Background: Operating room noise adversely affects communication, team performance, and patient safety. Emergency cesarean deliveries require rapid coordination among multiple personnel and may generate higher noise levels than elective procedures. Aims: To compare noise levels between emergency and elective cesarean deliveries across different procedural time points. Materials and Methods: This prospective observational study was conducted at a medical college hospital. Noise levels were measured using a calibrated mobile application during 162 cesarean deliveries (135 emergency and 27 elective) performed under neuraxial anesthesia in ASA II patients. Measurements were recorded at six predefined time points: anesthesia provider entry, surgical timeout, neuraxial block administration, skin incision, baby extraction, and skin closure. Noise levels were averaged over 30-second intervals. Data were analyzed using mixed-effects ANOVA with Bonferroni correction, and multivariable logistic regression was used to identify predictors of high noise levels. Results: Emergency cesarean deliveries showed significantly higher noise levels than elective procedures at all time points (overall mean 61.9 ± 5.2 dB vs. 57.0 ± 4.1 dB; P < 0.001). The greatest difference was observed during baby extraction (69.8 ± 9.3 dB vs. 62.4 ± 7.1 dB; P < 0.001). All procedures exceeded World Health Organization-recommended limits. Noise levels above 55 dB occurred in 94.8% of emergency and 81.5% of elective cases, with peak levels reaching 95 dB in emergencies. Emergency delivery, higher personnel numbers, and nighttime surgery were independent predictors of excessive noise. Conclusion: Emergency cesarean deliveries generate significantly higher operating room noise than elective procedures, consistently exceeding recommended limits. Targeted noise-reduction strategies are required, particularly during critical procedural phases, to improve communication and patient safety in obstetric operating rooms.
Context: Abdominal fascial plane blocks have proven effective and vital for multimodal opioid-sparing postoperative analgesia in multiple surgeries. Aims: The present study compared the postoperative analgesic efficacy of ultrasound-guided bilateral erector spinae plane block (UBESPB) to intrathecal fentanyl (ITF) after lower-segment cesarean section (LSCS). Settings and Design: This prospective, randomized controlled trial was conducted at a tertiary care teaching hospital between May 2021 and September 2022. Methods: A total of 60 term parturients of American Society of Anesthesiologists physical status II with singleton pregnancy planned for elective LSCS were randomized into two groups. Group 1 (UBESPB group, N = 30) were given spinal anesthesia with 1.5 ml heavy bupivacaine (0.5%), followed by UBESPB at the T9 level with levobupivacaine (0.25%) 30 ml, at the end of surgery. Group 2 (ITF group, N = 30) were given spinal anesthesia with 1.5 ml heavy bupivacaine (0.5%) added with 25 μg fentanyl. The static and dynamic pain (assessed by numerical rating scale [NRS]), total fentanyl consumption, residual motor blockade, time to ambulate and breastfeed, patient satisfaction rate, and opioid-related complications were evaluated for up to 48 h postoperatively. Statistical Analysis: Statistical analysis was performed using the Chi-square test to compare categorical variables and the independent sample t-test to compare continuous variables. A P value of <0.05 was considered significant. All analyses were carried out using SPSS version 16.0 (Chicago, USA). Results: In the UBESPB group, the mean static and dynamic NRS pain scores and the mean total fentanyl consumption were significantly lower (170.73 ± 37.71 μg) as compared to the ITF group (642.03 ± 177.49 μg). No additional increase in the residual motor blockade was seen in either group. Most of the patients in the UBESPB group were highly satisfied and able to ambulate and breastfeed early, as compared to the ITF group. Conclusion: UBESPB proved to be significantly more efficacious in terms of pain relief (static/dynamic), patients’ satisfaction, and early ambulation and breastfeeding with better newborn care as compared to ITF.
