Hands-and-Knees Positioning During Labor With Epidural Analgesia

Hands-and-knees position has shown promise as an intervention to improve labor and birth outcomes, but no reports exist that examine its use with women laboring with epidural analgesia. Concerns of safety, effects on analgesia, and acceptability of use may limit use of active positioning during labor with regional analgesia. This article presents a case study series of 13 women who used hands-and-knees position in the first stage of labor.     

罗比卡因和布比卡因用于自控硬膜外分娩镇痛的临床效果对比研究

目的 :比较罗比卡因和布比卡因联合芬太尼用于自控硬膜外分娩镇痛 (PCEA)的效果及运动神经阻滞情况。方法 :将 6 0例健康、单胎、足月的初产妇随机分为两组 ,接受 0 .1%罗比卡因加 1μg/ml芬太尼 (RF组 )或 0 .0 75 %布比卡因加 1μg/ml芬太尼 (BF组 )自控硬膜外分娩镇痛。两组进行视觉模拟镇痛评分 (VAS)和下肢运动神经阻滞评分(MBS)。记录两组产程时间、分娩方式、阴道流血量及新生儿Apgar评分。结果 :两组产妇均有较可靠的镇痛效果 ,差异无显著性 (P >0 .0 5 ) ;RF组可下床活动者为 96 .6 7% ,而BF组为 33.33% ,两组差异有显著性 (P <0 .0 5 ) ;两组产程时间和分娩方式差异无显著性 (P >0 .0 5 ) ;两组新生儿Apgar评分差异无显著性 (P >0 .0 5 )。结论 :低浓度罗比卡因或布比卡因联合小剂量芬太尼用于PCEA均可产生可靠的镇痛效果。产程中罗比卡因极少引起运动阻滞 ,产妇有下床活动能力 ,其效果优于布比卡因     

Epidural Analgesia in Labor: An Evaluation of Risks and Benefits

Background: Intrapartum epidural analgesia has become increasingly popular because it is the most effective method of providing pain relief during labor. Much attention is given to its safety and efficacy, and many health care providers and consumers are unaware of its potential drawbacks. This article reviews the literature about the effects of epidural analgesia on the mother and infant. Methods: We performed a computer-assisted MEDLINE search for articles and a review of bibliographies from articles on epidural analgesia. When reported data were incomplete, authors were contacted for more detailed information. Results: The most common procedure-related complications, hypotension, inadvertent dural puncture, and headache, are easily treated and usually self-limited. Permanent morbidity and mortality are rare. Retrospective studies and randomized controlled trials both demonstrate that epidural analgesia is associated with increases in duration of labor, instrument vaginal delivery, and cesarean birth. To date only three trials randomized patients to narcotic versus epidural groups, and all showed a twofold to threefold increase in cesarean section for dystocia. Limiting epidural use in nulliparous labor and delaying its placement until after 5 cm of cervical dilation may reduce the risk of operative intervention for dystocia. Epidural analgesia may also increase intervention for fetal distress. Several studies show its association with maternal fever in labor. Its association with chronic back pain, neonatal behavioral changes, and maternal-infant bonding are more tenuous and require further study. Conclusions: Epidural analgesia is a safe and effective method of relieving pain in labor, but is associated with longer labor, more operative intervention, and increases in cost. It must remain an option; however, caregivers and consumers should be aware of associated risks. Women should be counseled about these risks and other pain-relieving options before the duress of labor.     

