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PubMedDate not supplied

Subarachnoid morphine and fentanyl for labor analgesia. Efficacy and adverse effects.

BACKGROUND AND OBJECTIVES: The study was designed to compare analgesic efficacy and associated adverse effects between a group of parturients receiving subarachnoid opioids via the combined spinal-epidural (CSE) technique with a group receiving epidural analgesia alone for labor. METHODS: The authors studied 59 healthy parturients admitted for labor and delivery. Group 1 consisted of 26 consecutive patients who received the CSE technique, initially receiving subarachnoid morphine sulfate 0.25 mg, and fentanyl 25 micrograms, for labor analgesia. If patients requested additional analgesia, epidural analgesia was initiated. Group 2 was comprised of 33 consecutive patients who received conventional epidural analgesia. All patients were monitored for the occurrence and treatment of peripartum nausea and vomiting (N/V), pruritus, postdural puncture headache, and respiratory depression. RESULTS: Additional analgesia was requested by 20/26 (76%) patients in group 1. Group 1 reported more N/V (50% versus 15%, P = .01) and required more therapy for N/V (31% versus 0%, P < .01) than group 2. Furthermore, group 1 reported having more pruritus (50% versus 3%, P < .01), and required more treatment for pruritus (35% versus 3%, P < .01), than group 2. No patient developed significant respiratory depression. Only one patient in group 1 developed a postdural puncture headache, following unintentional dural puncture with the 18 gauge Tuohy needle. CONCLUSIONS: The combination of subarachnoid morphine 0.25 mg and fentanyl 25 micrograms, when used for labor analgesia as part of the CSE technique, was associated with a higher incidence of clinically significant nausea and vomiting and pruritus, compared to conventional epidural anesthesia. Furthermore, the combination of subarachnoid morphine and fentanyl proved ineffective in providing adequate pain relief for the duration of labor and delivery for the majority of patients. The authors recommend that subarachnoid morphine and fentanyl serve a limited role in the treatment of labor pain.

Adult↗
PubMed1993

[Comparison of Doppler ultrasound assessment of utero-placento-fetal perfusion in normal pregnancies and in those with threatened premature labor].

The aim this study to compare perfusion parameters, measured by Doppler sonography, between normal pregnancies and pregnancies with symptoms of preterm labor. The patient collective comprised of 3 groups: 62 normal pregnancies (group 1), 23 preterm labor before tocolysis (group 2) and 114 preterm labor up to 48 hours under tocolysis (group 3). In each case pulsatility index was measured in the uterine artery on the placental side and non-placental side, umbilical artery, fetal descending aorta and middle cerebral artery. In the contrary to patients in group 1, patients in group 2 and 3 showed significantly elevated PI values in uterine artery placental side and non-placental side, respectively. The median of PI for both uterine arteries in both groups was significantly higher compared to that of group 1. However, 1/3 of patients with preterm labor showed pathologic uterine perfusion before or during tocolysis. The values of PI in umbilical artery, fetal descending aorta and middle cerebral artery did not reveal significant difference in all group. Nevertheless, 30% of pregnancies with preterm labor have pathological perfusion in the fetal descending aorta. We conclude that some patients with symptoms of preterm labor have pathological perfusion in uterine arteries and fetal descending aorta not induced by uterine contractions. We believe that the complex assessment of uterine perfusion should include the median PI value of both uterine arteries in order to have a reliable information. A short-term intravenous tocolysis with betamimetics does not seem to have a positive influence on the hemodynamic insufficiency.

Adult↗
PubMed1996

Effect of maternal labor and mode of delivery on neutrophil actin response to N-formylmethionyl-leucyl-phenylalanine in healthy neonates.

Diminished actin response to N-formyl-methionyl-leucyl-phenylalanine (FMLP) has been used to explain the impaired chemotaxis of neonatal neutrophils, but the effect of labor on this response has not been evaluated before. Therefore, we tested the hypothesis that labor stress may have an effect on actin response of cord blood neutrophils to FMLP. This response is compared by phallacidin stain of neutrophil F-actin and flow cytometry analysis among 3 groups of healthy neonates: group I, 16 vaginally delivered neonates; group II, 16 neonates delivered by elective cesarean section without labor; and group III, 16 neonates delivered by cesarean section after labor. In the group III, 10 infants were delivered by an emergency cesarean section because of fetal heart rate deceleration indicating fetal distress (one minute Apgar score < 7 in 5 cases [50%]), and the other 6 infants were delivered because of failure of progression of labor (one minute Apgar score < 7 in 2 cases [33.3%]). Stimulated relative F-actin content of neutrophils in group III was increased compared with groups I and II. There was no such difference between neutrophils from infants of groups I and II. The results of this study indicate that fetal distress may enhance neutrophil actin response to FMLP, while labor or mode of delivery might not have such effect.

