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BMC Pregnancy and Childbirth Jun 2024Perineal massage, as a preventive intervention, has been shown to reduce the risk of perineal injuries and may have a positive impact on pelvic floor function in the... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Perineal massage, as a preventive intervention, has been shown to reduce the risk of perineal injuries and may have a positive impact on pelvic floor function in the early postpartum period. However, there is still debate concerning the best period to apply perineal massage, which is either antenatal or in the second stage of labor, as well as its safety and effectiveness. Meta-analysis was used to evaluate the effect of implementing perineal massage in antenatal versus the second stage of labor on the prevention of perineal injuries during labor and early postpartum pelvic floor function in primiparous women.
METHODS
We searched nine different electronic databases from inception to April 16, 2024. The randomized controlled trials (RCTs) we included assessed the effects of antenatal and second-stage labor perineal massage in primiparous women. All data were analyzed with Revman 5.3, Stata Statistical Software, and Risk of Bias 2 was used to assess the risk of bias. Subgroup analyses were performed based on the different periods of perineal massage. The primary outcomes were the incidence of perineal integrity and perineal injury. Secondary outcomes were perineal pain, duration of the second stage of labor, postpartum hemorrhage, urinary incontinence, fecal incontinence, and flatus incontinence.
RESULTS
This review comprised a total of 10 studies that covered 1057 primigravid women. The results of the analysis showed that perineal massage during the second stage of labor reduced the perineal pain of primigravid women in the immediate postpartum period compared to the antenatal period, with a statistical value of (MD = -2.29, 95% CI [-2.53, -2.05], P < 0.001). Additionally, only the antenatal stage reported that perineal massage reduced fecal incontinence (P = 0.04) and flatus incontinence (P = 0.01) in primiparous women at three months postpartum, but had no significant effect on urinary incontinence in primiparous women at three months postpartum (P = 0.80).
CONCLUSIONS
Reducing perineal injuries in primiparous women can be achieved by providing perineal massage both antenatally and during the second stage of labor. Pelvic floor function is improved in the postnatal phase by perineal massage during the antenatal stage.
TRIAL REGISTRATION
CRD42023415996 (PROSPERO).
Topics: Humans; Female; Perineum; Massage; Pregnancy; Pelvic Floor; Parity; Postpartum Period; Labor Stage, Second; Obstetric Labor Complications; Randomized Controlled Trials as Topic; Fecal Incontinence
PubMed: 38831257
DOI: 10.1186/s12884-024-06586-w -
World Journal of Urology May 2024Transperineal Prostate Biopsy (TPB) is a commonly used technique for the diagnosis of prostate cancer due to growing concerns related to infectious complications...
BACKGROUND
Transperineal Prostate Biopsy (TPB) is a commonly used technique for the diagnosis of prostate cancer due to growing concerns related to infectious complications associated with transrectal ultrasound-guided prostate biopsy (TRUSB). TPB is associated with an infective complication rate of near zero, however, acute urinary retention (AUR) remains the leading complication causing morbidity. Previously in TRUSB, there was weak evidence that alpha-blockers reduce AUR rates, and their usage has been extrapolated to clinical practice with TPB. This review aims to explore if there is an evidence base for using alpha-blockers to prevent AUR following TPB.
METHODS
A systematic approach was used to search Ovid Medline and Embase using keywords related to "Transperineal" and "Retention". Articles were then screened by applying inclusion and exclusion criteria to find studies that compared alpha-blocker recipients to no alpha-blocker use in the perioperative period and the subsequent effect on AUR in TPB.
RESULTS
361 records were identified in the initial search to produce 5 studies included in the final review. No randomised controlled trials (RCTs) were identified. One observational study showed a reduction in AUR rate from 12.5% to 5.3% with a single dose of tamsulosin. A previous systematic review of complications associated with prostate biopsy concluded there may be a potential benefit to alpha-blockers given in the TPB perioperative period. Three observational studies demonstrated a harmful effect related to alpha-blocker use; however, this was well explained by their clear limitations.
