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Background: Nitrous oxide (N2O) has been used nationally as an analgesic in many clinical settings. While neuraxial analgesia is still the most commonly used labor analgesic in the United States, there is increasing use of N2O in labor. Given the reduction in the partial pressure of gases at a higher altitude, N2O has been reported to have reduced analgesic properties. However, there is no study to date evaluating the impact of altitude on labor analgesia and N2O., Methods: We conducted a multicenter retrospective data analysis of a N2O registry collected from 4 institutions over a 3-year period. We compared the impact of altitude on 50% N2O administration for labor analgesia, conversion rates to another analgesic modality, as well as collected side effect frequencies and conversion predictors. Multivariable regression models were used to compare clinical characteristics and outcomes between parturients at high and low altitudes, while adjusting for race, ethnicity, education, and age (logistic and linear regressions for categorical and quantitative outcomes, respectively)., Results: A total of 1856 laboring parturients (age 18-50) were included in the analysis. The odds of converting from 50% N2O to another analgesic modality had no statistically significant difference between high- versus low-altitude institutions (adjusted odds ratio [aOR], 1.13; 95% confidence interval [CI], 0.90-1.42; P = .3). Yet, when parturients at low altitude converted from N2O, they were more likely (aOR, 3.03; 95% CI, 1.59-5.88) to choose neuraxial analgesia instead of another analgesic modality when compared to high-altitude parturients. This is possibly due to higher epidural rates at the low-altitude institutions. When parturients at high altitude did convert into another modality, they were more likely (aOR, 2.19; 95% CI, 1.14-4.21) to convert due to inadequate pain relief compared to low-altitude parturients; however, missing data may have affected this finding. Laboring individuals at low altitude were significantly more likely to experience side effects (aOR, 2.13; 95% CI, 1.45-3.12). Those requiring labor augmentation, assisted vaginal, or cesarean delivery converted to neuraxial analgesia significantly more often than those that delivered via spontaneous vaginal delivery (P < .05) in both high- and low-altitude groups., Conclusions: This is the first study evaluating 50% N2O as a labor analgesic at high altitude. As expected, we found lower side effects at high altitude, likely due to the lower partial pressure of N2O. However, there was not a statistically significant increase in conversion from N2O to another analgesic modality at high altitude and no clinically significant differences in neonatal outcomes., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2021 International Anesthesia Research Society.)

Background: The proportion of live births by cesarean delivery (CD) in China is significant, with some, particularly rural, provinces reporting up to 62.5%. The No Pain Labor & Delivery-Global Health Initiative (NPLD-GHI) was established to improve obstetric and neonatal outcomes in China, including through a reduction of CD through educational efforts. The purpose of this study was to determine whether a reduction in CD at a rural Chinese hospital occurred after NPLD-GHI. We hypothesized that a reduction in CD trend would be observed., Methods: The NPLD-GHI program visited the Weixian Renmin Hospital, Hebei Province, China, from June 15 to 21, 2014. The educational intervention included problem-based learning, bedside teaching, simulation drill training, and multidisciplinary debriefings. An interrupted time-series analysis using segmented logistic regression models was performed on data collected between June 1, 2013 and May 31, 2015 to assess whether the level and/or trend over time in the proportion of CD births would decline after the program intervention. The primary outcome was monthly proportion of CD births. Secondary outcomes included neonatal intensive care unit (NICU) admissions and extended NICU length of stay, neonatal antibiotic and intubation use, and labor epidural analgesia use., Results: Following NPLD-GHI, there was a level decrease in CD with an estimated odds ratio (95% confidence interval [CI]) of 0.87 (0.78-0.98), P = .017, with odds (95% CI) of monthly CD reduction an estimated 3% (1-5; P < .001), more in the post- versus preintervention periods. For labor epidural analgesia, there was a level increase (estimated odds ratio [95% CI] of 1.76 [1.48-2.09]; P < .001) and a slope decrease (estimated odds ratio [95% CI] of 0.94 [0.92-0.97]; P < .001). NICU admissions did not have a level change (estimated odds ratio [95% CI] of 0.99 [0.87-1.12]; P = .835), but the odds (95% CI) of monthly reduction in NICU admission was estimated 9% (7-11; P < .001), greater in post- versus preintervention. Neonatal intubation level and slope changes were not statistically significant. For neonatal antibiotic administration, while the level change was not statistically significant, there was a decrease in the slope with an odds (95% CI) of monthly reduction estimated 6% (3-9; P < .001), greater post- versus preintervention., Conclusions: In a large, rural Chinese hospital, live births by CD were lower following NPLD-GHI and associated with increased use of labor epidural analgesia. We also found decreasing NICU admissions. International-based educational programs can significantly alter practices associated with maternal and neonatal outcomes., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2020 International Anesthesia Research Society.)

