OBJECTIVE:Both preeclampsia and neuraxial anesthesia can alter placental perfusion, potentially affecting the neonatal status. The objective of our study is to quantify the association between type of neuraxial anesthetic and short-term neonatal morbidity among preeclamptic patients undergoing cesarean delivery.METHODS:We performed a secondary analysis of a prospective observational cohort study. Women with singleton gestations and a diagnosis of preeclampsia who underwent cesarean delivery with neuraxial anesthesia were included in the analysis. Short-term neonatal morbidities, defined as neonatal intensive care unit (NICU) admission, arterial cord gas pH ≤7.2 and 5-minute Apgar <7, were compared based on type of neuraxial anesthetic.RESULTS:A total of 4100 patients were included in the analysis, 1696 (41.4%) received spinal anesthesia 1848 (45.1%) received epidural anesthesia and 556 (13.5%) received a combined spinal-epidural (CSE). Antepartum and intrapartum characteristics significantly differed between the groups (p≤0.02). After adjusted analysis, spinal anesthesia was associated with reduced odds of NICU admission, compared with epidural or CSE (OR; 95% CI: 0.79; 0.63-0.98, 0.71; 0.53-0.94, respectively). Spinal anesthesia was also associated with lower odds of a 5-minute Apgar <7 compared with epidural anesthesia (OR 0.59; 95% CI; 0.43-0.83). We found no association between type of anesthesia and arterial cord pH ≤7.2. In stratiifed analysis by gestational age, no association between the type of neuraxial anesthesia and neonatal outcomes was noted among term infants, but associations persisted in preterm infants.CONCLUSIONS:Among women with preeclampsia undergoing cesarean delivery, spinal anesthesia may be associated with reduced short-term neonatal morbidity in preterm infants, compared with epidural or CSE.

Study Objective: To analyze the effects of epidural analgesia for labor when dystocia occurs. Design: Retrospective cohort study. Setting: Academic health center. Patients: 641 low risk, nulliparous women in spontaneous labor. Interventions: 406 (63%) women received epidurals analgesia and 253 (37%) did not. Sixty women (9.4%) required an abdominal delivery for dystocia. Measurements and Main Results: Women receiving epidural analgesia were more likely to be white, receive care from an attending physician, need labor augmentation, and deliver a heavier infant. Multivariate analysis identified five variables predictive of dystocia and abdominal delivery: pitocin augmentation odds ratio (O.R.) = 3.9 (2.0 to 7.6), duration of labor more than 20 hours O.R. = 2.4 (1.3 to 4.4), high epidural dose O.R. = 2.2 (1.2 to 4.1), birthweight over 4,000 grams O.R. = 2.0 (1.0 to 4.2), and early placement of epidural O.R. = 1.9 (1.0 to 3.5). Repeating the regression after excluding the 20 women who developed abnormal labor prior to epidural placement (18 of 20 women had protracted dilatation) demonstrated that pitocin augmentation O.R. = 4.0 (1.8 to 4.), high epidural dose O.R. = 3.0 (1.9 to 6.2), duration of labor greater than 20 hours O.R. = 2.7 (1.3 to 5.7), and birthweight over 4,000 grams O.R. = 2.1 (0.9 to 4.8) were associated with dystocia. Conclusion: Epidural analgesia appears to be a marker of abnormal labor rather than a cause of dystocia. High concentration anesthetics and epinephrine should be avoided, as they may influence labor. Randomized, controlled trials of this technique will be difficult to do; our work should reassure patients and their clinicians that epidural analgesia does not adversely affect labor.

In this case report, NTG provided sufficient uterine relaxation to allow difficult twin extraction at Caesarean delivery. Administration of NTG in this situation was controversial, and if it had not been effective, time may have been lost before general anaesthesia could have been induced. Nitroglycerin merits further evaluation as an antepartum uterine relaxant, but the initial experience is encouraging.

In this case report, NTG provided sufficient uterine relaxation to allow difficult twin extraction at Caesarean delivery. Administration of NTG in this situation was controversial, and if it had not been effective, time may have been lost before general anaesthesia could have been induced. Nitroglycerin merits further evaluation as an antepartum uterine relaxant, but the initial experience is encouraging. II s 'agit d'un cas o~ la nitroglycerine (NTG) a fourni un reldchement utdrin suffisant pour permettre l extraction difficile de jumeaux lors d une cdsarienne. L 'administration de NTG dans cette situation dtait controvers~e; si elle n'avait pas dtd efficace, il aura# pu y avoir perte de temps avant l'induction de l' anesth#sie g~n~rale. La nitroglycerine m~rite une ~valuation plus pouss~e comme myor~solutif ut~rin antepartum, mais l'exp~rience initiale est encourageante. Urgent uterine relaxation is occasionally necessary to allow obstetric manoeuvres within the uterus antepartum for both vaginal and Caesarean delivery. Trauma inflicted by fetal manipulation when the uterus is tightly contracted may lead to neonatal death.~ Uterine relaxation may be of particular value during difficult twin and breech deliveries and with fetal transverse lie. Anaesthesia with halogenated agents will relax the uterus, but this is time-consuming, requires rapid sequence induction and tracheal intubation,