Rebuilding the labor curve during neuraxial analgesia

Effects of neuraxial analgesia technique on labor and maternal-fetal outcomes: a retrospective study

PURPOSE

To compare the effects of epidural analgesia (EA) and combined spinal epidural analgesia (SEA) on labor and maternal-fetal outcomes.

METHODS

We retrospectively identified and included 1499 patients with a single cephalic fetus who delivered at the study center from January 2015 to December 2018 and received neuraxial analgesia at the beginning of the active phase of labor (presence of regular painful contractions and cervical dilatation between 4 and 6 cm). Data including analgesia, labor characteristics, and maternal-fetal outcomes were retrieved from the prospectively collected delivery room database and medical records.

RESULTS

SEA was associated with a shorter first stage of labor than EA, with a median difference of 60 min. On multivariable ordinal logistic regression analysis, neuraxial analgesia, gestational age, fetal weight, labor induction, and parity were independently associated with the first stage length: patients in the EA group were 1.32 times more likely to have a longer first stage of labor (95% CI 1.06-1.64, p = 0.012) than those in the SEA group. Additionally, a significantly lower incidence of fundal pressure was performed among patients who underwent SEA (OR 0.55, 95% CI 0.34-0.9, p = 0.017). No associations were observed between the used neuraxial analgesia technique and other outcomes.

CONCLUSIONS

SEA was associated with a shorter length of the first stage of labor and a lower rate of fundal pressure use than EA. Further studies confirming the effects of SEA on labor management and clarifying differences in maternal-fetal outcomes will allow concluding about the superiority of one technique upon the other.

Contemporary duration of spontaneous labor and association with maternal characteristics: A French national population-based study

BACKGROUND

The objective of this study was to describe labor duration of women managed with current obstetric practices in a French national population-based cohort and to assess the association of age and BMI on this duration.

METHODS

All women in the French perinatal survey of 2016 with a singleton cephalic fetus, delivering at term after a spontaneous labor were included. Duration of labor was defined as time between admission to the labor ward and birth. Duration of total labor and first and second stage of labor were described. Then, duration of labor was estimated according to maternal age and BMI, using Kaplan-Meier's method and compared with the log-rank test after stratification on parity. Intrapartum cesarean birth was considered as a censoring event. Multivariable modeling was performed using Cox's proportional hazard's method.

RESULTS

Data of 3120 nulliparous and 4385 multiparous women were analyzed. Median labor duration was 6.1 hours ([5th; 95th percentile]) [1.4; 12.6] and 3.1 hours [0.3; 8.5] in nulliparous and multiparous women. Multivariable Cox analysis showed no independent association of maternal age and duration of labor. Nulliparous obese women had significantly lower odds of having a shorter labor than women with a BMI < 25 kg/m² , HR: 0.75; 95% CI [0.64-0.88], but BMI was not associated with labor duration in multiparous women.

CONCLUSIONS

Our study provides important information for both women and care practitioners on what to expect when entering the labor ward. There appears to be little association between maternal characteristics and labor duration, with the exception of BMI in nulliparous women.

Comparison of the labor curves with and without combined spinal-epidural analgesia in nulliparous women- a retrospective study

Background

Neuraxial labor analgesia is known to increase the rate of instrumental delivery and prolong the second stage of labor; however, there is no standard method to evaluate the progress of labor under analgesia. Friedman curve is considered the gold standard for evaluating the progress of labor. However, it included not only neuraxial labor analgesia but also labor without analgesia. Thus we compared the labor curves of primiparous women undergoing labor with and without neuraxial labor analgesia, to understand the progress of labor in both groups and to arrive at a standard curve to monitor the progress of labor under neuraxial analgesia.

Methods

Primiparous women with cephalic singleton pregnancies who delivered at term from 2016 to 2017 were included. Two hundred patients who opted for combined spinal-epidural (CSE) labor analgesia were included in the CSE group and 200 patients who did not undergo CSE were included in the non-CSE group. In all, 400 cases were examined retrospectively. The evaluation parameters were cervical dilation and fetal station, and we calculated the average value per hour to plot the labor curves.

Results

The labor curve of the non-CSE group was significantly different from the Friedman curve. In the CSE group, the time from 4 cm dilation of the cervix to full dilation was 15 h; in addition, the speed of cervical dilation was different from that in the non-CSE group. The progress of labor in the CSE group was faster than that in the non-CSE group during the latent phase; however, the progress in the CSE group was slower than that in the non-CSE group during the active phase.

Conclusions

Neuraxial labor analgesia results in early cervical dilation and descent of the fetal head; thus, appropriate advance planning to manage the delivery may be essential.

