BACKGROUND:Maternal mortality rates in Vietnam and other low- and middle-income countries have remained stagnant over the past decade, suggesting opportunity for improvement in maternal care. Obstetric anesthesiologists are uniquely poised to enhance maternal outcomes. This study aimed to develop a needs assessment framework to identify and guide priorities for future quality improvement interventions at a high-volume maternal hospital in Hanoi, Vietnam. METHODS:An obstetric anesthesia needs assessment quality improvement framework was developed through an iterative and collaborative process, represented by three phases (pre-on-site, on-site, post-on-site visit). The final mixed-methods survey, disseminated to all hospital staff, included the following categories: maternal care, anesthesia capacity, maternal risk assessment and morbidity tracking, quality improvement initiatives, open-ended responses. RESULTS:A total of 1268 responses were analyzed. Respondents were predominantly in clinical roles (57%). Access to anesthesia providers for neuraxial procedures (66.4%) and use of safety checklists and protocols (90%) was high. Systems for maternal morbidity and mortality tracking were reported as inconsistently utilized (71.8%). Barriers included financial constraints (39%) and lack of interest (33.1%). Respondents considered outcome tracking important (74%), yet only 68.3% reported awareness of the institution's leading causes of maternal morbidity and mortality. CONCLUSIONS:We developed and piloted a structured obstetric anesthesia-led needs assessment framework capable of identifying locally supported priorities for future quality improvement initiatives with the aim of enhancing maternal safety. Further evaluation of the framework's transferability and scalability across diverse low- and middle-income countries' health systems is needed.
BACKGROUND:Open fetal myelomeningocele repair requires maternal general anesthesia and profound uterine relaxation. Total intravenous anesthesia may be an alternative to volatile anesthetics. We describe our anesthetic approach and maternal, fetal, surgical, and neonatal outcomes. METHODS:We retrospectively reviewed 25 cases of open fetal myelomeningocele repairs performed from January 2017 to July 2025. The anesthetic protocol comprised target-controlled infusions of propofol and remifentanil guided by bispectral index monitoring, neuromuscular blockade, intravenous uterine relaxation, and intramuscular fetal atropine, fentanyl, and vecuronium. RESULTS:All 25 procedures were completed under total intravenous anesthesia without use of volatile anesthetics. Combined magnesium sulfate and nitroglycerin were used for uterine relaxation in 60% of cases. Fetal bradycardia occurred in one case (4%), and no cases of maternal pulmonary edema occurred. Median gestational age at delivery was 36 weeks. DISCUSSION:Total intravenous anesthesia combined with intravenous uterine relaxants was feasible for open fetal myelomeningocele repair in this case series.
Malaria-associated thrombocytopenia may preclude neuraxial labor analgesia, leaving remifentanil intravenous patient-controlled analgesia as the primary alternative. The effect of remifentanil on fetal heart rate is incompletely characterized. We report a 31-year-old primigravida at 36 weeks gestation with active Plasmodium falciparum malaria and a platelet count of 64,000/μL who received remifentanil for labor analgesia. Category III fetal heart rate tracings occurred twice, five hours apart, at bolus doses of 0.14 and 0.18 μg/kg with a 2-min lockout period, in the absence of maternal side effects. Both times, fetal heart rate normalized within 10 min of discontinuation, averting cesarean delivery. The patient vaginally delivered a healthy neonate. Remifentanil can produce severe, rapidly reversible fetal heart rate changes at standard doses. Prompt recognition and discontinuation are essential in higher-risk populations where neuraxial analgesia is contraindicated.
