The effect of initiating neuraxial analgesia service on the rate of cesarean delivery in Hubei, China: A 16-month retrospective study

The effect of initiating neuraxial analgesia service on the rate of cesarean delivery in Hubei, China: A 16-month retrospective study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Help Center Sign In Submit a Preprint Cite Share Download PDF Research article The effect of initiating neuraxial analgesia service on the rate of cesarean delivery in Hubei, China: A 16-month retrospective study Yun ZHAO, Ying GAO, Guoqiang SUN, Ling YU, Ying LIN This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.2.13558/v4 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 12 Oct, 2020 Read the published version in BMC Pregnancy and Childbirth → Version 4 posted 2 You are reading this latest preprint version Show more versions Abstract Background No Pain Labor ＆Delivery (NPLD) is a nongovernmental project to increase access to safe neuraxial analgesia through specialized training. This study explores the change in overall cesarean delivery (CD) rate and maternal request CD(MRCD) rate in our hospital after the initiation of neuraxial analgesia service (NA). Methods NA was initiated in May 1st 2015 by the help of NPLD. Since then, the application of NA became a routine operation in our hospital, and every parturient can choose to use NA or not. The monthly rates of NA, CD, MRCD, multiparous women, intrapartum CD, episiotomy, postpartum hemorrhage (PPH), operative vaginal delivery and neonatal asphyxia were analyzed from January 2015 to April 2016. Results The rate of NA in our hospital was getting increasingly higher from 26.1% in May 2015 to 44.6% in April 2016 ( p< 0.001); the rate of CD was 48.1% (3577/7360) and stable from January to May 2015 ( p ＞0.05), then decreased from 50.4% in May 2015 to 36.3% in April 2016 ( p< 0.001); the rate of MRCD was 11.4% (406/3577) and also stable from January to May 2015 ( p ＞0.05), then decreased from 10.8% in May 2015 to 5.7% in April 2016 ( p< 0.001). At the same time, the rate of multiparous women remained unchanged during the 16 month of observation ( p ＞0.05). There was a negative correlation between the rate of NA and rate of overall CD, r=-0.782 (95%CI [-0.948, -0.534], p ＜0.001), and between the utilization rate of NA and rate of MRCD, r=-0.914 (95%CI [-0.989, -0.766], p ＜0.001). The rates of episiotomy, PPH, operative vaginal delivery and neonatal asphyxia in women who underwent vaginal delivery as well as the rates of intrapartum CD, neonatal asphyxia, and PPH in women who underwent CD remained unchanged, and there was no correlation between the rate of NA and anyone of those rates from January 1st 2015 to April 30th 2016 ( p ＞0.05). Conclusions: Our study shows that the rates of CD and MRCD in our department were significantly decreased from May 1st 2015 to April 30th 2016, which may be due to the increasing use of NA during vaginal delivery with the help of NPLD. Maternal & Fetal Medicine Obstetrics & Gynecology Neuraxial Labor Analgesia Cesarean Delivery Maternal Request Cesarean Delivery Figures Figure 1 Figure 2 Figure 3 Background The rate of cesarean delivery (CD) in China [1-5] has risen markedly from 2.0% (14/701) in 1978–1985 to 36.6% (813/2224) during 2006–2010 [1] . In recent years, nearly half of all newborns in China were delivered by CD [2,3] , among which 23.2% were performed based on maternal request rather than on medical indications [6] . The high rate of overall CD may result in increased risk of maternal complications such as infection, hemorrhage, or even death [6] . Previous researches have showed that Chinese women often choose CD to avoid the pain during vaginal delivery, because normally no analgesia service will be given during their labor and delivery in China [2, 7] . Neuraxial analgesia (NA) for labor is a safe and commonly available method in developed countries [7] , which has been recommended as a proactive approach for high-risk parturient during labor [8] . However, very few hospitals in China regularly carry out such approach at present [3,4] . A high CD rate and low or no availability of NA for labor is a common situation in hospitals of China. No Pain Labor＆Delivery(NPLD) is a nongovernment project, which was proposed by Ling-Qun Hu, an anesthesiologist at the Northwestern University Feinberg School of Medicine in 2008. After 10 years of efforts, this project has been supported by many nongovernment organizations from both America and China [7] . Before the use of NA, common services provided in our delivery room include midwives service, accompanying family members, and water immersion service [9] during the first stage of labor if patients had requirement (about 20% of them choose water immersion delivery). NA has been regularly carried out in our hospital since May 1st, 2015. This study is a retrospective study based on a large birth center to evaluate the correlation between NA availability and the rates of overall CD, MRCD, episiotomy, postpartum hemorrhage (PPH), operative vaginal delivery and neonatal asphyxia in women who undergo vaginal delivery, and intrapartum CD and neonatal asphyxia in women who undergo cesarean delivery after regular implementation of NA. The data from January 1st, 2015 to April 30th, 2016 were collected from our hospital. Methods 1. Participants and methods This study was conducted from January 1st, 2015 to April 30th, 2016 in our hospital, a tertiary- care teaching hospital in Hubei province, in central China. 1.1 Ethical approval The study protocol was retrospective research and was approved by the ethics committee of Maternal and Child Health Hospital of Hubei Province. 1.2 Preparation stage of NA in our hospital On March 1st, 2015, an organizing committee of NA was founded, which consisted of 10 members from our hospital, including 1 administrator, 2 anesthesiologists, 1 obstetrician, 1 neonatologist, 1 nurse, 1 midwife, and 3 experts from NPLD team. Among the members, three experts were born and educated in China and then immigrated to the United States for further academic development. They were fluent in both Mandarin and English and familiar with Western standards of obstetric care. In our hospital, a meeting is regularly organized 1-2 times a week. Questions would be discussed and communicated among the experts from NPLD through WeChat (the most popular online chat platform in China designed by Tencent Company), and the care givers from our hospital had more than 5 years of work experience in the department of anesthesia (attending physician) and NPLD experts took at least 7 days for field guidance in our hospital. Before May 1st, 2015, NA was not available in labor and delivery suite. All pregnant women with labor onset were generally transferred to labor and delivery suite when the dilation of cervix was more than 1 cm. If intrapartum CD was needed in labor, they would be transferred to the operating suite. In our labor and delivery suite, various . However, during labor, no NA could be provided, and nearly 20% of them chose water immersion during first stage of labor. All of the parturient women received bilateral perineal block anesthesia when the fetal head was crowned. After delivery, all of postpartum women would be returned to maternity room again. After May 1st, 2015, with the help of NPLD team via WeChat, NA could be provided every day at any time in our labor and delivery suite. One of our labor and delivery suites (total 10 rooms) was also set as operative suite to deal with maternal and fetal emergencies for extremely dangerous to undergo intrapartum CD, with an anesthesiologist and an anesthesia nurse on duty every day, two shifts a day, at 8:00am and 17:00 pm, respectively. 1.3 The NPLD program in our hospital From June 21 to 27 of 2015, a professional NPLD team consisting of 12 members from America ( Supplementary file 1 ) travelled to our hospital to give us a one-week training [7] . The training was conducted in a typical “hands-on” pattern. First, the trainer from the team gave an overall introduction about the training, and then trainees (Chinese medical staff) practiced the drills, and finally multidisciplinary debriefings were held at the end of each day. The practiced drills included 5-minute crash CD to deal with maternal and fetal emergencies for extremely dangerous, how to deal with neurological complications, how to use operative instrument, how to reduce the rate of episiotomy, and how to perform resuscitation of neonatal asphyxia. 1.4 Data sources This retrospective study was based on the maternity departments of a tertiary- level public hospital in Wuhan, China. This is a large birth center, with annual number of newborn babies of around 20.000 in the most recent 3 years. The delivery data were collected from the hospital’s information system from January 1st, 2015 to April 30 th, 2016. A total of 26,255 deliveries were included in our study, of which 53 cases of incomplete information, 28 cases of abortion before 28 weeks’ gestation, 821 cases of labor induction for fetal malformation, 60 cases of intrauterine fetal death were excluded. Therefore, a complete dataset of 25,293 cases was finally included (accounting for 96.3% of total data). Among them, 5,829 cases were from January 1 st 2015 to April 30 th 2015 before the implement of NA and 19,464 cases were from May 1st, 2015 to April 30 th , 2016 after NA. The data contains information such as demographic data, mother’s age, gravidity, parity, date of delivery, principal diagnosis of maternal or fetal pregnancy-related complications, gestational age at delivery, mode of delivery, primary indications of CD, maternal request cesarean delivery (MRCD), intrapartum CD, whether or not using NA, episiotomy, postpartum hemorrhage (PPH), operative vaginal delivery, neonatal asphyxia. (See Figure 1 ) In China, CD with medical indications can be divided into CD with absolute medical indications and CD with relative medical indications (for instance age more than 35 years). In our study, MRCD refers to a cesarean delivery based on maternal request, which lacks absolute or relative medical indications according to the classification standards above [10,11] . 1.5 Neuraxial labor analgesia Women undergoing vaginal delivery were evaluated by anesthesiologist and obstetrician to assess their desire for and suitability for NA once their cervical dilation was greater than 1 cm. Parturient women who had any systemic and local sepsis, deranged coagulation profile, or drug allergy (Lidocaine, bupivacaine and fentanyl) were excluded from the study. For labor NA, following conditions need to be recorded: nulliparous or parous, spontaneous labor or medicine induced labor, full-term delivery or premature delivery, spontaneous vaginal delivery or instrument assisted vaginal delivery or intrapartum CD. Epidural analgesia was initiated in the left lateral decubitus position. A sterile preparation with 1% alcohol iodophor was applied by an anesthesiologist after at least 500 mL of Ringer’s lactate solution was administered by an anesthesia nurse. Then, a 20-gauge catheter via a 17-gauge needle was inserted into the epidural space at the L3-4 or L4-5 interspace. Then 2-3 mL of 2% lidocaine was applied before observing for 5 min to see if there was any adverse reaction. If no adverse reaction was observed, the catheter was fixed and connected to a programmed intermittent epidural bolus (PIEB) pump (Master PCA pump, Fresenius Kabi USA, without continuous background infusion) to give 10 mL of mixed drugs of 0.08% ropivacaine +2ug/mL fentanyl. The PIEB pump was set to an automatic mode to deliver 10 mL of the drug mixture every 1 hour. The patient could push the PIEB button whenever she felt uncomfortable or any pain during delivery and labor. Each press releases 10 mL of the drug mixture, but the interval between the two doses must be at least 15 minutes. The continuous infusion rate was set to 0mL/h. Generally, anesthesia infusion was stopped after finishing the perineal stitch and was removed in two hours after delivery. Maternal HR, NIBP and SpO2 as well as fetal heart rate were continuously monitored throughout the PIEB period. Each parturient woman was supervised by a specialized midwife, and observed by an anesthesia nurse at regular intervals. Common side effects such as nausea, somnolence, and pruritus were recorded by anesthesia nurses. The PIEB pump was administered by the parturient woman herself according to the instruction of the anesthesiologist. Parturient women received exogenous oxytocin to obtain an enhanced labor process when indicated. All fetal and maternal events, therapeutic interventions, outcome of labor, and Apgar score of newborns at 1 and 5 min, PPH, and the mode of delivery were recorded. The analgesia effect was evaluated by visual analog scale (VAS) and numerical rating scale (NRS). The VAS was assessed on a 10 cm horizontal line. The selected pregnant women were informed that the left end of the scale represents “no pain” and that the right end represents the “most severe pain imaginable”. Then, they were instructed to mark the intensity of pain they were currently experiencing. For the NRS，a 11-point scale was used, with “0” representing “no pain” and “10” representing the “most severe pain imaginable.” All pain assessments were performed by an anesthesiologist before and after NA. After delivery, a questionnaire survey on the satisfaction on the NA effect was carried out by scanning the code on WeChat. 1.6 Patient’s education All our patients were educated by obstetrician in prenatal examination and the brochure for NA were given to them. On working day, midwives conducted specialized classes about NA to teach them how to improve compliance during analgesia. Women undergoing vaginal delivery were evaluated by anesthesiologist and obstetrician to assess their desire for and suitability for NA once their cervical dilation was greater than 1 cm and all of them signed written informed consent for NA. Women undergoing vaginal delivery could also choose water immersion delivery once their cervical dilation was greater than 5 cm. 1.7 Data analysis All data were inputted into SPSS software (v.19.0, SPSS Inc, Chicago, IL, USA) for statistical analysis. The Pearson correlation was adopted to evaluate the relationship among observed rates during 12 months. Value r and their 95% CIs were calculated. Cochran- Armitage Trend Test was carried out to evaluate the change trend of observed rates. All statistical tests were performed with 2-sided P values. If p value＜0.05, the difference was considered statistically significant. Results 2.1 A total of 25,293 cases of parturient women were finally enrolled in our hospital from January 1st, 2015 to April 30th, 2016, of which 14,205 cases (56.2%) underwent vaginal delivery and 11,088 cases (43.8%) underwent CD. There were 19,196 (75.9%) nulliparous and 6,097(24.1%) parous, and the rate of parous remained unchanged over the 16-month study period according to Cochran- Armitage Trend Test (z=3.474, p =0.062). (Figure 2) Among those 25.293 cases, there were 19464 cases undergoing delivery after the implement of NA. Among them, 3869 cases chose NA during labor, but 10 cases failed in epidural puncture 2 cases showed detachment of epidural catheter during labor, and 238 cases required intrapartum CD based on medical indications. Finally, there were 3619 cases undergoing vaginal delivery with NA including 41 cases of accidental dural punctures by redone with proper placement, and 7563 cases without NA, so the overall rate of NA in vaginal delivery was 32.4% (3619/11182). Among those 3619 cases, the average VAS and NRS before the use of NA was 9.2, and then dropped to 3.1 after effective analgesia, which indicates the pain was significantly eased ( p ＜0.001). Those who chose NA were satisfied with the effect of analgesia according to the results of questionnaire survey. 2.2 The rates of CD, MRCD, and NA in 16-month observation are shown in Figure 3 and Table 1 . The results of Cochran- Armitage testing ( Figure 3 ) indicates that CD and MRCD rates were stable during the first 5 month in 2015(z=3.080 and 1.114, p =3.080 and 0.291＞0.05), but the rates of CD and MRCD significantly decreased from 50.4% in May 2015 to 36.3% in April 2016 (z=93.375, p =0.000 < 0.001), and from 10.8% in May 2015 to 5.7% in April 2016 (z=14.788, p =0.000 < 0.001), respectively. Similarly, the rate of NA increased from 26.1 % in May 2015 to 44.6% in April 2016( p< 0.001). Among the 16 months, there were a negative correlation between the rate of NA and rate of overall CD, r=-0.782 (95%CI[-0.948,-0.534], p ＜0.001), and between the utilization rate of NA and rate of MRCD, r=-0.914 (95%CI[-0.989,-0.766], p ＜0.001) . 