Epidural analgesia for labor and delivery

Effect of dural puncture epidural block technique on fetal heart rate variability during labor analgesia

PURPOSE

To explore the effect of dural puncture epidural (DPE) block technique on fetal heart rate variability (HRV) during labor analgesia.

METHODS

Sixty full-term primiparas who were in our hospital from April 2021 to October 2021 were selected and randomized into epidural analgesia (CEA) and dural puncture epidural analgesia (DPEA) groups (n = 30). After a successful epidural puncture, routine epidural catheter (EC) was performed in CEA group, and spinal anesthesia needle (as an EC) was used to puncture the dura mater to subarachnoid space in DPE group. Anesthetics were injected through EC. The time when the temperature sensation plane reached T10 (W1) and visual analog pain score (VAS), baseline heart rate score, amplitude variation score, cycle variation score, acceleration score, deceleration score, and total score of the first contraction after W1 were recorded. Apgar scores at 1 min, 5 min, and 10 min of neonates after delivery were recorded.

RESULTS

The onset time of anesthesia in CEA group was significantly longer than that in DPEA group (p < .05). However, there are no significant differences in W1, VAS, baseline heart rate score, amplitude variation score, cycle variation score, acceleration score, deceleration score, and total score of the first contraction after W1 between the two groups (p > .05). Moreover, the Apgar scores at 1 min, 5 min and 10 min of neonates after delivery were not notably different between the two groups (p > .05).

CONCLUSION

Compared with CEA, DPE block technique in labor analgesia relieves maternal pain without adverse effects on fetal HRV and newborns.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

The influence of epidural anesthesia in pregnancies with scheduled vaginal breech delivery at term: a hospital-based retrospective analysis

INTRODUCTION

Epidural anesthesia is a well-established procedure in obstetrics for pain relief in labor and has been well researched as it comes to cephalic presentation. However, in vaginal intended breech delivery less research has addressed the influence of epidural anesthesia. The Greentop guideline on breech delivery states that there's little evidence and recommends further evaluation.

OBJECTIVE

The aim of this study was to compare maternal and neonatal outcomes in vaginally intended breech deliveries at term with and without an epidural anesthesia.

DESIGN

This study was a retrospective cohort study.

SAMPLE

This study included 2122 women at term with a singleton breech pregnancy from 37 + 0 weeks of pregnancy on and a birth weight of at least 2500 g at the obstetric department of University hospital Frankfurt from January 2007 to December 2018.

METHODS

Neonatal and maternal outcome was analyzed and compared between women receiving "walking" epidural anesthesia and women without an epidural anesthesia.

RESULTS

Fetal morbidity, measured with a modified PREMODA score, showed no significant difference between deliveries with (2.96%) or without (1.79%; p = 0.168) an epidural anesthesia. Cesarean delivery rates were significantly higher in deliveries with an epidural (35 vs. 26.2%, p = 0.0003), but after exclusion of multiparous women, cesarean delivery rates were not significantly different (40.2% cesarean deliveries with an epidural vs. 41.5%, p = 0.717). As compared to no epidurals, epidural anesthesia in vaginal delivery was associated with a significantly higher rate of manual assistance (33.8 versus 52.1%) and a longer duration of birth (223.7 ± 194 versus 516.2 ± 310 min) (both p < 0.0001)".

CONCLUSION

Epidural anesthesia can be offered as a safe option for pain relief without increasing neonatal or maternal morbidity and mortality. Nevertheless, it is associated with a longer birth duration and manually assisted delivery.

Headache that will not go away...Third ED visit is the charm?

Subdural hematoma is an uncommon complication of epidural analgesia or diagnostic lumbar puncture. Headache is a common complaint for patients with either a subdural hematoma or a post-dural puncture headache. Because post-dural puncture headaches are commonly seen in the Emergency Department, the potential to miss more serious pathology arises. We present the case of a young female who suffered bilateral subdural hematomas following epidural analgesia during childbirth. She presented twice to the Emergency Department and was treated for a post-dural puncture headache before computed tomography imaging revealed the diagnosis on the third Emergency Department encounter. This case highlights the importance of exploring all potential diagnoses when a patient presents with a headache after either epidural analgesia or a diagnostic lumbar puncture, especially if the patient returns after unsuccessful treatment for a presumptive post-dural puncture headache.

Epidural analgesia and neonatal short-term outcomes during routine childbirth: a 10-year retrospective analysis from the national birth registry of Austria

BACKGROUND

Epidural analgesia (EA) is well-accepted for pain relief during labor. Still, the impact on neonatal short-term outcome is under continuous debate. This study assessed the outcome of neonates in deliveries with and without EA in a nationwide cohort.

METHODS

We analyzed the National Birth Registry of Austria between 2008 and 2017 of primiparous women with vaginal birth of singleton pregnancies. Neonatal short-term morbidity was assessed by arterial cord pH and base excess (BE). Secondary outcomes were admission to a neonatological intensive care unit, APGAR scores, and perinatal mortality. Propensity score-adjusted regression models were used to investigate the association of EA with short-term neonatal outcome.

RESULTS

Of 247,536 included deliveries, 52 153 received EA (21%). Differences in pH (7.24 vs. 7.25; 97.5% CI -0.0066 to -0.0047) and BE (-5.89±3.2 vs. -6.15±3.2 mmol/L; 97.5% CI 0.32 to 0.40) with EA could be shown. APGAR score at five minutes <7 was more frequent with EA (OR 1.45; 95% CI: 1.29 to 1.63). Admission to a neonatological intensive care unit occurred more often with EA (4.7% vs. 3.4%) with an OR for EA of 1.2 (95% CI: 1.14 to 1.26). EA was not associated with perinatal mortality (OR 1.33; 95% CI: 0.79 to 2.25).

CONCLUSIONS

EA showed no clinically relevant association with neonatal short-term outcome. Higher rates of NICU admission and APGAR score after five minutes <7 were observed with EA. The overall use of EA in Austria is low, and an investigation of causes may be indicated.

Is epidural analgesia an independent risk factor for OASIS? A population-based cohort study

INTRODUCTION

To evaluate whether epidural analgesia is an independent risk factor for OASIS.

METHODS

A population-based cohort study including all women who delivered by spontaneous vaginal delivery or by instrumental delivery beyond 24 weeks gestation was conducted. Deliveries occurred between 1988 and 2016 at a large university tertiary medical center. Women with multiple gestations and those lacking prenatal care were excluded from the analysis.

RESULTS

During the study period, 252,542 women delivered at the Soroka University Medical Center and met the inclusion criteria. Of these, 583 (0.23%) were diagnosed with OASIS. Women with OASIS were more likely to be younger, nulliparous, with suspected fetal macrosomia, had higher rates of labor induction and vacuum extraction delivery, higher rates of conceiving after infertility treatments, more advanced gestational age at delivery, higher mean birth weight, higher rates of post-partum hemorrhage and need for blood transfusions. Use of epidural analgesia during pregnancy was significantly high among the OASIS group. Rates of episiotomy were not significantly different between the groups. Using a multimodal logistic regression model, after controlling for vacuum delivery, large for gestational age, nulliparity, gestational age, ethnicity, maternal age, induction of labor, fertility treatments, non-reassuring fetal heart rate and non-progressive second stage of labor, epidural analgesia was found to be significantly associated with OASIS.

CONCLUSION

Epidural analgesia was found to be an independent risk factor for OASIS in our population.

Maternal and neonatal effects of epidural levobupivacaine combined with fentanyl or sufentanil for elective cesarean-section in brachycephalic breeds

The aim of this study was to compare the safety and clinical efficacy of epidural levobupivacaine combined with fentanyl or sufentanil for bitches undergoing elective cesarean-section and the impact of these anesthetic protocols on neonatal viability. The anesthetic protocol consisted of intramuscular morphine (0.2 mg/kg), followed by an intravenous bolus of propofol, in a dose sufficient to allowed the puncture of the lumbosacral space. The dogs were randomly allocated to receive 0.5 % levobupivacaine plus fentanyl (2.5 µg/kg; LF: n = 9) or sufentanil (1 µg/kg; LS; n = 11). Maternal cardiorespiratory parameters were monitored at specific time points during surgery. Intraoperative propofol supplementation was based on the presence of head and/or thoracic limb movements. Neonatal reflex responses and the Apgar score (range 0-10 points) were assessed at 5 and 60 minutes after birth. Puppy mortality rate was recorded until 24 hours after birth. Data were analyzed using two-way ANOVA, Tukey's test, Wilcoxon signed rank test, and Fisher's exact test (P < 0.05). Intraoperatively, maternal cardiorespiratory variables and propofol requirements were similar between groups, with no detection of anesthetic complications. The puppy reflex responses did not differ between groups at any time point. The medians (range) of Apgar scores were lower (P = 0.016) in the LF [5 (1-9)] at 5 minutes in comparison with LS [6 (2-9)], while no intergroup differences were recorded at 60 minutes [LF = 8 (2-10); LS = 9 (6-10]. The total mortality rate was 4.1 %. In the LS group, no puppies died, while in the LF 8 % of the puppies died in the first 24 hours after birth (P = 0.11). Epidural levobupivacaine combined with fentanyl or sufentanil provided minimal maternal and neonatal adverse effects, but neither protocol enabled the performance of a C-section in 100 % of the French and English bulldogs, without propofol supplementation.

