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Obstetric Anesthesia Digest

Volume 33, Number 1, March 2013

Editorials and Reviews

success rates through improved muscle relaxation and improved maternal comfort during the version procedure. Population-based surveillance studies found that the incidence of postpartum hemorrhage (PPH) has increased in Canada, Australia, and the United Kingdom in the recent years. In the United States, 2 studies found that PPH increased 26% between 1994 and 2006. Most of this increase in hemorrhage was caused by uterine atony as PPH because of nonatonic causes were stable over time. The severity of PPH has also appeared to increase because the number of PPH cases that required transfusion doubled during the study period. Historically, PPH has been one of the leading causes of maternal death along with hypertensive disorders and infections. In addition to PPH, thrombotic pulmonary embolism, infection, hypertensive disorders of pregnancy, cardiomyopathy, cardiovascular conditions, and noncardiovascular medical conditions contribute almost equally to maternal mortality. The largest increase has been in the proportion of deaths associated with cardiovascular comorbidities. Ethnic disparities in care persist, with African American women having a 3- to 4-fold higher maternal mortality ratio than white women.


Use of air or oxygen for resuscitation after birth asphyxia has been controversial because of the potential harm to neonates from oxygen therapy, including oxidative damage and increased rates of childhood malignancy. Guidelines from the American Heart Association and European Resuscitation Council recommend initial resuscitation with air rather than oxygen, with the need for supplemental oxygen determined by a pulse oximeter. Blended air and oxygen should be used only if oxygenation does not improve during resuscitation efforts. It takes B8 minutes for neonates to reach an oxygen saturation of >90%, and it takes slightly longer for this milestone to be reached in preterm infants. Targeted preductal oxygen saturations at 1, 2, 3, 4, 5, and 10 minutes after birth are 60%-65%, 65%-70%, 70%-75%, 75%-80%, 80%-85%, and 85%-90%.

Coming changes in clinical practices will serve as the building blocks for future obstetric anesthesia. Using new and improved knowledge will improve the quality and safety of care delivered to parturients and neonates.

Preventing Maternal Death: 10 Clinical Diamonds
S.L. Clark, and G.D. Hankins
(Obstet Gynecol. 2012;119(2 Pt 1):360–364)
Hospital Corporation of America, Nashville, TN Copyright r 2013 by Lippincott Williams & Wilkins DOI: 10.1097/01.aoa.0000426063.26091.0b Topics: Maternal Complications





he authors have identified 10 specific recurrent errors that are associated with a large percentage of maternal deaths. The following aphorisms have been elevated for preventing these errors to “diamond status” because of their ability to prevent one of the most tragic occurrences in medicine. A pregnant patient reporting acute chest pain always should undergo an immediate computed tomography angiogram. Pulmonary embolism (PE) is a leading cause of death in pregnant women. The American College of Obstetricians and Gynecologists recommends that pneumatic compression should be provided to all women undergoing cesarean delivery who are not already receiving medical prophylaxis. Fatal PE may occur in any trimester and 30% of women with PE have no evidence of deep venous thrombosis. Most of the causes of chest pain during pregnancy are benign; however, for pregnant women with acute chest pain, PE cannot be ruled out by history, physical examination, or laboratory tests. Treatment with anticoagulation reduces the risk of death considerably. In a stable patient with acute chest pain, a computed tomography angiogram should be obtained immediately and if clinical suspicion of PE is high, a loading dose of intravenous (IV) heparin should be administered. A patient with preeclampsia reporting shortness of breath should undergo a chest x-ray immediately. Shortness of breath is common in pregnancy and if a clinician asks a pregnant woman if she is short of breath, she will often answer yes. However, if a patient volunteers she is short of breath, more evaluation is needed, especially if the patient has preeclampsia and is hospitalized. After the administration of IV fluids, pulmonary edema can develop. Undiagnosed pulmonary edema is a leading cause of preventable maternal death. The auscultation of rales is a valuable diagnostic tool, but few obstetricians or obstetric nurses will have sufficient opportunities to detect pulmonary rales. A simple chest x-ray will detect life-threatening pulmonary edema and while waiting for the results of this test, pulse oximetry can detect inadequate oxygenation and need for oxygen supplementation. Any hospitalized patient with preeclampsia experiencing either a systolic blood pressure of 160 or a diastolic pressure of 110 should receive an IV antihypertensive agent within 15 minutes. Cerebral hemorrhage secondary to uncontrolled hypertension is a leading cause of death in women with preeclampsia despite the fact that effective agents, including labetalol, nifedipine, and hydralazine are readily available. Delayed treatment can result from confusion about the pressure levels that require treatment, repeated pressure assessments, significance of elevated pressure in patients with chronic hypertension and preeclampsia, and risk of lowering the blood pressure to an extent that fetal hypoperfusion develops. However, hospitalized patients with these blood pressure values will not be harmed by 1 IV bolus of 5-10 mg hydralazine or 20 mg labetalol, but many could benefit. This treatment should be given as an automatic response; subsequent doses, if needed, can be based on the patient’s initial clinical response. Angiographic embolization is not meant to be used for acute, massive postpartum hemorrhage. Angiographic embolization allows radiographic visualization of the bleeding vessel and its occlusion. However, in most institutions, much time is needed to arrange for and perform vascular catheterization and embolization. Maternal deaths occur when clinicians fail to move quickly to definitive |

