Patient choice compared with no choice of intrathecal morphine dose for caesarean analgesia: a randomized clinical trial

Spiritual Health, Anxiety and Fear of Childbirth in Iran: Is there Any Relationship?

The most common reason for mothers' request for a cesarean section is fear of childbirth. The present study was conducted to determine the relationship between spiritual health and anxiety and fear of childbirth in pregnant women. This correlational cross-sectional study was performed on 426 pregnant women who were referred to Yahyanejad Hospital in Babol, Iran, during 2018-2021. These pregnant women were hospitalized in the maternity ward for vaginal delivery. Convenience sampling bases on inclusion criteria were done to select the subjects. The questionnaires used in this study included Demographic and Obstetric Questionnaire, Anxiety and Fear of Childbirth Questionnaire by Pirdel et al., and Palutzian & Ellison Spiritual Well-being Scale. Data were analyzed using SPSS version 16 using descriptive and analytical indicators and linear and multiple correlation tests. The results of the study showed that all pregnant women experienced moderate (23.1) or severe (76.9) fear and anxiety, and none of the women had low fear and anxiety. Moreover, all women in this study had moderate (50.5) or high (49.5) spiritual health. The results of linear regression test showed that there is a significant and inverse relationship between spiritual health and anxiety and fear of childbirth (R: - 0.12, CI - 0.14, - 0.019, P = 0.011). Furthermore, the results of multivariate linear regression test after adjustments for intervening demographic and midwifery variables showed a significant relationship between spiritual health (R: - 0.12, CI - 0.14, - 0.02, P = 0.009), education level and number of pregnancies, and anxiety and fear of childbirth. The results of the study showed that with the increase in spiritual health, anxiety and fear of childbirth decreases. Therefore, it can be inferred that women need spiritual care in addition to medical care to deal with fear and anxiety during pregnancy and childbirth.

Continuous wound infusion catheter as part of a multimodal analgesia regimen for post-Caesarean delivery pain: a quality improvement impact study

Background

The role of continuous wound infusion catheters as part of a multimodal analgesia strategy after Caesarean delivery is unclear. We introduced continuous wound infusion catheters to our multimodal analgesia regimen to evaluate the impact on analgesic outcomes after Caesarean delivery.

Methods

After institutional review board (IRB) approval, a 4-month practice change was instituted as a quality improvement initiative. In addition to multimodal analgesia, continuous wound infusion catheters for up to 3 days were offered on alternate weeks for all women undergoing Caesarean deliveries. The primary outcome was postoperative in-hospital opioid consumption. Secondary outcomes were static and dynamic pain scores at 24 and 72 h, time until first analgesic request, opioid-related side-effects, length of stay, satisfaction (0-100%), and continuous wound infusion catheter-related complications.

Results

All women scheduled for Caesarean delivery (n=139) in the 4-month period were included in the analysis, with 70 women receiving continuous wound infusion catheters, and 69 in the control group. Opioid consumption (continuous wound infusion catheter group 11.3 [7.5-61.9] mg morphine equivalents vs control group 30.0 [11.3-48.8] mg morphine equivalents), pain scores (except 24 h resting pain scores which were higher in the control group 2 [1-3] vs 1.5 [0-3] in the continous wound infusion catheters group; P=0.05), side-effects, length of stay, and complications were similar between groups. Satisfaction scores at 24 h were higher with continuous wound infusion catheters (100% [91-100%] vs 90% [86-100%]; P=0.003) with no differences at 72 h. One patient demonstrated symptoms of systemic local anaesthetic toxicity which resolved without significant harm.

Conclusions

The addition of continuous wound infusion catheters to a multimodal analgesia regimen for post-Caesarean delivery pain management demonstrated minimal clinically significant analgesic benefits. Future studies are needed to explore the use of continuous wound infusion catheters in populations that may benefit most from this intervention.

The analgesic effect of transversalis fascia plane block after caesarean section under spinal anaesthesia with intrathecal morphine: a randomised controlled trial

We aimed to test whether bilateral injection of bupivacaine 0.25% in the transversalis fascia plane reduced 24 h opioid dose after singleton caesarean section, under spinal anaesthesia with intrathecal morphine, compared with saline 0.9% injectate. We allocated randomly 52 women to bilateral injection of 20 ml saline 0.9% on arrival in the post-anaesthesia care unit and 54 women to bilateral injection of 20 ml bupivacaine 0.25% (with adrenaline 2.5 μg.ml-1 ). Mean (SD) cumulative morphine equivalent opioid dose 24 h after saline injection was 32.3 (28.3) mg and 18.7 (20.2) mg after bupivacaine injection, a mean (95%CI) difference of 13.7 (4.1-23.2) mg (p = 0.006). Median (IQR [range]) time to first postoperative opioid dose was 3.0 (1.5-10.3 [0.0-57.4]) h after saline 0.9% and 8.2 (2.7-29.6 [0.2-55.4]) h after bupivacaine 0.25% (p = 0.054). Transversalis fascia plane with bupivacaine 0.25% with adrenaline reduced postoperative pain at rest during 48 h (0-10-point scale) by a mean (95%CI) of 0.9 (0.2-1.6) points (p = 0.013) and on movement by 1.2 (0.4-2.1) points (p = 0.004). We conclude that transversalis fascia plane bupivacaine 0.25% with adrenaline reduces pain and opioid dose after caesarean section compared with saline 0.9%.

