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)

¿Han cambiado los conceptos de analgesia obstétrica en los últimos 100 años? / Have the concepts of obstetric analgesia changed in the last 100 years?

Objetivos: Comparar los conceptos y métodos de analgesia obstétrica actual con los existentes hace 100 años, cuando se publicaron por primera vez Anesthesia & Analgesia (1922) y British Journal of Anaesthesia (1923), que son las dos primeras revistas de anestesia publicadas de forma independiente.Material y métodos: Identificamos y analizamos todos los artículos relacionados con la analgesia obstétrica publicados en estas revistas durante los años 1922 y 1923, y los comparamos con la práctica clínica actual. También buscamos en estos números referencias indirectas a la atención prestada a la analgesia obstétrica en las reuniones científicas de la época.Resultados: En el primer número de Anesthesia & Analgesia que aparece en agosto de 1922, 3 de los 8 artículos publicados están relacionados exclusivamente con la anestesia y analgesia obstétrica, y entre 1922 y 1923 encontramos un alto número de artículos y referencias. El análisis de estos artículos publicados hace un siglo permite objetivar el interés de la época por los resultados, la comparación entre los diferentes métodos anestésicos, la seguridad y la divulgación del conocimiento científico. Son habituales las referencias a la mortalidad, a las complicaciones, al confort y la satisfacción de la paciente, a la influencia de la analgesia obstétrica en la duración del parto, así como al ahorro de tiempo y de gases anestésicos. Resulta obvio que la metodología de investigación actual no puede compararse con la de hace 100 años. Pero existen numerosos aspectos científicos que sentaron algunas de las bases de la investigación actual en obstetricia, entre los que destacan la recogida de amplias series de pacientes durante largos periodos de tiempo, la mención expresa a la publicación de resultados tanto favorables como desfavorables...(AU)

Objectives: To compare current obstetric analgesia concepts and methods with those existing 100 years ago, when Anesthesia & Analgesia (1922) and British Journal of Anaesthesia (1923), the first two independently published anesthesia journals, were first published.Methods: We identified and analyzed all articles related to obstetric analgesia published in these journals during the years 1922 and 1923 and compared them with current clinical practice. We also searched these issues for indirect references to the attention given to obstetric analgesia at scientific meetings of the time.Results: In the first issue of Anesthesia & Analgesia, appearing in August 1922, 3 of the 8 articles published are related exclusively to obstetric anesthesia and analgesia, and between 1922 and 1923 we found a high number of articles and references. The analysis of these articles published a century ago allows us to objectify the interest of the time in the results, the comparison between different anesthetic methods, safety and the dissemination of scientific knowledge. References to mortality, complications, patient comfort and satisfaction, the influence of obstetric analgesia on the duration of labor, as well as savings in time and anesthetic gases are common.It is obvious that today's research methodology cannot be compared with that of 100 years ago. But there are many scientific aspects that laid some of the foundations of current research in obstetrics, including the collection of large series of patients over long periods of time, the express mention of the publication of both favorable and unfavorable results, the references not only to cost but also to cost-effectiveness, as well as the use of specific parameters to measure not only results but also patient satisfaction.Conclusions: It is evident that over the years the outcomes in the practice of anesthesiology have improved, but also that many concepts remain the same 100 years later...(AU)

Multicenter Study Evaluating Nitrous Oxide Use for Labor Analgesia at High- and Low-Altitude Institutions.