2013 Lippincott Williams & Wilkins


206(2):104–107) Memorial Care Center for Women.” The authors of this paper initiated a performance improvement project at their health care facility to achieve the 30-minute standard and collected data from all cesarean sections. Trauma-based protocols for transfusion can be adapted for use in obstetrics. PPH should be treated with blood and component therapy while a specific diagnosis is aggressively sought and then specific treatment for that diagnosis is provided. Its use is indicated in women with pulmonary edema or fluid overload. dedicated anesthesia support. Repeat doses of uterotonic agents in a bleeding patient should not be ordered by telephone. logistical. Therefore. An obstetrician cannot get a true picture of the nature and degree of a patient’s bleeding or her stability from only telephone reports. get one today. resolution of this condition is not of prime importance in a patient with massive PPH. barriers and delays were identified. furosemide is not the answer. Management of acute PPH should be within the capabilities of a well-trained obstetrician. Furosemide results in increased urine output. which occurred in 5 phases. go to the patient’s bedside until the atony has resolved. No current diagnostic technique has sufficient negative predictive value to justify the delivery of a woman with placenta previa and Z 1 prior cesarean delivery in a center without full blood-banking capabilities. Nageotte. The procedure holds little value if a patient has massive postpartum bleeding that could lead to death within minutes. either by telephone. Number 1. If your labor and delivery unit does not have a recently updated massive transfusion protocol based on established trauma protocols. these patients must be treated in a tertiary care center. and the availability of other surgical specialists. anesthesiologist. Any patient with identified structural or functional cardiac disease gets a maternal-fetal medicine consultation. If the etiology of oliguria is uncertain. diuretics should not be given until a thorough work-up is done.0000426064. Any woman with placental previa and Z 1 cesarean delivery should be evaluated and delivered in a tertiary care medical center. hands-on consultation. If more than a single dose of medication is necessary to treat uterine atony. Achievement of the 30-Minute Standard in Obstetrics: Can It Be Done? M. Standard coagulation tests often are clinically irrelevant because they do not account for the in vivo hemostatic capacity in a bleeding patient and often results of these tests are delayed. Despite any Topics: Maternal Morbidity and Mortality. genital tract lacerations. These findings were presented to the physicians and nurses during an instructional conference. the obstetrician should evaluate her at the bedside. retained placenta. general surgeon. Medical. In the postpartum patient who is bleeding or who recently has stopped bleeding and is oliguric. Vander Wal (Am J Obstet Gynecol. Long Beach.03220. and B. often after delays in the diagnosis and treatment of hypovolemia. when present it is a leading cause of serious morbidity and death. Clinicians should seriously consider using these approaches in their practices. CA Copyright r 2013 by Lippincott Williams & Wilkins DOI: 10. placenta accreta. The differential diagnosis of PPH includes uterine atony. If the patient needs >1 dose of an uterotonic agent.P. When a patient with severe PPH becomes oliguric and is given furosemide.1097/01. PPH is not a diagnosis but rather a clinical sign of an underlying condition that can be diagnosed. Although cardiac disease in pregnancy is uncommon. heart disease in pregnancy can be extremely complex and consultation with an experienced maternalfetal specialist should be obtained. or by using remote transmission of data or images. March 2013 surgical treatment of hemorrhage after medical therapy has been ineffective. Because the kidneys of a young healthy woman can tolerate many hours of oliguria. Systems-based Practice T he established standard for the time interval from surgical decision to surgical incision in cases of fetal intolerance to labor is 30 minutes and has become “a benchmark for adequacy of obstetric care in the medicallegal arena. indicting continued hypovolemia. but not in patients who have lost or are losing significant blood. Adherence to these 10 maxims may require more time and expense than many practitioners have previously thought necessary. During this time 68 women experienced fetal indications of intolerance to labor and a surgical incision r30 minutes after decision occurred in only 17 (25%) of these cases with an average decision to incision (DI) interval of 39 minutes. physician. Uterine atony is a leading cause of postpartum hemorrhage (PPH) even though potent agents are available to treat this condition. and patient-related. Oliguria in this setting is most often prerenal. Making the diagnosis is essential because treatment for each of these conditions differs. Never treat “postpartum hemorrhage” without simultaneously pursuing an actual clinical diagnosis. and coagulopathy. PPH may require blood and component therapy while the cause of the bleeding is determined and treated.Editorials and Reviews Obstetric Anesthesia Digest  Volume 33. Few obstetricians or cardiologists have sufficient experience with complex heart disease in pregnant women to assess risk or recommend a management plan. A labor and delivery unit should have a trauma protocol-based policy by adapting and adopting one of the available massive transfusion protocols. and should be treated by additional fluid or blood replacement or both. or trauma specialist should be asked for help rather than a nonsurgical specialist/internist with little experience in the management of PPH. r 10 | www. Although some cardiac conditions are well tolerated and can be managed in a small facility. The incidence of placenta accreta is increasing because of increasing rates of cesarean delivery.obstetricanesthesia. Phase I consisted of data collection of cesarean births arising from the labor and delivery unit for all indications during a 6-month time span. If help is 2013 Lippincott Williams & Wilkins .aoa. Several meetings of medical and nursing staff were arranged throughout the study period. cardiac arrest can ensue. but they increase maternal safety and are associated with a relative lack of significant additional risk. Miller Children’s Hospital. another obstetrician. nursing. Long Beach Memorial Medical Center. which comes at the expense of intravascular volume. 2012.