Contemplating Our Maternity Care Crisis in the United States: Reflections of an Obstetrician Anesthesiologist (Anesth Analg. 2019;128(5):1036–1041) In this Open Mind article, Dr Pryde discusses his unusual career trajectory, his perspective on the state of obstetric medicine in the United States during the past 30 years, and the ongoing attendant crisis in maternal medicine.

Inpatient Opioid Use After Vaginal Delivery (Am J Obstet Gynecol. 2018;219:608.e1–608) Inpatient opioid use may serve as a first opioid exposure for many patients undergoing labor and delivery, as well as result in subsequent opioid abuse or dependence. However, data regarding this issue in this patient population are limited; current literature largely focuses on outpatient opioid prescription and treatment for the management of postdelivery pain. Therefore, this study evaluated opioid use in women during postpartum hospitalization and identified both maternal and prescribing provider characteristics associated with opioid prescription and use.

Effect of Immediate Versus Delayed Pushing on Rates of Spontaneous Vaginal Delivery Among Nulliparous Women Receiving Neuraxial Analgesia: A Randomized Clinical Trial (JAMA. 2018;320(14):1444–1454) Although >3 million women give birth in the United States every year, there is a lack of evidence regarding optimal labor management. In an effort to optimize cesarean delivery rates, there has been extensive research examining the management of labor. There are conflicting data on whether the mother should push immediately or delay pushing, as prolonged labor is associated with adverse outcomes for both mother and infant. The objective of this study was to evaluate whether immediate or delayed pushing would impact rates of spontaneous vaginal delivery as well as be more effective to reduce maternal and neonatal morbidities.

Immediate Versus Delayed Pushing During the Second Stage of Labor (JAMA. 2018;320(14):1439–1440) In an effort to optimize cesarean delivery rates, there has been extensive research examining the management of labor. A prolonged second stage of labor is associated with adverse outcomes for both mother and infant and whether women should push immediately or delay pushing upon complete cervical dilation is still unknown.

Prospective Observational Investigation of Capnography and Pulse Oximetry Monitoring After Cesarean Delivery With Intrathecal Morphine (Anesth Analg. 2019;128:513–522) Neuraxial morphine in low dosages is commonly used to provide high-quality analgesia to women after cesarean delivery. However, postoperative respiratory depression remains a concern, with reported incidences ranging from 0 to 32%. Inadequacy of ventilation and apneas can reliably be detected via capnography but current monitoring relies predominantly on pulse oximetry. No study has evaluated capnography use in women after cesarean delivery. Therefore, in the present study, the authors used capnography to estimate the number of “apnea alert events” (AAEs) in women who underwent cesarean delivery with spinal anesthesia that included 150 µg of intrathecal morphine.

Guidelines for Intraoperative Care in Cesarean Delivery: Enhanced Recovery After Surgery Society Recommendations (Part 2) (Am J Obstet Gynecol. 2018;219:533–544) This is the second document in a series of 3 focused on the Enhanced Recovery After Surgery (ERAS) care program, specifically in regards to cesarean delivery (CD) and its intraoperative care. ERAS has both clinical benefits (decreased length of stay, complications, and readmissions) and decreased cost of care. This special report focused on the period beginning 30 to 60 minutes before the start of the procedure (decision to operate) and ending at hospital discharge. The ERAS CD program provides audit and feedback cycles for both scheduled and unscheduled CD, and creates recommendations based on clinical evidence that allow physicians to learn, modify, and improve their care processes, leading to improved patient health outcomes.

Efficacy of Intrathecal Fentanyl for Cesarean Delivery: A Systematic Review and Meta-Analysis of Randomized Controlled Trials With Trial Sequential Analysis (Anesth Analg. 2019 Jan 8. doi: 10.1213/ANE.0000000000003975) Numerous studies have evaluated the risks and benefits of intrathecal fentanyl when added to bupivacaine during cesarean delivery. While potential advantages of intrathecal fentanyl over intrathecal morphine include faster onset and less cephalad spread, some have feared an increased risk of respiratory depression, a “ceiling effect” at doses >0.25 μg/kg, and increased postoperative intravenous opioid requirement. In order to clarify the benefits, harms, and optimal dosing of this opioid for cesarean delivery, these authors systematically reviewed evidence regarding the efficacy and safety of fentanyl when used as an additive to intrathecal bupivacaine with and without morphine.

Proceedings From the Society for Advancement of Blood Management Annual Meeting 2017: Management Dilemmas of the Surgical Patient—When Blood Is Not an Option (Anesth Analg. 2019;128:144–151) It is well established that blood loss >500 mL and/or hemoglobin (Hb) <5 g/dL are both associated with increased morbidity and mortality. Fortunately, perioperative bleeding is a known preventable complication, and procedures that are at increased risk of severe blood loss are well recognized (eg, obstetric, cardiothoracic, spine, and cancer surgeries). However, there are cases in which patient blood management (PBM) is complicated by religious or medicolegal issues. Therefore, in this special article, authors discuss PBM approaches in cases where blood transfusion is not an option (religious, inability to find blood matches, or lack of resources due to location).

Challenging the Traditional Definition of a Difficult Intubation: What is Difficult? (Anesth Analg. 2019;128(3):584–586. Doi:10.1213/ANE.0000000000003886) While video laryngoscopy (VL) has brought substantial changes to the practice of airway management, the way anesthesiologists define a “difficult intubation” has not been altered accordingly. The American Society of Anesthesiologists has defined a “difficult airway” as “the clinical situation in which a conventionally trained anesthesiologist experiences difficulty with facemask ventilation of the upper airway, difficulty with intubation, or both,” and also has set forth clear, separate definitions of difficult endotracheal intubation and difficult laryngoscopy. These latter 2 definitions can be subjective and interpreted inconsistently, however, and varied devices and contexts make these definitions even more ambiguous. A patient may not be labeled as a difficult intubation by one provider, but labeled difficult by another provider in a different setting. A study by Lewis and colleagues showed when VL was used, there were significantly fewer failed intubations compared with direct laryngoscopy (DL) alone. However, VL has not outdone the success rate of awake fiberoptic intubations in patients with perceived difficult airway. VL is available in >90% of operating rooms in British National Health Service hospitals according to a survey by Cook and Kelly, and some studies have recommended the use of VL become standard of care for both routine and difficult intubations.

Video Laryngoscopy: Positives, Negatives, and Defining the Difficult Intubation (Anesth Analg. 2019;128(3):399–401. Doi:10.1213/ANE.0000000000004023) A recent article by Bradley and colleagues argues video laryngoscopy has many advantages compared with conventional laryngoscopy and should be the new standard of care. It also asks whether an intubation should be considered “difficult” if video laryngoscopy is successful but conventional laryngoscopy fails, and highlights the importance of informing future providers of a difficult intubation. However, four critical factors are not addressed in this article: disparities in video laryngoscopy design, limitations in the availability of video laryngoscopy, limited experience with video laryngoscopy, and the impact of the results of preoperative airway evaluation on the success of video laryngoscopy.