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Obstetric analgesia in labor and its association with neonatal outcomes

Analgesia obstétrica en el trabajo de parto y su asociación con resultados neonatales

ABSTRACT

Objetives:

To investigate the association between analgesia during labor and occurrence of neonatal outcomes.

Methods:

Retrospective cohort study with medical records of 850 parturient. The exposure variable of interest was receiving pharmacological analgesia during labor and neonatal outcomes were: one- and five-minute Apgar, resuscitation maneuvers and referral of the newborn to Neonatal ICU. A logistic regression was carried out to obtain Odds Ratios and 95% confidence interval, with adjustment for confounding factors.

Results:

Among the women studied, 35% received analgesia and this use was associated with a greater chance of neonatal outcomes such as one-minute Apgar < 7 (p <0.0001), resuscitation maneuvers (p <0.001) and referral to the Neonatal ICU (p = 0.004), mostly were among low-risk pregnant women, even after adjustments.

Conclusions:

The use of pharmacological analgesia during labor is associated with one-minute Apgar < 7, resuscitation maneuvers and referral to the Neonatal ICU.

Descriptors:
Analgesia, Obstetrical; Infant, Neonatal; Labor, Obstetric; Apgar Score; Intensive Care Units, Neonatal

RESUMEN

Objetivos:

Investigar la asociación entre la analgesia en el trabajo de parto y la aparición de resultados neonatales.

Métodos:

Estudio de cohorte retrospectivo con datos de 850 parturientas. La exposición fue recibir analgesia farmacológica en el trabajo de parto, resultados: Apgar del primer y quinto minuto < 7, maniobras de reanimación y derivación a la UCIN. La regresión logística se utilizó para obtener el Odds Ratio (OR) y el intervalo de confianza del 95% (IC95%), ajustado por variables de confusión.

Resultados:

De las mujeres estudiadas, el 35% recibió analgesia y su uso se asoció con una mayor probabilidad de resultados como: Apgar en el primer minuto < 7 (p<0,0001), maniobras de reanimación (p<0,001) y derivación a la UCIN (p=0,004).

Conclusiones:

el uso de analgesia farmacológica durante el trabajo de parto se asoció con Apgar < 7 en el primer minuto, maniobras de reanimación y derivación a la UCIN.

Descriptores:
Analgesia Obstétrica; Recién nacido; Trabajo de Parto; Test de Apgar; Unidad de Cuidados Intensivos Neonatales (UCIN)

RESUMO

Objetivos:

Investigar a associação entre analgesia no trabalho de parto e ocorrência de desfechos neonatais.

Métodos:

Estudo de coorte retrospectiva com dados de prontuários de 850 parturientes. A exposição foi receber analgesia farmacológica no trabalho de parto e os desfechos: Apgar do primeiro e quinto minuto < 7, manobras de reanimação e encaminhamento para Unidade de Terapia Intensiva Neonatal (UTI). Utilizou-se regressão logística para obter Odds Ratio (OR) e intervalo de 95% de confiança (IC95%), sendo ajustados por confundidores.

Resultados:

Das mulheres estudadas, 35% receberam analgesia e seu uso esteve associado a maior chance de desfechos, como: Apgar do primeiro minuto < 7 (p<0,0001), manobras de reanimação (p<0,001) e encaminhamento para UTI Neonatal (p=0,004), principalmente entre gestantes de risco habitual, mesmo após ajustes.

Conclusões:

O uso de analgesia farmacológica durante o trabalho de parto foi associado a Apgar do primeiro minuto < 7, manobras de reanimação e encaminhamento para UTI neonatal.

Descritores:
Analgesia Obstétrica; Recém-Nascido; Trabalho de Parto; Índice de Apgar; Unidade de Terapia Intensiva Neonatal

INTRODUCTION

Advancements in obstetrics have improved the rates of maternal and perinatal morbidity and mortality. However, the model that has been consolidated treats gestation, birth and delivery as pathological events and contributes to the exposure of women and newborns to high rates of unnecessary and harmful interventions, which should be used only when indicated, and not as routine treatment. An example is the use of pharmacological analgesia, an obstetric intervention that is frequently used inappropriately for pain relief during labor(11 Sousa AMM, Souza KV, Rezende EM, Martins EF, Campos D, Lansky S. Practices in childbirth care in maternity with inclusion of obstetric nurses in Belo Horizonte, Minas Gerais. Esc Anna Nery. 2016;20(2):324-31. doi: 10.5935/1414-8145.20160044
https://doi.org/10.5935/1414-8145.201600...
).

