• Landmark obstetric anesthesia papers


    Daniel Jolley, James Griffiths, and Nick Jansen.

    25 articles.

    Created September 6, 2015, last updated 11 months ago.

    Collection: 50, Score: 3135, Trend score: 0, Read count: 3134, Articles count: 25, Created: 2015-09-06 10:10:33 UTC. Updated: 2021-02-09 21:30:18 UTC.



    A collection of landmark research articles relevant to obstetric anesthesia. Some, such as Hawkins' audits of U.S. maternal deaths, are significant because of their historical impact. Others hold direct clinical relevance for practice today.

    Daniel Jolley  Daniel Jolley
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    Collected Articles

    • Anesthesiology · Feb 1997

      Anesthesia-related deaths during obstetric delivery in the United States, 1979-1990.

      This historical landmark paper demonstrated the terribly-higher maternal mortality during cesarean section performed under general anesthesia vs regional anesthesia in the United States from 1979-1990.

      This resulted in the oft-quoted statistic of being '...17 times more likely to die under a GA cesarean section than epidural or spinal.'

      It is very important to note that this is a historical article and that the demonstrated very high mortality was greatly contributed to by a culture tolerating inexperienced anesthesia residents performing GA CS after-hours with limited senior support.

      Hawkins followed up this study with another in 2011: Anesthesia-related maternal mortality in the United States: 1979-2002. This reassuringly showed a much improved GA CS maternal mortality from 1997-2002 (although still higher than regional CS).

      The important take-home from this paper is that a GA cesarean section increases the risk of serious airway events, and if this is not managed by experienced and appropriately trained anaesthetists/anesthesiologists, will result in maternal deaths.


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    • Obstetrics and gynecology · Jan 2011

      Anesthesia-related maternal mortality in the United States: 1979-2002.

      This follow-up paper to Hawkin's original "Anesthesia-related deaths during obstetric delivery in the United States, 1979-1990" showed a dramatic improvement in the relative risk of cesarean section death with general vs regional anesthesia compared with the original 1979-1990.

      Where previously (1979-1990) the relative risk of death during GA CS was 16.7, from 1997-2002 the relative risk had fallen to 1.7. Worryingly though this was both due to a falling mortality rate for GA CS and an increasing mortality rate for regional anesthesia CS.

      Cesarean section under general anesthesia still exposes mothers to an increased risk of perioperative death, but this risk is much lower than previously, likely due to better anesthesia training, supervision and respect of the obstetric airway.


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    • Int J Obstet Anesth · Oct 2008

      Difficult and failed intubation in obstetric anaesthesia: an observational study of airway management and complications associated with general anaesthesia for caesarean section.

      Recent developments in anaesthesia and patient demographics have potentially changed the practice of obstetric general anaesthesia. There are few contemporary data on Australasian practice of general anaesthesia for caesarean section, especially relating to airway management, anaesthetic techniques and complications. ⋯ General anaesthesia is most commonly used in emergency situations. Tracheal intubation after rapid-sequence induction remains the predominant approach to airway management in Australasia. The incidence of failed intubation is consistent with previous studies. Aspiration prophylaxis is not routinely used for emergency surgery.

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    • Int J Obstet Anesth · Jul 2002

      Randomized Controlled Trial Clinical Trial

      Haemodynamic changes caused by oxytocin during caesarean section under spinal anaesthesia.

      The haemodynamic effects of oxytocin receive scant attention in pharmacology texts, but may be clinically significant in vulnerable patients. Despite prescriber information recommending a dose of 5 international units by slow i.v. injection, it is the authors' experience that it is very common practice in the UK to give 10 units as a rapid injection. We therefore conducted a randomised, double-blind study of the haemodynamic changes induced by rapid bolus of 5 or 10 units of oxytocin in 34 healthy term parturients at caesarean section under spinal anaesthesia. ⋯ This has been illustrated by a maternal death reported to the Confidential Enquiries into Maternal Deaths in the United Kingdom. The need to adhere to a dose regimen of 5 units by slow injection needs re-emphasis, but no evidence exists to claim that even this will be haemodynamically inert. We therefore recommend that oxytocin boluses be avoided in women with hypovolaemia or cardiac disease.

