Predictors of incomplete maternal satisfaction with neuraxial labor analgesia: A nationwide study

Nebulized dexmedetomidine in the treatment of obstetric post-dural puncture headache: two case reports

Post-dural puncture headache (PDPH) is a debilitating complication of neuraxial anesthesia, particularly prevalent in obstetric patients, usually characterized by a postural headache. PDPH is hypothesized to result from cerebrospinal fluid leakage through a dural puncture, triggering symptoms like neck stiffness and subjective hearing changes. While conservative measures are common for treatment, more refractory cases may require invasive interventions such as an epidural blood patch (EBP). Recent studies have shown promise in using nebulized dexmedetomidine (nDEX) for PDPH, offering a non-invasive alternative to EBP. Two case presentations illustrate the efficacy of nDEX in resolving PDPH symptoms rapidly and completely. These cases underscore the need for exploring novel therapeutic options, especially in obstetric patients where safe and prompt relief is essential for maternal and newborn well-being. While the EBP remains the gold standard, its limitations of accessibility and invasiveness highlight the significance of investigating alternatives like nDEX.

Prevalence and risk factors of maternal dissatisfaction after vaginal delivery: A multicenter prospective study

OBJECTIVE

To evaluate the prevalence and risk factors of maternal dissatisfaction 2 days after a singleton vaginal delivery at or near term.

METHODS

We conducted a planned ancillary cohort study of the TRanexamic Acid for Preventing Postpartum Hemorrhage After Vaginal Delivery (TRAAP) randomized controlled trial. Maternal dissatisfaction, related to the birth and to the subsequent hospital stay, was assessed 2 days postpartum by two self-administered questions: "Are you satisfied with the care you received during your child's birth?" and "Are you satisfied with the care you have received during your hospital stay?". Satisfaction was defined by answers of "extremely satisfied" or "very satisfied," and dissatisfaction by the responses "moderately satisfied," "not very satisfied," or "not at all satisfied". Their association with maternal dissatisfaction was analyzed by random-effects logistic regression.

RESULTS

The prevalence of maternal dissatisfaction with the birth was 2.9%, and with the hospital stay 9.5%. Characteristics associated with a higher risk of maternal dissatisfaction with the birth were labor exceeding 6 h, bad memories of the birth and, only for women without complicated deliveries, manual examination of the uterine cavity. The only characteristic associated with a higher risk of dissatisfaction with the hospital stay was non-French nationality. None of the postpartum hemorrhage, third- or fourth-degree perineal lacerations, operative vaginal delivery, episiotomy and uterine massage were associated with a higher risk of maternal dissatisfaction.

CONCLUSION

Maternal dissatisfaction was low after singleton vaginal deliveries at or near term. Strategies aiming to avoid labor longer than 6 h and manual examination of the uterine cavity may decrease maternal dissatisfaction after delivery.

Optimal Programmed Intermittent Epidural Bolus Interval Timing When Using 10 mL of 0.1% Ropivacaine and 0.5 mcg/mL Sufentanil for Labor Analgesia in Patients Without Breakthrough Pain: A Prospective, Randomized Study

Background

Interval time, defined as the period of time that effective analgesia can be achieved without the need for patient-controlled epidural analgesia (PCEA), has been investigated as an important parameter for the design of programmed intermittent epidural bolus (PIEB) approaches to labor analgesia. PCEA approaches offer flexibility in the management of labor-related pain while minimizing the risk of patient overdose. Here, the optimal interval between PIEB boluses of 0.1% ropivacaine and 0.5 μg/mL sufentanil was evaluated while using revised criteria to define effective analgesia that allowed for the administration of a rescue PCEA bolus during these intervals.

Methods

Participants were assigned at random to five different groups with PIEB intervals that ranged from 35 to 55 minutes. Labor epidural analgesia was initiated by administering 15mL of 0.1% ropivacaine with 0.5 μg/mL sufentanil over a 2-minute period. Analgesia was considered effective if there was no additional requirement for manual analgesia or an additional PCEA bolus beyond a maximum of one PCEA bolus between intervals during the first stage of labor. Probit regression analyses were used to estimate the effective PIEB intervals that achieved 50% (EI50) and 90% (EI90) success rates in patients.

