Regional analgesia and progress of labor

Shiv K. Sharma, Kenneth J. Leveno

Research output: Contribution to journalArticle

14 Citations (Scopus)

Abstract

Regional analgesia, and particularly epidural analgesia, has been extensively studied during childbirth in the last decade of the 20th century. It is clear that regional analgesia is the most effective method of pain relief for childbirth invented to date. Epidural analgesia is very safe for the fetus-neonate while the safety of CSE analgesia is less convincing. There is no doubt that regional analgesia interferes with first and second stage labor with the results that oxytocin use is increased as is forceps delivery. Cesarean delivery is not increased. Between November 1, 1993, and November 3, 2000, 4465 women of mixed parity, (3727 healthy parturients [83%] and 738 women with pregnancy-induced hypertension [17%]) in spontaneous labor at term were randomized to receive either epidural analgesia or intravenous opioid analgesia in 5 consecutive trials conducted at our hospital.8,9, 12,30,31 (Fig. 4). A total of 2236 women were randomized to receive epidural analgesia and 2229 women were randomized to receive intravenous meperidine analgesia. Overall, 27% of women violated the protocol (delivered before analgesia could be initiated, received a method of analgesia that was different than allocated, or crossed over). No difference was found in the overall rate of cesarean deliveries between the two analgesia groups by combining 5 studies using intention-to-treat analysis. Also, there was no significant difference in the rate of cesarean deliveries either in nulliparous or parous women (Fig. 4). In our opinion, this can be viewed as the final word on the effect of epidural analgesia on the rate of cesarean delivery. Given the superior pain relief and fetal safety of epidural analgesia, the prolongation of labor and associated need for oxytocin augmentation attributable to epidural analgesia is usually outweighed by the advantages of the pain relief. This undoubtedly is the reason epidural analgesia is so popular in the United States. In January 2002, ACOG reaffirmed its earlier committee opinion, published jointly with the American Society of Anesthesiologists (ASA), that while under a physician's care, in the absence of a medical contraindication, women in labor should be given pain reliefupon request. According to ACOG/ASA, there is no other circumstance where it is considered acceptable for a person to experience untreated severe pain that is amenable to safe intervention.

Original languageEnglish (US)
Pages (from-to)633-645
Number of pages13
JournalClinical Obstetrics and Gynecology
Volume46
Issue number3
DOIs
StatePublished - Sep 2003

Fingerprint

Epidural Analgesia
Analgesia
Pain
Parturition
Oxytocin
Second Labor Stage
First Labor Stage
Safety
Pregnancy Induced Hypertension
Meperidine
Intention to Treat Analysis
Parity
Surgical Instruments
Opioid Analgesics
Fetus
Newborn Infant
Physicians

ASJC Scopus subject areas

  • Obstetrics and Gynecology

Cite this

Regional analgesia and progress of labor. / Sharma, Shiv K.; Leveno, Kenneth J.

In: Clinical Obstetrics and Gynecology, Vol. 46, No. 3, 09.2003, p. 633-645.

Research output: Contribution to journalArticle

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abstract = "Regional analgesia, and particularly epidural analgesia, has been extensively studied during childbirth in the last decade of the 20th century. It is clear that regional analgesia is the most effective method of pain relief for childbirth invented to date. Epidural analgesia is very safe for the fetus-neonate while the safety of CSE analgesia is less convincing. There is no doubt that regional analgesia interferes with first and second stage labor with the results that oxytocin use is increased as is forceps delivery. Cesarean delivery is not increased. Between November 1, 1993, and November 3, 2000, 4465 women of mixed parity, (3727 healthy parturients [83{\%}] and 738 women with pregnancy-induced hypertension [17{\%}]) in spontaneous labor at term were randomized to receive either epidural analgesia or intravenous opioid analgesia in 5 consecutive trials conducted at our hospital.8,9, 12,30,31 (Fig. 4). A total of 2236 women were randomized to receive epidural analgesia and 2229 women were randomized to receive intravenous meperidine analgesia. Overall, 27{\%} of women violated the protocol (delivered before analgesia could be initiated, received a method of analgesia that was different than allocated, or crossed over). No difference was found in the overall rate of cesarean deliveries between the two analgesia groups by combining 5 studies using intention-to-treat analysis. Also, there was no significant difference in the rate of cesarean deliveries either in nulliparous or parous women (Fig. 4). In our opinion, this can be viewed as the final word on the effect of epidural analgesia on the rate of cesarean delivery. Given the superior pain relief and fetal safety of epidural analgesia, the prolongation of labor and associated need for oxytocin augmentation attributable to epidural analgesia is usually outweighed by the advantages of the pain relief. This undoubtedly is the reason epidural analgesia is so popular in the United States. In January 2002, ACOG reaffirmed its earlier committee opinion, published jointly with the American Society of Anesthesiologists (ASA), that while under a physician's care, in the absence of a medical contraindication, women in labor should be given pain reliefupon request. According to ACOG/ASA, there is no other circumstance where it is considered acceptable for a person to experience untreated severe pain that is amenable to safe intervention.",
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