Elaine L. Ross

Nulliparous active labor, epidural analgesia, and cesarean delivery for dystocia.

OBJECTIVE Our purpose was to examine the effect of epidural analgesia on dystocia-related cesarean delivery in actively laboring nulliparous women. STUDY DESIGN Active labor was confirmed in nulliparous women by uterine contractions, cervical dilatation of 4 cm, effacement of 80%, and fetopelvic engagement. Patients were randomized to one of two groups: epidural analgesia or narcotics. A strict protocol for labor management was in place. Patients recorded the level of pain at randomization and at hourly intervals on a visual analog scale. Elective outlet operative vaginal delivery was permitted. RESULTS One hundred women were randomized. No difference in the rate of cesarean delivery for dystocia was noted between the groups (epidural 8%, narcotic 6%; p = 0.71). No significant differences were noted in the lengths of the first (p = 0.54) or second (p = 0.55) stages of labor or in any other time variable. Women with epidural analgesia underwent operative vaginal delivery more frequently (p = 0.004). Pain scores were equivalent at randomization, but large differences existed at each hour thereafter. The number of patients randomized did not achieve prestudy estimates. A planned interim analysis of the results demonstrated that we were unlikely to find a statistically significant difference in cesarean delivery rates in a trial of reasonable duration. CONCLUSIONS With strict criteria for the diagnosis of labor and with use of a rigid protocol for labor management, there was no increase in dystocia-related cesarean delivery with epidural analgesia.

Prophylactic Angiotensin II infusion during spinal anesthesia for elective cesarean delivery

Background Angiotensin II may prove useful in treating regional anesthesia‐induced hypotension in obstetric patients, because it causes less uterine vasoconstriction than do other vasoconstrictor drugs (such as phenylephrine). This study compared (1) maternal blood pressure and heart rate and (2) fetal status at delivery in parturients given either prophylactic angiotensin II or ephedrine infusion during spinal anesthesia for elective cesarean delivery. Methods Fifty‐four women were randomized to receive either angiotensin II or ephedrine infusion intravenously during spinal anesthesia for elective cesarean section delivery. Simultaneous with subarachnoid injection, infusion of angiotensin II (2.5 [micro sign]g/ml) or ephedrine (5 mg/ml) was initiated at 10 ng [middle dot] kg‐1 [middle dot] min‐1 and 50 [micro sign]g [middle dot] kg‐1 [middle dot] min‐1, respectively. The rate of each infusion was adjusted to maintain maternal systolic blood pressure at 90–100% of baseline. Results Cumulative vasopressor doses (mean +/‐ SD) through 10, 20, and 30 min were 150 +/‐ 100, 310 +/‐ 180, and 500 +/‐ 320 ng/kg in the angiotensin group and 480 +/‐ 210, 660 +/‐ 390, and 790 +/‐ 640 [micro sign]g/kg in the ephedrine group. Maternal heart rate was significantly higher (P < 0.001) during vasopressor infusion in the ephedrine group than in the angiotensin group. Umbilical arterial and venous blood pH and base excess were all significantly higher (P < 0.05) in the angiotensin group than in the ephedrine group. Conclusions Angiotensin II infusion maintained maternal systolic blood pressure during spinal anesthesia without increasing maternal heart rate or causing fetal acidosis.

Maternal Hypoglycemia: Is It Associated with Adverse Perinatal Outcome?

OBJECTIVE:To determine if maternal hypoglycemia is associated with adverse perinatal outcome, particularly low birth weight.STUDY DESIGN:In this prospective study, all patients after 24 weeks’ gestation were screened for gestational diabetes using 50 gm of glucola (oral) followed by a 1-hour plasma glucose measurement and hypoglycemia was defined as ≤88 mg/dl.RESULTS:In these 426 women the mean (± SD) 1-hour plasma glucose value was 99.8 ± 22.7 mg/dl. Of these, 16 were diagnosed with gestational diabetes and 46 were lost to follow-up leaving 364 patients; 116 with hypoglycemia and 248 with euglycemia. Women with hypoglycemia weighed less at the beginning of pregnancy and at delivery, but total weight gain during pregnancy was similar between both groups. There was no difference between groups in maternal symptomatology, birth weight, or the rate of fetal growth restriction.CONCLUSION:Hypoglycemia on the 1-hour glucola screen is not predictive of fetal growth restriction or other adverse perinatal consequence.