Safety and effectiveness of butorphanol in epidural labor analgesia: A protocol for a systematic review and meta-analysis

BACKGROUND

Epidural analgesia is the most effective analgesic method during labor. Butorphanol administered epidurally has been shown to be a successful analgesic method during labor. However, no comprehensive study has examined the safety and efficacy of using butorphanol as an epidural analgesic during labor.

AIM

To assess butorphanol's safety and efficacy for epidural labor analgesia.

METHODS

The PubMed, Cochrane Library, EMBASE, Web of Science, China National Knowledge Infrastructure, and Google Scholar databases will be searched from inception. Other types of literature, such as conference abstracts and references to pertinent reviews, will also be reviewed. We will include randomized controlled trials comparing butorphanol with other opioids combined with local anesthetics for epidural analgesia during labor. There will be no language restrictions. The primary outcomes will include the visual analog scale score for the first stage of labor, fetal effects, and Apgar score. Two independent reviewers will evaluate the full texts, extract data, and assess the risk of bias. Publication bias will be evaluated using Egger's or Begg's tests as well as visual analysis of a funnel plot, and heterogeneity will be evaluated using the Cochran Q test, P values, and I2 values. Meta-analysis, subgroup analysis, and sensitivity analysis will be performed using RevMan software version 5.4. This protocol was developed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Protocols statement, and the PRISMA statement will be used for the systematic review.

RESULTS

This study provides reliable information regarding the safety and efficacy of using butorphanol as an epidural analgesic during labor.

CONCLUSION

To support clinical practice and development, this study provides evidence-based findings regarding the safety and efficacy of using butorphanol as an epidural analgesic during labor.

Association Between Epidural Labor Analgesia and Autism Spectrum Disorder in Offspring: A Systematic Review and Meta-Analysis

Purpose

Many studies have focused on the association between Autism spectrum disorder (ASD) and epidural labor analgesia (ELA), which is the most effective way to manage labor pain. The purpose of this meta-analysis was to summarize the current state of the association between ELA and ASD.

Methods

A search of the literature yielded 201 relevant studies, of which 7 cohort studies met our inclusion criteria. Two independent reviewers screened the inclusion results, extracted data, and assessed the risk of bias and quality of evidence.

Results

Compared to parturient who did not receive ELA, parturient who received ELA had a slightly increased risk of ASD (adjusted hazard ratio [aHR], 1.12; 95% confidence interval [CI], 1.06-1.17; I2, 69%; P < 0.001; seven studies). After excluding one literature (aHR, 1.09; 95% CI, 1.06-1.12; I2, 4%; P < 0.001; six studies). The sensitivity analyses had consistent outcomes with the main analyses involving siblings (aHR 1.11; 95% CI 1.03-1.19), cesarean section and instrumental deliveries (aHR 1.07; 95% CI 1.03-1.10), non-overlapping populations (aHR 1.09; 95% CI 1.05-1.12), full-term birth populations (aHR 1.10; 95% CI 1.06-1.14), and studies assessed to have moderate risk of bias (aHR 1.09; 95% CI 1.02-1.16).

Conclusion

This meta-analysis revealed a modest positive association between ELA and ASD, acknowledging a slight potential risk. However, it is important to note that this risk cannot be completely dismissed due to the possibility of bias and this association is based on low-quality evidence. Future studies are required to assess and mitigate different confounding biases and investigate the time-dose-response relationship.

Retrospective study to assess the effect of epidural analgesia on labor progress and women's pelvic floor muscle from the perspective of electromyography

OBJECTIVE

Epidural analgesia has been widely used as a form of pain relief during labor and its safety has been gradually recognized. However, few studies of the effect of epidural analgesia on the pelvic floor are known. Thus, we aim to analyze the effect of epidural analgesia on labor progress and women's pelvic floor muscle from the perspective of electromyography systematically. In addition, obstetric risk factors for dysfunction of pelvic floor muscle after vaginal delivery were also evaluated.

METHODS

Childbirth data of 124 primiparas who gave first birth vaginally in our hospital and their pelvic floor function assessment results at postpartum 7 weeks were retrospectively collected. Pelvic floor muscle electromyogram screenings were performed by a biofeedback electro-stimulant therapy instrument.

RESULTS

There was no significant difference in the percentage of episiotomy, forceps, artificial rupturing membrane, and the application of oxytocin, except perineal laceration. Woman who implemented epidural analgesia experienced a longer stage of labor. Statistically, there was no significant difference in the total score and pelvic floor muscle strength. The risk factors for the value of the pre-rest phase include the age of pregnant women, the fetal weight, and the length of the second stage while the value of the post-rest phase was only associated with the fetal weight and the length of the second stage. In addition, the value of type I muscles was associated with the gravida and fetal weight while the value of type II muscles was only associated with forceps. The sustained contraction was correlated with the gravida and the total scores had a significant correlation with forceps.

CONCLUSION

Epidural analgesia during labor is approved to be a safe and effective procedure to relieve pain with very low side effects on the mode of labor and pelvic floor muscle. The assessment of pelvic floor muscle before pregnancy is beneficial in guiding the better protection of pelvic floor muscle function. According to the evaluation results, the doctors can control the associated risk factors as much as possible to reduce the injury of pregnancy and parturition to the pelvic floor.

Awareness and Attitude Toward Epidural Analgesia During Labor Among Pregnant Women in Taif City: A Hospital-Based Study

Objectives This study aimed to investigate the awareness and attitudes towards epidural analgesia (EA) among pregnant women in Taif City, Saudi Arabia. The rationale was to identify potential barriers to the acceptance and use of EA, which is an effective pain management option during labor. Methods We conducted a cross-sectional survey at a single healthcare center in Taif City. The participants, pregnant women visiting the center, were recruited using a convenience sampling method. Data collection was facilitated by a questionnaire distributed through a quick response (QR) code. The questionnaire assessed demographic information, awareness levels, previous exposure to EA, and personal attitudes toward its use during labor. Data analysis focused on quantifying the levels of awareness and identifying patterns in attitudes. Results The results revealed a low level of awareness about EA among the participants, with a significant proportion having never been exposed to it before the survey. Attitudes towards EA were varied, with some expressing openness to its use and others displaying apprehension or resistance, which appeared to be influenced by cultural perceptions and a lack of information. Conclusions The study highlighted a substantial lack of awareness and varied attitudes towards EA among pregnant women in Taif City. Educational interventions are necessary to increase awareness and address cultural misconceptions. The study's limited scope and potential sample bias suggest the need for broader culturally tailored research to inform strategies for improving the acceptance and utilization of labor analgesia.

