Labour analgesia: Recent advances

Knowledge, Attitude, and Practices of Labor Analgesia Amongst Obstetric Residents: A Cross-Sectional Survey

BACKGROUND

Labor analgesia plays a crucial role in ensuring a comfortable and positive birthing experience. It provides physiological benefits to both the mother and the child. Knowledge, awareness, and communication between the anesthesiologist and the obstetrician are essential for the safe conduct of labor analgesia. We conducted this cross-sectional online survey amongst obstetric residents to assess their knowledge, attitude, and practices of labor analgesia.

METHODS

A structured questionnaire consisting of 19 questions was circulated amongst obstetric residents of various hospitals via electronic mode of communication. The responses were analyzed using statistical methods.

RESULTS

Among the obstetric residents that we surveyed, 75.7% of them only sometimes employed labor analgesia for their patients. The most commonly employed methods of pain relief are opioids and non-steroidal anti-inflammatory drugs (NSAID). Most of them feel that pain-free labor is necessary because it makes the whole labor process a pleasurable one. Labor analgesia was mostly advocated at patients' request and demand. The barrier to using labor analgesia was most commonly found to be the non-availability of labor analgesia services.

CONCLUSION

Despite the increasing awareness of labor analgesia there still lies a gap between the attitude toward it and the practice of it. Further education to rectify the misconceptions and barriers needs to be taken for providing beneficial services to pregnant females.

Comparison of Two Different Doses of Nalbuphine With Isobaric Ropivacaine in Patients Undergoing Lower Segment Cesarean Section Under Subarachnoid Block: A Randomized Controlled Trial

INTRODUCTION

Obstetric analgesia and anesthesia is a challenge in itself. It requires an understanding of the physiological changes during pregnancy and labor and the effect of anesthetic agents on the fetus and newborn. Because neuraxial techniques provide superior analgesia and materno-fetal benefits, their use have increased significantly over the past three decades or so. A combination of local anesthetics like ropivacaine with opioids like nalbuphine has been shown to have additive beneficial effects in subarachnoid block (SAB) in lower segment cesarean section (LSCS). However, the optimal dose combination of ropivacaine and nalbuphine to maximize their benefits and minimize side effects remains to be established. Our study has compared the clinical efficacy and safety of 0.75% isobaric ropivacaine (15 mg) with two different doses of nalbuphine (0.4 mg and 0.6 mg) when given intrathecally for LSCS in terms of quality of sensory and motor blocks, hemodynamic parameters, duration of effective analgesia, Apgar score in newborn, and associated side effects.

METHOD AND MATERIALS

In this prospective, randomized, double-blind study, a total of 69 parturients between the age of 20-45 years, belonging to American Society of Anesthesiologists (ASA) grade I and II, undergoing cesarean section under SAB were evaluated. Patients were randomly allocated into three groups of 23 each by using the draw-of-lots technique. The patient and the observer were kept blinded as to which dose of drug (intrathecal) was being given to the patient. Patients in Group A received 0.75% isobaric ropivacaine 15 mg (2 ml) + 0.3 ml normal saline; patients in Group B received 0.75% isobaric ropivacaine 15 mg (2 ml) + 0.4 mg of nalbuphine (0.2 ml) + 0.1 ml normal saline; patients in Group C received 0.75% isobaric ropivacaine 15 mg (2 ml) + 0.6 mg of nalbuphine (0.3 ml). The total volume of drug solution in all three groups was 2.3 ml.

RESULT

 We found that the time to onset of sensory block was shortest in Group A (5.87±1.290 minutes) followed by Group C (6.00±1.087 minutes) and Group B (6.17±1.696 minutes); time to two-segment regression of sensory block was longest in Group C (101.74±8.996 minutes) followed by Group B (85.87±15.348 minutes) and Group A (65.00±7.071 minutes); duration of effective analgesia was longest in Group C (206.09±18.766 minutes) followed by Group B (183.91±15.880 minutes) and Group A (121.74±11.833 minutes); and time from SAB to complete regression of motor block was longest in Group C (216.52±15.553 minutes) followed by Group B (203.48±20.138 minutes) and Group A (174.78±14.731 minutes). Side effects were comparable among all three groups.

CONCLUSION

The optimal dose combination in SAB for cesarean section was 15 mg of 0.75% isobaric ropivacaine + 0.6 mg nalbuphine, with minimal side effects.

Comparison of intravenous paracetamol infusion versus intramuscular tramadol as labor analgesia: a randomized control trial

PURPOSE

Labor pain is one of the most agonizing pains experienced by all delivered women. Many pharmacological agents used in labor analgesia require intense monitoring facilities, which are not available in routine obstetric practice in low-resource settings. This study aimed to compare the efficacy of intravenous (IV) paracetamol and intramuscular (IM) tramadol on labor pain relief, labor progression, and maternal and neonatal outcomes.

METHODS

This randomized drug trial was carried out on 110 women divided into two groups. Group A women received 1000 mg of IV paracetamol, and Group B women received 100 mg of IM tramadol during the active phase of labor. Pain intensity was assessed by the Visual Analogue Scale (VAS) at intervals till 120 min of delivery. The maternal and neonatal outcomes were recorded.

RESULTS

There was a statistically significant fall in pain score till 180 min of drug administration in the paracetamol group and 120 min in the tramadol group. At 180 min and 240 min, paracetamol is more effective than tramadol (p value 0.004 at 180 min and 0.0119 at 240 min). There were significantly low pain score levels at 60 min of delivery in the paracetamol group (p value-0.004). Nausea and vomiting were significantly higher in the tramadol group (p value 0.000013).

CONCLUSION

Compared to IM tramadol, IV paracetamol has a longer duration of action and fewer maternal side effects, making it suitable for parenteral analgesia in labor. Due to a better safety profile, there is no need for intense maternal and fetal monitoring with IV paracetamol.

