Intrapartum Epidural Analgesia Research Articles

An evaluation of a healthy participant laboratory model of epidural hyperthermia: a physiological study

BackgroundHyperthermia complicates 21% of cases of intrapartum epidural analgesia, but the mechanism is unclear. One hypothesis is that blockade of cholinergic sympathetic nerves prevents active vasodilation and sweating, thus limiting heat loss. Because labour increases heat production, this could create a situation in which heat production exceeds loss, causing body temperature to rise. This physiological study tested a novel laboratory model of epidural-related hyperthermia, using exercise to simulate the increased heat production of labour and surface insulation to simulate the effect of epidural analgesia. MethodsTwelve healthy non-pregnant participants (six female) cycled an ergometer for two hours at 20 Watts (W) on two occasions: once with surface insulation (intervention) and once without (control). Core temperature, skin temperature (eight sites), and heat loss (eight sites) were recorded. Mean body temperature and heat production were calculated. Values are mean (SD). ResultsExercise increased heat production on both visits (intervention 38 (18) W; control 37 (31) W; P = 0.94). Total heat loss was less on the intervention visit (intervention 115 (19) W; control 129 (23) W; P = 0.002). Core temperature increased on both visits (intervention 0.21 (0.37)°C; control 0.19 (0.27)°C; P < 0.001). The increase in mean body temperature was greater on the intervention visit (intervention 0.47 (0.41)°C; control 0.25 (0.19)°C; P = 0.007). ConclusionsThis laboratory model predicts that labour epidural analgesia limits heat loss by >14 W. Once the model is validated, it could be used to test the efficacy of potential interventions to prevent and treat epidural-related maternal hyperthermia.

Effect of intrapartum epidural analgesia on rate of emergency delivery for presumed fetal compromise: nationwide registry-based cohort study.

To determine the rate of emergency delivery for presumed fetal compromise after epidural analgesia (EDA) compared with that after alternative analgesia or no analgesia, and to assess whether this rate is increased in pregnancies with reduced placental reserve. This was a nationwide registry-based cohort study of 629 951 singleton pregnancies delivered at 36 + 0 to 42 + 0 weeks of gestation that were recorded in the Dutch national birth registry between 2014 and 2018, including 120 426 cases that received EDA, 86 957 that received alternative analgesia and 422 568 that received no analgesia during labor. Pregnancies with congenital anomaly, chromosomal abnormality, fetal demise, planned Cesarean delivery, non-cephalic presentation at delivery and use of multiple forms of analgesia were excluded. The primary outcome was emergency delivery for presumed fetal compromise. Secondary outcomes included delivery characteristics and neonatal outcome. Negative binomial regression analysis was stratified by parity and results are presented according to birth-weight centile, after adjusting for confounding. Among women who received EDA, 13.2% underwent emergency delivery for presumed fetal compromise, compared with 4.1% of women who had no analgesia (relative risk (RR), 3.23 (95% CI, 3.16-3.31)) and 7.0% of women who received alternative analgesia (RR, 1.72 (95% CI, 1.67-1.77)). Independent of birth weight, the RR of presumed fetal compromise after EDA vs no analgesia was higher in parous women (adjusted RR (aRR), 2.15 (95% CI, 2.04-2.27)) compared with nulliparous women (RR, 1.88 (95% CI, 1.84-1.94)). Stratified for parity, the effect of EDA was modified significantly by birth-weight centile (interaction P-value, < 0.001 for nulliparous and 0.004 for parous women). The emergency delivery rate following EDA was highest in those with a birth weight < 5th centile (25.2% of nulliparous and 16.6% of parous women), falling with each increasing birth-weight centile category up to the 91st -95th centile (11.8% of nulliparous and 7.2% of parous women). Intrapartum EDA is associated with a higher risk of emergency delivery for presumed fetal compromise compared with no analgesia and alternative analgesia, after adjusting for relevant confounding. The highest rate of emergency delivery for presumed fetal compromise was observed at the lowest birth-weight centiles. RRs of emergency delivery for presumed fetal compromise after EDA were modestly but consistently modified by birth-weight centile, supporting the hypothesis that the adverse effects of EDA are exacerbated by reduced placental function. While EDA provides effective pain relief during labor, alternative strategies for pain management may be preferable in pregnancies with a high background risk of fetal compromise. © 2023 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Factors associated with the intention of pregnant women to give birth with epidural analgesia: a cross-sectional study

