Labour pain relief practice by maternal health care providers at a tertiary facility in Kenya: An institution-based descriptive survey.

BACKGROUND: Although pain relief is a crucial component of modern obstetric care, it remains a poorly established service in sub-Saharan countries such as Kenya. Maternal health care providers have an extensive role to play in meeting the analgesic needs of women during childbirth. This study sought to examine the practice of labour pain relief among Kenyan maternal health care providers. METHODS: This was an institution-based, cross-sectional, descriptive survey. The study included midwives, obstetricians, and anaesthesiologists (n = 120) working at the second-largest tertiary facility in Kenya. A structured, self-administered questionnaire was used. The labour pain relief practice, knowledge, attitude, and perceived barriers to labour pain management were described. RESULTS: One hundred and seventeen respondents participated in the study representing a response rate of 97.5%. More than half of maternal health care providers routinely provided the service of labour pain relief (61.5%). Sixty-four (88.9%) respondents reported providing pharmacological and non-pharmacological methods, while 11.1% provided only pharmacological ones. The most common pharmacological method prescribed was non-opioids (12.8%). The most preferred non-pharmacological method of pain management was touch and massage (93.8%). Regional analgesia was provided by 3.4% of the respondents. More than half of the respondents (53%) had poor knowledge of labour pain relief methods. Almost all (94%) of the respondents had a positive attitude towards providing labour pain relief. Non-availability of drugs and equipment (58.1%), lack of clear protocols and guidelines (56.4%), and absence of adequate skilled personnel (55.6%) were reported as the health system factors that hinder the provision of labour analgesia. CONCLUSIONS: More than half of maternal health care providers routinely relieve labour pain. Epidural analgesia is still relatively underutilized. There is a need to develop institutional labour pain management protocols to meet the analgesic needs of women during childbirth.

Structural Racism and Use of Labor Neuraxial Analgesia Among Non-Hispanic Black Birthing People.

OBJECTIVE: To assess the association between structural racism and labor neuraxial analgesia use. METHODS: This cross-sectional study analyzed 2017 U.S. natality data for non-Hispanic Black and White birthing people. The exposure was a multidimensional structural racism index measured in the county of the delivery hospital. It was calculated as the mean of three Black-White inequity ratios (ratios for lower education, unemployment, and incarceration in jails) and categorized into terciles, with the third tercile corresponding to high structural racism. The outcome was the labor neuraxial analgesia rate. Adjusted odds ratios and 95% CIs of neuraxial analgesia associated with terciles of the index were estimated with multivariate logistic regression models. Black and White people were compared with the use of an interaction term between race and ethnicity and the racism index. RESULTS: Of the 1,740,716 birth certificates analyzed, 396,303 (22.8%) were for Black people. The labor neuraxial analgesia rate was 77.2% for Black people in the first tercile of the racism index, 74.7% in the second tercile, and 72.4% in the third tercile. For White people, the rates were 80.4%, 78.2%, and 78.2%, respectively. For Black people, compared with the first tercile of the racism index, the second tercile was associated with 18.4% (95% CI, 16.9-19.9%) decreased adjusted odds of receiving neuraxial analgesia and the third tercile with 28.3% (95% CI, 26.9-29.6%) decreased adjusted odds. For White people, the decreases were 13.4% (95% CI, 12.5-14.4%) in the second tercile and 15.6% (95% CI, 14.7-16.5%) in the third tercile. A significant difference in the odds of neuraxial analgesia was observed between Black and White people for the second and third terciles. CONCLUSION: A multidimensional index of structural racism is associated with significantly reduced odds of receiving labor neuraxial analgesia among Black people and, to a lesser extent, White people.

Is epidural analgesia non-inferior to intrathecal fentanyl as initiation for neuraxial analgesia in early non-spontaneous labour?

