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Background Postpartum depression (PPD) is the most common complication after childbirth, affecting 10–15% of women. It is associated with serious long-term consequences for the mother and family. Whether or not neuraxial labor analgesia mitigates the risk is uncertain and controversial. The purpose of this review was to summarize studies investigating the association between neuraxial labor analgesia and the incidence of PPD. Methods A systematic literature search for randomized controlled trials and cohort studies reporting the incidence of PPD among parturients who received neuraxial analgesia compared with non-neuraxial or no analgesia. The primary outcome was the incidence of PPD between 5 and 12 weeks’ postpartum. Depression was diagnosed using a cutoff score of ≥10 on the Edinburgh Postnatal Depression scale, a validated screening tool. The risk of bias of each study was evaluated, and odds ratios and 95% confidence intervals calculated from raw data or reported as adjusted odds ratios. Results Eleven observational studies involving 5717 patients were included. Three studies had a critical risk, three a serious risk, and five a moderate risk of bias. Two studies reported significantly lower odds for PPD associated with neuraxial analgesia compared with non-neuraxial or no analgesia, whereas the odds ratios in the remaining nine studies were not significantly different. Conclusions Our systematic review did not find compelling evidence for an association between PPD and labor analgesia. Studies were heterogenous in nature and had a high risk of bias. Further research controlling for confounding factors is recommended to determine if a relationship exists.

Caesarean delivery is the most commonly performed inpatient surgical procedure globally. Pain after caesarean delivery is moderate to severe if not adequately treated, and is a primary anaesthetic concern for patients. Transversus abdominis plane and quadratus lumborum blocks are fascial plane blocks that have the potential to improve analgesia following caesarean delivery. Although proponents of the quadratus lumborum block suggest that this technique may provide better analgesia compared with transversus abdominis plane block, there are limited data directly comparing these two techniques. We, therefore, performed a systematic review and network meta-analysis to compare transversus abdominis plane and quadratus lumborum block approaches, seeking randomised controlled trials comparing both techniques to each other, or to control, with or without intrathecal morphine. In all, 31 trials with 2188 patients were included and our primary outcome, the cumulative intravenous morphine equivalent consumption at 24 h, was reported in 12 trials. In the absence of intrathecal morphine, transversus abdominis plane and quadratus lumborum blocks were equivalent, and both were superior to control (moderate-quality evidence). In the presence of intrathecal morphine, no differences were found between control, transversus abdominis plane and quadratus lumborum blocks (moderate-quality evidence). Similar results were found for resting and active pain scores at 4-6 h, 8-12 h, 24 h and 36 h, although quadratus lumborum block was associated with lower pain scores at 36 h when compared with transversus abdominis plane block (very low-quality evidence). However, transversus abdominis plane block was associated with a reduced incidence of postoperative nausea and vomiting (moderate-quality evidence) and sedation when compared with inactive control following intrathecal morphine administration (low-quality evidence). There are insufficient data to draw definitive conclusions, but transversus abdominis plane and quadratus lumborum block appear to be superior to control in the absence of intrathecal morphine, but provide limited additional benefit over inactive control when intrathecal morphine is also used.

Spinal anaesthesia for caesarean section commonly causes maternal hypotension. This systematic review and network meta-analysis compared methods to prevent hypotension in women receiving spinal anaesthesia for caesarean section. We selected randomised controlled trials that compared an intervention to prevent hypotension with another intervention or inactive control by searching MEDLINE and Embase, Web of Science to December 2018. There was no language restriction. Two reviewers extracted data on trial characteristics, methods and outcomes. We assessed risk of bias for individual trials (Cochrane tool) and quality of evidence (GRADE checklist). We assessed 109 trials (8561 women) and 12 different methods that resulted in 30 direct comparisons. Methods ranked by OR (95%CI) from most effective to least effective were: metaraminol 0.11 (0.04-0.26); norepinephrine 0.13 (0.06-0.28); phenylephrine 0.18 (0.11-0.29); leg compression 0.25 (0.14-0.43); ephedrine 0.28 (0.18-0.43); colloid given before induction of anaesthesia 0.38 (0.24-0.61); angiotensin 2, 0.12 (0.02-0.75); colloid given after induction of anaesthesia 0.52 (0.30-0.90); mephentermine 0.09 (0.01-1.30); crystalloid given after induction of anaesthesia 0.78 (0.46-1.31); and crystalloid given before induction of anaesthesia 1.16 (0.76-1.79). Phenylephrine caused maternal bradycardia compared with control, OR (95%CI) 0.23 (0.07-0.79). Ephedrine lowered umbilical artery pH more than phenylephrine, standardised mean difference (95%CI) 0.78 (0.47-1.49). We conclude that vasopressors should be given to healthy women to prevent hypotension during caesarean section with spinal anaesthesia.

