Indian Journal of Pain

REVIEW ARTICLE
Year
: 2021  |  Volume : 35  |  Issue : 3  |  Page : 186--194

Recent updates in obstetric analgesia


Tazeen Beg1, Bahaa Eldin Daoud2, Tiffany E Angelo2,  
1 Division of Non-Operating Room Anesthesia, Renaissance School of Medicine at Stony Brook University, Stony Brook, NY, USA
2 Division of Women's Anesthesiology, Renaissance School of Medicine at Stony Brook University, Stony Brook, NY, USA

Correspondence Address:
Dr. Tazeen Beg
Division of Non-Operating Room Anesthesia, Renaissance School of Medicine at Stony Brook University, Stony Brook, NY 11794-8480
USA

Abstract

Analgesia for a parturient is an important element of care provided by an anesthesiologist as a member of the multidisciplinary team. Neuraxial anesthesia is considered the gold standard. With increasing evidence of safety and efficacy of various available techniques and equipment, including ultra-short–acting opioids, local anesthetics, newer combined spinal–epidural needles, monitors, patient-controlled infusion pumps, and point-of-care ultrasound, obstetric care has become less challenging with higher patient satisfaction rates and better safety profiles. Recent articles spanning the last few years on important related topics, including care of the parturient during COVID, newer developments, enhanced recovery after cesarean (ERAC) protocols, and patients with unique profiles, are discussed in this update on obstetric analgesia.



How to cite this article:
Beg T, Daoud BE, Angelo TE. Recent updates in obstetric analgesia.Indian J Pain 2021;35:186-194


How to cite this URL:
Beg T, Daoud BE, Angelo TE. Recent updates in obstetric analgesia. Indian J Pain [serial online] 2021 [cited 2022 Jan 21 ];35:186-194
Available from: https://www.indianjpain.org/text.asp?2021/35/3/186/334107


Full Text



 Introduction



Obstetric care is no longer the realm of obstetricians alone. It has become multidisciplinary with a team of healthcare providers, all working toward a common goal. Anesthesiologists are increasingly being called upon to participate in the care of laboring women with the increase in the age and overall complexity of a parturient. The fear of labor pains, considered to be one of the worst pains endured by women, has been an important element in the request for labor analgesia or elective cesarean delivery in different parts of the world. There are different ways of alleviating such pains using both pharmacological and nonpharmacological methods. Systemic analgesics, both oral and parenteral, regional anesthesia, as well as neuraxial anesthetics, have been in use since time immemorial.[1] The purpose of this article is to highlight some of the latest developments, researches, and recommendations that anesthesiologists around the world can find relevance for managing pain in obstetric patients. We also discuss unique patient populations, including those afflicted with the current SARS-CoV-2 infection, obesity, chronic pain, and transgender parturients, and implementation and effects of enhanced recovery protocols after cesarean delivery (ERAC).

 Labor Analgesia



Labor pains induce a physiological stress response resulting in hyperventilation, respiratory alkalosis, increased oxygen consumption, cardiac output, systemic vascular resistance, and blood pressure, all of which can have deleterious maternofetal effects.[2] Effective pain control through informed choice helps to provide the mother with a relaxing environment and a positive experience during childbirth. It may improve maternal satisfaction and decrease the risk of postpartum depression and posttraumatic stress disorder.[3]