BACKGROUND AND AIM: Intrathecal fentanyl, using the combined spinal-epidural (CSE) technique, provides rapid analgesia during early labour. Because of the technique's more complex and invasive nature, as its replacement we assessed the use of epidural analgesia in primiparous parturients with induced labour. The study was registered at www. CLINICALTRIALS: gov (NCT04645823). The aim was to compare the efficacy, duration of analgesia and maternal satisfaction. The primary outcome was the difference in pain visual analogue scale (VAS) between the interventions at 20 min after the analgesia administration. METHODS: Sixty volunteering parturients were randomly allocated in 1:1 ratio to receive either intrathecal fentanyl 20 µg or epidural analgesia (fentanyl 100 µg and lidocaine 80 mg). Contraction pain and maternal satisfaction were assessed by 0-100 mm VAS for 30 min, respectively. Foetal heart rate abnormalities, the time to first epidural dose and the incidence of pruritus were recorded. Non-inferiority margin for mean (95% CI) VAS after epidural analgesia was set at 20 mm above the VAS value for intrathecal fentanyl at 20 min. RESULTS: The contraction pain VAS fell from (median [interquartile range, IQR]) 82 (14) to 13 (20) mm and 76 (17) to 12 (27) mm in 20 min following the intrathecal fentanyl and epidural analgesia, respectively. The absolute mean difference (epidural-intrathecal fentanyl) in the VAS values was 3.3(-0.06 to 6.66) mm indicating non-inferiority. The median time to reach VAS <30 mm was 10 min in both groups. The duration until request for supplemental analgesia was 82(69-95) and 91(75-106) min after intrathecal fentanyl and epidural analgesia, respectively. The difference for the duration (epidural-intrathecal fentanyl) was 9 (6-12) min and for satisfaction-VAS 0.3 (-3.0 to 3.7) mm. There were no differences between the groups in the incidence of foetal heart rate abnormalities, while pruritus was more common after intrathecal fentanyl. CONCLUSION: After 20 min, epidural analgesia by lidocaine and fentanyl was within the non-inferior threshold compared with intrathecal fentanyl in efficacy. The duration of action was not shorter than that of intrathecal fentanyl and maternal satisfaction was also similar.

Técnicas complementarias de relajación y analgesia no farmacológicas durante el parto: revisión sistemática / Complementary techniques of relaxation and non-pharmacological analgesia during childbirth: systematic review

Introducción: Existe la necesidad de proporcionar estrategias de analgesia que alienten y promuevan la participación de la mujer en la toma de decisiones en el momento del parto y las técnicas de relajación podrían ser un método analgésico no far-macológico complementario y/o alternativo a la anestesia epidural ampliamente utilizado. en la estándar atención del trabajo de parto. Objetivo: El objetivode este estudio es analizar los efectos obstétricos de las técnicas de relajación en el manejo del dolor durante el parto. Método: Se realiza una revisión sistemática con lectura crítica de los estudios incluidos. La búsqueda de estudios se realizó en las principales bases de datos MEDLINE, Cochrane Library, Cuiden, LILACS y SciELO. Se incluyen estudios publicados en inglés o español entre 2015 y febrero de 2021. Se incluyen una vez estudios, seis de los cuales son revisados sistemáticamente y cinco son ensayos clínicos aleatorios. Las intervenciones analizadas fueron técnicas de relajación como hipnosis, inyección intradérmica de agua estéril, inmersión en agua tibia, masaje, acu-puntura, musicoterapia, aromaterapia, apoyo continuo y prácticas mente-cuerpo como respiración relajante, yoga y meditación, entre otras. Conclusión: La principal conclusión de este estudio es que las técnicas de relajación pueden disminuir el nivel de dolor durante el trabajo, aunque la evidencia científica actual es limitada y la calidad metodológica varía de baja a moderada. Se necesitan más ensayos controlados aleatorios para apoyar esta investigación (AU)

Introduction:There is a need to provide analgesia strategies that encourage and promote women's participation in decision-making at the time of delivery and relaxation techniques could be a complementary and/or alternative non-pharmacological analgesic method to the widely used epidural anaesthesia in standard labour care. Objective: Theobjective of this study is to analyze the obstetric effects of relaxation techniques on pain management during labour. Method: A systematic review is performed with critical reading of included studies. The search for studies was carried out in the main databases MEDLINE, Cochrane Library, Cuiden, LILACS and SciELO. Studies published in English or Spanish between 2015 and February 2021 were included. Eleven studies were included, six of which are systematic reviews and five are randomised clinical trials. The interventions analysed were relaxation techniques such as hypnosis, intradermal injection of sterile water, warm water immersion, massage, acupuncture, music therapy, aromatherapy, continuous support and mind-body practices like relaxing breathing, yoga and meditation, among others. Conclusion: The main conclusion of this study is that relaxation techniques may decrease the level of pain during labour, although the current scientific evidence is limited and the methodological quality varies from low to moderate. More randomised controlled trials are needed to support this research (AU)

Influence of different volumes and frequency of programmed intermittent epidural bolus in labor on maternal and neonatal outcomes: A systematic review and network meta-analysis.

