Diagnostic accuracy of a simple qualitative ultrasound assessment for the diagnosis of high-risk gastric contents in the parturient. A prospective observational cohort study.

STUDY OBJECTIVE: Interpretation of gastric ultrasound relies on the use of a clinical algorithm that combines qualitative analysis of the gastric antrum contents with the calculation of the volume of fluid contents. This reference method may be difficult to apply in the parturient. We therefore aimed to assess the diagnostic accuracy of a simple qualitative assessment in the supine position for the diagnosis of high-risk gastric contents in the parturient. We also assessed the diagnostic accuracy of a composite scale and another clinical algorithm based on a mathematical model different to that used in the reference method. DESIGN: Prospective observational cohort study. SETTING: University hospital, Lyon, France. PATIENTS: Adult women admitted to the delivery room. INTERVENTIONS: Qualitative and quantitative gastric ultrasound examination within the first hour following admission. MEASUREMENTS: With respect to the reference method, the diagnostic accuracy of a simple qualitative assessment for the diagnosis of high-risk gastric contents was assessed. The diagnostic accuracy of a composite scale and another clinical algorithm, and the agreement between each approach were also assessed. MAIN RESULTS: A total of 235 parturients were included and analyzed. The simple qualitative assessment led to conclusive ultrasound assessment in 233 (99%) women, while the reference method led to conclusive assessment in 213 (91%) women (P < 0.05). The sensitivity and the specificity of the simple qualitative assessment were 97% (95%CI: 93 to 99%) and 96% (95%CI: 90 to 99%), respectively. These were not significantly different from those of the composite scale and the clinical algorithm. The four approaches showed almost perfect agreement with each other. CONCLUSIONS: These results suggest that simple qualitative assessment may be useful in clinical practice to help the anesthesiologist in the assessment of gastric contents status and risk of aspiration.

Anesthesia practices for management of labor pain and cesarean delivery in France (EPIDOL): A cross-sectional survey.

BACKGROUND: This study aimed to collect obstetric anesthesia practice and patient-reported outcomes as an update to the last French Obstetric Anesthesia survey from 1996. METHODS: Maternity units were randomly selected across France and surveyed for 7 consecutive days from February, 2016, to January, 2017. Data was gathered prospectively by questionnaires filled out by patients and anesthesia providers. RESULTS: There were 1885 questionnaires received from 56 units, with 379 cesarean delivery (CD) and 1506 vaginal delivery (VD) cases analyzed. The overall neuraxial labor analgesia (NLA) rate was 82.5% (95% CI [82.4-82.6]), with 70.3% (95% CI [71.4-71.6]) receiving automated administration (PCEA/PIEB). NLA was effective throughout labor in 68.2% of cases, however, severe pain was reported by 29.4% of patients. The overall rate of alternative approaches for labor analgesia was 19.5% (95%CI [19.2-19.7]). Obesity (OR 2.8; 95% CI [1.0-7.5], p < 0.04) and delivery in level I units (OR 0.6; 95% CI [0.5-0.9], p < 0.01) were associated with severe pain during VD. Satisfaction was found to be similar in patients delivering with or without NLA. The incidence of pain during CD was similar in scheduled versus non-scheduled CD. Failure of NLA during CD was associated with severe pain (OR 10.0; 95% CI [3.1-31.9], p < 0.01) and dissatisfaction (OR 26.2; 95% CI [3.0-225.1], p < 0.01). CONCLUSION: Despite the high NLA rate in France, a significant proportion of women experience severe pain during labor and delivery. This study emphasizes the need for further practice guidelines in obstetric anesthesia to ensure optimal pain management and improve patients' experience during childbirth. CLINICALTRIALS: govNCT02853890.

Diagnostic accuracy of a simple qualitative ultrasound assessment for the diagnosis of empty stomach in the adult: A supplementary analysis of a prospective observer-blind randomized crossover study.

