Datta / Kodali / Segal Obstetric Anesthesia Handbook

5th Auflage 2010
ISBN: 978-0-387-88602-2
Verlag: Springer US
Format: PDF
Kopierschutz: 1 - PDF Watermark

E-Book, Englisch, 470 Seiten

Written by a highly regarded expert in the field of obstetric anesthesia Handy point of care Up-to-date information on the subject Good board review tool

Autoren/Hrsg.

Datta, Sanjay

Kodali, Bhavani Shankar

Segal, Scott

Inhaltsverzeichnis

1;Preface to the Fifth Edition;5
2;Preface to the First Edition;6
3;Contents;7
4;1 Maternal Physiological Changes During Pregnancy, Labor, and the Postpartum Period;9
4.1; Changes in the Hematological System;9
4.1.1; Clinical Implications;10
4.2; Changes in the Cardiovascular System;11
4.2.1; Clinical Implications;12
4.3; Changes in the Respiratory System;13
4.3.1; Clinical Implications;14
4.4; Changes in the Gastrointestinal System;15
4.4.1; Clinical Implications;17
4.5; Changes in the Renal System;17
4.5.1; Clinical Implications;17
4.6; Changes in the Central and Peripheral Nervous Systems;18
4.6.1; Clinical Implications;19
4.7; Changes in the Endocrine System;19
4.8; Changes in the Musculoskeletal System;20
4.9; Changes in the Dermatological System;20
4.10; Changes in Mammary Tissue;20
4.11; Changes in the Ocular System;20
5;2 Local Anesthetic Pharmacology;23
5.1; Chemistry;23
5.2; Physicochemical Properties;25
5.3; Other Factors Affecting Local Anesthetic Activity;27
5.3.1; Volume and Concentration;27
5.3.2; Addition of Vasoconstrictor Agents;28
5.3.3; Site of Injection;28
5.3.4; Bicarbonate;29
5.3.5; Mixtures of Local Anesthetics: Chloroprocaine and Other Drugs;29
5.3.6; Pregnancy;30
5.3.7; Temperature;30
5.4; Toxicity of Local Anesthetics;30
5.4.1; Systemic Toxicity: CNS;30
5.4.2; Systemic Toxicity: Cardiovascular System;31
5.4.3; Peripheral Neurotoxicity;32
5.4.4; Adverse Effects on the Fetus;34
6;3 Perinatal Pharmacology;37
6.1; General Principles;38
6.2; The Mother;40
6.2.1; Site of Administration;40
6.2.2; Addition of Epinephrine;40
6.2.3; Maternal Volume of Distribution and Clearance;40
6.2.4; Uteroplacental Blood Flow;41
6.2.5; Maternal Protein Binding;41
6.2.6; Maternal pH and Drug pKa;41
6.3; The Placenta;42
6.3.1; Area of Transfer and Diffusion Distance;42
6.3.2; Molecular Weight and Spatial Configuration of Drugs;42
6.3.3; Protein Binding and Lipid Solubility of Drugs;42
6.3.4; Metabolism of Drugs;43
6.4; The Fetus;43
6.4.1; Uptake;43
6.4.2; Distribution;44
6.4.3; Fetal Liver;44
6.4.4; Progressive Dilution of Umbilical Vein in Blood Concentration;44
6.4.5; Extensive Right-to-Left Shunt of the Fetal Circulation;44
6.5; Summary;46
7;4 Drug Interactions and Obstetric Anesthesia;48
7.1; Drugs Used for Maternal Indications;49
7.1.1; Antibiotics;49
7.1.2; Antiepileptic Drugs;49
7.1.3; Enzyme Induction;51
7.1.4; Sympatholytic and Sympathomimetic Drugs;51
7.1.4.1; Sympatholytic Drugs;51
7.1.4.2; Sympathomimetic Drugs;52
7.1.5; Antiasthmatic Drugs;53
7.1.5.1; Xanthine Derivatives;53
7.1.6; Corticosteroids;54
7.1.7; Histamine H2 Receptor Blockers;54
7.1.8; Psychotropic Agents;54
7.1.8.1; Phenothiazine, Thioxanthenes, and Butyrophenones;55
7.1.8.2; Tricyclic Antidepressants;55