Neonatal Neurobehavioral Organization After Exposure to Maternal Epidural Analgesia in Labor

ObjectiveTo explore relationships between maternal epidural analgesia and two measures of neurobehavioral organization in infants at the initial feeding 1 hour after birth.DesignProspective comparative design.SettingInner-city community hospital, Chicago, Illinois.ParticipantsConvenience sample of 52 low-risk, mainly Black and Latino, mother/infant dyads.MethodsMothers self-selected to labor with epidural or no labor pain medication. Neonatal neurobehavioral organization was measured in term infants at the initial feeding 1 hour after birth. A nutritive sucking apparatus generated data on total number of sucks and sucking pressure. Video recordings of infants (before and after the initial feeding) were coded for behavioral states, with analysis on frequency of alertness.ResultsTotal number of sucks and sucking pressure were not related to epidural exposure, although an epidural drug dosage effect on total number of sucks was evident when gender was a factor. Unmedicated girls demonstrated more sucks than girls in the high-dosage epidural group (p=.027). Overall, girls exhibited stronger sucking pressure than boys (p=.042). Frequency of alertness was not related to epidural exposure, although longer labor was related to greater alertness (p=.003), and Latino infants were more alert than Black infants (p=.002).ConclusionsResults suggest attenuated neonatal nutritive sucking organization in girls after exposure to high maternal epidural dosages. In comparison to boys, girls may have enhanced neurobehavioral organization at birth. Race/ethnicity and alertness may have spurious associations in which hidden factors drive the relationship.     

Effects of Epidural Analgesia: Some Questions and Answers

ABSTRACT: The effects of epidural analgesia on first labors have been studied by Thorp and colleagues (1,2). One study has been published (3) and is the subject of a question-and-answer discussion, presented here. In this study 711 consecutive nulliparous women at term, with spontaneous onset of labor and cephalic presentation, were divided into one group (n = 447) who received epidural analgesia in labor and another group (n = 264) who received narcotics or no analgesia. The frequency of cesarean section for dystocia was significantly greater (p < 0.005) in the epidural group (10.3%) than in the nonepidural group (3.8%), even after selection bias was corrected and the variables of maternal age and race; gestational age; cervical dilatation on admission; use, duration, and maximum infusion rate of oxytocin; labor duration; presence of meconium; and birth weight were controlled. For both groups the frequency of cesarean section for fetal distress was similar (p < 0.20), and the frequency of low Apgar scores at 5 minutes and cord blood gas values showed no significant differences. The authors concluded that “epidural analgesia in labor may increase the incidence of cesarean section for dystocia in nulliparous women’(3).     

Effects of Epidural Labour Analgesia in Mother and Foetus

Objective

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

Method

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

Results

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

Conclusion

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

     

Multisite Randomized Controlled Trial of Bladder Management in Labor With Epidural Analgesia/Anesthesia

ObjectiveTo compare the effects of continuous indwelling catheterization with those of intermittent catheterization during labor with epidural analgesia/anesthesia on mode of birth and incidence of urinary tract infection (UTI) symptoms in the postpartum period.DesignRandomized clinical trial.SettingLabor and delivery units at three metropolitan hospitals in the Western United States.ParticipantsWomen (N = 252) who were nulliparous with term, singleton pregnancies in labor with epidural analgesia/anesthesia.MethodsParticipants were randomized to indwelling or intermittent (every 2 hours) catheterization groups after the administration of epidural analgesia/anesthesia during labor. One to 2 weeks after discharge, participants were contacted and questioned about symptoms of UTI.ResultsA total of 252 participants were enrolled in the study: 81% (n = 202) gave birth vaginally, and 19% (n = 50) gave birth via cesarean. Between the indwelling and intermittent catheterization groups, demographic characteristics were similar. We found no significant difference in the incidence of cesarean birth between groups (15.6% vs. 22.5%, p = .172). Overall, 3% of participants reported and sought treatment for symptoms of UTI within 2 weeks with no significant difference between groups (p = .929).ConclusionWe found no differences in mode of birth or symptoms of UTI in women who received indwelling or intermittent catheterization during epidural analgesia/anesthesia. We recommend additional research with objective data for UTI diagnosis and larger samples to study the multiple potential confounding variables associated with cesarean birth after catheterization during epidural analgesia/anesthesia.     

