Maternal Pain Research Articles

Does local anesthesia decrease pain perception in women undergoing amniocentesis?

The null hypothesis is that local anesthesia does not decrease pain perception during amniocentesis. We performed a prospective randomized study comparing local anesthesia (1% lidocaine) with no anesthesia before amniocentesis in a racially diverse population. Immediately after the procedure, subjects were asked to assess their pain using both a Visual Analogue Scale and a 101-point Numerical Rating Scale. Two hundred four women were enrolled; 101 women received local, 102 women received no local, and 1 woman declined the amniocentesis after randomization. There was no difference in pain perception between the 2 groups as measured by either the visual analogue scale or the numeric rating scale (P = .28 and .18 respectively). The correlation coefficient between the 2 pain scales was strong with 0.86 for the local group and 0.92 for the no local group, (P < .001). Administration of local anesthesia before amniocentesis does not decrease maternal pain perception.

Ankyloglossia in Breastfeeding Infants: The Effect of Frenotomy on Maternal Nipple Pain and Latch

The aim of this study was to measure the effectiveness of frenotomy in ankyloglossic infants, by quantifying the changes in latch and maternal nipple pain using standardized tools. Infants below 12 weeks of age were recruited from the Goldfarb Breastfeeding Program between August 2004 and February 2005. Infants were selected based on the Frenotomy Decision Rule for Breastfeeding Infants (FDRBI), a new clinical tool for future validation. Latch was assessed using the Latch Tool. Maternal nipple pain was assessed using R. Melzack's Short Form McGill Pain Questionnaire, consisting of the Pain Rating Index (PRI) and Present Pain Intensity (PPI). Frenotomy was performed, followed by repeat latch and pain assessments. Mothers also received breastfeeding counseling throughout and after the procedure. A telephone questionnaire was administered 3 months later. Twenty-seven (27) mother-infant dyads participated in the study. No complications were seen with frenotomy. All infants had an equal or higher latch score after frenotomy, with an improvement in mean latch score of 2.5 (p < 0.0001, 95% confidence interval [CI], 2.038, 2.925). Maternal pain scores decreased significantly after frenotomy, with mean improvements of -11.4 points (p < 0.0001, 95% CI, -15.544, -7.345) on the PRI subscale and -1.5 points (p < 0.0001, 95% CI, -1.952, -1.011) on the PPI subscale. Seventy-seven point eight percent (77.8%) of subjects were still breastfeeding after 3 months; 92% were pain free after 3 months; and 88% felt the frenotomy had helped them. Timely frenotomy and breastfeeding counseling is an effective intervention, improving latch and decreasing nipple pain.

Prematurity represents an independent risk factor for eclampsia in preeclamptic women being treated with MgSO4

PREECLAMPTIC WOMEN BEING TREATED WITH MGSO4. MICHAEL BELFORT, JOHN ANTHONY, GEORGE SAADE, STEVEN CLARK, GARY DILDY, JANALEE THOMPSON, University of Utah, Obstetrics and Gynecology, Salt Lake City, Utah, University of Cape Town, Obstetrics and Gynaecology, Cape Town, South Africa, University of Texas Medical Branch at Galveston, Obstetrics & Gynecology, Galveston, Texas, University of Utah, Salt Lake City, Utah, Louisiana State University Medical Center at New Orleans, Obstetrics & Gynecology, Salt Lake City, Utah, St. Mark’s Hospital, Hospital Corporation of America, Maternal-Fetal Medicine, Salt Lake City, Utah OBJECTIVE: Magnesium sulfate (MgSO4) has an approximately 1% seizure prophylaxis failure rate in preeclampsia. Currently, factors predictive of seizure in such patients are unclear. STUDY DESIGN: Prospective data from preeclamptic women randomized to MgSO4 therapy were analyzed with univariate and multiple logistic regression analysis to determine independent variables associated with intrapartum and postpartum seizures. Variables included maternal age, race, gestational age, gravidity, previous preeclampsia, diabetes, chronic hypertension, epigastric pain, scotomata, headache, systolic BP, diastolic BP, platelet count, AST, ALT, and serum creatinine. A p ! 0.05 was used to denote statistical significance. RESULTS: 2038 patients were enrolled in two separate studies, of which 921 patients were randomized to MgSO4. Nine women or 0.98%, (95 percent confidence limits = 0.45% to 1.85%) on MgSO4 experienced seizure prophylaxis failure (8 intrapartum and 1 postpartum). No eclamptic patient had intracranial hemorrhage or other significant long-term neuropathology diagnosed and all recovered completely. By univariate analysis, lower gestational age and lower platelet count were identified as predictors of MgSO4 prophylaxis failure. On the multivariate regression analysis, only gestational age remained significantly associated with eclampsia (p = 0.04). 89% of patients in the seizure group (8/9) were !37 weeks while 61% (559/912) were preterm in the non-seizure group. CONCLUSION: Preterm preeclamptic patients (8/559 = 1.43%) receiving MgSO4 eclampsia prophylaxis are more likely to convulse than term patients (1/362 = 0.27%).