A structured approach to hemorrhagic emergencies in obstetrics has gained popularity with the implementation of massive hemorrhage protocols. The trauma literature suggests that routine quality reviews should be in place to improve patient outcomes. The aim of this study was to develop quality indicators and assess compliance by the clinical team.A multidisciplinary team set the institutional quality indicators for the massive hemorrhage protocol review. A retrospective review of all obstetrical massive hemorrhage protocol activation events from September 2010 to January 2015 was performed. All protocol events occurred before the creation of the quality indicators. Data were retrieved from patient records.There were 17 (0.09%) protocol activations for 19 790 deliveries during the study period. All 17 (100%) patients received at least one unit of red blood cells. Overactivation, defined as the transfusion of2 units of red blood cells, occurred in two cases (12%). Common causes of non-compliance were: 24% (4/17) temperature monitoring, 18% (3/17) lactate measurement, 41% (7/17) arterial blood gas sampling, and 18% (3/17) hemoglobin maintenance within the target range of 55-95 g/L. Admission to intensive care and peripartum hysterectomy occurred in 12 and 5 cases (71% and 29%), respectively.Suboptimal compliance was found in multiple areas, which may be attributable to the low frequency of activation of our massive haemorrhage protocol in obstetrics. The quality targets identified in this report can act as a basis for other institutions developing quality indicators to evaluate performance.

Background: Transesophageal echocardiography has important applications for the management of the critically ill patient. There is a need to develop effective training programs for the critical care community in acquiring skill at critical care transesophageal echocardiography. Objective: We studied the effectiveness of a 1-day simulation-based course that focused on the acquisition of skill in the performance of critical care transesophageal echocardiography. Methods: Learners received training in image acquisition with a transesophageal simulator and training in image interpretation in small group sessions. Skill at image acquisition and image interpretation was assessed at the beginning and at the completion of the course. Results: There were 27 learners who attended the course. Pre and post knowledge scores were 55 (19; mean [SD]) and 88 (9; P < .0005), respectively. Pre and post image acquisition scores were 3.6 (3.7) and 9.9 (0.3; P < .0001), respectively. Conclusions: A 1-day course in critical care transesophageal echocardiography that combined case-based image interpretation with image acquisition training using a simulator improved technical skills and knowledge base.

Team-based training and simulation can improve patient safety, by improving communication, decision making, and performance of team members. Currently, there is no general consensus on whether or not a specific assessment tool is better adapted to evaluate teamwork in obstetric emergencies. The purpose of this qualitative systematic review was to find the tools available to assess team effectiveness in obstetric emergencies.We searched Embase, Medline, PubMed, Web of Science, PsycINFO, CINAHL, and Google Scholar for prospective studies that evaluated nontechnical skills in multidisciplinary teams involving obstetric emergencies. The search included studies from 1944 until January 11, 2016. Data on reliability and validity measures were collected and used for interpretation. A descriptive analysis was performed on the data.Thirteen studies were included in the final qualitative synthesis. All the studies assessed teams in the context of obstetric simulation scenarios, but only six included anesthetists in the simulations. One study evaluated their teamwork tool using just validity measures, five using just reliability measures, and one used both. The most reliable tools identified were the Clinical Teamwork Scale, the Global Assessment of Obstetric Team Performance, and the Global Rating Scale of performance. However, they were still lacking in terms of quality and validity.More work needs to be conducted to establish the validity of teamwork tools for nontechnical skills, and the development of an ideal tool is warranted. Further studies are required to assess how outcomes, such as performance and patient safety, are influenced when using these tools.