Comparison of Two Different Doses of Nalbuphine With Isobaric Ropivacaine in Patients Undergoing Lower Segment Cesarean Section Under Subarachnoid Block: A Randomized Controlled Trial

INTRODUCTION

Obstetric analgesia and anesthesia is a challenge in itself. It requires an understanding of the physiological changes during pregnancy and labor and the effect of anesthetic agents on the fetus and newborn. Because neuraxial techniques provide superior analgesia and materno-fetal benefits, their use have increased significantly over the past three decades or so. A combination of local anesthetics like ropivacaine with opioids like nalbuphine has been shown to have additive beneficial effects in subarachnoid block (SAB) in lower segment cesarean section (LSCS). However, the optimal dose combination of ropivacaine and nalbuphine to maximize their benefits and minimize side effects remains to be established. Our study has compared the clinical efficacy and safety of 0.75% isobaric ropivacaine (15 mg) with two different doses of nalbuphine (0.4 mg and 0.6 mg) when given intrathecally for LSCS in terms of quality of sensory and motor blocks, hemodynamic parameters, duration of effective analgesia, Apgar score in newborn, and associated side effects.

METHOD AND MATERIALS

In this prospective, randomized, double-blind study, a total of 69 parturients between the age of 20-45 years, belonging to American Society of Anesthesiologists (ASA) grade I and II, undergoing cesarean section under SAB were evaluated. Patients were randomly allocated into three groups of 23 each by using the draw-of-lots technique. The patient and the observer were kept blinded as to which dose of drug (intrathecal) was being given to the patient. Patients in Group A received 0.75% isobaric ropivacaine 15 mg (2 ml) + 0.3 ml normal saline; patients in Group B received 0.75% isobaric ropivacaine 15 mg (2 ml) + 0.4 mg of nalbuphine (0.2 ml) + 0.1 ml normal saline; patients in Group C received 0.75% isobaric ropivacaine 15 mg (2 ml) + 0.6 mg of nalbuphine (0.3 ml). The total volume of drug solution in all three groups was 2.3 ml.

RESULT

 We found that the time to onset of sensory block was shortest in Group A (5.87±1.290 minutes) followed by Group C (6.00±1.087 minutes) and Group B (6.17±1.696 minutes); time to two-segment regression of sensory block was longest in Group C (101.74±8.996 minutes) followed by Group B (85.87±15.348 minutes) and Group A (65.00±7.071 minutes); duration of effective analgesia was longest in Group C (206.09±18.766 minutes) followed by Group B (183.91±15.880 minutes) and Group A (121.74±11.833 minutes); and time from SAB to complete regression of motor block was longest in Group C (216.52±15.553 minutes) followed by Group B (203.48±20.138 minutes) and Group A (174.78±14.731 minutes). Side effects were comparable among all three groups.

CONCLUSION

The optimal dose combination in SAB for cesarean section was 15 mg of 0.75% isobaric ropivacaine + 0.6 mg nalbuphine, with minimal side effects.

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.

What is the place of dural puncture epidural in labour analgesia?

Epidural analgesia is the gold standard for labour analgesia. Dural puncture epidural analgesia is a modification of the conventional technique, where the dura is intentionally perforated with a spinal needle but no intrathecal medication is given. This article reviews the evidence for and against the clinical use of dural puncture epidural.

Peripartum effects of synthetic oxytocin: The good, the bad, and the unknown

The first clinical applications of oxytocin (OT) were in obstetrics as a hormone to start and speed up labor and to control postpartum hemorrhage. Discoveries in the 1960s and 1970s revealed that the effects of OT are not limited to its peripheral actions around birth and milk ejection. Indeed, OT also acts as a neuromodulator in the brain affecting fear memory, social attachment, and other forms of social behaviors. The peripheral and central effects of OT have been separately subject to extensive scrutiny. However, the effects of peripheral OT-particularly in the form of administration of synthetic OT (synOT) around birth-on the central nervous system are surprisingly understudied. Here, we provide a narrative review of the current evidence, suggest putative mechanisms of synOT action, and provide new directions and hypotheses for future studies to bridge the gaps between neuroscience, obstetrics, and psychiatry.

Should remifentanil patient-controlled analgesia be a routine choice for pain relief in labour?

Patient-controlled analgesia with remifentanil is usually reserved for patients for whom other forms of pain relief are contraindicated. However, remifentanil patient-controlled analgesia reduces the likelihood of needing an epidural and therefore the risk associated with it, provides good pain relief compared to other options, and the risks can be mitigated with appropriate management.

Maternal childbirth experience and pain relief methods: a retrospective 7-year cohort study of 85 488 parturients in Finland

OBJECTIVES

The aim of this study was to analyse the relation between the used labour pain relief and childbirth experience measured by Visual Analogue Scale (VAS).

DESIGN

A retrospective cohort study.

SETTING

Childbirth in five Helsinki University Hospital delivery units from 2012 to 2018.

PRIMARY OUTCOME MEASURE

Childbirth experience measured by VAS and classified in three groups (negative VAS=1-5, positive VAS=6-8 and highly positive=9-10).

RESULTS

The use of epidural or non-epidural compared with non-medical pain relief methods decreased the likelihood to experience highly positive childbirth for primiparous (adjusted OR (aOR)_EPIDURAL=0.64, 95% CI 0.57 to 0.73; and aOR_NON-EPIDURAL=0.76, 95% CI 0.66 to 0.87) and multiparous (aOR_EPIDURAL=0.90, 95% CI 0.84 to 0.97 and aOR_NON-EPIDURAL=0.80, 95% CI 0.74 to 0.86) parturients. The effects of epidural differed between primiparas and multiparas. In multiparas epidural was associated with decreased odds for experiencing negative childbirth compared with the non-medical group (aOR=0.70, 95% CI 0.57 to 0.87), while the effect of epidural was considered insignificant in primiparas (aOR=1.28, 95% CI 0.93 to 1.77).

CONCLUSION

While the use of medical-epidural and non-epidural-pain relief methods were not associated with odds for experiencing negative childbirth in primiparas, using epidural helps to avoid negative experience in multiparas. However, the odds for experiencing highly positive childbirth were decreased if the parturients used any medical pain relief for both primiparas and multiparas. Consequently, the effect of pain relief on the childbirth experience is strongly confounded by indication. Thus, the use of pain relief per se plays a limited role in the complex formation of the overall childbirth experience.