Results

The final analysis included 142 patients who underwent PIEB for maintaining analgesia during labor. Intervals of 55, 50, 45, 40, and 35 minutes were associated with analgesia efficacy odds of 82.8% (24/29), 86.2% (25/29), 96.3% (26/27), 100% (29/29), and 100% (28/28), respectively. The respective EI50 and EI90 intervals associated with patients not suffering from breakthrough pain were 62.9 (95% CI 57.2-91.8) and 50.4 (95% CI 45.3-54.9) minutes.

Conclusion

Under the condition of this study, the optimal PIEB interval for the administration of 10 mL boluses of 0.1% ropivacaine and 0.5 μg/mL sufentanil is approximately 50 minutes.

A biased coin up-and-down sequential allocation trial to determine the ED90 of intrathecal sufentanil combined with ropivacaine 2.5 mg for labor analgesia

Purpose

To determine the 90 percent effective dose (ED90) of intrathecal sufentanil combined with ropivacaine 2.5 mg for labor analgesia and observe its safety for parturients and neonates.

Methods

We conducted a prospective, double-blind, biased coin up-and-down study. We injected a fixed 2.5 mg ropivacaine combined with a designated dose of sufentanil intrathecally to observe the labor analgesic effect. The initial dose of sufentanil was assigned 1.0 μg, and the remaining doses were assigned as per the biased coin up-and-down method. The criterion of successful response was defined as VAS ≤ 30 mm after intrathecal injection at 10 min. Safety was evaluated in terms of maternal and neonatal outcomes.

Results

The ED90 dose of intrathecal sufentanil combined with ropivacaine 2.5 mg (0.1%, 2.5 mL) was 2.61 μg (95% CI, 2.44 to 2.70 μg) by isotonic regression. No respiratory depression, hypotension, or motor block was observed. Thirty-one (77.5%) parturients complained of pruritus, and 14 (35.0%) suffered nausea and vomiting. Three neonates reported a 1 min Apgar score of ≤7, and none reported a 5 min Apgar score of ≤7.

Conclusion

The ED90 of intrathecal sufentanil combined with ropivacaine 2.5 mg for labor analgesia was 2.61 μg. The dose is safe for parturients and neonates.

Anesthesia practices for management of labor pain and cesarean delivery in France (EPIDOL): A cross-sectional survey

BACKGROUND

This study aimed to collect obstetric anesthesia practice and patient-reported outcomes as an update to the last French Obstetric Anesthesia survey from 1996.

METHODS

Maternity units were randomly selected across France and surveyed for 7 consecutive days from February, 2016, to January, 2017. Data was gathered prospectively by questionnaires filled out by patients and anesthesia providers.

RESULTS

There were 1885 questionnaires received from 56 units, with 379 cesarean delivery (CD) and 1506 vaginal delivery (VD) cases analyzed. The overall neuraxial labor analgesia (NLA) rate was 82.5% (95% CI [82.4-82.6]), with 70.3% (95% CI [71.4-71.6]) receiving automated administration (PCEA/PIEB). NLA was effective throughout labor in 68.2% of cases, however, severe pain was reported by 29.4% of patients. The overall rate of alternative approaches for labor analgesia was 19.5% (95%CI [19.2-19.7]). Obesity (OR 2.8; 95% CI [1.0-7.5], p < 0.04) and delivery in level I units (OR 0.6; 95% CI [0.5-0.9], p < 0.01) were associated with severe pain during VD. Satisfaction was found to be similar in patients delivering with or without NLA. The incidence of pain during CD was similar in scheduled versus non-scheduled CD. Failure of NLA during CD was associated with severe pain (OR 10.0; 95% CI [3.1-31.9], p < 0.01) and dissatisfaction (OR 26.2; 95% CI [3.0-225.1], p < 0.01).

