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Garabedian C, Sibiude J, Anselem O, Attie-Bittach T, Bertholdt C, Blanc J, Dap M, de Mézerac I, Fischer C, Girault A, Guerby P, Le Gouez A, Madar H, Quibel T, Tardy V, Stirnemann J, Vialard F, Vivanti A, Sananès N, Verspyck E. [Fetal death: Expert consensus from the College of French Gynecologists and Obstetricians]. GYNECOLOGIE, OBSTETRIQUE, FERTILITE & SENOLOGIE 2024; 52:549-611. [PMID: 39153884 DOI: 10.1016/j.gofs.2024.07.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/19/2024]
Abstract
Fetal death is defined as the spontaneous cessation of cardiac activity after fourteen weeks of amenorrhea. In France, the prevalence of fetal death after 22 weeks is between 3.2 and 4.4/1000 births. Regarding the prevention of fetal death in the general population, it is not recommended to counsel for rest and not to prescribe vitamin A, vitamin D nor micronutrient supplementation for the sole purpose of reducing the risk of fetal death (Weak recommendations; Low quality of evidence). It is not recommended to prescribe aspirin (Weak recommendation; Very low quality of evidence). It is recommended to offer vaccination against influenza in epidemic periods and against SARS-CoV-2 (Strong recommendations; Low quality of evidence). It is not recommended to systematically look for nuchal cord encirclements during prenatal screening ultrasounds (Strong Recommendation; Low Quality of Evidence) and not to perform systematic antepartum monitoring by cardiotocography (Weak Recommendation; Very Low Quality of Evidence). It is not recommended to ask women to perform an active fetal movement count to reduce the risk of fetal death (Strong Recommendation; High Quality of Evidence). Regarding evaluation in the event of fetal death, it is suggested that an external fetal examination be systematically offered (Expert opinion). It is recommended that a fetopathological and anatomopathological examination of the placenta be carried out to participate in cause identification (Strong Recommendation. Moderate quality of evidence). It is recommended that chromosomal analysis by microarray testing be performed rather than conventional karyotype, in order to be able to identify a potentially causal anomaly more frequently (Strong Recommendation, moderate quality of evidence); to this end, it is suggested that postnatal sampling of the placental fetal surface for genetic purposes be preferred (Expert Opinion). It is suggested to test for antiphospholipid antibodies and systematically perform a Kleihauer test and a test for irregular agglutinins (Expert opinion). It is suggested to offer a summary consultation, with the aim of assessing the physical and psychological status of the parents, reporting the results, discussing the cause and providing information on monitoring for a subsequent pregnancy (Expert opinion). Regarding announcement and support, it is suggested to announce fetal death without ambiguity, using simple words and adapting to each situation, and then to support couples with empathy in the various stages of their care (Expert opinion). Regarding management, it is suggested that, in the absence of a situation at risk of disseminated intravascular coagulation or maternal vitality, the patient's wishes should be taken into account when determining the time between the diagnosis of fetal death and induction of birth. Returning home is possible if it's the patient wish (Expert opinion). In all situations excluding maternal life-threatening emergencies, the preferred mode of delivery is vaginal delivery, regardless the history of cesarean section(s) history (Expert opinion). In the event of fetal death, it is recommended that mifepristone 200mg be prescribed at least 24hours before induction, to reduce the delay between induction and delivery (Low recommendation. Low quality of evidence). There are insufficient data in the literature to make a recommendation regarding the route of administration (vaginal or oral) of misoprostol, neither the type of prostaglandin to reduce induction-delivery time or maternal morbidity. It is suggested that perimedullary analgesia be introduced at the start of induction if the patient asks, regardless of gestational age. It is suggested to prescribe cabergoline immediately in the postpartum period in order to avoid lactation, whatever the gestational age, after