Combined spinal epidural (CSE) analgesia, fetal bradycardia, and uterine hypertonus

Multimodal general anesthesia approach for Ex Utero Intrapartum Therapy (EXIT) procedures: two case reports

High-dose volatile anesthesia is the most common method of achieving uterine relaxation for Ex Utero Intrapartum Therapy (EXIT) procedures. Other methods employ nitroglycerin for additional uterine relaxation with or without remifentanil for additional fetal analgesia. We report a combination approach including one minimum alveolar concentration of volatile anesthetic plus nitroglycerin and remifentanil infusions, to provide timely uterine relaxation under general anesthesia for both mother and fetus, during two EXIT procedures.

Update on Fetal Monitoring: Overview of Approaches and Management of Category II Tracings

Electronic fetal monitoring (EFM) is widely used to assess fetal status in labor. Use of intrapartum continuous EFM is associated with a lower risk of neonatal seizures but a higher risk of cesarean or operative delivery. Category II fetal heart tracings (FHTs) are indeterminate in their ability to predict fetal acidemia. Certain patterns of decelerations and variability within this category may be predictive of neonatal morbidity. Adjunct tests of fetal well-being can be used during labor to further triage patients. Intrauterine resuscitation techniques should target the suspected etiology of intrapartum fetal hypoxia. Clinical factors play a role in the interpretation of EFM.

Modern neuraxial labor analgesia: options for initiation, maintenance and drug selection

In the present review we outline the state-of-the-art of neuraxial analgesia. As neuraxial analgesia remains the gold standar of analgesia during labor, we review the most recent literature on this topic. The neuraxial analgesia techniques, types of administration, drugs, adjuvants, and adverse effects are investigated from the references. Most authors would agree that central neuraxial analgesia is the best form to manage labor pain. When neuraxial analgesia is administered to the parturient in labor, different management choices must be made by the anesthetist: how will we initiate analgesia, how will analgesia be maintained, which local anesthetic will we use for neuraxial analgesia and which adjuvant drugs will we combine? The present manuscript tries to review the literature to answer these questions.

Neuraxial analgesia and fetal bradycardia

PURPOSE OF REVIEW

To review the most recent data on labor analgesia and the risk of fetal heart rate changes.

RECENT FINDINGS

Fetal heart rate changes are more common with intrathecal opioids, especially when high doses are used. Intrathecal clonidine seems to increase the risk of hypotension and fetal heart rate changes. Intravenous fluid preloading is useful in high-dose labor epidural analgesia, but its use remains controversial with low-dose techniques of epidural analgesia. Despite the potential of neuraxial analgesia to induce fetal bradycardia, neonatal outcome is usually reassuring.

SUMMARY

Despite the potential of neuraxial analgesia to cause fetal heart rate problems, neuraxial analgesia is the most effective and safest form of labor analgesia. Specific techniques of labor analgesia, such as high-dose spinal opioids or intrathecal clonidine, must be avoided based on the most recent evidence. Maternal and neonatal outcome is good following regional analgesia.

Combined spinal-epidural analgesia for labor: breakthrough or unjustified invasion?

The combined spina-epidural (CSE) technique has become increasingly popular for labor analgesia. The advantages of the CSE include more rapid onset of analgesia, reduced total drug dosage, minimal or no motor blockade, and increased patient satisfaction. CSE has also been associated with more rapid cervical dilation when compared to epidural analgesia in nulliparous women in early labor. Despite these potential advantages, the indications for CSE versus epidural analgesia remain unclear and controversial. This review should allow better understanding of the benefits and risks of this technique, and bearing in mind that no ultimate neuraxial analgesic exists, it would seem that CSE should be considered a major breakthrough in the management of labor analgesia.