Stand der Analgesie und Anästhesie in der Geburtshilfe Eine Umfrage aus Nordrhein-Westfalen

Background: The purpose of this study was to determine obstetrical pain management practices for labour for spontaneous and operative vaginal deliveries since there were no comparative German data available for the past 10 years. Methods: A mail survey was sent to the chief anaesthetists of all hospitals in North Rhine-Westfalia designated to have obstetrical beds. The confidential and standardised questionnaire consisted of 24 mainly multiple-choice questions relating to general issues and methods of analgesia and anaesthesia for vaginal deliveries. Results: In all, 118 completed replies to 258 sent questionnaires were received, giving a response rate of 46%. Among the 118 hospitals there were 79,157 vaginal deliveries annually. All participating hospitals practiced either systemic analgesics/spasmolytics and/or regional-anaesthetic methods (Table 2). Perineal local infiltration (23.7% of vaginal deliveries, in 99% of cases performed by the obstetrician) and epidural analgesia (23.2% of vaginal deliveries, in 81% of cases performed by an anaesthetist) were the commonest regional-anaesthetic methods. Pudendal nerve blocks were performed in 18.5% of vaginal deliveries (Table 1). Of all participating hospitals, 97% provided a 24-h epidural service. The method of epidural anaesthesia was widely homogeneous in all 118 hospitals (Table 3). Other methods of regional analgesia (i.e., epidural infusions or patient-controlled epidural analgesia) were performed only rarely. Conclusions: The methods of obstetrical analgesia and anaesthesia are on a high level and show a broad homogeneity in all hospitals. Overall, the results indicate, in comparison to former studies and in common with other countries, steadily increasing use of regional anaesthesia performed by anaesthetists in contrast to decreasing numbers of local infiltrations performed by obstetricians.     

Effect of a mother-to-child HIV prevention programme on infant feeding and caring practices in South Africa.

OBJECTIVES: To conduct a rapid assessment of the impact of the Khayelitsha Prevention of Mother-to-Child Transmission (MTCT) programme on infant care practices among programme participants and the local population. STUDY DESIGN: Cross-sectional survey and qualitative in-depth interviews. SETTING. Khayelitsha, a large formal and informal settlement of about 300,000 people on the outskirts of Cape Town. At the time of the study the HIV seroprevalence rate among antenatal women was about 15% and the MTCT programme had enrolled nearly 800 infected women. SUBJECTS: Seventy randomly selected caregivers with young children in the survey; in-depth structured interviews with 11 nutrition counsellors and 11 mothers enrolled in the programme. RESULTS: Caregivers have good knowledge of the spread and prevention of HIV. A majority knew that breast-feeding can transmit HIV but 90% stated that this did not affect their feeding decisions. Over 80% had stopped exclusively breast-feeding by the time their infants were 3 months of age. All of the respondents felt that being diagnosed HIV-positive would result in serious social and domestic consequences. None of the health workers could correctly estimate the risk of spreading HIV through breast-feeding and many reported feeling confused about what they should counsel mothers. All the mothers on the programme reported exclusive formula-feeding. Some had serious problems with preparation and feeding of formula milk. Nearly all reported running out of feeds before being able to fetch new supplies. None reported any negative social effects of not breast-feeding. Most of the mothers endorsed the programme and felt that it had given them strength to face up to and plan for the consequences of their diagnosis. CONCLUSION: This rapid appraisal of the infant feeding and care component of the MTCT programme has raised a number of important challenges which health managers and policymakers need to address. Similar assessments in the new pilot sites will be important.     

Breast feeding after breast reduction]

Few authors have addressed the feasibility of breast-feeding after a reduction mammaplasty. Nowadays, the majority of plastic surgeons perform breast reductions with techniques preserving the continuity of the nipple-areola complex with the retained breast tissue. These pedicle techniques should permit lactation as opposed to the free nipple grafting technique used earlier. To find out how many women nurse their children after a reduction mammaplasty, we reviewed 806 charts to identify 243 women having had a pedicle technique breast reduction, between 1967-1987, at the age of 15 to 35 years. These women were contacted and 98 of them were reached. Eighteen women had become pregnant after their surgery. They agreed to answer a questionnaire regarding their decision to nurse their children, the duration of breast-feeding and the difficulties encountered. Eight of eighteen mothers (45%) nursed their children up to 32 weeks (mean 11 weeks). Among them, 3 nursed for less than 3 weeks and 5 nursed from 3 to 32 weeks (mean 20 weeks). Only one mother had to supplement nursing with formula. Two mothers used mixed formula and breast-feeding when they returned to work. Ten of eighteen mothers (55%) did not breast-feed for the following reasons: 6 by personal choice, 2 due to premature delivery, one was advised that nursing was not feasible and one had no lactation. We believe that the nursing capacity of the breast is preserved after a breast reduction and that women should be encouraged to nurse their children.     

