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BACKGROUND AND AIM The analgesic effect on labour pain of either spinal or epidural sufentanil or fentanyl was tested in a total of 80 primiparous parturients at an early phase of the delivery. The aim of the study was to compare the level of analgesia achieved within 20 minutes. METHODS The parturients were randomly assigned to groups receiving either spinal sufentanil (5 µg), epidural sufentanil (20 µg), spinal fentanyl (20 µg) or epidural fentanyl (100 µg), whereafter the parturients were monitored for reported pain during contraction and side effects for 30 minutes. The primary outcome was the level of analgesia achieved within 20 minutes, while the secondary outcome was the time until the administration of the first epidural bolus. RESULTS At baseline, the mean maximum pain VAS was 86 (84-89) mm. At 20 minutes after spinal sufentanil, epidural sufentanil, spinal fentanyl or epidural fentanyl, the maximum VAS was 19 (7-31), 45 (32-59), 25 (10-39) or 52 (40-63) mm, respectively (P

Objective (Primary) To establish the effect of antenatal group self-hypnosis for nulliparous women on intra-partum epidural use. Design Multi-method randomised control trial (RCT). Setting Three NHS Trusts. Population Nulliparous women not planning elective caesarean, without medication for hypertension and without psychological illness. Methods Randomisation at 28–32 weeks’ gestation to usual care, or to usual care plus brief self-hypnosis training (two × 90-minute groups at around 32 and 35 weeks’ gestation; daily audio self-hypnosis CD). Follow up at 2 and 6 weeks postnatal. Main outcome measures Primary: epidural analgesia. Secondary: associated clinical and psychological outcomes; cost analysis. Results Six hundred and eighty women were randomised. There was no statistically significant difference in epidural use: 27.9% (intervention), 30.3% (control), odds ratio (OR) 0.89 [95% confidence interval (CI): 0.64–1.24], or in 27 of 29 pre-specified secondary clinical and psychological outcomes. Women in the intervention group had lower actual than anticipated levels of fear and anxiety between baseline and 2 weeks post natal (anxiety: mean difference −0.72, 95% CI −1.16 to −0.28, P = 0.001); fear (mean difference −0.62, 95% CI −1.08 to −0.16, P = 0.009) [Correction added on 7 July 2015, after first online publication: ‘Mean difference’ replaced ‘Odds ratio (OR)’ in the preceding sentence.]. Postnatal response rates were 67% overall at 2 weeks. The additional cost in the intervention arm per woman was £4.83 (CI −£257.93 to £267.59). Conclusions Allocation to two-third-trimester group self-hypnosis training sessions did not significantly reduce intra-partum epidural analgesia use or a range of other clinical and psychological variables. The impact of women's anxiety and fear about childbirth needs further investigation. Tweetable abstract Going to 2 prenatal self-hypnosis groups didn't reduce labour epidural use but did reduce birth fear & anxiety postnatally at < £5 per woman.

Labour pain is influenced by numerous factors including maternal age, psychological factors and social deprivation [1]. There are no published data on how these variables interact. This study aimed to determine the key factor(s) predicting labour pain. The identification of any such factor(s) may allow appropriate resources to be targeted at those likely to benefit and improve maternal satisfaction.

Background Labour pain is severe. Thus, it is important to find effective methods to shorten the duration of labour and reduce labour pain. Objectives This non-randomised comparative study aimed to examine the use of the Prince of Songkla University Cat (PSU Cat) and upright positions, in conjunction with relaxing music, compared to oxytocin augmentation on the duration of the active phase of labour and labour pain in primiparous women. Methods Participants were assigned to two groups: group one (n=88) adopted the PSU Cat position alternating with an upright elevated head position (both at 45–60 degrees) while listening to relaxing music; group two (n=87) received oxytocin in the labour room. Both groups received the interventions when cervical dilation was 3–4 cm at the beginning of the study. Results Using t-tests, the position-adopting group was shown to have a significantly shorter duration of active labour than the oxytocin group. Repeated measures (using analysis of covariance) revealed that the position-adopting group had significantly less labour pain and distress of pain than the oxytocin group. Conclusions The results indicate that applying the PSU Cat positions, alternating with those where the head is elevated, while listening to relaxing music can shorten the duration of the active phase of labour and reduce labour pain and distress of pain compared with the use of oxytocin.