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    • Int J Obstet Anesth · Jan 1998

      Complications of obstetric epidural analgesia and anaesthesia: a prospective analysis of 10,995 cases.

      Although epidural anaesthesia and analgesia are widely used in obstetrics, there are no large contemporary prospective series detailing associated complications. Prospective data was collected on all obstetric epidural blocks performed for labour and delivery in a single institution between July 1989 and August 1994. A data entry sheet was compiled and entered onto a computer database. ⋯ There was no major local anaesthetic toxicity or neurological deficit. The incidence of potentially life-threatening morbidity was thus 0.02% although in both cases outcome was good. The only persisting complication was neurological, an apparent epidural catheter-induced traumatic mononeuropathy.

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    • Int J Obstet Anesth · Apr 2000

      Neurological complications in obstetric regional anaesthesia.

      Neurological complications after obstetric central neural blocks are rare events. Although central neural blockade does cause neurological complications, there must be awareness that neurological deficits may either develop spontaneously (e.g. epidural abscess/haematoma) or as a result of the labour and delivery process (maternal obstetric palsies). We have attempted to review as completely as possible the published survey and case reports in the English literature on neurological complications of obstetric regional blockade obtained from Medline spanning the period 1966 to November 1998. ⋯ Although we cannot eliminate the occurrence of neurological complications completely, preventive measures can still be taken to decrease their incidence (e.g. aseptic technique). There must also be regular monitoring after neural blockade for the development of neurological complications. Early diagnosis and prompt appropriate treatment will usually lead to complete resolution of the neurological deficit even in cases of epidural haematoma/abscess.

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    • Int J Obstet Anesth · Apr 1995

      Levels of anaesthesia and intraoperative pain at caesarean section under regional block.

      This prospective study recorded levels of analgesia (loss of sharp pin prick sensation) and anaesthesia (loss of touch sensation) in 220 women during caesarean section under regional anaesthesia (70 epidurals, 150 spinals). At delivery the difference between analgesia and anaesthesia varied from 0-7 segments for epidurals and 0-9 segments for spinals. ⋯ No patient with a level of anaesthesia which remained above T5 experienced pain. These results indicate that assessing the adequacy of block by sharp pin prick may be misleading and that in the absence of spinal or epidural narcotics a level of anaesthesia up to and including T5 is required to prevent pain during caesarean section.

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    • Lancet · Jun 2002

      Randomized Controlled Trial Multicenter Study Clinical Trial

      Do women with pre-eclampsia, and their babies, benefit from magnesium sulphate? The Magpie Trial: a randomised placebo-controlled trial.

      Magnesium sulphate halves the risk of eclampsia in pre-eclamptic pregnant women without significant adverse effect.


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    • Lancet · Jul 2001

      Randomized Controlled Trial Comparative Study Clinical Trial

      Effect of low-dose mobile versus traditional epidural techniques on mode of delivery: a randomised controlled trial.

      Low-concentration bupivacaine epidurals for labor analgesia result in a lower-incidence of instrumental delivery than 'traditional' high-dose bupivacaine epidurals.


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    • Anesthesiology · Dec 2002

      Randomized Controlled Trial Comparative Study Clinical Trial

      Randomized controlled trial comparing traditional with two "mobile" epidural techniques: anesthetic and analgesic efficacy.

      This follow-up paper to the original COMET study describes in detail the high and low-dose epidural techniques and the subsequent anesthetic characteristics.

      The low-dose techniques used infusions of 0.1% bupivacaine with 2 mcg/mL fentanyl, compared with 10mL boluses of 0.25% bupivacaine. Maternal analgesia experience was similar between the groups, all the CSE group experienced better analgesia in the first hour.


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    • N. Engl. J. Med. · Feb 2005

      Randomized Controlled Trial Comparative Study Clinical Trial

      The risk of cesarean delivery with neuraxial analgesia given early versus late in labor.