The pain of labor and its relief are important aspects for parturient, companions and newborns and are related to the evolution and outcome of delivery care. There are different pharmacological and non-pharmacological methods used to relieve pain during labor(22 Cunha A. Analgesia e anestesia no trabalho de parto e parto. Femina. 2010;38(11):599-606.). Non-pharmacological methods are strategies used during labor to increase pain tolerance and include a variety of techniques that, beyond the physical sensation of pain, also include psycho emotional and spiritual aspects of care(33 Chaillet N, Belaid L, Crochetiere C, Roy L, Gagné GP, Moutquin JM, et al. Nonpharmacologic approaches for pain management during labor compared with usual care: a meta-analysis. Birth. 2014;41(2):122-37. doi: 10.1111/birt.12103
https://doi.org/10.1111/birt.12103...
-44 Simkin P, Klein MC. Nonpharmacologic approaches to management of labor pain [Internet]. Uptodate.com. 2017 [cited 29 Aug 2018]. Available from: https://www.uptodate.com/contents/nonpharmacologic-approaches-to-management-of-labor-pain.
https://www.uptodate.com/contents/nonpha...
). Pharmacological methods are directed at eliminating the physical sensation of pain and include various substances and techniques(44 Simkin P, Klein MC. Nonpharmacologic approaches to management of labor pain [Internet]. Uptodate.com. 2017 [cited 29 Aug 2018]. Available from: https://www.uptodate.com/contents/nonpharmacologic-approaches-to-management-of-labor-pain.
https://www.uptodate.com/contents/nonpha...
). According to national guidelines for normal delivery, non-pharmacological methods should be used before pharmacological methods and should be offered according to recommendations(55 Ministério da Saúde (BR). Secretaria de Ciência, Tecnologia e Insumos Estratégicos. Departamento de Gestão e Incorporação de Tecnologias em Saúde. Diretrizes nacionais de assistência ao parto normal: relatório de recomendação. Brasília: Ministério da Saúde, 2017. 51 p.-66 Obstetric Anaesthetists' Association. Analgesia for Labour and C-section. [http://www.oaa-anaes.ac.uk/ui/content/content.aspx?id=194].
http://www.oaa-anaes.ac.uk/ui/content/co...
).

In Brazil, the right to pain relief and management is ensured by directives of the Ministry of Health (no. 2,815, 1998 and no. 572, 2000), which included obstetric analgesia in the obstetric procedures reimbursed by the Brazilian National Health System (SUS) and in the guidelines for the humanization of birth(55 Ministério da Saúde (BR). Secretaria de Ciência, Tecnologia e Insumos Estratégicos. Departamento de Gestão e Incorporação de Tecnologias em Saúde. Diretrizes nacionais de assistência ao parto normal: relatório de recomendação. Brasília: Ministério da Saúde, 2017. 51 p.,77 Ministério da Saúde (BR). Secretaria de Políticos de Saúde. Área Técnica de Saúde da Mulher. Parto, aborto e puerpério: assistência humanizada à mulher. Brasília: Ministério da Saúde, 2001. 199 p.). In addition, in 2011, the Rede Cegonha was created and proposed, among its objectives, a new model for labor and delivery care, centered on the role of women(88 Ministério da Saúde (BR). Secretaria de Atenção à Saúde. Manual prático para implementação da Rede Cegonha. Brasília: 2011.). This model aims to offer women and children a humane and quality care, providing a gestation, labor and delivery experience with safety, dignity and beauty, emphasizing the idea that giving birth is not a disease or pathological process(88 Ministério da Saúde (BR). Secretaria de Atenção à Saúde. Manual prático para implementação da Rede Cegonha. Brasília: 2011.-99 Wagner M. Getting the health out of people's daily lives. Lancet. 1982;8309, p.1207.), but a physiological and natural process that must be a unique experience for the woman and her partner, so it should be minimally invasive and use technology appropriately(88 Ministério da Saúde (BR). Secretaria de Atenção à Saúde. Manual prático para implementação da Rede Cegonha. Brasília: 2011.). For this, good practices in labor and delivery are recommended(88 Ministério da Saúde (BR). Secretaria de Atenção à Saúde. Manual prático para implementação da Rede Cegonha. Brasília: 2011.)and include pain management strategies.

In this context, obstetric analgesia has made great strides and, in recent years, more and more women have opted for using it for labor pain relief(1010 Amaral H, Sarmento Filho E, Silva D, Barbosa T, Gomes L. Repercussões maternas e fetais da analgesia obstétrica: uma revisão integrativa. Av.Enferm. 2015;33(2):282-294. doi: 10.15446/av.enferm.v33n2.52176
https://doi.org/10.15446/av.enferm.v33n2...
-1111 Singh KSCS, Yahya N, Misiran K, Masdar A, Nor MN, Yee LC. Combined spinal-epidural analgesia in labour: its effects on delivery outcome. Rev Bras Anestesiol [Internet]. 2016[cited 2018 Aug 29];66(3):259-264. Available from: http://dx.doi.org/10.1016/j.bjane.2014.09.006
http://dx.doi.org/10.1016/j.bjane.2014.0...
). Among the types of analgesia, the epidural provides more effective pain relief and greater maternal satisfaction; in addition, women remain involved, preventing hyperventilation and reducing maternal stress(1212 Reynolds F. Labour analgesia and the baby: good news is no news. Int J Obstet. Anesth. 2011;20(1):38-50. doi: 10.1016/j.ijoa.2010.08.004
https://doi.org/10.1016/j.ijoa.2010.08.0...
). The ideal epidural method should be the one with the least adverse effect on the fetus and the newborn(1010 Amaral H, Sarmento Filho E, Silva D, Barbosa T, Gomes L. Repercussões maternas e fetais da analgesia obstétrica: uma revisão integrativa. Av.Enferm. 2015;33(2):282-294. doi: 10.15446/av.enferm.v33n2.52176
https://doi.org/10.15446/av.enferm.v33n2...
). However, a previous study investigated the relationship between labor analgesia and delivery outcomes and found that the use of pharmacological analgesia in labor was associated with an increased risk of instrumental vaginal delivery(1313 Felisbino-Mendes MS, Santos LO, Amorim T, Costa IN, Martins EF. O uso de analgesia farmacológica influencia no desfecho de parto?. Acta Paul Enferm [Internet]. 2017[cited 2018 Aug 29];30(5):458-65. Available from: http://dx.doi.org/10.1590/1982-0194201700067
http://dx.doi.org/10.1590/1982-019420170...
). Other studies have also shown that the use of analgesia may be associated with neonatal outcomes(1414 Herrera-Gómez A, García-Martínez O, Ramos-Torrecillas J, De Luna-Bertos E, Ruiz C, Ocaña-Peinado FM. Retrospective study of the association between epidural analgesia during labour and complications for the newborn. Midwifery. 2015;31(6):613-6. doi: 10.1016/j.midw.2015.02.013
https://doi.org/10.1016/j.midw.2015.02.0...
-1515 Fernandes RLV, Damasceno AKC, Herculano MMS, Martins RST, Oriá MOB. Pharmacological obstetric analgesia: a study of obstetric and neonatal outcomes. Rev Rene (Fortaleza). 2017;18(5):687-94. doi: 10.1590/1982-0194201700067
https://doi.org/10.1590/1982-01942017000...
).