7.1.8.3; Monoamine Oxidase Inhibitors;56
7.1.8.4; Lithium Carbonate;58
7.1.8.5; Serotonin Reuptake Inhibitors;58
7.1.9; Anti-fungal Drugs;59
7.2; Drugs Used During Labor and Delivery;60
7.2.1; Tocolytic Drugs;60
7.2.1.1; Magnesium Sulfate;60
7.2.1.2;Mimetic Drugs;60
7.2.1.3; Calcium Channel Blockers;61
7.2.1.4; Prostaglandin Inhibitors;61
7.2.1.5; Oxytocin Antagonist;61
7.2.2; Hypotensive Drugs;62
7.2.2.1; Hydralazine;62
7.2.2.2; Nitroglycerin;62
7.2.2.3; Nitroprusside;62
7.2.2.4; Trimethaphan;62
7.2.3; Uterotonic Agents;62
7.2.3.1; Oxytocin;62
7.2.3.2; Ergot Alkaloids;63
7.2.3.3; Prostaglandins;64
7.2.4; Local Anesthetics;64
7.2.5; Narcotics;65
7.3; Drugs Used for Fetal Indications;65
8;5 Uteroplacental Blood Flow;71
8.1; Measurement of Uteroplacental Blood Flow;72
8.2; Clinical Implications of the Uteroplacental Circulation: Gas Exchange Across the Placenta;72
8.3; Factors That Can Alter Uteroplacental Blood Flow;75
8.3.1; Uterine Contraction;75
8.3.2; Pain and Stress of Labor;75
8.3.3; Regional Anesthesia;75
8.3.4; Pathological Conditions;76
8.3.5; Pharmacological Agents;76
8.3.5.1; Intravenous Induction Agents;76
8.3.5.2; Inhalation Agents;77
8.3.5.3; Local Anesthetics;78
8.3.5.4; Epinephrine;79
8.3.5.5; Opioids;79
8.3.5.6; Vasopressors;79
8.3.5.7; Antihypertensive Agents;80
8.3.5.8; Tocolytic Drugs (Magnesium Sulfate, Beta Adrenergic Agonists, Indomethacin);81
8.4; Summary;81
9;6 Pain of Labor and Delivery;86
9.1; Pain Score of Labor Pain;88
10;7 Non-pharmacological Methods for Relief of Labor Pain;90
10.1; Hypnosis;91
10.2; Psychoanalgesia;92
10.2.1; Natural Childbirth;92
10.2.2; Psychoprophylaxis;92
10.3; Leboyer Technique;93
10.4; Acupuncture;93
10.5; Transcutaneous Electrical Nerve Stimulation (TENS);94
10.6; Aromatherapy;95
10.7; Touch and Massage;95
10.8; Maternal Movements and Positional Changes;96
10.9; Water Birthing;97
10.10; Summary;97
11;8 Relief of Labor Pain by Systemic Medications and Inhalational Agents;99
11.1; Opioids;99
11.1.1; Morphine;100
11.1.2; Meperidine;100
11.1.3; Fentanyl;102
11.1.4; Remifentanil;103
11.2; Sedatives and/or Tranquilizers;104
11.2.1; Barbiturates;104
11.2.2; Phenothiazines;104
11.2.3; Benzodiazepines;104
11.2.3.1; Diazepam;105
11.2.3.2; Midazolam;105
11.3; Dissociative Medications;105
11.4; Amnestic Agents;106
11.5; Neuroleptanalgesia;106
11.6; Agonist and Antagonist Agents;106
11.7; Inhalation Analgesia;107
12;9 Relief of Labor Pain by Regional Analgesia/Anesthesia;111
12.1; Epidural Analgesia;113
12.1.1; Anatomy of the Epidural Space;113
12.1.2; Contents of the Epidural Space;114
12.1.3; Site of Action;115
12.1.4; Techniques;115
12.1.5; Epidural Analgesia Procedure;116
12.1.5.1; Multiorifice Versus Uniorifice Epidural Catheters;117
12.1.5.2; Changes in the Position of Epidural Catheters Associated with Patient Movement;118
12.1.5.3; Test Dose;119
12.1.5.4; Initial Bolus Administration;122
12.1.5.5; Maintenance of Labor Analgesia;122
12.1.5.6; Local Anesthetic and Opioid Infusion;124
12.2; Possible Block-Related Problems;125
12.2.1; Inadequate Perineal Analgesia;125
12.2.2; Asymmetric Sensory Block;125
12.2.3; Diminishing Analgesia;125
