Early versus late epidural analgesia and the risk of instrumental delivery in nulliparous women

Abstract

rics, of 12 993 nulliparous women, showing that even use in the latent phase, compared with later, led to no difference. It was really very early compared with later, rather than late. There was a very high rate of intervention in both arms, but the rate of caesarean section was modest (23-24%), although not at our current common rates of up to or exceeding 30%. Wong et al. 6 reported on a second study by the same group, in which nulliparous women were again exposed to combined spinal and epidural analgesia, and not epidural, but it was of induced women only. Hence its external validity to women in spontaneous labour is questionable.This meta-analysis illustrates the old issue of what constitutes the type of study that should be included in a meta-analysis. In my opinion, the only study that speaks to the issue at hand is that of Ohel et al. 4 One can conclude that in this setting, an early epidural will not lead to an increase in the rate of caesarean section. However, most of the environments in North America and most Western countries do not have a caesarean section rate of 11-13%. Thus, the Ohel study illustrates that if we could approach such a low caesarean section rate, epidurals are not likely to be a problem. In fact we could all learn from Ohel and company about how they achieve such a low rate of caesarean section. j However, we do not agree with his comments. Dr Klein suggests that the meta-analysis is primarily about caesarean section, and that the title is therefore misleading. The primary focus of our meta-analysis was the effect of early epidural analgesia (EA) on the rate of instrumental vaginal delivery or caesarean delivery. Table 3 illustrated the inclusion of six studies (15 399 women) for the rate of instrumental delivery and five studies (14 836 women) for the rate of caesarean delivery. Thus, we disagree with Klein's conclusion, and consider the title appropriate. MC KleinThe fact that Luxman's 3 study was underpowered is irrelevant because the results were pooled with results from other studies. In addition, Klein refers repeatedly to the fact that there is a low caesarean section rate in several studies. He does not argue, however, about what would be the effect of a higher, versus lower, rate of caesarean section on the relative risk. Looking at relative risks for different studies included in the meta-analysis, we see no link between the rate of caesarean section and the relative risk. Three studies with a caesarean section rate of less than 20% described relative risks of 0.67, 3 0.86, 4 and 1.16, 5 respectively, and two studies with caesarean rates over 20% reported relative risks of 1.02 6 and 1.05, 7 respectively. After the first request for analgesia, Wong et al.7 randomised women to receive intrathecal fentanyl or systemic hydromorphone. Subsequently, patient-controlled epidural analgesia was initiated in the intrathecal group at the second request, and in the systemic group at a cervical dilatation of at least 4 cm or at the third request for analgesia.In Wang's study, a min...

The 90% Effective Dose of Sufentanil for Epidural Analgesia in the Early First Stage of Labor: A Double-blind, Sequential Dose-Finding Study

“…Labor analgesia in the latent phase has been recognized and accepted by anesthesiologists worldwide. [1][2][3][4][5] However, the exact dose of sufentanil with the combination of ropivcaine required to administer epidural analgesia in the early first stage of labor remains unclear. Even in the practice guideline for obstetric anesthesia of 2016, the reasonable use of opioids in epidural administration of labor analgesia was not mentioned, and only a low concentration of local anesthetics was recommended.…”

The Tyranny of Meta‐analysis and the Misuse of Randomized Controlled Trials in Maternity Care

“…Since then, meta‐analysis has been broadened to include nonrandomized trials and, increasingly, studies that come from different environments or other nonheterogeneous settings. It is in the context of these concerns that the meta‐analysis by Wassen et al will be assessed (2).…”

“…Wassen et al have conducted a meta‐analysis of randomized controlled trials of women receiving epidural analgesia early versus later in labor (2). They concluded that the early use of epidural analgesia, before the active phase of labor, does not result in an increase in either instrumental delivery or cesarean section.…”

“…The meta‐analysis by Wassen et al (2) illustrates the old issue of what constitutes the type of study that should be included in a meta‐analysis or the principle: “garbage in, garbage out.” In my opinion, the only study with reasonable numbers that addresses the question of early versus late administration of epidural analgesia and its relation to cesarean section is that of Ohel et al (5). One can conclude that in this low cesarean section environment, an early epidural will not lead to an increase in the rate of cesarean section.…”