Long‐term Effects of Epidural Analgesia in Labor: A Randomized Controlled Trial Comparing High Dose with Two Mobile Techniques

Background: Epidural analgesia provides the most effective pain relief in labor, but it is not known if it causes adverse long‐term effects. The objective of this study was to assess the long‐term effects of two mobile epidural techniques relative to high‐dose epidural analgesia in a randomized controlled trial. Methods: A total of 1,054 nulliparous women were randomized to traditional high‐dose epidural, combined spinal epidural, or low‐dose infusion. Women in all groups were followed‐up at 12 months postpartum by postal questionnaire to assess long‐term symptoms. The primary long‐term outcome was backache occurring within 3 months of the birth persisting for longer than 6 weeks. Secondary outcomes were frequent headaches and fecal and urinary stress incontinence. Results: No significant differences were found in long‐term backache after combined spinal epidural or low‐dose infusion relative to high‐dose epidural. Significantly less headache occurred in combined spinal epidural analgesia than high‐dose epidural (OR: 0.57, 95% CI: 0.36–0.92), but no difference was found for low‐dose infusion. Significantly less fecal incontinence (OR: 0.51, 95% CI: 0.30–0.87) and stress incontinence (OR: 0.65, 95% CI: 0.42–1.00) occurred with low‐dose infusion. Conclusion: Trial evidence showed no long‐term disadvantages and possible benefits of low‐dose mobile relative to high‐dose epidural analgesia. (BIRTH 38:2 June 2011)     

Intrathecal Narcotics: New Approach for Labor Analgesia

Injection of narcotics in the subarachnoid space is the most recent advancement in managing pain during childbirth. This article reviews the history of labor pain control and discusses the introduction of intrathecal narcotics (ITNs), including administration, side effects, and nursing care, in one birthing center. The responses of clients and nurses to ITNs are discussed.     

NO FREE LUNCH ON LABOR DAY: The Risks and Benefits of Epidural Analgesia During Labor*

Epidural analgesia provides effective pain relief for women during labor. However, like all medical interventions, it also has potential side effects such as longer labor and a higher rate of intrapartum fever and operative vaginal delivery. A recent meta-analysis of randomized studies by Halpern et al concluded there was no association between epidural use and cesarean delivery. A critique of that meta-analysis, included in this paper, concludes that there are currently insufficient data to determine whether epidural analgesia leads to increased rates of cesarean delivery. This paper also presents results from several recent studies related to epidural analgesia conducted at Brigham and Women's Hospital in Boston. One study demonstrates a significant influence of prenatal planning on use of epidural during labor. Additional studies examine the strong association of epidural analgesia with intrapartum fever and the consequences of that fever for mother and infant. Epidural analgesia should remain an option available to women during labor. A more complete understanding of the risks and benefits that accompany its use is essential so that women and their care providers can make informed choices about pain relief during labor. J Nurse Midwifery 1999;44:394–8 © 1999 by the American College of Nurse-Midwives.     

Epidural Analgesia Use as a Marker for Physician Approach to Birth: Implications for Maternal and Newborn Outcomes

Background: Understanding the association between caregiver belief systems and practice patterns is an emerging area of research. We hypothesized an association between a maternity caregiver's belief system and his or her behavior. The study objective was to determine if a family physician's overall approach to maternity care, as measured by average use of epidural analgesia, was associated with maternal and fetal outcomes. Methods: Retrospective analysis was conducted of the births of three cohorts of 1992 nulliparous, low‐risk women attended by 96 family physicians within an 18‐month period in the department of family practice at the largest maternity hospital in Canada. Cohorts were based on the physicians' mean use of epidural analgesia for the women. Family physicians attending fewer than 5 births were excluded. The main outcome measures, by physician epidural utilization cohort, were maternal/newborn morbidity, procedure rates, consultation rates, and length of stay. Results: Family physicians were separated into cohorts based on their mean use of epidural analgesia at rates of: low, 0–30 percent (15 physicians, 263 births); medium, 31–50 percent (55 physicians, 1323 births); and high, 51–100 percent (26 physicians, 406 births). After adjustment for maternal age and race, patients of low versus high epidural users were admitted at a later state of cervical dilation (mean 4.0 vs 3.1 cm), received less electronic fetal monitoring (76.4 vs 87.2%) and oxytocin augmentation (12.2 vs 29.8%), sustained fewer malpositions (occiput posterior or transverse)(23.2 vs 34.2%), had fewer cesarean sections (14.0 vs 24.4%), less obstetric consultation (47.9 vs 63.8%), and fewer newborn special care admissions (7.2 vs 12.8%). Conclusions: In our setting, high use of epidural analgesia is a marker for a style of practice characterized by malpositions leading to dysfunctional labors and higher intervention rates leading, in turn, to excess maternal/newborn morbidity.     

