American Journal of Obstetrics & Gynecology
Volume 194, Issue 3 , Pages 598-599, March 2006

Timing of conduction analgesia in labor

  • Michael Nageotte, MD

      Affiliations

    • Corresponding Author InformationReprint requests: Michael Nageotte, MD, Executive Careline Director, Ob/Gyn/Newborn, Women's Pavilion, Miller Children's Hospital, 2801 Long Beach Blvd, Long Beach, CA 90801.

Obstetrics/Gynecology/Newborn, Women's Pavilion, Miller Children's Hospital, Memorial Medical Center, Long Beach, CA; Department of Obstetrics and Gynecology, University of California, Irvine, Irvine, CA

Article Outline

 

Pain and its relief for women in labor has been the subject of interest since the dawn of mankind. Following the initial recorded transgression in the Garden of Eden, God informed Eve that “I will greatly increase your pains in childbearing; with pain you will give birth to children” (Genesis 3:16). While unquestionably influenced by culture, psychology, and expectation, many women experience severe and memorable pain in the process of labor and delivery. Over the past 30 years in this country and increasingly in much of the developed world, the widespread use of conduction analgesia has dramatically altered the experiences of many laboring patients. Unfortunately, access to safe and adequate analgesia remains incomplete and many forces are at play in the availability of intrapartum conduction analgesia as an option for women in labor. However, the decision to utilize such pain relief when available remains the subject of controversy for both the patient and health care provider. If pain relief is the end point then intrapartum conduction analgesia is clearly efficacious. Yet important questions remain including the timing, control, and effect upon the overall labor experience of this valuable medical technique.

Modern obstetrics is as guilty as any other medical specialty of rapidly utilizing new technology without the necessary study and evidence-based research being established before widespread use. Only after years of clinical experience do well-designed studies appear confirming or refuting the medical efficacy of a particular technology, with electronic fetal heart rate monitoring being a prime example in our specialty. Unencumbered by adequate data and research, intrapartum conduction analgesia has become the standard for pain relief in laboring patients in many hospitals. This is usually in the form of a continuous or intermittent bolus infusion of dilute concentrations of both local anesthetics and narcotics into the lumbar epidural space. Clinical questions have arisen regarding the effects such analgesia may have upon labor progress, need for augmentation, frequency of instrumented delivery, as well as impact on the rate of cesarean delivery. Answering these questions has been very challenging because the performance of adequately designed prospective studies has been difficult. Issues regarding informed consent, adequacy of pain relief, consistency of epidural availability and effect, frequency of crossover, and patient satisfaction remain areas of concern particularly in studies comparing conduction analgesia with parenteral narcotics.1 Research appears to suggest that intrapartum epidural analgesia is positively associated with the use of pitocin augmentation of labor, diagnosis of dystocia, and intrapartum maternal fever.2, 3, 4 Additionally, several investigators have suggested a significant increase in cesarean delivery for nulliparous women with epidural, particularly in the cohort of women receiving epidural in early labor.2, 5, 6 While recent review suggests that epidural analgesia is not associated with such an overall risk, there remains concern over the effect of the timing of epidural placement on the incidence of cesarean birth.7 This has led the American College of Obstetricians and Gynecologists to recommend “when feasible, obstetric practitioners should delay the administration of epidural anesthesia in nulliparous women until the cervical dilation reaches 4-5 cm, and that other forms of analgesia be used until that time.”8 Consequently, women are routinely encouraged to delay receiving conduction analgesia until their labor and its attendant memories have been well established.

In this issue of the Journal, Ohel et al, from Haifa, Israel, report a prospective randomized study of early versus late epidural analgesia in laboring nulliparous women at term.9 Using conventional continuous epidural infusion, women randomized to the early group received epidural immediately upon request if their cervix was less than 3 cm dilated (mean dilation 2.4 cm). Women randomized to the late group received intravenous narcotics until they achieved cervical dilation of 4 to 5 cm, at which time epidural analgesia was initiated (mean dilation 4.6 cm). Results included a significantly shorter time from study randomization to full dilation in the early epidural group. There were no significant differences between the groups in rates of cesarean section, indications for cesarean section, rates of instrumentation, duration of the second stage, or neonatal or maternal outcomes. Although overall patient satisfaction was the same, significantly more women would prefer to be in the early epidural group with their next labor. This important study follows a publication by Wong et al that reported no difference between early and late neuraxial analgesia.10 In Wong's study, women were randomized to early intrathecal with later epidural analgesia versus systemic analgesia with later epidural. This is a different protocol than that used by Ohel et al but was again an effort to evaluate the issue of timing of conduction analgesia. Wong was similarly unable to demonstrate any difference in cesarean delivery rate or other outcomes between their 2 groups. Previous reports from Chestnut et al, although somewhat methodologically challenged, reached similar conclusions to these recent studies.11, 12 That is, early versus late conduction analgesia in nulliparous women does not appear to have an effect on the rate of cesarean delivery.

Where does this leave us and how should we counsel our patients regarding this important therapeutic modality? In light of these excellent studies, it is difficult to argue that epidural analgesia should be withheld from a woman who is requesting pain relief in labor. While such decisions should always be individualized, there should no longer be an arbitrary degree of cervical dilation necessary before such a decision is considered. No longer should a patient be made to feel guilty about her wish for pain relief early in labor, powerless in her choices or conflicted about the consequences of such a choice. Women should receive adequate pain relief when needed, as determined by the patient herself. What a concept—pain relief of real pain when requested. We all should now feel comfortable supporting this position for the patient in labor.

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References 

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  2. Nageotte M, Larson D, Rumney P, Sidhu M, Hollenbach K. A prospective randomized study of intrpartum epidural versus combination intrathecal epidural anesthesia with or without ambulation. N Engl J Med. 1997;337:1715–1719
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  7. Zhang J, Kleganoff MA, DerSimonian R. Epidural analgesia in association with duration of labor and mode of delivery: a quantitative review. Am J Obstet Gynecol. 1999;180:993–1000
  8. Goetzl LM. ACOG Practice Bulletin no. 36: Clinical management guidelines for obstetrician-gynecologists: obstetric analgesia and anesthesia. Obstet Gynecol. 2002;100:177–191
  9. Ohel G, Gonen R, Vaida S, Barak S, Gaitini L. Early versus late initiation of epidural analgesia in labor: does it increase the risk of cesarean section? A randomized trial. Am J Obstet Gynecol. 2006;194:600–605
  10. Wong CA, Savone BM, Peaceman AM, McCarthy RJ, Sullivan JT, Diaz NT, et al. The risk of cesarean delivery with neuraxial analgesia given early versus late in labor. N Engl J Med. 2005;352:655–665
  11. Chestnut DH, Vincent RD, McGrath JM, Choi WW, Bates JN. Does early administration of epidural analgesia affect obstetric outcome in nulliparous women who are receiving intravenous oxytocin?. Anesthesiology. 1994;80:1193–2000
  12. Chestnut DH, McGrath JM, Vincent RD, Penning DH, Choi WW, Bates JN, et al. Does early administration of epidural analgesia affect obstetric outcome in nulliparous women who are in spontaneous labor?. Anesthesiology. 1994;80:1201–1208

PII: S0002-9378(05)02500-7

doi:10.1016/j.ajog.2005.11.021

American Journal of Obstetrics & Gynecology
Volume 194, Issue 3 , Pages 598-599, March 2006

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