Maternal expectations and experiences of labour pain — options of 1091 Finnish parturients

A prospective survey of 1091 Finnish parturients was conducted in order to ascertain mothers' expectations for labour pain relief, to measure the actual pain during all three stages of labour and to question their satisfaction and the adequacy of pain relief on the third day following delivery. Antenatal expectations for pain relief were surveyed. Mothers were questioned on pain levels in the delivery room and 3 days after giving birth. Pain levels were ascertained using a visual pain score method. Antenatally, 90% of all parturients anticipated a need for pain relief during labour. In the delivery room over 80% of all parturients described their pain as very severe to intolerable, only 4% of the multiparous had low pain scores (0–2). After pain treatment 50% of multiparous women still had pain scores from 8 to 10, which reflects a lack of effective pain relief. Dissatisfaction with the childbirth experience was very low, and was associated with instrumental deliveries, but not with the usage of analgesia. 51% of all parturients complained of inadequate pain relief during childbirth, which, in multiparous women, was significantly associated with the second stage of labour.     

Impact of walking epidural analgesia on obstetric outcome of nulliparous women in spontaneous labour

BACKGROUND: To explore the effects of walking epidural analgesia on obstetric and neonatal outcomes, we performed a case-control study. METHOD: Each nulliparous woman receiving walking epidural analgesia using 0.0625% bupivacaine (n = 44) was matched to two nulliparous historical controls receiving 0.125% or 0.25% bupivacaine (n = 88 each) for epidural analgesia while recumbent. RESULTS: Maternal and obstetric parameters, fetal status and presentation, and oxytocin use were comparable among groups. Those receiving walking epidural analgesia walked for a mean of 60 min (range: 20-75 min). In the control groups the mean total durations of labour were shorter (58 min in the 0.125% group and 99 min in the 0.25% group, P < 0.05). Significantly fewer walking epidural analgesia cases than controls required instrumental vaginal delivery (P < 0.05). No other differences in obstetric or fetal outcome were observed and no mother fell or stumbled while walking. CONCLUSION: Although it was associated with a prolonged first stage of labour, walking epidural analgesia appeared safe for nulliparous women and their babies.     

Timing of epidural analgesia intervention for labor pain in nulliparous women in Taiwan: A retrospective study

BackgroundLabor pain is probably the most painful event in a woman's life. By the present consensus, epidural analgesia is the most effective and least depressive treatment for labor pain. Recent systematic reviews concluded that the risk of cesarean delivery or instrumental vaginal delivery for women receiving early epidural analgesia has not increased. However, studies designed for discussing this topic in Taiwan are few. In this study, the association of the intervention timing with labor outcomes in nulliparous women in Taiwan is discussed.MethodsWe performed a retrospective chart review in parturients who underwent epidural analgesia for labor pain. Only nulliparae were included and divided into four groups based on the cervical dilatation width of 1, 2, 3, and 4 cm when they underwent epidural analgesia. We retrieved each patient's demographic characteristics, the course of labor and delivery, and the management of epidural analgesia from the medical chart.ResultsA total of 799 nulliparae was included. The numbers of parturients with cervical dilatation width of 1, 2, 3, and 4 cm were 119, 338, 258, and 84 respectively. There was no significant difference in demographic factors, regimen of epidural analgesia, loading volume, and anesthesiologist in charge among the four groups. The percentages of cesarean delivery in the four groups were 27.73%, 20.71%, 15.89%, and 20.24%, respectively, and there was no significant difference among these four groups (p = 0.0651). The incidences of instrumental delivery in four groups were 13.51%, 14.59%, 18.65%, and 21.43% respectively, and there was no significant difference among these four groups either (p = 0.2278).ConclusionOur results revealed that the timing of epidural intervention affects neither the cesarean delivery rate nor the instrumental delivery rate on nulliparae in Taiwan with the cervical dilatation width ranging from 1 cm to 4 cm. The fear of increasing cesarean section rate after early epidural analgesia is unfounded. Women in labor can choose pain relief at any time.     