TRIAL REGISTRATION

Clinical Trials Registry-India (CTRI registration number-CTRI /2019/05/019244).

The Effect of Painless Delivery with Intrathecal Sufentanil on Labor Progress and Neonatal Outcomes: A Single Center Study on Pregnant Women

Background

Delivery pain is the most unbearable pain and can be relieved with intrathecal opioids. This study aimed to investigate the effect of intrathecal sufentanil for painless delivery on labor progress and neonatal outcomes in pregnant women.

Methods

This was a single-arm observational cohort study on 1055 pregnant women candidates for vaginal delivery with spinal analgesia referred to the Akbarabadi Hospital. First, 0.1 µg/kg of intrathecal sufentanil was used, and maternal blood pressure and maternal and fetal heart rates were recorded after analgesia. During delivery, the mothers were monitored for nausea, pruritus, motor block, apnea, urinary retention, or the possibility of an emergency cesarean section. The duration of the analgesia, the duration of the second stages of labor, and the mother's pain scores were recorded based on the Visual Analogue Scale (VAS). 1- and 5-minute Apgar scores and arterial blood gas (ABG) of the umbilical cord were also recorded.

Results

The most common station was -3 for 723 women, followed by -2 for 229 women. Fifty-two women underwent cesarean section, and fetal distress was the most common reason for cesarean section (57.7%). The mean time for initiating analgesia was 5.93 ± 2.87 minutes, and the mean visual analog scale was 1.08 ± 0.16. The mean Apgar was 9.0 ± 0.47; the mean weight at birth was 2917.39 ± 449.90 gr; PH was 7.31 ± 2.03; HCO₃ was 22.67 ± 3.08mEq/liter, and PaCo₂ was 43.36 ± 7.06 mmHg. Regarding complications, the patients just developed itching (n = 78), and hypotension, bradycardia, apnea, and decreased consciousness were overlooked.

Conclusions

Intrathecal sufentanil is safe and efficient in painless delivery, resulting in normal Apgar and normal PH with no specific side-effect.

Intralipid fails to rescue bupivacaine-induced cardiotoxicity in late-pregnant rats

Background

Females routinely receive bupivacaine for obstetric and regional anesthesia. An accidental overdose of bupivacaine can result in cardiotoxicity and cardiac arrest. Intralipid (ILP) rescues bupivacaine-induced cardiotoxicity in male rats. However, bupivacaine cardiotoxicity and ILP rescue have not been studied in non-pregnant and late-pregnant female rats. Here, we tested the hypothesis that an appropriate dose of ILP would rescue non-pregnant and late-pregnant rats from bupivacaine-induced cardiotoxicity.

Methods

Non-pregnant (n = 6) and late-pregnant (n = 7) female rats received intravenous bupivacaine (10-mg/kg bolus) to induce asystole. Resuscitation with 20% ILP (5-ml/kg actual body weight, single bolus, and 0.5-ml/kg/min maintenance) and chest compressions were continued for 10-min. Serial heart rate (HR), left ventricular ejection-fraction (LVEF%), and LV-fractional shortening (LVFS%) were recorded at baseline and 10-min after bupivacaine-induced cardiac arrest. Data are mean ± SD followed by 95% CI. P-values < 0.05 were considered statistically significant.

Results

All rats developed cardiac arrest within a few seconds after bupivacaine. All non-pregnant rats were successfully rescued by ILP, with a HR of 280 ± 32 bpm at baseline vs. 212 ± 18 bpm at 10-min post ILP (p < 0.01), LVEF of 70 ± 6% vs. 68 ± 5% (p = ns), and LVFS of 41 ± 5% vs. 39 ± 4% (p = ns). Interestingly, 6 out of 7 late-pregnant rats did not recover with ILP. Baseline HR, LVEF and LVFS for late-pregnant rats were 330 ± 40 bpm, 66 ± 5% and 38 ± 4%, respectively. At 10-min post ILP, the HR, LVEF, and LVFS were 39 ± 102 bpm (p < 0.0001), 8 ± 22% (p < 0.0001), and 5 ± 12% (p < 0.001), respectively.

Conclusions

ILP successfully rescued bupivacaine-induced cardiac arrest in non-pregnant rats, but failed to rescue late-pregnant rats.

Analgesic effects of sterile water injection in the management of low back pain during labor: A systematic review and meta-analysis

BACKGROUND

Sterile water injections (SWIs) as a non-pharmacologic and cost-effective method have been adopted to relieve low back labor pain (LBLP).

OBJECTIVE

To compare the efficacy of intradermal and subdermal SWIs in the treatment of LBLP.

SEARCH STRATEGY

Three databases (PubMed, Cochrane Library, and ScienceDirect) were searched to find relevant articles using two terms, "labor" and "sterile water".

SELECTION CRITERIA

Studies reporting women with LBLP treated by intradermal or subdermal SWIs in the low back area were included.

DATA COLLECTION AND ANALYSIS

Mean differences with 95% confidence interval (CI) and relative risk with 95% CI were used to estimate VAS score and cesarean section rate, respectively.

MAIN RESULTS

Except for 10 min, the patients in the intradermal or subdermal SWI group experienced considerable pain reduction compared with the control group for 30-45, 60, and 90 min. Directly comparing intradermal and subdermal SWI groups, the subdermal injection group had significantly better pain relief than the intradermal injection group only at 10 min after treatment.

CONCLUSIONS

Both intradermal and subdermal SWIs could reduce LBLP at 30-90 min. The subdermal SWI had significantly better LBLP relief than the intradermal injection only at 10 min after treatment.

