Effect of low-dose mobile versus traditional epidural techniques on mode of delivery: a randomised controlled trial. Adverse effects of combined spinal-epidural versus traditional epidural analgesia during labor. Comparison of combined spinal-epidural and low dose epidural for labour analgesia. Combined spinal epidural anaesthesia for caesarean section: a randomised comparison of Oxford, lateral and sitting positions. Hypotension following combined spinal-epidural anaesthesia for Caesarean section. Left lateral position vs. tilted supine position. Anaesthetic technique for elective caesarean section and neurobehavioural status of newborns. Prospective, randomized trial comparing general with spinal anesthesia for cesarean delivery in preeclamptic patients with a nonreassuring fetal heart trace. Prospective, randomized comparison of epidural and combined spinal epidural analgesia during labor. A randomized study of combined spinal-epidural analgesia versus intravenous meperidine during labor: impact on cesarean delivery rate. Neurologic activity of infants following anesthesia for cesarean section. Clinical study on labor pain relief using the combined spinal-epidural analgesia and inhaling nitrous oxide. A randomized controlled trial of the effect of combined spinal-epidural analgesia on the success of external cephalic version for breech presentation. Subarachnoid versus epidural bupivacaine 0.5% for caesarean section. Upright versus recumbent position in the second stage of labour in women with combined spinal-epidural analgesia. [Obstetric analgesia: peridural analgesia versus combined spinal and peridural analgesia]. Randomised controlled trial of labouring in water compared with standard of augmentation for management of dystocia in first stage of labour. Spinal or epidural anaesthesia for elective caesarean section? A Swedish experience. Prelabour rupture of the membranes at term--no advantage of delaying induction for 24 hours. Effect of delayed supine positioning after induction of spinal anaesthesia for caesarean section. Lumbar wedge versus pelvic wedge in preventing hypotension following combined spinal epidural anaesthesia for caesarean delivery. Randomized trial of amniotomy in labour versus the intention to leave membranes intact until the second stage. Labor analgesia: a comparative study between combined spinal-epidural anesthesia versus continuous epidural anesthesia.
Epidural analgesia is the most effective labour pain relief but is associated with increased rates of instrumental vaginal delivery and other effects, which might be related to the poor motor function associated with traditional epidural. New techniques that preserve motor function could reduce obstetric intervention. We did a randomised controlled trial to compare low-dose combined spinal epidural and low-dose infusion (mobile) techniques with traditional epidural technique.
                Between Feb 1, 1999, and April 30, 2000, we randomly assigned 1054 nulliparous women requesting epidural pain relief to traditional (n=353), low-dose combined spinal epidural (n=351), or low-dose infusion epidural (n=350). Primary outcome was mode of delivery, and secondary outcomes were progress of labour, efficacy of procedure, and effect on neonates. We obtained data during labour and interviewed women postnatally.
                The normal vaginal delivery rate was 35.1% in the traditional epidural group, 42.7% in the low-dose combined spinal group (odds ratio 1.38 [95% CI 1.01-1.89]; p=0.04); and 42.9% in the low-dose infusion group (1.39 [1.01-1.90]; p=0.04). These differences were accounted for by a reduction in instrumental vaginal delivery. Overall, 5 min APGAR scores of 7 or less were more frequent with low-dose technique. High-level resuscitation was more frequent in the low-dose infusion group.
                The use of low-dose epidural techniques for labour analgesia has benefits for delivery outcome. Continued routine use of traditional epidurals might not be justified. To compare two neuraxial block techniques during labor for maternal and fetal effects.
                Women in labor at term with cephalic singleton fetuses were randomized (nonblinded) to receive either labor epidural (EPI) or combined spinal-epidural (CSE) analgesia. Primary outcome was prolonged deceleration (PD) of fetal heart rate. Outcomes also included hypotension, mode of delivery, and efficacy of analgesia by visual analog pain scale (VAPS) before and after block placement.
                Randomization occurred in 127 patients: 63 received EPI, 64 received CSE. There was no difference in the rate of PD in the EPI group compared with the CSE group (3.2% vs 6.2% respectively; P=0.43, RR 2.0; 95% CI 0.4-9.3), rate of cesarean delivery, or mean epidural duration. VAPS ratings were significantly lower in the CSE group.
