Patients’ perspectives on pain relief during childbirth and utilization of neuraxial labor analgesia: A pilot qualitative study

Huang Y., Zhong Y., Chen Q., Zhou J., Fu B., Deng Y., Tu X., Wu Y.

Abstract Background Childbirth is a long-lasting physiological stress. As one of the main stressors, labor pain exists throughout the whole process. Childbirth self-efficacy is the confidence, or belief that they can manage pain during childbirth. This sense of self-efficacy determines how pregnant women deal with labor pain and enables them to regulate their behavior and actively deal with childbirth. However, the difference in pain sensitivity between single births (primiparas) and multiple births (multiparas) has rarely been investigated. Objectives This study is aimed at investigating self-efficacy, fear of childbirth, labor pain of primiparas and multiparas and exploring factors related to the perceived labor pain intensity of pregnant women. Design Prospective cross-sectional study. Setting(s) Labour and delivery in a large academic specialized hospital in Guangzhou, China. Participants A total of 347 women, (182 primiparas and 165 multiparas) were enrolled in the data analysis. Pain was assessed before cervical dilatation (cervical dilatation ≤ 3 cm for the first delivery and ≤ 2 cm for the second delivery). Method The general information of participants was obtained by questionnaire and obstetrical records of the subjects were obtained from the electronic medical records extracted from the electronic medical record system (EMRS). Childbirth self-efficacy, fear of childbirth (FOC) and labor pain were compared between primiparas and multiparas. Paired t-test, chi-square test, Mann–Whitney test, univariate and multivariate regression analysis were used to analyze labor pain between the two groups and investigate factors related perceived labor pain intensity. Results The total scores related to fear of childbirth, fetal health, self-control, and labor pain injury of multiparas were notably reduced compared with primiparas (all P < 0.05). The perceived labor pain intensity and duration of the first stage of labor was reduced in the multipara group compared with the primipara group. The childbirth control sense of the multipara was better than that of the primipara. The perceived labor pain intensity was negatively correlated with advanced age (age ≥ 35 years), self-efficacy score, family support, and education (all P < 0.05). In contrast, the perceived labor pain intensity was positively correlated with tension, severe fear of childbirth, and anxiety (P < 0.05). Self-efficacy, gravidity, delivery cognition, and fear of childbirth were independent risk factors for the perceived labor pain intensity in the latent period (all P < 0.05). Conclusions Fear of childbirth is a predictor of perceived labor pain intensity. The extent of labor pain (minimum and maximum) can be predicted by the level of fear the expectant mother has. During the latent phase of labor, self-efficacy, fear of childbirth and labor pain are different between primiparas and multiparas.

Kearns R.J., Kyzayeva A., Halliday L.O., Lawlor D.A., Shaw M., Nelson S.M.

Abstract Objectives To determine the effect of labour epidural on severe maternal morbidity (SMM) and to explore whether this effect might be greater in women with a medical indication for epidural analgesia during labour, or with preterm labour. Design Population based study. Setting All NHS hospitals in Scotland. Participants 567 216 women in labour at 24+0 to 42+6 weeks’ gestation between 1 January 2007 and 31 December 2019, delivering vaginally or through unplanned caesarean section. Main outcome measures The primary outcome was SMM, defined as the presence of ≥1 of 21 conditions used by the US Centers for Disease Control and Prevention (CDC) as criteria for SMM, or a critical care admission, with either occurring at any point from date of delivery to 42 days post partum (described as SMM). Secondary outcomes included a composite of ≥1 of the 21 CDC conditions and critical care admission (SMM plus critical care admission), and respiratory morbidity. Results Of the 567 216 women, 125 024 (22.0%) had epidural analgesia during labour. SMM occurred in 2412 women (4.3 per 1000 births, 95% confidence interval (CI) 4.1 to 4.4). Epidural analgesia was associated with a reduction in SMM (adjusted relative risk 0.65, 95% CI 0.50 to 0.85), SMM plus critical care admission (0.46, 0.29 to 0.73), and respiratory morbidity (0.42, 0.16 to 1.15), although the last of these was underpowered and had wide confidence intervals. Greater risk reductions in SMM were detected among women with a medical indication for epidural analgesia (0.50, 0.34 to 0.72) compared with those with no such indication (0.67, 0.43 to 1.03; P<0.001 for difference). More marked reductions in SMM were seen in women delivering preterm (0.53, 0.37 to 0.76) compared with those delivering at term or post term (1.09, 0.98 to 1.21; P<0.001 for difference). The observed reduced risk of SMM with epidural analgesia was increasingly noticeable as gestational age at birth decreased in the whole cohort, and in women with a medical indication for epidural analgesia. Conclusion Epidural analgesia during labour was associated with a 35% reduction in SMM, and showed a more pronounced effect in women with medical indications for epidural analgesia and with preterm births. Expanding access to epidural analgesia for all women during labour, and particularly for those at greatest risk, could improve maternal health.

masroor P., Mehrabi E., Nourizadeh R., Pourfathi H., Asghari-Jafarabadi M.

