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Maternal-fetal surgery is a rapidly evolving specialty, and significant progress has been made over the last 3 decades. A wide range of maternal-fetal interventions are being performed at different stages of pregnancy across multiple fetal therapy centers worldwide, and the anesthetic technique has evolved over the years. The American Society of Anesthesiologists (ASA) recognizes the important role of the anesthesiologist in the multidisciplinary approach to these maternal-fetal interventions and convened a collaborative workgroup with representatives from the ASA Committees of Obstetric and Pediatric Anesthesia and the Board of Directors of the North American Fetal Therapy Network. This consensus statement describes the comprehensive preoperative evaluation, intraoperative anesthetic management, and postoperative care for the different types of maternal-fetal interventions.

Purpose of review Recognition of the increasing maternal mortality rate in the United States has been accompanied by intense efforts to improve maternal safety. This article reviews recent advances in maternal safety, highlighting those of particular relevance to anesthesiologists. Recent findings Cardiovascular and other chronic medical conditions contribute to an increasing number of maternal deaths. Anesthetic complications associated with general anesthesia are decreasing, but complications associated with neuraxial techniques persist. Obstetric early warning systems are evolving and hold promise in identifying women at risk for adverse intrapartum events. Postpartum hemorrhage rates are rising, and rigorous evaluation of existing protocols may reveal unrecognized deficiencies. Development of regionalized centers for high-risk maternity care is a promising strategy to match women at risk for adverse events with appropriate resources. Opioids are a growing threat to maternal safety. There is growing evidence for racial inequities and health disparities in maternal morbidity and mortality. Summary Anesthesiologists play an essential role in ensuring maternal safety. While continued intrapartum vigilance is appropriate, addressing the full spectrum of contributors to maternal mortality, including those with larger roles beyond the immediate peripartum time period, will be essential to ongoing efforts to improve maternal safety.

Background Traditionally, epidural analgesia has been maintained using a continuous infusion (CEI) with the addition of patient‐controlled boluses (PCEA). In recent years, programmed intermittent boluses (PIEB) has emerged as an alternative showing better efficacy in randomized studies. In this study, the aim was to test PIEB + PCEA vs CEI + PCEA using an epidural solution containing adrenaline. Methods In total, 150 nulliparous and multiparous laboring women were randomized to maintain epidural analgesia with either PIEB + PCEA (5 ml bolus every hour, 5 ml PCEA bolus lockout 20 minutes) or CEI + PCEA (5 ml/h, 5 ml PCEA bolus, lockout 20 minutes) using a solution of bupivacaine 1mg/ml, fentanyl 2 mcg/ml and adrenaline 2 mcg/ml. The primary outcome was total hourly consumption of the epidural solution. Secondary outcomes included hourly pain scores, motor block at 60 minutes and 10 cm cervical dilation, maternal satisfaction, and the need for anesthetist intervention and time to this intervention. Results We found no differences in hourly drug consumption between the groups (mean 9.0 ml/h (SD 3.7) (CEI group) vs. 8.1 ml/h (SD 2.0) (PIEB group), P = .08). We found a significant difference in number of successfully administered PCEA boluses (mean no. 3.9 (SD 4.1) (CEI group) vs. 1.9 (SD 2.0) (PIEB group), P < .001). We found no significant differences in pain score, motor block, maternal satisfaction and the need for anesthetist intervention. Conclusion In this study, we found no clinically relevant differences using PIEB + PCEA compared to CEI + PCEA when using an epidural solution containing adrenaline. Editorial Comment For labor epidural analgesia infusions, to optimize the analgesic effect, additional programmed intermittent boluses can be used as an alternative to patient‐controlled boluses only. In this clinical trial, no differences in drug consumption or analgesic effect was observed when comparing these two different epidural bolus controls programs.

Background Neuraxial labor analgesia is known to increase the rate of instrumental delivery and prolong the second stage of labor; however, there is no standard method to evaluate the progress of labor under analgesia. Friedman curve is considered the gold standard for evaluating the progress of labor. However, it included not only neuraxial labor analgesia but also labor without analgesia. Thus we compared the labor curves of primiparous women undergoing labor with and without neuraxial labor analgesia, to understand the progress of labor in both groups and to arrive at a standard curve to monitor the progress of labor under neuraxial analgesia. Methods Primiparous women with cephalic singleton pregnancies who delivered at term from 2016 to 2017 were included. Two hundred patients who opted for combined spinal-epidural (CSE) labor analgesia were included in the CSE group and 200 patients who did not undergo CSE were included in the non-CSE group. In all, 400 cases were examined retrospectively. The evaluation parameters were cervical dilation and fetal station, and we calculated the average value per hour to plot the labor curves. Results The labor curve of the non-CSE group was significantly different from the Friedman curve. In the CSE group, the time from 4 cm dilation of the cervix to full dilation was 15 h; in addition, the speed of cervical dilation was different from that in the non-CSE group. The progress of labor in the CSE group was faster than that in the non-CSE group during the latent phase; however, the progress in the CSE group was slower than that in the non-CSE group during the active phase. Conclusions Neuraxial labor analgesia results in early cervical dilation and descent of the fetal head; thus, appropriate advance planning to manage the delivery may be essential.

Neuraxial analgesia provides excellent pain relief in labor. Optimizing initiation and maintenance of neuraxial labor analgesia requires different strategies. Combined spinal-epidurals or dural puncture epidurals may offer advantages over traditional epidurals. Ultrasound is useful in certain patients. Maintenance of analgesia is best achieved with a background regimen (either programmed intermittent boluses or a continuous epidural infusion) supplemented with patient-controlled epidural analgesia and using dilute local anesthetics combined with opioids such as fentanyl. Nitrous oxide and systemic opioids are also used for pain relief. Nitrous oxide may improve satisfaction despite variable effects on pain. Systemic opioids can be administered by healthcare providers or using patient-controlled analgesia. Appropriate choice of drug should take into account the stage and progression of labor, local safety protocols, and maternal and fetal/neonatal side effects. Pain in labor is complex, and women should fully participate in the decision-making process before any one modality is selected.

