Background
Epidural analgesia is a central nerve block technique achieved by injection of a local anaesthetic close to the nerves that transmit pain, and is widely used as a form of pain relief in ...labour. However, there are concerns about unintended adverse effects on the mother and infant. This is an update of an existing Cochrane Review (Epidural versus non‐epidural or no analgesia in labour), last published in 2011.
Objectives
To assess the effectiveness and safety of all types of epidural analgesia, including combined‐spinal‐epidural (CSE) on the mother and the baby, when compared with non‐epidural or no pain relief during labour.
Search methods
We searched Cochrane Pregnancy and Childbirth’s Trials Register (ClinicalTrials.gov), the WHO International Clinical Trials Registry Platform (ICTRP) (30 April 2017), and reference lists of retrieved studies.
Selection criteria
Randomised controlled trials comparing all types of epidural with any form of pain relief not involving regional blockade, or no pain relief in labour. We have not included cluster‐randomised or quasi‐randomised trials in this update.
Data collection and analysis
Two review authors independently assessed trials for inclusion and risks of bias, extracted data and checked them for accuracy. We assessed selected outcomes using the GRADE approach.
Main results
Fifty‐two trials met the inclusion criteria and we have included data from 40 trials, involving over 11,000 women. Four trials included more than two arms. Thirty‐four trials compared epidural with opioids, seven compared epidural with no analgesia, one trial compared epidural with acu‐stimulation, one trial compared epidural with inhaled analgesia, and one trial compared epidural with continuous midwifery support and other analgesia. Risks of bias varied throughout the included studies; six out of 40 studies were at high or unclear risk of bias for every bias domain, while most studies were at high or unclear risk of detection bias. Quality of the evidence assessed using GRADE ranged from moderate to low quality.
Pain intensity as measured using pain scores was lower in women with epidural analgesia when compared to women who received opioids (standardised mean difference ‐2.64, 95% confidence interval (CI) ‐4.56 to ‐0.73; 1133 women; studies = 5; I2 = 98%; low‐quality evidence) and a higher proportion were satisfied with their pain relief, reporting it to be "excellent or very good" (average risk ratio (RR) 1.47, 95% CI 1.03 to 2.08; 1911 women; studies = 7; I2 = 97%; low‐quality evidence). There was substantial statistical heterogeneity in both these outcomes. There was a substantial decrease in the need for additional pain relief in women receiving epidural analgesia compared with opioid analgesia (average RR 0.10, 95% CI 0.04 to 0.25; 5099 women; studies = 16; I2 = 73%; Tau2 = 1.89; Chi2 = 52.07 (P < 0.00001)). More women in the epidural group experienced assisted vaginal birth (RR 1.44, 95% CI 1.29 to 1.60; 9948 women; studies = 30; low‐quality evidence). A post hoc subgroup analysis of trials conducted after 2005 showed that this effect is negated when trials before 2005 are excluded from this analysis (RR 1.19, 95% CI 0.97 to 1.46). There was no difference between caesarean section rates (RR 1.07, 95% CI 0.96 to 1.18; 10,350 women; studies = 33; moderate‐quality evidence), and maternal long‐term backache (RR 1.00, 95% CI 0.89 to 1.12; 814 women; studies = 2; moderate‐quality evidence). There were also no clear differences between groups for the neonatal outcomes, admission to neonatal intensive care unit (RR 1.03, 95% CI 0.95 to 1.12; 4488 babies; studies = 8; moderate‐quality evidence) and Apgar score less than seven at five minutes (RR 0.73, 95% CI 0.52 to 1.02; 8752 babies; studies = 22; low‐quality evidence). We downgraded the evidence for study design limitations, inconsistency, imprecision in effect estimates, and possible publication bias.
Side effects were reported in both epidural and opioid groups. Women with epidural experienced more hypotension, motor blockade, fever, and urinary retention. They also had longer first and second stages of labour, and were more likely to have oxytocin augmentation than the women in the opioid group. Women receiving epidurals had less risk of respiratory depression requiring oxygen, and were less likely to experience nausea and vomiting than women receiving opioids. Babies born to women in the epidural group were less likely to have received naloxone. There was no clear difference between groups for postnatal depression, headache, itching, shivering, or drowsiness. Maternal morbidity and long‐term neonatal outcomes were not reported.
