The effects of maternal labour analgesia on the fetus

Maternal and neonatal cortisol and catecholamines throughout vaginal eutocia and C-section in dogs

Increased fetal cortisol is associated with catecholamine release, a primary factor for neonatal adaptive responses. However, relationship between canine peripartum cortisol and catecholamine is unknown. We aimed to compare serum adrenaline, noradrenaline and cortisol during peripartum in bitches and neonates of distinct obstetric conditions and to assess amniotic fluid cortisol concentration. Twenty females and maximum of three puppies per litter were allocated into Vaginal Eutocia (10 females; 17 neonates) and Elective C-section (10 females; 20 neonates) groups. Amniotic fluid was collected at delivery for cortisol concentration. Maternal and neonatal blood were collected prepartum, intrapartum, postpartum and 1h postpartum, and at birth, 30 and 60min, 12hs and 24hs, respectively, for cortisol, adrenaline and noradrenaline assessment. C-section determined higher noradrenaline throughout delivery and cortisol concentration from intrapartum through 1h postpartum, compared to vaginal birth. C-section maternal cortisol showed progressive increase from intrapartum onwards, while neonatal cortisol remained unchanged. No difference of maternal cortisol concentration occurred along whelping, whereas a significant decrease was verified for vaginal delivery puppies from birth until the 12hs. Puppies delivered vaginally had higher cortisol concentration at birth and 30min, compared to c-section puppies. There was a higher concentration of amniotic fluid cortisol in vaginal eutocia. In conclusion, c-section induces higher maternal stress during and after surgery, whilst vaginal delivery is a more neonatal physiologically stressful condition, contributing to better adaptation during transition.

Efficacy and Safety of Epidural Chloroprocaine for Breakthrough Pain During Labor Analgesia: A Prospective, Double-Blind, Randomized Trial

INTRODUCTION

A significant number of women who undergo neuraxial labor analgesia experience breakthrough pain. Prompt mitigation of breakthrough pain is essential to improve maternal and fetal outcomes. We evaluated epidural chloroprocaine compared with ropivacaine in alleviating labor breakthrough pain.

METHODS

We performed a double-blind randomized controlled clinical trial between May and July 2023. Eligible parturients received epidural analgesia with ropivacaine and sufentanil. Those with breakthrough pain were randomized to receive either 0.125% epidural ropivacaine (group R) or chloroprocaine at concentrations of 0.5% (group C1), 1.0% (group C2), or 1.5% (group C3), all in a volume of 6 mL. The primary outcome was the treatment success rate, indicated by a decrease of at least 4 points on the numerical rating scale pain score 9 min after analgesic injection. Secondary outcomes and adverse effects were also recorded.

RESULTS

Out of 323 patients receiving epidural analgesia, 192 experienced breakthrough pain. After exclusion of three patients because of protocol deviation, there were 47, 48, 47, and 47 patients in group R, C1, C2, and C3, respectively. Group C3 demonstrated a higher treatment success rate (39/47, 83.0%) in managing breakthrough pain than group R (26/47, 55.3%), group C1 (12/48, 25.0%), and group C2 (30/47, 63.8%) (p < 0.001). Group C3 had lower numerical rating scale scores at 6 and 9 min after injection and required fewer patient-controlled epidural boluses than other groups. In addition, group C3 reported greater satisfaction than the other groups (p < 0.001). No significant differences were observed in obstetric or neonatal outcomes across these groups.

CONCLUSION

Parturients experiencing breakthrough pain could receive 1.5% epidural chloroprocaine, rather than lower chloroprocaine concentrations and ropivacaine, to achieve more rapid and better pain relief with higher patient satisfaction.

TRIAL REGISTRATION

Chinese Clinical Trial Registry, ChiCTR2300071069, http://www.chictr.org.cn/index.aspx .

Endorphins, Sexuality, and Reproduction

Beta-endorphin is secreted from the hypothalamus and pituitary in both mother and newborn. The placenta produces numerous pituitary hormones from the third month of pregnancy, one of which is βE. It has been suggested that βE has a role in the appetitive and precopulatory phase of sexual behavior in animals. An increase in endorphin levels during sexual activity in humans may contribute to attachment and bonding between partners, but contradictory reports in the literature question the association between sexuality and βE levels. The level of βE also increases during pregnancy, rises in early labor, peaks in late labor, and drops in the postpartum period. This fluctuation provides natural analgesia, raises the pain threshold, decreases the sensation of pain, or suppresses pain, and decreases fear levels during labor and birth. Beta-endorphin also protects the fetus from hypoxia during labor and birth and potential neural damage by aiding blood flow to the brain under hypoxic conditions. It has been suggested that a variety of pharmacologic and nonpharmacologic complementary therapies, when used in pregnancy, labor, and birth, activate the opioid receptors in the CNS and alter the sensation of pain during labor and birth, affect the mother-child attachment and affect sexual function. These studies report contradictory results that will be discussed in this chapter.

Effect of Acupressure on Anxiety and Pain Levels in Primiparous Women During Normal Labor: A Randomized Controlled Trial

Background: Normal labor is stressful, and the intense pain and anxiety can have an adverse effect on the mother, the fetus, and the delivery procedure. This study aimed to determine how acupressure applied to multiple acupoints during normal labor affected labor pain and anxiety in primiparous women. Method: This study was a double-blinded randomized controlled trial that involved 43 primiparous women aging 20-30 years who were referred for normal labor. Subjects were randomly allocated to one of two groups: acupressure or control. Acupressure was administered to the Large Intestine 4 (LI4), Heart 7 (He-7), and Spleen 6 (SP6) acupoints in the acupressure group, whereas sham acupressure was administered to the control group. The study assessed the mothers' anxiety levels using the Spielberger Inventory questionnaire and measured their pain levels using the visual analog scale before and after the intervention. In addition, pulse rate and blood pressure were also measured. Result: In the acupressure group, both the anxiety score and pain level showed a substantial improvement (p < 0.001), but in the control group, only the anxiety score showed a significant improvement (p < 0.001). After the intervention, the difference in anxiety and pain scores between the two groups is statistically significant (p < 0.001). Furthermore, neither group's blood pressure nor pulse rate showed any significant changes (p < 0.05). Conclusion: According to the study's findings, acupressure targeting LI4, He-7, and SP6 acupoints was effective in relieving anxiety and pain during labor. Compared with the sham acupressure group, the acupressure group showed a greater decrease in both anxiety and pain levels. As such, acupressure may be recommended as an effective, affordable, and accessible technique for managing pain and anxiety during labor. This study has been registered in the database of clinical trials under the identifier Clinicaltrials.gov NCT05411289.