Caesarean delivery is the most commonly performed inpatient surgical procedure globally. Pain after caesarean delivery is moderate to severe if not adequately treated, and is a primary anaesthetic concern for patients. Transversus abdominis plane and quadratus lumborum blocks are fascial plane blocks that have the potential to improve analgesia following caesarean delivery. Although proponents of the quadratus lumborum block suggest that this technique may provide better analgesia compared with transversus abdominis plane block, there are limited data directly comparing these two techniques. We, therefore, performed a systematic review and network meta-analysis to compare transversus abdominis plane and quadratus lumborum block approaches, seeking randomised controlled trials comparing both techniques to each other, or to control, with or without intrathecal morphine. In all, 31 trials with 2188 patients were included and our primary outcome, the cumulative intravenous morphine equivalent consumption at 24 h, was reported in 12 trials. In the absence of intrathecal morphine, transversus abdominis plane and quadratus lumborum blocks were equivalent, and both were superior to control (moderate-quality evidence). In the presence of intrathecal morphine, no differences were found between control, transversus abdominis plane and quadratus lumborum blocks (moderate-quality evidence). Similar results were found for resting and active pain scores at 4-6 h, 8-12 h, 24 h and 36 h, although quadratus lumborum block was associated with lower pain scores at 36 h when compared with transversus abdominis plane block (very low-quality evidence). However, transversus abdominis plane block was associated with a reduced incidence of postoperative nausea and vomiting (moderate-quality evidence) and sedation when compared with inactive control following intrathecal morphine administration (low-quality evidence). There are insufficient data to draw definitive conclusions, but transversus abdominis plane and quadratus lumborum block appear to be superior to control in the absence of intrathecal morphine, but provide limited additional benefit over inactive control when intrathecal morphine is also used.

Epidural analgesia has been associated with more frequent intrapartum fever as well as neonatal antibiotic therapy. We examined whether intrapartum fever carries the same risk for neonatal sepsis with and without epidural.This is a retrospective cohort study of 34,371 deliveries at a single institution. Primary outcome variables included neonatal sepsis, Apgar scores, neonatal intensive care (NICU) admission, postpartum hemorrhage, prolonged labor, and cesarean delivery. Univariate analysis and multivariable logistic regression were used to assess the risk of sepsis while controlling for possible confounding covariables.A total of 34,371 patients were included in the study, 16,917 (49.9%) of whom had epidural anesthesia. Of the patients who had an epidural, 2103 (12.4%) had an intrapartum fever, compared to 446 (2.6%) of those who did not have an epidural (Neonates were less likely to sustain a diagnosis of sepsis in the setting of an epidural-associated fever compared to those in the setting of an intrapartum fever without an epidural. These data may be used by providers in counseling and guideline creation.

The programmed intermittent epidural bolus technique has shown superiority to continuous epidural infusion techniques, with or without patient-controlled epidural analgesia for pain relief, reduced motor block and patient satisfaction. Many institutions still use patient-controlled epidural analgesia without a background infusion, and a comparative study between programmed intermittent epidural bolus and patient-controlled epidural analgesia without a background infusion has not yet been performed. We performed a randomised, two-centre, double-blind, controlled trial of these two techniques. The primary outcome was the incidence of breakthrough pain requiring a top-up dose by an anaesthetist. Secondary outcomes included: motor block; pain scores; patient satisfaction; local anaesthetic consumption; and obstetric and neonatal outcomes. We recruited 130 nulliparous women who received initial spinal analgesia, and then epidural analgesia was initiated and maintained with either programmed intermittent epidural bolus or patient-controlled epidural analgesia using ropivacaine 0.12% with sufentanil 0.75 µg·ml-1 . The programmed intermittent epidural bolus group had a programmed bolus of 10 ml every hour, with on-demand patient-controlled epidural analgesia boluses of 5 ml with a 20 min lockout, and the patient-controlled epidural analgesia group had a 5 ml bolus with a 12 min lockout interval; the potential maximum volume per hour was the same in both groups. The patients in the programmed intermittent epidural bolus group had less frequent breakthrough pain compared with the patient-controlled epidural analgesia group, 7 (10.9%) vs. 38 (62.3%; p < 0.0001), respectively. There was a significant difference in motor block (modified Bromage score ≤ 4) frequency between groups, programmed intermittent epidural bolus group 1 (1.6%) vs. patient-controlled epidural analgesia group 8 (13.1%); p = 0.015. The programmed intermittent epidural bolus group had greater local anaesthetic consumption with fewer patient-controlled epidural analgesia boluses. Patient satisfaction scores and obstetric or neonatal outcomes were not different between groups. In conclusion, we found that a programmed intermittent epidural bolus technique using 10 ml programmed boluses and 5 ml patient-controlled epidural analgesia boluses was superior to a patient-controlled epidural analgesia technique using 5 ml boluses and no background infusion.

Background: Despite being an efficacious means of labour analgesia, there is a broad range of usage rates among countries worldwide. Australia sits between common usage in North America and more conservative usage in the UK. The reason for this is unclear, raising the question of whether there is a difference between Australia and other Western countries in pregnant women's attitudes toward epidural use, or the hospital context. Aim: To explore predictors for epidural analgesia request among pregnant women in Townsville, Australia. Materials and Methods: A three-phase mixed methods exploratory study design, with Phase One involving 12 one-on-one interviews with pregnant and post-partum women regarding attitudes toward labour analgesia decision-making and epidural preferences. Interview data were analysed thematically to develop a survey distributed to 265 third-trimester women in Phase Two. Phase Three involved a chart review of survey participants to record delivery mode, epidural request and indication. Bivariate and logistic regression analysis of Phases Two and Three data were used to develop predictive models for epidural decision-making. Results: Interviews revealed several themes influencing analgesia preferences in Townsville women: concerns regarding personal safety, trust in health professionals, and previous experiences with labour. The logistic regression identified epidural request in labour to be predicted by: primiparity, epidural experience, induction or augmentation of labour, and perceived sense of control associated with epidural use. Conclusions: This study suggests that the most significant influencers on Townsville women's epidural decision-making were parity, induction or augmentation of labour, previous experience of epidurals and attitude toward epidurals.

Objective To test for an association between blood loss and time until pushing (TUP) after full cervical dilation in nulliparous women with epidural analgesia. Methods A prospective cohort study was performed at the University Hospital of Zurich between October 2015 and November 2016. Included were 228 nulliparous women with singleton pregnancy, planned vaginal delivery after 36 completed weeks of gestation, epidural analgesia, and guided active pushing. TUP was defined as the interval between full cervical dilation and initiation of active pushing. The primary outcome measure was blood loss, assessed by the postpartum decrease in hemoglobin (ΔHb), estimated blood loss, and rate of ΔHb ≥30 g/L. Associations between TUP and primary and secondary maternal and neonatal delivery outcomes were assessed using Spearman correlation, Mann-Whitney U test, Kruskal-Wallis test, or Fisher exact test, as appropriate. Results Longer TUP correlated significantly with increased ΔHb (ρ=0.142, P=0.033) and higher rates of ΔHb ≥30 g/l (P=0.002). Composite adverse maternal and neonatal outcomes were unaffected. Conclusion On the grounds of increased maternal blood loss, and in contrast to the current International Federation of Gynecology and Obstetrics (FIGO) guideline, delayed active pushing is not recommended in nulliparous women with epidural analgesia.

