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.

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.

Efficacy and safety of misoprostol vaginal insert vs. oral misoprostol for induction of labor.

Objectives To compare the oral application form of misoprostol with the misoprostol vaginal insert (MVI) in a Swiss cohort with special regards to the efficacy and safety. Methods We performed a retrospective case series including a historical group induced with oral misoprostol (MO, n=101) and an MVI group (n=101). The primary outcome was time to delivery. Secondary outcomes were mode of delivery, occurrence of tachysystole, use of analgesia and neonatal adverse outcome. Results A total of 202 women were included in the analysis (101 in the MVI as well as in the MO group). Time from start of induction to delivery was significantly shorter in the MVI group compared to the MO group (15.91 h vs. 37.68 h, P<0.001). Within the first 24 h, 78.2% of the women in the MVI group had given birth compared to 28.7% in the MO group (P<0.001). Tachysystole occurred more often in the MVI group (22.8% vs. 5.0%, P<0.001). Women in the MVI group more often needed opioid analgesia during the induction before onset of active labor (31.7% vs. 2.0%, P<0.001). There was no significant difference between neonatal outcomes in the two groups. Conclusion Time to delivery was significantly shorter in the MVI group with a higher rate of vaginal deliveries within the first 24 h. However, patients needed more opioids for pain relief during induction with MVI. There was no difference in neonatal outcomes.

The Effect of Adding Subarachnoid Epinephrine to Hyperbaric Bupivacaine and Morphine for Repeat Cesarean Delivery: A Double-Blind Prospective Randomized Control Trial.

BACKGROUND: Spinal anesthesia has become the most common type of anesthetic for cesarean delivery. The major limitation to spinal anesthesia is that the duration of the anesthetic may not be adequate in the event of a prolonged surgery. Some practitioners add epinephrine to hyperbaric bupivacaine to increase the duration, although its effect has not been fully studied. We therefore aimed to evaluate whether adding epinephrine to the spinal medication prolongs the duration of action of the resultant block in women presenting for repeat cesarean delivery. METHODS: Sixty-eight patients were randomized to receive no epinephrine (NE group), epinephrine 100 µg (low-dose [LD] group), or epinephrine 200 µg (high-dose [HD] group) with a standardized spinal mixture (1.5 mL 0.75% hyperbaric bupivacaine with 0.25 mg morphine). Sixty-five patients were included for primary analysis. Our primary outcome was time to intraoperative activation of the epidural catheter or postoperative regression of sensory blockade to T-10 dermatome level as measured by pinprick sensation; motor recovery was a secondary outcome, and graded via a Modified Bromage scale. RESULTS: Block onset time, vital sign changes, and the incidence of hypotension; nausea, and vomiting were similar among groups. Median difference in time to T-10 regression was greatest in the HD group compared to the NE group (median difference [min] [95% confidence interval]: 40 [15-60]; P = .007), followed by the HD group to the LD group (30 [15-45]; P = .007). Comparisons of LD to NE were not significant, but trended to an increase in T-10 regression time (10 [-15 to 30]; P = .76). Median difference in time to knee extension (Bromage 3) was also greatest in the HD group when compared to both the LD and NE group (median difference [min] [95% confidence interval]: 30 [0-60]; P = .034, 60 [0-93]; P = .007). Median difference time to knee extension (min) between the LD and NE group was also significant (37.5 [15-60]; P = .001]. Pain scores during the procedure were higher in the NE group (median [interquartile range] HD: 0 [0-0], LD: 0 [0-0], NE: 0 [0-3]; P = .02) during uterine closure and were otherwise not significantly different from the other groups. CONCLUSIONS: In this single center, prospective, double-blind, randomized control trial, the addition of epinephrine 200 µg to hyperbaric bupivacaine and preservative-free morphine for repeat cesarean delivery prolonged the duration of the sensory blockade. Motor blockade was similarly prolonged and block quality may have been enhanced.

Labor pain in women with and without severe fear of childbirth: A population-based, longitudinal study.