Influence of different volumes and frequency of programmed intermittent epidural bolus in labor on maternal and neonatal outcomes: A systematic review and network meta-analysis

STUDY OBJECTIVE

In labor, programmed intermittent epidural bolus (PIEB) can be defined as the bolus administration of epidural solution at scheduled time intervals. Compared to continuous epidural infusion (CEI) with or without patient controlled epidural analgesia (PCEA), PIEB has been associated with decreased pain scores and need for rescue analgesia and increased maternal satisfaction. The optimal volume and dosing interval of PIEB, however, has still not been determined.

DESIGN

Systematic review and network meta-analysis registered with PROSPERO (CRD42022362708).

SETTINGS

Labor.

PATIENTS

Pregnant patients.

INTERVENTIONS

Central, CINAHL, Global Health, Ovid Embase, Ovid Medline and Web of Science were searched for randomized controlled trials that examined pregnant patients in labor who received CEI or PIEB with or without a PCEA component. Network meta-analysis was performed with a frequentist method, facilitating the indirect comparison of PIEB with different volumes and dosing intervals through the common comparator of CEI and substituting or supplementing direct comparisons with these indirect ones. Continuous and dichotomous outcomes were presented as mean differences and odds ratios, respectively, with 95% confidence intervals. The risk of bias was evaluated using the Cochrane risk of bias 2 tool.

MAIN RESULTS

Overall, 30 trials were included. For the first primary endpoint, need for rescue analgesia, PIEB delivered at a volume of 4 ml and frequency of 45 min (4/45) was inferior to PIEB 8/45 (OR 3.55; 95% CI 1.12-11.33), PIEB 10/60 was superior to PIEB 2.5/15 (OR 0.36; 95% CI 0.16-0.82), PIEB 4/45 (OR 0.14; 95% CI 0.03-0.71) and PIEB 5/60 (OR 0.23; 95% CI 0.08-0.70), and PIEB 5/30 was not inferior to PIEB 10/60 (OR 0.61; 95% CI 0.31-1.19). For the second primary endpoint, maternal satisfaction, no differences were present between the various PIEB regimens. The quality of evidence for these multiple primary endpoints was low owing to the presence of serious limitations and imprecision. Importantly, PIEB 5/30 decreased the pain score at 4 h compared to PIEB 2.5/15 (MD 2.45; 95% CI 0.13-4.76), PIEB 5/60 (MD -2.28; 95% CI -4.18--0.38) and PIEB 10/60 (MD 1.73; 95% CI 0.31-3.16). Mean ranking of interventions demonstrated PIEB 10/60 followed by PIEB 5/30 to be best placed to reduce the cumulative dose of local anesthetic, and this resulted in an improved incidence of lower limb motor blockade for PIEB 10/60 in comparison to CEI (OR 0.30; 95% CI 0.14-0.67). No differences in neonatal outcomes were found. Some concerns were present for the risk of bias in two thirds of trials and the risk of bias was shown to be high in the remaining one third of trials.

CONCLUSIONS

Future research should focus on PIEB 5/30 and PIEB 10/60 and how the method of analgesia initiation, nature and concentration of local anesthetic, design of epidural catheter and rate of administration might influence outcomes related to the mother and neonate.

Subcutaneous vs intravenous fentanyl for labor pain management: a multicenter randomized controlled trial

BACKGROUND

Labor pain is the most intense pain a woman will experience during her lifetime. Epidural anesthesia is recommended as the most effective method for pain relief, but it has several limitations. Fentanyl has high analgesic potency with short-acting duration, but the large-scale trials that assessed the effectiveness and safety of it for labor pain management are still limited.

OBJECTIVE

This study aimed to compare the effectiveness and harm and maternal satisfaction of subcutaneous vs intravenous fentanyl for labor pain management.

STUDY DESIGN

We conducted a multicenter, open-label randomized controlled trial. A total of 226 women were randomized to receive intravenous or subcutaneous fentanyl for labor pain management. Pain scores were evaluated before and after fentanyl administration at 5, 30, and 60 minutes and then every 60 minutes until delivery. The data were analyzed based on the intention-to-treat principle.

RESULTS

Both intravenous and subcutaneous fentanyl significantly decreased labor pain from baseline to delivery (overall mean change, -1.39; 95% confidence interval, -1.62 to -1.17; and -0.89; 95% confidence interval, -1.24 to -0.05, respectively). The reduction in the pain score between the 2 groups was not different (overall mean difference, -0.35; 95% confidence interval, -0.76 to 0.05). Maternal satisfaction was high for both intravenous and subcutaneous fentanyl (89.4% and 93.8%, respectively). There was no difference in the maternal satisfaction rate between the 2 groups (relative risk, 0.95; 95% confidence interval, 0.88-1.03). No serious maternal and neonatal adverse effects were observed.

CONCLUSION

Both intravenously and subcutaneously administered fentanyl were safe and significantly reduced pain from baseline to delivery among low-risk pregnancies. Maternal satisfaction with the childbirth experience was high regardless of the route of administration of fentanyl. No serious adverse effects of fentanyl were observed in either the mothers or the neonates.

Comparison of different interventions for the reduction of labor pain: A systematic review and network meta-analysis

OBJECTIVE

This systematic review and network meta-analysis were performed to compare different interventions for the reduction of labor pain.

METHODS

PubMed, Embase, Cochrane Library, Web of Science and ScienceDirect databases were searched for the randomized controlled trials (RCTs) meeting prespecified inclusion criteria up to January, 2023. Interventions including electrical acupoint stimulation (TEAS), epidural analgesia (EA) and control treatments. The primary outcomes included pain scores, failure rate of natural delivery, adverse events and Apgar scores. The methodological quality was assessed by the Cochrane risk of bias tool. Meta-analysis was performed by R software with gemtc package. Surfaces under the cumulative ranking curves (SUCRA) were used to rank the intervention.

RESULTS

Twelve studies met the inclusion criteria and were included in the network meta-analysis. TEAS (WMD -3.1, 95% CrI -3.8, -2.5) and EA (WMD -2.1, 95% CrI -2.8, -1.3) was more effective than the control in decreasing VAS. TEAS ranked first (SUCRA, 90.9%), EA ranked second (SUCRA, 74.0%) and control ranked last (SUCRA, 35.0%) for reducing VAS. For patients with labor pain, with respect to the most effective treatment for reducing failure rate of natural delivery, TEAS ranked first (SUCRA, 96.6%), EA ranked second (SUCRA, 50.4%) and control ranked last (SUCRA, 3.0%). With regard to the Apgar scores, there was high probability that TEAS ranked first (SUCRA, 80.7%), compared to control (SUCRA, 41.4%) and EA (SUCRA 27.9%). With regard to the adverse events, there was high probability that TEAS ranked first (SUCRA, 99.9%), compared to control (SUCRA, 33.2%) and EA (SUCRA 17.6%).

CONCLUSION

TEAS has the potential to serve as a viable alternative for women in labor, offering a simple, noninvasive, and non-pharmacological intervention that surpasses EA in terms of both analgesic effectiveness and safety for both mothers and neonates.

Overcoming Obstacles: The Legacy of Fidel Pagés, Founder of the Epidural, 100 Years After His Passing

Fidel Pagés, a Spanish surgeon, tragically died in 1923 at the age of 37, just 2 years after his publication "Anestesia Metamérica," the first description of human thoracolumbar epidural anesthesia. In the intervening 100 years, epidural anesthesia has faced countless obstacles, starting with the dissemination of his initial report, which was not widely read nor appreciated at the time. However, the merits of the technique have fueled innovations to meet these challenges over the years. Even today, while epidural anesthesia is widely embraced, particularly in obstetric and chronic pain medicine, the pressures of the operating room for efficiency and a low tolerance for failure, pose modern-day challenges. Here, we revisit Pagés' original report and highlight the key innovations that have allowed for the evolution of this essential anesthesia technique.

Development and Validation of a Nomogram for the Failed Conversion of Labor Analgesia to Cesarean Section Anesthesia

Purpose

The conversion of epidural labor analgesia (ELA) to epidural surgical anesthesia (ESA) for intrapartum cesarean section (CS) often encounters failures. This study aimed to develop a nomogram for predicting the failure rate of this conversion.

Patients and Methods

A retrospective analysis was conducted on data from the Fujian Maternity and Child Health Hospital. Pregnant women (n=214) who underwent cesarean section after receiving labor analgesia. We performed correlation heat map and Lasso regression in terms of exclusion confounding factors and screening independent variables. A nomogram was developed to predict the occurrence.

Results

The developed nomogram incorporated variables such as pregnant history, weight, premature rupture of membranes (PROM), dural puncture epidural (DPE), anesthesiologist level of cesarean section (ALOCS), and Anesthesiologist level of labor analgesia (ALOLA). The model demonstrated good predictive performance, providing a practical tool for assessing the risk of failure in converting labor analgesia to cesarean section anesthesia.

Conclusion

The nomogram can aid anesthesiologists in making informed decisions and optimizing patient care. By utilizing the nomogram, clinicians can estimate the probability of conversion failure based on individual patient characteristics and clinical factors.

