Epidural Analgesia and Back Pain after Labor

Enhancing functional recovery following postpartum femoral neuropathy: early neurorehabilitation and multidisciplinary obstetric care

Postpartum femoral neuropathy has a reported incidence of less than 1% and its total recovery time extends up to 6 months to a year. A multidisciplinary approach is vital to rule out permanent disability and to assure a correct diagnosis and earlier rehabilitation. We report a case of a 37-year-old puerperal woman with a history of intrapartum epidural analgesia, who presented post-labor unilateral lower-limb motor weakness and sensory loss, with functional compromise on independent gait. A multidisciplinary team consisting of an anesthesiologist, a physiatrist, a neurologist, and an obstetrician was then established. In the initial physiatry and neurology assessment, the patient reported pain (numerical rating scale 7/10) over the inguinal ligament, lower limb hypoesthesia, and muscle weakness. Femoral neuropathy was suspected. Magnetic resonance imaging ruled out potential complications related to the anesthetic procedure. The patient was then enrolled in a supervised rehabilitation program and, 3 weeks later, electrodiagnostic studies confirmed the initial suspicion. Two months later, the patient had regained lower-limb active range of motion and no pain nor paresthesia was reported. Our case report describes how an early multimodal rehabilitation program within a multidisciplinary framework allows for sooner neuromotor function improvement and activities of daily living independence.

Comparisons of nonpharmaceutical analgesia and pharmaceutical analgesia on the labor analgesia effect of parturient women

OBJECTIVE

We aimed to compare the labor analgesia effects of nonpharmaceutical analgesia and pharmaceutical analgesia on parturient women.

METHODS

One hundred and four parturient women with spontaneous births were selected and randomly divided into pharmaceutical and nonpharmaceutical analgesia groups. Before and after analgesia, the Visual Analogue Scale (VAS), parturient satisfaction with analgesia, serum pain stress factors (substance P [SP], neuropeptide Y [NPY], nerve growth factor [NGF], and prostaglandin E2 [PGE2]), duration of labor, vaginal bleeding at 2 h postpartum, postpartum urinary retention and dysuria incidence, Apgar score of 1 min and 5 min after birth, and neonatal cord blood gas analysis (pH, partial pressure of oxygen [PO₂ ], partial pressure of carbon dioxide [PCO₂ ], and lactate [Lac]) were compared in the two groups.

RESULTS

VAS scores were lower and the analgesia satisfaction was higher in the pharmaceutical analgesia group than in the nonpharmaceutical analgesia group (all p < .05). Serum levels of SP, NPY, NGF, and PGE2 in the pharmaceutical analgesia group were lower than those in the nonpharmaceutical analgesia group (all p < .05). The first and second stages of labor were longer and the bleeding volume at 2 h postpartum was greater in the pharmaceutical analgesia group than those in the nonpharmaceutical analgesia group (all p < .05). Reduced Lac and PCO₂ levels and increased PO₂ level were found in the pharmaceutical analgesia group in comparison to the nonpharmaceutical analgesia group (all p < .05).

CONCLUSION

This study demonstrates that the analgesic effect and neonatal condition of the pharmaceutical analgesia are better than the nonpharmaceutical analgesia, but the labor duration and postpartum bleeding volume of the pharmaceutical analgesia are greater than those of the nonpharmaceutical analgesia.

Chronic pain in parturients with an accidental dural puncture: A case-controlled prospective observational study

BACKGROUND

We set out to examine incidence of chronic headache and back pain in women with PDPH after accidental dural puncture during labor.

METHODS

Chronic headache, backache, and disability were assessed 18-24 months postpartum. Women with PDPH treated with epidural blood patch (PDPH-EBP) were identified and matched with women who had a PDPH without epidural blood patch (PDPH-no EBP), with women with uncomplicated epidural analgesia and with women without epidural analgesia. Our primary outcome was incidence of chronic headache and backache. Secondary outcome was the effect of epidural blood patch on chronic pain development. We used Chi-square or Fisher's exact test to calculate odds ratios.

RESULTS

There was no statistically significant difference in demographic characteristics between groups. In the no epidural group, no women reported chronic headache and 2/116 (1.7%) reported chronic backache. In the uncomplicated epidural group, no women reported chronic headache and 7/116 (6.0%) reported chronic backache. In the PDPH-no EBP group, 9/56 (16.1%) women reported chronic headache and 10/56 (17.9%) reported chronic backache. In the PDPH-EBP group, 12/59 (20.3%) had chronic headache and 14/59 (23.7%) had chronic backache. No women in the no epidural or uncomplicated epidural group reported disability (chronic pain score of 3 or 4). High disability was reported by 8.9% of women in the PDPH-no EBP group and by 8.4% in the PDPH-EBP group.

