Nitrous Oxide Use for Pain in Labor, Conversion to Neuraxial Anesthesia and Birth Outcome

INTRODUCTION

A variety of labor pain management options is essential to patients and their care providers. Inhaled, patient controlled nitrous oxide (N2O) is a valuable addition to these options. The purpose of this study was to examine laboring patient, newborn, and provider characteristics associated with N2O use for pain relief in labor and to examine the association between N2O, conversion to neuraxial analgesia, and cesarean birth.

METHODS

This was a retrospective observational cohort study of the first year of N2O use in one large academic medical center. Patients at least 37 weeks' gestation who were admitted for labor with intended vaginal birth from August 1, 2018, to June 30, 2019, were included (N = 2605). Laboring patient and newborn factors and their relationship to N2O use were calculated as unadjusted and adjusted relative risks (RRs). Poisson regression was used to model the association between N2O use and subsequent use of neuraxial analgesia and type of birth for both nulliparous and multiparous patients.

RESULTS

Overall, 20.2% of patients used N2O during labor. Multiparous patients were 24% less likely to use N2O than nulliparous patients (RR, 0.76; 95% CI, 0.69-0.84). Use of N2O did not differ significantly between patients cared for by midwives compared with patients cared for by physicians (RR, 0.95; 95% CI, 0.90-1.00). In multivariable modeling, N2O use in multiparous patients was associated with a 17% decrease in use of neuraxial analgesia (RR, 0.83; 95% CI, 0.73-0.94). There was no association between N2O use and use of neuraxial analgesia in nulliparous patients (RR, 0.99; 95% CI, 0.93-1.06). N2O use was not associated with cesarean birth in either group.

DISCUSSION

N2O is an important pain management option for laboring patients and those who care for them. Study results may assist midwives, physicians, and nurses in counseling patients about analgesia options.

Quality of analgesic care in labor: A cross-sectional study of the first national register-based benchmarking system

OBJECTIVE

Unlike other types of acute pain, labor pain is considered physiological. Due to the heterogeneous management during labor, there is a lack of intention to define quality of care of peripartal analgesia. This study presents the first results of the national register for this evaluation.

METHODS

This prospective cross-sectional study, conducted in five different German level-three hospitals, included women after vaginal childbirth between January 2020 and January 2022. A validated questionnaire was completed 24 h postpartum, including information about labor pain, satisfaction, and expectations regarding analgesia. Data were centrally recorded with obstetric records using the database of the QUIPS (Quality Improvement in Postoperative Pain Management) Project.

RESULTS

A total of 514 women were included. On an 11-point Numerical Rating Scale, pain intensity during labor was severe (8.68 ± 1.8) while postpartal pain was 3.9 (±2.1). The second stage of labor was considered the most painful period. Only 62.6% of the parturients obtained pharmacological support, with epidural being the most effective (reduction of 3.8 ± 2.8 points). Only epidural (odds ratio [OR] 0.22) and inhalation of nitrous oxide (OR 0.33) were protective for severe pain. In benchmarking, a relation between satisfaction, pain intensity, and the use of epidural was found; 40.7% of the women wished they had received more analgesic support during labor.

CONCLUSION

This study highlights deficiencies in analgesic management in high-level perinatal centers, with more than 40% of parturients considering actual practices as insufficient and wishing they had received more analgesic support, despite the availability of analgesic options. Using patient-reported outcomes can guarantee qualitative tailored analgesic care in women.

A prospective randomized double-blind study comparing the dose-response curves of epidural ropivacaine for labor analgesia initiation between parturients with and without obesity

Background: Previous studies have explored the median effective concentration (EC50) of ropivacaine for labor epidural analgesia in parturients with obesity. However, the clinical relevance of the 90% effective concentration (EC90) remains unclear. This study aimed to determine and compare the dose-response curve of epidural ropivacaine for labor analgesia between parturients with and without obesity. Methods: Parturients were divided into two groups based on body mass index (BMI): group N, consisting of parturients with BMI <30 kg/m2, and group O, consisting of parturients with BMI >30 kg/m2. Within each group, the patients were randomized to receive one of five concentrations (0.0375%, 0.075%, 0.1125%, 0.15%, or 0.1875%) of epidural ropivacaine for labor analgesia. Analgesia was induced with a loading dose of 15 mL of the assigned concentration. Visual analogue scale (VAS) scores were recorded at baseline and 30 min post-dose to calculate the response (%) using the formula [(baseline VAS pain score-VAS pain score at 30 min)/baseline VAS pain score] ×100%. The EC50 and EC90 values were determined via nonlinear regression analysis. Results: The EC50 and EC90 values of ropivacaine were 0.061% (95% confidence interval [CI], 0.056%-0.066%) and 0.177% (95% CI, 0.152%-0.206%) in group N and 0.056% (95% CI, 0.051%-0.061%) and 0.161% (95% CI, 0.138%-0.187%) in group O, respectively. No significant differences were observed in the EC50 and EC90 values between the two groups (p-values = 0.121 and 0.351, respectively. Conclusion: In conclusion, within the parameters of this study, our findings suggest that obesity, characterized by a mean BMI value of 30.9, does not significantly influence the EC50 and EC90 values of epidural ropivacaine for labor analgesia. Further investigations are warranted to elucidate the dose-response relationship between ropivacaine and obesity with higher BMI values. Clinical trial registration: https://www.chictr.org.cn/showproj.html?proj=190747, Identifier ChiCTR2300073273.

Development and Validation of a Nomogram for the Failed Conversion of Labor Analgesia to Cesarean Section Anesthesia

Purpose

The conversion of epidural labor analgesia (ELA) to epidural surgical anesthesia (ESA) for intrapartum cesarean section (CS) often encounters failures. This study aimed to develop a nomogram for predicting the failure rate of this conversion.

Patients and Methods

A retrospective analysis was conducted on data from the Fujian Maternity and Child Health Hospital. Pregnant women (n=214) who underwent cesarean section after receiving labor analgesia. We performed correlation heat map and Lasso regression in terms of exclusion confounding factors and screening independent variables. A nomogram was developed to predict the occurrence.

Results

The developed nomogram incorporated variables such as pregnant history, weight, premature rupture of membranes (PROM), dural puncture epidural (DPE), anesthesiologist level of cesarean section (ALOCS), and Anesthesiologist level of labor analgesia (ALOLA). The model demonstrated good predictive performance, providing a practical tool for assessing the risk of failure in converting labor analgesia to cesarean section anesthesia.

Conclusion

The nomogram can aid anesthesiologists in making informed decisions and optimizing patient care. By utilizing the nomogram, clinicians can estimate the probability of conversion failure based on individual patient characteristics and clinical factors.

A biased coin up-and-down sequential allocation trial to determine the ED90 of intrathecal sufentanil combined with ropivacaine 2.5 mg for labor analgesia

Purpose

To determine the 90 percent effective dose (ED90) of intrathecal sufentanil combined with ropivacaine 2.5 mg for labor analgesia and observe its safety for parturients and neonates.

Methods

We conducted a prospective, double-blind, biased coin up-and-down study. We injected a fixed 2.5 mg ropivacaine combined with a designated dose of sufentanil intrathecally to observe the labor analgesic effect. The initial dose of sufentanil was assigned 1.0 μg, and the remaining doses were assigned as per the biased coin up-and-down method. The criterion of successful response was defined as VAS ≤ 30 mm after intrathecal injection at 10 min. Safety was evaluated in terms of maternal and neonatal outcomes.

Results

The ED90 dose of intrathecal sufentanil combined with ropivacaine 2.5 mg (0.1%, 2.5 mL) was 2.61 μg (95% CI, 2.44 to 2.70 μg) by isotonic regression. No respiratory depression, hypotension, or motor block was observed. Thirty-one (77.5%) parturients complained of pruritus, and 14 (35.0%) suffered nausea and vomiting. Three neonates reported a 1 min Apgar score of ≤7, and none reported a 5 min Apgar score of ≤7.

Conclusion

The ED90 of intrathecal sufentanil combined with ropivacaine 2.5 mg for labor analgesia was 2.61 μg. The dose is safe for parturients and neonates.

Application of Dexmedetomidine in Epidural Labor Analgesia: A Systematic Review and Meta-Analysis on Randomized Controlled Trials

OBJECTIVES

To summarize and appraise the use of dexmedetomidine in epidural labor analgesia, we conducted a systematic review and meta-analysis of randomized controlled trials (RCTs).

METHODS

We conducted the literature search about the RCTs of epidural labor analgesia with or without dexmedetomidine from inception until November 1, 2022, in the following databases: PubMed, Cochrane Library, and Embase. The primary outcome was visual analog scale (VAS) within 2 hours after epidural intubation. The secondary outcomes included the duration of the first and second labor stages, Apgar score, umbilical blood pH, dosage of analgesics, and side effects.

RESULTS

Eight RCTs including 846 parturients were included. The VAS score of the dexmedetomidine group was significantly lower than that of the control group at the time of 15 minutes (mean difference [MD] -1.41, 95% confidence interval [CI] -2.23, -0.59), 30 minutes (MD -1.02, 95% CI -1.70, -0.33), 60 minutes (MD -0.90, 95% CI -1.36, -0.44), and 90 minutes (MD -0.70, 95% CI -1.16, -0.23). The incidence of pruritus in the dexmedetomidine group was lower than that of the control group （MD 0.28, 95% CI 0.11, 0.74), but the incidence of maternal bradycardia was higher (MD 6.41, 95% CI 1.64, 25.04). There were no significant difference in other outcomes.

DISCUSSION

Dexmedetomidine combined with local anesthetic for epidural labor analgesia can improve the VAS score of parturients. Except for the increased incidence of maternal bradycardia, it seems to be safe for the parturients and fetuses.