A recent integrative review has shown that studies on obstetric analgesia, maternal and fetal outcomes in Brazil have increased(1010 Amaral H, Sarmento Filho E, Silva D, Barbosa T, Gomes L. Repercussões maternas e fetais da analgesia obstétrica: uma revisão integrativa. Av.Enferm. 2015;33(2):282-294. doi: 10.15446/av.enferm.v33n2.52176
https://doi.org/10.15446/av.enferm.v33n2...
). However, the association between the use of analgesia and neonatal outcomes is still controversial(1010 Amaral H, Sarmento Filho E, Silva D, Barbosa T, Gomes L. Repercussões maternas e fetais da analgesia obstétrica: uma revisão integrativa. Av.Enferm. 2015;33(2):282-294. doi: 10.15446/av.enferm.v33n2.52176
https://doi.org/10.15446/av.enferm.v33n2...
,1414 Herrera-Gómez A, García-Martínez O, Ramos-Torrecillas J, De Luna-Bertos E, Ruiz C, Ocaña-Peinado FM. Retrospective study of the association between epidural analgesia during labour and complications for the newborn. Midwifery. 2015;31(6):613-6. doi: 10.1016/j.midw.2015.02.013
https://doi.org/10.1016/j.midw.2015.02.0...
). In addition, most of the studies compare different types of analgesia, and only few compare the use and non-use of analgesia. Given this scenario, it is relevant to analyze the association between pharmacological analgesia and neonatal outcomes.

OBJECTIVEs

To investigate the association between pharmacological analgesia in labor and occurrence of neonatal outcomes.

METHODs

Ethical aspects

This study was approved by the Research Ethics Committee of the Federal University of Minas Gerais (CONEP/UFMG) and by the Research Ethics Committee of the maternity studied.

Design, setting and period

Retrospective cohort study based on data from the medical records of women who delivered in a reference maternity hospital in Belo Horizonte, Minas Gerais. The hospital handles more than 10,000 deliveries a year and has a multidisciplinary and interdisciplinary team focused on humane assistance, women’s empowerment and on the development of the mother-child bond.

The data were collected from the medical records through a structured script containing 27 objective questions. Data collection occurred between February 2013 and May 2015.

Population or sample

Simple random sampling was used to select 978 deliveries performed in 2013 in a public maternity hospital in Belo Horizonte-MG. This sample was selected by monthly random draws. Further information on the composition of the sample can be found in a previous publication(1313 Felisbino-Mendes MS, Santos LO, Amorim T, Costa IN, Martins EF. O uso de analgesia farmacológica influencia no desfecho de parto?. Acta Paul Enferm [Internet]. 2017[cited 2018 Aug 29];30(5):458-65. Available from: http://dx.doi.org/10.1590/1982-0194201700067
http://dx.doi.org/10.1590/1982-019420170...
).

Inclusion and exclusion criteria

Inclusion criteria for the study were full-term gestations, with single live fetus in cephalic presentation. Multiple pregnancies, elective caesarean sections, prematurity, dead fetuses, abnormal presentations and intrapartum cesarean delivery were excluded. The final sample was composed of 850 women who had vaginal deliveries.

Study protocol

In this study, the exposure of interest was the use of pharmacological analgesia during labor (yes, no). The method of analgesia chosen was epidural. The outcomes analyzed were one- and five-minute Apgar (Apgar <7; Apgar ≥7), neonatal resuscitation in the delivery room (yes, no) and referral to the Neonatal ICU (yes, no). The covariates studied were maternal age (13 to 19 years, 20 to 29 years, 31 years or more), gestational age (37 to 40 weeks, 41 weeks or more) and number of previous deliveries (none, more than one).