CONCLUSION

Despite the high NLA rate in France, a significant proportion of women experience severe pain during labor and delivery. This study emphasizes the need for further practice guidelines in obstetric anesthesia to ensure optimal pain management and improve patients' experience during childbirth.

CLINICALTRIALS

govNCT02853890.

Association of epidural analgesia during labor and early postpartum urinary incontinence among women delivered vaginally: a propensity score matched retrospective cohort study

BACKGROUND

Although epidural analgesia is considered the gold standard for pain relief during labor and is safe for maternity and fetus, the association between the epidural analgesia and pelvic floor disorders remains unclear. Thus we estimate the association between epidural analgesia and early postpartum urinary incontinence (UI).

METHODS

A propensity score-matched retrospective cohort study was conducted at a university-affiliated hospital in Shanghai, China. Primiparous women with term, singleton, and vaginal delivery between December 2020 and February 2022 were included. UI was self-reported by maternity at 42 to 60 days postpartum and was classified by International Consultation on Incontinence Questionnaire-Urinary Incontinence Short Form (ICIQ-UI SF). Using logistic regression models, the associations between epidural analgesia and early postpartum UI were assessed.

RESULTS

Among 5190 participants, 3709 (71.5%) choose epidural anesthesia during labor. Analysis of the propensity-matched cohort (including 1447 maternal pairs) showed epidural anesthesia during labor was independently associated with UI in early postpartum period (aOR 1.50, 95% CI 1.24-1.81). This association was mainly contributed to stress UI (aOR 1.38, 95% CI 1.12-1.71) rather than urge UI (aOR 1.45, 95% CI 0.99-2.15) and mixed UI (aOR 1.52, 95% CI 0.95-2.45). Furthermore, we observed that the association between epidural anesthesia and UI was more pronounced among older women (≥ 35 y) and women with macrosomia (infant weight ≥ 4000 g), compared with their counterparts (both P for interaction < 0.01). After further analysis excluding the women with UI during pregnancy, the results remained largely consistent with the main analysis.

CONCLUSIONS

The findings support that epidural anesthesia was associated with SUI in the early postpartum period.

A randomized double-blinded study assessing the dose-response of ropivacaine with dexmedetomidine for maintenance of labor with epidural analgesia in nulliparous parturients

Background: The combination of ropivacaine and dexmedetomidine has been used as an epidural analgesic for inducing labor. However, there is limited data regarding the administration of epidural analgesia for labor maintenance, hence, this study aimed to determine the optimum concentration through dose-response curves of ropivacaine plus dexmedetomidine, which could be used along with the Programmed Intermittent Epidural Bolus (PIEB) technique. Methods: One hundred parturients were randomized into 4 groups who were administered four different doses of ropivacaine (dexmedetomidine at 0.4 μg mL-1): 0.04%, 0.06%, 0.08%, and 0.1%. The primary outcome that was determined included the proportion of patients experiencing breakthrough pain during their 1st stage of labor. Breakthrough pain was described as a visual analog scale [VAS] score of >30 mm, requiring supplemental epidural analgesia after the administration of at least one patient-controlled bolus. The effective concentration of analgesia that was used for labor maintenance in 50% (EC50) and 90% (EC90) of patients were calculated with the help of probit regression. Secondary outcomes included epidural block characteristics, side effects, neonatal outcomes, and patient satisfaction. Results: The results indicated that the proportion of patients without breakthrough pain was 45% (10/22), 55% (12/22), 67% (16/24), and 87% (20/23) for 0.04%, 0.06%, 0.08%, and 0.10% doses of the analgesic that were administered, respectively. The EC50 value was 0.051% (95% confidence interval [CI], 0.011%-0.065%) while the EC90 value was recorded to be 0.117% (95% CI, 0.094%-0.212%). Side effects were similar among groups. Conclusion: A ropivacaine dose of 0.117% can be used as epidural analgesia for maintaining the 1st stage of labor when it was combined with dexmedetomidine (0.4 μg mL-1) and the PIEB technique. Clinical Trial Register: https://www.chictr.org.cn/index.aspx, identifier ChiCTR2200059557.

