Obstetric epidural analgesia and postural hypotension.

Supine and erect arterial pressures were measured daily for six to seven days after delivery in 100 patients, of whom 50 had received epidural analgesia. There was no difference in the magnitude of postural hypotension between the epidural and control groups on any day after delivery, although in both groups the hypotension was greater during the first two days due almost entirely to changes in systolic arterial pressure. The incidence of dizziness on standing was similar in both groups (9%). Thus postural hypotension is no more common in women who have received epidural analgesia than in others. All patients should be helped out of bed after delivery, and any patient who experiences dizziness should have her blood pressure measured until the dizziness disappears.     

Oxytocin infusion during second stage of labour in primiparous women using epidural analgesia: a randomised double blind placebo controlled trial.

OBJECTIVE--To determine whether the high rate of forceps delivery associated with the use of epidural analgesia could be reduced through giving an intravenous infusion of oxytocin during the second stage of labour. DESIGN--A randomised, double blind, placebo controlled trial. SETTING--Delivery suites in three hospitals. SUBJECTS--226 Primiparous women with adequate epidural analgesia in whom full dilatation of the cervix had been achieved without prior stimulation with oxytocin. INTERVENTION--An infusion of oxytocin or placebo starting at the diagnosis of full cervical dilatation at an initial dose rate of 2 mU/min increasing to a maximum of 16 mU/min. MAIN OUTCOME MEASURES--The outcome of labour was assessed in terms of the duration of the second stage, mode of delivery, fetal condition at birth, postpartum blood loss, and the incidence of perineal trauma. RESULTS--Treatment with oxytocin was associated with a shorter second stage (p = 0.01), a reduction in the number of non-rotational forceps deliveries (p = 0.03), and less perineal trauma (p = 0.03) but was not associated with any reduction in the number of rotational forceps deliveries performed for malposition of the occiput. No adverse effects on fetal condition at birth or in the early puerperium were seen in association with the use of oxytocin. CONCLUSIONS--The use of an oxytocin infusion may reduce the high rate of operative delivery associated with epidural analgesia provided that the fetal occiput is in an anterior position at the onset of the second stage of labour but within the dose range studied does not seem to correct malposition of the fetal occiput.     

Fetal circulation during epidural analgesia for caesarean section.

Fetal blood flow was examined during epidural analgesia in six women with uncomplicated pregnancies undergoing elective caesarean section. A non-invasive, ultrasonic technique was used to measure blood flow in the fetal descending aorta and intra-abdominal part of the umbilical vein before induction of analgesia with etidocaine and bupivacaine and 15 and 30 minutes afterwards. No appreciable change in fetal blood flow was observed.     

Lumbar epidural analgesia in labour in twin pregnancy.

Fifty twin pregnancies in which the mother received epidural analgesia in labour were compared with 92 in which the mother received standard parenteral analgesia. The duration of the first and second stages of labour; the incidence of assisted deliveries when the head presented; the proportion of breech extractions when either the first or second twin presented by the breech; the incidence of low Apgar scores; and the perinatal mortality were not significantly different in the two groups. These findings suggest that lumbar epidural analgesia is safe for providing pain relief in labour for patients with a twin pregnancy. Moreover, an epidural block is preferable to conventional analgesia in these cases as it allows prompt intervention to effect delivery of the second twin.     

Postoperative analgesia: a comparison of intravenous on-demand fentanyl with epidural bupivacaine.

In a randomised trial postoperative pain relief was provided by either epidural injections of bupivacaine or an infusion of fentanyl adjusted by the patient to achieve adequate pain relief. Both techniques produced satisfactory analgesia without respiratory depression after peripheral arterial surgery. The technique of infusing intravenously a potent analgesic in a dose adjusted by the patient appears to offer several advantages in postoperative care.     

