Best practice & research. Clinical obstetrics & gynaecology
-
Best Pract Res Clin Obstet Gynaecol · Jun 2010
ReviewCardiopulmonary resuscitation and the parturient.
Cardiopulmonary arrest occurs in 1: 30 000 pregnancies. Although rare, optimal outcomes are dependent on the cause of the arrest, the rapid response team's understanding of the physiological effects of pregnancy on the resuscitative efforts and application of the latest principles of advanced cardiac life support (ACLS). Anaesthesia-related complications, secondary to difficult or failed intubation, and inability to oxygenate and ventilate can result in adverse outcomes for mother and baby. ⋯ Delivery of the baby helps in the maternal resuscitation efforts and recovery of circulation. Finally, the 2003 International Liaison Committee on Resuscitation (ILCOR) and the 2005 American Heart Association (AHA) advocate the provision of mild therapeutic hypothermia to the survivors of cardiac arrest. This will improve the neurological outcomes by decreasing cerebral oxygen consumption, suppression of the radical reactions and reduction of intracellular acidosis and inhibition of excitatory neurotransmitters.
-
Best Pract Res Clin Obstet Gynaecol · Jun 2010
ReviewThe ongoing challenges of regional and general anaesthesia in obstetrics.
The increasing trend of caesarean section in the setting of increasing maternal age, obesity and other concomitant diseases will continue to challenge the obstetric anaesthetist in his/her task of providing regional and general anaesthesia. The challenges of providing anaesthesia for an emergency caesarean section, particularly the risks of general anaesthesia, will be debated. The need for involvement of a multidisciplinary team, good communication and challenges surrounding the provision of anaesthesia to such patients are discussed.
-
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.
-
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.
-
Every minute of every day, a woman dies in pregnancy or childbirth. The biggest killer is obstetric haemorrhage, the successful treatment of which is a challenge for both the developed and developing worlds. The presence of an attendant at every birth and access to emergency obstetric care are key to reducing maternal morbidity and mortality in the developing world while resource-rich countries have a rising caesarean section rate with its consequential effect on the incidence of abnormal placentation and its link with peripartum hysterectomy. ⋯ Various methods are available to try to stop the bleeding - from pharmacological methods to aid uterine contraction (e.g., oxytocinon, ergometrine and prostaglandins) to surgical methods to stem the bleeding (e.g., balloon tamponade, compression sutures or arterial ligation). Interventional radiology can be used if placenta accreta is suspected. Cell salvage has been introduced into obstetrics relatively recently in an attempt to reduce allogeneic transfusion.