Comparison of different delivery modalities of epidural analgesia and intravenous analgesia in labour: a systematic review and network meta-analysis

Epidural or water immersion? A prospective cohort study of maternal and neonatal outcomes in a tertiary hospital

BACKGROUND

Providing evidence-based information on maternal and neonatal outcomes of epidural analgesia (EA) and water immersion (WI) is crucial for informed decision-making.

OBJECTIVE

To compare process outcomes, obstetric interventions, and maternal and neonatal outcomes in medium low-risk women based on their choice of analgesia: EA or WI.

METHODS

This prospective observational cohort study analysed 643 women from June 2020 to February 2023. Sociodemographic data, birth process characteristics, and outcomes were collected to compare 284 women who used EA and 319 who used WI (with 82.4% waterbirths). Additionally, 40 cases of women who switched from WI to EA were descriptively analysed. Propensity Score (PS) was applied to reduce selection bias in the comparative analysis.

FINDINGS

WI was associated with a higher probability of spontaneous vaginal birth (18.7%, E:0.187; SE:0.025; p < 0.001 95% CI 0.138,0.235), shorter first stage (-259.532 min; SE:13.592; p < 0.00195%, 95% CI -286.171, -232.892), shorter second stage of labour (-17.829 min; SE:4.665; p < 0.001 95% CI -26.973,-8.686) In terms of neonatal outcomes WI (with 82.4% of waterbirths) was associated with less neonatal ventilatory support (1.6%vs 9.5% p<0.001,RR 0.028 95% CI 0.11-0.56), less birth distress (0.9%vs 7.7% p<0.001,RR 0.22 95% CI 0.06-0.52), lower probability of neonatal admission rates (E:-0.102; SE 0.033, p=0.002, 95% CI -0.166, -0.088), and higher probability of exclusive breastfeeding at discharge especially for multiparous women (E:0.114; SE 0.045 p=0.01 95% CI 0.027, 0.202).

CONCLUSION AND IMPLICATION FOR PRACTICE

Water immersion for low-risk women emerges as a valid, evidence-based approach to supporting physiological childbirth and reducing unnecessary interventions. This study highlights the need to reinforce its availability in maternity care and to ensure women's informed decision-making.

A randomized sequential allocation study on the optimum programmed intermittent epidural boluses interval time with different concentrations of ropivacaine combined with the dural puncture epidural technique for labor analgesia

Background

The combined technique of programmed intermittent epidural boluses (PIEB) and dural puncture epidural (DPE) is currently considered a more effective mode for labor analgesia. We investigated the optimal interval time for PIEB administration with different concentrations of ropivacaine combined with the DPE for labor analgesia.

Methods

Ninety patients with cervical dilation of <5 cm and a VAS score >5 were randomly assigned to receive labor analgesia with ropivacaine at concentrations of 0.075% (0.075% group), 0.1% (0.1% group), and 0.125% (0.125% group). In each group, an initial administration of a combination of ropivacaine 12 mL and sufentanil 0.3 μg/mL was followed by an additional dose of ropivacaine 10 mL and sufentanil 0.3 μg/mL after 30 min. The initial PIEB interval time was set at 40 min for the first patient in each group, and subsequent interval times for the following patients were adjusted based on meeting analgesic needs (VAS score ≤1) with a gradient of 10 min. The primary outcome was the ED90 of interval time required to achieve analgesic needs during PIEB with different concentrations of ropivacaine, employing an up-and-down sequential allocation method.

Results

The optimal PIEB interval times for ropivacaine concentrations of 0.075%, 0.1%, and 0.125% were determined to be 40.9 (95% CI, 35.3-45.8), 45.3 (95% CI, 39.3-51.5), and 52.9 (95% CI, 46.8-59.3) minutes respectively, while comparable maternal and neonatal outcomes were observed across all groups.

Conclusion

When PIEB is combined with DPE for labor analgesia, the optimal PIEB interval times for ropivacaine concentrations of 0.075%, 0.1%, and 0.125% were determined to be 41, 45, and 53 min respectively.

Effective Dose of Epidural Hydromorphone for Analgesia Following Caesarean Section in Using Modified Dixon Sequential Method

BACKGROUND

A single dose of epidural hydromorphone has been suggested as an alternative method for providing analgesia after caesarean section (CS). Nevertheless, the optimal dosage of epidural hydromorphone for postoperative pain relief following CS has yet to be determined.

