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Tabernée Heijtmeijer ESE, Groen H, Damhuis SE, Freeman LM, Middeldorp JM, Ganzevoort W, Gordijn SJ. Epidural analgesia and emergency delivery for presumed fetal compromise: post-hoc analysis of RAVEL multicenter randomized controlled trial. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2023; 62:675-680. [PMID: 37448200 DOI: 10.1002/uog.26308] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/15/2023] [Revised: 06/27/2023] [Accepted: 06/28/2023] [Indexed: 07/15/2023]
Abstract
OBJECTIVE To investigate the association between epidural analgesia (EDA) vs patient-controlled remifentanil analgesia (PCRA) and emergency delivery for presumed fetal compromise, in relation to birth-weight quintile. METHODS This was a post-hoc per-protocol analysis of the RAVEL multicenter equivalence randomized controlled trial. Non-anomalous singleton pregnancies between 36 + 0 and 42 + 6 weeks' gestation were randomized at the time of requesting pain relief to receive EDA or PCRA. The primary outcome was emergency delivery for presumed fetal compromise. Secondary outcomes included mode of delivery and neonatal outcomes. Analysis was performed according to birth-weight quintile and was corrected for relevant confounding variables. RESULTS Of 619 pregnant women, 336 received PCRA and 283 received EDA. Among women receiving EDA, 14.8% had an emergency delivery for presumed fetal compromise, compared with 8.3% of women who received PCRA. After adjusting for parity, women receiving EDA had higher odds of presumed fetal compromise compared to those receiving PCRA (odds ratio, 1.69 (95% CI, 1.01-2.83)). A statistically significant linear-by-linear association was observed between presumed fetal compromise and birth-weight quintile (P = 0.003). The incidence of emergency delivery for presumed fetal compromise was highest in women receiving EDA and delivering a neonate with a birth weight in the lowest quintile. CONCLUSIONS Intrapartum EDA is associated with a higher rate of emergency delivery for presumed fetal compromise compared to treatment with PCRA. Birth-weight quintile is a strong predictor of this outcome, independent of pain management method. © 2023 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- E S E Tabernée Heijtmeijer
- Department of Obstetrics and Gynecology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - H Groen
- Department of Epidemiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - S E Damhuis
- Department of Obstetrics and Gynecology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
- Department of Obstetrics and Gynecology, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
| | - L M Freeman
- Department of Obstetrics and Gynecology, Leiden University Medical Center, Leiden, The Netherlands
| | - J M Middeldorp
- Department of Obstetrics and Gynecology, Ikazia Hospital, Rotterdam, The Netherlands
| | - W Ganzevoort
- Department of Obstetrics and Gynecology, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
- Amsterdam Reproduction and Development Research Institute, Amsterdam, The Netherlands
| | - S J Gordijn
- Department of Obstetrics and Gynecology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
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Borre-Naranjo D, Santacruz J, Gonzalez-Hernandez J, Anichiarico W, Rubio-Romero J. Infección por SARS-CoV-2 en la paciente obstétrica: una perspectiva desde el cuidado crítico. ACTA COLOMBIANA DE CUIDADO INTENSIVO 2020. [PMCID: PMC7158844 DOI: 10.1016/j.acci.2020.04.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
La nueva infección por coronavirus (COVID-19) se constituye en el principal problema de salud pública en el mundo. Entre el 5 y el 30% de los pacientes afectados por esta enfermedad requieren manejo en una unidad de cuidado intensivo. Se han generado diferentes publicaciones con recomendaciones para la población general. Sin embargo, en la población obstétrica la evidencia científica es reducida, aún más cuando se trata de infección por COVID-19 en escenarios de cuidado intensivo obstétrico. Por esta razón, se realizó una revisión narrativa no sistemática de la literatura utilizando como fuente de información MEDLINE, sociedades científicas y los repositorios de la Organización Mundial de la Salud y el Ministerio de Salud y Protección Social de Colombia, con el objetivo de describir algunas sugerencias para el manejo de una paciente embarazada con COVID-19 en una unidad de cuidado intensivo. Se resalta que la atención debe ser realizada por un equipo interdisciplinario, bajo monitorización materna y fetal cuando corresponda, vigilando los niveles de saturación de oxígeno y la hemodinamia materna para minimizar la hipoxemia fetal. Se describen recomendaciones sobre algunos tópicos relevantes en el escenario crítico, como la intubación oportuna, la utilización adecuada de los equipos de protección personal (EPP), el manejo de la falla circulatoria, las estrategias restrictivas de fluidos y/o vasopresores, entre otros.
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Wang L, Huang W, Zhan J. Grape Seed Proanthocyanidins Induce Autophagy and Modulate Survivin in HepG2 Cells and Inhibit Xenograft Tumor Growth in Vivo. Nutrients 2019; 11:E2983. [PMID: 31817589 PMCID: PMC6950679 DOI: 10.3390/nu11122983] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2019] [Revised: 12/02/2019] [Accepted: 12/04/2019] [Indexed: 01/02/2023] Open
Abstract
Liver cancer is one of the leading causes of death worldwide. Although radiotherapy and chemotherapy are effective in general, they present various side effects, significantly limiting the curative effect. Increasing evidence has shown that the dietary intake of phytochemicals plays an essential role in the chemoprevention or chemotherapy of tumors. In this work, HepG2 cells and nude mice with HepG2-derived xenografts were treated with grape seed proanthocyanidins (GSPs). The results showed that GSPs induced autophagy, and inhibition of autophagy increased apoptosis in HepG2 cells. In addition, GSPs also reduced the expression of survivin. Moreover, survivin was involved in GSPs-induced apoptosis. GSPs at 100 mg/kg and 200 mg/kg significantly inhibited the growth of HepG2 cells in nude mice without causing observable toxicity and autophagy, while inducing the phosphorylation of mitogen-activated protein kinase (MAPK) pathway-associated proteins, p-JNK, p-ERK and p-p38 MAPK and reducing the expression of survivin. These results suggested that GSPs might be promising phytochemicals against liver cancer.
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Affiliation(s)
| | | | - Jicheng Zhan
- Beijing Key Laboratory of Viticulture and Enology, College of Food Science and Nutritional Engineering, China Agricultural University, Beijing 100083, China; (L.W.); (W.H.)
