Where there is no anaesthetist: the role of obstetrician - administered spinal anaesthesia for emergency caesarean section

Context: Shortage of anaesthetic manpower is a stark reality in developing countries like Nigeria where “waiting for the anaesthetist” has been repeatedly identified as a cause of phase 3 delays. This has led to widespread abuse of ketamine anaesthesia for emergency caesarean section in private hospital settings.Objectives: To determine the effect of single handed obstetrician-anesthetist administered spinal anesthesia for caesarean section on Decision-Delivery Interval (DDI), postoperative hospital stay, fetal and maternal outcome.Materials and Methods: A prospective analytical study comparing caesarean DDI between 42 consecutive emergency caesarean sections (CS) under Obstetrician-administered Spinal anesthesia (OASA) versus 42 women who had locum anesthetist administered spinal anesthesia (LAASA) and an equal number who had ketamine anesthesia.Results: The DDI was about 2.5 fold shorter in the OASA (59.67 ± 9.40 minutes) compared with the LAASA (144.54 ± 28.00 minutes) group (pConclusion: Obstetrician-administered Spinal Anesthesia for emergency caesarean section reduces Decision-Delivery Interval and postoperative hospital stay. It is therefore judicious where there is no anesthetist. Moreover, it is superior to ketamine anesthesia for caesarean section.Keywords: Obstetric anaesthesia, Spinal anaesthesia, Caesarean section, Bupivacaine, KetamineTrop J Obstet Gynaecol, 30 (1), April 201

Birth outcomes in a Swedish population of women reporting a history of violence including domestic violence during pregnancy: a longitudinal cohort study.

BACKGROUND:Victimisation of women is encountered in all countries across the world, it damages the mental and physical health of women. During pregnancy and the postpartum period, women are at a greater risk of experiencing violence from an intimate partner. The aim of this study was to explore childbirth outcomes in a Swedish population of women reporting a history of violence including domestic violence during pregnancy. METHODS:A longitudinal cohort design was used. In total, 1939 pregnant women ≥18 years were recruited to answer two questionnaires, both questionnaires were administered in the early and late stages of their pregnancy. The available dataset included birth records of 1694 mothers who gave birth between June 2012 and April 2014. Statistical analyses included descriptive statistics, T-test and bivariate logistic regression. RESULTS:Of 1694 mothers 38.7% (n = 656) reported a history of violence and 2% (n = 34) also experienced domestic violence during pregnancy. Women who were single, living apart from their partner, unemployed, smoked and faced financial distress were at a higher risk of experiencing violence (p = 0.001). They also had significant low scores on the SOC-scale and high EDS-scores ≥13 (p = 0.001) when compared to women without a history of violence (p = 0.001). Having a history of violence increased the woman's risk of undergoing a caesarean section (OR 1.33, 95% CI 1.02-1.70). A history of emotional abuse also significantly increased the risk of having a caesarean section irrespective of whether it was a planned or an emergency caesarean section (OR 1.50, 95% CI 1.09-2.06). Infants born to a mother who reported a history of violence, were at significant risk of being born premature < 37 weeks of gestation compared to infants born by mothers with no history of violence (p = 0,049). CONCLUSIONS:A history of violence and/or exclusively a history of emotional abuse has a negative impact on childbirth outcomes including caesarean section and premature birth. Therefore, early identification of a history of or ongoing violence is crucial to provide women with extra support which may have positive impact on her birth outcomes

Delivery as a traumatic event: prevalence, risk factors, screening & treatment

This review looks at the evidence for postnatal posttraumatic stress disorder (PTSD). Postnatal traumatic stress responses are divided into: appraisal of birth as traumatic, traumatic stress responses (severe symptoms of intrusions and avoidance that do not fulfil criteria for PTSD), and PTSD. Evidence is examined for the prevalence of these types of responses after birth, and for prenatal, perinatal, and postnatal vulnerability and risk factors. Screening tools that could be used are outlined and possible intervention and treatment approaches considered. Various conceptual and methodological issues are also raised. It is concluded that up to 10% of women have severe traumatic stress responses to birth although only 1-2% of women actually develop chronic postnatal PTSD. The limited research available suggests that a history of psychiatric problems, mode of delivery, and low support during labour put women at increased risk of postnatal PTSD, although there is unlikely to be a simple relationship between mode of delivery and traumatic stress responses. A model of the possible pathways between vulnerability/risk factors and postnatal PTSD is proposed. Current evidence suggests that brief cognitive-behavioural therapy (CBT) interventions should be used with women who have a severe traumatic stress response, and longer CBT interventions with women with postnatal PTSD. More research is needed to further explore and confirm prenatal, birth, and postnatal risk factors

