Epidural analgesia side effects, co-interventions, and care of women during childbirth: A systematic review

The impact of antenatal massage practice on intrapartum massage application and their associations with the use of analgesics during labour : Sub-analysis of a randomised control trial

Background

Massage during labour is one form of intrapartum non-pharmacological pain relief but it is not known whether the frequency of practicing these massage techniques among couples during the antenatal period could enhance the effectiveness of intrapartum massage. This study was to evaluate the association between compliance of antenatal massage practice with intrapartum application and their impact on the use of analgesics during labour.

Methods

This was a sub-analysis of a childbirth massage programme which was carried out in two public hospitals with total births of around 8000 per year. Data from women who were randomized to the massage group were further analysed. After attending the pre-birth training class on massage at 36 weeks gestation, couples would be encouraged to practice at home. Their compliance with massage at home was classified as good if they had practiced for at least 15 minutes for three or more days in a week, or as poor if the three-day threshold had not been reached. Application of intrapartum massage was quantified by the duration of practice divided by the total duration of the first stage of labour. Women’s application of intrapartum massage were then divided into above and below median levels according to percentage of practice. Logistic regression was used to assess the use of epidural analgesia or pethidine, adjusted for duration of labour and gestational age when attending the massage class.

Results

Among the 212 women included, 103 women (48.6%) achieved good home massage compliance. No significant difference in the maternal characteristics or birth outcomes was observed between the good and poor compliance groups. The intrapartum massage application (median 21.1%) was inversely associated with duration of first stage of labour and positively associated with better home massage practice compliance (p = 0.04). Lower use of pethidine or epidural analgesia (OR 0.33 95% CI 0.12, 0.90) was associated with above median intrapartum massage application but not antenatal massage compliance, adjusted for duration of first stage of labour.

Conclusions

More frequent practice of massage techniques among couples during antenatal period could enhance the intrapartum massage application, which may reduce the use of pethidine and epidural analgesia.

Trial registration

(CCRBCTR) Unique Trial Number CUHK_ CCRB00525.

Satisfaction in parturients receiving epidural analgesia after prenatal shared decision-making intervention: a prospective, before-and-after cohort study

Background

The explanation of epidural analgesia by anesthesiologist would often begin after the parturient is admitted to the hospital. Because of labor pain, the decision of receiving epidural analgesia would often be made by the family members, instead of the parturient herself. We aimed to test whether earlier prenatal shared decision-making (SDM) interventions increase parturient’s comprehension and satisfaction of epidural labor analgesia, compared to conventional explanation after labor pain begun.

Methods

During the 28th week of gestation, we provided the SDM parturient health education as well as a leaflet with quick response codes. Scanning the code would link to education videoclips which explained what epidural analgesia is and its advantages and disadvantages. Original routine practice group parturients received explanation of analgesia after admission for delivery. To measure the satisfaction of labor pain service, the accessibility of information, and the communication with medical staff, we designed a questionnaire with reference to (1) Pregnancy and Maternity Care Patients’ Experiences Questionnaire (PreMaPEQ), (2) Preterm Birth Experience and Satisfaction Scale (P-BESS), and (3) Women’s Views of Birth Labor Satisfaction Questionnaire (WOMBLSQ). The questionnaire was amended after a pretest involving 30 parturients who had received epidural analgesia. Scree test analysis and exploratory factor analysis were performed; then, the questionnaire was revised again. A total of 200 valid questionnaires were collected—100 each from the original routine practice group and the SDM group.

Results

The SDM group reported significantly higher satisfaction with and understanding of epidural analgesia, and a significantly higher satisfaction with the information received, and the quality of pain relief. After SDM intervention, significant increasement of the average satisfaction scores in question “my epidural is effective” (9.10%; mean difference: 0.38; 95% confidence interval, 0.17 ~ 0.59; p < 0.001) and “The effect of epidural is just as what I have expected” (10.41%; mean difference: 0.41; 95% confidence interval, 0.18 ~ 0.64; p < 0.001) was demonstrated.

Conclusions

An earlier prenatal SDM intervention with sufficient information through videoclips increased parturients’ comprehensions and satisfaction of epidural analgesia service.