ABM Clinical Protocol #15: Analgesia and Anesthesia for the Breastfeeding Mother

Breastfeeding MedicineVol. 1, No. 4 Feature ArticlesABM Clinical Protocol #15: Analgesia and Anesthesia for the Breastfeeding MotherAnne Montgomery, Thomas W. Hale, and The Academy Of Breastfeeding Medicine Protocol CommitteeAnne MontgomerySearch for more papers by this author, Thomas W. HaleSearch for more papers by this author, and The Academy Of Breastfeeding Medicine Protocol CommitteeSearch for more papers by this authorPublished Online:7 Dec 2006https://doi.org/10.1089/bfm.2006.1.271AboutSectionsPDF/EPUB Permissions & CitationsPermissionsDownload CitationsTrack CitationsAdd to favorites Back To Publication ShareShare onFacebookTwitterLinked InRedditEmail FiguresReferencesRelatedDetailsCited byBreastfeeding woes: a family physician’s approach1 February 2022 | Singapore Medical Journal, Vol. 63, No. 2Medications and the breastfeeding motherEstrategias de tratamiento analgésico tras cesárea. Estado actual y nuevas alternativasRevista Española de Anestesiología y Reanimación, Vol. 67, No. 3Strategies of analgesic treatment after cesarean delivery. Current state and new alternativesRevista Española de Anestesiología y Reanimación (English Edition), Vol. 67, No. 3Effect on Baby-Friendly Hospital Steps When Hospitals Implement a Policy to Pay for Infant Formula18 August 2015 | Journal of Human Lactation, Vol. 32, No. 2Predictors of breastfeeding initiation in Hong Kong and Mainland China born mothers3 November 2015 | BMC Pregnancy and Childbirth, Vol. 15, No. 1The Need to Treat Maternal Pain in the Breastfeeding Mother: Are Opioids Safe?1 April 2015 | Pain Medicine, Vol. 16, No. 4Drug labeling in the practice of obstetric anesthesiaAmerican Journal of Obstetrics and Gynecology, Vol. 212, No. 1Guidelines for Recognition, Assessment and Treatment of Pain20 May 2014 | Journal of Small Animal Practice, Vol. 55, No. 6Safety of the breast-feeding infant after maternal anesthesia24 December 2013 | Pediatric Anesthesia, Vol. 24, No. 4Anesthetic considerations for high order cesarean sections: a prospective cohort study20 August 2013 | Archives of Gynecology and Obstetrics, Vol. 289, No. 3Strategies to Optimize Pain Control Following Cesarean DeliveryASA Refresher Courses in Anesthesiology, Vol. 42, No. 1Labor Epidural Anesthesia, Obstetric Factors and Breastfeeding Cessation13 June 2012 | Maternal and Child Health Journal, Vol. 17, No. 4Clinical Protocols for Management of BreastfeedingPediatric Clinics of North America, Vol. 60, No. 1Medications and the Breastfeeding MotherAssociation between Intrapartum Interventions and Breastfeeding Duration14 January 2013 | Journal of Midwifery & Women's Health, Vol. 58, No. 1Challenging the Truth of Some Breastfeeding Dogma Ruth A. Lawrence10 December 2012 | Breastfeeding Medicine, Vol. 7, No. 6Defining Lactation Acuity to Improve Patient Safety and Outcomes28 April 2011 | Journal of Human Lactation, Vol. 27, No. 2Breast Milk Hydrocodone and Hydromorphone Levels in Mothers Using Hydrocodone for Postpartum PainObstetrics & Gynecology, Vol. 117, No. 3Disorders of the Gastrointestinal Tract in Pregnancy9 July 2010Frühzeitige Epiduralanästhesie in der Geburtshilfe11 June 2010 | Der Anaesthesist, Vol. 59, No. 6Epidural Analgesia in the Latent Phase of Labor and the Risk of Cesarean DeliveryAnesthesiology, Vol. 111, No. 4Reasons for In-Hospital Formula Supplementation of Breastfed Infants From Low-Income Families1 February 2009 | Journal of Human Lactation, Vol. 25, No. 1Why Won't This Newborn Be Breast-Fed?Journal of Perinatal & Neonatal Nursing, Vol. 22, No. 3BreastfeedingDisease-a-Month, Vol. 54, No. 6 Volume 1Issue 4Dec 2006 InformationCopyright 2006, Mary Ann Liebert, Inc.To cite this article:Anne Montgomery, Thomas W. Hale, and The Academy Of Breastfeeding Medicine Protocol Committee.ABM Clinical Protocol #15: Analgesia and Anesthesia for the Breastfeeding Mother.Breastfeeding Medicine.Dec 2006.271-277.http://doi.org/10.1089/bfm.2006.1.271Published in Volume: 1 Issue 4: December 7, 2006PDF download