Purpose of Review: Recognition of the increasing maternal mortality rate in the United States has been accompanied by intense efforts to improve maternal safety. This article reviews recent advances in maternal safety, highlighting those of particular relevance to anesthesiologists., Recent Findings: Cardiovascular and other chronic medical conditions contribute to an increasing number of maternal deaths. Anesthetic complications associated with general anesthesia are decreasing, but complications associated with neuraxial techniques persist. Obstetric early warning systems are evolving and hold promise in identifying women at risk for adverse intrapartum events. Postpartum hemorrhage rates are rising, and rigorous evaluation of existing protocols may reveal unrecognized deficiencies. Development of regionalized centers for high-risk maternity care is a promising strategy to match women at risk for adverse events with appropriate resources. Opioids are a growing threat to maternal safety. There is growing evidence for racial inequities and health disparities in maternal morbidity and mortality., Summary: Anesthesiologists play an essential role in ensuring maternal safety. While continued intrapartum vigilance is appropriate, addressing the full spectrum of contributors to maternal mortality, including those with larger roles beyond the immediate peripartum time period, will be essential to ongoing efforts to improve maternal safety.

Pain relief is an important component of modern obstetric care and can be produced by neuraxial, systemic, or inhalational analgesia or various physical techniques. We review the most recent evidence on the efficacy and safety of these techniques. Over the past decade, the availability of safer local anaesthetics, ultra-short acting opioids, combined spinal-epidural needles, patient-controlled analgesic devices, and ultrasound have revolutionised obstetric regional analgesia. Recent meta-analyses have supported epidural analgesia as the most efficacious technique, as it leads to higher maternal satisfaction and good maternal and fetal safety profiles. We examine the controversies and myths concerning the initiation, maintenance, and discontinuation of epidural analgesia. Recent evidence will also be reviewed to address concerns about the effects of epidural analgesia on the rates of instrumental and operative delivery, lower back pain, and breastfeeding. New developments in labour analgesia are also discussed., Competing Interests: As an editor of the journal, MG Irwin was not involved in the peer review process of the article. The other authors have no conflicts of interest to disclose.

The "What's New in Obstetric Anesthesia Lecture" is presented every year at the annual meeting of the Society for Obstetric Anesthesia and Perinatology. This lecture was established in 1975 to update the membership on the most relevant articles that were published in the preceding calendar year. In 1995, the lecture was renamed as the "Ostheimer Lecture" in honor of Gerard W. Ostheimer, an obstetric anesthesiologist from the Brigham and Women's Hospital with significant contributions in the field. This review summarizes key articles published in 2017 that were presented in the 2018 Ostheimer Lecture with a focus on opioid prescriptions, anesthesia for external cephalic version, labor analgesia, maternal morbidity, and global health. A proposed list of action items based on the 2017 literature is also presented.

