Obstetric Anesthesia

Maternal Dissatisfaction and Anesthesia Care

Maternal dissatisfaction was studied in this retrospective study after vaginal or Cesarean delivery.

Maternal dissatisfaction was associated with: pain intensity during the first stage of labour; pain intensity during the second stage of labour; postpartum pain intensity; delay > 15 min in providing epidural analgesia and postpartum headache, pruritus. Non‐Hispanic ethnicity was negatively associated with dissatisfaction. After caesarean delivery, the intensity of postpartum pain, headache and pruritus were linked to dissatisfaction. Hispanic ethnicity also had a negative relationship with dissatisfaction after caesarean delivery.

The lessons learnt should spur timely provision of analgesia at all phases of the delivery process and efforts to minimize and treat side effects.

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Metaraminol use during spinal anaesthesia for caesarean section

Phenylephrine has recently displaced Ephedrine as the pressor of choice for spinal induced hypotension during Cesarean Section. However an older agent makes a comeback in this study, although it has remained popular in some countries.

Conclusions:Metaraminol appears superior to ephedrine for the prevention of feto-maternal complications.

Metaraminol is associated with better umbilical arterial pH values than phenylephrine.

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Anaesthesia and sedation in breastfeeding women

The Association of Anaesthetists has provided a draft copy open for comment on the topic of breastfeeding and anesthesia/sedation.

In general, the conclusion is that only tiny amounts of most agents are present in breast milk and feeding can be resumed after anesthesia once the mother is awake and lucid. The practice of “pump and dump” is largely unnecessary. However this draft document looks at all commonly used agents in anesthesia and sedation and evidence is in some cases limited, and some agents may pose some degree of risk, like Oxycodone.

Single doses of most analgesics pose little risk but caution is advised with repeated doses.

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Neuraxial labour analgesia reduces risk of maternal depression at 2 years after childbirth

This prospective study suggests another potential advantage to neuraxial analgesia for vaginal delivery.

It concluded: “For nulliparous women with single-term cephalic pregnancy planning for vaginal delivery, the use of neuraxial analgesia during labour was associated with a reduced risk of maternal depression at 2 years after childbirth.”

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Major Neurologic Complications Associated With Postdural Puncture Headache in Obstetrics

Sometimes considered a nuisance, this study reminds us of the potential serious ramifications of accidental post-dural puncture headache (PDPH) during epidural placement in obstetrics.

The incidence of complications was not negligible in this retrospective review, including: composite of cerebral venous thrombosis and subdural hematoma, bacterial meningitis, depression, headache, and low back pain. PDPH and complications were identified during the delivery hospitalization and up to 1 year post-delivery. 

Early recognition and management is therefore important.

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International consensus statement on the use of uterotonic agents during caesarean section

This statement updates use of uterotonic agents. Traditionally Oxytocin has been used in higher then needed doses and this statement reiterates current expert opinion on the use of smaller titrated doses in most situations, especially in elective Cesarean.

They discuss the increasing use of Carbetocin as an alternative, which has the advantage of a longer half life thereby obviating the need for an infusion. Side effects are similar.

Second line agents are discussed also.

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Cesarean Delivery and Neuraxial Opioids

This consensus statement from SOAP specifically addresses the use of neuraxial Morphine in Cesarean delivery and looks st dosing, safety and monitoring.

It clearly favours the use of neuraxial Morphine as part of a multimodal analgesia regime and how the benefits and risks may be addressed using appropriate monitoring.

It should be reviewed by all who provide Obstetric anesthesia.

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Stillbirth linked to more childbirth complications

A commentary on a journal study showing life-threatening delivery complications are more than four times as common during and after a stillbirth than a live birth. Some of these complications are more than 10 times as likely with stillbirths, per this Stanford study.

Complications included sepsis and shock, renal failure and cardiac problems. Certain causes if stillbirth like infection or hypertensive diseases were strongly linked to delivery complications for the mother.

This highlights another area to continuously improve maternal care, California also previously making important quality strides in maternal care improvement.

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In utero exposure to antibiotics and risk of congenital malformations

This population based study compared 10 commonly prescribed antibiotics and compared first trimester exposure to a cohort exposed to either of four penicillins considered safe during pregnancy (ampicillin, pivampicillin, benzylpenicillin and phenoxymethylpenicillin.

No increased risk of congenital malformations was found between the two. Compared to non-exposed pregnancies, small increased risks for major malformations and cardiac malformations were apparent for pivmecillinam, sulfamethizole, and azithromycin.

The overall conclusions are somewhat reassuring.

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