Use of Labor Neuraxial Analgesia for Vaginal Delivery and Severe Maternal Morbidity

Role of lumbar puncture level on the onset of epidural labor analgesia: a randomized controlled trial

OBJECTIVE

To compare the speed of achieving painless uterine contractions in parturients undergoing epidural analgesia at different lumbar puncture levels.

METHODS

This study is a randomized controlled trial at a tertiary A hospital with a history of over 80 years in Sichuan Province, China. Parturients aged 22-40 years old scheduled for vaginal delivery under epidural analgesia were recruited. Eligible patients were randomly allocated into lumbar 2-3 (L2-3) or lumbar 3-4 (L3-4) groups. Epidural analgesia was performed through the interspaces according to grouping. The primary outcome was the percentage of painless uterine contractions 15 min after the initiation of analgesia. The secondary outcomes included the percentage of painless status at 5 and 10 min, sensory block plane, motor block evaluation, adverse events of parturients, epidural analgesic consumption, Apgar score, and the parturients' evaluation of analgesia.

RESULTS

Between April 2023 and August 2023, a total of 150 women were finally recruited, and 136 of them were analyzed (68 in each group). In comparison with the L3-4 groups, there was a significantly larger proportion of painless uterine contractions at 5, 10, and 15 min after analgesia initiation in the L2-3 group (20.6% vs. 7.4%, 52.9% vs. 26.5%, and 80.9% vs. 64.7%, P = .026, .002, and .034, respectively). Similarly, the pain scores were lower in the L2-3 group at 5, 10, and 15 min than that in the L3-4 group (5(4,7) vs. 6(5,7), 3(2,5) vs. 4(3,6), and 2(1,3) vs. 3(2,5), P = .006, .004, and .020, respectively). Furthermore, puncturing through the L2-3 interspace contributed to a higher evaluation of parturients to the analgesia procedure (9(8,9) vs. 8(8,9), P < .001). However, there was no significant difference in sensory block, motor block, or adverse events between the two groups.

CONCLUSION

Puncturing through the L2-3 interspace is associated with faster pain relief and a better experience for parturients. These findings present a superior option for anesthesiologists when conducting epidural labor analgesia. Key messages What is already known on this topic?  Epidural analgesia is an effective way to relieve labor pain. What this study adds?  Puncturing via lumbar 2-3 interspace induces more rapid onset of epidural analgesia. How this study might affect research, practice or policy?  Lumbar 2-3 interspace is a superior option in terms of the speed of pain relief and satisfaction of parturients when conducting epidural labor analgesia.

Factors affecting womens' attitude towards labor epidural analgesia in a culturally diverse population: a prospective patient-reported outcome study

BACKGROUND

To evaluate pregnant women's intentions to deliver with labor epidural analgesia (LEA) and identify factors influencing decision-making in a diverse population in northern Israel.

METHODS

A cross-sectional survey was conducted at Galilee Medical Center from February to July 2024. Women completed pre- and post-labor questionnaires assessing demographics, religiosity, prior experience, prenatal education, attitude towards LEA, reasons for not intending to deliver with and actual LEA use. Statistical analysis included multivariate logistic regression.

RESULTS

The LEA rate among participants was 83.5% (380/455) (83.5%); 257 (56.5%) had indented to deliver with. Among those not intending to deliver with LEA, 66.7% (132/198) eventually delivered with. There were 297 (65.3%) Arab and 158 (34.7%) Jewish women; 180 (39.6%) identified as Muslim, 158 (34.7%) Jewish, 92 (20.2%) Druze, and 25 (5.5%) Christian. Factors associated with intention to deliver with LEA were nulliparity (P =0.024), childbirth preparation course (P =0.002), internet as source of information (P =0.016), and previous delivery with LEA (P <0.001). Factors associated with not intending to deliver with but ultimately delivering with LEA were nulliparity (P =0.033), partner presence (P <0.001), labor induction (P =0.044), and previous delivery with LEA (P <0.001).

CONCLUSION

Attitudes toward LEA are shaped by culture, knowledge, prior experiences, and social support. In our cohort, the most important factors for delivering with LEA when not intending to were previous delivery with LEA and partner presence. Factors associated with not delivering with LEA were preference for natural childbirth and fear of LEA-associated side effects. Promoting evidence-based information through language-adapted platforms can further improve informed decision-making about LEA.

