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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.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.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%.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.

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. 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). 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. 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. www.ClinicalTrials.gov (NCT03236298); registered 1 August 2017.

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.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·hrThe 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).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.RéSUMé: OBJECTIF: Une pénurie nationale d’ocytocine au Canada a entraîné l’utilisation temporaire de la carbétocine en remplacement de l’ocytocine pour toutes les femmes en post-partum dans notre établissement. Grâce à cette substitution, nous avons bénéficié d’une occasion unique de mener une évaluation comparative pragmatique de l’efficacité de la carbétocine et de l’ocytocine. MéTHODE: Dans une étude rétrospective avant-après, nous avons examiné les dossiers médicaux de 641 femmes dans le groupe carbétocine et de 752 femmes dans le groupe ocytocine. Le dosage standard de carbécotine était de 100 μg iv après un accouchement vaginal et pendant un accouchement par césarienne intrapartum, tandis que pour un accouchement par césarienne élective, le dosage était de 50 μg, avec 50 μg supplémentaires au besoin. Le dosage standard d’ocytocine était de 5 UI iv suivi de 2,4 UI·h

Approximately one in five women will experience severe postoperative pain after Cesarean delivery (CD). Previously, a bedside three-item questionnaire (3-IQ) has shown to predict women experiencing higher evoked pain intensity after CD, with an area under the receiver operator characteristics (ROC) curve of 0.72. We hypothesized that the addition of psychophysical pain tests to the existing 3-IQ would improve the ability to predict severe pain in women undergoing elective CD under spinal anesthesia This was a prospective cohort study on women undergoing elective CD under spinal anesthesia. Women were assessed preoperatively using the 3-IQ, pressure algometry (PA) and mechanical temporal summation (TS) response. All women received standard perioperative care, including a multimodal analgesia regimen that included intrathecal fentanyl and morphine. A 0–100 mm visual analogue scale (VAS) was used to assess the severity of pain at rest (VASr) and on movement (VASm) at 24 and 48 hr after surgery. Patient satisfaction and opioid consumption were also recorded. We performed ROC curve analyses to assess whether we could improve the ability to predict our primary outcome of severe pain on movement at 24 hr (VASm24 ≥ 70). We studied 195 women. Median [interquartile range] VASm24 was 53 [32–72] and 28% of patients experienced a VASm24 ≥ 70. The ability to predict a VASm24 ≥ 70 assessed by the area under the ROC curve was 0.64 using the 3-IQ and 0.67 using the 3-IQ combined with TS and PA. The addition of PA and TS to the 3-IQ model resulted in a predictive model that performed similarly to the 3-IQ model alone. Further research is warranted in this area to better predict women at risk of severe pain post CD.

The purpose of this review is to synthetize the latest evidence on the pharmacological management of postpartum hemorrhage (PPH) and apply it to the clinical context. The incidence of PPH in the developed world is rising. Oxytocin and its analogue carbetocin remain the number one choice as first-line uterotonics for the prevention of PPH due to excellent clinical efficacy and a favorable side effect profile. Doses of oxytocin and carbetocin currently recommended for prophylaxis are in excess to that required for clinical efficacy. There is no robust evidence suggesting that one second-line uterotonic drug is superior to another. Tranexamic acid is safe and highly effective and should be administered both for cases at high risk for PPH as well as early in established hemorrhage. Choosing a uterotonic drug strategy that uses the most appropriate agent in the clinical context at the minimal effective dose is essential for improving maternal safety and the quality of postpartum care.

We studied the programmed intermittent epidural bolus (PIEB) time interval between boluses of 2.5 mL of bupivacaine 0.25% with fentanyl 8 µg·mL−1 to produce effective analgesia in 90% of women (EI90) during the first stage of labour. In a double-blind sequential allocation trial using a biased coin up-and-down design to determine the EI90, the PIEB boluses of 2.5 mL of 0.25% bupivacaine plus fentanyl 8 µg·mL−1 were delivered at varying intervals—60, 50, 40, and 30 min. The primary outcome was the adequate response of the patient to the PIEB regimen, defined as no use of supplemental analgesia for six hours or until the first stage of labour was completed, whichever came first. The secondary outcomes were the upper sensory block level to ice, motor block and hypotension. The isotonic regression with extrapolation approach was used to estimate the EI90. In the 20 women studied, the estimated EI90 was 20 (95% CI, 5.9 to 28.8) min. For the secondary outcomes, we classified women into those assigned to 30 min (16 women) and those assigned to more than 30 min (four women). The median upper sensory block for women in the 30-min group and more than 30 min were T6 (or T5) and T7, respectively. No participants experienced motor block. Hypotension occurred in one patient in the 30-min group. The estimated EI90 for boluses of 2.5 mL of bupivacaine 0.25% with fentanyl 8 µg·mL−1 was 20 (95% CI, 5.9 to 28.8) min. These results suggest that there is no advantage in using this regimen compared with those reported in the literature using the same dose of bupivacaine in concentrations of 0.0625% and 0.125%. www.clinicaltrials.gov (NCT03735771); registered 7 November 2018.

The purpose of this study was to investigate myometrial contractility induced by oxytocin in women with advanced maternal age (AMA) and morbid obesity (MO). We hypothesized that both oxytocin-pretreated and oxytocin-naive myometrial tissues from women of AMA and women who are MO would exhibit poor myometrial contractility compared with women that are younger and of normal body mass index (BMI). This prospective in vitro study was conducted using myometrial samples obtained from women undergoing elective Cesarean deliveries. Three groups of patient were studied: control (≤ 35 yr; BMI, 20–24.9 kg·m−2), AMA (≥ 40 yr; BMI, 20–24.9 kg·m−2), and MO (≤ 35 yr BMI, ≥ 40 kg·m−2). Each myometrial strip was either pretreated with oxytocin 10−5 M or left in physiologic salt solution for two hours. This was followed by a dose-response testing to oxytocin (10−10 M to 10−5 M), during which contractile parameters were measured. The primary outcome was motility index (MI, amplitude × frequency) of contractions. The MI of contractions was reduced in oxytocin-pretreated samples when compared with their oxytocin naive counterparts in control (estimated difference −69%; 95% confidence interval [CI], −82 to −48; P < 0.001) and AMA groups (estimated difference, −44%; 95% CI, −68 to −2; P = 0.07). The MI of contractions was not different between oxytocin naive and oxytocin-pretreated samples from MO women (estimated difference, −26%; 95% CI, −63 to 49; P = 0.46); however, it was significantly lower in these groups compared with oxytocin-naive samples from the control group. Oxytocin pre-treatment reduced myometrial contractility in AMA and control group women compared with their oxytocin-naive counterparts, as a function of the desensitization phenomenon. Attenuated oxytocin-induced myometrial contractility in MO women in both oxytocin-pretreated and oxytocin-naive samples suggests that these women have intrinsically reduced uterine contractile ability. www.clinicaltrials.gov (NCT01865669; registered 28 May, 2013).

