Does epidural analgesia prolong labor and increase risk of cesarean delivery? A natural experiment

OBJECTIVE: More than 50% of pregnant women in the United States are using epidural analgesia for labor pain. However, whether epidural analgesia prolongs labor and increases the risk of cesarean delivery remains controversial. STUDY DESIGN: We examined this question in a community-based, tertiary military medical center where the rate of continuous epidural analgesia in labor increased from 1% to 84% in a 1-year period while other conditions remained unchanged-a natural experiment. We systematically selected 507 and 581 singleton, nulliparous, term pregnancies with spontaneous onset of labor and vertex presentation from the respective times before and after the times that epidural analgesia was available on request during labor. We compared duration of labor, rate of cesarean delivery, instrumental delivery, and oxytocin use between these two groups. RESULTS: Despite a rapid and dramatic increase in epidural analgesia during labor (from 1% to 84% in 1 year), rates of cesarean delivery overall and for dystocia remained the same (for overall cesarean delivery: adjusted relative risk, 0.8; 95% confidence interval, 0.6-1.2; for dystocia: adjusted relative risk, 1.0; 95% confidence interval, 0.7-1.6). Overall instrumental delivery did not increase (adjusted relative risk, 1.0; 95% confidence interval, 0.8-1.4), nor did the duration of the first stage and the active phase of labor (multivariate analysis; P >.1). However, the second stage of labor was significantly longer by about 25 minutes (P <.001). CONCLUSION: Epidural analgesia during labor does not increase the risk of cesarean delivery, nor does it necessarily increase oxytocin use or instrumental delivery caused by dystocia. The duration of the active phase of labor appears unchanged, but the second stage of labor is likely prolonged. (Am J Obstet Gynecol 2001;185:128-34).     

Epidural analgesia and the course of delivery in term primiparas

OBJECTIVES: Epidural analgesia provides the most effective pain control during labor. Of great concern is its influence on the course of delivery and perinatal complications. DESIGN: The aim of the study was to assess the effect of epidural analgesia on the course of delivery and perinatal outcome. MATERIALS AND METHODS: 609 deliveries among 1334 (323 women with epidural analgesia (53%) and 548 without epidural analgesia (47%)) met the following criteria: primipara, singleton, live pregnancy, > =37 weeks' gestation, cephalic presentation of a fetus, lack of contraindication for vaginal delivery. The incidence of instrumental deliveries and fetal distress, duration of the first, second and third stage of labor, perinatal outcome, perinatal complications and perinatal blood loss and were analyzed. RESULTS: The incidence of fetal distress during second stage of labor was significantly higher in the epidural group (12.69 vs. 6.99%, P=0.02). The incidence of fetal distress during first stage of labor did not differ in both groups (10.53% vs. 8.74%, NS). Cesarean sections rate was similar in epidural and non-epidural group (17.7 vs. 18.2%, NS). Among vaginal deliveries duration of the first and second stage of labor was longer in epidural group (6.5+/-2.4 vs. 5.4+/-2.5 godz., P=0,000003 and 47.3+/-34.8 vs. 29.1+/-25.8 min., P=0.000003) and this was independent of period of time between onset of first stage of labor and epidural analgesia. Oxitocin use was significantly more frequent in the epidural group (20.6 vs. 10.3%, P<0.004). There were no statistically significant differences in the rates of instrumental vaginal deliveries, 1 and 5-minute Apgar scores, length of third stage of labor and perinatal blood loss in patients with and without epidural analgesia. Perinatal outcome did not depend on previous use of epidural analgesia or mode of analgesia for the operation in cesarean section subgroup. CONCLUSION: Epidural labor analgesia is associated with slower progress of labor but has no adverse effect on perinatal outcome and perinatal complications.     

Effects of combined spinal–epidural analgesia on first stage of labor: a cohort study

Background: Neuraxial anesthesia is considered as the gold standard in the control labor of pain. Its variants are epidural analgesia and combined spinal–epidural analgesia. Few studies, as yet, have investigated the duration of labor as a primary outcome. Some authors have suggested that combined spinal–epidural analgesia may reduce labor duration but at the moment the benefit of shortening labor is uncertain. The main aim of this study was to compare combined spinal–epidural with epidural analgesia in terms of their effect on duration of stage I labor, maternal, and neonatal outcomes.