Prolonged Second Stage of Labor and Risk of Adverse Maternal and Perinatal Outcomes: A Systematic Review

Safe and effective management of the second stage of labor presents a clinical challenge for laboring women and practitioners of obstetric care. This systematic review was conducted to evaluate evidence for the influence of prolonged second stage of labor on the risk of selected adverse maternal and neonatal outcomes. Articles were searched using PubMed, Cochrane Library, and CINAHL from 1980 until 2005. Studies were included according to 3 criteria: if they reported duration of the second stage of labor, if they reported maternal and/or neonatal outcomes in relation to prolonged second stage, and if they reported original research. Our systematic review found evidence of a strong association between prolonged second stage and operative delivery. Although significant associations with maternal outcomes such as postpartum hemorrhage, infection, and severe obstetric lacerations were reported, inherent limitations in methodology were evident in the studies. Recurrent limitations included oversimplified categorization of second stage, inconsistency in study population characteristics, and lack of control of confounding factors. No associations between prolonged second stage and adverse neonatal outcomes were reported. The primary findings of our review indicated that most of the studies are flawed and do not answer the important questions for maternity caregivers to safely manage prolonged second stage. Meanwhile, approaches for promoting a normal second stage of labor are available to caregivers, such as maternal positioning and pain relief measures and also promoting effective pushing technique.

Types of intra-muscular opioids for maternal pain relief in labour

Pethidine is the most widely used intra-muscular opioid for the relief of labour pain. However concerns have been raised about its effectiveness and the possibility of depressing respiration in newborns. The objective of this review was to assess the effects of different opioids (and different doses of the same opioid) administered intra-muscularly in labour. We searched the Cochrane Pregnancy and Childbirth Group trials register, the Cochrane Controlled Trials Register (Cochrane Library, issue 4, 1997) and reference lists of articles. Randomised trials comparing the effects of different currently used opioids (and different doses of the same opioid) administered intramuscularly in labour for women who request systemic analgesia. Two reviewers assessed trial quality and extracted data. Analysis was based on the groups as randomly allocated. Sixteen trials were included. There were problems with methodological quality of some of the trials, and lack of consistency in the way various outcomes were reported. There was no evidence of a difference between pethidine and tramadol in terms of pain relief, interval to delivery, or instrumental or operative delivery. There appeared to be more adverse effects such as nausea and vomiting and drowsiness with pethidine. Maternal pain relief seemed almost identical between the meptazinol and pethidine groups, whether assessed as maternal satisfaction with pain relief, visual analogue scales, or use of other pain relief, but meptazinol gave rise to slightly more side effects. Maternal satisfaction with pain relief appeared similar for pentazocine and pethidine, with more frequent nausea and vomiting with pethidine. There is not enough evidence to evaluate the comparative efficacy and safety of the various opioids used for analgesia in labour.