This systematic review and network meta-analysis (NMA) compared postoperative analgesic efficacy of transversus abdominis plane (TAP) blocks with that of wound infiltration for Cesarean delivery (CD) without long-acting neuraxial opioid administration. We sought randomized-controlled trials comparing TAP vs wound infiltration, and inactive control vs either TAP or wound infiltration. Wound infiltration included single-dose infiltration (WI), or continuous infusion via a catheter (WC). The primary outcome was 24 hr opioid consumption. Secondary outcomes included 12 and 24 hr pain scores (resting and movement), time to first analgesia request, incidence of postoperative nausea and vomiting (PONV), maternal sedation, and pruritus. We performed a NMA incorporating both direct and indirect comparisons and reported standardized mean differences and odds ratios with 95% confidence intervals for continuous and dichotomous outcomes. Forty-two studies were included, comprising 2,906 participants. Transversus abdominis plane blocks and WC were associated with significantly lower 24 hr opioid consumption than inactive controls, but there were no significant differences between WI and inactive controls. There was no statistically significant difference in 24 hr opioid consumption between TAP blocks and WC or WI techniques. The network ranking of treatments was TAP block, followed by WC or WI. No significant differences were shown between TAP, WC, and WI groups for 24 hr pain scores, time to first analgesia, PONV, sedation, and pruritus. Quality of evidence was moderate for most of the outcomes assessed. In the absence of long-acting neuraxial opioid after CD, single-dose TAP blocks and WC are effective opioid-sparing strategies.

Introduction There have been numerous reports studying the effect of neuraxial analgesia on breastfeeding success, but the results are inconsistent. Methods We performed a literature search in various databases for studies comparing neuraxial analgesia to non-neuraxial or no analgesia. Outcomes were the percentage of women breastfeeding fully or mixed with formula. Where possible, nulliparous parturients were analyzed separately. We conducted an analysis excluding studies of serious and critical risk of bias. Odds ratios and 95% confidence intervals were calculated. Results We included 15 studies (13 observational studies, 1 secondary analysis of a randomized controlled trial, 1 case-control study) with 16,112 participants. Overall, there were 6 studies that found no difference between groups, 6 studies that showed a significantly lower incidence of breastfeeding in the neuraxial group and 3 studies finding mixed results (at some time-points statistically significant and at some time-point statistically non-significant results). In nulliparous only studies, 2 found no difference between study groups, 1 found a lower breastfeeding rate in the neuraxial group and 3 studies showed mixed results. Excluding studies with a serious and critical risk of bias, 1 study found no difference between study groups, 3 studies found a decrease of breastfeeding rates in the neuraxial group, and 1 study showed mixed results. Discussion In our review we found a high disparity in results. One reason is probably the high potential of confounding (immediate skin to skin placement, maternity leave etc.). Education programs and breastfeeding support are likely more important in determining long term breastfeeding success.