The Effect of Epidural Analgesia on the Maternal and Fetal Outcomes in Mothers Undergoing Induction of Labour

Introduction

Elective labour induction is associated with more pain, intrapartum interventions, cesarean deliveries, as compared with spontaneous labour, necessitating the use of labour analgesia. Epidural analgesia is one popular method for control of pain. This study was to determine the effect of epidural analgesia on the maternal and fetal outcomes in women undergoing induction of labour, as adequate data in this specific population is relatively sparse.

Materials and Methods

This was a cross-sectional study conducted over a period of 18 months which included mothers with singleton term gestation with cephalic presentation admitted for induction of labour.

Result

A sample of 238 mothers were included in the study. Among the study population, 52.7% opted for epidural analgesia. The pain score was less than 3/10 (VAS) in 81% of mothers who opted for epidural analgesia. The cesarean section rate was 20.5% and 34.3% in the epidural and non-epidural groups, respectively. After adjusting the confounding factors, there was a positive effect noted in the caesarean section rate among the epidural group, which was lesser than the non-epidural group. However, a higher instrumental delivery rate (18.8% vs. 10.5%, p-value < 0.05) was noted in the epidural group. There was no significant difference in the duration of labour and fetal outcome in the two groups.

Conclusion

Epidural analgesia providing good pain relief in the majority of the mothers was reinforced. In our study, epidural analgesia was associated with a reduction of caesarean section rate after adjusting the confounding factor. Epidural analgesia did not affect the duration of labour, cesarean section rate and fetal outcome independently, however, it was associated with increased risk of instrumental delivery. The outcomes mainly depend on the confounding factors. Therefore, mothers can be provided with an evidence-based information regarding the effect of epidural analgesia in induced labour and help those seeking epidural analgesia to make an informed choice.

Supplementary Information

The online version contains supplementary material available at 10.1007/s13224-022-01622-1.

A cascade of interventions: A classification tree analysis of the determinants of primary cesareans in Australian public hospitals

BACKGROUND

Both globally and in Australia, there has been a sharp rise in cesarean births (CB). Commonly, this rise has been attributed to the changing epidemiology of women giving birth. A significant body of knowledge exists on the risk factors associated with a greater need for cesarean. Yet, we have little information on the reasons recorded by clinicians as to why cesareans are provided. This study aimed to explore the drivers of primary cesareans in Australian public hospitals.

METHODS

Using a linked administrative data set, the frequency and percent of mothers' characteristics were compared between those who had a cesarean birth and those who had a vaginal birth (n = 98 967) with no history of previous cesareans in Queensland public hospitals between July 1, 2012, and June 30, 2015. The top 10 reasons recorded by clinicians for a primary cesarean were reported. Using a machine-learning algorithm, two decision trees were built to determine factors driving primary cesarean birth.

RESULTS

"Labour and delivery complicated by fetal heart rate anomaly" (23%) and "primary inadequate contractions" (22.8%) were the top two reasons for a primary cesarean birth. The most common characteristics among mothers who had fetal heart rate anomalies were as follows: artificial rupture of membranes (39%), oxytocin (32%), no obstruction of labor (42%), and epidural (52%). For women who had primary inadequate contractions, the most common characteristics were as follows: epidural (33%), oxytocin (49%), artificial rupture of membranes (45%), and fetal stress (56%).

CONCLUSIONS

Efforts should be made by health practitioners during the antenatal period to maximize the use of preventative measures that minimize the need for medical interventions.

Evaluating the effectiveness of TENS for maternal satisfaction in laboring parturients - Comparison with epidural analgesia

Background and Aims:

Labor pain is one of the most severe pain that a woman experiences in her lifetime. Various methods are being used to relieve this pain and to achieve higher maternal satisfaction. One such technique is transcutaneous electrical nerve stimulation (TENS) that uses low-frequency electrotherapy. The aim of our study was to evaluate TENS by comparing it to an established labor analgesia technique, i.e., epidural analgesia in terms of maternal satisfaction.

Material and Methods:

This prospective study was conducted on 60 parturients in active stage of labor. The choice of analgesia was made by the parturient after informed consent. In group A (n = 30) TENS was used, while in group B (n = 30) epidural ropivacaine 0.125% + 2 μg/ml fentanyl was given. Continuous monitoring of maternal vitals, visual analogue score, and fetal heart rate (FHR) was done. Maternal satisfaction was scored considering pain relief, ability to move and experience of labor at the end of delivery and outcome was labeled as favorable and unfavorable.

Results:

TENS was found to be favorable in 90% of parturients as compared to 96.6% in epidural (P 0.301). The number of highly satisfied parturients was 4 (13.3%) in TENS group and 17 (56.6%) in the epidural group (P= 0.000). Three patients in the epidural group had assisted delivery and two had cesarean section whereas all patients in TENS group delivered normally (P= 0.065). No significant difference was found in the fetal outcome.

Conclusions:

TENS is a good alternate choice for providing labor analgesia and may have a major role in future.

Obstetric anal sphincter injuries (OASIS) in multiparous women with the use of epidural anaesthesia: A retrospective cohort study

BACKGROUND

The use of epidural as a form of analgesia is increasingly common in labour, but this has shown to have been associated with increased rates of instrumental delivery, and prolonged second stage, resulting in increased rates of OASIS (Obstetric Anal Sphincter Injury).

AIMS

This study aimed to investigate the impact of epidural anaesthesia in multiparous women undergoing vaginal deliveries on OASIS and secondary maternal outcomes.

MATERIALS AND METHODS

A retrospective cohort study of multiparous women with singleton pregnancies delivering at term ≥37 weeks and the use of epidural analgesia in labour at a tertiary hospital in Melbourne, Victoria, Australia, the Royal Women's Hospital was undertaken between the period 2012-2018. Maternal outcomes were collated and dichotomised according to the presence of epidural use. Multiparous women with no prior history of a vaginal birth and non-cephalic presentation during labour were excluded.

RESULTS

There were 14 124 multiparous women who met the inclusion criteria; spontaneous labour is associated with an increased risk of OASIS at adjusted odds ratio (aOR) 1.46, P = 0.012. The overall rate of epidural use was 17%. Women with epidural use had significantly lower chances of sustaining OASIS in normal vaginal births and instrumental vaginal births. (1% vs 1.8%, aOR 0.49, P = 0.004). Epidural is associated with increased rates of prolonged second stage (8.5% vs 3.8%, P < 0.05), instrumental delivery (26.1% vs 4%, P < 0.05), and episiotomy use (23.8% vs 10.2%, P < 0.05).

