Epidural versus non-epidural or no analgesia in labour

Patients' perspectives on pain relief during childbirth and labor epidurals: a pilot qualitative study among women who chose to deliver without neuraxial labor analgesia

BACKGROUND

Studies have identified widespread variation in neuraxial labor analgesia use by race, ethnicity, and geographic location. However, limited research has investigated patient-level factors in the decision not to use neuraxial analgesia for labor.

METHODS

We conducted semi-structured interviews at a New York City medical center from October 1, 2022, to May 30, 2023. Participants had delivered vaginally and selected not to receive neuraxial labor analgesia. Structured demographic questions were asked after interview completion. Interviews were recorded and transcribed verbatim. We analyzed data and grouped responses into themes according to grounded theory.

RESULTS

We identified five themes encompassing the main factors participants had considered when deciding not to receive neuraxial analgesia for birth: preferences for a natural birth experience, an empowering and supportive labor environment, preparation or preparedness for birth without medication, positive outlook on labor pain, and information, misinformation, knowledge gaps and fears about the epidural. All study participants mentioned these overarching themes in their interviews.

CONCLUSIONS

Participants described various factors important in their decision to give birth without an epidural, which we mapped onto five primary themes. Our results can be used to guide effective patient-provider interactions centered on mutual understanding, evidence-based medicine, and honoring patients' wishes. The information gathered may provide insight into how providers can incorporate shared decision-making into their practice.

Impact of fetal spine alignment according to maternal lateralization during early labor on maternal comfort and birth outcomes: A prospective cohort study in Kelantan, Malaysia

INTRODUCTION

Maternal positioning during labor significantly influences maternal comfort. This study aims to identify the preferred maternal lateral position during the latent phase and examine the impact of alignment between maternal lateralization and fetal spine positioning during the active phase of the first stage of labor on maternal comfort.

METHODS

Pregnant women in the first stage of labor beyond 37 weeks of gestation were recruited over six months from March to August 2020 for this prospective cohort study at Hospital Raja Perempuan Zainab II, Kota Bharu, Kelantan, Malaysia. Eligible individuals were randomly allocated to align with the fetal spine (n=180) or oppose it (n=180). Fetal spine positions were confirmed via transabdominal ultrasound. Maternal mean comfort scores were assessed using the established Maternal Comfort Assessment Tool. Statistical analysis was performed using IBM SPSS version 27, with a p<0.05 considered significant.

RESULTS

There was a significant association between the preferred maternal position during the latent phase and concordance with the same maternal lateralization-fetal spine alignment (p<0.001). Higher mean comfort scores were observed when the maternal lateral position matched the fetal spine alignment during the active phase of labor. There was a significant association of normal CTG tracings when the maternal position was aligned with the fetal spine (p<0.001).

CONCLUSIONS

Parturients preferred lying in alignment with the fetal spine lateralization during the latent phase. This position also offers increased comfort during the active phase of labor. It highlights the importance of considering maternal-fetal alignment as a critical factor in intrapartum care.

Continuous care during labor by maternity care assistants in the Netherlands vs care-as-usual: a randomized controlled trial

BACKGROUND

Continuous support during labor has many benefits including lower use of obstetrical interventions. However, implementation remains limited. Insights into birth outcomes and peripartum costs are essential to assess whether continuous care by a maternity care assistant is a potentially (cost) effective program to provide for all women.

OBJECTIVE

Continuous care during labor, provided by maternity care assistants, will reduce the use of epidural analgesia and peripartum costs owing to a reduction in interventions.

STUDY DESIGN

This was a randomized controlled trial comparing continuous support during labor (intervention group) with care-as-usual (control group) with prespecified intention-to-treat and per-protocol analyses. The primary outcome was epidural analgesia use. The secondary outcomes were use of other analgesia, referrals from midwife- to obstetrician-led care, modes of birth, hospital stay, sense of control (evaluated with the Labor Agentry Scale), maternal and neonatal adverse outcomes and peripartum costs. Data were collected using questionnaires. Anticipating incomplete adherence to providing continuous care, both intention-to-treat and per-protocol analyses were planned. Peripartum costs were estimated using a healthcare perspective. Mean costs per woman and cost differences between the intervention and control group were calculated.

RESULTS

The population consisted of 1076 women with 54 exclusions and 30 discontinuations, leaving 992 women to be analyzed (515 continuous care and 477 care-as-usual). Intention-to-treat analyses showed statistically nonsignificant differences between the intervention and control group for epidural use (relative risk, 0.88; 95% confidence interval, 0.74-1.04; P=.14) and peripartum costs (mean difference, € 185.83; 95% confidence interval, -€ 204.22 to € 624.54). Per-protocol analyses showed statistically significant decreases in epidural analgesia (relative risk, 0.64; 95% confidence interval, 0.48-0.84; P=.001), other analgesia (relative risk, 0.59; 95% confidence interval, 0.37-0.94; P=.02), cesarean deliveries (relative risk, 0.53; 95% confidence interval, 0.29-0.95; P=.03) and increase in spontaneous vaginal births (relative risk, 1.09; 95% confidence interval, 1.01-1.18; P=.001) in the intervention group, but difference in total peripartum costs remained statistically nonsignificant (mean difference, € 246.55; 95% confidence interval, -€ 539.14 to € 13.50).

CONCLUSION

If the provision of continuous care given by maternity care assistants during labor can be secured, continuous care leads to more vaginal births and less epidural use, pain medication, and cesarean deliveries while not leading to a difference in peripartum costs compared with care-as-usual.

Women's experiences with implementation of the physiologic birth program in Iran: a qualitative content analysis study

Introduction

Increased rate of caesarean section (CS) without medical indication is a global concern. According to the guidelines of the World Health Organization (WHO), the physiologic birth program is one of the strategies for reducing the rate of unnecessary caesarean sections. The aim of this study is to explain women's experiences with the implementation of the physiologic birth program in Iran.

Materials and methods

This study is a part of a mixed-method study involving 15 targeted semi-structured interviews individually conducted with women attending physiologic birth classes between January 2022 and June 2022. Interviews continued until data saturation was achieved. Data were analyzed using conventional content analysis approach based on the criteria proposed by Graneheim and Lundman, using MAXQDA10 software.

Results

Analysis of the findings of the study led to the emergence of 2 themes, 4 categories, and 10 subcategories. The first theme was the positive experiences of the women ("satisfaction with pregnancy" and "making the childbirth process pleasant"), and the second theme was their negative experiences with physiologic birth ("challenges and limitation of physiologic birth program" and "lack of high-quality obstetric services in the public health system").

Conclusion

The results of this study showed that childbirth preparation classes reduced women's fear and stress and enhanced their positive attitude toward vaginal delivery by preparing them for childbirth. Also, effective communication with midwives and their support along with efficient implementation of physiologic birth techniques led to successful pain management and satisfaction with the birth process. Policymakers should implement strategies to remove limitations and make this program accessible to all women.

Neuraxial labor analgesia: Maintenance techniques

Since the advent of neuraxial analgesia for labor, approaches to maintaining intrapartum pain relief have seen significant advancement. Through pharmacologic innovations and improved drug delivery mechanisms, current neuraxial labor analgesia maintenance techniques have been shaped by efforts to maximize patient comfort during the birthing process, while minimizing undesirable side effects and promoting the unimpeded progress of labor. To these ends, a modern anesthesiologist may avail themselves of several techniques, including programmed intermittent epidural bolus (PIEB), patient controlled epidural analgesia (PCEA) and dilute concentration local anesthetic + opioid epidural solutions. We explore the historical development and the evidential underpinnings of these techniques, in addition to several contemporary neuraxial labor analgesia practices. We also summarize current understanding of the effects these interventions have on maternal/fetal health and the labor course, as well as several important aspects of analgesic safety and monitoring.

Comparison of Spinal Versus Epidural Analgesia for Vaginal Delivery: A Randomized Double Blinded Clinical Trial

BACKGROUND

Recently, one of the problems in developing countries is pregnant women who insist on cesarean section for fear of painful vaginal delivery. There are various methods to reduce labor pain, including medical and non-medical methods. Neuraxial analgesia is classified as one of the best ways to reduce labor pain. Epidural analgesia is a classic and popular procedure to decrease labor pain. Nevertheless, other methods, such as spinal or combined spinal-epidural analgesia, is more effective compared with the epidural.

OBJECTIVES

In this study, we investigated a single intrathecal versus epidural injection in pregnant women during childbirth.

METHODS

In our research, after obtaining informed consent, the patients were randomly assigned to two equal groups: epidural and spinal. Each group contained 50 parturient women in advanced labor. In the epidural group, 2.5 mL isobaric bupivacaine 0.5%, sufentanil (0.2 mcg/mL), and 7 mL saline 0.9% were injected by an 18-gauge Tuohy needle at the L4-5 or L5-S1 intervertebral space, and in the spinal group, 0.5 mL isobaric bupivacaine 0.5%, 2.5 mcg sufentanil, and 0.5 mL saline 0.9% were injected by a 25-gauge pencil-point Quincke needle at the L4-5 or L5-S1 intervertebral spaces. For pain intensity, the visual analog scale (VAS) was used at serial intervals, and other variables, such as the onset and duration of analgesia, hypotension, neonatal APGAR score, fetal heart rate (FHR) changes, and other variables were examined.

RESULTS

The mean time to onset analgesic effect was 4.6 min in the spinal group compared with 12.5 minutes in the epidural (P < 0.001). Duration of analgesia was 121 minutes in the spinal group compared with 104 min in the epidural group (P < 0.001). The time to reach the maximum block was 8.4 min in the spinal group vs. 22.2 min in the epidural group (P < 0.001). The duration of the second and third gestation stages was the same in both groups.

CONCLUSIONS

Spinal analgesia is short and easy to perform and does not require advanced equipment and technical experience. Spinal analgesia can be a good option for labor analgesia and leads to achieving a lower pain score than epidural analgesia.

Nitrous Oxide for Labor Analgesia: What We Know to Date

Background: Although nitrous oxide (N₂O) has been used since the 1880s for labor analgesia, its popularity has only recently increased in the United States. In 2011, only 3 centers in the country offered N₂O, but as of 2020, several hundred labor units have adopted its use.

