R. Russell

Intravenous versus oral iron therapy for postpartum anaemia.

Objective  Postpartum iron deficiency anaemia (IDA) is common in women. Most women are treated with either oral iron supplementation or blood transfusion. Hence, the aim of our study was to compare the effect of treatment with either oral ferrous sulphate or intravenous ferrous sucrose on postpartum IDA.

Assessing long term backache after childbirth.

OBJECTIVES--To investigate the factors associated with long term backache after childbirth, to assess all women reporting new onset long term backache, and to investigate any relation with pain relief in labour. DESIGN--Data collected from obstetric records and postal questionnaires or telephone interviews on morbidity after childbirth from all women delivering their first baby between March 1990 and February 1991, followed by analysis of data collected from outpatient consultations. SETTING--St Thomass Hospital, London. SUBJECTS--Questionnaires were sent to 1615 women who had delivered their first baby in the defined period; 1015 either replied by post or were contacted by telephone. RESULTS--299 women (29.5% of responders) reported backache lasting more than six months and of these 156 (15.4%) said they had had no back problems previously. Those women who had received epidural analgesia in labour were significantly more likely to report new onset backache (17.8%; 95% confidence interval 14.8% to 20.8%) than those who did not (11.7%; 8.6% to 14.8%). Younger women, unmarried women, and those reporting other antenatal symptoms were significantly more likely to report new long term backache. The 156 women reporting new backache were asked to attend an outpatient clinic and 36 (23%) did so. The majority had a postural backache which was not severe. Psychological factors were present in 14 women. CONCLUSIONS--Though new long term backache is reported more commonly after epidural analgesia in labour, it tends to be postural and not severe. There were no differences in the nature of the backache between those who had or had not received epidural analgesia in labour.

Epidural infusion of low-dose bupivacaine and opioid in labour : Does reducing motor block increase the spontaneous delivery rate ?

Labouring women were randomly allocated to receive epidural infusions during labour of either 0.125% plain bupivacaine (n = 200) or a combination of 0.0625% bupivacaine with either 2.5μg.ml‐1 fentanyl or 0.25μg.ml‐1 sufentanil (n = 199) each starting at 12 ml.h‐1 and adjusted as necessary to maintain analgesia. The dose of bupivacaine, both hourly (p < 0.001) and total (p < 0.001), was significantly lower in the group receiving the combination. Motor block was significantly less common and less severe in the combination group (p < 0.001). These reductions did not result in a significant increase in spontaneous deliveries. Maternal satisfaction with first (p < 0.001) and second stage analgesia (p < 0.001) was significantly increased in the combination group. The addition of opioid to the epidural infusion did not reduce the incidence of perineal pain. There were no significant differences between the groups in neonatal outcome or the incidence of early postnatal symptoms.

Back pain, pregnancy, and childbirth.

Backache is a common symptom in women of childbearing age. With as many as half of women reporting back pain at some stage during pregnancy,1 2 3 it is perhaps not surprising that many of their carers dismiss it as unimportant. But backache in pregnancy is a substantial problem. Many women are helped by understanding the likely cause of the pain and by advice on prevention and management. There seems to be little difference in the prevalence of backache between pregnant and non-pregnant women.3 4 Of Swedish women questioned between the ages of 38 and 64, two thirds reported experiencing back pain at some time, and only a minority said that it had started in pregnancy.3 4 However, backache experienced during pregnancy is more severe and disabling and present for a greater proportion of the time.1 About 10% of women may be prevented by it from working,2 and over a third report that it interferes with daily life.3 Though non-specific low back pain (radiating classically to buttocks and thighs) is experienced by both pregnant and non-pregnant women, more severe pain arising from sacroiliac dysfunction is particular to pregnancy. It increases in prevalence with gestation concentrations and is often associated with symphyseal pain.2 3 Relaxin, a polypeptide hormone that regulates collagen, softens the ligaments in preparation for parturition. …

The National Institute for Health and Clinical Excellence (NICE) guidelines for caesarean section, 2011 update: implications for the anaesthetist

In 2004 the first National Institute for Health and Clinical Excellence guidelines on caesarean section were published with the aim of providing evidence-based recommendations for best practice. With the publication of new evidence, the guidelines have been revised with the second edition released in 2011. This review highlights the changes that have been made which are of specific relevance to obstetric anaesthetists including planned caesarean section compared with vaginal birth in healthy women with an uncomplicated pregnancy; management of the morbidly adherent placenta; mother-to-child transmission of maternal infections; maternal request for caesarean section; decision-to-delivery interval for emergency caesarean section; timing of antibiotic administration and childbirth after caesarean section.

Epidural infusions for nulliparous women in labour. A randomised double-blind comparison of fentanyl/bupivacaine and sufentanil/bupivacaine.

