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Baricity is an important determinant of block characteristics of the spinal component of a combined spinal epidural (CSE) for labour analgesia. This study compares the analgesic efficacy and side effects of intrathecally administered plain and hyperbaric bupivacaine (both with fentanyl) during active labour. Sixty-two women in active labour (cervical dilatation >- 5 cm and pain score > 5) were randomized in a prospective, single-blinded fashion to receive 2.5 mg of either hyperbaric or plain bupivacaine both combined with 15 μg of fentanyl as the spinal component of a CSE. The primary outcome was failure of satisfactory analgesia within ten minutes of the intrathecal injection as defined by a verbal pain score > 3. Secondary outcomes included need for rescue analgesia, hypotension, respiratory depression, nausea and vomiting, pruritus and sustained fetal bradycardia. Sixty patients were analyzed. The failure rates were 20% in the hyperbaric groupvs 0% in the plain group (P = 0.024). The plain solution provided faster onset, higher sensory levels and less motor block at all times during the first 30 min. The incidence of both pruritus and sustained fetal bradycardia was 33% in the plain group and 10% in the hyperbaric group (P = 0.03). A plain rather than hyperbaric solution of bupivacaine 2.5 mg with fentanyl 15 μg provides a faster onset of analgesia, higher sensory levels and less motor block, while demonstrating an increased incidence of pruritus and sustained fetal bradycardia.

We sought to determine the incidence, etiology, characteristics and risk factors for all headaches in the first week postpartum.This was a prospective cohort study of 985 women delivering over a three-month period in a single tertiary-care institution. These women underwent a structured interview and follow-up to collect demographic data and to assess for the presence and characteristics of postpartum headache (PPHa) or neck/shoulder pain. All headaches were diagnosed using an algorithm based on the diagnostic criteria of the International Headache Society. Multivariate analysis was used to examine possible risk factors.Three hundred eighty-one of the 985 study participants (39%) reported headaches or neck/shoulder pain during the study period. The median time to onset of the PPHa was two days (0, 6; 1st and 3rd quartiles) and duration was four hours (2, 24; 1st and 3rd quartiles). Primary headaches accounted for75% of PPHa. Only a small number of headaches (4%) were incapacitating. Postdural puncture headache accounted for 4.7% of all PPHa. Significant risk factors for the development of PPHa were: known inadvertent dural puncture [odds ratio (OR)adj = 6.36; 95% confidence interval (CI) 1.29, 31.24]; previous headache history (1-12/yr-OR(adj) = 1.57; 95% CI 1.01, 2.44;12/yr-OR(adj) = 2.25; 95% CI 1.63, 3.11); multiparity (OR(adj) = 1.37; 95% CI 1.03, 1.82) and increasing age (OR(adj) = 1.03/yr; 95% CI 1.00, 1.06).Postpartum headaches are common, often first noted after discharge from hospital. The majority are related to primary headache disorders. Increased awareness of this epidemiological relationship and improved diagnosis of primary headache conditions may lead to improved headache-specific therapy and avoidance of unnecessary investigations or read-mission to hospital.

To describe the anesthetic management of two cases of amniotic fluid embolus (AFE) and disseminated intravascular coagulation (DIC) who underwent bilateral uterine artery embolization to control their postpartum hemorrhage. We report the clinical course and management of two women who suffered sudden cardiorespiratory events during labour. The first patient had a cardiac arrest whereas the second developed respiratory failure and altered neurological status. They were diagnosed as having had an AFE. Both of these events were accompanied by severe postpartum hemorrhage and DIC. They suffered prolonged bleeding and received massive transfusions. Successful management of hemorrhage was optimized by uterine artery embolization, thus avoiding ongoing problems with bleeding and possible hysterectomy. The role of uterine artery embolization is described, along with its advantages and anesthetic considerations. Women with severe postpartum hemorrhage, with or without DIC, should be considered for uterine artery embolization.