Patient-controlled Analgesia with Remifentanil in a Parturient with Ankylosing Spondylitis and SARS-CoV-2 Infection: A Case Report.

Parturients with both ankylosing spondylitis (AS) and SARS-CoV-2 Infection (COVID-19) present unique challenges to anesthesiologists. Neuraxial analgesia for labor remains the gold standard in obstetric patients. However, in patients with AS, this approach may be deemed difficult to impossible. Administration of systemic opioids for labor analgesia can be an option, bearing in mind the potential respiratory depressant effect to both the mother and the fetus, especially in the setting of concomitant COVID-19. This paper reports the successful management of such a patient using patient-controlled analgesia (PCA) with intravenous remifentanil.

Quality of analgesic care in labor: A cross-sectional study of the first national register-based benchmarking system.

OBJECTIVE: Unlike other types of acute pain, labor pain is considered physiological. Due to the heterogeneous management during labor, there is a lack of intention to define quality of care of peripartal analgesia. This study presents the first results of the national register for this evaluation. METHODS: This prospective cross-sectional study, conducted in five different German level-three hospitals, included women after vaginal childbirth between January 2020 and January 2022. A validated questionnaire was completed 24 h postpartum, including information about labor pain, satisfaction, and expectations regarding analgesia. Data were centrally recorded with obstetric records using the database of the QUIPS (Quality Improvement in Postoperative Pain Management) Project. RESULTS: A total of 514 women were included. On an 11-point Numerical Rating Scale, pain intensity during labor was severe (8.68 ± 1.8) while postpartal pain was 3.9 (±2.1). The second stage of labor was considered the most painful period. Only 62.6% of the parturients obtained pharmacological support, with epidural being the most effective (reduction of 3.8 ± 2.8 points). Only epidural (odds ratio [OR] 0.22) and inhalation of nitrous oxide (OR 0.33) were protective for severe pain. In benchmarking, a relation between satisfaction, pain intensity, and the use of epidural was found; 40.7% of the women wished they had received more analgesic support during labor. CONCLUSION: This study highlights deficiencies in analgesic management in high-level perinatal centers, with more than 40% of parturients considering actual practices as insufficient and wishing they had received more analgesic support, despite the availability of analgesic options. Using patient-reported outcomes can guarantee qualitative tailored analgesic care in women.

Socio-economic disadvantage and utilisation of labour epidural analgesia in Scotland: a population-based study†.

Socio-economic deprivation is associated with adverse maternal and childhood outcomes. Epidural analgesia, the gold standard for labour analgesia, may improve maternal well-being. We assessed the association of socio-economic status with utilisation of epidural analgesia and whether this differed when epidural analgesia was advisable for maternal safety. This was a population-based study of NHS data for all women in labour in Scotland between 1 January 2007 and 23 October 2020, excluding elective caesarean sections. Socio-economic status deciles were defined using the Scottish Index of Multiple Deprivation. Medical conditions for which epidural analgesia is advisable for maternal safety (medical indications) and contraindications were defined according to national guidelines. Of 593,230 patients in labour, 131,521 (22.2%) received epidural analgesia. Those from the most deprived areas were 16% less likely to receive epidural analgesia than the most affluent (relative risk 0.84 [95%CI 0.82-0.85]), with the inter-decile mean change in receiving epidural analgesia estimated at -2% ([95%CI -2.2% to -1.7%]). Among the 21,219 deliveries with a documented medical indication for epidural analgesia, the socio-economic gradient persisted (relative risk 0.79 [95%CI 0.75-0.84], inter-decile mean change in receiving epidural analgesia -2.5% [95%CI -3.1% to -2.0%]). Women in the most deprived areas with a medical indication for epidural analgesia were still less likely (absolute risk 0.23 [95%CI 0.22-0.24]) to receive epidural analgesia than women from the most advantaged decile without a medical indication (absolute risk 0.25 [95%CI 0.24-0.25]). Socio-economic deprivation is associated with lower utilisation of epidural analgesia, even when epidural analgesia is advisable for maternal safety. Ensuring equitable access to an intervention that alleviates pain and potentially reduces adverse outcomes is crucial.

Side effects from epidural analgesia in laboring women and risk of cesarean delivery.

