Search

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.

Postoperative delirium is an important public health concern without effective prevention strategies. This study tested the hypothesis that perioperative epidural use would be associated with decreased risk of delirium through postoperative day 3.This was a secondary, observational, nonrandomized analysis of data from The Prevention of Delirium and Complications Associated With Surgical Treatments Trial (PODCAST; NCT01690988). The primary outcome of the current study was the incidence of delirium (ie, any positive delirium screen, postanesthesia care unit through postoperative day 3) in surgical patients (gastrointestinal, hepatobiliary-pancreatic, gynecologic, and urologic) receiving postoperative epidural analgesia compared to those without an epidural. As a secondary outcome, all delirium assessments were then longitudinally analyzed in relation to epidural use throughout the follow-up period. Given the potential relevance to delirium, postoperative pain, opioid consumption, sleep disturbances, and symptoms of depression were also analyzed as secondary outcomes. A semiparsimonious multivariable logistic regression model was used to test the association between postoperative epidural use and delirium incidence, and generalized estimating equations were used to test associations with secondary outcomes described. Models included relevant covariates to adjust for confounding.In total, 263 patients were included for analysis. Epidural use was not independently associated with reduced delirium incidence (adjusted odds ratio, 0.65 [95% CI, 0.32-1.35]; P = .247). However, when analyzing all assessments over the follow-up period, epidural patients were 64% less likely to experience an episode of delirium (adjusted odds ratio, 0.36 [95% CI, 0.17-0.78]; P = .009). Adjusted pain scores (visual analog scale, 0-100 mm) were significantly lower in the epidural group on postoperative day 1 (morning, -16 [95% CI, -26 to -7], P.001; afternoon, -15 [95% CI, -25 to -5], P.01) and postoperative day 3 (morning, -13 [95% CI, -20 to -5], P.01). Adjusted mean oral and IV morphine equivalents were also significantly lower on postoperative day 1 in the epidural group (74% lower [95% CI, 55%-85%]; P.0001). Finally, postoperative epidural use was not significantly associated with new sleep disturbances or changes in depression symptoms.Postoperative epidural use was not associated with a reduced overall incidence of delirium. However, longitudinal analysis revealed reduced adjusted odds of experiencing an episode of delirium in the epidural group. Epidural use was also associated with reduced postoperative pain and opioid consumption. An appropriately designed follow-up study is warranted to further analyze the relationship among epidural use, postoperative delirium, and related outcomes.

Objective To investigate whether the proportion of pregnant women who use epidural analgesia during birth differed between women registered at a maternity clinic randomised to Mindfetalness or to routine care. Design An observational study including women born in Sweden with singleton pregnancies, with spontaneous onset of labour from 32 weeks' gestation. Data used from a cluster-randomised controlled trial applying the intention-to-treat principle in 67 maternity clinics where women were randomised to Mindfetalness or to routine care. ClinicalTrials.gov (NCT02865759). Interventions Midwives were instructed to distribute a leaflet about Mindfetalness to pregnant women at 25 weeks' gestation. Mindfetalness is a self-assessment method for the woman to use to become familiar with the unborn baby's fetal movement pattern. When practising the method in third trimester, the women are instructed to daily lie down on their side, when the baby is awake, and focus on the movements' intensity, character and frequency (but not to count each movement). Findings Of the 18 501 women with spontaneous onset of labour, 47 percent used epidural during birth. Epidural was used to a lower extent among women registered at a maternity clinic randomised to Mindfetalness than women in the routine-care group (46.2% versus 47.8%, RR 0.97, CI 0.94-1.00, p= 0.04). Epidural was more common among primiparous women, women younger than 35 years, those with educational levels below university, with BMI ≥25 and with a history of receiving psychiatric care or psychological treatment for mental illness. Conclusions and implications for practice Pregnant women who were informed about a self-assessment method, with the aim of becoming familiar with the unborn baby's fetal movement pattern, used epidural to a lower extent than women who were not informed about the method. Future studies are needed to investigate and understand the association between Mindfetalness and the reduced usage of epidural during birth.

A positive birth experience for the mother is an important goal in obstetric health care and is influenced by several factors. For this study, 186 women filled in questionnaires between 24 and 72 hours after giving birth vaginally. We evaluated the Big-Five personality traits (extraversion, neuroticism, openness, conscientiousness and agreeableness), trait anxiety, different dimensions of childbirth experience and pain management. Correlation analysis revealed that trait anxiety and neuroticism were negatively associated with several dimensions of the birth experience. Furthermore, conscientiousness and extraversion were positively correlated with the dimension Participation. Regression analysis for the individual dimensions and overall score respectively, confirmed the independent impact of anxiety trait on Perceived Safety, Participation and Professional Support and the overall score as well as of neuroticism on Perceived Safety and conscientiousness on Participation. The significant regression models showed small R2-scores (.084-.154). The birth experience did not differ whether the women received an epidural or not. Women who did not receive an epidural displayed higher scores on the personality trait conscientiousness. The study highlights small but important associations between personality traits and birth experience in vaginal births which should sensitize the medical staff when supporting women during labor.

