Comparative Effects of Target-Controlled Infusion of Propofol Versus Spinal and Thiopental-Sevoflurane Anesthesia on Lipid Peroxidation in Elective Cesarean Section: A Prospective, Open-Label Study.

BACKGROUND: During pregnancy, physiological changes can increase oxidative stress (OS) in both mothers and fetuses. The use of anesthesia for cesarean sections (CSs) could exacerbate this stress due to its impact on the ischemia-reperfusion effect. Our study aimed to explore the effects of target-controlled infusion of propofol on OS during CSs, and to compare these effects with those of spinal and thiopental-sevoflurane anesthesia. METHODS: The study included ninety parturients undergoing elective CS, allocated into three groups: Group S (spinal) (n = 30), Group P (propofol) (n = 30), and Group TS (thiopental-sevoflurane) (n = 30). Venous blood samples were taken from mothers at three time points, before, during, and after surgery, and one sample was taken from the umbilical vein after delivery. Blood samples were analyzed with the thiobarbituric acid reactive substances (TBARS) assay and blood gas analysis. A statistical comparison between groups was obtained by one-way analysis of variance (ANOVA) and the Wilcoxon test where appropriate. RESULTS: Levels of TBARS after the induction of anesthesia were lower in all groups compared to values preoperatively. In Group P, TBARS levels started to decrease in the first five minutes after the induction (1.90 ± 0.47; P < 0.001) and had significantly lower values compared to Group S (2.22 ± 0.21) and Group TS (2.40 ± 0.20). Two hours after surgery, TBARS values were the lowest in Group P (1.76 ± 0.15, P<0.001), compared to Group S (2.18 ± 0.24) and Group TS (2.41 ± 0.21). TBARS value in umbilical venous blood was significantly lower in Group P (1.56 ± 0.16, P < 0.001) compared to Group S (2.18 ± 0.17) and Group TS (2.09 ± 0.09). Umbilical cord venous blood gas values (pH, PCO2, HCO3, lactates, and base excess (BE)) were not different between the groups, except for PO2, which was significantly lower in Group S (20.5 ± 5.0; P < 0.001) compared to Group P (36.5 ± 19.2) and Group TS (33.5 ± 10.1). CONCLUSION: Target-controlled infusion of propofol anesthesia could be advantageous for parturients with compromised oxidative status, especially those undergoing emergency CSs when general anesthesia is required.

Anesthetic Practices for Lower Segment Cesarean Section in the Sultanate of Oman: A National Survey.

Background Over the years, obstetric anesthesia has evolved into a comprehensive sub-specialty. Several countries have their guidelines and recommendations for obstetric anesthesia. This survey aimed to describe the current obstetric anesthesia practices in the Sultanate of Oman by performing a questionnaire-based survey. Methods The Ministry of Health-Centre approved the survey for Studies and Research, Sultanate of Oman (MOH-CSR/25057). A Google Form with 25 questions (seven general questions and 18 specific questions) was initially shared in a WhatsApp group of members of the Oman Society of Anaesthesia and Critical Care (OSACC). Anesthesiologists who were not members were contacted directly and responses were recorded. Results Responses were accepted until midnight on December 31, 2023. The number of responses received was 66. Variations in practices like less compliance to Enhanced Recovery After Surgery (ERAS) pathways, use of oxytocin, and choice of intrathecal opioids were observed. Labor analgesia was not practiced by 30.3% of respondents. The majority of respondents did not follow international recommendations regarding the use of the uterotonic drug oxytocin. Conclusion A lot of heterogeneity in the practice of obstetric anesthesia in the Sultanate of Oman was observed. The limitations included the relatively low number of responses and many aspects that were missed in the survey. The findings of this survey will help in establishing a national task force for obstetric anesthesia, which will guide the members of the task force to develop practice guidelines based on international recommendations and the latest evidence.

Virginia Apgar (1909-1974): The Mother of Neonatal Resuscitation.

