Context.—Epidural labor analgesia, if selected by the
patient, is associated with high cesarean delivery rates. Results of
randomized trials comparing rates of cesarean delivery using epidural
anesthesia vs parenteral opioids are inconsistent.Objective.—To review the effects of epidural vs parenteral
opioid analgesia on cesarean delivery rates.Data Sources.—Studies were identified by searching MEDLINE
from January 1966 through January 1998, the Cochrane Database of
Perinatal Trials, and relevant nonindexed journals and abstracts.Study Selection.—We included all studies that randomized
patients to epidural vs parenteral opioid labor analgesia.Data Extraction.—Two authors independently extracted data
from 10 trials enrolling 2369 patients. Odds ratios (ORs) for
categorical data, weighted mean differences (WMDs) for continuous data,
and 95% confidence intervals (CIs) were calculated using a
random-effects model.Data Synthesis.—The risk of cesarean delivery did not
differ between patients receiving epidural (8.2%) vs parenteral opioid
(5.6%) analgesia (OR, 1.5; 95% CI, 0.81-2.76). Epidural patients had
longer first (WMD, 42 minutes; 95% CI, 17-68 minutes) and second (WMD,
14 minutes; 95% CI, 5-23 minutes) labor stages. While epidural
patients were more likely to have instrumented delivery (OR, 2.19; 95%
CI, 1.32-7.78), they were no more likely to have instrumented delivery
for dystocia (OR, 0.68; 95% CI, 0.31-1.49). After epidural analgesia,
neonates were less likely to have low 5-minute Apgar scores (OR, 0.38;
95% CI, 0.18-0.81) or to need naloxone (OR, 0.24; 95% CI, 0.07-0.77).
Women receiving epidural analgesia had lower pain scores during the
first (WMD, −40 mm on a 100-mm scale; 95% CI, −42 to −38 mm) and
second (WMD, −29 mm; 95% CI, −38 to −21 mm) stages of labor. The
odds of dissatisfaction were lower with epidural analgesia (OR, 0.25;
95% CI, 0.20-0.32).Conclusions.—Epidural labor analgesia is not associated
with increased rates of instrumented vaginal delivery for dystocia or
cesarean delivery. Patients receiving epidural analgesia have longer
labors. Patient satisfaction and neonatal outcome are better after
epidural than parenteral opioid analgesia.

https://jamanetwork.com/journals/JAMA/articlepdf/188294/jma80016.pdf

Effect of Epidural vs Parenteral Opioid Analgesia on the Progress of Labor: A Meta-analysis

BACKGROUND Reports indicate that the administration of epidural analgesia for pain relief during labor interferes with labor and increases cesarean deliveries. However, only a few controlled trials have assessed the effect of epidural analgesia on the incidence of cesarean delivery. The authors' primary purpose in this randomized study was to evaluate the effects of epidural analgesia on the rate of cesarean deliveries by providing a suitable alternative: patient-controlled intravenous analgesia. METHODS Seven hundred fifteen women of mixed parity in spontaneous labor at full term were randomly assigned to receive either epidural analgesia or patient-controlled intravenous meperidine analgesia. Epidural analgesia was maintained with a continuous epidural infusion of 0.125% bupivacaine with 2 microg/ml fentanyl. Patient-controlled analgesia was maintained with 10-15 mg meperidine given every 10 min as needed using a patient-controlled pump. Procedures recorded in a manual that prescribed the intrapartum management were followed for each woman randomized in the study. RESULTS A total of 358 women were randomized to receive epidural analgesia, and 243 (68%) of these women complied with the epidural analgesia protocol. Similarly, 357 women were randomized to receive patient-controlled intravenous meperidine analgesia, and 259 (73%) of these women complied with the patient-controlled intravenous analgesia protocol. Only five women who were randomized and received patient-controlled intravenous meperidine analgesia according to the protocol crossed over to epidural analgesia due to inadequate pain relief. There was no difference in the rate of cesarean deliveries between the two analgesia groups using intention-to-treat analysis based on the original randomization (epidural analgesia, 4% [95% CI: 1.9-6.2%] compared with patient-controlled intravenous analgesia, 5% [95% CI: 2.6-7.2%]). Similar results were observed for the analysis of the protocol-compliant groups (epidural analgesia, 5% [95% CI: 2.6-8.5%] compared with patient-controlled intravenous analgesia, 6% [95% CI: 3-8.9%]). Women who received epidural analgesia reported lower pain scores during labor and delivery compared with women who received patient-controlled intravenous analgesia. CONCLUSIONS Epidural analgesia was not associated with increased numbers of cesarean delivery when compared with a suitable alternative method of analgesia.