Epidural analgesia resulted in less reported pain when compared with placebo or no treatment, and with acu‐stimulation. Pain intensity was not reported in the trials that compared epidural with inhaled analgesia, or continuous support. Few trials reported on serious maternal side effects.
Authors' conclusions
Low‐quality evidence shows that epidural analgesia may be more effective in reducing pain during labour and increasing maternal satisfaction with pain relief than non‐epidural methods. Although overall there appears to be an increase in assisted vaginal birth when women have epidural analgesia, a post hoc subgroup analysis showed this effect is not seen in recent studies (after 2005), suggesting that modern approaches to epidural analgesia in labour do not affect this outcome. Epidural analgesia had no impact on the risk of caesarean section or long‐term backache, and did not appear to have an immediate effect on neonatal status as determined by Apgar scores or in admissions to neonatal intensive care. Further research may be helpful to evaluate rare but potentially severe adverse effects of epidural analgesia and non‐epidural analgesia on women in labour and long‐term neonatal outcomes.
Background
The pain that women experience during labour is affected by multiple physiological and psychosocial factors and its intensity can vary greatly. Most women in labour require pain relief. ...Pain management strategies include non‐pharmacological interventions (that aim to help women cope with pain in labour) and pharmacological interventions (that aim to relieve the pain of labour).
Objectives
To summarise the evidence from Cochrane systematic reviews on the efficacy and safety of non‐pharmacological and pharmacological interventions to manage pain in labour. We considered findings from non‐Cochrane systematic reviews if there was no relevant Cochrane review.
Methods
We searched the Cochrane Database of Systematic Reviews (The Cochrane Library 2011, Issue 5), The Cochrane Database of s of Reviews of Effects (The Cochrane Library 2011, Issue 2 of 4), MEDLINE (1966 to 31 May 2011) and EMBASE (1974 to 31 May 2011) to identify all relevant systematic reviews of randomised controlled trials of pain management in labour. Each of the contributing Cochrane reviews (six new, nine updated) followed a generic protocol with 13 common primary efficacy and safety outcomes. Each Cochrane review included comparisons with placebo, standard care or with a different intervention according to a predefined hierarchy of interventions. Two review authors extracted data and assessed methodological quality, and data were checked by a third author. This overview is a narrative summary of the results obtained from individual reviews.
Main results
We identified 15 Cochrane reviews (255 included trials) and three non‐Cochrane reviews (55 included trials) for inclusion within this overview. For all interventions, with available data, results are presented as comparisons of: 1. Intervention versus placebo or standard care; 2. Different forms of the same intervention (e.g. one opioid versus another opioid); 3. One type of intervention versus a different type of intervention (e.g. TENS versus opioid). Not all reviews included results for all comparisons. Most reviews compared the intervention with placebo or standard care, but with the exception of opioids and epidural analgesia, there were few direct comparisons between different forms of the same intervention, and even fewer comparisons between different interventions. Based on these three comparisons, we have categorised interventions into: " What works" ,“What may work”, and “Insufficient evidence to make a judgement”.
WHAT WORKS
Evidence suggests that epidural, combined spinal epidural (CSE) and inhaled analgesia effectively manage pain in labour, but may give rise to adverse effects. Epidural, and inhaled analgesia effectively relieve pain when compared with placebo or a different type of intervention (epidural versus opioids). Combined‐spinal epidurals relieve pain more quickly than traditional or low dose epidurals. Women receiving inhaled analgesia were more likely to experience vomiting, nausea and dizziness.
When compared with placebo or opioids, women receiving epidural analgesia had more instrumental vaginal births and caesarean sections for fetal distress, although there was no difference in the rates of caesarean section overall. Women receiving epidural analgesia were more likely to experience hypotension, motor blockade, fever or urinary retention. Less urinary retention was observed in women receiving CSE than in women receiving traditional epidurals. More women receiving CSE than low‐dose epidural experienced pruritus.
