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The Leading Articles in 2015-16 From Obstetrics and Obstetric Anesthesia That
Will Influence Your Practice

Robert Gaiser, M.D. Philadelphia, PA

Brenda A. Bucklin, M.D. Boulder, CO

For this lecture, we have gathered the most recent evidence-based information from various sources to
provide an overview of the leading articles from the obstetric and obstetric anesthesia literature.
Antepartum exposure of pregnant women to various medications during pregnancy continues to be of
concern. There has been no link to teratogenicity of the various anesthetic agents. A theoretical concern that
exposure to the various inhaled agents may cause learning difficulties if exposed during the third trimester
(the period of synaptogenesis) has been raised but not confirmed. 1 The FDA has established categories to
indicate the potential of a drug to cause birth defects if used during pregnancy:
Category A – Studies have failed to demonstrate a risk to the fetus
Category B – Animal studies have failed to demonstrate a risk to the fetus
Category C – Animal studies have shown an adverse effect on the fetus but there are no human studies
Category D – There is positive evidence of human fetal risk based on adverse reaction data but
potential benefits may warrant use of drug in pregnancy
Category X – Studies in animals or humans have demonstrated fetal abnormalities and there is
evidence of human fetal risk based on adverse reaction data from investigations
Use of common prescription drugs was evaluated during pregnancy. The most common prescription
medications were antibiotics (nitrofurantoin, metronidazole, amoxicillin, and azithromycin) followed by
promethazine.2 The most common Class D medications prescribed were codeine (11.9%) and hydrocodone
(10.2%). In a study examining prescription-use during pregnancy in a large insurance database, 14.4% of
the 76,742 pregnant women were prescribed an opioid. 3 Of these women, 5.7% received an opioid during
the 1st trimester, 5.7% received an opioid during the 2nd trimester, and 6.5% received an opioid during the
3rd trimester. The most common opioid dispensed in pregnancy was hydrocodone (Class D), followed by
codeine, oxycodone, and propoxyphene. Backpain was the most frequent condition for which an opioid was
prescribed, followed by abdominal pain, migraine, joint pain, and fibromyalgia. When opioids are used for
extended courses during pregnancy, there is the risk of neonatal dependence and subsequent withdrawal
following birth. Examining the time period of 2008-2012, more than one fourth of privately insured and
more than one third of Medicaid-enrolled women of childbearing age filled a prescription for an opioid.4
Cardiac arrest during pregnancy is a rare event with data from the US Nationwide Inpatient Sample
suggesting an incidence of 1:12,000 admissions. Causes of cardiac arrest include high neuraxial block, local
anesthetic toxicity, hemorrhage, pulmonary embolus, and sepsis. In 2014, the Society for Obstetric
Anesthesia and Perinatology published a consensus statement for the management of cardiac arrest in
pregnancy.5 This statement presented an approach to the pregnant patient experiencing cardiac arrest. Two
points deserve highlighting from the statement. The first is early delivery of a fetus who is 24 weeks’
gestation or greater. The recommendation is for delivery to occur within 5 minutes if there has not been the
return of spontaneous circulation. Early delivery relieves aortocaval compression and allows for effective
cardiopulmonary resuscitation. It also improves the chance of optimal outcome for the infant. Early delivery
(within five minutes) is good for both the mother and the fetus. 6 The other point is use of left uterine
displacement (LUD) during chest compressions. The recommendation is that LUD could be performed
manually or by tilting the patient to a full 30°. The 2015 AHA guidelines now state that chest compressions
should be performed with the patient in the supine position with manual displacement. It is not possible to
perform adequate chest compressions with the patient tilted to the left. This is of interest especially given
the study by Higuchi, et al.7 Patients with term pregnancies had MRIs while in the supine, 15°, 30°, and 45°
position. Aorta was not compressed in the supine position. The vena cava was compressed; however, the
compression was not relieved until the patient was tilted 30°. According to this study, there is no value to
tilting the patient less than 30°. It is extremely difficult to perform chest compressions in a 30° tilt and also
difficult to operate. The consensus statement also addressed management of the arrest, stating that
medications do not require alteration in pregnancy and that no medication should be withheld because of

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This publication contains material copyrighted by others. Individual refresher course lectures are reprinted by ASA with
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concerns about fetal teratogenicity. Finally, it is important to remember that fetal monitors should be
removed or detached as soon as possible during a cardiac arrest to facilitate CD without delay or hindrance.