Pharmacologic and non-pharmacologic labor pain management techniques in a resource-limited setting: A systematic review

Background

Despite improvement in pain management programs, labor pain is mostly ignored especially in low and middle-income countries.

Methods

The aim of this study is to establish a clear clinical working guideline for labor pain management in resource limited settings. This systematic review is conducted in line with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guideline 2020. After formulating clear criteria for the evidences to be included an appropriate method of searching was conducted by using the Pub Med, Google scholar and Cochrane library using the following MeSH terms: (‘Parenteral opioids’ AND′ Labor pain’, ‘Labor’ AND ‘Pain management, ‘Non-pharmacologic methods ‘AND ‘Labor pain’, ‘Labor pain management AND massage therapy). The study quality of literatures was categorized based on WHO 2011 level of evidence and degree of recommendation. Final conclusions and recommendations are done with the analysis of risk and benefits of alternative management strategies for non-regional techniques of labor pain management. The study is registered with research registry unique identifying number (UIN) of 1267 “https://www.researchregistry.com/browse-the-registry#registryofsystematicreviewsmeta-analyses/.” and the study is moderate based on AMSTAR 2 quality assessment criteria/https://amstar.ca/Amstar_Checklist.php.

Discussion

Combined forms of Non-pharmacologic and selected low dose pharmacologic approaches of labor pain management, provides significant benefits to women and their infants. During provision of labor analgesia complications may happen and the service provider should involve in the management of those complications.

Conclusion

This study has a paramount importance to practice the most reliable, available and cost effective method of labor analgesia.

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Appropriate history and physical examinations are crucial to avoid contraindicated medications in labor pain managment.

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Combined non-pharmacologic methods with a lower dose of indicated drugs provides significant advantages for both mothers and their infants.

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Using available and cost effective labor pain managment with minimal complications has paramount importance in resource limited setting.

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During provision of labor analgesia service provider should aware of complications to intervene at theright time.

Comparative evaluation of intrathecal dexmedetomidine and fentanyl as an adjuvant for combined spinal–epidural analgesia for labor

Background:

Combined spinal–epidural technique is a widely accepted and popular modality for labor analgesia. Opioids are being used as adjuvants since long time. Dexmedetomidine is a new drug that is being used as an intrathecal adjuvant.

Aim:

The study aims to compare the safety and efficacy of fentanyl and dexmedetomidine as intrathecal adjuvants in labor analgesia.

Settings and Design:

This was a continuous, prospective, randomized controlled trial with 120 parturients.

Materials and Methods:

After ethical approval and written consent, participants were divided randomly into two groups: Group A – bupivacaine 2.5 mg (0.5 mL diluted to 2 mL) + 20 μg of dexmedetomidine in 1 mL saline intrathecally (total volume: 3 mL) and Group B – bupivacaine 2.5 mg (0.5 mL diluted to 2 mL) + 15 μg of fentanyl in 1 mL saline intrathecally (total volume: 3 mL). Primary outcomes were satisfactory analgesia, mode of delivery, and neonatal outcome. Participants were monitored for the onset and duration of analgesia, degree of motor block, and maternal and fetal side effects.

Results:

A total of 108 parturients reported sufficient analgesia (Group A: 57; Group B: 51), and 74 patients delivered vaginally (Group A: 41; Group B: 44). The rates of normal vaginal delivery were higher in Group B. Group A reported earlier onset of analgesia (61.26 ± 18.23 s) that lasted for longer duration (124.16 ± 26.23 min) than in Group B. There were no serious side effects in any of the groups. Fetal ultrasound revealed attenuation of fetal heart rate variability. The heart rate of newborns was also found to be low in Group A.

Conclusion:

Chances of vaginal delivery are higher with intrathecal fentanyl as an adjuvant. Intensity and duration of analgesia are better with intrathecal dexmedetomidine.

The Effect of Pethidine Analgesia on Labor Duration and Maternal-Fetal Outcomes

Background and Aim:

Opioid analgesics had been used from time to time for treating labor pain. However, their use have been concerning. The aim of this study is to evaluate the effect of pethidine on duration of active phase of labor, labor pain and maternal-neonatal outcomes.

Methods:

In the present case-control study, the study group received a 50 mg pethidine intramuscular injection upon the start of active phase of labor, and the control group consisted of patients who receive placebo injeciton. In both groups, vital signs were measured before, and at 0, 5, 15, 30, 45 and 60 minutes after the injection. Pain intensity was evaluated with Visual Analogue Scale (VAS) prior to, and 1 hour and 2 hours after injection. Data regarding labor phase durations, maternal side effects, newborn APGAR scores and fetal respiratory problems were recorded.

Results:

102 patients in Pethidine group and 92 patients in control group, were included into the study. Labor pain VAS-scores were significantly lower in the study group (p<0.001). Moreover, active phase of labor duration was significantly shorter in the study group (p<0.001). Maternal pulse significantly decreased, and maternal nausea-vomiting was frequent in the study groups. However, the groups were similar in terms of other side effects and neonatal outcomes.

Conclusions:

Pethidine significantly reduces active phase of labor duration, has a favorable analgesic effect in treating labor pain and is not associated with serious maternal or neonatal complications. It is therefore considered an acceptable agent for use during active phase of labor. (www.actabiomedica.it)

Obstetric anaesthesia as a career

Obstetric anaesthesia is emerging as one of the most demanding subspecialities of anaesthesia. Obstetric anaesthesiologists are now an integral part of the multidisciplinary team managing the high-risk obstetrics. It has been recognised that targeted training in obstetric anaesthesia helps to recognise the mothers who need special care and formulate specific plan for delivery. Among the subspecialties of anaesthesia, obstetric anaesthesia has the potential to get established early. Obstetric anaesthesiologists have the prospect of choosing either a team or an independent practice. Group practice with a multidisciplinary team can mitigate some of the constraints and allows professional fulfilment and enough time for personal, family and societal commitments. Obstetric anaesthesia is a well-paid and sought-after speciality, and a dynamic field that demands excellent clinical and interpretative skills in a rapidly changing environment.