Analysis of results and statistics

Means and proportions of neonatal outcomes were estimated. The Pearson’s Chi-squared test, the Fisher’s test and the Student’s T-test were used to evaluate the statistical differences between the exposure of interest and the outcomes. The association between exposure and binary outcomes was analyzed using logistic regression, with unadjusted Odds Ratio (OR) and 95% confidence interval (95% CI). The analysis was then adjusted for confounding factors (gestational age, maternal age and number of previous deliveries). The analysis was stratified according to gestation risk: low risk and high risk, according to the criteria of the Ministry of Health(1616 Ministério da Saúde (BR). Secretaria de Atenção à Saúde. Departamento de Atenção Básica. Atenção ao pré-natal de baixo risco. Brasília: Ministério da Saúde; 2012. 318 p.: il. - (Série A. Normas e Manuais Técnicos) (Cadernos de Atenção Básica, nº 32).). Six women did not have their gestation risk recorded. Statistical analyzes were performed in the program Stata, version 14.0 (Stata Corp., College Station, TX, USA).

RESULTS

The study population had a mean age of 24.2 years ± SD (± 6.4), ranging from 13 to 45 years. The most frequent age group was 20 to 29 years (49.0%). Most of the women were primiparous (50.7%), had a gestational age between 37 and 40 weeks (87.7%), had more than 05 prenatal visits (76.9%) and were classified as low risk (73.2%) (data not shown).

Among the women studied, 297 (35%) received analgesia. Of these women, six did not have their gestation risk identified, 213 (71.7%) were classified as low risk pregnant women and 78 (26.3%) as high risk pregnant women.

According to the data, analgesia was more frequent among women who had a companion or doula (99%), had between 9 and 11 years of education (59.1%) and were between 20 and 29 years (49.7%). It was observed that the use of analgesia was more frequent among nulliparous women (p <0.0001). The mean ± SD duration of labor was 7.1 hours for those who received analgesia and 4.4 hours for those who did not receive it (p <0.0001). The women received analgesia with a mean of 7.4 (± 1.3) cm of cervical dilation, which ranged from 3 to 10 cm (Table 1).

Table 1
Characteristics of the women and of the delivery according to the use of analgesia

Among the total number of newborns (NB), 47 (5.5%) had one-minute Apgar score less than 7, and of these, 28 (9.4%) were children of mothers who received analgesia (p <0.0001). The use of analgesia tripled the chance of newborns with a one-minute Apgar score less than 7, even after adjustment for maternal age, gestational age and number of previous deliveries (adjusted OR = 2.80, 95% CI 1.52-5.17). Five-minute Apgar score was less than 7 for 8 (0.9%) newborns, and there was no association between analgesia and this outcome (Table 2).

Table 2
Neonatal outcomes according to use of analgesia during labor among women who had a vaginal delivery

Among the newborns, 49 required neonatal resuscitations, and 31 (10.4%) of these were children of mothers who received analgesia. The use of analgesia during labor was also associated with this outcome (OR = 3.5; 95% CI: 1.91-6.33).

It was observed that 18 (2.1%) neonates were referred to the neonatal ICU, and the chance of ICU referral increased with the use of analgesia. This association remained after adjusting for maternal age, gestational age and number of previous deliveries (Adjusted OR = 3.85, 95% CI: 1.40-10.65).

When analyzing the neonatal outcomes stratified by gestation risk, it was verified that, after adjustments, one-minute Apgar scores less than 7 (OR = 2.73, 95% CI 1.35-5.53) and referral for Neonatal ICU (OR = 4.32, 95% CI 1.27-14.66) remained associated with analgesia exposure only for low risk pregnant women. Regarding the need for resuscitation, the association remained independent of gestation risk, even after adjustments (OR = 3.69, 95% CI, 1.15-11.71) (Table 3).

Table 3
Neonatal outcomes according to use of analgesia during labor and according to gestation risk

Additionally, the relationship between one-minute Apgar scores and the need for resuscitation in the delivery room (p <0.0001) was analyzed, and a high correlation between these outcomes was found (76.6%). There was also a correlation between five-minute Apgar scores and referral to the neonatal ICU (p <0.0001), for which 100% of the NB with five-minute Apgar scores lower than 7 were referred.

DISCUSSION

The results of this study pointed to the association between pharmacological analgesia during labor and unfavorable neonatal outcomes, corroborating the findings of another retrospective study that also showed an association between analgesia and adverse effects on NBs, such as lower one-minute Apgar scores, need for resuscitation in the delivery room and referral of the newborn to the neonatal ICU(1414 Herrera-Gómez A, García-Martínez O, Ramos-Torrecillas J, De Luna-Bertos E, Ruiz C, Ocaña-Peinado FM. Retrospective study of the association between epidural analgesia during labour and complications for the newborn. Midwifery. 2015;31(6):613-6. doi: 10.1016/j.midw.2015.02.013
https://doi.org/10.1016/j.midw.2015.02.0...
). It should also be noted that there was a study that did not find the same relation(1515 Fernandes RLV, Damasceno AKC, Herculano MMS, Martins RST, Oriá MOB. Pharmacological obstetric analgesia: a study of obstetric and neonatal outcomes. Rev Rene (Fortaleza). 2017;18(5):687-94. doi: 10.1590/1982-0194201700067
https://doi.org/10.1590/1982-01942017000...
).

