Hilton Head I à · 2018-05-25 · pciety or Obstetric Anesthesia and Perinatology Hilton Head I à...

pciety or Obstetric Anesthesia and Perinatology

Hilton Head I à

The Society for Obstetric Anesthesia and Perinatology is accreditedby the Accreditation Council for Continuing Medical Education toprovide continuing medical education for physicians.

Valerie A. Arkoosh, MDMCP Ilahnemann University

Philadelphia, PA

Robert D'Angelo, MDWake Forest University School of Medicine

Winston-Salem, NC

Andrew P. Harris, MD, MHSJohns hopkins hospitalsBaltimore, MD

Annual Meeting Program CommitteeJoy L Hawkins, MDProgram Chair

University of Colorado health Science Center

Denver, CO

Craig M. Palmer, MDUniversity of Arizona health Science Center

Tucson, AZ

Linda S. Polley, MDUniversity of Michigan Medical School

Ann Arbor, MI

Alex F. Pue, MDMary Birch Hospital for Women

San Diego, CA

Gary M.S. Vasdev, MDProgram Vice Chair

Mayo Clinic

Rochester, MN

Richard N. Wissler, MD, PhDUniversity of Rochester Medical Center

Rochester, NY

Accreditation & DesignationThe Society for Obstetric Anesthesia and Perinatology is accredited by the Accreditation Council for Continuing Medical Education to providecontinuing medical education for physicians.

The Society for Obstetric Anesthesia and Perinatology designates this educational activity for a maximum of 25 hours incategory i credittowards the AMA Physician's Recognition Award. Each physician should claim only those hours of credit that he/she actually spent in theeducational activity

Mission of SOAPThe purpose of this Society is to provide a forum for discussion of medical problems unique to the peripartun-i period and to promoteexcellence in medical care, research, education in anesthesia, obstetrics, and neonatology.

Mission of SOAP Program CommitteeThe mission of the Society's Program Committee is to provide anesthesiologists, obstetricians, and other physicians and members of relatedallied health specialties with the knowledge and skills that will reinforce past learning as well as disseminatenew concepts and practicesinvolving anesthesia and analgesia for the pregnant woman.

Goals of the SOAP 2002 ProgramTo provide ongoing CME activities designed to teach our audience how to best provide analgesia for labor and anesthesia for cesariansection and other procedures during pregnancy and postpartum period;To provide an Annual Scientific Meeting to the members as a forum for discussion that includes the opportunity for expression of newclinical insights, research results, applications and courses that will enhance the practice of obstetrical anesthesiology;To provide a forum for discussions dealing with specific issues that will enhance the effectiveness and cost efficiency of obstetricalanesthesia and analgesia;

To provide information and a forum for discussion on subjects which have been requested by members of the previous annual meetingand via needs assessment requests.

Educational FormatCME activities may include the following formats: Plenary sessions, debates, lectures, poster discussions, problem-based learning, andrefresher courses.

Participants in the SOAP 2002 ProgramAttendance shall be open to all health practitioners, provided that they have registered for the meeting. CME credit will only be offered toMDs or DOs or equivalent. A Verification of Participation form (found on page 3) must be turned in to SOAP at the conclusion of themeeting.

Table of Contents

Distinguished Service Award 2

Verification of Participation 3

Abtract Presentor Disclosures 5

Faculty Disclosures 7

Faculty 8

General Information 10

Meeting at a Glan 11

Poster Exhibits 14

Wednesday / Thursday at a GlanceNeonatal Resuscitation 17

Gertie Marx Symposium 18

Oral Presentations #1 19

Debate No. 1: Anesthesiologis'ts May Leave the Hospital Wen a Patient Has an

Indwelling Epidural Catheter 20

Poster Review #1 21

Hands-on Airway Workshop 24

Refresher Course Lectures 38

Paternal Medicationsfor Labor & Delivery

Reimbursement Options in Obstetric Anesthesia

Friday at a GlanceZuspan Papers 53

What's New in Neonatology: Vignettes in Neonatal Resuscitation 54

What's New in Obstetrics? 60

Poster Review #2 65

Saturday at a GlanceMultidisciplinary Obstetric Simulated Emergency Scenarios (MOSES) 69

Research Works in Progress 72

Clinical Forum: Scripted Cases ofParturients with Cardiovascular Disorders 73

ASA Presidential Address 85

Debate No.2: FailedEpiduralfor Urgent C/S: Sp rinal is Preferable to Gen eralAnesthesia 86

Poster Review #3 87

Gerard W. Ostheimer: What New in Obstetric Anesthesia Lecture 89

Sunday at a GlanceBreakfast with the Experts 145

Fred Hehre Lecture 147

Oral Presentations #2 159

Oral Presentations - Best Paper of the Meeting Award 160

Exhibitors - Product Description 161

i

(JÓflP2OO22002 Distinguished Service Award

Founders of the Society forObstetric Anesthesia & Perinatology

Robert O. Bauer, MD *

Richard B. Clark, MD

James O. Elam, MD*

James A. Evans, MD*

Robert E Hustead, MD

Bradley E. Smith, MD

* deceased

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Abstract Presentor Disclosures

No relationship w/commercial supportersResearch SupportSpeaker's Bureau -

Consultant..Shareholder (Directly Purchased)Other Financial SupportLarge Gift(s)Did not receive disclosure information prior to printing. Disclosure will occur prior to presentation.Unless otherwise indicated all faculty will comply with Trade/Unlabeled Use of products policy in their presentation

Rishimani Adsumelli - I

Gilbert Aldape - IJames Alexander IBurak Alptekin

Astra Zeneca -3

Pamela Angle - I

Martin Angst- iEvelyn Ansa - I

Valerie Arkoosh - I

Paul Audu - IGubby Ayida - IUlku Aypar

Dupont Pharma - Paul BachProduct (bentastarch 10%)

N Bailur - IAti]io Barbeito - ISylviana Barsoum

AsfraZeneca-3James Bates - iJonathan Benumof - ISamina Bharmal - IDavid Bimbach - IFreeha Bokhari

Astra Zeneca -3

Terrance Breen - I

Nicole Brockhurst - IMichael Brown - iSimon Brown - IIngrid Browne - I

Alexandra Bullough - IElizabeth Burley

Astra Zeneca -3

Genelle Buti - iJodle Buxbaum -1Valerie Bythell - 1

Arthur Calimaran - 1

William Camann - ID Cariaso - iB Carvalho -1

Carmencita Castro - I

Renee Caswell - IDonald Caton - iDmitri Chamchad. I

Theodore Cheek - i

Michelle Chochinov - iChristopher Ciliberto - I

Fli7abeth Coates - I

SCohen. IShaul Cohen

Astra Zeneca -3

Sheila Cohen - I

Malachy ColumbStudy Group UK COMET

James Costello - I

James Coyne - I

Pushkar Dadarkar - IAshi Daftary -IPritiDalal -IDanette Daniels - 1Alaedin Darwich -IColin Davis-iRobin Davisson - iSebastian de la Fuente - I

Cheryl De Simone - i

Peter DeBaili - IHoward Denenberg

Astra Zeneca -3

Cheryl DeSimone - i

Connie Dimarco - I

Lauren DiMaria - I

Yanahang Dong - I

Joanne DouglasDupont Pharma - Paul BachÍvduct (pentastarcb 10%)

John Downing - ID Drover - IScott Drysdale - I

Clive Duke - ISusan Dumas - I

Peter Dwane - iDuke Eason - iRobert Eberle - I

Jeffrey Ecker - I

James Eisenach - I

Andrew Elimian -1

Habib El-Moalem - I

5

Mark EslerDupont Pharma - Paul BachProduct (pentastarcb 10%)

Steven Eubanks - ITammy Euliano - i

Scott Falk-ITahir Farooq

Astra Zeneca-3Roshan Fernando - IHelene Finegold - 1

Pamela Flood - IJ Forster - IRegina Fragneto - IMarilyn Fredericksen - I

Lanniece FreemanAstraZeneca-3

Jennifer Friedman - IMichael Froeich I

Amiram Gafni - ISophie Gagnon - I

Robert Griser - iPhilippe Gautier - iKaren Gertenbach - IK Giarrusso-I -JGinosar-iSteven Ginsberg

Astra Zeneca -3

Raphael Giraud - iRaymond Glassenberg - i

Samuel Glassenberg - I

Evan Goodman - IStephanie Goodman - I

Caroline Grange - 1

Mark Greenberg - I

Rebecca Greene - I

Anne Gregg-IVladimir Grodecki - i

Victor GrosuAstraZeneca-3

Vit GunkaDupont Pharma - Paul Bach

Product (pentastarcb 10%)

Brett Gutsche - i

Ashraf Habib - I

Stephen Hallworth - ISteven Hallworth

Stephen Halpern - IMaryHannah-IDenisa Haret - IHelen Harker - IMiriam Harnett - 1Scott Helsley - 1

David Hepner - iPhilip Hess-IJames Hill-iEllen Hodnett - iDarren Hoffmann - 1.David Hood - IJay Horrow-1McCallum Hoyt-IKaren Hsu-1Jane Huffnagle - iSu.zane Huffnagle - I

Osamu Ishihara - I

Andra James - IRobert James - I

Ben Johnson - I

E Johnson - IRaymond Johnson - I

Geena Joseph - iNinos Joseph - iAllaudin Kamani

Dupont Pbarma - Paul BachProduct (pentastarch 10%)

Bupesh Kaul - i

C Kenaan -1Beklen Kerimoglu - i

Christian Kern-iKhadija Khan - i

Katsuynki Kinoshita - i

Paul Kliffer-iPaul Kligfield - I

Bhavani-Shankar KOda1i - i

Antigoni Koutoulas - i

A Koutrouveis - iPiotr Krasuski - i

J.Yasha Kresh - I

Jean Kronberg - IKrzysztof Kuczkowski - IHector Lacassie - I

Madeline Lai - ISims Portex -3

Ruth Landau - IBee Lee - I

Aviva Lee-Parritz -

Lisa Leffert - I

Craig Leicht - I

Barbara Leighton - I

Dymtro Leschinskiy - I

Kenneth Leveno - IYunpmg Li-1Michael Lilly - I

Yin Lim-IE Lockhart-iTimothy Long -IStephen Longmire - INancy Lowe -IAlison Macarthur - IA. Makhdumi -1

Sabah Malek - ISonia Maihotra - I

Angela Maflozzi - I

Gordon Mandel - ISusan Mann-IRMarcus-IJulio Marenco - IRobert McCarthy -IDonald Mclntire - I

Mahfouz Megally - IJorge Melgen

Sims Portex-3

Pamela Mergens - IDavid Merrill -ISimon Millar - 1

Beth Minzter- IEdward Mirikatani -1Jenny Mitchell - IMay Mok-1Phyllis Money - iCMoore-IJulia Morch-Siddafl - I

Anwar Morgan -1

Kathleen Morgan - 1

Mary Mowbray :1

Holly Muir -iUrna Munnur -I

S Myers-ITerry Myhr - I

Lev Nakhamchik-I

Norah Naughton - I

Warwick Ngan Kee - I

Mark Norris - IJon Obray - iDavid O'Gorman - IArne Ohlsson - I

Adeyemi Olufolabi - I

Geraldine O'Suffivan - IMedge Owen - I

Quisqueya Palacios - I

Susan Palmer - IP Panni-iMoeen Panni - IRay Paschall - I

Nisa Patel - I

A Peaceman - IB. Perez - i

Amy Phelps - iJ.Philip-ISajith Philip - 1

Barbara Philips-Bute - IMay Pian-Smith - IJose Pinheiro - IJohn Plummer - iLinda Polley - ID Portnoy-IStephen Pratt - ISivam Ramanathan - iRamiah Ramasubramanjan - IKirk Ramm - iPatrick Ramsey - i.Jaynatbie Ranasinghe

Honorarium Sims Portex

Sudharma Ranasinghe - IEmily Ramer - IMira Razzaque - I

Felicity Reynolds - I

James Reynolds - iAnne Riddell - IAmy Riegel - i

Edward Riley - iJose Rivers - 1

Ryan Romeo -1Dwight Rouse - IR Russell - i

Noor Sabzposh - i

Syed Wasil Sabzposh - I

Chris Sadler - 1

Sukran Sahin - I

M. Ramez Salem - I

Andreas Sandner-Kiesling - iAlan Santos - I

Kavita Sarang - i

Rama Sashidharan -1

R Satya-Krishna - I

Barbara Scavone - I

Gunther Schlager -

6

John Schultz - IScott Segal - ISanjeev Sethi - I

Kelly Shannon - IShiv Sharma - iSSherwani-IG Shih - iNeeta Shukla - iMeraj Siddiqui

Sims Portex-3

F Siswawala - I

E. Slaymaker - i

Richard Smiley - I

Caroline Snowman - I

VinnieSodhi-ITede Spahn - I

Laura SpearsAstraZeneca Corporation -3

Joan Spiegai - I

Margaret Srebrnjak - IJoy Steadman

Sims Portex-3

Deborah Stein - I

Bonnie Stevens - IT Strauss-Hoder - IRobyn Stremler - iMax Su - iJohn Sullivan - iKishwar Sultana -1Maya Suresh - iJohn Szalai - 1

L Tabaczewska - ISatoru Takeda - iKennyTam-ISam Tang-IJunko Taya - iIan Taylor - I

Katsuo Terni - iUmamaheswary Tharmaratnam L iDorothy Thompson - IJenny Thompson - 1

Donna Thornley - 1Martha Tingle -1

Chuanyao Tong - i

Takeko ToyamaSims Portex -3

Connie Tran - I

Lawrence Tsen - I

Lori Tungpalan - i

Luminita Tureanu - I

Nesimi Uckunkaya - I

Rakesh Vadhera - I

Manuel Vallejo - I

Claire Van Harnel - i

Medha Vanarase - I

Gurinder Vasdev - I

Anasuya Vasudevau - I

Ivan Veickovic - ITracey Vogel - i

Deborah Wagner - IAshutosh Wali - IMaryWalsh-IVivien Walsh - I

Jason Wang - iCWass-iMalcolm Watters - iC. Weidner - I

Robert Weiss - I

Julie Weston - IDavida White-Pettaway - IMegan Whittaker - IJ. Wiley - I

Andrew Willan - 1

Matthew Wilson - IRoryWindrim-IDaniele Winkler - IDawn Wison - IRichard Wissler - IApril Wong - I

Cynthia Wong - iMaddy Woods - IE Yaghmour -1Yasin Zada

AstraZeneca Pbar,naceuticals- 3

Hui Zhu - ITracy Zinner - I

Faculty Disclosuresi. No relationship w/commercial supporters

Research SupportSpeaker's Bureau

4 ConsultantShareholde«Directly Purchased)Other Financial SupportLarge Gift(s)Did not receive disclosure information prior to printing. Disclosure will occur prior to presentation.Unless otherwise indicated all faculty will comply with Trade/Unlabeled Use of products policy in their presentation

Valerie A. Arkoosh, MDiG.M. Bassell, MDiYaakov Beilin, MD 1

Anthony Bissette, MD 8Kristi S. Borowski, MD 8

Brenda A. Bucklin, MD - iGerald A. Burger, MD 8

W Mark Burtinel, MD 8Christopher Burkie, MD - i

William R. Camann, MD - IDavid C. Campbell, MD, MSc, FRCPC 1

Robert Chantigian, MD - iTheodore G. Cheek, MD - iDavid H. Chestnut, MD 8Lauri P. Cox, RN, BSN, IBLLL I

Patricia A. Dailey, MD - i

Robert D'Angelo, MDiMarie L DeRuyter, MD 8

Martin DeRuyter, MD 8David M. Dewan, MD - iM. Joanne Douglas, MD, FRCP _i

Roshan Fernando, MBBS, FRCANeurocom 2PortexLtd.-2

William Franz, MD 8RobertRGaiser,MD_i -

Bhargavi,Gall,MD_1David R Gambling, MBBS - iBatty Glazer, MDiDebbie Ward Gordon, RN, MSN - I

Michael Greene, MD - iDeanna Griebenow, CNM 8

Stephen H. Halpern, MD 8

Andrew P. Harris, MD - iBarry A. Harrison, MD - iJoy L. Hawkins, MD 1

Christopher james, MD i

Keith L. Johansen, MD 1

Gerard S. Kamath, MD 8

Thomas Kastner, MD 8MarkT. Keegan,MD-1Mathew M. Kumar, MD,JD - iCraigH Leicht,MDiBarbara L. Leighton, MD - I

AlisonJ. MacArthur, MD 1Ronald A. MacKenzie, DO - i

Andrew M. Malinow, MD 1

GertieF.Marx,MDiAnne May, MBBS, FRCA - i

James P. McMichael, MD - i

Edward R Molina-Lamas, MD, FACA - i

Holly Muir, MDSkye Pharm Inc. 2

MariaMurry,CNM-8Geraldine O'Sullivan, MBBS, FRCA 8

Medge D. Owen, MD - i

Michael J. Paech, FANZCAAbbottAustralasia P74 Ltd-2, 4

Craig M. Palmer, MDPreferred Medical-2Ballard-2Kimberly-Clark-2

Susan K. Palmer, MD - i

Sumedha Panchal, MDIDonald H. Penning, MD, MSc, FRCPC 1Alex F.Pue,MDISivam Ramanathan, MD 8KirkRamin MDIMira Ra.zzaque, MD - I

Edwin H. Rho, MD 1

Edward T. Riley, MD 8

AlainSabri,MD-8Christopher Sadler, PhD, MBBS, FRCA - i

Sukran Sahin, MD 8

Alan C. Santos, MD, MPH

AstraZeneca 2Chiroscience-2Purdue-4

Mukesh C. Sarna, MD, FRCA 8

7

KennethP.Scott,MDiB.ScottSegal,MDIRichard M. Smiley, MD, PhD 1

AnilKSoni,MD-8Juraj Sprung, MD - i

Maya S.Suresh,MD-1Gary M.S. Vasdev, MD - i

Ashu Wall, MD, FRARCS - I

Mary Ellen Warner, MD - I

Carole Warnes, MD - i

Richard N. Wissler, MD, PhD 8

DavidJ.ody,MD-8Cynthia A. Wong, MD - i

Frederick P. Zuspan, MDMatrea Healtbcare (Board) 4

Kathryn J. Zuspan, MD - i

O

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PJi

iUîValerie A. Arkoosh, MD

MOE Hahnemann University

Philadelphia, PA

G.M. Bassell, MDWesley Medical Center

Wichita, KS

Yaakov Beim, MDMt. Sinai School of Medicine

New York NY

David J. Birnbach, MDSt. Luke's Roosevelt Medical Center

New York, NY

Anthony Bissette, MD*Mayo Clinic

Rochestei MN

Kristi S. Borowski, MDMayo Clinic

Rochester, MN

Brenda A. Bucklin, MDUniversity of Nebraska Medical Center

Omaha, NE

Gerald A. Burger, MDWyoming Medical Center

Casper, WY

W. Mark Burtinel, MD*Mayo Clinic

Rochester, MN

Christopher Burkie, MD*Mayo Clinic

Rochester, MN

William R. Camann, MDBrigham & Women's Hospital

Boston, MA

David C. Campbell, MD, MSc, FRCPCRoyal University hospital

University of Saskatchewan

Saskatoon, Saskatchewan, Canada

Robert Chantigian, MDMayo Clinic

Rochester, MN

Theodore G. Cheek, MDPhiladelphia, PA

University of Pennsylvania

David H. Chestnut, MDUniversity of Alabama - Birmingham

Birmingham, AL

Faculty

Laurie Cox, RN, BSN, IBLLLWake Forest University Medical Center

Winston-Salem, NC

Patricia A. Dailey, MDMills-Peninsula health System

Hilisborough, CA

Robert D'Angelo, MDWake Forest University School of Medicine

Winston-Salem, NC

Marie L DeRuyter, MD*Mayo Clinic

Jacksonville, FL

Martin DeRuyter, MD*Mayo Clinic

Rochester, MN

David M. Dewan, MDWake Forest University School of Medicine

Winston-Salem, NC

M.Joanne Douglas, MD, FRCPBritish Columbia Women's Ilospital

Vancouver, British Columbia, Canada

Roshan Fernando, MBBS, FRCARoyal Free hospital

London, United Kingdom

William Franz, MDMayo Clinic

Rochester, MN

Robert R. Gaiser, MDUniversity of Pennsylvania

Philadelphia, PA

Bhargavi Gall, MD*Mayo Clinic

Rochester, MN

David R. Gambling, MBBSMary Birch hospital for WomenSan Diego, CA

Barry Glazer, MDSt. Francis Hospital

Indianapolis, IN

Deborah Ward Gordon, RN, MSNWake Forest University Medical Center

Winston-Salem, NC

Michael Greene, MDMassachusetts General llospital

Boston, MA

* Denotes Airway WorkshopFaculty

8

Deanna Griebenow, CNMMayo Clinic

Rochester, MN

Stephen H. Halpern, MDUniversity of Toronto

Toronto, ON, Canada

Andrew P. Harris, MD, MHSJohns Hopkins hospitalBaltimore, MD

Barry Harrison, MD*Mayo Clinic

Rochester, MN

Joy L Hawkins, MDUniversity of Colorado hospital

Denver, CO

ChristopherJames, MDMayo Clinic.Jacksonville

Jacksonville, FL

KeithJohansen, MDMayo Clinic

Rochester, MN

Gerard S. Kamath, MD*Mayo Clinic

Rochester, MN

Thomas Kastner, MDMayo Clinic

Rochester, MN

Mark T. Keegan, MD*Mayo Clinic

Rochester, MN

MathewM. Kuniar, MD,JDMayo Clinic

Rochester, MN

Craig H. Leicht, MD, MPHWestern Pennsylvania h hospital

Pittsburgh, PA

Barbara L. Leighton, MDCornell University

New York, NY

Andrew M. Malinow, MDUniversity of Maryland School of Medicine

Baltimore, MD

Gertie F. Marx, MDAlbert Einstein College of Medicine

New York, NY

AlisonJ. MacArthur, MDMount Sinai Hospital

Toronto, ON, Canada

Ronald A. MacKenzie, DO*Mayo Clinic

Rochestei MN

Anne May, MBBS, FRCALeicester Royal Infirmary

Leicester, United Kingdom

James P. McMichael, MDCapital Anesthesiology Association

Austin, Dt

Edward R. Molina-Lamas, MD, FACAThe Women's Hospital of Texas

houston, TX

Holly Muir, MD, FRCPCDuke University Medical Center

Durham, NC

Maria Murry, CNMMayo Clinic

Rochester, MN

Geraldine O'Sullivan, MBBS, FRCASt. Thomas hospital


Medge Owen, MDWake Forest University Medical Center

Winston-Salem, NC

MichaelJ. Paech, FANZCAKing Edward Memorial Hospital for WomenPerth, Australia

Craig M. Palmer, MDUniversity of Arizona Health Science CenterTucson, AZ

Susan K. Palmer, MD*University of Colorado - AuroraAurora, CO

Sumedha Panchal, MDWeffi Medical College

Edgewater, NJ

Donald H. Penning, MD, MSc, FRCPCJohns Hopkins University

Baltimore, Ml)

Alex F. Pue, MD

Mary Birch Hospital for Women

San Diego, CA

Kirk Ramm, MDMayo Clinic

Rochester, MN

Sivam Ramanathan, MDMaGee Women's Hospital

Pittsbrugh, PA

Mira Razzaque, MDRoyal London Hospital

London, UK

Edwin H. Rho, MD*Mayo Clinic

Rochester, MN

Edward T. Riley, MDStanford University

Stanford, CA

AlainSabri,MD*Mayo Clinic

Rochester, MN

Christopher Sadler, PhD, MBBS, FRCARoyal London hospital


Sukran Sahin, MDUludag University Medical University

Bursa, Turkey

Alan C. Santos, MD, MPHSt. Luke's/Roosevelt Hospital Center

NewYork, NY

Mukesh C. Sarna, MD, FRCABeth Israel Deaconess Medical Center

Boston, MA

Kenneth R Scott, MD*Mayo Clinic

Rochester, MN

B. Scott Segal, MDBrigham & Women's Hospital

Boston, MA

Richard M. Smiley, MD, PhDColumbia University

New York, NY

Anil K. Soni, MDBeth Israel Deaconess Medical CenterBoston, MA

Jurai Sprung, MD*Mayo Clinic

Rochester, MN

Maya S. Suresh, MDBaylor College of Medicine

Houston, TX

Gary M.S. Vasdev, MD*Mayo Clinic

Rochester, MN

Ashu Wall, MD, FFARC*Baylor College of Medicine

houston, TX

Mary Ellen Warner, MD*Mayo Clinic

Rochester, MN

Carole Warnes, MDMayo Clinic

Rochester, MN

Richard N. Wissler, MD, PhDUniversity of Rochester Medical Center

Rochester, NY

David J. Wiody, MDState Univrsity of New York

New York, NY

Cynthia A. Wong, MDNorthwestern University Medical School

Chicago, IL

Frederick R Zuspan, MDOhio Stale University -

Columbus, OH

Kathryn J. Zuspan, MDHennepin County Medical Center

Edina, MN

* Denotes Airway Workshop Faculty

General InformationHotel InformationThe Hilton Head Island Marriott Beach and Golf Resort, a natural splendor of Hilton Head Island, South Carolina, is locatedin Palmetto Dunes, a premier oceanfront destination. The resort is 10 minutes from the Hilton Head Island Airport and 45minutes from the Savannah International Airport. SOAP will be one of the first groups to stay in this multi-million dollarrenovated premier resort. Beautiful ocean and island views are available from private terraces outside each guest room.You'll discover uncounted ways to enjoy the sun, basking beside the oceanfront Olympic size pool, stroking along nine milesof golden sand, or enjoy tee for two on one of the six world class 18-hole championship golf courses When the businessday is done, you can enjoy an invigorating match at a world-class tennis facility or visit the Spa, a fully equipped health club,complete with indoor heated pool, whirlpools, sauna and massage therapist. You can sightsee in near-by Shelter Cove orHarbour Town before dining in one of four elegant restaurants. Discover the perfect blend of experienced service andresort ambiance as only Marriott can deliver!

SOAP Dine-Around (Thursday, 6:00 pm)

Menus, sign-up sheets along with transportation options will be available on site.

Fun Run/VcTalk - Sea Pines Forest Preserve (Friday, 1:30 pm)Transportation will be provided from the Marriott to the natural preserve in Sea Pines Plantation for a 5K Fun Run. The605-acre Sea Pines Forest Preserve has approximately 8 miles of trails that follow antebellum rice dikes from the I 840s andold logging trails from the 1 950s. Supported by a grant from B. Braun.

SOAP Tennis Tournament (Friday, 1:45-5:15 pm)SOAP will host a tennis tournament Friday afternoon at the Palmetto Dunes Tennis center. The format will be a mixeddoubles round robin.

SOAP Golf Tournament - Golden Bear Golf Club (Friday, 1:00-6:00 pm)Created by the Jack Nicklaus' design team, the Golden Bear Golf Club is an excellent example of Hilton Head Island golf.Created on a fairly flat terrain, with little natural mounding, the Nicklaus Architectural group relied primarily on ponds, marshand the forest to carve a challenging, yet fair test of golf. Golden Bear is highly-regarded by, and a local favorite of the golfcommunity on Hilton Head Island. The course reaches just over 7,000 yards at the tips, but most visitors will have plenty ofchallenges at either 6,643 or 6,184 yards.

SOAP Banquet/Beach Music Party (Friday, 6:30)Our annual banquet theme is "Beach Music Party", which will be held at the Hilton Head Island Marriott Beach & GolfResort. Highlights of the Party will include a live band, "Sterlin Colvin and the Improv" who, along with a couple instructorswill have everyone "shagging" a popular dance indigenous to the Carolinas and Virginia. So get out your casual beach wearand enjoy a night of Hilton Head Island hospitality, casual dinner, dancing and merriment. Advance registration necessary.

Sunset Sailing (Saturday, 5:30 pm)Enjoy sunset sailing on America's Cup Race; "Stars and Stripes" and "Pau Hana" Catamaran. Cocktails and hors d'oeuvres,will be served. Seating is extremely limited (US Coast Guard Regulations). Sign-up will be at the Baxter booth on Thursdaymorning on a first-come, first-serve basis. If you are interested, please email <shane_montgomerybaxter.com>, however,sign-up will only be on-site. Please wear non-marking soft shoes and bring a light jacket. Those on Stars and Stripes shouldbe prepared to get a little wet. For liability/safety issues, sorry no children are allowed. Supported by Baxter.

Tours, Shopping, Sea Kayaking, Bike Rentals, etc.Deep sea fishing, parasailing, sunset sails and dolphin cruises are favorites, in addition to plenty of outlet and boutique shop-ping. Please contact the hotel concierge directly at 843-842-8000 for assistance in planning your extra-curricular activities.

lo

Scientific Program

Wednesday, May 1, 20028:00 am - 2:00 pnr Executive Committee / Board of Directors Meeting

2:00 - 6:00 pm Committee Meetings

2:00 .. 6:00 pm Registration

2:00 - 6:00 pm Poster Mounting (Both Sessions)3:00 - 6:00 pm Neonatal Resuscitation Course (Limited Registration - By Ticket Only)

Coordinator: Medge Owen, MD; uri P. Cox, RN, BSN, IB; Debbie Ward Gordon, RN, MSN

6:00 - 8:00 pm Wine/Cheesé Reception - (Hilton Head Island Marriott)

Thursday, May 2, 20027:00 am Registration

7:00 - 7:45 am Breakfast with Exhibitors & Posters

7:45 - 8:00 am Opening Remarks & WelcomeJoy L. Hawkins, MD; Gary M.S. Vasdev, MD

8:00 - 9:30 am Gertie Marx Symposium - Joy L. Hawkins, MD (Moderator)

9:30 - 9:45 am

9:45 - 10:15 am

10:15 am - 11:15 n

11:15 - 12:15 pm

12:15 - 1:15 pm

1:15 - 2:15 pm

2:15 - 2:30 pm

2:30 - 4:00 pm4:15 - 5:45 pm

Judges: Germi E Marx, MD; GM Bassell, MD; Geraldine O'Sullivan, FRCA; Robert D'Angelo, MD;Donald H. Penning, MD, MSc, FRCPC; David H. Chestnut, MD; Joy L Hawkins, MD

Distinguished Service Award PresentationValerie A. Arkoosh, MD

Break with Exhibitors & Posters

Oral Presentations #1Moderator: ChristopherJames,MD

Debate No. IAnesthesiologists May Leave the Hospital When a Patient Has an Indwelling EpiduralCatheterModerator: Kathryn J. Zuspan, MDPRO: Gerald A. Burger, MD CON: Theodore G. Cheek, MD

Lunch with Exhibitors and Posters

Poster Review #1Introduction: Valerie A. Arkoosh, MDModerator: Yaakov Beim, MD

Break with Exhibitors and Posters

"Hands on" Airway Workshop Refresher Course Lectures(Limited Registration - By Ticket Only) -

Group 1 2:30 - 3:30 pm Paren teral Medications for LaborGroup 2 & DeliveryCoordinators: Barry Harrison, MD; David C. Campbell, MD, MSc, FRCPC

Gerard S. Kamath, MD

6:00 pm SOAP Dine Around (sign-up on site)

4:00 - 5:00 pm Covering Labor & Delivery- in a Community Hospital

Patricia A. Dailey, MD

6:30 am

7:00 - 8:00 am

7:00 - 8:00 am

8:00 - 9:30 am

9:30 - 10:00 am

10:00 - 11:00 am

11:00 am - 12:00 n

12:00 - 1:00 pm

1:00 - 2:00 pm

2:00 - 3:00 pm

3:00 - 3:30 pm

3:30 - 5:00 pm

5:30 pm

Scientific Program

Friday, May 3 20026:30 am Registration

7:00 - 8:00 am Breakfast with Exhibitors & Posters8:00 - 9:00 am The Zuspan Award by Perinatal Resources Inc

Moderator/Judge: David J. Birnbach, MDJudges: David H. Chestnut, MD; Michael Greene, MD; Anne May, MBBS, FRCA; Alan C. Santbs, MD;Stephen H. Halpern, MD; Susan K. Palmer, MD

Registration

Breakfast with Exhibitors & PostersMultidisciplinary Obstetric SimulatedEmergency Scenarios (MOSES)(Limited Registration - By Ticket Only)

12

7:00 - 8:00 am Research Works in ProgressRobert D'Angelo, MD;Richard M. Smiley, MD, PhD

9:00 - 10:00 am What's New in Neonatology: Vignettes in Neonatal ResuscitationIntroduction: Gary M.S. Vasdev, MD; Presentor: Robert Chantigian, MD

10:00 - 10:10 am Presentation of the Zuspan Award by Perinatal Resources, IncFrederick P. Zuspan, MD;

10:10 - 10:30 am Break with Exhibitors & Posters

10:30 - 11:30 am What's New in Obstetrics?Introduction:Joy L Hawkins, MD; Presentor Michael Greene, MD

11:30 am - 12:30 pm Poster Review #2Moderator: Robert R. Gaiser, MD

1:30 pm Fun Run/Walk, Tennis Tournament, and Golf Tournament (12:45 pm)

6:30 pm Banquet - Beach Music Party (Hilton Head Island Marriott)

Saturday, May 4, 2002

Christopher Sadler, PhD, MBBS, FRCA; Mira Razzaque, MD

Clinical Forum: Scripted Cases of Parturients with Cardiovascular DisordersModerators: Carole Warnes, MD; Kirk Ramm, MD; William R. Camann, MD


ASA Presidential AddressBarry Glazer, MD

Debate No. 2Failed Epidural for Urgent C/S: Spinal is Preferable to General AnesthesiaModerator: Andrew M. Malinow, MDPRO: David R. Gambling, MBBS CON: M. Joanne Douglas, MD, FRCPC

Lunch

Poster Review #3Introduction: Alan C. Santos, MD; Moderator: Holly Muir, MD, FRCPC

Gerard W. Ostheimer Anesthesia Lecture: What's New in Obstetric Anesthesia?Introduction: Alan C. Santos, MD; Presentor: David H. Wiody, MD


Business MeetingSunset Sailing (Limited Space, Ticket Only)

Scientific Program

Sunday, Miy 5, 20026:30 am Registration

7:00 - 8:00 am Breakfast with the Experts (Limited Registration - By Ticket Only)1. Post-partum Analgesia - AlisonJ. MacArther, MD2., Continuous Spinal Analgesia - Craig M. Palmer, MD

Labor Analgesia with Limited Staffing Resources - Richard N. Wissler, MDInternational OB Anesthesia Education Opportunites - Medge Owen, MD; Sukran Sahin, MDFine Tuning Your CSE - Craig Leicht, MD, MPHAnswering Big Questions in Obstetric Anesthesia Research - B. Scott Segal, MD;Richard M. Smiley, MD, PhDAmbulation after Labor Regional Anesthesia - Roshan Fernando, MBBS, FRCAFetal Distress and Unable to Intubate. What Next? - Maya Suresh, MDThe Morbidly Obese Preeclamptic Parturient - Sumedha Panchal, MDPost Partum Tubal Ligation - Brenda A. Bucidin, MDBilling-James P. McMichael, MDBilling - Edward R. Molinas-Lamas, I'4D, FACAObstetrics and Family Medicine Issues in Labor and Delivery - Keith Johansen, MD;Thomas Kastner, DM; Walter Franz, MDIs OB Anesthesia More Liable for Litigation than Other Subspecialties - Mathew Kumar, MD,JDPost Dural Puncture Headache - Anil Soni, MD; Mukesh Sarna, MDLegislative Issues - Andrew P. Harris, MD, MHSPCEA Should Always Be Used in Preference to Continuous Epidural Infusion Analgesia in Labor-Michael J. Paech, FANZCAAnesthesia for Placenta Accerta - Alex E Pue, MD

8:15 - 9:15 am Fred Hehre LectureDavid M. Dewan, MD

9:15 - 10:15 am Oral Presentations #2Moderator: Cynthia A. Wong, MD

10:15 - 10:45 am Coffee Break

10:45 - 11:45 am Oral Presentations - Best Paper of the Meeting AwardModerator/Judge: MichaelJ. Paech, FANZCA

Judges: Sivam Ramanathan, MD; Edward T. Riley, MD; Scott Segal, MD

11:45 am - 12:00 n Best Paper of the Meeting Award I AdjournmentModerators: Joy L. Hawkins, MD; Gary M.S. Vasdev, MD

2002 Annual Meeting ElectionsDuring the annual business meeting in Hilton Head, South Carolina, members will elect a Second VicePresident, Secretary; Director at Large, 2006 Meeting Host and an Alternate Representative for theASA House of Delegates.

13

Poster Exhibits

P-16 LEG TOURNIQUETS TO SEQUESTER BLOOD DURING C/S IN AJEHOVAH's WIThESS WITH TWINS ANDPLACENTA PREVIAEason, D; Palmer, S.K.

P-17 ANESTHETIC MANAGEMENT OF TH EXIT (EX UThRO INTRAPARTEJM TREATMEN1) PROCEDURE UTIUZ-INGSEVOFLURANEPalk. S.A ; Hoyt, M.

P-18 PREGNANCY COMPUCATED BY HEPATOCELLULAR CARCINOMA$hih, G; Forster,J.; Myers, S.

P-19 ORALJEWELRY IN THE PARTURIENT: A NEW CONCERN FOR THE ANESTHESIOLOGISTJKuczkowsld. K.M; Benumof J.L

P-20 ONCE A POST-DURAL PUNCTURE HEADACHE PATIENT, ALWAYS POST-DURAL PUNCTURE HEADACHEPATIENTKuczkowski, K.M; Benumof, J.L

P-21 ANOTHER REBOUND PHENOMENON: HYPERJ'ZALEMIA AFIER CESSATION OF TOCOLYTIC THERAPYKuczkowski. KM. Benumof, J.L

P-22 COMBINED SPINAL EPIDURAL ANESTHESIA: A NEW ANESTHETIC OPTION FOR REPEAT CESAREANSECTION IN A MORBIDLY OBESE PARTURIENTKuczkowski, KM; Benumof, J.L

P-23 AMPHETAMINE ABUSE IN PREGNANCY: ANESTHETIC IMPLICATIONSKuczkowski. K M.; Benumof, J.L

P-24 ANESTHETIC CONSIDERATIONS FOR INTRA-ABDOMINAL PREGNANCYCoyne. J.T; Mitchell, J.Z.

P-25 CONTINUOUS SPINAL ANESTHESIA FOR CESAREAN SECTION IN A MORBIDLY OBESE PATIENT WITHMULTIPLE SCLEROSISWison D.C; Goodman, S.R.; Ciliberto, C.F.; Smiley, R.M.

P-26 INTRA-OPERATIVE MYOCARDIAL INFARCTION IN A PARTIJPJENT: ANESTHETIC IMPLICATIONSCostello,J.\V; Greenberg, M.; Kuczkowski, KM.

P-27 ANESThETIC CONSIDERATIONS IN A PARTURIENT WITH MITRAL VALVE ATRESIA AND SINGLE VEN-TRICLE PHYSIOLOGYHaret, D.M.; Fragneto, R.

P-28 BRADYCARDIA/ASYSTOLE AFIER LOW DOSE CSE LABOR ANALGESIA - IS IT BEZOLD-JARISCH REFLEX? ACASE DISCUSSION OF ETIOLOGY & MANAGEMENTPan, P.H; Moore, C.H.

P-29 AMNIOTIC FLUID EMBOUSM IN A PARTURIENT WITH AN UNDIAGNOSED PHEOCHROMOCYTOMAArisa, E.M; DeSimone, C.A.; Ebene, R.L

P-30 ATYPICAL SENSORY NEUROLOGIC CHANGE ASSOCIATED WITH POSTDURAL PUNCTURE HEADACHE IN APARTURIENT: A UNIQUE CASE OF LHERMI nE'S SIGNObray. J.J3,; Long, T.R.; Brown, M.J.; Wass, C.T.

P-31 CASE REPORT - SOLE COMBINED SPINAL EPIDURAL FOR CESAREAN SECTION AND HEMICOLECTOMYDadarkar, R; Vasdev, G.M.

P-32 ANESTHETIC MANAGEMENT OF A VENTILATOR-DEPENDENT PARTURIENT WITH THE KING-DENBOROUGH SYNDROMEHabib, A.S.; Millar, S.; Muir, H.A.

P-33 ANESTHESIA FOR CESAREAN SECTION IN A PATIENT WITH SPINAL MUSCULAR ATROPHYHabib, A.S; Helsley, S.; Millar, S.; Muir, H.A.

P-34 ANESTHETIC MANAGEMENT FOR DELI VERY FOR A PARTURIENT WITH MAY-HEGGUN ANOMALY: ACASE REPORT

Calimaran. A.L; Wong, C.A.

14

NOTES

z o CID

Scientific Program

WednesdayMay 1, 20028:00 am - 2:00 pm Executive Committee / Board of Directors Meeting

2:00 - 6:00 pm Committee Meetings

2:00 - 6:00 pm Registration

2:00 - 6:00 pm Poster Mounting (Both Sessions)3:00 - 6:00 pm Neonatal Resuscitation Course (Limited Registration - By Ticket Only)

Coordinator: Medge Owen, MD; Lauri P. Cox, RN, BSN; Debbie Ward Gordon, RN, MSN

6:00 - 8:00 pm Wine/Cheese Reception - (Hilton Head Island Marriott)

Thursday, May 2, 20027:00 am Registration

7:00 - 7:45 am Breakfast with Exhibitors & Posters7:45 - 8:00 am Opening Remarks & Welcome

Joy L. Hawkins, MD; Gary M.S. Vasdev, MD

8:00 - 9:30 am Gertie Marx Symposium - Joy L. Hawkins, MD (Moderator)

Judges: Gertie E Marx, MD; GM Bassell, MD; Geraldine O'Sullivan, FRCA;Robert D'Angelo, MD; Donald H. Penning, MD, MSc, FRCPC; David H. Chestnut, MD;Joy L. Hawkins, MD

9:30 - 9:45 am Distinguished Service Award PresentationValerie A. Arkoosh, MD

9:45 - 10:15 am Break with Exhibitors & Posters10:15 am - 11:15 n Oral Presentations #1

Moderator: Christopher James, MID

11:15 - 12:15 pm Debate No. iAnesthesiologists May Leave the Hospital When a Patient Has an IndwellingEpidural CatheterModerator: Kathryn J. Zuspan, MDPRO: Gerald A. Burger, MD CON: Theodore G. Cheek, MD

12:15 - 1:15 pm Lunch with Exhibitors and Posters1:15 - 2:15 pm Poster Review #1

Introduction: Valerie A. Arkoosh, MDModerator: Yaakov Beim, MD

2:15 - 2:30 pm Break with Exhibitors and Posters

"Hands on" Airway Workshop(Limited Registration - By Ticket Only)

2:30 - 4:00 pm Group I4:15 - 5:45 pm Group 2

Coordinators: Barry Harrison, IID;

Gerard S. Kamath, MD

Refresher Course Lectures

2:30 - 3:30 pm Parenteral Medications forLabor & DeliveryDavid C. Campbell, MD, MSc, FRCPC

4:00 - 500 pm Covering Labor & Deliveryin a Community HospitalPatricia A. Dailey, MD

Neonatal Resuscitation

Cócdiñator: Medge Owen, MD; Lauri P. Cox, RN, BSN;Debbie Ward Gordon, RN, MSN

3:OO-6:OOpm

Course material will be distributed at the beginning of the session.

In this course, the participant will be trained in neonatal resuscitation.Following examination, the participant will be certified by the AmericanAcademy of Pediatrics.

17

Gertie Marx Symposium

Judges: Gertie F. Marx, MD; GM Bassell, MD; Geraldine O'Suffivan, FRCA;Robert D'Angelo, MD; Donald H. Penning, MD, MSc, FRCPC;

David H. Chestnut, MD; Joy L. Hawkins, MD

8:00 - 9:30 am

GM-i THE EFFECT OF OVARIAN HORMONES ON ISOFLURANE HYPERALGESIAFlood, P.; Daniels, D.

GM-2 PEAK POINT CORRELATION DIMENSION: A NOVEL PREDICTOR OF ADVERSE HEMO-DYNAMIC RESPONSE TO SPINAL ANESTHESIA.Chamchad, D; Arkoosh, V.; Buxbaum, J.; Horrow, J.; Nakhamchik, L.; Kresh, J.