Maternal postures and epidural analgesia during labour

The evolution of birth is of interest for obstetricians and midwives. Postures with asymmetric stretching and balance, kneeling, or sitting have been claimed to be able to help foetal head rotation. Although walking during labour have no influence on the outcome of labour, hip-flexed postures enlarging the pelvic diameter are yet evaluated to improve the obstetric course of labour. In a prospective randomised study including 93 parturients, we compared the supine 30 degrees lateral tilt (control group) to three hip-flexed postures: sitting (S), right hip-flexed left lateral position (L) and left hip-flexed right lateral position (R). Epidural analgesia with 12 ml ropivacaine 0.1% and sufentanil 0.5 microg/ml was administered over a period of six minutes. The total epidural spread was 15+/-0.3 dermatomes and the upper level of thermo-analgesic blockade reached T7-T8 (T5 to T10) in each group. There were no differences between groups for the left and right total spread and upper level of epidural blockade, for the time to maximal block and pain relief. There was no motor block and no maternal or foetal side effects. We conclude that, for the three hip-flexed postures tested, position does not influence local anesthetic spread or symmetry of analgesia after induction of obstetric epidural anaesthesia.     

The elective use of oxytocin infusion during labour in nulliparous women using epidural analgesia: a randomised double-blind placebo-controlled trial

The obstetric outcome following the elective use of oxytocin infusion was determined in a randomised, double-blind placebo-controlled trial. 93 nulliparous women in a London hospital, who had requested epidural analgesia in labour (相似文献   

Pain and pain relief in labour: parturients' experiences

The experiences of 890 parturients were studied across Finland during one week to determine how they experienced labour pain and how effective they regarded the means to alleviate it. The majority of women (72%) had been afraid of labour and 88% had intended to request some pharmacological pain relief. 84% of primiparous and 72% of multiparous rated their pain severe or unbearable. Epidural analgesia was found to be the most effective method in the first stage of labour, but in the second this superiority was no longer apparent. Unfortunately, it seems to be readily available only during office hours in spite of the fact that the majority of deliveries happen outside of that time.     

Practice of epidural analgesia for labour pain: a German survey.

Epidural analgesia is one of the preferred methods of analgesia for labour. The aim of the present survey was to evaluate current practice in obstetric analgesia in departments of anaesthesia and to make a comparison with former surveys from Germany and other countries. Questionnaires on the practice of pain relief, especially epidural analgesia, during labour and delivery were sent to 1178 anaesthetic departments in Germany in the second half of 1996. Five hundred and thirty-two completed replies were received, which represent 46.9% of all German obstetric units. The majority of the departments of anaesthesia practising epidural analgesia have an epidural rate of less than 10% and 10.2% of the departments do not offer this method to their parturients. In 86.8% of all units performing epidural analgesia, the epidural catheter is placed by an anaesthetist. Only 6.5% of the units provide a 24-h epidural service which is exclusively assigned to labour and delivery. In 77.8% of the units, this service is not exclusively assigned to obstetrics, but also to other duties. Of the obstetric units offering epidural analgesia, 14.7% have no epidural service at night. Plain local anaesthetics for epidural analgesia are used by 55.9% of the departments, a combination of local anaesthetics with epidural opioids by 28.7%. Epidural analgesia is predominantly (82.2%) maintained by intermittent bolus administration. Although the rate of epidural analgesia increased during recent decades, this method is not offered to all parturients. Further improvements in the use of epidural analgesia for labour seem to be necessary.     

Cesarean delivery: a randomized trial of epidural analgesia versus intravenous meperidine analgesia during labor in nulliparous women

