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

A comparison of childbirth self-efficacy, fear of childbirth, and labor pain intensity between primiparas and multiparas during the latent phase of labor: a cross-sectional study

BACKGROUND

Childbirth is a long-lasting physiological stress. As one of the main stressors, labor pain exists throughout the whole process. Childbirth self-efficacy is the confidence, or belief that they can manage pain during childbirth. This sense of self-efficacy determines how pregnant women deal with labor pain and enables them to regulate their behavior and actively deal with childbirth. However, the difference in pain sensitivity between single births (primiparas) and multiple births (multiparas) has rarely been investigated.

OBJECTIVES

This study is aimed at investigating self-efficacy, fear of childbirth, labor pain of primiparas and multiparas and exploring factors related to the perceived labor pain intensity of pregnant women.

DESIGN

Prospective cross-sectional study.

SETTING(S)

Labour and delivery in a large academic specialized hospital in Guangzhou, China.

PARTICIPANTS

A total of 347 women, (182 primiparas and 165 multiparas) were enrolled in the data analysis. Pain was assessed before cervical dilatation (cervical dilatation ≤ 3 cm for the first delivery and ≤ 2 cm for the second delivery).

METHOD

The general information of participants was obtained by questionnaire and obstetrical records of the subjects were obtained from the electronic medical records extracted from the electronic medical record system (EMRS). Childbirth self-efficacy, fear of childbirth (FOC) and labor pain were compared between primiparas and multiparas. Paired t-test, chi-square test, Mann-Whitney test, univariate and multivariate regression analysis were used to analyze labor pain between the two groups and investigate factors related perceived labor pain intensity.

RESULTS

The total scores related to fear of childbirth, fetal health, self-control, and labor pain injury of multiparas were notably reduced compared with primiparas (all P < 0.05). The perceived labor pain intensity and duration of the first stage of labor was reduced in the multipara group compared with the primipara group. The childbirth control sense of the multipara was better than that of the primipara. The perceived labor pain intensity was negatively correlated with advanced age (age ≥ 35 years), self-efficacy score, family support, and education (all P < 0.05). In contrast, the perceived labor pain intensity was positively correlated with tension, severe fear of childbirth, and anxiety (P < 0.05). Self-efficacy, gravidity, delivery cognition, and fear of childbirth were independent risk factors for the perceived labor pain intensity in the latent period (all P < 0.05).

CONCLUSIONS

Fear of childbirth is a predictor of perceived labor pain intensity. The extent of labor pain (minimum and maximum) can be predicted by the level of fear the expectant mother has. During the latent phase of labor, self-efficacy, fear of childbirth and labor pain are different between primiparas and multiparas.

Neonatal Outcomes in Labor After Intravenous Remifentanil Analgesia vs. Epidural Analgesia: A Retrospective Observational Study

Background Some evidence indicates that maternal analgesia during labor may have adverse effects on neonates due to exposure to specific drugs or the potential effects of analgesia on the course of labor. We assessed the clinical outcome of term neonates born to mothers who received epidural analgesia (E) or systemic analgesia with remifentanil (R) during labor. Methods Data was collected retrospectively over one year. We have evaluated the medical records of 247 full-term neonates; 208 were born to mothers who received E and 39 to mothers who received R. Data on Apgar scores and neonatal complications (perinatal asphyxia, respiratory distress, infection, hyperbilirubinemia, and birth injuries), and average hospital stay were collected. Mann-Whitney U test, chi-square test, and logistic regression analysis were used where appropriate. Results The values of the mean Apgar scores between E and R at 1 and 5 minutes were similar (8.83 vs. 8.97, p = 0.252; 9.81 vs. 9.87, p = 0.762, respectively). The average length of neonatal hospitalization did not differ between groups (4.19 vs. 4; p = 0.557). The percentages of neonates with any complication were similar between groups (28.3% vs. 32.5%, p = 0.598). Neonates born by cesarean delivery (CD) had significantly worse outcomes than those born vaginally (p = 0.008, OR 2.8, 95% CI [1.30, 6.17]). Conclusion We did not find a statistically significant difference in mean Apgar scores and neonatal complications between neonates who received epidural vs. remifentanil analgesia. An increased rate of complications in neonates born via CD was found. Future studies should have a larger sample size and be powered to detect associations in these findings.