 Pharmacological Methods



Opioids, nitrous oxide (Entonox), and subanesthetic (0.8%) doses of sevoflurane and ketamine have all been used for pain relief in the first stage of labor. Among the opioids, intramuscular (IM) pethidine is a commonly prescribed potent opioid that shortens the duration of the active phase of labor but has maternofetal side effects including respiratory depression. It has recently been shown to significantly (P < 0.5) increase the false-positive rate of newborn hearing test.[4] Parenteral Butorphanol, a partial agonist at the μ- receptor with less respiratory depression compared to morphine, and thus, a better maternofetal safety profile, is more popular in the United States.[5] Another mixed opioid agonist–antagonist, nalbuphine, has been used for sudden intense labor pain in the late second stage. An ex vivo model studying transplacental transfer to a neonate after maternal intravenous (IV) administration found very low levels and suggested that it would be another safe option.[6] IV remifentanil due to its short duration and quick metabolism by plasma esterases has become a favorite on the labor floor. Its IV patient-controlled analgesia (PCA) regimen was compared to IM pethidine in multicenter RESPITE trial and found to decrease the requests for a subsequent epidural by 50% with no additional risks.[7] Remifentanil is helpful for patients with contraindications to neuraxial block (e.g., coagulopathy, increased intracranial pressure, or some severe cardiac conditions). A retrospective study of 5740 data sets from the RemiPCA SAFE Network (established to set standards and monitor outcomes) found very low rates (0.3%) of requiring neonatal cardiopulmonary resuscitation and moderate maternal hypoxia (24.7%) from its use.[8] However, when compared to epidural analgesia, remifentanil PCA was found to be a less effective analgesic and caused maternal desaturation (<95% oxygen saturation).[9] Another observational study compared remifentanil PCA with standard epidural and found it to promote shorter active labor and significantly higher rates of spontaneous delivery (94% vs. 65% for epidural, P < 0.001), with no difference in maternal and neonatal morbidity.[10] Despite its frequent use in Europe and other parts of the world, there is a developing interest in the use of nitrous oxide for labor analgesia (Entonox, a mixture of 50% oxygen and nitrous oxide) in the USA due to higher maternal satisfaction scores and ease of delivery than without any analgesic technique.[11] In a randomized clinical trial (RCT), 50% of parturients received Entonox for pain during each contraction (vs. no analgesic). The Entonox group had significantly better pain relief (P < 0.05) and shorter duration of labor (64.80 vs. 98.33 min) without affecting maternal hemodynamics or neonatal Apgar scores.[12] Nitrous oxide has a valid occupational exposure concern for healthcare professionals and can produce metabolic, oxidative, apoptosis, and epigenetic changes in both mother and fetus.[13] However, the Entonox nitrous oxide delivery system is a closed system with a built-in scavenger which significantly reduces environmental exposure. Two case reports have described supplementing nitrous oxide with low dose (0.2–0.4 mg/kg/h) ketamine infusion with satisfactory pain control and neonatal outcomes.[14] Ketamine is a useful adjunct, and its antidepressant effects could be studied further to mitigate postpartum depression.[15] Ketamine may be safer than diazepam in neonates of postpartum lactating females when used for tubal ligation.[16] Sevoflurane never gained favor for lack of analgesia, excessive sedation, and environmental pollution and its potential for significant tocolytic uterine-relaxing properties.[17]

 Nonpharmacological Methods



Neuraxial blockade utilizing multimodal analgesia with local anesthetics (LA) and opioids is considered the gold standard to alleviate labor pains due to its effectiveness and safety.[18] There are, however, certain other “time-tested” methods based on physiological, psychosocial, behavioral, and cognitive processes, such as relaxation techniques, hypnosis, deep breathing, massage, aromatherapy, hydrotherapy, acupuncture, virtual reality (VR), and transcutaneous electrical nerve stimulation (TENS). Most of the studies on these techniques have insufficient evidence to decrease labor pains, but they also do not cause any significant maternofetal complications. Their use depends on the patient's choice and hence may generate bias. In a cross-section of women taken from the 2016 National Perinatal Survey attempting vaginal delivery, the determinants of nonpharmacological analgesia use were found to be related to maternal educational level and preference, quality of prenatal care, and availability of resources or healthcare model.[19] However, a few recent studies have shown some promising results: In a single-blind RCT on 326 patients in the first stage of labor, the efficacy of TENS therapy was demonstrated to reduce pain and significantly (P < 0.001) shorten the active phase of the first stage of labor.[20] According to a Cochrane database systemic review, acupuncture when compared to a sham procedure showed increased satisfaction with pain management and decreased use of IV analgesics.[21] To observe the effects of a VR experience on pain and anxiety levels of women during labor, the VRAIL Study was created which showed decreases in sensory, affective, and cognitive pain scores,[22] and similar results were reciprocated in an RCT where maternal heart rates were found to be lower in those with exposure to a VR intervention.[23] Photo-biomodulation with LED light placed on the patient's dorsum between T10 and S4 levels for 10 min decreased pain significantly (P < 0.05) than heat therapy.[24] Another study investigated the cord blood levels of copeptin, interleukins, serum oxidant, antioxidant, and oxytocin in patients with neuraxial analgesia, water immersion, or no analgesia use and concluded that epidural analgesia produces more oxidative stress and lower APGAR scores than water immersion.[25] Labor pain is multifactorial, complex, and impacted by cultural and social factors, which may be the reason for some of these techniques' successes as adjuncts in modulating pain.

