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Objectives: Enhanced recovery programmes (ERP) have been shown to improve postoperative outcomes. The aim of our study was to investigate the impact of an ERP after caesarean delivery on maternal feelings and satisfaction towards mother-child bonding initiation, in comparison with traditional postoperative care., Study Design: A comparative, prospective and multicentre study was conducted in three maternity units of the Paris area: one applied traditional postoperative care while the two others applied an ERP, were included patients after elective or emergency caesarean delivery who had given birth to full-term healthy singleton newborns. Data were collected from 8th October 2014 to 31st January 2015. Patients were asked about their feelings toward the relationship with their infant using a questionnaire, to be completed one (D1) and three (D3) days after caesarean delivery., Results: Patients (n=86) received post-operative care in agreement with what was expected in the group in which they were included. Patients in the ERP group had more positive feelings toward the relationship with their newborn on D1 and D3, had a greater maternal satisfaction level on D1 and were more comfortable in caring for their newborn, especially for cradling and breastfeeding the child., Conclusion: Our study suggests that application of ERP after caesarean delivery is associated with improved maternal satisfaction and more positive feelings toward the relationship with the newborn., (Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.)

Caesarean delivery was performed in 20% of all deliveries in France in 2010 and this rate has remained unchanged during the last 10 years. Indications to perform this procedure are well defined, especially in case of scarred uterus, twin pregnancies, macrosomia or breech presentation. Surgical (haemorrhage, urinary or intestinal tract injury) and anaesthetic (hypotension after regional anaesthesia, difficult intubation and aspiration after general anaesthesia) complications may occur during the procedure. Complications may also be encountered in the early postoperative period (haemorrhage, infection, venous thromboembolism) but also on the long-term, such as placenta accreta or uterine rupture which may significantly impact obstetric outcomes. Enhanced recovery after surgery promotes early recovery and rapid convalescence. It simplifies nursing practice after surgery and is the first important step toward a patient- and family-centred care.

Objective: To determine guidelines for post-partum management after cesarean delivery regarding patient monitoring, organization, postoperative analgesia, time of urinary catheter removal, resumption of feeding and drinking, timing of ambulation, indication and modalities of thromboprophylaxis., Methods: The PubMed database, the Cochrane Library and the recommendations from the French and foreign obstetrical societies or colleges have been consulted., Results: Immediate postoperative monitoring after caesarean delivery should be performed in the recovery room, but in exceptional circumstances, it may be performed in the delivery unit provided safety rules are maintained and regulatory authorities are informed (professional consensus). Specific surveillance including emergency call procedures must be performed (professional consensus). Systematic blood count performed immediately after cesarean delivery is not recommended in the general population (professional consensus). An analgesic protocol developed by the medical team should be available for each patient (professional consensus). An indwelling bladder catheter should be inserted before and maintained during surgery (professional consensus). The bladder catheter should be preferentially removed in the first 12 hours after cesarean delivery (professional consensus). It is recommended to check that spontaneous voiding has occurred in the 4-6 hours after the removal of the bladder catheter. The physician in charge should be alerted if the patient has failed to void within 6 hours after catheter removal (grade C). Early ambulation on day 1 (or earlier from the 6th to 8th hour) with help is advised and encouraged (professional consensus). Early feeding and drinking after elective or emergency cesarean delivery, performed under regional or general anesthesia, is recommended (grade A). Administration of a prophylactic treatment using two antiemetic medications is recommended during cesarean delivery (grade B). For every cesarean delivery, thromboprophylaxis with elastic stockings applied on the morning of the surgery and kept for at least 7 postoperative days is recommended (professional consensus) with or without the addition of LMWH according to the presence or not of additional risk factors, and depending on the risk factor (major, minor). In obese patient, LMWH dose needs to be weight-adapted (grade C)., Conclusion: Harmonization of care according to these recommendations is expected to enhance recovery after cesarean delivery., (Copyright © 2015 Elsevier Masson SAS. All rights reserved.)

