Pharmacologic and nonpharmacologic options for pain relief during labor: an expert review.

Labor pain is among the most severe types of physical pain that women may experience during their lifetime. Thus, pain relief is an essential part of medical care during childbirth. Epidural analgesia is considered to be the most efficient method of pain relief during labor. Nevertheless, patient preferences, contraindications, limited availability, and technical failure may require the use of alternative pain reliving methods during labor including systemic pharmacologic agents, and nonpharmacologic methods. Nonpharmacologic methods for pain alleviation during vaginal birth have become popular over the years, either as a complement to pharmacologic agents or at times as the principal therapy. Methods such as relaxation techniques (ie, yoga, hypnosis, and music), manual techniques (ie, massage, reflexology, and shiatsu), acupuncture, birthing ball, and transcutaneous electrical nerve stimulation are considered safe, although the evidence supporting their effectiveness for pain relief is not as robust as it is for pharmacologic agents. Systemic pharmacologic agents are mostly administered by inhalation (nitrous oxide) or through the parenteral route. These agents include opioids such as meperidine, nalbuphine, tramadol, butorphanol, morphine, and remifentanil, and non-opioid agents such as parenteral acetaminophen and nonsteroidal anti-inflammatory drugs. Systemic pharmacologic agents suggest a diverse armamentarium of medication for pain management during labor. Their efficacy in treating pain associated with labor varies, and some continue to be used even though they have not been proven effective for pain relief. In addition, the maternal and perinatal side effects differ markedly among these agents. There is a relative abundance of data regarding the effectiveness of analgesic drugs compared with epidural, but the data regarding comparisons among the different types of alternative analgesic agents are scarce, and there is no consistency regarding the drug of choice for women who do not receive epidural pain management. This review aims to present the available data regarding the effectiveness of the different methods of relieving pain during labor other than epidural. The data presented are mainly based on recent level I evidence regarding pharmacologic and nonpharmacologic methods for pain relief during labor.

Meperidine Compared With Nitrous Oxide for Intrapartum Pain Relief in Multiparous Patients: A Randomized Controlled Trial.

OBJECTIVE: To compare the efficacy and adverse effects of intravenous meperidine and inhaled nitrous oxide for intrapartum analgesia in multiparous patients. METHODS: This randomized controlled trial was conducted in the delivery ward of a university teaching medical center in Afula, Israel. Multiparous patients with term, singleton pregnancies who were in labor were randomized in a 1:1 ratio to 50 mg intravenous meperidine or inhaled nitrous oxide. The primary outcome was pain intensity 20-30 minutes after analgesic administration, measured on a visual analog scale (VAS) from 0 to 10 cm. Secondary outcomes included the need for additional analgesia, labor length, delivery mode, patient satisfaction, and maternal and neonatal adverse effects. To detect a 1-cm (±2.6) difference in VAS score between the groups, 214 total participants were needed to achieve 80% power with an alpha of 0.05. RESULTS: From August 2016 through May 2019, 214 participants were enrolled. Fourteen were excluded after randomization. Of the 200 analyzed, 102 received nitrous oxide, and 98 received intravenous meperidine. Demographic and obstetric variables were comparable between the two groups. The VAS score 20-30 minutes after analgesic administration did not differ between the groups (7.7±2.3 cm and 7.6±2.7 cm in the nitrous oxide and meperidine groups, respectively, P=.89). There were no significant differences between the groups in the rate of additional analgesic use, labor length, delivery mode, Apgar scores, rate of breastfeeding, patient satisfaction, or maternal and neonatal adverse effects. CONCLUSION: Pain intensity was comparable in multiparous patients 20-30 minutes after administration of meperidine and nitrous oxide. Adverse effects were also comparable. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, NCT02783508.

Effect of lactation on the recurrence rate of gestational diabetes mellitus: a retrospective cohort study.

PURPOSE: To examine the impact of lactation on the recurrence rate of gestational diabetes mellitus (GDM). METHODS: Retrospective cohort study performed in a single teaching hospital on data between 2009 and 2016. The study group consisted of women who had a diagnosis of GDM and breastfed exclusively for ≥ 1 month. The control group consisted of women who had a diagnosis of GDM and did not breastfeed or added formula < 1 month postpartum. Data regarding breastfeeding duration, timing and amount of formula supplementation were obtained by a telephone questionnaire. We hypothesized that the recurrence of GDM would be lower in women who breastfed exclusively for ≥ 1 month. Therefore, to detect a decrease from 50 to 30% in the recurrence rate of GDM with alpha (one-sided) of 0.05 and 80% power, a sample size of 168 (84 per group) was needed. RESULTS: Overall, 229 women were found eligible; 139 and 90 in the study and control groups, respectively. Except for parity, baseline demographic and obstetric variables were not different between the two groups. After adjusting for parity, the incidence of GDM in subsequent pregnancy was significantly lower among the study compared to the control group [48 (34.5%) and 41 (45.6%), respectively; one-tailed p = 0.043; RR 0.56; 95% CI 0.35-0.90)]. The cesarean delivery (CD) rate was significantly lower as well [28 (20.1%) and 31 (34.4%), respectively; two-tailed p = 0.02; RR 0.48, 95% CI 0.26-0.89)]. CONCLUSION: Exclusive lactation for ≥ 1 month reduced the recurrence rate of GDM and possibly the risk of CD in the subsequent pregnancy.