Dr. Virginia Apgar was an American anesthesiologist and researcher who heavily influenced the development of neonatal resuscitation in the immediate postpartum period with her simple five-point scoring system. Today, the APGAR scoring system is used around the world in delivery rooms to guide clinicians in the evaluation of newborns and to distinguish which might need urgent resuscitation. With a simple scoring system, timer, and clipboard, Dr. Virginia Apgar shifted focus from the parturient to the neonate, improving infant mortality as a result.

Use of vasopressors to manage spinal anesthesia-induced hypotension during cesarean delivery.

Cesarean sections are commonly performed under spinal anesthesia, which can lead to hypotension, adversely affecting maternal and fetal outcomes. Hypotension following spinal anesthesia is generally defined as a blood pressure of 80-90% below the baseline value. Various strategies have been implemented to reduce the incidence of spinal anesthesia-induced hypotension. The administration of vasopressors is a crucial method for preventing and treating hypotension. In the past decade, phenylephrine, a primarily alpha-adrenergic agonist, has been the preferred vasopressor for cesarean sections. Recently, norepinephrine, a potent alpha-agonist with modest beta-agonist activity, has gained popularity owing to its advantages over phenylephrine. Vasopressors can be administered via a bolus or continuous infusion. Although administering boluses alone is simpler in a clinical setting, continuous prophylactic infusion initiated immediately after spinal anesthesia is more effective in reducing the incidence of hypotension. Tailoring the infusion dose based on the patient's body weight and adjusting the rate in response to blood pressure changes, in addition to using a prophylactic or rescue bolus, helps reduce blood pressure variability during cesarean sections under spinal anesthesia until neonatal delivery.

Postspinal Anesthesia Hypotension in Caesarean Delivery: A Narrative Review.

Anesthesiologists frequently deal with spinal hypotension when administering spinal anesthesia (SA) for a Caesarean section (C-section). The physiological changes that occur during pregnancy necessitate modifications to anesthesia and analgesia procedures to provide safe and efficient care for the expectant patient. It is believed that giving the patient SA during a C-section will increase their degree of comfort and pain management both during and after the surgical process. It is less expensive, easier to give, and delivers a consistent anesthetic onset, early ambulation, and the start of breastfeeding. As C-section is a very common operation performed in every healthcare unit, dealing with postspinal hypotension is a daily situation faced by anesthetists with variable levels of experience. However, understanding and addressing hypotension induced by SA is crucial as it affects the mother and the fetus negatively. This review aims to contribute to enhancing patient care and safety in the context of C-sections by identifying hypotension timely and managing it effectively. It is advised to healthcare workers to leverage the insights from the review to improve patient outcomes in routine practice.

Multidisciplinary Obstetric Simulation Training: Experience at KK Women's and Children's Hospital (KKH), Singapore, a Tertiary Referral Centre.

Background Multidisciplinary simulation training in the management of acute obstetric emergencies has the potential to reduce both maternal and perinatal morbidity. It is a valuable tool that can be adapted for targeted audiences of different specialities at all experience levels from medical students to senior consultants. Methods In this study, pre- and post-course questionnaires of learners with varying levels of clinical experience from Obstetrics and Gynaecology (O&G), Anaesthesia, Neonatology, Emergency Medicine, midwifery, and nursing who undertook two simulation courses (namely the Combined Obstetrics Resuscitation Training course, CORE, and the CORE Lite), which comprised lectures and simulation drills with manikins and standardized patients, between 2015 and 2023 were compared. This also included a period when training was affected by the coronavirus disease 2019 (COVID-19) pandemic.  Results The results showed that both simulation courses increased confidence levels among all learners in the management of obstetric emergencies.  Pre-course, participants were most confident in the management of neonatal resuscitation and severe pre-eclampsia, followed by postpartum haemorrhage. They were least confident in the management of vaginal breech delivery, uterine inversion, and twin delivery. Post-course, participants were most confident in the management of neonatal resuscitation and shoulder dystocia, followed by postpartum haemorrhage. They were least confident in the management of uterine inversion and maternal sepsis, followed by vaginal breech delivery and twin delivery. Whilst we saw a huge improvement in confidence levels for all obstetric emergencies, the greatest improvement in confidence levels was noted in vaginal breech delivery, twin delivery, and uterine inversion. Conclusion The simulation courses were effective in improving the confidence in the management of obstetric emergencies. While it may be difficult to measure the improvement in clinical outcomes as a result of simulation courses alone, the increase in confidence levels of clinicians can be used as a surrogate in measuring their preparedness in facing these emergency scenarios.