GM3 EFFECT OF EPIDURAL TEST DOSE ON AMBULATION AFTER A COMBINED SPINALEPIDURAL TECHNIQUE FOR LABOR ANALGESIACalimaran, A.L.; Strauss-Hoder, T.P.; McCarthy, R.J.; Wong, C.A.

GM-4 PLATELET COUNT & PLATELET FUNCTION: AN IN VITRO MODEL FOR PRODUCINGWHOLE BLOOD WITH LOW PLATELET COUNTSPatel. N.; Fernando, R.; Riddell, A.; Brown, S.

GM-5

GM-6

EARLY LABOR IS MORE PAINFUL IN PARTURIENTS WHO EVENTUALLY DELIVER BYCESAREAN SECTION FOR DYSTOCIAPanni. M.K.; Spiegel, J.; Segal, S.

THE IMPORTANCE OF METHODOLOGICAL VARIABLES IN THE STUDY OF HYPOTEN-SION AFTER SPINAL ANESTHESIA FOR CESAREAN SECTION: PENTASTARCH VS. NOR-MAL SALINEBach, P.S.; Kamani, A.A.; Douglas, J.M.; Gunka, V.; Esler, M.

All Abstracts listed on this page are in the Anesthesiology Supplement

18

Oral Presentations #1

Moderator: Christopher James, MD

1O:15- 11:15 am

BP-4 SPECTRAL ECG ANALYSIS PREDICTS LABOR OUTCOME IÑNULLIPAROUS INDUCED-LABOR PATIENTSLeighton, B.L.; DiMaria, L.J.; Whittaker, M.S.; Maihotra, S.; Kligfield, P.D.

01-2 HERPES SIMPLEX LABIAUS REACTIVATION WITH INTRATHECAL MORPHINE IN SEROP-OSITIVE PARTURIENTSShannon. K.T.; Ramanathan, S.

01-3 LEVOBUPIVACAINE IS UNREUABLE FOR USE AS A SPINAL TEST DOSE.Owen, M.D.; Hood, D.D.

01-4 INTRATHECAL FENTANYL AS AN ADJUNCT TO BUPIVACAINE/MORPHINE SPINAL ANES-THESIA FOR CESAREAN SECTIONVelickoviç T A, Leicht, C H

All Abstracts listed on this page are in the Anesthesiology Supplement.

19

Debate No i

Anesthesiologists Mqy Leave the Hospital When a Patient Hasan Indwelling Epidural Catheter

Moderator: Katheryn J. Zuspan, MDPRO: Gerald A. Burger, MD

CON: Theodore G. Cheek, MD

20

1:00 - 2:00 pm

Supporting manuscripts will be, available online after the meeting.

Following this debate, the participants will be able to outline the medical,medicolegal and administrative issûes involved in the decision to leavethe hospital when a parturient has an indwelling epidural catheter forlabor analgesia.

Poster Review #1

Moderator: Yaakov Beilin, MD

1:15-2:150 pm

p-35 RELATIVE MOTOR BLOCKING POTENCIES OF BUPWACAINE MD LEVO-BUPWACAINE IN LABOURLacassie. H.J; Columb, M.O.

P-36 DO DIFFICULT EPIDURAL PLACEMENTS OR INEXPERIENCED STAFF CAUSE MORE LOW BACK PAIN ONDAY ONE POSTPARTUM?Goodman, F.J.; Dumas, S.D.; Lilly, M.H. . ,

P-37 PATIENT CONTROLLED ANALGESIA USING FENTANYL FOR SECOND TRIMESTER LABOR ANALGESIA.VARYIÑG BOLUS DOSE AND LOCKOUT INTERVALCastto. C; Tharmaratnam, U; Tam, K.; Brockhurst, N.; Tureanu, L.; Windrim, R.; Mwbray, M.

P-38 THE EFFECTS OF LOW-DOSE EPIDURAL TECHNIQUE FOR LOR ANALGESIA ON FETAL HEART RATh(FHR) ,

JJiII,J.; Alexander,J.M.; Sharma, S.K.; Mclntirc, D.D.; Leveno, K.J.P-39 EPIDURAL ROPIVACAINE VS BUPWACAINE FOR LABOR: A META-ANALYSIS

Halpern. S.; Walsh, V.; Joseph, G.P-40 EPIDURAL ANALGESIA LENGTHENS THE FRIEDMAN ACTIVE PHASE OF LABOR

Alexander,J.M.; Sharma, S.K.; Mclntire, D.D.; Leveno, KJ.P-41 Influence of Heignt, Weight and Patient Postiion on Sensory Level After Intrathecal Lanor Analgesia with a Hypobaric Solution

\Vong. C.A; Johnson, E.;Strauss-Hoder, T.P.; Cariaso, D.F.; McCarthy, R.J.P-42 ASSESSING THE OUTCOME OF A TEST DOSE

Dalai, P, Gertenbach K Harker H , O Sullivan, G, Re) nolds FP-43 FETAL HEART RATE AND UTERINE CONTRACTION PAll ERN ABNORMALITIES AFIJiR COMBINED

SPINAL/EPIDURALVS.SYSTEMICLABORANALGESIAScavone, B.M.; Sullivan,J.T.; Peaceman, A.M.; McCarthy, R.K; Strauss-Hodr, T.P.; Wong, C.A.

e-44 THE INFLUENCE OF CONTINUOUS LABOR SUPPORT ON THE CHOICE OF ANALGESIA, AMBULATION ANDOBSTETEIC OUTCOMEMuir H A Hodnett, E D Hannah, M E, Lowe, N K \Villan, A R Stevens, B Weston, JA Ohisson, A, Gafni A,Myhr r

P-45 DOES PLACENTAL LOCATION AND/OR FETAL POSITION LEAD TO PROLONGED FETAL DECELERATIONSFOLLOWING LABOR ANALGESLVAnsa F M Ebene, RL De Simone C A Norris M C ,White Pettaway D, Koutoulas A Mallozzi, AUNIPORT VS MULTIPORT EPIDURAL CATHETERS FOR LABOUR:A META-ANALYSISSrehrnjak, M.; Halpern, S.HOW LOW IS LOW-RISK WHICH PARTURIENTS MAY NOT NEED AN WHess, EF; Mann, S.; Pratt, S.D.

P-48 DOES IYPE OF LABOR ANALGESIA ALTER THE PAÏIERN OF OXYTOCIN USE?Sullivan, J.T.; Scavone, B.M.; McCarthy, R.J;; Wong, C.A.

P-49 IS FETAL BRADYCARDIA FOLLOWING COMBINED SPINAL-EPIDURAL ANALGESIA DUE TO TETANICUTERINE CONTIIACTIONS WITH DECREASED UTEROPLACENTAL PERFUSION?Marenco, J.E.; Birnbach, D.J.; O'Gorman, D.A.; Browne, I.M.; Stein, D.J.; Santos, A.C.

P-so MINI-DOSE INTRATHECAL MORPHINE REDUCES ANALGESIC REQUIREMENTS WITHOUT INCREASINGSIDE EFFECTSVasudevan, A.; Wang, J.; Pratt, S.; Snowman, C.; Hess, P.E.

AllAbstracts listed on this page are in the Anesthesiology Supplement

21

Poster Review #1

P-51 POOLED ANALYSIS OF RANDOMIZED TEIALS OF EPIDURAL VS. OPIOID ANALGESIA ON THE RISK OFCESAREAN SECTIONSega!, S.; Su, M.

P-52 EFFECT OF LOW DOSE MOBILE VERSUS HIGH DOSE EPIDURAL TECHNIQUES ON THE PROGRESS OFLABORAMETA-ANALYSISAngle, P.; Halpern, S.; Morgan, A.

P-53 INITIATION OF LABOR ANALGESIA WITH EPIDURAL BUPIVACAINE: EFFECT OF PARITY[3reen, T.W,; Muir, H.A.; Dwane, P.; Olufolabi, A.; Schultz,J.; Habib, A.; Millar, S.; Drysdale, S.; Spahn, T.

P-54 COMPARISON OF THE MINIMUM LOCAL ANALGESIC CONCENTRATIONS OF BUPIVACAINE FOR NULLIPA-ROUS AND MULTIPAROUS WOMEN IN LABORPolicy, LS.; Columb, M.O.; Naughton, N.N.; Wagner, D.S.

P-55 PREGNANCY WEIGHT GAIN AND LABOR OUTCOMERomeo, R.C.; Ramanathan, S.

P-56 EPIDURAL-PCA FOR LABOR PAIN: DO MULTIPARAE REQUIRE LESS EPIDURAL MEDICATIONS THANPRIMIPARAE?Cohen, S.; Denenberg. H.; Bokhari, E; Farooq, T.; Burley, E.; Grosu, V.; Spears, L.; Freeman, L.; Barsoum, S.

P-57 HISTORICAL PERSPECTIVE OF RECTAL ANALGESIA FOR LABOR AND DELIVERYTungpalan, L.A.; Mergens, P.A.; Caswell, RE.; Vasdev, G.M.

P-58 TEMPERATURE OF SUFENTANIL INTRATHECAL INJECTATE AFFECTS SPINAL LABOR ANALGESIAZhu. H; Grodecki, V.; Huffnagle, S.; Huffnagle,J.; Audu, P.

P-59 ANESTHESIOLOGIST INTERVENTION RATE AND EFFICACY OF PARTURIENT-CONTROT I PD EPIDURALANALGESIA (PCEA) - EFFECT OF INCREASING CONCENTRATION OF BOLUS SOLUTION USING 0.0625%BUPIVACAINE + 0.0002% FENTANYL BACKGROUND INFUSIONJs1er, M.D,; Kliffer, P.; Money, P.; Douglas,J.;

P-60 HOWMOBILE DO MOBILE EPIDURALS NEED TO BE?Dharmai, S

P-61 A PROSPECTIVE RANDOMIZED DOUBLE-BUND COMPARISON OF OBSTETRIC OUTCOME AFrER LABOREPIDURAL ANALGESIA USING LOW CONCENTRATION ROPIVACAINE OR BUPIVACAINE INFUSIONS WITHFENTANYLLee. B.B, Ngan Kee, W.D.

P-62 EPIDURAL FENTANYL INFUSIONS IN THE PRESENCE OF LOCAL ANESTHETICS EXERT SEGMENTALANALGESIA: AN MLAC INFUSION STUDY IN NUWPAROUS LABORGinosar, Y; Columb, M.; Cohen, S.E.; Mirikatani, E.; Tingle, M.S.; Ratner, E.E; Riley, ET.


22

Poster Revièw. #1

P-95 j PERIODONTITIS ASSOCIATED WITH PRETERM LABOR, PRETERM LOW BIRTH WEIGHT, AND PREEC-LAMPSIA? ..Vallejos M.C.; Daftary,A. Riegel, A.R.; Phelps, A.L.; Kaul, B.; Mandell, G.L.; Ramanathan, S.

P-96 ASA PHYSICAL STATUS CLASSIFICATION - A PREGNANT PAUSEl3arbeito, A.; Schultz,J.; Muir, H.; Dwane, P.; Olufolabi, A.; Breen, T.; Habib, A.; Millar, S.; Drysdale, S.; Spahn, T.ECV FACIUTATION BY ANESTHESIA FOR BREECH PRESENTATION * A QUANTITATIVE SYSTEMATICREVIEWGagnon S.; Tureanu, L.M.; Macarthur, A.J.

P-98 META ANALYSTS CHALLENGE THE PUERPERAL PREDICTIONS OF MALLAMPATI ADVOCATESGlassenherg. R.; Fredericksen, M.EXPECTANT MANAGEMENT, POSTDURAL PUNCTURE HEADACHE AND LENGTH OF HOSPITAL STAYAngle, R; Tang, S.; Thompson, D.; Szalai, J.P.

P-100 INCIDENCE OF POST-DURAL PUNCTURE HEADACHE AND EPIDURAL BLOOD PATCH FOLLOWIÑG DURALPUNCTURE WITH EPIDURAL NEEDLE IN 15,411 OBSTETRIC PATIENTS IN A LARGE, TERTIARY CARETEACHING HOSPITALToyama. T.M.; Ranasinghe, J.S.; Siddiqui, M.N.; Steadman, J.L.; Lai, M..

P-loi A COMPARISON OF THE USE OF ATRAUMATIC SPINAL NEEDLES BETWEEN ANESTHESIOLOGY ANDEMERGENCY MEDICINE TRAINING PROGRAMSKerimoglu, R; Birnbach, D.J.; Marenco,J.E.; Stein, D.J.

P-102. EXPANDED ANTIGEN-MATCHING FOR ERYTHROCYTE TRANSFUSION OF WOMEN WITH SICKLE CELL

DISEASE DURING PREGNANCY REDUCES TRANSFUSION-RELATED ALLOIMMUNIZATIONRamsey, P.S.; Winkler, D.D.; Rouse, D.J.

P-103 SUPINE POSITION DURATION FOLLOWING AN EPIDURAL BLOOD PATCHHepner, DJ ; Kodali, B.; Camann , W.; Harnett, M.; Sega!, S.; Tsen, L.C.

P-104 ANESTHESIA FOR EGG RETRIEVAL IN JAPAN: THE FIRaT NATIONWIDE SURVEYTerui, K.; Taya,J.; Ishihara, O.; Takeda, S.; Kinoshita, K.

P-105 DECREASE IN THE INCIDENCE OF POST DURAL PUNCTURE HEADACHE: LONG TERM PLUGGING OF THEDURAL HOLE WITH THE EPIDURAL CATHETERKuczkowski, KM; Benumof, J.L.

P-106 DOES THE TIJ"IE OF THE DAYAFFECT OBSTETRIC ANESTHESIA WORKLOAD?Vogel, T.M; Ramanathan, S.

P-107 COSYNTROPIN FOR THE TREATMENT OF POSIDURAL PUNCTURE HEADACHEI-lelsley. S.; Muir, H.; Breen, T.; DeBalli, P.; Dwane, P.; Drysdale, S.; Habib, A.; Millar, S.; Schultz,J.; Olufolabi, A.

P-108 AMBULATORY GYNECOLOGICAL PROCEDURES OF CERVIX AND UTERUS CAN BE DONE SAFELY WITHMINIDOSELIDOCAINEANDFENTANYLSteadman, J.L; Siddiqui, M.N.; Ranasinghe, J.S.; Toyama, T.; Melgen, J.; Lai, M.


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"Hands on" Airway Workshop

Session 1: 2:30 - 4:00 pmSession 2: 4:15 - 5:45 pm

Coordinators: Barry Harrison, MD; Gerard S. Kamath, MD

Following this course, the participant ill be familiar with the use ofequipment for difficult airways. Participants will utilize mannequins andsimulated surgical airways with these devices.

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Management of the Difficult Airway in Obstetrics:- Brief Overview of Workshop Aims and Objectivés

BA Harrison, MD; GS Kamath, MD;Mayo Medical Center, Rochester, MN

Regional Anesthesia has largely supplanted general anesthesia in the management of the obstetric patient requiringsurgical intervention. However, general endotracheal anesthesia is required in a variety of situations.

Acute fetal distress.Maternal bleeding emergencies with hemodynamic instability.Failure of regional anesthesia.Refusal of regional anesthesiaOther contraindications to regional anesthetic

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Endotracheal intubation may also be required emergently in the eclamptic mother or following high spinal anesthesiaor local anesthetic toxicity

Epidemiology of the obstetric difficult airway.

Several studies have suggested that difficulties in airway management are more frequent in obstetric anesthesia than inthe general surgical population due to a combination of anatomical and physiological changes. In addition, the risk ofaspiration exists with every parturient because of higher gastric volumes, increased gastric acidity, and altered upperand lower esophageal sphincter competencies. Several factors make management of the difficult airway altogethermore challenging in obstetrics than in other surgical situations

Fetal priorities may preclude attention to complete airway assessment of the motherFrequently, this makes the option of waking the mother one that may severely compromise fetal outcomeInjudicious and frequent attempts at intubation increase incrementally the nsk of aspiration and airway traumaThe resultant edema and bleeding may make previously possible mask intubation difficult and even impossible.

, The parturient has a lower oxygen reserve (L FRC) and a rate of 02 utilization that can be up to twice that of the

non pregnant individual

The consequences of failure to maintain ventilation and oxygenation, therefore, result in more disastrous outcomes

more readily.

Airway management in obstetrics is also more challenging for a variety of factors other thai those already

enumerated.

The Obstetric Suite and OR's are frequently physically removed from the general OR's This makes rapid access

to skilled help and technical assistance more challengingAs these are frequently emergencies, they occur at least as often 'after hours" when additional assistance is

unavailableThe full time obstetric anesthesiologist has fewer opportunities at routine endotracheal intubation than his 'non

obstetric" colleagues.

Incidence of difficult, failed, and cannot intubate, cannot ventilate -

Study Intubation Measurement Obstetric Incidence General IncidenceCormack and Lehane Difficult: Mallampati grade III 1:2000Yeo and Thomas Difficult:

Laryngoscopy grade1:46 (2.1%)Gynecologic 1:56 (1.8%)

1:50 (2.0%)=

Lyons and MacDonald Failed 1:294 (0.34%)Sampsoon and Young Failed 1:283 (0.35%) 1:2330Rocke, Murray, Rout etal

FailedProspective

1:750(0.13%)

Benumof Cannot ventilate cannot intubate 0.00-1% to 0.02%

The aim of this airway workshop is to familiarize the anesthesia practitioner with current techniques and equipmentfor the management of the difficult and failed intubation. It is hoped that the course participants will familiarizethemselves with these techniques and have the equipment required readily available for their use in their practice.

It is beyond the scope of this outline to detail essentials like airway assessment. These arewell-covered in standard resources. However, it is important to note that despite rigorous detail to airway assessment,some will prove unexpectedly difficult and some assessed difficult will prove to be easily managed.

The reasons that the predictive tests fail are:The problem has a low prevalence.The predictive tests are subject to observer variation.They require patient cooperation.They utilize absolute measurements across a varying patient population.They measure "difficulty" which is hard to define. A prediction of failure is more appropriate, sincè difficultycan be managed by definition!

The following table indicates the sensitivity, specificity and positive predictive value of a variety of airway assessmenttests and the definition of difficulty utilized in these studies.

Table II. Reported sensitivities, specificities and positive predictive values (PPVs) of various tests for predictingdifficult tracheal intubation.

- 'ucasureu ano usea ro oerive a test such as a scoring system; validationstudies = predefined test(s) applied to a group of surgical patients in order to assess its (their) performance±Original sample = the one from which the scoring system was derivedT C&L = Cormack & Lehane scoring system for laryngoscopy (16); grades 3 or 4 defined in the original reference asno part of the glottis visible.ooAssuming an incidence of "difficulty" of 2%.

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Referencestudies* scoring system was applied

Derivation Sample to which the derived Sensitivity Specificity PPV Definition of "defficulty"

Original sample 96% 82% 31% C & L 3-42 Original sample 75% 75% <20% C & L 34/4

10% 99% 70%3 Original sample 87% 96% 31%oo Combination of view and no. of

intubation attempts4 New sample <92% <74% <15% C & L 3-45 New sample <94% <96% 37% Intubation aid, e.g. bougie or

different blade requiredValidationStudies*

6 Thyromental distance 62% 25% 16% C&L 3-47 7-17% 99% 15-39% C&L3-4/4

7, 8 65-91% 8 1-82% 8-15% C&L 3-4 or bougie required6,9 Mallampati test (original) 42-56% 8 1-84% 4-21% C&L 3-42 45-60% 87-89% 5-21% C&L 3-4/410 Mallampati test (modified) 68% 53% 2% C&L 3-47,8 65-81% 66-82% 8-9% C&L 3-4 or bougie required

Mallampati test7 Thyromental distance plus 81% 98% 64% C&L 3-4 pr bougie required

9,10 Wilson score 42-55% 86-92% 6-9% Epiglottis only visible/C&L 3-48 Sternomental distance 82% 89% 27% C&L 3-4 or bougie required2 Mouth opening 26-47% 94-95% 7-25% C&L 3-4/42 Neck movement 10-17% 98% 8-30% C&L 3-4/42 Jaw protrusion 17-26% 95-96% 5-21% C&L 3-4 or bougie required8 29% 85% 9%10 Indirect laryngoscopy 69% 98% 31% C&L 3-4*flerivtjnn tiir1c - Ç,t,,,.,,,, ___--------_j J -

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iii_ !!

ii¡I

I L

:i!iI

I_I

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AI

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loo

90

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70

Illustration i indicates the rate of desaturation in various individuals without adequate ventilation. As, indicatedearlierihe parturient mother has a lower reserve and higher oxygen utilization. Fatal desaturation may thus occurbefore an intubating dose of succinylcholine wears off sufficiently to allow adequate spontaneous respiration toresume.

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4 5 6 6.87

lime of VE = Ointninues

Airway TechniquesA. Visualization Decreases

This workshop will emphasize techniques that allow direct ventilation of the airway and passage of the tubethrough the cords.

Flexible fiberoptic bronchoscopesRigid fiberoptic devices

B. Rescue Ventilation1. Devices that allow "rescue" ventilation when two persons bag mask ventilation with oral and/or

nasopharyngeal airways has failed.2 LMA3 Combitube

Emphasize the role of the LMA "family" of devices (ILMA, LMA, Poro-Seal) as both ventilation devices andconduits that enable subsequent ET tube placement.

C. Surgical techniques, when the above fail:i Cricothyroidotomy2. Jet ventilation3. Tracheostomy

For the purpose of completeness, other devices on the ASA algorithm will be demonstrated. (Retrogradeintubation/light wand, etc)

-LL --..'. -i_W uF

_P!I1...60

o

Pathology and the difficult obstetric airway

The main disorder quoted extensively is difficult airway associated with pregnancy-induced hypertension. Severalpapers report case reports of pregnancy-induced hypertension and eclampsia with significant facial and laryngealedema contributing to difficult endotracheal intubation. Although difficult, it was still possible to intubate using asmall sized Erl'. The suggestion is to have small sized endotracheal tubes available at the time of intubation.However, in their prospective study, Rooke et al. found that neither facial edema nor swollen tongue predicteddifficult intubation. Other pregnancy related diagnosis related to hemorrhage and respiratory distress may indirectlycontribute to the obstetric difficult airway.

With improved medical care, many patients with congenital abnormalities are now able to conceive and deliverbabies. However, these congenital abnormalities may contribute to airway problems. It is also important to evaluateacquired medical diagnosis with respect to airway problems. Obesity and obstructive sleep apnea both contribute tothe difficult obstetric airway.

Intubation In Obstetrics: There is no easy airway in obstetrics! -,

Indications: Apart from endotracheal intubation for elective cesarean section all intubations are emergencies. Duringemergency endotracheal intubation, corners may be cut, a full airway assessment may not be performed, inductionsdrugs, monitors and equipment may not have been checked and these items may not be readily available. Pre-existingand pregnancy related diagnoses, maternal hypovolemia, or coagulopathy may not be fully appreciated. Skilled helpmay also not be readily available. All these factors contribute to the emergency airway posing higher risk than theelective airway.

Common indications for endotracheal intubation are general anesthesia for cesarean section. However, a failedregional technique, high spinal or high epidural block, local anesthesia toxicity, cardiac arrest, respiratory andneurological emergencies may all result in the need for endotracheal intubation. Although much debate exists, fetaldistress requiring cesarean section is probably the most common indication for endotracheal intubation and generalanesthesia. The purported advantages include faster onset and less hemodynamic disturbance. However, studiescomparing onset of anesthesia and fetal outcome judged by Apgar scores at 1 minute, neonatal blood gas analysishave demonstrated no difference between general anesthesia and regional anesthesia for fetal distress.

Obstetric Airway Assessment: An airway assessment is essential prior to all anesthesia and analgesia procedures onthe labor floor. A complete assessment can be performed in approximately 1-2 minutes. ,Table 3 outlines an airwayassessment. Some advocate that all patients on the labor floor should undergo an airway assessment examination onadmission. A committee report of American College of Obstetrician and Gynecologists state that the obstetric careteam should "be alert' for the general anesthesia risk factors, specialist consultation obtained and consideration givenfor the planned placement of an epidural catheter in early labor.

Unfortunately, only a few obstetric studies have evaluated airway assessment prospectively. Rocke et al. performedan airway assessment in 1500 parturient undergoing emergency and elective cesarean section under generalanesthesia. Their group discovered a significant correlation (p<O.Ol) between oropharyngeal structures and thelaryngoscopy view and difficulty at intubation. Multivariate analysis demonstrated visualization of oropharyngealstructures, short neck (obesity), receding mandible and protruding maxillary incisors all to be significant. It is

important to note that one of the end points in this study was difficult intubation, as judged by a scoring systemdeveloped by the authors. In there study, there were actually only two cases of failed intubation, giving an incidenéeof 1:750 or 0.13%. Yeo, Chung and Thomas demonstrated a significant (pczO.OS) prediction between Mallampatiscore and difficult intubation. Their end point was the laryngeal view. In this study, there were also difficult

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Table 3. Essentials of airway assessmentI Facial edema2 Obesity and short neck3 Neck flexion and extension - atlanto-occipital extension4 Mandibular space - thyromental distance

5 Mouth opening6 Dentition - Protruding maxillary incisors, missing teeth7 Oropharyngeal structures Mallampati Classification

intubations noted even though the Mallampati was Grade 2. In this study, the race was predominantly Asian while inthe Rocke paper the race was not stated; but as the paper was from South African maternity hospital, a proportion ofthe patients may have been African. An English paper demonstrated that racial origins influenced the difficulty ofintubation. Therefore, in airway assessment the racial origin may be an important clue of difficulty.

Preparation for Intubation: Routinely, 30 mls 0.3 M sodium citrate is administered to neutralize the stomach's acidity.To prevent further production of acid, a H2 blocker can also be administered. Metoclopramide will facilitate gastricemptying, provided that it is administered before systemic opioids are administered. Although the use of thesemedications is routine, it is difficult to prove that these medications have decreased the incidence or outcome ofaspiration pneumonitis. -

The presence of personnel in the delivery suite trained in airway management is essential. Because the delivery suiteis usually isolated from the main operating room and personnel not always available, it is advisable to have midwivestrained in airway management, importantly cricoid pressure. In papers detailing the difficult and failed airwayassessment in obstetrics, it is usually defined as the most senior anesthesia care personnel attempting, assessing andfailing. Standardization and quantification of skills is difficult.

All essential monitoring, drug and equipment must be checked and ready prior to any regional or general anestheticprocedure in the obstetric operating room. Emergency airway adjuncts such as oral and nasal airways, COPA airway,endotracheal tube stylets, a gum elastic bougie and a light wand should be readily available. An emergency airwaycart should be readily available.

Endotracheal Induction and Intubation: Because of the anatomical and physiological changes of pregnancy and labor,the techniques of endotracheal intubation need to be adapted. The patient needs to be correctly positioned. The neckneeds to be flexed at the cervico thoracic junction and extended at the atlanto occipital joint. Properly positionedpillows help to exaggerate the position, optimizing it and improving success. Measuring end tidal nitrogen, andwatching the level reach a plateau, infers complete denitrogenation and optimal pre oxygenation.

Anesthesia is usually induced intravenously with thiopentone, propofol or ketamine. Cricoid pressure is in position atthe onset of induction and fully applied as the patient is induced. There may be difficulty inserting the scope due topoor positioning of the patient, the increased size of the chest wall and improperly positioned cricoid pressure.Surprisingly, there has been no study suggesting which blade is optimal. At present the blade the operator is mostfamiliar with should be used. Following endotracheal intubation, confinnation is necessary by quantitative orqualitative measurement of end-tidal CO2.

Dfflcult Airway Algorithms and Failed Intubation Drills

ASA difficult airway ajgorìthm: The ASA Difficult Airway Algorithm has standardized the approach to the difficultairway. Standards or guidelines aim to minimize the mortality and morbidity assoçiated with the difficult airway andalso aids education and research. However, the ASA difficult airway algorithm needs to be adapted to obstetrics.

Significant differences between the obstetric and ASA algorithm are:Most cases are emergency and not elective.Maternal, uterine and fetal physiology.Both mother and fetal needs to be assessed.

4 Spontaneous breathing is preferred

Assessment and decisions: Similar to the ASA Difficult Airway Algorithm, initial assessments and then decisions

must be made. The initial assessments include:i Maternal status

Fetal statusAirway status -

The decisions that need to be made following these assessments are:1. Expected versus unexpected difficult airway2 Expected difficult airway

- Regional technique versus Awake technique- Awake: Surgical technique versus non-surgical technique

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Cardiac arrest: Difficult or failed intubation may lead to a cardiac arrest. Therefore, the potential for maternal cardiacarrest must be assessed. Aspiration and lung injury will exacerbate the hypoxia of the difficult and failed airway alsoincreasing the potential for cardiac arrest. Protocols for cardiopulmonary resuscitation in pregnancy advocateperimortem cesarean delivery within 5 minutes of cardiac arrest. In the difficult or failed intubation, earlier cesareansection may aid resuscitation.

Obstetric difficult and failed airway algorithm: Many difficult and failed obstetric airway algorithms exist. Most arecomplicated aiming to cover all contingencies related to the expected and unexpected difficult obstetric airway. Forthese algorithms, the quality of evidence for the algorithm is neither stated or they are mainly a compilation of casereports. Importantly, there is no evidence of efficacy.

Simplifying the algorithm has the potential to make it easier to use and also to assess its efficacy. Usually, thisapproach is related to failed intubation, and is referred to as drills. A 17-year review of a failed intubation drillillustrated some of the benefits of this approach. Out of 5802 cesarean sections between 1978 and 1994, there were 23(0.4%) failures to intubate the trachea. The algorithm used was simple and specific for unexpected failed intubation.Most of the failures were for emergency situations. Eighteen patients were allowed to waken and regional techniquesutilized. Manual ventilation was difficult in seven and impossible in two. Four patients had an LMA inserted. Usingthe LMA in this situation, the lungs were difficult to ventilate in two episodes and impossible to oxygenate on oneoccasion.

No anesthesia or anesthesia obstetric association or society has developed evidence based guidelines for the obstetricdifficult airway or failed obstetric intubation. As stated to be complete such guidelines are extremely complicated andlack evidence making their value questionable. An approach to the expected and the unexpected difficult airwayalgorithm are outlined in Figures 3 and 4, respectively. The main aim of these guidelines is intended for discussion ofthe airway management techniques.

Expected Difficult Intubation

Once the assessment and decision has determined that it is an expected difficult airway then the decision is betweenregional and awake intubation. If awake intubation is decided, then the decision is between surgical versus non-surgical technique. Though an awake surgical airway technique is included for completeness, for the obstetricdifficult airway it is most likely to be of benefit during upper airway trauma affecting the parturient or when anobvious pre-existing airway problem exists. There have been two case reports in the literature where the tracheotomywas inserted prior to delivery. In one case, the patient subsequently underwent cesarean section under regionalanesthesia with the tracheotomy used as a backup.

Expected Difficult Intubation/

Wu scope Surgical TechniqueTracheostomy

Figure 3: The "expected" difficult airway algorithm.

Regional anesthesia and the difficult obstetric airway: Regional is the usual selection in the expected difficult airway.In non-emergency obstetric situations the choice of regional technique is dependent on the anesthesiologist.

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Regional Technique Awake Intubation TechniqueNon Surgical Technique

Spinal anesthesia / Non fiberoptic

Epidural anesthesia LaryngoscopeLight wand

Combined spinal-epidural V' FiberopticLocal anesthetic agent Bronchoscope

Bullard bladeUpsher blade

Emergency situations with severe time limitations are no contraindications to a regional technique. Although theliterature supports equal outcome comparing regional to general anesthesia in emergency situations, there is noliterature to support the optimal regional technique. Usually, the regional technique is between a spinal anesthetic orloading a functioning epidural or loading an epidural from a continuous spinal epidural. In severely pre-eclampticpatients undergoing cesarean section, spinal versus epidural, the hemodynamic and fetal outcome showed nosignificant difference. When comparing combined spinal epidural anesthesia (CSEA) and epidural anesthesia forcesarean section, CSEA had greater efficacy and fewer side effects.

Although conventional wisdom endorses a regional technique in the expected difficult airway, complications or failureof the regional technique may make it necessary to intubate the trachea. Thus, a backup plan is necessary with theappropriate equipment being available. A case report described a patient with a failed combined spinal epidural, whofailed an endotracheal intubation, was then woken and underwent an awake, fiberoptic intubation. This is one ofmany case reports illustrating potential difficulties of regional anesthesia. The absolute contraindications to regionalanesthesia in obstetric anesthesia are patient refusal and a coagulopathy

When deciding on the regional technique, it is importantto select the technique that minimizes airway, cardiac, andrespiratory emergencies for the individual parturient.

Local anesthesia and the upper airway: Either the use of selected nerve blocks or direct application of local anestheticagents will provide adequate anesthesia of the upper airway The hormonal changes in pregnancy increase thesensitivity of peripheral nerves to local anesthetic agents With pregnancy the upper airway membranes haveincreased vascularity, increasing the uptake of the local anesthetic, decreasing the duration of action of the localanesthetic Thus these two factors may balance out, however, it is important to be vigilant for local anesthetictoxicity The local anesthetic agent pnlocaine may induce a dose related methemoglobinemia The fetus may bemore susceptible due to the inability to metabolize the compound due to metabolics and the administration of otherdrugs.

Awake Non-fiberoptic Techniques: Following adequate anesthesia to the upper airway, non-fiberoptic techniques canbe utilized for endotracheal intubation Different sized MacIntosh and Miller blades as well as specializedlaryngoscopes with fiberoptic light sources or different shapes can be used. Airway adjuncts, such as stylets,intubating bougies, and external manipulation of the larynx may all play a role in aiding intubation. The lighted styletcan also aid intubation in the awake non-fiberoptic intubation. Although blind nasal intubation can be used in awakenon-fiberoptic techniques, bleeding from the vascular membranes may further complicate the already difficultintubation.

The use of the LMA, ILM or the ProSeal can be utilized in the awake endotracheal intubation. The ILM is probably apreferred choice as a definitive cuffed airway can be introduced. However, a literature survey found no case reportsof the ILM in cesarean sections. There are two case series of the LMA being used for cesarean section. Positivepressure ventilation with peak airway pressure up to 20 cm H20 was used with no reports of aspiration. However,both of these were reported in abstract form, and review of the English literature failed to show that they have beenpublished in a peer review journal. There are no reports of the Proseal LMA and the obstetric airway.

Awake Fiberoptic Techniques: Fiberoptic techniques are popular for the expected difficult airway, especially in theparturient. Fiberoptic techniques use expensive equipment, have steep training curves and usually are not easilyportable. The fiberoptic devices should allow the delivery of supplemental oxygen, as hypoxia is a commoncomplication during these procedures.

There are multiple case reports of the success of the fiberoptic bronchoscope in the expected and also the unexpecteddifficult obstetric airway. However, there has been no case series, the failure rate is unknown as well as thecomplication rate. Potential complications include failure, hypoxia, and risk of bleeding from the vascularmembranes, especially if the nasal route is chosen. Difficulty passing the ETT may be seen in preeclampsia wherepatients may have laryngeal edema.

One case report exists concerning the use of the Bullard and the difficult obstetric airway. Although there have beenno published case reports concerning the Wu scope in the obstetric airway, the inventor, Dr Wu, has used the scopefor parturients with difficult obstetric airways undergoing cesarean section. (Personal communication, Dr Wu)

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Retrograde Technique: Retrograde intubation techniques can be utilized in the expected or unexpected difficultobstetric airway. In the expected difficult obstetric airway, it can utilize when an awake fiberoptic technique hasfailed. Many times when the initial technique has failed, bleeding and edema results increasing the difficulty ofsubsequent attempts. Once the guide wire has been passed through the cricothyroid membrane and exits the mouth ornose, it can be threaded up the suction channel of the fiberoptic scope. The fiberoptic scope is then advanced alongthe guide wire under direct vision through to the trachea.

Unexpected Difficult Intubation: - ???? Ventilation

Manual ventilation: With non-obstetric unexpected difficult airway the ability to demonstrate that mask ventilation ispossible is done before the administration of neuromuscular blockers and an attempt at intubation. In obstetricanesthesia, due to the aspiration risk, a rapid sequence induction is usually performed. Thus, it is unknown if maskventilation is successful before intubations attempts. Thus, when intubation is difficult, as demonstrated by thelaryngeal view or there is failure to intubate, then mask ventilation must be attempted to insure oxygenation andventilation. Because of the increased weight and edema in pregnancy, mask ventilation can be difficult.

Oral airways are introduced to improve the efficiency of mask ventilation. Nasal airways can also be utilized;however, the increased vascularity of the nasal mucosa increase the potential for bleeding and further make thealready difficult airway more difficult. Manipulation of the airway with the aim of improving the seal of the maskairway is important. Many algorithms and authors suggest that two people may be necessary, one to maintain a seal

of mask and airway while the other needs to ventilate the patient. While this is occurring, it is advocated to maintaincricoid pressure. If mask ventilation is inadequate with cricoid pressure, then it should be relieved to see if improved

ventilation occurs. In the British literature, it is advocated to place the patient in the Trendelenburg position. In thisposition, if vomiting or regurgitation does occur, they advocate that it is less likely to enter the trachea and lungs.

Throughout the mask ventilation, left lateral tilt is maintained.

The first step in the difficult or failed obstetric airway is to maintain oxygenation and ventilation through bag maskventilation. Once this first essential step has been undertaken then the assessment of the maternal fetal status isundertaken. The obstetric team present needs input at this stage and a decision made with respect to the immediacy of

delivering the baby.

Maintain bag mask ventilationVolatile anesthesiaTrendelenburgSpontaneous Ventilation

Unexpected Difficult Intubation

Wakepatient

Bag Mask Ventilation

LMACombitùbe

??Successful?

Continue: LMACombitube

Figure 4. The "unexpected" difficult airway algorithm

Surgical airwayNeedle jet ventilationCricothyrotomyTracheostomy

Unexpected dfficult intubation - Can ventilate

Non-urgent delivery: The suggested course of action is to awake the mother and then to use either a regional or anawake intubation technique. Case series have demonstrated that this approach works.

Immediate delivery: A suggested course of action is to continue to mask ventilate, with or without cricoid, induceanesthesia with a volatile anesthetic, allow for resumption of spontaneous ventilation and maintain left lateral tilt andTrendelenburg position. Again, case series suggests that this is practical.

U'4A: The LMA has been used with success in the can ventilate non-urgent and immediate delivery. These arepublished usually as "one off' case reports. With all case reports, there is a selection bias. If complications ornegative outcomes are present, they are least likely to be published.

Unexpected Difficult Intubation - Cannot ventilate

Non-urgent delivery: The implicit aim is to waken the patient and then use a regional or awake intubation technique.However, it is still essential to maintain oxygenation of the patient. Apneic oxygenation may be able to maintainadequate oxygen saturation during this period. Although adequate ventilation may be impossible, partial incompletebag mask ventilation may suffice in the interim allowing oxygenation and ventilation while the patient wakens.Evidence, even case reports, is difficult to discover to provide documentation for this step. Additionally, the use ofnon-surgical techniques (as described below) to maintain oxygenation and ventilation has also been described while

waiting for the patient to waken.

Urgent delivery: With urgent delivery, the decision must be made to go to an urgent non-surgical, surgical rescueventilatory mode. Cesarean delivery with local infiltration anesthesia may be considered. The technical or comfortfactor of the anesthesia care provider determines which technique to go to first in this situation. It is important to notethat the anatomical and physiological changes with pregnancy may make oxygenation and ventilation difficult with aLMA, Combitube or needle jet ventilator technique. High airway pressures will need to be generated by these devicesdue to the decreased lung compliance associated with pregnancy and also any lung injury. Therefore, the highpressures may lead to barotrauma and inadequate oxygenation and ventilation. It is important to determine theefficacy of each intervention at this stage in the cesarean delivery.

Non-surgical - urgent delivery

LMA: Case reports have described the successful use of the LMA in the cannot intubate cannot ventilate, failedobstetric intubation. In a survey of obstetric anesthesia consultants in the United Kingdom, 71% of the respondentsstated that they would use the LMA in the cannot intubate, cannot ventilate obstetric airway with 91% of the obstetricunits stating that the LMA was available. Twenty-four of the consultant anesthetists had personal experience with theuse of the LMA. Although complete details of the use was not stated, eight stated that it was life saving, two statedthat attempts to pass a gum elastic bougie through the LMA failed and three had used the LMA; but without success,removed it and established mask ventilation. Twenty-two consultant anesthetists were against the use of the LMA--risk of aspiration being the principle reason given. The ProSeal has the potential to offer advantage of being able toventilate and decrease the risk of aspiration, but it is still only FDA approved to 30 cm H20. The FasTrach LMA orintubating LMA has potential advantages as will allow the introduction of a definite airway. However, the lack ofexpertise and time may limit this technique. To date there are no case reports describing either the Proseal or theintubating LMA in the cannot intubate, cannot ventilate failed obstetric airway.

Combitube: There are no case reports in the literature describing the use of the Combitube in the difficult or failedobstetric intubation. The Combitube has been used with success in the cannot intubate, cannot ventilate non-obstetricdifficult airway. It has also been used with success in anesthetic cases in the operating room. Aspiration is the mainpotential complication with this device. There is a case report suggesting an esophageal perforation; however, multipleairway devices were used. The perforation also occurred distal to the site in the esophagus that the Combitube hadbeen inserted. In a can not intubate, can not ventilate failed obstetric an esophageal gastric tube airway was inserted.Following insertion into the esophagus, the EGTA was attached to the anesthesia machine. Anesthesia was thenadministered, the baby delivered and the mother had an uneventful recovery.

Surgical - urgent delivery

Transtracheal jet ventilation: There are no casè reports of the use of transtracheal jet ventilation in the difficult orfailed obstetric airway. High airway pressure may be required to overcome the decreased lung compliance seen inpregnancy. Acute lung injury secondary to pulmonary aspiration will decrease lung compliance even further makingit difficult to maintain oxygenation and ventilation with jet ventilation. Also, without a definitive secured airway,pulmonary aspiration may result.

Cricothyrotomy: There is not an abundance of case reports of cricothyrotomy, either surgical or using the Seldingertechniques in the difficult or failed obstetric airway. These techniques are used infrequently by anesthesiologists inthe difficult airway. Emergency room physicians and surgeons tend to use this technique, if the airway has provendifficult. When using either the Seldinger or surgical cricothyrotomy on Cadavers by naïve medical personnel, bothtechniques were equally poorly performed. Essential equipment is a surgical blade size, dissectors/introducer andtracheotomy tube.

Tracheotomy: In the obstetric setting, it is difficult to find a case report detailing an emergency tracheotomy in thedifficult or failed airway. Obstetricians usually do not have as much familiarity with the technique of tracheotomycompared with general surgeons. This may, in part, describe why it has not been used in the labor and delivery room.

Without anecdotal case reports to guide, no definitive conclusion is possible. The advice is to use whatever techniquethe anesthesia provider is the most comfortable. Thus, becoming familiar and practicing with difficult airwayequipment is crucial. In the emergency room, cricothyrotomy has become the default airway to use in the difficult orfailed airway.

34

Difficult airway equipment in obstetrics - not if, but when!

With the difficult and failed obstetric airway, it is more a question of "when" than "if." Therefore, it is essential tohave difficult airway equipment available. There are different approaches. One is to have every anesthesia machineequipped with one or two pieces of emergency airway equipment. This may consist of a gum elastic bougie to beused as an intubating guide and or a disposable LMA. These two pieces of equipment, or their equivalents, will be ofbenefit in most airway emergencies. Although each piece of equipment is inexpensive, fitting out each anesthesialocation will add to the expense. Many anesthetic departments have developed "difficult airway carts". The aim is tohave all difficult airway equipment available in one cart. It is usually portable, being able to be wheeled to whereneeded. There is continued upkeep needed to insure the equipment is in working order. The equipment on the airwaycart can vary; the selection is dependent on the preference and experience of the anesthesia care team. The carts cango from either basic to very sophisticated. Price of the equipment and the numbers required will also influence thedecision on the cart's equipment: Table 4 lists the specialized intubation equipment of one such airway cart used atthe Mayo Clinic.

