[Effects of double-catheter epidural analgesia by lidocaine injection respectively on the delivery outcomes and maternal-infant complications for persistent posterior or lateral occipital position of protracted active phase].

Objective: To evaluate the effect of dual-tube epidural segmental injection of lidocaine analgesia on the delivery outcome and maternal and infant complications of persistent posterior occipital position postpartum or lateral occipital position postpartum patients with protracted active phase. Methods: The full and single-term primiparas (n=216, 37 to 42 weeks gestation, 22 to 35 years) diagnosed as persistent posterior or lateral occipital position during the active period were selected from the Department of Obstetrics of Qingdao Municipal Hospital from January 2015 to October 2019. The subjects were randomly assigned into two groups: double-tube epidural block group (n=108) and single-tube epidural block group (n=108), 1% lidocaine was used for epidural analgesia respectively under ultrasound guidance. Senior midwife or obstetricians implement new partogram, and guide women to perform position management, and push or rotate the fetal head in a timely manner. Observation indicators: general condition, the use of non-pharmacological analgesic measures, analgesia related conditions and pain visual analogue scale (VAS) score, delivery-related indicator, cesarean section indication, anesthesia-related indicator, maternal and child complications. Results: (1) General condition: the age, weight, height, gestational age, the ratio of persistent lateral or posterior occipital position, cephalic score, and neonatal birth weight between the two groups of women were not statistically significant (all P>0.05). (2) The use of non-pharmacological analgesic measures: the women's Lamaze breathing method, Doula delivery companionship, percutaneous electrical stimulation, and other measures between two groups were compared, and there were not significant differences (all P>0.05). (3) Analgesia related conditions and VAS scores of women undergoing vaginal delivery: compared with the single-tube epidural block group (n=40), the second-partum time of the women in the double-tube epidural block group (n=59) was significantly shortened [(124±44) vs (86±33) minutes, P<0.01]; after 30 minutes of analgesia (4.4±0.5 vs 0.9±0.5, P<0.01), during forced labor in the second stage of labor (5.7±0.6 vs 1.3±0.4, P<0.01), the VAS scores of pain were also significantly reduced (P<0.01). (4) Labor-related indicators: compared with the single-tube epidural block group, the natural delivery rate (21.3% vs 49.1%) and the delivery experience satisfaction rate (51.9% vs 98.1%) of women in the double-tube epidural block group were significantly increased (all P<0.01), cesarean section rate (63.0% vs 45.4%), instrument assisted rate (15.7% vs 5.6%) decreased significantly (all P<0.05). (5) Cesarean section indications: compared with the single-tube epidural block group, the cesarean section rate caused by prolonged labor or protracted active phase of women in the double-tube epidural block group was significantly reduced (38.0% vs 22.2%； P<0.05), and the fetal distress, intrauterine infection, and social factors caused by cesarean section between the two groups were compared, while the differences were not statistically significant (all P>0.05).(6) Anesthesia related indexes: the block planes of the maternal upper tube administration in the double-tube epidural block group were mostly T7, T8, T9-L2 and L3,While,the block planes in the single-tube epidural block group were mostly T10, T11-S1, S2, S3, and the modified Bromage score were all 0. (7) Maternal and child complications: compared with the single-tube epidural block group, the postpartum hemorrhage rate (18.5% vs 7.4%), the perineal lateral cut rate (20.4% vs 5.6%), the neonatal asphyxia rate (12.0% vs 3.7%), ICU rate of transferred neonates (13.9% vs 4.6%) in the double-tube epidural block group were significantly reduced (all P<0.05). Soft birth canal injury rate, puerperal disease rate and neonatal birth rate between two groups were compared, and there were not statistically significant differences (all P>0.05). Conclusion: Dual-tube epidural segmental injection of lidocaine analgesia could increase the natural delivery rate of women with posterior occipital or lateral occipital position with active stagnation, reduce the rate of cesarean section and the rate of transvaginal instruments, and reduce the complications of mother and child.