BACKGROUND: It has been reported that qualitative ultrasound assessment performed in the semi-upright position had high sensitivity to detect gastric fluid volume >1.5 mL.kg-1 . Nevertheless, the diagnostic accuracy of qualitative assessment for the diagnosis of empty stomach (fluid volume <0.8 mL.kg-1 ) has not been assessed. We aimed to assess the diagnostic accuracy of simple qualitative ultrasound assessment with and without head-of-bed elevation to 45° for the diagnosis of an empty stomach. We also aimed to determine the diagnostic accuracy of a composite ultrasound scale and clinical algorithm. METHODS: We performed a supplementary analysis of a prospective observer-blind randomized crossover trial in which adult fasting volunteers attended two distinct sessions, with the head-of-bed angled either at 0° or 45°, in a randomized order. Three tests were performed within each session, each corresponding to a different (either 0, 50, 100, 150 or 200 mL) and randomized volume of water; the same volumes were ingested in both sessions, in a randomized order. Ultrasounds were performed 3 min after water ingestion, blindly to the volume ingested. RESULTS: We included 20 volunteers in whom 120 measurements were analyzed. The sensitivity and specificity of the qualitative assessment in the semirecumbent position were 93% (95% CI: 68-100) and 89% (95% CI: 76-96), respectively. The composite scale and clinical algorithm did not have better diagnostic accuracy than the qualitative assessment performed with head-of-bed elevation. Without head-of-bed elevation, the clinical algorithm had significantly higher specificity (98% [95% CI: 88-100]) than qualitative assessment (67% [95% CI: 51-80]; p < 0.05). CONCLUSION: These results suggest that qualitative assessment in the semirecumbent position had high diagnostic accuracy for the diagnosis of fluid volume <0.8 mL.kg-1 ; this method can be used in clinical practice for reliable diagnosis of empty stomach.

Alveolar target ventilation and dead space in children under anaesthesia: The proventiped cohort study.

INTRODUCTION: Ventilator settings in children under anaesthesia remain difficult because of the changes in the physiology and the high dead space. OBJECTIVE: To determine the alveolar minute-volume to sustain normocapnia in children under mechanical ventilation. DESIGN: A prospective observational study. SETTINGS: This study was performed between May and October 2019 in a tertiary care children's hospital. PATIENTS: Children between 2 months and 12 years, weighing between 5 and 40 kg, admitted for general anaesthesia. INTERVENTION: Volumetric capnography was used to estimate the alveolar and dead space volume (Vd). MAIN OUTCOME MEASURES: Total and alveolar minute ventilation in (ml kg -1  min -1 ) over 100 breaths. RESULTS: Sixty patients were included comprising 20 per group: 5 to 10 kg (group 1), 10 to 20 kg (group 2), 20 to 40 kg (group 3). Seven patients were excluded for aberrant capnographic curves. After normalisation to weight, the median [IQR] tidal volume per kilogram was similar between the three groups: 6.5 ml kg -1 [6.0 to 7.5 ml kg -1 ], 6.4  ml kg -1 [5.7 to 7.3  ml kg -1 ], 6.4  ml kg -1 [5.3 to 6.8  ml kg -1 ]; P  = 0.3. Total Vd (in ml kg -1 ) was negatively correlated to weight ( r  = -0.62, 95% confidence interval -0.41 to -0.76, P  < 0.001). The total normalised minute ventilation (ml kg -1  min -1 ) to obtain normocapnia was higher in group 1 than in group 2 and in group 3; 203  ml kg -1  min -1 [175 to 219 ml kg -1  min -1 ], 150  ml kg -1  min -1 [139 to 181  ml kg -1  min -1 ] and 128  ml kg -1  min -1 [107 to 157  ml kg -1  min -1 ]; P  < 0.001 (mean ± SD), but (mean ± SD) alveolar minute ventilation was similar between the three groups; 68 ±â€Š21  ml kg -1  min -1 . CONCLUSION: Total dead space volume (including apparatus dead space) represents a major component of tidal volume in children less than 30 kg, when using large heat and moisture exchanger filters. The total minute ventilation necessary to achieve normocapnia decreased with increasing weight, while the alveolar minute ventilation remained constant. TRIAL REGISTRATION: ClinicalTrials.gov, identifier: NCT03901599.

Effective dose of ephedrine for treatment of hypotension after induction of general anaesthesia in neonates and infants less than 6 months of age: a multicentre randomised, controlled, open label, dose escalation trial.

