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Evidence review for the optimal method of analgesia and anaesthesia during labour and birth
Evidence review H
NICE Guideline, No. 137
Authors
National Guideline Alliance (UK).Intrapartum care: analgesia and anaesthesia
Review question
What is the optimal method of analgesia and anaesthesia during labour and birth in twin and triplet pregnancy?
Introduction
This review compares the use of analgesic techniques, during attempted vaginal birth in twin and triplet pregnancy. This information can be used to address the uncertainty around different methods of analgesia for labour in these pregnancies and to enhance woman- and family-centred decision-making.
Summary of the protocol
Please see Table 1 for a summary of the Population, Intervention, Comparison and Outcome (PICO) characteristics of this review.
For full details see the review protocol in appendix A
Methods and process
This evidence review was developed using the methods and process described in Developing NICE guidelines: the manual 2014. Methods specific to this review question are described in the review protocol in appendix A and for a full description of the methods see supplementary document C.
Declaration of interests were recorded according to NICE’s 2014 conflicts of interest policy from March 2017 until March 2018. From April 2018 onwards they were recorded according to NICE’s 2018 conflicts of interest policy. Those interests declared until April 2018 were reclassified according to NICE’s 2018 conflicts of interest policy (see Interests Register).
Clinical evidence
Included studies
Three retrospective cohort studies (Ogbonna 1986; Weekes 1977; Williams 2003) concerning twin pregnancy were included in this review.
Evidence was identified for the comparisons of analgesia versus no analgesia, continuous lumbar epidural analgesia versus parenteral analgesia and epidural analgesia versus pethidine or nitrous oxide. There was no evidence identified for the non-pharmacological analgesic technique (TENS, birthing pools, hypnobirthing) interventions.
Evidence was identified for 2 important outcomes. One was maternal, mode of birth, and the other was neonatal, perinatal mortality.
No evidence was available for the critical maternal outcomes of pain and conversion to general anaesthesia for any operative intervention, nor for the critical neonatal outcomes of major morbidities (including hypoxic ischaemic encephalopathy, cerebral palsy, neurodevelopmental disability, developmental delay, neonatal seizures, meconium aspiration syndrome, fetal trauma, respiratory depression). Neither was evidence found for the important maternal outcomes of women’s satisfaction/experience of labour and birth and mortality.
No evidence was identified for triplet pregnancy.
The clinical studies included in this evidence review are summarised in Table 2.
See also the literature search strategy in appendix B, study selection flow chart in appendix C, study evidence tables in appendix D and GRADE tables in appendix F.
Excluded studies
Studies not included in this review with reasons for their exclusions are listed in Appendix K.
Summary of clinical studies included in the evidence review
Table 2 provides a brief summary of the included studies.
See appendix D for the full evidence tables.
Quality assessment of clinical studies included in the evidence review
The evidence for this review question is presented in Table 3 and Table 4, and in appendix F. All studies were observational.
The quality of the evidence regarding the mode of birth outcome from studies by Weekes 1977 and Ogbona 1986 was assessed using risk of bias. This was done because no data was presented that showed the numbers of women who gave birth via vaginal birth or caesarean section for both twins, for example vaginal birth for the first twin and caesarean section for the second twin which would be needed to calculate a risk ratio.
The mode of birth outcome using data from the Williams 2003 studies was evaluated and presented using GRADE. The evidence regarding neonatal/perinatal mortality was also evaluated and presented using GRADE.
See appendix F for the GRADE tables.
Economic evidence
Included studies
A systematic review of the economic literature was conducted but no economic studies were identified which were applicable to this review question.
See the appendix B for the economic search strategy and appendix G for the economic evidence selection flow chart for further information.
Excluded studies
No full-text copies of articles were requested for this review and so there is no excluded studies list.
Summary of studies included in the economic evidence review
No economic studies were identified which were applicable to this review question.
Economic model
No economic modelling was undertaken for this review because the committee agreed that other topics were higher priorities for economic evaluation.
Evidence statements
Comparison 1: analgesia versus no analgesia
Outcomes for the woman
Mode of birth
Caesarean section for both twins
Very low quality evidence from 1 study in women with twin pregnancy (N=927) showed a clinically important difference in the mode of birth with the incidence of caesarean section for both twins being higher in women who had no analgesia (control).
Vaginal birth for first twin and caesarean section for second twin
Very low quality evidence from 1 study in women with twin pregnancy (N=927) showed a clinically important difference in the mode of birth with the incidence of vaginal birth for the first twin and caesarean section for the second twin being higher in women who had no analgesia(control).
Comparison 2: continuous lumbar epidural analgesia versus parenteral analgesia
Outcomes for the woman
Mode of birth
This section contains only descriptive information on the outcome mode of birth as there were no data reported in the paper to calculate relative risks.
One study with high risk of bias of women with twin pregnancy who were eligible for vaginal birth (N=142) reported that in women who received parenteral analgesia during labour (N=92), the birth of the first twin was:
- spontaneous vertex in 48.9%;
- forceps used in 35.9%;
- assisted breech in 14.1%;
- breech extraction in 1.1%;
- internal version and breech extraction in 0%.
The birth of the second twin was:
- spontaneous vertex in 19.6%;
- forceps used in 34.8%;
- assisted breech in 26.1%;
- breech extraction in 8.7%
- internal version and breech extraction in 10.9%.
In women who received continuous lumbar epidural analgesia (N=50), the birth of the first twin was:
- spontaneous vertex in 40%;
- forceps used in 40%;
- assisted breech in 18%;
- breech extraction in 2%;
- internal version and breech extraction in 0%.
The birth of the second twin was:
- spontaneous vertex in 28%;
- forceps in used 18%;
- assisted breech in 28%;
- breech extraction in 24%;
- internal version and breech extraction in 2%.
Outcomes for the baby
Perinatal mortality
Very low quality evidence from 1 study in women with twin pregnancy (N=142) showed no clinically important difference in the incidence of perinatal mortality between women who had continuous lumbar epidural analgesia or parenteral analgesia.
Comparison 3: epidural analgesia versus pethidine or nitrous oxide
Outcomes for the woman
Mode of birth
This section contains only descriptive information on the outcome mode of birth as there were no data reported to calculate relative risks.
One study with high risk of bias in women with twin pregnancy (N=64) reported that in women who received pethidine or Entonox® during labour (n=30), the first twins’ birth was:
- a normal vaginal birth in 90%;
- forceps used in 3.3%;
- breech in 6.7%.
The second twins’ birth was:
- normal vaginal birth in 56.7%;
- forceps used in 3.3%;
- breech in 40%.
In women who received epidural analgesia during labour (n=34), the birth of the first twin was:
- normal vaginal birth in 52.9%;
- forceps used in 38.2%;
- breech in 8.8%.
The birth of the second twin was:
- normal vaginal birth in 29.4%;
- forceps used in 32.4%;
- ventouse used in 5.9%;
- caesarean section (for a transverse lie) in 2.9%;
- breech in 29.4%.