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.In this historical cohort study, we reviewed medical records of patients with a BMI ≥ 40 kg·mWe included 396 deliveries, distributed as follows: 258 with a BMI 40.0-49.9 kg·mNeuraxial 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.RéSUMé: OBJECTIF: La technique d’anesthésie neuraxiale préférée pour les patientes atteintes d’obésité de classe 3 bénéficiant d’un accouchement par césarienne programmée n’a pas encore été déterminée. Nous avons cherché à décrire la technique d’anesthésie utilisée dans notre établissement d’enseignement supérieur à travers les groupes d’indice de masse corporelle (IMC) et les différentes incisions chirurgicales. MéTHODE: Dans cette étude de cohorte historique, nous avons examiné les dossiers médicaux de patientes ayant un IMC ≥ 40 kg·m

IntroductionEpidural 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.MethodsWe 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.ResultsSixty-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)).ConclusionsAn unintentional dural puncture during epidural catheter insertion in parturients is associated with increased risk of chronic headache, back pain and auditory impairment.

Phenylephrine (PE) is currently the vasopressor of choice to prevent and treat spinal-induced hypotension at cesarean delivery (CD). However, its use is often associated with reflex bradycardia. Norepinephrine (NE) has been put forward as an alternative vasopressor during CD due to its ability to treat hypotension while maintaining heart rate (HR). Recent studies have focused on the role of NE used as an infusion with favorable results compared to PE. No studies have compared equipotent bolus doses of PE and NE at CD. We hypothesized that when used in equipotent doses as an intermittent bolus regimen to prevent and treat spinal-induced hypotension, NE would result in a reduction in the incidence of bradycardia compared to PE.This was a double-blind, randomized clinical trial of women undergoing elective CD under spinal anesthesia. Women were randomized to receive either PE 100 µg or NE 6 µg when the systolic blood pressure (SBP) was below baseline. In addition to the randomized treatment, ephedrine was given intravenously to both groups if the SBP was below baseline and the HR60 bpm or if the SBP was80% of baseline for 2 consecutive readings. The primary outcome was bradycardia (HR50 bpm) in the predelivery period. Secondary outcomes included hypotension (SBP80% of baseline), hypertension (SBP120% of baseline), tachycardia (HR120% of baseline), ≥2 episodes of bradycardia, nausea, vomiting, umbilical artery and vein blood gases, and Apgar scores.One hundred twelve patients were randomized. The incidence of bradycardia was lower in the NE group compared to the PE group (10.7% vs 37.5%; P.001; difference [95% confidence interval {CI}], -26.8% [-41.8% to -11.7%]), implying an estimated 71% relative reduction (95% CI, 35%-88%). The distribution of the number of bradycardia episodes was also different between the 2 groups (P = .007). Further testing showed that the patients in the PE group had a higher risk of multiple bradycardia episodes (≥2 episodes) compared to the NE group (19.6% for PE versus 3.6% for NE; P = .008). The proportion of patients requiring rescue boluses of ephedrine was lower in the NE group compared to the PE group (7.2% for NE versus 21.4% for PE; P.03; difference [95% CI], -14.3% [-27.0% to -1.6%]). No differences were observed between the 2 groups in the incidence of other secondary outcomes.When used as an intermittent bolus regimen to prevent and treat spinal-induced hypotension during CD, NE resulted in a significant reduction in the incidence of bradycardia as compared to an equipotent bolus regimen of PE. We conclude that the hemodynamic profile offered by NE during CD is superior to that of PE due to less fluctuations in HR and possibly cardiac output.

The optimal epidural mixtures and settings for programmed intermittent epidural bolus (PIEB) labour analgesia have yet to be determined. A previous study by our group demonstrated that 10 mL boluses of bupivacaine 0.0625% with fentanyl 2 µg·mL−1 administered every 40 min provided effective analgesia during the first stage of labour for 90% of women, without breakthrough pain. We wanted to determine the effective PIEB time interval of 5 mL boluses of bupivacaine 0.125% with fentanyl 2 µg·mL−1 under the same study circumstances, aiming at a future comparative study. This double-blind dose-finding study used the biased coin up-and-down sequential allocation method to determine the effective PIEB interval 90% (EI90) needed to provide effective analgesia without breakthrough pain during the first stage of labour. We used fixed 5 mL boluses of bupivacaine 0.125% with fentanyl 2 µg.mL−1 and studied time intervals of 60, 50, 40, and 30 min. The first patient was assigned an interval of 60 min and the remaining intervals were assigned as per the biased coin up-and-down method. The estimated EI90 was 36.5 min (95% confidence interval [CI], 34.0 to 39.0) by the truncated Dixon and Mood method and 34.2 min (95% CI, 30.8 to 41.5) by the isotonic regression method. We found that 20/40 women had an upper sensory block to ice above T6, 34/40 women had no motor block, and no woman required treatment for hypotension. The EI90 between 5 mL boluses of bupivacaine 0.125% with fentanyl 2 µg·mL−1 during the first stage of labour is approximately 35 min. www.clinicaltrials.gov (NCT #02758405); registered 2 May, 2016.

BACKGROUND Ultrasound assistance improves success rates and reduces adverse outcomes of lumbar punctures (LPs) among adult patients in the emergency room and the operating room, but has not been evaluated in pediatric patients with cancer. Our objectives were (1) to determine whether pediatric oncologists could perform ultrasound-assisted LPs following a structured teaching curriculum, and (2) to determine the feasibility of recruiting pediatric cancer patients to a clinical trial of this procedure. METHODS Three pediatric oncologists completed a curriculum composed of didactic teaching followed by hands-on workshops. Each learner was evaluated during 20 attempts at three ultrasound tasks using the cumulative sum method. The three pediatric oncologists then performed ultrasound assessments prior to routinely scheduled LPs. Feasibility was defined as ability to perform at least 30 ultrasound-assisted LPs within 6 months. Secondary outcomes were the proportion of successful, bloody, or traumatic LPs, time required, and perceived helpfulness of ultrasound. RESULTS All three pediatric oncologists achieved competence in the three tasks of ultrasound scanning within 20 evaluated attempts. We recruited 62 patients within 1 month, and 58 underwent an ultrasound-assisted LP. All LPs were successful. Two LPs (4%) had ≥500 red blood cells (RBCs)/μl, and nine (16%) had ≥10 RBCs/μl. Median time to conduct the scan was 1.9 minutes (range 0.8-4.0 minutes). In 37 (64%) of the LPs, ultrasound assistance was considered helpful or very helpful. CONCLUSIONS Pediatric oncologists readily achieved competence in ultrasound-assisted LPs, and ultrasound was commonly perceived as helpful. It is feasible to proceed to a randomized trial of this procedure in pediatric cancer.

