Epidural Labor Research Articles

Effect of a lower dose of intrathecal morphine on postoperative opioid consumption following cesarean delivery at a Texas level IV maternal care center

Background We hypothesized that patients who received a lower dose of intrathecal morphine (ITM) would have higher postoperative opioid consumption following cesarean delivery. Methods Patients who had cesarean deliveries from February 15, 2022, through February 14, 2024 at Baylor Scott & White Medical Center – Temple with single injection spinal or combined spinal epidural anesthesia who did not have labor epidural anesthesia were included. Morphine milligram equivalent (MME) opioid consumption in the first 24 postoperative hours was recorded along with patient demographic, physical, and clinical characteristics. Results A total of 535 and 502 patients received 0.2 and 0.15 mg ITM, respectively. Patients who received 0.15 mg ITM had higher rates of depression, scheduled cesarean deliveries, and acetaminophen administration compared to patients who received 0.2 mg ITM. Patients who received 0.2 mg ITM and 0.15 mg ITM had median (interquartile range) 24-hour MME consumption of 10.0 mg (0–30.0 mg) and 10.0 mg (0–40.0 mg), respectively (P = 0.97). Discussion MME consumption for 24 hours following cesarean delivery was similar between patients who received 0.2 and 0.15 mg ITM.

Success rate and outcome of labor epidural among variable levels of residents and practicing anesthesiologists in an academic medical center in Saudi Arabia

Background and Aims: This study aimed to highlight differences in success rates and patient outcomes during epidural insertion among anesthesia staff, junior trainees, and staff anesthesiologists. Methods: We included all women who received a labor epidural between January 1, 2020 and April 30, 2022. The cases were divided into three groups: junior residents, senior residents, and staff anesthesiologists. Results: Among 822 cases included in analysis, 92, 240, and 490 catheters were placed by junior residents, senior residents, and staff anesthesiologists, respectively. Although the success rate among junior residents (90.7%) was lower than those of senior residents (97%) and staff anesthesiologists (95.1%), the difference was not significant (P = 0.067). The mean procedural time in minutes was significantly longer in the junior resident’s group (18.1 min) compared to the senior residents (14.18 min) and staff anesthesiologists (14.87 min) (P < 0.001). A significant difference was observed in the number of needle pricks and catheter insertion attempts when comparing the junior residents, senior residents, and staff anesthesiologists’ groups (P < 0.001). In the logistic regression analysis, procedural time remained the only predictor of epidural success. Conclusions: With the success rate above 90%, junior anesthesia trainees require more time and attempts to insert labor epidurals. It is essential that training programs provide opportunities for anesthesia trainees to become proficient in their epidural insertion techniques prior to clinical practice.

Gonadotropins combined with and without 100mg Clomiphene Citrate drug on ovulation induction and role of epidural analgesia in pregnancy outcome of infertility women.

Successful ovulation induction can overcome the common condition of infertility associated with ovulatory dysfunction. Monotherapy of clomiphene citrate (CC) or combined with gonadotrophins are the best treatment modalities for ovulation induction with a successful outcome. We concentrated on evaluating the effects of 100 mg Clomiphene Citrate, both with and without gonadotrophins, on ovulation induction and the outcome of labor analgesia in women with infertility. This prospective cohort consists of 136 women with infertility who were medicated with 100 mg of clomiphene citrate alone and 100 mg of clomiphene citrate with gonadotropins. We recorded the endometrial thickness, details of the dominant follicle, and the incidence of a positive pregnancy rate. Women with positive pregnancy were managed with epidural labor with labor analgesia to relieve labor pain and evaluated the foetal outcome. In CC alone, the ovulation rate was 57%, while in CC with gonadotrophins, it was 81%. The mean dominant follicle size and endometrial thickness were high in CC with gonadotrophins (p < 0.05). The overall incidence of positive pregnancies was 28.98%. Levobupivacaine with dexmedetomidine significantly reduced the mean VAS score from baseline, resulting in a higher foetal body weight. Taking 100 mg of Clomiphene citrate with gonadotropins works better than taking Clomiphene citrate by itself at starting ovulation, increasing the size of the dominant follicle, and improving the thickness of the endometrium. With levobupivacaine plus dexmedetomidine, the labor analgesia showed better stability in hemodynamic parameters and effective control on labor pain scores.

Obstetric Outcomes of Nighttime Versus Daytime Delivery with Labor Epidural: An Observational Retrospective Study.

