An Innovative Approach to Determine Programmed Intermittent Epidural Bolus Pump Settings for Labor Analgesia: A Randomized Controlled Trial.

BACKGROUND: Three settings are required on a programmed intermittent epidural bolus (PIEB) pump for labor analgesia: the PIEB next bolus (PIEBnb), PIEB interval (PIEBi), and PIEB volume (PIEBv). The ideal settings for these parameters are still unknown. We hypothesized a mathematical modeling tool, response surface methodology (RSM), could estimate 3 PIEB pump parameters while balancing 3 clinically important patient outcomes simultaneously. The study objective was to use RSM to estimate PIEB settings (PIEBnb, PIEBi, and PIEBv) while maximizing maternal satisfaction, minimizing the need for clinician-administered boluses, and optimizing the ratio of delivered/requested patient-controlled epidural analgesia (PCEA) boluses simultaneously. METHODS: With institutional ethics approval, a double-blind randomized trial was completed in a tertiary care labor and delivery center. Nulliparous, English-speaking American Society of Anesthesiologists (ASA) physical status II patients aged 18 to 45 years at full term, single gestation in vertex presentation, in spontaneous labor and ≤7 cm cervical dilation were included. Patients with comorbidities, contraindications to neuraxial analgesia, using chronic analgesics, <152 cm, or body mass index (BMI) >45 kg/m 2 were excluded. After informed consent, labor analgesia was initiated using 10 mL ropivacaine 0.2% with 10 µg/mL fentanyl solution and PCEA (volume 6 mL every 10 minutes). Patients were randomized to predetermined PIEB settings. RSM identified 3 pump settings that represented a stationary point that best maximized or minimized 3 outcomes simultaneously: PCEA ratio (a ratio closest to 1), clinician bolus (optimal is 0), and maternal satisfaction (visual analog scale, 0-100, ideal response is ≥90). RESULTS: Of 287 potential participants, 192 did not meet inclusion criteria or declined to participate, and 26 were withdrawn, leaving 69 patients for study inclusion. Using RSM, the suggested PIEB settings for all the primary study outcomes were as follows: PIEBnb = 29.4 minutes, PIEBi = 59.8 minutes, and PIEBv = 6.2 mL. These PIEB settings corresponded to the following clinical outcomes: maternal satisfaction at 93.9%, PCEA ratio at 0.77, and need for clinician bolus at 0.29. The dermatome sensory score was between T10 and T5 in 89% of the patients. The median lowest Bromage score was 4. CONCLUSIONS: This novel study used a mathematical model to estimate PIEB pump settings while simultaneously maximizing 3 clinical outcomes. Equally weighted clinical outcomes prevent maximal outcome optimization and may not reflect patient priorities. Future studies or quality improvement endeavors could use RSM methodology to estimate PIEB pump settings targeting optimal values for a single clinical outcome of determined importance to parturients.

Radiographical presentations of inadvertent subdural placement of an epidural catheter for successful labor analgesia: A case report.

RATIONALE: Lumbar epidural analgesia is the gold standard for labor pain control. However, misplacement of epidural catheters into the subdural space may inadvertently happen. Unrecognized subdural administration of local anesthetics could result in serious consequences, including high spinal and brainstem blocks. This case report describes a case where subdural epidural catheter placement was recognized early but labor pain was adequately managed by dosage titration of subdural analgesia. PATIENT CONCERNS: This case report describes a 29-year-old primiparous pregnant woman who was admitted to our obstetric unit for labor induction at the gestational age of 38 weeks. An epidural catheter was inserted via the L2-3 intervertebral space using the standard loss of resistance to air technique. DIAGNOSES: The parturient experienced weakness in the lower extremities and numbness in the upper extremities within 15 minutes after administration of 5 mL of 2% v/v lidocaine as a loading dose and systolic blood pressure also dropped by 25%. INTERVENTIONS: The dose regimen (a mixture of 0.1% ropivacaine and 4 µg/mL fentanyl) for patient-controlled analgesia was given with bolus doses of 0.1 mL per demand and lockout intervals of 20 minutes. The analgesic effects were adequately maintained below the T8 dermatome for more than 12 hours without hypotensive episodes or obvious signs of neurological deficits. Computed tomographic myelography was performed by instillation of a nonionic iodinated contrast medium via the epidural catheter on postpartum day 2 for imaging confirmation of catheter placement in the extradural space. LESSONS: Early recognition that epidural catheters for neuraxial analgesia have been inserted into the subdural space is important for the prevention of high spinal blocks. Subdural analgesia could still be achieved by careful clinical assessment and titration of low analgesic doses. This report also presents important and clear serial computed tomographic images of catheter placement in the thoracic-lumbar subdural spaces and the extent of volume spread in the subdural space following administration of contrast medium.

