Acute Twin-to-Twin Transfusion Syndrome Resulting in Fetal Bradycardia and Neonatal Death: A Case Report.

In monochorionic twins with no evidence of chronic twin-to-twin transfusion syndrome or twin anemia-polycythemia sequence, a sudden onset of fetal transfusion syndrome after the second trimester of pregnancy is defined as acute twin-to-twin transfusion syndrome. Labor pain, change in the fetal position, and birth order are known risk factors for this condition, and the hemoglobin level of the donor twin is usually reported to be <12 g/dL. We report a recent case of acute twin-to-twin transfusion syndrome without effective labor pain causing cervical changes, resulting in fetal bradycardia and neonatal death after birth; however, the anemia of the donor twin was not as severe as has been reported previously in twin-to-twin transfusion syndrome cases.

Pain, Anxiety, and Fatigue During Labor: A Prospective, Repeated Measures Study.

BACKGROUND: Pain, anxiety, and fatigue are known to significantly influence labor; however, the interacting relationships among the three symptoms have not been empirically shown. PURPOSE: The aim of this study was to investigate the interrelationships among intrapartum pain, anxiety, and fatigue relative to the mode of delivery, with or without epidural analgesia (EDA). METHODS: A prospective, repeated measures design was adopted, and women with uncomplicated pregnancies at term (N = 186) were enrolled. Self-reported visual analog scales were used to assess pain, anxiety, and fatigue during the four phases of labor, as determined by cervical dilation (e.g., Phase 1 = 2-4 cm, Phase 2 = 4-6 cm, Phase 3 =10 cm, and Phase 4 = immediately after delivery of the placenta). Of the 186 participants, 48 received EDA when their cervical dilation was 3-4 cm. RESULTS: Throughout the process of labor, pain, anxiety, and fatigue were significantly correlated, no matter whether participants had received EDA, especially during Phases 1 and 3. For the participants undergoing EDA, the level of fatigue decreased more slowly than the levels of pain and anxiety. The participants who received EDA had significantly greater pain and fatigue in Phase 1 of labor than those who did not receive EDA. Mode of delivery was correlated with age, parity, and pain level in Phase 2 of labor and anxiety level in Phase 2 of labor. CONCLUSIONS/IMPLICATIONS FOR PRACTICE: Intrapartum pain, anxiety, and fatigue were strongly interrelated. Intrapartum pain management (EDA) led to a significant decline in anxiety and fatigue. Furthermore, fatigue accumulated during the course of labor and was not easily diminished. These findings provide a reference for maternity nurses to develop strategies for managing multiple symptoms.

Requests for cesarean deliveries: The politics of labor pain and pain relief in Shanghai, China.

Cesarean section rates have risen dramatically in China within the past 25 years, particularly driven by non-medical factors and maternal requests. One major reason women request cesareans is the fear of labor pain, in a country where a minority of women are given any form of pain relief during labor. Drawing upon ethnographic fieldwork and in-depth interviews with 26 postpartum women and 8 providers at a Shanghai district hospital in June and July of 2015, this article elucidates how perceptions of labor pain and the environment of pain relief constructs the cesarean on maternal request. In particular, many women feared labor pain and, in a context without effective pharmacological pain relief or social support during labor, they came to view cesarean sections as a way to negotiate their labor pain. In some cases, women would request cesarean sections during labor as an expression of their pain and a call for a response to their suffering. However, physicians, under recent state policy, deny such requests, particularly as they do not view pain as a reasonable indication for a cesarean birth. This disconnect leads to a mismatch in goals for the experience of birth. To reduce unnecessary C-sections, policy makers should instead address the lack of pain relief during childbirth and develop other means of improving the childbirth experience that may relieve maternal anxiety, such as allowing family members to support the laboring woman and integrating a midwifery model for low-risk births within China's maternal-services system.

Retrospective study of the association between epidural analgesia during labour and complications for the newborn.