WHAT MAY WORK
There is some evidence to suggest that immersion in water, relaxation, acupuncture, massage and local anaesthetic nerve blocks or non‐opioid drugs may improve management of labour pain, with few adverse effects. Evidence was mainly limited to single trials. These interventions relieved pain and improved satisfaction with pain relief (immersion, relaxation, acupuncture, local anaesthetic nerve blocks, non‐opioids) and childbirth experience (immersion, relaxation, non‐opioids) when compared with placebo or standard care. Relaxation was associated with fewer assisted vaginal births and acupuncture was associated with fewer assisted vaginal births and caesarean sections.
INSUFFICIENT EVIDENCE
There is insufficient evidence to make judgements on whether or not hypnosis, biofeedback, sterile water injection, aromatherapy, TENS, or parenteral opioids are more effective than placebo or other interventions for pain management in labour. In comparison with other opioids more women receiving pethidine experienced adverse effects including drowsiness and nausea.
Authors' conclusions
Most methods of non‐pharmacological pain management are non‐invasive and appear to be safe for mother and baby, however, their efficacy is unclear, due to limited high quality evidence. In many reviews, only one or two trials provided outcome data for analysis and the overall methodological quality of the trials was low. High quality trials are needed.
There is more evidence to support the efficacy of pharmacological methods, but these have more adverse effects. Thus, epidural analgesia provides effective pain relief but at the cost of increased instrumental vaginal birth.
It remains important to tailor methods used to each woman’s wishes, needs and circumstances, such as anticipated duration of labour, the infant's condition, and any augmentation or induction of labour.
A major challenge in compiling this overview, and the individual systematic reviews on which it is based, has been the variation in use of different process and outcome measures in different trials, particularly assessment of pain and its relief, and effects on the neonate after birth. This made it difficult to pool results from otherwise similar studies, and to derive conclusions from the totality of evidence. Other important outcomes have simply not been assessed in trials; thus, despite concerns for 30 years or more about the effects of maternal opioid administration during labour on subsequent neonatal behaviour and its influence on breastfeeding, only two out of 57 trials of opioids reported breastfeeding as an outcome. We therefore strongly recommend that the outcome measures, agreed through wide consultation for this project, are used in all future trials of methods of pain management.
Epidural analgesia is a central nerve block technique achieved by injection of a local anaesthetic close to the nerves that transmit pain and is widely used as a form of pain relief in labour. ...However, there are concerns regarding unintended adverse effects on the mother and infant.
To assess the effects of all modalities of epidural analgesia (including combined-spinal-epidural) on the mother and the baby, when compared with non-epidural or no pain relief during labour.
We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 March 2011).
Randomised controlled trials comparing all modalities of epidural with any form of pain relief not involving regional blockade, or no pain relief in labour.
Two of the review authors independently assessed trials for eligibility, methodological quality and extracted all data. We entered data into RevMan and double checked it for accuracy. Primary analysis was by intention to treat; we conducted subgroup and sensitivity analyses where substantial heterogeneity was evident.
We included 38 studies involving 9658 women; all but five studies compared epidural analgesia with opiates. Epidural analgesia was found to offer better pain relief (mean difference (MD) -3.36, 95% confidence interval (CI) -5.41 to -1.31, three trials, 1166 women); a reduction in the need for additional pain relief (risk ratio (RR) 0.05, 95% CI 0.02 to 0.17, 15 trials, 6019 women); a reduced risk of acidosis (RR 0.80, 95% CI 0.68 to 0.94, seven trials, 3643 women); and a reduced risk of naloxone administration (RR 0.15, 95% CI 0.10 to 0.23, 10 trials, 2645 women). However, epidural analgesia was associated with an increased risk of assisted vaginal birth (RR 1.42, 95% CI 1.28 to 1.57, 23 trials, 7935 women), maternal hypotension (RR 18.23, 95% CI 5.09 to 65.35, eight trials, 2789 women), motor-blockade (RR 31.67, 95% CI 4.33 to 231.51, three trials, 322 women), maternal fever (RR 3.34, 95% CI 2.63 to 4.23, six trials, 2741 women), urinary retention (RR 17.05, 95% CI 4.82 to 60.39, three trials, 283 women), longer second stage of labour (MD 13.66 minutes, 95% CI 6.67 to 20.66, 13 trials, 4233 women), oxytocin administration (RR 1.19, 95% CI 1.03 to 1.39, 13 trials, 5815 women) and an increased risk of caesarean section for fetal distress (RR 1.43, 95% CI 1.03 to 1.97, 11 trials, 4816 women). There was no evidence of a significant difference in the risk of caesarean section overall (RR 1.10, 95% CI 0.97 to 1.25, 27 trials, 8417 women), long-term backache (RR 0.96, 95% CI 0.86 to 1.07, three trials, 1806 women), Apgar score less than seven at five minutes (RR 0.80, 95% CI 0.54 to 1.20, 18 trials, 6898 women), and maternal satisfaction with pain relief (RR 1.31, 95% CI 0.84 to 2.05, seven trials, 2929 women). We found substantial heterogeneity for the following outcomes: pain relief; maternal satisfaction; need for additional means of pain relief; length of second stage of labour; and oxytocin augmentation. This could not be explained by subgroup or sensitivity analyses, where data allowed analysis. No studies reported on rare but potentially serious adverse effects of epidural analgesia.