Aims: Although most components of an enhanced recovery programme (ERP) can be applied to caesarean delivery, it is unknown if their implementation is large in France., Type of Study: Structured interview by telephone or e-mailing of an anaesthetist to describe usual perioperative practice in two French regions (Provence - Alpes - Côte d'Azur [PACA] and Île-de-France [IDF])., Methods: Questionnaire related to scheduled caesarean delivery., Results: Response rate 74% (111/149 maternity units). Multimodal analgesia was almost universally applied and intrathecal/epidural morphine used by 86% of respondents. Oral administration of analgesic drugs was started before h24 in 50% of responding units and immediately after delivery in 7% of them. The urinary catheter was withdrawn after h24 in 71% of responding centres. Women were allowed to drink between h4 and h6 (60%), in an unlimited amount (79%). The first meal was authorised after h6 (89%) but before h24 (65%) or after recovery of bowel function (13%). Oxytocin was used in 69% of respondents and maintained postoperatively for 12 to 24hours (70% of oxytocin users). Carbetocin was used in the remaining 31%, usually without any maintenance oxytocic drug. Attributing one point to each major component of the ERP protocol (0-6), the median value was 3 (2-4). An ERP protocol was available in 14% of responding units and was associated with a shorter duration of intravenous and urinary catheters use., Conclusion: The study shows that the components of an ERP are insufficiently implemented in France after caesarean delivery. Moreover, significant heterogeneity exists between maternity units and among regions., (Copyright © 2013. Published by Elsevier SAS.)

After an uneventful caesarean delivery under spinal anaesthesia (hyperbaric bupivacaine 10mg, sufentanil 5μg and morphine 50μg), hypothermia (nadir 34°C) was recorded in a ASA 1 patient. Partial recovery was rapidly obtained with 400μg of naloxone but full recovery was obtained after seven hours of active rewarming with a forced-air warming blanket. Suggested pathophysiology and incidence of this hypothermia are described., (Copyright © 2012. Published by Elsevier SAS.)

Aim: To compare combined spinal-epidural anaesthesia (CSE) VS spinal anaesthesia (SA) in caesarean section (CS) performed by Stark method., Material and Methods: 200 women were prospectively studied before undergoing to a Stark CS in two groups: 95 patients were assigned to a local anaesthesia by SA (first group) and 105 women to CSE anaesthesia (second group). After a pre-load of 500 ml of plasma expander in both groups, SA was performed at the L1-L2 interspace with an injection of 5 ml of levobupivacaine 0.15%, with a 5 mcg of Sufentanil. The CSE was performed by a spinal-epidural injection at the L1-L2 interspace, primarily by 4 ml of levobupivacaine 0.125% and 5 mcg of Sufentanil, then by 3-7 mL of xilocaine carbonate 0.5% plus 1 mcg/ml of Sufentanil. Successively a CS by Stark method was performed in both groups. The recorded anaesthesiologic side effects in two groups were: motor block, intraoperative discomfort, vomiting, bradycardia and hypotension. Statistical evaluation was by Z-Test referred to the comparison of 2 portions with great, independent samples., Results: In the group with CSE anaesthesia, the prevalence of side effects was less than in the group treated with SA, where the prevalence of the motor block and intraoperative discomfort were greater and statistically significant (p<0.001); so as the vomiting and bradycardia were all in a major percentage in SA group, but only significant for hypotension (p<0.001)., Conclusions: These preliminary data show that the association between CS and CSE anaesthesia in elective CS by Stark method allow to have less intra and post-operative side effects; further studies need to provide specific details on the anaesthetic and surgical techniques, to tailor and optimize both in each patient to select for surgery.