2.3The change trend of episiotomy, operative vaginal delivery, PPH and neonatal asphyxia in women undergoing vaginal delivery The monthly rates of episiotomy, operative vaginal delivery, and PPH and neonatal asphyxia in women who undergoing vaginal delivery remained unchanged during the 16 months (4 months before and 12 months after the utilization of NA). Moreover, there was no correlation between NA and the rates of episiotomy, operative vaginal delivery, and PPH and neonatal asphyxia in women who underwent vaginal delivery(p＞0.05). (Table 2, 3) 2.4 The change trend of intrapartum CD, PPH and neonatal asphyxia in women who underwent CD From May 1st, 2015 to April 1st, 2016, there were 728 cases underwent intrapartum CD but only 8 cases underwent CD within the Labor & Delivery suite. From Table 4, 5, it can be found that the monthly rates of intrapartum CD, neonatal asphyxia and PPH in women undergoing CD remain unchanged during the 16 months of observation, and there was no correlation between the rate of NA and the rates of intrapartum CD, neonatal asphyxia, and PPH in women undergoing CD ( p >0.05). Discussion At present, the high CD rate is a social problem in China. However, there are few hospitals conventionally carrying out NA during delivery and labor to meet the needs of parturient women [12] . Many Chinese people think labor pain is normal which is difficult to be avoided for parturient women especially nulliparous, so some of them choose CD, especially MRCD. Under the policy of one-child family taking effect from 1979, incorrect cognitions on delivery were prevalent in China, for example they thought the damage caused by episiotomy and that caused by CD were the same, CD might be less likely to affect the quality of sexual life than vaginal birth [13] , and giving birth by selecting a particular date may be more safe [14] . The relative medical indications of CD vary all over China, such as pregnancy with severe shortsightedness which is believed to cause retinal detachment during labor in certain extreme condition, pregnancy by assisted reproduction techniques, primipara more than 35 years old [7,15,16] . Most obstetric centers in China cannot meet the increasing requirements of pregnant women, such as lacking the company of family members especially husband, analgesia, or emotional support in labor [3,4] . In recent years, a few Chinese hospitals have started to control the unusually high CD rates with health education, painless delivery, doula delivery and psychological comforting and training programs for midwives and obstetricians [17] . In our birth center, with the help of NPLD program, NA has become available for women who request to relieve labor pain since May 1st, 2015. There were several reports in the US back in the 1990s about the effects of a sudden increase in neuraxial analgesia rate on cesarean delivery rates, with almost all of them showing no effect [18, 19] . NPLD is a nongovernment project aiming to help Chinese parturient women and their health care providers about the safe and effective use of NA [7] . According to the data collected from Shijiazhuang Obstetrics and Gynecology Hospital where the project was first introduced in 2008, the rate of overall CD decreased from 40.5% to 33.6% in the period when the rate of neuraxial labor analgesia increased from 0 to 33.5% [20]. At the second Affiliated Hospital, Wenzhou Medical University, Wang Q found that as the labor epidural analgesia rate increased from 0 to 57%, the vaginal delivery rate increased, and cesarean delivery rate decreased by 3.5%, at the same time the rate of episiotomy and severe perineal injury were decreased [21] . Our results are in accordance with those observational studies on the use of NA with the help of NPLD [7,20-21] . In our study, before the implement of NA, the rates of overall CD and MRCD were stable and high from January 1st to May 30th 2015, but with the increase of usage of NA, both of them were dropped. At the early implementation stage of NPLD program, the rate of NA was the lowest (26.1%); while the rates of overall CD and MRCD were 50.36% and 10.76% in May 2015, respectively. As the rate of NA increased to 44.6% in April 2016, the rates of overall CD and MRCD decreased to 36.3% and 5.7% respectively. There was a negative correlation between the rate of NA with the rate of CD or MRCD, and there was a positive correlation between the rate of CD and that of MRCD. Our research was consistent with the other birth centers helped by NPLD in China, but inconsistent with that in the US back in 1990. The difference may be related to China’s family policy and the high rate of MRCD. After implementing “one-child” policy for 30 years, the selective 2-child policy was announced in November 2013, which means that if one of the couples is the only child in her or his family, the couple will have the chance to have two children. China’s universal two- child policy was released in October of 2015 [22] . These policies may have an impact on the overall CD rate in China. Liao et al [23] collected data from 6 hospitals in Hubei and Gansu province of China from 2013 to 2016 and found that the overall CD rate decreased from 45.1% during 1-child policy period to 40.4% during selective 2- child policy period, and further to 38.9% during universal 2- child policy period, which is consistent with the results of many other studies [24, 25] . Our study period was from May 1st 2015 to April 30th 2016, during which selective 2-child policy did not have a large influence on the overall CD rate. The monthly rate of parous from January 1 st 2015 to April 30 th 2016 in our birth center was still around 24.1% (6097/25293), which was not affected by the following universal two- child policy. From those analyses, we believed that the decrease of overall CD rate was mainly related to initiation of labor analgesia services. Labor pain is probably the most severe pain that most women will endure in their lifetime. A neuraxial approach is accepted as the gold standard for intrapartum labor analgesia [26,27] . The mixed drugs of ropivacaine and fentanyl administrated by PIEB pump is extremely safe and effective for labor delivery analgesia [26-28] . Our clinical trial demonstrated that the NA proposed by NPLD was effective, which reduced the delivery pain from average 9.2 to 3.1 according to VAS and NRS. NA does not increase the risk of CD [7, 29] , but its impact on operative vaginal delivery and other parturient safety outcomes is still controversial [30,31] . Anwar S [30] conducted a quasi-experimental study and found that epidural analgesia did prolong the duration of second stage of labor and increased the instrumental delivery rate (58% vs 12%). Wassen MM [31] found the rate of epidural tripled increased from 7.7% to 21.9% over a 10-years span while the rates of CD and operative vaginal delivery did not change too much in the Netherlands. Our study showed that with the increase of NA rate, the rates of operative vaginal delivery remained nearly unchanged. As we all well know that it is difficult to study the effect of epidural analgesia on operative vaginal delivery rates under preconditions that are not double-blind [30,31] . The reason why the instrumental delivery was increased may be probably due to that the presence of decent analgesia makes it much easier for obstetricians to apply forceps or vacuum [30] . In our birth center, the rate of instrumental delivery remained unchanged, which may be related to the low rate of instrumental delivery (1.6%, 234/14205) and still high rate of CD (43.8%, 11088/25293) among the 16 months, most of instrumental delivery were instead by CD. At the same time, the rates of episiotomy, and PPH and neonatal asphyxia of vaginal delivery, and intrapartum CD, PPH, neonatal asphyxia of CD remained nearly unchanged before and after the use of NA in our birth center. Strengths and limitations of this study 1.The study shows the rate of NA, the rate of overall cesarean and the rate of MRCD in a large birth center of China with an annual capacity of 20,000newbornsbeing delivered. 2 The NPLD team helped to establish a neuraxial labor analgesia service in our hospital. The main limitation of this manuscript is that the findings are not so original that some other Chinese hospitals in conjunction with the NPLD program have reported similar results. 3.The data were selected from only one center, a tertiary- care teaching hospital in Hubei province, which cannot represent all hospitals from different geographical areas and in different levels in China. 4. The location of intrapartum CDs was moved to within the Labor & Delivery suite as part of the NPLD intervention, but there were only 8 cases underwent intrapartum CD within the Labor & Delivery suite to deal with maternal and fetal emergencies for extremely dangerous in our birth center, so it was difficult to analyze the relationship between the change in intrapartum CD and the location of CD(Labor & Delivery suite). 5.During the study period, China’s universal two-child policy was taking effect (2015.10), which may have some influence on the results. Conclusions In conclusion, initiation of a 24-hour labor analgesia services can relieve labor pain. Through a a16-month observation from May 1st 2015 to April 30th 2016, the rates of CD and MRCD were significantly reduced, which may be related to the increasing use of NA during delivery and labor by the help of NPLD. Abbreviations CD: cesarean delivery VD: vaginal delivery MRCD: maternal request cesarean delivery NPLD: No Pain Labor ＆Delivery NA: neuraxial labor analgesia PPH: postpartum hemorrhage VAS: visual analog scale NRS: numerical rating scale Declarations Ethics approval and consent to participate - The study conformed to the guidelines explained in the Declaration of Helsinki and was approved by the ethics committee of Maternal and Child Health Hospital of Hubei Province (MCHHHP, Wuhan, China). A waiver for the requirement of informed consent from the patients whose records were analyzed was granted by the Chair of the Committee on the grounds of being a minimal risk study. Consent for publication -Not applicable Availability of data and materials -Access to the qualitative data should be given upon request to the corresponding author after taking any necessary precautions to safeguard participants’ privacy and confidentiality. Competing interests -The authors declare that they have no competing interests Funding -This work was supported by the Foundation from Health and Family Planning Commission of Hubei Province (No: WJ2018H0133) and Key Projects of Natural Science Foundation in Hubei Province (No: 2019CFA033). Both of the foundations agreed to fund obstetric researcher for data analysis, English editing and other costs relating to dissemination of the study. Authors’ Contributions - YZ conceived the study, analyzed the data, interpreted the results, and drafted the manuscript. YG conceived the study, drafted the manuscript. GS, LY, YL analyzed the data and revised the manuscript. All authors read and approved the final manuscript. Acknowledgements The authors would like to thank NPLD team for their valuable assistance References Tian X, Wu J, Li B, Qin M, Qi J. 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Press conference of National Health and Family Planning Commission on July 10th, 2015 Liao Z, Zhou Y, Li H, Wang C, Chen D, Liu J. The Rates and Medical Necessity of Cesarean Delivery in the Era of the Two- Child Policy in Hubei and Gansu Provinces, China. Am J Public Health. 2019; 109(3): 476-82. PMID 30676790 Liang J , Mu Y , Li X , Tang W, Wang Y, Liu Z, et al. Relaxation of the one child policy and trends in caesarean section rates and birth outcomes in China between 2012 and 2016: observational study of nearly seven million health facility births. 2018; 360: k817. PMID:29506980 Li HT , Luo S , Trasande L , Hellerstein S , Kang C , Li JX , et al. Geographic Variations and Temporal Trends in Cesarean Delivery Rates in China, 2008-2014. 2017; 317(1): 69-76. PMID:28030701 Sia AT , Ruban P , Chong JL , Wong K . Motor blockade is reduced with ropiva caine 0.125% for parturient-controlled epidural analgesia during labour. Can J Anaesth. 1999; 46 (11):1019-23. PMID: 10566920 Ahirwar A , Prakash R , Kushwaha BB , Gaurav A , Chaudhary AK , Verma R , et al. Patient Controlled Epidural Labour Analgesia (PCEA): A Comparison Between Ropivacaine, Ropivacaine-Fentanyl and Ropivacaine-Clonidine. J Clin Diagn Res. 2014; 8 (8): GC09-13. PMID: 25302210 Patkar CS , Vora K , Patel H , Shah V , Modi MP , Parikh G . A comparison of continuous infusion and intermittent bolus administration of 0.1% ropivacaine with 0.0002% fentanyl for epidural labor analgesia. J Anaesthesiol Clin Pharmacol. 2015; 31 (2):234-8. PMID: 25948908 Anim-Somuah M , Smyth RM , Jones L .Epidural versus non-epidural or no analgesia in labour. Cochrane Database Syst Rev. 2011;7;(12): CD000331.PMID: 22161362 Anwar S , Anwar MW , Ahmad S . Effect of epidural analgesia on labor and its outcomes. J Ayub Med Coll Abbottabad. 2015; 27(1):146-50. PMID 26182762 Wassen MM , Hukkelhoven CW , Scheepers HC , Smits LJ , Nijhuis JG , Roumen FJ . Epidural analgesia and operative delivery: a ten-year population-based cohort study in The Netherlands. Eur J Obstet Gynecol Reprod Biol. 2014;183: 125-31. PMID 25461365 Tables Table 1: The relationships between the rate of NA and that of CD and MRCD during 16 months Rate of CD (95%CI) Rate of MRCD (95%CI) Rate of NA r -0.782 (-0.948 to -0.534) -0.914 (-0.989 to -0.766) P ＜0.001 ＜0.001 NA: neuraxial labor analgesia CD: cesarean delivery MRCD: maternal request cesarean delivery The Pearson correlation was used Table 2: The rates of NA, neonatal asphyxia, EP, ODV, PPH in vaginal delivery Rate Jan-15 % Feb-15 % Mar-15 % Apr-15 % May-15 % Jun-15 % Jul-15 % Aug-15 % Sep-15% Oct-15 % Nov-15 % Dec-15 % Jan-16 % Feb-16 % Mar-16 % Apr-16 % X 2 p -valua NA 0 0 0 0 26.1 26.5 26.2 31.6 30.8 28.8 29.6 27.2 32.7 34.3 44.1 44.6 71.295 ＜0.001 neonatal asphyxia 1.4 1.3 1.2 1.3 1.3 1.3 1.3 1.2 1.0 1.4 1.0 1.1 1.3 1.1 1.1 1.3 0.705 0.401 EP 45.2 56.8 57.0 56.4 65.4 63.9 54.7 50.6 55.7 46.6 49.8 61.9 56.2 51.7 50.2 56.1 2.786 0.095 ODV 0.6 1.7 0.7 1.3 4.0 1.8 1.4 3.5 2.0 2.1 2.2 1.3 1.2 0.7 1.2 0.9 2.722 0.099 PPH 2.6 3.4 5.0 5.0 4.6 4.0 3.4 3.5 6.0 3.4 3.5 3.9 3.7 3.5 3.8 3.0 1.081 0.299 NA: neuraxial labor analgesia; EP: episiotomy ODV: operation vaginal delivery (including forceps, vacuum and breech extraction) PPH: postpartum hemorrhage Cochran- Armitage Trend Test was used: Table 3: The relationships between the rate of NA and that of neonatal asphyxia, EP, ODV, PPH in vaginal delivery women Rate of neonatal asphyxia (95%CI) Rate of EP (95%CI) Rate of ODV (95%CI) Rate of PPH (95%CI) Rate of NA r -0.369 (-0.670 to 0.000) -0.017 (-0.483 to 0.391) 0.195 (-0.239 to 0.570) -0.147 (-0.783 to 0.445) p 0.159 0.951 0.470 0.587 NA: neuraxial labor analgesia; EP: episiotomy ODV: operation vaginal delivery (including forceps, vacuum and breech extraction) PPH: postpartum hemorrhage The Pearson correlation was used Table 4: The rates of intrapartum CD, neonatal asphyxia, PPH in CD women Rate Jan-15 % Feb-15 % Mar-15 % Apr-15 % May-15 % Jun-15 % Jul-15 % Aug-15 % Sep-15 % Oct-15 % Nov-15 % Dec-15 % Jan-16 % Feb-16 % Mar-16 % Apr-16 % X 2 p -valua Intrapartum CD 9.2 8.4 8.4 8.2 7.8 8.0 8.7 8.6 9.1 9.5 8.3 10.2 8.6 9.6 9.1 8.4 0.415 0.519 Neonatal asphyxia 1.2 1.1 1.1 1.2 1.0 1.2 1.1 1.5 0.9 1.2 1.3 1.6 1.9 1.4 1.3 1.6 2.265 0.132 PPH 3.9 4.2 3.9 4.1 3.6 3.6 2.7 2.6 3.6 4.0 2.8 4.2 4.7 3.8 2.7 2.8 0.618 0.432 CD: cesarean delivery PPH: postpartum hemorrhage Cochran- Armitage Trend Test was used Table 5: The relationships between the rate of NA and that of intrapartum CD, neonatal asphyxia, PPH in CD women Rate of intrapartum CD (95%CI) Rate of neonatal asphyxia (95%CI) Rate of PPH (95%CI) Rate of NA r 0.198 (-0.194 to 0.555) 0.419 (0.121 to 0.684) -0.494 (-0.795 to -0.120) p 0.461 0.106 0.052 NA: neuraxial labor analgesia; CD: cesarean delivery PPH: postpartum hemorrhage The Pearson correlation was used Supplementary Files supplementfile1.docx dataandmeterials.xls Cite Share Download PDF Status: Published Journal Publication published 12 Oct, 2020 Read the published version in BMC Pregnancy and Childbirth → Version 4 posted Submission checks completed at journal 29 Sep, 2020 Editorial decision: Accept 28 Sep, 2020 You are reading this latest preprint version Show more versions Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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12:53:27","currentVersionCode":4,"declarations":"","doi":"10.21203/rs.2.13558/v4","doiUrl":"https://doi.org/10.21203/rs.2.13558/v4","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12884-020-03294-z","type":"published","date":"2020-10-12T12:00:00+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":2793045,"identity":"a6e3da4f-a275-4ad2-858a-acd0a9fa4213","added_by":"auto","created_at":"2020-10-05 23:31:19","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":278846,"visible":true,"origin":"","legend":"Flow diagram","description":"","filename":"Fig1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4267/v4/180e1d738cb7e015e91282b1.jpg"},{"id":2793048,"identity":"e69bf4a9-8bbf-4116-9c2c-8f10f500ec41","added_by":"auto","created_at":"2020-10-05 23:31:19","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":83929,"visible":true,"origin":"","legend":"Rate of multiparous women (%)","description":"","filename":"Fig2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4267/v4/78880119d0b5889d977de202.jpg"},{"id":2793049,"identity":"f1ff81a4-b9cd-47e0-ae28-18f5c7c9c3be","added_by":"auto","created_at":"2020-10-05 23:31:19","extension":"jpg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":114680,"visible":true,"origin":"","legend":"The rates of CD, MRCD, and NA in 16-month observation.","description":"","filename":"Fig3.