Bupivacaine is a commonly used local anaesthetic for spinal anaesthesia for caesarean section, but may produce prolonged motor block, delaying discharge from the post-anaesthesia care unit. Ropivacaine may have a shorter time to recovery of motor function compared with bupivacaine. We performed a meta-analysis to assess the time difference in duration of motor block with intrathecal ropivacaine compared with bupivacaine for caesarean section.We searched MEDLINE, EMBASE and Cochrane Central Register of Controlled Trials databases for randomised controlled trials comparing ropivacaine with bupivacaine in parturients undergoing elective caesarean section under spinal anaesthesia. The primary outcome was the duration of motor block. Secondary outcomes included the time to onset of sensory block, need for conversion to general anaesthesia and the incidence of hypotension.Thirteen trials comprising 743 spinal anaesthetics were included. Intrathecal ropivacaine resulted in a reduced duration of motor block, regressing 35.7min earlier compared with intrathecal bupivacaine (P0.00001). There was no difference in the time to onset of sensory block (P=0.25) or the incidence of hypotension (P=0.10). Limited data suggested no difference in the rate of conversion to general anaesthesia, but an earlier request for postoperative analgesia with ropivacaine.Compared with bupivacaine, intrathecal ropivacaine is associated with more rapid recovery of motor block despite similar sensory properties and no increased rate of conversion to general anaesthesia. This may be useful in centres in which recovery of motor block is a criterion for discharge from the post-anaesthesia care unit. However, small numbers of trials and significant heterogeneity limit the interpretation of our results.

OBJECTIVE: To perform a systematic review of randomized trials comparing oral versus intravenous iron therapy to treat postpartum anemia. DATA SOURCES: Data sources were: PubMed (1972–2017); Cochrane Central Register of Controlled Trials, CENTRAL (1972–2017); CINAHL (1972–2017); Web of Science; Excerpta Medica Database, and EMBASE (1972–2017). STUDY ELIGIBILITY CRITERIA: We included randomized trials comparing oral versus intravenous iron monotherapy to treat postpartum anemia (classified as a hemoglobin

Congenital adrenal hyperplasia (CAH) refers to a group of autosomal recessive disorders of adrenal steroidogenesis, the most common of which is 21-hydroxylase deficiency. This results in impaired glucocorticoid and, less frequently, mineralocorticoid production, as well as androgen excess. Strategies for medical management that is safe for both mother and fetus will be presented. The anesthetic management of labor and delivery as well as operative deliveries will be discussed.

Hyperosmolar hyperglycemic state (HHS) is a serious complication of diabetes characterized by serum hyperglycemia and hyperosmolarity, without ketoacidosis. Strategies for medical management that are safe for both mother and fetus will be presented. The anesthetic management of labor and delivery as well as operative deliveries will be discussed.

The inherited glycogen storage diseases (GSD) are rare inborn errors of glycogen metabolism. The diseases that survive to adulthood with implications for anesthesia are discussed here. They follow autosomal recessive inheritance. Strategies for medical management that are safe for both mother and fetus will be presented. The anesthetic management of labor and delivery as well as operative deliveries will be discussed.

The syndrome of inappropriate antidiuretic hormone secretion (SIADH) is defined as serum hyponatremia and hypoosmolality resulting from inappropriately high levels of vasopressin, also known as antidiuretic hormone (ADH), which results in impaired water excretion. Strategies for medical management that is safe for both mother and fetus will be presented. The anesthetic management of labor and delivery as well as operative deliveries will be discussed.

Lysosomal storage diseases are a group of rare inherited diseases caused by enzyme deficiencies involved in glycolipid storage. Most are inherited as autosomal recessive disorders, and the majority of patients with lysosomal storage diseases do not survive until adulthood. The diseases that affect adults with implications for anesthesia are considered here: 1. Gaucher disease (GD) is an autosomal recessive disorder, caused by a mutation in lysosomal enzyme acid β-glucocerebrosidase resulting in deficiency or decreased activity. This leads to accumulation of glucocerebroside in monocyte-macrophage cells, infiltrating tissue [1]. 2. Fabry disease is an X-linked disorder due to alpha-galactosidase deficiency. Cells are unable to break down some membrane glycosphingolipids resulting in accumulation in tissues [2].