BACKGROUND: Epidural analgesia may cause maternal hypotension and changes in the fetal heart rate. The implications of such side effects on the course of labor and delivery are incompletely understood. OBJECTIVE: This study aimed to assess whether the occurrence of maternal or fetal side effects associated with labor epidural analgesia increased the risk for cesarean delivery. STUDY DESIGN: This was a cohort study of all women who underwent epidural analgesia during labor for the period October 1, 2020 to December 31, 2020. Excluded were cases of multiples, fetal death, noncephalic presentation, and gestational age at birth <37.0 weeks. Maternal vital signs and fetal heart rate tracings for the 1 hour before and 1 hour after epidural analgesia was administered were reviewed. The occurrence of maternal hypotension, defined as a continuous variable and dichotomized into a decrease in maternal systolic blood pressure to <90 mm Hg or a drop in systolic blood pressure by >20% below the last value before epidural analgesia was administered, was related to changes in the fetal heart rate category. The principal outcome was cesarean delivery rate; binary logistic regression analysis was used to control for confounders, and mediation model analysis was used to quantify the extent to which significant variables participated in the causation pathway to cesarean delivery (SPSS version 28 was used for the analyses). RESULTS: A total of 439 women met the study criteria. Significant adverse reactions owing to epidural occurred in 184 of 439 women (41.9%) and included severe maternal hypotension in 159 of 439 participants (36.2%) and worsening fetal heart rate category in 50 of 439 participants (11.4%). The logistic regression analysis revealed that cervical dilation at epidural (P=.03), the duration of labor after epidural (P<.001), and worsening fetal heart rate category within 60 minutes of epidural administration (P=.01) were independently associated with recourse to cesarean delivery. The mediation analysis showed that both cervical dilatation at epidural administration and worsening fetal heart rate category had significant direct and indirect effects in the pathway to cesarean delivery. CONCLUSION: Worsening fetal heart rate category related to labor epidural independently increased the risk for cesarean delivery.

Labor pain management practices and associated factors in Ethiopia: A systematic review and meta-analysis.

BACKGROUND: The pain that women experience during labor and childbirth is the central feature of parturition in humans. Despite improvement in the development of standards for pain assessment and treatment, labor pain is mostly ignored especially in low- and middle-income countries resulting in unmeasured suffering from childbirth for mothers. OBJECTIVES: We aimed to provide a comprehensive estimation of the pooled magnitude and associated factors of labor pain management practices in Ethiopian public health facilities. SEARCH STRATEGY: A systematic review and meta-analysis was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analysis statement. Electronic databases including Google Scholar, Web of Science, Excerpta Medica Database (EMBASE), PubMed/MEDLINE, and Scopus were searched from database inception to June 30, 2023. SELECTION CRITERIA: The inclusion criteria were established prior to article review and follows the population, intervention, comparison and outcome criterions. DATA COLLECTION AND ANALYSIS: We evaluated publication bias by means of funnel plots and Egger's test. Heterogeneity between studies was assessed using I2 statistics. For each associated factors in meta-regressions, the pooled odds ratio (OR) and its 95% confidence interval (CI) were extracted. A P value of 0.05 was used to determine the significance of the small study effect. MAIN RESULTS: Our search terms yielded 17 studies with 5735 participants. The pooled prevalence of labor pain management practices in Ethiopia was 45.73% (95% CI: 39.13, 52.32; I2 = 96.4). Having adequate knowledge regarding labor pain management (OR: 3.74; 95% CI: 2.74, 5.11; I2 = 53.8%), a favorable attitude toward labor pain management (OR: 2.90; 95% CI: 2.03, 4.14; I2 = 63.8%), availability of labor analgesics (OR: 3.23; 95% CI: 2.18, 4.79; I2 = 46.2%), and clinical experience of 10 or more years (OR: 3.45; 95% CI: 2.06, 5.78; I2 = 19.0%) were factors that were statistically associated with the use of labor pain management practices. CONCLUSION: We concluded that the routine practices of labor pain management by obstetric health providers in Ethiopia are still low. Therefore, it remains important to call for holistic and inclusive interventions targeting maternity health providers and hospital officials to update their long-standing practices. REGISTRATION: Registered in PROSPERO under protocol number CRD42023429140.