BACKGROUND/OBJECTIVE: To evaluate the association between the duration of the latent phase of labor and subsequent processes and outcomes. METHODS: Secondary analysis of prospectively collected data among 1,189 women with low-risk pregnancies and spontaneous labor. RESULTS: Longer latent phase duration was associated with labor dystocia (eg, nulliparous ≥ mean [compared with < mean] aOR 3.95 [2.70–5.79]; multiparous ≥ mean [compared with < mean] aOR 5.45 [3.43–8.65]), interventions to ameliorate dystocia, and epidurals to cope or rest (eg, oxytocin augmentation: nulliparous > 80th% [compared with < 80th%] aOR 6.39 [4.04–10.12]; multiparous ≥ 80th% [compared with < 80th%] aOR 6.35 [3.79–10.64]). Longer latent phase duration was also associated with longer active phase and second stage. There were no associations between latent phase duration and risk for cesarean delivery or postpartum hemorrhage in a practice setting with relatively low rates of primary cesarean. Newborns born to multiparous women with latent phase of labor durations at and beyond the 80th% were more frequently admitted to the NICU (≥80th% [compared with < 80th%] aOR 2.7 [1.22–5.84]); however, two-thirds of these NICU admissions were likely for observation only. CONCLUSIONS: Longer duration of the spontaneous latent phase of labor among women with low-risk pregnancies may signal longer total labor processes, leading to an increase in diagnosis of dystocia, interventions to manage dystocia, and epidural use. Apart from multiparous neonatal NICU admission, no other maternal or child morbidity outcomes were elevated with longer duration of the latent phase of labor.

Study objective To compare the rate of epidural use before and after the implementation of nitrous oxide (N 2 O). Design Data were obtained from a nursing database of N 2 O usage and our obstetric anesthesia database. We compared 8 months before and 8 months after the introduction of N 2 O. It was available 24 h/d, 7 d/wk, consistent with neuraxial analgesia availability. Epidural utilization before and after introduction of N 2 O was compared using χ 2 analysis. Setting Labor and delivery floor. Main results Total number of births over the study period was 8539: 4315 pre-N2O and 4224 post-N 2 O. The rate of epidural usage was 77% pre-N 2 O and 74% after N 2 O ( P = not significant, χ 2 ). A total of 762 patients used N 2 O. Monthly analysis showed no change in pattern of neuraxial analgesia use in post-N 2 O period compared with the pre-N 2 O period. Conclusion The introduction of N 2 O for labor analgesia was not associated with any change in our rate of labor epidural utilization. Under the conditions of our study, these results suggest that N 2 O does not discourage neuraxial use for labor pain relief.

Patient-controlled analgesia (PCA) and epidural are popular choices of analgesia postoperatively and in patients with complex pain syndromes. The aim was to assess the confidence of junior doctors in prescribing and monitoring PCA and epidurals on the ward. Additionally, we assessed the impact that this had on patient satisfaction. A survey was sent to all doctors of a UK hospital assessing confidence with PCA and epidural use between 1 December 2014 and 1 February 2015. We collected data on the participants’ specialty, …

INTRODUCTION AND OBJECTIVES:Epidural anesthesia is used to improve pain control after major surgery and has been associated with improved survival in some non-urologic cancers. Perioperative epidur...

Background Epidural analgesia increases length of labour and risk of operative delivery (caesarean or instrumental). Aim This study aimed to assess the impact of epidural anaesthesia on maternal and neonatal adverse outcomes when the second stage of labour was prolonged. Methods A retrospective cohort study of women delivering at term at the Mater Mother's Hospital, Brisbane between 2008 and 2017. Intrapartum, maternal and neonatal outcomes were assessed and dichotomised according to the presence of prolonged second stage of labour and further by epidural use. Prolonged second stage of labour was defined as: nulliparous women ≥3 h (with epidural) and ≥2 h (without); multiparous women ≥2 h (with epidural) and ≥1 h (without). Results There were 48 352 women who met the inclusion criteria - 43 676 without and 4676 with prolonged second stage of labour. The overall epidural rate was 35.9%. Women with epidural had significantly lower odds of achieving a spontaneous vaginal birth and higher odds of an operative birth regardless of length of second stage. While rates of several adverse maternal and neonatal outcomes were higher when the second stage was prolonged, after adjusting for clinically relevant confounders, epidural use was not associated with increased odds of the majority of these adverse outcomes. Indeed, epidural use was associated with a significant reduction in the odds of obstetric anal sphincter injuries and reduced odds of neonatal acidosis in women with prolonged second stage. Conclusion While epidural increases the risk of operative birth, this is not associated with an increase in adverse maternal or neonatal outcomes.

