Women In Active Labor Research Articles

Massage Therapy and Labor Outcomes: a Randomized Controlled Trial

Massage is a time-honored method by which women have received comfort throughout the millennia, yet it has not been rigorously evaluated in the modern day delivery suite. No study to date that we are aware of has evaluated the effect of massage therapy by a regulated massage therapist on labor pain. The purpose of this study was to evaluate the effectiveness of massage therapy provided by registered massage therapists in managing pain among women in active labor. BC Women's Hospital, Vancouver, BC. a randomized controlled trial. 77 healthy nulliparous women presenting in spontaneous labor. Swedish massage administered for up to five hours by a registered massage therapist during labor vs. standard care. Main outcome measures include: cervical dilation at the time of administration of epidural, compared using estimated marginal means in an analysis of covariance. We also compared perception of pain at three time periods during labor according to cervical dilation at 3-4 cm, 5-7 cm, and 8-10 cm using the McGill Present Pain Intensity Scale. The mean cervical dilation at the time of epidural insertion after adjustment for station of the presenting part, cervical dilation, and status of membranes on admission to hospital was 5.9 cm (95% CI 5.2-6.7) compared to 4.9 in the control group (95% CI 4.2-5.8). Scores on the McGill Pain Scale were consistently lower in the massage therapy group (13.3 vs. 16.9 at 3-4 cm, 13.3 vs. 15.8 at 5-6 cm, and 19.4 vs. 28.3 at 7-8 cm), although these differences were not statistically significant. Our findings from this pilot study suggest that massage therapy by a registered massage therapist has the potential to be an effective means of pain management that may be associated with delayed use of epidural analgesia. It may therefore have the potential to reduce exposure to epidural analgesia during labor and decrease rates of associated sequelae.

Prediction of Neonatal Metabolic Acidosis in Women with a Singleton Term Pregnancy in Cephalic Presentation: An External Validation Study

To externally validate two previously developed prognostic models that predict the risk for developing metabolic acidosis in newborns using both antepartum (model 1) and intrapartum (combined with antepartum, model 2) risk factors: parity, previous cesarean section, maternal diabetes mellitus, gestational age, induced onset of labor, meconium-stained amniotic fluid, and use of ST analysis. The two prediction models were applied in women in active labor at more than 36 gestational weeks with singleton fetuses in cephalic presentation and with high-risk pregnancies (n = 5049) who were included in a Swedish randomized trial between December 1, 1998, and June 4, 2000. The prognostic ability of the models was determined using calibration and discrimination measures. Of 5049 infants in the validation population, 54 (1.1%) suffered from metabolic acidosis. After adjustment for incidence differences between the Dutch and Swedish cohorts, the prognostic models showed good calibration and moderate overall discrimination (C statistic 0.63, 95% confidence interval [CI] 0.55 to 0.71; and 0.64, 95% CI 0.55 to 0.72), for models 1 and 2, respectively). External validation of the clinical prediction models for metabolic acidosis in Swedish infants showed good calibration and moderate discriminative ability. Updating of the models to enhance their predictive abilities seems indicated.

Relationship between glutamate, GOT and GPT levels in maternal and fetal blood: A potential mechanism for fetal neuroprotection

BackgroundExcess glutamate in the brain is thought to be implicated in the pathophysiology of fetal anoxic brain injury, yet little is known about the mechanisms by which glutamate is regulated in the fetal brain. This study examines whether there are differences between maternal and fetal glutamate concentrations, and whether a correlation between them exists. Methods10ml of venous blood was extracted from 87 full-term (>37weeks gestation) pregnant women in active labor. Immediately after delivery of the neonate, 10ml of blood from the umbilical artery and vein was extracted. Samples were analyzed for levels of glutamate, glutamate‐oxaloacetate transaminase (GOT), and glutamate pyruvate transaminase (GPT). ResultsFetal blood glutamate concentrations in both the umbilical artery and vein were found to be significantly higher than maternal blood (p<0.001). Similarly, fetal serum GOT levels in the umbilical artery and vein were found to be significantly higher than maternal GOT levels (p<0.001). The difference in GPT levels between maternal and fetal serum was not statistically significant. There was no difference in fetal glutamate, GOT or GPT between the umbilical artery and vein. There was an association observed between glutamate levels in maternal blood and glutamate levels in both venous (R=0.32, p<0.01) and arterial (R=0.33, p<0.05) fetal blood. ConclusionsThis study demonstrated that higher baseline concentrations of blood glutamate are present in fetal blood compared with maternal blood, and this was associated with elevated GOT, but not GPT levels. An association was observed between maternal and fetal blood glutamate levels.