The committee’s discussion of the evidence
Interpreting the evidence
The outcomes that matter most
The committee prioritised pain as a critical outcome for women in labour with twin and triplet pregnancies. This was because pain was considered to be a discriminating factor in a woman’s perception of her experience in labour. This could potentially have a long term psychological effect on the woman’s health.
The committee thought that conversion to general anaesthesia was an important outcome for the woman due to the increased risk of morbidity and mortality associated with general anaesthesia in obstetrics.
Perinatal or neonatal mortality and morbidity were prioritised as critical outcomes for the baby by the committee. Perinatal or neonatal death was prioritised as a critical outcome because of the long-term psychological impact that this may have on women and their families. The majority of women and babies would have been healthy prior to birth and so these outcomes were critical in determining the significance of intrapartum events. Neurodevelopmental disorders due to cerebral palsy, brain injury, nerve palsy, learning disability or cognitive impairment were also chosen as critical outcomes again due to the emotional and physical impact of these disorders on the children themselves and caring for them by their families.
The committee agreed that the mode of birth was an important outcome in twin and triplet pregnancy when considering the method of analgesia and anaesthesia.
The quality of the evidence
The quality of the evidence for mode of birth reported in Williams 2003 and for neonatal mortality was assessed with GRADE, and was rated as very low. The quality of the evidence from other included studies (Ogbonna 1986 and Weekes 1977) was based on the risk of bias only and was assessed as having high risk of bias. Overall, study design, risk of bias and imprecision were the main factors that lowered the confidence in the evidence. Furthermore it was unclear in the Williams 2003 study which type of epidural analgesia was used.
Benefits and harms
Information to support the planning of birth
The committee decided, based on their experience and knowledge, that discussions about birth plans are important and that such discussions should enable the woman to make informed choices about childbirth. At such a life changing time her wishes and preferences should be explored and information should be tailored to each woman. She can then feel better prepared and this may ease some of her concerns and anxieties. Due to the high risk of preterm birth in women with twin or triplet pregnancy such discussions (including analgesia or anaesthesia) should be initiated by week 24 and conducted at the latest by week 28 of the pregnancy. The committee also acknowledged that the best practice on how to provide information and how to communicate with adults is described in NICE’s guideline on patient experience in adult NHS services and cross-referred to it.
The committee agreed based on their experience, that it would be important to discuss options for analgesia and anaesthesia with the woman to enable shared decision making. It is important that this discussion takes place as soon as possible, but given the risk of preterm birth in twin and triplet pregnancies, it should take place no later than 28 weeks gestation for women with twin pregnancy and by 24 weeks gestation for women with triplet pregnancy (because of the higher risk of preterm birth associated with triplet compared to twin pregnancy).
Analgesia
The committee discussed and agreed to discount the evidence from 2 studies (Ogbonna 1986 and Weekes 1977) as the concentrations of analgesics/anaesthetics used in these studies are obsolete and are therefore not relevant to current practice. The committee had also little confidence in the Williams 2003 study since all outcomes were of very low quality and the particular analgesic treatment was not clearly defined. The committee therefore used their expertise and experience to make recommendations.
The committee agreed based that having effective regional anaesthesia would facilitate quicker labour and birth of the babies in an emergency situation reducing the risk of major neonatal morbidities and mortality. The committee discussed the established fact that women with twin or triplet pregnancy have an increased risk of intervention in labour, including the increased likelihood of an assisted birth or caesarean section for one or more of the babies, and additional internal manoeuvres. The committee agreed, based on their experience and the limited evidence, that having an epidural in place also reduces the need for emergency caesarean section for the second twin after vaginal birth of the first twin, possibly by allowing more effective internal manoeuvres to allow the second twin to be born vaginally. Even though there was no evidence for this, the committee acknowledged the necessity of pain relief when women have a caesarean section. This is currently done by using regional anaesthesia (which can be epidural or spinal) and the committee agreed that no change in practice is warranted. They also discussed that there are no recent comparative studies that assess how long it takes to top-up an epidural for the provision of de-novo spinal anaesthesia for operative birth, but there are many non-comparative studies examining the intervals between decision and birth with these top-up techniques. The committee agreed that it is widely recognised in obstetric anaesthesia that an effective epidural in place in a woman who is in established labour, confers a degree of safety because it can be converted rapidly from analgesia to anaesthesia if operative birth is required.
As there was no evidence available for many of the interventions specified in the protocol, the committee chose not to make any recommendations about other strategies of analgesia in labour (for example, those that are recommended for singleton pregnancies in the NICE guideline on intrapartum care for healthy women and babies). This was due to the lack of scientific certainty as to how generalisable and transferrable the singleton evidence would be to twin or triplet pregnancy.
Despite the limited evidence, the committee decided to prioritise other areas addressed by the guideline for future research and therefore made no research recommendations.
Cost effectiveness and resource use
In the absence of any economic evidence or original analysis, the committee made a qualitative assessment about the cost-effectiveness of methods of analgesia and anaesthesia during labour and birth in twin and triplet pregnancy.
Whilst the committee noted that epidurals are expensive, they were aware of evidence that having an epidural in place can reduce the need for an emergency caesarean section for the second twin after the vaginal birth of the first twin. The committee also reasoned that having an epidural in place can reduce the need for emergency general anaesthesia. Therefore, the committee considered that offering an epidural to women with a twin or triplet pregnancy who choose to have a vaginal birth was likely to be cost effective. Whilst recognising that current practice is varied they considered that their recommendations would reinforce current best practice and would not have a significant resource impact for the NHS.
References
Ogbonna 1986
Ogbonna B & Daw E. Epidural analgesia and the length of labour for vaginal twin delivery. J Obstet Gynaecol, 6:166–68, 1986Weekes 1977
Weekes AR, Cheridjian VE, Mwanje DK. Lumbar epidural analgesia in labour in twin pregnancy. Br Med J, 2(6089):730–2, 1977 [PMC free article: PMC1632118] [PubMed: 912272]Williams 2003
Williams KP & Galerneau F. Intrapartum influences on cesarean delivery in multiple gestation. Acta Obstet Gynecol Scand, 82(3):241–5, 2003 [PubMed: 12694120]
Appendix A. Review protocols
Review protocol – What is the optimal method of analgesia and anaesthesia during labour and birth in twin and triplet pregnancy?
