Association between perinatal pain and postpartum depression: A systematic review and meta-analysis.

INTRODUCTION: In recent years, clinical studies have shown that perinatal pain could increase the risk of postpartum depression, while such a conclusion appears controversial. Therefore, we conducted this systematic review and meta-analysis to explore the association between perinatal pain and postpartum depression, and to evaluate the effectiveness of epidural labor analgesia in reducing the risk of postpartum depression. METHODS: PubMed, Web of Science, Embase and Cochrane Library were searched from inception to Jan 30th, 2022. The effect size of the meta-analysis was calculated using odds ratio and 95 % confidence interval. Statistical analysis was performed using Stata 15.0 software. RESULTS: There were 19 studies included with a total of 96,378 patients. Among the included studies, 10 investigated the association between perinatal pain and the risk of postpartum depression, and 9 reported that between labor analgesia and the risk of postpartum depression. The results of meta-analysis showed that perinatal pain increased the risk of postpartum depression [OR = 1.43, 95% CI (1.23, 1.67), p<0.05], and epidural analgesia could reduce the risk of postpartum depression [OR = 0.42, 95% CI (0.33, 0.55), p < 0.05]. LIMITATIONS: Source of heterogeneity in the association between perinatal pain and PPD could not be identified due to the limitations of the original studies. There were mainly cohort studies included in the assessment for effectiveness of epidural analgesia in reducing the incidence of postpartum pain. Therefore, we look forward to more RCTs to confirm our results. CONCLUSION: Perinatal pain is one of the risk factors for postpartum depression, and epidural analgesia could reduce the risk of PPD. This result might provide guidance for clinical practice. However, psychological health counseling should be combined with epidural analgesia for perinatal pain to reduce the risk of PPD.

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

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

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.

Are labor pain and birth experience associated with persistent pain and postpartum depression? A prospective cohort study.

Background and aims A considerable research-literature focuses on pain during labor and associations with postpartum persistent pain and depression, with findings pointing in various directions. The aim of this study was to examine the role of labor pain and overall birth experience in the development of pain and depression 8 weeks after delivery. Methods The study sample was drawn from the Akershus Birth Cohort. Data from multiple sources were used, including the hospital's birth record (n = 4,391), questionnaire data from gestational week 17 of pregnancy (n = 3,752), 8 weeks postpartum (n = 2,217), and two questions about pain and birth experience asked within 48 h after delivery (n = 1,221). The Edinburgh Postnatal Depression Scale was used to measure postpartum depression, a single question was used to measure persistent pain 8 weeks postpartum, while pain and birth experience were measured by numeric rating scales. A history of pre-pregnant depression and chronic pain were measured through self-report questions in gestational week 17. A total of 645 women had complete data from all sources. We applied multiple imputation techniques to handle missing responses on the two questions about pain and birth experience. Results The results showed that neither labor pain nor birth experience were associated with persistent pain 8 weeks postpartum, whereas pain before pregnancy (OR 3.70; 95% CI 2.71-5.04) and a history of depression (OR 2.31; 95% CI 1.85-2.88) were statistically significant predictors of persistent pain. A negative birth experience was significantly (OR 1.16; 95% CI 1.04-1.29) associated with postpartum depression, whereas labor pain intensity was not. A history of depression (OR 3.95; 95% CI 2.92-5.34) and pre-pregnancy pain (OR 2.03; 95% CI 1.37-3.01) were important predictors of postpartum depression 8 weeks after delivery. Conclusions and implications Whilst the relationship between labor pain intensity and postpartum pain and depression remain unclear, our results do imply the need to screen for previous depression and chronic pain conditions in pregnant women, as well as consider preventive measures in those who screen positive.

Epidural Analgesia During Childbirth and Postpartum Depressive Symptoms: A Population-Based Longitudinal Cohort Study.