Actins↗
PubMed1997

Intrathecal narcotics for labor analgesia.

Intrathecal narcotics are a relatively recent addition to the list of analgesic options that are available for the management of labor pain. Pain during the first stage of labor is related to repetitive uterine contractions and resultant cervical dilatation, while pain during the second stage is due to stretching of the perineum. Traditionally, continuous epidural analgesia has been used as the reference standard for providing comfort during labor. Intrathecal narcotics represent a safe and effective alternative that provides significant, rapid relief of labor pain during the first stage of labor. The drugs most often used for intrathecal administration include sufentanil, fentanyl, meperidine and morphine. Use of intrathecal narcotics does not significantly affect the natural progression of labor, and no adverse fetal outcomes have been reported.

Analgesia, Obstetrical↗
PubMedDate not supplied

[Cytokine concentrations and expression of adhesion molecules in the lower uterine segment during parturition at term: relation to cervical dilatation and duration of labor].

OBJECTIVE: To determine the concentrations of tumor necrosis factor (TNF)alpha, interleukin (IL)beta, IL-6 and IL-8 and the expression of endothelial leukocyte adhesion molecule-1 (ELAM-1) and vascular cell adhesion molecule-1 (VCAM-1) in the lower uterine segment during parturition at term and to investigate correlations with the stage of cervical dilatation and with the duration of labor. PATIENTS AND METHODS: Biopsy specimens were taken from the lower uterine segment of 59 women undergoing non-elective cesarean sectin at term at different stages of cervical dilatation (< 2 cm, n = 17; 2-3 cm, n = 12; 4-6 cm, n = 13; > 6 cm, n = 17) after varying length of the time in labor (1-6 h, n = 18; > 6-12 h, n = 16; > 12-24 h, n = 15; > 24 h, n = 10). The concentrations of TNF alpha, IL-1 beta, IL-6 and IL-8 in protein extracts of these specimens were determined by enzyme linked immunosorbent assays and the expression of ELAM-1 and VCAM-1 was studied by immunohistochemistry. Staining was considered negative if < 5% of the endothelial cells were stained and positive if > or = 5% were stained. RESULTS: At < 2 cm dilated cervix the median concentrations of TNF alpha, IL-1 beta, IL-6 and IL-8 were 8.0 pg/mg total protein (TP), 1.3 pg/mg TP, 12.6 pg/mg TP and 17.2 pg/mg TP, respectively. At 4-6 cm dilatation the median concentrations were increased (TNF alpha: 22.2 pg/mg TP [P = 0.05], IL-1 beta: 22.2 pg/mg TP [P < 0.05], IL-6: 1226 pg/mg TP [P < 0.05], IL-8: 2081 mg/mg TP [P < 0.05]). At > 6 cm dilatation no further increase was observed. The expression of ELAM-1 and VCAM-1 was significantly greater at > 6 cm dilatation than < 2 cm dilatation (P < 0.001 and 0.05, respectively). With increasing duration of labor, the concentrations of IL-1 beta, IL-6 and IL-8 (but not of TNF alpha) increased and were significantly higher at > 6 cm dilatation than at < 2 cm (P < 0.05). Expression of ELAM-1 and VCAM-1 did not vary with duration of labor. CONCLUSIONS: These first investigations of cytokines and cell adhesion molecules in the lower uterine segment at both different stages of cervical dilatation and different duration of labor support the decisive role of cytokines for normal cervical dilatation. Local changes in the lower uterine segment independent from the effects of labor (e.g. increase of endothelial adhesivity) seem to be of special importance in this process.

Cell Adhesion Molecules↗
PubMed1998

Acute pain and use of local anesthesia: tooth drilling and childbirth labor pain beliefs among Anglo-Americans, Chinese, and Scandinavians.