Effect of Anesthesia During Pregnancy, Delivery, and Childhood on Autism Spectrum Disorder: A Systematic Review and Meta-analysis

To investigate the association between exposure to anesthesia during three periods of pregnancy, delivery, and childhood and autism spectrum disorder (ASD). PubMed, Scopus, Web of Science, Embase, Google Scholar, PsycArticles, and PsycINFO were searched from the date of database inception to 1 December 2022. Studies reported the association between exposure to anesthesia during pregnancy, delivery, and childhood and ASD were included. Extracted variables included hazard ratio (HR), relative risk or odds ratio, standard error, and 95% confidence interval (CI). Effect estimates were pooled using random-effects meta-analysis. In total, 16 studies including 8,156,608 individuals were included in the meta-analysis. Labor epidural anesthesia during delivery was associated with ASD in the general population (adjusted HR = 1.16, 95% CI, 1.06-1.28) but not in the sibling population (adjusted HR = 1.06, 95% CI, 0.98-1.15). Other anesthesia during delivery was not associated with ASD (general population: adjusted HR = 1.08, 95% CI, 0.99-1.17; sibling population: adjusted HR = 1.20, 95% CI, 0.81-1.79). Three studies suggested that exposure to anesthesia during pregnancy was associated with ASD in offspring (adjusted HR = 2.15, 95% CI, 1.32-3.48). There was no significant association between exposure to general anesthesia during childhood and ASD (adjusted HR = 1.02, 95% CI, 0.60-1.72). This meta-analysis did not confirm the association between exposure to anesthesia during labour and ASD. Previous observational studies used the neurotoxicity of anesthesia to biologically explain significant associations, but in fact different controls for confounding factors led to differences in associations. The evidence for pregnancy and childhood was limited given the small number of studies in these periods.

Prevalence of prescription and effectiveness of analgesia for treating vaginal delivery pain

OBJECTIVES

to assess pain management during labor.

METHODS

a cross-sectional study was carried out by reviewing medical records and conducting postpartum interviews. Prevalence and effectiveness of analgesia were assessed.

RESULTS

the prevalence of non-pharmacological analgesia was 61.86% of 215 women in labor in Obstetric Center and 82.51% of 62 in midwife-led unit. Prevalence of severe pain, on the Visual Analogue Scale, before and after non-pharmacological analgesia, was from 92.16% to 64.04% (p=0.00) in Obstetric Center and from 85.96% to 52.63% (p=0.01) in midwife-led unit. Prevalence of pharmacological analgesia in Obstetric Centers was 15.81%, with no variation in severe pain (p=0.57). Patients' request for analgesia was associated with education (p=0.00) and pain intensity (p=0.02).

CONCLUSIONS

non-pharmacological analgesia improved pain intensity. Prevalence of pharmacological analgesic prescription was lower than that identified in developed countries. Pain management needs to consider the preferences and needs of women in labor.

Patients' perspectives on pain relief during childbirth and labor epidurals: A pilot qualitative study among women who chose to deliver without neuraxial labor analgesia

BACKGROUND

Studies have identified widespread variation in neuraxial labor analgesia use by race, ethnicity, and geographic location. However, limited research has investigated patient-level factors in the decision not to use neuraxial analgesia for labor.

METHODS

We conducted semi-structured interviews at a New York City medical center from October 1, 2022, to May 30, 2023. Participants had delivered vaginally and selected not to receive neuraxial labor analgesia. Structured demographic questions were asked after interview completion. Interviews were recorded and transcribed verbatim. We analyzed data and grouped responses into themes according to grounded theory.

RESULTS

We identified five themes encompassing the main factors participants had considered when deciding not to receive neuraxial analgesia for birth: preferences for a natural birth experience, an empowering and supportive labor environment, preparation or preparedness for birth without medication, positive outlook on labor pain, and information, misinformation, knowledge gaps and fears about the epidural. All study participants mentioned these overarching themes in their interviews.

CONCLUSIONS

Participants described various factors important in their decision to give birth without an epidural, which we mapped onto five primary themes. Our results can be used to guide effective patient-provider interactions centered on mutual understanding, evidence-based medicine, and honoring patients' wishes. The information gathered may provide insight into how providers can incorporate shared decision-making into their practice.

Development and validation of a nomogram for predicting postpartum hemorrhage in women with preeclampsia: A retrospective case-control study