Trial registration

ISRCTN registry, 14,256,563. Registered April 1st, 2020 (10.1186/ISRCTN14256563).

Barriers and facilitators to birth without epidural in a tertiary obstetric referral center: Perspectives of health care professionals and patients

BACKGROUND

Epidural rates are high in tertiary obstetric referral centers, even though many patients in tertiary settings might not want or need epidural analgesia. Epidural rates are influenced by factors including labor support and routine medical intervention. This study aimed to identify barriers and facilitators to birth without epidural in a Canadian tertiary center, from the perspectives of doctors, nurses, and patients.

METHODS

In this qualitative exploratory study, individual, semi-structured interviews were conducted in 2016 with 5 doctors, 5 nurses, and 4 patients who intended to birth without epidural. Interviews were audio-recorded, transcribed, and analyzed using inductive qualitative thematic analysis.

RESULTS

Several contextual factors in the tertiary center facilitated or were barriers to birth without epidural. The following themes emerged: (1) differing perceptions of pain, (2) being ready for things to go wrong, (3) labor support is more labor intensive, and (4) having insufficient resources for birth without epidural.

CONCLUSIONS

Reconciling patient birth goals with staff focus on patient safety is challenging in the tertiary context. Discrepancies between health care professional and patient attitudes about childbirth pain may influence decision-making about epidural use. Maintaining labor support skills is challenging for health care professionals who have limited exposure to birth without epidural. There is a need to allocate dedicated resources to better support birth without epidural. Specifically, support could be improved through the implementation of guidelines for assessment and management of labor pain, provision of a variety of pain management options, and labor support training for health care professionals.

A Prospective Randomized Trial of Postural Changes vs Passive Supine Lying during the Second Stage of Labor under Epidural Analgesia

There exist very few studies comparing different postures or postural changes during labor in parturients with epidural analgesia.

AIM

To disclose whether the intervention of a multidisciplinary nursing team including a physiotherapist during the second stage of labor improves the obstetric outcome in parturients with epidural analgesia.

DESIGN

Prospective randomized trial.

SETTING

University-affiliated hospital.

POPULATION

Women undergoing labor with epidural analgesia after a normal gestation.

METHODS

150 women were randomized either to actively perform predefined postural changes during the passive phase of the second stage of labor under the guidance of the attending physiotherapist (study group), or to carry out the whole second stage of labor lying in the traditional supine position (control group).

RESULTS

There were significantly more eutocic deliveries (p = 0.005) and, conversely, significantly less instrumental deliveries (p < 0.05) and cesarean sections (p < 0.05) in the study group. The total duration of the second stage of labor was significantly shorter (p < 0.01) in the study group. This was at the expense of the passive phase of the second stage of labor (p < 0.01). Significantly less episiotomies were performed in the study group (31.2% vs 17.8%, p < 0.05).

CONCLUSION

The intervention of a physiotherapist during the second stage of labor significantly improved the obstetric outcome.

Second stage of labor

Current American College of Obstetricians and Gynecologists' definition of prolonged second stage diagnoses 10% to 14% of nulliparous and 3% to 3.5% of multiparous women as having a prolonged second stage. The progression of labor in modern obstetrics may have deviated from the current labor norms established in the 1950s, likely due to differences in obstetric population characteristics and variation in clinical practice. Optimal management of the second stage in women with and without epidural remains debatable. Although prolonged second stage is associated with increased risk of maternal morbidity, conflicting data exist regarding the duration of second stage and associated neonatal morbidity and mortality.

The degree of labor pain at the time of epidural analgesia in nulliparous women influences the obstetric outcome

Background

The increased pain at the latent phase can be associated with dysfunctional labor as well as increases in cesarean delivery frequency. We aimed to research the effect of the degree of pain at the time of epidural analgesia on the entire labor process including the mode of delivery.

Methods

We performed epidural analgesia to 102 nulliparous women on patients' request. We divided the group into three based on NRS (numeric rating scale) at the moment of epidural analgesia; mild pain, NRS 1-4; moderate pain, NRS 5-7; severe pain, NRS 8-10. The primary outcome was the mode of delivery (normal labor or cesarean delivery).