Intravenous infusion of paracetamol versus intravenous pethidine as an intrapartum analgesic in the first stage of labor

ObjectiveTo evaluate the efficacy and adverse effects of an intravenous infusion of 1000mg of paracetamol as compared with an intravenous injection of 50mg of pethidine hydrochloride for intrapartum analgesia. MethodsIn a randomized prospective study at Ain Shams University, Cairo, Egypt, between April and August 2010, 102 low-risk primiparous women in active labor were allocated to received either paracetamol (n=52) or pethidine hydrochloride (n=50). The primary outcome was the efficacy of the drug to supply adequate analgesia as measured by a change in the visual analog scale (VAS) pain intensity score at various times after drug administration. The secondary outcomes included the need for additional rescue analgesia and the presence of adverse maternal or fetal events. ResultsAs recorded by the VAS score, there was significant pain reduction at 15minutes, and at 1 and 2hours in both groups (P<0.001). The reduction in pain was significantly greater in the pethidine group only at 15minutes (P=0.004). None of the women in the paracetamol group had adverse effects, as compared with 64% of the women receiving pethidine. ConclusionThe effectiveness of intravenous paracetamol was comparable to that of intravenous pethidine, but paracetamol had fewer maternal adverse effects.

Observation on validity of the five-tier system for fetal heart rate pattern interpretation proposed by Japan Society of Obstetricians and Gynecologists

Objective: To evaluate the five-tier classification of fetal heart rate (FHR) tracings recently proposed by Japan Society of Obstetricians and Gynecologists (JSOG). Methods: The database between January and June 2009 was reviewed for women in active labor at ≥36 + 0 gestational weeks, with singleton fetuses in cephalic presentation and with umbilical artery blood gas analyses. Continuous FHR tracings were assessed according to the five-tier classification proposed by JSOG, where level 1 is normal, level 2 is subnormal and levels 3–5 are abnormal patterns. Results: A total of 341 parturient women were eligible for this study protocol. The median (range) of the levels in the first and the second stage of labor were 1 (1–4) and 2 (1–4), respectively (p < 0.001). Both pH and base excess of umbilical artery decreased with higher levels of FHR tracings interpretation (p < 0.01). Interventions resulting in delivery were more necessary in the first stage of labor than in the second stage of labor in cases of levels 3 and more. Conclusions: Five-tier system for FHR tracing interpretation proposed by JSOG intercorrelates with the fetal acid-base balance well. Categorization of FHR tracings by uniform diagnostic criteria will be useful to standardize therapeutic strategy by sharing common perception among obstetrical staff.

A dose-finding study of oral misoprostol for labor augmentation

We designed a dose-finding trial of oral misoprostol administered for labor augmentation. Healthy, nulliparous women in active labor and diagnosed with arrest of dilation were enrolled in cohorts of 10 at a time. Five regimens were studied: (1) 25 μg every 4 hours, (2) 50 μg every 4 hours, (3) 100 μg every 4 hours, (4) 50 μg every 2 hours, and (5) 75 μg every 4 hours. A total of 46 women were enrolled. Baseline uterine activity approximately doubled with 4 of the regimens and tripled with the highest dosage regimen (100 μg) (P < .001). The 100-μg regimen was truncated due to excessive uterine hyperstimulation (40%). An oral dose of 75 μg of misoprostol given at a 4-hour interval for a maximum of 2 doses is the highest tolerated dose. Randomized, controlled trials will be required before a regimen is employed routinely.

