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

The relationship of childbirth experience with postpartum depression and anxiety: a cross-sectional study

BACKGROUND

The childbirth experience is a personal life event that is influenced by physiologic and mental-psychological processes. Due to the prevalence of psychiatric problems after childbirth, it is important to recognize the factors affecting women's emotional reactions. This study was conducted to define the relationship of childbirth experience with postpartum anxiety and depression.

METHODS

This cross-sectional study was conducted on 399 women from 1 to 4 months after their childbirth who were referred to health centers in Tabriz-Iran from January 2021 to September 2021. Socio-demographic and obstetric characteristics questionnaire, Childbirth Experience Questionnaire (CEQ 2.0), Edinburgh Postpartum Depression Scale (EPDS), and Postpartum Specific Anxiety Scale (PSAS) were used to collect the data. The general linear modeling was used along with adjustment of socio-demographic characteristics to determine the relationship between the childbirth experience with depression and anxiety.

RESULTS

The mean (SD) of the overall score for childbirth experience, anxiety, and depression were 2.9 (0.2) (score range: 1 to 4), 91.6 (4.8) (score range: 0 to153), and 9.4 (0.7) (score range: 0 to 30), respectively. There was a significant inverse correlation between the overall score of childbirth experiences, the depression score (r= -0.36, p < 0.001), and the anxiety score (r= -0.12, p = 0.028) based on the Pearson correlation test. According to the general linear modeling and with adjustment of socio-demographic characteristics, with the increasing score of the childbirth experience, the depression score decreased (B= -0.2; 95%CI: -0.3 to -0.1). Moreover, the variable of control during pregnancy was a predictor for postpartum depression and anxiety, so in women with the control during pregnancy, the mean score of postpartum depression (B= -1.8; CI 95%: -3.0 to -0.5; P = 0.004) and anxiety (B=-6.0; CI 95%: -10.1 to -1.6; P = 0.007) was less.

CONCLUSION

Based on the study results, postpartum depression and anxiety are related to childbirth experiences, therefore considering the effects of mothers' mental health on other aspects of a woman and her family's life, the core role of health care providers and policymakers in creating positive childbirth experiences is determined.

The impact of antenatal massage practice on intrapartum massage application and their associations with the use of analgesics during labour : Sub-analysis of a randomised control trial

Background

Massage during labour is one form of intrapartum non-pharmacological pain relief but it is not known whether the frequency of practicing these massage techniques among couples during the antenatal period could enhance the effectiveness of intrapartum massage. This study was to evaluate the association between compliance of antenatal massage practice with intrapartum application and their impact on the use of analgesics during labour.

Methods

This was a sub-analysis of a childbirth massage programme which was carried out in two public hospitals with total births of around 8000 per year. Data from women who were randomized to the massage group were further analysed. After attending the pre-birth training class on massage at 36 weeks gestation, couples would be encouraged to practice at home. Their compliance with massage at home was classified as good if they had practiced for at least 15 minutes for three or more days in a week, or as poor if the three-day threshold had not been reached. Application of intrapartum massage was quantified by the duration of practice divided by the total duration of the first stage of labour. Women’s application of intrapartum massage were then divided into above and below median levels according to percentage of practice. Logistic regression was used to assess the use of epidural analgesia or pethidine, adjusted for duration of labour and gestational age when attending the massage class.

Results

Among the 212 women included, 103 women (48.6%) achieved good home massage compliance. No significant difference in the maternal characteristics or birth outcomes was observed between the good and poor compliance groups. The intrapartum massage application (median 21.1%) was inversely associated with duration of first stage of labour and positively associated with better home massage practice compliance (p = 0.04). Lower use of pethidine or epidural analgesia (OR 0.33 95% CI 0.12, 0.90) was associated with above median intrapartum massage application but not antenatal massage compliance, adjusted for duration of first stage of labour.

Conclusions

More frequent practice of massage techniques among couples during antenatal period could enhance the intrapartum massage application, which may reduce the use of pethidine and epidural analgesia.

Trial registration

(CCRBCTR) Unique Trial Number CUHK_ CCRB00525.

Parturients' Stated Preferences for Labor Analgesia: A Discrete Choice Experiment

OBJECTIVE

The objective was to investigate the extent to which treatment benefits, risks and costs affected parturients' preferences for labor analgesia.