BackgroundIn Belgium most women receive epidural analgesia during labour. Although, it offers satisfactory pain relief during labour, the risk on a series of adverse advents has been reported. The objective of this study was to determine factors associated with the intention of pregnant women, anticipating a vaginal birth, of requesting epidural analgesia during labour.MethodsA cross-sectional study, using an online self-report questionnaire was performed, including socio-demographic and personal details. Associated factors were examined with the HEXACO-60 questionnaire, the Mental Health Inventory-5, the Tilburg Pregnancy Distress Scale and the Labour Pain Relief Attitude Questionnaire for pregnant women. The level of intention to request epidural analgesia was based on two questions: Do you intend to ask for epidural analgesia (1) at the start of your labour; (2) at some point during labour? Data were collected predominantly during the second and third trimester of pregnancy. Descriptive analysis and a multiple linear regression analysis were performed.Results949 nulliparous (45.9%) and multiparous (54.1%) pregnant women, living in Flanders (Dutch-speaking part of Belgium) anticipating a vaginal birth completed the questionnaires. Birth-related anxiety (ß 0.096, p < 0.001), the attitude that because of the impact of pregnancy on the body, asking for pain relief is normal (ß 0.397, p < 0.001) and feeling more self-confident during labour when having pain relief (ß 0.034, p < 0.001) show a significant positive relationship with the intention for intrapartum epidural analgesia. The length of the gestational period (ß − 0.056, p 0.015), having a midwife as the primary care giver during pregnancy (ß − 0.048, p 0.044), and considering the partner in decision-making about pain relief (ß − 0.112, p < 0.001) show a significant negative relationship with the intention level of epidural analgesia. The explained variability by the multiple regression model is 54%.ConclusionsA discussion during pregnancy about the underlying reason for epidural analgesia allows maternity care providers and partners to support women with pain management that is in line with women’s preferences. Because women’s intentions vary during the gestational period, pain relief should be an issue of conversation throughout pregnancy.

Exposure to Intrapartum Epidural Analgesia and Risk of Autism Spectrum Disorder in Offspring

There is conflicting evidence on the association between intrapartum epidural analgesia and risk of autism spectrum disorder (ASD) in offspring. To evaluate the association between intrapartum epidural analgesia and the risk of ASD in offspring. This population-based cohort study was conducted in Ontario, Canada, using the health and administrative records of singleton live births by vaginal delivery between April 1, 2006, and March 31, 2014. Neonates with less than 24 weeks' gestation or weighing less than 500 g were excluded. Offspring were followed up from 18 months of age until ASD diagnosis, loss to follow-up, or the end of the study (December 31, 2020), whichever occurred first. Exposure, covariate, and outcome data were obtained using provincial health administrative databases. Any intrapartum exposure to epidural or combined spinal-epidural analgesia. The primary outcome was ASD diagnosis after 18 months of age. Inverse probability of treatment weighting (IPTW) of Cox proportional hazards regression models was used to estimate the hazard ratio (HR) of intrapartum epidural analgesia and ASD in offspring. Offspring head injury was used as a control outcome. Models were adjusted for maternal sociodemographic factors, health behaviors, and medical and obstetrical history as well as labor, delivery, and offspring characteristics. Post hoc analyses included restriction to term neonates, a conditional within-mother analysis, exclusion of records with concomitant intrapartum pain management exposures, a complete case analysis, use of an alternative ASD definition, and estimation of the average treatment effect in the treated group. Among the 650 373 mother-offspring pairs included in the study, 418 761 (64.4%) were exposed to intrapartum epidural analgesia. The mean (SD) maternal age at delivery was 29.7 (5.5) years; the offspring had a mean (SD) gestational age at delivery of 39.1 (1.6) weeks and included 329 808 male newborns (50.7%). The exposed and unexposed groups were similar in all maternal and newborn characteristics after IPTW (standardized difference <0.10). Autism spectrum disorder was diagnosed in 7546 offspring (1.8%) of mothers who received intrapartum epidural analgesia (incidence rate, 18.8 [95% CI, 18.4-19.3] per 10 000 person-years) compared with 3234 offspring (1.4%) who were unexposed (incidence rate, 14.4 [95% CI, 13.9-14.9] per 10 000 person-years). The crude HR for ASD associated with intrapartum epidural analgesia was 1.30 (95% CI, 1.25-1.36), and the IPTW-adjusted HR was 1.14 (95% CI, 1.08-1.21). Results did not qualitatively differ in post hoc analyses. Results of this study showed that intrapartum epidural analgesia was associated with a small increase in risk for ASD in offspring. The biological plausibility of this association, however, remains unclear, and the finding must be interpreted with caution.