To be able to use the equipment in an emergency it is important to gain previous exposure to devel6p the necessaryskills. Practice with equipment can be obtained on models. An additional approach is to use the equipment withevery day patient use. This can be safe and "real life" with small modifications. Increasingly, airway simulators bothaid the skill level with the difficult airway equipment and also, importantly, the relevance of the use of the difficultairway equipment in the airway algorithm.

Conclusions

35

The difficult and failed obstetric airway is a problem for all involved in the care of the pregnant patient in the laborand delivery room. All must be trained in the assessment and care of the obstetric airway--this means the non-difficultas well as the difficult airway. The anesthesia care provider must provide leadership in this endeavor, both at the localand national levels. Locally, they must be responsible for the education and training of all obstetric staff. They mustmeasure outcomes through continuous quality assurance. Although poor outcomes have been decreased substantially,other outcomes, example number of maternal intubations and morbidity are necessary. A difficult and failed airwayalgorithm needs to be developed for each labor and delivery room. Although there is an increase in the specializedobstetric anesthesiologist, it is necessary to insure that all anesthesia care practitioners are aware and skilled incarrying out the protocol. Situational awareness and optimal progression from one step of the algorithm to the next iskey to prevent morbidity. At the national level, general and specialized societies caring for the obstetric patient mustCooperate and act mutually to optimize airway management in obstetrics especially for the difficult and failed airway.

Table 4 List of Difficult Airway Cart Major Equipment -

I Intubating flexible fiberoptic bronchoscope2 Bullard portable laryngoscope3 Proseal LMA4 Fastrach LMA5 Combitube6 Jet ventilation apparatus7 Cricothyrotomy kit8 Trachlight

References

i . Nath G, Sekar M. Predicting difficult intubation-a comprehensive scoring system. Anaes and mt Care.. 1997; 25:482-6.

EI-Ganzouri AR, McCarthy RJ, Turnan KJ, Tanck EN, Ivankovich AD. Preoperative airway assessmentPredictive value of a multivariate risk index. Anes & Anaig 1996; 82:1 197-204.Karkouti K, Rose DK, Wigglesworth D, Cohen MM. Predicting difficult intubation: a multivariableanalysis. Can J Anes 2000; 47:730-9.

. Wilson ME, Spiegelhalter D, Robertson JA, Lesser P. Predicting difficult intubation. Br J Anaes. 1998;61:211-16.

r

. Arne J, Decoins P, Fusciardi J, et al. Preoperative assessment for difficult intubation in general and ENGsurgery: predictive values ofa clinical multivariate risk indes. Br J Anaes. 1998; 80:140-6.Butler PJ, Dhara SS. Prediction ofdifficult laryngoscopy: an assessment ofthyromental distance andMallampati predictive tests. Anaes & mt Care. 1992; 20:139-42.Frerk C.M. Predicting difficult intubation. Anaes. 1991; 46:1005-8.Savva D. Prediction ofdifficult trachael intubation. Br J Anaes. 1994; 73:149-53.Oates JD, Macleod AD, Oates PD, Pearsall FJ, Howie JC, Murray GD. Comparison of two methods forpredicting difficult intubation. Br J Anaes. 1991; 66:305-9.Yamamoto K, Tsubokawa T, Shibata K, Ohmura S, Nitta S, Kobayashi T. Predicting difficult intubation

- with indirect laryngoscopy. Anes. 1997; 86:316-21. .

Caton, Donald MD. John Snow's Practice of Obstetric Anesthesia. Anesthesiology. 2000; 92(1): 247-252.Mendelson, C.L. The aspiration of stomach contents into the lungs during obstetric anaesthsia. Am. J.Obstet. Gynec. 1946; 52:191.Tomkinson J, Turnball A, Robson G, Cloake E, Adeiskin AN, Weatherall J. Report on ConfidentialEnquiries into Maternal Deaths in England and Wales 1973-1975. London: Her Majesty's Stationery Office.1979;80Tunstall, M.E. Failed intubation drill. Anaesthesia. 1976; 31, 850.Albright, George A. MD. Editorial Views. Cardiac Arrest Following Regional Anesthesia with Etidocaineor Bupivacaine. Anes. i 979;5 I (4):285-87.

I 6. Ghosh MK Maternal mortality. A global perspective. Journal of Reproductive Medicine. 200 1 ;46(5):427-433.Hawkins JL, Koonin LM, Palmer SK, Gibbs CP. Anesthesia-related deaths during obstetric delivery in theUnited States, 1979-1990. Anesthesiology. 1997; 86:277-284.Panchal S, Arria A, Labhsetwa S. Maternal Mortality During Hospital Admission for Delivery: ARetrospective Analysis Using a State-Maintained Database. Anesthesia and Analgesia. 2001; 93:134-141.Chadwick HS: an analysis of obstetric anesthesia cases from the American Society of Anesthesiologistsclosed claims project database. International Journal of Obstetric Anesthesia. 1996; 5: 258-263.Sinclair M, Simmons S, Cyna A. Incidents in Obstetric Anaesthesia and Analgesia: An Analysis of 5000AIMS Reports. Anaesthesia and Intensive Care. 1999; 27:275-281.Cormack RS, Lehane J. Difficult tracheal intubation in obstetrics. Anaesthesia 1984; 39:1105-1111.Yen SW, Hong JL, Thomas E. Difficult Intubation: A Prospective Study. Singapore Med J. 1992; 33:362-364.Lyons G. Failed intubation. Six years experience in a teaching maternity unit. Anaesthesia 1985; 40(8) 759-762.Samsoon CLT, Young JRB. Difficult tracheal intubation: A retrospective study. Anesthesia 1987;42(5):487-490.Rocke DA, Murray WB, Rout CC, et al: Relative risk analysis of factors associated with difficult intubationin obstetric anesthesia. Anesthesiology 1992; 77(1):67-73.Benumof JL. Management of the difficult airway. With special emphasis on awake tracheal intubation.Anesthesiology 1991; 75: 1087-1110Mallampati SR, Gatt SP, Gugino LD et al. A clinical sign to predict difficult tracheal intubation: aprospective study. Canadian Anaesthetists Society Journal 1985; 32: 429- 434Crapo RO. Normal cardiopulmonary physiology during pregnancy. Clinical Obstetrics and Gynecology.1996;39:3-16.Brock-Utne JG, Downing JW, Seedat F. Laryngeal oedema associated with pre-eclamptic toxaemia.Anaesthesia 1977; 32:556-8.Brimacombe J. Acute Pharyngolarlyngeal Oedema and Pre-Eclamptic Toxaemia. Case Report. Anaesthesiaand Intensive Care 1991; 20(1):97-8.

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3 1 . Marx GF, Luykx WM, Cohen S. Fetal-neonatal status following caesarean section for fetal distress. BritishJournal of Anaesthesia. 1984;57(9): 1009-13.D'Alession JG, Ramanathan J. Effects of maternal anesthesia in the neonate. [Review]. Seminars inPerinatology 1998; 22(5):350-62.Morgan BM, Magni V, Goroszenuik T. Anaesthesia for emergency caesarean section. British Journal ofObstetrics & Gynecology 1990; 97(5):420-4.The American College of Ostetricians and Gynecologists. Anesthesia for emergency deliveries. ACOGCommittee opinion #104. Washington DC: American College of Obstetricians and Gynecologists, 1992.Johnson MD, Luppi CJ, Over D. Cardiopulmonary resuscitation in pregnancy. In Gambling DR, MJ Ed.Obstetric Anesthesia and Uncommon Disorders. 1997.Suresh MS, Wali A. Failed Intubation in Obstetrics Airway Management Strategies in the High RiskObstetric Patient Anesthesiology Clinics of North America. 1998; 477-498.Ezri T, Szmuk P, Evron S, Geva D, Hagay Z, Katz J. Difficult Airway Obstetric Anesthesia. A review.Obstetrical and Gynecological Survey 2001; 56, 10:631-641. 1

Davies JM, Weeks S, Crone LA, Pavlin E. Difficult Intubation in the Parturient. Can J. Anaesth. 1989;36:668-674.Hawthorne L, Wilson R, Lyons G, Dresner M. Failed Intubation Revisited: 17-year experience in a teachingmaternity unit. British Journal of Anaesthesia 1996; 76:680-684.Fuhrman TM, Farina RA. Elective tracheostomy for a patient with a history of difficult intubation. J. ClinAnesthes 1995;7:250-2. :Callander CC, Thomas JS. The ethics of difficult tracheal intubation (letter). Anaesthesia l988;43:703-4.Hood D, Curry R. Spinal versus Epidural Anesthesia for Cesarean Section in Sevrely Pre-eclamptic Patients:A Retrospective Study. Anesthesiology 1999; 90:1276-1282.Choi DH, Kim JA, Chung IS. Comparison of Combined Spinal Epidural Anesthesia and Epidural AnesthesiaforCesarean Section. Acta Anaesthesiologica Scandinavica. 2000; 44:214-19.Hawksworth CRE, Purdie J. Failed combined spinal epidural the failed intubation at an elective caesareansection. Hospital Medicine.59;1998: 173Popitz-Bergez F, Leeson S, Talhamirier J, et al. Intraneural Lidocaine Uptake Compared to AnalgesiaDifferences Between Pregnant and Non-pregnant Rats. Reg Anesth. 1997;22:363.Taddio A, Stevens B, Craig K et al. Efficacy and Safety of Lidocaine-prilocaine Cream for Pain duringCircumcision. N EngI J Med. 1997;336:1 197.Yang H, Suh B: Laryngeal mask airway in cesarean section. 1

1th World Congress of Anesthesiology,Sydney, 14-20 April 1996, Abstract Handbook p.439.Liew E, Chan-Liao M. Experience of using laryngeal mask anesthèsia for caesarean section.

11th WorldCongress of Anesthesiology, Sydney. 14-20 April 1996, Abstract Handbook p.439.Edwards RM. Fibreoptic Intubation: A Solution to Failed Intubation in a Parturient? Anaestehsia andIntensive Care 1994; 22(6):718-19.Cohn Aaron I. MD, Hart Robert T MD, McGraw Scott R MD, Blass Norman H MD. The BullardLaryngoscope for Emergency Airway Management in a Morbidly Obese Parturient. Anesthesia & Analgesia.1995; 81(4):872-873.Chadwick IS, Vohra A. Anaesthesia for emergency caesarean section using the Brain Laryngeal Airway(Letter). Anaesthesia 1989; 44:261-2.McLune S, Regan M, Moore J. Laryngeal mask airway for cesarean section. Aneaesthesia 1990; 45 :227-8.Gataure PS, Hughes JA. The laryngeal mask airway in obstetrical anesthesia. Can J Anaesth 1995;42:130-3.Baraka A, Salem R. The Combitube oesophageal-tracheal double lumen airway for difficult intubation.Canadian Journal of Anaesthesia. 1993 ;40( 12): 1222-3.Klein H FRCA, Williamson M, Sue-Ling HM MD FRCS, Vucevic M FRCA, Quin AC FFARCSI.Esophageal Rupture Associated with the Use of the Combitube. Anesthesia & Analgesia. 1997; 85(4):937-

939.Tunstall ME, Geddes C. Failed Intubation In Obstetric Anesthesia, An indication for use of the "EsophagealGastric Tube Airway". Br. J Anaesth 659-66 1, 1984

37

Refresher Course Lectures

Parental Medications for Labor & Deliver)'David C. Campbell, MD, MSc, FRCPC

2:30 - 3:30 pm

Following this lecture, the participants will be able to choose appropriateparenteral medications and methods of administration for providinganalgesia during labor.

Covering Labor and Delivery in a Communiy HospitalPatricia A. Dailey, MD

4:00 - 5:00 pm

Following this lecture, the participants will be able to describe and compareseveral different options for billing for obstetric anesthetics, newer codingprocedures in obstetric anesthesia, VBAC standby issues, staffing issues,J CAHO compliance issues, and realities of community practice.

38

Parenteral Medications for Labor and Delivery

David C. Campbell, MD, MSc, FRCPCAssociate ProfessorChairman (acting)

Director of Obstetric AnesthesiologyDepartment of Anesthesia

College of MedicineUniversity of Saskátchewan

E-mail: [email protected]

Refresher Course Outline:

Review Indications for Epidural Labor Analgesia

Review "State-of-the-Art" Initiation of Epidural Labor Analgesia

Review "State-of-the-Art" Maintenance of Epidural Labor Analgesia

Review Absolute Contraindications to Epidural Labor Analgesia

Review Parenteral Analgesic Options when Epidural Labor Analgesia Contraindicated

Review Patient Controlled Intravenous Analgesia (PCIA) Options

Review the University of Saskatchewan Experience

References:

Campbell DC. Low dose epidural labour analgesia.Techniques Reg Anesth and Pain Management 5:3-8, 2001Campbell DC. The Evolution and Revolution of Epidural Analgesia in Labour.The Canadian Journal of Continuing Medical EducationSpecial Women's Issue 12 233-42, 2000

3 Halpern SH, Breen TW, Campbell DC, Muir HA Intravenous PCA Fentanyl vsEpidural PCA Fentanyl/Bupivacaine: Neonatal Effects.Anesthesiology 90:A19, SOAP Suppi. April 1999

4. Muir HA, Breen TW, Campbell DC, Halpern SH. Is Intravenous PCA Fentanyl anEffective Method for Providing Labor Analgesia? Anesthesiology 90:A28, SOAPSuppi. April 1999

39

Covering Labor and Delivery in a Community HospitalStaffmg and Reimbursement Issues

Patricia A. Dailey, M.D.

I. What is required if your hospital provides labor and delivery services?

A. Guidelines for Perinatal Care. 4th Edition':

Basic Care FacilityCapability to begin an emergency CS within 30 min of the decision to do sóDetection and care of unanticipated maternal-fetal problemsAvailability of anesthesia on 24-hour basis

Specialty Care FacilityAbove+Care of high-risk mothers and fetusesCare of preterm infants with a birth weight of 1500 g or more; stable or moderately illnewborns who have problems expected to resolve rapidlyDirector of obstetric anesthesia services should be board certified in anesthesia andshould have training and experience in obstetric anesthesia

Subspecialty Care FacilityAbove+Personnel qualified to manage obstetric or neonatal emergencies should be in-house24 hours/day in house availability of anesthesiaBoard-certified anesthesiologist with special training or experience in maternal-fetalanesthesia should be in charge of obstetric anesthesia services

B. Joint Commission on Accreditation of Healthcare Organizations (JCAHO)Standard TX.2.1 Apresedation orpreanesthesia assessment is performedfor each patientbefore beginning moderate or deep sedation and before anesthesia induction.Intent of TX.2.1 (per JCAHO)The following is buried in the intent of TX.2.1:

"Hospitals providing obstetric or emergency operative services can pròvide anesthesiaservices within approximately 30 minutes after anesthesia is deemed necessary.

In organizations providing labor services for patients seeking vaginal delivery afterprevious cesarean delivery, appropriate facilities and personnel, including obstetric anesthesiaand nursing personnel, are immediately available to perform emergency cesarean delivery whenconducting a trial of labor for women with a prior uterine scar."

40

California Health and Safety Code 1256.2 (effective 1/1/1999)'"It is unprofessional conduct for a physician to deny or to threaten to withhold pain managementservices, from a woman in active labor, based upon that patient's source of payment, or ability topay for medical services."

Signs must be posted inLabor and Delivery Units that attest to the hospital's compliance withthis policy.

Comment: 1256.2 does not explicitly state that wemust provide regional analgesia. Ifthehospital doés not have the resources to provide labor epidurals to anyone, 1256.2 does notrequire regional analgesia availability. Rather, we cannot discriminate. In other words, wecannot provide epidurals to our friends or the wives or daughters of our colleagues unless weoffer epidurals to all women delivering at the institution. Small hospitals don't have to have alabor epidural service, but if the occasional VIP receives an epidural, then the same serviceshould be provided for all. I urge you to read Dr. Sheila Cohen's editorial writteñ for theCalifornia Society of Anesthesiologists Jan-Feb 1999 Bulletin and reprinted in IJOA2.

EMTALA (Emergency Medical Treatment and Labor ActThe general principle of EMTALA is "Access to care and non-discriminatory treatment".Patients may not be coerced into being transferred or seeking care elsewhere, even if theirinsurance will not pay for their visit or is required by their insurance. For a pregnant womanwho is having contractions, an emergency medical condition exists if there is inadequate time fora safe transfer or transfer may pose a health risk to the woman or baby

Vaginal Birth after Cesarean Delivery (VBAC)The ACOG Practice Bulletin of July 1999 on VBAC3 has generated much controversy amongobstetricians and anesthesiologists. This bulletin recommends that:

Because uterine rupture may be catastrophic, VBAC should be attempted in institutionsequipped to respond to emergencies with physicians immediately available tó provideemergency care.A physician be immediately available throughout active labor capableof monitoring labor and performing an emergency cesarean deliveryAnesthesia and personnel for emergency cesarean delivery be available

The previous Practice Bulletin of October 1998 said readily available vs. the current immediatelyavailable. Dictionary definitions of "immediately" include "without delay", "as soon as", and"without interval of time". Definitions for "readily" include "in a prompt, timely manner" and"without hesitating".

In our hospital, we have asked the obstetricians to notify the oncall anesthesiologist when aVBAC patient is in active labor so that we can be immediately available. This was recentlyinserted into the rules and regulations of the Department of OB/Gyn

In addition, the "30 minute rule" between decision to delivery may not be valid with VBAC. Afederal court decision, in a case in which the time elapsed from the onset of FHR deceleration todelivery was 27 minutes, concluded that the 30 minute rule represented the maximum period of

41

elapse and did not represent a minimum standard ofcare.4 A retrospective study of uterinerupture after previous CS deteniiined that significant neonatal morbidity occurred when> 18minutes elapsed between the onset of prolonged deceleration and delivery.'4 A recent ASAnewsletter includes the statement: "In contrast to other obstetric emergencies such as prolapsedcord or placenta accreta, VBAC is a completely elective procedure that allows for reasonableprecautions in assuming this small but significant risk."5

Nurse MidwivesNurse midwives are increasingly managing the labor and delivery ofpatients. Is it necessary foran obstetrician to become involved in the care of a patient once we are asked to provide neuraxialanalgesia? Our current ASA Guidelines say "yes".

The ASA "Guidelines for Regional Anesthesia in Obstetrics"6 state:"Regional anesthesia should not be administered until 1) the patient has been examined by aqualified individual; and 2) a physician with obstetrical privileges to perform operative vaginal

or cesarean delivery, who has knowledge of the maternal and fetal status and progress of andwho approves the initiation of labor anesthesia, is readily available to supervise the labor and

manage any obstetric complications that may arise."

The clinical and legal implications of anesthesiologists providing regional analgesia/anesthesia to

nurse midwife patients are discussed in an article in the ASA Newsletter7 and many letters to theeditor in response. In some states, certified nurse midwives only need to collaborate with aphysician, in California they must be supervised. There are many issues involved. A major issueis "the ability to rescue" in the case of either maternal or fetal distress.

AWHONN (Association of Women's Health, Obstetric and Neonatal Nurses)AWHONN has published a new position statement'5 on the role of RN's in the care of womenreceiving regional analgesia. Since publication of this statement, labor and delivery nurses at

some institutions are refusing to decrease the epidural infusion rate or restart an infusion that has

been stopped.

The AWHONN statement is noteworthy in what it states a non-anesthetist registered nurse

should not perform. These include:"Rebolus an epidural either by injecting medication into the catheter or increasing the rate

of a continuous infusionIncrease/decrease the rate of a continuous infusionRe-initiate an infusion once it has been stoppedManipulate PCEA doses or dosage intervalsBe responsible for obtaining informed consent for analgesia/anesthesia procedures;however, the nurse may witness the patient signature for informed consent prior to

analgesia/anesthesia administration."

42

It is the view of the California Society of Anesthesiologists Board of Directors that a RN shouldbe allowed to adjust an infusion rate, on a patient-specific order from the physician, provided thatthe RN has adequate education and training involving complications of labor regional anesthesiaand programming of the pumps. Of course, a physician with appropriate privileges must bereadily available during the regional anesthetic to manage anésthetic complications.

The AWHONN restrictions can be challenged provided we educate and train the riurses. The'AHWONN position statement says:

"The requisite education and clinical skill 'acquisition necessary to provide safemanagement ofregional analgesia/anesthesia for the pregnantwoman are not included inbasic education programs for entry intoj,ractice as a registered nurse; therefore suchanalgesia/anesthesia management should be reserved exclusively for licensed,credentialed anesthesia care providers."

We should take the lead and organize educational in-services on ànesthesià and analgesia for theregistered nurses in Labor and Delivery. As we all know, a new RN is not allowed to manage anOB patient without additional training. This knowledge is acquired.' But oncè acquired, the L& D RN manages the laboring patient by examining the patient, interpreting the fetal heart rate'strip, adjusting oxytocin infusions, and administering potentially-toxic medications suéh as IVmagnesium; often with no obstetrician or nurse midwife present in the facility."

II. How can we afford to provide an OB anesthesia service? '

A. Size of Service ' ' V

When is it possible to provide continuous obstetric anesthesia coverage? In the mid-1990's,Íbre the current penetration of HMOs and discounted fee for service, Ostheimer8 suggested

that 2000 deliveries/year is the borderline for full-time coverage of an obstetric service by adesignated anesthesiologist:

C/S rate of 20% (2000 x 20% = 400 cesarean deliveries)50% of vaginal deliveries would require epidurallspinal anesthesia (=800)400 + 800 = 1200 deliveries/365 days =3 -4 deliveries/day

Dr. Ostheimer suggested that 3-4 deliveries/day requiring anesthesia services providesenough work assuming at least 50% of the patients will completely pay their bill (at UCR rates).

What about the reimbursement for the 3-4 deliveries/day in the "real world" of HMO's,capitation, and discounted fee-for-service? Depending on the patient demographics, thesepatients could all be Medicaid/indigent or in the increasingly rare situation, all fee-for-service. Inmy practice (25OØ deliveries/yr; 55-65% epidural rate), it is a blend of Medicaid, HMO, andfee-for-service. Over the past few years, the Medicaid population has increased as financialincentives have been provided to the obstetricians. Unfortunately pediatricians andanesthesiologists have not seen the same incentives. Our reimbursement does not cover ourflj,aflpower cost to provide 24/7/3 65 dedicated OB anesthesia coverage even with 2500

jjyçrjes/year.

An excellent paper by Elizabeth Bell and coworkers looks at manpower cost and reimbursementfor an obstetric analgesia service at Duke University." The authors examined only the directattending physician costs ($206,405 average attending anesthesiologist compensation), without

43

including dependent providers, supplies, or equipment. They found that around-the clock,dedicated obstetric staffing cannot operate profitably under any reasonable circumstances at theirinstitution; they had 2351 obstetric anesthesia cases in fiscal year 1998. The cost per patientduring the study period was $325 if the obstetric anesthesia service was staffed on an intermittentbasis (2.5 FTEs); dedicated staffing (4.4 FTEs) cost $728/patient. Medicaid in North Carolinapaid $204/patient; indemity paid $300-430/1,atient. I suggest that you read this article" and theaccompanying editorial by David Chestnut. 2

The above article uses figures from North Carolina in 1998. You need to determine how manyFTEs you need to cover an obstetric anesthesia service. Are they on an intermittent basis ordedicated staffing? What does an FTE cost in your geographic area? Will you be an all MDpractice or use the anesthesia care team model?

In many areas there has been regionalization ofperinatal care. However, with the emergence ofHMOs/hospital alliances, many requiring their own Labor and Delivery Suite, there has been areturn to smaller units. This is happening all over the country and is being reported on innewspapers and gaining the attention of legislators. If the HMO/hospital sees 24 hour/day;obstetric anesthesia coverage as a selling point for their hospital and the number of deliveries donot justify full-time coverage, then anesthesiologists need to negotiate with HMOs/hospital tosupplement the income of the anesthesiologists on a "break even" basis.

This issue was addressed in a newspaper article'3 about a hospital 15 minutes outside ofSacramento: "A Right to Relief? In some small hospitals, women in labor are being refused whatthey have come to consider their childbirth right: the pain-blocking epidural." The following ismy letter to the editor.'4

"A Right to Relief' (January 26) discusses the availability of labor epidurals forchildbirth in small hospitals. Anesthesiologists are committed to minimizing the pain anddiscomfort of childbirth. However, we should not lose focus of our foremostcommitment; safety of the mother and baby.

Unfortunately, emergencies may occur during childbirth When selecting a hospital,expectant parents should consider the capabilities of the hospital and whether physiciansskilled in managing obstetric and anesthetic complications are available.

Optimally, an anesthesiologist should be available to provide the mother with access toall options for pain relief. However, hospitals must decide if optimal patient care justifiesobstetrical anesthesia services, particularly if there are not enough deliveries to support adedicated anesthesiologist around the clock. Hospitals must recognize that, to meet 2002standards of care, there are costs to provide such services. The trend is for small obstetricservices to merge so they may offer the safest care possible."

44

B. How to provide an OB anesthesia serviceKnow your practice (see sample calculation)

Number of patients- Regional analgesia rate

Cesarean section rateInsurance mix

How is this changing?Percentage of Medi-Ca! OB vs non-Medi-Cal OB

Is this increasing?OB style of practice

Timing of epidurals, induction rates, CS rate, patient expectations

Get hospital to provide stipendLearn what hospitals in the area or hospital system are providing asstipends. : --

Review state laws re physician on call services.Negotiate with your hospital to obtain financial support to facilitateprovision of 24-hour obstetric analgesia coverage.

Have your anesthesia group provide stipend r

We have recently gone to income pooling and pay a stipend for OBcoverage; any services provided while on OB go into the pooled units.

Maximize time on OB while being immediately available-do interruptible tasksCover acute pain management serviceAttend hospital admimstrative meetingsHelp cover preoperative evaluation climcContinuing educationComputer with on-line capability in call roóm

Improve collection rates; audit billing and payments

6 Attract insurersfHMOs/obstetncians with better payment/payer records

Increase the size of the service/merge services: increase patients, increase epiduralrate

Negotiate with insurers; write better contracts

45

III. Billing for your services

A. New ASA RVG Base Codeseffeòt ive 1/1/2002

01960 Anesthesia, vaginal delivery01961 Anesthesia, cesarean section01962 Anesthesia, emergency hysterectomy01963 Anesthesia, cesarean hysterectomy

1967 Neuraxial labor analgesia/anesthesia for planned vaginaldelivery (this includes any repeat subarachnoid needleplacement and drug injection and/or any necessaryreplacement of an epidural catheter during labor

1968 Anesthesia, cesarean delivery following neuraxiallabor analgesia/anesthesia(list separately in addition to code for primary procedure) 3(Use in conjunction with 01967)

1969 Anesthesia, cesarean hysterectomy followingNeuraxial labor analgesia/anesthesia(list separately in addition to code for primary procedure)(Use in conjunction with 01967) 5

B Neuraxial analgesiatime documentationThe ASA Committee on Economics has worked for the many years to develop guidelines

for a charge system to standardize time documentation for regional analgesia for labor. The ASA"Relative Value Guide" (RVG) for 2002 suggests four options for anesthesiologists to considerwhen billing for neuraxial labor analgesia. The guide states that professional charges andreimbursement policies should reasonably reflect the intensity and time involved in performingand monitoring any neuraxial labor analgesic.

Methods to determine professional charges consistent with these principles include:Basic units plus patient contact time (insertion, management óf adverse events,delivery, removal) plus one unit hourly.Basic units plus time units (insertion through delivery), subject to a reasonable cap.Single feeIncremental fees (e.g., 0<2 hrs, 2-6 hrs, >6hrs).

Most practitioners decide on a standard accounting method and use it for all their cases.However, you need to know how the different insurance carriers, HMO's, and state agencieshandle the time charges. For example, you may be billing based on method #1 but the carriermay assume you are billing according to method #2 and they may pay based on the time unitsbilled/4. Some state agencies may not pay except for direct patient contact time, i.e. they maynot pay one unit/hour for the continuous infusion.

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C.. Medicaid Billing

In many states, Medicaid uses the "base umts plus patient contact time" for OB Anesthesia Forexample, in California, MediCal states

"If billing for regiiialanesthesia ... only the time actually spent with the patient isreimbursable. For example, if the patient is under anesthesia for 9 hours and 15 butthe application of anesthesia and subsequent check-back periods total only 3 hoursand 15 minutes, then the claim should read

Epidural anesthesia start time 0500 Stop time 14 15 Time actually spent withthe patient: 195 minutes."9

"The modifier - ZB (adds one unit) may be used to bill for anesthesia services duringan emergency procedure on an otherwise healthy or medically stable anduncompromised patient Examples are a patient who requires a non-electivecesarean section 9

As Larry Sullivan, MD (past President California Society of Anesthesiologists) writes'0:"The ability to document physician-patient direct contact time accurately in an obstetrical settingis nearly impossible and ignores the point of the anesthesiologist's overall responsibility, evenwhen not at the bedside." It is his opinion that the CSA should pursue a FLAT or GLOBAL feearrangement for obstetrical anesthesia under the Medi-Cal program ONLY, rather than dependon time-based methodology.

Several states pay a flat fee for obstetrical anesthesia for Medicaid patients. For example,North Carolina Medi-Caid in 1999 paid a flat fee of $204 for continuous epidural analgesiaduring labor and delivery, whether vaginal or CS.12 (This is equal to 12 units x $17/unit.)

D. Billing for VBAC Standby: good and BAD news

In light of the new ACOG guidelines for VBAC, many anesthesiologists are questioning howthey can bill for being immediately available. The following is one possibility:

The CPT book has a code for Physician Standby Services:99360 Physician standby service, requiring prolonged physician attendance, each 30minutes (e.g. operativé standby, standby for frozen section, for cesarean/high riskdelivery, for monitoring EEG).

The CPT book even provides an example:A 24 y.o. patient is admitted to OB unit attempting VBAC. Fetal monitoring showsincreasing fetal distress. Patient's blood pressure is rising and labor is progressingslowly. A primary care physician is requested by the OB/GYN to standby in the unit forpossible cesarean delivery and neonatal resuscitation.

48

The code is used to bill for physician standby services, requested by another physician,that involve prolonged physician attendance without direct (face-to-face) patient contact.The physician may not be providing care or services to other patients during this period.It is also not used if the period of standby ends with the performance of a proceduresubject to a "surgical package" by the physician who was on standby.

Code 99360 is used to report the total duration of time spent by a physician on a givendate on standby. It is billed at a flat fee in 30-minute increments. A full 30 minutes ofstandby must be provided for each unit of service reported. The code is used to report thetotal amount of time spent by a physician on a given day on standby.

Here's the BAD news The code has a value of"0" under the Medicare's RBRVSthis makesit likely that many private payers would also fail to recognize the service Alternative codingwould be to use an E & M code provided the anesthesiologist evaluates the patieñt, interviewsher, and discusses the anesthetic options. If the anesthesiologist provides a service, the servicewould be billed and not the E & M code.

Example of a practice analysis

Assumptions:1000 deliveries / year20% cesarean section rate:

10% no labor epidural1 hr anesthesia time = 7 unit base + 5 time units:

10% labor epidural to CS:1 hr anesthesia time 3 unit base +4 time units:

50% epidural rate30 minutes to place +5 hours infusion

= 5 unit base + 2 units to place +5 units: total 12 unitsInsurance breakdown:

10% indemnity @ $60/unit60% HMO @ $40/unit30% MediCal @ $17/unit

.1000 x 10% c/s = 100 Cs! year x 12 units/cs = 1200 units/yearIndemnity (10%) 120 x $60/unit = $ 7,200HMO (60%) 720 x $40/unit = $ 28,800MediCal (30%) : 360 x $17/unit $ 6,120

Total expected reimb for C/S (no labor) $ 42,120

1000 xlO% c/s = .100 Cs! year x 7 units/cs 700 units/yearIndemnity (10%) 70 x $60/unit = $ 4,200HMO (60%) 420 x $40/unit = $ 16,800MediCal (30%) 210 x $17/unit = $ 3.570

Total expected reimb for C/S (had labor) $ 24,570

1000 x 50% epidural = 500 epid/year x 12 units = 6000 units/yearhidemnity (10%) 600 x $60/unit = $ 36,000HMO (60%) . 3600 x $40/unit = $144,000MediCal (30%) 1800 x $17/unit = $ 30,600

Total expected reimb for epidural $210,600

Grand total expected reimbursement for L & D for 1 year = $277,290Reimbursement for 24 hours = $ 760

Less cost of billingLess uncollectable

Cost of 4-5 FTE /year = cost of providing dedicated OB Anesthesiologist

49

total 12 units

total 7units

References

Guidelines for Perinatal Care, 4th Edition, American Academy of Pediatrics and theAmerican College of Obstetricians and Gynecologists, 1997.Cohen, Sheila: mt J ObstetAnesth 8:223-225, 2000ACOG Practice Bulletin Vaginal Birth after Previous cesarean Delivery. Number 5, July1999. Contact ACOG telephone 202-863-2518 or e-mail <[email protected]> for moreinformationPhelan IP: VBAC: Time to reconsider. OBG Management November 1996 pp62-68ACOG calls for "Immediately Available" VBAC Services. American Society ofAnesthesiologists NEWSLETTER November 1999 vol. 63 No 11, pg. 21.Guidelines for Regional Anesthesia in Obstetrics. American Society of Anesthesiologistsamended October 18, 2000.Hawkins, JL: Certified nurse midwives, obstetric anesthesia, and you. ASA NewsletterAugust 1999.Ostheimer GW: The Labor and Delivery Suite, pp 443-451 in Manual of ObstetricAnesthesia. Ostheimer GW, editor. New York, Churchill Livingstone, 1996.Medi-Cal Medical Service Provider Manual. California Department of Health Services.September 1999.Sullivan RL: President's Page. CSA bulletin November-December 1999, pg 5.Bell, ED, et al: How much labor is in a labor epidural? Anesthesiology 92:851-858, 2000.Chestnut DH: How do we measure (the cost of) pain relief? Anesthesiology 92:643 -645,2000.http://www.sacbee.comlcontentlriews/story/1 529336p-l6O5 807c.htmlhttp://www.sacbee.com/content/opinion/letters/stOry/l 61296lp-l689l 22c.htmlLeung AS, et al: Uterine rupture after previous cesarean delivery: Maternal and fetalconsequences. Am J Obstet Gynecol 169:945-950, 1993.

"Role of the Registered Nurse (RN) in the Care of the Pregnant Woman ReceivingAnalgesia/Anesthesia by Catheter Techniques (Epidural, Intrathecal, Spinal, PCEACatheters)".http://www.awhonn.org/sitemap/ebg/Cardiovascular_Health_BackroufllPositioflstatements/Epidural/epidural.htmlCalifornia Health and Safety Code. http://www.leginfo.ca.gov/cgi-bin/displaycode?sectionhsc&groupø 1001 -02000&flle=1 250-1263

NOTES

NOTES

Scientific ProgramFriday, May 3, 2002

6:30 am Registration

7:00 - 8:00 am Breakfast with Exhibitors & Posters

8:00 - 9:00 am The Zuspan Award by Perinatal Resources Inc

Moderator/Judge: David J. Birnbach, MDJudges: David H. Chestnut, MD; Michael Greene, MD; Anne May, MBBS, FRCA;Alan C. Santos, MD; Stephen H. Halpern, MD; Susan K. Palmer, MD

9:00 - 10:00 am What's New in Neonatology: Vignettes in Neonatal ResuscitationIntroduction: Gary M.S. Vasdev, MD; Presentor: Robert Chantigian, MD

10:00 - 10:10 am Presentation of the Zuspan Award by Perinatal Resources, IncFrederick P. Zuspan, MD;

10:10 - 10:30 am Break with Exhibitors & Posters

10:30 - 11:30 am What's New in Obstetrics?Introduction: Joy L. Hawkins, MD; Presentor: Michael Greene, MD

11:30 am - 12:30 pm Poster Review #2Moderator: Robert R. Gaiser, MD

1:30 pm Fun Run/Walk, Tennis Tournament, and Golf Tournament (12:45 pm)

6:30 pm Banquet - Beach Music Party (Hilton Head Island Marriott)

Zuspan Awàrd by Perinatal Resources, Inc.

Moderator/Judge: David J. Blrnbach, MDJudges: David H. Chestnut, MD; Michael Greene, MD; Anne May, MBBS,

FRCA; Alan C. Santos, MD; Stephen H. Halpern, MD; Susan K. Palmer, MD

8:00 -. 9:00 am

PULSE PRESSURE AS AN EARLY PREDICTOR ÓF PREECLAMPSIAMsumefli, R.S.; Elimian, A.

A RANDOMISED CONTROLLED TRIAL COMPARING TRADITIONAL WITH TWO "MOBILE"EPIDURAL TECHNIQUES: EFFECT ON URINARY CATHETEIUSATION IN LABORComet, S.; Wilson, M.J.

Z-3 ENDOTHELIAL DYSFUNCTION IN PREECLAMPSIA: A PILOT STUDY WITH NON-INVASWEBLOOD PRESSURE WAVEFORM ANALYSISPian-Smith, M.C; Ecke; J.; Hsu, K.; Leffert, L.; Louglirey, J,

Z-4 A DOUBLE-BUND PLACEBO-CONTROLLED TRIAL OF PROPHYLACTIC ACETAMINOPHENTO PREVENT EPIDURAL-FEVER: PILOT STUDY DATAGoetzl, L.; Evans, T.; Rivers, J.; Lieberman, E.

Z-i

Z-2


JVhatc New in Neoñatology:

V:gnettes in Neonatal Resuscitation?

Robert Chantigian, MD

9:30 - 10:00 am

Following this lecture, the participant will be familiarized with clinicalaspects of neonatal care as illustrated by study cases.

Vignettes In Newborn Resuscitation

Robert C. Chantigian, M.D.

- I. Introduction

The basic approach to resuscitating a newborn is similar to that of resuscitating an adult:"ABC's": Airway, Breathing, Circulation, Drying and Drugs, Evaluation, and Finish.

Mother - 21-year-old G1PO, term pregnancy, few early decelerations, CSE for laborand NSVD.Newborn - Newborn appears term, active, crying, but blue. What do you do now?

Mother 22 year old G1PO, term pregnancy. CSE for labor and a NSVDNewbòrn - Apgar 9/9, looked normal at birth but 15 minutes after birth is cyanotic.What do you do now?

Mother 23 year old G1PO, 33 weeks SPROM. No analgesia for labor, but had apudendal for her forceps delivery.Newborn Apgar scores 8/8, baby weighs 2000 grams. 20 minutes after birth the,baby had a "respiratory arrest" for 30 seconds. What do you do now?

Mother - 24-year-àld G2P1, term pregnancy, good FHR tracing, epidural for laborand for a difficult vaginal breech delivery.Newborn - Newborn is depressed, few respirations, little movement, and is very blue.What do you do now?

Mother 25 year old G1PO, term pregnancy, epidural for labor and NSVD.Newborn - Apgar 8/9. Normal at birth but very cyanotic when crying. What do youdo now?

Mother - 26 year old G1PO, term pregnancy, narcotics for analgesia. Variabledecelerations with little variability noted, vaginal delivery soon was performed andthe nuchal cord was cut for delivery.Newborn - At delivery respirations were poor and you quickly intubate the newborn.After a few breaths the newborn looks OK and is extubated. Apgar scores are 5/7 butsomething is not right. Baby has nasal flaring, tachypnea, grunting, and is getting

worse. What do you do now?

Mother 27 year old G4P3 with blood type O negative. Her previous child died atbirth from hydrops fetalis, which she attributes to medical care. Now she is about 38

weeks by history with no prenatal care. Her baby is about to be delivered.Newborn - A severely swollen newborn is delivered. Respirations are absent so you

attempt to intubate the trachea despite the obvious whole body edema. You get the

tube in but cannot get the chest to move. What do you do now?

55 -

Mother - 28-year-old G4P3 woman, 43-weeks pregnant has variable decelerationsnoted on the fetal monitor. Meconium staining is apparent when the membraneruptures. A forceps vaginal delivery is performed, and you are asked to take care ofthe newborn. -

Newborn - The newborn has obvious meconium staining. What do you do for thenewborn this year?

Mother - 29-year-old G1PO, 42-weeks EGA, labor induced, two doses of narcoticand epidural anesthetic for pain. Non-reassuring FHR tracing is noted and forcepsvaginal delivery quickly performed. S

Newborn - Initially active, Apgar 8; then develops obvious depression (littlerespiratory effort, floppy, blue, heart rate 60-80 beats/minute). Initial treatment isunsuccessful, now what? The UV cord gas from the time of delivery comes back p02- 30, pCO2 - 35, pH - 7.29. What does this mean?

Mother - 30-year-old G1PO has SPROM at 32-weeks EGA. Received an epiduralfor labor and has a normal vaginal delivery.Newborn - A small baby is delivered. What do you do now?

Mother - 31 year old G i PO, term pregnancy, good FHR tracing, epidural for laborand NSVD.Newborn - healthy active newborn with a birth defect, the left hand is missing. Whatdo you do now?

Mother - 32-year-old G5P3 woman, 41-weeks pregnant has a sudden onset ofvaginal bleeding. The fetal heart rate is rapidly decreasing, and a STAT cesareansection is performed with general anesthesia.Newborn - The newborn is very pale, and your initial Apgar score is zero. What doyou do now? The 5-minute Apgar score is zero. Now what do you do? The 10-minute Apgar score is zero. Now what do you do?

II. Basic Approach

Airway (suction mouth and nose, intubate as needed)Breathing (watch chest for expansion, listen for crying or auscultate for breath

sounds, assist breathing as needed)Newborns are obligate nasal breathers. The nasal passages are narrow, prone toobstruction, and should be suctioned in all newborns.5Extrauterine breathing usually begins by 30 seconds (average time 9 seconds)after delivery.

S

The tidal volume is similar to adults; 6 to 7 ml/kg. After a few minutes, theresting respiratory rate becomes about 30 to 40 breaths per minute. Slight nasalflaring, raies, and mild retractions are not uncommon at birth and usually clearspontaneously in less than an hour.

56

2

The cricoid cartilage is the narrowest part of the upper airway. If an endotrachealtube is needed, I use a 2.5 I.D. E'l'T for preterm and a 3.0 I.D. ET'!' for term orpostterm newborns. If a large air leak exists, the next larger size tube can then beplaced. When intubating newborns, keep in mind that the normal tracheal lengthis about 4 cm; therefore, put the tip of the oral endotracheal tube i to 2 cm pastthe vocal cords. For a typical 27-weék EGA newborn, thè lip to mid-tracheadistance is about 7 cm; for a 40-week EGA newborn, the lip to mid-tracheadistance is about 10 cm.If respirations are weak after stimulation or the heart rate is less than 100, startpositive pressure ventilation with 100% oxygen and watch the chest rise.

NORMAL BLOOD GASES AT BIRTHUMBILICAL ARTERIAL (minutes after delivery)

10 min 30 min 60 min60 68 70 s'

40 35 35

7.25 7.33 7.36

Circulation (check heart rate and, if needed, blood pressure and oxygen saturation)The newborn cardiovascular system undergoes significant changes at the timeof delivery (fetal to transitional to adult circulatory patterns).The heart rate for the first 30 minutes is quite labile with ratesof 100 to 200beats per minute. After 30 minutes, the heart rate is about 120 bèats perminute and varies with the newborn's activity. Heart rate can easily bechecked by palpating the base of the umbilical cord or by auscultating thechest for heart tones.Bradycardia is poorly tolerated in newborns. Start CPR (3:1 ratio = 3compressions I 1 ventilation or 90 compressions and 30 respirations perminute) when the heart rate is less than 60 beats per minute after 30 secondsof positive pressure ventilation. Compress the lower third of the sternum to adepth of approximately one third of the anterior-posterior diâmeter of thechest.

. Blood pressure in the term newborn is about 70/45. A systolic blood pressureless than 50 torr in a term newborn requires treatment, usually with volumeexpansion.The blood volume in the term newborn is 80 to 100 ml/kg.The hemoglobin level is 15 to 20 gm per 100 ml (Hct 45 to 60).

