating the use of non-loss of resistance syringes for epidural insertion: experience on a mannequin
The Obstetric Anaesthetists’ Association (OAA) has recently released a statement outlining the disruption to the supply of the Portex® Loss of Resistance (LOR) Syringe (Smiths Medical, UK) which is commonly used for epidural catheter insertion in our Trust and many Trusts around the country.1The incidence of breakthrough pain associated with programmed intermittent bolus volumes for labor epidural analgesia: a randomized controlled trial
Maintenance of epidural labor analgesia using programmed intermittent epidural bolus (PIEB) may be superior to continuous epidural infusion (CEI) analgesia in respects such as reducing the use of local anesthetic, improving the quality of analgesia, reducing motor block, and improving maternal satisfaction.1–4 In previous studies the incidence of breakthrough pain, defined as the woman complaining of pain or stress requiring supplemental treatment, was as high as 62.3%.5 Breakthrough pain may adversely affect the maternal labor experience.What is new in Obstetric Anesthesia in 2020: a focus on research priorities for maternal morbidity, mortality, and postpartum health
The annual Gerard W. Ostheimer lecture aims to update Society of Obstetric Anesthesia and Perinatology members on the relevant literature published in the preceding year. In this lecture, papers from the anesthesiology, obstetric, perinatology, neonatology, and health services literature published between January and December 2020 were evaluated and selected based on significance and relevance to clinicians and scientists. There were over 2000 articles in 90 medical journals that met this initial screening criteria for review.The role of total intravenous anaesthesia for caesarean delivery
Neuraxial anaesthesia is established as the preferred mode of anaesthesia in obstetrics, but general anaesthesia remains necessary in certain situations. It is estimated that 9% of women in the United Kingdom (UK) who have a caesarean delivery (CD) receive general anaesthesia, with the corresponding figure for the United States of America (USA) being 5.8%.1,2 Obstetric general anaesthesia usually entails intravenous anaesthetic induction, a neuromuscular blocking drug, cricoid pressure, and intubation with volatile anaesthetic maintenance.Cardiac ultrasonography in obstetrics: a necessary skill for the present and future anesthesiologist
In high-income countries, cardiovascular disease is the leading cause of maternal death,1 and the incidence of postpartum hemorrhage continues to increase.2 Point-of-care ultrasonography (POCUS) has emerged as a valuable tool in the assessment of high-risk obstetric patients and women who experience bleeding or other complications during childbirth. The increasing burden in morbidity and obstetric critical illness over recent decades has led anesthesia experts to advocate for the use of POCUS on all high-acuity obstetric units.The venous system during pregnancy. Part 2: clinical implications
A dynamic reservoir for blood volume, the venous system possesses a virtual point of conversion between unstressed volume (Vu) and stressed volume (Vs). Understanding the physiologic implications of this conversion during pregnancy, particularly as it relates to the maternal and fetal consequences of hypotension (e.g. supine and neuraxial technique-induced), hypertension (e.g. preeclampsia), and fluid administration (e.g. early recovery after cesarean delivery protocols), provides opportunities to understand and develop clinical options (Table 1).The effect of two groups of intrathecal fentanyl doses on analgesic outcomes and adverse effects in parturients undergoing cesarean delivery: a systematic review and meta-analysis of randomized controlled trials with trial sequential analysis
Cesarean delivery (CD) is one of the most common surgical procedures worldwide,1 mainly performed under spinal anesthesia. The addition of intrathecal opioids to local anesthetics for spinal anesthesia helps improve analgesia in the intra-operative and postoperative periods.2 Intrathecal morphine is recognized as a gold standard to provide a prolonged duration of postoperative analgesia.3 However, the drug has a delayed onset of action and cannot provide intra-operative analgesia.4,5 Further, there is limited availability of preservative-free morphine in developing countries, so it is common to use short-acting intrathecal opioids like fentanyl instead of morphine to enhance peri-operative analgesia after CD.General anesthesia for cesarean delivery and childhood neurodevelopmental and perinatal outcomes: a secondary analysis of a randomized controlled trial
