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MoonDragon's Pregnancy Information
EPIDURAL ANESTHESIA
Obstetric Myths VS Research Realities
Chapter 13
Page 4


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Epidural Anesthesia - Obstetric Myths VS Research Realities
Chapter 13 - By Henci Goer







COMPLICATIONS OF EPIDURAL ANALGESIA FOR LABOR


MOTHER ONLY

20. Crawford JS. Some maternal complications of epidural analgesia for labour. Anesthesia, 1985;40(12):1219-1225.
    "[T]here appears to be no reliable data relating to the incidence of complications of [epidural anesthesia] and to the grades of severity of such complications." This review of 26,490 consecutive cases was undertaken to fill that gap. [Yet epidurals have achieved immense popularity, and millions of women have been assured of their safety without this information.) The review excluded elective c-section, complications of anesthesia failure, and brief episodes of hypotension, backache, and bladder problems. Case histories were presented of life-threatening, serious, and moderately serious complications.

    The authors found nine (1:3000) potentially life-threatening complications, of which three (1:9000) caused a "relatively protracted period of real concern." These were intravenous or intrathecal injection causing loss of consciousness, convulsions, cardiopulmonary arrest, hypotension, or respiratory difficulty and fetal distress. There were as well two serious but not life-threatening complications:
      (1) foreign matter provoked cyst formation, which impinged on a nerve, causing foot drop (surgery effected a cure), and

      (2) an abscess formed due to an undetected strep infection (surgery effected a cure).

    There were 13 moderately serious complications, including prolonged hypotension; severe hypertension; persistent postpartum backache, legache, numbness, or weakness; and 17 mildly disturbing complications. A number of moderate and mild complications were blamed on the epidural but turned out to have other causes. The test dose did not prevent intrathecal or intravenous injection, and all the major problems occurred with experienced anesthesiologists.
21. Ong BY et al. Paresthesias and motor dysfunction after labor and delivery. Anesth Anaig 1987;66:l8-22.
    Reviewing the charts of 23,827 births over a 9-year period gave occurrence rates for paresthesias [abnormalities of sensation] and motor dysfunction [abnormalities of muscle control) of 36.2 per 10,000 for patients with epidurals versus 18.9 per 10,000 for deliveries overall, 2.4 per 10,000 for women with no analgesia, and 6.3 per 10,000 for women with inhalational analgesia. [Charts are likely to underreport problems.] The epidural rate was 40%. These injuries were more likely among primiparas than multiparas (" < 0.02) and with instrumental compared with spontaneous deliveries (p < O.O3). All were minor and resolved with supportive therapy. [They may not have been minor to the mother.] The authors believe that the increased instrumental delivery rate associated with epidurals was the likely cause of the difference rather than the epidural itself.
22. Scott DB and Hibbard BM. Serious non-fatal complications associated with extradural block in obstetric practice. Br JAnaesth 1990;64:537-541.
    All United Kingdom obstetric units were sent a questionnaire requesting information on the incidence and nature of serious complications following an epidural. Of the 271 obstetric units, 203 responded, representing 78% of British births. This study reports on 505,000 extradural blocks given between 1982 and l986 - 84% for pain relief in labor and 16% for cesarean section.

    Adverse events included
      (1) three cases of cardiac arrest, one leading to brain damage;
      (2) 39 cases of nerve damage, two with permanent effect;
      (3) one case of spinal abscess and one of hematoma, both listed as "still improving";
      (4) six cases of urinary problems "of sufficient severity to be remembered";
      (5) five cases of severe backache;
      (6) one case of memory loss;
      (7) 22 cases of dural tap, 16 causing severe headache, five leading to cranial nerve palsy, and one to subdural hematoma;
      (8) 20 cases of convulsions;
      (9) eight high or total spinals leading to paralysis of the respiratory muscles; and
      (10) one case of allergic shock. [It is a safe bet that with self-reporting on a voluntary basis, complications were underreported.]

23. Yancey MK et al. Maternal and neonatal effects of outlet forceps delivery compared with spontaneous vaginal delivery in term pregnancies. Obstet Gynecol 1991;78(4):646-650. (infusion 2% chlorprocaine or 0.25% bupivacaine)
    When the fetal head had descended to +2 station in the anterior position, women were randomly assigned to spontaneous birth (N = 168) or outlet forceps delivery (N = 165). Women who had epidurals made up half the group (7 of 14) that had to be excluded from the spontaneous arm because they required forceps. No woman who had an epidural was in the group (none of 13) that was excluded from the forceps arm because spontaneous birth was imminent. Infant outcomes were similar, but more women in the forceps group had episiotomy (93% versus 78%, p < 0.05) and tears into or through the rectal sphincter (24% versus 10%, p <0.05). [See Chapter 14 for the consequences of deep tears.)
24. MacArthur C, Lewis M, and Knox EG. Investigation of long term problems after obstetric epidural anaesthesia. BMJ 1992;304:1279-1282.
    Data on long-term postpartum effects (meaning began at 3 months or less after birth, lasted 6 or more weeks, never experienced prior to birth) of epidurals were gathered from hospital case notes and postal questionnaires mailed to mothers. Data ranged from 13 months to 9 years postpartum. No information on severity was obtained. The 11,701 women represented 78% or more of those mailed questionnaires. Of them, 4766 had epidurals, and 6935 did not. Discriminant analysis was used because it eliminates associations with epidurals that might arise because epidurals associate with more interventive deliveries. [But since epidurals cause operative delivery, they could be an indirect cause of problems in such cases.]

