@cochranecollab found little basis for offering CSE over epidurals (back in 2012). However, around this time, fetal heart rate abnormalities seemed the 🐘 in the room. #OAA3dc2022
There is an argument for CSE causing uterine hyperactivity - by removing pain, circulating catechamines would drop, removing their tocolytic effect. #OAA3dc2022
Uterine hypertonicity and fetal heart rate abnormalities were evaluated, and CSE was associated with hypertony and abnormal fetal heart rate. #OAA3dc2022
Work in 2009 had shown uterine hypertonus & abnormal FHR to be transient, either self limiting or responsive to simple measures, but NNH 4.2. Caution with initiation, care with concurrent oxytocin infusion. #OAA3dc2022
Fetal effects of CSE (@Anaes_Journal) and their relationship to oxytocin became more clear (suspicious & pathological traces seen for both CSE and epidural) - oxytocin independently increased risk (hyping the hypertonus?) #OAA3dc2022
Enter sufentanil (@MarcVandeVelde6 in @IARS_Journals) - a significant factor in non-reassuring FHR - uterine hypertonus with rapid analgesia may not be most NB factor? #OAA3dc2022
Further 2016 meta-analysis and systematic review showed increased OR, especially for fetal bradycardia. However, they made an important observation - epidural has similar effect, just seen later. #OAA3dc2022
A 2020 meta-analysis “focused” on opioids in CSE showed definite evidence of increased risk of FHR abnormalities, maternal hypotension and pruritis. #OAA3dc2022
Most recent 2022 work suggests the timing and patient selection for receiving CSE (labour with ROM or late active phase) may predispose to FHR abnormalities secondary uterine hypertonus #OAA3dc2022
DPE faster onset than epidural (statistically not clinically significant?) no other difference. A procedure in search of an indication - @bscottsegal in @_Anesthesiology 2022 questions if any real value to DPE #OAA3dc2022
@ashrafhabib5’s group, also @_Anesthesiology, found no advantage 4 DPE. Heesen et al, in @IJOA_Journal, found less epidural top ups, shorter onset (is this clinically relevant?) & better sacral analgesia. Of note, failed DO in 1/8 patients - wonder if epidural worked? #OAA3dc2022
@hnixon147 supervised a #ANES18 submission, where inability to obtain CSF predicts catheter failure. #OAA3dc2022
Needle THROUGH needle vs needle through needle technique, was evaluated in 1994. Personally have never had the former, does anyone have experience to share. I prefer sprotte to whitacre for the later (more distinct dural pop) #OAA3dc2022
@girardDev’s excellent summary and QR code for references. There is a potential place for everything - except perhaps the standard epidural. Consider DPE if history of AFHR or at risk (eg IUGR) (@SafePartum thread above 😉) #OAA3dc2022
@euklaas from @asznl presents on PDPH: new perspectives at #OAA3dc2022. (As promised by teaser) August Bier = father of PDPH, a surgeon started it not #OBAnes 😉
Current perspective on PDPH. ICHD-3 definition, tied to CSF pressure & volume as is pathophysiology. #OAA3dc2022
New anatomical perspectives challenge the classic CSF hypothesis. Choroid plexus not main site of production, CSF doesn’t circulate unidirectionally.
Bulat-Kiarica-Orešković hypothesis: osmotic & hydrostatic forces are main determinants of CSF movement, pulsates
Everyone needs to be on #Medtwitter@StephenLap! Watching @obstetriciasati talk about Obstetric hemorrhage I notice a trend observed at #OAA3dc2022 continuing: manual external aortic occlusion (a REBOA without surgeons or balloon catheter)
@ArviPalanisamy presents his philosophy on the Future of #OBAnes Research in this final session of #OAA3DC2022: practical, aspirational, inspirational (skipping the queue to catch a train, @noolslucas & @OAAinfo) very accommodating in view of train/tube strikes affecting London)
#OBAnes research has plateaued, advancing in increments. A change in thinking is required. Several low hanging fruit, #MindTheGap between #OBAnes research and practice - implementation science something for future? #OAA3dc2022
One subject ripe for implementation science study is awareness. DREAMY study factors associated are known, awareness common (perhaps we’re losing a skill?) & linked to PTSD. #BridgeTheGap#OAA3DC2022
@girardDev presents on managing the obese parturient at #OAA3dc2022. He sets the bar high for the future of presentations at #SOAPAM2023, #OAA23, #ASM23SYD: a QR code that links to all his references as well as a pdf of his slide deck - perfect for #OBAnes#SoMe & #FOAMed.
The value of PERI-oxygenation in obesity is not to be ignored. All patients will go blue, perioxygenated ones take 52 seconds longer (how long it feels depends on the sats?). We all remember the troop pillow, but do we remember the stool? Ergonomics of intubation #OAA3dc2022
@mbrrace meeting 10 November. Hope to see some live tweets of key messages @SusannaStanford. “We are ALL part of the solution” #OBAnes and obesity is definitely part of the puzzle, preventing it part of the solution. #OAA3dc2022