Background: Variability in obstetric outcomes in terms of the number and type of deliveries related to the day-night cycle has been described in previous studies. This 11-year retrospective analysis explores the effects of nighttime versus daytime delivery with labor epidural on obstetric outcomes. Methods: Data on deliveries performed between 1 October 2008 and 1 October 2019 were collected and differentiated into daytime, occurring from 8:00 a.m. to 7:59 p.m., and nighttime deliveries, occurring from 8:00 p.m. to 7:59 a.m. of the following day. The data collected included the patient history and maternal and neonatal outcomes. Results: A total of 29831 patients were included in the analysis. A positive and statistically significant correlation between the number of cesarean sections (Odds Ratio 1.35; 95% confidence interval = 1.26-1.44; p < 0.001) and the number of vaginal operative deliveries (Odds Ratio 1.21; 95% confidence interval = 1.01-1.44; p < 0.05) in patients who did not receive an epidural at nighttime was reported. Regarding the labor epidurals, a significantly greater incidence of accidental dural punctures with needles (0,4%; p < 0.05) in the nighttime versus daytime was reported. Conclusions: The absence of labor epidurals was associated with a significant increase in the number of cesarean sections and vaginal operative deliveries occurring at nighttime, without significant differences in labor duration. The incidence of anesthesiologic complications was greater in deliveries performed at nighttime.

The Accuracy of ChatGPT-Generated Responses in Answering Commonly Asked Patient Questions About Labor Epidurals: A Survey-Based Study.

The Accuracy of ChatGPT-Generated Responses in Answering Commonly Asked Patient Questions About Labor Epidurals: A Survey-Based Study.

Effect of Anesthesia During Pregnancy, Delivery, and Childhood on Autism Spectrum Disorder: A Systematic Review and Meta-analysis.

To investigate the association between exposure to anesthesia during three periods of pregnancy, delivery, and childhood and autism spectrum disorder (ASD). PubMed, Scopus, Web of Science, Embase, Google Scholar, PsycArticles, and PsycINFO were searched from the date of database inception to 1 December 2022. Studies reported the association between exposure to anesthesia during pregnancy, delivery, and childhood and ASD were included. Extracted variables included hazard ratio (HR), relative risk or odds ratio, standard error, and 95% confidence interval (CI). Effect estimates were pooled using random-effects meta-analysis. In total, 16 studies including 8,156,608 individuals were included in the meta-analysis. Labor epidural anesthesia during delivery was associated with ASD in the general population (adjusted HR = 1.16, 95% CI, 1.06-1.28) but not in the sibling population (adjusted HR = 1.06, 95% CI, 0.98-1.15). Other anesthesia during delivery was not associated with ASD (general population: adjusted HR = 1.08, 95% CI, 0.99-1.17; sibling population: adjusted HR = 1.20, 95% CI, 0.81-1.79). Three studies suggested that exposure to anesthesia during pregnancy was associated with ASD in offspring (adjusted HR = 2.15, 95% CI, 1.32-3.48). There was no significant association between exposure to general anesthesia during childhood and ASD (adjusted HR = 1.02, 95% CI, 0.60-1.72). This meta-analysis did not confirm the association between exposure to anesthesia during labour and ASD. Previous observational studies used the neurotoxicity of anesthesia to biologically explain significant associations, but in fact different controls for confounding factors led to differences in associations. The evidence for pregnancy and childhood was limited given the small number of studies in these periods.

Serum Magnesium Level as a Biomarker to Predict the Risk of Labor Epidural Anesthesia Associated Fever.

Excessive pain will have adverse effects on the mother and fetus. Labor epidural analgesia greatly reduces the pain, which is widely carried out abroad. Labor epidural anesthesia-associated fever (LEAF) is the biggest problem for labor epidural anesthesia. This study aimed to evaluate the clinical value of serum magnesium levels to predict the LEAF. Overall 528 singleton term-pregnant women who underwent labor epidural anesthesia in Fujian Provincial Maternity and Children's Health Hospital, affiliated hospital of Fujian Medical University from January 2019 to June 2019, were analyzed retrospectively. The serum magnesium level was detected using venous blood samples. The relationship between the serum magnesium level and LEAF was interpreted, and the optimal cut-off values of the serum magnesium level to predict LEAF were calculated. Overall, 65 (12.30%) participants had LEAF. And a higher rate of the bulging membrane, gestational hypertension, neonatal intensive care unit (NICU) admission, and the different mode of delivery was significantly associated with LEAF. Also, the serum magnesium level demonstrated higher significantly in presence of LEAF than absence (P<0.05). What is more, it indicated that the area under the receiver operating characteristic curve (AUC) for the serum magnesium level was 0.825, and an optimal cut-off of the serum magnesium level was 0.855 mg/dl. Furthermore, it demonstrated that the serum magnesium level had the highest OR (OR= 7.49; 95% CI (4.58-14.35)) (P<0.001). The bulging membrane is an independent risk factor presence of LEAF (OR = 1.55; 95% CI (1.01-2.43)) (P=0.038). This study demonstrated that the baseline of serum magnesium can provide a suitable biomarker to predict LEAF. It can help to provide a useful target for LEAF treatment and enhance surveillance before fever.