BACKGROUND: Severe pain has been linked to depression, which raises the question of whether epidural analgesia (EDA) during childbirth is associated with a reduced risk of postpartum depression (PPD). This association has been explored previously, but the studies were restricted by small sample sizes and the inability to control for relevant confounders. This study aimed to investigate the association between the administration of EDA and the development of PPD after adjusting for sociodemographic, psychosocial, and obstetric variables. METHODS: Data were retrieved from the Biology, Affect, Stress, Imaging and Cognition (BASIC) project (2009-2017), a population-based longitudinal cohort study of pregnant women conducted at Uppsala University Hospital, Sweden. The outcome was PPD at 6 weeks postpartum, defined as a score of ≥12 points on the Edinburgh Postnatal Depression Scale (EPDS). Information was collected through medical records and self-reported web-based questionnaires during pregnancy and 6 weeks after childbirth. Only primiparous women with spontaneous start of childbirth were included (n = 1503). The association between EDA and PPD was examined in multivariable logistic regression models, adjusting for sociodemographic, psychosocial, and obstetric variables. Results are presented as odds ratios (ORs) with 95% confidence intervals (CIs). RESULTS: Of the 1503 women included in the analysis, 800 (53%) reported use of EDA during childbirth. PPD at 6 weeks postpartum was present in 193 (13%) women. EDA was not associated with higher odds of PPD at 6 weeks postpartum after adjusting for suspected confounders (age, fear of childbirth, antenatal depressive symptoms; adjusted OR [aOR] = 1.22; 95% CI, 0.87-1.72). CONCLUSIONS: EDA was not associated with the risk of PPD at 6 weeks postpartum after adjusting for sociodemographic, psychosocial, and obstetric variables. However, these findings do not preclude a potential association between PPD and childbirth pain or other aspects of EDA that were not assessed in this study.

Pain and stress after vaginal delivery: characteristics at hospital discharge and associations with parity.

The objective of this study was to characterise pre-discharge maternal pain and stress severity after vaginal delivery and associations with parity. This is a descriptive analysis with 148 women in the early post-partum period (84 primiparae and 64 secondiparae) after vaginal delivery. Pain and stress were measured by McGill Pain Questionnaire (MGPQ) and by the Psychological Stress Measure (PSM). Vaginal delivery in primiparae women was associated with MGPQ, significantly higher pain scores. Sensorial, affective and mixed pain descriptive categories were also significantly higher. Pain location involved lower abdomen, vagina and perianal area. In addition, their PSM showed a significantly higher 'Sense of effort and confusion' subscale scores. In conclusion, this study provides important information on the quality of care implications of hospital-to-home discharge practices in puerperae after vaginal delivery, a critical time characterised by qualitatively and quantitatively high pain and stress in primiparae.Impact statementWhat is already known on this subject? Pain and fatigue are the most common problems reported by women in the early postpartum period.What the results of this study add? Primiparae who delivered vaginally presented at the time of hospital-to-home discharge significantly higher pain and stress, as compared to secondiparae. Pain involved lower abdomen, vagina and perianal area, whereas the stress was quantitatively higher in the 'sense of effort and confusion'.What the implications are of these findings for clinical practice and/or further research? Awareness of problematic pain and stress associations with parity may offer the opportunity to better support puerperae to develop maternal orientation and adjust to motherhood.

Pelota de parto versus petidina y haloperidol en la satisfacción en el parto / Birthing ball versus pethidine and haloperidol in satisfaction with childbirth

Objetivo: Determinar los efectos en la satisfacción materna del uso de la pelota de parto como método de alivio del dolor, comparado con la administración subcutánea de petidina (50mg) y haloperidol (2,5mg), en el periodo de latencia de parto. Método: Ensayo clínico aleatorizado, unicéntrico, paralelo y controlado. Participantes: gestantes de bajo riesgo, ingresadas en la planta de embarazo patológico del HGU Gregorio Marañón, por gestación cronológicamente prolongada, rotura prematura de membranas o pródromos de parto. Intervención: una vez que la paciente manifestaba dolor con su proceso, se implementaban una serie de movimientos predeterminados con la pelota de partos, en el caso del grupo intervención, o se administraba petidina más haloperidol, vía subcutánea. Tras la intervención y en planta de puérperas la satisfacción era medida con la escala Mackey Satisfaction Childbirth, validada al castellano en 2016, en las primeras 48-72h posparto. Análisis: comparación de grupos: la t de Student para las variables continuas y la Chi-cuadrado para las categóricas. Resultados: La satisfacción materna fue significativamente mayor en el grupo experimental que en el grupo de comparación, en todas las esferas de la escala: obstetra (4,24/3,87), dilatación (4,02/3,35), expulsivo (4,27/3,67), recién nacido (4,72/4,43) y acompañamiento y comodidad (4,78/4,44). No hubo, sin embargo, diferencias estadísticamente significativas en la subescala matrona, aunque las puntuaciones fueron igualmente altas (4,65/4,45). Conclusión: El uso de pelotas de parto durante el periodo de latencia aumenta la satisfacción de la mujer en el proceso de parto, en mayor medida que la administración conjunta de petidina y haloperidol