The study's rationale Women's experiences regarding labour pain preparation and management have been largely neglected. Aims and objectives Explore women's experiences regarding labour pain preparation and management in normal childbirth. Methodological design and justification The Vancouver School of doing phenomenology was the methodological approach of the study since it provides inside information about the lived experience. Research methods Data were collected through in-depth interviews with 14 participants; seven primiparous and seven multiparous women. Results The women described a challenging journey of no return through labour pain, with different landmarks on the journey. They described how they prepared for the pain; the context of the pain experience; how they experienced and managed the pain with different strategies and how they saw the pain at the journey's end. The quality of the midwife's presence and professionalism was of great importance to them. The ‘good midwives’ they described created a special atmosphere which was warm and secure and was conducive to their managing the pain. The women also described how important it was for them to have a supportive partner, with whom they had a mutual understanding, in order to manage the pain. Conclusions In this paper, we are presenting a study within the third paradigm in labour pain preparation and management: the childbearing woman's paradigm – the first and second being the midwifery and the medical paradigm, respectively. Midwives can play a major role in working with women in their preparation and management of labour pain. In the future, more research has to be done to illuminate this essential part of the childbearing woman's paradigm.

Aims and objectives To evaluate the effects of noninvasive electroacupuncture at LI4 or SP6 acupuncture points on labour pain and duration. Background The management of labour pain is one of the main goals of obstetrical care. Acupuncture has been reported to be useful for reducing labour length and for pain relief during labour. Design This was an experimental study with a control group. Methods The study was conducted at the Kayseri Maternity Hospital in Turkey. The participants were in the active phase of labour and were divided into three groups. In the LI4 group (n = 40), bilateral LI4 acupuncture points were stimulated using transcutaneous electrical nerve stimulation-acupuncture pen. In the SP6 group (n = 40), the acupuncture points of both legs were stimulated. The same procedure that was performed for the LI4 group was used for the SP6 group. The control group (n = 40) did not receive any stimulation. Visual Analog Scale was used for the assessment of pain. Results Duration of labour from initiation of the intervention was 6·2 ± 6·0 hours in the LI4 group, 7·2 ± 6·1 hours in the SP6 group and 8·2 ± 9·9 hours in the control group. Pain scores in the LI4 group were found as 8·0 (4–10) in the 30th minute after the intervention, while they were 9·0 (4–10) in the SP6 group and 10·0 (2–10) in the control group. There was not a statistically significant difference between the groups in terms of labour duration and pain scores measured during contraction and between contractions. Conclusion Although they were not statistically significant, labour pain scores and labour duration were lower in the acupuncture groups, especially in the LI4 group. Relevance to clinical practice Noninvasive electroacupuncture on the LI4 acupuncture point could be used easily during labour for labour pain relief.

This is the protocol for a review and there is no abstract. The objectives are as follows: To compare the effects (see outcomes below) of different total* doses (in terms of boluses, concentration, volume and timeframe) of opioid epidural (excluding combined-spinal epidural and intrathecal) analgesia administered (alone or as adjunctive) during labour on the woman and the infant. To compare the safety (see outcomes below) of different total* doses (as above) of opioid epidural analgesia administered during labour for the woman and the infant. *We define ‘total’ as the sum of all boluses and infusions (concentration, volume and timeframe) administered between onset of labour (as defined by authors) and delivery. If analgesia post-delivery is reported, we shall describe this separately. We shall undertake secondary analyses of drug concentrations and volumes, see Types of interventions. However, since opioids pass into the fetus, and may accumulate, total dose is an important consideration for infant adverse events, such as drowsiness. (see Why it is important to do this review).

Summary To improve the analgesic efficiency and to simplify the administration of remifentanil for systemic analgesia in labour, we contrived a modified delivery regimen with a specific infusion profile and variable dosing and conducted a single-blind randomised crossover study to compare it with the previous ‘classical’ regimen. Parturients received both regimens in interchangeable sets, each with five contractions. We compared pain and satisfaction scores, maternal and fetal vital parameters, side-effects and other events. Twenty-three parturients completed the study. No differences in observed parameters were noticed except for slightly lower blood pressure with the modified regimen. Pain estimates were lower in women starting with the modified regimen (p = 0.005), and there were fewer requests for analgesia within the lockout period (31 vs 69, p = 0.041) and bolus adjustments (0 vs 25, p

Several strategies and alternative therapies have been used to provide analgesia for labour pain. Over the last few years, a number of improvements have enhanced the efficacy and safety of neuraxial analgesia and ultimately have improved mothers' satisfaction with their birth experience. As labour analgesia is a field of obstetric anaesthesia that is rapidly evolving, this review is an update, from a clinical point of view, of developments over the last 5-7 years. We discuss advantages and controversies related to combined spinal-epidural analgesia, patient controlled epidural analgesia and the integration of computer systems into analgesic modalities. We also review the recent literature on future clinical and research perspectives including ultrasound guided neuraxial block placement, epidural adjuvants and pharmacogenetics. We finally look at the latest work with regards to epidural analgesia and breastfeeding.