Evaluating the effectiveness of TENS for maternal satisfaction in laboring parturients - Comparison with epidural analgesia

Background and Aims:

Labor pain is one of the most severe pain that a woman experiences in her lifetime. Various methods are being used to relieve this pain and to achieve higher maternal satisfaction. One such technique is transcutaneous electrical nerve stimulation (TENS) that uses low-frequency electrotherapy. The aim of our study was to evaluate TENS by comparing it to an established labor analgesia technique, i.e., epidural analgesia in terms of maternal satisfaction.

Material and Methods:

This prospective study was conducted on 60 parturients in active stage of labor. The choice of analgesia was made by the parturient after informed consent. In group A (n = 30) TENS was used, while in group B (n = 30) epidural ropivacaine 0.125% + 2 μg/ml fentanyl was given. Continuous monitoring of maternal vitals, visual analogue score, and fetal heart rate (FHR) was done. Maternal satisfaction was scored considering pain relief, ability to move and experience of labor at the end of delivery and outcome was labeled as favorable and unfavorable.

Results:

TENS was found to be favorable in 90% of parturients as compared to 96.6% in epidural (P 0.301). The number of highly satisfied parturients was 4 (13.3%) in TENS group and 17 (56.6%) in the epidural group (P= 0.000). Three patients in the epidural group had assisted delivery and two had cesarean section whereas all patients in TENS group delivered normally (P= 0.065). No significant difference was found in the fetal outcome.

Conclusions:

TENS is a good alternate choice for providing labor analgesia and may have a major role in future.

Strategies for Developing κ Opioid Receptor Agonists for the Treatment of Pain with Fewer Side Effects

There is significant need to find effective, nonaddictive pain medications. κ Opioid receptor (KOPr) agonists have been studied for decades but have recently received increased attention because of their analgesic effects and lack of abuse potential. However, a range of side effects have limited the clinical development of these drugs. There are several strategies currently used to develop safer and more effective KOPr agonists. These strategies include identifying G-protein-biased agonists, developing peripherally restricted KOPr agonists without centrally mediated side effects, and developing mixed opioid agonists, which target multiple receptors at specific ratios to balance side-effect profiles and reduce tolerance. Here, we review the latest developments in research related to KOPr agonists for the treatment of pain. SIGNIFICANCE STATEMENT: This review discusses strategies for developing safer κ opioid receptor (KOPr) agonists with therapeutic potential for the treatment of pain. Although one strategy is to modify selective KOPr agonists to create peripherally restricted or G-protein-biased structures, another approach is to combine KOPr agonists with μ, δ, or nociceptin opioid receptor activation to obtain mixed opioid receptor agonists, therefore negating the adverse effects and retaining the therapeutic effect.

Epidural analgesia for labour pain in nulliparous women in Norway in relation to maternal country of birth and migration related factors

OBJECTIVE

To investigate associations between maternal country of birth and other migration related factors (length of residence, reason for migration, paternal origin) and epidural analgesia for labour pain in nulliparous women in Norway.

DESIGN

Population-based register study including nulliparous migrant women (n = 75,922) and non-migrant women (n = 444,496) with spontaneous or induced labour. Data were retrieved from the Medical Birth Registry and Statistics Norway, 1990-2013. Odds ratios (OR) with 95% confidence intervals (CI) were estimated by logistic regression, and adjusted for maternal age, marital status, maternal education, gross income, birth year, hospital size and health region.

MAIN OUTCOME

Epidural analgesia for labour pain.

RESULTS

Epidural analgesia was administered to 38% of migrant women and 31% of non-migrant women. Compared with non-migrants, the odds of having epidural analgesia were lowest in women from Vietnam (adjOR 0.54; CI 0.50-0.59) and Somalia (adjOR 0.63; CI 0.58-0.68) and highest in women from Iran (adjOR 1.32; CI 1.19-1.46) and India (adjOR 1.19; CI 1.06-1.33). Refugees (adjOR 0.83; CI 0.79-0.87) and newly arrived migrants (adjOR 0.92; CI 0.89-0.94) had lower odds of epidural analgesia. Migrant women with a non-migrant partner (adjOR 1.14; CI 1.11-1.17) and those with length of residence ≥10 years (adjOR 1.06; CI 1.02-1.10) had higher odds.

CONCLUSION

The use of epidural analgesia varied by maternal country of birth, reason for migration, paternal origin and length of residence. Midwives and obstetricians should pay extra attention to the provision of adequate information about pain relief options for refugees and newly arrived migrants, who had the lowest use.

Comparative Analgesic Effects of Intradermal and Subdermal Injection of Sterile Water on Active Labor Pain

Background

The labor pain is one of the factors encouraging pregnant women for cesarean section delivery. Recently, intradermal and subdermal injection of distilled water has shown to be effective in improving this pain.

Objectives

The present study aimed to determine which method has a greater impact on labor pain reduction.

Methods

In this double-blind, randomized clinical trial, 121 nulliparous women with a gestational age of ≥ 37 weeks were randomly divided into three groups: (1) 0.5 cc sterile water injection subdermally at four sacral points with insulin needles (n = 40); (2) 0.5 cc sterile water injection intradermally (n = 39); and (3) needle contact with the mentioned points as the placebo (n = 42). Before the intervention, the VAS score was measured for labor pain, and it was repeated 10, 30, 60, and 90 min after the intervention. The results were compared between the three groups.