CONCLUSION
Based on this review and the extrapolation from TRUSB data, perioperative alpha-blockers may offer some weak benefits in preventing AUR following TPB. However, there is significant scope and need for an RCT to further develop the evidence base further given the significant gap in the literature and lack of a standard alpha blocker protocol in TPB.
Topics: Humans; Male; Urinary Retention; Prostate; Perineum; Prostatic Neoplasms; Adrenergic alpha-Antagonists; Postoperative Complications; Image-Guided Biopsy
PubMed: 38758413
DOI: 10.1007/s00345-024-05001-5 -
Healthcare (Basel, Switzerland) Mar 2024Non-pharmaceutical midwifery techniques, including perineal warm compresses, to improve maternal outcomes remain controversial. The aims of this study are to assess the... (Review)
Review
Effects of Perineal Warm Compresses during the Second Stage of Labor on Reducing Perineal Trauma and Relieving Postpartum Perineal Pain in Primiparous Women: A Systematic Review and Meta-Analyses.
Non-pharmaceutical midwifery techniques, including perineal warm compresses, to improve maternal outcomes remain controversial. The aims of this study are to assess the effects of perineal warm compresses on reducing perineal trauma and postpartum perineal pain relief. This systematic review included randomized controlled trials (RCTs). We searched seven bibliographic databases, three RCT register websites, and two dissertation databases for publications from inception to 15 March 2023. Chinese and English publications were included. Two independent reviewers conducted the risk of bias assessment, data extraction, and the evaluation of the certainty of the evidence utilizing the Cochrane risk of bias 2.0 assessment criteria, the Review Manager 5.4, and the online GRADEpro tool, respectively. Seven RCTs involving 1362 primiparous women were included. The combined results demonstrated a statistically significant reduction in the second-, third- and/or fourth- degree perineal lacerations, the incidence of episiotomy, and the relief of the short-term perineal pain postpartum (within two days). There was a potential favorable effect on improving the integrity of the perineum. However, the results did not show a statistically significant supportive effect on reducing first-degree perineal lacerations and the rate of perineal lacerations requiring sutures. In summary, perineal warm compresses effectively reduced the second-, third-/or fourth-degree perineal trauma and decreased the short-term perineal pain after birth.
PubMed: 38610125
DOI: 10.3390/healthcare12070702 -
The Cochrane Database of Systematic... Apr 2024Midwives are primary providers of care for childbearing women globally and there is a need to establish whether there are differences in effectiveness between midwife... (Review)
Review
BACKGROUND
Midwives are primary providers of care for childbearing women globally and there is a need to establish whether there are differences in effectiveness between midwife continuity of care models and other models of care. This is an update of a review published in 2016.
OBJECTIVES
To compare the effects of midwife continuity of care models with other models of care for childbearing women and their infants.
SEARCH METHODS
We searched the Cochrane Pregnancy and Childbirth Trials Register, ClinicalTrials.gov, and the WHO International Clinical Trials Registry Platform (ICTRP) (17 August 2022), as well as the reference lists of retrieved studies.
SELECTION CRITERIA
All published and unpublished trials in which pregnant women are randomly allocated to midwife continuity of care models or other models of care during pregnancy and birth.
DATA COLLECTION AND ANALYSIS
Two authors independently assessed studies for inclusion criteria, scientific integrity, and risk of bias, and carried out data extraction and entry. Primary outcomes were spontaneous vaginal birth, caesarean section, regional anaesthesia, intact perineum, fetal loss after 24 weeks gestation, preterm birth, and neonatal death. We used GRADE to rate the certainty of evidence.
