Progress in analgesia for labor: focus on neuraxial blocks

Neuraxial analgesia is widely accepted as the most effective and the least depressant method of providing pain relief in labor. Over the last several decades neuraxial labor analgesia techniques and medications have progressed to the point now where they provide high quality pain relief with minimal side effects to both the mother and the fetus while maximizing the maternal autonomy possible for the parturient receiving neuraxial analgesia. The introduction of the combined spinal epidural technique for labor has allowed for the rapid onset of analgesia with minimal motor blockade, therefore allowing the comfortable parturient to ambulate. Patient-controlled epidural analgesia techniques have evolved to allow for more flexible analgesia that is tailored to the individual needs of the parturient and effective throughout the different phases of labor. Computer integrated systems have been studied to provide seamless analgesia from induction of neuraxial block to delivery. New adjuvant drugs that improve the effectiveness of neuraxial labor analgesia while decreasing the side effects that may occur due to high dose of a single drug are likely to be added to future labor analgesia practice. Bupivacaine still remains a popular choice of local anesthetic for labor analgesia. New local anesthetics with less cardiotoxicity have been introduced, but their cost effectiveness in the current labor analgesia practice has been questioned

Cardiac Output Assessed by Invasive and Minimally Invasive Techniques

Cardiac output (CO) measurement has long been considered essential to the assessment and guidance of therapeutic decisions in critically ill patients and for patients undergoing certain high-risk surgeries. Despite controversies, complications and inherent errors in measurement, pulmonary artery catheter (PAC) continuous and intermittent bolus techniques of CO measurement continue to be the gold standard. Newer techniques provide less invasive alternatives; however, currently available monitors are unable to provide central circulation pressures or true mixed venous saturations. Esophageal Doppler and pulse contour monitors can predict fluid responsiveness and have been shown to decrease postoperative morbidity. Many minimally invasive techniques continue to suffer from decreased accuracy and reliability under periods of hemodynamic instability, and so few have reached the level of interchangeability with the PAC

Spontaneous rupture of uterus

Spontaneous rupture of the uterus is a life-threatening obstetrical emergency. Diagnosis may be delayed because of the bizarre presentation or absence of significant pain and tenderness, which could have been masked by the analgesic medications used during labor. We present a case of spontaneous rupture in a multigravid female who was undergoing oxytocin-augmented labor while receiving epidural analgesia. She had had no previous cesarean deliveries or uterine surgery. Half an hour after an initial complaint of left inguinal pain, which was thought to be related to a patchy epidural block, she presented with changes in vital signs and significant fetal decelerations. At emergent cesarean section, a uterine rupture was noted. The uterine rupture extended down to the left vaginal angle, was not reparable and a hysterectomy was performed. The fetus survived

Current Status of Obstetric Anaesthesia: Improving Satisfaction and Safety

The Centers for Disease Control and Prevention (CDC) reported in 2003 that although the maternal mortal-ity rate has decreased by 99% since 1900, there has been no further decrease in the last two decades [1] . A more recent report indicates a rate of 11.8 per 100,000 live births [2] , although anaesthesia-related maternal mortality and morbidity has considerably decreased over the lastfew decades. Despite the growing complexity of problems and increasing challenges such as pre-existing maternal disease, obesity, and the increasing age of pregnant mothers, anaesthesia related maternal mortality is extremely rare in the developed world. The current safety has been achievedthrough changes in training, service, technical advances and multidisciplinary approach to care. The rates of general anaesthesia for cesarean delivery have decreased and neuraxial anaesthetics have become the most commonly used techniques. Neuraxial techniques are largely safe and effective, but potential complications, though rare, can be severe

Anesthesia complications in the birthplace: is the neuraxial block always to blame?