Efficacy of regional blocks or local anaesthetic infiltration for analgesia after caesarean delivery: a network meta-analysis of randomised controlled trials

Caesarean delivery is common and can cause severe postoperative pain but injection of local anaesthetic at various sites for regional blocks or local anaesthetic infiltration may reduce this. We aimed to compare and rank these sites. We searched PubMed, Google Scholar, EMBASE and CENTRAL to June 2021 for randomised controlled trials and performed a random-effects Bayesian model network meta-analysis. The primary outcome was dose of parenteral morphine equivalents in the first 24 postoperative hours. We used surface under cumulative ranking probabilities to order techniques. We analysed 114 trials (8730 participants). The ordered mean (95% credible interval) reduction in morphine equivalents, from 34 mg with placebo, were as follows: ilio-inguinal 15 (1-32) mg; ilio-inguinal-iliohypogastric 13 (6-19) mg; transversalis fascia 11 (4-26) mg; erector spinae 11 (10-32); transverse abdominis 9 (4-13) mg; wound catheter infusion 8 (2-15) mg; quadratus lumborum 8 (1-15) mg; wound infiltration 8 (2-13) mg; and no intervention -4 (-10 to 2) mg. Ordered efficacies for injection sites were different for other relevant outcomes, including pain (to 4-6 h and to 24 h) and time to rescue analgesia: there was no single preferred route of injection. The ordered mean (95% credible interval) reduction in dynamic pain scores (0-10 scale) at 24 h compared with placebo were as follows: wound infusion 1.2 (0.2-2.1); erector spinae 1.3 (-0.5 to 3.1); quadratus lumborum 1.0 (0.1-1.8); ilio-inguinal-iliohypogastric 0.6 (-0.5 to 1.8); transverse abdominis 0.6 (-0.1 to 1.2); wound infiltration 0.5 (-0.3 to 1.3); transversalis fascia -0.8 (-3.4 to 1.9); ilio-inguinal -0.9 (-3.6 to 1.7); and no intervention -0.8 (-1.8 to 0.2). We categorised our confidence in effect sizes as low or very low.

The Generalizability of Patients' Preferences and Concerns regarding Anesthesia Care for Cesarean Delivery: A Prospective Survey

Background

False assumptions regarding the generalizability of patients' expectations and preferences across different demographic groups may contribute in part to the increased prevalence of negative peripartum outcomes seen among women of color. The intention of this study was to determine preferences and concerns regarding anesthesia care during cesarean delivery in a largely African-American population and to compare them to those obtained in a prior study conducted in a demographically distinct population.

Methods

Women presenting for scheduled cesarean delivery or induction of labor completed a preoperative survey requesting demographic information and the opportunity to rank ten common potential anesthetic outcomes in relation to each other from most to least desirable. Participants were also asked about their biggest fear concerning their anesthetic and their preferences and expectations regarding degree of wakefulness, pain, and other adverse events. Those who underwent cesarean delivery were administered a briefer postoperative survey. We tabulated preference rankings and then compared demographic and outcome data to that obtained in a previous study with a demographically dissimilar population.

Results

A total of 73 women completed the preoperative survey, and 64 took the postoperative survey. Pain during and after cesarean delivery was ranked as least desirable outcomes and fear of paralysis was respondents' principal concern with neuraxial anesthesia. Postoperative concerns were similar to preoperative concerns and did not correlate with the frequency with which specific adverse outcomes occurred. These results were consistent with those from the previous study despite the women in this study being more likely to be younger, unmarried, African-American, and less educated than those in the previous investigation.

Conclusions

Patient preference rankings and concerns were remarkably similar to those previously demonstrated despite a number of demographic differences between the two populations, suggesting generalizability of these preferences to a broader obstetric population.