Background and Objective: It is not known whether anaesthetic practices for ASA I parturients undergoing scheduled caesarean delivery have changed since the last (1996) survey and how practices reflect current recommendations., Methods: A 26-item survey questionnaire (organization of the maternity unit, preoperative evaluation, technical aspects describing regional or general anaesthesia, oxytocic and antibiotic drugs, postoperative analgesia) was distributed to all French obstetric units (excluding overseas)., Results: The response rate was 73% (451/621). Preoperative evaluation included a recent platelet count in 97% of responding units, and information was given to patients in 84% of cases. Antibiotic prophylaxis in accordance with French guidelines was used in 78% of units. Anaesthetic techniques were single-shot spinal, epidural, combined spinal epidural and general anaesthesia in decreasing order (92.5, 4.5, 2 and 1%, respectively). Effervescent cimetidine was the first choice in 62% of units. Cricoid pressure and succinylcholine were routinely used in 66 and 77% of units, respectively. Oxytocin was used appropriately in 65% of units. In addition to spinal or epidural opioids, paracetamol, NSAIDs and nefopam were added postoperatively in 98, 68 and 19% of units, respectively. Poorer practices were found in units having a lower annual delivery rate., Conclusions: Overall practice was in accordance with national guidelines or practice patterns defined by the expert committee. Regional anaesthesia and postoperative analgesia-related techniques particularly were adequate. Some deficits were of limited importance (antibiotic prophylaxis and oxytocin administration), whereas others (use of succinylcholine and cricoid pressure) remain of concern.

Background: Extension of a labour epidural for Caesarean delivery is thought to be successful in most cases and avoids the use of general anaesthesia. However, most previous studies that have estimated the failure rate of pre-existing epidural catheters were performed in small numbers of patients., Methods: Therefore, we undertook to retrospectively measure the failure rate of indwelling epidural catheters in a large number of patients., Results: The anaesthetic team was available at all times and was permanently led by a senior anaesthetist specialized in obstetrics. Extension was performed using lidocaine 2% with epinephrine (mean 18 (SD 6) ml), combined in most patients with sufentanil (9 (2.2) microg) and/or clonidine (75 microg). Among 194 consecutive extensions performed in a 1-yr period, general anaesthesia was required in five patients (2.6%) while sedation and/or i.v. analgesia were used in 27 patients (13.9%). In three cases where general anaesthesia was required, the interval between decision to incision was <10 min. No factor associated with failure could be identified. Addition of a lipophilic opioid or of clonidine did not modify the efficacy of the block (i.e. general anaesthesia or supplementation were required in a similar proportion)., Conclusions: The augmentation of labour epidurals for Caesarean section using lidocaine 2% plus epinephrine is a reliable and effective technique. No factor associated with failure could be identified.

Purpose: Early feeding is well tolerated after Cesarean delivery. However, patient wellbeing and nurses' attitudes toward implementation of early feeding have rarely been investigated., Methods: A quality-assurance program of 18 months duration was implemented because evaluation of traditional practice demonstrated significant deficiencies (phase I). Drinking was then allowed within one hour and feeding within six to eight hours after delivery. Gradual dietary expansion followed according to a detailed program. Three consecutive evaluations (phase II-IV) were performed: 1) to measure implementation by the ward nurses; 2) to record the type of food and the volume of water effectively received; 3) to evaluate patients' gastrointestinal tolerance and patients' levels of hunger and thirst and patients' overall satisfaction., Results: In phase I, 60% of patients received nothing by mouth and 28% received only water on the day of surgery (D0). Moderate or severe hunger and thirst were seen in a large portion of these patients (D0, hunger: 38%, thirst: 63%, D1, hunger: 40%, thirst: 28%). Introduction of the program significantly improved patient wellbeing as well as patient satisfaction. No side effects were encountered., Conclusion: Hunger and thirst are frequently encountered after Cesarean delivery when patients are allowed to eat only after return of the first flatus. By using a quality-assurance program, it was possible to reduce the incidence and the severity of these distressing symptoms and to improve patients' satisfaction while no side effects were encountered. These beneficial effects were maintained in phase IV suggesting a high acceptance rate from the nursing staff.

