Stress and pain response of neonates after spontaneous

birth and vacuum-assisted and cesarean delivery
Christine Schuller, MD; Nina Känel, MD; Olivia Müller, MD; André Boris Kind, MD;
Eva Maria Tinner, MD; Irene Hösli, MD; Roland Zimmermann, MD; Daniel Surbek, MD

OBJECTIVE: The objective of the study was to compare the stress re-
RESULTS: Significant differences were evident during the first 72 hours
sponse and pain expression of newborns (NBs) in the early postpartum postpartum with highest nominations in the VE group. Meconium- stained amniotic fluid was the only intrapartum stress factor with an im- STUDY DESIGN: This was a prospective study with 280 NBs enclosed at 3
Swiss university hospitals. Stress response and pain reaction were analyzed CONCLUSION: NBs delivered vaginally show a higher incidence of
according to the mode of delivery: elective cesarean section (ELCS), spon- stress response and pain expression than infants of the ELCS group.
taneous vaginal delivery, and assisted vaginal delivery by vacuum extraction The long-term impact of these findings remains to be determined.
(VE). Saliva cortisol and clinical pain expression were evaluated after deliv-ery and before and after heel prick for metabolic screening.
Key words: newborn, pain assessment, postpartum stress response Cite this article as: Schuller C, Känel N, Müller O, et al. Stress and pain response of neonates after spontaneous birth and vacuum-assisted and cesarean delivery.
Am J Obstet Gynecol 2012;207:xx-xx.
Afewdecadesago,itwasscientificbe- opedinthefetusat20-24weeksofges- Childbirth is considered to be the
capability to perceive pain at all or only tivity of a newborn‘s brain can be found riod. Previous literature describes a dif- ies, the mode of delivery results in spe- nerve tracts and neurons are fully devel- fluids (umbilical cord blood, saliva). The validated pain scores specially developed are linked to relevant clinical pain in the Switzerland (Drs Schuller, Känel, Müller, Kind, and Surbek); Department of Obstetrics and Pain Scale, Échelle de Douleur Inconfort Switzerland (Drs Hösli, Kind, and Tinner); and infants born by assisted vaginal delivery University Hospital Zürich, Switzerland (Dr Received May 24, 2012; revised July 24, 2012; levels and the expression of relevant pain, Freiwillige Akademische Gesellschaft Basel, we investigated newborns’ clinical pain as- sessment and their physiological pain re- The authors report no conflict of interest.
sponse during the first 72 hours after birth according to their mode of delivery.
individual’s response to stress stimuli Medicine, University Hospital of Bern,Effingerstrasse 102, CH-3010 Bern, consequences in later life. Hypertension, MATERIALS AND METHODS
Study design and population
and a higher susceptibility for depression Population
2012 Mosby, Inc. All rights reserved.
In this national, prospective, multicenter MONTH 2012 American Journal of Obstetrics & Gynecology 1.e1
Research Basic Science: Obstetrics
cubation period of 48 hours at 4°C, plates nurse. At the age of 72 hours, the expres- 2010 that ended in elective cesarean sec- sion of the neonates’ pain was assessed 30 tion, spontaneous vaginal delivery, or as- seconds before and at least 2 minutes af- sisted vaginal delivery by vacuum extrac- tion. Exclusion criteria were delivery less Guthrie test by a trained staff nurse, doc- than 35 weeks of gestation, use of opiates incubated for 48 hours at 4°C. Synthetic for pain relief during labor, birthweight saliva mixed with cortisol in a range from 0 to 100 nmol/L served as standards.
samples were given in duplicate wells.
reaction, we statistically tested characteris- tics of the birth process like the use of epi- niotic fluid, or long duration of the first cortisol and 2 validated pain scores.
biochemical stress response, the NB’s sa- tutional review board of all 3 participat- liva cortisol was collected before and af- lution induced the fluorescence, which can study did only measure the NBs’ clinical Statistical analysis
pain reaction and did not collect cortisol was calculated. The intraassay coefficient ery, the baseline characteristics of the de- liveries, and the neonates were statistically analyzed. Continuous data were calculated by 1-way analysis of variation in which the distribution was normal. When testing for under the infant’s tongue for 2 minutes.