    Symptoms that were more likely to be reported after epidural were backache (18.2% versus 10.2%, p < 0.001), frequent headaches (4.6% versus 2.9%, p < 0.001), migraines (1.9% versus 1.1%, p <0.001), neckache (2.4% versus 1.6%, p <0.01), tingling in the hands (3.0% versus 2.2%, p <0.01), dizziness or fainting (2.1% versus 1.6%, p <0.05), and visual disturbances (1.7% versus 1.3% [no p value given)). Spinal headache occurred in 34 women as a result of accidental dural puncture (0.1% of all epidurals) or spinal anesthesia (2.5% of all spinal blocks). Although this headache is believed to subside within a week even without treatment, nine women reported the headache lasted more than 6 weeks and five that it lasted more than 1 year. Headache, neckache, and tingling related to epidural only when reported in association with backache. Visual disturbances related only to migraine. In response to an open-ended question, 26 women reported numbness or tingling in lower back, buttocks, or leg, of whom 23 had an epidural - a "highly significant" difference. Most symptoms had lasted much longer than the six weeks of the study definition. "About two thirds were still present at the time of our inquiry. It was clear that many problems had become chronic."

BABY ONLY

\ PHYSICAL ADVERSE EFFECTS

25.Clark DA and Landaw SA. Bupivacaine alters red blood cell properties: a possible explanation for neonatal jaundice associated with maternal anesthesia. Pediatr Res 1985;19(4):341-343.
    "Neonatal jaundice has been correlated with epidural anesthesia. Bupivacaine has been especially suspect." This study confirms through in vitro and in vivo experiments that bupivacaine, compared with lidocaine, mepivacaine, or buffer, shortens neonatal red blood cell lifetime. [Neonatal jaundice results when the infant cannot cope with the breakdown products of dead red blood cells, so shortened survival time increases the likelihood of jaundice. See also Chapter 11. IV fluids, especially nonisotonic solutions given in bolus amounts, as is done prior to an epidural, cause swelling and rupture of red blood cells from osmotic pressure.]
26. Stavrou C, Hofmeyr GJ, and Boezaart AP. Prolonged fetal bradycardia during epidural analgesia. S Afr Med J 1990;77:66-68. (initial bolus 0.375%, top-ups of 0.25% or infusion 0.08%)
    The fetal monitor tracings of 207 women in normal labor with epidural anesthesia were analyzed. Prolonged bradycardia (defined as a fall in FHR of at least 50 beats per minute below the previous rate and lasting 3 minutes or more) occurred in 11% of the fetuses. In two cases, this led to an emergency cesarean and in three cases to an instrumental delivery. The cesarean rate was 31.4%, and 26.1% of those delivering vaginally had assisted deliveries. (Primiparas made up 79% of the population.) Since maternal hypotension "did not seem to play an important role" in this study, the authors theorized that the adrenaline-containing test dose was the culprit. The authors concluded that although epidurals associated with fetal bradycardia, this was not of clinical significance because all babies were fine. [Apparently the authors consider the two epidural caused cesareans to be trivial.]

27. Eddleston JM et al. Comparison of the maternal and fetal effects associated with intermittent or continuous infusion of extradural analgesia. Br J Anaesth 1992;69:154-158. (intermittent bolus 0.25% versus infusion 0.125%) To examine the effect of epidurals on FHR in first-stage labor, 80 healthy primigravidas in established labor with normal FHR who wanted epidural anesthesia were randomly and evenly assigned to either intermittent bolus (group A) or continuous infusion with top-ups as required (group B). Two women in the bolus group and three in the infusion group (6.2%) got no pain relief from the epidural. Five EFM tracings were missing. [This may be an important omission.] The cesarean rate was 15% (six women per group) and 40% of group A had instrumental delivery versus 53% of group B (NS). Five percent of the women in each group experienced hypotension (systolic arterial pressure < 100 mm Hg or drop > 30 mm Hg) after top-ups. Most babies experienced FHR decelerations (72.7%) after the epidural was given, and almost half (47.9%) of these decelerations were associated with top-ups or an increase in the infusion rate. None was associated with maternal hypotension. Group A had 20 deceleratory episodes lasting more than 10 minutes on 38 tracings (53%), of which 11(55%) were related to top-ups. Group B had 27 similar events on 37 tracings (73%), of which 13 (35%) were related to top-ups or increase in infusion rate. "Fetal myocardial uptake is the proposed mechanism to explain a proportion of fetal decelerations observed within a relatively short time interval (30 mm) after injection of bupivacaine."

