Epidural administration of neostigmine and clonidine to induce labor analgesia: evaluation of efficacy and local anesthetic-sparing effect. (1/52)

BACKGROUND: Epidural clonidine produces analgesia without motor impairment, and is associated with a local anesthetic-sparing effect during labor. The authors have recently demonstrated that epidural neostigmine initiates selective labor analgesia devoid of adverse effects. Both drugs possess common analgesic mechanisms mediated through spinal acetylcholine release. This study evaluates their epidural combination in parturients. METHODS: At the beginning of labor, parturients were randomly allocated to one of five groups to receive one of the following after a test dose: 150 microg epidural clonidine, 750 microg neostigmine, or 75 microg clonidine combined with 250, 500, or 750 microg neostigmine. A pain score (visual analog scale, 0-100) was recorded before administration and at regular intervals until request for a supplemental injection. Subsequent analgesia was provided by continuous epidural infusion of ropivacaine. RESULTS: Parturients did not differ regarding demographic data and initial pain score. Clonidine 150 microg , neostigmine 750 microg , and 75 microg clonidine plus 250 microg neostigmine produced ineffective and short-lasting effects. Clonidine 75 microg plus 500 microg neostigmine and 75 microg clonidine plus 750 microg neostigmine presented comparable durations of 90 +/- 32 and 108 +/- 38 min (mean +/- SD), respectively, and final analgesic efficacies, with 72.2% and 84%, respectively, of the parturients reporting a visual analog scale score of less than 30 out of 100 after 30 min. Ropivacaine use was significantly reduced in all clonidine groups (average, 9.5 mg/h) in comparison with neostigmine alone (17 +/- 3 mg/h). No adverse effects were observed for 75 mug clonidine combined with any dose of neostigmine while maternal sedation (20%) and hypotension (33%) occurred with 150 microg clonidine alone. CONCLUSIONS: Epidural clonidine, 75 microg , with 750 microg neostigmine is an effective combination to initiate selective labor analgesia without adverse effects. Clonidine use further reduces local anesthetic consumption throughout the course of labor.  (+info)

Please understand when I cry out in pain: women's accounts of maternity services during labour and delivery in Ghana. (2/52)

BACKGROUND: This study was undertaken to investigate women's accounts of interactions with health care providers during labour and delivery and to assess the implications for acceptability and utilisation of maternity services in Ghana. METHODS: Twenty-one individual in-depth interviews and two focus group discussions were conducted with women of reproductive age who had delivered in the past five years in the Greater Accra Region. The study investigated women's perceptions and experiences of care in terms of factors that influenced place of delivery, satisfaction with services, expectations of care and whether they would recommend services. RESULTS: One component of care which appeared to be of great importance to women was staff attitudes. This factor had considerable influence on acceptability and utilisation of services. Otherwise, a successful labour outcome and non-medical factors such as cost, perceived quality of care and proximity of services were important. Our findings indicate that women expect humane, professional and courteous treatment from health professionals and a reasonable standard of physical environment. Women will consciously change their place of delivery and recommendations to others if they experience degrading and unacceptable behaviour. CONCLUSION: The findings suggest that inter-personal aspects of care are key to women's expectations, which in turn govern satisfaction. Service improvements which address this aspect of care are likely to have an impact on health seeking behaviour and utilisation. Our findings suggest that user-views are important and warrant further investigation. The views of providers should also be investigated to identify channels by which service improvements, taking into account women's views, could be operationalised. We also recommend that interventions to improve delivery care should not only be directed to the health professional, but also to general health system improvements.  (+info)

Quantile regression for longitudinal data using the asymmetric Laplace distribution. (3/52)

In longitudinal studies, measurements of the same individuals are taken repeatedly through time. Often, the primary goal is to characterize the change in response over time and the factors that influence change. Factors can affect not only the location but also more generally the shape of the distribution of the response over time. To make inference about the shape of a population distribution, the widely popular mixed-effects regression, for example, would be inadequate, if the distribution is not approximately Gaussian. We propose a novel linear model for quantile regression (QR) that includes random effects in order to account for the dependence between serial observations on the same subject. The notion of QR is synonymous with robust analysis of the conditional distribution of the response variable. We present a likelihood-based approach to the estimation of the regression quantiles that uses the asymmetric Laplace density. In a simulation study, the proposed method had an advantage in terms of mean squared error of the QR estimator, when compared with the approach that considers penalized fixed effects. Following our strategy, a nearly optimal degree of shrinkage of the individual effects is automatically selected by the data and their likelihood. Also, our model appears to be a robust alternative to the mean regression with random effects when the location parameter of the conditional distribution of the response is of interest. We apply our model to a real data set which consists of self-reported amount of labor pain measurements taken on women repeatedly over time, whose distribution is characterized by skewness, and the significance of the parameters is evaluated by the likelihood ratio statistic.  (+info)

Horner's syndrome and trigeminal nerve palsy following epidural analgesia for labor. (4/52)

