Figure 1 - uploaded by Grace Lim
Content may be subject to copyright.
Subject areas of obstetric anesthesiology research advancements on maternal and neonatal outcomes over the last decade. Bubble size indicates relative impact of each topic.
Source publication
Obstetric anesthesia has evolved over the course of its history to encompass comprehensive aspects of maternal care, ranging from cesarean delivery anesthesia and labor analgesia to maternal resuscitation and patient safety. Anesthesiologists are concerned with maternal and neonatal outcomes, and with preventing and managing complications that may...
Context in source publication
Context 1
... and ongoing research in obstetric anesthesiology has contributed to a substantial reduction of anesthesia-related maternal mortality. 5 Obstetric anesthesiologists have contributed to interdisciplinary initiatives advancing maternal safety (Figure 1). Randomized control trials and impact studies improved understanding that neuraxial labor analgesia does not independently influence the risk for cesarean delivery. ...
Citations
... La hipotensión es una de las complicaciones más comunes, causada por la anestesia espinal o epidural, lo que puede resultar en mareos, náuseas y, en casos graves, hipoperfusión de órganos vitales (28). La dificultad respiratoria es otra complicación materna, especialmente asociada con la anestesia general, que puede causar depresión respiratoria y requerir intervención médica para garantizar una adecuada oxigenación (29). ...
... En cuanto a las complicaciones neonatales, la depresión respiratoria es una preocupación importante, ya que algunos medicamentos anestésicos pueden cruzar la placenta y afectar al recién nacido, resultando en una respiración deficiente al nacer (29,30). Además, la exposición a la anestesia puede afectar la capacidad del recién nacido para adaptarse a su nuevo entorno, lo que puede requerir intervención médica adicional (28). ...
La anestesia obstétrica es esencial en las cesáreas, pero aún enfrenta desafíos. Esta revisión analiza las innovaciones y desafíos recientes en este campo para mejorar la atención y resultados en pacientes. Objetivo: Analizar las innovaciones en anestesia obstétrica para cesáreas, con el fin de mejorar la atención y resultados obstétricos y neonatales. Metodología: Se establecieron criterios de inclusión para seleccionar estudios en inglés o español desde 2018. Se realizó una búsqueda en bases de datos reconocidas y se extrajeron datos relevantes para identificar tendencias. Resultados: La anestesia general y regional son las modalidades principales. La primera se reserva para urgencias o cuando no es posible la regional. La regional, como la epidural y raquídea, ofrece una opción segura y efectiva en la mayoría de los casos. En situaciones de emergencia, se han utilizado nuevas combinaciones anestésicas. La técnica combinada espinal-epidural (CEE) ofrece rapidez y prolongación del bloqueo. Otra combinación, epidural seguida de anestesia general, se usa cuando se necesita un rápido inicio de la anestesia general después de un bloqueo epidural insuficiente. Además, el bloqueo transverso del plano abdominal (TAP) ha ganado popularidad por su efectividad y reducción de efectos secundarios. Conclusiones: La selección cuidadosa del tipo de anestesia en cesáreas es crucial para la seguridad materno-fetal. Las nuevas combinaciones anestésicas ofrecen opciones seguras y efectivas en diferentes escenarios, resaltando la importancia de evaluar cada caso individualmente.
... Hypotension usually occurs in the first few minutes after SA and it is related to sympathetic preganglionic nerve fiber blockade [7]. The severity and duration of hypotension may cause not only maternal symptoms (such as nausea, vomiting and dyspnea), but also fetal complications [8]. Nausea and vomiting are significantly more frequent during SA for CS than during non-obstetric surgery. ...
Background: The aim of our study was to investigate the prevalence of perioperative hypotension after spinal anesthesia for cesarean section using non-invasive continuous hemodynamic monitoring and its correlation with neonatal well-being. Methods: We included 145 patients. Spinal anesthesia was performed with a combination of hyperbaric bupivacaine 0.5% (according to a weight/height scheme) and fentanyl 20 μg. Hypotension was defined as a mean arterial pressure (MAP) < 65 mmHg or <60 mmHg. We also evaluated the impact of hypotension on neonatal well-being. Results: Perioperative maternal hypotension occurred in 54.5% of cases considering a MAP < 65 mmHg and in 42.1% with the more conservative cut-off (<60 mmHg). Severe neonatal acidosis occurred in 1.4% of neonates, while an Apgar score ≥ 9 was observed in 95.9% at 1 min and 100% at 5 min. Conclusions: Continuous non-invasive hemodynamic monitoring allowed an early detection of maternal hypotension leading to a prompt treatment with satisfactory results considering neonatal well-being.