Purpose of review Even if its use is scarce in most countries, many articles concerning combined spinal epidural (CSE) were published. In this review, we present the latest advances concerning CSE in obstetrics. Recent findings During labour, CSE improves epidural analgesia quality. Epidural with intradural opioids can produce maternal hypotension and foetal heart rate abnormalities (FHR-Ab), without increasing the caesarean section rate. For caesarean section, CSE decreases the neuraxial block failure rate, with no significant increase of complications. Epidural volume extension (EVE) after CSE for caesarean section could be an interesting option even though more evidence is needed. Summary For labour analgesia, CSE has the fastest onset time of analgesia. Its side effects have no consequences on maternal, labour or foetal outcomes. It provides better analgesia than epidural analgesia and can be used for external cephalic version and high-risk patients. For caesarean section, CSE has become the reference neuraxial technique for low-dose spinal anaesthesia, with higher success rate compared with regular spinal anaesthesia. Recent systematic revisions did not confirm this superiority. CSE offers the advantage of EVE, intraoperative top-ups, postoperative administration of neuraxial opioids and local anaesthetics. The risk of complications is balanced by the benefits of the technique.

Introduction Epidural hydromorphone could be useful in obstetric analgesia as there is a need for a more water-soluble opioid than sufentanil or fentanyl with prolonged analgesic effect. To our knowledge, the pharmacokinetics of epidural hydromorphone has not been evaluated in parturients. Materials and methods In this pilot study, seven healthy parturients were given a single epidural dose of hydromorphone for labour pain. One parturient received 1.5 mg, two 0.75 mg and four 0.5 mg of hydromorphone hydrochloride. Dose was decreased due to nausea and pruritus. Hydromorphone’s effect, adverse effects and plasma concentrations were evaluated. Neonatal drug exposure was evaluated by umbilical vein and artery opioid concentration at birth. Neonatal outcomes were assessed using Apgar and the Neurologic Adaptive Capacity Score (NACS). Results All patients received additional levobupivacaine doses on parturients’ requests. The first dose was requested at a median of 163 min (range 19–303 min) after hydromorphone administration. A total of 12 opioid related expected adverse events were reported by seven parturients. All newborn outcomes were uneventful. Hydromorphone’s distribution and elimination after single epidural dose seem similar to that reported for non-pregnant subjects after intravenous hydromorphone administration, but further research is required to confirm this observation. Conclusions The optimal dose of hydromorphone in labour pain warrants further evaluation.

Background The provision of epidural analgesia during labor is ideally a shared decision between the woman and her health care provider. However, immigrant characteristics such as maternal birthplace could affect decision-making and thus access to pain relief. We aimed to assess disparities in the provision of epidural analgesia in planned vaginal birth according to maternal region of birth. Methods We performed a nation-wide register study of 842,496 live-born singleton deliveries in Norway between 2000 and 2015. Maternal birthplace was categorized according to the Global Burden of Disease framework. The provision of epidural analgesia was compared in regression models stratified by parity and mode of delivery. Results Compared to native-born women, primiparous women from Latin America/Caribbean countries with an instrumental vaginal delivery were most likely to be provided epidural analgesia (OR 2.12, 95%CI 1.69–2.66), whilst multiparous women from Sub-Saharan Africa with a spontaneous vaginal delivery were least likely to be provided epidural analgesia (OR 0.42, 95% C 0.39–0.44). Longer residence time was associated with a higher likelihood of being provided analgesia, whereas effects of maternal education varied by Global Burden of Disease group. Conclusions Disparities in the likelihood of being provided epidural analgesia were observed by maternal birthplace. Further studies are needed to consider whether the identified disparities represent women’s own preferences or if they are the result of heterogeneous access to analgesia during labor.

OBJECTIVES The purpose was to compare the effects of 3 different dose combinations of bupivacaine and sufentanil on the onset of analgesia and the occurrence of side effects. MATERIALS AND METHODS One hundred sixty-nine pregnant women were randomly assigned to 3 groups: the B1S5 group received 0.1% bupivacaine+5 μg sufentanil in 15 mL; the B125S5 group received 0.125% bupivacaine+5 μg sufentanil in 15 mL; and the B1S10 group received 0.1% bupivacaine+10 μg sufentanil in 15 mL. The primary outcome was the analgesic onset time, and the secondary outcomes were mode of delivery, patient satisfaction, maternal and neonatal side effects (pruritus, hypotension, sedation, motor block, decreased fetal heart rate, fever, and interference with breastfeeding). RESULTS The median (inter-quartile range) time to achieve effective analgesia was significantly faster in the B125S5 group than in the B1S5 group (10 [11-14 {4-30}] min vs. 15 [17-20 {5-30}] min, P

BACKGROUND The dural puncture epidural (DPE) technique is associated with faster onset than the conventional epidural (EP) technique for labor analgesia. The programmed intermittent epidural bolus (PIEB) mode for maintaining labor analgesia allows for lower anesthetic drug consumption than the continuous epidural infusion (CEI) mode. Whether DPE technique with PIEB mode offers additional benefits for analgesia onset, local anesthetic drug consumption, and side effects versus EP or DPE techniques with CEI mode remains unclear. METHODS Nulliparous women with a visual analog scale (VAS) pain score >50 mm and cervical dilation

To determine the effectiveness of extending epidural analgesia following epidural labor analgesia for intrapartum cesarean section, and provide a reference for clinical practice.Data of 1254 singleton parturient who failed trial of epidural labor analgesia and underwent intrapartum cesarean section were retrospectively included. After entering the operating room, parturient were given 3 ml of 1.5% lidocaine with 1:200,000 epinephrine 15 µg as a test dose, followed by a dose of 10 ml 0.75% ropivacaine plus 5 ml of 2% lidocaine mixed solution was administeredOf the 1254 parturient, 4.7% (59 of 1254) underwent general anesthesia directly, 7.1% (89 of 1254) were given combined spinal and epidural anesthesia, and the other 88.2% (1106 of 1254) underwent extending epidural anesthesia, 3.5% (39 of 1106) of them were given general anesthesia after extending epidural anesthesia failed, and 96.5% (1067 of 1106) parturient have a successful extending epidural anesthesia. Adverse reactions of extending epidural anesthesia: 6.7% (72 of 1067) parturient experienced hypotension and 12.1% (129 of 1067) of nausea and vomiting occurred. For the neonatal Apgar scores at 1 min, eleven of 1254 (0.9%) newborns were between 0 and 3 points, 107 (8.5%) newborns between 4 and 7 points, and 1136 (90.6%) newborns Apgar scores between 8 and 10 point. 24 (1.9%) newborns with Apgar scores between 4 to 7 points at 5 min transferred to the department of neonatology, and the rest 1230 (98.1%) newborns with Apgar scores 8-10 points.Extending epidural analgesia using the well-functioning epidural catheter for epidural labor analgesia might be a reliable and effective anesthetic method for intrapartum cesarean section.