57

Vein Artery

P°2 30 20

pCO2 40 50

pH 7.32 7.24

Drying (drying helps stimulate breathing änd often increases the heart rateas well as preventing heat loss)

DrugsOxygen

Indication - hypoxia, bradycardiaConcentration - loo % or with a blender 21 to 100 %Dose - Start with 100 % (although some are now suggesting room air); rapidlydecrease the concentration as tolerated to keep the oxygen saturation between85 to 95%

Epinephrine (needed in about 0.2% of all deliveries)Indication - Heart rate <60 after 30 seconds of PPV and chest compressionsConcentration - 1:10,000 (0.1 mg/mi)Dose - Start with 0.1 to 0.3 ml/kg (0.01 to 0.03 mg/kg) then q 3-5 minutes pm

NaloxoneIndication - respiratory depression due to acute use of narcotics (avoid in thedrug-addicted newborn)Concentration - 0.4 mg/mi or 1.0 mg/mlDose -0.1 mg/kg

Volume ExpansionIndication - hypovolemiaCrystalloid (Saline, Lactated Ringer's Solution)Blood (O negative)Dose - 10 ml/kg and repeat pm (usually more than 20 ml/kg are needed)

Sodium BicarbonateIndication - suspected or documented metabolic acidosisConcentration - 0.5 mEq/ml or 4.2 percent solutionDose -2 mEq/kg (or 4 mI/kg) given over at least 2 minutes (after adequateventilation has been established). Further doses are based on blood gasresults.

SurfactantIndication - Respiratory Distress Syndrome (RDS)Drugs - Beractant (Survanta), Colfosceril (Exosurfl, Calfactant (Infasurf),Poractant alfa (Curosurl)A neonatologist, should be involved as soon as possible. Administer down theETT with positive pressure ventilation.

Prostaglandin E1Indication - Maintain patency of the ductus arteriosus in children with certaincomplex cardiac defectsDose - 0.05 to 1.0 ugfkg/minA neonatologist, pediatric cardiologist, or pediatric intensivist should beinvolved as soon as possible.

Evaluate (assign Apgar Scores, look for birth defects, and diagnose and treatnewborn problems)

Finish (clamp umbilical cord, if the newborn is doing well, and find help if-needed)

III. Gestational age, birth weight and ETT size and distance inserted

IV. References

Desmond MM, Franklin RR, Valibona C, et al. The clinical behavior of thenewly born.

I. The term baby. J Pediatrics 62: 307-324, 1963. 't

Chantigian RC. Differential diagnosis of the neonate in distress. In Ostheimer GW (ed).Manual of Obstetric Anesthesia - 2nd edition. Churchill-Livingstone. 1992.

Heyman HJ. Neonatal resuscitation and anesthesiologist liability. Anesthesiology 81:783,

1994.

Chantigian RC. Resuscitation and Critical Care. Dewan DM, Hood DD (ed). PracticalObstetric Anesthesia. Saunders. 1997.

Liu WF, Harrington T. The need for delivery room intubation of thin meconium in thelow-risk newborn - a clinical trial. Am J Perinatology 15:675-682, 1998.

Cleary GM, Wiswell, TE. Meconium-stained amniotic fluid and the meconiumaspiration syndrome - an update. Pediatr Clinics of North America 45:511-529, 1998.

Lam BCC, Yeung CY. Surfactant lavage for meconium aspiration syndrome - a pilot

study. Pediatr 103:1014-1018, 1999.

International Guidelines for Neonatal Resuscitation: An Excerpt From the Guidelines

2000 for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care:International Consensus on Science. Pediatrics 2000; 106.

American Heart Association, American Academy of Pediatrics. Neonatal Resuscitation

Textbook 4th edition (NRP program textbook) 2000.

KlausMH, Fanaroff AA. Care of the High-Risk Neonate 5th Ed. Saunders 2001.

59

5

Gestational Mean Weight ET Tube Size ET Tube Distance

Age (weeks) (grams) (mm I.D.) (Lips to Mid-trachea cm)

22 500

27 1000 2.5 7

33 2000 2.5-3.0 8

38 3000 3.0-3.5? 9

40 3300 3.5-4.0? 10

What's New in Obstet,*s?

Michael Greene, MD

1030-11 30a1m

Following this lecture, the participant will understand some of the currentconcerns in obstetrics and their possible ramification in obstetric care.

60

What' s New with Vaginal Birth After Cesarean?

Michael F. Greene M.D.

Every medical student is taught early in his or her career the basic principle thatno tissue heals to produce a scar that is as strong as the native tissue was before it wasdisrupted. This is true despite our best efforts at surgical repair and pertains to skin,fascia, bone and uterine muscle. Thus, as cesarean sections became more commonplace,it came as no surprise when hysterotomy scars from cesarean deliveries ruptured underthe stress of subsequent pregnancies and labors. Douglas recognized this 40 years ago ina series that he published from the New York Lying-In Hospital.' At that time, the overallcesarean delivery rate was 4% with half of those done for the indication of a priorcesarean section. Among more than 2,000 women with prior cesarean section scars,uterine rupture during labor occurred in just over 1%, and more than a third of thoseinvolved fetuses died. Douglas concluded that, "Probably the most vehement objectionsto the policy of vaginal delivery after cesarean section allude to the occurrence ofcatastrophic ruptures of the uterine scar." That kind of experience and reason coupledwith the dogmatic proclamation of "once a cesarean section, always a cesarean section",cast the practice of vaginal birth after cesarean (VBAC) into widespread disrepute fordecades.

Subsequently, cesarean sections went from commonplace to epidemic with theU.S. national rate peaking in the late 1980s at nearly 23%. This attracted the attention ofmedical academicians, health care policy analysts, public health officials and those whopaid the nation's escalating health care bills, because cesarean sections generally result ingreater short term and long term maternal morbidity, mortality, and expense than vaginaldeliveries. A third of the cesarean sections were elective repeat procedures with absolutenumbers rising as the primary cesarean section rate rose. An obvious opportunity to curbthe overall cesarean section ratewas to revive the practice of vaginal birth after cesarean.

Enthusiastic reports of success2'3 and optimistic assessments of meta-analyses4 propelledthe VBAC juggernaut. Insurers assembled programs to promote VBAC and educatedoctors and patients regarding their benefits. Some insurers even felt justified in refusingtó pay for repeat cesarean seètions that were not preceded by attempts at VBAC.Individual physicians, and to some extent their professional organizations, were cajoled

or coerced into supporting these programs, lest they be dropped from the provider rosteror portrayed as uncooperative and non-progressive. As experience again accumulatedhowevèr, so too did reports of maternal and perinatal morbidity and mortality associatedwith VBAC, most of which was attributable to uterine rupture.5'6'7

Efforts to improve the safety of VBAC have focused on attempts to identify risk

factors for uterine rupture. Zelop et al.8 found that 1,021 women with a history of asùccessful vaginal delivery were at significantly lower risk of uterine rupturè (0.2%) than2,762 women without a vaginal delivery (L1%). Ironically, the two women who ruptured

their uteri in the prior vaginal delivery group, each had two prior successful VBACs.

Thus, even a history of a successful VBAC is not a guarantee that a patient will notrupture her uterus in a subsequent VBAC attempt. Not surprisingly, women with twoprior cesarean sections are at significantly greater risk of uterine rupture during VBAC

61

II i

attempt thán women with only one prior scar (3.7% vs. O.8%). Neither length of labor,nor use of epidural anesthesia, were associated with an increased risk for uterine ruptureduring VBAC attempt.9

Investigations into the effects of labor induction and oxytocic agents used toinduce labor have yielded inconsistent results. Compared to spontaneous labor, Ravasiaet aL'9 found a significantly higher incidence of uterine rupture associated with laborinduced with PGE2 gel (2.9% vs. 0.5%) but not with oxytocin (0.7%). In contrast, Zelopet al." found induction of labor with oxytocin to be associated with a statisticallysignificant increase in risk for uterine rupture (2.0% vs. 0.7%) compared to spontaneouslabor. Although their data suggested an increased risk for uterine rupture with PGE2induction of labor, the number of events was small, their confidence interval for this riskestimate was wide and included unity. Rageth et al.'2 observed a modest but statisticallysignificant increase in risk for uterine rupture with induction of labor but they do notspecify the oxytocic agent(s) used. Reports of two small uncontrolled case series'3"4suggested a 5-10% risk of uterine rupture associated with use of the very potent oxytocicsynthetic prostaglandin E, analog, misoprostol.

The most recent study to heat up the controversy appeared in the New EnglandJournal of Medicine in July 2001. In that study, Lydon-Rochelle et al)5 used a largestate-wide database of 20,000 women in Washington state to examine the risk of uterinerupture associated with induction of labor. All of the women were delivering their firstsingleton babies after one prior cesarean section. The overall risk of uterine rupture was4.5 per I ,000, which is very consistent with many other studies. The risks of ruptureassociated with spontaneous labor and non-prostaglandin induction of labor were 5.2 and

7.7 per 1,000 respectively. These were both significantly greater than the 1.6 per 1,000

rate seen with repeat cesarean section without labor but not different from one another.Most striking was the 24.5 per 1,000 rate ofuterine rupture observed with prostaglandininduction of labor. Their database did not contain information regarding the type ofprostaglandin used. To examine the possibility that all ormost of the observed increase in

risk associated with prostaglandin induction might be due to misoprostol, the authorsstratified their analysis by time prior to 1996 and during 1996. Misoprostol has been used

for this purpose only relatively recently and there was no suggestion of a recent increase

in incidence in rupture with prostaglandin induction. This suggests that the risk is notassociated with misoprostol alone but extends to other prostaglandin preparations. Purists

will object that prostaglandins are not approved, indicated or intended for use to inducelabor at term but only to prepare the unfavorable cervix. Extensive clinical experiencewith these agents suggests that they frequently do induce labor regardless of the intent

and that this is a semantic difference. The authors demonstrate that their 91 patients with

diagnoses oL uterine ruptures had substantially greater incidences of a variety ofpostpartum complications, suggesting that these were truly clinically important ruptures

and not merely asymptomatic dehiscences. Finally, there was an eleven-fold difference ininfant death (0.5% vs 5.5%) between the 20,000 women who did not rupture their uteriand the 91 who did. It is important to emphasize that this study, like all others to date,

was an observational study of the results of clinical practice and not a randomized trial.

The relative risk of 3.3 for uterine rupture with a trial of spontaneous labor ascompared to elective repeat cesarean section is consistent with the odds ratio of 2.1 for asimilar comparison calculated by Mozurkewich and Hutton in theirmeta-analysis of 11studies with 39,000 subjects.'6 Mozurkewich and Hutton also calculated statisticallysignificant increases in risk for fetal death (odds ratio i .7) and Apgar score less than 7 at5 minutes (odds ratio 2.2) associated with a trial of labor as compared to elective repeatcesarean delivery. These risks reflect broad experience with large numbers of subjectsover many years in a wide range of clinical practice settings. There is no evidence orreason to believe that they can be substantially reduced by improvements in clinical care.What benefits might offset these risks? Women who successfully complete trials of laborgenerally have less post partum discomfort and shorter lengths of hospital stay thanwomen who undergo repeat cesarean section. There is evidence that a trial of labor isassociated with a lower risk for febrile morbidity than elective repeat cesarean sectjon.16The findings of reduced risks for transfusion and hysterectomy with trial of labor arelikely due to patient selection because they are not driven by uterine ruptures, which aremore common with trial of labor. 16

Slovic recognized that "experts" (e.g. health care policy wonks, public healthofficials and insurance company executives) perceive "risk" differently from lay people(patients).'7 Experts judge risk according to technical estimates of actual numbers of"fatalities, which for perinatal mortality is 5.8 per 1,000 with trial of labor after cesareansection compared to 3.4 per 1,000 with elective repeat cesarean section. The absolutedifference between the two is 2.4 per 1,000 (1/4 17), a relatively small number. Laypeople judge "risk" more according to their degree of "dread" for the unwanted outcome."Dread" in turn is determined by the degree to which the outcome is irreversible,potentially lethal, and uncontrollable. By these criteria, perinatal mortality during a trialof labor would seem to be associated with a high degree of dread.

The process of obtaining informed consent for medical care requires thatphysicians provide patients with the information that a "reasonable person" would wantto know under the circumstances. Most reasonable persons would want to know thatattempt at VBAC is associated with a higher risk of perinatal mortality than electiverepeat cesarean section. People have different abilities to tolerate or accept risk. Somepeople would see the 5.8 per 1,000 risk of perinatal mortality associated with VBAC asvery small and acceptable. Others would ask if there is a way to further reduce that riskand, if there is, to take that alternative course.

63

1. Douglas RG, Birnbaum SJ, MacDonald FA. Pregnancy and labor followingcesarean section. Am J Obstet Gynecol 1963;86:961-971. -

2 Martin JN, Harris BA, Huddleston JF, et al. Vaginal delivery following previousr . cesarean birth. Am J Obstet Gynecol 1983;146:255-262.

. Phelan JP, Clark SL, Diaz F, Paul RH. Vaginal birth after cesarean section. Am JObstet Gynecol 1987;157:1510-1515. .

Rosen MG, Dickinson JC, Westhoff CL. Vaginal birth after cesarean: A meta-analysis of morbidity and mortality. Obstet Gynecol i 99 1 ;77:465-470;Scott JR. Mandatory trial of labor after cesarean delivery: An alternativeviewpoint; Obstet Gynecol 1991;77:811-814.Farmer RM, Kirschbaum T, Potter D, et al. Uterine rupture during trial of laboralter previous cesarean section. Am J Obstet Gynecol 1991;165:996-1001.McMahon MJ, Luther ER, Bowes WA, Olshan AF. Comparison of a trial of laborwith an elective second cesarean section. N Eng! J Med 1996;335:689-695.Zelop CM, Shipp TD, Repke JT, et al. Effect of previous vaginal delivery on therisk of uterine rupture during a subsequent trial of labor. Am J Obstet Gynecol2000;183:l 184-1 186.Caughey AB, Shipp TD, Repke JT, et al. Rate of uterine rupture during a trial oflabor in women with one or two prior cesarean deliveries. Am J Obstet Gynecol1999; 181:872-876.Ravasia DJ, Wood SL, Pollard JK. Uterine rupture during induced trial of laboramong women with previous cesarean delivery. Am J Obstet Gynecol200183:1176-1179.Zelop CM, Shipp TD, Repke JT, et al. Uterine rupture during induced oraugmented labor in gravid women with one prior cesarean delivery. Am J ObstetGynecol 1999; 181:882-886.Rageth JC, Juzi C, Grossenbacher H. Delivery after previous cesarean: A riskevaluation. Obstet Gynecol i 999;93 :332-337.Wing DA, Lovett K, Paul RH. Disruption of prior uterine incision followingmisoprostol for labor induction in women with previous cesarean delivery. ObstetGynecol 1998;91:828-830.Plaut MM, Schwartz ML, Lubarsky S. Uterine rupture associated with the use ofmisoprostol in the gravid patient with a previous cesarean section. Am J ObstetGynecol 1999;180:1535-1542.Lydon-Rochelle M, Holt VL, Easterling TR, Martin DP. Risk of uterine ruptureduring labor in women with prior cesarean delivery. N Engl J Med 2001 ;345:3-8.Mozurkewich EL, Hutton EK. Elective repeat cesarean delivery versus trial oflabor: A meta-analysis of the literature from 1989-1999. Am J Obstet Gynecol2000;183:1 187-1197.Slovic P. Perception of Risk. Science 1987;236:280-285.

Poster Review #2

Moderator: Robert R. Gaiser, MD

11:30 am- 12:30pm.

BEATING THE ODDS OF À FAILED INTUBATION: NUMBER NEEDED TO TREAT ORTHE TRICK OF TURNINGTO BINOMIALTABLESGlassenberg It; Fredericksen, M.SUPPLEMENTARY OXYGEN IMPROVES UMBIUCAL CORD BLOOD GASES IN OBESE MOTHERS UNDERGOINGELECTIVECAESAREANSECTION . .

Bullough, A.; Taylor, I.; Van Hamel, C.; Watters, M.THE URGENCY OF CAESAREAN CLASSIFICATION AND FETAL OUTCOMESashidharan R..; Duke, C.; Leschinskiy, D.; Philip, S.; Hallworth, S. -

FIBEROPTIC ENDOTRACHEAL INTUBATION OF THE ENDOMORPH: METAMORPHOSIS IN AIRWAYMANAGEMENTGlas senberg. R; Fredericksen, M.THROMBOPROPHYLAXIS IN EMERGENCY LSCS: AN AUDIT CYCLE COMPLETEDSashidharan. R..; Leschinskiy, D.SPINAL ANESTHESIA FOR CESAREAN SECTION FOLLOWING SUBOPTIMAL LABOR EPIDURAL ANALGESIADadarkar, P,; Philip,J.; Perez, B.; Makhdumi, A.; Slaymaker, E.; Weidner, C.; Tabaczewska, L; Wiley,J.; Sharma, S.DOES DENSITY INFLUENCE THE SPREAD OF INTRATHECAL BUPIVACAINE IN THE PROLONGED SITIINGPOSITION BEFORE ELECTIVE CESAREAN SECTION?Sodhi.. V,; Fernando, R; Hallworth, S.; Sarang, K.; Patel, N.LOW-DOSE ROPIVACAINE VS. BUPIVACAINE FOR SPINAL ANESTHESIA FOR CESAREAN SECTIONVelickovic T &; Leicht, C.H.SHORT STATURE IS ASSOCIATED WITH A HIGHER CESAREAN SECTION AND EPIDURAL RATEDimarca C.S,; Ramm, K.D.; Ramsey, P.S.; Vasdev, G.M.EPIDURAL MORPHINE FOR POST-CESAREAN ANALGESIA - DOES ADDING FENTANYL MAKE A DIFFERENCE?Ranasinghe. S,; Steadman,J.; Siddiqui, M.; Lai, M.; Kenaan, C.; Toyama, T.; Bailur, N.; Melgan,J.MORPHINE-INDUCED HYPOTHERMIA AFIER CESAREAN DELIVERY AND ITS REVERSAL WITH LORAZEPAMWang. J.; Snowman, C.; Pratt, S.; Hess, P.E.FACTORS PREDICTING FAILURE OF LABOR EPIDURAL CATHETERS DURING CESAREAN SECTIONHihib, A S.; Drysdale, S.; Olufolabi, A.J.; Philips-Bute, B.G.; Muir, H.A.PERIPARTUM HYSTERECTOMIES ANESTHETIC AND OBSTETRIC OUTCOMESZinner, T.R; Khan, K; Lee-Parritz, A.; Camann, WitFETAL ACIDEMIA AND ANESTHESIAFroc! ich, M.A,; Caton, D.FETAL EFFECTS OF MATERNAL ANALGOSEDATIONFroc! ich, M.A,; Euliano, T.Y.; Caton, D.FIBEROPTIC INTUBATION IN PARTURIENTS UNDERGOING CESAREAN SECTIONFZrasuski, P; Shukia, N.; Wali, A.; Um, Y.; Vadhera, R.; Longmire, S.; Munnur, U; Rivers, J.; Tran, C.; Palacios, Q.; Suresh, M.S.

DOES THE TYPE OF PRENATAL CAREGIVER INFLUENCE THE RATE OF EPIDURAL USAGE AMONGPARTURIENTS? -

Friedman,J.D.; Ramm, K.D.; Vasdev, G.M.; Ramsey, P.S.

All Abstracts are in the Anesthesiology Supplement.

65

Poster Review #2

P-81 ANALGESIA AFIER CESAREAN SECTION: DOES THE PRE-EMPTIVE EFFECT OF EPIDURAL DIAMORPHPAFFECT OUTCOME?Mok, M.U.; Thompson, J.; Vanarase, M.; Grangr. C

P-82 EXAMINING THE INFORMATION REQUIREMENTS OF WOMEN HAVING ELECTWE CESAREAN SECTIQDR JULIA MöRCH-SIDDALL DR VALERIE BYTHELL DEPARTMENT OF ANESTHESIA, ROYAL VICTOPINFIRMARY, NEWCASTLE UPON TYNE UKMorch-Siddall. J; Bythell, V.

P-83 DOES INCREASED INTRAVENOUS HYDRATION DECREASE THE INCIDENCF Al T'ZT' A /VcMrrT

FOLLOWING CESAREAN SECTION?Gaiser. RR; Dong, Y; Cheek, T.G.; Gutsche, B.B.

P-84 GENERAL ANESTHESIA FOR CESAREAN SECTION: CURRENT PRACTICE PAIIERNSSatya-Krishna, R.; Grange, C; Russell, R.

P-85 PRURITIS ASSOCIATED WITH INTRATHECAL MORPHINE FOR CESAREAN SECTION: A COMPARISOBETWEEN 100 AND 200 MCGHabib. A.S; Drysdale, S.; Phillips-But; B.G.; Muir, H.A.

P-86 ARE ROUTINE TYPE & SCREEN ORDERS NECESSARY FOR CESAREAN SECTION?DeBalli, R; Spahn, T.; Muir, HA.

P-87 THE EFFECT OF THE ADDITION OF EPINEPHRINE ON EARLY SYSTEMIC ABSORPTION OF EPIDUROPIVACAINE IN HUMANSLee. B.B; Ngan Kee, W.D.; Plummer,J.L.; Wong, A.S.

P-88 IS 6% HETASTARCH PREFERRED OVER PROPHYLACTIC W EPHEDRINE FOR PREVENTION OF HYPOTENSIO'FROM INThATHECAL ROPIVACAINEFORC/S?Cohen, S.; Penenherg. H; Aiptekin, B.; Ginsberg, S.; Bokhari, F.; Burley, E.; Zada, Y; Freeman, L.


NOTES

NOTES

Saturday, May 4, 20026:30 am

7:00 - 8:00 am

7:00 - 8:00 am

8:00 - 9:30 am

9:30 - 10:00 am

10:00 11:00 am

11:00 am - 12:00 n

12:00 1:00 pm

1:00 - 2:00 pm

2:00 - 3:00 pm

3:0e - 3:30 pm

3:30 5:00 pm

5:30 pm

Scientific Program

Registration

Breakfast with Exhibitors & Posters

Multidisciplinary Obstetric SimulatedEmergency Scenarios (MOSES)(Limited Registration - By Ticket Only)

Christopher Sadler, PhD, MBBS, FRCA;

Mira Razzaque, MD

Research Works in ProgressRobert D'Angelo, MD;Richard M. Smiley,'MD, PhD

Clinical Forum: Scripted Cases of Parturients with Cardiovascular DisordersModerators: Carole Warnes, MD; Kirk Ramm, MD; William R. Camann, MD


ASA Presidential AddressBarry Glazer, MD

Debate No. 2Failed Epidural for Urgent C/S: Spinal is Preferable to General AnesthesiaModerator: Andrew M. Malinow, MDPRO: David R. Gambling, MBBS CON: M. Joanne Douglas, MD, FRCPC

Lunch

Poster Review #3Introduction: Alan C. Santos, MD; Moderator: Holly Muir, MD, FRCPC

Gerard W. Ostheimer Anesthesia Lecture: What's New in Obstetric Anesthesia?Introduction: Alan C. Santos, MD; Presentor: David H. Wiody, MD


Business Meeting

Sunset Sailing (Limited Space, Ticket Only)

Multidiscplinarj' Obstetric Simulated Emergencjì Scenarios

(MOSES)Christopher Sadler, PhD, MIBBS, FRCA; Mira Razzaque, MD

700-800 am

During this presentation, the participant will learn about themultidisciplinary management of emergency situations in obstetrics.

69

Multidisciplinary Obstetric Simulated EmergencyScenarios (MOSES) workshop

Sadler C, FRCA, Razzaque M, FRCA & Davis C, MRCOGBarts and The London Medical Simulation Centre, St Bartholomew's Hospital

West Smithfield, London EC1A 7BE.

The NHS litigation bill in the UK stands at £400 million; half of this is from the field ofObstetrics and Gynaecology'. Substandard care was identified in over 60 % of directdeaths in the latest confidential enquiry into maternal deaths (CEMD)2. Healthcareproviders in Obstetrics and Gynaecology have been charged with achieving a 25 %reduction in the instances of harm resulting in litigation by 2005'. What risk reductionstrategies might make an impact on these figures?

Failure of communication and team working between professionals is the main cause ofmajor substandard care (42%) in direct and indirect deaths reported in the CEMD2. In anattempt to improve team efficiency, previous enquiries have recommended that obstetricunits run regular fire drills to ensure that all members of staff know exactly what to do inan emergency3. Simulation centres have been identified as possible tools to help in riskreduction strategies by allowing healthcare professionals to practice emergency drillswithout any risk to real patients'.

Human factors courses, which examine how behaviour can influence development andresolution of crisis situations, are available in Anaesthesia4. However, we are unaware ofany courses that look at behaviour and team working in a multidisciplinary setting.Consequently, we have devised the MOSES course for obstetricians, anaesthetists andmidwives with the goals of (1) teaching effective multidisciplinary team working (2)demonstrating the role human behaviour can play in crisis prevention and resolution and(3) practicing obstetric emergency drills.

The MOSES course is run in a High Fidelity Medical Simulation Centre using acomputerized manikin (Laerdal SimMan) as the pregnant mother. The simulation centreincludes a clinical area housing the manikin that can be arranged as labour ward or theobstetric operating theatre. The manikin is controlled by a laptop behind a one-waymirrored window looking onto the clinical area.

The clinical area is fully equipped and staffed. The manikin breathes spontaneously, hasbreath sounds and heart sounds, peripheral pulses, talks and can be anaesthetised andventilated. Modifications have been made to the manikin to allow assessment of cervicaldilation and delivery of a simulated fetus by Lower Segment Caesarean Section. Asimulated auditory and visual cardiotochograph adds to the realism.

Course participants manage real time multidisciplinary scenarios lasting about 30minutes. Participants are required to make diagnoses and treat as they see appropriateusing real drugs and simulated blood products when required. Several cameras record

70

different views of the scenarios onto videotape. After the scenario participants aredebriefed using video playback to demonstrate teaching points. Trained facilitators fromanaesthesia, obstetrics and midwifery direct the discussion to concentrate on teamworking and behavioural issues that can impact on crisis development and resolution.

This workshop will:

Introduce-the MOSES course.Involve the audience in a team working exercise to identify good/bad team workingbehaviours.Ask the audience to analyse some video footage of an obstetric emergency for good/badteam working behaviours.Demonstrate how Laerdal SimMan can be used for Obstetric 'fire drill' training.

References:

Building a Safer NHS for Patients. Department of Health 2001.Report on the Confidential Enquiries into Maternal Deaths in the United Kingdom2000.Report on the Confidential Enquiries into Maternal Deaths in the United Kingdom1997.Gaba DM, Howard SK, Fish Kl. Crisis Management in Anesthesiology. NewYork: Churchill-Livingstone, 1994.

71

Research Works. in Progress

Moderators Robert D'Angelo, MD, Richard M Smiley, MD, PhD

7:00 - 8:00 am

Notes:

Clinical Forum. Scrzbted Cases of Parturients with

Cardiovascùlar Disorders

Moderator: Carole Warnes, MD; Kirk Ramm, MD; William R. Camann, MD

8:00 - 9:30 am

Participant will learn about multidisciplinary management of obstetricpatients with life-threatening cardiovascular disease. These will beillustrated using study cases.

Clinical Forum: Scripted Cases of Parturients withCardiovascular Disorders

Carote Warnes, M.D.Professor of CardiologyDepartment of CardiologyMayo ClinicRochester, MN

MEDICAL PRESENTATION: (Dr. Warnes)

30-year-old woman transported by helicopter emergently and she is 30 weeks pregnant. Her pastmedical history reveals 2-weeks of dyspnea and cough treated with antibiotics, now in extremiswith orthopnea. On admission: BP 85/60, profoundly dyspneic, sitting upright, coughing. Low-volume pulses with a sinus tachycardia at 120 BPM. A Harsh systolic murmur was heard in theaortic area and a third heart sound. Investigations: Chest x-ray: Severe pulmonary edema withcardiac enlargement. Echocardiogram: Severe aortic stenosis with calcified valve (probablybicuspid valves) area approximately 0.7 cm2, mean gradient 50 mm Hg, peak 95 mm Hg. Aorticregurgitation grade 1-2/4. Left ventricular ejection fraction 36%

OBSTETRIC MANAGEMENT: (Dr. Ramm)

General Principles - All Obstetric Patients

Physiologic changes of pregnancyA. 50% increase in intravascular volumeB. Decreased systemic vascular resistance (SVE)

I. Potential right-to-left shunts2. Preeclampsia has opposite effect

C. Hypercoagulable state of pregnancyAll clotting factors increase except factors XI and XIIIMarked fibrinogen increaseFree protein S falls by second trimester

D. Marked fluctuations in cardiac output during labor and delivery

Kirk Ramm, M.D.Chair, Division of MFMDepartment of OB/GYNMayo ClinicRochester, MN

Case I

74

William Camann, M.D.Director, Obstetric AnesthesiaHarvard Medical SchoolBrigham and Women's HospitalBoston, MA

Specific

GeneralA. Aortic stenosis

1. Significant stenosis uncommon among women of childbearing age2. Majority secondary to congenitally stenotic aortic valves

- a. BicuspidUnicuspidSupra/subvalvular stenosis

B. Mortality1. Maternal 17%2. Perinatal 32%3. Greatest risk gradient >100 mmHg4. Risk of sudden death out of proportion to degree of clinical symptoms

C. ManagementVaries with degree of diseaseFixed cardiac outflow

3. Tachycardia - avoidReduced preloadShortened ejection periodIncreased myocardial oxygen consumptionCoronary perfusion

Increased ventricular diastolic pressureReduced systemic afterload

4. Prenatala. Reduce physical activityb; Bedrestc. Maintenance of venous return

5. Labor and deliverya. Factors

Increased cardiac effortSystemic peripheral dilationBlood loss with deliverySupine hypotensionValsalva

b. Pulmonary artery catheter(1) Optimize preload to avoid decreased output or

pulmonary edemac. Avoid Valsalva in second stage

ForcepsVacuum

d. Aggressive management of third stageAvoid postpartum hemorrhageCritical disease

D. ValvuloplastyE. Valvotomy -

75

ANESTHESIA MANAGEMENT: (Dr. Camann)

Vaginal:Invasive monitoring with arterial line and CVPIPA. Maintain CVPIPAWP at high-normallevels. Maintenance of sinus rhythm is important to preserve ventricular filling. Oxygenadministration throughout labor should be used. Careful attention to adequate uterinedisplacement is vital. Regional analgesia/anesthesia, previously thought to becontraindicated in patients with AS, has been used. Caution is essential, and a slow onsetof block should be sought. Intrathecal opioids (without local anesthetics) may be used forearly labor, with gradual instillation of a low-dose epidural local anesthetic infusion aslabor progresses. No epinephrine should be added, as unintentional IV injection couldcause life-threatening tachycardia. A dense anesthetic level of Tl0-T8 should be slowlyobtained as the patient approaches delivery, with consideration for an assisted secondstage and minimal maternal expulsive efforts.

II. Cesarean:General anesthesia would be advocated by most anesthesiologists. Thiopental or propofolmay result in unwanted myocardial depression, while ketamine may result in undesirabletachycardia. A combination of etomidate and opioid represents a good choice forinduction. Arterial and central monitoring are warranted. Regional anesthesia has beenused for cesarean delivery in the presence of severe AS. Single-shot spinal should beavoided. An epidural with slow titration of anesthetic level can be used. Oxygen,adequate uterine displacement and judicious sedation are all important.

REFERENCES:

Ramsey PS, Ramm KD, Ramm SM. Cardiac disease in pregnancy. Am JPerinatol 2001, 18:245-66.

Baker PN, Cunningham FG. Platelet and coagulation abnormalities. In: Lindhemier ML,Roberts JM, Cunningham FG, eds. Chesley's hypertensive diseases in pregnancy, 2nd ed.Stamford, CT Appleton & Lange, 1999 349, 1999

Bremme K, Ostlund E, Almqvist I, Heinonen K, Blomback M. Enhanced thrombingeneration and fibrinolytic activity in normal pregnancy and the puerperium. ObstetGynecol 1992, 80:132.

Faught W, Garner P, Jones G, Ivey B. Changes in protein C and protein S levels in normalpregnancy. Am J Obstet Gyncol 1995, 172;147.

Gatti L, Tenconi PM, Guarnen D, Bertulessi C, Qssola MW, Bosco P, Gianotti GA.Hemostatic parameters and platelet activation by flow-cytometry in normal pregnancy: alongitudinal study. mt J Clin Lab Res 1994, 24:2 17.

Cunningham FG, Gant NF, Leveno KJ, Gilstrap LC ifi, Hauth JC. Cardiovascular diseases.In: Seils A, Nougaim SR, Davis K, eds. Williams obstetrics, 21st ed. McGraw-Hill,2001:1181-207.

Gei AF, Hankins GDV. Cardiac disease and pregnancy. Obstet Gynecol Clin North Am2001, 28:465-5 12.

American College of Obstetricians and Gynecologists. Cardiac disease in pregnancy.Technical Bulletin 168, June 1992

Clark SL. Cardiac disease. In: Clark SL, Cotton DD, Hankins GDV, Phelan JF, eds.Critical care obstetrics, 3rd edition. Maiden, Massachusetts: Blackwell Science, 1997:290-313.

American College of Obstetricians and Gynecologists. Cardiac disease in pregnancy.ACOG Technical Bulletin 1992:168:1-8. r

Ramm SM, Maberry MC, Gilstrap LC. Congènital heart disease. Clin Obstet Gynecol1989, 32:41-7.

Easterling TR, Chadwick HS, Otto CM, Benedetti TJ. Aortic stenosis in pregnancy. ObstetGynecol 1988, 72:113-8.

Arias F, Pinedo J. Acrtic stenosis and pregnancy. J Reprod Med 1978, 20:229-32.


23-year-old with complex cyanotic congenital heart disease and severe pulmonary vasculardisease referred urgently with a 16 weeks gravid uterus. Patieñt was known to have complexpulmonary atresia with hypoplastic pulmonary arteries. Husband considers urgent referralunnecessary, and states that doctors are "completely mad". Her medical history: Patient cyanoticat an early age treated with a Right Blalock-Taussig shunt at aged 10 and a Left Blalock-Taussigshunt at aged 11. She underwent cardiac catheterization at aged 15, which demonstrated the leftBlalock-Taussig shunt was not working. One-year previously (1996) she had an ascending aorta-to-left pulmonary artery shunt. The pulmonary arteries severely hypoplastic with systemic

pressures in the pulmonary arteries; i.e., Eisenmenger physiology, patient functional class II.Patient had never been given any counseling regarding pregnancy or contraception. The patientpresented at 16 weeks pregnant feeling slightly more short of breath but has no ankle swelling or

palpitations, or on any medications

Her examination revealed: moderate cyanosis, bounding pulse 80 BPM and sinus rhythm, BP110/70, jugular venoùs pressure elevated 2 cm, left and right ventricular lifts, continuous murmur

over the sternum, an additional continuous murmur over the right side, and no peripheral edema.Hemoglobin: 14.3 g/dL

Patient would not consider termination of pregnancy.

At 20 weeks gestation: Getting a little more tired, resting saturation 84%, on prenatal vitamin

supplements and baby aspirin.

At 28 weeks: Patient more cyanotic, on modified bedrest and limited activity in the house,jugular venous pressure elevated 3 cm, pulse 85 BPM and sinus rhythm, BP 100/70.

Auscultation of the chest was clear. No hepatomegaly or peripheral edema.

Case II

77

OBSTETRIC MANAGEMENT: (Dr. Ramm)

Counseling

Risks with cyanotic heart diseaseA. Fetal

Increased risk for fetal conotruncal abnormality 6-10%Increased risk for spontaneous abortionIncreased risk intrauterine growth restriction, stillbirth, and prematurityIncreased cesarean delivery rates

B. MaternalIncreased risk of DVT, pulmonary infarction, strokeIncreased risk of arrhythmiaIncreased risk of death (up to 50%)Risk of aortic rupture given baseline dilation

C. GeneralTermination optionDelivery in tertiary care center

II. ManagementA. Fetal imaging

1. Early fetal ultrasoundEstablish dates as delivery will be prematureDocument intrauterine pregnancy as ectopic rupture and hemorrhage would behazardous

2. 18-week anatomy scanDocument normal anatomic relationshipsMultiple anomalies that would be incompatible with life importantconsiderations given maternal risks

3. Fetal echocardiograma. 20-22 weeks' gestation

4. Ultrasound every 4-6 weeks throughout gestation for fetal growth and fluidassessment

5. Fetal testing; biophysical profile (BPP) or nonstress testing (NST) weeklybeginning at 28 weeks until delivery

B. Maternal imagingCardiac echocardiogram early in pregnancy if not performed in pastyearRepeat echocardiogram late second trimester to early third trimester to assesschange in function

C. General prenatal care1. Diet and weight gain

Nutrition consultKeep weight gain at 20-25 poundsLimit exercise

78

2. Rest periodsAdjust per symptomsAdmission rest late second or early third trimester

3. Baby aspirin/anticoagulationD. Labor and delivery

1. Hemodyn amie changesAutotransfusionHemorrhage

e. Regional/general analgesiaMaternal positioningHemodynamic monitoring

2. Route of deliveryVaginalCesarean

3. Timing of deliveryPrematurity risksMaternal risks

4. MedicationSOxytocinProstaglandins

e. Steroids (lung maturity)AnticoagulatiOnVasodilators

5. Postpartum issuesTwo-week admissionSterilization

ANESTHESIA MAÑAGEMENT: (Dr. Camann)

General Principles:Pulmonary hypertension is poorly tolerated in pregnancy. Chronic hypoxemia may result in

restricted fetal growth. Fixed pulmonary vascular resistance may not allow for normal adaptation

to pregnancy. pregnancy-associated decrease in SVR may exacerbate right-to-left shunting.

Arterial monitoring should be used, but central/PA would be relatively contraindicated,

hazardous and unlikely to offer useful information. Oxygen should be continuously

administered. If responsive to pulmonary vasodilation, nitric oxide or prostacyclin may be

administered. Concerns for regional vs. general are similar to those discussed in the previous

case (aortic stenosis). Thromboembolic prophylaxis would likely be used, and this may

complicate regional techniques. Pulmonary or systemic embolism is the leading cause of

maternal mortality in pregnancy patients with Eisenmenger's syndrome. Life-threatening

pulmonary hemorrhage from excessive pulmonary tree pressures is often a terminal event.

79

REFERENCES

Ramsey PS, Ramm KD, Ramm SM. Cardiac disease in pregnancy. Am JPerinatol 2001, 18 245-66

Ramm KD, Ramm SM, Gilstrap LC ifi. Assessment of fetal well-being. In: Gall SA, ed.

Multiple pregnancy and delivery. Chicago, IL: Mosby-YearBook Inc., 1996:170-81.

Ramm SM, Ramm KD, Gilstrap LC. Anticoagulants and thrombolytics during pregnancy.Semin Perinatol 1997, 21:149-53. .

Manning FA, Morrison I, Harman CR, Lange IR, Menticoglou S. Fetal assessment based

on fetal biophysical profile scoring: experience in 19,221 referred high-risk pregnancies, 2.An analysis of false-negative fetal deaths. Am J Obstet Gynecol 1987, 157:880.

Manning FA, Platt LD, Sipos L. Antepartum fetal evaluation: development of a fetalbiophysical profile. Am J Obstet Gynecol 1980, 136:787. .

Cunningham FG, Gant NF, Leveno ¡U, Gilstrap LC ifi, Hauth JC. Cardiovasculardiseases. In: Seils A, Nougaim SR, Davis K, eds. Williams obstetriès, 21st ed. McGraw-Hill,2001:l181-207.

Whittemore R, Hobbins JC, Engle MA. Pregnancy and its outcome in women with and

Gei AF, Hankins GDV. Cardiac disease and pregnancy. Obstet Gynecol Clin North Am

2001, 28 465-5 12

Clark SL. Cardiac disease. In: Clark SL, Cotton DD, Hankins GDV, Phelan JF, eds.

Critical care obstetrics, 3' edition. Malden, Massachusetts: Blackwell Science, 1997:290-313.

Kerr MG. Cardiovascular dynamics in pregnancy and labor. Br Med Bull 1968, 24:19-24.

Robson SC, Dunlop W, Boys RI, Hunter S. Cardiac output during labor. Br Med J 1987,

295:1169-72.

Kjeldsen J. Hemodynamic investigations during labor and delivery. Acta Obstet Gynecol

Scand 1979, 89:10-252.

Whittemore R, Hobbins JC, Eagle MA. Pregnancy and its oùtcome in women with andwithout surgical treatment of congenital heart disease. Am J Cardiol 1982, 50:641-51.

Mortenson JD, Ellsworth HS. Pregnancy before and after surgical correction of left-to-right cardiovascular shunts. Obstet Gynecol 1967, 29:241.

Ducey JP, Ellsworth SM. The hemodynamic effects of severe mitral stenosis andpulmonary hypertension during labor and delivery. Intensive Care Med 1989, 15:192-5.

Fuster V, Steele PM, Edwards WD, Gersh BJ, McGoon MD, Frye RL. Primary pulmonaryhypertension: natural history and the importance of thrombosis. Circulation 1984, 70:580-

7.

Smedstad KG, Cramb R, Morison DH. Pulmonary hypertension and pregnancy: a series

of eight cases. Can J Anaesth 1994,41:502-12.

Tahir H. Pulmonary hypertension, cardiac disease and pregnancy. mt J Gynecol Obstet

1995, 5 1:109-13.

80

Sinnenberg RI. Pulmonary hypertension in pregnancy. South Med J 1980, 73:1529.

Midwall J, Jaffin H, Herman MV, Kupersmith J. Shunt flow and pulmonaryhemodynamics during labor and delivery in the Eisenmenger's syndrome. Am J Cardiol1978, 42:299-303.

McCaffrey RM, Dunn LI. Primary pulmonary hypertension in'pregnancy Obstet GynecolSurv 1964, 19:567-91.

Hoeper MM, Schwarze M, Ehierding S, Adler-Schuermeyer A, Spiekerkoetter E,Niedermeyer J, Hamm M, Fabel H. Long-term treatment of primary, pulmonaryhypertnsion with aerosolized iloprost, a prostacyclin analogue. N Engi J Med 2000,342:1866-70.

Easterling TR, Ralph DD, Schmucker BC. Pulmonary hypertensión in pregnancy:treatment with pulmonary vasodilators. Obstet Gynecol 1999, 93:494-8.

Lust KM, Boots RJ, Dooris M, Wilson J. Management of labor in Eisenmenger syndromewith inhaled nitric oxide. Am J Obstet Gynecol 1999, 18 1:419-23.

Goodwin TM, Gherman RB, Hameed A, Elkayam U. Favorable response of Eisenmengersyndrome to inhaled nitric oxide during pregnancy. Am J Obstet Gynecol 1999, 180:64-7.

Gleicher N, Midwell J, Hochberger D, Jaffin H. Eisenmenger's syndrome, and pregnancy.Obstet Gynecol Surv 1979, 34:721-41. '

Lieber S, Dewilde PH, Huyghens L, Traey E, Gepts E. Eisenmenger's syndrome andpregnancy. Acta Cardiol 1986, 40:421-4.

Yentis SM, Steer PJ, Plaat F. Eiseñmenger's syndrome in pregnancy: maternal and fetalmortality in the 1990's. Br J Obstet Gynaecol 1988, 105:921-2. '

81

'1

Case III


A 24-year-old woman referred at 12 weeks of pregnancy. She had a known history of Holt-Oramsyndrome, secundum ASD closed at 7 years of age. She was found to be in atrial flutter whilepregnant, duration unknown. On examination: Overweight, functional class 2, JVP. normal, pulse75 BPM, apical systolic murmur of mitral regurgitation.

Echocardiogram: Enlarged LV, EF=50%, moderate tricuspid and mild-to-moderate mitralregurgitation.