BACKGROUND: Controversy concerning increased cesarean births as a result of epidural analgesia for relief of labor pain has been attributed, in large part, to difficulties interpreting published studies because of design flaws. In this study, the authors compared epidural analgesia to intravenous meperidine analgesia using patient-controlled devices during labor to evaluate the effects of labor epidural analgesia, primarily on the rate of cesarean deliveries while minimizing limitations attributable to study design. METHODS: Four hundred fifty-nine nulliparous women in spontaneous labor at term were randomly assigned to receive either epidural analgesia or intravenous meperidine analgesia. Epidural analgesia was initiated with 0.25% bupivacaine and was maintained with 0.0625% bupivacaine and fentanyl 2 microg/ml at 6 ml/h with 5-ml bolus doses every 15 min as needed using a patient-controlled pump. Women in the intravenous analgesia group received 50 mg meperidine with 25 mg promethazine hydrochloride as an initial bolus, followed by 15 mg meperidine every 10 min as needed, using a patient-controlled pump. A written procedural manual that prescribed the intrapartum obstetric management was followed for each woman randomized in the study. RESULTS: A total of 226 women were randomized to receive epidural analgesia, and 233 women were randomized to receive intravenous meperidine analgesia. Protocol violations occurred in 8% (38 of 459) of women. There was no difference in the rate of cesarean deliveries between the two analgesia groups (epidural analgesia, 7% [16 of 226; 95% confidence interval, 4-11%] vs. intravenous meperidine analgesia, 9% [20 of 233; 95% confidence interval, 5-13%]; P = 0.61). Significantly more women randomized to epidural analgesia had forceps deliveries compared with those randomized to meperidine analgesia (12% [26 of 226] vs. 3% [7 of 233]; P < 0.001). Women who received epidural analgesia reported lower pain scores during labor and delivery compared with women who received intravenous meperidine analgesia. CONCLUSIONS: Epidural analgesia compared with intravenous meperidine analgesia during labor does not increase cesarean deliveries in nulliparous women.     

Maternal and neonatal side-effects of remifentanil patient-controlled analgesia in labour

Background. Remifentanil has been suggested as an ideal opioidfor patient-controlled analgesia (PCA) in labour, but the safetyprofile has not been established. The aims of this preliminaryprospective observational study were to investigate the maternalside-effects and early neonatal effects, and to assess the placentaltransfer of remifentanil PCA during labour. Methods. Women with no known obstetric complications or contraindicationto remifentanil were recruited (n=50). Remifentanil was administeredat a bolus dose of 0.5 µg kg^–1 and a lockout periodof 2 min. A visual analogue scale was used to assess pain, nauseaand itching. Maternal observations were recorded hourly andfetal heart rate trace was assessed every 2 h. Umbilical cordgases, 1 and 5 min Apgar scores and neurological evaluationof the neonate were recorded. Maternal venous blood and umbilicalartery and vein cord blood samples were collected for analysisof remifentanil concentration. Results. Fifty women enrolled in the study (24 multiparous,26 primiparous). There was no evidence of cardiovascular instabilityor respiratory depression. Pain scores decreased significantly,but there was no significant change in nausea after initiatingthe PCA. A statistically significant increase in itching wasfound to be clinically mild and 22 women were slightly drowsy(95% confidence interval [CI], 30–58.7%) but alert tovoice. Ten fetal heart rate traces demonstrated changes in thefirst 20 min, but did not require intervention (95% CI, 10–33.7%).The median 1 and 5 min Apgar scores were 9. The mean umbilicalcord gases and neurological examination were within normal limits.Maternal vein and umbilical vein cord samples demonstrated placentaltransfer of remifentanil, and small amounts were detected inumbilical artery samples. Conclusions. At the bolus dose used remifentanil PCA has anacceptable level of maternal side-effects and minimal effecton the neonate. Remifentanil crosses the placenta and appearsto be either rapidly metabolized or redistributed in the neonate.     

Labor analgesia and cesarean delivery: an individual patient meta-analysis of nulliparous women

BACKGROUND: The authors performed an individual patient meta-analysis of 2,703 nulliparous women who were randomized to either epidural analgesia or intravenous opioids for pain relief during labor from five trials conducted at their hospital. The primary purpose in this meta-analysis was to evaluate the effects of epidural analgesia during labor on the rate of cesarean delivery. METHODS: Between November 1, 1993, and November 3, 2000, 2,703 nulliparous women (2,188 healthy parturients and 515 women with pregnancy-induced hypertension) in spontaneous labor at term were randomized to receive either epidural analgesia or intravenous opioid analgesia in the five studies. Epidural analgesia was initiated with either epidural bupivacaine or intrathecal sufentanil and was maintained with a low-dose (0.0625% or 0.125%) mixture of bupivacaine with fentanyl. Intravenous opioid analgesia was initiated with 50 mg meperidine and 25 mg promethazine hydrochloride and was maintained with intravenous boluses of meperidine as needed. RESULTS: A total of 1,339 nulliparous women were randomized to receive epidural analgesia, and 1,364 women were randomized to receive intravenous meperidine analgesia. There was no difference in the rate of cesarean deliveries between the two analgesia groups (epidural analgesia, 10.5% [140 of 1,339] vs. intravenous meperidine analgesia, 10.3% [141 of 1,364]; adjusted odds ratio, 1.04; 95% confidence interval, 0.81-1.34; P = 0.920). Significantly more women randomized to epidural analgesia had forceps deliveries compared to meperidine analgesia (13% [172 of 1,339] vs. 7% [101 of 1,364]; adjusted odds ratio, 1.86; 95% confidence interval, 1.43-2.40; P < 0.001). Epidural women had longer first and second stages of labor. Women who received epidural analgesia reported lower pain scores during labor and delivery compared to women who received intravenous meperidine analgesia. CONCLUSION: Epidural analgesia compared to intravenous meperidine analgesia during labor does not increase the number of cesarean deliveries.     

