A randomized trial comparing surgeon-administered intraoperative transversus abdominis plane block with anesthesiologist-administered transcutaneous block.

BACKGROUND: Injection of local anesthetic into the transversus abdominis plane (TAP block) decreases systemic morphine requirements after abdominal surgery. We compared intraoperative surgeon-administered TAP block (surgical TAP) to anesthesiologist-administered transcutaneous ultrasound-guided TAP block (conventional TAP) for post-cesarean analgesia. We hypothesized that surgical TAP blocks would take less time to perform than conventional TAP blocks. METHODS: We performed a randomized trial, recruiting 41 women undergoing cesarean delivery under neuraxial anesthesia, assigning them to either surgical TAP block (n=20) or conventional TAP block (n=21). Time taken to perform the block was the primary outcome, while postoperative pain scores and 24-hour opioid requirements were secondary outcomes. Student's t-test was used to compare block time and Kruskal-Wallis test opioid consumption and pain-scores. RESULTS: Time taken to perform the block (2.4 vs 12.1 min, P <0.001), and time spent in the operating room after delivery (55.3 vs 77.9 min, P <0.001) were significantly less for surgical TAP. The 24 h morphine consumption (P=0.17) and postoperative pain scores at 4, 8, 24 and 48 h were not significantly different between the groups. CONCLUSION: Surgical TAP blocks are feasible and less time consuming than conventional TAP blocks, while providing comparable analgesia after cesarean delivery.

Uterine Tachysystole with Prolonged Deceleration Following Nipple Stimulation for Labor Augmentation.

Breast stimulation for inducing uterine contractions has been reported in the medical literature since the 18th century. The American college of Obstetricians and Gynecologists (ACOG) has described nipple stimulation as a natural and inexpensive nonmedical method for inducing labor. We report on a 37 year old P2 with a singleton pregnancy at 40 weeks gestation who developed tachysystole with a prolonged deceleration after nipple stimulation for augmentation of labor. Initial resuscitative measures, including oxygen by mask, a bolus of intravenous fluids and left lateral positioning, did not restore the fetal heart rate to normal. After the administration of Terbutaline 250 mcg subcutaneously, the tachysystole resolved and the fetal heart rate recovered after five minutes of bradycardia. Most trials of nipple stimulation for induction or augmentation of labor have had small study populations, and no conclusions could be drawn about the safety of nipple stimulation, though its use is widespread. While there have been a few reports of similar complications during nipple stimulation for contraction stress testing, there are no previous reports of tachysystole with sustained bradycardia following nipple stimulation for labor augmentation. In this report, we draw attention to the dangers of nipple stimulation so that providers will be aware of this potential complication.