Labor Neuraxial Analgesia and Its Association With Perinatal Outcomes in China in 2015-2016: A Propensity Score-Matched Analysis

BACKGROUND

The use of labor neuraxial analgesia (NA) in China has increased significantly in the past decade, and the current rate of use is unknown. This study aimed to describe the epidemiology of NA based on a large multicenter cross-sectional survey, the China Labor and Delivery Survey (CLDS) (2015-2016), and to evaluate the association between NA and intrapartum caesarean delivery (CD) and maternal and neonatal outcomes.

METHODS

The CLDS was a facility-based cross-sectional investigation with a cluster random sampling scheme conducted from 2015 to 2016. A specific weight was assigned to each individual based on the sampling frame. Logistic regression was adopted to analyze the factors associated with the use of NA. A propensity score matching scheme was used to analyze the associations between NA and intrapartum CD and perinatal outcomes.

RESULTS

A total of 51,488 vaginal deliveries or intrapartum CD were included in our study, excluding prelabor CDs. The weighted NA rate was 17.3% (95% confidence interval [CI], 16.6-18.0) in this survey population. Nulliparous, previous CD, hypertensive disorders, and labor augmentation were associated with higher use of NA. In the propensity score-matched analysis, NA was associated with reduced risks of intrapartum CD, especially intrapartum CD by maternal request (adjusted odds ratio [aOR], 0.68; 95% CI, 0.60-0.78 and aOR, 0.48; 95% CI, 0.30-0.76, respectively), 3rd or 4th degree perineal laceration (aOR, 0.36; 95% CI, 0.15-0.89), and 5-minute Apgar score ≤3 (aOR, 0.15; 95% CI, 0.03-0.66).

CONCLUSIONS

The use of NA may be associated with improved obstetric outcomes, including fewer intrapartum CD, less birth canal trauma, and better neonatal outcomes in China.

Risk factors for recurrence of post-dural puncture headache following an epidural blood patch: a retrospective cohort study

INTRODUCTION

Post-dural puncture headache (PDPH) occurs in 0.38-6.3% of neuraxial procedures in obstetrics. Epidural blood patch (EBP) is the standard treatment but fails to provide full symptom relief in 4-29% of cases. Knowledge of the risk factors for EBP failure is limited and controversial. This study aimed to identify these risk factors.

METHODS

We performed a retrospective cohort study using electronic records of 47920 patients who underwent a neuraxial procedure between 2001 and 2018 in a large maternity hospital in Switzerland. The absence of full symptom relief and the need for further treatment was defined as an EBP failure. We performed univariate and multivariate analyses to compare patients with a successful or failed EBP.

RESULTS

We identified 212 patients requiring an EBP. Of these, 55 (25.9%) had a failed EBP. Signs and symptoms of PDPH did not differ between groups. While needle size and multiple pregnancies were risk factors in the univariate analysis, mostly those related to the performance of the EBP remained significant following adjustment. The risk of failure increased when the epidural space was deeper than 5.5 cm (OR 3.08, 95% CI 1.26 to 7.49) and decreased when the time interval between the initial dural puncture and the EBP was >48 h (OR 0.20, 95% CI 0.05 to 0.83).

CONCLUSION

Persistence of PDPH following a first EBP is not unusual. Close attention should be given to patients having their EBP performed <48 h following injury and having an epidural space located >5.5 cm depth, as these factors are associated with a failed EBP.

Relationship between COMT Gene Polymorphism, Anxiety, and Pain Perception during Labour

BACKGROUND

The COMT gene polymorphism is associated with neurological and psychiatric disorders and pain perception. The present study investigates the existence of anxiety and pain perception in relation to the COMT (catechol-O-methyltransferase) gene polymorphism in labouring women (during "natural" childbirth) with or without inhaled analgesia.

METHODS

A total of 181 women who chose vaginal birth were enrolled in this study. To present the difference in pain perception, the parturients were divided into one group (n = 90) that chose labour analgesia with inhaled nitrous oxide (50% nitrous oxide and 50% oxygen) and one group (n = 91) without analgesia. The blood samples were taken during the pregnancy as a part of routine pregnancy controls in the hospital. The COMT gene polymorphism was detected with the PCR technique. The pain perception of parturients was self-evaluated two times according to the VAS (Visual Analogue Scale), and anxiety as a personality trait was determined with the STAI-T (State Trait Anxiety Inventory). Pain perception as well as anxiety were compared according to COMT genotypes.

RESULTS

In the 181 pregnant women, there were 40 women (22%) of wild homozygotes (GG) of COMT, 95 women (53%) of mutant heterozygotes (GA), and 46 women (25%) of mutant homozygotes (AA). A negative association of pain perception with the GA (mutant heterozygote) polymorphism of the COMT gene versus the wild-type (GG polymorphism) was observed. The GA polymorphism of the COMT gene was associated with 0.46 units lower pain perception compared to the wild type (GG). The anxiety trait score in group AA was lower than in groups GA and GG. The difference reached statistical significance only when comparing AA versus GA (p > 0.042). Analgesic efficacy of nitrous oxide was noticed in 22% of labouring women who reported moderate pain (VAS score 4-7).

CONCLUSIONS

The COMT gene polymorphism was associated with pain perception and anxiety among parturients. The COMT gene polymorphism GA was associated with negative pain perception among labouring women. Nitrous oxide showed statistical significance in anxiolytic efficacy during labour in women with mild anxiety as a personality trait. Anxiolytic efficacy of nitrous oxide has shown better efficacy in parturients with the COMT gene polymorphism AA.

'Walking epidural': comparison of the analgesic efficacy of levobupivacaine 0.0625% + fentanyl 2mcg/mL versus ropivacaine 0.075% + fentanyl 2mcg/mL

INTRODUCTION

Epidural infusion with low local anesthetic concentrations with opiates decrease the severity of the motor blockade associated. The present study aims to compare the analgesic efficacy and the motor blockade between two local anesthetic epidural infusions: levobupivacaine 0.0625% + fentanyl 2mcg/mL versus ropivacaine 0.075% + fentanyl 2mcg/mL.

MATERIALS AND METHODS

In a single-blind prospective randomized study, 60 laboring parturient had continuous epidural analgesia as follows: 30 of them received levobupivacaine 0.0625% + fentanyl 2mcg/mL and 30 of them received ropivacaine 0.075% + fentanyl 2mcg/mL and rates of infusion were adjusted to the height. Analgesic, motor blockade and satisfaction records were collected as well as maternal and neonate adverse events.

RESULTS

After 2 h of the catheter placement, patients who received levobupivacaine showed a mean VAS of 3.2 [1.8-4.6] versus 1.8 [1.2-2.5] (p = 0.05) in patients who received ropivacaine. In addition, patients who received levobupivacaine showed a punctuation in Bromage scale of 0.0 [0.0-1.0] versus 0.0 [0.0-0.0] (p = 0.04) in patients who received ropivacaine. Finally, the parturient who received levobupivacaine scored a mean satisfaction index of 8.1 [7.3-8.9] versus 9.3 [8.7-9.8] (p = 0.02) in those who received ropivacaine. We did not register maternal nor neonate adverse events.

CONCLUSION

Both infusions (levobupivacaine 0.0625% + fentanyl 2mcg/mL and ropivacaine 0.075% + fentanyl 2mcg/mL) are effective for labor analgesia. However, ropivacaine would present a better pharmacodynamic profile with less motor blockade and decreased need for analgesic rescue hence improving patient's satisfaction.

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.

Intrapartum Cesarean Section and Perinatal Outcomes after Epidural Analgesia or Remifentanil-PCA in Breech and Twin Deliveries

Comparative data on the potential impact of various forms of labor analgesia on the mode of delivery and neonatal complications in vaginal deliveries of singleton breech and twin fetuses are lacking. The present study aimed to determine the associations between type of labor analgesia (epidural analgesia (EA) vs. remifentanil patient-controlled analgesia (PCA)) and intrapartum cesarean sections (CS), and maternal and neonatal adverse outcomes in breech and twin vaginal births. A retrospective analysis of planned vaginal breech and twin deliveries at the Department of Perinatology, University Medical Centre Ljubljana, was performed for the period 2013-2021, using data obtained from the Slovenian National Perinatal Information System. The pre-specified outcomes studied were the rates of CS in labor, postpartum hemorrhage, obstetric anal sphincter injury (OASI), an Apgar score of <7 at 5 min after birth, birth asphyxia, and neonatal intensive care admission. A total of 371 deliveries were analyzed, including 127 term breech and 244 twin births. There were no statistically significant nor clinically relevant differences between the EA and remifentanil-PCA groups in any of the outcomes studied. Our findings suggest that both EA and remifentanil-PCA are safe and comparable in terms of labor outcomes in singleton breech and twin deliveries.