Results

There were significant differences in the mode of delivery among groups. Patients with severe labor pain had a significantly higher cesarean delivery compared to patients with moderate labor pain (P = 0.006). The duration of the first and second stage of labor, fetal heart rate, use of oxytocin and premature rupture of membranes had no differences in the three groups.

Conclusions

Our research showed that the degree of pain at the time of epidural analgesia request might influence the rate of cesarean delivery. Further research would be necessary for clarifying the mechanism that the augmentation of pain affects the mode of delivery.

Pain management for women in labour: an overview of systematic reviews

BACKGROUND

The pain that women experience during labour is affected by multiple physiological and psychosocial factors and its intensity can vary greatly.  Most women in labour require pain relief. Pain management strategies include non-pharmacological interventions (that aim to help women cope with pain in labour) and pharmacological interventions (that aim to relieve the pain of labour).

OBJECTIVES

To summarise the evidence from Cochrane systematic reviews on the efficacy and safety of non-pharmacological and pharmacological interventions to manage pain in labour. We considered findings from non-Cochrane systematic reviews if there was no relevant Cochrane review.

METHODS

We searched the Cochrane Database of Systematic Reviews (The Cochrane Library 2011, Issue 5), The Cochrane Database of Abstracts of Reviews of Effects (The Cochrane Library 2011, Issue 2 of 4), MEDLINE (1966 to 31 May 2011) and EMBASE (1974 to 31 May 2011) to identify all relevant systematic reviews of randomised controlled trials of pain management in labour. Each of the contributing Cochrane reviews (nine new, six updated) followed a generic protocol with 13 common primary efficacy and safety outcomes. Each Cochrane review included comparisons with placebo, standard care or with a different intervention according to a predefined hierarchy of interventions. Two review authors extracted data and assessed methodological quality, and data were checked by a third author. This overview is a narrative summary of the results obtained from individual reviews.

MAIN RESULTS

We identified 15 Cochrane reviews (255 included trials) and three non-Cochrane reviews (55 included trials) for inclusion within this overview. For all interventions, with available data, results are presented as comparisons of: 1. Intervention versus placebo or standard care; 2. Different forms of the same intervention (e.g. one opioid versus another opioid); 3. One type of intervention versus a different type of intervention (e.g. TENS versus opioid). Not all reviews included results for all comparisons. Most reviews compared the intervention with placebo or standard care, but with the exception of opioids and epidural analgesia, there were few direct comparisons between different forms of the same intervention, and even fewer comparisons between different interventions. Based on these three comparisons, we have categorised interventions into: " What works" ,"What may work", and "Insufficient evidence to make a judgement".WHAT WORKSEvidence suggests that epidural, combined spinal epidural (CSE) and inhaled analgesia effectively manage pain in labour, but may give rise to adverse effects. Epidural, and inhaled analgesia effectively relieve pain when compared with placebo or a different type of intervention (epidural versus opioids). Combined-spinal epidurals relieve pain more quickly than traditional or low dose epidurals. Women receiving inhaled analgesia were more likely to experience vomiting, nausea and dizziness.When compared with placebo or opioids, women receiving epidural analgesia had more instrumental vaginal births and caesarean sections for fetal distress, although there was no difference in the rates of caesarean section overall. Women receiving epidural analgesia were more likely to experience hypotension, motor blockade, fever or urinary retention. Less urinary retention was observed in women receiving CSE than in women receiving traditional epidurals. More women receiving CSE than low-dose epidural experienced pruritus.  WHAT MAY WORKThere is some evidence to suggest that immersion in water, relaxation, acupuncture, massage and local anaesthetic nerve blocks or non-opioid drugs may improve management of labour pain, with few adverse effects.  Evidence was mainly limited to single trials. These interventions relieved pain and improved satisfaction with pain relief (immersion, relaxation, acupuncture, local anaesthetic nerve blocks, non-opioids) and childbirth experience (immersion, relaxation, non-opioids) when compared with placebo or standard care. Relaxation was associated with fewer assisted vaginal births and acupuncture was associated with fewer assisted vaginal births and caesarean sections.INSUFFICIENT EVIDENCEThere is insufficient evidence to make judgements on whether or not hypnosis, biofeedback, sterile water injection, aromatherapy, TENS, or parenteral opioids are more effective than placebo or other interventions for pain management in labour. In comparison with other opioids more women receiving pethidine experienced adverse effects including drowsiness and nausea. 

