Use Of Epidural Analgesia Research Articles

Pain management with epidural catheter and epidural analgesia after spinal dorsal instrumentation of lumbar spine.

Spinal dorsal instrumentation (SDI) is an established treatment for degenerative spinal diseases. Adequate and immediate postoperative pain control is important for patient recovery and may be compromised by uncertainty about its efficacy and concern about early postoperative surgical complications or adverse events. The aim of the current study was to compare the use of epidural analgesia (EA) with systemic analgesia (SA) as regards pain reduction and early postoperative complications after SDI. Pain management with epidural or systemic analgesia in patients undergoing SDI by posterior approach between January 2019 and July 2020 was evaluated by clinical functional testing, measuring total opioid amounts used, and evaluating numerical rating scale values 24 and 96 hours postoperatively. The following were also monitored: demographic data, number of affected segments, length of hospital stay, inflammatory markers (leukocytes and serum C-reactive protein), early postoperative surgical complication rates, and adverse events. In total 79 patients were included (33 in the EA and 46 in the SA group). The SA group had significantly lower numerical rating scale values at days 1 to 4 after surgery (P ≤ .001) and lower cumulative opioid use than the EA group (P < .001). We found no difference in infection parameters, length of hospital stay or surgery-related complication rates. Our data demonstrate that epidural anesthesia was inferior to an opioid-based SA regime in reducing postoperative pain in patients undergoing spinal surgery. There is no benefit to the use of epidural catheters.

Evaluation of labor and childbirth care by nurse-midwives in Brazilian private hospitals: results of a quality improvement project

BackgroundIn 2015, a quality improvement project—the “Adequate Childbirth Project” (Projeto Parto Adequado, or PPA)—was implemented in Brazilian private hospitals with the goal of reducing unnecessary cesarean sections. One of the strategies adopted by the PPA was the implementation of labor and childbirth care by nurse-midwives. The objective of this study is to evaluate the results of the PPA in the implementation and adequacy of labor and childbirth care by nurse-midwives in Brazilian private hospitals.MethodsCross-sectional, hospital-based study, carried out in 2017, in 12 hospitals participating in the PPA. We assessed the proportion of women assisted by nurse-midwives during labor and childbirth care and the adequacy of 13 care practices following parameters of the World Health Organization. Women assisted in the PPA model of care and in the standard of care model were compared using the chi-square statistical test.Results4798 women were interviewed. Women in the PPA model of care had a higher proportion of labor (53% × 24.2%, p value < 0.001) and vaginal birth (32.7% × 11.3%, p value < 0.001), but no significant differences were observed in the proportion of women assisted by nurse-midwives during labor (54.8% × 50.1%, p value = 0.191) and vaginal birth (2.2% × 0.7%, p value = 0.142). The implementation of recommended practices was adequate, except the use of epidural analgesia for pain relief, which was intermediate. There was a greater use of recommended practices including “oral fluid and food”, “maternal mobility and position”, “monitoring of labor”, “use of non-pharmacological methods for pain relief” and “epidural analgesia for pain relief” in women assisted by nurse-midwives in relation to those assisted only by doctors. Many non-recommended practices were frequently used during labor by nurse-midwives and doctors.ConclusionsThere was an increase in the proportion of women with labor and vaginal birth in the PPA model of care and an appropriate use of recommended practices in women assisted by nurse-midwives. However, there was no difference in the proportion of women assisted by nurse-midwives in the two models of care. The expansion of nursing participation and the reduction of overused practices remain challenges.

Effect of Preemptive Multimodal Analgesia Regimen on Post-operative Epidural Demand Boluses in Lower Limb Orthopaedic Surgeries.

