These heterogeneous results on labor could be because of difference in labour management and analgesic administration protocol. Present study was carried out in women having spontaneous labour where oxytocin was given for augmentation of labour and epiduralanalgesia was withdrawn in second stage and tramadol was stopped after 8cm dilation , to facilitate bearing down efforts . Analgesia was initiated on maternal demand when VAS score was 8-9. These factors may be responsible for comparable duration of first and second stage of labour in both groups. In present study, instrumental deliveries and caesarean sections were also comparable to that in tramadol group explicably for the same reason. In present study, epiduralanalgesia resulted in far better analgesia and majority of women in that group rated its effect as excellent. They were interested in using the same in future pregnancy also. However, only a small number in tramadol rated it to be excellent, and the rest were dissatisfied with its effects.
The results of many studies in recent years are largely conflicting. First of all, the problem was whether the reduction of pain with epiduralanalgesia could affect breastfeeding. Some studies suggested that this is associ- ated with a delayed start of lactation and to an earlier suspension, others have found no association. Halpern and co-workers in their observational study reported that analgesia in labor is not associated with a reduction of breastfeeding in their study population at 6–8 weeks postpartum [2,20]. In their work, rather, it is highlighted the importance of the promotion of breastfeeding in hos- pital management, as reaffirmed in 2002 by Leighton .
-In our study parity status and their distribution among the population was also studied which showed 19(38%) primigravida and 31(62%) multigravida in group A and in group B primigravida17 (34%) and multigravida 33(66%). Thus the numbers of patients demanding epiduralanalgesia were more multigravida as compared to primigravida. During first pregnancy,the woman have a lot of pain and because of that pain during her second of later pregnancy she does not have any more energy to bear the same pain again and thus, she chooses epidural delivery. [15,16]
In this study, women who had epiduralanalgesia, a gen- eral anaesthetic and/or a caesarean section for the birth of their baby were more likely to be partially breastfeeding their baby in the first week postpartum. Partial breastfeed- ing in the first week may be indicative of difficulty estab- lishing breastfeeding and is important because these women are at increased risk of stopping breastfeeding altogether. Two-thirds of the women who were partially breastfeeding in the first week were not breastfeeding at all by 24 weeks, compared with only one third of women who were fully breastfeeding in the first week. The type and amount of breastfeeding support given to these women is not known but may be an important factor in women continuing to breastfeed in spite of initial difficul- ties. International recommendations advise that women exclusively breastfeed their infants until six months of age and continue breastfeeding until at least 12 months of age .
The base sample for this study was the 1934 nulliparous women enrolled in the active management of labor (ACT) trial conducted at Brigham and Women’s Hospital from May 1990 through October 1994. Approval for the study was obtained from the Human Research Committee of Brigham and Women’s Hos- pital, and informed consent was obtained from all participants. Women enrolling were randomly assigned to have labor managed either under a protocol of active management of labor or to usual care. The active management of labor protocol mandated the criteria for the diagnosis of labor, the timing and dose of oxytocin, and one-to-one nursing throughout the course of labor. Epiduralanalgesia was not part of the trial protocol. It was administered to women in both groups on request. Data were abstracted from the maternal medical record regarding the course of pregnancy and labor and from the newborn record regarding infant outcome. A complete description of the study methodology has been pub- lished elsewhere. 7
TKR between epiduralanalgesia and femoral nerve block. We compared analgesic efficacy, side effects, post-operative knee rehabilitation and duration of hospital stay. Materials and Methods: Fifty cases posted for elective unilateral TKR under spinal anaesthesia were randomly divided into two groups. Patients in group E received epiduralanalgesia (0.125% bupivacaine 15 ml) and group F received femoral nerve block (0.125% bupivacaine 15 ml). Analgesic efficacy in term of onset of action & duration of analgesia was assessed by using VAS (0 to 10cm) for 24hr. No of rescue analgesic doses and side effects were also assessed. Results: in group E: VAS score >6 in epidural (7.31+/- 0.52) and in group F: VAS score (6.85 +/-0.34) which suggest longer duration of pain relief in epiduralanalgesia. Total incidence of side effects 27% in case of group E compared to 5% in group F. Hypotension, Nausea,. Itching, Back pain, are common side effects in group E. Patient satisfaction was greater with group F. Although post-operative knee rehabilitation and hospital stay were not different. Conclusion: There is longer duration of pain relief in epiduralanalgesia but group F represents optimal analgesia with fewer side effects and greater patient satisfaction. Femoral block is safe, cheap & easy. Required less skill, equipment and cost effective. So for age related safety purpose, femoral block has higher value for pain relief in TKR even than epidural gives more analgesia.