Some studies have found an association between the use of analgesia and one-minute Apgar scores less than 7; the same did not occur with the five-minute Apgar scores(1414 Herrera-Gómez A, García-Martínez O, Ramos-Torrecillas J, De Luna-Bertos E, Ruiz C, Ocaña-Peinado FM. Retrospective study of the association between epidural analgesia during labour and complications for the newborn. Midwifery. 2015;31(6):613-6. doi: 10.1016/j.midw.2015.02.013
https://doi.org/10.1016/j.midw.2015.02.0...
), which may be related to resuscitation maneuvers, showing that these are effective to improve the condition of the newborn, resulting in a five-minute Apgar greater than 7(1717 Saraiva JP, Vogt SE, Rocha JS, Duarte ED, Simão DAS. Association between maternal and neonatal factors and Apgar in usual risk neonates. Rev Rene (Belo Horizonte). 2018;19:1-7. doi: 10.15253/2175-6783.2018193179
https://doi.org/10.15253/2175-6783.20181...
). This was demonstrated by the high correlation between Apgar 1 minute less than 7 and resuscitation maneuvers found in this study, as well as in other studies(1717 Saraiva JP, Vogt SE, Rocha JS, Duarte ED, Simão DAS. Association between maternal and neonatal factors and Apgar in usual risk neonates. Rev Rene (Belo Horizonte). 2018;19:1-7. doi: 10.15253/2175-6783.2018193179
https://doi.org/10.15253/2175-6783.20181...
). It is known that Apgar should not be used to indicate CPR for the newborn(1818 American Academy of Pediatrics Committee on Fetus and Newborn. American College of Obstetricians and Gynecologists Committee on Obstetric Practice. The Apgar score. Pediatr. 2015;136(4):819-22. doi:10.1542/peds.2015-2651.
https://doi.org/10.1542/peds.2015-2651...
-1919 International Liaison Committee on Resuscitation (ILCOR) Neonatal Task Force. Coordenação Geral do Programa de Reanimação Neonatal da SBP. Programa de Reanimação Neonatal. Reanimação do recém-nascido =34 semanas em sal parto: diretrizes 2016 da Sociedade Brasileira de Pediatria. São Paulo: SBP;2016.), but it is considered a viable parameter to evaluate the response and effectiveness of the measures taken(1717 Saraiva JP, Vogt SE, Rocha JS, Duarte ED, Simão DAS. Association between maternal and neonatal factors and Apgar in usual risk neonates. Rev Rene (Belo Horizonte). 2018;19:1-7. doi: 10.15253/2175-6783.2018193179
https://doi.org/10.15253/2175-6783.20181...
,1919 International Liaison Committee on Resuscitation (ILCOR) Neonatal Task Force. Coordenação Geral do Programa de Reanimação Neonatal da SBP. Programa de Reanimação Neonatal. Reanimação do recém-nascido =34 semanas em sal parto: diretrizes 2016 da Sociedade Brasileira de Pediatria. São Paulo: SBP;2016.). It is also worth noting that, in this study, all the NBs who had five-minute Apgar <7 were referred to the neonatal ICU, demonstrating the cascade effect of the outcomes analyzed.

This association is demonstrated in studies that showed the relationship between epidural analgesia, intrapartum maternal fever, and adverse neonatal outcomes(2020 Greenwell EA, Wyshak G, Ringer SA, Johnson LC, Rivkin MJ, Lieberman E. Intrapartum Temperature Elevation, Epidural Use, and Adverse Outcome in Term Infants. Pediatrics. 2012;129(2):447-454. doi:10.1542/peds.2010-2301
https://doi.org/10.1542/peds.2010-2301...
-2121 Törnell S, Ekéus C, Hultin M, Håkansson S, Thunberg J, Högberg U. Low Apgar score, neonatal encephalopathy and epidural analgesia during labour: a Swedish registry-based study. Acta Anaesthesiol. Scand. 2015;59(4):486-95. doi: 10.1111/aas.12477
https://doi.org/10.1111/aas.12477...
). This theory is based on intrapartum maternal hyperthermia caused by the use of epidural analgesia, both of which have been related to low Apgar scores, cardiopulmonary resuscitation and early-onset neonatal seizures. This latter outcome could have implications for longer-term health of the infant. The biological mechanism of this association is not yet clear however, it is known that fever is not due to infection and it is associated to an inflammatory response(2020 Greenwell EA, Wyshak G, Ringer SA, Johnson LC, Rivkin MJ, Lieberman E. Intrapartum Temperature Elevation, Epidural Use, and Adverse Outcome in Term Infants. Pediatrics. 2012;129(2):447-454. doi:10.1542/peds.2010-2301
https://doi.org/10.1542/peds.2010-2301...
,2222 Riley LE, Celi AC, Onderdonk AB, Roberts DJ, Johnson LC, Tsen LC, et al. Association of Epidural-Related Fever and Noninfectious Inflammation in Term Labor. Obstet. Gynecol. 2011;117(3):588-95. doi: 10.1097/01.aoa.0000414090.52839.ff
https://doi.org/10.1097/01.aoa.000041409...
).