Incidence of advanced maternal age continues to increase. According to the CDC, in 2014 the average
age of a woman having her first child was 26 years and 4 months, approximately, one year and 5 months
older than it was in 2000. Based upon ethnicity, Asian or Pacific Islanders had the oldest average age at 29
years and 6 months. The concern with the increasing age of pregnancy is that perinatal death, hypertensive
disorders, gestational diabetes mellitus, placenta previa, and placenta abruption are increased among
women 35 years of age or older than among younger women.8 Given these adverse outcomes, the question
arises whether early induction of labor and delivery would lower the complication rate. A study of 619
women randomized to induction of labor at 39 weeks gestation vs. expectant management revealed no
reduction in CD or in operative vaginal delivery. There was no difference in maternal or neonatal outcomes
between the two groups. There was no difference in postpartum hemorrhage (31%) in the two groups or in
the need for blood transfusion (3%).9 As such, anesthesiologists should be prepared to encounter older
parturients. These patients will not be induced just because of maternal age. However, advanced maternal
age is associated with increased epidural use during labor.10
Prolonged 2nd stage of labor for nulliparous parturients is currently defined as 3 h with epidural
anesthesia or 2 h without epidural anesthesia. This guideline is based upon expert opinion. Gimovsky et
al.11 randomized 78 nulliparous women with prolonged 2nd stage to either extending the labor by one
additional hour or CD. This simple maneuver decreased the CD rate from 43.2% to 19.5%. There was no
increase in neonatal or maternal morbidity with this simple maneuver. Given the results from this study, the
anesthesiologist may expect nulliparous women with prolonged 2nd stage to be pushing an additional hour,
assuming the FHR remains reassuring.
Zika virus has been extensively covered in the press and the medical literature. Zika is a mosquito-borne
favivirus with sporadic reports beginning in 2007. However, in 2015, an increase in the reporting of
infections with Zika virus occurred in Central and South America, with Brazil being the most affected
country. Zika virus is spread primarily through the bite of an infected Aedes species mosquito, although
there are documented cases of sexual transmission. The most common symptoms of Zika infection are
fever, rash, joint pain, and conjunctivitis. The illness is usually mild with symptoms lasting for several days
to a week after being infected. Zika virus infection during pregnancy may cause microcephaly as well as
other fetal brain defects. In one case of maternal infection in which the mother terminated the pregnancy,
the infant had micrenephaly, and multifocal dystrophic calcifications in the cortex and subcortical white
matter. The virus was found in the fetal brain.12 Laboratory diagnosis of Zika virus infection is possible by a
positive Zika virus real-time reverse transcription-polymerase chain reaction test or a positive Zika virus
immunoglobulin M neutralization test performed in conjunction with the IgM ELISA. In May 2016, there
were 279 reports of pregnant women with laboratory evidence of possible Zika virus infection, including
157 pregnant women residing in the US and the District of Columbia.13 Of these women, 73 reported
clinical symptoms consistent with Zika virus infection: 64 reported rash, 36 reported arthralgia, 37 reported
fever, and 17 reported conjunctivitis. For anesthesiologists, it is important to remember that Zika RNA has
been found in saliva, urine, and amniotic fluid. Currently, there have been no documented cases of
transmission from an infected patient to a health care provider. According to the CDC, anesthesiologists in
the labor and delivery setting “should adhere to Standard Precautions and wear sterile gloves and a surgical
mask when placing a catheter or administering intrathecal injections; additional equipment should be worn
based on anticipated exposure to body fluids. Double gloves might minimize the risk for percutaneous
injury when sharps are handled. Patient body fluids should not come into direct contact with health care
personnel clothing or footwear. Clothing, skin, and mucous membrane protections should be maintained for
procedures in the operating room.”14
Continuous fetal heart rate monitoring was developed to improve the detection of fetal hypoxia and to
