Epidural analgesia for labor pain and its relationship to fever.
Pediatrics ;– ; epidural analgesia, fever, neonatal sepsis, length of labor. epidural analgesia for pain relief during labor is associated with rate ratios and 95% confidence intervals (CI) for the association of intrapartum fever. The temperatures in the women prior to receiving epidural identify and treat women who are more prone to fever during labor, RELATED STORIES Hispanic Women Opt for Labor Pain Relief Less Often Than Others. The etiologies of intrapartum fever are diverse and include maternal In addition , epidural analgesia used for pain relief in labor is associated.
Epidural Analgesia during Labor and Maternal Fever | Anesthesiology | ASA Publications
Top This article is accompanied by an Editorial View. Intrapartum epidural analgesia and neonatal sepsis evaluations: A casual or causal association? SOME investigators have reported that epidural analgesia during labor is an independent risk factor for the development of maternal fever.
Therefore, there is the possibility that the association between maternal fever and epidural analgesia occurred as a result of selection bias for more difficult, dysfunctional labor, which in itself is an independent risk factor for the development of maternal fever.
We recently reported a randomized trial of the effects of epidural analgesia on the outcomes of labor in a carefully defined and homogenous group of parturients. Women were randomized to receive either epidural analgesia or patient-controlled intravenous meperidine analgesia PCIA. There were minimal cross-overs from one study arm to the other. We now report a secondary analysis of fever in these women. Methods and Materials Our sample for analysis included women enrolled in the randomized trial of epidural versus intravenous analgesia during labor, conducted at Parkland Memorial Hospital from June through February After approval by the Institutional Review Board of the University of Texas Southwestern Medical Center at Dallas and informed consent, healthy women with singleton cephalic gestations at term and presenting in spontaneous active labor were randomly assigned to receive either epidural analgesia or PCIA during labor from a randomization sequence that was computer-derived in blocks of 20 subjects and then placed in sealed opaque envelopes.
All staff followed a written procedural manual that prescribed the intrapartum management of women admitted to the low-risk labor unit. Our labor management approach encourages amniotomy in active labor when the fetal head is applied to the cervix. Internal electronic fetal monitoring was used in those women with meconium-stained amniotic fluid, known fetal heart rate decelerations, or inadequate progress of labor.
For women with epidural analgesia in the second stage of labour, delaying pushing for one to two hours after full dilatation or until the woman regains the sensory urge to bear down is recommended. Background Globally, approximately million births occur every year 2.
The majority of these are vaginal births among pregnant women with no identified risk factors for complications, either for themselves or their babies, at the onset of labour 3,4.
However, in situations where complications arise during labour, the risk of serious morbidity and death increases for both the woman and baby. Over a third of maternal deaths and a substantial proportion of pregnancy-related life-threatening conditions are attributed to complications that arise during labour, childbirth or the immediate postpartum period, often as result of haemorrhage, obstructed labour or sepsis 5,6. Similarly, approximately half of all stillbirths and a quarter of neonatal deaths result from complications during labour and childbirth 7.
The burden of maternal and perinatal deaths is disproportionately higher in low- and middle-income countries LMICs compared to high-income countries HICs. Therefore, improving the quality of care around the time of birth, especially in LMICs, has been identified as the most impactful strategy for reducing stillbirths, maternal and newborn deaths, compared with antenatal or postpartum care strategies 8.
WHO recommendation on epidural analgesia for pain relief during labour
Over the last two decades, women have been encouraged to give birth in health care facilities to ensure access to skilled health care professionals and timely referral should the need for additional care arise. However, accessing labour and childbirth care in health care facilities may not guarantee good quality care. Disrespectful and undignified care is prevalent in many facility settings globally, particularly for underprivileged populations, and this not only violates their human rights but is also a significant barrier to accessing intrapartum care services 9.
In addition, the prevailing model of intrapartum care in many parts of the world, which enables the health care provider to control the birthing process, may expose apparently healthy pregnant women to unnecessary medical interventions that interfere with the physiological process of childbirth. As highlighted in the World Health Organization WHO framework for improving quality of care for pregnant women during childbirth, experience of care is as important as clinical care provision in achieving the desired person-centred outcomes This up-to-date, comprehensive and consolidated guideline on intrapartum care for healthy pregnant women and their babies brings together new and existing WHO recommendations that, when delivered as a package of care, will ensure good quality and evidence-based care in all country settings.
To ensure that each recommendation is correctly understood and applied in practice, the context of all context-specific recommendations is clearly stated within each recommendation, and the contributing experts provided additional remarks where needed. In accordance with WHO guideline development standards, these recommendations will be reviewed and updated following the identification of new evidence, with major reviews and updates at least every five years. Methods These recommendations were developed using standard operating procedures in accordance with the process described in the WHO handbook for guideline development Briefly, these procedures include: Up-to-date systematic reviews were used to prepare evidence profiles for priority questions.