The instrumental delivery rate is yet another important outcome measure, as the procedure increases the risk of maternal perineal trauma, and adverse neonatal out- comes in cases of difficult delivery. It must be noted that results are often affected by multiple confounding factors, such as the neuraxial analgesic technique, method of epiduralanalgesia maintenance, local anesthetic concentration, degree of analgesia during second stage of labour and obstetric factors. 13 Instrumental births
Dissatisfaction with neuraxial analgesia occurred because of poor reliability, safety concerns, and the feeling of lower limb paralysis patients experienced when given large doses of local anesthetic. In the early 1960s, the lumbar epidural replaced caudal analgesia as the preferred technique. Com- pared with the caudal route, lumbar epiduralanalgesia is more comfortable for the patient and easier to perform. The technique required less local anesthetic. Motor function of the lower extremities and abdominal muscles can be maintained. The extent of sympathectomy can be better controlled, result- ing in less maternal hypotension. The block can be extended and used for cesarean section if necessary. During this period of time, bupivacaine was synthesized and became the drug of choice in obstetrics because of its long duration of action and absence of tachyphylaxis. The use of lumbar epidural catheters in the 1970s permitted administration of pain relief early in labor, rather than only at the time of delivery.
We planned this study to compare postoperative epiduralanalgesia after open abdominal hystrectomy by preemptive use of epidural administration of bupivacaine alone or in combination with ketamine or diltiazem singly or both in combination. Opioids were avoided because they could have prevented or attenuated central sensitization, thus leading to questionable results [9,12]. A sub-anesthetic ketamine dose, defined as intravenous or epidural bolus below 1 mg.kg- is related to analgesic effects, as compared to a higher dose which has psychomimetic symptoms and dissociative anaesthesia . At subanesthetic (i.e. low) doses, ketamine exerts a specific NMDA blockade and hence modulates central sensitization induced both by the incision and tissue damage and by perioperative analgesics such as opioids. We used very low dose of ketamine (5mg) along with bupivacaine. No studies have evaluated the effects of epidural bupivacaine and verapamil before Choe H.et al , who administered lumbar epidural bupivacaine or bupivacaine plus verapamil to investigate the possible role of the calcium channel blocker, verapamil, in postoperative pain. Later on Lin XM , also used epidural Bupivacaine + Verapamil. We decided to test diltiazem by epidural route along with bupivacaine and compare it with ketamine and bupivacaine. Analgesia was adequate in all the groups during intraoperative period as pulse rate and blood pressure remained stable. Both ketamine and diltiazem proved to be an effective adjuvant to plain bupivacaine for epiduralanalgesia as control group showed the shortest duration of postoperative pain free period (4.6 ± 0.74 hrs.) and required maximum number of top- ups in first (6.0 ± 0.85 ) and next 24 hours (8.13 ± 0.83). Ketamine proved to be better than diltiazem
Although this is a relatively small study, it demonstrates the lack of knowledge and understanding about epidurals by women in this region. Some of the reluctance to accepting epiduralanalgesia may relate to the various side-effects, 1 another reluctance has cultural roots and this warrants further investigation. Pain relief options available to women should be discussed early in pregnancy by doctors and midwives, who understand the cultural societal norms and who are able to give evidenced-based information about the choices available.
