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Competing Interests: Conflicts of Interest, Funding: Please see DISCLOSURES at the end of this article.

Objectives: Enhanced recovery after surgery (ERAS) protocols are multimodal evidence-based care plans that have been adopted for multiple surgical procedures to promote faster and better patient recovery and shorter hospitalization. This study aimed to explore whether worldwide fetal therapy centers offering prenatal myelomeningocele repair implement the ERAS principles and to provide recommendations for improved perioperative management of patients., Methods: In this survey study, a total of 53 fetal therapy centers offering prenatal surgery for open spina bifida were identified and invited to complete a digital questionnaire covering their pre-, intra- and postoperative management. An overall score was calculated per center based on compliance with 20 key ERAS principles, extrapolated from ERAS guidelines for Cesarean section, gynecological oncology and colorectal surgery. Each item was awarded a score of 1 or 0, depending, respectively, on whether the center did or did not comply with that principle, with a maximum score of 20., Results: The questionnaire was completed by 46 centers in 17 countries (response rate, 87%). In total, 22 (48%) centers performed exclusively open fetal surgery (laparotomy and hysterotomy), whereas 14 (30%) offered both open and fetoscopic procedures and 10 (22%) used only fetoscopy. The perioperative management of patients undergoing fetoscopic and open surgery was very similar. The median ERAS score was 12 (range, 8-17), with a mean ± SD of 12.5 ± 2.4. Center compliance was the highest for the use of regional anesthesia (98%), avoidance of bowel preparation (96%) and thromboprophylaxis (96%), while the lowest compliance was observed for preoperative carbohydrate loading (15%), a 2-h fasting period for clear fluids (20%), postoperative nausea and vomiting prevention (33%) and early feeding (35%). ERAS scores were similar in centers with a short (2-5 days), medium (6-10 days) and long (≥ 11 days) hospital stay (mean ± SD, 12.9 ± 2.4, 12.1 ± 2.0 and 10.3 ± 3.2, respectively, P = 0.15). Furthermore, there was no significant association between ERAS score and surgical technique or case volume., Conclusions: The perioperative management of fetal spina bifida surgery is highly variable across fetal therapy centers worldwide. Standardized protocols integrating ERAS principles may improve patient recovery, reduce maternal morbidity and shorten the hospital stay after fetal spina bifida surgery. © 2024 The Author(s). Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology., (© 2024 The Author(s). Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.)

Purpose: While regional anesthesia (RA) is considered preferable to general anesthesia (GA) for Cesarean delivery (CD), certain situations necessitate GA. This study reviewed the practice patterns around the use of GA for CD to identify modifiable predictors of GA with the goal of reducing GA rates., Methods: This was a retrospective, case-control study. Patients undergoing urgent/emergent CD over a 3-year period were identified, from which 102 patients undergoing GA and 102 patients undergoing RA were randomly selected. The data included patient characteristics, obstetrical indications for CD, type/indication of anesthetic, characteristics of airway management (GA group)/neuraxial anesthesia (RA group), and neonatal outcomes., Results: Abnormal fetal heart rate (aFHR) was the most common obstetrical indication for urgent/emergent CD amongst the cases (39%) and controls (39%). GA administration was most commonly due to "limited time due to maternal/fetal compromise" (56%), followed by "maternal contraindication to RA" (25%) and "inadequate RA" (17%). The most frequent modifiable anesthetic indication for GA was inadequate neuraxial anesthesia (17%). Anesthetic and obstetric predictors for GA included ASA classification [OR 0.11 (0.06-0.21)], emergency code activation [OR 13.55 (1.73-106.40)], failure to progress [OR 0.15 ((0.06-0.36)], labor in a patient scheduled for CD [OR 0.16 (0.05-0.57)], pregnancy-related illness [OR 8.63 (1.06-70.38)], cord/fetal prolapse [14.85(1.90-115.94)], and gestational age (OR 0.86 (0.81-0.92))., Conclusion: Abnormal fetal heart rate, specifically bradycardia, was the most common obstetrical indication of GA for urgent/emergent CD, while inadequate neuraxial anesthesia was the most  modifiable anesthetic indication. Our data suggest aFHR and cord/fetal prolapse as potentially modifiable risk factors for GA in certain situations., (© 2024. The Author(s) under exclusive licence to Japanese Society of Anesthesiologists.)