      Neuraxial analgesia early in labor does not increase the risk of cesarean delivery or increase the duration of labor compared with analgesia later in labor.


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    • Int J Obstet Anesth · Apr 2010

      Case Reports

      The use of fibrinogen concentrate to correct hypofibrinogenaemia rapidly during obstetric haemorrhage.

      Haemorrhage is a common complication of childbirth with 0.65% of deliveries associated with significant (>1500 mL) peripartum blood loss. Hypofibrinogenaemia secondary to dilutional and consumptive coagulopathies can be challenging to correct quickly with conventional blood and plasma therapy. Fibrinogen concentrate offers rapid restoration of fibrinogen levels with a small volume infusion and minimal preparation time. ⋯ Six cases of obstetric haemorrhage, associated with hypofibrinogenaemia, treated with fibrinogen concentrate in conjunction with platelets, fresh frozen plasma, packed red blood cells, uterotonics and obstetric intervention are described. In all cases, laboratory assessed coagulation was rapidly normalised and severe haemorrhage improved. These cases suggest that fibrinogen concentrate may be an effective addition to conventional treatments for obstetric haemorrhage associated with hypofibrinogenaemia.

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    • Int J Obstet Anesth · Jan 2010

      Persistent pain after caesarean section and vaginal birth: a cohort study.

      Although persistent pain has been described to occur after various types of surgery, little is known about this entity following caesarean section or vaginal birth. We sought to examine the association between mode of delivery and development of persistent pain, as well as the nature and intensity of the pain. ⋯ Persistent pain is more common one year after a caesarean section than after vaginal birth. A history of previous pain and pain on the day after delivery correlated with persistent pain.

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    • Int J Obstet Anesth · Oct 2011

      Anesthetic considerations for placenta accreta.

      When diagnosed antenatally placenta accreta has often been managed by cesarean hysterectomy, but recently techniques involving uterine preservation have been developed. Uterine artery embolization has become an adjuvant treatment, although the potential for obstetric hemorrhage still exists. A multidisciplinary approach has permitted the development of anesthetic strategies for these patients. ⋯ In this case series, the expectation of major blood loss at cesarean delivery in the presence of placenta accreta and attempts at uterine conservation surgery initially prompted a conservative approach using general anesthesia. Greater experience has permitted modification of this approach and neuraxial anesthesia is now employed more frequently. When managed appropriately, most patients are able to tolerate both prolonged surgery and significant blood loss under epidural anesthesia.

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    • Int J Obstet Anesth · Jan 2011

      Case Reports

      Prophylactic endovascular placement of internal iliac occlusion balloon catheters in parturients with placenta accreta: a retrospective case series.

      Endovascular occlusion balloon catheters can be placed preoperatively in internal iliac vessels of patients perceived to be at risk of major obstetric haemorrhage during caesarean section. Their safety and efficacy remains undefined, and we report our experience of 14 patients over four years. ⋯ Internal iliac balloon catheters can be inserted electively or in an emergency in patients at risk of major obstetric haemorrhage. Although useful in some, they are not universally effective; patients are still at risk of significant blood loss and at high risk of requiring a hysterectomy. In our experience, catheters can be placed electively or in an emergency but have been associated with adverse outcomes. These lessons have been important learning points in perioperative management.

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    • Int J Obstet Anesth · Oct 2004

      Incidence and characteristics of failures in obstetric neuraxial analgesia and anesthesia: a retrospective analysis of 19,259 deliveries.

      A retrospective analysis was performed on 19,259 deliveries that occurred in our institution from January 2000 to December 2002. Anesthesia records and quality assurance data sheets were reviewed for the characteristics and failure rates of neuraxial blocks performed for labor analgesia and anesthesia. The neuraxial labor analgesia rate was 75% and the overall failure rate was 12%. ⋯ The overall use of general anesthesia decreased from 8% to 4.3% over the three-year period. Furthermore, regional anesthesia was used in 93.5% of cesarean deliveries with no anesthetic-related mortalities. Future investigations should identify acceptable international standards, risk factors associated with failure and methods to reduce failure before cesarean section.