This retrospective case-control study aimed to develop a nomogram for predicting postpartum hemorrhage in women with preeclampsia. This study was carried out at the Fujian Maternity and Child Health Hospital, involving 542 preeclampsia patients who underwent vaginal deliveries. The participants were split into 2 groups: a training cohort (85%, n = 460) and a validation cohort (15%, n = 82). Least absolute shrinkage and selection operator regression was applied to pinpoint relevant risk factors by selecting appropriate candidate variables. Subsequently, multivariate logistic regression analysis was conducted on the training set, leading to the creation of a nomogram as a visual risk prediction tool. The model's performance was tested and verified internally and externally by examining receiver operating characteristic curves and calibration curves. The correlation heatmap revealed collinearity among variables, necessitating the use of least absolute shrinkage and selection operator regression to select 4 candidate variables. Multivariate logistic regression analysis identified significant associations with the following outcomes: white blood cell count (odds ratio [OR]: 2.485, 95% confidence interval [CI]: 1.483-4.166), third stage of labor (OR: 1.382, 95% CI: 1.182-1.616), anemia (OR: 9.588, 95% CI: 4.022-22.854), and labor analgesia (OR: 0.187, 95% CI: 0.073-0.477). These variables were utilized to construct the nomogram. The receiver operating characteristic curves demonstrated good predictive performance (area under the curve train = 0.867, area under the curve test = 0.882), and the calibration curve yielded a C-index of 0.867. The nomogram created in this study has good sensitivity and specificity to assess risk and support clinical decision-making for postpartum hemorrhage in women with preeclampsia.

Epidural analgesia in labour: separating fact from fiction for autism and neurodevelopment

Having epidural analgesia in labour has been associated with a later diagnosis of autism spectrum disorder in the offspring, resulting in concerns about childhood wellbeing. Neurodevelopmental changes are inconsistently reported in the literature, creating challenges in the interpretation of these findings. Here we explore the limitations of the current evidence base, and why findings differ between studies, concluding that the current body of evidence does not support a causal association between use of epidural analgesia in labour and autism spectrum disorder.

Behavioural and neuropsychological outcomes in children exposed in utero to maternal labour epidural analgesia

BACKGROUND

Recent studies report conflicting results regarding the relationship between labour epidural analgesia (LEA) in mothers and neurodevelopmental disorders in their offspring. We evaluated behavioural and neuropsychological test scores in children of mothers who used LEA.

METHODS

Children enrolled in the Raine Study from Western Australia and delivered vaginally from a singleton pregnancy between 1989 and 1992 were evaluated. Children exposed to LEA were compared with unexposed children. The primary outcome was the parent-reported Child Behaviour Checklist (CBCL) reporting total, internalising, and externalising behavioural problem scores at age 10 yr. Score differences, an increased risk of clinical deficit, and a dose-response based on the duration of LEA exposure were assessed. Secondary outcomes included language, motor function, cognition, and autistic traits.

RESULTS

Of 2180 children, 850 (39.0%) were exposed to LEA. After adjustment for covariates, exposed children had minimally increased CBCL total scores (+1.41 points; 95% confidence interval [CI] 0.09 to 2.73; P=0.037), but not internalising (+1.13 points; 95% CI -0.08 to 2.34; P=0.066) or externalising (+1.08 points; 95% CI -0.08 to 2.24; P=0.068) subscale subscores. Increased risk of clinical deficit was not observed for any CBCL score. For secondary outcomes, score differences were inconsistently observed in motor function and cognition. Increased exposure duration was not associated with worse scores in any outcomes.

CONCLUSIONS

Although LEA exposure was associated with slightly higher total behavioural scores, there was no difference in subscores, increased risk of clinical deficits, or dose-response relationship. These results argue against LEA exposure being associated with consistent, clinically significant neurodevelopmental deficits in children.

Long-term effects of neuraxial analgesia

PURPOSE OF REVIEW

This review article explores the potential longer-term implications of neuraxial analgesia in labour for both the mother and her child.

RECENT FINDINGS

Neuraxial techniques for labour analgesia are well tolerated and effective, and long-term adverse sequelae are rare. Labour epidural analgesia is not independently associated with long-term headache, backache, postnatal depression or anal sphincter injury, and evidence supports that epidurals may offer protection against severe maternal morbidity, particularly in women at a higher risk of complications. However, there is an increasing awareness that postdural puncture headache may be associated with chronic headache, back pain and postnatal depression, emphasizing the need for adequate follow-up until symptoms resolve.For the neonate, a growing body of evidence refutes any association between epidural analgesia in labour and the later development of autism spectrum disorder. The clinical significance of epidural related maternal fever remains uncertain and is a research priority.

SUMMARY

Women should continue to access the significant benefits of neuraxial analgesia in labour without undue concern about adverse sequelae for themselves or their offspring. Measures to prevent, appropriately manage and adequately follow-up women who have suffered complications of neuraxial analgesia, such as postdural puncture headache, are good practice and can mitigate the development of long-term sequelae.

Variation in Hospital Neuraxial Labor Analgesia Rates in California

BACKGROUND

Neuraxial analgesia provides effective pain relief during labor. However, it is unclear whether neuraxial analgesia prevalence differs across U.S. hospitals. The aim of this study was to assess hospital variation in neuraxial analgesia prevalence in California.

