The impact of epidural analgesia on the mode of delivery in nulliparous women that attain the second stage of labor

Knowledge, attitudes, and practices of pregnant women regarding epidural analgesia: a multicentre study from a developing country

BACKGROUND

Epidural analgesia has emerged as one of the best methods that can be used to reduce labour pain. This study was conducted to assess awareness, attitudes, and practices of pregnant women who visited maternity and antenatal healthcare clinics about epidural analgesia during normal vaginal birth.

METHODS

This multicentre study was conducted in a cross-sectional design among pregnant women using a pre-tested questionnaire. The study population in this study was pregnant women who visited maternity and antenatal healthcare clinics in Palestine.

RESULTS

In this study, a total of 389 pregnant women completed the questionnaire. Of the pregnant women, 381 (97.9%) were aware of the existence of epidural analgesia, 172 (44.2%) had already used epidural analgesia, and 57 (33.1%) experienced complications as a result of epidural analgesia. Of the pregnant women, 308 (79.2%) stated that epidural analgesia should be available during vaginal birth. Of the pregnant women, 243 (62.5%) stated that they would use epidural analgesia if offered for free or covered by insurance. Multivariate logistic regression showed that women who were younger than 32 years, who have used epidural analgesia, and those who stated that epidural analgesia should be available during vaginal birth were 2.78-fold (95% CI: 1.54-5.04), 4.96-fold (95% CI: 2.71-9.10), and 13.57-fold (95% CI: 6.54-28.16) more likely to express willingness to use epidural analgesia, respectively.

CONCLUSIONS

Pregnant women had high awareness of the existence, moderate knowledge, and positive attitudes towards epidural analgesia for normal vaginal birth. Future studies should focus on educating pregnant women about all approaches that can be used to reduce labour pain including their risks and benefits.

Cytochrome P4503A4 gene polymorphisms guide safe sufentanil analgesic doses in pregnant Chinese mothers: a multicenter, randomized, prospective study

BACKGROUND

Sufentanil and ropivacaine when used as epidural anesthetics effectively reduce maternal pain during labor. From previous reports, rs2242480 single nucleotide polymorphisms (SNPs) can alter sufentanil metabolism, which affects analgesic efficacy.

METHODS

We randomly divided 573 eligible mothers into groups A and B (in a 1 : 3 ratio). The control group (group A) was given sufentanil at the usual 0.5 mg/L-1 dose + 0.15% ropivacaine hydrochloride mixture in 10 ml. The sufentanil dose given to the intervention group (group B) was determined by genotype: the GA and AA genotype group (group B1) was given 87.6% (design based on previous study results) of the usual sufentanil clinical dose (0.438 mg/L-1 sufentanil + 0.15% ropivacaine hydrochloride mixture in 10 ml) and the GG genotype group (group B2) was given the same dose as group A. Efficacy indicators consisting of maternal vital signs, obstetric transfer, neonatal prognostic indicators, and adverse effects were recorded before and after analgesia across groups.

RESULTS

Visual analog scale scores after analgesia across groups were significantly different from scores before analgesia, showing that analgesic effects across groups were effective. No significant differences were observed in efficacy, obstetric transfer, and neonatal prognosis indicators between groups. In comparison to groups B1 and B2, group A showed more markedly suppressed cardiovascular and respiratory effects, and also a higher incidence of negative side effects such as vomiting and urinary retention.

CONCLUSION

We confirmed that individualizing sufentanil doses based on maternal genotypes increased safety and success rates for women during childbirth.

Association between Maternal Neuraxial Analgesia and Neonatal Outcomes in Very Preterm Infants