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    • Int J Obstet Anesth · Apr 1994

      Combined spinal epidural (CSE) analgesia: technique, management, and outcome of 300 mothers.

      Epidural analgesia in labour is commonly associated with some degree of lower limb weakness often severe enough to be described as paralysis by the mother. We aimed to produce rapid reliable analgesia with no motor block throughout labour. We report a pilot survey of 300 consecutive women requesting regional analgesia in labour who received a combined spinal epidural blockade (CSE). ⋯ Transient hypotension occurred in 24 women (8%) and was treated with 6 mg intravenous boluses of ephedrine. Complete satisfaction with analgesia and mobility was reported 12-24 h post partum by 95% of mothers. The use of this analgesic technique caused no alteration in obstetric management or post partum care of the women.

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    • Cochrane Db Syst Rev · Jan 2012

      Review Meta Analysis

      Combined spinal-epidural versus epidural analgesia in labour.

      Traditional epidural techniques have been associated with prolonged labour, use of oxytocin augmentation and increased incidence of instrumental vaginal delivery. The combined spinal-epidural (CSE) technique has been introduced in an attempt to reduce these adverse effects. CSE is believed to improve maternal mobility during labour and provide more rapid onset of analgesia than epidural analgesia, which could contribute to increased maternal satisfaction. ⋯ There appears to be little basis for offering CSE over epidurals in labour, with no difference in overall maternal satisfaction despite a slightly faster onset with CSE and conversely less pruritus with low-dose epidurals. There was no difference in ability to mobilise, maternal hypotension, rate of caesarean birth or neonatal outcome. However, the significantly higher incidence of urinary retention, rescue interventions and instrumental deliveries with traditional techniques would favour the use of low-dose epidurals. It is not possible to draw any meaningful conclusions regarding rare complications such as nerve injury and meningitis.

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    • Anaesthesia · Aug 2001

      Randomized Controlled Trial Clinical Trial

      Extension of epidural blockade in labour for emergency Caesarean section using 2% lidocaine with epinephrine and fentanyl, with or without alkalinisation.

      In a randomised, double-blind study, we investigated rapid extension of epidural analgesia to surgical anaesthesia for emergency Caesarean section. Parturients receiving epidural analgesia in labour who subsequently required Caesarean section were given a test dose of 3 ml lidocaine 2% with epinephrine 1 : 200 000, followed 3 min later by 12 ml lidocaine 2% with epinephrine 1 : 200 000 and fentanyl 75 microg, to which was added 1.2 ml sodium bicarbonate 8.4% (bicarbonate group; n = 20) or saline (saline group; n = 20). ⋯ Maternal side-effects and neonatal outcome were similar between groups. We conclude that pH-adjusted lidocaine 2% with epinephrine and fentanyl is effective for rapidly establishing surgical anaesthesia in patients with a functioning epidural catheter for labour who require emergency Caesarean section.

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    • Br J Anaesth · Jan 2002

      Randomized Controlled Trial Clinical Trial

      Effects of high inspired oxygen fraction during elective caesarean section under spinal anaesthesia on maternal and fetal oxygenation and lipid peroxidation.

      Oxygen supplementation is given routinely to parturients undergoing Caesarean section under regional anaesthesia. While the aim is to improve fetal oxygenation, inspiring a high oxygen fraction (FIO2) can also increase free radical activity and lipid peroxidation in both the mother and baby. In this prospective, randomized, double-blind study, we investigated the effect of high inspired oxygen fraction (FIO2) on maternal and fetal oxygenation and oxygen free radical activity in parturients having Caesarean section under spinal anaesthesia. ⋯ We conclude that breathing high FIO2 modestly increased fetal oxygenation but caused a concomitant increase in oxygen free radical activity in both mother and fetus.

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    • Br J Anaesth · Sep 2010

      Randomized Controlled Trial

      Effects of different inspired oxygen fractions on lipid peroxidation during general anaesthesia for elective Caesarean section.