The Influence of Dexmedetomidine as an Adjuvant in Intrathecal Labor Analgesia: A Multicenter Study on Efficacy and Maternal Satisfaction

In this study, we examined the impact of dexmedetomidine (DEX) on the effectiveness of epidural analgesia and labor outcomes. We administered different doses of DEX combined with 0.1% ropivacaine for epidural analgesia to evaluate the clinical effects and safety. To assess the effects of different concentrations of DEX in parturient women receiving epidural analgesia, we conducted a randomized double-blind trial. We selected 400 parturient women and randomly assigned them to 4 groups, with 100 parturient women in each group: S0.1 (0.1 µg/mL DEX), S0.2 (0.2 µg/mL DEX), S0.3 (0.3 µg/mL DEX), and a control group (0.3 µg/mL sufentanil). Post-analgesia, we recorded the Bromage score, duration of labor, method of delivery, bleeding, neonatal Apgar score, adverse reactions, and maternal satisfaction. The number of patients with a Bromage score of ≥2 and the incidence of bradycardia were higher in the S0.3 group compared with the other 3 groups (P < .05), whereas the high satisfaction rate was lower in the S0.3 group (P < .05). Moreover, we found that the number of times that additional patient-controlled analgesia was administered was higher in the S0.1 group compared with the remaining 3 groups (P < .05). The control group exhibited a higher incidence of pruritus than the other 3 groups (P < .05). In conclusion, when administering spinal anesthesia for the relief of labor pain, epidural analgesia with 0.1% ropivacaine combined with 0.2 µg/mL DEX provides relatively ideal analgesic effects, higher maternal satisfaction, and reduces the incidence of pruritus, compared with the combination of 0.1% ropivacaine and 0.3 µg/mL sufentanil.

Dexmedetomidine versus Opioids on Labor Analgesia: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

Effective control of labor pain is critical to the birthing experience. Dexmedetomidine is an alternative adjunct to labor analgesia without the risk of opioid-related adverse effects. The purpose of this study was to examine the efficacy and safety of neuraxial dexmedetomidine versus neuraxial opioids in labor analgesia. PubMed, CINAHL, Cochrane, Google Scholar, and grey literature were searched for evidence. Risk ratio and mean difference (MD) were used to estimate outcomes. The quality of evidence was assessed using the Risk of Bias and GRADE system. Sixteen studies including 1,669 patients were analyzed. Compared with opioids, dexmedetomidine prolonged the duration of analgesia (MD, 47.58 minutes; 95% confidence interval [CI], 1.57 to 93.58; P = .04), reduced pain score (MD, -0.71; 95% CI, -1.17 to -0.24; P = .003), and shortened the onset of analgesia (MD, -1.14 minutes; 95% CI, -1.93 to -0.35; P = .005). Dexmedetomidine did not affect the duration of first and second stages of labor, number of spontaneous, assisted, and cesarean delivery. Additionally, dexmedetomidine had little to no effects on maternal and neonatal outcomes. Neuraxial dexmedetomidine is more favorable than neuraxial opioids for labor analgesia. Extrapolation of the findings to clinical practice should take into considerations the review limitations.

Dural Puncture Epidural with 25-G Spinal Needles versus Conventional Epidural Technique in Conjunction with PIEB for Labor Analgesia: A Randomized Trial

Purpose

To compare the effect of Dural puncture epidural (DPE) and conventional epidural (EP), in conjunction with programmed intermittent epidural bolus (PIEB) and low-concentration ropivacaine strategy.

Methods

After written informed consent was obtained, healthy nulliparous women with singleton pregnancies, vertex presentation at 38-42 weeks' gestation, cervical dilation of 3-5 cm, and a desire for pain relief were randomly assigned to DPE or EP group. Dural matter was puncture with 25G Whitacre needle in DPE group. Analgesia was initiated with 15 mL of 0.1% ropivacaine over 5 minutes and was maintained by PIEB (8 mL of 0.08% ropivacaine with 2 μg/mL fentanyl every 40 min). Primary outcome was the percentage of adequate analgesia, defined as NRPS ≤1, at 30 minutes after the initiation of the epidural bolus.

Results

Out of 130 enrolled parturients, 127 were included in final analysis (64 in DPE group, 63 in EP group). No significant difference was found in percentage of adequate analgesia at 30 minutes (risk ratio: 1.09; 95% confidence interval: 0.90-1.31; P = 0.366). At 8, 12, 14, and 16 minutes, percentage of adequate analgesia was higher in DPE group (P = 0.023, 0.027, 0.016 and 0.033, respectively). NPRS scores in DPE group decreased more dramatically within the first 30 min. The incidence of S2 sensory blocks at 20 and 30 min in DPE group was higher (P = 0.010 and 0.006, respectively). There were no differences in patient satisfaction, delivery mode, adverse effects, fetal bradycardia, and Apgar scores at 1 and 5 minutes.

Conclusion

The combination of the use of DPE technique with 25G spinal needle and PIEB technique for labor analgesia appears to enhance the quality of labor analgesia by accelerating onset and providing improved sacral blockade, without increasing adverse effects.

Continuous Spinal Anesthesia for Labor Analgesia and Cesarean Delivery in a Parturient With Familial Dilated Cardiomyopathy: A Case Report

We report a case of successful continuous spinal anesthesia (CSA) for labor analgesia and cesarean delivery in a patient with familial dilated cardiomyopathy (DCM). A 33-year-old pregnant woman diagnosed with DCM was scheduled for a vaginal delivery under labor analgesia. An accidental intrathecal catheter was placed, and labor analgesia was provided by CSA. The vaginal delivery was converted to a cesarean delivery, and an intrathecal catheter was used for transition, which avoided hemodynamic changes and allowed the patient to safely undergo cesarean delivery. CSA is a reliable and rapidly titratable technique that provides excellent analgesia without hemodynamic changes in patients with DCM undergoing labor analgesia and subsequent cesarean delivery.

The Effects of Different Puncture Points on Labor Analgesia Onset: Study Protocol for a Randomized Controlled Trial

Purpose

Parturients suffer severe pain during the stages of labor, especially the first and second. Epidural anesthesia is an effective method to alleviate labor pain. L2-3, L3-4 and L4-5 spaces have been reported to be the recommendable puncture points owing to the adequate analgesia effect and high safety. However, the speed of pain alleviation via the three points has hardly been determined, which is of great importance to parturients. Thus, the aim of this study is to compare the onset time of parturients' painless uterine contraction after epidural labor analgesia through different puncture points.

Study Design and Methods

It is a prospective, randomized, controlled, and subject- and assessor-blinded study. Totally, 150 subjects scheduled for vaginal delivery are going to be randomly assigned into the L2-3 and L3-4 group. Puncture point in L2-3 group is lumbar 2-3 space, while in L3-4 group it is lumbar 3-4 space. Analgesia initiation and maintenance are the same between the two groups. Primary outcome will be percentage of painless uterine contraction 15 min after epidural labor analgesia initiation. Secondary outcomes will be the sensory blocking level, motor blocking score, adverse effects of parturients, drug liquid consumption in unit interval, apgar score and degree of satisfaction of the parturients.

Discussion

This study estimates the onset time of parturients' painless uterine contraction after epidural labor analgesia through L2-3 or L3-4 space. The results may provide a better choice to relieve labor pain as soon as possible.

Effects of dural puncture epidural technique with different drug delivery methods for labor analgesia: A randomized controlled clinical trial

This study aimed to investigate the effect of dural puncture epidural (DPE) combined with small-dose lidocaine for labor analgesia. Parturients were randomly divided into epidural anesthesia (EA), DPE1, and DPE2 groups. In the EA group, 5 mL of 1% lidocaine was administered via conventional L2-L3 puncture catheterization; in the DPE1 group, epidural drug was administered after catheterization using the DPE technique; in the DPE2 group, epidural puncture drug was administered through the epidural puncture needle before catheterization using the DPE technique. The primary outcome was the onset time of analgesia. The secondary outcomes included the numerical rating scale (NRS) scores during uterine contraction before bolus injection of experimental dose (T0) and the second time (T1), the fifth time (T2) and the tenth time (T3) after bolus injection of experimental dose; NRS scores at the second stage of labor (T4) and during perineal suture (T5); operation time of anesthesia; puncture related complications; anesthesia related complications; delivery outcome; use of local anesthesia during vaginal suture; and Apgar score of the neonates. There were 115 women included. The onset time in the DPE2 group was markedly shorter than in the EA and DPE1 groups (P < .001). The NRS scores in the DEP2 group at T1 and T4 were significantly lower than in the EA and DEP1 groups (P < .001). The overall incidence of puncture related complications in the DEP1 and DEP2 groups was markedly higher than in the EA group (P < .05). In dural puncture epidural analgesia, when the experimental dose was injected directly through the epidural puncture needle, the onset time was shorter and the analgesic effect was better as compared to the injection of test dose after inserting the epidural catheter.

Acute Stroke at Term Pregnancy: What Should Happen Before the Epidural?

Acute stroke is a time-sensitive medical diagnosis, and current standardized management algorithms do not specifically streamline care for pregnant patients with these symptoms. Here, we discuss the management of a 29-year-old parturient with a history of systemic lupus erythematosus (SLE) who presented with stroke-like symptoms. We discuss strategies to improve care by incorporating formal neurological and ophthalmologic evaluations prior to referral for neuraxial intervention, particularly in light of the developing concerns among ophthalmologists that retinal transient ischemic attacks (TIAs) and visual symptoms should be treated with the same acuity as cerebral TIAs and strokes. We propose an integrated stroke algorithm in the pregnant population with consideration for specific ophthalmologic evaluation. In the present case, labor induction and epidural placement were successfully performed once a more optimized workup was completed.