AUTHORS' CONCLUSIONS

Most methods of non-pharmacological pain management are non-invasive and appear to be safe for mother and baby, however, their efficacy is unclear, due to limited high quality evidence. In many reviews, only one or two trials provided outcome data for analysis and the overall methodological quality of the trials was low. High quality trials are needed.There is more evidence to support the efficacy of pharmacological methods, but these have more adverse effects. Thus, epidural analgesia provides effective pain relief but at the cost of increased instrumental vaginal birth.It remains important to tailor methods used to each woman's wishes, needs and circumstances, such as anticipated duration of labour, the infant's condition, and any augmentation or induction of labour.A major challenge in compiling this overview, and the individual systematic reviews on which it is based, has been the variation in use of different process and outcome measures in different trials, particularly assessment of pain and its relief, and effects on the neonate after birth. This made it difficult to pool results from otherwise similar studies, and to derive conclusions from the totality of evidence. Other important outcomes have simply not been assessed in trials; thus, despite concerns for 30 years or more about the effects of maternal opioid administration during labour on subsequent neonatal behaviour and its influence on breastfeeding, only two out of 57 trials of opioids reported breastfeeding as an outcome. We therefore strongly recommend that the outcome measures, agreed through wide consultation for this project, are used in all future trials of methods of pain management.

Oxytocin as a "high alert medication": a multilayered challenge to the status quo

Oxytocin is the drug most commonly associated with preventable adverse perinatal outcomes. In 2007 it was added to the Institute for Safe Medication Practices short list of medications "bearing a heightened risk of harm," which may "require special safeguards to reduce the risk of error." In January 2009 the American Journal of Obstetrics and Gynecology published a Clinical Opinion paper about oxytocin's inclusion on the list and how the obstetrics profession in the United States should respond. The authors call for the development of specific evidence-based guidelines to reduce the likelihood of patient harm by limiting elective use of oxytocin, decreasing the need for indicated use, reducing dosages during necessary use, giving more responsibility and authority for the patient's safety to the professional who is "at the bedside administering and monitoring the oxytocin infusion" (i.e., the nurse), and accepting that "more time rather than more oxytocin is generally preferable" once adequate uterine activity has been achieved. It is unfortunate that this important paper discounted the risk of harm from cesarean sections and did not mention the strong linkage between epidural analgesia and use of oxytocin. Physicians, midwives, nurses, and others should examine and discuss these issues further in view of increased alertness to the risk of harm from unsafe use of oxytocin.

Incidents in anaesthesia: past occurrence and future avoidance

This article is a revised version of an analysis of reported incidents related to anaesthesia, originally published in the journal Anaesthesia (Catchpole et al 2008a) and undertaken on behalf of the National Patient Safety Agency. The purpose was to examine the range, types, frequencies and causes of reported patient safety incidents associated with anaesthesia. First we examined anaesthetic incidents as a sub-set of the total number of reported incidents; then we examined pre-surgery assessment, epidural anaesthesia, and anaesthetic awareness incidents, as they were identified as being frequent and of potential concern. To our knowledge it was the first paper to analyse and present results of the NPSA's database in a clinical academic journal. Here, we take the opportunity to re-present and review the findings in light of subsequent progress in understanding and improving patient safety and quality of care.

Hands-and-knees positioning during labor with epidural analgesia

Hands-and-knees position has shown promise as an intervention to improve labor and birth outcomes, but no reports exist that examine its use with women laboring with epidural analgesia. Concerns of safety, effects on analgesia, and acceptability of use may limit use of active positioning during labor with regional analgesia. This article presents a case study series of 13 women who used hands-and-knees position in the first stage of labor.

