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F etal heart rate (FHR) abnormalities can occur after the initiation of labor analgesia. Although combined spinalepidural (CSE) analgesia with opioids has been associated with a higher incidence of nonreassuring FHR tracings immediately after block placement than with epidural analgesia, the possible causes have not been confirmed. One hypothesis is that the rapid onset of pain relief creates an imbalance in maternal catecholamine levels leading to uterine hyperactivity. This prospective, randomized study compared the effects of CSE and traditional epidural (EPI) analgesia on uterine basal tone and their association with FHR abnormalities.Low-risk laboring patients with singleton, cephalic, full-term pregnancies who requested analgesia before 7 cm of cervical dilatation were enrolled. Of the 91 patients who were initially enrolled, 14 were excluded, primarily for cardiotocographic failure. Forty-one patients were randomly assigned to receive CSE and 36 to EPI analgesia. All received a 10 mL/kg bolus of lactated Ringer's solution prior to an intrathecal injection of 2.5 mg of 0.5% bupivacaine with 2.5 mg sufentanil in the CSE group or 12.5 mg 0.125% bupivacaine with sufentanil 12.5 mg in the EPI group. Patients were monitored with an intrauterine pressure transducer for at least 15 minutes before and 15 minutes after labor analgesia. FHR was monitored with an external transducer and tracings were evaluated by a blinded observer. Pain was assessed with a 10-cm visual analogue scale (VAS). Primary outcomes were the occurrence of prolonged decelerations or fetal bradycardia and an increase of Z10 mm Hg in basal uterine tone after analgesia. Oxytocin use, hypotension, and speed of pain relief were also recorded. Power analysis suggested that 84 parturients would have to be randomized to have an 85% chance of detecting a 30% difference in uterine basal tone of 10 mm Hg.The groups did not differ in maternal demographic characteristics. Uterine tone was elevated in 17 (41.5%) and 6 (16.7%) patients in the CSE and EPI groups, respectively (P = 0.18) in the first 15 minutes after analgesia. FHR abnormalities were present in 13 (31.7%) of patients in the CSE group compared with 2 (5.6%) in the EPI group (P<0.01). Of the 13 women with FHR abnormalities during the first 15 minutes of analgesia in the CSE group, 7 had bradycardia and 6 had prolonged decelerations. In the EPI group, one tracing showed a prolonged deceleration and another had bradycardia. FHR abnormalities associated with hypertonus occurred in 11 (26.8%) of the CSE group and 1 (2.8%) of the EPI group (P<0.01). Two women in the CSE group had maternal hypotension compared with none in the EPI group, not a significant difference. Hypertonus and nonreassuring FHR were resolved with hydration, suspension of oxytocin if used before analgesia, and maternal supplementation with oxygen. No patient required tocolysis and no emergency cesarean delivery was performed because of fetal distress. Mean pain relief on VAS was higher in the CSE group at all evaluations up to 20 ...

I.

ObjectivesTo identify faculty perceptions of simulation insertion in the undergraduate program, considering the advantages and challenges posed by this resource. MethodsWe conducted a qualitative study with intentional sampling according to pre-defined criteria, following a semi-structured outline regarding data saturation. We have interviewed 14 healthcare instructors from a teaching institution that employs simulation in its syllabi. ResultsThe majority of the faculty interviewed considered the use of scenario, followed by debriefing, as an excellent teaching tool. However, the faculty also noted a number of difficulties, such as the workload necessary to assemble the scenario, the correlation between scenario goals and the competences of the program, the time spent with the simulation, and the ratio of students to faculty members. ConclusionsFaculties consider simulation an effective tool in the healthcare program and maintain that the main obstacle faced by them is the logistical demand.