This article highlights the common and some of the very serious complications that may occur following neuraxial analgesia for labor and delivery, including headache, backache, infection, hypotension, and hematoma. Total spinal and failed block also are discussed, as are complications unique to epidural anesthesia, such as the intravascular injection of large volumes of local anesthetic (causing seizure or cardiac arrest) and accidental dural puncture

Progress in analgesia for labor: focus on neuraxial blocks

J Sudharma Ranasinghe, David J BirnbachMiller School of Medicine, University of Miami, Florida, USAAbstract: Neuraxial analgesia is widely accepted as the most effective and the least depressant method of providing pain relief in labor. Over the last several decades neuraxial labor analgesia techniques and medications have progressed to the point now where they provide high quality pain relief with minimal side effects to both the mother and the fetus while maximizing the maternal autonomy possible for the parturient receiving neuraxial analgesia. The introduction of the combined spinal epidural technique for labor has allowed for the rapid onset of analgesia with minimal motor blockade, therefore allowing the comfortable parturient to ambulate. Patient-controlled epidural analgesia techniques have evolved to allow for more flexible analgesia that is tailored to the individual needs of the parturient and effective throughout the different phases of labor. Computer integrated systems have been studied to provide seamless analgesia from induction of neuraxial block to delivery. New adjuvant drugs that improve the effectiveness of neuraxial labor analgesia while decreasing the side effects that may occur due to high dose of a single drug are likely to be added to future labor analgesia practice. Bupivacaine still remains a popular choice of local anesthetic for labor analgesia. New local anesthetics with less cardiotoxicity have been introduced, but their cost effectiveness in the current labor analgesia practice has been questioned.Keywords: labor, neuraxial, analgesia, neuraxial labor analgesi

Infection associated with central venous or epidural catheters: how to reduce it?

Central venous catheters are a leading source of nosocomial bloodstream infection with an estimated 10% mortality. Infection associated with epidural catheterization is an uncommon but devastating complication. Diagnosis of spinal epidural abscess requires a high index of suspicion and imaging techniques such as MRI. Early diagnosis and treatment will minimize permanent damage, but primary prevention should be the aim, which depends on proper patient evaluation and use of full aseptic precautions. Recent studies suggest that epidural infection is no longer as rare a complication as once thought and may be increasing. It is not clear whether this increase is related to an increase in reporting, an overall increase in the total number of epidurals (especially extended use) being performed, or a true increase in infection rate. Implementation of multistep prevention programs has been shown to decrease central venous catheter-related bloodstream infection rate. Antiseptic or antibiotic-impregnated central venous catheters are effective in decreasing central venous catheter-related bloodstream infections. Healthcare worker education and training are essential to create standardization of aseptic care. Continuous surveillance is necessary for identifying lapses in infection-control practices

Complete heart block in pregnancy: case report, analysis, and review of anesthetic management

Maternal complete heart block can pose significant challenges for the anesthesiologist in the antepartum, peripartum, and postpartum periods. Some patients may present for the first time in the puerperium with dizziness, weakness, syncope, or congestive heart failure as a result of the additional hemodynamic burden that accompanies pregnancy. Although there is an increase in permanent pacemaker placement in young symptomatic patients before pregnancy, prophylactic placement of pacemakers in asymptomatic parturients is not always indicated. The need for temporary or permanent pacemakers in asymptomatic women should be assessed on a case-by-case basis; many of these patients may be safely managed during labor and delivery without pacing. The parturient with complete heart block must be followed vigilantly during pregnancy and post delivery, as the need for pacemaker insertion can also arise in the postpartum period. We present a case of third-degree heart block in a 26-year-old parturient

Fetal assessment for anesthesiologists: are you evaluating the other patient?

Suboptimal communication between anesthesiologists and obstetricians can be associated with unintended poor maternal and neonatal outcomes, especially for emergency cesarean deliveries. Obstetricians use the results of antepartum and intrapartum fetal assessments to assess fetal well-being and to make decisions about the timing and method of delivery. Because abnormal results may lead to the need for urgent or emergency cesarean deliveries, these decisions may directly impact anesthetic care. Lack of familiarity with fetal assessments and the significance of the results may thus hinder the communication necessary for optimal patient care. In this review article, we discuss the current antepartum and intrapartum fetal assessment modalities, including the nonstress test, biophysical profile, Doppler velocimetry, electronic fetal heart rate monitoring, fetal electrocardiogram (STAN-ST waveform analysis), and fetal pulse oximetry. The physiologic basis behind these modalities and the available evidence regarding their utility in clinical practice are also reviewed. The 2008 National Institute of Child Health and Human Development workshop report on electronic fetal monitoring categories, which are incorporated into the American College of Obstetricians and Gynecologists guidelines for intrapartum care, is examined. The implications of test interpretation to the practice of obstetric anesthesiology is also discussed. Anesthesia provider understanding of fetal assessment modalities is essential in improving communication with obstetricians and improving the planning of cesarean deliveries for high-risk obstetric patients