Introduction Excruciating pain is associated with lower limb orthopaedic surgeries involving femoral shaft fractures. Postoperative pain management is still ineffective in low-resource settings where the use of epidural and opioid-free analgesia is impractical. Literature is scarce with respect to the effect of a preemptive multimodal analgesia regimen on the requirement of postoperative epidural demand boluses.Hence, the present study aimed to evaluate the effectof pre-emptive multimodal analgesia in reducing the requirement of epidural demand boluses postoperatively, and to find out the time required to receive the first epidural bolus. Material and methods This double-blinded randomized control study included 48 subjects. Patients aged 18-60 years with lower limb fractures requiring surgery under combined spinal-epidural anesthesia were included. Patients were divided into two groups through random allocation. Group A: Preemptive multimodal group received intravenous paracetamol 1 g, IV diclofenac 75 mg diluted in 100ml NS, IV tramadol 50mg diluted in 100ml NS and tab pregabalin 75 mg orally, 30 mins before surgery. Group B:Placebo group received 3 pints of 100ml NS IV and tab ranitidine 150 mg, 30 mins before surgery. Intraoperatively, combined spinal-epidural anaesthesia was administered taking all theaseptic precautions. Visual analogue scale (VAS) was recorded immediately on shifting to a postoperative room, and then at 1, 4, 8, 12, and 24 hr for both groups. Epidural boluses (10 ml of 0.125% bupivacaine with 2 μg/ml of fentanyl) were given whenever the patient's visual analogue scale was more than 4. The time at which the first epidural bolus was required by the patient was recorded. The total number of epidural boluses given over 24 hours based on VAS was recorded for both, the preemptive and placebo groups. If the patient still complained of pain, IV diclofenac 75 mg was given if the VAS was more than 4, while IV diclofenac 75 mg along with IV tramadol 50 mg was given if the VAS was more than 6. Patient satisfaction with anesthesia care, in general, was assessed 24 hrs postoperatively. Results A total of 48 subjects were included in the study. During the immediate-postoperative period, and at 8, 12 and 24 hr, the median VASwas significantly low in group A as compared to group B. A significant increase in the demand for epidural bolusimmediate-postoperatively was observed in group B (70.83%) compared to group A (4.17%) (p-value of <0.001).At 8 hr, 12hr, and 24hr, patients in group A found a significantly less need for epidural boluses compared to Group B. The mean total number of epidural boluses taken in group A was significantly less compared to group B (1.79 ± 0.41 VS 3.33 ± 0.48, p-Value <0.001). In group A, all patients reported no requirement for diclofenac and tramadol. In group B, 8.33% required diclofenac 75 mg, while the remaining 91.66% had no requirement for diclofenac and tramadol. The difference in patient satisfaction with anaesthesia care in general between the two study groups was found to be significant with a p-value of 0.027. Patients in Group A were very satisfied compared with those in group B. Conclusions The study found that the pre-emptive multimodal analgesia group had better postoperative pain control because they required fewer epidural boluses and no extra analgesics postoperatively. This group was more satisfied with the anaesthesia care in general.

Maternal position during the second stage of labor and maternal-neonatal outcomes in nulliparous women: a retrospective cohort study

The existing evidence is insufficient to draw conclusions about the association between maternal position in labor and obstetrical outcomes. This study aimed to evaluate the effects of different maternal positions during the second stage of labor among women with and those without epidural analgesia on important obstetrical outcomes including perineal damage. In this retrospective cohort study, we collected data of women who delivered vaginally over a 2-year period. The associations between maternal and gestational characteristics and several obstetrical outcomes were analyzed. We considered perineal damage as the primary outcome. Secondary outcomes were the incidence of operative vaginal births, duration of fetal descent, intrapartum blood loss, and 1-minute and 5-minutes Apgar scores. A total of 2240 nulliparous, at-term pregnancies were included. Of those, 76.9% gave birth in a supine position and 23.1% gave birth in alternative positions. The results showed that regardless of the use of epidural analgesia, nonsupine positions in the second stage of labor are associated with a significant reduction in the risk of both episiotomy and perineal damage to any degree (P<.0001) and to a reduction in the duration of fetal descent (Spearman rho, 9.17; confidence interval, 3.07-15.32; P=.003). No statistically significant differences were found in the 1-minute and 5-minutes Apgar score between the 2 groups. Our results show that nonsupine positions in the second stage of labor and at the time of birth are associated with a significant increase in having an intact perineum and a reduction in any perineal trauma and in the need for an episiotomy regardless of the use of epidural analgesia.

Effect of Postoperative Pain Management after Robot-Assisted Radical Prostatectomy: A Study on Reducing Hospital Length of Stay and Medical Costs Using Japanese Nationwide Database.

Prostate cancer has a high incidence rate. Many articles reported its usefulness with the advent of robotic surgery in 2001. However, epidural analgesia is declining due to the spread of minimally invasive treatment. There have been no studies using nationwide databases on the impact of epidural analgesia use on length of hospital stay and medical costs. Therefore, we used a Japanese national inpatient database from April 2016 to March 2020. The study population included 46,166 patients. We compared a postoperative analgesia management group using epidural analgesia [Epidural Analgesia Group (EA Group): 5,354] and a group not using epidural analgesia [non-Epidural Analgesia Group (non-EA Group): 40,812]. We found significant differences among the two groups regarding the length of stay, days from surgery to discharge, and inpatient cost of surgery to discharge. Hospital length of stay and postoperative hospital stay was statistically shorter in the EA group than in the non-EA group (11.3 ± 2.8 days vs. 12.1 ± 3.1 days, p < 0.001 and 8.9 ± 2.5 days vs. 9.3 ± 2.7 days, p < 0.001), respectively, and medical costs were also significantly lower in the EA group (84,566 JPY vs. 294,277 JPY, p < 0.001). Also, the activities of daily living (ADL) assessment at discharge determined a considerably higher score in the EA group than in the non-EA groups. Epidural analgesia for postoperative pain management largely depends on each medical institution's treatment policy. However, epidural analgesia is declining due to the spread of minimally invasive treatment. Therefore, epidural analgesia should be reconsidered because it can reduce hospital stays and hospitalization costs.