Cyclosporine excretion into breast milk

Although many female patients of childbearing age who are receiving cyclosporine have successful pregnancies, these women may be advised not to breast-feed. During recent years, cases of uneventful pregnancies and subsequent successful breast-feeding have been reported in the literature. The infant's blood cyclosporine concentration was usually very low. Based on these findings and the lack of detectable adverse effects, some investigators have suggested that women on cyclosporine may breast-feed, challenging the conventional view that cyclosporine is contraindicated during breast-feeding. Here, we report our experience with cyclosporine use during breast-feeding in five mother-infant pairs. We show a wide range of infant exposures to the drug in milk, noting that one of the infants had therapeutic blood concentrations of cyclosporine despite relatively low concentrations of the drug in milk.     

Lack of association between duration of breast-feeding or introduction of cow's milk and development of islet autoimmunity.

The hypothesis that early exposure to cow's milk or lack of breast-feeding predisposes to type 1 diabetes remains controversial. We aimed to determine prospectively the relationship of, first, duration of exclusive breast-feeding and total duration of breast-feeding, and second, introduction of cow's milk protein as infant formula, cow's milk, or dairy products, to the development of islet antibodies in early life. Some 317 children with a first-degree relative with type 1 diabetes were followed prospectively from birth for 29 months (4-73). Mothers kept a home diary and answered infant feeding questionnaires at 6-month intervals. No systematic feeding advice was given. Insulin autoantibodies (normal range <5.5%), anti-GAD antibodies (<5.0 U), and anti-IA2 antibodies (<3.0 U) were measured at 6-month intervals. Cox proportional hazards model of survival analysis detected no significant difference between children who did not develop islet antibodies (225 of 317 [71%]), children with one islet antibody raised once (52 of 317 [16.4%]), children with one antibody raised repeatedly (18 of 317 [5.7%]), or children with two or more antibodies raised (22 of 317 [6.9%]), in terms of duration of exclusive breast-feeding, total duration of breast-feeding, or introduction of cow's milk-based infant formulas, cow's milk, or dairy products (relative risk: 0.91-1.09). Four of the children with two or more islet antibodies developed type 1 diabetes. We conclude that there is no prospective association between duration of breast-feeding or introduction of cow's milk and the development of islet autoimmunity in high-risk children.     

Long-term efficacy of a tongue tie service in improving breast feeding rates: A prospective study

Background

Breast feeding rates in England at 3 months of age are approximately 17% for exclusive breast-feeding and 55% for breast-feeds supplemented with formula. Tongue-tie (TT) in infants is cited as a significant cause of difficulty with maintaining breast-feeding. Early treatment and support can improve breast-feeding and allow infants to benefit from the many long-term benefits of breast-feeding. Our aim was to determine BF rates in infants 3 months after attending our tongue-tie clinic (TTC).

Current trends in infant feeding

This study examined aspects of newborn feeding in a maternity hospital and also investigated feeding practices during the first 6 months of life. Four hundred and fifty mothers were interviewed while in the maternity hospital. The majority (93%) had booked for their confinement and had attended antenatal clinics regularly. Most had had early contact with the baby at birth and stated that they thought breast-milk was best for the baby. Despite this only 54.6% had given breast-milk as the first feed and only 10% had done so within the first hour. Most mothers (54%) stated that they preferred a timed feeding routine to demand-feeding, while 86% planned to give water between feeds. The majority indicated they would change to formula feeds should they experience problems with breast-feeding. A follow-up visit of 78 mothers 6 months later showed that 50% breast-fed exclusively for 3 - 4 months and 23% for 6 - 7 months. When feeding problems occurred only 27% of the mothers utilised the local authority baby clinic for help. The main reasons given for stopping breast-feeds were insufficient milk, the need for employment and feeding problems. The implications of these findings are discussed.     

