Best practice & research. Clinical obstetrics & gynaecology
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Best Pract Res Clin Obstet Gynaecol · Jun 2010
ReviewObstetric anaesthesia in low-resource settings.
Close co-operation between obstetricians and obstetric anaesthesia providers is crucial for the safety and comfort of parturients, particularly in low-resource environments. Maternal and foetal mortality is unacceptably high, and the practice of obstetric anaesthesia has an important influence on outcome. Well-conducted national audits have identified the contributing factors to anaesthesia-related deaths. ⋯ The importance of current outreach initiatives is emphasised, and educational resources and the available financial sources discussed. The difficulties of efficient procurement of equipment and drugs are outlined. Guiding principles for the practice of analgesia for labour, anaesthesia for caesarean section and the management of obstetric emergencies, where the anaesthetist also has a central role, are suggested.
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Best Pract Res Clin Obstet Gynaecol · Jun 2010
Review Comparative StudyThe effects of maternal labour analgesia on the fetus.
Maternal labour pain and stress are associated with progressive fetal metabolic acidosis. Systemic opioid analgesia does little to mitigate this stress, but opioids readily cross the placenta and cause fetal-neonatal depression and impair breast feeding. Pethidine remains the most widely used, but alternatives, with the possible exception of remifentanil, have little more to offer. ⋯ Actual neonatal outcome, however, suggests that benefits outweigh detrimental influences. Meta-analysis demonstrates that Apgar score is better after epidural than systemic opioid analgesia, while neonatal acid-base balance is improved by epidural compared to systemic analgesia and even compared to no analgesia. Successful breast feeding is dependent on many factors, therefore randomized trials are required to elucidate the effect of labour analgesia.
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Best Pract Res Clin Obstet Gynaecol · Jun 2010
ReviewNerve injuries after neuraxial anaesthesia and their medicolegal implications.
Serious and permanent neurologic complications in the obstetric population are rare. Most neurologic complications following childbirth are intrinsic obstetric palsies. The most common intrinsic obstetric palsy is lateral femoral neuropathy. ⋯ Postpartum complaints should be addressed promptly. For infection and space-occupying lesions of the neuraxial canal, prompt diagnosis and treatment are essential to prevent permanent injury or death. Survey studies have demonstrated that women want to be told of the risks of neuraxial procedures, even when the incidence is rare.
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Best Pract Res Clin Obstet Gynaecol · Jun 2010
ReviewThe preoperative assessment of obstetric patients.
The importance of early identification and management of the high-risk obstetric patient is emphasised in the Confidential Enquiry into Maternal and Child Health (CEMACH) report. High-risk patients who need anaesthetic input include those with airway problems, cardiorespiratory disease and rare genetic conditions, such as malignant hyperthermia and suxamethonium apnoea. ⋯ Input from other medical teams, such as cardiologists or haematologists, are often needed. Ultimately, these measures should reduce maternal morbidity and mortality.
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Best Pract Res Clin Obstet Gynaecol · Jun 2010
ReviewObstetric audit and its implications for obstetric anaesthesia.
After briefly expounding the principles of an audit, this article focusses on the role of obstetric audit and how it can influence, and even shape, obstetric anaesthetic practice. The impact may be on service delivery, anaesthetic practice or the generation of new information. ⋯ Further examples include how different types of audit of pregnancy outcome, obstetric practice or areas of cross-interest to both obstetricians and anaesthetists are used by anaesthetists to evaluate health-care delivery, their own practices and to generate new audit and research agendas. Audits drive change and, hopefully, improvements that continue to make pregnancy a safer and more satisfying event for the mother and child.