Does regular massage from late pregnancy to birth decrease maternal pain perception during labour and birth?—A feasibility study to investigate a programme of massage, controlled breathing and visualization, from 36 weeks of pregnancy until birth

The present study was undertaken to produce a detailed specification of a programme of massage, controlled breathing and visualization performed regularly by birth partners, from 36 weeks gestation and assisted by a trained professional, following hospital admission during labour and birth. As current research on massage interventions for pain relief in labour is poorly characterized, we began by undertaking a feasibility study on an established massage programme [Goldstone LA. Massage as an orthodox medical treatment past and future. Complementary Therapies in Nursing & Midwifery. 2000;6:169-75]. The intervention was designed in light of experimental findings that repeated massage sessions over 14 days increases pain threshold, by an interaction between oxytocin and opioid neurons [Lund I, Yu L-C, Uvnas-Moberg K, Wang J, Yu C, Kurosawa M, et al. Repeated massage-like stimulation induces long-term effects on nociception: contribution of oxytocinergic mechanisms. European Journal of Neuroscience 2002;16:330-8]. A 4 week time-frame was selected to coincide with a physiological increase in maternal pain threshold [Cogan R, Spinnato JA. Pain and Discomfort Thresholds in Late Pregnancy. Pain 1986;27:63-8, Whipple B, Josimovich JB, Komisaruk BR. Sensory thresholds during the antepartum, intrapartum, and postpartum periods. International Journal of Nursing Studies 1990;27(3):213-21, Gintzler AR, Komisaruk BR. Analgesia is produced by uterocervical mechano-stimulation in rats: roles of afferent nerves and implications for analgesia of pregnancy and parturition. Brain Research 1991;566:299-302, Gintzler AR, Liu N-J. The maternal spinal cord: biochemical and physiological correlates of steroid-activated antinociceptive processes. In: Russell JA, Douglas AJ, Windle RJ, Ingram CD, editors., Progress in Brain Research. Volume 133. The Maternal Brain. Neurobiological and Neuroendocrine adaptation and disorders in pregnancy and postpartum. Amsterdam: Elsevier Science, 2001. p. 83-97]. The main objective was to measure the effects of the programme on maternal pain perception during labour and birth. To detect any effect of massage during labour, on maternal cortisol and catecholamines, cord venous blood was taken to measure plasma concentrations following birth. Twenty-five nulliparous (N) and 10 multiparous (M) women participated in the study. Cortisol values were similar to published studies following labour without massage but pain scores on a Visual Analogue Scale (VAS), at 90min following birth were significantly lower than scores recorded 2 days postpartum [Capogna G, Alahuhta S, Celleno D, De Vlieger H, Moreira J, Morgan B, et al. Maternal expectations and experiences of labour pain and analgesia: a multi-centre study of nulliparous women. International Journal of Obstetric Anaesthesia 1996;5:229-35]. The mean score was 6.6. Previous studies suggest that a reduction from 8.5 to 7.5 would significantly reduce pharmacological analgesia in labour [Capogna G, Alahuhta S, Celleno D, De Vlieger H, Moreira J, Morgan B, et al. Maternal expectations and experiences of labour pain and analgesia: a multi-centre study of nulliparous women. International Journal of Obstetric Anaesthesia 1996;5:229-35].

The Relationship Between Maternal Chronic Pain and Child Adjustment: The Role of Parenting as a Mediator

The role of parenting in the relationship between maternal chronic pain and negative child outcomes, including internalizing, externalizing, and social and health problems, was investigated. Parenting strategies used by mothers with chronic pain were compared to parenting strategies used by a control group of mothers without pain. Thirty-nine mothers experiencing chronic pain, their 55 children, 35 pain-free mothers, and their 48 children participated in the study. The results showed that for mothers with chronic pain, dysfunctional parenting strategies and the quality of the mother-child relationship were related to negative child outcomes. Mothers with chronic pain were more likely to engage in lax parenting and report reduced relationship quality with children than were control mothers. For the chronic pain group, over-reactive parenting was found to mediate the relationship between maternal physical functioning and child adjustment. Dysfunctional parenting strategies may constitute part of the risk that maternal chronic pain poses for children. The similarities between the impact of maternal chronic pain on child adjustment and that of other maternal stressors, such as depression, are discussed. Perspective In mothers with chronic pain, poor maternal physical functioning was associated with increased maternal over-reactive behavior that was in turn related to poor child adjustment. Maternal over-reactive behavior did not, however, differ in chronic pain and control mothers.