Differences in ethnic beliefs about the perceived need for local anesthesia for tooth drilling and childbirth labor were surveyed among Anglo-Americans, Mandarin Chinese, and Scandinavians (89 dentists and 251 patients) matched for age, gender, and occupation. Subjects matched survey questionnaire items selected from previously reported interview results to estimate (a) their beliefs about the possible use of anesthetic for tooth drilling and labor pain compared with other possible remedies and (b) the choice of pain descriptors associated with the use of nonuse of anesthetic, including descriptions of injection pain. Multidimensional scaling, Gamma, and Chi-square statistics as well as odds ratios and Spearman's correlations were employed in the analysis. Seventy-seven percent of American informants reported the use of anesthetics as possible remedies for drilling and 51% reported the use of anesthetics for labor pain compared with 34% that reported the use of anesthetics among Chinese for drilling and 5% for labor pain and 70% among Scandinavians for drilling and 35% for labor pain. Most Americans and Swedes described tooth-drilling sensations as sharp, most Chinese used descriptors such as sharp and "sourish" (suan), and most Danes used words like shooting (jagende). By rank, Americans described labor pain as cramping, sharp, and excruciating, Chinese used words like sharp, intermittent, and horrible, Danes used words like shooting, tiring, and sharp, and Swedes used words like tiring, "good," yet horrible. Preferred pain descriptors for drilling, birth, and injection pains varied significantly by ethnicity. Results corroborated conclusions of a qualitative study about pain beliefs in relation to perceived needs for anesthetic in tooth drilling. Samples used to obtain the results were estimated to approach qualitative representativity for these urban ethnic groups.

Adult↗
PubMed1998

The effect of epidural analgesia on the second stage of labor.

A retrospective review of 202 randomly selected records of parturient labors examined the relationship between cervical dilation at epidural analgesia administration and length of the second stage of labor. The epidural group received bupivacaine 0.11% or 0.125% with sufentanil 1 to 2 micrograms/mL using a Bard Patient Controlled Anesthesia II pump. Labor management and outcomes were compared with a nonepidural group who chose unmedicated childbirth, intravenous narcotics, or pudendal block. A significant inverse correlation was found between cervical dilation at epidural administration and second-stage length in labors that did not use oxytocin. However, linear regression explained only 13.5% of the variance, leaving 86.5% unexplained. In labors in the epidural group that used oxytocin, cervical dilation at epidural administration was not correlated with second-stage length. The epidural group experienced a significantly longer mean length of the second stage. Labors in the epidural group were 3.5 times more likely to have oxytocin induction or augmentation and 4.5 times more likely to experience instrument-assisted delivery. There were no significant differences in Apgar scores between the two infant groups.

Adjuvants, Anesthesia↗
PubMed1998

Epidural analgesia during labor.

Epidural analgesia is a commonly employed technique of providing pain relief during labor. The number of parturients given intrapartum epidural analgesia is reported to be over 50 percent at many institutions in the United States. The procedure has few contraindications, the primary ones being patient refusal, maternal hemorrhage and coagulopathy. Induction of epidural analgesia in early labor remains controversial. However, many physicians induce analgesia as soon as the diagnosis of active labor has been established and the patient has requested pain relief. The most common complications occurring with epidural analgesia are maternal hypotension and postdural puncture headache. Retrospective studies have demonstrated an association between epidural analgesia and increases in duration of labor, instrumental vaginal delivery and cesarean section for labor. However, several recent prospective studies have concluded that epidural analgesia does not adversely affect the progress of labor or increase the rate of cesarean section. These remain controversial issues among practicing physicians.

Analgesia, Epidural↗
PubMed1994

Intrapartum fetal pulse oximetry: fetal oxygen saturation trends during labor and relation to delivery outcome.