In the current study, we explored the relationship between a woman's personality, epidural use and perceptions of the labour and birth experience.Having a positive birthing experience is relevant to predicting a range of important outcomes including mother-infant bonding, fertility rates and delivery interventions. However, limited research has addressed the kinds of individual differences that may affect a woman's subjective birthing experience.One hundred and twenty-five women were surveyed about subjective aspects of the labour and birthing experience of their first-born child, including use of epidural, perceived pain, anxiety, self-capacity and positive experiences. The women also completed the Big Five personality inventory, which measures five dimensions of stable personality characteristics.Results show that four of the Big Five personality traits were found to correlate to the four different aspects of the labour and birth experience, and that these relationships were largely moderated by a woman's decision to have an epidural.These findings add to the limited body of research on the relationships between personality and the labour experience. They also highlight the importance of considering pain management decisions in understanding this relationship. Future research in this area may provide a new way for doctors, midwives and doulas to tailor support and intervention for women during the birthing process based on individual differences to help more women have positive birthing experiences.

In this book, we have set out to critically examine routine epidural use by exploring the personal, social, cultural, and institutional influences on women in deciding whether or not to use epidural analgesia in labour. By examining epidural analgesia, we also aimed to gain insight into hospital birth culture more broadly. This chapter concludes the book and the key themes are revisited. We contend that dominant conceptualisations of risk and safety, which influence midwifery practice and women’s experience of birth, are mediated by the institution. We draw the discussion to a close with reference to current literature and provide key ideas to contribute to the future of humanised birthing practices.

Fetal malposition, either occiput posterior or transverse (OT), leads to greater risk of cesarean delivery, prolonged labor, and increased perinatal morbidity. Historically, there is a known association between epidural use and malposition that was assumed to be due to the increased discomfort of laboring with a fetus in the occiput posterior position. However, evidence now suggests that the epidural itself may contribute to fetal malposition by impacting the probability of internal rotation. Fetal malposition may be impacted by manual rotation. Manual rotation has been associated with greater rates of delivering in the occiput anterior position and lower rates of cesarean delivery.

At our hospital, although90% of nulliparous parturients eventually choose epidural analgesia for labor, many delay its initiation, experiencing considerable pain in the interim. This survey probed parturients' views about the timing of initiation of epidural labor analgesia.Single-center, nonrandomized quantitative survey.Labor and delivery suite in a large tertiary academic medical center.Two hundred laboring nulliparous women admitted to the labor and delivery suite.After their pain was relieved, parturients completed a questionnaire regarding their decision to request labor epidural analgesia.A variety of factors regarding epidural use were assessed including the influence of painful contractions and of childbirth education class attendance on the decision to request epidural analgesia, and parturients' perception of the timing of epidural initiation on the progress and outcome of labor.Analysis revealed that the desire of parturients to use epidural analgesia was increased from 27.9% before the onset of painful contractions to 48.2% after (p0.01). Two-thirds of participants attended a non-physician taught childbirth education class. An antepartum plan to definitely forgo an epidural was 1.8 times more likely among women who attended a childbirth class when compared to those who did not attend. (OR=1.8; 95%CI:1.1-3.1; p=0.04). The most common views affecting decision-making were that epidural analgesia should not be administered "too early" (67.5%), and that it would slow labor (68.5%). Both of these views were more likely to be held if the parturient had attended a childbirth class, OR=2.0 (95%CI:1.1-3.8; p=0.03) and OR=2.0 (95% CI: 1.1 to 3.7; p=0.03), respectively.We found that nulliparous parturients have misconceptions about epidurals, which are not supported by evidence-based medicine. Moreover, we found that attendance at childbirth education classes was associated with believing these misconceptions.

Objective This study sought to assess change in knowledge and preference for epidural use associated with use of an information pamphlet and to explore women's decision-making and information needs regarding pain relief in labour. Methods Six focus groups with women who were pregnant or had given birth during the past 12 months were conducted in three northern communities in British Columbia. Following completion of a 10-item knowledge pretest, women were randomly assigned to read either a short version or a detailed version of the pamphlet and then complete a post-test. After reading the alternate pamphlet they participated in a moderated discussion. Pretest and post-test knowledge scores were compared, and a thematic analysis of focus group data was conducted. Results Knowledge scores increased (2.12 points out of a possible total of 10; standard deviation 2.38; 95% CI 1.38 to 2.87). There was no difference in knowledge change or epidural preferences according to which version participants read first. Women preferred the detailed version and indicated that its information was more balanced. Four themes related to decision-making and information needs arose from the focus groups: making an informed choice, being open-minded, wanting comprehensive information, and experiencing pressure to have/not have an epidural. Conclusion An illustrated information pamphlet can significantly increase women's knowledge of benefits and risks of epidural analgesia, but it is not associated with change of preference. Women prefer to receive comprehensive information prenatally to support informed choices in labour.