Results

Before the intervention, the mean VAS pain score had no significant difference between the three groups. However, 30, 60, and 90 min after the intervention, the mean pain score was significantly lower in the intradermal and subdermal injection groups than in the control group (P = 0.001); however, the difference between the intradermal and subdermal injection groups was not significant.

Conclusions

The injection of distilled water by either intradermal or subdermal method was associated with a significant reduction in the pain score during labor, but there was no difference between these two methods in terms of decreasing labor pain. As sterile water injection is a safe, effective, and low-cost method, it is proposed to increase the knowledge of midwives and obstetricians about this method.

Epidural levobupivacaine versus a combination of levobupivacaine and dexamethasone in patients receiving epidural analgesia

Background and Aims

The use of dexamethasone as an adjuvant to local anesthetic rarely has been described. Some studies have demonstrated the analgesic effect of local spinal and systemic corticosteroids in combination with bupivacaine. It works by decreasing inflammation and blocking transmission of nociceptive C-fibers and by stopping the ectopic discharge of the nerve. The aim of this randomized controlled trial was to compare the efficacy of epidural levobupivacaine alone versus a combination of levobupivacaine with dexamethasone for labor analgesia.

Material and Methods

This prospective double-blind trial included the 60 primigravidas during vaginal delivery with a cervical dilatation ≥4 cm and 50% effacement randomly assigned to one of two groups - Group A (n=30): epidural levobupivacaine 0.125% in normal saline in a total volume of 15 mL and Group B (n=30): epidural levobupivacaine 0.125% in normal saline combined with dexamethasone 4 mg in a total volume of 15 mL. At first request of analgesia, 10 mL of 0.125% levobupivacaine was administrated through epidural catheter. Further analgesia was provided with 8 mL of 0.125% levobupivacaine hourly. Primary outcome measure was the duration of epidural analgesia. Secondary outcome measures include pain score by Visual Analog Scale score before the block and 15 min following it, the total amount of levobupivacaine used, Apgar score and umbilical vein blood gas analysis, maternal satisfaction, and side effects recorded.

Results and Conclusion

The duration of epidural analgesia was significantly longer (P < 0.05) upon adding dexamethasone to levobupivacaine. Total epidural levobupivacaine consumption was significantly lower (P = 0.05) in Group B. There were no statistical differences between the two groups regarding hemodynamics, pain score, neonatal outcome, and complications. Epidural dexamethasone plus levobupivacaine prolongs the duration of epidural analgesia during management of labor pain with hemodynamic stability and limited maternal and neonatal adverse effects.

Pethidine in Low Doses versus Dipyrone for Pain Relief in Labor: A Randomized Controlled Trial

OBJECTIVE

 To compare low doses of pethidine with dipyrone in labor analgesia.

METHODS

 In a randomized prospective study conducted by Universidade de Fortaleza, in the state of Ceará, Brazil, between May and December 2016, 200 full-term parturients, with very painful uterine contractions and exhibiting uterine cervix dilatation ≥ 5 cm, were selected to receive a single intravenous dose of either 0.25 mg/kg of pethidine (n = 100) or of 25 mg/kg of dipyrone (n = 100). Pain was assessed using the visual analogue scale. The data were analyzed using the Student t-test, the chi-square test and the likelihood ratio.

RESULTS

 There was a significant improvement in pain in 35% of the parturients. Both drugs presented a similar analgesic effect 1 hour after the intervention (p = 0.692). There was no analgesic effect during the evaluation of the second hour after the intervention with pethidine or dipyrone. There were no adverse effects, such as maternal drowsiness, nausea or vomiting, related to the drugs used.

CONCLUSION

 Pethidine in low doses and dipyrone presented equivalent analgesia during labor.

PUBLIC REGISTRY OF CLINICAL TRIALS

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Can Epidural Dexamethasone Reduce Patient-Controlled Epidural Consumption of Fentanyl and Levobupivacaine in Laboring Women? A Double-Blind, Randomized, Placebo-Controlled Trial

Background

The efficacy of a single bolus dose of epidural dexamethasone added to levobupivacaine-fentanyl combination for labor analgesia has not been studied. In this randomized double-blind controlled trial, we assessed the effect of epidural dexamethasone in reducing the hourly average consumption of epidural levobupivacaine-fentanyl combination in laboring parturients and to study its effect on pain score, maternal satisfaction, maternal and neonatal outcome.

Methods

Sixty adult ASA I-II single-gestation full-term primigravid laboring parturients with cervical dilation ≤ 5 cm were randomly assigned to two equal-sized groups. Combined spinal-epidural block was performed in all the parturients. After placing the epidural catheter in epidural space, 8 mg of preservative-free dexamethasone was administered to the dexamethasone group, and 0.9% saline to the placebo group. All parturients received continuous background infusion of 5 ml of 0.1% levobupivacaine with 2 μg/ml of fentanyl with the provision of patient-controlled bolus of 5 ml of 0.1% levobupivacaine with 2 μg/ml of fentanyl (lockout interval 15 min). The primary outcome measure was the hourly total consumption of levobupivacaine-fentanyl mixture. The secondary outcome measures were maternal satisfaction, pain score, maternal hemodynamic parameters, fetal heart rate, duration of second stage of labor, mode of delivery, Apgar scores and adverse effects.

Results

Hourly drug consumption and hourly bolus requirement were significantly lower in the dexamethasone group than placebo group (6.97 ml ± 1.22 vs. 8.40 ml ± 2.59 and 0.41 ± 0.26 vs. 0.72 ± 0.55, respectively, P = 0.008 for both). There were no significant differences in other outcome measures.

Conclusion

Epidural dexamethasone significantly decreased average hourly drug consumption and the number of boluses in laboring parturients, thus providing epidural drug dose-sparing effect.

