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Kraft F, Wohlrab P, Meyer EL, Helmer H, Leitner H, Kiss H, Jochberger S, Ortner CM, Klein KU. Epidural analgesia and neonatal short-term outcomes during routine childbirth: a 10-year retrospective analysis from the national birth registry of Austria. Minerva Anestesiol 2024; 90:491-499. [PMID: 38869263 DOI: 10.23736/s0375-9393.24.17921-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/14/2024]
Abstract
BACKGROUND Epidural analgesia (EA) is well-accepted for pain relief during labor. Still, the impact on neonatal short-term outcome is under continuous debate. This study assessed the outcome of neonates in deliveries with and without EA in a nationwide cohort. METHODS We analyzed the National Birth Registry of Austria between 2008 and 2017 of primiparous women with vaginal birth of singleton pregnancies. Neonatal short-term morbidity was assessed by arterial cord pH and base excess (BE). Secondary outcomes were admission to a neonatological intensive care unit, APGAR scores, and perinatal mortality. Propensity score-adjusted regression models were used to investigate the association of EA with short-term neonatal outcome. RESULTS Of 247,536 included deliveries, 52 153 received EA (21%). Differences in pH (7.24 vs. 7.25; 97.5% CI -0.0066 to -0.0047) and BE (-5.89±3.2 vs. -6.15±3.2 mmol/L; 97.5% CI 0.32 to 0.40) with EA could be shown. APGAR score at five minutes <7 was more frequent with EA (OR 1.45; 95% CI: 1.29 to 1.63). Admission to a neonatological intensive care unit occurred more often with EA (4.7% vs. 3.4%) with an OR for EA of 1.2 (95% CI: 1.14 to 1.26). EA was not associated with perinatal mortality (OR 1.33; 95% CI: 0.79 to 2.25). CONCLUSIONS EA showed no clinically relevant association with neonatal short-term outcome. Higher rates of NICU admission and APGAR score after five minutes <7 were observed with EA. The overall use of EA in Austria is low, and an investigation of causes may be indicated.
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Affiliation(s)
- Felix Kraft
- Department of Anesthesia, Intensive Care Medicine, and Pain Medicine, Medical University of Vienna, Vienna, Austria -
| | - Peter Wohlrab
- Division of Cardiothoracic and Vascular Anesthesia and Intensive Care Medicine, Medical University of Vienna, Vienna, Austria
| | - Elias L Meyer
- Section for Medical Statistics, Center for Medical Statistics, Informatics and Intelligent Systems, Medical University of Vienna, Vienna, Austria
| | - Hanns Helmer
- Department of Obstetrics and Gynecology, Division of Obstetrics and Feto-Maternal Medicine, Medical University of Vienna, Vienna, Austria
| | - Hermann Leitner
- Department of Clinical Epidemiology, Tyrolean Federal Institute for Integrated Care, Tirol Kliniken GmbH, Innsbruck, Austria
| | - Herbert Kiss
- Department of Obstetrics and Gynecology, Division of Obstetrics and Feto-Maternal Medicine, Medical University of Vienna, Vienna, Austria
| | - Stefan Jochberger
- Department of Anesthesia and Intensive Care Medicine, St. Johann Hospital, St. Johann, Austria
| | - Clemens M Ortner
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford School of Medicine, Stanford, CA, USA
| | - Klaus U Klein
- Department of Anesthesia, Intensive Care Medicine, and Pain Medicine, Medical University of Vienna, Vienna, Austria
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Zamstein O, Sheiner E, Binyamin Y, Pariente G, Wainstock T. Examining the relationship between autism spectrum disorder in children whose mother had labour epidural analgesia for their birth: A retrospective cohort study. Eur J Anaesthesiol 2024; 41:282-287. [PMID: 38084085 DOI: 10.1097/eja.0000000000001932] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/02/2024]
Abstract
BACKGROUND Controversy exists regarding the association between autism spectrum disorder (ASD) in children whose mother had labour epidural analgesia for their birth, as the few existing investigations have reported mixed findings. OBJECTIVE This study aims to evaluate the possibility of an association in our heterogeneous population. DESIGN A retrospective population-based cohort study. SETTING Vaginal deliveries that took place between the years 2005 and 2017 at Soroka University Medical Center, a tertiary referral hospital in Israel, and a follow-up on the incidence of ASD in the children. PATIENTS A hundred and thirty-nine thousand, nine hundred and eighty-one labouring patients and their offspring. MAIN OUTCOME MEASURES The incidence of children diagnosed with ASD (both hospital and community-based diagnoses) was compared based on whether their mothers had received labour epidural analgesia during their labour. A Kaplan-Meier survival curve compared cumulative incidence of ASD. A Cox proportional hazards model was used to control for relevant confounders. RESULTS Labour epidural analgesia was administered to 33 315 women. Epidural analgesia was more common among high-risk pregnancy groups (including pregnancies complicated with diabetes mellitus, hypertensive disorders, intrauterine growth restriction, and oligohydramnios; P < 0.001). In a Cox proportional hazards model, the association between epidural analgesia during labour and ASD in the children lost statistical significance following adjustment for confounders such as maternal age, gestational age, hypertensive disorders, diabetes mellitus, and ethnicity [adjusted hazard ratio = 1.13, 95% confidence interval (CI), 0.96 to 1.34, P = 0.152]. CONCLUSION In our population, after adjusting for confounders, epidural analgesia is not independently associated with autism spectrum disorder in the children. These findings enhance our knowledge regarding the safety of epidural analgesia and enable patients to make informed decisions about their pain relief techniques during labour.
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Affiliation(s)
- Omri Zamstein
- From the Obstetrics and Gynecology Division, Soroka University Medical Center, Ben-Gurion University of the Negev, Beer-Sheva, Israel (OZ, ES, GP), Department of Anesthesiology, Soroka University Medical Center and the Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel (YB) and Department of Public Health, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel (TW)
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Libretti A, Troìa L, Cappello AM, Casarotti C, D'Amato AT, Dallarda G, Ghio M, Nicosia A, Ricci D, Savasta F, Sonzini M, Villa D, De Pedrini A, Surico D, Remorgida V. Pregnancy and neonatal outcomes of SARS-CoV-2 infection discovered at the time of delivery: a tertiary center experience in North Italy. J Perinat Med 2024; 52:215-221. [PMID: 37846639 DOI: 10.1515/jpm-2023-0280] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Accepted: 10/04/2023] [Indexed: 10/18/2023]
Abstract
OBJECTIVES Although the knowledge on SARS-CoV-2 infection in pregnancy has greatly improved, there is still a lack of information on its role in the later stages of gestation. The aim of this study is to investigate whether SARS-CoV-2 discovered at delivery is associated with any obstetric or neonatal complications. METHODS A retrospective case-control study was conducted at Department of Obstetrics, University Hospital Maggiore della Carità, Novara, Italy, from March 2020 to March 2023. Pregnant women admitted were tested for SARS-CoV-2. 168 women resulted positive at the time of delivery; the women were asymptomatic or paucisymptomatic. 170 negative women were selected as controls, selecting, for each SARS-CoV-2 positive patient, the patient who gave birth right before, if negative. Demographic and anamnestic characteristics, pregnancy, labor, and neonatal outcomes were evaluated. RESULTS SARS-CoV-2 positive patients were more likely to have gestational diabetes (13.7 vs. 5.3 %) and required less frequently intrapartum analgesia (11.3 vs. 27 %) and labor augmentation (7.3 vs. 16.5 %). Post-partum hemorrhage rate was lower (13.7 vs. 22.9 %) and a shorter length of first and second stage of labor occurred. There were no statistically significant differences between the two groups regarding the mode of delivery and neonatal outcomes. CONCLUSIONS SARS-CoV-2 positive patients have shorter labor length and a lower incidence of postpartum hemorrhage. Fewer obstetric interventions, as well as less use of intrapartum analgesia and oxytocin, could explain these findings. Moreover, gestational diabetes could increase susceptibility to infection. SARS-CoV-2 infection discovered at the time of delivery in asymptomatic or paucisymptomatic patients does not appear to increase the rate of cesarean delivery or other obstetric complications, and neonatal outcomes have not worsened.
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Affiliation(s)
- Alessandro Libretti
- Department of Gynaecology and Obstetrics, University Hospital Maggiore della Carità, Novara, Italy
- School of Gynaecology and Obstetrics, University of Eastern Piedmont, Novara, Italy
| | - Libera Troìa
- Department of Gynaecology and Obstetrics, University Hospital Maggiore della Carità, Novara, Italy
- School of Gynaecology and Obstetrics, University of Eastern Piedmont, Novara, Italy
| | - Anna Maria Cappello
- Department of Gynaecology and Obstetrics, University Hospital Maggiore della Carità, Novara, Italy
- School of Gynaecology and Obstetrics, University of Eastern Piedmont, Novara, Italy
| | - Carolina Casarotti
- Department of Gynaecology and Obstetrics, University Hospital Maggiore della Carità, Novara, Italy
- School of Gynaecology and Obstetrics, University of Eastern Piedmont, Novara, Italy
| | - Alessia Tony D'Amato
- Department of Gynaecology and Obstetrics, University Hospital Maggiore della Carità, Novara, Italy
- School of Gynaecology and Obstetrics, University of Eastern Piedmont, Novara, Italy
| | - Gloria Dallarda
- Department of Gynaecology and Obstetrics, University Hospital Maggiore della Carità, Novara, Italy
- School of Gynaecology and Obstetrics, University of Eastern Piedmont, Novara, Italy
| | - Matilda Ghio
- Department of Gynaecology and Obstetrics, University Hospital Maggiore della Carità, Novara, Italy
- School of Gynaecology and Obstetrics, University of Eastern Piedmont, Novara, Italy
| | - Anthony Nicosia
- Department of Gynaecology and Obstetrics, University Hospital Maggiore della Carità, Novara, Italy
- School of Gynaecology and Obstetrics, University of Eastern Piedmont, Novara, Italy
| | - Daria Ricci
- Department of Gynaecology and Obstetrics, University Hospital Maggiore della Carità, Novara, Italy
- School of Gynaecology and Obstetrics, University of Eastern Piedmont, Novara, Italy
| | - Federica Savasta
- Department of Gynaecology and Obstetrics, University Hospital Maggiore della Carità, Novara, Italy
- School of Gynaecology and Obstetrics, University of Eastern Piedmont, Novara, Italy
| | - Michela Sonzini
- Department of Gynaecology and Obstetrics, University Hospital Maggiore della Carità, Novara, Italy
- School of Gynaecology and Obstetrics, University of Eastern Piedmont, Novara, Italy
| | - Diletta Villa
- Department of Gynaecology and Obstetrics, University Hospital Maggiore della Carità, Novara, Italy
- School of Gynaecology and Obstetrics, University of Eastern Piedmont, Novara, Italy
| | - Alberto De Pedrini
- Department of Gynaecology and Obstetrics, University Hospital Maggiore della Carità, Novara, Italy
- School of Gynaecology and Obstetrics, University of Eastern Piedmont, Novara, Italy
| | - Daniela Surico
- Department of Gynaecology and Obstetrics, University Hospital Maggiore della Carità, Novara, Italy
- School of Gynaecology and Obstetrics, University of Eastern Piedmont, Novara, Italy
| | - Valentino Remorgida
- Department of Gynaecology and Obstetrics, University Hospital Maggiore della Carità, Novara, Italy
- School of Gynaecology and Obstetrics, University of Eastern Piedmont, Novara, Italy
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Enomoto N, Maki S, Nii M, Yamaguchi M, Tamaishi Y, Takakura S, Magawa S, Tanaka K, Tanaka H, Kondo E, Katsuragi S, Ikeda T. Accurate evaluation of the progress of delivery with transperineal ultrasound may improve vaginal delivery: a single-center retrospective study. Sci Rep 2023; 13:20945. [PMID: 38016993 PMCID: PMC10684555 DOI: 10.1038/s41598-023-47457-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Accepted: 11/14/2023] [Indexed: 11/30/2023] Open
Abstract
Although digital examination of the cervix is the standard method used worldwide for evaluating the progress of delivery, it is subjective. Transperineal ultrasound (TPU) is combined with digital evaluation for accurate assessment of fetal descent and rotation of the advanced part of the fetus. This retrospective study aimed to clarify the impact of introducing TPU on perinatal outcomes at Mie University Hospital. We analyzed singleton pregnant women who underwent delivery management at our hospital between April 2020 and March 2021. Perinatal outcomes were compared between patients who used TPU (TPU+ group) and those who did not (TPU- group). The angle of progression and head direction were measured. The rate of vaginal delivery was significantly increased (90.9% vs. 71.6%; P = 0.0017), and the second stage of labor was significantly prolonged in the TPU+ group (148.1 vs. 75.8 min; P < 0.0001). A significant difference was observed in termination in the latent phase between the TPU+ group [3/8 (37.5%) cases] and TPU- group [20/25 (80.0%) cases] (P = 0.036). The rate of vaginal delivery can be increased through accurate evaluation of the progress of delivery with TPU.
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Affiliation(s)
- Naosuke Enomoto
- Department of Obstetrics and Gynecology, Matsusaka Chuo General Hospital, 102 Kawaimachi, Matsusaka, Mie, Japan.