Abstract Introduction Childbirth may be associated with psychological, social, and emotional effects and provide the background for women’s health or illness throughout their life. This research aimed at comparing the impact of non-pharmacological pain relief and pharmacological analgesia with remifentanil on childbirth fear and postpartum depression. Materials and method This randomized clinical trial with two parallel arms was conducted on 66 women with term pregnancy referred to Taleghani Hospital in Tabriz for vaginal delivery during September 2022 to September 2023. First, all of the eligible participants were selected through Convenience Sampling. Then, they were randomly assigned into two groups of pharmacological analgesia with remifentanil and non-pharmacological analgesia with a ratio of 1:1 using stratified block randomization based on the number of births. Before the intervention, fear of childbirth (FOC) was measured using Delivery Fear Scale (DFS) between 4 and 6 cm cervical dilatation. Pain and fear during labor in dilatation of 8 cm were measured in both groups using VAS and DFS. After delivery, FOC was assessed using Delivery Fear Scale (W DEQ Version B) and postpartum depression using the Edinburgh’s postpartum depression scale (EPDS). Significance level was considered 0.05. Mean difference (MD) was compared with Independent T-test and ANCOVA pre and post intervention. Results The mean score of FOC in the non-pharmacological analgesia group was significantly lower than that in the pharmacological analgesia group after the intervention by controlling the effect of the baseline score (MD: -6.33, 95%, Confidence Interval (CI): -12.79 to -0.12, p = 0.04). In the postpartum period, the mean score of FOC in the non-pharmacological analgesia group was significantly lower than that in the pharmacological analgesia group after controlling the effect of the baseline score (MD: -21.89; 95% CI: -35.12 to -8.66; p = 0.002). The mean score of postpartum depression in the non-pharmacological analgesia group was significantly lower than that in the pharmacological analgesia group (MD: -1.93, 95% CI: -3.48 to -0.37, p = 0.01). Trial registration: Iranian Registry of Clinical Trials (IRCT): IRCT20170506033834N10. Date of registration: 05/07/2022 Date of first registration: 05/07/2022. URL: https://www.irct.ir/trial/61030; Date of recruitment start date05/07/2022. Conclusion The study results indicated a reduction in FOC and postpartum depression among parturient women receiving non-pharmacological strategies with active participation in childbirth compared to women receiving pharmacological analgesia. Owing to the possible side effects of pharmacological methods for mother and fetus, non-pharmacological strategies with active participation of the mother in childbirth are recommended to reduce the FOC and postpartum depression.

Mingote Á., Zamora Moreno E., García Díaz A., Chiara Graciani G., Elbal Sánchez C., Guadalix Sánchez C., Gutiérrez Martínez D., García - Fernández J., Fornet Ruiz I.

Abstract Introduction Epidural infusion with low local anesthetic concentrations with opiates decrease the severity of the motor blockade associated. The present study aims to compare the analgesic efficacy and the motor blockade between two local anesthetic epidural infusions: levobupivacaine 0.0625% + fentanyl 2mcg/mL versus ropivacaine 0.075% + fentanyl 2mcg/mL. Materials and methods In a single-blind prospective randomized study, 60 laboring parturient had continuous epidural analgesia as follows: 30 of them received levobupivacaine 0.0625% + fentanyl 2mcg/mL and 30 of them received ropivacaine 0.075% + fentanyl 2mcg/mL and rates of infusion were adjusted to the height. Analgesic, motor blockade and satisfaction records were collected as well as maternal and neonate adverse events. Results After 2 h of the catheter placement, patients who received levobupivacaine showed a mean VAS of 3.2 [1.8–4.6] versus 1.8 [1.2–2.5] (p = 0.05) in patients who received ropivacaine. In addition, patients who received levobupivacaine showed a punctuation in Bromage scale of 0.0 [0.0–1.0] versus 0.0 [0.0–0.0] (p = 0.04) in patients who received ropivacaine. Finally, the parturient who received levobupivacaine scored a mean satisfaction index of 8.1 [7.3–8.9] versus 9.3 [8.7–9.8] (p = 0.02) in those who received ropivacaine. We did not register maternal nor neonate adverse events. Conclusion Both infusions (levobupivacaine 0.0625% + fentanyl 2mcg/mL and ropivacaine 0.075% + fentanyl 2mcg/mL) are effective for labor analgesia. However, ropivacaine would present a better pharmacodynamic profile with less motor blockade and decreased need for analgesic rescue hence improving patient’s satisfaction.

