Epidural Use Research Articles

Labor epidural analgesia among Han and Uyghur parturients: a prospective observational study in China

BackgroundDisparities in pain sensitivity and tolerance have been described, however, little is known about variability in the experience of labor pain and childbirth in China. MethodsThis prospective observational study was conducted at a tertiary hospital in Xinjiang, China with two major ethnic groups: Han and Uyghur women. Women with a vaginal delivery with labor epidural analgesia were enrolled. The primary outcome was cervical dilation at labor epidural analgesia request, and multivariable linear regression analysis was performed to determine associated variables. Secondary outcomes were pain score at epidural request and epidural analgesics use. Data presented as mean ± standard deviation. ResultsCervical dilatation at labor epidural analgesia request was significantly lower (1.2 ± 0.7 vs. 0.8 ± 0.6 cm; p=0.0095), and pain score (numerical pain scale 0-10) was significantly higher (0.8 ± 1.0 vs. 4.2 ± 1.2; p=0.0002) among Uyghur compared to Han women. In the multivariate model, Uyghur women had a lower cervical dilation (p=0.0392) and a higher pain score (p<0.0001) at epidural request. During the labor process, a larger proportion of Uyghur women used the patient-controlled epidural analgesia (PCEA) pump (77.8% vs 53.6%, p=0.0011). They pressed the pump in a significantly shorter time (61.3±41.2 vs 104.0±105.2min, p=0.0015) and for more times (1.9±1.7 vs 1.2±1.4, p=0.0022), contributing to significantly more epidural analgesic use (sufentanil: 0.06±0.02 vs 0.07±0.03 μg/kg/h, p=0.0150, ropivacaine: 0.11±0.04 vs 0.14±0.06 mg/kg/h, p=0.0003, respectively). ConclusionsOur findings suggest that Uyghur women experience labor pain with higher levels of pain with a higher use of epidural analgesics than Han women. Further studies are needed to evaluate whether these differences are clinically relevant.FundingThis study was funded by the National Natural Science Foundation of China (No. 72074162).Ethics and Trial registration: Ethical approval was obtained (www.chictr.org.cn Identifier: ChiCTR2200062630).

Worth the pain? Postoperative epidural anesthesia use in gynecologic surgery

Worth the pain? Postoperative epidural anesthesia use in gynecologic surgery

Worth the pain? Postoperative epidural anesthesia use in gynecologic surgery

Worth the pain? Postoperative epidural anesthesia use in gynecologic surgery

A Validated Calculator to Estimate Risk of Chorioamnionitis in Laboring and Induced Patients at Term.

Chorioamnionitis is associated with neonatal morbidity and infection-related mortality, but our ability to predict intrapartum infection is limited. We sought to derive and validate a prediction model for chorioamnionitis among patients presenting to labor and delivery at term. This was a planned secondary analysis of a large cohort study from 2014 through 2018 at an academic tertiary care center. To derive a prediction model for chorioamnionitis, we limited our analysis to full-term (≥37 weeks) patients with a singleton gestation undergoing labor induction and presenting in labor. Both nulliparous and multiparous patients were included. Patients with a planned cesarean delivery, fever on admission, or missing data were excluded. The model was derived using multivariable logistic regression. Refinement of the prediction model with internal calibration was performed. External validation was performed utilizing a publicly available database (Consortium on Safe Labor) and applying the same inclusion and exclusion criteria. The discriminative power of each model was assessed using a bootstrap, bias-corrected area under the curve. The chorioamnionitis rates in the derivation and external validation groups were: 5% (1,005/19,966) and 5.8% (n = 3,005/52,171), respectively. In multivariable modeling, maternal age, nulliparity, gestational age, smoking status, group B streptococcus colonization, hours ruptured, number of cervical exams, length of labor, epidural use, internal monitoring, and meconium were significantly associated with infection. A calculator was created and externally validated with an area under the curve of 0.82 (95% confidence interval, 0.81-0.82). External validity was further confirmed with a calibration intercept of 0.81. This is the first infection calculator created and validated for the prediction of developing chorioamnionitis in patients undergoing induction of labor at term. This calculator can be used to augment patient counseling and guide intrapartum infection surveillance in laboring patients.