Does Intrapartum Epidural Analgesia Increase the Risk of Autism Spectrum Disorder in Offspring? Most Likely Not

There is no doubt that epidural analgesia is one of the most effective methods of pain relief in labor,1 with up to 7 of every 10 women receiving such analgesia during delivery.2 Local anesthetic with or without adjunct opioid is therefore one of the most common prenatal drug exposures.

Does Preferred Spoken Language Affect Time to Epidural for Nulliparous Patients? [A203

INTRODUCTION: Some studies have observed sociodemographic disparities in administration of intrapartum epidural anesthesia. Our objective was to determine whether preferred spoken language was associated with time to epidural administration. METHODS: This was a retrospective cohort study of all nulliparous patients admitted for labor or induction at one academic hospital in New York who received intrapartum epidural analgesia prior to delivery from January to December 2019. The outcome was time to epidural, which was evaluated for English-speaking and non-English-speaking patients. For patients undergoing scheduled induction, time to epidural was defined as the interval from induction agent to epidural administration. For patients admitted in spontaneous labor, time to epidural was defined as the time interval from hospital presentation to epidural administration. Demographic and clinical data were collected. Patients in the induction and spontaneous labor groups were analyzed separately. RESULTS: A total of 417 patients were included: 215 (52%) inductions and 202 (48%) presenting in spontaneous labor. Overall, 264 (63%) patients preferred English and 153 (47%) preferred another language (primarily Spanish). In the spontaneous labor group, there was no difference in time to epidural between English-speaking and non-English-speaking patients (307 versus 272 minutes, respectively). Among scheduled inductions, time to epidural was lower for English speakers than non-English speakers (869 versus 1,100 minutes, respectively; P&lt;.01). English-speaking patients were more likely to be induced (56% versus 43%, P&lt;.01). Sociodemographic factors such as age, race/ethnicity, and marital status were not associated with time to epidural. CONCLUSION: Preferred language was not associated with time to epidural in the spontaneous labor group, but a significant difference was noted for patients undergoing induction. Non-English-speakers may experience delayed analgesic interventions.

Intrapartum epidural analgesia and emergency delivery rates due to fetal compromise by birth weight percentile

Epidural analgesia (EDA) is widely used for maternal pain relief during labour. However, hemodynamic changes induced by EDA may adversely affect placental perfusion. In fetuses who already suffer from reduced placental function, manifested by fetal growth restriction, this may carry a higher risk of intrapartum compromise. This study aims to determine the emergency delivery rates due to fetal compromise after EDA compared to alternative- and no analgesia across the spectrum of birth weight centiles.

Intrapartum Epidural Analgesia and Low Apgar Score Among Singleton Infants Born at Term: A Propensity Score Matched Study

(Acta Obstet Gynecol Scand. 2020;99:1155–1162) While the infant mortality in at-term births is low in Western countries, a recent trend has developed wherein birth asphyxia (based on low Apgar score) is the leading cause of death in term infants in the Netherlands who were admitted to a neonatal intensive care unit (NICU). Therefore, additional attention should be given to term neonates with low Apgar scores, and research on NICU admission should be emphasized as part of the assessment of perinatal health in this group of patients. The underlying risks for asphyxia include hypertensive disorders, maternal diabetes (both preexisting and gestational), non-cephalic presentation at birth, prolonged second stage of labor, and intrapartum epidural analgesia (EA). As EA is not generally used in the Netherlands, although its popularity has slowly increased in recent years, this environment is ideal for analyzing the effects of EA on full-term infants. This study aimed to assess the effects of EA on low Apgar score and subsequent NICU admission in term, singleton births and to analyze other underlying risk factors.

