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The prevalence of pregnant people with opioid use disorder (OUD), including those receiving medications for opioid use disorder (MOUD), is increasing. Challenges associated with pain management in people with OUD include tolerance, opioid-induced hyperalgesia, and risk for return to use. Yet, there are few evidence-based recommendations for pain management in the setting of pregnancy and the postpartum period, and many peripartum pain management studies exclude people with OUD. This scoping review summarized the available literature on peridelivery pain management in people with OUD, methodologies used, and identified specific areas of knowledge gaps. PubMed and Embase were comprehensively searched for publications in all languages on peripartum pain management among people with OUD, both treated with MOUD and untreated. Potential articles were screened by title, abstract, and full text. Data abstracted were descriptively analyzed to map available evidence and identify areas of limited or no evidence. A total of 994 publications were imported for screening on title, abstracts, and full text, yielding 84 publications identified for full review: 32 (38.1%) review articles, 14 (16.7%) retrospective studies, and 8 (9.5%) case reports. There were 5 randomized controlled trials. Most studies (64%) were published in perinatology (32; 38.1%) journals or anesthesiology (22; 26.2%) journals. Specific areas lacking trial or systematic review evidence include: (1) methods to optimize psychological and psychosocial comorbidities relevant to acute pain management around delivery; (2) alternative nonopioid and nonpharmacologic analgesia methods; (3) whether or not to use opioids for severe breakthrough pain and how best to prescribe and monitor its use after discharge; (4) monitoring for respiratory depression and sedation with coadministration of other analgesics; (5) optimal neuraxial analgesia dosing and adjuncts; and (6) benefits of abdominal wall blocks after cesarean delivery. No publications discussed naloxone coprescribing in the labor and delivery setting. We observed an increasing number of publications on peripartum pain management in pregnant people with OUD. However, existing published works are low on the pyramid of evidence (reviews, opinions, and retrospective studies), with a paucity of original research articles (6%). Opinions are conflicting on the utility and disutility of various analgesic interventions. Studies generating high-quality evidence on this topic are needed to inform care for pregnant people with OUD. Specific research areas are identified, including utility and disutility of short-term opioid use for postpartum pain management, role of continuous wound infiltration and truncal nerve blocks, nonpharmacologic analgesia options, and the best methods to support psychosocial aspects of pain management.

Background Providing continuous health insurance coverage during the perinatal period may increase access to and utilization of labor neuraxial analgesia. This study tested the hypothesis that implementation of the 2010 Dependent Coverage Provision of the Patient Protection and Affordable Care Act, requiring private health insurers to allow young adults to remain on their parent’s plan until age 26, was associated with increased labor neuraxial analgesia use. Methods This study used a natural experiment design and birth certificate data for spontaneous vaginal deliveries in 28 US states between 2009 and 2013. The intervention was the Dependent Coverage Provision, categorized into pre- and post-intervention periods (January 2009-August 2010 and September 2010-December 2013, respectively). The exposure was women age, categorized as exposed (21 to 25 years) and unexposed (27 to 31 years). The outcome was the labor neuraxial analgesia utilization rate. Results Of the 4,515,667 birth certificates analyzed, 3,033,129 (67.2%) indicated labor neuraxial analgesia use. For women aged 21 to 25 years, labor neuraxial analgesia utilization rates were 64.9% during the pre-intervention period and 68.9% during the post-intervention period (difference: 4.0%; 95% CI: 3.9, 4.2). For women aged 27 to 31 years, labor neuraxial analgesia utilization rates were 64.9% during the pre-intervention period and 67.7% during the post-intervention period (difference: 2.8%; 95% CI: 2.7, 2.9). After adjustment, implementation of the Dependent Coverage Provision was associated with a 1.0% (95% CI: 0.8, 1.2) absolute increase in labor neuraxial analgesia utilization rate among women aged 21 to 25 years compared with women aged 27 to 31 years. The increase was statistically significant for White and Hispanic women but not for Black and Other race and ethnicity women. Conclusions Implementation of the Dependent Coverage Provision was associated with a statistically significant increase in labor neuraxial analgesia use, but the small effect size unlikely of clinical significance.

Placenta accreta spectrum (PAS) is a disorder of abnormal placentation associated with severe postpartum hemorrhage, maternal morbidity, and mortality. Predelivery prediction of this condition is important to determine appropriate delivery location and multidisciplinary planning for operative management. This study aimed to validate a prediction model for PAS developed by Weiniger et al in 2 cohorts who delivered at 2 different United States tertiary centers.Cohort A (Brigham and Women's Hospital; N = 253) included patients with risk factors (prior cesarean delivery and placenta previa) and/or ultrasound features of PAS presenting to a tertiary-care hospital. Cohort B (Columbia University Irving Medical Center; N = 99) consisted of patients referred to a tertiary-care hospital specifically because of ultrasound features of PAS. Using the outcome variable of surgical and/or pathological diagnosis of PAS, discrimination (via c-statistic), calibration (via intercept, slope, and flexible calibration curve), and clinical usefulness (via decision curve analysis) were determined.The model c-statistics in cohorts A and B were 0.728 (95% confidence interval [CI], 0.662-0.794) and 0.866 (95% CI, 0.754-0.977) signifying acceptable and excellent discrimination, respectively. The calibration intercept (0.537 [95% CI, 0.154-0.980] for cohort A and 3.001 [95% CI, 1.899- 4.335] for B), slopes (0.342 [95% CI, 0.170-0.532] for cohort A and 0.604 [95% CI, -0.166 to 1.221] for B), and flexible calibration curves in each cohort indicated that the model underestimated true PAS risks on average and that there was evidence of overfitting in both validation cohorts. The use of the model compared to a treat-all strategy by decision curve analysis showed a greater net benefit of the model at a threshold probability of0.25 in cohort A. However, no net benefit of the model over the treat-all strategy was seen in cohort B at any threshold probability.The performance of the Weiniger model is variable based on the case-mix of the population with regard to PAS clinical risk factors and ultrasound features, highlighting the importance of spectrum bias when applying this PAS prediction model to distinct populations. The model showed benefit for predicting PAS in populations with substantial case-mix heterogeneity at threshold probability of25%.