BACKGROUND: This prospective study aims to investigate whether severe fear of childbirth increases pain perceptions during birth and whether co-occurring maternal health and birth factors as well as length and weight of the child explain the association. METHODS: The study sample comprised women with a vaginal delivery and was drawn from the Akershus Birth Cohort. Data from the hospital birth's record and questionnaires at weeks 17-19 and 32 of pregnancy and 8 weeks postpartum were used (n = 1649). Analysis of variance and analysis of covariance were conducted to examine whether ratings of labor pain differed significantly between women with and without severe fear of childbirth and which factors explained the difference. RESULTS: Women with severe fear of childbirth experienced significantly more labor pain than women without severe fear of childbirth (P < .01). However, when controlling for symptoms of maternal depression and anxiety, use of epidural/spinal anesthetic or nitrous oxide gas, and menstrual pain, this difference was no longer significant (P = .09). DISCUSSION: Although the results show that labor pain is related to multiple physiological and psychological factors in a complex manner, symptoms of maternal depression and anxiety seem to play a central role for the experience of labor pain, and should therefore be focused on by health practitioners.

Non-pharmacological interventions during childbirth for pain relief, anxiety, and neuroendocrine stress parameters: A randomized controlled trial.

AIM: This study aimed to investigate the effect of warm shower hydrotherapy and perineal exercises with a ball on pain, anxiety, and neuroendocrine stress parameters during childbirth. METHODS: This randomized controlled trial was conducted with 128 women during childbirth, admitted for hospital birth in São Paulo, Brazil, from June 2013 to February 2014. The participants were randomly assigned into one of the following intervention groups: received warm shower hydrotherapy (GA); performed perineal exercises with a ball (GB); and combined intervention group, which received warm shower hydrotherapy and perineal exercises with a ball (GC) (n = 39). Pre-and post-intervention parameters were evaluated using visual analogue scales for pain and anxiety, and salivary samples were collected for the stress hormones analysis. RESULTS: Pain, anxiety, and epinephrine release decreased in the group performing perineal exercises with a ball (GB). ß-endorphin levels increased in this group (GB) after the intervention and showed significant difference in capacity to cause this effect (P = .007). However, no significant differences were observed in cortisol, epinephrine, and norepinephrine levels. CONCLUSIONS: Warm showers and perineal exercises could be considered as adjunct therapy for women suffering from pain, anxiety, and stress during childbirth. Clinical Trial Registry RBR-84xprt.

Nitrous Oxide Utility in Labor and Birth: A Multipurpose Modality.

The use of nitrous oxide (N2O) for labor and birth has very recently emerged as a viable modality in the United States, despite a long history of use in Canada and Europe. Usually associated with dental procedures, there are significant differences between dental and parturition utility, efficacy, and staff exposure. In addition to using it for pain relief and anxiolysis, those centers utilizing it have noted it to be multipurpose and useful for such situations as: external cephalic version, manual removal of placenta, intravenous starts, during placement of urinary catheters and intracervical Foley bulbs. Nitrous oxide has proven to be especially helpful for repair of lacerations under local anesthesia and is a multiuse modality that should be available to women in all birth settings. This article explores the history of N2O use, provides a comparison of obstetrical use to use in the dental industry, examines the contraindications to, and implications for usage, and discusses logistical points of consideration for clinicians working with women using N2O for labor and birth.

Geburtshilfe: Anästhesie bei EXIT-Prozedur.

The ex utero intrapartum treatment (EXIT) procedure is performed as a part of an extended caesarean section for example to treat fetal airway disorders. For treatment, optimal uterine relaxation is necessary, however utero-placental supply of the fetus has to be guaranteed as well. "Balanced" anesthesia, tocolysis and tight maternal arterial blood pressure control are recommended. Standard fetal monitoring comprises pulse oxymetry and echocardiography. The article describes the physiology and anesthestic goals of the EXIT procedure, discusses alternative anesthesia techniques and gives an outlook on emerging progress.

Increased pain relief with remifentanil does not improve the success rate of external cephalic version: a randomized controlled trial.