Vaajala M., Kekki M., Mattila V.M., Kuitunen I.

Guglielminotti J., Landau R., Daw J., Friedman A.M., Chihuri S., Li G.

Importance Addressing severe maternal morbidity (SMM) is a public health priority in the US. Use of labor neuraxial analgesia for vaginal delivery is suggested to reduce the risk of postpartum hemorrhage (PPH), the leading cause of preventable severe maternal morbidity. Objective To assess the association between the use of labor neuraxial analgesia for vaginal delivery and SMM. Design, Setting, and Participants In this population-based cross-sectional study, women aged 15 to 49 years undergoing their first vaginal delivery were included. Data were taken from hospital discharge records from New York between January 2010 and December 2017. Data were analyzed from November 2020 to November 2021. Exposures Neuraxial analgesia (ie, epidural or combined spinal-epidural) vs no neuraxial analgesia. Main Outcomes and Measures The primary outcome was SMM, as defined by the US Centers for Disease Control and Prevention, and the secondary outcome was PPH. Adjusted odds ratios (aORs) and 95% CIs of SMM associated with neuraxial analgesia were estimated using the inverse propensity score–weighting method and stratified according to race and ethnicity (non-Hispanic White vs racial and ethnic minority women, including non-Hispanic Asian or Pacific Islander, non-Hispanic Black, Hispanic, and other race and ethnicity) and to the comorbidity index for obstetric patients (low-risk vs high-risk women). The proportion of the association of neuraxial analgesia with the risk of SMM mediated through PPH was estimated using mediation analysis. Results Of 575 524 included women, the mean (SD) age was 28 (6) years, and 46 065 (8.0%) were non-Hispanic Asian or Pacific Islander, 88 577 (15.4%) were non-Hispanic Black, 104 866 (18.2%) were Hispanic, 258 276 (44.9%) were non-Hispanic White, and 74 534 (13.0%) were other race and ethnicity. A total of 400 346 women (69.6%) were in the low-risk group and 175 178 (30.4%) in the high-risk group, and 272 921 women (47.4%) received neuraxial analgesia. SMM occurred in 7712 women (1.3%), of which 2748 (35.6%) had PPH. Before weighting, the incidence of SMM was 1.3% (3486 of 272 291) with neuraxial analgesia compared with 1.4% (4226 of 302 603) without neuraxial analgesia (risk difference, −0.12 per 100; 95% CI, −0.17 to −0.07). After weighting, the aOR of SMM associated with neuraxial analgesia was 0.86 (95% CI, 0.82-0.90). Decreased risk of SMM associated with neuraxial analgesia was similar between non-Hispanic White women and racial and ethnic minority women and between low-risk and high-risk women. More than one-fifth (21%; 95% CI, 14-28) of the observed association of neuraxial analgesia with the risk of SMM was mediated through the decreased risk of PPH. Conclusions and Relevance Findings from this study suggest that use of neuraxial analgesia for vaginal delivery is associated with a 14% decrease in the risk of SMM. Increasing access to and utilization of labor neuraxial analgesia may contribute to improving maternal health outcomes.

D'Souza R.S., D'Souza S., Sharpe E.E.

Large gaps remain in our understanding of the role of social media platforms in the dissemination of medical information. This cross-sectional study quantitatively assessed the accuracy and quality of information on YouTube regarding epidural labor analgesia.YouTube was searched on May 23, 2020 using keywords 'epidural,' 'epidural for labor,' 'epidural for pregnancy,' 'epidural experience,' and 'epidural risks,' and the top 50 viewed videos from each search were screened. Primary outcomes included the proportion of videos containing non-factual information, and video quality analyzed using the modified DISCERN (mDISCERN) score.Thirteen of 60 (21.7%) videos included non-factual information about epidural analgesia; these videos were viewed more than 16.5 million times (60% of total viewership of the videos analyzed). Mean (standard deviation) mDISCERN score for all included videos was 1.9 (1.3), which is below the threshold for high video-quality. Videos from medical sources (hospitals, medical practices, physicians, other medical professionals) had a higher mDISCERN score compared with videos by non-medical sources (P

Gonzalez B., Gonzalez S.R., Rojo M., Mhyre J.

