Epidural analgesia in association with duration of labor and mode of delivery: A quantitative review,☆☆

Presented at the National Institute of Child Health and Human Development Workshop on Epidural Analgesia in Labor, National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland, February 19, 1998.
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Abstract

Objective: This study was undertaken to quantitatively summarize previous literature on the effects of epidural analgesia in labor on the duration of labor and mode of delivery. Study Design: Original studies published in English from 1965 through December 1997 were reviewed and assigned a quality score independently by 2 of the authors. Studies that met the minimal requirements were evaluated further. Data syntheses were performed separately according to study design and outcome measurements, including cesarean delivery, instrumental delivery, oxytocin augmentation, and durations of the first and second stages of labor. Results: Seven randomized clinical trials and 5 observational studies met the minimal requirements. Among them 4 studies of each sort were included in the data synthesis. Both types of studies showed that epidural analgesia increased risk of oxytocin augmentation 2-fold. Clinical trials suggested that epidural analgesia did not increase the risk of cesarean delivery either overall or for dystocia, nor did it significantly increase the risk of instrumental vaginal delivery; however, observational studies reported a more than 4-fold increased risk of cesarean and instrumental deliveries. Although most studies showed a longer labor among women with epidural analgesia than without it, especially during the second stage, most of the studies used inappropriate statistical analysis. Conclusion: Epidural analgesia with low-dose bupivacaine may increase the risk of oxytocin augmentation but not that of cesarean delivery. (Am J Obstet Gynecol 1999;180:970-7.)

Section snippets

Material and methods

We conducted a MEDLINE search on the key words epidural, labor, forceps, cesarean, and delivery. Articles published in English from 1965 to December 1997 were potentially eligible for this review. We narrowed the search to those focusing on the effects of epidural analgesia on duration of labor and mode of delivery. We collected these articles and searched for other potentially eligible studies by cross-checking all the references in these reports. We found 32 published original studies that

Randomized clinical trials by Chestnut et al

Chestnut et al6, 7, 10 conducted 3 of the 7 randomized clinical trials, 2 of them with a double-blind design. These studies were intended to examine whether continuing epidural analgesia in the second stage of labor affects the course of labor and mode of delivery in the second stage.6, 7 Both studies enrolled nulliparous patients with a term singleton gestation and vertex presentation. All patients had epidural analgesia in the first stage, but about half of them had normal saline solution

Comment

Whether epidural analgesia increases the risk of cesarean delivery and prolongs labor has been intensely debated during the last decade.17 Unfortunately, good studies are few and most have had small numbers of subjects. Randomized clinical trials are difficult to perform because epidural analgesia has been commonly used and provides superb pain relief during labor. Method switching, mostly from the control group to the epidural group, diminishes the ability to interpret randomized clinical

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    Reprint requests: Jun Zhang, MB, PhD, Division of Epidemiology, Statistics, and Prevention Research, National Institute of Child Health and Human Development, Building 6100, Room 7B03, Bethesda, MD 20892-7510.

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