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A Randomized, Double-blind, Placebo-controlled Trial of Epidural Morphine Analgesia After Vaginal Delivery
Abstract
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... En otro estudio realizado por MacDonald y Bickford en pacientes con episiotomía a quienes se les aplicó una dosis de morfina epidural, no se hallaron diferencias sobre la incidencia de efectos adversos entre los grupos expuestos y el grupo control 18 . Otro estudio sí registró aumento de la incidencia de prurito y náusea, aunque el diseño del estudio no era el adecuado 19,20 . ...
... En comparación con otros estudios, la incidencia de dolor posparto en esta población es menor a la informada previamente 17,18 . Es importante tener en cuenta que la edad promedio de las pacientes que hicieron parte de este estudio es menor que la informada en otros (tabla 1). ...
... Postoperative pain following episiotomy has been always stressful for primiparous women, with negative impacts on their first motherhood experience (7) and mother-child communication (8). This type of pain is one of the most common and influential factors for mothers' function after childbirth, leading to urinary dysfunction, bowel elimination, dyspareunia, and marital problems (9). ...
... Therefore, perineal pain not only causes physical trauma for mothers, but also results in emotional traumas and influences their quality of life, mental health, and mother-child communication (3,5,(11)(12)(13)(14). Therefore, for the faster recovery of mothers, perineal pain and discomfort should be eliminated (9). ...
Background & aim: Episiotomy is a common medical procedure for widening the perineum. In fact, perineal pain is the most common complaint after episiotomy. Therefore, it is important to determine factors associated with postoperative pain following episiotomy in order to provide comfort for women after delivery. This study aimed to investigate factors associated with postoperative pain following episiotomy in primiparous women.
Methods: This analytical, descriptive study was conducted on 119 eligible mothers, selected via convenience sampling, referring to Mashhad Omolbanin Hospital. Childbirth-related information was collected using a questionnaire. Neonates and mothers were also evaluated using Redness, Edema, Ecchymosis, Discharge, and Approximation (REEDA) scale and McGill Pain Questionnaire for perineal pain on days 1, 7, 10, and 14 after delivery. Kolmogorov-Smirnov, one-way ANOVA, Spearman’s test, and Pearson’s correlation were performed, using SPSS version 16. P-value ≤ 0.05 was considered statistically significant.
Results: A significant direct relationship was found between the severity of episiotomy pain on day 7 and length of wound cut (P=0.034), neonatal weight (P=0.040), and number of sutures (P=0.028). There was also a significant relationship between the severity of episiotomy pain on day 10 and the duration of active phase during the second stage of labor (P=0.047), duration of sitting position (P=0.011), and number of sutures (P=0.020). However, a reverse significant correlation was found between the severity of postoperative pain following episiotomy and wound recovery on days 7 (P=0.015) and 10 (P=0.035).
Conclusion: Perineal pain was related to factors such as long perineal cut, slow wound recovery, prolonged active phase in the second stage of labor, neonatal overweight, and mother’s prolonged sitting position. Therefore, it is recommended to train health care providers and mothers about these factors.
... Epidural morphine 2.5 mg was given for post-delivery pain relief. 6 Before transfer to CCU for on-going monitoring, the epidural catheter and NICOMä were removed. At our facility, NICOMä is used on the delivery unit for patients with cardiac conditions and is not available for use in other hospital areas. ...
... Epidural morphine analgesia may have also contributed to the prolonged reduction in TPR by suppressing sympathetic nervous system stimulation secondary to pain. 6 The postpartum course of patients with PPCM undergoing vaginal delivery is not well documented in the literature but is more frequently reported after cesarean delivery with spinal [13][14][15] or general anesthesia. 14,16 Approximately 15 h postpartum, the patient developed pulmonary edema and cardiogenic shock requiring inotropic support. ...