Comparison of labour and birth outcomes between nulliparous women who used epidural analgesia in labour and those who did not: A prospective cohort study

ObjectiveTo compare labour and birth outcomes between nulliparous women who used versus did not use intrapartum epidural analgesia. DesignProspective cohort study. SettingTwo maternity hospitals in Ireland. PopulationA total of 1221 nulliparous women who gave birth vaginally or by emergency caesarean section. MethodsMultinomial logistic regression was used to analyse categorical outcomes, with results presented as ratios of relative risks (RRR). For dichotomous outcomes we used logistic regression, with results presented as odds ratios (OR). Main outcome measuresMode of birth, IV syntocinon use, pyrexia (≥38°C), antibiotic treatment, first stage labour ≥10h, second stage labour ≥2h, blood loss (≥500mls, ≥1000mls), perineal trauma. Neonatal outcomes included Apgar score ≥7 at 1min and 5min, admission to neonatal intensive care unit, and infant feeding method. ResultsWomen using EA were more likely to require a vacuum-assisted birth (RRR 3.35, p<0.01) or forceps-assisted birth (RRR 11.69, p<0.01). Exposure to EA was associated with significantly greater risk of ≥10h first (OR 6.72, p=0.01) and ≥2h second (OR 2.25, p<0.01) stage labour, increased likelihood of receiving IV syntocinon (OR 9.38, p<0.01), antibiotics (OR 2.97, p<0.01) and a greater probability of pyrexia (OR 10.26, p<0.01). Women who used EA were half as likely to be breastfeeding at three months postpartum (OR 0.53, p<0.01). No differences were observed between groups in neonatal outcomes. ConclusionsOur data shows significant associations between EA use and several intrapartum outcomes.

Effect of maternal country of birth on intrapartum epidural use – A population-based register study of 602 095 deliveries

ObjectiveTo assess intrapartum epidural use during vaginal delivery among immigrant women giving birth in Norway, compared with Norwegian born women, and to explore associations between epidural use and other maternal characteristics, fetal and obstetrical variables. Study designPopulation-based cohort study. Data were obtained from Norwegian Medical Birth Registry and Statistics Norway, including 602 095 deliveries in 1999-2014. Intrapartum epidural analgesia use was described in percentages. Multivariable logistic regression analysis was performed to investigate the association between maternal country of birth and intrapartum epidural use, adjusted with maternal and fetal comorbidity, age, stillbirth, birthweight, fetal presentation, delivery method and time period. ResultsThere were significant differences in epidural use between women born in different parts of the world. Among nulliparous women, increased odds for intrapartum epidural use was observed among women born in Latin America compared with Norwegian born women, even after adjustment for maternal, fetal and obstetrical factors (aOR 1.93, CI 1.79-2.09). Reduced odds for intrapartum epidural use was observed among nulliparous women born in Sub-Saharan Africa (aOR 0.83, CI 0.78-0.88), East Asia and Pacific area (aOR 0.83, CI 0.80-0.87), and women with unknown country of birth (aOR 0.79, CI 0.71-0.89) compared with Norwegian born women. Similar pattern was observed among parous women from Latin America (aOR 1.69, CI 1.54-1.87), Sub-Saharan Africa (aOR 0.62, CI 0.57-0.67), East-Asia and Pacific area (aOR 0.68, CI 0.64-0.73), unknown country of birth (aOR 0.97, CI 0.84-1.13). Maternal hypertensive disorders, high infant birthweight, stillbirth, breech presentation and operative vaginal delivery increased the odds for use of intrapartum epidural analgesia. ConclusionsWe found differences between immigrant women from different parts of the world and use of intrapartum epidural, possibly related to un-measurable issues like cultural differences, maternal expectations and knowledge of safety on pain relief during childbirth. Intrapartum epidural use was more frequent in conditions related to maternal co-morbidity and factors indicating complicated delivery.