Restricting oral fluid and food intake during labour.

Restricting fluids and foods during labour is common practice across many birth settings with some women only being allowed sips of water or ice chips. Restriction of oral intake may be unpleasant for some women, and may adversely influence their experience of labour. To determine the benefits and harms of oral fluid or food restriction during labour. We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (April 2009). Randomised controlled trials (RCTs) and quasi-RCTs of restricting fluids and food for women in labour compared with women free to eat and drink. Two authors independently assessed the studies for inclusion, assessed risk of bias and carried out data extraction. We identified five studies (3130 women). All studies looked at women in active labour and at low risk of potentially requiring a general anaesthetic. One study looked at complete restriction versus giving women the freedom to eat and drink at will; two studies looked at water only versus giving women specific fluids and foods and two studies looked at water only versus giving women carbohydrate drinks.When comparing any restriction of fluids and food versus women given some nutrition in labour, the meta-analysis was dominated by one study undertaken in a highly medicalised environment. There were no statistically significant differences identified in: caesarean section (average risk ratio (RR) 0.89, 95% confidence interval (CI) 0.63 to 1.25, five studies, 3103 women), operative vaginal births (average RR 0.98, 95% CI 0.88 to 1.10, five studies, 3103 women) and Apgar scores less than seven at five minutes (average RR 1.43, 95% CI 0.77 to 2.68, three studies, 2574 infants), nor in any of the other outcomes assessed. Women's views were not assessed. The pooled data were insufficient to assess the incidence of Mendelson's syndrome, an extremely rare outcome. Other comparisons showed similar findings, except one study did report a significant increase in caesarean sections for women taking carbohydrate drinks in labour compared with water only, but these results should be interpreted with caution as the sample size was small. Since the evidence shows no benefits or harms, there is no justification for the restriction of fluids and food in labour for women at low risk of complications. No studies looked specifically at women at increased risk of complications, hence there is no evidence to support restrictions in this group of women. Conflicting evidence on carbohydrate solutions means further studies are needed and it is critical in any future studies to assess women's views.

How Reliable Is the Determination of Cervical Dilation? Comparison of Vaginal Examination With Spatial Position-Tracking Ruler

The traditional method for assessment of cervical dilation—vaginal examination—is subjective and has an accuracy of less than 60%. Although several devices for cervical dilation assessment have been developed, few have survived and cervical assessment is still performed by vaginal examination worldwide. This prospective study compared the accuracy of clinical measurement of cervical dilation for 2 methods, vaginal examination and use of a position-tracking system. The study subjects, enrolled at 3 centers (Poissy, France; Brooklyn, NY; and Haifa, Israel), were 188 singleton women in active labor with vertex presentation and no known contraindication to vaginal examination. For each routine vaginal examination, a sensor was attached to the midwife’s index fingertip and measurement was performed with a magnetic position tracking system, using personal computer-based controlling software, and ultrasound imaging technology. A total of 333 measurements were performed with the tracking system. Ninety cases with clinically full dilation were excluded from analysis. The data from the 3 centers were pooled; results were similar in each. There was an overall mean absolute difference of 10.2 ± 8.4 mm between the 2 methods. Analysis of subgroups stratified by dilation showed that the absolute difference was 7.5 ± 7.3 mm (70.0% accuracy) when the cervical dilation was >8 cm and 12.5 ± 8.7 mm (38.8% accuracy) when the cervical dilation was between 6.1 and 8 cm. These findings show that the accuracy of the positron-tracking system for assessment of cervical dilation during labor appears to be limited. The clinical relevance of this system in routine care is unclear and requires further evaluation.