BACKGROUND: The recommended dose of ephedrine in adults (0.1 mg kg-1) frequently fails to treat hypotension after induction of general anaesthesia in neonates and infants less than 6 months of age. The aim of this study was to determine the optimal dose of ephedrine in this population for the treatment of hypotension after induction of general anaesthesia with sevoflurane. METHODS: We conducted a multicentre, prospective, randomised, open-label, controlled, dose-escalation trial. Subjects were randomised if presenting a >20% change from baseline in MAP. Six cohorts of 20 subjects each were enrolled. Ten subjects in the first cohort received 0.1 mg kg-1 i. v. (reference dose). For each subsequent cohort, 10 subjects were assigned to the next higher dose (consecutively 0.6, 0.8, 1, 1.2, and 1.4 mg kg-1 i. v.), and the other subjects were assigned to one or more doses already investigated in previous cohorts. The primary outcome was the return of MAP to >80% of baseline at least once within 10 min after ephedrine administration. RESULTS: A total of 119 infants (25% females), with a mean age (standard deviation) of 2.7 (1.3) months, received their allocated dose of ephedrine. The optimal dose of ephedrine was 1.2 mg kg-1, with a percentage of success of 65.5% (95% confidence interval, 35.6-86.4). The doses of ephedrine investigated did not induce adverse events. CONCLUSIONS: Doses of ephedrine much higher (∼10-fold) than those used in adults are necessary in neonates and infants for the treatment of hypotension after induction of general anaesthesia with sevoflurane. CLINICAL TRIAL REGISTRATION: NCT02384876.

Association Between Anesthesia Provider Education and Carbon Footprint Related to the Use of Inhaled Halogenated Anesthetics.

BACKGROUND: Inhaled halogenated anesthetics are responsible for half of operating room total greenhouse gas emissions. Sustainable anesthesia groups were set up in 4 Lyon, France, university hospitals (Hospices Civils de Lyon) in January 2018 and have supported a specific information campaign about the carbon footprint related to the use of inhaled halogenated anesthetics in June 2019. We aimed to assess whether implementing such information campaigns was associated with a decrease in the carbon footprint related to inhaled halogenated anesthetics. METHODS: This retrospective cohort study was conducted from January 1, 2015, to February 29, 2020, in 4 hospitals of the Hospices Civils de Lyon in France. Information meetings on sustainable anesthesia practices were organized by sustainable anesthesia groups that were set up in January 2018. In addition, a specific information campaign about the carbon footprint related to inhaled halogenated anesthetics was conducted in June 2019; it was followed by a questionnaire to be completed online. The monthly purchase of sevoflurane, desflurane, and propofol was recorded, and the estimated monthly carbon footprint from desflurane- and sevoflurane-related perioperative emissions was calculated. The interrupted time-series data from January 2015 to February 2020 were analyzed by segmented regression, considering both interventions (setting up of the sustainable anesthesia groups and specific information campaign) in the analysis and adjusting for 2 confounding factors (seasonality of the data and number of general anesthesia uses). RESULTS: Among the 641 anesthesia providers from the study hospitals, 121 (19%) attended the information meetings about the carbon footprint of inhaled halogenated anesthetics, and 180 (28%) completed the questionnaire. The anesthetic activity from all 641 providers was considered in the analysis. After the sustainable anesthesia groups were set up, the carbon footprint of sevoflurane and desflurane started decreasing: the slope significantly changed ( P < .01) and became significantly negative, from -0.27 (95% confidence interval [CI], -1.08 to 0.54) tons.month -1 to -14.16 (95% CI, -16.67 to -11.65) tons.month -1 . After the specific information campaign, the carbon footprint kept decreasing, with a slope of -7.58 (95% CI, -13.74 to -1.41) tons.month -1 ( P = .02), which was not significantly different from the previous period ( P = .07). CONCLUSIONS: The setup of the sustainable anesthesia groups was associated with a dramatic reduction in the carbon footprint related to halogenated anesthetics. These results should encourage health care institutions to undertake information campaigns toward anesthesia providers so that they also take into account the environmental impact in the choice of anesthetic drugs, in addition to the benefits for the patient and economic concerns.

Diagnostic performance of qualitative ultrasound assessment for the interpretation of point-of-care gastric ultrasound to detect high gastric fluid volume: A prospective randomized crossover study.