Pain perception among parturients in Enugu, South-eastern Nigeria

In order to evaluate pain perception among parturients in Enugu, South-east Nigeria, a cross-sectional questionnaire study of parturients who delivered vaginally in four health institutions in Enugu from 2 December 2005 to 21 January 2006 was administered. Data analysis was by means of percentages, means +/- SD, correlation coefficients, t-tests, chi2-tests, one-way ANOVA and other inferential statistics using the statistical package SPSS for MS Windows at the 95% confidence level. A total of 250 questionnaires were distributed, out of which 181 were correctly filled and returned for a response rate of 72.4%. On a scale of 0 to 10, with 0 representing no pain and 10 representing maximal pain, the mean intensity of pain recorded by the respondents was 7.7 +/- 2.8. A total of 40 (22.1%) parturients received some pain relieving drug during their labour while 141 (77.9%) did not. Of the 40 women who received intra-partum analgesia, three women received pethidine, 17 (42.5%) received pentazocine, while 20 (50%) did not know the analgesic they received. Of the 141 respondents who did not receive intra-partum analgesia, 79 (56.0%) would have liked to have receive analgesia, while 62 (44.0%) would not. Of the 92 women who had their backs rubbed by companions during labour, 67 (72.8%) reported that this practice was helpful in relieving their labour pains, while 25 (27.2%) did not find it helpful. Of the 141 women who had a companion, 103 (73.0%) reported that this was helpful in relieving labour pains, while 38 (27.0%) reported no benefit. Antenatal care, place of residence, ethnicity, religion, marital status, occupational level, receiving intra-partum analgesia, type of analgesia received, having a companion during labour or receiving lectures on labour pains during the antenatal period had no significant impact on pain perception by the respondents (p > 0.05 for each of these variables). There was no significant correlation between pain scores and the respondents' ages and gestational age at delivery (p > 0.05). However, there was a significant positive correlation between the parturients' pain scores and their educational levels (r = 0.18, p = 0.018) and a significant negative correlation between pain scores and parity (r = -0.23, p = 0.009), with primigravidae having the highest perceived mean pain score compared with multiparas and grandmultiparas (7.5 +/- 2.3 vs 6.6 +/- 2.5 vs 6.3 +/- 2.1, p = 0.048). Additionally, those parturients who had their backs rubbed by a companion had a significantly higher mean perceived pain score than their counterparts whose backs were not rubbed (8.4 +/- 2.4 vs 6.8 +/- 2.9, p = 0.000). Parturients whose labours were either induced or augmented had a significantly higher perceived mean pain score than those who had spontaneous labour (8.9 +/- 2.5 vs 7.1 +/- 2.8, p = 0.001). It was concluded that parturients in Enugu, Eastern Nigeria, perceive labour as a very painful process with only a minority of them receiving any form of intra-partum analgesia. There is thus a large unmet need for pain relief among the parturients. Obstetric analgesia as is currently practiced in developed countries is long overdue in Nigeria.

Birth outcomes associated with interventions in labour amongst low risk women: A population-based study

INTRODUCTION

Despite concern over high rates of operative birth in many countries, particularly amongst low risk healthy women, the obstetric antecedents of operative birth are poorly described. We aimed to determine the association between interventions introduced during labour with interventions in the birth process amongst women of low medical risk.

METHODS

We undertook a population-based descriptive study of all low risk women amongst the 753,895 women who gave birth in Australia during 2000-2002. Adjusted odds ratios (AOR) were calculated using multinomial logistic regression to describe the association between mode of birth and each of four labour intervention subgroups separately for primiparous and multiparous women.

RESULTS

We observed increased rates of operative birth in association with each of the interventions offered during the labour process. For first time mothers the association was particularly strong.

CONCLUSIONS

This study underlines the need for better clinical evidence of the effects of epidurals and pharmacological agents introduced in labour. At a population level it demonstrates the magnitude of the fall in rates of unassisted vaginal birth in association with a cascade of interventions in labour and interventions at birth particularly amongst women with no identified risk markers and having their first baby. This information may be useful for women wanting to explore other methods of influencing the course of labour and the management of pain in labour, especially in their endeavour to achieve a normal vaginal birth.

Does epidural analgesia affect the rate of spontaneous obstetric lacerations in normal births?

The precise relationship between epidural use and genital tract lacerations in normal childbirth is unclear. Data from a clinical trial on measures to lower genital tract trauma in vaginal birth were used for a secondary analysis. The goal was to assess whether epidurals affect the rate of spontaneous obstetric lacerations in normal vaginal births. Maternal characteristics and intrapartum variables were compared in women who did and did not use an epidural in labor, and also in those with and without any sutured lacerations following vaginal birth. Variables that were statistically different in both cases were entered into regression equations for simultaneous adjustment. Epidural use was not an independent predictor of sutured lacerations. Predictors of sutured lacerations included nulliparity, a prolonged second stage, being non-Hispanic white, and an infant birthweight greater than 4000 grams. Elements of midwifery management need further research.