Objective: To determine the effects on maternal satisfaction of the use of the birthing ball as a method of pain relief compared to the subcutaneous administration of pethidine (50mg) and haloperidol (2.5mg), during the latent phase of labour. Method: Randomised, unicentric, parallel and controlled clinical trial. Participants: Low-risk pregnant women hospitalised in a pathological pregnancy ward at the Gregorio Marañón University General Hospital (Madrid) due to prolonged pregnancy, premature rupture of membranes, or labour prodromes. Intervention: once the patient's labour had become painful, a series of pre-established movements were implemented with a birthing ball in the intervention group, or pethidine and haloperidol were administered at the same dose subcutaneously. After the intervention and on the post-natal ward, satisfaction was measured with the Mackey Satisfaction Childbirth scale, validated in Spanish in 2016, in the first 48-72hours after delivery. Analysis: group comparisons: Student's t for continuous variables and Chi-squared for categorical variables. Significance at p<0.05. Results: The maternal satisfaction was significantly higher in the experimental group than in the comparison group, in all the domains of the scale: obstetrician (4.24/3.87), dilatation (4.02/3.35), second stage (4.27/3.67), newborn (4.72/4.43), accompaniment and comfort (4.78/4.44). There were, however, no statistically significant differences in the midwife subscale, although the scores were equally high (4.65/4.45). Conclusion: Using birthing balls during the latent phase of labour increases women's satisfaction with their labour process more than administering pethidine and haloperidol during this period

Prevalence & correlates of chronic perinatal pain - a study from India.

Objectives: To study the prevalence of chronic perinatal pain among mothers who had infants between the ages of 13-25 months in the State of Kerala, India and to report its correlates in the socio-demographic, obstetric and psychological domains. Methods: A total of 9305 mothers selected by cluster random sampling were assessed cross-sectionally for chronic perinatal pain using a questionnaire by Junior Public Health Nurses (JPHNs). In addition, information regarding socio-demographic profile, obstetric history, infant details and perinatal depression were collected. Results: Of the 8302 (89.3%) valid responses, 552 (6.6%) mothers reported chronic perinatal pain. Among those with pain, 142 (25.6%) reported pain during pregnancy, 314 (56.7%) during postpartum and 96 (17.7%) during both periods. The commonest sites of pain reported were back 280 (51%) and pelvic region 110 (19%). Mothers with chronic perinatal pain were more likely to be younger, less educated, employed and from an urban background. Chronic perinatal pain was associated with obstetric complications, delivery by instrumental/caesarean section, non-exclusive breast feeding and higher maternal depression scores. Conclusion: Chronic pain is common among mothers in India during the perinatal period and greater attention needs to be given for it to be recognised and treated early.

Labor Analgesia as a Predictor for Reduced Postpartum Depression Scores: A Retrospective Observational Study.

BACKGROUND: Using labor, epidural analgesia has been linked to a reduced risk of postpartum depression, but the role of labor pain relief in this association remains unclear. The goal of this study was to test the hypothesis that effective epidural analgesia during labor is associated with reduced postpartum depression symptomatology. METHODS: A single, institutional, retrospective, observational cohort design was chosen. The primary outcome was Edinburgh postnatal depression scale (EPDS) score, measured at the 6-week postpartum visit. Subjects included in the final analysis had (1) received labor epidural analgesia; (2) pain assessed during labor both before and during initiation of labor epidural analgesia by 0-10 numeric rating scores; and (3) depression risk assessed by the EPDS and documented at their 6-week postpartum visit. Simple and multiple linear regression was used to identify the best model for assessing the association between pain improvement, defined as percent improvement in pain (PIP), and depression, after adjusting for a history of anxiety or depression, other psychiatric history, abuse, trauma, mode of delivery, and other maternal or fetal comorbid diseases. RESULTS: Two hundred one patients were included in the final analysis. Women with higher improvements in pain were associated with lower EPDS scores (r = 0.025; P = .002). Variables known to be associated with depression (body mass index, anxiety and/or depression, third- and fourth-degree perineal lacerations, and anemia) were significantly correlated with EPDS score and included in the final model. After we adjusted for these covariates, PIP remained a significant predictor of EPDS score (r = 0.49; P = .008), accounting for 6.6% of the variability in postpartum depression scores. The full model including pain, body mass index, anxiety and/or depression, perineal lacerations, and anemia explained 24% of the variability in postpartum depression scores. CONCLUSIONS: Although the extent of labor pain relief by epidural analgesia predicts lower postpartum depression scores, the relative contribution of PIP to risk for postpartum depression symptoms may be less than other established risk factors for depression. These data support that the clinical significance of labor analgesia in the development of postpartum depression needs to be more clearly defined.