OBJECTIVE: our objective was to determine the association between epidural analgesia and different variables. BACKGROUND: the effect on newborns of epidural analgesia administered to the mother during labour remains under debate. METHOD: this association was retrospectively investigated in a cohort of 2399 children born in a Spanish public hospital. Only full-term (>37 weeks of gestation) deliveries were included. Other exclusion criteria were: induced delivery (medical or obstetric indication), elective caesarean section, or the presence of an important pregnancy risk factors (hypertension, diabetes, severe disease, toxaemia, retarded intrauterine growth, chronologically prolonged pregnancy, prolonged membrane rupture (>24 hours), oligoamnios, or polyhydramnios). The Mann-Whitney U test and Fisher׳s exact test were applied to determine the relationship between variables. KEY CONCLUSIONS: Apgar index values at one minute and five minutes were slightly but significantly lower in neonates whose mothers had received epidural analgesia. Neonatal intensive care unit admission was significantly more frequent in the epidural versus non-epidural group. Resuscitation was significantly more frequent in the epidural versus non-epidural group. Early breast feeding onset was more frequent in the non-epidural group. The adverse effect of epidural analgesia on early lactation remained significant after adjusting for NICU admission and the need for resuscitation in a logistic regression analysis. Epidural analgesia may have adverse effects on newborns, although the risks are low, and further research is required to elucidate the causal nature of this relationship.

Consulta preanalgésica del parto. Un proyecto hecho realidad / Pre-analgesic consultation for labour: a project comes true

Objetivo: el objetivo del presente estudio es dar a conocer la estrategia seguida en el Hospital Universitario Puerto Real para crear una consulta preanalgésica del parto con el fin de dar respuesta a los derechos de la embarazada a recibir una adecuada analgesia durante el trabajo del parto, cumpliendo la Ley 41/2002 Reguladora de la autonomía del paciente y de derechos y obligaciones en materia de información y documentación clínica. Valorar la situación en el resto de los hospitales andaluces. Material y método: analizamos los retos y dificultades que se plantearon en su momento y la estrategia para la creación de esta consulta. Las cuestiones que se plantearon fueron: ¿en qué momento de la gestación deberían acudir las gestantes? ¿Qué necesidades de personal y formación de personal supondría la creación de esta consulta? ¿Dónde se ubicaría la consulta? ¿Qué material didáctico sería necesario para informar adecuadamente a nuestras gestantes? Para determinar cómo se había dado respuesta a la analgesia del parto y la aplicación de la Ley 41/2002 en el resto de los hospitales andaluces realizamos una encuesta telefónica. Resultados: la consulta de preanalgesia para el parto comenzó en nuestro hospital en febrero del año 2007. Se desarrollaron cursos de formación para el personal de paritorio. La consulta se realiza en la semana 20 de gestación haciéndola coincidir con la ecografía que realiza el Servicio de Ginecología en la semana 20. El personal asignado es una auxiliar de enfermería y el anestesiólogo de guardia asignado a paritorio. La consulta se ubica en una sala en el Hospital de Día con capacidad suficiente para 12 personas, donde se imparte una charla y se proyecta un vídeo informativo. Posteriormente se hace una valoración individualizada, se cumplimenta y firma el consentimiento informado. Desde la creación de la consulta de preanalgesia del parto han sido citadas en la consulta 12.990 gestantes. La media anual de gestantes informadas y valoradas preoperatoriamente es de 1.384, lo que supone un 63,93 % del total de las gestantes. Los datos obtenidos de las encuestas telefónicas realizadas en los Centros Hospitalarios del Sistema Andaluz de Salud, corresponden a 27 de los 33 centros hospitalarios en los que se atienden partos. La valoración preanestésica a las gestantes sólo se realiza en 8 centros (29,63 %), en 5 de ellos de forma rutinaria (18,52 %) y en 3 (11,1 %) sólo a las gestantes de alto riesgo. El consentimiento informado se obtiene previamente al momento del parto tan sólo en 9 de los 27 hospitales encuestados (33,33 %), en los 18 centros restantes se obtiene en el momento del parto (66,67 %). Conclusiones: desde que se instauró la consulta de preanalgesia del parto en nuestro hospital se ha mejorado la valoración preanalgésica de la gestante y hemos conseguido dar cumplimiento a la Ley 41/2012 (AU)