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Czech I, Fuchs P, Fuchs A, Lorek M, Tobolska-Lorek D, Drosdzol-Cop A, Sikora J. Pharmacological and Non-Pharmacological Methods of Labour Pain Relief-Establishment of Effectiveness and Comparison. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2018; 15:E2792. [PMID: 30544878 PMCID: PMC6313325 DOI: 10.3390/ijerph15122792] [Citation(s) in RCA: 44] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/28/2018] [Revised: 12/06/2018] [Accepted: 12/07/2018] [Indexed: 12/12/2022]
Abstract
Background: To evaluate the effectiveness of pharmacological and non-pharmacological pain relief methods and to compare them. Materials and methods: 258 women were included in the study and interviewed using a questionnaire and the visual analogue scale for pain. They were divided into six groups depending on chosen method of labour pain relief: epidural anaesthesia (EA; n = 42), water immersion and water birth (WB; n = 40), nitrous oxide gas for pain control (G; n = 40), transcutaneous electrical nerve stimulation (TENS) (n = 50), multiple management (MM; n = 42), none (N; n = 44). Results: The average age of the women was 29.4 ± 3.74 years and 60.47% of them were nulliparous (n = 156). Mean values of labour pain intensity were 6.81 ± 2.26 during the first stage of labour; 7.86 ± 2.06 during the second stage, and 3.22 ± 2.46 during the third stage. There was no significant difference in pain level between epidural analgesia and gas groups in the first stage of labour (p = 0.74). Nevertheless, epidural analgesia reduced pain level during the second and third stage (both p < 0.01). The highest satisfaction level pertains to water immersion (n = 38; 95%). Conclusion: Epidural analgesia is the gold standard of labour pain relief, however water birth was found to be associated with the highest satisfaction level of the parturient women. The contentment of childbirth depends not only on the level of experienced pain, but also on the care provided to the parturient during pregnancy and labour.
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Affiliation(s)
- Iwona Czech
- Department of Pregnancy Pathology, Department of Woman's Health, School of Health Sciences in Katowice, Medical University of Silesia, 40-752 Katowice, Poland.
| | - Piotr Fuchs
- Student's Scientific Organisation of Gyneacology, Obstetrics and Sexology, Medical University of Silesia, 40-752 Katowice, Poland.
| | - Anna Fuchs
- Department of Pregnancy Pathology, Department of Woman's Health, School of Health Sciences in Katowice, Medical University of Silesia, 40-752 Katowice, Poland.
| | - Miłosz Lorek
- Student's Scientific Organisation of Gyneacology, Obstetrics and Sexology, Medical University of Silesia, 40-752 Katowice, Poland.
| | - Dominika Tobolska-Lorek
- Student's Scientific Organisation of Gyneacology, Obstetrics and Sexology, Medical University of Silesia, 40-752 Katowice, Poland.
| | - Agnieszka Drosdzol-Cop
- Department of Pregnancy Pathology, Department of Woman's Health, School of Health Sciences in Katowice, Medical University of Silesia, 40-752 Katowice, Poland.
| | - Jerzy Sikora
- Department of Pregnancy Pathology, Department of Woman's Health, School of Health Sciences in Katowice, Medical University of Silesia, 40-752 Katowice, Poland.
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Bos EME, Schut ME, Quelerij M, Kalkman CJ, Hollmann MW, Lirk P. Trends in practice and safety measures of epidural analgesia: Report of a national survey. Acta Anaesthesiol Scand 2018; 62:1466-1472. [PMID: 30066960 DOI: 10.1111/aas.13219] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2018] [Revised: 06/16/2018] [Accepted: 06/19/2018] [Indexed: 02/06/2023]
Abstract
BACKGROUND The clinical use of epidural analgesia has changed over past decades. Minimally invasive surgery and emergence of alternative analgesic techniques have led to an overall decline in its use. In addition, there is increasing awareness of the patient-specific risks for complications such as spinal haematoma and abscess. Local guidelines for management of severe neurological complications during or after epidural analgesia, ie, "epidural alert systems", have been introduced in hospitals to coordinate and potentially streamline early diagnosis and treatment. How widely such protocols have been implemented in daily practice is unknown. METHODS We conducted a survey to analyse trends in practice, key indications, safety measures, safety reporting, and management of complications of epidural analgesia in the Netherlands. Data were gathered using a web-based questionnaire and analysed using descriptive statistics. RESULTS Questionnaires from 85 of all 94 Dutch hospitals performing epidural analgesia were collected and analysed, a 90% response rate. Fifty-five percent reported a trend towards decreased use of perioperative epidural analgesia, while 68% reported increasing use of epidural analgesia for labour. Reported key indications for epidural analgesia were thoracotomy, upper abdominal laparotomy, and abdominal cancer debulking. An epidural alert system for neurological complications of epidural analgesia was available in 45% of hospitals. CONCLUSIONS This national audit concerning use and safety of epidural analgesia demonstrates that a minority of Dutch hospitals have procedures to manage suspected neurological complications of epidural analgesia, whereas in the remaining hospitals responsibilities and timelines for management of epidural emergencies are determined on an ad hoc basis.
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Affiliation(s)
- Elke M. E. Bos
- Department of Anaesthesiology Amsterdam UMC University of Amsterdam Amsterdam The Netherlands
| | - Maartje E. Schut
- Department of Anaesthesiology Amsterdam UMC University of Amsterdam Amsterdam The Netherlands
| | - Marcel Quelerij
- Department of Anaesthesiology Franciscus Gasthuis & Vlietland Rotterdam The Netherlands
| | - Cor J. Kalkman
- Division of Anaesthesiology, Intensive Care and Emergency Medicine University Medical Centre Utrecht The Netherlands
| | - Markus W. Hollmann
- Department of Anaesthesiology Amsterdam UMC University of Amsterdam Amsterdam The Netherlands
| | - Philipp Lirk
- Department of AnaesthesiologyPerioperative and Pain Medicine Brigham and Women's Hospital Harvard Medical School Boston Massachusetts
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An economic analysis of patient controlled remifentanil and epidural analgesia as pain relief in labour (RAVEL trial); a randomised controlled trial. PLoS One 2018; 13:e0205220. [PMID: 30307986 PMCID: PMC6181333 DOI: 10.1371/journal.pone.0205220] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2015] [Accepted: 09/06/2018] [Indexed: 11/22/2022] Open
Abstract
Objective To compare the costs of a strategy of patient controlled remifentanil versus epidural analgesia for pain relief in labour. Design We performed a multicentre randomised controlled trial in 15 hospitals in the Netherlands, the RAVEL trial. Costs were analysed from a health care perspective alongside the RAVEL trial. Population Pregnant women of intermediate to high risk beyond 32 weeks gestation who planned vaginal delivery. Methods Women were randomised before the onset of labour, to receive either patient controlled remifentanil or epidural analgesia when pain relief was requested during labour. Main outcome measures Primary outcome for effectiveness was satisfaction with pain relief, expressed as the area under the curve (AUC). A higher AUC represents higher satisfaction with pain relief. Here, we present an economic analysis from a health care perspective including costs from the start of labour to ten days postpartum. Health-care utilization was documented in the Case Report Forms and by administering an additional questionnaire. Results The costs in the patient controlled remifentanil group (n = 687) and in the epidural group (n = 671) were €2900 versus €3185 respectively (mean difference of -€282 (95% CI -€611 to €47)). The (non-significant) higher costs in the epidural analgesia group could be mainly attributed to higher costs of neonatal admission. Conclusion From an economic perspective, there is no preferential pain treatment in labouring intermediate to high risk women. Since patient controlled remifentanil is not equivalent to epidural analgesia with respect to AUC for satisfaction with pain relief we recommend epidural analgesia as the method of choice. However, if appropriately counselled on effect and side effects there is, from an economic perspective, no reason to deny women patient controlled remifentanil.