Purpose: The purpose of our study was to determine the minimum effective dose of oxytocin maintenance infusion required to maintain adequate uterine tone in 90% of patients (ED 90 ) after administration of the initial bolus at elective Cesarean delivery (CD) under spinal anesthesia., Methods: We conducted a prospective, double-blind dose-finding study with biased coin up-down design. Immediately after delivery, a 1-IU oxytocin bolus was administered, followed by a maintenance infusion. The obstetrician assessed the uterine tone by palpation as satisfactory or unsatisfactory. In case of unsatisfactory response, the dose for the next patient was increased by 2 IU·hr -1 . For satisfactory response, the dose for the next patient was either decreased by 2 IU·hr -1 with a probability of 1/9, or remained unchanged. The primary outcome was a satisfactory uterine tone from five minutes after delivery until discharge from postanesthesia care unit. The secondary outcomes were blood loss, need for additional uterotonics, and side effects., Results: We analyzed data for 40 patients. The ED 90 of oxytocin maintenance infusion was 4.5 IU·hr -1 (95% confidence interval, 3.3 to 5.5) based on the isotonic regression estimator. The median [interquartile range] blood loss was 861 [553-1,181] mL; 18% received additional uterotonics, and 38% developed hypotension post delivery., Conclusion: Based on the results of this dose-finding study, we recommend a maintenance infusion rate of 4.5 IU·hr -1 following an oxytocin bolus of 1 IU for adequate uterine tone in pregnant patients undergoing elective CDs. This infusion rate is four-fold lower than that required without an initial bolus., Study Registration: ClinicalTrials.gov ( NCT04946006 ); first submitted 25 June 2021., (© 2024. Canadian Anesthesiologists' Society.)

Purpose: A zone of differential block to cold has been recently documented during labour epidural analgesia, with an upper sensory block level (USBL) and a lower sensory block level (LSBL). We aimed to determine the correlation between USBL and LSBL to cold and pinprick and sensory block level to light touch during labour epidural analgesia., Methods: We conducted a prospective observational study in patients requesting labour epidural analgesia. We placed an epidural catheter at L2/L3 or L3/L4, followed by a programmed intermittent epidural bolus plus patient-controlled epidural analgesia regimen. We assessed the sensory block levels 140 min after administering the loading dose. The primary outcomes were the USBL and LSBL to cold and pinprick and the sensory block level to light touch., Results: We studied 30 patients. The median [interquartile range (IQR)] USBL and LSBL to ice were T7 [T7-T6] and T9 [T10-T8], respectively. The median [IQR] USBL and LSBL to pinprick were T8 [T10-T6] and T10 [T12-T10], respectively. There was a strong correlation between USBL to ice and pinprick (Spearman correlation coefficient, 0.57) and between LSBL to ice and pinprick (Spearman correlation coefficient, 0.52). There was no significant correlation between sensory block level to light touch and either USBL or LSBL to ice or pinprick., Conclusion: We observed two sensory block levels to ice and pinprick. Further studies are required to understand if one modality-cold or pinprick-is superior to the other in assessing sensory block levels in this context. Light touch is unreliable as a modality of sensory block assessment during labour epidural analgesia., Trial Registration: ClinicalTrials.gov (NCT05187962); registered 12 January 2022., (© 2023. Canadian Anesthesiologists' Society.)