TREATMENT OF CONGENITAL DUODENAL OBSTRUCTION: FROM OPEN TO LAPAROSCOPIC APPROACH FOR DUODENO-DUODENAL ANASTOMOSIS.

Conginental duodenal obstruction is a relatively rare malformation. Laparoscopic operation for this condition was described for the first time in 2001, but more than 20 years later, there is still debate over the preferred method of surgical correction. We believe that laparoscopic correction of conginental duodenal obstruction is a safe and feasible method and can be used in premature infants with low body weight. Materials and Methods: From September 2017 to December 2021, 27 children with conginental duodenal obstruction were treated in our department. We were able to identify the diagnosis in 17 children during the antenatal period, while plain X-ray confirmed postnatal diagnosis. In doubtful cases the contrast fluoroscopy was performed. Four children underwent open correction of the defect via a circumbilical approach, while laparoscopic duodeno-duodenal anastomosis using the Kimura technique was performed in the remaining 23 children. Results: Intraoperative complication in the form of duct injury was observed in 1 patient with an atypically located Wirsung duct. In the postoperative period, anastomotic failure was noted in 2 children, and perforation of the duodenum was detected in 2 patients. The mortality rate comprised 26%, which was partly attributed to severe concomitant pathologies. The use of prolonged epidural analgesia in combination with laparoscopic surgery provided early weaning from mechanical ventilation and transfer from the intensive care unit. Enteral feeding was initiated on postoperative day 5, and the average length of hospital stay was 29±10.5 days. Conclusion: There are no limitations to performing laparoscopic correction of congenital duodenal obstruction. When there are accompanying congenital defects, minimally invasive technology allows to perform combined operations on organs of the thoracic and abdominal cavity, which reduces the overall surgical time. In combination with prolonged epidural analgesia, laparoscopic technique reduces the length of stay in the intensive care unit and the need for parenteral nutrition, which ultimately lowers the risk of inflammatory complications and treatment costs.

Association of labor epidural analgesia use with exclusive breastfeeding up to six months: a online-based cross sectional survey in Jiaxing, China

BackgroundThe impact of labor epidural analgesia (LEA) on breastfeeding remains controversial. The aim of this study was to assess the relationship between LEA use and exclusive breastfeeding (EBF) up to 6 months.MethodsThis was a cross-sectional survey on healthy mothers who had vaginal delivery with infants aged 7-12 months from seven maternal health WeChat groups in Jiaxing, China. Data including EBF status up to 6 months, maternal sociodemographic characteristics, LEA use in labor, breastfeeding supports during hospitalization and reasons for stopping EBF were collected using online self-administered questionnaires in October 2021. A multivariable logistic regression model was used to determine the potential association of LEA use with EBF up to 6 months by the adjusted odds ratio (AOR) and 95% confidence interval (CI).ResultsOf a total of 537 surveyed mothers, 408 (76.0%) delivered with LEA and 398 (74.1%) exclusively breastfed their infants until 6 months. All mothers delivered in the hospitals with active breastfeeding policies. There was no statistical difference in the rate of EBF up to 6 months between mothers with and without LEA (73.8% versus 75.2%, P = 0.748). Multivariable logistic regression analysis indicated that only increased maternal age (AOR = 0.906, 95% CI 0.854-0.961, P = 0.001) and perceived insufficient breast milk (AOR = 0.129, 95% CI 0.082-0.204, P < 0.001) were associated with lower odds of EBF up to 6 months. The top three reasons for non-EBF were no or insufficient breast milk (41.7%), inability to breastfeed infants after return to work (27.3%), and maternal related factors (24.4%).ConclusionsLEA does not affect EBF up to 6 months. Other factors such as health education and breastfeeding-friendly hospital strategies may be much more important to breastfeeding outcomes compared to LEA use.