Medición del dolor durante el trabajo de parto: evaluación de la usabilidad de un nuevo dispositivo / Pain measurement during labor: usability evaluation of a new device

Objetivo: Evaluar la usabilidad de un dispositivo para medir el dolor durante el trabajo de parto a través de siete ítems: tamaño, textura, facilidad de uso, peso, resistencia, comodidad y seguridad. Método: Estudio descriptivo. Se solicitó a 60 pacientes usar el sensor manual durante el transcurso de seis contracciones uterinas (aproximadamente 10-20 minutos) y al día siguiente se aplicó una encuesta en la que las pacientes evaluaron la usabilidad del dispositivo en cuanto a textura, peso, resistencia, comodidad, facilidad de uso, tamaño del sensor, seguridad de uso, peso del sensor, resistencia y comodidad, mediante una escala de Likert de 1 a 7. La seguridad fue evaluada con una escala de 1 a 5. Resultados: Se realizaron gráficos de caja. Con respecto a la seguridad, un 86% de las usuarias marcaron 5 puntos en la escala, percibiendo el dispositivo como seguro. Conclusiones: El dispositivo fue percibido como seguro, liviano, fácil de usar y cómodo.

Objective: To evaluate the usability of a device to measure pain during labor through seven items: size, texture, ease of use, weight, resistance, comfort, and safety. Method: Longitudinal observational study. 60 patients were asked to use the manual sensor during the course of six uterine contractions (approximately 10-20 minutes) and the following day a survey was applied where the patients evaluated the usability of the device in terms of texture, weight, resistance, comfort, easiness of use, sensor size, safety of use, sensor weight, resistance and comfort through a Likert scale from 1 to 7. Safety was evaluated with a scale from 1 to 5. Results: They were schematized with a box plot. Regarding safety, 86% of the users scored 5 points on the scale, perceiving the device as safe. Conclusions: It can be seen that the device was perceived as safe, light, easy to use and comfortable.

Tools for assessing labour pain: a comprehensive review of research literature.

ABSTRACT: The experience of pain associated with labour is complex and challenging to assess. A range of pain measurement tools are reported in the literature. This review aimed to identify current tools used in research to assess labour pain across the past decade and to evaluate their implementation and adequacy when used in the context of labour pain. A literature search was conducted in databases MEDLINE and Cumulative Index of Nursing and Allied Health Literature, using search terms relating to labour, pain, and measurement. A total of 363 articles were selected for inclusion. Most studies (89.9%) assessed pain as a unidimensional experience, with the most common tool being the Visual Analogue Scale, followed by the Numerical Rating Scale. Where studies assessed pain as a multidimensional experience, the most common measurement tool was the McGill Pain Questionnaire. Only 4 studies that used multidimensional tools selected a tool that was capable of capturing positive affective states. Numerous variations in the implementation of scales were noted. This included 35 variations found in the wording of the upper and lower anchors of the Visual Analogue Scale, some assessment tools not allowing an option for "no pain," and instances where only sections of validated tools were used. It is clear that development of a standardised pain assessment strategy, which evaluates the multidimensions of labour pain efficiently and effectively and allows for both positive and negative experiences of pain to be reported, is needed.

The effects of interferential electrical stimulation current on labor pain and duration of active phase of labor in primiparous women: A randomized controlled trial.