Color Flow Doppler in Spinal Ultrasound: A Novel Technique for Assessment of Catheter Position in Labor Epidurals

(Reg Anesth Pain Med 2022;47:775–779) Epidural analgesia is one of the most common pain relief treatments during labor and delivery and is usually very effective. In a small percentage of epidurals, misplacement of the epidural catheter can cause inadequate anesthetic effects. To reduce instances of insufficient pain relief, it would be beneficial to be able to assess the position and flow of the catheter before administering medication. This study was designed to visualize flow in the epidural space using a structured color flow Doppler assessment, and to describe the location of the flow relative to the catheter insertion site. The primary outcome was the visualization of flow in the epidural space by color flow Doppler ultrasound. Secondary outcomes were visualization of catheter flow at the interspace of insertion, and at the interspaces above and below insertion, as well as visibility from unilateral or bilateral view, and visibility of flow on injection of saline only or an injection of a saline and air mixture.

Maternal Fever Associated With Continuous Spinal Versus Epidural Labor Analgesia: A Single-Center Retrospective Study

(Anesth Analg. 2022;135:1153–1158) Neuraxial labor analgesia commonly results in maternal fevers, though the cause is unknown. Possible causes include infection, inflammation, and altered thermoregulation. An alternative pain management to epidural labor is continuous spinal analgesia, which has lower neuraxial and systemic bupivacaine levels and may decrease the rate of maternal fever. No studies to date have compared maternal fever rates between epidural labor and continuous spinal analgesia. The aim of this study is to compare 2 techniques and better understand the mechanism that drives maternal fevers in association with epidural labor analgesia.

P51 Improving the consent process for labour epidurals; A quality improvement project

P51 Improving the consent process for labour epidurals; A quality improvement project

P123 Educating midwives in safe management of labour epidurals: design and delivery of a multi-modal learning session

P123 Educating midwives in safe management of labour epidurals: design and delivery of a multi-modal learning session

Labor epidural analgesia and risk of autism Spectrum disorders in offspring: A systematic review and meta-analysis.

The effect of labor epidural anesthesia (LEA) on the risk of autism spectrum disorder (ASD) in offspring has been investigated recently, and available results are inconsistent. We searched the PubMed and EMBASE databases for relevant studies and performed a systematic review and meta-analysis of the literature. Subgroup analyses were conducted to assess the sources of heterogeneity. Both fixed and random effects models were used was used to estimate overall relative risk. Our results showed that LEA was associated with an increased risk of ASD in offspring [HR = 1.3, 95% confidence interval (CI): 1.25-1.35; P < 0.001] after combining crude estimates from the included studies. This association was gradually reduced, but still statistically significant, when potential confounding factors were considered (HR 1.13, 95% CI 1.03-1.25, P = 0.014). However, there was no significant association when we combined data of siblings from other pregnancies (HR = 1.07, 95% CI: 0.99-1.16, P = 0.076), implying that the association was due to confounding factors. The statistically significant association between LEA and ASD in the offspring can be partially explained by unmeasured confounding. Identifier CRD42022302892.

Cesarean section in Swyer-James-Macleod syndrome: Anesthesia implications.