STUDY OBJECTIVE: In labor, programmed intermittent epidural bolus (PIEB) can be defined as the bolus administration of epidural solution at scheduled time intervals. Compared to continuous epidural infusion (CEI) with or without patient controlled epidural analgesia (PCEA), PIEB has been associated with decreased pain scores and need for rescue analgesia and increased maternal satisfaction. The optimal volume and dosing interval of PIEB, however, has still not been determined. DESIGN: Systematic review and network meta-analysis registered with PROSPERO (CRD42022362708). SETTINGS: Labor. PATIENTS: Pregnant patients. INTERVENTIONS: Central, CINAHL, Global Health, Ovid Embase, Ovid Medline and Web of Science were searched for randomized controlled trials that examined pregnant patients in labor who received CEI or PIEB with or without a PCEA component. Network meta-analysis was performed with a frequentist method, facilitating the indirect comparison of PIEB with different volumes and dosing intervals through the common comparator of CEI and substituting or supplementing direct comparisons with these indirect ones. Continuous and dichotomous outcomes were presented as mean differences and odds ratios, respectively, with 95% confidence intervals. The risk of bias was evaluated using the Cochrane risk of bias 2 tool. MAIN RESULTS: Overall, 30 trials were included. For the first primary endpoint, need for rescue analgesia, PIEB delivered at a volume of 4 ml and frequency of 45 min (4/45) was inferior to PIEB 8/45 (OR 3.55; 95% CI 1.12-11.33), PIEB 10/60 was superior to PIEB 2.5/15 (OR 0.36; 95% CI 0.16-0.82), PIEB 4/45 (OR 0.14; 95% CI 0.03-0.71) and PIEB 5/60 (OR 0.23; 95% CI 0.08-0.70), and PIEB 5/30 was not inferior to PIEB 10/60 (OR 0.61; 95% CI 0.31-1.19). For the second primary endpoint, maternal satisfaction, no differences were present between the various PIEB regimens. The quality of evidence for these multiple primary endpoints was low owing to the presence of serious limitations and imprecision. Importantly, PIEB 5/30 decreased the pain score at 4 h compared to PIEB 2.5/15 (MD 2.45; 95% CI 0.13-4.76), PIEB 5/60 (MD -2.28; 95% CI -4.18--0.38) and PIEB 10/60 (MD 1.73; 95% CI 0.31-3.16). Mean ranking of interventions demonstrated PIEB 10/60 followed by PIEB 5/30 to be best placed to reduce the cumulative dose of local anesthetic, and this resulted in an improved incidence of lower limb motor blockade for PIEB 10/60 in comparison to CEI (OR 0.30; 95% CI 0.14-0.67). No differences in neonatal outcomes were found. Some concerns were present for the risk of bias in two thirds of trials and the risk of bias was shown to be high in the remaining one third of trials. CONCLUSIONS: Future research should focus on PIEB 5/30 and PIEB 10/60 and how the method of analgesia initiation, nature and concentration of local anesthetic, design of epidural catheter and rate of administration might influence outcomes related to the mother and neonate.

Parturients feel capable of giving informed consent for epidural analgesia: A qualitative and quantitative analysis.

INTRODUCTION: The patient's right to autonomy confirmed by informed consent is a cornerstone in modern medicine. Epidural analgesia is increasingly popular in obstetric analgesia, but physicians disagree whether labour pain impairs parturient decision-making. We investigated the fraction of parturients feeling capable of giving informed consent including their knowledge of risks. METHODS: Bedside survey postpartum women at the Herlev Hospital, Denmark. The inclusion criteria were recipient of epidural analgesia during labour. A power calculation based on the recognition of genuine and false side effects required the inclusion of 50 participants. RESULTS: Forty out of fifty (80%) of the participants felt they could make a judicious consent during labour and 46 out of 50 (92%) felt they knew enough about epidural analgesia to give consent to the procedure again if necessary. Participants spontaneously reported a median of two risks associated with epidural analgesia. Additionally, when prompted with a cued list of true and false risks from epidural analgesia, the participants reported on average 5.1 genuine risks compared with 0.4 made-up risks. The difference (4.7) suggests the included women could discern genuine risks from made-up risks. DISCUSSION: The majority of participants reported the capacity to give informed consent. Our quantitative results show the participants could clearly distinguish genuine risks of epidural labour analgesia from made-up risks. Our qualitative data likewise suggest that participants understood the information and consequently their informed consent was genuine. Accordingly, parturients are able to give informed consent. This is supported by parturients' ability to identify risks from epidural labour analgesia.