Epidural analgesia appears to be effective in reducing pain during labour. However, women who use this form of pain relief are at increased risk of having an instrumental delivery. Epidural analgesia had no statistically significant impact on the risk of caesarean section, maternal satisfaction with pain relief and long-term backache and did not appear to have an immediate effect on neonatal status as determined by Apgar scores. Further research may be helpful to evaluate rare but potentially severe adverse effects of epidural analgesia on women in labour and long-term neonatal outcomes.
Background
Traditional epidural techniques have been associated with prolonged labour, use of oxytocin augmentation and increased incidence of instrumental vaginal delivery. The combined ...spinal‐epidural (CSE) technique has been introduced in an attempt to reduce these adverse effects. CSE is believed to improve maternal mobility during labour and provide more rapid onset of analgesia than epidural analgesia, which could contribute to increased maternal satisfaction.
Objectives
To assess the relative effects of CSE versus epidural analgesia during labour.
Search methods
We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (28 September 2011) and reference lists of retrieved studies. We updated the search on 30 June 2012 and added the results to the awaiting classification section.
Selection criteria
All published randomised controlled trials (RCTs) involving a comparison of CSE with epidural analgesia initiated for women in the first stage of labour. Cluster‐randomised trials were considered for inclusion. Quasi RCTs and cross‐over trials were not considered for inclusion in this review.
Data collection and analysis
Three review authors independently assessed the trials identified from the searches for inclusion, assessed trial quality and extracted the data. Data were checked for accuracy.
Main results
Twenty‐seven trials involving 3274 women met our inclusion criteria. Twenty‐six outcomes in two sets of comparisons involving CSE versus traditional epidurals and CSE versus low‐dose epidural techniques were analysed.
Of the CSE versus traditional epidural analyses five outcomes showed a significant difference. CSE was more favourable in relation to speed of onset of analgesia from time of injection (mean difference (MD) ‐2.87 minutes; 95% confidence interval (CI) ‐5.07 to ‐0.67; two trials, 129 women); the need for rescue analgesia (risk ratio (RR) 0.31; 95% CI 0.14 to 0.70; one trial, 42 women); urinary retention (RR 0.86; 95% CI 0.79 to 0.95; one trial, 704 women); and rate of instrumental delivery (RR 0.81; 95% CI 0.67 to 0.97; six trials, 1015 women). Traditional epidural was more favourable in relation to umbilical venous pH (MD ‐0.03; 95% CI ‐0.06 to ‐0.00; one trial, 55 women). There were no data on maternal satisfaction, blood patch for post dural puncture headache, respiratory depression, umbilical cord pH, rare neurological complications, analgesia for caesarean section after analgesic intervention or any economic/use of resources outcomes for this comparison. No differences between CSE and traditional epidural were identified for mobilisation in labour, the need for labour augmentation, the rate of caesarean birth, incidence of post dural puncture headache, maternal hypotension, neonatal Apgar scores or umbilical arterial pH.