Background Ventral hernias are a common, challenging, and expensive problem for general and reconstructive surgeons. The authors assessed the impact of epidurals on morbidity following abdominal wall reconstruction for hernia. Methods A retrospective review of abdominal wall reconstruction patients operated on between 2007 and 2012 was performed with a specific focus on the use of epidurals. Bivariate and multivariate logistic regression analyses were used to assess independent predictors of morbidity. Subgroup analyses were also performed. Results The study included 134 consecutive reconstructions performed by a single surgeon over a 5-year period at an academic teaching center. Patient groups were similar in terms of demographics, preoperative characteristics, hernia grade, and intraoperative characteristics. Epidural use was associated with a lower incidence of major surgical complications (19.7 percent versus 36.1 percent; p = 0.04) and medical complications (26.8 percent versus 54.1 percent; p = 0.001). A significant and independent reduction in medical morbidity (OR, 0.09; p ≤ 0.001) and unplanned reoperations (OR, 0.23; p = 0.052), was found with patients receiving epidurals. Furthermore, a notable trend toward reduced major surgical complications (OR, 0.45; p = 0.141) and cost savings (-$22,184; p = 0.01) was found in patients who received epidurals. Subgroup analysis did not demonstrate statistically significant reductions in major surgical morbidity in reconstruction either with (p = 0.13) or without (p = 0.07) concurrent intra abdominal procedures when epidurals were not or were used, respectively. Conclusions Epidural use may be associated with reduced morbidity and cost savings in abdominal wall reconstruction. This effect appears to be related to reduced medical morbidity and shortened length of stay in patients undergoing more complex, concurrent intraabdominal hernia procedures. Clinical question/level of evidence Risk, II.

OBJECTIVE:To examine the length of second stage of labor with and without an epidural during labor.METHODS:This was a retrospective cohort study of 42,268 women who delivered vaginally with normal neonatal outcomes. Median lengths and 95th percentiles of second stage of labor were compared by epidur

Background The purpose of this study was to evaluate the effect of epidural analgesia use on postoperative complications in patients undergoing pancreaticoduodenectomy. Methods This retrospective cohort study used the 2009 Nationwide Inpatient Sample from the Agency for Healthcare Research and Quality. Patients who underwent pancreaticoduodenectomy were grouped on the basis of whether they received epidural analgesia. The effect of epidural use on the composite end point of major complications including death was investigated using a generalized linear model. Results Overall, 8,610 cases of pancreaticoduodenectomy occurred within the United States in 2009, and 11.0% of these patients received epidural analgesia. After controlling for various potential confounders, results of the multivariate regression indicated that epidural analgesia use was associated with lower odds of composite complications including death (odds ratio, .61; 95% confidence interval, .37–.99; P = .044). Conclusions In patients who underwent pancreaticoduodenectomy, epidural analgesia was associated with significantly lower postoperative composite complications.

Background: Identify variables associated with intrapartum epidural use. Methods: Odds ratios were calculated to quantify associations between selected variables and epidural use using a population-based case-control study of Washington State birth certificate data from 2009. Results: Non-Whites had 10 - 45% lower odds of epidural use relative to Whites. Foreign-born women had 25 - 45% lower odds of epidural use compared to their US-born counterparts, except for Asians. Women who smoked or induced labor had higher roughly 2-fold higher odds of epidural use compared with non-smokers or women giving birth spontaneously, respectively. Women without a high school diploma or equivalent had lower odds of epidural use relative to those who graduated. Delivering at perinatal units, rural hospitals, or non-profit hospitals had ~ 50% lower odds of epidural use compared with secondary / teritiary perinatal units, urban hospitals or for-profit hospitals, respectively. Conclusion: Several individual and health service-related variables were associated with epidural use. These findings elucidate the clinical relevance of epidural use, and dispariaties in its utilization and in quality of care during delivery. doi:10.4021/jocmr810w Correction in J Clin Med Res. 2016;8(8):623-623, http://dx.doi.org/10.14740/jocmr810wc1

OBJECTIVES: To examine the association of intrapartum temperature elevation with adverse neonatal outcome among low-risk women receiving epidural analgesia and evaluate the association of epidural with adverse neonatal outcome without temperature elevation. METHODS: We studied all low-risk nulliparous women with singleton pregnancies ≥37 weeks delivering at our hospital during 2000, excluding pregnancies where infants had documented sepsis, meningitis, or a major congenital anomaly. Neonatal outcomes were compared between women receiving (n = 1538) and not receiving epidural analgesia (n = 363) in the absence of intrapartum temperature elevation (≤99.5°F) and according to the level of intrapartum temperature elevation within the group receiving epidural (n = 2784). Logistic regression was used to evaluate neonatal outcome while controlling for confounders. RESULTS: Maternal temperature >100.4°F developed during labor in 19.2% (535/2784) of women receiving epidural compared with 2.4% (10/425) not receiving epidural. In the absence of intrapartum temperature elevation (≤99.5°F), no significant differences were observed in adverse neonatal outcomes between women receiving and not receiving epidural. Among women receiving epidural, a significant linear trend was observed between maximum maternal temperature and all neonatal outcomes examined including hypotonia, assisted ventilation, 1- and 5-min Apgar scores 101°F had a two- to sixfold increased risk of all adverse outcomes examined. CONCLUSIONS: The proportion of infants experiencing adverse outcomes increased with the degree of epidural-related maternal temperature elevation. Epidural use without temperature elevation was not associated with any of the adverse outcomes we studied.