METHODS

We recruited 248 healthy parturients prior to labor at an antenatal ward and administered a discrete choice experiment survey. Parturients were asked to choose among four hypothetical forms of labor analgesia: epidural analgesia, pethidine, Entonox and no analgesia, which were defined by: pain score, duration of second stage of labor, risks of instrumental delivery, back pain and permanent nerve injury, and out-of-pocket cost. We used mixed logit model to calculate the relative importance of each attribute (out of 100).

RESULTS

Parturients preferred receiving labor analgesia over not receiving analgesia and those who had positive past experience with epidural preferred epidural over other modalities. Out-of-pocket cost (28%), duration of second stage of labor (26%) and pain score following treatment (18%) were the most important attributes.

CONCLUSION

Out-of-pocket cost was a major concern. Parturients prioritized having lower pain and shorter labor experience over risks associated with epidural analgesia. Parturients should be presented with realistic range of risks of side-effects so that they can decide how to balance risks against benefits and costs associated with child labor.

Mixed-methods systematic review: Childbearing women's views, experiences, and decision-making related to epidural analgesia in labour

AIMS

To investigate childbearing women's views, experiences and decision-making related to epidural analgesia in labour.

DESIGN

Mixed-methods systematic review.

DATA SOURCES

A comprehensive literature search was implemented across Medline, CINAHL and EMBASE from 2000 to September 2018. The literature search was undertaken in January 2018 and updated in September 2018. Thirty papers were selected.

RESULTS

Four overarching synthesized findings were identified: (a) choice; (b) pain management experience; (c) lack of information; and (d) information provision and consent.

REVIEW METHODS

Quality appraisal was conducted using JBI levels of evidence and other established tools. NVivo was used to independently dual code and thematically synthesize qualitative data. A narrative synthesis of the quantitative findings from the included studies was undertaken. The GRADE-CERQual approach was used to assess confidence in the review findings based on the qualitative data. A set of integrated mixed-methods synthesized findings was produced.

CONCLUSION

Recommendations for practice based on the systematic review findings are that midwives should dedicate time to discuss epidural with women and birth partners, ideally during the second or third trimester of pregnancy, asking women what coping strategies or pain relief they have been considering, if any. The factors which may influence the woman's choice of epidural, including pain threshold, ability to cope with pain, timing of epidural and length of labour should be continuously evaluated during labour. The midwife should remain with women after an epidural has been sited, demonstrating understanding of the woman's choice and providing an opportunity for discussion of plans for the remaining labour and birth.

IMPACT

The findings of this systematic review can inform both healthcare professionals and service users on various aspects of the decision-making process about the use of epidural analgesia in labour. Data can be transferable to similar settings in high-income countries.

Variables related to maternal satisfaction with intrapartum care in Northern Italy

BACKGROUND

The experience of labour and birth is complex, multidimensional and subjective and has the potential to affect the women and their families physically and emotionally. However, there is a lack of research around maternal satisfaction in Italy.

AIM

To evaluate mothers' satisfaction with their childbirth experience in relation to socio-demographic characteristics, obstetric history and intrapartum care variables.

METHODS

A cross-sectional study involving 277 women who had given birth in a low risk maternity unit in Northern Italy was undertaken. Satisfaction with birth was measured using the Italian version of the Birth Satisfaction Scale-Revised (I-BSS-R). The scale comprises three Sub-Scales: quality of care provided, personal attributes of women and stress experienced during childbirth.

FINDINGS

No socio-demographic variables were related to maternal satisfaction. Multiparous women had a higher satisfaction score (p=0.020; CI:0.23;2.75). Antenatal class attendance was negatively associated with maternal satisfaction (p=0.038; CI:-2.58; -0.07). Intrapartum variables that significantly reduced maternal satisfaction were: epidural usage (p=0.000; CI:-4.66; -2.07), active phase >12h (p=0.000; CI:-6.01; -2.63), oxytocin administration (p=0.000; CI:-5.08; -2.29) and vacuum assisted birth (p=0.001; CI:-6.50; -1.58). Women with an intact perineum were more likely to be satisfied (p=0.008; CI:-4.60; -0.69).

DISCUSSION

In accordance with other research, we showed that intrapartum interventions are negatively associated with maternal outcomes and therefore also with maternal satisfaction with birth. The sub-scale that measured Quality of Care provided scored higher than the other two Sub-Scales.