For CSE versus low‐dose epidurals, three outcomes were statistically significant. Two of these reflected a faster onset of effective analgesia from time of injection with CSE and the third was of more pruritus with CSE compared to low‐dose epidural (average RR 1.80; 95% CI 1.22 to 2.65; 11 trials, 959 women; random‐effects, T² = 0.26, I² = 84%). There was no significant difference in maternal satisfaction (average RR 1.01; 95% CI 0.98 to 1.05; seven trials, 520 women; random‐effects, T² = 0.00, I² = 45%). There were no data on respiratory depression, maternal sedation or the need for labour augmentation. No differences between CSE and low‐dose epidural were identified for need for rescue analgesia, mobilisation in labour, incidence of post dural puncture headache, known dural tap, blood patch for post dural headache, urinary retention, nausea/vomiting, hypotension, headache, the need for labour augmentation, mode of delivery, umbilical pH, Apgar score or admissions to the neonatal unit.
Authors' conclusions
There appears to be little basis for offering CSE over epidurals in labour, with no difference in overall maternal satisfaction despite a slightly faster onset with CSE and conversely less pruritus with low‐dose epidurals. There was no difference in ability to mobilise, maternal hypotension, rate of caesarean birth or neonatal outcome. However, the significantly higher incidence of urinary retention, rescue interventions and instrumental deliveries with traditional techniques would favour the use of low‐dose epidurals. It is not possible to draw any meaningful conclusions regarding rare complications such as nerve injury and meningitis.
Background
Midwives are primary providers of care for childbearing women around the world. However, there is a lack of synthesised information to establish whether there are differences in morbidity ...and mortality, effectiveness and psychosocial outcomes between midwife‐led continuity models and other models of care.
Objectives
To compare midwife‐led continuity models of care with other models of care for childbearing women and their infants.
Search methods
We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (25 January 2016) and reference lists of retrieved studies.
Selection criteria
All published and unpublished trials in which pregnant women are randomly allocated to midwife‐led continuity models of care or other models of care during pregnancy and birth.
Data collection and analysis
Two review authors independently assessed trials for inclusion and risk of bias, extracted data and checked them for accuracy. The quality of the evidence was assessed using the GRADE approach.
Main results
We included 15 trials involving 17,674 women. We assessed the quality of the trial evidence for all primary outcomes (i.e. regional analgesia (epidural/spinal), caesarean birth, instrumental vaginal birth (forceps/vacuum), spontaneous vaginal birth, intact perineum, preterm birth (less than 37 weeks) and all fetal loss before and after 24 weeks plus neonatal death using the GRADE methodology: all primary outcomes were graded as of high quality.
For the primary outcomes, women who had midwife‐led continuity models of care were less likely to experience regional analgesia (average risk ratio (RR) 0.85, 95% confidence interval (CI) 0.78 to 0.92; participants = 17,674; studies = 14; high quality), instrumental vaginal birth (average RR 0.90, 95% CI 0.83 to 0.97; participants = 17,501; studies = 13; high quality), preterm birth less than 37 weeks (average RR 0.76, 95% CI 0.64 to 0.91; participants = 13,238; studies = eight; high quality) and less all fetal loss before and after 24 weeks plus neonatal death (average RR 0.84, 95% CI 0.71 to 0.99; participants = 17,561; studies = 13; high quality evidence). Women who had midwife‐led continuity models of care were more likely to experience spontaneous vaginal birth (average RR 1.05, 95% CI 1.03 to 1.07; participants = 16,687; studies = 12; high quality). There were no differences between groups for caesarean births or intact perineum.