CONCLUSION

The use of epidural analgesia in multiparous women is associated with a reduction in anal sphincter injuries.

Mixed-methods systematic review: Childbearing women's views, experiences, and decision-making related to epidural analgesia in labour

AIMS

To investigate childbearing women's views, experiences and decision-making related to epidural analgesia in labour.

DESIGN

Mixed-methods systematic review.

DATA SOURCES

A comprehensive literature search was implemented across Medline, CINAHL and EMBASE from 2000 to September 2018. The literature search was undertaken in January 2018 and updated in September 2018. Thirty papers were selected.

RESULTS

Four overarching synthesized findings were identified: (a) choice; (b) pain management experience; (c) lack of information; and (d) information provision and consent.

REVIEW METHODS

Quality appraisal was conducted using JBI levels of evidence and other established tools. NVivo was used to independently dual code and thematically synthesize qualitative data. A narrative synthesis of the quantitative findings from the included studies was undertaken. The GRADE-CERQual approach was used to assess confidence in the review findings based on the qualitative data. A set of integrated mixed-methods synthesized findings was produced.

CONCLUSION

Recommendations for practice based on the systematic review findings are that midwives should dedicate time to discuss epidural with women and birth partners, ideally during the second or third trimester of pregnancy, asking women what coping strategies or pain relief they have been considering, if any. The factors which may influence the woman's choice of epidural, including pain threshold, ability to cope with pain, timing of epidural and length of labour should be continuously evaluated during labour. The midwife should remain with women after an epidural has been sited, demonstrating understanding of the woman's choice and providing an opportunity for discussion of plans for the remaining labour and birth.

IMPACT

The findings of this systematic review can inform both healthcare professionals and service users on various aspects of the decision-making process about the use of epidural analgesia in labour. Data can be transferable to similar settings in high-income countries.

Influence of non-pharmacological obstetric interventions on adverse outcomes of childbirth under regional analgesia

Background We examined the influence of companionship and the use of complementary therapies on adverse outcomes in parturients under regional analgesia. Methods This study is a single-center retrospective cohort of 986 term pregnant women, and it was based on data from medical records (hospitalization period: November 2012-November 2018). The women were in the active phase of labor under regional analgesia. A statistical program was used to search for an association between companionship and the use of complementary therapies with sample data. Bi- and multivariate logistic regressions based on significant associations were used to analyze the potential intervening variables in the adverse outcomes. Results Models were constructed for each of the maternal adverse outcomes. Childbirth complications were significantly associated with complementary therapies [adjusted odds ratio (AOR) = 0.42; 95% confidence interval (CI) = 0.28-0.63; P < 0.001] and companionship (AOR = 0.36; 95% CI = 0.22-0.57; P < 0.001). Prolonged maternal hospitalization was significantly associated with companionship (AOR = 0.57; 95% CI = 0.36-0.92; P < 0.05). Unplanned cesarean section showed a significant association with complementary therapies (AOR = 0.05; 95% CI = 0.01-0.47; P < 0.01). Conclusion The likelihood of childbirth complications and prolonged maternal hospitalization is reduced by companionship, whereas the likelihood of childbirth complications and cesarean section rates is reduced by the use of complementary therapies.

Effects of different analgesic methods used for vaginal delivery on mothers and fetuses

Background/aim

Knowledge regarding pain relief during labor remains insufficient. We aimed to determine and compare the effectiveness and safety of epidural analgesia, combined spinal–epidural analgesia, and parenteral meperidine on both mothers and fetuses.

Materials and methods

This study was designed as an observational case-control study. We collected prospective data from patients whose labor pain management was conducted with meperidine in addition to retrospective cohort data of neuraxial methods; 138 patients were enrolled. Epidural analgesia group consisted of 68 patients, whereas combined spinal-epidural (CSE) analgesia group and meperidine group consisted of 50 and 20 patients, respectively. We compared the delivery patterns, labor durations, pain levels, side effects, maternal satisfaction levels, and neonatal outcomes of the various pain management methods.

Results

Patient demographics, duration of first, second, and third labor stages, and instrumental delivery rates were comparable among groups (P > 0.05). Cesarean section tended to be less frequent in the CSE group. In the meperidine group, visual analog scale (VAS) values and sedation were significantly higher (P < 0.001) and maternal satisfaction lower (P < 0.001). Hypotension tended to be more frequent in the meperidine group. APGAR scores at the 1st and 5th min were similar among the groups and between meperidine subgroups defined by three different administration times (<1 h, 1‒4 h, ≥4 h; P > 0.05).

Conclusion

Neuraxial methods had no effect on instrumental delivery rates. CSE represented a near significant risk reduction in cesarean section. Our results demonstrated that regional analgesia methods were reasonably safe for both mother and fetus, and regional analgesia methods resulted in greater maternal satisfaction and pain control compared to meperidine.

Adverse effect of delayed pushing on postpartum blood loss in nulliparous women with epidural analgesia

OBJECTIVE

To test for an association between blood loss and time until pushing (TUP) after full cervical dilation in nulliparous women with epidural analgesia.

METHODS

A prospective cohort study was performed at the University Hospital of Zurich between October 2015 and November 2016. Included were 228 nulliparous women with singleton pregnancy, planned vaginal delivery after 36 completed weeks of gestation, epidural analgesia, and guided active pushing. TUP was defined as the interval between full cervical dilation and initiation of active pushing. The primary outcome measure was blood loss, assessed by the postpartum decrease in hemoglobin (ΔHb), estimated blood loss, and rate of ΔHb ≥30 g/L. Associations between TUP and primary and secondary maternal and neonatal delivery outcomes were assessed using Spearman correlation, Mann-Whitney U test, Kruskal-Wallis test, or Fisher exact test, as appropriate.

RESULTS

Longer TUP correlated significantly with increased ΔHb (ρ=0.142, P=0.033) and higher rates of ΔHb ≥30 g/l (P=0.002). Composite adverse maternal and neonatal outcomes were unaffected.

CONCLUSION

On the grounds of increased maternal blood loss, and in contrast to the current International Federation of Gynecology and Obstetrics (FIGO) guideline, delayed active pushing is not recommended in nulliparous women with epidural analgesia.

Intrapartum interventions that affect maternal and neonatal outcomes for vaginal birth after cesarean section

Objective

To investigate maternal and neonatal outcomes after different intrapartum interventions for vaginal birth after cesarean section (VBAC) in mainland China.

Methods

A retrospective study was performed on 143 VBAC cases from Beijing Obstetrics and Gynecology Hospital between January 2015 and November 2016. These cases were divided into two groups on the basis of different intrapartum interventions. Maternal and neonatal outcomes were compared.