Unlabelled: Seventy-eight pregnant women at term, scheduled for elective cesarean section, were enrolled in this multicenter trial to compare the analgesic efficacy and side effect profile of a spinal block with hyperbaric bupivacaine alone (Group B) or combined with 75 microg of clonidine (Group BC) or with clonidine 75 microg and fentanyl 12.5 microg (Group BCF). Intraoperatively, clonidine increased the spread of the sensory block and decreased pain (pain scores 23+/-7 mm vs 17+/-6 and 2+/-1 mm for Group B versus Groups BC and BCF; P < 0.05) and analgesic supplementation. This improved analgesia was best with the clonidine-fentanyl combination (Group BC versus Group BCF; P < 0.05). Postoperative analgesia was prolonged only in Group BCF (215+/-79 min vs 137+/-35 and 183+/-80 min for Group BCF versus Groups B and BC; P < 0.05). Blood pressure and heart rate changes were not significantly different among groups, whereas sedation and pruritus were significantly more frequent in Group BCF. Nausea and vomiting were decreased in Groups BC and BCF. Apgar scores and umbilical artery blood pH were not different among groups. We conclude that adding a small dose of intrathecal clonidine to bupivacaine increases the quality of intraoperative analgesia and decreases pain during cesarean section. Combining clonidine with fentanyl further improved analgesia., Implications: In this study, we demonstrate improved intraoperative spinal analgesia by adding 75 microg of clonidine to bupivacaine; side effects were not increased. The combination of clonidine and fentanyl further improved analgesia but moderately increased sedation and pruritus.

We report the case of a patient presenting with a placenta praevia and who donated autologous blood while she had beta 2-agonist tocolysis. As the restitution of blood containing salbutamol at therapeutic concentration may induce uterine atony and cardiovascular symptoms, we monitored maternal clinical signs and plasma concentrations of salbutamol when autologous blood was retransfused after the end of Caesarean section. The maternal plasma beta 2-agonist levels during tocolysis were in agreement with the usual therapeutic concentrations. The beta 2-agonist infusion was discontinued 30 minutes before the subarachnoid blockade and the blood concentration measured at the time of skin incision was below the therapeutic threshold. The retransfusion of autologous blood neither raised the salbutamol concentration above the therapeutic threshold value, nor induced any clinical symptoms. After Caesarean section the retransfusion of autologous blood containing therapeutic concentration of salbutamol seems to be innocuous.

Many authors have shown the analgesic efficacy of 150-800 micrograms of epidural clonidine in the postoperative period. Its use as an analgesic after caesarean section has recently been studied with higher dosages (400-800 micrograms). Our study aimed at assessing the analgesic and ventilatory effects of two smaller doses of epidural clonidine (150 and 300 micrograms), which were compared to the effects of 10 mg of parenteral morphine (M) during the first 3 h after caesarean section. The duration of the analgesic effect was longest with 150 micrograms of epidural clonidine. Arterial blood pressure decreased from 30 min after the injection to the end of the study in both epidural clonidine groups. A marked sedation was observed in patients receiving 300 micrograms of epidural clonidine and was frequently associated with snoring, obstructive apnoea and episodes of arterial oxygen desaturation. We conclude that 150 micrograms of epidural clonidine provides better and longer analgesia after caesarean section than 10 mg of parenteral morphine, and seems preferable to higher doses (300 micrograms) in this setting, since 300 micrograms of epidural clonidine may produce unacceptable respiratory obstructive disturbances.

The ventilatory response to CO2 was measured to evaluate the degree of respiratory depression after epidural sufentanil. After cesarean section performed with bupivacaine epidural anesthesia, 14 patients received either 30 micrograms (n = 7) or 50 micrograms (n = 7) of epidural sufentanil. Respiratory measurements were made before and 15, 45, and 120 min after sufentanil injection. The presence and severity of sedation and other nonrespiratory side effects were evaluated throughout the study. Plasma sufentanil assays were performed on blood samples obtained at frequent intervals during the first 2 h. Although changes in resting ventilation did not occur, both sufentanil doses depressed the ventilatory response to CO2. After sufentanil 30 micrograms, the slope of the CO2 response curve decreased significantly at 45 and 120 min (control value, 2.33 +/- 0.3 L.min-1.mm Hg-1 [mean +/- SEM] vs 1.61 +/- 0.24 and 1.72 +/- 0.15, respectively, P less than 0.05). After sufentanil 50 micrograms, significant decreases occurred at 15 and 45 min (control value, 2.84 +/- 0.71 vs 1.81 +/- 0.48 and 1.48 +/- 0.31 L.min-1.mm Hg-1, respectively). The mean maximal decrease in the slope occurred at 45 min and was more pronounced after 50 micrograms (-42.3% +/- 7.4%) than after 30 micrograms (-27.4% +/- 9.9%). Analgesia was similar in both groups. Side effects, particularly sedation, were more severe with the 50-micrograms dose. We conclude that 30 micrograms of epidural sufentanil is preferable to the higher dose with regard to both respiratory and nonrespiratory side effects. Even with the lower dose, monitoring of ventilation is advisable for a minimum of 2 h.

