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Epidural Analgesia Forceps Delivery

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Epidural Analgesia Forceps Delivery

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									Epidural Analgesia

    Grand Rounds
      April 2006
    Jose Mata, MD
               Objectives
Describe the effects that epidural analgesia
  may have on:
• Labor progress
• Rates of assisted vaginal delivery
• Rates of cesarean section
• Fetal well-being
                  General

• Approximately 50-60% of women in labor
  choose epidural analgesia in the US

• Approximately 20% of women in labor
  choose epidural analgesia in the UK

         Anim-Somuah et al. Cochrane Review.
                            Pathways of Labor Pain




Eltzschig, H. K. et al. N Engl J Med 2003;348:319-332
         Types of Epidurals
• All include some type of local anesthetic
• Most also include an opioid
• “Walking epidurals” have a lower
  concentration of local anesthetic and add
  an opioid in an attempt to decrease motor
  blockade
• Can combine it with a spinal
• Typically a continuous infusion, but may
  also be patient-controlled or bolused
                    Labor Pain during Different Stages of Labor




Eltzschig, H. K. et al. N Engl J Med 2003;348:319-332
 Undisputed Benefits of Epidurals

• The most effective form of analgesia for
  labor
• Provides good analgesia for vaginal
  procedures (assisted delivery, manual
  rotation, manual removal of placenta, etc.)
• Can be used for cesarean section
       Topics to be Covered
The effects of epidural analgesia on:
• Prolongation of labor
• Rates of operative vaginal delivery
• Rates of cesarean section
• Rates of malposition
• Maternal adverse effects
• Neonatal adverse effects
        Prolongation of labor
• A review article found an average increase in
  the first stage of labor by 42 minutes*
• The same review found an average increase in
  the second stage of labor by 14 minutes*
• A Cochrane review found no significant
  difference on the first stage of labor+
• The same Cochrane review found prolongation
  of the second stage of labor by 15.6 minutes
  (95% CI: 7.5 to 23.6 minutes)+
                *- Eltzschig et al. NEJM Review.
           +- Anim-Somuah et al. Cochrane Review.
       Prolongation of Labor:
         Alexander Study
• Participants were nulliparous and had
  uncomplicated pregnancies
• Compared patient-controlled epidural to
  patient-controlled parenteral opioids
• The active phase of labor was prolonged
  by one hour in the epidural group
• Rate of cervical dilation was significantly
  lower in the epidural group
                  Alexander et al.
    Rates of instrumental vaginal
               delivery
• Consistently increased rate of vacuum and
  forceps delivery is observed with
  epidurals*
• Relative risk of instrumental delivery of
  1.38 (95% CI: 1.24-1.53)+
• Almost every study reviewed for this
  presentation found an increased rate of
  operative vaginal delivery with epidurals
             *- Eltzschig et al. NEJM Review.
        +- Anim-Somuah et al. Cochrane Review.
      Adverse Effects of Operative
           Vaginal Delivery
•   Perineal trauma
•   Urinary incontinence
•   Fecal incontinence
•   Sexual dysfunction
•   Organ prolapse
•   Chronic pain
•   Neonatal trauma
         Management of the
        Second Stage of Labor
• Cochrane review of discontinuation of epidural
  to reduce the prolongation of the second stage
• No significant difference in the length of the
  second stage or time spent pushing
• No significant difference in rate of operative
  vaginal delivery or c-section
• Only significant difference was an increase in
  inadequate pain relief
              Torvaldsen et al. Cochrane Review.
         Management of the
        Second Stage of Labor
• Evaluated the effects of delayed (1hr) versus
  immediate pushing on the second stage of labor
• Significantly longer labor with delayed pushing
• No reduction in operative vaginal delivery or
  cesarean section
• Identical fetal outcomes
• No differences in anal manometry or
  neurophysiological studies
                 Fitzpatrick et al. BJOG.
          Management of the
         Second Stage of Labor
• Compared delayed versus immediate pushing to
  reduce rates of operative vaginal delivery
• Non-significant reduction in the rate of operative
  vaginal delivery
• Statistically significant reduction in rate of
  rotational forceps
• Non-significant reduction in c-section
• Longer second stage in the delayed pushing
  group
• Significant reduction the total time pushing in the
  delayed pushing group
             Roberts et al. BJOG Meta-Analysis.
          Management of the
         Second Stage of Labor
• Evaluated immediate pushing versus waiting for
  a strong urge to push at complete cervical
  dilation in nulliparous patients
• No difference in the rates of operative vaginal
  delivery or cesarean section
• No difference in fetal outcome
• Significantly longer second stage in the delayed
  group
• No difference in total time spent pushing
             Plunkett et al. Obstetrics & Gynecology.
    Effect of Epidurals on the
    Rate of Cesarean Section
• Many observational studies have found
  that epidurals increase the rate of
  cesarean section
• None of these studies were prospective,
  randomized trials
    Criticisms of Early Studies
   Suggesting Higher Cesarean
            Section Rate
• Some compared women who chose to get
  an epidural to women who chose not to
• Were not intention-to-treat analyses
• Non-randomized, retrospective studies
• Often had a small sample size
            Eltzschig et al. NEJM (1-14).
   Rates of Cesarean Section
• A review found no significant increase in
  the rate of cesarean section with
  epidurals*
• A Cochrane review also found no
  significant difference in the rate of
  cesarean section, but the relative risk was
  1.07 (95% CI: 0.93-1.23)
              *- Eltzschig et al. NEJM Review.
         +- Anim-Somuah et al. Cochrane Review.
      Rates of Cesarean section:
            Sharma Study
• Largest contributor to the Cochrane review
• Intention-to-treat analysis comparing rates of
  cesarean section with epidural analgesia with
  patient-controlled parenteral analgesia
• No difference in the rates of cesarean section
• Statistically significant increase in low forceps
  deliveries for the epidural group
                 Sharma et al. Anesthesiology.
     Rates of Cesarean section:
        Sharma Study (cont)
• Significantly prolonged first stage in the
  epidural group
• No significant difference in the length of
  the second stage
• Significantly more women in the epidural
  group required oxytocin augmentation
• Significantly more women in the epidural
  group had an intrapartum fever
             Sharma et al. Anesthesiology.
      Rates of Cesarean Section:
           Loughnan Study
• Intention-to-treat analysis comparing the rates of
  cesarean section between epidural analgesia
  and parenteral opioids using an active
  management of labor protocol
• No statistically significant difference in the rates
  of cesarean section
• Statistically significant difference at initiation of
  analgesia between the two groups with the
  parenteral opioids group have a smaller cervical
  dilation
                    Loughnan et al. BJA.
      Rates of Cesarean Section:
               Liu Study
• A systematic review evaluating the rate of
  cesarean section in the setting of low
  concentration epidurals versus parenteral
  opioids
• No statistically significant difference in rates of
  cesarean section
• Statistically significant increase in operative
  vaginal delivery
• Epidurals prolonged the second stage of labor
                       Liu et al. BMJ.
          Timing of Epidural