Interscalene block (ISB) can provide pain relief after shoulder surgery, but a reliable quantification of its analgesic benefits is lacking. This meta-analysis examines the effect of single-shot ISB on analgesic outcomes during the first 48 hours after shoulder surgery.We retrieved randomized and quasirandomized controlled trials examining the analgesic benefits of ISB compared with none in shoulder surgery. Severity of postoperative pain measured on a visual analog scale (10 cm scale, 0 = no pain, 10 = worst pain) at rest at 24 hours was the designated primary outcome. Secondary outcomes included pain severity at rest and with motion at 2, 4, 6, 8, 12, 16, 32, 36, 40, and 48 hours postoperatively. Opioid consumption, postoperative nausea and vomiting, patient satisfaction with pain relief, and postanesthesia care unit and hospital discharge time were also assessed.A total of 23 randomized controlled trials, including 1090 patients, were analyzed. Patients in the ISB group had more severe postoperative pain at rest by a weighed mean difference (95% confidence interval) of 0.96 cm (0.08-1.83; P = 0.03) at 24 hours compared with no ISB, but there was no difference in pain severity beyond that point. The duration of pain relief at rest and with motion after ISB were 8 and 6 hours, respectively, with a corresponding weighed mean difference in visual analog scale pain scores (99% confidence interval) of -1.59 cm (-2.60 to -0.58) and -2.20 cm (-4.34 to -0.06), respectively, with no additional pain relief benefits beyond these points. ISB reduced postoperative opioid consumption up to 12 hours, decreased postoperative nausea and vomiting at 24 hours, and expedited postanesthesia care unit and hospital discharge. The type, dose, and volume of local anesthetic used did not affect the results.ISB can provide effective analgesia up to 6 hours with motion and 8 hours at rest after shoulder surgery, with no demonstrable benefits thereafter. Patients who receive an ISB can suffer rebound pain at 24 hours but later experience similar pain severity compared with those who do not receive an ISB. ISB can also provide an opioid-sparing effect and reduce opioid-related side effects in the first 12 and 24 hours postoperatively, respectively. These findings are useful to inform preoperative risk-benefit discussions regarding ISB for shoulder surgery.

Background Both posterior and lateral transversus abdominis plane (TAP) block techniques provide effective early (0–12 h) postoperative analgesia after transverse incision surgery. However, whether either technique produces prolonged analgesia lasting beyond 12 h remains controversial. This meta-analysis examines the duration of analgesia associated with posterior and lateral TAP blocks in the first 48 h after lower abdominal transverse incision surgery. Methods We retrieved randomized controlled trials (RCTs) investigating the analgesic effects of TAP block compared with control in patients undergoing lower abdominal transverse incision surgery. Outcomes sought included interval postoperative i.v. morphine consumption and also rest and dynamic pain scores at 12, 24, 36, and 48 h postoperatively. Opioid-related side-effects and patient satisfaction at 24 and 48 h were also assessed. The 12–24 h interval morphine consumption was designated as a primary outcome. Results Twelve RCTs including 641 patients were analysed. Four trials examined the posterior technique and eight assessed the lateral technique. Compared with control, the posterior TAP block reduced postoperative morphine consumption during the 12–24 h and 24–48 h intervals by 9.1 mg (95% CI: −16.83, −1.45; P=0.02) and 5 mg (95% CI: −9.54, −0.52; P=0.03), respectively. It also reduced rest pain scores at 24, 36, and 48 h, and also dynamic pain scores at 12, 24, 36, and 48 h. Differences were not significant with the lateral TAP block. Conclusion Based on the comparisons with control, the posterior TAP block appears to produce more prolonged analgesia than the lateral TAP block. Future RCTs comparing these two techniques are required to confirm our findings.

Spinal anaesthesia is the primary anaesthetic technique for many types of surgery. Adjuncts to the local anaesthetics (LA) used in spinal anaesthesia can exhibit undesirable side-effects, limiting their use, but magnesium may have advantages in this respect. We sought randomized control trials (RCTs) in patients undergoing all types of surgery and in women in labour to compare the effect of intrathecal magnesium sulphate ± LA ± lipophilic opioid (experimental group) with the use of either intrathecal lipophilic opioids ± LA or LA only (control group). The primary outcome was the duration of spinal anaesthesia. Secondary outcomes were: onset and time to maximal sensory blockade, onset of motor block, and duration of sensory and motor blockade. We found 15 RCTs comprising 980 patients. The duration of spinal anaesthesia was significantly increased in the experimental group [standardized mean difference (SMD) -1.05 (-1.70, -0.41) (P = 0.001)], compared with the control group. This increased duration of spinal anaesthesia was seen in non-obstetric studies, SMD -1.38 (-2.11, -0.66) (P = 0.0002), but not in obstetric studies, SMD -0.55 (-1.87, 0.77) (P = 0.41). There was no delay in the onset of sensory or motor blockade. The incidence of hypotension and pruritus was similar in both groups. Heterogeneity was high in all outcome measures. The duration of spinal anaesthesia may be increased by the addition of magnesium to lipophilic opioids ± LA.