Evaluating the Pharmacokinetics of Fentanyl in the Brain Extracellular Fluid, Saliva, Urine, and Plasma of Newborns from Transplacental Exposure from Parturient Mothers Dosed with Epidural Fentanyl Utilizing PBPK Modeling

BACKGROUND AND OBJECTIVE

Fentanyl can mitigate the mother and newborn complications resulting from labor pain. However, fentanyl shows a narrow therapeutic index between its respiratory depressive and analgesic effects. Thus, prenatally acquired high fentanyl levels in the newborn brain extracellular fluid (bECF) may induce respiratory depression which requires therapeutic drug monitoring (TDM). TDM using saliva and urine in newborns can reduce the possibility of infections and distress associated with TDM using blood. The objective of this study was to develop  a physiologically based pharmacokinetic (PBPK) model to predict fentanyl concentrations in different newborn tissues due to intrauterine exposure.

METHODS

A fentanyl PBPK model in adults after intravenous and epidural administration was built, validated, and scaled to pregnancy and newborn populations. The dose that the newborn received transplacentally at birth was calculated using the pregnancy model. Then, the newborn bECF, saliva, plasma, and urine concentrations after such a dose were predicted using the newborn PBPK model.

RESULTS

After a maternal epidural dose of fentanyl 245 µg, the predicted newborn plasma and bECF levels were below the toxicity thresholds. Furthermore, the salivary threshold levels in newborns for fentanyl analgesic and respiratory depression effects were estimated to be 0.39 and 14.7-18.2 ng/ml, respectively.

CONCLUSION

The salivary TDM of fentanyl in newborns can be useful in newborns exposed to intrauterine exposure from parturient females dosed with epidural fentanyl. However, newborn-specific values of µ-opioid receptors IC50 for respiratory depression are needed.

The Analysis of Pethidine Pharmacokinetics in Newborn Saliva, Plasma, and Brain Extracellular Fluid After Prenatal Intrauterine Exposure from Pregnant Mothers Receiving Intramuscular Dose Using PBPK Modeling

BACKGROUND AND OBJECTIVE

Pethidine (meperidine) can decrease labor pain-associated mother's hyperventilation and high cortisol-induced newborn complications. However, prenatal transplacentally acquired pethidine can cause side effects in newborns. High pethidine concentrations in the newborn brain extracellular fluid (bECF) can cause a serotonin crisis. Therapeutic drug monitoring (TDM) in newborns' blood distresses them and increases infection incidence, which can be overcome by using salivary TDM. Physiologically based pharmacokinetic (PBPK) modeling can predict drug concentrations in newborn plasma, saliva, and bECF after intrauterine pethidine exposure.

METHODS

A healthy adult PBPK model was constructed, verified, and scaled to newborn and pregnant populations after intravenous and intramuscular pethidine administration. The pregnancy PBPK model was used to predict the newborn dose received transplacentally at birth, which was used as input to the newborn PBPK model to predict newborn plasma, saliva, and bECF pethidine concentrations and set correlation equations between them.

RESULTS

Pethidine can be classified as a Salivary Excretion Classification System class II drug. The developed PBPK model predicted that, after maternal pethidine intramuscular doses of 100 mg and 150 mg, the newborn plasma and bECF concentrations were below the toxicity thresholds. Moreover, it was estimated that newborn saliva concentrations of 4.7 µM, 11.4 µM, and 57.7 µM can be used as salivary threshold concentrations for pethidine analgesic effects, side effects, and the risk for serotonin crisis, respectively, in newborns.

CONCLUSION

It was shown that saliva can be used for pethidine TDM in newborns during the first few days after delivery to mothers receiving pethidine.

Association between combined spinal-epidural analgesia and neurodevelopment at 3 years old: The Japan Environment and Children's Study

AIM

To investigate the association between maternal combined spinal-epidural analgesia during vaginal delivery and neurodevelopment in 3-year-old children.

METHODS

Using data from the Japan Environment and Children's Study, a birth cohort study on pregnant women and their offspring, we described the background, perinatal outcomes, and neurodevelopmental outcomes of participants with a singleton pregnancy who received combined spinal-epidural analgesia during vaginal delivery and those who did not. The association between maternal combined spinal-epidural analgesia and abnormalities in five domains of the Ages and Stages Questionnaire, Third Edition, was analyzed using univariable and multivariable logistic regression analyses. Crude and adjusted odds ratios with 95% confidence intervals (95% CI) were calculated.

RESULTS

Among 59 379 participants, 82 (0.1%) children (exposed group) were born to mothers who received combined spinal-epidural analgesia during vaginal delivery. In the exposed versus control groups, 1.2% versus 3.7% had communication abnormalities (adjusted odds ratio [95% CI]: 0.30 [0.04-2.19]), 6.1% versus 4.1% exhibited gross-motor abnormalities (1.36 [95% CI: 0.55-3.36]), 10.9% vs. 7.1% had fine-motor abnormalities (1.46 [95% CI: 0.72-2.96]), 6.1% vs. 6.9% showed difficulties with problem-solving (0.81 [95% CI: 0.33-2.01]), and 2.4% vs. 3.0% had personal-social problems (0.70 [95% CI: 0.17-2.85]).

CONCLUSIONS

Exposure to combined spinal-epidural analgesia during vaginal delivery was not associated with the risk of neurodevelopmental abnormalities; however, the sample size of our study might not be appropriate for the study design.

Impact of maternal neuraxial labor analgesia exposure on offspring's neurodevelopment: A longitudinal prospective cohort study with propensity score matching

Background

Neuraxial analgesia is widely used to relieve labor pain; its effects on long-term neurodevelopment of offspring remain unclear. This study was designed to investigate the influence of maternal neuraxial labor analgesia on offspring mental development.

Methods

This was a predefined secondary analysis of a 2-year prospective longitudinal study. Nulliparous women with single-term cephalic pregnancy preparing for vaginal delivery self-selected neuraxial analgesia or not during labor. Mothers and their offspring were followed up 2 years later. children's mental development was assessed with the bayley scales of infant development. A multivariable logistic model was used to identify factors associated with below-average mental development (Mental Development Index <90).

Results

A Total of 508 pairs of mothers and children completed a 2-year follow-up. after propensity score matching, 387 pairs were included in the analysis. In both cohorts, the proportions with below-average mental development were slightly lower in children whose mothers received neuraxial labor analgesia, although not statistically significant [in the full cohort: 9.8 % (36/368) vs. 15.7% (22/140), P = 0.060; In the matched cohort: 8.3% (21/254) vs. 14.3% (19/133), P = 0.065]. A higher 2-year depression score (in the full cohort: Odds Ratio 1.15, 95% CI 1.08–1.22, P < 0.001; In the matched cohort: Odds Ratio 1.09, 95% CI 1.01–1.18, P = 0.037), but not neuraxial analgesia exposure, was associated with an increased risk of below-average mental development.

Conclusions

Maternal depression at 2 years was associated with the risk of below-average mental development, whereas maternal exposure to neuraxial labor analgesia was not.

Clinical Trial Registration

The study was registered with www.chictr.org.cn (ChiCTR-OCH-14004888) and ClinicalTrials.gov (NCT02823418).