Background: The clinical use of epidural analgesia has changed over past decades. Minimally invasive surgery and emergence of alternative analgesic techniques have led to an overall decline in its use. In addition, there is increasing awareness of the patient-specific risks for complications such as spinal haematoma and abscess. Local guidelines for management of severe neurological complications during or after epidural analgesia, ie, "epidural alert systems", have been introduced in hospitals to coordinate and potentially streamline early diagnosis and treatment. How widely such protocols have been implemented in daily practice is unknown., Methods: We conducted a survey to analyse trends in practice, key indications, safety measures, safety reporting, and management of complications of epidural analgesia in the Netherlands. Data were gathered using a web-based questionnaire and analysed using descriptive statistics., Results: Questionnaires from 85 of all 94 Dutch hospitals performing epidural analgesia were collected and analysed, a 90% response rate. Fifty-five percent reported a trend towards decreased use of perioperative epidural analgesia, while 68% reported increasing use of epidural analgesia for labour. Reported key indications for epidural analgesia were thoracotomy, upper abdominal laparotomy, and abdominal cancer debulking. An epidural alert system for neurological complications of epidural analgesia was available in 45% of hospitals., Conclusions: This national audit concerning use and safety of epidural analgesia demonstrates that a minority of Dutch hospitals have procedures to manage suspected neurological complications of epidural analgesia, whereas in the remaining hospitals responsibilities and timelines for management of epidural emergencies are determined on an ad hoc basis., (© 2018 The Acta Anaesthesiologica Scandinavica Foundation. Published by John Wiley & Sons Ltd.)

Drug poisoning deaths have more than doubled in the United States since 2000 with fentanyl and fentanyl analogues primarily responsible for the jump in opioid deaths. Robust data indicate a convincing correlation between the exposure of the fetus to other labor medications (morphine, pethidine hydrochloride, barbiturates, phenobarbitone, meperidine, and secobarbital) and the later addiction of young adults to the same category of drug. We present the hypothesis that this effect is also true of the opioid, fentanyl: there is a causal relationship between the increased popularity of fentanyl as a labor anesthetic in the United States since the 1980's and the current epidemic of fentanyl abuse., (Copyright © 2018 The Authors. Published by Elsevier Ltd.. All rights reserved.)

What We Already Know About This Topic: WHAT THIS ARTICLE TELLS US THAT IS NEW: BACKGROUND:: Neuraxial labor analgesia may benefit obese women by optimizing cardiorespiratory function and mitigating complications related to emergency general anesthesia. We hypothesized that obese women have a higher rate of neuraxial analgesia compared with nonobese parturients., Methods: Using U.S. natality data, our cohort comprised 17,220,680 deliveries, which accounts for 61.5% of 28 million births in the United States between 2009 and 2015. We examined the relationships between body mass index class and neuraxial labor analgesia, adjusting for sociodemographic, antenatal, pregnancy, and peripartum factors., Results: The study cohort comprised 17,220,680 women; 0.1% were underweight, 12.7% were normal body mass index, 37% were overweight, and 28.3%, 13.5%, and 8.4% were obesity class I, II, and III, respectively. Rates of neuraxial analgesia by body mass index class were as follows: underweight, 59.7% (9,030/15,128); normal body mass index, 68.1% (1,487,117/2,182,797); overweight, 70.3% (4,476,685/6,368,656); obesity class I, 71.8% (3,503,321/4,881,938); obesity class II, 73.4% (1,710,099/2,330,028); and obesity class III, 75.6% (1,089,668/1,442,133). Compared to women with normal body mass index, the likelihood of receiving neuraxial analgesia was slightly increased for overweight women (adjusted relative risk, 1.02; 95% CI, 1.02 to 1.02), obese class I (adjusted relative risk, 1.04; 95% CI, 1.04 to 1.04), obese class II (adjusted relative risk, 1.05; 95% CI, 1.05 to 1.05), and obese class III (adjusted relative risk, 1.06; 95% CI, 1.06 to 1.06)., Conclusions: Our findings suggest that the likelihood of receiving neuraxial analgesia is only marginally increased for morbidly obese women compared to women with normal body mass index.

Neuraxial labor analgesia can be initiated via combined spinal-epidural (CSE) or stand-alone epidural. Pros and cons of these techniques are outlined in this review. In recent years computer-integrated patient-controlled epidural analgesia (CI-PCEA) and programed intermittent epidural boluses (PIEB) have been developed, adding to continuous infusion and PCEA for the maintenance of neuraxial analgesia. Postdural puncture headache (PDPH) and fever can occur secondary to labor epidural that both have clinical relevance for the care givers. Insights into the mechanism of epidural fever and treatment strategies for PDPH are outlined. Due to the increase in obesity the specific considerations for this patient group are discussed. New data have been presented for remifentanil, an ultra-shortly acting opioid, that is used in obstetric analgesia. Without breaking new data, the use of nitrous oxide especially by midwives has a kind of renaissance, and this will be discussed, too.