For the secondary outcomes, women who had midwife‐led continuity models of care were less likely to experience amniotomy (average RR 0.80, 95% CI 0.66 to 0.98; participants = 3253; studies = four), episiotomy (average RR 0.84, 95% CI 0.77 to 0.92; participants = 17,674; studies = 14) and fetal loss less than 24 weeks and neonatal death (average RR 0.81, 95% CI 0.67 to 0.98; participants = 15,645; studies = 11). Women who had midwife‐led continuity models of care were more likely to experience no intrapartum analgesia/anaesthesia (average RR 1.21, 95% CI 1.06 to 1.37; participants = 10,499; studies = seven), have a longer mean length of labour (hours) (mean difference (MD) 0.50, 95% CI 0.27 to 0.74; participants = 3328; studies = three) and more likely to be attended at birth by a known midwife (average RR 7.04, 95% CI 4.48 to 11.08; participants = 6917; studies = seven). There were no differences between groups for fetal loss equal to/after 24 weeks and neonatal death, induction of labour, antenatal hospitalisation, antepartum haemorrhage, augmentation/artificial oxytocin during labour, opiate analgesia, perineal laceration requiring suturing, postpartum haemorrhage, breastfeeding initiation, low birthweight infant, five‐minute Apgar score less than or equal to seven, neonatal convulsions, admission of infant to special care or neonatal intensive care unit(s) or in mean length of neonatal hospital stay (days).
Due to a lack of consistency in measuring women's satisfaction and assessing the cost of various maternity models, these outcomes were reported narratively. The majority of included studies reported a higher rate of maternal satisfaction in midwife‐led continuity models of care. Similarly, there was a trend towards a cost‐saving effect for midwife‐led continuity care compared to other care models.
Authors' conclusions
This review suggests that women who received midwife‐led continuity models of care were less likely to experience intervention and more likely to be satisfied with their care with at least comparable adverse outcomes for women or their infants than women who received other models of care.
Further research is needed to explore findings of fewer preterm births and fewer fetal deaths less than 24 weeks, and all fetal loss/neonatal death associated with midwife‐led continuity models of care.
Epidural-related maternal fever in women is a common clinical phenomenon that leads to adverse consequences for mothers and neonates. The meta-analysis aimed to quantify the risk for intrapartum ...maternal fever after epidural analgesia (EA) stratified according to parity. The secondary objective was to investigate the association between EA and maternal outcomes.
An electronic literature search of the Medline/PubMed, Embase, Cochrane Library, Wanfang Data, and China National Knowledge Infrastructure databases was performed to identify studies reporting the occurrence of intrapartum fever in parturients. Studies were reviewed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, and meta-analysis was performed using Review Manager version 5.3.
Seventeen randomized controlled trials (RCTs) (5959 parturients) were included. Odds ratios for maternal fever in the analysis were 4.17 (95% confidence interval (CI) 2.93-5.94) and 5.83 (95% CI 4.96-6.87), respectively. Results of subgroup analysis according to parity were consistent. EA significantly prolonged the length of the first stage of labor (MD 34.52 95% CI 12.13-56.91) and the second stage of labor (MD 9.10 95% CI 4.51-13.68). Parturients who received EA were more likely to undergo instrumental delivery (OR 2.03 95% CI 1.44-2.86) and oxytocin augmentation (OR 1.45 95% CI 1.12-1.88). There were no differences in cesarean delivery rates between the EA and non-EA groups.
Parturients who received EA exhibited a higher incidence of intrapartum fever. Credibility of the subgroup analyses was low because the mixed group did not effectively represent multiparas.
Immersion in water during labour and birth Cluett, Elizabeth R; Burns, Ethel; Cuthbert, Anna ...
Cochrane database of systematic reviews,
05/2018, Volume:
2018, Issue:
6
Journal Article
Peer reviewed
Open access
Background
Water immersion during labour and birth is increasingly popular and is becoming widely accepted across many countries, and particularly in midwifery‐led care settings. However, there are ...concerns around neonatal water inhalation, increased requirement for admission to neonatal intensive care unit (NICU), maternal and/or neonatal infection, and obstetric anal sphincter injuries (OASIS). This is an update of a review last published in 2011.
Objectives
To assess the effects of water immersion during labour and/or birth (first, second and third stage of labour) on women and their infants.
Search methods
We searched Cochrane Pregnancy and Childbirth’s Trials Register, ClinicalTrials.gov and the WHO International Clinical Trials Registry Platform (ICTRP) (18 July 2017), and reference lists of retrieved trials.
Selection criteria
We included randomised controlled trials (RCTs) comparing water immersion with no immersion, or other non‐pharmacological forms of pain management during labour and/or birth in healthy low‐risk women at term gestation with a singleton fetus. Quasi‐RCTs and cluster‐RCTs were eligible for inclusion but none were identified. Cross‐over trials were not eligible for inclusion.