intervene to prevent hypoxia-induced neonatal encephalopathy. In fact, the updated Practice Guidelines for
Obstetric Anesthesia states, “Fetal heart patterns should be monitored by a qualified individual before and
after administration of neuraxial analgesia for labor.” The good news is that the guidelines acknowledged
that it may not be required in every setting and may not be possible during placement of a neuraxial
catheter.15 Despite an increase in the incidence of CD due to nonreassuring FHR patterns, there has not been
a decline in hypoxia-related neonatal encephalopathy. It was hoped that the inclusion of fetal
electrocardiography would improve neonatal outcomes. The basis behind this recommendation is the
analysis of ST-segments and T-waves. Fetal academia is associated with fetal ST-Segment elevation and

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increased T-wave amplitude. In a study of 11,108 patients who had the monitor applied, 5532 of the cases
had the information available to the provider. The frequency of a 5-minute Apgar score of 3 or less differed
significantly between neonates and was 0.1% in the group where the information was provided as compared
to 0.3% in the groups that did not have the information. There was no difference in rates of CD or operative
vaginal deliveries. The study concluded that ST-segment analysis can be used as an adjunct to continuous
electronic fetal monitoring but neither improved neonatal outcomes nor reduced the rates of CD.16

The American College of Obstetricians and Gynecologists (ACOG) updated their committee opinion
on the use of magnesium sulfate in pregnancy. It is important to remember that the FDA advises against
the use of magnesium sulfate for more than 5-7 days to stop preterm labor, due to the concern for fetal and
neonatal bone demineralization. The uses of magnesium sulfate for obstetric practice include prevention
and treatment of seizures in women with preeclampsia or eclampsia and fetal neuroprotection before
anticipated early preterm delivery. While magnesium sulfate is not indicated for prolonged administration,
it is recommended for short-term prolongation of pregnancy (up to 48 hours) to allow for the administration
of antenatal corticosteroids in pregnant women who are at risk of preterm delivery within 7 days. As such,
this period would be between 34 weeks’ gestation and 24 weeks’ gestation.17 However, it is important to
realize that this recommendation may change as the indications for antenatal corticosteroids changes.
Antenatal steroids are administered to women between 24-34 weeks’ gestation who develop preterm labor
so that if the mother should deliver, there is improved lung maturity and decreased respiratory distress in
the preterm neonate. The lower limit of 24 weeks’ gestation was chosen as it is the limit of fetal viability.
However, the definition of fetal viability is being challenged as neonates born at 23 weeks’ and 22 weeks’
gestation have survived. The use of antenatal corticosteroids in infants born at 22-25 weeks’ gestation was
determined.18 Antenatal steroids were shown to decrease death and neurodevelopmental impairment at 18-
22 months in infants born at 23-, 24-, and 25-weeks’ gestation, with no improvement in infants born at 22
weeks’ gestation. There was a reduction in intraventricular hemorrhage and necrotizing enterocolitis for
infants born at 23-25 weeks’ gestation. The results of this study suggest that fetal viability may be pushed to
23 weeks’ gestation. If this is the case, then the indication for the use of magnesium sulfate for short term
prolongation of pregnancy may be extended to pregnancies at 23 weeks’ gestation.
There have been many major changes in the definition and management of preeclampsia. According
to the guidelines established by ACOG in 2013, the diagnosis of preeclampsia no longer requires
proteinuria. Renal and hepatic dysfunction may occur without proteinuria; furthermore, the amount of
proteinuria does not correlate with the severity of the disease.19 Preeclampsia may be diagnosed as new
onset hypertension with proteinuria or new-onset hypertension without proteinuria and any of the
following: 1) platelet count less than 100,000/µL, 2) serum creatinine level above 1.1 mg/dL or doubling of
serum creatinine in the absence of other renal disease, 3) liver transaminase levels at least twice the normal
concentrations, 4) pulmonary edema, and 5) cerebral or visual symptoms. These symptoms also make the
diagnosis as severe but includes SBP of 160 mmHg or higher or DBP of 110 mmHg or higher.