A narrative review of the literature relevant to obstetric anesthesiologists: the 2023 Gerard W. Ostheimer lecture.

This narrative review of the 2023 Gerard W. Ostheimer lecture presented at the Society for Obstetric Anesthesia and Perinatology 2023 annual meeting summarizes 2022 literature relevant to obstetric anesthesiologists. ANTENATAL STUDIES: Neonatal morbidity is reduced with antenatal maternal buprenorphine compared with methadone for treatment of opioid use disorder. Antenatal pregnancy allergy testing is safe and feasible. ANALGESIA AND ANESTHESIA STUDIES: Intrathecal (IT) 3% chloroprocaine for cervical cerclage results in faster sensory block resolution and discharge readiness compared with bupivacaine. The ED90 of 3% chloroprocaine (with IT fentanyl 10 µg) is 49.5 mg. Dural puncture epidural technique does not improve the quality of labor analgesia in obese parturients compared with epidural analgesia. Low- (>0.08 to ≤0.1%) and ultra-low (<0.08%) concentrations of bupivacaine for epidural analgesia maintenance result in similar maternal and neonatal outcomes. Lower doses of first line uterotonic agents are non-inferior to higher doses (oxytocin 0.5 IU vs. 5 IU and carbetocin 20 vs. 100 µg) in patients at low risk for postpartum hemorrhage. Supplemental analgesia or conversion to general anesthesia is necessary in approximately 15% of elective cesarean deliveries. Intravenous dexamethasone improves analgesia outcomes, however optimal dosing and timing remain unclear; it may induce neonatal hypoglycemia in the setting of gestational diabetes. POSTPARTUM STUDIES: A core outcome set may help evaluate enhanced recovery protocol implementation. History of migraine and accidental dural puncture (ADP) above the L3 level are associated with epidural blood patch (EBP) failure and ADP at or below L3 and >48 h interval between ADP and EBP are associated with success.

The Role of TAP/RS Block in Minor Gynecologic Laparoscopic Surgery: A Randomized Clinical Trial.