OBJECTIVES: Our purpose was to study fetal arterial oxygen saturation trends by continuous pulse oximetry during labor in subjects with normal and abnormal delivery outcomes. STUDY DESIGN: Continuous fetal arterial oxygen saturation was measured during labor with a noninvasive reflectance pulse oximeter designed for fetal application. Averaged arterial oxygen saturation values were compared between stage 1 and stage 2 of labor, with stage 1 further subdivided into early (< or = 4 cm), middle (5 to 7 cm), and late (8 to 10 cm) phases. Delivery outcome was considered to be abnormal for any of the following conditions: gestational age < 37 weeks, maternal oxygen administration, delivery by cesarean section, 5-minute Apgar score < 7, umbilical artery pH < 7.10, birth weight < 2500 gm, or newborn intensive care unit admission. RESULTS: A total of 291 subjects were studied: 142 in Provo, 90 in Nijmegen and 59 in San Francisco. Subjects with delivery complications (n = 125) were evaluated separately from those with normal delivery outcomes (n = 160). Fetal arterial oxygen saturation was 58% +/- 10% (mean +/- SD) during the cumulative period of study for the normal-outcome group. A significant decrease (paired t test, p < 0.001) in fetal arterial oxygen saturation occurred from stage 1 (59% +/- 10%) to stage 2 (53% +/- 10%) labor. When stage 1 was subdivided into early (< or = 4 cm), middle (5 to 7 cm), and late (8 to 10 cm) phases, a gradual decreasing trend in fetal arterial oxygen saturation was observed: 62% +/- 9%, 60% +/- 11%, and 58% +/- 10%. CONCLUSIONS: With the use of reflectance pulse oximetry, a statistically significant decrease in fetal arterial oxygen saturation was observed during labor in women with normal and abnormal delivery outcomes.

Adult↗
PubMed1995

Amniotic fluid interleukin-6: correlation with upper genital tract microbial colonization and gestational age in women delivered after spontaneous labor versus indicated delivery.

OBJECTIVE: Our purpose was to determine whether amniotic fluid interleukin-6 is increased and inversely proportional to gestational age in women with chorioamnion colonization and spontaneous labor versus women delivered for medical or obstetric indications. STUDY DESIGN: The chorioamnion and amniotic fluid were cultured at cesarean delivery for aerobic and anaerobic bacteria, fungi, mycoplasmas, Chlamydia trachomatis and Trichomonas vaginalis in 269 women with singleton gestations with intact membranes. The amniotic fluid interleukin-6 concentration was also determined. RESULTS: Amniotic fluid interleukin-6 levels were (1) higher in women with spontaneous labor versus those with indicated deliveries (15.8 +/- 5.0 vs 2.2 +/- 0.2 ng/ml, p = 0.01), (2) inversely proportional to gestational age in women with spontaneous labor (< 34 weeks: 47.4 +/- 18.0 ng/ml vs > or = 34 weeks: 8.7 +/- 4.1 ng/ml, p = 0.001) but not in women with indicated deliveries (1.5 +/- 0.4 vs 2.4 +/- 0.3 ng/ml), (3) higher in women with a positive versus a negative chorioamnion (15.1 +/- 4.8 vs 3.0 +/- 0.8 ng/ml, p < 0.001) or amniotic fluid (17.4 +/- 7.7 vs 3.8 +/- 0.9 ng/ml, p < 0.001) culture, and (4) higher in women with a negative amniotic fluid but positive chorioamnion culture compared with women in whom both cultures were negative (10.0 +/- 4.4 vs 3.0 +/- 0.9 ng/ml, p = 0.002). CONCLUSIONS: Amniotic fluid interleukin-6 levels are (1) higher and inversely proportional to gestational age in women with intact membranes and spontaneous labor versus indicated deliveries, (2) higher in women with one or more microorganisms in the chorioamnion or amniotic fluid, and (3) reflective of chorioamnion microbial colonization, even when the amniotic fluid culture is negative, and may be a useful clinical marker for infection-mediated preterm labor.

Amnion↗
PubMed1995

Are labor abnormalities more common in shoulder dystocia?

OBJECTIVE: Our objective was to determine the association between labor abnormalities and shoulder dystocia. STUDY DESIGN: All consecutive cases of shoulder dystocia from January 1986 to August 1994 were reviewed (n = 276). For purposes of comparison a control group of vaginally delivered patients was randomly selected in a 2:1 ratio (n = 600). Charts were reviewed for demographic information, labor and delivery events, and neonatal outcome. RESULTS: Labor abnormalities were comparable in the shoulder dystocia and control groups, both in the active phase and in the second stage. When patients with diabetes and those with macrosomic infants were analyzed separately, no significant differences in labor abnormalities were identified. The rate of operative vaginal delivery was significantly higher in the shoulder group, and one third of the operative deliveries were midpelvic. In addition, the induction rate was higher in the shoulder group. CONCLUSIONS: Our data suggest that labor abnormalities may not serve as clinical predictors for subsequent development of shoulder dystocia, thus emphasizing the unpredictability of this condition.