COVID-19 et protoxyde d'azote pendant l'accouchement / COVID-19 and nitrous oxide during childbirth

PRÉSENTATION SOMMAIRE DE LA DEMANDE: Il a été demandé à l'INESSS de rechercher dans la littérature les données relatives à l'utilisation du protoxyde d'azote pendant l'accouchement en contexte de pandémie à la COVID-19 chez les femmes atteintes ou non du coronavirus afin d'en faire une utilisation optimale en contexte de pandémie et de crise. Le protoxyde d'azote (aussi appelé gaz hilarant ou oxyde nitreux) est un gaz incolore qui est utilisé, entre autres, en maintien de l'anesthésie générale ou comme analgésique (à dose subanesthésique) en obstétrique pendant l'accouchement. Lorsqu'il est utilisé comme analgésique, il doit être mélangé à de l'oxygène (50 %-50 %) et administré par inhalation par l'entremise d'un masque muni d'une valve à demande. Puisque ce gaz tend à dilater les cavités de l'organisme renfermant des gaz, le protoxyde d'azote serait contre-indiqué en présence d'air dans la plèvre, le péricarde ou le péritoine, de même que lors d'affection des voies aériennes chronique obstructive ou d'emphysème. MÉTHODOLOGIE: Questions d'évaluation: Quelles sont l'innocuité et les modalités d'utilisation du protoxyde d'azote pendant l'accouchement en contexte de pandémie à COVID-19? Critères de sélection: Population: Femmes atteintes ou non de la COVID-19. Intervention: Utilisation du protoxyde d'azote pendant l'accouchement Comparateur : Placebo ou autre analgésique Résultat d'intérêt : Innocuité, modalités d'utilisation. Types de documents retenus: Tout document contenant des informations pertinentes, que ce soit de la littérature scientifique ou de la littérature grise. Méthodes de recension: Date de recherch : 23 et 27 mars 2020. Une recherche rapide a été effectuée en utilisant les bases de données PubMed, MEDLINE, Embase, EBM Reviews et le moteur de recherche Google avec les mots-clés suivants: Coronavirus, pneumonia virus, 2019 ncov, COVID-19, nitrous Oxide, laughing gas, nitrogen protoxide, delivery, obstetric, childbirth, parturition, sage*-femme*, midwife*, midwives. Une recherche manuelle de la littérature a également été effectuée en consultant les sites Web des agences règlementaires, d'agences d'évaluation des technologies de la santé ainsi que ceux d'organismes gouvernementaux, d'associations ou ordres professionnels en lien avec le thème des travaux. Consultation menée: Aucune consultation d'experts n'a été menée dans le cadre de ces travaux. CONSTATS DE L'INESSS: Basé sur la documentation scientifique disponible au moment de sa rédaction, malgré l'incertitude existante dans cette documentation et dans la démarche utilisée de recension, il ressort que: Les recommandations liées à l'utilisation du protoxyde d'azote pendant l'accouchement chez les femmes confirmées ou suspectées COVID-19 sont divergentes selon les sociétés savantes ou organismes: Certains recommandent d'utiliser le protoxyde d'azote pendant l'accouchement en utilisant un filtre microbiologique pour prévenir la contamination du système d'inhalation du gaz; Certains recommandent d'utiliser le protoxyde d'azote pendant l'accouchement sans précision sur les précautions particulières; Certains recommandent d'évaluer les risques et bénéfices de l'utilisation du protoxyde d'azote pendant l'accouchement avant son utilisation vu les incertitudes entourant le nettoyage, les filtres à utiliser ainsi que le potentiel d'aérosolisation du produit; Certains ne mentionnent aucune opposition sur l'utilisation du protoxyde d'azote pendant l'accouchement puisqu'il n'existe aucune évidence que l'administration de ce médicament est une procédure pouvant générer des aérosols. Les incertitudes soulevées quant à la possibilité pour ce médicament de générer des aérosols rendent potentiellement nécessaire le port d'un équipement de protection approprié pour le personnel médical si utilisé par une personne avec statut COVID-19 positif ou suspecté. Or, ces équipements sont des ressources dont il serait judicieux de réserver l'usage pour des situations de nécessité absolue. De plus, le risque théorique de contamination par le virus du système d'administration du protoxyde d'azote est une considération importante.