The intrathecal morphine dose achieving optimal analgesia for cesarean delivery while minimizing side effects has not yet been deduced. In this meta-analysis, our objective was to determine whether low- or high-dose intrathecal morphine provides acceptable duration and intensity of analgesia with fewer side effects.A literature search (PubMed, EMBASE, MEDLINE, Scopus, Web of Science, and CINAHL) was performed to identify randomized controlled trials involving patients undergoing elective cesarean delivery under spinal anesthesia comparing low-dose (LD; 50-100 μg) morphine with higher dose (HD;100-250 μg). The primary outcome was the time for first request for supplemental analgesia. The secondary outcomes included pain scores, morphine use, maternal side effects (vomiting and pruritus), and Apgar scores. Mean differences (MDs) and odds ratios (ORs) were calculated using random effects modeling with 95% confidence intervals (CIs).Eleven articles met our inclusion criteria. Four hundred eighty patients were recruited in all study groups (233 patients in the HD and 247 in the LD groups). The mean time to first analgesic request was longer (MD, 4.49 hours [95% CI, 1.85-7.13]; P = 0.0008) in the HD group compared with the LD group. Pain scores (0-100 scale) at 12 hours (MD, 2.54 [95% CI, -2.55 to 7.63]; P = 0.33) as well as morphine consumption at 24 hours (MD, 1.31 mg [95% CI, -3.06 to 7.31]; P = 0.42) were not significantly different. The incidence of nausea or vomiting (OR, 0.44 [95% CI, 0.27-0.73]; P = 0.002) and pruritus (OR, 0.34 [95% CI, 0.20-0.59]; P = 0.0001) was lower in the LD group. The incidence of Apgar scores7 at 1 minute was not different between groups (OR, 1.11 [95% CI, 0.06-20.49]; P = 0.94).This meta-analysis shows that HDs of intrathecal morphine prolong analgesia after cesarean delivery compared with lower doses. The MD of 4.5 hours (95% CI, 1.9-7.1 and 99% CI, 1.0-8.2 hours) of pain relief must be balanced against the increased risk of maternal pruritus and vomiting. Results from this study can be used by clinicians to weigh the benefits and potential side effects of using HDs of intrathecal morphine for cesarean delivery.

The transversus abdominis plane (TAP) block is a field block that provides postoperative analgesia for abdominal surgery. Its analgesic utility after Caesarean delivery (CD) remains controversial. This systematic review and meta-analysis examines whether TAP block can reduce i.v. morphine consumption in the first 24 h after CD. The authors retrieved randomized controlled trials comparing TAP block with placebo in CD. Postoperative i.v. morphine consumption during the first 24 h was selected as a primary outcome. Pain scores and both maternal and neonatal opioid-related side-effects were secondary outcomes. Where possible, meta-analytic techniques and random effects modelling were used to combine data. Trials were stratified based on whether or not spinal morphine was used as part of the analgesic regimen. Five trials including 312 patients were identified. TAP block reduced the mean 24 h i.v. morphine consumption by 24 mg [95% confidence interval (CI) -39.65 to -7.78] when spinal morphine was not used. TAP block also reduced visual analogue scale pain scores (10 cm line where 0 cm, no pain, and 10 cm, worst pain) by 0.8 cm (95% CI -1.53 to -0.05, P=0.01), and decreased the incidence of opioid-related side-effects. The differences in primary and secondary outcomes were not significant when spinal morphine was used. TAP block provides superior analgesia compared with placebo and can reduce the first 24 h morphine consumption in the setting of a multimodal analgesic regimen that excludes spinal morphine. TAP block can provide effective analgesia when spinal morphine is contraindicated or not used.