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4267/v4/a40c39831e2dac29486f28bb.jpg"},{"id":13600146,"identity":"52dcf0f1-972d-4c59-98f4-9ae38503120d","added_by":"auto","created_at":"2021-09-17 05:42:28","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":548924,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4267/v4/a1c45ad3-a84c-4e88-bac8-4e3ee5a959e7.pdf"},{"id":2793046,"identity":"f49c9df0-c73a-4725-b836-4c3bb4c21251","added_by":"auto","created_at":"2020-10-05 23:31:19","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":13110,"visible":true,"origin":"","legend":"","description":"","filename":"supplementfile1.docx","url":"https://assets-eu.researchsquare.com/files/rs-4267/v4/82a9143207efd3dfb555fdad.docx"},{"id":2793047,"identity":"05e08ac5-6471-4ca9-a538-b76970c1f5d2","added_by":"auto","created_at":"2020-10-05 23:31:19","extension":"xls","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":30720,"visible":true,"origin":"","legend":"","description":"","filename":"dataandmeterials.xls","url":"https://assets-eu.researchsquare.com/files/rs-4267/v4/c2905835ab7201871d02acb4.xls"}],"financialInterests":"","formattedTitle":"The effect of initiating neuraxial analgesia service on the rate of cesarean delivery in Hubei, China: A 16-month retrospective study","fulltext":[{"header":"Background","content":"\u003cp\u003eThe rate of cesarean delivery (CD) in China \u003csup\u003e[1-5]\u003c/sup\u003e has risen markedly from 2.0% (14/701) in 1978\u0026ndash;1985 to 36.6% (813/2224) during 2006\u0026ndash;2010 \u003csup\u003e[1]\u003c/sup\u003e. In recent years, nearly half of all newborns in China were delivered by CD\u003csup\u003e [2,3]\u003c/sup\u003e, among which 23.2% were performed based on maternal request rather than on medical indications \u003csup\u003e[6]\u003c/sup\u003e. The high rate of overall CD may result in increased risk of maternal complications such as infection, hemorrhage, or even death\u003csup\u003e [6]\u003c/sup\u003e. Previous researches have showed that Chinese women often choose CD to avoid the pain during vaginal delivery, because normally no analgesia service will be given during their labor and delivery in China \u003csup\u003e[2, 7]\u003c/sup\u003e. Neuraxial analgesia (NA) for labor is a safe and commonly available method in developed countries \u003csup\u003e[7]\u003c/sup\u003e, which has been recommended as a proactive approach for high-risk parturient during labor \u003csup\u003e[8]\u003c/sup\u003e. However, very few hospitals in China regularly carry out such approach at present\u003csup\u003e [3,4]\u003c/sup\u003e. A high CD rate and low or no availability of NA for labor is a common situation in hospitals of China. No Pain Labor＆Delivery(NPLD) is a nongovernment project, which was proposed by Ling-Qun Hu, \u0026nbsp;an anesthesiologist at the Northwestern University Feinberg School of Medicine in 2008. After 10 years of efforts, this project has been supported by many nongovernment organizations from both America and China\u003csup\u003e [7]\u003c/sup\u003e. Before the use of NA, common services provided in our delivery room include midwives service, accompanying family members, and water immersion service\u003csup\u003e [9]\u003c/sup\u003e during the first stage of labor if patients had requirement (about 20% of them choose water immersion delivery). NA has been regularly carried out in our hospital since May 1st, 2015.\u003c/p\u003e\n\u003cp\u003eThis study is a retrospective study based on a large birth center to evaluate the correlation between NA availability and the rates of overall CD, MRCD, episiotomy, postpartum hemorrhage (PPH), operative vaginal delivery and neonatal asphyxia in women who undergo vaginal delivery, and intrapartum CD and neonatal asphyxia in women who undergo cesarean delivery after regular implementation of NA. The data from January 1st, 2015 to April 30th, 2016 were collected from our hospital.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e1. Participants and methods\u003c/p\u003e\n\u003cp\u003eThis study was conducted from January 1st, 2015 to April 30th, 2016 in our hospital, a tertiary- care teaching hospital in Hubei province, in central China.\u003c/p\u003e\n\u003cp\u003e1.1 Ethical approval\u003c/p\u003e\n\u003cp\u003eThe study protocol was retrospective research and was approved by the ethics committee of Maternal and Child Health Hospital of Hubei Province.\u003c/p\u003e\n\u003cp\u003e1.2 Preparation stage of NA in our hospital\u003c/p\u003e\n\u003cp\u003eOn March 1st, 2015, an organizing committee of NA was founded, which consisted of 10 members from our hospital, including 1 administrator, 2 anesthesiologists, 1 obstetrician, 1 neonatologist, 1 nurse, 1 midwife, and 3 experts from NPLD team. Among the members, three experts were born and educated in China and then immigrated to the United States for further academic development. They were fluent in both Mandarin and English and familiar with Western standards of obstetric care. In our hospital, a meeting is regularly organized 1-2 times a week. Questions would be discussed and communicated among the experts from NPLD through WeChat (the most popular online chat platform in China designed by Tencent Company), and the care givers from our hospital had more than 5 years of work experience in the department of anesthesia (attending physician) and NPLD experts took at least 7 days for field guidance in our hospital.\u003c/p\u003e\n\u003cp\u003eBefore May 1st, 2015, NA was not available in labor and delivery suite. All pregnant women with labor onset were generally transferred to labor and delivery suite when the dilation of cervix was more than 1 cm. If intrapartum CD was needed in labor, they would be transferred to the operating suite. In our labor and delivery suite, various . However, during labor, no NA could be provided, and nearly 20% of them chose water immersion during first stage of labor. All of the parturient women received bilateral perineal block anesthesia when the fetal head was crowned. After delivery, all of postpartum women would be returned to maternity room again.\u003c/p\u003e\n\u003cp\u003eAfter May 1st, 2015, with the help of NPLD team via WeChat, NA could be provided every day at any time in our labor and delivery suite. One of our labor and delivery suites (total 10 rooms) was also set as operative suite to deal with maternal and fetal emergencies for extremely dangerous to undergo intrapartum CD, with an anesthesiologist and an anesthesia nurse on duty every day, two shifts a day, at 8:00am and 17:00 pm, respectively.\u003c/p\u003e\n\u003cp\u003e1.3 The NPLD program in our hospital\u003c/p\u003e\n\u003cp\u003eFrom June 21 to 27 of 2015, a professional NPLD team consisting of 12 members from America (\u003cstrong\u003eSupplementary file 1\u003c/strong\u003e) travelled to our hospital to give us a one-week training\u003csup\u003e [7]\u003c/sup\u003e. The training was conducted in a typical \u0026ldquo;hands-on\u0026rdquo; pattern. First, the trainer from the team gave an overall introduction about the training, and then trainees (Chinese medical staff) practiced the drills, and finally multidisciplinary debriefings were held at the end of each day. The practiced drills included 5-minute crash CD to deal with maternal and fetal emergencies for extremely dangerous, how to deal with neurological complications, how to use operative instrument, how to reduce the rate of episiotomy, and how to perform resuscitation of neonatal asphyxia.\u003c/p\u003e\n\u003cp\u003e1.4 Data sources\u003c/p\u003e\n\u003cp\u003eThis retrospective study was based on the maternity departments of a tertiary- level public hospital in Wuhan, China. This is a large birth center, with annual number of newborn babies of around 20.000 in the most recent 3 years. The delivery data were collected from the hospital\u0026rsquo;s information system from January 1st, 2015 to April 30 th, 2016. A total of 26,255 deliveries were included in our study, of which 53 cases of incomplete information, 28 cases of abortion before 28 weeks\u0026rsquo; gestation, 821 cases of labor induction for fetal malformation, 60 cases of intrauterine fetal death were excluded. Therefore, a complete dataset of 25,293 cases was finally included (accounting for 96.3% of total data). Among them, 5,829 cases were from January 1\u003csup\u003est\u003c/sup\u003e 2015 to April 30\u003csup\u003eth\u003c/sup\u003e 2015 before the implement of NA and 19,464 cases were from May 1st, 2015 to April 30\u003csup\u003eth\u003c/sup\u003e, 2016 after NA. The data contains information such as demographic data, mother\u0026rsquo;s age, gravidity, parity, date of delivery, principal diagnosis of maternal or fetal pregnancy-related complications, gestational age at delivery, mode of delivery, primary indications of CD, maternal request cesarean delivery (MRCD), intrapartum CD, whether or not using NA, episiotomy, postpartum hemorrhage (PPH), operative vaginal delivery, neonatal asphyxia. (See\u003cstrong\u003e Figure 1\u003c/strong\u003e)\u003c/p\u003e\n\u003cp\u003eIn China, CD with medical indications can be divided into CD with absolute medical indications and CD with relative medical indications (for instance age more than 35 years). In our study, MRCD refers to a cesarean delivery based on maternal request, which lacks absolute or relative medical indications according to the classification standards above\u003csup\u003e [10,11]\u003c/sup\u003e.\u003c/p\u003e\n\u003cp\u003e1.5 Neuraxial labor analgesia\u003c/p\u003e\n\u003cp\u003eWomen undergoing vaginal delivery were evaluated by anesthesiologist and obstetrician to assess their desire for and suitability for NA once their cervical dilation was greater than 1 cm. Parturient women who had any systemic and local sepsis, deranged coagulation profile, or drug allergy (Lidocaine, bupivacaine and fentanyl) were excluded from the study. For labor NA, following conditions need to be recorded: nulliparous or parous, spontaneous labor or medicine induced labor, full-term delivery or premature delivery, spontaneous vaginal delivery or instrument assisted vaginal delivery or intrapartum CD.\u003c/p\u003e\n\u003cp\u003eEpidural analgesia was initiated in the left lateral decubitus position. A sterile preparation with 1% alcohol iodophor was applied by an anesthesiologist after at least 500 mL of Ringer\u0026rsquo;s lactate solution was administered by an anesthesia nurse. Then, a 20-gauge catheter via a 17-gauge needle was inserted into the epidural space at the L3-4 or L4-5 interspace. Then 2-3 mL of 2% lidocaine was applied before observing for 5 min to see if there was any adverse reaction. If no adverse reaction was observed, the catheter was fixed and connected to a programmed intermittent epidural bolus (PIEB) pump (Master PCA pump, Fresenius Kabi USA, without continuous background infusion) to give 10 mL of mixed drugs of 0.08% ropivacaine +2ug/mL fentanyl. The PIEB pump was set to an automatic mode to deliver 10 mL of the drug mixture every 1 hour. The patient could push the PIEB button whenever she felt uncomfortable or any pain during delivery and labor. Each press releases 10 mL of the drug mixture, but the interval between the two doses must be at least 15 minutes. The continuous infusion rate was set to 0mL/h. Generally, anesthesia infusion was stopped after finishing the perineal stitch and was removed in two hours after delivery.\u003c/p\u003e\n\u003cp\u003eMaternal HR, NIBP and SpO2 as well as fetal heart rate were continuously monitored throughout the PIEB period. Each parturient woman was supervised by a specialized midwife, and observed by an anesthesia nurse at regular intervals. Common side effects such as nausea, somnolence, and pruritus were recorded by anesthesia nurses. The PIEB pump was administered by the parturient woman herself according to the instruction of the anesthesiologist. Parturient women received exogenous oxytocin to obtain an enhanced labor process when indicated. All fetal and maternal events, therapeutic interventions, outcome of labor, and Apgar score of newborns at 1 and 5 min, PPH, and the mode of delivery were recorded. The analgesia effect was evaluated by visual analog scale (VAS) and numerical rating scale (NRS). The VAS was assessed on a 10 cm horizontal line. The selected pregnant women were informed that the left end of the scale represents \u0026ldquo;no pain\u0026rdquo; and that the right end represents the \u0026ldquo;most severe pain imaginable\u0026rdquo;. Then, they were instructed to mark the intensity of pain they were currently experiencing. For the NRS，a 11-point scale was used, with \u0026ldquo;0\u0026rdquo; representing \u0026ldquo;no pain\u0026rdquo; and \u0026ldquo;10\u0026rdquo; representing the \u0026ldquo;most severe pain imaginable.\u0026rdquo; All pain assessments were performed by an anesthesiologist before and after NA. After delivery, a questionnaire survey on the satisfaction on the NA effect was carried out by scanning the code on WeChat.\u003c/p\u003e\n\u003cp\u003e1.6 Patient\u0026rsquo;s education\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u0026nbsp; All our patients were educated by obstetrician in prenatal examination and the brochure for NA were given to them. On working day, midwives conducted specialized classes about NA to teach them how to improve compliance during analgesia. Women undergoing vaginal delivery were evaluated by anesthesiologist and obstetrician to assess their desire for and suitability for NA once their cervical dilation was greater than 1 cm and all of them signed written informed consent for NA. Women undergoing vaginal delivery could also choose water immersion delivery once their cervical dilation was greater than 5 cm.\u003c/p\u003e\n\u003cp\u003e1.7 Data analysis\u003c/p\u003e\n\u003cp\u003eAll data were inputted into SPSS software (v.19.0, SPSS Inc, Chicago, IL, USA) for statistical analysis. The Pearson correlation was adopted to evaluate the relationship among observed rates during 12 months. Value r and their 95% CIs were calculated. Cochran- Armitage Trend Test was carried out to evaluate the change trend of observed rates. All statistical tests were performed with 2-sided \u003cem\u003eP\u003c/em\u003e values. If \u003cem\u003ep\u003c/em\u003e value＜0.05, the difference was considered statistically significant.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003e2.1 A total of 25,293 cases of parturient women were finally enrolled in our hospital from January 1st, 2015 to April 30th, 2016, of which 14,205 cases (56.2%) underwent vaginal delivery and 11,088 cases (43.8%) underwent CD. There were 19,196 (75.9%) nulliparous and 6,097(24.1%) parous, and the rate of parous remained unchanged over the 16-month study period according to Cochran- Armitage Trend Test (z=3.474, \u003cem\u003ep\u003c/em\u003e=0.062).\u003cstrong\u003e (Figure 2)\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;Among those 25.293 cases, there were 19464 cases undergoing delivery after the implement of NA. Among them, 3869 cases chose NA during labor, but 10 cases failed in epidural puncture 2 cases showed detachment of epidural catheter during labor, and 238 cases required intrapartum CD based on medical indications. Finally, there were 3619 cases undergoing vaginal delivery with NA including 41 cases of accidental dural punctures by redone with proper placement, and 7563 cases without NA, so the overall rate of NA in vaginal delivery was 32.4% (3619/11182). Among those 3619 cases, the average VAS and NRS before the use of NA was 9.2, and then dropped to 3.1 after effective analgesia, which indicates the pain was significantly eased (\u003cem\u003ep\u003c/em\u003e＜0.001). Those who chose NA were satisfied with the effect of analgesia according to the results of questionnaire survey.