Association of labour epidural analgesia with neurodevelopmental disorders in offspring: a Danish population-based cohort study

BACKGROUND

Whether labour epidural analgesia impacts risk of neurodevelopmental disorders in offspring is unsettled, raising public and scientific concerns. We explored the association between maternal labour epidural analgesia and autism spectrum disorder, and specific developmental disorder, attention-deficit hyperactivity disorder, intellectual disability, and epilepsy in offspring.

METHODS

This nationwide population-based cohort study included 624 952 live-born singletons delivered by women who intended to deliver vaginally (i.e. vaginal and intrapartum Caesarean deliveries) in Denmark from 2005 to 2016. A total of 80 862 siblings discordant for exposure to labour epidural analgesia were analysed in a sibling-matched analysis. Both full-cohort and sibling-matched analyses were performed to estimate hazard ratios (HRs) of offspring risk of autism spectrum disorder, specific developmental disorder, attention-deficit hyperactivity disorder, intellectual disability, and epilepsy, according to exposure to labour epidural analgesia, adjusted for maternal socio-economic, pregnancy, and perinatal covariates.

RESULTS

In the full cohort, maternal labour epidural analgesia was associated with autism spectrum disorder in offspring (HR 1.11; 95% confidence interval [CI]: 1.04-1.18); however, in the sibling-matched analysis, no association with autism spectrum disorder was found (HR 1.03; 95% CI: 0.84-1.27). The association between labour epidural analgesia and specific developmental disorder (HR 1.12; 95% CI: 1.03-1.22) in the full cohort also disappeared in the sibling-matched analysis (HR 1.01; 95% CI: 0.78-1.31). No association between maternal labour epidural analgesia and the remaining neurodevelopmental disorders was found overall (attention-deficit hyperactivity disorder, HR 0.98; 95% CI: 0.92-1.03; intellectual disability, HR 0.98; 95% CI: 0.85-1.14; epilepsy, HR 0.89; 95% CI: 0.79-1.00) or in the sibling-matched analyses.

CONCLUSIONS

Our findings did not support an association between maternal attention-deficit hyperactivity disorder and autism spectrum disorder, specific developmental disorder, attention-deficit hyperactivity disorder, intellectual disability, or epilepsy.

Parturition in Mammals: Animal Models, Pain and Distress

Parturition is a complex physiological process and involves many hormonal, morphological, physiological, and behavioural changes. Labour is a crucial moment for numerous species and is usually the most painful experience in females. Contrary to the extensive research in humans, there are limited pain studies associated with the birth process in domestic animals. Nonetheless, awareness of parturition has increased among the public, owners, and the scientific community during recent years. Dystocia is a significant factor that increases the level of parturition pain. It is considered less common in polytocous species because newborns' number and small size might lead to the belief that the parturition process is less painful than in monotocous animal species and humans. This review aims to provide elements of the current knowledge about human labour pain (monotocous species), the relevant contribution of the rat model to human labour pain, and the current clinical and experimental knowledge of parturition pain mechanisms in domestic animals that support the fact that domestic polytocous species also experience pain. Moreover, both for women and domestic animal species, parturition's pain represents a potential welfare concern, and information on pain indicators and the appropriate analgesic therapy are discussed.

Efficacy and safety of non-pharmacological interventions for labour pain management: A systematic review and Bayesian network meta-analysis

AIMS AND OBJECTIVES

To compare and rank the efficacy and safety of non-pharmacological interventions in the management of labour pain.

BACKGROUND

Recently, various non-pharmacological interventions have been applied to manage labour pain and have shown positive effects. However, evidence identifying which type of non-pharmacological intervention is more efficient and safer is limited.

DESIGN

Systematic review and Bayesian network meta-analysis based on PRISMA-NMA.

METHODS

Seven databases were searched from database inception-March 2020. Two reviewers independently performed study selection, quality appraisal and data extraction. Conventional meta-analysis was conducted using either fixed-effects model or random-effects model according to statistical heterogeneity. The Bayesian network meta-analysis was conducted using the consistency model.

RESULTS

43 studies involving nine non-pharmacological interventions were included. The Bayesian network meta-analysis showed that acupressure (SMD = -2.00, 95% CrI -3.09 to -0.94), aromatherapy (SMD = -2.01, 95% CrI -3.70 to -0.35) and massage therapy (SMD = -1.26, 95% CrI -2.26 to -0.30) had significant positive effects on alleviating labour pain, with aromatherapy being the most effective. The results also revealed that yoga (SMD = -130.85, 95% CrI -212.01 to -59.32) and acupressure (SMD = -10.14, 95% CrI -20.24 to -0.41) were the most effective interventions for shortening the first stage and the second stage of labour, respectively. There were no significant differences between non-pharmacological interventions and usual care or placebo control on the use of pharmacological methods and neonatal 5-min Apgar score.

CONCLUSIONS

The evidence in this network meta-analysis illustrates that non-pharmacological interventions are effective and safe for labour pain management in low-risk pregnant women. In the future, well-designed studies are needed to validate the conclusion of this network meta-analysis.

RELEVANCE TO CLINICAL PRACTICE

The results support the use of non-pharmacological interventions, especially aromatherapy and acupressure, to relieve labour pain in low-risk pregnant women. Non-pharmacological interventions for labour pain management are recommended to apply according to maternal women's preference and values.

Potential impact of epidural labor analgesia on the outcomes of neonates and children

This review summarizes recent evidences regarding the potential influences of epidural labor analgesia (ELA) on the outcomes of neonates and children. Terms and relevant words including “ELA,” “ELA and neonatal outcomes,” “ELA and children's development,” and “ELA and children's neurocognitive development” were used to search articles published in PubMed database up to October 2019. Original articles and reviews regarding potential influences of ELA on neonates and children were identified. Relevant references of the selected articles were also screened. The anesthetics used during ELA can be absorbed, enter the fetus, and produce neonatal depression; however, these effects are less severe than those during systematic opioid analgesia. The impact of anesthetic exposure during ELA on children's neurodevelopment has not been fully studied, but would be mild if any. ELA increases the risk of intrapartum maternal fever; the latter may be harmful to neonatal outcomes. The use of ELA may increase birth injury by increasing instrumental delivery, although long-term adverse events are rare. On the other hand, ELA may reduce maternal depression and, thus, produce favorable effects on neurocognitive development in childhood; but evidences are still lacking in this aspect. ELA may produce both favorable and unfavorable effects on neonates and children. These effects should be discussed with parturient women before making decisions. The potential harmful effects should be carefully managed. The overall impacts of ELA on neonatal and children's outcomes need to be studied further.

The Effect of Pethidine Analgesia on Labor Duration and Maternal-Fetal Outcomes

Background and Aim:

Opioid analgesics had been used from time to time for treating labor pain. However, their use have been concerning. The aim of this study is to evaluate the effect of pethidine on duration of active phase of labor, labor pain and maternal-neonatal outcomes.