Association Between Lactate Concentration in Amniotic Fluid and Dysfunctional Labor

Objectives. To assess whether there is an association between high lactate concentration in amniotic fluid (AF) and labor dystocia. Design. Prospective observational study. Setting. Labor ward at General South Hospital, Stockholm, Sweden. Population and methods. Women in active labor attending labor ward, having at least two consecutive measurements of lactate concentration in AF, measured 60 minutes apart. Main outcome measure. Dysfunctional labor, defined as instrumental or operative delivery due to dystocia. Results. Among women with spontaneous vaginal deliveries (n=23) the mean lactate concentration in AF during labor was 8.9 mmol/l (range 6.6–10.8), and among women with operative delivery due to labor dystocia (n=31) the corresponding value was 10.9 mmol/l (range 8.0–16.1) (p<0.001). Of 29 women with a high lactate concentration (≥10.1 mmol/l) in at least two consecutive measures collected at least 60 minutes apart, 25 (86%) were delivered instrumentally/operatively due to dystocia. Using this defin...

Revising the primigravid partogram: does it make any difference?

To investigate the distribution of the rate of cervical dilatation of primigravid labour and its deviation from the standard partogram. Retrospective observational study. South African district hospital serving an indigent rural population. Expectant management of labour of healthy nulliparous women in active labour, at term, with a singleton pregnancy and cephalic presentation. Audit of 1,595 partograms of spontaneous primigravid labour. The standard partogram's alert line was replaced by a customised alert line based on the lowest 10th centile of the rate of cervical dilatation of the study population and an alert line representing the 10% slowest labours. The action line was placed parallel and 4 h to the right of the alert lines. The distribution of labours left to and on the respective alert lines, and right to the action lines. The lowest 90th centile of the customised alert line yielded a rate of cervical dilatation of 0.860 cm/h. Three quarters of labours evolved left to the revised alert line as opposed to 56.1% left of the standard alert line [Odds ratio (OR) 0.49, 95% confidence interval (CI) 0.42-0.56]. The mean rate of cervical dilatation of the 10% slowest labours was 0.535 +/- 0.076 cm/h (P < 0.0001), and 95.7% of labours evolved left to the corresponding alert line (OR 8.40, 95% CI 6.44-11.0). The alert line representing the mean of the 10% slowest labours leads to an unrealistic distribution of labour on the partogram. A revised alert line based on the lowest 10th centile of the local population is more representative and should perhaps be used in the management of labour.

Ultra performance liquid chromatography tandem mass spectrometry method for the measurement of anandamide in human plasma

Anandamide ( N-arachidonoylethanolamine, AEA) is an endocannabinoid present in human plasma that is associated with several physiological functions and disease states. Significant variability in AEA plasma concentrations has been reported between studies, because quantification of AEA is fraught with methodological difficulties. A rapid, highly sensitive, robust, specific, and highly reproducible ultra high performance liquid chromatography-tandem mass spectrometry (UPLC-MS/MS) method is described here for the analysis of AEA in human plasma. This fully validated method using octa-deuterated AEA (AEA-d8) as an internal standard represents an improvement over previous analyses in terms of run time (4 min), limit of detection (0.055 fmol on column, 18.75 fmol/ml plasma), precision (relative standard deviations of 3.7, 3.9, and 4.8% for 1.66, 6.65, and 133 fmol on column), and accuracy (97.5–104.5%). AEA analysis was linear over the range 0.23 to 19 nM (1.66 to 133 fmol on column). To demonstrate the usefulness of this method for the measurement of AEA levels in clinical samples, plasma samples obtained from female volunteers at different stages of the menstrual cycle and pregnant women were assayed. Plasma AEA concentrations were significantly ( P = 0.0078) lower in the luteal phase of the menstrual cycle compared to the follicular phase. In pregnancy, the concentrations were lowest in the first and second trimesters with levels comparable to those observed in the luteal phase of the menstrual cycle and modestly increased in the third trimester. The highest plasma AEA levels were observed in women in active labour, and these were significantly ( P = 0.0147) higher than those observed in women at term but not in active labour. Postmenopausal women had AEA concentrations comparable to levels observed during the luteal phase of premenopausal women and were significantly ( P = 0.0389) lower than AEA plasma concentrations obtained during the follicular phase. The sensitivity and precision of the validated method described here suggests that this method is suitable for the analysis of AEA in clinical samples and may be utilised for the investigation of biomatrices containing limited amounts of AEA.