Table 5Review protocol for analgesia and anaesthesia
| ID | Field (based on PRISMA-P) | Content |
|---|---|---|
| I | Review question | What is the optimal method of analgesia and anaesthesia during labour and birth in twin and triplet pregnancy? |
| II | Type of review question | Intervention |
| III | Objective of the review | There is uncertainty around the optimal method of analgesia during labour and birth in twin and triplet pregnancy. This review aims to address this issue. |
| IV | Eligibility criteria – population/disease/condition/issue/domain |
All women confirmed as having a twin or triplet pregnancy by the 11–13-week ultrasound scan and carried to ≥24 weeks of pregnancy and all fetuses confirmed alive. All women planning a vaginal birth and in established labour. Setting: hospitals |
| V | Eligibility criteria – intervention(s)/exposure(s)/prognostic factor(s) | Vaginal birth:
|
| VI | Eligibility criteria – comparator(s)/control or reference (gold) standard | Vaginal birth:
Studies examining combinations of analgesic techniques will be included. Studies examining within class comparisons will be excluded |
| VII | Outcomes and prioritisation | Critical For the woman:
For the baby:
Important For the woman:
For the baby:
|
| VIII | Eligibility criteria – study design |
Systematic reviews of randomised controlled trials. Randomised controlled trials. If insufficient trials evidence is available for each comparison:
|
| IX | Other inclusion exclusion criteria | Exclude:
|
| X | Proposed sensitivity/sub-group analysis, or meta-regression |
No subgroup analyses are planned. The following groups will used to explore any significant heterogeneity identified:
|
| XI | Selection process – duplicate screening/selection/analysis | Formal duplicate screening will not be undertaken for this question (as it has not been prioritised for economic analysis), although there will be senior supervision of the selection process. Hard copies of retrieved papers will be read by two reviewers and any disputes will be resolved in discussion with the Topic Advisor. Data extraction will be supervised by a senior reviewer. Draft excluded studies and evidence tables will be discussed with the Topic Advisor, prior to circulation to the Topic Group for their comments. Resolution of disputes will be by discussion between the senior reviewer, Topic Advisor and Chair |
| XII | Data management (software) | NGA STAR software will be used for generating bibliographies/citations, study sifting and data extraction and recording quality assessment using checklists Pairwise meta-analyses, if possible, will be performed using Cochrane Review Manager (RevMan5). ‘GRADEpro’ will be used to assess the quality of evidence for each outcome |
| XIII | Information sources – databases and dates |
Sources to be searched: Medline, Medline In-Process, CCTR, CDSR, DARE, HTA, Embase Limits (e.g. date, study design): Apply standard animal/non-English language exclusion. Limit to randomised controlled trials (RCTs) and systematic reviews in first instance but download all results |
| XIV | Identify if an update | This is a new area in the guideline |
| XV | Author contacts |
Developer: National Guideline Alliance
https://www |
| XVI | Highlight if amendment to previous protocol | For details please see section 4.5 of Developing NICE guidelines: the manual 2014 |
| XVII | Search strategy – for one database | For details please see appendix B |
| XVIII | Data collection process – forms/duplicate | A standardised evidence table format will be used, and published as appendix G (clinical evidence tables) or H (economic evidence tables) |
| XIX | Data items – define all variables to be collected | For details please see evidence tables in appendix G (clinical evidence tables) or H (economic evidence tables) of the full guideline |
| XX | Methods for assessing bias at outcome/study level |
Quality assessment of individual studies will be performed using the following checklists: AMSTAR for systematic reviews, Cochrane risk of bias for RCTs and Newcastle-Ottawa scale for cohort studies. For details please see section 6.2 of Developing NICE guidelines: the manual 2014. The risk of bias across all available evidence will be evaluated for each outcome using an adaptation of the ‘Grading of Recommendations Assessment, Development and Evaluation (GRADE) toolbox’ developed by the international GRADE working group http://www |
| XXI | Criteria for quantitative synthesis (where suitable) | For details please see section 6.4 of Developing NICE guidelines: the manual 2014 |
| XXII | Methods for analysis – combining studies and exploring (in)consistency | A full description of this is provided in the methods in supplementary material C |
| XXIII | Meta-bias assessment – publication bias, selective reporting bias | For details please see section 6.2 of Developing NICE guidelines: the manual 2014 |
| XXIV | Assessment of confidence in cumulative evidence | For details please see sections 6.4 and 9.1 of Developing NICE guidelines: the manual 2014 |
| XXV | Rationale/context – Current management | For details please see the introduction to the evidence review |
| XXVI | Describe contributions of authors and guarantor |
A multidisciplinary committee developed the guideline. The committee was convened by the National Guideline Alliance and chaired by Anthony Pearson in line with section 3 of Developing NICE guidelines: the 2014 Staff from the National Guideline Alliance undertook systematic literature searches, appraised the evidence, conducted meta-analysis and cost-effectiveness analysis where appropriate, and drafted the guideline in collaboration with the committee. A full description of this is provided in the methods in supplementary material C |
| XXVII | Sources of funding/support | The National Guideline Alliance is funded by NICE and hosted by the Royal College of Obstetricians and Gynaecologists |
| XXVIII | Name of sponsor | The National Guideline Alliance is funded by NICE and hosted by the Royal College of Obstetricians and Gynaecologists |
| XXIX | Roles of sponsor | NICE funds the National Guideline Alliance to develop guidelines for those working in the NHS, public health, and social care in England |
| XXX | PROSPERO registration number | Not registered with PROSPERO |
AMSTAR: Assessing the Methodological Quality of Systematic Reviews; CCTR: Cochrane Central Register for Controlled Trials; CDSR: Cochrane Database of Systematic Reviews; CS: caesarean section; BMI: body mass index; DARE: Database of Abstracts of Reviews of Effects; HTA: Health Technology Assessment; GRADE: Grading of Recommendations Assessment, Development and Evaluation; NGA: National Guideline Alliance; NICE: National Institute for Health and Care Excellence
Appendix B. Literature search strategies
Literature search for review question: What is the optimal method of analgesia and anaesthesia during labour in twin and triplet pregnancy?