MAIN RESULTS
We included 17 studies involving 18,533 randomised women. We assessed all studies as being at low risk of scientific integrity/trustworthiness concerns. Studies were conducted in Australia, Canada, China, Ireland, and the United Kingdom. The majority of the included studies did not include women at high risk of complications. There are three ongoing studies targeting disadvantaged women. Primary outcomes Based on control group risks observed in the studies, midwife continuity of care models, as compared to other models of care, likely increase spontaneous vaginal birth from 66% to 70% (risk ratio (RR) 1.05, 95% confidence interval (CI) 1.03 to 1.07; 15 studies, 17,864 participants; moderate-certainty evidence), likelyreduce caesarean sections from 16% to 15% (RR 0.91, 95% CI 0.84 to 0.99; 16 studies, 18,037 participants; moderate-certainty evidence), and likely result in little to no difference in intact perineum (29% in other care models and 31% in midwife continuity of care models, average RR 1.05, 95% CI 0.98 to 1.12; 12 studies, 14,268 participants; moderate-certainty evidence). There may belittle or no difference in preterm birth (< 37 weeks) (6% under both care models, average RR 0.95, 95% CI 0.78 to 1.16; 10 studies, 13,850 participants; low-certainty evidence). We arevery uncertain about the effect of midwife continuity of care models on regional analgesia (average RR 0.85, 95% CI 0.79 to 0.92; 15 studies, 17,754 participants, very low-certainty evidence), fetal loss at or after 24 weeks gestation (average RR 1.24, 95% CI 0.73 to 2.13; 12 studies, 16,122 participants; very low-certainty evidence), and neonatal death (average RR 0.85, 95% CI 0.43 to 1.71; 10 studies, 14,718 participants; very low-certainty evidence). Secondary outcomes When compared to other models of care, midwife continuity of care models likely reduce instrumental vaginal birth (forceps/vacuum) from 14% to 13% (average RR 0.89, 95% CI 0.83 to 0.96; 14 studies, 17,769 participants; moderate-certainty evidence), and may reduceepisiotomy 23% to 19% (average RR 0.83, 95% CI 0.77 to 0.91; 15 studies, 17,839 participants; low-certainty evidence). When compared to other models of care, midwife continuity of care models likelyresult in little to no difference inpostpartum haemorrhage (average RR 0.92, 95% CI 0.82 to 1.03; 11 studies, 14,407 participants; moderate-certainty evidence) and admission to special care nursery/neonatal intensive care unit (average RR 0.89, 95% CI 0.77 to 1.03; 13 studies, 16,260 participants; moderate-certainty evidence). There may be little or no difference in induction of labour (average RR 0.92, 95% CI 0.85 to 1.00; 14 studies, 17,666 participants; low-certainty evidence), breastfeeding initiation (average RR 1.06, 95% CI 1.00 to 1.12; 8 studies, 8575 participants; low-certainty evidence), and birth weight less than 2500 g (average RR 0.92, 95% CI 0.79 to 1.08; 9 studies, 12,420 participants; low-certainty evidence). We are very uncertain about the effect of midwife continuity of care models compared to other models of care onthird or fourth-degree tear (average RR 1.10, 95% CI 0.81 to 1.49; 7 studies, 9437 participants; very low-certainty evidence), maternal readmission within 28 days (average RR 1.52, 95% CI 0.78 to 2.96; 1 study, 1195 participants; very low-certainty evidence), attendance at birth by a known midwife (average RR 9.13, 95% CI 5.87 to 14.21; 11 studies, 9273 participants; very low-certainty evidence), Apgar score less than or equal to seven at five minutes (average RR 0.95, 95% CI 0.72 to 1.24; 13 studies, 12,806 participants; very low-certainty evidence) andfetal loss before 24 weeks gestation (average RR 0.82, 95% CI 0.67 to 1.01; 12 studies, 15,913 participants; very low-certainty evidence). No maternal deaths were reported across three studies. Although the observed risk of adverse events was similar between midwifery continuity of care models and other models, our confidence in the findings was limited. Our confidence in the findings was lowered by possible risks of bias, inconsistency, and imprecision of some estimates. There were no available data for the outcomes: maternal health status, neonatal readmission within 28 days, infant health status, and birth weight of 4000 g or more. Maternal experiences and cost implications are described narratively. Women receiving care from midwife continuity of care models, as opposed to other care models, generally reported more positive experiences during pregnancy, labour, and postpartum. Cost savings were noted in the antenatal and intrapartum periods in midwife continuity of care models.