OBJECTIVES: The aim of the study was to compare, in patients undergoing minor gynecological laparoscopic procedures, the effects of ultrasound (US)-guided transversus abdominis plane (TAP) + rectus sheath (RS) block versus no TAP/RS block in terms of post-surgical pain control using the numeric pain rating scale (NRS) and the degree of patient satisfaction, according to the main goals of Early Recovery After Surgery (ERAS) programs. The primary outcome is to value the postoperative abdominal pain using NRS in both groups. Secondary outcomes are to evaluate blood values, presence of postoperative nausea and vomiting (PONV), postoperative ileus, level of patient expected satisfaction, time of discharge, length of stay (LOS), and the amounts of additional analgesics required. DESIGN: In this prospective randomized controlled trial, patients were randomly assigned to loco-regional anesthesia (LRA) group, who received TAP and RS block under US guidance, or no loco-regional anesthesia (N-LRA) group. Enrolled patients were randomized 1:1 to either receive bilateral TAP/RS block with ropivacaine or sham treatment (patches were applied on the abdominal wall of the patients under general anesthesia). PARTICIPANTS: All patients aged between 18 and 75 years, with ASA (American Society of Anesthesiologists) physical status 1-2, undergoing laparoscopic minor gynecological surgery, were enrolled. SETTING: The study was conducted to the University of Campus Bio-Medico Hospital of Rome. METHODS: Half an hour before surgery, all patients received gabapentin 300 mg per os. Once the patient underwent general anesthesia, US-guided bilateral TAP/RS block was performed by the anesthesiology team, while the uterine manipulator was positioned by a gynecology resident (not involved in the study). In the operative room, all patients received the same standardized anesthetic regimen. Postoperative abdominal pain was assessed at rest, after palpation, during movement, and after a cough by evaluating the patient at 6, 12, 18, 24, 36, 48, and 72 h after surgery, using the NRS from 0 to 10 in both groups. The amount of drug used for analgesia in the first 48 h after surgery was recorded. Moreover, hemoglobin, white blood cells, and c-reactive protein levels were recorded at 24, 48, and 72 h. The presence of PONV and the postoperative ileus was recorded throughout convalescence. The expected level of patient satisfaction at discharge and finally the LOS were assessed. LIMITATIONS: The major weakness of this study is that 60 mL of 0.5% ropivacaine was administered to each patient, without considering weight differences, yet contemporary literature rarely suggests volume/dose titration in fascial blocks. RESULTS: A total of 104 women, undergoing gynecological minor laparoscopic surgery, were enrolled and assigned to LRA group (53 pts) and N-LRA group (51 pts). Postoperative pain was significantly reduced in patients who received TAP/RS block. A reduction in the intake of non-steroidal anti-inflammatory drugs after surgery was registered in LRA group (p < 0.01). Moreover, a significant reduction of LOS (45.97 ± 9.87 vs. 65.08 ± 17.32 h; p < 0.01) and PONV was observed in the LRA group, as well as a better level of patient satisfaction at discharge (9.43 ± 0.94 vs. 8.26 ± 1.19; p < 0.01), compared to the N-LRA group. CONCLUSIONS: US-guided TAP and RS block significantly reduces postoperative pain after minor gynecologic laparoscopic surgery and improves patients' post-operative recovery.

Anesthesia and postpartum pain management for placenta accreta spectrum: The healthcare provider perspective.

OBJECTIVE: To explore the management and experiences of healthcare providers around anesthetic care in placenta accreta spectrum (PAS). METHODS: This descriptive survey study was carried out over a 6-week period between January and March 2023. Healthcare providers, both anesthesiologists and those involved in operative care for women with PAS, were invited to participate. Questions invited both quantitative and qualitative responses. Qualitative responses were analyzed using content analysis. RESULTS: In all, 171 healthcare providers responded to the survey, the majority of whom were working in tertiary PAS referral centers (153; 89%) and 116 (70%) had more than 10 years of clinical experience. There was variation in the preferred primary mode of anesthesia for PAS cases; 69 (42%) used neuraxial only, but 58 (35%) used a combined approach of neuraxial and general anesthesia, with only 12 (8%) preferring general anesthesia. Ninety-nine (61%) were offering a routine antenatal anesthesia consultation. Content analysis of qualitative data identified three main themes, which were "variation in approach to primary mode of anesthesia", "perspectives of patient preferences", and "importance of multidisciplinary team care". These findings led to the development of a decision aid provided as part of this paper, which may assist clinicians in counseling women on their options for care to come to an informed decision. CONCLUSIONS: Approach to anesthesia for PAS varied between healthcare providers. The final decision for anesthesia should take into consideration the clinical care needs as well as the preferences of the patient.

Anesthesia and postpartum pain management for placenta accreta spectrum: The patient perspective and recommendations for care.