discussing the side effects of the treatment with the patient (Expert opinion). The risk of recurrence of fetal death after unexplained fetal death does not appear to be increased in subsequent pregnancies, and data from the literature are insufficient to make a recommendation on the prescription of aspirin. In the event of a history of fetal death due to vascular issues, low-dose aspirin is recommended to reduce perinatal morbidity, and should not be combined with heparin therapy (Low recommendation, very low quality of evidence). It is suggested not to recommend an optimal delay before initiating another pregnancy just because of the history of fetal death. It is suggested that the woman and co-parent be informed of the possibility of psychological support. Fetal heart rate monitoring is not indicated solely because of a history of fetal death. It is suggested that delivery not be systematically induced. However, induction can be considered depending on the context and parental request. The gestational age will be discussed, taking into account the benefits and risks, especially before 39 weeks. If a cause of fetal death is identified, management will be adapted on a case-by-case basis (expert opinion). In the event of fetal death occurring in a twin pregnancy, it is suggested that the surviving twin be evaluated as soon as the diagnosis of fetal death is made. In the case of dichorionic pregnancy, it is suggested to offer ultrasound monitoring on a monthly basis. It is suggested not to deliver prematurely following fetal death of a twin. If fetal death occurs in a monochorionic twin pregnancy, it is suggested to contact the referral competence center, in order to urgently look for signs of acute fetal anemia on ultrasound in the surviving twin, and to carry out weekly ultrasound monitoring for the first month. It is suggested not to induce birth immediately.
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Affiliation(s)
| | - Jeanne Sibiude
- Service de gynécologie-obstétrique, hôpital Trousseau, AP-HP, Paris, France
| | - Olivia Anselem
- Maternité Port-Royal, groupe hospitalier Paris Centre, AP-HP, 75014 Paris, France
| | | | - Charline Bertholdt
- Pôle de gynécologie-obstétrique, pôle laboratoires, CHRU de Nancy, université de Lorraine, 54000 Nancy, France
| | - Julie Blanc
- Service de gynécologie-obstétrique, hôpital Nord, hôpitaux universitaires de Marseille, AP-HM, Marseille, France
| | - Matthieu Dap
- Pôle de gynécologie-obstétrique, pôle laboratoires, CHRU de Nancy, université de Lorraine, 54000 Nancy, France
| | | | - Catherine Fischer
- Service d'anesthésie, maternité Port-Royal, groupe hospitalier Paris Centre, AP-HP, Paris, France
| | - Aude Girault
- Maternité Port-Royal, groupe hospitalier Paris Centre, AP-HP, 75014 Paris, France
| | - Paul Guerby
- Service de gynécologie-obstétrique, CHU de Toulouse, Toulouse, France
| | - Agnès Le Gouez
- Service d'anesthésie, hôpital Antoine-Béclère, AP-HP, université Paris Saclay, Clamart, France
| | - Hugo Madar
- Service de gynécologie-obstétrique, CHU de Bordeaux, 33000 Bordeaux, France
| | - Thibaud Quibel
- Service de gynécologie-obstétrique, CHI de Poissy Saint-Germain-en-Laye, Poissy, France
| | - Véronique Tardy
- Direction des plateaux médicotechniques, hospices civils de Lyon, Lyon, France; Département de biochimie biologie moléculaire, université Claude-Bernard Lyon, Lyon, France
| | - Julien Stirnemann
- Service de gynécologie-obstétrique, hôpital Necker, AP-HP, Paris, France
| | - François Vialard
- Département de génétique, CHI de Poissy Saint-Germain-en-Laye, Poissy, France
| | - Alexandre Vivanti
- Service de gynécologie-obstétrique, DMU santé des femmes et des nouveau-nés, hôpital Antoine-Béclère, AP-HP, université Paris Saclay, Clamart, France
| | - Nicolas Sananès
- Service de gynécologie-obstétrique, hôpital américain, Neuilly-sur-Seine, France
| | - Eric Verspyck
- Service de gynécologie-obstétrique, CHU Charles-Nicolle, Rouen, France
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Stopar Pintarič T, Pavlica M, Druškovič M, Kavšek G, Verdenik I, Pečlin P. Relationship between labour analgesia modalities and types of anaesthetic techniques in categories 2 and 3 intrapartum caesarean deliveries. BIOMOLECULES & BIOMEDICINE 2024; 24:1301-1309. [PMID: 38488674 PMCID: PMC11378996 DOI: 10.17305/bb.2024.10186] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Revised: 03/04/2024] [Accepted: 03/04/2024] [Indexed: 04/20/2024]