The Current Consideration, Approach, and Management in Postcesarean Delivery Pain Control: A Narrative Review

Optimal postoperative analgesia has a significant impact on patient recovery and outcomes after cesarean delivery. Multimodal analgesia is the core principle for cesarean delivery and pain management. For a standard analgesic regimen, the use of long-acting neuraxial opioids (e.g., morphine) and adjunct drugs, such as scheduled acetaminophen and nonsteroidal anti-inflammatory drugs, is recommended unless contraindicated. Oral or intravenous opioids should be reserved for breakthrough pain. In addition to the aforementioned use of multimodal analgesia, preoperative evaluation is critical to individualize the analgesic regimen according to the patient requirements. Risk factors for severe postoperative pain or analgesia-related adverse effects will require modifications to the standard analgesic regimen (e.g., the use of ketamine, gabapentinoids, or regional anesthetic techniques). Further investigation is required to determine analgesic drugs or dose alterations based on preoperative predictions for patients at risk of severe pain. Outcomes beyond pain and analgesic use, such as functional recovery, should be determined to evaluate analgesic treatment protocols.

Evidence-based guidance for use of intrathecal morphine as an alternative to diamorphine for Caesarean delivery analgesia

Intrathecal morphine in combination with fentanyl is an effective and safe alternative to diamorphine for Caesarean delivery analgesia. Evidence suggests minimal differences in clinical efficacy and side-effects between intrathecal morphine and diamorphine. Recommended intrathecal morphine doses for Caesarean delivery analgesia are 100-150 ug.

PROSPECT guideline for elective caesarean section: updated systematic review and procedure-specific postoperative pain management recommendations

Caesarean section is associated with moderate‐to‐severe postoperative pain, which can influence postoperative recovery and patient satisfaction as well as breastfeeding success and mother‐child bonding. The aim of this systematic review was to update the available literature and develop recommendations for optimal pain management after elective caesarean section under neuraxial anaesthesia. A systematic review utilising procedure‐specific postoperative pain management (PROSPECT) methodology was undertaken. Randomised controlled trials published in the English language between 1 May 2014 and 22 October 2020 evaluating the effects of analgesic, anaesthetic and surgical interventions were retrieved from MEDLINE, Embase and Cochrane databases. Studies evaluating pain management for emergency or unplanned operative deliveries or caesarean section performed under general anaesthesia were excluded. A total of 145 studies met the inclusion criteria. For patients undergoing elective caesarean section performed under neuraxial anaesthesia, recommendations include intrathecal morphine 50–100 µg or diamorphine 300 µg administered pre‐operatively; paracetamol; non‐steroidal anti‐inflammatory drugs; and intravenous dexamethasone administered after delivery. If intrathecal opioid was not administered, single‐injection local anaesthetic wound infiltration; continuous wound local anaesthetic infusion; and/or fascial plane blocks such as transversus abdominis plane or quadratus lumborum blocks are recommended. The postoperative regimen should include regular paracetamol and non‐steroidal anti‐inflammatory drugs with opioids used for rescue. The surgical technique should include a Joel‐Cohen incision; non‐closure of the peritoneum; and abdominal binders. Transcutaneous electrical nerve stimulation could be used as analgesic adjunct. Some of the interventions, although effective, carry risks, and consequentially were omitted from the recommendations. Some interventions were not recommended due to insufficient, inconsistent or lack of evidence. Of note, these recommendations may not be applicable to unplanned deliveries or caesarean section performed under general anaesthesia.

Endogenous opiates and behavior: 2017

This paper is the fortieth consecutive installment of the annual anthological review of research concerning the endogenous opioid system, summarizing articles published during 2017 that studied the behavioral effects of molecular, pharmacological and genetic manipulation of opioid peptides and receptors as well as effects of opioid/opiate agonists and antagonists. The review is subdivided into the following specific topics: molecular-biochemical effects and neurochemical localization studies of endogenous opioids and their receptors (1), the roles of these opioid peptides and receptors in pain and analgesia in animals (2) and humans (3), opioid-sensitive and opioid-insensitive effects of nonopioid analgesics (4), opioid peptide and receptor involvement in tolerance and dependence (5), stress and social status (6), learning and memory (7), eating and drinking (8), drug abuse and alcohol (9), sexual activity and hormones, pregnancy, development and endocrinology (10), mental illness and mood (11), seizures and neurologic disorders (12), electrical-related activity and neurophysiology (13), general activity and locomotion (14), gastrointestinal, renal and hepatic functions (15), cardiovascular responses (16), respiration and thermoregulation (17), and immunological responses (18).