Investigating the association between maternal childbirth intention, labor epidural analgesia, and postpartum depression: A prospective cohort study

BackgroundPostpartum depression (PPD) is a general depressive episode after childbirth. Studies have shown that unmatched analgesic intention increases the risk of PPD, but the use of labor epidural analgesia (LEA) during childbirth can reduce this risk. We aimed to investigate the association between maternal childbirth intention, LEA, and PPD and risk factors that may be related to PPD. MethodsA total of 590 mothers were included in this prospective cohort study. Demographic, prenatal, intrapartum and postpartum data were recorded. We investigated the association between childbirth intention, LEA and PPD and assessed the interactions between two factors. Logistic regression analysis was used to screen variables that might be associated with the occurrence of PPD. ResultsOverall, 130 of 451 women completing the study at 3 months had PPD (28.8 %). We did not find an association between unmatched childbirth intention, use of LEA and PPD (adjustOR = 0.684 CI 0.335–1.396, p = 0.296; adjustOR = 0.892, CI 0.508–1.565, p = 0.690). Chronic pain affecting daily life, prenatal EPDS, SAS, SSRS score, family accompaniment during labor, and 1-day numerical rating scale (NRS) score were significantly associated with PPD (p < 0.05). LimitationsIn the 3-month follow-up, we only recorded the EPDS score, not the pain score, and did not evaluate the association between postpartum chronic pain and PPD. ConclusionsThe association between maternal childbirth intention, LEA and PPD was not significant. Chronic pain affecting daily life, prenatal EPDS, SAS, SSRS score, family accompaniment during labor, and 1-day NRS score were significantly related to the occurrence of PPD (p < 0.05).

Strong Start Innovation: Equitable Outcomes Across Public and Privately Insured Clients Receiving Birth Center Care.

The Birth Center model of care is a health care delivery innovation in its fourth decade of demonstration across the United States. The purpose of this research was to evaluate the model's potential for decreasing poverty-related health disparities among childbearing families. Between 2013 and 2017, 26,259 childbearing people received care within the 45 Center for Medicare and Medicaid Innovation Strong Start birth center sites. Secondary analysis of the prospective American Association of Birth Centers Perinatal Data Registry was conducted. Descriptive statistics described sociobehavioral, medical risk factors, and core clinical outcomes to inform the logistic regression model. Privately insured consumers were independently compared with 2 subgroups of Medicaid beneficiaries: Strong Start enrollees (midwifery-led care with peer counselors) and non-Strong Start Medicaid beneficiaries (midwifery-led care without peer counselors). After controlling for medical risk factors, Strong Start Medicaid beneficiaries achieved similar outcomes to privately insured consumers with no significant differences in maternal or newborn outcomes between groups. Perinatal outcomes included induction of labor (adjusted odds ratio [aOR], 0.86; 95% CI 0.61-1.13), epidural analgesia use (aOR, 1.00; 95% CI, 0.68-1.48), cesarean birth (aOR, 1.16; 95% CI, 0.87-1.53), exclusive breastfeeding on discharge (aOR, 1.11; 95% CI, 0.48-2.56), low Apgar score at 5 minutes (aOR, 1.23; 95% CI, 0.86-1.83), low birth weight (aOR, 1.12; 95% CI, 0.77-1.64), and antepartum transfer of care after the first prenatal appointment (aOR, 1.53; 95% CI, 0.97-2.40). Medicaid beneficiaries who were not enrolled in the Strong Start midwifery-led, peer counselor program demonstrated similar results except for having higher epidural analgesia use (aOR, 1.30; 95% CI, 1.10-1.53) and significantly lower exclusive breastfeeding on discharge (aOR, 0.57; 95% CI, 0.40-0.81) than their privately insured counterparts. The midwifery-led birth center model of care complemented by peer counselors demonstrated a pathway to achieve health equity.

Use of Epidural Analgesia in Children With Neuromuscular Conditions Following Hip Reconstruction.