Intrapartum epidural analgesia and low Apgar score among singleton infants born at term: A propensity score matched study.

IntroductionThe associations of epidural analgesia and low Apgar score found in the Swedish Registry might be a result of confounding by indication. The objective of this study was to assess the possible effect of intrapartum epidural analgesia on low Apgar score and neonatal intensive care unit (NICU) admission in term born singletons with propensity score matching.Material and methodsThis was a propensity score matched study (n = 257 872) conducted in a national cohort of 715 449 term live born singletons without congenital anomalies in the Netherlands. Mothers with prelabor cesarean section were excluded. Main outcome measures were 5‐minute Apgar score <7, 5‐minute Apgar score <4 and admission to a NICU for at least 24 hours. First, an analysis of the underlying risk factors for low Apgar score <7 was performed. Multivariable analyses were applied to assess the effect of the main risk factor, intrapartum epidural analgesia, on low Apgar score to adjust the results for confounding factors. Second, a propensity score matched analysis on the main risk factors for epidural analgesia was applied. By propensity score matching the (confounding) characteristics of the women who received epidural analgesia with the characteristics of the control women without epidural analgesia, the effect of possible confounding by indication is minimized.ResultsIntrapartum epidural analgesia was performed in 128 936 women (18%). Apgar score <7 was present in 1.0%, Apgar score <4 in .2% and NICU admission in .4% of the deliveries. The strongest risk factor for Apgar score <7 was epidural analgesia (adjusted odds ratio [aOR] 1.9, 95% confidence interval [CI] 1.8‐2.0). The propensity score matched adjusted analysis of women with epidural analgesia showed significant adverse neonatal outcomes: aOR 1.8 (95% CI 1.7‐1.9) for AS <7, aOR 1.6 (95% CI 1.4‐1.9) for AS <4 and aOR 1.7 (95% CI 1.6‐1.9) for NICU admission. The results of epidural analgesia on AS <7 were also significantly increased for spontaneous start of labor (aOR 2.0, 95% CI 1.8‐2.1) and for spontaneous delivery.ConclusionsIntrapartum epidural analgesia at term is strongly associated with low Apgar score and more NICU admissions, especially in spontaneous deliveries. This association needs further research and awareness.

The effect of combined spinal epidural versus epidural analgesia on fetal heart rate in laboring patients at risk for uteroplacental insufficiency

Background The effects of neuraxial analgesia on fetal heart tracings have been studied in “healthy” pregnancies. Our objective was to compare the impact of intrapartum epidural analgesia (EA) versus combined spinal epidural analgesia (CSE) on fetal heart rate changes in pregnancies at risk for uteroplacental insufficiency (UPI). Methods Singleton pregnancies diagnosed with chronic hypertension, gestational hypertension and/or preeclampsia, and/or fetal growth restriction (FGR) and receiving neuraxial analgesia intrapartum from 2012 to 2015 were studied retrospectively. The primary outcome was change in fetal heart rate (FHR) category following neuraxial analgesia. Manual review of all FHR tracings was performed and classified by the National Institute of Child Health and Human Development (NICHD) categories. Data collection included maternal demographics, blood pressure, uterine tachysystole, uterine hypertonus, mode of delivery, interventions for FHR abnormalities and neonatal outcomes. Results Of laboring patients at risk for UPI, 110 patients received EA and 127 patients received CSE. The rate and change in FHR categories and abnormalities following neuraxial analgesia were the same in both groups. Both EA and CSE resulted in a significant increase in NICHD FHR category II, from 27.3 to 65.5% for EA and 20.9 to 64.3% for CSE. The occurrence of maternal hypotension, uterine tachysystole, interventions for FHR abnormalities, and uterine hypertonus following neuraxial analgesia was not found to be significantly different between the two groups. When compared to the EA group, CSE had a higher rate of NICU admission (29.5 versus 16.4%, p = .021). Conclusions FHR category increased following both CSE and EA. The side effects of maternal hypotension and need for fetal interventions was not different between CSE and EA.