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.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·mLWe 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.The maintenance of epidural analgesia with a PIEB delivery speed of 125 mL·hrwww.ClinicalTrials.gov (NCT03236298); registered 1 August 2017.RéSUMé: OBJECTIF: L’administration programmée intermittente de bolus périduraux (PIEB, pour programmed intermittent epidural bolus) fournit une meilleure analgésie pour la douleur du travail que l’analgésie péridurale par perfusion continue. Néanmoins, les régimes de PIEB couramment utilisés sont associés à un bloc sensoriel élevé. Nous avons émis l’hypothèse qu’une technique de PIEB avec une vitesse d’administration plus lente du bolus produirait des niveaux sensoriels inférieurs. MéTHODE: Nous avons recruté des femmes nullipares à terme ayant des grossesses uniques au cours de la première étape du travail obstétrical. Toutes les participantes avaient un score de statut physique II-III de l’American Society of Anesthesiologists, des cathéters périduraux placés au niveau L3/4 et une analgésie péridurale maintenue avec des PIEB de 10 mL de bupivacaïne 0,0625 % et de 2 μg·mL

Obesity is one of the most prevalent diseases in the developed world. Recent studies estimate as many as one in two pregnant women have a BMI ≥ 25. Special considerations with respect to assessing and caring for these patients are essential. While advances in ultrasound have expanded its intrapartum utility, its use in obstetrical patients with obesity can similarily facilitate care while also providing clinical challenges.

To evaluate whether prophylactic administration of oxytocin plus ergonovine or oxytocin plus carboprost is more effective than oxytocin alone in reducing the need for additional uterotonics among women undergoing cesarean delivery for labor arrest.In this double-blind, three-arm randomized controlled trial, participants were assigned to receive either oxytocin 5 units intravenous alone, or with ergonovine 0.25 mg intravenous or carboprost 0.25 mg intramuscular immediately after delivery, followed with maintenance infusion of oxytocin 40 milliunits/minute in all groups. Uterine tone was assessed at 3, 5, and 10 minutes after delivery, and additional uterotonics were administered if deemed necessary. The primary outcome was intraoperative need for additional uterotonics. Secondary outcomes included uterine tone, calculated blood loss, and side effects. A sample size of 34 per group (n=102), based on the null hypothesis that there is no association between treatment assignment and the need for additional uterotonics, permitted independent post hoc pairwise comparisons between oxytocin plus ergonovine, oxytocin plus carboprost, and oxytocin alone using an adjusted P-value of .025. The association between the need for additional uterotonics and treatment group was assessed using the χ2 test.From June 2013 through July 2019, 105 participants were randomized (35 per group) and data from 100 participants were analyzed: oxytocin (n=35), oxytocin plus ergonovine (n=33), and oxytocin plus carboprost (n=32). There was no difference in the requirement of additional intraoperative uterotonics across groups (oxytocin [37%] vs oxytocin plus ergonovine [33%] vs oxytocin plus carboprost [34%], P=.932). Uterine tone and calculated blood loss were similar across groups. Incidence of nausea or vomiting was higher in oxytocin plus ergonovine (85%; odds ratio [OR] 5.3, 95% CI 1.7-16.9, P=.003) and oxytocin plus carboprost (72%; OR 2.4, 95% CI 0.9-6.7, P=.086) compared with the oxytocin (51%) group.Compared with oxytocin alone, prophylactic use of a combination of uterotonic drugs did not reduce the need for additional uterotonics at cesarean delivery for labor arrest.ClinicalTrials.gov, NCT01869556.

Approximately one in five women will experience severe postoperative pain after Cesarean delivery (CD). Previously, a bedside three-item questionnaire (3-IQ) has shown to predict women experiencing higher evoked pain intensity after CD, with an area under the receiver operator characteristics (ROC) curve of 0.72. We hypothesized that the addition of psychophysical pain tests to the existing 3-IQ would improve the ability to predict severe pain in women undergoing elective CD under spinal anesthesia METHODS: This was a prospective cohort study on women undergoing elective CD under spinal anesthesia. Women were assessed preoperatively using the 3-IQ, pressure algometry (PA) and mechanical temporal summation (TS) response. All women received standard perioperative care, including a multimodal analgesia regimen that included intrathecal fentanyl and morphine. A 0-100 mm visual analogue scale (VAS) was used to assess the severity of pain at rest (VASr) and on movement (VASm) at 24 and 48 hr after surgery. Patient satisfaction and opioid consumption were also recorded. We performed ROC curve analyses to assess whether we could improve the ability to predict our primary outcome of severe pain on movement at 24 hr (VASm24 ≥ 70).We studied 195 women. Median [interquartile range] VASm24 was 53 [32-72] and 28% of patients experienced a VASm24 ≥ 70. The ability to predict a VASm24 ≥ 70 assessed by the area under the ROC curve was 0.64 using the 3-IQ and 0.67 using the 3-IQ combined with TS and PA.The addition of PA and TS to the 3-IQ model resulted in a predictive model that performed similarly to the 3-IQ model alone. Further research is warranted in this area to better predict women at risk of severe pain post CD.RéSUMé: OBJECTIF: Environ une femme sur cinq souffrira de douleur postopératoire sévère après un accouchement par césarienne. Un questionnaire à trois critères (Q3C) administré au chevet de la patiente a déjà été utilisé pour prédire quelles femmes éprouveraient une intensité de douleur évoquée plus élevée après une césarienne, avec une aire sous la courbe ROC de 0,72. Nous avons émis l’hypothèse que l’ajout de tests psychophysiques de douleur au Q3C existant améliorerait notre capacité à prédire la douleur sévère chez les femmes bénéficiant d’une césarienne élective sous rachianesthésie. MéTHODE: Il s’agissait d’une étude de cohorte prospective auprès de femmes bénéficiant d’une césarienne élective sous rachianesthésie. Les femmes ont été évaluées en préopératoire à l’aide du Q3C, de l’algométrie par pression (AP) et de la réponse à une sommation temporale (ST) mécanique. Toutes les femmes ont bénéficié des soins périopératoires standard, ainsi que d’un régime d’analgésie multimodal incluant fentanyl et morphine intrathécaux. Une échelle visuelle analogique (EVA) de 0 à 100 mm a été utilisée pour évaluer la sévérité de la douleur au repos (EVAr) et en mouvement (EVAm) à 24 et 48 heures après la chirurgie. La satisfaction des patientes et la consommation d’opioïdes ont également été enregistrées. Nous avons effectué des analyses de la courbe ROC pour déterminer s’il nous était possible d’améliorer notre capacité à prédire notre critère d’évaluation principal, soit la douleur sévère à la mobilisation à 24 heures (EVAm24 ≥ 70). RéSULTATS: Nous avons étudié 195 femmes. L’EVAm 24 médiane [écart interquartile] était de 53 [32-72] et 28 % des patientes ont noté un score sur l’EVAm24 ≥ 70. La capacité à prédire un score sur l’EVAm24 ≥ 70 tel qu’évalué par la surface sous la courbe ROC était de 0,64 en utilisant le Q3C et de 0,67 en utilisant le Q3C combiné à la ST et l’AP. CONCLUSION: L’ajout de l’AP et de la ST au modèle de Q3C a résulté en un modèle prédictif présentant une performance similaire au modèle de Q3C seul. D’autres recherches sont nécessaires dans ce domaine pour mieux prédire les femmes à risque de douleur sévères après une césarienne.

