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PubMed2001

Minimum local analgesic dose of intrathecal bupivacaine in labor and the effect of intrathecal fentanyl.

BACKGROUND: Combining bupivacaine with fentanyl for intrathecal analgesia in labor is well recognized, but dosages commonly used are arbitrarily chosen and may be excessive. This study aimed to determine the median effective dose (ED50) of intrathecal bupivacaine, defined as the minimum local analgesic dose (MLAD), and then use this to assess the effect of different doses of fentanyl. METHODS: In this double-blind, randomized, prospective study, 124 parturients receiving combined spinal epidural analgesia at 2-6-cm cervical dilatation were allocated to one of four groups to receive bupivacaine alone or with 5, 15, or 25 microg fentanyl, using the technique of up-down sequential allocation. Analgesic effectiveness was assessed using 100-mm visual analog pain scores, with less than or equal to 10 mm within 15 min defined as effective. MLAD was calculated using the formula of Dixon and Massey. Pruritus and duration of spinal analgesia were also recorded. RESULTS: Minimum local analgesic dose of intrathecal bupivacaine was 1.99 mg (95% confidence interval, 1.71, 2.27). There were similar significant reductions in MLAD (P < 0.001) for all bupivacaine-fentanyl groups compared with bupivacaine control. There was a dose-dependent increase in both pruritus and duration of spinal analgesia with increasing fentanyl (P < 0.0001). CONCLUSION: Under the conditions of this study, the addition of intrathecal fentanyl 5 microg offers a similar significant bupivacaine dose-sparing effect as 15 and 25 microg. Analgesia in the first stage of labor can be achieved using lower doses of fentanyl, resulting in less pruritus but with a shortening of duration of action.

Adult↗
PubMed2006

Subcutaneous sterile water injection for labour pain: a randomised controlled trial.

BACKGROUND: About 30% of women experience severe continuous low-back pain in labour, but limited options are available to reduce this pain especially in developing countries and remote areas. AIMS: To evaluate the efficacy of subcutaneous sterile water injection in reduction of labour pain compared with placebo. METHODS: One hundred (100) consecutive patients were enrolled in a double-blind randomised controlled trial. During the first stage of labour with planned normal vaginal delivery, the intervention group (n = 50) received 0.5 mL sterile water injected subcutaneously and the control group (n = 50) received normal saline as a placebo. Pain score was measured before and 10 and 45 min after the injection, using the faces rating scale. MAIN OUTCOME MEASURE: Low-back labour pain. RESULTS: The two groups were not significantly different regarding maternal age and weight, gestational age, parity and gravidity and degree of effacement. The median pain score was equal in both groups prior to the injection. Pain severity was reduced in both groups after the injection. However, the median pain score in the sterile water group was significantly lower than the placebo group 10 min (P < 0.01), as well as 45 min, after the injection (P < 0.01). CONCLUSION: Administering one subcutaneous injection of sterile water in a painful point of the lumbosacral area is effective in reducing low-back pain during labour.

Adult↗
PubMed2004

The range of coping strategies women use to manage pain and anxiety prior to and during first experience of labour.

OBJECTIVES: To investigate whether nulliparous women, during pregnancy, can identify their own pre-existing coping strategies for managing pain and anxiety and whether the range of coping strategies used in Labour by women who do not attend antenatal classes can be described. DESIGN: Qualitative semi-structured interviews. SETTING: Two large maternity units in a city in the North of England. PARTICIPANTS: Twenty-three nulliparous women were interviewed during their third trimester of pregnancy (prior to any antenatal class attendance) regarding strategies used to cope with previous experiences of pain and anxiety. A separate sample of 20 women, who had not attended any form of antenatal education, were interviewed within 72h of their first experience of labour regarding the coping strategies used to manage pain and anxiety during labour. FINDINGS: Template Analysis was used to code data from transcribed interviews. The findings indicate that as women approach their first experience of labour they can identify coping strategies that they have employed to manage pain and anxiety in their past. Equally women who have not attended antenatal classes use a wide range of strategies in labour. The range of identified coping strategies is described and comprises thoughts and behaviours with positive and negative consequences. KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: It is possible to help nulliparous women to identify, in pregnancy, a range of strategies that they have previously employed to manage pain and anxiety. This range reflects the coping strategies that women may potentially use in labour to manage pain and anxiety. Women may benefit from assistance in pregnancy to develop strategies for labour that are based on knowledge of their own coping repertoire, which includes enhancing positive strategies and finding alternatives to negative strategies.

