Assessment of quality of life indicators in the postpartum period.

BACKGROUND: Quality of life assessments are increasingly recognised in healthcare. The aim of this study was to evaluate psychometric characteristics of Nottingham Health Profile in the postpartum period. METHODS: A random sample of 133 English speaking women completed the scale in hospital between 24 and 48h of delivery and again at 7days postpartum. Descriptive analysis was used to evaluate psychometric parameters of the questionnaire. RESULTS: The questionnaire indicated that in the acute setting, physical ability, energy level and pain were most affected. At follow-up, women described greatest difficulties with energy level and pain domains. The scores for physical ability, pain, sleep and energy level improved compared to baseline (P<0.05). Women who had caesarean delivery had lower scores for physical ability, pain and energy level domains at 1-2week follow-up compared to the vaginal delivery group (P<0.05). CONCLUSIONS: The scale was found to be suitable for evaluation of quality of life in a population of postpartum women. However a more culturally and geographically diverse population is needed to test reliability and validity of the instrument.

Study of equivalence: spinal bupivacaine 15 mg versus bupivacaine 12 mg with fentanyl 15 µg for cesarean delivery.

BACKGROUND: A safe and effective intrathecal dose of bupivacaine alone for cesarean delivery has not yet been established. This study tested the hypothesis that an intrathecal dose of hyperbaric bupivacaine 15 mg would produce equivalent spinal anesthesia for cesarean delivery as the combination of hyperbaric bupivacaine 12 mg and fentanyl 15 µg. METHODS: This was a single center, double-blind, randomized clinical trial of equivalence. One hundred and thirty-eight healthy parturients scheduled for elective cesarean delivery were randomized to receive either intrathecal hyperbaric bupivacaine 15 mg (Group B) or hyperbaric bupivacaine 12 mg with fentanyl 15 µg (Group BF). Parturients where asked to describe their degree of sensation during surgery using a four-point scale 20 min after spinal injection. Secondary outcomes included the incidence of maternal side effects, maternal hemodynamics and the need for supplemental analgesia. RESULTS: There was no difference in the quality of anesthesia between the two groups. Sixty-eight of 69 and 69/69 patients in Group B and Group BF, respectively had anesthesia classified as successful (RR=1.01; 95% CI 0.85, 1.22). The only two secondary outcomes that were different between the groups were the largest change in mean arterial pressure (decrease of 40 mmHg and 34 mmHg for Group B and Group BF, respectively; P=0.004) and the incidence of nausea (59% and 35% for Group B and Group BF, respectively; P=0.006). CONCLUSION: There was no difference in the degree of sensation at 20 min between Group B and Group BF. The only significant differences between the two techniques were a higher incidence of nausea and decrease in maternal blood pressure in Group B.

Anesthetic considerations for placenta accreta.

BACKGROUND: When diagnosed antenatally placenta accreta has often been managed by cesarean hysterectomy, but recently techniques involving uterine preservation have been developed. Uterine artery embolization has become an adjuvant treatment, although the potential for obstetric hemorrhage still exists. A multidisciplinary approach has permitted the development of anesthetic strategies for these patients. METHODS: A retrospective case note review of patients with placenta accreta between 2000 and 2008 at our institution was conducted. Anesthetic technique, estimated blood loss, requirement for blood products and disposition of patients postoperatively were recorded. RESULTS: A total of 23 cases were identified. In six, epidural anesthesia with progression to general anesthesia was planned. In 17 cases, neuraxial anesthesia was planned and in five of these (29%) excessive blood loss necessitated conversion to general anesthesia. Nine patients (39%) had intraoperative blood loss estimated at > 2L, and six required intraoperative blood transfusion. Eleven patients (48%) required hysterectomy, seven of which were performed on the day of delivery. CONCLUSION: In this case series, the expectation of major blood loss at cesarean delivery in the presence of placenta accreta and attempts at uterine conservation surgery initially prompted a conservative approach using general anesthesia. Greater experience has permitted modification of this approach and neuraxial anesthesia is now employed more frequently. When managed appropriately, most patients are able to tolerate both prolonged surgery and significant blood loss under epidural anesthesia.

Is epidural anesthesia in labor associated with chronic low back pain? A prospective cohort study.

UNLABELLED: The association between epidural anesthesia during labor and subsequent postpartum low back pain remains unclear. The objective of this follow-up cohort study was to determine whether epidural anesthesia was associated with chronic back pain 1 yr after delivery. We contacted 329 women by telephone and asked them to complete a standardized questionnaire 1 yr (+/-1 mo) after delivery. One hundred sixty-four women had received epidural analgesia for labor and delivery, and 165 had not. Subjects were asked to quantify their back pain (yes/no, numeric rating score, and interference with daily activities). Differences between the two groups were tested by using the chi2 test and the Mann-Whitney U-test, and logistic regression was used to control for confounding variables. The response rate was 244 of 329 (74%). Responders and nonresponders were similar in their demographic and clinical characteristics. There was no difference in the prevalence of back pain between women who had received epidural anesthesia (12 of 121, 10%) and those who had not (17 of 123, 14%). The adjusted relative risk of low back pain at 1 yr (epidural versus nonepidural) was 0.63 (95% confidence interval 0.25, 1.56). There were also no differences between the two groups on numeric rating scores or level of interference with activities. This prospective follow-up study demonstrated no association between epidural anesthesia for labor and delivery and chronic back pain 1 yr after delivery. IMPLICATIONS: We evaluated the presence of low back pain 1 yr after delivery in two groups of women-those who chose epidural analgesia for labor and those who did not. There was no increased risk of back pain in women who had used epidural analgesia. This finding is consistent with those of other North American studies.

Determinants of pediatric day surgery cancellation.

Currently, most elective pediatric surgery is performed on an out-patient basis. The objective of this case-control study was to identify potential determinants of patient cancellation at a children's hospital. Cases were defined as patients that were canceled on the day of surgery, whereas controls were those patients who underwent surgery on the scheduled date. Demographic and clinical data were collected using chart review. Approximately 10% of all day surgery patients were canceled on the day scheduled for surgery, half for reasons deemed preventable. Of the preventable cancellations, stepwise logistic regression analysis showed that patients attending only the surgeon's office prior to day surgery, were more likely to be canceled because of inadequate preparation, compared to those patients attending both the surgeon's office and the hospital preoperative clinic (adjusted odds ratio = 3.18; 95% CI: 1.32, 7.63).