Effects of combined spinal-epidural analgesia on first stage of labor: a cohort study

Background: Neuraxial anesthesia is considered as the gold standard in the control labor of pain. Its variants are epidural analgesia and combined spinal-epidural analgesia. Few studies, as yet, have investigated the duration of labor as a primary outcome. Some authors have suggested that combined spinal-epidural analgesia may reduce labor duration but at the moment the benefit of shortening labor is uncertain. The main aim of this study was to compare combined spinal-epidural with epidural analgesia in terms of their effect on duration of stage I labor, maternal, and neonatal outcomes. Methods: A prospective cohort study was conducted. Parturients who requested analgesia at cervical dilatation <6 cm were included. Analgesia was either epidural with low concentration levobupivacaine or combined spinal epidural with subarachnoid sufentanil. The primary outcome was the length of stage I labor. Onset and quality of analgesia, mode of delivery, effects on uterine activity and use of oxytocin, fetal heart rate abnormalities and uterine hyperkinesia, maternal, and neonatal complications were also considered. Results: We enrolled 400 patients: 176 in the combined spinal-epidural group and 224 in the epidural group. Patients in the two treatment groups were similar with regard to demographic characteristics, parity, and incidence of obstetric comorbidities, labor induction, oxytocin infusion, Bishop score, and Visual Analogue Score (VAS) at analgesia request. Duration of stage I labor did not differ, at 195 (120-300) minutes for both the groups (p = .7). Combined spinal-epidural was associated with less reduction in uterine contractility after initial administration: 15.34 versus 39.73%, (p < .001) and with delayed need for oxytocin, at dilations of 7 ± 2.5 cm versus 6. ± 2.7, (p = .002). Onset of analgesia was quicker for combined spinal-epidural analgesia: 31 versus 20%, with VAS <4 after 5 minutes, (p < .001); and lower VAS scores after initial analgesia administration. No differences were found in the other outcomes. Conclusions: Combined spinal-epidural with subarachnoid sufentanil may not reduce the duration of stage I labor, but in our study it appeared to affect uterine contractility less. It also had a more rapid onset and was more effective, without any concomitant increase in maternal or neonatal complications.

Ultrasonographic evaluation of the second stage of labor. Predictive parameters for a successful vaginal delivery with or without neuraxial analgesia: a pilot study

PURPOSE

The aim of the study was to evaluate the progression and rotation of the fetal head during the second stage of labor using translabial ultrasound and to compare ultrasonographic data obtained in nulliparous women both receiving and not receiving neuraxial analgesia.

METHODS

The 49 patients enrolled in the study were divided into two groups according to receiving or not receiving neuraxial analgesia. Every half hour from full dilation to delivery, the ultrasonographic translabial parameters of Angle of Progression, Head Symphysis Distance, and Midline Angle were obtained and recorded by a single operator. Then, these records were compared between the two groups of patients.

RESULTS

Patients that underwent neuraxial analgesia presented with increased duration of the second stage of labor, with mean values of Angle of Progression significantly higher and of Midline Angle significantly lower for each time interval studied compared to patients without analgesia. A borderline significant relationship was found between administration of neuraxial analgesia and Head Symphysis Distance.

CONCLUSIONS

In this study, we demonstrated that combined spinal-epidural analgesia influences the duration of the second stage of labor and the initial progression and rotation of the fetal head through the birth canal, but not the kind of delivery. A correlation between Angle of Progression values and success in the application of a vacuum has been reported by other authors and confirmed in our study.

Central neuraxial analgesia for labor: an update of the literature

Numerous techniques are in use to provide analgesia for labor, of which central neuraxial block is widely considered superior to non-neuraxial options. Central neuraxial techniques have evolved over many years to provide greater efficacy, safety and maternal satisfaction. This narrative review focuses on the literature relating to central neuraxial labor analgesia from the past 5 years, from November 2010 to October 2015. We discuss the evidence related to the various central neuraxial techniques used, the increasingly widespread use of ultrasound guidance and the evidence surrounding other novel methods of central neuraxial block insertion. The timing of institution of central neuraxial analgesia in labor is considered, as are the advances in maintenance regimens for labor analgesia.

Effects of combined spinal epidural labor analgesia on episiotomy: a retrospective cohort study

BACKGROUND

According to some published studies, neuraxial analgesia may be associated with prolonged labor and an increased risk for instrumental vaginal delivery. However, its effects on episiotomy are unknown. This study aimed to examine the incidence of episiotomy with and without combined spinal-epidural analgesia (CSEA) during labor.