Clinical Searches
Date of initial search: 07/02/2018
Database(s): Embase Classic+Embase 1947 to 2018 February 06, Ovid MEDLINE(R) Epub Ahead of Print, In-Process & Other Non-Indexed Citations, Ovid MEDLINE(R) Daily and Ovid MEDLINE(R) 1946 to Present
Date of updated search: 11/09/2018
Database(s): Embase Classic+Embase 1947 to 2018 September 11, Ovid MEDLINE(R) Epub Ahead of Print, In-Process & Other Non-Indexed Citations, Ovid MEDLINE(R) Daily and Ovid MEDLINE(R) 1946 to Present
| # | Searches |
|---|---|
| 1 | exp Pregnancy, Multiple/ use ppez |
| 2 | exp multiple pregnancy/ use emczd |
| 3 | ((multiple* or twin* or triplet* or monozygotic or dizygotic or trizygotic) adj3 (birth* or pregnan* or gestation* or f?etus* or f?etal)).tw. |
| 4 | (chorionicity or monochorionic or dichorionic or trichorionic).tw. |
| 5 | or/1–4 |
| 6 | Labor Pain/ |
| 7 | exp Delivery, Obstetric/ or exp Labor, Obstetric/ or exp Parturition/ |
| 8 | or/6–7 use ppez |
| 9 | labor pain/ |
| 10 | exp obstetric delivery/ or exp labor/ or birth/ |
| 11 | or/9–10 use emczd |
| 12 | (deliver* or childbirth or birth* or labo?r* or c?esar* or c-section* or VBAC or forceps or vacuum or ventouse).tw. |
| 13 | 8 or 11 or 12 |
| 14 | Pain/pc |
| 15 | exp Analgesia/ |
| 16 | Anesthesia, Obstetrical/ |
| 17 | exp Anesthesia, Epidural/ |
| 18 | Analgesics, Opioid/ |
| 19 | Nitrous Oxide/ |
| 20 | Bupivacaine/ |
| 21 | Meperidine/ |
| 22 | Morphine/ |
| 23 | Heroin/ |
| 24 | Transcutaneous Electric Nerve Stimulation/ |
| 25 | Baths/ |
| 26 | Water/ |
| 27 | Immersion/ |
| 28 | exp Hypnosis/ |
| 29 | or/14–28 use ppez |
| 30 | exp analgesia/ |
| 31 | anesthesia/ |
| 32 | anesthetic agent/ |
| 33 | obstetric anesthesia/ |
| 34 | epidural anesthesia/ |
| 35 | narcotic analgesic agent/ |
| 36 | nitrous oxide/ |
| 37 | bupivacaine/ |
| 38 | pethidine/ |
| 39 | morphine/ |
| 40 | diamorphine/ |
| 41 | transcutaneous electrical nerve stimulation/ |
| 42 | water immersion labor pool/ |
| 43 | water birth/ |
| 44 | hypnosis/ |
| 45 | or/30–44 use emczd |
| 46 | (analges* or anaesthe* or anesthe* or pain control* or pain relief or pain relieving or epidural* or spinal or “gas and air” or nitrous oxide or entonox or bupivacain* or meperidin* or morphine or diamorphine or pethidin* or remifentanil).tw. |
| 47 | (TENS or electroanalgesi* or ((transcutaneous or cutaneous or percutaneous or transdermal or electric nerve) adj2 stimulation)).tw. |
| 48 | (hypnobirth* or hypno-birth* or (hypnoti* adj birth*) or hypnotherap*).tw. |
| 49 | (birthing pool* or (birth* adj pool*) or (water adj birth*)).tw. |
| 50 | or/46–49 |
| 51 | 29 or 45 or 50 |
| 52 | 5 and 13 and 51 |
| 53 | limit 52 to english language |
| 54 | Letter/ use ppez |
| 55 | letter.pt. or letter/ use emczd |
| 56 | note.pt. |
| 57 | editorial.pt. |
| 58 | Editorial/ use ppez |
| 59 | News/ use ppez |
| 60 | exp Historical Article/ use ppez |
| 61 | Anecdotes as Topic/ use ppez |
| 62 | Comment/ use ppez |
| 63 | Case Report/ use ppez |
| 64 | case report/ or case study/ use emczd |
| 65 | (letter or comment*).ti. |
| 66 | or/54–65 |
| 67 | randomized controlled trial/ use ppez |
| 68 | randomized controlled trial/ use emczd |
| 69 | random*.ti,ab. |
| 70 | or/67–69 |
| 71 | 66 not 70 |
| 72 | animals/ not humans/ use ppez |
| 73 | animal/ not human/ use emczd |
| 74 | nonhuman/ use emczd |
| 75 | exp Animals, Laboratory/ use ppez |
| 76 | exp Animal Experimentation/ use ppez |
| 77 | exp Animal Experiment/ use emczd |
| 78 | exp Experimental Animal/ use emczd |
| 79 | exp Models, Animal/ use ppez |
| 80 | animal model/ use emczd |
| 81 | exp Rodentia/ use ppez |
| 82 | exp Rodent/ use emczd |
| 83 | (rat or rats or mouse or mice).ti. |
| 84 | or/71–83 |
| 85 | 53 not 84 |
| 86 | remove duplicates from 85 |
Date of initial search: 07/02/2018
Database(s): The Cochrane Library, issue 2 of 12, February 2018
Date of updated search: 11/09/2018
Database(s) The Cochrane Library, issue 9 of 12, September 2018
| ID | Search |
|---|---|
| #1 | MeSH descriptor: [Pregnancy, Multiple] explode all trees |
| #2 | ((multiple* or twin* or triplet* or monozygotic or dizygotic or trizygotic) near/3 (birth* or pregnan* or gestation* or foetus* or foetal or fetus* or fetal)) |
| #3 | (chorionicity or monochorionic or dichorionic or trichorionic) |
| #4 | {or #1–#3} |
| #5 | MeSH descriptor: [Labor Pain] this term only |
| #6 | MeSH descriptor: [Delivery, Obstetric] explode all trees |
| #7 | MeSH descriptor: [Labor, Obstetric] explode all trees |
| #8 | MeSH descriptor: [Parturition] explode all trees |
| #9 | {or #5–#8} |
| #10 | MeSH descriptor: [Pain] this term only and with qualifier(s): [Prevention & control - PC] |
| #11 | MeSH descriptor: [Analgesia] explode all trees |
| #12 | MeSH descriptor: [Anesthesia, Obstetrical] this term only |
| #13 | MeSH descriptor: [Anesthesia, Epidural] explode all trees |
| #14 | MeSH descriptor: [Analgesics, Opioid] this term only |
| #15 | MeSH descriptor: [Nitrous Oxide] this term only |
| #16 | MeSH descriptor: [Bupivacaine] this term only |
| #17 | MeSH descriptor: [Meperidine] this term only |
| #18 | MeSH descriptor: [Morphine] this term only |
| #19 | MeSH descriptor: [Heroin] this term only |
| #20 | MeSH descriptor: [Transcutaneous Electric Nerve Stimulation] explode all trees |
| #21 | MeSH descriptor: [Baths] this term only |
| #22 | MeSH descriptor: [Water] this term only |
| #23 | MeSH descriptor: [Immersion] this term only |
| #24 | (analges* or anaesthe* or anesthe* or pain control* or pain relief or pain relieving or epidural* or spinal or “gas and air” or nitrous oxide or entonox or bupivacain* or meperidin* or morphine or diamorphine or pethidin* or remifentanil) |
| #25 | (TENS or electroanalgesi* or ((transcutaneous or cutaneous or percutaneous or transdermal or electric nerve) near/2 stimulation)) |