Perinatal outcomes after therapeutic rest in the latent phase of labor: A cohort study

INTRODUCTION

Therapeutic rest refers to the usage of medication to relieve pain in women in the latent phase of labor. Very few data are available to evaluate the safety and effect of its use. The objectives of this study were to compare perinatal and labor outcomes in women who were seeking hospital care during the latent phase of labor and who were treated either with or without therapeutic rest.

MATERIAL AND METHODS

Retrospective cohort study with inclusion of nulliparous singleton pregnant women in the latent phase of labor presenting at the labor ward at Aarhus University Hospital, Denmark from May 13, 2018 to June 1, 2021. We identified two groups: women who were treated with therapeutic rest and women who were not. The primary outcomes were neonatal admission and neonatal resuscitation. Secondary outcomes included use of cardiotocography during labor, nonreactive fetal heart rate, meconium-stained amniotic fluid, pediatric delivery room assistance, umbilical cord arterial pH and standard base excess, Apgar score at 5 minutes, interventions during labor and mode of delivery.

RESULTS

In our sample of 800 women in the latent phase of labor, 414 women (52%) were treated with therapeutic rest and 386 women (48%) were not. The most frequently used (n = 206) medication for therapeutic rest was a combination of paracetamol, triazolam and codeine. We found no significant difference in neonatal admission (9.2% vs 6.5%, adjusted odds ratio [aOR] 1.2, 95% confidence interval [CI] 0.4-3.1) or neonatal resuscitation (2.4% vs 3.1%, aOR 0.7, 95% CI 0.1-4.0) between women treated with or without therapeutic rest. There were no differences between the two groups in other perinatal adverse outcomes, interventions during labor or mode of delivery.

CONCLUSIONS

This study found no significant association between therapeutic rest and neonatal admission or resuscitation. Our findings indicate that therapeutic rest is a safe method for managing the latent phase of labor concerning neonatal health and does not increase the risk of labor complications.

Fear of childbirth and use of labor analgesia: A nationwide register-based analysis in Finland

OBJECTIVE

To calculate the rates of labor analgesia among women with fear of childbirth (FOC) in multiparous and nulliparous women, because FOC might be associated with higher rates of labor analgesia.

METHODS

In this retrospective register-based cohort study, data from the National Medical Birth Register was used to evaluate the usage of labor analgesia in pregnancies with FOC, when compared with those without. The analgesia methods were stratified into neuraxial analgesia, pudendal, paracervical, nitrous oxide, other medical, other non-medical, and no analgesia.

RESULTS

A total of 19 285 pregnancies with diagnosed maternal FOC were found during our study period. The control group consisted of 757 997 pregnancies without diagnosed maternal FOC. Nulliparous women with diagnosed FOC had a higher rate of epidural analgesia (70.2% vs 67.1%), spinal analgesia (12.3% vs 7.6%), and pudendal block (17.6% vs 9.6%). Multiparous women with FOC had a notably higher rate for epidural analgesia (47.0% vs 29.0%).

CONCLUSION

The main finding in this study was that women with diagnosed FOC had a higher rate of labor analgesia. The results of this study can be used by midwives, obstetricians, and anesthesiologists to provide optimal pain relief for mothers with FOC.

Remifentanil at a Relatively Elevated Dose in Active Phase is Safe and More Suitable Than Fixed Lower Dose for Intravenous Labor Analgesia

Background

Intravenous labor analgesia is recommended as an alternative for parturients who have contraindications to epidural analgesia. There are several opioid analgesics and different administering regimens used in the clinic. This study aimed to compare the effectiveness and safety of two intravenous remifentanil dosage regimens in the first labor stage.

Patients and Methods

One hundred and fifteen parturients with a contraindication to epidural analgesia but were willing to receive systemic labor analgesia were randomized into group A received a fixed dose of remifentanil throughout the first stage of labor, and group B received an elevated dose of remifentanil during the active phase of the first stage both by patient-controlled analgesia (PCA). Maternal numerical rating scale (NRS) pain score and oxygen desaturation, sedation efficacy, satisfaction, as well as maternal and fetal adverse reactions were recorded and compared.

Results

The mean NRS pain scores before analgesia and in the latent phase showed no statistically significant difference between the two groups (P > 0.05). However, during the active phase, group B demonstrated significantly lower mean NRS pain scores and lowest pain score compared to group A (P < 0.05). Furthermore, group B exhibited higher overall sedation scores and satisfaction scores in comparison to group A (P < 0.05). The incidence of adverse reactions between the two groups was similar (P > 0.05).

Conclusion

Relatively elevated intravenous dosage of remifentanil with PCA during the active phase in the first stage of labor is safe and more effective than a fixed-dosage regimen for labor analgesia.

Trial Registration

This study was registered with ChiCTR on 24/08/2021 with trial identification number: ChiCTR2100050247. First participant was recruited on 31/08/2021. The last patient was recruited on 12/08/2022.

Comparisons of nonpharmaceutical analgesia and pharmaceutical analgesia on the labor analgesia effect of parturient women

OBJECTIVE

We aimed to compare the labor analgesia effects of nonpharmaceutical analgesia and pharmaceutical analgesia on parturient women.

METHODS

One hundred and four parturient women with spontaneous births were selected and randomly divided into pharmaceutical and nonpharmaceutical analgesia groups. Before and after analgesia, the Visual Analogue Scale (VAS), parturient satisfaction with analgesia, serum pain stress factors (substance P [SP], neuropeptide Y [NPY], nerve growth factor [NGF], and prostaglandin E2 [PGE2]), duration of labor, vaginal bleeding at 2 h postpartum, postpartum urinary retention and dysuria incidence, Apgar score of 1 min and 5 min after birth, and neonatal cord blood gas analysis (pH, partial pressure of oxygen [PO₂ ], partial pressure of carbon dioxide [PCO₂ ], and lactate [Lac]) were compared in the two groups.

RESULTS

VAS scores were lower and the analgesia satisfaction was higher in the pharmaceutical analgesia group than in the nonpharmaceutical analgesia group (all p < .05). Serum levels of SP, NPY, NGF, and PGE2 in the pharmaceutical analgesia group were lower than those in the nonpharmaceutical analgesia group (all p < .05). The first and second stages of labor were longer and the bleeding volume at 2 h postpartum was greater in the pharmaceutical analgesia group than those in the nonpharmaceutical analgesia group (all p < .05). Reduced Lac and PCO₂ levels and increased PO₂ level were found in the pharmaceutical analgesia group in comparison to the nonpharmaceutical analgesia group (all p < .05).

CONCLUSION

This study demonstrates that the analgesic effect and neonatal condition of the pharmaceutical analgesia are better than the nonpharmaceutical analgesia, but the labor duration and postpartum bleeding volume of the pharmaceutical analgesia are greater than those of the nonpharmaceutical analgesia.

Bibliometric Analysis on Global Analgesia in Labor from 2002 to 2021

Background

Maternal pain during labor is one of the most important factors contributing to increased cesarean delivery rates and poor pregnancy outcomes, and this pain can be managed by labor analgesia. Many studies exist on labor analgesia, and the quantity and quality of these studies have not been reported. Therefore, we aimed to perform a bibliometric analysis of studies from 2002 to 2021.

Methods

We used the Web of Science database to obtain publications related to labor analgesia from January 2002 to December 2021. Various bibliographic information was collected, including country; author; journal; grant; discipline; institution and research hotspot. A total of 4536 papers were included.

Results

A total of 4536 articles were included in the study. The country with the most published articles on labor analgesia and the country of the funding agency was the United States. Most articles were published in the disciplines Anesthesiology and Obstetrics & Gynecology. The journal that published the most articles in this category was International Journal of Obstetric Anesthesia. In addition, we found different research hotspots for labor analgesia in the United States, Japan, and China.

Conclusion

This paper provides a bibliometric analysis of research on labor analgesia and highlights the differences in research hotspots for labor analgesia between countries.

Intrapartum Cesarean Section and Perinatal Outcomes after Epidural Analgesia or Remifentanil-PCA in Breech and Twin Deliveries

Comparative data on the potential impact of various forms of labor analgesia on the mode of delivery and neonatal complications in vaginal deliveries of singleton breech and twin fetuses are lacking. The present study aimed to determine the associations between type of labor analgesia (epidural analgesia (EA) vs. remifentanil patient-controlled analgesia (PCA)) and intrapartum cesarean sections (CS), and maternal and neonatal adverse outcomes in breech and twin vaginal births. A retrospective analysis of planned vaginal breech and twin deliveries at the Department of Perinatology, University Medical Centre Ljubljana, was performed for the period 2013-2021, using data obtained from the Slovenian National Perinatal Information System. The pre-specified outcomes studied were the rates of CS in labor, postpartum hemorrhage, obstetric anal sphincter injury (OASI), an Apgar score of <7 at 5 min after birth, birth asphyxia, and neonatal intensive care admission. A total of 371 deliveries were analyzed, including 127 term breech and 244 twin births. There were no statistically significant nor clinically relevant differences between the EA and remifentanil-PCA groups in any of the outcomes studied. Our findings suggest that both EA and remifentanil-PCA are safe and comparable in terms of labor outcomes in singleton breech and twin deliveries.