BACKGROUND: Labor pain is one of the most severe pains experienced by a woman during her life. Interferential current (IFC) is a type of transcutaneous electrical stimulation that can reduce pain, especially deep ones. OBJECTIVE: This randomized controlled clinical trial (RCT) aimed to study the effects of quadripolar IFC on pain and the duration of the active phase of labor in primiparous women. METHOD: In this RCT, 60 primiparous women were randomized into two groups of IFC and sham IFC. The IFC group received IFC in two periods. The sham group received sham IFC. Primary outcomes were labor pain in different times of active phase and duration of active phase, and secondary outcomes were delivery satisfaction; the number of infants transferred to neonatal intensive care units (NICUs), fetal heart rate (FHR) disorders, Apgar score, partograph variables, and adverse side effects were recorded. RESULT: Between-group changes showed a significant decrease in labor pain during the active phase in the IFC group compared to the sham IFC group (mean difference (MD) = -0.95; 95% confidence interval (95% CI) = -1.35 to -0.55; P < .001). The mean of active phase duration was significantly shorter in the IFC group than in the sham IFC group (MD = -38.25; 95% CI = -62.84 to -13.67; P = .003). CONCLUSION: This study showed the effectiveness of interferential electrical stimulation during labor to reduce pain and duration of the active phase, which can be valuable in improving the quality of care and encouraging natural childbirth.

Women's perceptions of counselling on pain assessment and management during labour in Finland: A cross-sectional survey.

BACKGROUND: The challenge is to identify pain assessment counselling that are effective and reliable to the woman during labour while also supporting appropriate management of labour pain. OBJECTIVE: This study aimed to describe women's perceptions of their counselling on pain assessment and pain management during labour. DESIGN: A descriptive, cross-sectional study. PARTICIPANTS: The sample consisted of women who had given birth (n=204) at a university hospital in Finland; 250 parturients were recruited by convenience sampling. METHODS: Data were collected using a questionnaire (P-PAPM) between November 2018 and February 2019. The statistical significance of observed differences was analysed using the Chi-squared test and Fischer's exact test. RESULTS: Eighty percent of women reported that they had received counselling on pharmacological treatments from midwives, but only 33 % received counselling on pain assessment. The non-pharmacological methods for alleviating labour pain most commonly taught by midwives were proper breathing techniques, cold/heat treatments, and trying different positions and movements. Women were less commonly counselled to try listening to music, thinking about pleasant and positive things, or concentrating their thoughts on something other than pain. The two most commonly used counselling methods were demonstrations and written material and least used Internet-based resources. The personal issue that midwives discussed most frequently during counselling was the women's individual hopes concerning pain management (91%), while the issue discussed least often was previous experiences of pain (58%). The participants' experiences of fear, age, and education were significantly associated with aspects of counselling on pain assessment and management. CONCLUSIONS: Women's counselling on pain assessment and management during labour varied widely. Therefore, to improve its quality, counselling should be routinely integrated into daily midwifery work. In particular, the counselling given on non-pharmacological pain relief methods during labour was inadequate. More varied counselling methods should be used in the future. Finally, the results indicate that midwives' knowledge of counselling should be increased and they should be encouraged to routinely offer counselling on pain assessment and management for parturing women.

Beyond the epidural: Alternatives to neuraxial labor analgesia.

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

No pain management for labour: individual and organisational determinants: A secondary analysis of the 2016 French National Perinatal Survey.

BACKGROUND: Disparities in access to pain management have been identified in several care settings, such as emergency departments and intensive care units, but with regard to labour analgesia, it remains poorly explored. OBJECTIVES: To determine the proportion of women without pain management during labour and its individual and organisational determinants. DESIGN: Secondary analysis of a nationwide cross-sectional population-based study, the 2016 French National Perinatal Survey. SETTINGS: All maternity units in France. PARTICIPANTS: Ten thousand and eleven women who attempted vaginal delivery with a labour duration at least 15 min. MAIN OUTCOME MEASURE: Absence of pain management, defined as absence of any pharmacological or nonpharmacological analgesic method during labour. RESULTS: Among the 10 011 women included, 542 (5.4%) had no labour pain management: 318 (3.7%) of the 8526 women who initially preferred to use neuraxial analgesia and 222 (15.8%) of the 1402 who did not. Using generalised estimating equations stratified according to the maternal antenatal preference for neuraxial analgesia, the common determinants of no labour pain management in both groups were no attendance at childbirth education classes and admission to a delivery unit during the night. Among women who initially preferred to use neuraxial analgesia, those who delivered in units with <1500 annual deliveries compared with units with 2000 to 3499 annual deliveries, were more likely to do without pain management [adjusted odds ratio (OR) = 1.96; 95% confidence interval (CI), 1.39 to 2.78]; among those who did not prefer to use it, women born abroad were more likely to do without labour pain management (adjusted OR = 1.64; 95% CI, 1.12 to 2.40). CONCLUSION: In France, 1 : 20 women had no labour pain management, and this proportion was three times higher among women who preferred not to use neuraxial analgesia. Enhancing maternal information on labour pain and its management, especially nonpharmacological methods, and rethinking care organisation, could improve access to analgesia of any kind.