The purpose of this article is to provide a summary of the Enhanced Recovery After Cesarean delivery (ERAC) protocol written by a Society for Obstetric Anesthesia and Perinatology (SOAP) committee and approved by the SOAP Board of Directors in May 2019. The goal of the consensus statement is to provide both practical and where available, evidence-based recommendations regarding ERAC. These recommendations focus on optimizing maternal recovery, maternal-infant bonding, and perioperative outcomes after cesarean delivery. They also incorporate management strategies for this patient cohort, including recommendations from existing guidelines issued by professional organizations such as the American College of Obstetricians and Gynecologists and the American Society of Anesthesiologists. This consensus statement focuses on anesthesia-related and perioperative components of an enhanced recovery pathway for cesarean delivery and provides the level of evidence for each recommendation.

Because up to 12% of obstetric patients meet criteria for the diagnosis of thrombocytopenia in pregnancy, it is not infrequent that the anesthesiologist must decide whether to proceed with a neuraxial procedure in an affected patient. Given the potential morbidity associated with general anesthesia for cesarean delivery, thoughtful consideration of which patients with thrombocytopenia are likely to have an increased risk of spinal epidural hematoma with neuraxial procedures, and when these risks outweigh the relative benefits is important to consider and to inform shared decision making with patients. Because there are substantial risks associated with withholding a neuraxial analgesic/anesthetic procedure in obstetric patients, every effort should be made to perform a bleeding history assessment and determine the thrombocytopenia etiology before admission for delivery. Whereas multiple other professional societies (obstetric, interventional pain, and hematologic) have published guidelines addressing platelet thresholds for safe neuraxial procedures, the US anesthesia professional societies have been silent on this topic. Despite a paucity of high-quality data, there are now meta-analyses that provide better estimations of risks. An interdisciplinary taskforce was convened to unite the relevant professional societies, synthesize the data, and provide a practical decision algorithm to help inform risk-benefit discussions and shared decision making with patients. Through a systematic review and modified Delphi process, the taskforce concluded that the best available evidence indicates the risk of spinal epidural hematoma associated with a platelet count ≥70,000 × 106/L is likely to be very low in obstetric patients with thrombocytopenia secondary to gestational thrombocytopenia, immune thrombocytopenia (ITP), and hypertensive disorders of pregnancy in the absence of other risk factors. Ultimately, the decision of whether to proceed with a neuraxial procedure in an obstetric patient with thrombocytopenia occurs within a clinical context. Potentially relevant factors include, but are not limited to, patient comorbidities, obstetric risk factors, airway examination, available airway equipment, risk of general anesthesia, and patient preference.

Perla Werner,1 Ruth Landau2 1Department of Community Mental Health, University of Haifa, Haifa, Israel; 2School of Social Work, Hebrew University, Jerusalem, IsraelCorrespondence: Perla WernerDepartment of Community Mental Health, University of Haifa, Mt. Carmel, Haifa, IsraelTel +972-54-3933066Email pwerner@univ.haifa.ac.ilPurpose: The current study aimed 1) to assess laypersons’ priority-setting preferences for allocating ventilators to COVID-19 patients with and without AD while differentiating between a young and an old person with the disease, and 2) to examine the factors associated with these preferences.Methods: A cross-sectional online survey was conducted among a sample of 309 Israeli Jewish persons aged 40 and above.Results: Overall, almost three quarters (71%) of the participants chose the 80-year-old patient with a diagnosis of AD to be the last to be provided with a ventilator. The preferences of the remaining quarter were divided between the 80-year-old person who was cognitively intact and the 55-year-old person with AD. Education and subjective knowledge about AD were significantly associated with participants’ preferences.Conclusion: Our results suggest that cognitive status might not be a strong discriminating factor for laypersons’ preferences for allocating ventilators during the COVID-19 pandemic.Keywords: pandemic, dementia, care rationing, prioritizing

Supplemental Digital Content is available in the text., BACKGROUND: Protecting first-line health care providers against work-related Coronavirus Disease 2019 (COVID-19) infection at the onset of the pandemic has been a crucial challenge in the United States. Anesthesiologists in particular are considered at risk, since aerosol-generating procedures, such as intubation and extubation, have been shown to significantly increase the odds for respiratory infections during severe acute respiratory syndrome (SARS) outbreaks. This study assessed the incidence of COVID-19–like symptoms and thepresence of COVID-19 antibodies after work-related COVID-19 exposures, among physicians working in a large academic hospital in New York City (NYC). METHODS: An e-mail survey was addressed to anesthesiologists and affiliated intensive care providers at Columbia University Irving Medical Center on April 15, 2020. The survey assessed 4 domains: (1) demographics and medical history, (2) community exposure to COVID-19 (eg, use of NYC subway), (3) work-related exposure to COVID-19, and (4) development of COVID-19–like symptoms after work exposure. The first 100 survey responders were invited to undergo a blood test to assess antibody status (presence of immunoglobulin M [IgM]/immunoglobulin G [IgG] specific to COVID-19). Work-related exposure was defined as any episode where the provider was not wearing adequate personal protective equipment (airborne or droplet/contact protection depending on the exposure type). Based on the clinical scenario, work exposure was categorized as highrisk (eg, exposure during intubation) or lowrisk (eg, exposure during doffing). RESULTS: Two hundred and five health care providers were contacted and 105 completed the survey (51%); 91 completed the serological test. Sixty-one of the respondents (58%) reported at least 1 work-related exposure and 54% of the exposures were highrisk. Among respondents reporting a work-related exposure, 16 (26.2%) reported postexposure COVID-19–like symptoms. The most frequent symptoms were myalgia (9 cases), diarrhea (8 cases), fever (7 cases), and sore throat (7 cases). COVID-19 antibodies were detected in 11 of the 91 tested respondents (12.1%), with no difference between respondents with (11.8%) or without (12.5%) a work-related exposure, including high-risk exposure. Compared with antibody-negative respondents, antibody-positive respondents were more likely to use NYC subway to commute to work and report COVID-19–like symptoms in the past90 days. CONCLUSIONS: In the epicenter of the United States’ pandemic and within 6–8 weeks of the COVID-19 outbreak, a small proportion of anesthesiologists and affiliated intensive care providers reported COVID-19–like symptoms after a work-related exposure and even fewer had detectable COVID-19 antibodies. Thepresenceof COVID-19 antibodies appeared to be associated with community/environmental transmission rather than secondary to work-related exposures involving high-risk procedures.

