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

Technion - Israel Institute of Technology, H̱efa, Haifa, Israel
American journal of obstetrics and gynecology (Impact Factor: 4.7). 03/2006; 194(3):600-5. DOI: 10.1016/j.ajog.2005.10.821
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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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    • "Ohel et al. [39] randomized 449 nulliparous female patients who were in spontaneous and induced labor into either immediate initiation of epidural analgesia at the first request or delay of the epidural until the cervix was 4-cm dilated. Mean cervical dilations at the beginning of epidural analgesia were 2.4 and 4.6 cm in the early and late epidural groups, respectively. "
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    ABSTRACT: Labor pain is one of the most challenging experiences encountered by females during their lives. Neuraxial analgesia is the mainstay analgesic for intrapartum pain relief. However, despite the increasing use and undeniable advantages of neuraxial analgesia for labor, there have been concerns regarding undesirable effects on the progression of labor and outcomes. Recent evidence indicates that neuraxial analgesia does not increase the rate of Cesarean sections, although it may be associated with a prolonged second stage of labor and an increased rate of instrumental vaginal delivery. Even when neuraxial analgesia is administered early in the course of labor, it is not associated with an increased rate of Cesarean section or instrumental vaginal delivery, nor does it prolong the labor duration. These data may help physicians correct misconceptions regarding the adverse effects of neuraxial analgesia on labor outcome, as well as encourage the administration of neuraxial analgesia in response to requests for pain relief.
    Korean journal of anesthesiology 11/2013; 65(5):379-384. DOI:10.4097/kjae.2013.65.5.379
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    • "Recent studies claiming that timing of epidural does not impact rates of caesarean section have reported on protocols that are not representative of North American practice, in that epidural analgesia was implemented on average at 1.6 cm of cervical dilation(16). As well, as many as 80% of participants in the delayed group(17,18) also received a narcotic which, in itself, may slow labor and increase the rate of caesarean section. "
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    ABSTRACT: Massage is a time-honored method by which women have received comfort throughout the millennia, yet it has not been rigorously evaluated in the modern day delivery suite. No study to date that we are aware of has evaluated the effect of massage therapy by a regulated massage therapist on labor pain. The purpose of this study was to evaluate the effectiveness of massage therapy provided by registered massage therapists in managing pain among women in active labor. BC Women's Hospital, Vancouver, BC. Research Design: a randomized controlled trial. 77 healthy nulliparous women presenting in spontaneous labor. Swedish massage administered for up to five hours by a registered massage therapist during labor vs. standard care. Main outcome measures include: cervical dilation at the time of administration of epidural, compared using estimated marginal means in an analysis of covariance. We also compared perception of pain at three time periods during labor according to cervical dilation at 3-4 cm, 5-7 cm, and 8-10 cm using the McGill Present Pain Intensity Scale. The mean cervical dilation at the time of epidural insertion after adjustment for station of the presenting part, cervical dilation, and status of membranes on admission to hospital was 5.9 cm (95% CI 5.2-6.7) compared to 4.9 in the control group (95% CI 4.2-5.8). Scores on the McGill Pain Scale were consistently lower in the massage therapy group (13.3 vs. 16.9 at 3-4 cm, 13.3 vs. 15.8 at 5-6 cm, and 19.4 vs. 28.3 at 7-8 cm), although these differences were not statistically significant. Our findings from this pilot study suggest that massage therapy by a registered massage therapist has the potential to be an effective means of pain management that may be associated with delayed use of epidural analgesia. It may therefore have the potential to reduce exposure to epidural analgesia during labor and decrease rates of associated sequelae.
    International Journal of Therapeutic Massage & Bodywork Research Education & Practice 12/2012; 5(4):15-20. DOI:10.3822/ijtmb.v5i4.164
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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 · 1.57 Impact Factor
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