Hydrotherapy During Labor and Birth in Water: A Review of Current Researches

Hydrotherapy is one of the most nonpharmacological methods for pain management in labor, where water at different temperatures is used to treat diseases and reduce pain. The American College of Obstetricians and Gynecologists states that hydrotherapy can be used in the first stage of labor, but there is insufficient evidence on the outcomes of water birth. When the effects of hydrotherapy were examined according to the stages of labor, it was determined that it had an effect on pain, anxiety, comfort level, sympathovagal balance, parenting behavior and active phase duration in the first stage of labor. In the second stage of labor; epidural and opioid use, maternal pain, episiotomy use, intact perineum, shoulder dystocia and duration of labor. In the postpartum period, it has been reported to have an effect on the incidence of postpartum hemorrhage, birth satisfaction and women's sense of autonomy, shorten the duration of hospitalization and increase the rate of breastfeeding. When the effects of water birth on the newborn are examined, it is determined that it has an effect on body temperature, arterial and venous pH, while it has no effect on Apgar. Although there are various studies on water birth in the literature, more studies are needed to obtain evidence-based results. The aim of this review is to examine the current research results of hydrotherapy applied in the first stage of labor and the second stage of labor in water (water birth) in the last 5 years.

Predictors of a positive birth experience in childbirth: A cross-sectional study

BackgroundRecognizing predictors of positive birth experience is viewed as essential for minimizing negative experiences during childbirth that are related to current obstetric care, especially when those could be attributed to intrapartum interventions. The CEQ-E is a suitable instrument for investigating maternal birth experience within the Spanish population, highlighting the necessity to identify predictors for all its domains. This study aimed to identify predictors of positive birth experience based on socio-demographic and clinical variables, and obstetric interventions. MethodsCross-sectional study conducted with consecutive sampling (N = 301). Quantitative data were collected by the Childbirth Experience Questionnaire (CEQ-E) and an Ad hoc questionnaire. Clinical data was obtained from participants' medical records. Descriptive, bivariant and multivariant analysis were performed. ResultsThe CEQ overall mean score was 3.18(SD:0.42), showing the highest score for the professional support (3.79; SD: 0.43) and the lowest for the own capacity (2.8; SD:0.57). All domains and overall score showed negative correlations with the number of intrapartum interventions (p ≤ .001). Inductions of labour, instrumental deliveries, and caesarean sections were inversely related to; overall birth experience score (p ≤ .001), perceived safety (p ≤ .001), and own capacity (p ≤ .001). Epidural analgesia was linked to worse values of birth experience (p ≤ .001). Predictors of positive birth experience were identified as having a midwife as birth attendant (p ≤ .001) and neonatal higher Apgar scores at birth (p ≤ .001), whereas higher maternal education grade (p = .04), inductions of labour (p ≤ .001) and caesarean births (p ≤ .001) had worse values on birth experience. ConclusionWomen reported a positive birth experience, and professional support was highly valued. Key predictors of lower scores in birth experience included higher maternal education, caesarean and instrumental deliveries, and neonatal intensive care unit (NICU) admission. Spontaneous labour onset predicted better capacity and safety. Epidural use decreased participation. Midwife-attended births reported better scores on birth experience, highlighting their importance in maternal care.