AUTHORS' CONCLUSIONS
Women receiving midwife continuity of care models were less likely to experience a caesarean section and instrumental birth, and may be less likely to experience episiotomy. They were more likely to experience spontaneous vaginal birth and report a positive experience. The certainty of some findings varies due to possible risks of bias, inconsistencies, and imprecision of some estimates. Future research should focus on the impact on women with social risk factors, and those at higher risk of complications, and implementation and scaling up of midwife continuity of care models, with emphasis on low- and middle-income countries.
Topics: Infant; Pregnancy; Infant, Newborn; Female; Humans; Midwifery; Cesarean Section; Perinatal Death; Birth Weight; Premature Birth; Continuity of Patient Care; Randomized Controlled Trials as Topic
PubMed: 38597126
DOI: 10.1002/14651858.CD004667.pub6 -
International Wound Journal Apr 2024The efficacy of episiotomy, particularly the angle of incision in mediolateral episiotomies, remains a significant area of inquiry in obstetrics. This meta-analysis... (Meta-Analysis)
Meta-Analysis
Evaluation of perineal wound healing and pain outcomes after low-angle mediolateral episiotomy in women undergoing vaginal childbirth: A systematic review and meta-analysis.
The efficacy of episiotomy, particularly the angle of incision in mediolateral episiotomies, remains a significant area of inquiry in obstetrics. This meta-analysis aimed to evaluate the impact of low-angle mediolateral episiotomy on perineal wound healing and pain outcomes in women undergoing vaginal childbirth. Adhering to PRISMA guidelines, a systematic review was conducted using the PICO framework. Studies were selected based on predefined inclusion and exclusion criteria, focusing on randomised controlled trials (RCTs) involving low-angle mediolateral episiotomies. Comprehensive literature searches were performed across major electronic databases including PubMed, Embase, Web of Science and Cochrane Library. Data extraction and quality assessments were meticulously carried out by independent reviewers, employing the Cochrane Collaboration's risk of bias tool. A total of 1246 articles were initially identified, with 8 articles meeting the strict inclusion criteria for the final analysis. The meta-analysis revealed significant heterogeneity among studies regarding postoperative pain (p < 0.0001, I = 77.5%), and employed a random-effects model. Results showed that low-angle episiotomies significantly reduced postoperative pain (OR = 0.27, 95% CI: 0.17-0.42, p < 0.001), and increased first-degree healing rates (OR = 2.95, 95% CI: 2.20-3.96, p < 0.001) compared to traditional angles. Sensitivity analyses confirmed the stability of these findings, and no significant publication bias was detected. The analysis suggests that low-angle episiotomies can potentially reduce postoperative perineal pain and enhance wound healing. However, the limited number and varying quality of the included studies warrant cautious interpretation of these results. Further well-designed studies are needed to corroborate these findings and guide clinical practice.
Topics: Female; Pregnancy; Humans; Episiotomy; Pain, Postoperative; Databases, Factual; Perineum; Postoperative Period
PubMed: 38512112
DOI: 10.1111/iwj.14826 -
AJOG Global Reports Feb 2024Obstetrical anal sphincter injury describes a severe injury to the perineum and perianal muscles after birth. Obstetrical anal sphincter injury occurs in approximately... (Review)
Review
OBJECTIVE
Obstetrical anal sphincter injury describes a severe injury to the perineum and perianal muscles after birth. Obstetrical anal sphincter injury occurs in approximately 4.4% of vaginal births in the United States; however, racial and ethnic inequities in the incidence of obstetrical anal sphincter injury have been shown in several high-income countries. Specifically, an increased risk of obstetrical anal sphincter injury in individuals who identify as Asian vs those who identify as White has been documented among residents of the United States, Australia, Canada, Western Europe, and the Scandinavian countries. The high rates of obstetrical anal sphincter injury among the Asian diaspora in these countries are higher than obstetrical anal sphincter injury rates reported among Asian populations residing in Asia. A systematic review and meta-analysis of studies in high-income, non-Asian countries was conducted to further evaluate this relationship.