CONCLUSION

Women with PDPH had a high incidence of chronic headache, back pain, and disability. We did not find a statistically significant difference in chronic pain development between conservatively treated and EBP-treated patients.

Induction of labour as compared with spontaneous labour in low-risk women: A multicenter study in Catalonia

OBJECTIVE

To compare birth and neonatal outcomes in low-risk women undergoing induced labour with those undergoing spontaneous onset.

METHODS

This retrospective multicentre study included 30 public maternity hospitals in Catalonia between 2016 and 2017. The study population consisted of 5,717 women.

RESULTS

Of the 5,717 births, 75.8% had spontaneous onset and 24.2% had an induction. Induced labour was more likely at week 41 of gestation and in nulliparous women. Induced labour increased the likelihood of undergoing caesarean section (adjusted OR [ORa], 2.59; 95% confidence interval [CI], 2.11-3.16), assisted vaginal birth (ORa, 1.70; 95% CI, 1.46-1.98), epidural analgesia (ORa, 2.64; CI, 2.14-3.27), postpartum haemorrhage (ORa, 1.56; 95% CI, 1.14-2.15) and episiotomy (ORa, 1.26; 95% CI, 1.08-1.47). Induced labour was also associated with not performing skin-to-skin contact with the mother (ORa, 0.47; 95% CI, 0.39-0.58) and with not performing early breastfeeding (ORa, 0.49; 95% CI, 0.39-0.61).

CONCLUSIONS

The frequency of labour inductions among low-risk women exceeds the level recommended by scientific organisations in Catalonia and Spain, and is associated with adverse birth outcomes such as increased caesarean section rates, assisted vaginal births, and episiotomy rates. It is also associated with the failure to perform early skin-to-skin contact with the mother and failure to initiate early breastfeeding.

The Incidence of and Risk Factors for Localized Pain at the Epidural Insertion Site After Epidural Anesthesia: A Prospective Survey of More Than 5000 Cases in Nonobstetric Surgery

Background

This prospective research aimed to determine the incidence of and risk factors for localized pain at the epidural insertion site following nonobstetric surgery performed with epidural anesthesia.

Methods

A total of 5083 surgical inpatients at the teaching hospital undergoing epidural anesthesia were included in the study. The characteristics of the patients, preoperative basic diseases, details of the epidural techniques, surgical procedures and complications were recorded pre-anesthesia until the complications resolved. Multivariate logistic regression analysis was performed to identify predictors of localized pain at the epidural insertion site.

Results

In our analysis, target complications were reported in 532 (10.5%) patients; localized pain at the epidural insertion site occurred in 460 (9.05%) patients, while other major complications occurred in 72 (1.45%) patients. A total of 334 patients had mild pain, and 126 patients had moderate pain. The incidence of localized pain at the epidural insertion site was highest among all complications, and the identified risk factors in the multivariate analysis were as follows: lumbar insertion (odds ratio, 1.77; 95% CI 1.33–2.35), age less than 50 years old (odds ratio, 1.56; 95% CI 1.29–1.89), multiple block attempts (odds ratio, 3.39; 95% CI 2.68–4.31), and postoperative patient-controlled epidural analgesia (odds ratio, 0.46; 95% CI 0.33–0.63).

Conclusion

Localized pain at the epidural insertion site is the most common complaint after epidural anesthesia and requires adequate clinical attention. Improving the proficiency of anesthesiologists to avoid repeated punctures is the best way to reduce injuries.

Labor epidural analgesia versus without labor epidural analgesia for multiparous women: a retrospective case control study

BACKGROUND

Labor epidural analgesia (LEA) effectively relieves the labor pain, but it is still not available consistently for multiparous women in many institutions because of their obviously shortened labor length.

METHODS

A total of 811 multiprous women were retrospective enrolled and firstly divided into two groups: LEA group or non-LEA group. And then they were divided into seven subgroups and analyzed according to the use of LEA and cervical dilation. The primary outcomes (time intervals, blood loss and Apgar scores) and secondary outcomes (maternal demographic characteristics and birth weight) were collected by checking electronic medical records.