... Additionally, no significant difference was detected regarding maternal-neonatal outcomes and labor interventions of interest; such as the need for instrumental delivery; postpartum bleeding; the use of uterotonics and transfusion; as well as severe adverse perinatal outcomes, such as stillbirth beyond 39 weeks, uterine rupture, maternal/neonatal mortality and neonatal brain injury; even if neonates in the VBAC group were significantly heavier than those in the comparison group. The later finding is also consistent with previous studies as neonates of multiparous women are heavier than these of nulliparous women [36]. Finally, women in the case group were older, which is a reasonable finding taking into consideration the completion of a previous full term pregnancy and maternal leave of absence until the next pregnancy. ...
Unlabelled:
Trial of labor after cesarean (TOLAC) is an alternative to repeated cesarean for women with singleton pregnancy and one previous transverse lower segment cesarean section (LSCS), resulting in most cases being a successful vaginal birth after cesarean section (VBAC). The primary objective of this study was to examine if the progress and the duration of the active first stage and the second stage of labor in nulliparous women with singleton pregnancy, spontaneous start of labor and vaginal birth differ from primiparous women succeeding VBAC after one previous elective LSCS in a country with a low cesarean section and high VBAC rate. Secondary objectives were to compare labor interventions and maternal-neonatal outcomes between the two groups.
Methods:
This is a retrospective comparative study. Data were collected in a four-year period at the departments of Obstetrics and Gynecology at Kristianstad and Ystad hospitals in Sweden. Out of 14,925 deliveries, 106 primipara women with one previous elective LSCS and a spontaneous labor onset in the subsequent singleton pregnancy were identified. Of these women, 94 (88.7%) delivered vaginally and were included in the study (VBAC group). The comparison group included 212 randomly selected nulliparous women that had a normal singleton pregnancy, spontaneous labor onset and delivered vaginally.
Results:
The rate of cervical dilation during the active first stage of labor as well as the duration of the second stage did not differ between the two groups. When adjusting for cervical dilation at admission, there was no significant difference between the two groups regarding the duration of the active phase of the first stage of labor. No significant differences were found in maternal-neonatal outcomes between the two groups except for higher birth weight in the VBAC group. The use of epidural analgesia was associated with slower dilation rhythm over the duration of the active phase and second stage of labor, need for labor augmentation, postpartum bleeding and need for transfusion at higher rates, irrespective of parity when epidural was used.
Conclusions:
Our study provides evidence that in women with one previous elective LSCS undergoing TOLAC in the subsequent pregnancy resulting in vaginal birth, the progress and duration of labor are not different from those in nulliparous women when labor is spontaneous and the it is a singleton pregnancy. The use of epidural was associated with prolonged labor, need for labor augmentation and higher postpartum bleeding, irrespective of parity. This information may be useful in patient counseling and labor management in TOLAC.
... Протягом останніх трьох десятиліть зберігався тренд до збільшення частоти використання реґіонарних методів знеболювання пологів. Сьогодні частота використання ЕА пологів у розвинених країнах коливається в межах 60-80% [5,6,14]. ...
... Оцінка за шкалою Апгар та аналіз лактату та pH пуповинної крові доводять мінімальний вплив даних методів знеболювання на дитину, ці дані сходяться з даними проведеного огляду Grace Lim та співавт. [6]. ...
... Відповідно до наявних даних проведеного огляду Grace Lim та співавт. [6], не відмічено збільшення частоти виконання кесаревого розтину за використання регіонарних методів знеболювання. ...