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.

Métodos no farmacológicos como medida efectiva en el control del dolor en el parto eutócico / Non-pharmacological methods as an effective measure for pain management in normal delivery

Objetivo: estudiar el uso de las medidas no farmacológicas existentes para el control del dolor en el parto eutócico. Específicamente se pretende mostrar las ventajas y los inconvenientes de cada uno de estos métodos, así como reflejar el papel de la matrona en su aplicación.Método: se ha realizado una revisión narrativa en las bases de datos Pubmed, CINAHL, Cuiden, Scielo y Cochrane Plus. También se ha recurrido a Google Académico. Se han utilizado los filtros de idioma (español, inglés y portugués) y de fecha (de 2018 a 2023).Resultados: se han incluido 33 artículos. La hidroterapia, el acompañamiento, la libertad de movimientos, el balón suizo y las inyecciones de agua estéril han mostrado resultados favorables en relación con el alivio del dolor en el parto. La estimulación eléctrica nerviosa transcutánea, acupresión, aromaterapia, musicoterapia o técnicas de relajación cuentan con resultados de baja calidad. Su combinación tiene un efecto positivo. La matrona es la encargada principalmente de informar y ejecutar estos métodos.Conclusiones: los resultados muestran que estas medidas son una alternativa para controlar el dolor en el parto, ofreciendo numerosos beneficios y escasos efectos adversos, aunque es necesario realizar más investigación sobre alguna de estas técnicas. La formación de las matronas es esencial para seguir impulsando su utilización. (AU)

Objective: to study the use of existing non-pharmacological measures for pain management in normal delivery. It is specifically intended to show the advantages and drawbacks of each of these methods, as well as to show the role of the midwife in their application.Method: a narrative review was conducted in the Pubmed, CINAHL, Cuiden, Scielo and Cochrane Plus databases. Google Academic was also a resource. Language filters were used (Spanish, English and Portuguese), as well as date filters (from 2018 to 2023).Results: the study included 33 articles. Hydrotherapy, accompaniment, freedom of movements, the fitness ball, and sterile water injections, have shown favourable results in terms of pain relief during delivery. On the other hand, transcutaneous electrical nerve stimulation, acupressure, aromatherapy, music therapy or relaxation techniques presented low quality results. Their combination had a positive effect. The midwife is mostly in charge of informing about these methods and conducting them.Conclusions: the results showed that these measures are an alternative in order to manage pain during delivery, offering many benefits and few adverse effects, although it is necessary to conduct further research about some of these techniques. Midwife training is essential in order to continue promoting their use. (AU)

Knowledge, attitudes and intentions of the Syrian pregnant women toward labour analgesia, and its associated factors: a cross sectional study in Syria (2022).

BACKGROUND: During the reproductive period among pregnant women, the worst pain a woman can experience is labour pain. Untreated labour pain has many detrimental effects on the mother and the fetus. Then, the inadequate levels of awareness and attitudes toward labour analgesia among pregnant women are considered a serious concern that influences no-healthy results for both the mother and the baby. Therefore, this research aimed to define the degree of Awareness, Attitude, and intent to use labour analgesia among pregnant women in Syria. METHODS: We conducted a cross-sectional study from 7 September to 23 October 2022, in which we included Pregnant Syrian women aged 18 and above. The questionnaire was based on a prior study that included verified and validated scales, which consisted of 23 questions separated into four sections. The sample size was calculated using Fisher's formula; however, our study included 638 participants. The data was analyzed using IBM SPSS Version 28.0, using descriptive and binary logistic regression methods. RESULTS: Among those who had previous deliveries, 39.4% performed a caesarian delivery, and only 1.9% had a delivery at home. Nearly half of the study participants (50.4%) reported adequate knowledge about analgesia for obstetric pain. The inquired pregnant women who had children had more odds of knowledge than participants who had not. Respondents who were childbearing at the health center were more likely to have a good attitude (Adjusted Odds ratio = 4.728, P-value < 0.05, 95%CI: 1.035-21.589) than those who were childbearing at a national referral hospital. Also, the respondents above 31 years were less likely to desire labour analgesia than those aged 18-24. CONCLUSION: Our results revealed that Syrian pregnant women have a moderated awareness, attitudes, and desire regarding labour analgesia, indicating a serious health problem among this population group. It is recommended that local and global health organizations address the current condition relevant to this issue by implementing healthy educational programmes for Syrian women through coordination with obstetric and gynaecological professionals.