Adaptation, Psychological↗
PubMed1979

Human fetal breathing activity during electively induced labor at term.

Human fetal breathing movements were measured during the first stage of electively induced labor in 20 healthy term pregnancies. Fetuses made breathing movements 25.6% of the time during a 1 hour control period and breathing decreased significantly to 8.3% during latent-phase labor and further decreased to 0.8% during active labor (P less than 0.001). Patterns of increased fetal breathing activity accompanied by increased gross fetal body movements and increased fetal heart rate variability for periods of 20 to 60 minutes out of every 1.0 to 1.5 hours were observed, and the intermittent patterns of increased body movement and heart rate variability continued throughout the first stage of labor despite the decrease in fetal breathing activity during latent- and active-phase labor. It will be important to account for rest activity patterns when interpreting variability of heart rate during labor. The absence of fetal breathing activity during electively induced labor at term is not a clinical indicator of fetal ill health.

Anesthesia, Epidural↗
PubMed2001

An investigation into the feasibility of comparing three management options (augmentation, conservative and water) for nulliparae with dystocia in the first stage of labour.

OBJECTIVE: to evaluate the feasibility of a randomised controlled trial (RCT) examining the effect of three options (augmentation, conservative and water) for the management of dystocia in nulliparae. The main objectives were to explore the feasibility of trial procedures in the clinical environment, consent rates and acceptability of the management options to women, local incidence of dystocia in nulliparae and the size of the subsequent study. DESIGN: a two part study: a pilot, RCT with follow-up through to delivery with postnatal maternal surveys, and a case review of nulliparae with dystocia. SETTING: a large maternity unit in the South of England in May-July 1997 inclusive. PARTICIPANTS: nulliparae with dystocia in the first stage of labour who had an otherwise uncomplicated obstetric background. INTERVENTIONS: women in the pilot RCT received one of three management options: labouring in a waterbirth pool, conservative management or augmentation of labour, which is the standard management of women with dystocia condition in the Unit. FINDINGS: it is feasible to conduct an RCT of management of dystocia in the Unit. Seventy per cent (95% confidence interval 47% to 87%) of women approached agreed to participate. Conservative management was the least acceptable option to women and has been dropped from the subsequent trial. The audit provided some idea of possible differences in operative delivery and epidural rates depending on augmentation or not. A sample of 220 women should be large enough to detect moderate changes and will require a 2-year recruitment period. CONCLUSIONS: a subsequent trial is feasible and is now underway. It has the potential to provide information enabling women and practitioners to have a greater choice of care options in the presence of dystocia, or provide a good basis for an even larger trial.

Baths↗
PubMedDate not supplied

[The influence of water immersion on the course of first stage of parturition in primiparous women].