Birth Plans: The Good, the Bad, and the Future

A written birth plan encourages women to clarify desires and expectations and communicate with their providers to make a realistic plan for care during labor. Tension between health professionals and patients caused by birth plans reflects the larger problems with contemporary maternity care: conflicting beliefs about birth, what constitutes safe, effective care, and ethical issues related to informed consent and informed refusal. The focus of birth plans should be to answer three patient-focused questions: What will I do to stay confident and feel safe? What will I do to find comfort in response to my contractions? Who will support me through labor, and what will I need from them? In this article, the history and purposes of birth plans and approaches to resolving tensions will be discussed.

Epidural analgesia during labor and delivery: effects on the initiation and continuation of effective breastfeeding

This prospective cohort study examined the association between epidural analgesia during labor and delivery, infant neurobehavioral status, and the initiation and continuation of effective breastfeeding. Healthy, term infants delivered vaginally by mothers who received epidural analgesia (n = 52) or no analgesia (n = 63) during labor and delivery were assessed at 8 to 12 hours postpartum, followed by a telephone interview with the mothers at 4 weeks postpartum. There was no significant difference between the epidural analgesia and no-analgesia groups in breastfeeding effectiveness or infant neurobehavioral status at 8 to 12 hours or in the proportion of mothers continuing to breastfeed at 4 weeks. Therefore, epidural analgesia did not appear to inhibit effective breastfeeding. There was a positive correlation between infant neurobehavioral status and breastfeeding effectiveness (Spearman rho = 0.48, P = .01), suggesting that neurobehavioral assessment may prove beneficial in identifying infants at greater risk for breastfeeding difficulties.

Analgesia and Anesthesia in Labor

Whether given as an epidural, spinal, or combination, regional anesthesia is an integral part of obstetrics in the United States. A variety of drugs and dosages are used in various combinations, with no one protocol exceeding others in terms of efficacy and safety. The availability of anesthesia and analgesia has had an extraordinary impact on the field of obstetrics in the twentieth century. Knowledge of the techniques and medications used, their potential toxicities, and effects on the labor process itself can only enhance obstetricians' management of the parturient in labor.

Reevaluation of Friedman's Labor Curve: A Pilot Study

OBJECTIVE

To reevaluate the average length of each phase/stage of labor for multiparous and primiparous women in North America who received no regional anesthesia or oxytocin augmentation or induction, to describe a range of labor lengths associated with good childbirth outcomes, and to determine if there is a consensus among labor and delivery nurse managers responding to the survey regarding the need to revise Friedman's Labor Curve.

DESIGN

This pilot study used a descriptive and anonymous cross-sectional survey design. Surveys were mailed to 500 maternity care agencies in the United States, Canada, and Mexico with a return rate of 17.8% (n = 89). Each participating agency was asked to submit five patient cases to be included in the analysis.

SAMPLE AND SETTING

The sample of patient cases (n = 419) was drawn from randomly selected maternity care agencies throughout North America representing all sizes of agencies and geographic locations. The cases submitted for analysis represented women 14 to 44 years of age with varying ethnicities who received no regional anesthesia or oxytocin augmentation or induction. Twenty-three percent of the women in the sample (n = 97) were primigravidas.

RESULTS

The average length of labor for primiparous and multiparous women today is similar to the average length of labor described by Friedman in 1954. However, a wider range of "normal" was found in cases included in the current study. Primiparous women remained in the first stage of labor for up to 26 hours and the second stage of labor up to 8 hours with no adverse effects to mother or infant. Multiparous women remained in the first stage of labor for up to 23 hours and the second stage of labor for up to 4.5 hours with good birth outcomes. In addition, 87.6% of nurse managers responding to the survey believed that Friedman's Labor Curve should be revised to meet the needs of current patient populations, technological advances, and nursing responsibilities.