OBJECTIVE: Placenta accreta spectrum (PAS) is a high-risk complication of pregnancy, which often requires complex surgical intervention. There is limited literature on the patient experience during the perioperative period and postpartum pain management for PAS. Therefore, this study aims to explore the patient perspective of anesthesia care. METHODS: Ethical approval was granted by the hospital ethics committee (EC02.2023). This was a descriptive survey study, including women with a history of pregnancy complicated by PAS who were members of two patient advocacy groups. The survey, consisting of both open and closed questions, was performed over a 6-week period between January and March 2023. Content analysis was performed on qualitative data to identify themes, and recommendations for care are suggested. RESULTS: A total of 347 participants responded to the survey; 76% (n = 252) had a cesarean hysterectomy (n = 252), and general anesthesia was the most common primary mode of anesthesia (39%, n = 130). We identified two overarching themes: experiences of anesthesia and experience of postpartum pain management. Under experiences of anesthesia, three subthemes were identified, namely "communication with the anesthesiologist", "deferring to the expertise of the team", and "consequences of decision around the mode of anesthesia." Under postpartum pain management, two subthemes emerged: "support of specialist PAS team" and "poor pain management following PAS surgery". CONCLUSIONS: Women want to be involved in decisions around their care, but do not always understand the consequences of their decision-making, such as missing the birth of their child. An antenatal anesthesiology consultation is important to provide women with information, explore preferences, and develop a plan of care for the birth.

A randomized controlled trial of spinal morphine with an enhanced recovery pathway and its effect on duration of analgesia after cesarean delivery.

BACKGROUND: Intrathecal morphine is frequently administered after cesarean delivery to provide pain relief lasting up to 24 h. An enhanced recovery after cesarean pathways reduces the amount of postoperative opioids needed. The ideal dose of intrathecal morphine when combined with a pathway has not been determined. METHODS: This was a non-inferiority trial in 72 healthy women undergoing a scheduled cesarean delivery. Women were randomized to receive either 50 mcg, 150 mcg, or 250 mcg of intrathecal morphine during spinal anesthesia, with a standardized postoperative enhanced recovery pathway. The time to request supplemental opioids was the primary outcome. Secondary outcomes included pain scores, side effects, and quality of recovery at 24 h. RESULTS: The duration of analgesia with 50 mcg of morphine (median 24.5 h [IQR: 3.5-34.4]) was inferior to 150 mcg (29.4 h [24.5-72]), and both doses were inferior to 250 mcg (32 h [30.5-72]). Women who received 50 mcg morphine had higher pain scores than the other doses, received more supplemental opioids, and had lower quality recovery scores. The secondary outcomes between 150 mcg and 250 mcg were similar. Side effects were similar among all groups. 63% of women who received 250 mcg remained opioid-free at 72 h, compared to 150 mcg (52%) and 50 mcg (30%). CONCLUSIONS: The duration of analgesia using intrathecal morphine with an enhanced recovery pathway was longer with 250 mcg than with lower doses, and side effects were similar. 50 mcg provided inferior pain relief over 24 h. More than half of our patients avoided additional opioids for up to 72 h with either 150 mcg or 250 mcg doses. REGISTRATION: Clinical trial number NCT05069012.

Motivations and demographic differences in pregnant individuals in the decision to participate in research.

PURPOSE: Although many patients agree to participate in research studies, many decline. The decision of whether or not to participate is especially complex in pregnant individuals as they may be concerned about both themselves and the fetus. We sought to understand patient reasoning for and demographic associations with participation in a trial surrounding the utility of epidural preservative-free morphine after successful vaginal delivery. METHODS: We conducted a survey-based study in which parturients were approached within 36 hr after delivery to complete a survey assessing reasons for why they participated or not in the original trial. The survey also included self-reported demographics. Survey responses were categorized as follows: active participation, passive participation, ambivalence, aversion, miscommunication, clinical difficulty, unwilling to receive placebo, and screening failures. RESULTS: The survey response rate was 47%. Having a bachelor's degree or higher was associated with participating in the study (odds ratio [OR], 1.97; 95% confidence interval [CI], 1.07 to 3.64; P = 0.03). Race and ethnicity were not predictive of participation. Participants who self-identified as Black were more likely to select reasons of aversion for why they did not participate in the trial (OR, 2.6; 95% CI, 1.00 to 6.75; P = 0.05). Seventy-three percent of participants who self-identified as Black and declined to participate selected aversion, compared with 31% of those who self-identified as non-Black. Additionally, 71% of participants who self-identified as Hispanic and declined to participate selected aversion, compared with 32% of those who self-identified as non-Hispanic. CONCLUSIONS: These findings can help identify areas for improvement of participation of pregnant individuals in research studies. Demographic associations may influence participation and reasons for participation.