Tympanic, rectal, and axillary temperatures were measured and compared in 12 ASA Physical Status I and II parturients during epidural anesthesia for cesarean delivery. Measurements were performed before (T0) and at 15 (T1), 30 (T2), 45 (T3), and 60 (T4) minutes after epidural anesthesia. At birth, rectal neonatal and maternal temperatures were measured. Before anesthesia, maternal tympanic and rectal temperatures were statistically not different but higher than axillary temperature (difference, 0.5 degrees C). During anesthesia, all three maternal temperatures decreased. There was no difference for the first 45 minutes between rectal and tympanic membrane temperatures and no difference between tympanic and axillary temperatures after 30 minutes. The difference between rectal and tympanic temperatures became significant at T4. During the same period, the difference between axillary and tympanic temperatures became nonsignificant at T3 and T4. At birth, both maternal and newborn rectal temperatures were similar at 36.0 +/- 0.2 degrees C. The relative hypothermia observed in the newborns at birth after regional anesthesia was well correlated with the decrease in maternal temperature. A decrease in tympanic temperature of 1.4 degrees C developed during the course of epidural anesthesia for cesarean delivery. This decrease was underestimated by the measurement of rectal and axillary temperatures.

This study aimed to compare the efficacy and side-effects of sublingual buprenorphine, a synthetic opioid agonist antagonist, with those of subcutaneous morphine. Fifty ASA class 1 patients were included in the study after having given their informed consent. Caesarean section was carried out under epidural block with 0.5% bupivacaine; no opioids were used during the procedure. The first dose of opioid was given 2 h after the first dose of bupivacaine. Patients were randomly given either 10 mg morphine (n = 25) or 0.4 mg buprenorphine (n = 25), followed by the same dose every 6 h for 36 h. When analgesia was insufficient, tablets containing dextropropoxyphene and paracetamol were given. No attempt was made to blind the study to the patient, but the investigator assessing pain was unaware of the drug given to the patient. Pain intensity was assessed before, and 2 h after each dose of opioid with a 100 mm visual scale, as well as systolic, diastolic and mean arterial blood pressures, heart and breathing rates, and SpO2. Side-effects (pruritus, nausea, vomiting, drowsiness) were also noted. In 2 patients in each group, the protocol was stopped before the 36th h, but after the fourth dose, either because of side-effects, or at the patient's request. Results were similar in both groups of patients, whether for degree of pain relief, or physiological effects. There was no clinically detectable respiratory depression. Duration and intensity of episodes of arterial oxygen desaturation, and the incidence of nausea, were similar in the 2 groups; pruritus was more common in the morphine group.(ABSTRACT TRUNCATED AT 250 WORDS)

Controversial results have been published in the literature concerning the efficacy of alkalinization of solutions of local anesthetics to shorten the time to onset of sensory block. Fifty-two parturients scheduled for cesarean section at term under epidural anesthesia were randomly allocated to one of four groups: group 1, 0.5% plain bupivacaine (pH = 5.38 +/- 0.05); group 2, 0.5% bupivacaine pH-adjusted with 1.4% sodium bicarbonate (pH = 6.87 +/- 0.01); group 3, 0.5% bupivacaine with 1:200,000 epinephrine (pH = 4.80 +/- 0.04); and group 4, 0.5% bupivacaine pH-adjusted with 1:200,000 epinephrine (pH = 6.68 +/- 0.01). The time to onset of the sensory block was evaluated using a nerve stimulator technique. Motor blockade was assessed using Bromage's scale. No differences in the characteristics of the onset of the sensory block were observed with epinephrine-containing solutions nor with pH-adjusted local anesthetics. The maximal degree of motor blockade was not significantly different in the four groups. We conclude that alkalinization of a 0.5% bupivacaine solution is not an effective way to shorten the latency of epidural block for cesarean section.