Preeclampsia has been shown to be associated with various changes in angiogenic proteins. There is an
increase in soluble fms-like tyrosine kinase 1 and endoglin (both antiangiogenic) and a decrease in placental
growth factor and vascular endothelial growth factor (both angiogenic). These changes may be measured in
the maternal serum or urine. As such, there are commercial tests that are being marketed for the prediction
of preeclampsia in the 1st trimester (before the onset of symptoms). ACOG has taken a stance against the
use of these tests as there are no studies documenting a benefit of reducing the incidence of preeclampsia
based upon these tests.20
Appropriate blood pressure management in women with hypertension during pregnancy not due to
preeclampsia has been debated. The question is what the appropriate blood pressure is for these individuals.
A large randomized study was conducted in 987 women with preexisting hypertension who were
randomized to tight control (DBP=85 mmHg) and to less-tight control (DBP=100 mgHg).21 Blood pressure
was primarily managed with labetalol. There was no difference in the risk of pregnancy loss, premature
birth, or maternal complications, although less-tight control was associated with a significantly higher
frequency of severe maternal hypertension. Given the results of this study, the anesthesiologist can expect
to encounter more women with poorly controlled blood pressure and have much more severe hypertension
during the labor process.
Neonatal resuscitation continues to be an important part of obstetric anesthesia practice. In an analysis of
closed malpractice claims for obstetric anesthesia, newborn death/brain damage was the leading cause for a
malpractice claim to be filed against an anesthesiologist.22 Most of the incidents were due to poor
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communication or anesthesia delay. Communication between the obstetrician and the anesthesiologist is
critical for an optimal outcome of the mother and neonate. According to the Guidelines for Neuraxial
Anesthesia in Obstetrics qualified personal, other than the anesthesiologist attending the mother, should be
immediately available to assume responsibility for resuscitation of the newborn as the primary
responsibility of the anesthesiologist is to provide care to the mother. However, there are times when the
anesthesiologist may be requested to provide assistance in the care of the newborn.

During the transition from intrauterine to extrauterine life, the neonate is required to make rapid and
profound physiologic changes as the neonate transfers from receiving oxygen from uterine blood flow and
nonfunctioning lungs to receiving oxygen completely from respiration. Approximately 10% of newborns
require some assistance to initiate respiration, while about 1% of newborns need extensive resuscitation.
Respirations are the first vital sign to be affected when a newborn is deprived of oxygen. After an initial
period of attempts to breathe, there is a period of primary apnea. During primary apnea, stimulation of the
infant will cause a resumption of breathing. If the oxygen deprivation continues, the baby gasps and enters a
period of secondary apnea. During secondary apnea, stimulation will not restart respirations. The only
therapy for secondary apnea is positive pressure ventilation.
There have been major changes in the provision of neonatal resuscitation.23 In infants not predicted to
require resuscitation, delayed clamping of the umbilical cord should be performed. Delayed clamping is
associated with less intraventricular hemorrhage, higher blood pressure, less need for transfusion, and
decreased risk of necrotizing enterocolitis. Another major change is thermal management of the neonate. It
is important to maintain thermal neutrality in the neonate, which means that delivery should occur in a
warm room. Admission temperature to the NICU is the strongest predictor of neonatal mortality.
Hypothermia is associated with an increased risk of intraventricular hemorrhage, respiratory difficulty,
hypoglycemia, and sepsis. Meconium should no longer be suctioned, even if the infant is depressed. It was
shown that more harm came from intubation and suctioning than benefit. In a comparison of stethoscope
versus EKG for determining the neonate’s heart rate, early application of EKG leads allowed for the
detection of a heart rate approximately 20-40 seconds faster. As such, use of an EKG for determining heart
rate is encouraged. If the neonate requires chest compressions, the two-thumb technique is recommended
as it generates higher blood pressure and coronary perfusion pressure. Following a successful resuscitation,
it is still recommended to have the neonate undergo mild hypothermia for 24-48 h.