Epidural analgesia (EA), most commonly used for labor analgesia, is an effective and relatively safe technique, but may be associated with slow onset, inadequate block. The use of Dural puncture epidural (DPE) is designed to find a balance between improving the quality of analgesia and reducing the frequency of side effects. Purpose - to compare two methods of labor analgesia. Materials and methods. All women (n=80) were divided into two groups: the Group I (n=40) used DPE, the Group II (n=40) used EA. In both groups, the same technique of epidural puncture and catheterization was used, in the Group I additionally puncture of the dura mater. Analgesia was evaluated using the visual analog pain rating scale (VAS). The quality and effectiveness of analgesia, the hemodynamics of the woman were evaluated. Complications and unwanted effects were recorded. Fetal condition: cardiotocography (CTG), umbilical cord blood lactate, pH. A statistical analysis of the obtained data was carried out. Results. The first contraction (VAS1) in the Group I were fixed on 11.43.3 min, and in the Group II on 21.57.2 min (p0.05). Monolateral block in the Group I - 4 (10%) versus 10 (25%) (p0.05). Contractions (VAS 1) after 30 min in the Group II - 7 (17.5%) versus the absence of such in the Group I. Stroke volume in the Group I decreased by 2.1% versus 1.5% in the Group II. The data for hypotension and occurrence of complications, CTG, cord blood lactate, and pH were not different by group. Conclusions. The use of the DPE technique against EA gives better results in terms of the quality and effectiveness of analgesia. The mother’s hemodynamics remained stable when using DPE. The DPE technique does not increase the frequency of complications compared to EA. There was no difference between the groups when assessing the state of the fetus according to CTG data, pH indicators and umbilical cord blood lactate. The research was carried out in accordance with the principles of the Helsinki Declaration. The study protocol was approved by the Local Ethics Committee of participating institution. The informed consent of the patient was obtained for conducting the studies. No conflict of interest was declared by the author.
... [2][3][4] Despite multidisciplinary efforts to improve maternal safety, significant health care disparities continue to disproportionally impact pregnant patients within racial and ethnic marginalized groups in the USA. 5,6 Based on the analysis of national data, Black patients have a 2.4-3.3-times higher risk for pregnancy-related deaths than White patients do. ...
... Second, although we focused on health services or outcomes related to obstetric anesthesia, clinical decisions for labouring patients are shared between anesthesiologists, obstetricians, and other stakeholders. 6 Findings may reflect clinical views or systematic issues outside of obstetric anesthesia. We also searched for articles published in 2000 and beyond and may have missed key articles published earlier. ...
Purpose:
Health disparities continue to affect racial and ethnic marginalized obstetric patients disproportionally with increased risk of Cesarean delivery and pregnancy-related death. Yet, the literature on what influences such disparities in obstetric anesthesia service and its clinical outcomes is less well known. We set out to describe racial and ethnic disparities in obstetric anesthesia during the peripartum period in the USA via a scoping review of the recent literature.
Source:
Using the Institute of Medicine's definition of disparities, we searched the National Library of Medicine's PubMed/Medline, Embase, Web of Science, APA PsycINFO, and Google Scholar for articles published between 1 January 2000 and 30 June 2022 to identify literature on racial and ethnic disparities in obstetric anesthesia.
Principal findings:
Out of 8,432 articles reviewed, 15 met our inclusion criteria. All but one study was observational. Seven studies were single-institutional while the remaining used multicentre data/databases. All studies compared two or more race and ethnicity classifications. Studies in this review described disparities in the use of labour epidural analgesia, labour epidural request timing, anesthesia for Cesarean deliveries, postpartum pain management, and epidural blood patch for postdural puncture headaches. Several studies reported disparities observed in the unadjusted models becoming no longer significant when adjusted for other covariates.
Conclusion:
Based on the findings of the present scoping review on racial and ethnic disparities in obstetric anesthesia, we present an evidence map identifying knowledge gaps and propose a future research agenda.
... However, the side effects, especially those related to the mode of delivery and neonatal outcomes, are of great concern. Some studies reported that LA is associated with the potential hazards of cesarean section (CS), instrumental vaginal delivery (IVD), and adverse neonatal outcomes [6][7][8][9][10][11][12]. While many studies from Europe and the United States concluded that epidural analgesia does not increase the risk of CS or adverse neonatal outcomes [13][14][15], Seybe a1111111111 a1111111111 a1111111111 a1111111111 a1111111111 et al. indicated that epidural analgesia in Asians may increase the risk of emergency CS (ECS) with an adjusted odds ratio (AOR) of 2.35 (95% confidence interval [95%CI] 1.04-5.34) ...
... This results showed that LA also increases the risk of IVD. While some studies reported that LA is not associated with the increased risk of IVD [15], many other studies, including a systematic review by Lieberman et al. [8], reported the association between LA and an increased risk of IVD [7,9,10,13]. Lieberman et al. estimated a pooled odds ratio of 2.2 (95% CI 1.3-7.8) ...