Background: Multiple pregnancy is associated with higher risk of uterine atony, postpartum hemorrhage (PPH), blood transfusion, hysterectomy, and death. The optimal dose of oxytocin at cesarean delivery in people with twin pregnancy is unknown. We sought to determine the effective bolus dose of oxytocin required to initiate adequate uterine tone in 90% of people (ED90) with twin pregnancy undergoing elective cesarean delivery. Our hypothesis was that the dose of oxytocin would be higher than 0.5 international units (IU) but lower than 5 IU., Methods: A double-blind dose-finding study using the biased coin up-down method was undertaken in people with twin pregnancy ≥36 weeks gestational age undergoing elective cesarean delivery under neuraxial anesthesia. Those with additional risk factors for PPH, apart from twin pregnancy, were excluded. Oxytocin was administered as an intravenous bolus over 1 minute on delivery of the second fetus. The first patient received 0.5 IU, and subsequent oxytocin doses were administered according to a sequential allocation scheme. The actual doses administered were 0.5, 1, 2, 3, 4, and 5 IU of oxytocin. The primary outcome was the response defined as the satisfactory uterine tone at 2 minutes after completion of administration of the oxytocin bolus, as assessed by the operating obstetrician. Secondary outcomes included need for rescue uterotonic drugs, adverse effects, and estimated blood loss. The ED90 was estimated using the Dixon-Mood and the isotonic regression methods., Results: Thirty patients were included in study. The estimated ED90 of oxytocin was 4.38 IU (95% confidence interval [CI], 3.68-4.86 IU) and 3.41 IU (95% CI, 2.83-3.98 IU) by the isotonic regression and Dixon-Mood methods, respectively. Seven patients had inadequate tone at the 2-minute evaluation point and required rescue uterotonic drugs. The median (interquartile range [IQR]) estimated blood loss was 1031 mL (732-1462 mL) calculated by the change in 24-hour hematocrit. Incidence of hypotension after oxytocin administration was 27%, nausea 30%, and vomiting 17%., Conclusions: Our results demonstrated that people with twin pregnancy require a much higher dose of oxytocin than those with singleton pregnancies. We recommended people with twin pregnancies should receive an initial 5 IU bolus over at least 1 minute when undergoing elective cesarean delivery under neuraxial anesthesia., Competing Interests: Conflicts of Interest: See Disclosures at the end of the article., (Copyright © 2022 International Anesthesia Research Society.)

Purpose: The preferred neuraxial anesthetic technique for patients with class 3 obesity undergoing elective Cesarean delivery is still under debate. We aimed to describe the anesthetic technique used in our tertiary institution across body mass index (BMI) groups and different surgical incisions., Method: In this historical cohort study, we reviewed medical records of patients with a BMI ≥ 40 kg·m -2 undergoing elective Cesarean delivery between July 2014 and December 2020. We collected data on patient characteristics, anesthetic and surgical technique, and procedural times. For data analysis, we stratified patients by BMI into three different groups: 40.0-49.9 kg·m -2 , 50.0-59.9 kg·m -2 , and ≥ 60.0 kg·m -2 ., Results: We included 396 deliveries, distributed as follows: 258 with a BMI 40.0-49.9 kg·m -2 , 112 with a BMI 50.0-59.9 kg·m -2 , and 26 with a BMI ≥ 60.0 kg·m -2 . For patients with a BMI 40.0-49.9 kg·m -2 , the anesthetic technique of first choice was predominantly spinal anesthesia (71%), whereas for those with a BMI ≥ 60.0 kg·m -2 , spinal anesthesia was never used as the anesthetic of first choice. With regard to the surgical incision, spinal anesthesia was almost exclusively used for patients undergoing Pfannenstiel incision and was rarely used for a higher supra- or infraumbilical transverse or midline incision. The overall incidence of general anesthesia was low (7/396, 1.8%). Anesthetic time, surgical time, and operating room time increased almost twofold in patients with a BMI ≥ 60.0 kg·m -2 compared with those with a BMI of 40.0-49.9 kg·m -2 ., Conclusion: Neuraxial anesthesia was successfully used in approximately 98% of patients with class 3 obesity undergoing elective Cesarean delivery. The choice of regional anesthesia technique varied with increasing BMI and with the planned surgical incision. Procedural times increased with increasing BMI. This information should prove useful for comparing anesthetic choices and outcomes in this challenging population., (© 2022. The Author(s).)