Obese parturients are at high risk of complications during anaesthesia and early use of epidural analgesia in labour has been recommended for obese patients during labour. To assess the outcome of anaesthesia outpatient consultation for obese parturients. We retrospectively compared outcomes of obese patients antenatally and an obese and non-obese control group over a 1-year period. Outcomes included potential airway problems, anaesthetic for caesarean section, use and success of epidural analgesia and cervical dilation at epidural placement. The proportion of obese patients who had predictable intubation difficulty was low (5%). Epidural use analgesia in labour (69 vs 36 vs 66%, P = 0.148) was similar between groups (obese, obese controls and non-obese controls, respectively). Cervical dilation at the time of epidural insertion in the obese group (2.0, 1.0–3.0 cm) was not different from obese controls (3.0, 1.75–5.75 cm). There was no difference in the number of attempts required to site the epidural between groups or the number of patients that required resiting of the epidural catheter. General anaesthesia was not required in any emergency case in this group. The outcomes of obese patients attending the anaesthetic clinic were mixed. Not all patients who were to advised have epidurals did so but those who did requested them in early labour and there was no requirement for general anaesthesia during emergency caesarean section and adverse airway events were avoided in this group.

Summary Interventions of baccalaureate nursing students, trained as doulas, were examined for their association with epidural anesthetic use. Doulas, trained to support laboring mothers, are associated with shorter labors and fewer medical interventions. Data from a convenience sample of 89 vaginal births attended between 1999 and 2002 were analyzed. Analysis showed an association of lower epidural use with increased complementary doula interventions (.62 OR, P = . 003 ) and an association of higher epidural use with longer labors (1.22 OR, P = . 004 ). No significant association was found between epidural use and parity, income, education and type of health care provider. These findings support previous research of decreased analgesia use by doula-supported women and suggest benefits of the interventions by student nurse doulas. Students trained in providing low-tech supportive care may change the environment for intrapartum nursing practice. Institutional changes may be required to allow greater opportunity for intrapartal nurses to provide support to laboring women.

The history of intrathecal and epidural anaesthesia is in parallel with the development of general anaesthesia. As ether anaesthesia (1846) is considered the first modern anaesthetic since its use by Morton 157 yr ago, so Bier made history by using cocaine for intrathecal anaesthesia in 1898. The first published report on opioids for intrathecal anaesthesia belongs to a Romanian surgeon, Racoviceanu-Pitesti, who presented his experience at Paris in 1901. It was almost a century before the opioids were used for epidural analgesia. Behar and his colleagues published the first report on the epidural use of morphine for the treatment of pain in The Lancet in 1979. Epidural and intrathecal opioids are today part of a routine regimen for intra- and postoperative analgesia. Over the last 30 yr, the use of epidural opioids has became a standard for analgesia in labour and delivery, and for the management of chronic pain. Finally, epidural opioids have been shown to have a pre-emptive effect, when used before major surgery. We present the evolution of neuraxial anaesthesia and the history of intrathecal and epidural administration of opioids.

Sir, Spinal anaesthesia mandates adherence to strict asepsis to prevent potentially dreaded complications such as meningitis. Ampoule impurities can be a potential cause of breach in asepsis. Here, we report an incidence of macroscopic ampoule impurity while loading the local anaesthetic for subarachnoid block. Local anaesthetics used for spinal anaesthesia are usually available in a single use glass ampoule. Few properties that are responsible for its wide use are excellent chemical resistance, impermeability and ability to tolerate sterilisation process. Problems encountered due to the use of glass ampoules are micro particles contamination and occupational risk due to percutaneous injuries while trying to break open the ampoule. To prevent percutaneous injury, mechanisms such as one point cut (OPC) and ‘rupture disk’ have been developed. In the OPC system, a small incision is made in the neck or strangulation point of the ampoule, between the head of the ampoule and the body. A small dot placed a few millimetres above the incision indicates the correct orientation for snapping the ampoule open.[1] In the ‘rupture disk’ system, an area of fragility is caused at the strangulation point using a temper process that partially penetrates the glass causing an area of fragility or weak point. A band is then painted at the strangulation point, indicating its point of weakness[1] [Figure 1a]. Figure 1 (a) ‘Rupture disk’ system and one point cut system. (b) Impurity detected in the local anaesthetic solution In our case, a fragment of paint from the band accidentally fell into the local anaesthetic solution, while trying to break open the ampoule [Figure 1b]. As the impurity was detected before loading the local anaesthetic solution, the ampoule was discarded and a fresh ampoule was used. Contamination of ampoule with micro particles has been a constant concern among the healthcare providers and has been reported for a long time.[2] In the incident that we report, a visible particle of paint has contaminated the local anaesthetic solution. This not only exposes the patient to the risk of infection and meningitis, but also to a risk of organic reaction due to the injected particle. Meningitis following subarachnoid block has been reported before.[3,4] Meningitis can occur either due to a breach in asepsis during the procedure or due to the presence of pre-existing bacteraemia in the patient at the time when spinal is performed.[5] Though aseptic causes are more likely, the occurrence of septic meningitis is not uncommon. Strong adherence to asepsis can prevent purely iatrogenic complications such as meningitis from developing. It is preferable to use OPC system as an aid to snap open the ampoule in drugs intended for spinal and epidural use. Even if drugs are loaded from ampoules that have ‘rupture disk’ system, we strongly recommend careful inspection of the drug solution before loading the drug. Pre-sterilising the package and providing sterile ampoules have also been recommended to prevent infection. In addition, prudent measures should be taken to make spinal and epidural drugs available in shatterproof and easily snappable ampoules. The manufacturers should also ensure that the paint used in ‘rupture disk’ ampoule does not get fragmented while snapping open the ampoule. Use of filters in needles and use of smaller gauge needles have also been advocated as measures to reduce loading of glass micro particles in syringes.[1] Use of pre-filled syringes can be the way forward to prevent contamination of drug as well as occupational hazards. To conclude, careful inspection for visible ampoule impurities and ensuring strict asepsis can prevent iatrogenic complications during spinal anaesthesia. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