The occurrence and severity of intra-abdominal adhesions in cases of pregnancies complicated by placenta accreta: A case control study.

OBJECTIVE: To examine the occurrence of intra-abdominal adhesions (IAA) among women with placenta accreta (PA). STUDY DESIGN: Case control study conducted at a single teaching hospital on data from January 2004 to December 2016. The cases included women who underwent a cesarean hysterectomy due to PA and had a pathological confirmation of accretion. The controls were matched for delivery date and number of cesarean deliveries (CDs) at a ratio of 1:4. IAA were categorized as "none", "filmy", or "dense". The outcome measures were rate of IAA. In order to detect a 25% difference in overall IAA between the groups, with alpha of 0.05 and 80% power, a sample size of 165 women was needed. RESULTS: Overall, 165 women (33 and 132 in the case and control groups, respectively) were included. Except for maternal age, there were no statistically significant differences between the groups in demographic and obstetric variables. Overall IAA rate was 30.3% and 47.7% in the case and control groups, respectively (RR: 0.64; 95% CI: 0.37-1.10, p = 0.04). Rate of dense adhesions was 15.2% and 32.6% in the case and control groups, respectively (RR: 0.47, 95% CI: 0.20-1.08; p = 0.03). After adjustment for maternal age, there was a significantly lower rate of overall IAA (RR = 0.39; 95% CI: 0.17-0.93; p = 0.02) and dense adhesions (RR = 0.30; 95% CI: 0.11-0.87; p = 0.02) among the cases. CONCLUSION: The incidence and severity of IAA following CDs are low, among women who develop PA.

Peripartum events associated with severe neurologic morbidity and mortality among acidemic neonates.

PURPOSE: To identify peripartum events that may predict the development of short-term neurologic morbidity and mortality among acidemic neonates. METHODS: Retrospective case-control study conducted at a single-teaching hospital on data from January 2010 to December 2015. The study cohort group included all acidemic neonates (cord artery pH ≤ 7.1) born at ≥ 34 weeks. Primary outcome was a composite including any of the following: neonatal encephalopathy, convulsions, intra-ventricular hemorrhage, or neonatal death. The study cohort was divided to the cases group, i.e., acidemic neonates who had any component of the primary outcome, and a control group, i.e., acidemic neonates who did not experience any component of the primary outcome. RESULTS: Of all 24,311 neonates born ≥ 34 weeks during the study period, 568 (2.3%) had a cord artery pH ≤ 7.1 and composed the cohort study group. Twenty-one (3.7%) neonates composed the cases group. Multivariate logistic regression analysis revealed that cases were significantly more likely to have experienced placental abruption (OR 18.78; 95% CI 5.57-63.26), born ≤ 2500 g (OR 13.58; 95% CI 3.70-49.90), have meconium (OR 3.80; 95% CI 1.20-11.98) and cord entanglement (OR 5.99; 95% CI 1.79-20.06). The probability for developing the composite outcome rose from 3.7% with isolated acidemia to 97% among neonates who had all these peripartum events combined with intrapartum fetal heart rate tracing category 2 or 3. CONCLUSION: Neonatal acidemia carries a favorable outcome in the vast majority of cases. In association with particular antenatal and intrapartum events, the short-term outcome may be unfavorable.

Comparison of single- and double-balloon catheters for labor induction: a systematic review and meta-analysis of randomized controlled trials.

