Impact of the introduction of neuraxial labor analgesia on mode of delivery at an urban maternity hospital in China

Effects of epidural analgesia at 1 cm cervical dilatation on multiparae: A retrospective cohort study using propensity score-matching

OBJECTIVE

The aim of the present study was to investigate the effects of epidural analgesia (EA) administered at cervical dilatation of 1 cm on multiparae who underwent vaginal delivery.

METHODS

This propensity score-matched retrospective cohort research was conducted between 2021 and 2022. All the singleton multiparae who had previous successful vaginal deliveries and epidural analgesia during this delivery were screened for eligibility. The primary outcome was the effect of EA on the duration of labor. The main secondary outcomes included the incidence of cesarean delivery and umbilical arterial pH.

RESULTS

This study incorporated 686 multiparae who were divided into two cohorts: EA 1 (cervical dilatation = 1 cm, n = 166) and EA 2 (cervical dilatation >1 cm, n = 520). In the propensity score-matched cohort (including 164 women in each group), there were no statistically significant differences in the incidence of cesarean delivery (4 [2.4%] vs 4 [2.4%], P = 1.000), umbilical arterial pH (7.28 ± 0.06 vs 7.28 ± 0.07, P = 0.550) and other secondary outcomes between the two groups. Based on a comparative assessment of the women who delivered vaginally to the Kaplan-Meier curves and propensity score-matching (including 160 women in each group), there was no statistical significance in the duration of the first, second and third stages of labor (log rank P, P = 0.811; P = 0.413; P = 0.773, respectively).

CONCLUSION

Initiation of epidural analgesia at cervical dilatation of 1 cm in multiparae did not cause adverse effects with regard to the duration of labor, increased cesarean deliveries, and bad neonatal outcomes.

Why do pregnant women with fear of birth prefer vaginal birth? A qualitative study in China

Background

Fear of birth (FOB) is becoming increasingly recognized as a mental health issue that may endanger maternal and infant health and affects women's subsequent fertility desires. It has also been shown to be related to the choice of delivery mode. Given the differences in healthcare systems and policies between countries, and the gaps in the exploration of women's experience of fear of birth and its association with the delivery mode in the Chinese cultural context, this study thus attempt to understand Chinese women's experience with fear of birth and their preferences for delivery mode through a qualitative study.

Methods

A descriptive qualitative research was performed among twenty pregnant women from the obstetric outpatient of a tertiary hospital in China. Colaizzi's method was used to analyze the participants' data.

Results

We proposed three themes and nine subthemes on the participants' experience with fear of birth: (1) an invisible dilemma: trapped in lingering fear (fear of all sides, the untold loneliness, and ambivalence with mixed feelings); (2) an unexpected decision: choose to give birth naturally (initiative selection and passive acceptance); and (3) A strength to confront challenges head-on: move forward with fear (awaken of maternal spirit, hope in bloom, Chinese tolerance culture, and obstetric analgesia).

Conclusion

Fear of birth is a complex emotion, accompanied by feelings of loneliness and ambivalence in addition to fear. We found that women with fear of birth in this study prefer vaginal birth, and it was revealed to be the result of a combined action of intrinsic and extrinsic factors.

Association between neuraxial labor analgesia and postpartum depression: A meta-analysis

BACKGROUND

Labor and delivery complications, particularly pain, are important risk factors for postpartum depression (PPD). Neuraxial labor analgesia can effectively relieve labor pain; however, the association between neuraxial labor analgesia and PPD, if any, has not been established.

METHODS

PubMed, MEDLINE, EMBASE, ClinicalTrials.gov, and Cochrane Library were searched. The incidence of PPD was the primary outcome. The secondary outcome was the difference in postpartum Edinburgh Postpartum Depression Scale scores between the neuraxial labor analgesia and control groups. Subgroup analyses and post-hoc meta-regression were performed.

RESULTS

Nineteen studies with a total of 8758 parturients were identified. Neuraxial labor analgesia did not decrease PPD risk compared to the control group (OR = 0.84, 95% CI: 0.58-1.23); however, after being stratified by PPD prevalence, neuraxial labor analgesia decreased the risk for PPD in the high prevalence (>14%) subgroup (OR = 0.61, 95% CI: 0.39-0.94) and increased the risk for PPD in the low prevalence (<14%) subgroup (OR = 1.56, 95% CI: 1.16-2.10) compared to the control group. Meta-regression analysis showed that the association between neuraxial labor analgesia and PPD was influenced by PPD prevalence. There was no difference in the postpartum Edinburgh Postpartum Depression Scale scores between the neuraxial labor analgesia and control groups (WMD = -0.11, 95% CI: -0.56-0.34).