Another possible explanation may be the effect of analgesia on labor length, which has been previously demonstrated(1313 Felisbino-Mendes MS, Santos LO, Amorim T, Costa IN, Martins EF. O uso de analgesia farmacológica influencia no desfecho de parto?. Acta Paul Enferm [Internet]. 2017[cited 2018 Aug 29];30(5):458-65. Available from: http://dx.doi.org/10.1590/1982-0194201700067
http://dx.doi.org/10.1590/1982-019420170...
,2323 Hasegawa J, Farina A, Turchi G, Hasegawa Y, Zanello M, Baroncini S. Effects of epidural analgesia on labor length, instrumental delivery, and neonatal short-term outcome. J Anesth. 2013;27:43-47. doi: 10.1007/s00540-012-1480-9
https://doi.org/10.1007/s00540-012-1480-...
-2424 Gizzo S, Di Gangi S, Saccardi C, Patrelli TS, Paccagnella G, Sansone L, et al. Epidural Analgesia During Labor: Impact on Delivery Outcome, Neonatal Well-Being, and Early Breastfeeding. Breastfeed Med. 2012;7(4):262-268. doi: 10.1089/bfm.2011.0099
https://doi.org/10.1089/bfm.2011.0099...
). It is known that nulliparous women tend to have longer labor compared to multiparous women(2323 Hasegawa J, Farina A, Turchi G, Hasegawa Y, Zanello M, Baroncini S. Effects of epidural analgesia on labor length, instrumental delivery, and neonatal short-term outcome. J Anesth. 2013;27:43-47. doi: 10.1007/s00540-012-1480-9
https://doi.org/10.1007/s00540-012-1480-...
), and that the use of analgesia is associated with instrumental vaginal delivery(1313 Felisbino-Mendes MS, Santos LO, Amorim T, Costa IN, Martins EF. O uso de analgesia farmacológica influencia no desfecho de parto?. Acta Paul Enferm [Internet]. 2017[cited 2018 Aug 29];30(5):458-65. Available from: http://dx.doi.org/10.1590/1982-0194201700067
http://dx.doi.org/10.1590/1982-019420170...
), which may be associated with neonatal outcomes such as low Apgar scores(2323 Hasegawa J, Farina A, Turchi G, Hasegawa Y, Zanello M, Baroncini S. Effects of epidural analgesia on labor length, instrumental delivery, and neonatal short-term outcome. J Anesth. 2013;27:43-47. doi: 10.1007/s00540-012-1480-9
https://doi.org/10.1007/s00540-012-1480-...
).

It is known that the use of analgesia in the maternity hospital studied is not indiscriminate and that the care offered follows recommendations of good practices in labor and delivery. This can be verified in the results of this study, such as the presence of a companion or doula in the majority of deliveries(1313 Felisbino-Mendes MS, Santos LO, Amorim T, Costa IN, Martins EF. O uso de analgesia farmacológica influencia no desfecho de parto?. Acta Paul Enferm [Internet]. 2017[cited 2018 Aug 29];30(5):458-65. Available from: http://dx.doi.org/10.1590/1982-0194201700067
http://dx.doi.org/10.1590/1982-019420170...
) and the use of more common pharmacological analgesia in primiparous women(1313 Felisbino-Mendes MS, Santos LO, Amorim T, Costa IN, Martins EF. O uso de analgesia farmacológica influencia no desfecho de parto?. Acta Paul Enferm [Internet]. 2017[cited 2018 Aug 29];30(5):458-65. Available from: http://dx.doi.org/10.1590/1982-0194201700067
http://dx.doi.org/10.1590/1982-019420170...
,1717 Saraiva JP, Vogt SE, Rocha JS, Duarte ED, Simão DAS. Association between maternal and neonatal factors and Apgar in usual risk neonates. Rev Rene (Belo Horizonte). 2018;19:1-7. doi: 10.15253/2175-6783.2018193179
https://doi.org/10.15253/2175-6783.20181...
,2323 Hasegawa J, Farina A, Turchi G, Hasegawa Y, Zanello M, Baroncini S. Effects of epidural analgesia on labor length, instrumental delivery, and neonatal short-term outcome. J Anesth. 2013;27:43-47. doi: 10.1007/s00540-012-1480-9
https://doi.org/10.1007/s00540-012-1480-...
) and in low-risk pregnant women, since the presence of risk factors could contraindicate the use of pharmacological analgesia(66 Obstetric Anaesthetists' Association. Analgesia for Labour and C-section. [http://www.oaa-anaes.ac.uk/ui/content/content.aspx?id=194].
http://www.oaa-anaes.ac.uk/ui/content/co...
).

For many women, the pain of labor and delivery is the worst pain they have ever experienced(2525 Whitburn LY, Jones LE, Davey MA, Small R. The meaning of labour pain: how the social environment and other contextual factors shape women's experiences. BMC Pregnancy Childbirth. 2017, 17(1):157. doi: 10.1186/s12884-017-1343-3
https://doi.org/10.1186/s12884-017-1343-...
). It is known that this pain is the result of complex interactions of inhibitory and excitatory effects and, even though its mechanisms are similar to acute pain, there are specific neurophysiological, obstetric, psychological and sociological factor that affect its intensity(44 Simkin P, Klein MC. Nonpharmacologic approaches to management of labor pain [Internet]. Uptodate.com. 2017 [cited 29 Aug 2018]. Available from: https://www.uptodate.com/contents/nonpharmacologic-approaches-to-management-of-labor-pain.
https://www.uptodate.com/contents/nonpha...
). Considering these aspects, strategies to reduce stress and anxiety during labor should be developed, since the use of several analgesics in itself is not able to manage the multidimensional phenomenon of labor pain(33 Chaillet N, Belaid L, Crochetiere C, Roy L, Gagné GP, Moutquin JM, et al. Nonpharmacologic approaches for pain management during labor compared with usual care: a meta-analysis. Birth. 2014;41(2):122-37. doi: 10.1111/birt.12103
https://doi.org/10.1111/birt.12103...
).