Modern labor epidural analgesia: implications for labor outcomes and maternal-fetal health

Epidural analgesia is an important means of pain control during labor throughout the world. Over its historic development, it has been implicated in several undesirable outcomes, including prolongation of labor and increased need for operative delivery. These effects have emerged in some retrospective and observational studies, but such methods of investigation are highly prone to bias and are particularly ill-suited for the study of labor analgesia. In high-quality studies, including Cochrane reviews and meta-analyses, epidural analgesia has been suggested to extend the first stage of labor by 30 minutes and the second stage by 15 minutes, when compared with alternative forms of analgesia. Although this may be a reproducible effect, it may be argued that it is clinically negligible. With respect to mode of delivery, similar high-quality studies have consistently shown no increased risk of cesarean delivery associated with epidural analgesia. Some forms of epidural analgesia were associated with higher risk of assisted vaginal delivery, but the use of newer modalities has been shown to abolish this effect. Specific advancements have centered on reducing total anesthetic consumption, given that local anesthetic-induced motor block is theorized to interfere with maternal expulsive efforts in the second stage of labor. These measures include the use of low-concentration local anesthetic solutions equivalent to ≤0.1% bupivacaine, shown in meta-analyses to lead to no higher risk of assisted vaginal delivery relative to nonepidural analgesia. Additional advancements in the maintenance of analgesia include programmed intermittent epidural bolus and patient-controlled epidural analgesia, the combination of which has been shown to reduce the risk of assisted vaginal delivery, also likely mediated by reduction in local anesthetic dose. These techniques have gained popularity in the past two decades, such that studies published since 2005 show no higher risk of assisted vaginal delivery with epidural than with opioid analgesia (as reported in a Cochrane review). Labor epidural analgesia has implications for maternal and fetal health perinatally. It is known to result in transient maternal hypotension (particularly with initiation), which may progress to the level of necessitating fluid or vasopressor therapy. This is not clearly associated with any adverse outcomes. There is also a consistently higher incidence of fever in parturients receiving neuraxial anesthesia, likely of noninfectious origin, which has similarly not been associated with adverse neonatal outcomes. Finally, neonates of parturients who receive epidural analgesia have been shown to have no worse Apgar scores and more favorable acid-base status than their counterparts. These observations should serve to reassure providers that modern labor analgesia, as currently understood, is not consistently associated with any significant adverse outcomes for the parturient or fetus. In this review, we describe variations of modern labor epidural analgesia, conduct an in-depth review of current literature on its use, and explore the most up-to-date evidence on its implications for the progression and outcomes of labor, including the pertinent maternal and fetal side effects.

Association between combined spinal-epidural analgesia and neurodevelopment at 3 years old: The Japan Environment and Children's Study

AIM

To investigate the association between maternal combined spinal-epidural analgesia during vaginal delivery and neurodevelopment in 3-year-old children.

METHODS

Using data from the Japan Environment and Children's Study, a birth cohort study on pregnant women and their offspring, we described the background, perinatal outcomes, and neurodevelopmental outcomes of participants with a singleton pregnancy who received combined spinal-epidural analgesia during vaginal delivery and those who did not. The association between maternal combined spinal-epidural analgesia and abnormalities in five domains of the Ages and Stages Questionnaire, Third Edition, was analyzed using univariable and multivariable logistic regression analyses. Crude and adjusted odds ratios with 95% confidence intervals (95% CI) were calculated.

RESULTS

Among 59 379 participants, 82 (0.1%) children (exposed group) were born to mothers who received combined spinal-epidural analgesia during vaginal delivery. In the exposed versus control groups, 1.2% versus 3.7% had communication abnormalities (adjusted odds ratio [95% CI]: 0.30 [0.04-2.19]), 6.1% versus 4.1% exhibited gross-motor abnormalities (1.36 [95% CI: 0.55-3.36]), 10.9% vs. 7.1% had fine-motor abnormalities (1.46 [95% CI: 0.72-2.96]), 6.1% vs. 6.9% showed difficulties with problem-solving (0.81 [95% CI: 0.33-2.01]), and 2.4% vs. 3.0% had personal-social problems (0.70 [95% CI: 0.17-2.85]).

CONCLUSIONS

Exposure to combined spinal-epidural analgesia during vaginal delivery was not associated with the risk of neurodevelopmental abnormalities; however, the sample size of our study might not be appropriate for the study design.

Efficacy and Safety of Transcutaneous Electrical Acupoint Stimulation (TEAS) As An Analgesic Intervention for Labor Pain: A Network Meta-analysis of Randomized Controlled Trials

INTRODUCTION

Epidural analgesia (EA) is the most widely used intervention for the reduction of labor pain; however, it is contra-indicated for patients with spinal deformity or allergy to anesthetics and may be refused by parturients. As a noninvasive and nonnarcotic analgesic intervention, transcutaneous electrical acupoint stimulation (TEAS) has gained increasing attention in recent years. Therefore, we performed a network meta-analysis to compare the efficacy and safety of TEAS and EA as measured by visual analog scale score, the failure rate of natural delivery, adverse events, and Apgar scores.

METHODS

Relevant randomized controlled trials (RCTs) from four electronic databases (PubMed, EMBASE, Web of Science, and Cochrane CENTRAL) and clinical trials.gov were searched from inception until September 4, 2022. A random effects model was used during analysis, and outcomes were evaluated as standard mean difference (SMD), odds ratio (OR), and 95% confidence intervals (CrI) using STATA (version SE15.0), R (version 3.6.1), and ADDIS (version 1.16.8) software.

RESULTS

Ten RCTs comprising 1214 parturients were identified by screening. Six RCTs compared TEAS and controls, three compared EA and controls, and one compared TEAS and EA. No heterogeneity was found within the four outcomes. There was no significant difference in any outcomes between interventions or control treatments in terms of SMD, OR, and CrI. Combined with the highest surface under the cumulative ranking curve score, TEAS demonstrated possible better effects in the aspects of analgesic efficacy and safety under certain circumstances.

CONCLUSIONS

TEAS may be a potential alternative for parturients as a simple, noninvasive, and non-pharmacological intervention compared with EA in terms of analgesic efficacy and safety for mothers and neonates.

Comparison of different delivery modalities of epidural analgesia and intravenous analgesia in labour: a systematic review and network meta-analysis

PURPOSE

In labour, neuraxial analgesia is the standard in the provision of pain relief. However, the optimal mode of delivering epidural solution has not been determined, and some parturients may need an alternative to epidural analgesia. We sought to conduct a systematic review and network meta-analysis to compare continuous epidural infusion (CEI), programmed intermittent epidural bolus (PIEB), computer-integrated CEI, computer-integrated PIEB, patient-controlled epidural bolus (PCEA), fentanyl patient-controlled analgesia (PCA), and remifentanil PCA, either alone or in combination.

METHODS

We searched CENTRAL, CINAHL, Ovid Embase, Ovid Medline, and Web of Science for randomized controlled trials that included nulliparous and/or multiparous parturients in spontaneous or induced labour. The maintenance epidural solution had to include a low concentration local anesthetic and an opioid. Specific subgroups in the obstetric population such as preeclampsia were excluded. Network meta-analysis was performed with a frequentist method, and continuous and dichotomous outcomes are presented as mean differences and odds ratios, respectively, with 95% confidence intervals.

RESULTS

Overall, 73 trials were included. For the first coprimary outcome, the need for rescue analgesia, CEI was inferior to PIEB and PIEB + PCEA was superior to PCEA alone, with a low certainty of evidence given the presence of serious limitations and imprecision. The second coprimary outcome, the maternal satisfaction, was improved by PIEB + PCEA compared with CEI + PCEA and PCEA alone, with a low quality of evidence in view of the presence of serious limitations and imprecision. Fentanyl PCA increased the requirement for rescue analgesia and decreased maternal satisfaction relative to many methods of delivering epidural solution. In terms of secondary outcomes, PIEB increased analgesic efficacy compared with CEI, and PCEA reduced local anesthetic consumption at the expense of inferior analgesia relative to CEI and PIEB. PIEB + PCEA was superior to CEI + PCEA in regard to the pain score at 2 h and 4 h, consumption of local anesthetic, incidence of lower lower limb motor blockade and the rate of spontaneous vaginal delivery. Fentanyl and remifentanil PCA did not provide the same level of analgesia as all epidural methods, resulted in increasing analgesic ineffectiveness with time spent in labour, and predisposed to a higher incidence of side effects such as nausea and/or vomiting and sedation. Remifentanil PCA was superior to fentanyl PCA for analgesia at an early time point, and it increased the incidence of oxygen desaturation relative to other strategies of delivering epidural solution.

CONCLUSIONS

Opioid PCA did not provide the same level of analgesia as epidural methods with a higher incidence of side effects. We interpret the findings of our systematic review and network meta-analysis as suggesting PIEB + PCEA to be the optimal delivery mode of epidural solution. Nevertheless, the potential differing importance of the various maternal, fetal, and neonatal outcomes in determining which is optimal has not, to our knowledge, been elucidated yet.

STUDY REGISTRATION

PROSPERO (CRD42021254978); registered 27 May 2021.