BACKGROUND: Nitrous oxide (N2O) has been used nationally as an analgesic in many clinical settings. While neuraxial analgesia is still the most commonly used labor analgesic in the United States, there is increasing use of N2O in labor. Given the reduction in the partial pressure of gases at a higher altitude, N2O has been reported to have reduced analgesic properties. However, there is no study to date evaluating the impact of altitude on labor analgesia and N2O. METHODS: We conducted a multicenter retrospective data analysis of a N2O registry collected from 4 institutions over a 3-year period. We compared the impact of altitude on 50% N2O administration for labor analgesia, conversion rates to another analgesic modality, as well as collected side effect frequencies and conversion predictors. Multivariable regression models were used to compare clinical characteristics and outcomes between parturients at high and low altitudes, while adjusting for race, ethnicity, education, and age (logistic and linear regressions for categorical and quantitative outcomes, respectively). RESULTS: A total of 1856 laboring parturients (age 18-50) were included in the analysis. The odds of converting from 50% N2O to another analgesic modality had no statistically significant difference between high- versus low-altitude institutions (adjusted odds ratio [aOR], 1.13; 95% confidence interval [CI], 0.90-1.42; P = .3). Yet, when parturients at low altitude converted from N2O, they were more likely (aOR, 3.03; 95% CI, 1.59-5.88) to choose neuraxial analgesia instead of another analgesic modality when compared to high-altitude parturients. This is possibly due to higher epidural rates at the low-altitude institutions. When parturients at high altitude did convert into another modality, they were more likely (aOR, 2.19; 95% CI, 1.14-4.21) to convert due to inadequate pain relief compared to low-altitude parturients; however, missing data may have affected this finding. Laboring individuals at low altitude were significantly more likely to experience side effects (aOR, 2.13; 95% CI, 1.45-3.12). Those requiring labor augmentation, assisted vaginal, or cesarean delivery converted to neuraxial analgesia significantly more often than those that delivered via spontaneous vaginal delivery (P < .05) in both high- and low-altitude groups. CONCLUSIONS: This is the first study evaluating 50% N2O as a labor analgesic at high altitude. As expected, we found lower side effects at high altitude, likely due to the lower partial pressure of N2O. However, there was not a statistically significant increase in conversion from N2O to another analgesic modality at high altitude and no clinically significant differences in neonatal outcomes.

The Effect of the No Pain Labor & Delivery-Global Health Initiative on Cesarean Delivery and Neonatal Outcomes in China: An Interrupted Time-Series Analysis.

BACKGROUND: The proportion of live births by cesarean delivery (CD) in China is significant, with some, particularly rural, provinces reporting up to 62.5%. The No Pain Labor & Delivery-Global Health Initiative (NPLD-GHI) was established to improve obstetric and neonatal outcomes in China, including through a reduction of CD through educational efforts. The purpose of this study was to determine whether a reduction in CD at a rural Chinese hospital occurred after NPLD-GHI. We hypothesized that a reduction in CD trend would be observed. METHODS: The NPLD-GHI program visited the Weixian Renmin Hospital, Hebei Province, China, from June 15 to 21, 2014. The educational intervention included problem-based learning, bedside teaching, simulation drill training, and multidisciplinary debriefings. An interrupted time-series analysis using segmented logistic regression models was performed on data collected between June 1, 2013 and May 31, 2015 to assess whether the level and/or trend over time in the proportion of CD births would decline after the program intervention. The primary outcome was monthly proportion of CD births. Secondary outcomes included neonatal intensive care unit (NICU) admissions and extended NICU length of stay, neonatal antibiotic and intubation use, and labor epidural analgesia use. RESULTS: Following NPLD-GHI, there was a level decrease in CD with an estimated odds ratio (95% confidence interval [CI]) of 0.87 (0.78-0.98), P = .017, with odds (95% CI) of monthly CD reduction an estimated 3% (1-5; P < .001), more in the post- versus preintervention periods. For labor epidural analgesia, there was a level increase (estimated odds ratio [95% CI] of 1.76 [1.48-2.09]; P < .001) and a slope decrease (estimated odds ratio [95% CI] of 0.94 [0.92-0.97]; P < .001). NICU admissions did not have a level change (estimated odds ratio [95% CI] of 0.99 [0.87-1.12]; P = .835), but the odds (95% CI) of monthly reduction in NICU admission was estimated 9% (7-11; P < .001), greater in post- versus preintervention. Neonatal intubation level and slope changes were not statistically significant. For neonatal antibiotic administration, while the level change was not statistically significant, there was a decrease in the slope with an odds (95% CI) of monthly reduction estimated 6% (3-9; P < .001), greater post- versus preintervention. CONCLUSIONS: In a large, rural Chinese hospital, live births by CD were lower following NPLD-GHI and associated with increased use of labor epidural analgesia. We also found decreasing NICU admissions. International-based educational programs can significantly alter practices associated with maternal and neonatal outcomes.

Maternal safety: recent advances and implications for the obstetric anesthesiologist.