374. INCIDENCE AND PREDICTORS OF STRICTURE DEVELOPMENT FOLLOWING ESOPHAGECTOMY: A RETROSPECTIVE ANALYSIS

Abstract Objective Anastomotic stricture (AS) is a well described complication after esophagectomy and not only affects nutritional status but also has a detrimental impact on long-term quality of life. This retrospective study explores the incidence of clinically relevant AS in patients undergoing esophagectomy for cancer and investigates the potentially reversible factors associated with AS. Methods A prospectively entered clinical database of consecutive patients undergoing esophagectomy at a high-volume referral center over a decade (1/2013-12/2022) was queried for the presence of post-operative clinically significant AS, defined as stricture requiring endoscopic dilation. Multiple variables encompassing patient-related risk factors, tumor pathology, prior treatment, operative factors, and post-op complications were included in logistic regression analyses to delineate predictors of stricture formation. Results Of 1015 patients in the database, 115 (11.3%) developed AS requiring at least 1 post-op dilation. Although higher American Society of Anesthesiologists (ASA) grading was associated with elevated AS rate impact with most patients being ASA 2 and 3; 24% and 49% respectfully (p &amp;lt; 0.05). Specific patient factors/comorbidities such as age, peripheral or coronary vascular disease, and diabetes mellitus did not emerge as significant predictors. Surprisingly, neither histology, nor neoadjuvant therapy (chemo or chemoradiation) were associated with AS. Both a cervical anastomosis and a intra-operative pyloromyotomy had a higher AS rate than an intra-thoracic anastomosis (OR 13.3, p=0.006) and patients without a myotomy (p=&amp;lt;0.006). Other operative factors including approach (open vs MIE) conduit type (stomach/jejunum/colon) or width (3/4/5/6 cm) did not impact AS rate. All patients had a hand-sewn anastomosis. No post-operative outcome measures (e.g. leak, epidural use, hypotension) was associated with the development of AS. Conclusion Our results highlight the interplay of patient-related risk factors, tumor pathology, prior treatment, and operative factors in the development of post esophagectomy strictures. Understanding these predictors could potentially influence risk stratification and may facilitate tailored postoperative care strategies for improved patient outcomes.

Antenatal education incorporating complementary medicine techniques for labour and birth to reduce the rates of epidural in primiparous women: A randomised control trial

ProblemGlobally medical management of labour and birth has significantly increased, with epidurals attributed to the cascade of interventions. BackgroundThere are few randomised control trials that evaluate the effectiveness of antenatal education programs. A previous trial at two Australian hospitals found an antenatal program of integrative complementary therapies significantly reduced rates of interventions for low-risk primiparous women. AimTo reduce rates of intervention in labour and birth, with a primary outcome of decreased epidural use during labour. MethodsLow to moderate risk primiparous women were randomised at 24–36 weeks’ gestation to the intervention group and standard care, or standard care alone. Clinical and psychological measures were analysed by intention-to-treat. Trial registration ACTRN12618001353280 FindingsIn total, 178 women participated (n = 88 intervention, n = 90 Standard care), demographic characteristics were similar between groups, almost half (49 %) reported a pre-existing medical condition, and wellbeing scores fell within the average range. Epidural use was lower in the intervention group (47.7% vs 56.7 %) with higher rates of vaginal birth (52.3% vs 42.2 %), however, no statistical differences for birth outcomes were found between groups. Attitude to childbirth scores were statistically higher for women who attended the intervention (59.1 vs 54.3 p00.001). DiscussionHigher psychometric scores demonstrated women in the intervention group felt an increased sense of coping and control. Antenatal education that includes complementary therapies can reduce fear and improve attitudes about childbirth. ConclusionsReplicating study protocols enabled the generalisability of findings to a more diverse group of women, and data will contribute to a larger meta-analysis design to detect smaller treatment effects for operative birth.

Brain Training to Facilitate Labor and Birth: Impact of a Mobile Health Application

The purpose of this study was to evaluate the effects of cognitive training strategies, inclusive of mindfulness-based techniques and pain neuroscience education (PNE), during pregnancy. Using a pre–posttest design, primiparous women seeking a physiological birth used a novel mobile application (GentleBirth) and a web-based PNE course as a means of labor/birth preparation. Self-report questionnaires at baseline, prebirth, and postbirth assessed all studied outcomes (pain knowledge, pain and birth self-efficacy, and birth outcomes). Use of the GentleBirth app combined with PNE during pregnancy was associated with improved pain knowledge, χ2(2) = 95.9,p&lt; .001, and birth self-efficacy,F(2, 268) = 71.54,p&lt; .001; high rates of labor coping, 7.48 (standard deviation 2.29); and lower rates of cesarean births and epidural use.