Duration of exposure to epidural anesthesia at delivery, DNA methylation in umbilical cord blood and their association with offspring asthma in Non-Hispanic Black women

Epidural anesthesia is an effective pain relief modality, widely used for labor analgesia. Childhood asthma is one of the commonest chronic medical illnesses in the USA which places a significant burden on the health-care system. We recently demonstrated a negative association between the duration of epidural anesthesia and the development of childhood asthma; however, the underlying molecular mechanisms still remain unclear. In this study of 127 mother-child pairs comprised of 75 Non-Hispanic Black (NHB) and 52 Non-Hispanic White (NHW) from the Newborn Epigenetic Study, we tested the hypothesis that umbilical cord blood DNA methylation mediates the association between the duration of exposure to epidural anesthesia at delivery and the development of childhood asthma and whether this differed by race/ethnicity. In the mother-child pairs of NHB ancestry, the duration of exposure to epidural anesthesia was associated with a marginally lower risk of asthma (odds ratio = 0.88, 95% confidence interval = 0.76-1.01) for each 1-h increase in exposure to epidural anesthesia. Of the 20 CpGs in the NHB population showing the strongest mediation effect, 50% demonstrated an average mediation proportion of 52%, with directional consistency of direct and indirect effects. These top 20 CpGs mapped to 21 genes enriched for pathways engaged in antigen processing, antigen presentation, protein ubiquitination and regulatory networks related to the Major Histocompatibility Complex (MHC) class I complex and Nuclear Factor Kappa-B (NFkB) complex. Our findings suggest that DNA methylation in immune-related pathways contributes to the effects of the duration of exposure to epidural anesthesia on childhood asthma risk in NHB offspring.

Association of epidural analgesia during labor with neurodevelopment of children during the first three years: the Japan Environment and Children's Study

BACKGROUND

Epidural analgesia relives pain during labor. However, the long-term effects on neurodevelopment in children remain unclear. We explored associations between exposure to epidural analgesia during labor and childhood neurodevelopment during the first 3 years of life, in the Japan Environment and Children's Study (JECS), a large-scale birth cohort study.

METHODS

Pregnant women were recruited between January 2011 and March 2014, and 100,304 live births of singleton children born at full-term by vaginal delivery, and without congenital diseases were analyzed. Data on mothers and children were collected using a self-administered questionnaires and medical record transcripts. The children's neurodevelopment was repeatedly assessed for five domains (communication, gross motor, fine motor, problem solving, and personal-social), using the Ages and Stages Questionnaires, Third Edition, at six time points from age 6 to 36 months. After adjusting for potential confounders, the associations between exposure to epidural analgesia during labor and children's neurodevelopment at each time point were assessed.

RESULTS

Of the 42,172 children with valid data at all six time points, 938 (2.4%) were born to mothers who received epidural analgesia during labor. Maternal exposure to epidural analgesia was associated with neurodevelopmental delays during the first 3 years after birth. Delay risks in gross and fine motor domains were the greatest at 18 months (adjusted odds ratio (aOR) [95% confidence interval (CI)]: 1.40 [1.06, 1.84] and 1.54 [1.17, 2.03], respectively), subsequently decreasing. Delay risks in communication and problem-solving domains were significantly high at 6 and 24 months, and remained significant at 36 months (aOR [95% CI]: 1.40 [1.04, 1.90] and 1.28 [1.01, 1.61], respectively). Exposure to epidural analgesia was also associated with the incidence of problem solving and personal-social delays from 18 to 24 months old. Neurodevelopmental delay risks, except for communication, were dominant in children born to mothers aged ≥30 years at delivery.

CONCLUSIONS

This study showed that maternal exposure to epidural analgesia during labor was associated with neurodevelopmental delays in children during the first 3 years after birth.

Association between perinatal pain and postpartum depression: A systematic review and meta-analysis

INTRODUCTION

In recent years, clinical studies have shown that perinatal pain could increase the risk of postpartum depression, while such a conclusion appears controversial. Therefore, we conducted this systematic review and meta-analysis to explore the association between perinatal pain and postpartum depression, and to evaluate the effectiveness of epidural labor analgesia in reducing the risk of postpartum depression.

METHODS

PubMed, Web of Science, Embase and Cochrane Library were searched from inception to Jan 30th, 2022. The effect size of the meta-analysis was calculated using odds ratio and 95 % confidence interval. Statistical analysis was performed using Stata 15.0 software.

RESULTS

There were 19 studies included with a total of 96,378 patients. Among the included studies, 10 investigated the association between perinatal pain and the risk of postpartum depression, and 9 reported that between labor analgesia and the risk of postpartum depression. The results of meta-analysis showed that perinatal pain increased the risk of postpartum depression [OR = 1.43, 95% CI (1.23, 1.67), p<0.05], and epidural analgesia could reduce the risk of postpartum depression [OR = 0.42, 95% CI (0.33, 0.55), p < 0.05].

LIMITATIONS

Source of heterogeneity in the association between perinatal pain and PPD could not be identified due to the limitations of the original studies. There were mainly cohort studies included in the assessment for effectiveness of epidural analgesia in reducing the incidence of postpartum pain. Therefore, we look forward to more RCTs to confirm our results.

CONCLUSION

Perinatal pain is one of the risk factors for postpartum depression, and epidural analgesia could reduce the risk of PPD. This result might provide guidance for clinical practice. However, psychological health counseling should be combined with epidural analgesia for perinatal pain to reduce the risk of PPD.

FBG-Based Soft System for Assisted Epidural Anesthesia: Design Optimization and Clinical Assessment

Fiber Bragg grating sensors (FBGs) are considered a valid sensing solution for a variety of medical applications. The last decade witnessed the exploitation of these sensors in applications ranging from minimally invasive surgery to biomechanics and monitoring physiological parameters. Recently, preliminary studies investigated the potential impact of FBGs in the management of epidural procedures by detecting when the needle reaches the epidural space with the loss of resistance (LOR) technique. In this article, we propose a soft and flexible FBG-based system capable of detecting the LOR, we optimized the solution by considering different designs and materials, and we assessed the feasibility of the optimized soft sensor (SS) in clinical settings. The proposed SS addresses some of the open challenges in the use of a sensing solution during epidural punctures: it has high sensitivity, it is non-invasive, the sensing element does not need to be inserted within the needle, and the clinician can follow the standard clinical practice. Our analysis highlights how the material and the design impact the system response, and thus its performance in this scenario. We also demonstrated the system’s feasibility of detecting the LOR during epidural procedures.

Delivery, maternal and neonatal outcomes in nulliparous women with gestational diabetes undergoing epidural labour analgesia: a propensity score-matched analysis

OBJECTIVE

This study aimed to retrospectively analyse the influence of epidural labour analgesia (ELA) on delivery and maternal and neonatal outcomes in nulliparous women with gestational diabetes mellitus (GDM) using propensity score-matched analysis.

DESIGN

Retrospective cohort analysis.

SETTING

Primary care practices in a teaching hospital from March 2018 to October 2021.

PARTICIPANTS

A total of 816 delivery records of nulliparous women with GDM were collected and retrospectively analysed.

INTERVENTIONS

ELA and non-ELA (NELA) cohorts were assessed.

MAIN OUTCOME MEASURE

The primary outcome assessed was delivery type (spontaneous, assisted vaginal or caesarean). The secondary outcomes assessed included labour duration and maternal and neonatal outcomes.

RESULTS

A total of 137 propensity score-matched pairs of ELA and NELA patients were analysed. ELA was associated with a decreased rate of caesarean section (18.3% vs 46.0% in the ELA vs NELA cohort, respectively; p<0.05) and an increased occurrence of assisted vaginal delivery (35.8% vs 12.4% in the ELA vs NELA cohort, respectively; p<0.05). The duration of the first and total stages of labour was prolonged, the occurrence of postpartum fever increased, and the duration of hospital stay was shortened in those receiving ELA (all p<0.05). Additionally, neonatal birth weight, plasma glucose levels and neonatal macrosomia occurrence increased, while neonatal intensive care unit admissions and neonatal hypoglycaemia decreased in the ELA versus the NELA group (all p<0.05). With respect to other maternal and neonatal outcomes, both cohorts were similar.

CONCLUSIONS

The use of ELA decreases the rate of caesarean section and improves maternal and neonatal outcomes in nulliparous women with GDM.

TRIAL REGISTRATION NUMBER

ChiCTR-2000033091.

Out of step societal and Darwinian adaptation during evolution is the cause of multiple women's health issues

During human evolution, major changes in our societal conditions and environment took place without sufficient time for concomitant genetic alterations, leading to out of step adaptation and diseases in women. We first discuss recent societal adaptation mismatch (menstrual bleeding; increases in cancers of reproductive organs, endometriosis; mother's nursing; polycystic ovarian syndrome; transgenerational epigenetic modifications), followed by Darwinian out of step adaptation (labor difficulties; sex chromosomes, human diseases and sex disparity in genomic DNA). We discuss the evolutionary basis of menstrual bleeding, followed by recent increases in cancers of reproductive organs and endometriosis. The importance of breastfeeding by mothers is also emphasized. Earlier onset of menarche, decreased rates of childbirths and breastfeeding resulted in increased number of menstrual cycles in a lifetime, coupled with excess estrogen exposure and incessant ovulation, conditions that increased the susceptibility to mammary and uterine cancers as well as ovarian epithelial cancer and endometriosis. Shorter lactation duration in mothers also contributed to more menstrual cycles. We further discuss the evolutionary basis of the prevalent polycystic ovary syndrome. During the long-term Darwinian evolution, difficulties in childbirth evolved due to a narrowed pelvis, our upright walking and enlarged fetal brain sizes. Because there are 1.5% genomic DNA differences between woman and man, it is of significance to investigate sex-specific human physiology and diseases. In conclusion, understanding out of step adaptation during evolution could allow the prevention and better management of female reproductive dysfunction and diseases.