This survey describes the current provision of multidisciplinary Acute Pain Teams (APTs) in acute English hospitals performing adult in-patient surgery (excluding maternity). Associations between the presence of an APT and a number of organizational and clinical initiatives for the management of postoperative pain are also explored. Postal questionnaires were sent to the Clinical Director of Anaesthetics or head of the APT at every acute English hospital providing separate anaesthetic services. After written and telephone reminders, the response rate was 86% (n = 226). Eighty-four per cent (n = 190) of respondents had an APT in their hospital. The presence of an APT was associated (P

To examine the association of intrapartum temperature elevation with adverse neonatal outcome among low-risk women receiving epidural analgesia and evaluate the association of epidural with adverse neonatal outcome without temperature elevation.

Objective To study the association between maternal age and emergency operative delivery. The roles of in-labour indications, and birthweight ≥ 4000 g, gestational age ≥ 42 weeks, induction of labour, and epidural use, according to maternal age were explored. Design Population-based study. Setting Medical Birth Registry of Norway and Statistics Norway. Population We studied 169 583 low-risk primiparous mothers with singleton, cephalic labours, at ≥37 weeks of gestation, from 1999 to 2009. Methods The associations between maternal age and mode of delivery were analysed using multinomial regression analyses, adjusting for sociodemographic factors. Main outcome measures Emergency caesarean section and operative vaginal delivery. Results Of women aged ≥40 years, 22% had emergency caesarean sections and 24% had operative vaginal deliveries, giving adjusted relative risk ratios (RRRs) of 6.60 (95% confidence interval, 95% CI 5.53–7.87) and 3.30 (95% CI 2.79–3.90), respectively, when compared with women aged 20–24 years. Adjustments for sociodemographic factors only slightly changed the estimates. Dystocia was the main indication, followed by fetal distress. All of the listed factors increased the level of emergency operative deliveries, mainly because of an increase in dystocia. The increase in risk for emergency caesarean section by all factors, and for operative vaginal deliveries by epidural, were greater in older than in younger women, but were significant for epidural only. Conclusions We found a close association between maternal age and emergency operative delivery in low-risk primiparas. Contributory factors increased the risk for both emergency operative delivery and epidural more in older than in younger women.

Summary The introduction of stereo-specific levorotary isomers of amide local anesthetics, ropivacaine and levobupivacaine, for clinical use is important. This is because these drugs have a wider margin of safety, but similar blocking properties to the currently available formulation of racemic bupivacaine, although at a higher cost. However, it is noteworthy that modifications in clinical practice, such as the use of appropriate test doses and fractionation of the induction dose, have made epidural use in obstetrics a very safe procedure even before the introduction of these new drugs 50 Thus, because of their greater cost, it is difficult to predict what role, if any, these amides will assume in obstetric practice without a cost-benefit analysis. From the standpoint of systemic toxicity, the anticipated benefit of these drugs during routine epidural analgesia for labor is questionable because of the widespread use of very dilute concentrations of local anesthetic by continuous infusion. Their use, in theory, may be more beneficial to women having a cesarean section where relatively higher volumes and concentrations of local anesthetics are required for satisfactory sensory and motor block. Nonetheless, in no circumstance should a greater margin of safety be relied on a substitute for proper technique.

Epidural analgesia provides effective pain relief for women during labor. However, like all medical interventions, it also has potential side effects such as longer labor and a higher rate of intrapartum fever and operative vaginal delivery. A recent meta-analysis of randomized studies by Halpern et al concluded there was no association between epidural use and cesarean delivery. A critique of that meta-analysis, included in this paper, concludes that there are currently insufficient data to determine whether epidural analgesia leads to increased rates of cesarean delivery. This paper also presents results from several recent studies related to epidural analgesia conducted at Brigham and Women's Hospital in Boston. One study demonstrates a significant influence of prenatal planning on use of epidural during labor. Additional studies examine the strong association of epidural analgesia with intrapartum fever and the consequences of that fever for mother and infant. Epidural analgesia should remain an option available to women during labor. A more complete understanding of the risks and benefits that accompany its use is essential so that women and their care providers can make informed choices about pain relief during labor.