 Peripheral Nerve Blocks



Knowledge of the pain pathways during labor is important to effectively manage it. The visceral pain of the first stage of labor is primarily caused by stretching of the lower uterine segment and cervix, which can be obtunded by bilateral paracervical blocks or a lumbar sympathetic block. The somatic pain caused by descent of the presenting part in the second stage of labor is caused by stretching of the pelvic structures and can be effectively ameliorated by placement of a pudendal nerve block (PNB). These blocks demonstrate better analgesia and patient satisfaction scores than placebo or traditional opioids in labor but have lost favor due to complications, availability of short-acting opiates, and much safer neuraxial techniques, which can cover all three stages of labor. They are used occasionally in emergencies, when neuraxial anesthesia is contraindicated, or for an incomplete or patchy epidural block. Pudendal blocks are considered safe for operative vaginal deliveries such as forceps and episiotomy repairs, though not so much for mid-cavity or rotational delivery.[26] A recent double-blinded RCT study showed that ultrasound-guided placement of bilateral PNB as an adjunct can significantly (P < 0.001) shorten the second stage of labor and amount of bupivacaine used for epidural with better motor function.[27] Paravertebral block, erector spinae block (ESB), and posterior quadratus lumborum blocks (QLBs) have also been used to relieve early labor pains. A recent case report described an effective posterior QLB in a laboring patient with hemophilia.[28]

 Neuraxial Blocks



Since the 1960s, neuraxial anesthesia has changed the perception of labor pain. With the introduction of safer LAs such as bupivacaine and ropivacaine as well as ultra-short–acting opioids, epidural blockade (EB) has become the most effective tool for labor analgesia.[18] The traditional EB with higher concentrations of bupivacaine (0.25% commonly) has been replaced by lower concentrations (0.0625%–0.1%) and addition of lipophilic short-acting opioids such as fentanyl with better safety profiles and maternal satisfaction scores.

Intrathecal (IT) opioids without LA have also been used with success. Sufentanil and fentanyl (7.5 mcg each in 1.5 ml injection) were compared in a double-blind RCT. Fentanyl had significantly better analgesia (P < 0.05), patient satisfaction, and faster onset (3.6 vs. 5.6 min; P = 0.037) though the duration was prolonged for sufentanil (113 vs. 103 min; P = 0.629) with lesser pruritus.[29] However, a single shot spinal cannot be placed for early labor pain because it would need to be repeated for prolonged labor increasing the risk of postdural puncture headache (PDPHA).[30] A combined spinal–epidural (CSE) could be advantageous for severe pain. A recent retrospective study included 400 primigravidae to determine the effects of CSE on the progress of labor by examining their labor curves. In the CSE group, labor progressed significantly faster in the latent stage with cervical dilation than in the non-CSE group (P < 0.005) but was delayed in the active stage with a higher incidence of instrumental delivery. The labor curve was interestingly different from the commonly used Friedman curve.[31] A dural puncture epidural (DPE) creates a hole in the dura but without directly delivering IT LA. It has been found to provide improved sacral block quality, less one-sided blocks, faster time to analgesia and spread compared to EB and with less side effects, and better patient satisfaction as compared to CSE.[32],[33] Intentional dural puncture by an epidural needle to utilize a continuous IT catheter may be advantageous in morbidly obese or high-risk patients who require cesarean section due to its controlled and fast onset, but the risks of infection and PDPHA preclude its widespread use.[34]

Maintenance of neuraxial blockade is most commonly through patient-controlled epidural analgesia (PCEA) or the more sophisticated computer-programmed intermittent epidural boluses (PIEB). PCEA with a high volume of a lower concentration of LA has been shown to provide better analgesia, less intense motor blockade, and higher maternal satisfaction due to a feeling of being in control of their pain. It has also recently been shown to protect against short-term pelvic floor dysfunction in a retrospective study.[35] PIEB can improve the spread of LA through the multi-orifice catheter tip,[36] require lesser total LA dose, and provide better maternal satisfaction as well as decreased instrumental delivery.[37],[38] A recent study could not demonstrate any significant advantage of PIEB over continuous epidural infusion other than a reduced motor block. They did find a clinically insignificant small (2.5 ml) decrease in LA use.[39] When combined with DPE, it provided a significant drug-sparing effect with the lowest use of additional LA boluses (P < 0.001)[40] and shorter median time to adequate analgesia.[41]