Methods: A prospective cohort study was conducted. Parturients who requested analgesia at cervical dilatation <6?cm were included. Analgesia was either epidural with low concentration levobupivacaine or combined spinal epidural with subarachnoid sufentanil. The primary outcome was the length of stage I labor. Onset and quality of analgesia, mode of delivery, effects on uterine activity and use of oxytocin, fetal heart rate abnormalities and uterine hyperkinesia, maternal, and neonatal complications were also considered.

Results: We enrolled 400 patients: 176 in the combined spinal–epidural group and 224 in the epidural group. Patients in the two treatment groups were similar with regard to demographic characteristics, parity, and incidence of obstetric comorbidities, labor induction, oxytocin infusion, Bishop score, and Visual Analogue Score (VAS) at analgesia request. Duration of stage I labor did not differ, at 195 (120–300) minutes for both the groups (p?=?.7). Combined spinal–epidural was associated with less reduction in uterine contractility after initial administration: 15.34 versus 39.73%, (p?p?=?.002). Onset of analgesia was quicker for combined spinal–epidural analgesia: 31 versus 20%, with VAS <4 after 5?minutes, (p?Conclusions: Combined spinal–epidural with subarachnoid sufentanil may not reduce the duration of stage I labor, but in our study it appeared to affect uterine contractility less. It also had a more rapid onset and was more effective, without any concomitant increase in maternal or neonatal complications.     

Outcomes of induced versus spontaneous labor

Purpose: Induced labor is associated with a higher request for analgesia than spontaneous labor. This study compared duration of labor, mode of delivery, quantity of blood loss, type of perineal outcome and neonatal outcomes between women in induced labor and women in spontaneous labor, both on epidural analgesia (administered at cervical dilation ≤?4?cm).

Methods: In a two-year longitudinal cohort study, data were gathered from nulliparous women with a single cephalic pregnancy of at least 37 weeks attending the labor and delivery ward in Policlinico San Matteo Fundation-Pavia. Data were compared for women with early labor analgesia in (1) spontaneous labor (Robson group 1) and (2) induced labor (dinoprostone – vaginal insert or gel, Robson group 2a).

Results: Of the 1104 women who underwent epidural analgesia in the study period, 531 were included: 326 in spontaneous labor and 205 in induced labor. The only significant difference found was duration of the first stage, which lasted 305 (200–390) min in spontaneous labor compared to 205?min (120–345) in induced labor (p <0.001).

Conclusions: In women on early epidural analgesia, induction is associated with a shorter duration of the first stage of labor and does not affect other outcomes.     

Prolonged second stage in nulliparous with epidurals: a systematic review

Objective: Management of prolonged second stage of labor remains a clinical challenge. Nulliparous with epidurals are the most likely women to have a prolonged second stage and can be difficult to manage. The aim of this study was to evaluate the maternal and fetal morbidities associated with prolonged second stage of labor in nulliparous women with epidurals.

Methods: A systematic review of the literature was performed using PubMed, Ovid and Scopus searches for case series evaluating the morbidities of prolonged second stage of labor. Search terms used were “prolonged”, “second stage”, and “labor”. Prolonged second stage was defined as three hours or more. Retrospective case series of prolonged second stage in nulliparous women with epidurals were identified. The primary outcome was the incidence of cesarean delivery.

Results: Two retrospective series with 5350 nulliparous women with prolonged second stage were identified. 76.3% (4 081/5 350) had an epidural. Of all nulliparous women with an epidural, 11.5% (4 081/35 469) had prolonged second stage. Cesarean Delivery occurred in 19.8% of these cases (782/4 081), while 80.2% had a vaginal delivery.

Conclusions: Over three quarters of nulliparous women with epidural diagnosed with a prolonged second stage deliver vaginally.     