Methods: We reviewed the literature and summarize the mechanism of action, clinical uses, and efficacy of N₂O for labor analgesia, as well as patient satisfaction related to its use.

Results: N₂O has several proposed mechanisms of action that make it a viable option for all 3 stages of labor and postpartum procedures. N₂O has been shown to be a safe option for both mom and baby during labor and delivery. Studies support N₂O as an analgesic for laboring. Even though 40% to 60% of women who use N₂O convert to a labor epidural analgesia, satisfaction surveys indicate that analgesia is not the only factor contributing to the use of N₂O during labor.

Conclusion: The use of N₂O has increased in labor and delivery units across the United States since 2011. Despite inferior analgesic properties compared to epidural analgesia, N₂O offers a safe alternative for many parturients who want a greater sense of control and mobility.

The Influence of Personality and Anxiety Traits on Birth Experience and Epidural Use in Vaginal Deliveries - A Cohort Study

A positive birth experience for the mother is an important goal in obstetric health care and is influenced by several factors. For this study, 186 women filled in questionnaires between 24 and 72 hours after giving birth vaginally. We evaluated the Big-Five personality traits (extraversion, neuroticism, openness, conscientiousness and agreeableness), trait anxiety, different dimensions of childbirth experience and pain management. Correlation analysis revealed that trait anxiety and neuroticism were negatively associated with several dimensions of the birth experience. Furthermore, conscientiousness and extraversion were positively correlated with the dimension Participation. Regression analysis for the individual dimensions and overall score respectively, confirmed the independent impact of anxiety trait on Perceived Safety, Participation and Professional Support and the overall score as well as of neuroticism on Perceived Safety and conscientiousness on Participation. The significant regression models showed small R2-scores (.084-.154). The birth experience did not differ whether the women received an epidural or not. Women who did not receive an epidural displayed higher scores on the personality trait conscientiousness. The study highlights small but important associations between personality traits and birth experience in vaginal births which should sensitize the medical staff when supporting women during labor.

The association between labor epidural analgesia and postpartum depression: a systematic review and meta-analysis

BACKGROUND

Previous studies have demonstrated that appropriate treatment for postoperative pain can lead to improvement in depressive symptoms, however the association between adequate intrapartum pain control and the development of postpartum depression is not clear. The purpose of the study was to examine the effects of labor epidural analgesia and postpartum depression.

METHODS

We performed a quantitative systematic review in compliance with the PRISMA statement. We conducted a search of PubMed, Embase, the Cochrane Database of Systematic Reviews and Google Scholar databases. The primary outcome was a positive screen of postpartum depression among women who received labor epidural analgesia up to 3 months into the postpartum period. Meta-analysis was performed using the random effect model.

RESULTS

Of the 148 studies available, 9 studies with 4442 patients were included in the analysis. The use of labor analgesia on positive depression screen compared to control revealed no significant effect, OR (95% CI) of 1.02 (0.62 to 1.66, P = 0.94).

CONCLUSION

Based on current literature, the use of epidural analgesia for pain relief during labor doesn't appear to affect the likelihood of postpartum depression. Future studies are warranted to further investigate these findings and identity other possible preventative interventions that reduce postpartum depression.

The Trend of Labor Analgesia in the World and China: A Bibliometric Analysis of Publications in Recent 30 Years

Purpose

Labor analgesia is part of the most important tasks an anesthesiologist needs to deal with. With the “two-child policy” in China, the number of parturients has increased significantly, labor analgesia more should be valued. There has been a tremendous change on labor analgesia research in China and around the world; however, broader trends in the prevalence and scope of labor analgesia research remain underexplored. The current study quantitatively analyzes trends in labor analgesia research publications in the past 30 years.

Methods

A bibliometric approach was used to search Scopus, PubMed, Web of Science and the China National Knowledge Infrastructure for all labor analgesia-related research articles. The research progress and growing trend were quantitatively analyzed by total publications, research types, research institutions, journal impact factors, and author’s contribution. Total citations frequency, average citations per item and h-index were used for evaluating literature quantity.

Results

From 1988 to 2018, over 8000 documents in labor analgesia research field were published worldwide. According to Scopus, 68.2% papers of all documents were articles. The USA published the largest number of articles (2204, 27.45%). China had published 175 articles (2.18%), ranking the 11th. According to WOS, there were 221 research categories for labor analgesia articles all over the world. The total citations were 76,207, average 9.086 citations per item, and the h-index was 114, average 14 citations per item worldwide. The total citations and h-index of papers published in China were as follows: 353 total citations, 7.06 citations per item, and 10 h-index. High contribution journals, authors, institutions and the top 10 most cited articles on labor analgesia in the world and China were also listed.

Conclusion

Labor analgesia research has grown markedly during the 1988–2018 period. Although China had made remarkable achievements, there was a gap in the high-quality studies between China and other leading countries.

Effects of Labor Epidural Analgesia on Short Term Neonatal Morbidity

BACKGROUND

Epidural Analgesia (EA) is the most effective and most commonly used method for pain relief during labor. Some researchers have observed an association between EA and increased neonatal morbidity. But this observation was not consistent in many other studies.

OBJECTIVES

The primary objective of the study was to examine whether exposure to epidural analgesia increased the risk of NICU admission. The secondary objectives included the risks of clinical chorioamnionitis, instrumental delivery, neonatal depression, respiratory distress, birth trauma, and neonatal seizure during the first 24 hours of life.

METHODS

This was a retrospective cohort study involving 2360 low-risk nulliparous women who delivered at AWH, Qatar, during the two years between January 2016 December and 2017. Short-term neonatal outcomes of the mothers who received EA in active labor were compared with a similar population who did not receive EA. As secondary objectives, labor parameters like maternal temperature elevation, duration of the second stage of labor, and instrumental delivery were compared.

RESULTS

Significantly higher numbers of neonates were admitted to the NICU from the EA group (P<0.001, OR 1.89, 95% CI 1.45 to 2.46). They were more likely to have respiratory distress (P=0.01, OR 1.49, 95% CI 1.07 to 2.07), birth injuries (P=0.02, OR =1.71, 95% CI 1.06 to 2.74), admission temperature>37.5 °C (P=0.04, OR 3.40, 95% CI 1.00 to 11.49), need for oxygen on the first day (P=0.04, OR 1.44, 95% CI 1.01 to 2.07) and receive antibiotics (P<0.001, OR 2.06,95% CI 1.47 to 2.79). There was no difference in the Apgar score at 1 minute (P=0.12), need of resuscitation at birth (P=0.05), neonatal white cell count (P=0.34), platelet count (P=0.38) and C reactive protein (P=0.84). Mothers who received EA had a lengthier second stage (P<0.001), temperature elevation >37.5°C (P<0.001, OR 7.40, 95% CI 3.93 to 13.69) and instrumental delivery (P<0.001, OR 2.13, 95% CI 1.69 to 2.68).

CONCLUSION

EA increases NICU admission, antibiotic exposure, neonatal birth injuries, need for positive pressure ventilation at birth, and respiratory distress in the first 24 hours of life. Mothers on epidural analgesia have prolonged second stage of labor, a higher rate of instrumental delivery, meconium-stained amniotic fluid, fetal distress, and temperature elevation.

A Systematic Evaluation of Hospital Performance of Childbirth Delivery Modes and Associated Factors in the Friuli Venezia Giulia Region (North-Eastern Italy), 2005-2015

Cesarean sections (CS) have become increasingly common in both developed and developing countries, raising legitimate concerns regarding their appropriateness. Since improvement of obstetric care at the hospital level needs quantitative evidence, using routinely collected health data we contrasted the performance of the 11 maternity centres (coded with an alphabetic letter A to L) of an Italian region, Friuli Venezia Giulia (FVG), during 2005-15, after removing the effect of several factors associated with different delivery modes (DM): spontaneous vaginal delivery (SVD), instrumental vaginal delivery (IVD), overall CS (OCS) and urgent/emergency CS (UCS). A multivariable logistic regression model was fitted for each individual DM, using a dichotomous outcome (1 = each DM; 0 = rest of hospital births) and comparing the stratum specific estimates of every term with their respective reference categories. Results were expressed as odds ratios (OR) with 95% confidence intervals (95%CI). The Benjamini-Hochberg (BH) false discovery rates (FDR) approach was applied to control alpha error due to the large number of statistical tests performed. In the entire FVG region during 2005-2015, SVD were 75,497 (69.1% out of all births), IVD were 7,281 (6.7%), OCS were 26,467 (24.2%) and UCS were 14,106 (12.9% of all births and 53.3% out of all CS). SVD were more likely (in descending order of statistical significance) with: higher number of previous livebirths; clerk/employed occupational status of the mother; gestational age <29 weeks; placentas weighing <500 g; stillbirth; premature rupture of membranes (PROM). IVD were predominantly more likely (in descending order of statistical significance) with: obstructed labour, non-reassuring fetal status, history of CS, labour analgesia, maternal age ≥35 and gestation >40 weeks. The principal factors associated with OCS were (in descending order of statistical significance): CS history, breech presentation, non-reassuring fetal status, obstructed labour, multiple birth, placental weight ≥ 600 g, eclampsia/pre-eclampsia, maternal age ≥ 35 and oligohydramnios. The most important risk factors for UCS were (in descending order of statistical significance): placenta previa/abruptio placenta/ antepartum hemorrage; non-reassuring fetal status, obstructed labour; breech presentation; PROM, eclampsia/pre-eclampsia; gestation 33-36 weeks; gestation 41+ weeks; oligohydramnios; birthweight <2,500 g, maternal age ≥ 35 and cord prolapse. After removing the effects of all other factors, we found great variability of DM rates across hospitals. Adjusting for all risk factors, all hospitals had a OCS risk higher than the referent (hospital G). Out of these 10 hospitals with increased adjusted risk of OCS, 9 (A, B, C, D, E, F, I, J, K) performed less SVD and 5 (A, C, D, I, J) less IVD. In the above 5 centres CS was therefore probably overused. The present study shows that routinely collected administrative data provide useful information for health planning and monitoring. Although the overall CS rate in FVG during 2005-15 was 24.2%, well below the corresponding average Italian national figure (38.1%), the variability of DM rates across FVG maternity centres could be targeted by policy interventions aimed at reducing the recourse to unnecessary CS. In some clinical conditions such as obstructed labor, non-reassuring fetal status, breech presentation, history of CS, higher maternal age and multiple birth, consideration may be given to more conservative DM. The overuse of CS in nulliparas and repeat CS (RCS) should be carefully monitored and subject to audit.