DATA SOURCES
MEDLINE, Ovid, Embase, EmCare, and the Cochrane databases were searched from inception to March 2023 for original research studies.
STUDY ELIGIBILITY CRITERIA
Observational studies using keywords and controlled vocabulary terms related to race, ethnicity and obstetrical anal sphincter injury. All observational studies, including cross-sectional, case-control, and cohort were included. 2 reviewers followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and the Meta-analysis of Observational Studies in Epidemiology recommendations.
METHODS
Meta-analysis was performed using RevMan (version 5.4; Cochrane Collaboration, London, United Kingdom) for dichotomous data using the random effects model and the odds ratios as effect measures with 95% confidence intervals. Subgroup analysis was performed among Asian subgroups. The risk of bias was assessed using the Joanna Briggs Institute Critical Appraisal tools. Meta-regression was used to determine sources of between-study heterogeneity.
RESULTS
A total of 27 studies conducted in 7 countries met the inclusion criteria encompassing 2,337,803 individuals. The pooled incidence of obstetrical anal sphincter injury was higher among Asian individuals than White individuals (pooled odds ratio, 1.64; 95% confidence interval, 1.48-1.80). Subgroup analyses showed that obstetrical anal sphincter injury rates were highest among South Asians and among population-based vs hospital-based studies. Meta-regression showed that moderate heterogeneity remained even after accounting for differences in studies by types of Asian subgroups included, study year, mode of delivery included, and study setting.
CONCLUSION
Obstetrical anal sphincter injury is more frequent among Asian versus white birthing individuals in multiple high-income, non-Asian countries. Qualitative and quantitative research to elucidate underlying causal mechanisms responsible for this relationship are warranted.
PubMed: 38283323
DOI: 10.1016/j.xagr.2023.100296 -
Acta Obstetricia Et Gynecologica... Jun 2024The complex process of pregnancy and childbirth significantly influences the well-being of both mother and child. Today all pregnant women without medical... (Meta-Analysis)
Meta-Analysis Review
Influence of pelvic floor muscle training alone or as part of a general physical activity program during pregnancy on urinary incontinence, episiotomy and third- or fourth-degree perineal tear: Systematic review and meta-analysis of randomized clinical trials.
INTRODUCTION
The complex process of pregnancy and childbirth significantly influences the well-being of both mother and child. Today all pregnant women without medical contraindications are recommended to start or continue regular aerobic and strength training for at least 150 min per week to prevent pregnancy-related diseases and conditions. Urinary incontinence in pregnancy, episiotomy and third- or fourth-degree perineal tear during labor can greatly impact womens' health, quality of life and ability to be physically active. The aim of this study was to examine the efficacy of pelvic floor muscle training (PFMT) during pregnancy in the prevention of urinary incontinence, episiotomy, and third- or fourth-degree perineal tear.
MATERIAL AND METHODS
A systematic review and meta-analysis (CRD42022370600) was performed. Only randomized clinical trials published between 2010 and 2023 were included. The following databases were examined: EBSCO (including Academic Search Premier, Education Resources Information Center, MEDLINE, SPORTDiscus and OpenDissertations databases), Clinicaltrials.gov, Web of Science, Scopus, Cochrane Database of Systematic Reviews and Physiotherapy Evidence Database (PEDro). Three meta-analyses to investigate the effect of PFMT exclusively or implemented as a section within a physical activity program during pregnancy on urinary incontinence, episiotomy, and third- or fourth-degree perineal tear were conducted.