RéSUMé: OBJECTIF: Bien que bon nombre de patient·es acceptent de participer à des études de recherche, beaucoup déclinent. La décision de participer ou non est particulièrement complexe chez les personnes enceintes, car elles peuvent être inquiètes pour elles-mêmes et pour le fœtus. Nous avons cherché à comprendre le raisonnement des patient·es et les associations démographiques concernant la participation à une étude portant sur l'utilité de la morphine péridurale sans agent de conservation après un accouchement vaginal réussi. MéTHODE: Nous avons mené une étude basée sur des questionnaires dans laquelle les personnes parturientes ont été approchées dans les 36 heures suivant l'accouchement afin de compléter un questionnaire évaluant les raisons pour lesquelles elles avaient participé ou non à l'étude initiale. Le questionnaire comprenait également des données démographiques autodéclarées. Les réponses au questionnaire ont été classées comme suit : participation active, participation passive, ambivalence, aversion, mauvaise communication, difficulté clinique, refus de recevoir un placebo et échecs au dépistage. RéSULTATS: Le taux de réponse était de 47 %. Le fait d'avoir un baccalauréat ou plus était associé à la participation à l'étude (rapport de cotes [RC], 1,97; intervalle de confiance [IC] à 95 %, 1,07 à 3,64; P = 0,03). La race et l'origine ethnique n'étaient pas prédictives de la participation. Les participant·es qui se sont identifié·es comme Noir·es étaient plus susceptibles de choisir des raisons d'aversion pour expliquer leur non-participation à l'étude (RC, 2,6; IC 95 %, 1,00 à 6,75; P = 0,05). Soixante-treize pour cent des participant·es qui se sont identifié·es comme Noir·es et ont refusé de participer ont choisi l'aversion, comparativement à 31 % des personnes qui se sont identifié·es comme non Noir·es. De plus, 71 % des participant·es qui se sont identifié·es comme d'origine hispanique et ont refusé de participer ont choisi l'aversion, comparativement à 32 % des personnes qui se sont identifié·es comme non Hispaniques. CONCLUSION: Ces résultats peuvent aider à identifier les domaines dans lesquels la participation des personnes enceintes aux études de recherche peut être améliorée. Les associations démographiques peuvent influencer la participation et les raisons de la participation.

Supraventricular Tachycardia Associated With Repeat Cesarean Section Under Spinal Anesthesia.

Supraventricular tachycardia (SVT) is the most common tachyarrhythmia of pregnancy. Catecholamine surges, the use of vasoactive agents during delivery, and increased cardiac output during pregnancy are the most common contributing factors to developing SVT. SVT is usually benign in presentation but can lead to more serious arrhythmias in patients with a history of mitral stenosis secondary to rheumatic heart disease. When an SVT is detected, organic heart causes should be ruled out first. Symptoms of SVT include shortness of breath, palpitations, syncope, sweating, chest pain, and dizziness. In patients who are refractory to pharmacologic management and hemodynamically unstable, electrical cardioversion has proven to be efficacious and safe in all trimesters. The initial treatment for hemodynamically stable patients is to attempt vagal maneuvers, such as carotid sinus massage or Valsalva maneuver. If the SVT does not convert to normal sinus rhythm, treatment with adenosine or beta-blockers may be initiated. Treatment with atenolol and verapamil should be avoided due to their teratogenic effects.

Spinal Introducer Needle Breakage During Spinal Anesthesia for Cesarean Section: A Case Report.