The New Fetal Protection : The Wrong Answer to the Crisis of Inadequate Health Care for Women and Children

This article will expand upon the feminist critique by focusing on children\u27s health as well as the health and liberty interests of their mothers. In the first part of this article, I examine the legal and cultural underpinnings of “fetal protection” and explore its current manifestations. In the second part, I place “fetal protection” in a broader context, documenting the ways in which American law currently promotes fetal life, while simultaneously neglecting the lives and health of born children. The third part of the article offers concrete recommendations about how government, both state and federal, can actually achieve the goal of bringing healthy children into the world and enabling them to live healthy lives, paying particular attention to the problems of children who are born into domestic violence and/or poverty and are therefore at high risk for poor educational and health care outcomes. If we are to truly become a society in which “no child [is] left behind,” we must implement a comprehensive public health strategy to promote women\u27s and children\u27s health across the lifespan, not just during the few months in which women are pregnant

Caesarean section for non-medical reasons at term

Background: Caesarean section rates are progressively rising in many parts of the world. One suggested reason is increasing requests by women for caesarean section in the absence of clear medical indications, such as placenta praevia, HIV infection, contracted pelvis and, arguably, breech presentation or previous caesarean section. The reported benefits of planned caesarean section include greater safety for the baby, less pelvic floor trauma for the mother, avoidance of labour pain and convenience. The potential disadvantages, from observational studies, include increased risk of major morbidity or mortality for the mother, adverse psychological sequelae, and problems in subsequent pregnancies, including uterine scar rupture and greater risk of stillbirth and neonatal morbidity. An unbiased assessment of advantages and disadvantages would assist discussion of what has become a contentious issue in modern obstetrics. Objectives: To assess, from randomised trials, the effects on perinatal and maternal morbidity and mortality, and on maternal psychological morbidity, of planned caesarean delivery versus planned vaginal birth in women with no clear clinical indication for caesarean section. Search methods: We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (April 2009). Selection criteria: All comparisons of intention to perform caesarean section and intention for women to give birth vaginally; random allocation to treatment and control groups; adequate allocation concealment; women at term with single fetuses with cephalic presentations and no clear medical indication for caesarean section. Data collection and analysis: We identified no studies that met the inclusion criteria. Main results: There were no included trials. Authors' conclusions: There is no evidence from randomised controlled trials, upon which to base any practice recommendations regarding planned caesarean section for non-medical reasons at term. In the absence of trial data, there is an urgent need for a systematic review of observational studies and a synthesis of qualitative data to better assess the short- and long-term effects of caesarean section and vaginal birth

A comparative study of frequency of postnatal depression among subjects with normal and caesarean deliveries

Background: Prevalence of postnatal depression (PND) is 12-15%. Recent studies are equivocal about the earlier inference that PND is higher among caesarian than normal delivery. Objective: The aim of this study is to investigate the frequency of PND among the Indian women and the association between the mode of delivery and PND. Material and method: Fifty subjects each; having delivered normally and by caesarian section was chosen. All the women were within 3 months post delivery and could understand Kannada language. Those who consented were asked to complete the Edinburgh Postnatal Depression Scale (EPDS). Those found to have scores suggestive of depression on EPDS were assessed for depression according to ICD-10. The data was analyzed using paired t test and chi square test. Result and conclusion: Among Post caesarean subjects, depression was diagnosed in 20% (n=10) as compared to 16% (n=8) in subjects that delivered normally. However there was no significant difference in the frequency of depression among the two groups. Due to the small sample size the results cannot be generalized