Sixty nulliparous women received epidural infusions in labour of 0.0625% bupivacaine containing either 2.5 μg.ml−1 of fentanyl or 0.25 μg.ml−1 of sufentanil, each starting at 12 ml.h−1. The duration of each stage of labour did not differ significantly between the groups nor did the mode of delivery. The quality of analgesia in the first and second stages of labour and at delivery was similar in the two groups and there were no significant differences in the bupivacaine dose requirements. In the fentanyl group, 90% of women required one or no top‐ups compared with 87% in the sufentanil group. Five women in the fentanyl group and four in the sufentanil group developed motor blockade, limited to movement of the hip only. Six women (20%) in each group reported pruritus. There were no significant differences in Apgar scores, umbilical cord blood pH levels or neurologic and Actaptive capacity scores at 2 or 24 h. Satisfaction with first and second stage analgesia was high with no differences between the groups. There were no significant differences in the incidence of postnatal symptoms with 52% of women reporting perineal pain and 45% localised backache.

A comparison of epidural diamorphine with intravenous patient‐controlled analgesia using the Baxter infusor following Caesarean section

In a randomised study of analgesia following Caesarean section, we compared the efficacy and side effects of on-demand epidural diamorphine 2.5 mg with intravenous patient-controlled analgesia using diamorphine from the Baxter infusor system. Pain scores fell more rapidly in the epidural group, but by the fourth hour, and thereafter, both techniques had a similar analgesic effect. The patient-controlled analgesia group used significantly more diamorphine (p < 0.001), median 62 mg (range 18-120 mg) compared to the epidural group, median 10 mg (range 2.5-20 mg), over a significantly longer time period (p < 0.001), median 54.25 h (range 38-68 h) compared to the epidural group, median 40.75 h (range 6-70 h). The frequency and severity of nausea, vomiting and pruritus were similar in the two groups, however, the patient-controlled analgesia group were more sedated during the first postoperative day. This reached statistical significance (p < 0.05) between 9-24 h. Overall satisfaction scores (0-100) were high, but the patient-controlled analgesia group scored significantly higher: mean 85.5 (SD 12.2) compared to mean 77.0 (SD 11.7) in the epidural group.

A national survey of support and counselling after maternal death

The 2000–2002 Confidential Enquiry into Maternal and Child Health report highlighted several cases of maternal death where the staff who had been involved, were not offered support. The report recommended that ‘Trusts must make provision for the prompt offer of support and/or counselling for all staff who have cared for a woman who has died.’ We conducted a postal survey to firstly establish whether Trusts had implemented this, and also to ascertain the experience of consultant obstetric anaesthetists. Of 706 respondents (response rate 64%), 60% involved in a maternal death or other traumatic event received no offer of support, 65% were unaware of potential sources of support and only 5% received details of further help available. Furthermore, 69% were unaware of policies within their own Trusts for the provision of support services. We suggest that a formal structure should exist within all units that offers confidential support services and/or debriefing facilities to all staff involved in a maternal death or other traumatic event.

Does the use of low dose bupivacaine/opioid epidural infusion increase the normal delivery rate?

To investigate whether using low dose epidural infusion improves the normal delivery rate, outcome of labour was studied in women with singleton vertex presentations randomised to receive either 0.0625% bupivacaine opioid, or plain bupivacaine 0.125% for labour. The infusion rate was titrated to maintain analgesia and a sensory level to T10. Data were analysed using the unpaired t test, Mann-Whitney U test and for categorical variables chi2 test. Adjusted odds ratios for factors significantly associated with non-normal delivery were calculated using stepwise logistic regression. There were 291 women in the low dose and 296 in the plain bupivacaine group. There were no significant differences between groups in parity, race, induction of labour, use of augmentation, cervical dilatation at epidural insertion, duration of any stage of labour or duration or volume of infusion. Total dose of bupivacaine (126 +/- 47 mg versus 91 +/- 32 mg) and the proportion of women with motor block at the end of labour (45% versus 27%) were significantly greater in the plain bupivacaine than in the low dose group (P < 0.0001). The adjusted odds ratios (95% CI) for factors significantly associated with non-normal delivery were primiparity: 4.68 (2.78-7.88), older maternal age: 1.1 (1.05-1.14), longer active second stage of labour: 1.01 (1.005-1.017), total bupivacaine dose: 1.01 (1.005-1.016) and greater cervical dilatation at epidural insertion 1.22 (1.08-1.37). Treatment group and motor block at the end of labour had no significant effect. We found no increase in normal delivery rate with low dose infusions.

Video laryngoscopes and the obstetric airway

The pitfalls surrounding securing the airway in the obstetric patient are well documented. From Tunstalls original failed intubation drill onwards, there has been progress both in recognition of the difficulties of airway management in the pregnant patient and development of algorithms to enhance patient safety. Current trends in obstetric anaesthesia have resulted in a significant decrease in exposure of anaesthetists, especially trainees, to caesarean section under general anaesthesia, compounding the difficulties in safely managing the airway. Video laryngoscopes have recently appeared in airway algorithms. They improve glottic visualisation and are useful in the management of the difficult non-obstetric airway, including those in morbidly obese patients and in the setting of a rapid-sequence induction. There is growing interest in the potential use of video laryngoscopes in the obstetric population and as a teaching tool to maximise training opportunities.