We studied the programmed intermittent epidural bolus (PIEB) time interval between boluses of 2.5 mL of bupivacaine 0.25% with fentanyl 8 µg·mLIn a double-blind sequential allocation trial using a biased coin up-and-down design to determine the EI90, the PIEB boluses of 2.5 mL of 0.25% bupivacaine plus fentanyl 8 µg·mLIn the 20 women studied, the estimated EI90 was 20 (95% CI, 5.9 to 28.8) min. For the secondary outcomes, we classified women into those assigned to 30 min (16 women) and those assigned to more than 30 min (four women). The median upper sensory block for women in the 30-min group and more than 30 min were T6 (or T5) and T7, respectively. No participants experienced motor block. Hypotension occurred in one patient in the 30-min group.The estimated EI90 for boluses of 2.5 mL of bupivacaine 0.25% with fentanyl 8 µg·mLwww.clinicaltrials.gov (NCT03735771); registered 7 November 2018.RéSUMé: OBJECTIF: Nous avons étudié l’intervalle de temps d’administration programmée de bolus périduraux (PIEB) entre des bolus de 2,5 mL de bupivacaïne 0,25 % avec 8 μg·mL

IntroductionWe wanted to better understand the quality of our labor epidural practice at a large urban academic medical center. Several practice changes were implemented between 2011 and 2017, namely a more uniform epidural loading dose of local anesthetic that includes fentanyl, an increase in both the hourly baseline offer and maximum allowed hourly amount of bupivacaine, and the change from a continuous epidural infusion to a programmed intermittent epidural bolus (PIEB) regimen. We aimed to assess the impact of those changes on the quality of labor analgesia.MethodsWe performed two separate audits representing before-and-after groups. The audits were performed in November 2011 (before group) and November–December 2017 (after group). The data for 2011 were extracted from a previously published study. Hence, we conducted a similar audit in 2017, including only outcomes that were included in the previous audit. The primary outcome was the presence of pain >3 (Numerical Rating Scale 0–10) at any time during first or second stage of labor. Secondary outcomes included top-up requirements, and women’s pain perception during the first and second stage of labor according to a postpartum questionnaire.ResultsWe studied 294 and 247 women in the before-and-after groups, respectively. The proportion of women reporting pain >3/10 at any time during labor and delivery significantly decreased in the after group (30% vs 41%; p3 for the after group (OR 0.65, 95% CI 0.46, 0.94). Women in the after group received fewer top-ups by nurses (3% vs 24%, pDiscussionA bundle of practice changes implemented in our clinical practice, including the PIEB regimen, has resulted in a significant improvement in the quality of labor analgesia. However, despite all the implemented changes, 30% of women still experience pain during labor and further optimization of our practice is warranted.

The purpose of this study was to investigate myometrial contractility induced by oxytocin in women with advanced maternal age (AMA) and morbid obesity (MO). We hypothesized that both oxytocin-pretreated and oxytocin-naive myometrial tissues from women of AMA and women who are MO would exhibit poor myometrial contractility compared with women that are younger and of normal body mass index (BMI). This prospective in vitro study was conducted using myometrial samples obtained from women undergoing elective Cesarean deliveries. Three groups of patient were studied: control (≤ 35 yr; BMI, 20–24.9 kg·m−2), AMA (≥ 40 yr; BMI, 20–24.9 kg·m−2), and MO (≤ 35 yr BMI, ≥ 40 kg·m−2). Each myometrial strip was either pretreated with oxytocin 10−5 M or left in physiologic salt solution for two hours. This was followed by a dose-response testing to oxytocin (10−10 M to 10−5 M), during which contractile parameters were measured. The primary outcome was motility index (MI, amplitude × frequency) of contractions. The MI of contractions was reduced in oxytocin-pretreated samples when compared with their oxytocin naive counterparts in control (estimated difference −69%; 95% confidence interval [CI], −82 to −48; P < 0.001) and AMA groups (estimated difference, −44%; 95% CI, −68 to −2; P = 0.07). The MI of contractions was not different between oxytocin naive and oxytocin-pretreated samples from MO women (estimated difference, −26%; 95% CI, −63 to 49; P = 0.46); however, it was significantly lower in these groups compared with oxytocin-naive samples from the control group. Oxytocin pre-treatment reduced myometrial contractility in AMA and control group women compared with their oxytocin-naive counterparts, as a function of the desensitization phenomenon. Attenuated oxytocin-induced myometrial contractility in MO women in both oxytocin-pretreated and oxytocin-naive samples suggests that these women have intrinsically reduced uterine contractile ability. www.clinicaltrials.gov (NCT01865669; registered 28 May, 2013).

The typical response to the Tsui test performed via an epidural catheter placed in the lumbar area is the unilateral motor response of the lower limbs. Studies show that longer pulse widths can stimulate peripheral nerves at a lower threshold current from a farther distance. Therefore, we designed a study to test the hypothesis that epidural catheter stimulation with a 1.0-msec pulse width would increase the incidence of bilateral motor response in parturients when compared with stimulation with a 0.1-msec pulse width. Parturients requesting epidural analgesia were recruited into this randomized crossover study. The Tsui test was performed at both pulse widths before and five minutes after an epidural test dose of 2% lidocaine 3 mL. The primary outcome was the motor response pattern (either unilateral or bilateral) to the epidural catheter stimulation at baseline. Twenty women were recruited for the study, which was stopped early due to futility. The rates of unilateral motor response in the 0.1-msec (18/20) and the 1-msec (18/20) group were both 90% (rate difference, 0%; 95% confidence interval [CI], −0.3 to 0.3; P = 1.0). The mean (SD) current required to elicit a motor response at baseline was 4.2 (2.6) mA in the 0.1-msec group and 1.7 (1.1) mA in the 1-msec group (mean difference, 2.5; 95% CI, 1.2 to 2.3; P < 0.001). The motor response pattern following the stimulation of a lumbar epidural catheter with pulse widths of 0.1 msec or 1 msec is similar and typically unilateral. The threshold current is lower with the 1-msec pulse width stimulus. www.clinicaltrials.gov, NCT02762149. Registered 2 May 2016.

The practice of obstetrical anesthesia relies on collaborative effort between anesthesiologists and nurses, but teamwork remains a challenge. We sought to identify a consensus on the perceived barriers to collaborative care between anesthesiologists and perinatal nurses in a Canadian tertiary labour and delivery (LD) unit.A cross-sectional consensus-building study was conducted using a modified Delphi technique. We aimed to reach consensus on the barriers to collaborative care as well as to identify the reasons behind the issues and possible interventions. This technique involved conducting four parallel sequential rounds of questionnaires: Round 1 - posing open-ended questions to nurses and anesthesiologists; Round 2 - establishing an initial within-group consensus; Round 3 - conducting a cross-over round to determine the interprofessional consensus and the remaining anesthesia and nursing consensuses; Round 4 - ranking to identify the top three barriers identified by the three consensuses.Twenty-one anesthesiologists and 15 nurses were recruited. Themes of barriers to collaboration included issues on professionalism, availability, dissonance, team coordination, communication, organizational structure, educational gaps, and role clarity. The top two barriers from the interprofessional consensus were communication issues.Anesthesiologists and nurses at our tertiary LD unit identified communication as a major barrier to collaborative care. This study also shows the feasibly of using the modified Delphi technique in LD units seeking to improve collaborative care.