The Relationship Between Women's Intention to Request a Labor Epidural Analgesia, Actually Delivering With Labor Epidural Analgesia, and Postpartum Depression at 6 Weeks: A Prospective Observational Study.

BACKGROUND: Postpartum depression (PPD) is associated with pain during and after delivery, with studies showing reduced rates among women delivering with labor epidural analgesia (LEA). We hypothesized that women who intend to deliver with LEA but do not receive it are at higher risk for PPD at 6 weeks due to the combined experience of untreated labor pain and unmatched expectations during labor, and evaluated the interaction between labor plans related to LEA, satisfaction with pain control when actually delivering with LEA, and PPD at 6 weeks after delivery. METHODS: A total of 1497 women with a vaginal delivery were enrolled into this prospective longitudinal study. Women's initial intention to deliver with or without LEA, how they subsequently delivered, and satisfaction with pain relief were recorded on postpartum day 1. Primary aim was selected as PPD at 6 weeks among women intending to deliver with but subsequently delivering without LEA compared with the rest of the cohort. Primary outcome was PPD at 6 weeks using the Edinburgh Postnatal Depression Scale; PPD was defined with a score ≥10 (scale from 0 to 30). Demographic and obstetric data were recorded. Fisher exact test was used for comparisons between groups. The interaction between intention and actual delivery with regard to LEA and PPD was tested. RESULTS: Overall, 87 of 1326 women completing the study at 6 weeks had PPD (6.6%). For the primary aim, 439 (29.3%) delivered without LEA, of which 193 (12.9%) had intended to deliver with LEA; the PPD rate among these women was 8.1%, which was not statistically different from the rest of the cohort (6.3%; odds ratio [OR], 1.30; 95% confidence interval [CI], 0.72-2.38; P = .41). A total of 1058 women (70.7%) delivered with LEA and 439 (29.3%) delivered without; therefore, 1169 (78.1%) delivered as intended and 328 (21.9%) did not (unmatched expectations). Evaluating the interaction between effects, there was a strong negative additive interaction between intending to deliver without LEA and actually delivering with LEA (risk difference = -8.6%, 95% CI, 16.2%-1.6%; P = .014) suggesting that unmatched intention effect is significantly associated with negative outcome. In multiple regression analysis, while intending to deliver with LEA (OR, 1.06; 95% CI, 1.01-1.11; P = .029) and actually delivering with LEA (OR, 1.07; 95% CI, 1.01-1.13; P = .018) both increased the odds for PPD, the multiplicative interaction was protective (OR, 0.92; 95% CI, 0.86-0.99; P = .022), after adjusting for cofactors. CONCLUSIONS: Our study results did not demonstrate a significant increase in the odds for PPD at 6 weeks among women who intended to deliver with LEA but subsequently delivered without. However, we identified a protective interaction between intended LEA use and actual use on the incidence of PPD. Our data suggest an increased risk when women do not deliver as intended, particularly when not initially intending to deliver with LEA. The relationship between unplanned LEA and PPD may be mediated by a physically difficult delivery rather than or in addition to negative emotions related to unmet expectations or a sense of personal failure; therefore, counseling women after delivery to address any negative perceptions may be useful.

Anesthetic and Obstetrical Factors Associated With the Effectiveness of Epidural Analgesia for Labor Pain Relief: An Observational Population-Based Study.

BACKGROUND AND OBJECTIVES: The effectiveness of labor epidural analgesia is difficult to explore, as it includes the maternal satisfaction with analgesia as well as the overall childbirth experience. In this population-based study, we sought to identify factors associated with the effectiveness of epidural analgesia for labor pain relief. METHODS: We performed a secondary analysis of the 2010 French National Perinatal Survey, a cross-sectional study of a representative sample of births in France. All participants who gave birth with an epidural analgesia were included. Effectiveness of epidural analgesia was assessed 2 to 3 days after delivery and intended to include analgesic efficacy and maternal satisfaction together. The factors analyzed were anesthetic management and maternal, obstetrical, and organizational characteristics, using a logistic regression with random effects model. RESULTS: Among the 9337 women who gave birth with an epidural analgesia and were included, 8377 (89.3%; 95% confidence interval [CI] = 88.7-89.9) considered their epidural to be very or fairly effective. In the multivariate analysis, effectiveness was significantly associated with the use of patient-controlled epidural analgesia (adjusted odds ratio [aOR] = 1.2 [1.0-1.5]; P = 0.02) and delivery in private maternity facilities (aOR = 1.3 [1.1-1.6]); it was significantly less effective in obese women (aOR = 0.6 [0.5-0.8]) and multiparous women not receiving oxytocin during labor (aOR = 0.4 [0.4-0.6]) as compared with nonobese and nulliparous women with oxytocin, respectively. CONCLUSIONS: At the population level, most women found epidural analgesia effective for labor pain relief, but specific attention should be paid to obese parturients and multiparous women not receiving oxytocin. High epidural effectiveness with patient-controlled analgesia should promote an increased use of this method.