The utility of a non-invasive cardiac output monitor (NICOMTM) in guiding the peripartum management and identification of postpartum complications in a patient with severe peripartum cardiomyopathy is reported. A 31-year-old nulliparous woman at 35 weeks of gestation presented with a three-week history of worsening dyspnea and progressive functional deterioration. A transthoracic echocardiogram showed severe left ventricular systolic dysfunction with an ejection fraction <20%. Cardiac status was monitored using NICOMTM during labor and delivery. The baseline values were: cardiac output 5.3 L/min, total peripheral resistance 1549 dynes.sec/cm5, stroke volume 42.1 mL and stroke volume variation 18%. She received early epidural analgesia during labor, titrated slowly with a loading dose of 0.0625% bupivacaine 10 mL and fentanyl 25 μg, followed by patient-controlled epidural analgesia (0.0625% bupivacaine with fentanyl 2 μg/mL, infusion at 10mL/h, bolus dose 5 mL and lockout interval 10 min). After epidural drug administration, total peripheral resistance decreased, cardiac output increased, and satisfactory analgesia was obtained. She had an uneventful vaginal delivery with a forceps-assisted second stage after prophylactic administration of furosemide 20 mg. NICOMTM was discontinued after delivery. Fifteen hours post-delivery, the patient developed cardiogenic shock, which resolved after aggressive therapy with inotropes and furosemide. NICOMTM can be used to guide treatment during labor and delivery in patients with critical peripartum cardiomyopathy. We suggest that use of NICOMTM be extended into the postpartum period to detect signs of cardiac decompensation in such patients.
... En otro estudio realizado por MacDonald y Bickford en pacientes con episiotomía a quienes se les aplicó una dosis de morfina epidural, no se hallaron diferencias sobre la incidencia de efectos adversos entre los grupos expuestos y el grupo control 18 . Otro estudio sí registró aumento de la incidencia de prurito y náusea, aunque el diseño del estudio no era el adecuado 19,20 . ...
... En comparación con otros estudios, la incidencia de dolor posparto en esta población es menor a la informada previamente 17,18 . Es importante tener en cuenta que la edad promedio de las pacientes que hicieron parte de este estudio es menor que la informada en otros (tabla 1). ...
Introduction: Prior studies have shown that the conventional management of post-partum pain (acetaminophen, NSAIDS) is insufficient. In our setting, no advantage is taken of the epidural catheter placed as part of the analgesic management of pregnant women during labor. Objective: To determine the efficacy of 2 and 3 mg doses of epidural morphine used for analgesia during vaginal post-partum in patients receiving epidural analgesia for labor, compared to placebo. Patients and methods: Double-blind randomized clinical trial with 114 patients, in which 38 patients received 10 ml of anesthetic solution with 2 mg of epidural morphine, 39 received 3 mg of epidural morphine, and another 37 received 10 ml of 0.9% epidural saline solution (control group), 1 hour after labor. The analgesic efficacy and the side effects occurring within the first 24 hours after administration were evaluated. Results: The dose of morphine was effective at controlling pain after delivery, making it possible to reduce the need for additional analgesia in the group receiving 2 mg (NNT=4.56), as well as in the group receiving 3 mg of morphine (NNT=3.66). The outcome was more marked in patients who needed perineorrhaphy (NNT =1.6) and in primiparity cases (NNT 2.4). In the experimental group, the analgesic effect extended over the 24-hour follow-up period. The incidence of side-effects in each of the treatment groups was as follows: pruritus, 30% and 36%; nausea, 18.4% and 15.4%; vomiting, 7.9% and 15.4%. Conclusions: The use of epidural morphine during the immediate post-partum period is effective for managing pain ensuing after labor. Although there was evidence of adverse side effects at the doses used, they were tolerable and did not require treatment. The present management of post-partum analgesia is insufficient. © 2012 Sociedad Colombiana de Anestesiología y Reanimación. Published by Elsevier. All rights reserved.
... En otro estudio realizado por MacDonald y Bickford en pacientes con episiotomía a quienes se les aplicó una dosis de morfina epidural, no se hallaron diferencias sobre la incidencia de efectos adversos entre los grupos expuestos y el grupo control 18 . Otro estudio sí registró aumento de la incidencia de prurito y náusea, aunque el diseño del estudio no era el adecuado 19,20 . ...
... En comparación con otros estudios, la incidencia de dolor posparto en esta población es menor a la informada previamente 17,18 . Es importante tener en cuenta que la edad promedio de las pacientes que hicieron parte de este estudio es menor que la informada en otros (tabla 1). ...