OBJECTIVE:To examine the length of second stage of labor with and without an epidural during labor.METHODS:This was a retrospective cohort study of 42,268 women who delivered vaginally with normal neonatal outcomes. Median lengths and 95th percentiles of second stage of labor were compared by epidur

Epidurals are frequently used as part of multi-modal perioperative analgesia. They are widely accepted as providing excellent pain relief but are associated with side-effects, have a significant failure rate and can limit a patient's mobility. We report on our use of rectus sheath catheters (RSCs), in conjunction with intravenous opiate via patient controlled analgesia (PCA), as a means of providing analgesia post-laparotomy for gynaecological oncological patients. Our experience is that this offers an alternative method of providing equivalent analgesia, avoiding the risks associated with epidural use and possibly has a role in reducing length of patient stay, although this requires further investigation.

Corrections to article “Risk Factors Associated With Epidural Use”, by Lancaster et al, published in Vol. 4, No. 2, 2012, p119-126, doi: http://dx.doi.org/10.4021/jocmr810w.

This study at the Logan Hospital, Australia, compared the outcome of induction of labour (IOL) in nulliparous women following replacement of Cervidil with Prostin. Eighty-two nulliparous women were identified for this retrospective cohort study over a period of three months on either side of the changed practice. Forty-four women received Prostin and 38 received Cervidil. Baseline characteristics were similar amongst the groups including maternal age, mean gestational age, and modified Bishop’s score at the commencement of IOL. The incidence of amniotomy, oxytocin augmentation of labour, and rate of epidural use did not differ significantly between the groups. The mean time to delivery (vaginally or abdominally) showed a significant difference, with women receiving Prostin delivering earlier than those having Cervidil ( 𝑃 = 0 . 0 1 8 ). Women receiving Prostin were more likely to have assisted vaginal delivery compared to the Cervidil group ( 𝑃 = 0 . 0 4 ).

Corrigendum to: Kerr, D, Taylor, D, Evans, B (2015) Patient-controlled intranasal fentanyl analgesia: A pilot study to assess practicality and tolerability during childbirth. International Journal of Obstetric Anesthesia 24, (2) 117-123

Item does not contain fulltext BACKGROUND: Enhanced recovery after surgery programs have been developed to improve recovery, shorten hospital stays, and reduce morbidity. OBJECTIVE: The aim of the current study was to examine the effects of the enhanced recovery program on the outcome of rectal surgery. DESIGN: A cohort of patients who underwent open rectal surgery after an enhanced recovery program was compared with a historic case-matched control group receiving conventional perioperative care. Patients were matched for type of surgery, disease, comorbidity, and demographic characteristics. Data regarding fast-track targets, length of hospital stay, mortality, complications, relaparotomies, and readmissions were collected. RESULTS: Forty-one patients in the enhanced recovery group were compared with 82 case-matched patients receiving conventional care. The length of hospital stay (median: 8 days vs 12 days, P < .005) was reduced in the enhanced recovery after surgery group. There were no significant differences in epidural use, mortality, morbidity, and readmission rates between groups. LIMITATIONS: This study performed an intention-to-treat analysis for the multimodal enhanced recovery program in rectal surgery. Specific elements of the program were not analyzed separately. The study used nonrandomly assigned historic controls for comparison. CONCLUSION: Enhanced recovery after surgery programs help to reduce the length of hospital stay after rectal surgery.

Objectives. The purpose of this study was to determine the factors associated with whether a woman received an epidural in labor and to determine the main source used to obtain information about labor epidurals.Methods. Over a one-month period, we surveyed all patients who labored, the day after their delivery. We used multiple logistic regression to identify potential predictive factors after initial univariate analysis.Results. 320 women who met enrollment criteria delivered during the study period and 94% completed the study. Of the 302 patients surveyed, 80% received an epidural for labor. Univariate analysis showed the following variables were associated with whether women received an epidural (P<.01): partner preference, prior epidural, language, education, type of insurance, age, duration, and pitocin use. Using computed multiple logistic regression only partner preference and prior epidural were associated with whether women received an epidural.Conclusion. It was not surprising that a previous epidural was predictive of a patient receiving an epidural. The strong association with partner preference and epidural use suggests this is an important factor when counseling pregnant women with regard to their decision to have a labor epidural.

INTRODUCTION Hypotension is commonly associated with epidural use in postoperative patients and is usually treated with fluid or vasopressor therapy. The former can result in fluid overload, associated with significant morbidity. This study aimed to identify factors increasing the likelihood of fluid overload in elective patients. PATIENTS AND METHODS A prospective audit of fluid therapy in elective, postoperative, epidural patients was carried out over a 6-week period in a teaching hospital in England. Demographic, biochemical, and fluid balance data were collected and analysed to determine which factors had the strongest correlation with fluid overload. Fluid overload was calculated as the percentage of net fluid input relative to pre-operative body weight (%FO). RESULTS Thirty-two patients were included in this study. An overload of 10% of the patients' pre-operative body weight was considered significant. The mean fluid overload incurred by patients in this study was 8.17 l (range, 2.89–14.62 l); %FO was 11.32% (range, 3.67–26.10%). The strongest independently correlating factor to fluid overload was initial, postoperative plasma albumin. Patients with a plasma albumin less than 27 g/l developed significant overload: mean overload 9.75 l (range, 2.89–14.62 l), %FO 15.12% (range, 4.81–26.10%), whilst those with an albumin level greater than 27 g/l did not: mean overload 6.77 l (range, 3.34–11.48 l), %FO 7.96% (range, 3.67–13.93%); P = 0.0001. CONCLUSIONS Patients receiving epidurals with initial, postoperative, plasma albumin levels below 27 g/l are at increased risk of significant fluid overload. Earlier instigation of vasopressor therapy in this subgroup of patients may help prevent this.

