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      Advances in labor analgesia

      review-article
      International Journal of Women's Health
      Dove Medical Press
      labor analgesia, neuraxial analgesia, epidural analgesia, childbirth pain

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          Abstract

          The pain of childbirth is arguably the most severe pain most women will endure in their lifetimes. The pain of the early first stage of labor arises from dilation of the lower uterine segment and cervix. Pain from the late first stage and second stage of labor arises from descent of the fetus in the birth canal, resulting in distension and tearing of tissues in the vagina and perineum. An array of regional nerve blocks, systemic analgesic, and nonpharmacologic techniques are currently used for labor analgesia. Nonpharmacologic methods are commonly used, but the effectiveness of these techniques generally lacks rigorous scientific study. Continuous labor support has been shown to decrease the use of pharmacologic analgesia and shorten labor. Intradermal water injections decrease back labor pain. Neuraxial labor analgesia (most commonly epidural or combined spinal-epidural) is the most effective method of pain relief during childbirth, and the only method that provides complete analgesia without maternal or fetal sedation. Current techniques commonly combine a low dose of local anesthetic (bupivacaine or ropivacaine) with a lipid soluble opioid (fentanyl or sufentanil). Neuraxial analgesia does not increase the rate of cesarean delivery compared to systemic opioid analgesia; however, dense neuraxial analgesia may increase the risk of instrumental vaginal delivery.

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          Most cited references123

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          Cardiac arrest following regional anesthesia with etidocaine or bupivacaine.

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            PDPH is a common complication of neuraxial blockade in parturients: a meta-analysis of obstetrical studies.

            Postdural puncture headache (PDPH) is an iatrogenic complication of neuraxial blockade. We systematically reviewed the literature on parturients to determine the frequency, onset, and duration of PDPH. Citations on PDPH in the obstetrical population were identified by computerized searches, citation review, and hand searches of abstracts and conference proceedings. Citations were included if they contained extractable data on frequency, onset, or duration of PDPH. Using meta-analysis, we calculated pooled estimates of the frequency of accidental dural puncture for epidural needles and pooled estimates of the frequencies of PDPH for epidural and spinal needles. Parturients have approximately a 1.5% [95% confidence interval (CI) 1.5% to 1.5%) risk of accidental dural puncture with epidural insertion. Of these, approximately half (52.1%; 95% CI, 51.4% to 52.8%) will result in PDPH. The risk of PDPH from spinal needles diminishes with small diameter, atraumatic needles, but is still appreciable (Whitacre 27-gauge needle 1.7%; 95% CI, 1.6% to 1.8%). PDPH occurs as early as one day and as late as seven days after dural puncture and lasts 12 hr to seven days. PDPH is a common complication for parturients undergoing neuraxial blockade.
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              Incidence and characteristics of failures in obstetric neuraxial analgesia and anesthesia: a retrospective analysis of 19,259 deliveries.

              A retrospective analysis was performed on 19,259 deliveries that occurred in our institution from January 2000 to December 2002. Anesthesia records and quality assurance data sheets were reviewed for the characteristics and failure rates of neuraxial blocks performed for labor analgesia and anesthesia. The neuraxial labor analgesia rate was 75% and the overall failure rate was 12%. After adequate analgesia from initial placement, 6.8% of patients had subsequent inadequate analgesia during labor that required epidural catheter replacement. Ultimately 98.8% of all patients received adequate analgesia even though 1.5% of patients had multiple replacements. Six percent of epidural catheters had initial intravenous placement but 46% were made functional by simple manipulations without higher subsequent failure. Unintended dural puncture occurred in 1.2% of labor neuraxial analgesia. The incidences of overall failure, intravenous epidural catheter, wet tap, inadequate epidural analgesia and catheter replacement were lower in patients receiving combined spinal-epidural versus epidural analgesia. For cesarean section, 7.1% of pre-existing labor epidural catheters failed and 4.3% of patients required conversion to general anesthesia. Spinal anesthesia for cesarean section had a lower failure rate of 2.7%, with 1.2% of the patients requiring general anesthesia. The overall use of general anesthesia decreased from 8% to 4.3% over the three-year period. Furthermore, regional anesthesia was used in 93.5% of cesarean deliveries with no anesthetic-related mortalities. Future investigations should identify acceptable international standards, risk factors associated with failure and methods to reduce failure before cesarean section.
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                Author and article information

                Journal
                Int J Womens Health
                International Journal of Women's Health
                International Journal of Women's Health
                Dove Medical Press
                1179-1411
                9 August 2010
                2009
                : 1
                : 139-154
                Affiliations
                Department of Anesthesiology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
                Author notes
                Correspondence: Cynthia A Wong, Department of Anesthesiology, Northwestern University Feinberg School of Medicine, 251 E. Huron St., F5-704, Chicago, IL 60611, USA, Tel +1 312 472 3585, Fax +1 312 472 3590, Email c-wong2@ 123456northwestern.edu
                Article
                ijwh-1-139
                10.2147/ijwh.s4553
                2971706
                21072284
                a48dcd38-30e8-46e5-b015-719d2df79c32
                © 2009 Wong, publisher and licensee Dove Medical Press Ltd.

                This is an Open Access article which permits unrestricted noncommercial use, provided the original work is properly cited.

                History
                : 5 October 2009
                Categories
                Review

                Obstetrics & Gynecology
                epidural analgesia,neuraxial analgesia,childbirth pain,labor analgesia
                Obstetrics & Gynecology
                epidural analgesia, neuraxial analgesia, childbirth pain, labor analgesia

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