- Department of Obstetrics and Gynecology, Mie University Faculty of Medicine, Mie, Japan.
| | - Shintaro Maki
- Department of Obstetrics and Gynecology, Mie University Faculty of Medicine, Mie, Japan
| | - Masafumi Nii
- Department of Obstetrics and Gynecology, Mie University Faculty of Medicine, Mie, Japan
| | - Mizuki Yamaguchi
- Department of Obstetrics and Gynecology, Mie University Faculty of Medicine, Mie, Japan
| | - Yuya Tamaishi
- Department of Obstetrics and Gynecology, Mie University Faculty of Medicine, Mie, Japan
| | - Sho Takakura
- Department of Obstetrics and Gynecology, Mie University Faculty of Medicine, Mie, Japan
| | - Shoichi Magawa
- Department of Obstetrics and Gynecology, Mie University Faculty of Medicine, Mie, Japan
| | - Kayo Tanaka
- Department of Obstetrics and Gynecology, Mie University Faculty of Medicine, Mie, Japan
| | - Hiroaki Tanaka
- Department of Obstetrics and Gynecology, Mie University Faculty of Medicine, Mie, Japan
| | - Eiji Kondo
- Department of Obstetrics and Gynecology, Mie University Faculty of Medicine, Mie, Japan
| | - Shinji Katsuragi
- Department of Obstetrics and Gynecology, Faculty of Medicine, University of Miyazaki, Miyazaki, Japan
| | - Tomoaki Ikeda
- Department of Obstetrics and Gynecology, Mie University Faculty of Medicine, Mie, Japan
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5
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Verheggen AFO, Lapage K, Poelaert J. Re: Effect of intrapartum epidural analgesia on rate of emergency delivery for presumed fetal compromise: nationwide registry-based cohort study. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2023; 62:753. [PMID: 37910795 DOI: 10.1002/uog.27486] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Accepted: 09/13/2023] [Indexed: 11/03/2023]
Abstract
Linked article: This Correspondence comments on Damhuis et al. Click here to view the article.
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Affiliation(s)
- A F O Verheggen
- Department of Anesthesiology, ICU and Chronic Pain Therapy, General Hospital Maria Middelares, Ghent, Belgium
| | - K Lapage
- Department of Anesthesiology, ICU and Chronic Pain Therapy, General Hospital Maria Middelares, Ghent, Belgium
| | - J Poelaert
- Department of Anesthesiology, ICU and Chronic Pain Therapy, General Hospital Maria Middelares, Ghent, Belgium
- Vrije Universiteit Brussel (VUB), Jette, Belgium
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6
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Rongen APM, Willems S, Bruhn J, Rex S, Devroe S, Özkan S, van de Velde M. Unwarranted association between epidural analgesia and emergency delivery: critical review of methodological shortcomings. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2023; 62:754-755. [PMID: 37910796 DOI: 10.1002/uog.27487] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/11/2023] [Accepted: 09/13/2023] [Indexed: 11/03/2023]
Abstract
Linked articles: This Correspondence comments on Damhuis et al. and Tabernée Heijtmeijer et al.
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Affiliation(s)
- A P M Rongen
- Department of Anesthesiology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - S Willems
- Department of Anesthesiology, Pain and Palliative Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - J Bruhn
- Department of Anesthesiology, Pain and Palliative Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - S Rex
- Department of Anesthesiology, KU Leuven, Leuven, Belgium
- Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium
| | - S Devroe
- Department of Anesthesiology, KU Leuven, Leuven, Belgium
- Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium
| | - S Özkan
- Department of Anesthesiology, Pain and Palliative Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - M van de Velde
- Department of Anesthesiology, KU Leuven, Leuven, Belgium
- Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium
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7
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van den Bosch OFC, Beenakkers ICM, Boonstra L, Papazova DA, Schyns-van den Berg AMJV. Epidural analgesia and emergency delivery: exploring causal misconceptions. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2023; 62:755-757. [PMID: 37910797 DOI: 10.1002/uog.27489] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/16/2023] [Accepted: 09/13/2023] [Indexed: 11/03/2023]
Abstract
Linked article: This Correspondence comments on Tabernée Heijtmeijer et al. Click here to view the article.
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Affiliation(s)
- O F C van den Bosch
- Department of Anesthesiology, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, The Netherlands
| | - I C M Beenakkers
- Department of Anesthesiology, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, The Netherlands
| | - L Boonstra
- Department of Anesthesiology, ZorgSaam Hospital, Terneuzen, The Netherlands
| | - D A Papazova
- Department of Anesthesiology, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, The Netherlands
| | - A M J V Schyns-van den Berg
- Department of Anesthesiology, Albert Schweitzer Hospital, Dordrecht, The Netherlands
- Department of Anesthesiology, Leiden University Medical Center, Leiden, The Netherlands
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Callahan EC, Lee W, Aleshi P, George RB. Modern labor epidural analgesia: implications for labor outcomes and maternal-fetal health. Am J Obstet Gynecol 2023; 228:S1260-S1269. [PMID: 37164496 DOI: 10.1016/j.ajog.2022.06.017] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2022] [Revised: 06/13/2022] [Accepted: 06/14/2022] [Indexed: 05/12/2023]
Abstract
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.
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Affiliation(s)
- Elliott C Callahan
- Department of Anesthesia and Perioperative Care, University of California San Francisco, San Francisco, CA.
| | - Won Lee
- Department of Anesthesia and Perioperative Care, University of California San Francisco, San Francisco, CA
| | - Pedram Aleshi
- Department of Anesthesia and Perioperative Care, University of California San Francisco, San Francisco, CA
| | - Ronald B George
- Department of Anesthesia and Perioperative Care, University of California San Francisco, San Francisco, CA
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9
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Neuraxial analgesia in labour and the fetus. Best Pract Res Clin Anaesthesiol 2023. [DOI: 10.1016/j.bpa.2023.02.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/07/2023]
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10
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Gutzeit O, Justman N, Zvi DB, Siegler Y, Khatib N, Ginsberg Y, Beloosesky R, Weiner Z, Vitner D, Liberman S, Zipori Y. Late preterm delivery has a distinctive second-stage duration and characteristics. Am J Obstet Gynecol MFM 2023; 5:100845. [PMID: 36572106 DOI: 10.1016/j.ajogmf.2022.100845] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Revised: 12/06/2022] [Accepted: 12/20/2022] [Indexed: 12/25/2022]
Abstract
BACKGROUND Late preterm neonates born between 34.0 and 36.6 weeks' gestation are at increased risk for short- and long-term morbidity and mortality when compared with their term counterparts. Currently, no separate labor curve is available for late preterm births, and this group's optimal duration of the second stage of labor has never been defined separately. OBJECTIVE This study aimed to compare the second stage duration between late preterm and term births. STUDY DESIGN This was a retrospective study from May 2014 until May 2021. Eligible were women with a singleton pregnancy, vertex presentation, spontaneous or induced onset of labor, and those who delivered vaginally beyond 34.0 weeks of gestation. The primary outcome of our study was to compare and characterize the second stage of labor duration between late preterm and term births. RESULTS We analyzed 962 late preterm and 9476 term vaginal deliveries. Women who delivered during the late preterm period were more likely to be multiparous (52.4% vs 45.2%; P<.001) and fewer required oxytocin during labor (41.2% vs 54.4%; P<.001) or used epidural analgesia (75.2% vs 83.6%; P<.001). The overall mean duration of the second stage of labor was significantly shorter in the late preterm period than at term (1.08±1.09 hours vs 1.49±1.22 hours; P<.001). This was even more pronounced for nulliparous women (1.05±1.00 hours vs 2.10±1.17 hours; P<.001). Among multiparous women, epidural use significantly affected the duration of the second stage of labor, and the second stage was relatively longer during the late preterm period than at term in this subgroup (1.16 vs 0.5 hours; P<.001). Using a multivariate Cox regression, variables such as maternal age (hazard ratio, 1.02; 95% confidence interval, 1.01-1.04), parity (hazard ratio, 4.11; 95% confidence interval, 3.65-4.63), preterm birth (hazard ratio, 2.08; 95% confidence interval, 1.4-3.10), and birthweight at delivery (hazard ratio, 1.15; 95% confidence interval, 1.01-1.30) shortened the second stage, whereas induction of labor (hazard ratio, 0.75; 95% confidence interval, 0.66-0.86) and epidural use (hazard ratio, 0.68; 95% confidence interval, 0.64-0.86) extended its total duration. Regardless of parity, lower rates of operative vaginal deliveries were observed in the late preterm period than at term (3.7% vs 15.5%; P<.001). This period was also associated with lower rates of third- and fourth-degree perineal lacerations (0.2% vs 2.2%; P<.001) but higher rates of chorioamnionitis (1.7% vs 0.1%; P<.001), Apgar score at 5 minutes <7 (1.0% vs 0.2%; P<.001), and admission to the neonatal intensive care unit (19.3% vs 1.0%; P<.001). CONCLUSION Women who delivered vaginally during the late preterm period had a distinctive second-stage duration. Primarily, it was shown to be significantly shorter for nulliparous and multiparous women. Future studies should further clarify the optimal duration of this stage in relation to neonatal outcomes at such a vulnerable period.
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Affiliation(s)
- Ola Gutzeit
- Department of Obstetrics and Gynecology, Rambam Health Care Campus, Haifa, Israel (Drs Gutzeit, Justman, Ben Zvi, Siegler, Khatib, Ginsberg, Beloosesky, Weiner, Vitner, Liberman, and Zipori)
| | - Naphtali Justman
- Department of Obstetrics and Gynecology, Rambam Health Care Campus, Haifa, Israel (Drs Gutzeit, Justman, Ben Zvi, Siegler, Khatib, Ginsberg, Beloosesky, Weiner, Vitner, Liberman, and Zipori)
| | - Dikla Ben Zvi
- Department of Obstetrics and Gynecology, Rambam Health Care Campus, Haifa, Israel (Drs Gutzeit, Justman, Ben Zvi, Siegler, Khatib, Ginsberg, Beloosesky, Weiner, Vitner, Liberman, and Zipori)
| | - Yoav Siegler
- Department of Obstetrics and Gynecology, Rambam Health Care Campus, Haifa, Israel (Drs Gutzeit, Justman, Ben Zvi, Siegler, Khatib, Ginsberg, Beloosesky, Weiner, Vitner, Liberman, and Zipori)
| | - Nizar Khatib
- Department of Obstetrics and Gynecology, Rambam Health Care Campus, Haifa, Israel (Drs Gutzeit, Justman, Ben Zvi, Siegler, Khatib, Ginsberg, Beloosesky, Weiner, Vitner, Liberman, and Zipori); Ruth & Bruce Rappaport Faculty of Medicine, Technion Institute of Technology, Haifa, Israel (Drs Khatib, Ginsberg, Beloosesky, Weiner, Vitner, and Zipori)
| | - Yuval Ginsberg
- Department of Obstetrics and Gynecology, Rambam Health Care Campus, Haifa, Israel (Drs Gutzeit, Justman, Ben Zvi, Siegler, Khatib, Ginsberg, Beloosesky, Weiner, Vitner, Liberman, and Zipori); Ruth & Bruce Rappaport Faculty of Medicine, Technion Institute of Technology, Haifa, Israel (Drs Khatib, Ginsberg, Beloosesky, Weiner, Vitner, and Zipori)
| | - Ron Beloosesky
- Department of Obstetrics and Gynecology, Rambam Health Care Campus, Haifa, Israel (Drs Gutzeit, Justman, Ben Zvi, Siegler, Khatib, Ginsberg, Beloosesky, Weiner, Vitner, Liberman, and Zipori); Ruth & Bruce Rappaport Faculty of Medicine, Technion Institute of Technology, Haifa, Israel (Drs Khatib, Ginsberg, Beloosesky, Weiner, Vitner, and Zipori)
| | - Zeev Weiner
- Department of Obstetrics and Gynecology, Rambam Health Care Campus, Haifa, Israel (Drs Gutzeit, Justman, Ben Zvi, Siegler, Khatib, Ginsberg, Beloosesky, Weiner, Vitner, Liberman, and Zipori); Ruth & Bruce Rappaport Faculty of Medicine, Technion Institute of Technology, Haifa, Israel (Drs Khatib, Ginsberg, Beloosesky, Weiner, Vitner, and Zipori)
| | - Dana Vitner
- Department of Obstetrics and Gynecology, Rambam Health Care Campus, Haifa, Israel (Drs Gutzeit, Justman, Ben Zvi, Siegler, Khatib, Ginsberg, Beloosesky, Weiner, Vitner, Liberman, and Zipori); Ruth & Bruce Rappaport Faculty of Medicine, Technion Institute of Technology, Haifa, Israel (Drs Khatib, Ginsberg, Beloosesky, Weiner, Vitner, and Zipori)
| | - Sapir Liberman
- Department of Obstetrics and Gynecology, Rambam Health Care Campus, Haifa, Israel (Drs Gutzeit, Justman, Ben Zvi, Siegler, Khatib, Ginsberg, Beloosesky, Weiner, Vitner, Liberman, and Zipori)
| | - Yaniv Zipori
- Department of Obstetrics and Gynecology, Rambam Health Care Campus, Haifa, Israel (Drs Gutzeit, Justman, Ben Zvi, Siegler, Khatib, Ginsberg, Beloosesky, Weiner, Vitner, Liberman, and Zipori); Ruth & Bruce Rappaport Faculty of Medicine, Technion Institute of Technology, Haifa, Israel (Drs Khatib, Ginsberg, Beloosesky, Weiner, Vitner, and Zipori).