                There were no differences in the rate of PD or other adverse outcomes. Hypotension occurred more frequently with CSE during labor at term. The study supports both EPI and CSE during labor as safe and effective techniques for neuraxial analgesia. To compare the combined spinal-epidural (CSE) technique with the epidural technique with regard to time to initiate and manage, motor block, onset of analgesia and satisfaction during labour.
                Upon requesting analgesia, 50 healthy term parturients were randomized in a prospective, double-blind fashion to receive either CSE analgesia or lumbar epidural analgesia in the labour floor of a university hospital at an academic medical centre. The epidural group (n = 24) received bupivacaine 0.0625%-fentanyl 0.0002% with 0.05 ml in 10 ml local anesthetic sodium bicarbonate 8.4% and epinephrine 1:200,000. The CSE group (n = 26) received intrathecal 25 microg fentanyl and 2.5 mg bupivacaine. Additional analgesia was provided upon maternal request.
                There were no differences (P>0.05) in time to perform either technique, motor blockade, or parturient satisfaction or in the number of times that the anesthesiologist was called to perform any intervention. Although the first sign of analgesia was not different between the two groups, the onset of complete analgesia was more rapid with the CSE technique (Visual Analogue Pain Score (VAPS) at five minutes < three: 26/26 vs. 17/24, P+/-0.001).
                Although epidural analgesia with a low concentration of local anesthetic and opioid mixture takes longer to produce complete analgesia, it is a satisfactory alternative to CSE. Maternal position during induction of intrathecal anaesthesia for caesarean section influences block height and haemodynamic stability. In a randomised study of 90 women presenting for elective caesarean section using combined spinal-epidural anaesthesia, three positions were compared--the Oxford position (group O), the right lateral to supine wedged (group R) and the sitting to supine wedged (group S). Hyperbaric bupivacaine 12.5 mg with fentanyl 12.5 microg was injected intrathecally using a needle-through-needle CSE technique. Intravenous ephedrine 6 mg was given every minute that systolic blood pressure fell below 80% of baseline. Time required for block height to reach T5 as assessed by light touch, was similar in the three groups. There were no significant differences in blood pressure although ephedrine requirements were less in group R. There were no significant differences in the incidence of maternal nausea and vomiting or in neonatal outcome as assessed by Apgar scores and umbilical cord blood gas analysis. Although the study failed to show any significant differences in block height between the groups, no women in group O had a block above T2 compared with three in group R and three in group S. Eighty-seven pregnant mothers undergoing elective Caesarean section were randomly allocated either to the full left lateral position (n = 45) or to the supine position with 12 degrees left lateral tilt (n = 42) after a combined spinal-epidural (CSE) in the sitting position and an initial 2 min in the full right lateral position. Fewer mothers were hypotensive while in the study position [29 (64%) in lateral group vs. 38 (90%) in the tilted supine group; p = 0.03]. Mothers in the lateral group tended to become hypotensive after turning them back to the tilted supine position immediately before surgery; hence the number of mothers who were hypotensive from the insertion of the CSE until delivery were similar [36 (80%) vs. 38 (90%)]. Mothers in the lateral group needed a lower dose of ephedrine to treat their hypotension while in their study position (median (interquartile range [range]) 6 (0-12 [0-36]) mg vs. 12 (6-18 [0-36]) mg, respectively; p = 0.04) but ephedrine requirements were similar overall (12 (6-12 [0-36]) mg vs. 12 (6-18 [0-36]) mg), respectively. The full left lateral position reduces the incidence of early hypotension compared with the tilted supine position with tilt, and makes it easier to treat. Ninety healthy parturients undergoing elective caesarean section were randomly allocated to receive either general (n = 30), epidural (n = 30) or spinal (n = 30) anaesthesia. Acid-base status, Apgar score and neurobehavioural status, using the neurologic and adaptive capacity scoring (NACS) system, were studied in the newborn. Apgar scores and acid-base parameters were similar in all the three groups. NACS testing revealed significantly more vigorous babies in the spinal anaesthesia group than in the other two groups at 15 min and 2 h interval after delivery, despite a higher incidence of maternal hypotension. We conclude that newborns tend to have a better neurobehavioural status in the early post-delivery period if their mothers receive spinal anaesthesia rather than general or epidural anaesthesia for caesarean section. There are no randomized studies on neonatal outcome after spinal versus general anesthesia for cesarean delivery in preeclamptic patients with a nonreassuring fetal heart trace. This study examined both markers of neonatal hypoxia and maternal hemodynamics.
