A review of randomized trials comparisons of epidural with parenteral forms of pain relief during labour and its impact on operative and cesarean delivery rate
Abstract
Objectives: The aim of this review was to summarise the available literature on different modalities of labour pain relief (epidural vs. parenteral) and to assess their impact on the rate of caesarean section deliveries and instrumental deliveries, and on the need to support the uterine contractile function.
Material and methods: The PubMed, Web of Science and Cochrane databases were reviewed to identify articles describing the effect of labour pain relief on the course of labour. This review includes 16 studies with 7150 patients.
Results: The analysis of the obtained data revealed that epidural analgesia (EA) or combined epidural and spinal anaesthesia (CESA) provided significantly better labour pain relief when compared with parenteral opioids. Conduction anaesthesia was not associated with an increase in the caesarean section delivery rate. Some authors concluded that conduction anaesthesia was associated with the need for assisted delivery.
Conclusions: Epidural analgesia is a well-recognised method of labour pain relief. It is associated with the parturient’s higher satisfaction when compared to parenteral opioids. EA does not directly increase the caesarean section delivery rate, yet it can lead to instrumental deliveries (vacuum-assisted, obstetrics forceps) and a need to pharmacologically support the uterine contractile function. Further studies are required to evaluate the effect of EA on the course of labour, and methods of minimising its adverse effects.
Keywords: epidural analgesialabourdeliverycaesarean sectioninstrumental delivery
References
- Definicja bólu wg International Association for the Study of Pain, IASP Taxonomy 1979.
- Andres J, Dobrogowski J. (ed.). Neurologia, znieczulenie regionalne i terapia bólu. Ośrodek Regionalny CEEA, Kraków 2011: 239–253.
- Sulima E, Gonik M. Alternatywne metody łagodzenia bólu porodowego. European Journal of Medical Technologies. 2013; 1(1): 32–38.
- Rozporządzenie Ministra Zdrowia z dn. 9 listopada 2016 w sprawie standardów postępowania medycznego w łagodzeniu bólu porodowego Dz. U. RP Warszawa, dnia 30 listopada 2015 r. poz. 1997.
- Caton D. The history of obstetric anesthesia. In: Chestnut DH, Polley LS, Tsen LC, Wong CA. ed. Obstetric Anesthesia Principles and Practice. 4th ed. Elsevier Mosby, Philadelphia 2009: 3–13.
- Chutowski R, Wódarski B, Malec-Milewska M. Metody i organizacja analgezji porodu — doświadczenia własne. 5604/1640324x, indexed in Pubmed. 2015; 16(2): 7–15.
- Anim-Somuah M, Smyth R, Howell C. Epidural versus non-epidural or no analgesia in labour. Cochrane Database Syst Rev. 2005(4): CD000331.
- Deneux-Tharaux C, Carmona E, Bouvier-Colle MH, et al. Postpartum maternal mortality and cesarean delivery. Obstet Gynecol. 2006; 108(3 Pt 1): 541–548.
- https://www.nik.gov.pl/plik/id,11621,vp,13972.pdf (12.02.2018).
- http://www.who.int/reproductivehealth/publications/maternal_perinatal_health/cs-statement/en (12.02.2018).
- Health at a Glance 2017 c OECD 2017 OECD (2017), “Caesarean sections”. In: Health at a Glance 2017: OECD Indicators. OECD Publishing, Paris 2017: doi: 10.1787/health_glance-2017-66-en.
- Suchocki S. Jak ograniczyć epidemię cięć cesarskich? Gin Pol Med Project. 2012; 2(24): 9–16.
- Sharma SK, Alexander JM, Messick G, et al. Cesarean delivery: a randomized trial of epidural analgesia versus intravenous meperidine analgesia during labor in nulliparous women. Anesthesiology. 2002; 96(3): 546–551.
- Philipsen T, Jensen NH, Philipsen T, et al. Epidural block or parenteral pethidine as analgesic in labour; a randomized study concerning progress in labour and instrumental deliveries. Eur J Obstet Gynecol Reprod Biol. 1989; 30(1): 27–33.
- Thorp JA, Hu DH, Albin RM, et al. The effect of intrapartum epidural analgesia on nulliparous labor: a randomized, controlled, prospective trial. Am J Obstet Gynecol. 1993; 169(4): 851–858.
- Ramin SM, Gambling DR, Lucas MJ, et al. Randomized trial of epidural versus intravenous analgesia during labor. Obstet Gynecol. 1995; 86(5): 783–789.