Neuraxial techniques of labour analgesia

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.

Practice of Labor Analgesia among Anesthesiologists Across India: Cross-sectional Study

BACKGROUND

The practice of labor analgesia is an essential part of standard obstetric care. There are many guidelines and programs, which have been setup in labor pain management, in the developed country. In India, the practice of labor analgesia is not very popular. The role of labor analgesia providers lies in educating the parturients about the need of labor analgesia and also to develop comprehensive programs and guidelines in providing it.

AIM

The aim of our study was to assess knowledge and practice of labour analgesia among anaesthesiologists across India.

METHODS

Survey was carried out using SurveyMonkey, an online internet website. Questionnaires were sent by mail to 11,986 anesthesiologists. The questions were based on methods of labor analgesia practice, regional analgesia techniques, commonly used drugs, complications and myths surrounding labor analgesia.

STATISTICAL ANALYSIS

Responses were compiled and data was analysed. Results were expressed as percentages.

RESULTS

There were 1351 responses to the survey. Labor analgesia was practiced mainly by anesthesiologists across India (71.34%, n = 945). Regional analgesia techniques were the most common techniques followed in providing labor analgesia (69.61%, n = 940) and among regional analgesia techniques, epidural analgesia (43.52%, n = 588) was the most common method. Bupivacaine was considered the drug of choice (64.10% n = 866) and Fentanyl was the standard adjuvant used (83.34% n = 1126). Majority of the respondents did not believe in myths surrounding labor analgesia.

CONCLUSION

Epidural analgesia is the most common technique practiced, bupivacaine the commonly used local anaesthetic, fentanyl common adjuvant used in practice of labour analgesia by anaesthesiologists across India.

Effects of Epidural Labour Analgesia in Mother and Foetus

OBJECTIVE

Aim of study was to determine effect of epidural analgesia on progress of labour and mode of delivery, to find out its complications in labour and puerperium and to evaluate neonatal outcome in terms of APGAR score.

METHOD

The present study was conducted in Department of Obstetrics and Gynaecology at Government Medical College Aurangabad over period of 2 years from June 2014 to June 2016 after taking approval from institutional ethical board. Hundred low-risk primigravidas were included in the study, 50 women received epidural analgesia for relief of labour pain at 3-4 cm and 50 women served as control. The important  outcome  FACTORS studied were the following : (1) duration of active phase of I stage, and II stage, (2) mode of delivery, (3) APGAR scores, (4) untoward reactions and intrapartum complications, (5) overall satisfaction of the mother.

RESULTS

The operative delivery rates were not significantly different in both the groups (8% in the control group and 6% in the study group: p value NS, i.e. > 0.05). The duration of first stage (our study showed no significant difference in the duration of first stage in both the study and control groups p value > 0.05) and second stage of labour (p value NS > 0.05) and the need for oxytocin were comparable in the two groups. The side effects observed were minimal. It has given excellent pain relief and improved neonatal outcome (5 min). EA is associated with rates of vaginal delivery (88 v/s 84%) and LSCS rate (8 v/s 6%) which are comparable with control group.

CONCLUSION

Epidural analgesia is a very promising, safe and effective method of pain relief. No major complications and a good APGAR score make it a good option of care in modern obstetrics.

Using dexamethasone as an adjuvant to levobupivacaine in epidural anesthesia to change the pain intensity and duration in painless labor

Background and Objective

This is a randomized controlled trial aiming at comparing the effectiveness of levobupivacaine alone versus a levobupivacaine with dexamethasone in the epidural injection for painless labor.

Patients and Methods

This is a comparative randomized controlled double-blinded clinical trial with 49 patients were included in this study, all of them were primigravidas and were during vaginal delivery with a cervical dilatation ≥4 cm. Patients were included randomly in one of two groups either Group C (26 cases) with epidural levobupivacaine 0.125% in normal saline or Group D (23 cases) with epidural levobupivacaine 0.125% in normal saline combined with dexamethasone 8 mg. The duration of a second dose request, total dose given, neonatal outcome and adverse effects of epidural were recorded.

Results

Group D showed a longer duration of analgesia than Group C (80.5 ± 12.39 min in Group D vs. 61.75 ± 10.74 min in Group C) with a P < 0.05 (0.001). Furthermore, the patients in Group D received smaller dose of levobupivacaine than those in Group C with a statistically significant difference (90.87 ± 33.42 vs. 127.21 ± 40.68 mg with P = 0.002). There were no statistical differences between the two groups regarding hemodynamics, pain score, neonatal outcome, and complications.

Conclusion

Dexamethasone in epidural analgesia for painless labor has a prolonged duration of analgesia with no complications for both the mother and the infant.

Efficacy of Intravenous Infusion of Acetaminophen for Intrapartum Analgesia

INTRODUCTION

The intensity of pain experienced by women in labour, has been found to affect the progress of labour, foetal well-being and maternal psychology. Adverse effects associated with commonly used opioids for providing intrapartum analgesia have created a need for an alternative non-opioid drug.

AIM

To evaluate the efficacy of an intravenous infusion of 1000 mg of acetaminophen as an intrapartum analgesic.

MATERIALS AND METHODS

The present prospective single-centre, single blind, placebo-controlled randomized interventional study was conducted in Department of Obstetrics and Gynaecology in Vardhaman Mahavir Medical College & Safdarjung Hospital over a period of six months from September 2014 to March 2015. After receiving the ethical clearance and written informed consent. The first 200 consecutive parturients fulfilling the inclusion criteria were recruited into the study. Women were then randomised to receive either intravenous 1000 mg (100ml) of acetaminophen (Group A, n=100) or 100 ml normal saline (Group B, n=100). Primary outcome assessed was effectiveness of acetaminophen to provide an adequate amount of analgesia, as measured by a change in Visual Analogue Scale (VAS) pain intensity score at various times after drug administration. Secondary outcomes measured were duration of labour, need for additional rescue analgesia and presence of adverse maternal or foetal effect.