Objectives First, to compare the manual sagittal and parasagittal and automated parasagittal methods of measuring the angle of progression (AoP) by transperineal ultrasound during labor, and, second, to develop models for the prediction of time to delivery and need for Cesarean section (CS) for failure to progress (FTP) in a population of patients undergoing induction of labor. Methods This was a prospective observational study of transperineal ultrasound in a cohort of 512 women with a singleton pregnancy undergoing induction of labor. A random selection of 50 stored images was assessed for inter- and intraobserver reliability of AoP measurements using the manual sagittal and parasagittal and automated parasagittal methods. In cases of vaginal delivery, univariate linear, multiple linear and quantile regression analyses were performed to predict time to delivery. Univariate and multivariate binomial logistic regression analyses were performed to predict CS for FTP in the first stage of labor. Results The intraclass correlation coefficient (ICC) for the manual parasagittal method for a single observer was 0.97 (95% CI, 0.95-0.98) and for two observers it was 0.96 (95% CI, 0.93-0.98), indicating good reliability. The ICC for the sagittal method for a single observer was 0.93 (95% CI, 0.88-0.96) and for two observers it was 0.74 (95% CI, 0.58-0.84), indicating moderate reliability for a single observer and poor reliability between two observers. Bland-Altman analysis demonstrated narrower limits of agreement for the manual parasagittal approach than for the sagittal approach for both a single and two observers. The automated parasagittal method failed to capture an image in 19% of cases. The mean difference in AoP measurements between the sagittal and manual parasagittal methods was 11°. In pregnancies resulting in vaginal delivery, 54% of the variation in time to delivery was explained in a model combining parity, epidural and syntocinon use during labor and the sonographic findings of fetal head position and AoP. In the prediction of CS for FTP in the first stage of labor, a model which combined maternal factors with the sonographic measurements of AoP and estimated fetal weight was superior to one utilizing maternal factors alone (area under the receiver-operating-characteristics curve, 0.80 vs 0.76). Conclusions First, the method of measuring AoP with the greatest reliability is the manual parasagittal technique and future research should focus on this technique. Second, over half of the variation in time to vaginal delivery can be explained by a model that combines maternal factors, pregnancy characteristics and ultrasound findings. Third, the ability of AoP to provide clinically useful prediction of CS for FTP in the first stage of labor is limited. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.

This study aimed to identify the maternal, labour and newborn risk factors associated with an Apgar score of ≤3 in the first minute of life. This was a cross-sectional evaluation from an internal database information system in a tertiary referral obstetric and neonatal centre. Newborns with gestational age ≥24 weeks and birth weight ≥500 g with a registered Apgar score in the first minute of life were included. A total of 4475 newborns had an Apgar score3 and 154 newborns had an Apgar score ≤3 in the first minute of life. A multivariate analysis revealed that eclampsia (OR = 31.53), twin pregnancy (OR = 7.06), analgesia (OR = 1.97), prematurity (OR = 2.00) and caesarean section (OR = 2.06) were risk factors for an Apgar score ≤3 in the first minute of life. Identification of these risk factors indicates prompt assistance during prenatal and labour care to prevent neonatal hypoxia and low Apgar scores, identifying newborns that may need resuscitation procedures.Impact Statement

Objective To evaluate the efficacy of wound infusion with ropivacaine plus ketorolac compared with placebo for post-cesarean delivery analgesia in women who received a multimodal analgesic regimen including intrathecal morphine. Methods In a randomized double-blind study, women undergoing scheduled cesarean delivery under spinal or combined spinal epidural anesthesia were randomized to wound infusion with ropivacaine 0.2% plus ketorolac, or saline placebo using an elastometric pump for 48 hours. The primary outcome was pain score with movement at 24 hours after surgery (0-10 scale, 0=no pain and 10=worst possible pain). Secondary outcomes included pain scores at rest at 24 hours, pain scores at rest and with movement at 2 and 48 hours, opioid consumption, and time to first rescue analgesic. A sample size of 35 per group (n=70) was planned. Results From November 8, 2016, to May 17, 2019, 247 women were screened, and 71 completed the study per protocol: 38 in the placebo group and 33 in the ropivacaine plus ketorolac group. Patient demographics and intraoperative characteristics were comparable between the groups. There was no significant difference between the groups in the primary outcome of pain score with movement at 24 hours (difference in median score 0, 95% CI -1 to 2, P=.94). There were also no significant differences between the placebo and ropivacaine plus ketorolac groups in pain scores at other time points, in total opioid consumption (difference in median consumption -12.5 mg, 95% CI -30 to 5, P=.11), or in time to rescue analgesics (median [interquartile range] 660 [9-1,496] vs 954 [244-1,710] minutes, hazard ratio 0.69, 95% CI 0.41 to 1.17, P=.16). Conclusion There was no benefit of wound infusion with ropivacaine and ketorolac in women who received intrathecal morphine and a multimodal analgesic regimen. Clinical trial registration ClinicalTrials.gov, NCT02829944. Funding source The study was supported in part by Avanos Medical Inc.

Background Studies report an increased risk of maternal and fetal adverse side effects when combined spinal-epidural, rather than standard epidural, analgesia is provided for labour and delivery. Intrathecal opioids used with local anaesthetic in combined spinal-epidural analgesia may be a cause. It is not known whether this is due to the addition of opioid to local anaesthetic in the intrathecal space only or due to concomitant administration into the intrathecal and epidural spaces. Methods We searched for randomised trials comparing maternal, obstetrical and neonatal outcomes in parturients having combined spinal-epidural or standard epidural analgesia, and compared subgroups of patients according to the route of administration of opioids in combined spinal-epidural techniques. Studies were evaluated for eligibility and quality. Fixed and random-effects models were used for pooled data analysis and outcomes were compared using relative risk (RR) or mean difference with 95% confidence intervals (CI). Results We identified 1658 reports and 41 fully published randomised controlled trials. In patients who received combined spinal-epidural techniques, an increased risk of nausea/vomiting (RR 1.31, CI 1.0 to 1.72), pruritus (RR 4.26, CI 2.59 to 7.0) and fetal bradycardia (RR 2.38, CI 1.57 to 3.62) was observed regardless of the route of administration. In contrast, hypotension occurred more frequently after combined intrathecal and epidural opioid (RR 1.54, 1.22 to 1.93; P-value 0.02 for subgroup difference). Conclusion For combined spinal-epidural techniques, the administration of opioids in combination with local anaesthetic, particularly when used in both the intrathecal and epidural space, should be carefully considered.