ED90 of epidural esketamine with 0.075% ropivacaine for labor analgesia in nulliparous parturients: a prospective, randomized and dose-finding study

Background: Because it has been reported that racemic ketamine had a local anesthetic-sparing effect when used for epidural analgesia this would suggest the likelihood of a potential advantage (less pruritus) over opioid drugs. Esketamine has greater analgesic efficacy than racemic ketamine, but the optimum dosage regimen for epidural use is undetermined. The aim of this study was to determine the ED₉₀ of epidural esketamine when coadministered with 0.075% ropivacaine for labor analgesia. Methods: A total of 65 laboring nulliparous patients were enrolled in this study from 16 March 2022 to 15 October 2022. The patients were randomly assigned to receive 0, 0.25, 0.5, 0.75 or 1.0 mg/mL esketamine with 0.075% ropivacaine epidurally. An effective response to the epidural loading dose was defined as numerical rating scale pain score ≤3 at 30 min after the end of the epidural loading dose (10 mL of the ropivacaine 0.075% solution with the added esketamine). The ED₉₀ of epidural esketamine coadministered with 0.075% ropivacaine with 95% confidence intervals for labor analgesia was determined using probit regression. Secondary outcomes and side effects were recorded. Results: The estimated value of ED₉₀ with 95% CIs for epidural esketamine with 0.075% ropivacaine was 0.983 (0.704-2.468) mg/mL. The characteristics of sensory and motor block, consumption of ropivacaine per hour, duration of first or second stage, Apgar scores did not differ among the five groups. The incidence of mild dizziness in Group esketamine 1.0 mg/mL was significantly higher than that in other groups (p < 0.05). No statistical differences were found in other side effects among groups. Conclusion: The ED₉₀ value of epidural esketamine coadministered with 0.075% ropivacaine for labor analgesia in nulliparous parturients was about 1.0 mg/mL. Furthermore, our results suggested that epidural esketamine would cause dose-dependent mild dizziness especially at doses up to 1.0 mg/mL. As a single epidural additive, esketamine may not be suitable for labor analgesia. Future studies may investigate the appropriate dosage of esketamine at slightly higher concentrations of local anesthetics or larger initial volume of analgesia, or explore other potential advantages of esketamine. Clinical Trial Registration: (https://www.chictr.org.cn/bin/project/edit?pid=159764), identifier (ChiCTR2200057662).

High Dosage of Patient-Controlled Epidural Analgesia (PCEA) with Low Background Infusion during Labor: A Randomized Controlled Trial

BACKGROUND

Patient-controlled epidural analgesia (PCEA) is well documented; however, it is unclear whether a high dosage of PCEA with a low dosage of background infusion during labor can be a safe and effective application.

METHODS

Group LH was administered a continuous infusion (CI) of 0.084 mL/kg/h with PCEA of 5 mL every 40 min. Group HL was given a CI of 0.028 mL/kg/h and PCEA of 10 mL every 40 min; Group HH was given a CI of 0.084 mL/kg/h and PCEA of 10 mL every 40 min. The primary outcomes were VAS pain score, the number of supplemental boluses, incidence of pain outbreaks, drug dose for pain outbreaks, PCA times, effective PCA times, anesthetic consumption, duration of analgesia, duration of labor and delivery outcome. Secondary outcomes included adverse reactions such as itching, nausea and vomiting during analgesia and neonatal Apgar scores 1 min and 5 min after birth.

RESULTS

A total of 180 patients, 60 in each group were randomly assigned to one of three groups included group LH, group HL or group HH. The VAS scores were obviously decreased in HL group and HH group in comparison with LL group at 2 h after analgesia and the time point of full cervical dilation and delivery of baby. The time for third stage of labor in HH group was increased compared with LH group and HL group. Incidence of pain outbreaks in LH group was obviously increased compared with HL and HH group. The effective PCA times in HL group and HH group were remarkably reduced compared with those in LH group.

CONCLUSIONS

High dose of PCEA with a low background infusion can reduce effective PCA times, incidence of outbreak pain and the total amount of anesthetics without diminishing analgesia effects. However, high dose of PCEA with a high background infusion can enhance analgesia effect but increase the third stage of labor, instrumental delivery ratio and the total amount of anesthetics.

Implementation of an Epidural Rounding Reminder in the Electronic Medical Record Improves Performance of Standardized Patient Assessments during Labor

BACKGROUND

Poorly functioning labor epidural catheters lead to pain and dissatisfaction. Regular catheter assessment ensures timely identification of malfunction and may improve safety by facilitating rapid and successful conversion to general anesthesia for emergency cesarean. Informatics-based systems encourage standardization of care to identify epidural malfunctions earlier.

OBJECTIVES

This article demonstrates that visual epidural rounding reminder display on an electronic patient board would alert clinicians to elapsed time and decrease mean time between assessments.

METHODS

As a quality initiative, we implemented an epidural rounding reminder on our obstetric patient board. The reminder indicated the number of elapsed minutes since placement or last patient assessment. We retrospectively reviewed labor epidural charts 3 months prior to and 5 months following reminder implementation, with a 4-week washout period. The primary outcome was mean time between documented epidural assessments, with secondary outcomes including maximum time between assessments, total number of assessments during labor, catheter replacement rates, and patient satisfaction. Unadjusted comparisons between pre- and postimplementation groups were conducted using Wilcoxon's rank-sum and Pearson's chi-square tests, as appropriate. A test for equal variances was conducted for time between assessment outcomes.

RESULTS

Following implementation, mean time between assessments decreased from a median of 173 (interquartile range [IQR]: 53, 314) to 100 (IQR: 74, 125) minutes (p <0.001), and maximum time between assessments decreased from median 330 (IQR: 60, 542) to 162 (IQR: 125, 212) minutes (p < 0.001). Total number of evaluations during labor increased from 3 (IQR: 2, 4) to 5 (IQR: 3, 7; p < 0.001). Decreased variance in mean and maximum time between assessments was noted following reminder implementation (p < 0.001). Epidural replacement rates decreased from 14 to 5% postimplementation (p < 0.001). Patient satisfaction was unchanged.

CONCLUSION

Implementation of an informatics-based solution can promote standardization of care. A simple epidural rounding reminder prompted clinicians to perform more frequent labor epidural assessments. In the future, these process improvements must be linked to improvements in patient experiences and outcomes.

Labor risk factors for fetal heart rate abnormality after combined spinal-epidural analgesia

OBJECTIVE

To explore the association between obstetric factors or outcomes and fetal heart rate (FHR) abnormalities after combined spinal-epidural analgesia (CSEA).

METHODS

Women with singleton term deliveries who received CSEA at our institution between January 1 and December 31, 2017, were analyzed using medical records. We performed a logistic regression analysis to compare factors and outcomes between cases with and without new FHR abnormalities within 1 h after CSEA.

RESULTS

Of the 393 women, 163 showed the new occurrence of FHR abnormality after CSEA. Rupture of the membrane (odds ratio [OR] 2.49; 95% confidence interval [CI] 1.52-4.09; P < 0.01) and dilatation of the cervix (OR 1.24; 95% CI 1.07-1.44; P < 0.01) were significantly associated with FHR abnormalities. There were significant differences in FHR abnormality rates between women with cervical dilatation of 2 cm or less and 3 cm or more (OR 2.20; 95% CI 1.01-4.81; P = 0.047) and 6 cm or less and 7 cm or more (OR 2.46; 95% CI 1.01-6.01; P = 0.048). FHR abnormalities were not significantly associated with cesarean delivery during labor, instrumental delivery, APGAR score below 7 at 1 or 5 min, or umbilical arterial blood gas pH less than 7.2.

CONCLUSION

Rupture of the membrane and an advanced dilated cervix were risk factors for FHR abnormality when CSEA was initiated.

Comparison between neonatal outcomes of labor and delivery with labor neuraxial analgesia and without analgesia: A propensity score-matched study

AIM

This single-center observational study aimed to investigate the association between labor neuraxial analgesia (LNA) and neonatal outcomes.

METHODS

We conducted a retrospective cohort study at a tertiary perinatal center and included all vaginal deliveries performed between November 2015 and December 2021. Obstetric and neonatal outcomes were compared between deliveries with LNA (LNA group) and without analgesia (control group). Propensity score (PS) matching was used for statistical analysis.

RESULTS

We included 2343 singleton deliveries performed in 1367 nulliparous and 976 multiparous women, in whom LNA was induced in 352 and 178 deliveries, respectively. After PS matching, the nulliparous LNA group had a significantly higher incidence of Apgar scores <7 at 1 (7.1% vs. 3.6%, p = 0.0139) and 5 min (2.3% vs. 0.7%, p = 0.0397) and meconium staining (29.8% vs. 23.2%, p = 0.0272) than the nulliparous control group. Other neonatal outcomes, including umbilical artery pH and neonatal intensive care unit admission rate, were comparable between the nulliparous LNA and control groups. No significant differences in neonatal outcomes were seen in multiparous women. Regarding fetal heart rate abnormalities, severe late deceleration (4.8% vs. 1.7%, p = 0.0036) and severe prolonged deceleration (17.0% vs. 11.9%, p = 0.0224) were more common in the nulliparous LNA group than in the nulliparous control group, and the multiparous LNA group exhibited more severe variable deceleration (21.3% vs. 14.3%, p = 0.0485) than the multiparous control group.

CONCLUSION

Our findings suggest that LNA is associated with short-term adverse neonatal and obstetric outcomes in vaginal deliveries. LNA should be performed with precautionary measures and adequate medical resources.

Comparison between intermittent epidural bolus of levobupivacaine 0.125% and ropivacaine 0.2% with fentanyl as adjuvant for combined spinal epidural technique in labor analgesia: A double blinded prospective study

Objective

This study aims to compare levobupivacaine 0.125% and ropivacaine 0.2% with fentanyl as epidural drugs for labor analgesia using combined spinal epidural (CSE) technique regarding time for onset, duration of analgesia achieved by first epidural bolus dose and to compare the quality of labor analgesia. In addition, the study is also designed to assess the maternal and fetal outcome, incidence of instrumental delivery, degree of motor blockade, and maternal satisfaction.