LIMITATION

Heterogeneity and a limited number of randomized controlled trials may bias the interpretation of the results.

CONCLUSION

Neuraxial labor analgesia had a protective effect when administered to parturients in the region with a high prevalence of PPD, but became a risk factor when administered to parturients in the region with a low prevalence of PPD.

Satisfaction as a Mediator and Its Interaction With Adherence to Labor Analgesia Protocols: A Cross-Sectional Survey of Chinese Medical Personnel

Background

Although the Chinese promotion of labor analgesia began in 2018 to improve maternal health, high-quality medical care is difficult to provide to pregnant women when medical staff cannot implement standard labor analgesia procedures. This study aims to examine medical personnel's adherence to labor analgesia protocols and to explore the relationships among adherence, satisfaction, and other factors.

Methods

The data were from a national cross-sectional dataset (N = 13,944) of the 2020 Chinese Labor Analgesia Pilot Evaluation Project. Mediating and moderating effects analyses were used to examine the role of satisfaction as a mediator between support measures and adherence.

Results

There were differences in adherence between different types of medical personnel. Support measures and satisfaction had a positive association with adherence to labor analgesia protocols. Satisfaction had a significant mediating and moderating effect on the relationship between support measures and adherence to labor analgesia standards. Moderating effects of professional titles and attitudes were also observed.

Conclusion

Primary health care policies worth considering include comprehensive incentives for medical institutions to improve the use of labor analgesia by medical personnel. It is also worth considering providing more training opportunities for the staff in anesthesiology departments.

Why is the labor epidural rate low and cesarean delivery rate high? A survey of Chinese perinatal care providers

Objective

China has a high cesarean delivery (CD) and low labor epidural analgesia (LEA) rate. This online survey was conducted to explore the reasons behind this phenomenon and potential solutions.

Methods

A voluntary, anonymous survey was distributed via both WeChat and professional websites for 4 months amongst groups of Chinese perinatal professionals. Data was collected and analyzed using a Chi-square test and presented as percentages of respondents.

Results

1412 respondents were recorded (43% anesthesiologists, 35% obstetricians, 15.5% midwives or labor and delivery nurses, and 6.5% others), and 1320 respondents were care providers. It was found that 82.7% (1092/1320) of the provider respondents used CD per patient request in fear of lawsuits or yinao/yibao and 63.4% (837/1320) used CD for respecting superstitious culture. The number one reason (noted by 60.2% (795/1320) of all the three specialties) for low LEA use was lack of anesthesia manpower without statistical difference among specialties. The most recommended solution was increasing the anesthesia workforce, proposed by 79.8% (1053/1320) of the three specialties. However, the top solution provided by the two non-anesthesia specialties is different from the one proposed by anesthesiologists. The later (83%, 504/606) suggested increasing the incentive to provide the service is more effective. The answers to questions related to medical knowledge about CD and LEA, and unwillingness of anesthesiologists, parturients and their family members to LEA were similar for the most part, while the opinions regarding low LEA use related to poor experiences and unwillingness of obstetricians and hospital administrators were significantly divided among the three specialties. In the providers’ point of view, the unwillingness to LEA from parturient’s family members was the most salient (26.1%, 345/1320), which is more than all care providers, hospital administrators, and parturients themselves (16.8%, 222/1320).

Conclusion

The reasons for high CD rate and low LEA use are multifactorial. The sociological issues (fear of yinao/yibao and superstitious culture) were the top two contributing factors for the high CD rate in China, while lack of anesthesia manpower was the top response for the low LEA use, which contributes to its being the most recommended solution overall from the three specialties. An incentive approach to providers is a short-term solution while training more perinatal care providers (especially among anesthesiologists and midwives), improving billing systems, and reforming legal systems are 3 systemic approaches to tackling this problem in the long-term.

The trends and associated adverse maternal and perinatal outcomes of labour neuraxial analgesia among vaginal deliveries in China between 2012 and 2019: a real-world observational evidence

BACKGROUND

There is a lack of national report of the labour neuraxial analgesia (NA) rates in China in recent years, especially after the national promotion policy. The adverse maternal and perinatal outcomes associated with NA in China are also unknown. The aim of this study is to estimate the trends of NA rates from 2012 to 2019, to evaluate the effect of national policy on promoting NA and to identify the association between NA and adverse outcomes in China.