Results

The durations of the first stage and total labor after oxytocin were significantly longer than those before oxytocin use. The proportion of operative vaginal delivery with oxytocin was significantly higher than that without oxytocin (43.9% vs. 11.8%). The times of the first stage, second stage, and total labor with analgesia were significantly longer than those without analgesia (548.4±198.1 vs. 341.8±233.0 minutes, 52.0±38.9 vs. 36.0± 29.1 minutes, and 606.3±212.1 vs. 387.3±233.0 minutes, respectively). Postpartum hemorrhage and operative vaginal delivery occurred significantly more frequently in women with epidural analgesia than in those without epidural analgesia (29.7% vs. 12.3 and 35.1% vs. 16.0%, respectively).

Conclusions

Induction can increase the rate of operative vaginal delivery in VBAC. Oxytocin and epidural analgesia may increase the risk of operative vaginal delivery, and may be associated with a prolonged duration of labor.

Station of the fetal head at complete cervical dilation impacts duration of second stage of labor

Objective

To examine the association between station of the fetal head at complete cervical dilation and duration of second stage of labor, as well as prolonged second stage of labor, without and with the use of analgesia (EA).

Study design

We conducted a population-based retrospective cohort study of 3311 women with a singleton pregnancy, gestational age ≥ 37⁰ weeks, and cephalic presentation. Station of the fetal head at complete cervical dilation was categorized as at the pelvic floor, beneath the ischial spines, but above the pelvic floor, and at or above the ischial spines. In logistic regression analysis, we defined prolonged second stage of labor as > 2 h without and > 3 h with EA in nulliparous women, and > 1 h and > 2 h, respectively, in parous women.

Results

Survival curves demonstrated longer durations of second stage of labor in nulliparous women and women with EA in each category of station of fetal head. The adjusted odds ratio of prolonged second stage of labor was 13.1 (95% confidence interval (CI): 8.5-20.1) times higher when the fetal head was beneath the ischial spines, but above the pelvic floor, and 32.9 (95% CI: 21.5-50.2) times higher when the fetal head was at or above the ischial spines compared to at the pelvic floor.

Conclusion

Station of the fetal head at complete cervical dilation was significantly associated with duration of second stage of labor.

Infrared thermography to assess dermatomal levels of labor epidural analgesia with 1 mg/mL ropivacaine plus 0.5 µg/mL sufentanil: a prospective cohort study

BACKGROUND

Assessment of the effectiveness of obstetric epidural analgesia may be difficult and techniques for objective assessment of epidural spread of local anesthetic would be useful. In this prospective cohort study we assessed whether obstetric epidural analgesia from a low concentration of ropivacaine led to significant change in cutaneous temperature, related to sympathetic block detected by infrared thermography, at dermatomes C4, T4, T10, L2 and L5.

METHODS

Women in spontaneous labor who requested epidural analgesia were consecutively recruited. Epidural analgesia was induced with a bolus of 10-15 mL of ropivacaine 1 mg/mL and sufentanil 0.5 µg/mL, followed by continuous epidural infusion. Skin temperature was measured using thermography before and 20 min after the epidural bolus. The verbal pain score using a numeric rating scale was recorded before and 60 min after the epidural bolus. The upper sensory block to cold sensation was tested 30 and 60 min after the bolus by a physician blinded to the skin temperature. Failed epidural analgesia was defined as verbal pain score >3 at 60 min.

RESULTS

Fifty-three parturients were included and analyzed. We found a significant increase in skin temperatures measured at T4, T10, L2 and L5 dermatomes, but not at C4, and a significant difference in the change in skin temperature at T10 between failed (n=3) and successful (n=50) epidural analgesia.

CONCLUSIONS

These results suggest that infrared thermography might be useful for the early diagnosis of successful obstetric epidural analgesia.

Neuraxial labor analgesia: a literature review

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

Impact of epidural on labor duration and vacuum deliveries in twin gestations

INTRODUCTION

Epidural analgesia may lead to a prolonged second stage, and increased instrumental vaginal deliveries rate in singleton gestations. We aimed to examine the association between epidural and vacuum deliveries rate and second stage duration among twin deliveries.

METHODS

Retrospective study conducted at a single teaching hospital on data between January 1995 and December 2015. All twin pregnancies, >24 weeks that had a trial of labor were included. Twins with major malformations, intrauterine death, or had a caesarean delivery without a trial of labor, were excluded. Women were divided to those who had an epidural analgesia (group 1) and those who did not (group 2). Primary outcome was vacuum delivery rate.

RESULTS

Of all 1955 twin pregnancies delivered during the study period, 827 (42.3%) were eligible and included; 332 (40.1%) in group 1 and 495 (59.9%) in group 2. Vacuum delivery rate of any twin was 7.5% and 6.3% in groups 1 and 2, respectively (p = 0.48; Relative Risk 1.20; 95% Confidence Interval: 0.72-2.0). Vacuum delivery rate of first twin only or second twin only did not differ significantly as well. After adjusting for variables that differed significantly between the groups in univariate analysis, second stage duration of first and second twins in group 1 was significantly longer than in group 2 (p = 0.001; ratio=1.66; 95% Confidence Interval: 1.42-1.94 and p = 0.001; ratio=1.40; 95% Confidence Interval: 1.24-1.58, respectively).

CONCLUSIONS

Epidural use in twin deliveries did not affect vacuum deliveries rate. Epidural was associated with a prolonged second stage of both twins.

[Neuraxial labor analgesia: a literature review]

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

Combined spinal-epidural block for labor analgesia. Comparative study with continuous epidural block

Introduction

Lumbar epidural block is an effective and routinely used technique for labor pain relief, and the combined spinal-epidural block has the benefit of using lower doses of local anesthetics and rapid onset of analgesia. The objective of this study was to evaluate the effectiveness and safety of two anesthetic techniques: combined spinal-epidural block and continuous epidural block in pregnant women for labor analgesia.

Methods

Eighty patients, ASA II and III, with cephalic presentation and cervical dilation between 5 and 6 cm, undergoing labor analgesia, allocated in two groups according to the anesthetic technique: combined spinal-epidural (GI) and continuous epidural (GII). Pain severity before the blockade, time to complete analgesia, degree of motor blockade, time to full cervical dilation, duration of the second stage of labor, pain severity during the 1st and 2nd stage of labor, type of delivery, use of oxytocin during labor, maternal cardiocirculatory and respiratory parameters and adverse events, and neonatal repercussions were recorded.