Maternal satisfaction with single-dose spinal analgesia for labor pain in Indonesia: a landmark study

The purpose of this study was to assess maternal satisfaction with single-dose spinal analgesia for the management of obstetric pain in Indonesian women. The investigation included 62 laboring women with single pregnancy at term, with 45 primigravidas and 17 multigravidas. The participants’ ages ranged from 15 to 29 years. All participants were screened for physical health and were classified as healthy according to the American Society of Anesthesiologists classification system. All 62 parturients received single-dose spinal anesthesia with a 27-gauge pencil-point needle at either the L3–4 or L4–5 intervertebral interspace, with a combination of bupivacaine, 2.5 mg; morphine, 0.25 mg; and clonidine, 45 μg. Maternal satisfaction, duration of pain relief, and side effects were studied. The overall maternal satisfaction with the single-dose spinal technique for labor analgesia in our study group was high, with 50 patients (81%) being very satisfied, and 7 patients (11%) being satisfied with the quality of labor analgesia. Forty-nine patients (79%) stated that they would select single-dose spinal analgesia for pain control in labor in the future. Our study was the first one in Indonesia to assess maternal satisfaction with single-dose spinal analgesia for labor pain. We concluded that single-dose spinal analgesia with a combination of bupivacaine, morphine, and clonidine provided effective labor pain control for Indonesian women, and maternal satisfaction with this technique was very high. This technique is very cost-effective and should be recommended for routine obstetric pain control in Indonesia and other developing countries. Presented in part by doctors Susilo Chandra and Krzysztof M. Kuczkowski at the Annual Meeting of the Society for Obstetric Anesthesia and Perinatology (SOAP) in Banff, Alberta, Canada, May 16–19, 2007.     

Patient-controlled analgesia for labour using remifentanil: a feasibility study

We have investigated the efficacy and safety of remifentanilin a patient-controlled analgesia device for labour in 21 women.Remifentanil was available in increasing doses (bolus doses0.25–1.0 µg kg^–1) with and without a backgroundinfusion (0.025–0.05 µg kg^–1 min^–1).A lockout time of 2 min was used. Thirteen out of 21 (62%) womenchose to continue using remifentanil up to and during delivery.Nineteen out of 21 (90%) achieved a reduction in pain scorefrom baseline. Using a VAS of 0–10 cm the median maximumreduction in pain score was 3 cm (range 0–8 cm). Therewas a significant reduction (P<0.05) from baseline pain scores(median= 8 cm) to scores at bolus doses in the range 0.25–0.5µg kg^–1 (median=5 cm). There were no significantreductions in the fetal heart rate. Apgar scores and cord bloodgas analyses remained within normal limits. We conclude thata remifentanil patient-controlled analgesia system (bolus doses0.25–0.5 µg kg^–1, without a background infusion)may safely provide worthwhile, although incomplete, analgesiafor labour. Br J Anaesth 2001; 87: 415–20     

The effect of labour and epidural analgesia on pain threshold

Pain thresholds were measured using forehead pressure in 30 women before amniotomy and then during labour up to the point of their requesting analgesia. Measurements continued subsequently only in those having epidural analgesia alone. No significant change in pain threshold was seen in any patient up to the administration of analgesia, nor thereafter in the ten patients having epidurals. This study fails to confirm previous reports in animals of significant rises in pain threshold during parturition. It calls into question the view that previously reported changes in plasma endorphin levels may be associated with altered pain thresholds.     