The effect of longer epidural duration after open pancreaticoduodenectomy on pain and mobilisation: A retrospective single-centre analysis.

The optimal length of epidural use following open pancreaticoduodenectomy has not been defined. The aim of this study was to investigate whether the length of patient-controlled epidural analgesia affected pain and ability to mobilise on epidural termination following open pancreaticoduodenectomy in the context of enhanced recovery after surgery. A retrospective single-centre cohort analysis was performed between November 2015 and December 2021 on patients who underwent open pancreaticoduodenectomy. As part of a continual review process of the enhanced recovery after surgery protocol, patient-controlled epidural analgesia duration changed allowing stratification of patients into either three- or five-day patient-controlled epidural analgesia groups. Of the 196 patients identified, 157 were included with 80 (50.9%) and 77 (49.1%) allocated to the three-day and five-day patient-controlled epidural analgesia groups, respectively. Patient-controlled epidural analgesia termination on postoperative day 3 was associated with transiently higher pain and less mobilisation, although no greater rescue analgesia requirement. Conversely, longer patient-controlled epidural analgesia usage following open pancreaticoduodenectomy was associated with less pain and greater mobilisation in the immediate postoperative period. Earlier patient-controlled epidural analgesia termination transiently leads to increased pain and decreased mobilisation following open pancreaticoduodenectomy. Ensuring appropriate analgesia requirements or longer patient-controlled epidural analgesia usage should be considered to avoid patient discomfort and enhance recovery.

Prophylactic cosyntropin after unintentional dural puncture and incidence of post-dural puncture headache and epidural blood patch use: A retrospective cohort study (2019–2022)

BackgroundCosyntropin has been suggested to decrease the incidence of post-dural puncture headache (PDPH) by increasing the production of cerebrospinal fluid. This study examined the association of prophylactic cosyntropin administration with the incidence of PDPH and its management with an epidural blood patch after an unintentional dural puncture (UDP). MethodsWe conducted a retrospective cohort study of cases with UDP during placement of neuraxial labor analgesia. Per institutional practice and at the discretion of the anesthesiologist, intravenous cosyntropin 1 mg may be administered for PDPH prophylaxis. PDPH, time from UDP to cosyntropin administration, time to development of PDPH, and management with epidural blood patch(es) were recorded. ResultsCosyntropin was administered in 164 of 234 (70%) cases with UDP. PDPH occurred 98/164 (60%) with cosyntropin and 45/70 (64%) without cosyntropin (p = 0.66). The PDPH adjusted incidence was 53% with cosyntropin and 62% without cosyntropin, difference 9% (95% CI −6% to 24%, p = 0.25). The adjusted epidural blood patch rate was 66% with cosyntropin and 78% without cosyntropin, difference of 12% (95% CI −5% to 28%, p = 0.17). ConclusionsProphylactic cosyntropin following UDP was not associated with a significant decrease in PDPH rate or use of epidural blood patch for management of PDPH. There was no significant difference in the rate of adverse hyperglycemic or hypertensive events amongst those who did or did not receive cosyntropin.

Influence of smoking and socioeconomic status on labor analgesia: a nationwide register-based study in Finland