Background and purpose: While remifentanil can be used either during labour or fetal surgery, more should be known about the transplacental transfer of this opioid. The aim of this study was to investigate the placental transfer and haemodynamic effects of remifentanil after i.v. administration to pregnant ewes. Experimental approach: Seven pregnant ewes received a continuous infusion of remifentanil (0.33 mu g.kg(-1).min(-1)) for 1 h, and maternal and fetal arterial blood samples were drawn at regular intervals during and up to 1 h after the discontinuation of the infusion. Haemodynamic parameters were monitored continuously. Blood gas samples were drawn at baseline and once during the infusion. Key results: Peak maternal remifentanil plasma levels of 4.0 +/- 0.9 ng.mL(-1) (mean +/- SD) and peak fetal plasma levels of 0.4 +/- 0.3 ng.mL(-1) were obtained. Remifentanil plasma levels dropped rapidly after the discontinuation of the infusion. The continuous infusion of remifentanil did not result in significant maternal or fetal haemodynamic changes. Conclusions and implications: Remifentanil rapidly passes through the placenta of pregnant ewes and although remifentanil concentrations stay significantly lower in the fetus compared with those in the mother, remifentanil can be detected in significant amounts in the fetus. British Journal of Pharmacology (2010) 161, 1472-1476; doi:10.1111/j.1476-5381.2010.00783.x

Aims. The purpose of the study was to investigate the effects of music on pain reaction and anxiety during labour. Background. Music therapy has been used on clinical medicine. Only few scientific studies validate the value on labour women. Design. Randomised controlled trial. Methods. Sixty primiparas expected to have a normal spontaneous delivery were randomly assigned to either the experimental group (n = 30) or the control group (n = 30). The experimental group received routine care and music therapy, whereas the control group received routine care only. A self-report visual analogue scale for pain and a nurse-rated present behavioural intensity were used to measure labour pain. Anxiety was measured with a visual analogue scale for anxiety and finger temperature. Pain and anxiety between groups were compared during the latent phase (2–4 cm cervical dilation) and active phase (5–7 cm) separately. Results. Our results revealed that compared with the control group, the experimental group had significantly lower pain, anxiety and a higher finger temperature during the latent phase of labour. However, no significant differences were found between the two groups on all outcome measures during the active phase. Conclusions. This study provides evidence for the use of music as an empirically based intervention of women for labour pain and anxiety during the latent phase of labour. Relevance to clinical practice. The findings support that music listening is an acceptable and non-medical coping strategy for labouring women. Especially, apply in reducing the pain and anxiety for women who are at the early phase of labour.

Keywords: Acupuncture; Biofeedback; Complementary and alternative medicine; Hypnosis; Intracutaneous sterile water injections; Labour pain; Massage

Background. This topic had not been researched previously and the information gained could have implications for midwives working with Chinese women everywhere. Aims. To explore the specific childbirth expectations of Hong Kong Chinese first-time pregnant women. Methods. This was a cross-sectional descriptive survey study and a Chinese version of the Childbirth Expectations Questionnaire was used to collect data. The sample consisted of 186 first-time pregnant women who first attended the antenatal clinic at a large public hospital in a major geographical region of Hong Kong. Results. Results showed that the Chinese pregnant women, the majority of who had not attended childbirth education classes, had high expectations of support from both their partners and midwives during labour and delivery. Conversely, expectations toward their own ability to cope with pain were relatively low. In addition, the pregnant women expressed concerns about the severity of labour pain and indicated low expectations about minimal use of medical interventions during labour. Conclusions. This study results add to the existing literature about childbirth expectations of first-time pregnant Hong Kong Chinese women. Midwife educators should incorporate the findings into childbirth education classes to help pregnant women develop realistic and positive expectations.