Accidental dural puncture during labor analgesia and obstetric outcomes in nulliparous women

BackgroundThe effect of accidental dural puncture during labor epidural analgesia on obstetric outcomes remains unexplored. In this retrospective cohort study, we tested the hypothesis that accidental dural puncture is associated with prolonged second stage of labor.MethodsAnesthetic and obstetric data from nulliparous parturients who suffered an accidental dural puncture at term labor (n=89) during the years 2006–2012 were compared with randomly selected parturients with uncomplicated epidural analgesia (n=232). The primary outcome was the proportion of parturients with prolonged second stage of labor: secondary outcomes were the proportion of instrumented and cesarean deliveries. Statistical analysis included student t-test for continuous variables, chi-square test for binary variables, and logistic regressions for associations between accidental dural puncture and outcomes.ResultsDemographic and obstetric characteristics of parturients were comparable except for a non-significant increase in prolonged second stage of labor in the accidental dural puncture group (27% vs. 17%, P=0.06). After adjusting for known potential confounders, multivariate logistic regression analyses revealed a significant association between accidental dural puncture and prolonged second stage of labor (adjusted risk ratio [aRR] 1.99, 95% CI 1.04 to 3.82; P=0.037). This was not accompanied by an increase in instrumented (aRR 0.57, 95% CI 0.27 to 1.21; P=0.15) or cesarean delivery (aRR 1.83, 95% CI 0.89 to 3.77; P=0.10).ConclusionAccidental dural puncture during labor analgesia was associated with prolonged second stage of labor in nulliparous parturients. Prospective studies are needed to assess the relationship between the quality of neuraxial block after accidental dural puncture and obstetric outcomes.     

Breast-feeding problems after epidural analgesia for labour: a retrospective cohort study of pain, obstetrical procedures and breast-feeding practices

Various clinical practices have been found to be associated with breast-feeding problems. However, little is known about the effect of pain, obstetrical procedures and analgesia on breast-feeding behaviour. We designed a retrospective study with a questionnaire concerning pain, obstetrical procedures and breast-feeding practices mailed to 164 primiparae in Lapland. Altogether 99 mothers (60%) returned completed questionnaires that could be included in the analysis, which was carried out in two steps. Firstly, all accepted questionnaires were grouped according to the success or failure to breast-feed fully during the first 12 weeks of life. Secondly, an ad hoc cohort study was performed on the sub-sample of 64 mothers delivered vaginally. As many as 44% of the 99 mothers reported partial breast feeding or formula feeding during the first 12 weeks. Older age of the mother, use of epidural analgesia and the problem of "not having enough milk" were associated with the failure to breast-feed fully. Caesarean section, other methods of labour analgesia and other breast-feeding problems were not associated with partial breast feeding or formula feeding. In the sub-sample, 67% of the mothers who had laboured with epidural analgesia and 29% of the mothers who laboured without epidural analgesia reported partial breast feeding or formula feeding (P = 0.003). The problem of "not having enough milk" was more often reported by those who had had epidural analgesia. Further studies conducted prospectively are needed to establish whether a causal relationship exists between epidural analgesia and breast-feeding problems.     

Maternal and fetal effects of intravenous patient-controlled fentanyl analgesia during labour in a thrombocytopenic parturient

The use of intravenous (i.v.) patient-controlled fentanyl analgesia during labour in a parturient with unexplained thrombocytopenia (70 x 10(3).ml-1) is described. The patient self-administered boluses of 25 micrograms of fentanyl with a lock-out interval of ten min. In addition, a concurrent fentanyl infusion of 25 micrograms.hr-1 was given. Effective analgesia was achieved during labour and a total of 1025 micrograms of fentanyl was infused over 11 hr 55 min until delivery of a vigorous infant with Apgar scores of 9 after one and five min. Respiratory depression or undue sedation were not observed in the mother either during labour or in the post-partum period. At birth, maternal total plasma fentanyl concentration was 1.11 ng.ml-1, whereas neonatal umbilical total plasma fentanyl concentration was 0.43 ng.ml-1. Newborn plasma protein binding of fentanyl was lower compared to the mother (63% vs 89%). Thus, free fentanyl concentrations (0.16 ng.ml-1) were identical in the mother and newborn at delivery.