The addition of opioids to neuraxial blocks for labor prolongs the analgesic effect but sometimes with undesirable maternofetal effects. Minimizing the doses has given better results.[42] Oxycodone (0.2 mg/ml) when added to 0.1% ropivacaine for a labor epidural in an RCT with 80 nulliparous women produced significantly prolonged and faster onset analgesia but did cause maternal pruritus.[43] Several medications have been tried to improve analgesia and prevent side effects in the past. Oral acetaminophen (1 g) as a single dose produced significantly less utilization of CEI plus PCEA and is a cheap, safe addition for multimodal analgesia regimens.[44] The alpha-2 adrenoceptor agonist dexmedetomidine (0.5 mcg/ml) with 0.1% ropivacaine when compared with sufentanil (0.5 mcg/ml) provided better analgesia with lesser total analgesic use (71.5 ml vs. 78.1 ml; P < 0.05) and shortened the duration of first stage of labor (378 vs. 406 min; P < 0.05) but at the cost of significantly increased sedation (Ramsay sedation scale 2.8 vs. 2.4; P < 0.05).[45] In a prospective RCT, 0.4 mcg/ml dexmedetomidine in ropivacaine was found to have an opioid-sparing effect and resulted in the lowest effective concentration (EC50) with greatest clinical effect during labor.[46] However, dexmedetomidine has not yet been approved for neuraxial use by the US Food and Drug Administration.

 Postpartum Analgesia



To prevent over-treatment with consequent problems and side effects, it is important to assess the individual pain requirements of a parturient preoperatively to develop an individualized plan. This will help optimize their care with targeted treatment protocols and help in their recovery and improve satisfaction.[47] In a prospective Swedish study, more than 1500 women were sent two questionnaires about chronic pain, one 24–36 h after labor started and another 8 months after a live childbirth. 16.7% of the total respondents (n = 1171) reported pain. Of these, 61/916 or 6.7% after vaginal delivery and 28/255 or 11% after cesarean delivery developed chronic pain that affected their daily activities considerably.[48]

Pain after vaginal delivery is variable, often dependent upon the predelivery status of the patient, as with anxiety, depression, obesity, and chronic pain being most common. In a retrospective case–control study, 20% of normal uncomplicated vaginal delivery patients received an opioid. With complications of a perineal tear, episiotomy, postpartum hemorrhage, or tubal ligation, most pain was controlled with NSAIDs (97.1%), oral acetaminophen (25.8%), or opioids (24.8%).[49]

Analgesia for an emergent CD with an epidural catheter in place is induced most commonly with 3% 2-chloroprocaine (CP) or 2% lidocaine. A recent study compared the two with additional epinephrine (150 mcg), 8.4% bicarbonate (2 ml), and fentanyl (10 mcg) added to lidocaine. The mean onset time to sensory block at T7 level was not significantly different at 655 s for CP group to 558 s for lidocaine group, demonstrating the noninferiority of chloroprocaine as a quick onset LA with a better maternal and fetal safety profile.[50]

Neuraxial opioids

Elective cesarean sections are performed under spinal and epidural blocks supplemented with IT opioids. In a systematic review and meta-analysis of 17 RCTs, the addition of lipophilic opioid fentanyl (5–25 mcg) to IT bupivacaine (7.5–13.75 mg) reduced the need for supplemental analgesia by 82%, intraoperative nausea vomiting by 59% and increased the time to first analgesic request postoperatively by more than 90 min. However, the incidence of pruritus increased 6-fold. Similar results were obtained when fentanyl was added to IT bupivacaine and morphine.[51] Recently, 0.6 mg epidural hydromorphone was found to provide satisfactory analgesia in the first 24 h postoperative.[52]

Diamorphine and IT morphine, both hydrophilic opioids, are the most commonly used opioids and the gold standard in the UK and US respectively, and considered the most effective form of post-cesarean analgesia.[53],[54] A systematic review of 75 studies where neuraxial morphine or diamorphine was administered for postcesarean pain found the prevalence of clinically significant respiratory depression (CSRD) to be low (highest - 1.63 in 10,000 and lowest - 0.83 in 10,000 for morphine) and most of the patients who had CSRD received >150 mcg of IT morphine. There was no CSRD with IT diamorphine.[55] The Society of Obstetrics Anesthesia and Perinatology (SOAP) Task Force in accordance with the ASA Practice Guidelines strongly recommends that neuraxial morphine should be the preferred method for pain management after cesarean section in healthy mothers and that the frequency of respiratory monitoring should be customized according to the preoperative risk factors.[56]