INTRODUCTION: Our objective was to compare the effect of two pain relief methods (remifentanil vs. nitrous oxide) on the success rate of external cephalic version. MATERIAL AND METHODS: We conducted a randomized open label parallel-group controlled single-center clinical trial with sequential design, at Cruces University Hospital, Spain. Singleton pregnancies in noncephalic presentation at term that were referred for external cephalic version were assigned according to a balanced (1:1) restricted randomization scheme to analgesic treatment with remifentanil or nitrous oxide during the procedure. The primary endpoint was external cephalic version success rate. Secondary endpoints were adverse event rate, degree of pain, cesarean rate and perinatal outcomes. RESULTS: The trial was stopped early after the second interim analysis due to a very low likelihood of finding substantial differences in efficacy (futility). The external cephalic version success rate was the same in the two arms (31/60, 51.7%) with 120 women recruited, 60 in each arm. The mean pain score was significantly lower in the remifentanil group (3.2 ± 2.4 vs. 6.0 ± 2.3; p < 0.01). No differences were found in external cephalic version-related complications. There was a trend toward a higher frequency of adverse effects in the remifentanil group (18.3% vs. 6.7%, p = 0.10), with a significantly higher incidence rate (21.7 events/100 women vs. 6.7 events/100 women with nitrous oxide, p = 0.03). All reported adverse events were mild and reversible. CONCLUSIONS: Remifentanil for analgesia decreased external cephalic version-related pain but did not increase the success rate of external cephalic version at term and appeared to be associated with an increased frequency of mild adverse effects.

Dural puncture epidural with 25-G spinal needles versus conventional epidural technique for labor analgesia: A systematic review of randomized controlled trials.

BACKGROUND: Dural mater is punctured by using a spinal needle without drugs administrated into intrathecal space directly in dural puncture epidural (DPE) analgesia. OBJECTIVE: This study aimed to summarize the evidence of benefits and risks of DPE analgesia with 25-G spinal needles for labor pain relief. METHODS: DPE analgesia with EP analgesia for labor pain relief were systematically searched. The Embase, MEDLINE, Cochrane Central Register of Controlled Trials, Scopus and Web of Science databases were systematically searched till 6th November 2022 to find out randomized controlled trials (RCTs) comparing DPE (using 25-G spinal needles) with conventional epidural (EP) analgesia. The risk of bias was assessed with the Cochrane tool. Risk ratio, mean difference, and 95% confidence intervals were calculated. RESULTS: Seven RCTs with 761 parturients were identified. Pool data showed that DPE technique was associated with shorter time to pain score ⩽ 3/10, higher percentage with pain score ⩽ 3/10 at 10 min and 20 min, lower incidence of epidural top-up bolus and no S2 block, higher incidence of bilateral S2 blockade at 10 min and during labor, lower incidence of epidural top-up bolus and incidence of asymmetric block. No statistical difference in side effect and parturient satisfaction between DPE and EP technique. CONCLUSION: DPE technique with 25-G spinal needles was associated with faster analgesia onset and sacral coverage, greater sacral spread, lesser requirement of epidural top-up and lower incidence of asymmetric block. DPE technique with 25-G spinal needles showed a greater benefit to parturients.

Women's concerns and satisfaction with induced labour at term in a Nigerian population.

AIMS AND OBJECTIVES: To explore the concerns, experiences and satisfaction of women who had induction of labour at term MATERIALS AND METHODS: A cross-sectional study conducted in Nigeria, among 252 pregnant women who had induction of labour at term using a two part pre and post induction questionnaire. RESULTS: Concerns expressed by the women prior to labour induction were the fear of caesarean delivery (16.6%), labour pains (15.1%) and an adverse foetal or maternal outcome (4.8%). Overall, 180 women (71.4%) expressed satisfaction with the induction process while 72 (28.6%) were dissatisfied. Comparatively, a higher mean age and shorter induction-delivery interval (470±180 vs 660±370, p<0.001) was significantly associated with maternal satisfaction with induced labour. It was also associated with significantly lower caesarean section rates (13.3% vs 61.1%, p=0.001) and composite maternal or foetal morbidities. The common reasons for dissatisfaction with induced labour included caesarean delivery (13.4%), painful labour (8.7%) while 2.4% felt the duration of the procedure was too long. CONCLUSION: This study suggests that a substantial number of pregnant women who had induction of labour had unsatisfactory experience. The reasons for dissatisfaction should be addressed by physicians in order to promote a positive psycho-emotional experience of pregnancy and childbirth.