METHODS

We used the individual data from China's National Maternal Near Miss Surveillance System (NMNMSS) between 2012 and 2019, covering 438 hospitals from 326 urban districts or rural counties in 30 provinces across China. The analysis was restricted to singleton pregnant women who underwent vaginal delivery at or after 28 completed weeks of gestation. We estimate the trends of NA rates between 2012 and 2019, both at the national and provincial levels using Bayesian multilevel model. We also estimated the effect of the national pilot policy launched in 2018 using interrupted time-series analysis and identified the association between NA and adverse outcomes using modified Poisson regression combined with propensity score analysis.

RESULTS

Over the study period, 620,851 of 6,023,046 women underwent vaginal delivery with NA. The estimated national NA rates increased from 8.4% in 2012 to 16.7% in 2019. Most provinces experienced the same rapid rise during this period. The national pilot policy accelerated the rise of the rates. No differences were observed between women with NA and without any analgesia in the incidence of uterine atony, placental retention, intrapartum stillbirths and 1- and 5-min Apgar scores lower than 7. However, women with NA had higher incidences of genital tract trauma (adjusted relative risk (aRR) 1.53, 95% confidence interval (CI) 1.04-2.26) and maternal near miss (aRR 1.35, 95% CI 1.08-1.69), only in hospitals which were not covered by the national pilot policy and usually lack of sufficient equipment and personnel.

CONCLUSIONS

The national policy can effectively increase the NA rate. However, as genital tract trauma and maternal near miss may increase in low-resource hospitals, but not in high-resource hospitals, further study is required to identify the reasons.

The Effect of the No Pain Labor & Delivery-Global Health Initiative on Cesarean Delivery and Neonatal Outcomes in China: An Interrupted Time-Series Analysis

BACKGROUND

The proportion of live births by cesarean delivery (CD) in China is significant, with some, particularly rural, provinces reporting up to 62.5%. The No Pain Labor & Delivery-Global Health Initiative (NPLD-GHI) was established to improve obstetric and neonatal outcomes in China, including through a reduction of CD through educational efforts. The purpose of this study was to determine whether a reduction in CD at a rural Chinese hospital occurred after NPLD-GHI. We hypothesized that a reduction in CD trend would be observed.

METHODS

The NPLD-GHI program visited the Weixian Renmin Hospital, Hebei Province, China, from June 15 to 21, 2014. The educational intervention included problem-based learning, bedside teaching, simulation drill training, and multidisciplinary debriefings. An interrupted time-series analysis using segmented logistic regression models was performed on data collected between June 1, 2013 and May 31, 2015 to assess whether the level and/or trend over time in the proportion of CD births would decline after the program intervention. The primary outcome was monthly proportion of CD births. Secondary outcomes included neonatal intensive care unit (NICU) admissions and extended NICU length of stay, neonatal antibiotic and intubation use, and labor epidural analgesia use.

RESULTS

Following NPLD-GHI, there was a level decrease in CD with an estimated odds ratio (95% confidence interval [CI]) of 0.87 (0.78-0.98), P = .017, with odds (95% CI) of monthly CD reduction an estimated 3% (1-5; P < .001), more in the post- versus preintervention periods. For labor epidural analgesia, there was a level increase (estimated odds ratio [95% CI] of 1.76 [1.48-2.09]; P < .001) and a slope decrease (estimated odds ratio [95% CI] of 0.94 [0.92-0.97]; P < .001). NICU admissions did not have a level change (estimated odds ratio [95% CI] of 0.99 [0.87-1.12]; P = .835), but the odds (95% CI) of monthly reduction in NICU admission was estimated 9% (7-11; P < .001), greater in post- versus preintervention. Neonatal intubation level and slope changes were not statistically significant. For neonatal antibiotic administration, while the level change was not statistically significant, there was a decrease in the slope with an odds (95% CI) of monthly reduction estimated 6% (3-9; P < .001), greater post- versus preintervention.

CONCLUSIONS

In a large, rural Chinese hospital, live births by CD were lower following NPLD-GHI and associated with increased use of labor epidural analgesia. We also found decreasing NICU admissions. International-based educational programs can significantly alter practices associated with maternal and neonatal outcomes.