METHODS

A retrospective cross-sectional study analyzed birthing patients who underwent labor in 200 California hospitals from 2016 to 2020. The primary exposure was the delivery hospital. The outcomes were hospital neuraxial analgesia prevalence and between-hospital variability, before and after adjustment for patient and hospital factors. Median odds ratio and intraclass correlation coefficients quantified between-hospital variability. The median odds ratio estimated the odds of a patient receiving neuraxial analgesia when moving between hospitals. The intraclass correlation coefficients quantified the proportion of the total variance in neuraxial analgesia use due to variation between hospitals.

RESULTS

Among 1,510,750 patients who underwent labor, 1,040,483 (68.9%) received neuraxial analgesia. Both unadjusted and adjusted hospital prevalence exhibited a skewed distribution characterized by a long left tail. The unadjusted and adjusted prevalences were 5.4% and 6.0% at the 1st percentile, 21.0% and 21.2% at the 5th percentile, 70.6% and 70.7% at the 50th percentile, 75.8% and 76.6% at the 95th percentile, and 75.9% and 78.6% at the 99th percentile, respectively. The adjusted median odds ratio (2.3; 95% CI, 2.1 to 2.5) indicated substantially increased odds of a patient receiving neuraxial analgesia if they moved from a hospital with a lower odds of neuraxial analgesia to one with higher odds. The hospital explained only a moderate portion of the overall variability in neuraxial analgesia (intraclass correlation coefficient, 19.1%; 95% CI, 18.8 to 20.5%).

CONCLUSIONS

A long left tail in the distribution and wide variation exist in the neuraxial analgesia prevalence across California hospitals that is not explained by patient and hospital factors. Addressing the low prevalence among hospitals in the left tail requires exploration of the interplay between patient preferences, staffing availability, and care providers' attitudes toward neuraxial analgesia.

EDITOR’S PERSPECTIVE

Epidural analgesia during labour and severe maternal morbidity: population based study

OBJECTIVES

To determine the effect of labour epidural on severe maternal morbidity (SMM) and to explore whether this effect might be greater in women with a medical indication for epidural analgesia during labour, or with preterm labour.

DESIGN

Population based study.

SETTING

All NHS hospitals in Scotland.

PARTICIPANTS

567 216 women in labour at 24+0 to 42+6 weeks' gestation between 1 January 2007 and 31 December 2019, delivering vaginally or through unplanned caesarean section.

MAIN OUTCOME MEASURES

The primary outcome was SMM, defined as the presence of ≥1 of 21 conditions used by the US Centers for Disease Control and Prevention (CDC) as criteria for SMM, or a critical care admission, with either occurring at any point from date of delivery to 42 days post partum (described as SMM). Secondary outcomes included a composite of ≥1 of the 21 CDC conditions and critical care admission (SMM plus critical care admission), and respiratory morbidity.

RESULTS

Of the 567 216 women, 125 024 (22.0%) had epidural analgesia during labour. SMM occurred in 2412 women (4.3 per 1000 births, 95% confidence interval (CI) 4.1 to 4.4). Epidural analgesia was associated with a reduction in SMM (adjusted relative risk 0.65, 95% CI 0.50 to 0.85), SMM plus critical care admission (0.46, 0.29 to 0.73), and respiratory morbidity (0.42, 0.16 to 1.15), although the last of these was underpowered and had wide confidence intervals. Greater risk reductions in SMM were detected among women with a medical indication for epidural analgesia (0.50, 0.34 to 0.72) compared with those with no such indication (0.67, 0.43 to 1.03; P<0.001 for difference). More marked reductions in SMM were seen in women delivering preterm (0.53, 0.37 to 0.76) compared with those delivering at term or post term (1.09, 0.98 to 1.21; P<0.001 for difference). The observed reduced risk of SMM with epidural analgesia was increasingly noticeable as gestational age at birth decreased in the whole cohort, and in women with a medical indication for epidural analgesia.

CONCLUSION

Epidural analgesia during labour was associated with a 35% reduction in SMM, and showed a more pronounced effect in women with medical indications for epidural analgesia and with preterm births. Expanding access to epidural analgesia for all women during labour, and particularly for those at greatest risk, could improve maternal health.