Women's experiences of pharmacological and non-pharmacological pain relief methods for labour and childbirth: a qualitative systematic review

BACKGROUND

Many women use pharmacological or non-pharmacological pain relief during childbirth. Evidence from Cochrane reviews shows that effective pain relief is not always associated with high maternal satisfaction scores. However, understanding women's views is important for good quality maternity care provision. We undertook a qualitative evidence synthesis of women's views and experiences of pharmacological (epidural, opioid analgesia) and non-pharmacological (relaxation, massage techniques) pain relief options, to understand what affects women's decisions and choices and to inform guidelines, policy, and practice.

METHODS

We searched seven electronic databases (MEDLINE, CINAHL, PsycINFO, AMED, EMBASE, Global Index Medicus, AJOL), tracked citations and checked references. We used thematic and meta-ethnographic techniques for analysis purposes, and GRADE-CERQual tool to assess confidence in review findings. We developed review findings for each method. We then re-analysed the review findings thematically to highlight similarities and differences in women's accounts of different pain relief methods.

RESULTS

From 11,782 hits, we screened full 58 papers. Twenty-four studies provided findings for the synthesis: epidural (n = 12), opioids (n = 3), relaxation (n = 8) and massage (n = 4) - all conducted in upper-middle and high-income countries (HMICs). Re-analysis of the review findings produced five key themes. 'Desires for pain relief' illuminates different reasons for using pharmacological or non-pharmacological pain relief. 'Impact on pain' describes varying levels of effectiveness of the methods used. 'Influence and experience of support' highlights women's positive or negative experiences of support from professionals and/or birth companions. 'Influence on focus and capabilities' illustrates that all pain relief methods can facilitate maternal control, but some found non-pharmacological techniques less effective than anticipated, and others reported complications associated with medication use. Finally, 'impact on wellbeing and health' reports that whilst some women were satisfied with their pain relief method, medication was associated with negative self-reprisals, whereas women taught relaxation techniques often continued to use these methods with beneficial outcomes.

CONCLUSION

Women report mixed experiences of different pain relief methods. Pharmacological methods can reduce pain but have negative side-effects. Non-pharmacological methods may not reduce labour pain but can facilitate bonding with professionals and birth supporters. Women need information on risks and benefits of all available pain relief methods.

Maternal position in the second stage of labour for women with epidural anaesthesia

BACKGROUND

Epidural analgesia in labour prolongs the second stage and increases instrumental delivery. It has been suggested that a more upright maternal position during all or part of the second stage may counteract these adverse effects. This is an update of a Cochrane Review published in 2017.

OBJECTIVES

To assess the effects of different birthing positions (upright or recumbent) during the second stage of labour, on maternal and fetal outcomes for women with epidural analgesia.

SEARCH METHODS

We searched Cochrane Pregnancy and Childbirth's Trials Register, ClinicalTrials.gov, the WHO International Clinical Trials Registry Platform (ICTRP) (5 June 2018), and the reference lists of retrieved studies.

SELECTION CRITERIA

All randomised or quasi-randomised trials including pregnant women (primigravidae or multigravidae) in the second stage of induced or spontaneous labour receiving epidural analgesia of any kind. Cluster-randomised controlled trials would have been eligible for inclusion but we found none. Studies published in abstract form only were also eligible.We assumed the experimental intervention to be maternal use of any upright position during the second stage of labour, compared with the control condition of remaining in any recumbent position.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trials for inclusion, assessed risks of bias, and extracted data. We contacted study authors to obtain missing data. We assessed the quality of the evidence using the GRADE approach.We carried out a planned sensitivity analysis of the three studies with low risks of bias for allocation concealment and incomplete outcome data reporting, and further excluded one study with a co-intervention (this was not prespecified).

MAIN RESULTS

We include eight randomised controlled trials, involving 4464 women, comparing upright positions versus recumbent positions in this update. Five were conducted in the UK, one in France and two in Spain.The largest UK trial accounted for three-quarters of all review participants, and we judged it to have low risk of bias. We assessed two other trials as being at low risk of selection and attrition bias. We rated four studies at unclear or high risk of bias for both selection and attrition bias and one study as high risk of bias due to a co-intervention. The trials varied in their comparators, with five studies comparing different positions (upright and recumbent), two comparing ambulation with (recumbent) non-ambulation, and one study comparing postural changes guided by a physiotherapist to a recumbent position.Overall, there may be little or no difference between upright and recumbent positions for our combined primary outcome of operative birth (caesarean or instrumental vaginal): average risk ratio (RR) 0.86, 95% confidence interval (CI) 0.70 to 1.07; 8 trials, 4316 women; I² = 78%; low-quality evidence. It is uncertain whether the upright position has any impact on caesarean section (RR 0.94, 95% CI 0.61 to 1.46; 8 trials, 4316 women; I² = 47%; very low-quality evidence), instrumental vaginal birth (RR 0.90, 95% CI 0.72 to 1.12; 8 trials, 4316 women; I² = 69%) and the duration of the second stage of labour (mean difference (MD) 6.00 minutes, 95% CI -37.46 to 49.46; 3 trials, 456 women; I² = 96%), because we rated the quality of the evidence as very low for these outcomes. Maternal position in the second stage of labour probably makes little or no difference to postpartum haemorrhage (PPH), (PPH requiring blood transfusion): RR 1.20, 95% CI 0.83 to 1.72; 1 trial, 3093 women; moderate-quality evidence. Maternal satisfaction with the overall childbirth experience was slightly lower in the upright group: RR 0.95, 95% CI 0.92 to 0.99; 1 trial, 2373 women. Fewer babies were born with low cord pH in the upright group: RR 0.43, 95% CI 0.20 to 0.90; 2 trials, 3159 infants; moderate-quality evidence.The results were less clear for other maternal or fetal outcomes, including trauma to the birth canal requiring suturing (average RR 1.00, 95% CI 0.89 to 1.13; 3 trials, 3266 women; I² = 46%; low-quality evidence), abnormal fetal heart patterns requiring intervention (RR 1.69, 95% CI 0.32 to 8.84; 1 trial, 107 women; very low-quality evidence), or admission to neonatal intensive care unit (RR 0.54, 95% CI 0.02 to 12.73; 1 trial, 66 infants; very low-quality evidence). However, the CIs around some of these estimates were wide, and we cannot rule out clinically important effects.In our sensitivity analysis of studies at low risk of bias, upright positions increase the chance of women having an operative birth: RR 1.11, 95% CI 1.03 to 1.20; 3 trials, 3609 women; high-quality evidence. In absolute terms, this equates to 63 more operative births per 1000 women (from 17 more to 115 more). This increase appears to be due to the increase in caesarean section in the upright group (RR 1.29; 95% CI 1.05 to 1.57; 3 trials, 3609 women; high-quality evidence), which equates to 25 more caesarean sections per 1000 women (from 4 more to 49 more). In the sensitivity analysis there was no clear impact on instrumental vaginal births: RR 1.08, 95% CI 0.91 to 1.30; 3 trials, 3609 women; low-quality evidence.

AUTHORS' CONCLUSIONS

There may be little or no difference in operative birth between women who adopt recumbent or supine positions during the second stage of labour with an epidural analgesia. However, the studies are heterogeneous, probably related to differing study designs and interventions, differing adherence to the allocated intervention and possible selection and attrition bias. Sensitivity analysis of studies at low risk of bias indicated that recumbent positions may reduce the need for operative birth and caesarean section, without increasing instrumental delivery. Mothers may be more satisfied with their experience of childbirth by adopting a recumbent position. The studies in this review looked at left or right lateral and semi-recumbent positions. Recumbent positions such as flat on the back or lithotomy are not generally used due to the possibility of aorto-caval compression, although we acknowledge that these recumbent positions were not the focus of trials included in this review.

Epidural versus non-epidural or no analgesia for pain management in labour

BACKGROUND

Epidural analgesia is a central nerve block technique achieved by injection of a local anaesthetic close to the nerves that transmit pain, and is widely used as a form of pain relief in labour. However, there are concerns about unintended adverse effects on the mother and infant. This is an update of an existing Cochrane Review (Epidural versus non-epidural or no analgesia in labour), last published in 2011.

OBJECTIVES

To assess the effectiveness and safety of all types of epidural analgesia, including combined-spinal-epidural (CSE) on the mother and the baby, when compared with non-epidural or no pain relief during labour.

SEARCH METHODS

We searched Cochrane Pregnancy and Childbirth's Trials Register (ClinicalTrials.gov), the WHO International Clinical Trials Registry Platform (ICTRP) (30 April 2017), and reference lists of retrieved studies.

SELECTION CRITERIA

Randomised controlled trials comparing all types of epidural with any form of pain relief not involving regional blockade, or no pain relief in labour. We have not included cluster-randomised or quasi-randomised trials in this update.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trials for inclusion and risks of bias, extracted data and checked them for accuracy. We assessed selected outcomes using the GRADE approach.