Involving a Dedicated Epidural-Caring Nurse in Labor Ward Practice Improves Maternal Satisfaction towards Childbirth: A Retrospective Study

The quality of healthcare is crucially linked to patient satisfaction, particularly in the provision of neuraxial analgesia for labor pain. Neuraxial analgesia for labor pain control should ideally be readily available when requested. However, in real-world practice, anesthesiologists may not always respond immediately to maternal demands, which can compromise the quality of care. To address this issue, this study aimed to evaluate the effectiveness of involving a dedicated nurse in epidural care to improve maternal satisfaction. This study was conducted in a single tertiary center. Medical records of women with singleton pregnancies above 36 gestational weeks who received neuraxial analgesia for labor pain control were reviewed (N = 354). Among them, 104 women (29%) received care from a dedicated nurse. The results showed that involving a dedicated nurse led to higher maternal satisfaction scores before (4.7 ± 0.5 versus 4.5 ± 0.6, p = 0.001), during (4.7 ± 0.6 versus 4.5 ± 0.6, p = 0.002), and at 24 h postpartum (4.7 ± 0.5 versus 4.5 ± 0.5, p = 0.001), without any adverse impact on maternal, neonatal, or epidural-related complications. These findings suggest that allocating a dedicated nurse to epidural care can effectively enhance maternal satisfaction and potentially improve overall care quality.

Results of the 2021 French National Perinatal Survey and trends in perinatal health in metropolitan France since 1995

OBJECTIVE

To report results of the 2021 French National Perinatal Survey (ENP) in metropolitan France and assess trends in the main indicators of perinatal health, medical practices, and risk factors in France since 1995.

POPULATION AND METHOD

All the samples included all women giving birth at a gestational age of at least 22 weeks of gestation and/or to an infant weighing at least 500 grams in all maternity units in metropolitan France during one week in 1995 (N=13 048), 2003 (N=14 324), 2010 (N=14 546), 2016 (N=12 553), and 2021 (N=12 088). The data came from postpartum interviews of the women at the hospital and their medical records. Comparisons between surveys showed trends over time.

RESULTS

Between 1995 and 2021, maternal characteristics changed. Maternal age and the frequency of women with obesity rose: in 2021, 24.6% of women were 35 years or older (21.1% in 2016, 19.2% in 2010, 15.9% in 2003 and 12.4% in 1995) and 14.4% were obese (11.8% in 2016, 9.9% in 2010 and 7.4% in 2003). Some antenatal prevention behaviors that improved in 2021 were not smoking during the third trimester, acid folic administration before pregnancy, and vaccination against influenza. The percentage of women with an early prenatal appointment ("4^th month appointment"), implemented to facilitate screening of maternal vulnerability during pregnancy, has continued to rise. The percentage of women receiving prenatal care by midwives has risen markedly (39.0% in 2021 versus 11.7% in 2016). Serum screening for Down syndrome continues to increase (91.8% of women in 2021). The rate of induction of labor has risen significantly (20.2% in 1995 and 25.8% in 2021). The mode of delivery has not varied significantly since 2003; in 2021, the cesarean rate was 21.4% and the instrumental vaginal delivery rate 12.4%. Episiotomy was increasingly rare, among both primiparous and multiparous women (16.5% and 2.9% in 2021, respectively). The prevalence of coronavirus (SARS-CoV2) infection during pregnancy was 5.7%. Preterm live births increased regularly, slightly but significantly over the 1995-2016 period and then remained stable between 2016 and 2021 (7.0%). In 2021, 56.3% of women exclusively breastfed during their hospital stay, a modest increase in comparison with 2016 (54.6%).

CONCLUSION

Routine national perinatal surveys highlight positive trends over time in some preventive practices, decreases in some medical interventions consistent with national guidelines, and the increasing role of midwives in prenatal care. Nonetheless, some indicators remain less than optimal and require more detailed analyses.