Induction of labor compared to expectant management in term nulliparas with a latent phase of labor of more than 8\u2009hours: a randomized trial

BackgroundProlonged latent phase of labor is associated with adverse maternal and neonatal outcomes. Preliminary data indicate that labor induction for prolonged latent phase may reduce cesarean delivery. We performed a study powered to Cesarean delivery to evaluate labor induction compared to expectant management in full term nulliparas hospitalized for persistent contractions but non-progressive to established labor after an overnight stay.MethodsFrom 2015 and 2017, nulliparas, ≥ 39 weeks’ gestation with prolonged latent phase of labor (persistent contractions after overnight hospitalization > 8 h), cervical dilation ≤3 cm, intact membranes and reassuring cardiotocogram were recruited. Participants were randomized to immediate induction of labor (with vaginal dinoprostone or amniotomy or oxytocin as appropriate) or expectant management (await labor for at least 24 h unless indicated intervention as directed by care provider). Primary outcome measure was Cesarean delivery.ResultsThree hundred eighteen women were randomized (159 to each arm). Data from 308 participants were analyzed. Cesarean delivery rate was 24.2% (36/149) vs. 23.3%, (37/159) RR 1.0 95% CI 0.7–1.6; P = 0.96 in induction of labor vs. expectant arms. Interval from intervention to delivery was 17.1 ± 9.9 vs. 40.1 ± 19.8 h; P < 0.001, intervention to active labor 9.6 ± 10.2 vs. 29.6 ± 18.5 h; P < 0.001, active labor to delivery 7.6 ± 3.6 vs. 10.5 ± 7.2 h; P < 0.001, intervention to hospital discharge 2.4 ± 1.2 vs. 2.9 ± 1.4 days; P < 0.001 and dinoprostone use was 19.5% (29/149) vs. 8.2% (13/159) RR 2.4 95% CI 1.3–4.4; P = 0.01 in IOL compared with expectant arms respectively. Intrapartum oxytocin use, epidural analgesia and uterine hyperstimulation syndrome, postpartum hemorrhage, patient satisfaction on allocated intervention, during labor and delivery and baby outcome were not significantly different across trial arms.ConclusionsInduction of labor did not reduce Cesarean delivery rates but intervention to delivery and to hospital discharge durations are shorter. Patient satisfaction scores were similar. Induction of labor for prolonged latent phase of labor can be performed without apparent detriment to expedite delivery.Trial registrationRegistered in Malaysia National Medical Research Register (NMRR-15-16-23,886) on 6 January 2015 and the International Standard Randomised Controlled Trials Number registry, registration number ISRCTN14099170 on 5 Nov 2015.

Trajectory of Platelets in Pregnancy: Do Low-risk Women Need an Intrapartum Full Blood Count Prior to Epidural?

(Aust N Z J Obstet Gynaecol. 2015;55(5):511–514) Thrombocytopenia, defined as a platelet count &lt;150×109/L, occurs in 7% to 10% of pregnancies. There is no clear agreement as to whether women who are determined to be low risk for thrombocytopenia need a platelet count before intrapartum epidural analgesia can be administered and awaiting this laboratory value could delay epidural administration. As women typically receive a full blood count around 28 weeks of gestation, the authors of this study sought to determine whether women with normal platelet levels during that routine check-up and overall low risk of thrombocytopenia tended to maintain a normal platelet count up until the peripartum period.

Intrapartum epidural fixation methods: a randomised controlled trial of three different epidural catheter securement devices.