\u003c/p\u003e\n\u003cp\u003e2.2 The\u0026nbsp; rates of CD, MRCD, and NA in 16-month observation are shown in \u003cstrong\u003eFigure 3 and Table 1\u003c/strong\u003e. The results of Cochran- Armitage testing (\u003cstrong\u003eFigure 3\u003c/strong\u003e) indicates that CD and MRCD rates were stable during the first 5 month in 2015(z=3.080 and 1.114, \u003cem\u003ep\u003c/em\u003e=3.080 and 0.291＞0.05), but the rates of CD and MRCD significantly decreased from 50.4% in May 2015 to 36.3% in April 2016 (z=93.375, \u003cem\u003ep\u003c/em\u003e=0.000\u003cem\u003e\u0026lt;\u003c/em\u003e0.001), and from 10.8% in May 2015 to 5.7% in April 2016 (z=14.788, \u003cem\u003ep\u003c/em\u003e=0.000\u003cem\u003e\u0026lt;\u003c/em\u003e0.001), respectively. Similarly, the rate of NA increased from 26.1 % in May 2015 to 44.6% in April 2016(\u003cem\u003ep\u0026lt;\u003c/em\u003e0.001). Among the 16 months, there were a negative correlation between the rate of NA and rate of overall CD, r=-0.782 (95%CI[-0.948,-0.534], \u003cem\u003ep\u003c/em\u003e＜0.001), and between the utilization rate of NA and rate of MRCD, r=-0.914 (95%CI[-0.989,-0.766], \u003cem\u003ep\u003c/em\u003e＜0.001) .\u003c/p\u003e\n\u003cp\u003e2.3The change trend of episiotomy, operative vaginal delivery, PPH and neonatal asphyxia in women undergoing vaginal delivery\u003c/p\u003e\n\u003cp\u003eThe monthly rates of episiotomy, operative vaginal delivery, and PPH and neonatal asphyxia in women who undergoing vaginal delivery remained unchanged during the 16 months (4 months before and 12 months after the utilization of NA). Moreover, there was no correlation between NA and the rates of episiotomy, operative vaginal delivery, and PPH and neonatal asphyxia in women who underwent vaginal delivery(p＞0.05).\u003cstrong\u003e (Table 2, 3)\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e2.4 The change trend of intrapartum CD, PPH and neonatal asphyxia in women who underwent CD\u003c/p\u003e\n\u003cp\u003eFrom May 1st, 2015 to April 1st, 2016, there were 728 cases underwent intrapartum CD but only 8 cases underwent CD within the Labor \u0026amp; Delivery suite. From Table 4, 5, it can be found that the monthly rates of intrapartum CD, neonatal asphyxia and PPH in women undergoing CD remain unchanged during the 16 months of observation, and there was no correlation between the rate of NA and the rates of intrapartum CD, neonatal asphyxia, and PPH in women undergoing CD (\u003cem\u003ep\u003c/em\u003e\u0026gt;0.05).\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eAt present, the high CD rate is a social problem in China. However, there are few hospitals conventionally carrying out NA during delivery and labor to meet the needs of parturient women \u003csup\u003e[12]\u003c/sup\u003e. Many Chinese people think labor pain is normal which is difficult to be avoided for parturient women especially nulliparous, so some of them choose CD, especially MRCD. Under the policy of one-child family taking effect from 1979, \u0026nbsp;incorrect cognitions on delivery were prevalent in China, for example they thought the damage caused by episiotomy and that caused by CD were the same, CD might be less likely to affect the quality of sexual life than vaginal birth\u003csup\u003e[13]\u003c/sup\u003e, and giving birth by selecting a particular date may be more safe \u003csup\u003e[14]\u003c/sup\u003e. The relative medical indications of CD vary all over China, such as pregnancy with severe shortsightedness which is believed to cause retinal detachment during labor in certain extreme condition, pregnancy by assisted reproduction techniques, primipara more than 35 years old\u003csup\u003e [7,15,16]\u003c/sup\u003e. Most obstetric centers in China cannot meet the increasing requirements of pregnant women, such as lacking the company of family members especially husband, analgesia, or emotional support in labor\u003csup\u003e [3,4]\u003c/sup\u003e. In recent years, a few Chinese hospitals have started to control the unusually high CD rates with health education, painless delivery, doula delivery and psychological comforting and training programs for midwives and obstetricians\u003csup\u003e [17]\u003c/sup\u003e. In our birth center, with the help of NPLD program, NA has become available for women who request to relieve labor pain since May 1st, 2015.\u003c/p\u003e\n\u003cp\u003eThere were several reports in the US back in the 1990s about the effects of a sudden increase in neuraxial analgesia rate on cesarean delivery rates, with almost all of them showing no effect \u003csup\u003e[18, 19]\u003c/sup\u003e. NPLD is a nongovernment project aiming to help Chinese parturient women and their health care providers about the safe and effective use of NA\u003csup\u003e [7]\u003c/sup\u003e. According to the data collected from Shijiazhuang Obstetrics and Gynecology Hospital where the project was first introduced in 2008, the rate of overall CD decreased from 40.5% to 33.6% in the period when the rate of neuraxial labor analgesia increased from 0 to 33.5%\u003csup\u003e [20].\u003c/sup\u003e At the second Affiliated Hospital, Wenzhou Medical University, Wang Q found that as the labor epidural analgesia rate increased from 0 to 57%, the vaginal delivery rate increased, and cesarean delivery rate decreased by 3.5%, at the same time the rate of episiotomy and severe perineal injury were decreased \u003csup\u003e[21]\u003c/sup\u003e. Our results are in accordance with those observational studies on the use of NA with the help of NPLD\u003csup\u003e [7,20-21]\u003c/sup\u003e. In our study, before the implement of NA, the rates of overall CD and MRCD were stable and high from January 1st to May 30th 2015, but with the increase of usage of NA, both of them were dropped. At the early implementation stage of NPLD program, the rate of NA was the lowest (26.1%); while the rates of overall CD and MRCD were 50.36% and 10.76% in May 2015, respectively. As the rate of NA increased to 44.6% in April 2016, the rates of overall CD and MRCD decreased to 36.3% and 5.7% respectively. There was a negative correlation between the rate of NA with the rate of CD or MRCD, and there was a positive correlation between the rate of CD and that of MRCD. Our research was consistent with the other birth centers helped by NPLD in China, but inconsistent with that in the US back in 1990. The difference may be related to China\u0026rsquo;s family policy and the high rate of MRCD.\u003c/p\u003e\n\u003cp\u003eAfter implementing \u0026ldquo;one-child\u0026rdquo; policy for 30 years, the selective 2-child policy was announced in November 2013, which means that if one of the couples is the only child in her or his family, the couple will have the chance to have two children. China\u0026rsquo;s universal two- child policy was released in October of 2015\u003csup\u003e[22]\u003c/sup\u003e. These policies may have an impact on the overall CD rate in China. Liao et al \u003csup\u003e[23]\u003c/sup\u003e collected data from 6 hospitals in Hubei and Gansu province of China from 2013 to 2016 and found that the overall CD rate decreased from 45.1% during 1-child policy period to 40.4% during selective 2- child policy period, and further to 38.9% during universal 2- child policy period, which is consistent with the results of many other studies \u003csup\u003e[24, 25]\u003c/sup\u003e. Our study period was from May 1st 2015 to April 30th 2016, during which selective 2-child policy did not have a large influence on the overall CD rate. The monthly rate of parous from January 1\u003csup\u003est\u003c/sup\u003e 2015 to April 30\u003csup\u003eth\u003c/sup\u003e 2016 in our birth center was still around 24.1% (6097/25293), which was not affected by the following universal two- child policy. From those analyses, we believed that the decrease of overall CD rate was mainly related to initiation of labor analgesia services.\u003c/p\u003e\n\u003cp\u003eLabor pain is probably the most severe pain that most women will endure in their lifetime. A neuraxial approach is accepted as the gold standard for intrapartum labor analgesia\u003csup\u003e [26,27]\u003c/sup\u003e. The mixed drugs of ropivacaine and fentanyl administrated by PIEB pump is extremely safe and effective for labor delivery analgesia \u003csup\u003e[26-28]\u003c/sup\u003e. Our clinical trial demonstrated that the NA proposed by NPLD was effective, which reduced the delivery pain from average 9.2 to 3.1 according to VAS and NRS.\u003c/p\u003e\n\u003cp\u003eNA does not increase the risk of CD \u003csup\u003e[7, 29]\u003c/sup\u003e, but its impact on operative vaginal delivery and other parturient safety outcomes is still controversial\u003csup\u003e [30,31]\u003c/sup\u003e. Anwar S \u003csup\u003e[30] \u003c/sup\u003econducted a quasi-experimental study and found that epidural analgesia did prolong the duration of second stage of labor and increased the instrumental delivery rate (58% vs 12%). Wassen MM \u003csup\u003e[31]\u003c/sup\u003e found the rate of epidural tripled increased from 7.7% to 21.9% over a 10-years span while the rates of CD and operative vaginal delivery did not change too much in the Netherlands. Our study showed that with the increase of NA rate, the rates of operative vaginal delivery remained nearly unchanged. As we all well know that it is difficult to study the effect of epidural analgesia on operative vaginal delivery rates under preconditions that are not double-blind\u003csup\u003e [30,31]\u003c/sup\u003e. The reason why the instrumental delivery was increased may be probably due to that the presence of decent analgesia makes it much easier for obstetricians to apply forceps or vacuum\u003csup\u003e[30]\u003c/sup\u003e. In our birth center, the rate of instrumental delivery remained unchanged, which may be related to the low rate of instrumental delivery (1.6%, 234/14205) and still high rate of CD (43.8%, 11088/25293) among the 16 months, most of instrumental delivery were instead by CD. At the same time, the rates of episiotomy, and PPH and neonatal asphyxia of vaginal delivery, and intrapartum CD, PPH, neonatal asphyxia of CD remained nearly unchanged before and after the use of NA in our birth center.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStrengths and limitations of this study\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e1.The study shows the rate of NA, the rate of overall cesarean and the rate of MRCD in a large birth center of China with an annual capacity of 20,000newbornsbeing delivered.\u003c/p\u003e\n\u003cp\u003e2 The NPLD team helped to establish a neuraxial labor analgesia service in our hospital. The main limitation of this manuscript is that the findings are not so original that some other Chinese hospitals in conjunction with the NPLD program have reported similar results.\u003c/p\u003e\n\u003cp\u003e3.The data were selected from only one center, a tertiary- care teaching hospital in Hubei province, which cannot represent all hospitals from different geographical areas and in different levels in China.\u003c/p\u003e\n\u003cp\u003e4. The location of intrapartum CDs was moved to within the Labor \u0026amp; Delivery suite as part of the NPLD intervention, but there were only 8 cases underwent intrapartum CD within the Labor \u0026amp; Delivery suite to deal with maternal and fetal emergencies for extremely dangerous in our birth center, so it was difficult to analyze the relationship between the change in intrapartum CD and the location of CD(Labor \u0026amp; Delivery suite).\u003c/p\u003e\n\u003cp\u003e5.During the study period, China\u0026rsquo;s universal two-child policy was taking effect (2015.10), which may have some influence on the results.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eIn conclusion, initiation of a 24-hour labor analgesia services can relieve labor pain. Through a a16-month observation from May 1st 2015 to April 30th 2016, the rates of CD and MRCD were significantly reduced, which may be related to the increasing use of NA during delivery and labor by the help of NPLD.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eCD: cesarean delivery\u003c/p\u003e\n\u003cp\u003eVD: vaginal delivery\u003c/p\u003e\n\u003cp\u003eMRCD: maternal request cesarean delivery\u003c/p\u003e\n\u003cp\u003eNPLD: No Pain Labor ＆Delivery\u003c/p\u003e\n\u003cp\u003eNA: neuraxial labor analgesia\u003c/p\u003e\n\u003cp\u003ePPH: postpartum hemorrhage\u003c/p\u003e\n\u003cp\u003eVAS: visual analog scale\u003c/p\u003e\n\u003cp\u003eNRS: numerical rating scale\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e-\u003c/strong\u003e The study conformed to the guidelines explained in the Declaration of Helsinki and was approved by the ethics committee of Maternal and Child Health Hospital of Hubei Province (MCHHHP, Wuhan, China). A waiver for the requirement of informed consent from the patients whose records were analyzed was granted by the Chair of the Committee on the grounds of being a minimal risk study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e-Not applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e-Access to the qualitative data should be given upon request to the corresponding author after taking any necessary precautions to safeguard participants\u0026rsquo; privacy and confidentiality.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e-The authors declare that they have no competing interests\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e-This work was supported by the Foundation from Health and Family Planning Commission of Hubei Province (No: WJ2018H0133) and Key Projects of Natural Science Foundation in Hubei Province (No: 2019CFA033). Both of the foundations agreed to fund obstetric researcher for data analysis, English editing and other costs relating to dissemination of the study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; Contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e- YZ conceived the study, analyzed the data, interpreted the results, and drafted the manuscript. YG conceived the study, drafted the manuscript. GS, LY, YL analyzed the data and revised the manuscript. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors would like to thank NPLD team for their valuable assistance\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eTian X, Wu J, Li B, Qin M, Qi J. Occurrence of cesarean section and related factors in 40 counties of China from 1978 to 2010.Zhonghua Yu Fang Yi Xue Za Zhi. 2014; 48(5):391-5.(In Chinese). 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PMID:29506980\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://www.ncbi.nlm.nih.gov/pubmed/?term=Li%20HT%5BAuthor%5D\u0026amp;cauthor=true\u0026amp;cauthor_uid=28030701\"\u003eLi HT\u003c/a\u003e, \u003ca href=\"https://www.ncbi.nlm.nih.gov/pubmed/?term=Luo%20S%5BAuthor%5D\u0026amp;cauthor=true\u0026amp;cauthor_uid=28030701\"\u003eLuo S\u003c/a\u003e, \u003ca href=\"https://www.ncbi.nlm.nih.gov/pubmed/?term=Trasande%20L%5BAuthor%5D\u0026amp;cauthor=true\u0026amp;cauthor_uid=28030701\"\u003eTrasande L\u003c/a\u003e, \u003ca href=\"https://www.ncbi.nlm.nih.gov/pubmed/?term=Hellerstein%20S%5BAuthor%5D\u0026amp;cauthor=true\u0026amp;cauthor_uid=28030701\"\u003eHellerstein S\u003c/a\u003e, \u003ca href=\"https://www.ncbi.nlm.nih.gov/pubmed/?term=Kang%20C%5BAuthor%5D\u0026amp;cauthor=true\u0026amp;cauthor_uid=28030701\"\u003eKang C\u003c/a\u003e, \u003ca href=\"https://www.ncbi.nlm.nih.gov/pubmed/?term=Li%20JX%5BAuthor%5D\u0026amp;cauthor=true\u0026amp;cauthor_uid=28030701\"\u003eLi JX\u003c/a\u003e, et al. Geographic Variations and Temporal Trends in Cesarean Delivery Rates in China, 2008-2014. 2017; 317(1): 69-76. PMID:28030701\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://www.ncbi.nlm.nih.gov/pubmed/?term=Sia%20AT%5BAuthor%5D\u0026amp;cauthor=true\u0026amp;cauthor_uid=10566920\"\u003eSia AT\u003c/a\u003e,\u0026nbsp;\u003ca href=\"https://www.ncbi.nlm.nih.gov/pubmed/?term=Ruban%20P%5BAuthor%5D\u0026amp;cauthor=true\u0026amp;cauthor_uid=10566920\"\u003eRuban P\u003c/a\u003e,\u0026nbsp;\u003ca href=\"https://www.ncbi.nlm.nih.gov/pubmed/?term=Chong%20JL%5BAuthor%5D\u0026amp;cauthor=true\u0026amp;cauthor_uid=10566920\"\u003eChong JL\u003c/a\u003e,\u003ca href=\"https://www.ncbi.nlm.nih.gov/pubmed/?term=Wong%20K%5bAuthor%5d\u0026amp;cauthor=true\u0026amp;cauthor_uid=10566920\"\u003eWong K\u003c/a\u003e. Motor blockade is reduced with\u0026nbsp;ropiva\u0026nbsp;\u0026nbsp; caine\u0026nbsp;0.125% for parturient-controlled epidural analgesia during labour. \u003ca href=\"https://www.ncbi.nlm.nih.gov/pubmed/10566920\"\u003eCan J Anaesth.