MAIN RESULTS

Fifty-two trials met the inclusion criteria and we have included data from 40 trials, involving over 11,000 women. Four trials included more than two arms. Thirty-four trials compared epidural with opioids, seven compared epidural with no analgesia, one trial compared epidural with acu-stimulation, one trial compared epidural with inhaled analgesia, and one trial compared epidural with continuous midwifery support and other analgesia. Risks of bias varied throughout the included studies; six out of 40 studies were at high or unclear risk of bias for every bias domain, while most studies were at high or unclear risk of detection bias. Quality of the evidence assessed using GRADE ranged from moderate to low quality.Pain intensity as measured using pain scores was lower in women with epidural analgesia when compared to women who received opioids (standardised mean difference -2.64, 95% confidence interval (CI) -4.56 to -0.73; 1133 women; studies = 5; I2 = 98%; low-quality evidence) and a higher proportion were satisfied with their pain relief, reporting it to be "excellent or very good" (average risk ratio (RR) 1.47, 95% CI 1.03 to 2.08; 1911 women; studies = 7; I2 = 97%; low-quality evidence). There was substantial statistical heterogeneity in both these outcomes. There was a substantial decrease in the need for additional pain relief in women receiving epidural analgesia compared with opioid analgesia (average RR 0.10, 95% CI 0.04 to 0.25; 5099 women; studies = 16; I2 = 73%; Tau2 = 1.89; Chi2 = 52.07 (P < 0.00001)). More women in the epidural group experienced assisted vaginal birth (RR 1.44, 95% CI 1.29 to 1.60; 9948 women; studies = 30; low-quality evidence). A post hoc subgroup analysis of trials conducted after 2005 showed that this effect is negated when trials before 2005 are excluded from this analysis (RR 1.19, 95% CI 0.97 to 1.46). There was no difference between caesarean section rates (RR 1.07, 95% CI 0.96 to 1.18; 10,350 women; studies = 33; moderate-quality evidence), and maternal long-term backache (RR 1.00, 95% CI 0.89 to 1.12; 814 women; studies = 2; moderate-quality evidence). There were also no clear differences between groups for the neonatal outcomes, admission to neonatal intensive care unit (RR 1.03, 95% CI 0.95 to 1.12; 4488 babies; studies = 8; moderate-quality evidence) and Apgar score less than seven at five minutes (RR 0.73, 95% CI 0.52 to 1.02; 8752 babies; studies = 22; low-quality evidence). We downgraded the evidence for study design limitations, inconsistency, imprecision in effect estimates, and possible publication bias.Side effects were reported in both epidural and opioid groups. Women with epidural experienced more hypotension, motor blockade, fever, and urinary retention. They also had longer first and second stages of labour, and were more likely to have oxytocin augmentation than the women in the opioid group. Women receiving epidurals had less risk of respiratory depression requiring oxygen, and were less likely to experience nausea and vomiting than women receiving opioids. Babies born to women in the epidural group were less likely to have received naloxone. There was no clear difference between groups for postnatal depression, headache, itching, shivering, or drowsiness. Maternal morbidity and long-term neonatal outcomes were not reported.Epidural analgesia resulted in less reported pain when compared with placebo or no treatment, and with acu-stimulation. Pain intensity was not reported in the trials that compared epidural with inhaled analgesia, or continuous support. Few trials reported on serious maternal side effects.

AUTHORS' CONCLUSIONS

Low-quality evidence shows that epidural analgesia may be more effective in reducing pain during labour and increasing maternal satisfaction with pain relief than non-epidural methods. Although overall there appears to be an increase in assisted vaginal birth when women have epidural analgesia, a post hoc subgroup analysis showed this effect is not seen in recent studies (after 2005), suggesting that modern approaches to epidural analgesia in labour do not affect this outcome. Epidural analgesia had no impact on the risk of caesarean section or long-term backache, and did not appear to have an immediate effect on neonatal status as determined by Apgar scores or in admissions to neonatal intensive care. Further research may be helpful to evaluate rare but potentially severe adverse effects of epidural analgesia and non-epidural analgesia on women in labour and long-term neonatal outcomes.

Immersion in water during labour and birth

BACKGROUND

Water immersion during labour and birth is increasingly popular and is becoming widely accepted across many countries, and particularly in midwifery-led care settings. However, there are concerns around neonatal water inhalation, increased requirement for admission to neonatal intensive care unit (NICU), maternal and/or neonatal infection, and obstetric anal sphincter injuries (OASIS). This is an update of a review last published in 2011.

OBJECTIVES

To assess the effects of water immersion during labour and/or birth (first, second and third stage of labour) on women and their infants.

SEARCH METHODS

We searched Cochrane Pregnancy and Childbirth's Trials Register, ClinicalTrials.gov and the WHO International Clinical Trials Registry Platform (ICTRP) (18 July 2017), and reference lists of retrieved trials.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) comparing water immersion with no immersion, or other non-pharmacological forms of pain management during labour and/or birth in healthy low-risk women at term gestation with a singleton fetus. Quasi-RCTs and cluster-RCTs were eligible for inclusion but none were identified. Cross-over trials were not eligible for inclusion.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trials for inclusion and risk of bias, extracted data and checked them for accuracy. Two review authors assessed the quality of the evidence using the GRADE approach.

MAIN RESULTS

This review includes 15 trials conducted between 1990 and 2015 (3663 women): eight involved water immersion during the first stage of labour; two during the second stage only; four during the first and second stages of labour, and one comparing early versus late immersion during the first stage of labour. No trials evaluated different baths/pools, or third-stage labour management. All trials were undertaken in a hospital labour ward setting, with a varying degree of medical intervention considered as routine practice. No study was carried out in a midwifery-led care setting. Most trial authors did not specify the parity of women. Trials were subject to varying degrees of bias: the intervention could not be blinded and there was a lack of information about randomisation, and whether analyses were undertaken by intention-to-treat.Immersion in water versus no immersion (first stage of labour)There is probably little or no difference in spontaneous vaginal birth between immersion and no immersion (82% versus 83%; risk ratio (RR) 1.01, 95% confidence interval (CI) 0.97 to 1.04; 6 trials; 2559 women; moderate-quality evidence); instrumental vaginal birth (14% versus 12%; RR 0.86, 95% CI 0.70 to 1.05; 6 trials; 2559 women; low-quality evidence); and caesarean section (4% versus 5%; RR 1.27, 95% CI 0.91 to 1.79; 7 trials; 2652 women; low-quality evidence). There is insufficient evidence to determine the effect of immersion on estimated blood loss (mean difference (MD) -14.33 mL, 95% CI -63.03 to 34.37; 2 trials; 153 women; very low-quality evidence) and third- or fourth-degree tears (3% versus 3%; RR 1.36, 95% CI 0.85 to 2.18; 4 trials; 2341 women; moderate-quality evidence). There was a small reduction in the risk of using regional analgesia for women allocated to water immersion from 43% to 39% (RR 0.91, 95% CI 0.83 to 0.99; 5 trials; 2439 women; moderate-quality evidence). Perinatal deaths were not reported, and there is insufficient evidence to determine the impact on neonatal intensive care unit (NICU) admissions (6% versus 8%; average RR 1.30, 95% CI 0.42 to 3.97; 2 trials; 1511 infants; I² = 36%; low-quality evidence), or on neonatal infection rates (1% versus 1%; RR 2.00, 95% CI 0.50 to 7.94; 5 trials; 1295 infants; very low-quality evidence).Immersion in water versus no immersion (second stage of labour)There were no clear differences between groups for spontaneous vaginal birth (97% versus 99%; RR 1.02, 95% CI 0.96 to 1.08; 120 women; 1 trial; low-quality evidence); instrumental vaginal birth (2% versus 2%; RR 1.00, 95% CI 0.06 to 15.62; 1 trial; 120 women; very low-quality evidence); caesarean section (2% versus 1%; RR 0.33, 95% CI 0.01 to 8.02; 1 trial; 120 women; very low-quality evidence), and NICU admissions (11% versus 9%; RR 0.78, 95% CI 0.38 to 1.59; 2 trials; 291 women; very low-quality evidence). Use of regional analgesia was not relevant to the second stage of labour. Third- or fourth-degree tears, and estimated blood loss were not reported in either trial. No trial reported neonatal infection but did report neonatal temperature less than 36.2°C at birth (9% versus 9%; RR 0.98, 95% CI 0.30 to 3.20; 1 trial; 109 infants; very low-quality evidence), greater than 37.5°C at birth (6% versus 15%; RR 2.62, 95% CI 0.73 to 9.35; 1 trial; 109 infants; very low-quality evidence), and fever reported in first week (5% versus 2%; RR 0.53, 95% CI 0.10 to 2.82; 1 trial; 171 infants; very low-quality evidence), with no clear effect between groups being observed. One perinatal death occurred in the immersion group in one trial (RR 3.00, 95% CI 0.12 to 72.20; 1 trial; 120 infants; very low-quality evidence). The infant was born to a mother with HIV and the cause of death was deemed to be intrauterine infection.There is no evidence of increased adverse effects to the baby or woman from either the first or second stage of labour.Only one trial (200 women) compared early and late entry into the water and there were insufficient data to show any clear differences.

AUTHORS' CONCLUSIONS

In healthy women at low risk of complications there is moderate to low-quality evidence that water immersion during the first stage of labour probably has little effect on mode of birth or perineal trauma, but may reduce the use of regional analgesia. The evidence for immersion during the second stage of labour is limited and does not show clear differences on maternal or neonatal outcomes intensive care. There is no evidence of increased adverse effects to the fetus/neonate or woman from labouring or giving birth in water. Available evidence is limited by clinical variability and heterogeneity across trials, and no trial has been conducted in a midwifery-led setting.

Role of maternal characteristics and epidural analgesia on caesarean section rate in groups 1 and 3 according to Robson's classification: a cohort study in an Italian university hospital setting

OBJECTIVE

To investigate the role of maternal characteristics and epidural analgesia (EA) on caesarean section (CS) rates in selected groups by using the Robson 10-Group Classification System (RTGCS).

DESIGN

Cohort study.

SETTING

Department of Obstetrics and Gynaecology, Fondazione Policlinico Universitario 'A. Gemelli', Rome, Italy.

PATIENTS

A total of 12 098 deliveries in periods I (1998-1999) and II (2010-2011).

MAIN OUTCOME MEASURES

CS rates in groups 1 and 3 of RTGCS.

