Early versus late epidural analgesia and risk on instrumental delivery in nulliparous women: a systematic review

Abstract

Background The optimal timing of epidural analgesia during labour and delivery has been a controversial issue.Objective Review of the literature regarding the relation between the timing of epidural analgesia and the rate of caesarean or instrumental vaginal deliveries.Search strategy Pubmed, Embase and the Cochrane Library were searched for articles published until 31 July 2010.Selection criteria Studies were selected in which the effects of early latent phase (defined as a cervical dilatation of 3 cm or less) epidural analgesia (including combined-spinal epidural) and late active phase epidural analgesia on the mode of delivery in nulliparous women at 36 weeks of gestation or more were evaluated.Data collection and analysis Data extraction was completed by using a data-extraction form. Risk ratio and its 95% confidence intervals were calculated for caesarean delivery and instrumental vaginal delivery. Pooled data were calculated.Main results The search retrieved 20 relevant articles, of which six fulfilled the selection criteria of inclusion. These six studies reported on 15 399 nulliparous women in spontaneous or induced labour with a request for analgesia. Risk of caesarean delivery (pooled risk ratio 1.02, 95% CI 0.96-1.08) or instrumental vaginal delivery (pooled risk ratio 0.96, 95% CI 0.89-1.05) was not significantly different between groups.Authors' conclusions This systematic review showed no increased risk of caesarean delivery or instrumental vaginal delivery for women receiving early epidural analgesia at cervical dilatation of 3 cm or less in comparison with late epidural analgesia.

Outcome of labor with epidural analgesia in primigravida at term

“…This is in contrast to the study by Wang et al 6 More recently, a systematic review of 6 studies (N=15,399) showed no increased risk of cesarean (pooled risk ratio 1.02 95% CI 0.96-1.08) or instrumental (pooled risk ratio 0.96 95% CI 0.89-1.05) delivery for women receiving early epidural (defined as 3 cm or less) in comparison with late epidural placement. 7 Wassen et al8 suggested that routine epidural analgesia may increase the rate of operative deliveries, however the difference between vaginal (difference: 4.5% (95%CI: -1.6, 10.6)) or via cesarean (3.6% (95%CI: -3.1, 10.3) did not reach statistical significance. Also, adverse labor outcomes such as incidence of shoulder dystocia, postpartum hemorrhage, manual placenta extraction, and third/fourth degree perineal lacerations; and neonatal outcomes were no different.…”

Neuraxial analgesia effects on labour progression: facts, fallacies, uncertainties and the future

“…Furthermore, these investigators observed no effects of early labor analgesia on operative vaginal or cesarean birth rates. More recently, a systematic review of 6 studies (N=15,399) showed no increased risk of cesarean (pooled risk ratio 1.02 95% CI 0.96–1.08) or instrumental (pooled risk ratio 0.96 95% CI 0.89–1.05) delivery for women receiving early epidural (defined as 3 cm or less) in comparison with late epidural placement 32 .…”

“…More recently, a systematic review of six studies (n = 15 399) showed no increased risk of caesarean (pooled risk ratio 1.02, 95% CI 0.96-1.08) or instrumental (pooled risk ratio 0.96, 95% CI 0.89-1.05) delivery for women receiving early epidural (defined as dilatation ≤3 cm) in comparison with late epidural placement. 32 The aforementioned findings have led ACOG to conclude that,…”

Neuraxial analgesia: a review of its effects on the outcome and duration of labor

“…A 2011 meta-analysis of five randomized trials and one retrospective cohort study (n = 14,836) indicated that early administration of neuraxial analgesia (cervical dilation ≤ 3 cm) did not increase the incidence of Cesarean sections (RR 1.02, 95% CI 0.96 to 1.08) or instrumental deliveries (RR 0.96, 95% CI 0.89 to 1.05) in comparison to later administration (cervical dilation ≥ 4 cm) [44]. …”