• Most observational studies show higher
  rates of cesarean section if epidurals
  started at cervical dilation of less than 4cm

• No randomized controlled trial to date has
  supported the above finding
                Eltzschig et al. NEJM.
     Rates of Cesarean Section:
            Wong Study
• Evaluated cesarean section rate in the setting of
  early epidurals compared to parenteral opioids
• There was a significant differences of cervical
  dilation at the initiation of analgesia
• There was also a significant difference in the
  percentage of spontaneous rupture of
  membranes prior to randomization
• No difference in cesarean section or operative
  vaginal delivery
• Parenteral opioid group required significantly
  more oxytocin
                   Wong et al. NEJM.
        Rates of Malposition

• An association between occiput posterior
  position and epidurals has been reported*

• The relative risk for malposition with an
  epidural is 1.4 (95% CI: 0.98-1.99)
              *- Eltzschig et al. NEJM Review.
         +- Anim-Somuah et al. Cochrane Review.
          Intrapartum Fever
• Epidural analgesia is consistently
  associated with maternal temperature >
  100.4oF about 20% of the time*
• No difference in the rates of neonatal
  sepsis*
• Relative risk of intrapartum fever of 3.7
  (95% CI: 2.8-4.9) with epidural analgesia+
             *- Eltzschig et al. NEJM Review.
        +- Anim-Somuah et al. Cochrane Review.
       Maternal Hypotension
• The relative risk of maternal hypotension
  is 20.1 (95% CI: 4.83-83.64) with epidurals
• The hypotension is usually transient and
  typically resolves within one hour
• The hypotension is very likely to be
  associated with a non-reassuring FHT
• Can be prevented by IV bolus of at least
  500mL of isotonic fluid
         Anim-Somuah et al. Cochrane Review.
     Post-Epidural Headache

• Thought to be due to puncture of the dura

• Incidence of 1%

• Blood patch effectively treats the above
  60% of the time
         Anim-Somuah et al. Cochrane Review.
    Long-term Low Back Pain