METHODS

This was a retrospective cohort study, in which the computerized medical records of nulliparous women with singleton, cephalic and live births were reviewed and women with and without CSEA were matched based on their propensity scores. Univariate and multivariate analyses were used to examine the association between CSEA and the incidence of episiotomy during vaginal delivery.

RESULTS

In the cohort study with 11,994 vaginal deliveries, 5748 received CSEA and 6246 did not receive CSEA. 4116 CSEA women were successfully matched with 4116 Non-CSEA women. In the univariate analysis, the incidence of episiotomy was 47.4% in the CSEA group and 44.7% in the Non-CSEA group. However, after a multivariable logistic regression analysis, CSEA did not increase the risk of episiotomy (adjusted OR, 1.080; 95% confidence interval [CI], 0.988-1.180).

CONCLUSIONS

The use of CSEA during labor and vaginal delivery did not increase the risk of episiotomy.

Prevention of primary caesarean delivery: comprehensive management of dystocia in nulliparous patients at term

PURPOSE

Dystocia is the leading indication for primary caesarean sections. Our aim is to compare two approaches in the management of dystocia in labor in nulliparous women with a singleton fetus in cephalic presentation at term in spontaneous or induced labor.

METHODS

Prospective cohort study. Four hundred and nineteen consecutive patients were divided into two groups: the standard management group (SM), in acceleration of labor was commenced at the "action line" in the case of arrested or protracted labor, and the comprehensive management group (CM) in which arrested or protracted labor was considered as a warning sign promoting further diagnostic assessment prior to considering intervention.

RESULTS

Caesarean sections rate was 22.2 % in the SM group (216 patients) and 10.3 % in the CM group (203 patients) (p = 0.001). The rate of oxytocin use decreased from 33.3 % in SM group to 13.8 % in the CM group (p < 0.0005). The rate of amniotomy decreased from 41.7 % in the SM group to 7.4 % in the CM group (p < 0.0005). The percentage of newborns with 5-min Apgar score <7 and/or umbilical cord arterial pH ≤ 7.00 decreased from 2.3 % in SM cohort to 0.5 % in CM cohort (p = ns). The average length of labor did not differ between the two groups of patients (264 vs 277 min; p = ns).

CONCLUSION

Comprehensive management of dystocia enabled us to achieve a reduction in iatrogenic interventions in labor while maintaining good neonatal outcomes.

Neuraxial analgesia effects on labour progression: facts, fallacies, uncertainties and the future

Approximately 60% of women who labour in the USA receive some form of neuraxial analgesia, but concerns have been raised regarding whether it negatively impacts the labour and delivery process. In this review, we attempt to clarify what has been established as truths, falsities and uncertainties regarding the effects of this form of pain relief on labour progression, negative and/or positive. Additionally, although the term 'epidural' has become synonymous with neuraxial analgesia, we discuss two other techniques, combined spinal-epidural and continuous spinal analgesia, that are gaining popularity, as well as their effects on labour progression.

Epidural analgesia during labor: impact on delivery outcome, neonatal well-being, and early breastfeeding

BACKGROUND

The effect of epidural analgesia on labor and effective breastfeeding is still being debated. The aim of this study is to define its impact on the trend of labor, the newborns' well-being, and early breastfeeding.

METHODS

We considered first-term physiologic pregnant women who delivered by the vaginal route. We divided them into two groups: group A received epidural analgesia during labor, whereas group B received no analgesia. We recorded maternal age, gestational age, modality of delivery, length of labor, and length of active labor. All newborns received skin-to-skin contact; early breastfeeding was encouraged. We recorded data on birth weight and length, Apgar score at minutes 1 and 5, type of crying, neonatal reactivity, and time between birth and exposure to the breast. Statistical significance was considered for p<0.05.

RESULTS

Of 934 pregnant women who delivered by the vaginal route, 317 patients required labor analgesia, and 245 patients agreed to participate in our study. Only 128 patients met inclusion criteria. We randomized them in 64 women in group A and 64 women in group B. Data on maternal age, gestational age, type of delivery, neonatal birth weight and length, and Apgar score showed no significant differences. Total length of labor was 363.58±62.20 minutes in Group A versus 292.30±64.75 minutes in group B (p<0.001). The length of active labor showed no significant difference. Among neonatal parameters we found a statistically significant difference only for length of first breastfeeding, with a mean duration of <30 minutes in 62.2% in group A versus 29.3% in Group B (p<0.001).

CONCLUSIONS

Epidural analgesia has little effect on trend of labor and duration of first breastfeed and none on neonatal outcome. A new protocol of epidural analgesia may solve these side effects.