Tangel V.E., Matthews K.C., Abramovitz S.E., White R.S.

To evaluate racial and ethnic disparities in severe maternal morbidity (SMM) and administered anesthesia techniques. Retrospective cohort study. Administrative database study using 2007–2014 data from California, Florida, New York, Maryland, and Kentucky from the State Inpatient Databases (SID), Healthcare Cost and Utilization Project (HCUP), Agency for Healthcare Research and Quality (AHRQ). 6,879,332 parturients aged ≥18 years old who underwent deliveries were identified by International Classification of Disease, 9th Revision, Clinical Modification (ICD-9-CM) codes: V27.0 and V27.1 for singleton deliveries, and V27.2 through V27.8 for multiple births. Patients who had a singleton or multiple delivery. Patients were cohorted by race/ethnicity: white (reference category), black, Hispanic, other, or missing. Demographic characteristics and comorbidities were compared. Adjusted odds ratios with generalized linear mixed modeling were calculated for SMM. We also conducted additional exploratory analyses of racial/ethnic disparities in the anesthesia technique used for cesarean deliveries, as well as the use of analgesia in vaginal deliveries. When controlling for patient demographics, comorbidities, and hospital characteristics, black women were more likely than white women to experience any SMM (adjusted odds ratio: 1.38, 95% CI: 1.35–1.41). This finding was consistent in stratified analyses. Black women were also more likely than white women to receive general anesthesia for cesarean delivery (aOR: 1.44, 95% CI: 1.39–1.49) and to receive no analgesia for vaginal delivery (aOR: 1.45, 95% CI: 1.43–1.47). Our findings highlight the differences in outcomes and care for black as compared to white parturients related to SMM and administered anesthesia techniques. • After adjusting for patient and hospital factors, black women were more likely than white women to experience severe maternal morbidity • Black women were also more likely than white women to receive general anesthesia for cesarean and no analgesia for vaginal deliveries • Racial disparities in severe maternal morbidity were present across categories of anesthetic and analgesic techniques

Butwick A.J., Weiniger C.F.

Thomson G., Feeley C., Moran V.H., Downe S., Oladapo O.T.

Many women use pharmacological or non-pharmacological pain relief during childbirth. Evidence from Cochrane reviews shows that effective pain relief is not always associated with high maternal satisfaction scores. However, understanding women’s views is important for good quality maternity care provision. We undertook a qualitative evidence synthesis of women’s views and experiences of pharmacological (epidural, opioid analgesia) and non-pharmacological (relaxation, massage techniques) pain relief options, to understand what affects women’s decisions and choices and to inform guidelines, policy, and practice. We searched seven electronic databases (MEDLINE, CINAHL, PsycINFO, AMED, EMBASE, Global Index Medicus, AJOL), tracked citations and checked references. We used thematic and meta-ethnographic techniques for analysis purposes, and GRADE-CERQual tool to assess confidence in review findings. We developed review findings for each method. We then re-analysed the review findings thematically to highlight similarities and differences in women’s accounts of different pain relief methods. From 11,782 hits, we screened full 58 papers. Twenty-four studies provided findings for the synthesis: epidural (n = 12), opioids (n = 3), relaxation (n = 8) and massage (n = 4) – all conducted in upper-middle and high-income countries (HMICs). Re-analysis of the review findings produced five key themes. ‘Desires for pain relief’ illuminates different reasons for using pharmacological or non-pharmacological pain relief. ‘Impact on pain’ describes varying levels of effectiveness of the methods used. ‘Influence and experience of support’ highlights women’s positive or negative experiences of support from professionals and/or birth companions. ‘Influence on focus and capabilities’ illustrates that all pain relief methods can facilitate maternal control, but some found non-pharmacological techniques less effective than anticipated, and others reported complications associated with medication use. Finally, ‘impact on wellbeing and health’ reports that whilst some women were satisfied with their pain relief method, medication was associated with negative self-reprisals, whereas women taught relaxation techniques often continued to use these methods with beneficial outcomes. Women report mixed experiences of different pain relief methods. Pharmacological methods can reduce pain but have negative side-effects. Non-pharmacological methods may not reduce labour pain but can facilitate bonding with professionals and birth supporters. Women need information on risks and benefits of all available pain relief methods.

