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Risks and Benefits (Review)
RISKS AND BENEFITS (Review)
1. Avard DM and Nimrod CM. Risks and benefits of obstetric epidural analgesia: a review. Birth 1985;12(4):215-225. Based on a literature review, the authors conclude:
INCREASE IN OPERATIVE DELIVERY
FORCEPS (VACUUM EXTRACTION)
2. Studd JWW et al. The effect of lumbar epidural analgesia on the rate of cervical dilatation and the outcome of labour of spontaneous onset. Br J Obstet Gynaecol 1980;87:1015-1021. (no dosage given)Outcomes were compared for 583 primiparas, of whom 80 had an epidural, and 1122 multiparas, of whom 46 had an epidural. All women had spontaneous onset of labor. Labor was augmented in 30% of primiparas and 16% of multiparas.
An epidural made no difference in cesarean rate (2.2% versus 2.5% in primiparas and 0.6% versus 0 in multiparas). Epidurals reduced spontaneous delivery rates among both primiparas (34.0% versus 79.0%, p <0.001) and multiparas (67.0% versus 94.0%, p <0.001). Rotational forceps were needed 20 times more often with an epidural (20.0% versus 0.8% in primiparas, p <0.001; 4.3% versus 0.2% in multiparas, p <0.001). When a subset of women in dysfunctional, augmented labor were compared, the trend was toward higher cesarean rates with an epidural (4.8% versus 5.8% in primiparas; 4.8% versus 7.5% in multiparas).
3. Phillips KC and Thomas TA. Second stage of labour with or without extradural analgesia. Anesthesia 1983;38:972-976. (initial bolus 0.5%, first top-up 0.375%, other top-ups 0.25%)Primigravidas with uncomplicated labors and epidurals were randomly allocated to two groups of 28. In group A, anesthesia was allowed to wear off when the mother was fully dilated and the fetal head descended below 0 station. The mother pushed when she felt the urge. In group B, anesthesia was continued, and the mother was directed to push when the fetal head got below 0 station. Fifty percent of group A and 68% of group B had oxytocin augmentation.
There was no difference in the incidence of malpositions at full dilation (43% in each group), but malposition was more likely to continue in group A (6 versus 2, p <0.05). The forceps rate in group A was 43% versus 25% in group B, but the difference was not significant [possibly because of the small number of subjects]. Thus, allowing epidural anesthesia to wear off appears to increase both malpositions and forceps delivery rates while increasing the mother's experience of pain.
4. Maresh M, Choong KH, and Beard RW. Delayed pushing with lumbar epidural analgesia in labour. Br J Obstet Gynaecol 1983;90:623.627. (no dosage given)Primiparas with epidurals and uncomplicated labors (N = 40) were told to push as soon as they had the desire (early pushing), and outcomes were compared with 36 similar women who rested on their side and were told not to push until the head was visible (delayed pushing). Augmentation rates were 27.5% in the early pushing group versus 19.4% in the delayed pushing group.
Mean waiting time was 30 minutes for early pushing and two hours for delayed pushing. Delayed pushing was associated with more spontaneous deliveries (50% versus 35%, NS). The difference was wholly due to less need for rotational forceps (4% versus 11%). [This study may have been too small to demonstrate a significant difference.] Delayed pushing did not harm the baby.
5. Bailey PW and Howard MB. Epidural analgesia and forceps delivery: laying a bogey. Anaesthesia 1983;38:282-285. (top-ups 0.25% in labor, 0.5% for perineal pain)Comparing the year 1977, prior to introduction of an epidural service, with 1980, when 72.4% of primiparas had epidurals, little change in instrumental delivery (24.3% in 1977 versus 26.8% in 1980) or cesarean rates (7.9% in 1977 versus 10.4% in 1980) was found. Active pushing was encouraged only when the mother felt the urge to push or the fetal head had descended onto the perineum.
