Epidural Analgesia Compared with Combined Spinal–Epidural Analgesia during Labor in Nulliparous Women

Women's Hospital, Long Beach, CA, USA.
New England Journal of Medicine (Impact Factor: 55.87). 01/1998; 337(24):1715-9. DOI: 10.1056/NEJM199712113372402
Source: PubMed


Among nulliparous women, there appears to be an association between the use of epidural analgesia during labor and an increased risk of dystocia. We tested the hypothesis that combined spinal-epidural analgesia, which permits ambulation during labor, is associated with a lower incidence of dystocia than continuous lumbar epidural analgesia.
Between July 1995 and September 1996, we randomly assigned 761 nulliparous women in spontaneous labor at term who requested epidural analgesia to receive either continuous lumbar epidural analgesia or a combination of spinal and epidural analgesia. Among the women who received combined spinal-epidural analgesia, some were discouraged from walking and others were encouraged to walk. Maternal and neonatal outcomes, the incidence of dystocia necessitating cesarean section, and measures of patients' satisfaction were compared in the two groups.
There were no significant differences in the overall rate of cesarean section, the incidence of dystocia, the frequency of maternal or fetal complications, the patients' or nursing staff's assessment of the adequacy of analgesia, or the degree of overall satisfaction between the two groups. Significantly more women receiving combined spinal-epidural analgesia had pruritus (P<0.001) and requested additional epidural bolus doses of local anesthetic (P=0.01). For all the women, dystocia necessitating cesarean section was significantly more likely when analgesia was administered with the fetal vertex at a negative station (odds ratio, 2.5; P<0.001) or at less than 4 cm of cervical dilatation (odds ratio, 2.2; P<0.001).
As compared with continuous lumbar epidural analgesia, the combination of spinal and epidural analgesia is not associated with an overall decrease in the incidence of cesarean delivery.

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    • ", United States rCS N — N Nulliparous women; the primary endpoint was to quantify the risk of cesarean delivery associated with EA; analysis was adjusted for confounding factors Nageotte et al., 14 1997, United States RCT N Not assessed N Nulliparous women; the primary endpoint was to study the association of CSE and EA with dystocia; EA timing analysis was post hoc "
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    ABSTRACT: A systematic review, including a meta-analysis, on the timing effects of neuraxial analgesia (NA) on cesarean and instrumental vaginal deliveries in nulliparous women was conducted. Of 20 articles identified, 9 met the inclusion quality criteria (3,320 participants). Cesarean delivery (odds ratio, 1.00; 95% confidence interval, 0.82-1.23) and instrumental vaginal delivery (odds ratio, 1.00; 95% confidence interval, 0.83-1.21) rates were similar in the early NA and control groups. Neonates of women with early NA had a higher umbilical artery pH and received less naloxone. In the early NA group, fewer women were not compliant with assigned treatment and crossed over to the control group. Women receiving early NA for pain relief are not at increased risk of operative delivery, whereas those receiving early parenteral opioid and late epidural analgesia present a higher risk of instrumental vaginal delivery for nonreassuring fetal status, worse indices of neonatal wellness, and a lower quality of maternal analgesia.
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    • "Dans une étude française cas-témoin, la déambulation prolongée (60 minutes en moyenne) sous analgésie péridurale avait effectivement entraîné une réduction significative des extractions instrumentales (9 % versus 24 %) mais précédée d'une prolongation inattendue de la 1 ère phase du travail [20]. En fait, une deuxième grande étude randomisée a permis de mieux comprendre certaines de ces discordances : la réduction du taux d'extraction instrumentale et l'éventuelle plus grande vitesse de dilatation cervicale sont liées à l'emploi d'une technique d'analgésie périmédullaire « allégée », et non à la déambulation ellemême [21]. Ainsi, c'est la disparition du bloc-moteur obligatoirement recherchée pour la déambulation (i.e., l'aptitude à déambuler) qui a des effets favorables sur la mécanique obstétricale ; en revanche, le rôle propre de la déambulation en ellemême est faible ou nul. "

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