Maternal mortality continues to be a worldwide concern. In 2006, the World Health Organization
concluded, “No issue is more central to global well-being than maternal and perinatal health. Every
individual every family and every community is at some point intimately involved in pregnancy and the
success of childbirth.”24 With the exception of the US, there have been worldwide decreases in maternal
mortality. Although maternal death is rare, reports from the Institute for Health Metrics and Evaluation in
2013 reported that the US experienced the largest increase in maternal death in the developed world since
1990.25 Increases in obesity, hypertension, diabetes, and abnormal placentation have “fueled” the recent rise
in maternal mortality, “near misses” and severe morbidity. Recently, data from the Pregnancy Mortality
Surveillance System was used to calculate pregnancy-related mortality ratios by year, age group, and race-
ethnicity during 2006-2010.26 Causes of pregnancy-related deaths were compared to causes since 1987.
Although pregnancy-related deaths due to hemorrhage, hypertensive disorders of pregnancy, embolism, and
anesthesia complications declined over the time period, pregnancy-related mortality ratios increased with
maternal age. Non-Hispanic black women were at highest risk of dying from pregnancy-related
complications. In addition, cardiovascular disease and infection were important contributors to maternal
mortality. This study suggests that chronic diseases are important contributors to pregnancy-related
mortality. Early detection, thorough assessment, disease stabilization, timely referrals, and counseling are
essential to improving outcomes.
Maternal comorbidities, disease and racial disparities contribute to risk during pregnancy. Increasing
numbers of pregnant women in the US have chronic medical conditions including hypertension, diabetes,
heart disease, and obesity.
Cardiovascular disease. The data from the Pregnancy Mortality Surveillance System indicate that
cardiovascular conditions including cardiomyopathy contributed to more than 26% of the
pregnancy-related deaths.26 A recent prospective review of 212 parturients with mechanical heart
valves revealed rates of maternal and fetal mortality of 1.4% and 18% respectively. Although
parturients had better outcomes with tissue values compared to mechanical valves, there were high
rates of thrombotic complications (5%) and hemorrhage (23%).27 The 1994-2011 Nationwide
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Inpatient Sample was used to evaluate trends and associations with hypertensive disorders of
pregnancy.28 In the study, patients with hypertensive disorders were at increased risk for stroke and
stroke-related complications. Patients with typical stroke-related risk factors (e.g., congenital heart
disease, atrial fibrillation, sickle cell anemia, congenital coagulation defects) have increased
independent risk for stroke when combined with a hypertensive disorder. This report and others
reinforce the importance of early identification and management of cardiovascular disease
including severe hypertensive disease.19

Infection and sepsis increase risk for morbidity and mortality. The Pregnancy Mortality
Surveillance System data revealed infection (13.6% of 8,645 pregnancy-related deaths) as a
leading cause of maternal mortality behind cardiovascular disease (14.6% of 8,645 pregnancy-
related deaths).26 The severe H1N1 influenza outbreak from 2009-2010 resulted in significant
morbidity and mortality among pregnant women.29 In the report, 75 women were confirmed to
have died from H1N1 with another 34 identified as probable cases. Flu vaccines are designed to
protect against the main flu viruses and are safe in pregnant women. A recent study of sepsis-
related deaths in the state of Michigan from 1999-2006 determined that death due to sepsis resulted
in 2.1 per 100,000 and 15% of all pregnancy-related maternal mortality.30 This study emphasizes
the importance of early diagnosis, appropriate antibiotic choice, and escalation of care.
Racial disparities have continued to be important contributors to maternal morbidity and mortality.
The Pregnancy Mortality Surveillance System data revealed that non-Hispanic black women were
at highest risk of dying from pregnancy-related complications.26 Besides a 3.2 times higher risk of
dying of pregnancy complications than non-Hispanic white women, these women were younger,
less educated, more likely to be unmarried, start prenatal care in the 2nd and 3rd trimesters of
pregnancy, and die of ectopic pregnancy complications than non-Hispanic white women. A
prospective study of the incidence of maternal morbidity (e.g., hemorrhage, infection, and perineal
laceration) also revealed stark racial and ethnic differences in the incidence maternal mortality. In
the study, non-Hispanic white women were least likely to experience hemorrhage (1.6% non-
Hispanic white compared with 3.0% non-Hispanic black compared with 3.1% Hispanic compared
with 2.2% Asian) and infection (4.1% non-Hispanic white compared with 4.9% non-Hispanic
black compared with 6.4% Hispanic compared with 6.2% Asian).31 The risk of perineal injury was
increased in Asian women. The authors suggest that the adverse outcomes could not be explained
by differences in patient characteristics or by delivery hospital and that racial and ethnic disparities
continue to persist in delivery of obstetric care. They emphasize the importance of determining the
cause of these racial and ethnic differences and prioritization of these important issues.