Application of dural puncture epidural technique combined with programmed intermittent epidural bolus mode in labor analgesia: A randomized clinical trial.

BACKGROUND: This study aims to evaluate the onset, maintenance, side effects s and the effect on newborns of dural puncture epidural (DPE) technique combined with programmed intermittent epidural bolus (PIEB) mode for labor analgesia as compared to conventional epidural (EP) technique combined with continuous epidural infusion (CEI) mode. METHODS: All patients were randomly assigned to receive EP + CEI (Group EC), EP + PIEB (Group EP), DPE + CEI (Group DC) and DPE + PIEB (Group DP). Record the time to reach Numerical Rating Scale (NRS) ≤ 1, ropivacaine consumption, the NRS when the uterine neck whole opened (NRS2), the incidence of bilateral sensory block level to S2, asymmetric block, incomplete analgesia, replacement of catheter, intrapartum fever, as well as the occurrence of neonatal Apgar score ≤ 7 at 1 minute and 5 minutes. RESULTS: A total of 455 women were included (111 in Group EC, 116 in Group EP, 114 in Group DC and 114 in Group DP). The time to reach NRS ≤ 1 in Group DP and Group DC was shorter than that in Group EP and Group EC (P < .05); the consumption of ropivacaine in Group DP was less than that in 3 other groups (P < .05); the incidence of incomplete analgesia and intrapartum fever in Group DP was lower than that in other 3 groups (P < .05). CONCLUSIONS: DPE technique can provide faster analgesia than conventional EP technique, combined with PIEB mode maybe superior to traditional methods as a labor analgesia regimen.

Association between the use of epidural analgesia during labour and incidence of postpartum depression.

INTRODUCTION: Postpartum depression is a significant episode of depression beginning after giving birth. The prevalence of postpartum depression is approximately 20% in Jeddah, Saudi Arabia. Epidural analgesia is the gold standard for labour pain management. Conflicting results exist regarding the association between postpartum depression and epidural analgesia use during labour. Accordingly, this study assessed the association between epidural analgesia use and postpartum depression incidence. METHODS: A prospective observational study of 170 mothers was conducted, with surveys administered after labour and at six weeks postpartum. Surveys included the following: mothers' demographics, obstetric history, postpartum depression (Edinburgh Postnatal Depression Scale), and pain severity (Visual Analogue Scale). RESULTS: In the final analysis, 91 patients were enrolled. Epidural analgesia was administered to 48.4% of mothers during labour. Nearly two-thirds of mothers learned about EA via sources including family members and social media. However, more than half reported worries regarding epidural analgesia. Edinburgh Postnatal Depression Scale scores showed that 38 mothers (41.8%) likely had depressive symptoms within two days following delivery. Further, 35 (38.5%) met criteria for postpartum depression at six weeks postpartum. For both groups regardless use of analgesia, the mean Visual Analogue Scale score at two days postpartum was 4.16 ± 2.13. Data revealed no correlation between epidural analgesia use and Edinburgh Postnatal Depression Scale within two days and at six weeks postpartum. Multiple regression analysis showed Edinburgh Postnatal Depression Scale scores correlated with Visual Analogue Scale scores but not epidural analgesia use at 1-2 days postpartum. CONCLUSION: This study showed that depressive symptoms resolved in three percent of participants. This suggests that institutions should increase postpartum depression awareness during the antenatal period and implement effective post-delivery screening systems for postpartum depression.

Physical and psychological recovery after vaginal childbirth with and without epidural analgesia: A prospective cohort study.