Worldwide, about 150 000 infants are born with spina bifida yearly, making this condition one of the most common fetal central nervous system anomalies compatible with life. Over the last decade, major changes have been introduced in the prenatal diagnosis and management of spina bifida. In this review, we provide a brief summary of the current management of fetal spina bifida and present essential information that should be provided to expecting parents when their fetus has been diagnosed with spina bifida. This information is focused around common parental questions, as encountered in our typical clinical practice, to facilitate knowledge translation.

IMPORTANCE: Women giving birth have high rates of dural puncture secondary to neuraxial anesthesia and are at high risk for a resulting headache. It appears to be unknown whether there is a significant association between post–dural puncture headache and subsequent intracranial subdural hematoma. OBJECTIVE: To determine the association of post–dural puncture headache with postpartum intracranial subdural hematoma. DESIGN, SETTING, AND PARTICIPANTS: This cohort study of patients used hospital discharges recorded in the US Agency for Healthcare Research and Quality National Readmission Database for women who experienced childbirth from January 2010 to December 2016. Patients were included if they had been admitted for childbirth, had 2 months of follow-up data, and did not receive a diagnostic lumbar puncture. Only the first delivery for a calendar year was studied. Data were analyzed from January 2018 to June 2019. EXPOSURES: Women with post–dural puncture headache associated with neuraxial anesthesia in the 2-month postpartum period were identified using International Classification of Disease (Ninth Edition and Tenth Edition) codes and were compared with those without post–dural puncture headaches. MAIN OUTCOME AND MEASURES: The primary outcome was intracranial subdural hematoma in the 2-month postpartum period. Secondary outcomes included in-hospital mortality and occurrence of neurosurgery. RESULTS: A total of 26 469 771 patients with 26 498 194 deliveries were included. Exclusion of repeated deliveries (n = 28 423), deliveries without 2 months of follow-up data (n = 4 329 621), and deliveries with diagnostic lumbar puncture (n = 9334) resulted in a final cohort of 22 130 815 patients and deliveries. For the cohort, the mean (SD) age was 28.1 (6.0) years, and there were 68 374 post–dural puncture headaches, for an overall rate of 309 (95% CI, 302-316) per 100 000. There were 342 cases of subdural hematoma identified, indicating a rate of 1.5 (95% CI, 1.3-1.8) per 100 000 women. Of these, 100 cases were in women with post–dural puncture headache, indicating a rate of 147 (95% CI, 111-194) hematoma cases per 100 000 deliveries in this subgroup. Post–dural puncture headache had an unadjusted absolute risk increase of 145 (95% CI, 117-174) subdural hematoma cases per 100 000 deliveries. After adjusting for confounders, post–dural puncture headache had an odds ratio for subdural hematoma of 199 (95% CI, 126-317; P

Objective Fetal myelomeningocele closure results in better infant outcomes than postnatal closure at the cost of potential prematurity and maternal morbidity. Our aim is to describe the setup of a fetal myelomeningocele closure program in Canada and document its outcomes. Methods We conducted a retrospective review of all open fetal myelomeningocele closure surgeries performed at the Ontario Fetal Centre in its first 3 years of operation (2017–2020). Maternal and fetal baseline characteristics, surgical details, pregnancy outcomes, and infant follow-up until 1 year of age were recorded. Results Twenty-seven women underwent fetal myelomeningocele closure surgery, 10 of whom (37%) resided outside of Ontario. Mean gestational age at surgery was 25.0 ± 0.7 weeks. All surgeries were technically uncomplicated and no fetal deaths occurred. There was a significant negative correlation between increasing experience and skin-to-skin surgical time (R² = 0.36; P = 0.001). Of the 26 patients who have delivered, 4 (15.4%) experienced preterm prelabour rupture of membranes. Mean gestational age at delivery was 34.9±3.0 weeks. All but 1 patient delivered by cesarean. Maternal complications occurred in 9 women (34.6%). There were no maternal deaths, but 3 (11.5%) infant deaths. Of the 14 surviving infants who have reached at least 1 year of age, 5 (35.7%) underwent ventriculo-peritoneal shunting. Of the 9 infants who have not yet reached 1 year of age, 3 (33.3%) underwent endoscopic third ventriculostomy and none underwent shunting. Conclusion Fetal open spina bifida closure can be performed in Canada, with results similar to those reported by other international expert centres. Long-term follow-up is ongoing.

Apelin is a potent inotropic agent and causes endothelium-mediated vasodilation. Its cardiovascular profile suggests a role in the regulation of gestational hemodynamics.We longitudinally assessed maternal serum apelin levels and hemodynamics (cardiac output and total peripheral resistance) between 20 and 34 weeks gestation in 18 women at high risk of placental dysfunction. Placental apelin staining was assessed by immunohistochemistry in placentas from uncomplicated pregnancies (n = 6), preterm deliveries (n = 6), preeclampsia (PET, n = 8), and isolated intrauterine growth restriction (IUGR, n = 8). Placental apelin gene expression was assessed by quantitative polymerase chain reaction.In the high-risk cohort, 4 fetuses developed isolated IUGR and 6 women developed PET. We obtained a median of 5 (range 2-9) hemodynamic and apelin measurements per woman. Apelin levels throughout gestation were best fitted by a quadratic curve. Apelin levels between 20 and 26 weeks gestation correlated with total peripheral resistance (r = .57, P = .01) and showed a trend toward an inverse correlation with stroke volume (r = -.42, P = .08). Apelin serum levels were 30% lower in pregnancies complicated by IUGR than in uncomplicated pregnancies or in women with preeclampsia (P = .009). Placental apelin gene expression was similar in IUGR, PET, preterm, and term normal placentas. Apelin staining was seen both in syncytiotrophoblast and stroma of the placental villi. In IUGR placentas, apelin staining was strongly decreased in both compartments compared to normals. Preeclamptic placentas showed an intermediate staining.Apelin levels mirror the cardiovascular changes seen in pregnancy. Serum and placental apelin levels are decreased in IUGR.