Materials and Methods

Following approval from Institutional Ethical Committee, 50 American Society of Anesthesiologists Physical Status II pregnant women requesting labor analgesia, satisfying the inclusion criteria were randomly divided equally into Groups L and R. CSE performed, 0.5 ml hyperbaric bupivacaine 0.5% with fentanyl 25 mcg administered intrathecally. IEBs 10 ml of study drugs given through epidural catheter as demand dose.

Results

The mean onset of analgesia with Group R and group L were 16.280 ± 1.59 min and 21.480 ± 1.32 min(P = 0.000) respectively. The total duration of analgesia in Group R = 72.08 ± 1.97 min, whereas Group L = 82.160 ± 2.07 min (P = 0.000). There was no difference between the groups in terms of maternal demographic traits, mode of delivery, maternal and fetal outcome, and maternal satisfaction. Both 0.125% levobupivacaine and 0.2% ropivacaine produce excellent-quality of analgesia.

Conclusion

Ropivacaine produces an early onset of analgesia than levobupivacaine but levobupivacaine had significantly prolonged analgesia compared to ropivacaine. Both drugs were found to be safe for labor analgesia. Maternal satisfaction and fetal outcome were similar with both the drugs.

Preprocedural ultrasonography as an adjunct to landmark technique for identification of epidural space in parturients for labor analgesia

Background

Pregnancy-induced softening of tissues and ligaments may increase the false-positive rates when identifying the epidural space in parturients by the landmark technique. To mitigate these problems, Ultrasonography (USG), which has now become the eye of anesthesiologists, can be used as a reliable tool to facilitate more accurate epidural needle placement in parturients. This study was conducted to know the efficacy of USG when compared to the traditional landmark method.

Methods

After the approval from the institutional ethics committee and CTRI registration, 62 parturients of ASA-2 requesting labor analgesia were randomized into 2 groups of 31 each: Group-L (conventional landmark technique) and Group-U (preprocedural USG done before epidural). In group-U, Tuohy's needle was introduced through the USG predetermined insertion point and epidural space was located using the LOR technique.

Results

USG increased the success rate of epidural at first attempt from 51.6% in group "L" to 87% in group "U." Fewer needle attempts (P-value - 0.001) were required in group "U" as compared to group "L." No accidental dural puncture in group-U, compared to 2 in group-L. Mean Depth of epidural space (cm) ultrasound depth (UD) = 3.89 ± 0.45 cm and needle depth (ND) = 4.05 ± 0.37 cm. Side effects profile in the ultrasound group was better.

Conclusion

Preprocedural ultrasonography is a simple safe, accurate tool with less number of attempts to determine the needle insertion site, decrease the incidence of accidental dural punctures, and assess epidural space depth in parturients.

Duration of exposure to epidural anesthesia at delivery, DNA methylation in umbilical cord blood and their association with offspring asthma in Non-Hispanic Black women

Epidural anesthesia is an effective pain relief modality, widely used for labor analgesia. Childhood asthma is one of the commonest chronic medical illnesses in the USA which places a significant burden on the health-care system. We recently demonstrated a negative association between the duration of epidural anesthesia and the development of childhood asthma; however, the underlying molecular mechanisms still remain unclear. In this study of 127 mother-child pairs comprised of 75 Non-Hispanic Black (NHB) and 52 Non-Hispanic White (NHW) from the Newborn Epigenetic Study, we tested the hypothesis that umbilical cord blood DNA methylation mediates the association between the duration of exposure to epidural anesthesia at delivery and the development of childhood asthma and whether this differed by race/ethnicity. In the mother-child pairs of NHB ancestry, the duration of exposure to epidural anesthesia was associated with a marginally lower risk of asthma (odds ratio = 0.88, 95% confidence interval = 0.76-1.01) for each 1-h increase in exposure to epidural anesthesia. Of the 20 CpGs in the NHB population showing the strongest mediation effect, 50% demonstrated an average mediation proportion of 52%, with directional consistency of direct and indirect effects. These top 20 CpGs mapped to 21 genes enriched for pathways engaged in antigen processing, antigen presentation, protein ubiquitination and regulatory networks related to the Major Histocompatibility Complex (MHC) class I complex and Nuclear Factor Kappa-B (NFkB) complex. Our findings suggest that DNA methylation in immune-related pathways contributes to the effects of the duration of exposure to epidural anesthesia on childhood asthma risk in NHB offspring.

Beyond the epidural: Alternatives to neuraxial labor analgesia

Labor creates an intense pain experienced by women across the world. Although neuraxial analgesia is the most effective treatment of labor pain, in many cases, it may not be undesired, not available, or have contraindications. In addition, satisfaction with labor analgesia is not only determined by the efficacy of analgesia but a woman's sense of agency and involvement in the childbirth experience are also key contributors. Providing safe choices for labor analgesia and support is central to creating a tailored, safe, and effective analgesic treatment plan with high maternal satisfaction. Healthcare provider knowledge of various nonneuraxial analgesic options, including efficacy, contraindications, safe clinical implementation, and side effects of various techniques is needed for optimal patient care and satisfaction. Future rigorous scientific studies addressing all of these labor analgesia options are needed to improve our understanding. This review summarizes the current published literature for commonly available non-neuraxial labor analgesic options.

Neuraxial labor analgesia: Maintenance techniques

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.

Epidural analgesia in labor: A narrative review

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.

Programmed intermittent epidural bolus in parturients: A meta-analysis of randomized controlled trials

BACKGROUND

To evaluate the efficacy and safety of programmed intermittent epidural bolus (PIEB) in parturients.

METHODS

The PubMed, Embase, and the Cochrane Library (from inception to July 2021) were searched for identification of randomized placebo-controlled trials in which PIEB was applied in parturients. The outcomes were the effect of analgesia, satisfaction score, mode of delivery, duration of labor, neonatal condition, and adverse events. The pooled odds ratios (OR), weighted mean difference (WMD), and 95% confidence intervals (CIs) were calculated using random- and fixed-effects models.

RESULTS

PIEB was found to be associated with decreased total consumption of ropivacaine (WMD = -15.83, 95% CI: -19.06 to -12.60, P < .00001; I2 = 61%; P for heterogeneity = .04), total consumption of sufentanil (WMD = -4.93, 95% CI: -6.87 to 2.98, P < .00001; I2 = 68%; P for heterogeneity = .05), numbers of patients who require patient-controlled epidural analgesia bolus (OR = 0.27, 95% CI: 0.14-0.51, P < .0001; I2 = 65%; P for heterogeneity = .01), the number of attempts (WMD = -4.12, 95% CI: -7.21 to -1.04, P = .009; I2 = 100%; P for heterogeneity < .00001), rate of breakthrough pain (OR = 0.47, 95% CI: 0.28-0.80, P = .005; I2 = 47%; P for heterogeneity = .09). Eight studies focus on the duration of analgesia. After by meta-analysis, we found that the pain visual analogue scale (VAS) score at 30 minutes, 2 hours, 4 hours, and 5 hours in PIEB group was significantly lower when compared with control group, (WMD = -0.15, 95% CI: -0.26 to -0.04, P = .006; I2 = 0%; P for heterogeneity = .64), (WMD = -0.79, 95% CI: -1.32 to 0.25, P = .004; I2 = 97%; P for heterogeneity < .00001), (WMD = -1.00, 95% CI: -1.08 to -0.91, P < .00001; I2 = 0%; P for heterogeneity = .67), (WMD = -1.81, 95% CI: -3.23 to -0.39, P = .01; I2 = 98%; P for heterogeneity < .00001), respectively. Nineteen studies discussed the mode of delivery between 2 groups. The results suggest that the rate of normal delivery is significantly higher in PIEB group compared with control group (OR = 1.37, 95% CI: 1.08-1.75, P = .01). The time of first and second stage of labor are significantly shorter in PIEB group compared with control group, the result is (WMD = -10.52, 95% CI: -14.74 to 4.76, P < .00001; I2 = 0%; P for heterogeneity = .86), (WMD = -1.48, 95% CI: -2.26 to -0.69, P = .0002; I2 = 35%; P for heterogeneity = .10), respectively. Thirteen studies concerned the satisfaction score of patients. The satisfaction score of patients in the PIEB group was significantly higher when compared with control group (WMD = 0.91, 95% CI: 0.42-1.39, P = .0003; I2 = 98%; P for heterogeneity < .00001). The Apgar score at 1, 5 minutes in PIEB group are significantly higher (WMD = 0.07, 95% CI: 0.02-0.13 P = .007; I2 = 55%; P for heterogeneity = .04), (WMD = -0.08, 95% CI: -0.12 to -0.05, P < .00001; I2 = 21%; P for heterogeneity = .27), respectively.

CONCLUSIONS

PIEB is a good alternative for labor analgesia with better analgesic effect, maternal and infant outcome.

Parturients' Stated Preferences for Labor Analgesia: A Discrete Choice Experiment

OBJECTIVE

The objective was to investigate the extent to which treatment benefits, risks and costs affected parturients' preferences for labor analgesia.

METHODS

We recruited 248 healthy parturients prior to labor at an antenatal ward and administered a discrete choice experiment survey. Parturients were asked to choose among four hypothetical forms of labor analgesia: epidural analgesia, pethidine, Entonox and no analgesia, which were defined by: pain score, duration of second stage of labor, risks of instrumental delivery, back pain and permanent nerve injury, and out-of-pocket cost. We used mixed logit model to calculate the relative importance of each attribute (out of 100).

RESULTS

Parturients preferred receiving labor analgesia over not receiving analgesia and those who had positive past experience with epidural preferred epidural over other modalities. Out-of-pocket cost (28%), duration of second stage of labor (26%) and pain score following treatment (18%) were the most important attributes.