Approximately 7% of all cesarean deliveries and 18% of preterm cesarean deliveries in the USA require the use of general anesthesia, with earlier gestational age being associated with a greater use of general anesthesia.1,2 In 2016, the U.S. Food and Drug Administration (FDA) released a statement expressing concern that pediatric neurodevelopment may be affected negatively by exposure to anesthesia or sedation in the third trimester of pregnancy or before three years of age.3 The FDA acknowledged that a single, short exposure may not have an effect, but the report called for research to characterize the impact of exposure to general anesthesia on neurodevelopment.Prediction of breakthrough pain during labour neuraxial analgesia: comparison of machine learning and multivariable regression approaches
Epidural analgesia has excellent clinical efficacy and safety and is the gold standard for labour pain relief.1 However, effective analgesia is dependent on the interplay of obstetric factors, anaesthetic variables, and labour progression. Hence, an estimated 0.9%–25%2–6 of parturients experience breakthrough pain,2 with an adverse impact on satisfaction and healthcare workload. Accurate a priori identification of parturients at risk for breakthrough pain would facilitate individualised risk-counselling and optimisation of labour analgesia.Enhanced Recovery After Cesarean (ERAC) – beyond the pain scores
Enhanced recovery protocols aim to optimize patient outcomes by modifying the inflammatory and metabolic changes associated with surgery. Multimodal evidence-based interventions that may reduce the surgical stress response have been organized into a specific care pathway which can shorten the recovery period and reduce peri-operative complications.1 More than 20 years ago, Henrik Kehlet, a pioneer in peri-operative pathophysiology and rehabilitation, initiated the first enhanced recovery protocol for colorectal surgery.Baseline parameters for rotational thromboelastometry (ROTEM®) in healthy pregnant Australian women: a comparison of labouring and non-labouring women at term
Rotational thromboelastometry (ROTEM®; Instrumentation Laboratory™, Munich, Germany) is a point-of-care visco-elastic test of coagulation that is well established in hepatic and cardiac surgery, obstetrics and trauma.1,2 Women become more hypercoagulable as pregnancy progresses through the three trimesters and this has been measured by both thromboelastography and rotational thromboelastometry in uncomplicated pregnancies.3 To date there has been a paucity of substantial, well-researched reference ranges for ROTEM® in pregnant labouring and non-labouring women.Rescue supraglottic airway devices at caesarean delivery: What are the options to consider?
The rate of caesarean delivery (CD) has tripled in the last three decades.1 Most CDs are performed under regional anaesthesia because of its various advantages: better parental experience associated with the delivery; avoidance of exposure to general anaesthetic agents that have a risk of causing anaphylaxis and uterine atony; avoidance of intra-operative awareness; and reduced mortality.2 Importantly, regional anaesthesia avoids or minimizes the risks of airway management and its associated complications such as failed intubation, oesophageal intubation and aspiration.Reducing post-caesarean delivery surgical site infections: a narrative review
Infectious complications following labour and delivery are common and can be caused by infection of a surgical incision, endometritis, mastitis, urinary tract infection, pneumonia or drug-induced high temperatures.1 The frequency of infectious complications depends on the mode of delivery, with surgical incision infection most common following caesarean delivery and mastitis most common following vaginal delivery.2 The United States (US) Centers for Disease Control and Prevention (CDC) provide definitions of surgical site infection (SSI) for a wide range of procedures.Carbetocin reduces the need for additional uterotonics in elective caesarean delivery: a systematic review, meta-analysis and trial sequential analysis of randomised controlled trials
Primary postpartum haemorrhage (PPH) is a major cause of morbidity and the leading cause of direct maternal death worldwide,1 with uterine atony accounting for approximately 70% of cases.2 Oxytocin is the most commonly used uterotonic in the developed world, with recent Cochrane reviews showing that it is effective for treating PPH.3,4 However, failure of PPH prophylaxis with oxytocin, as shown by the need for a rescue uterotonic, has been demonstrated to be as high as 13% in women having an elective caesarean delivery (CD).Induction opioids for caesarean section under general anaesthesia: a systematic review and meta-analysis of randomised controlled trials
Caesarean section (CS) under general anaesthesia (GA) is commonly performed due to surgical urgency, inadequate previous block, maternal refusal or contraindication to neuraxial anaesthesia.1 The induction of general anaesthesia and initial surgical incisions cause significant sympathetic drive which may result in adverse effects, for example intracranial haemorrhage in the context of comorbidities such as pre-eclampsia.2–5 For this reason sympatholysis is often required on induction of GA and initiation of CS.