12.2.4; Dense Motor Block;126
12.2.5; Patchy Block;126
12.2.6; Miscellaneous;127
12.2.7; Spinal Anesthesia;127
12.3; Continuous Spinal Anesthesia;127
12.4; Combined Spinal/Epidural (CSE);128
12.5; Monitoring Following Administration of Regional Analgesia;130
12.6; Contraindications;130
12.7; Complications of Regional Analgesia;131
12.7.1; Paresthesia;131
12.7.2; Accidental Dural Puncture;131
12.7.3; Treatment of Headache Following Accidental Dural Puncture;132
12.7.3.1; Conservative Management;132
12.7.3.2; Epidural Saline;132
12.7.3.3; Prophylactic Blood Patch;133
12.7.3.4; Therapeutic Blood Patch;133
12.7.3.5; Experimental and Alternative Techniques;135
12.7.4; Subdural Injection;135
12.7.5; Massive Epidural Analgesia;136
12.7.6; Accidental Intravascular Injection;136
12.7.7; Methemoglobinemia;137
12.7.8; Broken Epidural Catheter;137
12.7.9; Shivering;137
12.7.10; Horners Syndrome;137
12.7.11; Backache;138
12.7.12; Major Neurologic Injury;138
12.7.12.1; Obstetric Causes;139
12.7.12.2; Anesthesia-Related Causes;142
12.8; Other Methods of Regional Anesthesia;145
12.8.1; Caudal Anesthesia;146
12.8.2; Paracervical Block;146
12.8.3; Lumbar Sympathetic Block;146
12.8.4; Pudendal Block;146
12.9; Summary;147
13;10 Effects of Epidural Analgesia on Labor and the Infant;154
13.1; Epidural Analgesia and Progress of Labor;154
13.1.1; Methodological Difficulties;155
13.1.2; Initiation of the Block;155
13.1.3; Duration of Labor;156
13.1.4; Instrumental Vaginal Delivery (Forceps, Vacuum);156
13.1.5; Cesarean Delivery;157
13.1.6; Patient Satisfaction and Neonatal Outcome;158
13.2; Effect of Epidural Analgesia on Maternal Temperature and the Newborn;158
13.3; Epidural Analgesia and Breastfeeding;160
13.4; Summary;160
14;11 Fetal Monitoring;165
14.1; Antepartum Monitoring;165
14.1.1; Biophysical Profile;166
14.1.2; Nonstress Test (NST);166
14.1.3; Contraction Stress (Oxytocin Challenge) Test;167
14.1.4; Doppler Velocimetry;167
14.1.5; Assessment of Fetal Lung Maturity;167
14.2; Uterine Contraction Monitoring;168
14.3; Fetal Heart Rate Monitoring;169
14.3.1; Baseline Heart Rate;169
14.3.2; Baseline Variability;171
14.3.3; Fetal Heart Rate Pattern (Periodic Changes);172
14.3.3.1; Early Decelerations;172
14.3.3.2; Variable Decelerations;174
14.3.3.3; Late Decelerations;176
14.4; Other Modalities;178
14.4.1; Fetal Scalp Blood Sampling;178
14.4.2; Fetal Pulse Oximetry;178
14.5; Implications for Anesthesia Care;178
15;12 Anesthesia for Cesarean Delivery;181
15.1; Regional Anesthesia;182
15.1.1; Spinal Anesthesia (Subarachnoid Block);182
15.1.1.1; Problems Associated with Spinal Anesthesia;183
15.1.1.2; Medications for Spinal Anesthesia;192
15.1.1.3; Summary of Spinal Anesthesia for Cesarean Section;193
15.1.1.4; Contraindications for Spinal Anesthesia for Cesarean Section;194
15.1.2; Epidural Anesthesia;195
15.1.2.1; Problems Associated with Epidural Anesthesia;195
15.1.2.2; Complications of Epidural Anesthesia;196
15.1.2.3; Contraindications for Epidural Anesthesia;196
15.1.2.4; Local Anesthetics for Epidural Anesthesia;197
15.1.2.5; Summary of Epidural Anesthesia for Cesarean Section;198