| #26 | (hypnobirth* or hypno-birth* or (hypnoti* near birth*) or hypnotherap*) |
| #27 | (birthing pool* or (birth* near pool*) or (water near birth*)) |
| #28 | {or #10–#27} |
| #29 | #4 and #9 and #28 |
Health economics searches
For the Cochrane Library, see above
Date of initial search: 07/02/2018
Database(s): Embase Classic+Embase 1947 to 2018 February 06, Ovid MEDLINE(R) Epub Ahead of Print, In-Process & Other Non-Indexed Citations, Ovid MEDLINE(R) Daily and Ovid MEDLINE(R) 1946 to Present
Date of updated search: 11/09/2018
Database(s): Embase Classic+Embase 1947 to 2018 September 11, Ovid MEDLINE(R) Epub Ahead of Print, In-Process & Other Non-Indexed Citations, Ovid MEDLINE(R) Daily and Ovid MEDLINE(R) 1946 to Present
| # | Searches |
|---|---|
| 1 | exp Pregnancy, Multiple/ use ppez |
| 2 | exp multiple pregnancy/ use emczd |
| 3 | ((multiple* or twin* or triplet* or monozygotic or dizygotic or trizygotic) adj3 (birth* or pregnan* or gestation* or f?etus* or f?etal)).tw. |
| 4 | (chorionicity or monochorionic or dichorionic or trichorionic).tw. |
| 5 | or/1–4 |
| 6 | Labor Pain/ |
| 7 | exp Delivery, Obstetric/ or exp Labor, Obstetric/ or exp Parturition/ |
| 8 | or/6–7 use ppez |
| 9 | labor pain/ |
| 10 | exp obstetric delivery/ or exp labor/ or birth/ |
| 11 | or/9–10 use emczd |
| 12 | (deliver* or childbirth or birth* or labo?r* or c?esar* or c-section* or VBAC or forceps or vacuum or ventouse).tw. |
| 13 | 8 or 11 or 12 |
| 14 | Pain/pc |
| 15 | exp Analgesia/ |
| 16 | Anesthesia, Obstetrical/ |
| 17 | exp Anesthesia, Epidural/ |
| 18 | Analgesics, Opioid/ |
| 19 | Nitrous Oxide/ |
| 20 | Bupivacaine/ |
| 21 | Meperidine/ |
| 22 | Morphine/ |
| 23 | Heroin/ |
| 24 | Transcutaneous Electric Nerve Stimulation/ |
| 25 | Baths/ |
| 26 | Water/ |
| 27 | Immersion/ |
| 28 | exp Hypnosis/ |
| 29 | or/14–28 use ppez |
| 30 | exp analgesia/ |
| 31 | anesthesia/ |
| 32 | anesthetic agent/ |
| 33 | obstetric anesthesia/ |
| 34 | epidural anesthesia/ |
| 35 | narcotic analgesic agent/ |
| 36 | nitrous oxide/ |
| 37 | bupivacaine/ |
| 38 | pethidine/ |
| 39 | morphine/ |
| 40 | diamorphine/ |
| 41 | transcutaneous electrical nerve stimulation/ |
| 42 | water immersion labor pool/ |
| 43 | water birth/ |
| 44 | hypnosis/ |
| 45 | or/30–44 use emczd |
| 46 | (analges* or anaesthe* or anesthe* or pain control* or pain relief or pain relieving or epidural* or spinal or “gas and air” or nitrous oxide or entonox or bupivacain* or meperidin* or morphine or diamorphine or pethidin* or remifentanil).tw. |
| 47 | (TENS or electroanalgesi* or ((transcutaneous or cutaneous or percutaneous or transdermal or electric nerve) adj2 stimulation)).tw. |
| 48 | (hypnobirth* or hypno-birth* or (hypnoti* adj birth*) or hypnotherap*).tw. |
| 49 | (birthing pool* or (birth* adj pool*) or (water adj birth*)).tw. |
| 50 | or/46–49 |
| 51 | 29 or 45 or 50 |
| 52 | 5 and 13 and 51 |
| 53 | limit 52 to english language |
| 54 | Letter/ use ppez |
| 55 | letter.pt. or letter/ use emczd |
| 56 | note.pt. |
| 57 | editorial.pt. |
| 58 | Editorial/ use ppez |
| 59 | News/ use ppez |
| 60 | exp Historical Article/ use ppez |
| 61 | Anecdotes as Topic/ use ppez |
| 62 | Comment/ use ppez |
| 63 | Case Report/ use ppez |
| 64 | case report/ or case study/ use emczd |
| 65 | (letter or comment*).ti. |
| 66 | or/54–65 |
| 67 | randomized controlled trial/ use ppez |
| 68 | randomized controlled trial/ use emczd |
| 69 | random*.ti,ab. |
| 70 | or/67–69 |
| 71 | 66 not 70 |
| 72 | animals/ not humans/ use ppez |
| 73 | animal/ not human/ use emczd |
| 74 | nonhuman/ use emczd |
| 75 | exp Animals, Laboratory/ use ppez |
| 76 | exp Animal Experimentation/ use ppez |
| 77 | exp Animal Experiment/ use emczd |
| 78 | exp Experimental Animal/ use emczd |
| 79 | exp Models, Animal/ use ppez |
| 80 | animal model/ use emczd |
| 81 | exp Rodentia/ use ppez |
| 82 | exp Rodent/ use emczd |
| 83 | (rat or rats or mouse or mice).ti. |
| 84 | or/71–83 |
| 85 | 53 not 84 |
| 86 | remove duplicates from 85 |
| 87 | Economics/ |
| 88 | Value of life/ |
| 89 | exp “Costs and Cost Analysis”/ |
| 90 | exp Economics, Hospital/ |
| 91 | exp Economics, Medical/ |
| 92 | Economics, Nursing/ |
| 93 | Economics, Pharmaceutical/ |
| 94 | exp “Fees and Charges”/ |
| 95 | exp Budgets/ |
| 96 | or/87–95 use ppez |
| 97 | health economics/ |
| 98 | exp economic evaluation/ |
| 99 | exp health care cost/ |
| 100 | exp fee/ |
| 101 | budget/ |
| 102 | funding/ |
| 103 | or/97–102 use emczd |
| 104 | budget*.ti,ab. |
| 105 | cost*.ti. |
| 106 | (economic* or pharmaco?economic*).ti. |
| 107 | (price* or pricing*).ti,ab. |
| 108 | (cost* adj2 (effective* or utilit* or benefit* or minimi* or unit* or estimat* or variable*)).ab. |
| 109 | (financ* or fee or fees).ti,ab. |
| 110 | (value adj2 (money or monetary)).ti,ab. |
| 111 | or/104–109 |
| 112 | 96 or 103 or 111 |
| 113 | 86 and 112 |
Appendix C. Clinical evidence study selection
Clinical evidence study selection for review question: What is the optimal method of analgesia and anaesthesia during labour in twin and triplet pregnancy?
Figure 1Flow diagram of clinical article selection for the optimal method of analgesia and anaesthesia during labour and birth in twin and triplet pregnancy review
Appendix D. Clinical evidence tables
Clinical evidence tables for review question: What is the optimal method of analgesia and anaesthesia during labour in twin and triplet pregnancy?
Download PDF (246K)
Appendix E. Forest plots
Forest plots for review question: What is the optimal method of analgesia and anaesthesia during labour in twin and triplet pregnancy?
No meta-analysis was undertaken for this review and so there are no forest plots.
Appendix F. GRADE tables
GRADE profile for review question: What is the optimal method of analgesia and anaesthesia during labour in twin and triplet pregnancy?