Data collection and analysis
Two review authors independently assessed trials for inclusion and risk of bias, extracted data and checked them for accuracy. Two review authors assessed the quality of the evidence using the GRADE approach.
Main results
This review includes 15 trials conducted between 1990 and 2015 (3663 women): eight involved water immersion during the first stage of labour; two during the second stage only; four during the first and second stages of labour, and one comparing early versus late immersion during the first stage of labour. No trials evaluated different baths/pools, or third‐stage labour management. All trials were undertaken in a hospital labour ward setting, with a varying degree of medical intervention considered as routine practice. No study was carried out in a midwifery‐led care setting. Most trial authors did not specify the parity of women. Trials were subject to varying degrees of bias: the intervention could not be blinded and there was a lack of information about randomisation, and whether analyses were undertaken by intention‐to‐treat.
Immersion in water versus no immersion (first stage of labour)
There is probably little or no difference in spontaneous vaginal birth between immersion and no immersion (83% versus 82%; risk ratio (RR) 1.01, 95% confidence interval (CI) 0.97 to 1.04; 6 trials; 2559 women; moderate‐quality evidence); instrumental vaginal birth (12% versus 14%; RR 0.86, 95% CI 0.70 to 1.05; 6 trials; 2559 women; low‐quality evidence); and caesarean section (5% versus 4%; RR 1.27, 95% CI 0.91 to 1.79; 7 trials; 2652 women; low‐quality evidence). There is insufficient evidence to determine the effect of immersion on estimated blood loss (mean difference (MD) ‐14.33 mL, 95% CI ‐63.03 to 34.37; 2 trials; 153 women; very low‐quality evidence) and third‐ or fourth‐degree tears (3% versus 3%; RR 1.36, 95% CI 0.85 to 2.18; 4 trials; 2341 women; moderate‐quality evidence). There was a small reduction in the risk of using regional analgesia for women allocated to water immersion from 43% to 39% (RR 0.91, 95% CI 0.83 to 0.99; 5 trials; 2439 women; moderate‐quality evidence). Perinatal deaths were not reported, and there is insufficient evidence to determine the impact on neonatal intensive care unit (NICU) admissions (6% versus 6%; average RR 1.30, 95% CI 0.42 to 3.97; 2 trials; 1511 infants; I² = 36%; low‐quality evidence), or on neonatal infection rates (1% versus 1%; RR 2.00, 95% CI 0.50 to 7.94; 5 trials; 1295 infants; very low‐quality evidence).
Immersion in water versus no immersion (second stage of labour)
There were no clear differences between groups for spontaneous vaginal birth (98% versus 97%; RR 1.02, 95% CI 0.96 to 1.08; 120 women; 1 trial; low‐quality evidence); instrumental vaginal birth (2% versus 2%; RR 1.00, 95% CI 0.06 to 15.62; 1 trial; 120 women; very low‐quality evidence); caesarean section (0% versus 2%; RR 0.33, 95% CI 0.01 to 8.02; 1 trial; 120 women; very low‐quality evidence), and NICU admissions (8% versus 11%; RR 0.78, 95% CI 0.38 to 1.59; 2 trials; 291 women; very low‐quality evidence). Use of regional analgesia was not relevant to the second stage of labour. Third‐ or fourth‐degree tears, and estimated blood loss were not reported in either trial. No trial reported neonatal infection but did report neonatal temperature less than 36.2°C at birth (9% versus 9%; RR 0.98, 95% CI 0.30 to 3.20; 1 trial; 109 infants; very low‐quality evidence), greater than 37.5°C at birth (15% versus 6%; RR 2.62, 95% CI 0.73 to 9.35; 1 trial; 109 infants; very low‐quality evidence), and fever reported in first week (2% versus 5%; RR 0.53, 95% CI 0.10 to 2.82; 1 trial; 171 infants; very low‐quality evidence), with no clear effect between groups being observed. One perinatal death occurred in the immersion group in one trial (RR 3.00, 95% CI 0.12 to 72.20; 1 trial; 120 infants; very low‐quality evidence). The infant was born to a mother with HIV and the cause of death was deemed to be intrauterine infection.