RESULTS

In group 1, 1144 (20%) patients were assigned to period I and 1302 (20.4%) to period II, while in group 3, 1587 (27.8%) were assigned to period I and 1502 (23.5%) to period II. CS rates were 16.4% and 23.1% in group 1 and 12.7% and 10.9% in group 3 in periods I and II, respectively. In group 1, significant and independent contributions to CS rate were provided by maternal age (p=0.018; OR 0.95 (95% CI 0.85 to 0.97)), body mass index (BMI) (p=0.022; OR 0.89 (95% CI 0.85 to 0.91)) and EA administration (p=0.037; OR 0.59 (95% CI 0.43 to 0.77)). In group 3, maternal age (p<0.001; OR 0.93 (95% CI 0.89 to 0.96)) and BMI (p=0.023; OR 0.98 (95% CI 0.96 to 0.99)) were found to be significantly associated with CS.

CONCLUSIONS

RTGCS is an effective tool for analysing changes in obstetric care, allowing for the recognition of maternal age, BMI and EA administration in the strategic planning for mitigation of CS rates in selected groups.

Relaxation techniques for pain management in labour

BACKGROUND

Many women would like to avoid pharmacological or invasive methods of pain management in labour and this may contribute to the popularity of complementary methods of pain management. This review examined currently available evidence on the use of relaxation therapies for pain management in labour. This is an update of a review first published in 2011.

OBJECTIVES

To examine the effects of mind-body relaxation techniques for pain management in labour on maternal and neonatal well-being during and after labour.

SEARCH METHODS

We searched Cochrane Pregnancy and Childbirth's Trials Register (9 May 2017), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library, Issue 5 2017), MEDLINE (1966 to 24 May 2017), CINAHL (1980 to 24 May 2017), the Australian New Zealand Clinical Trials Registry (18 May 2017), ClinicalTrials.gov (18 May 2017), the ISRCTN Register (18 May 2017), the WHO International Clinical Trials Registry Platform (ICTRP) (18 May 2017), and reference lists of retrieved studies.

SELECTION CRITERIA

Randomised controlled trials (including quasi randomised and cluster trials) comparing relaxation methods with standard care, no treatment, other non-pharmacological forms of pain management in labour or placebo.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trials for inclusion and risk of bias, extracted data and checked them for accuracy. We attempted to contact study authors for additional information. We assessed evidence quality with GRADE methodology.

MAIN RESULTS

This review update includes 19 studies (2519 women), 15 of which (1731 women) contribute data. Interventions examined included relaxation, yoga, music and mindfulness. Approximately half of the studies had a low risk of bias for random sequence generation and attrition bias. The majority of studies had a high risk of bias for performance and detection bias, and unclear risk of bias for, allocation concealment, reporting bias and other bias. We assessed the evidence from these studies as ranging from low to very low quality, and therefore the effects below should be interpreted with caution.RelaxationWe found that relaxation compared to usual care provided lowered the intensity of pain (measured on a scale of 0 to 10 with low scores indicating less pain) during the latent phase of labour (mean difference (MD) -1.25, 95% confidence interval (CI) -1.97 to -0.53, one trial, 40 women). Four trials reported pain intensity in the active phase; there was high heterogeneity between trials and very low-quality evidence suggested that there was no strong evidence that the effects were any different between groups for this outcome (MD -1.08, 95% CI -2.57 to 0.41, four trials, 271 women, random-effects analysis). Very low-quality evidence showed that women receiving relaxation reported greater satisfaction with pain relief during labour (risk ratio (RR) 8.00, 95% CI 1.10 to 58.19, one trial, 40 women), and showed no clear benefit for satisfaction with childbirth experience (assessed using different scales) (standard mean difference (SMD) -0.03, 95% CI -0.37 to 0.31, three trials, 1176 women). For safety outcomes there was very low-quality evidence of no clear reduction in assisted vaginal birth (average RR 0.61, 95% CI 0.20 to 1.84, four trials, 1122 women) or in caesarean section rates (average RR 0.73, 95% CI 0.26 to 2.01, four trials, 1122 women). Sense of control in labour, and breastfeeding were not reported under this comparison.YogaWhen comparing yoga to control interventions there was low-quality evidence that yoga lowered pain intensity (measured on a scale of 0 to 10) with low scores indicating less pain) (MD -6.12, 95% CI -11.77 to -0.47, one trial, 66 women), greater satisfaction with pain relief (MD 7.88, 95% CI 1.51 to 14.25, one trial, 66 women) and greater satisfaction with childbirth experience (MD 6.34, 95% CI 0.26 to 12.42 one trial, 66 women (assessed using the Maternal Comfort Scale with higher score indicating greater comfort). Sense of control in labour, breastfeeding, assisted vaginal birth, and caesarean section were not reported under this comparison.MusicWhen comparing music to control interventions there was evidence of lower pain intensity in the latent phase for women receiving music (measured on a scale of 0 to 10 with low scores indicating less pain) (MD -0.73, 95% CI -1.01 to -0.45, random-effects analysis, two trials, 192 women) and very low-quality evidence of no clear benefit in the active phase (MD -0.51, 95% CI -1.10 to 0.07, three trials, 217 women). Very low-quality evidence suggested no clear benefit in terms of reducing assisted vaginal birth (RR 0.41, 95% CI 0.08 to 2.05, one trial, 156 women) or caesarean section rate (RR 0.78, 95% CI 0.36 to 1.70, two trials, 216 women). Satisfaction with pain relief, sense of control in labour, satisfaction with childbirth experience, and breastfeeding were not reported under this comparison.Audio analgesiaOne trial evaluating audio analgesia versus control only reported one outcome and showed no evidence of benefit in satisfaction with pain relief.MindfulnessOne trial evaluating mindfulness versus usual care found an increase in sense of control for the mindfulness group (using the Childbirth Self-Efficacy Inventory) (MD 31.30, 95% CI 1.61 to 60.99, 26 women). There is no strong evidence that the effects were any different between groups for satisfaction in childbirth, or for caesarean section rate, need for assisted vaginal delivery or need for pharmacological pain relief. No other outcomes were reported in this trial.

AUTHORS' CONCLUSIONS

Relaxation, yoga and music may have a role with reducing pain, and increasing satisfaction with pain relief, although the quality of evidence varies between very low to low. There was insufficient evidence for the role of mindfulness and audio-analgesia. The majority of trials did not report on the safety of the interventions. Further randomised controlled trials of relaxation modalities for pain management in labour are needed. Trials should be adequately powered and include clinically relevant outcomes such as those described in this review.

Massage, reflexology and other manual methods for pain management in labour

BACKGROUND

Many women would like to avoid pharmacological or invasive methods of pain management in labour, and this may contribute towards the popularity of complementary methods of pain management. This review examined the evidence currently available on manual methods, including massage and reflexology, for pain management in labour. This review is an update of the review first published in 2012.

OBJECTIVES

To assess the effect, safety and acceptability of massage, reflexology and other manual methods to manage pain in labour.

SEARCH METHODS

For this update, we searched Cochrane Pregnancy and Childbirth's Trials Register (30 June 2017), the Cochrane Central Register of Controlled Trials (CENTRAL; 2017, Issue 6), MEDLINE (1966 to 30 June 2017, CINAHL (1980 to 30 June 2017), the Australian New Zealand Clinical Trials Registry (4 August 2017), Chinese Clinical Trial Registry (4 August 2017), ClinicalTrials.gov, (4 August 2017), the National Center for Complementary and Integrative Health (4 August 2017), the WHO International Clinical Trials Registry Platform (ICTRP) (4 August 2017) and reference lists of retrieved trials.

SELECTION CRITERIA

We included randomised controlled trials comparing manual methods with standard care, other non-pharmacological forms of pain management in labour, no treatment or placebo. We searched for trials of the following modalities: massage, warm packs, thermal manual methods, reflexology, chiropractic, osteopathy, musculo-skeletal manipulation, deep tissue massage, neuro-muscular therapy, shiatsu, tuina, trigger point therapy, myotherapy and zero balancing. We excluded trials for pain management relating to hypnosis, aromatherapy, acupuncture and acupressure; these are included in other Cochrane reviews.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trial quality, extracted data and checked data for accuracy. We contacted trial authors for additional information. We assessed the quality of the evidence using the GRADE approach.

MAIN RESULTS

We included a total of 14 trials; 10 of these (1055 women) contributed data to meta-analysis. Four trials, involving 274 women, met our inclusion criteria but did not contribute data to the review. Over half the trials had a low risk of bias for random sequence generation and attrition bias. The majority of trials had a high risk of performance bias and detection bias, and an unclear risk of reporting bias. We found no trials examining the effectiveness of reflexology.MassageWe found low-quality evidence that massage provided a greater reduction in pain intensity (measured using self-reported pain scales) than usual care during the first stage of labour (standardised mean difference (SMD) -0.81, 95% confidence interval (CI) -1.06 to -0.56, six trials, 362 women). Two trials reported on pain intensity during the second and third stages of labour, and there was evidence of a reduction in pain scores in favour of massage (SMD -0.98, 95% CI -2.23 to 0.26, 124 women; and SMD -1.03, 95% CI -2.17 to 0.11, 122 women). There was very low-quality evidence showing no clear benefit of massage over usual care for the length of labour (in minutes) (mean difference (MD) 20.64, 95% CI -58.24 to 99.52, six trials, 514 women), and pharmacological pain relief (average risk ratio (RR) 0.81, 95% CI 0.37 to 1.74, four trials, 105 women). There was very low-quality evidence showing no clear benefit of massage for assisted vaginal birth (average RR 0.71, 95% CI 0.44 to 1.13, four trials, 368 women) and caesarean section (RR 0.75, 95% CI 0.51 to 1.09, six trials, 514 women). One trial reported less anxiety during the first stage of labour for women receiving massage (MD -16.27, 95% CI -27.03 to -5.51, 60 women). One trial found an increased sense of control from massage (MD 14.05, 95% CI 3.77 to 24.33, 124 women, low-quality evidence). Two trials examining satisfaction with the childbirth experience reported data on different scales; both found more satisfaction with massage, although the evidence was low quality in one study and very low in the other.Warm packsWe found very low-quality evidence for reduced pain (Visual Analogue Scale/VAS) in the first stage of labour (SMD -0.59, 95% CI -1.18 to -0.00, three trials, 191 women), and the second stage of labour (SMD -1.49, 95% CI -2.85 to -0.13, two trials, 128 women). Very low-quality evidence showed reduced length of labour (minutes) in the warm-pack group (MD -66.15, 95% CI -91.83 to -40.47; two trials; 128 women).Thermal manual methodsOne trial evaluated thermal manual methods versus usual care and found very low-quality evidence of reduced pain intensity during the first phase of labour for women receiving thermal methods (MD -1.44, 95% CI -2.24 to -0.65, one trial, 96 women). There was a reduction in the length of labour (minutes) (MD -78.24, 95% CI -118.75 to -37.73, one trial, 96 women, very low-quality evidence). There was no clear difference for assisted vaginal birth (very low-quality evidence). Results were similar for cold packs versus usual care, and intermittent hot and cold packs versus usual care, for pain intensity, length of labour and assisted vaginal birth.Music One trial that compared manual methods with music found very low-quality evidence of reduced pain intensity during labour in the massage group (RR 0.40, 95% CI 0.18 to 0.89, 101 women). There was no evidence of benefit for reduced use of pharmacological pain relief (RR 0.41, 95% CI 0.16 to 1.08, very low-quality evidence).Of the seven outcomes we assessed using GRADE, only pain intensity was reported in all comparisons. Satisfaction with the childbirth experience, sense of control, and caesarean section were rarely reported in any of the comparisons.