Persistent Pain After Cesarean Delivery and Vaginal Delivery: A Prospective Cohort Study.

BACKGROUND: Persistent pain after cesarean delivery and vaginal delivery has been the subject of only a few research articles. The primary outcome of our prospective study was the incidence of persistent pain and its association to mode of delivery. We also studied the nature and intensity of pain after delivery. METHODS: A questionnaire was distributed on postpartum day 2 to 1052 women who had given birth vaginally and to 502 who had undergone cesarean delivery in a tertiary maternity hospital in Helsinki, Finland, in 2010. A second questionnaire was mailed to the women 1 year later. We recorded the women's health history, obstetric history and previous pain history, details of cesarean delivery or vaginal delivery, and description of pain, if present. RESULTS: The incidence of persistent pain at 1 year after delivery was greater after cesarean delivery (85/379 [22%]) than after vaginal delivery (58/713 [8%]: P < .001, relative risk 2.8, 95% confidence interval 2.0-3.8). Because of initial differences in the groups, we performed logistic regression analysis with persistent pain as a dependent factor that confirmed the mode of delivery as a predictor of persistent pain. The incidence of persistent pain graded as moderate or more severe (25/379 [7%] vs 25/713 [4%]: P = .022, relative risk 1.9, 95% confidence interval 1.1-3.2) was also greater after cesarean delivery than vaginal delivery. The incidence of persistent pain was significantly more common in women with a history of previous pain and among primiparous women in logistic regression analysis. The women with persistent pain had experienced more pain the day after cesarean delivery (P = .023) and during vaginal delivery (P = .030) than those who did not report persistent pain. Complications such as perineal trauma, episiotomy, vacuum extraction, endometritis, wound infection, or ante- or postpartum depression did not predispose women to persistent pain. Dyspareunia was reported by 41% of women after vaginal delivery and by 2% after cesarean delivery among women with persistent pain at 1 year. CONCLUSIONS: The incidence of persistent pain at 1 year is greater after cesarean delivery than after vaginal delivery. Pain shortly after cesarean delivery and during vaginal delivery correlated with persistent pain.

Lateral asymmetric decubitus position for the rotation of occipito-posterior positions: multicenter randomized controlled trial EVADELA.

BACKGROUND: Fetal occiput posterior positions are associated with poorer maternal outcomes than occiput anterior positions. Although methods that include instrumental and manual rotation can be used at the end of labor to promote the rotation of the fetal head, various maternal postures may also be performed from the beginning of labor in occiput posterior position. Such postures might facilitate flexion of the fetal head and favor its rotation into an occiput anterior position. OBJECTIVE: The purpose of this study was to determine whether a lateral asymmetric decubitus posture facilitates the rotation of fetal occiput posterior into occiput anterior positions. STUDY DESIGN: Evaluation of Decubitus Lateral Asymmetric posture was a multicenter randomized controlled trial that included 322 women from May 2013 through December 2014. Study participants were women who labored with ruptured membranes and a term fetus that was confirmed by ultrasound imaging to be in cephalic posterior position. Women who were assigned to the intervention group were asked to lie in a lateral asymmetric decubitus posture on the side opposite that of the fetal spine during the first hour and encouraged to maintain this position for as long as possible during the first stage of labor. In the control group, women adopted a dorsal recumbent posture during the first hour after random assignment. The primary outcome was occiput anterior position at 1 hour after random assignment. Secondary outcomes were occiput anterior position at complete dilation, mode of delivery, speed of dilation during the active first stage, maternal pain, and women's satisfaction. RESULTS: One hundred sixty women were assigned to the intervention group, and 162 women were assigned to the control group. One hour after random assignment, the rates of occiput anterior position did not differ between the intervention and control groups (21.9% vs 21.6%, respectively; P=.887). Occiput anterior rates did not differ between groups at complete dilation (43.7% vs 43.2%, respectively; P=.565) or at birth (83.1% vs 86.4%, respectively; P=.436). Finally, the groups did not differ significantly for cesarean delivery rates (18.1% among women in lateral asymmetric decubitus and 14.2% among control subjects (P=0.608) or for speed of cervical dilation during the active first stage of labor (P=.684), pain assessment (P=.705), or women's satisfaction (P=.326). No maternal or neonatal adverse effect that was associated with either posture was observed. CONCLUSION: Lateral asymmetric decubitus position on the side opposite that of the fetal spine did not facilitate rotation of fetal head. Nevertheless, other maternal positions may be effective in promoting fetal head rotation. Further research is needed; posturing during labor, nonetheless, should remain a woman's active choice.