Background: Neuromuscular conditions, such as cerebral palsy, are the most common motor disabilities in the pediatric population. Children with these conditions frequently have accompanying hip deformities that require pelvic and femur osteotomy to correct the spastic hip dislocations. However, postoperative pain management remains an elusive and challenging problem. The purpose of this study was to determine whether postoperative use of epidural analgesia in patients with neuromuscular conditions provided similar outcomes with regard to pain scores, length of stay, duration of foley placement, duration of pain control, and complications as compared to traditional pain management regimens. To our knowledge, this is the first study comparing the use of epidural analgesia to conventional pain relief modalities following hip reconstruction in patients with neuromuscular conditions.Methods: A retrospective cohort study was performed using records of pediatric patients with neuromuscular conditions treated at our tertiary care center between January 2009 and December 2019. Patients with neuromuscular conditions treated with epidural or non-epidural analgesia for pain relief following unilateral or bilateral proximal femoral osteotomies, pelvic osteotomies, or open hip reduction were eligible for study inclusion. Multiple linear regression was used to determine differences in length of stay, pain score, pain modality, duration of Foley placement, and complications between the two cohorts.Results: Seventy patients met the inclusion criteria for the study. In all, 58 patients underwent unilateral procedures, of which 30 (52%) received epidural analgesia, and 28 (48%) received non-epidural pain control modalities. Demographic and baseline characteristics were similar among the cohort, except for BMI, which varied slightly. Average pain scores and pain control duration were not statistically different between the pain control modalities. After controlling for demographics, procedure, and immobilization type, the epidural group experienced significantly increased length of stay (+3.18 days, P=0.032) and duration of Foley placement (+1.04 days, P=.013). Complication rates between the two groups were not statistically significant.Conclusions: The use of epidural analgesia in children with neuromuscular conditions was associated with comparable pain scores, despite the increased length of stay and duration of Foley placement. No statistically significant difference in complication rates was observed between patients receiving epidural anesthesia and those receiving traditional pain modalities.

A Review on the Efficacy of Extraosseous Local Infiltration of Multimodal Drug Cocktail for Pain Management After Total Knee or Hip Arthroplasty

Total knee arthroplasty (TKA) patients express minimal comfort regarding postoperative pain management. The use of parenteral opioids or epidural analgesia may have unfavorable adverse impacts that interfere with quick healing and rehabilitation. It is uncertain if periarticular multimodal drug injections (PMDI) are effective at easing pain following total knee or total hip arthroplasty (THA). We conducted this study to assess the effectiveness of PMDI following TKA or THA. Articles were sourced using the following keywords on Pubmed, Google scholar,and the Web of Science: multimodal drug cocktail in total knee arthroplasty OR hip arthroplasty, periarticular injections AND multimodal drug cocktail, epidural versus periarticular injections AND pain management after total joint arthroplasty. After screening 438 articles and abstracts, 200 pertinent studies were found, of whicha total of 10 articles were included in the study. From this review, we want to conclude that despite the various ways to address postoperative pain, there is no acknowledged gold standard for postoperative pain management following total joint arthroplasty. To reduce narcotic intake and prevent narcotic-related adverse reactions, multimodal techniques utilizing regional anesthetics appear to be on the rise such as periarticular injections, or patient-controlled analgesia with or without femoral nerve block. Even though the ideal duration and kind of medications are unclear, preoperative pain management or preemptive analgesia with anti-inflammatory drugs and opioid analgesics seemto be useful in lowering postoperative pain.

Gaining insight from future mothers: A survey of attitudes and perspectives of childbirth

ObjectiveTo determine whether participant characteristics and/or birth preferences of future mothers are associated with a fear of birth. DesignA cross-sectional survey was used to determine if fear of birth could be profiled in specific participant characteristics and birth choices. SettingUrban New Zealand university. ParticipantsA convenience sample of women (final n = 339) who were < 40 years old, attending university, not pregnant nor had been pregnant but wished for at least one child in the future. FindingsMultivariable analysis identified a subset of four variables that were independently associated with the instrument Childbirth Fear Prior to Pregnancy (CFPP) measuring fear of birth (mean CFPP=38.0, SE=10.1). Preferences of birth by caesarean section (n=32, mean CFPP=44.3, SE=1.8, p < 0.0001), use of epidural analgesia (n=255, mean CFPP=45.0, SE=1.1, p < 0.0001), participants born outside of New Zealand (n=123, mean CFPP=42.9, SE=1.4, p < 0.0001), and participants who scored > 20 (‘severe’) for depression on DASS-21 scale (n=11, mean CFPP=44.8, SE=1.7, p < 0.0001) were all positively associated with CFPP. Post-hoc analyses revealed that mean CFPP was higher for those that perceived birth technologies as easier, safer, necessary, and required. ConclusionsWomen born outside of New Zealand and/or suffering ‘severe’ depression were more likely to have a fear of birth. Fear of birth was associated with the participants choices towards medicalised childbirth. Familiarising women with the provision of maternity care in New Zealand and identifying mental health status early could reduce fear of birth and possibly support the vaginal birth intentions of future parents.

Economic Outcomes and Incidence of Postsurgical Hypotension With Liposomal Bupivacaine vs Epidural Analgesia in Abdominal Surgeries.