Drotaverine hydrochloride versus hyoscine-N-butylbromide in augmentation of labor

Objectives: To study and compare the efficacy and side effects of drotaverine hydrochloride and hyoscine-N-butylbromide in the augmentation of labor. Methods: A prospective randomized trial of 150 women in active labor included 50 women given drotaverine (group 1), 50 women given hyoscine-N-butylbromide (group 2), and 50 women given no medication (group 3). Duration of labor, rate of cervical dilation, mode of delivery, side effects, and neonatal outcome were compared among the groups. Results: The mean duration of the active phase of labor was 4.48 ± 2.26 h, 3.9 ± 2.42 h, and 3.6 ± 2.07 h in groups 1, 2, and 3, respectively. The mean rate of cervical dilation was 2.6 cm/h, 2.4 cm/h, and 2.5 cm/h, respectively. The differences were not statistically significant. There was no difference in the duration of the second and third stages of labor. No adverse maternal or fetal outcomes were noted. Conclusion: Drotaverine hydrochloride and hyoscine-N-butylbromide do not have a role in augmentation of labor.

Pharmacokinetics of oral zidovudine administered during labour: a preliminary study*

The aim of this study was to determine whether oral zidovudine (ZDV) given during labour would provide a similar systemic exposure to the established intravenous regimen used to prevent mother-to-child transmission in HIV-infected pregnant women. ZDV pharmacokinetic parameters following oral administration during labour were determined in 10 HIV-infected pregnant women in active labour. All subjects were converted to intravenous ZDV prior to delivery. In cohort 1 (n=6), subjects received 300 mg oral ZDV every 3 h for three doses. Oral therapy was well tolerated but plasma ZDV concentrations were substantially lower than previously reported with continuous intravenous therapy. Based on the pharmacokinetic results from cohort 1, women in cohort 2 (n=4) received an initial 600 mg dose followed by two 400 mg doses every 3 h. ZDV area under the curve and concentrations in cohort 2 increased approximately in proportion to the increase in dose but varied 6-7-fold. In both cohorts, ZDV pharmacokinetic parameters suggested erratic absorption. While ZDV exposure improved with the increased dosing regimen, our sample size was small and larger studies are needed to establish whether oral ZDV administration during labour can consistently provide equivalent exposure to intravenous administration.

Determination of the ED95 for intrathecal plain bupivacaine combined with fentanyl in active labor

Combined spinal-epidural (CSE) analgesia is an effective technique for pain control in labor and is particularly useful in the active phase. Excessive doses of intrathecal bupivacaine may be associated with adverse effects. This study is designed to estimate the ED95 for intrathecal plain bupivacaine with fentanyl 15 microg in labor. Forty healthy women in active labor (cervical dilatation > or = 5 cm and verbal numeric pain score > or = 6/10) were given CSE for labor analgesia with intrathecal plain bupivacaine and fentanyl 15 microg. The initial dose of bupivacaine was 1.75 mg. Doses were varied in a 0.25-mg testing interval according to a method of sequential allocation designed to cluster the dose around the ED95. Effectiveness was defined as a verbal numeric pain score < or = 1 within 10 min of intrathecal injection. There was a 100% response rate to the 1.75-mg dose (95% CI 84.6-100.0%) and an 85.0% response rate to 1.50 mg (95% CI 64.0-95.8%). The ED95 for intrathecal plain bupivacaine with fentanyl 15 microg in active labor was 1.66 mg (95% CI 1.50-482.5 mg). The incidence of fetal bradycardia was 7.5%. The incidence of pruritus was 55%. No patient experienced motor block. This is the first dose-finding study specifically designed to estimate the ED95 of intrathecal bupivacaine combined with a fixed amount of fentanyl for analgesia in active labor. The combination of bupivacaine 1.75 mg with fentanyl 15 microg rapidly and reliably alleviated pain in the active phase of labor.