Manejo anestésico de las pacientes embarazadas tetrapléjicas durante el parto: una revisión sistemática / Anaesthetic management of tetraplegic pregnant patients during child delivery: A systematic review

Introducción: El embarazo en pacientes con lesión de la médula espinal tiene unas características específicas. Sin embargo, las guías para orientar su manejo son escasas. Métodos: Se realizó una revisión sistemática de la literatura sobre el manejo anestésico durante el parto de pacientes embarazadas con lesión de la médula espinal cervical. Resultados: Se observó una mayor incidencia de parto prematuro y cesárea. El manejo anestésico fue diverso, aunque la mayoría de las pacientes embarazadas recibieron analgesia epidural. Los síntomas de disreflexia autónoma se observaron en el 51% de las mujeres. Conclusión: El manejo adecuado de estas pacientes podría reducir posiblemente la tasa de cesáreas y partos prematuros, y minimizar las complicaciones comunes, reduciendo al mismo tiempo los costes. Se recomienda una derivación precoz a la consulta de anestesiología y un enfoque multidisciplinario.(AU)

Introduction: Pregnancy in spinal cord injured patients has specific issues that must be carefully addressed. However, guidelines for their management are scarce. Methods: A systematic review of the literature regarding the anaesthetic management during delivery of pregnant patients with cervical spinal cord injury was performed on the electronic databases of PubMed (Medline) and Cochrane. Results: A higher incidence of preterm birth and caesarean delivery were seen. Anaesthetic management was diverse, although most pregnant patients received epidural analgesia. Autonomic dysreflexia symptoms were present in 51% of pregnancies. Conclusion: Timely management of these patients could possibly reduce caesarean and preterm delivery rates, avoid or minimize common complications, as well as reduce costs. An early reference to anaesthesiology consultation and a multidisciplinary approach is recommended.(AU)

Anaesthetic management of tetraplegic pregnant patients during child delivery: A systematic review.

BACKGROUND: Pregnancy in spinal cord injured patients has specific issues that must be carefully addressed. However, guidelines for their management are scarce. METHODS: A systematic review of the literature regarding the anaesthetic management during delivery of pregnant patients with cervical spinal cord injury was performed on the electronic databases of PubMed (Medline) and Cochrane. RESULTS: Twenty-two papers were included. A higher incidence of preterm birth and caesarean delivery were seen. Anaesthetic management was diverse, although most pregnant patients received epidural analgesia. Autonomic dysreflexia symptoms were present in 51% of pregnancies. CONCLUSION: Timely management of these patients could possibly reduce caesarean and preterm delivery rates, avoid or minimize common complications, as well as reduce costs. An early reference to anaesthesiology consultation and a multidisciplinary approach is recommended.

¿Han cambiado los conceptos de analgesia obstétrica en los últimos 100 años? / Have the concepts of obstetric analgesia changed in the last 100 years?

Objetivos: Comparar los conceptos y métodos de analgesia obstétrica actual con los existentes hace 100 años, cuando se publicaron por primera vez Anesthesia & Analgesia (1922) y British Journal of Anaesthesia (1923), que son las dos primeras revistas de anestesia publicadas de forma independiente.Material y métodos: Identificamos y analizamos todos los artículos relacionados con la analgesia obstétrica publicados en estas revistas durante los años 1922 y 1923, y los comparamos con la práctica clínica actual. También buscamos en estos números referencias indirectas a la atención prestada a la analgesia obstétrica en las reuniones científicas de la época.Resultados: En el primer número de Anesthesia & Analgesia que aparece en agosto de 1922, 3 de los 8 artículos publicados están relacionados exclusivamente con la anestesia y analgesia obstétrica, y entre 1922 y 1923 encontramos un alto número de artículos y referencias. El análisis de estos artículos publicados hace un siglo permite objetivar el interés de la época por los resultados, la comparación entre los diferentes métodos anestésicos, la seguridad y la divulgación del conocimiento científico. Son habituales las referencias a la mortalidad, a las complicaciones, al confort y la satisfacción de la paciente, a la influencia de la analgesia obstétrica en la duración del parto, así como al ahorro de tiempo y de gases anestésicos. Resulta obvio que la metodología de investigación actual no puede compararse con la de hace 100 años. Pero existen numerosos aspectos científicos que sentaron algunas de las bases de la investigación actual en obstetricia, entre los que destacan la recogida de amplias series de pacientes durante largos periodos de tiempo, la mención expresa a la publicación de resultados tanto favorables como desfavorables...(AU)

