Anesthesiology clinics
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Anesthesiology clinics · Mar 2017
ReviewObstetric and Anesthetic Approaches to External Cephalic Version.
Breech presentation is the most common abnormal fetal presentation and complicates approximately 3% to 4% of all pregnancies. External cephalic version (ECV) should be recommended to women with a breech singleton pregnancy, if there is no maternal or fetal contraindication. ⋯ The success rate of ECV is approximately 60%. Review of the risks and benefits for performing an ECV and for both the timing of ECV and the number of attempts should be should be discussed with the patient.
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Anesthesiology clinics · Mar 2017
ReviewEpidural Analgesia for Labor: Continuous Infusion Versus Programmed Intermittent Bolus.
Despite the traditional practice to maintain labor analgesia with a combination of continuous epidural infusion and patient-controlled epidural analgesia using an automated epidural pump; compelling data now shows that bolus injection through the epidural catheter may result in better distribution of anesthetic solution in the epidural space. The programmed intermittent epidural bolus technique is proposed as a better maintenance mode and may represent a more effective mode of maintaining epidural analgesia for labor, especially prolonged labor. Additional prospective and adequately powered studies are needed to confirm findings and determine the optimal combination of volume, rate, time, and drug concentration.
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Cesarean delivery rates are increasing worldwide, and effective postoperative pain management is a key priority of women undergoing cesarean delivery. Inadequate pain management in the acute postoperative period is associated with persistent pain, greater opioid use, delayed functional recovery, and increased postpartum depression. In addition to pain relief, optimal management of patients after cesarean delivery should address the goals of unrestricted maternal mobility, minimal maternal and neonatal side effects, rapid recovery to baseline functionality, and early discharge home. Multimodal analgesia should include neuraxial morphine in conjunction with nonopioid adjuncts, with additional oral or intravenous opioids reserved for severe breakthrough pain.
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Nitrous oxide, long used during labor in Europe, is gaining popularity in the United States. It offers many beneficial attributes, with few drawbacks. ⋯ Despite being less effective in treating labor pain than neuraxial analgesic modalities, nitrous oxide serves the needs and preferences of a subset of laboring parturients. Nitrous oxide should, therefore, be considered for inclusion in the repertoire of modalities used to alleviate pain and facilitate effective coping during labor.