Psychosocial Influences on Women’s Experience of Planned Elective Cesarean Section

The successful management of pain from normal or interventional delivery is an important part of women's experience of childbirth. Our objective was to examine psychosocial factors (expectations, control beliefs, anxiety sensitivity) as measured in mothers and birth partners before an elective cesarean section. We focused on the impact that these variables have on maternal fear and pain during and after delivery. Sixty-five women booked for an awake cesarean section with a regional nerve block and their birth partners were recruited. Data were collected at three time points for the mothers, before, during the cesarean section and after delivery on the postnatal ward, and at two time points for the birth partners (before and during the cesarean section). Maternal fear responses varied during the operation, in that fear was greatest at the point of administration of the nerve block. Within mothers, preoperative negative expectations were related to fear experiences during delivery, which was in turn related to their postoperative pain. Maternal anxiety sensitivity was found to mediate the relationship between negative expectations and fear, whereas birth partner's fear mediated between maternal fear and postoperative pain. Mothers' prenatal perceptions of control over drugs predicted their postoperative pain. Maternal fear during cesarean section not only fluctuates, but may be influenced by psychosocial factors, including their birth partner. Psychosocial factors were also important predictors of postoperative experiences. Interventions that appropriately manage psychological and social factors during cesarean delivery may facilitate a more positive experience for mothers.

Maternal experience of pain during external cephalic version at term

This study was designed to investigate maternal pain perception during external cephalic version (ECV). This prospective study included 97 pregnant women with singleton breech presentation at or above 36 weeks of gestation undergoing ECV. No analgesia or anesthesia were used during ECV. The women were asked to rate the degree of pain on a 10-cm visual analog scale after ECV. Ninety-eight ECVs were performed and the overall success rate was 66%. The median pain score was 5.7 (interquartile range 2.7-6.8). The visual analog pain score was significantly lower among those with a successful ECV than those with a failed procedure (median score 4.6 vs. 6.8, p < 0.001). Similarly, those procedures rated as easy by the operator were associated with a significantly lower pain score (3.4 vs. 6.4, p < 0.001). However, the pain score was not found to be related to the operator, parity or placental site. Among the five subjects with a pain score of 8.5 and beyond, the ECV procedure was still successful in four (80%). ECV performed without analgesia was associated with a moderate degree of pain that was well tolerated by the majority of patients because of its short duration.

Delivery Pain and the Development of Mother-Infant Interaction.

This study examined delivery pain as a possible risk factor for the development of mother-infant interaction. Eighty-one mothers completed the Pain Catastrophizing Scale, the State-Trait Anxiety Inventory, and the Edinburgh Postnatal Depression Scale. A retrospective evaluation of labor pain was performed using the Visual Analog Scale at 2 days postpartum. Six weeks after birth the mothers were visited at home, completed measures of anxiety and depression, and were observed during a free play session with the infant. The mother's tendency to catastrophize pain predicted lower levels of mother-infant reciprocity at 6 weeks, controlling for maternal age, education, parity, epidural analgesia, pain perception, anxiety, and depression. Trait anxiety was related to lower maternal sensitivity. The mother's tendency to catastrophize pain was discussed in relation to the personality trait of exaggerated emotional perception of pain and its potential interference with the formation of the mother-infant relationship.

Prenatal Constriction of the Fetal Ductus Arteriosus - Related to Maternal Pain Medication?

Physiological fetal circulation requires patency of the ductus arteriosus. As gestation proceeds, the sensitivity of the ductus to dilating prostaglandins diminishes. The sensitivity to constricting agents like PGE-synthetase inhibitors, present in many analgetics, however, increases. Fetuses affected by an antenatal constriction of the ductus arteriosus (DC) may present with different signs of cardiac failure including dilated right ventricle, tricuspid regurgitation and abnormal venous Doppler. We report on four cases with prenatal DC, presenting at 34, 35, 36 and 37 weeks of gestation. They were referred to fetal echocardiography because of abnormal routine echo scans with unexplained signs of right heart decompensation. Three patients were medicated during pregnancy with either aspirin (low dose), metamizole or ibuprofen. One patient did not take any drugs, especially no pain medication drug in pregnancy. Immediate delivery was performed in all cases. The neonates were in a good condition; echocardiography showed different degrees of right heart hypertrophy which disappeared in all infants by the age of 3 months except in case 2. Unexplained fetal right heart decompensation requires detailed echocardiographic evaluation of the ductus arteriosus and a sophisticated medical history with regard to analgesics. In contrast to ibuprofen and high-dose aspirin, metamizole and low-dose aspirin have not yet been reported as possible agents constricting the fetal arterial duct. In any suspected context, early delivery as in our cases may save babies life. Any application of non-steroidal anti-inflammatory drugs in pregnancy requires close fetal follow-up due to their potentially life-threatening effect.