Adult↗
PubMed1987

Amniotic fluid prostaglandin D2 in spontaneous and augmented labor.

Prostaglandin D2 (PGD2) was quantified in human amniotic fluid obtained from women in various phases of the first stage of spontaneous labor, augmented labor, and induced labor. PGD2 increased significantly only in late labor in the spontaneous and augmented labor groups.

Amniotic Fluid↗
PubMed1992

Predictive value of pelvic scores for induction of labor by local PGE2.

The predictive value of pelvic scores, parity, age and gestational age for induction of labor by local prostaglandin-E2 (PGE2) was examined in 336 women attempting induction of labor by intracervical or vaginal PGE2. The patient characteristics were correlated to: (1) vaginal delivery within 48 h, (2) the period from induction to onset of labor (latency period), and (3) the duration of labor. The Bishop score (P < 0.01) and even more the Lange score (P < 0.0001) were significantly inversely correlated to both latency period and induction-delivery period. This was caused by cervical dilatation (P < 0.001), fetal station (P < 0.05) and cervical length (P < 0.05), whereas position and consistency of the cervix were of no importance. All three periods studied were significantly (P < 0.0001) shorter in parous women. In primiparous women, gestational age was of no importance for the latency period; however, higher gestational age was associated with longer labor (P < 0.001). We conclude that the predictive value of pelvic scores on induction hardly differs using local PGE2 compared to conventional methods; furthermore, the Bishop score should be substituted, disregarding position and consistency of the cervix, but putting more weight to cervical dilatation. A new pelvic score is proposed.

Adult↗
PubMed2004

Severe maternal bradycardia and asystole after combined spinal-epidural labor analgesia in a morbidly obese parturient.

Serious maternal bradycardia and asystole in laboring parturients after combined spinal-epidural labor analgesia are rare. We report such a case in a morbidly obese laboring parturient after receiving combined spinal-epidural labor analgesia. The differential diagnosis, risk factors, potential contributing factors, and the successful management of the complications with our positive patient outcome are discussed. Even with the low dose of neuraxial drugs commonly administered in combined spinal-epidural labor analgesia, this case underscores the importance of vigilance, frequent monitoring, proper positioning, and rapid resuscitation with escalating doses of ephedrine, atropine, and epinephrine, all of which are essential in the presence of bradycardia or asystole in these patients.

Adult↗
PubMed1999

Fetal heart rate patterns in term labor vary with sex, gestational age, epidural analgesia, and fetal weight.

OBJECTIVES: Our purpose was to analyze the previously unreported effect of fetal sex on the fetal heart rate in labor and to measure its magnitude in relation to the effects of other independent clinical variables. STUDY DESIGN: The last hour of the intrapartum heart rates of 1884 term singleton fetuses collected during routine clinical monitoring over 19 months in Oxford, United Kingdom, was analyzed by computerized techniques. The records were selected for completeness and continuity until within at least 30 minutes of delivery. A subset of records from earlier in labor and a separate archive of antepartum normal term records were also examined. RESULTS: Female fetuses had significantly faster heart rates than male fetuses (P <.0001). Epidural analgesia, weight percentile (adjusted for age and sex), parity, the duration of first and second stages of labor, and a fall in umbilical arterial blood pH at birth also independently modulated the fetal heart rate (all P <.0001). The effects of these independent variables on heart rate were additive, the most important being epidural analgesia as a cause of tachycardia. The effect of fetal sex was less in the first stage, 6 to 7 hours before delivery, and was not present before the onset of labor (in another 552 pregnancies at 37 to 38 weeks). CONCLUSIONS: The fetal heart rate response of female fetuses to normal labor differs from that of male fetuses. Computerized numeric analysis of intrapartum fetal heart rate patterns will need to take into account the multiple factors that influence the fetal heart rate to identify precisely which patterns predict clinical outcome.

Adult↗
PubMed2005

Outcomes of women presenting in active versus latent phase of spontaneous labor.