PURPOSE OF REVIEW: Recognition of the increasing maternal mortality rate in the United States has been accompanied by intense efforts to improve maternal safety. This article reviews recent advances in maternal safety, highlighting those of particular relevance to anesthesiologists. RECENT FINDINGS: Cardiovascular and other chronic medical conditions contribute to an increasing number of maternal deaths. Anesthetic complications associated with general anesthesia are decreasing, but complications associated with neuraxial techniques persist. Obstetric early warning systems are evolving and hold promise in identifying women at risk for adverse intrapartum events. Postpartum hemorrhage rates are rising, and rigorous evaluation of existing protocols may reveal unrecognized deficiencies. Development of regionalized centers for high-risk maternity care is a promising strategy to match women at risk for adverse events with appropriate resources. Opioids are a growing threat to maternal safety. There is growing evidence for racial inequities and health disparities in maternal morbidity and mortality. SUMMARY: Anesthesiologists play an essential role in ensuring maternal safety. While continued intrapartum vigilance is appropriate, addressing the full spectrum of contributors to maternal mortality, including those with larger roles beyond the immediate peripartum time period, will be essential to ongoing efforts to improve maternal safety.

Labour analgesia: update and literature review.

Pain relief is an important component of modern obstetric care and can be produced by neuraxial, systemic, or inhalational analgesia or various physical techniques. We review the most recent evidence on the efficacy and safety of these techniques. Over the past decade, the availability of safer local anaesthetics, ultra-short acting opioids, combined spinal-epidural needles, patient-controlled analgesic devices, and ultrasound have revolutionised obstetric regional analgesia. Recent meta-analyses have supported epidural analgesia as the most efficacious technique, as it leads to higher maternal satisfaction and good maternal and fetal safety profiles. We examine the controversies and myths concerning the initiation, maintenance, and discontinuation of epidural analgesia. Recent evidence will also be reviewed to address concerns about the effects of epidural analgesia on the rates of instrumental and operative delivery, lower back pain, and breastfeeding. New developments in labour analgesia are also discussed.

What's New in Obstetric Anesthesia? The 2018 Gerard W. Ostheimer Lecture.

The "What's New in Obstetric Anesthesia Lecture" is presented every year at the annual meeting of the Society for Obstetric Anesthesia and Perinatology. This lecture was established in 1975 to update the membership on the most relevant articles that were published in the preceding calendar year. In 1995, the lecture was renamed as the "Ostheimer Lecture" in honor of Gerard W. Ostheimer, an obstetric anesthesiologist from the Brigham and Women's Hospital with significant contributions in the field. This review summarizes key articles published in 2017 that were presented in the 2018 Ostheimer Lecture with a focus on opioid prescriptions, anesthesia for external cephalic version, labor analgesia, maternal morbidity, and global health. A proposed list of action items based on the 2017 literature is also presented.

What Is New in Obstetric Anesthesia: The 2017 Gerard W. Ostheimer Lecture.

The Gerard W. Ostheimer lecture is given each year at the Society for Obstetric Anesthesia and Perinatology annual meeting and is intended to summarize important new scientific literature relevant to practicing obstetric anesthesiologists. This review highlights some of the most consequential papers covered in this lecture. It discusses landmark clinical trials that are likely to change the practice of obstetrics and obstetric anesthesia. It summarizes several articles that focus on how to optimize the provision of neuraxial anesthesia and postoperative pain control. Finally, it reviews studies aimed at identifying systems-based interventions that can improve obstetrical outcomes. A proposed "to-do" list focused on quality improvement initiatives that can be implemented on labor and delivery units is provided.

A plausible causal relationship between the increased use of fentanyl as an obstetric analgesic and the current opioid epidemic in the US.

Drug poisoning deaths have more than doubled in the United States since 2000 with fentanyl and fentanyl analogues primarily responsible for the jump in opioid deaths. Robust data indicate a convincing correlation between the exposure of the fetus to other labor medications (morphine, pethidine hydrochloride, barbiturates, phenobarbitone, meperidine, and secobarbital) and the later addiction of young adults to the same category of drug. We present the hypothesis that this effect is also true of the opioid, fentanyl: there is a causal relationship between the increased popularity of fentanyl as a labor anesthetic in the United States since the 1980's and the current epidemic of fentanyl abuse.

