Remifentanil patient controlled analgesia versus epidural analgesia in labour. A multicentre randomized controlled trial.

BACKGROUND: Pain relief during labour is a topic of major interest in the Netherlands. Epidural analgesia is considered to be the most effective method of pain relief and recommended as first choice. However its uptake by pregnant women is limited compared to other western countries, partly as a result of non-availability due to logistic problems. Remifentanil, a synthetic opioid, is very suitable for patient controlled analgesia. Recent studies show that epidural analgesia is superior to remifentanil patient controlled analgesia in terms of pain intensity score; however there was no difference in satisfaction with pain relief between both treatments. METHODS/DESIGN: The proposed study is a multicentre randomized controlled study that assesses the cost-effectiveness of remifentanil patient controlled analgesia compared to epidural analgesia. We hypothesize that remifentanil patient controlled analgesia is as effective in improving pain appreciation scores as epidural analgesia, with lower costs and easier achievement of 24 hours availability of pain relief for women in labour and efficient pain relief for those with a contraindication for epidural analgesia.Eligible women will be informed about the study and randomized before active labour has started. Women will be randomly allocated to a strategy based on epidural analgesia or on remifentanil patient controlled analgesia when they request pain relief during labour. Primary outcome is the pain appreciation score, i.e. satisfaction with pain relief.Secondary outcome parameters are costs, patient satisfaction, pain scores (pain-intensity), mode of delivery and maternal and neonatal side effects.The economic analysis will be performed from a short-term healthcare perspective. For both strategies the cost of perinatal care for mother and child, starting at the onset of labour and ending ten days after delivery, will be registered and compared. DISCUSSION: This study, considering cost effectiveness of remifentanil as first choice analgesia versus epidural analgesia, could strongly improve the care for 180.000 women, giving birth in the Netherlands yearly by giving them access to pain relief during labour, 24 hours a day. TRIAL REGISTRATION NUMBER: Dutch Trial Register NTR2551, http://www.trialregister.nl.

The influence of prenatal breech presentation on neonatal leg posture.

UNLABELLED: The aim of our study was to examine the effect of prenatal breech presentation on postnatal leg posture. Twelve infants were born after breech presentation and nine infants after cephalic presentation participated. At 2, 4, 6, 12 and 18 weeks postnatal age leg posture was examined during general movements in supine and vertical position. RESULTS: Transient differences in hip posture between the groups were observed during the first 6 weeks postnatal age, with significantly more hip flexion and less hip extension in the breech group. For knee extension, differences between the groups were not statistically significant. Changing from supine to vertical position, the breech group demonstrated a significant increase in hip extension, with no significant changes in hip posture for the cephalic group. For both groups the vertical condition resulted in a significant increase in knee extension. Continuity from pre- to postnatal life was found for hip posture in both groups and for knee extension only in the breech group. CONCLUSIONS: Significant differences between breech and cephalic-born infants were found during the first 6 weeks after birth and mainly concerned hip posture and not knee posture. An increase in gravitational force has more impact on leg posture in the breech than in the cephalic group. The observed differences in hip posture between the studied groups were found to be transient, however, in the long term subtle differences still remain between the groups.

Fetal leg posture in uncomplicated breech and cephalic pregnancies.

BACKGROUND: The objective of our study was to determine differences in prenatal leg posture development between breech and cephalic-born babies. MATERIALS AND METHODS: Ten healthy fetuses in breech and ten healthy fetuses in cephalic presentation were observed by means of weekly ultrasounds from 33 weeks gestational age until birth to assess leg posture. RESULTS: The breech fetuses showed a clear preference for an extended leg position; they spent significantly more time with their knees in extension than the cephalic fetuses (p<0.001). The cephalic fetuses showed significantly more leg-crossing than the breech fetuses (p<0.01). For both findings, no significant change over time could be observed in either group. CONCLUSION: These findings show that the intra-uterine position does influence the fetal postural and motor development. However, it seems unlikely that intra-uterine movement restriction can solely be held accountable for the observed differences in leg position between breech and cephalic fetuses.

Does intra-uterine environment influence fetal head-position preference? A comparison between breech and cephalic presentation.

BACKGROUND: Cephalic fetuses have increasing lateralised head-position near term. AIM: Is this development affected by breech presentation? SUBJECTS AND METHODS: Fetal head-position was studied longitudinally in 13 healthy fetuses in breech presentation and 10 healthy fetuses in cephalic presentation by means of real-time ultrasound. Recordings were obtained weekly from 33 weeks gestational age until birth. RESULTS: As in previous research, a significant (p = 0.045) decrease in midline head-position was found for the cephalic fetuses with advancing gestational age. The development of a lateralised head-position preference was clearly less outspoken in the breech fetuses when compared to the cephalic ones, especially after 36 weeks gestational age. Furthermore, as cephalic fetuses showed a preference for a right-sided head-position, breech fetuses that did show a lateralised head-position did not have a clear preference for left or right. Our data show an association between the orientation of the fetal vertebral column and head-position predominance in the group of cephalic fetuses, which complies with Previc's left-otolithic dominance theory. No association could be detected between fetal head shape and head-position preference. CONCLUSIONS: This study shows evidence that development in head laterality is influenced by the breech presentation. The discussion addresses possible explanations for the differences we found between the breech and cephalic fetuses.

Influence of breech presentation on the development of fetal arm posture.

BACKGROUND: In previous research, an age-related developmental trend towards increasing arm flexion has been found for cephalic fetuses. AIM: To determine if the development of arm posture in breech fetuses is comparable to that of cephalic ones. SUBJECTS AND METHODS: Fetal arm posture was studied longitudinally by means of real-time ultrasound in 13 healthy breech and 10 healthy cephalic fetuses. Observations started from 33 weeks gestational age until birth and were performed weekly in the breech group and every 2 weeks in the cephalic group. RESULTS: No difference could be found in arm posture between the left and the right arm in either group. Both breech and cephalic fetuses showed a clear preference for flexion in elbow and finger joints at all studied ages. After 36 weeks gestational age, the breech group showed significantly less wrist flexion when compared to the cephalic group (p = 0.037). A clear preference for location of the fetal hands near the fetal head could be observed for both groups. CONCLUSIONS: As there is no evidence for an abnormal neuromotor development in healthy breech fetuses, the observed difference in wrist flexion is probably due to differences in intrauterine environment. Because of the preference for location of the hands in the vicinity of the fetal head, breech fetuses probably experience a less restricted environment (in the upper part of the uterus) than cephalic fetuses (in the lower part of the uterus).