Bupivacaïne intrathécale pure vs hyperbare pour l’analgésie du travail obstétrical: efficacité et effets secondaires

Baricity is an important determinant of block characteristics of the spinal component of a combined spinal epidural (CSE) for labour analgesia. This study compares the analgesic efficacy and side effects of intrathecally administered plain and hyperbaric bupivacaine (both with fentanyl) during active labour. Sixty-two women in active labour (cervical dilatation >or=5 cm and pain score > 5) were randomized in a prospective, single-blinded fashion to receive 2.5 mg of either hyperbaric or plain bupivacaine both combined with 15 microg of fentanyl as the spinal component of a CSE. The primary outcome was failure of satisfactory analgesia within ten minutes of the intrathecal injection as defined by a verbal pain score > 3. Secondary outcomes included need for rescue analgesia, hypotension, respiratory depression, nausea and vomiting, pruritus and sustained fetal bradycardia. Sixty patients were analyzed. The failure rates were 20% in the hyperbaric group vs 0% in the plain group (P=0.024). The plain solution provided faster onset, higher sensory levels and less motor block at all times during the first 30 min. The incidence of both pruritus and sustained fetal bradycardia was 33% in the plain group and 10% in the hyperbaric group (P=0.03). A plain rather than hyperbaric solution of bupivacaine 2.5 mg with fentanyl 15 microg provides a faster onset of analgesia, higher sensory levels and less motor block, while demonstrating an increased incidence of pruritus and sustained fetal bradycardia.

A comparison of intrapartum automated fetal electrocardiography and conventional cardiotocography—a randomised controlled study

To examine whether intrapartum monitoring by means of automatic ST analysis (STAN) of fetal electrocardiography could reduce the rate of neonatal acidemia and the rate of operative intervention during labour, compared with monitoring by means of cardiotocography (CTG). Randomised controlled trial. Labour ward in tertiary-level university hospital. A total of 1483 women in active labour with singleton term fetus in cephalic presentation. Women were randomly assigned to be monitored either by STAN or by CTG. Fetal blood sampling (FBS) was optional in both groups. Neonatal acidemia (umbilical artery pH <7.10), neonatal metabolic acidosis (umbilical artery pH <7.05 and base excess <-12 mmol/l) and operative interventions: caesarean section rate, vacuum outlet (VO) rate and FBS rate. There were no statistically significant differences between the STAN group and CTG group in the incidence of neonatal acidemia (5.8 versus 4.7%) or metabolic acidosis (1.7 versus 0.7%). The caesarean section rate (6.4 versus 4.7%) and the VO rate (9.5 versus 10.7%) were also similar in the STAN and CTG groups. The incidence of FBS was lower (P < 0.001) in the STAN group (7.0%) than in the CTG group (15.6%). Intrapartum fetal monitoring by means of automatic STAN did not improve the neonatal outcome or decrease the caesarean section rate. However, the need for FBS during labour was lower in the STAN group.

Increased intravenous fluid intake and the course of labor in nulliparous women

Objective To compare the effect of 2 regimens of intravenous fluid therapy on the course of labor. Methods In a prospective, randomized, double-blind study of 300 nulliparous pregnant women at term conducted at a teaching hospital, 153 women received 125 mL and 147 received 250 mL of intravenous fluid per hour. The groups were matched and analysis was done using the t, χ 2, and Fisher exact tests. P < 0.05 was considered statistically significant. Results In the group that received intravenous fluid at a rate of 250 mL per hour the mean ± S.D. duration of labor was significantly shorter (253 ± 97 vs. 386 ± 110 min; P = 0.0001), the frequency of labor lasting both more than 10 h and more than 15 h was statistically lower (4.8% vs. 13.8%; P = 0.001 and 0% vs. 4.5%; P = 0.02, respectively), and the frequency of oxytocin administration was significantly lower (8.1% vs. 20.4%; P = 0.001). There was a trend toward a lower frequency of cesarean deliveries in the 250-mL group (16% vs. 22.8%; P = 0.1). Conclusion A greater volume per hour of intravenous fluid than is commonly administered to nulliparous women in active labor is associated with significantly shorter duration of labor and lower frequency of both prolonged labor and oxytocin administration.