Regional blocks

With the emergence of enhanced recovery concept in obstetrics, regional blocks are increasingly being performed specifically in patients with contraindications for neuraxial opioids, as rescue analgesia or after general anesthesia is administered. There is ample evidence through various systematic reviews and meta-analyses to support the use of these blocks.[57],[58],[59],[60],[61],[62]

In a meta-analysis of 17 RCT studies from 2009 to 2019 utilizing transverse abdominis plane (TAP) blocks with ultrasonography (USG-TAP) compared to placebo or no block, it was found that in the absence of IT opioids, USG-TAP blocks provided significantly better analgesia with delayed first analgesic use and decreased 6/12/24 h cumulative opioid use.[58] Through a Bayesian network meta-analysis which allows comparing several interventions through the use of a common comparison group, TAP block was found to be the safest and most effective regional technique in the absence of IT morphine.[61] Low-dose TAP block with <50 mg bupivacaine on each side will provide the same analgesic effect and is preferable to prevent toxicity.[54],[59] QLB can be placed via posterior, lateral, or anterior approaches. In a meta-analysis, opioid consumption was significantly reduced (14.1 mg to 7.5 mg) in comparison to a placebo or no block placement,[60] while another systematic review reported a decrease in oral morphine consumption by 24.1 mg.[62] However, a recent RCT comparing QLB (40 ml 0.25% levobupivacaine bilateral) with control or sham block failed to show any significant advantage of QLB after 6 h in the presence spinal anesthesia with IT morphine.[63] In an RCT, the severity of persistent postoperative pain after 1 (P < 0.01) and 6 months (P < 0.039) was less in patients who received a posterolateral QLB; and both USG-TAP blocks and QLB showed better pain scores and decreased morphine consumption.[64] Bilateral ESB performed at the T9 level as part of an RCT in 140 women was found to have better pain scores (VAS 0–10) than neuraxial morphine at 8 h (0.31 points) and up to 24 h (0.25 points) after CD. Time to first analgesic was prolonged while opioid consumption was decreased.[65] Another RCT combined ilioinguinal nerve block with USG-TAP blocks as a multimodal analgesia protocol and compared it to a single shot spinal bupivacaine with IT 15 mcg fentanyl and 150 mcg morphine. 24-h consumption of IV-PCA fentanyl was 72 mcg versus 179 mcg in the IT opioid group (P < 0.001).[66] Rectus sheath block with bupivacaine did not show much promise without neuraxial opioid postcesarean section; however, they can be combined and performed under USG guidance.[67] Wound catheter, when considered as an element of multimodal analgesia, should be placed under the fascia and continuous infusion may be considered for better outcomes.[57] All these blocks need more comparative studies between blocks and also in combination with or without long-acting neuraxial opioids. It should be realized, however, that in the absence of expertise and other resources, simple wound infiltration could be useful. Preemptive analgesia with local infiltration before making an incision has not been shown to help with pain relief.[57]

Utilizing the procedure-specific postoperative pain management (PROSPECT) methodology, a systematic review of RCTs (n = 126) and systematic reviews (n = 19) published between 2014 and 2020 was undertaken, and recommendations were made for pain control for elective CD. Important recommendations include: acetaminophen and NSAIDs post-operatively to decrease opioid consumption; IV dexamethasone, after delivery of the baby, which demonstrated analgesic and anti-emetic effects; IT morphine (<100 mcg) or diamorphine (<300mcg); if neuraxial blockade is contraindicated, a single dose of LA infiltration, wound catheter infusion or regional anesthesia blocks (USG-TAP, QLB); supplemental analgesic methods like TENS; and utilizing a better surgical technique with no peritoneal closure.[68]

Hematologic disorders

Decreased mobility of pregnant patients in the third trimester, and that from epidural anesthesia and CD, can increase the risk for venous thromboembolism since pregnancy predisposes to a hypercoagulable state. Risk/benefit analysis of thrombotic event versus bleeding should be assessed before a neuraxial block placement. Thrombocytopenia (<70 K) increases the risk of epidural hematoma, but platelet count between 70 and 100 K has a very low risk as per data from a multicenter study[69] and as per SOAP 2018 consensus statement (1:200,000–1:250,000).[70] Fresh frozen plasma, fibrinogen, antithrombin, tissue plasminogen activator, and tranexamic acid (TXA) should be considered for postpartum hemorrhage.[71]