Efficacy and safety of intravenous paracetamol in management of labour pains in a low resource setting: a randomized clinical trial.

OBJECTIVE: To assess the use of single dose of paracetamol intravenously in management of labour pains. BACKGROUND: Pain during labour is a complex, subjective and multi-faceted physiological phenomenon that varies in intensity among women and is subjected to many social and cultural modifiers. SUBJECTS AND METHODS: This randomized clinical study was conducted in Obstetrics and gynecology department from March 2019 to March 2020 including 96 primiparous women randomized into paracetamol group (n = 48) received 1000 mg of paracetamol IV infusion and pethidine group (n = 48) received 50 mg of pethidine given slowly IV. Primary outcome is the change of the intensity of perceived labor pain. Pain score was followed and recorded by visual analogue scale (VAS). Our study protocol was registered at ClinicalTrials.gov; NCT04744727. RESULTS: VAS score was highly significant improved gradually after 30 min, 1, 2 and 3 h of paracetamol and pethidine taken compared at start study, but participants in paracetamol group had lower pain after 2 and 3 h (3.92 ± 1.42 and 5.69 ± 1.07) than those of the pethidine groups (4.42 ± 1.87 and 5.38 ± 1.34). Also, 2.1% of paracetamol group developed dizziness and 4.2% developed nausea and vomiting, while there was 29.2% of pethidine group developed dizziness and 37.5% developed nausea and vomiting. CONCLUSIONS: Intravenous paracetamol as labour analgesia is effective, safe, inexpensive, available and with no maternal or fetal side effects as compared to Pethidine. Paracetamol needs to have more chance in comparison to other forms as a labour pain analgesia, especially in our communities.

Start of induction of labour with oxytocin in the morning or in the evening. A randomised controlled trial.

OBJECTIVE: The objective of this study was to compare outcomes of induced labour with intravenous oxytocin with a start in the evening versus in the morning. DESIGN: Randomised controlled trial. SETTING: Labour wards of three hospitals in Amsterdam, the Netherlands. PARTICIPANTS: Women with an indication for induction of labour with intravenous oxytocin. METHODS: Included women were randomized to either the evening group with a start of induction of labour at 21:00 hours, or the morning group with a start at 07:00 hours. MAIN OUTCOME MEASURES: Primary outcome was duration of labour. Secondary outcomes were instrumental delivery rate, adverse neonatal outcome defined as an Apgar score below 7 after 5 minutes, number and indications of paediatric consults and neonatal admissions, duration of second stage, number of intrapartum infections and necessity of pain relief. RESULTS: We randomised 371 women. Mean duration of labour was not significantly different (primiparae: morning 12 hours and 8 minutes versus evening 11 hours and 22 minutes, P value 0.29; multiparae: morning 7 hours and 34 minutes versus evening 7 hours and 46 minutes, P value 0.70). There were no significant differences in instrumental deliveries rates, number of infections or patient satisfaction. Unexpectedly, neonatal outcome was better in women induced in the evening. CONCLUSION: Induction of labour with intravenous oxytocin in the evening is equally effective as induction in the morning.

Fatigue in Pregnancy: The validity and reliability of the Farsi Multidimensional Assessment of Fatigue scale.