CONCLUSION

Out-of-pocket cost was a major concern. Parturients prioritized having lower pain and shorter labor experience over risks associated with epidural analgesia. Parturients should be presented with realistic range of risks of side-effects so that they can decide how to balance risks against benefits and costs associated with child labor.

Progress of labor and obstetric outcome in parturients with combined spinal-epidural analgesia for labor: A comparative study

Background:

Alleviation of labour pain is known to improve maternal and fetal outcome. Combined Spinal-Epidural (CSE) analgesia is an excellent method.

Aim and objectives:

In view of reports of its concerns on labour, this study was conducted to evaluate the progress of labour, obstetric outcome in cases with and without CSE analgesia, the maternal pain relief and fetomaternal adverse effects.

Materials and methods:

In this comparative study, 60 parturients were allocated into case and control groups of 30 each. CSE analgesia was administered utilizing 0.5 ml of 0.125% Levobupivacaine / 0.2% Ropivacaine with 2 mcg/ml fentanyl. Progress of labour was recorded in partogram including duration of labour, mode of delivery, pain relief - Visual Analogue Scale (VAS) score, development of motor block, maternal satisfaction and Apgar score. Data was analyzed by Descriptive and Inferential statistics.

Results:

Mean duration of first and second stage of labour among cases was 530±44.1 minutes, 61.5±12.7 minutes respectively and that of control was 526.6±64.9 minutes, 60±10.8 minutes respectively with no prolongation of labour P > 0.05. CSE analgesia did not alter the mode of delivery P=0.145 with rapid onset of pain relief. Apgar score was normal in both groups. Total 29 (97%) parturients experienced effective labour analgesia following CSE analgesia with VAS score 0. Maternal adverse effects included pruritus, transient initial motor blockade and post spinal headache.

Conclusion:

CSE analgesia did not affect the duration of labour, mode of delivery with minimal fetomaternal adverse effects and provides rapid onset of pain relief. CSE analgesia can be considered for safe and effective labour analgesia.

Circadian Variation in the Median Effective Dose of Epidural Ropivacaine for Labor Analgesia

Background: Labor pain perception has been demonstrated to exhibit a circadian rhythm with lower pain scores during the day compared with the night. This study aimed to determine and compare the median effective dose (ED₅₀) of ropivacaine in parturients having epidural labor analgesia during the day vs. during the night.

Methods: The study group consisted of 60 nulliparous healthy parturients who were assigned to one of two groups according to the time they requested labor analgesia: Day Group (7:01 am to 7:00 pm) and Night Group (7:01 pm to 7:00 am). A bolus of.15% ropivacaine was administered epidurally and effective analgesia was defined as the attainment of a visual analog scale (VAS) pain score ≤ 10 mm within 30 min. The dose of ropivacaine for the first parturient in each group was 18 mg. The dose for each subsequent parturient was varied with increments or decrements of 3 mg based on the response of the previous subject. The ED₅₀ was calculated using up-down sequential analysis. Probit regression was used to estimate the relative mean potency of ropivacaine between groups.

Results: The ED₅₀ (mean [95% CI]) of ropivacaine was lower in the Day Group (17.9 [16.5–19.4] mg) than in the Night Group (20.9 [19.2–22.7] mg) (P = 0.003). The estimate of relative potency for ropivacaine for the Night Group vs. the Day Group was 0.85 (95% CI:0.56–0.98).

Conclusions: Under the conditions of this study, the dose requirement for epidural ropivacaine for labor analgesia was ~ 15% greater during the night than during the day.

Clinical Trials Registration: Chinese Clinical Trial Registry (No.: ChiCTR1900025269. http://www.chictr.org.cn/showprojen.aspx?proj=36993).

Management of pregnancy with diffuse cutaneous systemic sclerosis: a case report and literature review

Diffuse cutaneous systemic sclerosis may occur in women of childbearing age. Pregnancies in this population are associated with a markedly increased risk of adverse obstetric and maternal outcomes even before the onset of symptoms related to sclerosis. We report a case involving the management and outcome of pregnancy in a 30-year-old woman with diffuse cutaneous systemic sclerosis. The course of her pregnancy was good and was assisted by a group consultation including obstetricians and rheumatologists. Vaginal delivery was the patient’s preferred choice because she had irregular skin tightness in her lower abdominal skin. She underwent induction of labor and combined spinal-epidural analgesia, and successfully delivered. Importantly, these pregnancies need to be planned, where possible, to allow the opportunity to counsel women and their partners in advance and to decrease any risks. These pregnancies should be considered high risk, and they require close antenatal monitoring and good supervision from an expert multidisciplinary team experienced in high-risk pregnancies. The management of delivery for patients with cutaneous systemic sclerosis is challenging, and vaginal delivery with labor analgesia is an alternative option to cesarean section.

Acupoint Injection Decreases Anesthetic Cosumption during Combined Spinal-Epidural and Patient-Controlled Epidural Labor Analgesia

OBJECTIVE

To explore if acupoint injection can improve analgesic effects or delivery outcomes in parturients who received combined spinal-epidural analgesia (CSEA) and patient-controlled epidural analgesia (PCEA) for labor analgesia.

METHODS

A total of 307 participants were prospectively collected from July 2017 to December 2019. The participants were randomized into the combined acupoint injection with CSEA plus PCEA group (AICP group, n=168) and CSEA plus PCEA group (CP group, n=139) for labor analgesia using a random number table. Both groups received CSEA plus PCEA at cervical dilation 3 cm during labor process, and parturients of the AICP group were implemented acupoint injection for which bilateral acupoint of Zusanli (ST 36) and Sanyinjiao (SP 6) were selected in addition. The primary outcome was Visual Analogue Scale (VAS) score, and the secondary outcomes were obstetric outcomes and requirement of anesthetics doses. Safety evaluations were performed after intervention.

RESULTS

The VAS scores were significantly lower in the AICP group than in the CP group at 10, 30, 60, and 120 min after labor analgesia (all P<0.05). The latent phase of the AICP group was shorter than that of the CP group (P<0.05). There were less additional anesthetics consumption, lower incidences of uterine atony, fever, pruritus and urinary retention in the AICP group than those in the CP group (all P<0.05).

CONCLUSION

Acupoint injection combined CSEA plus PCEA for labor analgesia can decrease the anesthetic consumption, improve analgesic quality, and reduce adverse reactions in the parturients. (Registration No. ChiMCTR-2000003120).

The association between intrapartum opioid fentanyl and early breastfeeding: A prospective observational study

INTRODUCTION

Intrapartum opioids in labor may interfere with the early breastfeeding phase and cause breastfeeding difficulties. This study examines the effects of intrapartum fentanyl given intravenously (IV) or through epidural analgesia (EDA) on early breastfeeding.

MATERIAL AND METHODS

This is a prospective observational study conducted in a regional maternity unit. We included 1101 healthy mothers of term singleton babies in vertex presentation born between 2016 and 2018 (468 nulliparous and 633 multiparous). The main data were collected prospectively, and additional data were retrieved from hospital records. The main outcome measures were exclusive breastfeeding at discharge, spontaneous suckling, and breastfeeding problems after birth. We assessed the outcomes in four groups categorized by intrapartum opioid exposure: none, IV fentanyl, EDA fentanyl and IV+EDA fentanyl. We also analyzed the dose-response relation of fentanyl administered by epidural or IV and early breastfeeding. Ultimately, we dichotomized the IV fentanyl group into two groups (≤200 µg and >200 µg) to further study the effect on early breastfeeding.

RESULTS

The odds of non-exclusive breastfeeding were doubled with EDA fentanyl (odds ratio [OR] 2.45, 95% CI 1.34-4.48, p = 0.004) and four times higher with IV+EDA fentanyl (OR 4.20, 95% CI 2.49-7.09, p < 0.001) compared with no opioid exposure. Spontaneous suckling was negatively associated with intrapartum fentanyl use (p < 0.001) irrespective of mode of administration. When the IV fentanyl doses exceeded 200 µg compared with less than 200 µg, we found a reduction in exclusive breastfeeding (81% vs. 89%; p = 0.014) and spontaneous suckling (68% vs. 83%; p < 0.001) and an increase in breastfeeding problems (41% vs. 27%; p = 0.004).

CONCLUSIONS

Fentanyl in labor is associated with breastfeeding difficulties. However, IV fentanyl in low doses (≤200 µg) seems to affect breastfeeding less than EDA fentanyl and is therefore a viable alternative when labor analgesia is needed. This could be most relevant for multiparous women, where a shorter labor is expected. More research is needed to determine the optimal dose and route of administration of fentanyl for labor analgesia.

Feasibility of epidural injection of ropivacaine and dexamethasone for labor analgesia in women with preeclampsia

OBJECTIVE

This study aimed to investigate the feasibility of epidural injection of ropivacaine (Rop) and dexamethasone (Dex) for labor analgesia in women with preeclampsia.

METHODS

A total of 80 women with preeclampsia delivered in our hospital were enrolled, and were divided into a study group (n=41, Rop + Dex) and a control group (n=39, Rop alone). The changes in pain level, sedation, catecholamine hormone levels and vital signs were compared between the two groups after intervention. The motor blockade score and the incidence of adverse reactions after administration of anesthesia were compared in both groups.

RESULTS

Pain level [visual analogue scale (VAS) score], sedation (Ramsay score), adrenaline (AD), norepinephrine (NE), heart rate (HR), and mean arterial pressure (MAP) did not differ significantly between the two groups at pre-analgesia (T0) (P>0.05), and Ramsay score in the study group was significantly higher than that in the control group at 30 min (T1), 60 min (T2), 120 min after analgesia (T3), and cessation of analgesia (T4), and VAS score, AD, NE, HR, MAP in the study group were significantly lower than those in the control group during all stages of labor.