Background Peripartum anemia and transfusion contribute to maternal morbidity. While demographic and socioeconomic differences in anemia are known, gaps remain in how these relate to transfusion patterns across institutions. This study explored whether anemia prevalence and transfusion differed by site and patient context, and their association with sociodemographic factors. Methods This retrospective cohort included singleton deliveries ≥28 weeks at two Chicago hospitals (March 1, 2018 - February 29, 2020). 31,979 patients with third-trimester Hb values were included. Anemia was defined as Hb <11 g/dL and categorized as mild (9–10.9 g/dL), moderate (6–8.9 g/dL), or severe (<6 g/dL). The primary outcome was third trimester anemia; the secondary outcome was peripartum transfusion. Modified Poisson regression estimated adjusted risk ratios for anemia, and logistic regression estimated adjusted odds of transfusion. Analyses explored factors associated with these outcomes. Results Third-trimester anemia affected 12,841 patients (40.2%). Anemia was more common among non-Hispanic Black patients (53.3%), and lower-income neighborhood residents. Anemia was associated with younger age (adjusted risk ratio 0.99 per year), and delivery at University of Chicago (adjusted risk ratio 1.92). Transfusions occurred more frequently at Northwestern. In adjusted transfusion models, transfusion was associated with anemia severity, cesarean delivery, Hispanic ethnicity (adjusted odds ratio 1.62), and Asian race (adjusted odds ratio 1.42); non-Hispanic Black race was not (adjusted odds ratio 1.10). Discussion Anemia was more common among socioeconomically disadvantaged and non-Hispanic Black patients. Transfusion was associated with site, clinical factors, and anemia severity.
Background Neuraxial anesthesia use for cesarean delivery and neuraxial labor analgesia in the Balkans is low due to previous regional conflict and long-standing traditions. In 2012, Serbian anesthesiologists at the University Clinical Center of Vojvodina initiated collaboration with Kybele, Inc. to improve obstetric anesthesia practices. A unique training experience was offered to anesthesiologists from Serbia and surrounding countries, facilitated by international experts. This study describes the intervention and changes in neuraxial anesthesia use from 2012 to 2025. Methods A one to two week hands-on and didactic obstetric anesthesia school was conducted annually or biannually from 2012 to 2025; in-person activities were interrupted from 2020 to 2022. Training included spinal, epidural and combined-spinal epidural techniques for cesarean delivery and labor analgesia, and truncal nerve blocks for postoperative pain control. Participant demographics and longitudinal trends in neuraxial anesthesia use for cesarean delivery and neuraxial labor analgesia were collected. Results 130 anesthesiologists from 41 hospitals across five countries attended the hands-on school; 36.2% participated multiple times. At University Clinical Center of Vojvodina, neuraxial anesthesia use for cesarean delivery increased from 13.8% in 2011 to 79.9% in 2025 (4.7% average annual rate of change; t value = 3.24; p = 0.006). Labor analgesia use increased from 2.0% to 14.1% (p < 0.001). Conclusion A longitudinal global health partnership supported obstetric anesthesia education and local training capacity. During this period, use of neuraxial anesthesia for cesarean delivery and neuraxial labor analgesia increased at University Clinical Center of Vojvodina.
BACKGROUND:Remifentanil patient-controlled analgesia became a routinely available option for all labouring women at North Zealand Hospital in Denmark in March 2025. The aim of this study was to explore women's experiences of remifentanil during labour, including pain relief, side effects, and its role alongside other analgesia options. METHODS:Qualitative single-centre study including women who had given birth using remifentanil PCA. Remifentanil was administered as 10-30 μg boluses with one-to-one midwife care. Semi-structured interviews were analysed using manifest content analysis. RESULTS:Eighteen women were interviewed, median 6 days postpartum. Three themes emerged: "Balancing pain relief, bodily awareness and control during birth," "Practical experiences of remifentanil," and "Reflections on labour analgesia options." Women described remifentanil as enabling a balance between pain relief and feeling connected to their body, fostering a sense of control. Remifentanil was positioned between nitrous oxide and epidural analgesia among available options, often chosen to avoid epidural-related risks and side effects. Most reported high satisfaction and few side effects. Initial guidance from the midwife was necessary to time remifentanil administration, after which most women learned to time the doses themselves. CONCLUSIONS:Remifentanil was described as a controllable and acceptable form of labour analgesia that enabled women to balance pain relief with bodily awareness, and active participation during labour. Women positioned RemiPCA between nitrous oxide and epidural analgesia and often described it as a less invasive option that still provided meaningful pain relief. These findings support remifentanil as a relevant additional option within individualised labour analgesia.