Methods:

In the present case-control study, the study group received a 50 mg pethidine intramuscular injection upon the start of active phase of labor, and the control group consisted of patients who receive placebo injeciton. In both groups, vital signs were measured before, and at 0, 5, 15, 30, 45 and 60 minutes after the injection. Pain intensity was evaluated with Visual Analogue Scale (VAS) prior to, and 1 hour and 2 hours after injection. Data regarding labor phase durations, maternal side effects, newborn APGAR scores and fetal respiratory problems were recorded.

Results:

102 patients in Pethidine group and 92 patients in control group, were included into the study. Labor pain VAS-scores were significantly lower in the study group (p<0.001). Moreover, active phase of labor duration was significantly shorter in the study group (p<0.001). Maternal pulse significantly decreased, and maternal nausea-vomiting was frequent in the study groups. However, the groups were similar in terms of other side effects and neonatal outcomes.

Conclusions:

Pethidine significantly reduces active phase of labor duration, has a favorable analgesic effect in treating labor pain and is not associated with serious maternal or neonatal complications. It is therefore considered an acceptable agent for use during active phase of labor. (www.actabiomedica.it)

Effect of analgesia with pethidine during labour on false positivity of newborn hearing screening test

OBJECTIVES

Newborn hearing screening may fail due to some perinatal and neonatal factors. False positivity of newborn hearing screening increases costs, familial concerns and anxiety. The objective of this study was to determine the effects of pethidine administered in the mother for labor analgesia on the false positivity rates of the newborn hearing screening test.

METHODS

This study was designed as a retrospective and cross-sectional study. A total of 75 pregnant women scheduled for vaginal delivery who received 50 mg intramuscular pethidine at the beginning of the active phase of the labor were included as the patient group and 68 pregnant women who did not receive pethidine as the control group. A total of 143 infants born with vaginal delivery were evaluated with otoacoustic emission (OAE) test before discharge. Perinatal and neonatal variables and test outcomes were recorded, and the correlation between false positivity rate and pethidine usage was evaluated.

RESULTS

Initially, system records of 148 healthy term newborns were screened. Four patients who failed in both OAE tests and were referred to the Automated Auditory Brainstem Response (AABR) test and one patient who failed in all tests (first OAE, control OAE and AABR) and was referred to an upper center for further investigations and treatment were excluded from the study. No statistically significant difference was found between the groups in terms of birth features. First stage OAE test was reported as 'passed' in 8 (10.7%) and 58 (85.3%) newborns in the study and control groups, respectively; while OAE was reported as 'referred' and 'passed' in the second test in 67 (89.3%) and 10 (14.7%) newborns in the study and control groups, respectively. There was a statistically significant difference between both groups in terms of false positivity ratio (p < 0.5).

CONCLUSION

Pethidine significantly decreases the duration of the active phase, providing a good analgesic effect for pain management during labor. Therefore, it seems that pethidine can be used as an acceptable agent during labor. However, it may have neonatal effects after the delivery, causing false positivity in newborn hearing screening tests. The results of this study support the opinion that the OAE test should be performed in postpartum later dates in order to increase OAE passing rates and minimize costs and parents' concerns.

[Effects of Obstetric Analgesia with Systemic Opioids on the Newborn - A Review]

INTRODUCTION

Three-quarters of all women receive analgesia during labor. There are regional and systemic analgesia procedures available. In this review, we investigate the impact of obstetric analgesia using systemic opioids on neonatal outcomes.

METHODS

We searched the PubMed and Cochrane Library databases using the following search terms: "meptazinol", "meptide", "analgesia", "painkiller", "pain reliever", "obstetrics", "labor", "labour", "delivery", "neonate", "newborn", "child", "baby", "infant", "fetus", "fetal", "opioid" and "opiate" as well as performed an additional MeSH Terms search in PubMed.

RESULTS

Of 355 potentially relevant studies, we included 23 studies in this review. The studies varied widely in quality, sample size, and outcome criteria. Neonatal outcome was often only a secondary endpoint. Rarely were significant differences related to neonatal outcome reported between the different systemic opioids or compared with control groups. Twelve studies compared neonatal APGAR scores between treatment groups, with ten (83%) of these studies showing no differences.

DISCUSSION/OUTLOOK

In summary, we assess the evidence as limited and ambiguous as to whether systemic obstetric opioid therapy negatively affects the newborn. Studies regarding the long-term outcome of the newborns are lacking. A statement regarding the necessity of postnatal monitoring of newborns after maternal obstetric opioid therapy cannot be concluded. Further studies, ideally with a prospective study design and control group, should be considered.

Effectiveness of breathing exercises, foot reflexology and back massage (BRM) on labour pain, anxiety, duration, satisfaction, stress hormones and newborn outcomes among primigravidae during the first stage of labour in Saudi Arabia: a study protocol for a randomised controlled trial

INTRODUCTION

Labour pain is among the severest pains primigravidae may experience during pregnancy. Failure to address labour pain and anxiety may lead to abnormal labour. Despite the many complementary non-pharmacological approaches to coping with labour pain, the quality of evidence is low and best approaches are not established. This study protocol describes a proposed investigation of the effects of a combination of breathing exercises, foot reflexology and back massage (BRM) on the labour experiences of primigravidae.

METHODS AND ANALYSIS

This randomised controlled trial will involve an intervention group receiving BRM and standard labour care, and a control group receiving only standard labour care. Primigravidae of 26-34 weeks of gestation without chronic diseases or pregnancy-related complications will be recruited from antenatal clinics. Eligible and consenting patients will be randomly allocated to the intervention or the control group stratified by intramuscular pethidine use. The BRM intervention will be delivered by a trained massage therapist. The primary outcomes of labour pain and anxiety will be measured during and after uterine contractions at baseline (cervical dilatation 6 cm) and post BRM hourly for 2 hours. The secondary outcomes include maternal stress hormone (adrenocorticotropic hormone, cortisol and oxytocin) levels, maternal vital signs (V/S), fetal heart rate, labour duration, Apgar scores and maternal satisfaction. The sample size is estimated based on the between-group difference of 0.6 in anxiety scores, 95% power and 5% α error, which yields a required sample size of 154 (77 in each group) accounting for a 20% attrition rate. The between-group and within-group outcome measures will be examined with mixed-effect regression models, time series analyses and paired t-test or equivalent non-parametric tests, respectively.

ETHICS AND DISSEMINATION

Ethical approval was obtained from the Ethical Committee for Research Involving Human Subjects of the Ministry of Health in the Saudi Arabia (H-02-K-076-0319-109) on 14 April 2019, and from the Ethics Committee for Research Involving Human Subjects (JKEUPM) Universiti Putra Malaysia on 23 October 2019, reference number: JKEUPM-2019-169. Written informed consent will be obtained from all participants. Results from this trial will be presented at regional, national and international conferences and published in indexed journals.

TRIAL REGISTRATION NUMBER

ISRCTN87414969, registered 3 May 2019.