15.1.2.6; Cardiovascular Complications of Bupivacaine and Neurological Complications of 2-Chloroprocaine;199
15.1.2.7; Differences Between Spinal and Epidural Anesthesia for Cesarean Delivery;202
15.2; Combined Spinal Epidural (CSE) Technique;202
15.3; General Anesthesia;203
15.3.1; Complications of General Anesthesia;204
15.3.1.1; Maternal Aspiration;204
15.3.1.2; Airway Management;204
15.3.2; Choice Between Regional and General Anesthesia when Difficult Airway Is Anticipated;209
15.3.2.1; Regional Anesthesia;209
15.3.2.2; General Anesthesia;210
15.3.3; Effect of General Anesthesia on the Baby;210
15.3.3.1; Underlying Physiology;211
15.3.3.2; Pharmacological Effects;213
15.3.4; Maternal Awareness;217
15.3.5; Summary of General Anesthesia for Cesarean Delivery;217
15.4; Air Embolism During Cesarean Delivery;218
15.5; Postoperative Pain Relief;219
15.5.1; Intravenous Method;219
15.5.2; Neuraxial Narcotics;219
15.6; Summary;220
16;13 Neonatal Resuscitation;233
16.1; Physiologic Adaptation to Extrauterine Life;234
16.1.1; Cardiovascular System;234
16.1.2; Respiratory System;237
16.1.3; Thermoregulation;238
16.2; General Principles of Neonatal Resuscitation;238
16.3; Evaluation of the Neonate: The Apgar Score;240
16.4; Steps in Neonatal Resuscitation;241
16.4.1; Airway;242
16.4.2; Breathing;244
16.4.3; Circulation;244
16.4.4; Drug Therapy;245
16.4.4.1; Indications for Volume Expanders;245
16.4.4.2; Other Drugs;246
16.5; Unusual Specific Causes of Neonatal Respiratory Problems;246
16.5.1; Choanal Atresia;247
16.5.2; Upper Airway Obstruction;247
16.5.3; Anomalies of the Larynx;248
16.5.4; Anomalies of the Trachea;248
16.5.5; Diaphragmatic Hernia;248
16.5.6; Pneumothorax;249
16.6; Summary;249
17;14 High-Risk Pregnancy: Maternal Comorbidity;251
17.1; Endocrine Disorders;253
17.1.1; Diabetes Mellitus;253
17.1.1.1; Pathophysiological Changes;254
17.1.1.2; Anesthetic Management;256
17.1.2; Hyperthyroidism;260
17.1.2.1; Anesthetic Management;260
17.1.3; Pheochromocytoma;261
17.2; Cardiac Disease;261
17.2.1; Anesthetic Management;262
17.3; Respiratory Problems;267
17.3.1; Bronchial Asthma;267
17.3.1.1; Cesarean Section;268
17.3.1.2; Regional Anesthesia;268
17.3.1.3; General Anesthesia;268
17.3.2; Cystic Fibrosis;269
17.4; Neurological Problems;270
17.4.1; Paraplegia;271
17.4.1.1; Anesthetic Management;272
17.4.2; Cerebrovascular Accidents;272
17.4.2.1; Anesthetic Management;272
17.4.3; Multiple Sclerosis;273
17.4.3.1; Anesthetic Management;273
17.4.4; Space-Occupying Lesions (Brain Tumors);275
17.4.4.1; Labor and Delivery;275
17.4.4.2; Cesarean Section;275
17.4.5; Epilepsy;276
17.4.6; Myasthenia Gravis;276
17.4.6.1; Labor and Delivery;277
17.4.6.2; Cesarean Delivery;277
17.4.6.3; Neonatal Myasthenia Gravis;278
17.5; Renal Disorders;278
17.5.1; Physiological Changes;278
17.5.2; Anesthetic Management;279
17.5.2.1; Labor and Delivery;279
17.5.2.2; Cesarean Section;279
17.6; Hematological Disorders;280
17.6.1; Sickle Cell Disease;282
17.6.1.1; Anesthetic Management;282
17.6.2; Idiopathic Thrombocytopenia;282
17.6.3; Von Willebrand Disease;283
17.7; Hypercoaguable States;283
17.7.1; Protein C and Protein S Deficiency, Phospholipid and Cardiolipin Antibodies;283