The characteristics of women who use hypnotherapy for intrapartum pain management: Preliminary insights from a nationally-representative sample of Australian women.

OBJECTIVES: This manuscript presents a preliminary examination of the characteristics of women who choose intrapartum hypnosis for pain management. DESIGN: Cross-sectional analysis of 2445 women (31-36 years) from a sub-study of the Australian Longitudinal Study on Women's Health (ALSWH), employing Fisher exact tests. SETTING: Australia. MAIN OUTCOME MEASURES: Use of intrapartum hypnosis, or hypnobirthing, for pain management during labour and birth. RESULTS: Women using hypnobirthing were more likely to have consulted with an acupuncturist or naturopath, or attended yoga/meditation classes during pregnancy (p<0.0001). Use of CM products such as herbal medicines, aromatherapy oils, homoeopathy, herbal teas or flower essences (p<0.001) was also more common amongst these women. Women choosing hypnotherapy for intrapartum pain management less commonly identified as feeling safer knowing that an obstetrician is providing their care (p<0.001), and were more likely to labour in a birth centre or in a community centre (i.e. at home). CONCLUSIONS: This analysis provides preliminary analysis into an as yet unexamined topic in contemporary maternity health service utilisation. The findings from this analysis may be useful for maternity health professionals and policy makers when responding to the needs of women choosing to use hypnotherapy for intrapartum pain management.

Inmersión en agua caliente. Un ayudante natural en el proceso de parto / Inmersion in hot wáter: a natural helper in labour

Introducción. El dolor que acompaña al proceso de parto es resultado de un cúmulo de estímulos fisiológicos, psicológicos y socioculturales. En nuestra sociedad, la analgesia epidural es la técnica más empleada en obstetricia para aliviar este dolor, a pesar de no ser inocua. Sin embargo, existen otros métodos basados en técnicas complementarias que poseen efectos analgésicos demostrados y tienen el beneficio de no tener efectos perjudiciales para la gestante o el feto. Entre estos métodos se encuentra la inmersión en agua caliente (IA). El objetivo de esta revisión es dar a conocer la utilidad, ventajas e inconvenientes de la IA, para hacer de ella un recurso accesible para la gestante y los profesionales encargados de su atención. Métodos. Revisión bibliográfica acerca de la IA durante la primera y segunda etapa de parto. Resultados. La IA como método para aliviar el malestar y el dolor durante el trabajo de parto fue popularizado por el obstetra Michel Odent en la década de los ochenta. La Sociedad Española de Ginecología y Obstetricia, entre otras asociaciones, recomienda altamente su uso durante el periodo de dilatación, puesto que presenta beneficios para la gestante a nivel circulatorio, psicoafectivo y sobre su mecánica corporal; sin embargo, su utilización en la segunda etapa de parto parece más controvertida. Conclusiones. La IA es un método analgésico no invasivo, accesible y económico. Su uso se relaciona con menores tasas de intervención por parte de los profesionales al tiempo que permite proporcionar una atención más centrada en las necesidades de la gestante (AU)

Introduction. The pain during the birth process is the result of a pile of physiological, psychological and socio-cultural stimulus. In our society, epidural analgesia is the most common technique used in obstetrics to relieve this pain, despite not being harmless. However, there are other complementary techniques ased on methods that have demonstrated analgesic effects and they benefit of lacking adverse effects either on the mother or on the fetus. Among these methods is the immersion in warm water (WI). The aim of this review is to show the usefulness, advantages and disadvantages of WI, to make it an accessible resource for pregnant women and those who are responsible for their care. Methods. Literature review about Water Immersion during the first and second stage of labor. Results. The WI as a method to relieve discomfort and pain during labor was popularized by the obstetrician Michel Odent in 1980s. The Spanish Society of Gynecology and Obstetrics, among other associations, highly recommend its use during the cervical dilation period. It is benificial for the mother blood circulation, psychologically and for body mechanics; however, this use in the second stage of labor seems to be more controversial. Conclusions. WI is an analgesic non-invasive, accessible and affordable. Its use is associated with lower rates of intervention by professionals and provide a more focused attention on the needs of pregnant women (AU)

Failed Obstetric Spinal Anesthesia in a Nigerian Teaching Hospital: Incidence and Risk Factors.