THE AIM: To find whether, and if so to which degree, water immersion may influence the duration of the first stage of labour and to what extent progression of delivery depends on the timing of immersion. MATERIAL AND METHODS: The analysis was conducted for 205 deliveries including 100 in the control group. The following parameters were measured: 1. degree in gaping of the external opening of the uterine cervix during immersion in water; 2. time elapsed between the end of immersion and full gaping of the uterine cervix, 3. course of uterine contraction activity during and after the immersion in water. RESULTS: It was observed that the immersion in water applied to primiparae at any stage of labour, beginning from the 2-cm gaping of the external opening of the uterine cervix, decreased significantly the duration of parturition in comparison to those delivered in a traditional way. In no case the water immersion caused disturbances in the contraction activity of the uterus, instead, it raised both the amplitude and frequency of uterine contractions in a degree proportional to the uterine cervix gaping. CONCLUSIONS: In the authors' opinion the optimal timing for the application of water immersion in the primiparae is determined by a 3-cm gaping of the uterine cervix. An earlier bath at the 2-cm uterine cervix gaping also accelerated the labour but required either repeating of the immersion or a correction of weakened uterine contraction activity by oxytocin.

Adult↗
PubMed1993

Comparison of 0.125% bupivacaine with 0.125% bupivacaine and clonidine as extradural analgesia in the first stage of labour.

We have studied 42 healthy parturients with singleton vertex pregnancies, who were in the first stage of labour and requesting extradural analgesia. They were allocated randomly in a double-blind fashion to receive either 0.125% bupivacaine plain or 0.125% bupivacaine with clonidine 120 micrograms. Efficacy of analgesia was evaluated using linear visual analogue scoring (VAS), sensory block was assessed using bilateral pinprick in the mid-clavicular line and sedation scored on a five-point scale. Maternal and fetal cardiovascular variables were measured every 2 min for 20 min, at 30 min and subsequently at 15-min intervals. The reduction in VAS was greater at all times in the bupivacaine-clonidine group (P < 0.01). The median (range) duration of analgesia was greater in the bupivacaine-clonidine group (114.5 (30-243) min) compared with the bupivacaine group (53 (30-100) min) (P < 0.001). Analgesia was associated with a reduction in arterial pressure in both groups, but there were no between-group differences. Maternal heart rate was less than baseline values at 30-90 min in the bupivacaine-clonidine group only. Sedation was greater in the bupivacaine-clonidine group, especially from 15 to 45 min (P < 0.01). There were no differences in fetal heart rate, mode of delivery or Apgar scores between the two groups.

Adolescent↗
PubMed2004

Randomised controlled trial of labouring in water compared with standard of augmentation for management of dystocia in first stage of labour.

OBJECTIVES: To evaluate the impact of labouring in water during first stage of labour on rates of epidural analgesia and operative delivery in nulliparous women with dystocia. DESIGN: Randomised controlled trial. SETTING: University teaching hospital in southern England. PARTICIPANTS: 99 nulliparous women with dystocia (cervical dilation rate < 1 cm/hour in active labour) at low risk of complications. Interventions Immersion in water in birth pool or standard augmentation for dystocia (amniotomy and intravenous oxytocin). MAIN OUTCOME MEASURES: Primary: epidural analgesia and operative delivery rates. Secondary: augmentation rates with amniotomy and oxytocin, length of labour, maternal and neonatal morbidity including infections, maternal pain score, and maternal satisfaction with care. RESULTS: Women randomised to immersion in water had a lower rate of epidural analgesia than women allocated to augmentation (47% v 66%, relative risk 0.71 (95% confidence interval 0.49 to 1.01), number needed to treat for benefit (NNT) 5). They showed no difference in rates of operative delivery (49% v 50%, 0.98 (0.65 to 1.47), NNT 98), but significantly fewer received augmentation (71% v 96%, 0.74 (0.59 to 0.88), NNT 4) or any form of obstetric intervention (amniotomy, oxytocin, epidural, or operative delivery) (80% v 98%, 0.81 (0.67 to 0.92), NNT 5). More neonates of women in the water group were admitted to the neonatal unit (6 v 0, P = 0.013), but there was no difference in Apgar score, infection rates, or umbilical cord pH. CONCLUSIONS: Labouring in water under midwifery care may be an option for slow progress in labour, reducing the need for obstetric intervention, and offering an alternative pain management strategy.

