Early Versus Late Epidural Analgesia and Risk of Instrumental Delivery in Nulliparous Women: A Systematic Review

Wassen, Martine M L H; Zuijlen, J.; Roumen, Frans J.M.E.; Smits, Luc; Marcus, Marco A. E.; Nijhuis, Jan G.

doi:10.1097/ogx.0b013e31823b5f58

Cited by 7 publications

(8 citation statements)

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“…We did not control for the timing of epidural placement; however, there appears to be no difference in incidence of AVD between early and late epidural in labour. 37 In conclusion, LCs (B 0.1% bupivacaine or equivalent ropivacaine dose) of labour epidural solutions improve obstetric outcomes (decreased AVD, shorter duration of second stage of labour) and reduce maternal side effects (less motor blockade, better ambulation, and decreased urinary retention) without compromising analgesia. Adverse neonatal effects (lower one-minute Apgar scores) with questionable clinical significance should be weighed against the clear maternal advantages gained.…”

Section: Discussionmentioning

confidence: 99%

The effect of low concentrations versus high concentrations of local anesthetics for labour analgesia on obstetric and anesthetic outcomes: a meta-analysis

Sultan

Murphy

Halpern

et al. 2013

Can J Anesth/J Can Anesth

120

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Introduction The influence that different concentrations of labour epidural local anesthetic have on assisted vaginal delivery (AVD) and many obstetric outcomes and side effects is uncertain. The purpose of this meta-analysis was to determine whether local anesthetics utilized at low concentrations (LCs) during labour are associated with a decreased incidence of AVD when compared with high concentrations (HCs). Methods We searched PubMed, Ovid EMBASE, Ovid MEDLINE, CINAHL, Scopus, clinicaltrials.gov, and Cochrane databases for randomized controlled trials of labouring patients that compared LCs (defined as B 0.1% epidural bupivacaine or B 0.17% ropivacaine) of epidural local anesthetic with HCs for maintenance of analgesia. The primary outcome was AVD and secondary outcomes included Cesarean delivery, duration of labour, analgesia, side effects (nausea and vomiting, motor block, hypotension, pruritus, and urinary retention), and neonatal outcomes. The odds ratios (OR) or weighted mean differences (WMD) and 95% confidence intervals (CI) were calculated using random effects modelling. An OR \ 1 or a WMD \ 0 favoured LCs. Results Eleven studies met our criteria (eight bupivacaine and three ropivacaine studies), providing 1,145 patients in the LCs group and 852 patients in the HCs group for analysis of the primary outcome. Low concentrations were associated with a reduction in the incidence of AVD (OR = 0.70; 95% CI 0.56 to 0.86; P \ 0.001). There was no difference in the incidence of Cesarean delivery (OR 1.05; 95% CI 0.82 to 1.33; P = 0.7). The LCs group had less motor block (OR 3.9; 95% CI 1.59 to 9.55; P = 0.003), greater ambulation (OR 2.8; 95% CI 1.1 to 7.14; P = 0.03), less urinary retention (OR 0.42; 95% CI 0.23 to 0.73; P = 0.002), and a shorter second stage of labour (WMD -14.03; 95% CI -27.52 to -0.55; P = 0.04) compared with the HCs group. There were no differences between groups in pain scores, maternal nausea and vomiting, hypotension, fetal heart rate abnormalities, five-minute Apgar scores, and need for neonatal resuscitation. One-minute Apgar scores \ 7 favoured the HCs group (OR 1.53; 95% CI 1.07 to 2.21; P = 0.02), and there was more pruritus in the LCs group (OR 3.36; 95% CI 1.00 to 11.31; P = 0.05). Conclusion When compared with HCs of local anesthetics, the use of LCs for labour epidural analgesia reduces the incidence of AVD. This may be due to a Author contributions Pervez Sultan, Caitriona Murphy, Stephen Halpern, and Brendan Carvalho made substantial contributions to the conception and design of the study and were involved in drafting the article for important intellectual content. -013-9981-z reduction in the amount of local anesthetic used and the subsequent decrease in motor blockade. We therefore recommend the use of LCs of local anesthetics for epidural analgesia to optimize obstetric outcome.123 Can J Anesth/J Can Anesth (2013) 60:840-854 DOI 10.1007/s12630 RésuméObjectif Nous connaissons mal l'influence de différentes concentrations d'anesthésique local pour la péridurale...

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Section: Discussionmentioning

confidence: 99%

The effect of low concentrations versus high concentrations of local anesthetics for labour analgesia on obstetric and anesthetic outcomes: a meta-analysis

Sultan

Murphy

Halpern

et al. 2013

Can J Anesth/J Can Anesth

120

View full text Add to dashboard Cite

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“…Although it has been suggested that the use of neuraxial analgesia (epidural, spinal, or combined spinal-epidural) may prolong the latent phase of spontaneous labor, numerous trials have failed to find an increase in cesarean delivery with neuraxial analgesia, either during labor induction or after spontaneous labor. (22)(23)(24) As such, neuraxial analgesia should not be withheld or delayed because of concerns regarding the risk of cesarean delivery.…”

Section: Labor Analgesiamentioning

confidence: 99%

Preventing the First Cesarean Delivery

Spong

Berghella

Wenstrom

et al. 2012

Obstetrics & Gynecology

604

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With over one-third of pregnancies in the United States being delivered by cesarean and the growing knowledge of morbidities associated with repeat cesarean deliveries, the Eunice Kennedy Shriver National Institute of Child Health and Human Development, the Society for Maternal-Fetal Medicine, and the American College of Obstetricians and Gynecologists convened a workshop to address the concept of preventing the first cesarean. The available information on maternal and fetal factors, labor management and induction, and non-medical factors leading to the first cesarean were reviewed as well as the implications of the first cesarean on future reproductive health. Key points were identified to assist with reduction in cesarean rates including that labor induction should be performed primarily for medical indication; if done for non-medical indications, the gestational age should be at least 39 weeks or more and the cervix should be favorable, especially in the nulliparous patient. Review of the current literature demonstrates the importance of adhering to appropriate definitions for failed induction and arrest of labor progress.

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“…Epidural placement at 2 to 5 cm is associated with similar maternal (instrumental delivery, CD, etc.) and neonatal outcomes compared with epidural placement at !3 to 5 cm in women in spontaneous labor or receiving oxytocin (16)(17)(18)(19)(20). Therefore, the decision of when to place epidural analgesia should be made individually with each woman (1).…”

Section: Epidural Analgesiamentioning

confidence: 99%