Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology & Reproductive Sciences, University of California, San Francisco, San Francisco, CA (Drs Maykin and Ukoha, Ms Tilp, and Dr Gaw); Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology, and Women's Health, John A. Burns School of Medicine, University of Hawaii, Honolulu, HI (Dr Maykin).
Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology & Reproductive Sciences, University of California, San Francisco, San Francisco, CA (Drs Maykin and Ukoha, Ms Tilp, and Dr Gaw).
Am J Obstet Gynecol MFM. 2021 May;3(3):100325. doi: 10.1016/j.ajogmf.2021.100325. Epub 2021 Feb 2.
Pain and exhaustion in early labor are important to address, yet treatment options are limited. Therapeutic rest has existed for decades, although medication regimens and management strategies vary. In addition, there are little prospective data on perinatal outcomes and patient satisfaction to support and guide its use as an outpatient pain control option.
This study aimed to evaluate whether outpatient therapeutic rest in early labor using intramuscular morphine sulfate and promethazine is associated with differences in perinatal outcomes and to assess patient satisfaction with this therapy.
This prospective cohort study was conducted at a tertiary care academic medical center from September 2017 to April 2020. Participants presenting to the hospital for labor evaluation were offered therapeutic rest if they met the following criteria: reassuring modified biophysical profile, cervical dilation of ≤5 cm without contraindications to vaginal delivery, and plan to discharge home after evaluation. The primary outcome was subsequent hospital admission in active labor, defined as cervical dilation of ≥6 cm. Secondary outcomes included hospitalization duration and perinatal outcomes. The outcomes between participants who accepted therapeutic rest and those who declined it were compared. All P values were calculated using the Fisher exact test, and multivariable regression was used to adjust for potential confounding baseline variables with P<.2. In addition, a prespecified sensitivity analysis was performed, limiting subjects to nulliparous participants. Furthermore, postpartum surveys were administered to a subset of women who received therapeutic rest.
Of the 82 individuals offered therapeutic rest and consented for the study, 66 (80%) accepted and 16 (20%) declined. Although the rate of active labor at admission to the labor and delivery unit in the treatment group was markedly higher (26% [17 of 66] vs 13% [2 of 16]), this difference was not statistically significant (P=.3) (adjusted relative risk, 1.87; 95% confidence interval, 0.44-7.89). Women who received therapeutic rest were less likely to require induction of labor compared with those who declined therapeutic rest (adjusted relative risk, 0.15; 95% confidence interval, 0.041-0.54). There was no difference between the groups in mode of delivery, epidural use, length of hospitalization, maternal complications, or adverse neonatal outcomes. These findings persisted in our prespecified sensitivity analysis, limiting the study to nulliparous participants. A subset (27 of 66 [40%]) of women were surveyed after receiving therapeutic rest, and all women (n=27) who were surveyed reported satisfaction.
There was no detectable difference in the primary outcome of active labor at admission between patients who accepted outpatient therapeutic rest and those who declined it. However, fewer participants in the treatment group eventually required induction of labor, and this group did not experience an increase in adverse perinatal outcomes. Among the participants surveyed, a high rate of treatment satisfaction was reported. This study suggested that therapeutic rest is a well-tolerated and effective option for outpatient pain control in early labor.
分娩早期的疼痛和疲惫是需要解决的重要问题，但治疗选择有限。尽管药物治疗方案和管理策略有所不同，但治疗性休息已经存在了几十年。此外，几乎没有关于围产期结局和患者满意度的前瞻性数据来支持和指导将其作为门诊疼痛控制的选择。
本研究旨在评估在早期分娩中使用肌内注射硫酸吗啡和盐酸异丙嗪的门诊治疗性休息是否与围产期结局的差异有关，并评估患者对这种治疗的满意度。
这是一项前瞻性队列研究，于 2017 年 9 月至 2020 年 4 月在一家三级保健学术医疗中心进行。如果符合以下标准，参加医院分娩评估的患者将被提供治疗性休息：令人放心的改良生物物理概况、宫颈扩张<5cm 且无阴道分娩禁忌证、并计划在评估后出院回家。主要结局是后续的活跃分娩入院，定义为宫颈扩张≥6cm。次要结局包括住院时间和围产期结局。比较接受治疗性休息和拒绝治疗性休息的参与者之间的结局。所有 P 值均使用 Fisher 精确检验计算，使用多变量回归调整 P<.2 的潜在混杂基线变量。此外，还进行了一项预设的敏感性分析，将研究对象限定为初产妇。此外，还对接受治疗性休息的部分女性进行了产后调查。
在 82 名接受治疗性休息并同意参加研究的患者中，66 名（80%）接受了治疗，16 名（20%）拒绝了治疗。尽管治疗组入院时活跃分娩的发生率明显较高（26%[66 名中的 17 名] vs 13%[16 名中的 2 名]），但这一差异无统计学意义（P=.3）（调整后的相对风险，1.87；95%置信区间，0.44-7.89）。与拒绝治疗性休息的患者相比，接受治疗性休息的患者不太可能需要引产（调整后的相对风险，0.15；95%置信区间，0.041-0.54）。两组在分娩方式、硬膜外使用、住院时间、产妇并发症或不良新生儿结局方面无差异。这些发现在我们预设的敏感性分析中仍然存在，将研究对象限定为初产妇。在接受治疗性休息的患者中，有一部分（27 名中的 66 名[40%]）接受了调查，所有接受调查的女性（n=27）均报告了满意度。
接受和拒绝门诊治疗性休息的患者在入院时的主要结局（活跃分娩）方面没有可检测到的差异。然而，治疗组中最终需要引产的患者较少，而且该组并未出现围产期不良结局增加的情况。在接受调查的参与者中，报告了较高的治疗满意度。本研究表明，治疗性休息是分娩早期门诊疼痛控制的一种耐受良好且有效的选择。