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11
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Prolonged Dystocic Labor in Neuraxial Analgesia and the Role of Enkephalin Neurotransmitters: An Experimental Study. Int J Mol Sci 2023; 24:ijms24043767. [PMID: 36835178 PMCID: PMC9962106 DOI: 10.3390/ijms24043767] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2022] [Revised: 01/25/2023] [Accepted: 02/10/2023] [Indexed: 02/16/2023] Open
Abstract
The investigation studied the enkephalinergic neuro fibers (En) contained in the Lower Uterine Segment (LUS) during the prolonged dystocic labor (PDL) with Labor Neuraxial Analgesia (LNA). PDL is generally caused by fetal head malpositions in the Occiput Posterior Position (OPP), Persistent Occiput Posterior Position (POPP), in a transverse position (OTP), and asynclitism (A), and it is detected by Intrapartum Ultrasonography (IU). The En were detected in the LUS samples picked up during cesarean section (CS) of 38 patients undergoing urgent CS in PDL, compared to 37 patients submitted to elective CS. Results were statistically evaluated to understand the differences in En morphological analysis by scanning electron microscopy (SEM) and by fluorescence microscopy (FM). The LUS samples analysis showed an important reduction in En in LUS of CS for the PDL group, in comparison with the elective CS group. The LUS overdistension, by fetal head malpositions (OPP, OTP, A) and malrotations, lead to dystocia, modification of vascularization, and En reduction. The En reduction in PDL suggests that drugs used during the LNA, usually local anesthetics and opioids, cannot control the "dystocic pain", that differs from normal labor pain. The IU administration in labor and the consequent diagnosis of dystocia suggest stopping the numerous and ineffective top-up drug administration during LNA, and to shift the labor to operative vaginal delivery or CS.
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12
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Malvasi A, Vinciguerra M, Lamanna B, Cascardi E, Damiani GR, Muzzupapa G, Kosmas I, Beck R, Falagario M, Vimercati A, Cicinelli E, Trojano G, Tinelli A, Cazzato G, Dellino M. Asynclitism and Its Ultrasonographic Rediscovery in Labor Room to Date: A Systematic Review. Diagnostics (Basel) 2022; 12:2998. [PMID: 36553005 PMCID: PMC9776610 DOI: 10.3390/diagnostics12122998] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Revised: 11/08/2022] [Accepted: 11/14/2022] [Indexed: 12/03/2022] Open
Abstract
Asynclitism, the most feared malposition of the fetal head during labor, still represents to date an unresolved field of interest, remaining one of the most common causes of prolonged or obstructed labor, dystocia, assisted delivery, and cesarean section. Traditionally asynclitism is diagnosed by vaginal examination, which is, however, burdened by a high grade of bias. On the contrary, the recent scientific evidence highly suggests the use of intrapartum ultrasonography, which would be more accurate and reliable when compared to the vaginal examination for malposition assessment. The early detection and characterization of asynclitism by intrapartum ultrasound would become a valid tool for intrapartum evaluation. In this way, it will be possible for physicians to opt for the safest way of delivery according to an accurate definition of the fetal head position and station, avoiding unnecessary operative procedures and medication while improving fetal and maternal outcomes. This review re-evaluated the literature of the last 30 years on asynclitism, focusing on the progressive imposition of ultrasound as an intrapartum diagnostic tool. All the evidence emerging from the literature is presented and evaluated from our point of view, describing the most employed technique and considering the future implication of the progressive worldwide consolidation of asynclitism and ultrasound.
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Affiliation(s)
- Antonio Malvasi
- Unit of Obstetrics and Gynaecology, Department of Biomedical Sciences and Human Oncology, 70124 Bari, Italy
| | - Marina Vinciguerra
- Unit of Obstetrics and Gynaecology, Department of Biomedical Sciences and Human Oncology, 70124 Bari, Italy
- Department of Maternal and Child Health, Madonna delle Grazie Hospital, 75100 Matera, Italy
| | - Bruno Lamanna
- Unit of Obstetrics and Gynaecology, Department of Biomedical Sciences and Human Oncology, 70124 Bari, Italy
- Fetal Medicine Research Institute, King’s College Hospital, London SE5 9RS, UK
| | - Eliano Cascardi
- Department of Medical Sciences, University of Turin, 10126 Torino, Italy
- Pathology Unit, FPO-IRCCS Candiolo Cancer Institute, Str. Provinciale 142 km 3.95, 10060 Candiolo, Italy
| | - Gianluca Raffaello Damiani
- Unit of Obstetrics and Gynaecology, Department of Biomedical Sciences and Human Oncology, 70124 Bari, Italy
| | - Giuseppe Muzzupapa
- Unit of Obstetrics and Gynaecology, Department of Biomedical Sciences and Human Oncology, 70124 Bari, Italy
| | - Ioannis Kosmas
- Department of Obstetrics and Gynecology, Ioannina State General Hospital G. Chatzikosta, 45332 Ioannina, Greece
| | - Renata Beck
- Department of Anesthesia and Intensive Care, Policlinico Riuniti Hospital, University of Foggia, 71122 Foggia, Italy
| | - Maddalena Falagario
- Unit of Obstetrics and Gynaecology, Department of Biomedical Sciences and Human Oncology, 70124 Bari, Italy
- Department of Obstetric and Gynecology, Lund University, SE-221 00 Lund, Sweden
| | - Antonella Vimercati
- Unit of Obstetrics and Gynaecology, Department of Biomedical Sciences and Human Oncology, 70124 Bari, Italy
| | - Ettore Cicinelli
- Unit of Obstetrics and Gynaecology, Department of Biomedical Sciences and Human Oncology, 70124 Bari, Italy
| | - Giuseppe Trojano
- Unit of Obstetrics and Gynaecology, Department of Biomedical Sciences and Human Oncology, 70124 Bari, Italy
| | - Andrea Tinelli
- Department of Obstetrics and Gynecology and CERICSAL (CEntro di RIcerca Clinico SALentino), Veris Delli Ponti Hospital, 73020 Scorrano, Italy
- Division of Experimental Endoscopic Surgery, Imaging, Technology and Minimally Invasive Therapy, Vito Fazzi Hospital, 73100 Lecce, Italy
| | - Gerardo Cazzato
- Section of Pathology, Department of Emergency and Organ Transplantation (DETO), University of Bari “Aldo Moro”, 70124 Bari, Italy
| | - Miriam Dellino
- Unit of Obstetrics and Gynaecology, Department of Biomedical Sciences and Human Oncology, 70124 Bari, Italy
- Department of Obstetrics and Gynecology, San Paolo Hospital, 70124 Bari, Italy
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13
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Zanfini BA, Catarci S, Vassalli F, Laurita Longo V, Biancone M, Carducci B, Frassanito L, Lanzone A, Draisci G. 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. J Clin Med 2022; 11:jcm11206124. [PMID: 36294447 PMCID: PMC9604843 DOI: 10.3390/jcm11206124] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Revised: 10/14/2022] [Accepted: 10/15/2022] [Indexed: 12/04/2022] Open
Abstract
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.
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Affiliation(s)
- Bruno Antonio Zanfini
- Department of Emergency, Anesthesiological and Reanimation Sciences, Fondazione Policlinico Universitario A Gemelli IRCCS, Largo A Gemelli 8, 00168 Roma, Italy
- Correspondence:
| | - Stefano Catarci
- Department of Emergency, Anesthesiological and Reanimation Sciences, Fondazione Policlinico Universitario A Gemelli IRCCS, Largo A Gemelli 8, 00168 Roma, Italy
| | - Francesco Vassalli
- Obstetric Anesthesia, Department of Critical Care and Perinatal Medicine, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Istituto Giannina Gaslini, 16147 Genova, Italy
| | - Valentina Laurita Longo
- Department of Women, Children and Public Health Sciences, Fondazione Policlinico Universitario A Gemelli IRCCS, Largo A Gemelli 8, 00168 Roma, Italy
- Università Cattolica del Sacro Cuore Roma, Largo F. Vito 1, 00168 Roma, Italy
| | - Matteo Biancone
- Department of Emergency, Anesthesiological and Reanimation Sciences, Fondazione Policlinico Universitario A Gemelli IRCCS, Largo A Gemelli 8, 00168 Roma, Italy
| | - Brigida Carducci
- Department of Women, Children and Public Health Sciences, Fondazione Policlinico Universitario A Gemelli IRCCS, Largo A Gemelli 8, 00168 Roma, Italy
| | - Luciano Frassanito
- Department of Emergency, Anesthesiological and Reanimation Sciences, Fondazione Policlinico Universitario A Gemelli IRCCS, Largo A Gemelli 8, 00168 Roma, Italy
| | - Antonio Lanzone
- Department of Women, Children and Public Health Sciences, Fondazione Policlinico Universitario A Gemelli IRCCS, Largo A Gemelli 8, 00168 Roma, Italy
- Università Cattolica del Sacro Cuore Roma, Largo F. Vito 1, 00168 Roma, Italy
| | - Gaetano Draisci
- Department of Emergency, Anesthesiological and Reanimation Sciences, Fondazione Policlinico Universitario A Gemelli IRCCS, Largo A Gemelli 8, 00168 Roma, Italy
- Obstetric Anesthesia, Department of Critical Care and Perinatal Medicine, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Istituto Giannina Gaslini, 16147 Genova, Italy
- Department of Women, Children and Public Health Sciences, Fondazione Policlinico Universitario A Gemelli IRCCS, Largo A Gemelli 8, 00168 Roma, Italy
- Università Cattolica del Sacro Cuore Roma, Largo F. Vito 1, 00168 Roma, Italy
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14
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Zeng Y, Jiang T, Zheng YH, He WR, Wang XW, Wei H, Wang L, Liu ZR, Zhang XF, Yi C, Chen KM. Evaluation efficacy and safety of epidural analgesia in second-trimester induced labor: A single-center, prospective, non-randomized, controlled study. Medicine (Baltimore) 2022; 101:e30767. [PMID: 36197253 PMCID: PMC9509083 DOI: 10.1097/md.0000000000030767] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
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.
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Affiliation(s)
- Yong Zeng
- Department of Obstetrics and Gynecology, The First Affiliated Hospital of Yangtze University, Jingzhou City, China
| | - Tao Jiang
- Department of Obstetrics and Gynecology, The First Affiliated Hospital of Yangtze University, Jingzhou City, China
| | - Ya-Hong Zheng
- Department of Obstetrics and Gynecology, The First Affiliated Hospital of Yangtze University, Jingzhou City, China
| | - Wen-Rong He
- Department of Obstetrics and Gynecology, The First Affiliated Hospital of Yangtze University, Jingzhou City, China
| | - Xiao-Wen Wang
- Department of Obstetrics and Gynecology, The First Affiliated Hospital of Yangtze University, Jingzhou City, China
| | - Hua Wei
- Department of Obstetrics and Gynecology, The First Affiliated Hospital of Yangtze University, Jingzhou City, China
| | - Li Wang
- Department of Obstetrics and Gynecology, The First Affiliated Hospital of Yangtze University, Jingzhou City, China
| | - Zu-Rong Liu
- Department of Obstetrics and Gynecology, The First Affiliated Hospital of Yangtze University, Jingzhou City, China
| | - Xu-Feng Zhang
- Department of Obstetrics and Gynecology, The First Affiliated Hospital of Yangtze University, Jingzhou City, China
| | - Cunjian Yi
- Department of Obstetrics and Gynecology, The First Affiliated Hospital of Yangtze University, Jingzhou City, China
| | - Ke-Ming Chen
- Department of Obstetrics and Gynecology, The First Affiliated Hospital of Yangtze University, Jingzhou City, China
- *Correspondence: Ke-Ming Chen, 8 Hangkong Road, Shashi District, Jingzhou City, Hubei Province 434000, China (e-mail:)
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15
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Chen Y, Ye X, Wu H, Yuan X, Yu X, Wu H, Wu X, Chen Y. Delivery, maternal and neonatal outcomes in nulliparous women with gestational diabetes undergoing epidural labour analgesia: a propensity score-matched analysis. BMJ Open 2022; 12:e060245. [PMID: 35906056 PMCID: PMC9345031 DOI: 10.1136/bmjopen-2021-060245] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVE This study aimed to retrospectively analyse the influence of epidural labour analgesia (ELA) on delivery and maternal and neonatal outcomes in nulliparous women with gestational diabetes mellitus (GDM) using propensity score-matched analysis. DESIGN Retrospective cohort analysis. SETTING Primary care practices in a teaching hospital from March 2018 to October 2021. PARTICIPANTS A total of 816 delivery records of nulliparous women with GDM were collected and retrospectively analysed. INTERVENTIONS ELA and non-ELA (NELA) cohorts were assessed. MAIN OUTCOME MEASURE The primary outcome assessed was delivery type (spontaneous, assisted vaginal or caesarean). The secondary outcomes assessed included labour duration and maternal and neonatal outcomes. RESULTS A total of 137 propensity score-matched pairs of ELA and NELA patients were analysed. ELA was associated with a decreased rate of caesarean section (18.3% vs 46.0% in the ELA vs NELA cohort, respectively; p<0.05) and an increased occurrence of assisted vaginal delivery (35.8% vs 12.4% in the ELA vs NELA cohort, respectively; p<0.05). The duration of the first and total stages of labour was prolonged, the occurrence of postpartum fever increased, and the duration of hospital stay was shortened in those receiving ELA (all p<0.05). Additionally, neonatal birth weight, plasma glucose levels and neonatal macrosomia occurrence increased, while neonatal intensive care unit admissions and neonatal hypoglycaemia decreased in the ELA versus the NELA group (all p<0.05). With respect to other maternal and neonatal outcomes, both cohorts were similar. CONCLUSIONS The use of ELA decreases the rate of caesarean section and improves maternal and neonatal outcomes in nulliparous women with GDM. TRIAL REGISTRATION NUMBER ChiCTR-2000033091.