AUTHORS' CONCLUSIONS

Massage, warm pack and thermal manual methods may have a role in reducing pain, reducing length of labour and improving women's sense of control and emotional experience of labour, although the quality of evidence varies from low to very low and few trials reported on the key GRADE outcomes. Few trials reported on safety as an outcome. There is a need for further research to address these outcomes and to examine the effectiveness and efficacy of these manual methods for pain management.

Vacuum extraction vaginal delivery: current trend and safety

Operative vaginal birth retains an important role in current obstetric practice. However, there is an increasing trend in the rate of cesarean section in Korea. Surgical delivery is more advantageous than cesarean section, but the rate of operative vaginal delivery is decreasing for various reasons. Furthermore, there is no unified technique for vacuum extraction delivery. In this context, this review was performed to provide details of the necessary conditions, techniques, benefits, and risks of operative vaginal delivery. Future research should focus on overcoming the limitations of operative vaginal delivery.

[Epidural analgesia in 20 parturients at the Sylvanus Olympio University Hospital Center in Lomé (Togo)]

Etude prospective et descriptive sur la pratique de l’analgésie péridurale (APD) obstétricale au CHU Sylvanus Olympio (CHU SO) de Lomé. Etude menée de février à juin 2014. Après accord des gestantes choisies au hasard et en l’absence de contre-indication à l’issue de la consultation d’anesthésie, faite au 8ème mois de la grossesse, des femmes ont été retenues pour l’étude. Sur 29 gestantes retenues, 20 (69%) ont bénéficiées de l’APD. Age moyen 30,6±6,6 ans, primigestes : 35%, multipares 50%, Obèses (BMI>30): 25%. Nombre moyen de ponctions: 1,2±0,5; reflux de sang dans le cathéter: 5%, brèche dure-mérienne : 0. Délai moyen d’installation: 8,5 ±2,2mn. Quantité moyenne de bupivacaine isobare à 0,125%: 28,8±8ml; Echelle Numérique à T10min < 3 pour toutes les parturientes. Bloc moteur: 0. Hypotension: 1cas (5%). Mode d’accouchement: voie basse: 19 (95%), césarienne: 1 (5%). Détresse respiratoire à la naissance du nouveau né: 0. Note de satisfaction: 9,8±0,5 /10. L’APD obstétricale est possible au CHU Sylvanus Olympio de Lomé. En attendant sa vulgarisation à toutes les parturientes par la disponibilité des moyens humains et matériels, la réaliser pour ses indications médicales serait un premier pas.

A comparison of intrapartum interventions and adverse outcomes by parity in planned freestanding midwifery unit and alongside midwifery unit births: secondary analysis of 'low risk' births in the birthplace in England cohort

BACKGROUND

For low risk women, there is good evidence that planned birth in a midwifery unit is associated with a reduced risk of maternal interventions compared with planned birth in an obstetric unit. Findings from the Birthplace cohort study have been interpreted by some as suggesting a reduced risk of interventions in planned births in freestanding midwifery units (FMUs) compared with planned births in alongside midwifery units (AMUs). However, possible differences have not been robustly investigated using individual-level Birthplace data.

METHODS

This was a secondary analysis of data on 'low risk' women with singleton, term, 'booked' pregnancies collected in the Birthplace national prospective cohort study. We used logistic regression to compare interventions and outcomes by parity in 11,265 planned FMU births and 16,673 planned AMU births, adjusted for potential confounders, using planned AMU birth as the reference group. Outcomes considered included adverse perinatal outcomes (Birthplace primary outcome measure), instrumental delivery, intrapartum caesarean section, 'straightforward vaginal birth', third or fourth degree perineal trauma, blood transfusion and maternal admission for higher-level care. We used a significance level of 1% for all secondary outcomes.

RESULTS

There was no significant difference in adverse perinatal outcomes between planned AMU and FMU births. The odds of instrumental delivery were reduced in planned FMU births (nulliparous: aOR 0.63, 99% CI 0.46-0.86; multiparous: aOR 0.41, 99% CI 0.25-0.68) and the odds of having a 'straightforward vaginal birth' were increased in planned FMU births compared with planned AMU births (nulliparous: aOR 1.47, 99% CI 1.17-1.85; multiparous: 1.86, 99% CI 1.35-2.57). The odds of intrapartum caesarean section did not differ significantly between the two settings (nulliparous: p = 0.147; multiparous: p = 0.224). The overall pattern of findings suggested a trend towards lower intervention rates and fewer adverse maternal outcomes in planned FMU births compared with planned AMU births.

CONCLUSIONS

The findings support the recommendation that 'low risk' women can be informed that planned birth in an FMU is associated with a lower rate of instrumental delivery and a higher rate of 'straightforward vaginal birth' compared with planned birth in an AMU; and that outcomes for babies do not appear to differ between FMUs and AMUs.

Position in the second stage of labour for women with epidural anaesthesia

BACKGROUND

Epidural analgesia for pain relief in labour prolongs the second stage of labour and results in more instrumental deliveries. It has been suggested that a more upright position of the mother during all or part of the second stage may counteract these adverse effects. This is an update of a Cochrane review first published in 2013.

OBJECTIVES

To assess the effects of different birthing positions (upright and recumbent) during the second stage of labour, on important maternal and fetal outcomes for women with epidural analgesia.

SEARCH METHODS

We searched Cochrane Pregnancy and Childbirth's Trials Register (19 September 2016) and reference lists of retrieved studies.

SELECTION CRITERIA

All randomised or quasi-randomised trials including pregnant women (either primigravidae or multigravidae) in the second stage of induced or spontaneous labour receiving epidural analgesia of any kind. Cluster-RCTs would have been eligible for inclusion in this review but none were identified. Studies published in abstract form only were eligible for inclusion.We assumed the experimental type of intervention to be the maternal use of any upright position during the second stage of labour, compared with the control intervention of the use of any recumbent position.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trials for inclusion, assessed risk of bias, and extracted data. Data were checked for accuracy. We contacted study authors to try to obtain missing data.

MAIN RESULTS

Five randomised controlled trials, involving 879 women, comparing upright positions versus recumbent positions were included in this updated review. Four trials were conducted in the UK and one in France. Three of the five trials were funded by the hospital departments in which the trials were carried out. For the other three trials, funding sources were either unclear (one trial) or not reported (two trials). Each trial varied in levels of bias. We assessed all the trials as being at low or unclear risk of selection bias. None of the trials blinded women, staff or outcome assessors. One trial was poor quality, being at high risk of attrition and reporting bias. We assessed the evidence using the GRADE approach; the evidence for most outcomes was assessed as being very low quality, and evidence for one outcome was judged as moderate quality.Overall, we identified no clear difference between upright and recumbent positions on our primary outcomes of operative birth (caesarean or instrumental vaginal) (average risk ratio (RR) 0.97; 95% confidence interval (CI) 0.76 to 1.29; five trials, 874 women; I² = 54% moderate-quality evidence), or duration of the second stage of labour measured as the randomisation-to-birth interval (average mean difference -22.98 minutes; 95% CI -99.09 to 53.13; two trials, 322 women; I² = 92%; very low-quality evidence). Nor did we identify any clear differences in any other important maternal or fetal outcome, including trauma to the birth canal requiring suturing (average RR 0.95; 95% CI 0.66 to 1.37; two trials; 173 women; studies = two; I² = 74%; very low-quality evidence), abnormal fetal heart patterns requiring intervention (RR 1.69; 95% CI 0.32 to 8.84; one trial; 107 women; very low-quality evidence), low cord pH (RR 0.61; 95% CI 0.18 to 2.10; one trial; 66 infants; very low-quality evidence) or admission to neonatal intensive care unit (RR 0.54; 95% CI 0.02 to 12.73; one trial; 66 infants; very low-quality evidence). However, the CIs around each estimate were wide, and clinically important effects have not been ruled out. Outcomes were downgraded for study design, high heterogeneity and imprecision in effect estimates.There were no data reported on blood loss (greater than 500 mL), prolonged second stage or maternal experience and satisfaction with labour. Similarly, there were no analysable data on Apgar scores, and no data reported on the need for ventilation or for perinatal death.