STUDY OBJECTIVE: This study aimed to assess whether elevating the head of the bed to 45° was associated with sensitivity >90% of the qualitative ultrasound assessment for the diagnosis of gastric fluid volume > 1.5 ml.kg-1. We also assessed the performance of qualitative assessment, composite ultrasound scale, and clinical algorithm, for the diagnosis of fluid volume > 1.5 ml.kg-1 according to whether the head of the bed was elevated to 45° or not. DESIGN: Prospective randomized observer-blind crossover trial. SETTING: Hospices Civils de Lyon, France. PATIENT: Healthy adult volunteers. INTERVENTIONS: Two separate study sessions in fasting volunteers: with and without head-of-bed elevation to 45°, in a randomized order. Each session consisted of three tests, each corresponding to a randomized and different volume of water (either 0, 50, 100, 150 or 200 ml); the same volumes were used in both sessions and in a randomized order. Gastric ultrasounds were performed three minutes after the ingestion of water by an investigator blinded to the volume ingested. MEASUREMENTS: Diagnostic performance of each approach for the diagnosis of gastric fluid volume > 1.5 ml.kg-1. MAIN RESULTS: Twenty volunteers were included, and 120 measurements were analyzed. The sensitivity of the qualitative assessment for the diagnosis of gastric fluid volume > 1.5 ml.kg-1 with and without head-of-bed elevation was 91% (95%CI: 75-98) and 75% (95%CI: 57-89), respectively. The clinical algorithm with head-of-bed elevation had significantly better sensitivity than the qualitative assessment with no head-of-bed elevation; there was no significant difference for other comparisons. CONCLUSIONS: The results suggest that qualitative examination of gastric antrum in the supine position with head-of-bed elevation to 45° can discriminate between low and high gastric fluid volume with high sensitivity, while neither the composite ultrasound scale nor the clinical algorithm improved the diagnostic performance of gastric ultrasound for the diagnosis of gastric fluid volume > 1.5 ml.kg-1.

Pregnancy and Labor Epidural Effects on Gastric Emptying: A Prospective Comparative Study.

BACKGROUND: The lack of reliable data on gastric emptying of solid food during labor has led to some discrepancies between current guidelines regarding fasting for solid food in the parturient. This prospective comparative study aimed to test the hypothesis that the gastric emptying fraction of a light meal would be reduced in parturients receiving epidural analgesia and with no labor analgesia compared with nonpregnant and pregnant women. METHODS: Ten subjects were enrolled and tested in each group: nonpregnant women, term pregnant women, parturients with no labor analgesia, and parturients with epidural labor analgesia. After a first ultrasound examination was performed to ensure an empty stomach, each subject ingested a light meal (125 g yogurt; 120 kcal) within 5 min. Then ultrasound measurements of the antral area were performed at 15, 60, 90, and 120 min. The fraction of gastric emptying at 90 min was calculated as [(antral area90 min / antral area15 min) - 1] × 100, and half-time to gastric emptying was also determined. For the Parturient-Epidural group, the test meal was ingested within the first hour after the induction of epidural analgesia. RESULTS: The median (interquartile range) fraction of gastric emptying at 90 min was 52% (46 to 61), 45% (31 to 56), 7% (5 to 10), and 31% (17 to 39) for nonpregnant women, pregnant women, parturients without labor analgesia, and parturients with labor epidural analgesia, respectively (P < 0.0001). The fraction of gastric emptying at 90 min was statistically significant and lower in the Parturient-Epidural group than in the Nonpregnant and Pregnant Control groups. In addition, the fraction of gastric emptying at 90 min was statistically significant and lower in the Parturient-No-Epidural group than in the Parturient-Epidural group. CONCLUSIONS: Gastric emptying in parturients after a light meal was delayed, and labor epidural analgesia seems not to worsen but facilitates gastric emptying. This should be taken into consideration when allowing women in labor to consume a light meal.

Lost Venous Access Guidewire Identified by Its Late Cervical Protrusion: Case Report.

We report a pediatric patient who underwent a central venous catheter (CVC) insertion and presented with a sudden protrusion of a guidewire from the neck 26 months later. The guidewire was extracted via femoral venotomy. A 5-cm portion of the guidewire adhering to the superior vena cava wall was left in place. We recommend always using a CVC checklist, inspecting the guidewire before and after insertion, and carefully examining the postinsertion radiographs. This checklist should be mandatory with every CVC insertion, including the perioperative period.

Ultrasound assessment of gastric contents prior to placental delivery: A prospective multicentre cohort study.