Postdural puncture headache

An unintentional debilitating complication of an EB is a dural puncture (0.15%–1.5%). Almost 50% of cases may develop PDPHA.[72] It was found to be associated with increased risks of subdural hematoma, cerebral venous thrombosis, meningitis, postpartum depression, headache, and chronic back pain in a retrospective cohort of 4808 women who received neuraxial anesthesia and developed PDPHA.[73] In a recent data analysis on >1.5 million women, 71.9% received neuraxial labor analgesia for vaginal delivery and 0.58% (95% confidence interval) had a PDPHA. Epidural blood patch (EBP) is the gold standard of treatment, but it is invasive. Almost 80% of patients receiving an EBP get relief.[74] Another simpler option is a sphenopalatine ganglion block that may provide relief in 50% of patients. In a retrospective 17-year chart review, it was found to provide better patient satisfaction than an EBP[75] which is encouraging but requires further investigation.

 Parturient with Chronic Pain



There is an increasing trend for opioid prescriptions after cesarean section in the US.[76] However, if the patients are involved in shared decision-making and educated about postoperative pain and consequences of opioid use, there is decreased utilization with improved patient satisfaction.[77] In an opioid-dependent patient, who has higher patient requirements and who may be stigmatized, there is a risk of inadequate care during pregnancy with poor intrapartum pain relief and neonatal abstinence syndrome. For opioid-tolerant recovering patients on maintenance therapy for opioid abuse, it is recommended to continue buprenorphine or methadone. Buprenorphine has a better safety profile for neonatal outcomes, and breastfeeding is encouraged since it is expressed in breast milk and prevents newborns from going into the abstinence syndrome.[78] The rest of their care should be standard with the addition of the various adjuncts as mentioned previously. Postpartum follow-up of these patients is equally important. A collaborative team approach between the various disciplines that includes an addiction medicine expert would be beneficial.[79]

 Obesity



Obesity has important anesthetic implications in a pregnant woman. The associated comorbidities increase the risk of perioperative morbidity and mortality. These patients are at an increased risk of CD (23.4% vs. 11.7%; P < 0.001)[80] and general anesthesia which should be emphasized early on in the peripartum period. Routine consultation with an anesthesiologist as part of the multidisciplinary team involved in the care of the obese parturient is encouraged.[81] Early neuraxial labor analgesia is recommended[81] with CSE or DPE techniques that have better success rates.[82] In a retrospective study on 3653 patients, >3 attempts for epidural puncture were taken in 9.1% obese versus 5.3% nonobese women.[80] Therefore, it is recommended that blocks be performed in the sitting position, possibly with ultrasound guidance for landmark identification in morbidly obese patients.[83] If general anesthesia is required, video laryngoscopy should be employed to prevent rapid desaturation,[84] and multimodal analgesia with truncal blocks is recommended for postoperative pain.[81]

 Enhanced Recovery after Cesarean



The SOAP released a consensus statement and recommendations for ERAC based on the outcomes and research on ERAS protocols.[85] These are important for early recovery and ambulation facilitating mother–baby bonding and early hospital discharge. Multimodal analgesia is the hallmark of pain management in an ERAC protocol. Gabapentin and acetaminophen preoperatively, neuraxial anesthesia with long-acting opioid for cesarean section, and acetaminophen and ibuprofen or ketorolac for postoperative pain control have been suggested. In a RCT on 58 women, no significant increase in the number of women discharged on postoperative day 2 or decreased narcotic use was observed, but there was a significantly reduced postoperative length of stay (LOS).[86] In another study, however, following the implementation of a similar protocol, decreased postoperative opioid use (total postoperative morphine milligram equivalents was 0 vs. 140, P < 0.001), shorter LOS, and decreased pain after CD was observed.[87] In a review to ascertain the attitude of healthcare workers toward the implementation of ERAC protocol, the authors found a lot of variation among different countries with minimal or no change in practice despite ERAS protocols being adopted in their hospitals. Opioids were still found to be widely used with insufficient knowledge about pain management.[88] Moreover, in the developing world, the implementation of recent guidelines from the ERAS Society[89] may be even more difficult due to minimal antenatal and follow-up care and paucity of funds and resources.[90]