Objective: The aim of this study was to evaluate the feasibility, adherence, and safety of a newly implemented postoperative monitoring protocol based on the modified early obstetric warning score (MEOWS) in a dedicated bonding room following cesarean delivery with low-dose intrathecal morphine (100 μg) at the University Hospital of Innsbruck. Material and Methods: In this retrospective observational cohort study, 250 women were included, who underwent elective cesarean delivery under spinal anesthesia with 100 μg intrathecal morphine between April 2021 and April 2022. After surgery, patients were monitored in a bonding room located on the maternity ward, bypassing the post-anesthesia care unit. Monitoring was performed by trained nurses using a standardized MEOWS chart, including predefined escalation criteria. The primary outcome was the incidence of respiratory complications. Secondary outcomes were protocol adherence, analgesic effectiveness, and maternal adverse events. Results: No respiratory complications, naloxone administration, or code blue events occurred. MEOWS protocol adherence exceeded 98%. Pain scores remained low (median maximum NRS 3 [IQR 2–4]); 82% of patients required no systemic opioids. No cases of severe maternal morbidity were observed. Minor side effects were rare and self-limiting. Conclusion: Structured MEOWS-based monitoring in a bonding room proved feasible and safe in a selected low-risk cohort with intrathecal morphine for cesarean delivery. This model may offer a resource-conscious alternative to post-anesthesia care unit-based surveillance, enabling early maternal-newborn contact, while maintaining patient safety. Broader implementation should be supported by local adaptation, staff training, and validation in higher-risk populations.
Background: Excessive noise in the operating room during anesthetic induction has shown to have negative consequences for healthcare workers and patients. Data regarding noise levels during anesthetic induction in obstetric theaters in India is lacking. Aim: Report noise during anesthetic induction for caesarean deliveries. Methods: One hundred patients scheduled for caesarean delivery were recruited. Baseline, time-weighted (TW) maximum, minimum and average, and peak noise levels were measured during anesthetic induction using a decibel meter (Decibel X Software, SkyPaw Co Ltd, Hanoi, Vietnam). At the end of surgery, patients reported their satisfaction with OR noise on a 5-point Likert scale. Results: The overall mean TW average and maximum noise were 32.4 ± 7.51 dBA and 56.02 ± 6.74 dBA, respectively. The mean TW average dBA did not differ significantly between elective (n = 47) and emergency (n = 53) caesarean deliveries [32.64 ± 4.32 vs. 32.18 ± 9.46, MD (95%CI) –0.46 (–3.33 to 2.52), P = 0.76]. The mean TW average dBA was significantly lower in caesarean deliveries done at night (n = 38) compared to those done in the day (n = 62) [30.78 ± 5.08 vs. 34.27 ± 6.90, MD (95%CI) –3.49 (–6.05 to –0.92), P = 0.008]. 92 (92%) patients reported being satisfied with the noise levels during anesthetic induction. Conclusion: The TW average noise levels reported in our study were within the recommendation of ≤45 dBA for hospitals. Mean TW average noise levels during anesthetic induction in our obstetric theaters did not differ significantly between elective and emergency caesareans, but was significantly lower in the night compared to day.
Aim: To evaluate the diagnostic accuracy of the perfusion index (PI) in predicting postspinal hypotension (PSH) in parturients undergoing elective lower segment caesarean section (LSCS) under subarachnoid block (SAB). Methods: This prospective observational study included 99 parturients above 36 weeks gestation undergoing elective LSCS under SAB. Perfusion index and hemodynamic variables were monitored using Masimo pulse oximetry. Hypotension was defined as SBP <80 mmHg and/or MAP <50 mmHg. Receiver operating characteristic (ROC) curve analysis was used to determine PI cut-off values predictive of hypotension. Results: PSH occurred in 51.5% of patients. PI at 15 minutes post-SAB significantly predicted hypotension at 20 minutes with an AUC of 0.972, sensitivity of 82.14%, and specificity of 91.55% at a cutoff of 10.85. Baseline PI had poor predictive value (AUC 0.490, P = 0.867). Conclusion: PI measured at 15 minutes post-SAB is a strong predictor of PSH at 20 minutes. Timely monitoring of PI can guide individualized fluid and vasopressor therapy.