Trends in practice and safety measures of epidural analgesia: Report of a national survey.

BACKGROUND: The clinical use of epidural analgesia has changed over past decades. Minimally invasive surgery and emergence of alternative analgesic techniques have led to an overall decline in its use. In addition, there is increasing awareness of the patient-specific risks for complications such as spinal haematoma and abscess. Local guidelines for management of severe neurological complications during or after epidural analgesia, ie, "epidural alert systems", have been introduced in hospitals to coordinate and potentially streamline early diagnosis and treatment. How widely such protocols have been implemented in daily practice is unknown. METHODS: We conducted a survey to analyse trends in practice, key indications, safety measures, safety reporting, and management of complications of epidural analgesia in the Netherlands. Data were gathered using a web-based questionnaire and analysed using descriptive statistics. RESULTS: Questionnaires from 85 of all 94 Dutch hospitals performing epidural analgesia were collected and analysed, a 90% response rate. Fifty-five percent reported a trend towards decreased use of perioperative epidural analgesia, while 68% reported increasing use of epidural analgesia for labour. Reported key indications for epidural analgesia were thoracotomy, upper abdominal laparotomy, and abdominal cancer debulking. An epidural alert system for neurological complications of epidural analgesia was available in 45% of hospitals. CONCLUSIONS: This national audit concerning use and safety of epidural analgesia demonstrates that a minority of Dutch hospitals have procedures to manage suspected neurological complications of epidural analgesia, whereas in the remaining hospitals responsibilities and timelines for management of epidural emergencies are determined on an ad hoc basis.

Maternal Body Mass Index and Use of Labor Neuraxial Analgesia: A Population-based Retrospective Cohort Study.

WHAT WE ALREADY KNOW ABOUT THIS TOPIC: WHAT THIS ARTICLE TELLS US THAT IS NEW: BACKGROUND:: Neuraxial labor analgesia may benefit obese women by optimizing cardiorespiratory function and mitigating complications related to emergency general anesthesia. We hypothesized that obese women have a higher rate of neuraxial analgesia compared with nonobese parturients. METHODS: Using U.S. natality data, our cohort comprised 17,220,680 deliveries, which accounts for 61.5% of 28 million births in the United States between 2009 and 2015. We examined the relationships between body mass index class and neuraxial labor analgesia, adjusting for sociodemographic, antenatal, pregnancy, and peripartum factors. RESULTS: The study cohort comprised 17,220,680 women; 0.1% were underweight, 12.7% were normal body mass index, 37% were overweight, and 28.3%, 13.5%, and 8.4% were obesity class I, II, and III, respectively. Rates of neuraxial analgesia by body mass index class were as follows: underweight, 59.7% (9,030/15,128); normal body mass index, 68.1% (1,487,117/2,182,797); overweight, 70.3% (4,476,685/6,368,656); obesity class I, 71.8% (3,503,321/4,881,938); obesity class II, 73.4% (1,710,099/2,330,028); and obesity class III, 75.6% (1,089,668/1,442,133). Compared to women with normal body mass index, the likelihood of receiving neuraxial analgesia was slightly increased for overweight women (adjusted relative risk, 1.02; 95% CI, 1.02 to 1.02), obese class I (adjusted relative risk, 1.04; 95% CI, 1.04 to 1.04), obese class II (adjusted relative risk, 1.05; 95% CI, 1.05 to 1.05), and obese class III (adjusted relative risk, 1.06; 95% CI, 1.06 to 1.06). CONCLUSIONS: Our findings suggest that the likelihood of receiving neuraxial analgesia is only marginally increased for morbidly obese women compared to women with normal body mass index.

Maintenance of epidural labour analgesia: The old, the new and the future.

Neuraxial analgesia is considered the gold standard in labour analgesia, providing the most effective pain relief during childbirth. Improvements have enhanced the efficacy and safety of epidural analgesia through better drugs, techniques and delivery systems. This review describes the history of epidural labour analgesia and recent improvements in labour epidural analgesia. We discuss the role of the combined spinal epidural technique, low-concentration local anaesthetic-opioid epidural solutions, patient-controlled epidural analgesia, and programmed intermittent or automated mandatory boluses in the maintenance of epidural labour analgesia. We also review the newer interactive techniques for drug delivery, such as computer-integrated patient-controlled epidural analgesia and variable frequency automated mandatory bolus. Finally, we discuss future clinical research developments, including the use of data analytics and long-term outcomes associated with childbirth pain management.