Objectives: To compare current obstetric analgesia concepts and methods with those existing 100 years ago, when Anesthesia & Analgesia (1922) and British Journal of Anaesthesia (1923), the first two independently published anesthesia journals, were first published.Methods: We identified and analyzed all articles related to obstetric analgesia published in these journals during the years 1922 and 1923 and compared them with current clinical practice. We also searched these issues for indirect references to the attention given to obstetric analgesia at scientific meetings of the time.Results: In the first issue of Anesthesia & Analgesia, appearing in August 1922, 3 of the 8 articles published are related exclusively to obstetric anesthesia and analgesia, and between 1922 and 1923 we found a high number of articles and references. The analysis of these articles published a century ago allows us to objectify the interest of the time in the results, the comparison between different anesthetic methods, safety and the dissemination of scientific knowledge. References to mortality, complications, patient comfort and satisfaction, the influence of obstetric analgesia on the duration of labor, as well as savings in time and anesthetic gases are common.It is obvious that today's research methodology cannot be compared with that of 100 years ago. But there are many scientific aspects that laid some of the foundations of current research in obstetrics, including the collection of large series of patients over long periods of time, the express mention of the publication of both favorable and unfavorable results, the references not only to cost but also to cost-effectiveness, as well as the use of specific parameters to measure not only results but also patient satisfaction.Conclusions: It is evident that over the years the outcomes in the practice of anesthesiology have improved, but also that many concepts remain the same 100 years later...(AU)

Changes in sensory block level during a programmed intermittent epidural bolus regimen for labour analgesia: a prospective observational cohort study.

PURPOSE: In the context of a programmed intermittent epidural bolus (PIEB) regimen for labour analgesia, one can identify an upper sensory block level (USBL), defined as the highest dermatome with any altered sensation to cold, and a lower sensory block level (LSBL), defined as the highest dermatome with complete sensory block to cold. This study investigated whether and how these sensory block levels vary within PIEB cycles. METHODS: We enrolled patients requesting epidural analgesia. An epidural catheter was placed at L2/L3 or L3/L4. A test dose of 3 mL of bupivacaine 0.125% with fentanyl 3.3 µg·mL-1 was administered, followed by 12 mL of the same solution as the loading dose. A PIEB plus patient-controlled epidural analgesia (PCEA) regimen was initiated 40 min after the loading dose, with bupivacaine 0.0625% with fentanyl 2 µg·mL-1: PIEB 10 mL, PIEB interval 40 min, PCEA 5 mL, lockout interval 10 min, maximum hourly 30 mL. As per institutional protocol, sensory block levels to ice were assessed 20 min after the loading dose and then hourly. Patients included in the study underwent eight extra assessments: immediately before the second and fourth PIEB and 10, 20, and 30 min after the second and third PIEB. RESULTS: We studied 30 patients. The USBL and LSBL achieved their peak value 100 min after the loading dose. The median [interquartile range] USBL was T8 [T9-T7] and T6 [T7-T4] 20 and 100 min after the loading dose, respectively; LSBL was T10 [T11-T6] and T8 [T9-T6], respectively. There was no significant variation in USBL or LSBL within the PIEB cycle between the second and the third or the third and the fourth PIEB. CONCLUSION: Once peak sensory block levels are established, there is no significant variation in the USBL and LSBL within the PIEB cycles. STUDY REGISTRATION: www. CLINICALTRIALS: gov (NCT04716660); registered 21 January 2021.

RéSUMé: OBJECTIF: Dans le contexte du schéma de bolus périduraux intermittents programmés (PIEB) pour l'analgésie du travail, on peut identifier un niveau de bloc sensoriel haut (USBL) défini comme étant le dermatome le plus haut ayant une quelconque modification de la sensation au froid et un niveau de bloc sensoriel bas (LSBL) défini comme étant le dermatome le plus haut ayant un bloc sensoriel complet au froid. Cette étude a cherché à savoir si et comment ces niveaux de blocs sensoriels varient au cours des cycles de PIEB. MéTHODES: Nous avons recruté des patientes demandant une analgésie péridurale. Un cathéter péridural a été placé au niveau L2/L3 ou au niveau L3/L4. Une dose test de 3 mL de bupivacaïne 0,125% avec fentanyl 3,3 µg·ml−1 était administrée, suivie de 12 mL de la même solution représentant la dose de base. Un protocole de PIEB plus analgésie péridurale contrôlée par la patiente (PCEA) a débuté 40 min après l'administration de la dose de base, comportant de la bupivacaïne 0,0625% et du fentanyl 2 µg·ml−1: PIEB 10 mL; intervalle de PIEB 40 min.; PCEA 5 ml; intervalle de verrouillage 10 min.; maximum par heure 30 mL. Conformément au protocole de l'établissement, les niveaux de bloc sensoriel à la glace ont été évalués 20 min après l'administration de la dose de base, puis toutes les heures. Les patientes incluses dans l'étude ont eu huit évaluations supplémentaires: immédiatement avant le deuxième et le quatrième PIEB et 10, 20 et 30 min après les deuxième et troisième PIEB. RéSULTATS: Nous avons étudié 30 patientes. L'USBL et le LSBL ont atteint leur valeur pic 100 min après l'administration de la dose de base. L'USBL médian [plage interquartile] était T8 [T9­T7] et T6 [T7­T4], respectivement 20 et 100 min après la dose de base; Le LSBL était, respectivement, T10 [T11­T6] et T8 [T9­T6]. Il n'y avait pas de variation significative de l'USBL ou du LSBL dans le cycle de PIEB entre le deuxième et le troisième ou le troisième et le quatrième PIEB. CONCLUSION: Une fois les niveaux maximums de blocs sensoriels établis, il n'y a pas de variation significative dans l'USBL et le LSBL dans les cycles de PIEB. ENREGISTREMENT DE L'éTUDE: www.clinicaltrials.gov (NCT04716660); enregistrée le 21 janvier 2021.