Background: Epidural analgesia can be associated with high costs and postsurgical risks such as hypotension, despite its widespread use and value in providing opioid-sparing pain management. We tested the hypothesis that liposomal bupivacaine (LB) might be a reliable alternative to epidural analgesia in this real-world study.Objectives: To compare economic outcomes and hypotension incidence associated with use of LB and epidural analgesia for abdominal surgery.Methods: This retrospective analysis identified records of adults who underwent abdominal surgeries between January 2016 and September 2019 with either LB administration or traditional epidural analgesia using the Premier Healthcare Database. Economic outcomes included length of stay, hospital costs, rates of discharge to home, and 30-day hospital readmissions. Secondary outcomes included incidence of postsurgical hypotension and vasopressor use. Subgroup analyses were stratified by surgical procedure (colorectal, abdominal) and approach (endoscopic, open). A generalized linear model adjusted for patient and hospital characteristics was used for all comparisons.Results: A total of 5799 surgical records (LB, n=4820; epidural analgesia, n=979) were included. Compared with cases where LB was administered, cases of epidural analgesia use were associated with a 1.6-day increase in length of stay (adjusted rate ratio [95% confidence interval (CI), 1.2 [1.2-1.3]]; P<.0001) and $6304 greater hospital costs (adjusted rate ratio [95% CI], 1.2 [1.2-1.3]]; P<.0001). Cost differences were largely driven by room-and-board fees. Epidural analgesia was associated with reduced rates of discharge to home (P<.0001) and increased 30-day readmission rates (P=.0073) compared with LB. Epidural analgesia was also associated with increased rates of postsurgical hypotension (30% vs 11%; adjusted odds ratio [95% CI], 2.8 [2.3-3.4]; P<.0001) and vasopressor use (22% vs 7%; adjusted odds ratio [95% CI], 3.1 [2.5-4.0]; P<.0001) compared with LB. Subgroup analyses by surgical procedure and approach were generally consistent with overall comparisons.Discussion: Our results are consistent with previous studies that demonstrated epidural analgesia can be associated with higher utilization of healthcare resources and complications compared with LB.Conclusions: Compared with epidural analgesia, LB was associated with economic benefits and reduced incidence of postsurgical hypotension and vasopressor use.

Economic Outcomes and Incidence of Postsurgical Hypotension With Liposomal Bupivacaine vs Epidural Analgesia in Abdominal Surgeries

Background: Epidural analgesia can be associated with high costs and postsurgical risks such as hypotension, despite its widespread use and value in providing opioid-sparing pain management. We tested the hypothesis that liposomal bupivacaine (LB) might be a reliable alternative to epidural analgesia in this real-world study. Objectives: To compare economic outcomes and hypotension incidence associated with use of LB and epidural analgesia for abdominal surgery. Methods: This retrospective analysis identified records of adults who underwent abdominal surgeries between January 2016 and September 2019 with either LB administration or traditional epidural analgesia using the Premier Healthcare Database. Economic outcomes included length of stay, hospital costs, rates of discharge to home, and 30-day hospital readmissions. Secondary outcomes included incidence of postsurgical hypotension and vasopressor use. Subgroup analyses were stratified by surgical procedure (colorectal, abdominal) and approach (endoscopic, open). A generalized linear model adjusted for patient and hospital characteristics was used for all comparisons. Results: A total of 5799 surgical records (LB, n=4820; epidural analgesia, n=979) were included. Compared with cases where LB was administered, cases of epidural analgesia use were associated with a 1.6-day increase in length of stay (adjusted rate ratio [95% confidence interval (CI), 1.2 [1.2-1.3]]; P&lt;.0001) and $6304 greater hospital costs (adjusted rate ratio [95% CI], 1.2 [1.2-1.3]]; P&lt;.0001). Cost differences were largely driven by room-and-board fees. Epidural analgesia was associated with reduced rates of discharge to home (P&lt;.0001) and increased 30-day readmission rates (P=.0073) compared with LB. Epidural analgesia was also associated with increased rates of postsurgical hypotension (30% vs 11%; adjusted odds ratio [95% CI], 2.8 [2.3-3.4]; P&lt;.0001) and vasopressor use (22% vs 7%; adjusted odds ratio [95% CI], 3.1 [2.5-4.0]; P&lt;.0001) compared with LB. Subgroup analyses by surgical procedure and approach were generally consistent with overall comparisons. Discussion: Our results are consistent with previous studies that demonstrated epidural analgesia can be associated with higher utilization of healthcare resources and complications compared with LB. Conclusions: Compared with epidural analgesia, LB was associated with economic benefits and reduced incidence of postsurgical hypotension and vasopressor use.

Midwifery Management of a Birthing Person with Cervical Edema During Labor.