17.7.2; Factor V Leiden Mutation;283
17.8; Autoimmune Disease;285
17.8.1; Rheumatoid Arthritis;285
17.8.1.1; Anesthetic Management;286
17.8.2; Systemic Lupus Erythematosus;286
17.8.2.1; Anesthetic Management;286
17.9; Maternal Addiction;287
17.9.1; Alcohol;288
17.9.1.1; Major Problems;288
17.9.1.2; Anesthetic Management;288
17.9.2; Amphetamines;288
17.9.2.1; Anesthetic Management;288
17.9.3; Cocaine;288
17.9.3.1; Anesthetic Management;289
17.10; Infectious Diseases;290
17.10.1; Genital Herpes;290
17.10.2; Infection with the Human Immunodeficiency Virus;291
17.10.2.1; Anesthetic Technique;293
17.10.2.2; Risk to the Anesthesiologist;293
17.11; Psychiatric Disorders;293
17.11.1; Clinical Implications;294
17.12; Malignant Hyperthermia;295
17.12.1; Anesthetic Management;295
17.12.1.1; Regional Anesthesia;295
17.12.1.2; General Anesthesia;296
17.13; Obesity;296
17.13.1; Anesthetic Management;297
17.13.1.1; Labor and Delivery;297
17.13.1.2; Elective Cesarean Section;297
17.13.1.3; General Anesthesia;298
17.14; Summary;298
18;15 High-Risk Pregnancy:Pregnancy-Related Problems;304
18.1; Maternal-Related Issues;305
18.1.1; Antepartum Hemorrhage;305
18.1.1.1; Placenta Previa;305
18.1.1.2; Abruptio Placentae;308
18.1.2; Postpartum Hemorrhage;310
18.1.2.1; Lacerations;311
18.1.2.2; Retained Placenta;311
18.1.2.3; Uterine Inversion;312
18.1.2.4; Uterine Rupture;314
18.1.3; Vaginal Birth After Cesarean Delivery (VBAC) (also called Trial of Labor After Cesarean Delivery; TOLAC);314
18.1.3.1; Anesthetic Management;314
18.1.4; Pregnancy-Induced Hypertension;315
18.1.4.1; Definition and Terminology;315
18.1.4.2; Pathogenesis;316
18.1.4.3; Pathophysiology;317
18.1.4.4; Magnesium Therapy;320
18.1.4.5; Fluid Balance and Cardiovascular Function;321
18.1.4.6; Monitoring;326
18.1.4.7; Anesthetic Management;326
18.1.4.8; HELLP Syndrome;333
18.1.4.9; Eclampsia;334
18.1.5; Embolism in Pregnancy;335
18.1.5.1; Thromboembolism;335
18.1.5.2; Amniotic Fluid Embolism;335
18.1.5.3; Venous Air Embolism;336
18.2; Fetal-Related Issues;337
18.2.1; Prematurity;337
18.2.1.1; Tocolytic Agent Therapy;338
18.2.1.2; Anesthetic Management of Prematurity;343
18.2.2; Postmaturity;345
18.2.2.1; Anesthetic Management of Postmaturity;345
18.2.3; Breech Presentation;345
18.2.4; Multiple Gestations;346
18.2.4.1; Twins;346
18.2.4.2; Triplets or Quadruplets;346
18.2.4.3; Anesthetic Management;346
18.2.5; Fetal Distress (Nonreassuring Fetal Status);347
18.2.5.1; Maternal Causes;347
18.2.5.2; Placental Causes;347
18.2.5.3; Fetal Causes;347
18.2.5.4; Diagnosis;348
18.2.5.5; Anesthetic Management;348
18.2.6; Intrauterine Fetal Death;349
18.3; Transfusion-Related Issues (Newer Transfusion Protocols);350
18.3.1; Recombinant Factor VIIa;351
18.4; Summary;352
19;16 Non-delivery Obstetric Procedures;358
19.1; Cervical Cerclage;358
19.1.1; Anesthetic Options;359
19.1.1.1; Regional Anesthesia;359
19.1.1.2; General Anesthesia;360
19.1.2; Cerclage Removal;360
19.2; Dilation and Evacuation (DE);361
19.2.1; Anesthetic Options;361
19.3; Postpartum Tubal Ligation;363
19.3.1; Timing of Tubal Ligation;363
19.3.1.1; Physiologic Changes of Pregnancy in the Postpartum Period;364