Comparison of Continuous Infusion of Ropivacaine and Fentanyl With Intermittent Bolus Doses of Ropivacaine and Fentanyl for Epidural Labor Analgesia: A Randomized Open-Label Study.

Background The purpose of this study was to compare the efficacy of continuous epidural infusion with intermittent bolus doses for labour analgesia using ropivacaine 0.2% and opioids. Methods In this study, 70 primigravida patients were randomly divided into two groups of 35 each. Both groups received a loading dose of 10ml of 0.2% ropivacaine and 1µg/ml fentanyl in 5ml incremental doses while monitoring blood pressure and heart rate. Subsequently, Group I received a continuous epidural infusion of 0.2% ropivacaine with fentanyl at 10ml/hr, while Group II received 10 ml of 0.2% ropivacaine with fentanyl in bolus form every hour manually, with the first dose given after one hour of the initial loading dose. A rescue bolus dose of 5ml of 0.2% ropivacaine was given in both groups when they complained of breakthrough pain (VAS score >3). An additional 5ml bolus dose was given in both groups at the time of crowning. The blood pressure, heart rate, and severity of pain using the visual analogue scale (VAS) were assessed. Total drug volume utilized, the number of bolus doses, duration of the first and second stage of labour, rate of instrumental delivery and cesarean section, and neonatal Apgar scores were also recorded. Results The total volume of drugs consumed and the number of boluses required for breakthrough pain were both significantly lower in Group II. There was a similar decrease in hemodynamic parameters (systolic blood pressure, diastolic blood pressure, and mean arterial pressure) from baseline in both the groups with no significant difference between them. The onset of analgesia was significantly faster in Group I with both groups achieving optimum analgesia (VAS ≤ 3) within 20 minutes of the loading dose. Maternal motor blockade scores, the duration of the first and second stage of labour, the rate of instrumental delivery, cesarean section, and neonatal Apgar scores, did not show any statistically significant difference between the two groups. Conclusion Both techniques, i.e. continuous epidural infusion and intermittent epidural boluses are effective for providing labour analgesia. But consumption of drugs and episodes of breakthrough pain was higher in the continuous infusion group (Group I).

Epidural analgesia in labor: A narrative review.

Lumbar epidural is the most effective form of pain relief in labor with around 30% of laboring women in the UK and 60% in the USA receiving epidural analgesia. Associations of epidural on maternal, obstetric, and neonatal outcomes have been the subject of intense study, though a number of uncertainties persist. The present narrative review explores important areas of research surrounding epidural analgesia in obstetric patients including methods of initiation and administration, choice of local anesthetic solution, and the addition of adjuvants. Key meta-analyses exploring associations of epidural analgesia on maternal and neonatal outcomes are identified and summarized.

Obstetric analgesia utilization in labor pain management and associated factors among obstetric care providers in the West Shewa Zone, Central Ethiopia.

