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The effect of epidural

analgesia on labour outcome

Dr. Tarek Ansari, FFARCSIChief of Services

Department of AnaesthesiaCorniche Hospital

Abu Dhabi

The origin of metameric anaesthesiaPages or Dogliotti

Pages F. Anestesia Metamerica. Rev San Militar (Madrid) 1921; 11: 3-30.Dogliotti A M. A new method of block anesthesia: segmental peridural spinal anesthesia. Am J Surg 1933;20: 107-118.

Fidel Pages 1886-1923Achile M Dogliotti 1897-1996

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Pioneers of obstetric analgesia

Graffagnino P, Seyler W: Epidural anaesthesia in obstetrics. Am J ObstetGynaecol 35: 597-600, 1938

. .1916-1984

Dr. Andrew Doughty1916 -

Physician Alert

Epidural is safe and may be a superior laboranalgesic when compared with narcotics; however,patients should be informed that epidural analgesiamay increase the risk of Cesarean birth in first

labors."u e ne:Delay placement of epidural until five centimeters ofcervical dilation has occurred to reduce the risk ofCesarean section. August 1 1996

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How did it all start?

Thorp, J A et al .The effect of continuous epidural analgesia oncesarean section for dystocia in nulliparous women.Am J ObstetGynecol. 1989; 161(3): 670-5

Thorp JA et al.Epidural analgesia and cesarean section for dystocia :r s ac ors n nu paras. m per na o ogy. ; : -

Thorp, JA et al. The effect of Intrapartum Epidural Analgesia on

Nulliparous Labor: A Randomized, Controlled, Prospective Trial. Am JObstet Gynecol 1993 196(4):851-858.

Pethidine Epidural

Duration of 1st stage (min) 519 676

ura on o n s age m n

Oxytocin augmentation (%) 26.7 58.3

Malpositions foetal head (%) 4.4 18.8

Spontaneous delivery (%) 86.7 56.2

Assisted vaginal delivery (%) 11.1 18.8Caesarean section (%) 2.2 25

Thorp, JA et al. The effect of Intrapartum Epidural Analgesia on Nulliparous Labor: ARandomized, Controlled, Prospective Trial. Am J Obstet Gynecol 1993 196(4):851-858.

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-

Epidural analgesia had no statisticallysignificant impact on the risk of caesareansection, or long-term backache and did notappear to have an immediate effect on

analgesia in labour

neonatal status as determined by Apgarscores. However, women who use this form

of pain relief are at increased risk of havingan instrumental delivery.

Anim-Somuah M, Smyth R, Howell C. Epidural versus non-epidural or no analgesia inlabour. Cochrane Database of Systematic Reviews 2005, Issue 4.

Study Intervention

Bofill 1997 Bup. 0.25% / Bup. 0.125% +Fent 1.5 mcg/ml

Clark 1998 Bup. 0.25% / Bup. 0.125% +Fent 1. mcg/ml

Dickinson 2002 CSE / Bup. 0.125%.

Gambling 1998 Bup. 0.25% / Bup. 0.125% +Fent 2 mcg/ml

Grandjean 1979 Lidocaine 1.5%

Head 2002 Bup. 0.25% / Bup. 0.125% +Fent. 2 mcg/ml

Hogg 2000 Bup. 0.25% / Bup. 0.125% +Fent. 2 mcg/ml

Howell 2001 Bup. 0.25% / Bup. 0.25% +Fent. 2 mcg/ml

Jain 2003 Bup. 0.15% /Bup. 0.1%+Fent. 1 mcg/ml

Long 2003 CSE/Ropivacaine 0.1%+Fent. 1.5 mcg

Loughan 2000 Bup. 0.25% / Bup. 0.125% +Fent. 2 mcg/ml

Lucas 2001 Bup. 0.25% / Bup. 0.125% +Fent. 2 mcg/ml

Morgan-Ortiz 1999 No information

Muir 1996 Bup. 0.125% /Bup. 0.125 %+Fent. 1 mcg/mlMuir 2000 Bup. 0.08% + Fent. 1.67 mcg/ml

Nikkola 1997 Bup. 0.5%

Philipsen 1989 Bup. 0.375%

Sharma 1997 Bup. 0.125% +Fent. 2 mcg/ml

Sharma 2002 Bup. 0.25% / Bup. 0.0625% +Fent. 2 mcg/ml

Thalme 1974 Bup. 0.25%

Thorp 1993 Bup. 0.25%

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COMET A small solar system body that orbits the sun

Comparative Obstetric MobileEpidural Trial COMET

,continued routine use oftraditional epidurals might notbe justified.