Risk factors for forceps delivery in nulliparous patients

OBJECTIVE: To identify risk factors for forceps delivery during first pregnancy. MATERIALS AND METHODS: A retrospective case-control study was carried out in a tertiary maternity ward between January 2001 and December 2003. A total of 582 nulliparous women, with full-term (>37 weeks gestation), singleton, cephalic pregnancies, who delivered by the vaginal route with or without instrumental assistance were evaluated. RESULTS: The strongest risk factors for forceps delivery were birth weight greater than 4000 g (OR: 6.5; 95% CI: 1.6, 26.9), the occiput posterior position of the fetal head (OR: 5.8; 95% CI: 2.5, 13.8), and epidural analgesia (OR: 7.7; 95% CI: 4.1, 14.7). Other significant risk factors for forceps delivery were age over 35 years (OR: 2.4; 95% CI: 1.1, 5.1), induction of labor (OR: 2.1; 95% CI: 1.4, 3.1), first stage of labor longer than 420 min (OR: 2.3, 95% CI: 1.3,4.2), and a prolonged second stage of labor (OR: 1.6, 95% CI: 1.1, 2.4). CONCLUSION: Age over 35 years and induction of labor are risk factors for forceps delivery at admission. Epidural use, fetal head in occiput posterior position, and birth weight >4000 g are strong intrapartum risk factors for instrumental delivery in nulliparous women.     

Manejo expectante del período expulsivo frente a actitud activa en gestantes usuarias de analgesia epidural

ObjectiveTo determine the influence of epidural analgesia on the expulsion period when a policy of delayed pushing was used by analyzing its effect on type of delivery and perinatal outcomes.Material and methodsWe performed a retrospective observational study comparing a group of women without epidural analgesia (238) who were advised to commence pushing at full dilatation with a second group of women with epidural analgesia (238) who were advised to wait 1-2 hours after full dilatation before starting to push. The variables measured included length of second stage, type of delivery, Apgar scores, and arterial cord pH values.ResultsThe second stage was longer in the group with passive fetal descent (MD = 39.61; 95% CI, 33.2-46.01). However, Apgar scores (OR = 1; 95% CI, 0.44-2.27), arterial cord pH values (MD = 0.0012; 95% CI, -0.011-0.013), and rates of cesarean (OR = 0.81; 95% CI, 0.42-1.55) and instrumental delivery (OR = 0.88; 95% CI, 0.41-1.91) were similar in both groups.ConclusionsDelayed pushing was not associated with higher rates of adverse outcome, although the second stage of labor was longer.     

Second stage of labor and intraventricular hemorrhage in early preterm infants in the vertex presentation

Abstract

Objective: To investigate the association between exposure to second stage of labor and duration of second stage, and risk of intraventricular hemorrhage (IVH) among infants delivered <30 weeks of gestation.

Methods: We conducted a retrospective cohort study among 158 singleton vertex deliveries (97 vaginal and 61 cesarean). Multivariable logistic regression was used to evaluate the risk of IVH related to second stage.

Results: Infants exposed to second stage as compared to those not exposed to second stage irrespective of their mode of delivery had increased risk of mild IVH (odds ratio [OR] 2.69; 95% confidence interval [CI] 1.15, 6.29) but not of severe IVH (OR 1.14; 95% CI 0.33, 3.84). No relation with risk of mild (OR 0.98; 95% CI 0.95, 1.01) and severe (OR 1.00; 95% CI 0.95, 1.05) IVH was observed for each 1?min increase in duration of second stage. We also observed no significant association between quartiles of duration of second stage and risk of mild (p?=?0.20) and severe (p?=?0.29) IVH. We did not observe any significant interaction by gestational age, chorioamnionitis, birth weight or presenting complaint on admission.

Conclusion: The risk of mild IVH was increased in those exposed to a second stage of labor. However, no clear association was observed between duration of second stage and mild or severe IVH.     

The association between neonatal head circumference and second stage duration

Abstract

Purpose: To determine if head circumference (HC) is an independent factor influencing second stage duration stratified by parity and epidural use.