Objectives: Labor pain is the worst pain that almost every woman experiences during childbirth. Labor pain management plays a crucial role in promoting maternal-wellbeing, contributing enormously to maternal satisfaction with the childbirth experience and the high quality of services. Although there have been previous studies, they have primarily been conducted at referral or general hospitals located in urban settings. Thus, this study aimed to assess the utilization of labor pain analgesia and associated factors among obstetric care providers at all levels of health facilities in central Ethiopia. Methods: A multicenter institution-based cross-sectional study design was employed from 1 July to 30 September 2020. Simple random sampling using the lottery method was employed to select 399 obstetric care providers. The data were entered into Epi-data version 4.2 and analyzed using SPSS version 26. Bivariate and multivariable logistic regression analysis were used to identify the associated factors. The adjusted odds ratio with its 95% confidence interval and p value ⩽ 0.05 were used to identify associated factors. Results: The overall utilization of obstetric analgesia was 46% (95% confidence interval: 41.2%-50.8%). Being a Midwife (adjusted odds ratio: 2.10, 95% confidence interval: 1.27-3.47), having heard of the World Health Organization pain ladder (adjusted odds ratio: 2.95, 95% confidence interval: 1.73-5.01), having favorable attitude (adjusted odds ratio: 1.89, 95% confidence interval: 1.17-3.05), the expectation of obstetric care providers about labor pain (adjusted odds ratio: 3.26, 95% confidence interval: 1.27-8.36), having training on labor pain management (adjusted odds ratio: 2.51, 95% confidence interval: 1.03-6.07), and presence of chance for preference of obstetric analgesia for mothers in the facility (adjusted odds ratio = 2.30, 95% confidence interval: 1.33-3.98) were identified as factors significantly associated with the practice of obstetric analgesia among obstetric care providers. Conclusion: The overall use of labor pain management methods among obstetric care providers is low. Professional category, provider attitude, labor pain severity expectations, and having training were found to be factors associated with the use of obstetric analgesia. Therefore, working on adapting and disseminating the harmonized guideline and protocols on labor pain management and provision of training for obstetric care providers on labor pain management techniques were recommended.

Assessment of sensory block during labour epidural analgesia: a prospective cohort study to determine the influence of the direction of testing.

PURPOSE: Assessment of sensory block level during labour epidural analgesia is an essential component of clinical practice and patient safety. Nevertheless, the methods and direction of testing are not standardized. In our hospital, sensory block testing to ice is routinely used, but while some anesthesiologists test the block from a nonanesthetized to an anesthetized area, some do it in the opposite direction. It is unknown how these two different practices affect identification of the sensory block level. The objective of this study was to determine the agreement between these two practices. METHODS: We enrolled 31 patients admitted to the labour and delivery unit in a prospective cohort study. At their request, labour epidural analgesia was performed as per institutional routine. Sensory block level to ice was assessed using opposite directions by two randomly assigned independent investigators, one and two hours after the loading dose was administered. RESULTS: Sensory block levels to ice assessed from an anesthetized area to a nonanesthetized area were lower than those when assessed with the stimulus applied in the opposite direction, typically one segment lower. DISCUSSION: Given the small difference detected with both methods, it may be acceptable to use either in clinical practice. Nevertheless, the lack of standardization may have a significant impact when comparing studies involving assessment of sensory block to ice. STUDY REGISTRATION: www. CLINICALTRIALS: gov (NCT03572439); registered 28 June 2018.

RéSUMé: OBJECTIF: L'évaluation du niveau de bloc sensoriel pendant l'analgésie péridurale obstétricale est une composante essentielle de la pratique clinique et de la sécurité des patientes. Néanmoins, les méthodes et l'orientation des tests ne sont pas standardisées. Dans notre hôpital, les tests à la glace des blocs sensoriels sont couramment utilisés, mais alors que certains anesthésiologistes testent le bloc d'une zone non anesthésiée à une zone anesthésiée, certains le font dans la direction opposée. Nous ne savons pas dans quelle mesure ces deux pratiques différentes affectent l'identification du niveau du bloc sensoriel. L'objectif de cette étude était de déterminer la concordance entre ces deux pratiques. MéTHODE: Nous avons recruté 31 patientes admises à l'unité obstétricale dans une étude de cohorte prospective. À leur demande, l'analgésie péridurale obstétricale a été réalisée conformément à la routine institutionnelle. Le niveau du bloc sensoriel tel que mesuré par un test à la glace a été évalué dans les deux directions par deux chercheurs indépendants assignés au hasard, une et deux heures après l'administration de la dose de charge. RéSULTATS: Les niveaux de blocs sensoriels tels que mesurés par un test à la glace évalués d'une zone anesthésiée à une zone non anesthésiée étaient inférieurs à ceux évalués lorsque le stimulus était appliqué dans la direction opposée, habituellement un segment plus bas. DISCUSSION: Compte tenu de la petite différence détectée entre les deux méthodes, il peut être acceptable d'utiliser l'une ou l'autre dans la pratique clinique. Néanmoins, le manque de standardisation peut avoir un impact significatif lors de la comparaison d'études impliquant l'évaluation du bloc sensoriel à l'aide d'un test à la glace. ENREGISTREMENT DE L'éTUDE: www.ClinicalTrials.gov (NCT03572439); enregistrée le 28 juin 2018.