Thrombocytopenia (defined as a platelet count <100,000) develops in up to 1 in 20 healthy women by the
end of pregnancy. Although there is no consensus about the minimum platelet count that ensures safe
neuraxial techniques, most agree that a platelet count of 75,000-80,000 is adequate for safe administration
of neuraxial analgesia/anesthesia.32 However, more recent data were analyzed from a multisite retrospective
review of obstetric medical records from 1997-2007 and previous studies.33 Two hundred eighty patients of
~52,000 deliveries from two institutions and 254 of 499 patients from previous studies34-40 were analyzed.
The authors concluded that even with a large data set, the data may be insufficient to confidently offer
epidural analgesia to patients with platelet counts between 75,000-80,000. More recently, a database of
20,244 parturients was evaluated.41 Of those parturients, 368 met criteria and had platelet counts of <
100,000. These results were combined with results from the previous study33 for a final composite sample
size of 755. Results suggested that the upper limit of the 95% CI for the risk of neuraxial hematoma was
0.012 and of all cohorts together 0.004. The authors concluded that the risks of neuraxial anesthesia must be
weighed against the benefits and suggest that a national registry is needed to gather more robust data.
Important questions in assessment of thrombocytopenia include: 1) What is the etiology of the
thrombocytopenia?; 2) What is the absolute platelet count?; 3) What is the time interval since the platelet
count was measured?; 4) What is the trend in the platelet count?; 5) Are there clinical signs of bleeding?
Workforce surveys have been used since 1981 to measure trends in staffing and obstetric anesthesia
services every decade.42-45 The first survey revealed that more than 30% of epidural anesthetics were being
performed by obstetricians.42 In response, the availability of neuraxial labor analgesia not only increased
but was more often administered and managed by an anesthesiologist.43 However, in the smallest hospitals
neuraxial labor analgesia was unavailable in ~20% of cases. The 2001 survey reported further increases in
delivery of neuraxial labor analgesia, especially in the smallest hospitals, with 95% of all hospitals
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reporting availability of neuraxial labor analgesia.44 The most recent survey findings revealed the
following:45
Neuraxial labor analgesia is now available 24 h per day, even in the smallest hospitals.
Combined spinal epidural (CSE) is administered for labor in <20% of anesthetics, although it results in
improved maternal satisfaction and fewer top-ups during 1st stage labor.
Use of PCEA was used at 82% of responding hospitals. It decreases workload and increases maternal
satisfaction.
(TOLAC) was allowed in 65% of responding hospitals with 500-1499 births and <50% of hospitals
with <500 deliveries.
Fewer hospitals are providing obstetric services, especially the smallest hospitals surveyed.
Staffing for postpartum tubal ligation (PPTL) nights and weekends needs improvement, especially after
a 2010 study revealed that 47% of women who desired PPTL did not undergo the procedure while in
the hospital and had an unwanted pregnancy within 1 year of discharge from the hospital. 46
Emergency cardiac life support training for nurses is an area of obstetric care needing improvement.
Massive transfusion protocols are used in more than 76% of the largest responding hospitals and 42%
of respondents in the smallest hospitals. Implementing protocols is important to resolve maternal
hemorrhage, reduce blood product use and coagulopathy, and improve perception of patient safety.
Independent CRNA practice is highest in hospitals with <500 deliveries per year.
American Society of Anesthesiologists Practice Guidelines for Obstetric Anesthesia have been updated
and recently published.15 Since the first guidelines published in 1999, these systematically developed
recommendations have been used to assist practitioners and patients in health care decision-making. The
new guidelines were developed to “incorporate an analysis of current scientific literature and expert
consultant survey results.”