This randomised controlled trial investigated the efficacy of Epi-Fix(™) , LockIt Plus(®) and Tegaderm(™) as fixation devices for intrapartum epidural catheters. One hundred and sixty-five women requesting intrapartum epidural analgesia were randomised to receive different fixation devices to secure their epidural catheter. The amount of epidural catheter migration (measured to the nearest 0.5 cm) was analysed for three devices: Epi-Fix (n = 55); LockIt Plus (n = 54); and Tegaderm dressing (n = 51). Median (IQR [range]) catheter migration for Epi-Fix was 1.0 cm (0.0-2.0 [-2.0 to 9.5]), vs 0.0 cm (0.0-0.5 [-1.0 to 5.5]) for LockIt Plus and 0.5 cm (0.0-1.8 [-1.5 to 8.0]) for Tegaderm (p = 0.003). Thirty-eight (69.1%) epidural catheters secured with Epi-Fix migrated < 2.0 cm, compared with 49 (90.7%) with LockIt Plus and 40 (78.4%) with Tegaderm. Sixteen epidural catheters required resiting due to failure of analgesia of which 12 (75.0%) occurred in patients with epidural catheters that had migrated ≥ 2.0 cm. This study shows that intrapartum epidural catheters secured with the LockIt Plus device exhibit less catheter migration compared with fixation with Epi-Fix and Tegaderm.

Self-hypnosis for intrapartum pain management in pregnant nulliparous women: a randomised controlled trial of clinical effectiveness.

Objective(Primary) To establish the effect of antenatal group self-hypnosis for nulliparous women on intra-partum epidural use.DesignMulti-method randomised control trial (RCT).SettingThree NHS Trusts.PopulationNulliparous women not planning elective caesarean, without medication for hypertension and without psychological illness.MethodsRandomisation at 28–32 weeks’ gestation to usual care, or to usual care plus brief self-hypnosis training (two × 90-minute groups at around 32 and 35 weeks’ gestation; daily audio self-hypnosis CD). Follow up at 2 and 6 weeks postnatal.Main outcome measuresPrimary: epidural analgesia. Secondary: associated clinical and psychological outcomes; cost analysis.ResultsSix hundred and eighty women were randomised. There was no statistically significant difference in epidural use: 27.9% (intervention), 30.3% (control), odds ratio (OR) 0.89 [95% confidence interval (CI): 0.64–1.24], or in 27 of 29 pre-specified secondary clinical and psychological outcomes. Women in the intervention group had lower actual than anticipated levels of fear and anxiety between baseline and 2 weeks post natal (anxiety: mean difference −0.72, 95% CI −1.16 to −0.28, P = 0.001); fear (mean difference −0.62, 95% CI −1.08 to −0.16, P = 0.009) [Correction added on 7 July 2015, after first online publication: ‘Mean difference’ replaced ‘Odds ratio (OR)’ in the preceding sentence.]. Postnatal response rates were 67% overall at 2 weeks. The additional cost in the intervention arm per woman was £4.83 (CI −£257.93 to £267.59).ConclusionsAllocation to two-third-trimester group self-hypnosis training sessions did not significantly reduce intra-partum epidural analgesia use or a range of other clinical and psychological variables. The impact of women's anxiety and fear about childbirth needs further investigation.Tweetable abstractGoing to 2 prenatal self-hypnosis groups didn't reduce labour epidural use but did reduce birth fear & anxiety postnatally at < £5 per woman.

Differential effects of epidural analgesia on modes of delivery and perinatal outcomes between nulliparous and multiparous women: a retrospective cohort study.

BackgroundEpidural analgesia is considered one of the most effective methods for pain relief during labor. However, it is not clear whether similar effects of epidural analgesia on the progression of labor, modes of delivery, and perinatal outcomes exist between nulliparous and multiparous women.Methodology/Principal FindingsA retrospective cohort study was conducted to analyze all deliveries after 37 weeks of gestation, with the exclusion of pregnancies complicated by multiple gestations and fetal anomalies and deliveries without trials of labor; these criteria produced a study population of n=16,852. A multivariable logistic regression model was constructed to control for confounders. In total, 7260 of 10,175 (71.4%) nulliparous and 2987 of 6677 (44.7%) multiparous parturients were administered epidural analgesia. The independent factors for intrapartum epidural analgesia included a low prepregnancy body mass index, genetic amniocentesis, group B streptococcal colonization of the genito-rectal tract, and augmentation and induction of labor. In the nulliparous women, epidural analgesia was a significant risk factor for operative vaginal delivery (adjusted odds ratio [OR] 2.14, 95% confidence interval [CI] 1.80-2.54); however, it was a protective factor against Caesarean delivery (adjusted OR 0.62, 95% CI 0.55-0.69). Epidural analgesia remained a significant risk factor for operative vaginal delivery (adjusted OR 2.17, 95% CI 1.58-2.97) but not for Caesarean delivery (adjusted OR 1.09, 95% CI 0.77-1.55) in the multiparous women. Furthermore, the women who were administered epidural analgesia during the trials of labor had similar rates of adverse perinatal outcomes compared with the women who were not administered epidural analgesia, except that a higher rate of 1-minute Apgar scores less than 7 was noted in the nulliparous women who were administered epidural analgesia.Conclusions/SignificanceIntrapartum epidural analgesia has differential effects on the modes of delivery between nulliparous and multiparous women, and it is not associated with adverse perinatal outcomes.