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Abstract
BACKGROUND Parenteral opioids (intramuscular and intravenous drugs including patient-controlled analgesia) are used for pain relief in labour in many countries throughout the world. This review is an update of a review first published in 2010. OBJECTIVES To assess the effectiveness, safety and acceptability to women of different types, doses and modes of administration of parenteral opioid analgesia in labour. A second objective is to assess the effects of opioids in labour on the baby in terms of safety, condition at birth and early feeding. SEARCH METHODS We searched Cochrane Pregnancy and Childbirth's Trials Register, ClinicalTrials.gov, the WHO International Clinical Trials Registry Platform (ICTRP) (11 May 2017) and reference lists of retrieved studies. SELECTION CRITERIA We included randomised controlled trials examining the use of intramuscular or intravenous opioids (including patient-controlled analgesia) for women in labour. Cluster-randomised trials were also eligible for inclusion, although none were identified. We did not include quasi-randomised trials. We looked at studies comparing an opioid with another opioid, placebo, no treatment, other non-pharmacological interventions (transcutaneous electrical nerve stimulation (TENS)) or inhaled analgesia. DATA COLLECTION AND ANALYSIS Two review authors independently assessed trials for inclusion and risk of bias, extracted data and checked them for accuracy. We assessed the quality of each evidence synthesis using the GRADE approach. MAIN RESULTS We included 70 studies that compared an opioid with placebo or no treatment, another opioid administered intramuscularly or intravenously or compared with TENS applied to the back. Sixty-one studies involving more than 8000 women contributed data to the review and these studies reported on 34 different comparisons; for many comparisons and outcomes only one study contributed data. All of the studies were conducted in hospital settings, on healthy women with uncomplicated pregnancies at 37 to 42 weeks' gestation. We excluded studies focusing on women with pre-eclampsia or pre-existing conditions or with a compromised fetus. Overall, the evidence was graded as low- or very low-quality regarding the analgesic effect of opioids and satisfaction with analgesia; evidence was downgraded because of study design limitations, and many of the studies were underpowered to detect differences between groups and so effect estimates were imprecise. Due to the large number of different comparisons, it was not possible to present GRADE findings for every comparison.For the comparison of intramuscular pethidine (50 mg/100 mg) versus placebo, no clear differences were found in maternal satisfaction with analgesia measured during labour (number of women satisfied or very satisfied after 30 minutes: 50 women; 1 trial; risk ratio (RR) 7.00, 95% confidence interval (CI) 0.38 to 128.87, very low-quality evidence), or number of women requesting an epidural (50 women; 1 trial; RR 0.50, 95% CI 0.14 to 1.78; very low-quality evidence). Pain scores (reduction in visual analogue scale (VAS) score of at least 40 mm: 50 women; 1 trial; RR 25, 95% CI 1.56 to 400, low-quality evidence) and pain measured in labour (women reporting pain relief to be "good" or "fair" within one hour of administration: 116 women; 1 trial; RR 1.75, 95% CI 1.24 to 2.47, low-quality evidence) were both reduced in the pethidine group, and fewer women requested any additional analgesia (50 women; 1 trial; RR 0.71, 95% CI 0.54 to 0.94, low-quality evidence).There was limited information on adverse effects and harm to women and babies. There were few results that clearly showed that one opioid was more effective than another. Overall, findings indicated that parenteral opioids provided some pain relief and moderate satisfaction with analgesia in labour. Opioid drugs were associated with maternal nausea, vomiting and drowsiness, although different opioid drugs were associated with different adverse effects. There was no clear evidence of adverse effects of opioids on the newborn. We did not have sufficient evidence to assess which opioid drug provided the best pain relief with the least adverse effects. AUTHORS' CONCLUSIONS Though most evidence is of low- or very-low quality, for healthy women with an uncomplicated pregnancy who are giving birth at 37 to 42 weeks, parenteral opioids appear to provide some relief from pain in labour but are associated with drowsiness, nausea, and vomiting in the woman. Effects on the newborn are unclear. Maternal satisfaction with opioid analgesia was largely unreported. The review needs to be examined alongside related Cochrane reviews. More research is needed to determine which analgesic intervention is most effective, and provides greatest satisfaction to women with acceptable adverse effects for mothers and their newborn.