Epidural analgesia during labor and its optimal initiation time-points: A real-world study on 400 Chinese nulliparas

ABSTRACT

Recent research has suggested that 6 cm of cervical dilation should be the threshold for the active labor phase, and it has confirmed that epidural analgesia (EA) is a safe method of pain relief during labor. However, the evidence provided for these findings comes mainly from randomized controlled clinical trials (RCTs), which suffer from the limitation of real-world generalizability.To test the generalizability of the conclusions from these previous RCTs, we conducted a prospective cohort, real-world study (RWS) on 400 Chinese term nulliparas. A total of 200 of the participants (the EA group) received EA upon request. The participants in the EA group were further subdivided as follows according to their cervical dilation when the EA administration was initiated (CDE): [EA1 group (CDE < 3 cm), EA2 group (3 cm ≤ CDE < 6 cm), and EA3 group (CDE ≥ 6 cm)]. We compared the labor duration of the EA group versus the non-EA (NEA) group, and the NEA group versus the 3 EA subgroups. We also compared delivery outcomes between the EA and NEA groups.The median total labor duration for the EA group [676 (511-923) minutes] was significantly longer than that of the NEA group [514 (373-721) minutes] (P < 0.001). The median durations of both the first- and second-stages of labor for the EA group [600 (405-855) minutes, 68 (49-97) minutes] were longer than those of the NEA group [420 (300-630) minutes, 50 (32-85) minutes] (P < .001, P < .001)]. In addition, the median total labor durations in both the EA1 [720 (548-958) minutes] and EA2 groups [688 (534-926) minutes] were longer than in the NEA group (P < .001 and P < .001, respectively), and the first- and second-stage labor durations of these subgroups were similar to their total labor durations. A Cox regression analysis showed that EA was associated with longer first-stage labor [hazard ratio (HR) 0.55, 95% confidence interval (CI) 0.42-0.71, P < .001] and longer second-stage labor (HR 0.66, 95% CI 0.51-0.85, P = .001). The delivery modes and neonatal outcomes between the EA and NEA groups were not statistically different, however.Our findings suggest that EA administered before a cervical dilation of 6 cm may be associated with longer total, first-, and second-stage labor durations compared with no EA, while later EA administration is not. In addition, though EA prolongs labor duration, it does not impact delivery outcomes. These results confirm the significance of a 6 cm cervical dilation threshold in real-world labor settings.

Comparison of Spinal Versus Epidural Analgesia for Vaginal Delivery: A Randomized Double Blinded Clinical Trial

Background

Recently, one of the problems in developing countries is pregnant women who insist on cesarean section for fear of painful vaginal delivery. There are various methods to reduce labor pain, including medical and non-medical methods. Neuraxial analgesia is classified as one of the best ways to reduce labor pain. Epidural analgesia is a classic and popular procedure to decrease labor pain. Nevertheless, other methods, such as spinal or combined spinal-epidural analgesia, is more effective compared with the epidural.

Objectives

In this study, we investigated a single intrathecal versus epidural injection in pregnant women during childbirth.

Methods

In our research, after obtaining informed consent, the patients were randomly assigned to two equal groups: epidural and spinal. Each group contained 50 parturient women in advanced labor. In the epidural group, 2.5 mL isobaric bupivacaine 0.5%, sufentanil (0.2 mcg/mL), and 7 mL saline 0.9% were injected by an 18-gauge Tuohy needle at the L4-5 or L5-S1 intervertebral space, and in the spinal group, 0.5 mL isobaric bupivacaine 0.5%, 2.5 mcg sufentanil, and 0.5 mL saline 0.9% were injected by a 25-gauge pencil-point Quincke needle at the L4-5 or L5-S1 intervertebral spaces. For pain intensity, the visual analog scale (VAS) was used at serial intervals, and other variables, such as the onset and duration of analgesia, hypotension, neonatal APGAR score, fetal heart rate (FHR) changes, and other variables were examined.

Results

The mean time to onset analgesic effect was 4.6 min in the spinal group compared with 12.5 minutes in the epidural (P < 0.001). Duration of analgesia was 121 minutes in the spinal group compared with 104 min in the epidural group (P < 0.001). The time to reach the maximum block was 8.4 min in the spinal group vs. 22.2 min in the epidural group (P < 0.001). The duration of the second and third gestation stages was the same in both groups.

Conclusions

Spinal analgesia is short and easy to perform and does not require advanced equipment and technical experience. Spinal analgesia can be a good option for labor analgesia and leads to achieving a lower pain score than epidural analgesia.

Evaluation of cesarean delivery rates in different levels of hospitals in Jiangsu Province, China, using the 10-Group classification system

OBJECTIVE

To compare cesarean delivery (CD) rates in referral and non-referral hospitals in Maternal Safety Collaboration in Jiangsu province, China.