Cesarean delivery: a randomized trial of epidural versus patient-controlled meperidine analgesia during labor.

Fluid therapy for the surgical patient.

BACKGROUND Controversy concerning increased cesarean births as a result of epidural analgesia for relief of labor pain has been attributed, in large part, to difficulties interpreting published studies because of design flaws. In this study, the authors compared epidural analgesia to intravenous meperidine analgesia using patient-controlled devices during labor to evaluate the effects of labor epidural analgesia, primarily on the rate of cesarean deliveries while minimizing limitations attributable to study design. METHODS Four hundred fifty-nine nulliparous women in spontaneous labor at term were randomly assigned to receive either epidural analgesia or intravenous meperidine analgesia. Epidural analgesia was initiated with 0.25% bupivacaine and was maintained with 0.0625% bupivacaine and fentanyl 2 microg/ml at 6 ml/h with 5-ml bolus doses every 15 min as needed using a patient-controlled pump. Women in the intravenous analgesia group received 50 mg meperidine with 25 mg promethazine hydrochloride as an initial bolus, followed by 15 mg meperidine every 10 min as needed, using a patient-controlled pump. A written procedural manual that prescribed the intrapartum obstetric management was followed for each woman randomized in the study. RESULTS A total of 226 women were randomized to receive epidural analgesia, and 233 women were randomized to receive intravenous meperidine analgesia. Protocol violations occurred in 8% (38 of 459) of women. There was no difference in the rate of cesarean deliveries between the two analgesia groups (epidural analgesia, 7% [16 of 226; 95% confidence interval, 4-11%] vs. intravenous meperidine analgesia, 9% [20 of 233; 95% confidence interval, 5-13%]; P = 0.61). Significantly more women randomized to epidural analgesia had forceps deliveries compared with those randomized to meperidine analgesia (12% [26 of 226] vs. 3% [7 of 233]; P < 0.001). Women who received epidural analgesia reported lower pain scores during labor and delivery compared with women who received intravenous meperidine analgesia. CONCLUSIONS Epidural analgesia compared with intravenous meperidine analgesia during labor does not increase cesarean deliveries in nulliparous women.

Cesarean delivery: A randomized trial of epidural analgesia versus intravenous meperidine analgesia during labor in nulliparous women

Summary Neuraxial analgesic techniques are the gold standards for pain relief during labour and delivery. Despite the increased use and known benefits of neuraxial labour analgesia, there has been significant controversy regarding the impact of neuraxial analgesia on labour outcomes. Review of the evidence suggests that effective neuraxial labour analgesia does not increase the rate of Caesarean delivery, even when administered early in the course of labour; however, its use is associated with a prolonged second stage of labour. Effective second-stage analgesia might also be associated with an increased rate of instrumental vaginal delivery.

Labour analgesia and obstetric outcomes

This study was designed to observe the effects of i.v. fluid infusion on uterine activity during normal labour in women receiving an extradural block. Thirty-four women in spontaneous labour at term gestation were allocated randomly and prospectively to one of three i.v. pre-extradural fluid load groups: group A, no fluid load; group B, normal saline 500 ml; and group C, normal saline 1000 ml. Continuous internal measurement of uterine activity was observed before, during and after fluid infusion and extradural block. In groups A and B, uterine activity did not change. In group C, uterine activity decreased after infusion of saline (P

B B Gutsche

Papers

Normal saline i.v. fluid load decreases uterine activity in active labour.