RESULTS
Thirty studies were analyzed (N = 6691). An effective preventive action of PFMT was found for urinary incontinence (z = 3.46; p < 0.0005; relative risk [RR] = 0.72, 95% confidence interval [CI]: 0.59, 0.87, I = 59%) and third- or fourth-degree perineal tear (z = 2.89; p = 0.004; RR = 0.50, 95% CI: 0.31, 0.80, I = 48%) but not for episiotomy (z = 0.80; p = 0.42; RR = 0.95, 95% CI: 0.85, 1.07, I = 75%).
CONCLUSIONS
PFMT during pregnancy proves to be an effective preventive intervention for reducing the risk of urinary incontinence and the occurrence of third- or fourth-degree perineal tears. These findings highlight the importance of incorporating PFMT into antenatal care and training programs to improve maternal well-being and overall childbirth outcomes.
Topics: Humans; Female; Pregnancy; Episiotomy; Urinary Incontinence; Perineum; Pelvic Floor; Randomized Controlled Trials as Topic; Exercise Therapy; Obstetric Labor Complications; Pregnancy Complications; Exercise; Lacerations
PubMed: 38140841
DOI: 10.1111/aogs.14744 -
Quantitative Imaging in Medicine and... Dec 2023Induction of labor (IOL) is a common obstetric approach to start or encourage uterine contractions to achieve a vaginal birth. It is recommended when continuing the...
BACKGROUND
Induction of labor (IOL) is a common obstetric approach to start or encourage uterine contractions to achieve a vaginal birth. It is recommended when continuing the pregnancy may be more dangerous for the mother or baby. Different ultrasonographic measures, such as cervical length, have been investigated as possible predictors of the outcomes of IOL. This meta-analysis aimed to assess the accuracy of ultrasound measurements in anticipating successful IOL.
METHODS
The study conducted a thorough search on three databases (PubMed, Scopus, and Web of Science) until 04 March 2023, to find clinical studies published in English that reported different sonographic cervical measures and their ability to predict IOL outcomes. The chosen studies were stratified based on the type of indicator reported, and a meta-analysis was conducted to determine the best indicator for both successful and failed induction. The risk of bias and concerns about the applicability of the included studies was evaluated using the Quality Assessment of Diagnostic Accuracy Studies-2 (QUADAS-2) method.
RESULTS
This study analyzed 57 studies with 9,338 patients. Cervical length is moderately effective in predicting successful IOL, with pooled sensitivity (SN) and specificity (SP) of 0.67 and 0.70, respectively. However, cervical length had a pooled SN and SP of 0.70 and 0.61 for predicting failed IOL. The posterior cervical angle was found to have a higher pooled SN and SP of 0.79 and 0.73 for predicting successful IOL. Fetal head-perineum distance demonstrated moderate accuracy with a pooled SN, SP, positive likelihood ratio, negative likelihood ratio, diagnostic odds ratio, and area under the curve of 0.58, 0.66, 1.95, 0.36, 5.33, and 0.9992, respectively, for predicting successful IOL.
CONCLUSIONS
Fetal head-perineum distance was the most effective predictor for successful IOL compared to cervical length, which only had a moderate predictive ability. Shortening of cervical length was not a useful indicator for successful IOL. On the other hand, the posterior cervical angle was the most reliable factor for predicting failed induction. The study's findings can aid in developing more effective management strategies for IOL.
PubMed: 38106269
DOI: 10.21037/qims-23-507 -
Journal of Gynecology Obstetrics and... Oct 2023Natural childbirth is associated with the risk of damage to the perineum - a tears or a episiotomy. Adequate preparation of the woman for childbirth is essential to... (Review)
Review
BACKGROUND
Natural childbirth is associated with the risk of damage to the perineum - a tears or a episiotomy. Adequate preparation of the woman for childbirth is essential to minimize the occurrence of perinatal injuries.