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Affiliation(s)
- Lesley A Smith
- Oxford Brookes UniversityDepartment of Psychology, Social Work and Public HealthJack Straws LaneMarstonOxfordUKOX3 0FL
| | - Ethel Burns
- Faculty of Health and Life Sciences, Oxford Brookes UniversityDepartment of Psychology, Social Work and Public HealthJack Straws LaneOxfordUKOX3 0FL
| | - Anna Cuthbert
- The University of LiverpoolCochrane Pregnancy and Childbirth Group, Department of Women's and Children's HealthFirst Floor, Liverpool Women's NHS Foundation TrustCrown StreetLiverpoolUKL8 7SS
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Anim‐Somuah M, Smyth RMD, Cyna AM, Cuthbert A. Epidural versus non-epidural or no analgesia for pain management in labour. Cochrane Database Syst Rev 2018; 5:CD000331. [PMID: 29781504 PMCID: PMC6494646 DOI: 10.1002/14651858.cd000331.pub4] [Citation(s) in RCA: 162] [Impact Index Per Article: 27.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND Epidural analgesia is a central nerve block technique achieved by injection of a local anaesthetic close to the nerves that transmit pain, and is widely used as a form of pain relief in labour. However, there are concerns about unintended adverse effects on the mother and infant. This is an update of an existing Cochrane Review (Epidural versus non-epidural or no analgesia in labour), last published in 2011. OBJECTIVES To assess the effectiveness and safety of all types of epidural analgesia, including combined-spinal-epidural (CSE) on the mother and the baby, when compared with non-epidural or no pain relief during labour. SEARCH METHODS We searched Cochrane Pregnancy and Childbirth's Trials Register (ClinicalTrials.gov), the WHO International Clinical Trials Registry Platform (ICTRP) (30 April 2017), and reference lists of retrieved studies. SELECTION CRITERIA Randomised controlled trials comparing all types of epidural with any form of pain relief not involving regional blockade, or no pain relief in labour. We have not included cluster-randomised or quasi-randomised trials in this update. DATA COLLECTION AND ANALYSIS Two review authors independently assessed trials for inclusion and risks of bias, extracted data and checked them for accuracy. We assessed selected outcomes using the GRADE approach. MAIN RESULTS Fifty-two trials met the inclusion criteria and we have included data from 40 trials, involving over 11,000 women. Four trials included more than two arms. Thirty-four trials compared epidural with opioids, seven compared epidural with no analgesia, one trial compared epidural with acu-stimulation, one trial compared epidural with inhaled analgesia, and one trial compared epidural with continuous midwifery support and other analgesia. Risks of bias varied throughout the included studies; six out of 40 studies were at high or unclear risk of bias for every bias domain, while most studies were at high or unclear risk of detection bias. Quality of the evidence assessed using GRADE ranged from moderate to low quality.Pain intensity as measured using pain scores was lower in women with epidural analgesia when compared to women who received opioids (standardised mean difference -2.64, 95% confidence interval (CI) -4.56 to -0.73; 1133 women; studies = 5; I2 = 98%; low-quality evidence) and a higher proportion were satisfied with their pain relief, reporting it to be "excellent or very good" (average risk ratio (RR) 1.47, 95% CI 1.03 to 2.08; 1911 women; studies = 7; I2 = 97%; low-quality evidence). There was substantial statistical heterogeneity in both these outcomes. There was a substantial decrease in the need for additional pain relief in women receiving epidural analgesia compared with opioid analgesia (average RR 0.10, 95% CI 0.04 to 0.25; 5099 women; studies = 16; I2 = 73%; Tau2 = 1.89; Chi2 = 52.07 (P < 0.00001)). More women in the epidural group experienced assisted vaginal birth (RR 1.44, 95% CI 1.29 to 1.60; 9948 women; studies = 30; low-quality evidence). A post hoc subgroup analysis of trials conducted after 2005 showed that this effect is negated when trials before 2005 are excluded from this analysis (RR 1.19, 95% CI 0.97 to 1.46). There was no difference between caesarean section rates (RR 1.07, 95% CI 0.96 to 1.18; 10,350 women; studies = 33; moderate-quality evidence), and maternal long-term backache (RR 1.00, 95% CI 0.89 to 1.12; 814 women; studies = 2; moderate-quality evidence). There were also no clear differences between groups for the neonatal outcomes, admission to neonatal intensive care unit (RR 1.03, 95% CI 0.95 to 1.12; 4488 babies; studies = 8; moderate-quality evidence) and Apgar score less than seven at five minutes (RR 0.73, 95% CI 0.52 to 1.02; 8752 babies; studies = 22; low-quality evidence). We downgraded the evidence for study design limitations, inconsistency, imprecision in effect estimates, and possible publication bias.Side effects were reported in both epidural and opioid groups. Women with epidural experienced more hypotension, motor blockade, fever, and urinary retention. They also had longer first and second stages of labour, and were more likely to have oxytocin augmentation than the women in the opioid group. Women receiving epidurals had less risk of respiratory depression requiring oxygen, and were less likely to experience nausea and vomiting than women receiving opioids. Babies born to women in the epidural group were less likely to have received naloxone. There was no clear difference between groups for postnatal depression, headache, itching, shivering, or drowsiness. Maternal morbidity and long-term neonatal outcomes were not reported.Epidural analgesia resulted in less reported pain when compared with placebo or no treatment, and with acu-stimulation. Pain intensity was not reported in the trials that compared epidural with inhaled analgesia, or continuous support. Few trials reported on serious maternal side effects. AUTHORS' CONCLUSIONS Low-quality evidence shows that epidural analgesia may be more effective in reducing pain during labour and increasing maternal satisfaction with pain relief than non-epidural methods. Although overall there appears to be an increase in assisted vaginal birth when women have epidural analgesia, a post hoc subgroup analysis showed this effect is not seen in recent studies (after 2005), suggesting that modern approaches to epidural analgesia in labour do not affect this outcome. Epidural analgesia had no impact on the risk of caesarean section or long-term backache, and did not appear to have an immediate effect on neonatal status as determined by Apgar scores or in admissions to neonatal intensive care. Further research may be helpful to evaluate rare but potentially severe adverse effects of epidural analgesia and non-epidural analgesia on women in labour and long-term neonatal outcomes.