Intrapartum epidural analgesia and onset of lactation: a prospective study in an Italian birth centre.

The objective of this study is to investigate the relationship between epidural analgesia (EDA) in labor and the onset of lactation in healthy women after birth. In a Regional Perinatal Center in northern Italy, women who had had a vaginal delivery were recruited by convenience sampling. Analyses were carried out on the data of 366 women. 209 women received EDA and 157 women did not receive EDA or any other pharmacological analgesia. A structured follow-up was carried out interviewing women by telephone after 5 days and, a second time, 20 days after delivery. The primary outcome was the time (in hours) of the onset of lactation. Timing of the onset of lactation in the EDA and non-EDA groups did not statistically differ (p = 0.15), although the non-EDA group was more likely to initiate breastfeeding. On the basis of the results of this study, we concluded that intrapartum EDA does not have an effect on delays in the onset of lactation.

827: Effect of targeted prenatal education on acceptance of epidural analgesia: a randomized controlled trial

Racial/ethnic disparities exist in the proportion of patients receiving epidural analgesia. We sought to determine if targeted prenatal educational program on womens' perceptions of epidural increases the acceptance of intrapartum epidural analgesia. During prenatal care visits, patients were randomized to a video targeted at cultural myths and perceived risks of epidural presented in the subjects' native language (English or Spanish) in addition to routine care versus routine prenatal care alone. They were asked to fill out a survey before and after their assigned intervention to assess desire and perception of epidurals. Desire for epidural and actual epidural rate at delivery were analyzed in the two groups. 111 women were randomized: 59 to the intervention group and 52 to the control group. The groups only differed on race/ethnicity, with the intervention group having more Hispanic women than the control group (65 v 43%, p=0.02). Rates of attending the routine prenatal epidural class were similar (40 v 40% p=0.97). The actual epidural rate was greater in the intervention group than the control group (81 v 67%; adjusted risk ratio [aRR] 1.4, 95% confidence interval [CI] 1.1-1.7). There were no significant differences in the stated desire to receive epidural rate in the educational intervention group compared to the control group (51 v 40%, p= 0.19). After adjusting for race/ethnicity, the targeted educational video increased the likelihood of receiving a intrapartum epidural in all subjects regardless of stated desire for intrapartum epidural as indicated on the survey (Table).Tabled 1Effect of educational video on actual epidural use Participation in culturally-sensitive, targeted prenatal education increased epidural rate compared to routine prenatal care. This finding highlights the importance of patient-centered and culturally-sensitive educational efforts to improve informed decision making of intrapartum pain control to decrease the racial/ethnic disparity of epidural use in women.

Analysing adverse effects of epidural analgesia in labour

Epidural analgesia is a widely available method of pain relief in labour in Western countries. This article analyses the various adverse outcomes of labour and birth after the administration of epidural analgesia. A literature review found that the use of intrapartum epidural analgesia for women with low-risk pregnancy has not only disempowered women but can also lead to maternal and fetal morbidity connected with major obstetric interventions, such as operative deliveries. Epidural analgesia also interferes with breastfeeding success and effective oxytocin circulation in the maternal blood-stream, and may even impact on childhood behavioural development.