PurposeLabor pain can be treated by medical and non-medical analgesia. Smoking during pregnancy has been shown to increase the incidence of several complications and may influence analgesic effectiveness. Previous studies have linked socioeconomic status to the use of epidurals for labor analgesia. We aimed to determine whether smoking and socioeconomic status influence the use of labor analgesia in Finland.MethodsFrom January 1, 2004 to December 31, 2018, we collected data from the national Finnish Medical Birth Register on smoking status, labor analgesia, and socioeconomic status during pregnancy. These categorized variables were presented as absolute numbers and percentages. We included data on singleton pregnancies and excluded any data on pregnancies that missed smoking or socioeconomic status.Results71,603 women smoked during the first trimester, 42,079 women continued to smoke after the first trimester, and 641,449 were non-smokers. The four most used labor analgesia were nitrous oxide, epidural, other medical analgesia, and non-medical analgesia. The most frequently used analgesia was nitrous oxide, which was used by 60.8% of the group of smokers after the first trimester, 58.8% of smokers during the first trimester, and 54.5% of non-smokers. There were no substantial differences between socioeconomic status classes and labor analgesia used.ConclusionWomen who continued smoking after the first trimester used labor analgesia more often than non-smokers. There were no clear differences between socioeconomic status classes and labor analgesia used. These findings highlight the need to reduce maternal smoking during pregnancy, and universal social healthcare systems should promote equality in labor analgesia.

The effect of antenatal hypnosis training on pharmacological analgesia use during labour and birth: A systematic review and meta-analysis

BackgroundThe use of hypnosis as a means of pain management during labour is becoming increasingly popular. While recent reviews have reported on pain perception, relaxation and other psychological benefits the impact of hypnosis on the use of pharmacological analgesia use has not been specifically examined. QuestionFor women in labour at term, does antenatal hypnosis instruction compared to no instruction result in decreased use of pharmacological analgesia and influence maternal and infant birth outcomes. MethodsDatabases such as PubMed, CINAHL, Cochrane Central Register of Controlled Trials and Embase were searched with dates ranging from 1947-2024. We included randomised controlled trials (RCTs) that compared antenatal hypnosis training to no hypnosis control groups, published in English and reported on pharmacological analgesia use. The Cochrane's Risk of Bias 2 for RCTs was used to assess design quality. Study selection, quality assessment, data extraction and analysis were undertaken by two independent researchers. FindingsSix RCTs met the inclusion criteria (n=2937). The use of hypnosis did not result in a significant reduction in the risk of epidural use (RR. 0.79 95% CI 0.39-1.61) or other forms of pharmacological analgesia. Factors such as blinding of care providers to the participants allocated group may have reduced the chances of successful use of hypnosis. Variations in the presentation of hypnosis between studies may also impact on outcomes. Discussion and ConclusionThis review reports no effect on the use of pharmacological analgesia in women trained in hypnosis antenatally compared with those who were not. Our review does highlight several RCT design characteristics that could impact on the measurement and analysis of the use and efficacy of hypnosis.

Early Opioid Use and Postoperative Delirium Following Open Abdominal Aortic Aneurysm Repair

Postoperative delirium is a common complication following open abdominal aortic aneurysm repair (OAR). Opioids have been found to contribute to delirium, especially at higher doses. This study assessed the impact of early postoperative opioid analgesia on postoperative delirium incidence and time to onset. We hypothesized that higher early postoperative opioid utilization would be associated with increased postoperative delirium incidence. This was a retrospective analysis of OAR cases at a single quaternary care center from years 2012-2020. The primary exposure was oral morphine equivalents use (OME), calculated for postoperative days 1-7. A cut point analysis using a receiver operator curve for postoperative delirium determined the threshold for high OME (OME>37mg). The primary outcome was postoperative delirium incidence identified via chart review. Multivariable logistic regression was performed for postoperative delirium and adjusted for covariates meeting P<0.1 on bivariate analysis. Among 194 OAR cases, 67 (35%) developed postoperative delirium with median time to onset of 3days (IQR=2-6). Patients with postoperative delirium were older (74years vs. 69years), more frequently presented with symptomatic AAA (47% vs. 27%) and had a higher proportion of comorbidities (all P<0.05). Cases with high OME utilization on postoperative day 1 (55%) were younger (69 vs. 73years), less frequently had an epidural (46% vs. 77%), and more frequently developed delirium (42% vs. 25%, all P<0.05). Epidural use was associated with a significant decrease in OME utilization on postoperative day 1 (33 vs. 83, P<0.01). Postoperative delirium onset was later in those with high OME use (4 vs. 2days, P=0.04). On multivariable analysis, high OME remained associated with postoperative delirium (Table II). High opioid utilization on postoperative day 1 is associated with increased postoperative delirium and epidural along with acetaminophen use reduced opioid utilization. Future study should examine the impact of opioid reduction strategies on outcomes after major vascular surgery.