normality failed, Kruskal-Wallis was used.
cortisol levels, the less invasive proce- Posttesting correction with Bonferroni’s minutes after the prick, and the material and Dunn’s test was used. Categorical data was then sent to a certified external lab- were evaluated by ␹2 test or Fisher exact saliva samples were stored at Ϫ20°C un- gression analysis. All statistical calcula- til analysis. After thawing, saliva samples were centrifuged at 2000 ϫ g for 10 min- Stat 3.0 (GraphPad, San Diego, CA). P Ͻ .05 was considered statistically significant.
heart and breathing rate of the newborn.
croliters of saliva were used for duplicate ery. The assisted vaginal delivery by vac- lac). Ninety-six-well Maxisorb microtiter EDIN Scale assessment at the age of 2, 4, est number of primiparous women (P Ͻ 1.e2 American Journal of Obstetrics & Gynecology MONTH 2012
Basic Science: Obstetrics Research
Baseline characteristics of mothers and the birth process
One-way ANOVA/Kruskal- If significant: posttest:
Wallis/2 test/Mann-
(n ؍ 112)
SVD (n ؍ 107) VE (n ؍ 61)
Whitney test
Fisher exact test
500 (200-1500) 300 (150-1500) 350 (200-2000) Ͻ .0001 .
ANOVA, analysis of variance; BMI, body mass index; ELSC, elective cesarean section; SVD, spontaneous vaginal delivery; VE, vacuum extraction.
a Normality test not passed, values in median (range), calculated by Kruskal Wallis, if significant posttest: Dunn’s; b Categorical data (if ␹2 significant, posttest: Fisher exact test: SVD und VE); c Significant difference between ELCS and SVD (P Ͻ .001) and between ELSC und VE (P Ͻ .001) and between SVD and VE (P Ͻ .05); d Significant difference between ELSC und SVD (P Ͻ .001) and between ELSC und VE (P Ͻ .001); e Categorial data (␹2 test).
Schuller. Pain response of neonates according to their mode of delivery. Am J Obstet Gynecol 2012. .0001) and highest proportion of potential tistically significant, they probably are of stress factors during labor like elevated blood loss (P Ͻ .05), more frequent use of group, but this was not statistically sig- analgesia (P Ͻ .0001), and a higher per- (17.14%) had at least 1 positive score at centage of nonreassuring fetal heart rate the particular time points of the serially tisol values after heel prick rose in all of (P Ͻ .0001). A longer interval between (P Ͻ .001), nonreassuring fetal heart rate (P Ͻ .0001), and a longer duration of the statistically significant (P ϭ .2420).
first (P ϭ .0014) and second stages of la- bor (P Ͻ .0001) were more frequent in before and after the Guthrie rest regard- ing the Bernese Pain Scale (P ϭ .054, P ϭ were statistically significant (P ϭ .0022 this difference was not statistically signif- and P ϭ .0016, respectively).
vealed that only the presence of meconium- cortisol values were almost equal in all 3 Guthrie test (P ϭ .179). However, after hours, P ϭ .011, EDIN 2-24 hours, P ϭ .031). All the other intrapartum features (use of regional analgesia, length of sec- cesarean section (ELCS), respectively, in ond stage of labor, interval between rup- minutes. Although these results were sta- tion to the stress response and pain reac- MONTH 2012 American Journal of Obstetrics & Gynecology 1.e3
Research Basic Science: Obstetrics
ference is small and statistically nonsig- nificant. This might be due to their phys- Baseline characteristics of neonates
ELSC (n ؍ 112)
SVD (n ؍ 107)
VE (n ؍ 61)
during labor known as fetal inhibition.
cortisol levels differed among groups ac- .
Statistical significant difference between all outcome parameters of the neonates of the 3 groups: P ϭ .0015 for Apgar 1 minute; P ϭ .0009 for Apgar 5 minutes; P ϭ .0195 for Apgar 10 minutes; P Ͻ .0001 for pH value cord artery; P ϭ .0024 for pH cord value vein.