OBJECTIVE: There is a paucity of head-to-head randomized trials that compare single- and double-balloon catheters, and the results of the available data in terms of time from catheter insertion to delivery and delivery mode are mixed. This meta-analysis of randomized controlled trials compares the efficacy of single- and double-balloon catheters in women undergoing labor induction. STUDY DESIGN: Searches were made in MEDLINE, EMBASE, PubMed, ClinicalTrials.gov, and the Cochrane Library from inception through June 2016. Peer-reviewed randomized and quasi-randomized trials that compared single- and double-balloon catheters head-to-head for cervical ripening or labor induction were identified. Eligible study populations consisted of women with singleton pregnancies that had any indication for labor induction and were randomly assigned to undergo induction with a single- or a double-balloon catheter. The primary outcome was time from catheter insertion to delivery and delivery mode. The secondary outcomes were intrapartum fever or chorioamnionitis, woman's satisfaction, and neonatal Apgar score. RESULTS: Of the 520 records identified, five randomized trials (996 women; 491 with single-balloon and 505 with double-balloon catheters) were considered eligible and included in the meta-analysis. Time from catheter insertion to delivery did not differ between the two types of catheter (p = 0.527; WMD -0.87; 95% CI: -3.55, 1.82). The incidence of cesarean delivery also did not differ (p = 0.844; RR 0.97; 95% CI: 0.69, 1.35). Delivery within 24 h, delivery mode, incidences of intrapartum fever or chorioamnionitis, and neonatal Apgar score <7 at 5 min did not differ between the two types of catheter as well. Women who were induced with the single-balloon catheter were more satisfied (p = 0.029; WMD 0.56; 95% CI: 0.06, 1.06). CONCLUSION: Time from catheter insertion to delivery and delivery mode were comparable between the two types of catheter.

Risk of preterm birth and low birthweight following consecutive surgical and medical abortions.

PURPOSE: To examine the effect of consecutive surgical compared to medical uterine evacuations on spontaneous preterm birth (SPTB) and low birthweight (LBW) rates in the immediate subsequent delivery. METHODS: Retrospective study, conducted at a teaching hospital on data from January 2000 to March 2016. First study group consisted of all women who had ≥2 consecutive medical evacuations (ME-Group); second study group consisted of women who had ≥2 consecutive surgical evacuations (SE-Group). Both had a subsequent singleton delivery. Control group consisted of women without previous evacuations (unexposed group). The groups were matched for year of birth and ethnicity. The primary outcome was a composite that included SPTB (<37 weeks) and LBW (<2500 g). RESULTS: All 70 women found eligible in the ME-Group during the study period were included. SE-Group and the unexposed group consisted of 140 and 210 women, respectively. Primary outcome occurred in 4.3, 11.4, and 2.4% in the ME-Group, SE-Group, and the unexposed group, respectively (p = 0.002). After adjusting for variables that differed between the groups in univariate analysis, the primary outcome incidence was significantly higher among the SE-Group compared to the unexposed group (adjusted OR 6.8, 95% CI 1.7-26.3, p = 0.006). The difference was insignificant between the ME-Group and the unexposed group (adjusted p = 0.31). In the SE-Group, 7.1% women required fertility treatments to achieve a desired pregnancy compared to 1.4% in the ME-Group (p = 0.04). CONCLUSION: Two or more consecutive surgical evacuations were associated with an increased risk of both SPTB and LBW compared to unexposed group.

The impact of postpartum cervical tear on the occurrence of preterm birth in subsequent pregnancy.

PURPOSE: To examine the occurrence of subsequent preterm birth (PTB) among women who experienced a cervical tear during prior delivery. METHODS: A retrospective study conducted at a single teaching hospital on data from January 1994 to March 2014. The study group included all women who had a cervical tear detected at uterine and cervical examination, performed due to early postpartum hemorrhage. The control group consisted of women who delivered vaginally, experienced an early postpartum hemorrhage, and had an intact cervix at uterine and cervical examination. The control group was matched for maternal age and ethnicity at a ratio of 1:2. Women who had a cervical tear but then did not have a subsequent delivery, or had multiple fetal gestations or cervical cerclage at subsequent pregnancies were excluded. Primary outcome was spontaneous PTB rate (<37 weeks) in the subsequent pregnancy. Secondary outcomes included any PTBs in other subsequent pregnancies. RESULTS: Overall, 389 women were included. Of all cases of cervical tear, 129 were identified eligible and included in the final analysis. The control group included 260 women with an intact cervix. No significant differences were found between the study and control groups in the incidence of spontaneous PTB in the immediate subsequent pregnancy [1.6% (2/129) vs. 3.8% (10/260), respectively, p = 0.35]. The incidence of any spontaneous PTBs in all subsequent pregnancies did not differ also [4.7% (6/129) vs. 7.3% (19/260), respectively, p = 0.31]. CONCLUSION: Cervical tear detected after delivery does not increase the risk of spontaneous PTB in subsequent pregnancies.

The effect of type and volume of fluid hydration on labor duration of nulliparous women: a randomized controlled trial.

