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Introduction Transversus abdominis plane (TAP) block is a simple and effective technique of providing analgesia for lower abdominal surgeries with easily identifiable landmarks. This study investigated the postoperative analgesic efficacy of bilateral ultrasound-guided transversus abdominis plane blocks, in patients undergoing caesarean delivery at Paropakar Maternity and Women's Hospital, Kathmandu, Nepal. Methods Seventy-four patients undergoing caesarean section under spinal anesthesia were randomized to receive TAP block with bupivacaine (n =37) versus no TAP group (n =37), in addition to analgesia with intravenous paracetamol 1gram 6 hourly. At the end of the surgery, an ultrasound-guided TAP block was given bilaterally using 0.25% bupivacaine or no TAP block. Each patient was assessed postoperatively at regular intervals up to 24 hours for numerical pain rating scale and requirement of pethidine. SPSS version 20.0 software was used. Demographic data were analyzed using Student’s t-test and Mann–Whitney U-test. Results The TAP block with bupivacaine compared with no TAP group reduced the postoperative numerical pain rating scale. The time to first analgesic demand time was shorter in the control group (79.05±26.99) minutes compared to the bupivacaine group (416.75±87.29) minutes (P

DOI: https://doi.org/10.3126/jcmc.v9i1.23790 Fetal liver tumors represent approximately 5% of all congenital tumors and hemangiomas account for approximately 15% of all fetal liver tumors. Hemangioma and hemangioendothelioma are benign vascular tumors but they are associated with a significant morbidity and mortality due to high output congestive heart failure and arteriovenous shunting. Ultrasound features of hepatic hemangioma can overlap with arteriovenous malformation. This is a case report of fetal hepatic hemangioma with aretriovenous shunting detected on routine anomaly scan at 20 weeks of gestation in 22 years old Nepalese women who was asymptomatic. Prenatally, a 3.2cm x 2.8cm multicystic mass was seen in the left hypochondrium of the fetal abdomen displacing the stomach. On color Doppler examination, the mass showed internal color flow and multiple tortuous dilated vessels noted around the lesion. After counseling regarding the lesion to the mother and her family; decision to abort the fetus was made. Autopsy was done for the final diagnosis of the lesion, which showed vascular mass in the left lobe of liver insinuating between stomach and spleen. Keywords: Arteriovenous shunting, Fetal Hepati Hemangioma, Utrasonography

Aims: To correlate the level of lumbar puncture used for subarachnoid block in parturient undergoing elective cesarean delivery between palpation and ultrasound method; and to find its accuracy. Methods: This is an observational study, conducted in 314 parturient undergoing elective caesarean delivery under spinal anesthesia over the period of three months at Paropakar Maternity and Women's Hospital Kathmandu. The interspinous space identified by palpation method on lateral position for subarachnoid block and later the site confirmed by ultrasound. Results: In this study, intervertebral space identified by palpation was matched in 38.1% (i.e. 107 in 281 patients) when assessed with ultrasound (USG). In 166 (59.1%) patients, skin puncture level was determined by palpation was found to be one intervertebral space cephalic. In eight (2.8%) patients, one intervertebral space caudal while assed with USG. The correlation between intervertebral space determined by palpation and by ultrasonography was poor (correlation coefficient r=0.288).The kappa was 0.293±0.015. Conclusions: The level of lumbar puncture used for subarachnoid block in elective cesarean delivery by palpation method is poorly correlated (38.1%) with ultrasonographic identification of corresponding interspinous level.