Effect of low-dose mobile versus traditional epidural techniqueson mode of delivery: a randomised controlled trial. Lancet 2001;358:19-23

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Early vs. late epidurals

cervical dilation is not a reliable means of determining whenregional analgesia should be initiated, it should be.

guidelines 1999)

when feasible, obstetric practitioners should delay theadministration of NA in nulliparous women until cervicaldilation reaches 45 cm, and other forms of analgesia shouldbe used until that time. (ACOG practice bulletin 2002)

associated with an increased risk of CD and IVD comparedwith the control group. Labouring women receiving early

systemic opioids before late NA have a higher incidence ofIVD for NRFS than women having early NA *

* Marucci M et al.Patient-requested Neuraxial Analgesia for Labor,Impact on Rates ofCaesarean and Instrumental Vaginal Delivery. Anaesthesiology 2007;106:1035-45

The PEOPLE study: Pushing EarlyOr Pushing Late with Epidural

Fraser Wd et al. Multicenter, randomized,controlled trial of delayed pushing for nulliparouswomen in the second stage of labor with continuous epidural analgesia. Am J Obstet Gynecol2000;182:1165-72

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Nov. 2008

the inability to sustain optimal epidural analgesia is associated withan increased risk of adverse second-stage obstetrical outcomes

Tripler Army Medical Center

In late 1993 a policy change within the US Departmentof Defense required the availability of on-demand laborepidural analgesia in military medical centers.

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A natural experiment

Zhang J et al. Does epidural analgesia prolong labor and increase risk ofcesarean delivery ? A natural experiment. Am J Obstet Gynecol 2001; 185, 128 134.

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Labour epidural does not increase risk of CD, , oxytocin use or IVD fordystocia; however it may prolong the second stage of labour

Conclusion The continued use of traditional epidural(high

concen ra on canno e us e .

The practice of stopping epidural analgesia routinelyduring the second stage should be discouraged.Suboptimal analgesia during the second stage mayincrease the risk of obstetric interventions

,the second stage may increase the chances ofspontaneous vaginal delivery, however careful foetalmonitoring is recommended

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What we should tell our patients

There is no causal relationship between epidural for

section.

There seems to be sufficient evidence to concludethat epidural is associated with prolonged secondstage, that may lead to higher incidence ofinstrumental delivery.

patients with epidural , this association may beweakening.

No association between labour epidural and chroniclow back pain

Labour results in severepain for many women.There is no othercircumstance where it isconsidered acceptable for aperson to experience severepain, amenable to safeintervention, while underphysician's care..Maternalrequest is a sufficient

justification for pain reliefur ng a our.

Joint statement of the ASA & ACOG

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Benchmarking maternity

Data supplied by participating member hospitals for 2005-06covers the birth of 96,195 babies to 94,170 women. Of those

births, 95,325 (97.8%) were live.

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Rate of Caesarean section atCorniche Hospital 2006

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Caesarean sections performed under generalanaesthesia at Corniche Hospital 2006

Caesarean section rate atCorniche Hospital 2008Total deliveries 10478, caesarean section rate

25.03%

No Epidural Epidural

Overall 24.6% 30.6%

Multiparous 23.3% 18%

Nulliparous

Spontaneous labour 26.5% 26.4%

Induced labour 33.6% 44.7 %

70% of mothers delivered at ACH were multiparous, 72% of those whohad epidurals were nulliparous.

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Corniche Hospital Statistics 2008

Nulliparous mothers with spontaneous labours

o ep ura p ura

Caesarean section(%)

26.5% 22% 26.4% 21.1%

Instrumental delivery(%)

5.96% 4.7% 14.1% 12.3%

Oxytocin 11.9% 47.1%augmentation (%)

Bakhamees H, Hegazy E. Does epidural increase the incidence of caesarean deliveryor instrumental labor in Saudi population ? Middle Eas J Anaesthesiol 2007;19(3): 693