Sterile water injections for relief of labour pain (the SATURN trial): study protocol for a randomised controlled trial.

BACKGROUND: Up to 80% of women use some form of pharmacological analgesia during labour and birth. The side effects of pharmacological agents are often incompatible with the concurrent use of non-pharmacological pain-relieving strategies, such as water immersion, ambulation and upright positioning, or may have negative effects on both the mother and foetus. Sterile water injections given into the skin of the lumbar region have been demonstrated to reduce back pain during labour. However, the injections given for back pain have no effect on abdominal contraction pain. The analgesic efficacy of sterile water injections for abdominal pain during childbirth is unknown. The injections cause an immediate, brief but significant pain that deters some women from using the procedure. This study aims to investigate the use of water injections given intradermally into the abdomen to relieve labour contraction pain. A vapocoolant spray will be applied to the skin immediately prior to the injections to reduce the injection pain. METHODS: In this pragmatic, placebo-controlled trial, 154 low-risk women in labour at term with a labour pain score ≥ 60 on a 100-ml visual analogue scale (VAS) will be randomly allocated to receive either six injections of sterile water or a sodium chloride 0.9% solution as a placebo (0.1-0.3 ml per injection). Three injections are given along the midline from the fundus to the supra-pubis and three laterally across the supra-pubis. The primary outcome will be the difference in VAS score 30 min post-injection between the groups. Secondary outcomes include VAS score of the injection pain on administration, VAS score of labour pain at 60 and 90 min and maternal and neonatal birth outcomes. DISCUSSION: Access to effective pain relief during labour is fundamental to respectful and safe maternity care. Pharmacological analgesics should support rather than limit other non-pharmacological strategies. Sterile water injections have the potential to provide an alternative form of labour pain relief that is easy to administer in any labour and birth setting and is compatible with other non-pharmacological choices. TRIAL REGISTRATION: ANZCTR ACTRN12621001036808 . Registered on 05 August 2021.

Effects of the addition of transcutaneous electrical stimulation to non-pharmacological measures in labor pain: study protocol for a randomized controlled trial.

BACKGROUND: Labor, although natural and physiological, is a period that can be marked by stress, pain, anxiety, suffering, fear, and anguish for a woman. Thus, non-pharmacological methods that reduce pain during labor are important to allow a better experience without the use of medications. Therefore, the aim of this study is to evaluate the effects of non-pharmacological pain relief methods, added or not to the application of transcutaneous electrical stimulation (TENS), on pain, satisfaction with the childbirth, duration of labor, and newborn conditions. METHODS: This is a randomized controlled clinical trial, with a non-probabilistic convenience sample, composed of women in the first active stage of labor, admitted to a public institution. The parturients will be divided into 3 groups: group 1 (n = 36) composed of parturients who will have continuous support and will be encouraged to walk, adopting different positions with the use of the Swiss ball and receiving back massage for 30 min; group 2 (n = 36) composed of parturients who will also have continuous support and will be encouraged to walk, adopt different positions using the Swiss ball, and will receive the application of TENS for 30 min; and group 3 (n = 36) composed of parturients who will have continuous support and will be encouraged to walk, adopting different positions with the use of the Swiss ball, and will receive placebo TENS application for 30 min. The outcomes evaluated in the study will be pain intensity assessed by the visual analog scale of pain applied before, immediately after, and 30 min and 1 h after the interventions; Experience and Satisfaction with Childbirth Questionnaire (QESP) applied 12 to 24 h after delivery; and data regarding delivery (type of delivery, total duration of labor, and possible obstetric complications) and neonate (weight, height, possible complications, Apgar score in the first and fifth minutes). DISCUSSION: With this research, it is expected to understand the effects of the intervention through TENS electrostimulation added to other non-pharmacological methods for pain management during labor. TRIAL REGISTRATION: Brazilian Registry of Clinical Trials (REBEC) RBR-68kh6j . Registered on March 17, 2020.