Abstract: A 34-year-old multiparous woman with a breech presentation, intrauterine growth restriction and premature rupture of membranes was transferred to our referral unit at 33weeks of gestation. She was diagnosed with Alagille syndrome soon after birth because of cholestasis and pruritus. Her condition was later complicated by esophageal varices, treated with propranolol, thrombocytopenia, and insulin-dependent diabetes. She had characteristic facies, posterior embryotoxon, “butterfly” vertebrae but had no cardiac or renal abnormalities. Due to the early onset of spontaneous labor, emergency cesarean section under general anesthesia was performed 48h after admission. This is the first case describing anesthetic care during delivery in a patient with Alagille syndrome. We discuss the anesthetic implications of the syndrome, emphasizing problems associated with portal hypertension and cholestasis, thrombocytopenia and cardiac abnormalities such as pulmonary artery stenosis. [Copyright &y& Elsevier]

Purpose: To investigate if early epidural analgesia can influence fetal head engagement into the pelvis and if it can increase the rate of transverse and asynclitic position during labour. Materials and Methods: 195 women with combined spinal-epidural analgesia (CSE) or without neuraxial analgesia were studied. CSE was performed using a mixture of ropivacaine 0.02% with 0.3 µg/ml of sufentanil administered in the spinal space. Maintenance of analgesia was managed with intermittent epidural administration of 10-15 ml of ropivacaine (0.07%-0.10%) mixed with 0.5 µg/ml of sufentanil, based on the stage of labour and the degree of pain. 2D transabdominal ultrasound (US) was used. Serial transabdominal US examinations were performed at 45-90 min intervals to detect transverse and asynclitic positions, using the following signs: squint sign, sunset thalamus and cerebellum signs that best details the fetal head station. After delivery, the complete set of clinical and US data obtained by each examination were recorded and compared in women with and without labour analgesia. Data were examined by independent reviewers. Results: There was no difference in obstetric outcome between women in whom CSE had been used and those who did not request analgesia during labour (p>0.05). Conclusions: Epidural analgesia initiated early during labour and using low doses does not increase the rate of dystocic labors. Transverse fetal head positioning with anterior or posterior asynclitism does not seem to be promoted by drug or technique-related mechanisms, but rather should be the consequence of cephalopelvic disproportion. [ABSTRACT FROM AUTHOR]

Objective. – To study the reciprocal interferences between pregnancy and myasthenia gravis (MG) and to describe obstetric and anaesthetic management during labour and the post-partum period.Study design. – Retrospective, single centre study.Methods. – The files of 10 patients with MG, who delivered between October 1994 and May 2002, were examined.Results. – No stillbirth occurred and all pregnancies were brought to term. All patients were maintained on their long-term anticholinesterase medications during pregnancy. Seven exacerbations were detected and controlled, five by increasing the anticholinesterase treatment, one by using plasmapheresis and one by using intravenous immunoglobulins. No patient required admission to the intensive care unit during pregnancy. All patients had a pre-anaesthetic visit at/near 33 weeks of gestation. Delivery was induced for six patients. Regional analgesia was performed early in labour (epidural, n = 7; combined spinal–epidural = 2) using low concentrations of local anaesthetic and no complication was detected. Three patients required a caesarean section for an obstetrical indication. Seven patients delivered vaginally using instrumental extraction (n = 5). During the post-partum period, four patients were monitored in the intensive care unit during 48 h and close neurological follow-up disclosed no exacerbation during the first 6 post-partum weeks.Conclusions. – MG has no significant effect on the course of pregnancy and delivery, but MG exacerbation can occur, especially in the first trimester. Regional analgesia is medically indicated and must be performed early in labour, using low concentration of local anaesthetic to lessen the risk of motor block. [Copyright &y& Elsevier]