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Affiliation(s)
| | - Rebecca MD Smyth
- The University of ManchesterDivision of Nursing Midwifery and Social WorkJean McFarlane BuildingOxford RoadManchesterUKM13 9PL
| | - Allan M Cyna
- Women's and Children's HospitalDepartment of Women's Anaesthesia72 King William RoadAdelaideSouth AustraliaAustralia5006
| | - Anna Cuthbert
- The University of LiverpoolCochrane Pregnancy and Childbirth Group, Department of Women's and Children's HealthFirst Floor, Liverpool Women's NHS Foundation TrustCrown StreetLiverpoolUKL8 7SS
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Weibel S, Jelting Y, Afshari A, Pace NL, Eberhart LHJ, Jokinen J, Artmann T, Kranke P. Patient-controlled analgesia with remifentanil versus alternative parenteral methods for pain management in labour. Cochrane Database Syst Rev 2017; 4:CD011989. [PMID: 28407220 PMCID: PMC6478102 DOI: 10.1002/14651858.cd011989.pub2] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
BACKGROUND Multiple analgesic strategies for pain relief during labour are available. Recently remifentanil, a short-acting opioid, has recently been used as an alternative analgesic due to its unique pharmacological properties. OBJECTIVES To systematically assess the effectiveness of remifentanil intravenous patient-controlled analgesia (PCA) for labour pain, along with any potential harms to the mother and the newborn. SEARCH METHODS We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (9 December 2015), ClinicalTrials.gov, the WHO International Clinical Trials Registry Platform (ICTRP), handsearched congress abstracts (November 2015), and reference lists of retrieved studies. SELECTION CRITERIA Randomised controlled trials (RCTs) and cluster-randomised trials comparing remifentanil (PCA) with another opioid (intravenous (IV)/intramuscular (IM)), or with another opioid (PCA), or with epidural analgesia, or with remifentanil (continuous IV), or with remifentanil (PCA, different regimen), or with inhalational analgesia, or with placebo/no treatment in all women in labour including high-risk groups with planned vaginal delivery. DATA COLLECTION AND ANALYSIS Two review authors independently assessed trials for inclusion, extracted data, and appraised study quality.We contacted study authors for additional information other than incomplete outcome data. We performed random-effects meta-analysis.To reduce the risk of random error in meta-analysis we performed trial sequential analysis. We included total zero event trials and used a constant continuity correction of 0.01 (ccc 0.01) for meta-analysis. We applied the Grades of Recommendation, Assessment, Development, and Evaluation (GRADE) approach to assess the quality of evidence. MAIN RESULTS Twenty RCTs with 3569 women were included. Of those, 10 trials (2983 participants) compared remifentanil (PCA) to an epidural, four trials (216 participants) to another opioid (IV/IM), three trials (215 participants) to another opioid (PCA), two trials (135 participants) to remifentanil (continuous IV), and one trial (20 participants) to remifentanil (PCA, different regimen). No trials were identified for the remaining comparisons.Methodological quality of studies was moderate to poor. We assessed risk of bias as high for blinding issues and incomplete outcome data in 65% and 45% of the included studies, respectively.There is evidence of effect that women in the remifentanil (PCA) group were more satisfied with pain relief than women in the other opioids (IV/IM) group (standardised mean difference (SMD) 2.11, 95% confidence interval (CI) 0.72 to 3.49, four trials, very low-quality evidence), and that women were less satisfied compared to women in the epidural group (SMD -0.22, 95% CI -0.40 to -0.04, seven trials, very low-quality evidence).There is evidence of effect that remifentanil (PCA) provided stronger pain relief at one hour than other opioids administered IV/IM (SMD -1.58, 95% CI -2.69 to -0.48, three trials, very low-quality evidence) or via PCA (SMD -0.51, 95% CI -1.01 to -0.00, three trials, very low-quality evidence). Pain intensity was higher in the remifentanil (PCA) group compared to the epidural group (SMD 0.57, 95% CI 0.31 to 0.84, six trials, low-quality evidence).Data were limited on safety aspects for both the women and the newborns. Only one study analysed maternal apnoea in a comparison of remifentanil (PCA) versus epidural and reported that half of the women in the remifentanil and none in the epidural group had an apnoea (very low-quality evidence). There is no evidence of effect that remifentanil (PCA) was associated with an increased risk for maternal respiratory depression when compared to epidural analgesia (RR 0.91, 95% CI 0.51 to 1.62, ccc 0.01, three trials, low-quality evidence) and no reliable conclusion might be reached compared to remifentanil (continuous IV) (all study arms included zero events, two trials, low-quality evidence). In one trial of remifentanil (PCA) versus another opioid (IM) three out of 18 women in the remifentanil and none out of 18 in the control group had a respiratory depression (very low-quality evidence).There is no evidence of effect that remifentanil (PCA) was associated with an increased risk for newborns with Apgar scores less than seven at five minutes compared to epidural analgesia (RR 1.26, 95% CI 0.62 to 2.57, ccc 0.01, five trials, low-quality evidence) and no reliable conclusion might be reached compared to another opioid (IV) and compared to remifentanil (PCA, different regimen) both with zero events in all study arms (one trial, very-low quality evidence). In one trial of remifentanil (PCA) versus another opioid (PCA) none out of nine newborns in the remifentanil and three out of eight in the opioid (PCA) group had Apgar scores less than seven (very-low quality evidence).There is evidence that remifentanil (PCA) was associated with a lower risk for the requirement of additional analgesia when compared to other opioids (IV/IM) (RR 0.57, 95% CI 0.40 to 0.81, three trials, moderate-quality evidence) and that it was associated with a higher risk compared to epidural analgesia (RR 9.27, 95% CI 3.73 to 23.03, ccc 0.01, six trials, moderate-quality evidence). There is no evidence of effect that remifentanil (PCA) reduced the requirement for additional analgesia compared to other opioids (PCA) (RR 0.76, 95% CI 0.45 to 1.28, three trials, low-quality evidence).There is evidence that there was no difference in the risk for caesarean delivery between remifentanil (PCA) and other opioids (IV/IM) (RR 0.63, 95% CI 0.30 to 1.32, ccc 0.01, four trials, low-quality evidence) and epidural analgesia (RR 1.0, 95% CI 0.82 to 1.22, ccc 0.01, nine trials, moderate-quality evidence), respectively. Pooled meta-analysis revealed an increased risk for caesarean section under remifentanil (PCA) compared to other opioids (PCA) (RR 2.78, 95% CI 0.99 to 7.82, two trials, very low-quality evidence). However, a wide range of clinically relevant and non-relevant treatment effects is compatible with this result. AUTHORS' CONCLUSIONS Based on the current systematic review, there is mostly low-quality evidence to inform practice and future research may significantly alter the current situation. The quality of evidence is mainly limited by poor quality of the studies, inconsistency, and imprecision. More research is needed on maternal and neonatal safety outcomes (maternal apnoea and respiratory depression, Apgar score) and on the optimal mode and regimen of remifentanil administration to provide highest efficacy with reasonable adverse effects for mothers and their newborns.
