International journal of obstetric anesthesia
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Int J Obstet Anesth · Nov 2019
Meta AnalysisCarbetocin reduces the need for additional uterotonics in elective caesarean delivery: a systematic review, meta-analysis and trial sequential analysis of randomised controlled trials.
Carbetocin has been found to be superior to oxytocin in terms of need for additional uterotonics and prevention of postpartum haemorrhage at caesarean delivery. However, this is based on combined data from labouring and non-labouring parturients and it remains unclear how effective carbetocin is in the purely elective setting. The aim of this review was to compare carbetocin to oxytocin in elective caesarean delivery. ⋯ Carbetocin is associated with a reduced need for additional uterotonics when compared with oxytocin at elective caesarean delivery. Standardisation of bleeding-related outcomes in studies is necessary to facilitate synthesis of data in future analyses.
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Int J Obstet Anesth · Nov 2019
ReviewLocal anaesthetic techniques for post-caesarean delivery analgesia.
In this narrative review we summarise pertinent data from published studies investigating the use of local anaesthetic techniques as adjuncts for managing post-caesarean delivery pain. Based on currently available evidence, ultrasound-guided transversus abdominis plane (TAP), quadratus lumborum (QL) and ilio-inguinal and iliohypogastric (ILIH) blocks are preferable to landmark techniques. When intrathecal morphine is used for caesarean delivery analgesia, TAP blocks do not confer any additional benefit. ⋯ Quadratus lumborum and ILIH blocks show promising results but the data are limited, so recommendations for routine use cannot be made. In summary, evidence supports the use of local anaesthetic techniques for post-caesarean delivery pain but additional research is required to determine the optimum dosing regimens, and the potential role of liposomal local anaesthetics. Further studies are required to compare techniques and determine their role in conjunction with low-dose long-acting neuraxial opioids.
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Int J Obstet Anesth · Nov 2019
ReviewPre-eclampsia through the eyes of the obstetrician and anesthesiologist.
Due to the high risk of morbidity and mortality from unrecognized and untreated pre-eclampsia, clinicians should have a high index of suspicion to evaluate, treat and monitor patients presenting with signs concerning for pre-eclampsia. Early blood pressure management and seizure prophylaxis during labor are critical for maternal safety. Intrapartum, special anesthetic considerations should be employed to ensure the safety of the parturient and fetus. Patients who have pre-eclampsia should be aware that they are at high risk for the future development of cardiovascular disease.
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Current pain and analgesic management strategies apply a standardized one-size-fits-all approach to women undergoing cesarean delivery. These standardized protocols do not account for significant variability in women's pain and may lead to under-treatment in patients with high analgesic needs and overtreatment, associated with increased analgesic-related side effects, in women with low analgesic needs and higher analgesic drug sensitivity. Pre-operative identification of patients at-risk of developing severe pain might allow clinicians to optimize care by offering personalized, stratified or targeted analgesic treatment protocols. ⋯ Patient-driven analgesic dose and protocol selection (based on individual preferences for pain relief and for avoidance of side effects after cesarean delivery) may optimally balance individual pain needs and side effect concerns compared to standardized postoperative pain treatment protocols. Individualized or stratified post-discharge opioid prescribing practices have been shown to reduce unnecessary opioid analgesic prescriptions and consumption, so should be implemented routinely. Outcomes other than pain and analgesic use, including recovery measures and maternal satisfaction metrics, should be considered when evaluating personalized or patient-selected pain treatment protocols.
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Int J Obstet Anesth · Nov 2019
ReviewSystemic adjunct analgesics for cesarean delivery: a narrative review.
It is critical to adequately treat postoperative cesarean delivery pain. The use of parenteral or neuraxial opioids has been a mainstay, but opioids have side effects that can be troubling and the opioid crisis in the United States has highlighted the necessity to utilize analgesics other than opioids. Other analgesic options include neuraxial analgesics, nerve blocks such as the transversus abdominis plane block, and non-opioid parenteral and oral medications. The goal of this article is to review non-opioid systemic analgesic adjuncts following cesarean delivery, focusing on their efficacy and side effects as well as their impact on reduction of opioid requirements after surgery.