Article

Early versus late initiation of epidural analgesia in labor: Does it increase the risk of cesarean section? A randomized trial

Technion - Israel Institute of Technology, H̱efa, Haifa, Israel
American journal of obstetrics and gynecology (Impact Factor: 3.97). 03/2006; 194(3):600-5. DOI: 10.1016/j.ajog.2005.10.821
Source: PubMed

ABSTRACT To determine whether early initiation of epidural analgesia in nulliparous women affects the rate of cesarean sections and other obstetric outcome measures.
A randomized trial in which 449 at term nulliparous women in early labor, at less than 3 cm of cervical dilatation, were assigned to either immediate initiation of epidural analgesia at first request (221 women), or delay of epidural until the cervix dilated to at least 4 cm (228 women).
At initiation of the epidural the mean cervical dilatation was 2.4 cm in the early epidural group and 4.6 cm in the late group (P < 0.0001). The rates of cesarean section were not significantly different between the groups--13% and 11% in the early and late groups, respectively (P = 0.77). The mean duration from randomization to full dilatation was significantly shorter in the early compared to the late epidural group--5.9 hours and 6.6 hours respectively (P = 0.04). When questioned after delivery regarding their next labor, the women indicated a preference for early epidural.
Initiation of epidural analgesia in early labor, following the first request for epidural, did not result in increased cesarean deliveries, instrumental vaginal deliveries, and other adverse effects; furthermore, it was associated with shorter duration of the first stage of labor and was clearly preferred by the women.

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    • "Interestingly, we were able to find an association with the timing of epidural analgesia, measured by the time interval from onset of labour until epidural analgesia. We found only one study which analysed this for cervical dilatation before epidural (Ohel et al., 2006). "
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    ABSTRACT: OBJECTIVE: childbearing women and their midwives differ in their diagnoses of the onset of labour. The symptoms women use to describe the onset of labour are associated with the process of labour. Perinatal factors and women's attitudes may be associated with the administration of epidural analgesia. Our study aimed to assess the correlation between women's perception of the onset of labour and the frequency and timing of epidural analgesia during labour. DESIGN: prospective cohort study. SETTING: 41 maternity units in Lower Saxony, Germany. PARTICIPANTS: 549 nulliparae (as defined in the "Methods" section) and 490 multiparae giving birth between April and October 2005. Women were included after 34 completed weeks of gestation with a singleton in vertex presentation and planned vaginal birth. MEASUREMENTS: the association between women's symptoms at the onset of labour and the administration of epidural analgesia - frequency, timing in relation to onset of labour and cervical dilatation - was assessed. The analysis was performed by Kaplan-Meiers estimation, logistic regression and Cox regression. FINDINGS: a total of 174 nulliparae and 49 multiparae received epidural analgesia during labour. Nulliparae received it at a median time of 5.47hrs (range: 0.25-51.17hrs) after onset of labour, at a median cervical dilatation of 3.3cm (range: 1.0-10.0cm). In multiparae, epidural analgesia was applied at a median time of 3.79hrs (range: 0.42-28.55hrs) after onset of labour; the median cervical dilatation was 3.0cm (range: 1.0-8.0cm). Women who were admitted with advanced cervical dilatation received epidural analgesia less often. Women who defined their onset of labour earlier than it was diagnosed by their midwives received epidural analgesia earlier. Gastrointestinal symptoms and irregular pain at the onset of labour were associated with later administration of epidural analgesia. Induction of labour was associated with a reduced interval from the onset of labour to epidural analgesia. KEY CONCLUSIONS: women's self-diagnosis of the onset of labour and their perception of their labour duration when meeting their midwives has some impact on their admission to the labour ward and the timing of epidural analgesia. IMPLICATIONS FOR PRACTICE: consideration of women's own perceptions and expectations regarding the onset and process of labour is necessary for individual care during labour.
    Midwifery 10/2012; 29(4). DOI:10.1016/j.midw.2012.08.006 · 1.71 Impact Factor
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    • "Neuraxial analgesia is generally administered more often to nulliparae than to multiparae. According to current research it is not beneficial to delay neuraxial analgesia until advanced cervical dilation, e.g. 3 cm, is reached (Ohel et al., 2006; Wong et al., 2009). "
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    ABSTRACT: To describe the timing and frequency of interventions during labour, and in addition to compare the timings of the interventions against the partogram action lines. Longitudinal prospective and retrospective cohort study. 47 Hospitals in Lower Saxony, Germany. 3963 Births of nulliparae and multiparae with singletons in vertex presentation giving birth between April and October 2005. The participation rate for the prospectively recruited sample (n = 1169) was 4.7%. Time intervals until intrapartal interventions were calculated by Kaplan-Meiers estimation. Outcome variables were duration of labour and mode of birth. Multiparae had slightly longer median time intervals between the onset of labour and the beginning of care by the midwife than nulliparae. With regard to the intervals between the onset of labour and the occurrence of interventions, multiparae had shorter median durations than nulliparae in respect of amniotomy, oxytocin augmentation and neuraxial analgesia. By three hours after onset of labour 8.4% of nulliparae had received oxytocin augmentation, 10.7% neuraxial analgesia and 8.9% an amniotomy. Of multiparae, 9.1% had received oxytocin augmentation but only 5.6% neuraxial analgesia; 20.0% had had an amniotomy. The median time interval before the initiation of water immersion and massage was between three and four hours; that before the initiation of vertical positioning was 1.8 hours. Current German practice without the use of partogram action lines reveals that early interventions were performed before the partogram action lines were met. Interventions applying midwifery care techniques such as vertical positioning preceded more invasive medical interventions during the process of childbirth.
    Midwifery 12/2010; 27(6):e267-73. DOI:10.1016/j.midw.2010.10.017 · 1.71 Impact Factor
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    • "Par ailleurs, ces techniques modernes d'analgésie périmédullaire ne prolongent plus la durée du premier stade du travail lorsqu'elles sont initiées tôt, plutôt que tard durant cette période [12] ; elles pourraient même la raccourcir modérément [13] [14]. Il n'est donc plus justifié ni éthique de retarder l'instauration d'une analgésie périmédullaire souhaitée par une parturiente par crainte de retarder la progression du travail (NP1). "
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    ABSTRACT: The aim of the anaesthesia for instrumental delivery is to provide optimal operation conditions for the obstetrician, appropriate maternal comfort, altogether with safety for the mother and her fœtus. The type and location for this intervention are chosen individually for each case according to the indication, the risk of caesarean section and the local specificities. The general safety recommendations for obstetric anaesthesia apply in every case. Since an epidural analgesia is often already working, this type of anaesthesia is the most frequently used for the extractions. A spinal anaesthesia is a logical choice where an epidural in sot yet working. The pudendal block is a second line choice and the general anaesthesia remains as the last alternative in acute emergencies, in cases of failed regional anaesthesia or when the mother refuses any other anaesthesia despite proper information or proves unable to cooperate.
    Journal de Gynécologie Obstétrique et Biologie de la Reproduction 12/2008; 37(8). DOI:10.1016/S0368-2315(08)74764-1 · 0.62 Impact Factor
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