During active labor, a birthing person with cervical edema often has a dysfunctional or prolonged labor and, therefore, an increased risk for cesarean birth. Midwives seeking evidence on how to manage cervical edema when they are faced with this clinical situation will note a gap in the literature regarding the management of cervical edema that this report aims to fill. This case will discuss the use of intravenous diphenhydramine (Benadryl), the application of ice to the cervix, side-lying release, epidural analgesia use, manual reduction of the cervix, and various positions to encourage reduction in cervical swelling. It is hoped these strategies will add to a midwife's clinical resources by providing ways to promote vaginal birth in the setting of cervical edema during labor.

Time Matters: A Swedish Cohort Study of Labor Duration and Risk of Uterine Rupture

(Acta Obstet Gynecol Scand. 2021;100:1902–1909) In medium- to high-resource settings, a previous cesarean delivery (CD) is the main risk factor for uterine rupture, which is associated with maternal and neonatal morbidity and mortality. Induction of labor and augmentation of labor with oxytocin are both modifiable risk factors but are also common in patients who do not experience uterine rupture. One risk factor that could potentially help identify patients at risk of uterine rupture is slower progression in labor. This study aimed to examine the relationship between duration of labor and uterine rupture in the first trial of labor after one CD. The study also aimed to evaluate risk factors such as induction and use of prostaglandins, oxytocin, and epidural analgesia.

Short-Term Outcomes of Epidural Analgesia in Minimally Invasive Esophagectomy for Esophageal Cancer: Nationwide Inpatient Data Study in Japan.

Studies have shown that epidural analgesia (EDA) is associated with a decreased risk of pneumonia and anastomotic leakage after esophagectomy, and several guidelines strongly recommend EDA use after esophagectomy. However, the benefit of EDA use in minimally invasive esophagectomy (MIE) remains unclear. The aim of this retrospective study was to compare the short-term outcomes between patients with and without EDA undergoing MIE for esophageal cancer. Data of patients who underwent oncologic MIE (April 2014-March 2019) were extracted from a Japanese nationwide inpatient database. Stabilized inverse probability of treatment weighting (IPTW), propensity score matching, and instrumental variable analyses were performed to investigate the associations between EDA use and short-term outcomes, adjusting for potential confounders. Among 12,688 eligible patients, EDA was used in 9954 (78.5%) patients. In-hospital mortality, respiratory complications, and anastomotic leakage occurred in 230 (1.8%), 2139 (16.9%), and 1557 (12.3%) patients, respectively. In stabilized IPTW, EDA use was significantly associated with decreased in-hospital mortality (odds ratio [OR] 0.46 [95% confidence interval 0.34-0.61]), respiratory complications (OR 0.74 [0.66-0.84]), and anastomotic leakage (OR 0.77 [0.67-0.88]). EDA use was also associated with decreased prolonged mechanical ventilation, unplanned intubation, nonsteroidal anti-inflammatory drug use, acetaminophen use, postoperative length of stay, and total hospitalization costs and increased vasopressor use. One-to-three propensity score matching and instrumental variable analyses demonstrated equivalent results. EDA use in oncologic MIE was associated with low in-hospital mortality as well as decreased respiratory complications, and anastomotic leakage, suggesting the potential advantage of EDA use in MIE.

The sonographic measurement of the ratio between the fetal head circumference and the obstetrical conjugate is accurate in predicting the risk of labor arrest: results from a multicenter prospective study