19.3.2; Anesthetic Techniques;364
19.3.2.1; Epidural Anesthesia;364
19.3.2.2; Spinal Anesthesia;365
19.3.2.3; General Anesthesia;366
19.3.3; Postoperative Pain Relief;367
20;17 Anesthesia for Nonobstetric Surgery During Pregnancy;369
20.1; Maternal Safety;370
20.2; Fetal Well-Being;370
20.2.1; Acute Exposure to Anesthetics;371
20.2.2; Chronic Exposure to Anesthetics;371
20.2.3; Effect of Anesthetics on the Fetus;372
20.2.3.1; Sedative and Hypnotic Agents;372
20.2.3.2; Opioids;373
20.2.3.3; Muscle Relaxants;373
20.2.3.4; Local Anesthetics;373
20.2.3.5; Oxygen and Carbon Dioxide;374
20.2.3.6; Inhalation Anesthetics;374
20.2.3.7; Effects on the Fetal Brain: Behavioral Teratogenicity;376
20.3; Continuation of the Pregnancy;377
20.3.1; Recommendations for Minimizing Chances of Abortion or Premature Labor;377
20.4; Intrauterine Surgery;379
21;18 Assisted Reproductive Technology;386
21.1; In Vitro Fertilization Process;387
21.2; Effect of Anesthetics on IVF Process;388
21.2.1; Propofol and Thiopentone;388
21.2.2; Nitrous Oxide;389
21.2.3; Inhalational Anesthetic Agents;389
21.2.4; Local Anesthetic Agents;390
21.2.5; Opioids, Benzodiazepines, and Ketamine;391
21.2.6; Antiemetic Agents;391
21.3; Anesthetic Techniques for Ultrasound-Guided Transvaginal Oocyte Retrieval;391
21.4; Complications of IVF Procedure;393
21.4.1; Ovarian Hyperstimulation Syndrome (OHSS);393
21.4.2; Other Complications;393
22;19 Maternal Mortality and Morbidity;398
23;Appendix A: Guidelines for Regional Anesthesia in Obstetrics;403
23.1;19.1 GUIDELINE I;403
23.2;19.2 GUIDELINE II;403
23.3;19.3 GUIDELINE III;404
23.4;19.4 GUIDELINE IV;404
23.5;19.5 GUIDELINE V;404
23.6;19.6 GUIDELINE VI;405
23.7;19.7 GUIDELINE VII;405
23.8;19.8 GUIDELINE VIII;405
23.9;19.9 GUIDELINE IX;405
23.10;19.10 GUIDELINE X;405
23.11;19.11 References;406
24;Appendix B: Practice Guidelines for Obstetric Anesthesia;407
24.1;19.1 Methodology;408
24.1.1;19.1.1 A. Definition of Perioperative Obstetric Anesthesia;408
24.1.2;19.1.2 B. Purposes of the Guidelines;408
24.1.3;19.1.3 C. Focus;408
24.1.4;19.1.4 D. Application;408
24.1.5;19.1.5 E. Task Force Members and Consultants;409
24.1.6;19.1.6 F. Availability and Strength of Evidence;409
24.1.7;19.1.7 Guidelines;411
24.1.7.1; I. Perianesthetic Evaluation;411
24.1.7.2; II. Aspiration Prevention;413
24.1.7.3; III. Anesthetic Care for Labor and Vaginal Delivery;414
24.1.7.4; IV. Removal of Retained Placenta;422
24.1.7.5; V. Anesthetic Choices for Cesarean Delivery;423
24.1.7.6; VI. Postpartum Tubal Ligation;426
24.1.7.7; VII. Management of Obstetric and Anesthetic Emergencies;427
24.1.7.8; VIII. Perianesthetic Evaluation;430
24.1.7.9; IX. Aspiration Prophylaxis;431
24.1.7.10; X. Anesthetic Care for Labor and Delivery;432
24.1.7.11; XI. Removal of Retained Placenta;434
24.1.7.12; XII. Anesthetic Choices for Cesarean Delivery;434
24.1.7.13; XIII. Postpartum Tubal Ligation;436
24.1.7.14; XIV. Management of Obstetric and Anesthetic Emergencies;436
24.2;19.2 Methods and Analyses;437
24.3;19.3 References;443
25;Appendix C: Optimal Goals for Anesthesia Care in Obstetrics;445
25.1;19.1 References;449
26;Index;450