Effect of labor epidural analgesia with and without fentanyl on infant breast-feeding: a prospective, randomized, double-blind study

BACKGROUND: The influence of labor epidural fentanyl on the neonate is controversial. The purpose of this study was to determine whether epidural fentanyl has an impact on breast-feeding. METHODS: Women who previously breast-fed a child and who requested labor epidural analgesia were randomly assigned in a double-blinded manner to one of three groups: (1) no fentanyl group, (2) intermediate-dose fentanyl group (intent to administer between 1 and 150 microg epidural fentanyl), or (3) high-dose epidural fentanyl group (intent to administer > 150 microg epidural fentanyl). On postpartum day 1, the mother and a lactation consultant separately assessed whether the infant was experiencing difficulty breast-feeding, and a pediatrician assessed infant neurobehavior. All women were contacted 6 weeks postpartum to determine whether they were still breast-feeding. RESULTS: Sixty women were randomly assigned to receive no fentanyl, 59 were randomly assigned to receive an intermediate dose, and 58 were randomly assigned to receive high-dose fentanyl. On postpartum day 1, women who were randomly assigned to receive high-dose fentanyl reported difficulty breast-feeding (n = 12, 21%) more often than women who were randomly assigned to receive an intermediate fentanyl dose (n = 6, 10%), or no fentanyl (n = 6, 10%), although this did not reach statistical significance (P = 0.09). There was also no significant difference among groups in breast-feeding difficulty based on the lactation consultant's evaluation (40% difficulty in each group; P = 1.0). Neurobehavior scores were lowest in the infants of women who were randomly assigned to receive more than 150 microg fentanyl (P = 0.03). At 6 weeks postpartum, more women who were randomly assigned to high-dose epidural fentanyl were not breast-feeding (n = 10, 17%) than women who were randomly assigned to receive either an intermediate fentanyl dose (n = 3, 5%) or no fentanyl (n = 1, 2%) (P = 0.005). CONCLUSIONS: Among women who breast-fed previously, those who were randomly assigned to receive high-dose labor epidural fentanyl were more likely to have stopped breast-feeding 6 weeks postpartum than woman who were randomly assigned to receive less fentanyl or no fentanyl.     

Heart rate changes after acute fetal haemorrhage--a basis for the pathophysiology of the sinusoidal pattern

Our study was designed to obtain information about the prevalence of breast-feeding among rural and urban Blacks, to determine whether the number of women providing early supplementary feeding has increased over a 4-year period, and to discover groups at particular risk of failure to breast-feed optimally. Women attending child health clinics were interviewed. Over 95% had commenced breast-feeding, but only 50% were still doing so after 5--8 weeks. Women uncertain of whether or not to breast-feed and those unsuccessful on a previous occasion are as likely to commence breast-feeding as are other groups, but are likely to introduce early supplementation. Improvements in hospital and clinic practice as regards a greater emphasis on health education, early suckling and the avoidance of supplementary feeding in neonates may have contributed to the slight improvement in breast-feeding practices seen over the 4-year period studied.     

Delivery room analgesia: an analysis of maternal satisfaction

On the first post-partum day, 324 mothers completed a questionnaire designed to assess maternal perception of delivery room experience. Antenatal pain expectation, actual pain severity, analgesia received, as well as maternal satisfaction and choice of analgesia for future deliveries were recorded. Forty-five percent of primiparae and 36% of multiparae reported that they anticipated suffering extreme pain during delivery. The incidence of unbearable pain was similar among patients who received no analgesia or intravenous pethidine but significantly (P<0.0001) higher when compared to epidural analgesia. During the first stage of labour, continuous epidural analgesia was associated with severe or unbearable pain in 51% and 58% of primiparae and multiparae, respectively. The incidence of severe or unbearable pain during the second stage of labour was 43% and 46% for primiparae and multiparae, respectively. Patient satisfaction with epidural analgesia did not correlate with subjective pain scores. Among mothers who received continuous epidural analgesia 70% described their experience as good or excellent and 65.8% indicated that they would request similar pain relief in the future. Despite advances in obstetric analgesia, women anticipate and actually experience severe pain during childbirth. However, due to psychological and cultural factors, as well as possible post-partum euphoria, satisfaction with the delivery room experience is high.     