Comparison of the effect of educational software and booklet on anxiety and pain during labour: a randomised controlled clinical trial.

This randomised clinical trial was conducted on 153 pregnant women. Participants were assigned into two intervention groups including educational software and an educational booklet and a control group through block randomisation. A training session was implemented for the intervention groups at 30-36 weeks and they were taught how to use the educational methods. Participants were followed-up until the childbirth time and the severity of pain was measured at four stage of cervical dilatation (4, 6, 8 and 10 cm) by Visual Analogue Scale (VAS). Spielberger State-Trait Anxiety Inventory was completed at 4-5 cm cervical dilatation. There was no significant difference between groups in terms of the labour pain intensity (p > .05). After intervention, mean (SD) of state anxiety score was 38.7 (2.6) in educational software group, 44.3 (7.4) in educational booklet group and 63.3 (8.2) in control group. Also, mean (SD) of trait anxiety score was 47.4 (2.7) in educational software group, 47.2 (2.4) in educational booklet group and 61.8 (3.9) in control group. The mean state and trait anxiety scores in both intervention groups were significantly lower than control group (p < .001). Both intervention groups were effective in reducing anxiety. Thus, these educational methods should be recommended for pregnant women in clinical practices.IMPACT STATEMENTWhat is already known on this subject? Childbirth is one of the most important crises in women's life, in which stress and other forms of emotional distress such as anxiety are likely to occur during it. Safe practices and effective interventions can be offered to pregnant women to tolerate the labour pain and reduce anxiety during labour.What do the results of this study add? There was no statistically significant difference between two intervention groups (educational software and educational booklet groups) and control group in terms of the pain intensity at the cervical dilatation of 4, 6, 8 and 10 cm. But the state and trait anxiety in both groups (educational software and educational booklet groups) was significantly less than the control group. Also, the anxiety level was significantly lower in the educational software group than the educational booklet group.What are the implications of these findings for clinical practice and/or future research? Educational software and booklet with educational content about position modification during pregnancy, stretching exercises, breathing techniques and exercises, relaxation and lower back massage for reducing anxiety should be recommended for pregnant women in clinical practices.

Development of the Labor Pain Relief Attitude Questionnaire for pregnant women (LPRAQ-p).

BACKGROUND: Receiving epidural analgesia during labor can possibly have negative consequences for mother and child. Yet, the use of epidural analgesia rapidly increased in the Netherlands over the last decade. Since antenatal plans for labor pain relief have been related to epidural analgesia use during labor, the aim of the current study was to develop a Labor Pain Relief Attitude Questionnaire for pregnant women (LPRAQ-p). METHODS: Three focus group interviews were conducted with pregnant women, new mothers and caregivers and 13 candidate items were derived. Psychometric properties were tested with explorative factor analysis in sample I (N = 429) and a subsequent confirmatory factor analysis in a different sample II (N = 432). RESULTS: The explorative factor analysis suggested a two-factor seven-item solution: a 'women's perception' and 'social environment' subscale. The confirmatory factor analysis confirmed an excellent six-item model fit with appropriate internal consistency. Higher scores on the six-item LPRAQ-p indicate greater willingness for request of pain relief medication during labor. Two-tailed t-tests showed that women with elevated levels of depression and pregnancy-specific distress symptoms, nulliparous women and multiparous women with complications during a previous delivery had greater willingness for request of pain relief medication during labor. Linear regression showed that the most important association with higher scores on the LPRAQ-p were high pregnancy-specific distress symptoms. CONCLUSIONS: This study showed the LPRAQ-p to be a valid instrument to evaluate attitude towards labor pain relief in pregnant women. High scores on this questionnaire are associated with high levels of pregnancy-specific distress symptoms.

Analgesic Efficacy and Adverse Effects of Meperidine in Managing Postoperative or Labor Pain: A Narrative Review of Randomized Controlled Trials.