OBJECTIVE: To evaluate outcome differences between women presenting in latent and active labor. METHODS: We evaluated all low-risk women with term, singleton, vertex gestations who presented in active phase or latent phase labor at MetroHealth Medical Center from January 1993 to June 2001. Baseline characteristics were compared. Labor outcomes were assessed by logistic regression, controlling for parity. RESULTS: A total of 6,121 active phase and 2,697 latent phase women met the study criteria. More latent phase women were nulliparous (51 compared with 28%). Latent phase women had more cesarean deliveries (nulliparas 14.2% compared with 6.7%, multiparas 3.1% compared with 1.4%). Controlling for parity, latent phase women had more active phase arrest (odds ratio [OR] 2.2), oxytocin use (OR 2.3), scalp pH performed (OR 2.2), intrauterine pressure catheter placed (OR = 2.2), fetal scalp electrocardiogram monitoring (OR = 1.7), and amnionitis (OR 2.7) (P < .001 for each). CONCLUSION: It is uncertain whether inherent labor abnormalities resulted in latent phase presentation and subsequent physician intervention or early presentation and subsequent physician intervention are the cause of labor abnormalities.

Cesarean Section↗
PubMed2005

Effect of fetal position on second-stage duration and labor outcome.

OBJECTIVE: To evaluate the effect of fetal position on 1) second-stage labor duration and 2) indicators of maternal and neonatal morbidity. METHODS: A retrospective cohort study was conducted using a database from a previously reported randomized clinical trial. The data set includes 210 women with the fetus in a posterior position, 200 women with the fetus in a transverse position, and 1,198 women with the fetus in an anterior position. Mean durations of the second stage of labor for different fetal positions were compared using Tukey studentized test. A multivariate logistic regression model was performed to examine the determinants of prolonged second-stage duration (>or= 3 hours). Kaplan-Meier survival curves were used to graph and compare the duration of the second stage of labor for spontaneous delivery according to the fetal position at full dilatation and study group. RESULTS: Fetal malposition at full dilatation was associated with a significantly increased risk of instrumental vaginal delivery, cesarean delivery, oxytocin administration before full cervical dilatation, episiotomy, severe perineal laceration, and maternal blood loss of more than 500 mL (all P values < .01). Compared with the occiput anterior positions, there were significant differences in the duration of the second stage of labor, with a mean of 3.1 hours (95% confidence interval [CI] 3.0-3.2) for occiput anterior positions, 3.6 hours (95% CI 3.3-3.9) for occiput transverse positions (P < .05), and 3.8 hours (95% CI 3.5-4.1) for occiput posterior positions (P < .05) in the delayed pushing group. For the early pushing group, means were 2.2 hours (95% CI 2.1-2.3) for occiput anterior positions, 2.5 hours (95% CI 2.3-2.8) for occiput transverse positions (P < .05), and 3.0 hours (95% CI 2.7-3.3) for occiput posterior positions (P < .05). CONCLUSION: Fetal malposition at full dilatation results in a higher risk of prolonged second stage of labor and increases maternal morbidity indicators. LEVEL OF EVIDENCE: II-2.

Adolescent↗
PubMed1979

Spontaneous labor and elective induction--a prospective randomized study. I. Effects on mother and fetus.

In a prospective randomized study spontaneous and oxytocin induced labor "for convenience" have been compared with respect to uterine activity, duration of labor, the condition of the fetus and the newborn infant. The study consists of 84 normal patients, of whom 43 were induced at full term by amniotomy and oxytocin infusion using the Cardiff Infusion System Mark II; 41 patients served as controls. No difference in maternal age, number of previous pregnancies and pelvic score one week before the day of delivery were found between the groups. The following parameters were calculated: duration of labor, uterine activity, amount of bleeding in the third stage of labor, number of early and late decelerations as well as number of episodes of bradycardia in the CTG-recordings, birth weight, Apgar score one and five minutes post-delivery and blood gases in mother and child 60 seconds after delivery. No significant differences between the two groups were found. It is concluded that there are no increased risks to mother or fetus compared to normal labor provided that there is cephalic presentation and normal pregnancy, careful selection with respect to the length of pregnancy and the condition of the cervix and that the Cardiff infusion system is used with intrauterine pressure recording and continuous fetal heart monitoring.

Adolescent↗