BACKGROUND: In a retrospective survey, we found 1% cases with complete and partial failure of spinal anesthesia for cesarean delivery between 2008 and 2010, which we attributed to underreporting because of the study design. In this prospective study, we determined the incidence of failed spinal anesthesia and identified the factors that increased its risk. METHODS: This prospective, observational study consisted of all spinal anesthetics administered for cesarean delivery surgery from January 2011 to December 2013. Our definition of failure covered complete (preoperative) failure to achieve a pain-free operative condition and pain during surgery (intraoperative failure). RESULTS: Of a total of 3568 cesarean deliveries, there were 3239 (90.8%) spinal blocks, and the overall failure was 294 (9.1%). These were rescued by conversion to general anesthesia (22.8%) and repeating spinal (23.1%) and IV analgesic supplementation (54.1%). Analysis by logistic regression model indicated that factors associated with failure were the level of experience of the anesthesia provider as shown by senior registrar (adjusted risk ratio [RR], 1.4; 95% confidence interval [CI], 1.0-1.9), >1 lumbar puncture attempt (adjusted RR, 1.5; 95% CI, 1.1-1.9), and use of the L4/L5 interspace (adjusted RR, 1.7; 95% CI, 1.4-2.0). CONCLUSIONS: The rate of failed spinal anesthesia from this study was high. The independent predictors of failure were multiple lumbar puncture attempts, use of the L4/L5 interspace, and the level of experience of the anesthesia provider. It is imperative to develop clear guidelines to standardize our obstetric spinal anesthetic practice as well as the management of failures.

Acupuncture with manual and electrical stimulation for labour pain: a two month follow up of recollection of pain and birth experience.

BACKGROUND: In a previous randomised controlled trial we showed that acupuncture with a combination of manual- and electrical stimulation (EA) did not affect the level of pain, as compared with acupuncture with manual stimulation (MA) and standard care (SC), but reduced the need for other forms of pain relief, including epidural analgesia. To dismiss an under-treatment of pain in the trial, we did a long-term follow up on the recollection of labour pain and the birth experience comparing acupuncture with manual stimulation, acupuncture with combined electrical and manual stimulation with standard care. Our hypothesis was that despite the lower frequency of use of other pain relief, women who had received EA would make similar retrospective assessments of labour pain and the birth experience 2 months after birth as women who received standard care (SC) or acupuncture with manual stimulation (MA). METHODS: Secondary analyses of data collected for a randomised controlled trial conducted at two delivery wards in Sweden. A total of 303 nulliparous women with normal pregnancies were randomised to: 40 min of MA or EA, or SC without acupuncture. Questionnaires were administered the day after partus and 2 months later. RESULTS: Two months postpartum, the mean recalled pain on the visual analogue scale (SC: 70.1, MA: 69.3 and EA: 68.7) did not differ between the groups (SC vs MA: adjusted mean difference 0.8, 95% confidence interval [CI] -6.3 to 7.9 and SC vs EA: mean difference 1.3 CI 95% -5.5 to 8.1). Positive birth experience (SC: 54.3%, MA: 64.6% and EA: 61.0%) did not differ between the groups (SC vs MA: adjusted Odds Ratio [OR] 1.8, CI 95% 0.9 to 3.7 and SC vs EA: OR 1.4 CI 95% 0.7 to 2.6). CONCLUSIONS: Despite the lower use of other pain relief, women who received acupuncture with the combination of manual and electrical stimulation during labour made the same retrospective assessments of labour pain and birth experience 2 months postpartum as those who received acupuncture with manual stimulation or standard care. TRIAL REGISTRATION: ClinicalTrials.gov: NCT01197950.

Maternal Physical Health Symptoms in the First 8 Weeks Postpartum Among Primiparous Australian Women.

BACKGROUND: To describe prospectively the extent, onset, and persistence of maternal physical health symptoms (cesarean delivery pain, perineal pain, back pain, constipation, hemorrhoids, urinary incontinence, bowel incontinence, and fatigue) in the first 8 weeks postpartum. METHODS: A prospective cohort of 229 primiparous women was recruited antenatally from a public and a private maternity hospital, Melbourne, Australia, between 2009 and 2011. Data were collected by self-report questionnaires at weeks 1, 2, 3, 4, and 8. Main outcome measures were a checklist of maternal health symptoms and a standardized assessment of fatigue symptoms. RESULTS: Birth-related pain was common at week 1 (n = 80/88, 91% cesarean delivery pain; n = 92/125, 74% perineal pain), and still present for one in five women who had a cesarean birth (n = 17, 18%) at week 8. Back pain was reported by approximately half the sample at each study interval, with 25 percent (n = 48) reporting a later onset at week 2 or beyond. Fatigue was not relieved between 4 and 8 weeks. CONCLUSIONS: Women experience significant morbidity in the early weeks postpartum, the extent of which may have been underestimated in previous research relying on retrospective recall. Findings contribute to the growing body of evidence that supports early identification, treatment, and support for women's physical health problems in the postpartum.