Obstructive sleep apnea (OSA) is characterized by upper airway collapse and obstruction during sleep. It is estimated to affect nearly 5% of the general female population. Obesity is often associated with OSA. The physiological changes associated with pregnancy may increase the severity of OSA with a higher risk of maternal and fetal morbidity. However, very few parturients are diagnosed during pregnancy. These undiagnosed parturients pose great challenge to the attending anaesthesiologist during the perioperative period. Parturients at risk should be screened for OSA, and if diagnosed, treated. This review describes the anaesthetic concerns in obese parturients at risk for OSA presenting to the labor and delivery unit.

Neuraxial analgesia is frequently administered to women in labor. For many years, bupivacaine has been used because of its long duration of action, lack of excessive motor block, and minimal fetal and neonatal effects. However, bupivacaine is one of the most cardiotoxic local anesthetics in current use and motor block is still a problem. Many local anesthetics such as bupivacaine exist in 2 forms, levorotatory and dextrorotatory. Ropivacaine, an amide local anesthetic produced in the pure levorotatory form addresses some of the concerns related to bupivacaine. In this article, we present the literature comparing ropivacaine and bupivacaine to determine whether there is an advantage to using one of these local anesthetics for labor analgesia. We found that there is no advantage to the routine use of ropivacaine for labor analgesia.

Purpose of review Labor is among the most painful experiences that humans encounter. Neuraxial analgesia is the most effective means of treating this pain. In this review, we discussed the effect of neuraxial analgesia on the progress of labor when compared with parenteral opioids. We then compared initiation of analgesia with a combined spinal-epidural technique (CSE) to conventional epidural analgesia. Finally we discussed the impact of neuraxial analgesia, given early in labor, compared with later administration. Recent findings Compared with parenteral opioids, neuraxial analgesia does not increase the incidence of cesarean section, although it is associated with a longer (approximately 16 min) second stage of labor. The incidence of operative vaginal delivery is higher in the epidural group but this may be due to indirect reasons such as changes in physician behavior. There was no difference in labor outcome when CSE was compared with low-concentration epidural analgesia, but higher concentrations may prolong labor. Early administration of neuraxial analgesia does not increase the incidence of operative delivery or prolong labor. Summary Neuraxial analgesia does not interfere with the progress or outcome of labor. There is no need to withhold neuraxial analgesia until the active stage of labor.

Clinical identification of lumbar spinous processes is inaccurate in most patients. The purpose of this study was to determine the number of patients required to train anesthesiologists in the use of ultrasound imaging to accurately identify the lumbar spinous processes.In this pilot study, two anesthesiologists studied patients scheduled for a diagnostic computed tomography (CT) scan, including the lumbar spine. Before the CT scan, the anesthesiologist completed a systematic ultrasound scan of the lumbar spine and placed a radio-opaque marker at a designated level. The actual level was determined by a radiologist after reviewing the CT scans. The primary outcome was the number of procedures each anesthesiologist needed (by cumulative sum analysis) to be able to identify the designated spinous process 90% of the time. Secondary outcomes included the overall success rate, the magnitude of the failures (number of segments from the designated spinous process), and the incidence of spinal anomalies and their effect on reliability.We studied 74 patients. One anesthesiologist required 36 patients to meet reliability criteria, whereas the other required 22 patients. The overall accuracy rate was 68%. There were only two patients where the marker was placed more than one segment from the designated spinous process. The incidence of lumbar spine anomalies was 6.8% (n = 5), and 80% (n = 4) of these were associated with inaccurate marker placement.It is possible to use ultrasound scanning to accurately identify the lumbar spinous processes in unselected patients. This result suggests that, with appropriate training, this tool can be used to enhance the accuracy of needle placement during neuraxial techniques.