Bruce A. Meyer

The effect of intrapartum epidural analgesia on nulliparous labor: A randomized, controlled, prospective trial

OBJECTIVE Our purpose was to determine the effect of epidural analgesia on nulliparous labor and delivery. STUDY DESIGN Normal term nulliparous women in early spontaneous labor were randomized to receive either narcotic or epidural analgesia. RESULTS When compared with the group receiving narcotic analgesia (n = 45), the group receiving epidural analgesia (n = 48) had a significant prolongation in the first and second stages of labor, an increased requirement for oxytocin augmentation, and a significant slowing in the rate of cervical dilatation. Epidural analgesia was associated with a significant increase in malposition (4.4% vs 18.8%, p < 0.05). Cesarean delivery occurred more frequently in the epidural group (2.2% vs 25%, p < 0.05), primarily related to an increase in cesarean section for dystocia (2.2% vs 16.7%, p < 0.05). CONCLUSIONS In a randomized, controlled, prospective trial epidural analgesia resulted in a significant prolongation in the first and second stages of labor and a significant increase in the frequency of cesarean delivery, primarily related to dystocia.

Pregnancy-Specific Stress, Prenatal Health Behaviors, and Birth Outcomes

OBJECTIVE Stress in pregnancy predicts earlier birth and lower birth weight. The authors investigated whether pregnancy-specific stress contributes uniquely to birth outcomes compared with general stress, and whether prenatal health behaviors explain this association. DESIGN Three structured prenatal interviews (N = 279) assessing state anxiety, perceived stress, life events, pregnancy-specific stress, and health behaviors. MAIN OUTCOME MEASURES Gestational age at delivery, birth weight, preterm delivery (<37 weeks), and low birth weight (<2,500 g). RESULTS A latent pregnancy-specific stress factor predicted birth outcomes better than latent factors representing state anxiety, perceived stress, or life event stress, and than a latent factor constructed from all stress measures. Controlling for obstetric risk, pregnancy-specific stress was associated with smoking, caffeine consumption, and unhealthy eating, and inversely associated with healthy eating, vitamin use, exercise, and gestational age at delivery. Cigarette smoking predicted lower birth weight. Clinically-defined birth outcomes were predicted by cigarette smoking and pregnancy-specific stress. CONCLUSION Pregnancy-specific stress contributed directly to preterm delivery and indirectly to low birth weight through its association with smoking. Pregnancy-specific stress may be a more powerful contributor to birth outcomes than general stress.

Beneficial Associations Between Optimistic Disposition and Emotional Distress in High-Risk Pregnancy

This study was conducted to examine whether optimistic women experience less distress in high-risk pregnancy than non-optimistic women, and if so, whether this difference is explained by differences in coping or perceptions of control over pregnancy. As predicted, optimistic women ( N = 167) were more likely to evaluate their high-risk pregnancy as controllable, which was associated with lower distress. They were also less likely to use avoidant coping, an emotionally deleterious form of coping. Furthermore, optimism had an independent association with emotional distress that was stronger than the associations mediated by perceived control and coping. Results suggest that there are emotional benefits of optimism in high-risk pregnancy which are only partly explained by the way optimists perceive and cope with this stressful life event.

Prenatal maternal stress is associated with delivery analgesia and unplanned cesareans

We tested the hypothesis that women with greater prenatal maternal stress (PNMS) would be more likely to receive intravenous opiates and epidural for delivery, and thereby increase the likelihood of unplanned cesarean delivery. PNMS was assessed during early, mid, and late pregnancy using psychometrically sound instruments in structured interviews with women receiving prenatal care at a public university clinic. Medical records were abstracted for analgesia during delivery, fetal heart tracing (FHT) abnormalities, and method of delivery. Only subjects attempting vaginal delivery (N = 298) were included. Using structural equation modeling, a PNMS variable was constructed from five indicators: pregnancy-specific distress, number of prenatal stressful life events, distress from life events, state anxiety, and perceived stress. After controlling for medical predictors of analgesia receipt and surgical delivery, women with higher PNMS were more likely to receive analgesia, and those who received analgesia were more likely to deliver surgically. Analgesia was also associated with FHT abnormalities, which in turn was associated with surgical delivery (all ps < 0.05). Women who received both an epidural and meperidine were most likely to have a cesarean delivery; 29% of this group delivered surgically. Results indicate that PNMS contributes to higher likelihood of unplanned cesarean delivery through its association with delivery analgesia.

The risk of pulmonary edema and colloid osmotic pressure changes during magnesium sulfate infusion

OBJECTIVES The purposes of this study were to evaluate the effect of magnesium sulfate therapy on colloid osmotic pressure and to determine whether changes in colloid osmotic pressure increased the risk of pulmonary edema. STUDY DESIGN During a 1-year time period 294 patients received parenteral magnesium sulfate for the treatment of preterm labor or preeclampsia. Both changes in colloid osmotic pressure and magnesium sulfate values and their relationship to clinical outcome parameters were analyzed. RESULTS Serum magnesium levels were similar for both patients with preeclampsia and patients with preterm labor. Pulmonary edema developed in only four patients, all of whom had preeclampsia and low colloid osmotic pressure values. CONCLUSIONS This study demonstrated that parenteral magnesium sulfate therapy does not cause significant changes in colloid osmotic pressure values until nearly 48 hours of continuous therapy.