Abstract
General anesthesia (GA) is typically recommended for category 1 emergency cesarean delivery (CD). For categories 2-4 emergencies, either regional or GA can be used. The factors influencing the choice of anesthetic technique in these categories remain poorly understood. We analyzed the association between the type of labor analgesia and subsequent anesthetic techniques employed for intrapartum categories 2 and 3 CD. In a prospective longitudinal cohort study, 300 women were consequently enrolled and categorized according to Lucas's classification of CD urgency. The techniques of anesthesia (GA, spinal, and epidural anesthesia [EA]) employed for CD were analyzed with respect to labor analgesia methods (remifentanil patient-controlled analgesia [remifentanil-PCA], EA, and nitrous oxide [N2O]). EA was the most frequent analgesic option (43.8%), followed by remifentanil-PCA (20.7%) and N2O (5.1%), while 30.4% of parturient women received no analgesia. All anesthetic methods showed a significant relationship with analgesic modalities (P < 0.001). Remifentanil-PCA was associated with a higher incidence of GA. Contraindication to EA was the primary factor related to the transition from remifentanil-PCA to GA. Most parturients who received EA were successfully converted to EA. Spinal anesthesia was the most common technique in women using N2O and those without labor analgesia. GA was associated with lower 5-min Apgar scores. The method of labor analgesia was associated with the anesthesia technique employed for categories 2 and 3 CD. This finding may guide patient counseling and intrapartum anesthetic planning. However, the analysis should be cautiously interpreted as the selection of anesthesia is a complex decision influenced by several clinical considerations.
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Affiliation(s)
- Tatjana Stopar Pintarič
- Department of Anaesthesiology and Intensive Therapy, University Medical Centre Ljubljana, Ljubljana, Slovenia; Institute of Anatomy, Medical Faculty, University of Ljubljana, Ljubljana, Slovenia
| | - Maja Pavlica
- Department of Perinatology, Division of Obstetrics and Gynaecology, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Mirjam Druškovič
- Department of Perinatology, Division of Obstetrics and Gynaecology, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Gorazd Kavšek
- Department of Perinatology, Division of Obstetrics and Gynaecology, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Ivan Verdenik
- Department of Perinatology, Division of Obstetrics and Gynaecology, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Polona Pečlin
- Department of Perinatology, Division of Obstetrics and Gynaecology, University Medical Centre Ljubljana, Ljubljana, Slovenia
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Parkies LE, Murray D, Okafor UB. Pharmacological labour pain interventions: South African midwives' perspective. BMC Nurs 2024; 23:176. [PMID: 38486184 PMCID: PMC10938825 DOI: 10.1186/s12912-024-01844-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2023] [Accepted: 03/04/2024] [Indexed: 03/18/2024] Open
Abstract
BACKGROUND Women of childbearing age feel great about giving birth, but the pain could be excruciating depending on their pain tolerances. Midwives requires obstetrical knowledge and skills such as pain management during labour and safety. We explored midwives' perspectives on the utilisation of pharmacological pain alleviation interventions during labour in selected hospitals in Matjhabeng Municipality, Free State province, South Africa. A qualitative study was undertaken, involving a sample of ten midwives, using a semi-structured interview guide. The interviews were audio-recorded and transcribed verbatim. Tesch's open coding data analysis method was applied to analyse the data. The midwives were restricted to use Pethidine and Phenergan prescribed by doctors for labour pain relief, which disrupted labour pain management and obliged them either to wait for a physician or follow telephone instructions. According to the midwives, women taking Pethidine and Phenergan encountered adverse effects and discomfort. Midwives identified high workload, inadequate personnel, lack of skill and knowledge, lack of medication availability, and lack of