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Affiliation(s)
- Stephanie Weibel
- University of WürzburgDepartment of Anaesthesia and Critical CareOberduerrbacher Str. 6WürzburgGermany
| | - Yvonne Jelting
- University of WürzburgDepartment of Anaesthesia and Critical CareOberduerrbacher Str. 6WürzburgGermany
| | - Arash Afshari
- Rigshospitalet, Copenhagen University HospitalJuliane Marie Centre ‐ Anaesthesia and Surgical Clinic Department 4013CopenhagenDenmark
| | - Nathan Leon Pace
- University of UtahDepartment of Anesthesiology3C444 SOM30 North 1900 EastSalt Lake CityUTUSA84132‐2304
| | - Leopold HJ Eberhart
- Philipps‐University MarburgDepartment of Anaesthesiology & Intensive Care MedicineBaldingerstrasse 1MarburgGermany35043
| | - Johanna Jokinen
- University of WürzburgDepartment of Anaesthesia and Critical CareOberduerrbacher Str. 6WürzburgGermany
| | - Thorsten Artmann
- Cnopf Children´s Hospital, Hospital HallerwieseDepartment of Anaesthesia and Intensive Care MedicineNuernbergGermany
| | - Peter Kranke
- University of WürzburgDepartment of Anaesthesia and Critical CareOberduerrbacher Str. 6WürzburgGermany
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Gärtner FR, de Bekker-Grob EW, Stiggelbout AM, Rijnders ME, Freeman LM, Middeldorp JM, Bloemenkamp KWM, de Miranda E, van den Akker-van Marle ME. Calculating Preference Weights for the Labor and Delivery Index: A Discrete Choice Experiment on Women's Birth Experiences. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2015; 18:856-864. [PMID: 26409614 DOI: 10.1016/j.jval.2015.07.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/24/2014] [Revised: 06/04/2015] [Accepted: 07/01/2015] [Indexed: 06/05/2023]
Abstract
OBJECTIVE The aim of this study was to calculate preference weights for the Labor and Delivery Index (LADY-X) to make it suitable as a utility measure for perinatal care studies. METHODS In an online discrete choice experiment, 18 pairs of hypothetical scenarios were presented to respondents, from which they had to choose a preferred option. The scenarios describe the birth experience in terms of the seven LADY-X attributes. A D-efficient discrete choice experiment design with priors based on a small sample (N = 110) was applied. Two samples were gathered, women who had recently given birth and subjects from the general population. Both samples were analyzed separately using a panel mixed logit (MMNL) model. Using the panel mixed multinomial logit (MMNL) model results and accounting for preference heterogeneity, we calculated the average preference weights for LADY-X attribute levels. These were transformed to represent a utility score between 0 and 1, with 0 representing the worst and 1 representing the best birth experience. RESULTS In total, 1097 women who had recently given birth and 367 subjects from the general population participated. Greater value was placed on differences between bottom and middle attribute levels than on differences between middle and top levels. The attributes that resulted in larger utility increases than the other attributes were "feeling of safety" in the sample of women who had recently given birth and "feeling of safety" and "availability of professionals" in the general population sample. CONCLUSIONS By using the derived preference weights, LADY-X has the potential to be used as a utility measure for perinatal (cost-) effectiveness studies.
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Affiliation(s)
- Fania R Gärtner
- Department of Medical Decision Making, Leiden University Medical Center, Leiden, The Netherlands.
| | - Esther W de Bekker-Grob
- Department of Public Health, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Anne M Stiggelbout
- Department of Medical Decision Making, Leiden University Medical Center, Leiden, The Netherlands
| | | | - Liv M Freeman
- Department of Obstetrics, Leiden University Medical Center, Leiden, The Netherlands
| | - Johanna M Middeldorp
- Department of Obstetrics, Leiden University Medical Center, Leiden, The Netherlands
| | | | - Esteriek de Miranda
- Department of Gynecology and Obstetrics and Gynecology, Academic Medical Center, Amsterdam, The Netherlands
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11
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Gärtner FR, de Miranda E, Rijnders ME, Freeman LM, Middeldorp JM, Bloemenkamp KWM, Stiggelbout AM, van den Akker-van Marle ME. Good reliability and validity for a new utility instrument measuring the birth experience, the Labor and Delivery Index. J Clin Epidemiol 2015; 68:1184-94. [PMID: 26115813 DOI: 10.1016/j.jclinepi.2015.05.020] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2014] [Revised: 04/01/2015] [Accepted: 05/22/2015] [Indexed: 10/23/2022]
Abstract
OBJECTIVES To validate the Labor and Delivery Index (LADY-X), a new delivery-specific utility measure. STUDY DESIGN AND SETTING In a test-retest design, women were surveyed online, 6 to 8 weeks postpartum and again 1 to 2 weeks later. For reliability testing, we assessed the standard error of measurement (S.E.M.) and the intraclass correlation coefficient (ICC). For construct validity, we tested hypotheses on the association with comparison instruments (Mackey Childbirth Satisfaction Rating Scale and Wijma Delivery Experience Questionnaire), both on domain and total score levels. We assessed known-group differences using eight obstetrical indicators: method and place of birth, induction, transfer, control over pain medication, complications concerning mother and child, and experienced control. RESULTS The questionnaire was completed by 308 women, 257 (83%) completed the retest. The distribution of LADY-X scores was skewed. The reliability was good, as the ICC exceeded 0.80 and the S.E.M. was 0.76. Requirements for good construct validity were fulfilled: all hypotheses for convergent and divergent validity were confirmed, and six of eight hypotheses for known-group differences were confirmed as all differences were statistically significant (P-values: <0.001-0.023), but for two tests, difference scores did not exceed the S.E.M. CONCLUSION The LADY-X demonstrates good reliability and construct validity. Despite its skewed distribution, the LADY-X can discriminate between groups. With the preference weights available, the LADY-X might fulfill the need for a utility measure for cost-effectiveness studies for perinatal care interventions.
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Affiliation(s)
- Fania R Gärtner
- Department of Medical Decision Making, Leiden University Medical Centre, Albinusdreef 2, 230 RC Leiden, The Netherlands.
| | - Esteriek de Miranda
- Department of Obstetrics & Gynaecology, Academic Medical Center, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
| | | | - Liv M Freeman
- Department of Obstetrics, Leiden University Medical Centre, Albinusdreef 2, 230 RC Leiden, The Netherlands
| | - Johanna M Middeldorp
- Department of Obstetrics, Leiden University Medical Centre, Albinusdreef 2, 230 RC Leiden, The Netherlands
| | - Kitty W M Bloemenkamp
- Department of Obstetrics, Leiden University Medical Centre, Albinusdreef 2, 230 RC Leiden, The Netherlands
| | - Anne M Stiggelbout
- Department of Medical Decision Making, Leiden University Medical Centre, Albinusdreef 2, 230 RC Leiden, The Netherlands
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Khooshideh M, Shahriari A, Sheikh M. Comparison of the Effect of Incremental Bolus and Incremental Infusion Regimens of Remifentanil on Labour Pain. ACTA ACUST UNITED AC 2015. [DOI: 10.17795/semj25626] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
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13