- Bofill JA, Vincent RD, Ross EL, et al. Nulliparous active labor, epidural analgesia, and cesarean delivery for dystocia. Am J Obstet Gynecol. 1997; 177(6): 1465–1470.
- Clark A, Carr D, Loyd G, et al. The influence of epidural analgesia on cesarean delivery rates: a randomized, prospective clinical trial. Am J Obstet Gynecol. 1998; 179(6 Pt 1): 1527–1533.
- Gambling DR, Sharma SK, Ramin SM, et al. A randomized study of combined spinal-epidural analgesia versus intravenous meperidine during labor. Anesthesiology. 1998; 89: 1336–1344.
- Loughnan BA, Carli F, Romney M, et al. Randomized controlled comparison of epidural bupivacaine versus pethidine for analgesia in labour. Br J Anaest. 2000; 84(6): 715–719.
- Lucas MJ, Sharma SK, McIntire DD, et al. A randomized trial of labor analgesia in women with pregnancy-induced hypertension. Am J Obstet Gynecol. 2001; 185(4): 970–975.
- Howell CJ, Kidd C, Roberts W, et al. A randomised controlled trial of epidural compared with non-epidural analgesia in labour. BJOG. 2001; 108(1): 27–33.
- Henderson JJ, Dickinson JE, Evans SF, et al. The impact of intrapartum analgesia on labour and delivery outcomes in nulliparous women. Aust N Z J Obstet Gynaecol. 2002; 42(1): 59–66.
- Head BB, Owen J, Vincent RD, et al. A randomized trial of intrapartum analgesia in women with severe preeclampsia. Obstet Gynecol. 2002; 99(3): 452–457.
- Jain S, Arya VK, Gopalan S, et al. Analgesic efficacy of intramuscular opioids versus epidural analgesia in labor. Int J Gynaecol Obstet. 2003; 83(1): 19–27.
- Long J, Yue Y. Patient controlled intravenous analgesia with tramadol for labor pain relief. Chin Med J (Engl). 2003; 116(11): 1752–1755.
- Douma MR, Middeldorp JM, Verwey RA, et al. A randomised comparison of intravenous remifentanil patient-controlled analgesia with epidural ropivacaine/sufentanil during labour. Int J Obstet Anesth. 2011; 20(2): 118–123.
- Freeman LM, Bloemenkamp KW, Franssen MT, et al. Patient controlled analgesia with remifentanil versus epidural analgesia in labour: randomised multicentre equivalence trial. BMJ. 2015; 350: h846.
- Rogers R, Gilson G, Kammerer-Doak D. Epidural analgesia and active management of labor: effects on length of labor and mode of delivery. Obstet Gynecol. 1999; 93(6): 995–998.
- Gupta N, Gupta S, Agarwal A, et al. To study the painless labour by epidural analgesia and its effects on cardiotocographic parameters and labour. Int J Reprod Contracept Obstet Gynecol. 2013; 2(4): 666.
- Fogel ST, Shyken JM, Leighton BL, et al. Epidural labor analgesia and the incidence of cesarean delivery for dystocia. Anesth Analg. 1998; 87(1): 119–123.
- Naik T, Acharya N, Shrivastav D, et al. Comparative study of the effect of early versus late initiation of epidural analgesia on labour. Int. J. Gynecol. Obstet. Neonatal Care. 2015; 2(3): 26–32.
- Ohel G, Gonen R, Vaida S, et al. Early versus late initiation of epidural analgesia in labor: does it increase the risk of cesarean section? A randomized trial. Am J Obstet Gynecol. 2006; 194(3): 600–605.
- Kaul B, Vallejo M, Ramanathan S, et al. Epidural labor analgesia and neonatal sepsis evaluation rate: a quality improvement study. Anesth Analg. 2001; 93(4): 986–990.
- Lieberman E, Lang JM, Frigoletto F, et al. Epidural analgesia, intrapartum fever, and neonatal sepsis evaluation. Pediatrics. 1997; 99(3): 415–419.
- Hoult IJ, MacLennan AH, Carrie LE. Lumbar epidural analgesia in labour: relation to fetal malposition and instrumental delivery. Br Med J. 1977; 1(6052): 14–16.
- Doughty A. Selective epidural analgesia and the forceps rate. Br J Anaesth. 1969; 41(12): 1058–1062.
- Yancey MK, Pierce B, Schweitzer D, et al. Observations on labor epidural analgesia and operative delivery rates. Am J Obstet Gynecol. 1999; 180(2 Pt 1): 353–359.
![](https://journals.viamedica.pl/plugins/generic/popups/images/icons/close.png)