CONCLUSIONS

This study suggests that the parameters to determine if a labor is progressing satisfactorily may need to be expanded. With the availability of technology to assess maternal and fetal well-being, labor should be allowed to progress past the rigid 2-hour time limit for the second stage of labor artificially imposed on women in some childbirth settings. More emphasis should be placed on the nursing assessment techniques used to reassure the family and health care practitioners that labor is progressing safely and the nursing interventions that may have an impact on the length of each stage of labor.

A prospective randomised trial on the effect of position in the passive second stage of labour on birth outcome in nulliparous women using epidural analgesia

OBJECTIVE

To determine whether the rate of instrumental birth in nulliparous women using epidural analgesia is affected by maternal position in the passive second stage of labour.

DESIGN

A pragmatic prospective randomised trial.

SETTING

Consultant maternity unit in the Midlands.

PARTICIPANTS

One hundred and seven nulliparous women using epidural analgesia and reaching the second stage of labour with no contraindications to spontaneous birth.

INTERVENTIONS

The lateral versus the supported sitting position during the passive second stage of labour.

MEASUREMENTS

Mode of birth, incidence of episiotomy, and perineal suturing.

FINDINGS

Recruitment was lower than anticipated (107 vs. 220 planned). Lateral position was associated with lower rates of instrumental birth rate (lateral group 33%; sitting group 52%; p=0.05, RR 0.64, CI for RR: 0.40-1.01; Number-needed-to-treat (NNT)=5), of episiotomy (45% vs. 64%; p=0.05, RR 0.66, CI for RR: 0.44-1.00, NNT=5), and of perineal suturing (78% vs. 86%; p=0.243, RR 0.75, CI for RR 0.47-1.17). The odds ratio for instrumental birth in the sitting group was 2.2 (CI 1.00-4.6). Logistic regression of potential confounder variables was undertaken, due to a large variation in maternal weight between the randomised groups. Of the nine possible confounders tested, only position of the baby's head at full dilation affected the risk of instrumental birth significantly (p=0.4, OR 2.7 where the fetal head was in the lateral or posterior position). Maternal weight did not appear to have any effect. The odds ratio for instrumental delivery for women randomised to the sitting position was slightly higher within the logistic regression model (adjusted OR 2.3).

KEY CONCLUSIONS

Women randomised to the lateral position had a better chance of a spontaneous vaginal birth than those randomised to the supported sitting position. Position of the babies head at full dilation had an additional effect on mode of birth. These effects are not conclusively generalizable. RECOMMENDATIONS FOR PRACTICE: The lateral position is likely to be at best beneficial, and at the worst no less harmful than the sitting position for most women and their babies who meet the criteria set for this study. Conclusive evidence for or against the technique should be established using larger trials.

Effects on the fetus and newborn of maternal analgesia and anesthesia: a review

PURPOSE

To review the effects of maternal anesthesia and analgesia on the fetus and newborn.

METHODS

An on-line computerized search of Medline, Embase, and the Cochrane Collaboration via PubMed was conducted. English language articles were selected. The bibliographies of relevant articles and additional material from other published sources were retrieved and reviewed.

PRINCIPAL FINDINGS

No one test clearly separates the effects on the fetus/newborn, if any, of maternally administered medication during labour and delivery, or during surgery for non-obstetric indications. Supposition in this regard is limited in part by methodology previously used to study the transplacental passage of various drugs. This work needs to be repeated using a human model. Routine maternal supplemental oxygen administration is being questioned in light of research showing that free radical generation and oxidative stress are implicated as the underlying mechanisms in several neonatal conditions. Maternal hypotension is associated with neonatal acidemia and base excess correlates with neonatal outcome. Common postpartum analgesics transfer minimally into breast milk. Maternal or fetal surgery conducted during pregnancy necessitates modification of both anesthetic and surgical approaches. The key to resuscitation of the fetus is resuscitation of the mother: intra-uterine maneuvers, including perimortem Cesarean section, aim to reverse treatable causes of fetal asphyxia, restore fetal oxygenation, and correct fetal acidosis.

CONCLUSIONS

The well-being of the infant is a major criterion for evaluating the anesthetic management of pregnant women. Many tools exist to assist with this determination for the fetus, whereas few are available to evaluate the newborn.