The Apgar Score Has Survived the Test of Time

In 1953, Virginia Apgar, M.D. published her proposal for a new method of evaluation of the newborn infant. The avowed purpose of this paper was to establish a simple and clear classification of newborn infants which can be used to compare the results of obstetric practices, types of maternal pain relief and the results of resuscitation. Having considered several objective signs pertaining to the condition of the infant at birth she selected five that could be evaluated and taught to the delivery room personnel without difficulty. These signs were heart rate, respiratory effort, reflex irritability, muscle tone and color. Sixty seconds after the complete birth of the baby a rating of zero, one or two was given to each sign, depending on whether it was absent or present. Virginia Apgar reviewed anesthesia records of 1025 infants born alive at Columbia Presbyterian Medical Center during the period of this report. All had been rated by her method. Infants in poor condition scored 0-2, infants in fair condition scored 3-7, while scores 8-10 were achieved by infants in good condition. The most favorable score 1 min after birth was obtained by infants delivered vaginally with the occiput the presenting part (average 8.4). Newborns delivered by version and breech extraction had the lowest score (average 6.3). Infants delivered by cesarean section were more vigorous (average score 8.0) when spinal was the method of anesthesia versus an average score of 5.0 when general anesthesia was used. Correlating the 60 s score with neonatal mortality, Virginia found that mature infants receiving 0, 1 or 2 scores had a neonatal death rate of 14%; those scoring 3, 4, 5, 6 or 7 had a death rate of 1.1%; and those in the 8-10 score group had a death rate of 0.13%. She concluded that the prognosis of an infant is excellent if he receives one of the upper three scores, and poor if one of the lowest three scores.

Intrathecal epinephrine in combined spinal-epidural analgesia for labor: dose-response relationship for epinephrine added to a local anesthetic-opioid combination

The purpose was to investigate the dose-response relationship for intrathecally administered epinephrine added to a local anesthetic-opioid combination in combined spinal-epidural analgesia for labor, in order to evaluate analgesia and side-effects. The subjects were 100 consecutive ASA I or II parturients at 37 weeks' gestation, who received combined spinal-epidural analgesia during labor. Each woman was randomly assigned to one of five groups that received 2-mL volumes of different spinal solutions. The control group received an intrathecal injection of bupivacaine 2.5 mg and fentanyl 25 microg only. The others received epinephrine 12.5, 25, 50 or 100 microg added to this intrathecal regimen. Maternal arterial pressure, heart rate and pain scores were recorded before and 5, 10, 15 and 30 min after intrathecal injection. Level of sensory blockade, motor blockade score, duration of intrathecal analgesia, side effects, fetal heart rate, and 1- and 5-min Apgar scores were also assessed. Compared to the control group, all four epinephrine groups had significantly longer duration of intrathecal analgesia, but the durations were similar. The frequencies of side effects were similar in all five groups. The results suggest that adding epinephrine to a combination of standard intrathecal doses of bupivacaine and fentanyl in combined spinal-epidural analgesia for labor significantly prolongs spinal analgesia. Of the four epinephrine doses tested, the lowest one (12.5 microg) was optimal for this clinical setting.