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Affiliation(s)
- Yu Chen
- Department of Anaesthesiology, Fujian Provincial Jinshan Hospital, Fuzhou, China
- Department of Anaesthesiology, Southern Medical University Nanfang Hospital, Guangzhou, China
- Department of Anaesthesiology, Fujian Medical University, Fuzhou, China
| | - Xin Ye
- Department of Anaesthesiology, Fujian Medical University, Fuzhou, China
| | - Han Wu
- Department of Anaesthesiology, Fujian Provincial Jinshan Hospital, Fuzhou, China
| | - Xueling Yuan
- Department of Anaesthesiology, Fujian Provincial Jinshan Hospital, Fuzhou, China
| | - Xiaofang Yu
- Department of Anaesthesiology, Fujian Provincial Jinshan Hospital, Fuzhou, China
| | - Huanghui Wu
- Department of Anaesthesiology and Perioperative Medicine, Shanghai Fourth People's Hospital Affiliated to Tongji University, Shanghai, China
- Clinical Research Centre for Anaesthesiology and Perioperative Medicine, Shanghai Fourth People's Hospital Affiliated to Tongji University, Shanghai, China
| | - Xiaodan Wu
- Department of Anaesthesiology, Fujian Provincial Jinshan Hospital, Fuzhou, China
- Department of Anaesthesiology, Fujian Medical University, Fuzhou, China
| | - Yanqing Chen
- Department of Anaesthesiology, Fujian Provincial Jinshan Hospital, Fuzhou, China
- Department of Anaesthesiology, Fujian Medical University, Fuzhou, China
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16
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Halliday L, Kinsella M, Shaw M, Cheyne J, Nelson SM, Kearns RJ. Comparison of ultra-low, low and high concentration local anaesthetic for labour epidural analgesia: a systematic review and network meta-analysis. Anaesthesia 2022; 77:910-918. [PMID: 35607864 PMCID: PMC9543867 DOI: 10.1111/anae.15756] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/25/2022] [Indexed: 11/28/2022]
Abstract
Lumbar epidural is the gold standard for labour analgesia. Low concentrations of local anaesthetic are recommended. This network meta‐analysis investigated whether further reducing the concentration of local anaesthetic can improve maternal and neonatal outcomes without compromising analgesia. We conducted a systematic search of relevant databases for randomised controlled trials comparing high (>0.1%), low (>0.08% to ≤0.1%) or ultra‐low (≤0.08%) concentration local anaesthetic (bupivacaine or equivalent) for labour epidural. Outcomes included mode of delivery, duration of labour and maternal/neonatal outcomes. Bayesian network meta‐analysis with random‐effects modelling was used to calculate odds ratios or weighted mean differences and 95% credible intervals. A total of 32 studies met inclusion criteria (3665 women). The total dose of local anaesthetic received increased as the concentration increased; ultra‐low compared with low (weighted mean difference −14.96 mg, 95% credible interval [−28.38 to −1.00]) and low compared with high groups (weighted mean difference −14.99 [−28.79 to −2.04]), though there was no difference in the number of rescue top‐ups administered between the groups. Compared with high concentration, ultra‐low concentration local anaesthetic was associated with increased likelihood of spontaneous vaginal delivery (OR 1.46 [1.18 to 1.86]), reduced motor block (Bromage score >0; OR 0.32 [0.18 to 0.54]) and reduced duration of second stage of labour (weighted mean difference −13.02 min [−21.54 to −4.77]). Compared with low, ultra‐low concentration local anaesthetic had similar estimates for duration of second stage of labour (weighted mean difference −1.92 min [−14.35 to 10.20]); spontaneous vaginal delivery (OR 1.07 [0.75 to 1.56]; assisted vaginal delivery (OR 1.35 [0.75 to 2.26]); caesarean section (OR 0.76 [0.49 to 1.22]); pain (scale 1–100, weighted mean difference −5.44 [−16.75 to 5.93]); and maternal satisfaction. Although a lower risk of an Apgar score < 7 at 1 min (OR 0.43 [0.15 to 0.79]) was reported for ultra‐low compared with low concentration, this was not sustained at 5 min (OR 0.12 [0.00 to 2.10]). Ultra‐low concentration local anaesthetic for labour epidural achieves similar or better maternal and neonatal outcomes as low and high concentration, but with reduced local anaesthetic consumption.
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Affiliation(s)
- L Halliday
- School of Medicine, Dentistry and Nursing, University of Glasgow, UK
| | - M Kinsella
- School of Medicine, Dentistry and Nursing, University of Glasgow, UK
| | - M Shaw
- Department of Medical Physics, NHS Greater Glasgow and Clyde, Glasgow, UK
| | - J Cheyne
- Cochrane Stoke Group, Centre for Clinical Brain Science, University of Edinburgh, UK
| | - S M Nelson
- School of Medicine, Dentistry and Nursing, University of Glasgow, UK.,National Institute for Health Research Bristol Biomedical Research Centre, Bristol, UK.,The Fertility Partnership, Institute of Reproductive Sciences, Oxford, UK
| | - R J Kearns
- School of Medicine, Dentistry and Nursing, University of Glasgow, UK
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17
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Callahan EC, Lim S, George RB. Neuraxial labor analgesia: Maintenance techniques. Best Pract Res Clin Anaesthesiol 2022; 36:17-30. [PMID: 35659953 DOI: 10.1016/j.bpa.2022.03.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Accepted: 03/12/2022] [Indexed: 11/17/2022]
Abstract
Since the advent of neuraxial analgesia for labor, approaches to maintaining intrapartum pain relief have seen significant advancement. Through pharmacologic innovations and improved drug delivery mechanisms, current neuraxial labor analgesia maintenance techniques have been shaped by efforts to maximize patient comfort during the birthing process, while minimizing undesirable side effects and promoting the unimpeded progress of labor. To these ends, a modern anesthesiologist may avail themselves of several techniques, including programmed intermittent epidural bolus (PIEB), patient controlled epidural analgesia (PCEA) and dilute concentration local anesthetic + opioid epidural solutions. We explore the historical development and the evidential underpinnings of these techniques, in addition to several contemporary neuraxial labor analgesia practices. We also summarize current understanding of the effects these interventions have on maternal/fetal health and the labor course, as well as several important aspects of analgesic safety and monitoring.
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Affiliation(s)
- Elliott C Callahan
- Department of Anesthesia and Perioperative Care, University of California San Francisco (UCSF), 513 Parnassus Ave, MSB, 436, Box 0427, San Francisco, CA 94143, USA.
| | - Stephanie Lim
- Department of Anesthesia and Perioperative Care, UCSF, San Francisco, CA, USA
| | - Ronald B George
- Department of Anesthesia and Perioperative Care, UCSF, San Francisco, CA, USA
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18
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Halliday L, Nelson SM, Kearns RJ. Epidural analgesia in labor: A narrative review. Int J Gynaecol Obstet 2022; 159:356-364. [PMID: 35277971 DOI: 10.1002/ijgo.14175] [Citation(s) in RCA: 27] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Revised: 02/20/2022] [Accepted: 02/23/2022] [Indexed: 11/11/2022]
Abstract
Lumbar epidural is the most effective form of pain relief in labor with around 30% of laboring women in the UK and 60% in the USA receiving epidural analgesia. Associations of epidural on maternal, obstetric, and neonatal outcomes have been the subject of intense study, though a number of uncertainties persist. The present narrative review explores important areas of research surrounding epidural analgesia in obstetric patients including methods of initiation and administration, choice of local anesthetic solution, and the addition of adjuvants. Key meta-analyses exploring associations of epidural analgesia on maternal and neonatal outcomes are identified and summarized.
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Affiliation(s)
- Lucy Halliday
- School of Medicine, University of Glasgow, Glasgow, UK
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19
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Orso D, Scapol S, Dogareschi T, Spasiano A, Driul L, Bove T. Correlation between epidural analgesia and type of delivery in the low Robson score classes: a registry based-cohort study. Minerva Anestesiol 2022; 88:525-526. [PMID: 35199976 DOI: 10.23736/s0375-9393.21.16356-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Daniele Orso
- Department of Medicine, University of Udine, Udine, Italy -
| | - Sara Scapol
- Department of Medicine, University of Udine, Udine, Italy
| | - Teresa Dogareschi
- Department of Medicine, University of Udine, Udine, Italy.,Department of Anesthesia and Intensive Care Medicine, ASUFC Santa Maria della Misericordia Hospital of Udine, Udine, Italy
| | - Alessandra Spasiano
- Department of Medicine, University of Udine, Udine, Italy.,Department of Anesthesia and Intensive Care Medicine, ASUFC Santa Maria della Misericordia Hospital of Udine, Udine, Italy
| | - Lorenza Driul
- Department of Medicine, University of Udine, Udine, Italy.,Department of Obstetrics and Gynaecology, ASUFC Santa Maria della Misericordia Hospital of Udine, Udine, Italy
| | - Tiziana Bove
- Department of Medicine, University of Udine, Udine, Italy.,Department of Anesthesia and Intensive Care Medicine, ASUFC Santa Maria della Misericordia Hospital of Udine, Udine, Italy
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20
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Zhu HJ, He Y, Wang SY, Han B, Zhang Y. A Randomized Clinical Trial Comparing Different Concentrations of Chloroprocaine with Lidocaine for Activating Epidural Analgesia During Labor. Int J Gen Med 2022; 15:1307-1317. [PMID: 35173469 PMCID: PMC8841447 DOI: 10.2147/ijgm.s351030] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2021] [Accepted: 01/21/2022] [Indexed: 11/23/2022] Open
Affiliation(s)
- Hai-Juan Zhu
- Department of Anesthesiology and Perioperative Medicine, The Second Hospital of Anhui Medical University, Key Laboratory of Anesthesiology and Perioperative Medicine of Anhui Higher Education Institutes, Anhui Medical University, Hefei, 230601, People’s Republic of China
- Department of Anesthesiology, Anhui Maternal and Child Health Care Hospital, Maternal and Child Health Care Hospital of Anhui Medical University, Hefei, 230001, People’s Republic of China
| | - Yan He
- Department of Anesthesiology, Wannan Medical College, Wuhu, Anhui Province, 241002, People’s Republic of China
| | - Sheng-You Wang
- Department of Anesthesiology, Anhui Maternal and Child Health Care Hospital, Maternal and Child Health Care Hospital of Anhui Medical University, Hefei, 230001, People’s Republic of China
| | - Bo Han
- Department of Anesthesiology, Anhui Maternal and Child Health Care Hospital, Maternal and Child Health Care Hospital of Anhui Medical University, Hefei, 230001, People’s Republic of China
| | - Ye Zhang
- Department of Anesthesiology and Perioperative Medicine, The Second Hospital of Anhui Medical University, Key Laboratory of Anesthesiology and Perioperative Medicine of Anhui Higher Education Institutes, Anhui Medical University, Hefei, 230601, People’s Republic of China
- Correspondence: Ye Zhang, Department of Anesthesiology and Perioperative Medicine, The Second Hospital of Anhui Medical University, Key Laboratory of Anesthesiology and Perioperative Medicine of Anhui Higher Education Institutes, Anhui Medical University, Hefei, 230601, People’s Republic of China, Tel +86-551-63869485; +86-13966768081, Fax +86 551-63869400, Email
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21
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Kearns RJ, Shaw M, Gromski PS, Iliodromiti S, Lawlor DA, Nelson SM. Association of Epidural Analgesia in Women in Labor With Neonatal and Childhood Outcomes in a Population Cohort. JAMA Netw Open 2021; 4:e2131683. [PMID: 34709386 PMCID: PMC8554639 DOI: 10.1001/jamanetworkopen.2021.31683] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2021] [Accepted: 07/24/2021] [Indexed: 12/25/2022] Open
Abstract
Importance Although use of epidural analgesia during labor is safe, detailed information about its association with neonatal and child outcomes is limited. Objective To investigate the association of labor epidural analgesia with neonatal outcomes and childhood development during the first 1000 days of life. Design, Setting, and Participants This population-based cohort study used Scottish National Health Service hospital administrative data of all 435 281 singleton live births in Scotland between January 1, 2007, and December 31, 2016, with follow-up over the first 1000 days of life. All 435 281 mother-infant pairs delivering between 24 weeks 0 days and 43 weeks 6 days' gestation who were in active labor with cephalic presentation and who delivered vaginally or via unplanned cesarean delivery were included. Stillbirths and infants with known congenital anomalies were excluded. Data were analyzed between August 1, 2020, and July 23, 2021. Exposures Epidural analgesia in labor. Main Outcomes and Measures Neonatal outcomes included resuscitation, Apgar score less than 7 at 5 minutes, and neonatal unit admission. Childhood development measures (gross and fine motor function, communication, and social functioning) were obtained from standardized national childhood surveillance assessments performed at 2 years. Results This study included a total of 435 281 live births with cephalic presentation in labor (median gestational age at delivery, 40 weeks [IQR, 39-41 weeks]; 221 153 male infants [50.8%]), of which 94 323 (21.7%) had labor epidural. Epidural analgesia was associated with a reduction in spontaneous vaginal deliveries (confounder-adjusted [Cadj] relative risk [RR], 0.46; 95% CI, 0.42-0.50), an increased risk of neonatal resuscitation (Cadj RR, 1.07; 95% CI, 1.03-1.11), and an increased risk of neonatal unit admission (Cadj RR, 1.14; 95% CI, 1.11-1.17). With additional analysis for mediation by mode of delivery (CMadj), these associations were reversed (CMadj RR, 0.83; 95% CI, 0.79-0.86 for neonatal resuscitation and CMadj RR, 0.94; 95% CI, 0.91-0.97 for neonatal unit admission). Epidural analgesia was associated with a reduced risk of an Apgar score less than 7 at 5 minutes in both confounder and confounder/mediation analyses. Epidural analgesia was associated with a reduced risk of having developmental concern in any domain at 2 years in confounder and confounder/mediation analyses (CMadj RR, 0.96; 95% CI, 0.93-0.98), with specifically fewer concerns regarding communication (CMadj RR, 0.96; 95% CI, 0.93-0.99) and fine motor skills (CMadj RR, 0.89; 95% CI, 0.82-0.97). Conclusions and Relevance The results of this cohort study suggest that labor epidural analgesia is not independently associated with adverse neonatal or childhood development outcomes. Associations with neonatal resuscitation and admission were likely mediated by mode of delivery.