IntroductionPrior studies have shown that the conventional management of post-partum pain (acetaminophen, NSAIDS) is insufficient. In our setting, no advantage is taken of the epidural catheter placed as part of the analgesic management of pregnant women during labor.Objective
To determine the efficacy of 2 and 3 mg doses of epidural morphine used for analgesia during vaginal post-partum in patients receiving epidural analgesia for labor, compared to placebo.Patients and methodsDouble-blind randomized clinical trial with 114 patients, in which 38 patients received 10 ml of anesthetic solution with 2 mg of epidural morphine, 39 received 3 mg of epidural morphine, and another 37 received 10 ml of 0.9% epidural saline solution (control group), 1 hour after labor. The analgesic efficacy and the side effects occurring within the first 24 hours after administration were evaluated.ResultsThe dose of morphine was effective at controlling pain after delivery, making it possible to reduce the need for additional analgesia in the group receiving 2 mg (NNT=4.56), as well as in the group receiving 3 mg of morphine (NNT=3.66). The outcome was more marked in patients who needed perineorrhaphy (NNT =1.6) and in primiparity cases (NNT 2.4). In the experimental group, the analgesic effect extended over the 24-hour follow-up period.The incidence of side-effects in each of the treatment groups was as follows: pruritus, 30% and 36%; nausea, 18.4% and 15.4%; vomiting, 7.9% and 15.4%.Conclusions
The use of epidural morphine during the immediate post-partum period is effective for managing pain ensuing after labor. Although there was evidence of adverse side effects at the doses used, they were tolerable and did not require treatment. The present management of post-partum analgesia is insufficient.
... 15 Likewise, a considerably higher percentage of our patients received opioids in comparison to MacArthur et al, who reported opioid use in 7% of patients who received epidural morphine and 32% in those who did not receive epidural morphine. 16 This is contradictory to our finding that women who received epidural analgesia were significantly more likely to use opiates in the inpatient setting (p=0.009). ...
Background
Recommendations for the management of pain following vaginal delivery are not specific and do
not differentiate patients based on the degree of perineal trauma. Our objective is to describe
patterns of postpartum opioid use in women with no or minor perineal trauma.
Methods
This is a retrospective cohort study describing the characteristics of opioid analgesia usage
among women with no or minor perineal lacerations at the time of vaginal delivery in a
university-affiliated regional hospital.
Results
For the 6-month study period, 433 patients were eligible for inclusion. Of these, 423 (97.69%)
were ordered as-needed narcotics during their post-partum hospitalization. Of women with an asneeded narcotic prescribed, 285 (65.82%) used at least one dose of narcotics while hospitalized.
Significant patient characteristics of women using opioids during their inpatient post-partum
course included those who used epidural analgesia during labor (p=0.009) and primiparous
patients (p=0.05). Thirty-five of the women included in the study received a prescription for
opioid analgesics at the time of discharge (8.08%). Significant findings among these women
include increasing maternal age (p=0.007). Non-academic physicians with resident coverage
were 3.1 times more likely to prescribe opioids at discharge compared to academic physicians
with residents and non-academic physicians without resident coverage.
Conclusions
Focusing specifically on women with no or minor perineal lacerations at the time of delivery, our
findings indicate that if given the option of opioids analgesia during their hospitalization, many
women will request at least one dose of opioid analgesia, but rarely require opioids after
discharge.
... In the current study, warm compress relaxed the perineum and led to relief from pain and fatigue by reducing the sensitivity and rigidity of the muscles while improving blood circulation (45). In the research by Macarthur, the prevalence of perineal pain on the day after delivery was 97%, which reached 71% on the 10th day (12). In the present study, the control group's pain intensity was higher compared to the intervention group, revealing the effectiveness of warm compress. ...
