Obstetric analgesia - update 2016

Combined spinal-epidural analgesia and epidural analgesia induced maternal fever with a similar timing during labor-A randomized controlled clinical trial

Background

Both epidural and combined spinal-epidural (EA and CSEA) analgesia can induce intrapartum maternal fever. CSEA has a more rapid onset and wider nerve block than EA. Therefore, CSEA might have a different profile of intrapartum maternal fever, including higher temperatures or earlier occurrence. This randomized clinical trial was to determine whether CSEA could cause maternal fever earlier than EA.

Methods

A randomized, double-blind, controlled clinical trial was performed on 233 nulliparous full-term pregnant women during vaginal delivery. The pregnant women were randomly allocated into the EA group (n = 113) and the CSEA group (n = 120). The fever latent period, from analgesia start to fever occurrence, was the primary endpoint in this study. The temperature was measured every 30 min using an eardrum thermometer during labor analgesia. The fever was defined as an eardrum temperature of ≥38 °C.

Results

No difference was found in the maternal fever rate between the EA and the CSEA groups (10/113 vs. 7/120, P = 0.356). There was no significant difference in the fever latent period between the two groups (4.75 ± 0.86 h vs. 3.79 ± 2.2 h, p = 0.305). The temperatures at all points had no differences between EA and CSEA.

Conclusion

CSEA had a similar latent fever period as EA. A further study is warranted to confirm the similar characteristic between CSEA and EA in the development of intrapartum maternal fever.

Clinical trial registration

www.chictr.org.cn, identifier ChiCTR2000038793.

Utilization of Obstetric Analgesia for Labor Pain Management and Associated Factors among Obstetric Care Providers in Public Hospitals of Addis Ababa, Ethiopia: A Cross-Sectional Study

BACKGROUND

In low-income countries, pain-free labor initiative is an emerging concept and still parturient undergoes through painful labor; this is not different in Ethiopia; despite the national direction to use analgesia for labor pain and strong demand from the women, evidence on utilization of obstetric analgesia for labor pain management in Ethiopia is scarce. The objective of this study was to assess level of obstetric analgesia utilization and associated factors among obstetric care providers in public hospitals in Addis Ababa, Ethiopia.

METHODS

An institution-based cross-sectional study was used. All obstetric care providers working in labor and delivery units in public hospitals in Addis Ababa were included. The data were collected using a self-administered structured questionnaire. After checking for completeness, data were entered into Epi-data 3.1 and analyzed using SPSS 20. Bivariate and multivariable logistic regressions were used to identify factors associated with utilization of obstetric analgesia.

RESULT

Of 391 obstetric care providers included in the study, 143 (36.6%; 95% CI: 31.5-40.9%) reported providing labor analgesia. Having adequate knowledge (AOR 2.7; 95% CI: 1.37-5.23), ten and more years of work experience (AOR 4.3; 95% CI: 1.81-10.13), and availability of analgesics (AOR 3.3; 95% CI: 1.99-5.53) were significantly associated with providing labor analgesia.

CONCLUSION

Slightly more than 3 in 10 obstetric care providers reported providing labor analgesics to women. Training of providers and ensuring adequate supply of analgesics is required to make sure that women in labor would not suffer from labor pain.

The Trend of Labor Analgesia in the World and China: A Bibliometric Analysis of Publications in Recent 30 Years

Purpose

Labor analgesia is part of the most important tasks an anesthesiologist needs to deal with. With the “two-child policy” in China, the number of parturients has increased significantly, labor analgesia more should be valued. There has been a tremendous change on labor analgesia research in China and around the world; however, broader trends in the prevalence and scope of labor analgesia research remain underexplored. The current study quantitatively analyzes trends in labor analgesia research publications in the past 30 years.

Methods

A bibliometric approach was used to search Scopus, PubMed, Web of Science and the China National Knowledge Infrastructure for all labor analgesia-related research articles. The research progress and growing trend were quantitatively analyzed by total publications, research types, research institutions, journal impact factors, and author’s contribution. Total citations frequency, average citations per item and h-index were used for evaluating literature quantity.

Results

From 1988 to 2018, over 8000 documents in labor analgesia research field were published worldwide. According to Scopus, 68.2% papers of all documents were articles. The USA published the largest number of articles (2204, 27.45%). China had published 175 articles (2.18%), ranking the 11th. According to WOS, there were 221 research categories for labor analgesia articles all over the world. The total citations were 76,207, average 9.086 citations per item, and the h-index was 114, average 14 citations per item worldwide. The total citations and h-index of papers published in China were as follows: 353 total citations, 7.06 citations per item, and 10 h-index. High contribution journals, authors, institutions and the top 10 most cited articles on labor analgesia in the world and China were also listed.

Conclusion

Labor analgesia research has grown markedly during the 1988–2018 period. Although China had made remarkable achievements, there was a gap in the high-quality studies between China and other leading countries.