METHODS

This trial included 30 singleton primiparous women undergoing scheduled caesarean delivery, who were recruited to determine doses of epidural hydromorphone using the modified Dixon sequential method. The initial hydromorphone dose was 0.75 mg, with adjustments based on the efficacy of the preceding participant's dose over 12 hours. Various parameters such as blood pressure, heart rate, respiratory rate, visual analog scale (VAS) pain score, postoperative adverse reactions, and patient satisfaction with analgesic effect were recorded at each time point. The VAS scores were categorized as positive (score >3) or negative (score ≤3). Participants received a single epidural injection of 0.2% ropivacaine 20 mg along with a study dose of hydromorphone. The median effective dose (ED50), 90% effective dose (ED90), and corresponding 95% confidence intervals (CIs) of hydromorphone with ropivacaine for analgesia after caesarean section were calculated using the probit method.

RESULTS

The ED90 and ED50 in our population were 1.105 mg (95% CI: 0.825-2.324 mg) and 0.659 mg (95% CI: 0.434-0.883 mg), respectively.

CONCLUSION

Epidural hydromorphone can be safely used for postoperative analgesia in patients undergoing caesarean section, and the analgesic effect is satisfactory when the dosage is appropriate.

The influence of epidural analgesic techniques on obstetrical outcomes

PURPOSE

The aim of this study is to compare and evaluate the obstetrical differences between three techniques, including the programmed intermittent epidural bolus (PIEB), the patient-controlled epidural analgesia (PCEA), and the continuous epidural analgesia (CEA).

METHODS

This is a retrospective cohort study that investigates the obstetrical outcomes of 2240 patients who received EA during labor in a tertiary maternal unit over the course of 9 years (2011-2018). The only inclusion criterion was the use of epidural analgesia during childbirth and the only exclusion criteria were multiplets' gestation. Multivariate logistic regression, Kruskal-Wallis test, and the log-rank test were utilized to compare the differences between the three EA techniques in terms of cesarean section rate, the incidence of perineal tears, the use of Oxytocin, the duration of labor, and the incidence of paresthesia.

RESULTS

Out of the 2240 included deliveries; 1084 utilized PIEB, 1086 PCEA, and 70 CEA techniques. The incidence of Cesarean section was the highest in the CEA group (45.7%) compared to PIEB (24.8%) and PCEA (24.4%) P < 0.001. A significantly shorter duration of labor (vaginal delivery) was observed in the PCEA group (n: 821, 336.7 min) compared to the PIEB group (n: 814, 368.8 min) P < 0.001. There were no statistically significant differences in the incidence of perineal tears, the need of uterotonics, and the incidence of paresthesia.

CONCLUSION

The results of this study indicate that the PIEB and PCEA techniques are superior to the CEA technique when it comes to analgesia during childbirth. In this study, the PCEA technique seems to be the best-suited technique for childbirth, since it had a significantly shorter duration of labor than the PIEB technique.

Effects of different neuraxial analgesia modalities on the need for physician interventions in labour: A network meta-analysis

BACKGROUND

Neuraxial labour analgesia can be initiated with epidural (EPL), combined spinal epidural (CSE) or dural puncture epidural (DPE) and maintained with continuous epidural infusion (CEI), patient-controlled epidural analgesia (PCEA) or programmed intermittent epidural bolus (PIEB), but the optimal analgesia modality is still controversial.

OBJECTIVE

To compare the effects of commonly used neuraxial analgesia modalities on the proportion of women needing physician interventions, as defined by the need for physician-administered epidural top-ups for inadequate analgesia in labour.

DESIGN

Bayesian network meta-analysis.

DATA SOURCES

PubMed, Embase, CENTRAL, Web of Science and Wanfang Data were searched from January 1988 to August 2023 without language restriction.

ELIGIBILITY CRITERIA

Randomised controlled trials comparing two or more modalities of the following six neuraxial analgesia modalities in healthy labouring women: EPL+CEI+PCEA, EPL+PIEB+PCEA, CSE+CEI+PCEA, CSE+PIEB+PCEA, DPE+CEI+PCEA and DPE+PIEB+PCEA.

RESULTS

Thirty studies with 8188 women were included. Compared with EPL+CEI+PCEA, EPL+PIEB+PCEA [odds ratio (OR) = 0.44; 95% credible interval (CrI), 0.22 to 0.86], CSE+PIEB+PCEA (OR = 0.29; 95% CrI, 0.12 to 0.71) and DPE+PIEB+PCEA (OR = 0.19; 95% CrI, 0.08 to 0.42) significantly reduced the proportion of women needing physician interventions. DPE+PIEB+PCEA had fewer women needing physician interventions than all other modalities, except for CSE+PIEB+PCEA (OR = 0.63; 95% CrI, 0.25 to 1.62). There were no significant differences in local anaesthetic consumption, maximum pain score, and the incidence of instrumental delivery between the different neuraxial modalities.