Objective: The objective of this study is to report the strategy followed in the Hospital Universitario Puerto Real (Cádiz, Spain) to create a pre-analgesic consultation for labor in order to provide an appropriate analgesia during delivery, complying with Law 41/2002 which regulates the autonomy rights and obligations of patients regarding information and clinical documentation. We evaluate the approach taken in the rest of the hospitals in Andalusia. Material and method: We analyzed the challenges and difficulties that arose at the time and the strategy for the creation of this consultation. The questions which were raised were: At what stage of pregnancy pregnant women should attend the consultation? What staffing and training would be required to create this consultation? Where would it be located? What materials would be needed to properly inform our pregnant women? We conducted a phone survey in order to determine how our response was given to labor analgesia and how Law 41/2002 was being applying in the rest of hospitals in Andalusia. Results: The pre-analgesic labor consultation of the Hospital Universitario Puerto Real was created in February 2007. Training courses were developed for delivery room staffing. Consultations are currently carried out during the 20th week of gestation, coincident with the echography done by the Gynecology Service of the Hospital. The staffs assigned are a nurse assistant and the anesthesiologist on duty in the delivery room. The consultation room is located in the in the outpatient department of the hospital and has a capacity for 12 people. Pregnant women receive a lecture and an informative video. After this, we complete the individualized pre-analgesic assessment of each patient and the informed consent process. Since its creation, they have been cited 12,990 pregnant women. The annual average of pregnant women informed and preoperatively evaluated is of 1,384; which represents the 63.93 % of all pregnant women. Twenty-seven of the 33 hospitals of the Andalusia Health System in which deliveries are practiced, telephone survey respondents. The results of this survey show that the pre-anesthetic assessment for pregnant women is only performed in 8 centers (29.63 %), in 5 of them routinely (8.52 %) and only to high-risk pregnant women in 3 (11.1 %). The informed consents are obtained before the delivery only in 9 of the 27 hospitals surveyed (33 %). In the 18 centers remaining they were obtained at delivery (66.67 %). Conclusions: Since the foundation of the pre-analgesic consultation for delivery in our hospital, we have improved the pre-analgesic assessment of pregnant women and we have achieved complying with Law 41/2012 (AU)

Hypnotherapy for labor and birth.

Hypnotherapy is an integrative mind-body technique with therapeutic potential in various health care applications, including labor and birth. Evaluating the efficacy of this modality in controlled studies can be difficult, because of methodologic challenges, such as obtaining adequate sample sizes and standardizing experimental conditions. Women using hypnosis techniques for childbirth in hospital settings may face barriers related to caregiver resistance or institutional policies. The potential anxiolytic and analgesic effects of clinical hypnosis for childbirth merit further study. Nurses caring for women during labor and birth can increase their knowledge and skills with strategies for supporting hypnotherapeutic techniques.

Relationship between use of labor pain medications and delayed onset of lactation.