In many situations, pain can be managed with adequate physical and emotional support. Professionals must demonstrate safety to the woman in labor and guide her about the evolution of her labor, the pain and the methods of relief. The presence of a companion of the woman’s choice can contribute with this support and security(2626 Andrade MAC, Lima JBMC. O modelo obstétrico e neonatal que defendemos e com o qual trabalhamos [Internet]. Cadernos Humaniza SUS - Parto e Nascimento. 2014[cited 2018 Aug 29];4:20-46. Available from: http://www.redehumanizasus.net/sites/default/files/caderno_humanizasus_v4_humanizacao_parto.pdf
http://www.redehumanizasus.net/sites/def...
), but this person must also be oriented and supported in order to support. In addition, non-pharmacological methods such as body massages, bathing (shower or immersion), ambulation, breathing and relaxation techniques, comforting touches and birthing balls should also be used for pain relief(2626 Andrade MAC, Lima JBMC. O modelo obstétrico e neonatal que defendemos e com o qual trabalhamos [Internet]. Cadernos Humaniza SUS - Parto e Nascimento. 2014[cited 2018 Aug 29];4:20-46. Available from: http://www.redehumanizasus.net/sites/default/files/caderno_humanizasus_v4_humanizacao_parto.pdf
http://www.redehumanizasus.net/sites/def...
). The obstetrics nurse has the role of providing care based on support, safety and use of non-pharmacological methods of pain relief(11 Sousa AMM, Souza KV, Rezende EM, Martins EF, Campos D, Lansky S. Practices in childbirth care in maternity with inclusion of obstetric nurses in Belo Horizonte, Minas Gerais. Esc Anna Nery. 2016;20(2):324-31. doi: 10.5935/1414-8145.20160044
https://doi.org/10.5935/1414-8145.201600...
,2727 Gayeski ME, Brüggemann OM. Métodos não farmacológicos para alívio da dor no trabalho de parto: uma revisão sistemática. Texto Contexto Enferm [Internet]. 2010 [cited 2018 Aug 29];19(4):774-782. Available from: http://dx.doi.org/10.1590/S0104-07072010000400022
http://dx.doi.org/10.1590/S0104-07072010...
). However, when women need or request pharmacological methods, they should be used(2626 Andrade MAC, Lima JBMC. O modelo obstétrico e neonatal que defendemos e com o qual trabalhamos [Internet]. Cadernos Humaniza SUS - Parto e Nascimento. 2014[cited 2018 Aug 29];4:20-46. Available from: http://www.redehumanizasus.net/sites/default/files/caderno_humanizasus_v4_humanizacao_parto.pdf
http://www.redehumanizasus.net/sites/def...
), but only after the consent of the woman, who must be aware of the risks, benefits and implications of this analgesia to her childbirth(2626 Andrade MAC, Lima JBMC. O modelo obstétrico e neonatal que defendemos e com o qual trabalhamos [Internet]. Cadernos Humaniza SUS - Parto e Nascimento. 2014[cited 2018 Aug 29];4:20-46. Available from: http://www.redehumanizasus.net/sites/default/files/caderno_humanizasus_v4_humanizacao_parto.pdf
http://www.redehumanizasus.net/sites/def...
).

Reducing the damage caused to the woman and fetus by the use of analgesia has been the objective of different studies. Recent meta-analysis results demonstrated that non-pharmacological approaches are associated with a reduction in epidural analgesia and a higher maternal satisfaction with childbirth, providing significant benefits to women and their infants without causing additional harm. In turn, pharmacological analgesia was associated with odds of cesarean delivery, instrumental delivery, use of oxytocin, longer duration of labor and a lesser satisfaction with childbirth(33 Chaillet N, Belaid L, Crochetiere C, Roy L, Gagné GP, Moutquin JM, et al. Nonpharmacologic approaches for pain management during labor compared with usual care: a meta-analysis. Birth. 2014;41(2):122-37. doi: 10.1111/birt.12103
https://doi.org/10.1111/birt.12103...
). In addition, results of a systematic review have shown that non-pharmacological methods are effective in reducing stress and relieving pain and anxiety and contribute to maternal satisfaction(2828 Liu L, Coenen A, Tao H, Jansen KR, Jiang AL. Developing a prenatal nursing care. International Classification for Nursing Practice catalogue. Int Nursing Review. 2017;64:371-8. doi: 10.1111/inr.12325
https://doi.org/10.1111/inr.12325...
).

Therefore, prenatal care is a favorable moment for providing guidelines that facilitate informed choices about the delivery process, especially in relation to pain control strategies, including non-pharmacological methods and analgesia, and their indication, risks and benefits. These guidelines have proven efficacy in reducing the use of epidural analgesia and improving women’s satisfaction with labor(2525 Whitburn LY, Jones LE, Davey MA, Small R. The meaning of labour pain: how the social environment and other contextual factors shape women's experiences. BMC Pregnancy Childbirth. 2017, 17(1):157. doi: 10.1186/s12884-017-1343-3
https://doi.org/10.1186/s12884-017-1343-...
) and have been recommended for the practice of nurses in prenatal care, both for low-risk and high-risk pregnant women, in order to recognize risks and adopt postures that benefit the woman and the newborn(2929 Alleemudder DI, Kuponiyi Y, Kuponiyi C, McGlennan A, Fountain S, Kasivisvanathan R. Analgesia for labour: an evidence-based insight for the obstetrician. Obstetr Gynaecol. 2015;17:147-55. doi: 10.1111/tog.12196
https://doi.org/10.1111/tog.12196...
).