Coarctation of the aorta (CoA) is a rare but high-risk congenital cardiac disease which can complicate pregnancy by leading to heart failure, aortic dissection, or rupture. The hemodynamic stress of a twin pregnancy and concurrent severe preeclampsia significantly increases the risk of maternal and fetal morbidity. We report a 28-year-old primigravida at 33 weeks of gestation with dichorionic diamniotic twins, referred from outside hospital with severe CoA diagnosed at 20 weeks of gestation. Echocardiography revealed a 5 mm aortic narrowing and a bicuspid aortic valve. She had an uneventful antenatal course, but at 33 weeks of gestation, the patient presented with NYHA Class III dyspnea. She was scheduled for an elective cesarean section in view of the development of signs of early onset severe preeclampsia. Here, we discuss the anesthetic challenges encountered and the successful perioperative management of uncorrected severe CoA in complex obstetric situations.
Background: Labor epidural analgesia (LEA) is the gold standard for pain relief during normal delivery. Up to 25% of parturients receiving labor epidurals may experience incomplete analgesia. The failure of epidural analgesia triggers the use of alternative techniques, adding to the cost and the risk of maternal and fetal complications. This retrospective analysis of labor epidurals focuses on the incidence of secondary failure, its associated risk factors, and the management protocol. Methods: Data were retrieved for patients who received labor epidurals performed between January 2023 and December 2024. The patients were divided into two groups according to the incidence of secondary failure of LEA. Results: The analysis included 1178 cases, with an incidence of secondary failure of LEA of 3.9%. Multiparity, a preceding incidence of primary failure, labor augmentation, and a longer infusion time were significantly associated with secondary failure, with P values of 0.039, 0.001, 0.004, and 0.000, respectively. Conclusion: This study highlights independent risk factors for the failure of LEA, allowing for the creation of preventive strategies for high-risk parturients. Further studies are encouraged to incorporate targeted management policies to increase maternal satisfaction and safety.
Abnormalities of placenta can cause severe peripartum hemorrhage, leading to maternal morbidity and mortality. Imaging modalities, like magnetic resonance imaging (MRI) and ultrasonography, help in antenatal diagnosis of these abnormalities. Intravascular interventional therapy, like intra-aortic balloon occlusion (IABO), has been used to effectively reduce intraoperative blood loss in patients with placental abnormalities. We report anesthetic management of three cases of placenta increta and one case of placenta accreta who underwent IABO preoperatively before elective cesarean section for decreasing intraoperative hemorrhage. All cases were administered general anesthesia in anticipation of massive blood loss and prolonged duration of surgery. Though IABO helped in controlling intraoperative blood loss in three patients, one patient lost approximately 4000 ml of blood intraoperatively and required massive blood transfusion. A proper preoperative planning and communication between the anesthesiologist, surgical team, cardiology team, and blood bank are important for safe outcome of these patients.
Functional neurological symptom disorder (FND), also known as conversion disorder, is a somatoform disease that can cause neurological deficits without anatomical or physiological causes. It can be caused by any physical or psychological stressor, including trauma, hospital admission, surgery, as well as having to undergo anesthesia. We report about a pediatric patient (with a history of previous FND) who became suddenly unresponsive and exhibited seizure-like activity in the postanesthesia care unit after undergoing general anesthesia for a gynecological procedure (intrauterine device placement). After undergoing largely normal testing, including electrolytes, imaging, and consultation from pediatric neurology, she spontaneously recovered and was eventually discharged to psychiatry follow-up. FND is a debilitating disease both physically and mentally for both patients and families; diagnosis and treatment both need multidisciplinary involvement. Ultimately, individually tailored perioperative care is needed for patients with a history of FND; the anesthesiologist’s role in preparing patients and their families for surgery and anesthesia, as well as appropriate follow-up care, may improve long-term patient outcomes.
Congenital factor VII deficiency is a rare autosomal recessive bleeding disorder with a variable clinical phenotype, ranging from asymptomatic individuals to those with severe hemorrhage. The peripartum management of such patients, especially regarding the use of neuraxial anesthesia, remains controversial due to the absence of evidence-based guidelines or expert consensus. We present the case of a 31-year-old primiparous woman with an incidental diagnosis of mild heterozygous factor VII deficiency. Several months before conception, she had revealed a significantly prolonged prothrombin time. Serial factor measurements during pregnancy revealed a physiological rise in factor VII levels. Following a multidisciplinary assessment and patient-informed decision-making, she underwent a successful vaginal delivery with uneventful epidural analgesia. No factor replacement or administration of procoagulant agents was required. This case underscores the importance of individualized management strategies in rare bleeding disorders and suggests that neuraxial anesthesia may be safely considered in select patients with factor VII deficiency.