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.

The Effect of Epidural Analgesia on Labour and Neonatal and Maternal Outcomes in 1, 2a, 3, and 4a Robson's Classes: A Propensity Score-Matched Analysis

Background: Lumbar epidural analgesia (EA) is the most commonly used method for reducing labour pain, but its impact on the duration of the second stage of labour and on neonatal and maternal outcomes remains a matter of debate. Our aim was to examine whether EA affected the course and the outcomes of labour among patients divided according to the Robson-10 group classification system. Methods: Patients of Robson’s classes 1, 2a, 3, and 4a were divided into either the EA group or the non-epidural analgesia (NEA) group. A propensity score-matching analysis was performed to balance the intergroup differences. The primary goal was to analyse the duration of the second stage of labour. The secondary goals were to evaluate neonatal and maternal outcomes. Results: In total, 21,808 cases were analysed. The second stage of labour for all groups was prolonged using EA (p < 0.05) without statistically significant differences in neonatal outcomes. EA resulted in a lower rate of episiotomies in nulliparous patients, with a higher rate of operative vaginal deliveries (OVD) (p < 0.05) and Caesarean sections (CS) (p < 0.05) in some classes. Conclusions: EA prolonged the duration of labour without affecting neonatal outcomes and reduced the rate of episiotomies, but also increased the rate of OVDs.

Evaluation efficacy and safety of epidural analgesia in second-trimester induced labor: A single-center, prospective, non-randomized, controlled study

BACKGROUND

Second-trimester induced labor in pregnant women was often more likely to suffer from psychological and physiological double pain. However, the analgesic management received less attention, and the optimal analgesic mode for second-trimester induced labor had not been determined. Our objective was to evaluate the feasible of epidural analgesia (EA) in second-trimester induced labor.

METHODS

From January 2020 to December 2021, Primipara who planned to undergo second-trimester induced labor in the First Affiliated Hospital of Yangtze University were collected. The method of labor induction was oral mifepristone + amniotic cavity injection of Ethacridine Lactate. Based on whether or not patients received epidural analgesia, which were divided into EA group (30 cases) and non-EA (NEA) group (30 cases). The primary outcome were visual analog scale (VAS) score of pain and result of follow-up, the secondary outcomes included relative clinical parameter and labor duration.

RESULTS

Vaginal induction of labor was successful in both groups. There was no statistically significant difference in VAS of pain between the two groups before analgesia (P > .05), but the VAS of pain in the EA group was significantly lower than the NEA group (P < .05) after analgesia or at delivery. The following outcomes showed no statistical difference between two groups: labor duration, postpartum hemorrhage, hemorrhage ≥ 500 mL, intrapartum injury, second days hemoglobin, C-reactive protein, antibiotic therapy days, hospitalizations days, and placenta residue (P > .05). The median hospitalization costs of EA group was 4697.5 yuan, and NEA group was 3673 yuan, the difference was statistically significant (P < .001). No adverse events related to EA occurred during hospitalization, only 3 patients showed mild lumbago and back pain after follow-up to three months postpartum, which was significantly relieved after proper rest.

CONCLUSION

EA can significantly reduce the pain of parturients, which may be effective and safe in the second-trimester induced labor.

Effects of using epidural analgesia during delivery on maternal and infant outcomes

OBJECTIVES

To estimate the impact of epidural analgesia (EA) during delivery on maternal and infant outcomes.

DESIGN

This study was a prospective cohort study.

PARTICIPANTS

In total, 159 pregnant women in Women and Children's Hospital, School of Medicine, Xiamen university from Nov. 2019 to May 2020. Patients were randomly divided into EA group (n=80) and no analgesia group (n=79).