RESULTS

The prevalence of using LEA in multiprous women was 54.5 %. Using LEA significantly lengthened the duration of labor stage by 56 min (P < 0.001), increased the blood loss (P < 0.001) and lowered Apgar scores (P = 0.001). In the comparison of sub-group analysis, using LEA can obviously prolong the duration of first-second stage in women with 2 cm cervical dilation (P < 0.001) and 3 cm cervical dilation (P = 0.014), while there was no significant difference with 4 cm or more cervical dilation (P = 0.69). Using LEA can significantly increased the blood loss when the initiation of LEA in the women with 2 cm cervical dilation (P < 0.001) and 3 cm cervical dilation (P = 0.035), meanwhile there were no significantly differences in the women with 4 cm or more cervical dilation (P = 0.524). Using LEA can significantly lower the Apgar scores when the initiation of LEA in the women with 2 cm cervical dilation (P = 0.001) and 4 cm or more cervical dilation (P = 0.025), while there were no significantly differences in the women with 3 cm cervical dilation (P = 0.839).

CONCLUSIONS

Labor epidural analgesia for the multiparous woman may alter progress of labor, increase postpartum blood loss and lower Apgar scores. Early or late initiation of LEA should be defined as with cervical dilatation of less or more than 3 cm and the different effect should be understand.

TRIAL REGISTRATION

ChiCTR2100042746. Registered 27 January 2021-Prospectively registered, http://www.chictr.org.cn .

Oxytocin Administration in Low-Risk Women, a Retrospective Analysis of Birth and Neonatal Outcomes

Background: In recent years, higher than the recommended rate of oxytocin use has been observed among low-risk women. This study examines the relationship between oxytocin administration and birth outcomes in women and neonates. Methods: A retrospective analysis of birth and neonatal outcomes for women who received oxytocin versus those who did not. The sample included 322 women with a low-risk pregnancy. Results: Oxytocin administration was associated with cesarean section (aOR 4.81, 95% CI: 1.80–12.81), instrumental birth (aOR 3.34, 95% CI: 1.45–7.67), episiotomy (aOR 3.79, 95% CI: 2.20–6.52) and length of the second stage (aOR 00:18, 95% CI: 00:04–00:31). In neonatal outcomes, oxytocin in labor was associated with umbilical artery pH ≤ 7.20 (OR 3.29, 95% CI: 1.33–8.14). Admission to neonatal intensive care unit (OR 0.56, 95% CI: 0.22–1.42), neonatal resuscitation (OR 1.04, 95% CI: 0.22–1.42), and Apgar score <7 (OR 0.48, 95% CI: 0.17–1.33) were not associated with oxytocin administration during labor. Conclusions: Oxytocin administration during labor for low-risk women may lead to worse birth outcomes with an increased risk of instrumental birth and cesarean, episiotomy and the use of epidural analgesia for pain relief. Neonatal results may be also worse with an increased proportion of neonates displaying an umbilical arterial pH ≤ 7.20.

Comparison of ropivacaine plus sufentanil and ropivacaine plus dexmedetomidine for labor epidural analgesia: A randomized controlled trial protocol

OBJECTIVE

Effective analgesia during delivery can not only decrease pain, but also have a significant function in ensuring the safety of baby and mother. Sufentanil is generally used opioid with ropivacaine in epidural anesthesia in labor pain management; however it can cause some adverse reaction. Dexmedetomidine is an a2-adrenoceptor agonist with high selectivity. It possesses opioid-sparing and analgesic effects and it is suitable for the long-term and short-term intraoperative sedation. The purpose of this present study is to compare the analgesic effect of ropivacaine with dexmedetomidine against ropivacaine with sufentanyl in epidural labor.

METHODS

This is a single center, placebo-controlled randomized trial which will be performed from May 2020 to May 2021. It was authorized via the Institutional Review Committee in the first medical center of Chinese PLA General Hospital (S2018-211-0). One hundred sixty full-term protozoa are included in this work. They are randomly divided into four groups (n = 40 per group): the RD1 group (with the epidural administration of 0.125% ropivacaine + dexmedetomidine of 0.5 μg/mL), and the RD2 group (with the epidural administration of 0.08% ropivacaine + dexmedetomidine 0.5 μg/mL), the RS1 group (with the epidural administration of 0.125% ropivacaine + sufentanil of 0.5 μg/mL), as well as RS2 group (with the epidural administration of 0.08% ropivacaine + sufentanil of 0.5 μg/mL). Clinical outcomes are pain score, a modified Bromage scale, the Ramsay Sedation Scale, and adverse reactions during analgesia. All the needed analyses are implemented through utilizing SPSS for Windows Version 20.0.

RESULTS

The first table shows the clinical outcomes between these four groups.

CONCLUSION

This current work can provide a primary evidence regarding the clinical outcomes of dexmedetomidine versus sufentanil for labor epidural analgesia.

TRIAL REGISTRATION

This study protocol was registered in Research Registry (researchregistry5877).