                Seventy patients were randomized to general (n = 35) or spinal anesthesia (n = 35). The general anesthesia group received thiopentone, magnesium sulfate, and suxamethonium intravenously before intubation, followed by 50% nitrous oxide in oxygen, 0.75-1.5% isoflurane, and morphine after delivery. The target end-tidal partial pressure of carbon dioxide (Pco2) was 30-34 mmHg. The spinal anesthesia group received 1.8 ml hyperbaric bupivacaine plus 10 microg fentanyl at the L3-L4 interspace. Heart rate and blood pressure were measured at specific time points. Hypotension was treated with ephedrine. Maternal arterial and neonatal umbilical arterial blood gas samples were taken at delivery. Resuscitation requirements were recorded.
                In both groups, hemodynamic measures remained within acceptable limits. Spinal anesthesia patients required more ephedrine (13.7 vs. 2.7 mg). Maternal Paco2 was lower in the spinal group (28.9 vs. 32.4 mmHg). One-minute Apgar scores were lower after general anesthesia. Base deficit was greater (7.13 vs. 4.68 mEq/l) and neonatal umbilical arterial pH was lower (7.20 vs. 7.23) after spinal anesthesia. Post hoc analysis showed that if maternal diastolic blood pressure on admission was greater than 110 mmHg, neonatal umbilical arterial base deficit was greater after spinal anesthesia. There was no difference in the number of patients with Apgar scores less than 7 at 1 or 5 min or umbilical arterial pH less than 7.2 or in the requirements for resuscitation.
                In preeclamptic patients with a nonreassuring fetal heart trace, spinal anesthesia for cesarean delivery was associated with a greater mean neonatal umbilical arterial base deficit and a lower median umbilical arterial pH. The clinical significance remains to be established. Maternal hemodynamics were similar and acceptable with either anesthetic technique. The analgesic efficacy and incidence of maternal, fetal and neonatal side-effects of combined spinal epidural (CSE) and epidural (EPI) analgesia, using a mixture of bupivacaine 0.125%, epinephrine (1.25 micrograms.ml-1) and sufentanil (0.75 microgram.ml-1) for the relief of labor pain, were randomly and prospectively compared in 110 parturients. A 29 gauge Whitacre tip spinal needle was used to perforate the dura in CSE patients. Compared to EPI, CSE resulted in rapid (326 +/- 22 vs 766 +/- 79 sec, p < 0.05), excellent analgesia, using less bupivacaine (23.5 +/- 2.3 vs 33.9 +/- 2.9 mg, p < 0.05) and sufentanil (12.5 +/- 1.0 vs 16.5 +/- .7 micrograms, p < 0.05). A tendency to improved patient satisfaction in the CSE group was observed. The incidence of maternal or neonatal side effects was similar in both groups. No PDPH was observed. We conclude that CSE analgesia results in excellent pain relief during labor with immediate gratification as compared to epidural analgesia. Combined spinal-epidural (CSE) analgesia produces rapid-onset pain relief and allows ambulation in early labor. Epidural local anesthetics may contribute to an increase in operative deliveries by decreasing perineal sensation and causing motor weakness. Operative delivery rates might be reduced with CSE, by avoiding or delaying administration of local anesthetics. This study compares the operative delivery rates associated with a CSE technique and those associated with intravenous meperidine for labor analgesia.
                Healthy parturients at full term were assigned randomly to receive CSE or intravenous meperidine analgesia. The CSE group received 10 microg intrathecal sufentanil, followed by epidural bupivacaine and fentanyl at their next request for analgesia. Parturients receiving intravenous meperidine had 50 mg on demand (maximum, 200 mg in 4 h). Labor and delivery outcomes in both groups were recorded and compared.