子宫切除术后硬膜外自控镇痛对机体免疫功能的影响

目的:探讨硬膜外自控镇痛(PCEA)对子宫切除术后机体免疫功能的影响。方法:选择择期施行腹式子宫切除术的患者6 0例,其中4 0例于手术结束后行PCEA(PCEA组) ,另2 0例于手术结束后肌内注射哌替啶止痛(对照组)。比较两组病例的镇痛效果,并分别测定术前2 4小时,术后2 4、72小时的血清免疫球蛋白IgG、IgA、IgM及补体C3、C4 含量。结果:①施行PCEA者术后伤口疼痛明显减轻;②术后2 4小时两组免疫球蛋白及补体含量均下降,但以对照组下降明显(P <0 .0 5 ) ,术后72小时PCEA组免疫球蛋白IgG、IgA与补体C3含量回升,IgM及补体C4 含量仍处于低水平,而对照组在术后72小时免疫球蛋白IgG、IgA、IgM及补体C3、C4 含量仍处于低水平。结论:子宫切除术后施行硬膜外自控镇痛能有效地减轻手术后伤口的疼痛,并能减轻应激反应所致的免疫抑制,从而保护机体的免疫功能,利于机体的康复。     

静脉输注右美托咪定联合规律性问断硬膜外注射分娩镇痛疗效分析

目的:探讨静脉输注右关托咪定联合规律性间断硬膜外注射用于分娩镇痛的安全性及可行性.方法:选择2014年7～12月在我院产科接受硬膜外分娩镇痛的初产妇100例,随机分为两组:规律性间断硬膜外注射组(对照组)和右美托咪定联合规律性间断硬膜外注射组(右美托咪定组),每组50例.比较两组分娩镇痛期间生命体征的变化、分娩镇痛时间(T0～T4时)、第二产程时间、硬膜外药物消耗量、分娩方式、新生儿Apgar评分、镇痛前及镇痛后血浆儿茶酚胺的变化.结果:①两组产妇分娩镇痛期间平均动脉压(MBP)、视觉模拟评分(VAS)组间比较,差异无统计学意义(P＞0.05);虽然右美托咪定组在T2和T4时的心率低于对照组(P＜0.05),但在正常范围内.两组产妇分娩镇痛时间、分娩方式及新生儿Apgar评分比较,差异均无统计学意义(P＞0.05).②右美托咪定组较对照组第二产程时间更短、硬膜外药物消耗量更少(P＜0.05).③两组产妇实施分娩镇痛后血浆肾上腺素及去甲肾上腺素均明显下降,右美托咪定组下降幅度明显高于对照组(P＜0.05).结论:静脉输注右美托咪定联合规律性间断硬膜外注射可安全及有效地应用于分娩镇痛,并能增强镇痛效能及利于阴道分娩.     

Epidural Analgesia in Labour Performed by Obstetricians

Summary: The use of epidural analgesia by obstetricians in 2,645 women in labour is reported. The use of this technique as one of the routine methods is proposed even in those centres where no anaesthetist for pain relief is available for the 24-hour period. This is possible by the previous training of obstetricians. Advantages, side-effects and complications of epidural analgesia are discussed.