BACKGROUND: Meperidine, a synthetic opioid, has a rapid onset and short duration of action. Mounting evidence has challenged meperidine's analgesic benefits, and concerns have been raised about its safety profile. Despite recommendations to restrict the prescription of meperidine, the drug remains frequently used. OBJECTIVES: The aim of this study was to evaluate the evidence regarding the efficacy and safety of meperidine for acute postoperative and labor pain. STUDY DESIGN: This was a narrative review of the analgesic efficacy and side effects of meperidine compared to other analgesic drugs for acute postoperative and labor pain in adults. SETTING: Randomized controlled trials that compared the analgesic efficacy and side effect profile of meperidine versus another analgesic drug in adult patients were evaluated. METHODS: A systemized search of randomized controlled trials studying meperidine for acute postoperative or labor pain in the adult patient population from PubMed, Medline, and EMBASE was performed. Included studies reported on different routes of meperidine administration including intramuscular, intravenous, and patient-controlled analgesia in various surgical procedures such as abdominal surgery, Cesarean section, gynecological surgery, orthopedic surgery, cardiothoracic surgery, as well as for labor analgesia. Meperidine's analgesic efficacy and safety profile were compared to other opioids (morphine, tramadol, fentanyl, buprenorphine, nalbuphine, and pentazocine), nonsteroidal anti-inflammatory drugs (ketorolac, diclofenac, and indomethacin), dipyrone, ketamine, and bupivacaine. RESULTS: A total of 62 randomized controlled trials published between 1972 and 2018 were reviewed. Meperidine had a similar or inferior analgesic efficacy compared to other analgesics for acute postoperative or labor pain. Meperidine was associated with more sedation and respiratory depression. LIMITATIONS: The sample sizes of many clinical studies were small, and therefore probably insufficiently powered to detect differences in uncommon side effects, such as central nervous system toxicity. In addition, some of the included clinical studies were old. CONCLUSION: Considering the availability of other effective analgesics with potentially fewer side effects, the use of meperidine for acute postoperative or labor pain should not be recommended. KEY WORDS: Acute postoperative pain, adverse effects, labor analgesia, meperidine, pethidine.

Comparison of Programmed Intermittent Epidural Boluses With Continuous Epidural Infusion for the Maintenance of Labor Analgesia: A Randomized, Controlled, Double-Blind Study.

BACKGROUND: Programmed intermittent epidural boluses may improve the spread of local anesthetics compared to continuous epidural infusion, improving labor analgesia and obstetric outcomes. However, there are limited data from studies using commercially available pumps capable of coadministering programmed intermittent epidural boluses or continuous epidural infusion with patient-controlled epidural analgesia. Therefore, we performed this prospective, randomized, double-blind study to compare the impact of programmed intermittent epidural boluses versus continuous epidural infusion on labor analgesia and maternal/neonatal outcomes. We hypothesized that programmed intermittent epidural boluses will result in lower patient-controlled epidural analgesia consumption compared to that with continuous epidural infusion. METHODS: Following standardized initiation of epidural labor analgesia, women were randomized to receive 0.1% ropivacaine with 2 µg/mL fentanyl as 6-mL programmed intermittent epidural boluses every 45 minutes or continuous epidural infusion at 8 mL/h in a double-blind fashion with similar patient-controlled epidural analgesia settings in both groups. The primary outcome was patient-controlled epidural analgesia consumption per hour. Secondary outcomes included a need for physician interventions, patterns of patient-controlled epidural analgesia use, motor blockade, number of patients who developed hypotension, pain scores, duration of second stage of labor, mode of delivery, and maternal satisfaction. RESULTS: We included 120 patients (61 in programmed intermittent epidural boluses group and 59 in continuous epidural infusion group) in the analysis. The median (interquartile range) patient-controlled epidural analgesia volume consumed per hour was not significantly different between the groups: 4.5 mL/h (3.0-8.6 mL/h) for the continuous epidural infusion group and 4.0 mL/h (2.2-7.1 mL/h) for the programmed intermittent epidural boluses group (P = .17). The Hodges-Lehmann location shift estimate of the difference (95% CI) from the continuous epidural infusion to the programmed intermittent epidural boluses group is 0.9 mL/h (-0.4 to 2.2 mL/h). There were also no significant differences between the groups in any of the secondary outcomes except for higher median (interquartile range) patient-controlled epidural analgesia attempts per given ratio per hour in the programmed intermittent epidural bolus group (0.17 [0.10-0.30] vs 0.12 [0.08-0.18]; P = .03) and more motor block in the continuous epidural infusion group (those with Bromage score <5, 27.5% vs 50.0%; P = .03). CONCLUSIONS: Under the conditions of our study, we did not find improved outcomes with programmed intermittent epidural boluses compared to continuous epidural infusion except for less motor block with programmed intermittent epidural boluses. Future studies should assess whether smaller but clinically important differences exist and evaluate different parameters of programmed intermittent epidural boluses to optimize analgesia and outcomes with this mode of analgesia.