Epidural analgesia has become a popular way to reduce pain during labor. Because epidural use is not limited to women who plan its use, but extends to some who originally planned a nonmedicated birth, it is important for the childbirth educator to provide information on this topic to all women. In this column, the authors provide examples of Web sites that address epidural anesthesia. Web sites for professionals and consumers are included. Encouraging the use of such resources by expectant parents can provide them with good information and allow the class time on this topic to be that of clarification.

A postal questionnaire was sent to anaesthetic clinical tutors in the United Kingdom describing two hypothetical 75-year-old patients requiring abdominal surgery. Patient 1 (ASA 2) required elective anterior resection and patient 2 (ASA 3-4) required emergency laparotomy. There was a 65% response rate. For patient 1, 98.5% of respondents would insert an epidural, 93% inserting this awake and 50% placing it in the high-mid thoracic region. All respondents would use local anaesthesia (concentration varied four-fold) and 62% would use opioids. All respondents would place the epidural pre-operatively; although 36% would administer the epidural block pre-operatively and 3% postoperatively. For patient 2, 70% of respondents would insert an epidural (p < 0.0001), drug administration would be more frequently delayed until postoperatively (13%); p = 0.0005) and epidural opioid use decreased (57%); p = n/s. Epidural insertion influenced the postoperative destination in 42% of departments. Use of a critical care facility was anticipated for more than half of these patients; 60% reported difficulty accessing critical care beds.

Objective Epidural anesthesia (EA) is used in 80% of vaginal deliveries and is linked to neonatal and maternal trauma. Our objectives were to determine (1) whether EA affected clinician-applied force on the fetus and (2) whether this force influenced perineal trauma. Study design After informed consent, multiparas with term, cephalic, singletons were delivered by 1 physician wearing a sensor-equipped glove to record force exerted on the fetal head. Those with EA were compared with those without for delivery force parameters. Regression analysis was used to identify predictors of vaginal laceration. Results The force required for delivery was greater in patients with EA (n=27) than without (n=5) ( P P =.31) were similar between the groups. Clinician force was similar in those with no versus first- versus second-degree laceration ( P =.5). Only birth weight was predictive of laceration ( P =.02). Conclusion Epidural use resulted in greater clinician force required for vaginal delivery of the fetus in multiparas, but this force was not associated with perineal trauma.

The aim of the study is to identify factors associated with a second stage of labour greater than 2 hours in nulliparous women delivering at term. It a retrospective case-control study of 182 women with a second stage less than 2 hours' duration, matched with 182 women with a second stage greater than 2 hours. Women with a short second stage of labour were significantly younger (mean age 23.2 vs. 24.9 years) and had significantly smaller babies (mean weight 3315 g vs. 3463 g) than women with a long second stage. Long duration of the second stage of labour was significantly associated with oxytocin and epidural use. The intervention rate did not rise above 50% until the second stage exceeded 5 hours duration. The fetal outcome was good in both groups of patients.

Background: Trial of labor after cesarean section has been an important strategy for lowering the rate of cesarean delivery in the United States, but concerns regarding its safety remain. The purpose of this study was to evaluate the outcome of newborns delivered by elective repeat cesarean section compared to delivery following a trial of labor after cesarean. Methods: All low-risk mothers with 1 or 2 previous cesareans and no prior vaginal deliveries, who delivered at our institution from December 1994 through July 1995, were identified. Neonatal outcomes were compared between 136 women who delivered by elective repeat cesarean section and 313 women who delivered after a trial of labor. To investigate reasons for differences in outcome between these groups, neonatal outcomes within the trial of labor group were then compared between those mothers who had received epidural analgesia (n = 230) and those who did not (n = 83). Results: Infants delivered after a trial of labor had increased rates of sepsis evaluation (23.3% vs 12.5%, p = 0.008); antibiotic treatment (11.5% vs 4.4%, p = 0.02); intubation to evaluate for the presence of meconium below the cords (11.5% vs 1.5%, p

Inadvertent administration of non-epidural medications into the epidural space has the potential for serious morbidity and mortality. The aim of this study was to collate reported incidents of this type, describe the potential mechanisms of occurrence and identify possible solutions. We searched medical databases and reviewed reference lists of papers retrieved, covering a period of 35 years, regarding this type of medication incident. The 31 reports of 37 cases found is likely to represent a gross underestimation of the actual number of incidents that occur. “Syringe swap”, “ampoule error”, and epidural/intravenous line confusion were the main sources of error in 36/37 cases (97%). Given that no effective treatment for such errors has been identified, prevention should be the main defence strategy. Despite all the precautions that are currently undertaken, accidents will inevitably occur. We have identified areas for system-wide change that may prevent these types of incidents from occurring in future.