Cesarean delivery occurs in roughly one third of pregnancies. Effective postoperative pain control is a goal for patients and physicians. Limiting opioid use in this period is important as some percentage of opioid naive individuals will develop persistent use. Gabapentin is a non-opioid medication that has been used perioperatively to improve postoperative pain and limit opioid requirements. The goal of this study is to determine the efficacy of perioperative gabapentin in improving post cesarean delivery pain control. The following data sources were searched from their inception through October 2018: MEDLINE, Ovid, ClinicalTrials.gov, Sciencedirect, and the Cochrane Library at the CENTRAL Register of Controlled Trials. A systematic review of the literature was performed to include all randomized trials examining the effect of perioperative gabapentin on post cesarean delivery pain control and other postoperative outcomes. The primary outcome was the analgesic effect of gabapentin on post cesarean delivery pain, measured by visual analog scale (VAS; 0–100) or Numerical Rating Scale (NRS; 0–10) on movement 24 hours (h) postoperative. These scores were directly compared by multiplying all NRS scores by a factor of 10. Meta-analysis was performed using the random effects model of DerSimonian and Laird, to produce summary treatment effects in terms of mean difference (MD) with 95% confidence interval (CI). Six placebo controlled trials (n = 645) were identified as relevant and included in the meta-analysis. All studies included only healthy pregnant women (American Society of Anesthesiologist (ASA) physical status I or II) undergoing spinal anesthesia for cesarean delivery at term. Participants were randomized to either 600 mg oral gabapentin or placebo preoperatively and in one study the medications were also continued postoperatively. Pooled data showed that women who received gabapentin prior to cesarean delivery had significantly lower VAS pain scores at 24 h on movement (MD -11.58, 95% CI -23.04 to -0.12). VAS pain scores at other time points at rest or on movement were not significantly different for those who received gabapentin and placebo although there was a general trend toward lower pain scores for women receiving gabapentin. There was no significant between-group difference in use of additional pain medications, supplemental opioids, and maternal or neonatal side effects. There was higher pain control satisfaction at 12 and 24 h in the gabapentin versus placebo groups.

Objective To compare the efficacy between intravenous patient-controlled analgesia (IVPCA) and patient-controlled epidural analgesia (PCEA) in women undergoing medically induced second trimester termination of pregnancy (TOP). Methods We conducted a randomized trial in a Canadian quaternary care hospital. We included in the study women of gestational age 12 weeks to 23+6 weeks who were undergoing second trimester induction of labour between June 2012 and January 2014. Participants were computer-randomized to receive either IVPCA with fentanyl or PCEA with bupivacaine and fentanyl, with the option to cross over between treatment groups. We administered Quality of Recovery-40 (QoR-40) questionnaires pre-procedure, at the time of discharge, and 24 hours after discharge. Pain scores, satisfaction scores, and obstetrical complications also were noted. Results One hundred thirty-eight women were approached for participation in the study; 80 declined and 16 were ineligible, leaving 42 participants. Three women subsequently withdrew consent, and two were not included in the results because of protocol violations. A total of 37 women completed the study. Twenty (54%) were allocated to the IVPCA group and 17 (46%) to the PCEA group. Although the QoR-40 values at the time of discharge and at 24 hours after discharge were significantly higher in the PCEA group, they also were significantly higher before the procedure in that group. The within-group differences in QoR-40 (between QoR-40 at discharge and QoR pre-procedure, and between QoR-40 at 24 hours after discharge and QoR pre-procedure), maximum pain scores, satisfaction, and obstetrical complication rates did not differ significantly between the two groups. Conclusion IVPCA and PCEA provide similar quality of recovery, quality of analgesia, and satisfaction for women undergoing second trimester TOP.

Ultrasound biometry is an important clinical tool for the identification, monitoring, and management of fetal growth restriction and development of macrosomia. This is even truer in populations in which perinatal morbidity and mortality rates are high, which is a reason that much effort is put onto making the technique available everywhere, including low-income societies. Until recently, however, commonly used reference ranges were based on single populations largely from industrialized countries. Thus, the World Health Organization prioritized the establishment of fetal growth charts for international use. New fetal growth charts for common fetal measurements and estimated fetal weight were based on a longitudinal study of 1387 low-risk pregnant women from 10 countries (Argentina, Brazil, Democratic Republic of Congo, Denmark, Egypt, France, Germany, India, Norway, and Thailand) that provided 8203 sets of ultrasound measurements. The participants were characterized by median age 28 years, 58% nulliparous, normal body mass index, with no socioeconomic or nutritional constraints (median caloric intake, 1840 calories/day), and had the ability to attend the ultrasound sessions, thus essentially representing urban populations. Median gestational age at birth was 39 weeks, and birthweight was 3300 g, both with significant differences among countries. Quantile regression was used to establish the fetal growth charts, which also made it possible to demonstrate a number of features of fetal growth that previously were not well appreciated or unknown: (1) There was an asymmetric distribution of estimated fetal weight in the population. During early second trimester, the distribution was wider among fetuses50th percentile compared with those above. The pattern was reversed in the third trimester, with a notably wider variation50th percentile. (2) Although fetal sex, maternal factors (height, weight, age, and parity), and country had significant influence on fetal weight (1-4.5% each), their effect was graded across the percentiles. For example, the positive effect of maternal height on fetal weight was strongest on the lowest percentiles and smallest on the highest percentiles for estimated fetal weight. (3) When adjustment was made for maternal covariates, there was still a significant effect of country as covariate that indicated that ethnic, cultural, and geographic variation play a role. (4) Variation between populations was not restricted to fetal size because there were also differences in growth trajectories. (5) The wide physiologic ranges, as illustrated by the 5th-95th percentile for estimated fetal weight being 2205-3538 g at 37 weeks gestation, signify that human fetal growth under optimized maternal conditions is not uniform. Rather, it has a remarkable variation that largely is unexplained by commonly known factors. We suggest this variation could be part of our common biologic strategy that makes human evolution extremely successful. The World Health Organization fetal growth charts are intended to be used internationally based on low-risk pregnancies from populations in Africa, Asia, Europe, and South America. We consider it prudent to test and monitor whether the growth charts' performance meets the local needs, because refinements are possible by a change in cut-offs or customization for fetal sex, maternal factors, and populations. In the same line, the study finding of variations emphasizes the need for carefully adjusted growth charts that reflect optimal local growth when public health issues are addressed.

Background: Oxytocin receptor desensitization has been shown to occur in humans at biomolecular level and in isolated rat myometrium; however, its effect on human myometrial contractility has not been demonstrated. The objective of this in vitro study was to investigate the contractile response of human pregnant myometrium to oxytocin after pretreatment with different concentrations of oxytocin for variable durations. Methods: Myometrial samples were obtained from 62 women undergoing elective cesarean deliveries under regional anesthesia. The strips were pretreated with oxytocin 10−10, 10−8, 10−5M, or physiological salt solution (control) for 2, 4, 6, or 12 h, followed by a dose–response testing with oxytocin 10−10 to 10−5M. Amplitude and frequency of contractions, motility index, and area under the curve during the dose–response period were recorded, analyzed with linear regression models, and compared among groups. Results: Pretreatment with oxytocin 10−5 and 10−8M significantly reduced motility index (estimate [standard error]: −0.771 [0.270] square root units, P = 0.005 and −0.697 [0.293], P = 0.02, respectively) and area under the curve (−3.947 [1.909], P = 0.04 and −4.241 [2.189], P = 0.05, respectively) compared with control group, whereas pretreatment with oxytocin 10−10M did not significantly attenuate contractions. Increase in duration of oxytocin pretreatment from 2 to 12 h significantly decreased amplitude (type 3 generalized estimating equation analysis: chi-square = 14.0; df = 3; P = 0.003), motility index (chi-square = 9.3; df = 3; P = 0.03), and area under the curve (chi-square = 10.5; df = 3; P = 0.02), but not the frequency of oxytocin-induced contractions. Conclusion: Pretreatment with oxytocin decreases oxytocin-induced myometrial contractions in a concentration and time-dependent manner, likely as a function of the oxytocin receptor desensitization phenomenon.