Purpose: In the context of a programmed intermittent epidural bolus (PIEB) regimen for labour analgesia, one can identify an upper sensory block level (USBL), defined as the highest dermatome with any altered sensation to cold, and a lower sensory block level (LSBL), defined as the highest dermatome with complete sensory block to cold. This study investigated whether and how these sensory block levels vary within PIEB cycles., Methods: We enrolled patients requesting epidural analgesia. An epidural catheter was placed at L2/L3 or L3/L4. A test dose of 3 mL of bupivacaine 0.125% with fentanyl 3.3 µg·mL -1 was administered, followed by 12 mL of the same solution as the loading dose. A PIEB plus patient-controlled epidural analgesia (PCEA) regimen was initiated 40 min after the loading dose, with bupivacaine 0.0625% with fentanyl 2 µg·mL -1 : PIEB 10 mL, PIEB interval 40 min, PCEA 5 mL, lockout interval 10 min, maximum hourly 30 mL. As per institutional protocol, sensory block levels to ice were assessed 20 min after the loading dose and then hourly. Patients included in the study underwent eight extra assessments: immediately before the second and fourth PIEB and 10, 20, and 30 min after the second and third PIEB., Results: We studied 30 patients. The USBL and LSBL achieved their peak value 100 min after the loading dose. The median [interquartile range] USBL was T 8 [T 9 -T 7 ] and T 6 [T 7 -T 4 ] 20 and 100 min after the loading dose, respectively; LSBL was T 10 [T 11 -T 6 ] and T 8 [T 9 -T 6 ], respectively. There was no significant variation in USBL or LSBL within the PIEB cycle between the second and the third or the third and the fourth PIEB., Conclusion: Once peak sensory block levels are established, there is no significant variation in the USBL and LSBL within the PIEB cycles., Study Registration: www., Clinicaltrials: gov (NCT04716660); registered 21 January 2021., (© 2022. Canadian Anesthesiologists' Society.)

Background: Ultrasound is commonly used to facilitate epidural catheter placement. However, data are lacking regarding its potential to confirm its position in the epidural space. Our aim was to visualize flow in the epidural space of patients receiving epidural analgesia for labor using color flow Doppler ultrasound., Methods: We conducted a prospective observational cohort study that included patients who had delivered vaginally under epidural analgesia. We used a 5-2 mHz curvilinear probe in a left and right paramedian longitudinal oblique view to visualize the anterior and posterior complex at the interspace of epidural catheter insertion, one and two interspaces above and below. At each window, the color flow Doppler function was used to visualize flow within the epidural space on injection of normal saline (1 mL). If no flow was visualized at any interspace, one assessment at the level of insertion was repeated with a 1 mL air/saline mixture. We studied a convenience sample size of 40 patients., Results: We visualized flow in the epidural space in all 40 patients. Flow was visualized on injection of 1 mL of saline in 37/40 patients (93%). In the remaining 3/40 patients (7%), flow was visualized with an air/saline mixture. Flow on injection of saline was visualized only at the interspace of insertion in 26/37 patients (70%), at the interspace of insertion and one interspace above in 10/37 (27%), or only at one interspace above in 1/37 (3%). Flow was visualized only on the left or on the right paramedian view in 19/37 patients (51%), despite a symmetrical sensory block in all patients., Conclusion: Color flow Doppler ultrasound is a feasible and fast way to determine flow in the epidural space in the obstetric population. Its potential clinical uses are confirmation of the epidural catheter position after placement, as well as troubleshooting of unsatisfactory epidural analgesia. Interestingly, our results suggest that epidural catheters predominantly remain at the interspace of insertion., Trial Registration Number: NCT05126745., Competing Interests: Competing interests: None declared., (© American Society of Regional Anesthesia & Pain Medicine 2022. No commercial re-use. See rights and permissions. Published by BMJ.)

Carbetocin or oxytocin are given routinely as first-line uterotonic drugs following delivery of the neonate during caesarean delivery to prevent postpartum haemorrhage. Low doses may be as effective as high doses with a potential reduction in adverse effects. In this double-blind, randomised, controlled, non-inferiority trial, we assigned low-risk patients undergoing elective caesarean delivery under spinal anaesthesia to one of four groups: carbetocin 20 μg; carbetocin 100 μg; oxytocin 0.5 IU bolus + infusion; and oxytocin 5 IU bolus + infusion. The study drug was given intravenously after delivery of the neonate. Uterine tone was assessed by the obstetrician 2, 5 and 10 minutes after study drug administration according to an 11-point verbal numerical rating scale (0 = atonic, 10 = excellent tone). The primary outcome measure was uterine tone 2 min after study drug administration. The pre-specified non-inferiority margin was 1.2 points on the 11-point scale. Secondary outcomes included uterine tone after 5 and 10 minutes, use of additional uterotonics, blood loss and adverse effects. Data were available for 277 patients. Carbetocin 20 μg resulting in uterine tone of (median (IQR [range])) 8 (7-8 [1-10]) was non-inferior to carbetocin 100 μg with tone 8 (7-9 [3-10]), median (95%CI) difference 0 (-0.44-0.44). Similarly, oxytocin 0.5 IU with tone 7 (6-8 [3-10]) was non-inferior to oxytocin 5 IU with tone 8 (6-8 [2-10]), median (95%CI) difference 1 (0.11-1.89). Carbetocin 20 μg was also non-inferior to oxytocin 5 IU, and oxytocin 0.5 IU was non-inferior to carbetocin 100 μg. Uterine tone after 5 and 10 minutes, use of additional uterotonics, blood loss and adverse effects were similar in all groups., (© 2022 Association of Anaesthetists.)