硬膜外分娩镇痛的临床研究

目的 :探讨硬膜外分娩镇痛效果及其对产程、母婴状况的影响。方法 :将 0 1%布比卡因及芬太尼 5 μg/ml混合液硬膜外分娩镇痛的 30 0例产妇作为镇痛组 ,将未用任何镇痛药的 30 0例产妇作为对照组 ,比较两组的产痛程度、产程时间、分娩方式、产后出血量、羊水粪染率、新生儿窒息及缩宫素应用等。结果 :镇痛组 30 0例产妇中显效 90 33% (2 71/30 0 ) ,有效 9 6 7% (2 9/30 0 ) ,总镇痛有效率 10 0 % ;镇痛组的活跃期和第二产程时间短于对照组 ,差异有显著性意义 (P <0 0 1) ;镇痛组自然分娩率明显高于对照组 (P <0 0 5 ) ,剖宫产率则以对照组为高 (P <0 0 5 ) ;两组羊水粪染率、新生儿窒息、Apgar评分、产后出血量及缩宫素应用的比较无显著性差异 (P <0 0 5 )。结论 :硬膜外分娩镇痛是一种理想的、安全有效的分娩镇痛方法。     

Lumbar epidural analgesia in labour: relation to fetal malposition and instrumental delivery.

The incidence of instrumental delivery and malposition immediately before delivery was compared in patients who were given lumbar epidural analgesia and those who were not. Instrumental delivery was five times more common and a malposition of the fetal head was more than three times as common in the epidural group as in women who did not receive regional analgesia. Similar incidences were found even when the epidural was electively chosen before labour in the absence of medical indications. The instrumental delivery rate was affected by parity, the length of the second stage of labour, and the return of sensation by the second stage but not by other factors studied. The high incidence (20%) of malposition associated with epidural analgesia was not affected by any of the factors studied. The psychological and physical disadvantages of malposition and instrumental delivery have yet to be assessed. In the meantime, when there are no medical indications for epidural analgesia, the advantages of pain relief should be weighed against those of a normal spontaneous delivery.     

不同剂量舒芬太尼复合罗哌卡因用于术后 硬膜外镇痛效应比较

目的:研究不同剂量的舒芬太尼复合0.125%罗哌卡因用于硬膜外上腹部术后镇痛的临床疗效和安全性。方法:选择60例麻醉风险评级(ASA)I-II级,年龄(56±12.3)岁,在静脉快速诱导气管插管静吸复合全身麻醉下行上腹部手术的病人随机均分为四组,分别为0.125%罗哌卡因(R)组,0.125%罗哌卡因+0.25ug/ml舒芬太尼(R+0.25S)组,0.125%罗哌卡因+0.5ug/ml舒芬太尼(R+0.5S)组,0.125%罗哌卡因+0.75ug/ml舒芬太尼(R+0.75S)组。于T9-11行硬膜外穿刺置管后接入镇痛泵行术后持续硬膜外输注镇痛,观察术后3、6、12、24小时VAS评分,辅助镇痛用药量及恶心、呕吐、皮肤骚痒、呼吸抑制等副作用。结果:(R+0.5S)组和(R+0.75S)组的患者静息和咳嗽时的VAS评分、24小时内辅助镇痛用药量均显著低于(R)组和(R+0.25S)组,(P<0.05);(R)组、(R+0.25S)组、(R+0.5S)组、(R+0.75S)组四组的瘙痒发生率分别为0%、27.2%、54.5%、63.6%,各组间瘙痒的发生率有显著差异(P<0.05)。60例患者均未发生呼吸抑制等严重并发症;四组间的镇静评分、恶心、呕吐发生率无显著性差异。结论:0.5ug/ml舒芬太尼复合0.125%罗哌卡因可取得较佳的镇痛效果及较少的副作用。     

Assessment of xylazine hydrochloride epidural analgesia for open castration of rams