With increasing numbers of coronavirus disease 2019 (COVID-19) cases due to efficient human-to-human transmission of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in the United States, preparation for the unpredictable setting of labor and delivery is paramount. The priorities are 2-fold in the management of obstetric patients with COVID-19 infection or persons under investigation (PUI): (1) caring for the range of asymptomatic to critically ill pregnant and postpartum women; (2) protecting health care workers and beyond from exposure during the delivery hospitalization (health care providers, personnel, family members). The goal of this review is to provide evidence-based recommendations or, when evidence is limited, expert opinion for anesthesiologists caring for pregnant women during the COVID-19 pandemic with a focus on preparedness and best clinical obstetric anesthesia practice.

Study Objective The primary objective was to compare carbon dioxide (CO2) absorption rates in patients undergoing gynecologic laparoscopy with a standard versus valveless insufflation system (AirSeal; ConMed, Utica, NY) at intra-abdominal pressures (IAPs) of 10 and 15 mm Hg. Secondary objectives were assessment of surgeons’ visualization of the operative field, anesthesiologists’ ability to maintain adequate end-tidal CO2 (etCO2), and patients’ report of postoperative shoulder pain. Design A randomized controlled trial using an equal allocation ratio into 4 arms: standard insufflation/IAP 10 mm Hg, standard insufflation/IAP 15 mm Hg, valveless insufflation/IAP 10 mm Hg, and valveless insufflation/IAP 15 mm Hg. Setting Single tertiary care academic institution. Patients Women ≥ 18 years old undergoing nonemergent conventional or robotic gynecologic laparoscopic surgery. Interventions A standard or valveless insufflation system at IAPs of 10 or 15 mm Hg. Measurements and Main Results One hundred thirty-two patients were enrolled and randomized with 33 patients per group. There were 84 robotic cases and 47 conventional laparoscopic cases. CO2 absorption rates (mL/kg*min) did not differ across groups with mean rates of 4.00 ± 1.3 in the valveless insufflation groups and 4.00 ± 1.1 in the standard insufflation groups. The surgeons’ rating of overall visualization of the operative field on a 10-point Likert scale favored the valveless insufflation system (median visualization, 9.0 ± 2.0 cm and 9.5 ± 1.8 cm at 10 and 15 mm Hg, respectively) over standard insufflation (7.0 ± 3.0 cm and 7.0 ± 2.0 cm at 10 and 15 mm Hg, respectively; p .05). Conclusion CO2 absorption rates, anesthesiologists’ ability to maintain adequate etCO2, and postoperative shoulder pain did not differ based on insufflation system type or IAP. Surgeons’ rating of visualization of the operative field was significantly improved when using the valveless over the standard insufflation system.

Addressing severe maternal morbidity (SMM) is a public health priority in the US. Use of labor neuraxial analgesia for vaginal delivery is suggested to reduce the risk of postpartum hemorrhage (PPH), the leading cause of preventable severe maternal morbidity.To assess the association between the use of labor neuraxial analgesia for vaginal delivery and SMM.In this population-based cross-sectional study, women aged 15 to 49 years undergoing their first vaginal delivery were included. Data were taken from hospital discharge records from New York between January 2010 and December 2017. Data were analyzed from November 2020 to November 2021.Neuraxial analgesia (ie, epidural or combined spinal-epidural) vs no neuraxial analgesia.The primary outcome was SMM, as defined by the US Centers for Disease Control and Prevention, and the secondary outcome was PPH. Adjusted odds ratios (aORs) and 95% CIs of SMM associated with neuraxial analgesia were estimated using the inverse propensity score-weighting method and stratified according to race and ethnicity (non-Hispanic White vs racial and ethnic minority women, including non-Hispanic Asian or Pacific Islander, non-Hispanic Black, Hispanic, and other race and ethnicity) and to the comorbidity index for obstetric patients (low-risk vs high-risk women). The proportion of the association of neuraxial analgesia with the risk of SMM mediated through PPH was estimated using mediation analysis.Of 575 524 included women, the mean (SD) age was 28 (6) years, and 46 065 (8.0%) were non-Hispanic Asian or Pacific Islander, 88 577 (15.4%) were non-Hispanic Black, 104 866 (18.2%) were Hispanic, 258 276 (44.9%) were non-Hispanic White, and 74 534 (13.0%) were other race and ethnicity. A total of 400 346 women (69.6%) were in the low-risk group and 175 178 (30.4%) in the high-risk group, and 272 921 women (47.4%) received neuraxial analgesia. SMM occurred in 7712 women (1.3%), of which 2748 (35.6%) had PPH. Before weighting, the incidence of SMM was 1.3% (3486 of 272 291) with neuraxial analgesia compared with 1.4% (4226 of 302 603) without neuraxial analgesia (risk difference, -0.12 per 100; 95% CI, -0.17 to -0.07). After weighting, the aOR of SMM associated with neuraxial analgesia was 0.86 (95% CI, 0.82-0.90). Decreased risk of SMM associated with neuraxial analgesia was similar between non-Hispanic White women and racial and ethnic minority women and between low-risk and high-risk women. More than one-fifth (21%; 95% CI, 14-28) of the observed association of neuraxial analgesia with the risk of SMM was mediated through the decreased risk of PPH.Findings from this study suggest that use of neuraxial analgesia for vaginal delivery is associated with a 14% decrease in the risk of SMM. Increasing access to and utilization of labor neuraxial analgesia may contribute to improving maternal health outcomes.

ObjectivesExcessive opioid prescribing is a contributing factor to the opioid epidemic in the USA. We aimed to develop, implement and evaluate the usability of a clinical decision-making mobile application (app) for opioid prescription after surgery.MethodsWe developed two clinical decision trees, one for opioid prescription after adult laparoscopic cholecystectomy and one for posterior spinal fusion surgery in adolescents. We developed a mobile app incorporating the two algorithms with embedded clinical decision-making, which was tested by opioid prescribers. A survey collected prescription intention prior to app use and participants’ evaluation. Participants included opioid prescribers for patients undergoing (1) laparoscopic cholecystectomy in adults or (2) posterior spinal fusion in adolescents with idiopathic scoliosis.ResultsEighteen healthcare providers were included in this study (General Surgery: 8, Paediatrics: 10). Intended opioid prescription before app use varied between departments (General Surgery: 0–10 pills (mean=5.9); Paediatrics: 6–30 pills (mean=20.8)). Intention to continue using the app after using the app multiple times varied between departments (General Surgery: N=3/8; Paediatrics: N=7/10). The most reported reason for not using the app is lack of time.ConclusionsIn this project evaluating the development and implementation of an app for opioid prescription after two common surgeries with different prescription patterns, the surgical procedure with higher intended and variable opioid prescription (adolescent posterior spinal fusion surgery) was associated with participants more willing to use the app. Future iterations of this opioid prescribing intervention should target surgical procedures with high variability in both patients’ opioid use and providers’ prescription patterns.