Table 6Comparison: analgesia versus no analgesia for mode of birth for twin pregnancy, outcomes for the woman
| Quality assessment | Number of women | Effect | Quality | Importance | ||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Number of studies | Design | Risk of bias | Inconsistency | Indirectness | Imprecision | Other considerations | Analgesia | No analgesia | Relative (95% CI) | Absolute | ||
| Caesarean section for both twins | ||||||||||||
| 1 | Observational studies | Very serious2 | No serious inconsistency | No serious indirectness | No serious imprecision | None |
140/689 (20.3%) |
105/238 (44.1%) | RR 0.46 (0.37 to 0.57) | 238 fewer per 1000 (from 190 fewer to 278 fewer) |
⊕⊝⊝⊝ VERY LOW | IMPORTANT |
| Vaginal birth for first twin and caesarean section for second twin | ||||||||||||
| 1 | Observational studies | Very serious2 | No serious inconsistency | No serious indirectness | Serious3 | None |
11/689 (1.6%) |
10/238 (4.2%) | RR 0.38 (0.16 to 0.88) | 26 fewer per 1000 (from 5 fewer to 35 fewer) |
⊕⊝⊝⊝ VERY LOW | IMPORTANT |
CI: confidence interval; MID: RR: risk ratio; VB: vaginal birth
- 2
Unclear risk of selection bias; high risk of comparability bias as the study does not control for any factor; high risk of attrition bias as not all subjects were accounted for in the analysis; analgesia not defined
- 3
The quality of the evidence was downgraded by 1 level because the 95% CI crosses one default MID threshold
Table 7Comparison: continuous lumbar epidural analgesia versus parenteral analgesia for perinatal mortality for twin pregnancy, outcomes for the baby
| Quality assessment | Number of women | Effect | Quality | Importance | ||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Number of studies | Design | Risk of bias | Inconsistency | Indirectness | Imprecision | Other considerations | Epidural analgesia | Parenteral analgesia | Relative (95% CI) | Absolute | ||
| 1 | Observational studies | Very serious1 | No serious inconsistency | No serious indirectness | Very serious2 | None |
2/50 (4%) |
10/92 (10.9%) | RR 0.37 (0.08 to 1.61) | 68 fewer per 1000 (from 100 fewer to 66 more) |
⊕⊝⊝⊝ VERY LOW | IMPORTANT |
CI: confidence interval; RR: risk ratio
- 1
Unclear risk of selection bias; unclear risk of outcome bias; high risk of comparability bias as the study does not control for any factor; perinatal mortality not defined
- 2
The quality of the evidence was downgraded by 2 levels because the 95% CI crosses 2 default MID thresholds
Appendix G. Economic evidence study selection
Economic evidence study selection for review question: What is the optimal method of analgesia and anaesthesia during labour in twin and triplet pregnancy?
No economic evidence was identified for this review.
Figure 2Flow diagram of economic article selection for the optimal method of analgesia and anaesthesia during labour in twin and triplet pregnancy
Appendix H. Economic evidence tables
Economic evidence tables for review question: What is the optimal method of analgesia and anaesthesia during labour in twin and triplet pregnancy?
No economic evidence was identified for this review.
Appendix I. Economic evidence profiles
Economic profiles for review question: What is the optimal method of analgesia and anaesthesia during labour in twin and triplet pregnancy?
No economic evidence was identified for this review.
Appendix J. Economic analysis
Economic analysis for review question: What is the optimal method of analgesia and anaesthesia during labour in twin and triplet pregnancy?
No economic analysis was conducted for this review.
Appendix K. Excluded studies
Excluded studies for review question: What is the optimal method of analgesia and anaesthesia during labour in twin and triplet pregnancy?
Clinical studies
| Study | Reason for exclusion |
|---|---|
| Aaron, J. B., Halperin, J., Fetal survival in 376 twin deliveries, American journal of obstetrics and gynecology (Print), 69, 794–804, 1955 | More than half of the babies were premature |
| Aaron, J. B., Silverman, S. H., Halperin, J., Fetal survival in twin delivery, American journal of obstetrics and gynecology (Print), 81, 331–334, 1961 | Comparison not relevant |
| Adams, D. M, Chervenak, F. A., Intrapartum management of twin gestation, Clinical Obstetrics & Gynecology, 33, 52–60, 1990 | Narrative review on the intrapartum management of twin pregnancy |
| Anim-Somuah, Millicent, Smyth, Rebecca Md, Cyna, Allan M, Cuthbert, Anna, Epidural versus non-epidural or no analgesia for pain management in labour, Cochrane Database of Systematic Reviews, 2018 | Potentially relevant studies were assessed for the inclusion |
| Ayres,A., Johnson,T.R.B., Management of multiple pregnancy: Labor and delivery, Obstetrical and Gynecological Survey, 60, 550–554, 2005 | Narrative review on the intrapartum management of twin pregnancy |
| Behforouz, N, Dounas, M, Benhamou, D., Epidural anaesthesia for caesarean delivery in triple and quadruple pregnancies, Acta Anaesthesiologica ScandinavicaActa Anaesthesiol Scand, 42, 1088–91, 1998 | Non relevant population as women were scheduled for an elective CS and not vaginal birth |
| Brown, D. C., Hammond, D. C., Evidence-based clinical hypnosis for obstetrics, labor and delivery, and preterm labor, International Journal of Clinical and Experimental Hypnosis, 55, 355–371, 2007 | Not multiple pregnancy |
| Carroll, M. A, Yeomans, E. R., Vaginal delivery of twins, Clinical Obstetrics & Gynecology, 49, 154–66, 2006 | Narrative review on the management of labour in twin pregnancy |
| Chamberlain, G., Steer, P., ABC of labour care. Unusual presentations and positions and multiple pregnancy, British Medical Journal, 318, 1192–1194, 1999 | Clinical review on malpresentations and malpositions of the fetus |
| Cochran, J. L., Hill, S. A., Birth of twins under impromptu psychosomatic anesthesia, Brit, J. Med. Hypnot. 7, 3–5, 1956 | A full-text copy of the article could not be obtained |
| Crawford, J. S, Weaver, J. B., Anaesthetic management of twin and breech deliveries, Clinics in Obstetrics & Gynaecology, 9, 291–6, 1982 | Narrative paper about the obstetric management of breech presentation in twin pregnancy |
| Crawford,J.S., An appraisal of lumbar epidural blockade in labour in patients with multiple pregnancy, British Journal of Obstetrics and Gynaecology, 82, 929–935, 1975 | Not all fetuses were alive at the time of labour; no relevant outcomes were reported |
| Daniels, J. C., Hehre, F. W., Anesthetic considerations for complicated obstetrics: I. A retrospective study of 527 twin deliveries, Anesthesia and Analgesia, 46, 527–539, 1967 | Mixed population as some women had vaginal birth, others had a caesarean section |
| de Veciana, M, Major, C, Morgan, M. A., Labor and delivery management of the multiple gestation, Obstetrics & Gynecology Clinics of North America, 22, 235–46, 1995 | Narrative article about the intrapartum management of twin pregnancy |
