Studies have historically demonstrated associations between women's acceptance of, or access to, LEA and their education, socioeconomic status, ethnicity, insurance status, and urban versus rural residence, regardless of the type of health care system (public or privately funded) involved [9][10][11][12].More recent work, however, suggests that factors associated with acceptance of LEA or primary elective CD may be changing.For example, research conducted in Canada suggested that healthy multiparous

Parturients with renal insufficiency or failure present a significant challenge for the anesthesiologist. Impaired renal function compromises fertility and increases both maternal and fetal morbidity and mortality. Close communication amongst medical specialists, including nephrologists, obstetricians, neonatologists and anesthesiologists is required to ensure the safety of mother and child. Pre-existing diseases should be optimized and close surveillance of maternal and fetal condition is required. Kidney function may deteriorate during pregnancy, necessitating early intervention. The goal is to maintain hemodynamic and physiologic stability while the demands of the pregnancy change. Drugs that may adversely affect the fetus, are nephrotoxic or are dependent on renal elimination should be avoided.

Angle, P.; Landy, C.K.; Charles, C.; Yee, J.; Watson, J.; Kung, R.; Kronberg, J.; Halpern, S.; Lam, D.; Lie, L.M.; Streiner, D. Author Information

Obstetric Anesthesia Digest: March 2011 - Volume 31 - Issue 1 - p 11-12 doi: 10.1097/01.aoa.0000393133.09544.7d

Obstetric Anesthesia Digest 29(3):p 153-154, September 2009. | DOI: 10.1097/01.aoa.0000358426.13971.ec

BACKGROUNDThe incidence of general anaesthesia (GA) has been used as a marker for the quality of obstetric anaesthesia care. Recent guidelines suggest the rate of GA for Caesarean section in parturients with pre-existing epidural analgesia for labour should be <3%. The primary purpose of this study is to determine whether or not this is an achievable standard in a university teaching hospital. We also wished to determine the factors influencing the incidence of inadequate anaesthesia.METHODSWe studied a consecutive cohort of 501 patients who had a Caesarean section after epidural labour analgesia. The incidence of GA, the total incidence of failure, and the factors previously associated with failure were recorded. Factors shown to be significant with univariate analysis were used in a binary logistic regression to determine the independent risk factors for failure.RESULTSTwenty-one of 501 parturients required GA (4.1%, 95% confidence interval 2.6-6.3%), not significantly different from 3% (P=0.1). Fifteen of 21 (71%) of these occurred intraoperatively. The total rate of failure was 30/501 (5.9%, 95% confidence interval 4.0-8.4%). Maternal height and the number of clinician top-ups in labour were the significant independent risk factors for failure.CONCLUSIONSIntraoperative conversion to GA may increase both maternal and fetal risks. Strategies to reduce the incidence may include early recognition of inadequate labour analgesia and reliable assessment of adequacy of surgical anaesthesia.

Introduction: Women should receive adequate analgesia after cesarean section.The Royal College of Anaesthetists1 has proposed standards for post C/S pain relief, including the following: 1) >90% women to have a worst pain score of <3 on a VAS of 0-10, 2) 100% women to be prescribed NSAIDs, and 3) >90% women to be satisfied with pain management.We sought to compare our practice with these standards.Methods: After obtaining ethics approval, we recruited a convenience sample of 100 women.Questionnaires were administered via face-to-face interviews between postoperative days 2 and 4. Term, ASA I and II patients who had elective C/S under spinal anesthesia were included.We collected data related to the following: spinal morphine dose, analgesic consumption, worst pain scores, pain at rest and on movement, monitoring of respiratory rate and sedation level, side effects (pruritis, nausea and vomiting, drowsiness, constipation), and satisfaction with post C/S pain management.Data were gathered from August to December, 2006.Descriptive statistics were used for group data.Non parametric tests were used for comparative data.Results: 100 women were interviewed in hospital between 42 and 119hrs postoperatively.Demographic data are shown in the table.All women received a self-medication package upon transfer to the postpartum ward, including acetaminophen, ibuprofen, and docusate sodium.All patients who were did not have allergies to NSAIDS received them (N=98).The mean overall VAS worst pain score was 6.43+/-2.12.No significant differences were seen in oxycodone consumption, worst pain scores, pain at rest and on movement as a function of spinal morphine dose.Patients who received 0.2mg of spinal morphine experienced more pruritus than those that received 0.15mg (p=0.01).94%(94/100) of women were satisfied or very satisfied with their pain management.Discussion: The VAS pain scores were significantly higher than those recommended by the College, in spite of the administration of appropriate analgesia.However, maternal satisfaction with analgesia exceeded the recommendation.Our results suggest that the analgesic target, derived from the general surgery literature2, is not appropriate for obstetric patients possibly because of our poor understanding of pain measurement and the interplay between the pain experience and patient expectations.

Phenytoin hypersensitivity syndrome (PHS) is a rare delayed hypersensitivity reaction which occurs following exposure to phenytoin sodium. Pulmonary involvement is uncommonly described. Herein is reported the first case of histopathologic bronchiolitis obliterans organizing pneumonia (BOOP) found on open-lung biopsy in a patient with severe PHS. New onset, clinically significant, cold agglutinin disease was also documented. Hemodynamic parameters mimicking sepsis were present in the absence of significant clinical infection. Rapid, dramatic improvement followed high-dose steroid therapy.