AIM
The aim of the review is to assess and analyze the impact of APM (antental perineal massage) on perinatal perineal injuries and the development of pelvic pain and other complications in postpartum women, such as dyspareunia, urinary (UI), gas (GI), and fecal incontinence (FI).
METHODS
PubMed, Web of Science, Scopus and Embase were searched. Three authors independently searched databases and selected articles for inclusion and exclusion criteria. Next one author did Risk of Bias 2 and ROBINS 1 analyze.
FINDINGS
Of 711 articles, 18 publications were left for the review. All 18 studies examined the risk of perineal injuries (tearing and episiotomy), 7 pain in postpartum period, 6 postpartum urinary, gas/fecal incontinence and 2 described dyspareunia. Most authors described APM from 34 weeks of pregnancy until delivery. There were different techniques and times for doing APM procedures.
DISCUSSION
APM has many benefits for women during labor and the postpartum period (e.g. lower rate of perineal injuries and pain). However, it can be observed that individual publications differ from each other in the time of massage, the period and frequency of its performance, the form of obtaining instruction and control of patients. These components may affect the results obtained.
CONCLUSION
APM can protects the perineum from injuries during labor. It also reduces risk of fecal and gas incontinence in postpartum period.
Topics: Pregnancy; Female; Humans; Perineum; Fecal Incontinence; Dyspareunia; Parturition; Massage; Pelvic Pain; Urinary Incontinence
PubMed: 37414371
DOI: 10.1016/j.jogoh.2023.102627 -
The Cochrane Database of Systematic... Jun 2023Epidural analgesia is often used for pain relief during labour and childbirth, and involves administration of local anaesthetics (LA) into the epidural space resulting... (Review)
Review
BACKGROUND
Epidural analgesia is often used for pain relief during labour and childbirth, and involves administration of local anaesthetics (LA) into the epidural space resulting in sensory blockade of the abdomen, pelvis, and perineum. Epidural opioids are often co-administered to improve analgesia. Administration of epidural medications can be accomplished by basal infusion (BI) or automated mandatory bolus (AMB). With BI, medications are administered continuously, while AMB involves injecting medications at set time intervals. Patient-controlled epidural analgesia (PCEA) on top of AMB or BI enables patients to initiate additional boluses of epidural medications. The superior method of delivering epidural medications would result in lower incidence of pain requiring anaesthesiologist intervention (breakthrough pain). Also, it should be associated with lower incidence of epidural-related adverse effects including caesarean delivery, instrumental delivery (use of forceps or vacuum devices), prolonged duration of labour analgesia, and LA consumption. However, clear evidence of the superiority of one technique over the other is lacking. Also, differences in the initiation of epidural analgesia such as combined spinal-epidural (CSE) (medications given into the intrathecal space in addition to the epidural space) compared to epidural only, and medications used (types and doses of LA or opioids) may not have been accounted for in previous reviews. Our prior systematic review suggested that AMB reduces the incidence of breakthrough pain compared to BI with no significant difference in the incidence of caesarean delivery or instrumental delivery, duration of labour analgesia, and LA consumption. However, several studies comparing AMB and BI have been performed since then, and inclusion of their data may improve the precision of our effect estimates.
OBJECTIVES
To assess the benefits and harms of AMB versus BI for maintaining labour epidural analgesia in women at term.
SEARCH METHODS
We searched CENTRAL, Wiley Cochrane Library), MEDLINE, (National Library of Medicine), Embase(Elseiver), Web of Science (Clarivate), the WHO-ICTRP (World Health Organization) and ClinicalTrials.gov (National Library of Medicine) on 31 December 2022. Additionally, we screened the reference lists of relevant trials and reviews for eligible citations, and we contacted authors of included studies to identify unpublished research and ongoing trials.