Background: The programmed intermittent epidural bolus (PIEB) technique is widely used in labor analgesia, but the parameter settings of PIEB have not yet been standardized. We designed a study to identify the optimal interval duration for PIEB using 10 mL of ropivacaine 0.08% and sufentanyl 0.3 μg/mL, a regimen commonly used to control labor pain in China, to provide effective analgesia in 90% of women during the first stage of labor without breakthrough pain. Methods: We conducted a double-blind sequential allocation trial to obtain the effective interval 90% (EI90%) during the first stage of labor between April 2019 and May 2019. This study included the American Society of Anesthesiologists physical status II–III nulliparous parturients at term, who requested epidural analgesia. The bolus volume was fixed at 10 mL of ropivacaine 0.08% with sufentanyl 0.3 μg/mL. Participants were divided into four groups (groups 60, 50, 40, and 30) according to the PIEB intervals (60, 50, 40, and 30 min, respectively). The interval duration of the first parturient was set at 60 min and that of subsequent parturients varied according to a biased-coin design. The truncated Dixon and Mood method and the isotonic regression analysis method were used to estimate the EI90% and its 95% confidence intervals (CIs). Results: Forty-four women were enrolled in this study. The estimated optimal interval was 44.1 min (95% CI 41.7–46.5 min) and 39.5 min (95% CI 32.5–50.0 min), using the truncated Dixon and Mood method and isotonic regression analysis, respectively. The maximum sensory block level above T6 was in nearly 20% of parturients in group 30; however, 5.3%, 0%, and 0% of the parturients presented with sensory block level above T6 in groups 40, 50, and 60, respectively. There were no cases of hypotension and only one parturient complained of motor block. Conclusion: With a fixed 10 mL dose of ropivacaine 0.08% with sufentanyl 0.3 μg/mL, the optimal PIEB interval is about 42 min. Further studies are warranted to define the efficacy of this regimen throughout all stages of labor. Trial registration: Chinese Clinical Trial Registry, ChiCTR1900022199; http://www.chictr.org.cn/com/25/historyversionpuben. aspx?regno=ChiCTR1900022199. Key words: Anaesthetic techniques; First stage labor; Labor analgesia; Ropivacaine

A number of studies show that acupuncture may help with labour and delivery. An NHS maternity acupuncture service providing birth preparation acupuncture has assessed its routine hospital maternity annual data from 2014 to 2016 to see what effect it had on labour and delivery outcomes. The data from this service was analysed and women who had birth preparation acupuncture were compared with those who did not receive it. Maternal age, parity and socio-economic status were considered confounders and were adjusted for in the analysis. Women who received acupuncture had more normal births (less surgical births) [OR 0.76 (0.64, 0.91)], required less intrapartum analgesia [OR 0.74 (0.63, 0.86)], fewer components of an induction of labour [OR 0.74 (0.61, 0.91)] and a reduced length of a hospital stay [OR 0.91 (0.87, 0.95)]. The patients highly valued the availability of acupuncture within the maternity service as it enhanced their patient journey.Impact statementWhat is already known on this subject? Numerous studies provide evidence for the effects of acupuncture in normalising pregnancy and birth. These effects include musculoskeletal preparation of the pelvis, cervical ripening, enhancing endogenous oxytocin release, and analgesic properties.What do the results of this study add? Our analysis shows that women who received birth preparation acupuncture had fewer surgical births, required less intrapartum analgesia, less components of induction of labour and had a reduced length of hospital stay, supporting the use of maternity acupuncture in normalising birth outcomes.What are the implications of these findings for clinical practice and/or further research? The findings show that acupuncture, by potentially normalising birth, may lead to reductions in costs of service. Further, additional research is required to see whether acupuncture is cost effective and could have an adjunctive role as a complementary therapy for improving birth outcomes and a woman's experience of childbirth.

The effects of neuraxial analgesia on fetal heart tracings have been studied in "healthy" pregnancies. Our objective was to compare the impact of intrapartum epidural analgesia (EA) versus combined spinal epidural analgesia (CSE) on fetal heart rate changes in pregnancies at risk for uteroplacental insufficiency (UPI).Singleton pregnancies diagnosed with chronic hypertension, gestational hypertension and/or preeclampsia, and/or fetal growth restriction (FGR) and receiving neuraxial analgesia intrapartum from 2012 to 2015 were studied retrospectively. The primary outcome was change in fetal heart rate (FHR) category following neuraxial analgesia. Manual review of all FHR tracings was performed and classified by the National Institute of Child Health and Human Development (NICHD) categories. Data collection included maternal demographics, blood pressure, uterine tachysystole, uterine hypertonus, mode of delivery, interventions for FHR abnormalities and neonatal outcomes.Of laboring patients at risk for UPI, 110 patients received EA and 127 patients received CSE. The rate and change in FHR categories and abnormalities following neuraxial analgesia were the same in both groups. Both EA and CSE resulted in a significant increase in NICHD FHR category II, from 27.3 to 65.5% for EA and 20.9 to 64.3% for CSE. The occurrence of maternal hypotension, uterine tachysystole, interventions for FHR abnormalities, and uterine hypertonus following neuraxial analgesia was not found to be significantly different between the two groups. When compared to the EA group, CSE had a higher rate of NICU admission (29.5 versus 16.4%,FHR category increased following both CSE and EA. The side effects of maternal hypotension and need for fetal interventions was not different between CSE and EA.