Objectives: Perineal warm packs with an increase in subcutaneous temperature and the stimulation of cutaneous receptors are advocated in the belief of pain and probably increase comfort during labor and delivery. This study aimed to investigate the effectiveness of warm compress bi-stage on pain strength in the first two stages of labor and after delivery in primiparous women. Materials and Methods: This study was a randomized clinical trial that was conducted in Shiraz hospitals from July 2012 to March 2013, in which 150 women participated and were separated into intervention (15-20-minute warm compress bi-stage in the first two stages of normal delivery at 7 and 10 cm dilations and zero position) and control (just usual hospital cares) groups. Then, pain strength was evaluated in both groups in the first two stages of normal delivery and after delivery similar to the frequency of episiotomy. The chi-square, t test, and odds ratio analysis were used for data analysis Results: The results of the t test showed that the mean intensity of pain reduced significantly in intervention group in both first (P<0.002) and second stages (P<0.001) and on the day after delivery (P<0.001). Besides, the frequency of episiotomy meaningfully decreased in the intervention group in comparison with the control group (P<0.001). Conclusions: The research participants experienced less pain through the labor and after delivery by using warm compress bi-stage at 7 and 10 cm dilatations. Thus, this method might be suitable for reducing perineal pain resulting from episiotomy
... However, more pressure generated in the perineum area due to prolonged sitting can cause higher perineal pain (Aradmehr et al., 2015). Therefore, discomfort and perineal pain need to be get rid of for faster recovery of mothers (Macarthur et al., 2010). The study's aim is to overcome postpartum mothers' problems due to the pain at their episiotomy wound while sitting at the waiting area of clinic for treatment of baby. ...
This study seeks to address issues faced by postpartum mothers when they are sitting. This will help to overcome their pain due to episiotomy wound when they are seated in a clinic's waiting area for 20 to 60 minutes. The study was conducted at the Ayer Keroh Health Clinic in Melaka. To design an ergonomic chair, first, we identified the problem areas, including the technical requirements of postpartum mothers. A new design feature(s) was integrated to the chair, which was then verified in terms of usability and feasibility. Based on the technical requirements, a questionnaire is prepared and House of Quality (HOQ) and Analytic Hierarchy Process (AHP) are employed for data analysis. The selected design, amongst the three conceptual designs, was then fed to a SolidWorks software. For chair dimensions, Minitab 17 was employed to compute the 5th, 50th and 95th percentile based on postpartum mothers' anthropometry measurements. The corroboration process considered the technical method that used pressure mapping and the survey's subjective methodology. The ergonomic chair model and the present chair in the clinic's waiting area are compared to determine respondents' contact pressure. At the perineal area, it was found that the contact pressure decreased in the normal, overweight and obese category by 5%, 3% and 52%, respectively. The technical requirements of postpartum mothers were examined through the projected outcome from the chair design and if the episiotomy wound decreased with the ergonomic chair's designs.
... There is scant previously published data available to allow for establishment of norms for opioid use after vaginal delivery. Minassian et al. 20 reported 76% of women with perineal laceration or episiotomy after vaginal delivery required opioids within the first 48 h, whereas Macarthur et al. 21 reported incidences of opioid use during 24 h after vaginal delivery of 7% in patients who received epidural morphine and 32% in those not receiving epidural morphine. Our study highlights that the majority of patients undergoing vaginal delivery do not require opioids after discharge from the hospital. ...
Background:
The majority of parturients in the United States first return for evaluation by their obstetric practitioner 6 weeks after delivery. As such, there is little granular data on the pain experience, analgesic requirements, and functional recovery during the postpartum period. This prospective observational study was performed to evaluate these factors to provide expectations for patients.
Methods:
A total of 213 nulliparous women were enrolled and assessed daily until they completed 3 outcomes: (1) pain resolution; (2) opioid cessation; and (3) self-assessed functional recovery from delivery. The primary endpoint, pain- and opioid-free functional recovery, was the time required to reach all three of the endpoints. Pain burden was assessed as the area under the curve created by plotting the daily numerical pain rating scale against the days required to attain pain resolution. Times to attain study endpoints after cesarean delivery and vaginal delivery were compared using survival analysis.
Results:
After vaginal delivery, days required for pain and opioid-free functional recovery (median [interquartile range (IQR)]) were 19 [11 to 26], for opioid cessation 0 [0 to 2], termination of all analgesic (including nonsteroidal antiinflammatories and acetaminophen) 11 [5 to 17], and pain resolution 14 [7 to 24]. Achievement of these endpoints after cesarean delivery required 27 [19 to 40], 9 [5 to 12], 16 [11 to 24], and 21 [14 to 27] days, respectively.
Conclusions:
There is clinically significant variability between healthy nulliparous parturients in the pain experience, opioid use, and functional recovery after childbirth following vaginal and cesarean delivery. Recovery to predelivery function is similar after vaginal and cesarean delivery, and approximately half of the variance was explained by pain burden.