      During general anaesthesia (GA) for Caesarean section (CS), fetal oxygenation is increased by administering an inspired oxygen fraction (Fi(o(2))) of 1.0. However, it is unclear whether such high Fi(o(2)) will increase oxygen free radical activity. ⋯ GA for CS is associated with a marked increase in free radical activity in the mother and baby. The mechanism is unclear but it is independent of the inspired oxygen in the anaesthetic mixture. Therefore, when 100% oxygen is administered with sevoflurane for GA, fetal oxygenation can be increased, without inducing an increase in lipid peroxidation.

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    • Anesthesia and analgesia · Apr 2002

      Meta Analysis

      A quantitative, systematic review of randomized controlled trials of ephedrine versus phenylephrine for the management of hypotension during spinal anesthesia for cesarean delivery.

      This quantitative systematic review compared the efficacy and safety of ephedrine with phenylephrine for the prevention and treatment of hypotension during spinal anesthesia for cesarean delivery. Seven randomized controlled trials (n = 292) were identified after a systematic search of electronic databases (MEDLINE, EMBASE, The Cochrane Controlled Trials Registry), published articles, and contact with authors. Outcomes assessed were maternal hypotension, hypertension and bradycardia, and neonatal umbilical cord blood pH values and Apgar scores. For the management (prevention and treatment) of maternal hypotension, there was no difference between phenylephrine and ephedrine (relative risk [RR] of 1.00; 95% confidence interval [CI], 0.96-1.06). Maternal bradycardia was more likely to occur with phenylephrine than with ephedrine (RR of 4.79; 95% CI, 1.47-15.60). Women given phenylephrine had neonates with higher umbilical arterial pH values than those given ephedrine (weighted mean difference of 0.03; 95% CI, 0.02-0.04). There was no difference between the two vasopressors in the incidence of true fetal acidosis (umbilical arterial pH value of <7.2; RR of 0.78; 95% CI, 0.16-3.92) or Apgar score of <7 at 1 and 5 min. This systematic review does not support the traditional idea that ephedrine is the preferred choice for the management of maternal hypotension during spinal anesthesia for elective cesarean delivery in healthy, nonlaboring women. ⋯ Phenylephrine and ephedrine to manage hypotension during spinal anesthesia for elective cesarean delivery were compared in this systematic review. Women given ephedrine had neonates with lower umbilical cord blood pH values compared with those given phenylephrine. However, no differences in the incidence of fetal acidosis (pH value of <7.2) or neonatal Apgar scores were found.

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    • Anesthesiology · Oct 2005

      Randomized Controlled Trial

      Prevention of hypotension during spinal anesthesia for cesarean delivery: an effective technique using combination phenylephrine infusion and crystalloid cohydration.

      Many methods for preventing hypotension during spinal anesthesia for cesarean delivery have been investigated, but no single technique has proven to be effective and reliable. This randomized study studied the efficacy of combining simultaneous rapid crystalloid infusion (cohydration) with a high-dose phenylephrine infusion. ⋯ Combination of a high-dose phenylephrine infusion and rapid crystalloid cohydration is the first technique to be described that is effective for preventing hypotension during spinal anesthesia for cesarean delivery.

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    • Anaesthesia · Nov 2014


      Hypertension and haemodynamics in pregnant women - is a unified theory for pre-eclampsia possible?

      no abstract available

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    • Int J Obstet Anesth · May 2015


      MBRRACE-UK: saving lives, improving mothers care - implications for anaesthetists.

      In December 2014, the latest UK Confidential Enquiry into Maternal Deaths report was published, covering the surveillance period from 2009 to 2012. This is the first report since a significant change in the organisational structure of the body responsible for surveillance and dissemination of reports. The Confidential Enquiry Reports are regarded as a gold standard worldwide and have contributed to quality improvement of maternity care both in the UK and elsewhere. This article aims to give obstetric anaesthetists an overview of the current report and highlight the pertinent implications for anaesthetic practice.

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