La administración de ropivacaína durante el trabajo de parto: analgesia y bloqueo motor / Ropivacaine in obstetric labor: analgesia and motor block

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Obstetric analgesia - update 2016.

Neuraxial labor analgesia can be initiated via combined spinal-epidural (CSE) or stand-alone epidural. Pros and cons of these techniques are outlined in this review. In recent years computer-integrated patient-controlled epidural analgesia (CI-PCEA) and programed intermittent epidural boluses (PIEB) have been developed, adding to continuous infusion and PCEA for the maintenance of neuraxial analgesia. Postdural puncture headache (PDPH) and fever can occur secondary to labor epidural that both have clinical relevance for the care givers. Insights into the mechanism of epidural fever and treatment strategies for PDPH are outlined. Due to the increase in obesity the specific considerations for this patient group are discussed. New data have been presented for remifentanil, an ultra-shortly acting opioid, that is used in obstetric analgesia. Without breaking new data, the use of nitrous oxide especially by midwives has a kind of renaissance, and this will be discussed, too.

Obstetric Anesthesia Workforce Survey: A 30-Year Update.

BACKGROUND: Obstetric Anesthesia Workforce Surveys were conducted in 1981, 1992, and 2001, and the 10-year update was conducted in 2012. Anesthesia providers from US hospitals were surveyed to identify the methods used to provide obstetric anesthesia. Our primary hypothesis was that the provision of obstetric anesthesia services has changed in the past 10 years. METHODS: A sample of hospitals was generated based on the number of births per year and US census region. Strata were defined as follows: I ≥ 1500 annual births (n = 341), II ≥ 500 to 1499 annual births (n = 438), and III < 500 annual births (n = 414). Contact email information for the anesthesia provider in charge of obstetric services was obtained by phone call. Electronic questionnaires were sent through email. RESULTS: Administration of neuraxial (referred to as "regional" in previous surveys) labor analgesia was available 24 hours per day in all stratum I hospitals responding to the survey. Respondents across all strata reported high rates of in-house coverage, with 86.3% (95% confidence interval [CI] = 82.7%-90%) of stratum I providers reporting that they provided in-house anesthesiology services for obstetrics. The use of patient-controlled epidural analgesia in stratum I hospitals was reported to be 35% in 2001 and 77.6% (95% CI = 73.2%-82.1%) in this survey. Independent Certified Registered Nurse Anesthetists were reported to provide obstetric anesthesia services in 68% (95% CI = 57.9%-77.0%) of stratum III hospitals. Although 76% (95% CI = 71.2%-80.3%) of responding stratum I hospitals allow postpartum tubal ligations, 14% report inadequate staffing to provide anesthesia either always or at off-hours. CONCLUSIONS: Since 2001, there have been significant changes in how responding hospitals provide obstetric anesthesia care and staff the labor and delivery ward. Obstetric anesthesia surveys, updated every 10 years, continue to provide information about changes in obstetric anesthesia practice.

The 2015 Gerard W. Ostheimer Lecture: What's New in Labor Analgesia and Cesarean Delivery.

Every year the Board of Directors of the Society for Obstetric Anesthesia and Perinatology selects an individual to review the literature pertinent to obstetric anesthesiology published the previous calendar year. This individual selects the most notable contributions, creates a syllabus of the articles, and then presents his/her overview in an annual lecture named in honor of the late Gerard W. Ostheimer, a pioneering obstetric anesthesiologist from the Brigham and Women's Hospital. This article reviews the literature published in 2014 focusing on the themes of labor analgesia and cesarean delivery. Its contents were presented as the Gerard W. Ostheimer Lecture at the 47th Annual Meeting of the Society for Obstetric Anesthesia and Perinatology, May 16, 2015, in Colorado Springs, Colorado. The syllabus is available as Supplemental Digital Content (http://links.lww.com/AA/B397).