Next steps in her medical management.Options:

Leave in atrial flutterAnticoagulationDC cardioversionPharmacological CardioversionOptimization of Cardiac function

OBSTETRIC MANAGEMENT (Dr Ramm)

Genetic CounselingA. Holt-Oram Syndrome

1. "Atriodigital dysplasia," "cardiac-limb," "hand-heart"Congenital heart defect (secundum ASD)Upper extremity defects

(1) PolydactylySyndactylyRadial defects (including thumb)

2. Autosomal dominanta. High degree penetrance

3. Antiepileptic medicationsH. Arrhythmia

A. CardioversionElectrocardioversiona. Little risk to fetusPharmacologic - antiarrhythmics

Risk drug dependentInterferes directly with depolarization

Lidocaine - may cause uterine artery spasmProcainamide - chronic use lupus-like syndromeEncainide - no human studiesFlecainide - no human studiesTocainide - no human studiesDisopyramide - embryotoxic lab animals/uterine contractions

82

Mexiletine - no human studiesQuinidine - probably safe; no well-controlled trials

c Antisympathetic effects(1) Propranolol - intrauterine growth-retardation, bradycardia, apnea, andrespiratory depression, hypoglycemia

d Markedly prolonged duration of action potentialBretylium - no human studiesAmiodarone - no human studies/possible fetal cretinism

Blockade of slow inward (calcium-sodium channel) depolarization current(1) Verapamil - may affect uterine blood flowCardiac glycosides - many years of use, no reported adverse fetal effects orteratogenicity

B. AnticoagulationCoumadina. Crosses placenta

- b. Warfarin syndrome - - -

Heparin -

a. Fetal safetyb. Osteoporosisc. Thrombocytopenia

III. Pregnancy management - -

- A. Fetal surveillance -

B. Labor and delivery - - -

Regional analgesiaAnticoagulationForceps delivery

ANESTHESIA MANAGEMENT: (Dr. Camann) -

Anesthetic management for cardioversion:Sedation using propofol until loss of eyelid reflex, usually not more than 75-100 mg. Oralantacid prophylaxis, but not metoclopramide, as this may exacerbate tachycardia. No opioids, as

post-procedure emesis may be induced. My preference is to avoid airway instrumentation, even

in later stages of pregnancy, as induction of GA and endotracheal intubation is likely to beassociated with more problems than a brief sedative with GIprophylaxis in an appropriately

fasted patient.

83

REFERENCES:

Ramsey PS, Ramm KD, Ramm SM. Cardiac disease in pregnancy. Am J Perinatol 2001,

18:245-66.

Magalini SI, Magalini SC, de Francisci G. Holt-Oram. In: Dictionary ofmedical

syndromes, Yd edition. Philadelphia, PA: J. B. Lippincott Company, 1990:420.

cunningham FG, Gant NF, Leveno KJ, Gilstrap LC ifi, Hauth JC. Cardiovasculardiseases. In: Seils A, Nougaim SR, Davis K, eds. Williams obstetrics,

215t ed. McGraw-Hill, 2001:1181-207.

Gilstrap LC ifi, Little BB. Cardiovascular'drugs during pregnancy. In: Drugs andpregnancy. New York, NY: Elsevier Science Publishing Co, Inc., 1992:69-91.

Gei AF, Hankins GDV. Cardiac disease and pregnancy. Obstet Gynecol Clin North Am

2001,28:465-512.

Clark SL. Cardiac disease. In: Clark SL, Cotton DD, Hankins GDV, Phelan JF, eds.

Critical care obstetrics, 3rd edition. Maiden, Massachusetts: Blackwell Science, 1997:290-

313.

Brown CEL, Wendel GD. Cardiac arrhythmias during pregnancy. Çlin Obstet Gynecol

1989, 32:89-102.

Schroeder JS, Harrison DC. Repeated cardioversion during pregnancy. Treatment ofrefractory paroxysmal atrial tachycardia during three successive pregnancies. Am J

Cardiol 1971, 27:445.

Rotmensch HH, Rotmensch S, Eikayam U. Management of cardiac dysrhythmia during

pregnancy: Current concepts. Drugs 1987, 33:623-33.

Jaffe R, Gruber A, Fejgin M, et al. Pregnancy with an artificial pacemaker. Obstet

Gynecol Surv 1987,42:137-9.

ASA Presidential Address

Barry Glazer, MD

1O:OO-11:OOam

NOTES:

85

Debate No. 2

Failed Epiduralfor Urgent C/S.' Spinal isPreferable to GeneralAnesthesia

Moderator: Andrew M. Malinow MDPro: David R. Gambling, MIBBS

Con: M. Joanne Douglas, MD, FRCPC

ll:OOam - 12:00 n

Supporting manuscripts will be available online after the meeting.

Following this debate, the participants will be able to compare and contrastthe risks and benefits of spinal versus general anesthesia when an epiduralcatheter has failed for an urgent cesarean delivery.

86

Poster Review #3

Moderator: Holly Muir, MD, FRCPC

11:30 am-12:3Opm

LOWER LIMB NEUROLOGICAL SEQUELAE AI1ER LABOR EPIDURAL ANALGESIA

pKaul, B.; Darwich, A.A.; Vallejo, M.C.; Ramanathan, S.; Mandel, G.L

-2 SPINAL ANESTHESIA FOR CESAREAN SECTION AFIER FAILED LABOR EPIDURAL ANALGESIA: RETRO-SPECTIVE ANALYSIS OF TWO DOSING REGIMENS

p3Vadher., R.B; Siswawala, EJ.; Portnoy, D.; Koutrouveis, A.P.RESEARCH: AN INNOVATIVE TOOL FOR INITIATING AN OBSTETRiC ANESTHESIA SERVICE

p Owen, M.D; Sahin, S.; Uckunkaya, N.DEVELOPING OUTCOMEMEASURES FOROBSTETRICANESTHESIA EDUCATIONOwen, M.D; Sabin, S.; Aypar, U.; James, R.NATIONAL IN-TRAINING EXAM TRENDS: BACK TO THE FUTURE OR FORWARD TO THE PAST

Glas senherg. R..COMBINED SPINAL-EPIDURAL WITH PATIENT-CONTROL EPIDURAL ANALGESIA FOR LABOR. QUALflYASSURANCE SURVEY FROM A UNIVERSITY HOSPITAL IN SWITZERLAND

P7 T 'andau; Giraud; KernESTABLISHING A HIGH RISK REGISTRY TO IMPROVE PATIENT CARE AND RESIDENT EDUCATION

Finegold, H. Ramanathan, S.HOW DO WE EDUCATE OUR PATIENTS ABOUT OBSTETRIC ANESTHESIA? (ANIMATED WEBSITE:-

çW.PAINFREEBIRTHING.COM)Kodali. B

O MEDICAL STUDENT EDUCATION IN OB ANESTHESIOLOGY: CONNECTING BASIC AND CLINICAL SCI-

ENCES IN A NEW MEDICAL SCHOOL CURRICULUMWissler,R.INITIAL FEEDBACK ON MOSES (MULTIDISCIPLINARY OBSTETRIC SIMULATED EMERGENCY SCENARIOS):

A COURSE ON TEAM TRAINING, HUMAN BEHAVIOUR AND 'FIRE DRILLS'

Davis, C; Gregg, A.; Thornley, D.; Razzaque, M.; Woods, M.; Ayida, G.; Sadler, C.2 COMBINED OBSTETRIC AND ANESTHESIAJOURNAL CLUB SERIES: A FORUM FOR COLLABORATION.

SHANKAR B KODAU, CAMANN WR, DEPARTMENT OF ANESTHESIA BRIGHAM AND WOMEN'S HOSPITAL,

HARVARD MEDICAL SCHOOL BOSTON, MA 02115

Camanri, W; KodaJi, B.IS THERE A RELATIONSHIP BETWEEN RESPONSE TIME FOR LABOR EPIDURAL AND PATIENT SATISFAC-

TION?

-i4Megally, M.; Joseph, N.J.; Salem, M.NITROGLYCERIN FORMANUAL REMOVALOF PLACENTA

Sahzposh, S.A; Sabzposh, N.A.; Sultana, K.REGIONAL ANESTHESIA USE IN PARTURIENTS WITH FACTOR V LEIDEN MUTATION

Walsh, MJ; Harnett, M.J.; Tsen, LC.

All Abstracts are. in the Anesthesiology Supplement.

87

Poster Review #3

P-89 IN VITRO IN VESTIGATION:DURAL TRAUMA PA'i .LERNS,CSF LEAK AND EPIDURAL NEEDLE PUNCTUREAngle, P,; Kronberg, J.; Thompson, D.

P-90 SODIUM NITROPRUSSIDE (SNP) INHIBITh HYPDXIC FETO-PLACENTAL VASOCONSTRICTION (HFPV) INDUAL PERFUSED, SINGLE ISOLATED HUMAN PLACENTAL COTYLEDONDowning. Ramasubramanian, it; Minzter, B.H.; Paschall, RL.; E, L.; Johnson, B.; Johnson, R.

P-91 SPINAL PROSTAGLANDINS MODULATE PAIN FROM UTERINE CERVICAL DISTENSIONTong. C,; Eisenach, J.C.

P-92 USE OF NIRS TO MONITOR PLACENTA TISSUE OXYGENATIONOlufolahi, A.; James, A.; Coates, E.; El-Moalem, H.; Reynolds,J.

P-93 EXTRACELLULAR REGULATED KINASE-MEDIATED PHOSPHORYLATION OF MYOMETRIAL CALDESMODURING PREGNANCYAND LABORJi. Y,; Malek, S.; Morgan, KG.

P-94 EPIDURAL BOLUS ADMINISTRATION AND CONTINUOUS EPIDURAL INFUSION F FENTANYL DIFFER 1THEIRMECHANISMOFACTIONGinosar. 1; Riley, E.T.; Angst , M.S.


88

Gerard W': Ostheimer: What's New in

Obstetric Anesthesia Lecture

David H. Wiody, MD

2:00 - 3:00 pm

Following this lecture, the participant will know the current obstetricanesthesia literature and its impact on anesthetic management of thepregnant woman.

89

'i

'I

Society for Obstetric Anesthesia and Perinatology

The Gerard W. Ostheimer Anesthesia Lecture:What's New in Obstetric Anesthesia?

David Wiody, M.D.Clinical Associate Professor of Anesthesia

Vice Chair for Clinical AffairsState University of New York

Downstate Medical Center

90

MethodsA hand search of the table of contents of the following anesthesia, OB-GYN, midwifery,and general medicine journals was performed:

Acta Anaesthesiologica BelgicaActa Anaesthesiologica ScandinavicaActa Obstetricia et Gynecologica ScandinavicaAANA JournalAmerican Journal of HypertensionAmerican Journal of Obstetrics and GynecologyAnaesthesiaAnaesthesia and Intensive CareDer AnaesthesistAnesthesia and AnalgesiaAnesthesiologyAnnales Francaises d'Anesthesie et de de ReanimationBirthBritish Journal of AnaesthesiaBritish Journal of Obstetrics and GynaecologyBritish Medical JournalCanadian Journal of AnaesthesiaChest

91

CirculationEuropean Journal of AnaesthesiologyEuropean Journal of Obstetrics & Gynecology

and Reproductive BiologyInternational Journal of Obstetric AnesthesiaJournal of the American Medical

AssociationJournal of Clinical AnesthesiaJournal of Human LactationJournal of Nurse Midwifery and Women's

HealthJournal of PediatricsThe LancetMiddle East Journal of AnaesthesiologyNew England Journal of MedicineObstetrics and GynecologyPediatricsRegional Anesthesia and Pain Medicine

In addition, PUBMED (http://www.pubmed.gov) and NLM Gateway(http://gateway.nlm.flih.gOV) searches were performed for a number of topics that were felt to

be pertinent to the practice of obstetric anesthesia, including coexisting diseases, medicolegal

and economic issues in obstetric anesthesia, and the effect of maternal analgesia on the

progress of labor and newborn behavior. A LEXIS-NEXIS search was also performed to

identify articles published in the popular press, in both the US and the UK, whichmight

affect the public's view' of obstetric anesthesia, for both good and ill.

This review defines "What's New in Obstetric Anesthesia" quite broadly. I have attempted

to identify all those papers published in 200 ithat deal specifically with the anesthetic

management of the pregnant patient. I have also chosen papers dealing with local anesthetic

pharmacology, spinal and epidural anesthesia, and postoperative pain management, which,

while not specifically dealing with obstetric anesthesia, are certainly applicable to the field.

A broad range of articles dealing with obstetric management issues (VBAC, labor induction,

preterm labor, obstetric complications) was selected. I have chosen a number of papers that

deal with the prevention of RDS, the mechanisms of newborn neurologic injury, and the

pathophysiology of meconium aspiration syndrome, even when they do not address

anesthetic management issùes. Finally, I have undoubtedly cited more articles about pre-

eclampsia than is absolutely necessary, but I am sure that many of you find this disorder as

fascinating as I do.

Alternative medicineCesarean sectionCoagulationCoexisting disease

CardiacEndocrineHematologicHepaticHIVNeoplasmNeurologicOrthopedicPsychiatric/substance abuseRenalRespiratory

Complications-anestheticAirwayAllergyCardiac arrestEquipmentHigh spinal

HypotensionInfectionLocal anesthetic neurotoxicityNeurologicSpinal headacheComplications-obstetricAbdominal pregnancyAmniotic fluid embolismHemorrhageHyperemesis gravidarumIncontinenceMaternal mortalityMultiple gestationPreterm labor-antenatal steroidsPreterm labor-Surveillance/tocolysisRetained placentaShiveringDebatesEconomics and staffingFetal monitoringLabor analgesia

Alternative techniquesEpidural techniques-ambulation

OutlineEpidural techniques-anatomyEpidural techniques-CSEAEpidural techniques-equipmentEpidural techniques-fetal effectsEpidural techniques-maternal satisfactionEpidural techniques-PCEAEpidural techniques-pharmacologyEpidural techniques-physiologyEpidural techniques-test doseIntrathecal techniques

Local anesthetic pharmacologyMass mediaMaternal fever and neonatal sepsis workupMedicolegal issues/medical ethicsNewborn

BehaviorBrachial plexus injuryCerebral palsyChorioamnionitisMeconium aspirationRespiratory distressResuscitation/evaluationNonobstetric surgeryObstetric management issuesBreech

- Induction of laborInstrumental deliveryIntrapartum care -

VBACPharmacologic/physiologic alterations of pregnancyPostoperative pain management

Adjuvant drugsComplicationsEpiduralIntrathecal

PreeclampsiaAnesthetic management

Blood pressure managementHELLPOutcomePathophysiologyPrediction/Prevention

Progress of laborEpidural anesthesiaRisk factors for cesarean section

92

Alternative medicine . .

Eàkert K, Turnbull D, MacLennan A. Immersion in water in the first stage of labor: a.randomized controlled trial. Birth 28:84-93, 2001.Women who bathed during the first stage of labor used analgesics as frequently as controls;their infants were more likely to require resuscitation. .

Factor-Litvak P, Cushman LF et al. Use of complementary and alternative medicineamong women in NYC. J Altern Complement Med 6:659-66, 2001.More than half of the women surveyed have used an alternative therapy.

Hodnett ED. Caregiver support for women during childbirth (Cochrane Review). In: TheCochrane Library, 1, 2002.Reduces need for analgesic interventions..

Kanakura Y, Kometani K et al. Moxibustion treatment of breech presentation. Am J ChinMed 29:37-45, 2001. .. . . .. .

In women with breech presentation noted at 28 weeks EGA, 92% who underwentmoxibustion therapy converted to vertex compared to 74% of controls.

Kavanaugh J, Kelly AJ, Thomas J. Sexual intercourse for cervical ripening and inductionof labor. (Cochrane Review). In: The Cochrane Library, 1, 2002.The investigators concluded that there was insufficient published evidence to support theefficacy of sexual intercourse for induction of labor. They surmise that it may prove dfficultto standardize sexual intercoursefor future studies.

Kavanaugh J, Kelly Ai, Thomas J. Breast stimulation for cervical ripening and inductionof labor (Cochrane Review). In: The Cochrane Library, 1, 2002.Breast stimulation reduced the number of patients not in labor at 72 hours compared with

women receiving no intervention; There were no signcant differences compared to anoxytocin group.

Knight B, Mudge C et al. Effect of acupuncture on nausea of pregnancy: a randomizedcontrolled trial. Obstet Gynecol 97:184-8, 2001.Acupuncture and sham acupuncture were equally as effective in reducing nausea in the first

trimester.

Ohlsson G, Buchhave P et al. Warm tub bathing during labor: maternal and neonatal

effects. Acta Obstet Gynecol Scand 80:311-314, 2001.

No djfference in the use ofepidural analgesia; unlike #1, no evidence of deleterious effect on

the newborn. .

93

Rayburn WF, Gonzalez CL et al. Effect of prenatally administered hypericum (St. John'swort) on growth and physical maturation of mouse offspring. Am J Obstet Gynecol 184:19 1-5,2001.

Rayburn WF, Gonzalez CL et al. Impact of hypericum (St. John's wort) given prenatallyon cognition of mice offspring. Neurotoxicol Teratol 23:629-37, 2001.Neither of these studies demonstrated any adverse effect on growth or development.

Simpson M, Parsons M et al. Raspberry leaf in pregnancy: its safety and efficacy in labor.J Midwifery Womens Health 46:51-9, 2001.While no adverse effects could be identified, neither did raspberry leaf have any signcanreffect on the duration of the first sta ge of labor.

Slotnick RN. Safe, successful nausea suppression in early pregnancy with P-6acustimulation. J Reprod Med 46:811-4, 2001.

Smith CA, Crowther CA. Acupuncture for induction of labor (Cochrane Review). In: TheCochrane Library, 1, 2002.None of the published trials of acupuncture met the inclusion requirements for this review.

Smith CA. Homeopathy for induction of labor (Cochrane Review). In: The CochraneLibrary, 1, 2002.

15.Stamp G, Kruzins G, Crowther C. Perineal massage in labor and prevention of perinealtrauma: randomized controlled trial. BMJ 322:1277-80,2001.There were no dWerences in the incidence of 1 and 2nd degree tears or episiotomies betweenthe massage and control groups.

Steele NM, French J et al. Effect of acupressure by Sea-Bands on nausea and vomiting ofpregnancy. J Obstet Gynecol Neonatal Nurs 30:61-70, 2001.

Tsui B, Dennehy CE, Tsourounis C. A survey of dietary supplement use during pregnancyat an academic medical center. Am J Obstet Gynecol 185:433-7, 2001.

Vutyavanich T, Kraisarin T, Ruangsri R. Ginger for nausea and vomiting in pregnancy.Obstet Gynecol 97:577-82, 2001.28/32 patients receiving ¡ gm ginger daily had improvement in nausea scores compared to10/35 controls.

Werntoft E, Dykes AK. Effect of acupressure on nausea and vomiting during pregnancy.J Reprod Med 46:835-9, 2001.

94

95

Cesarean section ,

Anderson L, Walker J. Rate of injection through Whitacre needles affects distribution ofspinal anaesthesia. Br J Anaesth 86:245-8, 2001 . . :

In patients undergoing GU surgery, injection ofbupivacaine 15 mg over ¡Os led to a morerapid onset (20 minutes vs 30 minutes) and more rapid recovery (180 minutes vs 270minutes) compared to injection over three minutes.

Bagratee JS, Moodley J et al. A randomized controlled trial of antibiotic prophylaxis in

elective caesarean delivery. Br J Obstet Gynaecol 108:143-8, 2001.Cefoxitin prophylaxis had no effect on infectious morbidity. .

Chelmow D, Ruehli MS, Huang E. Prophylactic use of antibiotics for nonlaboringpatients undergoing cesarean delivery with intact membranes: a meta-analysis. Am J Obstet

Gynecol 184:656-61, 2001.Unlike #21, this meta-analysis showed signcant decreases in maternal fever and,endometritis, and a trend toward reduction in wound infections.

Chung C-J, Choi S-R et al. Hyperbaric spinal ropivacaine for cesarean delivery: a

comparison to hyperbaric bupivacaine. Anesth Analg 93:157-61,2001.18 mg 0.5% hyperbaric ropivacaine compared to 12 mg 0.5% hyperbaric bupivacaine; time to

complete recovery ofmotorfunction 159 minutes vs. 114 minutes.

Connolly C, Mci_cod GA, Wildsmith JAW. Spinal anaesthesia for caesarean section

with bupivacaine 5 mg ml in glucose 8 or 80 mg ml'. Anaesthesia 86:85-7, 2001.No djfference in onset time, dose of ephedrine required, or patient satisfaction. Medianblock was higher (2 dermatomes) in 8 mg mt' group for first 120 minutes.

Cotzias CS, Paterson-Brown S, Fisk NM. Obstetricians say yes to maternal request for

elective caesarean section: a survey of current opinion. Eur J Obstet Gynecol Reprod Biol

97:15-6, 2001.69% of obstetricians in the UK would peiform a cesarean section upon maternal request.

26.Han T-H, Brimacombe J et al. The LMA is effective (and probably safe) in selected

healthy parturients for elective cesarean section: a prospective study of 1067 cases. Can J

Anesth 48:1117-21, 2001.Effective, yes. Safe?-the jury is out. Would any of you electively use an LMAforCesarean section in the absence of a failed intubation?

Kapur D, Grimseh K. A comparison of CSF pressure and block height after spinal

anesthesia in the right and left lateral position. Eur J Anaesthesiol 18:668-672, 2001.

No dWerence.Khaw KS, Ngan Kee WD et al. Spinal ropivacaine for cesarean section. Anesthesiology

95:1346-50, 2001.ED50=16.7 mg, estimated ED95-26.8 mg

Lam DTC, Ngan Kee WD, Khaw KS. Extension of epidural blockade in labour foremergency caesarean section using 2% lidocaine with epinephrine and fentanyl, with orwithout alkalinization. Anaesthesia 56:790-4, 2001.Alkalinization decreased time to surgical anesthesia from 9.7 to 5.2 minutes.

Liu SS, McDonald SB. Current issues in spinal anesthesia. Anesthesiology 94:888-906,2001.Discusses ambulatory anesthesia, CSEA, TNS, spinal headache, anticoagulation.

McGurgan P, Coulter-Smith S, O'Donovan PJ. A national confidential survey ofobstetrician's personal preferences regarding mode of delivery. Eur J Obstet GynecolReprod Biol 97:17-19, 2001.

Moodley J, Jjuuko G, Rout C. Epidural compared with general anesthesia for cesareandelivery in conscious women with eclampsia. Br J Obstet Gynaecol 108:378-82, 2001.Epidural anesthesia was as safe as general anesthesia in "stable" patients.

Moran C, Ni Bhuinneain M et al. Myocardial ischaemia in normal patients undergoingelective cesarean section. Anaesthesia 56:1051-1058, 2001.

Patolia DS, Hilliard RLM et al. Early feeding after cesarean: randomized trial. ObstetGynecol 98:113-6,2001.Early feeding (regular diet <8 hrs postop) led to shorter hospital stays. When surgeryexceeded 40 minutes, ileus was more likely to develop.

Reid VC, Hartmann KE et al. Vaginal preparation with povidone iodine andpostcesarean infectious morbidity. Obstet Gynecol 97: 147-52, 2001.No effect on wound infection, fever, endometritis.

Russell 1F. Editorial: Assessing the block for cesarean section. mt J Obstet Anesth10:83-5,2001.Suggests that loss of touch sensation is more reliable than loss of pinprick or cold foridentifying adequate block.

Wright JB, Wright AL et al. A survey of trainee obstetricians' preferences for childbirth.Eur J Obstet Gynecol Reprod Biol 97:23-5, 2001.15% of trainees preferred elective cesarean delivery for themselves.

CoagulationBurrows RF, Gan ET et al. A randomized double-blind placebo controlled trial of

LMWH as prophylaxis in preventing venous thrombotic events after cesarean section: a pilotstudy. Br J Obstet Gynaecol 108:835-9, 2001.

Douglas MJ. Platelets, the parturient and regional anesthesia. Tnt J Obstet Anesth 10:113-120, 2001.

96

Harnett MJP, Datta S, Bhavani-Shankar K. The effect of magnesium on coagulation inparturients with preeclampsia Anesth Analg 92 1257-60, 2001No significant effect on overall coagulation function as measure by TEG

McDonagh RJ, Ray JG et al. Platelet count may predict abnormal bleeding time amongpregnant women with hypertension and preeclampsia; Can J Anesth 48:563-9, 2001.A platelet count <75,000 predicted prolonged bleeding time. But does itpredict abnormalbleeding '

Miller JM, Nolan TE. Case-control study of antenatal cocaine use and platelet levels.Am J Obstet Gynecol 184:434-7, 2001.Cocaine use identified by toxicology screen was not associated with thrombocytopenia

Obstetric Medicine Group of Australasia. Anticoagulation in pregnancy and thepuerperium. MJA 175:258-263, 200L

Vincelot A, Nathan N et al. Platelet function during pregnancy: an evaluation using thePFA-100 analyzer. Br J Anaesth 87:890-3, 2001.Platelet function may be preserved with levels as low as 60,000.

Wu CL. Regional anesthesia and anticoagulation. J Clin Anesth 13:49-58, 2001.A nice review, including detailed discùssion of timing of catheter removal.

Coexisting diseaseCARDIAC46 Ayhan A, Yucel A et al Feto-maternal morbidity and mortality after cardiac valvereplacement. Acta Obstet Gynecol Scand 80:713-8, 2001.Anticoagulation with either heparin or coumadin was well-tolerated by mother and fetus.

47 Brar HBK Anaesthetic management of a caesarean section in a patient with Marfan's

syndrome and aortic dissection Anaesth Intensive Care 29 67-70, 2001

Cole PJ, Cross MH, Dresner M. Incremental spinal anaesthesia for caesarean section in a

patient with Eisenmenger'S syndrome. Br J Anaes 86:723-6, 2001.

Hemodynamics monitored with CVP and transthoracic bioimpedance cardiography

Easterling TR, Carr DB et al. Treatment of hypertension in pregnancy: effect of atenolol

on maternal disease, preterm delivery, and fetal growth. Obstet Gynecol 98:427-33, 2001.

Maternal blood pressure was well-controlled, fetal growth was better maintained when

maternal hemodynamics were optimized.

97

Elkayam U, Tummala P. Maternal and fetal outcomes of subsequent pregnancies inwomen with peripartum cardiomyopathy. N Engi J Med 344:1567-71, 2001. See alsoReimold SC, Rutherford JD. Editorial: Peripartum cardiomyopathy. N Engi J Med344:1629-30,2001.During subsequent pregnancies, heart failure developed in 44% of those with persistent LVdysfunction after a previous episode of peripartum cardiomyopathy and, surprisingly, in21% of women with normalization of LVfunction by echo. Stress echocardiography may bea more sensitive method of evaluating women who have apparently recovered fromperipartum cardiomyopathy.

Ellison J, Thomson AJ et al. Use of enoxaparin in a pregnant woman with a mechanicalheart valve prosthesis. Br J Obstet Gynaecol 108:757-9, 2001.

Gei AF, Hankins GDV. Cardiac disease in pregnancy. Obstet Gynecol Clin North Am28(3):465-505, 2001.An extensive review.

Lam GK, Stafford RE. Inhaled nitric oxide for primary pulmonary hypertension inpregnancy. Obstet Gynecol 98:895-8, 2001.

Lasinka-Kowara M, Dudziak M. Two cases of postpartum cardiomyopathy initiallymisdiagnosed for pulmonary embolism. Can J Anesth 48:773-7,2001.Echocardiography established correct diagnosis.

Lee M-J, Huang A et al. Labor and vaginal delivery with maternal aortic aneurysm.Obstet Gynecol 98:935-8, 2001.Good outcome in a patient with a 4.5 cm aortic aneurysm unassociated with Marfan 's syndrome.LEA was used, 2nd stage was shortened with low forceps delivery.

Lind J, Wallenberg HCS. The Marfan syndrome and pregnancy: a retrospective study ina Dutch population. Eur J Obstet Gynecol Reprod Biol 98:28-35, 2001.Risk factors for poor outcomes included aortic diameter> 40 mm, progressive dilatation,and decreased cardiac function.

McCarroll CP, Paxton LD et al. Use of remifentanil in a patient with peripartumcardiomyopathy requiring caesarean section. Br J Anesth 86:135-8, 2001

McKechnie RS, Patel D et al. Spontaneous coronary artery dissection in a pregnantwoman. Obstet Gynecol 98:899-902, 2001.Successfully treated with ECMO and angioplasly followed by stent placement.

Monnery L, Nanson J, Charlton G. Primary pulmonary hypertension in pregnancy: a rolefor novel vasodilators. Br J Anaesth 87:295-8, 2001.

Nanson J, Elcock D et al. Do physiological changes in pregnancy change defibrillationenergy requirements? Br J Anaesth 87:237-9, 2001. =

No signcant change in transthoracic impedance at term.

Olofsson Ch, Bremme K et al. Cesarean section under epidural ropivacaine 0.75% in aparturient with severe pulmonary hypertension. Acta Anaesthesiol Scand 45:258-60, 2001.

Penning S, Robinson KD et al. A comparison of echocardiography and PAcatheterization for evaluation of PA pressures in pregnant patients with suspected pulmonaryhypertension. Am J Obstet Gynecol 184:1568-70, 2001.32% of patients estimated to have pulmonary hypertension by echocardiography had normalPA pressures when catheterized.

Penning S, Thomas N et al. Cardiopulmonary bypass support for emergency cesareandelivery in a patient with severe pulmonary hypertension. Am J Obstet Gynecol 184:225-6,2001.

Ramsey PS, Ramm KD, Ramm SM. Cardiac disease in pregnancy. Am J Perinatol18:245-65, 2001.

Roberts N, Ross D et al. Thromboembolism in pregnant women with mechanicalprosthetic heart valves anticoagulated with low molecular weight heparin. Br J ObstetGynaecol 108:327-9, 2001.LMWH may not be a suitable substitute for coumadin

Schabe! JE, Jasiewicz RC. Anesthetic management of a pregnant patient withcongenitally corrected transposition of the great arteries for labor and vaginal delivery. JClin Anesth 13:517-20, 2001.

Shnaider R, Ezri T et al. CSEA for cesarean section in a patient with peripartum dilatedcardiomyopathy. Can J Anesth 48:681-3, 2001.

Siu SC, Sermer M et al. Prospective multicenter study of pregnancy outcomes in women

with heart disease. Circulation 104:525-52 1, 2001.Survey of 562 women with a wide variety of cardiac disorders. 13% ofpregnancies werecomplicated by significant morbidity or mortality.

Stewart R, Tuazon D et al. Pregnancy and primary pulmonary hypertension: successful

outcome with epoprostenol therapy. Chest 119:973-5, 2001.

Suntharalingam G, Dob D, Yentis SM. Obstetric epidural analgesia in aortic stenosis: alow dose technique for labour and instrumental delivery. lin J Obstet Anesth 10:129-34,

2001.Good outcomes in five patients. Invasive monitoring was not used.

99

ENDOCRINE

ACOG Practice Bulletin. Clinical management guidelines for obstetrician-gynecologists:thyroid disease in pregnancy. Obstet Gynecol 98:879-88, 2001.

Lucas MJ. Diabetes complicating pregnancy. Obstet Gynecol Clin North Am 28(3):513-36, 200L

Mandel SJ, Cooper DS. The use of antithyroid drugs in pregnancy and lactation. J ClinEndocrinol Metab 86:2354-9, 2001.

Maresh M. Diabetes in pregnancy. Curr Opin Obstet Gynecol 13:103-7, 2001.

HEMATOLOGICEuliano TY. Cesarean section combined with splenectomy in a parturient with ITP. J

Clin Anesth 13:313-318, 2001.

Schmitt HJ, Becke K, Neihardt B. Epidural anesthesia for cesarean delivery in a patientwith polycythemia rubra vera and preeclampsia. Anesth Analg 92:1535-7, 2001.

Stoche RM, Garcia LV, Klamt JG. Labor analgesia in a patient with paroxysmal nocturnalhemoglobinuria with thrombocytopenia. Reg Anesth Pain Med 26:79-82, 2001.

HEPATIC

Goh S-K, Gull SE, Alexander GJM. Pregnancy in primary biliary cirrhosis complicatedby portal hypertension: report of a case and review of the literature. Br J Obstet Gynaecol108:760-2, 2001.

Holzman RS, Riley LE et al. Perioperative care of a patient with acute fatty liver ofpregnancy. Anesth Analg 92:1268-70, 2001.Patient required aggressive treatment of coagulopathy; article discusses overlap withHELLP syndrome.

HIV80 Ahdieh L Pregnancy and infection with human immunodeficiency virus Clin ObstetGynecol 44:154-66, 2001.

Ahmad H, Mehta NJ et al. Pneumocystis carinii pneumonia in pregnancy. Chest120:666-671, 2001.

i

Clinical course is more aggressive during pregnancy. PCPprophylaxis should not bewithheld from HI V-infected pregnant women in whom it is indicated.

Chen KT, Sell RL, Tuomala RE. Cost-effectiveness of elective cesarean delivery inHIV-infected women. Obstet Gynecol 97:161-8, 2001.Elective cesarean section will not be cost-effecive jfantiretroviral therapy decreasesperinatal transmission by 50%

Rodriquez EJ, Spann C et al. Postoperative morbidity associated with cesarean deliveryamong HIV-seropositive women. Am J Obstet Gynecol 184:1108-11, 2001.No increase in major postoperative complications compared to age-matched controls.

Scarrow SE. Obstetrical delivery of the HIV-positive woman: legal and ethicalconsiderations. Obstet Gynecol Surv 56:178-83, 2001.Asserts need to respect a woman 's wishes f she declines antiretrovirals or elective C/S.

NEOPLASMBullough AS, Karadia S, Watters M. Phaeochromocytoma: an unusual cause of

hypertension in pregnancy. Anaesthesia 56:43-6, 2001.Severe hypertension developed after C/S. A rare etiology that must always be ruled out.

Crosby E. Clinical case discussion: anesthesia for cesarean section in a parturient with alarge intrathoracic tumour. Can J Anesth 48:575-83, 2001.

Chan YK. Anesthetic management of a parturient with superior vena cava obstruction'for cesarean section. Anesthesiology 94:167-9, 2001.A successful epidural anesthetic was administered; a cardiac surgeon wasprepared toinitiate fern-fern bypass should cardiopulmonary collapse occur.

NEUROLOGICBeni-Adani L, Pomeranz S et al. Huge acoustic neurinomas presenting in the late stage

of pregnancy. Acta Obstet Gynecol Scand 80:179-84, 2001.In this slowly-growing tumor, surgery was delayed until one week post-cesarean section. VPshunting made this delay acceptable.

Boker A, Ong BY. Anesthesia for cesarean section and posterior fossa craniotomy in apatieñt with von Hippel-Lindau disease. Can J Anesth 48:387-90, 2001.General anesthesia was indicated due to symptomatic intracranial hypertension andsignificant local mass effects in the posterior fossa.

Brown MD, Levi ADO. Surgery for lumbar disc herniation during pregnancy. Spine

26 440-3, 2001Three cases with severe preop neurologic deficits, successfully treated surgically, two

peiformed under LEA.

Daskalakis GJ Katsetos CN et al. Syringomyelia and pregnancy-case report. Eur JObstet Gynecol Reprod Bio! 97:98-100, 2001.Cesarean section was elected to avoid straining in the second stage; general anesthesia was

administered to avoid changes in CSF dynamics.

Demiraran Y, Ozgön M et al. Epidural anaesthesia for cesarean section in a patient with

von Hippel-Lindau disease. Eur J Anaesthesiol 18:330-332, 2001.

Engrand N, Van de Pene P et al. Intratheca! baclofen for severe tetanus in a pregnant

woman. Eur J Anaesthesiol 18:26 1-3, 2001.

Gençosmanoglu BE, Hand M et al. Case report: spinal cord injury caused by gunshotwound during pregnancy. J Spinal Cord Med 24:123-6, 2001.Epidural analgesia during labor prevented autonomic hyperrefixia.

Holmes LB, Harvey EA et al. The teratogenicity of anticonvulsant drugs. N Eng! J Med344:1132-8, 2001.Birth defects were secondary to drug treatment, not epilepsy itself

Murayama K, Mamiya K et al. Cesarean section in a patient with syringomyelia. Can JAnesth 48:474-7, 2001

Penney DJ, Smailman JMB. Arnold-Chiari malformation and pregnancy. mt J ObstetAnesth 10:139-41, 2001.Durai puncture may lead to neurologic deterioration.

Piotin M, de Sousa Fiiho CBA et al. Endovascular treatment of acutely rupturedintracranial aneurysms in pregnancy. Am J Obstet Gynecol 185:1261-2, 2001.In selected patients in experienced centers, a viable alternative to surgery..

Roberts LI, Goucke CR. Retro-orbital tumour: an uncommon cause of headache inpregnancy. Anaesth Intensive Care 29:276-80, 2001.This patient required large doses of morphine (150 mg t.i.d.) for pain control due to her.desire to avoid surgery or radiotherapy during pregnancy.

Schabel JE. Subarachnoid block for a patient with progressive chronic inflammatorydemyelinating polyneuropathy. Anesth Anaig 93:1304-6, 2001.First reported case of regional anesthesia.

Van Calenbergh SGK, Poppe WAJ, Van Calenbergh F. An intracranial tumour: anuncommon cause of hyperemesis in pregnancy. Eur J Obstet Gynecol Reprod Bio! 95:182-3,

2001.

Vassiliev DV, Nystrom EUM et al. Combined spinal and epidural anesthesia for labor.and cesarean delivery in a patient with Guillain-Barre syndrome. Reg Anesth Pain Med.26:174-6, 2001.This patient with resolving Guillain-Barre syndrome underwent cesarean section underepidural anesthesia. There was no evidence of unusual drug sensitivity.

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ORTHOPEDICMeger GR, Majewski WT, Lyle WG. Free tissue transfer in pregnancy: guidelines for

perioperative managemenL Microsurgery 21:202-207, 2001.

Michel TC, Rosenberg AL, Poiley LS. Obstetric anesthetic management of a parturientwith Larsen syndrome and short stature. Anesth Anaig 92: 1266-7, 2001.Cesarean section peifonned under epidural anesthesia in a 130 cm pczrturient. T3 level wasobtained with 15 ml 2% lidocaine.

PSYCHIATRIC/SUBSTANCE ABUSEBirnbach DJ, Browne 1M et al. Identification of polysubstance abuse in the parturient.

Br J Anaesth 87:488-90, 2001.Confirmation of reliability of the TesTcup system. 52% of unregistered parturients testedpositive for cocaine.

Franko DL, Biais MA et al. Pregnancy complications and neonatal outcomes in womenwith eating disorders. Am J Psychiatry 158:1461-6, 2001.Women with symptomatic eating disorders during pregnancy were more likely to deliver bycesarean section and suffer postpartum depression.

Lester BM, El Sohly M et al. The maternal lifestyle study: drug use by meconiumtoxicology and maternal self-report. Pediatrics 107:309-3 17, 2001.

Rabheru K. The use of electroconvulsive therapy in special patient populations. Can J

Psychiatry 46:710-9, 2001.Suggests that ECT should be considered as afirst-line therapy for depression duringpregnancy due to the potential teratogenic effects of psychotropic drugs.

RENALDavison iM. Renal disorders in pregnancy. Cuff Opin Obstet Gynecol 13:109-1 14,

2001.An extensive review, including normal renal physiology, pregnancy in chronic renal diseaseand in dialysis patients, and in patients with a renal allo graft.

Lindheimer MD, Davison JM, Katz AI. The kidney and hypertension in pregnancy:twenty exciting years. Semin Nephrol 21:173-89, 2001.An extensive discussion of chronic renal disease and the renal effects of preeclampsia.

Sanders CL, Lucas MJ. Renal disease in pregnancy. Obstet Gynecol Clin North Am

28(3):593-600, 2001.

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RESPIRATORYCatanzarite V, Wilims D et al. Acute respiratory distress syndrome in pregnancy and

the puerperium: causes, courses, and outcomes. Obstet Gynecol 97:760-4, 2001.Leading causes: infection, preeclampsia, aspiration. Maternal mortality was 39%. Onethird of cases were felt to be preventable. O

Dietrich CL, Smith CE. Anesthesia for cesarean delivery in a patient with anundiagnosed traumatic diaphragmatic hernia. Anesthesiology 95:1028-3 1, 2001.

Gershon AS, Faughnan ME. Transcatheter embolotherapy of maternal pulmonary;arteriovenous malformations during pregnancy. Chest 119:470-7, 2001.Seven patients with worsening symptomatic pulmonary AVMs underwent successfulembolotherapy

Liu S, Wen SW et al. Maternal asthma and pregnancy outcomes: a retrospective cohortstudy. Am J Obstet Gynecol 184:90-6, 2001.Maternal asthma was significantly assòciated with preterm birth, SGA infants, pretermlabo r, preeclampsia, and cesarean section.

MandaI NG, White N, Wee MYK. Carbon monoxide poisoning in a parturient and theuse of hyperbaric oxygen for treatment. mt J Obstet Anesth 10:71-4, 2001.Maternal symptoms and non-reassuring fetal heart rate resolved with hyperbaric oxygentherapy.

Ratner EF, Cohen SE et al. Mask induction with sevoflurane in a parturient with severetracheal stenosis. Anesthesiology 95:553-5, 2001.

Wendel PJ. Asthma in pregnancy. Obstet Gynecol Clin North Am 28(3):537-51, 2001.

Complications-anestheticAIRWAY

Ezri T, Szmuk et al. Difficult airway in obstetric anesthesia: a review. Obstet GynecolSurv 56:631-41, 2001.A comprehensive review written for obstetricians, but a valuable resource foranesthesiologists as well. O

Ng A, Smith G. Gastroesophageal reflux and aspiration of gastric contents in anestheticpractice. Anesth Anaig 93:494-5 13, 2001.An extensive review of the anatomy and physiology of the LES, npo status, and the risks ofaspiration with some of the newer airway devices.

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ALLERGYBrowne IM, Birnbach DJ. A pregnant woman with previous anaphylactic reaction to

local anesthetics: a case report. Am J Obstet Gynecol 185:1253-4, 2001.Local anesthetic allergies are best evaluated prior to pregnancy; this patient underwentuncomplicated skin testing at 29 weeks EGA.

Eckhout GV, Ayad S. Anaphylaxis due to airborne exposure to latex in aprimigravida.

Anesthesiology 95:1034-5, 2001.

Stannard L, Bellis A. Maternal anaphylactic reaction to a general anaesthetic atemergency caesarean section for fetal bradycardia. Br J Obstet Gynaecol 108:539-40, 2001.Patient was later found to be allergic to atracurium and succinylcholine. Promptresuscitation was lifesaving.

CARDIAC ARRESTKinsella SM, Tuckey JP. Perioperative bradycardia and asystole: relationship to

vasovagal syncope and the Bezold-Jarisch reflex. Br J Anaesth 86:859-68, 2001.Once again, reinforces the necessity of aggressive treatment, including early use of

epinephrine.

Krismer AC, Hogan QH et al. The efficacy of epinephrine or vasopressin forresuscitation during epidural anesthesia. Anesth Analg 93:734-42, 2001.Response to a single dose ofvasopressin was more prolonged and acidosis after multiple

doses was less than after epinephrine.

Pollard JB. Cardiac arrest during spinal anesthesia: common mechanisms and strategies

for prevention. Anesth Analg92:252-6, 2001.Discounts the role of a respiratory etiology, in these cases. Physiologic changes of

pregnäncy may protect against cardiac arrest..

EQUIPMENTAsai T, Yamamoto K et al. Breakage of epidural catheters: a comparison of an Arrow

reinforced catheter and other nonreinforced catheters. Anesth Analg 92:246-8, 2001.

In vitro study suggesting that reinforced catheters may be more prone to breakage.

Burns SM, Cowan CM et al. Intrapartum epidural catheter migration: a comparative

study of three dressing applications. Br J Anaes 86:565-7, 2001.

Nishio I, Sekiguchi M et al. Decreased tensile strength of an epidural catheter during its

removal by grasping with a hemostat. Anesth Analg 93:210-2, 2001. .

Vallejo MC, Adler U et al.. Periosteal entrapment of an epidural catheter in the

intrathecal space. 'Anesth Analg 92:1532-4, 2001. , , .

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HIGH SPINAL131.Kar GS, Jenkins JG. High spinal anesthesia: two cases encountered in a survey of81,322 obstetric epidurals. mt j Obstet Anesth 10:189-91, 2001. See also Yentis SM, DobDP. Editorial: High regional block-the failed intubation of the new millennium? mt j ObstetAnesth 10:159-61, 2001.Although the incidence of high regional block is lower than failed intubation, the absolutenumber of such high blocks is likely to increase as the administration of regional anesthesiabecomes more frequent. The editorial provides a detailed protocolfor the management ofhigh block.