CONCLUSION

The epidural injection of Rop + Dex in women with preeclampsia can play a better analgesic and sedative effect, stabilize maternal hemodynamic index and improve postpartum motor blockade.

A randomized comparison of epidural, dural puncture epidural, and combined spinal-epidural without intrathecal opioids for labor analgesia

Background and Aims

Dural puncture epidural (DPE) has been shown to improve labor analgesia over epidural (EPL), with fewer side effects than a combined spinal-epidural (CSE). However, there is some debate regarding the superiority of DPE over EPL and CSE. Therefore, we aimed to compare the effects of EPL, DPE, and CSE without intrathecal opioids on the epidural local anesthetic (LA) consumption and occurrence of side effects in early labor.

Material and Methods

We randomly assigned parturient to one of the 3 groups; EPL, DPE, or CSE. EPL and DPE groups received a 10 mL loading dose of 0.1% bupivacaine with fentanyl 2 μg/mL. CSE group received intrathecal 2.5 mg bupivacaine (without opioids). Labor analgesia was maintained in all patients via patient-controlled epidural analgesia (PCEA). The primary outcome was the mean hourly consumption of epidural LA.

Results

The mean hourly consumption of epidural LA anesthetic was significantly lower in CSE (9.55 mL), compared with the EPL (11 mL), and DPE (10.5 mL), P < 0.01; but no significant difference was seen between EPL and DPE. Compared with EPL and DPE, CSE achieved faster time to complete analgesia defined as a numeric rating pain scale (NRPS) ≤1 and sensory block, lower NRPS in the first hour and higher frequencies of complete analgesia. There were no differences between groups in terms of physician top-up boluses, the occurrence of side-effects, mode of delivery, Apgar scores, and maternal satisfaction.

Conclusion

Compared with EPL and DPE, CSE without intrathecal opioids, had a less epidural LA consumption, faster onset of analgesia, with no difference in the incidence of side effects.

Trial Registration

This study was registered at www.clinicaltrials.gov (NCT03980951).

Effect of ropivacaine and sufentanil in epidural labor analgesia

OBJECTIVE

To investigate the application value of ropivacaine combined with sufentanil for epidural labor analgesia in painless labor.

METHODS

A total of 157 cases of pregnant female received painless labor in our hospital from January 2019 to December 2020 were randomly divided into observation group (n=81 cases) and control group (n=76 cases). The subjects in the observation group received 0.1% ropivacaine combined with sufentanil (0.25 μg/ml) 10 ml and added into the painless delivery pump, and the control group received 0.1% ropivacaine 10 ml into the painless delivery pump. The analgesic effect, lactation function, delivery outcomes and the labor course of the two groups were compared.

RESULTS

In the active stage of labor, the time of first labor process was shorter compared with the control group, those in the observation group were more active than the control group (P<0.05). The lactation initiation time of the observation group was shorter than that of the control group, and the effective rate of lactation was higher than that of the control group (P<0.05). The Visual analogue scale (VAS) score at 5 min, 30 min, 60 min, and 90 min after analgesia were improved in the observation group, the analgesic effect of ropivacaine combined with sufentanil for epidural labor analgesia was prior to ropivacaine alone. There were significant differences in the rates of conversion to cesarean section and usage rate of forceps between the two groups (P<0.05), while there had no significant differences in lateral episiotomy rate and Apgar scores at 1 and 5 min after birth between the two groups (P>0.05).

CONCLUSION

Ropivacaine combined with sufentanil for epidural labor analgesia in painless labor can effectively relieve labor pain, improve lactation function, active the first stage of labor, shorten the time of labor, reduce the incidence of cesarean section and ensure the safety of mother and infant.

A comparative study of epidural labor analgesia and natural delivery without analgesia

OBJECTIVE

To investigate the effects of epidural labor analgesia and natural delivery without analgesia on labor duration, pain, uterine continuous contraction time, abnormal labor process and complications.

METHODS

A total of 220 primiparas in our hospital were selected and divided into two groups according to whether they accepted epidural labor analgesia, including 146 cases in the study group and 74 cases in the blank group. Primiparas in the study group received epidural block analgesia, and those in the blank group received routine labor without analgesia. Duration of the first, second and third stages of labor was observed and recorded. The NRS pain score and uterine continuous contraction time were detected before and after the analgesia. The abnormal situation and complications of primiparas in the two groups were recorded.

RESULTS

Compared with those in the blank group, the duration of the first stage of labor and the amount of postpartum hemorrhage in the study group were decreased (all P<0.001). The primiparas' NRS score in the study group was lower than that in the blank group at 10 min, 15 min, 30 min, 60 min and 120 min after analgesia (all P<0.001). The duration of uterine contractions in the study group was lower than that in the blank group at 15 min, 30 min and 60 min after analgesia (all P<0.01). Compared with those in the blank group, primiparas in the study group had a higher probability of active phase arrest in the process of labor (P<0.05). Compared with the blank group, the probability of urinary retention in the study group increased (P<0.05).

CONCLUSION

The effect of epidural labor analgesia is better, which is conducive to shorten the time of the first stage of labor, good analgesic effect, shorter duration of the uterine contraction and higher safety.

The 90% Effective Dose of Sufentanil for Epidural Analgesia in the Early First Stage of Labor: A Double-blind, Sequential Dose-Finding Study

PURPOSE

Epidural analgesia in the latent phase of the first stage of labor has been recognized and accepted by anesthesiologists worldwide. However, there is no unified consensus on the exact dosage of sufentanil with the combination of ropivacaine in the induction of epidural analgesia in the early first stage of labor. In this sequential dose-finding study, the 90% effective dose (ED₉₀) of sufentanil for epidural administration in the early first stage of labor was estimated to minimize the adverse effects of using higher doses.

METHODS

Forty parturients with cervical dilatation of 2 to 4 cm who requested epidural analgesia were enrolled in this study. Parturients received 15 mL of a combination of ropivacaine 13 mg and the test dose of sufentanil. The initial dose of sufentanil in epidural administration was 1 μg, and the dose of sufentanil for the next parturient was based on the response of the preceding participant as per a biased coin up-and-down design. The primary outcome was the dose of sufentanil that resulted in successful epidural administration by maintaining the parturients' visual analog scale scores at ≤30 mm in the first 15, 30, and 45 minutes of induction. The ED₉₀ and 95% CIs were estimated using isotonic regression methods and bootstrapping.

FINDINGS

The estimated ED₉₀ of sufentanil in epidural administration in the early first stage of labor was 1.91 μg (95% CI, 1.82-2.35 μg) in this sequential dose-finding study.

IMPLICATIONS

Sufentanil at a dosage of 2 μg is recommended for the administration of epidural analgesia in parturients in the early first stage of labor. ChiCTR.org.cn identifier: 1900021683.

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

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.

Obesity decreases the EC50 of epidural ropivacaine when combined with dexmedetomidine for labor analgesia

OBJECTIVES

This study aims to estimate the EC50 of ropivacaine when co-administered with dexmedetomidine for epidural labor analgesia in antepartum obese and non-obese parturients.

METHODS

Sixty parturients scheduled for epidural labor analgesia were enrolled and divided into antepartum obesity (AO) and control (CON) groups, according to their body mass index at labor. Both groups received 0.5 µg/mL dexmedetomidine with ropivacaine as anesthetics. The concentration of ropivacaine was initially set at 0.125% and varied by 0.01% according to the up-and-down rule for sequential allocation. Hemodynamic parameters were monitored and pain intensity was assessed using a visual analog scale.

RESULTS

When co-administered with dexmedetomidine, the EC50 of ropivacaine was 0.095% (95% confidence interval [CI]: 0.090-0.100%) and 0.070% (95% CI: 0.062-0.076%) in CON and AO groups, respectively. There was a significant difference between the two groups (P < 0.001). EC95 values of ropivacaine were 0.084% (95% CI: 0.077-0.122%) and 0.106% (95% CI: 0.101-0.128%) in AO and CON groups, respectively.

CONCLUSION

Patients with antepartum obese may require decreased ropivacaine concentration for epidural labor analgesia when co-administered with 0.5 µg/mL dexmedetomidine.

Adjuvant Sufentanil Decreased the EC50 of Epidural Ropivacaine for Labor Analgesia in Healthy Term Pregnancy

Objective

The optimal concentration of ropivacaine as epidural labor analgesia combined with sufentanil has not been established. This study aimed to determine the median effective concentration (EC50) of epidural ropivacaine for labor analgesia in healthy term pregnancy when co-administered with sufentanil as an adjuvant or alone.

Patients and Methods

Sixty healthy parturients scheduled for epidural labor analgesia were enrolled in the study. They were divided into a saline group (Group C) and an epidural sufentanil (0.5 µg/mL) group (Group S). The initial concentration of ropivacaine was set at 0.125%, which was then varied by 0.01% using the up-and-down sequential allocation method. The hemodynamics were continuously monitored during delivery. A visual analog scale was used to evaluate the degree of pain. The Ramsay sedation score, duration of the labor stages, the onset of epidural analgesia, and adverse effects were recorded. Neonatal outcomes were evaluated using the Apgar scores and umbilical artery blood gas analysis.

Results

The EC50 of ropivacaine was 0.085% (95% CI, 0.079–0.090%) in Group S and 0.109% (95% CI, 0.105–0.112%) in Group C. The EC95 of ropivacaine was 0.096% (95% CI, 0.090–0.118%) in Group S, and 0.116% (95% CI, 0.113–0.127%) in Group C. The difference between the groups was statistically significant (p < 0.001). The stable hemodynamics, satisfactory analgesia, and good neonatal outcomes were comparable in both groups (P > 0.05).