Competing Interests: The authors declare that they have no conflicts of interest.

Introduction: Epidural analgesia is the preferred method to manage pain during labor and delivery. The insertion of the epidural catheter can be complicated by unintentional dural puncture that may result in postdural puncture headache. There is limited evidence on the long-term implications of this complication. We sought to investigate if women who sustained a dural puncture have a higher risk of developing chronic headache, low back pain and visual or auditory impairment., Methods: We conducted a 1:1 case-control study with women who delivered at our institution from January 2015 to December 2019. Cases were women who received epidural analgesia and sustained an unintentional dural puncture, and controls were women who received epidural analgesia but did not sustain such complication. We matched cases and controls for date of delivery, age, and body mass index. All women completed an online survey with validated questionnaires for diagnosis of chronic headache and chronic back pain. We used dichotomic (yes/no) questions to look for the presence of chronic visual and auditory impairment., Results: Sixty-three case-control pairs were studied. Women who sustained a dural puncture during their epidural catheter insertion had a higher risk of developing chronic headache (14.3%, vs 4.8%, p=0.057, adjusted OR (AOR): 3.67 (95% CI 1.05 to 12.82)) and chronic back pain (39.7% vs 19.1%, p=0.009, AOR: 2.67 (95% CI 1.25 to 5.72)) than women who did not sustain a dural puncture. The incidence of chronic auditory impairment was also higher in the dural puncture group (14.3% vs 1.6%, p=0.01, AOR: 9.98 (95% CI 1.21 to 82.62))., Conclusions: An unintentional dural puncture during epidural catheter insertion in parturients is associated with increased risk of chronic headache, back pain and auditory impairment., Competing Interests: Competing interests: None declared., (© American Society of Regional Anesthesia & Pain Medicine 2022. No commercial re-use. See rights and permissions. Published by BMJ.)

Purpose: Assessment of sensory block level during labour epidural analgesia is an essential component of clinical practice and patient safety. Nevertheless, the methods and direction of testing are not standardized. In our hospital, sensory block testing to ice is routinely used, but while some anesthesiologists test the block from a nonanesthetized to an anesthetized area, some do it in the opposite direction. It is unknown how these two different practices affect identification of the sensory block level. The objective of this study was to determine the agreement between these two practices., Methods: We enrolled 31 patients admitted to the labour and delivery unit in a prospective cohort study. At their request, labour epidural analgesia was performed as per institutional routine. Sensory block level to ice was assessed using opposite directions by two randomly assigned independent investigators, one and two hours after the loading dose was administered., Results: Sensory block levels to ice assessed from an anesthetized area to a nonanesthetized area were lower than those when assessed with the stimulus applied in the opposite direction, typically one segment lower., Discussion: Given the small difference detected with both methods, it may be acceptable to use either in clinical practice. Nevertheless, the lack of standardization may have a significant impact when comparing studies involving assessment of sensory block to ice., Study Registration: www., Clinicaltrials: gov (NCT03572439); registered 28 June 2018., (© 2022. Canadian Anesthesiologists' Society.)

Objective: To describe the evolution and evaluation of protocol-based multidisciplinary quality improvement (QI) in women undergoing cesarean hysterectomy for radiologically suspected and pathologically confirmed placenta accreta spectrum (PAS) disorders., Methods: A single-center, retrospective cohort study was conducted of all patients undergoing cesarean hysterectomy for PAS disorders between March 2009 and June 2018. Two distinct periods were defined to compare outcomes: 2009-2011 (initial period) and 2017-2018 (current period). Primary outcomes included blood loss and administration of blood products. Secondary outcomes included perioperative levels of hemoglobin, adverse events and complications, time to mobilization, and length of hospitalization., Results: Among the 105 consecutive patients identified, there were 26 in the initial period and 32 in the current period. With the implementation of all QI care bundles, median estimated surgical blood loss halved from 2000 ml in the initial period to 1000 ml in the current period, and fewer patients required allogenic blood transfusion (61.5% vs 25%). Patients in the current period demonstrated improved postoperative levels of hemoglobin compared to those in the initial period (101 g/L vs 89 g/L) and had a shorter median postoperative hospital stay (3 days vs 5 days)., Conclusion: These results support the implementation of a multifaceted QI and patient care initiative for women with PAS disorders., (© 2021 International Federation of Gynecology and Obstetrics.)