Spinal and epidural sufentanil and fentanyl in early labour

BACKGROUND AND AIM

The analgesic effect on labour pain of either spinal or epidural sufentanil or fentanyl was tested in a total of 80 primiparous parturients at an early phase of the delivery. The aim of the study was to compare the level of analgesia achieved within 20 minutes.

METHODS

The parturients were randomly assigned to groups receiving either spinal sufentanil (5 µg), epidural sufentanil (20 µg), spinal fentanyl (20 µg) or epidural fentanyl (100 µg), whereafter the parturients were monitored for reported pain during contraction and side effects for 30 minutes. The primary outcome was the level of analgesia achieved within 20 minutes, while the secondary outcome was the time until the administration of the first epidural bolus.

RESULTS

At baseline, the mean maximum pain VAS was 86 (84-89) mm. At 20 minutes after spinal sufentanil, epidural sufentanil, spinal fentanyl or epidural fentanyl, the maximum VAS was 19 (7-31), 45 (32-59), 25 (10-39) or 52 (40-63) mm, respectively (P < .01 spin vs epid groups). There were no differences in efficacy between spinal or epidural sufentanil and fentanyl. The mean (95% CI) time to the activation of epidural analgesia was 151 (111-192), 130 (93-168), 177 (121-234) and 112 (80-143) minutes after spinal sufentanil, epidural sufentanil, spinal fentanyl and epidural fentanyl, respectively.

CONCLUSIONS

In terms of a reduction of VAS score at 20 minutes, epidural sufentanil or fentanyl provide 63% and 60% of the analgesic effect of the corresponding spinal analgesia. Epidural sufentanil or fentanyl could be used in situations in which spinal/CSE administration is not possible or desired.

Managing pain and anxiety during transabdominal chorionic villus sampling. A noninferiority randomized trial of nitrous oxide vs local anesthesia

INTRODUCTION

Transabdominal chorionic villus sampling (CVS) is an invasive procedure for prenatal diagnosis reported to be associated with anxiety and pain. In this context, the need for analgesia during CVS has been considered useful. Even though several authors have been interested in pain management during amniocentesis, no study has been published on pain reduction during CVS. Our objective was to evaluate pain and anxiety management during transabdominal CVS using nitrous oxide (N₂ O) and local anesthesia.

MATERIAL AND METHODS

In a randomized controlled noninferiority trial, self-administered nitrous oxide (N₂ O) inhalation (equimolar premix of oxygen and nitrous oxide) was compared with local anesthesia (1% lidocaine) before CVS. Primary outcome was pain and secondary outcome was anxiety, both measured on a visual analog scale 30-60 minutes before, immediately after (5-10 minutes) and 30-60 minutes after CVS. With a statistical power of 90%, type I error of 5% and two-sided test and potential exclusions, a sample size of 96 patients per group was enrolled and randomized. No patient was enrolled before the trial registration date.

RESULTS

From 13 March 2013 through 10 February 2015, 192 patients (96 per group) were screened and randomized. Most characteristics were similar across groups. Pain in the N₂ O group was 2.65 ± 0.22 vs 3.32 ± 0.26 in local anesthesia group [mean ± standard error of mean  (SEM)]. Mean anxiety in the N₂ O group was 3.17 ± 0.27 vs 5.19 ± 0.30 in the local anesthesia group.

CONCLUSION

N₂ O was as efficient and even superior to local anesthesia for both pain and anxiety reduction during CVS, as the 95% confidence intervals were both below the prespecified noninferiority margin of 0.8 and below zero.

Effect of pre-administration with aminophylline on the occurrence of post-dural puncture headache in women undergoing caesarean section by combined spinal-epidural anaesthesia

Objective

To investigate the effect of the pre-administration with aminophylline on the occurrence of post-dural puncture headache (PDPH) in women undergoing caesarean section by combined spinal-epidural anaesthesia (CSEA).

Methods

The study enrolled women undergoing elective caesarean sections with CSEA and randomly allocated them into two groups; for 30 min immediately after the infant was delivered, group A received 250 mg aminophylline intravenously and group B received an equal volume of normal saline. Demographic data, operation time, intraoperative blood loss, intraoperative transfusion volume and the occurrence of PDPH during the first 7 days after the operation were recorded. Side-effects such as hypersensitivity, convulsion and arrhythmia were also recorded in the patients and infants in group A within 24 h after aminophylline administration.

Results

A total of 120 patients aged 24–38 years (pregnancy range, 38–42 weeks) were randomly allocated into two groups (n = 60). The incidence of PDPH in group A was significantly lower than group C (two of 59 [3.4%] versus 10 of 58 [17.2%], respectively). There were no related side-effects within 24 h after aminophylline administration in group A.

Conclusions

Intraoperative intravenous infusion of 250 mg aminophylline reduced the incidence of PDPH after caesarean section under CSEA with no side-effects.