Labor analgesia (LA) is associated with the potential hazard of high-risk delivery, such as cesarean section (CS) and instrumental vaginal delivery (IVD), and adverse neonatal outcomes such as neonatal asphyxia and respiratory distress. The objective was to examine the impact of LA on mode of delivery and neonatal outcomes and to counsel pregnant women about a potentially higher risk and allow them to decide LA or non-LA. This retrospective cohort study containing 5,184 pregnant women analyzed the association between LA and both mode of delivery and neonatal outcomes. LA increased the risk of IVD (Adjusted Odds Ratio [AOR] 3.25, 95% confidence interval [95%CI] 2.51-4.20) but decreased that of CS (AOR 0.52, 95%CI 0.44-0.60). Two factors (advanced maternal age [AOR 1.70, 95%CI 1.33-2.17] and primipara [AOR 4.72, 95%CI 3.30-6.75]) increased the risk of IVD. We should carefully consider the indication of LA for cases with these two factors since LA can increase the risk of IVD and adverse neonatal outcomes.
... Cardiac output studies have shown that SA has a biphasic effect, in which cardiac output initially increases following a reduction in afterload from arterial vasodilatation and subsequently decreases due to a reduced preload [2]. Hypotension affects both the mother and fetus, including maternal nausea, vomiting, dizziness, rare loss of consciousness, cardiac arrest, and death [27]; and fetal symptoms, including low Apgar scores and low umbilical arterial pH (umbilical acidosis), have been shown to be associated with the duration and severity of hypotension [28]. Hypotension may be related to maternal and neonatal morbidity. ...
Background and aims
This consensus statement presents a comprehensive and evidence-based set of guidelines that modify the general European or US guidelines for hypotension management with vasopressors during cesarean delivery. It is tailored to the Southeast Asian context in terms of local human and medical resources, health system capacity, and local values and preferences.
Methods and results
These guidelines were prepared using a methodological approach. Two principal sources were used to obtain the evidence: scientific evidence and opinion-based evidence. A team of five anesthesia experts from Vietnam, the Philippines, and Thailand came together to define relevant clinical questions; search for literature-based evidence using the MEDLINE, Scopus, Google Scholar, and Cochrane libraries; evaluate existing guidelines; and contextualize recommendations for the Southeast Asian region. Furthermore, a survey was developed and distributed among 183 practitioners in the captioned countries to gather representative opinions of the medical community and identify best practices for the management of hypotension with vasopressors during cesarean section under spinal anesthesia.
Conclusions
This consensus statement advocates proactive management of maternal hypotension during cesarean section after spinal anesthesia, which can be detrimental for both the mother and fetus, supports the choice of phenylephrine as a first-line vasopressor and offers a perspective on the use of prefilled syringes in the Southeast Asian region, where factors such as healthcare features, availability, patient safety, and cost should be considered.
... The mechanisms through which epidural analgesia increases neurodevelopmental delay risk remain unknown. Although epidural analgesia is known to prolong the duration of labor [40], prolonged labor has not been demonstrated to be associated with increased risk of ASD [41][42][43]. Qiu et al. [21] therefore suggested that prolonged exposure to anesthesia may be a risk factor for ASD. ...
Background: Epidural analgesia relives pain during labor. However, the long-term effects on neurodevelopment in children remain unclear. We explored associations between exposure to epidural analgesia during labor and childhood neurodevelopment during the first 3 years of life, in the Japan Environment and Children’s Study (JECS), a large-scale birth cohort study.
Methods: Pregnant women were recruited between January 2011 and March 2014, and 100,304 live births of singleton children born at full-term by vaginal delivery, and without congenital diseases were analyzed. Data on mothers and children were collected using a self-administered questionnaires and medical record transcripts. The children’s neurodevelopment was repeatedly assessed for five domains (communication, gross motor, fine motor, problem solving, and personal-social), using the Ages and Stages Questionnaires, Third Edition, at six time points from age 6 to 36 months. After adjusting for potential confounders, the associations between exposure to epidural analgesia during labor and children’s neurodevelopment at each time point were assessed.