CONCLUSIONS

PIEB+PCEA is associated with a lower risk of physician interventions in labour than CEI+PCEA. DPE or CSE and PIEB+PCEA may be associated with a lower likelihood of physician interventions than other neuraxial modalities. Otherwise, the new neuraxial analgesia techniques do not appear to offer significant advantages over traditional techniques. However, these results should be interpreted with caution due to limited data and methodological limitations.

TRIAL REGISTRATION

PROSPERO (CRD42023402540).

Rapid detection of adulterated lamb meat using near infrared and electronic nose: A F1-score-MRE data fusion approach

Individual detection techniques cannot guarantee accurate and reliable results when combatting the presence of adulterated lamb meat in the market. Here, we propose an approach combining the electronic nose and near-infrared spectroscopy fusion data with machine learning methods to effectively detect adulterated lamb meat (mixed with duck meat). To comprehensively analyse the data from both techniques, the F1-score-based Model Reliability Estimation (F1-score-MRE) data fusion method was introduced. The obtained results demonstrate the superiority of the F1-score-MRE method, achieving an accuracy rate of 98.58% (F1-score: 0.9855) in detecting adulterated lamb meat. This surpasses the performance of the traditional data fusion and feature concatenation methods. Furthermore, the F1-score-MRE data fusion method exhibited enhanced stability and accuracy compared with the single electronic nose and near-infrared data processed by the self-adaptive BPNN model (accuracy: 94.36%, 93.66%; F1-score: 0.9435, 0.9368). This study offers a promising solution to address concerns regarding adulterated lamb meat.

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

STUDY OBJECTIVE

In labor, programmed intermittent epidural bolus (PIEB) can be defined as the bolus administration of epidural solution at scheduled time intervals. Compared to continuous epidural infusion (CEI) with or without patient controlled epidural analgesia (PCEA), PIEB has been associated with decreased pain scores and need for rescue analgesia and increased maternal satisfaction. The optimal volume and dosing interval of PIEB, however, has still not been determined.

DESIGN

Systematic review and network meta-analysis registered with PROSPERO (CRD42022362708).

SETTINGS

Labor.

PATIENTS

Pregnant patients.

INTERVENTIONS

Central, CINAHL, Global Health, Ovid Embase, Ovid Medline and Web of Science were searched for randomized controlled trials that examined pregnant patients in labor who received CEI or PIEB with or without a PCEA component. Network meta-analysis was performed with a frequentist method, facilitating the indirect comparison of PIEB with different volumes and dosing intervals through the common comparator of CEI and substituting or supplementing direct comparisons with these indirect ones. Continuous and dichotomous outcomes were presented as mean differences and odds ratios, respectively, with 95% confidence intervals. The risk of bias was evaluated using the Cochrane risk of bias 2 tool.

MAIN RESULTS

Overall, 30 trials were included. For the first primary endpoint, need for rescue analgesia, PIEB delivered at a volume of 4 ml and frequency of 45 min (4/45) was inferior to PIEB 8/45 (OR 3.55; 95% CI 1.12-11.33), PIEB 10/60 was superior to PIEB 2.5/15 (OR 0.36; 95% CI 0.16-0.82), PIEB 4/45 (OR 0.14; 95% CI 0.03-0.71) and PIEB 5/60 (OR 0.23; 95% CI 0.08-0.70), and PIEB 5/30 was not inferior to PIEB 10/60 (OR 0.61; 95% CI 0.31-1.19). For the second primary endpoint, maternal satisfaction, no differences were present between the various PIEB regimens. The quality of evidence for these multiple primary endpoints was low owing to the presence of serious limitations and imprecision. Importantly, PIEB 5/30 decreased the pain score at 4 h compared to PIEB 2.5/15 (MD 2.45; 95% CI 0.13-4.76), PIEB 5/60 (MD -2.28; 95% CI -4.18--0.38) and PIEB 10/60 (MD 1.73; 95% CI 0.31-3.16). Mean ranking of interventions demonstrated PIEB 10/60 followed by PIEB 5/30 to be best placed to reduce the cumulative dose of local anesthetic, and this resulted in an improved incidence of lower limb motor blockade for PIEB 10/60 in comparison to CEI (OR 0.30; 95% CI 0.14-0.67). No differences in neonatal outcomes were found. Some concerns were present for the risk of bias in two thirds of trials and the risk of bias was shown to be high in the remaining one third of trials.