To evaluate the relief of pain in labour with subcutaneous and intracutaneous injections of sterile water, compared with placebo.Randomised controlled trial.Labour ward with approximately 3000 deliveries annually in a suburban area near Gothenburg, Sweden.Ninety-nine pregnant women at term, requiring pain relief for severe lower back pain during the first stage of labour. The women were randomised to receive four injections of 0.1 mL sterile water (without salt) intracutaneously (n = 33), four injections of 0.5 mL sterile water subcutaneously (n = 33) or placebo treatment (n = 33).Reduction of labour pain measured by visual analogue scale.The median visual analogue scale pain score for labour pain was significantly lower compared with initial values in the two study groups and compared with placebo at 10 and 45 minutes after treatment. The median reductions in visual analogue scores after 10 minutes were 5.0 cm and 4.5 cm in the intracutaneous and subcutaneous injection groups, respectively; women in the placebo group scored a median reduction of 1.7 cm. After 45 minutes the median reductions in the visual analogue scores were 4.9 cm and 4.0 cm in the intracutaneous and subcutaneous injection groups, respectively, compared with 1.0 cm for women in the placebo group. No significant differences in analgesic effect or pain experienced during administration were found between the two study groups.The new subcutaneous method of administering sterile water, as well as the earlier described intracutaneous injection method, were effective for the relief of pain in labour.

Summary: The use of epidural analgesia (EA) during labour is increasing in Australasia. This highlights the need for improved educational and resource materials, current factual information about EA, and identification of consumer attitudes towards EA. In this survey, 350 parturients who had recently used EA for labour pain relief in a single maternity unit were asked to complete a questionnaire about their expectations and experience. The response rate was 90%. Prepartum information was most commonly derived from hearsay and least commonly from medical health professionals, 56% of respondents wanted pain to be made tolerable and 34% wanted complete pain relief. Almost half considered unrestricted mobility and delivery without obstetric assistance important. A minority were concerned about possible effects of EA on the baby or labour outcome. Anticipated pain during epidural placement was significantly greater than that experienced. Satisfaction with EA was high, although 36% described unpleasant or annoying effects associated with EA. Parent educators and epidural service providers should be aided by knowledge of where parturients obtain information and of consumer views about EA.

We describe a case of pneumomediastinum and subcutaneous emphysema during labour. The patient had previously received an epidural anaesthesia to alleviate labour pain. We found several reports of subcutaneous emphysema and pneumomediastinum (or pneumothorax) possibly caused by or related to epidural anaesthesia use, but conclude that the epidural anaesthesia was probably not a cause in our case.

BACKGROUND Intrathecal injection of sufentanil offers labour pain relief of short duration. This double-blind randomised study evaluates if the combination of adenosine to sufentanil could give relevant prolongation (40%) of the duration of sufentanil spinal analgesia. METHODS Twenty-five healthy parturients requesting labour analgesia were included. Patients received 10 micro g of sufentanil + 500 micro g of adenosine or 10 micro g of sufentanil intrathecally. Pain intensity and duration of pain relief were assessed. RESULTS Pain relief was equal between groups. Duration of analgesia was not increased by adenosine + sufentanil, 99 +/- 54 min, vs. sufentanil, 89 +/- 56 min. CONCLUSION Adding 500 micro g of adenosine to 10 micro g of sufentanil could not provide any prolongation of labour pain relief.

Smith CA, Collins CT, Crowther CA, Levett KM. Acupuncture or acupressure for pain management in labour. Cochrane Database Syst Rev 2011; 7: CD009232.

Smith CA, Collins CT, Crowther CA. Aromatherapy for pain management in labour. Cochrane Database Syst Rev 2011; 7: CD009215.

Hjelmstedt A, Shenoy ST, Stener-Victorin E, Lekander M, Bhat M, Balakumaran L, Waldenstrom U. Acupressure to reduce labor pain: a randomized controlled trial. Acta Obstet Gynecol 2010; 89: 1453–9.

SUMMARY The pain-relieving effect of pethidine 100 mg and dihydrocodeine 30 mg was investigated in 419 women during labour pain in three hospitals. A double-blind technique was used, and the two drugs were given as the first and second injection to every other parturient woman. The analgesic effects of the drugs were rated as “good” when more than 50% pain relief was obtained, “fair” when 50% relief was obtained, and “poor” when less than 50% pain relief was achieved. The results from the three hospitals were consistent enough to warrant pooling of the data. When the total number of doses for each drug were compared, pethidine 100 mg gave “good” pain relief in 64.2% against 41.4% when dihydrocodeine 30 mg was used. When “paired doses” of the drugs were considered, the percentage of “good” pain relief afforded by pethidine was 76.5 and that by dihydrocodeine 47.1. The newborn infants were given a score according to a system suggested by V. Apgar (1953)1. Evaluation of the data thus obtained revealed that the scores of the infants whose mothers had received pethidine within 4 hours prior to delivery were significantly lower than the scores of those whose mothers had been given no analgesic. The number of observations on infants whose mothers had been given dihydrocodeine was small, and the differences between this group and the two others may have been due to chance.