BACKGROUND: Enhanced recovery is the gold standard in modern perioperative management, including that for cesarean deliveries. However, qualitative and quantitative data on the physical and psychological recovery of women after vaginal childbirth are limited. Whether neuraxial labor analgesia influences postpartum recovery is unknown. METHODS: Primiparous women anticipating a vaginal childbirth between January 2020 and May 2021 were enrolled. Women with major comorbidities or postpartum complications and those who underwent a cesarean delivery were excluded. Daily step count was measured using a wrist-worn activity tracker (FitbitTM Inspire HR) for 120 hours after vaginal childbirth. Subjective fatigue levels and health-related quality of life were assessed using the Multidimensional Fatigue Inventory (MFI) and EuroQol 5 Dimension 5 Level (EQ-5D-5L), respectively, at the 3rd trimester antenatal visit, on postpartum day 1 and 3, and at the one-month postpartum visit. Rest and dynamic pain scores and the location of pain were documented by participants during postpartum hospitalization. RESULTS: Among 300 women who were enrolled antenatally, 95 and 116 had a vaginal delivery without (NCB group) and with (EPL group) epidural analgesia, respectively. The median number of steps per 24 hours increased daily in both groups, and no significant difference was detected between the groups. Postpartum pain was mild overall, with median rest and dynamic pain scores being less than 4 and similar between the groups. MFI and EQ-5D-5L scores were the worst on postpartum day 1 in both groups and gradually improved to antepartum level by the one-month postpartum visit. Higher MFI score on postpartum day 1, but not the use of epidural analgesia, was associated with lower odds of achieving adequate postpartum ambulation (defined as >3500 steps between 48 and 72 hours postpartum). CONCLUSION: The use of epidural analgesia was not associated with worse recovery outcomes during postpartum hospitalization. TRIAL REGISTRATION: UMIN-CTR, #UMIN000039343, registered on January 31, 2020.

Research hotspots and trends on post-cesarean section analgesia: A scientometric analysis from 2001 to 2021.

This study aims to demonstrate current research priorities and predict future trends of post-cesarean section analgesia by scientometric analysis. We collected nearly 20 years (2002-2021) of publications related to post-cesarean section analgesia in the web of science database. Citespace was applied to evaluate the knowledge mapping. There are 2735 manuscripts about the post-cesarean section in total. The country, institution, and author posted the most separately are the USA, Univ Calif Irvine, and BRENDAN CARVALHO. INTERNATIONAL JOURNAL OF OBSTETRIC ANESTHESIA (21) publishes the most articles of this type, and ANESTHESIOLOGY has the greatest impact (1496 co-citations). In addition, the most key cited reference is McDonnell, J.G (43). Post-cesarean section analgesia research, including spinal anesthesia, postoperative pain, and epidural analgesia, has been a research hotspot in recent years. Through scientometric analysis of the past 20 years, we know the TAP blocks and drug selection in patient-controlled analgesia are the focus of future research. The USA, China, and Turkey have become the main research forces in this field, with high publication rates and centrality. This is important for accurately and quickly locating trends in this field.

Programmed intermittent epidural bolus in maintenance of epidural labor analgesia: a literature review.

Programmed intermittent epidural bolus (PIEB), administered by the infusion pump programmed to deliver boluses of epidural solution at certain intervals, is gradually gaining more attention as a technique to maintain the labor analgesia in recent years. Many studies find that it may have some advantages when compared with other methods. However, its exact effectiveness and optimal regimen are still unclear. We conducted a literature search in PubMed, Web of Science, and Cochrane Database of Systematic Reviews for studies published between January 2010 and June 2022. Of the 263 publications identified, 27 studies were included. The purpose of this review is to discuss the effects of PIEB with continuous epidural infusion (CEI) and patient-controlled epidural analgesia (PCEA) in maintenance of epidural labor analgesia on labor outcomes and elucidate the latest research progress of implementation strategies.

Does the timing of neuraxial analgesia initiation in elective induction of multiparous women prolong the duration of delivery?

AIM: To investigate whether the early initiation of neuraxial analgesia prolongs the duration of electively induced labor in Japanese multiparous women. METHODS: This retrospective study included multiparous term women who underwent elective induction of labor using combined spinal-epidural analgesia at the Showa University Hospital between October 2018 and March 2021. The participants were divided into two groups: early and late. If neuraxial analgesia was initiated when the cervical dilation was ≤3 cm, the patient was included in the early group. The remaining patients were included in the late group. The obstetric and neonatal outcomes were compared between the two groups. The primary outcome was the duration of delivery. The secondary outcomes were the rates of instrumental and cesarean deliveries. RESULTS: Two hundred and ninety-seven women (early group = 139, late group = 158) were included in the analysis. The duration of the first stage of labor did not differ significantly between the early and late groups (median: 232 vs. 260 min, p = 0.35). Similarly, there was no significant difference in the duration of the second stage (37 vs. 40 min, p = 0.20). Moreover, the rates of instrumental and cesarean deliveries did not differ significantly between the groups, and the neonatal outcomes were comparable. CONCLUSION: Early initiation of neuraxial analgesia in the elective induction of parous Japanese women did not prolong the duration of delivery. Our results suggest that neuraxial analgesia may be initiated whenever a parturient desires it.

