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The issue of obesity continues to reach new levels globally, affecting individuals across the age continuum. Obesity in pregnancy is associated with myriad comorbidities which may negatively impact the fetus, particularly dysfunctional labor and failure to progress ending in unplanned cesarean delivery. Neuraxial anesthesia represents the gold standard for cesarean delivery anesthesia and is increasingly beneficial for obese patients due to the risk of difficult airway. Obese parturients demonstrate higher rates of venous thromboembolism and wound infections and appropriate prophylaxis strategies to prevent these complications is imperative. While neuraxial anesthesia is the preferred technique for peripartum analgesia and cesarean delivery anesthesia, procedures can be technically challenging in patients with obesity, and may require more time, longer needles, increased experience, or ultrasound guidance. There is some concern for respiratory depression with the administration of neuraxial opioids in patients with obesity which has culminated in the development of post-operative monitoring guidelines., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024. Published by Elsevier Ltd.)

Objective: To evaluate the efficacy of wound infusion with ropivacaine plus ketorolac compared with placebo for post-cesarean delivery analgesia in women who received a multimodal analgesic regimen including intrathecal morphine., Methods: In a randomized double-blind study, women undergoing scheduled cesarean delivery under spinal or combined spinal epidural anesthesia were randomized to wound infusion with ropivacaine 0.2% plus ketorolac, or saline placebo using an elastometric pump for 48 hours. The primary outcome was pain score with movement at 24 hours after surgery (0-10 scale, 0=no pain and 10=worst possible pain). Secondary outcomes included pain scores at rest at 24 hours, pain scores at rest and with movement at 2 and 48 hours, opioid consumption, and time to first rescue analgesic. A sample size of 35 per group (n=70) was planned., Results: From November 8, 2016, to May 17, 2019, 247 women were screened, and 71 completed the study per protocol: 38 in the placebo group and 33 in the ropivacaine plus ketorolac group. Patient demographics and intraoperative characteristics were comparable between the groups. There was no significant difference between the groups in the primary outcome of pain score with movement at 24 hours (difference in median score 0, 95% CI -1 to 2, P=.94). There were also no significant differences between the placebo and ropivacaine plus ketorolac groups in pain scores at other time points, in total opioid consumption (difference in median consumption -12.5 mg, 95% CI -30 to 5, P=.11), or in time to rescue analgesics (median [interquartile range] 660 [9-1,496] vs 954 [244-1,710] minutes, hazard ratio 0.69, 95% CI 0.41 to 1.17, P=.16)., Conclusion: There was no benefit of wound infusion with ropivacaine and ketorolac in women who received intrathecal morphine and a multimodal analgesic regimen., Clinical Trial Registration: ClinicalTrials.gov, NCT02829944., Funding Source: The study was supported in part by Avanos Medical Inc.

Purpose: Hypotension is common after spinal anesthesia for Cesarean delivery. It is associated with nausea, vomiting, and fetal acidosis. Previous research on phenylephrine excluded obese subjects. We compared the incidence of intraoperative nausea and vomiting (IONV) in obese patients who received a prophylactic phenylephrine infusion vs those who received bolus dosing for the treatment of spinal-induced hypotension., Methods: In this multicentre, double-blinded randomized controlled trial, 160 obese women undergoing elective Cesarean delivery under spinal anesthesia were randomized to receive a prophylactic phenylephrine infusion initiated at 50 μg·min -1 (and titrated according to a predefined algorithm) or 100 μg phenylephrine boluses to treat hypotension. Maternal systolic blood pressure was maintained within 20% of baseline. The primary study outcome was the incidence of IONV., Results: Intraoperative nausea and vomiting were significantly reduced in the infusion group compared to the bolus group (46% vs 75%, respectively; relative risk [RR], 0.61; 95% confidence interval [CI], 0.47 to 0.80; P < 0.001). This was associated with significantly reduced need for intraoperative rescue antiemetics (26% vs 42%, respectively; RR, 0.62; 95% CI, 0.40 to 0.97; P = 0.04), but no difference in the incidence of vomiting. Postoperative vomiting at two hours was reduced in the infusion group (11% vs 25%; RR, 0.44; 95% CI, 0.21 to 0.90; P = 0.02);however, there were no differences in the incidence or severity of postoperative nausea, need for rescue antiemetics at two hours and 24 hr, or the incidence of postoperative vomiting at 24 hr., Conclusion: In obese women undergoing Cesarean delivery with spinal anesthesia, prophylactic phenylephrine infusion was associated with less intraoperative nausea, less need for rescue antiemetics, and reduced early postoperative vomiting., Trial Registration: www.clinicaltrials.gov (NCT01481740). Registered 22 July 2011.