CONCLUSIONS

Future research should focus on PIEB 5/30 and PIEB 10/60 and how the method of analgesia initiation, nature and concentration of local anesthetic, design of epidural catheter and rate of administration might influence outcomes related to the mother and neonate.

Effect of esketamine on postpartum depression after labor analgesia and potential mechanisms: a randomized, double-blinded controlled trial

BACKGROUND

To evaluate the effect of esketamine combined with ropivacaine hydrochloride on the occurrence of postpartum depression (PPD) after labor analgesia under epidural analgesia pump and explore the possible mechanisms.

METHODS

A total of 120 women aged 24 to 36 years old who underwent labor analgesia by epidural analgesia pump, with American Society of Anesthesiologists (ASA) physical status II were enrolled. According to the formula of epidural analgesia pump, all participants were randomly divided into two groups: esketamine group (Group E) and control group (Group C). Epidural anaesthesia were operated in all women between L2 and L3 after cervical dilation up to 2 ~ 3 cm. After successful puncture, the epidural catheter was placed 3.5 cm toward the head and 1% lidocaine was injected for 3 ml. The epidural analgesia pump was connected. Esketamine (0.2 mg/kg) combined with 0.75% ropivacaine hydrochloride (20 ml) were diluted by normal saline up to 100 ml in Group E, when only the equal dose of ropivacaine hydrochloride was used in Group C. The visual analogue scale (VAS) before analgesia (T1), 5 (T2), 10 (T3) and 20 (T4) minutes after analgesia were measured. The duration of the first and second stage of labor, the Apgar score of fetus at delivery, postpartum hemorrhage, consumption of esketamine and ropivacaine were recorded. The incidence of PPD was recorded at 1 week and 6 weeks after delivering. The occurrence of side effects such as nausea and vomiting, dizziness, and nightmares were also recorded for 48 h after delivering. The levels of leptin, norepinephrine(NE), and epinephrine(E) in the peripheral venous blood were measured before labor analgesia and at 24 h, 1 week, and 6 weeks after delivering.

RESULTS

Compared with Group C, the VAS score at T2, T3 and T4 were significantly lower in Group E (P < 0.01). Compared with Group C, the incidence of PPD was significantly lower at 1 week and 6 weeks after delivering in Group E (P < 0.01). Compared with Group C, the levels of leptin were significantly higher at 24 h and 1 week after delivering in Group E (P < 0.01), while NE and E (P < 0.01) were lower at the same time (P < 0.01). There were no significant difference of the duration of the first and second stage of labor, the Apgar score of fetus at delivery, postpartum hemorrhage, consumption of ropivacaine and the side effects for 48 h after delivering between the two groups.

CONCLUSION

Esketamine combined with ropivacaine hydrochloride used in labor analgesia can significantly reduce the incidence of postpartum depression after delivering without increasing related side effects, which may be related to the regulation of leptin, norepinephrine, and epinephrine in the serum.

TRIAL REGISTRATION

The trial was registered at the Chinese Clinical Trial Registry on 30/05/2022 (CTRI registration number-ChiCTR2200060387). URL of registry: https://www.chictr.org.cn/bin/home .

Combined Programmed Intermittent Bolus and Patient-Controlled Bolus Is a More Favorable Setting for Epidural Pain Relief Than Continuous Infusion

Epidural analgesia is a suitable and effective treatment for labor pain. However, the preferable modality setting for delivery remains debatable. This study adopted a programmed intermittent epidural bolus (PIEB) setting in conjunction with a patient-controlled epidural analgesia (PCEA) setting to improve the quality of labor analgesia and reduce the number of medical staff. We conducted a prospective observational analysis of primigravida parturients scheduled for spontaneous labor, which required epidural analgesia for painless labor. A total of 483 healthy primigravida parturients with singleton pregnancies were included in this cohort; 135 nulliparous patients were assigned to the continuous infusion setting (CEI) group and 348 to the PIEB + PCEA group. Compared to the CEI setting, the PIEB + PCEA setting significantly reduced the manual rescue by the clinician, extended the time required for the first manual rescue dose, and acclaimed good maternal satisfaction. The use of the CEI mode increased for poor performance requiring more than two rescues with an odds ratio of 2.635 by a binary logistic regression analysis. Using the PIEB + PCEA setting as the maintenance infusion had a longer duration for the first requested manual rescue, fewer manual rescue boluses, excellent satisfaction, and no significant increase in adverse events compared to the CEI setting.