Shaw IC, Birks RJS. A case of extensive block with the combined spinal-epiduraltechnique during labor. Anaesthesia 56:346-9,2001.Etiology was unclear: subarachnoid or subdural.

HYPOTENSIONAyorinde BT Buczkowski Pet al. Evaluation of pre-emptive intramuscular

phenylephrine and ephedrine for reduction of spinal anaesthesia-induced hypotension duringcaesarean section. Br J Anaesth 86:372-6, 2001.Phenylephrine 4 mg and ephedrine 45 mg significantly reduced incidence of hypotension(33% and 48 % incidence, respectively) compared to controls (70%).

Burns SM, Cowan CM, Wilkes RG. Prevention and management of hypotension duringspinal anaesthesia for elective caesarean section: a survey of practice. Anaesthesia 56:794-8,2001.Survey of UK practice.

Emmett RS, Cyna AM et al. Techniques for preventing hypotension during spinalanaesthesia for caesarean (Cochrane Review). In: The Cochrane Library, 1, 2002.No intervention was found to eliminate the need to treat hypotension during SAB. Effectivemethods of reducing hypotension were crystalloid 20 mI/kg, colloid vs crystalloid,prophylactic ephedrine, and lower limb compression.

Ewaldsson C-A, Hahn RG. Volume kinetics of Ringer's solution during induction ofspinal and general anaesthesia. Br J Anaes 87:406-14, 2001.In a non-obstetric population, volume kinetic analysis suggested 350 ml crystalloidadministered over 2 minutes immediately prior to anesthetic induction could preventhypotension.

Frölich MA. Role of the atrial natriuretic factor in obstetric spinal hypotension.Anesthesiology 95:37 1-6, 2001.

Mercier FJ, Riley ET et al. Phenylephrine added to prophylactic ephedrine infusionduring spinal anesthesia for elective cesarean section. Anesthesiology 95:668-74, 2001.Addition of phenylephrine decreased the incidence of hypotension by 50%. UA pH valueswere signcantly higher.

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Morgan PJ, Halpern SH, Tarshis J. The effects of an increase of central blood volumebefore spinal anesthesia for cesarean delivery: a qualitative systematic review. Anesth Anaig92:997-1005,2001.

Ngan Kee WD, Khaw KS et al. Metaraminol infusion for maintenance of arterial bloodpressure during spinal anesthesia for cesarean delivery: the effect of a crystalloid bolus.Anesth Anaig 93:703-8, 2001.Crystalloid preload had no additional benefit in patients receiving a metaraminol infusion tomaintain BP.

Ngan Kee WD, Khaw KS et al. Randomized controlled study of colloid preload beforespinal anesthesia for caesarean section. Br J Anesth 87:772-4, 2001.

Ngan Kee WD, Lau TK et ai. Comparison of metaraminol and ephedrine infusions formaintaining arterial pressure during spinal anesthesia for elective cesarean section.Anesthesiology 95:307-13, 2001.Metaraminol improved pH values and more closely maintained BP in target range.

142a.Picker O, Schindler AW, Scheeren TWL. Endogenous endothelin and vasopressinsupport blood pressure during epidural anesthesia in conscious dogs. Anesth Analg 93:1580-6, 2001.

Simon L, Provenchère S et ai. Dose of prophylactic intravenous ephedrine during spinalanesthesia for cesarean section. J Clin Anesth 13:366-9, 2001.

INFECTIONDawson S. Epidural catheter infections. J Hosp Infect 47:3-8, 2001.

Kinirons B, Mimoz O et aL Chlorhexidine versus povidone iodine in preventingcolonization of continuous epidural catheters in children. Anesthesiology 94:239-44, 2001.Chlorhexidine more effectively reduced catheter colonization.

Mann TJ, Ori ikowski CE et al. The effect of the biopatch, a chiorhexidine impregnated

dressing, on bacterial colonization of epidural catheter exit sites. Anaesth Intensive care

29:600-3, 2001.Bacterial colonization at exit site: 40% controls, 3.4% biopatch.

Tsen LC. Letter to the editor: the mask avenger. Anesth Anaig 92:279,2001. See also

Browne IM, Birnbach DJ. Letter to the editor: unmasked mischief. 92:279-80, 2001 and

Dolinski SY. Reply. 92:280-1, 2001.

Are masks necessary during neuraxial anesthetic placement?

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LOCAL ANESTHETIC NEUROTOXICITYAouad MT, Siddik SS et al. Does pregnancy protect against intrathecal lidocaine-

induced transient neurologic symptoms? Anesth Analg 92:401-4, 2001.The incidence of TNS was zero percent in 200 women undergoing C/S. Authors concludethat the true frequency of TNS does not exceed 3% in parturients.

Hashimoto K, Hampl KF et al. Epinephrine increases the neurotoxic potential ofintrathecally administered lidocaine in the rat. Anesthesiology 94:876-8 1, 2001.

Oka S, Matsumoto M et al. The addition of epinephrine to tetracaine injectedintrathecally sustains an increase in glutamate concentrations in the CSF and worsensneuronal injury. Anesth Analg 93:1050-7, 2001.These two studies support the hypothesis that epinephrine increases the toxicity ofintrathecal local anesthetics. Is there any rationale for using this technique?

Philip J, Sharma SK. Transient neurologic symptoms after spinal anesthesia withlidocaine in obstetric patients. Anesth Anaig 92:405-9, 2001.3% incidence in 58 patients undergoing PPBTL.

Saito S, Radwan Jet al. Direct neurotoxicity of tetracaine on growth cones and neuntesof growing neurons in vitro. Anesthesiology 95:726-33, 2001.

Salazar F, Bogdanovich A et al. Transient neurologic symptoms after spinal anaesthesiausing isobaric 2% mepivacaine and isobaric 2% lidocaine. Acta Anaesthesiol Scand 45:240-5, 2001.

Schneider MC, Birnbach DJ. Editorial: Lidocaine neurotoxicity in the obstetric patient:is the water safe? Anesth Analg 92:287-90, 2001."We believe that, for the present, there is still insufficient safety evidence to suggest thatspinal hyperbaric 5% lidocaine be routinely used in obstetrics"

Truong HHL, Girard M et al. Spinal anesthesia: a comparison of procaine andlidocaine. Can J Anesth 48:470-3, 2001. See also Boucher C, Girard M. Intrathecalfentanyl does not modify the duration of spinal procaine block. Can J Anesth 48:466-9,2001.Procaine has been suggested to replace lidocaine for brief procedures. The incidence offailed blocks, however, is higher with procaine. Addition offentanyl does not appear to haveany benefit.

Winnie AP, Nader AM. Santayana's prophecy fulfilled. Reg Anesth Pain Med 26:558-64, 2001.A critique of the completely short sighted decision to manufacture a generic preparation ofchioroprocaine with a low pH and containing metabisulfite.

NEUROLOGICCrofts TR, Monagle J et al. Bilateral frontal haemorrhages associated with continuous

spinal analgesiá. Anaesth Intensive Care 29:51-3, 2001.

Eggert SM, Eggers KA. Subarachnoid haemorrhage following spinal anaesthesia in anobstetric.patient. Br J Anesth 86:442-4,2001.

Farrar D, Raoof N. Bell's palsy, childbirth and epidural analgesia; mt J Obstet Anesth10:68-70, 2001.Seventh nerve palsy is more common in pregnancy. The authors postulate a possible role forotherwise uncomplicated epidural analgesia in precipitating this disorder.

Joseph D, AñwariJS. CSF cutaneous fistula after labor epidural analgesia. Middle EastJ Anesthesiol 16:223-230, 2001.

Litz Rl, Hübler M et al. Spinal-epidural hematoma following epidural anesthesia in thepresence of antiplatelet and heparin therapy. Anesthesiology 95:1031-3, 2001.The combination of a borderline platelet count, LMWH, and ibuprofen undoubtedlypredisposed this 63 year old to the development of a neuraxial hematoma.

Reynolds F. Damage to the conus medullaris following spinal anaesthesia. Anaesthesia56:235-47,2001.Seven patients with conus medullaris damage, all of whom underwent durai puncture at whatwas thought to be the L2.3 interspace. Because of the difficulty of identifying spinalinterspaces accurately utilizing Tuffer's line, the author recommends avoiding punctureabove the L3 vertebra.

Rorarius MK, Suominen P et al. Neurologic sequelae after caesarean section. ActaAnaesthesiol Scand 45:34-41, 2001.Most neurologic symptoms resolved within 1-2 days.

Wang LP, Hauerberg J, Schmitt JF. Long-term outcome after neurosurgically treatedspinal epidural abscess following epidural analgesia. Acta Anaesthesiol Scand 45:233-9,

2001.Only 20%of patients with paresis secondary to epidural abscess had made a successful

recovery by discharge. 44% of survivors had persistent bowel or bladder dysfunction on

long term follow up.

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SPINAL HEADACHEBanks S, Paech M, Gurrin L. An audit of epidural blood patch after accidental durai

puncture with a Tuohy needle in obstetric patients. mt i Obstet Anesth 10: 172-6, 2001.81% of patients with an accidental durai puncture developed headache. In patients whoreceived a blood patch, 31% had recurrence of headache, and 28% required more than onepatch. Volume of blood used did not affect the success rate.

Boezaart AP. Effects of CSF loss and epidural blood patch on cerebral blood flow inswine. Reg Anesth Pain Med 26:401-6, 2001.CSF loss increased CBF; epidural blood patch restored it to normal.

Charsley MM, Abram SE. The injection of intrathecal normal saline reduces theseverity of postdural puncture headache. Reg Anesth Pain Med 26:30 1-5, 2001. See alsoBenzon HT, Wong CA. Editorial: Postdural puncture headache: mechanisms, treatment, andprevention. Reg Anesth Pain Med 26:293-295, 2001.Injection of 10 ml normal saline either through the Tuohy needle or an intrathecal catheterdecreased the headache rate from 62% to 32%.

Chisholm ME, Campbell DC. Postpartum postural headache due to superior sagittalsinus thrombosis mistaken for spontaneous intracranial hypotension. Can J Anesth 48:302-4,2001.Not all headaches are spinal.

Davies iM, Murphy A et al. Subdural haematoma after durai puncture headache treatedby epidural blood patch. Br J Anaesth 86:720-3, 2001.

Elbiaadi-Aziz N, Benzon HT et al. CSF leak treated by aspiration and epidural bloodpatch under CT guidance. Reg Anesth Pain Med 26:363-7, 2001.

Jeskins GD, Moore PAS et al. Long-term morbidity following durai puncture in anobstetric population. mt J Obstet Anesth 10:17-24,2001. See also Schneider MC. Editorial:Pleading not guilty for long-term maternal morbidity following durai puncture. mt J ObstetAnesth 10:1-3, 2001;This retrospective patient survey suggests a disturbingly high incidence of chronic headacheand backache after accidental durai puncture. The accompanying editorial presents a moresanguine view, commenting on the methodological shortcomings of the survey.

Landau R, Ciliberto CF et al. Complications with 25g and 27g Whitacre needles duringcombined spinal-epidural analgesia in labor. Tnt J Obstet Anesth 10:168-71, 2001.In patients undergoing CSEfor labor, the incidence of PDPH was 4% in the 25g group and0.7% in the 27g group.

Levine DN, Rapalino O. The pathophysiology of lumbar puncture headache. J NeurolSci 192:1-8, 2001.Postulates that altered lumbar epidural space compliance is the primary mechanism for

PDPH after lumbar puncture.

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Paech M, Banks S, Gurrin L. An audit of accidentai durai puncture during epiduralinsertion of a Tuohy needle in obstetric patients. mt j Obstet Anesth 10:162-7, 2001.Intraspinal opioid administration decreased headache; intrathecal catheterization did notdecrease headache but decreased EBP. -

Safa-Tisseront V, Thormann F et al. Effectiveness of epidural blood patch in themanagement of post-dural puncture headache. Anesthesiology 95:334-9,2001.Contrary to common belief EBP produced complete relief in only 75% of patients. Successrate was related to the size of the durai puncture.

Thoennissen J, Herker H et al. Does bed rest after cervical or lumbar puncture preventheadache? a systematic review and meta-analysis. CMAJ 165:1311-6, 2001.

Van de Veide M, Teunkens A et al. PDPH following spinal epidural or epiduralanaesthesia in obstetric patients. Anaesth Intensive Care 29:595-9, 2001.

Complications-obstetricABDOMINAL PREGNANCY

Carpenter T, Evans P, Wheeler T. An unusual mode of delivery. Br J Obstet Gynaecol

108:436-7, 2001.

Hughes S, Goodyear P, Sansome A. The anaesthetic management of a woman with a31-week abdominal pregnancy. mt J Obstet Anesth 10:321-4,2001.Preparation for massive hemorrhage is essential; leaving the placenta in situ minimizes

blood loss.

AMNIOTIC FLUID EMBOLISMAwad iT, Shorten GD. Amniotic fluid embolism and isolated coagulopathy: atypical

presentation of amniotic fluid embolism. Eur J Anaesthesiol 18:410-3, 2001.Hypoxemia and hypotension were absent; was it AFE?

Benson MD, Kobayashi H et al. Immunologic studies in presumed amniotic fluidembolism. Obstet Gynecol 97:510-4, 2001.Complement activation, not anaphylaxis, appears to be the mechanism.

Davies S. Amniotic fluid embolus: a review of the literature. Can J Anesth 48:88-98,

2001.

Farrar SC, Gherman RB. Tryptase analysis in a woman with amniotic fluid embolism: a

case report. J Reprod Med 46:926-8, 2001.Unlike #181, elevated tryptase levels suggest an anaphylactoid mechanism.

111

Kaneko Y, Ogihara et al. Continuous hemodiafiltration for DIC and shock due toamniotic fluid embolism. Intern Med 40:945-7,2001.

Pang ALY, Watts RW. AFE during caesarean section under spinal anaesthesia: issympathetic blockade a risk factor? Aust NZ J Obstet Gynaecol 4 1:342-3, 2001.Speculates that maternal vasodilatation predisposes to entry of amniotic fluid into thecirculation. - -

HEMORRHAGEAbdi S, Cameron IC et al. Spontaneous hepatic rupture and maternal death following an

uncomplicated pregnancy and delivery. Br J Obstet Gynaecol 108:431-3, 2001.:

Alexander J, Thomas P, Sanghera J. Treatments for secondary postpartum haemorrhage(Cochran Review). In: The Cochrane Library, 1, 2002There were no suitable studies dealing with hemorrhage between 24 hours and 12 weekspostpartum.

Bouvier-Colle M-H, El Joud DO et al. Evaluation of the quality of care for severeobstetrical haemorrhage in three French regions. Br J Obstet Gynaecol 108:898-903, 2001.Risks for substandard care: <500 deliveries/year, no 24 hour on-site anesthetist.

den Hertog CEC, de Groot ANJA, van Dongen PWJ. History and use of oxytocics. EurJ Obstet Gynecol Reprod Biol 94:8-12, 2001.

Elbourne Dr, Prendiville WJ et al. Prophylactic use of oxytocin in the third stage oflabor (Cochrane Review). In: The Cochrane Library, 1, 2002Less blood loss, more manual removals of placentas compared to controls.

Guid Oei S, Kho SN, ten Broeke EDM. Arterial balloon occlusion of the hypogastricarteries: a life-saving procedure for severe obstetric hemorrhage. Am J Obstet Gynecol185:1255-6, 2001.

Moon PF, Bliss SP et al. Fetal oxygen content is restored after maternal hemorrhageand fluid replacement with polymerized bovine hemoglobin, but not with hetastarch, inpregnant sheep. Anesth Analg 93: 142-50, 2001.

Munn MB, Owen J et al. Comparison of two oxytocin regimens to prevent uterineatony at cesarean delivery. Obstet Gynecol 98:386-90, 2001.80 U/500 ml infused over 30 minutes sign zfi cantly reduces the need for additional uterotdnicagents compared to JOU/500 ml.

Pandian Z, Wagaarachchi PT, Danelian PJ. An unusual cause of hypovolemic shock inthe postpartum period. Acta Obstet Gynecol Scand 80:871-2, 2001.Ruptured splenic artery aneurysm.

Ramsey PS, Meyer LM et al. Delayed postpartum hemorrhage: a rare presentation ofcarbon monoxide poisoning. Am J Obstet Gynecol 184:243-4, 2001.

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Singla AK,' Lapinski RH et al. Are women who are Jehovah's Witnesses at risk of,'maternal death? Am J Obstet Gynecol 185:893-5, 2001.,...44 times more likely to die from hemorrhage despite optimum presurgical preparation.Early hysterectomy may be lifesaving." . . '' ,

Tamzian O, Arulkumaran S. The surgical management of postpartum hemorrhage.Curr Opin Obstet Gynecol 13:127-3 1, 2001. ' ' ..

Yap OW, Kim ES, Laros RK. Maternal and neonatal outcomes after,uterine rupture in,.labor. Am J Obstet Gynecol 184:1576-81, 2001. . . .

"In an institution that has in-house obstetric, anesthesia and surgical staff uterine rupturedoes not result in major maternal morbidity or mortality or neonatal mortality."

HYPEREMESIS GRAVIDARUM . . .' .

Jewel! D, Young G. Interventions for nausea and vomiting in early pregnancy(Cochrane Review). In: The Cochrane Library, 1, 2002.' , .

Kölble N, Hummel T et al. Gustatory and olfactory function in the first trimester of,pregnancy. Eur J Obstet Gynecol Reprod Biol 99:179-83, 2001. .

Olfaction was unchanged; gustatory function was diminished. The authors hypothesize thatthis encourages nutrient intake.. . ' .

INCONTINENCE'Farrell SA, Allen VA, Baskett TF. Parturition and urinary incontinence in primiparas.

Obstet Gynecol 97:350-6, 2001.Cesarean protects against development of incontinence.: 'Forceps delivery increased risk ofincontinence by 1.5 compared with NSVD. '' :

MacArthur C, Glazener CMA et al. Obstetric practice and faeca! incontinence three,months after delivery. Br J Obstet Gynaecol 108:678-83, 2001.

Vacuum extraction unassociated with increased likelihood offecal incontinence;forcepsdelivery increased risk offecal incontinence by a factor of two.

MATERNAL MORTALITYHoron IL, Çheng D. Enhanced surveillance for pregnancy-associated mortality:

Maryland, 1993-1998. JAMA 285:1455-9,2001. . ' . , . .

In Maryland, a pregnant or recently pregnant woman is more likely to be the victim of a

homicide than to die of àny other cause. . ' . ' ,' ' . « «

Lydon-Rochelle M, Holt VL et al. Cesarean delivery and postpartum mortality among

primiparas in Washington state, 1987-96. Obstet Gynecol 97:169-74, 2001.

Cesarean delivery is a markerfor preexisting conditions that increase maternal mortality,

rather than being an independent riskfactorfor maternal death.

Panchal S, Arria A, Labhsetwar SA. Maternal mortality during hospital admission for

delivery: a retrospective analysis using a state-maintained database. Anesth Analg 93:134-

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41, 2001. See also Hawkins JL, Birnbach DJ. Editorial: Maternal mortality in the UnitedStates: where are we going and how will we, get there? Anesth Analg 93:1-3, 200LDetailed analysis from a single state. The editorialists comment on the shortcomings ofmaternal mortality data in the US compared with the Confidential Enquiries in the UK.

MULTIPLE GESTATION'Johansson BGA, Helgadottir EA. A case of locked twins successfully treated with

nitroglycerin sublingually before manual reposition and vaginal delivery. Acta ObstetGynecol Scand 80:275-6, 2001. '

Breech/vertex twins became locked at delivery. NTG saved the day, but common OB practicein the US is to electively section breech/vertex twins.

Marino TM, Goudas L et al. The anesthetic management of triplet cesarean delivery: aretrospective case series of maternal outcomes. Anesth Analg 93:991-5, 2001.

PRETERM LAB OR-ANTENATAL STEROIDS '

Bloom SL, Sheffield JS et al. Antenatal dexamethasone and decreased birth weight.Obstet Gynecol 97:485-90, 2001.Dexamethasone appears to impair fetal growth.

Canterino JC, Verma U et al. Antenatal steroids and neonatal periventricular.leukomalacia. Obstet Gynecol 97:135-9, 2001.Antenatal steroids significantly reduced the incidence of periventricular leukomalacia withand without intraventricular hemorrhage. '

Goldenberg RL, Wright LL. Clinical commentary: repeated courses of antenatalsteroids. Obstet Gynecol 97:316-7,2001.

Guinn DA, Atkinson MW. Single vs. weekly courses of antenatal corticosteroids forwomen at risk of preterm delivery. JAMA 286:1581-7, 2001.

NIH consensus development panel. Antenatal corticosteroids revisited: repeatedcourses. Obstet Gynecol 98:144-50.

Vermillion ST, Soper DE. Is betamethasone effective longer than 7 days aftertreatment? Obstet Gynecol 97:49 1-3, 2001.

Walfisch A, Hallak M, Mazor M. Multiple courses of antenatal steroids: risks andbenefits. Obstet Gynecol 98:491-7, 2001.#210-214 all suggest that there is insufficient evidence to support the routine administrationof repeated doses of antenatal corticosteroids outside the setting of a randomized controlledtrial.

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PRETERM LABOR-SURVEILLANCE AND TOCOLYSISThe European atosiban study group. The oxytocin antagonist atosiban versus the beta -

agonist terbutaline in the treatment of preterm labor. Acta Obstet Gynecol Scand 80:413-22,2001. -Atosiban is as effective, and has a better safety profile than terbutaline.

Kotani N, Kushikata T et al. Rebound perioperative hyperkalemia in sixpatients altercessation of ritodrine for premature labor. Anesth Anaig 93:709-11, 2001.Peak potassium levels ranged form 6.8-7.9 mmol/L.

Locatelli A, Vergani P et al. Can a cyclo-oxygenase type-2 selective tocolytic agentavoid the fetal side effects of indomethacin? Br J Obstet Gynaecol 108:325-6, 2001.The selective COX-2 inhibitor nimesulide has similar side effects as indomethacin.

Macones GA, Marder SJ et al. The controversy surrounding indomethacin for tocolysis.

Am J Obstet Gynecol 184:264-72, 2001.

Owen J, Yost N et al. Mid-trimester endovaginal sonography in women at high risk for

spontaneous preterm birth. JAMA 286:1340-8, 2001.

Papatsonis DNM, Lok CAR et al. Calcium channel blockers in the management ofpreterm labor and hypertension in pregnancy. EurJ Obstet Gynecol Reprod Biol 97:122-40,

2001.Compared with ß-adrenergic agents, nfedipine is associated with a more frequent successful

prolongation of pregnancy.

Rosen Ii, Zucker D et al. The great tocolytic debate: some pitfalls in the study of

safety. Am J Obstet Gynecol 184:1-7, 2001.Documents the methodological problems with many studies evaluating the safety of tocolytic

agents.

Sorenson HT, Czeizel AE et al. The risk of limb deficiencies and other congenitalabnormalities in children exposed in utero to calcium channel blockers. Acta Obstet Gynecol

Scand 80 397-401, 2001No evidence of increased birth defects.

The worldwide atosiban versus beta-agonists study group. Effectiveness and safety ofthe oxytocin antagonist atosiban versus beta-agonists in the treatment of preterm labor. Br J

Obstet Gynaecol 108:133-42, 2001.

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RETAINED PLACENTA

Caponas G. Glycerol trinitrate and acute uterine relaxation: á literature review.Anaésth Intense Care 29:163-77, 2001.D espite numerous case reports, there is scant evidence demonstrating the efficacy of.nitroglycerine to provide acute uterine relaxation.

Caroli G, Berger E. Umbilical vein injection for management of retained placenta(Cochrane Review). In: The Cochrane Library, 1, 2002.Safe and effective.

SHIVERINGRavid D, Gideon Y et al. Postpartum chills phenomenon: Is it a feto-maternal

transfusion reaction? Acta Obstet Gynecol Scand 80:149-5 1, 2001.Maternal-fetal blood group incompatibility is signflcantly more common among shiveringthan non-shivering parturients. . ;

Schwartzkopf KRG, Hoff H et al. A comparison between meperidine, clonidine, andurapidil in the treatment of postanesthetic shivering. Anesth Analg 92:257-60, 2001

Tsai Y-C, Chu K-S. A comparison of tramadol, amitryptiline, and meperidine forpostepidural anesthetic shivering in parturients. Anesth Analg 93:1288-92, 2001.Tramadol is as effective as meperidine and produces less somnolence.

DebatesThe use of CSEA for elective caesarean section is a waste of time and money.

Pro: KD Thomson. Con: M Paech. mt J Obstet Anesth 10:30-5, 2001.

Should nurses manage epidural or intrathecal analgesia/anesthesia by rebolusing oradjusting dosages of continuous infusions during labor and birth?Pro: JP McMichael. Con: KR Simpson. MCN Am J Matern Child Nurs 26:234-5, 2001.

Research on women in labour is ethically unsound.Pro: EL Horsman. Con: A Holdcroft. Tnt J Obstet Anesth 10:297-30 1, 2001.

Economics and staffingDexter F, Macario A. Optimal number of beds and occupancy to minimize staffing

costs in an obstetrical unit? Can J Anesth 48:295-301, 2001. See also Halpern S, Watson-MacDonell J. Editorial: Optimizing obstetrical suite staffing: it's more than mathematics.Can J Anesth 48:219-221, 2001.Provides a mathematical model for staffing based on the assumption that patient censusfollows a Poisson distribution. The editorial points out that this represents afirstapproximation that will of necessity be modified by local conditions.

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Leighton BL. Letter: To increase obstetric reimbursement rates, we need to improve theproduct. Anesthesiology 94:178, 2001. See also Reply: Bell E. Anesthesiology 94:179,2001.An exchange on the problem of diminishing thi rd party reimbursement for labor analgesia.Does LEA increase the cost of medical care through increased section rates, prolongedlabor, and neonatal sepsis workup?

Obst TE, Nauenberg E, Buck GM. Maternal health insurance coverage as a determinantof obstetrical anesthesia care. J Health Care Poor Underserved 12:177-91, 2001.Women in northern New York State were less likely to receive epidural analgesia if they wereinsured by Medicaid; Are anesthesiologists refusing to provide LEA to these patients, arethey admitted to hospitals that do not offer an epidural service, or are they less likely torequest LEA because of other factors?

Fetal monitoring .

Albers LL. Monitoring the fetus in labor: evidence to support the methods. JMidwifery Womens Health 46:366-73, 2001.Provides a rationale for the use of intermittent auscultation in selected low risk pregnancies.

Amer-Wahlin I, Hellsten C et al. Cardiotocography only versus cardiotocography plisST analysis of fetal electrocardiogram for intrapartum fetal monitoring. Lancet 358:534-8,2001.The addition of ST segment analysis significantly decreased the incidence offetal academiaand cesarean section for fetal distress.

Roberts D, Kumar B et al. Computerised antenatal fetal heart rate recordings between24 and 28 weeks of gestation. Br J Obstet Gynaecol 108:858-62, 2001.

Sheiner E, Hadar A et al. Clinical significance of fetal heart rate tracings during thesecond stage of labor. Obstet Gynecol 97:747-52, 2001.Late decelerations and FHR<70 in the second stage were associated with fetal acidemia.

Astrakhan BK, Sahota DS et al. Computerised analysis of the fetal heart rate andrelation to acidaemia at delivery. Br J Obstet Gynaecol 108:848-52, 2001.

Tan KH, Sabapathy A. Fetal manipulation for facilitating tests of fetal well being.(Cochrane Review). In: The Cochrane Library, 1, 2002.Published studies do not demonstrate that fetal manipulation reduces the incidence of non-reactive tracings. .

Thacker SB, Stroup D, Chang M. Continuous electronic heart rate monitoring for fetalassessment during labor (Cochrane Review). In: The Cochrane Library, 1, 2002.The only significant benefit of continuous EFM was a reduction in the incidence of neonatal

seizures.

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Tincello D, White S, Walkinshaw S. Computerised analysis of fetal heart raterecordings in maternal type I diabetes. Br JObstet Gynaecol 108:853-7, 2001.Fetuses of diabetic mothers had a more immature form of FHR than was expected.

Westgate JA, Bennet L et al. Fetal heart rate overshoot during repeated umbilical cordocclusion in sheep. Obstet Gynecol 97:454-9, 2001.

Labor analgesiaALTERNATIVE TECHNIQUES

Alehagen S, Wijma K, Wijma B. Fear during labor. Acta Obstet Gynecol Scand80:315-20, 2001.Primiparous women reported higher levels offear. Fear during the first stage wascorrelated with the total amount of pain relief received.

Blair JM, Hill DA, Fee JPH. Patient-controlled analgesia for labour using remifentanil.Br J Anaesth 87:415-20, 2001.Bolus doses of 0.25-0.5 mcg/kg with a 2 minute lockout and no background infusion providedadequate analgesia.

Nadir V, Henry R. Bilateral paravertebral block: a satisfactory technique for labouranalgesia. Can J Anesth 48: 179-84, 2001.An alternative to the more technically difficult lumbar sympathetic block in patients whocould not receive epidural analgesia.

Righard L. Making childbirth a normal process. Birth 28:1-4, 2001.

Roelants F, De Franceschi et al. Patient-controlled intravenous analgesia usingremifentanil in the parturient. Can J Anesth 48:175-8, 2001.0.05 mcg/kg/min basal infusion, 25 mcg bolus, 5 minute lockout provided adequate analgesiawith minimal sedation and no reported newborn depression.

Tsen LC, Thomas J et al. Transcutaneous electrical nerve stimulation does not augmentepidural labor analgesia. J Clin Anesth 13:57 1-5, 2001.

Young D. Editorial: The nature and management of labor pain: what is the evidence?Birth 28;149-51, 2001.Report on "The nature and management of labor pain: an evidence based symposium"sponsored by the Maternity Center Association and the New York Academy of Medicine.Needless to say, the emphasis of this editorial is colored by its provenance.

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EPIDURAL TECHNIQUES-AMBULATION

Connelly NR, Parker RK et al. The influence of a bupivacaine and fentanyl epiduralinfusion after epidural fentanyl in patients allowed to ambulate in early labor. Anesth Arìalg93:1001-5, 2001.

Vallejo MC, Firestone LL et al. Effect of epidural analgesia with ambulation on laborduration. Anesthesiology 95:857-61, 2001.Ambulation did not shorten labor in women receiving epidural ropivacaine.

EPIDURAL TECHNIQUES-ANATOMY

Grau T, Leipold RW et al. The lumbar epidural space in pregnancy: visualization byultrasonography. Br J Anaesth 86:798-804, 2001.Ultrasound demonstrated anatomic changes in pregnant women that predisposed to moredfflcult epidural placement, changes which regressed by 9 months postpartum.

Grau T, Leipold RW. Colour Doppler imaging of the interspinous and epidural space.Eur J Anaesthesiol 18:706-12, 2001.

EPIDURAL TECHNIQUES-CSEAComparative Obstetric Mobile Epidural Trial (COMET) Study Group UK. Effect of

low-dose mobile versus traditional epidural techniques on mode of delivery: a randomizedcontrolled trial. Lancet 358:19-23, 2001. See also Thornton JG, Capogna G. Editorial:Reducing likelihood of instrumental delivery with epidural anesthesia. Lancet 358:2, 2001and Letters to the editor: Lancet 358:1725-6, 2001.In this study of 1054 nulliparas, the NSVD rate was 43% in a low-dose CSE group and 43%in a low dose infusion group, compared with 35%in a traditional epidural group.

Hess PB, Pratt SD et al. Predictors of breakthrough pain during labor epiduralanalgesia. Anesth Analg 93:414-8, 2001.Patients receiving CSEA were less likely to have breakthrough pain than conventionalepidurals. Risks for breakthrough pain: nulliparity, heavier fetal weight, epidural placementat an earlier cervical dilation.

Norris MC, Fogel ST, Conway-Long C. Combined spinal-epidural versus epidurallabor analgesia. Anesthesiology 95:913-20, 2001.Labor outcome and progress were similar in both groups. Incidence of accidental duraipuncture, headache, and blood patch were similar.

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EPIDURAL TECHNIQUES-EQUIPMENTFrölich MA, Caton D. Pioneers in epidural needle design. Anesth Anaig 93:215-20,

2001.

EPIDURAL TECHNIQUES-FETAL EFFECTSCapogna G. Effect of epidural analgesia on the fetal heart rate. Eur J Obstet Gynecol

Reprod Biol 98:160-4, 2001.Suggests that bradycardia may be secondary to changes in uterine contraction patterns.Reaffirms that these changes need not lead to maternal or fetal morbidity.

Paternoster DM, Micaglio M et al. The effects of epidural analgesia and uterinecontractions on fetal oxygen saturation during the first stage of labor. Tnt J Obstet Anesth10:103-7, 2001.Oxygen saturation measured by fetal pulse oximetly was unchanged by epidural analgesia.Saturation increased during contractions, but then fell signcantly below baseline levels.

Stuart KAC, Krakauer H et al. Labor epidurals improve outcomes for babies of mothersat high risk for unscheduled cesarean section. J Perinatol 21:1768-85, 2001.In a high risk population, epidural analgesia was cost neutral and led to better neonatal,outcomes.

Van de Velde M, Vercauteren M, Vandermeersch E. Fetal heart rate abnormalities alterregional analgesia for labor pain: the effect of intrathecal opioids. Reg Anesth Pain Med26:257-62, 2001.ITsufentanil 7.5 mg was more likely to lead to fetal bradycardia than conventional epidural.or IT bupivacaine 2.5 mg/sufentanil 1.5 mcg. This did not result in more cesarean deliveriesor adverse fetal outcome.

EPIDURAL TECHNIQUES-MATERNAL SATISFACTIONKannan S, Jamison RN, Datta S. Maternal satisfaction and pain control in women

electing natural childbirth. Reg Anesth Pain Med 26:468-72, 2001.D espite lower pain scores, women who planned an unmedicated birth but received epiduralanalgesia reported less satisfaction with their birthing experience than women who deliveredwithout analgesia.

Wu CL, Naqibuddin M et al. Measurement of patient satisfaction as an outcome ofregional anesthesia and analgesia: a systematic review. Reg Anesth Pain Med 26:196-208,2001.

EPIDURAL TECHNIQUES-PCEA

Smedvig JP, Soreide E, Gjessing L. Ropivacaine 1 mg/mi, plus fentanyl 2 mcg/ml forepidural analgesia during labor: is mode of administration important? Acta AnaesthesioiScand 45:595-9, 2001.

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EPIDURAL TECHNIQUES-PHARMACOLOGYBernard J-M, Le Roux D et al. The dose-range effects of sufentanil added to 0.125%

bupivacaine on the quality of patient-controlled epidural analgesia during labor. AnesthAnaig 92:184-8, 2001.

Capogna G, Parpaglioni R et al. Minimum analgesic dose of epidural sufentanil forfirst-stage labor analgesia: a comparison between spontaneous and prostaglandin-inducedlabors in nulliparous women. Anesthesiology 94:740-4,2001.Minimum analgesic dose was 22.2 mcg in spontaneous labor and 27.3 mcg in prostaglandininduced labor.

Cherng C-H, Wong C-S. Epidural fentanyl speeds the onset of sensory block duringepidural lidocaine anesthesia. Reg Anesth Pain Med 26:523-26, 2001.Onset time: 8.3 minutes vs 14.2 minutes in patients undergoing knee arthroscopy.

Chua NP, Sia AT, Ocampo CE. Parturient-controlled epidural analgesia during labour:bupivacaine vs. ropivacaine. Anaesthesia 56:1169-73, 2001.Equal amounts of 0.25% bupivacaine and 0.25% ropivacaine were consumed.

Kopacz DJ, Bernards CM. Effect of clonidine on lidocaine onlidocaine clearance invivo. Anesthesiology 95:1371-6, 2001. '1

Decreased blood flow prolonged the duration of lidocaine at the superficial peroneal nerve.

Debon R, Allaouchiche B et al. The analgesic effect of sufentanil combined withropivacaine 0.2% for labor analgesia: a comparison of three sufentanil doses. Anesth Analg92:180-3, 2001.Addition of 5, 10, and 15 mcg of sufentanil to 12 ml 0.2% ropivacaine prolonged analgesiato a similar degree.

Fernandez-Guisasola J, Serrano ML. A comparison of 0.0625% bupivacaine withfentanyl and 0.1% ropivacaine with fentanyl for continuous epidural labor analgesia. AnesthAnalg 92:1261-5, 2001.Analgesia was equivalent, suggesting that bupivacaine is more potent than ropivacaine.

Lee BB, Ngan Kee WD et al. Dose-response study of epidural ropivacaine for laboranalgesia. Anesthesiology 94:767-72, 2001.ED50=18.4mg. s

Le Guen H, Roy D et al. Comparison of fentanyl and sufentanil in combination withbupivacaine for patient-controlled epidural analgesia during labor. J Clin Anesth 13:98-102,2001.

Litwin AA. Mode of delivery following labor epidural analgesia: influence ofropivacaine and bupivacaine. AANA Journal 69:259-60, 2001.

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Palm S, Gertzen W et al. Minimum local analgesic dose of plain ropivacaine vs.ropivacaine combined with sufentanil during epidural analgesia for labor. Anaesthesia56:526-9,200LMLAC=0.13% plain, 0.09% when sufentanil 0.75 mcg/ml was added:

Porter JM, Kelleher N et al. Epidural ropivacaine hydrochloride during labour: proteinbinding, placental transfer and neonatal outcome. Anaesthesia 56:418-23, 2001.

Robinson AP, Lyons GR et al. Levobupivacaine for epidural analgesia in labor: thesparing effect of epidural fentanyl. Anesth Analg 92:410-4, 2001.MLAC=0.091% in controls, 0.047% with fentanyl 2 mcg/ml, and 0.050% with fentanyl 3mcg/ml; i.e., the effect offentanyl was not dose dependent.

Rodriquez J, Rodriquez V et al. Epidural washout with high volumes of saline toaccelerate recovery from epidural anaesthesia. Acta Anaesthesiol Scand 45:893-8, 2001.No clinically useful effect; signs of intracranial hypertension developed in one patient whoreceived 4 times the volume of the initial LA dose.

Sitzman BT, DiFazio CA et al. Reversal of lidocaine with epinephrine epiduralanesthesia using epidural saline washout. Reg Anesth Pain Med 26:246-5 1, 2001.Two 15 ml boluses of normal saline administered 15 minutes apart at the end ofsurgeryreduced time offull recovery from a T4 level block from 153 to 108 minutes.

Vercauteren MP, Meert TP et al. Drug iñteractions in the epidural space. ActaAnaesthesiol BeIg 52:437-43, 2001.A review of the drugs that can be added to local anesthetics to improve the quality of block:opioids, ketamine, a-adrenergic agents.

Wang C, Sholas MG et al. Evidence that spinal segmental nitric oxide mediatestachyphylaxis to peripheral local anesthetic nerve block. Acta Anaesthesiol Scand 45:945-53, 2001.The NO synthase inhibitor L-NAME prevents the development of tachyphylaxis to sciaticnerve blockade. It is much more effective when administered intrathecally rather thansystemically, suggesting that tachyphylaxis has a spinal site of action.

EPIDURAL TECHNIQUES-PHYSIOLOGYHawthorne L, Slaymaker A et al. Effect of fluid preload on maternal haemodynamics

for low-dose epidural analgesia in labor. mt J Obstet Anesth 10:312-5, 2001.No preload vs. 7 ml/kg bolus: no difference in cardiac index or mean BP after 20 mlbupivacaine + 2 mcg/mlfentanyl.

Leather HA, Wouters PF. Oesophageal Doppler monitoring overestimates cardiacoutput during lumbar epidural anaesthesia. Br J Anaesth 86:794-7, 2001.Redistribution of blood flow renders esophageal Doppler measurement of CO unreliable.

Rajek A, Greif R, Sessler DI. Effects of epidural anesthesia on thermal sensation. RegAnesth Pain Med 26:527-31, 2001.

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EPIDURAL TECHNIQUES-TEST DOSE/IV INJECTIONBahar M, Chanimov M et al. Lateral recumbent head-down posture for epidural

catheter insertion reduces intravascular injection. CanJ Anesth 48:48-53, 2001.

Gogarten W, Striimper D et al. Testing an epidural catheter in obstetrics: epinephrine orisoproterenol) Tnt J Obstet Anesth 10 40-5,2001Discusses limitations of standard epinephrine test dose and possible advantage ofisoproterenol, once neurotoxicily concerns are allayed.

Ngan Kee WD, Khaw KS et al. The limitations of ropivacaine with epinephrine as anepidural test dose in parturients. Anesth Anaig 92:1529-31, 2001.

Tanaka M, Nishikawa T. T-wave amplitude as an indicator for detecting intravascularinjection of epinephrine test dose in awake and anesthetized elderly patients. Anesth Anaig93:1332-7, 2001.

Tanaka M, Sato M et al. The efficacy of simulated intravascular test dose in sedatedpatients. Anesth Analg 93:1612-7, 2001. r

An increase in systolic BP and a decrease in T-wave amplitude are more reliable thantachycardia for detecting IV injection of an epinephrine-containing test dose in sedatedpatients.

INTRATHECAL TECHNIQUESD'Angelo R, Dean LS et al. Neostigmine combined with bupivacaine, clonidine, and

sufentanil for spinal labor analgesia. Anesth Analg 93:1560-4, 2001.Addition of spinal neostigmine produces severe nausea in parturients (53%) with no usefulprolongation of analgesia.

Hughes D, Hill D, Fee JPH. Intrathecal ropivacaine or bupivacaine with fentanyl forlabor. Br J Anaesth 87:733-7, 2001.IT ropivacaine 2.5 mg with fentanyl 25 mcg provided equivalent analgesia and less motorblock than bupivacaine 2.5 mg with fentanyl. If the local anesthetic dose was decreasedwould the dWerence in motor block persist?

Muiroy MF, Larkin KL, Siddiqui A. Intrathecal fentanyl-induced pruritus is moresevere in combination with procaine than with lidocaine or bupivacaine. Reg Anesth PainMed 26:252-6, 2001.Addition offentanyl to procaine appears to be of little benefit.

Palmer CM. Continuous intrathecal sufentanil for postoperative analgesia. AnesthAnalg 92:244-5, 2001.

Pavy TJG. Patient-controlled spinal analgesia for labour and cesarean delivery.Anaesth Intensive Care 29:58-61, 2001.

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Soni AK, Miller CG et al. Low dose intrathecal ropivacaine with or without sufentanilprovides effective analgesia and does not impair motor strength during labour Can J Anesth48:677-80, 2001.Ropivacaine 3 mg provides effective analgesia; addition of sufentanil 10 mcg prolongseffective analgesia (time to first request for additional analgesia) from 41 to 95 minutes.This duration appears similar to duration of sufentanil alone; therefore, is there any benefitto adding ropivacaine?

Stocche RM, Klamt JG et al. Effects of intrathecal sufentanil on plasma oxytocin andcortisol concentrations in women during the first stage of labor. Reg Anesth Pain Med26:545-50, 2001.IT sufentanil decreases both oxytocin and cortisol concentrations. Can this have any effecton the progressof labor?

Stocks GM, Hallworth SP et al. Minimum local analgesic dose of intrathecalbupivacaine in labor and the effect of intrathecal fentanyl. Anesthesiology 94:593-8, 2001.Addition of either 5, 15, or 25 mcgfentanyl to IT bupivacaine produces similar decreases inminimum local analgesic dose (from 1 99 mg to 069, 0 71, and 085, respectively)

Swenson JD, Owen J et al. The effect of distance from injection site to the brainstemusing spinal sufentanil. Reg Anesth Pain Med 26:306-9, 2001. See also Eisenach JC.Editorial: Lipid soluble opioids do move in cerebrospinal fluid. Reg Anesth Pain Med26 296-7, 2001Despite its high lipid solubility, sufentanil migrates large distances in the suba rachnoidspace; distance from the injection site to the brainstem will influence the likelihood ofrespiratory depression.

Vaughan DJA, Ahmad N et al. Choice of opioid for initiation of combined spinalepidural analgesia in labour: fentanyl or diamorphine. Br J Anaesth 86:567-9, 2001.ITDiamorphine 250 mcg has a similar side effect profile and a longer duration (101 minutesvs. 73 minutes) compared tofentanyl 25 mcg.