Abstract: Aims: Although most components of an enhanced recovery programme (ERP) can be applied to caesarean delivery, it is unknown if their implementation is large in France. Type of study: Structured interview by telephone or e-mailing of an anaesthetist to describe usual perioperative practice in two French regions (Provence - Alpes - Côte d’Azur [PACA] and Île-de-France [IDF]). Methods: Questionnaire related to scheduled caesarean delivery. Results: Response rate 74% (111/149 maternity units). Multimodal analgesia was almost universally applied and intrathecal/epidural morphine used by 86% of respondents. Oral administration of analgesic drugs was started before h24 in 50% of responding units and immediately after delivery in 7% of them. The urinary catheter was withdrawn after h24 in 71% of responding centres. Women were allowed to drink between h4 and h6 (60%), in an unlimited amount (79%). The first meal was authorised after h6 (89%) but before h24 (65%) or after recovery of bowel function (13%). Oxytocin was used in 69% of respondents and maintained postoperatively for 12 to 24hours (70% of oxytocin users). Carbetocin was used in the remaining 31%, usually without any maintenance oxytocic drug. Attributing one point to each major component of the ERP protocol (0–6), the median value was 3 (2–4). An ERP protocol was available in 14% of responding units and was associated with a shorter duration of intravenous and urinary catheters use. Conclusion: The study shows that the components of an ERP are insufficiently implemented in France after caesarean delivery. Moreover, significant heterogeneity exists between maternity units and among regions. [Copyright &y& Elsevier]

Abstract: Objective: The equipment and practices in obstetric analgesia, anaesthesia and intensive care, as well as their evolution between 2003 and 2010 in metropolitan France, were described. Population and methods: Data were derived from two representative samples of births in 2003 and 2010, based on all births in France during one week. The sample included 534 maternity units and 14,903 births in 2010 and 618 maternity units and 14,737 births in 2003. Results: The caesarean operating room was adjacent or inside the labour ward in 66% of maternity units in 2010 vs 56% in 2003. An anaesthetist was appointed permanently to the labour ward in 38.9% of maternity units in 2010 vs 21.5% in 2003. Locoregional analgesia or anaesthesia rate increased significantly: 81.5% in 2010 compared to 74.9% in 2003. Almost all operative vaginal deliveries were performed under epidural anesthesia in 2010. Patient controlled epidural analgesia (PCEA) was available in 58% of the units in 2010 but only 34.2% of women had PCEA. Newborn''s resuscitations were performed mainly by paediatricians in 2010, but 11.4% of children were resuscitated by an anaesthetist in level 1 maternity units. Conclusion: The conditions required to ensure anaesthetic care safety in maternity units has improved since 2003. Improvements in quality of care are still possible. [Copyright &y& Elsevier]

Abstract: Objective: To describe the effects of anaesthetic techniques and agents on the risk of foetal distress during labour pain relief and anaesthesia for caesarean section. Study design: Data on obstetric anaesthesia- and analgesia-induced fœtal distress were searched in Medline database using Mesh terms: foetal distress, anaesthesia, analgesia, labour, caesarean section, and umbilical artery pH. Trials published in English or French language were selected. Results: Because of their haemodynamic effects, regional anaesthesia and analgesia, especially spinal anaesthesia for Caesarean section, could induce a decrease in umbilical artery pH (UApH). Moreover, intravenous ephedrine, especially when used in large doses can worsen the acidosis. Labour epidural analgesia is associated with a better acid-base balance than systemic analgesia. Experimental studies have demonstrated harmful effects of systemic opioids and hypnotic drugs on UApH and the foetal brain respectively. Clinical implications of these potentially detrimental effects remain to be determined. Conclusion: All obstetric anaesthesia and analgesia techniques are associated with a theoretical risk of fetal distress, but given the fact that regional anaesthesia techniques are also associated with well-demonstrated benefits for the mother and the newborn, the latter remain the preferred choice in obstetric practice. [Copyright &y& Elsevier]