Implementation of an Evidence-Based Practice Change to Offer Nitrous Oxide During Labor.

OBJECTIVE: The aim of this evidence-based practice change was to implement use of nitrous oxide as a pain management option during labor and to examine women's satisfaction with that option. DESIGN: Evidence-based practice change guided by the model for evidence-based practice change. SETTING: Labor and delivery unit in a tertiary medical center in the southwestern United States. PARTICIPANTS: Laboring women who met eligibility criteria were offered the option of nitrous oxide during a 2-month period. MEASUREMENTS: Process indicators to measure compliance with the practice change among staff, uptake of nitrous oxide among women, and women's satisfaction with the choice to use nitrous oxide. RESULTS: Nitrous oxide was offered to 26% (n = 55) of eligible women. Most of the 55 women who used nitrous oxide during the implementation period reported satisfaction with it and indicated that they would consider nitrous oxide for a future labor. CONCLUSION: Our experience implementing a practice change to offer nitrous oxide to laboring women indicated that use of nitrous oxide was feasible in this setting and that women were receptive to this option, were satisfied with its use, and would use nitrous oxide for a future labor.

Oxytocin Augmentation in Spontaneously Laboring, Nulliparous Women: Multilevel Assessment of Maternal BMI and Oxytocin Dose.

BACKGROUND: Synthetic oxytocin, the primary tool for labor augmentation, is less effective among obese women, leading to more unplanned cesarean deliveries for slow labor progress. It is not known if obese women require higher doses of oxytocin due to maternal, fetal, or labor factors related to maternal obesity. OBJECTIVES: This study had two main objectives: (1) examine the influence of maternal body mass index (BMI) on hourly doses of oxytocin from augmentation initiation until vaginal delivery in obese women; and (2) examine the influence of other maternal, fetal, and labor factors on hourly doses of oxytocin in obese women. STUDY DESIGN: Longitudinal study of a cohort ( N = 136) of healthy, nulliparous, spontaneously laboring obese women (BMI ≥ 30 kg/m2) who received oxytocin augmentation and achieved vaginal delivery. We performed iterative multilevel analyses to examine the influence of maternal BMI and other factors on hourly oxytocin doses. RESULTS: Maternal BMI explained 16.56% (95% confidence interval [CI] = [13.7, 20.04], p < .001) of the variance in hourly oxytocin doses received in a multilevel model controlling for influence of maternal, fetal, and labor characteristics. Maternal age, gestational age, status of amniotic membranes at hospital admission, and admission cervical dilation examination were not significant; however, neonatal birthweight and cervical dilation at oxytocin initiation were significant predictors of hourly oxytocin dose in these women ( p < .001). CONCLUSIONS: Even when parturition preparation has progressed adequately for spontaneous labor initiation, there still may be some obesity-related blunting of myometrial contractility and response to oxytocin used for augmentation.

Epidural analgesia during labour, routinely or on request: a cost-effectiveness analysis.