Effect of Intravenous Oxycodone Versus Sufentanil on the Incidence of Postoperative Nausea and Vomiting in Patients Undergoing Gynecological Laparoscopic Surgery

More than 30% of patients who undergo surgery will experience postoperative nausea and vomiting (PONV) if no prophylactic treatments are used. Although numerous studies have been performed to investigate the factors related to PONV, the effect of perioperative intravenous oxycodone on the incidence of PONV has not been well investigated. In this study, gynecological patients (grade I-II, aged 18-65 years, scheduled to undergo elective gynecological laparoscopic surgery under general anesthesia) were randomized to the oxycodone group or the sufentanil group. In the oxycodone group, patients received intravenous oxycodone for the induction and maintenance of anesthesia, as well as postoperative analgesia, while sufentanil was used in the sufentanil group. The primary outcome variable was the incidence of PONV. As secondary outcomes, time to first PONV, the rating of the most severe PONV, postoperative pain scores at different time points, hemodynamics, and side effects were evaluated. We found that, compared with sufentanil, oxycodone decreased the incidence of PONV by 13.5% (P = .041). The time to first vomiting was longer in the oxycodone group than in the sufentanil group. Postoperative pain scores at different time points and hemodynamics were comparable between the oxycodone and sufentanil groups. We concluded that the incidence of PONV in gynecological patients who underwent laparoscopic surgery was lower when using intravenous oxycodone for anesthesia induction, anesthesia maintenance, and postoperative analgesia than when using intravenous sufentanil. However, oxycodone and sufentanil provided the same stable hemodynamics during surgery and satisfactory postoperative analgesia.

Impact of patient choice for different postcesarean delivery analgesic protocols on opioid consumption: a randomized prospective clinical trial

BACKGROUND

Choice of postcesarean delivery analgesic protocol may improve pain experience and reduce analgesic requirements.

METHODS

Cesarean delivery patients were randomly assigned either to choose their postcesarean delivery analgesia protocol or to have no choice and receive routine care. Choices were low (50 μg intrathecal morphine), medium (identical to routine care: 150 μg intrathecal morphine), or high (300 μg intrathecal morphine with 600 mg oral gabapentin). All groups received scheduled acetaminophen and ibuprofen. The primary outcome was oxycodone requirements 0-48 hours postdelivery in those offered versus not offered a choice.

RESULTS

Of 160 women enrolled, 120 were offered a choice and 40 were not offered a choice. There was no difference in oxycodone requirements or pain associated with choice, but those who had a choice expressed more satisfaction than those who did not have a choice (mean (95% CI) difference 5% (0% to 10 %), p=0.005). In the choice group, the high dose group required more oxycodone (5 (0 to 15) mg 0-24 hours after delivery and 15 (10 to 25) mg at 24-48 hours; p=0.05 and p=0.001) versus the low and medium groups. The low dose group had less pruritus (p=0.001), while the high dose group had more vomiting (p=0.01) requiring antiemetic treatment (p=0.04).

CONCLUSION

Having a choice compared with no choice routine care did not reduce oxycodone requirements or pain scores. However, women have insight into their analgesic needs; women offered a choice and who chose the higher dose analgesic protocol required more oxycodone, and women who chose the lower dose protocol required less oxycodone. Despite providing additional analgesic (six times more intrathecal morphine plus gabapentin in high dose vs low dose protocols), we still did not equalize postcesarean oxycodone requirement differences between groups.

TRIAL REGISTRATION NUMBER

NCT02605187.

Enhanced recovery after cesarean delivery

Enhanced recovery after surgery is a concept initially developed for patients undergoing colorectal surgery but has been adopted by other surgical specialties with similar positive outcomes. The adoption of enhanced recovery after surgery in the obstetric patient population is rapidly gaining popularity. This review highlights perioperative interventions that should be considered in an enhanced recovery after surgery protocol for women undergoing cesarean delivery.

Relationship between Spiritual Intelligence with Happiness and Fear of Childbirth in Iranian Pregnant Women

Background:

Spiritual intelligence is a person's ability to feel a connection to a higher power and a sacred entity. With regard to its relation with happiness, it can have an important effect on the mental health of pregnant women. Therefore, this study aimed to investigate the relationship between spiritual intelligence and happiness and fear of childbirth in pregnant women.

Materials and Methods:

This cross-sectional study was conducted on 245 low-risk pregnant women from June till September 2015. Using random cluster sampling method, the subjects were selected among the women who referred to health care centers in Shahroud (Northeast of Iran). After obtaining informed consent, the researchers evaluated the spiritual intelligence, happiness, and fear of childbirth. Data were analyzed using STATA12 and Chi-square test, t-test, analysis of variance, and Strucrural Equation Model.

Results:

In this study, the spiritual intelligence mean (SD) score was 64.43(16.51). Comparison between mothers with and without fear of childbirth showed there was a significant difference between the spiritual intelligence score and happiness mean scores in these two groups. There is a negative correlation between spiritual intelligence and happiness with fear of childbirth (−0.73 and −0.69, respectively).

Conclusions:

Increased level of spiritual intelligence in pregnant women can lead to an increase in their happiness and reduce their fear of childbirth. The fear of childbirth can be prevented via trainings to pregnant women about the components of spiritual intelligence; moreover, training the techniques to achieve more happiness can help mothers to reduce their fear of childbirth and hence promote natural childbirth.