Background  Although the use of neuraxial analgesia has been shown to improve uteroplacental blood flow and maternal and fetal hemodynamics related to labor pain, possibly improving immediate outcomes in term neonates, the association between neuraxial analgesia use and outcomes in preterm neonates remains unclear. Objective  The aim of this article was to evaluate the association between maternal use of neuraxial analgesia and neonatal outcomes in very preterm infants. Methods  This is a retrospective cohort study of women delivering singleton neonates between 23 and 32 weeks' gestation at a large academic center between 2012 and 2016. Outcomes of neonates born to women who used neuraxial analgesia for labor and/or delivery were compared to those whose mothers did not. Multivariable logistic regression was utilized to assess the independent associations of neuraxial analgesia use with neonatal outcomes after controlling for potential confounders, including gestational age, mode of delivery, and existing interventions to improve neonatal outcomes of prematurity. Results  Of 478 eligible women who delivered singleton very preterm neonates in this study period, 352 (73.6%) used neuraxial analgesia. Women who used neuraxial analgesia were more likely to have delivered at a later preterm gestational age, to have a higher birthweight, to have preeclampsia and/or hemolysis, elevated liver enzymes, low platelet count (HELLP), to have undergone labor induction, to have delivered by cesarean delivery, and to have received obstetric interventions such as magnesium prophylaxis for fetal neuroprotection, antenatal corticosteroids for fetal lung maturity, and antibiotics prior to delivery; they were less likely to have been diagnosed with a clinical abruption. Neuraxial analgesia was associated with decreased incidence of cord umbilical artery pH less than 7.0 (24.7 vs. 34.9%, p  = 0.03), as well as decreased incidence of neonatal intensive care unit length of stay over 60 days (35.5 vs. 48.4%, p  = 0.01), although these associations did not persist on multivariable analysis. On multivariable analyses, neuraxial analgesia remained independently associated with decreased odds of necrotizing enterocolitis (adjusted odds ratio [aOR]: 0.28, 95% confidence interval [CI]: 0.12-0.62) and grade III/IV intraventricular hemorrhage (aOR: 0.33, 95% CI: 0.13-0.87). These associations remained significant on sensitivity analyses, which were performed between 10 and 90% of the overall cohort in order to control for outliers, as well as between the subgroup of patients who received obstetric interventions. Conclusions  Maternal neuraxial analgesia use may be associated with lower odds of adverse outcomes in very preterm infants, even after controlling for existing interventions for prematurity. Prior work has suggested such effects may be due to improved neonatal acid-base status from changes in placental perfusion and maternal pain management, but further work is required to prospectively investigate such associations.

The effects of a midwife-led weight management program for pregnant women: A randomized controlled trial

BACKGROUND

Inappropriate weight gain during pregnancy may present risks for maternal and newborn health. Pregnancy is considered the optimal time to intervene on women's health behaviors such as eating habits and physical activity. However, current clinical practice guidelines for weight management during pregnancy were not fully based on randomized trials, thus lacking specific "active intervention ingredients" that are proven effective in achieving appropriate gestational weight gain. Therefore it is essential to develop and implement an evidence-based weight management program for pregnant women.

OBJECTIVE

To examine the effects of a midwife-led weight management program on improving appropriate gestational weight gain, health literacy, experience of antenatal care, and maternal and neonatal outcomes among Chinese pregnant women.

DESIGN

A two-group randomized controlled trial.

SETTINGS AND PARTICIPANTS

A total of 426 pregnant women were recruited from a tertiary women's hospital in eastern China.

METHODS

Participants were randomly allocated to either intervention group (n = 213) or control group (n = 213). Women in the intervention group participated in a midwife-led weight management program during pregnancy, while women in the control group received the conventional obstetrician-led antenatal care. We assessed women at the first antenatal contact, 35-36 weeks gestation and 2-3 days postpartum. Data on gestational weight gain, health literacy, experience of antenatal care, and maternal and neonatal outcomes were compared between the two groups. Dummy variable analysis was conducted to reveal the effect of weight management program on gestational weight gain.

RESULTS

The overall gestational weight gain between the two groups was not statistically different (t = -1.377, P = 0.170). Compared with women in the control group, the odds of having inappropriate gestational weight gain was lower in the intervention group (OR = 0.270, 95%CI 0.169, 0.431). Further subgroup analyses showed that women in the intervention group had lower risk of inadequate gestational weight gain (OR = 0.305, 95%CI 0.180, 0.515) and excessive gestational weight gain (OR = 0.236, 95%CI 0.138, 0.404) than those in the control group. The score of experience of antenatal care was significantly higher in the midwife-led weight management group than that in the control group (193.70 ± 18.51 versus 165.70 ± 28.23, P < 0.001). Women's health literacy score was higher in the intervention group than control group [74.41 (69.57, 81.77) versus 71.88 (66.23, 77.18), P = 0.004].

CONCLUSION

Compared with the conventional antenatal care, the midwife-led weight management program could facilitate appropriate gestational weight gain, enhance health literacy, and promote positive experience of antenatal care for Chinese pregnant women.