Spinal and epidural anesthesia are the preferred choices for patients undergoing a cesarean section (CS). The increased use of neuraxial anesthesia in obstetrics may lead to certain complications such as needle breakage. While several cases of broken spinal and epidural needles have been reported, the exact incidence of needle breakage remains uncertain. The use of pencil-point needles with smaller diameters and the increasing BMI among pregnant individuals may have contributed to the increase in the reported incidents of broken needles during obstetric surgery. We present a case of a patient who was found to have a leftover spinal introducer needle in her back after undergoing spinal anesthesia for CS.

Anesthetic Management of an Obstetric Patient With Ehlers-Danlos and Wolff-Parkinson-White Syndromes.

A 31-year-old, primigravida, nullipara (G1P0) female with a past medical history of Ehlers-Danlos Syndrome (EDS), newly diagnosed Wolff-Parkinson-White Syndrome (WPW), and fetal breech presentation initially presented at 36+5 weeks gestation for an external cephalic version (ECV). The patient noted significant symptomatology related to her WPW which had worsened over the course of her pregnancy despite being started on oral metoprolol. Despite joint recommendations from the anesthesia and obstetric teams to combine the ECV with a same-day scheduled induction of labor or cesarean section, the patient declined. An epidural catheter was placed using ultrasound guidance and slowly titrated with 2% lidocaine; however, the ECV was unsuccessful. At 39 weeks gestation, the patient underwent an uncomplicated low transverse cesarean section under combined spinal-epidural anesthesia. The patient was discharged two days later in stable condition with a referral to an electrophysiologist. Here we describe the anesthetic preparation and management for an external cephalic version and subsequent cesarean section in a patient with these two rare conditions.

Anesthesia for cesarean delivery in a patient with congenitally corrected transposition of the great arteries: A case report.

Congenitally corrected transposition of the great arteries (CCTGA) is a rare form of congenital heart disease often associated with other cardiac defects. The adaptations and physiologic changes in pregnancy can present maternal challenges and complications; multidisciplinary care allows for the safest management of pregnancy and delivery in these patients. We present a case of the anesthetic management of cesarean delivery in a woman with CCTGA with her pregnancy complicated by recurrent volume overload, pulmonary hypertension, and dysrhythmias.

Anesthesiology resident preferences regarding learning to perform epidural anesthesia procedures in obstetrics: a qualitative phenomenological study.

BACKGROUND: Learning to perform neuraxial techniques in obstetrics is considered one of the most difficult skills for anesthesiology trainees to acquire and no consensus exists regarding the best practices for teaching these procedures. Utilizing a qualitative, phenomenological approach, we aimed to explore what trainees perceive as the best approaches to teaching epidural anesthesia techniques; identify how these perceptions align or differ from those of faculty anesthesiologists; and examine how these approaches fit into the cognitive apprenticeship framework, which describes a process of reflection on how learning occurs in the authentic environment. METHODS: Semi-scripted interviews were conducted with 10 residents and three faculty members from the division of obstetric anesthesiology at an academic center. Interviews were transcribed, de-identified, fragmented, and coded. A thematic analysis was conducted, and codes re-organized into the cognitive apprenticeship framework of (1) content, (2) method (including subcategories modeling, coaching, scaffolding, articulation, reflection, and exploration), (3) sequence, and (4) sociology (including situated learning and culture of expert practice). RESULTS: Trainees valued a staged approach to learning epidural techniques, independent trouble-shooting, graded independence, focused feedback, and a calm instructor. The challenges of learning and teaching epidural techniques identified by trainees and instructors included the tactile nature of the procedure, teaching on awake, non-sedated patients, limited teaching time, and creating an environment of psychological safety. CONCLUSION: Trainee and instructor preferences for teaching epidural procedures in obstetrics aligned with the cognitive apprenticeship framework. These concepts may be applied to curriculum design, evaluation, feedback, self-assessment and faculty development.