Socio-economic disadvantage and utilisation of labour epidural analgesia in Scotland: a population-based study†

Socio-economic deprivation is associated with adverse maternal and childhood outcomes. Epidural analgesia, the gold standard for labour analgesia, may improve maternal well-being. We assessed the association of socio-economic status with utilisation of epidural analgesia and whether this differed when epidural analgesia was advisable for maternal safety. This was a population-based study of NHS data for all women in labour in Scotland between 1 January 2007 and 23 October 2020, excluding elective caesarean sections. Socio-economic status deciles were defined using the Scottish Index of Multiple Deprivation. Medical conditions for which epidural analgesia is advisable for maternal safety (medical indications) and contraindications were defined according to national guidelines. Of 593,230 patients in labour, 131,521 (22.2%) received epidural analgesia. Those from the most deprived areas were 16% less likely to receive epidural analgesia than the most affluent (relative risk 0.84 [95%CI 0.82-0.85]), with the inter-decile mean change in receiving epidural analgesia estimated at -2% ([95%CI -2.2% to -1.7%]). Among the 21,219 deliveries with a documented medical indication for epidural analgesia, the socio-economic gradient persisted (relative risk 0.79 [95%CI 0.75-0.84], inter-decile mean change in receiving epidural analgesia -2.5% [95%CI -3.1% to -2.0%]). Women in the most deprived areas with a medical indication for epidural analgesia were still less likely (absolute risk 0.23 [95%CI 0.22-0.24]) to receive epidural analgesia than women from the most advantaged decile without a medical indication (absolute risk 0.25 [95%CI 0.24-0.25]). Socio-economic deprivation is associated with lower utilisation of epidural analgesia, even when epidural analgesia is advisable for maternal safety. Ensuring equitable access to an intervention that alleviates pain and potentially reduces adverse outcomes is crucial.

Structural Racism and Use of Labor Neuraxial Analgesia Among Non-Hispanic Black Birthing People

OBJECTIVE

To assess the association between structural racism and labor neuraxial analgesia use.

METHODS

This cross-sectional study analyzed 2017 U.S. natality data for non-Hispanic Black and White birthing people. The exposure was a multidimensional structural racism index measured in the county of the delivery hospital. It was calculated as the mean of three Black-White inequity ratios (ratios for lower education, unemployment, and incarceration in jails) and categorized into terciles, with the third tercile corresponding to high structural racism. The outcome was the labor neuraxial analgesia rate. Adjusted odds ratios and 95% CIs of neuraxial analgesia associated with terciles of the index were estimated with multivariate logistic regression models. Black and White people were compared with the use of an interaction term between race and ethnicity and the racism index.

RESULTS

Of the 1,740,716 birth certificates analyzed, 396,303 (22.8%) were for Black people. The labor neuraxial analgesia rate was 77.2% for Black people in the first tercile of the racism index, 74.7% in the second tercile, and 72.4% in the third tercile. For White people, the rates were 80.4%, 78.2%, and 78.2%, respectively. For Black people, compared with the first tercile of the racism index, the second tercile was associated with 18.4% (95% CI, 16.9-19.9%) decreased adjusted odds of receiving neuraxial analgesia and the third tercile with 28.3% (95% CI, 26.9-29.6%) decreased adjusted odds. For White people, the decreases were 13.4% (95% CI, 12.5-14.4%) in the second tercile and 15.6% (95% CI, 14.7-16.5%) in the third tercile. A significant difference in the odds of neuraxial analgesia was observed between Black and White people for the second and third terciles.

CONCLUSION

A multidimensional index of structural racism is associated with significantly reduced odds of receiving labor neuraxial analgesia among Black people and, to a lesser extent, White people.

Racial and Ethnic Disparities in Receipt of General Anesthesia for Cesarean Delivery

Importance

General anesthesia for cesarean delivery is associated with increased maternal morbidity, and Black and Hispanic pregnant patients have higher rates of general anesthesia use compared with their non-Hispanic White counterparts. It is unknown whether risk factors and indications for general anesthesia differ among patients of differing race and ethnicity.

Objective

To evaluate differences in general anesthesia use for cesarean delivery and the indication for the general anesthetic by race and ethnicity.

Design, Setting, and Participants

In this retrospective, cross-sectional, single-center study, electronic medical records for all 35 117 patients who underwent cesarean delivery at Northwestern Medicine's Prentice Women's Hospital from January 1, 2007, to March 2, 2018, were queried for maternal demographics, clinical characteristics, obstetric and anesthetic data, the indication for cesarean delivery, and the indication for general anesthesia when used. Data analysis occurred in August 2023.

Exposure

Cesarean delivery.

Main Outcomes and Measures

The rate of general anesthesia for cesarean delivery by race and ethnicity.