Neuraxial analgesia is considered the gold standard in labour analgesia, providing the most effective pain relief during childbirth. Improvements have enhanced the efficacy and safety of epidural analgesia through better drugs, techniques and delivery systems. This review describes the history of epidural labour analgesia and recent improvements in labour epidural analgesia. We discuss the role of the combined spinal epidural technique, low-concentration local anaesthetic-opioid epidural solutions, patient-controlled epidural analgesia, and programmed intermittent or automated mandatory boluses in the maintenance of epidural labour analgesia. We also review the newer interactive techniques for drug delivery, such as computer-integrated patient-controlled epidural analgesia and variable frequency automated mandatory bolus. Finally, we discuss future clinical research developments, including the use of data analytics and long-term outcomes associated with childbirth pain management., (Copyright © 2017 Elsevier Ltd. All rights reserved.)

Background: Obstetric Anesthesia Workforce Surveys were conducted in 1981, 1992, and 2001, and the 10-year update was conducted in 2012. Anesthesia providers from US hospitals were surveyed to identify the methods used to provide obstetric anesthesia. Our primary hypothesis was that the provision of obstetric anesthesia services has changed in the past 10 years., Methods: A sample of hospitals was generated based on the number of births per year and US census region. Strata were defined as follows: I ≥ 1500 annual births (n = 341), II ≥ 500 to 1499 annual births (n = 438), and III < 500 annual births (n = 414). Contact email information for the anesthesia provider in charge of obstetric services was obtained by phone call. Electronic questionnaires were sent through email., Results: Administration of neuraxial (referred to as "regional" in previous surveys) labor analgesia was available 24 hours per day in all stratum I hospitals responding to the survey. Respondents across all strata reported high rates of in-house coverage, with 86.3% (95% confidence interval [CI] = 82.7%-90%) of stratum I providers reporting that they provided in-house anesthesiology services for obstetrics. The use of patient-controlled epidural analgesia in stratum I hospitals was reported to be 35% in 2001 and 77.6% (95% CI = 73.2%-82.1%) in this survey. Independent Certified Registered Nurse Anesthetists were reported to provide obstetric anesthesia services in 68% (95% CI = 57.9%-77.0%) of stratum III hospitals. Although 76% (95% CI = 71.2%-80.3%) of responding stratum I hospitals allow postpartum tubal ligations, 14% report inadequate staffing to provide anesthesia either always or at off-hours., Conclusions: Since 2001, there have been significant changes in how responding hospitals provide obstetric anesthesia care and staff the labor and delivery ward. Obstetric anesthesia surveys, updated every 10 years, continue to provide information about changes in obstetric anesthesia practice.

Background: Variability in the mean durations of labor analgesia for vaginal delivery among hospitals is unknown. Such differences in means among hospitals would influence appropriate equitable fee-for-service payment to US anesthesia groups. Equitable payment is the foundational principle of relative value unit payment, which, for anesthesia in the United States, means use of the American Society of Anesthesiologist's Relative Value Guide., Methods: We analyzed data from the American Society of Anesthesiologists' Anesthesia Quality Institute to test whether there are large differences in mean durations of labor analgesia for vaginal delivery among US hospitals. We choose the statistical methodology for that analysis using detailed data from 2 individual hospitals. Analyses of the means were performed for the 172 hospitals reporting a total of at least 200 durations; having no greater than 5.0% of durations 1.0 hour or less; and at least 5 four-week periods each having a mean of at least one epidural every couple of days. The 172 hospitals provided for n = 5671 combinations of hospital and 4-week period and 551,707 labor epidurals, with an overall mean duration of 6.12 hours (SE, 0.001 hour)., Results: 55.2% of the 172 hospitals had mean durations of labor analgesia for vaginal delivery that each differed (P < 0.001) from the overall mean. Among those 55.2% were the 9.9% of hospitals with means ≤5.12 hours. Those mean durations on the low end ranged from 2.68 (SE, 0.17) to 5.10 (SE, 0.07) hours. Also, among the 55.2% were the 12.2% of hospitals with means ≥7.12 hours. Those mean durations at the high end ranged from 7.13 (SE, 0.08) to 12.03 (SE, 0.23) hours. The heterogeneity in the mean durations among hospitals would have been greater had the inclusion criteria not been applied., Conclusions: Our results show that the number of labor epidurals alone is not a valid measure to quantify obstetrical anesthesia productivity. In addition, payment to US anesthesia groups for labor analgesia based solely on the number of labor epidurals initiated is not equitable. Previous work showed lack of validity and equality of payment based on face-to-face time with the patient (i.e., like a surgical anesthetic). The use of base and time units, with one time unit per hour, is a suitable payment system.