Butwick A.J., Bentley J., Wong C.A., Snowden J.M., Sun E., Guo N.

Neuraxial labor analgesia is recognized as the most effective method of providing pain relief during labor. Little is known about variation in the rates of neuraxial analgesia across US states. Identifying the presence and extent of variation may provide insights into practice variation and may indicate where access to neuraxial analgesia is inadequate.To test the hypothesis that variation exists in neuraxial labor analgesia use among US states.Retrospective, population-based, cross-sectional analysis using US birth certificate data. Participants were 2 625 950 women who underwent labor in 2015.State-specific prevalence of neuraxial analgesia per 100 women who underwent labor and variability in neuraxial analgesia use among states, assessed using multilevel multivariable regression modeling with the median odds ratio and the intraclass correlation coefficient to evaluate variation by state.In the study population of 2 625 950 women, 0.1% (n = 2010) were younger than 15 years, 7.0% (n = 183 546) were between the ages of 15 and 19 years, 23.6% (n = 620 118) were between the ages of 20 and 24 years, 29.6% (n = 777 957) were between the ages of 25 and 29 years, 26.0% (n = 683 656) were between the ages of 30 and 34 years, 11.4% (n = 298 237) were between the ages of 35 and 39 years, 2.2% (n = 57 130) were between the ages of 40 and 44 years, and 0.1% (n = 3296) were between the ages of 45 and 54 years. More than 90% were privately insured or insured with Medicaid. Neuraxial analgesia was used by 73.1% (n = 1 920 368) of women. After adjustment for antepartum, obstetric, and intrapartum factors, Maine had the lowest neuraxial analgesia prevalence (36.6%; 95% CI, 33.2%-40.1%) and Nevada the highest (80.1%; 95% CI, 78.3%-81.7%). The adjusted median odds ratio was 1.5 (95% CI, 1.4-1.6), and the intraclass correlation coefficient was 5.4% (95% CI, 4.0%-7.9%).Results of this study suggest that a small portion of the overall variation in neuraxial analgesia use is explained by US states. Unmeasured patient-level and hospital-level factors likely account for a large portion of the variation between states. Efforts should be made to understand what the main reasons are for this variation and whether the variation influences maternal or perinatal outcomes.

Lange E.M., Rao S., Toledo P.

Racial and ethnic disparities are prevalent within healthcare and have persisted despite advances in medicine and public health. Disparities have been described in the use of neuraxial labor analgesia, with minority women being less likely to use neuraxial labor analgesia than non-minority white women. Minority women are also more likely to have a general anesthetic for cesarean delivery than non-minority women. The origins of these disparities are likely multi-factorial, with patient-, provider-, and systems-level contributors. The purpose of this article is to give an overview of disparities in obstetric anesthesia.

Whitburn L.Y., Jones L.E., Davey M., Small R.

The majority of women experience pain during labour and childbirth, however not all women experience it in the same way. In order to develop a more complete understanding of labour pain, this study aimed to examine women’s experiences within the perspective of modern pain science. A more complete understanding of this phenomenon can then guide the development of interventions to enhance women’s experiences and potentially reduce their need for pharmacological intervention. A qualitative study was conducted using phenomenology as the theoretical framework. Data were collected from 21 nulliparous women, birthing at one of two large maternity services, through face-to-face interviews and written questionnaires. Data were analysed using an Interpretative Phenomenological Analysis approach. The data from this study suggest that a determining factor of a woman’s experience of pain during labour is the meaning she ascribes to it. When women interpret the pain as productive and purposeful, it is associated with positive cognitions and emotions, and they are more likely to feel they can cope. Alternatively, when women interpret the pain as threatening, it is associated with negative cognitions and emotions and they tend to feel they need help from external methods of pain control. The social environment seems particularly important in shaping a woman’s pain experience by influencing her interpretation of the context of the pain, and in doing so can change its meaning. The context and social environment are dynamic and can also change throughout labour. A determining factor in a woman’s experience of pain during labour is its perceived meaning which can then influence how the woman responds to the pain. The meaning of the pain is shaped by the social environment and other contextual factors within which it is experienced. Focussed promotion of labour pain as a productive and purposeful pain and efforts to empower women to utilise their inner capacity to cope, as well as careful attention to women’s cognitions and the social environment around them may improve women’s experiences of labour pain and decrease their need for pain interventions.