Aim: To evaluate the effect of epiduralanalgesia during labour on neonat- al-maternal outcomes. Methods: A retrospective cohort study of nulliparous parturients who gave birth in Västernorrland County, Sweden, over a 2-year period between 2015 and 2016. Neonatal outcomes (Apgar score at 5 min and umbilical cord arterial blood gases), maternal outcomes (perineal injury, total bleeding volume and maternal satisfaction with birth) and labour parameters (mode of delivery and the durations of labour and postpartum hospital stay) were evaluated. Results: The study cohort consisted of 1449 women with sin- gleton pregnancies. Patients were divided into two groups according to whether during labour they were administered epiduralanalgesia using bu- pivacaine and sufentanil (EDA group, n = 615) or not (non-EDA group, n = 834). The rate of assisted vaginal delivery was significantly higher in the EDA group than in the non-EDA group (15.6% and 11.3%, respectively, p < 0.05), whereas the rates of caesarean section were similar. The duration of the active phase of labour was significantly longer in the EDA group than in the non-EDA group (489 ± 217 min versus 371 ± 210 min, respectively, p < 0.001). The Apgar score at 5 min and umbilical cord blood pH were lower and the base deficit greater in the EDA group (p < 0.001, p < 0.001 and p < 0.01, respectively). Bleeding volume was similar between the groups after ad- justing for gestational age. Women in the EDA group were more satisfied with their labour experience, as measured by the visual analogue scale (p < 0.05). Conclusion: The results of this study suggest that EDA affects delivery and neonatal-maternal outcomes negatively, but increases the mother’s satis- faction with labour.
Our results highlight the importance of the communica- tion factor, as women from Western European countries with a socioeconomic status similar to that prevailing in Spain have lower rates of use. There also appears to be a socioeconomic component, as women from South Amer- ica, who speak Spanish, present a lower degree of epidural use although significantly higher than that observed for women from areas that are less economically developed, like Africa and Asia. Specific interventions would be ne- cessary to ensure that the mother ’ s geographic origin is not a barrier to access to epiduralanalgesia during labor.
in patients undergoing laparoscopic colorectal surgery in- creased the time to return bowel function and showed simi- lar pulmonary function compared to spinal analgesia in their prospective randomized controlled trial. These differences from our results may be because of a characteristic of the colorectal surgery or the analgesic regimen. However, in their study, the epiduralanalgesia group received more in- travenous fluid than the spinal analgesia group throughout the peri-operative period and had a small degree of motor blockade, which could inhibit early mobility. Excessive flu- id administration could lead to edematous bowel and lungs, which consequently causes ileus and adverse respiratory function. 25 Immobility can also prevent enhanced recovery. 26
In conclusion, our findings reveal that PCEA can provide superior postoperative pain management and shorten the time to the first passage of flatus. No difference was observed between groups regarding postoperative complications and the length of the hospital stay. PCEA is a safe technique that could improve short-term outcomes after gastrectomy for GC. However, older patients were more likely to have a risk of seri- ous hypotension and epidural malfunction when PCEA was applied. In our opinion, epiduralanalgesia is a valid option for postoperative analgesia to improve short-term outcomes that can be used for patients undergoing gastrectomy after individual risk assessment.