OBJECTIVES: Fatigue is a common discomfort experienced during pregnancy and may contribute to severe labour pain and postpartum depression. This study aimed to translate the Multidimensional Assessment of Fatigue (MAF) scale into Farsi and validate it in a sample of pregnant Irani women. METHODS: This cross-sectional questionnaire study was conducted between January and June 2016 at eight healthcare centres in Sabzevar, Iran. The English version of the MAF scale was translated into Farsi and assessed for content validity. Participants completed the Farsi MAF scale and the Farsi World Health Organization-5 Well-being index (WHO-5). Construct validity was assessed through exploratory factor analysis (EFA). Cronbach's alpha coefficient and the intraclass correlation coefficient (ICC) were used to determine the internal consistency and stability of the Farsi MAF scale. RESULTS: A total of 582 women met the inclusion criteria, of which 541 completed the MAF scale (response rate: 93%). The EFA of the 15 items confirmed the previously proposed one-factor structure with a Cronbach's alpha coefficient of 0.957 for the Farsi MAF scale. Stability was confirmed by the ICC value (0.702) for the Global Fatigue Index (GFI) and the mean GFI was 20.33 ± 12.71. Concurrent validity was confirmed by a moderate negative correlation (r = -0.35; P <0.001) between the scores of the Farsi MAF scale and the Farsi WHO-5. Women who received a high level of support from their husbands, who were satisfied with the quality of their marital relationship and with a well-being score of >50 reported a lower level of fatigue than the other groups (P ≤0.012). CONCLUSION: The Farsi MAF scale is a reliable and valid questionnaire to investigate fatigue in pregnant Irani women. Interventions to promote marital satisfaction and women's well-being are recommended.

A systematic review of DURAL puncture epidural analgesia for labor.

STUDY OBJECTIVE: This systematic review aimed to summarize the evidence derived from randomized controlled trials (RCTs) comparing dural puncture epidural analgesia (DPEA) and conventional lumbar epidural analgesia (LEA) for women undergoing labor. INTERVENTIONS: The MEDLINE and EMBASE databases were searched from inception to July 2018 in order to find RCTs published in the English language, which investigated DPEA in laboring women. MAIN RESULTS: Six RCTs were included in the final analysis. Their collective results remain ambiguous. Dural puncture with small (i.e., 26- or 27-gauge) spinal needles seems to confer either minimal benefits or improved analgesic quality and lower pain scores in the first 10 min. Dural puncture with 25-gauge spinal needles has been reported to provide higher success rate than conventional LEA in one trial; however two other studies could only agree on the fact that DPEA results in improved sacral blockade and fewer unilateral blocks compared to LEA. CONCLUSIONS: The current evidence regarding DPEA for labor analgesia remains ambiguous. Future research should investigate the optimal (spinal) needle size for dural puncture as well as factors governing transmeningeal flux of local anesthetics and opioids in the presence of a dural hole.

Anaesthetic management of a parturient with severe kyphoscoliosis.

Use of neuraxial block in a patient with severe kyphoscoliosis is controversial. We describe the anaesthetic management by spinal anaesthesia of a parturient with severe kyphoscoliosis in obstructed labour. The perioperative course was uneventful. We suggest that a patient with severe kyphoscoliosis may be successfully managed by spinal anaesthesia for caesarean section.

An evolutionary interpretation of the significance of physical pain experienced by human females: defloration and childbirth pains.

The phenomena surrounding the pains commonly related to both first coitus and delivery have been addressed rather poorly in previous work, as regards their evolutionary aspects, during the investigation of human sexuality and reproductive behavior. In particular, the function of the hymen and the significance of defloration are largely misunderstood. The present paper aims to analyse the meaning of these two female physical pains in an evolutionary context. Accordingly, childbirth and defloration pains are hypothesized to manifest an adaptation designed to increase inclusive fitness in human evolutionary history. Clearly, the significance of pain as a message is essentially emotional. Indeed, the intense sexual emotions that may precede and/or follow the pain, the breaking and bleeding of the hymen during the first complete sexual act may generate distinctive strong feelings on/from each side of the newly formed couple. As to labor pain, both the shared intimacy with the mother and the emotional background during confinement may create mutual solicitude among the protagonists (i.e. midwifes, father, mother). Such feelings or attitudes may subsequently turn out to be beneficial to all of them, and more particularly to the newborn. As a general consequence, it appears that the two physical pains under consideration may have behavioral implications, in the sense that they contribute to increasing the stability of the connection between partners and thus, indirectly, to the welfare or even the survival (especially in former times) of the newborn child.

The effects of childbirth self-efficacy and anxiety during pregnancy on prehospitalization labor.