Background: The purpose of this national survey was to determine current anesthesia practices for cesarean delivery in the Czech Republic., Methods: In November 2011, we invited all departments of obstetric anesthesia in the Czech Republic to participate in a prospective study to monitor consecutive peripartum obstetric anesthesia procedures. Data were recorded online in the TrialDB database (Yale University, New Haven, CT)., Results: The response rate was 51% (49 of 97 departments); participating centers represented 60% of all births in the country during the study period. There were 1943 cases of peripartum anesthesia care, of which 1166 cases (60%) were anesthesia for cesarean delivery. Estimates were weighted based on population distribution of cesarean delivery among types of participating centers. Neuraxial anesthesia was used in 55.6% (95% confidence interval [CI], 52.8%-58.5%); the distribution of anesthesia techniques differed among type of participating center. The rate of neuraxial anesthesia in university hospitals was 55.6% (95% CI, 51.5%-59.6%), 32.4% (95% CI, 26.4%-39.0%) in regional hospitals, and 60.7% (95% CI, 55.2%-66.0%) in local hospitals. The reasons for cesarean delivery under general anesthesia were emergency procedure (67%), refusal of neuraxial blockade by parturient (30%), failure of neuraxial anesthesia (6%), and preoperative administration of low-molecular-weight heparin (3%). Postcesarean analgesia was primarily provided by systemic opioid (66%) and nonopioid analgesics (61%), solely or in combination. Epidural postoperative analgesia was used in 14% of cases. Compared with national neuraxial anesthesia rate data published in the 1990s (6.7% in 1993), there has been an upward trend in the use of neuraxial anesthesia for cesarean delivery during the 21st century (40.5% in 2000) in the Czech Republic., Conclusions: The rate of neuraxial anesthesia use for cesarean delivery has increased in the Czech Republic in the last 2 decades. However, the current rate of general anesthesia is high compared with other Western countries.

Approximately 60% of women who labour in the USA receive some form of neuraxial analgesia, but concerns have been raised regarding whether it negatively impacts the labour and delivery process. In this review, we attempt to clarify what has been established as truths, falsities and uncertainties regarding the effects of this form of pain relief on labour progression, negative and/or positive. Additionally, although the term 'epidural' has become synonymous with neuraxial analgesia, we discuss two other techniques, combined spinal-epidural and continuous spinal analgesia, that are gaining popularity, as well as their effects on labour progression., (© 2014 Royal College of Obstetricians and Gynaecologists.)

Objective: To describe trends in the use of epidural analgesia (EA) and to evaluate the association of EA with operative deliveries., Study Design: In this population-based, retrospective cohort study, women with an intention to deliver vaginally of a term, cephalic, singleton between 2000 and 2009 (n=1378458) were included. Main outcome measures were labor EA rates, unplanned caesarean section (CS), and instrumental vaginal delivery (IVD) including deliveries by either vacuum or forceps. Data were obtained from the Perinatal Registry of The Netherlands and logistic regression analyses were used., Results: Among nulliparous, EA use almost tripled over the 10-year span (from 7.7% to 21.9%), while rates of CS and IVD did not change much (+2.8% and -3.3%, respectively). Among multiparous, EA use increased from 2.4% to 6.8%, while rates of CS and IVD changed slightly (+0.8% and -0.7%, respectively). Multivariable analysis showed a positive association of EA with CS, which weakened in ten years, from an adjusted OR of 2.35 (95% CI, 2.18 to 2.54) to 1.69 (95% CI, 1.60 to 1.79; p<0.001) in nulliparous, and from an adjusted OR of 3.17 (95% CI, 2.79 to 3.61) to 2.56 (95% CI, 2.34 to 2.81; p<0.001) in multiparous women. A weak inverse association between EA and IVD was found among nulliparous (adjusted OR, 0.76; 95% CI, 0.75 to 0.78), and a positive one among multiparous women (adjusted OR, 2.08; 95% CI, 2.00 to 2.16). Both associations grew slightly weaker over time., Conclusions: A near triplication of EA use in The Netherlands in ten years was accompanied by relatively stable rates of operative deliveries. The association between EA and operative delivery became weaker. This supports the idea that EA is not an important causal factor of operative deliveries., (Copyright © 2014 Elsevier Ireland Ltd. All rights reserved.)

