Knowledge
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Articles of interest relevant to labor epidural analgesia, both specifically focusing on obstetric epidurals and more peripherally relevant to obstetric labor analgesia.
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Carbetocin is a long-acting synthetic oxytocin analog. Although a 100 mcg dose is currently recommended, there is still some question as to the ideal dose. Dosing as low as 20 mcg may possibly be equally effective.
Carbetocin is currently only recommended for use during elective cesarean delivery, obviating the need for a post-operative oxytocin infusion currently practiced in many countries. In some countries it is also used after vaginal delivery.
It is at least as efficacious as intravenous oxytocin, and may possibly be superior at reducing postpartum haemorrhage.
Due to it's comparatively high cost compared with oxytocin however, the economic benefit of avoiding post-operative oxytocin infusions has not been demonstrated.
In the scenario of emergency cesarean section after labor augmentation with oxytocin, a much larger dose is likely required and carbetocin cannot be recommended.
One study has suggested a post-operative analgesic benefit of carbetocin vs oxytocin, although the evidence base for this is far from conclusive.
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Cardiac arrest is rare in pregnancy (1 in 30,000) and resuscitation is founded on the same approach used for the non-pregnant patient, focusing on:
- Recognition
- Calling for help
- A B C (D)
- Good for mother = good for baby
However, unique to maternal resuscitation:
- Airway difficulties are more likely.
- Aortocaval compression dramatically impedes resuscitation – employ left lateral tilt!
- Consider perimortem cesarean section
The rationale for Perimortem Cesarean Section is:
- The presence of baby and gravid uterus severely limits resuscitation of the mother.
- Emergency cesarean section at cardiac arrest is done for the mother’s benefit, not the baby.
- A decision to perform emergency CS must be made within 4 minutes of arrest, and the baby delivered within 5 minutes. (Although there is some evidence of benefit when performed up to 10 minutes after arrest.)
- The only equipment required is a scalpel and an appropriately skilled doctor.
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