BEHAVIORAL ADVERSE EFFECTS

28. Murray AD et al. Effects of epidural anesthesia on newborns and their mothers. Child Develop 1981;52:71-82.
    The effects of an epidural on newborn behavior were assessed among women having vaginal births. Twenty mothers had a bupivacaine epidural, 20 mothers a bupivacaine epidural plus oxytocin, and 15 control mothers "little or no medication." Bupivacaine was found in umbilical vein plasma. Five women were excluded from the control group because fetal blood levels of lidocaine from the local perineal injection for episiotomy were so high. These babies exhibited the same "worrisome" symptoms as the epidural babies. Those conducting neonatal behavioral tests and evaluating mother-baby interactions were blinded to groups.

    Epidural mothers were more likely to have malpositions (0 unmedicated, 25% epidural, 40% oxytocin and epidural, p <0.02) and forceps deliveries (0 unmedicated, 60% epidural, 80% oxytocin and epidural, p < 0.01). They were also more likely to be separated from their babies (0 unmedicated, 20% epidural, 30% oxytocin and epidural, p <0.07 [probably did not reach significance because the groups were so small]). During the first 24 hours, medicated babies performed poorly compared with control babies. Oxytocin and forceps delivery further depressed scores. By the fifth day, scores had improved, but medicated babies still showed poor state organization [crying, feeding, alertness, sleeping]. The mother's observations of behavior and feedings agreed with scores. A higher incidence of neonatal jaundice in the oxytocin-epidural group may have contributed to lowering scores. Twenty percent needed phototherapy versus none in the unmedicated group and 5% in the epidural-only group. By one month, few differences between groups persisted, but mothers of medicated babies perceived them to be more difficult to care for. The authors theorize that the first days of life may have an imprinting effect on the mother's perceptions.

29. Kuhnert BR, Linn PL, and Kuhnert PM. Obstetric medication and neonatal behavior. Clin Perinatol 1985;12(2):423-439.
    Confined to recent studies, this review paper focuses on the difficulties of conducting studies on behavioral effects of labor medications in the newborn and evaluating the results. Epidural anesthetic medications do affect the newborn, but the significance of the effect is debated.

FEVER

30. Fusi L et al. Maternal pyrexia associated with the use of epidural analgesia in labour. Lancet Jun 3, 1989;1250-1252. (0.375%)
    Fifteen healthy women in spontaneous labor who had no evidence of infection and used pethidine [a narcotic] for pain relief were compared with a similar group of 18 women who had epidurals. Temperatures were taken both orally and vaginally. The body temperature of the pethidine group remained constant; the vaginal temperature of the epidural group rose roughly l degree centigrade every seven hours (p <0.001). Vaginal and oral temperatures correlated. In the mother, pyrexia [fever), even in the absence of uterine infection, can lead to hypertonic [overly contracted] uterus, hypotension, tachycardia [rapid heartbeat), and metabolic acidosis. Maternal fever can cause fever in the fetus, leading to tachycardia, and reduced ability to adapt to the stress of labor [also separation from the mother after birth and a septic workup to rule out infection]. Persistent fetal fever can lead to hypotension and acidosis.
31. Macaulay JH, Bond K, and Steer PJ. Epidural analgesia in labor and fetal hyperthermia. Obstet Gynecol l992;80(4):665~669. (0.5%)
    An intrauterine probe was used to measure uterine wall and fetal skin temperature in laboring women, of whom 33 had epidurals and 24 used other methods of pain control. Maternal oral temperatures were also taken. Only two women had oral temperatures over 37~50 degrees C, but uterine temperatures rose above this point in 45% of the epidural versus 8% of the nonepidural group. Among the fetuses, 30%, all from the epidural group, had skin temperatures over 38 degrees C. Maximum fetal skin temperature correlated with time since epidural induction (p = 0.012), but there was no correlation with time in the nonepidural group. Anesthetic dosage also did not correlate with temperature. An estimated 5% of fetuses reached a core temperature more than 400 degrees C, all in association with an epidural. "[T]he fetus whose mother has a long labor using epidural analgesia in a hot environment may reach a temperature at which heat-induced neurologic injury can occur."