Purpose: A nationwide shortage of oxytocin in Canada resulted in a temporary switch from oxytocin to carbetocin for all postpartum women at our institution. This change offered a unique opportunity to conduct a pragmatic comparative assessment of the efficacy of carbetocin and oxytocin., Methods: In a retrospective before-after study, we reviewed the medical records from 641 women in the carbetocin group and 752 women in the oxytocin group . The standard carbetocin dosing was 100 µg iv following vaginal and intrapartum Cesarean delivery, while for elective Cesarean delivery it was 50 µg, with an additional 50 µg if required. The standard oxytocin dosing was 5 IU iv followed by 2.4 IU·hr -1 for four to six hours after vaginal delivery, while for Cesarean delivery it was 1-3 IU iv, three minutes apart, up to 10 IU if required, followed by the same maintenance. In both modalities of delivery, if uterine tone was suboptimal, the maintenance dose of oxytocin could be increased to 4.8 IU·hr -1 . In both groups, additional uterotonics were used as required. The primary outcome was the need for additional uterotonics. Secondary outcomes included estimated and calculated blood loss, the occurrence of postpartum hemorrhage, and the need for blood transfusion., Results: The incidence of additional uterotonic use was not different between the carbetocin and oxytocin groups (12.0% vs 8.8%; P = 0.05; odds ratio, 1.39; 95% confidence interval, 0.97 to 2.00). The incidence of postpartum hemorrhage was higher in the carbetocin group than in the oxytocin group (10.3% vs 6.6%; P = 0.01). Blood transfusion was more common in the carbetocin group (1.4% vs 0.3%; P = 0.02)., Conclusion: There was no difference in the use of additional uterotonics when carbetocin or oxytocin were used in a cohort of women undergoing vaginal deliveries and both elective and emergency Cesarean deliveries., (© 2021. Canadian Anesthesiologists' Society.)

Purpose: Programmed intermittent epidural bolus (PIEB) provides better analgesia for labour pain than continuous epidural infusion does. Nevertheless, commonly used PIEB regimens are associated with high sensory block. We hypothesized that a PIEB technique with slower bolus delivery speed would produce lower sensory levels., Methods: We recruited term nulliparous women with singleton pregnancies during the first stage of labour. All participants had an American Society of Anesthesiologists Physical Status score of II-III, had epidural catheters placed at L3/4, and had epidural analgesia maintained with PIEB 10 mL every 40 min using 0.0625% bupivacaine with fentanyl 2 µg·mL -1 . Women were randomized to receive PIEB delivered at 250 mL·hr -1 (G250) or 125 mL·hr -1 (G125). The study was completed six hours after the loading dose or at full cervical dilatation, whichever occurred first. The primary outcome was the presence of sensory block to ice ≥ T6 in at least one assessment during the study period (maximum six hours)., Results: We analyzed data from 90 women. The proportion of women presenting sensory block ≥ T6 at any time was not different between G125 and G250 groups (60.0% vs 64.4%; difference, -4.4%; 95% confidence interval [CI], -24.5 to 15.6; P = 0.66). The median [interquartile range] highest sensory block level was also not different between G125 and G250 groups (T6 [T7-T5] vs T5 [T7-T5], P = 0.39). Women in the G125 group had a lower incidence of hypotension than women in the G250 group did (11.1% vs 33.3%; difference, -22.2%; 95% CI, -38.8 to -5.67; P = 0.01). Quality of analgesia and patient satisfaction were not different between groups., Conclusion: The maintenance of epidural analgesia with a PIEB delivery speed of 125 mL·hr -1 did not produce lower sensory block levels when compared with 250 mL·hr -1 . The slower injection speed regimen was associated with lower incidence of hypotension, but this secondary finding warrants confirmation in a future trial., Trial Registration: www.ClinicalTrials.gov (NCT03236298); registered 1 August 2017., (© 2021. Canadian Anesthesiologists' Society.)