This review summarises the current (and controversial) topics in the field of anaesthesia and analgesia in obstetrics. In the British report "Saving mothers' lives 2006-2008" it is shown that the direct causes of maternal deaths are as before mainly sepsis, preeclampsia and eclampsia, thrombosis, thromboembolisms, and amniotic fluid embolism as well as haemorrhagic complications. Deaths associated with anaesthesia still involve airway complications. In the "closed claims" in U.S. American statistics, in the meantime ones finds maternal and perinatal deaths and brain damage to be less frequent whereas liability claims due to nerve damage and back pain have increased, presumably as a result of the change away from the use of general anaesthesia to the use of regional anaesthesia in obstetrics., (© Georg Thieme Verlag Stuttgart · New York.)

In the new millennium, the horizons of modern anesthesia practice continue to expand beyond the provision of surgical anesthesia to encompass areas outside of the operating room, including preoperative evaluation, labor analgesia, postanesthesia care, critical care and acute and chronic pain management. Adequate postoperative analgesia following caesarean delivery hastens ambulation, decreases maternal morbidity, improves patient outcome, and facilitates care of the newborn. There is currently no "gold standard" for post-cesarean pain management. The number of options is large and the choice of the method of pain control is determined by drug availability, institutional protocols, individual preferences, available resources, and financial considerations. This article provides an overview of the currently available methods of post-cesarean analgesia.

The trial of labor analgesia in Japan dates back to the year 1929. After the foundation of the original Japan Society of Obstetric Anesthesia and Perinatology in 1961, various labor analgesia techniques were widely attempted. Some anesthetists relieved the labor pain with balanced anesthesia using intravenous (diazepam and pethidine during the 1st stage of labor, followed by pentobarbital or ketamine during the 2nd stage of labor) combined with inhalational anesthetic (methoxyflurane or enflurane), while the others tried regional anesthesia. In 1990's, epidural analgesia with bupivacaine became more popular as a standard method of labor analgesia. Recently, the choice of local anesthetic has changed to ropivacaine or levobupivacaine, and in most cases combined with an opioid. Combined spinal-epidural analgesia or patient-controlled epidural analgesia has also been accepted in some hospitals, because these techniques may lessen the total consumption of local anesthetics and also induce mothers' satisfaction. However, the ideal labor analgesia technique has been still controversial. We, obstetric anesthesiologists, should grope for safer and more comfortable anesthetics to the mother and fetus. In next 50 years, the standard method for labor analgesia may change to no needle system with non-placental transfer anesthetics.

Background: Since January 2005 the Regional Government of Lombardia, a large Italian region with over 1/5 of all Italian births, allocated public funds for 3 consecutive years to help provide epidural analgesia (EA) for women in labor. The aim of the present study was to evaluate the trend of diffusion of EA in the triennium 2005-2007., Methods: Data obtained from regional Obstetric Departments, recognized by the National Health Care System, were elaborated by the Epidemiological Service of Regione Lombardia. The software looked for specific codes for vaginal deliveries, with or without EA, and Cesarean sections included in the administrative patient records., Results: A substantial increase in epidurals administered in comparison to total vaginal deliveries was recorded after assignment of regional financing: from 8.2% in 2005, to 10.4% in 2006 and 12.9% in 2007 (P<0.0001). More than 60% of epidurals were performed in 8 hospitals with >2 000 births per year. The rate of EAs in these hospitals was 18% in 2005, 22% in 2006 and 24.9% in 2007. In the 69 hospitals with <2000 births per year, the rate of EAs was markedly lower: 4% in 2005, 5.5% in 2006 and 7.8% in 2007. In both cases, the increase was statistically significant (P<0.0001). At the three-year time-point, the rate of Cesarean sections did not change., Conclusions: The continuous increase of EA for labor after regional financings suggests that the low rate of pain relief procedures in Lombardia was mainly due to economic and organizational issues, rather than to cultural and psychological factors.