                An intent-to-treat analysis of 1,223 women indicated that CSE does not increase the rate of cesarean delivery for dystocia in nulliparous and parous women (CSE, 3.5% vs. intravenous meperidine, 4; P=not significant) or in nulliparous women alone (CSE, 7% vs. intravenous meperidine, 8%; P=not significant). Profound fetal bradycardia that necessitated emergency cesarean delivery within 1 h of the time the mother received sufentanil occurred in 8 of 400 parturients (compared with 0 of 352 who received meperidine; P < 0.01). However, the method of fetal monitoring differed between the two groups. Despite this, neonatal outcomes were similar overall.
                Combined spinal-epidural analgesia during labor does not increase the cesarean delivery rate for dystocia in healthy parturient patients at full term, regardless of parity. However, an unexpected increase in the number of cesarean deliveries for profound fetal bradycardia after intrathecal sufentanil was observed. Further investigation is warranted. Elective cesarean section was performed in a consecutive series of 30 patients with full-term pregnancies who were not in labor. Epidural (lidocaine, 1.5 per cent, with epinephrine, 1:200,000) and general anesthesia (thiopental, nitrous oxide-oxygen, succinylcholine infusion) was used alternately. Neonatal acid-base values and Apgar scores showed no significant difference between the two anesthetic groups, and most infants were vigorous at birth. The neurologic recoveries of the infants showed no significant difference between the two groups. In the group receiving epidural anesthesia, there was a significant correlation between maternal hypotension and weak rooting and sucking reflexes of the infants during the first two days. All infants of high-risk obstetric patients in the series, independent of anesthetic technique used, had abnormal neurologic activity, as evidenced by either depression of muscle tone and the reflexes or all the tested variables. Neurologic assessment as followed in this series is a sensitive indicator of the effects of fetal stress factors acting during cesarean section. To study the pain relief effectiveness of the combined spinal-epidural analgesia (CSEA) and the inhalation of nitrous oxide, and the influences on the mothers and infants.
                The 300 cases of pregnant women were randomly divided into 3 groups: CSEA group, nitrous oxide group and control group. The nitrous oxide group was that pregnant women inhaled nitrous oxide premixed with oxygen (50%:50%), the pregnant women of the CSEA group were injected fentanyl and bupivacaine in the subarachnoid and epidural space, analgesic was not used in the control group. The degree of labor pain, duration of the labor, way of delivery, bleeding volume, rate of anoxia of newborn, blood gas analysis to maternal radius artery and fetal umbilical blood among 3 groups were observed.
                The effect for analgesia labor of the CSEA group was much better than that of the nitrous oxide group (P < 0.01). In the first stage of labor and total stage of labor, the CSEA group was shorter than the others (P < 0.05), but there was no difference between the nitrous oxide group and the control group (P > 0.05). In the second stage of labor, the 3 groups were alike to each other. The bleeding volume of caesarean section (373 +/- 77) ml in the nitrous oxide group was much more than the other 2 groups, there was no difference between the CSEA group (259 +/- 78) ml and the control group (239 +/- 89) ml. The rate of obstetric forceps of CSEA group was higher than the control group (P < 0.01), and the rate of caesarean section of the nitrous oxide group was much higher than the CSEA group. The blood gas analysis to maternal radius artery and fetal umbilical blood and the rate of anoxia of newborn of 3 groups revealed no significant difference.
                The effectiveness of the combined spinal-epidural analgesia CSEA for analgesia labor is confirmed and has rarely side-effect, and it can be the first choice, and the inhalation of nitrous oxide can safely provide effective labor analgesia, too. Improving the success of external cephalic version (ECV) for breech presentation may help avoid some cesarean deliveries. The results of randomized trials comparing the success of ECV with neuraxial analgesia compared to control are inconsistent. We hypothesized that combined spinal-epidural (CSE) analgesia would increase the success of ECV when compared with systemic opioid analgesia.
                Parturients with singleton breech presentation (n=96) were randomized to receive CSE analgesia with bupivacaine 2.5mg and fentanyl 15 microg (CSE group) or intravenous fentanyl 50 microg (SYS group) before ECV attempt. The primary outcome was ECV success.