Dear Editor, Swyer-James-MacLeod Syndrome (SJMS) is a rare, acquired postinfectious condition characterized by bronchiectasis or emphysematous changes.[1,2] These patients have a high risk of perioperative pulmonary complications. A 28-year-old primigravida, at 24 weeks of gestation, came with dyspnea on exertion (grade-3) for the 3 months with no history of recurrent infections. On examination, there was diminished breath sounds on the left side. Chest radiograph (done with abdominal shield) showed left hyperlucent lung with reduced vascular markings and slight mediastinal shift. Rest of the investigations were normal. The patient was referred to chest physician for optimization and a diagnosis of Swyer-James syndrome with left lung bulla/pneumothorax was made. The patient was managed with bronchodilators (Metered-Dose Inhaler levosalbutamol and Tiotropium bromide) and breathing exercises (pursed-lip breathing, diaphragmatic breathing). Spirometry was not done since the patient was in the second trimester of pregnancy. The patient got symptomatically better and an elective cesarean section was planned. Blood gas analysis performed a day before surgery showed PH: 7.441, PCO2:25.6, PO2 = 70.6, Bicarbonate = 17, Base excess = 7.21, Oxygen saturation = 94.4%. High-risk written consent was taken and expected complications were explained. On the day of surgery, the patient was taken in the operation theatre after giving inhalational bronchodilators. Ondansetron 4 mg and ranitidine hydrochloride 50 mg were given intravenously 30 min prior to surgery. A 20-G intravenous cannula was secured, Ringer lactate was started and vital parameters were monitored. Spinal anesthesia with 10 mg of heavy bupivacaine and 25 micrograms of fentanyl in the right lateral position was given. The intraoperative period was uneventful. SJMS was first described in 1953 by Swyer and James, and later explained in detail by MacLeod. A chest radiograph demonstrates lobar or unilateral hyperlucent lung and normal or reduced volume of the affected lung. Patients can present with a multitude of symptoms ranging from asymptomatic with incidental radiographical diagnosis to severe symptoms such as dyspnea and repeated pulmonary infections.[1,2] This syndrome is usually diagnosed in childhood after an evaluation for recurrent respiratory infections, but sometimes they are asymptomatic and may be diagnosed in adulthood.[3,4] In a case series by S. S. Hadice et al.,[3] three out of four patients had no history of airway infection in childhood and were diagnosed in adulthood. The clinical incidence of SJMS in pregnancy is 1:2500.[2] The management focuses on early diagnosis, prevention, and treatment of recurrent pulmonary infections and vaccine administration.[2–4] Severe cases of SJMS may require anesthetic care cautiously tailored to significant obstructive pulmonary physiology.[5] Regional anesthesia should be preferred whenever feasible. Chopra S et al.,[2] reported the successful delivery in a case of SJMS under spinal anesthesia in emergency. Labor epidural anesthesia can also be used in electively scheduled patients and supplemented with low-dose spinal anesthesia before surgery, if required. General anesthesia is associated with risk of bulla rupture, worsening of pneumothorax, and other pulmonary complications. Drugs that can cause histamine release and bronchoconstriction should be avoided. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient and her father have given their consent for his images and other clinical information to be reported in the journal. The patient and father understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

Do significant adverse reactions to labor epidural anesthesia affect interval to delivery?

Epidural anesthesia during labor may lead to maternal hypotension and changes in fetal heart rate (FHR). We have evaluated whether occurrence of such adverse reactions affect the interval to delivery after anesthesia. Cohort study of all laboring women who underwent epidural anesthesia during labor for the period October 1, 2020-December 31, 2020. Excluded were cases of elective CD, non-cephalic presentation, twins or multiples, fetal death, and gestational age < 37.0 weeks. Significant adverse reactions included severe maternal hypotension (defined as systolic blood pressure < 100 mm Hg in the 60 minutes after epidural or decreasing by >20% compared with before epidural) or presence of severe (prolonged or recurrent late) decelerations in the 60 minutes after epidural. Occurrence of any significant adverse reaction was related to the interval-to-delivery after completion of epidural anesthesia using linear regression analysis (SPSS 28). Among the 438 women in the cohort, significant adverse reactions to epidural occurred in 172 (39.2%), including severe maternal hypotension in 149 (34%) and severe FHR decelerations in 50 (11.4%). Interval-to-delivery after labor epidural anesthesia was associated with maternal age (P=0.007), body mass index (P< 0.001), cervical dilation at epidural (P< 0.001) as well as occurrence of severe adverse reactions to epidural (P=0.019), cesarean delivery (CD) (P< 0.001) and CD for non-reassuring FHR (P=0.009). Linear regression demonstrated that only cervical dilation at epidural (P< 0.001) and CD (P< 0.001) were related to interval-to-delivery after epidural, whereas adverse reactions to epidural were not (P=0.22). Although significant adverse reactions to labor anesthesia were not uncommon in our cohort, they did not independently affect interval-to-delivery after completion of anesthesia.

Can side effects of labor epidural anesthesia predict subsequent cesarean delivery?

Can side effects of labor epidural anesthesia predict subsequent cesarean delivery?

Influence of Laboring People's Mobility and Positional Changes on Birth Outcomes in Low-Dose Epidural Analgesia Labor: A Systematic Review with Meta-Analysis.