Obesity is a major global crisis associated with significantly increased perioperative morbidity and mortality in pregnancy. As per World Health Organisation, obesity is classified according to body mass index (BMI) as class I (30–34.9 kg/m2), class II (35–39.9 kg/m2) and class III (40 kg/m2 and above). A BMI of 50 kg/m2 and above is termed as super morbid obesity. Challenges include management of a difficult airway, obscure landmarks for regional anesthesia, patient positioning, venous cannulation, blood pressure recording, equipment inadequacy and increased surgical duration and complexity and co-morbid conditions like hypertension, diabetes mellitus, obstructive sleep apnea, cardiovascular disease notably associated with increased obstetric and perinatal morbidity and mortality. The article describes one such case with BMI of 78 kg/m2 presenting with many of these challenges which we were able to overcome with meticulous planning, multidisciplinary therapeutic team, active patient engagement and employing Ultrasound guidance for regional anesthesia.
Background: Effective pain relief during labor is essential to reduce maternal and perinatal morbidity and to prevent unnecessary cesarean deliveries prompted by maternal anxiety. While both 0.2% and 0.15% concentrations of ropivacaine have demonstrated efficacy in labor analgesia, limited data exist from the Indian subcontinent comparing their effectiveness. Aim: To evaluate and compare the effectiveness of 0.15% versus 0.2% ropivacaine for labor epidural analgesia. Objectives: To assess the analgesic efficacy of 0.15% and 0.2% ropivacaine during the first and second stages of labor and to evaluate the incidence of instrumental deliveries, cesarean sections, motor blockade, the need for additional analgesia, and medical interventions. Materials and Methods: In this open-label randomized controlled trial, 205 parturient women were randomly assigned to receive either 0.15% or 0.2% ropivacaine. Data were collected and analyzed using SPSS software. Results: Compared to the 0.15% concentration, 0.2% ropivacaine was associated with a faster onset of motor blockade (P < 0.001) and a higher incidence of motor block and instrumental deliveries (P = 0.009). Both concentrations provided equivalent analgesia. Conclusion: The use of 0.2% ropivacaine is linked to a faster onset and higher incidence of motor blockade, along with a greater likelihood of instrumental deliveries and inadequate maternal pushing efforts.
Background:Shivering during cesarean delivery under spinal anesthesia is an undesirable complication. Intravenous phenylephrine infusion, at varying doses, decreases the intensity of redistribution hypothermia with no consensus on ideal dosing regimen. We hypothesized that prophylactic infusion of phenylephrine based on maternal weight would reduce the incidence of shivering and hypothermia, along with stable hemodynamics during cesarean delivery performed under spinal anesthesia.Methods and Materials:In this prospective randomized double-blinded controlled trial, 112 patients undergoing elective cesarean section were randomly allocated to receive phenylephrine 0.25 mu g/kg/min (Group P) or saline infusion (Group S) after spinal anesthesia. The primary outcome was the incidence and grade of shivering. The secondary outcome included changes in tympanic membrane temperature, mean arterial pressure, and heart rate.Results:The incidence of shivering in the phenylephrine group was 16.1% (95% CI 7.6-28.3%) compared to 30.4% (95% CI 18.8%- 44.1%) in the saline group (P = 0.05). The intensity of shivering was Grade 2 in both groups. The mean tympanic membrane temperature was comparatively lower in the saline group throughout the intraoperative period without statistical significance. The need for phenylephrine bolus dose to maintain mean arterial pressures was lower in the phenylephrine group (7.1% vs 33.9%; P = 0.001) compared to the control group. The incidence of bradycardia was higher with phenylephrine infusion (17.9% vs 1.8%; P = 0.004).Conclusion:Prophylactic weight-based infusion of phenylephrine reduces both the incidence of shivering and hypotension simultaneously during cesarean delivery performed under spinal anesthesia.