| Dewan, D. M., Anesthesia for preterm delivery, breech presentation, and multiple gestation, Clinical Obstetrics & Gynecology, 30, 566–78, 1987 | Narrative review on the use of anaesthesia in high-risk pregnancies during labour |
| Dowswell, Therese, Bedwell, Carol, Lavender, Tina, Neilson, James P, Transcutaneous electrical nerve stimulation (TENS) for pain management in labour, Cochrane Database of Systematic Reviews, 2009 | Potentially relevant studies were assessed for the inclusion |
| Dusitkasem, S., Herndon, B. H., Somjit, M., Stahl, D. L., Bitticker, E., Coffman, J. C., Comparison of Phenylephrine and Ephedrine in Treatment of Spinal-Induced Hypotension in High-Risk Pregnancies: A Narrative Review, Frontiers in MedicineFront Med (Lausanne), 4, 2, 2017 | Non relevant population as women had a caesarean section and not vaginal birth |
| Freeman, L. M., Bloemenkamp, K. W., Franssen, M. T., Papatsonis, D. N., Hajenius, P. J., Hollmann, M. W., Woiski, M. D., Porath, M., van den Berg, H. J., van Beek, E., Borchert, O. W., Schuitemaker, N., Sikkema, J. M., Kuipers, A. H., Logtenberg, S. L., van der Salm, P. C., Oude Rengerink, K., Lopriore, E., van den Akker-van Marle, M. E., le Cessie, S., van Lith, J. M., Struys, M. M., Mol, B. W., Dahan, A., Middeldorp, J. M., Patient controlled analgesia with remifentanil versus epidural analgesia in labour: randomised multicentre equivalence trial, BMJ, 350, h846, 2015 | Insufficient data reported (only in a figure) |
| Gullestad,S., Sagen,N., Epidural block in twin labour and delivery, Acta Anaesthesiologica Scandinavica, 21, 504–508, 1977 | Study design not relevant to protocol (casecontrol study) |
| Hyndman, N., Molloy, M., Anaesthetic management of twin deliveries at a tertiary care centre: A service provision project, International Journal of Obstetric Anesthesia, 1), S29, 2016 | The abstract presents the data of the analysis of the current local practice in the management of twin births on a labour ward |
| James, F. M, 3rd, Crawford, J. S, Davies, P, Naiem, H., Lumbar epidural analgesia for labor and delivery of twins, American Journal of Obstetrics & Gynecology, 127, 176–80, 1977 | Comparison not relevant |
| Jarvis, G. J., Whitfield, M. F., Epidural analgesia and the delivery of twins, Journal of Obstetrics and Gynaecology, 2, 90–92, 1981 | Comparison not relevant |
| Jaschevatzky,O.E, Shalit,A, Levy,Y, Grunstein,S., Epidural analgesia during labour in twin pregnancy, British Journal of Obstetrics and Gynaecology, 84, 327–331, 1977 | Study design not relevant to protocol (casecontrol study); also one of the inclusion criteria in the study was gestational age ≥23 weeks |
| Klomp, Trudy, van, Poppel Mireille, Jones, Leanne, Lazet, Janine, Di, Nisio Marcello, Lagro-Janssen, Antoine Lm, Inhaled analgesia for pain management in labour, Cochrane Database of Systematic Reviews, 2012 | Singleton pregnancies |
| Kryc, J. J., Anesthesia for the high risk obstetric patient, Clinics in Perinatology, 9, 113–34, 1982 | Narrative article about the anaesthetic management of high risk pregnancy |
| Laube, D. W., Multiple pregnancy, operative delivery, anesthesia, and analgesia, Current Opinion in Obstetrics & GynecologyCurr Opin Obstet Gynecol, 2, 40–4, 1990 | Narrative review on the intrapartum management of multiple gestation |
| Little, W. A., Friedman, E. A., The twin delivery - Factors influencing second twin mortality, Obstetrics and Gynecology, 13, 611–623, 1958 | Narrative review on the intrapartum management of twin pregnancy. Authors also describe the results of their own study about the factors affecting the mortality rate of the second twin including anaesthesia. However, not all fetuses were alive before labour |
| Lucovnik, M., Blajic, I., Verdenik, I., Mirkovic, T., Stopar Pintaric, T., Impact of epidural analgesia on cesarean and operative vaginal delivery rates classified by the Ten Groups Classification System, International journal of obstetric anesthesia, 2018 | No separate results for twin and triplet pregnancies |
| Madden, K., Middleton, P., Cyna, A. M., Matthewson, M., Jones, L., Hypnosis for pain management during labour and childbirth, Cochrane Database of Systematic Reviews, 2016 (5) (no pagination), 2016 | Potentially relevant studies were assessed for the inclusion |
| Malinow, A. M, Ostheimer, G. W., Anesthesia for the high-risk parturient, Obstetrics & Gynecology, 69, 951–64, 1987 | Narrative review on the use of anaesthesia during high-risk pregnancies |
| Marino,T, Goudas,L.C, Steinbok,V, Craigo,S.D, Yarnell,R.W., The anesthetic management of triplet cesarean delivery: a retrospective case series of maternal outcomes, Anesthesia and Analgesia, 93, 991–995, 2001 | Non relevant population as women had a caesarean section and not vaginal birth |
| Meehan,F.P, Magani,I.M, Mortimer,G., Perinatal mortality in multiple pregnancy patients, Acta Geneticae Medicae et Gemellologiae, 37, 331–337, 1988 | Not relevant population as not all women had a planned vaginal birth, some had an elective caesarean section |
| Pollack,K.L., Chestnut,D.H., Anesthesia for complicated vaginal deliveries, Anesthesiology Clinics of North America, 8, 115–129, 1990 | Narrative article about the anaesthetic management of complicated vaginal births |
| Pratt,S.D., Anesthesia for breech presentation and multiple gestation, Clinical Obstetrics & Gynecology, 46, 711–731, 2003 | Narrative review on the use of anaesthesia in high-risk pregnancies |
| Redick, L. F., Anesthesia for twin delivery, Clinics in Perinatology, 15, 107–22, 1988 | Narrative article about the physiologic and pathophysiologic aspects of labour, and the intrapartum management of analgesia and anaesthesia for twin pregnancy |
| Saxena, N., Lewis, E., Anaesthetic interventions for vaginal twin deliveries; role of epidural analgesia, International Journal of Obstetric Anesthesia, 1), S42, 2010 | Conference abstract |
| Scott Wheeler, A., James, F. M., Anesthesia for complicated obstetrics, Journal of the American Association of Nurse Anesthetists, 47, 300–308, 1979 | Narrative review on the basic anaesthetic considerations in complicated pregnancies |
| Smith, Lesley A, Burns, Ethel, Cuthbert, Anna, Parenteral opioids for maternal pain management in labour, Cochrane Database of Systematic Reviews, 2018 | Potentially relevant studies were assessed for the inclusion |
| Sng, Ban Leong, Zeng, Yanzhi, de, Souza Nurun Nisa A, Leong, Wan Ling, Oh, Ting Ting, Siddiqui, Fahad Javaid, Assam, Pryseley N, Han, Nian-Lin R, Chan, Edwin Sy, Sia, Alex T, Automated mandatory bolus versus basal infusion for maintenance of epidural analgesia in labour, Cochrane Database of Systematic Reviews, 2018 | Potentially relevant studies were assessed for the inclusion |
| Writer, W. D. R., Breech presentation and multiple pregnancy: Obstetrical aspects and anaesthetic management, Clinics in Anaesthesiology, 4, 305–320, 1986 | Narrative article about the intrapartum management of anaesthesia for multiple pregnancy |
Economic studies
No economic evidence was identified for this review.