Results

Of the 35 117 patients (median age, 33 years [IQR, 30-36 years]) who underwent cesarean delivery, 1147 (3.3%) received general anesthesia; the rates of general anesthesia were 2.5% for Asian patients (61 of 2422), 5.0% for Black patients (194 of 3895), 3.7% for Hispanic patients (197 of 5305), 2.8% for non-Hispanic White patients (542 of 19 479), and 3.8% (153 of 4016) for all other groups (including those who declined to provide race and ethnicity information) (P < .001). A total of 19 933 pregnant patients (56.8%) were in labor at the time of their cesarean delivery. Of those, 16 363 (82.1%) had neuraxial labor analgesia in situ. Among those who had an epidural catheter in situ, there were no racial or ethnic differences in the rates of general anesthesia use vs neuraxial analgesia use (Asian patients, 34 of 503 [6.8%] vs 1289 of 15 860 [8.1%]; Black patients, 78 of 503 [15.5%] vs 1925 of 15 860 [12.1%]; Hispanic patients, 80 of 503 [15.9%] vs 2415 of 15 860 [15.2%]; non-Hispanic White patients, 255 of 503 [50.7%] vs 8285 of 15 860 [52.2%]; and patients of other race or ethnicity, 56 of 503 [11.1%] vs 1946 of 15 860 [12.3%]; P = .16). Indications for cesarean delivery and for general anesthesia were not different when stratified by race and ethnicity.

Conclusions and Relevance

Racial disparities in rates of general anesthesia continue to exist; however, this study suggests that, for laboring patients who had labor epidural catheters in situ, no disparity by race or ethnicity existed. Future studies should address whether disparities in care that occur prior to neuraxial catheter placement are associated with higher rates of general anesthesia among patients from ethnic and racial minority groups.

Effects of early- and late- neuraxial analgesia on multiparous women: a retrospective monocentric study

BACKGROUND

The mechanism underlying maternal fever and prolonged labor progression associated with neuraxial analgesia (NA) remains elusive, raising concerns among certain pregnant women regarding the application of NA during vaginal delivery. This study aimed to investigate the impact of early and late NA on maternal and neonatal outcomes in multiparous women.

METHODS

This retrospective study collected data from 1119 multiparous women with singleton pregnancies, full term and live births at our labor and delivery center between August 1st, 2021 and July 31st, 2022. Based on the timing of NA initiation, participants were categorized into three groups: no-NA, early-NA and late-NA. The no-NA group comprised of 172 women who did not receive NA during vaginal delivery; the early-NA group included 603 women in which NA was initiated when cervical dilation was between 0.5 and 2.0 cm; and the late-NA group comprising 344 cases in which NA was initiated at the cervical dilation of ≥ 2 cm. Maternal and neonatal outcomes were observed, including durations of the first, second, third and total stage of labor, the rate of intrapartum cesarean delivery (CD), intrapartum fever, postpartum hemorrhage (PPH), transfer to intensive care unit (ICU), admission to the neonatal intensive care unit (NICU), meconium-stained amniotic fluid, and neonatal Apgar scores at 1 and 5 min.

RESULTS

No differences were noted in the maternal age, body mass index (BMI) on admission, gestations, parity, gestational weeks at delivery and neonatal birth weight, or the rate of gestational diabetes mellitus (GDM) and hypertension disorder did not significantly differ among the three groups (p > 0.05). The no-NA group had shorter durations of first stage, second stage of labor compared to the early-NA or late-NA group (median, 215.0 min and 10.0 min vs. 300.0 min and 12.0 min vs. 280.0 min and 13.0 min) (p < 0.05), but no differences were observed between the early-NA and late-NA group (p > 0.05). There were no differences in the rate of intrapartum CD, intrapartum fever, PPH, maternal transferred to ICU, neonatal transfer to NICU, meconium-stained amniotic fluid, and postpartum stay ≥ 7d, as well as the neonatal the Apgar scores at 1 and 5 min among the three groups (p > 0.05).

CONCLUSION

NA is associated with extended durations of the first, second and total stages of labor. However, the early initiation of NA in multiparous women (cervical dilation within 0.5-2.0 cm) does not increase the risk of intrapartum CD or intrapartum fever. These findings endorse the secure utilization of early NA for pain relief during labor in multiparous women.

Association of Labor Neuraxial Analgesia with Maternal Blood Transfusion

BACKGROUND

Labor neuraxial analgesia may reduce the odds of postpartum hemorrhage, the leading indication for maternal blood transfusion during childbirth. This study tested the hypothesis that labor neuraxial analgesia is associated with reduced odds of maternal blood transfusion overall.

METHODS

U.S. birth certificate data in the Natality File of the National Vital Statistics System for all 50 states from 2015 to 2018 for vaginal and intrapartum cesarean deliveries were analyzed. The exposure was labor neuraxial analgesia. The primary outcome was maternal blood transfusion, recorded on the birth certificate, which has low sensitivity for this outcome. Adjusted odds ratios and 95% CIs of blood transfusion associated with neuraxial analgesia were estimated using propensity score matching. The adjusted odds ratios were estimated overall and according to delivery mode, and treatment effect was compared between vaginal and intrapartum cesarean deliveries using an interaction term. Sensitivity analyses were performed using inverse propensity score weighting and quantitative bias analysis for outcome misclassification.