Results

At the time of anesthesia, pain severity was similar in both groups. Pain relief was faster in GI (4.5 ± 1.5 min) when compared to GII (11.6 ± 4.6 min) p = 0.01; pain scores in the first and second stages of delivery were lower in GI (0.9 ± 0.3 and 1.8 ± 0.7, respectively) when compared to GII (1.9 ± 0.6 and 2.2 ± 0.5, respectively), with p = 0.01 only in the first stage of labor; there was need for local anesthetics supplementation in GII; there were more frequent spontaneous deliveries in GI (80% of patients) than in GII (50%) (p = 0.045) and more frequent use of instrumental (p = 0.03) in GII (12 patients) compared to GI (4 patients); the frequency of cesarean deliveries was significantly higher (p = 0.02) in Group II than in Group I, with 4 cases in GI and 8 cases in GII; absence of maternal cardiocirculatory and respiratory changes and neonatal repercussions; more frequent pruritus in GI (10 patients) and (0 patients in GII) (p = 0.02).

Conclusion

The combined blockade proved to be effective with better quality of analgesia and greater comfort for pregnant women, constituting a good option for the practice of obstetric analgesia.

Breastfeeding and its outcome in Women Receiving Epidural Analgesia for Childbirth

Background:

Breastfeeding is an important issue in postpartum period and critical to the infant's health, but childbirth interventions such as childbirth analgesia may affect the onset and duration of the process. This study aimed to determine the status of breastfeeding in women receiving epidural analgesia.

Materials and Methods:

This cohort study was conducted on 393 mothers in the postpartum period that had vaginal delivery with or without using epidural analgesia (with their own choice) between December 2017 and September 2018. After selecting the convenient samples, the researcher-made outcome breastfeeding checklists were completed in selected hospitals in Isfahan, Iran, Within 24 hours and 4 weeks after delivery. Data were analyzed using statistical methods (Independent t test, Mann-Whitney, ANCOVA, and Chi-square). The significance level of the tests was less than 0.05.

Results:

According to the results, most of the subjects in the two groups began breastfeeding during the first hour after childbirth. There was no significant difference between the two groups in the beginning of breastfeeding while controlling the number of labors. There was no significant difference between the two groups in comparison to the type of milk given to the infant Within 24 hours after birth and 4 weeks after birth, either. There was no significant difference between the two groups in comparison to breastfeeding problems at either time.

Conclusions:

According to the results, saying that there is no negative effect by epidural analgesia on the breastfeeding process, using this analgesia is recommended to promote natural childbirth.

[Combined spinal-epidural block for labor analgesia. Comparative study with continuous epidural block]

INTRODUCTION

Lumbar epidural block is an effective and routinely used technique for labor pain relief, and the combined spinal-epidural block has the benefit of using lower doses of local anesthetics and rapid onset of analgesia. The objective of this study was to evaluate the effectiveness and safety of two anesthetic techniques: combined spinal-epidural block and continuous epidural block in pregnant women for labor analgesia.

METHODS

Eighty patients, ASA II and III, with cephalic presentation and cervical dilation between 5 and 6 centimeters, undergoing labor analgesia, allocated in two groups according to the anesthetic technique: combined spinal-epidural (GI) and continuous epidural (GII). Pain severity before the blockade, time to complete analgesia, degree of motor blockade, time to full cervical dilation, duration of the second stage of labor, pain severity during the 1^st and 2^nd stage of labor, type of delivery, use of oxytocin during labor, maternal cardiocirculatory and respiratory parameters and adverse events, and neonatal repercussions were recorded.

RESULTS

At the time of anesthesia, pain severity was similar in both groups. Pain relief was faster in GI (4.5±1.5min) when compared to GII (11.6±4.6min) p=0.01; pain scores in the first and second stages of delivery were lower in GI (0.9±0.3 and 1.8±0.7, respectively) when compared to GII (1.9±0.6 and 2.2±0.5, respectively), with p=0.01 only in the first stage of labor; there was need for local anesthetics supplementation in GII; there were more frequent spontaneous deliveries in GI (80% of patients) than in GII (50%) (p=0.045) and more frequent use of instrumental (p=0.03) in GII (12 patients) compared to GI (4 patients); the frequency of cesarean deliveries was significantly higher (p=0.02) in Group II than in Group I, with 4 cases in GI and 8 cases in GII; absence of maternal cardiocirculatory and respiratory changes and neonatal repercussions; more frequent pruritus in GI (10 patients) and (0 patients in GII) (p=0.02).

CONCLUSION

The combined blockade proved to be effective with better quality of analgesia and greater comfort for pregnant women, constituting a good option for the practice of obstetric analgesia.

Practice of Labor Analgesia among Anesthesiologists Across India: Cross-sectional Study

BACKGROUND

The practice of labor analgesia is an essential part of standard obstetric care. There are many guidelines and programs, which have been setup in labor pain management, in the developed country. In India, the practice of labor analgesia is not very popular. The role of labor analgesia providers lies in educating the parturients about the need of labor analgesia and also to develop comprehensive programs and guidelines in providing it.

AIM

The aim of our study was to assess knowledge and practice of labour analgesia among anaesthesiologists across India.

METHODS

Survey was carried out using SurveyMonkey, an online internet website. Questionnaires were sent by mail to 11,986 anesthesiologists. The questions were based on methods of labor analgesia practice, regional analgesia techniques, commonly used drugs, complications and myths surrounding labor analgesia.

STATISTICAL ANALYSIS

Responses were compiled and data was analysed. Results were expressed as percentages.

RESULTS

There were 1351 responses to the survey. Labor analgesia was practiced mainly by anesthesiologists across India (71.34%, n = 945). Regional analgesia techniques were the most common techniques followed in providing labor analgesia (69.61%, n = 940) and among regional analgesia techniques, epidural analgesia (43.52%, n = 588) was the most common method. Bupivacaine was considered the drug of choice (64.10% n = 866) and Fentanyl was the standard adjuvant used (83.34% n = 1126). Majority of the respondents did not believe in myths surrounding labor analgesia.

CONCLUSION

Epidural analgesia is the most common technique practiced, bupivacaine the commonly used local anaesthetic, fentanyl common adjuvant used in practice of labour analgesia by anaesthesiologists across India.

Current Practice in Obstetric Anesthesia and Analgesia in Public Hospitals of Greece: A 2016 National Survey

Aims:

This descriptive survey was to evaluate the use of regional anesthesia in obstetrics in Greek public hospitals.