Analgesia, Epidural↗
PubMed1994

Application of vaginal misoprostol before cervical dilatation to facilitate first-trimester pregnancy interruption.

OBJECTIVE: To study the capacity of vaginal misoprostol to soften the cervix and facilitate cervical dilatation in women undergoing first-trimester pregnancy interruption. METHODS: We performed a double-blind, placebo-controlled study in 100 women opting for voluntary pregnancy interruption. The subjects were randomly allocated to two treatment groups, receiving either 200 micrograms misoprostol or placebo in the posterior vaginal fornix 6 hours before cervical dilatation. We noted the number of women with vaginal bleeding, with chorionic tissue in the vagina, or with no resistance to a Hegar 8 dilator, and recorded the total time in minutes for pregnancy interruption. RESULTS: Vaginal bleeding from the cervix occurred in 70% of the misoprostol group and in 8% of the placebo group (odds ratio 26.83; 95% confidence interval [CI] 9.73-74.00). Almost one-fourth (22%) of the misoprostol-treated women had chorionic tissue in the vagina, compared to one woman (2%) in the placebo group (odds ratio 13.82; 95% CI 2.59-73.61). Cervical dilatation was achieved in 74 and 10% of the misoprostol- and placebo-treated women, respectively (odds ratio 25.62; 95% CI 9.61-68.28). The time required for pregnancy interruption was significantly shorter with misoprostol (P < .004). CONCLUSION: Misoprostol is significantly more effective in facilitating cervical dilatation than is placebo. The average intervention time for pregnancy interruption was reduced by 35%.

Abortion, Induced↗
PubMed2004

A randomized comparison of sublingual and vaginal misoprostol for cervical priming before suction termination of first-trimester pregnancy.

This randomized trial compares the efficacy and side effects of sublingual and vaginal misoprostol for cervical priming before first-trimester pregnancy termination. One-hundred pregnant women between 6 and 12 weeks of gestation opting for termination of pregnancy by suction evacuation were included in this study. The women were randomly allocated into two groups. Group 1 received 400 microg of sublingual misoprostol and group 2 received 400 microg of vaginal misoprostol 2 h prior to suction evacuation. The abortion was carried out by suction evacuation using a Karman's cannula attached to an electrically operated suction machine under intravenous analgesia. Baseline cervical dilatation, duration of the procedure, operative blood loss, side effects and complications were noted in both groups. There was a significant difference between the sublingual and vaginal misoprostol groups with respect to mean cervical dilatation (8.6 mm vs. 6.8 mm, p < 0.05). However, the duration of the procedure (3.03 min vs. 3.16 min) and the amount of blood loss (29 mL vs. 31.2 mL) were not significantly different between the two groups. The women in the sublingual group experienced significantly more shivering and preoperative vaginal bleeding (68% vs. 56%, p < 0.05). None of the women in the two groups had either uterine perforation or excessive hemorrhage. In our study, sublingual misoprostol (400 microg) was significantly more effective in facilitating cervical dilation prior to surgical abortion than vaginal misoprostol.

Abortifacient Agents, Nonsteroidal↗
PubMed2001

[Water birth in the parturients' estimation].

OBJECTIVES: The purpose of the study was to characterise a group of women who decided for under water birth and to show an influence of warm water on their psychosomatic reactions. MATERIALS AND METHODS: The results of the inquiry conducted among 45 women bathed during first stage of normal labour and delivery under water were analysed. The demographic data, water birth knowledge and psychosomatic reactions were studied traditional. The age, education, obstetric history of the women was compared with a group of 45 women who gave birth in a way. RESULTS: The average age of women in labour under water was 25.6 years and no significant difference to control group (25 years) was found. The most common in our research group was secondary education (62%), after that elementary (20%) and university education (18%). Worse educated women were more rarely decided for water birth (20% in research group vs 41% in control; p < 0.05). A midwife was the most important source of information about warm tub bath during delivery, especially among worse educated women (67%). Concerning reactions after entering the pool, in 69% cases decrease of labour pain and in 64% decrease of spasm pains was observed. In 58% cases the time of delivery was advanced, only in 13% it lasted longer after going into the warm tub. Immersion in the pool was sensed in a positive way by all the parturients. The women described appeasement (78%), relaxation (67%), better opportunities for mid-spasm rest (67%). The water tub bath during delivery was estimated good by all of the women. 76% of the group gave 5 points in 1 to 5 scale. As many as 87% of women wish they born another baby in a water. CONCLUSIONS: A midwife has an essential role in information and making a decision of water birth. Entering the pool causes subjective decrease of labour pain and advance of delivery. Women very good estimate birth in water.