\u003c/a\u003e\u0026nbsp;1999; 46 (11):1019-23. PMID: 10566920\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://www.ncbi.nlm.nih.gov/pubmed/?term=Ahirwar%20A%5BAuthor%5D\u0026amp;cauthor=true\u0026amp;cauthor_uid=25302210\"\u003eAhirwar A\u003c/a\u003e,\u0026nbsp;\u003ca href=\"https://www.ncbi.nlm.nih.gov/pubmed/?term=Prakash%20R%5BAuthor%5D\u0026amp;cauthor=true\u0026amp;cauthor_uid=25302210\"\u003ePrakash R\u003c/a\u003e,\u0026nbsp;\u003ca href=\"https://www.ncbi.nlm.nih.gov/pubmed/?term=Kushwaha%20BB%5BAuthor%5D\u0026amp;cauthor=true\u0026amp;cauthor_uid=25302210\"\u003eKushwaha BB\u003c/a\u003e,\u0026nbsp;\u003ca href=\"https://www.ncbi.nlm.nih.gov/pubmed/?term=Gaurav%20A%5bAuthor%5d\u0026amp;cauthor=true\u0026amp;cauthor_uid=25302210\"\u003eGaurav A\u003c/a\u003e,\u0026nbsp;\u003ca href=\"https://www.ncbi.nlm.nih.gov/pubmed/?term=Chaudhary%20AK%5bAuthor%5d\u0026amp;cauthor=true\u0026amp;cauthor_uid=25302210\"\u003eChaudhary AK\u003c/a\u003e,\u0026nbsp;\u003ca href=\"https://www.ncbi.nlm.nih.gov/pubmed/?term=Verma%20R%5bAuthor%5d\u0026amp;cauthor=true\u0026amp;cauthor_uid=25302210\"\u003eVerma R\u003c/a\u003e, et al. Patient Controlled Epidural Labour Analgesia (PCEA): A Comparison Between\u0026nbsp;Ropivacaine,\u0026nbsp;Ropivacaine-Fentanyl and\u0026nbsp;Ropivacaine-Clonidine. \u003ca href=\"https://www.ncbi.nlm.nih.gov/pubmed/25302210\"\u003eJ Clin Diagn Res.\u003c/a\u003e\u0026nbsp;2014; 8 (8): GC09-13. PMID: 25302210\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://www.ncbi.nlm.nih.gov/pubmed/?term=Patkar%20CS%5BAuthor%5D\u0026amp;cauthor=true\u0026amp;cauthor_uid=25948908\"\u003ePatkar CS\u003c/a\u003e,\u0026nbsp;\u003ca href=\"https://www.ncbi.nlm.nih.gov/pubmed/?term=Vora%20K%5BAuthor%5D\u0026amp;cauthor=true\u0026amp;cauthor_uid=25948908\"\u003eVora K\u003c/a\u003e,\u0026nbsp;\u003ca href=\"https://www.ncbi.nlm.nih.gov/pubmed/?term=Patel%20H%5BAuthor%5D\u0026amp;cauthor=true\u0026amp;cauthor_uid=25948908\"\u003ePatel H\u003c/a\u003e,\u0026nbsp;\u003ca href=\"https://www.ncbi.nlm.nih.gov/pubmed/?term=Shah%20V%5BAuthor%5D\u0026amp;cauthor=true\u0026amp;cauthor_uid=25948908\"\u003eShah V\u003c/a\u003e,\u0026nbsp;\u003ca href=\"https://www.ncbi.nlm.nih.gov/pubmed/?term=Modi%20MP%5BAuthor%5D\u0026amp;cauthor=true\u0026amp;cauthor_uid=25948908\"\u003eModi MP\u003c/a\u003e,\u0026nbsp;\u003ca href=\"https://www.ncbi.nlm.nih.gov/pubmed/?term=Parikh%20G%5BAuthor%5D\u0026amp;cauthor=true\u0026amp;cauthor_uid=25948908\"\u003eParikh G\u003c/a\u003e. A comparison of continuous infusion and intermittent bolus administration of 0.1% ropivacaine with 0.0002%\u0026nbsp;fentanyl\u0026nbsp;for epidural labor\u0026nbsp;analgesia. \u003ca href=\"https://www.ncbi.nlm.nih.gov/pubmed/25948908\"\u003eJ Anaesthesiol Clin Pharmacol.\u003c/a\u003e\u0026nbsp;2015; 31 (2):234-8. PMID: 25948908\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://www.ncbi.nlm.nih.gov/pubmed/?term=Anim-Somuah%20M%5bAuthor%5d\u0026amp;cauthor=true\u0026amp;cauthor_uid=22161362\"\u003eAnim-Somuah M\u003c/a\u003e,\u003ca href=\"https://www.ncbi.nlm.nih.gov/pubmed/?term=Smyth%20RM%5bAuthor%5d\u0026amp;cauthor=true\u0026amp;cauthor_uid=22161362\"\u003eSmyth RM\u003c/a\u003e,\u0026nbsp;\u003ca href=\"https://www.ncbi.nlm.nih.gov/pubmed/?term=Jones%20L%5bAuthor%5d\u0026amp;cauthor=true\u0026amp;cauthor_uid=22161362\"\u003eJones L\u003c/a\u003e.Epidural versus non-epidural or no analgesia in labour. \u003ca href=\"https://www.ncbi.nlm.nih.gov/pubmed/?term=22161362\"\u003eCochrane Database Syst Rev.\u003c/a\u003e\u0026nbsp;2011;7;(12): CD000331.PMID: 22161362\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://www.ncbi.nlm.nih.gov/pubmed/?term=Anwar%20S%5BAuthor%5D\u0026amp;cauthor=true\u0026amp;cauthor_uid=26182762\"\u003eAnwar S\u003c/a\u003e,\u0026nbsp;\u003ca href=\"https://www.ncbi.nlm.nih.gov/pubmed/?term=Anwar%20MW%5BAuthor%5D\u0026amp;cauthor=true\u0026amp;cauthor_uid=26182762\"\u003eAnwar MW\u003c/a\u003e,\u0026nbsp;\u003ca href=\"https://www.ncbi.nlm.nih.gov/pubmed/?term=Ahmad%20S%5BAuthor%5D\u0026amp;cauthor=true\u0026amp;cauthor_uid=26182762\"\u003eAhmad S\u003c/a\u003e. Effect of epidural analgesia on labor and its outcomes. \u003ca href=\"https://www.ncbi.nlm.nih.gov/pubmed/26182762\"\u003eJ Ayub Med Coll Abbottabad.\u003c/a\u003e2015; 27(1):146-50. PMID 26182762\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://www.ncbi.nlm.nih.gov/pubmed/?term=Wassen%20MM%5BAuthor%5D\u0026amp;cauthor=true\u0026amp;cauthor_uid=25461365\"\u003eWassen MM\u003c/a\u003e,\u0026nbsp;\u003ca href=\"https://www.ncbi.nlm.nih.gov/pubmed/?term=Hukkelhoven%20CW%5BAuthor%5D\u0026amp;cauthor=true\u0026amp;cauthor_uid=25461365\"\u003eHukkelhoven CW\u003c/a\u003e,\u0026nbsp;\u003ca href=\"https://www.ncbi.nlm.nih.gov/pubmed/?term=Scheepers%20HC%5BAuthor%5D\u0026amp;cauthor=true\u0026amp;cauthor_uid=25461365\"\u003eScheepers HC\u003c/a\u003e,\u0026nbsp;\u003ca href=\"https://www.ncbi.nlm.nih.gov/pubmed/?term=Smits%20LJ%5bAuthor%5d\u0026amp;cauthor=true\u0026amp;cauthor_uid=25461365\"\u003eSmits LJ\u003c/a\u003e,\u0026nbsp;\u003ca href=\"https://www.ncbi.nlm.nih.gov/pubmed/?term=Nijhuis%20JG%5bAuthor%5d\u0026amp;cauthor=true\u0026amp;cauthor_uid=25461365\"\u003eNijhuis JG\u003c/a\u003e,\u0026nbsp;\u003ca href=\"https://www.ncbi.nlm.nih.gov/pubmed/?term=Roumen%20FJ%5bAuthor%5d\u0026amp;cauthor=true\u0026amp;cauthor_uid=25461365\"\u003eRoumen FJ\u003c/a\u003e. Epidural\u0026nbsp;analgesia\u0026nbsp;and\u0026nbsp;operative\u0026nbsp;delivery: a ten-year population-based cohort study in The Netherlands. \u003ca href=\"https://www.ncbi.nlm.nih.gov/pubmed/25461365\"\u003eEur J Obstet Gynecol Reprod Biol.\u003c/a\u003e\u0026nbsp;2014;183: 125-31. PMID 25461365\u003c/li\u003e\n\u003c/ol\u003e\n"},{"header":"Tables","content":"\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 1: The relationships between the rate of NA and that of CD and MRCD during 16 months\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" width=\"599\"\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd width=\"72\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"72\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"72\"\u003e\n\u003cp\u003eRate of CD\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"160\"\u003e\n\u003cp\u003e(95%CI)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"72\"\u003e\n\u003cp\u003eRate of MRCD\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"151\"\u003e\n\u003cp\u003e(95%CI)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"0\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd rowspan=\"3\" width=\"72\"\u003e\n\u003cp\u003eRate of NA\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd rowspan=\"2\" width=\"72\"\u003e\n\u003cp\u003er\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd rowspan=\"2\" width=\"72\"\u003e\n\u003cp\u003e-0.782\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd rowspan=\"2\" width=\"160\"\u003e\n\u003cp\u003e(-0.948 to -0.534)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd rowspan=\"2\" width=\"72\"\u003e\n\u003cp\u003e-0.914\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd rowspan=\"2\" width=\"151\"\u003e\n\u003cp\u003e(-0.989 to -0.766)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"0\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"72\"\u003e\n\u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" width=\"232\"\u003e\n\u003cp\u003e＜0.001\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" width=\"223\"\u003e\n\u003cp\u003e＜0.001\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"0\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eNA: neuraxial labor analgesia\u003c/p\u003e\n\u003cp\u003eCD: cesarean delivery\u003c/p\u003e\n\u003cp\u003eMRCD: maternal request cesarean delivery\u003c/p\u003e\n\u003cp\u003eThe Pearson correlation was used\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2: The rates of NA, neonatal asphyxia, EP, ODV, PPH in vaginal delivery \u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" width=\"936\"\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd width=\"114\"\u003e\n\u003cp\u003eRate\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"46\"\u003e\n\u003cp\u003eJan-15\u003c/p\u003e\n\u003cp\u003e%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"49\"\u003e\n\u003cp\u003eFeb-15\u003c/p\u003e\n\u003cp\u003e%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"49\"\u003e\n\u003cp\u003eMar-15\u003c/p\u003e\n\u003cp\u003e%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"49\"\u003e\n\u003cp\u003eApr-15\u003c/p\u003e\n\u003cp\u003e%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"49\"\u003e\n\u003cp\u003eMay-15\u003c/p\u003e\n\u003cp\u003e%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"40\"\u003e\n\u003cp\u003eJun-15\u003c/p\u003e\n\u003cp\u003e%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"39\"\u003e\n\u003cp\u003eJul-15\u003c/p\u003e\n\u003cp\u003e%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"45\"\u003e\n\u003cp\u003eAug-15\u003c/p\u003e\n\u003cp\u003e%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"40\"\u003e\n\u003cp\u003eSep-15%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"42\"\u003e\n\u003cp\u003eOct-15\u003c/p\u003e\n\u003cp\u003e%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"45\"\u003e\n\u003cp\u003eNov-15\u003c/p\u003e\n\u003cp\u003e%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"47\"\u003e\n\u003cp\u003eDec-15\u003c/p\u003e\n\u003cp\u003e%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"43\"\u003e\n\u003cp\u003eJan-16\u003c/p\u003e\n\u003cp\u003e%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"45\"\u003e\n\u003cp\u003eFeb-16\u003c/p\u003e\n\u003cp\u003e%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"47\"\u003e\n\u003cp\u003eMar-16\u003c/p\u003e\n\u003cp\u003e%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"44\"\u003e\n\u003cp\u003eApr-16\u003c/p\u003e\n\u003cp\u003e%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"50\"\u003e\n\u003cp\u003eX\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"50\"\u003e\n\u003cp\u003e\u003cem\u003ep\u003c/em\u003e-valua\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"114\"\u003e\n\u003cp\u003eNA\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"46\"\u003e\n\u003cp\u003e0\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"49\"\u003e\n\u003cp\u003e0\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"49\"\u003e\n\u003cp\u003e0\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"49\"\u003e\n\u003cp\u003e0\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"49\"\u003e\n\u003cp\u003e26.1\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"40\"\u003e\n\u003cp\u003e26.5\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"39\"\u003e\n\u003cp\u003e26.2\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"45\"\u003e\n\u003cp\u003e31.6\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"40\"\u003e\n\u003cp\u003e30.8\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"42\"\u003e\n\u003cp\u003e28.8\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"45\"\u003e\n\u003cp\u003e29.6\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"47\"\u003e\n\u003cp\u003e27.2\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"43\"\u003e\n\u003cp\u003e32.7\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"45\"\u003e\n\u003cp\u003e34.3\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"47\"\u003e\n\u003cp\u003e44.1\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"44\"\u003e\n\u003cp\u003e44.6\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"50\"\u003e\n\u003cp\u003e71.295\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"50\"\u003e\n\u003cp\u003e＜0.001\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"114\"\u003e\n\u003cp\u003eneonatal asphyxia\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"46\"\u003e\n\u003cp\u003e1.4\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"49\"\u003e\n\u003cp\u003e1.3\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"49\"\u003e\n\u003cp\u003e1.2\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"49\"\u003e\n\u003cp\u003e1.3\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"49\"\u003e\n\u003cp\u003e1.3\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"40\"\u003e\n\u003cp\u003e1.3\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"39\"\u003e\n\u003cp\u003e1.3\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"45\"\u003e\n\u003cp\u003e1.2\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"40\"\u003e\n\u003cp\u003e1.0\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"42\"\u003e\n\u003cp\u003e1.4\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"45\"\u003e\n\u003cp\u003e1.0\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"47\"\u003e\n\u003cp\u003e1.1\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"43\"\u003e\n\u003cp\u003e1.3\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"45\"\u003e\n\u003cp\u003e1.1\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"47\"\u003e\n\u003cp\u003e1.1\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"44\"\u003e\n\u003cp\u003e1.3\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"50\"\u003e\n\u003cp\u003e0.705\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"50\"\u003e\n\u003cp\u003e0.401\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"114\"\u003e\n\u003cp\u003eEP\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"46\"\u003e\n\u003cp\u003e45.2\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"49\"\u003e\n\u003cp\u003e56.8\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"49\"\u003e\n\u003cp\u003e57.0\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"49\"\u003e\n\u003cp\u003e56.4\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"49\"\u003e\n\u003cp\u003e65.4\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"40\"\u003e\n\u003cp\u003e63.9\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"39\"\u003e\n\u003cp\u003e54.7\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"45\"\u003e\n\u003cp\u003e50.6\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"40\"\u003e\n\u003cp\u003e55.7\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"42\"\u003e\n\u003cp\u003e46.6\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"45\"\u003e\n\u003cp\u003e49.8\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"47\"\u003e\n\u003cp\u003e61.9\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"43\"\u003e\n\u003cp\u003e56.2\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"45\"\u003e\n\u003cp\u003e51.7\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"47\"\u003e\n\u003cp\u003e50.2\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"44\"\u003e\n\u003cp\u003e56.1\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"50\"\u003e\n\u003cp\u003e2.786\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"50\"\u003e\n\u003cp\u003e0.095\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"114\"\u003e\n\u003cp\u003eODV\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"46\"\u003e\n\u003cp\u003e0.6\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"49\"\u003e\n\u003cp\u003e1.7\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"49\"\u003e\n\u003cp\u003e0.7\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"49\"\u003e\n\u003cp\u003e1.3\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"49\"\u003e\n\u003cp\u003e4.0\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"40\"\u003e\n\u003cp\u003e1.8\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"39\"\u003e\n\u003cp\u003e1.4\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"45\"\u003e\n\u003cp\u003e3.5\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"40\"\u003e\n\u003cp\u003e2.0\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"42\"\u003e\n\u003cp\u003e2.1\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"45\"\u003e\n\u003cp\u003e2.2\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"47\"\u003e\n\u003cp\u003e1.3\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"43\"\u003e\n\u003cp\u003e1.2\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"45\"\u003e\n\u003cp\u003e0.7\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"47\"\u003e\n\u003cp\u003e1.2\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"44\"\u003e\n\u003cp\u003e0.9\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"50\"\u003e\n\u003cp\u003e2.722\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"50\"\u003e\n\u003cp\u003e0.099\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"114\"\u003e\n\u003cp\u003ePPH\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"46\"\u003e\n\u003cp\u003e2.6\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"49\"\u003e\n\u003cp\u003e3.4\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"49\"\u003e\n\u003cp\u003e5.0\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"49\"\u003e\n\u003cp\u003e5.0\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"49\"\u003e\n\u003cp\u003e4.6\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"40\"\u003e\n\u003cp\u003e4.0\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"39\"\u003e\n\u003cp\u003e3.4\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"45\"\u003e\n\u003cp\u003e3.5\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"40\"\u003e\n\u003cp\u003e6.0\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"42\"\u003e\n\u003cp\u003e3.4\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"45\"\u003e\n\u003cp\u003e3.5\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"47\"\u003e\n\u003cp\u003e3.9\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"43\"\u003e\n\u003cp\u003e3.7\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"45\"\u003e\n\u003cp\u003e3.5\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"47\"\u003e\n\u003cp\u003e3.8\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"44\"\u003e\n\u003cp\u003e3.0\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"50\"\u003e\n\u003cp\u003e1.081\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"50\"\u003e\n\u003cp\u003e0.299\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eNA: