Obstetric anaesthesia: Overview + SIG resources

Abstract
Background: Spinal anesthesia is considered the method of choice for elective cesarean sections; however, it is not without maternal-fetal risks. Materials and Methods: This study compared the effects on maternal hemodynamics of intrathecal administration of fentanyl or morphine in parturients undergoing spinal anesthesia with 0.5% hyperbaric bupivacaine, with doses varied between 7.5 and 11 mg, depending on the patient's height. Data from a cohort of 170 parturients were analyzed. The administered doses were intrathecal morphine at 0.1 mL (100 µg, solution of 1 mg/mL) or fentanyl at 0.25 mL (25 µg, solution of 50 µg/mL). This study included 80 patients in the fentanyl (F) group and 90 in the morphine (M) group. Results: Group F showed significantly higher post-intervention systolic blood pressure values than group M (95.30 ± 12.99 mmHg vs. 90.58 ± 14.75 mmHg, p = 0.032). The incidence of vomiting was significantly less frequent in group F compared to group M (1, 1.3% vs. 10, 11.1%, p = 0.011). The total dose of ephedrine required for hypotension correction was significantly lower in the F group (12.75 ± 13.26 mg vs. 17.72 ± 16.73 mg, p = 0.035). Conclusions: The addition of fentanyl as an adjuvant alongside the local anesthetic in cesarean section is associated with enhanced hemodynamic stability compared to morphine, requiring lower doses of ephedrine and contributing to increased patient safety during elective cesarean surgery.

Abstract
Cesarean deliveries are often performed under spinal anesthesia because of the reduced risk of complications compared with that of general anesthesia. However, hypotension frequently occurs and adversely affects both the mother and fetus. Indices, such as the perfusion index (PI) and pleth variability index (PVI), which are derived from pulse oximetry have been used in numerous studies to predict hypotension after spinal anesthesia. However, their predictive abilities remain controversial. This study aimed to investigate the ability of PI and PVI, measured before the initiation of spinal anesthesia, to predict hypotension after spinal anesthesia in patients undergoing cesarean deliveries. To this end, we conducted a systematic review and meta-analysis. We searched MEDLINE, Embase, Web of Science, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, ClinicalTrials.gov, European Union Clinical Trials Register, World Health Organization International Clinical Trials Registry Platform, and University Hospital Medical Information Network Clinical Trials Registry databases from inception until June 15, 2023. We included retrospective and prospective observational studies and randomized controlled trials that assessed the ability of PI and PVI, measured before the initiation of spinal anesthesia, to predict hypotension after spinal anesthesia during cesarean delivery. We did not restrict our search to specific languages. Of the 19 studies, involving 1437 patients, 17 assessed the PI in 1,311 patients, and 5 assessed the PVI in 344 patients. The summary sensitivity and specificity of the PI were 0.75 (95% confidence interval [CI]: 0.69-0.80) and 0.64 (95%CI: 0.48-0.77), respectively, while those of the PVI were 0.63 (95%CI: 0.47-0.76) and 0.76 (95%CI: 0.64-0.84), respectively. The area under the summary receiver operating characteristic curve was approximately 0.75 for both indexes. Baseline PI and PVI have a moderate predictive ability for hypotension after spinal anesthesia in patients undergoing cesarean delivery.

Abstract
Objectives: To document information on the available obstetric anaesthesia services and structure of resident training in a Pakistani setting.

Methods: The survey was conducted from June to September 2018 across the Sindh province of Pakitan after approval from the ethics reiew committee of the Pakistan Society of Anaesthesiology, and covered all teaching hospitals in both public and private sectors recognised for residents' training for fellowship in Anaesthesiology by the College of Physician and Surgeons of Pakistan. A standardised questionnaire was filled by either the department chairperson or a senior designated faculty member in each institution regarding obstetric anaesthesia services and structure of resident training. Data was analyse using SPSS 22.

Results: The results reflect the obstetric anaesthesia practice in 12 teaching institutions of Sindh province, seven government-run, and five private. Only 2 (17%) hospitals had dedicated preoperative assessment clinics for obstetric patients. Epidural service for pain free labour was available in 8(67 %) of the hospitals. Eleven (91.6%) hospitals had dedicated operating rooms and nine (75%) had separate recovery facilities. Onsite laboratory and blood banks were available in only 3(42%) of government and 3(60%) of private institutions. In 9( 75%) hospitals staffing of these units were by Senior Medical Officers. Regarding training of residents, a shortage of trainers was observed in two government and one private hospital leading to unsupervised work by the trainees. There was wide variation in training in spite of a standardised curriculum provided by the national training body.

Conclusions: Gaps were identified in the practice of obstetric anaesthesia and structure of residents' training. It is important to improve both service and training to improve patient safety.