Factores maternos y fetales asociados a la inducción del trabajo de parto, Hospital Vicente Corral Moscoso, Cuenca 2019 / Maternal and fetal factors associated with induction of labor, Hospital Vicente Corral Moscoso, Cuenca 2019

Antecedentes: La inducción del parto es una práctica frecuente en obstetricia, observándose un aumento de sus cifras en las últimas décadas a nivel mundial. Objetivo: Determinar los factores maternos y fetales asociados a la inducción del parto en pacientes hospitalizadas en el departamento de Ginecología y Obstetricia del hospital Vicente Corral Moscoso, Cuenca, 2019. Métodos: Estudio analítico realizado a 208 gestantes ingresadas en el área de Ginecología y Obstetricia. La información se procesó en el programa SPSS versión 15. Para el análisis utilizamos estadística descriptiva en base a frecuencias y porcentajes, se midió la asociación estadística con la prueba Chi 2 y Razón de Prevalencia (RP), intervalo de confianza 95%, considerando estadísticamente significativo p < 0,05. Resultados: La edad media fue 24,7 (DS± 5,93), predominó la instrucción secundaria, estado civil estable. Hubo asociación y significancia estadística de factores materno fetales a inducción como: ruptura prematura de membranas RP 2,97 (IC95%: 2,09­4,24 valor p 0,000); preeclampsia RP 2,13 (IC95%: 1,46­3,10 valor p 0,000); embarazo término tardío RP 2,91 (IC95%: 2,12­3,99 valor p 0,000); restricción del crecimiento RP 3,22 (IC95%: 2,62-3,95 valor p 0,000). No así para corioamnionitis RP 3,08 (IC95%: 2,53­3,76 valor p 0,33) y muerte fetal RP 1,55 (IC95%: 0,68­3,54 valor p 0,31). Conclusiones: Se encontró asociación y significancia estadística con factores materno fetales e inducción como: ruptura prematura de membranas, preeclampsia, embarazo término tardío, restricción del crecimiento. No para corioamnionitis y muerte fetal.

Background: Induction of labor is a frequent practice in obstetrics, with an increase in its numbers being observed in recent decades worldwide. Objective: To determine the maternal and fetal factors associated with labor induction in hospitalized patients in the Gynecology and Obstetrics department of the Vicente Corral Moscoso hospital, Cuenca, 2019. Methods: Analytical study carried out on 208 pregnant women admitted to the Gynecology and Obstetrics area who met the inclusion criteria. The information was processed in the SPSS version 15 program. For the analysis we used descriptive statistics based on frequencies and percentages, the statistical association was measured with the Chi 2 test and Prevalence Ratio (RP), 95% confidence interval, considering statistically significant p <0.05. Results: The mean age was 24.7 (SD ± 5.93), secondary education, stable marital status predominated. There was association and statistical significance of maternal-fetal factors to induction of labor such as: premature rupture of membranes RP 2.97 (95% CI: 2.09­4.24 p-value 0.000); preeclampsia RP 2.13 (95% CI: 1.46­3.10 p-value 0.000); late term pregnancy RP 2.91 (95% CI: 2.12­3.99 p-value 0.000); intrauterine growth restriction RP 3.22 (95% CI: 2.62-3.95 p-value 0.000). Not so for chorioamnionitis RP 3.08 (95% CI: 2.53­3.76 p value 0.33) and fetal death RP 1.55 (95% CI: 0.68­3.54 p value 0.31). Conclusions: There was an association and statistical significance with maternal-fetal factors associated with induction such as: premature rupture of membranes, pre-eclampsia, late-term pregnancy, intrauterine growth restriction. Not so for chorioamnionitis and fetal death.

Decreasing Opioid Use Postpartum: A Quality Improvement Initiative.