Pain management during labor and vaginal birth

Neuraxial analgesia provides excellent pain relief in labor. Optimizing initiation and maintenance of neuraxial labor analgesia requires different strategies. Combined spinal-epidurals or dural puncture epidurals may offer advantages over traditional epidurals. Ultrasound is useful in certain patients. Maintenance of analgesia is best achieved with a background regimen (either programmed intermittent boluses or a continuous epidural infusion) supplemented with patient-controlled epidural analgesia and using dilute local anesthetics combined with opioids such as fentanyl. Nitrous oxide and systemic opioids are also used for pain relief. Nitrous oxide may improve satisfaction despite variable effects on pain. Systemic opioids can be administered by healthcare providers or using patient-controlled analgesia. Appropriate choice of drug should take into account the stage and progression of labor, local safety protocols, and maternal and fetal/neonatal side effects. Pain in labor is complex, and women should fully participate in the decision-making process before any one modality is selected.

Outcomes of intrathecal analgesia in multiparous women undergoing normal vaginal delivery: A randomised controlled trial

Background and Aims

Although intrathecal analgesia is an effective option during labour, there is a need to establish sustainable and assured analgesia during the entire labour process. We aimed to assess the effect of adding dexmedetomidine, fentanyl or morphine to low-dose bupivacaine-dexamethasone for intrathecal labour analgesia in multiparous women.

Methods

This was a triple-blind, randomised controlled trial that included 140 multiparous women. Eligible women were randomly allocated to have intrathecal bupivacaine-dexamethasone with dexmedetomidine (group D), fentanyl (group F), morphine (group M) or saline (placebo) (group C). The duration of analgesia, intrathecal block characteristics and maternal and foetal outcomes were assessed and analysed.

Results

The longest analgesia duration and S1 regression time was recorded in group D followed by groups M, F and C, respectively, with statistical significance between all of them (P < 0.001). The shortest analgesia onset time and the highest sensory levels were recorded in group D followed by group F then group M with statistical significance between all of them (P < 0.001 and 0.003, respectively). Visual analogue scale values were comparable among groups M, F and D (P > 0.05) at most of the measurement time points and at the peak of the last uterine contraction before delivery while being significantly lower than those in group C (P < 0.001). However, there were similar motor block characteristics and normal neonatal outcomes in all groups.

Conclusion

In comparison to morphine and fentanyl, dexmedetomidine addition to intrathecal bupivacaine-dexamethasone significantly prolonged the duration and accelerated the onset of labour analgesia, with a good maternal and neonatal outcome.

Epidural use in labour is not associated with an increased risk of maternal or neonatal morbidity when the second stage is prolonged

BACKGROUND

Epidural analgesia increases length of labour and risk of operative delivery (caesarean or instrumental).

AIM

This study aimed to assess the impact of epidural anaesthesia on maternal and neonatal adverse outcomes when the second stage of labour was prolonged.

METHODS

A retrospective cohort study of women delivering at term at the Mater Mother's Hospital, Brisbane between 2008 and 2017. Intrapartum, maternal and neonatal outcomes were assessed and dichotomised according to the presence of prolonged second stage of labour and further by epidural use. Prolonged second stage of labour was defined as: nulliparous women ≥3 h (with epidural) and ≥2 h (without); multiparous women ≥2 h (with epidural) and ≥1 h (without).

RESULTS

There were 48 352 women who met the inclusion criteria - 43 676 without and 4676 with prolonged second stage of labour. The overall epidural rate was 35.9%. Women with epidural had significantly lower odds of achieving a spontaneous vaginal birth and higher odds of an operative birth regardless of length of second stage. While rates of several adverse maternal and neonatal outcomes were higher when the second stage was prolonged, after adjusting for clinically relevant confounders, epidural use was not associated with increased odds of the majority of these adverse outcomes. Indeed, epidural use was associated with a significant reduction in the odds of obstetric anal sphincter injuries and reduced odds of neonatal acidosis in women with prolonged second stage.

CONCLUSION

While epidural increases the risk of operative birth, this is not associated with an increase in adverse maternal or neonatal outcomes.

Influence of Different Methods of Intrapartum Analgesia on the Progress of Labour and on Perinatal Outcome

Background Various methods of intrapartum analgesia are available these days. Pethidine, meptazinol and epidural analgesia are among the most commonly used techniques. A relatively new one is patient-controlled intravenous analgesia with remifentanil, although the experiences published so far in Germany are limited. Our goal was to study the influence of these analgesic techniques (opioids vs. patient-controlled intravenous analgesia with remifentanil vs. epidural analgesia) on the second stage of labour and on perinatal outcome. Material and Methods We conducted a retrospective study with 254 parturients. The women were divided into 4 groups based on the analgesic technique and matched for parity, maternal age and gestational age (opioids n = 64, patient-controlled intravenous analgesia with remifentanil n = 60, epidural analgesia n = 64, controls without the medicinal products mentioned n = 66). Maternal, fetal and neonatal data were analysed. Results The expulsive stage was prolonged among both primiparas and multiparas with patient-controlled intravenous analgesia with remifentanil (79 [74] vs. 44 [55] min, p = 0.016, and 28 [68] vs. 10 [11] min, p < 0.001, respectively) and epidural analgesia (90 [92] vs. 44 [55] min, p = 0.004, and 22.5 [73] vs. 10 [11] min, p = 0.003, respectively) compared with the controls. The length of the pushing stage was similar among primiparas in all groups but prolonged compared with the controls in multiparas with patient-controlled intravenous analgesia with remifentanil (15 [17] vs. 5 [7] min, p = 0.001) and epidural analgesia (10 [15] vs. 5 [7] min, p = 0.006). The Apgar, umbilical arterial pH and base excess values were similar between the groups, as were the rates of acidosis and neonatal intensive care unit admission. Conclusion Parturients with patient-controlled intravenous analgesia with remifentanil and epidural analgesia showed a prolonged expulsive stage compared with the opioid group and controls. The short-term neonatal outcome was not influenced by the three methods examined.

Naloxone for opioid-exposed newborn infants

BACKGROUND

Naloxone, a specific opioid antagonist, is available for the treatment of newborn infants with cardiorespiratory or neurological depression that may be due to intrauterine exposure to opioid. It is unclear whether newborn infants may benefit from this therapy and whether naloxone has any harmful effects.

OBJECTIVES

To determine the effect of naloxone on the need for and duration of neonatal unit stay in infants of mothers who received opioid analgesia prior to delivery or of mothers who have used a prescribed or non-prescribed opioid during pregnancy.

SEARCH METHODS

We searched the following databases in February 2018: the Cochrane Central Register of Controlled Trials (the Cochrane Library 2018, Issue 1), MEDLINE (OvidSP), MEDLINE In process & Other Non-Indexed Citations (OvidSP), Embase (OvidSP), CINAHL (EBSCO), Maternity and Infant Care (OvidSP), and PubMed. We searched for ongoing and completed trials in the WHO International Clinical Trials Registry Platform and the EU Clinical Trials Register. We checked the reference lists of relevant articles to identify further potentially relevant studies.