Effect of Dural-Puncture Epidural vs Standard Epidural for Epidural Extension on Onset Time of Surgical Anesthesia in Elective Cesarean Delivery: A Randomized Clinical Trial.

Importance: Dural-puncture epidural (DPE) and standard epidural are common modes of neuraxial labor analgesia. Little is known about conversion of DPE-initiated labor analgesia to surgical anesthesia for cesarean delivery. Objective: To determine whether DPE provides a faster onset and better-quality block compared with the standard epidural technique for cesarean delivery. Design, Setting, and Participants: This double-blind, randomized clinical trial was conducted between April 2019 and October 2022 at a tertiary care university hospital (University of Arkansas for Medical Sciences). Participants included women aged 18 years and older undergoing scheduled cesarean delivery with a singleton pregnancy. Interventions: Participants were randomized to receive DPE or standard epidural in the labor and delivery room. A T10 sensory block was achieved and maintained using a low concentration of bupivacaine with fentanyl through the epidural catheter until the time of surgery. Epidural extension anesthesia was initiated in the operating room. Main Outcomes and Measures: The primary outcome was the time taken from chloroprocaine administration to surgical anesthesia (T6 sensory block). The secondary outcome was the quality of epidural anesthesia, as defined by a composite of the following factors: (1) failure to achieve a T10 bilateral block preoperatively in the delivery room, (2) failure to achieve a surgical block at T6 within 15 minutes of chloroprocaine administration, (3) requirement for intraoperative analgesia, (4) repeat neuraxial procedure, and (5) conversion to general anesthesia. Results: Among 140 women (mean [SD] age, 30.1 [5.2] years), 70 were randomized to the DPE group, and 70 were randomized to the standard epidural group. The DPE group had a faster onset time to surgical anesthesia compared with the standard epidural group (median [IQR], 422 [290-546] seconds vs 655 [437-926] seconds; median [IQR] difference, 233 [104-369] seconds). The composite rates of lower quality anesthesia were 15.7% (11 of 70 women) in the DPE group and 36.3% (24 of 66 women) in the standard epidural group (odds ratio, 0.33; 95% CI, 0.14-0.74; P = .007). Conclusions and Relevance: Anesthesia initiated following a DPE technique resulted in faster onset and improved block quality during epidural extension compared with initiation with a standard epidural technique. Further studies are needed to confirm these findings in the setting of intrapartum cesarean delivery. Trial Registration: ClinicalTrials.gov Identifier: NCT03915574.

High-volume patient-controlled epidural vs. programmed intermittent epidural bolus for labour analgesia: a randomised controlled study.

The aim of neuraxial analgesia is to achieve excellent pain relief with the fewest adverse effects. The most recently introduced technique for epidural analgesia maintenance is the programmed intermittent epidural bolus. In a recent study, we compared this with patient-controlled epidural analgesia without a background infusion and found that a programmed intermittent epidural bolus was associated with less breakthrough pain, lower pain scores, higher local anaesthetic consumption and comparable motor block. However, we had compared 10 ml programmed intermittent epidural boluses with 5 ml patient-controlled epidural analgesia boluses. To overcome this potential limitation, we designed a randomised, multicentre non-inferiority trial using 10 ml boluses in each group. The primary outcome was the incidence of breakthrough pain and total analgesic intake. Secondary outcomes included motor block; pain scores; patient satisfaction; and obstetric and neonatal outcomes. The trial was considered positive if two endpoints were met: non-inferiority of patient-controlled epidural analgesia with respect to breakthrough pain; and superiority of patient-controlled epidural analgesia with respect to local anaesthetic consumption. A total of 360 nulliparous women were allocated randomly to patient-controlled epidural analgesia-only or programmed intermittent epidural bolus groups. The patient-controlled group received 10 ml boluses of ropivacaine 0.12% with sufentanil 0.75 µg.ml-1 ; the programmed intermittent group received 10 ml boluses supplemented by 5 ml patient-controlled boluses. The lockout period was 30 min in each group and the maximum allowed hourly local anaesthetic/opioid consumption was identical between the groups. Breakthrough pain was similar between groups (11.2% patient controlled vs. 10.8% programmed intermittent, p = 0.003 for non-inferiority). Total ropivacaine consumption was lower in the PCEA-group (mean difference 15.3 mg, p < 0.001). Motor block, patient satisfaction scores and maternal and neonatal outcomes were similar across both groups. In conclusion, patient-controlled epidural analgesia is non-inferior to programmed intermittent epidural bolus if equal volumes of patient-controlled epidural analgesia are used to maintain labour analgesia and superior with respect to local anaesthetic consumption.