Appendix L. Research recommendations
Research recommendations for review question: What is the optimal method of analgesia and anaesthesia during labour in twin and triplet pregnancy?
No research recommendations were made for this review.
Tables
Table 1Summary of the protocol (Population, Intervention, Comparison and Outcome [PICO])
| Population |
All women confirmed as having a twin or triplet pregnancy by the 11–13-week ultrasound scan and carried to ≥24 weeks of pregnancy with all fetuses confirmed alive. All women planning a vaginal birth and in established labour. Setting: hospital |
|---|---|
| Intervention |
|
| Comparison |
|
| Outcomes | Critical outcomes:
|
Table 2Summary of included studies for twin pregnancy
| Study | Population | Intervention/Comparison | Outcomes | Comments |
|---|---|---|---|---|
|
Retrospective cohort UK |
N=64 women with twin pregnancy who had VB. n=34/64 (53%) received epidural analgesia, n=30/64 (47%) received other analgesia | Epidural analgesia versus pethidine or nitrous oxide | For the woman:
|
Epidural analgesia defined as bupivacaine hydrochloride, without adrenaline, 0.25%, 0.5% or 0.375%; n=25 mothers received between 4 and 8 ml of 0.5%, n=2 mothers received between 8 and 14 ml of 0.375%, and n=7 mothers received between 8 and 15 ml of 0.25% bupivacaine. Pethidine or nitrous oxide defined as either pethidine in doses of 100 or 150 mg not more often than 4-hourly, or nitrous oxide and oxygen by face mask, as Entonox® |
|
Retrospective cohort UK |
N=142 women with twin pregnancy eligible for VB. n=50/142 (35%) received lumbar epidural analgesia, n=92/142 (65%) received parenteral analgesia | Continuous lumbar epidural analgesia versus pethidine and promethazine as required and supplementary Entonox® (parenteral analgesia) | For the woman:
For the baby:
|
Epidural analgesia defined as bupivacaine 0.5% with adrenaline 1/400 000. An initial test dose of 2 ml was given, and incremental doses of 4 ml were then given as required; 6 ml was administered in the sitting position when the cervix was fully dilated and the presenting part visible. Parenteral analgesia defined as analgesia provided during labour by pethidine 150 mg and promethazine hydrochloride 25 mg as required, supplemented by nitrous oxide and oxygen (Entonox®). N=10 women in this group required a general anaesthetic to expedite the birth of the second twin |
|
Retrospective cohort USA |
N=927 women with twin pregnancy eligible for VB. n=689/927 (74%) had epidural analgesia, n=238/927 (26%) had no epidural analgesia | Epidural analgesia versus no epidural analgesia | For the woman:
| No definition of epidural analgesia was given |
VB: vaginal birth
Table 3Comparison: continuous lumbar epidural analgesia versus parenteral analgesia for mode of birth for twin pregnancy, outcomes for the woman
| Outcome | No of women (studies) | % of women | RoB | |
|---|---|---|---|---|
| Continuous lumbar epidural analgesia | Parenteral analgesia | |||
| First twin | ||||
| Spontaneous vertex (Weekes 1977) | 142 (1) | 40% | 48.9% | Very serious1 |
| Forceps (Weekes 1977) | 142 (1) | 40% | 35.9% | Very serious1 |
| Assisted breech (Weekes 1977) | 142 (1) | 18% | 14.1% | Very serious1 |
| Breech extraction (Weekes 1977) | 142 (1) | 2% | 1.1% | Very serious1 |
| Internal version and breech extraction (Weekes 1977) | 142 (1) | 0% | 0% | Very serious1 |
| Second twin | ||||
| Spontaneous vertex (Weekes 1977) | 142 (1) | 28% | 19.6% | Very serious1 |
| Forceps (Weekes 1977) | 142 (1) | 18% | 34.8% | Very serious1 |
| Assisted breech (Weekes 1977) | 142 (1) | 28% | 26.1% | Very serious1 |
| Breech extraction (Weekes 1977) | 142 (1) | 24% | 8.7% | Very serious1 |
| Internal version and breech extraction (Weekes 1977) | 142 (1) | 2% | 10.9% | Very serious1 |
RoB: risk of bias
- 1
Unclear risk of selection bias; unclear risk of outcome bias; high risk of comparability bias as the study does not control for any factor
Table 4Comparison: epidural analgesia versus Pethidine or nitrous oxide for mode of birth for twin pregnancy, outcomes for the woman
| Outcome | No of women (studies) | % of women | RoB | |
|---|---|---|---|---|
| Epidural analgesia | Pethidine or nitrous oxide | |||
| First twin | ||||
| Normal vaginal birth (Ogbonna 1986) | 64 (1) | 52.9% | 90% | Very serious1 |
| Forceps (Ogbonna 1986) | 64 (1) | 38.2% | 3.3% | Very serious1 |
| Breech (Ogbonna 1986) | 64 (1) | 8.8% | 6.7% | Very serious1 |
| Second twin | ||||
| Normal vaginal birth (Ogbonna 1986) | 64 (1) | 29.4% | 56.7% | Very serious1 |
| Forceps (Ogbonna 1986) | 64 (1) | 32.4% | 3.3% | Very serious1 |
| Ventouse (Ogbonna 1986) | 64 (1) | 5.9% | Not reported | Very serious1 |
| Caesarean section (for transverse lie) (Ogbonna 1986) | 64 (1) | 2.9% | Not reported | Very serious1 |
| Breech (Ogbonna 1986) | 64 (1) | 29.4% | 40% | Very serious1 |
RoB: risk of bias
- 1
Unclear risk of selection bias; unclear risk of outcome bias; high risk of comparability bias as the study does not control for any factor
Final
Evidence review
This evidence review was developed by the National Guideline Alliance which is a part of the Royal College of Obstetricians and Gynaecologists
Disclaimer: The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or service users. The recommendations in this guideline are not mandatory and the guideline does not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Local commissioners and/or providers have a responsibility to enable the guideline to be applied when individual health professionals and their patients or service users wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this guideline should be interpreted in a way that would be inconsistent with compliance with those duties.
NICE guidelines cover health and care in England. Decisions on how they apply in other UK countries are made by ministers in the Welsh Government, Scottish Government, and Northern Ireland Executive. All NICE guidance is subject to regular review and may be updated or withdrawn.