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      Labour analgesia: Recent advances

      review-article

      Indian Journal of Anaesthesia

      Medknow Publications

      Ambulatory epidurals, labour analgesia, recent advances

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          Abstract

          Advances in the field of labour analgesia have tread a long journey from the days of ether and chloroform in 1847 to the present day practice of comprehensive programme of labour pain management using evidence-based medicine. Newer advances include introduction of newer techniques like combined spinal epidurals, low-dose epidurals facilitating ambulation, pharmacological advances like introduction of remifentanil for patient-controlled intravenous analgesia, introduction of newer local anaesthetics and adjuvants like ropivacaine, levobupivacaine, sufentanil, clonidine and neostigmine, use of inhalational agents like sevoflourane for patient-controlled inhalational analgesia using special vaporizers, all have revolutionized the practice of pain management in labouring parturients. Technological advances like use of ultrasound to localize epidural space in difficult cases minimizes failed epidurals and introduction of novel drug delivery modalities like patient-controlled epidural analgesia (PCEA) pumps and computer-integrated drug delivery pumps have improved the overall maternal satisfaction rate and have enabled us to customize a suitable analgesic regimen for each parturient. Recent randomized controlled trials and Cochrane studies have concluded that the association of epidurals with increased caesarean section and long-term backache remains only a myth. Studies have also shown that the newer, low-dose regimes do not have a statistically significant impact on the duration of labour and breast feeding and also that these reduce the instrumental delivery rates thus improving maternal and foetal safety. Advances in medical technology like use of ultrasound for localizing epidural space have helped the clinicians to minimize the failure rates, and many novel drug delivery modalities like PCEA and computer-integrated PCEA have contributed to the overall maternal satisfaction and safety.

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          Most cited references52

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          The risk of cesarean delivery with neuraxial analgesia given early versus late in labor.

          Epidural analgesia initiated early in labor (when the cervix is less than 4.0 cm dilated) has been associated with an increased risk of cesarean delivery. It is unclear, however, whether this increase in risk is due to the analgesia or is attributable to other factors. We conducted a randomized trial of 750 nulliparous women at term who were in spontaneous labor or had spontaneous rupture of the membranes and who had a cervical dilatation of less than 4.0 cm. Women were randomly assigned to receive intrathecal fentanyl or systemic hydromorphone at the first request for analgesia. Epidural analgesia was initiated in the intrathecal group at the second request for analgesia and in the systemic group at a cervical dilatation of 4.0 cm or greater or at the third request for analgesia. The primary outcome was the rate of cesarean delivery. The rate of cesarean delivery was not significantly different between the groups (17.8 percent after intrathecal analgesia vs. 20.7 percent after systemic analgesia; 95 percent confidence interval for the difference, -9.0 to 3.0 percentage points; P=0.31). The median time from the initiation of analgesia to complete dilatation was significantly shorter after intrathecal analgesia than after systemic analgesia (295 minutes vs. 385 minutes, P<0.001), as was the time to vaginal delivery (398 minutes vs. 479 minutes, P<0.001). Pain scores after the first intervention were significantly lower after intrathecal analgesia than after systemic analgesia (2 vs. 6 on a 0-to-10 scale, P<0.001). The incidence of one-minute Apgar scores below 7 was significantly higher after systemic analgesia (24.0 percent vs. 16.7 percent, P=0.01). Neuraxial analgesia in early labor did not increase the rate of cesarean delivery, and it provided better analgesia and resulted in a shorter duration of labor than systemic analgesia. Copyright 2005 Massachusetts Medical Society.
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            The effects of epidural analgesia on labor, maternal, and neonatal outcomes: a systematic review.

            Mothers given an epidural rather than parenteral opioid labor analgesia report less pain and are more satisfied with their pain relief. Analgesic method does not affect fetal oxygenation, neonatal pH, or 5-minute Apgar scores; however, neonates whose mothers received parenteral opioids require naloxone and have low 1-minute Apgar scores more frequently than do neonates whose mothers received epidural analgesia. Epidural labor analgesia does not affect the incidence of cesarean delivery, instrumented vaginal delivery for dystocia, or new-onset long-term back pain. Epidural analgesia is associated with longer second-stage labor, more frequent oxytocin augmentation, hypotension, and maternal fever (particularly among women who shiver) but not with longer first-stage labor. Analgesic method does not affect lactation success. Epidural use and urinary incontinence are associated immediately postpartum but not at 3 or 12 months. The mechanisms of these unintended effects need to be determined to improve epidural labor analgesia.
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              Effect of low-dose mobile versus traditional epidural techniques on mode of delivery: a randomised controlled trial.

              (2001)
              Epidural analgesia is the most effective labour pain relief but is associated with increased rates of instrumental vaginal delivery and other effects, which might be related to the poor motor function associated with traditional epidural. New techniques that preserve motor function could reduce obstetric intervention. We did a randomised controlled trial to compare low-dose combined spinal epidural and low-dose infusion (mobile) techniques with traditional epidural technique. Between Feb 1, 1999, and April 30, 2000, we randomly assigned 1054 nulliparous women requesting epidural pain relief to traditional (n=353), low-dose combined spinal epidural (n=351), or low-dose infusion epidural (n=350). Primary outcome was mode of delivery, and secondary outcomes were progress of labour, efficacy of procedure, and effect on neonates. We obtained data during labour and interviewed women postnatally. The normal vaginal delivery rate was 35.1% in the traditional epidural group, 42.7% in the low-dose combined spinal group (odds ratio 1.38 [95% CI 1.01-1.89]; p=0.04); and 42.9% in the low-dose infusion group (1.39 [1.01-1.90]; p=0.04). These differences were accounted for by a reduction in instrumental vaginal delivery. Overall, 5 min APGAR scores of 7 or less were more frequent with low-dose technique. High-level resuscitation was more frequent in the low-dose infusion group. The use of low-dose epidural techniques for labour analgesia has benefits for delivery outcome. Continued routine use of traditional epidurals might not be justified.
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                Author and article information

                Journal
                Indian J Anaesth
                IJA
                Indian Journal of Anaesthesia
                Medknow Publications (India )
                0019-5049
                0976-2817
                Sep-Oct 2010
                : 54
                : 5
                : 400-408
                Affiliations
                Department of Anaesthesia, Pain and Critical Care, Fernandez Hospital (Hospital for Women and Newborns) and Prerna Anaesthesia and Critical Care Services Pvt. Ltd., Hyderabad - 500 001, India
                Author notes
                Address for correspondence: Dr. Sunil T Pandya, 2B, Subhodaya Apartments, Bogulkunta, Hyderabad - 500 001, AP, India. E-mail: suniltp05@ 123456gmail.com
                Article
                IJA-54-400
                10.4103/0019-5049.71033
                2991649
                21189877
                0e3d8c71-98e2-4089-997d-ba79f2b902be
                © Indian Journal of Anaesthesia

                This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

                Categories
                Review Article

                Anesthesiology & Pain management

                ambulatory epidurals, labour analgesia, recent advances

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