CONCLUSION

Further studies on maternal satisfaction in Italy should be conducted, using the I-BSS-R with the aim to compare outcomes and understand what matters to women during childbirth.

Exploring the medicalisation of childbirth through women's preferences for and use of pain relief

BACKGROUND

Sweden, along with other countries, is facing rising intrapartum intervention rates.

AIM

To explore the medicalisation of childbirth through women's preferences for and use of pain relief, and to investigate whether the presence of a birth plan had any impact on use of pain relief, rate of intervention, and satisfaction with the birth experience.

METHODS

The study was cross-sectional, and included 129 women with birth plans and 110 without, all of whom gave birth in one hospital in Sweden between March and June 2016. Data from birth plans and medical records was analysed through descriptive statistics and logistic regression.

FINDINGS

Parity rather than birth plan was a greater determinant for use of pain relief, frequency of interventions, and level of satisfaction; primiparas used more pain relief, had more interventions, and were less satisfied with their birth experiences than multiparas. Epidural analgesia was associated with a two to threefold increase in interventions, but 79.5% of all women had some form of intervention during birth, regardless of having an epidural or not. Women were generally highly satisfied with their birth experiences, women without epidural analgesia and interventions slightly more so.

CONCLUSION

Contrary to their initial plans, especially primiparas used more pharmacological pain relief than intended, and nearly all (94.6%) had some form of intervention during labour and birth. More interventions were associated with lower levels of satisfaction. The high rate of intervention in a healthy population of birthing women is disquieting and requires further attention.

The Effect of Massage Therapy Using Frangipani Aromatherapy Oil to Reduce the Childbirth Pain Intensity

BACKGROUND

Pain during labor is one of the worst pains experienced by women. If the woman cannot adapt to it, it may lead to uncoordinated uterine contractions causing a long-complicated labor with the possibility of death of the mother and baby.

PURPOSE

The aim of the study is to observe the effect of massage treatment using frangipani aromatherapy oil to reduce the childbirth pain intensity.

SETTING

Pembantu Dauh Puri Health Center Denpasar, Bali, Indonesia.

PARTICIPANTS

Pregnant women in labor.

RESEARCH DESIGN

A quasi-experimental research design was used with pretreatment and posttreatment groups and a control. The respondents were 70 pregnant women in labor in Pembantu Dauh Puri Health Center Denpasar, Bali, Indonesia. Data were collected during scheduled observation and were analyzed using the Mann-Whitney statistical test.

INTERVENTION

The participants in the treatment group were massaged with frangipani aromatherapy oil by rubbing and pressing the hand palms to the back region at thoracic vertebrae 10, 11, 12 and lumbar 1 levels. The women in the control group were massaged with virgin coconut oil in the same manner as that done to the treatment group.

MAIN OUTCOME MEASURE

This study aimed to investigate the potential of frangipani aromatherapy oil to be used as maternity care in helping pregnant women become more comfortable in the process of normal birthing, based on modified midwife examination form, which contain Numeric Rating Score (NRS), and interviews with the participants to measure the pain intensity.

RESULT

Before the massage treatment, most of the respondents experienced severe pain. While receiving massage without aromatherapy, respondents mostly still experienced severe pain. However, after a massage treatment using frangipani oil aromatherapy, most respondents experienced reduced pain. There was a statistically significant effect of massage treatment using frangipani aromatherapy oil on the childbirth pain intensity (p < .001).

CONCLUSION

In this study, massage treatment using frangipani oil aromatherapy decreased the childbirth pain intensity.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Predictors of traumatic birth experience among a group of Iranian primipara women: a cross sectional study

BACKGROUND

Traumatic birth experience has undesirable effects on the life of the mother, child, family, and society. The identification of predictive factors can be useful in improving birth experiences among women. This study aimed to assess the prevalence of a traumatic birth experience and identify its predictors among a group primiparous women.

METHODS

A cross-sectional study was conducted among 64 health centres in Tabriz, the second largest city in Iran. Cluster sampling was used to recruit 800 eligible women at one to 4 months postpartum. The Persian version of the Childbirth Experience Questionnaire was used to measure the womens' birth experiences. Data were collected through face to face interviews and analysed mainly by multivariable logistic regression.