OBJECTIVES:Consistent with guidelines, anaesthetists administer pre-incision cefazolin to patients having caesarean delivery in Australia. These antibiotics may impact the breastmilk microbiome. We hypothesised that the breastmilk microbiome of mothers administered cefazolin would differ from those administered placebo. METHODS:In this nested cohort within a randomised clinical trial, samples were collected from adult females having caesarean delivery. Patients received cefazolin 2 g in 100 mL normal saline (cefazolin group) or 100 mL normal saline (placebo group) prior to skin incision. Breastmilk samples were collected by participants on post-operative day 14 and 30 and immediately frozen. Microbial composition of samples was assessed via long-read 16S rRNA sequencing. RESULTS:From the cefazolin group, there were 12 samples (day 14) and 13 (day 30). From the placebo group, there were 11 (day 14) and 9 (day 30). Full-length 16S rRNA sequencing yielded sufficient reads to characterise the breastmilk microbiota at both time points. Cefazolin exposure was associated with alterations in the composition, including increased abundances of the aerobic species Roseateles spp. and Cutibacterium acnes and a predominance of Gram-negative taxa. These shifts suggest suppression of Gram-positive commensals. The resulting microbial communities appeared relatively static and enriched with less-characterised, environmentally associated genera, indicating that cefazolin may potentially disrupt normal breastmilk microbial maturation by creating niches preferentially occupied by antibiotic-tolerant taxa. CONCLUSIONS:In this small, restricted sample, cefazolin exposure prior to delivery exerted modest effects on the breastmilk microbiome. The clinical implications require further evaluation in a larger, diverse population.
BACKGROUND:Neuraxial anesthesia is preferred for cesarean deliveries, yet general anesthesia use remains notably high in certain locations. We aimed to quantify general anesthesia use for cesarean delivery and explore obstetric unit provider perspectives on contributing factors. METHODS:We conducted a single-center explanatory sequential mixed-methods study at a quaternary referral academic center. Cesarean deliveries from July 1, 2023, to June 30, 2024, were identified from the institutional Multicenter Perioperative Outcomes Group (MPOG) database. Primary outcome was rate of general anesthesia, grouped by case-timing and emergency-status. Semi-structured interviews were conducted with anesthesiologists, obstetricians, and labor nurses (n = 23). The interviews were analyzed using the Knowledge-Attitudes-Practices framework. RESULTS:Among 1894 cesarean deliveries, 223 (11.8%) were performed under general anesthesia, which was more frequent after-hours (13.8% [142/1033] vs. 9.4% [81/861]) and in emergencies (13.9% [130/938] vs. 9.7% [93/956]). Providers preferred neuraxial anesthesia when feasible and viewed general anesthesia as rapid and reliable but associated with maternal airway risk, adverse patient experience, and neonatal risk. Reported drivers of general anesthesia included emergency workflow compression, after-hours resource limitations, inefficient team communication, absent or failed labor epidural analgesia, and pain during cesarean delivery. A functioning labor epidural catheter was considered protective. Efficient communication at both the system- and provider levels was the most frequently suggested improvement. CONCLUSIONS:General anesthesia was more frequent after-hours and in emergency cases. Mixed methods integrated analysis suggests that improving provider and system-level communication and clarifying decision-making roles may improve neuraxial feasibility under time-pressure and reduce avoidable general anesthesia.
BACKGROUND:Moyamoya disease may increase vulnerability to peripartum hemodynamic changes. We hypothesized a higher 30-day incidence of stroke or transient ischemic attack after cesarean delivery under spinal anesthesia in women with moyamoya disease than in those without. METHODS:This single-center retrospective case-control study included cesarean deliveries under spinal or combined spinal epidural anesthesia (2005-2021). Moyamoya disease was confirmed from medical records and neuroimaging. The primary outcome was confirmed stroke or transient ischemic attack within 30 days. The secondary outcome was any neurological diagnosis or symptom; sensitivity analysis excluded postdural puncture headache. Outcomes were described at the delivery level, with a woman-level sensitivity analysis restricted to the index cesarean delivery. RESULTS:Among 1,910 cases screened, 1,750 were analyzed (moyamoya disease: 73 deliveries/48 women; no moyamoya disease: 1,677 deliveries/1,445 women). At the delivery level, stroke or transient ischemic attack occurred in 9/73 (12.3%) versus 1/1,677 (0.1%) (crude odds ratio, 235.7; 95% confidence interval, 29.3-1892.2; P < 0.001). The secondary outcome occurred in 31/73 (42.5%) versus 214/1677 (12.8%) (crude odds ratio, 5.0; 95% confidence interval, 3.1-8.2; P < 0.001); excluding postdural puncture headache, it occurred in 25/73 (34.2%) versus 207/1677 (12.3%) (crude odds ratio 3.7, 95% confidence interval 2.2-6.1; P < 0.001). In the woman-level analysis, stroke or transient ischemic attack occurred in 8/48 (16.7%) versus 1/1,445 (0.07%). All events occurred within 7 days. CONCLUSIONS:Moyamoya disease was associated with early neurological events after cesarean delivery under spinal or combined spinal epidural anesthesia; this association does not imply causality but supports early postpartum neurological surveillance.