BACKGROUND: Despite estimates that 83% of mothers in the United States receive labor pain medications, little research has been done on how use of these medications affect onset of lactation. OBJECTIVE: To investigate whether use of labor pain medications is associated with delayed onset of lactation (DOL). METHODS: We analyzed data from the 2005-2007 Infant Feeding Practices Study II, a longitudinal study of women from late pregnancy through the entire first year after birth (n = 2366). In multivariable logistic regression analyses, we assessed the relationship between mothers' use of labor pain medication/method and DOL (milk coming in > 3 days after delivery). RESULTS: Overall, 23.4% of women in our sample experienced DOL. Compared with women who delivered vaginally and received no labor pain medication, women who received labor pain medications had a higher odds of experiencing DOL: vaginal with spinal/epidural only (aOR 2.05; 95% CI, 1.43-2.95), vaginal with spinal/epidural plus another medication (aOR 1.79; 95% CI, 1.16-2.76), vaginal with other labor pain medications only ([not spinal/epidural]; aOR 1.84; 95% CI, 1.14-2.98), planned cesarean section with spinal/epidural only (aOR 2.13; 95% CI, 1.39-3.27), planned cesarean with spinal/epidural plus another medication (aOR 2.67; 95% CI, 1.35-5.29), emergency cesarean with spinal/epidural only (aOR 2.17; 95% CI, 1.34-3.51), and emergency cesarean with spinal/epidural plus another medication (aOR 3.03; 95% CI, 1.77-5.18). CONCLUSION: Mothers who received labor pain medications were more likely to report DOL, regardless of delivery method. This information could help inform clinical decisions regarding labor/delivery.

A dream birth? Try hypnobirthing!

Hypnobirthing is often regarded as a method of pain relief without drugs. This is to miss the point, as it presupposes that pain is there in the first place. When a woman learns to release the preconceptions, fears and worries about birth that are endemic in our society, her experience of giving birth to her baby can be the most wonderful and empowering experience of her life. Mind and body working together can be a powerful and efficient combination. This is how birth is designed to be, as midwives and hospitals are beginning to discover. Thus hypnobirthing can provide a service that women want as well as save scarce NHS funds.

Hypnotherapy for childbirth.

The birthing process, although often a joyful and proud moment, can also create an overwhelming sense of anxiety. As a result some women are now turning to hypnobirthing to help them to cope. This practice is used to relax women before and during their labour. It also helps encourage a stress free birth and reduce the need for drugs and interventions, such as caesarean section. In this article, Sheila Granger helps to dispel some of the myths surrounding the use of hypnotherapy and looks specifically at its application to childbirth. The role of midwives and the benefits to them are also discussed.

Clinical implications of neuraxial anesthesia in the parturient with scoliosis.

Scoliosis can pose challenges to the initiation and function of neuraxial anesthetics. We reviewed the available literature exploring neuraxial techniques in parturients with uncorrected or corrected (i.e., surgically instrumented) scoliosis. The 22 articles reported 117 attempted neuraxial procedures (uncorrected n = 24 and corrected n = 93). Of these procedures, 79% of uncorrected patients and 69% of corrected patients were successfully managed with neuraxial anesthesia. Procedures were typically more challenging in corrected patients; 90% of all reported difficulties in this subgroup involved epidural anesthetics. Complications were reported in 3 of 103 patients. We provide suggestions for optimizing efficacy of neuraxial techniques in these patients.

Evidence-based anesthesia: fever of unknown origin in parturients and neuraxial anesthesia.

The safety of neuraxial analgesia in febrile patients is controversial. We performed an evidenced-based project in an effort to establish a guideline for our active obstetric clinical practice. Neuraxial anesthesia is generally safe for parturients, and complications are rare; however, serious adverse outcomes can result. Because of the devastating nature of the morbidity, the decision to proceed with a neuraxial anesthetic in the face of infection may be contentious. Fever and sepsis are considered relative contraindications to regional anesthesia; however, epidural anesthesia is a superior method of management of pain during labor. One must also consider that 30% to 40% of patients with chorioamnionitis require cesarean delivery. Because of the increased morbidity and mortality of general anesthesia in this population, it may be reasonable to proceed with regional anesthesia. Based on a review of the literature, it is difficult to estimate the risk of an infrequently occurring event. We recommend evaluation of each individual to determine the risks and benefits of the anesthetic. However, it is prudent to administer antibiotics before the regional anesthetic and adhere to strict aseptic technique. Postprocedure monitoring is essential for early detection and treatment of complications.

[Anxiety assessment in parturients requesting epidural analgesia for pain relief]. / Ocena leku u rodzacych zdecydowanych na analgezje zewnatrzoponowa.