OBJECTIVE: To assess the cost-effectiveness of routine labour epidural analgesia (EA), from a societal perspective, as compared with labour analgesia on request. STUDY DESIGN: Women delivering of a singleton in cephalic presentation beyond 36+0 weeks' gestation were randomly allocated to routine labour EA or analgesia on request in one university and one non-university teaching hospital in the Netherlands. Costs included all medical, non-medical and indirect costs from randomisation to 6 weeks postpartum. Effectiveness was defined as a non-operative, spontaneous vaginal delivery without EA-related maternal adverse effects. Incremental cost-effectiveness ratio (ICER) was defined as the ratio of the difference in costs and the difference in effectiveness between both groups. Data were analysed according to intention to treat and divided into a base case analysis and a sensitivity analysis. RESULTS: Total delivery costs in the routine EA group (n=233) were higher than in the labour on request group (n=255) (difference -€ 322, 95% CI -€ 60 to € 355) due to more medication costs (including EA), a longer stay in the labour ward, and more operations including caesarean sections. Total postpartum hospital costs in the routine EA group were lower (difference -€ 344, 95% CI -€ 1338 to € 621) mainly due to less neonatal admissions (difference -€ 472, 95% CI -€ 1297 to € 331), whereas total postpartum home and others costs were comparable (difference -€ 20, 95% CI -€ 267 to € 248, and -€ 1, 95% CI -€ 67 to € 284, respectively). As a result, the overall mean costs per woman were comparable between the routine EA group and the analgesia on request group (€ 8.708 and € 8.710, respectively, mean difference -€ 2, 95% CI -€ 1.012 to € 916). Routine labour EA resulted in more deliveries with maternal adverse effects, nevertheless the ICER remained low (€ 8; bootstrap 95% CI -€ 6.120 to € 8.659). The cost-effectiveness acceptability curve indicated a low probability that routine EA is cost-effective. CONCLUSION: Routine labour EA generates comparable costs as analgesia on request, but results in more operative deliveries and more EA-related maternal adverse effects. Based on cost-effectiveness, no preference can be given to routine labour EA as compared with analgesia on request.

Oral versus vaginal misoprostol for induction of labor in Enugu, Nigeria: a randomized controlled trial.

OBJECTIVE: The study aimed at comparing the effectiveness and maternal satisfaction of oral misoprostol with vaginal misoprostol for induction of labor at term. MATERIALS AND METHODS: A randomized controlled trial of 140 term pregnant women at the University of Nigeria Teaching Hospital Enugu, Nigeria, was conducted from April 2011 to May 2012. The women were equally randomized into two groups (A and B) to receive oral and vaginal misoprostol, respectively. RESULTS: The vaginal route reduced the mean induction-vaginal delivery interval by four-and-half hours (20.7 ± 12.1 vs. 16.2 ± 10.4; mean difference: 4.50, 95% CI 0.63-0.82; p = 0.02). Furthermore, the mean dose of misoprostol required to achieve induction of labor and the mean duration of oxytocin augmentation when indicated were significantly less in the vaginal group than in the oral group (2.5 ± 1.3 vs. 2.0 ± 1.1; mean difference: 0.50, 95% CI 0.10-0.90; p = 0.02 and 4.6 ± 3.2 vs. 3.4 ± 3.1; mean difference: 1.20, 95% CI 0.15-0.23; p = 0.03 respectively). However, neonatal complications and maternal satisfaction were similar between the two groups. CONCLUSION: Both routes of administration are effective in the induction of labor at term and have comparable maternal satisfaction. However, the vaginal route has the added advantage of shorter induction-delivery interval among others, and thus should be highly considered when induction of labor is indicated at term.

Labor epidural anesthesia, obstetric factors and breastfeeding cessation.

Breastfeeding benefits both infant and maternal health. Use of epidural anesthesia during labor is increasingly common and may interfere with breastfeeding. Studies analyzing epidural anesthesia's association with breastfeeding outcomes show mixed results; many have methodological flaws. We analyzed potential associations between epidural anesthesia and overall breast-feeding cessation within 30 days postpartum while adjusting for standard and novel covariates and uniquely accounting for labor induction. A pooled analysis using Kaplan-Meier curves and modified Cox Proportional Hazard models included 772 breastfeeding mothers from upstate New York who had vaginal term births of healthy singleton infants. Subjects were drawn from two cohort studies (recruited postpartum between 2005 and 2008) and included maternal self-report and maternal and infant medical record data. Analyses of potential associations between epidural anesthesia and overall breastfeeding cessation within 1 month included additional covariates and uniquely accounted for labor induction. After adjusting for standard demographics and intrapartum factors, epidural anesthesia significantly predicted breastfeeding cessation (hazard ratio 1.26 [95% confidence interval 1.10, 1.44], p < 0.01) as did hospital type, maternal age, income, education, planned breastfeeding goal, and breastfeeding confidence. In post hoc analyses stratified by Baby Friendly Hospital (BFH) status, epidural anesthesia significantly predicted breastfeeding cessation (BFH: 1.19 [1.01, 1.41], p < 0.04; non-BFH: 1.65 [1.31, 2.08], p < 0.01). A relationship between epidural anesthesia and breastfeeding was found but is complex and involves institutional, clinical, maternal and infant factors. These findings have implications for clinical care and hospital policies and point to the need for prospective studies.