BACKGROUND:Neuraxial anesthesia is the preferred technique for cesarean delivery, yet some women experience inadequate anesthesia and intraoperative pain. Little is known about the experiences and consequences when conversion to general anesthesia does not occur. This study explored women's experiences of intraoperative pain during cesarean delivery without conversion to general anesthesia. METHODS:This qualitative study included women who experienced inadequate neuraxial anesthesia during cesarean delivery without conversion to general anesthesia within the previous four years. Participants were recruited via social media, underwent semi-structured interviews and post-traumatic stress screening, and interview transcripts were analyzed using manifest content analysis. RESULTS:Twenty-five women were interviewed. Three themes were identified, "the experience of intraoperative pain", "information and communication is crucial" and "consequences". Pain ranged from discomfort to extreme pain, sometimes accompanied by fear of death. Most women were unaware that conversion to general anesthesia was an option and were reluctant to undergo it. Communication with the anesthesia team before, during, and after the CD was deemed crucial, yet most received no follow-up and lacked documentation in medical files. Many participants screened positive for post-traumatic stress or symptoms of it. CONCLUSION:Intraoperative pain during cesarean delivery without conversion to general anesthesia varies in severity but may lead to long-term psychological distress, loss of trust in healthcare, and avoidance of future pregnancies. Participants expressed a wish for timely information, a clear and explicitly communicated plan for managing intraoperative pain, and systematic follow-up by the anesthesia team if inadequate neuraxial anesthesia occurs during cesarean delivery.
Liver transplantation during pregnancy is rare but may be lifesaving in cases of acute liver failure occurring before fetal viability. A primigravida with chronic hepatitis B virus (HBV) infection developed HBV-related acute liver failure with grade III hepatic encephalopathy at 17 weeks gestation. Because delivery could not improve fetal survival, the multidisciplinary team prioritized transplantation while pregnancy continued. Laboratory investigations demonstrated severe thrombocytopenia and hypofibrinogenemia. Anesthetic management was guided by predefined maternal physiologic and hematologic targets to support uteroplacental perfusion and included temporary portosystemic shunting. Staged fetal ultrasonography confirmed viability. Surgery lasted 10 h 55 min, with 2,410 mL blood loss. The mother recovered. Following preterm premature rupture of membranes, breech presentation prompted an emergency cesarean delivery at 34 weeks with spinal anesthesia, followed by neonatal intensive care. This case shows that when delivery cannot offer fetal rescue, urgent transplantation and continued pregnancy can be integrated through multidisciplinary decision-making and specialized perioperative management.
BACKGROUND:In resource-limited settings with few obstetric anesthesiology specialists, cardiac anesthesiologists may serve as alternative consultants for high-risk pregnancy with cardiovascular disease. We compared maternal outcomes in women with congenital or acquired cardiac disease undergoing cesarean delivery under the care of cardiac versus non-cardiac anesthesiologists. METHODS:We conducted a retrospective cohort analysis of 283 pregnant women with cardiovascular disease who underwent cesarean delivery at a tertiary-care university hospital. Patients were managed by either cardiac anesthesiologists (n = 42) or non-cardiac anesthesiologists (n = 241). Maternal characteristics, anesthetic management, and perioperative outcomes were compared. RESULTS:Heart failure occurred in 4.6% of the cohort, with similar rates in the cardiac and non-cardiac anesthesia groups (7.1% vs. 4.1%, P = 0.418); other major maternal outcomes were comparable. Patients managed by cardiac anesthesiologists had higher baseline cardiovascular risk, including more New York Heart Association class III, American Society of Anesthesiologists physical status IV, and modified World Health Organization class IV disease (all P ≤ 0.010). Cardiac anesthesiologists more frequently placed arterial and central lines (35.7% vs. 17%, P = 0.005; 11.9% vs. 1.2%, P = 0.002). CONCLUSIONS:In a tertiary-care setting with a limited obstetric anesthesia subspecialty workforce, cardiac anesthesiologists may contribute to the management of cesarean deliveries in women with cardiovascular disease. Cases managed by cardiac anesthesiologists more frequently involved invasive monitoring and general anesthesia, likely reflecting greater clinical complexity. Future studies should evaluate whether standardized care pathways and additional training in high-risk obstetric anesthesia can further optimize maternal outcomes.