Focused assessment of the gastric antrum by ultrasound is a feasible tool to evaluate the quality of the stomach content. We aimed to determine the amount of training an anesthesiologist would need to achieve competence in the bedside ultrasound technique for qualitative assessment of gastric content. Six anesthesiologists underwent a teaching intervention followed by a formative assessment; then learning curves were constructed. Participants received didactic teaching (reading material, picture library, and lecture) and an interactive hands-on workshop on live models directed by an expert sonographer. The participants were instructed on how to perform a systematic qualitative assessment to diagnose one of three distinct categories of gastric content (empty, clear fluid, solid) in healthy volunteers. Individual learning curves were constructed using the cumulative sum method, and competence was defined as a 90% success rate in a series of ultrasound examinations. A predictive model was further developed based on the entire cohort performance to determine the number of cases required to achieve a 95% success rate. Each anesthesiologist performed 30 ultrasound examinations (a total of 180 assessments), and three of the six participants achieved competence. The average number of cases required to achieve 90% and 95% success rates was estimated to be 24 and 33, respectively. With appropriate training and supervision, it is estimated that anesthesiologists will achieve a 95% success rate in bedside qualitative ultrasound assessment after performing approximately 33 examinations.

Objective To assess the effectiveness of a multidisciplinary team approach to reduce severe maternal morbidity in women with invasive placenta previa. Methods We conducted a prospective study of 33 women with placenta previa and increta-percreta (diagnosed by ultrasound and/or magnetic resonance imaging) delivering at Mount Sinai Hospital, Toronto, following the introduction in January 2008 of a team-based approach to women with this condition. We included women who delivered by June 2012. We reviewed antenatal outpatient and inpatient records for use of six pre-defined team components by the attending staff obstetrician: (1) antenatal maternal–fetal medicine consultation, (2) surgical gynaecology consultation, (3) antenatal MRI, (4) interventional radiology consultation and preoperative placement of balloon catheters in the anterior divisions of the internal iliac arteries, (5) pre-planned surgical date, and (6) surgery performed by members of the invasive placenta surgical team. Antenatal course, delivery, and postpartum details were recorded to derive a five-point composite severe maternal morbidity score based on the presence or absence of: (1) ICU admission following delivery, (2) transfusion > 2 units of blood, (3) general anaesthesia start or conversion, (4) operating time in highest quartile (> 125 minutes), and (5) significant postoperative complications (readmission, prolonged postpartum stay, and/or pulmonary embolism). Results All 33 women survived during this time period. Two thirds (22/33) had either five or six of the six components of multidisciplinary care. Increasing use of multidisciplinary team components was associated with a significant reduction in composite morbidity ( R 2 = 0.228, P = 0.005). Conclusion Team-based assessment and management of women with invasive placenta previa is likely to improve maternal outcomes and should be encouraged on a regional basis.

This article provides an overview of the use of ultrasonography in obstetric anesthesia. It discusses the indications, benefits, and techniques of using ultrasonography to optimize the delivery of anesthesia and provide safe and efficacious clinical care. More specifically, it discusses the use of ultrasonography to facilitate neuraxial anesthesia, abdominal field blocks, central and peripheral vascular access, as well as the assessment of the lung fields and gastric contents, and identification of the cricothyroid membrane.

The use of ultrasound for neuraxial blockade is a new application of technology that is rapidly becoming accepted as a standard of care. This new skill has shown to improve success, but it is a challenge to teach. To assist with teaching the use of ultrasound in regional anesthesia of the lumbar spine, we have developed an interactive educational model ( http://pie.med.utoronto.ca/vspine or http://www.usra.ca/vspine.php ). In this study, we aimed to determine whether use of this model for a two-week period would improve the performance of novice operators in determining defined landmarks during real-time ultrasound imaging of the lumbar spine. We evaluated the educational benefit of the ultrasound module by randomly assigning 16 postgraduate first-year (PGY1) anesthesia residents to either a control group with password-protected access to only the lumbar anatomy module or to an intervention group with access to the complete module. All residents had access to the module for two weeks following a full-day workshop that is part of the university teaching program which consists of a didactic lecture on ultrasound-facilitated neuraxial anesthesia, mentored teaching on cadaveric spine dissections, and hands-on ultrasound scanning of live models. At the end of the two weeks, the performance of the residents was evaluated using a 12-item task-specific checklist while carrying out a scout scan on a live model. The control group had a median score of 5.5 (25th percentile: 4, 75th percentile: 18), while the intervention group had a median score of 11.5 (25th percentile: 8, 75th percentile: 12) in the task-specific checklist, with a significant difference of 6 (confidence interval 1.5 to 10.5) between groups (P = 0.021). Our results show superior performance by the residents who had access to both components of the module, indicating that access to the interactive ultrasound spine module improves knowledge and skills prior to clinical care.

Cesarean delivery is a commonly performed procedure worldwide. Despite improvements in balanced multimodal analgesia, there remains a proportion of women for whom postoperative pain relief and patient satisfaction are still inadequate. Intraperitoneal instillation of local anesthetic has been shown to be effective in reducing postoperative pain after abdominal surgery. We sought to investigate the effect of intraperitoneal instillation of lidocaine on postcesarean delivery pain as part of a multimodal analgesia regimen.We studied women scheduled for elective cesarean delivery under spinal anesthesia. Spinal anesthesia was performed with 0.75% hyperbaric bupivacaine, fentanyl, and morphine. At the end of the cesarean delivery, immediately before parietal peritoneum or fascia closure, patients were randomized to receive either lidocaine (20 mL 2% lidocaine with epinephrine) or placebo (20 mL normal saline) instilled into the peritoneal cavity. The primary outcome was pain score on movement at 24 hours. Secondary outcomes were pain score at rest and on movement at 2, 24, and 48 hours; maternal satisfaction score; analgesic consumption; incidence of nausea, vomiting, and itching; and return of bowel function.Two hundred four women were recruited. Baseline characteristics were similar between the lidocaine and placebo groups. Pain scores at 24 hours postcesarean delivery on movement (parameter estimate 0.02 [95% confidence interval {CI} -0.14 to 0.18]; P = .823) and at rest (parameter estimate 0.00 [95% CI -0.32 to 0.33]; P = .986) were similar in both groups. Pain scores at 2 hours postcesarean delivery on movement (parameter estimate -0.58 [95% CI -0.90 to -0.26]; P = .001) and at rest (parameter estimate -1.00 [95% CI -1.57 to -0.43]; P = .001) were lower in the lidocaine group. Subgroup analysis of patients with peritoneum closure revealed significantly lower pain scores at 24 hours on movement (parameter estimate -0.33 [95% CI -0.64 to -0.03]; P = .032) in the lidocaine group. The number of women requesting postoperative opioids for breakthrough pain was significantly lower in the lidocaine group compared with that of the placebo (40 [40%] vs 61 [65%], respectively, relative risk 0.59 [95% CI 0.43-0.81]; P = 0.001).The use of intraperitoneal instillation of lidocaine improves early postoperative pain management after cesarean delivery. Furthermore, it reduces the number of women requesting systemic opioids in the immediate postpartum period. Women undergoing peritoneal closure may particularly benefit from this intervention.