Materials and methods: A retrospective cohort analysis of all live, singleton, term (37–42 weeks) vaginal deliveries in one university affiliated medical center (2012–2014). Exclusion criteria included operative deliveries due to fetal distress, major fetal anomalies/chromosomal abnormalities or cases with missing anthropometric data. Maternal demographics, labor characteristics and neonatal anthropometrics including birth weight and HC were retrieved. Multivariate linear regression was utilized to evaluate the association between HC and second stage duration. Analysis was stratified into four groups by parity and epidural use.

Results: Of the 16 240 singleton vaginal deliveries during study period, 12 428 deliveries met inclusion criteria. Stratification by parity and epidural analgesia yielded four groups: 3337 (26.9%), 735 (5.9%), 5099 (41.0%) and 3257 (26.2%) deliveries – nullipara with/without epidural and multipara with/without epidural, respectively. In all groups, a large neonatal HC was significantly and independently associated with longer second stage duration: nullipara with epidural (beta 10.06, 95% CI 7.75–12.37), nullipara without epidural (beta 7.58, 95% CI 4.73–10.43), multipara with epidural (beta 4.64, 95%CI 3.47–5.8) and multipara without epidural (beta 1.35, 95% CI 0.76–1.94), p?<?.001 for all. Birth weight was not associated with second stage duration in any of the groups (p?>?.05).

Conclusion: Large neonatal HC is significantly associated with longer second stage duration.     

Intra-partum epidural analgesia in grandmultiparous women

Objective. The present study aimed to characterise grandmultiparous women receiving intra-partum epidural analgesia and investigate associations between this method of pain relief and labour outcomes in grandmultiparas.

Methods. A population-based study was conducted comparing obstetric and perinatal characteristics of grandmultiparous women with and without epidural analgesia. Deliveries occurred during the years 1988–2006. Multiple logistic regression models were constructed to find independent risk factors associated with epidural analgesia, cesarean section and 1st stage labour dystocia.

Results. Out of 41,488 deliveries to grandmultiparous women included in the study, intra-partum epidural analgesia was utilised in 877 (2.1%). Multivariate analysis revealed that grandmultiparas who received epidural pain relief were significantly older and more likely to suffer from pre-mature rupture of the membranes, polyhydramnion, oligohydramnion, labour induction and a macrosomic fetus. After controlling for potential confounding, use of epidural analgesia remained an independent risk factor for 1st stage labour dystocia (odds ratio (OR) = 1.5; 95% confidence interval (CI) = 1.08–2.2) and cesarean delivery (OR = 2.9; 95% CI = 2.4–3.5) in grandmultiparas.

Conclusion. Grandmultiparous women who received intra-partum epidural analgesia have entirely different obstetric characteristics as compared with those who did not receive this method of pain relief. Although epidural use was demonstrated to be an independent risk factor for 1st stage labour dystocia and cesarean section in this population, residual confounding cannot be excluded.     

Trends in labour and birth interventions among low-risk women in New South Wales

OBJECTIVE: To examine recent trends in obstetric intervention rates among women at low-risk of poor pregnancy outcome. DESIGN: Cross-sectional analytic study SETTING AND POPULATION: A population of 336,189 women categorised as low-risk of a poor pregnancy outcome who gave birth to a live singleton in NSW from 1 January 1990 to 31 December 1997. MAIN OUTCOME MEASURES: Obstetric intervention rates including oxytocin induction and augmentation of labour, epidural analgesia, instrumental births, caesarean section and episiotomy METHODS: Trends over time were assessed by fitting trend-lines to numbers of births or by trends in proportions. Unconditional logistic regression was used to assess the impact of epidural analgesia on instrumental birth over time. RESULTS: Rates of operative births did not rise despite increases in maternal age and use of epidural analgesia. Instrumental births declined over time from 26% to 22% among primiparas and 5% to 4% among multiparas. There was also a shift to vacuum extraction rather than forceps. Although instrumental birth was strongly associated with epidural analgesia, the strength of the association declined over the study period, for primiparas from an adjusted odds ratio of 7.2 to 5.2 and for multiparas from 13.2 to 10.3. CONCLUSIONS: Increased use of epidural analgesia for labour has been a feature of the management of birth at term during the 1990s. The decline in the strength of association between epidural analgesia and instrumental birth may reflect improved epidural techniques and management of epidural labour, and recognition of the adverse maternal outcomes associated with forceps and vacuum births.     

