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The effect of epidural
analgesia on labour outcome
What should we tell our patients ? What should we tell our patients ?
Dr. Tarek Ansari, FFARCSI
Chief of Services
Department of Anaesthesia
Corniche Hospital
Abu Dhabi
The origin of metameric anaesthesia
Pages 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 1886-1923
Achile M Dogliotti 1897-1996
Pioneers of obstetric analgesia
Dr Peter C Graffagnino
Graffagnino P, Seyler W: Epidural anaesthesia in obstetrics. Am J Obstet
Gynaecol 35: 597-600, 1938
Dr. Peter C. Graffagnino
Dr. Andrew Doughty
1916 -
Physician Alert
Epidural is safe and may be a superior labor
analgesic when compared with narcotics; however,
patients should be informed that epidural analgesia
may increase the risk of Cesarean birth in first
G id li Guideline:
Delay placement of epidural until five centimeters of
cervical dilation has occurred to reduce the risk of
Cesarean section. August 1 1996
How did it all start?
Thorp, J A et al .The effect of continuous epidural analgesia on
cesarean section for dystocia in nulliparous women.Am J Obstet
Gynecol. 1989; 161(3): 670-5
Thorp JA et al.Epidural analgesia and cesarean section for dystocia :
risk factors in nulliparas Am j perinatology 1991; 8 (6): 402 410 risk factors in nulliparas.Am j perinatology.1991; 8 (6): 402-410
Thorp, JA et al. The effect of Intrapartum Epidural Analgesia on
Nulliparous Labor: A Randomized, Controlled, Prospective Trial. Am J
Obstet Gynecol 1993 196(4):851-858.
Pethidine Epidural
Duration of 1st stage (min)
519 676
Duration of 2nd stage (min)
54 115
Duration of 2nd stage (min)
54 115
Oxytocin augmentation (%)
26.7 58.3
Malpositions foetal head (%)
4.4 18.8
Spontaneous delivery (%)
86.7 56.2
Assisted vaginal delivery (%)
11.1 18.8
Caesarean section (%)
2.2 25
Thorp, JA et al. The effect of Intrapartum Epidural Analgesia on Nulliparous Labor: A
Randomized, Controlled, Prospective Trial. Am J Obstet Gynecol 1993 196(4):851-858.
Epidural versus non-epidural or no
Epidural analgesia had no statistically
significant impact on the risk of caesarean
section, or long-term backache and did not
appear to have an immediate effect on
t l t t d t i d b A
Epidural versus non epidural or no
analgesia in labour
neonatal status as determined by Apgar
scores. However, women who use this form
of pain relief are at increased risk of having
an instrumental delivery.
Anim-Somuah M, Smyth R, Howell C. Epidural versus non-epidural or no analgesia in
labour. 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/ml
Muir 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%
COMET A small solar system body that orbits the sun
Comparative Obstetric Mobile
Epidural Trial COMET
in relation to delivery outcome in relation to delivery outcome,
continued routine use of
traditional epidurals might not
be justified.
Effect of low-dose mobile versus traditional epidural techniques
on mode of delivery: a randomised controlled trial. Lancet 2001;358:19-23
Early vs. late epidurals
cervical dilation is not a reliable means of determining when
regional analgesia should be initiated, it should be
administered on an individualized basis ( ASA practice administered on an individualized basis.( ASA practice
guidelines 1999)
when feasible, obstetric practitioners should delay the
administration of NA in nulliparous women until cervical
dilation reaches 45 cm, and other forms of analgesia should
be used until that time. (ACOG practice bulletin 2002)
In nulliparous women early administration of NA is not In nulliparous women early administration of NA is not
associated with an increased risk of CD and IVD compared
with the control group. Labouring women receiving early
systemic opioids before late NA have a higher incidence of
IVD for NRFS than women having early NA *
* Marucci M et al.Patient-requested Neuraxial Analgesia for Labor,Impact on Rates of
Caesarean and Instrumental Vaginal Delivery. Anaesthesiology 2007;106:1035-45
The PEOPLE study: Pushing Early
Or Pushing Late with Epidural
Fraser Wd et al. Multicenter, randomized,controlled trial of delayed pushing for nulliparous
women in the second stage of labor with continuous epidural analgesia. Am J Obstet Gynecol
Nov. 2008
the inability to sustain optimal epidural analgesia is associated with
an increased risk of adverse second-stage obstetrical outcomes
Tripler Army Medical Center
In late 1993 a policy change within the US Department
of Defense required the availability of on-demand labor
epidural analgesia in military medical centers.
A natural experiment
Zhang J et al. Does epidural analgesia prolong labor and increase risk of
cesarean delivery ? A natural experiment. Am J Obstet Gynecol 2001; 185, 128
Labour epidural does not increase risk of CD, , oxytocin use or IVD for
dystocia; however it may prolong the second stage of labour
The continued use of traditional epidural(high
t ti ) t b j tifi d concentration) cannot be justified.
The practice of stopping epidural analgesia routinely
during the second stage should be discouraged.
Suboptimal analgesia during the second stage may
increase the risk of obstetric interventions
For women with epidurals Delayed pushing during For women with epidurals, Delayed pushing during
the second stage may increase the chances of
spontaneous vaginal delivery, however careful foetal
monitoring is recommended
What we should tell our patients
There is no causal relationship between epidural for
labour pain relief and increased risk of caesarean labour pain relief and increased risk of caesarean
There seems to be sufficient evidence to conclude
that epidural is associated with prolonged second
stage, that may lead to higher incidence of
instrumental delivery.
With modifying the obstetric management plan for With modifying the obstetric management plan for
patients with epidural , this association may be
No association between labour epidural and chronic
low back pain
Labour results in severe
pain for many women.
There is no other
circumstance where it is
considered acceptable for a
person to experience severe
pain, amenable to safe
intervention, while under
physician's care..Maternal
request is a sufficient
justification for pain relief
d i l b during labour.
Joint statement of the ASA & ACOG
Benchmarking maternity
care care
Data supplied by participating member hospitals for 2005-06
covers the birth of 96,195 babies to 94,170 women. Of those
births, 95,325 (97.8%) were live.
Rate of Caesarean section at
Corniche Hospital 2006
Caesarean sections performed under general
anaesthesia at Corniche Hospital 2006
Caesarean section rate at
Corniche Hospital 2008
Total deliveries 10478, caesarean section rate
No Epidural Epidural
Overall 24.6% 30.6%
Multiparous 23.3% 18%
Nulliparous p
Spontaneous labour 26.5% 26.4%
Induced labour 33.6% 44.7 %
70% of mothers delivered at ACH were multiparous, 72% of those who
had epidurals were nulliparous.
Corniche Hospital Statistics 2008
Nulliparous mothers with spontaneous labours
N id l E id l No epidural Epidural
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 delivery
or instrumental labor in Saudi population ? Middle Eas J Anaesthesiol 2007;19(3): 693