BackgroundEarly reports associating severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) infection with adverse pregnancy outcomes were biased by including only women with severe disease without controls. The Society for Obstetric Anesthesia and Perinatology (SOAP) coronavirus disease 2019 (COVID-19) registry was created to compare peripartum outcomes and anesthetic utilization in women with and without SARS-CoV-2 infection delivering at institutions with widespread testing.MethodsDeliveries from 14 US medical centers, from March 19 to May 31, 2020, were included. Peripartum infection was defined as a positive SARS-CoV-2 polymerase chain reaction test within 14 days of delivery. Consecutive SARS-CoV-2-infected patients with randomly selected control patients were sampled (1:2 ratio) with controls delivering during the same day without a positive test. Outcomes were obstetric (eg, delivery mode, hypertensive disorders of pregnancy, and delivery

Background Medicaid expansions under the Affordable Care Act have increased insurance coverage and prenatal care utilization in low-income women. However, it is not clear whether they are associated with any measurable improvement in maternal health outcomes. In this study, we compared the changes in the incidence of severe maternal morbidity (SMM) during delivery hospitalizations between low- and high-income women associated with the 2014 Medicaid expansion in New York State. Methods Data for this retrospective cohort study came from the 2006-2016 New York State Inpatient Database, a census of discharge records from community hospitals. The outcome was SMM during delivery hospitalizations, as defined by the Centers for Disease Control and Prevention. We used regression coefficients (β) from multivariable logistic models: (1) to compare independently in low-income women and in high-income women the changes in slopes in the incidence of SMM before (2006-2013) and after (2014-2016) the expansion, and (2) to compare low- and high-income women for the changes in slopes in the incidence of SMM before and after the expansion. Results A total of 2,286,975 delivery hospitalizations were analyzed. The proportion of Medicaid beneficiaries in parturients increased a relative 12.1% (95% confidence interval [CI], 11.8-12.4), from 42.9% in the preexpansion period to 48.1% in the postexpansion period, whereas the proportion of the uninsured decreased a relative 4.8% (95% CI, 2.8-6.8). Multivariable logistic modeling revealed that implementation of the 2014 Medicaid expansion was associated with a decreased slope during the postexpansion period both in low-income women (β = -0.0161 or 1.6% decrease; 95% CI, -0.0190 to -0.0132) and in high-income women (β = -0.0111 or 1.1% decrease; 95% CI, -0.0130 to -0.0091). The decrease in slope during the postexpansion period was greater in low- than in high-income women (β = -0.0042 or 0.42% difference; 95% CI, -0.0076 to -0.0007). Conclusions Implementation of the Medicaid expansion in 2014 in New York State is associated with a small but statistically significant reduction in the incidence of SMM in low-income women compared with high-income women.

BACKGROUND:Increased risks of cerebral venous thrombosis or subdural hematoma, bacterial meningitis, persistent headache, and persistent low back pain are suggested in obstetric patients with postdural puncture headache (PDPH). Acute postpartum pain such as PDPH may also lead to postpartum depressio

Objective: To validate the Weiniger model, a multivariable prediction model for placenta accreta spectrum (PAS). Design: Multicentre external validation study. Setting: Two tertiary care hospitals in the United States. Population: Cohort A included patients with risk factors (prior caesarean delivery, placenta praevia) and/or ultrasound features of PAS (variable risk) presenting to a tertiary care hospital. Cohort B patients were referred to a tertiary care hospital specifically for ultrasound features of PAS (higher risk). Methods: Weiniger model variables (prior caesarean deliveries, placenta praevia and ultrasound features of PAS) were retrospectively collected from both cohorts and predictive performance of the model was evaluated. Main Outcome Measures: Surgical and/or pathological diagnosis of PAS. Results: The model c-statistic in cohorts A and B was 0.728 (95% CI: 0.662, 0.794) and 0.866 (95% CI: 0.754, 0.977) signifying acceptable and excellent discrimination, respectively. Based on calibration curves, the model underestimated average PAS risk in both cohorts. In both cohorts, high risk was overestimated and low risk underestimated. Use of this model compared to a “treat all” strategy had greater net benefit at a threshold probability of > 0.25 in cohort A, but no net benefit in cohort B. Conclusions: This study provides multicentre external validation of the Weiniger model for PAS prediction, making it a useful triaging tool for management of this high-risk obstetric condition. Clinical usefulness of this model is influenced by the incidence of risk factors and PAS ultrasound features, with better performance in a variable-risk population at threshold probability >25%.

BACKGROUND Exposure to surgery and anesthesia in early childhood has been found to be associated with an increased risk of behavioral deficits. While the US Food and Drug Administration (FDA) has warned against prenatal exposure to anesthetic drugs, little clinical evidence exists to support this recommendation. This study evaluates the association between prenatal exposure to general anesthesia due to maternal procedures during pregnancy and neuropsychological and behavioral outcome scores at age 10. METHODS This is an observational cohort study of children born in Perth, Western Australia, with 2 generations of participants contributing data to the Raine Study. In the Raine Study, the first generation (Gen1) are mothers enrolled during pregnancy, and the second generation (Gen2) are the children born to these mothers from 1989 to 1992 with neuropsychological and behavioral tests at age 10 (n=2024). In the primary analysis, 6 neuropsychological and behavioral tests were evaluated at age 10: Raven's Colored Progressive Matrices (CPM), McCarron Assessment of Neuromuscular Development (MAND), Peabody Picture Vocabulary Test (PPVT), Symbol Digit Modality Test (SDMT) with written and oral scores, Clinical Evaluation of Language Fundamentals (CELF) with Expressive, Receptive, and Total language scores, and Child Behavior Checklist (CBCL) with Internalizing, Externalizing, and Total behavior scores. Outcome scores of children prenatally exposed to general anesthesia were compared to children without prenatal exposure using multivariable linear regression models adjusting for demographic and clinical covariates (sex, race, income, and maternal education, alcohol or tobacco use, and clinical diagnoses: diabetes, epilepsy, hypertension, psychiatric disorders, or thyroid dysfunction). Bonferroni adjustment was used for the 6 independent tests in the primary analysis, so a corrected P value