This study used functional magnetic resonance imaging to explore the neural networks of pain during labor and its relief. It was hypothesized that epidural analgesia would affect the neural activities and the underlying network connectivity. Analysis using dynamic causal modelling and functional connectivity was performed to investigate the spatial activity and network connection of labor pain with and without epidural analgesia. This Institutional Review Board approved study acquired Magnetic Resonance Imaging from 15 healthy women of spontaneous normal delivery (with/without epidural analgesia = 7/8, aged 29.6 ± 2.3 and 29.3 ± 4.8 years old respectively) using a 1.5 Tesla scanner. Numerical rating score of pain was evaluated by a research nurse in the beginning of the first stage of labor and approximately 30 min after imaging examination. Six regions of interested from the activated clusters and literature were selected for dynamic causal modelling, which included primary and secondary somatosensory cortex, middle frontal gyrus, anterior cingulate cortex, insula and lentiform. Functional connectivity was calculated from selected sensory and affective regions. All analyses were performed by using software of statistical parametric mapping version 8 and CONN functional connectivity toolbox. The result showed that the experience of labor pain can lead to activations within a distributed brain network. The pain relief from epidural analgesia can be accompanied with altered functional connectivity, which was most evident in the cingulo-frontal system. The present study, therefore, provides an overview of a pain-related neural network that occur during labor and upon epidural analgesia.

Background Remifentanil patient-controlled analgesia (rPCA) and epidural analgesia (EA) has been used for pain relief in labor. We aimed to evaluate the efficacy and safety of rPCA versus EA in labor, to provide evidence support for clinical analgesia and pain care. Methods We searched PubMed, EMBASE, ScienceDirect, Cochrane Library, China National Knowledge Infrastructure (CNKI), Wanfang and Weipu databases for RCTs comparing rPCA and EA in labor until February 15, 2022. Two researchers independently screened literature and extracted data. RevMan 5.3 software was used for data analysis. Results A total of 10 RCTs involving 3086 parturients were enrolled, 1549 parturients received rPCA and 1537 received EA. Meta-analysis indicated that the incidence of intrapartum maternal fever within 1 hour of labor analgesia (OR = 0.43, 95%CI: 0.30~0.62), after 1 hour of labor analgesia (OR = 0.42, 95%CI: 0.20~0.90) in the rPCA was significantly less than that of EA (all P0.05). Conclusion rPCA can be an optional alternative to EA with similar pain relief and less risk of intrapartum maternal fever. However, rPCA was associated with increased risk of respiratory depression. Future studies with rigorous design and larger sample size are needed to provide more reliable evidences for clinical rPCA and EA use.

This manuscript aims to review the risks and the current treatments for postdural puncture headache (PDPH).PDPH is a relatively frequent complication after neuraxial blocks. It is typically orthostatic in nature, presenting as a positional and dull aching or throbbing headache, with added dysregulation of auditory and/or visual signals. Certain characteristics, such as female sex and young age, may predispose patients to the development of PDPH, as may factors such as previous PDPH, bearing down during the second stage of labor, and the neuraxial technique itself. Long-term complications including chronic headache for years following dural puncture have brought into question of the historical classification of PDPH as a self-limiting headache. So far, the underlying mechanism governing PDPH remains under investigation, while a wide variety of prophylactic and therapeutic measures have been explored with various degree of success. In case of mild PDPH, conservative management involving bed rest and pharmacological management should be used as first-line treatment. Nerve blocks are highly efficient alternatives for PDPH patients who do not respond well to conservative treatment. In case of moderate-to-severe PDPH, epidural blood patch remains the therapy of choice. An interdisciplinary approach to care for patients with PDPH is recommended to achieve optimal outcomes.

Lumbar epidural is the most effective form of pain relief in labor with around 30% of laboring women in the UK and 60% in the USA receiving epidural analgesia. Associations of epidural on maternal, obstetric, and neonatal outcomes have been the subject of intense study, though a number of uncertainties persist. The present narrative review explores important areas of research surrounding epidural analgesia in obstetric patients including methods of initiation and administration, choice of local anesthetic solution, and the addition of adjuvants. Key meta-analyses exploring associations of epidural analgesia on maternal and neonatal outcomes are identified and summarized.

Background. Side effects of the use of opioid analgesics during painless delivery are the main factors that affect rapid postpartum recovery. Opioid use can result in dangerous respiratory depression in the patient. Opioids can also disrupt the baby’s breathing and heart rate. The nonopioid analgesic dexmedetomidine, a new a2-adrenergic agonist, possesses higher selectivity, greater analgesic effects, and fewer side effects. Moreover, epidural administration of dexmedetomidine also reduces local anesthetic consumption. Objective. Our study aims to compare the analgesic effects as well as the side effects of ropivacaine with dexmedetomidine against sufentanyl as an epidural labor analgesia. Methods. This study is a randomized, double-blinded, controlled trial (registration no. ChiCTR2200055360) involving 120 primiparous (a woman who has given birth once), singleton pregnancy women who are greater than 38 weeks into gestation and have requested epidural labor analgesia. The participants were randomized to receive 0.1% ropivacaine with sufentanyl (0.4 μg/ml) or dexmedetomidine (0.4 μg/ml). The primary outcomes included Visual Analogue Score (VAS), duration of first epidural infusions, the requirement of additional PCEA bolus, and adverse reactions during labor analgesia. Results. Of the 120 subjects who consented, 91 parturient women (women in the condition of labor) had complete data for analysis. Demographics and VAS, as well as maternal and fetal outcomes, were similar between the groups. The duration of first epidural infusions in dexmedetomidine was significantly longer than sufentanyl (median value: 115 vs 68 min, P P P

Neuraxial labor analgesia is associated with elevations in maternal temperature; the mechanism responsible is unknown. Proposed mechanisms have included infection, altered thermoregulation, and inflammation, potentially triggered by local anesthetics. Studies of the association between neuraxial labor analgesia and maternal fever have focused on epidural analgesia, and there have been no comparisons of the rate of maternal fever between continuous spinal and epidural labor analgesia.We performed a retrospective study to compare the rate of maternal fever between patients who received continuous spinal versus epidural labor analgesia between June 2012 and March 2020. Each patient who received continuous spinal analgesia was matched to 2 patients who received epidural analgesia and had the same nulliparous status. The primary outcome of our study was the incidence of intrapartum maternal fever, which we defined as any temperature ≥38 °C before delivery and compared between the continuous spinal and epidural groups using Fisher exact test.We identified 81 patients who received continuous spinal analgesia and 162 matched controls who received epidural analgesia. Demographic and obstetric characteristics of the patients were similar between groups. While the duration of analgesia did not significantly differ, there was markedly increased bupivacaine consumption in women with epidural analgesia. Eight of 81 (9.9%; 95% confidence interval [CI], 5.1-18.3) women with continuous spinal analgesia developed an intrapartum fever compared to 18 of 162 (11.1%; 95% CI, 7.1-16.9) of women with epidural analgesia ( P = .83; Fisher exact test).There was no significant difference in the rate of maternal fever between women with continuous spinal compared to epidural labor analgesia. While the route of administration and dose of bupivacaine differs between epidural and spinal labor analgesia, they are titrated to produce similar levels of neuraxial blockade. Our results are consistent with a model in which epidural related maternal fever is due to altered thermoregulation from a central neuraxial block and argue against a direct effect of bupivacaine or fentanyl, although we cannot rule out a concentration-independent effect of bupivacaine or fentanyl or an inflammatory effect of the catheter itself. These retrospective results highlight the importance of prospective and mechanistic study of neuraxial analgesia-related maternal fever.