neuraxial labor analgesia;\u003c/p\u003e\n\u003cp\u003eEP: episiotomy\u003c/p\u003e\n\u003cp\u003eODV: operation vaginal delivery (including forceps, vacuum and breech extraction)\u003c/p\u003e\n\u003cp\u003ePPH: postpartum hemorrhage\u003c/p\u003e\n\u003cp\u003eCochran- Armitage Trend Test was used:\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 3: The relationships between the rate of NA and that of neonatal asphyxia, EP, ODV, PPH in vaginal delivery women\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\"\u003e\n\u003ctbody\u003e\n\u003ctr style=\"height: 48px;\"\u003e\n\u003ctd style=\"height: 48px;\" width=\"98\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"height: 48px;\" width=\"78\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"height: 48px;\" width=\"116\"\u003e\n\u003cp\u003eRate of neonatal asphyxia\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"height: 48px;\" width=\"110\"\u003e\n\u003cp\u003e(95%CI)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"height: 48px;\" width=\"67\"\u003e\n\u003cp\u003eRate of EP\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"height: 48px;\" width=\"99\"\u003e\n\u003cp\u003e(95%CI)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"height: 48px;\" width=\"54\"\u003e\n\u003cp\u003eRate of ODV\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"height: 48px;\" width=\"94\"\u003e\n\u003cp\u003e(95%CI)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"height: 48px;\" width=\"55\"\u003e\n\u003cp\u003eRate of PPH\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"height: 48px;\" width=\"104\"\u003e\n\u003cp\u003e(95%CI)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr style=\"height: 48px;\"\u003e\n\u003ctd style=\"height: 48px;\" width=\"98\"\u003e\n\u003cp\u003eRate of NA\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"height: 48px;\" width=\"78\"\u003e\n\u003cp\u003er\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"height: 48px;\" width=\"116\"\u003e\n\u003cp\u003e-0.369\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"height: 48px;\" width=\"110\"\u003e\n\u003cp\u003e(-0.670 to 0.000)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"height: 48px;\" width=\"67\"\u003e\n\u003cp\u003e-0.017\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"height: 48px;\" width=\"99\"\u003e\n\u003cp\u003e(-0.483 to 0.391)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"height: 48px;\" width=\"54\"\u003e\n\u003cp\u003e0.195\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"height: 48px;\" width=\"94\"\u003e\n\u003cp\u003e(-0.239 to 0.570)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"height: 48px;\" width=\"55\"\u003e\n\u003cp\u003e-0.147\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"height: 48px;\" width=\"104\"\u003e\n\u003cp\u003e(-0.783 to 0.445)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr style=\"height: 35px;\"\u003e\n\u003ctd style=\"height: 35px;\" width=\"98\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"height: 35px;\" width=\"78\"\u003e\n\u003cp\u003e\u003cem\u003ep\u003c/em\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"height: 35px;\" width=\"116\"\u003e\n\u003cp\u003e0.159\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"height: 35px;\" width=\"110\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"height: 35px;\" width=\"67\"\u003e\n\u003cp\u003e0.951\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"height: 35px;\" width=\"99\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"height: 35px;\" width=\"54\"\u003e\n\u003cp\u003e0.470\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"height: 35px;\" width=\"94\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"height: 35px;\" width=\"55\"\u003e\n\u003cp\u003e0.587\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"height: 35px;\" width=\"104\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eNA: neuraxial labor analgesia;\u003c/p\u003e\n\u003cp\u003eEP: episiotomy\u003c/p\u003e\n\u003cp\u003eODV: operation vaginal delivery (including forceps, vacuum and breech extraction)\u003c/p\u003e\n\u003cp\u003ePPH: postpartum hemorrhage\u003c/p\u003e\n\u003cp\u003eThe Pearson correlation was used\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 4: The rates of intrapartum CD, neonatal asphyxia, PPH in CD women \u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" width=\"941\"\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd width=\"112\"\u003e\n\u003cp\u003eRate\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"49\"\u003e\n\u003cp\u003eJan-15\u003c/p\u003e\n\u003cp\u003e%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"49\"\u003e\n\u003cp\u003eFeb-15\u003c/p\u003e\n\u003cp\u003e%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"49\"\u003e\n\u003cp\u003eMar-15\u003c/p\u003e\n\u003cp\u003e%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"49\"\u003e\n\u003cp\u003eApr-15\u003c/p\u003e\n\u003cp\u003e%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"49\"\u003e\n\u003cp\u003eMay-15\u003c/p\u003e\n\u003cp\u003e%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"41\"\u003e\n\u003cp\u003eJun-15\u003c/p\u003e\n\u003cp\u003e%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"39\"\u003e\n\u003cp\u003eJul-15\u003c/p\u003e\n\u003cp\u003e%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"46\"\u003e\n\u003cp\u003eAug-15\u003c/p\u003e\n\u003cp\u003e%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"41\"\u003e\n\u003cp\u003eSep-15\u003c/p\u003e\n\u003cp\u003e%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"42\"\u003e\n\u003cp\u003eOct-15\u003c/p\u003e\n\u003cp\u003e%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"46\"\u003e\n\u003cp\u003eNov-15\u003c/p\u003e\n\u003cp\u003e%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"47\"\u003e\n\u003cp\u003eDec-15\u003c/p\u003e\n\u003cp\u003e%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"43\"\u003e\n\u003cp\u003eJan-16\u003c/p\u003e\n\u003cp\u003e%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"46\"\u003e\n\u003cp\u003eFeb-16\u003c/p\u003e\n\u003cp\u003e%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"47\"\u003e\n\u003cp\u003eMar-16\u003c/p\u003e\n\u003cp\u003e%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"44\"\u003e\n\u003cp\u003eApr-16\u003c/p\u003e\n\u003cp\u003e%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"51\"\u003e\n\u003cp\u003eX\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"51\"\u003e\n\u003cp\u003e\u003cem\u003ep\u003c/em\u003e-valua\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"112\"\u003e\n\u003cp\u003eIntrapartum CD\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"49\"\u003e\n\u003cp\u003e9.2\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"49\"\u003e\n\u003cp\u003e8.4\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"49\"\u003e\n\u003cp\u003e8.4\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"49\"\u003e\n\u003cp\u003e8.2\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"49\"\u003e\n\u003cp\u003e7.8\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"41\"\u003e\n\u003cp\u003e8.0\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"39\"\u003e\n\u003cp\u003e8.7\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"46\"\u003e\n\u003cp\u003e8.6\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"41\"\u003e\n\u003cp\u003e9.1\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"42\"\u003e\n\u003cp\u003e9.5\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"46\"\u003e\n\u003cp\u003e8.3\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"47\"\u003e\n\u003cp\u003e10.2\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"43\"\u003e\n\u003cp\u003e8.6\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"46\"\u003e\n\u003cp\u003e9.6\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"47\"\u003e\n\u003cp\u003e9.1\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"44\"\u003e\n\u003cp\u003e8.4\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"51\"\u003e\n\u003cp\u003e0.415\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"51\"\u003e\n\u003cp\u003e0.519\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"112\"\u003e\n\u003cp\u003eNeonatal asphyxia\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"49\"\u003e\n\u003cp\u003e1.2\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"49\"\u003e\n\u003cp\u003e1.1\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"49\"\u003e\n\u003cp\u003e1.1\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"49\"\u003e\n\u003cp\u003e1.2\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"49\"\u003e\n\u003cp\u003e1.0\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"41\"\u003e\n\u003cp\u003e1.2\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"39\"\u003e\n\u003cp\u003e1.1\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"46\"\u003e\n\u003cp\u003e1.5\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"41\"\u003e\n\u003cp\u003e0.9\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"42\"\u003e\n\u003cp\u003e1.2\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"46\"\u003e\n\u003cp\u003e1.3\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"47\"\u003e\n\u003cp\u003e1.6\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"43\"\u003e\n\u003cp\u003e1.9\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"46\"\u003e\n\u003cp\u003e1.4\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"47\"\u003e\n\u003cp\u003e1.3\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"44\"\u003e\n\u003cp\u003e1.6\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"51\"\u003e\n\u003cp\u003e2.265\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"51\"\u003e\n\u003cp\u003e0.132\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"112\"\u003e\n\u003cp\u003ePPH\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"49\"\u003e\n\u003cp\u003e3.9\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"49\"\u003e\n\u003cp\u003e4.2\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"49\"\u003e\n\u003cp\u003e3.9\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"49\"\u003e\n\u003cp\u003e4.1\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"49\"\u003e\n\u003cp\u003e3.6\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"41\"\u003e\n\u003cp\u003e3.6\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"39\"\u003e\n\u003cp\u003e2.7\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"46\"\u003e\n\u003cp\u003e2.6\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"41\"\u003e\n\u003cp\u003e3.6\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"42\"\u003e\n\u003cp\u003e4.0\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"46\"\u003e\n\u003cp\u003e2.8\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"47\"\u003e\n\u003cp\u003e4.2\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"43\"\u003e\n\u003cp\u003e4.7\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"46\"\u003e\n\u003cp\u003e3.8\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"47\"\u003e\n\u003cp\u003e2.7\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"44\"\u003e\n\u003cp\u003e2.8\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"51\"\u003e\n\u003cp\u003e0.618\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"51\"\u003e\n\u003cp\u003e0.432\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eCD: cesarean delivery\u003c/p\u003e\n\u003cp\u003ePPH: postpartum hemorrhage\u003c/p\u003e\n\u003cp\u003eCochran- Armitage Trend Test was used\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 5: The relationships between the rate of NA and that of intrapartum CD, neonatal asphyxia, PPH in CD women\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\"\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd width=\"78\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"62\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"82\"\u003e\n\u003cp\u003eRate of intrapartum CD\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"78\"\u003e\n\u003cp\u003e(95%CI)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"73\"\u003e\n\u003cp\u003eRate of neonatal asphyxia\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"79\"\u003e\n\u003cp\u003e(95%CI)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"44\"\u003e\n\u003cp\u003eRate of PPH\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"83\"\u003e\n\u003cp\u003e(95%CI)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"78\"\u003e\n\u003cp\u003eRate of NA\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"62\"\u003e\n\u003cp\u003er\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"82\"\u003e\n\u003cp\u003e0.198\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"78\"\u003e\n\u003cp\u003e(-0.194 to 0.555)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"73\"\u003e\n\u003cp\u003e0.419\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"79\"\u003e\n\u003cp\u003e(0.121 to 0.684)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"44\"\u003e\n\u003cp\u003e-0.494\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"83\"\u003e\n\u003cp\u003e(-0.795 to -0.120)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"78\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"62\"\u003e\n\u003cp\u003e\u003cem\u003ep\u003c/em\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"82\"\u003e\n\u003cp\u003e0.461\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"78\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"73\"\u003e\n\u003cp\u003e0.106\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"79\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"44\"\u003e\n\u003cp\u003e0.052\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"83\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eNA: neuraxial labor analgesia;\u003c/p\u003e\n\u003cp\u003eCD: cesarean delivery\u003c/p\u003e\n\u003cp\u003ePPH: postpartum hemorrhage\u003c/p\u003e\n\u003cp\u003eThe Pearson correlation was used\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-pregnancy-and-childbirth","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"prch","sideBox":"Learn more about [BMC Pregnancy and Childbirth](http://bmcpregnancychildbirth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/prch/default.aspx","title":"BMC Pregnancy and Childbirth","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Neuraxial Labor Analgesia, Cesarean Delivery, Maternal Request Cesarean Delivery","lastPublishedDoi":"10.21203/rs.2.13558/v4","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.2.13558/v4","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u0026nbsp;\u003c/strong\u003eNo Pain Labor ＆Delivery (NPLD) is a nongovernmental project to increase access to safe neuraxial analgesia through specialized training. This study explores the change in overall cesarean delivery (CD) rate and maternal request CD(MRCD) rate in our hospital after the initiation of neuraxial analgesia service (NA). \u003c/p\u003e\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e NA was initiated in May 1st 2015 by the help of NPLD. Since then, the application of NA became a routine operation in our hospital, and every parturient can choose to use NA or not. The monthly rates of NA, CD, MRCD, multiparous women, intrapartum CD, episiotomy, postpartum hemorrhage (PPH), operative vaginal delivery and neonatal asphyxia were analyzed from January 2015 to April 2016. \u003c/p\u003e\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e The rate of NA in our hospital was getting increasingly higher from 26.1% in May 2015 to 44.6% in April 2016\u0026nbsp;(\u003cem\u003ep\u0026lt;\u003c/em\u003e0.001); the rate of CD was 48.1% (3577/7360) and stable from January to May 2015 (\u003cem\u003ep\u003c/em\u003e＞0.05), then decreased from 50.4% in May 2015 to 36.3% in April 2016 ( \u003cem\u003ep\u0026lt;\u003c/em\u003e0.001); the rate of MRCD was 11.4% (406/3577) and also stable from January to May 2015 (\u003cem\u003ep\u003c/em\u003e＞0.05), then decreased from 10.8% in May 2015 to 5.7% in April 2016 (\u003cem\u003ep\u0026lt;\u003c/em\u003e0.001). At the same time, the rate of multiparous women remained unchanged during the 16 month of observation (\u003cem\u003ep\u003c/em\u003e＞0.05). There was a negative correlation between the rate of NA and rate of overall CD, r=-0.782 (95%CI [-0.948, -0.534], \u003cem\u003ep\u003c/em\u003e＜0.001), and between the utilization rate of NA and rate of MRCD, r=-0.914 (95%CI [-0.989, -0.766], \u003cem\u003ep\u003c/em\u003e＜0.001). The rates of episiotomy, PPH, operative vaginal delivery and neonatal asphyxia in women who underwent vaginal delivery as well as the rates of intrapartum CD, neonatal asphyxia, and PPH in women who underwent CD remained unchanged, and there was no correlation between the rate of NA and anyone of those rates from January 1st 2015 to April 30th 2016 (\u003cem\u003ep\u003c/em\u003e＞0.05). \u003c/p\u003e\u003cp\u003e\u003cstrong\u003eConclusions:\u003c/strong\u003e Our study shows that the rates of CD and MRCD in our department were significantly decreased from May 1st 2015 to April 30th 2016, which may be due to the increasing use of NA during vaginal delivery with the help of NPLD.