Effect of Labor Epidural Analgesia with and without Fentanyl on Infant Breast-feeding: A Prospective, Randomized, Double-blind Study

Background: The influence of labor epidural fentanyl on the neonate is controversial. The purpose of this study was to determine whether epidural fentanyl has an impact on breast-feeding.

Methods: Women who previously breast-fed a child and who requested labor epidural analgesia were randomly assigned in a double-blinded manner to one of three groups: (1) no fentanyl group, (2) intermediate-dose fentanyl group (intent to administer between 1 and 150 [mu]g epidural fentanyl), or (3) high-dose epidural fentanyl group (intent to administer > 150 [mu]g epidural fentanyl). On postpartum day 1, the mother and a lactation consultant separately assessed whether the infant was experiencing difficulty breast-feeding, and a pediatrician assessed infant neurobehavior. All women were contacted 6 weeks postpartum to determine whether they were still breast-feeding.

Results: Sixty women were randomly assigned to receive no fentanyl, 59 were randomly assigned to receive an intermediate dose, and 58 were randomly assigned to receive high-dose fentanyl. On postpartum day 1, women who were randomly assigned to receive high-dose fentanyl reported difficulty breast-feeding (n = 12, 21%) more often than women who were randomly assigned to receive an intermediate fentanyl dose (n = 6, 10%), or no fentanyl (n = 6, 10%), although this did not reach statistical significance (P = 0.09). There was also no significant difference among groups in breast-feeding difficulty based on the lactation consultant's evaluation (40% difficulty in each group; P = 1.0). Neurobehavior scores were lowest in the infants of women who were randomly assigned to receive more than 150 [mu]g fentanyl (P = 0.03). At 6 weeks postpartum, more women who were randomly assigned to high-dose epidural fentanyl were not breast-feeding (n = 10, 17%) than women who were randomly assigned to receive either an intermediate fentanyl dose (n = 3, 5%) or no fentanyl (n = 1, 2%) (P = 0.005).     

Does feeding in infancy effect the development of IgA nephropathy?

Gut permeability to antigens is immature at birth, and while early administration of antigenic foods delays its maturation, breast-feeding accelerates it. We aimed to evaluate whether exposure to antigenic foods in early life is associated with a predisposition for immunoglobulin A nephropathy (IgAN). Three groups of children with IgAN (group 1), non-IgA glomerulopathies (group 2), and healthy controls (group 3) were formed. Parents filled out a questionnaire regarding gestational and postnatal ages, birth weight, and feeding by breast milk, formula, cow’s milk, and complementary foods. All groups were similar for age, gender, birth weight, rate and duration of breast-feeding, and rate of formula feeding. Cow’s milk consumption rate was higher in groups 1 and 2 than in group 3. Whereas introduction of formula was earlier in groups 1 and 2 than in group 3, feeding by cow’s milk and weaning were earlier in group 1 than in the other groups. The respective best cutoff ages were 3.5 [odds ratio (OR) 28)], 3.75 (OR 5.7), and 5.5 (OR 10.5) months for formula, cow’s milk, and complementary foods, respectively, for predicting the presence of IgAN. The results of this preliminary study indicate that early introduction of antigenic foods might increase the risk of future primary IgAN.     

Maternal satisfaction and pain control in women electing natural childbirth

BACKGROUND AND OBJECTIVES: Many women who choose natural childbirth for labor ultimately request epidural analgesia to control labor pain. Unfortunately, parturients and family members may often be unprepared for epidural anesthesia, which can contribute to disappointment and dissatisfaction with their labor and delivery. This study examines how epidural analgesia for labor influences maternal satisfaction in women who initially choose natural childbirth. METHODS: This study compared pain and maternal satisfaction in women who elected natural childbirth and successfully followed through (n = 23), with those who elected natural childbirth, but requested epidural analgesia during their labor (n = 24). Subjects rated their pain throughout labor and completed pre- and postlabor questionnaires. RESULTS: Women who requested epidural analgesia for pain during labor reported significantly lower pain scores than those women who had natural childbirth (P < .001). However, 88% of women who requested an epidural for pain reported being less satisfied with their childbirth experience than those who did not, despite lower pain intensity. Antenatal survey results suggest that concerns about epidurals and their effect on the baby, greater than anticipated labor pain, perceived failure of requesting an epidural, and longer duration of labor may have accounted for these findings. CONCLUSIONS: This study examined the influence of epidural analgesia in parturients electing natural childbirth. Pain relief alone was not found to improve maternal satisfaction. This study highlights the importance of experience and prelabor expectations on maternal satisfaction with childbirth.     