Methods:

The survey was conducted between March and August 2016. A structured questionnaire was sent to 50 anesthesia departments in Greek public hospitals with obstetric units.

Results:

The response rate was 94%. Data corresponding to 9475 cesarean and 8155 vaginal deliveries were collected. Regional anesthesia was used in 69.2% of all cesareans, with single shot spinal being the most popular (44.3% of all cesareans). Combined spinal-epidural anesthesia was used in 18.1% of all cesareans (35.1% in hospitals of Athens versus 7.9% outside Athens, p<0.001). Post-cesarean analgesia was applied with simple analgesics and systematic opioids (78.6%). Long-acting spinal opioids were rarely used (4.4% of spinal and spinal/epidurals). Labor epidural analgesia was applied in 19.1% of all vaginal deliveries (30.3% in Athens versus 13.1% outside Athens, p<0.001). Paracetamol and pethidine represented the standard labor analgesics in 48.9% and 55.3% of all hospitals. Intravenous remifentanil was used in 10.6% of hospitals (50% in Athens versus 2.5% outside Athens, p=0.002). In 48.9% of hospitals, mainly outside Athens, the anesthesiologists did not get involved in labor analgesia.

Conclusion:

Regional anesthesia is the most common practice for cesareans in Greek public hospitals; however, the percentage of general anesthesia remains high. In addition, the use of labor epidural analgesia is limited in hospitals outside Athens.

Investigating determinants for patient satisfaction in women receiving epidural analgesia for labour pain: a retrospective cohort study

BACKGROUND

Epidural analgesia is a popular choice for labour pain relief. Patient satisfaction is an important patient-centric outcome because it can significantly influence both mother and child. However, there is limited evidence in the correlations between clinical determinants and patient satisfaction. We aim to investigate clinical covariates that are associated with low patient satisfaction in parturients receiving labour neuraxial analgesia.

METHODS

After institutional ethics approval was obtained, we conducted a retrospective cohort study using electronic and corresponding hardcopy records from 10,170 parturients receiving neuraxial analgesia between the periods of January 2012 to December 2013 in KK Women's and Children's Hospital in Singapore. Demographic, obstetric and anesthetic data were collected. The patient satisfaction scores on the neuraxial labour analgesia was reported by the parturient at 24 to 48 h post-delivery during the post-epidural round conducted by the resident and pain nurse. Parturients were stratified into one of three categories based on their satisfaction scores. Ordinal logistic regression models were used to identify potential covariates of patient dissatisfaction.

RESULTS

10,146 parturients were included into the study, of which 3230 (31.8%) were 'not satisfied', 3646 (35.9%) were 'satisfied', and 3270 (32.2%) were 'very satisfied'. Multivariable ordinal logistic regression analysis showed that instrument-assisted vaginal delivery (p = 0.0007), higher post-epidural pain score (p = 0.0016), receiving epidural catheter resiting (p <  0.0001), receiving neuraxial analgesia at a more advanced cervical dilation (p = 0.0443), multiparity (p = 0.0039), and post-procedure complications headache (p = 0.0006), backache (p <  0.0001), urinary retention (p = 0.0002) and neural deficit (p = 0.0297) were associated with patient dissatisfaction. Chinese, compared with other ethnicities (p = 0.0104), were more likely to be dissatisfied.

CONCLUSIONS

Our study has identified several clinical determinants that were independent associated factors for low patient satisfaction. These covariates could be useful in developing a predictive model to detect at-risk parturients and undertake time-sensitive precautionary measures for better patient satisfaction.

The Effect of Epidural-Spinal Anesthesia on Labor Outcome and Satisfaction in Parturient Mothers: A Randomized Controlled Trial

Introduction: One of the health system concerns is the use of medications for pain relief during labor and its side effects. Therefore, the aim of this study was to investigate the effect of epiduralspinal anesthesia (combined anesthesia [CA]) on labor outcome and satisfaction in pregnant women. Methods: In this randomized controlled trial study, we included 80 nulliparous women who had been admitted to Fatemieh hospital (Hamadan, Iran) during 2015-2016 due to spontaneous onset of labor. They were randomly assigned into 2 groups of 40, one group with CA versus normal vaginal delivery (NVD) group. Data were collected by using of demographic questionnaire, satisfaction questionnaire, and baby truck scales. Data were analyzed by descriptive and analytical statistics in SPSS version 16.0. Results: Average maternal age (mean ± SD) in the CA group was 26.94 ± 4.34 and in the NVD group was 25.89 ±5.18, respectively. There was a significant difference between the 2 groups in terms of length of second stage of labor (P=0.001), headache (P=0.04), and Apgar score (first minute) (P=0.001). Chi-square test showed a significant difference between the 2 groups in terms of satisfaction with childbirth (P=0.004). Conclusion: In this study, labor pain relief by using the spinal-epidural anesthesia (CA) increased the labor satisfaction. Nevertheless, this approach was associated with some maternal and neonatal complications such as: headaches, length of third stage of labor, and low Apgar score. It seems that the use of this method for painless delivery requires further studies.

Effect of Epidural Dexmedetomidine Combined With Ropivacaine in Labor Analgesia: A Randomized Double-Blinded Controlled Study

BACKGROUND

The purpose of our study is to evaluate the effect of adding dexmedetomidine to epidural ropivacaine in patients undergoing labor epidural analgesia.

METHODS

Eighty healthy women were randomly assigned to 2 groups: control group (R; n=40) received epidural 0.125% ropivacaine for labor analgesia, whereas the study group (D; n=40) received epidural 0.125% ropivacaine with dexmedetomidine in addition. The blood pressure, heart rate, and the severity of pain of the parturient was assessed, the duration of the first stage and the second stage of labor time, the rate of instrumental delivery and the rate of cesarean section were recorded. The side effects (nausea and vomiting), intensity of maternal sedation, and neonatal Apgar scores were also recorded.

RESULTS

The visual analog scales, systolic blood pressure, diastolic blood pressure, and heart rates of D group were significant lower than that of R group at most time intervals after epidural analgesia. The duration of the first and second stage of labor, the rate of instrumental delivery and cesarean section, neonatal 1- and 5-minute Apgar scores, umbilical artery pH, maternal motor blockade scores, intensity of maternal sedation, and the incidence of maternal complications did not show significant difference between 2 groups.

CONCLUSIONS

Low concentration of epidural ropivacaine (0.125%) combined with dexmedetomidine (0.5 μg/kg) reduces the feeling of pain, and does not show the problems of motor blockage, hemodynamic instability, extension of production process, and complications such as nausea and vomiting. Our study was registered with Chinese Clinical Trial Registry (ChiCTR-IOR-15007263).