SELECTION CRITERIA

Randomised controlled trials comparing the administration of naloxone versus placebo, or no drug, or another dose of naloxone to newborn infants with suspected or confirmed in utero exposure to opioid.

DATA COLLECTION AND ANALYSIS

We extracted data using the standard methods of Cochrane Neonatal with separate evaluation of trial quality and data extraction by two review authors and synthesis of data using risk ratio, risk difference, and mean difference.

MAIN RESULTS

We included nine trials, with 316 participants in total, that compared the effects of naloxone versus placebo or no drug in newborn infants exposed to maternal opioid analgesia prior to delivery. None of the included trials investigated infants born to mothers who had used a prescribed or non-prescribed opioid during pregnancy. None of these trials specifically recruited infants with cardiorespiratory or neurological depression. The main outcomes reported were measures of respiratory function in the first six hours after birth. There is some evidence that naloxone increases alveolar ventilation. The trials did not assess the effect on the primary outcomes of this review (admission to a neonatal unit and failure to establish breastfeeding).

AUTHORS' CONCLUSIONS

The existing evidence from randomised controlled trials is insufficient to determine whether naloxone confers any important benefits to newborn infants with cardiorespiratory or neurological depression that may be due to intrauterine exposure to opioid. Given concerns about the safety of naloxone in this context, it may be appropriate to limit its use to randomised controlled trials that aim to resolve these uncertainties.

Epidural Analgesia and Neonatal Morbidity: A Retrospective Cohort Study

(1) Background: Epidural analgesia (EA), at the present time, is one of the most effective methods to reduce labor pain. In recent years its use has increased, being used between 20–70% of all deliveries; (2) Methods: Historical cohort on a total of 2947 deliveries during the years 2012–2016 at the “Mancha-Centro Hospital” of Alcázar de San Juan. The main outcome variables were four neonatal morbidity (NM) criteria: umbilical artery pH of <7.10, Apgar score at 5 min < 7, need for advanced resuscitation and composite morbidity. We used the multivariate analysis to control confounding bias. (3) Results: No statistical relationship between EA and the second stage of labor duration with none of the four criteria of NM used (p > 0.005). However, the type of delivery was associated with three criteria (pH, resuscitation, and composite morbidity). The instrumental delivery presented an OR of pH < 7.10 of 2.68 95% CI [1.15, 6.27], an OR of advanced resuscitation of 2.44 95% CI [1.17, 5.08] and OR of composite morbidity of 2.86 95% CI [1.59, 5.12]; (4) Conclusions: The EA and the second stage of labor duration are not related to the NM. While the instrumental delivery doubles the risk of NM compared to the normal vaginal delivery.

[What does the Internet teach the obstetric patient about labor analgesia?]

BACKGROUND AND OBJECTIVES

It has been observed a general public increased search on the Internet for health information, including Anesthesiology. The objective of this study was to evaluate the information available to the lay person in Portuguese on the internet about labor analgesia for the Brazilian population.

METHOD

Using the term "labor anesthesia", the first 20 sites found on Google in November 2014 were evaluated by two resident physicians and classified as medical and non-medical. Legibility and Design - accessibility, reliability and navigability-were compared using Flesch Reading Ease Score (FRESH) and Minervation validation tool for healthcare websites (LIDA) tools. The websites' content was confronted with that of the medical literature.

RESULTS

Medical and non-medical websites were considered difficult to read according to FRESH. Regarding the design, there was no difference between groups regarding navigability, however, accessibility was considered superior in non-medical websites (p = 0.042); while reliability was higher in medical websites (p = 0.019).

CONCLUSIONS

With the increased search for health information on the Internet and concern about improving the quality of childbirth care, it is fundamental that the content available to the layperson about labor analgesia is of quality and well understood. This study demonstrated that both medical and non-medical websites are difficult to read and that non-medical websites are more accessible while the medical ones are more accurate.

[Analgesic drugs during pregnancy]

Some important limitations must be taken into consideration for analgesic therapy during pregnancy. Paracetamol is the agent of choice for mild to moderate pain in any stage of pregnancy. Ibuprofen is the non-steroidal anti-inflammatory drug (NSAID) of choice; however, these substances are contraindicated after 28 weeks of gestation due to the increasing risk of premature closure of the ductus arteriosus and impairment of fetal kidney function. Even opioids can be used for severe pain but peripartum administration can lead to neonatal respiratory depression and adaptation disorders and long-term therapy up to the end of pregnancy can lead to neonatal withdrawal symptoms. Migraine can also be treated with sumatriptan. Antiepileptic drugs should not be taken during pregnancy as a teratogenic risk mostly cannot be excluded; however, well studied antidepressants, such as amitriptyline can be used for chronic pain with the appropriate indications.

Comparison Between the Use of Ropivacaine Alone and Ropivacaine With Sufentanil in Epidural Labor Analgesia

To compare the analgesic efficacy and safety of the sole local anesthetic ropivacaine with the combination of both local anesthetic ropivacaine and opioidergic analgesic sufentanil given epidurally on the labor pain control.After institutional review board approval and patient consent, a total of 500 nulliparas requesting epidural labor analgesia were enrolled and 481 eventually were randomized into 2 groups: a sole local anesthetic group (ropivacaine 0.125%) and a combination of local anesthetic and opioidergic analgesic group (0.125% ropivacaine + 0.3 μg/mL sufentanil). After the test dose, a 10-mL epidural analgesic solution was given in a single bolus, followed by intermittent bolus injection of 10 to 15 mL of the solution. The primary outcome was the analgesic efficacy measured using Numerical Rating Scale (NRS) of pain. Other maternal and infant variables were evaluated as secondary outcomes.A total of 346 participants completed the study. The median NRS pain score during the 1st stage of labor was significantly lower in the combination group 2.2 (interquartile range [IQR]: 1.8-2.7) comparing to the sole local analgesic group 2.4 (IQR: 2.0-2.8) (P < 0.0001). No significant difference was observed in NRS pain score prior epidural analgesia and during the 2nd stage of labor. Patients in both groups rated same satisfaction of analgesia. Patients in the sole local analgesic group experienced fewer side effects than those in the combination group (37.7% vs 47.2%, P = 0.082). The individual analgesia-related cost in the sole local analgesic group was less ($5.7 ± 2.06) than that in the combination group ($9.76 ± 3.54) (P < 0.0001). The incidence of 1-minute Apgar ≤ 7 was lower in the sole local analgesic group 2 (1.2%) than the combination group 10 (5.5%) (P = 0.038). No difference was found between other secondary outcomes.The sole local anesthetic ropivacaine produces a comparable labor analgesic effect as the combination of both local anesthetic ropivacaine and opioidergic analgesic sufentanil at different stages of labor (ΔNRS = 0.2) but the former has less side effects, lower cost, and less incidence of lower 1-minute Apgar scoring. These results imply the necessity of a systematic reevaluation of epidural labor analgesia with sole local anesthetics against combination regimens of local anesthetics and other opioids.