BACKGROUND:Game-based learning shows promise in health professions training, but guidance for large-group education is limited. We describe the design, implementation, and evaluation of a multi-station game-based workshop delivered during anesthesiology grand rounds. METHODS:Four game-based stations were designed using constructive alignment. Seventy-two participants, including anesthesia residents and faculty, rotated through all four 15-min stations focusing on anesthesia in pregnancy, point-of-care ultrasound, thromboelastography, and crisis resource management. Each station included structured debriefing. A post-workshop survey assessed perceived engagement, knowledge reinforcement, and participant experience. RESULTS:Fifty-five participants completed the survey (76.4%). Median item scores ranged from 4 to 5, with agreement rates above 80% across items. Free-text comments emphasized enjoyment, and perceived knowledge reinforcement, while a minority noted concerns about learning depth. CONCLUSIONS:A game-based workshop was well-received for obstetric anesthesia education, with findings highlighting the importance of aligning game mechanics with learning objectives and protecting time for structured debriefing.
Perinatal blood management is critical for all obstetric patients as peripartum haemorrhage is common, unpredictable, and consequences can be severe. Patients who do not consent to allogeneic transfusion of blood products introduce additional complexity and are at greater risk of morbidity and mortality. There is growing evidence that reinfusion of autologous blood salvaged from vaginal deliveries is safe and can be lifesaving. Delivering this potentially lifesaving care requires that staff well trained in intraoperative cell salvage are always resident on the delivery suite, and that the delivery suite multidisciplinary team is familiar with the procedure. Here we present a case of a Jehovah's Witness who suffered a severe postpartum haemorrhage following a vacuum-assisted vaginal delivery who was successfully reinfused with a large quantity of vaginally cell salvaged autologous blood. We discuss the key learning points from this case that enabled the delivery of this care in the complex socio-technical environment of the delivery suit.
BACKGROUND:Practice variability in obstetric anesthesia remains common despite evidence-based recommendations, and standardizing care may be challenging in clinical practice settings. We hypothesized that a peer-led implementation process grounded in Society for Obstetric Anesthesia and Perinatology (SOAP) Centers of Excellence benchmarks recommendations, combining structured weekly meetings and a co-authored digital reference tool, could achieve clinically meaningful reductions in self-reported practice variability within a newly established obstetric anesthesia team. METHODS:This prospective quality improvement project was conducted in a tertiary-care private hospital in Brazil between February and December 2025, with 21 anesthesiologists providing obstetric anesthesia care. This implementation project comprised five steps, including weekly peer-led meetings to build consensus on institutional practice and address components identified as having the highest pre-intervention variability. These were identified to be the spinal needle used for cesarean delivery, neuraxial labor analgesia technique and solutions, intrathecal adjuvants for cesarean delivery, and vasopressor strategy for spinal-induced hypotension. After selecting these four practices for the intervention, a digital pocket guide was developed. A 20-question survey collecting self-reported practice changes was distributed post-intervention, and the primary outcome was self-reported adoption of team-agreed clinical practices. RESULTS:The response rate to the survey was 76.2%. Complete adoption was reported for spinal needle selection, labor analgesia solution, and intrathecal adjuvants for cesarean delivery. Programmed intermittent epidural bolus analgesia use increased from 6.25% to 93.75%, and prophylactic norepinephrine infusion was adopted by 93.75%. Residual barriers included technical confidence, interprofessional resistance, and logistical difficulty. CONCLUSIONS:This quality improvement initiative achieved near-complete self-reported practice standardization within 10 months at minimal cost, offering a reproducible template for translating SOAP recommendations into institutional practice.