Adult↗
PubMed2003

The effect of oral versus vaginal misoprostol on cervical dilatation in first-trimester abortion: a double-blind, randomized study.

OBJECTIVES: To determine the effect of oral versus vaginal misoprostol on cervical dilatation in first-trimester intrauterine evacuation or menstrual regulation (MR). DESIGN AND METHODS: A total of 120 patients were randomly assigned to a double-blind prestudy. Four groups, each consisting of 30 cases, were administered one of four regimens: 200 microg misoprostol orally, 200 microg misoprostol intravaginally, placebo orally, or placebo intravaginally, 10 h before MR, respectively. Age, number of births and abortions, birth methods, date of last delivery and last abortion were recorded. The gestational age was determined by ultrasonography. Prior to MR, data regarding the time of the application of the drug, the presence of placenta in the cervical canal, the degree of cervical dilatation, the duration of MR and patients' complaints were recorded. The MRs were performed by the same physician. The statistical analyses were evaluated with the chi(2) test and Fisher's exact test in the Aegean University Science Faculty Department of Statistics. RESULTS: In the oral misoprostol group, four patients had cervical bleeding and one had intracervical placenta. In the intravaginal misoprostol group, cervical bleeding was observed in seven patients and intracervical placenta was recorded in four cases. Cervical bleeding was observed in one case and intracervical placenta was also observed in one case in the oral placebo group. Cervical dilatation reached 8 mm in seven patients in the oral misoprostol group and in three patients in the intravaginal group, with none in the placebo group. Symptoms such as pelvic pain, headache and nausea were observed in 11 cases in the oral and 14 cases in the vaginal misoprostol groups. CONCLUSIONS: Different methods of misoprostol administration may not be equivalent in terms of efficacy and side-effects. Therefore, we decided to extend the study to include more patients so as to achieve statistically significant results.

Abortifacient Agents, Nonsteroidal↗
PubMedDate not supplied

Effects of narcotic and non-narcotic continuous epidural anesthesia on intrapartum fetal heart rate tracings as measured by computer analysis.

OBJECTIVE: To evaluate the effect of narcotic and non-narcotic continuous epidural anesthesia on intrapartum fetal heart rate (FHR) tracings as measured by computer analysis. METHODS: We studied 37 women with uncomplicated pregnancies at term with reactive FHR tracings. The women were randomized to receive epidural anesthesia with either bupivicaine with fentanyl or bupivicaine alone. One-hour FHR tracings were obtained before epidural anesthesia. Thirty minutes after the initial bolus of the epidural a repeat computer analysis of 60-minute FHR tracing was obtained. Median values are reported for FHR parameters with statistical analysis performed by the Mann-Whitney U and Wilcoxon signed rank tests where appropriate. A power calculation was performed using a power of 90% to determine a required sample size of 28 patients. Statistical significance was set at P < .05. RESULTS: In early first stage of labor, there was no significant difference in pre- and postepidural anesthesia FHR baseline, accelerations of 10 and 15 beats per minute, episodes of high and low variation, and short- and long-term variation when using either narcotic or non-narcotic anesthetic agents. CONCLUSIONS: Thus, the clinician can consider the use of narcotic as well as non-narcotic continuous epidural anesthesia in the dosages used in our study with its attendant advantages without fear of obscuring the fetal heart rate tracing.