The effect of inflatable obstetric belts in nulliparous pregnant women receiving patient-controlled epidural analgesia during the second stage of labor

Abstract

Objective: The aim of this study was to evaluate the effect of inflatable obstetric belts on uterine fundal pressure in the management of the second stage of labor.

Method: Between July 2009 and December 2010, 188 nulliparous women with a singleton pregnancy at term were enrolled and only one dropped. The participants were randomized to receive either standard care (control group, n?=?91) or uterine fundal pressure by the Labor Assister? (Baidy M-520/Curexo, Inc., Seoul, Korea; active group, n?=?97) during the second stage of labor in addition to standard care. The Labor Assister is an inflatable obstetric belt that is synchronized to apply constant fundal pressure during a uterine contraction. The primary endpoint was duration of the second stage of labor in women who delivered vaginally (control, n?=?80 versus active, n?=?93). It was not analyzed in women who delivered by cesarean section (n?=?14) and delivered precipitously (n?=?1). The secondary outcomes are perinatal outcomes and perineal laceration. Participants received patient-controlled epidural analgesia.

Results: The 93 women in the active group spent less time in the second stage of labor when compared to the 80 women in the control group (46.51?±?28.01?min versus 75.02?±?37.48?min, p?<?0.001). There was no significant difference in perinatal outcomes and perineal laceration between the two groups.

Conclusion: The uterine fundal pressure exerted by the inflatable obstetric belt reduces the duration of the second stage of labor without complications in nulliparous women who receive patient-controlled epidural analgesia.     

Prolonged second stage of labor and postpartum hemorrhage

Objective.?To examine the relationship between prolonged second stage and postpartum hemorrhage (PPH).

Methods.?We conducted a retrospective case–control study of all cases of PPH which occurred at four Southern California hospitals in 2003. Cases were identified by ICD-9 codes and confirmed by chart reviews, and non-cases were randomly selected as controls. The relationship between PPH and prolonged second-stage was examined using bivariate and multivariate analyses.

Results.?The sample consisted of 91 cases and 323 controls. Cases were significantly more likely than controls to have had a prolonged second stage of labor, over a range of definitions for PPH and prolonged second stage. In multivariable analyses, prolonged second stage was associated with greater than three-fold (OR = 3.35; 95% CI 1.22–9.19) increased risk for PPH.

Conclusion.?Prolonged second stage is an important risk factor for PPH. Close supervision is warranted for women with a prolonged second stage.     

A meta-analysis of upright positions in the second stage to reduce instrumental deliveries in women with epidural analgesia

BACKGROUND: Epidural analgesia is associated with an increased risk of instrumental delivery. We, in this study, present a systematic review in order to assess the effectiveness of maintaining an upright position during the second stage of labor to reduce instrumental deliveries among women choosing epidural analgesia. The study population included women with uncomplicated pregnancies at term with epidural analgesia established in the first stage of labor. METHODS: We searched MEDLINE, EMBASE, and CINAHL databases and the Cochrane Trials Register up to July 2003 and cross-checked the reference lists of published studies. Trial eligibility and outcomes were pre-specified. Group tabular data were obtained for each trial and were analyzed by using meta-analytic techniques. RESULTS: Only two studies were included with data on 281 women (166 upright and 115 recumbent). Upright positions in the second stage were associated with a non-significant reduction in the risk of both instrumental delivery (relative risk (RR) = 0.77, 95% confidence interval (CI) = 0.46-1.28) and cesarean section (RR = 0.57, 95% CI = 0.28-1.16). Both studies reported a statistically significant reduction in labor duration associated with upright positions. Data on other outcomes, including perineal trauma, postpartum hemorrhage, maternal satisfaction, and infant well-being, were insufficient. CONCLUSIONS: There were insufficient data to show a significant benefit from upright positions in the second stage of labor for women who choose epidural or to evaluate safety aspects. However the magnitude of the reductions in instrumental delivery and cesarean section warrants an adequately powered randomized, controlled trial to fully evaluate the practice of upright positions in the second stage for women with an epidural.     