RESULTS

There was pain reduction at 1 and 2 hours in both groups (p<0.001). However, it was more significant in the acetaminophen group, especially at 1 hour. Duration of labour was shortened in both the groups, without any maternal and foetal adverse effects.

CONCLUSION

Intravenous acetaminophen is an efficacious non-opioid drug for relieving labour pain without any significant maternal and foetal adverse effects.

Comparison of continuous epidural infusion and programmed intermittent epidural bolus in labor analgesia

BACKGROUND

This study aims to investigate differences between continuous epidural infusion (CEI) and programmed intermittent epidural bolus (IEB) analgesia for the Chinese parturients undergoing spontaneous delivery and to approach their safety to parturients and neonates.

METHODS

Two hundred healthy American Society of Anesthesiologists class I or II, term (≥37 weeks' gestation), nulliparous women who requested analgesia for labor were recruited. Epidural analgesia was initiated with a solution of 0.15% ropivacaine 10 mL and maintained with 0.1% ropivacaine mixed with sufentanil 0.3 μg/mL by CEI at a rate of 5 mL/h combined with a patient-controlled epidural analgesia (PCEA) bolus of 5 mL of ropivacaine sufentanil mixture or IEB of 5 mL of ropivacaine sufentanil mixture combined with a PCEA bolus of 5 mL of ropivacaine sufentanil mixture. The lockout interval was 20 minutes in each arm between the CEI and the IEB group. After 20 minutes of first dosage, visual analog scale (VAS) score was obtained every 60 minutes. The maternal and fetal outcome and total consumption of analgesic solution were compared.

RESULTS

There was no difference in demographic characteristics, duration of first and second stages, delivery methods, sensory block, fetal Apgar scores, and the maternal outcomes between the CEI and IEB groups. There was a significant difference in VAS scores and epidural ropivacaine total consumption between the two groups (IEB vs CEI: 51.27±9.61 vs 70.44±12.78 mg, P<0.01).

CONCLUSION

The use of programmed IEB mixed with PCEA improved labor analgesia compared to CEI mixed with PCEA, which could act as maintenance mode for epidural labor analgesia.

Fentanyl versus tramadol with levobupivacaine for combined spinal-epidural analgesia in labor

Background:

Neuraxial labor analgesia using new local anesthetics such as levobupivacaine has become very popular by virtue of the safety and lesser motor blockade caused by these agents. Combined spinal-epidural analgesia (CSEA) has become the preferred method for labor analgesia as it combines benefits of both spinal analgesia and flexibility of the epidural catheter. Adding opioids to local anesthetic drugs provide rapid onset and prolonged analgesia but may be associated with several maternal and fetal adverse effects. The purpose of this study is to compare fentanyl and tramadol used in CSEA in terms of duration of analgesia and frequency of the adverse fetomaternal outcome.

Materials and Methods:

A total of 60 primiparas with a singleton pregnancy in active labor were given CSEA after randomly allocating them in two groups of 30 each. Group I received intrathecal 2.5 mg levobupivacaine + 25 μg fentanyl followed by epidural top ups of 20 ml 0.125% solution of the same combination. Group II received 25 mg tramadol instead of fentanyl. Epidural top ups were given when parturient complained of two painful contractions (visual analogue scale ≥ 4). Data collected were demographic profile of the patients, analgesic qualities, side- effects and the fetomaternal outcome.

Results:

Patients in Group II had significantly prolonged analgesia (145 ± 9 minutes) than in Group I (95 ± 7 minutes). Patients receiving fentanyl showed rapid onset of analgesia, but there were more incidence of side-effects like shivering, pruritus, transient fetal bradycardia, hypotension, nausea and vomiting. Only side-effect in the tramadol group was nausea and vomiting. During labor, maternal satisfaction was excellent.

Conclusions:

Adding tramadol to local anesthetic provides prolonged analgesia with minimal side effects. Fentanyl, when used as adjuvant to local anesthetic, has a rapid onset of analgesia but has certain fetomaternal side-effects.

A comparison of continuous infusion and intermittent bolus administration of 0.1% ropivacaine with 0.0002% fentanyl for epidural labor analgesia

BACKGROUND AND AIMS

Minimal consumption of local anesthetic and opioid for epidural labor analgesia has been advocated for safe obstetric outcome and superior maternal satisfaction. The primary objective of this study was to evaluate and compare the analgesic efficacy of mode of administration of epidural 0.1% ropivacaine with 0.0002% fentanyl via continuous infusion or intermittent boluses during labor.

MATERIAL AND METHODS

Sixty term primi or second gravida healthy parturients in labor requesting epidural analgesia were recruited in this study. Lumbar epidural catheter was inserted, and analgesia initiated with 0.2% ropivacaine. Patients were randomized to receive ropivacaine 0.1% with fentanyl 0.0002% via either continuous infusion (Group A) or intermittent boluses (Group B) on an hourly basis. If the parturient complained of pain and visual analog scale (VAS) score was >3, an additional bolus of the study drug was given. VAS score, motor blockade, maternal hemodynamics and fetal heart sounds were frequently monitored. Side effects, mode of delivery and neonatal outcome were noted.

RESULTS

To achieve similar VAS, the mean total dose of ropivacaine was 18.78 ± 3.88 mg in Group A and 16.86 ± 4.3 mg in Group B, the difference being statistically significant (P = 0.04). Seventeen out of 30 patients in Group A that is, 56.6% and nine patients in Group B that is, 30% required additional top-ups, and this was significantly higher (P = 0.037). Side effects, mode of delivery and neonatal outcome were comparable in both groups.