RESULTS

Of the 12,503,042 deliveries analyzed, 9,479,291 (75.82%) were with neuraxial analgesia, and 42,485 (0.34%) involved maternal blood transfusion. After propensity score matching, the incidence of blood transfusion was 0.30% in women without neuraxial analgesia (7,907 of 2,589,493) and 0.20% in women with neuraxial analgesia (5,225 of 2,589,493), yielding an adjusted odds ratio of 0.87 (95% CI, 0.82 to 0.91) overall. For intrapartum cesarean deliveries, the adjusted odds ratio was 0.55 (95% CI, 0.48 to 0.64), and for vaginal deliveries it was 0.93 (95% CI,. 0.88 to 0.98; P value for the interaction term < 0.001). The results were consistent in the sensitivity analyses, although the quantitative bias analysis demonstrated wide variation in potential effect size point estimates.

CONCLUSIONS

Labor neuraxial analgesia may be associated with reduced odds of maternal blood transfusion in intrapartum cesarean deliveries and, to a lesser extent, vaginal deliveries. The specific effect size varies widely by delivery mode and is unclear given the poor sensitivity of the data set for the maternal transfusion primary outcome.

EDITOR’S PERSPECTIVE

United States rural residence is associated with increased acute maternal end-organ injury or mortality after birth: a retrospective multi-state analysis, 2007-2018

BACKGROUND

Geographic-based healthcare determinants and choice of anesthesia have been shown to be associated with maternal morbidity and mortality. We explored whether differences in maternal outcomes based on maternal residence, and anesthesia type for cesarean and vaginal birth, exist.

METHODS

This study was a retrospective multi-state analysis; patient residence was the predictor variable of interest and a composite binary measure of maternal end-organ injury or inpatient mortality was the primary outcome. Our secondary outcomes included a binary measure of anesthesia type for cesarean birth (general vs. neuraxial [NA]) and NA analgesia for vaginal birth (no NA vs. NA). Our predictor variable of interest was patient residency (reference category central metropolitan areas of >1 million population), fringe large metropolitan county, medium metropolitan, small metropolitan, micropolitan, and non-metropolitan or micropolitan county.

RESULTS

Women residing in micropolitan (OR 1.17; 95% CI 1.09 to 1.27) and non-metropolitan or micropolitan counties (OR 1.14; 95% CI 1.04 to 1.24) had the highest adjusted increased odds of adverse maternal outcomes. Those residing in suburban, medium, and small metropolitan areas underwent general anesthesia less often during cesarean births than those residing in urban areas. Patients residing in micropolitan rural (OR 2.07; 95% CI 2.02 to 2.12) and non-metropolitan or micropolitan (2.25; 95% CI 2.16 to 2.34) counties underwent vaginal births without NA analgesia more than twice as often as those residing in urban areas.

CONCLUSIONS

Rural-urban disparities in maternal end-organ damage and mortality exist and anesthesia choice may play an important role in these disparate outcomes.

Association of the United States Affordable Care Act Dependent Coverage Provision with Labor Neuraxial Analgesia Use

BACKGROUND

Providing continuous health insurance coverage during the perinatal period may increase access to and utilization of labor neuraxial analgesia. This study tested the hypothesis that implementation of the 2010 Dependent Coverage Provision of the Patient Protection and Affordable Care Act, requiring private health insurers to allow young adults to remain on their parent's plan until age 26 yr, was associated with increased labor neuraxial analgesia use.

METHODS

This study used a natural experiment design and birth certificate data for spontaneous vaginal deliveries in 28 U.S. states between 2009 and 2013. The intervention was the Dependent Coverage Provision, categorized into pre- and postintervention periods (January 2009 to August 2010 and September 2010 to December 2013, respectively). The exposure was women's age, categorized as exposed (21 to 25 yr) and unexposed (27 to 31 yr). The outcome was the labor neuraxial analgesia utilization rate.