METHODS

Sixteen participants (4 referral hospitals, 12 non-referral hospitals) from Drum Tower Hospital Collaboration for Maternal Safety reported CD rates in 2019 using ten-group classification system and maternal/neonatal morbidity and mortality.

RESULTS

A total of 22,676 CDs were performed among 52,499 deliveries and the average CD rate was 43.2% (range 34.8-69.6%). CD rate in non-referral hospitals (44.7%) was significantly higher than it was in referral hospitals (40.4%, p < .001). Term singleton cephalic nulliparous women with spontaneous labor (Group 1) or induced labor (Group 2a) had higher CD rates if they were cared in non-referral hospitals compared with those in referral hospitals (Group 1: 11.8% vs. 4.4%, p < .001; Group 2a: 29.1% vs. 21.3%, p < .001). In non-referral hospitals, CD rate in Group 5 and the proportion of Group 5 to the overall population were also significantly higher than those in referral hospitals (98.5% vs. 92.5%, p < .001; and 21.0% vs. 14.5%, p < .001).

CONCLUSION

To decrease the CD rate, we need to take efforts in decreasing unnecessary operations for term singleton cephalic nulliparous women and increasing the rate of trial of labor after CD.

[Normal childbirth: physiologic labor support and medical procedures. Guidelines of the French National Authority for Health (HAS) with the collaboration of the French College of Gynaecologists and Obstetricians (CNGOF) and the French College of Midwives (CNSF) - Mother's wellbeing and regional or systemic analgesia for labor]

INTRODUCTION

These guidelines deal with the parturient wellbeing in terms of hydration and regional and systemic pain management during labour.

METHOD

Guidelines were established based on literature analysis and experts consensus.

RESULTS

Clear liquids consumption is permitted all along labor and postpartum, without volume limitation, in patients at low risk of general anesthesia (grade B). The consumption of solid foods is not recommended during the active stage of labor (consensus agreement). It is recommended to promote on regional analgesia to prevent inhalation (grade A). Pain relief using regional analgesia is a part of normal childbirth. It is recommended to provide regional analgesia to parturient who wish these technics. Regional analgesia is the safest and most effective analgesic method for the mother (grade A) and the child (grade B). It is recommended to inform women on the analgesic technics, to respect their choice and consider the right for a parturient to change her strategy in obstetrical circumstances or in cases of untractable pain (consensus agreement). It is recommended to perform a "low-dose" regional analgesia that respects the experience of childbirth (grade A) and maintain it with a patient controlled epidural analgesia technics (grade A). There is no minimum cervical dilation to allow epidural analgesia (grade A). In cases of rapid labor or after delivery for revision, spinal or combined spinal epidural can be used (grade C). Epidural has not to be ended before birth (consensus agreement). Blood pressure and fetal heart rate must be monitored every 3minutes after induction and/or each 10mL bolus then hourly (consensus agreement). Systematic and preventive fluid loading is not needed if only due to regional analgesia (grade B). Deambulation or postures are allowed in the absence of motor block and must be traced and do not alter the distribution of the regional analgesia (grade C). The postures of childbirth do not alter regional analgesia spread (NP2). There is no effect low dose regional analgesia on the duration of obstetric labor, nor the rate of instrumental births or caesarean section (NP1). Systematic use of oxytocin due to epidural analgesia is neither useful nor recommended (AE). Regional analgesia has no side effect on the fetus or newborn (NP1). If regional analgesia is contraindicated or during the waiting time, alternatives analgesic drugs (entonox, nalbuphine and tramadol or pudendal block) can be used but their analgesic efficiency remains mediocre to moderate and they are associated with adverse maternal and especially neonatal side effects (NP2). Remifentanil, ketamine and volatile anesthetics are excluded from these recommendations.

CONCLUSION

The present guidelines were established to update wellbeing of normal parturient during normal labor: hydration is recommended and low dose patient-controlled regional (epidural and spinal) analgesia is the most effective and safest analgesic method.

Analgesia for vaginal birth: Secondary analysis from the WHO Multicountry Survey on Maternal and Newborn Health

OBJECTIVE

To evaluate the use of analgesia during labor in women who had a vaginal birth and to determine the factors associated with its use.

METHODS

A secondary analysis was performed of the WHO Multicountry Survey on Maternal and Newborn Health, a cross-sectional, facility-based survey including 359 healthcare facilities in 29 countries. The prevalence of analgesia use for vaginal birth in different countries was reported according to the Human Development Index (HDI). Sociodemographic and obstetric characteristics of the participants with and without analgesia were compared. The prevalence ratios were compared across countries, HDI groups, and regions using a design-based χ² test.