Parturients with super-morbid obesity, defined as body mass index greater than 50kg/m(2), represent a growing segment of patients who require anesthetic care for labor and delivery. Severe obesity and its comorbid conditions place the parturient and fetus at greater risk for pregnancy complications and cesarean delivery, as well as surgical and anesthetic complications. The surgical approach for cesarean delivery in these patients may require a supra-umbilical vertical midline incision due to a large pannus. The dense T4-level of spinal anesthesia can cause difficulties with ventilation for the obese patient during the procedure, which can be prolonged. Patients also may have respiratory complications in the postoperative period due to pain from the incision. We describe the anesthetic management of three parturients with body mass index ranging from 73 to 95kg/m(2) who had a cesarean delivery via a supra-umbilical vertical midline incision. Continuous lumbar spinal and low thoracic epidural catheters were placed in each patient for intraoperative anesthesia and postoperative analgesia, respectively. Continuous spinal catheters were dosed with incremental bupivacaine boluses to achieve surgical anesthesia. In one case, the patient required respiratory support with non-invasive positive pressure ventilation. Two cases were complicated by intraoperative hemorrhage. All patients had satisfactory postoperative analgesia with a thoracic epidural infusion. None suffered postoperative respiratory complications or postdural puncture headache. The use of a continuous lumbar spinal catheter and a low thoracic epidural provides several advantages in the anesthetic management of super-morbidly obese parturients for cesarean delivery., (Copyright © 2015 Elsevier Ltd. All rights reserved.)

Respiratory depression can occur after neuraxial morphine administration. In the obstetric population, there are little data on respiratory depression after neuraxial morphine administration in women undergoing cesarean delivery. In this single-center, retrospective study in 5036 obstetric patients (mean body mass index = 34 kg/m) who underwent cesarean delivery and received neuraxial morphine, we did not identify any instances of respiratory depression requiring naloxone administration or rapid response team involvement. Therefore, the upper 95% confidence limit for respiratory depression in our study is 0.07% (1 event per 1429 cases).

Purpose of Review: Neuraxial morphine is commonly used for analgesia after cesarean delivery, but is frequently associated with postoperative nausea and vomiting (PONV) and pruritus. This review describes the recent advances in the management of those side-effects., Recent Findings: Neuraxial-morphine-induced side-effects are dose related; therefore, the minimum effective dose should be used. Dexamethasone, 5HT3 receptor antagonists, antihistamines, and anticholinergics reduce the incidence of PONV, whereas metoclopramide 10 mg does not appear to be effective for PONV prophylaxis in this patient population. Combination antiemetic therapy provides improved prophylaxis compared with monotherapy, but has seldom been studied in women undergoing cesarean delivery with neuraxial morphine. Studies of P6 acupressure reported inconsistent results. Polymorphism of the μ-opioid receptor may affect the severity of neuraxial-morphine-induced pruritus. Opioid antagonists and mixed agonist/antagonists appear to be the most useful for the management of opioid-induced pruritus. Prophylactic 5HT3 receptor antagonists and dexamethasone do not seem to be effective for reducing the incidence of pruritus. In contrast, ondansetron, pentazocine, and dimenhydrinate may be useful for treating established pruritus., Summary: PONV and pruritus are frequent side-effects of neuraxial morphine. Future studies investigating combination antiemetic therapy, long-acting antiemetics, and strategies to manage pruritus are needed.