Vercauteren MP, Hans G et al. Levobupivacaine combined with sufentanil andepinephrine for intrathecal labor analgesia: a comparison with racemic bupivacaine. AnesthAnaig 93:996-1000, 2001.Clinically similar, except for motor block. Incidence of Bromage i block: bupivacaine 34%,levobupivacaine 0%.

Vercauteren MP, Jacobs S et al. Intrathecal labor analgesia with bupivacaine andsufentanil: the effect of adding 2.25 mcg epinephrine. Reg Anesth Pain Med 26:473-7, 2001.Duration of analgesia increased from 79 to 93 minutes with the addition of epinephrine.

Yeh H-M, Chen L-K et al. The addition of morphine prolongs fentanyl-búpivacainespinal analgesia for the relief of labor pain. Anesth Analg 92:665-8, 2001.Addition of morphine 0.15 mg prolonged analgesia form 148 to 252 minutes.

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Local anesthetic pharmacologyAydin ON, Eyigor M, Aydin N. Antimicrobial activity of ropivacaine and other local

anesthetics. Eur J Anaesthesiol 18:687-94, 2001.Ropivacaine has no antimicrobial activity; lidocaine was somewhat more active. Theclinical significance is unclear.

Groban L, Deal DD et al. Cardiac resuscitation after incremental overdosage withlidocaine, bupivacaine, levobupivacaine, and ropivacaine in anesthetized dogs. AnesthAnalg 92:37-43, 2001.

Lefrant J-Y, de La Coussaye JE et al. The comparative electrophysiologic andhemodynamic effects of a large dose of ropivacaine and bupivacaine inanesthetized andventilated piglets. Anesth Analg 93:1598-1605, 2001.4 mg/kg bupivacaine and 6 mg/kg ropivacaine had similar hemodynamic effects; bupivacainehad a greater effect on ventricular conduction.

Liu B-G, Zhuang X-L et al. Effects of bupivacaine and ropivacaine on high-voltage-activated calcium currents of the dorsal horn neurons in newborn rats. Anesthesiology95:139-43, 2001.

Lo B, Hönemann CW et al. Local anesthetic actions on thromboxane-induced plateletaggregation. Anesth Analg 93: 1240-5, 2001.Local anesthetics have only a limited ability to inhibit thromboxane-induced plateletaggregation; this mechanism is unlikely to account for the antithrombotic effects of localanesthetics.

Lyons G, Reynolds F. Editorial: Toxicity and safety of epidural local anesthetics. mt JObstet Anesth 10:259-62, 2001.A nice discussion of the issues in toxicity studies and the problems of assessing potency oflocal anesthetics.

McLeod GA, Burke D. Levobupivacaine. Anaesthesia 56:331-41, 2001.Considers the relative toxicities of bupivacaine and levobupivacaine, and essentiallyconcludes that the older compound should be .uperseded by the single isomer preparation.

312.Ohmura S, Kawada M et al. Systemic toxicity and resuscitation in bupivacaine-,levobupivacaine-, or ropivacaine-infused rats. Anesth Analg 93 :743-8, 2001.Toxicity of levobupivacaine was intermediate between the other agents; less epinephrine wasrequired to resuscitate from ropivacaine-induced asystole.

313. Porter JM, Crowe B et al. The effects of ropivacaine hydrochloride on platelet function:an assessment using the platelet function analyzer (PFA-100). Anaesthesia 56:15-18, 2001.

Santos AC, DeArmas PI. Systemic toxicity of levobupivacaine, bupivacaine andropivacaine during continuous intravenous infusion to pregnant and non-pregnant ewes.95:1256-64, 2001.For all three agents, the doses required to produce convulsions were lower in pregnant thanin non-pregnant sheep. Cardiovascular collapse occurred at similar doses for both pregnantand non-pregnant animals.

Zapata-Sudo G, Traciez MM et al. Is comparative cardiotoxicity of S(-) and R(+)bupivacaine related to enantiomer-selective inhibition of L-type Ca2 channels? AnesthAnalg 92:496-501, 2001.

Mass mediaGood Morning America, February 6, 2001. New techniques used during pregnancy and

birth.

The Mail on Sunday, February 11, 2001. Jab blunder kills another patient."The latest victim of a hospital injection blunder died yesterday as an inquiry began into thetragedy. The unnamed patient had spent three days in intensive care after an 'experiencedconsultant' injected a local anesthetic into a vein instead of the spine."

The Times, March 29, 2001. Maternal bonding "affected by painkillers""Women who take painkillers during childbirth may have trouble breastfeeding and bondingwith their babies, Swedish scientists have reported. Infants whose mothers were given anepidural anesthetic during labor were less likely to breastfeed normally in the first few hoursafter childbirth."

Sunday Express, April 15, 2001. We must have the truth about birth pain injections"The potential risks of epidurals remain one of the Health Service's most closely guardedsecrets. This cover-up cannot be allowed to continue."

Sunday Express, April 22, 2001. World health expert backs our warning over thedanger of using pain-killing drugs for childbirth."Dr. Marsden Wagner, former director of women and children's health at WHO and adviserto UNICEF, said injections into the spine to relieve labor pains were fraught with peril."

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Maternal fever and neonatal sepsis workupGoetzl L, Cohen A et al. Maternal epidural use and neonatal sepsis evaluation in

afebrile mothers. Pediatrics 108:1099-1102, 2001.Criteria for sepsis workup in afebrile women included ROM>24 hours, FHR>160 (majorcriteria), and temperature 99.6-100.4°, ROM 12-24 hours, WBC>15,000 on admission, andApgar <7 at five minutes (minor criteria). Increases in the frequency of several of thesecriteria in women receiving epidural analgesia led to increased sepsis workups, although,once again, the incidence of sepsis was unchanged.

Impey L, Greenwood C et al. Fever in labour and neonatal encephalopathy: aprospective cohort study. Br J Obstet Gynaecol 108:594-7, 2001.Maternalfever is more predictive of encephalopathy than even an abnòrmal FH. Theauthors somewhat off-handedly suggest that this relationship may have implications for theprovision of epidural analgesia; they go on to say, however, that a large increase in epiduraluse has not been associated with an increase in neonatal encephalopathy.

Kaul B, Vallejo M et al. Epidural labor analgesia and neonatal sepsis evaluation rate: aquality improvement study. Anesth Analg 93:986-90, 2001.In one institution, refined criteria for neonatal sepsis evaluations seems to eliminate anincreased risk of sepsis workup in infants whose mothers received LEA.

Negishi C, Lenhardt R et al. Opioids inhibit febrile responses in humans, whereasepidural analgesia does not. Anesthesiology 94:218-22, 2001.Implies that the incidence offever in mothers receiving LEA must be compared with truecontrols, i.e. women receiving no analgesics.

Petrova A, Demissie K et al. Association of maternal fever during labor with neonataland infant morbidity and mortality. Obstet Gynecol 98:20-7, 2001.Intrapartum fever is associated with increased neonatal morbidity; it is unclear to me if thisis in reality an association between infection and neonatal morbidity.

Sciscione AC, Zainia et al. A new device for measuring intrauterine temperature. Am JObstet Gynecol 184: 1431-5, 2001.Intrauterine temperatures displayed a linear relationship with oral and lympanictemperatures. All were increased in women receiving epidural analgesia.

Vallejo MC, Kaul B et al. Chorioamnionitis, not epidural analgesia, is associated with

maternal fever during labour. Can J Anesth 48:1122-6, 2001.When women with chorioamnionitis are excluded, LEA is unassociated with fever.

Yancey MK, Zhang J et al. Labor epidural analgesia and intrapartum maternal

hyperthermia. Obstet Gynecol 98:763-70, 2001.The same natural experiment that demonstrates a neutral effect ofepidural analgesia on C/S

rates can also implicate the technique for less desirable results. Incidence offever. of

>100.4°rose from 0.6% before introduction of an epidural service to 11% afterwards.

Neonatal sepsis workups increased, but the proportion of infants receiving antibiotics after

workup was unchanged.

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Medicolegal issues/medical ethicsCoates J. Medicolegal diary: obtaining consent for epidural analgesia for women in

labour. NZMedJ114:72-3,2001.

Yentis SM. Ethical guidance for research in obstetric anaesthesia. Tnt J Obstet Anesth10:289-9 1.Guidelines of the OAA, must reading for clinical researchers.

NewbornBEHAVIOR

331 Halpern SH, Littleford JA et al The neurologie and adaptive capacity score is not areliable method of newborn evaluation Anesthesiology94 958-62, 2001The NACS is the most widely-used tool in the anesthetic literature for assessing newbornbehavior. However, its reliability had never been evaluated until this study. The furtherusefulness of the NAGS is drawn into serious question by this paper.

Ransjö-Arvidson A-B, Matthiesen A-S et al. Maternal analgesia during labor disturbsnewborn behavior: effects on breastfeeding, temperature, and crying. Birth 28:5-12, 2001.This study, widely reported in the popular press, studied 28 newborns, two (i) of whichreceived epidural analgesia alone and no other analgesics. The difficulties in drawingconclusions from a such a small study are apparent:

BRAcHIAL PLEXUS INJURYBar J, Dvir A et al. Brachial plexus injury and obstetrical risk factors. Tnt J Gynecol

Obstet 73:21-25, 2001.Greater maternal age, diabetes, and higher birth weight were associated with a higher riskof Erb 's palsy. 2/62 affected infants were born by elective cesarean section.

CEREBRAL PALSY

Croen LA, Grether JK et al. Congenital abnormalities among children with cerebralpalsy: more evidence for prenatal antecedents. J Pediatr 138:804-10, 2001.Congenital malformations were found in 19% of infants with GP and 4% of controls

Farkouh LI, Thorp JA et al. Antenatal magnesium exposure and neonatal demise. AmJObstet Gynecol 185:869-72, 2001.Enthusiasm for studies suggesting that maternal magnesium sulfate therapy reduces theincidence of cerebral palsy are tempered by other studies suggesting an increase in perinatalmortality. This study of 12,876 cases failed to show any relationship between magnesiumadministration and neonatal death.

Lemons JA, Bauer CR et al. VLBW outcomes of the National Institute of Child Healthand Human Development Neonatal Research Network, January 1995 through December1996. Pediatrics 107:1-8, 2001.

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Sameshima H, Ikenoue T. Long-term magnesium sulfate treatment as protection againsthypoxic-ischemic brain injury in seven-day-old rats. Am J Obstet Gynecol 184:185-90,2001.Post-insult administration of magnesium protected against neuronal loss.

Thorp JA, James PG et al. Perinatal factors associated with severe intracranialhemorrhage. Am J Obstet Gynecol 185:859-62, 2001;

CH0RI0AMNI0NITIsHitti J, Tarczy-Hornoch P et al. Amniotic fluid infection, cytokines, and adverse

outcome among infants at 34 weeks' gestation or less. Obstet Gynecol 98:1080-8, 2001.

Schmidt B, Cao L et al. Chorioamnionitis and inflammation of the fetal lung. Am JObstet Gynecol 184:173-7, 2001.

MECONIUM ASPIRATIONBlackwell SC, Moldenhauer J et al. Meconium aspiration syndrome in term neonates

with normal acid-base status at delivery: is it different? Am J Obstet Gynecol 184:1422-6,2001.Normal acid-base status was seen in many cases of severe meconium aspiration syndrome;this implies a preexisting injury or a non-hypoxic mechanism.

Ghidini A, Spong CY. Severe meconium aspiration syndrome is not caused byaspiration of meconium. Am J Obstet Gynecol 185:931-8, 2001.

RESPIRATORY DISTRESSAlano MA, Ngougmna E et al. Analysis of NSAIDs in meconium and its relation to

persistent pulmonary hypertension of the newborn. Pediatrics 107:519-23, 2001.Maternal exposure to NSA IDs was greatly underreported and strongly associated withpersistent pulmonary hypertension.

Clark RH, Gerstmann DR et al. Lung injury in neonates: causes, strategies forprevention, and long-term consequences. J Pediatr 139:478-86, 2001.Discusses ventilator strategies to decrease lung injury.

Levine EM, Ghai V et al. Mode of delivery and risk of respiratory diseases innewborns. Obstet Gynecol 97:439-42, 2001..Even in elective cesareans, the incidence of persistent pulmonary hypertension was almostfive-fold higher than in vaginal deliveries.

RESUSCITATION/EVALUATION

Casey BM, Mclntire DD, Leveno KJ. The continuing value of the Apgar score for theassessment of newborn infants. N Engi J Med 344:467-47 1, 2001.A study of 152,000 live births that validates the Ap gar score 's predictive value.

Gaiser R, Lewin SB et al. Anesthesiologist's interest in neonatal resuscitationcertification. J Clin Anesth 13:374-6, 2001.

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Moster D, Lie RT et al. The association of Apgar score with subsequent death andcerebral palsy: a population-based study in term infants. J Pediatr 138:798-803, 2001.Infants with a 5 minute Apgar score of 0-3 had a 386-fold increased risk of neonatal deathcompared to infants with scores of 7-10.

Pate! D, Piotrowski ZH et al. Effect of a statewide neonatal resuscitation trainingprogram on Apgar scores among high-risk neonates in flhinois. Pediatrics 107:648-55, 2001.After widespread training in newborn resuscitation was implemented, high-risk newbornswith low 1 minute Ap gars were more likely to increase their 5 minute score.

Vento M, Asensi M et al. Resuscitation with room air instead of 100% oxygen preventsoxidative stress in moderately asphyxiated term neonates. Pediatrics 107:642-7, 2001.Room air resuscitated infants recover more quickly than those resuscitated with 100%oxygen. Biochemical markers of oxidative stress are present up to 4 weeks afterresuscitation with 100% oxygen.

Nonobstetric surgeryCastro MA, Shipp TD et al. The use of helical computed tomography in pregnancy for

the diagnosis of acute appendicitis. Am J Obstet Gynecol 184:954-7, 2001.Both sensitive and specific.

Fisk NM, Gitau R et al. Effect of direct fetal opioid analgesia on fetal hormonal andhemodynamic stress response to intrauterine needling. Anesthesiology 95:828-35, 2001.Intravenous fentanyl administered to fetuses prior to intrahepatic vein transfusion forjetaihydrops attenuated the fetal stress response.

Schwartz DA, Moriarty KP et al. Anesthetic management of the EXIT (Ex uterointrapartum treatment) procedure. J Clin Anesth 13:387-91, 2001.

Steinbrook RA, Bhavani-Shankar K. Hemodynamics during laparoscopic surgery inpregnancy. Anesth Analg 93:1570-1, 2001.Hemodynamic changes were similar to those seen in non-pregnant patients.

Tsen LC, Schultz R et al. Intrathecal low-dose bupivacaine versus lidocaine for in vitrofertilization procedures. Reg Anesth Pain Med 26:52-6, 2001.Bupivacaine delayed discharge but was otherwise a suitable substitute for lidocaine.

Wiesner G, Hoerauf K et al. High-level, but not low-level, occupational exposure toinhaled anesthetics is associated with genotoxicity in the micronucleus assay. Anesth Anaig92:118-22, 2001.

130.

Obstetric management issuesBREECH

ACOG Committee on Obstetric Practice. Committee opinion #265: mode of termsingleton breech delivery. Obstet Gynecol 98:1189-90, 2001."Planned vaginal delivery of a term singleton breech may no longer be appropriate."

Birnbach DJ, Matut J et al. The effect of intratheòal analgesia on the success of externalcephalic version. Anesth Analg 93:410-3, 2001.Success rate: 80% spinal, 33% controls.

Hofmeyr GJ. External cephalic version facilitation for breech presentation at term(Cochrane Review). In: The Cochrane Library, 1, 2002.Not enough evidence at present to evaluate the use of regional anesthesia. Tocolysisenhances success rates.

Hofmeyr GJ, Hannah ME. Planned caesarean section for term breech delivery(Cochrane Review). In: The Cochrane Library,1, 2002.Provides support for A COG Opinion (ref#357)

INDUCTION OF LABORAlfirevic Z. Oral misoprostol for induction of labor (Cochrane Review). In: The

Cochrane Library, 1, 2002.Effective, but data on optimal regimens and safety are lacking.

Boulvain M, Stan C, Irion O. Membrane sweeping for induction of labor (Cochrane

Review). In: The Cochrane Library, 1,2002.Routine use of membrane sweeping has no apparent clinical benefit.

French L. Oral prostaglandin E2 for induction of labor (Cochrane Review). In: The

Cochrane Library, 1, 2002.Oral prostaglandin E2 was sign jJï cantly associated with GI disturbances; there were no clear

advantages to its use compared with other induction techniques.

Hofmeyr GJ, Gulmezoglu AM. Vaginal misoprostol for cervical ripening and induction

of labor (Cochrane Review). In: The Cochrane Library, 1, 2002.Effective, but uterine hyperstimulaiton is a concern; reviewers could not exclude the

possibility of uterine rupture.

Howarth GR, Botha DJ. Amniotomy plus intravenous oxytocin for induction of labor

(Cochrane Review). In: The Cochrane Library, 1, 2002.The reviewers concluded that data on the effectiveness of this combination are lacking. No

clinical recommendations were made.

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Goldberg AB, Greenberg MB, Darney PD. Misoprostol and pregnancy. New Eng! JMed 344:38-47, 2001. See also Hale RW, Zinberg S. Editorial: Use of misoprostol inpregnancy. N Engi J Med 344:59-60. 2001 and Friedman MA. Letter: Manufacturer'swarning regarding unapproved uses of misoprostol. N Engi J Med 344:61, 2001.Goldberg provides an extensive review of the uses of misoprostol during pregnancy,including pregnancy termination, cervical ripening, and treatment of PPH. The editorialdiscusses the efforts of the manufacturer, G.D. Searle, to dissuade physicians from utilizingthe drug for those off-label uses.

Kelly AJ, Kavanaugh J, Thomas J. Vaginal prostaglandin (PGE2 and PGF2) forinduction of labor at term (Cochrane Review). In: The Cochrane Library, 1, 2002.

Yawn BP, Wollan P et al. Temporal changes in rates and reasons for medical inductionof term labor, 1980-1996. Am J Obstet Gynecol 184:611-9,2001.Rate of induction increased from 13% to 26%; The most common indications are electiveinduction and postdates pregnancy (40-41 weeks).

INSTRUMENTAL DELIVERY

Gardella C, Taylor M et al. The effects of sequential use of vacuum and forceps forassisted vaginal delivery on neonatal and maternal outcomes. Am J Obstet Gynecol 185:896-902, 2001.Sequential use of vacuum and forceps increases the risk of both maternal and fetal injury.

INTRAPARTUM CARE

Chalmers B, Mangiaterra V, Porter R. WHO principles of perinatal care: the essentialantenatal, perinatal, and postpartum care course. Birth 28:202-7, 2001."Do not restrict fluids during labor, and allow women with normally progressing labors toeat light meals if needed".

Chien L-Y, Whyte R et al. Improved outcome of preterm infants when delivered intertiary care centers. Obstet Gynecol 98:247-52, 2001.

Enkin M, Keirse MJNC et al. Effective care in pregnancy and childbirth: a synopsis.Birth 28:41-51, 2001."Forms of care with a trade-off between beneficial and adverse effects" include epiduralanalgesia and fluid preload prior to epidural. "Forms ofcare unlikely to be beneficial"include withholding food and drink from women in labor.

Hofmeyr GJ. Amnioinfusion for meconium-stained liquor in labour (CochraneReview). In: The Cochrane Library, 1, 2002.

Hofmeyr GJ, Gulmezoglu AM. Maternal hydration for increasing amniotic fluidvolume in oligohydramnios and normal amniotic fluid volume (Cochrane Review). In: TheCochrane Library, 1, 2002.Two liters of oralfluid signcantly increased amniotic fluid volume and may be useful incases of oligohydramnios.

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Lauzon L, Hodnett E. Labour assessment programs to delay admission to labour wards(Cochrane Review). In: The Cochrane Library, 1,2002.

Nager CW, Helliwell JP. Episiotomy increases perineal laceration length inprimiparous women. Am J Obstet Gynecol 185:444-50, 2001.Why are routine episiotomies still performed?

Rouse DJ, Owen J et al. Active phase labor arrest: revisiting the 2-hour minimum.Obstet dynecol 98:550-4, 2001.Women with such an arrest can often achieve successful vaginal delivery.

Sherard GB, Newton ER. Is routine hemoglobin and hematocrit testing on admission tolabor and delivery needed? Obstet Gynecol 98:1038-40, 2001.If Hgb obtained at 26-28 weeks is acceptable, there is no advantage to obtaining a repeatdetermination upon admission.

VBACBujold E, Gauthier RJ. Should we allow a trial of labor after a previous cesarean for

dystocia in the second stage of labor? Obstet Gynecol 98:652-5, 2001.VBAC after a previous cesarean section performed for second stage dystocia has a 75%success rate.

Goetzl L, Shipp TD et al. Oxytocin dose and the risk of uterine rupture in trial of labor

after cesarean. Obstet Gynecol 97:38 1-4, 2001.

Hibbard JU, Ismail MA et al. Failed vaginal birth after a cesarean section: how risk)) is

it? I. Maternal morbidity. Am J Obstet Gynecol 184:1365-73, 2001.

Lydon-Rochelle M, Holt V et al. Risk of uterine rupture during labor among womenwith a prior cesarean delivery. N Engl J Med 345:3-8, 2001. See also Greene MF. Editorial:Vaginal delivery after cesarean section: is the risk acceptable? N Engi J Med 345:54-5, 2001

and Flamm BL. Editorial: VBAC and the New England Journal of Medicine: a strange

controversy. Birth 28:276-9, 2001.Induction, particularly induction with prostaglandins, was associated with a higher risk ofuterine rupture during VBAC than when labor commenced spontaneously. Even in the

spontaneous group, however, uterine rupture occurred in 5.2/1000 deliveries.

Shipp TD, Zelop CM et al. Interdelivery interval and risk of symptomatic uterine

rupture. Obstet Gynecol 175-7, 2001.Interdelivery intervals of up to 18 months were associated with a higher risk of symptomatic

uterine rupture duringVBAC compared to longer intervals.

Pharmacologic and physiologic alterations of pregnancyBernstein 1M, Ziegler W, Badger GJ. Plasma volume expansion in early pregnancy.

Obstet Gynecol 97:669-72, 2001.Plasma volume expansion cannot be identified before the sixth week of gestation. By the endof the first trimester, plasma volume increases by 14%.

Greenwood JP. Sympathetic neural mechanisms in normal and hypertensive pregnancyin humans. Circulation 104:2200-2204, 2001.Central sympathetic outflow is increased during normalpregnancy. It is further augmentedin women with pregnancy-induced hypertension.

He Y-L, Seno H et al. The effects of uterine and umbilical blood flows on the transferof propofol across the human placenta during in vitro perfusion. Anesth Analg 93:15 1-6,2001.

Higuchi H, Adachi Y et al. Early pregnancy does not reduce the C50 of propofol for lossof consciousness. Anesth Analg 93:1565-9, 2001.

Hsu M-M, Chou Y-Y et al. An analysis of excitatory amino acids, nitric oxide, andprostaglandin E2 in the CSF of pregnant women: the effect on labor pain. Anesth Anaig93:1293-6, 2001.Labor pain increases CSF concentrations of the excitatory amino acids glutamate andaspartate but not prostaglandin E2 or NO.

McAuliffe F, Kametas et al. Blood gases in pregnancy at sea level and at high altitude.BrJ Obstet Gynaecol 108:980-5, 2001.

Pan PH, Moore C. Comparison of cisatracurium induced neuromuscular blockadebetween immediate postpartum and nonpregnant patients. J Clin Anesth 13:112-7, 2001.Mean onset time and clinical duration of cisatracurium are considerably shorter immediatelypostpartum than in nonpregnant controls.

Rodriquez I, Kilborn MJ et al. Drug-induced QT prolongation in women during themenstrual cycle. JAMA 285:1322-6, 2001.Can this be related to the cardiotoxicizy of local anesthetics in pregnancy?

Tsen LC, Natale et al. Can estrogen influence the response to noxious stimuli? J ClinAnesth 13:118-21, 2001.

Tsujiguchi N, Yamakage M et al. Mechanisms of direct inhibitory action of propofol onuterine smooth muscle contraction in pregnant rats. Anesthesiology 95:1245-55, 2001.

Veille J-C, Kitzman DW et al. LV diastolic filling response to stationary bicycleexercise during pregnancy and the postpartum period. Am J Obstet Gynecol 185:822-7,2001.LV chamber stzfJhess increases during maximal exercise in pregnancy.

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Yoo KY, Lee J et al. The effects of opioids on isolated human pregnant uterinemuscles. Anesth Analg 92:1006-9, 2001.Fentanyl and meperidine appear to directly inhibit uterine contractility, but at levels 1000times greater than those seen clinically.

Postoperative pain managementADJUVANT DRUGS

American Academy of Pediatrics Committee on Drugs. The transfer of drugs and otherchemicals into human milk. Pediatrics 108:776-89, 2001.States that the use of ketorolac is acceptable in breasifeeding women. Unfortunately, this isnot supported by the manufacturer's package insert.

Charuluxananan S, Kyokong O et al. Nalbuphine vs. propofol for treatment of lTmorphine-induced pruritus after cesarean delivery. Anesth Anaig 93:162-5, 2001.

Ko S-H, Lim H-R et al. Magnesium sulfate does not reduce postoperative analgesicrequirements. Anesthesiology 95:640-6, 2001.

Lim NLSH, Lo WK et al. Single dose diclofenac suppository reduces post-CesareanPCEA requirements. Can J Anesth 48:383-6, 2001.Diclofenac group used 52 ml of local anesthetic mixture, controls used 74 ml.

Pavy TJG, Paech MJ, Evans SF. The effect of intravenous ketorolac on ópioidrequirement and pain after cesarean delivery. Anesth Analg 92:1010-4, 2001.Reduced epidural meperidine usage by 30%, but did not improve quality of pain relief orreduce opioid side-effects.

Siddik SM, Aouad MT et al. Diclofenac and/or propacetamol for postoperative painmanagement after cesarean delivery in patients receiving PCA morphine. Reg Anesth PainMed 26:310-5, 2001. See also Halpern SH, Walsh VL. Editorial: Multimodal therapy forpost-cesarean delivery pain. Reg Anesth Pain Med 26:298-300, 2001.

Yanagidate F, Hamaya Y, Dohi S. Clonidine premedication reduces maternalrequirement for intravenous morphine after cesarean delivery without affecting newborn'soutcome. Reg Anesth Pain med 26:461-7, 2001.

COMPLICATIONS .

Cherian VT, Smith I. Prophylactic ondansetron does not improve patient satisfaction inwomen using PCA after caesarean section. Br J Anaesth 87:502-4, 2001.

Ho S-T, Wang J-J et al. Dexamethasone for preventing nausea and vomiting associatedwith epidural morphine: a dose-ranging study. Anesth Analg 92:745-8, 2001.5 mg dexamethasone reduced incidence of nausea and vomiting from 50% to 18%.

Kjellberg F, Tramèr MR. Pharmacological control of opioid-induced pruritus: aquantitative systematic review of randomized trials. Eur J Anaesth 18:346-57, 2001.

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Murphy DB, El Behiery H et al. Pharmacokinetic profile of epidurally administeredmethylnaltrexone, a novel peripheral opioid antagonist in a rabbit model. Br J Anaesth86:120-2, 2001.

Pan PH, Moore CH. Comparing the efficacy of prophylactic metoclopramide,ondansetron, and placebo in cesarean section patients given epidural anesthesia. J ClinAnesth 13:430-5, 2001.

Pellegrini JE, Bailey SL et al. The impact of nalmefene on side effects due tointrathecal morphine at cesarean section. AANA Journal 69:199-201, 2001.

Wang J-J, Ho S-t et al. Dexamethasone prophylaxis ofnausea and vomiting afterepidural morphine for post-Cesarean analgesia. Can J Anesth 48:185-90, 2001.

EPIDURAL

Hodgson PS, Liu SS. A comparison of ropivacaine with fentanyl to bupivacaine withfentanyl for postoperative PCEA. Anesth Analg 92:1024-8, 2001.No signflcant differences between drugs; recommends the use of 0.05% solutions tominimize motor block

Jastrzab G, Fairbrother G, Khor. Management of postoperative epidural analgesia: asurvey of Australian practice. Anaesth Intensive Care 29:266-72, 2001.

Lee J, Shim JY et al. Epidural naloxone reduces intestinal hypomotility but notanalgesia of epidural morphine. Can J Anesth 48 :54-58, 2001.

Menigaux C, Guignard B et al. More epidural than intravenous sufentanil is required toprovide comparable postoperative pain relief. Anesth Analg 93:472-6, 2001.Suggests that epidural sufentanil has a primarily systemic effect.

Subramaniam B, Subramaniam K et al. Preoperative epidural ketamine in combinationwith morphine does not have a clinically relevant intra- and postoperative opioid-sparingeffect. Anesth Analg 93:1321-6, 2001.

INTRATHECAL

Campbell DC, Riben CM et al. Intrathecal morphine for postpartum tubal ligationpostoperative analgesia. Anesth Analg 93; 1006-11, 2001.100 mcg provided effective relief Maternal pain was surprisingly high in the control group;they required 40 mg PCA morphine over the first 24 hours.

Kim MH, Lee YM. Intrathecal midazolam increases the analgesic effects of spinalblockade with bupivacaine in patients undergoing hemorrhoidectomy 86:77-9, 2001.Lamina 2 is densely packed with benzodiazepine receptors

Standl TG, Horn E-p et al. Subarachnoid sufentanil for early postoperative painmanagement in orthopedic patients. Anesthesiology 94:230-8, 2001.

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Pre eclampsiaANESTHETIC MANAGEMENT

Ramanathan J, Vaddadi AK, Arheart KL. CSEA with low doses of intrathecalbupivacaine in women with severe preeclampsia. Reg Anesth Pain Med 26:46-5 1, 2001.Effective, with minimum blood pressure changes and good newborn outcomes.

\Veè L, Sinha P, Lewis M. The management of eclampsia by obstetric anaesthetists inUK: a postal survey. mt J Obstet Anes 10:108-112, 2001.Survey of experience with use of magnesium and other anticonvulsants in treatment ofeclamptic seizures. Mg:69%, diazepam:29%.

BLOOD PRESSURE MANAGEMENTBlumenfeld JD, Laragh JH.. Management of hypertensive crises: the scientific basis for

treatment decisions. Am J Hypertens 14:1154-67, 2001.

HELLP SYNDROMEIsler CM, Barrilleaux et al. A prospective, randomized trial comparing the efficacy of

dexamethasone and betamethasone for the treatment of antepartum HELLP. Am J ObstetGynecol, 184:1332-9, 2001.Dexamethasone increases, urine output, decreases AST, and decreases blood pressure to agreater extent than betamethasone. Both increase platelet count.

Vigil-De Gracia P. Acute fatty liver and HELLP syndrome: two distinct pregnancydisorders. mt J Gynecol Obstet 73:215-220,2001.More common in AFLP: hyperbilirubinemia, hypoglycemia, hypofibrinogenemia..Encephalopathy is more common in AFLP, as is renal insufficiency. These differencesreflect the dWerent pathologic alterations (HELLP: endothelial dysfunction, AFLP:mitochondrial dysfunction.)

OUTCOMEMackay AP, Berg CJ, Atrash HK. Pregnancy-related mortality from preeclampsia and

eclampsia. Obstet Gynecol 97:533-8, 2001.Preeclampsia accounts for 1.5 deaths/100,000 live births in the US. Mortality increases withage. Black women are three times more likely to die from preeclampsia-eclampsia thanwhite women.

PATHOPHYSIOLOGYBelfort MA, Tooke-Miller C et al. Pregnant women with chronic hypertension and

superimposed pre-eclampsia have high cerebral perfusion pressure. Br J Obstet Gynaecol108:1141-7, 2001.Suggests a mechanism for the increased incidence of eclampsia in women with superimposedpreeclampsia.

Blanco MV, Grosso O et al. Dimensions of the left ventricle, atrium, and aortic root inpregnancy-induced hypertension. Am J Hypertension 14:390-2, 2001.

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Chambers JC, Fusi L. Association of maternal endothelial dysfunction withpreeclampsia. JAMA 285:1607-12, 2001.Endothelial dysfunction persists postpartum in previously preeclamptic women.

Diedrich F, Renner A et al. Lipid hydroperoxides and free radical scavenging enzymeactivities in preeclampsia and HELLP syndrome: no evidence for circulating primary productof lipid peroxidation. Am J Obstet Gynecol 185:166-72, 2001.

Esplin MS, Fausett MB et al. Paternal and maternal components of the predisposition topreeclampsia. N Engi J Med 344:867-72, 2001. See also Pipkin FB. Editorial: Risk factorsfor preeclampsia. N Engi J Med 344:925-6, 2001.

Granger JP, Alexander BT et al. Pathophysiology of pregnancy-induced hypertension.Am J Hypertens 14:178S-185S, 2001.

Granger JP, Alexander BT et al. Pathophysiology of hypertension during preèclampsialinking placental ischemia with endothelial dysfunction. Hypertension 38 (part 2):7 18-22,2001.

Magnus P, Eskild A. Seasonal variation in the occurrence of pre-eclampsia. Br J ObstetGynaecol 108:1116-9, 2001.Mothers of children born in August had the lowest risk of preeclampsia, and mothers of thoseborn in December had the highest risk (adjusted odds ratio 1.26).

Mortenson JT, Thultrup AM et al. Smoking, sex of the offspring, ànd risk of placentalabruption, placenta previa, and preeclampsia: a population-based cohort study. Acta ObstetGynaecol Scand 80:894-8, 2001.Smoking is again shown to protect against preeclampsia. Female fetuses were moresusceptible to the effects of smoking on the incidence of placenta previa.

Regan CL, Levine RJ et al. No evidence for lipid peroxidation in severe preeciampsia.Am J Obstet Gynecol 185:572-8, 2001.

Roberts JM, Cooper. Pathogenesis and genetics of pre-eclampsia. Lancet 357:53-6,2001.

Sharkey LC, McCune SA et al. Spontaneous pregnancy-induced hypertension andintrauterine growth restriction in rats. Am J Hypertension 14:1058-66, 2001.A possibly useful animal model for preeclampsia.

Trogstad LIS, Eskild A et al. Is preeclampsia an infectious disease? Acta ObstetGynecol Scand 80:1036-8, 2001.The risk of developing preeclampsia was greater in women who were seronegative forantibodies to HSV-2, CMV, and EBV. The authors suggest that seronegative women aremore likely to acquire these infections during pregnancy, and postulate that infection duringpregnancy might lead to preeclampsia.

PREDICTION/PREVENTIONAtallah AN, Hofmeyr GJ, Duley L. Calcium supplementation during pregnancy for

preventing hypertensive disorders and related problems (Cochrane review). In: TheCochrane Library, 1,2002.Calcium supplementation appears to be benefi cia! for women at high risk of developingpreeclampsia. The optimal dosage is unclear at this time.

Coomarasamy A, Papaioannou S et al. Aspirin for the prevention of preeclampsia inwomen with abnormal uterine artery Doppler: a meta-analysis. Obstet Gynecol 98:861-6,2001.Meta -analysis offive trials demonstrates that abnormal uterine artery Doppler studiesidentify women who would benefit from ASA therapy.

Dekker G, Sibai B. Primary, secondary, and tertiary prevention of pre-eclampsia.Lancet 357:209-15, 2001.

Duley L, Henderson-Smart D et al. Antiplatelet drugs for prevention of preeclampsiaand its consequences: systematic review. BMJ 322:329-33, 2001.A meta-analysis of 39 trials consisting of 30,000 women demonstrated a 15% decrease in theincidence of preeclampsia, an 8% decrease in preterm birth, and a 14% decrease in fetal orneonatal death.

Goffinet F, Aboulker D et al. Screening with a uterine Doppler in low risk pregnantwomen followed by low dose aspirin in women with abnormal results: a multicenterrandomized controlled trial. Br J Obstet Gynaecol 108:510-8, 2001.There were no differences between screened and non-screened women in the incidence ofIUGR, preeclampsia, or any other markers of Perinatal morbidity.

Roberts JM. Preeclampsia: Is there value in assessing before clinically evident disease?Obstet Gynecol 98:596-9, 2001.

Thadhani R, Ecker JL et al. Pulse pressure and risk of preeclampsia: a prospectivestudy. Obstet Gynecol 97:515-20, 2001.Elevated pulse pressure at 7-15 weeks identifies women at high risk of developingpreeclampsia.

Wallenberg HCS. Prevention of pre-eclampsia: status and perspectives 2000. Eur JObstet Gynecol Reprod Biol 94:13-22, 2001.

Progress of laborEPIDURAL ANESThESIA

Howell CJ, Kidd C et al. A randomized controlled trial of epidural compared with non-epidural analgesia in labour. Br J Obstet Gynaecol 108:27-33. See also Kinsella SM.Commentary: Epidural analgesia for labor and instrumental vaginal delivery: an anaestheticproblem with an obstetric solution. Br J Obstet Gynaecol 108:1-2;No difference in the incidence of chronic backache; instrumental delivery rates wereincreased in the epidural group (30% vs 19%).

Lindeberg SN, Thorén T, Hanson U. A high rate of epidural analgesia withbupivacaine-sufentanil is consistent with a low rate of caesarean section and instrumentaldeliveries. EurJ Obstet Gynecol Reprod Biol 98:193-8, 2001.An alteration in technique increased the use of LEA from 38% to 63%. The cesarean sectionrate was unchanged (approximately 10%), as was the instrumental delivery rate.

Lucas MJ, Sharma SK. A randomized trial of labor analgesia in women withpregnancy-induced hypertension. Am J Obstet Gynecol 185:970-5, 2001.The authors stated that the duration of labor was increased "significantly" in the epiduralgroup, although analysis of their data showed no dWerence in the length ofthefirst stage(epidural 271 minutes, IV 266 minutes) and only a slight increase in the length of the secondsta ge (53 minutes vs. 40 minutes). The C/S rate was the same in both groups. The authorsstate in their abstract that the incidence of chorioamnionitis was increased in the epiduralgroup; in reality, this was based on an increased incidence of maternalfever in the epiduralgroup, and not on any objective measure of maternal infection. Finally, the authors wereconcerned about the 11% incidence of hypotension requiring treatmént in the epiduralgroup. This seems to be a fairly low incidence of what is usually a minor side-effect, andshould be contrasted with the 12-fold increase in the need for neonatal naloxoneadministration in the IV group.

Yancey MK, Zhang J et al. Epidural analgesia and fetal head malposition at vaginaldelivery. Obstet Gynecol 97:608-12, 2001.Another natural experiment from Tripler Army Medical Center (See also #328). An increasein epidural utilization from 1% to 83% had no effect on the rate offetal head malposition.

Zhang J Yancey MK et al. Does epidural analgesia prolong labor and increase risk ofcesarean delivery? A natural experiment. Am J Obstet Gynecol 185:128-34, 2001.No change in rate of cesarean section, cesarean section for dystocia, instrumental delivery,or length offirst sta ge; second stage was prolonged (by 25 minutes).

RISK FACTORS FOR CESAREAN SECTION

Alexander JM, Sharma SK. Intensity of labor pain and cesarean delivery. AnesthAnalg 92:1524-8, 2001.Women who required >50 mg/hr meperidine via PCA were 10 times more likely to requirecesarean section for obstructed labor.

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Sheiner E, Shoham-Vardi I et al. Infertility treatment is an independent risk factor forcesarean section among nulliparous women aged 40 and above. 185:888-92, 2001.The investigators analyzed the deliveries of 115 nulliparas aged >40 years with singletongestations. There were 80 spontaneous pregnancies, and 35 were the result of infertilitytreatment. There were no djfferences in obstetric risk factors or labor characteristicsbetween the two groups. Interestingly, the use of epidural analgesia was not mentioned inthe study. Cesarean section was more likely in the infertility group (71.4%) than in thespontaneous pregnancy group (41.3%).

ADDITIONAL ARTICLESSome of the articles that were identified via PUBMED were published in journals that wereeither unavailable to me or written in languages other than English. Their abstracts seemedinteresting enough, however, that I have listed them for those of you with a greater access tojournals or a more well rounded education than I possess...

Besmer I, Schupfer G et al. Postpartum neurologic complications following delivery withperidural analgesia: case report with literature review. Anaesthesist 50:852-5.

Ferrari L, De Sevin F et al. Intracranial subdural hematoma after obstetric duraipuncture. Ann Fr Anesth Reanim 20:563-6, 2001.

Frigo MG, Camorcia M et al. Prehydration and anaesthesia in obstetrics: state of the art.Minerva Anestesiol 67:161-8, 2001.

Hagberg C, Ezri T, Abouleish E. Etiology and incidence of endotracheal intubationfollowing spinal anesthesia for cesarean section. Isr Med Assoc J 9:653-6, 2001.

Ishikawa T, Kawahara S et al. Anesthesia for electroconvulsive therapy duringpregnancy: a case report. Masui 50:991-7, 2001. .

Iwama H, Furuta S et al. Extra-strong compression stocking reduces use of vasopressoragents during spinal anesthesia for cesarean section. Arch Gynecol Obstet 265:60-3, 2001.

Use of ephedrine was decreased from 85% to 49%.

Kulka PJ, Scheu C et al. Myocardial infarction during pregnancy. Anaesthesist 50:280-

4, 2001.

Lahme T, Jung WK et al. Patient surgical masks during regional anesthesia: hygienic

necessity or dispensable ritual? Anaesthesist 50:846-5 1, 2001.Use of a patient mask did not reduce the airborne concentration of bacteria over the

operative field.

Leykin Y, Luccca M. Complications related to the epidural catheter in caesarean

delivery. Minerva Anestesiol 67:175-80, 2001.

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Sheiner E, Shoham-Vardi I et al. Infertility treatment is an independent risk factor forcesarean section among nulliparous women aged 40 and above. 185:888-92, 2001.The investigators analyzed the deliveries of 115 nulliparas aged >40 years with singletongestations. There were 80 spontaneous pregnancies, and 35 were the result of infertilitytreatment. There were no differences in obstetric risk factors or labor characteristicsbetween the two groups. Interestingly, the use of epidural analgesia was not mentioned inthe study. Cesarean section was more likely in the infertility group (71.4%) than in thespontaneous pregnancy group (41.3%).

ADDITIONAL ARTICLESSome of the articles that were identified via PUBMED were published in journals that wereeither unavailable to me or written in languages other than English. Their abstracts seemedinteresting enough, however, that I have listed them for those of you with a greater access tojournals or a more well rounded education than I possess.

Besmer I, Schupfer G et al. Postpartum neurologic complications following delivery withperidural analgesia: case report with literature review. Anaesthesist 50:852-5.

460. Ferrari L, De Sevin F et al. Intracranial subdural hematoma after obstetric duraipuncture. Ann Fr Anesth Reanim 20:563-6, 2001.

Frigo MG, Camorcia M et al. Prehydration and anaesthesia in obstetrics: state of the art.Minerva Anestesiol 67:161-8, 2001.

Hagberg C, Ezri T, Abouleish E. Etiology and incidence of endotracheal intubationfollowing spinal anesthesia for cesarean section. Isr Med Assoc J 9:653-6, 2001.

Ishikawa T, Kawahara S et al. Anesthesia for electroconvulsive therapy duringpregnancy: a case report. Masui 50:991-7, 2001.

Iwama H, Furuta S et al. Extra-strong compression stocking reduces use of vasopressoragents during spinal anesthesia for cesarean section. Arch Gynecol Obstet 265:60-3, 2001.Use of ephedrine was decreased from 85% to 49%.

Kulka PJ, Scheu C et al. Myocardial infarction during pregnancy. Anaesthesist 50:280-4,2001.

Lahme T, Jung WK et al. Patient surgical masks during regional anesthesia: hygienicnecessity or dispensable ritual? Anaesthesist 50:846-5 1, 2001.'Use of a patient mask did not reduce the airborne concentration of bacteria over theoperative field.

Leykin Y, Luccca M. Complications related to the epidural catheter in caesareandelivery. Minerva Anestesiol 67:175-80, 2001.

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Newman MG, Lindsay MK Graves W. The effect of epidural analgesia on rates ofepisiotomy use and episiotomy extension in an inner city hospital. J Matern Fetal Med10:97-101, 2001.Epidural anesthesia increased the use of episiotomy but decreased the likelihood ofepisiotomy extension. -

Rezig K, Diar N et al. Goiter in pregnancy: a predictable cause of difficult intubation.Ann Fr Anesth Reanim 20:639-42, 2001.