... La morphine péridurale permettait, dans ce contexte, une réduction d'environ 78 % des besoins analgésiques par voie orale ou systémique au cours des premières 24h post-partum et facilite ainsi la mobilisation des patientes et leur réhabilitation. De nouvelles études devraient permettre de pouvoir cibler les sous-groupes les plus à risque de douleurs importantes et qui pourrait bénéficier de cette administration précoce de morphine péridurale (extractions instrumentales, lésions périnéales sévères) [61][62][63]. ...
La prise en charge optimale de la douleur est déterminante pour permettre une réhabilitation dans la période péri-opératoire. Ces principes, bien connus en chirurgie, s’appliquent aux patientes après un accouchement par césarienne ou un accouchement par voie basse (AVB). En effet, si la césarienne a longtemps été considérée comme un modèle de douleur aiguë « reproductible », les douleurs aiguës après AVB ont été en grande partie sous-estimées, voire méconnues, et leur prise en compte en suites de couches est relativement récente. Les douleurs périnéales sont pourtant très fréquentes: leur durée et leur intensité sont corrélées à la gravité des lésions. Elles représentent une véritable gêne à la réhabilitation post-partum.
Pour le praticien, la réhabilitation post-partum centrée sur des stratégies analgésiques adaptées, devra également tenir compte des spécificités de la période post-partum que sont la facilitation de la relation mère-enfant, l’allaitement et la mise en oeuvre des soins au nouveau-né. Par-delà la réhabilitation post-partum immédiate, la prise en compte et le traitement de la douleur aiguë permettent également de prévenir l’émergence de douleurs chroniques et de syndromes dépressifs à distance de l’accouchement. L’incidence de ces derniers, non négligeable, est mieux connue aujourd’hui et semble indépendante du mode d’accouchement.
... The use of epidural or intrathecal morphine for labor analgesia is limited due to concerns regarding such side effects (nausea, vomiting, pruritus, and urinary retention), particularly respiratory depression. [23,24] It has been suggested that epidural morphine results in emetic effects by activating opioid receptors in the chemoreceptor trigger zone. [24] Moreover, the pregnancy status and the further intensification ofthe delay of gastric passage caused by opioids in pregnant women may lead to nausea and vomiting. ...
Aim:
Labor is one of the most painful experiences a woman may face during her lifetime. One of the most effective methods used for eliminating this pain is epidural analgesia. The aim of this study to determine the impact of adding morphine to low-dose bupivacaine epidural anesthesia on labor and neonatal outcomes, and maternal side effects.
Materials and methods:
This is a prospective randomized double-blind study comparing two regimens of anesthetic agents used for epidural anesthesia in labor. A total of 120 pregnant women were randomized into two groups with 60 subjects in each study arm. A catheter was inserted, and 0.1% bupivacaine + 2 μg/mL fentanyl in 15 mL saline were given to Group bupivacaine-fentanyl (Group BF), while 0.0625% bupivacaine + 2 μg/ml fentanyl + 2 mg morphine in 15 mL saline were given to Group bupivacaine-fentanyl-morphine (Group BFM) with no test dosing from the needle. No morphine was added to the subsequent epidural injections in Group BFM.
Results:
The total dose of bupivacaine was significantly lower in Group BFM relative to Group BF (P = 0.0001). The visual analogu scalescores at 15, 30, and 45 min were significantly lower in Group BF compared to thosein Group BFM (P = 0.0001, P = 0.001, and P = 0.006, respectively). The second stage of labor was significantly shorter in Group BFM relative to Group BF (P = 0.027 and P = 0.003, respectively). The satisfaction with analgesia following the first dose was higher in the nonmorphine group (P = 0.0001). However, maternal postpartum satisfaction was similar in both groups. Either nausea or vomiting was recorded in eight patients in Group BFM.
Conclusion:
We believe that epidural analgesia comprised of a low-dose local anaesthetic and 2 mg morphine provides a painless labor that significantly reducesthe use of local anesthetic without changing the efficiency of the analgesic, ensuring the mother's satisfaction without leading to an adverse effect on the mother or foetus, while mildly (but significantly) shortening the second stage of labor.