BACKGROUND: There is ongoing debate regarding the optimal general anaesthetic technique for manual removal of the placenta after vaginal delivery. Using ultrasound examination of the gastric antrum, this study aimed to assess the change in gastric contents during vaginal delivery and to determine the prevalence of stomach at risk for pulmonary aspiration in the immediate postpartum period before placental delivery. METHODS: In this prospective multicentre cohort study, antral ultrasonography was performed at full cervical dilatation within the thirty minutes preceding the beginning of expulsive efforts and after vaginal birth, before placental delivery. High-risk gastric content was defined as the visualisation of any solid content in the antrum or antral cross-sectional area in the semi-recumbent position (SR-CSA) > 608 mm². RESULTS: Twenty-six women were included and analysed. There was a significant decrease in both the proportion of patients with solid gastric content and the SR-CSA between the two-ultrasound examinations. Twenty-one patients (80.8%) exhibited a decrease in the SR-CSA during vaginal delivery. The prevalence of stomach at risk for pulmonary aspiration was significantly lower after vaginal delivery than before vaginal delivery (23.1% vs. 57.7%, P = 0.0004). CONCLUSION: Our results suggest that gastric emptying is at least partially preserved during vaginal birth. Nevertheless, almost a quarter of women did have high-risk gastric content in the immediate postpartum period. Point-of-care antral ultrasonography may be of interest for the fast assessment of the gastric content status when a general anaesthesia is required for manual removal of retained placenta.

Raising awareness to prevent, recognise and manage acute pain during caesarean delivery: The French Practice Bulletin.

The incidence of acute pain during caesarean section varies between studies, with a reported rate ranging between 0.5%-17% for spinal anaesthesia and 1.7%-20% for epidural anaesthesia. Leaders from the French Club anesthésie-réanimation en obstétrique (CARO) convened to provide a clinical framework and practice bulletin to prevent, recognise and treat acute pain during caesarean section. First, a steering group agreed on 5 themes guiding quality of anaesthesia care for caesarean section: (1) appropriate neuraxial anaesthesia and testing of the surgical block prior to incision (PREVENTION); (2) appropriate organisation around decision to delivery time (COMMUNICATION); 3) appropriate management of pain before and/or after skin incision (RECOGNITION & RESPONSE); (4) appropriate prevention, identification and management of post-traumatic stress disorder (SCREENING, PREVENTION AND MANAGEMENT OF COMPLICATIONS); (5) management of medico-legal issues (MITIGATION). Then, an interdisciplinary multi-professional taskforce composed of obstetric anaesthesiologists, obstetricians, neonatologists, psychiatrists, midwifes, nurse anaesthetists, lawyers and patients, developed 23 statements that contribute to optimise care for caesarean section under neuraxial anaesthesia, of which 10 were deemed key recommendations. A decision-tree was built to optimise prevention, communication, recognition, response and management. The aim of this practice bulletin, which was endorsed by 6 societies, is to raise awareness on the risks associated with severe acute pain during caesarean section and to provide best clinical practices; pain during caesarean is not acceptable and should be prevented and managed by all stakeholders.

Post-partum relapse in women with multiple sclerosis after neuraxial labour analgesia or neuraxial anaesthesia: A multicentre retrospective cohort study.

BACKGROUND: The proportion of women with multiple sclerosis experiencing a relapse in the post-partum period after neuraxial labour analgesia or neuraxial anaesthesia remains uncertain. This study aimed to assess the association between neuraxial labour analgesia or neuraxial anaesthesia and the occurrence of relapse during the first three months post-partum. METHODS: In this retrospective cohort study, cases of women with a diagnosis of multiple sclerosis delivering between January 2010 and April 2015 were analysed. Demographic, anaesthetic and obstetric characteristics, occurrence and number of relapses in the year preceding pregnancy, during pregnancy, and the first three post-partum months, were recorded. Logistic regression analyses were performed for the identification of factors associated with the occurrence of post-partum relapse. RESULTS: A total of 118 deliveries in 104 parturients were included, these were 78 (66%) vaginal deliveries and 40 (34%) caesarean deliveries. Neuraxial analgesia was provided in 50 deliveries, and neuraxial anaesthesia in 46 deliveries; no neuraxial anaesthesia or analgesia was administered in remaining 22 deliveries. Post-partum relapse occurred in 31 women (26%). There was no association between obstetric or anaesthetic characteristics and post-partum relapse. Both the occurrence and number of relapses prior to and during pregnancy, and the time between last relapse and delivery, were significantly associated with post-partum relapse in univariate analysis. The occurrence of relapse within the year preceding the pregnancy was the sole independent factor associated with post-partum relapse. CONCLUSION: Neuraxial procedures were not associated with increased rate of post-partum relapse; only disease activity prior to pregnancy was predictive of post-partum relapse.