OBJECTIVES: Neuraxial methods provide the most effective labor pain relief. This study aimed at assessing anxiety level in parturients requesting epidural analgesia (EA). MATERIAL AND METHODS: Forty five women in spontaneous, active labor were enrolled, both primiparas (n=36) and multiparas (n=9). Anxiety was assessed by means of Spielberger State and Trait Anxiety Inventory (STAI) before administration of EA, and pain was measured by visual-analog scale (VAS) before and after analgesia. RESULTS: In all the studied parturients state anxiety was strikingly higher than the trait (53.9 +/- 11.8 vs. 39.3 +/- 8.4; P < 0.0001); the difference appeared insignificant in multiparas only. State anxiety was comparable independently of parity, labor outcome and systemic opioid administration. No association between anxiety level and labor pain intensity preceding analgesia, the duration of labor stages and demographic parameters could be found. However, a negative correlation between state anxiety and pain intensity reported after EA administration was noted (R = -0.315, p = 0.040), and, in cases of physiological labor, a negative association between state anxiety and the neonate Apgar score at the 1st minute after birth could be observed (R = -0.337, p = 0.047, Spearman rank test). CONCLUSIONS: In parturients requesting EA, state anxiety level is increased and not connected with the trait. Furthermore, in these women, anxiety appears not to be associated with labor pain but may influence the analgesic effect of the blockade. Anxiety does not determine labor duration and outcome; however, it may be connected with the well-being of the neonate immediately after birth.

Impact of pseudotumor cerebri (idiopathic intracranial hypertension) in pregnancy: a case report.

This case report reviews anesthetic management and medical considerations for a pregnant patient with a history of pseudotumor cerebri (PTC). The 24-year-old woman, gravida 2, paragravida 0, spontaneous abortion 1, was in active labor at an estimated 38 weeks' gestation and had been given a diagnosis of PTC 4 years earlier. This patient first experienced global headaches and blurred vision at age 20 years. At the time of onset of her headache symptoms, she underwent a full diagnostic workup and detailed neurologic examination, including magnetic resonance imaging (MRI) of the brain and a lumbar puncture. The MRI was normal. Her lumbar puncture showed elevated cerebral spinal fluid (CSF) pressures and normal CSF composition. The patient's initial symptoms of headache and blurred vision were managed with medication and serial lumbar punctures. The patient was free of PTC symptoms on admission for labor. A lumbar epidural was placed for labor analgesia. The patient delivered a healthy infant after approximately 10.5 hours of patient-controlled epidural analgesia.

Why women prefer epidural analgesia during childbirth: the role of beliefs about epidural analgesia and pain catastrophizing.

This study investigated the reasons that might lead women to choose or not choose epidural analgesia as a strategy for the management of pain in childbirth. In our sample 55% of 114 women chose EA. Logistic regression resulted in a statistical model with four unique and independent predictors: Parity status and the fear of the side effects of EA each reduced the odds of choosing EA by half, whereas the desire to have a pain-free childbirth and positive experiences with EA of family and friends each doubled the odds of choosing EA. Pain catastrophizing was not related to EA use. The lack of an interrelationship between pain catastrophizing and EA use is probably due to an ambivalent attitude towards EA in pain catastrophizers. Pain catastrophizing was positively associated with the fear of being overwhelmed by labour pain and tendencies to avoid the pain, but also positively with the fear of pain during the insertion of the EA needle. Pain catastrophizing was also strongly related to recommendations to use EA from others, in particular from the midwife and from the gynecologist. Results are discussed in terms of the social impact of pain catastrophizing.

Hypnosis: removing the labour from birth.

Hypnosis has been used in obstetrics for more than a century. However, with increasing numbers of women looking for alternative coping strategies for use during labour, the birth of a new discipline, HypnoBirthing, is gaining in popularity. HypnoBirthing is a hypnotherapy programme specifically designed for birth, employing the principles and techniques of hypnosis and self-relaxation. This article explains the philosophy and principles of HypnoBirthing, the evidence base and its physiological impact on labouring women, brought to life by real accounts.