Epidural analgesia in primigravidae in spontaneous labour at term: a prospective study

OBJECTIVES: To prospectively study the intervention rate, duration of labour, malpositions, fetal outcome, maternal satisfaction, voiding complications and adverse events in healthy primigravidae in spontaneous labour at term following epidural analgesia. METHODS: A prospective randomized study involving 55 patients in the epidural group and 68 in the control pethidine--inhalational entonox group. RESULTS: There were significantly more obstetric interventions (instrumental deliveries) in the epidural group (p < 0.01). The total duration of labour and the duration of the second stage was prolonged in the epidural group (p < 0.01). There were more malpositions at the second stage of labour in the epidural group (p < 0.02). There were no differences in fetal outcome (Apgar scores and Special Care Nursery admissions). Patients in the epidural group were consistently happier with their method of pain relief (p < 0.01). Two patients required blood patches while another 2 patients had persistent backache post epidural analgesia. CONCLUSION: Epidural analgesia in primigravidae in spontaneous labour at term led to an increased instrumental delivery rate, prolonged duration of labour, greater rate of malpositions in the second stage, increased oxytocin requirements but with no difference in fetal outcomes but with happier mothers as compared to the control group.     

罗哌卡因用于分娩镇痛对产程和分娩方式的影响

目的探讨罗哌卡因用于分娩镇痛对产妇产程和分娩方式的影响。方法采用回顾性分析的方法,选择行0.1%罗哌卡因+芬太尼(1μg/ml)硬膜外阻滞的190例健康、单胎、足月临产初产妇为镇痛组。另选择同期222例条件相似、未行任何镇痛措施的自然临产产妇为对照组。记录两组产妇产程时间、分娩方式、新生儿1分钟和5分钟Apgar评分。结果(1)产程时间比较:镇痛组第一产程、第二产程和总产程时间分别为(426±161)min、(54±27)min、(489±166)min;对照组分别为(364±167)min、(37±22)min、(409±170)min,两组比较,差异均有统计学意义(P<0.01)。(2)分娩方式比较:镇痛组阴道器械助产率为20.0%(38/190),明显高于对照组的6.3%(14/222),两组比较,差异均有统计学意义(P<0.01);镇痛组剖宫产率及阴道顺产率分别为20.0%(38/190)、60.5%(115/190),对照组分别为28.4%(63/222)、65.8%(146/222),两组比较,差异均无统计学意义(P>0.05)。(3)Apgar评分比较:镇痛组新生儿1分钟及5分钟Apgar评分<7分者分别为7.9%(15/190)、2.6%(5/190),对照组分别为4.5%(10/222)、0.5%(1/222),两组比较,差异均无统计学意义(P>0.05)。结论罗哌卡因用于分娩镇痛对产妇产程有延长作用及增加阴道器械助产率,但对新生儿出生结局无明显影响。     

Epidural Analgesia Use as a Marker for Physician Approach to Birth: Implications for Maternal and Newborn Outcomes