Hydrotherapy in Pain Management in Pregnant Women: A Meta-Analysis of Randomized Clinical Trials.

Background: the benefits of water are significant during the birth process. Improved maternal experience of labor, less use of epidurals, better pain management, shorter labor, and a greater sense of control are observed during the birth process. Objective: This report aims to determine the benefits of hydrotherapy in clinical childbirth approaches and its applicability in pain control. Methods: A meta-analysis of randomized clinical trials selected from various databases with no publication date limits was conducted, comparing groups that did not use hydrotherapy with groups that did during labor. Results: Seven articles met the inclusion criteria, with five articles using hot water immersion and two using hot water shower as hydrotherapy treatments. This study identified 840 participants, with the intervention groups including 417 term pregnant women and the control groups including 423 pregnant women. The effect size of hydrotherapy on pain was calculated using the visual analog scale in five articles and analgesic use in the other two articles. Hydrotherapy significantly reduced pain during labor with a mean difference of -0.97 (95% CI: -1.91 to -0.03; I2 = 97.32%, p < 0.001). The duration of the first stage of labor was not significantly affected, with a mean difference of -0.17 h (95% CI: -0.55 to 0.21; I2 = 56.75%, p = 0.059). Additionally, hydrotherapy did not significantly impact the newborns' Apgar scores at 5 min, with a mean difference of 0.18 (95% CI: -0.48 to 0.85; I2 = 2.15%, p = 0.939). Conclusions: Hydrotherapy is beneficial for pain control in the first stage of labor and does not increase its duration or negatively affect the Apgar score of newborns.

Maternity Service Delivery in Manitoba, Canada: A Retrospective Analysis of Three Maternity Care Provider Types

Background: Alleviating shortages in health workforce and delivery of efficient maternity care models are unresolved policy issues in Canada. In the province of Manitoba, obstetricians do the majority of maternity care, family practice physicians take care of low-risk women, and midwives continue to deliver care to about 5% of the low-risk pregnant women. The purpose of this study was to describe how maternity care is provided in Manitoba, based on a revised definition of Most Responsible Provider, and to compare maternal and perinatal outcomes by provider type. Methods: Administrative data were used from the Manitoba Centre for Health Policy (MCHP) to select women who had a low-risk pregnancy. Descriptive statistics and logistic regression were used to examine differences in types of intervention, mode of delivery, and outcomes by provider type among low-risk women. Logistic regression models controlled for socio-demographic and birth-related covariates. Results: From 2004/05 to 2012/13, there were a total of 132,918 births in Manitoba. Of those births, 47,083 were identified as high risk (35%), and 85,835 (65%) were identified as low risk. Key findings demonstrate midwifery care compared to obstetrical care was associated with lower odds of interventions such as cesarean section (0.47 [0.40–0.54]), induction (0.42 [0.39–0.49]), and episiotomy (0.48 [0.41–0.55]), but higher odds of postpartum hemorrhage (1.35 [1.18–1.55]), and shorter lengths of stay in hospital (-0.58 [-0.61-0.56]). Family practice physicians also had decreased odds of assisted vaginal delivery (0.82 [0.76–0.89]), epidural use (0.59 [0.57–0.62]) and third- and fourth-degree tears (0.82 [0.73–0.92]), but higher odds of augmentation (1.06 [1.01–1.11]). Results reported for midwives and family practice are compared to obstetricians. Conclusions: A health workforce strategy that optimizes how to address the maternity care needs in the province of Manitoba is needed. There is suboptimal integration of midwifery services that could meet the low-risk population needs. Human health workforce development requires a good understanding of each provider’s role, opportunities for collaboration and integration to be strengthened, and the potential to optimize the outcomes for mothers and infants. This article has been peer reviewed.