A history of abuse and operative delivery - results from a European multi-country cohort study

Objective: The main aim of this study was to assess whether a history of abuse, reported during pregnancy, was associated with an operative delivery. Secondly, we assessed if the association varied according to the type of abuse and if the reported abuse had been experienced as a child or an adult. Design: The Bidens study, a cohort study in six European countries (Belgium, Iceland, Denmark, Estonia, Norway, and Sweden) recruited 6724 pregnant women attending routine antenatal care. History of abuse was assessed through questionnaire and linked to obstetric information from hospital records. The main outcome measure was operative delivery as a dichotomous variable, and categorized as an elective caesarean section (CS), or an operative vaginal birth, or an emergency CS. Non-obstetrically indicated were CSs performed on request or for psychological reasons without another medical reason. Binary and multinomial regression analysis were used to assess the associations. Results: Among 3308 primiparous women, sexual abuse as an adult (≥ 18 years) increased the risk of an elective CS, Adjusted Odds Ratio 2.12 (1.28-3.49), and the likelihood for a non-obstetrically indicated CS, OR 3.74 (1.24-11.24). Women expressing current suffering from the reported adult sexual abuse had the highest risk for an elective CS, AOR 4.07 (1.46-11.3). Neither physical abuse (in adulthood or childhood \u3c18 years), nor sexual abuse in childhood increased the risk of any operative delivery among primiparous women. Among 3416 multiparous women, neither sexual, nor emotional abuse was significantly associated with any kind of operative delivery, while physical abuse had an increased AOR for emergency CS of 1.51 (1.05-2.19). Conclusion: Sexual abuse as an adult increases the risk of an elective CS among women with no prior birth experience, in particular for non-obstetrical reasons. Among multiparous women, a history of physical abuse increases the risk of an emergency CS

'dis ɔhord' : one woman’s experience of confronting and understanding the lived experience of birth.

This paper is a collaborative piece written by a midwifery academic and an artist. It presents and interprets a number of mixed media art works created by Caroline Calonder in response to the traumatic birth of her son, and utilises findings derived from Lesley Kay’s doctoral study about birth and birth stories as a means of contextualising, understanding and interpreting the work (Kay et al 2017). In sharing elements of Caroline’s experience, the psychological harm it caused her, and the means she used (and continues to use) to understand, and come to terms with the experience, the paper highlights some of the distressing and harmful sequelae which can arise when a woman’s disembodied experience of birth is accepted as normal and mainstream. Furthermore, it emphasises the need for health care professionals to actively work towards safeguarding women’s emotional health, and the value of art as a means of confronting and recovering from birth trauma

Benefits of using intrathecal buprenorphine

Background: General anesthesia draws attention to the most commonly used modalities for post cesarean delivery pain relief in systemic administration of opioids, while the administration of small dose of intrathecal opioid during spinal anesthesia can be a possible alternative. The aim of this study was to evaluate the effects of buprenorphine on cesarean section prescribed intrathecally. Methods: This double blind randomized clinical trial study was conducted in patients for cesarean section under spinal anesthesia. The patients were randomly divided into case and control groups. Case group (208 patients) received 65-70 mg of 5% lidocaine plus 0.2 ml of buprenorphine while the same amount of 5% lidocaine diluted with 0.2 ml of normal saline was given to 234 cases in the control group. Hemodynamic changes and neonatal APGAR scores (Appearance, Pulse, Grimace, Activity, Respiration) were recorded. Pain score was recorded according to the visual analog scale. This study was registered in the Iranian Registry of clinical Trials; IRCT2013022112552N1. Results: The mean age of case and control groups was 24.4±5.38 and 26.84±5.42 years, respectively. Systolic blood pressure was not significantly different until the 45th minute but diastolic blood pressure showed a significant difference at the 15th and the 60th minutes (P<0.001). Heart rate changes were significantly different between cases and controls at the initial 5th, 15th and after 60th minutes (P<0.001). Pain-free period was significantly different between two groups (1.25 h versus 18.73 h) (P<0.001). Conclusion: The results show that prescription of intratechal buprenorphine prolongs the duration of analgesia without any significant considerable side effects