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Affiliation(s)
- Rachel J. Kearns
- Department of Anesthesia, Glasgow Royal Infirmary, United Kingdom
- School of Medicine, University of Glasgow, United Kingdom
| | - Martin Shaw
- Department of Medical Physics, National Health Service Greater Glasgow and Clyde, United Kingdom
| | | | - Stamatina Iliodromiti
- Centre for Women’s Health, Institute of Population Health Sciences, Queen Mary University, London, United Kingdom
| | - Deborah A. Lawlor
- Medical Research Council Integrative Epidemiology Unit at the University of Bristol, United Kingdom
- Population Health Science, Bristol Medical School, United Kingdom
- Bristol National Institute for Health Research Biomedical Research Centre, Bristol, United Kingdom
| | - Scott M. Nelson
- School of Medicine, University of Glasgow, United Kingdom
- Population Health Science, Bristol Medical School, United Kingdom
- Bristol National Institute for Health Research Biomedical Research Centre, Bristol, United Kingdom
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22
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Bourgès J, Gakuba C, Plass F, Gérard JL, Simonet T, Hanouz JL. Effect of patient-controlled epidural analgesia with and without automatic intermittent bolus on levobupivacaine consumption during labour: A single-centre prospective double-blinded randomised controlled study. Anaesth Crit Care Pain Med 2021; 40:100936. [PMID: 34391982 DOI: 10.1016/j.accpm.2021.100936] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2021] [Revised: 06/03/2021] [Accepted: 06/22/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND During labour, the effects of adding a programmed intermittent epidural bolus (PIEB) baseline analgesic regimen to patient-controlled epidural analgesia (PCEA) remain uncertain. METHODS This single centre prospective double-blinded controlled study randomised nulliparous women over 35 weeks of gestational age in a PCEA + PIEB or PCEA only group. After an epidural analgesia catheter was inserted, a specific pump administered a solution of levobupivacaine 0.625 mg mL-1, sufentanil 0.25 µg mL-1, and clonidine 0.375 µg mL-1. In both groups the PCEA mode delivered an 8 mL bolus with a lockout period of 8 min. In the PCEA + PIEB group, women also received a programmed 8 mL bolus every 60 min. Additional bolus were allowed if required. The primary outcome was the hourly consumption of levobupivacaine from epidural catheter placement to new-born delivery. Secondary outcome were motor block, oxytocin use, sufentanil consumption, additional bolus required, instrumental vaginal delivery, unplanned caesarean section, pain during labour and women's satisfaction. RESULTS Analysis included 162 and 155 women in the PCEA and PCEA + PIEB groups, respectively. The median [IQR] hourly consumption of levobupivacaine was significantly lower in the PCEA group (9.9 (7.8-12.4] mg h-1) as compared to the PCEA + PIEB group (11.2 [7.9-14.3] mg h-1; p = 0.046). The difference between medians was 1.3 mg h-1 95 % CI (0.1-2.9). There was no difference between groups for secondary outcomes. CONCLUSIONS PCEA only modestly decreased the hourly consumption of local anaesthetic as compared to PCEA + PIEB but the difference was not clinically relevant.
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Affiliation(s)
- Jennifer Bourgès
- Department of Anaesthesia and Intensive Care Medicine, Caen University Hospital, Avenue de la Côte de Nacre, CS 30001, F-14000 Caen, France; Normandie University, UNICAEN, INSERM UMR-S U1237, 14000 Caen, France
| | - Clément Gakuba
- Department of Anaesthesia and Intensive Care Medicine, Caen University Hospital, Avenue de la Côte de Nacre, CS 30001, F-14000 Caen, France; Normandie University, UNICAEN, INSERM UMR-S U1237, 14000 Caen, France
| | - Felipe Plass
- Department of Anaesthesia and Intensive Care Medicine, Caen University Hospital, Avenue de la Côte de Nacre, CS 30001, F-14000 Caen, France
| | - Jean-Louis Gérard
- Department of Anaesthesia and Intensive Care Medicine, Caen University Hospital, Avenue de la Côte de Nacre, CS 30001, F-14000 Caen, France
| | - Thérèse Simonet
- Department of Anaesthesia and Intensive Care Medicine, Caen University Hospital, Avenue de la Côte de Nacre, CS 30001, F-14000 Caen, France
| | - Jean-Luc Hanouz
- Department of Anaesthesia and Intensive Care Medicine, Caen University Hospital, Avenue de la Côte de Nacre, CS 30001, F-14000 Caen, France.
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23
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Zidan R, Saad N, Sigler Y, Justman N, Mick I, Ben-Asher H, Beloosesky R, Ginsberg Y, Weiner Z, Zipori Y. The impact of prolonged second stage in twins on perinatal outcomes. Int J Gynaecol Obstet 2021; 157:347-352. [PMID: 34118077 DOI: 10.1002/ijgo.13787] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Revised: 05/28/2021] [Accepted: 06/11/2021] [Indexed: 11/12/2022]
Abstract
OBJECTIVE To assess the duration of the second stage of labor in twin pregnancies in relation to maternal and neonatal outcomes. METHODS A retrospective study between 2014 and 2020. Eligible cases were twin pregnancies that reached the second stage. The pre-defined groups were based on the total time spent in the second stage of labor; Group 1 (<1 h), group 2 (1-2 h), and group 3 (>2 h), which was considered the prolonged second stage group. RESULTS Among the 439 planned vaginal births, successful vaginal delivery of both twins was achieved in 63.8%. Prolonged second stage was observed in 25.8% (89/345). Nulliparity (odds ratio [OR] 7.72, 95% confidence interval [CI] 4.5-13.4) and use of epidural analgesia (OR 5.45, 95% CI 1.2-24.7), were the only independent variables significantly associated with prolonged second stage. Prolonged second stage was associated with a greater risk of intrapartum cesarean delivery (32.6%, P < 0.001), combined delivery (10.1%, P < 0.001), chorioamnionitis (8.3%, P = 0.006) and a admission to neonatal intensive care unit of at least one of the twins (30.3%, P = 0.02). CONCLUSION Prolonged second stage of labor affects maternal and fetal outcome in twin pregnancies.
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Affiliation(s)
- Ragda Zidan
- Department of Obstetrics and Gynecology, Rambam Health Care Campus, Haifa, Israel
| | - Niveen Saad
- Bruce Rappaport Faculty of Medicine, Technion Institute of Technology, Haifa, Israel
| | - Yoav Sigler
- Department of Obstetrics and Gynecology, Rambam Health Care Campus, Haifa, Israel
| | - Naphtali Justman
- Department of Obstetrics and Gynecology, Rambam Health Care Campus, Haifa, Israel
| | - Ido Mick
- Department of Obstetrics and Gynecology, Rambam Health Care Campus, Haifa, Israel
| | - Hila Ben-Asher
- Department of Obstetrics and Gynecology, Rambam Health Care Campus, Haifa, Israel
| | - Ron Beloosesky
- Department of Obstetrics and Gynecology, Rambam Health Care Campus, Haifa, Israel.,Bruce Rappaport Faculty of Medicine, Technion Institute of Technology, Haifa, Israel
| | - Yuval Ginsberg
- Department of Obstetrics and Gynecology, Rambam Health Care Campus, Haifa, Israel
| | - Zeev Weiner
- Department of Obstetrics and Gynecology, Rambam Health Care Campus, Haifa, Israel.,Bruce Rappaport Faculty of Medicine, Technion Institute of Technology, Haifa, Israel
| | - Yaniv Zipori
- Department of Obstetrics and Gynecology, Rambam Health Care Campus, Haifa, Israel
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24
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Zhang L, Hu Y, Wu X, J Paglia M, Zhang X. A Systematic Review and Meta-Analysis of Randomized Controlled Trials of Labor Epidural Analgesia Using Moderately High Concentrations of Plain Local Anesthetics versus Low Concentrations of Local Anesthetics with Opioids. J Pain Res 2021; 14:1303-1313. [PMID: 34054305 PMCID: PMC8154542 DOI: 10.2147/jpr.s305838] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Accepted: 04/19/2021] [Indexed: 12/12/2022] Open
Abstract
Purpose Compared to low concentrations of local anesthetics with opioids for labor epidural analgesia, very high concentrations of local anesthetics are associated with an increased risk of assisted vaginal delivery. We aimed to investigate if moderately high concentrations of plain local anesthetics are also associated with this risk. Methods We searched for published randomized controlled trials that compared moderately high concentrations of plain local anesthetics (>0.1% but ≤0.125% bupivacaine, >0.1% but ≤0.125% levobupivacaine, or >0.17% but ≤0.2% ropivacaine) to low concentrations of local anesthetics (≤0.1% bupivacaine, ≤0.1% levobupivacaine, or ≤0.17% ropivacaine) with opioids for labor analgesia. Meta-analyses were performed to compare the risk of assisted vaginal delivery and other perinatal outcomes between these two groups. Results We identified nine randomized controlled trials with a total of 1334 participants. Meta-analysis of these nine trials showed no differences in the risks of assisted vaginal delivery (odds ratio [OR] = 1.18; 95% confidence interval [CI], 0.93–1.49) or Cesarean delivery (OR = 0.96; 95% CI, 0.71–1.29) between the two groups. The incidence of motor block was higher in the group of moderately high concentrations (OR = 4.05; 95% CI, 2.19–7.48), while the incidence of pruritus was lower (OR = 0.07; 95% CI, 0.03–0.16). Conclusion This systematic review and meta-analysis suggests that the current evidence is inadequate to support that moderately high concentrations of plain local anesthetics increase the risk of assisted vaginal delivery compared to low concentrations of local anesthetics with opioids.
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Affiliation(s)
- Li Zhang
- Department of Anesthesiology, Geisinger Medical Center, Danville, PA, USA
| | - Yirui Hu
- Population Health Sciences, Geisinger Medical Center, Danville, PA, USA
| | - Xianren Wu
- Department of Anesthesiology, Geisinger Medical Center, Danville, PA, USA
| | - Michael J Paglia
- Department of Obstetrics and Gynecology, Geisinger Medical Center, Danville, PA, USA
| | - Xiaopeng Zhang
- Department of Anesthesiology, Geisinger Medical Center, Danville, PA, USA
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25
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Zha Y, Gong X, Yang C, Deng D, Feng L, Luo A, Wan L, Qiao F, Zeng W, Chen S, Wu Y, Han D, Liu H. Epidural analgesia during labor and its optimal initiation time-points: A real-world study on 400 Chinese nulliparas. Medicine (Baltimore) 2021; 100:e24923. [PMID: 33655955 PMCID: PMC7939169 DOI: 10.1097/md.0000000000024923] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2020] [Accepted: 02/04/2021] [Indexed: 01/04/2023] Open
Abstract
Recent research has suggested that 6 cm of cervical dilation should be the threshold for the active labor phase, and it has confirmed that epidural analgesia (EA) is a safe method of pain relief during labor. However, the evidence provided for these findings comes mainly from randomized controlled clinical trials (RCTs), which suffer from the limitation of real-world generalizability.To test the generalizability of the conclusions from these previous RCTs, we conducted a prospective cohort, real-world study (RWS) on 400 Chinese term nulliparas. A total of 200 of the participants (the EA group) received EA upon request. The participants in the EA group were further subdivided as follows according to their cervical dilation when the EA administration was initiated (CDE): [EA1 group (CDE < 3 cm), EA2 group (3 cm ≤ CDE < 6 cm), and EA3 group (CDE ≥ 6 cm)]. We compared the labor duration of the EA group versus the non-EA (NEA) group, and the NEA group versus the 3 EA subgroups. We also compared delivery outcomes between the EA and NEA groups.The median total labor duration for the EA group [676 (511-923) minutes] was significantly longer than that of the NEA group [514 (373-721) minutes] (P < 0.001). The median durations of both the first- and second-stages of labor for the EA group [600 (405-855) minutes, 68 (49-97) minutes] were longer than those of the NEA group [420 (300-630) minutes, 50 (32-85) minutes] (P < .001, P < .001)]. In addition, the median total labor durations in both the EA1 [720 (548-958) minutes] and EA2 groups [688 (534-926) minutes] were longer than in the NEA group (P < .001 and P < .001, respectively), and the first- and second-stage labor durations of these subgroups were similar to their total labor durations. A Cox regression analysis showed that EA was associated with longer first-stage labor [hazard ratio (HR) 0.55, 95% confidence interval (CI) 0.42-0.71, P < .001] and longer second-stage labor (HR 0.66, 95% CI 0.51-0.85, P = .001). The delivery modes and neonatal outcomes between the EA and NEA groups were not statistically different, however.Our findings suggest that EA administered before a cervical dilation of 6 cm may be associated with longer total, first-, and second-stage labor durations compared with no EA, while later EA administration is not. In addition, though EA prolongs labor duration, it does not impact delivery outcomes. These results confirm the significance of a 6 cm cervical dilation threshold in real-world labor settings.