OBJECTIVE: To describe levels of anxiety and self-efficacy for childbirth in nulliparous women during the late third trimester and to identify relationships among those variables, prehospitalization labor pain, management strategies, and hospital admission status. DESIGN: A longitudinal, descriptive study. PARTICIPANTS: Thirty-five English-speaking nulliparous women, 18 to 40 years of age, more than or equal to 38 week's gestation, with uncomplicated pregnancies. All participants had a significant other (husband or partner) and attended childbirth education programs. MAIN OUTCOME MEASURES: Spielberger Trait Anxiety Inventory, Prenatal Self-Evaluation Questionnaire, Childbirth Self-Efficacy Inventory, McGill Pain Questionnaire-Short Form, postpartum interviews, and medical records review. RESULTS: Prenatal anxiety was significantly related to self-efficacy for childbirth in late pregnancy, labor pain, number of hours at home in labor, and admitting cervical dilation. The number of management strategies used was related to pain scores during labor before hospital admission. Women who spent longer periods of time at home in labor arrived at the hospital with a greater cervical dilation. CONCLUSIONS: Antenatal characteristics influence intrapartal outcomes in nulliparas. Labor environment, at home and in the hospital, is recognized as an important component of the first childbirth experience.

The efficacy of lidocaine-prilocaine cream to reduce pain in genetic amniocentesis.

OBJECTIVE: Evaluate whether local anesthesia by lidocaine-prilocaine cream decreases maternal pain during mid-trimester genetic amniocentesis. MATERIAL AND METHOD: This randomized controlled study of mid-trimester genetic amniocentesis was conducted between 1 October 2006 and 30 April 2007. Pregnant women were randomized to receive lidocaine-prilocaine cream or placebo cream 30 minutes prior to amniocentesis. Patients, blinded to allocation, recorded anticipated and actual pain before and after the procedure. The visual analog score (VAS) was evaluated, using a 0-10 scale. RESULTS: One hundred and twenty women participated in the present study. Sixty women were randomized to lidocaine-prilocaine group. The two groups were similar with respect to clinical correlations and procedure characteristics. Anticipated pain was 6.1 +/- 2.0 in the lidocaine-prilocaine group and 6.3 +/- 2.3 in the placebo group (p = 0.61). Actual pain was 2.3 +/- 2.2 in the lidocaine-prilocaine group and 2.9 +/- 2.5 in the placebo group (p = 0. 16). CONCLUSION: Lidocaine-prilocaine cream does not decrease pain during mid-trimester genetic amniocentesis.

Survey of nulliparous parturients' attitudes regarding timing of epidural analgesia initiation.

STUDY OBJECTIVE: At our hospital, although >90% of nulliparous parturients eventually choose epidural analgesia for labor, many delay its initiation, experiencing considerable pain in the interim. This survey probed parturients' views about the timing of initiation of epidural labor analgesia. DESIGN: Single-center, nonrandomized quantitative survey. SETTING: Labor and delivery suite in a large tertiary academic medical center. PATIENTS: Two hundred laboring nulliparous women admitted to the labor and delivery suite. INTERVENTIONS: After their pain was relieved, parturients completed a questionnaire regarding their decision to request labor epidural analgesia. MEASUREMENTS: A variety of factors regarding epidural use were assessed including the influence of painful contractions and of childbirth education class attendance on the decision to request epidural analgesia, and parturients' perception of the timing of epidural initiation on the progress and outcome of labor. MAIN RESULTS: Analysis revealed that the desire of parturients to use epidural analgesia was increased from 27.9% before the onset of painful contractions to 48.2% after (p<0.01). Two-thirds of participants attended a non-physician taught childbirth education class. An antepartum plan to definitely forgo an epidural was 1.8 times more likely among women who attended a childbirth class when compared to those who did not attend. (OR=1.8; 95%CI:1.1-3.1; p=0.04). The most common views affecting decision-making were that epidural analgesia should not be administered "too early" (67.5%), and that it would slow labor (68.5%). Both of these views were more likely to be held if the parturient had attended a childbirth class, OR=2.0 (95%CI:1.1-3.8; p=0.03) and OR=2.0 (95% CI: 1.1 to 3.7; p=0.03), respectively. CONCLUSIONS: We found that nulliparous parturients have misconceptions about epidurals, which are not supported by evidence-based medicine. Moreover, we found that attendance at childbirth education classes was associated with believing these misconceptions.