Background and Aims:Atonic PPH remains one of the most common causes of mortality among patients undergoing caesarean section. Oxytocin continues to be the first-line uterotonic but has undesirable effects due to its extrauterine receptor action. Carbetocin, a newer oxytocin analogue, has a better haemodynamic profile while retaining uterotonic effect and improved pharmacokinetics. Thus, this study aimed to compare the haemodynamic effects of carbetocin versus oxytocin for the prevention of PPH.Methodology:This was a double-blind randomized controlled trial performed on 60 ASA II/III parturients who underwent caesarean section under spinal anesthesia. After the delivery of the baby, patients in group A (n = 30) received Inj. carbetocin 100 mu g in 10 ml saline intravenously over 1 minute followed by infusion of 0.9%NS at 10 ml/h for 4h. group B (n = 30) received Inj. oxytocin 5IU in 10 ml saline over 1 minute followed by Inj. oxytocin (10 IU/hr) at 10 ml/h for 4h. The primary objective was to compare the heart rate, systolic, diastolic, and mean arterial pressures of parturients receiving these two different medications. The secondary objectives were to compare the uterine tone, requirement of additional uterotonics, blood loss, and adverse drug effects.Results:Heart rate values at 0, 1, 3, and 5 minutes in the carbetocin group were 86.1 +/- 12.615, 87.87 +/- 12.176, 85.63 +/- 12.979, and 83.87 +/- 12.67 beats per minute, respectively. Corresponding values in the oxytocin group were 99.57 +/- 12.632, 107.07 +/- 14.911, 94.83 +/- 14.046, and 92.43 +/- 13.221 with statistically significant differences observed at all time points (P < 0.05). Diastolic blood pressure at 0 and 1 minute in the carbetocin group was 66 +/- 9.962 and 64.97 +/- 9.604, respectively, compared with 60.07 +/- 10.751 and 58.87 +/- 11.97 (P < 0.05) in the oxytocin group. No statistically significant differences were observed between the two groups with respect to uterine tone, blood loss, reduction in hemoglobin levels, or the incidence of nausea and vomiting. One patient in carbetocin group experienced transient chest discomfort and abdominal pain.Conclusion:This study concluded that carbetocin causes less tachycardia than oxytocin.
Parturients with severe mitral and aortic stenosis [modified World Health Organization Class (mWHO) IV] carries high maternal and fetal risk, particularly during emergency caesarean section. A 33-year-old woman at 35 weeks gestation, diagnosed with chronic rheumatic heart disease involving severe mitral stenosis (mitral valve area 0.9 cm2), severe aortic stenosis (peak velocity 4.53 m/s), moderate aortic regurgitation, and severe pulmonary hypertension, underwent emergency caesarean section. General anesthesia (GA) with invasive hemodynamic monitoring, cautious fluid and vasopressor management, and intensive postoperative care ensured maternal stability and favorable outcome. This case underscores the complexities of anesthetic management in parturients with combined severe mitral and aortic stenosis, both classified as mWHO Class IV lesions with extremely high maternal risk. The physiological changes of pregnancy, compounded by the stress of emergency surgery, can precipitate decompensation in these patients. GA with invasive monitoring was selected to provide precise control over hemodynamic parameters, avoiding the risks of neuraxial-induced hypotension. Judicious fluid management, early vasopressor use, and a multimodal analgesic approach contributed to a stable intraoperative course and favorable maternal–fetal outcomes. Women with mWHO Class IV valvular lesions require individualized anesthetic strategies, multidisciplinary approach involving pregnancy heart team, and specialized care to optimize outcomes during high-risk pregnancy.
This case report describes the successful intraoperative management of a cesarean section (CS) in a 40-year-old parturient with a history of bidirectional Glenn procedure for complex single-ventricle congenital heart disease. Key anesthetic strategies included combined spinal-epidural anesthesia with low-dose ropivacaine to minimize sympathetic blockade, and the simultaneous infusion of phenylephrine (via a lower limb vein) and dobutamine (via an upper limb vein) to maintain systemic vascular resistance (SVR) and reduce pulmonary vascular resistance (PVR), respectively. Combined with non-pharmacological anxiolysis and careful positioning, this approach ensured stable hemodynamics and oxygenation for both the mother and the fetus throughout the procedure.