Neuraxial labor analgesia: is there a place for neuraxial adjuvants beyond opioids

Neuraxial labor analgesia is considered the gold standard technique for analgesia. Ideally, a good neuraxial technique uses dilute local anesthetic solutions to produce effective pain relief with no or minimal motor impairment. Adjuvant drugs that are co-administered with the local anesthetic either epidurally or intrathecally are useful in achieving this goal. The current review focuses on the effectivity and side-effect profile of various commonly used or tested adjuvants.

Neuraxial labor analgesia: Maintenance techniques

Since the advent of neuraxial analgesia for labor, approaches to maintaining intrapartum pain relief have seen significant advancement. Through pharmacologic innovations and improved drug delivery mechanisms, current neuraxial labor analgesia maintenance techniques have been shaped by efforts to maximize patient comfort during the birthing process, while minimizing undesirable side effects and promoting the unimpeded progress of labor. To these ends, a modern anesthesiologist may avail themselves of several techniques, including programmed intermittent epidural bolus (PIEB), patient controlled epidural analgesia (PCEA) and dilute concentration local anesthetic + opioid epidural solutions. We explore the historical development and the evidential underpinnings of these techniques, in addition to several contemporary neuraxial labor analgesia practices. We also summarize current understanding of the effects these interventions have on maternal/fetal health and the labor course, as well as several important aspects of analgesic safety and monitoring.

Immersive virtual reality on childbirth experience for women: a randomized controlled trial

OBJECTIVE

To evaluate the effectiveness of immersive virtual reality (VR) on patient satisfaction as a distractive tool and pain relief among laboring women.

METHODS

This was a randomized, controlled clinical trial with 42 laboring women allocated to VR intervention and control groups. Among women in the VR group, patient satisfaction with the use of VR was assessed by a Virtual Reality Satisfaction Survey, measured by a Visual Analog Scale (VAS) score and evaluated by questioning them about whether they would choose VR in future labor. As a primary outcome, patient satisfaction scores regarding the overall childbirth experience were compared between women in the two groups. A secondary outcome was pain assessed by a visual pain rating scale in the early and active phases of labor in women in both groups. Psychometric information was also collected from participants in each group using the Beck Anxiety Inventory and Beck Depression Inventory.

RESULTS

We observed a high level of patient satisfaction with the use of immersive VR during labor. The VAS revealed a mean satisfaction score of 87.7 ± 12.9 out of a maximum of 100. Twenty out of 21 (95%) women in the VR group stated that they would like to use VR again in future labor. VR improved pain scores in early labor and contributed positively to the overall childbirth experience. The mean pain score pre-VR was 2.6 ± 1.2 compared to 2.0 ± 1.3 post-VR (p < 0.01). Anxiety and depression scores were similar in participants in the intervention and control groups (p = 0.103 and p = 0.13, respectively).

CONCLUSION

Immersive VR application during labor was associated with higher patient satisfaction based on our study findings. VR also improved participants' pain scores in early labor before epidural administration. Immersive VR may find a place as an adjunct in labor and delivery units to improve lengthy labor experiences for women. Studies with larger groups of participants are needed to confirm these observations.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT05032456.

Epidural analgesia information sessions provided by anesthetic nurses: impact on satisfaction and anxiety of parturient women a prospective sequential study

BACKGROUND

Information on epidural analgesia delivered to parturient women is frequently incomplete, making it difficult for expectant mothers to make an appropriate choice for their delivery. We assessed the impact of a multimodal information session on epidural analgesia delegated to anesthetic nurses on new-mothers' satisfaction.

METHODS

We performed a prospective sequential study including parturient women who gave birth with epidural analgesia. During the first period, information on epidural analgesia was delivered by anesthetists during the scheduled anesthesia consultation, according to French standard-of-care. Then, a dedicated information session about epidural analgesia provided by anesthetic nurses was implemented. The primary endpoint was the satisfaction of women with the quality of information received. Main secondary endpoints were knowledge of women about epidural analgesia, anxiety before epidural catheter placement, and satisfaction with delivery.

RESULTS

259 and 298 women were included during the first and second periods respectively, among whom 178 and 188 were analyzed. Information on epidural analgesia delivered by anesthetic nurses was associated with improvement of new-mothers' satisfaction with information received (9 (8-10) vs. 10 (9-10) - p < 0.001). Moreover, information delivered by anesthetic nurses was associated with decreased anxiety before epidural catheter placement (4 (1-8) vs. 3 (1-6) - p = 0.006) and increased satisfaction with delivery (8 (7-10) vs. 9 (8-10) - p = 0.01). Women's knowledge on epidural analgesia was durably increased when information was delivered by anesthetic nurses compared to conventional information by anesthetists. After adjustment, the only variable associated with both new mothers' satisfaction with information and delivery was the information session taught by anesthetic nurses.

CONCLUSIONS

Information sessions on epidural analgesia delivered by anesthetic nurses was associated with improved satisfaction of women with their delivery. Such information sessions may be used in maternity wards to improve new-mothers' childbirth experience.

Reasons for a Lower Rate of Epidural Anesthesia During Birth for Immigrant Women in the Eyes of Medical Staff: A Mixed-Methods Analysis

Various studies have shown that immigrant women in comparison to non-immigrant women of the same parity have lower rates of epidural anesthesia (EDA). Data from two studies on immigrant obstetric care in Berlin, Germany were analyzed to answer the following question: What reasons do the medical staff see for the lower rate of EDA in immigrant women? Between May and August 2017, 34 interviews with obstetricians and midwives in four obstetric clinics in Berlin were conducted on the topic of obstetric care for immigrant women. After anonymizing the more than 20 h of interview material, transcripts were coded with MaxQDa and analyzed according to the qualitative content analysis.The quantitative data is from an online survey conducted between May and October 2017, in all but one obstetric clinic in Berlin with obstetricians and midwives. Regarding the research question, 121 questionnaires could be analyzed. In the online survey, (multiple answers were possible), the top reason for a lower rate of EDA given was mostly fear on the part of the immigrant women (64%). A language barrier, which results in logistic and time constrictions, is mentioned as the second most frequent reason (50%). The explorative analysis of the interviews shows that doctors and midwives regard cultural aspects such as different expectations on the birth experience as a reason for a lower EDA rate. Furthermore, within the medical staff the impression persists that in some cases the companion decides on the behalf of the patient about the application of an EDA, which from time to time is against the wish of the immigrant woman giving birth. In the view of the medical staff, the reasons for a lower rate of EDA during birth for immigrant women were varied. On one side, this is attributed to the wishes of the respective women ("demand") but on the other side this can be attributed to the health care system ("supply"). In the case of a language barrier, the "supply" and the access of EDA for immigrant women is limited and can be then shifted to the German-speaking companion to make a decision regarding EDA ("structural deprivation of self-determination").

Intrathecal Injection of Ropivacaine Reduces Cervical Resistance in Late-Pregnant Rats

Purpose

Materials and Methods

Results

Conclusion

Effect of Patient-Controlled Epidural Analgesia (PCEA) Based on ERAS on Postoperative Recovery of Patients Undergoing Gynecological Laparoscopic Surgery

Objective

To explore the effect of patient-controlled epidural analgesia (PCEA) based on enhanced recovery after surgery (ERAS) on the postoperative recovery of patients undergoing gynecological laparoscopic surgery.

Methods

Between January 2019 and December 2020, 90 patients scheduled for gynecological laparoscopic surgery and assessed for eligibility were recruited and randomly assigned at a ratio of 1 : 1 to receive either conventional analgesic management (regular group) or PCEA based on ERAS (ERAS group). Comparisons of postoperative rehabilitation indicators, visual analogue scale (VAS) score, self-care ability, complications, and nursing satisfaction were conducted between the two groups.

Results

The ERAS group had significantly shorter first exhaust time (FET), first defecation time (FDT), out-of-bed activity time (OAT), and length of stay (LOS) versus the regular group (P < 0.05). The VAS scores were significantly decreased after treatment, with lower results observed in the ERAS group (P < 0.05). The level of self-responsibility, self-concept, self-care skills, and health knowledge increased significantly in both groups after the intervention, and the ERAS group showed significantly higher results than the regular group (P < 0.05). The total incidence of complications in the ERAS group was significantly lower than that in the regular group (P < 0.05). Eligible patients given PCEA based on ERAS were associated with a higher nursing satisfaction (97.78%) versus conventional analgesic management (82.22%) (P < 0.05).

Conclusion

The application of ERAS for postoperative PCEA management in gynecological laparoscopy provides promising results by effectively enhancing the quality of surgery and promoting rapid postoperative recovery, with a good safety profile.

Comparative study of the efficacy of dexmedetomidine and fentanyl on anxiety and pain of parturients with different COMTva1158met genotypes

Objective

This study investigates the effects of COMTval158met gene polymorphism on maternal anxiety and pain during delivery and on the analgesic and anxiety efficacy of dexmedetomidine during delivery.