Epidural analgesia is a widely used method of pain control in the labor and delivery setting but is not without risks. We present a case of Horner's syndrome and trigeminal nerve palsy as a rare complication of epidural analgesia in an obstetric patient. Although reported in few instances in the anesthesia literature, awareness among providers in obstetrics is critical because this could be the first sign of a high sympathetic blockade resulting in potential maternal-fetal morbidity.  (+info)

The postpartum visit--why wait 6 weeks? (5/52)

BACKGROUND: In many western countries, the traditional 6 week check is a routine medical review of a mother and her baby 6 weeks after the birth. In Australia, general practitioners perform the majority of postpartum assessments. OBJECTIVE: This article discusses some of the common issues that concern women following the birth of a baby, and the medical conditions GPs need to address in the postpartum period. DISCUSSION: The research literature does not support any benefit of a 6 week check. However, clinical evidence, our expertise as GPs, and our personal experiences, clearly indicate that the postpartum period is a time of tremendous change, increased health problems, and emotional upheaval for new parents. General practitioners are in an ideal position to assist families during this period and may consider a sooner rather than later, proactive rather than reactive, approach to postpartum care.  (+info)

Epidural analgesia in labor: Turkish obstetricians' attitudes and knowledge. (6/52)

Epidural analgesia is the most common preferred method of labor analgesia. The aim of this study is to evaluate the knowledge and attitudes of Turkish obstetricians and gynecologists concerning epidural analgesia and to reveal their doubts as well. A prospective survey amongst obstetricians and gynecologists in Turkey (n=152) was conducted to obtain information about obstetricians' education, knowledge and attitudes with respect to epidural analgesia during labor. The response rate to the survey was 94.7 %. Most respondents only received lectures about epidural analgesia after their specialty training. 35 % of respondents did not achieve an adequate knowledge score. Those with six to fifteen years experience achieved significantly better scores. A delay up to twenty minutes before epidural placement is acceptable to 84 % of respondents. In our opinion, the results of this survey indicate that education regarding epidural analgesia, both during and after obstetric speciality training, could be improved, and this education would best be provided by anesthetists in collaboration with obstetricians. It is hoped that closer collaboration between anesthetists and obstetricians during their respective training and in continuing medical education can be fostered.  (+info)

Intrathecal morphine reduces breakthrough pain during labour epidural analgesia. (7/52)

BACKGROUND: When using the combined spinal-epidural (CSE) technique for labour analgesia, parturients often experience breakthrough pain after the spinal medication has receded. We tested the hypothesis that a small dose of intrathecal morphine would reduce breakthrough pain. METHODS: This was a randomized, double-blind, placebo-controlled trial. Subjects were randomized to receive either 100 microg of morphine (MS) or placebo (PLCB) with the spinal injection of bupivacaine and fentanyl. Assessments included need for supplementation during labour analgesia, use of pain medications for 24 h after delivery, and side-effects. The primary end-point was the rate of breakthrough pain. RESULTS: Sixty subjects were enrolled, 55 subjects completed the trial. The MS group had a significantly lower rate of breakthrough pain than the PLCB group [0.6 (0.6) vs 1.1 (0.8) episodes per patient; P < 0.01], and longer time to first episode of breakthrough pain (300 vs 180 min; P = 0.03). The MS group used 75% less opioid medications during the subsequent 24 h, but had a 17% incidence of nausea. CONCLUSIONS: The addition of small dose of morphine to the spinal component of the CSE technique improved the effectiveness of epidural labour analgesia and reduced the need for pain medications over 24 h, but resulted in a small increase in nausea.  (+info)

A questionnaire survey on patients' attitudes towards epidural analgesia in labour. (8/52)

OBJECTIVES: To evaluate patient attitudes about epidural services in labour and correlate them with patient options and actual usage of epidural analgesia. DESIGN: Questionnaire survey. SETTING: Eight Hospital Authority obstetrics units. PARTICIPANTS: A cohort of new antenatal patients and a cohort of postnatal in-patients over 1 calendar month. MAIN OUTCOME MEASURES: Antenatal patient awareness of epidural services and attitudes towards epidural analgesia during labour; the actual usage of such analgesia and the reported experience of postnatal patients. RESULTS: A total of 2109 and 2851 patients completed the antenatal and postnatal survey, respectively. The former revealed that only 47% of patients had been exposed to the concept of epidural analgesia in labour, and only 13% opted for such analgesia. In the postnatal cohort, the overall epidural analgesia rate was 10%, although 19% had actually requested it. Patients who received epidural analgesia in labour were more likely to consider their experience as favourable (85%) compared to those who went through labour without such analgesia (26%) [P<0.001]. There was no significant improvement in knowledge about epidural analgesia among postnatal as compared to antenatal patients. The main reasons generally ascribed by patients for not being able to obtain an epidural service despite it being requested, were related to limited resources. CONCLUSION: The results showed poor general awareness of pregnant women about the proper role of epidural analgesia in labour, leading to a low patient demand for such services. Despite the low prevailing request rate for epidural analgesia in labour, there appears to be a lack of adequate resources to meet the demand.  (+info)