ELSC, elective cesarean section; F, female; M, male; SVD, spontaneous vaginal delivery; VE, vacuum extraction.
a Normality test not passed values in median (range); b Normality test passed, values in mean [SD].
statistically significant. These findings Schuller. Pain response of neonates according to their mode of delivery. Am J Obstet Gynecol 2012. correspond to the data of other studieslooking at the time immediately after tion of the neonates during the entire ob- different behavioral as well as biochemi- were no clear alterations of the modified Bernese Pain Scale to be noted before but have a direct clinical implication and are lance of 72 hours after birth, we can con- pression. In our study, the most signifi- response and also clinical pain reaction, first 24 hours of surveillance after birth.
proportion of children is the most stress- During this very first period of their life, subjectively. Indicators of neonatal pain children of the ELCS group, but this dif- touse clinically recovers after a period of Number of positive EDIN scores (>7)
If significant
(n ؍ positive
(n ؍ positive
(n ؍ positive
posttest: Fisher
(n ؍ total)
(n ؍ total)
(n ؍ total)
2 test
exact test
Categorical data (if ␹2 test significant, posttest: Fisher exact test: between SVD und VE).
EDIN, Échelle de Douleur Inconfort Nouveau-Née, Neonatal Pain and Discomfort Scale; ELSC, elective cesarean section; SVD, spontaneous vaginal delivery; VE, vacuum extraction.
Schuller. Pain response of neonates according to their mode of delivery. Am J Obstet Gynecol 2012. 1.e4 American Journal of Obstetrics & Gynecology MONTH 2012
Basic Science: Obstetrics Research
Bernese Pain Scale and saliva cortisol 72 h post partum

ELSC (n ؍ 112)
SVD (n ؍ 107)
VE (n ؍ 61)
ELSC, elective cesarean section; SVD, spontaneous vaginal delivery; VE, vacuum extraction.
a Normality test not passed; values in median (range) calculated by Kruskal Wallis; b Significant difference between VE and ELSC (P Ͻ .05) but not between VE und SVD (P Ͼ .05) posttest: Dunn’s.
Schuller. Pain response of neonates according to their mode of delivery. Am J Obstet Gynecol 2012. the infant during the peripartum period.
ery has a positive long-term effect of the ever, when we measure the saliva cortisol of the NBs after the heel prick for Guth- ACKNOWLEDGMENTS
rie test, the physiological reaction to a We give special acknowledgments to N. Schöbiund K. Jost, who made substantial contribu- tions to the acquisition of data at University children exposed to elevated cortisol lev- Hospital Basel (Basel, Switzerland) and Univer- birth. This observation is remarkable, and sity Hospital Zürich (Zürich, Switzerland). C.S.
we must presume that vaginal birth, espe- made substantial contributions to the study de- cially VE for some children, can be consid- sign, drafted the manuscript, and made sub-stantial contributions to acquisition, analysis, erable not only short-living trauma with a and interpretation of data. N.K. made substan- tial contributions to acquisition, video recording, stress or pain stimuli later in life with a born after elective cesarean section with- and analysis and interpretation of data and re- higher physiological stress response.
vised the manuscript critically for important in- by cesarean section at onset of labor or at tellectual content. O.M. ex aequo made sub- stantial contributions to acquisition, videorecording, and analysis and interpretation of terms of elevated cortisol levels at vaginal cause elective cesarean section in our set- data and revised the manuscript critically for important intellectual content. I.H. and E.M.T.
later on the occasion of neonatal circum- made substantial contributions to acquisition of group with cesarean after onset of labor.
data and financial support and revised the man- uscript critically for important intellectual con- tually be addressed in future studies.
tent. R.Z. and A.B.K. made substantial contri-butions to acquisition of data and revised the manuscript critically for important intellectual content. D.S. made substantial contributions to the study design, acquisition, analysis, and in- terpretation of data, and revised the manuscript HPA with all its potential health hazards critically for important intellectual content.
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