RESULTS

The prevalence of traumatic birth experience was 37% in the study group. The independent predictors of the traumatic birth experience were related to antenatal and intrapartum factors. The antenatal predictor was the lack of exercise during pregnancy (OR = 2.81, CI 1.40-5.63, P = .003) and the intrapartum predictors were the absence of pain relief during labour and birth (OR = 4.24, CI 2.12-8.50, P < .001), and the fear of childbirth (OR = 3.47, CI 1.68-7.19, P < .001).

CONCLUSIONS

The findings revealed the high rate of traumatic birth experience among the primimarous women and identified the importance of a woman-centered care where a woman can actively make decision about the care she receives receive during labour and birth.

'It's your body, but…' Mixed messages in childbirth education: Findings from a hospital ethnography

OBJECTIVE

to investigate the personal, social, cultural and institutional influences on women making decisions about using epidural analgesia in labour. In this article we discuss the findings that describe practices around the gaining of consent for an epidural in labour, which we juxtapose with similar processes relating to use of water for labour and/or birth.

DESIGN

ethnography.

SETTING

tertiary hospital in Australian city.

PARTICIPANTS

sequential interviews were conducted with 16 women; hospital staff (primarily midwives and doctors) participated during six months of participatory observation fieldwork.

FINDINGS

women were not given full disclosure of either practice and midwives tailored the information they gave according to the institutional policies rather than evidence.

KEY CONCLUSIONS

informed consent is an oft-cited human right in health care, yet in maternity care the micro-politics of how informed consent is gained is difficult to ascertain, leading to a situation whereby the concept of informed consent is more robust than the reality of practice; an illusion of informed consent exists, yet information is often biased towards medicalised birth practices.

IMPLICATIONS FOR PRACTICE

as primary maternity care-givers, midwives have a role in providing unbiased information to women; however it appears that hospital culture and policy affect the way that this information is presented. It is arguable whether women in such instances are giving true informed consent, and for this reason, the ethics of these hidden practices are questioned.

Women's Experiences with Neuraxial Labor Analgesia in the Listening to Mothers II Survey: A Content Analysis of Open-Ended Responses

BACKGROUND

Most women who give birth in United States hospitals receive neuraxial analgesia to manage pain during labor. In this analysis, we examined themes of the patient experience of neuraxial analgesia among a national sample of U.S. mothers.

METHODS

Data are from the Listening to Mothers II survey, conducted among a national sample of women who delivered a singleton baby in a U.S. hospital in 2005 (N = 1,573). Our study population consisted of women who experienced labor, did not deliver by planned cesarean, and who reported neuraxial analgesia use (n = 914). We analyzed open-ended responses about the best and worst parts of women's birth experiences for themes related to neuraxial analgesia using qualitative content analysis.

RESULTS

Thirty-three percent of women (n = 300) mentioned neuraxial analgesia in their open-ended responses. We found that effective pain relief was frequently spontaneously mentioned as a key positive theme in women's experiences with neuraxial analgesia. However, some women perceived timing-related challenges with neuraxial analgesia, including waiting in pain for neuraxial analgesia, receiving neuraxial analgesia too late in labor, or feeling that the pain relief from neuraxial analgesia wore off too soon, as negative aspects. Other themes in women's experiences with neuraxial analgesia were information and consent, adverse effects of neuraxial analgesia, and plans and expectations.

CONCLUSIONS

The findings from this analysis underscored the fact that women appreciate the effective pain relief that neuraxial analgesia provides during childbirth. Although pain control was 1 important facet of women's experiences with neuraxial analgesia, their experiences were also influenced by other factors. Anesthesiologists can work with obstetric clinicians, nurses, childbirth educators, and pregnant and laboring patients to help mitigate some of the challenges with timing, communication, neuraxial analgesia administration, or expectations that may have contributed to negative aspects of women's birth experiences.

Moving beyond the debate: a holistic approach to understanding and treating effects of neuraxial analgesia

Neuraxial analgesia is here to stay, yet, spirited debate continues over potential harms and the quality of research that fails to identify them. This paper proposes moving beyond the debate and examining holistically the impact of neuraxial analgesia on the psychophysiology of mother and baby. A review of alterations in functioning of many systems is followed by a suggested four-part protocol to partially restore normal physiology and emotional well-being, and improve outcomes of neuraxial analgesia.