Soluble Endoglin for the Prediction of Preeclampsia in a High Risk Cohort

Objectives. To evaluate soluble endoglin (sEng) and the soluble fms-like tyrosine kinase 1 (sFlt1) to placental growth factor (PlGF) ratio for the prediction of preeclampsia in high-risk women, and to evaluate differences in sEng between women with high-risk singleton and multiple gestation pregnancies. Study Design. We collected serial serum specimens from 119 women at high preeclampsia risk. sEng, sFlt1 and PlGF were measured by ELISA. Results. Among subjects who did not develop preeclampsia, mean serum sEng was significantly higher in those with multiple gestation pregnancies vs. high-risk singletons. Among women with singleton gestations, mean serum sEng was higher in subjects who developed early-onset (<34 weeks) and late-onset (≥ 34 weeks) preeclampsia, as compared with subjects without preeclampsia, from 22 weeks and 28 weeks gestation onward, respectively. The within-woman rate of change of sEng was also higher in women who later developed preeclampsia. Conclusions. sEng is higher in women with multiple gestations vs. high-risk singleton pregnancies. In high-risk women, serum sEng is increased prior to preeclampsia onset.

Distress associated with prenatal screening for fetal abnormality

A theoretically-based, multivariate approach was used to identify factors associated with emotional distress for pregnant women undergoing maternal serum alpha fetoprotein (MSAFP or AFP) testing, used to detect abnormalities of the fetal brain and spinal cord. Participants were those who received normal results (N = 87). Study results supported the hypothesis that different factors would predict distress before and after testing. Satisfaction with information about testing predicted lower emotional distress early in the testing process; concerns about the child having other medical conditions and low-dispositional optimism predicted distress later. Study findings indicate that even in women who receive normal test results, AFP testing is associated with a modest degree of emotional disturbance which declines, but does not completely abate, after testing.

Obtaining patient permission for student participation in obstetric-gynecologic outpatient visits: a randomized controlled trial ☆

OBJECTIVES Our purpose was to compare a scripted verbal query with a detailed written permission slip in obtaining patient satisfaction and permission for student involvement in outpatient obstetrics-gynecologic visits. STUDY DESIGN A prospective, randomized, controlled study was performed using a questionnaire to compare current practice to the study groups. The chi(2) test was used to calculate P values; P<.05 was considered significant. RESULTS Patient demographics and satisfaction were similar among the three groups: 86% of controls and 79% of study groups agreed to student participation (P=.056). All preferred having the nurse ask permission (86% vs 86%) versus the physician (34% vs 25%) or the student (6% vs 3%). Permission was independent of student gender, visit purpose, or previous exposure to students. CONCLUSION Patients want a nonphysician to ask permission for student participation independent of method of request, visit purpose, student gender, or previous experience with students. Physician or student requests for consent may unduly influence participation.

Epidural analgesia in labor and cesarean delivery for dystocia

Published studies assessing the effect of epidural analgesia in nulliparous labor on the frequency of cesarean delivery for dystocia are reviewed. There are at least four retrospective studies and two prospective studies that suggest that epidural analgesia may increase the risk of cesarean delivery for dystocia in first labors. The potential for epidural to increase the frequency of cesarean delivery for dystocia is likely influenced by multiple variables including parity, cervical dilatation at epidural placement, technique of epidural placement, management of epidural during labor, and the obstetrical management of labor after placement of epidural analgesia. Two studies suggest that delaying placement of the epidural until 5 cm of cervical dilatation or greater may reduce the risk of cesarean birth. Epidural is safe and may be a superior labor analgesic when compared with narcotics. However, patients should be informed that epidural analgesia may increase the risk of cesarean birth in first labors.

Effect of Epidural Analgesia on Fundal Dominance during Spontaneous Active-Phase Nulliparous Labor

Background The purpose of this investigation was to determine if epidural analgesia, established during active phase labor, results in elimination or reversal of fundal dominance (lower uterine segment pressure equal to or greater than fundal pressure). Methods Upper and lower uterine segment intrauterine pressures were prospectively evaluated for 50 min before and 50 min after epidural analgesia using 0.25% bupivacaine in 11 nulliparous women in spontaneous active labor. A total of 958 contractions were evaluated. Results No significant differences were found in the number of contractions in the interval before epidural analgesia compared to after epidural analgesia. Significantly greater pressure readings were recorded in the upper segment than in the lower segment (consistent with fundal dominance) both before and after epidural analgesia (P < 0.01). In addition, fundal dominance increased after epidural analgesia when compared to the preanalgesia period (P < 0.01). Conclusions Fundal dominance is present both before and after active phase epidural analgesia and is increased during the immediate 50‐min postanalgesia period.