The authors identify the effects which epidural analgesia can have on the final stages of child birth, observing the neonatal (Apgar) results in births which used epidural analgesia, comparing the results in births in the years 2000 and 2006. Transversal retrospective study. Those interested can consult an extensive statistical annex which the authors prepared in order to carry out their project.

At the Kagoshima City Hospital, the epidural labor analgesia is not given by anesthesiologists. Education of the pregnant woman as well as medical staff and the sufficint manpower are necessary. Furthermore, satisfactory cooperation between obstetricians and anesthesiologists together with the maternity ward increases the safety of epidural labor analgesia.

Background: Experience from our hospital has shown a significant increase in the use of epidural analgesia during labour. We wanted to see if this was a general trend in Norway, and wanted to find out for what kind of labour analgesia was offered in the different labour wards., Material and Method: A questionnaire concerning obstetric analgesia and anaesthetic methods for caesarean section was sent to chief anaesthetists and head midwives in Norwegian hospitals. The information was compared to an identical questionnaire from 1996. In addition, data concerning obstetric analgesia was collected from the Norwegian Medical Birth Register. 77% of the anaesthetic departments and 88% of the labour wards responded to the questionnaire., Results: The use of epidural analgesia was on an average 20.6% (range 0-40.5%), which is twice as much as in 1996. 75% answered that the parturients' wish for epidural analgesia was reason enough to give an epidural. 84% of caesarean sections were performed in regional anaesthesia and 16% were done in general anaesthesia. This represents a significant reduction in the use of general anaesthesia. 85% of the labour wards offered acupuncture, which is a tremendous increase compared to 1996. Systemic opioids are still widely used, and pethidine is still the most frequently used opioid. Pethidine's negative side effect profile has been widely focused on during the past decade. The hospital's information on the various analgesic methods available for labour analgesi, is clearly improved since 1996., Conclusion: Obstetric analgesia in Norwegian hospitals has improved substantially since the last survey.

With the acceptance of new ideas in medicine and modernization of life styles, it is necessary to conduct delivery as a beautiful act of giving life with the least amount of pain possible using epidural anesthesia. Thus, not only is the physical aspect of delivery improved but also benefits from anesthesia are seen in obstetrics. To conduct epidural anesthesia successfully during delivery, certain conditions are necessary regarding the fetus and mother. Such conditions include an adequate Bishop score, fetal head presentation, the presence of amnion, adequate term of delivery and Doppler flows that do not compromise vaginal delivery. Primiparas in term pregnancies without pathological conditions related to mother or fetus were examined. The duration of delivery was observed in a group of primiparas that did not receive epidural anesthesia (group A) and a group of primiparas that received epidural anesthesia (group B). The study lasted one year.

Maternal heart disease complicates 0.2-3% of pregnancies. The optimal management of the pregnant patient with cardiac disease depends on the cooperative efforts of the obstetrician, the cardiologist and the anesthesiologist involved in peripartum care. A comprehensive understanding of physiology of pregnancy and pathophysiology of underlying cardiac disease is of primary importance in provision of obstetric analgesia or anesthesia for this high-risk group of patients. This article will review the current guidelines and standards pertinent to management of obstetric analgesia and anesthesia in parturients with cardiac disease.

The authors review the changes in obstetric anesthesia and analgesia that have contributed to a decreased maternal mortality as well as those accounting for the clinically significant improvements of maternal and neonatal morbidity.

Regional analgesia and anesthesia for obstetrical patients are undergoing revolutionary changes which will, ultimately, benefit parturients and neonates. These changes have taken place in the arena of techniques, equipment, as well as in medications. This review will cover the management techniques both for vaginal delivery and cesarean section.