CONCLUSION

Intermittent bolus administration provides a more efficacious route of drug delivery when compared to continuous infusion by significantly decreasing the total amount of local anesthetic plus opioid without adversely affecting patient safety or maternal satisfaction.

Intravenous paracetamol infusion versus intramuscular tramadol as an intrapartum labor analgesic

OBJECTIVES

To compare intravenous paracetamol and intramuscular tramadol as labor analgesics.

METHODS

This prospective-randomized study conducted in 200 primigravidae in active labor, distributed into two groups of 100 women each with one receiving intravenous 1,000 mg Paracetamol and other 100 mg intramuscular tramadol. Pain intensity is recorded by McGills scale before, one and 3 h after drug administration. Perinatal outcome is recorded.

RESULTS

No difference in pain intensity is seen before drug administration. After 1 h of drug administration, in paracetamol group, 4 % women had horrible pain, and 29 % had distressing pain, while in tramadol group, 30 % women had horrible pain, and 60 % had distressing pain. After 3 h of drug administration, in paracetamol group, 26 % had distressing pain, while in tramadol group, 51 % women had horrible pain, and 35 % had distressing pain. Labor duration in paracetamol and tramadol group was 4.3 and 5.9 h, respectively. In paracetamol group, nausea is seen in 2.2 % and vomiting in 1.1 %, while in tramadol group, nausea is seen in 6.4 % and vomiting in 4.3 %.

CONCLUSIONS

Intravenous paracetamol is more effective labor analgesic with fewer maternal adverse effects and shortens labor as compared to intramuscular tramadol.

Epidural analgesia, neonatal care and breastfeeding

The objective of our study is to evaluate the correlation between epidural analgesia during labor, start of breastfeeding and type of maternal-neonatal care.Two different assistance models were considered: Partial and Full Rooming-in.In this cohort study, 2480 healthy infants were enrolled, 1519 in the Partial Rooming-in group and 1321 in the Full Rooming-in group; 1223 were born to women subjected to epidural analgesia in labor.In case of Partial Rooming-in the rate of exclusive or prevailing breastfeeding is significant more frequent in newborns born to mothers who didn't receive analgesia. Instead, in case of Full Rooming-in the rate of exclusive or prevailing breastfeeding is almost the same and there's no correlation between the use or not of epidural analgesia.The good start of lactation and the success of breastfeeding seems to be guaranteed by the type of care offered to the couple mother-infant, that reverses any possible adverse effects of the use of epidural analgesia in labor.

Prevalence of low back pain experienced after delivery with and without epidural analgesia: A non-randomised prospective direct and telephonic survey

BACKGROUND AND AIMS

The most frequent concern of patients receiving epidural analgesia for labour pain relief is post-partum back pain. This survey was designed to assess the prevalence of post-partum backache with and without epidural analgesia among post-partum women.

METHODS

The study was conducted at a university teaching hospital and women presenting to labour room for labour and delivery formed the target population. A total of 482 women were recruited during the study period. Response rate was 95.4% and these cases were included in our statistical analysis. Two forms were designed for data collection before and after delivery; form I was filled by one of the investigators while form II was filled by a research assistant to prevent bias which included follow-up of back pain. The primary outcome variable was backache quantified with visual analogue scale score. Out of 460 women, 230 women received epidural analgesia for labour and 230 women had not.

RESULTS

The prevalence of post-partum back pain in epidural analgesia versus non epidural analgesia groups was 40.9% versus 40% on day one and 32.2% versus 35.2% after 1 week. However, after one and 3(rd) months follow-up, backache prevalence was less in epidural analgesia group (unadjusted odds ratio [OR]: 0.63; 95% confidence interval [CI]: 0.39-0.99) and (unadjustedd OR: 0.32; 95% CI: 0.15-0.69) respectively. The adjusted odd ratio was 0.59 at 1st month and 0.25 at 3rd month. There was no significant difference between the two groups in pain scores.

CONCLUSION

There was no association between the epidural analgesia and post-partum back pain.

Comparison of remifentanil and fentanyl regarding hemodynamic changes due to endotracheal intubation in preeclamptic parturient candidate for cesarean delivery

BACKGROUND

Intravenous opioids are administered to prevent and control hemodynamic changes due to endotracheal intubation. Except for special cases such as preeclampsia, these drugs are not recommended for parturants candidate for cesarean section because of the respiratory depression caused in the newborn.

OBJECTIVES

According to rapid metabolism of remifentanil, the current study aimed to compare hemodynamic changes in preeclamptic parturants who received remifentanil and fentanyl for cesarean section under general anesthesia.

PATIENTS AND METHODS

This single blind randomized clinical trial was performed on preeclamptic pregnant women candidate for cesarean section under general anesthesia. They were divided into two groups. In the first group 0.05 μg/kg/min remifentanil was infused for 3 minutes before induction of anesthesia and in the second group 1ml (50 μg) fentanyl was injected before induction. Heart rate (HR), systolic blood pressure (SBP) and diastolic blood pressure (DBP) before and after intubation and also Apgar index were measured and compared between the two groups.

RESULTS

All hemodynamic variables increased after intubation in the fentanyl group (pSBP = 0.146, pDBP = 0.019, pHR < 0.001). Additionally, decrease in SBP (P = 0.018) and DBP (P = 0.955) and mild increase in HR (P = 0.069) after intubation in the remifentanil group was observed. No significant difference was found between Apgar indexes of the two groups (P = 0.771).

CONCLUSIONS

It can be postulated that remifentanil can be used in partituents candidate for cesarean delivery under general anesthesia to prevent severe increase in blood pressure and heart rate during tracheal intubation without adverse effects on newborn.