RESULTS

Among the 221 345 women who had a vaginal birth, only 4% received labor analgesia, mainly epidural. The prevalence of women receiving analgesia was significantly higher in countries with a higher HDI than in countries with a lower HDI. Education was significantly associated with increased use of analgesia; nulliparous women and women undergoing previous cesarean delivery had a significantly increased likelihood of receiving analgesia.

CONCLUSION

Use of analgesia for women undergoing labor and vaginal delivery was low, specifically in low-HDI countries. Whether low use of analgesia reflects women's desire or an unmet need for pain relief requires further studies.

Women's experience of psychological birth trauma in China: a qualitative study

BACKGROUND

The psychological birth trauma is a universal phenomenon in childbearing women. The influences could extend in a wide range, which includes the mothers' health, mother-infant relationship, partner relationship. The medical staff could even choose to quit playing their part in the birthing process. The phenomenon has gradually garnered attention around the world. However, it has rarely been discussed under Chinese special conditions. The study was to explore Chinese women's lived experiences of psychological birth trauma during labor and birth.

METHODS

A descriptive phenomenological approach was adopted in this study. Twenty-four women were recruited, who reported having experienced psychological birth trauma. In-depth interviews were conducted within 1 week after birth. Colaizzi's method was used to analyze the data.

RESULTS

Twenty-four women participated in the study. Four themes emerged to describe the women's experience of psychological birth trauma: "How am I supposed to relieve the endless pain?" " Can't I be weak?" "Am I not important?" "What uncertainties are waiting for me?"

CONCLUSIONS

The findings provide deep insight into Chinese women's unique experience of psychological birth trauma. The social and health system could prevent psychological harm during birth and promote maternal health by measures of pain management, thoughtful attention, adequate caring, and prenatal preparation.

The effect of initiating neuraxial analgesia service on the rate of cesarean delivery in Hubei, China: a 16-month retrospective study

BACKGROUND

No Pain Labor &Delivery (NPLD) is a nongovernmental project to increase access to safe neuraxial analgesia through specialized training. This study explores the change in overall cesarean delivery (CD) rate and maternal request CD(MRCD) rate in our hospital after the initiation of neuraxial analgesia service (NA).

METHODS

NA was initiated in May 1st 2015 by the help of NPLD. Since then, the application of NA became a routine operation in our hospital, and every parturient can choose to use NA or not. The monthly rates of NA, CD, MRCD, multiparous women, intrapartum CD, episiotomy, postpartum hemorrhage (PPH), operative vaginal delivery and neonatal asphyxia were analyzed from January 2015 to April 2016.

RESULTS

The rate of NA in our hospital was getting increasingly higher from 26.1% in May 2015 to 44.6% in April 2016 (p < 0.001); the rate of CD was 48.1% (3577/7360) and stable from January to May 2015 (p>0.05), then decreased from 50.4% in May 2015 to 36.3% in April 2016 (p < 0.001); the rate of MRCD was 11.4% (406/3577) and also stable from January to May 2015 (p>0.05), then decreased from 10.8% in May 2015 to 5.7% in April 2016 (p < 0.001). At the same time, the rate of multiparous women remained unchanged during the 16 month of observation (p>0.05). There was a negative correlation between the rate of NA and rate of overall CD, r = - 0.782 (95%CI [- 0.948, - 0.534], p<0.001), and between the utilization rate of NA and rate of MRCD, r = - 0.914 (95%CI [- 0.989, - 0.766], p<0.001). The rates of episiotomy, PPH, operative vaginal delivery and neonatal asphyxia in women who underwent vaginal delivery as well as the rates of intrapartum CD, neonatal asphyxia, and PPH in women who underwent CD remained unchanged, and there was no correlation between the rate of NA and anyone of those rates from January 1st 2015 to April 30th 2016 (p>0.05).

CONCLUSIONS

Our study shows that the rates of CD and MRCD in our department were significantly decreased from May 1st 2015 to April 30th 2016, which may be due to the increasing use of NA during vaginal delivery with the help of NPLD.