A comparison of continuous infusion and intermittent bolus administration of 0.1% ropivacaine with 0.0002% fentanyl for epidural labor analgesia

BACKGROUND AND AIMS

Minimal consumption of local anesthetic and opioid for epidural labor analgesia has been advocated for safe obstetric outcome and superior maternal satisfaction. The primary objective of this study was to evaluate and compare the analgesic efficacy of mode of administration of epidural 0.1% ropivacaine with 0.0002% fentanyl via continuous infusion or intermittent boluses during labor.

MATERIAL AND METHODS

Sixty term primi or second gravida healthy parturients in labor requesting epidural analgesia were recruited in this study. Lumbar epidural catheter was inserted, and analgesia initiated with 0.2% ropivacaine. Patients were randomized to receive ropivacaine 0.1% with fentanyl 0.0002% via either continuous infusion (Group A) or intermittent boluses (Group B) on an hourly basis. If the parturient complained of pain and visual analog scale (VAS) score was >3, an additional bolus of the study drug was given. VAS score, motor blockade, maternal hemodynamics and fetal heart sounds were frequently monitored. Side effects, mode of delivery and neonatal outcome were noted.

RESULTS

To achieve similar VAS, the mean total dose of ropivacaine was 18.78 ± 3.88 mg in Group A and 16.86 ± 4.3 mg in Group B, the difference being statistically significant (P = 0.04). Seventeen out of 30 patients in Group A that is, 56.6% and nine patients in Group B that is, 30% required additional top-ups, and this was significantly higher (P = 0.037). Side effects, mode of delivery and neonatal outcome were comparable in both groups.

CONCLUSION

Intermittent bolus administration provides a more efficacious route of drug delivery when compared to continuous infusion by significantly decreasing the total amount of local anesthetic plus opioid without adversely affecting patient safety or maternal satisfaction.

Low Apgar score, neonatal encephalopathy and epidural analgesia during labour: a Swedish registry-based study

BACKGROUND

Maternal intrapartum fever (MF) is associated with neonatal sequelae, and women in labour who receive epidural analgesia (EA) are more likely to develop hyperthermia. The aims of this study were to investigate if EA and/or a diagnosis of MF were associated to adverse neonatal outcomes at a population level.

METHODS

Population-based register study with data from the Swedish Birth Register and the Swedish National Patient Register, including all nulliparae (n=294,329) with singleton pregnancies who gave birth at term in Sweden 1999-2008. Neonatal outcomes analysed were Apgar score (AS)<7 at 5 min and ICD-10 diagnosis of neonatal encephalopathy (e.g. convulsions or neonatal cerebral ischaemia). Multivariate logistic regression was used to calculate adjusted odds ratios (AOR) with 95% confidence intervals (CI).

RESULTS

EA was used in 44% of the deliveries. Low AS or encephalopathy was found in 1.26% and 0.39% of the children in the EA group compared with 0.80% and 0.29% in the control group. In multivariate analysis, EA was associated with increased risk with low AS, AOR 1.27 (95% CI 1.16-1.39), but not with diagnosis of encephalopathy, 1.11 (0.96-1.29). A diagnosis of MF was associated with increased risk for both low AS, 2.27 (1.71-3.02), and of neonatal encephalopathy, 1.97 (1.19-3.26).

CONCLUSION

Diagnosis of MF was associated with low AS and neonatal encephalopathy, whereas EA was only associated with low AS and not with neonatal encephalopathy. The found associations might be a result of confounding by indication, which is difficult to assess in a registry-based population study.

Epidural analgesia, neonatal care and breastfeeding

The objective of our study is to evaluate the correlation between epidural analgesia during labor, start of breastfeeding and type of maternal-neonatal care.Two different assistance models were considered: Partial and Full Rooming-in.In this cohort study, 2480 healthy infants were enrolled, 1519 in the Partial Rooming-in group and 1321 in the Full Rooming-in group; 1223 were born to women subjected to epidural analgesia in labor.In case of Partial Rooming-in the rate of exclusive or prevailing breastfeeding is significant more frequent in newborns born to mothers who didn't receive analgesia. Instead, in case of Full Rooming-in the rate of exclusive or prevailing breastfeeding is almost the same and there's no correlation between the use or not of epidural analgesia.The good start of lactation and the success of breastfeeding seems to be guaranteed by the type of care offered to the couple mother-infant, that reverses any possible adverse effects of the use of epidural analgesia in labor.

Effects of uncomplicated vaginal delivery and epidural analgesia on fetal arterial acid-base parameters at birth in gestational diabetes

AIM

To investigate the effects of uncomplicated vaginal delivery and epidural analgesia on fetal acid-base parameters in women with gestational diabetes (GDM) compared with controls.

METHODS

A retrospective case-control study of 142 women with gestational diabetes and 284 controls. To evaluate the effect of diabetes and analgesia on acid-base status correcting for potential confounders we used ordered logistic equations including quartiles of fetal arterial acid-base parameters collected at birth as outcomes and categories of diabetes and epidural analgesia as explanatory variables.

RESULTS

In the GDM group cord base deficit (-2.63 mmol/l, interquartile range [IQR]=4.2 to -0.65 mmol/l vs. -1.9 mmol/l, IQR=-3.3 to -0.2 mmol/l, p=0.009, odds ratio (OR)=1.51, 95% confidence interval (CI)=1.04-2.18) was lower and concentration of calcium higher (1.49 mmol/l, IQR=1.42-1.56 mmol/l vs. 1.47 mmol/l, IQR=1.41-1.51 mmol/l, p=0.009, OR=1.69, 95% CI=1.12-2.56) compared with controls. Epidural analgesia in the GDM group was associated with reduced cord concentration of glucose (84.0mg/dl [4.7 mmol/l], IQR=70-103.3mg/dl vs. 92.5mg/dl [5.1 mmol/l], IQR=76.5-121.8 mg/dl, p=0.004), lactate (2.65 mmol/l (IQR=1.80-4.20) vs. 3.70 mmol/l (IQR=2.90-5.55 mmol/l), p=0.002) and less pronounced base deficit (-2.05 mmol/l, IQR=-3.90 to -0.17 mmol/l vs. -2.8, IQR=-5.57 to -1.05 mmol/l, p=0.01, OR=0.7, 95% CI=0.49-0.99).

CONCLUSIONS

In uncomplicated pregnancies and deliveries, well-controlled gestational diabetes mellitus has potentially significant detrimental effects on fetal acid-base status at birth. Epidural analgesia reduces cord arterial glucose and lactates.

Naloxone for opiate-exposed newborn infants

BACKGROUND

Naloxone, a specific opiate antagonist, is available for the treatment of newborn infants with cardiorespiratory or neurological depression that may be due to intrauterine exposure to opiate. It is unclear whether newborn infants may benefit from this therapy and whether naloxone has any harmful effects.

OBJECTIVES

To determine the effect of naloxone as a treatment for newborn infants who have been exposed in utero to opiate.