                The success rate of ECV was 47% with CSE and 31% in the SYS group (P=0.14). Subsequent vaginal delivery was 36% for CSE and 25% for SYS (P=0.27). Median [IQR] visual analog pain scores (0-100mm scale) were lower with CSE (3 [0-12]) compared to SYS analgesia (36 [16 to 54]) (P<0.005) and patient satisfaction (0-10 scale) was higher (CSE 10 [9 to 10] versus SYS 7 [4 to 9]) (P<0.005). There were no differences in fetal heart rate patterns, but median time to return to fetal heart rate reactivity after analgesia was shorter with CSE (13 [IQR 9-21] min) compared to the SYS group (39 [IQR 23-51] min) (P=0.02).
                There was no difference in the rate of successful ECV or vaginal delivery with CSE compared to intravenous fentanyl analgesia. Pain scores were lower and satisfaction higher with CSE analgesia, and median time to fetal heart rate reactivity was shorter in the CSE group. In order to compare subarachnoid (spinal) and epidural block for caesarean section, 40 women were randomly allocated to spinal or epidural analgesia with bupivacaine. The median dose of bupivacaine was 13 mg in the spinal group versus 155 mg in the epidural group. The mean time from induction to delivery was 32 min shorter in the spinal group (P less than 0.001). In the spinal group one woman was excluded because of spontaneous labour. Three patients in the spinal and one in the epidural group failed to develop adequate analgesia to initiate surgery. For the remaining patients both techniques provided good analgesia during operation. Postoperatively, epidural block provided better pain relief. The patients in the epidural group had a lower pain score during the first 4 h after the operation (P less than 0.01). In spite of similar haemodynamic changes in the two groups, the mean base deficit in umbilical cord blood at delivery was higher in the spinal group (P less than 0.05). Neuraxial blockade is widely used for pain relief in labour. This form of analgesia may be associated with an increase in instrumental delivery rates due to dystocia. 'Traditional' epidurals cause motor blockade and hence immobility. Using a low dose anaesthetic-opioid combination with either epidural or combined spinal-epidural, selective sensory blockade can be achieved, allowing mobility as well as pain relief. In this study, we randomised women with combined spinal-epidural analgesia either to mobilise (upright group n = 25) or to remain recumbent (n = 41) in the second stage of labour. We found women in the upright group had significantly shorter total second stage, (132 vs 109 min,P = 0.019) particularly during the pushing phase (73 vs 51 min, P = 0.011). Although there were fewer instrumental deliveries in the upright group, this was not statistically significant. Women who were randomised to the upright group, did actually mobilise. We conclude that mobilisation in the second stage of labour is possible, and may reduce the length of the second stage. To compare the analgesic efficiency, side effects and obstetrical repercussions of epidural analgesia (EP) and combined spinal-epidural analgesia (CSE).
                Prospective, randomized, double or single-blind studies as required, approved by the ethical committee of the institution.
                The study included 80 parturients, in active labour with a singleton in vertex presentation and a cervical dilatation of 3 cm or less, randomly allocated to receive either EP (n = 40) or CSE (n = 40).
                In the EP group, sufentanil (20 micrograms) and 0.25% bupivacaine (6-8 mL) were injected into the epidural space. In those of the CSE group, sufentanil (10 micrograms) was first injected into the subarachnoid space, followed by an epidural injection of the same agents at the same quantities as for the EP group. Additional analgesia was obtained in both groups by top-ups of 6-8 mL of 0.25% bupivacaine at the request of the patients. Analgesia, course of labour, obstetrical outcome, and neonatal status were assessed. Statistical analysis was performed using Anova, chi 2 analysis, Yates' correction or Fisher's exact test, with a P < 0.05 considered as significant.
                Both groups had similar demographic and obstetric data. The onset of analgesia was more rapid in CSE group (8 +/- 11 min vs. 12 +/- 7 min, P < 0.05), however the duration was similar. Technical incidents were more frequent in the CSE group (30% vs. 7%, P < 0.05). The technique of analgesia did not influence the bupivacaine amounts required for its maintenance. The incidence of adverse effects were comparable with the exception of vertigo, which was more frequent in the EP group (57% vs. 28%, P < 0.05). The first stage of labour was increased by 30% in the CSE group (281 +/- 130 min vs. 216 +/- 97 min, P < 0.05), without significant prolongation of labour length. Durations of second stage and expulsion were similar in both groups, despite the administration of a lower dose of bupivacaine in the CSE group (33 +/- 17 mg vs. 46 +/- 12 mg, P < 0.05). The rates of instrumental deliveries and Caesarien sections were comparable. The Apgar scores were satisfactory at 5 min.