Anesthesia, Epidural↗
PubMedDate not supplied

Antibiotic prophylaxis at Cesarean delivery.

OBJECTIVE: Our aim was to compare the efficacy of ampicillin, cefotetan, and ampicillin/sulbactam in the prevention of post-Cesarean endomyometritis. METHODS: Consenting patients undergoing Cesarean delivery at the University of Louisville Hospital were enrolled in a prospective, double-blinded randomization to receive either ampicillin/sulbactam (Group 1), cefotetan (Group 2), or ampicillin (Group 3) single dose antibiotic prophylaxis following umbilical cord clamping. The primary outcome variable was the frequency of endomyometritis in the respective groups. RESULTS: Among 301 randomized patients, outcome data was available for 298 patients. Fourteen patients (4.7%), all of whom underwent non-elective Cesarean delivery, developed endomyometritis. The frequency of endomyometritis was not different among groups: Group 1, 4/101 (4%); Group 2, 4/96 (4.2%); and Group 3, 6/101 (5.9%). Wound infections were infrequently observed 4/298 (1.3%) without significant differences among groups. Stepwise discriminative analysis identified only last cervical dilatation as a significant predictor of endomyometritis (P = 0.006). CONCLUSION: Post-Cesarean endomyometritis occurs infrequently following single dose antibiotic prophylaxis after umbilical cord clamping. An advantage of broader spectrum antibiotics over ampicillin was not demonstrated.

Adult↗
PubMed1980

Investigation of the Urinary excretion of pethidine and five of its metabolites in man using selected ion monitoring.

The urinary excretion in man of pethidine and five of its metabolites (norpethidine, pethidinic acid, norpethidinic acid, p-hydroxypethidine and pethidine N-oxide) after a single intramuscular dose has been investigated using analytical procedures based on selected ion monitoring. New methods for the determination of p-hydroxypethidine and pethidine N-oxide have been developed, and the selectivity and sensitivity of the procedures are discussed. Only some 5% of the administered dose was excreted as unchanged pethidine. The mean urinary excretion of norpethidine was 16.4%. Pethidinic acid and norpethidinic acid constituted the major fraction of the dose excreted in urine. The total excretion of pethidinic acid and norpethidinic acid was 41.7 and 23.2%, respectively. Pethidine N-oxide constituted less than 0.5% of the excreted amount, and p-hydroxypethidine could only be detected in the urine of two of the patients. A mean total recovery of about 90% of the dose was found in urine as pethidine and the five metabolites.

Adult↗
PubMed2004

Sonographic imaging of cervical scars after Cesarean section.

OBJECTIVE: To investigate whether uterine contractions at the time of a Cesarean section have an impact on future presence and location of a cervical Cesarean scar. METHODS: A targeted transvaginal ultrasound examination of the fetus, uterus and cervix was done in 2973 consecutive women at 14-16 weeks' gestation. The sonographer was blinded to the women's previous obstetric histories. The presence and location of a sonographic cervical hypoechogenic line, which probably represented a Cesarean scar, was recorded. RESULTS: There were 180 women with a previous Cesarean section performed before the start of uterine contractions and 173 with a Cesarean section performed during contractions in labor. The cervical hypoechogenic line was more common in sections performed during contractions (75.7% vs. 52.7%; P < 0.001) and was more distally located from the internal os (17.9 +/- 9.4 vs. 14.6 +/- 9.1 mm; P = 0.01). A hypoechogenic line was observed in 21/2620 women without a previous Cesarean section, representing a false-positive rate of 0.8%. CONCLUSION: Cesarean sections, especially those done during uterine contractions, are actually performed through cervical tissue. This finding is in agreement with the physiological process of cervical effacement during contractions.

Cervix Uteri↗