Assessment of behavior during labor in rats and effect of intrathecal morphine.

BACKGROUND: Efficacy of analgesics varies with the type of pain. Little is known in this regard concerning labor pain, given the ethical barriers to study in humans and the lack of surrogate animal models. To address this, the authors classified and quantified spontaneous behaviors during labor and delivery in rats and examined the effects of a known analgesic, intrathecal morphine. METHODS: Pregnant rats were video recorded for 72 h surrounding the time of anticipated labor and delivery. Specific behaviors were identified and classified into general activities, phasic stretching behaviors, and maternal attention activities. Rats received intrathecal infusion of saline or morphine, 0.035-3.5 microg/h, beginning approximately 1 day before delivery, and effects on behaviors and response to noxious heating of the paw were quantified. RESULTS: Phasic stretching behaviors occurred with high frequency before delivery of the first pup and were rare after delivery of the last pup. Intrathecal morphine at infusion rates greater than 0.035 microg/h abolished these behaviors without affecting general or maternal behaviors or the timing or duration of labor and delivery. Morphine was also antinociceptive to noxious heat, but only at infusion rates of 1.0 microg/h or higher. CONCLUSIONS: Phasic stretching behaviors are observed after distension or inflammation of pelvic viscera in rats, and similar behaviors occur during labor and delivery. Selective and dose-related blockade by intrathecal morphine of only these behaviors suggests that they reflect nociception and that this simple monitoring method can be used to study therapies for the pain of labor and delivery.

Medical potential of plants used by the Q'eqchi Maya of Livingston, Guatemala for the treatment of women's health complaints.

Investigation on the medical ethnobotany of the Q'eqchi Maya of Livingston, Izabal, Guatemala, was undertaken in order to explore Q'eqchi perceptions, attitudes, and treatment choices related to women's health. Through participant observation and interviews a total of 48 medicinal plants used to treat conditions related to pregnancy, childbirth, menstruation, and menopause were collected and identified followed by the evaluation of 20 species in bioassays relevant to women's health. Results of field interviews indicate that Q'eqchi cultural perceptions affect women's health experiences while laboratory results (estrogen receptor and serotonin receptor binding assays) provide a scientific correlation between empirical medicinal plant use among the Q'eqchi and the pharmacological basis for their administration. These data can contribute to Guatemala's national effort to promote a complementary relationship between traditional Maya medicine and public health services and can serve as a basis for further pharmacology and phytochemistry on Q'eqchi medicinal plants for the treatment of women's health conditions.

Lower epidural anesthesia use associated with labor support by student nurse doulas: implications for intrapartal nursing practice.

Interventions of baccalaureate nursing students, trained as doulas, were examined for their association with epidural anesthetic use. Doulas, trained to support laboring mothers, are associated with shorter labors and fewer medical interventions. Data from a convenience sample of 89 vaginal births attended between 1999 and 2002 were analyzed. Analysis showed an association of lower epidural use with increased complementary doula interventions (.62 OR, P=.003) and an association of higher epidural use with longer labors (1.22 OR, P=.004). No significant association was found between epidural use and parity, income, education and type of health care provider. These findings support previous research of decreased analgesia use by doula-supported women and suggest benefits of the interventions by student nurse doulas. Students trained in providing low-tech supportive care may change the environment for intrapartum nursing practice. Institutional changes may be required to allow greater opportunity for intrapartal nurses to provide support to laboring women.

A benefit-risk assessment of misoprostol for cervical ripening and labour induction.