Background Infections are among the leading causes of maternal mortality and morbidity. The Global Maternal Sepsis and Neonatal Initiative, launched in 2016 by WHO and partners, sought to reduce the burden of maternal infections and sepsis and was the basis upon which the Global Maternal Sepsis Study (GLOSS) was implemented in 2017. In this Article, we aimed to describe the availability of facility resources and services and to analyse their association with maternal outcomes. Methods GLOSS was a facility-based, prospective, 1-week inception cohort study implemented in 713 health-care facilities in 52 countries and included 2850 hospitalised pregnant or recently pregnant women with suspected or confirmed infections. All women admitted for or in hospital with suspected or confirmed infections during pregnancy, childbirth, post partum, or post abortion at any of the participating facilities between Nov 28 and Dec 4 were eligible for inclusion. In this study, we included all GLOSS participating facilities that collected facility-level data (446 of 713 facilities). We used data obtained from individual forms completed for each enrolled woman and their newborn babies by trained researchers who checked the medical records and from facility forms completed by hospital administrators for each participating facility. We described facilities according to country income level, compliance with providing core clinical interventions and services according to women's needs and reported availability, and severity of infection-related maternal outcomes. We used a logistic multilevel mixed model for assessing the association between facility characteristics and infection-related maternal outcomes. Findings We included 446 facilities from 46 countries that enrolled 2560 women. We found a high availability of most services and resources needed for obstetric care and infection prevention. We found increased odds for severe maternal outcomes among women enrolled during the post-partum or post-abortion period from facilities located in low-income countries (adjusted odds ratio 1middot84 [95% CI 1middot05-3middot22]) and among women enrolled during pregnancy or childbirth from non-urban facilities (adjusted odds ratio 2middot44 [1middot02-5middot85]). Despite compliance being high overall, it was low with regards to measuring respiratory rate (85 [24%] of 355 facilities) and measuring pulse oximetry (184 [57%] of 325 facilities). Interpretation While health-care facilities caring for pregnant and recently pregnant women with suspected or confirmed infections have access to a wide range of resources and interventions, worse maternal outcomes are seen among recently pregnant women located in low-income countries than among those in higher-income countries; this trend is similar for pregnant women. Compliance with cost-effective clinical practices and timely care of women with particular individual characteristics can potentially improve infection-related maternal outcomes. Funding UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction, WHO, Merck for Mothers, and US Agency for International Development. Copyright (c) 2021 World Health Organization; licensee Elsevier. This is an Open Access article under the CC BY 3.0 IGO license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. In any use of this article, there should be no suggestion that WHO endorses any specific organisation, products, or services. The use of the WHO logo is not permitted. This notice should be preserved along with the article's original URL.

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IntroductionSpinal opioids have gained popularity in recent years as they augment the analgesia produced by local anesthetics. Fentanyl is one of the opioids used for such purpose however the optimal dose has not been described adequately in the literature available so far in our setup. The aim of this study is to find out the effect of adding various doses of Fentanyl to low dose hyperbaric Bupivacaine intrathecally.Materials and methodsSeventy-five parturients scheduled for caesarean delivery were randomly allocated into three groups (Bupivacaine-Fentanyl) BF10, BF20 and BF30 who received intrathecal 0.5% hyperbaric Bupivacaine 1.6 ml with Fentanyl 10µg, 20 µg and 30 µg respectively. Total volume was made to 2.2ml by adding normal saline. The outcomes measured were peak sensory level, degree of motor block, quality of intraoperative anesthesia, duration of effective analgesia, neonatal APGAR score and side effects were noted if any.ResultsPeak sensory level and degree of motor block was similar in all the groups. Peak sensory level (Thoracic Dermatome) was 4.52± 0.82, 4.32± 0.62 and 4.32± 0.74 (p=0.540) in BF10, BF20 and BF30 respectively. Degree of motor block was not significantly different (p=1.000). Quality of intraoperative anesthesia improved from BF10 to BF20 (P=0.040) but did not improve significantly from BF20 and BF30 (P=0.189). Duration of effective analgesia prolonged as the dose of Fentanyl increased which was in minutes 173.64±41, 216.80±32 and 273.16±35 (p=0.000) in BF10,BF20 and BF30 respectively. Neonatal APGAR scores were similar in all groups and very little adverse effects in higher doses. ConclusionThe combination of 1.6 ml of 0.5% hyperbaric Bupivacaine and 20 µg of Fentanyl intrathecally provides excellent surgical anesthesia, prolonged postoperative effective analgesia with very few side effects. Increasing the dose of Fentanyl beyond it could prolong the postoperative pain relief but at the cost of increased adverse effects.