\u0026nbsp;\u003c/p\u003e","manuscriptTitle":"The effect of initiating neuraxial analgesia service on the rate of cesarean delivery in Hubei, China: A 16-month retrospective study","msid":"","msnumber":"","nonDraftVersions":[{"code":4,"date":"2020-10-05 23:31:17","doi":"10.21203/rs.2.13558/v4","editorialEvents":[{"type":"communityComments","content":0},{"type":"checksComplete","content":"","date":"2020-09-29T12:00:00+00:00","index":"","fulltext":""},{"type":"decision","content":"Accept","date":"2020-09-28T12:00:00+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-pregnancy-and-childbirth","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"prch","sideBox":"Learn more about [BMC Pregnancy and Childbirth](http://bmcpregnancychildbirth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/prch/default.aspx","title":"BMC Pregnancy and Childbirth","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}},{"code":3,"date":"2020-08-11 14:32:44","doi":"10.21203/rs.2.13558/v3","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Minor revision","date":"2020-09-23T12:00:00+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2020-09-14T12:00:00+00:00","index":1,"fulltext":"Recommendation: Accept after discretionary revisions\nForm responses:\n---\n\nComments to Author:\n---\nThis is the second revision of a neuraxial(epidural) analgesia service in a large obstetric hospital in Hubei, China, and its effect on cesarean delivery rates, which was to decrease the cesarean delivery rate.\n\nThe authors have responded to many of my (and other reviewers) comments.\n\n1. In response to my concern that had no data from before the intervention to show that the CD rate (and other outcomes) were stable before the initiation of a labor analgesia service, they have added data from the 4 months BEFORE the NPLD program, started to increase the labor analgesia rate. While this data was not originally intended to be part of the study period, so its inclusion can technically be criticized, I think it helps the \"story\" they are telling by showing a stable CD rate before the beginning of the actual \"intervention.\" Since all of this data is retrospectively gathered, adding another 4 months of data collection should not bias the outcomes/data/conclusions very much. This is major improemnet to their report in my opinion\n\n2. Abstract: Now that the Jan-May 2015 time period is included in the retrospective analysis, the CD rate form Jan-May should be included here (presumably it was around 50%). Other rates from this \"pre-intervention\" time period should also be reported (NA rate was zero or close, MRCD was probably higher than in the post-intervention period).\n\n3. The authors did not respond to my question about whether the LOCATION of CDs could have affected the outcome. This location was moved to within the L\u0026D suite as part of the NPLD intervention. It seems that the decrease in CD rate must have been a combination of decreased maternal request and decreased \"medical indicated\" elective CD, with no change in intrapartum CD, the type most likely to be affected by location of CD within the unit. Still, if there is another revision, a comment in the Discussion might make sense.\n\n4. The PCEA recipe was clarified as I requested. If I understand correctly now, patients received 10 ml of the ropivacaine/fentanyl every 2 hours. And could get additional 10 ml boluses every 15 minutes by pushing the PCEA button. Since there is no infusion, but only boluses programmed and patient-requested, this would probably be referred to in the US as \"PIEB\" (programmed intermittent epidural bolus) rather than PCEA, but this is not a critical issue.\n\n5. The English is also much improved. I have several suggestions that could improve the language if another revision is done but all are minor, and none are important for understanding the paper.\n\n6. Line 30: I would insert the word \"service\" between \"(NA)\" and \"was initiated\"\n\n7. Line 51: change \"by\" to \"with\"\n\n8. Line 78: cut \"A\" and start sentence with \"Neuraxial analgesia for labor is a safe…\"\n\n9. Line 83-85: would change to \"was proposed by Ling Hu, an anesthesiologist at Northwestern University Feinberg School of Medicine…\"\n\n10. Line 91: \"retrospective study based at a large birth center\". I would suggest changing \"big\" to \"large\" everywhere in the manuscript that the center is referred to.\n\n11. Line 102: cut \"a\" before \"retrospective\"\n\n12. Line 107-109: If there were only 10 in the group, and the authors have listed 7 different types of participants, it seems that they should not all be plural. Probably there was one anesthesiologist, one neonatologist, maybe two obstetricians, etc. Not critical, but could be clearer.\n\n13. Line 134-135: should be \"12 members from America\". (The words \"12 members\" are repeated, and then it says \"American\")\n\n14. Line 140: I think they mean to say something like \"to deal with maternal and fetal emergencies.\"\n\n15. Line 146: would add \"the most\" between \"\"in\" and \"recent\"\n\n16. Line 151: change \"data\" to \"dataset\". Or cut the word \"a complete data of\" and simply write \"Therefore, 25,293 cases…\"\n\n17. Line 177: 18G catheter, or was it a catheter placed via an 18G needle? (which seems more likely (we use a 20G catheter via a 17G needle)\n\n18. Line 183:would change \"mixed drugs\" to \"drug mixture\"\n\n19. Line 185: would change \"mixed drugs\" to the drug mixture\"\n\n20. Line 186: would change \"presses\" to \"doses\"\n\n21. Line 191: add \"an\" between \"by\" and \"anesthesia nurse\"\n\n22. Line 194: add \"the\" before \"anesthesiologist\"\n\n23. Line 195: replace \"they need\" with \"indicated\"\n\n24. Line 196\" \"newborn\" can be one word\n\n25. Line 230-233: were there NO accidental dural punctures (\"wet taps\")? Or was the procedure redone with proper placement so these patients were included in the study?\n\n26. Line 285: change to \"back in the 1990s about the effects…\"\n\n27. Line 306: change to \"other birth centers\"\n\n28. Line 319: change \"make big\" to \"have a large\"\n\n29. Line 343: I am not sure I understand what is being said here. Is it that you do not expect the availability and presence of labor analgesia to increase the operative vaginal delivery rate because your obstetricians are experienced? This was the case in many studies published where labor analgesia was supposed to increase the forceps or vacuum rate, and t does seem that in many circumstances, the fact that women will \"tolerate\" the placement of forceps does increase their use.\n\n\n* Publons Reviewer Recognition. Springer Nature can send verification of this review directly to Publons (a subsidiary of Clarivate Analytics). If you would like to take advantage of this service, please click on the “Yes” option below. Your name, email address, title of the reviewed manuscript, name of the journal, and date of your review submission (the “Review Data”) will then be transmitted to Publons upon publication of the manuscript. If you have already registered at Publons, they will notify you of the receipt of this review and update your profile as per your settings and their policy. If you are not registered with Publons, you will receive an email from them asking you to register in order for them to be able to recognize your review on your new profile page. Publons may use the Review Data to generate derivative metadata for the benefit of Publons and you as a reviewer, carefully considering the sensitivity of such information. For example, Publons may verify your record as a reviewer by updating your profile published on its webservice if you have registered for such service or help editors to identify candidate reviewers. Please find the details of processing in Publons’ privacy policy https://publons.com/about/terms: **Yes**\n* Declaration of competing interests: **I declare that I have no competing interests**\n* Reviewer Publication Consent. I agree for my report to be made available under an Open Access Creative Commons CC-BY License (http://creativecommons.org/licenses/by/4.0) if this manuscript is accepted for publication. Any comments that I do not wish to be included in the published report have been included as confidential comments to the editor, which will not be published.: **I agree to the terms of the CC-BY 4.0 license; please publish my name with my report.**\n* Is the study design appropriate to answer the research question (including the use of appropriate controls), and are the conclusions supported by the evidence presented?: **Yes**\n* Are the methods sufficiently described to allow the study to be repeated?: **Yes**\n* Is the use of statistics and treatment of uncertainties appropriate?: **Yes**\n* Is the presentation of the work clear?: **Yes**\n* Are the images in this manuscript (including electrophoretic gels and blots) free from apparent manipulation?: **Yes**\n"},{"type":"reviewerAgreed","content":"","date":"2020-08-25T12:00:00+00:00","index":1,"fulltext":""},{"type":"reviewersInvited","content":"","date":"2020-08-24T12:00:00+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2020-08-03T12:00:00+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2020-08-02T12:00:00+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2020-08-02T12:00:00+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-pregnancy-and-childbirth","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"prch","sideBox":"Learn more about [BMC Pregnancy and Childbirth](http://bmcpregnancychildbirth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/prch/default.aspx","title":"BMC Pregnancy and Childbirth","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}},{"code":2,"date":"2020-03-16 14:30:33","doi":"10.21203/rs.2.13558/v2","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Major revision","date":"2020-07-13T12:00:00+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2020-04-07T12:00:00+00:00","index":1,"fulltext":"Recommendation: Accept after minor essential revisions\nForm responses:\n---\n\nComments to Author:\n---\n\nThis is the first revision of a manuscript describing the institution of a neuraxial (epidural) analgesia service in a large obstetric hospital in Hubei, China, and its effect on cesarean delivery rates, which was to decrease the cesarean delivery rate, including the \"maternal request cesarean,\" presumably due to the availability of analgesia. \n\nAs an anesthesiologist in New York City right now, let me first comment that I am impressed that the investigators could do this revision in Wuhan, China given what they have gone through in early 2020.\n\nAs I have commented in my review of the original submission, this finding that a labor analgesia service does not increase the CD rate was reported back in the US in the 1990s as labor analgesia services started expanding, and decrease in the very high CD rate in China has been reported form several centers in China as labor analgesia services were instituted there. So while this work is not unique, it supports the growing body of literature that confirms that labor analgesia does NOT necessarily increases cesarean deliveries, as had (and sometime still is) claimed by \"natural childbirth\" advocates. The data the authors report seems clear; a weakness is that they have no data form BEFORE their initiation of the labor analgesia service, so they can only report on the trends during the year in which the analgesia rate increased from 26% to 45%. The report would still be aided by some numbers form the year or two before the labor analgesia initiative.\n\nThe authors have responded to almost all the reviewer and editorial comments, but unfortunately there still are some issues that are confusing or concerning.. The English is still not perfect of course, but is much more understandable. There are still some areas of confusion (mine or theirs) that could use some further explanation/revision. I have also made a few language corrections below.\n\n1. Page 2, lm16: change \"is\" to \"in\" (I have made several few minor language corrections to the Abstract since that is the most read part of any manuscript. I will not continue to correct all small errors or issues of style.\n2. Lm 18: add \"a\" before neuraxial\n3. Page 3, lm 10 and 12: add \"who\" between \"women\" and \"underwent\"\n4. Page 3, lm 16: change \"significantly were\" to \"were significantly\"\n5. Lm 20: I might cut \"with the help of NPLD\", which is not essentially to understanding the conclusions of the paper.\n6. Page 4, lm 24-26: These data on CD rates are from this one institution, but the sentence makes it sound like they are for all of China. Actually, I am not dsure what these numbers represent, as elsewhere the authors mention 20,000 deliveries per year at their institution recently.\n7. Lm 39: add \"often\" after Chinese women and drop \"only\". Certainly some women choose CD for other reasons.\n8. Page 6, lm 12: I assume this means women consented to the labor analgesia procedure, not the research. If so (and I do not see why they would need to consent to this kind of retrospective chart review research) then this sentence about consent is not needed. (It is also mentioned again on page 12)\n9. Lm 16-41: I am not sure all this detail about the NPLD process is needed; it seems this could be shortened considerably\n10. Lm 46-page 7, lm 39 could this change in WHERE CDs were done have had any effect on the rate of CD? It does appear that this change in location coincides with the start of this study and the introduction of labor analgesia. Could obstetricians have been LESS likely to \"call\" a CD because it was easier to get the woman to an OR when really needed?\n11. Page 8, lm 16: change \"stuff\" to \"staff\"\n12. Page 8: a lot of this description of how the NPLD program worked is snot strictly relevant to the point of this study, and has been described in prior publications from institutions that had NPLD programs\n13. Page 9, lm 16: change \"operation\" to \"operative\"\n14. Page 10: I am still not clear what this PCEA (or PIEB) recipe was. It seems the patients got 10 ml each hour, and then could press a PCEA button, but I cannot figure out what that PCEA dose was, or how often they could get an additional PCEA dose.\n15. Page 13, lm 34: This 19464 number is not the number admitted to the hospital for delivery, it is the number studied after exclusions.\n16. Lm 49: what does unintended dural puncture for blood\" mean? \n17. Page 15, lm 46: No real need to comment/answer, but I do not undersatdn why shortsightedness is an indication for CD?\n18. Page 16, lm 18-20: What do the authors mean here that the rate of NA correlated with the rate of CD and MRCD? They were, if anything, INVERSELY correlated, right, which is what is stated on page 17, lm 20-22? This sentence on page 16 could probably be eliminated with no loss to meaning of the paper.\n19. I am please the authors included some description of the timeline and poissble effect of the rescinding of the 1-child policy.