Important recommendations regarding labor analgesia should be followed, such as administration technique, dose, substances used and maintenance of analgesia during labor(55 Ministério da Saúde (BR). Secretaria de Ciência, Tecnologia e Insumos Estratégicos. Departamento de Gestão e Incorporação de Tecnologias em Saúde. Diretrizes nacionais de assistência ao parto normal: relatório de recomendação. Brasília: Ministério da Saúde, 2017. 51 p.). In addition, the clinical evaluation for the indication or contraindication of analgesia should be undertaken and include evaluation of fetal well-being(3030 Silva TC, Bisognin P, Prates LA, Bortoli CFC, Oliveira, G, Ressel LB. Práticas de atenção ao parto e nascimento: uma revisão integrativa. RECOM. 2017;7:e1294. doi: 10.19175/recom.v7i0.1294
https://doi.org/10.19175/recom.v7i0.1294...
). Among these contraindications, the maternal refusal should be emphasized, along with the presence of infection, hemorrhage and poor positioning of the fetus(3030 Silva TC, Bisognin P, Prates LA, Bortoli CFC, Oliveira, G, Ressel LB. Práticas de atenção ao parto e nascimento: uma revisão integrativa. RECOM. 2017;7:e1294. doi: 10.19175/recom.v7i0.1294
https://doi.org/10.19175/recom.v7i0.1294...
). Accurate indication of the use of analgesia can reduce harm to the fetus and to the woman. Thus, providing information on the advantages and disadvantages of this procedure can contribute to the humanization of labor(11 Sousa AMM, Souza KV, Rezende EM, Martins EF, Campos D, Lansky S. Practices in childbirth care in maternity with inclusion of obstetric nurses in Belo Horizonte, Minas Gerais. Esc Anna Nery. 2016;20(2):324-31. doi: 10.5935/1414-8145.20160044
https://doi.org/10.5935/1414-8145.201600...
,55 Ministério da Saúde (BR). Secretaria de Ciência, Tecnologia e Insumos Estratégicos. Departamento de Gestão e Incorporação de Tecnologias em Saúde. Diretrizes nacionais de assistência ao parto normal: relatório de recomendação. Brasília: Ministério da Saúde, 2017. 51 p.).

It is important to note that in the context of the humanization and demedicalization of delivery care, nursing professionals have a fundamental role in the construction of a prosperous environment in labor and delivery care in Brazil, which should be based on public policies of humanization, use of appropriate and necessary technologies and consideration of the singularity of each woman(2727 Gayeski ME, Brüggemann OM. Métodos não farmacológicos para alívio da dor no trabalho de parto: uma revisão sistemática. Texto Contexto Enferm [Internet]. 2010 [cited 2018 Aug 29];19(4):774-782. Available from: http://dx.doi.org/10.1590/S0104-07072010000400022
http://dx.doi.org/10.1590/S0104-07072010...
). More specifically, obstetric nursing has an important participation in labor and delivery care and important assistance contributions in this process, according to national and international guidelines for good practices and based on the principles of humanization(11 Sousa AMM, Souza KV, Rezende EM, Martins EF, Campos D, Lansky S. Practices in childbirth care in maternity with inclusion of obstetric nurses in Belo Horizonte, Minas Gerais. Esc Anna Nery. 2016;20(2):324-31. doi: 10.5935/1414-8145.20160044
https://doi.org/10.5935/1414-8145.201600...
).

Limitations of the study

This study presents some limitations, such as incomplete or absent records, which made it impossible to identify other factors that could be relevant for the association of analgesia and unfavorable neonatal outcomes, such as duration of each phase of labor, doses and substances used for analgesia, and specific aspects related to the health of the newborn. Despite this, it should be noted that multiple pregnancies, elective caesarean sections, prematurity, dead fetuses and abnormal presentation were exclusion criteria of the study. In addition, the gestation risk was stratified, and the associations remained for low-risk pregnant women. It should also be noted that the results were adjusted for important confounding factors in this relation.

Contributions to the areas of Nursing, health or public policies

A care model in which health systems contribute to the empowerment of women to make decisions that benefit themselves and their child should be developed in order to achieve the best physical, emotional and psychological outcome for women and their infants. Thus, the role of nursing professionals, beginning in prenatal care and preparing the woman for the delivery process, including aspects related to labor pain and coping strategies, is highlighted. Women should be guided on non-pharmacological and pharmacological pain relief methods, highlighting the risks and benefits of each method, in addition to their rights.

CONCLUSIONs

The use of pharmacological analgesia during labor was associated with neonatal outcomes such as one-minute Apgar scores less than 7, resuscitation maneuvers, and referral of the newborn to the Neonatal ICU, especially for low-risk pregnant women.

ACKNOWLEDGEMENTS

The authors acknowledge the support from the Pró-Reitoria de Pesquisa, Universidade Federal de Minas Gerais (PRPq/UFMG).

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Edited by

EDITOR IN CHIEF: Dulce Aparecida Barbosa
ASSOCIATE EDITOR: Andrea Bernardes

Publication Dates

  • Publication in this collection
    30 Mar 2020
  • Date of issue
    2020

History

  • Received
    21 Sept 2018
  • Accepted
    03 July 2019
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