                In the early phase of labour, the CSE technique using intrathecal sufentanil has no significant benefit when compared to the EP technique using bupivacaine and sufentanil. In the CSE group, technical incidents were more frequent and the length of the first stage of labour was increased. To evaluate the impact of labouring in water during first stage of labour on rates of epidural analgesia and operative delivery in nulliparous women with dystocia.
                Randomised controlled trial.
                University teaching hospital in southern England.
                99 nulliparous women with dystocia (cervical dilation rate < 1 cm/hour in active labour) at low risk of complications. Interventions Immersion in water in birth pool or standard augmentation for dystocia (amniotomy and intravenous oxytocin).
                Primary: epidural analgesia and operative delivery rates. Secondary: augmentation rates with amniotomy and oxytocin, length of labour, maternal and neonatal morbidity including infections, maternal pain score, and maternal satisfaction with care.
                Women randomised to immersion in water had a lower rate of epidural analgesia than women allocated to augmentation (47% v 66%, relative risk 0.71 (95% confidence interval 0.49 to 1.01), number needed to treat for benefit (NNT) 5). They showed no difference in rates of operative delivery (49% v 50%, 0.98 (0.65 to 1.47), NNT 98), but significantly fewer received augmentation (71% v 96%, 0.74 (0.59 to 0.88), NNT 4) or any form of obstetric intervention (amniotomy, oxytocin, epidural, or operative delivery) (80% v 98%, 0.81 (0.67 to 0.92), NNT 5). More neonates of women in the water group were admitted to the neonatal unit (6 v 0, P = 0.013), but there was no difference in Apgar score, infection rates, or umbilical cord pH.
                Labouring in water under midwifery care may be an option for slow progress in labour, reducing the need for obstetric intervention, and offering an alternative pain management strategy. Ninety seven women undergoing elective lower segment caesarean section were randomly divided into two groups, group 1 received spinal anaesthesia with hyperbaric bupivacaine and group 2 received mepivacaine 20 mg/ml with adrenaline 5 microg/ml via an epidural catheter. All patients were given a preload of Ringer acetate and Macrodex prior to onset of anaesthesia. Ephedrine 5 mg was given if the systolic blood pressure fell below 100 mmHg. There was a small (<30%) but significant (P<0.01) fall in blood pressure in both groups of women. Six women in the epidural group required supplemental analgesics during the operation compared to only 1 patient in the spinal group (P<0.01). Muscle relaxation was judged to be inadequate in 3 patients in the spinal group and in 5 patients in the epidural group. One patient in the spinal group had a characteristic post-spinal headache lasting 3 days. The injection-delivery time was shorter (P<0.01) in the spinal group compared to the epidural group. The Apgar scores at 1 and 5 min were similar in both groups. The results from our study suggest that spinal anaesthesia is a good alternative to epidural anaesthesia for elective caesarean section. A fall in blood pressure, which is equally possible in both groups of patients, should be prevented by adequate fluid preload and treated immediately by intravenous ephedrine. We performed a prospective randomized study to compare maternal and fetal outcomes in pregnancies with prelabour rupture of the membranes (PROM) at term with early induction of labour or expectant management, 126 women with singleton pregnancy, cephalic presentation and gestational duration > or = 37 weeks, were randomized either to immediate induction of labour with oxytocin (Group 1) (n=52), or conservative management (Group 2) (n=74). Women who constituted Group 2 were divided into 2 groups. The first group (Group 2A) (n=25) included women in whom spontaneous labour did not begin after a waiting period of 24 hours, in which case labour was induced with oxytocin i.e. expectant management. The second group consisted of women (Group 2B) (n=49) in whom labour began spontaneously within 24 hours. The base Caesarean section rate was significantly higher in Group 2 (28.4%) (p<0.05). The rates of Caesarean section in the Groups 1-2A-2B were 19.2%, 60%, and 12.2%, respectively for nulliparous and parous women together. The rate of fetal distress was significantly higher in Group 2 (p<0.05). For determining maternal outcomes, the other parameters such as clinical chorioamnionitis, fever before or during labour, receiving antibiotics before or during labour, postpartum fever, analgesia, anaesthesia did not differ in Groups 1 and 2. Women in Group 1 went into active labour sooner, had fewer digital vaginal examinations, had a shorter interval between membrane rupture and delivery, and spent less