Epidural xylazine injected at the sacrococcygeal site 40 to 150 min prior to surgery (at a dose of 0.05 to 0.10 mg/kg) provided good analgesia during scrotal skin incision in all 20 experimental rams but in only 10 rams (50%) at incision and separation of tunica vaginalis, and 6 rams (30%) during ligation of the spermatic cord. There was a significant correlation between the decrease in heart rate and the dosage of epidural xylazine. Heart rate increased significantly during incision of the tunics and spermatic cord ligation but was not significantly correlated to the clinical assessment of analgesia. There was no significant correlation between the presence of surgical analgesia and the dosage of epidural xylazine: Pelvic limb ataxia was still evident in 12 rams (60%) at 8 h after epidural xylazine injection. Epidural xylazine provided good somatic analgesia during open castration of 20 rams but visceral analgesia was unpredictable. Factors in addition to the dosage of sacrococcygeal epidural xylazine affects the degree of surgical analgesia obtained for open castration of rams.     

Fluid loading to reduce abnormalities of fetal heart rate and maternal hypotension during epidural analgesia in labour.

Fetal heart rate (FHR) was recorded and maternal blood pressure measured in 104 patients in whom lumbar epidural analgesia was induced in labour. Fifty-one patients received an intravenous load of 11 of Hartmann''s solution immediately before the epidural injection. This infusion significantly reduced the incidence of abnormalities of FHR from 34% to 12% and of maternal hypotension from 28% to 2%. We did not study mothers with pre-eclampsia and hypertension, but we conclude that there is a strong case for preloading all other mothers in whom lumbar epidural analgesia is induced in labour.     

Comparison of oxidative stress markers in vaginal deliveries with or without epidural analgesia

Abstract

Background

It has been demonstrated that oxidative stress can induce red blood cell rigidity and haemolysis, which in turn can cause hyperviscosity and hyperbilirubinaemia, respectively. However, haemolysis may be associated with a low level of haemoglobin, which reduces whole blood viscosity (WBV). Bilirubin can behave as antioxidant or oxidant, and one uncharted course for diagnostic pathology is how or whether bilirubinaemia and viscosity are associated. Further, oxidative stress is now being assessed using lipoprotein-a (Lp(a)), among other things but whether it is associated with blood viscosity has not been established.

Aim

This study investigates the association and correlation of haemoglobin level and WBV with serum Lp(a) and bilirubin levels in a general population of patients.

Materials and methods

Sixty-eight cases that were tested for Lp(a), concomitantly with full blood count and liver function, in our archived clinical pathology database were used in this study. WBV levels were determined using a validated formula. Multivariate and univariate analyses as well as correlation were performed.

Results

WBV was found to be significantly associated with bilirubin (P < 0.02), but not with Lp(a). Haemoglobin concentration was inversely correlated with Lp(a) (P < 0.04), but not with bilirubinaemia.

Conclusion

This pilot study suggests that hyperbilirubinaemia and hyperviscosity are associated and positively correlated. Consideration of whether serum bilirubin (as an indirect index of oxidative stress) can be used in combination with WBV (as index of macrovascular effect of oxidative stress) to assess oxidative damage is recommended.     

Randomised study of long term outcome after epidural versus non-epidural analgesia during labour

ObjectiveTo determine whether epidural analgesia during labour is associated with long term backache.DesignFollow up after randomised controlled trial. Analysis by intention to treat.SettingDepartment of obstetrics and gynaecology at one NHS trust.Participants369 women: 184 randomised to epidural group (treatment as allocated received by 123) and 185 randomised to non-epidural group (treatment as allocated received by 133). In the follow up study 151 women were from the epidural group and 155 from the non-epidural group.ResultsThere were no significant differences between groups in demographic details or other key characteristics. The mean time interval from delivery to interview was 26 months. There were no significant differences in the onset or duration of low back pain, with nearly a third of women in each group reporting pain in the week before interview. There were no differences in self reported measures of disability in activities of daily living and no significant differences in measurements of spinal mobility.ConclusionsAfter childbirth there are no differences in the incidence of long term low back pain, disability, or movement restriction between women who receive epidural pain relief and women who receive other forms of pain relief.

What is already known on this topic

Previous research has suggested an association between epidural analgesia during labour and low back painIt is not known whether this association is causal

What this study adds

This long term follow up study found no evidence of a causal link between epidural analgesia during labour and low back pain