Background Severe acute post-cesarean delivery (CD) pain has been associated with an increased risk for persistent pain and postpartum depression. Identification of women at increased risk for pain can be used to optimize post-cesarean analgesia. The impact of labor prior to CD (intrapartum CD) on acute post-operative pain and opioid use is unclear. We hypothesized that intrapartum CD, which has been associated with both increased inflammation and affective distress related to an unexpected surgical procedure, would result in higher postoperative pain scores and increased opioid intake. Methods This is a secondary analysis of a prospective cohort study examining opioid use up to 2 weeks following CD. Women undergoing CD at six academic medical centers in the United States 9/2014-3/2016 were contacted by phone two weeks following discharge. Participants completed a structured interview that included questions about postoperative pain scores and opioid utilization. They were asked to retrospectively estimate their maximal pain score on an 11-point numeric rating scale at multiple time points, including day of surgery, during hospitalization, immediately after discharge, 1st week, and 2nd week following discharge. Pain scores over time were assessed utilizing a generalized linear mixed-effects model with the patient identifier being a random effect, adjusting for an a priori defined set of confounders. A multivariate negative binomial model was utilized to assess the association between intrapartum CD and opioid utilization after discharge, also adjusting for the same confounders. In the context of non-random prescription distribution, this model was constructed with an offset for the number of tablets dispensed. Results A total of 720 women were enrolled, 392 with and 328 without labor prior to CD. Patients with intrapartum CD were younger, less likely to undergo repeat CD or additional surgical procedures, and more likely to experience a complication of CD. Women with intrapartum CD consumed more opioid tablets following discharge than women without labor (median 20, IQR 10–30 versus 17, IQR 6–30; p = 0.005). This association persisted after adjustment for confounders (incidence rate ratio 1.16, 95% CI 1.05–1.29; p = 0.004). Pain scores on the day of surgery were higher in women with intrapartum CD (difference 0.91, 95% CI 0.52–1.30; adj. p = Conclusion Intrapartum CD is associated with worse pain on the day of surgery but not other time points. Opioid requirements following discharge were modestly increased following intrapartum CD.

SARS-CoV-2-related mortality and hospitalizations differ substantially between New York City neighborhoods. Mitigation efforts require knowing the extent to which these disparities reflect differences in prevalence and understanding the associated drivers. Here, we report the prevalence of SARS-CoV-2 in New York City boroughs inferred using tests administered to 1,746 pregnant women hospitalized for delivery between March 22nd and May 3rd, 2020. We also assess the relationship between prevalence and commuting-style movements into and out of each borough. Prevalence ranged from 11.3% (95% credible interval [8.9%, 13.9%]) in Manhattan to 26.0% (15.3%, 38.9%) in South Queens, with an estimated city-wide prevalence of 15.6% (13.9%, 17.4%). Prevalence was lowest in boroughs with the greatest reductions in morning movements out of and evening movements into the borough (Pearson R = −0.88 [−0.52, −0.99]). Widespread testing is needed to further specify disparities in prevalence and assess the risk of future outbreaks., New York City is one of the areas most affected by the SARS-CoV-2 pandemic in the United States, and there has been large variation in rates of hospitalisation and death by city borough. Here, the authors show that boroughs with the largest reduction in daily commutes also had the lowest SARS-CoV-2 prevalence.

The COVID-19 pandemic has prompted obstetric anesthesiologists to reconsider the ways in which basic anesthesia care is provided on the Labor and Delivery Unit. Suggested modifications include an added emphasis on avoiding general anesthesia, a strong encouragement to infected individuals to opt for early neuraxial analgesia, and the prevention of emergent cesarean delivery, whenever possible. Through team efforts, adopting these measures can have real effects on reducing the transmission of the viral illness and maintaining patient and caregiver safety in the labor room.

Supplemental Digital Content is available in the text.

BACKGROUND: Labor neuraxial analgesia (LNA) utilization has increased in the United States but its impact on maternal safety is unknown. This study analyzed the temporal trends in the incidence of post-dural puncture headache (PDPH) in obstetrics. METHODS: Data for vaginal or intrapartum cesarean deliveries came from the National Inpatient Sample 2006–2015, an US 20% representative sample of hospital discharge records. The outcome was PDPH (ICD-9-CM codes 349.0 and 03.95) categorized into 1) PDPH coded as without epidural blood patch (EBP), and 2) PDPH coded as with EBP. Temporal trends in incidence were described using the percent change (PC) between 2006 and 2015 and its 95% confidence interval (CI). RESULTS: Of the 29,011,472 deliveries studied, 86,558 (29.8 per 10,000; 95% CI: 29.3, 30.2) recorded a diagnosis of PDPH, including 34,019 PDPH without EBP (11.7 per 10,000; 95% CI: 11.4, 12.0) and 52,539 PDPH with EBP (18.1 per 10,000; 95% CI: 17.8, 18.4). A statistically significant decrease in the incidence of PDPH was observed from 31.5 per 10,000 in 2006 to 29.2 per 10,000 in 2015 (PC −7.5%; 95% CI: −2.2, −0.5; P-value = 0.001). The decrease in the incidence of PDPH was statistically significant irrespective of the presence of EBP. The decrease was observed in the 3 categories of hospitals examined (rural, urban non-teaching, and urban teaching). CONCLUSIONS: During the study period, the reported incidence of PDPH in the United States has decreased modestly. Intervention programs are needed to address this persistent and preventable cause of maternal morbidity.