time in the hospital before delivery than those in Group 2 (p<0.05). Babies in Group 2 were more likely to receive antibiotics, and more likely to stay in an intensive care nursery for more than 24 hours, and more likely to receive ventilation after initial resuscitation than those babies in Group 1. For developing apnoea and hypotonia, there was no significant difference between Groups 1 and 2. However, for babies in Group 2A there was a significant difference. We conclude that immediate induction of labour with oxytocin does not increase the risk of Caesarean section, compared with a practice of expectant management. Women at term with prelabour rupture of the membranes should therefore be reassured that immediate induction with oxytocin currently appears to be the best policy with respect to maternal and neonatal morbidity. The study tested the hypothesis that the incidence of hypotension during spinal anaesthesia for caesarean section is less in parturients who remain in the sitting position for 3 min compared with parturients who are placed in the modified supine position immediately after induction of spinal anesthesia.
                Spinal anaesthesia was induced with the woman in the sitting position using 2.8 ml hyperbaric bupivacaine 0.5% at the L(3-4) or L(2-3) interspace. Ninety-eight patients scheduled for elective caesarean section under spinal anaesthesia were randomised to assume the supine position on an operating table tilted 10 degrees to the left (modified supine position) immediately after spinal injection (group 0, n=52) or to remain in the sitting position for 3 min before they also assumed the modified supine position (group 3, n=46). Isotonic saline 2-300 ml was given intravenously over 15 min before spinal injection followed by 15 ml/kg over 15-20 min after induction of spinal anaesthesia. If the systolic blood pressure decreased to less than 70% of baseline or to less than 100 mmHg or if there was any complaint of nausea, ephedrine was given in 5 mg boluses intravenously every 2 min.
                The blood pressure decreased significantly in both groups following spinal injection (P<0.001). Blood pressure variations over time differed significantly between the two groups (P<0.05). However, the incidence of maternal hypotension before delivery was similar in the two groups. The difference was caused by the time to the blood pressure nadir being significantly shorter in group 0 compared with group 3 (9.1+/-4.5 min vs. 11.7+/-3.7 min, P<0.01). Similar numbers of patients received rescue with ephedrine before delivery: 35 (67%) in group 0 vs. 26 (57%) in group 3 (NS). The mean total dose of ephedrine before delivery was 10.9 mg in group 0 vs. 9.2 mg in group 3 (NS). There were no differences in neonatal outcome between the two groups.
                At elective caesarean section, a 3-min delay before supine positioning does not influence the incidence of maternal hypotension after induction of spinal anaesthesia in the sitting position with 2.8 ml of bupivacaine 0.5% with 8% dextrose. Aortocaval compression is a major cause of maternal hypotension. A randomised controlled clinical trial was designed to compare two wedged supine positions for prevention of hypotension following combined spinal epidural anaesthesia for caesarean delivery. Sixty parturients undergoing elective caesarean delivery were randomly assigned to two different wedged supine positions. After the completion of subarachnoid injection, parturients were placed with either a wedge under the right pelvis (group P pelvic wedge) or under the right lumbar region (group L, lumbar wedge). Systolic blood pressure and heart rate were recorded every minute for 20 minutes from the subarachnoid injection. Hypotension, defined as systolic blood pressure <100 mmHg or 80% of the baseline, was treated with intravenous ephedrine 5 mg. The incidence of hypotension, ephedrine use and neonatal Apgar scores and umbilical arterial pH were recorded. The incidence of hypotension was significantly higher in group P than that in group L (23/30 [77%] vs. 14/30 [47%], P=0.016). Systolic blood pressure decreased significantly in both groups at seven, eight and nine minutes (P < 0.001); moreover it was lower at seven, eight and nine minutes in group P than in group L (P < 0.01). Heart rate did not change significantly in either group. There were no significant differences between the two groups for Apgar score and umbilical arterial pH. A lumbar wedge is more effective than a pelvic wedge in preventing hypotension following combined spinal epidural anaesthesia for caesarean delivery, although it does not eliminate hypotension. To compare by randomized prospective clinical trial the outcome of labours which are managed with the intention to leave the membranes intact, compared with the practice of elective artificial rupture of the membranes (ARM) in early established labour.