Impacto del uso de analgesia peridural controlada por la paciente en la disminución del dolor durante el trabajo de parto en un hospital del suroccidente colombiano / Impact of the use of patient-controlled epidural analgesia on pain reduction during labor in a hospital in southwestern colombia

Introducción: La analgesia epidural controlada por la paciente (PCA) provee flexibilidad al permitir acomodar la analgesia de acuerdo con las necesidades crecientes del dolor a medida que progresa el trabajo de parto (TP). El propósito de este estudio es objetivar el impacto en el alivio del dolor y satisfacción materna en pacientes en TP con analgesia PCA.Pacientes y métodos: Estudio descriptivo prospectivo realizado en el segundo semestre del 2020. Se incluyeron gestantes con embarazo único con escala verbal numérica (EVN) mayor a 3 y se excluyeron a las pacientes con contraindicaciones para inserción de catéter. Posterior a la inserción, se valoró el dolor y se entregó un cuestionario para calificar el dolor a los 15 min y en el expulsivo.Resultados: La población estaba constituida por mujeres jóvenes, el 72 % con embarazo a término. El catéter peridural se insertó en la fase latente del trabajo de parto en el 53,4 % de los casos. Al momento de la inserción del catéter, la mediana de dolor fue de 8 (6-10), a los 15 minutos 2 (0-4) y en el expulsivo 5 (3-8). El 75 % de las maternas refirieron estar muy satisfechas y el 19 % satisfechas; un 3 % indicaron estar poco satisfechas y el 1 % restante, insatisfechas. La prevalencia náusea y vómito fue del 16 % y 15 %, respectivamente.Conclusiones: PCA como estrategia analgésica durante el trabajo de parto a través de bolos intermitentes a demanda logró un adecuado control del dolor en los primeros minutos posterior a la inserción sin un control óptimo durante el expulsivo, sin embargo, se obtuvo una satisfacción materna global alta.(AU)

Introduction: Patient-controlled analgesia (PCA) allows patients to accommodate analgesia according to increasing pain needs as labor progresses. This study aims to objectify the impact on pain relief and maternal satisfaction in labor patients with PCA analgesia.Patients and methods: A prospective descriptive study was carried out in the second semester of 2020. Pregnant women with a singleton pregnancy with a numerical rating scale (NRS) greater than three were included, and patients with contraindications for catheter insertion were excluded. After insertion, pain was assessed, and a questionnaire was given to rate pain at 15 min and during expulsion.Results: The population consisted of young women, 72 % of whom were pregnant at term. The epidural catheter was inserted in the latent phase of labor in 53.4 % of cases. At the time of catheter insertion, the median pain was 8 (6-10), at 15 minutes 2 (0-4), and expulsion 5 (3-8). Seventy-five percent of the mothers reported being very satisfied and 19 % satisfied; 3 % reported being slightly satisfied, and the remaining 1 % dissatisfied. The prevalence of nausea and vomiting was 16 % and 15 %, respectively.Conclusions: PCA as an analgesic strategy during labor through intermittent boluses on-demand achieved adequate pain control in the first minutes after insertion without optimal control during expulsion. However, high overall maternal satisfaction was obtained.(AU)

Pain Relief During Childbirth in the Context of 50 Years of Social and Technological Change.

Pain relief during childbirth continues to stimulate controversy as new treatments emerge and continuing interventions in the birth process invoke concerns about safety, technologic imperatives, and informed consent. In this historical commentary, I identify a complex dissonance between scientific advances and women's needs and expectations regarding childbirth. Evidence-based practice became the standard during the last 50 years and has reinforced a more conservative and parsimonious use of technology to respond to women's needs for pain relief. In reviewing this history, it is apparent that pain relief during labor is inextricably linked to interventions. Nurses can advance evidence-based practice and facilitate robust informed consent as they support women during childbirth.

Meningitis tras técnica combinada raquídea-epidural para analgesia del parto: reporte de un caso / Case report of meningitis after combined spinal-epidural analgesia for labor

La meningitis pospunción es una complicación importante y poco frecuente de la anestesia neuroaxial. Describimos el caso de una paciente que ingresa para inducción del parto. Se realiza técnica espinal-epidural para analgesia del parto. Cursando 48 h de puerperio instala cefalea intensa, fotofobia y fiebre. No focalidad neurológica. Sin rigidez de nuca. Al examen, restos cavitarios que impresionan fétidos. Se plantea endometritis puerperal iniciando tratamiento antibiótico. Dado la persistencia del cuadro clínico se plantea punción lumbar para confirmación diagnóstica mediante análisis de líquido cefalorraquídeo; siendo éste turbio, por lo cual ingresa a cuidados intensivos con diagnóstico de meningitis aguda. Bacterióloga informa a los 10 días que el cultivo desarrolla estreptococo mitis oralis. La importancia esta dada porque la meningitis puede ser potencialmente devastadora si no se realiza un diagnóstico y tratamiento tempranos, existiendo medidas que se pueden adoptar para prevenir esta complicación.