The GRADE evidence-to-decision EtD framework 14an evidence-to-decision tool that includes intervention effects, values, resources, equity, acceptability and feasibility criteria, was used to guide the formulation of recommendations by the Guideline Development Group GDG — an international group of experts assembled for the purpose of developing this guideline — at two technical consultations in May and September In addition, relevant recommendations from existing WHO guidelines approved by the Guidelines Review Committee GRC were systematically identified and integrated into this guideline for the purpose of providing a comprehensive document for end-users.
Recommendation question For this recommendation, we aimed to answer the following question: For healthy pregnant women requesting pain relief during labour Pshould epidural analgesia Icompared with no pain relief or other forms of pain relief Cbe offered to relieve labour pain and improve birth outcomes O?
Epidural analgesia for labor pain and its relationship to fever.
Evidence summary This evidence is derived from a Cochrane systematic review, to which 43 trials contributed data Any epidural analgesia compared with placebo or no epidural analgesia Seven trials involving women compared epidural analgesia with no analgesia.
Trials were conducted in hospital settings in China 3 trials and in Brazil, India, Mexico and Turkey 1 trial each. Sample sizes of individual trials ranged from under to just over women. One trial took place between andthree from onwards, and dates were not stated in the other three trials.
All trials used bupivacaine or ropivacaine for the epidural analgesia. Ropivacaine was supplemented with sufentanil in one trial; bupivacaine was supplemented with fentanyl in one trial and with tramadol in another. Patient-controlled epidural analgesia was used in two trials. Three trials used the combined spinal—epidural technique.
Maternal outcomes Pain relief: It is uncertain whether epidural analgesia compared with no analgesia reduces pain scores, pain intensity or the need for additional analgesia during labour because the certainty of the evidence for all of these outcomes is very low. Moderate-certainty evidence suggests that epidural analgesia probably leads to fewer women undergoing caesarean birth compared with no analgesia 5 trials, women, RR 0.
It is uncertain whether epidural has an effect on instrumental births because the certainty of this evidence is very low. It is not clear whether epidural analgesia makes any difference to the length of the first or second stages of labour compared with placebo, as the certainty of the evidence is very low. Low-certainty evidence suggests that epidural analgesia may make little or no difference to whether or not women receive oxytocin for labour augmentation 3 trials, women, RR 0.
Low-certainty evidence from a single trial suggests that epidural may increase the proportion of women reporting they were satisfied or very satisfied with pain relief in labour 70 women, RR 1. Review evidence on the relative effect of epidural compared with placebo or no intervention on hypotension, vomiting, fever, drowsiness or urinary retention is very uncertain.
Fetal and neonatal outcomes Perinatal hypoxia-ischaemia: It is uncertain whether epidural analgesia has an effect on the number of babies born with Apgar scores of less than 7 at 5 minutes because the certainty of this evidence is very low.
These were not reported in the included studies. Mother—baby interaction and breastfeeding: These were not reported in any of the included trials. When interventions are being considered, women would like to be informed about the nature of the interventions and, where possible, given a choice high confidence in the evidence.
However, some women are fearful of receiving an epidural injection due to potential pain and complications, and there were mixed views on whether the pain relief provided was actually effective or ineffective in their experience low confidence in the evidence. Some women perceive that epidural analgesia helped them to have a positive childbirth experience moderate confidence in the evidence.No Joke: Laughing Gas Relieving Labor Pains
Women value the opportunity to make a choice about this method of pain relief and value the support of professionals and family members for their decision on pain-relief low confidence in the evidence.
Additional considerations All the included qualitative studies on the use of epidural analgesia were undertaken in high-income settings.
Six were undertaken in the USA. It was not possible to identify, within the included studies, whether women had had augmentation, induction of labour or other forms of intervention that may have influenced how they valued the outcomes associated with this form of pain relief.
In some cultures, women might consider labour pain an integral part of childbirth and view physical expression of pain or discomfort as a sign of weakness. In addition, some women might view the use of epidural analgesia as an intervention that negatively impacts their sense of control during labour and childbirth.
Resources No recent reviews on costs and cost-effectiveness were found; however, a USA review of the cost-effectiveness of epidural compared with opioid analgesia suggests that providing epidural analgesia for labour pain relief costs more than opioid analgesia Additional considerations Findings from other studies suggest that costs per birth are substantially higher with epidural analgesia 20, The health care professionals required to administer and monitor epidural analgesia, and to perform instrumental births, are probably the main cost component of this intervention.