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Affiliation(s)
- Ying Zha
- Department of Obstetrics and Gynecology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, People's Republic of China
| | - Xun Gong
- Department of Obstetrics and Gynecology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, People's Republic of China
| | - Chengwu Yang
- Department of Epidemiology and Health Promotion, College of Dentistry, New York University, New York City, NY
| | - Dongrui Deng
- Department of Obstetrics and Gynecology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, People's Republic of China
| | - Ling Feng
- Department of Obstetrics and Gynecology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, People's Republic of China
| | - Ailin Luo
- Department of Anesthesiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, People's Republic of China
| | - Li Wan
- Department of Anesthesiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, People's Republic of China
| | - Fuyuan Qiao
- Department of Obstetrics and Gynecology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, People's Republic of China
| | - Wanjiang Zeng
- Department of Obstetrics and Gynecology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, People's Republic of China
| | - Suhua Chen
- Department of Obstetrics and Gynecology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, People's Republic of China
| | - Yuanyuan Wu
- Department of Obstetrics and Gynecology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, People's Republic of China
| | - Dongji Han
- Department of Anesthesiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, People's Republic of China
| | - Haiyi Liu
- Department of Obstetrics and Gynecology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, People's Republic of China
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26
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Benfield R, Song H, Salstrom J, Edge M, Brigham D, Newton ER. Intrauterine contraction parameters at baseline and following epidural and combined spinal-epidural analgesia: A repeated measures comparison. Midwifery 2021; 95:102943. [PMID: 33596500 DOI: 10.1016/j.midw.2021.102943] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Revised: 01/23/2021] [Accepted: 02/04/2021] [Indexed: 10/22/2022]
Abstract
OBJECTIVE The effects of epidural and combined spinal-epidural analgesia on uterine contraction parameters are unclear, although as many as 80% of laboring women use neuraxial analgesia. We explored the effects of epidural and combined spinal-epidural analgesia on all uterine contraction parameters using a retrospective analysis of selected parturients, who required Intrauterine Pressure Catheter (IUPC) instrumentation for clinical management. Additionally, we analyzed the effects of parity, Pitocin dose, and mode of neuraxial anesthesia, i.e. epidural verses combined spinal-epidural on uterine contractility. DESIGN Using a retrospective within and between repeated measure design we compared uterine contraction parameters at 4 time points (epochs): (1) baseline, (2) pre-epidural fluid bolus, (3) immediate and (4) secondary post-epidural/combined spinal-epidural analgesia to detect differences in contractility over time comparing two types of epidural interventions. METHODS Eighteen healthy parturients at term gestation were admitted to the labor unit for induction, augmentation, or spontaneous labor. Contraction parameters including frequency, duration, peak intensity, resting intensity and duration, and Montevideo Units (MVUs) were collected using fetal monitor strip data with intrauterine pressure catheter (IUPC) instrumentation. FINDINGS Parametric and non-parametric tests showed no significant differences within or between the two Epidural intervention groups for frequency, duration, peak intensity, resting intensity and duration, and MVUs at all epochs at the .05 alpha level. Compared with Nulliparous women, multiparous women had significantly lower contraction intensity and longer contraction duration. Based on multilevel modeling (MLM), neither Pitocin dose nor type of epidural intervention revealed significant differences on any contraction parameters. CONCLUSIONS When parity, other demographic variables and Pitocin dose were statistically controlled, no uterine contraction parameter changed from baseline through 90 min following either epidural or combined spinal-epidural analgesia. Obstetrical care providers should consider the preciseness their contraction monitoring instrumentation and their clinical management preferences as well parity as before prescribing Pitocin after neuraxial analgesia intervention.
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Affiliation(s)
| | - Huaxin Song
- School of Nursing, University of Nevada, Las Vegas, NV, USA; School of Nursing, Texas Tech University Health Sciences Center, Lubbock, TX, USA
| | - Jan Salstrom
- Department of Obstetrics and Gynecology, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
| | - Melydia Edge
- Department of Advanced Nursing Practice and Education, East Carolina University, Greenville, NC, USA
| | - Denise Brigham
- Department of Internal Medicine, East Carolina University, Greenville, NC, USA
| | - Edward R Newton
- Department of Obstetrics and Gynecology, East Carolina University, Greenville, NC, USA
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27
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Butwick AJ, Wong CA, Lee HC, Blumenfeld YJ, Guo N. Association between Neuraxial Labor Analgesia and Neonatal Morbidity after Operative Vaginal Delivery. Anesthesiology 2021; 134:52-60. [PMID: 33045040 DOI: 10.1097/aln.0000000000003589] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Up to 84% of women who undergo operative vaginal delivery receive neuraxial analgesia. However, little is known about the association between neuraxial analgesia and neonatal morbidity in women who undergo operative vaginal delivery. The authors hypothesized that neuraxial analgesia is associated with a reduced risk of neonatal morbidity among women undergoing operative vaginal delivery. METHODS Using United States birth certificate data, the study identified women with singleton pregnancies who underwent operative vaginal (forceps- or vacuum-assisted delivery) in 2017. The authors examined the relationships between neuraxial labor analgesia and neonatal morbidity, the latter defined by any of the following: 5-min Apgar score less than 7, immediate assisted ventilation, assisted ventilation greater than 6 h, neonatal intensive care unit admission, neonatal transfer to a different facility within 24 h of delivery, and neonatal seizure or serious neurologic dysfunction. The authors accounted for sociodemographic and obstetric factors as potential confounders in their analysis. RESULTS The study cohort comprised 106,845 women who underwent operative vaginal delivery, of whom 92,518 (86.6%) received neuraxial analgesia. The proportion of neonates with morbidity was higher in the neuraxial analgesia group than the nonneuraxial group (10,409 of 92,518 [11.3%] vs. 1,271 of 14,327 [8.9%], respectively; P < 0.001). The unadjusted relative risk was 1.27 (95% CI, 1.20 to 1.34; P < 0.001); after accounting for confounders using a multivariable model, the adjusted relative risk was 1.19 (95% CI, 1.12 to 1.26; P < 0.001). In a post hoc analysis, after excluding neonatal intensive care unit admission and neonatal transfer from the composite outcome, the effect of neuraxial analgesia on neonatal morbidity was not statistically significant (adjusted relative risk, 1.07; 95% CI, 1.00 to 1.16; P = 0.054). CONCLUSIONS In this population-based cross-sectional study, a neonatal benefit of neuraxial analgesia for operative vaginal delivery was not observed. Confounding by indication may explain the observed association between neuraxial analgesia and neonatal morbidity, however this dataset was not designed to evaluate such considerations. EDITOR’S PERSPECTIVE
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28
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Kennedy J, Hasham F. Reversal of motor block due to epidural analgesia for the second stage of labor. Int J Obstet Anesth 2020; 44:1-2. [DOI: 10.1016/j.ijoa.2020.06.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Revised: 06/11/2020] [Accepted: 06/22/2020] [Indexed: 12/27/2022]
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29
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Zeng H, Guo F, Lin B, Liu L, Wei W, He P, Lai Y. The effects of epidural analgesia using low-concentration local anesthetic during the entire labor on maternal and neonatal outcomes: a prospective group study. Arch Gynecol Obstet 2020; 301:1153-1158. [PMID: 32219521 DOI: 10.1007/s00404-020-05511-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2019] [Accepted: 03/12/2020] [Indexed: 12/19/2022]
Abstract
PURPOSE The purpose of this study was to study the impact of epidural analgesia using low-concentration local anesthetic during the entire labor on maternal and neonatal outcomes. METHODS The authors enrolled 2310 parturient mothers who underwent vaginal delivery at their hospital since January 1, 2019. The parturients were allocated either into the analgesia or into the non-analgesia groups based on whether they received analgesia during the delivery process. To investigate the effects of epidural analgesia using low-concentration local anesthetic on maternal and neonatal outcomes, the authors assessed between-group differences in the labor duration, newborn Apgar score, and maternal and neonatal outcomes. RESULTS Compared to the non-analgesia group, the first and second labor stage durations in the analgesia group were significantly longer. Similarly, the analgesia group had a higher frequency of oxytocin injections, Category II and III fetal heart rate tracing during labor, and intrapartum fever development. Further, the need for episiotomy and assisted vaginal delivery was higher in the analgesia group than that in the non-analgesia group. Regarding neonatal outcomes, the neonatal hospitalization rate and incidence rate of umbilical cord blood pH < 7.2 were higher in the analgesia group than those in the non-analgesia group. However, there were no significant between-group differences in the incidence rates of stained amniotic fluid, mild neonatal asphyxia, and severe perinatal asphyxia. CONCLUSION Patient-controlled epidural analgesia using low-concentration local anesthetic during the entire labor did not increase the incidence rate of severe adverse outcomes in neonates born through vaginal delivery; however, it increased the delivery duration, and thus, the chance of possible perinatal interventions.
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Affiliation(s)
- Huiqian Zeng
- Department of Obstetrics, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, 9 Jinsui Road, Guangzhou, 510623, China
| | - Fang Guo
- Department of Obstetrics, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, 9 Jinsui Road, Guangzhou, 510623, China
| | - Baohua Lin
- Department of Obstetrics, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, 9 Jinsui Road, Guangzhou, 510623, China
| | - Lei Liu
- Department of Obstetrics, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, 9 Jinsui Road, Guangzhou, 510623, China
| | - Wei Wei
- Department of Anesthesia, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, China
| | - Ping He
- Department of Obstetrics, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, 9 Jinsui Road, Guangzhou, 510623, China
| | - Yumian Lai
- Department of Obstetrics, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, 9 Jinsui Road, Guangzhou, 510623, China.
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Nanji JA, Carvalho B. Pain management during labor and vaginal birth. Best Pract Res Clin Obstet Gynaecol 2020; 67:100-112. [PMID: 32265134 DOI: 10.1016/j.bpobgyn.2020.03.002] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2019] [Revised: 02/18/2020] [Accepted: 03/03/2020] [Indexed: 11/20/2022]
Abstract
Neuraxial analgesia provides excellent pain relief in labor. Optimizing initiation and maintenance of neuraxial labor analgesia requires different strategies. Combined spinal-epidurals or dural puncture epidurals may offer advantages over traditional epidurals. Ultrasound is useful in certain patients. Maintenance of analgesia is best achieved with a background regimen (either programmed intermittent boluses or a continuous epidural infusion) supplemented with patient-controlled epidural analgesia and using dilute local anesthetics combined with opioids such as fentanyl. Nitrous oxide and systemic opioids are also used for pain relief. Nitrous oxide may improve satisfaction despite variable effects on pain. Systemic opioids can be administered by healthcare providers or using patient-controlled analgesia. Appropriate choice of drug should take into account the stage and progression of labor, local safety protocols, and maternal and fetal/neonatal side effects. Pain in labor is complex, and women should fully participate in the decision-making process before any one modality is selected.
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Affiliation(s)
- Jalal A Nanji
- Department of Anesthesiology and Pain Medicine, University of Alberta Faculty of Medicine and Dentistry, Royal Alexandra Hospital, 10240 Kingsway Avenue NW, Edmonton, AB, T5H 3V9, Canada.
| | - Brendan Carvalho
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, 300 Pasteur Drive MC: 5640, Stanford, CA, 94305, USA.