RESULTS

Of the 4,515,667 birth certificates analyzed, 3,033,129 (67.2%) indicated labor neuraxial analgesia use. For women aged 21 to 25 yr, labor neuraxial analgesia utilization rates were 64.9% during the preintervention period and 68.9% during the postintervention period (difference, 4.0%; 95% CI, 3.9 to 4.2). For women aged 27 to 31 yr, labor neuraxial analgesia utilization rates were 64.9% during the preintervention period and 67.7% during the postintervention period (difference, 2.8%; 95% CI, 2.7 to 2.9). After adjustment, implementation of the Dependent Coverage Provision was associated with a 1.0% (95% CI, 0.8 to 1.2) absolute increase in labor neuraxial analgesia utilization rate among women aged 21 to 25 yr compared with women aged 27 to 31 yr. The increase was statistically significant for White and Hispanic women but not for Black and Other race and ethnicity women.

CONCLUSIONS

Implementation of the Dependent Coverage Provision was associated with a statistically significant increase in labor neuraxial analgesia use, but the small effect size is unlikely of clinical significance.

EDITOR’S PERSPECTIVE

Review of racial/ethnic disparities in obstetrics-related anesthesia administration and pain management

While racial/ethnic disparities in maternal outcomes including mortality and severe maternal morbidity are well documented, there is limited information on disparities in obstetric anesthesia practices. This paper reviews literature on racial/ethnic disparities in peripartum anesthesia administration and postpartum pain management. Current literature demonstrates racial/ethnic disparities in several aspects of obstetric anesthesia care including neuraxial administration for vaginal labor pain, neuraxial versus general anesthesia for cesarean delivery, post neuraxial anesthesia complications, postpartum pain management and postdural puncture headache treatment practices. However, many studies are dated or have limited data from single institutions or states. More research on nation-wide racial/ethnic disparities in obstetric anesthesia is needed to understand its broader practice and management in the USA.

Visual estimation of blood loss versus quantitative blood loss for maternal outcomes related to obstetrical hemorrhage

Background

This study was undertaken to evaluate if there are differences between visual estimation of blood loss (EBL) and quantitative blood loss (QBL) for maternal outcomes related to obstetrical hemorrhage.

Methods

This retrospective study compared EBL (n = 500) to QBL (n = 501) for outcomes of length of stay, readmission within 30 days of discharge, percent receiving blood transfusions, time between delivery to receiving blood transfusion, and postpartum hemoglobin level.

Results

The QBL group had a significantly lower mean length of stay than the EBL group (2.6 vs 3.2 days, P < 0.001). Multivariate linear regression analysis adjusting for relevant covariates had a similar finding of lower length of stay for QBL vs EBL (B = -0.13, SE = 0.01, P < 0.001). Readmission within 30 days, blood transfusion, time to transfusion since delivery, and postpartum hemoglobin did not significantly differ between the QBL and EBL groups.

Conclusion

We recommend that clinicians adopt QBL over EBL as standard practice since QBL is associated with lower length of stay and does not negatively impact other clinical outcomes.

Association of General Anesthesia and Neuraxial Anesthesia in Caesarean Section with Maternal Postpartum Depression: A Retrospective Nationwide Population-Based Cohort Study

Although cesarean section (CS) has become a common method of child delivery in recent decades, the choice between general anesthesia (GA) and neuraxial anesthesia (NA) for CS must be carefully considered. Depending on the type of anesthesia used in CS, a major outcome observed is the occurrence of postpartum depression (PPD). This study investigated the association between PPD risk and the anesthesia method used in CS by using data from three linked nationwide databases in Taiwan, namely, the National Health Insurance Research Database, the National Birth Reporting Database, and the National Death Index Database. After propensity score matching by baseline depressive disorders, maternal demographics, status at delivery, infant’s health, maternal diseases during pregnancy, and age of partner, we included women who had natural births (n = 15,706), cesarean sections with GA (n = 15,706), and cesarean sections with NA (n = 15,706). A conditional logistic regression was used to estimate the odds ratios and 95% confidence intervals (CIs) of PPDs, including depression, sleep disorder, and medication with hypnotics or antidepressants, under anesthesia during CS. The prevalence rates of combined PPDs were 26.66%, 43.87%, and 36.30% in natural births, CS with GA, and CS with NA, respectively. In particular, the proportions of postpartum use of hypnotic drugs or antidepressants were 21.70%, 39.77%, and 31.84%, which were significantly different. The aORs (95% CIs) were 2.15 (2.05–2.25) for the included depressive disorders, 1.10 (1.00–1.21) for depression, 1.03 (0.96–1.11) for sleep disorder, and 2.38 (2.27–2.50) for medication with hypnotics or antidepressants in CS with GA compared with natural births. Women who underwent CS with GA had a significantly higher risk of depressive disorders and a higher need for antidepressants for sleep problems than those who underwent CS with NA. The risks of PPD were significantly associated with the anesthesia method, especially GA. Our results can assist physicians in carefully considering the appropriate anesthesia method for CS delivery, particularly with regard to postpartum drug abuse and drug safety.