Novel coronavirus disease 2019 is rapidly spreading throughout the New York metropolitan area since its first reported case on March 1, 2020. The state is now the epicenter of coronavirus disease 2019 outbreak in the United States, with 84,735 cases reported as of April 2, 2020. We previously presented an early case series with 7 coronavirus disease 2019–positive pregnant patients, 2 of whom were diagnosed with coronavirus disease 2019 after an initial asymptomatic presentation. We now describe a series of 43 test-positive cases of coronavirus disease 2019 presenting to an affiliated pair of New York City hospitals for more than 2 weeks, from March 13, 2020, to March 27, 2020. A total of 14 patients (32.6%) presented without any coronavirus disease 2019–associated viral symptoms and were identified after they developed symptoms during admission or after the implementation of universal testing for all obstetric admissions on March 22. Among them, 10 patients (71.4%) developed symptoms of coronavirus disease 2019 over the course of their delivery admission or early after postpartum discharge. Of the other 29 patients (67.4%) who presented with symptomatic coronavirus disease 2019, 3 women ultimately required antenatal admission for viral symptoms, and another patient re-presented with worsening respiratory status requiring oxygen supplementation 6 days postpartum after a successful labor induction. There were no confirmed cases of coronavirus disease 2019 detected in neonates upon initial testing on the first day of life. Based on coronavirus disease 2019 disease severity characteristics by Wu and McGoogan, 37 women (86%) exhibited mild disease, 4 (9.3%) severe disease, and 2 (4.7%) critical disease; these percentages are similar to those described in nonpregnant adults with coronavirus disease 2019 (about 80% mild, 15% severe, and 5% critical disease).

With increasing numbers of Coronavirus Disease 2019 (COVID19) cases due to efficient human-to-human transmission of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in the United States, preparation for the unpredictable setting of labor and delivery is paramount. The priorities are 2-fold in the management of obstetric patients with COVID-19 infection or persons under investigation (PUI): (1) caring for the range of asymptomatic to critically ill pregnant and postpartum women; (2) protecting health care workers and beyond from exposure during the delivery hospitalization (health care providers, personnel, family members). The goal of this review is to provide evidence-based recommendations or, when evidence is limited, expert opinion for anesthesiologists caring for pregnant women during the COVID19 pandemic with a focus on preparedness and best clinical obstetric anesthesia practice.

OBJECTIVE: To assess trends in use of long-acting opioids during delivery hospitalizations. METHODS: The Perspective database, an administrative inpatient database that includes medication receipt, was analyzed to evaluate patterns of long-acting opioids use during delivery hospitalizations from January 2006 through March 2015. Medications evaluated included methadone, formulations including buprenorphine and extended-release formulations of oxycodone, morphine, fentanyl and other opioids. Temporal trends in use of these medications were determined. Unadjusted and adjusted models evaluating the role of demographic and hospital factors were created evaluating both use of these medications and risk for severe morbidity. Risk for severe morbidity was determined based on Centers for Disease Control and Prevention criteria. RESULTS: Our analysis included 2,994,630 delivery hospitalizations meeting study criteria. Over the entire study period, use of long-acting opioids increased significantly from 457 to 844 per 100,000 deliveries. While buprenorphine and methadone use increased, use of other long-acting opioids decreased. In 2006, methadone and buprenorphine accounted for less than a third of all long-acting opioids used during delivery hospitalizations. By 2015 buprenorphine and methadone represented 73.5% of long-acting opioids used. In adjusted and unadjusted models, risk for severe morbidity was significantly lower with buprenorphine or methadone compared to other long-acting opioids. Restricting the cohort to only women with drug abuse or dependence, risk for severe morbidity was lower with methadone and buprenorphine than without any long-acting opioids. CONCLUSION: Increased use of methadone and buprenorphine in this study supports the feasibility of use of these medications during pregnancy and uptake of clinical recommendations for women with opioid use disorder. Use of methadone and buprenorphine are associated with decreased maternal morbidity although causation cannot be presumed from this study model.

BACKGROUND:Postpartum depression (PPD) is associated with pain during and after delivery, with studies showing reduced rates among women delivering with labor epidural analgesia (LEA). We hypothesized that women who intend to deliver with LEA but do not receive it are at higher risk for PPD at 6 wee

Venous thromboembolism is recognized as a leading cause of maternal death in the United States. Thromboprophylaxis has been highlighted as a key preventive measure to reduce venous thromboembolism-related maternal deaths. However, the expanded use of thromboprophylaxis in obstetrics will have a major impact on the use and timing of neuraxial analgesia and anesthesia for women undergoing vaginal or cesarean delivery and other obstetric surgeries. Experts from the Society of Obstetric Anesthesia and Perinatology, the American Society of Regional Anesthesia, and hematology have collaborated to develop this comprehensive, pregnancy-specific consensus statement on neuraxial procedures in obstetric patients receiving thromboprophylaxis or higher dose anticoagulants. To date, none of the existing anesthesia societies' recommendations have weighed the potential risks of neuraxial procedures in the presence of thromboprophylaxis, with the competing risks of general anesthesia with a potentially difficult airway, or maternal or fetal harm from avoidance or delayed neuraxial anesthesia. Furthermore, existing guidelines have not integrated the pharmacokinetics and pharmacodynamics of anticoagulants in the obstetric population. The goal of this consensus statement is to provide a practical guide of how to appropriately identify, prepare, and manage pregnant women receiving thromboprophylaxis or higher dose anticoagulants during the ante-, intra-, and postpartum periods. The tactics to facilitate multidisciplinary communication, evidence-based pharmacokinetic and spinal epidural hematoma data, and Decision Aids should help inform risk-benefit discussions with patients and facilitate shared decision making.

More than 70 years ago, the phenomenon of "postural shock" in the supine position was described in healthy women in late pregnancy. Since then, avoidance of the supine position has become a key component of clinical practice. Indeed, performing pelvic tilt in mothers at term to avoid aortocaval compression is a universally adopted measure, particularly during cesarean delivery. The studies on which this practice is based are largely nonrandomized, utilized a mix of anesthetic techniques, and were conducted decades ago in the setting of avoidance of vasopressors. Recent evidence is beginning to refine our understanding of the physiologic consequences of aortocaval compression in the context of contemporary clinical practice. For example, magnetic resonance imaging of women at term in the supine and tilted positions has challenged the dogma that 15° of left tilt is sufficient to relieve inferior vena cava compression. A clinical investigation of healthy term women undergoing elective cesarean delivery with spinal anesthesia found no difference in neonatal acid-base status between women randomized to be either tilted to the left by 15° or to be in the supine position, if maternal systolic blood pressure is maintained at baseline with a crystalloid coload and prophylactic phenylephrine infusion. This review presents a fresh look at the decades of evidence surrounding this topic and proposes a reevaluation and appraisal of current guidelines regarding entrenched practices.