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Butwick A, Weiniger C. Combatting myths and misinformation about obstetric anesthesia. Int J Obstet Anesth 2019; 40:1-3. [DOI: 10.1016/j.ijoa.2019.08.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2019] [Revised: 08/19/2019] [Accepted: 08/30/2019] [Indexed: 01/21/2023]
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Colciago E, Fumagalli S, Inzis I, Borrelli SE, Nespoli A. Management of the second stage of labour in women with epidural analgesia: A qualitative study exploring Midwives’ experiences in Northern Italy. Midwifery 2019; 78:8-15. [DOI: 10.1016/j.midw.2019.07.013] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2019] [Revised: 05/14/2019] [Accepted: 07/14/2019] [Indexed: 10/26/2022]
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Huang D, Dai L, Zeng T, Huang H, Wu M, Yuan M, Zhang K. Exploring Contributing Factors to Psychological Traumatic Childbirth from the Perspective of Midwives: A Qualitative Study. Asian Nurs Res (Korean Soc Nurs Sci) 2019; 13:270-276. [PMID: 31605769 DOI: 10.1016/j.anr.2019.10.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2019] [Revised: 10/01/2019] [Accepted: 10/01/2019] [Indexed: 11/26/2022] Open
Abstract
PURPOSE As midwives witness and attend the whole process of childbirth, they have a better understanding of which factors may cause traumatic childbirth. However, because most of the studies paid their attention on mothers, little is known about psychological birth trauma from the perspective of midwives. This study aims to gain a full understanding of which factors may contribute to psychological traumatic childbirth from the perspective of midwives. METHODS A qualitative research was conducted using in-depth interviews, which involved fourteen midwives from the maternal ward of a tertiary hospital. The interviews were recorded and transcribed, and then, Colaizzi's method was used to analyze the contents of the interviews. RESULTS We proposed four themes and eight subthemes on the influencing factors of psychological traumatic childbirth from the perspective of midwives: low perceived social support (lack of support from family and lack of support from medical staff), hard times (protracted labor in the first stage and futile efforts during the second stage), poor birth outcomes (poor birth outcomes of the mother and poor birth outcomes of the baby), and excruciating pain (unbearable pain of uterine contraction and labor pain was incongruent with the mother's expectations). CONCLUSION Medical staff should pay attention to psychological traumatic childbirth and its effects, and emphasis on the screening and assessment of birthing women with negative feelings so that their psychological traumatic childbirth can be prevented and decreased.
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Affiliation(s)
- Deqin Huang
- Department of Nursing, Tongji Hosptial, Huazhong University of Science & Technology, Wuhan, Hubei, China
| | - Ling Dai
- Department of Nursing, Tongji Hosptial, Huazhong University of Science & Technology, Wuhan, Hubei, China
| | - Tieying Zeng
- Department of Nursing, Tongji Hosptial, Huazhong University of Science & Technology, Wuhan, Hubei, China.
| | - Haishan Huang
- Department of Neurology, Tongji Hosptial, Huazhong University of Science & Technology, Wuhan, Hubei, China
| | - Meiliyang Wu
- Department of Nursing, Tongji Hosptial, Huazhong University of Science & Technology, Wuhan, Hubei, China
| | - Mengmei Yuan
- Department of Nursing, Tongji Hosptial, Huazhong University of Science & Technology, Wuhan, Hubei, China
| | - Ke Zhang
- Department of Nursing, Tongji Hosptial, Huazhong University of Science & Technology, Wuhan, Hubei, China
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Lozada MJ, Weiniger CF, Carvalho B, Bauchat JR. Pain relief during labour. Lancet 2019; 394:e12. [PMID: 31262493 DOI: 10.1016/s0140-6736(19)30710-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2018] [Accepted: 03/15/2019] [Indexed: 11/20/2022]
Affiliation(s)
- M James Lozada
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN 37232, USA.
| | - Carolyn F Weiniger
- Division of Anesthesiology and Critical Care & Pain, Sourasky Medical Center, Tel Aviv, Israel
| | - Brendan Carvalho
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Jeanette R Bauchat
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN 37232, USA
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Abstract
Clinicians encounter an ever increasing and frequently overwhelming amount of information, even in a narrow scope or area of interest. Given this enormous amount of scientific information published every year, systematic reviews and meta-analyses have become indispensable methods for the evaluation of medical treatments and the delivery of evidence-based best practice. The present basic statistical tutorial thus focuses on the fundamentals of a systematic review and meta-analysis, against the backdrop of practicing evidence-based medicine. Even if properly performed, a single study is no more than tentative evidence, which needs to be confirmed by additional, independent research. A systematic review summarizes the existing, published research on a particular topic, in a well-described, methodical, rigorous, and reproducible (hence "systematic") manner. A systematic review typically includes a greater range of patients than any single study, thus strengthening the external validity or generalizability of its findings and the utility to the clinician seeking to practice evidence-based medicine. A systematic review often forms the basis for a concomitant meta-analysis, in which the results from the identified series of separate studies are aggregated and statistical pooling is performed. This allows for a single best estimate of the effect or association. A conjoint systematic review and meta-analysis can provide an estimate of therapeutic efficacy, prognosis, or diagnostic test accuracy. By aggregating and pooling the data derived from a systemic review, a well-done meta-analysis essentially increases the precision and the certainty of the statistical inference. The resulting single best estimate of effect or association facilitates clinical decision making and practicing evidence-based medicine. A well-designed systematic review and meta-analysis can provide valuable information for researchers, policymakers, and clinicians. However, there are many critical caveats in performing and interpreting them, and thus, like the individual research studies on which they are based, there are many ways in which meta-analyses can yield misleading information. Creators, reviewers, and consumers alike of systematic reviews and meta-analyses would thus be well-served to observe and mitigate their associated caveats and potential pitfalls.
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Affiliation(s)
- Thomas R Vetter
- From the Department of Surgery and Perioperative Care, Dell Medical School at the University of Texas at Austin, Austin, Texas
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A Review of the Impact of Obstetric Anesthesia on Maternal and Neonatal Outcomes. Anesthesiology 2019; 129:192-215. [PMID: 29561267 DOI: 10.1097/aln.0000000000002182] [Citation(s) in RCA: 85] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Obstetric anesthesia has evolved over the course of its history to encompass comprehensive aspects of maternal care, ranging from cesarean delivery anesthesia and labor analgesia to maternal resuscitation and patient safety. Anesthesiologists are concerned with maternal and neonatal outcomes, and with preventing and managing complications that may present during childbirth. The current review will focus on recent advances in obstetric anesthesia, including labor anesthesia and analgesia, cesarean delivery anesthesia and analgesia, the effects of maternal anesthesia on breastfeeding and fever, and maternal safety. The impact of these advances on maternal and neonatal outcomes is discussed. Past and future progress in this field will continue to have significant implications on the health of women and children.
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Butwick AJ, Bentley J, Wong CA, Snowden JM, Sun E, Guo N. United States State-Level Variation in the Use of Neuraxial Analgesia During Labor for Pregnant Women. JAMA Netw Open 2018; 1:e186567. [PMID: 30646335 PMCID: PMC6324365 DOI: 10.1001/jamanetworkopen.2018.6567] [Citation(s) in RCA: 75] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
IMPORTANCE Neuraxial labor analgesia is recognized as the most effective method of providing pain relief during labor. Little is known about variation in the rates of neuraxial analgesia across US states. Identifying the presence and extent of variation may provide insights into practice variation and may indicate where access to neuraxial analgesia is inadequate. OBJECTIVE To test the hypothesis that variation exists in neuraxial labor analgesia use among US states. DESIGN, SETTING, AND PARTICIPANTS Retrospective, population-based, cross-sectional analysis using US birth certificate data. Participants were 2 625 950 women who underwent labor in 2015. MAIN OUTCOMES AND MEASURES State-specific prevalence of neuraxial analgesia per 100 women who underwent labor and variability in neuraxial analgesia use among states, assessed using multilevel multivariable regression modeling with the median odds ratio and the intraclass correlation coefficient to evaluate variation by state. RESULTS In the study population of 2 625 950 women, 0.1% (n = 2010) were younger than 15 years, 7.0% (n = 183 546) were between the ages of 15 and 19 years, 23.6% (n = 620 118) were between the ages of 20 and 24 years, 29.6% (n = 777 957) were between the ages of 25 and 29 years, 26.0% (n = 683 656) were between the ages of 30 and 34 years, 11.4% (n = 298 237) were between the ages of 35 and 39 years, 2.2% (n = 57 130) were between the ages of 40 and 44 years, and 0.1% (n = 3296) were between the ages of 45 and 54 years. More than 90% were privately insured or insured with Medicaid. Neuraxial analgesia was used by 73.1% (n = 1 920 368) of women. After adjustment for antepartum, obstetric, and intrapartum factors, Maine had the lowest neuraxial analgesia prevalence (36.6%; 95% CI, 33.2%-40.1%) and Nevada the highest (80.1%; 95% CI, 78.3%-81.7%). The adjusted median odds ratio was 1.5 (95% CI, 1.4-1.6), and the intraclass correlation coefficient was 5.4% (95% CI, 4.0%-7.9%). CONCLUSIONS AND RELEVANCE Results of this study suggest that a small portion of the overall variation in neuraxial analgesia use is explained by US states. Unmeasured patient-level and hospital-level factors likely account for a large portion of the variation between states. Efforts should be made to understand what the main reasons are for this variation and whether the variation influences maternal or perinatal outcomes.
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Affiliation(s)
- Alexander J. Butwick
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, California
| | - Jason Bentley
- Quantitative Sciences Unit, Stanford University School of Medicine, Stanford, California
| | - Cynthia A. Wong
- Department of Anesthesia, Roy J. and Lucille A. Carver College of Medicine, University of Iowa, Iowa City
| | - Jonathan M. Snowden
- School of Public Health, Oregon Health & Science University–Portland State University, Portland
| | - Eric Sun
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, California
| | - Nan Guo
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, California
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Shmueli A, Salman L, Orbach-Zinger S, Aviram A, Hiersch L, Chen R, Gabbay-Benziv R. The impact of epidural analgesia on the duration of the second stage of labor. Birth 2018; 45:377-384. [PMID: 29790194 DOI: 10.1111/birt.12355] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2017] [Revised: 03/22/2018] [Accepted: 03/22/2018] [Indexed: 11/30/2022]
Abstract
BACKGROUND We aimed to describe the length of second stage of labor in a contemporary cohort. We calculated the 5th, 50th, and 95th percentiles for second-stage length stratified by parity and epidural analgesia use and evaluated the effect of labor induction and oxytocin augmentation in our cohort. METHODS We did a retrospective analysis of all live, singleton, term vaginal deliveries in one tertiary hospital. Multivariate linear regression was used to evaluate second-stage duration confounders. First, we calculated the second-stage length and presented it as 5th, 50th, and 95th percentiles stratified by epidural analgesia and parity. Second, we evaluated the effect of labor induction and oxytocin augmentation on second-stage length, and third, we determined the demographic and obstetrical confounders that affected second-stage length. RESULTS Overall, 15 500 deliveries were included. Nulliparity, oxytocin augmentation, epidural use, birthweight, labor induction, lower body mass index, and higher maternal age were found to be significantly associated with prolongation of the second stage. Epidural use was associated with an additional 82 minutes for the 95th percentile for both nulliparas and multiparas and tripled the rate of prolonged second stage for the entire cohort. Labor induction was associated with clinically significant prolongation of the second stage in nulliparas with epidural analgesia only. Oxytocin was associated with longer duration of the second stage for nulliparas, regardless of epidural use. DISCUSSION Our findings suggest a significant prolongation of the second stage in women receiving epidural analgesia. Recommendations for management of second stage should be reconsidered by contemporary data.
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Affiliation(s)
- Anat Shmueli
- Helen Schneider Hospital for Women, Rabin Medical Center, Petach Tikva, Israel.,The Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Lina Salman
- Helen Schneider Hospital for Women, Rabin Medical Center, Petach Tikva, Israel.,The Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Sharon Orbach-Zinger
- The Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Department of Anesthesia, Rabin Medical Center, Petach Tikva, Israel
| | - Amir Aviram
- The Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Lis Maternity Hospital, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Liran Hiersch
- The Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Lis Maternity Hospital, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Rony Chen
- Helen Schneider Hospital for Women, Rabin Medical Center, Petach Tikva, Israel.,The Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Rinat Gabbay-Benziv
- Hillel Yaffe Medical Center, Hadera, Israel.,The Rappaport Faculty of Medicine, Technion, Haifa, Israel
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Challenges and hurdles for patient safety in obstetric anesthesia in Japan. J Anesth 2018; 32:901-907. [DOI: 10.1007/s00540-018-2571-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2018] [Accepted: 10/18/2018] [Indexed: 10/28/2022]
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Interprofessional provider attitudes toward the initiation of epidural analgesia in the laboring patient: are we all on the same page? Int J Obstet Anesth 2018; 37:57-67. [PMID: 30245261 DOI: 10.1016/j.ijoa.2018.08.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2018] [Revised: 08/01/2018] [Accepted: 08/13/2018] [Indexed: 11/22/2022]
Abstract
BACKGROUND The timing of initiation of neuraxial labor analgesia should ultimately depend on patient preference although obstetricians, anesthesiologists and nurses may influence decision-making. We hypothesized that provider groups would have similar attitudes toward the timing of epidural placement, but some identifiable differences could be used to improve understanding and communication among providers. METHODS Anesthesiologists, nurses and obstetricians completed a survey assessing their knowledge and attitudes on the timing of epidural placement in specified clinical circumstances. RESULTS Anesthesiologists (100%) and nurses (86.2%) reported being more familiar with epidural management than obstetricians (43.3%, P <0.01). The willingness of providers to advocate epidural placement based on the magnitude of cervical dilation was similar, although at 10 cm dilatation obstetricians (73.3%) were significantly more likely to advocate neuraxial block compared to both nurses (27.6%, P <0.01) and anesthesiologists (36.7%, P <0.01). The impact of patient factors and clinical circumstances on the timing of neuraxial block placement showed significant differences among provider groups in five of 24 areas assessed, including patient desire for an epidural, primigravid patients without membrane rupture, oxytocin infusion initiated, labor epidural in a previous pregnancy, and a difficult airway. CONCLUSIONS There were differences between providers in factors that may impact the timing of epidural placement and in their self-perceived familiarity with epidural management. These present an opportunity for furthering interprofessional education and collaboration.