High-risk conditions and comorbidities may be associated with obstetric complications 47 48,49 28,50
The oral intake of moderate amounts of clear liquids may be allowed. Solid foods should be avoided.
A routine platelet count is not necessary in the healthy parturient.
A routine blood cross-match is not necessary for healthy and uncomplicated parturients.
FHR patterns should be monitored before and after administration of neuraxial analgesia for labor.
Patients in early labor (i.e.< 5 cm dilation) should have the option of neuraxial analgesia when this
service is available. Offer neuraxial analgesia on an individualized basis regardless of cervical dilation.
Neuraxial techniques should be offered to patients attempting TOLAC.
IV fluid preloading or co-loading may be used to reduce the frequency of maternal hypotension after
spinal anesthesia for CD. Spinal anesthesia should not be delayed in order to administer IV fluid.
For postoperative analgesia for CD, neuraxial opioids should be considered rather than intermittent
injections of parenteral opioids.
IV ephedrine or phenylephrine may be used for treating hypotension during neuraxial anesthesia. In the
absence of maternal bradycardia, consider selecting phenylephrine because of improved fetal acid–base
status in uncomplicated pregnancies.
Management of obstetric and anesthetic emergencies consists of (1) resources for management of
hemorrhagic emergencies, (2) equipment for management of airway emergencies,
and (3) cardiopulmonary resuscitation.
Failure of neuraxial blockade for CD is defined as a neuraxial block that is inadequate in density,
duration, or level. Failure may result from technical, anatomic, or obstetric factors. A multicenter
prospective observational study of more than 34,000 patients found that epidural anesthesia failed more
often than spinal or CSE techniques for CD.51 In the study, increased maternal size, rapid decision to
incision, and placement later in labor were all associated with risk of failed neuraxial anesthesia. A meta-
analysis of studies evaluating risk of failed extension of labor epidural anesthesia for CD determined that a
higher number of boluses administered during labor, patient characteristics (e.g., obesity), and time from
placement to CD increased the risk for epidural failure.30 More recently, a study examined unplanned
conversion to general anesthesia in 4300 parturients over a 6-year period.52 The study evaluated conversions
when there was adequate time to provide neuraxial anesthesia. Epidural anesthetics had the highest
conversion rate, followed by spinal, and CSE anesthetics. Conversion was most often associated with
hemorrhage and neonatal compromise.
Uterotonic agents are used prophylactically to prevent uterine atony. Oxytocin is the 1st-line drug for
prophylaxis and is used in conjunction with uterine massage during the active management of the 3 rd stage
of labor in order to decrease blood loss and reduce transfusion requirements. Several studies have evaluated
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the dose of oxytocin required to achieve uterine tone. The ED90 of bolus-dose oxytocin ranges from 0.35
international units (IU) in non-laboring women undergoing CD53 to ~3 IU in laboring women undergoing
CD for labor arrest after oxytocin augmentation during labor. 54 Because data demonstrate lower oxytocin
dose requirements than previously thought, there is now greater appreciation of serious side-effects55 when
higher doses are administered, especially in hypovolemic or hemodynamically compromised individuals. A
recent randomized, double-blinded trial of a “rule of threes” algorithm vs. continuous infusion of oxytocin
during CD determined that there were no differences in uterine tone, maternal hemodynamics, side effects
or blood loss between the two groups.56 However, the group randomized to the “rule of threes” using
oxytocin 3 IU, timed uterine tone evaluations, and a systematic approach to alternative uterotonic agents
received lower oxytocin doses when compared with a continuous infusion of oxytocin. When uterine atony
persists, 2nd-line uterotonic agents are utilized. A recent study of women receiving 2 nd-line agents
(carboprost or methylergonovine) revealed that women who received carboprost were more likely to
experience hemorrhage-related complications (hysterectomy, uterine artery ligation) compared with women
who received an ergot alkaloid.57 When women had received oxytocin during labor, the difference remained
but confidence intervals crossed. The authors suggest that methylergonovine may be more effective than
carboprost as a 2nd line uterotonic agent.