Neuraxial labor analgesia: a literature review

The use of analgesia techniques for labor has become increasingly frequent, with neuraxial techniques being the most commonly used and most effective. Labor pain entails a number of physiological consequences that may be negative for the mother and fetus, and therefore must be treated. This literature review was performed through a search in the PubMed database, from July to November 2016, and included articles in English or Portuguese, published between 2011 and 2016 or anteriorly, if relevant to the topic. The techniques were divided into the following topics: induction (epidural, combined epidural-spinal, continuous spinal, and epidural with dural puncture) and maintenance of analgesia (continuous epidural infusion, patient-controlled epidural analgesia, and intermittent epidural bolus). Epidural analgesia does not alter the incidence of cesarean sections or fetal prognosis, and maternal request is a sufficient indication for its initiation. The combined technique has the advantage of a faster onset of analgesia; however, patients are subject to a higher incidence of pruritus resulting from the intrathecal administration of opioids. Patient-controlled analgesia seems to be an excellent technique, reducing the consumption of local anesthetics, the number of anesthesiologist interventions, and increasing maternal satisfaction.

Impact of epidural analgesia during labor on breastfeeding initiation and continuation: a retrospective study

Objective: Although epidural analgesia is widely used during labor, its impact on breastfeeding has not yet reached a consensus. This retrospective cohort study was to investigate the association of patient-controlled epidural analgesia (PCEA) during labor with breastfeeding initiation and continuation.Methods: Medical records from 1 February, 2016 to 31 December, 2016 at Guangzhou Women and Children's Medical Center, China were reviewed for women received PCEA or not. Breastfeeding continuation was assessed by a questionnaire at 6 months after hospital discharge.Results: Nine hundred twenty-two women were enrolled in the study, with 527 of these women received PCEA for labor analgesia. The proportion of timely initiation of breastfeeding (within 1 h after birth), and exclusive or partial breastfeeding at any of the evaluation time points (1, 3, and 6 months) between two groups showed no statistically significant difference.Conclusion: Our data do not support an association between the PCEA and discontinuation of breastfeeding within 6 months postpartum.

[Neuraxial labor analgesia: a literature review]

The use of analgesia techniques for labor has become increasingly frequent, with neuraxial techniques being the most commonly used and most effective. Labor pain entails a number of physiological consequences that may be negative for the mother and fetus, and therefore must be treated. This literature review was performed through a search in the PubMed database, from July to November 2016, and included articles in English or Portuguese, published between 2011 and 2016 or anteriorly, if relevant to the topic. The techniques were divided into the following topics: induction (epidural, combined epidural-spinal, continuous spinal, and epidural with dural puncture) and maintenance of analgesia (continuous epidural infusion, patient-controlled epidural analgesia, and intermittent epidural bolus). Epidural analgesia does not alter the incidence of cesarean sections or fetal prognosis, and maternal request is a sufficient indication for its initiation. The combined technique has the advantage of a faster onset of analgesia; however, patients are subject to a higher incidence of pruritus resulting from the intrathecal administration of opioids. Patient-controlled analgesia seems to be an excellent technique, reducing the consumption of local anesthetics, the number of anesthesiologist interventions, and increasing maternal satisfaction.

The effect of labor epidural analgesia on maternal-fetal outcomes: a retrospective cohort study

PURPOSE

To evaluate the impact of labor epidural analgesia on maternal-fetal safety outcomes in a signal Chinese academic medical center.

METHODS

A single-intervention impact study was conducted at The Second Affiliated Hospital, Wenzhou Medical University. The study period was divided into three phases: (1) baseline phase: from January 1 and June 30, 2009 when no analgesic method was routinely employed during labor; (2) phase-in period: the epidural analgesia was implemented 8 a.m.-5 p.m. during weekdays; and (3) the post-No Pain Labor N'Delivery phase when the labor epidural was applied 24 h a day, 7 days a week, from June 1, 2010 and June 30, 2011. The maternal-fetal safety outcomes of delivery were compared between the different periods.

RESULTS

There were 15,415 deliveries with 42.3% of nulliparous parturients in the 31-month study period. As the primary outcomes, the labor epidural analgesia rate increased from 0 to 57%, the vaginal delivery rate increased, and cesarean delivery rate decreased by 3.5% after full implementation. As the secondary outcomes, the rate of episiotomy and severe perineal injury after the implementation periods were significant decreased. The rate of postpartum oxytocin administration was decreased by 17.8%. No significant difference between the baseline and implementation periods was found in the rate of postpartum hemorrhage, Apgar scores less than 7 at both 1 and 5 min, 7-day mortality, and the overall neonatal intensive care unit admission rate.

CONCLUSION

Implementation of labor epidural analgesia increased the vaginal delivery rate and use of labor epidural analgesia is safe to parturients and fetus.