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Abstract
In recent years, many neuraxial techniques have been introduced to initiate and maintain labour analgesia, with low-dose mixtures of local anaesthetics and opioids, which have improved the quality of analgesia and made it safer for both mother and neonate. An independent search of the databases of PubMed, Medline, and Cochrane controlled trial data was conducted by two researchers, and randomized controlled trials that compared different methods of neuraxial analgesia and the different techniques of maintaining labor analgesia were retrieved and analyzed. The advantages, disadvantages, and indications of each technique along with the doses of intrathecal and epidural drugs are discussed. The myths and controversies involving neuraxial labor analgesia and the current consensus on their effect on the maternal and foetal outcomes are also outlined.
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Affiliation(s)
- Sunanda Gupta
- Department of Anaesthesiology, Geetanjali Medical College and Hospital, Udaipur, Rajasthan, India
| | - Seema Partani
- Department of Anaesthesiology, Geetanjali Medical College and Hospital, Udaipur, Rajasthan, India
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43
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Nanji JA, Carvalho B. Modern techniques to optimize neuraxial labor analgesia. Anesth Pain Med (Seoul) 2018. [DOI: 10.17085/apm.2018.13.3.233] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Affiliation(s)
- Jalal A. Nanji
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Brendan Carvalho
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA, USA
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Munro A, George RB, Allen VM. The impact of analgesic intervention during the second stage of labour: a retrospective cohort study. Can J Anaesth 2018; 65:1240-1247. [PMID: 29987805 DOI: 10.1007/s12630-018-1184-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2017] [Revised: 05/25/2018] [Accepted: 05/25/2018] [Indexed: 11/25/2022] Open
Abstract
PURPOSE The incidence of epidural top-ups received in the second stage of labour in nulliparous women and the obstetrical and neonatal implications associated with these boluses are explored in this retrospective observational study. We hypothesized that an epidural top-up in the second stage of labour reduces operative deliveries by resolving inadequate analgesia. METHODS A population-based cohort analysis was performed using perinatal data from 1 January 2013 through 31 December 2014. An anesthesia database provided information to determine the top-up incidence. Women with or without a top-up for second-stage duration were compared for method of delivery and neonatal characteristics using descriptive statistics. Logistic regression identified predictive factors for method of delivery. RESULTS Of the 1,462 women with a second stage of labour > one hour who received epidural analgesia, 105 (7%) required a top-up during the second stage of labour. Women who received a top-up were more likely to have had induction of labour and/or augmentation (89% vs 76%; odds ratio [OR], 2.43; 95% confidence interval [CI], 1.32 to 4.49; P = 0.003), a longer second stage (303 min vs 171 min; mean difference, 132 min; 95% CI, 113 to 151; P < 0.001), and more assisted vaginal (41% vs 17%; OR, 3.35; 95% CI, 2.21 to 5.1; P < 0.001) or Cesarean deliveries (26% vs 11%; OR, 3.04; 95% CI, 1.91 to 4.8; P < 0.001) than women without a top-up. CONCLUSION Most women who received a top-up had a vaginal (spontaneous or assisted) delivery. Compared with women without a top-up, women requiring a top-up had more predictors of difficult labour and higher rates of assisted vaginal delivery and Cesarean delivery.
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Affiliation(s)
- Allana Munro
- Department of Women's & Obstetric Anesthesia, IWK Health Centre, Dalhousie University, Halifax, NS, Canada.
- Department of Anesthesia, Pain Management and Perioperative Medicine, Dalhousie University, Halifax, NS, Canada.
- Department of Women's & Obstetric Anesthesia, IWK Health Centre, 5850/5980 University Avenue, Halifax, NS, B3K 6R8, Canada.
| | - Ronald B George
- Department of Women's & Obstetric Anesthesia, IWK Health Centre, Dalhousie University, Halifax, NS, Canada
- Department of Anesthesia, Pain Management and Perioperative Medicine, Dalhousie University, Halifax, NS, Canada
| | - Victoria M Allen
- Department of Obstetrics and Gynaecology IWK Health Centre, 5850/5980 University Ave., Halifax, NS, Canada
- Department of Obstetrics and Gynecology, Dalhousie University, Halifax, NS, Canada
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Baliuliene V, Macas A, Rimaitis K. The optimal concentration of bupivacaine and levobupivacaine for labor pain management using patient-controlled epidural analgesia: a double-blind, randomized controlled trial. Int J Obstet Anesth 2018; 35:17-25. [PMID: 29914785 DOI: 10.1016/j.ijoa.2018.05.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2018] [Revised: 04/29/2018] [Accepted: 05/09/2018] [Indexed: 11/24/2022]
Abstract
BACKGROUND The study aim was to evaluate the efficacy and safety of different low concentrations of two local anesthetics for labor analgesia using patient-controlled epidural analgesia. METHODS A double-blind, randomized controlled trial recruiting healthy nulliparous women was conducted from 2014 to 2017. Epidural analgesia was provided using local anesthetic and fentanyl. Patients were allocated to six groups, according to the concentration of bupivacaine or levobupivacaine (0.0625%, 0.1%, 0.125%). Analgesic efficacy, vital parameters, and side effects were evaluated at different time points. Satisfaction was evaluated using verbal and written scores. The primary outcome was the total dose of local anesthetic used. RESULTS Two-hundred-and-thirty-seven cases were analyzed. The total dose of local anesthetic was significantly lower in the two lower concentration groups (P <0.0001). The rate of cesarean section was lower in 0.1% bupivacaine versus 0.1% levobupivacaine (P=0.005), 0.125% levobupivacaine (P=0.049) and 0.125% bupivacaine (P=0.002) groups. Pain breakthrough, patient-controlled and rescue boluses were significantly different between groups (P=0.03, P=0.003 and P <0.0001 respectively). The rate of motor block increased with higher concentrations (P=0.033), but the incidence of other maternal and fetal side effects was not significantly different. Satisfaction with labor analgesia did not differ across groups. Satisfaction score 72 hours after delivery was significantly lower than that two hours after delivery (P <0.0001). CONCLUSIONS Higher local anesthetic concentration resulted in higher total doses infused and greater motor block. Labor analgesia was less effective when the lowest concentrations were used, but patient satisfaction was unaffected.
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Affiliation(s)
- V Baliuliene
- Department of Anesthesiology, Lithuanian University of Health Sciences, Academy of Medicine, A. Mickeviciaus 9, 44307 Kaunas, Lithuania; Department of Anesthesiology, The Hospital of Lithuanian University of Health Sciences Kaunas Clinics, Eiveniu 2, 50161 Kaunas, Lithuania.
| | - A Macas
- Department of Anesthesiology, Lithuanian University of Health Sciences, Academy of Medicine, A. Mickeviciaus 9, 44307 Kaunas, Lithuania; Department of Anesthesiology, The Hospital of Lithuanian University of Health Sciences Kaunas Clinics, Eiveniu 2, 50161 Kaunas, Lithuania
| | - K Rimaitis
- Department of Anesthesiology, Lithuanian University of Health Sciences, Academy of Medicine, A. Mickeviciaus 9, 44307 Kaunas, Lithuania; Department of Anesthesiology, The Hospital of Lithuanian University of Health Sciences Kaunas Clinics, Eiveniu 2, 50161 Kaunas, Lithuania
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Poma S, Scudeller L, Verga C, Mirabile G, Gardella B, Broglia F, Ciceri M, Fuardo M, Pellicori S, Gerletti M, Zizzi S, Masserini E, Delmonte MP, Iotti GA. Effects of combined spinal-epidural analgesia on first stage of labor: a cohort study. J Matern Fetal Neonatal Med 2018; 32:3559-3565. [PMID: 29768964 DOI: 10.1080/14767058.2018.1467892] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
Abstract
Background: Neuraxial anesthesia is considered as the gold standard in the control labor of pain. Its variants are epidural analgesia and combined spinal-epidural analgesia. Few studies, as yet, have investigated the duration of labor as a primary outcome. Some authors have suggested that combined spinal-epidural analgesia may reduce labor duration but at the moment the benefit of shortening labor is uncertain. The main aim of this study was to compare combined spinal-epidural with epidural analgesia in terms of their effect on duration of stage I labor, maternal, and neonatal outcomes. Methods: A prospective cohort study was conducted. Parturients who requested analgesia at cervical dilatation <6 cm were included. Analgesia was either epidural with low concentration levobupivacaine or combined spinal epidural with subarachnoid sufentanil. The primary outcome was the length of stage I labor. Onset and quality of analgesia, mode of delivery, effects on uterine activity and use of oxytocin, fetal heart rate abnormalities and uterine hyperkinesia, maternal, and neonatal complications were also considered. Results: We enrolled 400 patients: 176 in the combined spinal-epidural group and 224 in the epidural group. Patients in the two treatment groups were similar with regard to demographic characteristics, parity, and incidence of obstetric comorbidities, labor induction, oxytocin infusion, Bishop score, and Visual Analogue Score (VAS) at analgesia request. Duration of stage I labor did not differ, at 195 (120-300) minutes for both the groups (p = .7). Combined spinal-epidural was associated with less reduction in uterine contractility after initial administration: 15.34 versus 39.73%, (p < .001) and with delayed need for oxytocin, at dilations of 7 ± 2.5 cm versus 6. ± 2.7, (p = .002). Onset of analgesia was quicker for combined spinal-epidural analgesia: 31 versus 20%, with VAS <4 after 5 minutes, (p < .001); and lower VAS scores after initial analgesia administration. No differences were found in the other outcomes. Conclusions: Combined spinal-epidural with subarachnoid sufentanil may not reduce the duration of stage I labor, but in our study it appeared to affect uterine contractility less. It also had a more rapid onset and was more effective, without any concomitant increase in maternal or neonatal complications.
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Affiliation(s)
- Silvia Poma
- a Department of Anesthesia and Intensive Care , Unit of Obstetric Anesthesia, IRCCS Policlinic San Matteo Hospital Foundation , Pavia , Italy
| | - Luigia Scudeller
- b Clinical Epidemiology and Biostatistics, Scientific Direction , IRCCS Policlinic San Matteo Hospital Foundation , Pavia , Italy
| | - Chiara Verga
- c Department of Anesthesia and Intensive Care, ASST Lecco , Presidio Ospedaliero "S.L. Mandic" , Merate , Italy
| | - Giorgio Mirabile
- d Department of Anesthesia and Intensive Care , Policlinic Tor Vergata , Roma , Italy
| | - Barbara Gardella
- e Department of Obstetrics and Gynecology , IRCCS Policlinic San Matteo Hospital Foundation , Pavia , Italy
| | - Federica Broglia
- a Department of Anesthesia and Intensive Care , Unit of Obstetric Anesthesia, IRCCS Policlinic San Matteo Hospital Foundation , Pavia , Italy
| | - Maria Ciceri
- a Department of Anesthesia and Intensive Care , Unit of Obstetric Anesthesia, IRCCS Policlinic San Matteo Hospital Foundation , Pavia , Italy
| | - Marinella Fuardo
- a Department of Anesthesia and Intensive Care , Unit of Obstetric Anesthesia, IRCCS Policlinic San Matteo Hospital Foundation , Pavia , Italy
| | - Simona Pellicori
- a Department of Anesthesia and Intensive Care , Unit of Obstetric Anesthesia, IRCCS Policlinic San Matteo Hospital Foundation , Pavia , Italy
| | - Maddalena Gerletti
- a Department of Anesthesia and Intensive Care , Unit of Obstetric Anesthesia, IRCCS Policlinic San Matteo Hospital Foundation , Pavia , Italy
| | - Silvia Zizzi
- a Department of Anesthesia and Intensive Care , Unit of Obstetric Anesthesia, IRCCS Policlinic San Matteo Hospital Foundation , Pavia , Italy
| | - Elena Masserini
- a Department of Anesthesia and Intensive Care , Unit of Obstetric Anesthesia, IRCCS Policlinic San Matteo Hospital Foundation , Pavia , Italy
| | - Maria Paola Delmonte
- a Department of Anesthesia and Intensive Care , Unit of Obstetric Anesthesia, IRCCS Policlinic San Matteo Hospital Foundation , Pavia , Italy
| | - Giorgio Antonio Iotti
- a Department of Anesthesia and Intensive Care , Unit of Obstetric Anesthesia, IRCCS Policlinic San Matteo Hospital Foundation , Pavia , Italy
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Affiliation(s)
- Cynthia A Wong
- From the Department of Anesthesia, University of Iowa Carver College of Medicine, Iowa City, Iowa
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Abstract
The availability of safe, effective analgesia during labor has become an expectation for women in most of the developed world over the past two or three decades. More than 60% of women in the United States now receive some kind of neuraxial procedure during labor. This article is a brief review of the advantages and techniques of neuraxial labor analgesia along with the recent advances and controversies in the field of labor analgesia. For the most part, we have aimed the discussion at the non-anesthesiologist to give other practitioners a sense of the state of the art and science of labor analgesia in the second decade of the 21st century.
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Affiliation(s)
- Marie-Louise Meng
- Department of Anesthesiology, Columbia University Medical Center, New York, NY, USA
| | - Richard Smiley
- Department of Anesthesiology, Columbia University Medical Center, New York, NY, USA
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