Freedom of movement has been identified as a key issue for pregnant individuals during the birthing process, even if they opt for epidural analgesia, which has relegated people to more static positions during birth for many years. The aims of this systematic review were to evaluate the influence of mobility and positional changes on perinatal and neonatal outcomes in people in labor with epidural analgesia, describe the range of movement interventions used during the first and second stage of labor, and describe the level of motor blockade among people with low-dose epidural analgesia. Bibliographic databases (Web of Science, Cochrane, CINAHL) were consulted from December 2020 to January 2021. The articles selected were clinical trials and observational or analytical studies, the subject of which was mobilization during labor in people with epidural analgesia. The outcome measures were mode of birth, duration of labor, and extrauterine adaptation after birth. A narrative synthesis was used to describe the types of movements interventions employed during the stages of labor and the level of motor blockade among people with low-dose epidural analgesia. Ten articles were selected (8 clinical trials, one cross-sectional study, and one quasiexperimental study), with a total sample of 6086 individuals. A meta-analysis showed nonsignificant results between groups for mode of birth (relative risk [RR], 1.00; 95% CI, 0.87-1.14), duration of labor (RR, 1.64; 95% CI, -34.57 to 37.86), and extrauterine adaptation after birth (RR, 0.86; 95% CI, 0.39-1.93). There was heterogeneity among studies in the type of movement interventions used during the first and second stage of labor. Although no clear benefit was observed for mobilization in epidural labor, no detrimental effects were found either, so perinatal care providers should encourage mobilization if the laboring person so desires, throughout the entire childbirth process.

Peripartum neurological complications and labor epidural: an anesthesiologist predicament

BackgroundDismissing the process of labor, postpartum neurological complications tend to implicate anesthetic interventions as the cause, a predicament to the anesthesiologist mandating utmost periprocedural vigilance.Case presentationTwo obstetric patients with no comorbidities received uneventful labor epidurals. They presented with rare peripartum neurological complications.ConclusionsUnrecognized dural puncture is often a retrospective diagnosis made with the onset of symptoms in a presumed uneventful epidural. Negative aspiration of cerebrospinal fluid (CSF) during epidural insertion does not completely rule out the dural puncture. Th dural puncture can be obscured by initial dural tenting and tear without loss of CSF, followed by a breach in the weakened arachnoid during maternal efforts (Reynolds and Speedy, Anaesthesia 45:120-3, 1990). Obstruction of the TUOHY l umen with clot or ligamentum flavum, preventing CSF flow into the needle and subarachnoid migration of a subdurally placed catheter, is another cause.Delay in management of neurological complications resulting from unrecognized dural punctures can occur.

3.33 Is Intrapartum Epidural Anesthesia Associated With Increased Synthetic Oxytocin Exposure and ASD?

Labor epidural anesthesia (LEA) can block the Ferguson reflex that stimulates maternal oxytocin release during labor. Thus, LEA can increase the need for synthetic oxytocin (sOT) exposure to augment labor. Recent research indicated an association of elevated OR of ASD with higher dose and longer duration of exposure to sOT. Consequently, this study examined possible associations between LEA, sOT dosing, and a diagnosis of ASD.

O.7 Thermographic assessment of the feet in labour epidurals can provide early assessment of efficacy

O.7 Thermographic assessment of the feet in labour epidurals can provide early assessment of efficacy

Recognized and unrecognized dural punctures in 12,981 labor epidurals: an audit of management

PurposeUnintentional dural puncture (DP) and post-dural puncture headache (PDPH) continue to cause discomfort and disability in a small proportion of post-partum women. We report an audit of the management of recognized and unrecognized DP over 10 years.MethodsClinical data were prospectively collected for women who experienced a recognized DP or developed symptoms following a neuraxial procedure. Details were documented regarding patient characteristics, the neuraxial procedure, symptoms reported, and epidural blood patches. We reported rates of recognized DP, unrecognized DP, PDPH, and blood patches performed. Data were presented as number (percent) and proportions of interest compared using Chi square analysis.ResultsBetween January 2009 and December 2018, 12,981 women utilized labor epidural analgesia. A recognized DP occurred in 131 (1.0%) and an unrecognized DP in 60 (0.5%), with unrecognized DPs comprising 31% of the total. Of 131 recognized punctures, 86 (66%) developed a PDPH. A total of 146 (1.1%) women experienced a PDPH. Of those, a blood patch was performed in 93 (64%). Intrathecal catheters were inserted for > 24 h in 43 (33%) women with a recognized DP. Of those, 33 (77%) developed a PDPH, compared to 53 (60%) of those without an intrathecal catheter in situ for > 24 h (P = 0.06).ConclusionsRates of DP were consistent with those reported by others. Unrecognized DP comprised a third of all DP, and systematic post-neuraxial follow-up is essential to identify these women. Epidural blood patch was performed in most women experiencing symptoms of PDPH.