The purpose of this study was to determine the contractile patterns induced by oxytocin in myometrium exposed to magnesium sulfate (MgSO4). We hypothesized that MgSO4 pretreatment would reduce oxytocin-induced myometrial contractions in both oxytocin-naive and oxytocin-desensitized myometrium. In this prospective in vitro study, myometrial samples were obtained from 26 women undergoing elective Cesarean deliveries. Samples were divided into six groups. Four groups were apportioned to no pretreatment (control group), oxytocin 10−5 M pretreatment (desensitization group), MgSO4 3.5 mM pretreatment, and MgSO4 3.5 mM + oxytocin 10−5M pretreatment. This was followed by dose-response testing to oxytocin 10−10 to 10−5M in all four groups. Two additional groups included MgSO4 3.5 mM pretreatment and MgSO4 3.5 mM + oxytocin 10−5 M pretreatment, followed by dose-response testing to oxytocin along with MgSO4 3.5 mM. The outcomes were motility index (MI), as defined by the amplitude (g) × frequency of myometrial contractions (c) over ten minutes, and area under the curve (AUC). In oxytocin-naive myometrium, the mean (standard error [SE]) MI was not affected by MgSO4 pretreatment [3.31 (0.20) √g⋅c/10 min] as compared with control (P = 0.88), even when MgSO4 was continued during dose-response testing [2.50 (0.19) √g⋅c/10 min; P = 0.41]. In the oxytocin-desensitized model, mean (SE) MI was not affected by MgSO4 pretreatment [2.60 (0.21) √g⋅c/10 min; P = 0.68], but when MgSO4 was continued during the dose-response period, the MI was significantly reduced compared with control [1.89 (0.13) √g⋅c/10 min; P < 0.001]. The results for AUC were similar to MI, except for a significant reduction in oxytocin-naive myometrium when MgSO4 was continued during dose-response testing (P = 0.02). Magnesium sulfate pretreatment does not impair oxytocin-induced myometrial contractility in oxytocin-naive or desensitized myometrium unless it is continued during oxytocin dose-response testing. These results suggest that its tocolytic effect is likely dependent on an extracellular mechanism. The study was registered with ClinicalTrials.gov, number NCT02647268.

Objective To develop an integrated checklist for the management of patients with suspected morbidly adherent placenta (MAP). Methods A checklist process was developed incrementally by clinicians in the disciplines of maternal-fetal medicine, gynaecology, medical imaging, and anaesthesia for management of women with suspected MAP. Results Over a five-year period of debriefing after individual cases, a comprehensive checklist system was developed. The checklist is activated upon referral if MAP is suspected at an initial maternal-fetal medicine consultation; the process is subsequently guided by a clinical nurse specialist, leading to a standardized program of care. Conclusions Having a checklist process facilitates standardized care and optimal communication between specialists, providing team-based care for women with this potentially serious complication of pregnancy.

Tetralogy of Fallot (TOF) is one of the most common causes of cyanotic congenital heart disease. The anesthetic management of parturients with uncorrected TOF is challenging and controversial, especially for Cesarean delivery (CD). We describe the use of noninvasive cardiac output (CO) monitoring to assist the management of CD for a woman with palliated TOF under general anesthesia.A 34-yr-old woman presented for elective CD at 38 weeks gestation. Having been born with TOF, she underwent a modified Blalock-Taussig shunt at six years of age, followed nine years later by creation of an aortopulmonary connection. The patient's functional status was New York Heart Association class I despite evident central cyanosis. A CD was performed under general anesthesia. Fentanyl, etomidate, and succinylcholine were utilized for induction, and intrathecal morphine was administered for postoperative pain control. The baseline CO (7.2 L·min(-1)), blood pressure (156/74 mmHg), heart rate (74 beats·min(-1)), and total peripheral resistance (1,059 dynes·sec(-1)·cm(-5)) remained stable throughout the procedure. Maintenance anesthesia consisted of rocuronium, sevoflurane, and an oxygen/nitrous oxide mixture. Upon delivery, an infusion of oxytocin combined with ergometrine was administered. Hemodynamic parameters remained stable and no vasopressor was required.Balanced general anesthesia and careful titration of uterotonic agents provided stable hemodynamic conditions during CD in a patient with a palliated TOF, as assessed by a continuous noninvasive CO monitor. Noninvasive CO monitoring may improve our understanding of the hemodynamic implications of various anesthetic techniques for CD in cardiac patients.

Invasive placentation is one of the most important causes of postpartum hemorrhage and Cesarean hysterectomies (CHyst). The optimal mode of anesthesia in the management of these patients remains uncertain. The purpose of this study was to review the impact of mode of anesthesia on maternal and neonatal outcomes in women with invasive placentation undergoing Cesarean delivery (CD). A retrospective cohort study was conducted in women with invasive placentation who delivered at our hospital during 2000-2012. Patients’ charts and electronic health records were searched for relevant data, including obstetric and anesthetic procedures, blood loss, use of resuscitation fluids, and neonatal and maternal complications. Based on the initial planned mode of anesthesia (i.e., general or regional) for CD, comparisons were made between groups for maternal blood loss and transfusion, respiratory complications, and neonatal Apgar scores. Of the 50 women with confirmed invasive placentation, 25 (50%) underwent elective CD, while the remaining 25 (50%) had unplanned CD; 36 (72%) required CHyst. Surgery for 34 (68%) patients commenced under regional anesthesia (RA), and surgery for 16 (32%) patients commenced under general anesthesia (GA). In women who received GA vs RA, there was no difference in mean (SD) blood loss [3,206 (3,777) mL vs 1,906 (1096) mL, respectively; mean difference, 1,300 mL; 95% confidence interval (CI), -739 to 3,339 mL; P = 0.20] or median [IQR] blood transfusion (4 [0-6] units vs 2 [0-4] units, respectively; median difference, 2 units; 95% CI, 0 to 4 units; P = 0.16). In neonates of women who received only RA before delivery vs those who received GA prior to delivery, significantly higher median [IQR] Apgar scores were observed at both one minute (8 [8-9] vs 3 [0-5], respectively; median difference, 5; 95% CI, 3 to 8; P < 0.001) and five minutes (9 [9-9] vs 7 [0-9], respectively; median difference, 2; 95% CI, 1 to 9; P < 0.001). Postoperative respiratory complications were more common with GA (6%) than with RA (0%) (P = 0.03). Having safely performed two-thirds of our cases of CHyst under RA, our study suggests that RA, when compared with GA, is associated with no differences in blood loss or blood transfusion, superior neonatal outcome, and fewer respiratory complications. This suggests that RA can be considered a primary mode of anesthesia for such cases.