• A review found no significant association
  between epidurals and long-term low back
  pain*
• A Cochrane review also failed to find any
  significant association between epidurals
  and long-term low back pain+
             *- Eltzschig et al. NEJM Review.
        +- Anim-Somuah et al. Cochrane Review.
    Long-term Low Back Pain:
          Howell Study
• Follow-up study after a randomized,
  controlled trial
• No significant difference in self reported
  low back pain after more than 2 years
• No significant differences in physical exam
  after more than 2 years
• No significant differences in terms of
  disability after more than 2 years
                 Howell et al. BMJ.
      Neonatal Complications
• No significant difference in Apgar scores
  with epidurals
• A relative risk of arterial cord pH<7.2 of 0.8
  (95% CI: 0.66-0.96)
• A relative risk of naloxone administration
  (when compared to parenteral opioids) of
  0.13 (95% CI: 0.08-0.21)
          Anim-Somuah et al. Cochrane Review.
            Fetal Heart Rate
• Reported rates of abnormal fetal heart tracings
  after epidural of 11% to 78%
• Typically lasts less than 30-40 minutes after
  initiation of epidural anlagesia
• 34% of all patient experienced abnormal fetal
  heart rate tracings within 40 minutes of epidural
  initiation
• Repetitive late decelerations were rare (<2%)
               Hill et al. Obtetrics & Gynecology
      Effects of Epidurals on
     Fetal Acid-Base Balance
• Significant improvement in cord arterial pH
  with epidurals
• An odds ratio of 0.54 (P-value < 0.05) for a
  1-minute Apgar <7
• An odds ratio of 0.20 (P-value < 0.01) for
  naloxone administration
                Reynolds et al. BJOG.
      Summary of the Effects of
            Epidurals
• Consistently associated with statistically
  significant prolongation of labor
• Consistently associated with statistically
  significant increased rates of operative
  vaginal delivery
• May lead to increased rates of cesarean
  section
• May increase the rates of malposition
      Summary of the Effects of
         Epidurals (cont)
• Increased rate of intrapartum fever
• Increased rate of transient maternal
  hypotension
• Increased rate of transient non-reassuring
  fetal heart tracings
• Have no direct adverse affects on the
  fetus
• Do not cause long-term low back pain
              Conclusion
ACOG guidelines from 2002 state that a
 woman’s request for pain relief during
 labor alone is sufficient medical
 justification for the use of epidural
 analgesia
        Recommendations
• Discuss epidural analgesia with your
  patients during prenatal visits
• Present the data in an unbiased manner
  and help the patient make the decision
  that is best for them
• Support your patient in whatever decision
  they make
                           References
1.   Anim-Somuah, M. et al. Epidural versus non-epidural or no analgesia in
     labour. The Cochrane Database of Systematic Reviews 2005.
2.   Eltzschig, H.K. et al. Regional Anesthesia and Analgesia for Labor and
     Delivery. NEJM. Jan 23, 2003. vol 348(4): 319-332.
3.   Alexander, J.M. et al Epidural Analgesia Lengthens the Friedman Active Phase of
     Labor. Obstetrics & Gynecology. July 2002. vol 100(1):46-50.
4.   Torvaldsen, S. et al. Discontinuation of epidural analgesia late in labour for
     reducing the adverse delivery outcomes associated with epidural analgesia. The
     Cochrane Database of Systematic Reviews 2004.
5.   Fitzpatrick, M. et al. A randomised clinical trial comparing the effects of delayed
     versus immediate pushing with epidural analgesia on mode of delivery and faecal
     continence. BJOG. December 2002. vol 109: 1359-1365.
6.   Roberts, C.L. et al. Delayed versus early pushing in women with epidural
     analgesia: a systematic review and meta-analysis. BJOG. December 2004. vol
     111: 1333-1340.
                 References (cont)
7.    Plunkett, B.A. et al. Management of the Second Stage of Labor in
      Nulliparas With Continuous Epidural Analgesia. Obstetrics & Gynecology.
      July 2003. vol 102(1): 109-114.
8.    Sharma, S.K. et al. Cesarean Delivery: A Randomized Trial of Epidural
      versus Patient-controlled Meperidine Analgesia during Labor.
      Anesthesiology. September 1997. vol 87(3): 487-494.
9.    Loughnan, B.A. et al. Randomized controlled comparison of epidural
      bupivacaine versus pethidine for analgesia in labour. British Journal of
      Anaesthesia. 2000. vol 84(6): 715-719.
10.   Liu, E.H.C. et al. Rates of caesarean section and instrumental vaginal
      delivery in nulliparous women after low dose concentration epidural
      infusions or opioid analgesia: systematic review. BMJ. June 12, 2004. vol
      328(7453): 1410-1415.
11.   Wong, C.A. et al. The Risk of Cesarean Delivery with Neuraxial
      Analgesia Given Early versus Late in Labor. NEJM. February 17, 2005.
      vol 352(7): 655-665.
                 References (cont)
12.   Howell, C.J. et al. Randomised study of long term outcome after epidural
      versus non-epidural analgesia during labor. BMJ. August 17, 2002. vol
      325(7360): 357-360.
13.   Hill, J.B. et al. A Comparison of the Effects of Epidural and Meperidine
      Analgesia During Labor on Fetal Heart Rate. Obstetrics & Gynecology.
      August 2003. vol 102(2): 333-337.
14.   Reynolds, F. et al. Analgesia in labour and fetal acid-base balance: a
      meta-analysis comparing epidural with systemic opioid analgesia. BJOG.
      December 2002. vol 109: 1344-1353.

								
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