Background Current recommendations for women undergoing cesarean delivery include 15° left tilt for uterine displacement to prevent aortocaval compression, although this degree of tilt is practically never achieved. We hypothesized that under contemporary clinical practice, including a crystalloid coload and phenylephrine infusion targeted at maintaining baseline systolic blood pressure, there would be no effect of maternal position on neonatal acid base status in women undergoing elective cesarean delivery with spinal anesthesia. Methods Healthy women undergoing elective cesarean delivery were randomized (nonblinded) to supine horizontal (supine, n = 50) or 15° left tilt of the surgical table (tilt, n = 50) after spinal anesthesia (hyperbaric bupivacaine 12 mg, fentanyl 15 μg, preservative-free morphine 150 μg). Lactated Ringer’s 10 ml/kg and a phenylephrine infusion titrated to 100% baseline systolic blood pressure were initiated with intrathecal injection. The primary outcome was umbilical artery base excess. Results There were no differences in umbilical artery base excess or pH between groups. The mean umbilical artery base excess (± SD) was −0.5 mM (± 1.6) in the supine group (n = 50) versus −0.6 mM (± 1.5) in the tilt group (n = 47) (P = 0.64). During 15 min after spinal anesthesia, mean phenylephrine requirement was greater (P = 0.002), and mean cardiac output was lower (P = 0.014) in the supine group. Conclusions Maternal supine position during elective cesarean delivery with spinal anesthesia in healthy term women does not impair neonatal acid–base status compared to 15° left tilt, when maternal systolic blood pressure is maintained with a coload and phenylephrine infusion. These findings may not be generalized to emergency situations or nonreassuring fetal status.

Venous thromboembolism remains a major source of morbidity and mortality in obstetrics with an incidence of 29.8/100,000 vaginal delivery hospitalizations; cesarean delivery confers a 4-fold increased risk of thromboembolism when compared with vaginal delivery. Revised national guidelines now stipulate that the majority of women delivering via cesarean and women at risk for ante- or postpartum venous thromboembolism receive mechanical or pharmacological thromboprophylaxis. This practice change has important implications for obstetric anesthesiologists concerned about the risk of spinal epidural hematoma (SEH) among anticoagulated women receiving neuraxial anesthesia. We conducted a systematic review of published English language studies (1952-2016) and of the US Anesthesia Closed Claims Project Database (1990-2013) to identify cases of SEH associated with neuraxial anesthesia and thromboprophylaxis. We also report on SEH in obstetric patients receiving thromboprophylaxis and neuraxial anesthesia without adherence to the American Society of Regional Anesthesia (ASRA) recommendations. In our review, we initially identified 736 publications of which 10 met inclusion criteria; these were combined with the 5 cases of SEH identified in 546 obstetric Anesthesia Closed Claims reviews. None of these publications revealed SEH associated with neuraxial anesthesia and thromboprophylaxis with unfractionated heparin or low-molecular-weight heparin in obstetric patients. Based on data from 6 reports, 28 parturients had their neuraxial blockade before the minimum ASRA recommended time interval between the last anticoagulant dose and the neuraxial procedure. Based on data from 2 reports, 52 parturients received neuraxial anesthesia without their low-molecular-weight heparin dose being discontinued during the intrapartum period. Although the very low level of evidence and high heterogeneity in these reports make it difficult to draw quantitative conclusions from this systematic review, it is encouraging that this comprehensive search did not identify a single case of SEH in an obstetric patient receiving thromboprophylaxis and neuraxial anesthesia. Analysis of large-scale registries (eg, the Anesthesia Incident Reporting System of the Anesthesia Quality Institute) with more granular clinical and pharmacological data is needed to assess the impact of these practice changes on obstetric SEH incidence. In the interim, optimal care of obstetric patients depends on multidisciplinary planning of anticoagulation dosing to facilitate neuraxial anesthesia and thoughtful weighing of the relative risks and benefits of providing versus withholding neuraxial in favor of general anesthesia.

To define the amount of opioid analgesics prescribed and consumed after discharge after cesarean delivery.We conducted a survey at six academic medical centers in the United States from September 2014 to March 2016. Women who had undergone a cesarean delivery were contacted by phone 2 weeks after discharge and participated in a structured interview about the opioid prescription they received on discharge and their oral opioid intake while at home.A total of 720 women were enrolled; of these, 615 (85.4%) filled an opioid prescription. The median number of dispensed opioid tablets was 40 (interquartile range 30-40), the median number consumed was 20 (interquartile range 8-30), and leftover was 15 (interquartile range 3-26). Of those with leftover opioids, 95.3% had not disposed of the excess medication at the time of the interview. There was an association between a larger number of tablets dispensed and the number consumed independent of patient characteristics. The amount of opioids dispensed did not correlate with patient satisfaction, pain control, or the need to refill the opioid prescription.The amount of opioid prescribed after cesarean delivery generally exceeds the amount consumed by a significant margin, leading to substantial amounts of leftover opioid medication. Lower opioid prescription correlates with lower consumption without a concomitant increase in pain scores or satisfaction.

The effect of labor epidural analgesia (LEA) on successful breastfeeding has been evaluated in several studies with divergent results. We hypothesized that LEA would not influence breastfeeding status 6 weeks postpartum in women who intended to breastfeed in an environment that encourages breastfeeding.In this prospective observational cohort study, a total of 1204 women intending to breastfeed, delivering vaginally with or without LEA, were included; breastfeeding was recorded at 3 days and 6 weeks postpartum. Primary outcome was breastfeeding at 6 weeks, and the χ test was used for comparisons between women delivering with and without LEA, according to parity status and previous breastfeeding experience. Total epidural fentanyl dose and oxytocin use (yes/no) were recorded. A multivariable logistic regression was performed to assess factors affecting breastfeeding at 6 weeks.The overall breastfeeding rate at 6 weeks was 76.9%; it was significantly lower among women delivering with LEA (74.0%) compared with women delivering without LEA (83.4%; P.001). Among 398 nulliparous women, 84.9% delivered with LEA, compared with 61.8% of multiparous women (P.001). Multiparous women (N = 806) were more likely to breastfeed at 6 weeks (80.0% vs 70.6% nullipara; P.001). Using multivariable logistic regression that accounted for 14 covariates including parity, and an interaction term between parity and LEA use, LEA was significantly associated with reduced breastfeeding at 6 weeks (odds ratio, 0.60; 95% confidence interval, 0.40-0.90; P = .015). In a modified multivariable logistic regression where parity was replaced with previous breastfeeding experience, both as a covariate and in the interaction term, only previous breastfeeding experience was associated with increased breastfeeding at 6 weeks (odds ratio, 3.17; 95% confidence interval, 1.72-5.80; P.001).In our mixed-parity cohort, delivering with LEA was associated with reduced likelihood of breastfeeding at 6 weeks. However, integrating women's previous breastfeeding experience, the breastfeeding rate was not different between women delivering with and without LEA among the subset of multiparous women with previous breastfeeding experience. Therefore, our findings suggest that offering lactation support to the subset of women with no previous breastfeeding experience may be a simple approach to improve breastfeeding success. This concept subscribes to the notion that women at risk for an undesired outcome be offered tailored interventions with a personalized approach.