Methods

Sixty-one pregnant women, who were hospitalized in our hospital from January to November of 2016 were recruited and randomly divided into two groups, F and D groups. The pregnant women in the F group were given labor analgesia with ropivacaine combined with fentanyl. The pregnant women in the D group were given labor analgesia with ropivacaine combined with dexmedetomidine. Before and after labor analgesia, the genotype of COMT in the blood from two groups was detected, and the situation of labor anxiety and analgesia was analyzed. Then, the relationship between labor anxiety, analgesia, and COMT polymorphism was analyzed.

Results

In the 61 pregnant women, there were 30 women of wild homozygotes (GG) of COMT, 22 women of mutant heterozygotes (GA), and nine women of mutant homozygotes (AA), the mutation rate of allele A was 23.77%. The anxiety status score, anxiety trait score, and pain score in the AA genotype were significantly higher than those in the GG and GA genotype (p < 0.05). There was a significant difference in the efficacy of GG and AA genotypes between groups D and F for treating labor anxiety (p < 0.05), the efficacy of group D was better than that of group F in treating delivery anxiety, there was no significant difference in anxiety scores between the two groups in GA genotypes (p > 0.05); there was no significant difference in pain between group D and F in GG, GA, and AA genotypes (p > 0.05). There was no significant difference in pain and anxiety scores between the three genotypes in group D (p > 0.05), there was significant difference in pain scores among the three genotypes in group F (p < 0.05), but there was no significant difference in anxiety (p > 0.05).

Conclusions

The mutation of the COMTval158met gene leads to increased anxiety and pain during childbirth. The effect of dexmedetomidine on the anxiety of GG and AA genotypes is better than that of fentanyl, and the mutation of the COMTval158met gene has no impact on dexmedetomidine effect.

Epidural Catheterization in Obstetrics: A Checklist-Based Video Assessment of Free Available Video Material

Epidural catheterization has become an indispensable part of modern pain therapy, for example, in obstetrics. Learning how to master this skill is an important competency. Videos are among the information sources with the highest information content for learning such skills. The present study aims to analyze videos regarding epidural catheter placement provided on the YouTube platform based on a validated checklist. An expert workshop selected crucial items for learning epidural catheterization in obstetrics. Items were identified and optimized in a five-step testing process. Using this checklist, videos from YouTube were evaluated by eleven health care professionals. Sixteen videos were identified and analyzed. Concerning the catheterization-specific part of the checklist, only two videos showed satisfactory quality. In the didactic part, eleven out of 21 items reached a mean score >50% of the points. Regarding interrater reliability, the catheterization-specific checklist was shown to be substantial (Fleiss’ kappa = 0.610), and the didactic part was shown to be fair (Fleiss’ kappa = 0.401). Overall, standard monitoring and appropriate aseptic technique were followed in only 42% and 49% for the procedure. There was a significant correlation between the runtime and the content quality (p < 0.001). No correlation could be found in terms of platform rating parameters. The video quality varied highly in terms of the requirements of this practical skill. The majority appear unsuitable for self-study due to serious errors and deficiencies regarding patient safety. However, there is no quality control on free platforms. Accordingly, it is difficult to identify suitable videos for educational purposes.

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

IMPORTANCE

Addressing severe maternal morbidity (SMM) is a public health priority in the US. Use of labor neuraxial analgesia for vaginal delivery is suggested to reduce the risk of postpartum hemorrhage (PPH), the leading cause of preventable severe maternal morbidity.

OBJECTIVE

To assess the association between the use of labor neuraxial analgesia for vaginal delivery and SMM.

DESIGN, SETTING, AND PARTICIPANTS

In this population-based cross-sectional study, women aged 15 to 49 years undergoing their first vaginal delivery were included. Data were taken from hospital discharge records from New York between January 2010 and December 2017. Data were analyzed from November 2020 to November 2021.

EXPOSURES

Neuraxial analgesia (ie, epidural or combined spinal-epidural) vs no neuraxial analgesia.

MAIN OUTCOMES AND MEASURES

The primary outcome was SMM, as defined by the US Centers for Disease Control and Prevention, and the secondary outcome was PPH. Adjusted odds ratios (aORs) and 95% CIs of SMM associated with neuraxial analgesia were estimated using the inverse propensity score-weighting method and stratified according to race and ethnicity (non-Hispanic White vs racial and ethnic minority women, including non-Hispanic Asian or Pacific Islander, non-Hispanic Black, Hispanic, and other race and ethnicity) and to the comorbidity index for obstetric patients (low-risk vs high-risk women). The proportion of the association of neuraxial analgesia with the risk of SMM mediated through PPH was estimated using mediation analysis.

RESULTS

Of 575 524 included women, the mean (SD) age was 28 (6) years, and 46 065 (8.0%) were non-Hispanic Asian or Pacific Islander, 88 577 (15.4%) were non-Hispanic Black, 104 866 (18.2%) were Hispanic, 258 276 (44.9%) were non-Hispanic White, and 74 534 (13.0%) were other race and ethnicity. A total of 400 346 women (69.6%) were in the low-risk group and 175 178 (30.4%) in the high-risk group, and 272 921 women (47.4%) received neuraxial analgesia. SMM occurred in 7712 women (1.3%), of which 2748 (35.6%) had PPH. Before weighting, the incidence of SMM was 1.3% (3486 of 272 291) with neuraxial analgesia compared with 1.4% (4226 of 302 603) without neuraxial analgesia (risk difference, -0.12 per 100; 95% CI, -0.17 to -0.07). After weighting, the aOR of SMM associated with neuraxial analgesia was 0.86 (95% CI, 0.82-0.90). Decreased risk of SMM associated with neuraxial analgesia was similar between non-Hispanic White women and racial and ethnic minority women and between low-risk and high-risk women. More than one-fifth (21%; 95% CI, 14-28) of the observed association of neuraxial analgesia with the risk of SMM was mediated through the decreased risk of PPH.

CONCLUSIONS AND RELEVANCE

Findings from this study suggest that use of neuraxial analgesia for vaginal delivery is associated with a 14% decrease in the risk of SMM. Increasing access to and utilization of labor neuraxial analgesia may contribute to improving maternal health outcomes.

Combined spinal-epidural anesthesia with acupoint injection for labor anesthesia reduces IL-1β/IL-10 ratio in maternal peripheral blood, umbilical cord blood and improves the labor outcomes: A prospective randomized controlled trial

BACKGROUND

This study aimed to investigate the effects of combined spinal-epidural anesthesia (CSEA) with acupoint injection (AI) on the maternal-fetal expression of interleukin-1β (IL-1β), interleukin-10 (IL-10), analgesia effect, and labor outcomes.

METHODS

A total of 360 healthy primiparas were randomized into the CSEA+AI group, the CSEA group, the AI group, and the control group (n = 90, each group) according to the labor analgesia methods.

RESULTS

Compared to the CSEA group, the CSEA+AI group had significantly lower visual analog scale (VAS) scores, adverse events, dose of ropivacaine/sufentanil, and shorter labor durations. The IL-1β/IL-10 ratio in maternal peripheral blood and umbilical cord blood was reduced in the CSEA+AI group compared with the CSEA group.

CONCLUSION

The combination of CSEA and AI can reduce the ratio of IL-1β/ IL-10 in maternal peripheral blood and umbilical cord blood, which can effectively relieve labor pain.

Effects of epidural analgesia exposure during parturition on autism spectrum disorder in newborns: A systematic review and meta-analysis based on cohort study

BACKGROUND

Labor epidural analgesia (LEA) is one of the most effective and widely used approaches for pain relief during parturition. we conducted this meta-analysis to evaluate the association between LEA exposure during parturition and ASD in newborns.

METHODS

PubMed, Cochrane Library, EMBASE and Web of Science database were searched from inception to January 2, 2022 to identify related articles. Literature screening was carried out strictly according to the inclusion and exclusion criteria, and data were extracted and imported into STATA 15.0 software for meta-analysis.

RESULTS

A total of 5 studies with 1763454 participants were included. A statistically significant correlation was observed between LEA and changed ASD (RR = 1.20, 95%CI (1.17, 1.24)), and the correlation between LEA and ASD were analyzed by univariate HR (ES = 1.34, 95%CI(1.27,1.40), P < 0.05) and Multivariate HR (ES = 1.13, 95%CI (1.05,1.21), P < 0.05).

LIMITATION

First, few studies were included, and most patients were from the United States. Second, the included studies were observational cohort designs, which cannot avoid selection and measurement bias. Third, the results of the included studies were heterogeneous, and a more detailed subgroup analysis was not possible.

CONCLUSION

There is a correlation between LEA during parturition and the risk of ASD in newborns. The Newborn whose mother received LEA during her birth-giving might be more likely to develop ASD.

Parturients' Stated Preferences for Labor Analgesia: A Discrete Choice Experiment

OBJECTIVE

The objective was to investigate the extent to which treatment benefits, risks and costs affected parturients' preferences for labor analgesia.

METHODS

We recruited 248 healthy parturients prior to labor at an antenatal ward and administered a discrete choice experiment survey. Parturients were asked to choose among four hypothetical forms of labor analgesia: epidural analgesia, pethidine, Entonox and no analgesia, which were defined by: pain score, duration of second stage of labor, risks of instrumental delivery, back pain and permanent nerve injury, and out-of-pocket cost. We used mixed logit model to calculate the relative importance of each attribute (out of 100).