Rout CC. Anaesthesia and analgesia for the critically ill parturient. Best Pract Res ClinObstet Gynaecol 15:507-22, 2001.

Sanchez-Conde P, Nicolas J et al. Comparison of ropivacaine and bupivacaine forepidural analgesia during labor. Rev Esp Anestesiol Reanim 48:199-203, 2001.

ACKNOWLEDGEMENTSMany thanks to Dr. James Cottreil and the SUNY-Downstate Medical Center Department ofAnesthesiology for providing the time necessary for me to prepare this review. I would alsolike to acknowledge the invaluable assistance of the staff of the Morgan Library at LongIsland College Hospital, and the Library of the New York Academy of Medicine. Thisreview would be incomplete if I failed to recognize the many contributions of Dr. Ostheimerto this Society and to obstetric anesthesiology. Finally, special thanks to Dr. Patrick Gibson,himself a student of Dr. Ostheimer, and the person most responsible for my decision todevote my energies to obstetric anesthesia.

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Sunday, May 5, 20026:30 am

7:00 - 8:00 am

8:15 - 9:15 am

9:15 - 10:15 am

11.45 am - 12:00 n

Scientific Program

Registration

Breakfast with the Experts (Limited Registration - By Ticket Only)Post-partum Analgesia - Alison J. MacArther, MD

Continuous Spinal Analgesia - Craig M. Palmer, MD

Labor Analgesia with Limited Staffing Resources - Richard N. Wissler, MD

International OB Anesthesia Education Opportunites - Medge Owen, MD;Sukran Sahin, MD

Fine Tuning Your CSE - Craig Leicht, MD, MPH

Answering Big Questions in Obstetric Anesthesia Research - B. Scott Segal, MD;Richard M. Smiley, MD, PhD

Ambulation after Labor Regional Anesthesia - Roshan Fernando, MBBS, FRCA

Fetal Distress and Unable to Intubate. What Next? - Maya Suresh, MD

The Morbidly Obese Preeclamptic Parturient - Sumedha Panchal, MD

Post Partum Tubal Ligation - Brenda A. Bucklin, MD

Billing - James P. McMichael, MD

Billing - Edward R. Molinas-Lamas, MD, FACA

Obstetrics and Family Medicine Issues in Labor and Delivery - Keith Johatsen, MD;Thomas Kastner, DM; Walter Franz, MD

Is OB Anesthesia More Liable for Litigation than Other SubspecialtiesMathew Kumar, MD, JD

Post Durai Puncture Headache - Anil Soni, MD; Mukesh Sarna, MD

Legislative Issues - Andrew P. Harris, Ml), MHS

PCEA Should Always Be Used in Preference to Continuous Epidural InfusionAnalgesia in Labor- MichaeFJ. Paech, FANZCA

Anesthesia for Placenta Accerta - Alex E Pue, MD

Fred Hehre LectureDavid M. Dewan, MD

Oral Presentations #2Moderator: Cynthia A. Wong, MD

10:15 - 10:45 am Coffee Break

10:45 - 11:45 am Oral Presentations - Best Pa.er of the Meetin' AwardModerator/Judge: Michael J. Paech, FANZCAJudges: Sivam Ramanathan, MD; Edward T. Riley, MD; Scott Segal, MD

Best Paper of the Meeting Award / AdjournmentModerators: Joy L. Hawkins, MD; Gary M.S. Vasdev, MD

Breakfast with the Experts(Limited Registration - By Ticket Ónly)

7:00 - 8:00 àm

Post-p artum Analgesia - Alison J. MacArther, MD

Continuous Spinal Analgesia - Craig M. Palmer, MD

Labor Analgesia with Limited Staffing Resources - Richard N. Wissler, MD

International OB Anesthesia Education Opportunites - Medge Owen, MD;Sukran Sahin, MD

Fine Tuning Your CSE - Craig Leicht, MD, MPH

Answering Big Questions in Obstetric Anesthesia Research - B. Scott Sega!, MD;Richard M. Smiley, MD, PhD

Ambulation after Labor Regional Anesthesia - Roshan Fernando, MBBS, FRCA

Fetal Distress and Unable to Intubate. What Next? - Maya Suresh, MD

The Morbidly Obese Preeclamptic Parturient - Sumedha Panchal, MD

Post Partum Tubal Ligation - Brenda A. Bucklin, MD

Billing - James P. McMichael, MD

Billing - Edward R. Molinas-Lamas, MD, FACA

Obstetrics and Family Medicine Issues in Labor and Delivery - Keith Johansen, MD;

Thomas Kastner, DM; Walter Franz, MD

Is OB Anesthesia More Liable for Litigation than Other SubspecialtiesMathew Kumar, MD, JD

Post Durai Puncture Headache - Anil Soni, MD; Mukesh Sarna, MD

Legislative Issues - Andrew P. Harris, MD, MHS

PCEA Should Always Be Used in Preference to Continuous Epidural InfusionAnalgesia in Labor- Michael J. Paech, FANZCA

Anesthesia for Placenta Accerta - Alex F Pue, MD

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The Morbidly Obese Preeclamptiò PatientBreakfast With The Experts

38 year old G! P0000 presents at 38 2/7 weeks presents for induction of labor.She is 5'5" and weighs 340 lbs. Her medical history is significant for morbid obesity,gestational diabetes, and mild preeclampsia (BP 150/92, 2 proteinuria).Laboratory studies include: Hgb 10.1; platelet count 142,000.She has a class IV airway.Medications include magnesium sulfate and oxytocin.What is your plan for labor analgesia?What is your plan for anesthesia if the patient requires a cesarean delivery?

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Fred Hehre Lecture

David M. Dewan, MD

8:15 -9:15 am

Participant will learn about the changes in obstetric anesthesia practiceover the last 25 years and how these changes have impacted the specialty.

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Obstetric Anesthesia 1977 - 2002

A personal perspective - From Consilience to Victory

OBJECTIVE: This lecture will provide an overview of the changes in obstetricanesthesia during the last 24 years Following this lecture theaudience will gain an understanding of how these changes haveimpacted the specialty of obstetric anesthesia, academic anesthesiatraining, the patients and themselves.

The period from 1977 to 2002 has been a remarkable era for obstetric anesthesia,both at my institution and nationally. We have made tremendous progress in the deliveryof health care to the pregnant patient, making it more accessible, and of higher quality.We, as a specialty, have gained credibility. It has been two and a half decades of victory.A victory we won by, doing three things: 1) being there, 2) doing the right thing, and 3)being memorable. These three actions lead us to victory whether it is in our personal orprofessional lives or with patient care, resident education, or research. This is the pathwe must choose if we are to continue to move forward, for we have many challengeslying before us.

When you compare the progress made at our institution during the last 25 yearsand the progress we have made nationally, the similarities are remarkable. I believe thetools we utilized at our institutiàn to achieve victory parallel those used by you to achievenational success. The tools we used are set forth in the book entitled Consilience: TheUnity of Knowledge.' Consilience is the concept that for a given situation the bestsolution is one which is compatible with social science, ethics, biology, andenvironmental science. In other words, the best solution is best for all parties.Something that is good for science, but detrimental to society, is not a good solution. Theoutcome does not meet the consilience test. By doing three things, being there, doing theright thing, and being memorable, we have victory and we have a test for consilience, avictory within itself. Doing the right thing is a good solution and a victory.

Let's look at being memorable. To do that means we have to understand whatmemory is. Good solutions create good memories for you, the obstetrician, and thepatient. In the same, highly difficult to read, but incredibly insightful book, the authordelves into what distinguishes recall and memory. In the authors perspective, recall issimply the recollection of facts. In contradistinction, memory has associated emotions.For example, reading about the World Trade Center 100 years from now will have asignificantly different impact on the reader than for those who witnessed the event whenit occurred. The history reader will recall facts, we will have memories which will befelt.

Let's transfer this to our specialty. In the practice of anesthesia, reading about adurai puncture clearly has a different impact than the memory of performing anunintentional durai puncture with its astounding intensity of emotion. As one of mycolleagues once said, "The room sure gets hot." According to the Consilience concept,and documented by my own personal experience, attached emotions which accompanymemory may allow the brain to prioritize previously experienced scenarios. Forexample, as a second-year anesthesia resident I was dispatched to the labor and deliverysuite to assist a medical student in providing a generai anesthetic for cesarean section inan obese patient. My attending was four floors away. We proceeded with a rapidsequence induction; the medical student attempted laryngoscopy and informed me, "I .

don't see anything." My response was "try again"; he did - same result. I asked him tostep aside, and I unsuccessfully attempted mask ventilation. As my heart rate increased Iattempted laryngoscopy only to substantiate the medical students findings. Nothingrecognizable was visible. Once more I attempted mask ventilation and heard the horriblesound behind me of a slowing heart rate. This patient was about to die! I inserted an oralairway to no avail and followed that with a nasal trumpet. Fortunately I was able tomarginally ventilate the patient with this latter maneuver as she recovered from hersuccinylcholine. As she regained adequate respirations, my attending entered the room.The patient returned the subsequent day for cesarean section utilizing epidural analgesia.

It is little wonder that when my brain replays scenarios regarding the managementof obese patients, general anesthesia does not top my list. I do not recall this patient, Iremember this patient. The emotions attached to this memory warn me about the hazardsof general anesthesia in the obese pregnant patient. Memories, both positive andnegative, help determine future behavior. Memories create victories and reinforceconsilience. In the next hour I will discuss the achievements we made locally and youmade nationally and share with you our experience at Wake Forest and I hope to providea template for futuré actions. The template is one of being visible, doing the right thing,and creating memories, resulting in victòry.

Let's go back to 1977, how our victory got started. In 1977 there were 3,326,632live births in the United States.2 The cesarean section rate had increased dramatically inthe preceding 10 years and was now l5.2%. Maternal mortality was at 14.3/100,000deliveries,3 with anesthesia accounting for 4-6% of all maternai deaths.4'5 Obstetricanesthesia was a lonely stepchild as far as most anesthesia departments were concerned,with job advertisements promoting a benefit of employment as "no OB." The presidentof the Florida Society of Anesthesiologists once said, "Obstetric anesthesia, if it wouldjust go away, we would all be happy.ó In 1969 an anesthesiologist was present at only,12% of déliveries and CRNAs were present at only 25%. The remainder of coveragewas provided by obstetricians and "others." As late as 1981 full-time anesthesia waspresent at only 21% of hospitals.8 Regional anesthesia was utilized for 50% of cesareansections and epidural analgesia was utilized in only 16% of labors. We were not present!As a resident at Wake Forest, I witnessed first-hand the negative aspects of this level ofcare. While covering the ICU, we received a transfer from a nearby hospital of a womanwho received a mask anesthetic, by a CRNA, for cesarean section that resulted in massiveaspiration. It was a lethal event. I vividly recall a baby, a husband, and a dying mother.There was no consilience, no being there, no doing the right thing, no positive memory.

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, It was in this environment that I entered, with Dr. Frank James, my Section Headand mentor, the world of obstetric anesthesia. In 1977, Winston-Salem, North Carolina,was a community of approximately 120,000 with three hospitals delivering infants. Noneof the hospitals were happy. The medical school had a marginal number of deliveries toprovide adequate resident training. The community hospital, in part because it was new,received an inordinate (from their perspective) number of indigent patients, and the thirdhospital delivered insufficient numbers of patients to remain viable. In order to solve thisproblem, through the wisdom of Dr. Frank James, Section Head, and Dr. Frank Greis,;Chairman of the department of OB/GYN at Wake Forest (both Fred Hehre lecturers), thecommunity leaders made the decision to consolidate obstetric services in the communityhospital. The medical school would provide anesthesia coverage, a high-risk perinatal

.

service, and neonatology coverage. At that time, the physical plant we would use seemedlarge. We were allocated 13,831 square feet for the acute services which included 2 ORs,2 cesarean section rooms, 3 delivery rooms, and 10 labor beds, of which half were doublepatient rooms. We were to provide coverage with five anesthesiologists, five CRNA's,three residents (one of whom was an obstetric resident), and one fellow. Our workloadfor the first year was 2,141 gynecology cases and 4,028 deliveries. The cesarean sectionrate during the first year was 18.1%.

Considering the disrespect obstetric anesthesia had nationally at the time and thefact that the medical school was "invading" the community hospital, to say that ourreception was "not warm" would be an understatement. The barriers we confronted werenumerous: 1) fear of regional anesthesia (and its perceived impact on the progress oflabor) by obstetricians, 2) perceived loss of control by the obstetricians and labor nurses,3) the poorlyreceived concept of residents working on private patients, 4) a communityhospital with an administration that didn't trust the "school" to the degree that theydemanded the right to oversee department finances, 5) a visible and vocal lamazecommunity that was vigorously anti-epidural. I remember well walking in my first day,hardly finding my way to where I was supposed to be, knowing only a few people, andknowing full well that some of the others, "as yet unidentified," clearly opposed mypresence. s.

Fortunately, Dr. James had clearly outlined our mission, which was to provideexcellent patient care, resident teaching, and research. However our more immediategoals were 1) to establish regional analgesia for labor, 2) reduce the use of generalanesthesia for cesarean section, 3) provide safe regional anesthesia for cesarean section(remembering that left uterine displacement and volume preloading were new and notuniversally accepted advances even among anesthesia practitioners at that time), and 4)establish a working relationship with hospital administration. We would do all this byproviding a 24-hour a day, in-house coverage, the first commitment by any anesthesiateam in the community in that era to take in-house call. We would be visible - we wouldbe present. One of the first steps to victory - being there.

Our first year of experience was neither good nor bad but laid the foundation forthe future. Thirty-two percent of vaginal deliveries utilized epidural analgesia, 36%received inhalation analgesia, and 32% received monitored anesthesia care (we attended

vaginal deliveries). For cesarean section 5% received spinal anesthesia, 42% epiduralanesthesia, and, in retrospect, an astounding 53% had general endotracheal anesthesia forthe cesarean section. It is fair to emphasize endotracheal anesthesia considering the time.

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How would we accomplish our mission outlined by Dr. James in thisenvironment? By being there, doing the right thing and being memorable, establishingconsilience, establishing victory, one patient at a time. As it turns out the mode ofdelivery of anesthesia care was perfect for the mission. It would make us visible andpresent. It was up to us to do the right thing and be memorable.

Let me take you back to a typical delivery. 4J.i patients were interviewed as soonas they arrived. This preanesthesia consultation was uniformly applied. If a patient optedfor epidural analgesia, following catheter placement, blocks were initiated with 2%chioroprocaine and maintained with incremental injections of 0.25% bupivacaine. Everypatient received a "sitting dose." Perineal analgesia was nearly always established inthe labor room prior to transfer to the traditional delivery room. Patients not utilizingepidural analgesia were also transferred to the delivery room where they either receivedmonitored anesthesia care or inhalation analgesia. Finally, following delivery patientswere transferred to the PACU prior to discharge to the ward. This was an incrediblytime-consuming venture for anesthesia, but had the unanticipated benefit of forcedinteraction with obstetricians, nurses, and most importantly the patients. So many timeswe were told by the patients that they knew us better than their obstetrician because bythe time delivery occurred, we had spent more time with them than their obstetrician had.Memories were being created. We had to make them memorable and we had to do theright thing. .

For example if a patient has a unilateral block which you correct resulting in acomfortable patient, the memory and emotion created for you and the patient is one ofsatisfaction, trust and, for you, personal victory. However ignoring or missing a patchyblock meant you might have the "opportunity" to be present for the exquisite pain of amid-forceps delivery. Neither the patient, the obstetrician, nor the nurses are left with afeeling of trust regarding your services. Fortunately, the time-consuming venture ofhourly redoses and forced patient interactions made us confront our failures rather thanignore them. Anesthesiologists, despite intellectually knowing that there is a minimumfailure rate associated with epidural analgesia, find it difficult to revisit patients ¡n whomanalgesia is poor, thus avoiding stress. How many times in this setting when called for aredose have you said, " Oh no, not her again!" It is, however, this patient who deservesattention. Confronting and dealing with our failures and observing the outcome allows usto prioritize memories. Prioritizing memories enables us to choose a course of action inthe next similar scenario which may improve the outcome. Seen from this perspective,each of our encounters with family, administrators, colleagues, and patients is not only anopportunity for us to learn but, more importantly, an opportunity for us to create apositive memory for all concerned. It is the memories we create by our individual,ethical, interactions that predict future experiences and lead us to victory.

Let's see how being there, doing the right thing, and creating memories applies tomy personal and professional life experience. Each of us has personal, professional,patient care, and, for some of us, research triumphs. In each of these doing the right thingand being ethical will create victorious memories.

I was asked the question, "What is your greatest personal triumph?" and aftersurprisingly little reflection I answered "Raising my daughter." I have had theopportunity to raise a daughter from age 12 to 24 as the sole parent, a task which wasunexpected and intimidating. I remember vividly while traveling by car with her at age

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13 to New York State to see her grandfather for Christmas, when she suddenly made thefollowing statement; "Dad, I don't have any memories." At that time I resolved to takepersonal responsibility for providing positive, ethical, and enriching memories. Certainlythese included memorable vacations, but in retrospect memories were more about beingthere and doing the right thing. For example, when she was ill, thanks to my incrediblyunderstanding colleagues, I was uniformly able to arrange to be with her. As part of her"treatment" I prepared mashed potatoes. For me this was parenting, for her it wascreating an environment of warmth, trust, and safety. My mashed potatoes were attachedto a memory. My daughter is now 24 and, to this day, mashed potatoes are still the bestthings that I can cook. Doing the right thing creates good memories and creates victories, -sometimes in unanticipated ways.

Arriving at Forsyth as ajunior faculty I had proven clinical skills. During myresidency and two years in the Navy, however, administration was a blank area. WhenDr. James left to become the Chairman of the Department of Anesthesiology and Iassumed the position of Section Head, I was inexperienced and somewhat

:administratively unprepared. Remember, this was a hostile environment. In fact when Iassumed the Section Head position and asked to meet with the chief hospital -

administrator, he refused because he said he only met with chairmen. Within my firstfour months I had my first catastrophe. At that time the department of anesthesia had aseparate professional contract and a billing contract, both with a 90-day lock in. Unlessrenegotiation was requested within 90 days of the expiration date, the contract wasautomatically renewed. I met with an administrator in advance of the deadline regardingthe professional contract and made the fatal assumption that I was discussing bothcontracts. When the executive asked to delay discussions for a week, I made the secondfaulty assumption that this was done in good faith. . After the week passed, theadministration invoked automatic renewal of the contract because negotiations had notbegun regarding Jth contracts. I had experienced my first journey into the area ofadministration and the memories created for me were distasteful. I now had a scenarioand a memory with attached emotions, which if not replaced by better emotions, boded illfor the future. I needed a victory. Urgently I met with the administrator, and while tryingto keep my composure, stated that his actions were not consistent with the character andvalues I expected from an honorable person and were not compatible with developing along-term working relationship. To his credit he came to me, sincerely apologized, and inthe next few years supported our Sections position in various arenas. I subsequentlyreturned his good faith by opting for one year not to increase rates. It was the appropriateethical decision at that time because it was good for us (at that time our cash flow wasexcellent), it was good for the hospital which was worried about its public image, and itwas good for the patients. It was a memory that he did not forget and is a victory aboutdoing the right thing. He subsequently became the leader of the entire Piedmont NovantHealth system of which Forsyth hospital is only a part. We have become friends,respectful of each other, and because of the mutual trust our memories have evoked, overthe lastlO years have operated on a handshake contract. With his approval I recently -

completely a two-year tenure as Chairman of the Surgical Services Counsel whichoversees the workings of all surgical services in three community hospitals. Twenty-fiveyears previously I was one of the enemies. Who would have thought this could happen?Doing the right thing does matter. I ask each of you now to think about what is your

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relationship with your hospital. What is your relationship with your administrators? Doyou have one? Are you visible and present? Are you interacting? Are you taking eachencounter as an opportunity to do the right and ethical thing and creating positivememories - establishing victories for both of you. Doing the right thing does matter.Sometimes you won't even remember the event, but they will.

Patient care is simplistically no more than repetitive encounters with the public;encounters filled with memories and recall. As with your personal and professional life itcan be filled with victories and defeats; Some victories will occur because ofhappenstance. As you recall, in our opening unit, many of the labor rooms were doublepatient rooms. This had unintended positive consequences for us. For exämple, I vividlyremember interviewing a primiparous patient regarding her anesthetic options and beinginformed by her that she would not need anesthesia and did not need to speak with me.This felt like an immediate discounting of the need or use for my service. From thecurtain behind me came the voice of the other patient, "I have already had a baby and Iwill listen to anything you have to say." Immediately there was a sense of validation ofour work and value. I assure you, the patient who discounted our service also heard. Ifwe had not been visible by interviewing jj patients, only those who requested ourservice, this would not have happened. There would be no memory of our section, of ourrole, and our importance. I felt victorious. In another circumstance I placed an epiduralin a patient and, after removing her pain, walked over to the other patient and asked herwhat analgesia she wanted. She pointed to the patient I just anesthetized and said, 1

don't know what it is, but I want what she has." A "When Harry met Sally" moment.Visible and memorable. Happenstance created memories. We did not sell epiduralanalgesia to the public; being there and creating memories "sold" them.

At other times being involved created the opportunity for victory. While attendinga monitored anesthesia care delivery, a previously healthy gravida one experienced apulmonary embolism. Because we were there and the equipment was there, the patientwas intubated, ventilated, and ultimately had a good outcome. The nurses, obstetricians,patient, and husband all had a memory of that event. No longer were we viewed as anintrusion at delivery.

At other times creating positive memories involves doing the right, albeituncomfortable, thing. When obstetric anesthesia arrived at Forsyth, one of the privateobstetricians, who was particularly anti-anesthesia, hated left uterine displacementperceiving that it interfered with surgery. One morning, at three A.M., the surgeon waspreparing to do a cesarean section. He requested that left uterine displacement beremoved. We refused and the obstetrician became irate and refused to operate. Theobstetrician lost his composure and proceeded to call the Dean at home in an attempt tohave left uterine displacement removed. He failed. Was the memory good for allparties? Ultimately, yes. The patient received the best anesthetic, we did the right thing,and the obstetrician learned that we had principles regarding patient care. The sameobstetrician became one of our strongest advocates. Being present, acceptingresponsibility for outcomes, both good and bad, builds a history of trust (not blame)which creates the future. What I learned over 25 years was that doing the right thing,being present, creates learning experiences and memories. Are you visible on labor anddelivery? Do your patients remember you? Is your relationship with your obstetricians arelationship of trust or blame? Are you celebrating your victories one by one?

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One final vignette from my own personal experience. I was informed one daythat a patient was requesting me to perform her anesthetic for cesarean section. I did notrecognize the patient's name nor did she give a reason for requesting my service. Iwalked by the door to the interview room to see if I could recognize her and could not. Icould not ever recall seeing this woman in my life. I entered the room and introducedmyself and confirmed the fact that she was requesting me to perform her anesthetic. Shesaid yes. I apologized for not remembering her and asked her why she was requestingme. She informed me that I had performed her last anesthetic. I said, "I assume all wentwell?" A frown crossed her face as she reflected upon her previous experience,obviously reliving it, and said, "It was horrible!" "The epidural did not work." "Youattempted to repair it, and when they started the surgery I had great pain and you had toput me to sleep." I asked, feeling perplexed, why, considering this, she wanted me to beher attending again. Her answer was, "Because no matter how bad it got, I trusted you."A memory I hold now from seven years ago. These are the relationships we build onepatient at a time: being there, being present and committed, and doing the right thing andbeing memorable - developing consilience with a unity of knowledge. Are youestablishing relationships with your patients? Do your patients remember you helpingthem achieve their victory?

Victory is also about resident education. Resident education involves acontinuum from data acquisition to wisdom. Wisdom is the ability to transfer skills andexpertise learned in one area to other areas. Progression through the learning processoffers potential ethical conflicts between resident teaching and patient care. One of ourobligations to residents is to create memories for them that will enable them in later yearsto subsequently prioritize scenarios when confronted with dilemmas, that is, to transferknowledge and have wisdom. Residents, especially in early training, tend to focus ondata acquisition, and, not infrequently, the data acquired conflict with a diagnosis. Forexample dermatomes identified utilizing a pin should not discount the patient'scomplaint, "I am more numb on one side." At our facility the attending anesthesiologistmakes postoperative visits for Li deliveries. One realization,I have had over the years isthat it is a rare patient who complains when a poor block is replaced by an effective one.In contrast, the number of patients who complained because a block is not repeated isremarkable. Not infrequently the patient will state, "I was numb on one side" while thechart documents symmetry. Distinguishing between an adequate and an inadequateblock is a surprisingly difficult venture. It is hard for residents, like all of us, to accept aperceived failure. Accepting the fact that 5% of epidurals fail, despite perfect technique,is gaining expertise. Learning when to replace blocks is wisdom. How do we creatememories for residents to teach wisdom without creating ethical conflict?

If we see a patient with a marginal block during labor who is proceeding tocesarean section, our action or inaction will dictate outcome. Not infrequently, a residentwill maintain the blockade is adequate and that the patient is simply experiencing"pressure." In this case we could proceed with the marginal block, allow the resident toexperience first-hand the quality of the block he or she has just utilized and probablyhave the opportunity to do a general anesthetic. Alternatively, we may insist they repairthe quality of block and an uneventful regional anesthetic will follow. In the secondscenario the only emotion likely attached to this scenario is the irritation the resident hasfor the attending's forcing upon them the extra work of replacing' an "adequate block." In

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the first scenario the patient experiences pain and suffers the risk of general anesthesia.At our institution, ethics are always for the patient, and we have to use alternativestrategies to create memories for the residents. Some solutions may not be as effective aswe anticipate. The department has a patient simulator which we hoped would offer analternative strategy for acquiring skills. While this may be true, a recent paper by our.plTysicians revealed that simple skills, taught in the anesthesia simulator lab, wereforgotten relatively quickly.9 It is my contention that the lack of emotions, thus the lackof sustained memory, attached with the simulator accounts for the short-term retentionrate. .

We have to find the intermediate ground. I was recently informed about a patientwho was having a cesarean section for failure to progress utilizing a preexisting epidural.The resident and I visited the patient where I was unimpressed by the quality of blockade,but the resident contended that it would workjust fine. Since this was a non-emergentcircumstance, I offered the resident the chance to attempt to achieve anesthesia forcesarean section. Hoping to guide him to the correct decision, I obtained an Allis clampand asked the house-staff to use it and check for anesthesia by pinching the abdomenprior to transport to the operating room. At transfer the resident called me, I asked himabout the quality of blockade, and he informed me that the patient had passed the "Allistest." Following prep and drape the obstetrician clamped the abdomen which wasaccompanied by a groan of pain by the patient. I asked the resident did you use the Allis?He answered, "Yes, but not that hard." We repaired the epidural in the operating roomby manipulating the catheter and the outcome was good. Other than inconvenience forthe obstetrician all parties experienced benefit, the patient remained awake, the residentlearned, and the surgeon was content with regional anesthesia. Three months later theresident returned bringing his own Allis clamp with him. As the years have proceededand technology has replaced incremental injections and the time we spend with eachpatient has declined, the opportunities to create memories are lost for residents, patients,and ourselves We need to explore other ways to achieve victory

Some of our victories have occurred in the area of research Successful researchoutcomes provide value for the anesthesiologist, patient, and the obstetrician, accordingto the theory of cons ilience. In our early years one of our anesthesiologist wanted tocompare end tidal CO2 vs. arterial PCO2 at cesarean section. Capnògraphy was not as yeton the horizon for the anesthesia specialty. We obtained a laboratory device whichmeasured end tidal CO2 and proceeded with the investigation Dunng one of the studies,we diagnosed esophageal intubation The endotracheal tube was replaced and the patientdid well Suffice it to say we never removed the device from the cesarean section roomand later capnography became a national standard of care A victory and a memory ofdoing the right thing and being there Our institution was one of the first institutions toinvestigate PCEA and publish results speculating about its benefits It appears all arewinners, all are victorious Patients like PCEA because they retain some control,obstetricians like PCEA because, with proper coaching, less dense analgesia is present atdelivery, and it is good for us because it dramatically decreases our workload, freeing usto provide analgesia to others who might otherwise not have received our serviceSimilarly CSE because of its rapid onset has enabled us to reach even more patients Thenumber of required physician encounters per patient by the anesthesia team has decreaseddramatically over the years since the introduction of CSE and PCEA. I did some

155

calculations regarding our current anesthesia delivery practice compared with 1977. Itturns out that comparing these two practices resulted in 28 1 days saved in workload bynot redosing when you compare CSEIPCEA vs the older technique of incrementalredosing Research is good for patient care and an opportunity for victory

So what has happened in our hospital after 25 years') We are currentlyredesigning and building a new LDR suite which will open in 2005 It will include43,200 square feet for acute care services including 2 cesarean section rooms, 5 operatingrooms, and 24 LDR's In 2001, the last year of available statistics we have had asignificant growth in service. We had 6,539 deliveries which included 5,124 vaginaldeliveries and i 4 1 5 cesarean sections for a cesarean section rate of 2 1 . i 6%- this, inaddition to, our 3,000 gynecologic cases. For cesarean section 1 . i % received CSE,56.3% spinal anesthesia, 35.5% epidural anesthesia, and 7. 1 % general anesthesia. Forvaginal delivery, 50 5% received epidural analgesia and 29 4% received a combinedspinal epidural analgesic A remarkable shift in the utilization of anesthetic techniquesRegional anesthesia is the preferred anesthetic

Contrast the following scenario regarding cesareañ section anesthesia with ourearly experience An obstetrician, at two a m was to perform an emergent cesareansection for a laboring patient with a breech presentation The patient was ASA I with aClass I airway, NPO, with no contraindications to general anesthesia The patient refusedregional anesthesia When the obstetrician heard this he said, "This decision is notacceptable " He walked into the patient room and again the patient refused regionalanesthesia The obstetrician said, "That is fine, and I will see if I can find you a newobstetrician " The patient relented, had a spinal anesthetic, loved it and all parties werehappy We were victorious We are now uniformly accepted by administration, patients,and obstetricians Research is accepted as an important aspect of our care

Nationally in 2000 there were 4,064,948 births IO The cesarean section rate was22 9% in 2000,b0 and the maternal mortality rate was approximately 7 5/100,000deliveries Anesthesia mortality has declined from 4 3/million births in 1 979- 1 98 1 toi 7/million in 1988-1990 12

By 1992 eighty-four percent of cesarean sections utilizedregional anesthesia, and 37% of labor patients received epidural analgesia 13 Regionalanesthesia is more prevalent and safer than ever before. We have succeeded and havehad a quarter of a century of resounding victory

What's left for us to do') General anesthesia mortality is 17 fold the rate forregional anesthesia.i2 As when I entered the specialty 25 years ago, aspiration añdairway problems remain We must not rest on our laurels but bring new skills from theoperating room to labor and delivery for managing difficult airways The LMA,fiberoptic intubator, and the Fastrach LMA may be life saving Interestingly, when askedwhat our faculty thought were the greatest advances in the previous 25 years were,technology advances led the list Technology enabled us to make regional anesthesiaavailable to more patients, and that has been one of our foci Now we must make surethat we are not distancing ourselves from the patients with this victory Technology canimpose impediments for reliably assessing the adequacy of analgesia We aren't thereToday when a patient requires additional analgesia she pushes a button. In many wayswe have replaced ourselves with a round, fingertip operated device Despite the fact thatthe number of redoses predicts the failure rate of epidural anaigesia,i4 I have seen lockoutcreep The number of cc's allocated per hour either by continuous infusion or PCEA

156

bolus increases in an effort to save time by not having to personally db a redose. We arenot confronting our failures as quickly or reliably as we did because we aren't there. Upto 10% of labor epidurals may not be used for cesarean section. How many of these areinadequate? What is the conversion rate to general anesthesia rate at your institution?According to the ASA Closed Claims Survey, aspects which differentiate obstetricanesthesia suits from non-obstetric suits are the greater number of claims for minorcomplaints and pain during anesthesia.'6 Is this an accident? Is it because we aren'tthere? Will one of these inadequate blocks lead to a catastrophe?

Twenty-five years ago anesthesia personnel used the argument against placingendotracheal tubes for cesarean sections because aspiration had never happened to"them." Today I am concerned that the same attitude is developing regarding failedintubation subsequent to failed regional blockade associated with poor labor analgesia.The frequency of failed intubation and ventilation is low. Is it likely that a failedintubation and failed ventilation will occur in your career during a conversion fromregional to general anesthesia? Probably not. Yet there were over four million deliveriesin the United States in 2000 SO it is likely that this event did occur. Are we in danger ofbecoming Firestone? The individual utilizing Firestone tires was probably safe but thenation had a problem. Attention to detail is vital. Each of us should assess how often alabor analgesic is insufficient at our institution. We must do this by being visible andpresent. :

We have been victorious in the last 25 years personally and professionally. Asyou look around the room remember that this audience was started by a handful of peopleat a time when most anesthesia provider's viewed obstetric anesthesia as best if youdidn't have to do it. What a great victory. It is now you, the audience, who are going towrite the next 25 year history. I challenge you to be ethical by doing the right thing,being visible, and present, and creating for yourself and others, positive memories, oneencounter at a time. You may not remember the encounter but certainly in the case ofpatients, they will remember you. Practice consilience, do what's best for all, and youwill gain wisdom. Even better, you will be victorious.

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References

i . Book ' Wilson EO, Consilience: The Unity of Knowledge. New York::. Alfred A. Knopflnc., 1999.

Website www.cdc.gov/faststarts/births.htmCDC, NVSR vol; 29, April 2001

Journal Petitti DB, Cefalo RC, Shapiro S, Whalley P. In-hospital maternalmortality in the United States: Time trends and relation to methodofdelivery. Obstet Gynecol 1982, 59(1) 6-12.

Journal ' Kaunitz AM, Hughes JM, Grimes DA, et al. Causes of maternalmortality in the United States. Obstet Gynecol, May 1985, 65:(5)

.

605-612.Journal McLean R, Mattison E, Cochrane N. Symposium/Maternal

mortality study. Annual Report, 1970-1976. New York StateJournal of Medicine, January 1979.

Newsletter Garrett LP. Florida Society of Anesthesiologists' Newsletter,February 1984.

Journal James FM. Availability of anesthesia personlie for obstetrics.Southern Medical Journal, August 1971, 64(8): 992-995.

Journal Gibbs CP, Krischer J, Peckham BM, et al. Obstetric Anesthesia: Anational survey. Anesthesiology 1986, 65:298-306.

Presentation Ford RPA, Saunders 1CM, Whelan R, Olympio MA. Wake ForestUniversity Baptist Medical Center. Changes in technicalmanagement of esophageal intubation following simulationtraining. Given at the International Meeting on MedicalSimulation. January 2002.

Journal Martin JA, Hamilton BE, Ventura MA. Births: Preliminary Datafor 2000. Division of Vital Statistics. National Vital StatisticsReports, July 24, 2001,49(5)1-6.

PublicationMaternal Mortality - United States, 1982-1996.

Journal Hawkins JL, Koonin LM, Palmer SK, Gibbs CP. Anesthesia-related deaths during obstetric delivery in the United States, 1979-1990. Anesthesiology 1997; 96:277-84.

Journal Hawkins JL, Gibbs CP, Orleans M, et al. Obstetric anesthesiawork force survey, 1981 versus 1992. Anesthesiology1 997;87: 135-43.

Journal Coq CL, Ducot B, Benhamou D. Reports of Investigation. Riskfactors of inadequate pain releif during epidural analgesia forlabour and delivery. Can J Anaesth 1998; 45(8) 7 19-723.

Journal Garry M, Davies S. Failure of regional blockade forcaesareansection. International Journal of Obstetric Anesthesia (2002) Il,9-12.

Journal Chadwick HS, Posner K, Caplan RA, et al. A comparison ofobstetric and nonobstetric anesthesia malpractice claims.Anesthesiology 1991, 74:242-249.

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Oral Presentations #2

Moderator: Cynthia A. Wong, MD

- 9:15-1O:l5am

02-1 CAN ROPIVACAINE AND LEVONUPIVACAINE BE USED AS AN INTRAVENOUS TESTDOSE FOR REGIONAL ANESTHESIA?Gautier, P.; OEven. M.D.; Hood, D.D.

02-2 THE VIRTUAL LARYNX: TEACHING INTUBATION SKILLS WITH FEWER PATIENTSGlassenberg, R. Glassenberg, S.

02-3 MATERNAL SURGERY DURING PREGNANCY: A POSTNATAL OUTCOME STUDY USINGGUINEA PIGSde la Fuente, S.G.; Pibeiro, J.C.; Greene, R.R.; Eubanks, S.W.; Reynolds1, J.D.

P-9 THE USE OF VIDEO TAPES OF SPECIFIC ERRORS AS AN ADJUNCT TO TEACHEPIDURAL TECHNIQUEJ3irnbach, D.J.; Marenco, J.E.; Kerimoglu, B.; Stein, D.J.; Santos, A.C.


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Oral Presentatioñs. I Best Paper of the Meeting Award

Moderator/Judge: Michael J. Paech, FANZCAJudges: Sivam Ramanathan, MD; Edward T. Riley, MD; Scott Segal, MD

10:45 - 11:45 am

02-4 ALPHA-1 AGONISTS VS EPHEDRINE FOR C/S HYPOTENSION: A SYSTEMATIC REVIEWHalpern, S.; Chochinow, M,

BP-2 IN VITRO INVESTIGATION: EPIDURAL CATHETER PENETRATION OF HUMAN DURAAngle, EJ.; Kronberg, J.; Thompson, D.

BP-3 MORPHINE'S SITE OF ACTION FOR ANALGESIA TO UTERINE CERVICAL DISTENSION ISCENTRAL AND ANTAGONIZED BY ESTROGENRisenach, J.C.; Sandner-Kiesling, A.

01-1 RANDOMIZED TRIAL OF NEURAXIALVS. SYSTEMIC ANALGESIA FOR LATENT PHASELABOR: EFFECT ON INCIDENCE OF CESAREAN DELIVERY

- \Vong, C.A.; Scavone, B.M.; Sullivan, J.T.; Marcus, R.L.; Sherwani, S.S.; Strauss-Hoder, 'r.P.;Yaghmour, E.A.; McCarthy, R.J.

All Abstracts on this page are located in the Anesthesiology Supplement.

160

SOAP 2002 Annual MeetingExhibitors

The Sociqy for Obstetric Änesthesià & Perinatologylye/comes and thanks all representatives of industrj for

their support of this meeting, and for providing education

through their exhibits.

A list of 2002 exhibItors follows

COMJANy NAME

Exhibit Hall HoursThursday, May 2, 2002

7:00 am - 2:30 pm

7:00-7:45 ara Breakfast w! Exhibitors

9:45-10:15 am Coffee Break w/Exhibitors

12:15-1:15 pm Lunch w! Exhibitors

2:15-2:3Opm BreakwlExhibitors

Friday, May 3, 20027:00 - 10:30 am

7:00-8:00 am Breakfast w/Exhibitors

10:10-10:30 am Coffee Break w/Exhibitors

Saturday, May 4, 20027:00 - 10:30 am

7:00-8:00 am Breakfast w!Exhibitors

9:30-10:00 am Coffee Breakw!Exhibitors

3:00-3:30 pm BreakwfExhibitors

Arrow InternationalArrow International develops, manufactures, and markets a broad range of clinically advanced disposable catheters and related products.

e product offering includes central venous catheters, hemodialysis catheters, P1CC catheters, wire-reinforced "Super Arrow-Flex"

introducers, as well as Arrow's unique AltROWgard® infection protection surface treatment technology.

AstraZenecaAstraZeneca produces a wide range of products that make significant contributions to treatment options and patient care. The company

has one of the world's leading portfolios to treat cancer and gastrointestinal disorders, in addition to the areas of anesthesia, pain

Iflanagement, cardiovascular disease, respiratory and central nervous system disorders. You are invited to visit our exhibit to speak with

a representative about our products.

13. Braun Medical Inc.B. Braun Medical offers a full range of regional anesthesia products featuring the Perifix SoftTip and the Perifix® FX springwound

epidural catheters, Pencan® pencil point spinal needles, Espocan® combined spinal/epidural sets with Docking System, Stirnuplex®

insulated nerve block needles, Contiplex® insulated Tuohy needle and the new Stimuplex® HNSI I peripheral nerve stimulator.

13D Medical SystemsPull line of spinal, epidural, combined spinal epidural and nerve block procedure trays and accessories.

GlaxoSmjthKlineGlaxoSmithKline is one of the world's leading research-based pharmaceutical companies with a powerful combination of skills to

discover and deliver innovative medicines. Please visit our exhibit to learn more about our products and programs. We are dedicated to

improving patient care and access to medicines.

Imgyn Medical TechnologiesItnagyn Medical Technologies is developing a unique reflectance pulse oximeter technology [PRO (subscript 2)] that measures arterial

Oxygen saturation via a surface mounted sensor. The system performs over a wider saturation range with less sensitivity to hair,

Pigmentation and other factors than other oximetry systems currently on the market. The reflectance approach overcomes many of the

ositionaI limitations of current transmission systems by measuring reflected light rather than transmitted light. Imagyn has success-

fully demonstrated its PRO2 performance in the most difficult of applications by measuring fetal oxygen saturation intrapartum

through the intact amniotic membrane and fetal hair. PRO2 is currently an investigational device.

161

BOOTH #

21

30

10

25

26

ii SOAP 2002 Annual Meeting Corporate Supporters

B. Braun BaxterFun Run Sunset Sailing

Lippincott, Williams & WilkinsLippincott Williams & Wilkins is a global publisher of medical, nursing and allied health information resources in books, journals,newsletters, and electronic media formats. Please stop by booth # 15 to reviewone of the many titles that we have available for display.

PNA Medical Systems

PNA Medical Systems is presenting advanced Regional Anesthesia and Plexus Anesthesia systems, the Sprotte Spinal Needle, InsulatedSprotte and Short Bevel Unipolar needles. "MultiStim Plex" for percutaneous nerve identification and "MultiStim VARIO" forpercutaneous nerve identification as well as measuring depth of neuro-muscular blocks. Also being displayed, a full spectrum ofinnovative Continuous Plexus Anesthesia kits.

Portex, Inc.Portex Inc. presents a full line of pain management products featuring continuous epidural, single shot epidural, CSE and spinalproducts. With the recent Portex aquisition of the Abbott pain management line of kits and trays, Portex now offers an even widerselection of pain management options in both standard and custom configurations.

Purdue Pharma, LP 22, 29I Stamford ForumStanford, CT 06901(203) 588-5000

Rusch, Inc.Rusch is a worldwide leader in the manufacture of disposable and airway management devices. Since 1885, our high standards of qualityand continuous innovation have provided anesthesiologists with Endotracheal and Endobronchial tubes, Laryngoscopes, Oral andNasal airways and specialty devices in a complete range of sizes.

Sorenson Medical, Inc.Microject® Pumps represent a low cost alternative to other ambulatory pumps. They are electronically programmable, accurate, andsimple to operate. Microject Pumps are about the size and weight of a TV remote control and require only two AA batteries. For moreinformation, contact Sorenson Medical at 877-352-1888.

W.B. Saunders/Mosby/Churchifi 19WB. SAUNDERS, MOSBY, and CHURCHILL LIVINGSTONE, a combined premier worldwide medical and health science publishingcompany, under the umbrella of ELSEVIER SCIENCE, HEALTH SCIENCE DIVISION, presentsour latest titles in ANESTHESIA.Come visit our booth and browse through our complete selection of publications induding books, periodicals, and software.

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Society for Obstetric Anesthesia and Perinatology

Future Meetings

May 14-17, 200335th Annual Meeting

Point Hilton at Squaw PeakPhoenix, AZ

May 12-16, 200436th Annual Meeting

Sanibel Harbor Resort and SpaFt. Myers, FL

Society for Obstetric Anesthesia and PerinatologyP.O. Box 11086 / 2209 Dickens Road

Richmond, VA 23230-1086Phone (804) 282-5051 / Fax (804) 282-0090

Email: [email protected]

wwwsoap.org

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