Background: Spinal anesthesia is the preferred anesthetic technique for cesarean deliveries. But there is a dosage dilemma regarding block to the desired level and preventing hypotension. We aim to study effects of fixed dose with height and weight-adjusted dose of intrathecal 0.5% hyperbaric bupivacaine during elective cesarean section. Methods: Eighty-eight singleton term parturients were enrolled and divided into two groups, Group FD (Fixed Dose) and CD (Calculated Dose) in this prospective, double-blind, randomized controlled trial. Group FD received 2.2 ml and CD received a height and weight adjusted calculated dose based on Harten's chart. Hemodynamic changes, onset time to sensory block to T6, maximum block in 20 minutes, and adverse effects were compared. Results: There was a significant reduction in median drug dosage of 11mg in FD versus 9 mg in CD group. The decrease in the MAP was less in group CD (14.5±2.98) mmHg compared to (17.6±4.66) mmHg in group FD (P= 0.03). The median onset time of spinal block to T6 in group FD of 2 minutes with IQR (2-3) was faster than Group CD 4 minutes with IQR (3-5). The spinal block extended above T4 in the larger number of parturients 23 (52 %) in Group FD than in three (6.8%) in group CD (p

Introduction: Gabapentin is one of the adjuncts when given before surgery as a multi modal analgesia regimen has shown to decrease pain scores and opioid consumption in the first 24 hour after surgery. The aim of the study is to assess total opioid consumption in first 24 hour postoperatively after giving 600 mg of preemptive oral Gabapentin in lower extremity orthopedic surgery done under subarachnoid block. Methods: A randomized single blinded study was conducted for duration of 6 months after approval from institutional review board. A total of 52 American Society of Anesthesiology physical status grade I and II cases were included in the study of which 26 patients received oral Gabapentin two hours prior to surgery and 26 patients in the control group. They were evaluated postoperatively for total opioid consumption in first 24 hours, Visual Analogue Score after 2, 4, 6 and 24 hours at rest. Results: Total opioid consumption in first 24 hours was 74.13 ± 27.78 mg in Gabapentin group versus 123.53 ± 64.48 mg in Control (p = 0.001). VAS score was 1.23 ± 1.47 in Gabapentin group versus 2.12 ± 1.58 in Control group (p=0.04) at 2 hours and 2.19 ± 0.40 in Gabapentin group versus 2.77 ± 1.17 in control group (p=0.02) at 24 hours postoperatively at rest which were found to be statistically significant. Incidence of sedation was minimal and comparable in both groups. Conclusions: Oral Gabapentin 600mg given two hours before surgery reduces total opioid consumption in first 24 hours after surgery and also reduces Visual Analogue score for pain postoperatively at rest in 2 and 24 hours with minimum sedation. Keywords: analgesia; gabapentin; opioid; preemptive; sedation; visual analogue score.

Background In some developing countries a woman’s decision to utilize maternal health care services is not made by the woman herself but by other family members. The perception of family members regarding who is the most influential person for making the decision to utilize these services is inconclusive. Hence, this study aimed to determine the perceived influential person on utilization of antenatal care (ANC) and delivery care services among teen, young adult and adult pregnant women from the perspective of the woman themselves, their husband and their mother-in-law, identify the factors associated with the woman being the most influential person, and assess the level of agreement between the woman’s and her husband’s response to the woman being the most influential person. Methods A cross-sectional study was conducted at Paropakar Maternity and Women’s Hospital and Tribhuvan University Teaching Hospital. Purposive sampling technique was used to select 315 women of which 105 were from each age group and their accompanied husbands (n = 315) and mothers-in-law (n = 315). The proportion of perceived influential person and mean priority score of the perceived influence with its 95% confidence interval was calculated. The factors associated with the woman perceived as the most influential person were analyzed by multivariate logistic regression model. The agreement was analyzed using kappa statistic. Results Among teens and young adults and their husband and mother-in-law, the woman’s husband was perceived as the most influential person. Among adults, the most influential person for ANC was the woman herself but for delivery care was the woman’s husband. A woman of adult age, having a non-indigenous ethnicity or who was not referred was more likely to perceive herself as the most influential person in the decision to utilize delivery care. A fair to poor level of agreement was found on the perception of the most influential person for ANC and delivery care utilization. Conclusions Both women and their husbands influenced the decision to utilize ANC and delivery care but husbands were more influential, especially in teens and young adults. Thus, husband’s involvement is crucial as a strategy to improve maternal health care utilization in Nepal. Electronic supplementary material The online version of this article (doi:10.1186/1742-4755-11-92) contains supplementary material, which is available to authorized users.