Initial Preference for Labor Without Neuraxial Analgesia and Actual Use: Results from a National Survey in France.

BACKGROUND: The rate of neuraxial analgesia during labor in France is one of the highest among high-income countries: 77% of vaginal deliveries in 2010. In this context, the question of how women's preferences for delivering without neuraxial analgesia relate to actual use is of interest. Our objective was to study the factors associated with women's initial preference for labor without neuraxial analgesia and those associated with its use in women who initially preferred not to have it. METHODS: We used data from the 2010 French National Perinatal Survey, a cross-sectional study of a representative sample of all births in France. Data were collected from interviews with mothers in the postpartum ward and from medical records. Our sample included 7123 women who had vaginal deliveries and were at low risk for cesarean delivery. The factors analyzed were maternal sociodemographic characteristics, prenatal care, childbirth class attendance, labor management, and organization of maternity units. Multilevel Poisson regression models were used to study factors associated with women's initial preference in the overall population and to study factors associated with actual use of neuraxial analgesia in the group of women who initially preferred not to have it. RESULTS: Initially, 26% of our population (n = 1835) preferred to deliver without neuraxial analgesia; this preference was associated with high parity, unfavorable social conditions, and delivery in a public maternity unit. Among these women, 52% (n = 961) delivered with neuraxial analgesia. This discrepancy between initial preference and actual use was significantly associated with nulliparity (adjusted relative risk [aRR] = 1.4; 95% confidence interval [CI], 1.3-1.6), oxytocin augmentation of labor (aRR = 2.4; 95% CI, 2.1-2.7), presence of an anesthesiologist in the unit 24/7 (aRR = 1.4; 95% CI, 1.2-1.6; compared with delivery in hospitals without an anesthesiologist on site 24/7), and high midwife workload (aRR = 1.1; 95% CI, 1.0-1.2). There was no clear association with maternal educational level. CONCLUSIONS: Our results suggest that parity, the management of labor, and availability of anesthesiologists play a major role in the intrapartum decision to use neuraxial analgesia for women who initially preferred not to have it. Further research is necessary in the clinical circumstances leading to this decision and the role of women's demands and medical staff attitudes throughout labor.

Self-hypnosis for intrapartum pain management in pregnant nulliparous women: a randomised controlled trial of clinical effectiveness.

OBJECTIVE: (Primary) To establish the effect of antenatal group self-hypnosis for nulliparous women on intra-partum epidural use. DESIGN: Multi-method randomised control trial (RCT). SETTING: Three NHS Trusts. POPULATION: Nulliparous women not planning elective caesarean, without medication for hypertension and without psychological illness. METHODS: Randomisation at 28-32 weeks' gestation to usual care, or to usual care plus brief self-hypnosis training (two × 90-minute groups at around 32 and 35 weeks' gestation; daily audio self-hypnosis CD). Follow up at 2 and 6 weeks postnatal. MAIN OUTCOME MEASURES: Primary: epidural analgesia. Secondary: associated clinical and psychological outcomes; cost analysis. RESULTS: Six hundred and eighty women were randomised. There was no statistically significant difference in epidural use: 27.9% (intervention), 30.3% (control), odds ratio (OR) 0.89 [95% confidence interval (CI): 0.64-1.24], or in 27 of 29 pre-specified secondary clinical and psychological outcomes. Women in the intervention group had lower actual than anticipated levels of fear and anxiety between baseline and 2 weeks post natal (anxiety: mean difference -0.72, 95% CI -1.16 to -0.28, P = 0.001); fear (mean difference -0.62, 95% CI -1.08 to -0.16, P = 0.009) [Correction added on 7 July 2015, after first online publication: 'Mean difference' replaced 'Odds ratio (OR)' in the preceding sentence.]. Postnatal response rates were 67% overall at 2 weeks. The additional cost in the intervention arm per woman was £4.83 (CI -£257.93 to £267.59). CONCLUSIONS: Allocation to two-third-trimester group self-hypnosis training sessions did not significantly reduce intra-partum epidural analgesia use or a range of other clinical and psychological variables. The impact of women's anxiety and fear about childbirth needs further investigation.