                Prospective randomized controlled trial of low risk women admitted in spontaneous labour, with intact membranes.
                The labour ward of St. James's University Hospital, Leeds, UK.
                362 women in spontaneous labour with intact membranes and no evidence of fetal distress, between 37 and 42 weeks gestation. During the course of the trial it was found that some randomization cards could not be accounted for and a system of daily checks was instituted. The results were analysed for all recorded women (n = 362) and after institution of the more rigorous system (n = 120).
                The duration of each phase of labour, epidural rate, prevalence of an abnormal cardiotocograph (CTG) (assessed blind), method of delivery and neonatal outcome.
                178 of the 183 women (97%) in the ARM group had their membranes ruptured in early labour, and 83 (46%) of the 179 women allocated to non-intervention had ARM performed at some stage. A significant decrease in the duration of labour (mean 8.3, SD 4.1 h vs mean 9.7, SD 4.8 h, n = 156; P = 0.05) was found amongst primigravidae allocated to ARM when compared with non intervention. The duration of the second stage of labour was unaffected. In the ARM group the epidural rate was higher and labour was more often complicated by CTG abnormalities. There were no differences in the method of delivery, fetal condition at birth (cord blood lactate, Apgar score) or postpartum pyrexia between the ARM and non-intervention groups. The same trends were observed when analysis was confined to women entered into the trial after the system of rigour was instituted.
                Routine ARM results in labour that is slightly shorter than if the membranes are allowed to rupture spontaneously but more epidurals are used suggesting that labour is more painful. There are fewer fetal heart rate abnormalities if the membranes are left intact but amniotomy has no effect on fetal condition at birth. Pain relief during labor is a permanent concern, aiming at the maternal well being, decreasing the stress secondary to pain, and reducing its consequences on the fetus. Several analgesia techniques can be used during labor. The aim of this study was to compare continuous and combined epidural analgesia, both of them using 0.25% bupivacaine with 50% enantiomeric excess and fentanyl.
                Forty pregnant women, in labor, with cervical dilation between 4 and 5 cm, were randomly divided in two groups. Group I received continuous epidural anesthesia. Group II received combined anesthesia. The following parameters were evaluated: anthropometric measurements, gestational age, cervical dilation, length of time between the blockade and absence of pain according to the visual analogic scale, ability to walk, length of time between analgesia and complete cervical dilation, duration of the expulsive phase, maternal hemodynamic parameters, and vitality of the newborn. Possible complications, such as respiratory depression, maternal hypotension, pruritus, nausea, and vomiting were also evaluated. The Student t test was used to compare the means and the Chi-square test was used to compare the number of pregnancies and type of labor.
                There were no statistically significant differences between both groups regarding the length of time between the beginning of analgesia and complete cervical dilation, as well as regarding the duration of the expulsive phase, incidence of cesarean section related to the analgesia, maternal hemodynamic parameters, and vitality of the newborn.
                Both techniques are effective and safe for labor analgesia, although the combined technique provided fast and immediate pain relief. Clinical studies with a larger number of patients are necessary to evaluate the differences in the incidence of cesarean sections.
There appears to be little basis for offering CSE over epidurals in labour, with no difference in overall maternal satisfaction despite a slightly faster onset with CSE and conversely less pruritus with low-dose epidurals. There was no difference in ability to mobilise, maternal hypotension, rate of caesarean birth or neonatal outcome. However, the significantly higher incidence of urinary retention, rescue interventions and instrumental deliveries with traditional techniques would favour the use of low-dose epidurals. It is not possible to draw any meaningful conclusions regarding rare complications such as nerve injury and meningitis.