Conclusion

The EC50 of ropivacaine was reduced by 22% when co-administered with sufentanil for epidural labor analgesia in primipara. (www.chictr.org.cn; registration number: ChiCTR2000039547).

[Effect of magnetic beads auricular point sticking therapy on intrapartum fever in primipara with epidural labor analgesia]

OBJECTIVE

To observe effect of magnetic beads auricular point sticking therapy on intrapartum fever in primipara with epidural labor analgesia and explore its possible mechanism.

METHODS

A total of 160 primipara were randomly divided into an observation group (80 cases, 12 cases dropped off ) and a control group (80 cases, 15 cases dropped off ). The primipara in the control group received epidural labor analgesia. In the observation group, 15 min after epidural labor analgesia was performed, magnetic beads auricular point sticking therapy was given at shenmen (TF₄), neishengzhiqi (TF₂), neifenmi (CO₁₈) and jiaogan (AH_6a), pressing and kneading once every 15 min, 1 min each time, until the end of first stage of labor. The tympanic temperature on T_a (before labor analgesia), T_b (2 h after labor analgesia), T_c (4 h after labor analgesia) and T_d (1 h after labor) was recorded, and the intrapartum fever incidence and level of serum cortisol and IL-6 between two groups were compared. The visual analogue scale (VAS) score before and after labor analgesia, the pressing times of patient controlled epidural analgesia (PCEA), and the dosage of sufentanil were observed. The active labor period, the second stage of labor, and the time of analgesia, the use of oxytocin, the number of vaginal examination and the rate of cesarean section were recorded in the two groups.

RESULTS

There was no significant difference in tympanic temperature in the observation group at each time point (P>0.05), the tympanic temperature at T_c and T_d in the control group was higher than that at T_a (P<0.05); the tympanic temperature at T_c and T_d in the observation group was lower than that in the control group (P<0.05). The levels of serum cortisol and IL-6 at T_d in the two groups were higher than those at T_a (P<0.05), and those in the observation group were lower than the control group (P<0.05). The second stage of labor in the observation group was shorter than that in the control group (P<0.05), and the pressing times of PCEA, the dosage of sufentanil, intrapartum fever incidence, usage rate and total amount of oxytocin and the number of vaginal examinations were all lower than those in the control group (P<0.05).

CONCLUSION

Magnetic beads auricular point sticking therapy can reduce the amount of anesthetics, decrease the effect of epidural analgesia on primipara's body temperature regulation and labor progress, and lower the incidence of fever during labor analgesia by regulating the level of inflammatory response in the primipara.

Labor Epidural in a Patient Who is Allergic to Lidocaine: A Case Series

Continuous epidural anesthesia is considered the best modality for pain relief during labor, local anesthetic allergy is an uncommon occurrence but if a patient has an allergy to bupivacaine or lidocaine owing to its cross-reactivity with bupivacaine then it becomes very challenging to manage labor analgesia. A direct challenge test to rule out actual hypersensitivity was not considered a viable option given the risks involved if a severe allergic reaction occurred with the test dose. Using IV opioid-based analgesia has harmful effects for both mother and the baby in addition to decreasing participation of mothers in the birthing process owing to its sedative properties. We report two cases where the mother had a history of lidocaine allergy, so labor analgesia was managed using chloroprocaine patient-controlled epidural analgesia (PCEA).

The Analgesic Effect of Transcutaneous Electrical Acupoint Stimulation on Labor: A Randomized Control Study

Objective

This study aimed to investigate the analgesic effect of transcutaneous electrical acupoint stimulation (TEAS) on labor.

Methods

Primiparas with single birth and head presentation were enrolled in this study and randomly divided into three groups: TEAS group (n = 76), patient-controlled epidural analgesia (PCEA) group (n = 75), and control group without any analgesic measures (n = 78).

Results

Compared with the control group, the visual analog scores of the TEAS group and the PCEA group at each time point decreased (P < 0.01). The decrease was greater in the PCEA group than that in the TEAS group (P < 0.01). At 120 minutes after analgesia, there were significant differences in plasma β-endorphin content between the TEAS group, PCEA group, and control group (P < 0.01). The difference between the PCEA group and the control group was statistically significant (P < 0.01). Among the parturients having a vaginal delivery, the duration of the first stage of labor was significantly shorter in the TEAS group and control group than in the PCEA group (P < 0.01). The duration of the second stage of labor was significantly shorter in the TEAS group than in the PCEA group (P < 0.01). Oxytocin usage rate during labor was significantly lower in the TEAS group and control group than in the PCEA group (P < 0.01), and adverse reactions were significantly fewer in the TEAS group and control group than in the PCEA group (P < 0.01).

Conclusion

The duration of the first and second stage of labor is significantly shorter in the TEAS group than in the PCEA group. TEAS does not increase the use rate of oxytocin or the rate of cesarean section and will not bring about obvious maternal or fetal adverse reactions.

Impact of therapeutic rest in early labor on perinatal outcomes: a prospective study

BACKGROUND

Pain and exhaustion in early labor are important to address, yet treatment options are limited. Therapeutic rest has existed for decades, although medication regimens and management strategies vary. In addition, there are little prospective data on perinatal outcomes and patient satisfaction to support and guide its use as an outpatient pain control option.

OBJECTIVE

This study aimed to evaluate whether outpatient therapeutic rest in early labor using intramuscular morphine sulfate and promethazine is associated with differences in perinatal outcomes and to assess patient satisfaction with this therapy.

STUDY DESIGN

This prospective cohort study was conducted at a tertiary care academic medical center from September 2017 to April 2020. Participants presenting to the hospital for labor evaluation were offered therapeutic rest if they met the following criteria: reassuring modified biophysical profile, cervical dilation of ≤5 cm without contraindications to vaginal delivery, and plan to discharge home after evaluation. The primary outcome was subsequent hospital admission in active labor, defined as cervical dilation of ≥6 cm. Secondary outcomes included hospitalization duration and perinatal outcomes. The outcomes between participants who accepted therapeutic rest and those who declined it were compared. All P values were calculated using the Fisher exact test, and multivariable regression was used to adjust for potential confounding baseline variables with P<.2. In addition, a prespecified sensitivity analysis was performed, limiting subjects to nulliparous participants. Furthermore, postpartum surveys were administered to a subset of women who received therapeutic rest.

RESULTS

Of the 82 individuals offered therapeutic rest and consented for the study, 66 (80%) accepted and 16 (20%) declined. Although the rate of active labor at admission to the labor and delivery unit in the treatment group was markedly higher (26% [17 of 66] vs 13% [2 of 16]), this difference was not statistically significant (P=.3) (adjusted relative risk, 1.87; 95% confidence interval, 0.44-7.89). Women who received therapeutic rest were less likely to require induction of labor compared with those who declined therapeutic rest (adjusted relative risk, 0.15; 95% confidence interval, 0.041-0.54). There was no difference between the groups in mode of delivery, epidural use, length of hospitalization, maternal complications, or adverse neonatal outcomes. These findings persisted in our prespecified sensitivity analysis, limiting the study to nulliparous participants. A subset (27 of 66 [40%]) of women were surveyed after receiving therapeutic rest, and all women (n=27) who were surveyed reported satisfaction.

CONCLUSION

There was no detectable difference in the primary outcome of active labor at admission between patients who accepted outpatient therapeutic rest and those who declined it. However, fewer participants in the treatment group eventually required induction of labor, and this group did not experience an increase in adverse perinatal outcomes. Among the participants surveyed, a high rate of treatment satisfaction was reported. This study suggested that therapeutic rest is a well-tolerated and effective option for outpatient pain control in early labor.

The effect of programmed intermittent epidural bolus compared with continuous epidural infusion in labor analgesia with ropivacaine: a meta-analysis of randomized controlled trials

BACKGROUND

Programmed intermittent epidural bolus (PIEB) as a new technique for labor analgesia has aroused extensive attention. The character of separation of the motor block to sensory block makes ropivacaine becoming an important local anesthetic for labor analgesia. In this meta-analysis, we aimed to assess the efficiency and safety of PIEB regime compared to continuous epidural infusion (CEI) regime on labor analgesia with ropivacaine following the evidence emerged newly.

METHODS

PubMed, EMBASE and the Cochrane library were searched for potential articles. Eligible studies should meet these criterions: (I) healthy women; (II) it should compare PIEB and CEI; (III) ropivacaine should be use as local anesthetic for the maintenance of analgesia; (IV) the study should report the any of the outcomes we need. Maternal satisfaction, consumption of ropivacaine and duration of labor as well as the adverse effect were used to measure the efficacy and safety of those two regimes. Mean difference (MD), relative risk (RR), 95% confidence intervals (CI) were used to present the final results.

RESULTS

Ten articles of randomized controlled trials and 3,790 subjects were eventually included in study. The pooled results showed that PIEB with ropivacaine significantly improved satisfaction (MD, 7.87; 95% CI: 6.02 to 9.72; I2 =0%; P<0.001), reduced the local anesthetic (milligram) in total (MD, -10.37 milligrams; 95% CI: -17.70 to -3.03; I2 =94%; P<0.001) and hourly (MD, -1.80 milligrams; 95% CI: -2.62 to -0.98; I 2 =56%; P<0.001). PIEB shortened the second stage of labor but has similar total duration of labor and it also decrease the incidence of motor block compare to CEI. There were no differences in mode of delivery and rescue bolus between two groups.

CONCLUSIONS

This study shows that PIEB regime was associated with higher satisfaction, lower consumption of ropivacaine in hours and totally, and shorter duration of second stage of labor compared to CEI in analgesia with ropivacaine during childbirth. PIEB regime has greater safety on fetus and maternity than CEI regime and it decreased the incidence of motor block without increasing other side effects compared to CEI.