NEWER TECHNIQUES OFFER NO IMPROVEMENT


CONTINUOUS INFUSION

32. Bogod DG, Rosen M, and Rees GAD. Extradural infusion of 0.125% bupivacaine at 10 Ml H1 to women during labour. Br J Anaesth 1987;59 (3):325~330. (initial bolus 0.5%, top-ups 0.5% or 0.25%, infusion 0.125%)
    Outcomes were compared between primigravidae assigned to continuous infusion (N = 50) or to intermittent top-ups (N = 50). Twenty percent of the infusion group versus 18% of the top-up group had cesareans. Fifty-two percent of the infusion group versus 46% who had top-ups had instrumental deliveries. Eighty-two percent of the infusion group had bladder catheterizations versus 84% of the top-up group. The mean maximum decrease in systolic blood pressure was 16 mm Hg in the infusion group versus 17 mm Hg in the top-up group and the mean slowest fetal heart rate was 122 beats per minute in the infusion group versus 118 beats per minute among top-ups. [The lower limit of normal is 120 beats per minute. The mean does not tell how many babies experienced bradycardia or how severely)
33. Smedstad KG and Morison DH. A comparative study of continuous and intermittent epidural analgesia for labour and delivery. Can J Anaesth 1988;35(3):234-241. (initial bolus 0.25%, top-ups 0.25%, infusion 0.25%)
    Twenty-eight women had continuous infusions, of whom 29% had a cesarean, 11% had mid-forceps, and 43% had low forceps. Twenty-nine women had an initial bolus and top-ups, of whom 24% had cesarean sections and 7% had mid-forceps, and 17% had low forceps. Continuous epidural anaesthesia offers no improvement over top-ups with regard to cesarean section and mid-forceps. Top-ups reduced the need for low forceps (p <0.05).



ANESTHETIC PLUS NARCOTIC

34. Chestnut DH et al. Continuous infusion epidural analgesia during labor: A randomized, double-blind comparison of 0.0625% bupivacaine/0.0002% fentanyl versus 0.125% bupivacaine. Anesthesiol 1988;68:754-759. (see article title)
    When 41 healthy nulliparous women with a fentanyl-bupivacaine epidural were compared with a similar group of 39 women with a bupivacaine epidural, outcomes were similar. Cesarean rates were 15% and 18% and forceps rates were 27% and 21%, respectively. [These forceps rates were despite discontinuing the infusion at full dilation and delaying pushing one hour if the mother felt no urge to push.] Of the fentanyl bupivacaine group, 27% were augmented with oxytocin after the epidural started (37% were already on IV oxytocin) versus an 18% augmentation rate among the bupivacaine epidural group (33% were already on IV oxytocin). Eight fetuses in each group had FHR patterns alarming enough to prompt fetal scalp blood pH determinations (20% total fetal distress rate), and 39% fentanyl-bupivacaine babies versus 31% bupivacaine babies had meconium-stained amniotic fluid. Fentanyl-bupivacaine women were more likely to experience pruritis [mild itching] (22% versus 5%).

35. Naulty JS. Continuous infusions of local anesthetics and narcotics for epidural analgesia in the management of labor. Int Anesthes Clin 1990;28(l):17-24.
    Naulty reviews the literature on narcotic-bupivacaine epidurals and pure narcotic epidurals. He favors narcotic-bupivacaine epidurals because there is less total dosage and less motor blockade (leg paralysis). Even so, he reports on two studies where this did not increase the percentage of spontaneous deliveries.




ORGANIZATION OF ABSTRACTS


Epidural OB Myth: Risks and Benefits (Review)
Epidural OB Myth: Increase in Operative Delivery
Epridural OB Myth: Forceps/Vacuum Extraction
Epidural OB Myth: Cesarean
Epidural OB Myth: Complications
Epidural OB Myth: Papers Including Complications in Both Mother and Baby
Epidural OB Myth: Mother Only
Epidural OB Myth: Baby Only
Epidural OB Myth: Physical Adverse Effects
Epidural OB Myth: Behavioral Adverse Effects Fever
Epidural OB Myth: Newer Techniques Offer No Improvement
Epidural OB Myth: Continuous Infusion Anesthetic Plus Narcotic
Epidural OB Myth: Precautions Are Not Foolproof
Epidural OB Myth: Test Dose
Epidural OB Myth: Technique of Administration
Epidural OB Myth: References


Epidurals - Obstetric Myths VS Research Realities: Page 1 - Introduction
Epidurals - Obstetric Myths VS Research Realities: Page 2 - Abstracts
Epidurals - Obstetric Myths VS Research Realities: Page 3 - Abstracts
Epidurals - Obstetric Myths VS Research Realities: Page 4 - Abstracts
Epidurals - Obstetric Myths VS Research Realities: Page 5 - Abstracts & References





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