 COVID-Positive Parturient



SARS-CoV-2 infection, the coronavirus disease commonly known as COVID-19, is a challenge to treat in a pregnant patient. Mild cases of COVID-19 in pregnancy and labor do not increase the risk of maternal morbidity and mortality although comorbidities do increase the risk of severity of infection and consequent intensive care.[91] A SOAP COVID-19 registry with 1454 patients from 14 US centers from March 2020 to May 2020 analyzed the outcomes of pregnant women with the disease and their newborns against controls. Patients with infection had an increased risk for preterm delivery (<37 weeks of gestation), with increased risk of CD and length of hospitalization,[92] which has previously been shown in an early case series from China.[93]

Obstetric care being very fluid requires flexibility and preparedness at the same time. All standard operating procedures, therefore, incorporate various scenarios including general anesthesia, which is a high-risk aerosol-generating procedure (AGP) for a possible emergent cesarean section. A recently published study recommends a 'temporal sequence of steps' in checklists and workflows to minimize deviation from standards; procedure specific packs to conserve the much-needed personal protective equipment (PPE); and other resources, which would be prudent to use in countries with an overwhelming lack of resources and personnel.[94]

Neuraxial analgesia with minimal oxygen flows to maintain saturation is preferable in patients with COVID-19 since it avoids general anesthesia and aerosolization.[95] Neuraxial analgesia has been found to be safe and not associated with neurological damage or seeding.[96],[97],[98] Early placement of neuraxial analgesia in labor is recommended with a backup plan for general anesthesia with full PPE precautions and preparation in case of failure of the block and need for cesarean delivery.[91],[92] Mild thrombocytopenia has been reported in COVID-19 patients, but a disseminated intravascular clotting (DIC) like state with microthrombi is more commonly found in nonpregnant patients.[99] There is insufficient evidence for any recommendations for prophylaxis; however, it would be prudent to give obstetric COVID-19 patients with symptomatic disease and/or increased oxygen requirements, thromboprophylaxis with low-molecular weight heparin, and time the neuraxial block accordingly.[100] Avoid TXA in case of postpartum hemorrhage.[101] All patients including those that have been vaccinated should be tested with a polymerase chain reaction test before any procedure.[102] Other options for labor analgesia include administration of nitrous oxide (Entonox) which is not considered an AGP but should be used with a heat and moisture exchange microbial filter. Intravenous opioids should be used with caution in patients with low oxygen saturation and respiratory distress.[103],[104] Nonopioid analgesics such as ketorolac and other NSAIDs have not been shown to have any detrimental effects on COVID-19 patients in a meta-analysis of 266 studies with observational data mentioning their use but should be used cautiously.[105] Acetaminophen is a safe alternative analgesic.[98] Dexamethasone for Postoperative nausea vomiting (PONV) prophylaxis should be avoided.[98],[103] For patients with COVID-19, maternal fever is more pronounced; therefore, continuous maternal temperature and fetal monitoring should be encouraged.[104] The major interventions for managing a COVID-19 patient are summarized in [Table 1].{Table 1}

 Transgender Parturient



As experts in reproductive endocrinology and surgery, obstetricians and gynecologists are sometimes sought out for the care of this special population, so it would be prudent to be aware of their unique needs and sensitivities. There is a need for increased awareness of gender dysphoria, removal of barriers and bias in the care, improved resource allocation, and support of transgender individuals. The Oncofertility Consortium, an international, interdisciplinary initiative, has been helping individuals transitioning between gender identities to look forward to fertility limiting treatments or a fertile future.[106] A recent case report emphasized the importance of early multidisciplinary planning and collaboration, use of gender-appropriate language, and interventions in the care of a transgender parturient during the peripartum period. The patient may actually forego labor due to the anxiety related to labor pains. The authors, therefore, recommend early offer of neuraxial block and its continuance during the postdelivery period if cervical examinations or other invasive procedures and exacerbation of gender dysphoria are anticipated. An elective cesarean section, and possibly, a personal room should be offered to the “at-risk” patient.[107] Despite efforts to familiarize and educate the healthcare workers, and society at large, discrimination still exists preventing these individuals from seeking healthcare. A recent review discusses standards and recommendations for the care, and cancer screenings in particular, in transgender patients.[108]

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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