Maternal fever associated with epidural analgesia administration has been of great interest since it was
first observed in 1989.58 Although the mechanisms by which epidural analgesia are uncertain, several
explanations have been proposed: 1) thermoregulatory factors; 2) non-infectious inflammatory process; 3)
effects of systemic opioids in patients without epidural analgesia. Although there have been longstanding
concerns about whether epidural analgesia-related fever places the fetus at risk for neurologic injury, a
recent study of the Swedish Birth Registry including ~300,000 births over 10 years concluded that epidural-
related fever is a benign rise in temperature that is not associated with neonatal neurologic consequences. 59
Levels of maternal care and systems to facilitate rapid diagnosis and treatment are gathering increased
interest as the prevalence of severe illness and chronic comorbidities increase in obstetric patients. In 2015,
the ACOG and the Society of Maternal-Fetal Medicine proposed 4 Levels of Care [birth centers, basic care
(level I), specialty care (level II), subspecialty care (level III), and regional perinatal health care centers
(level IV)] with a goal of regionalizing maternal care for pregnant women who are at high risk in order for
them to receive specialized care.60 One specific example of a system approach is the recent postpartum
hemorrhage bundle developed by the National Partnership for Maternal Safety. 61 This document
recommends a system-wide approach to obstetric hemorrhage emphasizing a rapid response team and
anesthesiologist-led resuscitation. Such systems have been shown to improve outcomes.
Along with more system-specific approaches, there is increasing evidence that morbidity and costs are
increased in smaller-volume facilities.62 In addition to increased rates of hemorrhage and infection, one
recent report describes a 2-fold increased risk of major and minor anesthetic complications in hospitals that
perform <200 CDs per year.63 Costs are also increased at these facilities and likely result from prolonged
hospital stays, ineffective staffing models, billing exceptions, and increased morbidities.
Obstetric neuraxial drug administration errors can have serious consequences. A recent review of
published case reports and series were qualitatively analyzed for involvement of human factors in order to
propose modifications to practice.64 The analysis of 29 cases included identification of drugs, error setting,
source of error, observed complications, and therapeutic interventions. Although the most commonly
reported complication was the failure of an intended neuraxial anesthetic, 4 maternal deaths resulted from
the accidental intrathecal injection of tranexamic acid. The most common human factors were similar drug
appearances and drug storage problems. The authors suggest implementation of processes to reduce the risk
of such errors including: “(1) Careful reading of the label on any drug ampule or syringe before the drug is
drawn up or injected; (2) labeling all syringes; (3) checking labels with a second person or a device (such as
a barcode reader linked to a computer) before the drug is drawn up or administered; and (4) use of non-Luer
lock connectors on all epidural/spinal/combined spinal-epidural devices.”
Conclusion: The obstetric population is becoming older and pregnancies are often complicated by
comorbidities and illness. Levels of maternal care and systems will become increasingly important in order
to facilitate rapid diagnosis and treatment as the prevalence of severe illness and chronic comorbidities
increase in obstetric patients. Care of parturients and pregnant patients requires knowledge about obstetric
and anesthetic concerns. The great news is that it is rewarding and appreciated by patients and families.
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Refresher Course Lectures Anesthesiology 2016 © American Society of Anesthesiologists. All rights reserved. Note:
This publication contains material copyrighted by others. Individual refresher course lectures are reprinted by ASA with
permission. Reprinting or using individual refresher course lectures contained herein is strictly prohibited without
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Refresher Course Lectures Anesthesiology 2016 © American Society of Anesthesiologists. All rights reserved. Note:
This publication contains material copyrighted by others. Individual refresher course lectures are reprinted by ASA with
permission. Reprinting or using individual refresher course lectures contained herein is strictly prohibited without
permission from the authors/copyright holders.
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Refresher Course Lectures Anesthesiology 2016 © American Society of Anesthesiologists. All rights reserved. Note:
This publication contains material copyrighted by others. Individual refresher course lectures are reprinted by ASA with
permission. Reprinting or using individual refresher course lectures contained herein is strictly prohibited without
permission from the authors/copyright holders.