Getting it right with discrete choice experiments: Are we hot or cold?

Discrete Choice Experiments (DCEs) are widely employed survey-based methods to assess preferences for healthcare services and products. While they offer an experimental way to represent health-related decisions, the stylized representation of scenarios in DCEs may overlook contextual factors that could influence decision-making. The aim of this paper was to evaluate the predictive validity of preferences elicited through a DCE in decisions likely influenced by a hot-cold empathy gap, and compare it to another commonly used method, a direct-elicitation question. We focused on preferences for pain-relief modalities, especially for an epidural during childbirth - a context where direct-elicitation questions have shown a preference for or intention to have a natural birth (representing the “cold” state), yet individuals often opt for an epidural during labor (representing the “hot” state). Leveraging a unique dataset collected from 248 individuals, we incorporated both the stated preferences collected through a survey administered upon hospital admission for childbirth and the actual pain-relief modality usage data documented in medical records. The DCE allowed for the evaluation of scenarios outside of those expected by respondents to simulate decision-making during childbirth. When we compared the predicted epidural use with the actual epidural use during labor, we observed a choice concordance of 71-60%, depending on the model specification. The concordance rate between the predicted and actual choices increased to 77-76% when accounting for the initial use of other ineffective modalities. In contrast, the direct-elicitation choices, relying solely on respondents’ baseline expectations, yielded a lower concordance rate of 58% with actual epidural use. These findings highlight the flexibility of the DCE method in simulating complex decision contexts, including those involving hot-cold empathy gaps. The DCE proves valuable in assessing nuanced preferences, providing a more accurate representation of the decision-making processes in healthcare scenarios.

Retrospective Case-Control Study of Extended Birth Perineal Tears and Risk Factors.

A perineal tear is a rupture of the skin or muscle between the vagina and anus (perineum). A third-degree tear is one type of extended perineal tear (EPT), and it involves the penetration of the anal sphincter muscle.Another type of EPT is a fourth-degree laceration, which penetrates deeper into the lining of the anus or rectum. The stretching of the perineum during childbirth may result in perineal trauma. Invasive surgical interventions are required for the treatment of EPTs.For this reason, the reduction of their incidence can be achieved by fully comprehending the risk aspects associated with them. The aim of this study is to contribute to the body of knowledge by providing insight into the various risk factors that are associated with extended perineal trauma.By following this path, this study aims to contribute to and advance Saudi Arabia's development of evidence-oriented obstetric care recommendations. The current study is a case-control study where a review of 5000 vaginal delivery records was carried out between March 1, 2018, and March 19, 2023. For the study, cases (n = 71) were female patients who had documented greater than second-degree perineal injury.The control group (n = 238) was randomly chosen from women who had vaginal delivery but with less or equal to a second-degree perineal laceration. For each patient, we reviewed medical and obstetrics records for the following characteristics: age of diagnosis, gestational age, parity, labor induction, second-stage labor duration, mode of delivery, infant birth weight, epidural use and episiotomy indication, healthcare worker (HCW) experience,and APGAR (appearance, pulse, grimace, activity, and respiration) score. From the 5000 births analyzed, the cases were 71 patients (1.42% of 5000 births).The mean age at diagnosis in our sample was (28.05 ± 4.66 years).The study's results showed that the following variables significantly affected the occurrence of EPTs: birth weight, labor durations, parity, HCW experience, and mode of delivery.The odds for tears were 3.69 (95% CI: 0.156-0.469) higher in nulliparous patients relative to multiparous patients. Instrumental deliveries resulted in more tears than non-instrumental deliveries with an odds ratio (OR) of 5.901 (95% CI: 2.443-14.525). This study also found that prolonged second-stage labor seems to be associated with an increased risk of perineal damage. HCW experience was looked at in relation to the increased incidence of EPTs, which showed that midwives had a lower incidence rate than physicians with an ORof 2.25 (95% CI: 1.169-4.366). Epidural usage has also been significantly associated with a lesser incidence of perineal tears, which indicates that using epidural could protect against the occurrence of EPTs. In conclusion,the occurrence of perineal lacerations could be prevented during childbirth by taking preventative measures and having more precise judgments. Epidural was a protective factor in our study against the incidence of extensive perineal tearing.Furthermore, as compared to midwives, our study showed that the majority of EPTS occurred in cases of physicians (residents/consultants). Further research, proper documentation, and the development of evidence-based guidelines are needed to improve perineal care and reduce EPTincidence.