Editor’s Perspective What We Already Know about This Topic What This Article Tells Us That Is New Background Compared with neuraxial anesthesia, general anesthesia for cesarean delivery is associated with increased risk of maternal adverse events. Reducing avoidable general anesthetics for cesarean delivery may improve safety of obstetric anesthesia care. This study examined adverse events, trends, and factors associated with potentially avoidable general anesthetics for cesarean delivery. Methods This retrospective study analyzed cesarean delivery cases without a recorded indication for general anesthesia or contraindication to neuraxial anesthesia in New York State hospitals, 2003 to 2014. Adverse events included anesthesia complications (systemic, neuraxial-related, and drug-related), surgical site infection, venous thromboembolism, and the composite of death or cardiac arrest. Anesthesia complications were defined as severe if associated with death, organ failure, or prolonged hospital stay. Results During the study period, 466,014 cesarean deliveries without a recorded indication for general anesthesia or contraindication to neuraxial anesthesia were analyzed; 26,431 were completed with general anesthesia (5.7%). The proportion of avoidable general anesthetics decreased from 5.6% in 2003 to 2004 to 4.8% in 2013 to 2014 (14% reduction; P < 0.001). Avoidable general anesthetics were associated with significantly increased risk of anesthesia complications (adjusted odds ratio, 1.6; 95% CI, 1.4 to 1.9), severe complications (adjusted odds ratio, 2.9; 95% CI, 1.6 to 5.2), surgical site infection (adjusted odds ratio, 1.7; 95% CI, 1.5 to 2.1), and venous thromboembolism (adjusted odds ratio, 1.9; 95% CI, 1.3 to 3.0), but not of death or cardiac arrest. Labor neuraxial analgesia rate was one of the most actionable hospital-level factors associated with avoidable general anesthetics. Relative to hospitals with a rate greater than or equal to 75%, the adjusted odds ratio of avoidable general anesthetics increased to 1.3 (95% CI, 1.2 to 1.4), 1.6 (95% CI, 1.5 to 1.7), and 3.2 (95% CI, 3.0 to 3.5) as the rate decreased to 50 to 74.9%, 25 to 49.9%, and less than 25%, respectively. Conclusions Compared with neuraxial anesthesia, avoidable general anesthetics are associated with increased risk of adverse maternal outcomes.

OBJECTIVES The intensity of post-egg retrieval pain is underestimated, with few studies examining post-procedural pain and predictors to identify women at risk for severe pain. We evaluated the influence of pre-procedural hormonal levels, ovarian factors, as well as mechanical temporal summation (mTS) as predictors for post-egg retrieval pain in women undergoing in vitro fertilization (IVF). METHODS Eighteen women scheduled for ultrasound-guided egg retrieval under standardized anesthesia and post-procedural analgesia were enrolled. Pre-procedural mTS, questionnaires, clinical data related to anesthesia and the procedure itself, post-procedural pain scores and pain medication for breakthrough pain were recorded. Statistical analysis included Pearson product moment correlations, Mann-Whitney U tests and multiple linear regressions. RESULTS Average peak post-egg retrieval pain during the first 24 hours was 5.0±1.6 on an NRS scale (0=no pain, 10=worst pain imaginable). Peak post-egg retrieval pain was correlated with basal antimullerian hormone (AMH) (r=0.549, P=0.018), pre-procedural peak estradiol (r=0.582, P=0.011), total number of follicles (r=0.517, P=0.028) and number of retrieved eggs (r=0.510, P=0.031). Ovarian hyperstimulation syndrome (OHSS) (n=4) was associated with higher basal AMH (P=0.004), higher peak pain scores (P=0.049), but not with peak estradiol (P=0.13). The mTS did not correlate with peak post-procedural pain (r=0.266, P=0.286), or peak estradiol level (r=0.090, P=0.899). DISCUSSION Peak post-egg retrieval pain intensity was higher than anticipated. Our results suggest that post-egg retrieval pain can be predicted by baseline AMH, high peak estradiol, and OHSS. Further studies to evaluate intra- and post-procedural pain in this population are needed, as well as clinical trials to assess post-procedural analgesia in women presenting with high hormonal levels.

Remifentanil is most commonly offered when neuraxial labor analgesia is contraindicated. There is no consensus regarding the optimal administration, dosing strategy, or requirements for maternal monitoring, which may pose a patient safety issue. This exploratory survey evaluated the current practices regarding remifentanil use for labor analgesia at academic centers in the United States. Of 126 obstetric anesthesia directors surveyed, 84 (67%) responded. In 2014 to 2015, an estimated 36% (95% confidence interval: 25.7-46.3) of centers used remifentanil, most of which did so less than 5 times. Some serious maternal and neonatal respiratory complications occurred, emphasizing that clinical protocols and adequate monitoring are key to ensure maternal and neonatal safety.

During the novel Coronavirus Disease 2019 pandemic, New York City became an international epicenter for this highly infectious respiratory virus. In anticipation of the unfortunate reality of community spread and high disease burden, the Anesthesia and Obstetrics and Gynecology departments at NewYork-Presbyterian / Columbia University Irving Medical Center, an academic hospital system in Manhattan, created an Obstetric Intensive Care Unit on Labor and Delivery to defray volume from the hospital's preexisting intensive care units. Its purpose was threefold: (1) to accommodate the anticipated influx of critically ill pregnant and postpartum patients due to novel coronavirus, (2) to care for critically ill obstetric patients who would previously have been transferred to a non-obstetric intensive care unit, and (3) to continue caring for our usual census of pregnant and postpartum patients, who are novel Coronavirus negative and require a higher level of care. In this chapter, we share key operational details for the conversion of a non-intensive care space into an obstetric intensive care unit, with an emphasis on the infrastructure, personnel and workflow, as well as the goals for maternal and fetal monitoring.