The Effect of Epidural Analgesia on Labour and Neonatal and Maternal Outcomes in 1, 2a, 3, and 4a Robson's Classes: A Propensity Score-Matched Analysis

Background: Lumbar epidural analgesia (EA) is the most commonly used method for reducing labour pain, but its impact on the duration of the second stage of labour and on neonatal and maternal outcomes remains a matter of debate. Our aim was to examine whether EA affected the course and the outcomes of labour among patients divided according to the Robson-10 group classification system. Methods: Patients of Robson’s classes 1, 2a, 3, and 4a were divided into either the EA group or the non-epidural analgesia (NEA) group. A propensity score-matching analysis was performed to balance the intergroup differences. The primary goal was to analyse the duration of the second stage of labour. The secondary goals were to evaluate neonatal and maternal outcomes. Results: In total, 21,808 cases were analysed. The second stage of labour for all groups was prolonged using EA (p < 0.05) without statistically significant differences in neonatal outcomes. EA resulted in a lower rate of episiotomies in nulliparous patients, with a higher rate of operative vaginal deliveries (OVD) (p < 0.05) and Caesarean sections (CS) (p < 0.05) in some classes. Conclusions: EA prolonged the duration of labour without affecting neonatal outcomes and reduced the rate of episiotomies, but also increased the rate of OVDs.

Path analysis model of epidural/spinal anesthesia on breastfeeding among healthy nulliparous women: Secondary analysis of the United States Certificate of Live Births 2016

BACKGROUND

The effect of epidural/spinal anesthesia during labor on breastfeeding is unclear. Few studies had assessed whether or how medically assisted delivery (operative vaginal delivery or unscheduled cesarean birth) plays a mediating role. We aimed to examine whether the relationship between using epidural/spinal anesthesia and breastfeeding is mediated by increased medically assisted delivery among healthy nulliparous women.

METHODS

A secondary, cross-sectional analysis was conducted using US birth certificate data from 2016 (n = 381 199). Logistic regression was used to examine associations between factors. Structural equation modeling (SEM) was used to analyze the model fit of the path models and to quantify the direct, indirect, and total effect of anesthesia on breastfeeding at discharge, considering medically assisted delivery as a mediator.

RESULTS

Women who were administered epidural/spinal anesthesia were more likely to experience medically assisted delivery (adjusted odds ratio [AOR]: 95% confidence interval [CI] 3.01 (2.91-3.12)) and less likely to be breastfeeding at discharge (0.95 [0.92-0.98]). Operative vaginal and unscheduled cesarean deliveries were significantly associated with nonbreastfeeding at discharge (0.81 [0.77-0.84] and 0.81 [0.79-0.84], respectively). SEM revealed excellent model fit for our model. The indirect effect was significant (β = -0.038; 95% CI, -0.043 to -0.033), as was the total effect (β = -0.038; 95% CI, -0.043 to -0.033).

CONCLUSIONS

Epidural/spinal anesthesia is associated with nonbreastfeeding at discharge, mediated through medically assisted delivery. Health care providers should consider these risks and provide adequate support to help all parents attain their breastfeeding goals.

Association of Epidural Analgesia in Women in Labor With Neonatal and Childhood Outcomes in a Population Cohort

Importance

Although use of epidural analgesia during labor is safe, detailed information about its association with neonatal and child outcomes is limited.

Objective

To investigate the association of labor epidural analgesia with neonatal outcomes and childhood development during the first 1000 days of life.

Design, Setting, and Participants

This population-based cohort study used Scottish National Health Service hospital administrative data of all 435 281 singleton live births in Scotland between January 1, 2007, and December 31, 2016, with follow-up over the first 1000 days of life. All 435 281 mother-infant pairs delivering between 24 weeks 0 days and 43 weeks 6 days' gestation who were in active labor with cephalic presentation and who delivered vaginally or via unplanned cesarean delivery were included. Stillbirths and infants with known congenital anomalies were excluded. Data were analyzed between August 1, 2020, and July 23, 2021.

Exposures

Epidural analgesia in labor.

Main Outcomes and Measures

Neonatal outcomes included resuscitation, Apgar score less than 7 at 5 minutes, and neonatal unit admission. Childhood development measures (gross and fine motor function, communication, and social functioning) were obtained from standardized national childhood surveillance assessments performed at 2 years.