No Pain Labor & Delivery: A Global Health Initiative's Impact on Clinical Outcomes in China

The availability of labor analgesia is highly variable in the People's Republic of China. There are widespread misconceptions, by both parturients and health care providers, that labor epidural analgesia is harmful to mother and baby. Meanwhile, China has one of the highest cesarean delivery rates in the world, exceeding 50%. The goal of the nongovernmental No Pain Labor & Delivery (NPLD) is to facilitate sustainable increases in vaginal delivery rates by increasing access to safe neuraxial labor analgesia, thereby decreasing the cesarean delivery rate. NPLD was launched in 2008 with the stated goal of improving labor outcome in China by increasing the absolute labor epidural analgesia rate by 10%. NPLD established 10 training centers over a 10-year period. We hypothesized that increased availability of labor analgesia would result in reduced requests for cesarean delivery and better labor outcomes for mother and baby. Multidisciplinary teams of Western clinicians and support staff traveled to China for 8 to 10 days once a year. The approach involved establishing 24/7 obstetric anesthesia coverage in Chinese hospitals through education and modeling multidisciplinary approaches, including problem-based learning discussions, bedside teaching, daily debriefings, simulation training drills, and weekend conferences. As of November 2015, NPLD has engaged with 31 hospitals. At 24 of these sites, 24/7 obstetric anesthesia coverage has been established and labor epidural analgesia rates have exceeded 50%. Lower rates of cesarean delivery, episiotomy, postpartum blood transfusion, and better neonatal outcomes were documented in 3 impact studies comprising approximately 55,000 deliveries. Changes in practice guidelines, medical policy, and billing codes have been implemented in conjunction with the modernization of perinatal practice that has occurred concurrently in China since the first NPLD trip in 2008.

[Pain therapy during labour]

To date the gold standard of treating labour pain is regional analgesia by application of epidural analgesia. When offering epidural analgesia, the programmed intermittent epidural bolus (PIEB) is more effective in terms of pain reduction, less motor blocks and higher satisfaction of the parturient compared to continuous application via perfusor pump. An upcoming alternative to epidural analgesia is remifentanil, a short acting and potent opioid. Remifentanil, however, requires haemodynamic monitoring as cardiac and respiratory impairment has been described. Nitrous oxide has been used for decades in the Anglosphere but it is a greenhouse gas, and interactions with Vitamin B₁₂ are possible. Using novel extraction systems, nitrous oxide has become more attractive for treatment of the initial phase of labour pain in Central Europe. In order to provide the parturient with the best possible and with a tailored pain concept an interdisciplinary approach with obstetricians, midwives and anaesthesiologists is required.

Requests for cesarean deliveries: The politics of labor pain and pain relief in Shanghai, China

Cesarean section rates have risen dramatically in China within the past 25 years, particularly driven by non-medical factors and maternal requests. One major reason women request cesareans is the fear of labor pain, in a country where a minority of women are given any form of pain relief during labor. Drawing upon ethnographic fieldwork and in-depth interviews with 26 postpartum women and 8 providers at a Shanghai district hospital in June and July of 2015, this article elucidates how perceptions of labor pain and the environment of pain relief constructs the cesarean on maternal request. In particular, many women feared labor pain and, in a context without effective pharmacological pain relief or social support during labor, they came to view cesarean sections as a way to negotiate their labor pain. In some cases, women would request cesarean sections during labor as an expression of their pain and a call for a response to their suffering. However, physicians, under recent state policy, deny such requests, particularly as they do not view pain as a reasonable indication for a cesarean birth. This disconnect leads to a mismatch in goals for the experience of birth. To reduce unnecessary C-sections, policy makers should instead address the lack of pain relief during childbirth and develop other means of improving the childbirth experience that may relieve maternal anxiety, such as allowing family members to support the laboring woman and integrating a midwifery model for low-risk births within China's maternal-services system.

American-trained Chinese anesthesiologists: how are they doing?

More than 60 years have passed since 3 pioneer Chinese anesthesiologists were trained by American physicians. After returning to China, they applied their new knowledge and skills to develop a new anesthesia specialty in their own country. Over the past 2 decades, close to 600 Chinese medical graduates have been trained in the United States and have become part of the American anesthesia workforce. Unlike their elder generation, they did not go back to China after their training. People are always wondering how this new generation of American-trained Chinese anesthesiologists is doing in a different culture and different health care and political systems. This review indicates that these newly American-trained Chinese anesthesiologists not only provide high-quality patient care but also conduct outstanding anesthesia teaching and research. In addition, as their pioneer anesthesiologists did in China, they use professional organizations and publications as 2 major means to advance professional development and promote academic exchanges between Chinese and American anesthesiologists, through which American anesthesiology continues to have influence on modern Chinese anesthesiology.