Labor arrest is estimated to account for approximately one-third of all primary cesarean deliveries, and is associated with an increased risk of adverse maternal and perinatal outcomes. One of the main causes is the mismatch between the size of the birth canal and that of the fetus, a condition usually referred to as cephalopelvic disproportion. This study aimed to describe a new ultrasound predictor of labor arrest leading to cesarean delivery because of suspected cephalopelvic disproportion. This was a multicenter prospective study conducted at 3 maternity units from January 2021 to January 2022. A nonconsecutive series of singleton pregnancies with cephalic-presenting fetuses, gestational age of 34 weeks+0 days or above, and no contraindication to vaginal delivery attending at the antenatal clinics of each institution were considered eligible. Between 34+0 and 38+0 weeks of gestation, all eligible patients were submitted to transabdominal 2D ultrasound measurement of the obstetrical conjugate. On admission to the labor ward, the fetal head circumference was measured on the standard transthalamic plane by transabdominal ultrasound. The primary outcome of the study was the accuracy of the ratio between the fetal head circumference and the obstetrical conjugate measurement (ie, head circumference/obstetrical conjugate ratio) in predicting the occurrence of cesarean delivery secondary to labor arrest. The secondary outcome was the relationship between the head circumference/obstetrical conjugate ratio and labor duration. A total of 263 women were included. Cesarean delivery for labor arrest was performed in 7.6% (20/263) of the included cases and was associated with more frequent use of epidural analgesia (95.0% vs 45.7%; P<.001), longer second stage of labor (193 [120-240] vs 34.0 [13.8-66.5] minutes; P=.002), shorter obstetrical conjugate (111 [108-114] vs 121 [116-125] mm; P<.001), higher head circumference/obstetrical conjugate ratio (3.2 [3.2-3.35] vs 2.9 [2.8-3.0]; P<.001), and higher birthweight (3678 [3501-3916] vs 3352 [3095-3680] g; P=.003) compared with vaginal delivery. At logistic regression analysis, the head circumference/obstetrical conjugate ratio expressed as Z-score was the only parameter independently associated with risk of cesarean delivery for labor arrest (odds ratio, 8.8; 95% confidence interval, 3.6-21.7) and had higher accuracy in predicting cesarean delivery compared with the accuracy of fetal head circumference and obstetrical conjugate alone, with an area under the curve of 0.91 (95% confidence interval, 81.7-99.5; P<.001). A positive correlation between the head circumference/obstetrical conjugate ratio and length of the second stage of labor was found (Pearson coefficient, 0.16; P=.018). Our study, conducted on an unselected low-risk population, demonstrated that the head circumference/obstetrical conjugate ratio is a reliable antenatal predictor of labor arrest leading to cesarean delivery.

Procedural Aspects of Epidural Catheter Placement: A Prospective Observational Study of 173 Epidural Catheter Insertions

The risks and benefits of epidural analgesia have been studied extensively, but information regarding many other aspects of epidural catheter insertion is limited. The authors aimed to add information regarding procedural pain, procedure duration, failure rates, and the effect of experience to the ongoing discussion on this procedure. A prospective observational study. A Danish tertiary hospital. Patients scheduled to undergo video-assisted thoracic surgery. Epidural catheter insertion in 173 patients undergoing video-assisted thoracic surgery for lung cancer. The authors recorded the time required for the epidural insertion procedure, the attempts used, insertion level, access use, patient position, placement technique used, and the designation of the physician placing the catheter. Furthermore, the authors asked the patients to evaluate the expected procedural pain, and after the procedure the authors asked them to evaluate the actual level of pain experienced. Six and 24 months after discharge, the authors examined persistent sequelae by using questionnaire assessments. The median procedure duration was 13 minutes, with 75% of the catheters placed within 22 minutes. Actual procedure-related pain (mean score [M]=3.5, SD=2.0) was significantly (p < 0.0001) less than that expected before the procedure (M=4.9, SD=2.0). The patients' expected pain, attempts required for successful catheter placement, and approach used to access the epidural space significantly affected the actual procedure-related pain (p=0.001, p ≤ 0.003, and p=0.023, respectively). Persistent pain and sensory disturbances were observed in 11% and 4% of the patients, respectively, after 6 months and in 6% and 4% of the patients, respectively, after 2 years. In this study, the authors examined several lesser-known aspects of epidural procedures. The use of epidural analgesia as part of the pain management plan after surgery requires a more complex evaluation instead of merely discussing the possibility of procedural infections, hematomas, or neurologic injuries. The procedure time, patients' expected and experienced pain related to the procedure, and the potential long-term side effects should be a part of the decision-making process.

Childbirth Satisfaction during the COVID-19 Pandemic in a Hospital in Southwestern Spain

Satisfaction, in relation to care received, is a good indicator of quality of care. The objective of this study was to analyze the degree of satisfaction with childbirth and postpartum care as reported by women from one hospital in southwestern Spain during the COVID-19 pandemic. Factors that influenced care were also examined. A cross-sectional study was carried out between the months of October 2020 and February 2021. Satisfaction was measured through the COMFORTS scale, validated in Spanish. A final sample of 116 women was included in the study. The mean age was 32.08 (±4.68) years. A total of 111 (95.69%) women were satisfied or very satisfied with the care received. The median satisfaction score was higher among multiparous women (187 (199–173)) than among primiparous women (174 (193–155.50)) (p = 0.003). Differences in satisfaction were found as a function of the use of epidural analgesia, being higher among women who had planned its use but ultimately did not use it (188 (172.50–199.75)) or who planned its use and did (186 (169.50–198)) than among those who had not planned to use epidural analgesia but ultimately received it (173.50 (187.50–146.25)) or those who did not use it, as planned, before childbirth (172 (157–185)) (p = 0.020). Overall satisfaction rate between SARS-CoV-2-negative women assisted was high. Parity and use of epidural analgesia were two factors influencing satisfaction scores in our sample.