Results

This study included a total of 435 281 live births with cephalic presentation in labor (median gestational age at delivery, 40 weeks [IQR, 39-41 weeks]; 221 153 male infants [50.8%]), of which 94 323 (21.7%) had labor epidural. Epidural analgesia was associated with a reduction in spontaneous vaginal deliveries (confounder-adjusted [Cadj] relative risk [RR], 0.46; 95% CI, 0.42-0.50), an increased risk of neonatal resuscitation (Cadj RR, 1.07; 95% CI, 1.03-1.11), and an increased risk of neonatal unit admission (Cadj RR, 1.14; 95% CI, 1.11-1.17). With additional analysis for mediation by mode of delivery (CMadj), these associations were reversed (CMadj RR, 0.83; 95% CI, 0.79-0.86 for neonatal resuscitation and CMadj RR, 0.94; 95% CI, 0.91-0.97 for neonatal unit admission). Epidural analgesia was associated with a reduced risk of an Apgar score less than 7 at 5 minutes in both confounder and confounder/mediation analyses. Epidural analgesia was associated with a reduced risk of having developmental concern in any domain at 2 years in confounder and confounder/mediation analyses (CMadj RR, 0.96; 95% CI, 0.93-0.98), with specifically fewer concerns regarding communication (CMadj RR, 0.96; 95% CI, 0.93-0.99) and fine motor skills (CMadj RR, 0.89; 95% CI, 0.82-0.97).

Conclusions and Relevance

The results of this cohort study suggest that labor epidural analgesia is not independently associated with adverse neonatal or childhood development outcomes. Associations with neonatal resuscitation and admission were likely mediated by mode of delivery.

The relationship between epidural analgesia and intrapartum maternal fever and the consequences for maternal and neonatal outcomes: a prospective observational study

AIM

To use continuous real-time monitoring of maternal core body temperature during labor and investigate the association between epidural analgesia, intrapartum maternal fever, and maternal and neonatal outcomes.

METHODS

Among 201 pregnant women attending our institution for a vaginal in-hospital delivery, 159 women received epidural analgesia and 42 women did not receive epidural analgesia. Women's core body temperature was continuously monitored for the duration of labor using a smartphone/iPad-connected wireless thermometer positioned in an axilla. The primary outcome was a change in maternal core body temperature during labor. Among women receiving epidural analgesia, maternal and neonatal outcomes were compared in women who developed an intrapartum fever and those who had no intrapartum temperature elevation.

RESULTS

Of the women receiving epidural analgesia, 26.4% (n = 42/159) developed intrapartum fever ≥38 °C compared to 7.1% (n = 3/42) of women not receiving epidural analgesia. Among those receiving epidural analgesia, women who developed intrapartum fever had a significantly longer first stage of labor and a higher incidence of cesarean section, assisted vaginal delivery, intrapartum hemorrhage, and turbid amniotic fluid compared to women with no intrapartum temperature elevation. Neonates of women who developed intrapartum fever had lower 1- and 5-min Apgar scores compared to neonates of women with no intrapartum temperature elevation; however, the difference was not significant.

CONCLUSION

This study used a precise and accurate method to monitor core body temperature among women receiving epidural analgesia. Results showed that the use of epidural analgesia during labor was associated with intrapartum maternal fever in all stages of labor. Fever after epidural analgesia was associated with adverse maternal outcomes, independent of neonatal complications.

Relation between Length of Exposure to Epidural Analgesia during Labour and Birth Mode

Objective: To appraise the relationship between the length of exposure to epidural analgesia and the risk of non-spontaneous birth, and to identify additional risk factors. This study is framed within the MidconBirth project. Study design: A multicentre prospective study was conducted between July 2016 and November 2017 in three maternity hospitals in different Spanish regions. The independent variable of the study was the length of exposure to epidural analgesia, and the dependent variable was the type of birth in women with uncomplicated pregnancies. The data was analyzed separately by parity. A multivariate logistic regression was performed. The odds ratios (OR), using 95% confidence intervals (CI) were constructed. Main outcome measures: During the study period, 807 eligible women gave birth. Non-spontaneous births occurred in 29.37% of the sample, and 75.59% received oxytocin for augmentation of labour. The mean exposure length to epidural analgesia when non-spontaneous birth happened was 8.05 for primiparous and 6.32 for multiparous women (5.98 and 3.37 in spontaneous birth, respectively). A logistic regression showed the length of exposure to epidural during labour was the major predictor for non-spontaneous births in primiparous and multiparous women followed by use of oxytocin (multiparous group). Conclusions: The length of exposure to epidural analgesia during labour is associated with non-spontaneous births in our study. It highlights the need for practice change through the development of clinical guidelines, training programs for professionals and the continuity of midwifery care in order to support women to cope with labour pain using less invasive forms of analgesia. Women also need to be provided with evidence-based information.