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Freeman LM, Bloemenkamp KW, Franssen MT, Papatsonis DN, Hajenius PJ, Hollmann MW, Woiski MD, Porath M, van den Berg HJ, van Beek E, Borchert OWHM, Schuitemaker N, Sikkema JM, Kuipers AHM, Logtenberg SLM, van der Salm PCM, Oude Rengerink K, Lopriore E, van den Akker-van Marle ME, le Cessie S, van Lith JM, Struys MM, Mol BWJ, Dahan A, Middeldorp JM. Patient controlled analgesia with remifentanil versus epidural analgesia in labour: randomised multicentre equivalence trial. BMJ 2015; 350:h846. [PMID: 25713015 PMCID: PMC4353278 DOI: 10.1136/bmj.h846] [Citation(s) in RCA: 66] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/16/2015] [Indexed: 11/24/2022]
Abstract
OBJECTIVE To determine women's satisfaction with pain relief using patient controlled analgesia with remifentanil compared with epidural analgesia during labour. DESIGN Multicentre randomised controlled equivalence trial. SETTING 15 hospitals in the Netherlands. PARTICIPANTS Women with an intermediate to high obstetric risk with an intention to deliver vaginally. To exclude a clinically relevant difference in satisfaction with pain relief of more than 10%, we needed to include 1136 women. Because of missing values for satisfaction this number was increased to 1400 before any analysis. We used multiple imputation to correct for missing data. INTERVENTION Before the onset of active labour consenting women were randomised to a pain relief strategy with patient controlled remifentanil or epidural analgesia if they requested pain relief during labour. MAIN OUTCOME MEASURES Primary outcome was satisfaction with pain relief, measured hourly on a visual analogue scale and expressed as area under the curve (AUC), thus providing a time weighted measure of total satisfaction with pain relief. A higher AUC represents higher satisfaction with pain relief. Secondary outcomes were pain intensity scores, mode of delivery, and maternal and neonatal outcomes. Analysis was done by intention to treat. The study was defined as an equivalence study for the primary outcome. RESULTS 1414 women were randomised, of whom 709 were allocated to patient controlled remifentanil and 705 to epidural analgesia. Baseline characteristics were comparable. Pain relief was ultimately used in 65% (447/687) in the remifentanil group and 52% (347/671) in the epidural analgesia group (relative risk 1.32, 95% confidence interval 1.18 to 1.48). Cross over occurred in 7% (45/687) and 8% (51/671) of women, respectively. Of women primarily treated with remifentanil, 13% (53/402) converted to epidural analgesia, while in women primarily treated with epidural analgesia 1% (3/296) converted to remifentanil. The area under the curve for total satisfaction with pain relief was 30.9 in the remifentanil group versus 33.7 in the epidural analgesia group (mean difference -2.8, 95% confidence interval -6.9 to 1.3). For who actually received pain relief the area under the curve for satisfaction with pain relief after the start of pain relief was 25.6 in the remifentanil group versus 36.1 in the epidural analgesia group (mean difference -10.4, -13.9 to -7.0). The rate of caesarean section was 15% in both groups. Oxygen saturation was significantly lower (SpO2 <92%) in women who used remifentanil (relative risk 1.5, 1.4 to 1.7). Maternal and neonatal outcomes were comparable between both groups. CONCLUSION In women in labour, patient controlled analgesia with remifentanil is not equivalent to epidural analgesia with respect to scores on satisfaction with pain relief. Satisfaction with pain relief was significantly higher in women who were allocated to and received epidural analgesia. TRIAL REGISTRATION Netherlands Trial Register NTR2551.
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Affiliation(s)
- Liv M Freeman
- Obstetrics, Leiden University Medical Centre, Leiden, Netherlands
| | | | - Maureen T Franssen
- Obstetrics and Gynaecology, University Medical Centre Groningen, Groningen, Netherlands
| | | | - Petra J Hajenius
- Obstetrics and Gynaecology, Academic Medical Centre, Amsterdam, Netherlands
| | | | - Mallory D Woiski
- Obstetrics and Gynaecology, Radboud University Medical Centre, Nijmegen, Netherlands
| | - Martina Porath
- Obstetrics and Gynaecology, Maxima Medical Centre, Veldhoven, Netherlands
| | | | - Erik van Beek
- Obstetrics and Gynaecology, Saint Antonius Hospital, Nieuwegein, Netherlands
| | | | - Nico Schuitemaker
- Obstetrics and Gynaecology, Diakonessen Hospital, Utrecht, Netherlands
| | - J Marko Sikkema
- Obstetrics and Gynaecology, Hospital Group Twente, Almelo, Netherlands
| | - A H M Kuipers
- Anaesthesiology, Hospital Group Twente, Almelo, Netherlands
| | | | | | | | - Enrico Lopriore
- Paediatrics, Leiden University Medical Centre, Leiden, Netherlands
| | | | - Saskia le Cessie
- Medical Statistics and Clinical Epidemiology, Leiden University Medical Centre, Leiden, Netherlands
| | - Jan M van Lith
- Obstetrics, Leiden University Medical Centre, Leiden, Netherlands
| | - Michel M Struys
- Anaesthesiology, University of Groningen and University Medical Centre Groningen, Groningen, Netherlands
| | - Ben Willem J Mol
- Robinson Institute, School of Paediatrics and Reproductive Health, University of Adelaide, Australia
| | - Albert Dahan
- Anaesthesiology, Leiden University Medical Centre, Leiden, Netherlands
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Gärtner FR, Freeman LM, Rijnders ME, Middeldorp JM, Bloemenkamp KWM, Stiggelbout AM, van den Akker-van Marle ME. A comprehensive representation of the birth-experience: identification and prioritization of birth-specific domains based on a mixed-method design. BMC Pregnancy Childbirth 2014; 14:147. [PMID: 24758274 PMCID: PMC4021407 DOI: 10.1186/1471-2393-14-147] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2014] [Accepted: 04/14/2014] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND In obstetrics, effectiveness and cost-effectiveness studies often present several specific outcomes with likely contradicting results and may not reflect what is important for women. A birth-specific outcome measure that combines the core domains into one utility score would solve this problem. The aim of this study was to investigate which domains are most relevant for women's overall experience of labor and birth and should be included in such a measure. METHODS A sequential mixed-method design with three steps was applied. First, the domains were identified by literature review and online focus groups consisting of pregnant women, women who recently gave birth, and their partners. Second, in a prioritizing task, women who recently gave birth and professionals (midwives, gynecologists, and researchers) selected and ranked their top seven domains. Third, the domains that were most frequently selected and had the highest ranking scores determined the basis for a consensus discussion with experts, whereby the definitive list of domains was formed. RESULTS In the first step, 34 birth-specific domains were identified, which cover domains regarding the caregivers, intrapersonal aspects of the mother, partner support, and contextual and medical aspects of birth. Based on the prioritizing task results (step 2) of 96 women and 89 professionals, this list was reduced to 14 most relevant domains. In a consensus discussion, the final seven domains were selected by combining several of the 14 remaining domains and giving priority to the domains indicated to be relevant by mothers. The seven definite domains were: 1) availability of competent health professionals; 2) health professionals' support; 3) provision of information; 4) health professionals' response to needs and requests; 5) feelings of safety; 6) worries about the child's health; and 7) experienced duration until the first contact with the child. CONCLUSIONS The experienced availability and quality of received care, concerns about safety and the baby's health, and first contact with the baby are regarded as key aspects for a mother's overall birth experience. Therefore, these domains are considered to be the most crucial for inclusion in a birth-specific outcome measure.
