Comparative Study on the Efficacy of Two Regimens of Single-Shot Spinal Block for Pain Relief in Women Presenting in Established Labour

Background: Most women experience moderate to severe pain during  labour and delivery, often requiring some form of pharmacologic  analgesia. The lack of proper psychological preparation combined with fear and anxiety can greatly enhance the patientfs sensitivity to pain and further add to the discomfort. Skillfully conducted obstetric analgesia, in addition to relieving pain and anxiety, may benefit the mother by increasing self esteem and improving bonding with the baby.Objective: To assess and compare the satisfaction and efficacy of two regimens of single-shot spinal blocks for the relief of labor pain in women who present in active phase of labour.Design: A prospective randomised single-blind observational studySetting: Labour ward of Kenyatta National Hospital, Nairobi.Subjects: All consenting primiparous women presenting in active phase of labor with uncomplicated singleton pregnancy at term (> 37 weeks) and in cephalic presentation, who reported a > 70 mm VAS (Visual Analog Scale) pain score at cervical dilatation . 5 cm at the time of request for labour analgesia.Results: Effective labour analgesia lasting up to 120 minutes was observed in the fentanyl-bupivacaine group but with a high incidence of  breakthrough pain. The fentanyl-bupivacaine-morphine group had labour analgesia lasting up to 180 minutes or even more with a lower incidence of breakthrough pain. The one-minute and fiveminute Apgar scores in the morphine group were significantly lower (p = 0.026 and 0.044 respectively) than in the fentanyl group but the difference in neonatal outcome had no clinical significance, and there were no significant differences in adverse effects, sensory levels, and motor power between the two groups.:Conclusion Effective analgesia for about 120 minutes was observed in the fentanylbupivacaine group with high incidence of breakthrough pain while the fentanylbupivacaine-morphine group had labour analgesia prolonged up to more than three hours. The difference in fetal outcome had no clinical significance for the morphine group, and there were no significant differences in adverse effect, sensory levels, and motor power between the two groups. These findings show that intrathecal analgesia is safe and the use of the combination of fentanyl-bupivacaine-morphine gives adequateand safe analgesia during labour and delivery

Maternal and neonatal outcomes after caesarean delivery in the African Surgical Outcomes Study: a 7-day prospective observational cohort study.

BACKGROUND: Maternal and neonatal mortality is high in Africa, but few large, prospective studies have been done to investigate the risk factors associated with these poor maternal and neonatal outcomes. METHODS: A 7-day, international, prospective, observational cohort study was done in patients having caesarean delivery in 183 hospitals across 22 countries in Africa. The inclusion criteria were all consecutive patients (aged ≥18 years) admitted to participating centres having elective and non-elective caesarean delivery during the 7-day study cohort period. To ensure a representative sample, each hospital had to provide data for 90% of the eligible patients during the recruitment week. The primary outcome was in-hospital maternal mortality and complications, which were assessed by local investigators. The study was registered on the South African National Health Research Database, number KZ_2015RP7_22, and on ClinicalTrials.gov, number NCT03044899. FINDINGS: Between February, 2016, and May, 2016, 3792 patients were recruited from hospitals across Africa. 3685 were included in the postoperative complications analysis (107 missing data) and 3684 were included in the maternal mortality analysis (108 missing data). These hospitals had a combined number of specialist surgeons, obstetricians, and anaesthetists totalling 0·7 per 100 000 population (IQR 0·2-2·0). Maternal mortality was 20 (0·5%) of 3684 patients (95% CI 0·3-0·8). Complications occurred in 633 (17·4%) of 3636 mothers (16·2-18·6), which were predominantly severe intraoperative and postoperative bleeding (136 [3·8%] of 3612 mothers). Maternal mortality was independently associated with a preoperative presentation of placenta praevia, placental abruption, ruptured uterus, antepartum haemorrhage (odds ratio 4·47 [95% CI 1·46-13·65]), and perioperative severe obstetric haemorrhage (5·87 [1·99-17·34]) or anaesthesia complications (11·47 (1·20-109·20]). Neonatal mortality was 153 (4·4%) of 3506 infants (95% CI 3·7-5·0). INTERPRETATION: Maternal mortality after caesarean delivery in Africa is 50 times higher than that of high-income countries and is driven by peripartum haemorrhage and anaesthesia complications. Neonatal mortality is double the global average. Early identification and appropriate management of mothers at risk of peripartum haemorrhage might improve maternal and neonatal outcomes in Africa. FUNDING: Medical Research Council of South Africa.Medical Research Council of South Africa