Gerard W. Ostheimer “What’s New in Obstetric Anesthesia” Lecture

Gerard W. Ostheimer “What’s New in Obstetric Anesthesia” Lecture

Immersion in Water in Pregnancy, Labour, and Birth

A substantive amendment to this systematic review was last made on 10 October 2003. Cochrane reviews are regularly checked and updated if necessary. AbstractBackground: Enthusiasts for immersion in water during labour and birth have advocated its use to increase maternal relaxation, reduce analgesia requirements, and promote a midwifery model of supportive care. Sceptics are concerned that there may be greater harm to women and/or babies, for example, a perceived risk associated with neonatal inhalation of water and maternal/neonatal infection.Objectives: To assess the evidence from randomised controlled trials about the effects of immersion in water during pregnancy, labour, or birth on maternal, fetal, neonatal, and caregiver outcomes.Search strategy: We searched the Cochrane Pregnancy and Childbirth Group trials register (September 2003).Selection criteria: All randomised controlled trials comparing any kind of bath tub/pool with no immersion during pregnancy, labour, or birth.Data collection and analysis: We assessed trial eligibility and quality and extracted data independently. One reviewer entered the data and another checked them for accuracy.Main results: Eight trials are included (2939 women). No trials were identified that evaluated immersion versus no immersion during pregnancy, considered different types of baths/pools, or considered the management of third stage of labour. There was a statistically significant reduction in the use of epidural/spinal/paracervical analgesia/anaesthesia amongst women allocated to water immersion during the first stage of labour compared to those not allocated to water immersion (odds ratio (OR) 0.84, 95% confidence interval (CI) 0.71 to 0.99, four trials). There was no significant difference in vaginal operative deliveries (OR 0.83, 95% CI 0.66 to 1.05, six trials), or caesarean sections (OR 1.33, 95% CI 0.92 to 1.91). Women who used water immersion during the first stage of labour reported statistically significantly less pain than those not labouring in water (40/59 versus 55/61)(OR 0.23, 95% CI 0.08 to 0.63, one trial). There were no significant differences in incidence of an Apgar score less than 7 at five minutes (OR 1.59, 95% CI 0.63 to 4.01), neonatal unit admissions (OR 1.05, 95% CI 0.68 to 1.61), or neonatal infection rates (OR 2.01, 95% CI 0.50 to 8.07).Reviewers’ conclusions: There is evidence that water immersion during the first stage of labour reduces the use of analgesia and reported maternal pain, without adverse outcomes on labour duration, operative delivery, or neonatal outcomes. The effects of immersion in water during pregnancy or in the third stage are unclear. One trial explores birth in water, but is too small to determine the outcomes for women or neonates.Citation: Cluett ER, Nikodem VC, McCandlish RE, Burns EE. Immersion in water in pregnancy, labour and birth (Cochrane Review). In: The Cochrane Library, Issue 3, 2004. Chichester, UK: John Wiley &amp; Sons, Ltd. ••• The preceding report is an abstract of a regularly updated, systematic review prepared and maintained by the Cochrane Collaboration. The full text of the review is available in The Cochrane Library (ISSN 1464‐780X). The Cochrane Library is designed and produced by Update Software Ltd, and published by John Wiley &amp; Sons, Ltd.

Obstetric Uterine Rupture: A 20-Year Clinical Analysis

To analyze the obstetric and gynecologic history of women with uterine rupture during pregnancy, and examine maternal and perinatal morbidity and mortality outcomes after uterine rupture. A retrospective review of patients with rupture of the gravid uterus at Mackay Memorial Hospital, for the period between January 1984 and September 2003, was undertaken. The records of these patients were studied with regard to previous cesarean section, the use of uterine stimulants, the use of instruments in delivery, clinical features, treatment modality, and maternal and fetal morbidity and mortality. A total of 21 cases of rupture of the gravid uterus were found. The prevalence of uterine rupture was 1 in 6,056 deliveries. The most common risk factor was previous cesarean section scar (48%). Fetal distress (43%) and postpartum hemorrhage (24%) were the two most common manifestations of ruptured uterus. Fourteen cases were term pregnancies. However, seven cases presented before term, including one in the first trimester, two in the second trimester, and four in the early third trimester. There was only one maternal death (5%), but five cases (24%) presented with intrauterine fetal demise. Physicians should be alert to the possibility of uterine rupture at all stages of pregnancy. The ability to recognize the various signs of a possible rupture event, such as fetal distress, maternal pain, or hypotension, and then to address the situation immediately, is critical to a good outcome.