PURPOSE: Type and volume of fluid administered for intrapartum maintenance had been reported to differently affect labor length, delivery mode, and cord artery pH and glucose level. We aimed to compare the effect of three different fluid regimens on labor duration. METHODS: In a randomized trial, healthy nulliparous in labor were randomized into one of three intravenous fluid regimens: group 1, the reference group, lactated Ringer's solution infused at a rate of 125 mL/h; group 2, lactated Ringer's solution infused at a rate of 250 mL/h; group 3, 0.9% saline solution boosted with 5% glucose, infused at a rate of 125 mL/h. The primary outcome was labor length from enrollment until delivery. RESULTS: Between December 2010 and July 2015, 300 women were randomized to one of the three groups. Demographic and baseline obstetric characteristics were comparable between the groups. There was no significant difference in the time from enrollment to delivery (p = 0.62). Furthermore, there were no significant differences in second stage duration (p = 0.73), mode of delivery (p = 0.21), cord artery pH and glucose level between the groups. CONCLUSIONS: Increasing the intravenous volume of lactated Ringer's solution or substituting to fluid containing 5% glucose solution does not affect labor length. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, http://www.clinicaltrials.gov , NCT01242293.

Postcesarean wound infection: prevalence, impact, prevention, and management challenges.

Surgical site infection (SSI) is one of the most common complications following cesarean section, and has an incidence of 3%-15%. It places physical and emotional burdens on the mother herself and a significant financial burden on the health care system. Moreover, SSI is associated with a maternal mortality rate of up to 3%. With the global increase in cesarean section rate, it is expected that the occurrence of SSI will increase in parallel, hence its clinical significance. Given its substantial implications, recognizing the consequences and developing strategies to diagnose, prevent, and treat SSI are essential for reducing postcesarean morbidity and mortality. Optimization of maternal comorbidities, appropriate antibiotic prophylaxis, and evidence-based surgical techniques are some of the practices proven to be effective in reducing the incidence of SSI. In this review, we describe the biological mechanism of SSI and risk factors for its occurrence and summarize recent key clinical trials investigating preoperative, intraoperative, and postoperative practices to reduce SSI incidence. It is prudent that the surgical team who perform cesarean sections be familiar with these practices and apply them as needed to minimize maternal morbidity and mortality related to SSI.

Risk factors and peripartum outcomes of failed epidural: a prospective cohort study.

PURPOSE: Awareness to rate, risk factors, and the associated peripartum outcomes of failed epidural analgesia (FEA) may improve expectations and labor management. We aimed to identify risk factors for FEA and to examine peripartum outcomes associated with failure. METHODS: A prospective cohort study conducted between March 2015 and August 2015, at a single university medical center. Laboring women at ≥34 weeks, receiving epidural analgesia, were eligible. Pain was evaluated using a 0-10 cm visual analogue scale (VAS). FEA was defined as VAS score ≥5, 30 min after the loading dose. The primary outcome was to identify risk factors for FEA. In addition, second-stage duration and operative vaginal delivery rate were also examined. Univariate logistic regression and stepwise multivariate logistic regression were performed to estimate the predictors for FEA. RESULTS: Of all 414 women included, 35 (8.5%) had FEA. Multivariate stepwise logistic regression revealed that fetal head station 1 cm above the ischial spines (p = 0.002, adjusted OR 5.4, 95% CI 1.9-16.0), oxytocin use (p = 0.026, adjusted OR 2.8, 95% CI 1.1-6.8), and seniority of the anesthesiologist (p = 0.046, adjusted OR 0.97, 95% CI 0.93-0.99) at epidural insertion were found as significant variables associated with FEA. Second-stage duration and operative vaginal delivery rate did not differ significantly between women with failed and successful epidural. CONCLUSION: Higher fetal head station and oxytocin use may be associated with higher failure rate. Labor outcomes related to epidural use, occurred at comparable rates, among women with failed and successful epidural.

Trend in major neonatal and maternal morbidities accompanying the rise in the cesarean delivery rate.

The aim of the study was to explore a cesarean delivery rate (CDR) beyond which major neonatal and maternal morbidities may outweigh the benefits of the procedure itself. A retrospective population-based cohort study was conducted at a single university teaching hospital between 1993 and 2012. Pregnant women who delivered at a gestational age of 23 weeks or more were included. Data including delivery mode, brachial plexus injury (BPI), neonatal encephalopathy (NE), placenta accreta (PA), blood transfusion (BT), and cesarean hysterectomy (CH) for each year were extracted, plotted, and trends analyzed. The Cochran-Armitage Trend Test was used to identify trends and correlations. Overall, 83,806 deliveries took place during this period. CDR increased from 10.9% to 21.7% (p < 0.001). Significant decreases in the incidence of BPI (p < 0.001) and NE (p = 0.006) were observed. At CDRs of 13.6% and 20%, there was no further significant decrease in the incidence of BPI and NE, respectively. The incidence of BT increased significantly (p < 0.001) while the increase in the incidence of PA was not significant (p = 0.06) nor the change in the incidence of CH (p = 0.4). A CDR of 20% may still confirm additional beneficial effect on major perinatal morbidities without a significant increase in the incidence of PA.