There is no evidence of increased adverse effects to the baby or woman from either the first or second stage of labour.
Only one trial (200 women) compared early and late entry into the water and there were insufficient data to show any clear differences.
Authors' conclusions
In healthy women at low risk of complications there is moderate to low‐quality evidence that water immersion during the first stage of labour probably has little effect on mode of birth or perineal trauma, but may reduce the use of regional analgesia. The evidence for immersion during the second stage of labour is limited and does not show clear differences on maternal or neonatal outcomes intensive care. There is no evidence of increased adverse effects to the fetus/neonate or woman from labouring or giving birth in water. Available evidence is limited by clinical variability and heterogeneity across trials, and no trial has been conducted in a midwifery‐led setting.
BACKGROUND:The dural puncture epidural (DPE) technique is a modification of the combined spinal epidural (CSE) technique, where a dural perforation is created from a spinal needle but intrathecal ...medication administration is withheld. The DPE technique has been shown to improve caudal spread of analgesia compared with epidural (EPL) technique without the side effects observed with the CSE technique. We hypothesized that the onset of labor analgesia would follow this orderCSE > DPE > EPL techniques.
METHODS:A total of 120 parturients in early labor were randomly assigned to EPL, DPE, or CSE groups. Initial dosing for EPL and DPE consisted of epidural 20 mL of 0.125% bupivacaine plus fentanyl 2 μg/mL over 5 minutes, and for CSE, intrathecal 0.25% bupivacaine 1.7 mg and fentanyl 17 μg. Upon block completion, a blinded coinvestigator assessed the outcomes. Two blinded obstetricians retrospectively interpreted uterine contractions and fetal heart rate tracings 1 hour before and after the neuraxial technique. The primary outcome was time to numeric pain rating scale (NPRS) ≤ 1 analyzed by using Kaplan-Meier curves and Cox proportional hazard model. Secondary outcomes included block quality, maternal adverse effects, uterine contraction patterns, and fetal outcomes analyzed by using the χ test with Yates continuity correction.
RESULTS:There was no significant difference in the time to NPRS ≤ 1 between DPE and EPL (hazard ratio 1.4; 95% confidence interval CI 0.83–2.4, P = .21). DPE achieved NPRS ≤ 1 significantly slower than CSE (hazard ratio 0.36; 95% CI 0.22–0.59, P = .0001). The median times (interquartile range) to NPRS ≤ 1 were 2 (0.5–6) minutes for CSE, 11 (4–120) minutes for DPE, and 18 (10–120) minutes for EPL. Compared with EPL, DPE had significantly greater incidence of bilateral S2 blockade at 10 minutes (risk ratio RR 2.13; 95% CI 1.39–3.28; P < .001), 20 minutes (RR 1.60; 95% CI 1.26–2.03; P < .001), and 30 minutes (RR 1.18; 95% CI 1.01–1.30; P < .034), a lower incidence of asymmetric block after 30 minutes (RR 0.19; 95% CI 0.07–0.51; P < .001) and physician top-up intervention (RR 0.45; 95% CI 0.23–0.86; P = .011). Compared with CSE, DPE had a significantly lower incidence of pruritus (RR 0.15; 95% CI 0.06–0.38; P < .001), hypotension (RR 0.38; 95% CI 0.15–0.98; P = .032), combined uterine tachysystole and hypertonus (RR 0.22; 95% CI 0.08–0.60; P < .001), and physician top-up intervention (RR 0.45; 95% CI 0.23–0.86; p = .011).
CONCLUSIONS:Analgesia onset was most rapid with CSE with no difference between DPE and EPL techniques. The DPE technique has improved block quality over the EPL technique with fewer maternal and fetal side effects than the CSE technique for parturients requesting early labor analgesia.
Analgesia and Anesthesia in the Intrapartum Period Hale, Susan; Hill, Catherine M; Hermann, Melanie ...
Journal of obstetric, gynecologic, and neonatal nursing,
03/2020, Volume:
49, Issue:
2
Journal Article
PDF