P02.14: Continuous vacuum depression vs. syringe amnioreduction for polyhydramnios: a prospective randomised study

Objectives: To prospectively compare the efficacy and tolerance of two techniques of amniodrainage used in the treatment of symptomatic polyhydramnios: syringe aspiration (SA) and continuous vacuum depression (VD). Patients and Methods: Prospective randomised study, performed over 37 months. The main comparison criterion was maternal pain, blindly assessed by a midwife using a visual quantitative scale (EVA from 0 to 100 points). Comparison also included: duration and volume of fluid drained, need to stop the procedure because of maternal pain, uterine activity after drainage, foetal tolerance controlled with CTG (FHR blindly analysed by 2 obstetricians) and absence of placenta abruption controlled by histological examination of the placenta. We calculated that 35 patients would be necessary in each group to show a 20 points difference on the EVA with a power of 80% (alpha: 0.05). Results: 80 amnioreductions were performed in 53 patients. The two groups were comparable for the tested variables (age, parity, term, deepest pool and amniotic fluid index before drainage, uterine contractility, tocolysis) as well as for the aetiology of polyhydramnios. Drained volume was significantly higher in the VD group (2540 ml +/− 860 versus 1250 ml +/− 530; p < 0.01) and the drainage duration significantly shorter (12 mn +/− 10 versus 38 mn +/− 25; p < 0.01). Maternal pain was significantly lower in the VD group compared to the SA group (25 +/− 12 vs. 55 +/− 22; p < 0.01). No significant difference was noted in uterine contractility or FHR abnormalities between the two groups and they were no occurrence of clinical placental abruption. In four cases, histological analysis of the placentas revealed the presence of old placental infarctions (three in the SA group and one in the VD group). Conclusion: Continuous vacuum depression appears to be faster and has a better maternal tolerance than syringe aspiration.

P02.15: Percutaneous ultrasound‐guided drainage of an enlarged intrathoracic stomach may increase lung volume in fetuses with life‐threatening congenital diaphragmatic hernia

Objectives: To prospectively compare the efficacy and tolerance of two techniques of amniodrainage used in the treatment of symptomatic polyhydramnios: syringe aspiration (SA) and continuous vacuum depression (VD). Patients and Methods: Prospective randomised study, performed over 37 months. The main comparison criterion was maternal pain, blindly assessed by a midwife using a visual quantitative scale (EVA from 0 to 100 points). Comparison also included: duration and volume of fluid drained, need to stop the procedure because of maternal pain, uterine activity after drainage, foetal tolerance controlled with CTG (FHR blindly analysed by 2 obstetricians) and absence of placenta abruption controlled by histological examination of the placenta. We calculated that 35 patients would be necessary in each group to show a 20 points difference on the EVA with a power of 80% (alpha: 0.05). Results: 80 amnioreductions were performed in 53 patients. The two groups were comparable for the tested variables (age, parity, term, deepest pool and amniotic fluid index before drainage, uterine contractility, tocolysis) as well as for the aetiology of polyhydramnios. Drained volume was significantly higher in the VD group (2540 ml +/− 860 versus 1250 ml +/− 530; p < 0.01) and the drainage duration significantly shorter (12 mn +/− 10 versus 38 mn +/− 25; p < 0.01). Maternal pain was significantly lower in the VD group compared to the SA group (25 +/− 12 vs. 55 +/− 22; p < 0.01). No significant difference was noted in uterine contractility or FHR abnormalities between the two groups and they were no occurrence of clinical placental abruption. In four cases, histological analysis of the placentas revealed the presence of old placental infarctions (three in the SA group and one in the VD group). Conclusion: Continuous vacuum depression appears to be faster and has a better maternal tolerance than syringe aspiration.

Epidural analgesia in labour

Since epidural analgesia was introduced four decades ago for pain relief in labour, controversy has persisted about its effect on the labour process. As a result of this, considerable research has been performed and findings have led to changes in practice. Epidurals have been credited with prolonging labour; increasing oxytocin requirements, instrumental and operative delivery rates; and causing maternal pyrexia and postpartum back pain. There is increasing evidence that refutes some of these claims. Despite ongoing controversies, epidural rates have increased; ∼25% of women in the UK and 66% of women in the USA receive epidural analgesia in labour. The following statement from the American College of Obstetricians and Gynecologists summarizes the background to these figures: ‘labour results in severe pain for many women. There is no other circumstance where it is considered acceptable for a person to experience untreated severe pain, amenable to safe intervention, while under a physician's care.’