infrastructure as the primary challenges of administering pharmacological methods to women in labour. The lack of standing orders, which delays the administration of medications pending a physician's prescription, constituted an additional difficulty. In the instance that Pethidine and Phenergan were unavailable or ineffective for some women, the midwives recommended that women be administered alternative pharmacological pain relievers. They also advocated for institutionalization of pharmacological guidelines allowing them to use their discretion when treating labour pain. Midwives can only utilise a few standardised and regulated pharmacological medications for labour pain management. The midwives' ability to administer pharmacological pain relief during labour was hampered by a high workload burden, insufficient staff, lack of skill and understanding, drug unavailability, and inadequate infrastructure. Midwives advocated for supported guidelines that would allow them to treat labour pain at their discretion. Intersectoral stakeholders are required to improve midwife skills and attitudes. Health facilities need to train and supply analgesics to midwives. Midwives ought to be familiar with pharmacological pain relievers.
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Affiliation(s)
- L E Parkies
- Department of Nursing Science, University of Fort Hare, 50 Church Street, 5201, East London, South Africa
| | - D Murray
- Department of Public Health, University of Fort Hare, 5 Oxford Street, 5201, East London, South Africa
| | - U B Okafor
- Faculty of Health Sciences, University of Fort Hare, 5 Oxford Street, 5201, East London, South Africa.
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Guasch Arévalo E, Brogly N. Intravenous remifentanil for labour analgesia: is it effective, safe, and feasible? REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2023; 70:487-490. [PMID: 37865140 DOI: 10.1016/j.redare.2023.03.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Accepted: 03/01/2023] [Indexed: 10/23/2023]
Affiliation(s)
- E Guasch Arévalo
- Sección Anestesia-Reanimación Obstétrica, Hospital Universitario La Paz, Madrid; Comité de Anestesia Obstétrica de la Federación Mundial de Sociedades de Anestesia (WFSA); Board Europeo de Anestesia de la Unión Europea de Médicos Especialistas (EBA-UEMS); Board y Council WFSA, Spain.
| | - N Brogly
- Servicio Anestesia-Reanimación, Hospital Universitario La Paz, Madrid; Servicio de Anestesia, Hospital Universitario La Zarzuela; Madrid; Sección de Anestesia Obstétrica de la Sociedad Española de Anestesia-Reanimación (SEDAR); Subforum de Anestesia obstétrica Sociedad Europea de Anestesia y Cuidados Intensivos (ESAIC); Chair SubComité Parte 1 del Diploma Europeo Anestesia y Cuidados intensivos (EDAIC part 1) de la Sociedad Europea de Anestesia y Cuidados Intensivos (ESAIC), Spain
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Kurdi MS, Rajagopal V, Sangineni KSDL, Thalaiappan M, Grewal A, Gupta S. Recent advances in obstetric anaesthesia and critical care. Indian J Anaesth 2023; 67:19-26. [PMID: 36970483 PMCID: PMC10034925 DOI: 10.4103/ija.ija_1032_22] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Revised: 12/23/2022] [Accepted: 12/30/2022] [Indexed: 01/20/2023] Open
Abstract
Newer modalities in labour analgesia and anaesthesia for caesarean section including regional anaesthesia techniques and airway management are emerging constantly. Techniques such as point of care ultrasound, especially of the lungs and stomach and point of care tests of coagulation based on viscoelastometry are about to revolutionise perioperative obstetric care. This has improved the quality of care thereby ensuring good perioperative outcomes in the parturient with comorbidities. Critical care for obstetrics is an emerging field that requires a multidisciplinary approach with obstetricians, maternal-foetal medicine experts, intensivists, neonatologists, and anaesthesiologists working together with enhanced preparedness and uniform protocols. Newer techniques and concepts of understanding have thus been established in the traditional speciality of obstetric anaesthesia over the last decade. These have improved maternal safety and neonatal outcomes. This article touches upon some recent advances that have made a significant impact in the field of obstetric anaesthesia and critical care.