SELECTION CRITERIA
We included all randomised controlled studies that compared bolus dosing AMB with continuous BI during epidural analgesia. We excluded studies of women in preterm labour, with multiple pregnancies, with fetal malposition, intrathecal catheters, those that did not use automated delivery of medications, and those where AMB and BI were combined.
DATA COLLECTION AND ANALYSIS
We used standard methodology for systematic review and meta-analysis described by Cochrane. Primary outcomes included: incidence of breakthrough pain requiring anaesthesiologist intervention; incidence of caesarean delivery; and incidence of instrumental delivery. Secondly, we assessed the duration of labour; hourly LA consumption in bupivacaine equivalents, maternal satisfaction after fetal delivery, and neonatal Apgar scores. The following subgroup analyses were chosen a priori: epidural alone versus CSE technique; regimens that used PCEA versus those that did not; and nulliparous versus combination of nulli- and multi-parous women. We used the GRADE system to assess the certainty of evidence associated with our outcome measures.
MAIN RESULTS
We included 18 studies of 4590 women, of which 13 enrolled healthy nulliparous women and five included healthy nulli- and multiparous women. All studies excluded women with preterm or complicated pregnancies. Techniques used to initiate epidural analgesia differed between the studies: seven used combined spinal epidural, 10 used epidural, and one used dural puncture epidural (DPE). There was also variation in analgesics used. Eight studies utilised ropivacaine with fentanyl, three used ropivacaine with sufentanil, two utilised levobupivacaine with sufentanil, one used levobupivacaine with fentanyl, and four utilised bupivacaine with fentanyl. Most of the studies were assessed to have low risk of randomisation, blinding, attrition, and reporting biases, except for allocation concealment where eight studies were assessed to have uncertain risk and three with high risk. Our results showed that AMB was associated with lower incidence of breakthrough pain compared to BI (risk ratio (RR) 0.71; 95% confidence interval (CI) 0.55 to 0.91; I = 57%) (16 studies, 1528 participants), and lower hourly LA consumption in bupivacaine equivalents (mean difference (MD) -0.84 mg/h; 95% CI -1.29 to -0.38, I = 87%) (16 studies, 1642 participants), both with moderate certainty. AMB was associated with an estimated reduction in breakthrough pain incidence of 29.1% (incidence 202 per 1000, 95% CI 157 to 259), and was therefore considered clinically significant. The incidence of caesarean delivery (RR 0.85; 95% CI 0.69 to 1.06; I = 0%) (16 studies, 1735 participants) and instrumental delivery (RR 0.85; 95% CI 0.71 to 1.01; I = 0%) (17 studies, 4550 participants) were not significantly, both with moderate certainty. There was no significant difference in duration of labour analgesia (MD -8.81 min; 95% CI -19.38 to 1.77; I = 50%) (17 studies, 4544 participants) with moderate certainty. Due to differences in the methods and timing of outcome measurements, we did not pool data for maternal satisfaction and Apgar scores. Results reported narratively suggest AMB may be associated with increased maternal satisfaction (eight studies reported increased satisfaction and six reported no difference), and all studies showed no difference in Apgar scores. WIth the exception of epidural alone versus CSE which found significant subgroup differences in LA consumption between AMB and BI, no significant differences were detected in the remaining subgroup analyses.
AUTHORS' CONCLUSIONS
Overall, AMB is associated with lower incidence of breakthrough pain, reduced LA consumption, and may improve maternal satisfaction. There were no significant differences between AMB and BI in the incidence of caesarean delivery, instrumental delivery, duration of labour analgesia, and Apgar scores. Larger studies assessing the incidence of caesarean and instrumental delivery are required.
Topics: Female; Humans; Infant, Newborn; Pregnancy; Analgesia, Epidural; Analgesics; Analgesics, Opioid; Breakthrough Pain; Levobupivacaine; Ropivacaine; Sufentanil; United States
PubMed: 37276327
DOI: 10.1002/14651858.CD011344.pub3