6. Diro M and Beydoun S. Segmental epidural analgesia in labor: a matched control study. J Nat Med Assoc 1985;78(l):569-573. (0.25%)Women in spontaneous labor who elected epidurals for pain relief (N = 43) were matched with respect to age range, parity, stage of gestation, and infant birth weight to the next patient who did not have an epidural. The clinicians were not aware of the study, and the investigators were not involved in patient care.
7. Chestnut DH et al. The influence of continuous epidural bupivacaine analgesia on the second stage of labor and method of delivery in nulliparous women. Anesthesiology 1987;66:774.780. (initial bolus 0.25%, infusion 0.125%)
Augmentation was more frequent in the epidural group (74.4% versus 30.2%, p < 0.001). Among primigravidas, 7 of 35 (20%) had cesareans for failure to progress, all in the epidural group. All women having forceps deliveries were primigravidas - 25.6% in the epidural group versus 9.3% in the nonepidural group (p < 0.05). "Segmental epidural anesthesia is reasonably safe for both mother and fetus. This is predicated on the premise that the patient is fully aware she would most likely undergo prolonged labor, necessitating oxytocin augmentation and eventual forceps delivery." [The 20% versus 0% cesarean rate among primigravidas is not mentioned.]This trial randomly assigned 92 healthy nulliparous women with epidural anesthesia to one of two groups (N = 46 per group), one receiving bupivacaine as a top-up dose at 8 cm dilation, the other saline. (Five women were excluded who underwent cesarean section for dystocia before 8 cm). Ten percent of the women experienced "transient hypotension," and 11% of the fetuses had heart rate patterns alarming enough to prompt fetal scalp blood sampling.
Six women in each group underwent c-section for cephalopelvic disproportion (CPD) after the start of the study solution. Fifty-three percent of the bupivacaine group had an instrumental delivery versus 28% of the saline group ("<0.05). While pain relief was superior with analgesia, letting the epidural wear off shortened second-stage labor and reduced the instrumental delivery rate. [The overall cesarean rate was 17.1%, all for dystocia. There is no discussion of this.]
8. Kaminski HM, Stafi A, and Aiman J. The effect of epidural analgesia on the frequency of instrumental obstetric delivery. Obstet Gynecol 1987;69(5):770-773. (0.25%) Women who elected epidural anesthesia for pain relief (N = 155) were matched with women who had either local or pudendal anesthesia [pudendal blocks can also interfere with pushing]. Both groups were instructed to push at full dilation.Although birth weights did not differ, women who had epidurals had instrumental deliveries 2.5 times more often and midforceps procedures 3.4 times as often. White multigravidas who had epidurals were nine times more likely to have an instrumental delivery than white multigravidas who did not. OP presentations were found in 27% of those with epidurals versus 8% of controls. Of 103 women whose babies were born in the anterior (favorable) position, instruments were used three times as often and mid-forceps 3.7 times more often. All differences were significant (1' <0.05). Since birth weights were not different, this study refutes the theory that a bigger baby leads to a more painful labor, which leads to epidural anesthesia. It also refutes the theory that posterior babies lead to more painful labor and thus to epidurals because differences persisted when only anterior presentations were compared.
9. Saunders NJ et al. Oxytocin infusion during second stage of labour in primiparous women using epidural analgesia: a randomized double blind placebo controlled trial. BMJ 1989;299: 1423-1426. (0.375%)This trial examined the effect of oxytocin on primiparous women with epidural anesthesia who reached full dilation without oxytocin. Women were given either oxytocin (N 108) or saline (N= 118) at the onset of second stage. At this point 35% of babies were OP or OT. Oxytocin reduced the number of nonrotational instrumental deliveries (31% versus 47%, p = 0.03) and, because of this, the incidence of perineal trauma (episiotomy or second-degree tear [no information on deep tears]) (66% versus 79%, p = 0.04) but had no significant effect on rotational instrumental deliveries (18% oxytocin versus 9% controls).
ORGANIZATION OF ABSTRACTS
Epidurals - Obstetric Myths VS Research Realities... Continued Page 3
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