SEARCH METHODS

We searched the following databases in June 2012 for new studies published since the previous search in 2007: The Cochrane Central Register of Controlled Trials (The Cochrane Library 2012, Issue 6), MEDLINE (OvidSP), MEDLINE In process & Other Non-Indexed Citations (OvidSP), EMBASE (OvidSP), CINAHL (EBSCO), Maternity and Infant Care (OvidSP) and PubMed. We searched for ongoing and completed trials in Clinical Trials.gov, metaRegister of Controlled Trials, WHO International Clinical Trials Registry Platform and the EU Clinical Trials Register. We checked the reference lists of relevant articles to identify further potentially relevant studies.

SELECTION CRITERIA

Randomised controlled trials comparing the administration of naloxone versus placebo, or no drug, or another dose of naloxone to newborn infants with suspected or confirmed in utero exposure to opiate.

DATA COLLECTION AND ANALYSIS

We extracted data using the standard methods of the Cochrane Neonatal Review Group with separate evaluation of trial quality and data extraction by two review authors and synthesis of data using risk ratio, risk difference and weighted mean difference.

MAIN RESULTS

We included nine trials that compared the effects of naloxone versus placebo or no drug in newborn infants exposed to maternal opiate analgesia prior to delivery. None of these trials specifically recruited infants with cardiorespiratory or neurological depression. The main outcomes reported were measures of respiratory function in the first six hours of life. There is some evidence that naloxone increases alveolar ventilation. The trials did not assess the effect on the primary outcomes of this review (admission to a neonatal unit and failure to establish breastfeeding).

AUTHORS' CONCLUSIONS

The existing evidence from randomised controlled trials is insufficient to determine whether naloxone confers any important benefits to newborn infants with cardiorespiratory or neurological depression that may be due to intrauterine exposure to opiate. Given concerns about the safety of naloxone in this context it may be appropriate to limit its use to randomised controlled trials that aim resolve these uncertainties.

Pain management for women in labour: an overview of systematic reviews

BACKGROUND

The pain that women experience during labour is affected by multiple physiological and psychosocial factors and its intensity can vary greatly.  Most women in labour require pain relief. Pain management strategies include non-pharmacological interventions (that aim to help women cope with pain in labour) and pharmacological interventions (that aim to relieve the pain of labour).

OBJECTIVES

To summarise the evidence from Cochrane systematic reviews on the efficacy and safety of non-pharmacological and pharmacological interventions to manage pain in labour. We considered findings from non-Cochrane systematic reviews if there was no relevant Cochrane review.

METHODS

We searched the Cochrane Database of Systematic Reviews (The Cochrane Library 2011, Issue 5), The Cochrane Database of Abstracts of Reviews of Effects (The Cochrane Library 2011, Issue 2 of 4), MEDLINE (1966 to 31 May 2011) and EMBASE (1974 to 31 May 2011) to identify all relevant systematic reviews of randomised controlled trials of pain management in labour. Each of the contributing Cochrane reviews (nine new, six updated) followed a generic protocol with 13 common primary efficacy and safety outcomes. Each Cochrane review included comparisons with placebo, standard care or with a different intervention according to a predefined hierarchy of interventions. Two review authors extracted data and assessed methodological quality, and data were checked by a third author. This overview is a narrative summary of the results obtained from individual reviews.

MAIN RESULTS

We identified 15 Cochrane reviews (255 included trials) and three non-Cochrane reviews (55 included trials) for inclusion within this overview. For all interventions, with available data, results are presented as comparisons of: 1. Intervention versus placebo or standard care; 2. Different forms of the same intervention (e.g. one opioid versus another opioid); 3. One type of intervention versus a different type of intervention (e.g. TENS versus opioid). Not all reviews included results for all comparisons. Most reviews compared the intervention with placebo or standard care, but with the exception of opioids and epidural analgesia, there were few direct comparisons between different forms of the same intervention, and even fewer comparisons between different interventions. Based on these three comparisons, we have categorised interventions into: " What works" ,"What may work", and "Insufficient evidence to make a judgement".WHAT WORKSEvidence suggests that epidural, combined spinal epidural (CSE) and inhaled analgesia effectively manage pain in labour, but may give rise to adverse effects. Epidural, and inhaled analgesia effectively relieve pain when compared with placebo or a different type of intervention (epidural versus opioids). Combined-spinal epidurals relieve pain more quickly than traditional or low dose epidurals. Women receiving inhaled analgesia were more likely to experience vomiting, nausea and dizziness.When compared with placebo or opioids, women receiving epidural analgesia had more instrumental vaginal births and caesarean sections for fetal distress, although there was no difference in the rates of caesarean section overall. Women receiving epidural analgesia were more likely to experience hypotension, motor blockade, fever or urinary retention. Less urinary retention was observed in women receiving CSE than in women receiving traditional epidurals. More women receiving CSE than low-dose epidural experienced pruritus.  WHAT MAY WORKThere is some evidence to suggest that immersion in water, relaxation, acupuncture, massage and local anaesthetic nerve blocks or non-opioid drugs may improve management of labour pain, with few adverse effects.  Evidence was mainly limited to single trials. These interventions relieved pain and improved satisfaction with pain relief (immersion, relaxation, acupuncture, local anaesthetic nerve blocks, non-opioids) and childbirth experience (immersion, relaxation, non-opioids) when compared with placebo or standard care. Relaxation was associated with fewer assisted vaginal births and acupuncture was associated with fewer assisted vaginal births and caesarean sections.INSUFFICIENT EVIDENCEThere is insufficient evidence to make judgements on whether or not hypnosis, biofeedback, sterile water injection, aromatherapy, TENS, or parenteral opioids are more effective than placebo or other interventions for pain management in labour. In comparison with other opioids more women receiving pethidine experienced adverse effects including drowsiness and nausea. 

AUTHORS' CONCLUSIONS

Most methods of non-pharmacological pain management are non-invasive and appear to be safe for mother and baby, however, their efficacy is unclear, due to limited high quality evidence. In many reviews, only one or two trials provided outcome data for analysis and the overall methodological quality of the trials was low. High quality trials are needed.There is more evidence to support the efficacy of pharmacological methods, but these have more adverse effects. Thus, epidural analgesia provides effective pain relief but at the cost of increased instrumental vaginal birth.It remains important to tailor methods used to each woman's wishes, needs and circumstances, such as anticipated duration of labour, the infant's condition, and any augmentation or induction of labour.A major challenge in compiling this overview, and the individual systematic reviews on which it is based, has been the variation in use of different process and outcome measures in different trials, particularly assessment of pain and its relief, and effects on the neonate after birth. This made it difficult to pool results from otherwise similar studies, and to derive conclusions from the totality of evidence. Other important outcomes have simply not been assessed in trials; thus, despite concerns for 30 years or more about the effects of maternal opioid administration during labour on subsequent neonatal behaviour and its influence on breastfeeding, only two out of 57 trials of opioids reported breastfeeding as an outcome. We therefore strongly recommend that the outcome measures, agreed through wide consultation for this project, are used in all future trials of methods of pain management.