RESULTS

Parturients preferred receiving labor analgesia over not receiving analgesia and those who had positive past experience with epidural preferred epidural over other modalities. Out-of-pocket cost (28%), duration of second stage of labor (26%) and pain score following treatment (18%) were the most important attributes.

CONCLUSION

Out-of-pocket cost was a major concern. Parturients prioritized having lower pain and shorter labor experience over risks associated with epidural analgesia. Parturients should be presented with realistic range of risks of side-effects so that they can decide how to balance risks against benefits and costs associated with child labor.

Influence of Catheter-Incision Congruency in Epidural Analgesia on Postcesarean Pain Management: A Single-Blinded Randomized Controlled Trial

Patient-controlled epidural analgesia (PCEA) or epidural morphine may alleviate postcesarean pain; however, conventional lumbar epidural insertion is catheter–incision incongruent for cesarean delivery. Methods: In total, 189 women who underwent cesarean delivery were randomly divided into four groups (low thoracic PCEA, lumbar PCEA, low thoracic morphine, and lumbar morphine groups) for postcesarean pain management. Pain intensities, including static pain, dynamic pain, and uterine cramp, were measured using a 100 mm visual analog scale (VAS). The proportion of participants who experienced dynamic wound pain with a VAS score of >33 mm was evaluated as the primary outcome. Adverse effects, including lower extremity blockade, pruritus, postoperative nausea and vomiting, sedation, and time of first passage of flatulence, were evaluated. Results: The low thoracic PCEA group had the lowest proportion of participants reporting dynamic pain at 6 h after spinal anesthesia (low thoracic PCEA, 28.8%; lumbar PCEA, 69.4%; low thoracic morphine, 67.3%; lumbar morphine group, 73.9%; p < 0.001). The aforementioned group also reported the most favorable VAS scores for static, dynamic, and uterine cramp pain during the first 24 h after surgery. Adverse effect profiles were similar among the four groups, but a higher proportion of participants in the lumbar PCEA group (approximately 20% more than in the other three groups) reported prolonged postoperative lower extremity motor blockade (p = 0.005). In addition, the first passage of flatulence after surgery reported by the low thoracic PCEA group was approximately 8 h earlier than that of the two morphine groups (p < 0.001). Conclusions: Epidural congruency is essential to PCEA for postcesarean pain. Low thoracic PCEA achieves favorable analgesic effects and may promote postoperative gastrointestinal recovery without additional adverse effects.

Evaluation of Epidural Analgesia Use During Labor and Infection in Full-term Neonates Delivered Vaginally

IMPORTANCE

Quantification of potential consequences associated with the use of epidural analgesia during labor could help to improve the safety and quality of labor and delivery care for parturient women.

OBJECTIVE

To evaluate the association between epidural analgesia use during labor and neonatal infection in a large cohort of parturient women.

DESIGN, SETTING, AND PARTICIPANTS

This propensity score-matched cohort study was conducted at a university-affiliated hospital in Shanghai, China. Women at full-term pregnancy undergoing vaginal delivery between January 2013 and October 2018 were included in the study. Parturient women who were parous, experiencing premature delivery (gestational age <37 weeks), were pregnant with more than 1 fetus, or had experienced a stillbirth were excluded. Data were analyzed from October 2019 to June 2020.

EXPOSURES

The use of epidural analgesia during labor.

MAIN OUTCOMES AND MEASURES

The primary outcome was the incidence of neonatal infection, including neonatal sepsis, neonatal uncharacterized infection, neonatal pneumonia, and neonatal necrotizing enterocolitis reported in the medical record. Secondary outcomes included the incidence of maternal intrapartum fever and histologic chorioamnionitis.

RESULTS

Among 37 786 parturient women included (mean [SD] age, 29.5 [3.0] years), 19 968 (52.8%) received epidural analgesia during labor. In the propensity score-matched cohort (including 15 401 parturient women in each group), use of epidural analgesia was associated with a higher incidence of neonatal infection (absolute risk difference, 2.6%, 95% CI, 2.2%-3.0%; relative risk [RR], 2.43; 95% CI, 2.11-2.78), including higher incidence of sepsis (absolute risk difference, 0.1%, 95% CI, 0.1%-0.2%; RR, 3.50; 95% CI, 1.73-7.07) and uncharacterized infection (absolute risk difference, 2.2%, 95% CI, 1.9% to 2.6%; RR, 2.69; 95% CI, 2.30-3.15), compared with no epidural analgesia use. Use of epidural analgesia was also associated with greater incidence of maternal intrapartum fever (RR, 4.12; 95% CI, 3.78-4.50) and histologic chorioamnionitis (RR, 4.08; 95% CI, 3.59-4.64) compared with no epidural analgesia use.

CONCLUSIONS AND RELEVANCE

This cohort study found that use of epidural analgesia in full-term nulliparous women undergoing vaginal delivery was associated with an increased risk of neonatal infection, pending further investigation. These findings support efforts to further improve safety and quality of labor and delivery care for parturient women.

Effect of Epidural Analgesia on Pelvic Floor Dysfunction at 6 Months Postpartum in Primiparous Women: A Prospective Cohort Study

INTRODUCTION

Epidural analgesia has become a universal intervention for relieving labor pain, and its effect on the pelvic floor is controversial.

AIM

To investigate the effect of epidural analgesia on pelvic floor dysfunction (PFD) in primiparous women at 6 months postpartum.

METHODS

We performed a prospective cohort study involving 150 primiparous women in preparation for vaginal delivery, with 74 (49.3%) receiving epidural analgesia. Baseline demographic and intrapartum data were collected. At 6 months postpartum, PFD symptoms, including stress urinary incontinence, overactive bladder, defecation disorder, pelvic organ prolapse, and 4 kinds of sexual dysfunction (arousal disorder, low sexual desire, dyspareunia, and orgasm disorder), were evaluated. Pelvic floor muscle (PFM) function and postpartum depression were also assessed. Multivariate logistic regression was applied to identify factors associated with the PFD symptoms affected by epidural analgesia.

MAIN OUTCOME MEASURE

PFD symptoms and sexual dysfunction were evaluated through Pelvic Floor Distress Inventory-20 (PFDI-20) and Female Sexual Function Index (FSFI-12). PFM function was examined with palpation and surface electromyography (sEMG). Postpartum depression was assessed using Self-Rating Depression Scale (SDS).

RESULTS

At 6 months postpartum, women who delivered with epidural analgesia had a higher incidence of dyspareunia (43.2% vs 26.3%, P <0.05) and longer first, second, and total stage of labor durations (P <0.01) than those who without. No significant difference in other PFD symptoms or PFM function was found between the 2 groups (P >0.05). Multivariate logistic regression revealed that epidural analgesia (OR = 3.056, 95% CI = 1.217-7.671) and SDS scores (OR = 1.066, 95% CI = 1.009-1.127) were independent risk factors for dyspareunia.

CONCLUSION

At 6 months postpartum in primiparous women, epidural analgesia was associated with an increased risk of postpartum dyspareunia and longer labor durations, which deserves attention for rehabilitation after delivery. Future studies with a larger sample size are needed to evaluate the impact of epidural analgesia on other PFD symptoms. Du J, Ye J, Fei H, et al. Effect of Epidural Analgesia on Pelvic Floor Dysfunction at 6 Months Postpartum in Primiparous Women: A Prospective Cohort Study. Sex Med 2021;9:100417.

Virtual Reality Reduces Pain in Laboring Women: A Randomized Controlled Trial

OBJECTIVE

Virtual reality (VR) represents a potential method for easing labor pain and in nonpregnant patients has been shown to achieve similar or greater analgesia than hydromorphone. Few studies of VR have been performed in pregnant women. The aim of this randomized controlled trial (RCT) is to evaluate whether VR is effective in reducing pain in laboring women.

STUDY DESIGN

An open-label, RCT of nulliparous, term women in labor in a tertiary care hospital. We included women with a pain score level of 4 to 7 having regular contractions at least every 5 minutes. We excluded women who had received any pharmacologic pain relief including neuraxial analgesia and those with contraindications to VR. Participants were randomized to up to 30 minutes of either VR or the control arm (no additional intervention). Our primary outcome was the difference in differences from pre- to postintervention pain score. Prespecified secondary outcomes included postintervention pain scores, duration of intervention use, pharmacologic analgesia use, maternal vitals, and obstetric outcomes.

RESULTS

From March 2018 to February 2019, 40 subjects were enrolled, randomized, and completed the study; 19 were randomized to control and 21 to the VR arm. Most baseline characteristics were similar between groups. For the primary outcome, those assigned to the control arm had a statistically significant increase in pain of +0.58, while the VR arm had a significant reduction in pain of -0.52 (p = 0.03). There was also a difference in the proportion who had a minimum clinically important difference in pain (0% control and 23.8% VR; p = 0.049). Postintervention maternal heart rate was higher in the control arm (86.8 vs. 76.3, p = 0.01). Most other secondary outcomes did not differ.

CONCLUSION

In our study, we found that VR was effective for reducing pain in women in labor as compared with those receiving no intervention.

KEY POINTS

· Virtual reality (VR) represents a nonpharmacologic option for pain relief.. · VR has been little studied in pregnant or laboring women.. · VR was associated with a reduction in pain in nulliparous women in labor..