Introduction: Delay in episiotomy repair leads to adverse anatomic outcomes, increased infections, decreased sexual function, and impaired relationships between mother and baby, but little research has been done in this field. Therefore, this study was performed with aim to determining the relationship between delivery and neonatal factors with healing of episiotomy in primiparous women. Methods: This correlation study was conducted on 119 eligible mothers referring to Mashhad Omolbanin Hospital in 2013. Information about delivery, neonate and mother was gathered by the questionnaires and their relationship with wound healing as measured by Reda form on 1st, 7th, 10th and 14th days after delivery was determined. Data was analyzed using SPSS software (version 16) and Kolmogorov-Smirnov, one-way ANOVA, regression, Spearman’s test, and Pearson’s correlation tests. P <0.05 was considered statistically significant. Results: At 10th and 14th days after delivery, inverse correlation was found between length skin incision (P=0.037, P=0.026), the number of sutures with 2/0 catgut (P=0.042, P=0.028), the activity leading to tension and pressure on the stitches (P=0.037, P=0.048), rate of sitting (P=0.011, P=0.030) with episiotomy healing; and direct correlation was found between hygiene (P=0.048, P=0.039) with episiotomy healing. Inverse correlation was found between pain and episiotomy healing at 7th (P=0.015) and 10th days (P=0.035). Also, inverse correlation was observed between the number of skin sutures (P=0.012) and episiotomy healing at 14th days after delivery; it means that more number of skin sutures leads to delay in episiotomy healing. Conclusion: Among all variables, more extensive incision, more number of skin sutures and more sutures with 2/0 catgut, long sitting, tension and pressure on the stitches, severe episiotomy pain and lack of hygiene lead to delay in healing of episiotomy. Therefore, it is recommended to train health care providers and mothers about these factors. © 2016, Mashhad University of Medical Sciences. All rights reserved.
Introducción y objetivos: Las complicaciones postoperatorias asociadas al empleo epidural de opiáceos, limitan su mayor uso como método analgésico. El objetivo de esta investigación fue describir el comportamiento de las náuseas y vómitos postoperatorios con la aplicación de morfina liofilizada en la anestesia epidural. Método: Estudio prospectivo, observacional y a simple ciegas, donde se conformaron aleatoriamente 3 grupos de 20 pacientes cada uno: Grupo I recibió medicación preoperatoria con 10 mg de metoclopramida, Grupo II con 4 mg de ondansetrón y el Grupo III no recibió ninguna medicación preoperatoria. Resultados: Las náuseas y vómitos postoperatorios se presentaron en la muestra estudiada con una incidencia de 20,6 %. No hubo diferencias significativas entre la metoclopramida y el ondansetrón en la incidencia de náuseas y vómitos; efectos que se presentaron con mayor frecuencia en aquellas pacientes que se movilizaron en las primeras 12 horas y en las que tuvieron ingesta oral en ese mismo período de tiempo. Conclusiones: Las náuseas y vómitos postoperatorios fueron efectos adversos, relativamente frecuentes, al aplicar morfina liofilizada a la anestesia epidural. La metoclopramida fue tan efectiva como el ondansetrón en su efecto antiemético. Las náuseas y vómitos fueron más habituales en los pacientes que se movilizaron y tuvieron ingesta oral en las primeras 12 horas, y en los que no recibieron premedicación antiemética.
Introducción y objetivos: La analgesia epidural constituye un pilar básico en la cirugía cardíaca. El objetivo del estudio fue comparar el uso de la morfina liofilizada y la bupivacaína epidural en la analgesia postoperatoria para la cirugía de las arterias corona-rias. Método: Se realizó un estudio prospectivo e inferencial en 20 pacientes, divididos en dos grupos. Los del grupo M recibieron analgesia epidural con morfina 2 mg asociada a 100 mg de bupivacaína y los del grupo B solo bupivacaína. Resultados: Predominó el sexo masculino. Las edades y pesos promedio de ambos grupos fueron similares (p > 0,05). El 90 % de los enfermos del grupo M tenían analgesia excelente a las 8 horas de la intervención, y se mantuvo entre buena y excelente a las 12 y 24 horas. Mientras que el 50 % de los pacientes del grupo B referían una analgesia regular a las 8 horas de operados, que se extendió al 80 % de los enfermos a las 12 horas. En el control de las 24 horas, la totalidad de los pacientes del grupo B se aquejaban de una analgesia insuficiente o mala (p
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