OBJECTIVE: To estimate the effects of an inpatient initiative to decrease opioid use among women admitted to labor and delivery. METHODS: We created a multimodal pain power plan with standard therapeutic postpartum activity goals rather than pain goals, tiered order sets with scheduled administration of nonsteroidal antiinflammatory drugs (NSAIDs), and embedded changes into the electronic health record. Before the multimodal pain power plan launch, pain was assessed on a 10-point scale; women received NSAIDs for pain levels of 3 or less and opioids for pain levels higher than 3. For this analysis, we included women who delivered at 5 hospitals in the 10 months before and 12 months after the multimodal pain power plan launch. Women with prior substance use disorder or complicated deliveries were excluded and we stratified analyses into women who delivered vaginally compared with by cesarean. Opioid use was converted to morphine milligram equivalent (MME). Women rated pain control in 24-hour blocks using individually ascertained cutoffs. A multivariable regression analysis was performed, and adjusted odds ratios are reported. RESULTS: We compared the 6,892 women who delivered 10 months before the pain power plan launch to the 7,527 who delivered in the 12 months after the launch. The mean cohort age was 29.6±6.0 years; the majority (75%) were white. Risk of opioid use decreased by 26% among women who delivered vaginally (risk ratio [RR] 0.74; 95% CI [0.68, 0.81]) and 18% among women who delivered by cesarean (RR 0.82; 95% CI [0.72, 0.92]). Among women who received opioids, mean MME use decreased 21% (RR 0.79; 95% CI [0.70, 0.88]) and 54% (RR 0.46; 95% CI [0.35, 0.61]) in the vaginal and cesarean delivery groups, respectively. Fewer women reported acceptable pain levels, with decreases of 82-69% (P<.01) and 82-74% (P<.01) in the vaginal and cesarean delivery groups, respectively. Within the postlaunch cesarean delivery group, women also reported that they were less likely to have their pain well controlled on the Hospital Consumer Assessment of Healthcare Providers and Systems questionnaires (82% vs 62%, P <.01). CONCLUSION: A standardized multimodal pain power plan reduced opioid use among a large cohort of women admitted to labor and delivery in Central Texas. Despite meeting functional goals, some women reported increased pain during their hospital stay.

Complementary therapies in labor: randomized clinical trial. / Terapias complementares no trabalho de parto: ensaio clínico randomizado.

OBJECTIVE: To evaluate the effect of isolated and combined warm shower bath and perineal exercise with Swiss ball, on perception of pain, anxiety and labor progression. METHOD: Randomized, controlled clinical trial with 128 patients allocated into three groups of therapies: isolated and combined bath and ball. Pain and anxiety perception was evaluated before and thirty minutes after therapeutic intervention through visual analogic scales (VAS). RESULTS: Pain perception score increased, and anxiety decreased in all groups, mainly when using a shower bath. The cervical dilation increased in all groups (p<.001), as well as the number of uterine contractions increased, mainly in the group that used combined bath and ball and also showed shorter labor time. CONCLUSION: The studied therapies contribute to maternal adaptation and well-being and favor labor's evolution.

Labor pain control and associated factors among women who gave birth at Leku primary hospital, southern Ethiopia.

OBJECTIVE: To assess labor pain control and associated factors among women who give birth at Leku primary hospital, southern Ethiopia, 2018/19. A systematic random sampling technique was used to select 404 mothers who gave birth at Leku hospital during the data collection period. Data were collected by two first degree midwives immediately after delivery using Labor Agentry Scale (LAS). RESULTS: In this study, 404 mothers were participated making the response rate of 100%. Among the participants, 104 (25.7%) of mothers reported Mild control of labor pain. Maternal age of 19 to 24 year AOR = 5.85 (95% CI 2.14, 15.98), being farmer AOR = 2.5 (1.14, 5.57), primi-para AOR = 0.13 (0.06, 0.3), good family support AOR = 2.8 (1.49, 5.3), short duration of labor (< 12 h) AOR = 3.2 (1.65, 6.23) and history of pregnancy loss AOR = 0.06 (0.03, 0.14) were significantly associated with greater control of labor pain. In general, compared to other studies, the level of labor pain control is good in this study area. Enhancing factors of labor pain control have to be strengthened to increase greater control of labor pain. Qualitative research is highly recommended to identify cultural factors related to labor pain control and management.