\n20. Page 18, lm 25-page 19, lm 12: I am still not sure this discussion of ropivacaine and the specific concentrations used is necessary; the point of the paper is about the availbility of a reasonably effective labor analgesia service on the CD rates—it seem unlikely that the specific recipes or drugs used would effect that too much in the population.\n21. Page 19, lm 40: The issue of the effect of epidural analgesia on operative vaginal delivery rates has always been hard to study when it is done in an unblinded fashion, since the presence of decent analgesia makes it MUCH easier for obstetricians to apply forceps or vacuum, and their sense that patients are comfortable also tend to make OBs think that the patients are not \"trying\" hard enough to push. The best studies of this issue have tended to blind practitioner to exactly what was being given in the second stage (drug v placebo) but of course that does not directly address the issue of whether the presence of analgesia for the entire labor has an effect on second stage effectiveness. I am not sure how the tow papers picked for citation were the two that seemed most important to this longstanding controversy.\n* Are the methods appropriate and well described?: **Yes**\n* Does the work include the necessary controls?: **Yes**\n* Are the conclusions drawn adequately supported by the data shown?: **Yes**\n* Are you able to assess any statistics in the manuscript or would you recommend an additional statistical review?: **I am able to assess the statistics**\n* Quality of written English: **Needs some language corrections before being published**\n* Declaration of competing interests: **I declare that I have no competing interests**\n* I agree to the open peer review policy of the journal. I understand that my name will be included on my report to the authors and, if the manuscript is accepted for publication, my named report including any attachments I upload will be posted on the website along with the authors' responses. I agree for my report to be made available under an Open Access Creative Commons CC-BY license (http://creativecommons.org/licenses/by/4.0/). I understand that any comments which I do not wish to be included in my named report can be included as confidential comments to the editors, which will not be published.: **\nI agree to the open peer review policy of the journal**\n"},{"type":"reviewersInvited","content":"","date":"2020-03-23T12:00:00+00:00","index":"","fulltext":""},{"type":"reviewerAgreed","content":"","date":"2020-03-23T12:00:00+00:00","index":1,"fulltext":""},{"type":"editorAssigned","content":"","date":"2020-03-09T12:00:00+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2020-03-08T12:00:00+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2020-03-08T12:00:00+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-pregnancy-and-childbirth","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"prch","sideBox":"Learn more about [BMC Pregnancy and Childbirth](http://bmcpregnancychildbirth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/prch/default.aspx","title":"BMC Pregnancy and Childbirth","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}},{"code":1,"date":"2019-08-25 16:52:04","doi":"10.21203/rs.2.13558/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Major revision","date":"2020-02-13T12:00:00+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2020-02-06T12:00:00+00:00","index":2,"fulltext":"Recommendation: Major revisions required\nForm responses:\n---\n* Are the methods appropriate and well described?: **No**\n* Does the work include the necessary controls?: **No**\n* Are the conclusions drawn adequately supported by the data shown?: **No**\n* Are you able to assess any statistics in the manuscript or would you recommend an additional statistical review?: **I recommend additional statistical review**\n* Quality of written English: **Needs some language corrections before being published**\n* Declaration of competing interests: **'I declare that I have no competing interests**\n\nComments to Author:\n---\nComments : It is a useful study but need major corrections . It seems like an impact study, meant to study the impact of initiation of the epidural services . However data collection was done after the start of epidural service from May 2015 where initiation has already started . The true impact can only be seen if the data is collected before the start of epidural service, as at present this study is showing the progression once the service is started as it has no data to back up before the service .\n\nIt seems very unlikely that one week of training can make people expert in the epidural institution . Authors need to explain if the care givers were already well versed in the institution of epidural or not and what was their level .\nThere is no mention of patient education and how counselling was done for them to agree .\nReference number 9 seems from a study done in Baltimore and not their local data of water emersion technique."},{"type":"editorInvitedReview","content":"","date":"2020-01-21T12:00:00+00:00","index":1,"fulltext":"Recommendation: Major revisions required\nForm responses:\n---\n* Are the methods appropriate and well described?: **No**\n* Does the work include the necessary controls?: **Yes**\n* Are the conclusions drawn adequately supported by the data shown?: **Yes**\n* Are you able to assess any statistics in the manuscript or would you recommend an additional statistical review?: **I am able to assess the statistics**\n* Quality of written English: **Not suitable for publication unless extensively edited**\n* Declaration of competing interests: **I do want to acknowledge a possible conflict of interet in my review of this manuscript. I have worked with the “No Pain Labor \u0026Delivery (NPLD)” program on a trip to China (Shanghai) a few years ago.**\n\nComments to Author:\n---\nA neuraxial labor analgesia service was initiated in conjunction with the No Pain Labor \u0026Delivery (NPLD) program in May 2015 in a hospital in Hubei China. The No Pain Labor \u0026Delivery (NPLD) program is a program started by an Chinese-American anesthesiologist at Northwestern University that has helped to initiate neuraxial analgesia services at many hospitals in China over the past 10-12 years. The authors report on the increase in neuraxial analgesia, and the associated changes in cesarean delivery rate, maternal request cesareans, post partum hemorrhage, and other obstetric indicators over the following year. They report that the cesarean rate decreased, as did the rate of women requesting cesarean delivery with no \"medical\"indication. They conclude that in their environment, where no neuraxial anlagseia had been previously available, led to a decrease in cesarean deliveries.\n\n\n\nCOMMENTS\n\nThere has long been interest in the effect of \"epidural rate\" on the rate of cesarean delivery, with the belief in the 1980s and 90s being that \"epidurals cause C-sections.\" There were several reports in the US back in 1990 about the effects of a sudden increase in neuraxial analgesia rate on cesarean delivery rates, with almost all of them showing no effect, summarized in a meta-analysis review by Segal et al (Segal S, Su M, Gilbert P. The effect of a rapid change in availability of epidural analgesia on the cesarean delivery rate: a meta-analysis. Am J Obstet Gynecol 2000;183:974-8).\n\nThe No Pain Labor \u0026Delivery (NPLD) program has reported results from other hospitals in China that similar to those reported here when the NPLD program has been initiated (e.g., Wang Q, Zheng SX, Ni YF, Lu YY, Zhang B, Lian QQ, Hu MP. The effect of labor epidural analgesia on maternal-fetal outcomes: a retrospective cohort study. Arch Gynecol Obstet 2018;298:89-96 and ref 7 and 18 in manuscript). So the information reported here is by no means unique, although the sudden establishment of a 24 hour labor analgesia service is to be commended, indeed celebrated, and there is much to learn about the process of modern childbirth by examining what happens when such a endeavor is undertaken. This report is consistent with other reports and gives further weight to the idea that initiation of labor analgesia services can have benefits beyond simply pain relief, as critical as pain relief itself can be.\n\nIt should be noted that there may have been a decrease in cesarean delivery rate in China over the past few years even without such intervention, as the elimination of the \"one-child\" policy has somewhat loosened anxiety about having a \"perfect baby\" and the possibility of undergoing several deliveries has perhaps led more women to opt for labor over cesarean delivery for their first.\n\nThe English writing in this manuscript could be improved, although it is understandable in almost all areas. I have commented on some but not language issues in my \"specific comments.\"\n\nI am confused by several different dates in the manuscript. In the introduction (lm 96)it is stated that the neuraxial analgesia service was initiated on May 1 2015 and the study examined the period form May , 2015 to April 30, 2016. However (lm 151) it is stated that data was collected from June 1, 2015 to July 1, 2016. This needs to be clarified.\n\nSPECIFIC COMMENTS\n1. lm 82-83: The sentence \"Higher rate of CD and lower rate of NA are China's major present situation\" is a poor sentence. Maybe \"A high CD rate and low or no availability of NA for labor is a common situation in Chinese hospitals.\"\n\n2. Lm 23: change \"as\" to \"is\"\n\n3. Lm 92: change \"evaluates\" to \"evaluate\"\n\n4. Lm 94/94: not critical for meaning, but it would better to refer to women not a \"CD women\" and \"vaginal delivery women\" but rather as \"women undergoing vaginal delivery\" and \"women undergoing cesarean delivery\"\n\n5. Lm 116: I think the authors mean that prior to 2015, cesarean section could not be carried out in the delivery suite, but that patients needed to be transported to another part of the hospital, but after that there was an operating room nearby. I would suggest changing \"delivery room\" to labor and delivery suite\" to be better understood by a Western readership.\n\n6. Lm 118: I do not understand the phrase \"pregnant women were generally admitted to hospital in maternity room first, and then moved to delivery room till the dilation of cervix to 1 cm or more.\" Do they mean they were moved to the delivery room when dilation was MORE than 1 cm?\n\n7. Lm 121 \"what is Daole?\" do they mean \"doula?\"\n\n8. Lm 125: Here the room is called \"maternal room,\" in line 117 it is \"maternity room\".\n\n9. Lm 146\" should be \"how to perform resuscitation for neonatal asphyxia\". I'd leave out the \"and so on\"\n\n10. Lm 148: \"departments\"\n\n11. Lm 150: \"newborn\" can be one word\n\n12. Lm 151: see general comment above regarding dates of data collection -this must be clarified\n\n13. Lm 159: do they mean \"maternal request cesarean delivery\"?\n\n14. Lm 169-171: This sentence does not seem appropriate. I do not really know what is meant by \"women undergoing vaginal delivery should be evaluated both by anesthesiologist and obstetrician to make sure if they need NA when their cervical dilation more than 1cm. I am not sure, but suspect that what is meant is more like \"women undergoing vaginal delivery are evaluated both by anesthesiologist and obstetrician to assess their desire for and suitability for NA once their cervical dilation was greater than 1cm\"\n\n15. Lm 175: change \"nature\" to \"spontaneous\" (or at the very least to \"natural\", but spontaneous is the more appropriate term)\n\n16. Lm 181-192: The description of the epidural technique and drug administration is very difficult to understand. Not all epidural spaces could be at 3 cm, which is implied in line 183. How can the patient get 30 ml in an hour if the PCEA dosing was 10 ml with an hour lockout? Was the \"Automatic\" injection a mandatory PIEB injection and the woman could get two more per hour?\n\n17. Lm 193: Would change to \"Maternal HR, NIBP and SpO2 was continuously monitored throughout the PCEA period…\"\n\n18. Lm 195: change \"one-by-one\" to \"one-on-one\"\n\n19. Lm 212: This starts Section 1.7 but there is no Section 1.6\n\n20. Lm 213 and 216: cut \"basically\". I actually think most of lines 213-224 (the entire section 1,7) could be eliminated. The definitions should be known to most readers.\n\n21. Lm 234-235: \"accepted\" cannot be the right word here. Is it \"underwent?\" or do they mean that 11182 women were willing to TRY to deliver vaginally?\n\n22. Lm 237-239: I am not sure I understand the numbers regarding vaginal delivery and neuraxial analgesia. There were 11182 vaginal deliveries (or attempts, see point 21 above), with 3869 requesting NA and 3619 \"natural.\" What about the other almost 4000 deliveries?\n\n23. Lm 275: What is \"high myopia?\"\n\n24. Lm 278: Cut the word \"pain\"\n\n25. Lm 282-285: This is very porly worded; I am not sure I completely understand what is meant. Do the authors mean \"In our birth center, with the help of NPLD program NA was available for women who requested in to relieve labor pain from May. We observed that the rate of NA also have good correlation with the rates of overall CD and MRCD?\" But they actually are reporting a NEGATIVE correlation of NA with CD rates. I would suggest these lines simply be removed.\n\n26. Lm 289: cut \"it can be know that\"\n\n27. Lm 292: change \"by the use of NA\" to \"of the use of NA\". This section (lm 292-299) seems to re-state the results and conclusions of the study and may not be necessary\n\n28. Lm 299-303: I am not sure I fully understand the point the authors are trying to make about the effect of the end of the one-child policy.\n\n29. Lm 304: cut \"The\" from the beginning of sentence.\n\n30. Lm 306-331: Most of this can be cut, as there is no need for discussion of ropivacaine specifically. A discussion of the controversies regarding the potential effect of epidural analgesia on delivery may be appropriate, but could be significantly shortened.\n\n31. Lm 330: \"asphyxia\" not \"aphasia\" (two places)\n\n32. Lm 333: \"study\"\n\n33. Lm 334-335: Is there supposed to be some listing of factor after \"including?\" This sentence needs to be re-written. \"With\" instead of \"for in line 3336 I think.\n\n34. Lm 336: \"delivery\"\n\n35. Lm 340: \"every\" not \"very\"\n\n36. Lm 341: \"neuraxial\". Re-write sentence as \"The NPLD team helped to establish a neuraxial labor analgesia service in our hospital.\"\n\n37. Table 4: what is \"transfer CD\"—is this \"intrapartum CD\u003c \" i.e., women who were laboring and then needed CD?\n\n38. Many of the tables or line in the tabke could be eliminated since they are well summarized in Figure 2\n\n"},{"type":"reviewerAgreed","content":"","date":"2020-01-04T12:00:00+00:00","index":2,"fulltext":""},{"type":"reviewerAgreed","content":"","date":"2020-01-02T12:00:00+00:00","index":1,"fulltext":""},{"type":"checksComplete","content":"","date":"2019-08-21T12:00:00+00:00","index":"","fulltext":""},{"type":"reviewersInvited","content":"","date":"2019-08-21T12:00:00+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2019-08-13T12:00:00+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2019-08-12T12:00:00+00:00","index":"","fulltext":""},{"type":"submitted","content":"","date":"2019-08-11T12:00:00+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-pregnancy-and-childbirth","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"prch","sideBox":"Learn more about [BMC Pregnancy and Childbirth](http://bmcpregnancychildbirth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/prch/default.aspx","title":"BMC Pregnancy and Childbirth","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"3f254d9a-704d-439c-a59e-70d289cf833d","owner":[],"postedDate":"October 5th, 2020","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[{"id":276946,"name":"Maternal \u0026 Fetal Medicine"},{"id":276947,"name":"Obstetrics \u0026 Gynecology"}],"tags":[],"updatedAt":"2020-10-18T15:02:32+00:00","versionOfRecord":{"articleIdentity":"rs-4267","link":"https://doi.org/10.1186/s12884-020-03294-z","journal":{"identity":"bmc-pregnancy-and-childbirth","isVorOnly":false,"title":"BMC Pregnancy and Childbirth"},"publishedOn":"2020-10-12 12:00:00","publishedOnDateReadable":"October 12th, 2020"},"versionCreatedAt":"2020-10-05 23:31:17","video":"","vorDoi":"10.1186/s12884-020-03294-z","vorDoiUrl":"https://doi.org/10.1186/s12884-020-03294-z","workflowStages":[]},"version":"v4","identity":"rs-4267","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"identity":"rs-4267","version":["v4"]},"buildId":"369fNeqWncA4NS6XSWjrt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}