Effects of Intradermal Sterile Water Injections in Women with Low Back Pain in Labor: A Randomized, Controlled, Clinical Trial

Background:

In addition to the pain caused byuterine contractions during labour, continuous and severe back pain is observed in 33% of women. Several pharmacological and nonpharmacological methods are available for managing this pain. Sterile water injection is considered as alternative method for nonpharmacological pain management.

Aims:

To assess the satisfaction level and effectiveness of sterile water injection for back pain among women in labour.

Study Design:

Randomized controlled trial.

Methods:

A total of 168 term, healthy women with labour pain and severe back pain were randomized into the sterile water injection (study) and dry injection (placebo) groups. Injections were applied to the rhombus of Michaelis in the sacral area. Pain scores were assessed at 10, 30, 60, 120, and 180 min using a visual analogue scale. Additionally, the need for epidural analgesia, Apgar score, mode of delivery, time of delivery, maternal satisfaction, and breastfeeding score were assessed.

Results:

The mean back pain scores at 30 min after injections were significantly lower in the study group (study group: 31.66±11.38; placebo: 75±18.26, p<0.01). The mean decrease in pain scores after 30 min according to baseline was significantly higher in the study group (study group: 54.82±7.81; placebo: 13.33±12.05, p<0.01). The need for epidural analgesia, time of delivery, mode of delivery, and Apgar and breastfeeding scores were similar in both groups. Maternal satisfaction from the analgesic effect was significantly higher in the study group (study group: 84.5%; placebo: 35.7%, p<0.01).

Conclusion:

The application of sterile water injection is effective for relieving back pain in the first stage of labour and has a sufficient satisfaction level among women.

Modern Neuraxial Anesthesia for Labor and Delivery

The availability of safe, effective analgesia during labor has become an expectation for women in most of the developed world over the past two or three decades. More than 60% of women in the United States now receive some kind of neuraxial procedure during labor. This article is a brief review of the advantages and techniques of neuraxial labor analgesia along with the recent advances and controversies in the field of labor analgesia. For the most part, we have aimed the discussion at the non-anesthesiologist to give other practitioners a sense of the state of the art and science of labor analgesia in the second decade of the 21st century.

Midwives perceptions of partner presence in childbirth pain alleviation in Nigeria hospitals

OBJECTIVE

partner presence in the labour room can influence childbirth pain outcomes and maternal well-being. We examined midwives' perception of the use of partner presence in the management of childbirth pain in Nigerian hospitals.

DESIGN

a descriptive cross-sectional quantitative study.

SETTING

maternity units of four hospitals in Abuja, Nigeria, Jun.-Dec., 2014.

PARTICIPANTS

100 midwives selected through convenience sampling.

MEASUREMENTS

data collected using the Abuja Instrument for Midwives (AIM) questionnaire underwent frequency, correlation, and content analysis.

FINDINGS

most midwives felt partner presence contributed to pain relief and were willing to allow partner presence as an intervention for childbirth pain. However, only every fourth midwife reported using partner presence as a pain management intervention.

KEY CONCLUSION

partner presence is perceived as contributing to pain relief and is a non-pharmacological technique reported to be utilised by midwives for pain management during childbirth. However, Nigeria suffers from poor utilisation of partner presence as a pain management intervention during childbirth.

IMPLICATION FOR PRACTICE

information from this study can improve midwifery practice and aid further research regarding midwives' attitudes, knowledge and usage of partner presence in pain management during childbirth.

A comprehensive analysis of continuous epidural analgesia's effect on labor and neonates in maternal hypertensive disorder patients

BACKGROUND

Maternal hypertensive disorder is one of the most common and severe medical complications during pregnancy. Epidural analgesia administration is widely used during labor process.

AIM

To evaluate the potential advantage or disadvantage of continuous epidural analgesia's on labor and neonates for maternal hypertensive disorder patients comprehensively.

METHODS

We have retrospectively analyzed 232 patients who diagnosed as maternal hypertensive disorder in our hospital since 2015. Among which, 126 patients including 28 cases of severe preeclampsia were administrated with continuous epidural analgesia (Analgesia group), the other 106 patients were untreated (Control group). We have compared the maternal age, body weight, gestational weeks, period for the first and second labor stage; the incidence of eclampsia, natural labor, cesarean section, forceps delivery and postpartum hemorrhage between these two groups respectively; furthermore, we recorded patients who received oxytocin and antihypertensive treatment during the delivery progress as well as evaluated the neonate body weight, Apgar score and performed umbilical cord blood gas analysis.

RESULTS

Continuous epidural analgesia does not affect the first and second labor stage period (p=0.36), However, there is a significantly higher demand for oxytocin treatment (36.5% Vs 19.8%, p<0.01) and a significantly lower requirement for antihypertensive treatment (22.2% Vs 81.1%, p<0.001) in analgesia group compared to control group. We also notice that the natural delivery ratio in analgesia group is higher than control group and most importantly, continuous epidural analgesia can increase 1min Apgar score and has no other effect on neonates' body weight, umbilical cord blood gas parameters, 5min and 10min Apgar score.

CONCLUSIONS

Our result based on a large cohort comprehensive analysis indicates that continuous epidural analgesia can benefit both maternal hypertensive disorder patients and neonates without any side effect.

The Effect of Epidural Analgesia on the Delivery Outcome of Induced Labour: A Retrospective Case Series

Objective. To investigate whether the use of epidural analgesia during induced labour was a risk factor for instrumental vaginal delivery and caesarean section (CS) delivery. Study Design. This was a retrospective case series of primigravidae women being induced at term for all indications with a normal body mass index (BMI) at booking and under the age of 40 years. Results. We identified 1,046 women who fulfilled the inclusion criteria of which 31.2% had an epidural analgesia. Those with an epidural analgesia had significantly greater maternal age, higher BMI, greater percentage of oxytocin usage, and a longer first and second stage of labour. Women with an epidural analgesia had a higher instrumental delivery (37.9% versus 16.4%; p < 0.001) and CS delivery rate (26% versus 10.1%; p < 0.001). Multivariable analysis indicated that the use of an epidural was not a risk factor for a CS delivery but was a risk factor for an instrument-assisted delivery (adjusted OR = 3.63; 95% CI: 2.51–5.24; p < 0.001). Conclusion. Our study supports the literature evidence that the use of an epidural increases the instrumental delivery rates. It has also added that there is no effect on CS delivery and the observed increase is due to the presence of confounding factors.