Misoprostol, a prostaglandin E(1) analogue, is widely used in the US and other countries for cervical ripening and labour induction. Its use for these indications is not approved by the US Food and Drug Administration (FDA). The manufacturer of misoprostol issued a letter to American healthcare providers in August 2000, cautioning against the use of misoprostol in pregnant women and citing a lack of safety data for its use in obstetrical practice. The only FDA-approved indication in the product labelling is the treatment and prevention of intestinal ulcer disease resulting from nonsteroidal anti-inflammatory drug use. Multiple trials have proven that when applied vaginally, misoprostol is an effective agent for cervical ripening and labour induction in term pregnancy. The use of oxytocin augmentation is reduced when intravaginal misoprostol is used compared with other agents. Misoprostol use in obstetrics carries the added benefits of temperature stability at room temperature, which is unlike other prostaglandin preparations which require refrigeration or freezing, and reduced cost. However, debate continues regarding the optimal dose, dosage regimen, and route of administration. Uterine contraction abnormalities are often found in association with higher misoprostol doses (50 microg or more) given vaginally or orally. Some trials also indicate increased frequencies of meconium passage, neonatal acidaemia and caesarean delivery for fetal distress in women receiving higher doses of vaginally applied misoprostol. However, most trials fail to demonstrate a significant change in the caesarean delivery rate with the use of misoprostol, although a recent meta-analysis indicated that the use of intravaginal misoprostol is associated with a lowering of the caesarean rate when compared with pooled controls. Low-dose misoprostol (25 microg) is an effective agent for cervical ripening and labour induction when used in a judicious and cautious fashion. There are insufficient data to support the widespread use of oral misoprostol for cervical ripening and labor induction. Some trials suggest that this approach may be effective; however, the ideal dose and administration regimen have yet to be defined.

The effect of epidural anesthesia on the length of labor.

BACKGROUND: Epidural anesthesia, although effective, has been associated with changing the course of labor. Previous studies have been criticized for not pinpointing the factors determining the use of epidural anesthesia. The purpose of this study was to determine the effect of epidural anesthesia use on the course of labor. METHODS: A retrospective chart review of 224 women who gave birth from July 1, 1993, to June 30, 1994, was completed in a small-town family practice. The time frame included 6 months before and after the initiation of Tenncare, a state-funded health insurance plan designed to serve the uninsured and those previously served by Medicaid in Tennessee. RESULTS: The rate of epidural anesthesia use in this study population fell sharply after January 1, 1994, the start date for Tenncare. Epidural anesthesia by women in this study was found to increase the average length of the second stage of labor by 38 minutes for primiparas and 23 minutes for multiparas. CONCLUSIONS: The average length of the second stage of labor is significantly longer for women who receive epidural anesthesia. The rate of epidural anesthesia use in this study population was strongly influenced by a change in health-care financing.

Caesarean section for dystocia: a comparison of practices in two countries.

Retrospective data collected from the medical records of 1040 low-risk nulliparous obstetric patients presenting for delivery in a general community hospital in Ireland and a comparable one in the United States showed a significantly higher rate of caesarean section for dystocia or abnormal labour in the American hospital--a discrepancy which was not easily explained by differences in patient characteristics (eg, maternal age, known risk factors, birthweight). Acceleration of labour with oxytocin was significantly more common in the Irish group, and average duration of labour was shorter. No advantage to the infant, as measured by the Apgar score, resulted from the greater use of caesarean section for dystocia.

Cardiotoxicity of ritodrine: assessment based on serum creatine kinase activity.

Thirty-three gravidas undergoing chronic tocolysis with ritodrine were assessed with respect to potential drug-induced cardiotoxic effects. The immunological and electrophoretic determination of serum creatine kinase activity gave no indication of such effects. The results of this study confirm the significant increase reported for the serum activity of the MB, BB, and MM creatine kinase isoenzymes during the post-partum period. In most cases no difference was found between the isoenzyme distribution pattern characterizing acute myocardial infarction and normal labor, and therefore the measurement of serum creatine kinase activity during labor has no value for the diagnosis of acute myocardial infarction.