Results: Of the 42,172 children with valid data at all six time points, 938 (2.4%) were born to mothers who received epidural analgesia during labor. Maternal exposure to epidural analgesia was associated with neurodevelopmental delays during the first 3 years after birth. Delay risks in gross and fine motor domains were the greatest at 18 months (adjusted odds ratio (aOR) [95% confidence interval (CI)]: 1.40 [1.06, 1.84] and 1.54 [1.17, 2.03], respectively), subsequently decreasing. Delay risks in communication and problem-solving domains were significantly high at 6 and 24 months, and remained significant at 36 months (aOR [95% CI]: 1.40 [1.04, 1.90] and 1.28 [1.01, 1.61], respectively). Exposure to epidural analgesia was also associated with the incidence of problem solving and personal-social delays from 18 to 24 months old. Neurodevelopmental delay risks, except for communication, were dominant in children born to mothers aged ≥30 years at delivery.
Conclusions: This study showed that maternal exposure to epidural analgesia during labor was associated with neurodevelopmental delays in children during the first 3 years after birth.
... Spinal anestezi; kolay uygulanması, etkisinin hızlı başlaması ve iyi bir duyusal blok sağlaması nedeniyle elektif sezaryen doğumlarda kullanılan en yaygın tekniktir [1]. Spinal anesteziye bağlı hipotansiyon (SABH), elektif sezaryen vakalarının %70-80'inde karşımıza çıkar ve hem maternal hem de fetal ciddi yan etkilere neden olur [2]. ...
Objective: Spinal anesthesia is the preferred technique in cesarean delivery. Hypotension (>80%) is the most common and concerning adverse effect (>80%) if no prophylaxis is given, which is major cause of maternal and fetal morbidity. Current literature suggests that vasopressor therapy is mainstay in prevention and management of spinal anesthesia-induced hypotension. Here, we aimed to compared effects of prophylactic intravenous ephedrine and norepinephrine boluses on hypotension incidence in elective cesarean delivery under spinal anesthesia. Method: The study included 62 term pregnant women (ASA II) with baseline systolic blood pressure (SBP) of 90-140 mmHg who were scheduled for elective cesarean section under spinal anesthesia. Ephedrine (10 mg, IV bolus) and norepinephrine (6 µg, IV bolus) were given simultaneously with spinal induction in group E and N, respectively. Hypotension was defined as SBP below 90% of baseline value (10% decrease from baseline) and respective agents in each group were given at same doses for treatment. Findings: Hypotension incidence was comparable in group E and N (64.5% vs. 74.2%, respectively). Severe hypotension (defined as SBP
... · Providing adequate postoperative analgesia and preventing postoperative nausea and vomiting (PONV). Mothers with poorly managed postoperative pain and vomiting will have difficulty breastfeeding (15,16). · Identifying and providing early treatment for low blood pressure after spinal techniques and for postpuncture headache, as they can interfere with effective breastfeeding (17). ...
... Anesthetists must identify a strategy to avoid postoperative pain, considering that many intravenous opioids (most widely used in immediate postoperative pain) can interfere with effective breastfeeding, particularly when given in repeated doses, and prioritize regional techniques (neuraxial morphine or abdominal wall block). Adequate pain management after cesarean section has been found to be associated with increased neonatal ponderal index gain (15). ...
The importance of breastfeeding with its positive impact on the wellbeing of the mother-infant pair is well established. Anesthesiologists should encourage the promotion of lactation by being willing to give reassurance during the preoperative period and preparing a plan that does not interfere with safe breastfeeding. There is concern regarding the transfer of drugs into breast milk, which may lead to inconsistent advice from many health professionals and to early discontinuation. However, evidence shows that most anesthetic drugs are safe in terms of transfer into breast milk, and hence, compatible with breastfeeding, which should be resumed after anesthesia as soon as the mother is alert and feels well enough to hold her infant, without the need to “pump and dump”. This review provides pharmacokinetic information on commonly used anesthesia drugs and their passage into breast milk, to help practitioners discuss risks and benefits with the mother, emphasizing that anesthesia should not interfere with the benefits of breastfeeding. Four practical clinical scenarios are presented: pregnant women concerned about the effect of epidural analgesia on subsequent breastfeeding, spinal anesthesia for c-section and lactation, patients who will receive general anesthesia during cesarean section, and finally women who are breastfeeding and require anesthesia for elective or urgent surgery. Neuraxial anesthesia allows for better pain control and immediate skin-to-skin contact at the time of childbirth. Also, it interferes the least with the woman’s ability to care for her infant. Regional techniques, opioid-sparing techniques and outpatient surgery are preferred. Drugs such as opioids and longer-acting benzodiazepines should be administered cautiously, particularly in repeat doses.