AUTHORS' CONCLUSIONS

There are insufficient data to say anything conclusive about the effect of position for the second stage of labour for women with epidural analgesia. The GRADE quality assessment of the evidence in this review ranged between moderate to low quality, with downgrading decisions based on design limitations in the studies, inconsistency, and imprecision of effect estimates.Women with an epidural should be encouraged to use whatever position they find comfortable in the second stage of labour.More studies with larger sample sizes will need to be conducted in order for solid conclusions to be made about the effect of position on labour in women with an epidural. Two studies are ongoing and we will incorporate the results into this review at a future update.Future studies should have the protocol registered, so that sample size, primary outcome, analysis plan, etc. are all clearly prespecified. The time or randomisation should be recorded, since this is the only unbiased starting time point from which the effect of position on duration of labour can be estimated. Future studies might wish to include an arm in which women were allowed to choose the position in which they felt most comfortable. Future studies should ensure that both compared positions are acceptable to women, that women can remain in them for most of the late part of labour, and report the number of women who spend time in the allocated position and the amount of time they spend in this or other positions.

Labor Epidural Analgesia and Breastfeeding: A Systematic Review

Despite widespread use of epidural analgesia during labor, no consensus has been reached among obstetric and anesthesia providers regarding its effects on breastfeeding. The purpose of this review was to examine the relationship between labor epidural analgesia and breastfeeding in the immediate postpartum period. PubMed, Cochrane Library, and Cumulative Index to Nursing and Allied Health Literature were searched for articles published in 1990 or thereafter, using the search term breastfeeding combined with epidural, labor epidural analgesia, labor analgesia, or epidural analgesia Of 117 articles, 23 described empirical studies specific to labor epidural analgesia and measured a breastfeeding outcome. Results were conflicting: 12 studies showed negative associations between epidural analgesia and breastfeeding success, 10 studies showed no effect, and 1 study showed a positive association. Most studies were observational. Of 3 randomized controlled studies, randomization methods were inadequate in 2 and not evaluable in 1. Other limitations were related to small sample size or inadequate study power; variation and lack of information regarding type and dosage of analgesia or use of other intrapartum interventions; differences in timing, definition, and method of assessing breastfeeding success; or failure to consider factors such as mothers' intention to breastfeed, social support, siblings, or the mother's need to return to work or school. It is also unclear to what extent results are mediated through effects on infant neurobehavior, maternal fever, oxytocin release, duration of labor, and need for instrumental delivery. Clinician awareness of factors affecting breastfeeding can help identify women at risk for breastfeeding difficulties in order to target support and resources effectively.

Delivery-related risk factors for covert postpartum urinary retention after vaginal delivery

Introduction and hypothesis

Postpartum urinary retention (PUR) is a common consequence of bladder dysfunction after vaginal delivery. Patients with covert PUR are able to void spontaneously but have a postvoid residual bladder volume (PVRV) of ≥150 mL. Incomplete bladder emptying may predispose to bladder dysfunction at a later stage of life. The aim of this cross-sectional study was to identify independent delivery-related risk factors for covert PUR after vaginal delivery in order to identify women with an increased risk of covert PUR.

Methods

The PVRV of women who delivered vaginally was measured after the first spontaneous micturition with a portable bladder-scanning device. A PVRV of 150 mL or more was defined as covert PUR. Independent risk factors for covert PUR were identified in multivariate regression analysis.

Results

Of 745 included women, 347 (47 %) were diagnosed with covert PUR (PVRV ≥150 mL), of whom 197 (26 %) had a PVRV ≥250 mL (75th percentile) and 50 (7 %) a PVRV ≥500 mL (95th percentile). In multivariate regression analysis, episiotomy (OR 1.7, 95 % CI 1.02 – 2.71), epidural analgesia (OR 2.08, 95 % CI 1.36 – 3.19) and birth weight (OR 1.03, 95 % CI 1.01 – 1.06) were independent risk factors for covert PUR. Opioid analgesia during labour (OR 3.19, 95 % CI 1.46 – 6.98), epidural analgesia (OR 3.54, 95 % CI 1.64 – 7.64) and episiotomy (OR 3.72, 95 % CI 1.71 – 8.08) were risk factors for PVRV ≥500 mL.

Conclusions

Episiotomy, epidural analgesia and birth weight are risk factors for covert PUR. We suggest that the current cut-off values for covert PUR should be reevaluated when data on the clinical consequences of abnormal PVRV become available.

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.

Tweetable abstract

Going to 2 prenatal self-hypnosis groups didn't reduce labour epidural use but did reduce birth fear & anxiety postnatally at < £5 per woman.

Documenting risk: A comparison of policy and information pamphlets for using epidural or water in labour

BACKGROUND

Approximately 30% of Australian women use epidural analgesia for pain relief in labour, and its use is increasing. While epidural analgesia is considered a safe option from an anaesthetic point of view, its use transfers a labouring woman out of the category of 'normal' labour and increases her risk of intervention. Judicious use of epidural may be beneficial in particular situations, but its current common use needs to be assessed more closely. This has not yet been explored in the Australian context.

AIM

To examine personal, social, institutional and cultural influences on women in their decision to use epidural analgesia in labour. Examining this one event in depth illuminates other birth practices, which can also be analysed according to how they fit within prevailing cultural beliefs about birth.

METHODS

Ethnography, underpinned by a critical medical anthropology methodology.

RESULTS

These findings describe the influence of risk culture on labour ward practice; specifically, the policies and practices surrounding the use of epidural analgesia are contrasted with those on the use of water. Engaging with current risk theory, we identify the role of power in conceptualisations of risk, which are commonly perpetuated by authority rather than evidence.

CONCLUSIONS

As we move towards a risk-driven society, it is vital to identify both the conception and the consequences of promulgations of risk. The construction of waterbirth as a 'risky' practice had the effect of limiting midwifery practice and women's choices, despite evidence that points to the epidural as the more 'dangerous' option.

The effect of epidural analgesia on labour, mode of delivery and neonatal outcome in nullipara of India, 2011-2014

AIMS

This study aimed to evaluate the effect of ropivacaine epidural analgesia on duration and outcome of labour in nulliparous parturients of India with parturient not receiving any analgesia.

SETTINGS AND DESIGN

One hundred and twenty nulliparous parturient in established labour at full term with a singleton vertex presentation were assigned to the study. Parturients who request epidural analgesia were allocated in the epidural group (n=60), whereas those not enthusiastic to labour analgesia were allocated in the control group (n=60).

MATERIALS AND METHODS

Epidural analgesia was provided by a bolus injection of 10 ml of ropivacaine 0.2% and 50μg fentanyl and maintained by using a continuous infusion of ropivacaine 0.1% with fentanyl 2μl/ml at a 10ml/hour rate. The outcomes were duration of labour, incidence of cesarean sections and instrumental vaginal delivery and neonatal outcome.

STATISTICAL ANALYSIS USED

Statistical analysis was conducted using unpaired student t-test and chi-square test as required. All tests of significance were performed using two-tailed probability tests. Differences were considered significant when p-value was <0.05.

RESULTS

The two groups were comparable in terms of socio-demographic data. The mean duration of first stage of labour was shorter in epidural group (4.83 ± 1.59 h) compared with control group (5.48 ± 1.56 h) while the duration of second stage of labour was prolong in epidural group (33.13 ± 12.78 min) as compared to control (27.53 ± 11.73 min). Instrumental vaginal or caesarean delivery rate did not increase in the epidural group. The APGAR scores at 5 min were statistically similar in both groups.

CONCLUSION

Epidural analgesia by ropivacaine in Indian nulliparous resulted in shorter duration of first stage and prolongs duration of second stage of labour compared with parturients without analgesia; however, instrumental vaginal or caesarean delivery rate does not increase in the epidural group.

Intervenções obstétricas durante o trabalho de parto e parto em mulheres brasileiras de risco habitual

Este artigo avaliou o uso das boas práticas (alimentação, deambulação, uso de métodos não farmacológicos para alívio da dor e de partograma) e de intervenções obstétricas na assistência ao trabalho de parto e parto de mulheres de risco obstétrico habitual. Foram utilizados dados da pesquisa Nascer no Brasil, estudo de base hospitalar realizada em 2011/2012, com entrevistas de 23.894 mulheres. As boas práticas durante o trabalho de parto ocorreram em menos de 50% das mulheres, sendo menos frequentes nas regiões Norte, Nordeste e Centro-oeste. O uso de ocitocina e amniotomia foi de 40%, sendo maior no setor público e nas mulheres com menor escolaridade. A manobra de Kristeller, episiotomia e litotomia foram utilizada, em 37%, 56% e 92% das mulheres, respectivamente. A cesariana foi menos frequente nas usuárias do setor público, não brancas, com menor escolaridade e multíparas. Para melhorar a saúde de mães e crianças e promover a qualidade de vida, o Sistema Único de Saúde (SUS) e, sobretudo o setor privado, necessitam mudar o modelo de atenção obstétrica promovendo um cuidado baseado em evidências científicas.

Labor epidural anesthesia, obstetric factors and breastfeeding cessation

Breastfeeding benefits both infant and maternal health. Use of epidural anesthesia during labor is increasingly common and may interfere with breastfeeding. Studies analyzing epidural anesthesia's association with breastfeeding outcomes show mixed results; many have methodological flaws. We analyzed potential associations between epidural anesthesia and overall breast-feeding cessation within 30 days postpartum while adjusting for standard and novel covariates and uniquely accounting for labor induction. A pooled analysis using Kaplan-Meier curves and modified Cox Proportional Hazard models included 772 breastfeeding mothers from upstate New York who had vaginal term births of healthy singleton infants. Subjects were drawn from two cohort studies (recruited postpartum between 2005 and 2008) and included maternal self-report and maternal and infant medical record data. Analyses of potential associations between epidural anesthesia and overall breastfeeding cessation within 1 month included additional covariates and uniquely accounted for labor induction. After adjusting for standard demographics and intrapartum factors, epidural anesthesia significantly predicted breastfeeding cessation (hazard ratio 1.26 [95% confidence interval 1.10, 1.44], p < 0.01) as did hospital type, maternal age, income, education, planned breastfeeding goal, and breastfeeding confidence. In post hoc analyses stratified by Baby Friendly Hospital (BFH) status, epidural anesthesia significantly predicted breastfeeding cessation (BFH: 1.19 [1.01, 1.41], p < 0.04; non-BFH: 1.65 [1.31, 2.08], p < 0.01). A relationship between epidural anesthesia and breastfeeding was found but is complex and involves institutional, clinical, maternal and infant factors. These findings have implications for clinical care and hospital policies and point to the need for prospective studies.