Combined spinal epidural (CSE) analgesia: technique, management, and outcome of 300 mothers

Epidural analgesia in labour is commonly associated with some degree of lower limb weakness often severe enough to be described as paralysis by the mother. We aimed to produce rapid reliable analgesia with no motor block throughout labour. We report a pilot survey of 300 consecutive women requesting regional analgesia in labour who received a combined spinal epidural blockade (CSE). The initial dose was given into the subarachnoid space and analgesia maintained via an epidural catheter. A subarachnoid injection of 2.5 mg bupivacaine and 25 mug fentanyl was successfully given in 268 women (89.3%). Completely pain-free contractions within 3 min of this injection occurred in 195 women (65%) and in all 300 within 20 min and there was no associated motor block in 291 (97%). 141 women chose to stand, walk or sit in a rocking chair at some time during labour. Only 38 women (12.6%) were immobile during the first stage of labour. Analgesia was maintained via the epidural catheter with bolus doses of 10-15 ml of 0.1% bupivacaine and 0.0002% fentanyl. The mean bupivacaine requirement was 9.5 mg/h throughout the entire duration of analgesia. The incidence of post lumbar puncture headache was 2.3%. Transient hypotension occurred in 24 women (8%) and was treated with 6 mg intravenous boluses of ephedrine. Complete satisfaction with analgesia and mobility was reported 12-24 h post partum by 95% of mothers. The use of this analgesic technique caused no alteration in obstetric management or post partum care of the women.     

Congenital bilateral cataracts in newborns exposed to elexacaftor-tezacaftor-ivacaftor in utero and while breast feeding

Elexacaftor-tezacaftor-ivacaftor (ETI) is known to pass through the placenta and into breast milk in mothers who continue on this therapy while pregnant and breast feeding. Toxicity studies of ivacaftor in rats demonstrated infant cataracts, but cataracts were not reported in human infants exposed to ivacaftor. We describe 3 cases of infants exposed to elexacaftor-tezacaftor-ivacaftor (ETI) in utero and while breast feeding who were found to have bilateral congenital cataracts within six months of birth. None of the infants had significant visual impairment from the cataracts nor any report of elevated liver function testing. These data highlight the need to counsel females who continue ETI throughout pregnancy and while breast feeding to consider cataract screen for their infants.     

Excretion of lidocaine and bupivacaine in breast milk following epidural anesthesia for cesarean delivery

BACKGROUND: There is a lack of information and knowledge about the practical importance of even low concentrations of the excretion of local anesthetics into breast milk, particularly concerning bupivacaine. The present work aims to confirm, under practical clinical conditions of admission of parturients, the passage of local anesthetics (lidocaine and bupivacaine) into breast milk after an epidural anesthesia. METHODS: Twenty-seven pregnant women admitted for cesarean delivery received epidural anesthesia with 0.5% bupivacaine and 2% lidocaine. Blood and milk samples were simultaneously collected at 2, 6 and 12 h after the beginning of the epidural infusion. Lidocaine, bupivacaine and its main metabolite, pipecolylxylidide (PPX), were determined in serum and milk by a gas-liquid chromatographic technique. APGAR scores were systematically performed at delivery and a clinical examination was done 24 h after delivery. RESULTS: Our data indicate that lidocaine and bupivacaine as well as PPX are excreted into breast milk. The milk/serum ratio based upon area under the curve values were 1.07 +/- 0.82, 0.34 +/- 0.24 and 1.37 +/- 0.61 mean +/- SD for lidocaine, bupivacaine and PPX, respectively. Most of the newborns had a maximal APGAR score. Our study does not reveal any adverse reactions related to the excretion of local anesthetics into breast milk. CONCLUSION: This study documents the magnitude of excreted lidocaine, bupivacaine and PPX in breast milk, and indicates that the use of both lidocaine and bupivacaine for epidural anaesthesia is safe with regard to breast-feeding.     