Post-puncture meningitis is an important and rare complication of neuraxial anesthesia. We describe case of patient who is admitted for induction of labor. A spinal-epidural technique is performed for labor analgesia. During 48 hours of puerperium, she installed intense headache, photophobia and fever. No neurological focus. No stiff neck. On physical exam, cavitary remains that appear fetid. Puerperal endometritis arises starting antibiotic treatment. Given the persistence of the clinical picture, lumbar puncture is considered for diagnostic confirmation by analysis of cerebrospinal fluid; This being cloudy, for which he was admitted to Intensive Care with a diagnosis of acute meningitis. Bacteriologist reports 10 days later develops streptococcus mitis oralis. The importance is given because meningitis can be potentially devastating if early diagnosis and treatment is not performed, and there are measures that can be taken to prevent this complication.

Nitrous Oxide Use During Labor: Satisfaction, Adverse Effects, and Predictors of Conversion to Neuraxial Analgesia.

INTRODUCTION: Women desire safe and effective choices for pain management during labor. Currently, neuraxial and opioid analgesia are the most common methods used in the United States. The purpose of this study was to investigate demographic characteristics, safety, and satisfaction in a cohort of parturients who used inhaled nitrous oxide (N2 O) analgesia and to determine predictors of conversion from N2 O to neuraxial analgesia. METHODS: This was a prospective chart review study. Individuals aged at least 18 years who used inhaled N2 O during the first or second stage of labor between March 1, 2016, and July 23, 2017, on the labor and delivery unit of one academic medical center (N = 463) and their neonates were included. Data describing maternal and neonatal factors are reported. Logistic regression and chi-square tests were used to model the effects of oxytocin augmentation, labor induction, parity, prior cesarean birth, pre-N2 O cervical dilatation, and post-N2 O cervical dilatation on the odds of conversion from N2 O to neuraxial analgesia. RESULTS: In this cohort, 31% who chose N2 O for analgesia did not convert to any other analgesic method. Significant positive predictors for conversion from N2 O to neuraxial analgesia included labor induction (odds ratio [OR], 2.9; 95% CI, 1.7-5.0), oxytocin augmentation (OR, 3.1; 95% CI, 1.6-6.0), and labor after cesarean (OR, 6.4; 95% CI, 2.5-16.5). Multiparity (OR, 0.4; 95% CI, 0.2-0.6) and post-N2 O cervical dilatation (OR, 0.8; 95% CI, 0.7-0.9) were negative predictors. Adverse effects related to N2 O use during labor were rare (8%) and were not a significant reason for conversion to neuraxial analgesia. Parturients had moderately high satisfaction with N2 O for pain management (11-point scale, mean [SD], 7.4 [2.9]). Five-minute Apgar scores were 7 or greater in 97.8% of the newborns. DISCUSSION: Understanding predictors of conversion from inhaled N2 O to neuraxial analgesia may assist perinatal care providers in their discussions with women about analgesia options during labor. N2 O is a useful, safe option for labor analgesia in the United States.

Management of Obstetric Analgesia in the Developing Countries during the Coronavirus Disease Pandemic: A Narrative Review.

Coronavirus disease (COVID), also known as COVID-19, has brought the immense challenges for the health-care system globally. All the branches of medicine are equally involved in managing these patients. During this pandemic, care of obstetric patients in terms of obstetric analgesia becomes crucial. Hence, the purpose of this review was to draft a basic model of strategies related to the provision of safe obstetric analgesia during this coronavirus pandemic, which will assist the health-care providers across the developing countries to formulate their own protocols depending upon the resource availability. All research articles related to obstetric analgesia during the COVID-19 pandemic from January 2020 to December 01, 2020 available on PubMed, Cochrane, Google scholar, and Embase are included in this study. The keywords used for data search were "obstetric analgesia during COVID-19," "coronavirus pandemic," "Labor pain," "obstetric pain management guidelines," and "regional anesthesia during COVID-19." Eventually, our review yielded the most recentmodel for the provision of safe and effective obstetric analgesia practices during the COVID-19 pandemic across the developing countries.