Intercostal nerve cryoablation as part of an opioid-sparing protocol reduces opioid and epidural use after lung transplant

IntroductionInadequate pain control after lung transplantation increases perioperative complications. Standard opioid-based regimens are associated with adverse effects and epidural catheters that reduce opioid use are limited by contraindications and technical challenges. We report the use of intercostal nerve cryoablation to enhance perioperative pain control as part of an opioid-sparing protocol for lung transplant recipients (LTR). MethodsWe conducted a retrospective cohort study of LTRs from 1/1/2016-12/31/2021, before (pre-cryo) and after (post-cryo) initiation of an opioid-sparing protocol utilizing intraoperative intercostal nerve cryoablation. The pre-cryo cohort included consecutive patients treated with opioids and selective use of epidural catheters. The post-cryo cohort received intercostal nerve cryoablation at levels 3-7, scheduled acetaminophen, gabapentin, and tramadol. Additional opioids or epidural catheters were used for breakthrough pain. ResultsIn total, 49 pre-cryo and 40 post-cryo patients were analyzed. Baseline demographics were similar aside from a shift to performing more bilateral lung transplants in the post-cryo cohort (57% vs 95%, p<0.0001). Total opioid usage during the index hospitalization decreased by 24% (1110 vs 841 morphine milligram equivalents [MME], p=0.027), and 28% in the bilateral LTR subgroup analysis (1168 vs 846 MME, p=0.007). Epidural use declined from 61% to 3% (p<0.0001). Median opioids prescribed at discharge decreased by 66% (450 vs 154 MME, p<0.0001). ConclusionsThe implementation of a perioperative pain management protocol that included intercostal nerve cryoablation was associated with a significant reduction in epidural utilization and opioid use during index hospitalization and upon discharge. Further research is needed to understand the impact on outcomes.

Racial/Ethnic Disparities in Peripartum Pain Assessment and Management

This study was conducted to determine if there were racial/ethnic disparities in pain assessment and management from labor throughout the postpartum period. This was a retrospective cohort study of all births from January 2019 to December 2021 in a single urban, quaternary care hospital, excluding patients with hysterectomy, ICU stay, transfusion of more than 3 units of packed red blood cells, general anesthesia, or evidence of a substance abuse disorder. We characterized and compared patterns of antepartum and postpartum pain assessments, epidural use, pain scores, and postpartum pain management by racial/ethnic group with bivariable analyses. Multivariable regression was performed to test for an association between race/ethnicity and amount of opioid pain medication in milligram equivalent units, stratified by delivery mode. There were 18,085 births between 2019 and 2021 with available race/ethnicity data. Of these, 58.3% were white, 15.0% were Hispanic, 11.9% were Asian, 7.4% were Black, and the remaining 7.4% were classified as Other/Declined. There were no significant differences by race/ethnicity in the number of antepartum or postpartum pain assessments or the proportion of patients who received epidural analgesia. Black and Hispanic patients reported the highest maximum postpartum pain scores after vaginal and cesarean birth compared to white and Asian patients. However, Black and Hispanic patients received lower daily doses of opioid medications than white patients, regardless of delivery mode. After adjusting for patient factors and non-opioid medication dosages, all other racial/ethnic groups received less opioid medication than white patients. Inequities were found in postpartum pain treatment, including among patients reporting the highest pain levels.