The fetal head malposition in labor leads to prolonged labor, cesarean delivery and increased perinatal morbidity. Epidural analgesia has been associated with fetal head malposition, but it remains unknown if this relation is causal.To compare the incidence of fetal malposition during labor and maternal/fetal outcomes, between women who received epidural analgesia with those who did not use the analgesic method.Case control study including 500 women with a single fetus in vertex position who gave birth at term at the Policlinic Hospital of Modena between May 2019 and July 2019. Two-hundred and fifty women belonged to theThe rate of posterior occiput positions occurred 4 times more frequently in the EA group than in the control group (8.8% vs 2.2%,Women receiving epidural analgesia in labor have higher rate of fetal malposition, prolonged labors, and more cesarean sections than controls. However, further studies are required to confirm a causal association between EA and fetal head malposition.

During the last decades, the age of pregnant women significantly increased. The incidence of maternal and labor complications is higher among older women, but conclusive data have not been delivered whether labor epidural analgesia (EA) may affect the duration of labor and delivery outcomes in this population of patients. The aim of this study is to evaluate the effect of EA among women aged over 35 years.We retrospectively reviewed medical records of all, singleton, at term deliveries, laboring with EA, between December 2011 and October 2017. Women aged ≥35 years (study group) were compared with women aged35 years (control group) to evaluate EA effects on the duration of labor and neonatal outcome.The study enrolled 459 women with EA: 122 women were included in the study group and 337 in the control group. The multiple regression analysis showed that parity was an independent variable for a shorter dilation period (Results of this study indicate that women aged ≥35 with EA may have labor duration and neonatal short-term outcomes similar to younger women with EA.

Background: Up to 80% of women use some form of pharmacological analgesia during labour and birth. The side effects of pharmacological agents are often incompatible with the concurrent use of non-pharmacological pain-relieving strategies, such as water immersion, ambulation and upright positioning, or may have negative effects on both the mother and foetus. Sterile water injections given into the skin of the lumbar region have been demonstrated to reduce back pain during labour. However, the injections given for back pain have no effect on abdominal contraction pain. The analgesic efficacy of sterile water injections for abdominal pain during childbirth is unknown. The injections cause an immediate, brief but significant pain that deters some women from using the procedure. This study aims to investigate the use of water injections given intradermally into the abdomen to relieve labour contraction pain. A vapocoolant spray will be applied to the skin immediately prior to the injections to reduce the injection pain. Methods: In this pragmatic, placebo-controlled trial, 154 low-risk women in labour at term with a labour pain score ≥ 60 on a 100-ml visual analogue scale (VAS) will be randomly allocated to receive either six injections of sterile water or a sodium chloride 0.9% solution as a placebo (0.1–0.3 ml per injection). Three injections are given along the midline from the fundus to the supra-pubis and three laterally across the supra-pubis. The primary outcome will be the difference in VAS score 30 min post-injection between the groups. Secondary outcomes include VAS score of the injection pain on administration, VAS score of labour pain at 60 and 90 min and maternal and neonatal birth outcomes. Discussion: Access to effective pain relief during labour is fundamental to respectful and safe maternity care. Pharmacological analgesics should support rather than limit other non-pharmacological strategies. Sterile water injections have the potential to provide an alternative form of labour pain relief that is easy to administer in any labour and birth setting and is compatible with other non-pharmacological choices. Trial registration: ANZCTR ACTRN12621001036808. Registered on 05 August 2021. CC BY 4.0This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data.© 2022, The Author(s).Correspondence to Nigel Lee.Springer NatureThe trial was funded by the Australian Government Department of Health Medical Research Future Fund (APP2006488)Corrigendum in: Trials 23, Article number: 321 (2022). doi:10.1186/s13063-022-06171-6

ObjectivesTo investigate whether neuraxial analgesia and other medical interventions have effects on the circadian rhythm of labor.MethodsIt was a retrospective propensity score matched cohort study. Parturients were recruited, who delivered term singletons in cephalic position, from seven hospitals in Harvard University Partners Healthcare Systems, 2016–2018. The parturients were divided into two groups, neuraxial analgesia delivery and spontaneous vaginal delivery, the stratification was performed according to labor induction, oxytocin, operative delivery. The parturients in each group were divided into 12 periods in every 2 h based on the birth time of babies. Cosine function fitting was used to verify whether the birth time had the characteristic of circadian rhythm.ResultsIn spontaneous vaginal deliveries, the peak of birth time was at 2:00–4:00, and the nadir was at 14:00–16:00, this showed a circadian rhythm presented by a cosine curve fitting with the formula (y = 0.0847 + 0.01711 × cos(− 0.2138 × x + 0.4471). The labor rhythm of NAD (Neuraxial Analgesia Delivery) group changed completely, inconsistent with the cosine curve fitting of the circadian rhythm. The intervention of induction and oxytocin blurred the circadian rhythm of SVD (Spontaneous Vaginal Delivery) group and increased the amplitude of the fluctuation in NAD (Neuraxial Analgesia Delivery) group. The intervention of operative delivery had changed the distribution curve completely both in the SVD (Spontaneous Vaginal Delivery) group and the NAD (Neuraxial Analgesia Delivery) group.ConclusionsNeuraxial analgesia did affect on circadian rhythm of labor, changed the cosine rhythm of labor with spontaneous vaginal delivery, and this trend was aggravated by the use of induction, oxytocin and operative delivery.