Effect of patient head position on the aspirated volume of regurgitated clear fluid. A fresh human cadaver study.

INTRODUCTION: The relationship between regurgitated and aspirated volume of clear fluids remains undetermined and may depend on anatomical factors and patient position. We aimed to assess whether head position (sniffing vs. extension position) affected this relationship in fresh human cadavers. We also determined the critical volume of water regurgitated that led to pulmonary aspiration of volume ≥ 0.8 mL kg-1 and ≥ 1.5 mL kg-1 for each head position. MATERIAL AND METHODS: Six volumes of water (40, 80, 100, 120, 150, and 200 mL) were injected each twice, in a randomised order, at a flow rate of 20 mL per second, into the oesophagus of seven fresh human cadavers lying in the supine position on a non-tilted table, with the head in the sniffing position and in the extension position. Aspirated volume was measured in the trachea, blindly to the volume injected. RESULTS: Overall, more than 85% of the regurgitated volume was aspirated into the trachea. The volume of aspirated water was significantly greater in the sniffing position than in the extension position. The cut-off volumes of water injected into the oesophagus leading to aspirated volume ≥ 0.8 mL kg-1 and ≥ 1.5 mL kg-1 were, respectively, 0.8 mL kg-1 and 1.5 mL kg-1 in the sniffing position, and 1.2 mL kg-1 and 1.8 mL kg-1 in the extension position. CONCLUSIONS: These results confirm that most of the regurgitated clear fluid enters the trachea in humans lying in the supine position on a non-tilted table, especially when the head is in the sniffing position.

European minimum standards for obstetric analgesia and anaesthesia departments: An experts' consensus.

: An important variability of anaesthetic standards of care was discovered in the obstetric departments of many European Union countries. After discussing this issue in various meetings of the European Society of Anaesthesiology (ESA) board and its obstetric subcommittee, European Board of Anaesthesiology of the European Union of Medical Specialists (EBA-UEMS) executive members, ESA obstetric subcommittee members and European experts in obstetric anaesthesiology have participated in the elaboration of this document. This experts' opinion is focused mainly on obstetric patients and safety concerns in terms of minimum standards of practice. An initial bibliographical search was performed in medical databases and general literature, searching for obstetric anaesthesiology standards to select the most important safety issues. After the initial presentation of the project during EBA-UEMS and ESA obstetric subcommittee meetings, participants were asked to review the document; several rounds of revisions were performed by the experts, to reach a common opinion concerning the topics considered central to patient safety in the obstetric setting. After three rounds of revision, a consensus was reached and is presented in this document, which includes the list of topics considered relevant by the involved areas, and the respective recommendations. These recommendations covered some EBA-UEMS strategic key areas, in addition to several clinical aspects of common obstetric practice.

Women's view on fasting during labor in a tertiary care obstetric unit. A prospective cohort study.

OBJECTIVE: Maternal satisfaction and comfort may in part depend on fasting instruction given during labor. This study aimed to assess the satisfaction and the wishes of parturients with regards to fasting during labor. STUDY DESIGN: This prospective cohort study was conducted among parturients assessing the fasting instructions they were given. We assessed whether women did have any oral intake during labor and focused on women's view of fasting during labor. Maternal discomfort related to thirst and hunger was assessed using 0-10 scales. RESULTS: A total of 193 women were included, among whom 71 (37 %) received spontaneously given instructions and 60 (31 %) received instruction upon request. One hundred sixteen (60 %) women were allowed to drink clear fluids, in a limited way for 106 women (91 % of those concerned); 119 women did drink clear fluids during labor. One hundred thirty-two (68 %) women had a thirst-related discomfort score ≥ 4 without any statistical difference whether they had or had not drunk clear fluids. Colder water, unrestricted volume of water and sweet drink were desired by 74 (64 %), 38 (33 %) and 28 (24 %) women who had been allowed to drink, respectively. CONCLUSION: These results emphasize that thirst contributes to maternal discomfort during labor. Permitting limited intake of water does not ensure high maternal satisfaction. Fresh clear fluids, unrestricted amounts of fluids and sweet fluids could contribute to improve maternal comfort.