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Affiliation(s)
- Fania R Gärtner
- Department of Medical Decision Making, Leiden University Medical Centre, P.O.Box 9600, Leiden 2300RC, The Netherlands
| | - Liv M Freeman
- Department of Obstetrics, Leiden University Medical Centre, P.O.Box 9600, Leiden 2300RC, The Netherlands
| | | | - Johanna M Middeldorp
- Department of Obstetrics, Leiden University Medical Centre, P.O.Box 9600, Leiden 2300RC, The Netherlands
| | - Kitty WM Bloemenkamp
- Department of Obstetrics, Leiden University Medical Centre, P.O.Box 9600, Leiden 2300RC, The Netherlands
| | - Anne M Stiggelbout
- Department of Medical Decision Making, Leiden University Medical Centre, P.O.Box 9600, Leiden 2300RC, The Netherlands
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Varposhti MR, Ahmadi N, Masoodifar M, Shahshahan Z, Tabatabaie MH. Comparison of remifentanil: Entonox with Entonox alone in labor analgesia. Adv Biomed Res 2013; 2:87. [PMID: 24524033 PMCID: PMC3908727 DOI: 10.4103/2277-9175.122511] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2012] [Accepted: 02/03/2013] [Indexed: 01/30/2023] Open
Abstract
Background: We designed a study to evaluate the effectiveness of continuous low dose infusion of remifentanil adding to self-administration of entonox administered for pain relief during the active phase of first stage of labor. Materials and Methods: Thirty healthy term pregnant women recruited in our randomized double-blind, cross over study. They received the study medicines during two 30-min periods with a 15-min wash-out sequence after each period. Fifteen parturient used remifentanil as a single bolus dose followed by constant low dose infusion and self-administration of entonox (group R) during the first period and entonox and saline (group P) during the second period, while the remainder of the parturient used the drugs in a reverse order. Pain and Ramsay score, maternal and fetal hemodynamic, and ventilation were assessed during each intervention. Results: In this study, mean pain severity scores were 8 ± 0.9 before and 5.4 ± 1.7 after intervention in group P, and 7.8 ± 0.1, 3.5 ± 1.3 in group R, respectively. Mean pain severity difference was 2.6 ± 1.5 in group P, while 4.3 ± 1.5 in group R; so, use of entonox and remifentanil can decrease labor pain two times more in comparison with entonox/placebo (normal saline). However, hemodynamic and ventilation parameter in remifentanil/entonox period were same as in entonox/placebo period. No statistical differences were seen in mean Ramsay score between group R and P. There was no episode of maternal bradycardia, hypotension, or hypoxemia. Conclusion: Not only adding low dose infusion of remifentanil to self-administration of entonox was notable in labor pain reduction, it did n’t make more parturient and neonatal side-effects.
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Affiliation(s)
- Mojtaba Rahimi Varposhti
- Department of Anesthesiology, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Naghmeh Ahmadi
- Department of Anesthesiology, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Mehrdad Masoodifar
- Department of Anesthesiology, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Zahra Shahshahan
- Department of Obstetrics and Gynecology, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
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Kranke P, Girard T, Lavand’homme P, Melber A, Jokinen J, Muellenbach RM, Wirbelauer J, Hönig A. Must we press on until a young mother dies? Remifentanil patient controlled analgesia in labour may not be suited as a "poor man's epidural". BMC Pregnancy Childbirth 2013; 13:139. [PMID: 23815762 PMCID: PMC3700797 DOI: 10.1186/1471-2393-13-139] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2012] [Accepted: 06/28/2013] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The epidural route is still considered the gold standard for labour analgesia, although it is not without serious consequences when incorrect placement goes unrecognized, e.g. in case of intravascular, intrathecal and subdural placements. Until now there has not been a viable alternative to epidural analgesia especially in view of the neonatal outcome and the need for respiratory support when long-acting opioids are used via the parenteral route. Pethidine and meptazinol are far from ideal having been described as providing rather sedation than analgesia, affecting the cardiotocograph (CTG), causing fetal acidosis and having active metabolites with prolonged half-lives especially in the neonate. Despite these obvious shortcomings, intramuscular and intravenously administered pethidine and comparable substances are still frequently used in delivery units. Since the end of the 90 ths remifentanil administered in a patient-controlled mode (PCA) had been reported as a useful alternative for labour analgesia in those women who either don't want, can't have or don't need epidural analgesia. DISCUSSION In view of the need for conversion to central neuraxial blocks and the analgesic effect remifentanil has been demonstrated to be superior to pethidine. Despite being less effective in terms of the resulting pain scores, clinical studies suggest that the satisfaction with analgesia may be comparable to that obtained with epidural analgesia. Owing to this fact, remifentanil has gained a place in modern labour analgesia in many institutions. However, the fact that remifentanil may cause harm should not be forgotten when the use of this potent mu-agonist is considered for the use in labouring women. In the setting of one-to-one midwifery care, appropriate monitoring and providing that enough experience exists with this potent opioid and the treatment of potential complications, remifentanil PCA is a useful option in addition to epidural analgesia and other central neuraxial blocks. Already described serious consequences should remind us not refer to remifentanil PCA as a "poor man's epidural" and to safely administer remifentanil with an appropriate indication. SUMMARY Therefore, the authors conclude that economic considerations and potential cost-savings in conjunction with remifentanil PCA may not be appropriate main endpoints when studying this valuable method for labour analgesia.
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Affiliation(s)
- Peter Kranke
- Department of Anaesthesia and Critical Care, University Hospitals of Würzburg, Oberdürrbacher Str. 6, Würzburg 97080, Germany
| | - Thierry Girard
- Department of Anaesthesia, University Hospital Basel, Spitalstrasse 21, Basel, CH 4031, Switzerland
| | - Patricia Lavand’homme
- Department of Anesthesiology, Cliniques Universitaires Saint Luc, Université Catholique de Louvain, Brussels, Belgium
| | - Andrea Melber
- Department of Anaesthesia, Salem-Spital, Schänzlistrasse 39, 3000, Bern 25, Switzerland
| | - Johanna Jokinen
- Department of Anaesthesia and Critical Care, University Hospitals of Würzburg, Oberdürrbacher Str. 6, Würzburg 97080, Germany
| | - Ralf M Muellenbach
- Department of Anaesthesia and Critical Care, University Hospitals of Würzburg, Oberdürrbacher Str. 6, Würzburg 97080, Germany
| | - Johannes Wirbelauer
- University Children’s Hospital, Josef-Schneider-Strasse 2, Würzburg 97080, Germany
| | - Arnd Hönig
- Department of Obstetrics and Gynecology, University Hospitals of Würzburg, Josef-Schneider-Strasse 4, Würzburg 97080, Germany
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