Butorphanol in labour analgesia: A prospective cohort study

OBJECTIVE

Parenteral opioids can be administered with ease at a very low cost with high efficacy as labour analgesia. However, there are insufficient data available to accept the benefits of parenteral opioids over other proven methods of labour analgesia. Butorphanol, a new synthetic opioid, has emerged as a promising agent in terms of efficacy and a better safety profile. This study investigates the effect of butorphanol as a labour analgesia to gather further evidence of its safety and efficacy to pave the way for its widespread use in low resource settings.

MATERIAL AND METHODS

One hundred low risk term consenting pregnant women were recruited to take part in a prospective cohort study. Intramuscular injections of butorphanol tartrate 1 mg (Butrum 1/2mg, Aristo, Mumbai, India) were given in the active phase of labour and repeated two hourly. Pain relief was noted on a 10-point visual pain analogue scale (VPAS). Obstetric and neonatal outcome measures were mode of delivery, duration of labour, Apgar scores at 1 and 5 minutes and Neonatal Intensive Care Unit admissions. Collected data were analysed for statistically significant pain relief between pre- and post-administration VPAS scores and also for the incidence of adverse outcomes.

RESULTS

Pain started to decrease significantly within 15 minutes of administration and reached the nadir (3.08 SD0.51) at the end of two hours. The pain remained below four on the VPAS until the end of six hours and was still significantly low after eight hours. The incidence of adverse outcomes was low in the present study.

CONCLUSION

Butorphanol is an effective parenteral opioid analgesic which can be administered with reasonable safety for the mother and the neonate. The study has the drawback of lack of control and small sample size.

Neuraxial analgesia: a review of its effects on the outcome and duration of labor

Labor pain is one of the most challenging experiences encountered by females during their lives. Neuraxial analgesia is the mainstay analgesic for intrapartum pain relief. However, despite the increasing use and undeniable advantages of neuraxial analgesia for labor, there have been concerns regarding undesirable effects on the progression of labor and outcomes. Recent evidence indicates that neuraxial analgesia does not increase the rate of Cesarean sections, although it may be associated with a prolonged second stage of labor and an increased rate of instrumental vaginal delivery. Even when neuraxial analgesia is administered early in the course of labor, it is not associated with an increased rate of Cesarean section or instrumental vaginal delivery, nor does it prolong the labor duration. These data may help physicians correct misconceptions regarding the adverse effects of neuraxial analgesia on labor outcome, as well as encourage the administration of neuraxial analgesia in response to requests for pain relief.

The long-term effects of birthing interventions on childhood empathy

OBJECTIVES

birthing practices have changed drastically over the past century. It is now more common for women to birth in a hospital, receive drug interventions, and to birth via caesarean section, yet there is a paucity of research on long-term outcomes associated with practices. The research was designed to determine if there were any long-term effects of the birthing experience on child empathic behaviour.

METHODS

two-hundred-and-sixty-four mother-child dyad (M(child_age)=5.92 years; SD=.85 years; 127 boys) completed either a questionnaire on birthing practices (mothers) or a modified Stickers Task to assess empathic behaviour (child).

RESULTS

there was a non-significant effect (Δ=.22, p=.395) of home versus hospital birth and a small-moderate, significant (Δ=.33, p=.017) effect of the use of epidurals during, with children of mothers who did not use an epidural or who birthed at home showing greater empathic behaviour.

CONCLUSIONS

the birthing location and the decision to have an epidural can have long-term consequences on children's empathy. While researchers need to further examine the mechanisms behind these findings, parents should be made aware of the potential long-term effects in order to allow them to make fully informed decisions.

Incidence of and risk factors for perineal trauma: a prospective observational study

BACKGROUND

Our aim was to describe the range of perineal trauma in women with a singleton vaginal birth and estimate the effect of maternal and obstetric characteristics on the incidence of perineal tears.

METHODS

We conducted a prospective observational study on all women with a planned singleton vaginal delivery between May and September 2006 in one obstetric unit, three freestanding midwifery-led units and home settings in South East England. Data on maternal and obstetric characteristics were collected prospectively and analysed using univariable and multivariable logistic regression. The outcome measures were incidence of perineal trauma, type of perineal trauma and whether it was sutured or not.

RESULTS

The proportion of women with an intact perineum at delivery was 9.6% (125/1,302) in nulliparae, and 31.2% (453/1,452) in multiparae, with a higher incidence in the community (freestanding midwifery-led units and home settings). Multivariable analysis showed multiparity (OR 0.52; 95% CI: 0.30-0.90) was associated with reduced odds of obstetric anal sphincter injuries (OASIS), whilst forceps (OR 4.43; 95% CI: 2.02-9.71), longer duration of second stage of labour (OR 1.49; 95% CI: 1.13-1.98), and heavier birthweight (OR 1.001; 95% CI: 1.001-1.001), were associated with increased odds. Adjusted ORs for spontaneous perineal truama were: multiparity (OR 0.42; 95% CI: 0.32-0.56); hospital delivery (OR 1.48; 95% CI: 1.01-2.17); forceps delivery (OR 2.61; 95% CI: 1.22-5.56); longer duration of second stage labour (OR 1.45; 95% CI: 1.28-1.63); and heavier birthweight (OR 1.001; 95% CI: 1.000-1.001).

CONCLUSIONS

This large prospective study found no evidence for an association between many factors related to midwifery practice such as use of a birthing pool, digital perineal stretching in the second stage, hands off delivery technique, or maternal birth position with incidence of OASIS or spontaneous perineal trauma. We also found a low overall incidence of OASIS, and fewer second degree tears were sutured in the community than in the hospital settings. This study confirms previous findings of overall high incidence of perineal trauma following vaginal delivery, and a strong association between forceps delivery and perineal trauma.

Position in the second stage of labour for women with epidural anaesthesia

BACKGROUND

Epidural analgesia for pain relief in labour prolongs the second stage of labour and results in more instrumental deliveries. It has been suggested that a more upright position of the mother during all or part of the second stage may counteract these adverse effects.

OBJECTIVES

To assess the effects of different birthing positions (upright versus recumbent) during the second stage of labour, on important maternal and fetal outcomes for women with epidural analgesia.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (30 June 2012) and reference lists of retrieved studies

SELECTION CRITERIA

All randomised or quasi-randomised trials including pregnant women (either primigravidae or multigravidae) in the second stage of induced or spontaneous labour receiving epidural analgesia of any kind.We assumed the experimental type of intervention to be the maternal use of any upright position during the second stage of labour, compared with the control intervention of the use of any recumbent position.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trials for inclusion, assessed risk of bias, and extracted data. Data were checked for accuracy. We contacted authors to try to obtain missing data.

MAIN RESULTS

Five randomised controlled trials, involving 879 women, were included in the review.Overall, we identified no statistically significant difference between upright and recumbent positions on our primary outcomes of operative birth (caesarean or instrumental vaginal) (average risk ratio (RR) 0.97; 95% confidence interval (CI) 0.76 to 1.29; five trials, 874 women), or duration of the second stage of labour measured as the randomisation to birth interval (average mean difference -22.98 minutes; 95% CI -99.09 to 53.13; two trials, 322 women). Nor did we identify any clear differences in the incidence of instrumental birth or caesarean section separately, nor in any other important maternal or fetal outcome, including trauma to the birth canal requiring suturing, operative birth for fetal distress, low cord pH or admission to neonatal intensive care unit. However, the CIs around each estimate were wide, and clinically important effects have not been ruled out.There were no data reported on excess blood loss, prolonged second stage or maternal experience and satisfaction with labour. Similarly, there were no analysable data on Apgar scores, and no data reported on the need for ventilation or for perinatal death.

AUTHORS' CONCLUSIONS

There are insufficient data to say anything conclusive about the effect of position for the second stage of labour for women with epidural analgesia. Women with an epidural should be encouraged to use whatever position they find comfortable in the second stage of labour. Future research should involve large trials of positions that women can maintain and predefined endpoints. One large trial is ongoing.

[Does low-risk delivery exist?]

OBJECTIVES

The main objective of our study is to evaluate the rate of call of the obstetrician during childbirth supposed in low-risk and compare it to high-risk deliveries in a maternity service level II. The secondary objective is to assess the level of intervention of the obstetrician with the patient in both groups.

PATIENTS AND METHODS

This is a prospective study of 490 patients including 259 classified as low risk based on obstetric criteria of Bourgogne Perinatal Network. The criteria considered for the call and/or intervention of the obstetrician were the following: altered fetal heart rate, lactate scalp, instrumental delivery, cesarean section, complete or complicated perineal, serious event during labor (cord prolapse, uterine rupture…), postpartum hemorrhage treated by prostaglandin ocytocic. The high-risk group is taken as reference for the calculation of confidence intervals.

RESULTS

The rate of call of the obstetrician in the low versus high risk are: 37% [95% CI: 0.98-2.11] and 29% [95% CI: 1.00] (P=0.0587). The rate of intervention of the obstetrician in the low versus high risk is 21% [95% CI: 1.15-3.07] and 12% [95% CI: 1.00] (P=0.0109).

CONCLUSION

The delivery process is unpredictable and potentially risky. Thirty-seven percent of patients classified as low risk at the beginning of labour have required intervention of the obstetrician and 21% of them his intervention.

Giving birth with epidural analgesia: the experience of first-time mothers

The purpose of our qualitative descriptive study was to describe the birth experiences of women using epidural analgesia for pain management. We interviewed nine primiparas who experienced vaginal births. Five themes emerged: (a) coping with pain, (b) finding epidural administration uneventful, (c) feeling relief having an epidural, (d) experiencing joy, and (e) having unsettled feelings of ambivalence. Although epidural analgesia was found to be effective for pain relief and may contribute to some women's satisfaction with the birth experience, it does not guarantee a quality birth experience. In order to support and promote childbearing women's decision making, we recommend improved education on the variety of available pain management options, including their risks and benefits. Fostering a sense of caring, connection, and control in women is a key factor to ensure positive birth experiences, regardless of pain management method.