Background: Understanding the association between caregiver belief systems and practice patterns is an emerging area of research. We hypothesized an association between a maternity caregiver's belief system and his or her behavior. The study objective was to determine if a family physician's overall approach to maternity care, as measured by average use of epidural analgesia, was associated with maternal and fetal outcomes. Methods: Retrospective analysis was conducted of the births of three cohorts of 1992 nulliparous, low‐risk women attended by 96 family physicians within an 18‐month period in the department of family practice at the largest maternity hospital in Canada. Cohorts were based on the physicians' mean use of epidural analgesia for the women. Family physicians attending fewer than 5 births were excluded. The main outcome measures, by physician epidural utilization cohort, were maternal/newborn morbidity, procedure rates, consultation rates, and length of stay. Results: Family physicians were separated into cohorts based on their mean use of epidural analgesia at rates of: low, 0–30 percent (15 physicians, 263 births); medium, 31–50 percent (55 physicians, 1323 births); and high, 51–100 percent (26 physicians, 406 births). After adjustment for maternal age and race, patients of low versus high epidural users were admitted at a later state of cervical dilation (mean 4.0 vs 3.1 cm), received less electronic fetal monitoring (76.4 vs 87.2%) and oxytocin augmentation (12.2 vs 29.8%), sustained fewer malpositions (occiput posterior or transverse)(23.2 vs 34.2%), had fewer cesarean sections (14.0 vs 24.4%), less obstetric consultation (47.9 vs 63.8%), and fewer newborn special care admissions (7.2 vs 12.8%). Conclusions: In our setting, high use of epidural analgesia is a marker for a style of practice characterized by malpositions leading to dysfunctional labors and higher intervention rates leading, in turn, to excess maternal/newborn morbidity.     

Does meperidine analgesia affect the incidence of obstetric lacerations at vaginal delivery?

Purpose: To study whether meperidine analgesia affects the incidence of obstetric lacerations at normal vaginal deliveries.

Materials and methods: A retrospective cohort study of all women with term vertex singleton pregnancies, who underwent normal vaginal deliveries, in a single tertiary hospital, between 2011 and 2015, was performed. The incidence of various obstetric lacerations was compared between deliveries with meperidine analgesia and deliveries with no analgesia. Deliveries with epidural analgesia and instrumental deliveries were excluded. An intravenous infusion of 75?mg of meperidine was administered together with 25?mg of promethazine. A multivariate logistic regression analysis was performed to assess the association between meperidine analgesia and obstetric lacerations, after controlling for confounders.

Results: Overall, 5227 (91.8%) deliveries with no analgesia and 466 (8.1%) deliveries with meperidine analgesia were included. Meperidine analgesia was associated with a decreased risk of first- and second-degree perineal lacerations (adjusted OR?=?0.63, 95% CI?=?0.49–0.81), and a decreased risk of any suturing (adjusted OR?=?0.73, 95% CI?=?0.59–0.91), after controlling for confounders. Meperidine analgesia did not affect the risk of severe perineal lacerations or episiotomies.

Conclusion: Meperidine analgesia may have a protective effect against first- and second-degree perineal lacerations.     

Risk factors for accidental dural puncture during epidural anesthesia for laboring women

Background and objectives: Accidental dural puncture (ADP) during epidural analgesia is a debilitating complication. Symptoms of ADP post-dural puncture headache (PDPH) are headache while rising from supine to upright position, nausea, and neck stiffness. While age, gender and needle characteristics are established risk factors for ADP, little is known about risk factors in laboring women.

Methods: All cases of ADP during epidural analgesia treated with blood-patching during a 3-years period were retrospectively reviewed. Each case was matched to two controls according to delivery period.

Results: Forty-nine cases of blood patches after ADP out 17?977 epidural anesthesia procedures were identified (0.27%). No differences were found between cases and controls with regards to body mass index, labor stage at time of epidural, length of second stage, location of epidural along the lumbar vertebrae, anesthesiologist’s experience or time when epidural was done. In cases of ADP, significantly lower doses of local anesthetics were injected (10.9 versus 13.5?cc, p?<?0.001); anesthesiologists reported significantly more trials of epidurals (70 versus 2.8% more than one trial, p?<?0.001), more patient movement during the procedure (13 versus 0%, p?<?0.001), more intra-procedure suspicion of ADP (69 versus 0%, p?<?0.001) and more cases where CSF/blood was drawn with the syringe (57 versus 2.4%, p?<?0.001).

Conclusion: ADP during labor is a rare but debilitating complication. Risk factors for this iatrogenic complication include patient movement and repeated epidural trials. Intra-procedure identification of ADP is common, allowing early intervention with blood patching where indicated.