Carlos Delgado

Purpose of review: Limited English proficiency (LEP) impacts patient access to safe and comprehensive care during the antepartum, intrapartum, and postpartum periods. In this review, we explore disparities in care delivery and outcomes that LEP women experience, and discuss the importance of providing language concordant care and using interpretation services appropriately. Recent findings: The number of individuals with LEP is steadily increasing in the United States. Pregnant women with LEP suffer disparities in obstetric care and are at risk for postpartum depression, breastfeeding difficulties, and substandard newborn care after neonatal ICU discharge because of insufficient education. Addressing these issues requires the implementation of language concordant care and education, along with the utilization of medically trained interpreters. Although further evidence is needed, the authors support these interventions to improve patient satisfaction, decrease medical errors, and curtail misdiagnoses. Summary: The pregnant woman with limited English proficiency is at risk of receiving suboptimal care and experiencing negative outcomes during the antepartum, intrapartum, and postpartum periods. The use of medically trained interpreters and the provision of language concordant care, through workforce diversification and the creation of forms and educational materials in diverse languages, can improve patient safety, outcomes, and quality of care.

BACKGROUND: Neuraxial analgesia is the gold standard for labor analgesia in the United States, and postdural puncture headache (PDPH) is one of the most common complications. PDPH is frequently treated with an epidural blood patch (EBP), but conservative treatment approaches remain common. Our current understanding of the incidence of PDPH and the frequency of EBP utilization is heavily based on reports from academic medical centers. We studied a private insurance database to provide estimates of neuraxial labor analgesia (NLA) use and PDPH and EBP incidence in the United States. METHODS: Labor and delivery insurance claims from the Truven MarketScan Commercial Claims and Encounters database were analyzed. Mode of delivery, analgesic and/or operative anesthesia information, and EBP placement were identified using Current Procedural Terminology (CPT) codes. PDPH was identified using International Classification of Diseases, Ninth Revision (ICD-9) codes. RESULTS: The analytic dataset consisted of 1,752,243 deliveries. Vaginal deliveries (VD) comprised 64.6% of the sample. Of these, 72.9% received NLA, with a PDPH incidence of 0.58% (95% confidence interval [CI], 0.57–0.60). Using VD with NLA as a referent, the risk ratio for PDPH following cesarean delivery (CD) without a prior NLA was 1.1 (95 CI, 1.05–1.15; P = .0001), while the risk ratio for PDPH following CD with a prior NLA was 0.81 (95% CI, 0.76–0.87; P < .0001). EBP placement was documented in 68.4% PDPH cases following VD with NLA, 67.2% of PDPH cases following CD with prior NLA, and 59.7% of PDPH cases following CD without prior NLA. The median number of days between delivery and first and EBP was 3. A second EBP was performed in 8.3% of initially patched patients, and a third in 0.1%. In patients who went on to receive a repeat EBP, the median interval between delivery and the first EBP was 1 day. CONCLUSIONS: This analysis confirms findings of prior studies regarding the present utilization of neuraxial analgesia and the incidence of PDPH. When compared to patients undergoing VD with NLA, patients having CD without NLA had a higher incidence of PDPH, presumably due to intentional dural puncture. Women having CD with a prior NLA had a lower incidence of PDPH, possibly due to avoidance of pushing during the second stage of labor. EBP was a commonly pursued strategy for the treatment of PDPH and was more commonly pursued in patients with a history of NLA. Repeat EBP was rare.

Background: Use of an in situ epidural catheter has been suggested to be efficient to provide anesthesia for postpartum tubal ligation (PPTL). Reported epidural reactivation success rates vary from 74% to 92%. Predictors for reactivation failure include poor patient satisfaction with labor analgesia, increased delivery-to-reactivation time and the need for top-ups during labor. Some have suggested that this high failure rate precludes leaving the catheter in situ after delivery for subsequent reactivation attempts. In this study, we sought to evaluate the success rate of neuraxial techniques for PPTL and to determine if predictors of failure can be identified. Methods: After obtaining IRB approval, a retrospective chart review of patients undergoing PPTL after vaginal delivery from July 2010 to July 2016 was conducted using CPT codes, yielding 93 records for analysis. Demographic, obstetric and anesthetic data (labor analgesia administration, length of epidural catheter in epidural space, top-up requirements, time of catheter reactivation, final anesthetic technique and corresponding doses for spinal and epidural anesthesia) were obtained. Results: A total of 70 patients received labor neuraxial analgesia. Reactivation was attempted in 33 with a success rate of 66.7%. Patient height, epidural volume of local anesthetic and administered fentanyl dose were lower in the group that failed reactivation. Overall, spinal anesthesia was performed in 60 patients, with a success rate of 80%. Conclusions: Our observed rate of successful postpartum epidural reactivation for tubal ligation was lower than the range reported in the literature. Our success rates for both spinal anesthesia and epidural reactivation for PPTL were lower than the generally accepted rates of successful epidural and spinal anesthesia for cesarean delivery. This gap may reflect a lower level of motivation on behalf of both the patients and anesthesia providers to tolerate “imperfect” neuraxial anesthesia once fetal considerations are removed.