METHODS

The duration of labor, levels of umbilical arterial blood gas [pH and partial pressure oxygen (PaO2)], VAS, adverse events were evaluated to compare differences between EA group and no analgesia group, respectively.

RESULTS

The duration of the first stage of labor was shorted in the total stage (P=0.002) and the first stage of labor (P=0.001) in EA group compared with no analgesia group. The second stage of labor and third stage of labor, levels of umbilical arterial blood gas and 1min Apgar score in neonates were similar in EA and no analgesia groups (All P>0.05). After adjusting age, pre-pregnancy BMI, and past and present medical history, the VAS was low in EA group compared with no analgesia group when the uterine orifice was completely open [odds ratio (OR)=0.001, 95% confidence interval (CI):0.001-0.002], 8h post-delivery (OR=0.508, 95%CI:0.264-0.977) and 24h post-delivery (OR=0.321, 95%CI:0.167-0.617). EA increased the proportion of adverse events occurring 5 min post-delivery (χ2=10.137, P=0.001), while decreased the proportion of adverse events occurring 24h post-delivery (χ2=4.750, P=0.029).

LIMITATIONS

In terms of the effects of EA on neonates, we only measured the 1 min Apgar score of neonates.

CONCLUSIONS

EA might be a promising pain relief method for pregnant women. The results of our study might give a reference for the use of EA during delivery in clinic.

Intrapartum Analgesia-Have Women's Preferences Changed over the Last Decade?

Background: Global access to social media has supposedly changed women’s awareness about the pharmacological and alternative methods of pain relief during vaginal delivery. The purpose of the study was to analyze changes in women’s preference and opinion about different forms of labor analgesia over the past decade. Materials and methods: The study was designed as an anonymous survey with questions about women’s knowledge and preference of different forms of pain relief in labor. The survey was conducted in 2010 and 2020, with data collected from 1175 women in 2010 and 1033 in 2020. Results: There were no differences between 2010 and 2020 in the proportion of women who wanted to receive analgesia in labor, at, respectively 67.9% of women in 2010 and 73.9% in 2020. About 50% of women chose epidural analgesia as the only efficacious method of pain relief in labor both in 2010 and 2020. There were no differences between the two time-points in the distribution of chosen methods of pain relief. In total, 92.3% of women in 2010 and 94.9% in 2020 thought that they should have the possibility of independent choice of analgesia method before the delivery (p < 0.04). Conclusions: A high proportion of Polish women choose EDA over other pharmacological and nonpharmacological methods of pain relief in labor, and this preference has not changed over the last decade. Increasing women’s knowledge about different methods of intrapartum pain relief may lead to wider use of nonpharmacological methods of pain relief.

Assessing the duration of obstetric analgesia and the time elapsed between analgesia and delivery. Observational trial

Introduction: The duration of labor and the immediate puerperium are affected by obstetric and maternal-fetal factors. Interventions to provide obstetric analgesia may prolong the hospital stay. Objective: To characterize the procedure for obstetric analgesia and describe the time elapsed between analgesia and delivery and postpartum surveillance in healthy mothers. Methods: Observational, descriptive trial. The time elapsed between analgesia and delivery, and postpartum surveillance were measured in healthy pregnant women with vaginal delivery and a prescription of a neuraxial analgesia technique. Results: 226 patients were included. The mean time elapsed between analgesia an delivery was 4 hours (IQR 3-7). 50.7 % (n = 114) received early analgesia (neuraxial technique with ≤ 4 centimeters of cervical dilatation), of which 48.2 % (n = 109) experienced a duration of analgesia until delivery longer than expected. The mean cervical dilatation at the time of the neuraxial approach was 4 centimeters (IQR 4-6) and the epidural technique was the most frequently used – 92.9 % (n = 210). The mean postpartum surveillance was 20 hours (IQR 15-27). Conclusions: Half of the patients included received early analgesia and around fifty percent of them took longer than expected in completing delivery. The postpartum surveillance time was consistent with the provisions of the Ministry of Health and with the current trend of a short postpartum surveillance aimed at early hospital discharge and the benefits thereof.