Analgesia and Anesthesia During Labor and Birth: Implications for Mother and Fetus

Labor and birth, although viewed as a normal physiological process, can produce significant pain, requiring appropriate pain management. Systemic analgesia and regional analgesia/anesthesia have become less common, whereas the use of newer neuraxial techniques, with minimal motor blockade, have become more popular. Low- and ultra-low-dose epidural analgesia, spinal analgesia, and combination spinal-epidural analgesia have replaced the once traditional epidural for labor. The shift from regional anesthesia during labor, in which the woman became a passive participant during the labor and birth, to a collaborative approach for pain management, in which the woman becomes an active participant, has resulted in a new philosophy of labor analgesia. This article provides a review of the current systemic analgesics and regional and neuraxial analgesia/anesthesia techniques for pain management in labor and birth. Also addressed are implications for perinatal nurses who participate in pain management choices during labor and birth.

Neuraxial analgesia for labor and birth: implications for mother and fetus

Women are better educated today on issues related to labor and childbirth. Pain management options for the woman in labor have changed dramatically over the last decade. Systemic analgesia and dense-motor-blockade regional analgesia/anesthesia have become less common for childbirth while the use of newer neuraxial and regional techniques, with minimal motor blockade, have become more popular. The shift from regional anesthesia with significant motor-blockade during labor, where the woman is a passive participant during the labor and birth, to a collaborative approach for pain management, where the woman becomes an active participant, has resulted in a new philosophy of analgesia for labor and birth. This article provides a review of current neuraxial analgesia/anesthesia techniques used for pain management in labor and birth and their implications for the perinatal nurse.

Use of upright positioning with epidural analgesia: findings from an observational study

PURPOSE

To present research findings and related nursing implications from an observational study designed to evaluate the use of upright positioning during second stage labor with patients who had received low-dose epidural analgesia.

STUDY DESIGN AND METHODS

This descriptive study evaluated outcomes from a sample of 74 healthy women having their first childbirth. They had all received epidural analgesia during the first and second stages of labor. Data were also collected by nurses on the use of birthing beds, and the extent of physical and emotional support the women needed while following the upright positioning study protocol.

RESULTS

All women were able to maintain upright positions throughout the second stage of labor following epidural analgesia administration. No adverse neonatal outcomes or maternal problems (such as excessive vaginal bleeding) were documented.

CLINICAL IMPLICATIONS

Although women were capable of assuming upright positions during second stage, the study results indicated that constant physical and emotional support was necessary for most women. Future research on methods to prepare women for multiple position options after administration of low-dose epidural analgesia should be undertaken. In addition, nurses should evaluate the benefits of upright positioning in terms of facilitating progress of labor.

Nursing responsibilities in preventing, preparing for, and managing epidural emergencies

An increasing number of women receive epidurals during labor and birth. Although the incidence of adverse reactions remains very low, the potential for life-threatening complications still exists. The Association of Women's Health, Obstetric and Neonatal Nurses (AWHONN) states that the safety of women undergoing procedures, such as the administration of epidural analgesia/anesthesia, depends significantly on the competence, attentiveness, and experience of those responsible for their care. The purpose of this article is to review the significant complications related to obstetric epidural. Recommendations are presented to aid the nurse in preparing for and managing epidural emergencies. Specific responsibilities of nurse managers and educators in competency training, evaluation, and guidance of nurses are also discussed.

The nature and management of labor pain: executive summary

This report describes the background and process for a rigorous project to improve understanding of labor pain and its management, and summarizes the main results and their implications. Labor pain and methods to relieve it are major concerns of childbearing women, with considerable implications for the course, quality, outcome, and cost of intrapartum care. Although these issues affect many women and families and have major consequences for health care systems, both professional and public discourse reveal considerable uncertainty about many questions, including major areas of disagreement. An evidence-based framework, including commissioned papers prepared according to carefully specified scopes and guidelines for systematic review methods, was used to develop more definitive and authoritative answers to many questions in this field. The papers were presented at an invitational symposium jointly sponsored by the Maternity Center Association and the New York Academy of Medicine, were peer-reviewed, and are published in full in this issue of the journal. The results have implications for policy, practice, research, and the education of both health professionals and childbearing women.