Neuraxial Block for Delivery Among Women With Low Platelet Counts: A Retrospective Analysis (Int J Obstet Anesth. 2018;35:4–9) Pregnant women with low platelet counts may be denied neuraxial block due to concerns about causing a spinal-epidural hematoma (SEH). As a result of this denial, they may not receive adequate labor analgesia. In the event of a cesarean delivery, there will be a need for general anesthesia, which has increased risk in parturients. The lowest safe platelet count to perform neuraxial block is unknown.

Anesthesiologist Specialization and Use of General Anesthesia for Cesarean Delivery (Anesthesiology. 2019;130(2):237–246) Neuraxial anesthesia (ie, spinal or epidural anesthesia), rather than general anesthesia, is recommended for most women undergoing cesarean delivery. There are a paucity of data regarding the role of obstetric anesthesiologist specialization in influencing anesthesia choice and outcomes for cesarean delivery. Knowledge of associations of anesthesia subspecialist care (compared with generalist anesthesiologist care) and patterns of anesthesia use may improve staffing in health systems, inform accreditation standards, and determine future purchasing by health care payers. This study compared use of general anesthesia for cesarean delivery among patients cared for by generalist versus obstetric-specialized anesthesiologists.

Interprofessional Provider Attitudes Toward the Initiation of Epidural Analgesia in the Laboring Patient: Are We All on the Same Page? (Int J Obstet Anesth. 2019;37:57–67) During labor and delivery, the initiation of labor epidural analgesia should ultimately be determined by the patient’s preference. Practice guidelines from both the American Society of Anesthesiologists and the American College of Obstetricians and Gynecologists state that epidural analgesia can be offered early in labor and maternal request should be a legitimate indication for performing the procedure. However, different healthcare providers may prioritize different factors when counseling patients on the subject of the “best” time during labor to request epidural analgesia. In fact, information is limited about the attitudes of different types of health care providers regarding the timing of epidural placement during labor. This study surveyed a variety of providers to determine how patient factors or circumstances might affect their decision-making about the timing of epidural labor analgesia initiation. Their goal was to use this survey data to identify differences among provider types and ultimately improve understanding and education on the topic to promote patient-centered care.

A Qualitative Analysis of Parturients’ Experiences Using Nitrous Oxide for Labor Analgesia: It is not Just About Pain Relief (Birth. 2019;46(1):97–104) Although nitrous oxide provides less effective labor analgesia compared with neuraxial modalities, its popularity is increasing in the United States. At the authors’ tertiary center, ∼20% of women choose to use nitrous oxide, and of those who use nitrous oxide and have vaginal deliveries, 40% convert to neuraxial analgesia. Although nearly half report low or intermediate analgesic effectiveness with nitrous oxide, 93% report high satisfaction with their overall analgesia experience. Satisfaction can be difficult to assess and is influenced by many factors, including perceived involvement in medical decisions, personal expectations and quality of the patient-caregiver relationship. This study aimed to identify determinants of satisfaction in women who use nitrous oxide as their sole labor analgesic in vaginal births to better understand patient motivations to use nitrous oxide despite variable analgesic effectiveness.

Management of Postpartum Haemorrhage: From Research into Practice, a Narrative Review of the Literature and the Cardiff Experience (Int J Obstet Anesth. 2019;37:106–117) The incidence of postpartum hemorrhage (PPH) continues to rise in many countries. Worldwide, PPH remains the most common cause of maternal death. Although most postpartum bleeding results from obstetric complications, the presence of hemostatic impairment can result in more excessive blood loss. The goal of this review was to summarize the evidence regarding coagulation profiles in women with PPH, describe how algorithms used in conjunction with point-of-care (POC) testing can provide timely information to assist clinicians with appropriate transfusion strategies during PPH, and describe how protocols developed for research studies could also have a positive impact on all patients with PPH.

Obstetric Anesthesia Management of the Patient With Cardiac Disease (Int J Obstet Anesth. 2019;37:73–85) Cardiovascular disease is now the leading cause of maternal mortality in much of the developed world. This has occurred for a variety of reasons, including the increasing frequency of cardiovascular risk factors among women of childbearing age and the improved treatment for congenital heart disease that allows most of these patients to reach adulthood. The level of care required to address the needs of parturients with cardiovascular conditions requires a coordinated effort among experts in cardiology, obstetrics, perinatology, neonatology, and anesthesiology.

Addressing Maternal Mortality: The Pregnant Cardiac Patient (Am J Obstet Gynecol. 2019;220(2):167.e1–167.e8) There has been an upward trend in maternal mortality in the United States over the past 3 years. One major contributor to this trend is cardiovascular disease, which accounted for 15.5% of maternal deaths between 2011 and 2013. To combat the rise in maternal mortality, obstetric and gynecological experts recommend the creation of models of care suited to manage high-complexity pregnant patients. A possible treatment solution would include cardiovascular screening, patient education, and multidisciplinary team planning.

Safety of Spinal Anesthesia in Thrombocytopenic Patients: Are There Lessons to be Learnt From Oncology? (Reg Anesth Pain Med. 2019;44(1):29–31) Lumbar puncture (LP) is commonly performed for diagnostic and therapeutic purposes in patients with leukemia and lymphoma, who often develop thrombocytopenia. Oncologists are typically cautious to expose patients to unnecessary blood products for fear of alloimmunization, and therefore will perform LP at thrombocytopenic levels beyond that which anesthesiologists would deem acceptable for neuraxial procedures. There may be lessons anesthesiologists can learn from oncologists regarding spinal anesthesia in thrombocytopenic patients and the lowest platelet count at which regional blocks can be “safely” performed.

Remifentanil Patient-controlled Analgesia (PCA) in Labour–in the Eye of the Storm (Anaesthesia. 2019;74:277–279) A recent study published by Wilson and colleagues in the Lancet has attracted a lot of media attention regarding the use of intravenous remifentanil patient-controlled analgesia (PCA) to replace intramuscular pethidine for labor analgesia. The study reported that the need for conversion to neuraxial analgesia was approximately halved with remifentanil compared with pethidine, and the rate of instrumental delivery was decreased from 26% to 15%. The conclusions of this study contradicted previous recommendations that remifentanil PCA not be considered a standard analgesic option in labor due to safety concerns. This editorial addressed the ramifications of implementing routine remifentanil PCA labor analgesia and the measures that would need to be taken to ensure maternal and neonatal safety.

Comparison Between General, Spinal, Epidural, and Combined Spinal-Epidural Anesthesia for Cesarean Delivery: A Network Meta-analysis (Int J Obstet Anesth. 2019;37:5–15) As the rate of cesarean deliveries has increased in the United States, the choice of anesthesia for this surgery has been discussed at length. Although spinal anesthesia is the preferred anesthetic choice of many anesthesiologists, general anesthesia is still used in circumstances such as time constraints or neuraxial anesthesia failure. Numerous studies have assessed neonatal outcomes with the various anesthetic techniques available, but direct comparisons of all 4 commonly used techniques are lacking. Therefore, this study used the network meta-analysis statistical technique, which allows comparisons of different drugs and treatments that have not previously been directly compared through randomized controlled trials. The aim of this network meta-analysis was to determine which anesthetic technique is associated with the best maternal and neonatal outcomes during cesarean delivery.