Nitrous oxide is commonly used in Australia for labour analgesia. Its use in labour is potentially associated with aerosol generation. During the first wave of the COVID-19 pandemic of 2020, nitrous oxide was suspended on many birthing units to reduce the risk of transmission. We aimed to determine the impact of withholding nitrous oxide for labour analgesia, during the COVID-19 pandemic, on epidural rates, opioid analgesia use, and maternal and neonatal outcomes. Withholding nitrous oxide for labour analgesia did not alter epidural rates but did significantly increase opioid analgesia use. Caesarean section rates, post-partum blood loss and neonatal APGAR scores did not change. Refereed/Peer-reviewed

Introduction: Epidural analgesia is considered a gold standard in obstetric anaesthesia and analgesia. However, in situation when it is contraindicated, unwanted by the patient or simply unavailable, remifentanil can be an excellent alternative. The goal of our study is to analyse the side effects of intravenous patient-controlled analgesia (IV PCA) with remifentanil compared with epidural analgesia during delivery. Material and methods: This study included 155 pregnant women in term for birth, divided into 2 groups: a remifentanil group (RG), and an epidural group (EG). Patients in the RG received intravenous PCA with remifentanil, while patients in the ЕG received epidural analgesia with programmed intermittent bolus dosing. Our primary outcome was maternal safety; the secondary outcome was neonatal safety. Results: The results present a significantly lower SaO2 value of the parturients in the RG (96.95 ± 1.4 vs 98.22 ± 0.6), and a significantly higher respiratory rate per minute in the EG at all time points after the onset of analgesia (20.85 ± 1.4 vs 18.67 ± 0.9). There was more frequent sedation, nausea and vomiting in the RG, while in the EG there was a more elevated temperature, itching and irregularities in the CTG record. Regarding the newborn, there was no significant difference between the two groups in the Apgar scores, pH, pCO2, pO2, and bicarbonate, while there was a significantly lower value of the base excess in the RG group. Conclusion: PCA with remifentanil is safe for the mother, foetus and the newborn, with minimal side effects. Continuous respiratory monitoring, oxygen supply and following of all consensus recommendations are mandatory.

Background The trial of labor after cesarean section (TOLAC) is a relatively new technique in mainland of China, and epidural analgesia is one of the risk factors for uterine rupture. This study aimed to evaluate the effect of epidural analgesia on primary labor outcome [success rate of vaginal birth after cesarean (VBAC)], parturient complications and neonatal outcomes after TOLAC in Chinese multiparas based on a strictly uniform TOLAC indication, management and epidural protocol. Methods A total of 423 multiparas undergoing TOLAC were enrolled in this study from January 2017 to February 2018. Multiparas were divided into two groups according to whether they received epidural analgesia (study group, N = 263) or not (control group, N = 160) during labor. Maternal delivery outcomes and neonatal characteristics were recorded and evaluated using univariate analysis, multivariable logistic regression and propensity score matching (PSM). Results The success rate of VBAC was remarkably higher (85.55% vs. 69.38%, p p p = 0.003, and p Conclusions Epidural analgesia could reduce labor pain, and no increased risk of postpartum bleeding or uterine rupture, as well as adverse effects in newborns were observed. The labor duration of multiparas was increased, but within acceptable range. In summary, epidural analgesia may be safe for both mother and neonate in the three studied hospitals. Trial registration Chineses Clinical Trial Register, ChiCTR-ONC-17010654. Registered February 16th, 2017.

Background Labor represents a period of significant physical activity. Inefficient energy supply may delay labor process and even lead to cesarean delivery. Herein we investigated whether ingestion of a carbohydrate-rich beverage could reduce cesarean delivery in laboring women with epidural analgesia. Methods This multicenter randomized trial was conducted in obstetrician-led maternity units of nine tertiary hospitals in China. Primigravidae with single term cephalic pregnancy who were preparing for vaginal birth under epidural analgesia were randomized to intake a carbohydrate-rich beverage or commercially available low-carbohydrate beverages during labor. The primary outcome was the rate of cesarean delivery. Secondary outcomes included maternal feeling of hunger, assessed with an 11-point scale where 0 indicated no hunger and 10 the most severe hunger, and maternal and neonatal blood glucose after childbirth. Results Between 17 January 2018 and 20 July 2018, 2008 women were enrolled and randomized, 1953 were included in the intention-to-treat analysis. The rate of cesarean delivery did not differ between the two groups (11.3% [111/982] with carbohydrate-rich beverage vs. 10.9% [106/971] with low-carbohydrate beverages; relative risk 1.04, 95% CI 0.81 to 1.33; p = 0.79). Women in the carbohydrate-rich beverage group had lower subjective hunger score (median 3 [interquartile range 2 to 5] vs. 4 [2 to 6]; median difference − 1; 95% CI − 1 to 0; p < 0.01); their neonates had less hypoglycemia (1.0% [10/968] vs. 2.3% [22/956]; relative risk 0.45; 95% CI 0.21 to 0.94; p = 0.03) when compared with those in the low-carbohydrate beverage group. They also had higher rates of maternal hyperglycemia (6.9% [67/965] vs. 1.9% [18/953]; p < 0.01) and neonatal hyperglycemia (9.2% [89/968] vs. 5.8% [55/956]; p < 0.01), but none required special treatment. Conclusions For laboring primigravidae with epidural analgesia, ingestion of a carbohydrate-rich beverage compared with low-carbohydrate beverages did not reduce cesarean delivery, but relieved maternal hunger and reduced neonatal hypoglycemia at the expense of increased hyperglycemia of both mothers and neonates. Optimal rate of carbohydrate supplementation remains to be determined. Trial registration www.chictr.org.cn; identifier: ChiCTR-IOR-17011994; registered on 14 July 2017.

The effect of massage for pain relief during labour has been controversial. This study investigated the efficacy of a programme combining intrapartum massage, controlled breathing, and visualisation for non-pharmacological pain relief during labour.This randomised controlled trial was conducted in two public hospitals in Hong Kong. Participants were healthy low-risk nulliparous Chinese women ≥18 years old whose partners were available to learn massage technique. Recruitment was performed at 32 to 36 weeks of gestation; women were randomised to attend a 2-hour childbirth massage class at 36 weeks of gestation or to receive usual care. The primary outcome variable was the intrapartum use of epidural analgesia or intramuscular pethidine injection.In total, 233 and 246 women were randomised to the massage and control groups, respectively. The use of epidural analgesia or pethidine did not differ between the massage and control groups (12.0% vs 15.9%; P=0.226). Linear-by-linear analysis demonstrated a trend whereby fewer women used strong pharmacological pain relief in the massage group, and a greater proportion of women had analgesic-free labour (29.2% vs 21.5%; P=0.041). Cervical dilatation at the time of pethidine/epidural analgesia request was significantly greater in the massage group (3.8 ± 1.7 cm vs 2.3 ± 1.0 cm; P0.001).The use of a massage programme appeared to modulate pain perception in labouring women, such that fewer women requested epidural analgesia and a shift was observed towards the use of weaker pain relief modalities; in particular, more women in the massage group were analgesic-free during labour.