This prospective, randomised study compared the effectiveness of patient controlled epiduralanalgesia (PCEA) versus continuous epidural infusion (CEI) in providing pain relief post gynaecological surgery. Sixty six ASA I or II patients planned for gynaecological surgery via Pfannensteil incision under combined spinal epidural anaesthesia were recruited. They were randomised into two groups: Group A patients received PCEA while Group B patients received CEI. In the recovery area, both groups received an epidural combination of levobupivacaine 0.1% and fentanyl 2 µg/ml. Group A patients were allowed demand bolus doses of 5 ml with a 20 minute lockout interval, while Group B patients had their epidural infusion initiated at 6 ml/hour with increments as required to a maximum of 12 ml/hour. Pain score and degree of motor blockade was assessed hourly in the first four hours and subsequently at four hourly intervals. Side effects were recorded at four-hourly interval. The total amount of analgesia, number of anaesthetic interventions and patient satisfaction was assessed 24 hours, postoperatively. There was no significant difference in pain score, total amount of analgesia, number of anaesthetic interventions and patient satisfaction. The degree of motor blockade and side effects were comparable between the groups. In conclusion, PCEA was comparable to CEI for pain relief after gynaecological surgery.
In the Group E, patients were preloaded with 500 ml Ringer’s solution. The procedure was done in sitting po- sition. The interspinous space was identified by utilizing anatomic landmarks and palpation. Paramedian access plane is for needle insertion with loss of resistance technique . Local anesthetic was injected into the skin and interspinous ligament after sterilization. The epidural space was located using a manual “loss-of-resistance” technique. A Tuohy needle was inserted into the interspinous ligament and advanced very slowly until there was no longer any resistance felt, indicating that the tip of the needle was in the epidural space. A catheter was threaded through the needle upwards for 3 cm more than the distance between skin and epidural space and re- mains in the epidural space during needle removal . After that, epiduralanalgesia was activated using 6 ml 0.125% bupivacaine and 2 μg/ml fentanyl, which followed by continuous infusion of 6 ml/hour for 48 hours.
Epiduralanalgesia is a pre-requisite for many women to choose TOLAC, and for obstetricians, it is a means of allowing adequate and long-lasting pain relief in the management of normal and dysfunctional labors. How- ever, none of above predictive models has mentioned analgesic effect. TOLAC is still in the early stages in mainland of China because of its unique medical envir- onment. Notably, the doctor-patient relationship in China is tense due to patient distrust. Therefore, in order to reduce medical disputes, doctors often have to choose the surgical treatment according to patients’ needs, rather than the natural childbirth based on patients’ own conditions . With increasing inter- national acceptance of TOLAC and improved technol- ogy, more and more Chinese medical institutions begin to use TOLAC. It has been reported that the epiduralanalgesia is unsafe for maternal and newborn at risk of uterine rupture, but the 2010 American Association of Obstetricians and Gynecologists (ACOG) guidelines ex- plicitly recommend that epidural anesthesia in TOLAC is safe [8, 9]. In addition, different policies for labor dys- tocia management and epidural anesthesia permissive- ness at TOLAC challenge the interpretation of previous studies. Several reports have revealed the relationship between labor pain intensity and dystocia, suggesting
without epidural catheter receive IV piritramide at the discretion of the anesthetist (Opioid Group). Piritramide is an opioid commonly used in Germany with approxi- mately 0.7 times the potency of morphine. Patients are ad- mitted to the intensive care unit for one night and receive 1 g of dipyrone every 6 hours and IV piritramide bolus doses when NRS (numeric rating scale, 0 = no pain up to 10 = worst pain imaginable) is >3. If patients have epidurals, the EDA is continued at 4–6 mls/h. If epiduralanalgesia is not effective, patients are switched to systemic analgesia before dismission from intensive care unit.
Among all the techniques available, the epiduralanalgesia is the gold standard in alleviating labour pain and is safe for both the mother and the fetus (26). Use of low concentrations of local anaesthetics produce only selective sensory blockade, thereby sparing the motor fibres, thus diminishing adverse effect of motor blockade, their effect can be potentiated by the use of adjuvants like adrenaline, clonidine and opioids. Among these, opioids are the most commonly used.
Aim: To evaluate the effect of epiduralanalgesia in primigravida on maternal and fetal outcomes on these parameters - Duration and progress of labor, Mode of delivery (Spontaneous/Instrumental/Operative), Apgar score of newborn, Untoward reaction and intra-partum complications following epiduralanalgesia.