What is the place of dural puncture epidural in labour analgesia?

Epidural analgesia is the gold standard for labour analgesia. Dural puncture epidural analgesia is a modification of the conventional technique, where the dura is intentionally perforated with a spinal needle but no intrathecal medication is given. This article reviews the evidence for and against the clinical use of dural puncture epidural.

Low-dose intranasal dexmedetomidine premedication improves epidural labor analgesia onset and reduces procedural pain on epidural puncture: a prospective randomized double-blind clinical study.

BACKGROUND: Epidural labor analgesia is a safe and effective method of pain management during labor with the drawbacks of delayed onset and maternal distress during epidural puncture. This study aimed to determine whether pretreatment with intranasal low-dose dexmedetomidine effectively shortens the onset of analgesia and reduces procedural pain. METHODS: In this prospective, randomized double-blind trial, nulliparous patients were randomly assigned to either the intranasal dexmedetomidine group or the control group. The intranasal dexmedetomidine group received 0.5 µg/kg dexmedetomidine intranasally, and the control group received an equal volume of normal saline intranasally. Both groups were maintained with a programmed intermittent epidural bolus. The primary outcome was the onset time of analgesia and scores of pain related to the epidural puncture. RESULTS: Seventy-nine patients were enrolled, and 60 completed the study and were included in the analysis. The time to achieve adequate analgesia was significantly shorter in the intranasal dexmedetomidine group than in the control group (hazard ratio = 2.069; 95% CI, 2.187 to 3.606; P = 0.010). The visual analogue scale pain scores during epidural puncture in the intranasal dexmedetomidine group were also significantly lower than those in the control group (2.0 (1.8-2.5) vs. 3.5 (3.3-4.5), P ≤ 0.001, Table 2). Pretreatment with intranasal dexmedetomidine before epidural labor analgesia was associated with improved visual analogue scale pain scores and Ramsay scores, less consumption of analgesics and higher maternal satisfaction (P < 0.05). No differences were observed for labor and neonatal outcomes or the incidence of adverse effects between the two groups. CONCLUSIONS: Pretreatment with intranasal dexmedetomidine before epidural labor analgesia yielded a faster onset of analgesia and decreased epidural puncture pain without increasing adverse effects. Pretreatment with intranasal dexmedetomidine may be a useful adjunct for the initiation of epidural analgesia, and further investigation should be encouraged to determine its utility more fully. TRIAL REGISTRATION: This trial was prospectively registered at Chictr.org.cn on 29/05/2020 with the registration number ChiCTR2000033356 ( http://www.chictr.org.cn/listbycreater.aspx ).

Obstetric neuraxial analgesia - is it a matter of ethnic disparity?

OBJECTIVE: Pain is an essential element of humane childbirth. Neuraxial analgesia is the most effective method for relieving pain during childbirth. More and more women are using this type of analgesia in childbirth. The aim of the study was to identify ethnic differences in the application of neuraxial analgesia. SUBJECTS AND METHODS: The research was conducted through a face-to-face survey. The respondents are patients after vaginal delivery. The experimental group consists of patients of the ethnic minority, the Romani group (32 women), and the control group consists of patients of the majority, the Serb group (99 women). We investigated the quality and quantity of prenatal care, information about regional anesthesia, and its application in these two groups. RESULTS: There is a significant ethnic disparity between the Serb and Romani ethnic groups. Patients of the Romani ethnic group have qualitatively and quantitatively poorer antenatal care, less information regarding the use of neuraxial analgesia, and use it significantly less often. CONCLUSIONS: Neuraxial analgesia must be available to all patients regardless of ethnicity or social status.