Mammalian Ste20‐like Protein Kinase 3 (Mst3) Plays an Important Role in Spontaneous Delivery

It has been shown that prior term labor a substantial population of trophoblasts of human fetal membrane underwent apoptosis. The apoptosis was thought to be induced by oxidative stress with the evidence that women in active labor exhibited high level serum hydroperoxides. Thus, oxidative stress is postulated to be involved in initiating the labor process. To understand the molecular mechanism underlying the oxidative stress-induced trophoblast apoptosis we checked the signs of oxidative stress, DNA fragmentation, caspase 3 activation and Mst3 expression in the human full term and selective cesarean placenta and 6~8 weeks endometrium spacemen by Immunohistochemistry. Mst3 is a human Ste20-like protein kinase that may play a role in apoptosis in response to apoptotic signals. Interestingly, compared with cytotrophoblasts in the first-trimester of pregnancy and selective cesarean placenta, we found that the cytotrophoblasts underwent an extensive apoptosis in a full term placenta. Furthermore, the cytotrophoblasts at full term placenta contained high level Mst3 and nitrotyrosine, a marker of oxidative stress, which were undetectable in trophoblasts of first-trimester and of selective cesarean placenta. The H2O2-induced apoptosis and Mst3 overexpression were also observed in a human cytotrophoblast cell line 3A-sub-E through in vitro studies. These results suggest that the apoptosis of cytotrophoblasts in active labor may be induced by oxidative stress in the Mst3-dependdent manner. (The work was financially supported by National Science Council, ROC (Taiwan) under Contract No. NSC-94-2311-B-009-003.)

Informed consent for labor epidurals: a survey of Society for Obstetric Anesthesia and Perinatology anesthesiologists from the United States

Ethicists agree that informed consent is a process rather than just simply the signing of a form. It should provide the patient with needed information and understanding to authorize a procedure. Essential elements of informed consent for women requesting labor epidurals include a description of the procedure, the risks and benefits, and alternative treatments for analgesia including the associated risks and benefits. The purpose of this pilot study was to determine practices and opinions of obstetric anesthesiologists regarding informed consent for parturients. Questionnaires were sent to 885 anesthesiologists who were members of the Society of Obstetric Anesthesia and Perinatology based in United States institutions in 2002. Of the 885 questionnaires sent, 448 (51%) were returned with 47% from academic and 47% from private practice institutions. Forty-six percent worked as part of an obstetric anesthesia team; 51% worked in centers where there were >3000 deliveries/year. Sixty-eight percent suggested that "parturients in active labor are able to give informed consent for labor epidural analgesia." Thirteen percent recommend antenatal anesthesia consults for parturients inquiring about labor epidurals and 41% participated in childbirth classes. Responses did not differ significantly between physicians in academic vs. private practice. More obstetric team practices than non-team practices participated in childbirth education (54% vs. 30%, P < 0.0001). Despite the painful, stressful circumstances confronted by parturients, many respondents (76% in academic, 64% in private practice) thought that women in active labor are able to give informed consent.

Liability in Triage: Management of EMTALA Regulations and Common Obstetric Risks

The Emergency Medical Treatment and Active Labor Act (EMTALA) affects all clinicians who provide triage care for pregnant women. EMTALA has specific regulations for hospitals relative to women in active labor. Violations can carry stiff penalties. It is critical for clinicians performing obstetric triage to understand the duties and obligations of this law. This article discusses EMTALA and reviews common liability risks in obstetric triage as well as strategies to modify those risks.