Editor's Choice Articles
- 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.
- 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.
- 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.
- 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.
- 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.
- 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).
- 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.