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Affiliation(s)
- Madhuri S. Kurdi
- Department of Anaesthesiology, Karnataka Institute of Medical Sciences (KIMS), Hubli, Karnataka, India
| | - Vennila Rajagopal
- Department of Anaesthesiology, Apollo Womens Hospital, Chennai, Tamil Nadu, India
| | | | - Murugan Thalaiappan
- Department of Anaesthesiology, Government Kilpauk Medical College, Chennai, Tamil Nadu, India
| | - Anju Grewal
- Department of Anaesthesiology, AIIMS, Bathinda, Punjab, India
| | - Sunanda Gupta
- Department of Anaesthesiology, Geetanjali Medical College, Udaipur, Rajasthan, India
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Lei X, Yu Y, Li M, Fang P, Gan S, Yao Y, Zhou Y, Kang X. The efficacy and safety of remifentanil patient-controlled versus epidural analgesia in labor: A meta-analysis and systematic review. PLoS One 2022; 17:e0275716. [PMID: 36534641 PMCID: PMC9762599 DOI: 10.1371/journal.pone.0275716] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2022] [Accepted: 09/22/2022] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Remifentanil patient-controlled analgesia (rPCA) and epidural analgesia (EA) has been used for pain relief in labor. We aimed to evaluate the efficacy and safety of rPCA versus EA in labor, to provide evidence support for clinical analgesia and pain care. METHODS We searched PubMed, EMBASE, ScienceDirect, Cochrane Library, China National Knowledge Infrastructure (CNKI), Wanfang and Weipu databases for RCTs comparing rPCA and EA in labor until February 15, 2022. Two researchers independently screened literature and extracted data. RevMan 5.3 software was used for data analysis. RESULTS A total of 10 RCTs involving 3086 parturients were enrolled, 1549 parturients received rPCA and 1537 received EA. Meta-analysis indicated that the incidence of intrapartum maternal fever within 1 hour of labor analgesia (OR = 0.43, 95%CI: 0.30~0.62), after 1 hour of labor analgesia (OR = 0.42, 95%CI: 0.20~0.90) in the rPCA was significantly less than that of EA (all P<0.05). The incidence of respiratory depression (OR = 3.56, 95%CI: 2.45~5.16, P<0.001) in the rPCA was significantly higher than that of EA. There were no significant differences in the incidence of Apgar scores<7 at 5 minutes (OR = 1.18, 95%CI: 0.71~1.96, P = 0.53), the patients' satisfaction of pain relief during labor analgesia (SMD = 0.03, 95%CI: -0.40~0.46, P = 0.90) between rPCA and EA (all P>0.05). CONCLUSION rPCA can be an optional alternative to EA with similar pain relief and less risk of intrapartum maternal fever. However, rPCA was associated with increased risk of respiratory depression. Future studies with rigorous design and larger sample size are needed to provide more reliable evidences for clinical rPCA and EA use.
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Affiliation(s)
- Xiuzhen Lei
- Department of Anesthesiology, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, China
| | - Yang Yu
- Department of Anesthesiology, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, China
| | - Mei Li
- Department of Anesthesiology, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, China
| | - Peng Fang
- Department of Anesthesiology, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, China
| | - Shuyuan Gan
- Department of Anesthesiology, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, China
| | - Yongxing Yao
- Department of Anesthesiology, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, China
| | - Yanfeng Zhou
- Department of Anesthesiology, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, China
| | - Xianhui Kang
- Department of Anesthesiology, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, China
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