Maternal opinion about analgesia for labour. A controlled trial between epidural block and intramuscular pethidine combined with inhalation

In a randomised controlled trial epidural analgesia with bupivacaine 0.5% (mean dose 112.8 mg) was compared with pethidine (mean dose 200 mg) and inhalational analgesia in primipara (28 and 30 mothers) and multipara (17 and 18 mothers). Mothers who had an uneventful pregnancy and labour and agreed to have either treatment were studied during labour and followed-up at interviews for 5 months after delivery. Epidural block was rated significantly superior in respect of pain relief and comfort, there were no differences between the groups in reports of perineal discomfort. Twice as many primipara required forceps delivery after epidural block. Very few mothers, in each group, reported something missing in their experience of childbirth. Two thirds of each group would use the same method again. Epidural block can therefore be recommended to uncommitted mothers as a satisfying and effective method of pain relief for labour.     

Breast-feeding, self-exam, and exercise practices before and after reduction mammoplasty

The current indications for reduction mammoplasty include the relief of painful physical symptoms of macromastia. Numerous studies have demonstrated not only improvement in physical symptoms following reduction mammoplasty, but postoperative psychological benefits as well, including increased ability to participate in physical activity as a result of pain relief and decreased breast mass. Reduction mammoplasty may have additional effects on the patient's ability to breast-feed and perform breast self-exam. The present study is a retrospective study of the effects of reduction mammoplasty on breast-feeding, breast self-exam, physical symptoms, and physical activity. One-hundred and forty-one patients who underwent reduction mammoplasty at our institution between the years 1996-2005 agreed to participate in the study. Each was asked a series of questions in order to assess changes in symptoms and behaviors including breast-feeding and breast self-exam practices before and after the surgery. Patients were also asked questions regarding their pain symptoms and physical activity profiles. Ninety-seven percent of the participants claimed to have back, neck, and/or shoulder pain that was either significantly improved or completely resolved. Moreover, 100% of patients report that physical activity such as exercise was easier following reduction mammoplasty. Ninety-three percent of participants reported that performing breast self-exam following surgery was either the same (68%) or easier (25%) as a result of having less breast tissue. Eighty-nine percent of participants had no children following surgery, therefore effects on breast-feeding practices following reduction mammoplasty were not statistically significant. However, we suggest that when patients are seen in consultation or in the perioperative period, there is an opportunity to teach patients about the benefits of breast-feeding, and to assure patients that a pedicle flap reduction will likely allow breastfeeding. This is also a chance for physicians to teach patients how to perform breast self-examination and explain the importance of early breast mass detection.     

Lactation and breast-feeding ability following lateral pedicle mammaplasty.

A retrospective study was undertaken to evaluate the ability of breast-feeding using lateral pedicle reduction mammaplasty. A standard questionnaire was sent to 72 patients who had been operated on at a fertile age. Data was collected regarding the duration and quality of preoperative and postoperative breast-feeding, difficulties while breast-feeding, reasons for discontinuation of breast-feeding or for not attempting to breast-feed, and postoperative subjective sensitivity. Thirteen of the women who replied to the questionnaire had given birth after surgery.The pressure threshold sensitivity of areola-nipple complex was measured in nine of the above cases.To preserve lactation, a technique leaving structures untouched within the pedicle with increased dimensions was used.Breast-feeding was considered successful in this study if it was performed exclusively, without supplementation, for two months.Seven women (54%) breast-fed successfully for between two and 14 months (5.8+/-1.3) following surgery. Two women (16%) were classified as unsuccessful and four women (30%) did not breast-feed at all. The success of breast-feeding was limited by nonsurgical factors including the influence of medical personal.Five of eight women (62%) who had children preoperatively improved their rate of breast-feeding after surgery. No correlation was demonstrated between measured sensitivity and breast-feeding (p=0.65). No significant correlation was found between the resected tissue and breast-feeding (p=0.08). No relation was observed between the duration of breast-feeding and the period between operation and partus.